Chief complaint
Mr. Hall reports severe cramping pain and swelling in his left lower leg, as well as a fall due to
dizziness upon standing.
Orientation
A&O x 4
History of present illness
Mr. Hall is an 80-year-old White man with a history of HTN, BPH with urinary incontinence,
and arthritis who presented to the ER with complaints of left lower leg pain x 2 days and
dizziness. He describes the pain as being localized to the left lower leg. He says the pain was
increasingly severe yesterday and he noticed that his calf was swollen. He describes the pain as
sharp, nagging and constant. He also states that this pain is different from the usual arthritis pain
m
he gets in his hips and knees and that nothing makes the pain better or worse. He tried taking
er as
Advil for the pain at home, but it was ineffective. Upon arrival to the ER, he reports pain level
co
10/10 and describes it as a cramp like pain that won't ease up. Patient reports feeling dizzy for
eH w
about 2 weeks, since he has had his prescription refilled. Has fallen in the past prior to the fall
o.
yesterday. However, he did not have any major injuries as a result of these falls.
Past Medical Hxof rs e
ou urc
HTN, diagnosed at age 57 Arthritis, diagnosed at age 57 Prostate enlargement with minimal
urinary incontinence, diagnosed at age 69
o
aC s
Past surgical hx
vi y re
Mr. Hall reports that he had one previous surgery for abdominal hernia at age 58.
Medication hxR
ed d
Metoprolol 25 mg, 1 tab daily for high blood pressure. Last dose this morning Finasteride
ar stu
(Proscar) 5 mg, 1 tab P.O. once a day last dose 1 day ago Benadryl, dosage unknown, 1 tab PRN
as a sleep aid, last dose earlier this week Advil (ibuprofen) 200 mg, 1 tab PRN for leg pain last
dose yesterday
is
Family Hx
Th
Father died of colon cancer at age 62 Mother died of heart failure at age 78
Social History
sh
Employment: Mr. Hall is a retired carpenter.
Marital status: He is a widower and has two adult daughters. One of them lives close by and
checks on him frequently, at least every other day comes to visit and calls daily.
Tobacco use: Mr. Hall smoked cigarettes for 40 years, but quit 20 years ago.
This study source was downloaded by 100000831788613 from CourseHero.com on 09-28-2021 17:46:40 GMT -05:00
https://www.coursehero.com/file/37216336/Shadow-Health-Mr-Halldocx/
Mr. Hall reports severe cramping pain and swelling in his left lower leg, as well as a fall due to
dizziness upon standing.
Orientation
A&O x 4
History of present illness
Mr. Hall is an 80-year-old White man with a history of HTN, BPH with urinary incontinence,
and arthritis who presented to the ER with complaints of left lower leg pain x 2 days and
dizziness. He describes the pain as being localized to the left lower leg. He says the pain was
increasingly severe yesterday and he noticed that his calf was swollen. He describes the pain as
sharp, nagging and constant. He also states that this pain is different from the usual arthritis pain
m
he gets in his hips and knees and that nothing makes the pain better or worse. He tried taking
er as
Advil for the pain at home, but it was ineffective. Upon arrival to the ER, he reports pain level
co
10/10 and describes it as a cramp like pain that won't ease up. Patient reports feeling dizzy for
eH w
about 2 weeks, since he has had his prescription refilled. Has fallen in the past prior to the fall
o.
yesterday. However, he did not have any major injuries as a result of these falls.
Past Medical Hxof rs e
ou urc
HTN, diagnosed at age 57 Arthritis, diagnosed at age 57 Prostate enlargement with minimal
urinary incontinence, diagnosed at age 69
o
aC s
Past surgical hx
vi y re
Mr. Hall reports that he had one previous surgery for abdominal hernia at age 58.
Medication hxR
ed d
Metoprolol 25 mg, 1 tab daily for high blood pressure. Last dose this morning Finasteride
ar stu
(Proscar) 5 mg, 1 tab P.O. once a day last dose 1 day ago Benadryl, dosage unknown, 1 tab PRN
as a sleep aid, last dose earlier this week Advil (ibuprofen) 200 mg, 1 tab PRN for leg pain last
dose yesterday
is
Family Hx
Th
Father died of colon cancer at age 62 Mother died of heart failure at age 78
Social History
sh
Employment: Mr. Hall is a retired carpenter.
Marital status: He is a widower and has two adult daughters. One of them lives close by and
checks on him frequently, at least every other day comes to visit and calls daily.
Tobacco use: Mr. Hall smoked cigarettes for 40 years, but quit 20 years ago.
This study source was downloaded by 100000831788613 from CourseHero.com on 09-28-2021 17:46:40 GMT -05:00
https://www.coursehero.com/file/37216336/Shadow-Health-Mr-Halldocx/
