What's in Your Pet's Medical Record?

Medical records

Have you ever wondered what exactly your veterinarian jots down in your pet's medical record? Here's a sample chart to give you an idea of what your pet's file may hold.

General Info

Pet’s name: Sandy
DOB: Sept. 16, 2010

Breed: Cocker Spaniel
Sex: Female, spayed

Owner: Ms. Jorges
Date of visit: Sept. 18, 2017

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, Body Condition Score (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 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 classical music, aromatherapy and behavior training. Reminded Ms. Jorges behavioral problems may worsen with age, so intervention 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 interaction.

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