Health History and Medical Information

Health History

Mr. M., a 70-year-old male, has been living at the assisted living facility where you work. He has no know allergies. He is a nonsmoker and does not use alcohol. Limited physical activity related to difficulty ambulating and unsteady gait. Medical history includes hypertension controlled with ACE inhibitors, hypercholesterolemia, status post appendectomy, and tibial fracture status postsurgical repair with no obvious signs of complications. Current medications include Lisinopril 20mg daily, Lipitor 40mg daily, Ambien 10mg PRN, Xanax 0.5 mg PRN, and ibuprofen 400mg PRN.

Case Scenario

Over the past 2 months, Mr. M. seems to be deteriorating quickly. He is having trouble recalling the names of his family members, remembering his room number, and even repeating what he has just read. He is becoming agitated and aggressive quickly. He appears to be afraid and fearful when he gets aggressive. He has been found wandering at night and will frequently become lost, needing help to get back to his room. Mr. M has become dependent with many ADLs, whereas a few months ago he was fully able to dress, bathe, and feed himself. The assisted living facility is concerned with his rapid decline and has decided to order testing.

Objective Data

1. Temperature: 37.1 degrees C

2. BP 123/78 HR 93 RR 22 Pox 99%

3. Denies pain

4. Height: 69.5 inches; Weight 87 kg

Laboratory Results

1. WBC: 19.2 (1,000/uL)

2. Lymphocytes 6700 (cells/uL)

3. CT Head shows no changes since previous scan

4. Urinalysis positive for moderate amount of leukocytes and cloudy

5. Protein: 7.1 g/dL; AST: 32 U/L; ALT 29 U/L

Critical Thinking Essay

In 750-1,000 words, critically evaluate Mr. M.’s situation. Include the following:

1. Describe the clinical manifestations present in Mr. M.

1. Based on the information presented in the case scenario, discuss what primary and secondary medical diagnoses should be considered for Mr. M. Explain why these should be considered and what data is provided for support.

2. When performing your nursing assessment, discuss what abnormalities would you expect to find and why.

3. Describe the physical, psychological, and emotional effects Mr. M.’s current health status may have on him. Discuss the impact it can have on his family.

4. Discuss what interventions can be put into place to support Mr. M. and his family.

5. Given Mr. M.’s current condition, discuss at least four actual or potential problems he faces. Provide rationale for each.