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
Temperature: 37.1 degrees C
BP 123/78 HR 93 RR 22 Pox 99%
Denies pain
Height: 69.5 inches; Weight 87 kg
Laboratory Results
WBC: 19.2 (1,000/uL)
Lymphocytes 6700 (cells/uL)
CT Head shows no changes since previous scan
Urinalysis positive for moderate amount of leukocytes and cloudy
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
Temperature: 37.1 degrees C
BP 123/78 HR 93 RR 22 Pox 99%
Denies pain
Height: 69.5 inches; Weight 87 kg
Laboratory Results
WBC: 19.2 (1,000/uL)
Lymphocytes 6700 (cells/uL)
CT Head shows no changes since previous scan
Urinalysis positive for moderate amount of leukocytes and cloudy
