The PRAXIS Nexus The PRAXIS Nexus

A PRAXIS Case Study: Meg S.

Posted on March 13, 2018   |   
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COPD case study

Meg S., age 62

Meg S. was referred to pulmonary rehabilitation following a visit with her primary care provider. Here is some of the information shared in the pulmonary rehab intake interview.

Past utilization: Meg has been seen in the ER x 3 over the last three months for extreme shortness of breath, rib pain and intractable cough, feeling as if she’s “choking on my phlegm.” On the second visit, she refused an overnight admission to acute care due to obligations at home. One week later, on her third visit, in addition to nebulizer treatments, low flow O2, and smoking cessation counseling, she was provided with an Acapella device for secretion mobilization.

Medical history: COPD, perforated spleen related to a colonoscopy. Her spleen was subsequently removed. FEV1 is 35% normal predicted. 75-pack-year cigarette history, still smoking. Negative for Alpha-1 Antitrypsin Deficiency. 2+ pitting edema in feet and ankles.

Family history: Father, age 84, living alone in another state, seemingly in good health. Mother deceased at age 38 after a prolonged illness, etiology unknown. (Throughout her teenage years, Meg was her mother’s primary caregiver.) Meg has two adult children, one 34-year-old son is on the autism spectrum with generalized anxiety disorder and lives at home. Her 30-year-old daughter in good health, lives in town.

CXR: Severe hyperinflation, no pneumonia.

Pulse oximetry: Room air 92%.

Height: 62” Weight: 89 lbs.

Medications: Spiriva q day, Albuterol MDI q4 hours and prn at noc, Acapella. Xanax. Mucinex prn.

Psych/Social: Meg appears much older than her stated age. She appears to be malnourished. Color after walking from the parking lot on room air is ashen. Worked as a realtor and interior designer, retired last year. Drinks two glasses of wine every evening. Lives with husband who is 82 years old. “He’s not as spry as he used to be and he’s becoming forgetful. My son from my second marriage works part time at a grocery store but still lives at home and requires a lot of help and support. I belong to a 'parents of autism' support group. Evan, my four-year-old grandson, is the light of my life and spends every Wednesday at my house. I know it makes for a busy day, but spending time with him is the highlight of my week and I don’t know what I’d do if I didn’t have him. I’m glad you don’t have rehab classes here on Wednesdays because I wouldn’t come. With taking care of my son and spending time with Evan, plus my book club, I don’t know if I have enough time for this rehab program as it is.”


  • What are your impressions?
  • Would you expect Meg to complete her course of pulmonary rehab?
  • What additional consults would you recommend?
  • If you could accomplish only one thing in the course of Meg’s care in pulmonary rehab, what would that be?


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  • Still smoking is lane. She doesn't seem to care about her health.
    • Could it be, at that time, that the addiction was stronger than Meg and her willingness to make a change?
  • I wonder if Meg will be able to complete pulmonary rehab if she doesn't realize it needs to be a priority -- along with the other important parts of her life? How can her healthcare team best educate her on the importance of enrolling in and sticking to the program -- and on how it will improve her QOL all around, including her time with her grandson?
  • It doesn't seem that Meg has a good idea of the benefits of Pulm Rehab - she seems to have the impression that it is just another thing to busy up her week. She may not think she needs help, but I'm not sure she realizes how much better she would feel after completing the program.
    I'm also a little concerned about the lower extremity edema and that she is quite a bit below her ideal body weight...
    Sounds like she could use some nutritional support...

    To me, it sounds like Meg is going to have to start seeing some benefits of the program right away, or she may not stick with it. The rehab team is going to have to focus in on what motivates her right away to keep her engaged.

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