D222 Shadow Health Case Study: Interview with Robert Hall

Student 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 and initiated the session by asking about the reason for his visit. Mr. Hall explained that he had fallen earlier that morning after experiencing sudden dizziness upon exiting his car. He described the sensation as a wave of dizziness causing the garage to spin, leading to his fall. His daughter found him afterward. He also reported severe pain and swelling in his lower left leg, which he was unsure was related to the fall. The nurse expressed empathy toward his situation.

Patient Identification and Orientation

The nurse confirmed Mr. Hall’s full name and date of birth to verify identity. When asked about his awareness of location and date, Mr. Hall correctly identified that he was at Shadow General and provided the accurate date, demonstrating good orientation.

History of Present Illness: Pain Description and Onset

Mr. Hall shared that while he usually experiences mild arthritis pain, the pain in his left leg had intensified over the last two days, prompting him to seek medical attention even before his fall. He localized the pain to the lower left calf and described it as sharp and nagging, likening it to repeated jabbing. On a pain scale from 0 (no pain) to 10 (worst pain), he rated his current pain as a 2, noting it was milder now than before. The pain worsened with any activity, especially walking.

Pain Management and Treatments Tried

He had initially taken Advil without relief. He denied using herbal supplements but reported that applying heat usually alleviates his arthritis pain.

Medical History and Chronic Conditions

Mr. Hall has a history of osteoarthritis, hypertension, and an enlarged prostate. He was diagnosed with hypertension and arthritis around age 57, and with prostate enlargement at age 69. He controls his blood pressure with metoprolol, 25 mg daily, and his prostate condition with Proscar, 5 mg daily, both reportedly without side effects.

Allergies and Medication Use

Mr. Hall reported no allergies to medications or latex. He takes Benadryl occasionally for sleep, approximately once or twice a week, but was unsure of the exact dosage. He adheres well to his prescribed medication regimen, with his daughter recently filling his prescriptions at a new pharmacy.

Family History

His father had colon cancer diagnosed too late for effective treatment, and his mother passed away from heart failure after generally being healthy.

Lifestyle and Social History

He does not currently use alcohol or substances but occasionally drinks less than once a month. He smoked for 40 years, quitting at age 60. Mr. Hall exercises occasionally but has recently reduced physical activity due to dizziness and fatigue.

Review of Systems

He denied fever, chills, cough, chest pain, abdominal pain, or swallowing difficulties. He has mild hearing loss managed with a hearing aid and uses glasses for reading. He has no history of blood clots or respiratory symptoms but noted numbness and tingling in his left lower leg associated with pain.

Functional Status and Daily Living

Mr. Hall reported some difficulty with morning stiffness affecting his ability to get out of bed but manages bathing, dressing, toileting, meal preparation, and feeding independently. His enlarged prostate sometimes causes bladder control issues, resulting in occasional accidents. He feels safe at home, although experiences loneliness when his daughter is not around.

Sleep Patterns and Mental Health

He reports disrupted sleep without a fixed schedule, waking multiple times at night. He denies mood changes, anxiety, or depression, describing himself as generally laid-back and resilient.