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.Health History and Medical Information Essay.
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.Health History and Medical Information Essay.
Objective Data
Laboratory Results
Critical Thinking Essay
In 750-1,000 words, critically evaluate Mr. M.\’s situation. Include the following:
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. Health History and Medical Information Essay.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
Clinical Manifestations in Mr. M
The patient is a 70-year-old called Mr. M living in an assisted facility and has a UTI and AD. Neither does he drink alcohol nor smokes but has limited physical activity resulting from an unsteady gait and difficulty ambulating. His overall health status seemed to be declining with trouble recalling his room number, names of his loved ones, and repeating what he has just read. Mr. M quickly becomes aggressive and agitated and appears to be fearful during the episodes of aggression. At night, Mr. M wanders and frequently gets lost requiring assisting to find his room and is unable to perform ADLs. The objective data reveals that Mr. M has a blood pressure of 123/78mmHg, a normal temperature of 37.10c, pulse rate of 93(elevated), pulse oximetry of 99 %( room air), respiratory rate of 22(slightly elevated). Laboratory findings reveal a WBC of 19.2 (1,000/uL), Lymphocytes 6700 (cells/uL), A CT scan with no changes from the previous one and a positive urinalysis for moderate leukocytes and cloudy, a protein 7.1 g/dL, AST 32 U/L, and ALT 29 U/L.Health History and Medical Information Essay.
Primary and Secondary Medical Diagnoses to Consider
Mr. M’s primary medical diagnosis is UTI and Alzheimer’s disease (AD). Secondary diagnoses are; hypertension and hypercholesterolemia.
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