Clinical Health History and Medical Information

Clinical Health History and Medical Information. It is necessary for an RN-BSN-prepared nurse to demonstrate an enhanced understanding of…

It is necessary for an RN-BSN-prepared nurse to demonstrate an enhanced understanding of the pathophysiological processes of disease, the clinical manifestations and treatment protocols, and how they affect clients across the life span.

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

  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.
  2. 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.
  3. When performing your nursing assessment, discuss what abnormalities would you expect to find and why.
  4. 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.
  5. Discuss what interventions can be put into place to support Mr. M. and his family.
  6. 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.

Critical Appraisal of an Epidemiological Study


This paper discusses the clinical manifestations presented by the patient in this case scenario, probable primary and secondary medical diagnoses, and expected abnormalities. The paper also describes the physical, psychological, and emotional effects of the patient’s health status on himself and his family. Lastly, the paper discusses probable interventions to support the patient and his family and actual/potential problems faced by the patient.

Clinical Manifestations

Considering the presented information, Mr. M’s health is on the decline over the past two months. He has memory problems –remembering names of family members, room number, and repeating what he has just read. He presents personality and behavioral changes – he is agitated, fearful, and aggressive. He presents a sign of increased confusion – he is often withdrawn, sometimes wandering and feeling lost.

Most significantly is his inability to perform activities of daily living, including dressing, bathing, eating, and feeding himself. According to Weller & Budson (2018), the clinical manifestations presented by Mr. M represent Alzheimer’s symptoms.

From the objective assessments, the patient has a normal temperature indicating no fever. The patient’s BP 123/78 HR 93 RR 22 Pox 99% indicates prehypertension considering the systolic value above 120. Considering a height of .5 inches and a bodyweight of 87kg, Mr. M BMI is 28.4, indicating overweight. The results from a CT scan of the head show no alteration since the initial scan.

Mr. M Urinalysis read the presence of a moderate amount of leukocytes. Equally, protein analysis shows 7.1 g/dL; AST: 32 U/L; ALT 29 U/L. The urinalysis and protein analysis could indicate inflammation of the Urinary tract system of infection. However, Mr. M also denies pain and a CT scan reveals no changes in the brain.

Primary and Secondary Medical Diagnoses

A primary diagnosis for Mr. M would include Alzheimer’s Dementia (AD) because it is common dementia with symptoms of decline in reasoning and thinking skills, memory decline, poor judgment, a reduced attention span and focus, and changes in language skills. Besides, Mr. M exhibits four risk factors of AD: his overweight, old age, sedentary lifestyle, and hypertension.

This primary diagnosis is also justified because Mr. M has exhibited the signs of mild AD that are in the process of progressing to moderate AD (Bertrand et al., 2018). Therefore, a PET scan should be conducted to identify abnormal patterns of glucose decline in the brain and any amyloid plaque deposits. In addition, the PET scan should also ascertain the abnormal build-up of the tau protein in the nerve cells.

A second primary diagnosis for Mr. M would be the possibility of a urinary tract infection as evidenced by the elevated white blood cell count, cloudy urinalysis with moderate leukocytes, and elevated lymphocytes. An unusually high number of leukocytes in urine signifies swelling or infection in the urinary tract, most commonly in the bladder or kidney (Pol et al., 2017).

The diagnosis is essential to Mr. M, who is undertaking medications such as Lipitor and Lisinopril, which have known side effects on the kidneys. Hence, further diagnosis of urinary tract infection is necessary.


During the assessment, characteristic abnormalities include diverticular pouching in the bladder or urethra and an enlarged bladder. Diverticular pouching often harbor bacteria, consequently leading to urinary tract infection (Swanson & Strate, 2018). Equally, an enlarged bladder can cause blockage of the urinary tract system, preventing normal drainage of all the urine from the bladder (Serlin et al., 2018).

The retention of urine is associated with UTIs.  A CT scan is necessary to identify infected or inflamed pouches or bladder blockage, confirm the abnormalities, and guide treatment.

Physical, Psychological, and Emotional Effects

Alzheimer’s dementia causes physical effects on the brain in critical weight. Since Mr. M is likely suffering from Alzheimer’s, his brain may be developing amyloid plaques or neurofibrillary tangles in the brain (Stanford Health Care, n.d.). The brain’s physical structure changes result in unusual clumps of protein and degenerating bits of neurons. Psychological effects that Mr. M could be suffering from psychosis, depression, and anxiety (Bertrand et al., 2018).

Emotionally, the patient’s condition can lead to apathy and irritability (Bertrand et al., 2018). Diagnosis with Alzheimer’s would also affect the patient’s family members overwhelmingly. The effects of fear, anger, frustrations, sadness, depression, and even conflicts are shared among family members of Alzheimer’s patients (Grabher, 2018). The effect Alzheimer has on family members is associated with the many decisions to make about treatment, care, living arrangements, finances, and end-of-life care.

Potential Interventions

Potential interventions for implementation to support Mr. M include mental health assessment to ascertain his condition.  Besides, Mr. M should be assigned a therapist to help him gain the ability to carry out routine activities and minimize possible aggression to himself and others.

Besides, the patient should be assigned a clinical practitioner to help him in physical exercise to minimize confounding factors associated with a sedentary lifestyle. The practitioners should also establish a routine visit with family members to cheer him up since he slowly forgets their names.

Actual and Potential Problems

Mr. M’s actual problems include memory loss, prehypertension, and UTIs. The provided status shows that Mr. M cannot remember his family members’ names or room numbers. Equally, his BMI Index shows that Mr. M has prehypertension. Lastly, lab results indicate a moderate amount of leukocytes, which is a clear indication of UTI.

On the other hand, Mr. M’s potential problems include the risk of stroke. Due to his prehypertension status and inability to carry out activities of daily living, Mr. M is predisposed to developing stroke (U.S. Department of Health & Human Services, 2019).


The patient is like to have Alzheimer’s dementia considering the prominence of memory issues and UTI as indicated by the urinalysis and protein analysis. However, further diagnosis is necessary to ascertain this diagnosis. Equally, the patient should be assigned a therapist and a practitioner to provide guided care and assistance with the routine living activities.


Bertrand, E., van Duinkerken, E., Landeira-Fernandez, J., Dourado, M. C., Santos, R. L., Laks, J., & Mograbi, D. C. (2017). Behavioral and psychological symptoms impact clinical competence in Alzheimer’s disease. Frontiers in aging neuroscience9, 182.

Grabher, B. J. (2018). Alzheimer’s Disease and the Effects it has on the Patient and their Family. Journal of Nuclear Medicine Technology, jnmt-118.

Serlin, D. C., Heidelbaugh, J. J., & Stoffel, J. T. (2018). Urinary retention in adults: evaluation and initial management. American family physician98(8), 496-503.

Stanford Health Care. (n.d.). Alzheimer’s disease. Available at: [Accessed 24 May 2021]

Swanson, S. M., & Strate, L. L. (2018). Acute Colonic Diverticulitis (Japanese Version). Annals of internal medicine168(9), JITC65-JITC80.  10.7326/AITC201805010

U.S. Department of Health & Human Services. (2019).Stroke. Available at: [Accessed 24 May 2021]

Weller, J., & Budson, A. (2018). Current understanding of Alzheimer’s disease diagnosis and treatment. F1000Research7.


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