C10027395 / invoice 10000

Appointment Notes: Luna (Dog) - Consult [Clinician : Dr. John Thirlwell (Preferred Clinician)] - Seizure 3am Thursday and vomited 7 times since. - Web BookingClient name: Bettina ThomasContact number: 0402451038Email address: bettinathomas@me.comPatient name: LunaSubjectivePresenting Concerns:-   Luna presented for assessment following a seizure episode and subsequent vomiting. The owner reported a cluster of 2 seizures the night before last, each lasting approximately 1 minute. This was followed by approximately 7 episodes of vomiting yesterday, with the last episode occurring at midnight.  Historical Conditions:-   History of infrequent seizures, with the last known episode occurring over a year ago. The condition is considered idiopathic epilepsy and may be hereditary, as an aunt is also affected.-   Suffered an eye injury from a cricket ball approximately 1 year ago.  Diet/Appetite:-   Vomited all meals and treats yesterday.-   Ate and kept food down this morning.-   Possible dietary indiscretion on Wednesday, having eaten an unknown item off the ground.  Drinking/Urination:-   Increased thirst was noted yesterday.  V/D/C/S:-   Approximately 7 episodes of vomiting yesterday following the seizure. The vomitus contained undigested food.  Current Medications:-   Not currently on any flea or tick treatment due to owner concern about seizure risk.  Lifestyle Risk Factors:-   Receives a 20-minute walk daily.-   Was off-leash near shops on Wednesday.ObjectiveMentation: BAR  Wt: —  BCS: --/9  T: Not taken  P: —  R: —  MM: pink/moist. CRT < 2sec.  Hydration: Normal    Emotional Assessment: —    Eyes: Clear. No discharge or erythema OU.  Ears: Clean with no discharge or erythema AU.  Nose: Clear, moist without discharge.  Throat: No inducible cough upon tracheal palpation; no palpable masses.  Oral: Stage 1 periodontal disease noted.  Cardiovascular: No murmurs or arrhythmias, strong synchronous pulses.  Respiratory: Normal bronchovesicular sounds bilaterally.  Abdominal: No organomegaly or mass effects. No pain on palpation.  Lymph Nodes: No peripheral lymphadenopathy.  Integumentary: No evidence of ectoparasites, full coat with clear skin.  Neurologic: No ataxia, normal mentation.  Musculoskeletal: Ambulation normal, no lameness observed.  Urogenital: Normal external anatomy.  Rectal: Not performed.AssessmentIdiopathic epilepsy - The recent cluster seizure is consistent with the patient's history of infrequent seizures. Given the long interval between episodes, initiating anti-convulsant medication is not warranted at this time, as the potential side effects outweigh the benefits.    Vomiting - The vomiting is assessed to be post-ictal and centrally mediated, secondary to the seizure activity.    Stage 1 periodontal disease - An incidental finding during examination.PlanVaccinations:-   Recheck at the end of the year for annual vaccine boosters.  Medications/Treatments:-   No medications were prescribed at this time.  Diet & Feeding Recommendations:-   To address potential food preservation behaviors, it was recommended to offer smaller treats that can be consumed more quickly.  Additional Discussion:-   The owner was advised to monitor for seizure activity, noting the duration and any clustering.-   Emergency care is recommended if a seizure lasts longer than 5 minutes or if cluster seizures occur.-   Discussed that the side effects of anti-seizure medication would likely be more detrimental to her quality of life than the infrequent seizures themselves.    Vital Signs    Weight: 19;