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Clinical manifestations present in Mr. M.
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Based on the case scenario, Mr. M is a 70-year-old patient with mental deterioration for the past two months, as reflected by his difficulties in recalling the names of his family members, room number, and what he just read. In addition, Mr. M exhibits aggressiveness and agitation and seems fearful and afraid when aggressive. He is found wandering at night and frequently gets lost, requiring assistance to get back to his room. A few months ago, Mr. M was in a position to dress, bathe, and feed himself; however, he currently depends on ADLs. He has a medical history of hypertension managed by Lisinopril 20mg daily and hypercholesterolemia managed with 40 mg of Lipitor. He has previously undergone a surgical procedure for appendectomy and repair of tibial fracture. Furthermore, he leads a sedentary lifestyle, depicted by an unsteady gait and ambulation. Subjective findings also demonstrate PRN medication, including Ambien 10mg, Xanax 0.5mg, and Ibuprofen 400mg. Objective data shows the temperature of 37.1 C, B/P – 123/78, HR – 93, RR – 22, and O2Sat – 99%. Mr. M appears overweight at 69.5 inches and 87 kg in weight. Lab results indicate that Mr. M has 19.2 WBC with Lymphocytes of 6700 cells/uL. However, urinalysis is positive for leukocytes, cloudy and protein – 7.1g/dL; AST – 32 U/L; and ALT – 29 U/L.
Clinical manifestations present in Mr. M.
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