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Dorothee Dolly

76 year old retired teacher

PC:      fall

HPC:    found by carer in bathroom

            can't remember fall exactly

            felt dizzy when going to “spend a penny”

            now left occipital head and right elbow hurting

            no incontinence or tongue biting

PMH:   previous falls (suspected arrhythmia, awaiting 24-hour ECG)

                    heart attack, ischaemic heart disease, DM


            cerebrovascular accidents

            Left total knee replacement 1988

            right hip fractured and replaced 1990 after fall

            hysterectomy; bilateral cataracts

DHx:    eyedrops

            night sedation (Zopiclone)

            hormone replacement therapy

            antacid prn (prn = pro re nata; when needed)

            Severe skin reaction to amiodarone 2 years ago

FHx:     mother and sister: hyperthyroidism

            nephew: ulcerative colitis, has stoma for 4 weeks now

SHx:    lives in sheltered accommodation, carer comes twice daily

                    regular Sherry at night, smokes 2 cigarettes per day

            close family on holiday in Teneriffe at present

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