Retrospective Change Scenario for COPD Disease Patient No. 3
| Basic Information: | |||
| Age: 66 | |||
| Sex: female | |||
| Disease diagnosis: COPD | |||
| Comorbid diagnoses: | Current medications: | ||
| Schizophrenia | albuterol inhaler | ||
| hypertension | pseudoephedrine | ||
| knee pain | Maxzide | ||
| positive PPD | trifluoperazine | ||
| Visit No. 1: 4/11/95 | |||
| Clinical information: | |||
| History: Patient seen in Medicine Clinic one month previously for runny nose, productive cough with yellow sputum, and dyspnea on exertion. Oxygen saturation at that time was 93% (FIO2 not specified). On previous visit, she had end-expiratory wheezes without crackles. Patient was given the diagnosis at that visit of bronchitis with COPD exacerbation, and treated with amoxicillin, pseudoephedrine, and albuterol inhaler prn. Also scheduled pulmonary function studies. On 4/11/95, patient complained of swelling in her abdomen and feeling a “knot” in her right lower quadrant. She had a history of cervical and breast cancer. | |||
| Physical exam: BP 172/89, pulse 89, weight 166 (increased 6 lbs over past month). Abdomen obese without masses or organomegaly. No other examination documented. | |||
| Test results: FEV1 1.29 liters (63% of predicted), FVC 2.18 (78% of predicted). | |||
| Treatment plan: Continue inhalers. Obtain CT scan for questionable abdominal mass. Follow-up in 1-2 months to Medicine Clinic. | |||
| Changes in treatment:: Restart Maxzide for hypertension. | |||
| Visit No. 2: 10/17/95 | |||
| Clinical Information: | |||
| History: Patient doing well. Out of blood pressure medications. Only 1 episode of wheezing in the last few months. | |||
| Physical exam: BP 168/80, pulse 84, weight 181 (increased 15 lbs). Lungs clear. Neck without bruits. Heart with an S4 gallop, but no S3. | |||
| Test results: CT scan showed renal cyst and ventral hernia. | |||
| Treatment plan: Continue albuterol as needed for COPD/reactive airways disease. Continue isradipine for hypertension. Follow-up in 6-7 months to Medicine Clinic; get mammogram at that time. | |||
| Changes in treatment: Discontinue Maxzide for hypertension. | |||
| HEALTH-RELATED QUALITY OF LIFE DATA | |||
| Domains of the CHQ | Interview 1 Date: 4/17/95 | Interview 2 Date: 10/17/95 | Change (T2 − T1) |
| Dyspnea | 35 | 31 | −4 |
| Fatigue | 18 | 25 | 7 |
| Emotional Function | 36 | 39 | 3 |
| Mastery | 20 | 27 | 7 |
| Domains of the SF-36 | |||
| Physical Functioning | 60.00 | 33.33 | −26.67 |
| Role-Physical | 100.00 | 100.00 | 0.00 |
| Bodily Pain | 100.00 | 100.00 | 0.00 |
| General Health Perception | 78.33 | 87.00 | 8.67 |
| Vitality | 70.00 | 65.00 | −5.00 |
| Social Functioning | 100.00 | 100.00 | 0.00 |
| Role-Emotional | 100.00 | 100.00 | 0.00 |
| Mental Health | 60.00 | 76.00 | 16.00 |