Jonathan, this is Dr. Jones and our internal medicine service team. Hi. Hi Jonathan.
We're going to be, I'm going to be presenting your case to them. Is that all right if I do that in the presence of your girlfriend and co-worker here? Yes, that's fine. Thanks, Jonathan.
So this is the first UMC visit for Jonathan, who is a 24-year-old African-American with a history of sickle cell disease who presented to the emergency department with a two-day history of bilateral knee pain. He's ectomorphic and is in moderate distress. The pain began Tuesday at approximately 4 a.m.
while he was working a night shift. at Walmart. He had difficulty sleeping because of the pain that night and the pain gradually continued to increase due to a severity of 8 out of 10 today.
The pain was exacerbated with walking and standing and was not significantly relieved with Percocet which he received from another physician that we aren't sure who it was. Jonathan has never experienced knee pain to this extent before but he did say that he's had a few a few episodes in the distant past of knee pain. He reports some chills and a mild shortness of breath, but he denied fever, nausea, vomiting, cough, chest pain, abdominal pain, or recent trauma to the knees. He has no other known medical illness and isn't on any chronic medication for sickle cell disease either. In the ED, he was given an IV bolus and received two doses of morphine at six milligrams and eight milligram doses.
For past medical history, he was diagnosed with sickle cell disease at age six and has had six to eight previous hospitalizations for that. He has a history of lower extremity ulcers as well, but he has never had a pneumococcal vaccine, which is interesting. His social history includes he lives with his mother and four siblings.
He works at Walmart as a stalker, but denies any IV drug use or tobacco use. He does consume alcohol occasionally. and last time was this last weekend.
He has two siblings that also have sickle cell disease. In the review of systems, it was negative except for lower extremity ulcers and intermittent left hand pain. In his vitals, he had a temperature of 36.3 degrees Celsius, heart rate of 96, respiratory rate of 16, blood pressure of 108 over 70, and his O2 saturation was 89% on room air. Um...
For Hint, he's normocephalic, atraumatic, pearly, and extraocular movements are intact. With lungs, they're cleared to auscultation and percussion with no wheezes, rails, or bronchi. For CV, his S1, S2 were normal.
He is tachycardic with a soft flow murmur heard at the base. There was no S4, but he does have decreased pedal pulses. For abdominal exam, bowel sounds were normal, and the spleen tip was not palpable.
For GU, he did didn't have any urethral discharge either. For skin, he had a silver scaly rash on the flexor surface of the right elbow and there are non-healing bilateral ulcers of one centimeter diameter on both medial malleoli. For musculoskeletal, he has mild swelling of the right knee and small effusion.
There's no erythema and it's not tender to palpation but there was pain on full extension. His left knee didn't have any significant swelling or tenderness. and he did have full range of motion bilaterally with his knees. On lab work, we have a CBC, BMP, and liver function test pending.
And so in conclusion or in summary, Jonathan, he's a 24-year-old African-American man with a history of sickle cell disease and hypoxia. He presented at the emergency department with bilateral knee pain and minor right knee effusion. On the differential diagnosis, we have vaso-occlusive disease, periarticular disease, infarct, septic arthritis, and gout. Vaso-occlusive disease is most likely due to the afebrile presentation of the patient. And the pending CBC results will likely rule out septic arthritis due to a gram-negative Neisseria, staph, or salmonella.
Potential plans of treatment include knee pain. Well, for knee pain, we would consider NSAID treatment with morphine for breakthrough pain. For sickle cell disease, we should monitor closely for acute chest and... splenic sequestration and aplastic crisis and consult a hemonc for a sickle cell referral after he is released from the hospital.
And then we should also obtain a chest x-ray to rule out new infiltrates and consider oxygen therapy if he becomes symptomatic in his lungs again. Alright, any questions? I'd also recommend adding two liters of oxygen via nasal cannuline.
I think that would be a great idea. And great job Bryce, you really were very thorough. Thank you for letting us.
is present in front of you. That was really great. Thank you.