Health History and Medical Information

Running Head: HEALTH HISTORY AND MEDICAL INFORMATION
Health History and Medical Information (Case study)
Student Name
University Name
Student Notes

HEALTH HISTORY AND MEDICAL INFORMATION1
Introduction
Considering the case study mentioned, the 70 year old subject, who already has a medical history
of high blood pressure, and high cholesterol, has been showing symptoms like sudden agitation
and aggressiveness. He has been observed to have difficulty remembering obvious details, and
performing his ADL’s (Toot et al., 2017). Considering his symptoms of memory loss,
behavioral issues and cognitive impairment, it might be considered that he is suffering from
dementia, which is common given his age. The blood tests ordered by the assisted care facility,
detected the increase in the white blood cell count indicating infection in the body. The urinalysis
test came positive by appearing cloudy and highlighting the presence of leukocytes, indicating
urine infection. The following essay will discuss the different primary and secondary medical
diagnoses, abnormalities detected during nursing assessment, physical, psychological and
emotional effects, interventions, as well as the actual and potential issues of the Mr. M’s current
health status.
Diagnosis
Primary medical diagnosis:
The significant loss of memory and the increased dependence of Mr. M for the execution of his
ADL’s due to the observable cognitive impairment, it can be associated with different
neurodegenerative diseases, sepsis, urinary tract infection associated delirium and more.
Considering the sudden onset of the symptoms and the increased incidence of agitated and
aggravated behavior on Mr. M’s end, this situation needs more priority rather than the other
observed symptoms in the blood and urine tests conducted. The increased white blood cell count

HEALTH HISTORY AND MEDICAL INFORMATION2
detected in the blood tests can lead to delirium including symptoms like temporary state of
confusion and agitation, or the increased white blood cell count can also indicate the contraction
of UTI, which was confirmed in the urinalysis.
Secondary medical diagnosis:
Mr. M had been observed to have difficulty in efficiently executing his ADL’s. This matter of his
increased dependency on others requires medical attention. Physiotherapy sessions need to be
conducted for Mr. M, to help increase his limited physical activity, which might reduce his
dependency on others for executing his ADL’s (Toot et al., 2017).
Abnormalities detected during nursing assessment
During the nursing assessment of Mr. M, a nurse would be expected to deal with his agitated and
aggressive behavior. Due to his impaired cognitive status, he might be expected to have
difficulty understanding the simple medical procedures that are to be conducted on him. He
might be very uncooperative and might appear to be fearful of his surroundings. This can be due
to the incidence of infection induced delirium, or the sudden onset of dementia (Steis et al.,
2015). During the assessment, evaluating the blood and urine tests would help in understanding
that he contracted a urinary tract infection, which would need to be treated accordingly.