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Case Study of Mr. M
, Case Study of Mr. M 2
Clinical Manifestations of Mr.
A 70-year-old male Mr. M who live at an assisted living facility. Mr. M has Alzheimer’s
disease and Urinary Tract Infection (UTI). Does not smoke nor take alcohol, has reduced
physical activity associated to trouble ambulating and an unsteady gait. Mr. M has history of
hypercholesterolemia, status post appendectomy, hypertension controlled with ACE inhibitors
and tibial fracture status post-surgical repair with no apparent signs of complications. For the
past two months patient appears to be deteriorating and having trouble remembering loved one’s
names, room number, repeats what he just read. Easily becomes agitated and aggressive, appears
to be frightened during these episodes of aggression. During this period, patient become reliant
with several ADLs, few months back patient was able to dress, bathe, and feed himself. The
objective information presented at this time are Temperature 37.1 oC, B/P 123/78, pulse Spo2
99% on room air, respiration rate of 22, and heart rate of 93 bpm. Labs disclose WBC of 19.2
(1000, /uL), lymphocytes 6700 (cell/uL), CT head reveals nil changes since prior scan, urinalysis
positive for mild number of leukocytes, cloudy, protein 7.1 g/dL, AST 32 u/L, and ALT 29 u/L.
Primary and Secondary Medical Diagnoses
Patient primary medical diagnosis is Alzheimer and UTI while secondary diagnoses are
hypertension, hypercholesterolemia, status post appendectomy, and tibial fracture status post-
surgical repair. Alzheimer is the utmost common type of dementia Sign and Symptoms (S/S) of
the onset of this disease are: memory loss, trouble planning and solving problems, trouble
finishing recognizable chores, difficulty determining place and time, sight loss, finding right
words and making decisions, losing items, social withdrawal and mood changes (Hansen, 2016).