Case Study Assignment: Mr. M’s Health History and Medical Information Analysis
Case Study Assignment: Mr. M’s Health History and Medical Information Analysis
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.
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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.
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Mr. M’s Health History and Medical Information Analysis
The paper evaluates the condition of the case study patient identified as Mr. M. Hence the main assessment will highlight the patient’s clinical manifestation, primary and secondary medical diagnosis, possible abnormalities, and physical, psychological, and emotional effects. Also, the paper will evaluate the interventions effective for Mr. M’s condition and the potential issues he faces.
The Patient’s Clinical Manifestation
The objective and subjective data from the patient history indicates that Mr. M does not suffer from a critical or life-threatening disease. However, Mr. M likely has Alzheimer’s, evidenced by his memory loss status. The memory loss is evident through the patient’s inability to recall the names of his family members, repeating what he just read and his room number, which is facilitated by dementia conditions which are all Alzheimer’s signs and symptoms. Also, the patient presents aggressiveness and agitation, especially when he faces any fear. Another factor that portrays his memory loss is when he wanders at night and forgets his room. The patient presents Alzheimer’s condition because Alzheimer’s patients always get it wrong when making judgments and engaging in their activities of daily living (ADLs) (Dorszewska & Kozubski, 2018). The case study patient is dependent when engaging in ADLs, proving the worsening state of his memory lapse. Therefore, considering that the patient is 70-year-old, age could be the main contributing factor to the dementia condition.
Patient’s Primary and Secondary Medical Diagnosis
When diagnosing any disease, it is always essential to consider both primary and secondary medical diagnoses. When diagnosing Alzheimer’s, it is essential to assess both the primary and secondary diagnostic processes. The primary diagnosis will be evaluating the cognitive impairment, thus ensuring that the patient’s mental status is tested. Also, there will be a need to involve family members to get more information about the patient condition, especially detailed behavior information. According to Abeysinghe et al. (2020), the main cognitive impairment signs and symptoms includes mood and behavior changes, inability to recognize family members, and memory loss which are all present in the case study patient.
The secondary test that will be effective for Mr. M will involve brain imaging, neuropsychological testing, and mental status laboratory tests. The brain imaging test is essential and will include a CT Scan and MRI since it would help the physician identify any brain abnormalities the patient may exhibit. In most cases, MRI tests help establish brain effects caused by instances like stroke, brain tumors, and trauma that may affect the patient’s cognitive abilities. The laboratory tests will also be crucial, including the urinalysis and blood tests that would help the physician to assess if thyroid disorders and vitamin deficiencies cause the memory loss, that is because the patient has a WBC: of 19.2 (1,000/uL), whereas the normal white blood cells (WBCs) is between 4,000/uL and 10000/uL thus indicating a probability of Vitamin B12 deficiency. Consequently, the lymphocyte level is higher than normal since normal levels are usually at 1,000 and 4,800 lymphocytes compared to the patient’s Lymphocytes 6700 (cells/uL), which might trigger an infection (Cleveland Clinic, 2022). It will also be necessary to conduct a neurological examination since it will provide the medical team with comprehensive information concerning the patient’s neurological status to help in further evaluation. That way, the medical team will assess Mr. M’s case using evidence-based information from other patients within the same age group, thus easily tracking the symptoms’ progression. However, if the physician rules out these abnormalities, it will prove that the patient has Alzheimer
Possible Abnormalities
Physicians can find abnormalities as they assess a patient. The main abnormality will involve the thyroid that will emanate from the results obtained from the lab tests. Low white blood cell counts may present an instance of thyroid disease and Alzheimer’s. Hence, it will be crucial for the physician to evaluate these issues do not lead to a diagnosis error.
The Physical, Psychological, and Emotional Effects
Alzheimer’s presents issues that may influence patients’ and their families’ physical, psychological, and emotional statuses (Dorszewska & Kozubski, 2018). The main physical impact includes affecting how the patient handles the ADLs. For instance, Mr. M has an issue with his unstable gait, which may cause other complications like falls, leading to the patient’s fracturing his bones. The psychological impact of the Alzheimer’s includes Mr. M and the family developing depression. The most probable reason for Mr. M developing depression is that he cannot feed and do other essential activities and has to rely on other people. Also, the family may become depressed due to the aggressive state of the patient, and they may decide to seclude him to avoid harming himself and other people. Such stress will not only affect their mental health since it will also influence their emotions.
Effective Intervention Support
The main intervention will be engaging the patient and the family members in a patient education session before deciding the best therapy for the patient. That way, they will effectively understand the patient’s condition and the importance of being part of the patient’s treatment, especially ensuring that the patient adheres to the prescribed medication (Abeysinghe et al., 2020). Patient education will also help the physician and the family members outline the most effective communication plan since it is imperative to patient education and care coordination.
Potential Issues Mr. M Faces and Conclusion
The potential health implications Mr. M may face due to his prevailing conditions include falls and injuries that his poor judgment may facilitate. Other factors include Mr. M’s experiencing starvation and dehydration due to his latest incapability to feed himself. Also, Mr. M may face issues with infections since he cannot conduct ADLs. In conclusion, it will be easier to manage Mr. M’s condition through such diagnosis procedures and interventions.
References
Abeysinghe, A. A. D. T., Deshapriya, R. D. U. S., & Udawatte, C. (2020). Alzheimer’s disease; a review of the pathophysiological basis and therapeutic interventions. Life sciences, 256, 117996. https://doi.org/10.1016/j.lfs.2020.117996
Cleveland Clinic (June 20, 2022). Lymphocytes. https://my.clevelandclinic.org/health/body/23342-lymphocytes
Dorszewska, J., & Kozubski, W. (Eds.). (2018). Alzheimer’s Disease: The 21st Century Challenge. BoD–Books on Demand.