C09995453 / invoice 10000

Reason: recheckNotes PRXXXXXXXXXXXXXXXXXXXXXXXXXXXHistory: Herbert is a 3 year 3 month old male neutered Rottweiler, presenting for a recheck of IE tier I. 29/5/25: First presentation to ARH Neurology. OR GTC episodes in total which only occur when resting or sleeping. First episode was 14/4/25. Presented to AEC for this. Maintenance tx not commenced, intranasal Midazolam was dispensed. Earlier episodes were no longer than 1 minute but now they are almost 3 minutes. Has had 2 sets of clusters. Started Keppra 1000mg PO TID and KBr loading then 750mg PO BID, MDZ PRN. Phenobarbitone is deemed to be a less suitable option for him due to its (often) significant polyphagic effect. Declined MRI and CSF. Subsequently Herbert's seizures have been somewhat difficult to manage, with a frequency of about every 8 days in August. He had issues initially with vomiting on KBr, which improved a bit when food was consistently given prior to KBr administration. October more vomiting occurring in mornings. Plan to wean off daily keppra after serum KBr levels, may need to consider trialling hypoallergenic diet.15/10/25 latest recheck. Seizure frequency of about every 2 weeks. Vomiting in the mornings is still happening every few days. Also intermittent diarrhoea. Bloods performed, KBR serum level of 24.9. Started zonisamide 200mg PO BID.15/1/26 O reports no seizures in December, then last two seizures were 8 days in between. No obvious triggers. Not a lot of time by himself over Christmas, maybe this helped. Now on Royal canin maxi food, kibble. Still vomiting in the mornings, intermittently, couple days a week. Infrequent diarrhoea. Has much more difficulty taking keppra than any other tablet - hates the taste. No changes in demeanour or energy levels since starting zonisamide. Zonisamide seemed to improve seizure frequency initially, however last two were closer together. PEx WNL. Recommended weaning off keppra as O's are giving it BID. Increased ZN, continue KBr, MDZ PRN, Keppra post seizure. O to consider IM consultation to investigate GI issues.6/3/26 (today) O reports that Herbert had four seizures in February, 3 to 6 days apart each.1 vomit this morning, first one since stopping keppra - keppra seems to have been th cause of the vomiting. No diraahoea, only occasional soft stools. Still bright and active, no change with last xonisamide increase. O giving MDZ in more severe episodes. Only wobbly after the midaz. Giving 1 vial post seizure. Appetite otherwise normal. Seizure history – Description:  GTCDuration: 2-3 minutesTime of day: varyingActivity on onset: General tonic clonic Autonomic signs: frothing of mouth Pre-ictal signs: seeking Os for comfort Post-ictal signs: Ataxia and loss of awareness, occasional tremblingClusters: none since starting medications Interictal period: varying, historically around q8dInterictal signs: none Possible triggers: no known triggers  Family history of seizures: unknownToxin access: none, but has history of chewing on sticks Owner concerns today – recheckAppetite – normalDiet – Royal Canin maxi adult kibble. Peanut butter with meds.Water intake – NormalUrination – NormalDefecation – NormalVomiting/diarrhoea – ongoing intermittent vomitingCoughing/sneezing – NoneEnergy levels – NormalExercise/activity – 20-30mins walk dailyWeight changes – NoneBehavioural changes – NonePrevious medical history –  Otitis externa (no present currently), s ome intermittent vomiting/diarrhoea from dietary indiscretion Preventative medications – UTDIndoor / outdoor access - bothCurrent medications:  Potassium Bromide 875mg PO BID (1750mg total daily, compounded capsules)Zonisamide 300mg PO BID (100mg capsules)Levetiracetam 2000mg once post seizure, then 1500mg PO q8h for 48hMidazolam 5mg IN PRN during seizures during more violent episodes - causes significant sedationExamination findings: Limited examination as very wriggly T:  NT                 MM: pink and moistP:  80bpm        CRT: 1 secR:  PantDemeanour: BARHydration: EuhydratedWeight: 45.5kg BCS: 5/9MCS: 3/3Cardiovascular: Normal rate and rhythm, no murmur detected, PSSRespiratory: Normal RE, RR and BVSEENT: WNLOral exam: WNLPeripheral LNs: All soft, symmetrical and normal sizedAbdomen: Soft and comfortable, no abnormalities notedIntegument: Full clear haircoat, no ectoparasites Musculoskeletal: Ambulatory with no pain or lameness detectedUrogenital: NSFRectal: NPNeurologic Exam Findings: Mentation/Demeanour - BARGait and posture – No significant findingsProprioception – PPR, RS and hopping intact in all limbsMotor function:1.Spinal reflexes - Intact2.Muscle bulk - Normal3.Muscle tone - NormalCranial nerves - IntactContinence - IntactSpinal hyperpathia – None noted Nociception - IntactOphthalmic exam - NPAdditional findings - NoneNeuroanatomical localisation:ForebrainProblem list:- Generalised tonic clonic seizuresPotential causes:1. Idiopathic epilepsy2. Structural - ie inflammatory/infectious (ie meningitis, protozoal) vs mass (neoplasia vs abscess vs cyst) vs vascular/ischaemic 3. Reactive - ie metabolic or toxinAssessment:Herbert's seizure control seemed significantly improved after starting zonisamide initially, however the latest two seizures were only 8 days apart. He is still considered moderately refractory to medication.It is recommended today to increase zonisamide to try to increase control. Counselled owners again today that Herbert is very difficult to control, and ongoing management will likely involve ongoing increases in medication and possibly adding additional AEDs in the future.Weaning off keppra is recommended today as O's are only able to give it BID, and he is intolerant of the taste. This medication also is unlikely to be helping much with seizure control at this stage. Plan:- Increase Zn to 300mg PO BID- Wean off keppra- Continue other meds- O to email update in 1m - advise to increase to 4 tabs zn if no improvement- Recheck again in a few months, sooner if requiredCould increase Zn to 400mg PO BIDCan consider PHeno after that???    Vital Signs