Name
Western Governors University
D222 Comprehensive Health Assessment
Prof. Name
Date
The nurse greeted Mr. Robert Hall 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 feeling sudden dizziness upon exiting his car. He described the dizziness as a wave of vertigo, causing the garage to spin and leading to a loss of balance. His daughter found him after the fall. Besides dizziness, Mr. Hall complained of significant pain and swelling in his lower left leg, unsure if these symptoms were related to the fall. Throughout the interview, the nurse maintained a compassionate and reassuring demeanor.
To verify his identity, the nurse confirmed Mr. Hall’s full name and date of birth. When asked about his current location and the date, Mr. Hall accurately stated he was at Shadow General Hospital and correctly identified the date. This indicated full orientation to person, place, and time, demonstrating intact cognitive function.
Mr. Hall mentioned that he generally experiences mild arthritis-related pain but noted a marked increase in pain in his left leg over the past two days, prompting him to seek medical attention before his fall. He localized the pain to his lower left calf, describing it as sharp and persistent, similar to repetitive jabbing. On a pain scale from 0 to 10, he rated his current pain as a 2, which was less intense compared to previous days. Movement, especially walking, intensified the discomfort.
To manage the pain, Mr. Hall had taken Advil (ibuprofen), but it did not provide significant relief. He mentioned not using herbal remedies but said applying heat typically eases his arthritis symptoms.
Mr. Hall’s medical history includes osteoarthritis, hypertension, and benign prostatic hyperplasia (BPH). He was diagnosed with hypertension and arthritis at age 57 and with prostate enlargement at age 69. His blood pressure is controlled with Metoprolol 25 mg daily, and Proscar 5 mg daily is prescribed for prostate health. He reports no side effects from these medications.
Mr. Hall stated he has no known allergies to medications or latex. He occasionally uses Benadryl to aid sleep about once or twice weekly, though he is unsure of the exact dosage. He adheres to his prescribed medications diligently, with his daughter managing prescription refills at a local pharmacy.
When asked about family medical history, Mr. Hall revealed that his father died from late-stage colon cancer, while his mother passed away due to heart failure but was otherwise generally healthy before her condition worsened.
Mr. Hall reported no current use of alcohol or illicit substances, though he drinks socially less than once a month. He smoked for 40 years but quit at age 60. While he used to exercise regularly, recent dizziness and fatigue have reduced his activity levels.
He denied experiencing fever, chills, chest pain, abdominal pain, or swallowing difficulties. He acknowledged mild hearing loss managed with a hearing aid and uses reading glasses. Mr. Hall denied a history of blood clots or respiratory issues but reported numbness and tingling in his left lower leg, accompanying the pain.
Despite morning stiffness that complicates getting out of bed, Mr. Hall remains independent in daily activities such as bathing, dressing, toileting, meal preparation, and eating. Occasional urinary incontinence occurs due to his enlarged prostate, but bowel function is normal. He feels safe at home but experiences loneliness when his daughter is away.
Mr. Hall described his sleep as irregular, with frequent nighttime awakenings and no consistent sleep routine. He denied symptoms of anxiety, depression, or mood changes, describing himself as emotionally stable and easygoing.
Question | Answer |
What brought you here today? | Fell after a sudden dizzy spell; reports left leg pain and swelling. |
What is your full name? | Robert Hall. |
What is your date of birth? | December 28th (correct year provided). |
Do you know where you are? | Yes, Shadow General Hospital. |
What day is it? | Correctly identified date. |
When did the leg pain start? | Began two days ago; progressively worsening. |
Can you describe the pain? | Sharp, nagging pain resembling repetitive jabbing in the left calf. |
How would you rate your pain (0–10)? | Currently 2/10; previously higher. |
Does anything make the pain worse? | Pain worsens with movement, particularly walking. |
Have you used anything for pain relief? | Tried Advil without improvement; heat helps arthritis discomfort. |
Do you have any health conditions? | Osteoarthritis, hypertension, and enlarged prostate. |
When was your hypertension diagnosed? | At age 57. |
How is your blood pressure controlled? | Metoprolol 25 mg daily; well managed. |
Tell me about your arthritis. | Mild hip and knee pain with stiffness; leg pain more severe recently. |
When were you diagnosed with prostate enlargement? | At age 69. |
Do you have any allergies? | No known drug or latex allergies. |
What medications do you take at home? | Metoprolol, Proscar, occasional Benadryl for sleep. |
Do you take medications as prescribed? | Yes, consistently. |
Do you take any vitamins or supplements? | None. |
Do you experience any side effects from medications? | No. |
How often do you use Benadryl? | Once or twice a week, dosage unspecified. |
Can you tell me about your parents’ health? | Father had colon cancer; mother died from heart failure. |
Do you use alcohol or substances? | Drinks occasionally; denies substance use. |
Do you smoke? | Quit smoking at 60 after 40 years. |
Do you exercise? | Occasionally, but limited due to 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. |
Do you have shortness of breath or cough? | No. |
Do you have a history of blood clots? | No. |
Do you have headaches or mood changes? | No frequent headaches; stable mood. |
Can you perform daily activities independently? | Yes. |
Do you experience bladder or bowel control issues? | Occasional bladder accidents; bowel control intact. |
How is your sleep? | Irregular, frequently wakes at night. |
Question / Action | Response / Notes |
Have you noticed any confusion or forgetfulness? | No, remains fully aware of surroundings. |
Tell me about your fall history. | Fell twice in the last six months. |
Did you feel dizzy before falling? | Yes, dizziness was sudden and intense. |
What brings on the dizziness? | Uncertain; suspects pain or fatigue may contribute. |
Do you have trouble with balance? | Yes, increased instability lately. |
Do you use an assistive device? | Occasionally uses a cane when standing or sitting. |
Any rashes or wounds? | None; joints appear slightly red. |
Any bruising? | Bruising on legs from the fall. |
Weight changes? | Unintentional 10-pound weight loss. |
Changes in appetite? | Decreased appetite recently. |
Social interaction? | Less social due to health concerns. |
General health perception? | Feels overall health has 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. |
Safety at home? | Feels safe; no threats or fears. |
Fall prevention plan | Bed rails secured, fall risk bracelet applied, patient education completed. |
Consent to fall prevention plan | Yes, verbal consent provided. |
Mr. Hall presents a multifactorial risk for falls, likely stemming from a combination of dizziness, localized musculoskeletal pain, and age-related physiological changes. His history of hypertension is well controlled, but the increasing balance instability and leg pain warrant further evaluation. A comprehensive fall-prevention strategy has been initiated, including environmental safety measures, medication review, and patient education, all with Mr. Hall’s informed consent.
American Psychological Association. (2020). Publication manual of the American Psychological Association (7th ed.). https://doi.org/10.1037/0000165-000
