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Internal MedicinePresentation

Michael Sicat

February 2, 2012


2/23

Introduction

Source: Patient, 24 years old

Reliability: reliable historian

Chief Complaint: "my stomach, back, and leg hurt"


3/23

HPI

24 y/o African American male with PMHx of sickle cell anemiapresents with sharp lower back pain, RLQ abdominal pain, andright thigh pain. Patient states the abdominal pain started first.Pt denies any trauma. Pt also denies any headache, chestpain, shortness of breath, or any other symptoms. The pain isdescribed as 10/10 and worse abdominally and down to histhigh. It is not relieved or exacerbated positionally. Patient tooksome Ibuprofen which offered some relief but eventually wore

off.


4/23

PMHxAllergies: NKA

Medical: sickle cell anemia

Family: Father, 56 A&W, HTN, DMMother, 52 A&W, HTN, DM, Breast CAsister 22, A&W

Medications: none

H

ospitalizations: none

Surgical: none

Social: denies alcohol, smoking, illicit drugs

Sexual: active uses rotection


5/23

Review of Systems

General: afebrile, no headacheSkin: denies rashes, pruritisHead: denies recent traumaEyes: denies pain, double vision, rednessEars: denies hearing loss, tinnitusMouth: denies sore throatPulmonary: denies cough, wheezing, pleuritic chest painCardiovascular: denies shortness of breath

Abdomen: +RLQ pain, denies nausea/vomiting/diarrheaUrinary: denies hematuria, dysuriaNeurologic: A&Ox3Musculoskeletal: +lower back pain, +right thigh painPsychiatric: denies depression, anxiety


6/23

Vitals

T: 97.6 F

P: 110

RR: 18

BP: 122/78

O2:98% RA


7/23

Physical Exam

General: pt in acute distressHead: atraumatic, normocephalicEyes: PERRLA, EOMIEars: TM intact, no erythemaNose: septum midlineThroat/Mouth: no thyromegaly, oral mucosa moist, no erythemaCVS: +tachycardia, S1S2 RRR, no murmurs/rubs/gallopsPulm: clear to auscultation, no wheezes, rhonchi, rales

Abdomen: +tender to palpation, no rebound tenderness, soft,

non-distended, +BSMusculoskeletal: +tenderness on lower back, +tenderness onright legExtremities: no dactylitis, no edemaNeurological: no focal defecits, cranial nerves intact


8/23

Differential Diagnoses

Vaso-occlusive Sickle Cell Crisis: CBC with differential, (HgBelectrophoresis), peripheral blood smear

Acute Abdomen: Abdominal CT- appendicitis- pancreatitis- cholecystitis

Osteomyelitis: blood cultures (MRI)

Avascular Necrosis: MRI


9/23

Ancillary Tests

LABS- CBC with differential- Peripheral Smear- Blood Cultures- (Electrophoresis)

IMAGING- CT Abdomen- Chest X-Ray


10/23

Imaging

PA/Lateral X-ray: no consolidation, no infiltrates, no atelectasis,no PTX

Abdominal CT w/ no contrast: no inflammation of the appendix,no kidney stones, no inflammation of the gallbladder, nomasses


11/23

Labs

141 | 105 | 11 | 80--------------------------------4.1 | 25 | 0.8 |

14.2

10.5 350

42

MCV: 95 Lipase: NormalMCH: 30 Amylase: NormalMCHC: 33.3 Cultures: NEGATIVERDW: 16%Reticulocyte Count: 2.5%


12/23

Peripheral Smear

+1 Elliptocyte+1 Sickle Cells+1 Target Cells


13/23

Assessment

24 y/o African American male with PMHx of sickle cell anemiapresenting with abdominal pain, right thigh and lower back painconsistent with vaso-occlusive sickle cell crisis.


14/23

Plan

#1 Vaso-occlusive Crisis- MonitorH/H- Monitor CBC- Monitor Reticulocyte Count- Hydroxyurea 500 mg; up to 15 mg/kg (Patient = ~70 kg)#2 Musculoskeletal Pain- Pain management

- Morphine 8mg IV

- Dilaudid 8 mg IV


15/23

Hospital Course

- 3 days in hospital

- H/H remained normal- values not consistent with anemia

- Reticulocyte stabilized- remained < 2.7%- unusual in sickle cell crisis

- Maintained Hydroxyurea- Maintained Dilaudid PO

- Patient stabilized and pain free and was discharged


16/23

Sickle Cell Crisis

- Homozygous recessive (Sickle Cell Disease)

- Crisis brought on by stress- infection- sickling of cells


17/23

Pathophysiology

- Sickling of cells can result in ischemia and pain

http://www.unm.edu/~mpachman/Blood/sickle_cell_image_1.jpg


18/23

Complications of Ischemia

- End organ damage

- Stroke

- Avascular Necrosis

- Osteomyelitis

- Priaprism

- Ulcers


19/23

Treatment

HYDROXYUREA- increases HgF (Fetal Hemoglobin)

- slows sickling and formation ofHgS- reduces leukocytes

- decreases adherence of neutrophils to endothelium

- originally used in chemotherapy- may be carcinogenic- studies showed children taking 1 year had only minor

adverse effects- long term effects are still unknown

Transfusion

Pain Management- NSAIDs

- Narcotics


20/23

Prognosis

1994: Life expectancy was expected around 42-48.

Today: 50s-60s with treatments/medications


21/23

Pain Management

Annals of Internal Medicine (2008)

- Study of pain in sickle cell disease patients

- Diary- Track of Pain

1. Presence of Pain/Crisis or No Pain2. Hospitalizations3. Pain + Hospitalization4. Crisis + Hospitalization


22/23

Results (6 months)

- Chronicity ofVaso-occlusion- hemolysis >> ischemia >> organ damage

- Pain managed mostly at home

- About 1/3 had pain almost everyday

- Crisis + Hospitalization not common- sensitization to pain?

- Crisis + Home Management more common- 4 x MC vs hospital- social issues?

- Si nificant amount of sickle cell crisis/ ain unre orted


23/23

References

http://en.wikipedia.org/wiki/Sickle-cell_disease#Hydroxyurea

http://www.ncbi.nlm.nih.gov/books/NBK1377/#sickle.Differential_Diagnosis

http://www.ncbi.nlm.nih.gov/books/NBK1377/#sickle.Differential_Diagnosis

http://emedicine.medscape.com/article/205926-treatment#aw2aab6b6b2aa

http://emedicine.medscape.com/article/205926-workup#aw2aab6b5c11

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