C09972125 / invoice 10000

HISTORY - Dr Jenna Rickards
Dexter has represented for a recheck following his initial presentation for acute HL neurological deficits.

Dexter initially was referred to our internal medicine department on 06/02/2026. A CT scan performed revealed findings consistent with spinal meningitis. A spinal tap was not performed at the time as the working diagnosis had been FCE or ANNPE. A CSF tap has still not been performed as he improved without specific therapy.

Kay reports that Dexter is currently improving, albeit with some residual weakness and occasional yelping. He is on one painkiller in the morning for the past week.

Current Medications:

Gabapentin (one dose in the morning).

PHYSICAL EXAMINATION
Hard to examine as is extremely fearful.

BCS: 6 out of 9.
LOC: Normal. Bright, alert, responsive.
TEMPERATURE: Not taken.
AMBULATORY STATUS: Ambulatory without ataxia.
HEAD AND NECK: Unable to assess fully. Symmetrical.
CARDIOVASCULAR: Not assessed.
RESPIRATORY: Normal. RR panting brpm. The respiratory effort was normal.
GASTROINTESTINAL: Not assessed.
UROGENITAL: Not assessed.
OPTIC: Normal. Unremarkable.
AURAL: Normal. Unremarkable.
INTEGUMENT: Normal. No changes were appreciated of the coat or skin. There were no ectoparasites present at the time of examination.
LYMPHATICS: Normal. The peripheral lymph nodes were within normal limits.
NEUROLOGICAL: Not performed.
MUSCULOSKELETAL: Normal. Ambulatory without lameness. Muscle coverage was normal
OTHER COMMENTS: No.
PROBLEM LIST

Acute polymyositis - improving.
Suspected meningoencephalitis of unknown origin.
History of a similar, undiagnosed episode.
Marked anxiety during veterinary visits.
ASSESSMENT
Dexter is a 2.5-year-old neutered male Cattle Dog X re-presenting for a recheck of acute neurological deficits. He has been steadily improving since his initial presentation in early February 2026. A CT scan at that time was suggestive of spinal meningitis, but his clinical course of rapid improvement is atypical. The current clinical picture is of a dog with a good quality of life. The aetiology remains unclear, with autoimmune disease being a possibility given his age and breed. Given his current stable and improving condition, a conservative approach is warranted. The risks and side effects of long-term steroid therapy for a potential autoimmune condition were discussed with the owner, and it was agreed that the current clinical signs do not warrant such treatment.

PLAN

Discontinue regular gabapentin dosing. Paracetamol and gabapentin can be used for pain management as needed.
Monitor for any deterioration. If he becomes unwell again with similar signs, he should be re-presented for assessment. The owner can call if unsure.
No further recheck scheduled. The owner will contact us if Dexter's condition deteriorates.