Retrospective Change Scenario for COPD Disease Patient No. 5

Basic Information:
Age: 72
Sex: male
Disease diagnosis:  COPD
Comorbid diagnoses:		Current medications:
pleural effusion		albuterol inhaler	ranitidine
decubitus ulcer		ipratropium inhaler	Robitussin
laryngeal cancer, s/p resection		triamcinolone inhaler	acetaminophen with codeine
	metoclopramide
Visit No. 1:  10/24/95
Clinical information:
History: Presents for follow-up. He feels better. On antibiotics for bronchitis.
Physical exam: BP 125/70, pulse 89, weight 167 lbs. S/P vocal chord excision on exam. Lungs show bibasilar rhonchi. Distant heart sounds. Unremarkable abdomen.
Test results: None.
Treatment plan: Continue same meds for stable COPD. Follow-up at ENT clinic for laryngeal cancer; 6 months to Medicine Clinic.
Changes in treatment:: None.
Visit No. 2:  7/2/96
Clinical Information:
History: Had follow-up with ENT the previous week. Complains of pain in left shoulder and hands. Otherwise feels pretty well.
Physical exam: BP 118/70, pulse 76, weight 174 (up 7 lbs). In no acute distress. Lungs show a few crackles in the right lung. Heart exam normal. Left shoulder and hands tender but no head, redness, or swelling.
Test results: None.
Treatment plan: Continue acetaminophen for shoulder and hand pain. Give pneumovax. Follow-up in 6 months at Medicine Clinic.
Changes in treatment: None.
HEALTH-RELATED QUALITY OF LIFE DATA
Domains of the CHQ	Interview 1 Date: 10/24/95	Interview 2 Date: 7/02/96	Change (T2 − T1)
Dyspnea	22.50	26.67	4.17
Fatigue	16	16	0
Emotional Function	28	34	6
Mastery	18	19	1
Domains of the SF-36
Physical Functioning	55.00	50.00	−5.00
Role-Physical	66.67	100.00	33.33
Bodily Pain	84.00	51.00	−33.00
General Health Perception	50.00	35.00	−15.00
Vitality	50.00	50.00	0.00
Social Functioning	62.50	62.50	0.00
Role-Emotional	100.00	66.67	−33.33
Mental Health	64.00	48.00	−16.00