What's in Your Pet's Medical Record?

Pets’ files include much info—too much to share here. But this condensed version for a fictitious dog gives you an idea of what’s tracked and why. Want to know more? Ask your veterinarian

Pet’s Name: Sandy
DOB: Sept. 16, 2004
Breed: Cocker Spaniel
Sex: Female, spayed
Owner: Ms. Jorges
Date of visit: Sept. 18, 2011
Reason for visit: 6-month wellness examination

AGE: 7 years old, senior pet
Discussed need for senior-specific nutrition. Reviewed common signs of many senior pet conditions, such as increased thirst or urination, joint stiffness, changes in appetite, coughing or difficulty breathing, increased behavioral challenges (thunderstorm phobia, separation anxiety, decreased mental awareness), loose stools, and vomiting. Stressed that subtle signs can be significant and that Ms. Jorges should get Sandy examined if she notices any.

WEIGHT: 35 lbs. (gained 3) Ideal weight: 25-27 lbs. Classified as obese (BCS 5)
This is Sandy’s biggest health threat. Veterinary team told Ms. Jorges the key to Sandy’s disease-free health and longevity is weight loss. Discussed weight-related diseases like osteoarthritis, high blood pressure, kidney disease, heart and breathing problems, and diabetes. The veterinarian calculated Sandy’s weight-loss calories (440-480 calories per day) and prescribed a therapeutic weight-loss food for older pets. Ms. Jorges needs to briskly walk Sandy 30 minutes each day (rain or shine!) or enroll her in a treadmill weight-loss program. Ms. Jorges will bring in Sandy for monthly weight checks until Sandy weighs 27 lbs.

LIFESTYLE: Mainly indoors, mostly sedentary
Sandy doesn’t receive adequate exercise (less than 10 minutes daily). Discussed ways to motivate Sandy to walk (ideal outdoor temperature, liberal praise, toy at midway point). Sandy experiences mild separation anxiety. Reviewed offering soft classical music, aromatherapy, and behavior training. Reminded Ms. Jorges behavioral problems may worsen with age so intervention now helps prevent future severe issues. Advised Ms. Jorges to visit dog parks or friends with dogs because Sandy is an only pet and would benefit from social interaction.

PARASITE PREVENTION: Year-round heartworm. Add year-round flea & tick
Ms. Jorges says she uses year-round heartworm preventive and a flea preventive during warmer months. We discussed the importance of year-round flea prevention, as well as adding tick prevention. Sandy has a history of skin allergies and year-round flea prevention is critical to decrease her risk of skin problems. Recommended bathing with hypoallergenic shampoo every one to two weeks, especially during warmer months.

DENTAL GRADE: Level 3 disease out of 4
Sandy needs her teeth cleaned as soon as possible. Periodontal disease can lead to heart valve infections, pain, and tooth root abscessation (pus pockets). Ms. Jorges doesn’t brush Sandy’s teeth regularly due to a busy schedule. Advised her to try antiseptic rinses, treats designed to reduce tartar and plaque, water additives, and brushing when possible. Reminded her that pets with good oral health live two to three years longer—with less pain.

VACCINATIONS: Core plus
Gave core vaccines: distemper, hepatitis, parvovirus, and rabies. Also vaccinated against leptospirosis, which has been reported in area. With Sandy’s low-risk lifestyle, gave no other noncore vaccines. Reminded Ms. Jorges that parainfluenza and Bordetella vaccinations are needed 14 days before Sandy is boarded or groomed. Mentioned that if Ms. Jorges plans to travel with Sandy to areas with Lyme disease, we should vaccinate before the trip.

PARASITE SCREENINGS
Heartworm/B. burgdorferi/A. phagocytophilum/E. canis: negative
Intestinal parasite test: negative

SENIOR WELLNESS TESTING
Normal complete blood cell count and platelets. Slightly elevated (1.5-2 times normal) liver enzymes, alkaline phosphatase, and alanine aminotransferase. Normal kidney enzymes, blood glucose, pancreatic enzymes, and electrolytes.

Slightly low urine specific gravity (USG) at 1.020; other parameters within normal limits. Potential causes: early kidney disease, Cushing’s disease (hyperadrenocorticism), or normal daily fluctuation (well-hydrated when tested).

Discussed follow-up liver and kidney enzyme tests and urinalysis (UA) in 30 days. Monitor UA every 3 to 6 months until we determine if kidney function is normal. If liver enzymes are persistently elevated, may perform a Cushing’s disease test (low-dose dexamethasone suppression test), bile acids test, or both. Also discussed abdominal radiographs and ultrasound based on future test results. No need for change or concern now—no associated clinical signs other than weight gain.

SUMMARY
Sandy’s health is on track with her age, and she’ll be in better condition after she loses weight and gets her teeth cleaned. Ms. Jorges is dedicated to Sandy’s health and bringing her in at least every six months for wellness checks, including diagnostic testing. We’re thrilled to work with Ms. Jorges to help her keep Sandy in tip-top shape.