C10021212 / invoice 10000

Reason: RecheckNotes XWHistory: Ollie is a 7 year 1 month old male neutered Shih Tzu X presenting to ARH Neurology today (9/1/24) for a recheck of meningoencephalomyelitis of unknown origin, presenting primarily as tetraparesis and cervical discomfort. 26/10/22 MRI performed, showing severe, diffuse, T2W hyperintensity within the cervical spinal cord,with a contrast enhancing lesion at C4, and multiple T2W hyperintensities within the brainstem, forebrain and cerebellum with contrast enhancement in the cerebellum. Ollie's CSF returned with a severe lymphocytic pleocytosis (NCC = 1540 x 10^6/L, protein 0.76g/L). Two doses of dexamethasone were given (26 and 27-10-22) before he was initiated on prednisolone 5mg BID as well as pregabalin 12.5mg BID. He was discharged 28/10. Neuro PCR returned negative on 01/11/22. 25/05/23 recheck, Ollie's cervical hyperpathia was slightly worse than previous, and he was exhibiting mild steroid adverse effects. Prednisolone was reduced to 1.25mg PO EOD, pregabalin 25mg PO BID was continued and physiotherapy and a complete balanced diet were recommended. 04/08/23 recheck, prednisolone was reduced further to 1.25mg PO twice weekly as he was continuing to to do well. 22/08 Melanie called the clinic advising that he started becoming hyporexic, he struggled getting over the front door step, and then he began stumbling around the house. O's were giving prednisolone every Mon/Tues and every Thurs/Fri. He had become progressively lethargic and not himself. Onset of the episode was across 4 days, and O felt like he had regressed >50% cf normal. His prednisolone was increased back to 1.25mg PO EOD. 2/09/23 recheck, OR Ollie had returned to 100% normal self within a week of changing prednisolone dose. NEx showed persistent cervical hyperpathia and so paracetamol for a week (until amantadine has effect) and amantadine were both commenced. Prednisolone was continued at the same dose. Since this time Ollie has been doing well; he has maintained high energy levels, good appetite. Prednisolone has continued to be weaned over subsequent rechecks.5/9/24 latest recheck, OR that Ollie has been well at home. Owner notes that prednisolone side effects appear to be decreasing with a return to normal thirst and hunger, there have been no episodes of urinary incontinence or panting noted and they think the coat is helthier too. He will occasionally have episodes of increased pain for which the owner will give a prednisolone dose a day early (every 2 days) for one dose that she reports resolves the symptoms. NEx noted mild hyperpathia of the mid thoracic spine, and cervical hypaxial muscles. Advised to continue medications, recheck CBC and MBA with RV, recheck 3 months.9/1/25 recheck, O reports Ollie has been doing really well at home. O is now giving prednisolone every 3 days. Still a bit grumpy, O considering CBD oil. EDDU as normal, never been a big eater. O not really noticing discomfort. NEx revealed mild hyperpathia along the length of the vertebral column. Recommended at this stage to continue the current prednisolone medication regime as it appears to be controlling the signs well. Continue pregabalin, amantadine, Start CBD oil 0.5mg/kg BID, Consider physioRx and acupuncture.15/7/25: O reports that Ollie has been doing very well, there has been no issues that O can think off. EDDU well, no vomiting, no diarrhoea. Currently on medications: Prednisolone, CBD oil, Amantadine, Pregablin. Requires a script for Prednisolone and Pregablin. Has not yet started physiotherapy as O has a very busy schedule. 12/3/26 (today): O felt that when his Amantadine 20mg/ml PO SID was reduced from 1ml to 0.5ml on 5/3/26, he has been more grumpy with his sister - O feels that this is attributed to pain. He last finished his Amantadine yesterday. Otherwise, O feels that he has been fine for months, and no overt concerns except for this increased grumpiness towards his sister. Current medications:Prednisolone 1.25mg PO every 3rd dayPregabalin 25mg PO BIDCBD oil 0.4ml PO SID 10mg/mlSteroid history -26/10/22: dexamethasone 0.1mg/kg IV once28/10/22: prednisolone 5mg BID 04/11/22: 5mg AM and 2.5mg PM02/12/22: prednisolone 5 mg SID - **RELAPSE10/02/23: prednisolone 2.5 mg SID23/03/23: prednisolone 1.25mg SID 25/05/23: prednisolone 1.25mg PO EOD04/08/23: prednisolone 1.25mg PO twice weekly22/08/23: prednisolone 1.25mg EOD - **RELAPSE2/3/24: prednisolone 1.25mg PO alternating q2d and q3dEarly November 2024: prednisolone 1.25mg PO every 3 daysExamination findings: T:  NT                 MM: pink and moistP:  128bpm        CRT: 1-2 secR:  28Demeanour: BARHydration: EuhydratedWeight: 6.4kgBCS: 5.5/9MCS: 2/3Cardiovascular: Normal rate and rhythm, no murmur detected, PSSRespiratory: Normal RE, RR and BVSEENT: WNLOral exam: WNLPeripheral LNs: All soft, symmetrical and normal sizedAbdomen: Soft and comfortable, no abnormalities notedIntegument: Full clear haircoat, no ectoparasites Musculoskeletal: Ambulatory with no pain or lameness detectedUrogenital: NSFRectal: NPNeurologic Exam Findings: Mentation/Demeanour - QARGait and posture - No significant findingsProprioception - PPR, RS, hopping intact all limbs. Motor function: 1.Spinal reflexes - Intact 2.Muscle bulk - Slightly reduced muscle bulk on PL. 3.Muscle tone - NormalCranial nerves - IntactContinence - IntactVertebral hyperpathia - mild reactivity interspinous L1-L2, hypaxial muscles cervical region. Range of movement not performed due to discomfort Nociception - IntactOphthalmic exam - not performedNeuroanatomical localisation: Multifocal CNSProblem list: - Vertebral hyperpathiaPossible causes: 1. MUO Assessment: Ollie's neurological examination today reveals no deficits except for mild hyperpathia along the length of the vertebral column, especially when palpating the interspinous region of L1-L2. Ollie has made significant improvements since his initial diagnosis, and has remained static in condition in the past few months. It is recommended at this stage to continue the current prednisolone medication regime as it appears to be controlling the signs well.Ongoing spinal hyperpatthia may also benefit from physioRx and /or acupuncture. O is keen for this to be done sometime next week but Dr Laura is away then. Will pursue this week if any cancellations or when Dr. Laura returns. Plan:    Vital Signs    Weight: 6.4;       

Reason: PhysioAppointment Notes: Special payment terms existHistory:Have changed onto Amantadine liquid over the past few weeks - started at 1ml for 1 week then reduced No issues joint wise and no issues with mobility prior Subjective:Current ability:Previous exercise regime:Activities of daily living:Home environment: Owners live on acherage and Ollie still Floor surface: No issues with slidingStairs: Activity indoors - uses steps to go up onto the bed but often jumps offOutdoor space/accessOther petsDiet:Other medical concerns:Medications:Supplements:Objective:Posture:Gait:Transitions:Palpation:LFRFLHRH - Significant tension, moderate spasm and discomfort Rectus femoris mm, mild spasm pectinus mm. Moderate tension biceps femoris and gastrocnemius mm. Moderate gluteal mm atrophy. Mild restriction in hip extension, no pain or crepitus felt. No cranial drawer felt, no effusion. Patella tracking OKSpine - significant tension, moderate spasm cleidocervicalis mm, distal omotransversius mm and moderate tension occipital portion of sternocephalicus mm (towards insertion at nuchal crest) - L significantly more than RHSTension and restricted mobility C3-C4 (LHS) Moderate spasm epaxial mm T6-T12Moderate tension lumbar paraspinal mm (R>L) with mild restriction R SIJTreatment:-Massage/manual therapy/stretches-Exercises:AROM neck and lateral stretch for thoracic mobilityForward stretch in sternal to help with lumbar and gluteal mm activation Step stretch (to help with hip flexor tension) with added forward/back movements to activate core mm stabilisation-Acupuncture – GV21, 14,4,3,SI 11, BL 23,25,28,54Plan:    Vital Signs    Weight: 6.4;