BKA and L AKA, ESRD, and recurring UTIs.
WW is a 54 y/o AA male. Pt. presented to the due to suspected C4 fx, dialysis catheter infection, and possible UTI. He has a PMH of poorly controlled DM2 s/p R BKA and L AKA, ESRD, and recurring UTIs. Used to smoke 2/3 ppd but quit years ago, and used to drink a pint of ETOH per day, but quit after a stroke (unknown date – data gap). Post stroke hx of heroin and cocaine abuse. Pt has a brother and sister who help him, but lives in a nursing home for the past few years. His mother recently died of a heart attack and father’s health is unknown. Brothers also have DM2. Currently on disability, used to work as a mason water operator.
I. Subjective and Objective Data and Analysis of Data
Subjective Data Objective Data Analysis of Data
Date Time Temp HR Resp BP Sa02
03/28 1500 36.5 77 16 129/59 92%
03/29 0400 37.0 88 18 156/71 100%
03/29 1400 36.0 76 12 144/66 98%
03/30 0540 36.0 78 18 145/67 98%
WW’s oral temperature consistently falls within normal limits (36.1 – 37.8 ° C), despite increased WBC count and infection. Often times with severe infection patients will experience fever, though this is not the case for WW, though many older patients may have a decreased core body temperature as their baseline (Mattson Porth, 2004).