Transcript Journal Club

NYU Medical Grand Rounds
Clinical Vignette
Maryann Kwa, MD
PGY-3
March 20, 2012
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
The patient is a 21-year-old male presenting
with pain in the extremities and fatigue for
three months.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• 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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
• 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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
• Family History:
• Mother, alive at age 50, with sickle cell anemia
•Allergies:
• No Known Drug Allergies
•Medications:
• None
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
• 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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
• 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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
• 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)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
• Chest X-ray: normal
• Urinalysis: normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working 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 AFFAIRS
Hospital 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 AFFAIRS
Final Diagnosis
• Sickle Cell Anemia (HbS) with
Vaso-oclusive Crisis
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS