This section should include any previous patient history that is relevant to the case or the patient’s general health and should include vaccination status, current diet, recorded allergies and parasite prevention information where available.
This should not be copied directly from the patient history in the file, but should be summarised in your own words.
Examples:
Grade: Fail
Charlie presented with a sudden onset paralysis that lasted five days. A few days prior to that he had been for a walk and seemed unusually lethargic afterwards. He was taken to the emergency Centre. Two days later he was admitted to his regular veterinarian and placed onto intravenous fluid therapy for 48 hours. The owner then took him home for continued nursing care. Two days later he was presented to our clinic for a second opinion.
Grade: Pass
Charlie presented with a sudden onset paralysis of unexplained origin of 5 days duration. A few days prior to that he had been for a walk and seemed unusually lethargic afterwards. He was taken to the emergency centre where anti inflammatories and antibiotics were prescribed. Over the next couple of days, Charlie became inappetant, hypothermic and unable to walk. He was admitted to his regular veterinarian and placed onto intravenous fluid therapy for 48 hours. The client saw improvement in Charlie after 48 hours of fluids, so elected to take him home for continued nursing care. The client nursed Charlie at home where he had a good appetite and was drinking but was completely recumbent. Two days later he was presented to our clinic for a second opinion.
Grade: Credit+
Charlie presented with a sudden onset paralysis of unexplained origin of 5 days duration. Eight days prior to his presentation, he had been for a walk and seemed unusually lethargic afterwards. He was taken to the emergency centre where anti inflammatories and antibiotics were prescribed. Over the next couple of days, Charlie became inappetent, hypothermic and unable to walk. He was taken to his regular Veterinarian by his owner. At this point Charlie was placed onto intravenous fluid therapy for 48 hours. The client saw improvement in Charlie after 48 hours of fluids, so elected to take him home for continued nursing care. The client nursed Charlie at home where he had a good appetite and was drinking. He was producing urine at regular intervals, but was completely recumbent. This continued until late morning two days later, when he presented at our clinic for a second opinion.