C10026416 / invoice 10000

Species:CANINE
Breed:Labradoodle
Age (years):8
Diagnosis or signs:Ear Infection
Consult notes
13/03/2026 HISTORY: has been doing better, doesn't seem as irritated by the ears but is still shaking head. One side doesn't appear worse than the other

CLINICAL EXAM:
Demeanor: BAR, nervous
Ears: Right ear no inflammation visible, minimal discharge, left ear moderate brown discharge and inflamation
Eyes: NAD - clear
Nose: NAD - no discharge or changes
Lymph Nodes: NAD
Skin: NAD
Musculoskeletal: gait normal

ASSESSMENTS: Ear cytology - Right ear improved with reduced Malassezia count ~9/hpf, left ear increased Malassezia count ~5/hpf

TREATMENTS OPTIONS:
1. Continue Neptra in the right ear.
2. Option to treat left ear with Neptra or BID daily drops; chose Neptra for ease of administration.

PLAN:
Continue Neptra treatment in the right ear for an additional 2 weeks. Begin Neptra treatment in the left ear. Recheck in two weeks to assess progress and effectiveness of treatment.

Animal clinical history (3 most recent)

2026-03-13T00:00:00Z 12:12:53
HISTORY: has been doing better, doesn't seem as irritated by the ears but is still shaking head. One side doesn't appear worse than the other

CLINICAL EXAM:
Demeanor: BAR, nervous
Ears: Right ear no inflammation visible, minimal discharge, left ear moderate brown discharge and inflamation
Eyes: NAD - clear
Nose: NAD - no discharge or changes
Lymph Nodes: NAD
Skin: NAD
Musculoskeletal: gait normal

ASSESSMENTS: Ear cytology - Right ear improved with reduced Malassezia count ~9/hpf, left ear increased Malassezia count ~5/hpf

TREATMENTS OPTIONS:
1. Continue Neptra in the right ear.
2. Option to treat left ear with Neptra or BID daily drops; chose Neptra for ease of administration.

PLAN:
Continue Neptra treatment in the right ear for an additional 2 weeks. Begin Neptra treatment in the left ear. Recheck in two weeks to assess progress and effectiveness of treatment.
2026-03-02T00:00:00Z 12:31:40
STAFF MEMBER: LC
REASON FOR CALL: Update after appointment 

OWNERS UPDATE/HISTORY: She is doing really well. Not shaking as much already. Seems happier. 

ADVICE GIVEN: Keep going with medication as directed by vet

ACTION: Has booked a recheck appointment 13h march

Previous claim history (16)

DateClaim #Diagnosis
2026-02-27C09964554OTITIS EXTERNA
2025-10-09C9326681VACCINATIONS OR HEALTH CHECKS
2025-10-09C9326681ALLERGY
2025-09-21C9251204LACERATION
2024-11-18C7964109LAMENESS RH
2024-10-16C7826773VACCINATIONS OR HEALTH CHECKS
2024-10-16C7826773HYPERSENSITIVITY (ALLERGIC) SKIN DISORDER
2024-09-30C7762188VACCINATIONS OR HEALTH CHECKS
2024-09-30C7762188EAR INFECTION
2024-04-23C7148078OPHTHALMIC (EYE) ABNORMALITY - PRESENTING COMPLAINT
2024-04-23C7148078ALLERGY
2023-10-18C6427617EAR (AURAL) INFECTION - FUNGAL
2023-10-04C6377361VACCINATIONS OR HEALTH CHECKS
2023-10-04C6377361ALLERGY
2023-10-04C6377361FLEA/TICK/WORM CONTROL
2023-10-04C6377361HEARTWORM CONTROL

Line items(lines with upstream diagnosis are skipped by the model)

LinetstarcAmountDateUpstream diagnosis
10000tstarc_diagnostic_test_-_cytology79.002026-03-13
20000tstarc_ear_medication_-_antibacterial_and_anti-fungal131.952026-03-13
30000tstarc_consultation-revisit107.552026-03-13

UPM+

  • DG01185OTITIS EXTERNADSTP_otitis_externa

Variant (sleepy_king)

OTITIS EXTERNA
DSTP_otitis_externa
Conf: 0.980
Threshold: 0.07
Above:
Correct?