Retrospective Change Scenario for COPD Disease Patient No. 4
| Basic Information: | |||
| Age: 74 | |||
| Sex: female | |||
| Disease diagnosis: COPD | |||
| Comorbid diagnoses: | Current medications: | ||
| atrial fibrillation | albuterol inhaler and nebulized solution | ipratropium inhaler | |
| congestive heart failure | beclomethasone inhaler | KCl | |
| hypertension | benazepril | nifedipine XL | |
| obesity | digoxin | TheoDur | |
| renal insufficiency | furosemide | warfarin | |
| CAD | |||
| Visit No. 1: 3/17/95 | |||
| Clinical information: | |||
| History: Recently discharged after COPD exacerbation requiring mechanical ventilation. Has been doing well since then. Breathing comfortably. No cough, fever, or chills. Still losing weight with Slim Fast. Plays Eucre once a week and asking if he can have an occasional beer. | |||
| Physical exam: BP 108/46, pulse 68, weight 268 lbs. Lungs clear. Heart shows 2/6 systolic ejection murmur at left lower sternal border. Abdomen unremarkable. Extremities show 1+ pitting edema. | |||
| Test results: Many from recent hospitalization, but none commented upon in note. | |||
| Treatment plan: Continue inhaled steroids, bronchodilators, and TheoDur for reactive airways disease. Continue diuretics, afterload reduction, and inotropes for left ventricular dysfunction. Continue coumadin for atrial fibrillation. Try to obtain hospital bed through Social Work. Follow-up to obtain INR in 1 week, call if INR >3 or <2. Follow-up to Medicine Clinic in 4-6 months. | |||
| Changes in treatment:: None. | |||
| Visit No. 2: 9/15/95 | |||
| Clinical Information: | |||
| History: In for routine office visit. Complains of occasional dyspnea on exertion and cough productive of whitish sputum. No fevers. Has dry, irritated eyes. | |||
| Physical exam: BP 101/56, pulse 86, weight 266 (down 2 lbs). HEENT normal except 2X2 cm non-tender moveable supraclavicular lymph node. Lungs clear. Heart shows 2/6 systolic ejection murmur, but no gallops. Abdomen unremarkable. There is a trace of lower extremities edema. | |||
| Test results: None. | |||
| Treatment plan: Continue inhaler regimen for COPD. Check INR. Consider giving artificial tears for dry eyes. Consider Eye appointment in the future. Follow-up on INR check in 4 weeks, Medicine Clinic in 2 months. | |||
| Changes in treatment: None. | |||
| HEALTH-RELATED QUALITY OF LIFE DATA | |||
| Domains of the CHQ | Interview 1 Date: 3/22/95 | Interview 2 Date: 9/15/95 | Change (T2 − T1) |
| Dyspnea | 18 | 15 | −3 |
| Fatigue | 19 | 6 | −13 |
| Emotional Function | 33 | 18 | −15 |
| Mastery | 16 | 11 | −5 |
| Domains of the SF-36 | |||
| Physical Functioning | 68.75 | 30.00 | −38.75 |
| Role-Physical | 100.00 | 0.00 | −100.00 |
| Bodily Pain | 80.00 | 10.00 | −70.00 |
| General Health Perception | 20.00 | 6.25 | −13.75 |
| Vitality | 50.00 | 5.00 | −45.00 |
| Social Functioning | 100.00 | 62.50 | −37.50 |
| Role-Emotional | 66.67 | 100.00 | 33.33 |
| Mental Health | 76.00 | 28.00 | −48.00 |