C10026065 / invoice 10000

Reason: RecheckNotes: PRXXXXXXXXXXXXXXXXXXXXXXXXXXHistory: Charlie Girl is a Maltese X presenting to ARH Neurology today for a recheck of transient vestibular events. 4/7/25: Presented to RV for 2x neurological events. First occurred on 1/7/26. Video shows leaning to R and against walls, choosing to walk along walls where possible, lip licking and wide eyes, exaggerated lateral head movements when in bed with difficulty righting herself, exaggerated R ear twitches. However, no hemi-inattention, tonic clonic movements and no loss of consciousness. Bloods performed: Low Na:K ratio, elevated BUN, low cholesterol, low glucose, low T4. Recommend investigation into Addisons disease, cortisol tests and further diagnostics (BAST, ACTH stim) ; all WNL.19/8/25: Presented to BVECCS after another similar episode that evening lasting 30 mins. Events described as appearing dazed but responsive to audible cues. Videos reveal proprioceptive ataxia to the RHS, appears fully conscious. No signs of facial or eye twitches, but had tension in her muscles when being held by O. NEx: unremarkable. Ddx: Partial seizure vs paroxysmal dyskinesia. Recommended further monitoring.4/9/25 first consult with ARH Neurology. O confirms history as above and has videos of episodes. Videos show sudden stumbling and ataxia towards the RHS, she appears to be conscious of her surroundings and though she stumbled from time to time, was able to jump on the Os bed in one of the videos. Outside of episodes, has been well. EDDU okay. No vestibular signs: head tilt, nystagmus. NEx WNL. DDx vestibular paroxysmia or other structural vestibular disease. CBC MBA WNL except for mildy elevated urea (w/o creatinine). Advised to monitor.9/1/26 RV emailed advising of ongoing episodes, most recently 1/1/26, described as intermittent tremoring, flexion in right limbs, responsive mentation, turning right when placed on ground, ambulating but leaning right. No nystagmus. Post-ictal quietness about 30-60mins. NEx the following day WNL.Today (13/3/26) O reports that Charlie Girl has had two more episodes since last consult; 1/1/26 10/1/26No head tilt or nystamusStumbling is consistently to the right sideNo leg liftingIs ataxic and tremoringHaving more altercations with other dog at home who is blind and bigger than herNo behavioural changesWhining more recently in the past 6 monthsEpisode history - Description: 4 total Duration: 20-30 mins all of themTime of day: all events in the eveningActivity on onset: resting at home, not necessarily sleepingAutonomic signs: nonePre-ictal signs: nonePost-ictal signs: noneClusters: noneInterictal period: varying Interictal signs: nonePossible triggers: noneFamily history of seizures: unknownToxin access: noneOwner's primary goal/concerns today - Appetite – NormalDiet – Hills science diet small breed skin/gutWater intake – NormalUrination – NormalDefecation – NormalVomiting/diarrhoea – NoneCoughing/sneezing – NoneEnergy levels – NormalExercise/activity – plays with other dog for an hour in the morning, an hour of walks. Weight changes – NoneBehavioural changes – NonePreventative medications – tick preventatives Indoor/outdoor access - BothToxin exposure – None notedBIOP – since 2 years old Other pets at home - other dog at homePrevious medical history – - Anxiety issues - goes to behavioural consults - pododermatitis with malassezia overgrowthCurrent medications: ClomipramineClonazepam 1mg BIDPregabalin 75mg PO TID + 50mg (midday dose) +75mg PMExamination findings: T:  NT                 MM: pink and moistP:  124bpm        CRT: 1 secR:  20Demeanour: BARHydration: EuhydratedBP: 126/94, 106Weight: 7.2kg BCS: 5/9MCS: 3/3Cardiovascular: No murmur auscultated, sinus rhythm, femoral pulses strong and synchronous Respiratory: Clear bronchovesicular sounds bilaterally, normal respiratory effort.Abdomen: Soft, comfortable on palpation. No mass effect appreciableOral exam: No obvious oral lesionsEars: No erythema or discharge notedEyes: No lesions or discomfort notedIntegument: No lesions noted. Lymph nodes: Symmetrical, NSF Gait: NormalMusculoskeletal: Full exam np, no obvious lameness.  Rectal: NP Neurologic exam findings: Mentation/Demeanour - BARGait and posture – No significant findingsProprioception – PPR, RS and hopping intact in all limbsMotor function:1.Spinal reflexes - Intact2.Muscle bulk - Normal3.Muscle tone - NormalCranial nerves - IntactContinence - IntactVertebral hyperpathia – None noted Nociception - IntactOphthalmic exam - NPAdditional findings - Neuroanatomical localisation:Vestibular systemProblem list:Intermittent staggering towards the RHSPotential causes:1. Infectious/inflammatory (Otitis interna/media, neuritis); MUO - infectious (protozoal, fungal, bacterial)2. Vascular - vestibular paroxysmia (transient ischaemia or hypertension) 3. Metabolic - endrocrine eg Hypothyroidism or adrenal dysfunction.4.  NeoplasiaAssessment:Charlie Girl's neurological examination today reveals no neurological abnormalities. However, videos reveal sudden onset stumbling towards the RHS with full consciousness, tending to use the wall as support. As such, these episodes present as transient vestibular events. The neuroanatomical localisation of these clinical signs is vestibular system The primary differential diagnosis at this stage is an infectious/inflammatory cause (otitis interna/media) or vestibular paroxysmiaOther differential diagnoses to consider include hypothyroidism and neoplasia.Inflammatory and neoplastic disease usually result in persistent neurological signs, rather than intermittent ictal events. It is recommended at this stage to consider either further monitoring, performing a repeat blood test/BP or an MRI +- CSF tap. O elected for monitoring and blood tests. Plan:Repeat CBC, MBA and thyroid levels.Potential for MRI and CSF analysis in the future (Estimate $5500-6500)Lab Findings:  5-9-25Urea + 16.1 mmol/L (2.5-9.0)Total T4 16 nmol/L (13-47)Assessment: Increase in Urea without an increase in creatinine can possibly be due to a high protein meal, otherwise a pre-renal/renal/post renal azotaemia though this is unlikely. Need to check on what O is feeding her and if there are any blood in her stools, and also if it is a fasted sampleFurther testing of urinalysis is recommended to determine if true azotaemia.Plan: to follow up with owner    Vital Signs    

COMMS EM from RVDear Dr Christine Thomson and Dr Perri Rea,I am seeking your opinion regarding Charlie Girl Aganoff, a female desexed dog with recurrent vestibular-type episodes occurring approximately every 4–5 months (July 2025, August 2025, and most recently 1 January 2026). I would appreciate your guidance on whether referral back to you for further diagnostics (MRI ± CSF) are warranted at this stage.A Dropbox folder containing two videos of the most recent event is available here:Video 1:   HYPERLINK "https://aus01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.dropbox.com%2Fscl%2Ffi%2F0fil40bfu3wwhxmaswiuy%2F20260101_141240-Julie-Aganoff.mp4%3Frlkey%3Doghac2cv5dpvmub0qw1j197ch%26st%3D55ythclv%26dl%3D0&data=05%7C02%7Cbrisbane%40arhvets.com%7C07331019e9a146f736e308de4f3b3885%7C81b41bb66c4c4fe984ed78d69bdee3a9%7C0%7C0%7C639035313020073583%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=KKQw%2FxvIB9ujuNnD1cjyle5K3eYoyzSxGQiZu7XuLvg%3D&reserved=0"https://www.dropbox.com/scl/fi/0fil40bfu3wwhxmaswiuy/20260101_141240-Julie-Aganoff.mp4?rlkey=oghac2cv5dpvmub0qw1j197ch&st=55ythclv&dl=0Video 2: HYPERLINK "https://aus01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.dropbox.com%2Fscl%2Ffi%2F0716agz8sk1yph5g6fkv3%2F20260101_142147-Julie-Aganoff.mp4%3Frlkey%3Dxh2c9o05xq4g6klm5tkuc93zn%26st%3Dujdy0ga2%26dl%3D0&data=05%7C02%7Cbrisbane%40arhvets.com%7C07331019e9a146f736e308de4f3b3885%7C81b41bb66c4c4fe984ed78d69bdee3a9%7C0%7C0%7C639035313020102603%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=T%2BTSc5tBt8LGnoLEhC7tUPF2QVsllkzQ1k%2F2bE2mia0%3D&reserved=0"https://www.dropbox.com/scl/fi/0716agz8sk1yph5g6fkv3/20260101_142147-Julie-Aganoff.mp4?rlkey=xh2c9o05xq4g6klm5tkuc93zn&st=ujdy0ga2&dl=0Signalment & BackgroundFemale desexed small breed (Maltese Terrier X Shih Tzu) dogHistory of anxiety, noise reactivity, inter-dog tension with a cohabiting dogOngoing pododermatitis with Malassezia overgrowthOn pregabalin, clonazepam, and clomipramine for behavioural managementMost Recent Vestibular Episode – 1 January 2026Onset: ~2:15–2:17 PMDuration: 15–20 minutes of acute signs, with 30–60 minutes of post-episode quietnessReturn to baseline: ~4:00–5:00 PMClinical Features ObservedIntermittent tremor-type events involving all limbs and neckMost pronounced flexion in the right forelimb and right hindlimbTremors rhythmic, brief (1–2 seconds), with 2–5 second intervalsEyes wide, staring ahead, but fully responsive (nose-licking, reacting to guardians)When placed on the ground: consistent rightward turning before lying downAmbulation: walking close to right wall, leaning right when sitting, stumbling/falling to the rightNo loss of consciousnessNo vomiting or nystagmus reported during the eventNeurological Examination (02/01/2026)Normal cranial nerve exam and mentationNormal postural reactionsNo nystagmus on vestibular manipulationGait normal at time of examHyperextended left pelvic limb noted with walking, likely secondary to known mild (grade I)  patella luxationNormal Cardiovascular and otoscopic exam.AssessmentThe episodic, transient nature of the events and absence of persistent neurological deficits make structural disease (e.g., neoplasia) or progressive inflammatory/infectious CNS disease less likely.Most likely differential at this stage:Vestibular paroxysmia (transient ischaemia or hypertension)Other differentials considered:Infectious/inflammatory (otitis interna/media, neuritis; MUO—protozoal, fungal, bacterial)Inflammatory CNS disease (e.g., GME)Neoplasia (less likely given intermittent, self-resolving pattern)Dermatology FindingsPersistent foot lickingCytology: marked Malassezia overgrowth, no bacteria or parasitesStarted on terbinafine (weekend dosing) + Malaseb foot soaksCurrent PlanContinue behavioural medications at current dosesTreat Malassezia pododermatitisMonitor for recurrenceSeeking your recommendation on whether to proceed with: MRI ± CSF tapRepeat bloodworkAny additional diagnostics you feel are indicatedRequestGiven the recurrent nature of these episodes and the right-sided vestibular bias, I would greatly appreciate your opinion on:Whether these events warrant advanced imaging or CSF analysisWhether the pattern is consistent with vestibular paroxysmiaAny additional diagnostics or management strategies you would recommendThank you very much for your time and expertise. I’m happy to provide any further information you need.Sincerely, Dr Jessica PickettCTN EM reply 9-1-26Hello Jessica.Thank you for the email. It would be worth us checking Charlie Girl again. It may be that we see something new, or may be we don’t.But happy to reassess.If she has any more episodes, then please ask the owners to video her again, with her down on the floor free to move about. Video from the front and side view please.Please also ask them to look closely at the eyes to look for flicking movements (nystagmus)Kind regards.Christine.    Vital Signs    

Reason: SeizuresNotes: XWRV: synergyvetbehaviour@outlook.comHistory: Charlie Girl is a Maltese X presenting to ARH Neurology today for transient vestibular events. 4/7/25: Presented to RV for 2x neurological events. First occurred on 1/7/26. Video shows leaning to R and against walls, choosing to walk along walls where possible, lip licking and wide eyes, exaggerated lateral head movements when in bed with difficulty righting herself, exaggerated R ear twitches. However, no hemi-inattention, tonic clonic movements and no loss of consciousness. Bloods performed: Low Na:K ratio, elevated BUN, low cholesterol, low glucose, low T4. Recommend investigation into Addisons disease, cortisol tests and further diagnostics (BAST, ACTH stim) 12/7/25: UA ran. USG 1.055, pH 5, Protein 1. No evidence of chronic ammonia elevations. Recommended repeat biochemistry to check ALT levels 14/7/25: ACTH Stimulation test:  CORTISOL (nmol/L) 37  (30-100)  BASELINE/RANDOM CORTISOL: NORMAL DOG:      30-100 nmol/L Addison's disease ruled out. 19/8/25: Presented to BVECCS. O reports ictal events that started back in July. First time 10 mins, 2nd time (a few days later) 7 mins and tonights episode 30mins. Events described as appearing dazed but responsive to audible cues. Videos reveal proprioceptive ataxia to the RHS, appears fully conscious. No signs of facial or eye twitches, but had tension in her muscles when being held by O. NEx: unremarkable. Ddx: Partial seizure vs paroxysmal dyskinesia. Recommended further monitoring.4/9/25 (today): O confirms history as above and has videos of episodes. Videos show sudden stumbling and ataxia towards the RHS, she appears to be conscious of her surroundings and though she stumbled from time to time, was able to jump on the Os bed in one of the videos. Outside of episodes, has been well. EDDU okay. No vestibular signs: head tilt, nystagmus. Owner's primary goal/concerns today - Appetite – NormalDiet – Hills science diet small breed skin/gutWater intake – NormalUrination – NormalDefecation – NormalVomiting/diarrhoea – NoneCoughing/sneezing – NoneEnergy levels – NormalExercise/activity – plays with other dog for an hour in the morning, an hour of walks. Weight changes – NoneBehavioural changes – NonePreventative medications – tick preventatives Indoor/outdoor access - BothToxin exposure – None notedBIOP – since 2 years old Other pets at home - other dog at homePrevious medical history –  Anxiety issues - goes to behavioural consults Current medications: Fluoxetine 20mg SIDClonazepam 1mg BIDPregabalin 75mg BID + 50mg (midday dose)Examination findings: T:  NT                 MM: pink and moistP:  120bpm        CRT: 1 secR:  pantDemeanour: BARHydration: EuhydratedWeight: 6.9kg BCS: 5/9MCS: 3/3Cardiovascular: No murmur auscultated, sinus rhythm, femoral pulses strong and synchronous Respiratory: Clear bronchovesicular sounds bilaterally, normal respiratory effort.Abdomen: Soft, comfortable on palpation. No mass effect appreciableOral exam: No obvious oral lesionsEars: No erythema or discharge notedEyes: No lesions or discomfort notedIntegument: No lesions noted. Lymph nodes: Symmetrical, NSF Gait: NormalMusculoskeletal: Full exam np, no obvious lameness.  Rectal: NP Oscillometric left cephalicBP: 106/79 (86) - average of 3 readings, standing, left thoracicNeurologic exam findings: Mentation/Demeanour - BARGait and posture – No significant findingsProprioception – PPR, RS and hopping intact in all limbsMotor function:1.Spinal reflexes - Intact2.Muscle bulk - Normal3.Muscle tone - NormalCranial nerves - IntactContinence - IntactVertebral hyperpathia – None noted Nociception - IntactOphthalmic exam - NPAdditional findings - Neuroanatomical localisation:Vestibular systemProblem list:Intermittent staggering towards the RHSPotential causes:1. Infectious/inflammatory (Otitis interna/media, neuritis); MUO - infectious (protozoal, fungal, bacterial)2. Vascular - vestibular paroxysmia (transient ischaemia or hypertension) 3. Metabolic - endrocrine eg Hypothyroidism or adrenal dysfunction.4.  NeoplasiaAssessment:Charlie Girl's neurological examination today reveals no neurological abnormalities. However, videos reveal sudden onset stumbling towards the RHS with full consciousness, tending to use the wall as support. As such, these episodes present as transient vestibular events. The neuroanatomical localisation of these clinical signs is vestibular system The primary differential diagnosis at this stage is an infectious/inflammatory cause (otitis interna/media) or vestibular paroxysmiaOther differential diagnoses to consider include hypothyroidism and neoplasia.Inflammatory and neoplastic disease usually result in persistent neurological signs, rather than intermittent ictal events. It is recommended at this stage to consider either further monitoring, performing a repeat blood test/BP or an MRI +- CSF tap. O elected for monitoring and blood tests. Plan:Repeat CBC, MBA and thyroid levels.Potential for MRI and CSF analysis in the future (Estimate $5500-6500)Lab Findings:  5-9-25Urea + 16.1 mmol/L (2.5-9.0)Total T4 16 nmol/L (13-47)Assessment: Increase in Urea without an increase in creatinine can possibly be due to a high protein meal, otherwise a pre-renal/renal/post renal azotaemia though this is unlikely. Need to check on what O is feeding her and if there are any blood in her stools, and also if it is a fasted sampleFurther testing of urinalysis is recommended to determine if true azotaemia.Plan: to follow up with owner--- 10/09/2025 17:06:03 XWW: Phone call with OO reports that she has been going well. Has been boarding and no abnormalities have been seen since last visit. Discussed with O about blood results: Food has been Hills Science dry kibble for sensitive gut and skin, no other snacks, no history of kidney diseases, no blood in stool and is a fasted sample. As such, it was recommended to O if she would like to perform further work up or investigation, urinalysis was the next step. However, monitoring is also another option as she is healthy otherwise. O understands and would like to monitor for now.No further action for now.--- 11/09/2025 RV email:Good morning, Drs Rea and Thomson, Thank you again for seeing Charlie Girl Aganoff and her guardians, Jule Aganoff and Peter Low, on 4/9/25. I appreciate your insights and the time you’ve taken with this complex case.Charlie Girl remains under my care for a range of behavioural concerns. I’ve been considering a transition from fluoxetine (SSRI) to clomipramine (TCA) to better target her anxiety-related behaviours. I’m aware that TCAs may lower the seizure threshold more than SSRIs, and I wanted to seek your opinion on any potential risks associated with this change, particularly in light of her suspected vestibular condition.The transition plan would involve a strict taper of fluoxetine, followed by a six-week washout period prior to initiating clomipramine.I also wanted to acknowledge that I have limited clinical experience with vestibular paroxysmia in dogs. My understanding is that the underlying mechanisms may involve disease or irritation of the vestibulocochlear nerve—such as neurovascular or microvascular compression, idiopathic nerve irritability, or structural abnormalities near the brainstem or inner ear.If this is consistent with Charlie Girl’s presentation, I assume that continuation of clonazepam and pregabalin would be appropriate, but I’d be grateful for your confirmation or any additional considerations you’d recommend.Feel free to reply to this email, or you can call me on 0493 520 393. Thank you!Sincerely, Dr Jessica Pickett--- 12/09/2025 17:08:30 PRA:EmailedHi Jessica,Thanks for your email. The question of SSRIs and TCAs and seizures is a good and not so straightforward one! There is a lot of varying info out there about whether these medications do in fact reduce the seizure threshold, however it's worth noting that we have a number of patients who have epilepsy wherein the addition of these behaviour meds doesn't seem to have made a difference to episode frequency.Charlie Girl's episodes do seem to be vestibular in nature, but are more likely to be vestibular paroxysmia or another disorder of the vestibular system as opposed to vestibular epilepsy. Vestibular epilepsy usually presents as dogs who have both GTC seizures and vestibular events, which does not appear to be what Charlie has. You are correct about those theories for the pathophysiology of VP, and so because it's not considered a forebrain disorder like seizures and instead likely localises to the inner ear or CNN VIII, I don't think these meds would have any effect on the episodes. Having said that, Charlie Girl has not had an MRI, there are no papers that I know of that directly look at dogs with this disorder who are put on SSRIs or TCAs, and there is very little in the literature in general about VP.All that is to say that I think whichever medication protocol you deem suitable for managing Charlie Girl's behaviour is unlikely to have an effect on these episodes, but it is still worth keeping a track of the events if any changes are made to her meds.Hope this helps.Kind regards,PerriDr Perri ReaBVSc MANZCVSVeterinary Neurology ResidentARH Brisbane    Vital Signs    Weight: 6.9;