Medical Case Presentation Notes: Jonathan
Patient Details
- Name: Jonathan
- Age: 24 years old
- Ethnicity: African-American
- Medical History: Sickle Cell Disease
- Social Situation: Lives with mother and four siblings, works at Walmart as a stalker.
- Family History: Two siblings with sickle cell disease.
Presenting Complaint
- Symptoms: Bilateral knee pain for two days, severity 8/10.
- Additional Symptoms: Chills, mild shortness of breath.
- Exclusion: No fever, nausea, vomiting, cough, chest pain, abdominal pain, or knee trauma.
Medical History
- Sickle Cell Disease diagnosed at age 6.
- Hospitalizations: 6-8 previous for sickle cell crises.
- Other Conditions: History of lower extremity ulcers.
- Vaccination: No pneumococcal vaccine.
- Substance Use: Occasional alcohol, no IV drug or tobacco use.
Clinical Findings
- Vitals:
- Temperature: 36.3°C
- Heart Rate: 96 bpm
- Respiratory Rate: 16 breaths/min
- Blood Pressure: 108/70 mmHg
- Oxygen Saturation: 89% on room air
- Physical Exam:
- Respiratory: Clear lungs, no wheezes or rales.
- Cardiovascular: Normal S1, S2, tachycardic, soft flow murmur at base, decreased pedal pulses.
- Skin: Silver scaly rash on right elbow, 1 cm bilateral medial malleoli ulcers.
- Musculoskeletal: Mild right knee swelling, small effusion, pain on full extension, full range of motion bilaterally.
Labs
- Pending: CBC, BMP, Liver function tests.
Differential Diagnosis
- Vaso-occlusive disease (most likely)
- Periarticular disease
- Infarct
- Septic arthritis
- Gout
Treatment Plan
- Pain Management: NSAIDs, morphine for breakthrough pain.
- Monitor: For acute chest syndrome, splenic sequestration, aplastic crisis.
- Consult: Hematology/oncology for sickle cell follow-up.
- Diagnostic Imaging: Chest x-ray to rule out new infiltrates.
- Oxygen Therapy: Consider if symptomatic, 2 liters via nasal cannula suggested.
Conclusion
Jonathan presented with signs consistent with vaso-occlusive crisis, further lab results and monitoring needed to tailor treatment strategies.