Lily Rozario, 75 years and born on the 12th of October, 1937. She was married but was now a widow. Her eldest son reliably assisted with the history. The chief complaints were that she was “not being able…
Previously she could walk or board the bus to town for shopping or to church. Her memory too became poorer. Executive functions slowly dwindled and she was unable to do many things herself. Help was needed on occasions. Sleep became disturbed. Moreover she seemed to withdraw from her friends and family whom she used to meet frequently and spend her time laughing and conversing with in better days. Recently she had a fall and had broken her femur. This had upset her further though that phase had been successfully passed over. Winter aggravated her mobility problem. Even with multiple complaints and problems she had been reluctant to approach anyone for help. She attributed her complaints to aging. It was at the behest of her son that she had now agreed to come. With the son’s assistance, the problems were all hopefully revealed.
It said that she had been taking anti-hypertensives for the last twenty years. She used to be regular in her appointments with the physician but had lost that regularity of late. Previous medical history did not reveal any significant issue. Her pregnancies terminated normally and she has two children. Significant childhood diseases or history of immunizations were not remembered. Hospitalization had been only for her deliveries and her recent fracture femur. With no history of allergies, she could take any medicine. She was on 25 mg. Atenolol daily and had antacids occasionally. Analgesics and pills for sleeping comfortably had been prescribed at the local care center as and when she found it difficult to walk because of pain or could not sleep.
Her diet included more of cereals and porridges with small quantity of fruits and vegetables. Her dentures did not fit well due to her loss of weight and so she would rather have a diet easily swallowed. She was having a diminished appetite. The history of ...
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Her eldest son reliably assisted with the history. The chief complaints were that she was “not being able to walk ably due to pain and was not capable of doing her daily functions”. Both complaints had been troubling her for the past 3 years apart from her hypertension which had been present for the past twenty years and other “general problems of aging”.
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