C09984276 / invoice 10000

Reason: Falling Over MoreNotes PRXXXXXXXXXXXXXXHistory: Maya is a 14 year 4 month old female entire Border Collie, presenting to ARH Neurology today due to collapse episodes. Early 2022 Maya moved with O from Canada to Australia.31/3/22 Maya experienced her first episode of ataxia, described as unsteady on feet, with improvement and then a subsequent second episode in the morning that was of shorter duration. Did not fall to ground completely.31/3/24 at Maya had an episode ay 0900 wherein she was outside on grass, ran to the ground, started rubbing her face on the ground, fell to the side. Lasted about 30s, got up and walked completely normally afterwards. O believes she may have been stung by a bee. O took Maya for a swim that afternoon for 20 mins and when she came home, Maya had another episode at 1600 inside on the tile at home where she began panting, scrabbling at the floor, and was ataxic. No nystagmus noted, was responsive throughout, did not fall to the ground. Presented to Manly Road RV, bloods taken and were reportedly unremarkable (not available for review). Vet administered Berensa injection and commenced meloxicam in case of pain associated with episode. 2/4/24 Maya experienced another episode from about 0900-1500; video footage at home shows trembling, scrabbling on tiles, panting and ataxia. Presented to AES, transferred to VSS in the morning. 3/4/24 VSS NEx noted low head carriage and subtle delayed RHL proprioceptive paw replacement. When exiting the cage Maya collapsed in forelimbs, and nurse reported this occurred again during walk outside following a car noise. At times struggles ambulating on the smooth clinic floors or when anxious with forelimb nails contact and poor grip. Intermittently stands with LFL non-weight bearing at rest, but at other times weight bears and ambulates normally. Review of previous blood testing on 20/04/23, 30/03/22, and 12/01/21 respectively revealed values of creatinine at 167, 132, 123, urea at 8.2, 6.43, 6.78, ALT at 158, 58, 52, and ALP at 18, 22, <10. Concern for possible episodic vestibular syndrome.4/4/24 First consult with ARH Neurology. O confirms episodes as above. Also noted that when she was younger, after exercise she had episodes of collapse, described as lying on the ground after exercising. O believes this was Border Collie collapse, no longer over-exerts her when exercising. Always pants a lot. Seems more clingy lately in the past few days. O has started hydrotherapy sessions due to reduced mobility in her age and is doing physio exercises at home. NEx noted no abnormalities. CBC and MBA performed, noting no abnormalities except for a mildly elevated ALT (218). No specific treatment recommended, advised to monitor at home.15/10/24 Cardiology consultation. Echocardiogram performed, stage B1 MMVD identified. Hx not attached. 17/10/24 general recheck consult with VSS. Hx noted another collapse episode the week prior, described as whole body collapsed to floor but remained conscious and aware. NAD on NEx. PEx otherwise noted grade I left systolic heart murmur, a 3cm left flank mass, and resistance to bilateral hip and elbow extension. Suspect osteoarthritis. CBC and MBA performed, noting mild leukopenia (4.9), mild eosinopenia (0.05), and mild basopenia. Biochemistry performed, noting mildly elevated CK (494), mild hypertriglyceridemia (3.3). 20/11/24 recheck, OR she has had a few more episodes since last visit, all described as scrambling of the limbs then collapse to the ground, all occurring whilst on tiled floor. Mainly wanting to present today as she is due for a GA and dental procedure soon, wanting a check before then. She had a few episodes in June, one or two in the past 2 months. She is generally a lot happier since putting rugs down at home; no episodes since being on carpet. O feels back legs definitely getting weaker. O concerned about degenerative myelopathy. EDDU as normal, still bright and active, doing the same amount of exercise as she was last year. NEx revealed generalised muscle atrophy, kyphosis, lumbar hyperpathia, and delayed proprioception in the PLs. Brief musculoskeletal examination revealed pain on extension of hips, stifles, and elbows. Based on the history of episodes exclusively occurring on tiled floor surfaces, and the description of scrambling followed by limb collapse, as well as the findings on today's examination, the most likely cause of these episodes is orthopaedic pain and general muscle weakness. It is recommended at this stage to continue monitoring Maya at home, consider physiotherapy with acupuncture, and start CBD oil for pain relief.27/2/25 recheck, OR Maya is doing really well at home, hydrotherapy 3x weekly at Raby bay. Put on a bit of weight. No further legs scrambling episodes, O has carpet around entire house. Back legs seem about the same. Left hip maybe seems worse than right. Still squatting to toilet, seems bright and active. Energy levels are good. On days without hydrotherapy, slow 20 mins walking. NEx revealed generalised muscle atrophy, kyphosis, and mildly delayed proprioception in the PLs. She is no longer having episodes of ataxia/weakness. Maya demonstrates reduced reactivity to vertebral palpation today than in previous assessments. It is recommended at this stage to continue monitoring Maya at home, continue physiotherapy and current medication plan. CBC and MBA revealed low grade anaemia which may be associated with geriatric dog iron deficiency or low-grade chronic inflammation. Very mild ALT elevation, ALP WNL. No elevations in CK and AST.17/10/25 O reports that Maya is going well overall, however main concern is that she seems sore and has a bent back when she gets up after lying down. Recent bloods at RV, work-up and diagnosis of Cushings. Energy levels okay, hgh appetite. Eyesight worse in the dark, hearing maybe reduced a bit. No disorientation, no behaviour changes, or vacant staring. Occasional slipping/stumbling when walking. No shuffling when toileting but not squatting as deeply. 4/3/26 (today): falling over more. Diagnosed with cushings. R TL paw curls in while lying down. Hoarse voice. Ictal history – Description: ataxia, falling on the groundDuration: 30s-many hoursTime of day: variableActivity on onset: resting at homeAutonomic signs: drooling at VSS, not during other Mentation change: nonePre-ictal signs: nonePost-ictal signs: noneClusters: YesInterictal period: variableInterictal signs: nonePossible triggers: none knownToxin access: noneOwner concerns today – recheckAppetite – NormalDiet – RC hepatic dry food, Nosh.Water intake – NormalUrination – NormalDefecation – NormalVomiting/diarrhoea – NoneCoughing/sneezing – NoneEnergy levels – NormalExercise/activity – 20 min walks daily, beach swimming 20 mins twice weeklyWeight changes – Yes, weight loss since AprilBehavioural changes – nonePrevious medical history – nonePreventative medications – UTDIndoor/outdoor access - BothToxin exposure – None notedBIOP – 8 weeksCurrent medications: Meloxicam 1ml PO SID in AMCBD oil 0.6ml PO BID (~1mg/kg)Trilostane 30mg (30mg tabs) PO SIDLiver support supplementAnxiety support supplementEye support supplementBrain support supplementHip and joint supplementExamination findings: T:  NT                 MM: pink and moistP:  100bpm        CRT: 1 secR:  28Demeanour: BARHydration: EuhydratedWeight: 15.1BCS: 3.5/9MCS: 1/3Cardiovascular: Normal rate and rhythm, no murmur detected, PSSRespiratory: Normal RE, RR and BVSEENT: WNL. Small 1mm diameter nodule ventral eyelid margin OS. Oral exam: WNLPeripheral LNs: All soft, symmetrical and normal sizedAbdomen: Soft and comfortable, no abnormalities notedIntegument: Full clear haircoat, no ectoparasites. ~3cm diameter lipoma L flank.Musculoskeletal: Stiff gait generally. Moderate pain bilateral hip, elbow, and stifle extension with crepitus in all of these joints. Urogenital: NSFRectal: NPNeurologic exam findings: Mentation/Demeanour - QARGait and posture – Mildly wide based stance. Mild thoracolumbar kyphosis.Proprioception – PPR mildly delayed in PLs, L worse than R, normal TLs. Hopping and RS mildly delayed PLs, normal TLs.Motor function:1.Spinal reflexes - normal2.Muscle bulk - Moderate generalised skeletal muscle atrophy, particularly significant in PLs3.Muscle tone - NormalCranial nerves - Menace mildly less brisk OD, CNN otherwise intact. Continence - IntactVertebral hyperpathia – noneNociception - IntactOphthalmic exam - mild iridal atrophy dorsal aspect of OD, nuclear sclerosis OUAdditional findings - Neuroanatomical localisation: OpenProblem list:- Ataxia episodes- Generalised muscle atrophy- Thoracolumbar kyphosis- Mild lumbar hyperpathia- Delayed proprioception PLs- Suspect osteoarthritisPotential causes (PL deficits):1) Degenerative; IVDD, DLSS, foraminal stenosis, OA2) TraumaAssessment:Maya presents today as a recheck for pelvic limb weakness and ataxia episodes. Her neurological examination today revealed generalised muscle atrophy, kyphosis, and mildly delayed proprioception in the PLs. Her condition is largely static compared to previous examinations. It is recommended at this stage to increase CBD oil to improve discomfort, continue physiotherapy and current medication plan.Plan:Increase CBD oil to 0.6ml PO BID (1mg/kg)Reduce meloxicam to 1ml (0.1mg/kg) PO SIDContinue hydrotherapyRechecks 6 monthly    Vital Signs