Katy Kingshaw

64 year old pensioner

 

PC:      SOBOE (shortness of breath on exertion)

HPC:    worsening SOB for 3 weeks

            now unable to climb 1 flight of stairs or walk >200 yards

            cough with white sputum, especially at night

            needs 2-4 pillows at night

            both ankles swollen in the evening

            no chest pain, no palpitations

            also noticed fine macular rash on her trunk about 1 month ago

PMH:   DM Type I for 40 years

            Glomerulonephritis 1978

            Tinnitus (seen by ENT specialist = ear-nose-throat specialist)

DHx:    Aspirin

            Insulin self administered according to meals

            ACE inhibitor

FHx:     Daughter: protein S deficiency

            Son: vitiligo

            Sister: coeliac disease

SHx:    lives with husband (wheelchair bound)

            is main carer for husband, does all shopping and cleaning

            non smoker

            alcohol: sparkling wine for birthdays only