Mrs. C.M.
- Mrs. C. M. is an 82-year-old female. She presents to her surgical oncologist for a follow-up appointment after a double mastectomy with lymph node dissection. (indwelling urinary catheter was used during surgery and on POD 1)
- Mrs. C. M. is accompanied by her husband. He is concerned as she has recently been confused and had a fall yesterday morning after feeling dizzy on her way to the bathroom. Mrs. C. M. cannot recall if she hit her head.
- Mrs. C. M.’s husband tells the nurse that Mrs. C. M. has been complaining of mild abdominal pain, malaise, painful and frequent urination over the past 4-5 days.
- Mrs. C. M. has no fever, flank pain or chills. She is not sexually active and denies any vaginal discharge.
Medical History
- Stage IIA Right Breast Cancer with lymph node involvement – diagnosed two months ago
- Hypertension – diagnosed at age 60
- Insulin-dependent Diabetes Mellitus – diagnosed at age 58
- Hyperlipidemia – diagnosed at age 50
- Smoker – quit 6 months ago.
Surgical History
- Double Mastectomy – 2 weeks post-op
- Ureter Stent – age 75 for kidney stones
Family History
- Mother: Left Breast Cancer, CKD, HTN- died at age 88
- Father: Colon Cancer, HTN, HLD, COPD, Smoker and alcohol abuse – died at age 50
Social History
- 20 year retired English teacher
- Lives in one story condominium with her husband and a cat
- Involved in weekly walking club with some ladies in the neighborhood, enjoys gardening and spending time with her 8 grandchildren.