C09978711 / invoice 10000

Reason: Hold For GoorumNotes: PRXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXHistory: Gooreum is a 5 year old male neutered Maltese, presenting to ARH Neurology today for 13/1/26 Gooreum presented to RV after having had seizures; first was 4 days prior, then had 1-2 seizures each day since. 1-2 mins duration each. No known toxin injection, otherwise well. PEx WNL. Another GTC occurred during consult, 1 min. In house CBC and MBA all WNL. Rx pexion 100mg PO BID and diazepam to give in event of seizure PR.15/2/26 Gooreum presented to ARH ECC after having 3 x cluster focal seizures during the day., described as fully conscious however passing diarrhoea, shaking and laying to his side. NEx WNL. DIspensed keppra for clusters, continue pexion, offered transfer to Neuro Tues or book in for neuro at a later date. Today (3/3/26) O reports pexion hasn't seemed to reduce episode frequency. Keppra maybe helped a little bit - bit less violent. Episodes atrted 25/12/25, pretty much every day since then, about 2-3 times. About 1-2 minutes, full body tremoring and stiffness, uncoordinated walking, stumbling overOften lifts individual limbsOne video was circling right1 video seemed almost hypermetric gaitOften seems a bit distressed, vocalising during.After an episode he stands still for a minute then back to normal and rests. Has had GTCs intermittently as well. The GTCs have stopped since medication. Difficult to determine level of awareness during an episode.Slipping over on legs more recentlyDon't want to do daily keppra yet due to logistic difficulty and also want to do one med at a time to see if it helpsAt recheck talk about bloods and also wean of pexionSeizure history – Description: Duration: Time of day: varying timesActivity on onset: resting at homeAutonomic signs: yes in GTCs, not in partialsPre-ictal signs: Post-ictal signs: Clusters: yesInterictal period: Interictal signs:Possible triggers: noneFamily history of seizures: noneToxin access: noneOwner's primary goal/concerns today - Appetite – NormalDiet – dry food, chicken, treatsWater intake – NormalUrination – NormalDefecation – NormalVomiting/diarrhoea – NoneCoughing/sneezing – NoneEnergy levels – NormalExercise/activity – walks a few times a week, playing with toysWeight changes – Maybe lost a bitBehavioural changes – Maybe barking a bit more than usualPreventative medications – UTD with NexgardIndoor/outdoor access - BothToxin exposure – None notedBIOP – since a puppyOther pets at home - nonePrevious medical history –  dfwCurrent medications: PexionKeppra post seizureExamination findings: T:  NT                 MM: pink and moistP:  120bpm        CRT: 1 secR:  pantHydration: EuhydratedWeight: kg (+/- g/ kg)BCS: 5/9MCS: 3/3Cardiovascular: No murmur auscultated, sinus rhythm, femoral pulses strong and synchronous Respiratory: Clear bronchovesicular sounds bilaterally, normal respiratory effort.Abdomen: Soft, comfortable on palpation. No mass effect appreciableOral exam: No obvious oral lesionsEars: No erythema or discharge notedIntegument: No lesions noted. Lymph nodes: Symmetrical, NSF Musculoskeletal: Full exam np, no obvious lameness.  Grade 2/4 MPL left side 3/4 right side.Rectal: NP Neurologic exam findings: Mentation/Demeanour - BARGait and posture – No significant findingsProprioception – PPR, RS and hopping intact in all limbsMotor function:1.Spinal reflexes – Intact pedal, proximal sciatic, patellar, CTR, and perineal reflexes.2.Muscle bulk - Normal3.Muscle tone - NormalCranial nerves - IntactContinence - IntactVertebral hyperpathia – None noted Nociception - IntactOphthalmic exam - NPAdditional findings - noneNeuroanatomical localisation: ForebrainProblem list:- SeizuresPotential causes:1. Idiopathic Epilepsy (IE)2. Structural (neoplasia, vascular, infectious, inflammatory)3. Reactive (metabolic vs toxin)Assessment:X neurological examination today reveals no specific abnormalities. Based on the history of GTC seizures, the neuroanatomical localisation of these clinical signs is the forebrain. Due to patient signalment, previous diagnostic investigation, and seizure semiology, the primary aetiological differential diagnosis is idiopathic epilepsy. It is recommended at this stage to consider MRI to assess for structural causes of seizures.Plan:DIspense midaz due to c;usters - see how far apart    Vital Signs    

Reason: Seizuring Past Few Months -> Three Today.History:Presented today following 3 x focal cluster seizures during the day. First seizures occured in December 2025 after he possibly had access to weed/weed killer. They are described as focal seizures-  He was seen to be fully conscious however passing diarrhoea, shaking and laying to his side. Further seizure activities were observed on 3rd Jan 2026 where he was shaking and unable to stand. These episodes lasted for a few minutes. Gooreum was taken to his reg vet in Mid January, where full bloods tests were run and was started on Pexion 100mg PO BID. Blood test results were all reportedly normal. Since 3 dd ago, he was observed holding up his LPL and walking sideways, like a crab. He was also seen flexing his neck. Gooreum has otherwise been well in his self with no other concerns reported by owner. Current medications: Pexion 100mg PO BID Examination Findings:General demeanour: BARHR: 112 RR: 20 mm: pink CRT: 1-2Temperature: 38.1Cardiovascular: No murmur and regular rhythm, SSFP Respiratory: Clear BV sound, no crackling/wheezing. Normal respiratory effortGastrointestinal: Comfortable in abdominal palpation. No obvious palpable object in abdomen. Peripheral LN: WNL (submandibular, prescapular, popliteal symmetrical and normal in size)  Eyes/Ears: nil anisocoria, nil nystagmus, nil ocular discharge. Both ear canals hairy, R>L subjectively dirtier and brown ceruminous material presentIntegument: Recently groomed coat - No ectoparasite, skin coat normal. Skin tent NAD.  Oral exam: class III malocclusion (underbite). No obvious occlusal trauma. Generalised mild 1/4 calculus buildup. Mild gingivitis. No other oral lesions present. Musculoskeletal: ambulating/weight bearing normally, no obv lameness on distant exam. Grade 2/4 MPL L, 3 R. No spinal pain,  Gait: Weight bearing on 4 limbs. Normal gait.  Neurological: PLRs and menace wnl , no obv proprioceptive deficits . Menation normal. Gait is normal Rectal exam: Not performed/performed Problem List: Cluster seizures (focal) Medial patella luxation (bilateral, grade 2-3/4) Class III malocclusion (underbite)Assessment: Intracranial (idiopathic epilepsy, infectious [bacterial, fungal, parasitic, protozoal, rickettsial, viral], inflammatory/immune-mediate [necrotising ME, eosinophilic ME, granulomatous ME, steroid-responsive ME], trauma, neoplasia [primary intracranial, metastatis, local extension - skull, middle ear, nasal/paranasal sinus, pituitary], haemorrhagic - trauma, coagulopathy], thromboembolism/infarction)VsExtracranial (metabolic [electrolyte imbalances, hepatic encephalopathy, hypoglycaemia, renal failure], thiamine deficiency, drugs/toxins)Further imaging and CSF analysis is recommended to rule out other causes of seizures. Treatment: Keppra (100mg/ml) 1.7mL PO q8hr (30mg/kg) for cluster seizures Continue with Pexion as previously instructed. Plan: Discussed possibile causes of seizures. Suspect idiopathic epilepsy is on the top of the differential list given his age and unremarkable bloodwork from January 2026. However further imaging is required to rule out other extra / intracranial causes of seizures. Offered monitoring in hospital for further seizure activities with view for neurology assessment on Tuesday. There is an increased risk of further seizure activity within the next 24 hours. Owners elected to continue monitoring Gooreum at home with additional anti-seizure medications. Fees for neurologist assessment was discussed (consult fee $330, MRI usually $6000-7000). Owners may pursue this in the coming weeks.    Vital Signs