Mrs KFG 83 yo woman Lives alone Presents

Mrs. KFG, 83 yo woman • Lives alone • Presents with several weeks B/L LL oedema and redness • Background of: – Heart failure 2° to IHD and MR – Myelodysplastic syndrome – Asthma/COPD – CKD – Significant PVD with chronic LL ulcers – Multiple other comorbidities

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

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

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

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

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, Sp. O 2 98% RA • Temp 36. 2 o

Examination (cont. ) Cardio/resp: • JVP elevated 6 cm • 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

Medications • • • Cephalexin 250 mg d Frusemide 20 mg d Aspirin 100 mg d Quinapril 5 mg d Metoprolol 50 mg BD Prednisolone 2. 5 mg d Duro K ii d Folic acid 0. 5 mg d Pregabalin 75 mg d • • Panadeine forte ii d Pantoprazole 40 mg d Allopurinol 200 mg d Lumigan drops Alphagan drops Azopt drops Salbutamol inhaler Ciclesonide inhaler

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

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

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

Management • • • Diuresis and 1. 5 L fluid restriction Strict fluid balance and daily weighs Optimisation of heart failure medications Further Ix of intracranial cyst Physiotherapy, as below PMLOF Currently: – Assist x 1 to T/F – Supervision to ambulate with gait aid • Full allied health r/v, re: d/c needs

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

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

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