D222 Shadow Health Case Study: Interview with Robert Hall

Grace J.
November 11, 2025November 11, 2025
BSN, D222, Western Governors University

Student Name

Western Governors University

D222 Comprehensive Health Assessment

Prof. Name

Date

Transcript Summary: Patient Interview with Mr. Robert Hall

Introduction and Presenting Complaint

During the initial interaction, the nurse welcomed Mr. Robert Hall and began the assessment by inquiring about the reason for his hospital visit. Mr. Hall reported that he had fallen earlier that morning following a sudden episode of dizziness upon exiting his vehicle. He described the sensation as a wave of vertigo that caused the garage to appear as if it were spinning, leading to his loss of balance and subsequent fall. His daughter discovered him after the incident. In addition to dizziness, he complained of severe pain and swelling in his lower left leg, uncertain whether these symptoms were related to the fall. The nurse demonstrated empathy and reassurance throughout the discussion.

Patient Identification and Orientation

To confirm the patient’s identity, the nurse verified Mr. Hall’s full name and date of birth. When asked to state his current location and the date, Mr. Hall correctly identified that he was at Shadow General Hospital and provided the correct date. This demonstrated that he was fully oriented to person, place, and time, indicating an intact cognitive status.

History of Present Illness: Pain Description and Onset

Mr. Hall reported that he typically experiences mild arthritis-related pain, but the pain in his left leg had worsened significantly over the past two days, motivating him to seek medical evaluation even prior to his fall. He localized the discomfort to his lower left calf and described it as sharp and persistent, comparable to “repeated jabbing.” On a pain scale from 0 to 10, he rated his current pain as 2, stating it had subsided compared to previous days. Physical activity, particularly walking, exacerbated the discomfort.

Pain Management and Treatments Tried

To alleviate the pain, Mr. Hall took Advil (ibuprofen), which provided no significant relief. Although he does not use herbal supplements, he mentioned that applying heat tends to relieve his arthritis symptoms effectively.

Medical History and Chronic Conditions

Mr. Hall’s medical history includes osteoarthritis, hypertension, and benign prostatic hyperplasia (BPH). He was diagnosed with hypertension and arthritis at age 57, followed by prostate enlargement at age 69. His conditions are managed pharmacologically with Metoprolol (25 mg daily) for blood pressure control and Proscar (5 mg daily) for prostate health. He reported no side effects from either medication.

Allergies and Medication Use

Mr. Hall denied having any allergies to medications or latex. He occasionally takes Benadryl to assist with sleep, approximately once or twice per week, though he is unsure of the exact dosage. He adheres closely to his medication regimen, with his daughter managing prescription refills at a new local pharmacy.

Family History

In discussing his family medical history, Mr. Hall stated that his father was diagnosed with colon cancer at a late stage and passed away due to the disease. His mother died of heart failure but had been generally healthy before her condition worsened.

Lifestyle and Social History

Mr. Hall reported that he does not currently use alcohol or illicit substances, though he drinks occasionally (less than once a month). He was a smoker for 40 years, quitting at the age of 60. While he used to exercise regularly, recent dizziness and fatigue have limited his activity levels.

Review of Systems

He denied fever, chills, chest pain, abdominal pain, or swallowing difficulties. He experiences mild hearing loss, managed with a hearing aid, and uses reading glasses. Mr. Hall denied a history of blood clots or respiratory conditions, though he reported tingling and numbness in his left lower leg accompanying the pain.

Functional Status and Activities of Daily Living

Despite morning stiffness that makes it challenging to get out of bed, Mr. Hall maintains independence in daily activities, including bathing, dressing, toileting, meal preparation, and eating. His enlarged prostate occasionally causes urinary incontinence, but bowel function remains intact. He reported feeling safe at home, though he experiences loneliness when his daughter is absent.

Sleep Patterns and Mental Health

Mr. Hall described his sleep as irregular, waking multiple times during the night and lacking a fixed sleep routine. He denied anxiety, depression, or mood changes, characterizing himself as easygoing and emotionally stable.