H and P SC Crisis
Informant: Patient - reliable
CC: pain in head, neck, arms, stomach, and legs
Reason for Admission: pain in head, neck, arms, stomach, and legs
History of Present Illness:
Patient 43 yo AAM presented with pain in arms, back, stomach and legs which started yesterday morning. His last crisis was 2-3 years ago. It is well localized to the areas mentioned. He tried using Percocet and Oxycontin but they were ineffective in controlling his pain. He also complains of a productive cough with yellow phlegm for 2-3 weeks. He had no associated chest pain. He had no nasal congestion, but he did have post nasal drip. He has no nausea, vomiting, diarrhea, fever or chills.
Past Medical History:
Sickle Cell Disease (SC) diagnosed at age 12. Not significant for any other chronic conditions such as diabetes or hypertension.
Past Surgical History:
No surgical history.
Injuries/Disabilities: Considers SC a disability.
Oxycontin 80 mg po bid
Percocet 5 mg 1-2 tablets q 4-6 hours prn pain
Folic Acid 1mg po qday
Herbal Meds: none
Immunizations: Pneumo and flu vaccines up to date since last year
Drugs: Morphine - lack of coordination, nervous; toradol - lack of coordination
Mother has sickle cell disease and diabetes. His family has no history of hypertension, cancer, cardiac diseases, or thalassemia.
He lives in an appartment with his fiance. He's currently unemployed due to his sickle cell disability. He has no history of alcohol abuse. He smokes 3-4 cigarettes per day.
Review of Systems:
Summary: - f/c, -n/v/d, -dysuria, + cough for 3 weeks, - rhinorrhea, - headache
General Appearance: Pt in acute distress from pain
Temperature: 96.7 F Oxygen Saturation: 98% Room Air
Blood Pressure: 100/46
Respiratory Rate: 16 Pulse Rate: 68
Skin/Nails: no clubbing
HEENT: PERRL, clear nasal turbinates, non-erythematous pharynx, no thyroid enlargement, no lymphadenopathy
Pulmonary: CTA BL, -w/c/r
CV: S1S2, RRR, II/VI SEM
Abdomen: soft, NT, ND
Peripheral pulses: 2+ DP
Musculoskeletal: pain in both arms, legs, and neck
CXR - clear and normal
Retic Index 8.9
Assessment: 43 yo AAM with sickle cell crisis in arms, legs, neck, and head.
1. sickle cell crisis
2. increased white count
He's presenting with acute onset of pain which is most likely related to a sickle cell crisis. He presents with no other signs, symptoms, or lab values suggesting other etiologies such as acute rheumatic fever, osteoid arthritis, or any other polyarticular arthritis. His pain is spread throughout his bones and joints which makes an SC crisis more likely.
His white blood count could be due to an infection, but he is not presenting with fever or any inflammatory reaction symptoms. He has no tachypnea, but he does have upper respiratory infection symptoms. His pulse ox is normal. His CXR is clear and this does not appear to be pneumonia. He should be worked up with urine cultures, urine analysis, and blood cultures.
1. CBC w diff
2. Screen 8
3. Retic count and Retic Index
4. Blood Cx
5. Urine Cx
6. Urine Analysis
1. Dilautid 4mg IV q4h
2. 125 cc/hr D5W