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1Case Study: Mr. MLuz EspinozaGCUNRS-410VDecember 5, 2021
2Case Study: Mr. MIn this case study Mr. M is a 70-year-old male living in an assisted living facility (SNF).His medical history includes hypertension, high cholesterol, appendectomy, and recent post-surgical repair of a tibial fracture that demonstrates no signs of infection. Sadly, Mr. M’s healthbegins to decline quickly and the SNF orders testing to be completed. This paper will discuss theclinical manifestations of Mr. M, a primary and secondary medical diagnosis, nursingassessment, Mr. M’s health status, interventions to support Mr. M and his family; And lastlypotential and actual problems Mr. M faces.Clinical ManifestationsMr. M does not smoke or drink alcohol but has decreased physical activity due to anunsteady gait and trouble ambulating. Mr. M's list of medications includes lisinopril 20 MGdaily, Lipitor 40 MG daily, Ambien 10 MG as needed, Xanax 0.5 MG as needed, and Ibuprofen400 MG as needed. For the past two months it seems that Mr. M has been rapidly declining asevidenced by not remembering family members names, unable to recall his room number, andrepeating what he most recently read. He has been showing signs of aggressiveness an agitation;Becoming afraid and fearful during aggressive episodes. A couple of months ago Mr. M was ableto dress, bathe and feed himself. Now, he is unable to perform activities of daily living (ADL)and wanders around at night, constantly becoming lost and needing help locating his room. As aresult of his mental and physical decline the SNF has ordered testing to be completed. His vitalsigns are as follows: Temperature of 37.1 degrees Celsius, controlled blood pressure of 123 / 78,heart rate of 93 beats per minute, respirations of 22, and oxygen saturation reading of 99%. Hedenies any pain, his height is 69.5 inches and weighs 87 kilograms. Mr. M’s lab results show anelevated white blood cell count (WBC) of 19.2 (1,000/uL), increase lymphocyte count of 6,700,
3presence of leukocytes in uranalysis (UA) with urine being cloudy in appearance, protein resultsshow 7.1g/dL, AST results are 32 U/L and ALT lab value being 29 U/L.Medical DiagnosisThe primary diagnosis that should be considered for Mr. M would be a urinary tractinfection (UTI). A UTI can be bacterial or fungal involving the renal system. The olderpopulation is most at risk for UTI’s but often do not show symptoms (Gbinigie et al., 2018). It isalso important to note that UTI’s in the elderly are treated based on mental status change not

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