C10027650 / invoice 10000
Species:CANINE
Breed:Cavoodle
Age (years):1
Diagnosis or signs:Consult NB
Consult notes
<html><meta http-equiv="Content-Type" content="text/html; charset=utf-8"><div><strong>History:</strong></div> <div> <p>Client History:<br>Previous underbite noted few months ago.<br>Routine check up. Smelly ear potentially. Her R ear. More than a month or so. An ear cleaner - not sure on name from petstore. Sis epioptic - has settled a bit. shaking at ear a lot.<br>L ear - clean, and back gunk. Gunky and matted in fur. Few weeks ago - given a clean.<br>Last few days quite bothered by it.<br>Remainder of skin fine.<br>EDDU normally. No vomiting, diarrhoea, coughing, sneezing. 1x vomit other day.<br>First heat - Christmas period - 2 weeks.<br><br>Diet: Eats once daily now. Gone off dry food in the morning. Loves her wet food now. Tried several brands. <br>HW/ flea + tick preventative: UTD vacc<br>Current Medications/ supplements: Epioptic. <br><br><strong>Objective:<br></strong>Weight: - kg<br>Temperature: Not taken<br>HR: WNL<br>RR: WNL<br>BCS: 5 out of 9<br>FAS: Green<br>Hydration: Hydration appears normal<br>Eyes: no clouding, no debris, sclera is clear<br>Ears: No debris or erythema<br>Oral Cavity: healthy teeth and gums<br>Cardiovascular: no murmur or arrhythmia, strong pulses.<br>Respiratory: Lungs sounds are clear, no crackles or wheezes<br>Abdomen: comfortable on palpation, no mass effect, no fluid wave<br>Musculoskeletal: Normal ambulation, Normal ROM<br>Integument: skin looks normal; hair coat in good condition. No ectoparasites. No masses found.<br>Lymph nodes: Lymph nodes are soft and small<br>Urogenital: External genitalia appears normal; bladder palpates normally<br>Neurologic: Normal mentation<br><br><strong>Problem List:<br><br><br></strong><strong>Differentials:<br><br><br></strong><strong>Treatment/Plan:</strong><br>Diagnostics Completed:<br><br>Treatments: <br><br>Prescriptions: <br><br>Follow up:<br><br>Subjective: <br>Pet's signalment: Pippa, 9-month-old, Cavoodle, intact female<br>History: Presenting for a routine checkup and a left ear issue. The owner reports Pepper has been scratching her left ear for approximately 1-2 months. There is a black, waxy discharge and a yeast-like odor from the left ear only. The owner has been using an over-the-counter ear cleaner. The right ear appears normal. The owner also has concerns about a possible malocclusion (underbite) that was noted when she was a puppy.<br>General health is good. Appetite is good, though she now refuses her morning meal of dry kibble and only eats one large meal of wet food in the evening. Water intake is normal. One episode of vomiting occurred recently, which the owner attributes to eating grass. No coughing or sneezing reported.<br>Pepper experienced her first estrus cycle around Christmas 2025, which lasted about two weeks. Her behavior has reportedly been calmer since the heat cycle. The owner is planning to have her spayed.<br>Diet: One meal per day in the evening, consisting of wet food. Refuses dry kibble.<br>HW/ flea + tick preventative:<br>Current Medications / supplements: An over-the-counter ear cleaner.<br>Any vaccine or medication reactions:<br>Recent blood test:<br><br>Objective: <br>Weight: - kg<br>Temperature: Not taken<br>HR: WNL<br>RR: WNL<br>BCS: 5 out of 9<br>FAS: Green<br>Hydration: Hydration appears normal<br>Eyes: no clouding, no debris, sclera is clear. Pupil sizes are symmetrical<br>Nasal: Patent and clear. No lesions or other abnormalities<br>Ears: Right ear is clean with no abnormalities noted. LEFT EAR CANAL IS ERYTHEMATOUS AND INFLAMED with a moderate amount of black, waxy debris present. The tympanic membrane was visualized and appears intact. Cytology of the left ear revealed a SIGNIFICANT OVERGROWTH OF YEAST (MALASSEZIA).<br>Oral Cavity: MILD TO MODERATE CLASS III MALOCCLUSION (UNDERBITE) IS PRESENT. There is concern for potential traumatic contact from the maxillary incisors onto the mandibular gingiva or mandibular canines.<br>Cardiovascular: no murmur or arrhythmia, strong pulses.<br>Respiratory: Lungs sounds are clear, no crackles or wheezes<br>Abdomen: comfortable on palpation, no mass effect, no fluid wave<br>Musculoskeletal: Normal ambulation, Normal ROM<br>Integument: skin looks normal; hair coat in good condition. No ectoparasites. No masses found.<br>Lymph nodes: Lymph nodes are soft and small<br>Urogenital: Intact female. External genitalia appears normal; bladder palpates normally<br>Neurologic: Normal mentation<br><br>Assessment: <br>Problem List:<br>1. LEFT OTITIS EXTERNA SECONDARY TO YEAST INFECTION<br>2. CLASS III MALOCCLUSION (UNDERBITE)<br>3. Intact female, due for ovariohysterectomy<br><br>Plan: <br>Treatments: Owner was instructed on proper ear cleaning technique. To treat the left ear, owner will clean thoroughly, then administer medication.<br>Diagnostics Completed: Otoscopic examination, ear cytology (left ear).<br>Prescriptions: Dispensed topical ear medication. Instructed owner to apply one pump into the left ear canal once daily for 5 consecutive days.<br>Follow up:<br>- Recheck examination in 7-8 days for repeat otoscopy and ear cytology. Owner was instructed to stop all ear cleaning and medication for 2 days prior to the appointment.<br>- Discussed performing an ovariohysterectomy (spay). Recommended a thorough dental assessment under general anesthesia at the time of surgery to evaluate the malocclusion for any points of traumatic contact that may require intervention.<br>- An estimate for the ovariohysterectomy will be emailed to the owner.</p> </div></html>
Animal clinical history (3 most recent)
2025-08-08T00:00:00Z 16:38:00
Subjective: Pet's signalment: Pippa, 12-week-old, Cavoodle, female, intactHistory: Patient was acquired by the owner on July 11, 2025, and is settling in well. House training is progressing with occasional accidents. The owner reports that the patient eats her food very quickly and appears bloated afterward. She has been observed eating grass but has not vomited. The owner notes some discharge and matting of the fur around the patient's eyes. This is the owner's first dog.Diet: Transitioning from My Dog wet food to Open Paddock kibble. Still receiving some wet food. Fed twice daily.HW/ flea + tick preventative: Was dewormed by the breeder. Owner is seeking recommendations for ongoing prevention.Current Medications/ supplements: NoneAny vaccine or medication reactions: None reportedObjective: Weight: 2.98 kgTemperature: Not takenHR: WNLRR: WNLBCS: 5 out of 9FAS: GreenHydration: Hydration appears normalEyes: MILD EPIPHORA (TEAR STAINING) BILATERALLY, likely secondary to teething. No clouding, no debris, sclera is clear.Ears: No debris or erythemaOral Cavity: Deciduous dentition present. SUPERIOR BRACHYGNATHIA (CLASS 3 MALOCCLUSION) NOTED; the mandible is longer than the maxilla, causing the lower incisors to sit rostral to the upper incisors.Cardiovascular: no murmur or arrhythmia, strong pulses.Respiratory: Lungs sounds are clear, no crackles or wheezesAbdomen: Comfortable on palpation, no mass effect, no fluid wave. No hernia detected.Musculoskeletal: Normal ambulation, Normal ROMIntegument: Skin looks normal; hair coat in good condition. No ectoparasites. No masses found.Lymph nodes: Lymph nodes are soft and smallUrogenital: External genitalia appears normal; bladder palpates normallyNeurologic: Normal mentationAssessment: Problem List:1. Healthy puppy examination and vaccination2. SUPERIOR BRACHYGNATHIA (MALOCCLUSION)3. MILD EPIPHORA (TEAR STAINING)4. Owner education on puppy careDifferentials: Stable on examPlan: Treatments: Administered early-start intranasal kennel cough vaccine. Patient can socialize in public 10 days from today.Diagnostics Completed: Physical examination.Prescriptions:- NexGard Spectra (2-3.5 kg) - Dispensed one chew. Administer one chew monthly for flea, tick, heartworm, and intestinal worm control.- Tapewormer tablet - Dispensed one tablet. Administer 1/2 tablet now, and the remaining 1/2 tablet in 3 months, provided patient is under 5kg.Follow up:- Recheck examination scheduled in 4 weeks (September 6, 2025) to monitor dental and jaw development.- Discussed feeding smaller, more frequent meals to prevent post-prandial bloating.- Discussed cleaning the fur around the eyes with warm water to prevent skin irritation from tear staining.- Recommended starting at-home dental care with a pet-safe toothpaste.- Discussed desexing at 8-10 months of age to allow for complete growth, which may reduce the risk of orthopedic issues like patellar luxation.- Discussed grooming, house training, and environmental enrichment.- Nurse provided information on council registration and ensuring microchip details are updated. Are they signed up for insurance and council reg
Previous claim history
| Date | Claim # | Diagnosis |
|---|---|---|
| No prior claims. | ||
Line items(lines with upstream diagnosis are skipped by the model)
| Line | tstarc | Amount | Date | Upstream diagnosis |
|---|---|---|---|---|
| 10000 | tstarc_consultation-revisit | 109.00 | 2026-03-13 | — |
| 20000 | tstarc_diagnostic_test_-_cytology | 62.50 | 2026-03-13 | — |
| 30000 | tstarc_ear_medication_-_antibacterial_and_anti-fungal | 106.20 | 2026-03-13 | — |
UPM+
- DG01185OTITIS EXTERNADSTP_otitis_externa
Variant (sleepy_king)
OTITIS EXTERNA
DSTP_otitis_externa
Conf: 0.970
Threshold: 0.07
Above: ✓
Correct?