Patient History Report Client: Ruffin, Chris (128828) Patient: CHAOS (128828-1) Phone: (972) 567-0244 Species: FELINE Breed: SAVANNAH CAT Address: 2303 Laci Lane Age: 7 Yrs. 3 Mos. Sex: Neutered Male Royse City, TX 75189 Color: Date Type Staff History 8/25/2020 C BAG Email CC from Owner and Signed written script for Chlorpheniramine Maleate 4mg - FINAL Aug 25/2020 8/25/2020 C CR Client Comm/Call Back Notes - Closed Aug 26/2020 8/25/2020 08:15 Called the owner in reference to his email. The prescription for the chlopheniramine is an over the counter medication and does not require a prescription. He should be able to go the pharmacy at Kroger and get this medication ro find it in the isle. I am sending the prescription for the OTC medication to your email. No answer. LMOM. 6/8/2020 C SET Client Comm/Call Back Notes - Closed Jun 09/2020 6/8/2020 09:54 SWO to let client know that pet's Immunotherapy is ready. Also called to see if they are going to pick it up or if they wanted to send a lawler to have it shipped out via overnight in a styrofoam container due to being heat sensitive and has to be kept cold. Client will come by to pick up through the pharmacy drive through window. 6/5/2020 C CR Intradermal Allergy Test - Dr. Rees - FINAL Jun 05/2020 Dallas Veterinary Specialists Christine Rees, DVM, Diplomate ACVD Start Time: 12:02pm End Time: 12:12pm SMALL ANIMAL ALLERGY SKIN TEST SHEET B:Billing, C:Med note, CB:Call back, CK:Check-in, CM:Communications, D:Diagnosis, DH:Declined to history, E:Examination, ES:Estimates, I:Departing instr, L:Lab result, M:Image cases, P:Prescription, PA:PVL Accepted, PB:problems, PP:PVL Performed, PR:PVL Recommended, R:Correspondence, T:Images, TC:Tentative medl note, V:Vital signs HILLSIDE VETERINARY CLINIC, P.C. Page 1 of 8 Date: 9/23/2021 6:01 PM Patient History Report Client: Ruffin, Chris (128828) Patient: CHAOS (128828-1) Phone: (972) 567-0244 Species: FELINE Breed: SAVANNAH CAT Address: 2303 Laci Lane Age: 7 Yrs. 3 Mos. Sex: Neutered Male Royse City, TX 75189 Color: Date Type Staff History CONTROLS TREES (Con't) 1 Histamine 4 __ 36 Ash 1 __ 2 Saline 0 __ 37 Bald Cypress 0 __ 38 Eastern Sycamore 0 __ GRASSES 39 Hackberry 0 __ 3 Johnson 3 X 4 Bermuda 3 X MOLDS 5 Bahia 2 X 40 Alternaria 1 __ 6 Rye, perennial 0 __ 41 Aspergillus 0 __ 7 Timothy 0 __ 42 Botrytis 2 X 8 Brome 0 __ 43 Ac r emonium 0 __ 9 Couch/Quack 2 X 44 Cladosporium 0 __ 10 Orchard Grass 0 __ 45 Drescshlera 0 __ 11 Kentucky/June 4 X 46 Fusarium 0 __ 12 Meadow Fescue 0 __ 47 Bipolaris 0 __ 48 Mucor 1 __ WEEDS 49 Aureobasidium 0 __ 13 Cocklebur 4 X 50 Penicillium 0 __ 14 DockSorrel 3 X 51 Rhizopus 0 __ 15 Dog Fennel 1 __ 52 Epicoccum 1 __ 16 Enqlish Plantain 0 __ 53 Grass Smut Mix 0 __ 17 Firebush/Kochia 3 X 18 Lambs Quarter 0 __ ENVIRONMENTALS 19 Pigweed 0 __ 54 Feathers 0 __ 20 Raqweed 1 __ 55 Sheep Wool 0 __ 21 Marsh Elder 0 __ 56 Cat Epithelia 0 __ 22 Russian Thistle 3 X 57 Fire Ant 0 __ 23 Sagebrush 2 X 58 Cockroach 0 __ 24 Goldenrod 0 __ 59 Mosquito 3 X 25 Nettle 2 X 60 House dust 1 __ 61 D .F arinae 0 __ TREES 62 D. Pteronyssinus 0 __ 26 Elm 2 X 63 Flea 3 X 27 Willow, Arroyo 0 __ 64 Histamine 4 __ 28 Cottonwood 0 __ 65 Staphage lysate 0 __ 29 Pine 0 __ 66 Red Cedar 0 __ 30 Mulberry 0 __ 67 Storage Mite 1 __ 31 Oak , Virginia Live 0 __ 68 Malassezia 0 __ 32 Maple/Bo x Elder 0 __ 33 Hickory/Pecan 0 __ B:Billing, C:Med note, CB:Call back, CK:Check-in, CM:Communications, D:Diagnosis, DH:Declined to history, E:Examination, ES:Estimates, I:Departing instr, L:Lab result, M:Image cases, P:Prescription, PA:PVL Accepted, PB:problems, PP:PVL Performed, PR:PVL Recommended, R:Correspondence, T:Images, TC:Tentative medl note, V:Vital signs HILLSIDE VETERINARY CLINIC, P.C. Page 2 of 8 Date: 9/23/2021 6:01 PM Patient History Report Client: Ruffin, Chris (128828) Patient: CHAOS (128828-1) Phone: (972) 567-0244 Species: FELINE Breed: SAVANNAH CAT Address: 2303 Laci Lane Age: 7 Yrs. 3 Mos. Sex: Neutered Male Royse City, TX 75189 Color: Date Type Staff History 34 Mountain Cedar 0 __ 35 Mesquite 0 __ 6/4/2020 C CR DVS Outside Pharmacy - FINAL Jun 04/2020 Prescribing Doctor: Christine Rees, DVM, DACVD Pharmacy Name: To Be Determined By Owner (TBDO) Pharmacy Phone: TBDO Pharmacy Staff: TBDO Medication: chlorpheniramine maleate 4 mg (over the counter antihistamine) Quantity: 60 Directions: Give 1 tablet every 12 hours as needed for allergies. Refills: prn for 1 year 6/4/2020 C BAG Anesthetic Record - FINAL Jun 04/2020 6/4/2020 C BAG Estimate - FINAL Jun 04/2020 B:Billing, C:Med note, CB:Call back, CK:Check-in, CM:Communications, D:Diagnosis, DH:Declined to history, E:Examination, ES:Estimates, I:Departing instr, L:Lab result, M:Image cases, P:Prescription, PA:PVL Accepted, PB:problems, PP:PVL Performed, PR:PVL Recommended, R:Correspondence, T:Images, TC:Tentative medl note, V:Vital signs HILLSIDE VETERINARY CLINIC, P.C. Page 3 of 8 Date: 9/23/2021 6:01 PM Patient History Report Client: Ruffin, Chris (128828) Patient: CHAOS (128828-1) Phone: (972) 567-0244 Species: FELINE Breed: SAVANNAH CAT Address: 2303 Laci Lane Age: 7 Yrs. 3 Mos. Sex: Neutered Male Royse City, TX 75189 Color: Date Type Staff History 6/4/2020 C BAG Sedation Consent Form - FINAL Jun 04/2020 6/3/2020 C CR Surgery Record - CLOSED Jun 08/2020 Surgery Procedure:_Allergy Testing_ Admitting Technician:SET Contact Numbers:972-567-0244 DVM:Christine Rees, DVM, DACVD Vaccines Current: Update Today: If not being done or owner declining reason:__ AKC Reunite Microchip: Requested: # __ Deciduous Teeth: Extraction Approved: If not being done or owner declining reason:__ Presurgical Information: Temp:100.5 Pulse:150 Resp Rate:60 Bloodwork: Done Declined If declined reason for or DVM approval:__ Temperament:__ Medical Alerts:__ Pre-Anesthetic Exam : Alopecia on the insides of both front legs, down the rear legs and belly. Skin cytologies showed the presence of cocci bacteria. __ Surgical Drugs: Acepromazine 1mg/ml: Amount: __ Route: SubCu IM IV Administration Time:__ Atropine 0.54mg/ml: Amount: __ Route: SubCu IM IV Administration Time:__ Bupivacaine 0.5%: Amount: __ Route: SubCu IM IV Administration Time:__ Buprenorphine 0.5 mg/ml: Amount: __ Route: SubCu IM IV Administration Time:__ Butorphanol 10mg/ml: Amount: __ Route: SubCu IM IV Administration Time:__ Carprofen 50mg/ml: Amount: __ Route: SubCu IM IV Administration Time:__ Cefazolin 100mg/ml: Amount: __ Route: SubCu IM IV Administration Time:__ Cerenia 10mg/ml: Amount: __ Route: SubCu IM IV Administration Time:__ Clindamycin 150mg/ml: Amount: __ Route: SubCu IM IV Administration Time:__ Convenia 80mg/ml: Amount: __ Route: SubCu IM IV Administration Time:__ Glycopyrrolate 0.2mg/ml: Amount: __ Route: SubCu IM IV Administration Time:__ Hydromorphone 2mg/ml: Amount: __ Route: SubCu IM IV Administration Time:__ Ketamine 100mg/ml: Amount: __ Route: SubCu IM IV Administration Time:__ Lidocaine 2% (20mg/ml): Amount: __ Route: SubCu IM IV Administration Time:__ Meloxicam 5mg/ml: Amount: __ Route: SubCu IM IV Administration Time:__ B:Billing, C:Med note, CB:Call back, CK:Check-in, CM:Communications, D:Diagnosis, DH:Declined to history, E:Examination, ES:Estimates, I:Departing instr, L:Lab result, M:Image cases, P:Prescription, PA:PVL Accepted, PB:problems, PP:PVL Performed, PR:PVL Recommended, R:Correspondence, T:Images, TC:Tentative medl note, V:Vital signs HILLSIDE VETERINARY CLINIC, P.C. Page 4 of 8 Date: 9/23/2021 6:01 PM Patient History Report Client: Ruffin, Chris (128828) Patient: CHAOS (128828-1) Phone: (972) 567-0244 Species: FELINE Breed: SAVANNAH CAT Address: 2303 Laci Lane Age: 7 Yrs. 3 Mos. Sex: Neutered Male Royse City, TX 75189 Color: Date Type Staff History Midazolam 5mg/ml: Amount: __ Route: SubCu IM IV Administration Time:__ Onsior 20mg/ml: Amount: __ Route: SubCu IM IV Administration Time:__ Unasyn17mg/ml: Amount: __ Route: SubCu IM IV Administration Time:__ IV Catheter Placed 22g right ceph None If no catheter reason __ Fluids: Type: PhyLyte 25ml/H TVI:9mls CRI: Additive: __ TVI:__ Anesthetic Agents: Induction: Propoflo Amount:1.0 Administration Time:__ Discarded Amount: __ Sevofluorane Mask/Box Induction ET Tube Size:4.0mm Telazol __ Acepromazine __ Injectable/ Reversal Anesthetic: Dexdomitor Amount:0.20cc Route: IM IV Administration Time:11.27am Antisedan Amount:0.20cc Route: IM IV Administration Time:12:16pm Surgery Start Time:12:02pm Pre/Post-Induction HR:120/90 Surgery Stop Time:12:12pm Extubation Time:12:30pm Post Temperature: 99.0 Anesthesia Time :25 minutes Biopsy Taken Results: __ Surgical Notes:_The right side of the chest was clipped and 68 different allergens were injected intradermally. Ten minutes post injection the allergy test was read. This test showed several positive reactions to various allergens. See attached results for specifics. post op this cat was injected with 1 cc of Depo and 0.5 cc Convenia. The owner will apply the bravecto once every 3 months tomorrow. _ Post-Operative Tech Check- Initial:set Post Operative Tech Checks - Subsequent:set 6/3/2020 C CR Discharge Dermatology ADESA - FINAL Jun 03/2020 DISCHARGE SUMMARY Today’s Date: 6/3/2020 Presenting Complaint: In today for allergy testing and evaluation Diagnostic tests performed: B:Billing, C:Med note, CB:Call back, CK:Check-in, CM:Communications, D:Diagnosis, DH:Declined to history, E:Examination, ES:Estimates, I:Departing instr, L:Lab result, M:Image cases, P:Prescription, PA:PVL Accepted, PB:problems, PP:PVL Performed, PR:PVL Recommended, R:Correspondence, T:Images, TC:Tentative medl note, V:Vital signs HILLSIDE VETERINARY CLINIC, P.C. Page 5 of 8 Date: 9/23/2021 6:01 PM Patient History Report Client: Ruffin, Chris (128828) Patient: CHAOS (128828-1) Phone: (972) 567-0244 Species: FELINE Breed: SAVANNAH CAT Address: 2303 Laci Lane Age: 7 Yrs. 3 Mos. Sex: Neutered Male Royse City, TX 75189 Color: Date Type Staff History 1. Skin cytologies showed mild to moderate amounts of cocci bacteria. 2. Intradermal allergy testing showed several positive reactions (see attached results for specifics). 3. Rectal examination revealed pea sized glands that were easy to express. Diagnoses: Atopic dermatitis , superficial pyoderma or bacterial skin infection, insect allergies ( fleas and mosquitoes) Medications Dispensed: 1. Depomedrol, a steroid injection, was administered sub Q post allergy testing. 2. Convenia, a long acting antibiotic injection, was administered sub Q for the treatment of the bacterial skin infection. 3. Bravecto- Part the hair on the back of the neck and apply the contents of 1 ampule to the skin once every 3 months. Start tomorrow. 4. Sublingual immunotherapy or allergy drops have been ordered (3 pumps of the blue with white pump starter schedule). The allergy drops should be ready next week. We will contact you when the allergy drops are ready for pick up. Treatment Recommendations: The allergy test showed several positive reactions to various allergens (see attached results for specifics). The bacterial infection noted on the cytologies is secondary to the allergies. An antibiotic injection was administered for the infections and a steroid injection, Depomedrol, was administered for the allergies and itching. Diet : Please do not feed until after 6 pm tonight. When you feed tonight, you will want to feed half of the normal amount of cat food. Tomorrow you may feed normally. Follow-up in : 1 month You may schedule the above appointment by calling (214) 828-5800. Please do NOT bathe your pet for 1 week prior to a dermatology exam. Please do NOT clean the ears or apply ear / topical meds the morning of an exam. Thank you for coming to the dermatology service. I appreciate your business! If you have any questions, you may contact me directly at (214) 828-5800. Take care and have a great day. Sincerely, Christine Rees, DVM, DACVD 6/3/2020 C CR New Appointment Template - CLOSED Jun 05/2020 Appointment Template Share Records with Primary Veterinary Clinic? Yes No If yes - Clinic Name and Contact Information __ B:Billing, C:Med note, CB:Call back, CK:Check-in, CM:Communications, D:Diagnosis, DH:Declined to history, E:Examination, ES:Estimates, I:Departing instr, L:Lab result, M:Image cases, P:Prescription, PA:PVL Accepted, PB:problems, PP:PVL Performed, PR:PVL Recommended, R:Correspondence, T:Images, TC:Tentative medl note, V:Vital signs HILLSIDE VETERINARY CLINIC, P.C. Page 6 of 8 Date: 9/23/2021 6:01 PM Patient History Report Client: Ruffin, Chris (128828) Patient: CHAOS (128828-1) Phone: (972) 567-0244 Species: FELINE Breed: SAVANNAH CAT Address: 2303 Laci Lane Age: 7 Yrs. 3 Mos. Sex: Neutered Male Royse City, TX 75189 Color: Date Type Staff History Added to rDVM: Yes No Room Number: Curbside DVM: Dr. Rees Technician:Shannon ET Temperature: 100.4 Pulse: 150 Respiration: 60 Diet: Whole Hearted wet (vomits more on dry food) Fecal: Container Sent Not Needed In House Sent to Lab Results: __ Medications: None Complaint: Pulling hair out for the last 2 years, possible allergy testing History: Owner reports pet starting to chew and lick more January 2017 while they where living in Florida, then seemed to get worse when they moved to Texas and had a flea issue in the new house, owner did say that her husbands dad is a vet and they have been treating pet through him, has done some what of a food trial with no resolution, owner also mention that pet vomits on a regular basis, at least 3 times a week; and that recently had eaten part of a blanket but has been defecating fine, did say pet did vomit this am and that since eating the blanket the belly seems firm and tight, eating and drinking normally, no d/c/s BCS: 1 2 3 4 5 6 7 8 9 Physical Exam General Appearance Normal Abnormal __ Eyes Normal Abnormal __ Ears Normal Abnormal __ Dental Normal Abnormal Stage 1 2 3 4 Mucous Membrane Normal Abnormal __ Integument Normal Abnormal Barbered alopecia with erythema on the belly, insides of the front legs and back of rear legs.__ Digestive Normal Abnormal Occasional vomits. Discussed internal medicine appointment but this would need to be scheduled. If it is a major problem then we can postpone the allergy test and get it worked up through HVC with possible transfer to internal medicine. Declined. __ Lymph Nodes Normal Abnormal __ Musculo-Skeletal Normal Abnormal __ Genito-Urinary Normal Abnormal __ Circulatory Normal Abnormal __ B:Billing, C:Med note, CB:Call back, CK:Check-in, CM:Communications, D:Diagnosis, DH:Declined to history, E:Examination, ES:Estimates, I:Departing instr, L:Lab result, M:Image cases, P:Prescription, PA:PVL Accepted, PB:problems, PP:PVL Performed, PR:PVL Recommended, R:Correspondence, T:Images, TC:Tentative medl note, V:Vital signs HILLSIDE VETERINARY CLINIC, P.C. Page 7 of 8 Date: 9/23/2021 6:01 PM Patient History Report Client: Ruffin, Chris (128828) Patient: CHAOS (128828-1) Phone: (972) 567-0244 Species: FELINE Breed: SAVANNAH CAT Address: 2303 Laci Lane Age: 7 Yrs. 3 Mos. Sex: Neutered Male Royse City, TX 75189 Color: Date Type Staff History Respiratory Normal Abnormal __ Neural Systems Normal Abnormal __ Thyroid (CATS ONLY) Normal Abnormal __ Other Physical Findings: __ Diagnostic Tests: 1. Skin cytologies showed mild to moderate amounts of cocci bacteria. 2. Anal gland expression had pea sized glands that were easy to express 3. IDATing, strong positive reactions to various allergens.__ Assessment: Atopic dermatitis, allergies to mosquitoes and fleas ( insect allergies), superficial pyoderma__ Diagnosis: _ Allergic dermatitis (probable atopic dermatitis with or without insect allergies, less likely food allergies), superficial pyoderma__ _ Plan: _ 1. Sedate and allergy testing today.The owner wants allergy drops. This cat is easy to handle at home for the husband. 2. Convenia 0.5 cc sub Q post allergy testing. 3. Depomedrol 1 cc sub Q post allergy testing. 4. Bravecto once every 3 months topically. Recheck: 1 month__ B:Billing, C:Med note, CB:Call back, CK:Check-in, CM:Communications, D:Diagnosis, DH:Declined to history, E:Examination, ES:Estimates, I:Departing instr, L:Lab result, M:Image cases, P:Prescription, PA:PVL Accepted, PB:problems, PP:PVL Performed, PR:PVL Recommended, R:Correspondence, T:Images, TC:Tentative medl note, V:Vital signs HILLSIDE VETERINARY CLINIC, P.C. Page 8 of 8 Date: 9/23/2021 6:01 PM