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Mrs. KFG, 83yo woman

Mrs. KFG, 83yo woman. Lives alone P resents with several weeks B/L LL oedema and redness ​ B ackground of : H eart failure 2° to IHD and MR M yelodysplastic syndrome A sthma /COPD CKD S ignificant PVD with chronic LL ulcers M ultiple other comorbidities. HOPC.

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Mrs. KFG, 83yo woman

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  1. Mrs. KFG, 83yo woman Lives alone Presents with several weeks B/L LL oedema and redness ​Background of: Heartfailure 2° to IHD and MR Myelodysplastic syndrome Asthma/COPD CKD SignificantPVD with chronic LL ulcers Multipleother comorbidities

  2. HOPC • 2-3 weeks of increasing leg swelling bilaterally associated with redness • Associated functional decline • Fatigue • Decreased Ex tolerance 2o to weakness • Nil dyspnoea, chest pain, othropnoea, PND, fever • Heart failure medications were changed 3/52 ago

  3. HOPC (cont.) • Treated empirically as B/L cellulitis • Adm. as symptoms failed to improve • Has been very tired during the day, sleeping frequently • Reports poor sleep at night • 2 x recent falls

  4. Medical history • IHD: MI ~2011 (medically managed) • MR • Asthma/COAD • She states asthma • Late onset • Lifetime non-smoker • Myelodysplastic syndrome • Managed with monthly blood transfusions • Tolerates well and gets symptomatic relief

  5. Medical history (cont.) • CKD • Recurrent UTIs, on cephalexin prophylaxis • PVD • Chronic non-healing ulcers on LLs prev. • B/L LL operations, ?fem-pop bypass • Thyroidectomy • HTN, shingles, GORD, glaucoma, visual impairment • Multiple other surgeries i.e. appendicectomy, cholecystectomy, hysterectomy

  6. Examination GA: • Frequently sleeping deeply at any time of day, rousable • Otherwise appears comfortable, not dyspnoeic Obs: • BP 135/60, HR 70 reg • RR 18, SpO2 98% RA • Temp 36.2o

  7. Examination (cont.) Cardio/resp: • JVP elevated 6cm • Loud pansystolic murmur • Loudest at mitral region, radiating to axilla • Louder on expiration • Chest clear • Pitting oedema to knees B/L, with associated erythema • Dressing on L) leg

  8. Medications • Cephalexin 250mg d • Frusemide 20mg d • Aspirin 100mg d • Quinapril 5mg d • Metoprolol 50mg BD • Prednisolone 2.5mg d • Duro K ii d • Folic acid 0.5mg d • Pregabalin 75mg d • Panadeine forte ii d • Pantoprazole 40mg d • Allopurinol 200mg d • Lumigan drops • Alphagan drops • Azopt drops • Salbutamol inhaler • Ciclesonide inhaler

  9. Issues • RHF • Peripheral oedema, raised JVP • Intracranial cyst found on CTB (8/9) • Mass effect as evidenced by midline shift • Recurrent falls (x2 in 2/52) • Discharge planning

  10. Social history • Lives alone, nearest family in Williamstown • Independent with personal care, shopping, cooking and most domestic chores • HH 1/14 to clean floors • Private services for gardening, maintenance • Goes out to lunch with friends at least once a week

  11. Social history (cont.) • Husband died 20 years ago (sudden cardiac death) • 2 daughters: • One in Williamstown who is very supportive, although has a young family • One in Byron Bay, their relationship is strained although they still talk • 2 living younger siblings live interstate • Does not drive • A lot of anxiety around new diagnosis of heart failure

  12. Management • Diuresis and 1.5L fluid restriction • Strict fluid balance and daily weighs • Optimisation of heart failure medications • Further Ix of intracranial cyst • Physiotherapy, as below PMLOF Currently: • Assist x1 to T/F • Supervision to ambulate with gait aid • Full allied health r/v, re: d/c needs

  13. Myelodysplastic syndrome • Characterised by dyshaematopoesis • Dyserythropoesis Anaemia • Dysgranulocytopoesis Neutropenia • Dysmegakaryopoesis Thrombocytopenia • Classified broadly by the above + the percentage of blasts in peripheral film + bone marrow findings • >20% blasts = transformation to AML

  14. Prognosis • Dependent on disease phenotype and patient’s age and comorbidities • May be as little as months, up to ten years or more • Manifestations of isolated anaemia with few blasts have the most favourable prognosis

  15. Treatment options • Supportive blood transfusion • EPO +/- GCSF • Thalidomide/lenalidomide • Hypomethylating agents • Azacitidine • Decitabine • Allogenic HSCT

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