Dorothee Dolly
76 year old retired teacher
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PC: fall
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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
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PMH: previous falls (suspected arrhythmia, awaiting 24-hour ECG)
heart attack, ischaemic heart disease, DM
epilepsy
cerebrovascular accidents
Left total knee replacement 1988
right hip fractured and replaced 1990 after fall
hysterectomy; bilateral cataracts
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DHx: eyedrops
night sedation (Zopiclone)
hormone replacement therapy
antacid prn (prn = pro re nata; when needed)
Severe skin reaction to amiodarone 2 years ago
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FHx: mother and sister: hyperthyroidism
nephew: ulcerative colitis, has stoma for 4 weeks now
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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