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NYU Medical Grand Rounds Clinical Vignette

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 Vignette

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  1. NYU Medical Grand Rounds Clinical Vignette Maryann Kwa, MD PGY-3 March 20, 2012 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS The patient is a 21-year-old male presenting with pain in the extremities and fatigue for three months.

  3. History of Present Illness UNITED 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.

  4. Additional History UNITED 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

  5. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Family History: • Mother, alive at age 50, with sickle cell anemia • Allergies: • No Known Drug Allergies • Medications: • None

  6. Physical Examination UNITED 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

  7. Laboratory Findings UNITED 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

  8. Laboratory Findings UNITED 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)

  9. Other Studies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Chest X-ray: normal • Urinalysis: normal

  10. 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

  11. 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.

  12. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • Sickle Cell Anemia (HbS) with Vaso-oclusive Crisis

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