Clinical Case Presentation Young Adult Inpatient Teaching Rounds P32 Group 16

okay Nerissa let's hear about this patient that you've been seeing so we have Jonathan who is a 24 year old male african-american male who presented to the IDI last night with bilateral pain in both knees he has a history of sickle-cell disease he said that the pain started two days ago while he was working the night shift and has gradually gotten worse the pain is an 8 out of 10 and has not been relieved with his percocet it is also worse upon standing and walking he reports chills mild soreness of breath but he does deny having a fever any chest pain nausea vomiting and abdominal pain his past medical history does include a history of stuttering priapism and lower extremity ulcers he also has last pain crisis about a year ago he also lives with his mom and four siblings two of which also have sickle cell disease and he doesn't smoke he doesn't do any drugs but he does drink alcohol socially and the last time was last weekend his review of systems was unremarkable except for some intermittent left hand pain his vitals were also normal except for an elevated heart rate and his o2 SATs were actually pretty low at 89% what was the heart rate elevated at at 98 okay yes sorry Edward 120 it was at 120 okay I was that was fit with pain yes good okay so yeah his heart rate was at 120 his o2 SATs were also at 89% but that's normal for him for his history so on physical exam he was lying in his bed an obvious discomfort he also appeared thin but his heart sounds were normal no murmurs his lungs were clear to auscultation and percussion he did have a scaly rash on his flexpa flexor side of his elbow his testes were normal no priapism is noted and then his right knee had mild swelling and a small effusion but no erythema it was non tender to palpation but upon full extension there was some tenderness his left knee there was no swelling no tenderness noted and both knees had full range of motion so what are you for else you're gonna do at this point well at this point for the assessment is that what is that what you didn't guess that's what I'm Brown we talked if I carry wood what's the next step you want to decide what you need to do to finalize your diagnosis what else additional tests things like this right so we did order the CBC um and we decided we didn't need to take an Esther x-ray because they're usually not really conclusive and don't really show much good choice um so again for his assessment we did we have this 24 year old male who has a history of sickle-cell disease and so the differentials could include baso occlusive disease peri articular infarct septic arthritis or gout because he's a febrile the meso occlusive disease or the peri articular infarct are more likely than not so how are we gonna treat him we are going to give him n sets for the pains what I would think and then morphine for any breakout pain if his CBC comes back with any market leukocytosis or if he does develop a fever we can order blood culture cultures and start him on antibiotics empirically for staph and Salmonella for the sickle cell we could give we could monitor him we should monitor him for acute chest syndrome splenic infarct and sorry aplastic crisis and splenic sequestration and then we can monitor his o2 SATs and if he becomes symptomatic also administer that would you give him fluids and oxygen now are you going to wait wait while we might as well since his o2 SATs are pretty low at 89% so it wouldn't be a bad idea to start him on any on oxygen right why this B would not be vase occlusive disease take a little bit of basin you said he had some ulcers in the past but he doesn't have them now okay what does that tell you about his vascular system he can heal yes okay okay so they so occlusive disease or necrosis where would that occur when you think of bones where's the easiest place yep because remember there's one artery serving that how many arteries are serving the knees many okay we'd be hard to occlude that right see that's that's part of the weapon so see that's probably I want you take your Anatomy and bring that in as you thinking and talking about it now Gao what would you expect to see with gap well a pataga and your big toe there's another joints but it's what usually happens with gap remember in a joint very hot swollen set will be swollen yes so that that kind of that takes that out plus it's highly unusual and large joint I can see it an ankle in the toe you might see it in fingers but using the larger joint don't end with there or something one of the things you've given a history of sickle cell and this little bit let's talk a little bit about sickle cell disease what does that mean when you say disease versus trait well with the disease yaks on both I guess both his parents had to have had it with the trait only his mother or his father would have had it usually trait is asymptomatic generally so because he has a disease he got it from the generally camps sickle that significant cells are very mild whereas with the disease they are and you know what a peripheral sphere would look like on this describe a peripheral smear the cells would beat sickle shaped yeah that's where it gets its name and what occurs with that as it flows why the priapism itches so with the priapism basically it's a prolonged erection and so with the sickling it kind of blocks the blood from being able to flow in and out properly so that's why it's a stuttering pipe is sometimes it comes sometimes it goes just because it gets stuck for saying stuttering because it could be there and kind of resolve on its own and the sickling of the cell sludges was difficult to pass through the memory anatomy and the corpus spongiosum I mean the corpus cavernosum in the sponges areas they'll poorly flow the user will reverse if you don't you have to do find you friendly urologist and Teachout it take care of those things but I think you've got a good understanding of that the fact that he doesn't have one now tells us he's probably not at a significant cyclists the cycling problem with the sickle cells crushing yet the one thing I would suggest in here is probably go ahead and use the oxygen and their fluids because that helps oxygenating helps increase the oxygen level so they function better the fluids keeps it from getting as acidotic so they won't sickle as much worried that there may be a component of sickle cell information or changes with this and minimize the second camp so what are you going to do over the next few days to see where he goes we'll definitely monitor him for all the things that could happen because of his sickle cell Stef's dude I think you did a very good presentation at this point you were six engineer areas for what we want now this is the way I want you to do it you're covering a lot of detail and the months ahead as we go on rounds other things you'll learn how to compress that down to where it's a more succinctly because we'll already know about the page but overall very good nervous thank you you