NYU Medical Grand Rounds Clinical Vignette

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NYU Medical Grand Rounds Clinical Vignette. Maryann Kwa, MD PGY-3 March 20, 2012. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.
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NYU Medical Grand Rounds Clinical VignetteMaryann Kwa, MDPGY-3March 20, 2012 UNITED STATES DEPARTMENT OF VETERANS AFFAIRSChief ComplaintUNITED STATES DEPARTMENT OF VETERANS AFFAIRSThe patient is a 21-year-old male presenting with pain in the extremities and fatigue for three months. History of Present IllnessUNITED STATES DEPARTMENT OF VETERANS AFFAIRS
  • The patient was in his usual state of health until one year prior to admission when he started experiencing intermittent episodes of pain in his extremities.
  • The pain was severe, sharp and crampy, involving the arms and legs, lasting several hours to days at a time and were self-limited. Accompanied by fatigue. No clearly defined precipitating factors.
  • Severity, frequency and duration of these painful episodes gradually worsened over the last three months, including a recent episode that had lasted for 4 days without improvement at which time he presents to the ER.
  • Additional HistoryUNITED STATES DEPARTMENT OF VETERANS AFFAIRS
  • Past Medical History:
  • None
  • Past Surgical History:
  • None
  • Social History:
  • Denied tobacco, alcohol or drug use
  • Immigrated from Africa to the United States six months ago
  • Additional HistoryUNITED STATES DEPARTMENT OF VETERANS AFFAIRS
  • Family History:
  • Mother, alive at age 50, with sickle cell anemia
  • Allergies:
  • No Known Drug Allergies
  • Medications:
  • None
  • Physical ExaminationUNITED STATES DEPARTMENT OF VETERANS AFFAIRS
  • General: Young male who appeared fatigued and in mild acute distress
  • Vital Signs: T: 98.7 BP: 117/65 HR: 90 RR: 18 and O2 sat: 95% room air
  • HEENT: scleral icterus, pale mucous membranes
  • Cardiovascular: II/VI systolic murmur heard over the precordium
  • Abdomen: palpable spleen tip
  • Extremity: trace lower extremity edema bilaterally
  • The remainder of the physical exam was normal
  • Laboratory FindingsUNITED STATES DEPARTMENT OF VETERANS AFFAIRS
  • CBC:
  • WBC 10.0
  • Hg 8.0 (MCV 87)
  • Hct 24.5
  • Platelets 350
  • Differential: neutrophils 75%, lymphocytes 10%, monocytes 7%,
  • basophils 7%, eosinophils 1%
  • Basic Metabolic panel: within normal limits
  • Hepatic panel: total bilirubin 2.7, direct bilirubin 0.7
  • Remainder of hepatic was within normal limits
  • Laboratory FindingsUNITED STATES DEPARTMENT OF VETERANS AFFAIRS
  • LDH: 502 (110-225 U/L)
  • Haptoglobin: 45 (30-200 mg/dL)
  • Reticulocyte %: 5.1 (0.5-1.5)
  • Iron: 50 (42-146 ug/dL)
  • TIBC: 320 (250-450 ug/dL)
  • Ferritin: 650 (22-322 ng/mL)
  • Other StudiesUNITED STATES DEPARTMENT OF VETERANS AFFAIRS
  • Chest X-ray: normal
  • Urinalysis: normal
  • UNITED STATES DEPARTMENT OF VETERANS AFFAIRSWorking or Differential Diagnosis
  • The patient was admitted to the medicine service for further work-up of anemia.
  • Differential diagnoses:
  • Sickle Cell Anemia
  • Leukemia
  • UNITED STATES DEPARTMENT OF VETERANS AFFAIRSHospital Course
  • Analysis of a peripheral smear revealed sickled erythrocytes.
  • The patient’s symptoms improved with IV hydration, opioids for pain and 1 unit packed red blood cells. Folic acid was also initiated.
  • Hemoglobin electrophoresis confirmed HbS
  • Symptom resolution by hospital day 3.
  • He was initiated on hydroxyurea and received a pneumococcus vaccine prior to discharge.
  • UNITED STATES DEPARTMENT OF VETERANS AFFAIRSFinal Diagnosis
  • Sickle Cell Anemia (HbS) with
  • Vaso-oclusive Crisis
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