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. Â She regularly visits the ED for sickle cell pain crises requiring high doses of injectable hydromorphone. Â The patient has been having N/V for the past 8 hours along with malaise and fatigue x 1 day. Â She reports having joint pains in her knees as well as lower back, typical for her sickle cell crises, for the previous three days. Â The pains have been becoming progressively worse with no improvement taking her home po pain medication. Â She reports being nearly out of all her pain medication. Â When she started vomiting, she decided to call EMS. Â 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? Â 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. Â Good luck!
James Hassel
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