C10017651 / invoice 10000

Appointment Notes: staggering and falling to side and eyes moving side to side.History: Basil presents as a walk-in for ataxia and nystagmus. 20mins prior to presentation Basil had an episode of 1min duration where he was ataxic and had a horizontal nystagmus (O reports horizontal). Basil has had an episode like this 3-4mths ago where bloodwork (including ACTH stim) and pex. Showed no obvious cause for episode. O reports basil did not seem unusual prior or after presentation. No access to trash or other medications around the house. Preventatives: Bravecto quantum UTD, worming given on saturday. Basil has been otherwise well eddu regular, no V+ or D+.Diet: Hills t/dCurrent medication: Fluoxetine 10mg PO SID - missed this mornings dose. Has been on for approx 4mths and started this prior to his last episode 3-4mths ago. Examination: BAR - walking into consult, no nystagmus on presentationHR: 80. No murmur or arrhythmiasRR: Panting. BV soundsCRT/MM: Pink, moist <1sT: 38.3EYES: Nsf. Pupils equal and reactive. No blepharospasm, epiphora or chemosis. No nystagmus at presentation. EARS: Clean on inner pinna. Otoscopic examination shows relatively stenotic ear canals with brown waxy discharge at bottom of ear canal. R TM intact and normal, L TM difficult to visualise due to more reactive (pain possibly), but possibly intact??ORAL: Nsf. DS 1/4ABDO: Soft and comfortable on palpation. No obvious organomegaly, mass or FB palpated. RECTAL: Faeces (firm) in rectum. L anal gland moderately distended and firm, could not express as Basil began to bite. R anal gland full, expressed easily (hard gritty substance). Externally no scouring or obvious distension of anal glands. Neuro: decreased CP LHL (in comparison to RHL). PLR, menace. MSK: Neck flexion and extension and L + R fine. Possible pain over T13-L2 region. Good hip ROM, no creptius in HLs.INTEG: Good coat condition - no evidence of external parasites observed.Laboratory: CHEM17/ CBC/ LYTES/ T4/ CRP:- ThrombocytopaeniaAssessment: Ataxic/ neuro episodes: seizure vs. Inner/middle ear dz? Vs. Other (missed fluoxetine dose?)Plan:Discussed no overt clinical findings to indicate why Basil has had this episode today. Reccommended referral to neurologist for examination/ workup. Monitor Basil closely over next 24/48hrs.    Vital Signs