Transcript Mrs. KFG, 83yo woman - Oncology Clinics Victoria

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