C10030696 / invoice 10000

Species:CANINE
Breed:Maltese Cross
Age (years):4
Diagnosis or signs:Consult
Consult notes
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<p><strong>HISTORY </strong><br><br><strong>EXAM</strong><br><br><strong>ASSESSMENT </strong><br><br><strong>LABORATORY</strong><br><br><strong>TREATMENT </strong><br><br><strong>PLAN</strong><br><br><strong>OWNER COMMUNICATION</strong></p></html>
</br><p>HISTORY<br>Presenting for: Ponyo presented for annual vaccines and general health check, as they haven't been seen for a long time.<br>Current Meds: Vaccines up to date from last year</p><p>EXAM<br>Mentation: <br>Wt: <br>BCS: <br>T: <br>HR: <br>R: <br>MM: <br>Hydration: <br>Behavioural: Initially cooperative but became increasingly stressed during examination procedures, particularly during eye examination and staining<br>Eyes: Bilateral conjunctivitis with erythema and discharge present. Pruritic for couple of months duration. Patient observed pawing at eyes. Fluorescein stain performed bilaterally - no corneal ulcers detected<br>Ears: <br>Nose: <br>Throat: <br>Oral: Dental tartar present, would benefit from scale and polish<br>Cardiovascular: <br>Respiratory: <br>Abdominal: <br>Lymph Nodes: <br>Integumentary: <br>Neurologic: <br>Musculoskeletal: <br>Urogenital: <br>Rectal: <br>Diagnostics: Fluorescein stain both eyes - negative for ulcers. Schirmer tear test - negative for dry eye</p><p>ASSESSMENT<br>Bilateral conjunctivitis - likely allergic etiology with possible secondary bacterial component<br>Dental disease - moderate tartar accumulation<br>Otherwise apparently healthy</p><p>PLAN<br>Vaccinations: <br>- Annual vaccines administered<br>New Meds/Tx: <br>- Topical eye drops prescribed BID for one week to address conjunctivitis and reduce erythema and pruritus<br>Additional Discussion: <br>- Dental scale and polish recommended for future appointment<br>- Eye drops should provide significant improvement in redness and itching</p>

Animal clinical history (3 most recent)

2025-03-15T00:00:00Z 15:10:00
HistoryBIB: Current medications: T/F/W/vacc Prophy? Monthly and due for wormerPresenting Complaint/s? RIGHT scratching getting worseCleaning - didn't try - not really regularly3-4 daysYesterday noticedNot sure if due for vaccination'ExamineMentation/Demeanour: BSC: MM: CRT: CVS-Resp: HR/RR Femoral Pulse:Mouth: Neck: Eyes: Ears: Nose: LNs (subman, pre-scap, axillary, inguinal, popliteal): Abd: Integument: Urogenital: Rectal: MSK: Neuro: Problem ListAssessmentLaboratoryTreatmentScript or MedicationRecommendationsConversationPlan
2023-02-04T00:00:00Z 00:00:00
Examination Text:Appointment Notes: rhodes@baysidevets.com.auAM sent hx to above vet--- 01/06/2023 16:38:33 AG:Resent hx to Bayside.
2023-01-17T00:00:00Z 00:00:00
Examination Text:Sent birthday card

Previous claim history (11)

DateClaim #Diagnosis
2023-02-04C5554531DIARROHEA
2022-12-12C5523681GASTROINTESTINAL PROBLEMS
2022-10-24C5523680DIARROHEA
2022-10-22C5519360OTITIS EXTERNA
2022-09-27C5144857GASTROINTESTINAL PROBLEMS
2022-09-27C5144857SKIN (CUTANEOUS) ABNORMALITY - OTHER - PRESENTING COMPLAINT
2022-09-09C5144858GASTROINTESTINAL PROBLEMS
2022-08-29C5144850MISCELLANEOUS CONDITIONS
2022-07-15C4928297SKIN (CUTANEOUS) ABNORMALITY - OTHER - PRESENTING COMPLAINT
2022-07-05C4928295DENTAL (TOOTH) DISORDER
2022-06-09C4928294LEG INJURY

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

LinetstarcAmountDateUpstream diagnosis
10000tstarc_vaccination_(canine)41.002026-03-14
upstreamDSTP_routine_care_-_vaccinations_or_health_checks
20000tstarc_consultation94.002026-03-14
30000tstarc_vaccination_(canine)42.002026-03-14
upstreamDSTP_routine_care_-_vaccinations_or_health_checks
40000tstarc_diagnostic_test_-_schirmer_tear_test29.402026-03-14
50000tstarc_diagnostic_test_-_fluorescein_eye_stain19.302026-03-14
60000tstarc_eye_medication_-_antibiotics_and_anti-inflammatory54.792026-03-14

UPM+

  • DG00512CONJUNCTIVITISDSTP_eyelid_-_conjunctivitis

Variant (sleepy_king)

CONJUNCTIVITIS
DSTP_eyelid_-_conjunctivitis
Conf: 0.840
Threshold: 0.25
Above:
Correct?