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CASE STUDY MR. MLeticia HernandezGrand Canyon University: NRS-410VAugust 8, 20191
CASE STUDY MR. MMedical Case of Mr. M This case study is on Mr. M who is a 70 years old male living in an assisted living facility he has a history hypertension, hypercholesterolemia and is status post appendectomy and tibia fracture status post-surgical repair with no signs of complications. Mr. M hypertension is controlled with ACE inhibitors and takes Lisinopril daily for his hypercholesterolemia. Mr. M also takes a sleeping aid Ambien 10mg when needed and Xanax 0.5mg his orders also include ibuprofen 400mg also as needed for pain. Mr. M has no know allergies and no history of smoking or use ofalcohol. Mr. M is limited with his physical activity which is related to difficulty with ambulation and unsteady gait.Subjective and Objective Data Mr., M is a resident at an assisted living facility and in the past two months the medical team has notice cognitive mental decline in Mr. M memory, he is demonstrating trouble with recalling the names of his family members and recall of his resident room number. Mr.M is presenting with behavioral issues such as repeating himself and his mood has become agitated and aggressive, he also appears to be fearful when he is aggressive. He has been found wandering in the middle of the night and needs help to find his room. He has also become dependent with his activities of daily living from dressing to feeding himself. Upon a head to toe assessment Mr. M is a seventy-year-old male approximately 69.5 (five-feet seven inches) and is 87 kilograms (191lbs), his vital signs are temperature 37.1 (98.7 Fahrenheit), blood pressure of 123/78 with Heart rate of 93 respirations’ are 22 and Pox is at 99%, upon assessment of diagnostic labs there is an elevated WBC count of 19.2 (1,000/ul) and elevated levels of lymphocytes at 6700 (cells/ul), the U/A is positive for moderate amounts of leukocytes and appears cloudy which is indicative of a urinary tract infection. Protein levels are also elevated at 2
CASE STUDY MR. M

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