Complete Shadow Health Mobility Assessment for Robert Hall. 80-year-old presenting to ER with left calf pain 10/10 (suspected DVT), 2-week history of dizziness correlating with medication refill, prior fall history, and complex PMH (HTN, BPH with urinary incontinence, arthritis). Fall risk assessment, medication review and mobility evaluation fully documented.
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Robert Hall is an 80-year-old presenting to the ER with left lower leg pain for 2 days and dizziness for approximately 2 weeks. He rates the leg pain as 10/10 on arrival — sharp, nagging, constant and cramp-like. He noticed calf swelling yesterday. He explicitly states this pain is different from his usual hip and knee arthritis pain. Advil was ineffective.
The dizziness correlates precisely with a recent prescription refill. He has a prior fall history and fell yesterday without major injury. PMH includes HTN (on antihypertensives — suspected cause of dizziness), BPH with urinary incontinence (nocturia increases fall risk), and arthritis of hips and knees.
Suspected DVT — Doppler ultrasound ordered. Dizziness — medication review completed. Fall risk score elevated — precautions implemented.