
Lydia Lemongrass
65 yo female
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PC
Progressive weakness of her legs
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HPC
Started 2 weeks ago, getting worse, today its very bad
Legs feel like they are getting numb
She noticed she hasn’t passed water since last night
She’s very embarrassed because in the night she soiled herself (incontinent of faeces)
She has metastatic breast cancer affecting the lungs and spine
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PMH
Metastatic breast cancer diagnosed 2 months ago, palliative chemotherapy since 6 weeks ago
High blood pressure
Type 2 Diabetes mellitus
DH
Insulin, a short acting and a long acting, she’s not sure the names
Aspirin 100mg in the mornings
Ramipril 2.5mg mornings
Lercanidipin mornings, unsure of dose
Oxycodone retard 10mg mornings and evenings (for the back pain)
Allergy/intolerance: Palexia (tapentadol) – ‘felt woozy’
Family Hx
Mother and sister RIP Breast cancer
Brother Diabetes type 1
Social Hx
Lives with husband and daughter, who care for her
She has a hospital bed at home
She used to walk with her wheely walker but now she uses a wheelchair
Smokes 5 a day, when she has energy
No alcohol anymore