Lydia Lemongrass

65 yo female

PC 

Progressive weakness of her legs

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

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