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NYU Medical Grand Rounds Clinical
Vignette
Maryann Kwa, MDPGY-3
March 20, 2012
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.
Chief Complaint
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.
History of Present Illness
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 limitsUNITED 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
• The patient was admitted to the medicine service for further work-up of anemia.
• Differential diagnoses:•Sickle Cell Anemia•Leukemia
Working or Differential Diagnosis
UNITED STATES DEPARTMENT OF VETERANS AFFAIRS
– 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.
Hospital Course
UNITED STATES DEPARTMENT OF VETERANS AFFAIRS
• Sickle Cell Anemia (HbS) with Vaso-oclusive Crisis
Final Diagnosis
UNITED STATES DEPARTMENT OF VETERANS AFFAIRS
