C09998802 / invoice 10000

Reason: 12.8Appointment Notes: post-seizure, possibly bloods CLHistory: Doing well at home, back to normal Still thinking about referral No further seizures EDUF good, no V+ or D+ Current Medication: none Examination: Demeanour: BAR, anxious BCS: 3/5HR/PR: 140. No murmur or arrhythmia, pulses strong and synchronous RR/Chest: 20. Normal effort and BV sounds MM/CRT: pink, moist/1.5 Oral/Teeth/Gums: stage 2 dental diseaseTemp: not taken Ears: external pinna clean Eyes:- bilateral mydriasis again - PLRs not present. Completely dimmed room and shone bright light into each eye - no meaningful change in pupil size- eyes are still visual - normal menace, palpebral and moving around objeccts well LNs: SM, PS, P wnl Abdo/GIT: soft and comfortable U/G: not assessedM/Skel: ambulating well Neuro: - CP normal LH, much improved but still slightly delayed RH - otherwise mentation appropriate, no further deficits Derm: good coat quality, no lesions noted Problem List:1. Previous seizure2. Persistent bilateral mydriasisA: no further seizure activity reported and has otherwise gone back to normal. Discussed problem 2 does raise concern for possible CNS pathology. Went over options - can either monitor for further seizure episodes, refer to PCEV for outpatient CT to assess for intracranial disease only, or ideally consider referral to medicine specialist. Still on the fence but consented to referral to TAHMU. Recommend rechecking calcium at least given previously hypocalcaemic - consented.P: to organise referral to TAHMU mx, await IH chemistry results.    Vital Signs