mrs. kfg, 83yo woman lives alone presents with several weeks b/l ll oedema and redness background...
TRANSCRIPT
![Page 1: 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](https://reader036.vdocuments.us/reader036/viewer/2022082817/56649e425503460f94b348e9/html5/thumbnails/1.jpg)
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
![Page 2: 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](https://reader036.vdocuments.us/reader036/viewer/2022082817/56649e425503460f94b348e9/html5/thumbnails/2.jpg)
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
![Page 3: 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](https://reader036.vdocuments.us/reader036/viewer/2022082817/56649e425503460f94b348e9/html5/thumbnails/3.jpg)
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
![Page 4: 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](https://reader036.vdocuments.us/reader036/viewer/2022082817/56649e425503460f94b348e9/html5/thumbnails/4.jpg)
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
![Page 5: 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](https://reader036.vdocuments.us/reader036/viewer/2022082817/56649e425503460f94b348e9/html5/thumbnails/5.jpg)
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
![Page 6: 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](https://reader036.vdocuments.us/reader036/viewer/2022082817/56649e425503460f94b348e9/html5/thumbnails/6.jpg)
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
![Page 7: 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](https://reader036.vdocuments.us/reader036/viewer/2022082817/56649e425503460f94b348e9/html5/thumbnails/7.jpg)
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
![Page 8: 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](https://reader036.vdocuments.us/reader036/viewer/2022082817/56649e425503460f94b348e9/html5/thumbnails/8.jpg)
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
![Page 9: 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](https://reader036.vdocuments.us/reader036/viewer/2022082817/56649e425503460f94b348e9/html5/thumbnails/9.jpg)
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
![Page 10: 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](https://reader036.vdocuments.us/reader036/viewer/2022082817/56649e425503460f94b348e9/html5/thumbnails/10.jpg)
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
![Page 11: 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](https://reader036.vdocuments.us/reader036/viewer/2022082817/56649e425503460f94b348e9/html5/thumbnails/11.jpg)
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
![Page 12: 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](https://reader036.vdocuments.us/reader036/viewer/2022082817/56649e425503460f94b348e9/html5/thumbnails/12.jpg)
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
![Page 13: 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](https://reader036.vdocuments.us/reader036/viewer/2022082817/56649e425503460f94b348e9/html5/thumbnails/13.jpg)
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
![Page 14: 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](https://reader036.vdocuments.us/reader036/viewer/2022082817/56649e425503460f94b348e9/html5/thumbnails/14.jpg)
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
![Page 15: 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](https://reader036.vdocuments.us/reader036/viewer/2022082817/56649e425503460f94b348e9/html5/thumbnails/15.jpg)
Treatment options
• Supportive blood transfusion• EPO +/- GCSF• Thalidomide/lenalidomide• Hypomethylating agents
– Azacitidine– Decitabine
• Allogenic HSCT