Patient Details
|
Name |
Felix Winters |
|
Age |
87 |
|
Sex |
M |
|
Medications |
Warfarin 4mg mane Metoprolol 140mg PO mane Ramipril 5mg PO BD Atorvostatin 10mg PO mane Furosemide 40mg PO mane Zyrtec PRN |
|
HPC |
Patient presented to the Emergency Department with a four-hour history of bleeding from his right nostril. There was no preceding trauma. |
|
PSxHx |
Bioprosthetic mitral valve, 6 months ago |
|
PMHx |
Congestive heart failure Atrial fibrillation Hypertension Hyperlipidaemia Type 2 diabetes- diet controlled |
|
Allergies |
NKDA |
|
FHx |
Father died at 45 in a tractor accident. Mother died at 72 from an acute myocardial infarction. Both brothers have type 2 diabetes, one has had a stroke (age 81) and one has had a heart attack (age 66). |
|
SHx |
Patient lives with son and his wife, in an independent granny flat out the back. He is a widower, his wife died five years ago with ovarian cancer. He mobilises independently, and is independent with all his ADLS and IADLS. He has never learnt to drive, his daughter-in-law takes him grocery shopping and to any appointments. Ex-smoker, quit 40 years ago, had a 20 pack year history. Drinks a nip of whisky each night to help him fall asleep, has done so for 50 years. |