Case Of the Month 6 - Presentation

Before you all start to get your holiday groove on, crunch some brain cells and take a swing at the halfway point for this year’s COtM series.

A 34 y/o F with PMH sickle cell disease is BIBEMS to the ED. She regularly visits the ED for sickle cell pain crises requiring high doses of injectable hydromorphone. The patient has been having N/V for the past 8 hours along with malaise and fatigue x 1 day. She reports having joint pains in her knees as well as lower back, typical for her sickle cell crises, for the previous three days. The pains have been becoming progressively worse with no improvement taking her home po pain medication. She reports being nearly out of all her pain medication. When she started vomiting, she decided to call EMS. No fevers, chills, diarrhea, abd pain, sick contacts, recent travel.

PMH: SS disease

PSH: Cholecystectomy

Meds: Folic acid, hydroxyurea, Percocet prn

All: NKDA

SH: No toxic habits

ROS: Negative aside from above

PE:

Vitals – 100/66, HR 118, temp 98.9 rectally, RR 16, 98% on RA

Gen – Lying in bed, appears sick and fatigued, breathing comfortably

HEENT – Conjunctival pallor, mild scleral icterus, normal pupils

CV – Tachycardic, soft grade 2/6 systolic murmur

Resp – CTA b/l, no w/r/r

Abd – soft, nt, nd, +BS, (-) Murphy’s

Ext – No c/c/e

Skin – No lesions appreciated

Remainder of the exam is unremarkable

Labs (only significant values are written):

CBC – Hgb 7.6 (at baseline), retic 2%, platelets 450

Comp – Na 129, Cl 98, CO2 32, BUN 19, Creatinine 1.0, AST 550, ALT 490, tbili 1.5

Cardiac enzymes negative x 1

Lactate 2.8, pH 7.47

CXR – No focal consolidation

EKG – Sinus tachycardia

Think you have it? Go ahead and post in the comments your differential diagnosis list, what your further workup would entail, and any interventions you might do in the ED. Good luck!