C10009322 / invoice 10000

Reason: Recheck Albumin, Focal GB Ultrasound, NEx +/- MRIIntern: SNHistory:Max is presented for a recheck of his albumin, focal gall bladder ultrasound and NEx by the Neurology team.Max has been managed for hyperadrenocorticism, hypothyroidism, seizure disorder, and R AGASACA (staged clear 19.05.25) by ARH IM, ONC, and his referring veterinarian. Please see prior record/s for comprehensive history.He was recently hospitalised from 2/3 to 3/3 for a 2-3 week history of lethargy, hyporexia, and a new swelling in the left submandibular region. OR 'vacant' demeanour at home and worsened weakness and stumbling. Bloodwork showed worsened hypoalbuminaemia, in-house ACTH stimulation not consistent with iatrogenic hypoadrenocorticism. Phenobarbitone level returned within reference intervals at 82 umol/L. AUS showed progression in gall bladder changes, with polyp-like lesions identified. Other changes include mild progression in the known splenic mass, more significant bilateral adrenomegaly, urinary bladder apex polyp and static changes of the intestines and gastric cardia mass. CT of the head, neck, thorax and abdomen on 3/3 showed a left mandibular sialocele and concern for a pituitary mass. Given his hypocobalaminaemia, a transition to Z/D low fat food was advised. NEx and consideration for an MRI will be pursued to further investigate for a pituitary macroadenoma. Amoxyclav was commenced due to progression in gall bladder changes sonographically. Today, OR that Max has tolerated the diet change well and retains a good appetite. Stools have been well formed. There has been no seizure activity, but O has observed Max 'head bobbing' and is unsure if these are neurological events. He is no longer falling over like previous, and is subjectively stronger. Past Pertinent History: - Hyperadrenocorticism, primarily mananged by RV- Diagnosed hypothyroid 23/7/24 (lethargy, mild PL ataxia). TT4 7nmol/L, TSH 0.18ng/ml, ft4 by dialysis 4qmol/L (6-42). Commenced thyroxine 100mcg PO BID.Non-interpreted profile with ARH 29.12.25 TT4 17 nmol/L.  - Managed for seizure disorder. Last phenobarbitone blood test on file from 28.04.25. Phenobarbitone level was below reference range (see attached). - Known orthopaedic disease in both stifles (luxating patellas). - Historically managed for R AGASACA by ARH Oncology. Last staging performed 19.05.25, staged clear. - Dental disease, managed by dental procedures intermittently. Last had a stage 3 dental procedure this year, with numerous teeth removed. Date not known, no hx available. Current Medications:Amoxyclav 125mg PO BIDPhenobarbitone 22.5mg PO BIDPexion 150 mg: PO BID.Levothyroxine 75 mcg PO BIDClopidogrel 18.75mg PO SID Trilostane 20mg PO BID - last given last night at 6:30pmExamination Findings:T: 38.1        MM: pinkP: 136 bpm       CRT: <2R: 40 Demeanour: QARHydration: euhydrated Weight: 5.6kg (+250g) Body Condition Score: 6/9 pot belliedMuscle Condition Score: 2/3 Cardiovascular: heart murmur not noted today, strong synchronous pulsesRespiratory: Mild respiratory effort, and serous nasal discharge. Abdomen: marked abdominal distension, nil fluid wave, comfortableSuperficial LNs: WNLOcular: Bilateral marked increase in lens opacity (nuclear sclerosis)Ears: WNL Integument: Generalised thinning of the skin, alopecia, regions of pigmentation. Small ~1cm pigmented lesion on R lateral thorax. Cutaneous red pigmented lesion at lateral right nare. Swelling noted deep to left submandibular lymph node. Oral exam: G3/4 dental disease. Musculoskeletal: Full MSK exam not performedNeurological: See visit with Neurology team for comprehensive NEx. Rectal: NPLaboratory: PCV/TP:  57/60, clearALB 25 g/L 22 - 39 (cf. 21 on 2/3)Procedure:Focal gall bladder ultrasound by EC: ################Neurological Exam (with Neurology team): ################Assessment:Problem List:Altered mentation - worsenedAtaxia/falling over - possibly progressingWeakness - progressing Spinal hyperpathia - not reassessed Hyperadrenocorticism Hypoalbuminaemia - worsenedSplenic nodulesSplenic mass lesion Marked hepatopathyGall bladder - Mild cystic mucinous hyperplasiaGastric nodules at gastric cardia  Segmental lymphangiectasia - predominantly jejunumSeizures - well managed on current medication Hypothyroidism ########Treatment:########Plan:########    Vital Signs    

Reason: In-house neuro examAppointment Notes: IN today - assessment in the morning, pituitary macroadenomaNotes: PRXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXHistory: Max is a 13 year 5 month old male neutered Maltese, presenting to ARH Neurology today for an in-house neuro exam with IM due to concern for pituitary macroadenoma.Max has been managed for hyperadrenocorticism, hypothyroidism, seizure disorder (IE tier I, since at least 6yo) , and R AGASACA (staged clear 19.05.25) by ARH IM, ONC, and his referring veterinarian. Please see prior record/s for comprehensive history.2/2/26 Max presented to IM for an ACTH stimulation yesterday, when the OR lethargy and hyporexia for 2-3 weeks and a new swelling at the left hand side of his neck. O was also concerned about 'vacant' demeanour and worsened weakness and stumbling. Mild respiratory effort was noted on PEx, and a swelling in the deep left submandibular region confirmed. Bloodwork showed worsened hypoalbuminaemia, in-house ACTH stimulation not consistent with iatrogenic hypoadrenocorticism. Blood submitted to QML for phenobarbitone level quantification given affected protein levels, returned 82 umol/L (not trough). AUS showed progression in gall bladder changes, with polyp-like lesions identified. Other changes include mild progression in the known splenic mass, more significant bilateral adrenomegaly, urinary bladder apex polyp and static changes of the intestines and gastric cardia mass. Full-body CT performed, revealed generalised attenuation in the region of the pituitary gland and left mandibular sialocoele. Recommended MRI to investigate pituitary macroadenoma, however control of hypoalbuminemia and GI dz is prioritised first. Started amoxyclav.Current medications: XXXXXXXXXXXXXXXXXXNeurologic exam findings: Mentation/Demeanour - BARGait and posture – No significant findingsProprioception – PPR, RS and hopping intact in all limbsMotor function:1.Spinal reflexes – Intact pedal, proximal sciatic, patellar, CTR, and perineal reflexes.2.Muscle bulk - Normal3.Muscle tone - NormalCranial nerves - IntactContinence - IntactVertebral hyperpathia – None noted Nociception - IntactOphthalmic exam - NPAdditional findings - noneNeuroanatomical localisation:Problem list:- Moderate generalised ataxia- PL proprioceptive deficits- Cervical hyperpathia- Generalised muscle atrophy, particularly PLsPotential causes:1.2. 3.No evidence of intracranial NALAssessment:X neurological examination today revealsthe neuroanatomical localisation of these clinical signs isThe primary differential diagnosis at this stageOther differential diagnoses to consider includeIt is recommended at this stage to--- 10/03/2026 11:58:36 PRA:Called LisaWobbliness one weekHead jerking, no tilting, only a jerk or two at a time, sometime causes him to fall Has a ramp to get up on bedNo real exerciseNo definitive intracranial signs - Can consider brain MRI if surgery or RT, however co-morbidities probably take priority at this stageNEx myelopathyCT REVIEW CERVICAL regionPlan:    Vital Signs