Intern Report Case 1.7

intern-report

Presented by Richard Gordon, MD

CC
“My chest hurts”

HPI
30 year old AAM presents to ED with 2 day history of worsening sharp chest pain located over the anterior/lateral right ribs.  Patient states the pain is 8/10 in intensity, non-radiating, and exacerbated with deep breathing/coughing.  No obvious alleviating factors.  Patient has never experienced this kind of pain in the past. Patient also complains of mild shortness of breath.  The patient states that he has had a dry cough for the last 4 days without any measured fever, but has felt warm.   No recent travel, no history of DVT in the patient/family, and no history of hypercoagulability. No nausea, vomiting, or abdominal pain. Review of CIS shows the patient was in the ED 7 days ago for “sickle pain” and was treated with 2 rounds of morphine sulfate 10 mg IVP, Benadryl 50 mg IVP, and one liter bolus of normal saline, and subsequently discharged home with pain under control.
PMH: Sickle cell SS, Asthma

PSH: No previous surgery

FH: Mother died at 65 MI. Father died at 62 CVA.  Brother alive 37 HTN, asthma, sickle cell trait. Sister alive 35 sickle cell anemia SS, asthma.

SH: Denies smoking, drinking, or use of illicit drugs.

Meds: Albuterol inhaler 2 puffs PRN for SOB.  Advair Diskus 250/50 inhaled BID. Morphine sulfate controlled release 100 mg BID.  Morphine sulfate instant release 30 mg 1-2 tab Q3H PRN for pain.

All: NKDA

PE:
Vitals:  BP:140/90    HR:115     RR:25     T:39.0     Sat:89% room air

General: Alert and oriented X3. Upright in stretcher answering questions appropriately. However, anxious appearing and looks uncomfortable breathing with accessory muscles, speaking in partial sentences.

HEENT: Head is normocephalic and atraumatic. Pupils equal and reactive to light. Extraocular movements intact. There is scleral icterus. Nares have no discharge. Oropharynx  has moist mucus membranes, no exudates, no erythema. Neck is supple with no JVD, trachea midline, no adenopathy.

Chest Wall: Reproducible chest pain with palpation of ribs bilateral left greater than right.  Reproducible parasternal tenderness.  No crepitus.
Cardiac:  S1S2 regular and tachycardic.  No murmus, rubs or gallops.

Lungs: Good air entry bilateral, end expiratory wheeze, prolonged expiratory phase. Basilar rales present.  No ronchi.

Abdomen: Bowel sounds present, nontender to palpation, nondistended, no masses, no organomegaly.

Extremities: Moves all four with full Range of motion. No asymmetric swelling or erythema. 2+ distal pulses. Calves nontender to palpation.

Skin: No jaundice. No rashes. No diaphoresis

Neuro: Alert and oriented X3. Pupils equal and reactive to light. External ocular muscles intact. No facial asymmetry. 5/5 strength all 4 extremities. Walks with normal gait. No obvious sensory deficits.

Lab Results:

ABG on room air:  7.45/59/30/16/89%

HbG: 8.5 Baseline HbG 9.5

WBC: 15

Lytes: Na-140 K-5 Cl-100 HCO3-15 BUN-18 Cre-0.8
Diagnostics:

12 lead ECG shows sinus tachycardia at rate of 110.

Chest PA shows middle lobe infiltrate.

12
CT chest with PE protocol: No pulmonary embolus, infiltrates right middle and lower lobe.

Course in ED
Patient immediately placed on non-rebreather with saturation rapidly increasing to 100%.  3 doses of albuterol and atrovent via nebulizer were administered with improvement of tachypnea and wheezing.  Patient now maintiaing 94-96% 4L NC breathing more comfortably.  IV established with 1 liter normal saline bolus followed by 1.5 maintenance.  Blood cultures X2 sent, followed by,  IV doxycycline and ceftriaxone administration.  Morphine 10mg with Benadryl 50mg and titrated to pain control.   Patient was type and crossed followed by transfusion with 2 units of blood.  Saturation again improved 96-98% on 2 liters.  Patient admitted to hematology oncology service.

Questions:

1.    Which of the following is NOT considered to be one of the clinical diagnostic criteria for acute chest syndrome in a patient with sickle cell disease?
a)    chest pain and hypoxia
b)    new pulmonary infiltrate(s) on chest x-ray
c)    recent sickle cell pain crisis
d)    tachypnea, wheezing, or cough
e)    temperature > 38.5

2.    Which of the following statements related to acute chest syndrome in sickle cell anemia is correct?
a)    bronchodilators have no role in the acute treatment.
b)    most common chest x-ray finding is new infiltrate in bilateral upper lobes.
c)    only exchange transfusion provides benefit.
d)    pulmonary infection is rarely the inciting cause.
e)    transfusion of packed red blood cells can significantly improve the patient’s condition.

3.    Which of the following statements regarding acute chest syndrome is INCORRECT?
a)    acute chest syndrome is a leading cause of hospital admission and mortality in sickle cell patients.
b)    adequate pain control and incentive spirometry are important adjuncts to therapy.
c)    choice of antibiotic should cover for atypical and encapsulated organisms.
d)    fat embolism is a leading cause.
e)    hydration at 2-2.5 times the maintenance fluid requirement is indicated for treatment.

Please submit your answers to the questions in the “leave a reply” box or click on the “comments” link.  Your submission will not immediately post.  Answers with a case discussion will post on Friday.  If you have any difficulty, please contact the site administrator at arosh@med.wayne.edu. Thank you for participating in Receiving’s: Intern Report.

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