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Health History and Medical Information.

Health History and Medical Information.

Sample Answer 

Health History and Medical Information.

Health History and Medical Information for Mr. C

            Mr. C has bilateral pitting edema on his feet and ankles. Pitting edema occurs when the swollen skin remains indented after pressure application using a finger. Pitting edema can either indicate a localized problem with veins in the affected area or a systemic problem. Some of its etiological factors include congestive heart failure, liver disease, obesity, and kidney failure. Grade 3+ pitting edema implies that the depth of the indentation is 5 to 6 millimeters, and the rebound time is 10 to 30 seconds. Mr. C’s blood pressure is 172/98; this indicates that he is hypertensive. Hypertension is usually defined as a systolic blood pressure of 140 mmHg or more and a diastolic blood pressure of 90 mmHg or more. His respiratory rate of 26 beats per minute is above the normal range of 12 to 20 beats per minute.

Mr. C has a fasting blood glucose of 146mg/dl. This value is above the normal range of 70 to 110 mg/dl. The elevation indicates that he has diabetes mellitus. His total cholesterol and triglyceride levels are 250 mg/dl and 312 mg/dl, respectively. The normal levels of cholesterol and triglycerides should be lesser than 200 mg/dl and 150mg/dl, respectively. Therefore, the patient has hypercholesterolemia. His HDL value of 30mg/dl is lower than the recommended range of 40 t 60 mg/dl. This contributes to hypercholesterolemia. HDL is responsible for transporting cholesterol from tissues to the liver for its elimination via bile. Mr. C’s serum creatine levels, 1.8 mg/dl, and BUN, 32 mg/dl, are both elevated. The normal range should be 0.6 t 1.2 mg/dl and 10-20, respectively. This suggests the presence of kidney failure.

Obesity is associated with a variety of health problems. It is associated with Type II diabetes mellitus, hypertension, heart disease, sleep apnea, kidney disease, and fatty liver disease (Lavie et al., 2018). The health risk factors that are of concern to Mr. C are hypertension, heart disease, diabetes mellitus, and kidney disease. The patient’s clinical manifestations suggest the presence of these conditions, which can be linked to obesity. Bariatric surgery entails gastric bypass and other weight-loss surgeries that help to lose weight (Lavie et al., 2018). It is indicated in obese patients to help to reduce the risk of potentially life-threatening obesity-related health problems. These health problems include heart disease, stroke, hypertension, type II diabetes mellitus, sleep apnea, lipid abnormalities, and nonalcoholic fatty liver disease (Loundou et al., 2021). It is usually done after the patient has tried weight loss through lifestyle modification and failed. Mr. C is obese and has weight-related comorbidities, including type II diabetes mellitus, hypertension, heart disease, and lipid abnormalities. Therefore, Bariatric surgery is an appropriate intervention.

The first functional health pattern of Mr. C is health perception and management. He acknowledges that he has been heavy since childhood and that he has gained about 100 pounds over the past 2 to 3 years. He doesn’t report any intervention he took to control his weight at that time. He also reports having hypertension which he says he tries to control through dietary sodium restriction. The other functional health pattern is activity-exercise. Mr. C reports having been working at a catalog telephone center. The nature of his work does not promote constant mobility. He doesn’t report that he performs any regular exercise during the day or the week. The other functional health pattern is self-perception. Mr. C considers himself to have been heavy since childhood. He further acknowledges that he has gained about 100 pounds over the past 2-3 years. The other functional health pattern is sleep rest. Mr. C reports that sleep quality has reduced significantly due to sleep apnea.

The first problem is the failure to use health-promoting interventions. Mr. C acknowledges that he has been heavy since childhood and even admits to recent weight gain. He should have taken the necessary precautions to prevent further weight gain that promoted obesity its comorbidities. The second problem is the delay in initiating drug therapy. Mr. C reports being aware that he is hypertensive. However, he states that the only intervention he uses is reducing sodium intake. He should have sought medical help promptly and started on antihypertensive medications. The third problem is the nature of his work. His work encourages a sedentary lifestyle. Since he is obese, he should have sought a job that involves constant movement. This could have helped in the reduction of his weight. The fourth problem is his self-perception. Mr. C perceives himself to be obese. This may have contributed to the failure to seek early interventions to reduce his weight. The fifth potential problem is Mr. C’s complacency because he knew that bariatric surgery could be done. Mr. C visits the hospital to seek advice concerning bariatric surgery.  He didn’t visit the hospital earlier to seek advice on healthy lifestyles because he knew that surgery was an alternative. This contributed to the progress of his obesity and comorbidities.

During the staging of chronic kidney failure, end-stage renal disease is classified as stage 5. This occurs when the Glomerular filtration rate is lesser than 15 milliliters per minute (15 ml/min) (Rosenberg & Ibrahim, 2019). Numerous chronic diseases contribute to end-stage renal failure. They include hypertension, diabetes mellitus, glomerulonephritis, recurrent pyelonephritis, and drugs such as Non-Steroidal Anti-inflammatory medications. Hyperlipidemia, smoking, dehydration, and hyperphosphatemia further worsens end-stage renal failure.

Mr. C should take part in routine screening for chronic kidney disease. This is because he has other comorbidities, such as diabetes and hypertension, that worsen his condition. Mr. C should change his diet. His nutritional therapy should involve restriction f protein intake, water restriction, sodium restriction, phosphate restriction,s, and potassium restriction. Phosphate consumption should be equal to or less than 1000 milligrams per day (Cominato et al., 2018). Protein intake should be 0.6 to 0.8 grams per kilogram of body weight per day. Daily sodium intake should be between 2 to 4 grams based on the degree of edema and hypertension (Rosenberg & Ibrahim, 2019). Patients should know the importance of taking antihypertensives and hypoglycemic agents. They help to control hypertension and diabetes, both of which worsen the progress of the end-stage renal disease. The patient should be educated on the importance of dialysis. They should attend all scheduled dialysis appointments.

The availability of a cycler has enabled automated peritoneal dialysis. This can be intermittent, continuous cycling, or nightly dialysis. This allows the patient to have control over their daily activities. The patient can do dialysis without assistance. Furthermore, the cycler is cost-effective hence readily available. The presence of support groups such as the American Kidney Fund enables the patients t share their experiences in dealing with the disease (Rosenberg & Ibrahim, 2019). The American Renal Associates department helps patients to schedule their dialysis treatments when traveling. A multidisciplinary team consisting of all health care providers can ensure the well-being of these patients. They can ensure that the right doses of drugs are given to the patient and that all nephrotoxic drugs are avoided.


Cominato, L., Di Biagio, G. F., Lellis, D., Franco, R. R., Mancini, M. C., & de Melo, M. E. (2018). Obesity Prevention: Strategies and Challenges in Latin America. Current Obesity Reports, 7(2), 97–104.

Lavie, C. J., Laddu, D., Arena, R., Ortega, F. B., Alpert, M. A., & Kushner, R. F. (2018). Reprint of: Healthy Weight and Obesity Prevention: JACC Health Promotion Series. Journal of the American College of Cardiology, 72(23), 3027–3052.

Loundou, A., Crémades, A., & Gentile, S. (2021). Comorbidity Profiles among Obese – Diabetic End-Stage Renal Disease Patients : Data from REIN Registry of PACA Region of France.

Rosenberg, M. E., & Ibrahim, T. (2019). Winning the war on kidney disease perspective from the American society of nephrology. Clinical Journal of the American Society of Nephrology, 14(12), 1792–1794.


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Health History and Medical Information.

It is necessary for an RN-BSN-prepared nurse to demonstrate an enhanced understanding of the pathophysiological processes of disease, the clinical manifestations and treatment protocols, and how they affect clients across the life span.

Evaluate the Health History and Medical Information for Mr. C., presented below.

Based on this information, formulate a conclusion based on your evaluation, and complete the Critical Thinking Essay assignment, as instructed below.

Health History and Medical Information

Health History
Mr. C., a 32-year-old single male, is seeking information at the outpatient center regarding possible bariatric surgery for his obesity. He currently works at a catalog telephone center. He reports that he has always been heavy, even as a small child, gaining approximately 100 pounds in the last 2-3 years. Previous medical evaluations have not indicated any metabolic diseases, but he says he has sleep apnea and high blood pressure, which he tries to control by restricting dietary sodium. Mr. C. reports increasing shortness of breath with activity, swollen ankles, and pruritus over the last 6 months.

Objective Data:

Health History and Medical Information.

Health History and Medical Information.

  • Height: 68 inches; weight 134.5 kg
  • BP: 172/98, HR 88, RR 26
  • 3+ pitting edema bilateral feet and ankles
  • Fasting blood glucose: 146 mg/dL
  • Total cholesterol: 250 mg/dL
  • Triglycerides: 312 mg/dL
  • HDL: 30 mg/dL
  • Serum creatinine 1.8 mg/dL
  • BUN 32 mg/dl
Critical Thinking Essay
In 750-1,000 words, critically evaluate Mr. C.’s potential diagnosis and intervention(s). Include the following:

  1. Describe the clinical manifestations present in Mr. C.
  2. Describe the potential health risks for obesity that are of concern for Mr. C. Discuss whether bariatric surgery is an appropriate intervention.
  3. Assess each of Mr. C.’s functional health patterns using the information given. Discuss at least five actual or potential problems can you identify from the functional health patterns and provide the rationale for each. (Functional health patterns include health-perception, health-management, nutritional, metabolic, elimination, activity-exercise, sleep-rest, cognitive-perceptual, self-perception/self-concept, role-relationship, sexuality/reproductive, coping-stress tolerance.)
  4. Explain the staging of end-stage renal disease (ESRD) and contributing factors to consider.
  5. Consider ESRD prevention and health promotion opportunities. Describe what type of patient education should be provided to Mr. C. for prevention of future events, health restoration, and avoidance of deterioration of renal status.
  6. Explain the type of resources available for ESRD patients for nonacute care and the type of multidisciplinary approach that would be beneficial for these patients. Consider aspects such as devices, transportation, living conditions, return-to-employment issues.

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.

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