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3 pages/β‰ˆ825 words
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Style:
APA
Subject:
Health, Medicine, Nursing
Type:
Case Study
Language:
English (U.S.)
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Topic:

Evaluating Health History and Medical Information of a Patient

Case Study Instructions:

Evaluate the Health History and Medical Information for Mr. M., presented below.
Based on this information, formulate a conclusion based on your evaluation, and complete the Critical Thinking Essay assignment, as instructed below.
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
Temperature: 37.1 degrees C
BP 123/78 HR 93 RR 22 Pox 99%
Denies pain
Height: 69.5 inches; Weight 87 kg
Laboratory Results
WBC: 19.2 (1,000/uL)
Lymphocytes 6700 (cells/uL)
CT Head shows no changes since previous scan
Urinalysis positive for moderate amount of leukocytes and cloudy
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:
Describe the clinical manifestations present in Mr. M.
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.
When performing your nursing assessment, discuss what abnormalities would you expect to find and why.
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.
Discuss what interventions can be put into place to support Mr. M. and his family.
Given Mr. M.'s current condition, discuss at least four actual or potential problems he faces. Provide rationale for each.
You are required to cite to a minimum of two sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. Refer to the LopesWrite Technical Support articles for assistance.

Case Study Sample Content Preview:

Critical Thinking Essay Assignment
Student Full Name
Institutional Affiliation
Course Full Title
Instructor Full Name
Due Date
Critical Thinking Essay Assignment
Mr. M displays the classic symptoms of Alzheimer's disease, including rapid mental degradation in remembering things and organizing thoughts. The memory impairments have resulted in Mr. M having trouble recalling the names of family members, remembering his room number, and even repeating what he has just read. Moreover, the disease has resulted in changes in personality and behavior, including aggressiveness, wandering, anxiety, and fearfulness. Mr. M has also lost the skills required for personal care and has become dependent on many ADLs. Even while a few months ago, he was fully capable of dressing, bathing, and feeding himself. Besides, the patient also shows signs of urinary tract infection, hypertension, and hypercholesterolemia as demonstrated by the following clinical results: WBC 19.2 (1,000/uL); Lymphocytes 6,700 (cells/uL); as well as urinary test results that indicate a moderate amount of leukocytes and cloudy protein 7.1 g/dL; AST 32 U/L; ALT 29 U/L. Mr. M also has slightly high blood pressure readings: BP 123/78 HR 93 RR 22 Pox 99%.
Based on the information presented in the case scenario, the primary medical diagnosis for Mr. M is Alzheimer's disease, while secondary diagnoses are urinary tract infection, hypertension, and hypercholesterolemia. The patient's rapid memory loss, along with mood and personality changes, points to Alzheimer's disease. Besides, the laboratory test results (WBC of 19.2, Lymphocytes 6,700 (cells/uL), together with a positive urinalysis for moderate leukocytes and cloudy proteins indicate urinary tract infection, which could also have heightened Mr. M's sudden behavior changes like agitation and aggression. In addition, the patient is currently taking ACE inhibitors to control his hypertension and has high blood pressure. Moreover, Mr. M has a medical history of hypercholesterolemia, as evident from the laboratory findings of a protein 7.1g/dL, AST 32 U/L, and ALT 29 U/L, which indicate high cholesterol levels in the blood.
When performing my nursing assessment, I expect to find abnormalities for a urinary tract infection: most adult males have a lymphocyte count of between 1,000 and 4,800. However, the patient's lymphocytes are way beyond the normal range (6,700 cells/uL). Lymphocytes are produced in the one marrow and serve as the body's immune cells. Mr. M's high number of lymphocytes is likely to result from the body's response to the urinary tract infection. At the same time, Mr. M's WBC of 19.2 (1,000/uL) exceeds the usual WBC range of 4.5 to 11 (1,000/uL). The higher white blood cells indicate an underlying infection, most likely to...
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