Retrospective Change Scenario for COPD Disease Patient No. 6
| Basic Information: | |||
| Age: 65 | |||
| Sex: male | |||
| Disease diagnosis: COPD | |||
| Comorbid diagnoses: | Current medications: | ||
| positive PPD | vocal cord polyp | albuterol inhaler | pilocarpine eye drops |
| CAD | weight loss | aspirin | betaxolol eye drops |
| colon polyp | glaucoma | nitroglycerine | |
| gout | multivitamins | ||
| Visit No. 1: 1/29/96 | |||
| Clinical information: | |||
| History: No complaints. No other comments or history given. | |||
| Physical exam: BP 124/69, pulse 75, weight 114 lbs. Lungs clear. No other examination documented. | |||
| Test results: None. | |||
| Treatment plan: Continue current medications. Follow-up in 6 months to Medicine Clinic. | |||
| Changes in treatment: None. | |||
| Visit No. 2: 7/29/96 | |||
| Clinical information: | |||
| History: Follow-up for multiple complaints. “Anxiety attacks” manifested by episodic non-exertional dyspnea. Lasts 10-15 minutes. No chest pain, dizziness, etc., but he takes nitroglycerine for relief. Also notes urinary frequency with nocturia every hour, but no pain. Abdominal pain in mornings, relieved by eating. Decreased oral intake due to finances. Smokes 1 cigarette every 2-3 days now. Denies alcohol or IV drug abuse. Feels down, but denies suicidal thoughts. | |||
| Physical exam: BP 119/73, pulse 79, weight 113 (down 1 lb). In no acute distress. Lungs clear except for questionable left upper lobe rub. Heart: 3/6 holosystolic murmur with a diastolic murmur also present. No lower extremity edema. | |||
| Test results: Hemoglobin 14.9, WBC 6.0. Electrolytes normal except for a bicarbonate of 33. BUN and creatinine normal. SMA-12 normal except for SGOT/ALT of 47 (elevated). Urinalysis shows 2-5 white blood cells and 5-10 red blood cells per high power field. EKG shows clockwise rotation consistent with either pulmonary disease or prior anterior myocardial infarction. | |||
| Treatment plan: Multiple unrelated complaints with labs not revealing. Suspect depression or other emotional component along with medical problems. Refer to Midtown Mental Health. Try doxazosin for urinary frequency, and check UA. Follow-up in 2 weeks to Medicine Clinic. | |||
| Changes in treatment: Add doxazosin for presumed BPH. Add nutritional supplements. | |||
| HEALTH-RELATED QUALITY OF LIFE DATA | |||
| Domains of the CHQ | Interview 1 Date: 1/23/96 | Interview 2 Date: 7/30/96 | Change (T2 − T1) |
| Dyspnea | 5 | 5 | 0 |
| Fatigue | 23 | 8 | −15 |
| Emotional Function | 39 | 23 | −16 |
| Mastery | 19 | 10 | −9 |
| Domains of the SF-36 | |||
| Physical Functioning | 20.00 | 10.00 | −10.00 |
| Role-Physical | 100.00 | 0.00 | −100.00 |
| Bodily Pain | 100.00 | 61.00 | −39.00 |
| General Health Perception | 45.00 | 40.00 | −5.00 |
| Vitality | 70.00 | 5.00 | −65.00 |
| Social Functioning | 62.50 | 37.50 | −25.00 |
| Role-Emotional | 100.00 | 33.33 | −66.67 |
| Mental Health | 100.00 | 68.00 | −32.00 |