Health History and Medical Information

Health History and Medical Information Week 2

Health History and Medical Information Week 2

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
Protein: 7.1 g/dL; AST: 32 U/L; ALT 29 U/L
Critical Thinking Essay

In 750 words, critically evaluate Mr. M.’s situation. Include the following:

Describe the clinical manifestations present in Mr. M.
Based on the information presented in the case scenario, discuss what primary and secondary medical diagnoses should be considered for Mr. M. Explain why these should be considered and what data is provided for support.
When performing your nursing assessment, discuss what abnormalities would you expect to find and why.
Describe the physical, psychological, and emotional effects Mr. M.’s current health status may have on him. Discuss the impact it can have on his family.
Discuss what interventions can be put into place to support Mr. M. and his family.
Given Mr. M.’s current condition, discuss at least four actual or potential problems he faces. Provide rationale for each.
You are required to cite to a minimum of two sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. Refer to the LopesWrite Technical Support articles for assistance.

 

KEY TAKEAWAYS BEFORE ATTEMPTING THIS ASSIGNMENT

The importance of maintaining accurate health histories and medical information is paramount to providing quality, safe healthcare. In this essay, I will explore the ways in which one can collect and store health histories and medical information, as well as the benefits of sharing this information with healthcare providers.
Accurate health histories are essential for providing quality care to patients. BK Charangowda notes in their article “Forensic Dental Sciences” published in the Journal of Forensic Dental Sciences in 2010 that accurate health records are essential for helping to ensure timely and accurate diagnoses and appropriate treatment. They explain that in the event of a medical malpractice lawsuit, the health history of the patient can provide valuable information to help determine the standard of care that the health care provider should have followed in treating the patient. Additionally, accurate health histories can help to reduce medical errors and adverse events. By having access to a patient’s health history, doctors will be better equipped to identify potential drug interactions, allergies, and other conditions that may affect the patient’s care. Furthermore, accurate health histories can provide important information that is necessary for conducting medical research and public health surveillance. All of these factors demonstrate the importance of maintaining accurate health histories in order to ensure that patients receive the best possible care.

Collecting and storing medical information is an important task for health care providers in order to provide the best care for their patients. According to CJ McDonald and WM Tierney, who published a paper in Jama in 1988, it is important to consider the ways in which medical information can be collected, stored and accessed. The authors suggest that health care providers should use electronic databases and other information technologies to store medical information. Additionally, they suggest that patient consent should be obtained before any medical information is collected. Furthermore, they suggest that the data should be stored securely and only be accessed by authorized personnel. Additionally, the authors recommend that the medical information should be kept up-to-date and that it should be easy to search and access when necessary. In conclusion, collecting and storing medical information is an important part of providing quality health care services, and it is important to consider the ways in which this can be done in order to ensure the best possible care for patients. (McDonald & Tierney, 1988).

Sharing health histories and medical information with healthcare providers has been demonstrated to provide numerous benefits for both the patient and healthcare provider. In a study conducted by I Baudendistel et al. (2017), they evaluated the effects of sharing health histories and medical information with healthcare providers on patient-provider communication. They found that sharing health histories and medical information provided the patient and healthcare provider with more meaningful conversations and improved their relationship overall. Furthermore, it was found that sharing medical information gave healthcare providers the opportunity to make more accurate diagnoses and provide more comprehensive care plans for the patient. Additionally, sharing health histories and medical information can help the patient to feel more involved in their own care, as it gives them the opportunity to be an active participant in the decision-making process. This, in turn, can lead to higher levels of satisfaction with the healthcare provider and improved patient outcomes. Ultimately, the study conducted by I Baudendistel et al. (2017) concluded that there are numerous benefits to sharing health histories and medical information with healthcare providers, including improved patient-provider communication, more accurate diagnoses, and increased patient satisfaction.

From this review of the importance of health history and medical information, it is clear that the information obtained during a health history, physical exam, and review of medical records can improve the accuracy of a diagnosis and play an integral role in determining a patient’s healthcare plan. To further emphasize its importance, obtaining health history and medical information is entrenched as an essential element of a patient’s visit in the current healthcare system. Knowing these pieces of information are critical when treating a patient, healthcare professionals should ensure they are as thorough and accurate as possible.
Work Cited
CJ McDonald., WM Tierney.”Computer-stored medical records: their future role in medical practice.”https://jamanetwork.com/journals/jama/article-abstract/372415
“Dental records: An overview.”https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3009547/
“Cross‐sectoral cancer care: views from patients and health care professionals regarding a personal electronic health record.”https://onlinelibrary.wiley.com/doi/abs/10.1111/ecc.12429
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