Phillip December 11, 2025 No Comments

D222 Shadow Health Case Study: Interview with Robert Hall

Name

Western Governors University

D222 Comprehensive Health Assessment

Prof. Name

Date

Transcript Summary: Patient Interview with Mr. Robert Hall

Introduction and Presenting Complaint

The nurse greeted Mr. Robert Hall warmly and initiated the assessment by asking about the reason for his hospital visit. Mr. Hall explained that he had experienced a fall earlier that morning after suddenly feeling dizzy when stepping out of his vehicle. He described the dizziness as a vertigo sensation, with the garage appearing to spin, which caused him to lose his balance and fall. His daughter found him after the fall. Besides the dizziness, he reported severe pain and swelling in his lower left leg but was unsure if these symptoms were related to the fall. The nurse responded with empathy and reassurance throughout the conversation.

Patient Identification and Orientation

To verify Mr. Hall’s identity, the nurse confirmed his full name and date of birth. Mr. Hall correctly identified his current location as Shadow General Hospital and stated the correct date, demonstrating full orientation to person, place, and time. This indicated that his cognitive status was intact.

History of Present Illness: Pain Description and Onset

Mr. Hall mentioned that he normally experiences mild arthritis-related pain, but the pain in his left leg had significantly worsened over the past two days. This deterioration prompted him to seek medical evaluation even before his fall. He localized the pain to the lower left calf and described it as sharp, persistent, and similar to repeated jabbing. On a pain scale of 0 to 10, he rated the current pain as 2, which he noted was an improvement compared to previous days. Physical activity, especially walking, increased the pain.

Pain Management and Treatments Tried

To manage the pain, Mr. Hall took ibuprofen (Advil), but this did not provide substantial relief. Although he does not use herbal supplements, he noted that applying heat usually helps ease his arthritis symptoms.

Medical History and Chronic Conditions

Mr. Hall has a history of osteoarthritis, hypertension, and benign prostatic hyperplasia (BPH). He was diagnosed with hypertension and arthritis at age 57, and prostate enlargement at age 69. His hypertension is controlled with Metoprolol (25 mg daily), and he takes Proscar (5 mg daily) for his prostate condition. He reported no side effects from his medications.

Allergies and Medication Use

Mr. Hall denied allergies to medications or latex. Occasionally, he uses Benadryl to help with sleep, about once or twice a week, but was unsure of the exact dose. He follows his medication regimen diligently, with his daughter managing his prescription refills at a new pharmacy.

Family History

Regarding family health history, Mr. Hall shared that his father had colon cancer diagnosed at a late stage and passed away from the disease. His mother died of heart failure but was generally healthy before her condition worsened.

Lifestyle and Social History

Mr. Hall reported that he rarely drinks alcohol (less than once per month) and does not use illicit drugs. He smoked for 40 years but quit at age 60. Although he used to exercise regularly, recent episodes of dizziness and fatigue have reduced his physical activity.

Review of Systems

Mr. Hall denied experiencing fever, chills, chest pain, abdominal pain, or difficulty swallowing. He has mild hearing loss managed with a hearing aid and wears reading glasses. He denied respiratory problems or a history of blood clots but mentioned tingling and numbness in his left lower leg alongside the pain.

Functional Status and Activities of Daily Living

Despite morning stiffness that makes it difficult to get out of bed, Mr. Hall remains independent in daily activities such as bathing, dressing, toileting, meal preparation, and eating. He experiences occasional urinary incontinence due to his enlarged prostate but maintains normal bowel function. He reported feeling safe at home, though he experiences loneliness when his daughter is away.

Sleep Patterns and Mental Health

Mr. Hall described his sleep as irregular, often waking multiple times at night without a fixed routine. He denied symptoms of anxiety, depression, or mood changes, describing himself as easygoing and emotionally stable.

Question and Answer Table

Question	Answer
What brought you here today?	Fell after sudden dizziness; left leg pain and swelling.
What is your full name?	Robert Hall.
What is your date of birth?	December 28 (year provided).
Do you know where you are?	Yes, Shadow General Hospital.
What day is it?	Correctly identified.
When did the leg pain start?	Two days ago; worsening progressively.
Can you describe the pain?	Sharp, nagging, like repetitive jabbing in left calf.
How would you rate your pain (0–10)?	Currently 2/10; previously higher.
Does anything make the pain worse?	Walking and physical activity worsen pain.
Have you tried anything for pain relief?	Took Advil; no relief; heat helps arthritis.
Do you have any health conditions?	Osteoarthritis, hypertension, benign prostatic hyperplasia.
When was hypertension diagnosed?	Age 57.
How is your blood pressure controlled?	Metoprolol 25 mg daily; well managed.
Tell me about your arthritis.	Mild hip/knee pain; recent leg pain more severe.
When were you diagnosed with prostate enlargement?	Age 69.
Do you have any allergies?	None known.
What medications do you take?	Metoprolol, Proscar, occasional Benadryl for sleep.
Do you take medications as prescribed?	Yes, consistently.
Do you take vitamins or supplements?	None.
Any medication side effects?	No.
How often do you use Benadryl?	Once or twice weekly; dosage unknown.
Tell me about your parents’ health.	Father had colon cancer; mother died of heart failure.
Do you use alcohol or substances?	Occasional alcohol; no illicit drugs.
Do you smoke?	Quit at age 60 after 40 years.
Do you exercise?	Occasionally; limited by dizziness and fatigue.
Have you had fever or chills?	No.
Do you have hearing or vision problems?	Mild hearing loss; uses hearing aid and reading glasses.
Shortness of breath or cough?	No.
History of blood clots?	No.
Headaches or mood changes?	None frequent; stable mood.
Can you perform daily activities independently?	Yes.
Bladder or bowel control issues?	Occasional bladder accidents; bowel control intact.
How is your sleep?	Irregular; frequent awakenings.

Additional Assessment Notes and Physical Findings

Question/Action	Response/Notes
Confusion or forgetfulness?	No; fully aware of surroundings.
Fall history?	Fell twice in last six months.
Dizziness before falling?	Yes, sudden and intense.
Cause of dizziness?	Uncertain; possibly related to pain or fatigue.
Balance issues?	Yes, increased instability recently.
Use of assistive devices?	Occasionally uses a cane for standing or sitting.
Rashes or wounds?	None; slight joint redness.
Bruising?	Bruising on legs from fall.
Weight changes?	Unintentional 10-pound weight loss.
Appetite changes?	Decreased recently.
Social interaction?	Reduced due to health concerns.
Perception of general health?	Declined due to dizziness and leg pain.
Fatigue?	Yes, tires easily.
Recent hospitalizations?	ER visit two months ago for hip X-ray; no fracture.
Surgeries?	Abdominal hernia repair at age 58.
Home safety?	Feels safe; no threats or fears.
Fall prevention plan?	Bed rails, fall risk bracelet, patient education.
Consent to fall prevention plan?	Yes, verbal consent given.

Summary of Clinical Impression

Mr. Hall presents a complex risk for falls, likely caused by a combination of dizziness, musculoskeletal pain, and age-related physiological changes. His hypertension and arthritis are well managed with medication, but his balance instability and localized leg pain need further investigation. A fall prevention strategy including environmental safety measures, medication review, and patient education has been initiated with his consent to minimize future risk.