What details should I include in a patient history?

A: The patient history should be a brief summary of the primary complaint and reason for imaging.  

Here's an example:

  • Reason for Visit: chronic diarrhea /check dewclaw 
  • History: 10 yr old Neutered Male German Shepherd presents today for chronic diarrhea. O states P gets diarrhea episodes every 2 weeks, she medicates P, it goes away, then comes back. P's diarrhea started 3 days ago, O sees no blood in the stool but very liquidy. P is asking to go out every 15 minutes. P is a little more anxious, but overall acting like his normal self. O states P there's an alley behind O's house and people throw things over the fence that P sometimes gets to. O tries to clean up, but sometimes P finds stuff. P also ripped off his dewclaw on his left paw coming out of the car today for his appointment. Dewclaw still intact, but bleeding. 
  • C/S/V/D: diarrhea
  • E/D/U/D: diarrhea 
  • FAS Score: 0 good boy 
  • Current Medications (dose and frequency): Gaba 600mg 1/2 tab SID//Apoquel//probiotics Heartworm Prevention / Flea Prevention: Trifexis
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