Health History and Medical Information Mr. M Assignment





Health History and Medical Information Mr. M




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Health History and Medical Information Mr. M

`The provided case study demonstrates a 70-year-old male patient, Mr. M in the assisted living facility with rapidly deteriorating health. He has limited physical activity associated with unsteady gait and difficulty ambulating. The patient has a history of hypertension which he manages well with ace inhibitors. He also has a history of status post appendectomy, hypercholesterolemia, and tibia fracture status postsurgical rapid but no signs of complications were reported. The patient is on several medications to manage these conditions. However, he is currently concerned about his rapidly deteriorating health and seek further testing. The purpose of this discussion is to evaluate and diagnose the patient to promote the development of appropriate intervention necessary to promote the patient health and provide support to his family.

Clinical Manifestations of Mr. M.

            Mr. M. is concerned about his rapidly deteriorating health. He presents with limited physical activity associated with unsteady gait and difficulty ambulating. Additional symptoms provided in the subjective portion of the patient history include memory loss, agitation, and aggressiveness. He reports being fearful and afraid whenever he gets aggressive. He is currently unable to independently go through his daily activities. From the provided objective data, Mr. M BMI indicates that he is overweight. His heart rate and blood pressure are also elevated. White blood cell count and lymphocytes are very high showing signs of infection. His urine is cloudy and positive for moderate amounts of leukocytes. Liver function tests reveal normal results.

Diagnoses and Secondary Diagnoses

Based on the provided history, the most likely primary medical diagnosis for the patient is Alzheimer’s disease. This is the commonest form of dementia characterized by memory loss in advanced age. The patient claims that he is very forgetful and sometimes he even gets lost and needs help to identify his room within the assisted living facility. The decline in cognitive function as displayed by the patient in addition to memory loss is some of the common indicating signs of Alzheimer’s disease (Na et al., 2020). Additional positive symptoms include agitation and aggression associated with being afraid and fearful.

            The most likely secondary diagnosis for the patient is Urinary Tract Infection. This diagnosis is mainly supported by the patient laboratory findings such as high WBC and Lymphocyte count. The patient urine is also cloudy, with moderate leukocytes. Studies also show that UTIs in the elderly can exacerbate dementia symptoms such as memory loss, agitation, and aggressiveness (Chang et al., 2021). Additional secondary diagnoses include hypertension and hypercholesterolemia as reported in the patient medical history.

Explanation of Expected Abnormalities During Nursing Assessment

When assessing the patient, it is necessary to identify the abnormalities displayed in the patient’s objective data. His lab works and urinalysis results reveal abnormalities for a UTI. For instance, the patient’s WBC is 19.2 (1,000/uL) way higher than the normal range for male adults at 4.5 to 11.0 × 109/L (Roy et al., 2020). His lymphocyte count is also high at 6700 (cells/uL) above the normal range of between 1000 to 4800 cells/uL. Urinalysis results also reveal the presence of leukocytes in the patient’s urine which is a sign of inflammation or infection of the urinary tract. As such, further assessment such as abnormalities in urinary patterns like hesitancy, urgency, or frequency is necessary. Additionally, the patient also presents with signs of multiple mental comorbidities associated with impaired cognitive function, which may result from dementia, depression, delirium, or endocrine derangements. Most of these mental conditions normally result from concurrent disease processes which in the case of this patient is a UTI.

Effects of Health Status on Physical, Psychological, and Emotional Aspects of Patient and Family

            The patient current health status indicates signs of Alzheimer’s disease which might have been triggered by a urinary tract infection, impairing his physiological and physical functioning. For instance, due to Mr. M’s Alzheimer’s condition, he presents with limited physical activity associated with unsteady gait and difficulty ambulating (Na et al., 2020). He is even unable to support independent living and needs help in doing most of his routine daily activities. Psychologically, the patient’s decline in cognitive function can lead to comorbid mental problems such as depression and delirium among others. Emotionally, the patient memory loss to the point that he forgets even his family members can be very frustrating, making him sad. This can also be very overwhelming for the family members leading to a range of emotions like fear, anger, sadness, and frustration.

Interventions for Support

To promote the health and well-being of the patient, it is necessary to manage all the underlying diseases such as UTIs, to reduce their impact on deteriorating the patient health. Consequently, with the suspected Alzheimer’s disease, the patient will greatly benefit from memory training, physical exercise programs, and mental and social stimulation (Gowan & Roller, 2019). Such interventions will help improve the patient’s cognitive performance and promote his independence. The patient’s family members will also need to be educated on how to help the patient recover. They also need emotional support which will be achieved through support groups and counseling.



Actual or Potential Problems Based on Condition

            The first problem the patient is facing is the presence of a urinary tract infection supported by cloudy urine with leukocytes and high WBC and lymphocyte count. If the patient’s UTI goes untreated, it may lead to additional complications such as renal impairment or sepsis. These two conditions can precipitate acute kidney injury declining the functioning of his kidneys (Gracner et al., 2019). The patient also displays possibilities of Alzheimer’s disease, supported by the patient’s decline in cognitive function causing memory loss, agitation, and aggressiveness. Alzheimer’s disease can lead to dysphagia for both solids and liquids causing dehydration, malnutrition, or aspiration pneumonia.


The patient in the provided case study is concerned with his rapidly deteriorating health status. From the provided history, the patient is most likely suffering from Alzheimer’s disease which may have been accelerated by his urinary tract infection. He needs to undergo memory training, physical exercise programs, and mental and social stimulation to promote his cognitive function. His family members also need to join a support group for emotional support.




Chang, C. W., Juan, Y. S., Yang, Y. H., & Lee, H. Y. (2021). The Relationship Between Lower Urinary Tract Symptoms and Severity of Alzheimer’s Disease. American Journal of Alzheimer’s Disease & Other Dementias®36, 1533317521992657. DOI: 

Gowan, J., & Roller, L. (2019). Disease state management: Alzheimer’s disease and other common dementias. AJP: The Australian Journal of Pharmacy100(1188), 64-75.

Gracner, T., Sorbero, M., Stone, P. W., Agarwal, M., & Dick, A. W. (2019). Advanced illness among elderly nursing home residents with Alzheimer’s disease and related dementia. Innovation in Aging3(Suppl 1), S509. DOI: 

Na, H. R., & Cho, S. T. (2020). Relationship between lower urinary tract dysfunction and dementia. Dementia and Neurocognitive Disorders19(3), 77.

Roy, H. A., Nettleton, J., Blain, C., Dalton, C., Farhan, B., Fernandes, A., … & Drake, M. J. (2020). Assessment of patients with lower urinary tract symptoms where an undiagnosed neurological disease is suspected: A report from an International Continence Society consensus working group. Neurourology and Urodynamics39(8), 2535-2543.

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