Mrs. KFG, 83yo 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 2o 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

ExaminationGA:• 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

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

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

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

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 1.5L 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

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