Assessment in time Interview/history-taking Related PT goals Emerging problems during PT
0 weeks A-specific low back pain, VAS = 7/10
Walking < 5 min
Reduce pain, VAS < 7
Sit and walk > 30 min
Non-reported dyspneaoverlooked; not all comorbidities and medication known to PT
8 weeks A-specific low back pain, VAS = 1/10
Walking ≤ 6 min
Dyspnea, MRC = 4/5
8 weeks* COPD GOLD IV
­FEV1/FVC = 0.41
­FEV1 = 46% of predicted, chronic respiratory failure
­Resting SpO2 = 95%
­Dyspnea, MRC = 4/5
­Walking ≤ 6 min
­Nicotine addiction, 67.5 pack years
­Physical activity, daily walking 15 min
Hypotension, 79/53 mmHg, resting heart rate = 57 beats/min
­Oral corticosteroids
­Long term oxygen therapy (2.0 l/min
­Anti-depressive drug
­Vitamin pill
­Stomach protective drug
Reduce dyspnea, MRC < 4
Improve exercise capacity & physical activity in daily life, walk > 30 min
Patient information as source for comorbidity and medication is not sufficient à information from referring physician and pharmacy needed!
9 weeks† Exercise SpO2 = 78%
Decompensated heart failure: stomach protective drug = beta-adrenergic blocker!
  Patient information on medication not checked by PT à pharmacy records or drug packing material
*Reassessment at 8 weeks due to unattained goals (walk ≤ 6 min); †Serious adverse event during exercise happened at 9 weeks; ‡ Emerging problems during PT due to failures in the communication and the clinical decision-making process.
PT: Physical Therapist; VAS: Visual Analogue Scale; min: minute; MRC: Medical Research Council Dyspnea scale; COPD: Chronic Obstructive Pulmonary Disease; GOLD IV: very severe COPD; FEV1/FVC: Forced Expiratory Ratio; FEV1: % Forced Expiratory Volume in one second of predicted; SpO2: Transcutaneous Oxygen saturation
Table 1: Collected data and assessment data of case 1.
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