Monday, March 7, 2011

Intern Report Case 3.3

Case Presentation by Dr. Ryan Doss

A 28 year old male with a PMH of sickle cell disease presents to the emergency department complaining of a one day history of worsening shortness of breath and a subjective sensation of fever. He states this was preceded by 3 days of intractable “sickle cell crisis” pain unrelieved by his home pain medications. When questioned further about the nature of this pain, he reports lower back and bilateral lower extremity pain which is typical of his previous sickle cell crises. After thinking about it, however, he does report that this time a new right lower chest pain accompanied his usual symptoms. His home medications include morphine and dilaudid po.

Physical Exam:
Vitals: BP 128/62, HR 108, RR 30, Sat 93% on RA, and Temp 38.1C
General:He appears to be anxious and in mild respiratory distress with no accessory muscle use.
HEENT: NC/AT, PERRL, mucous membranes moist
CV: S1 S2 present, regular rhythm and tachycardic rate, no murmurs
Resp: Tachypnea, equal rise and fall, rales auscultated in the RLL
Abd: Soft, nondistended, nontender all 4 Qs
Ext: Peripheral pulses present in all 4 limbs, cap refill <2 seconds, strength 5/5 proximally and distally in all 4 limbs
Back: No tenderness to palpation throughout cervical, thoracic, and lumbar spine. No bony deformity, crepitus, or step-offs noted.
Neuro: A&Ox3, alert, cooperative, no gross focal deficits

An AP and lateral chest radiograph is obtained with the following results:

An ABG is obtained on room air:

Laboratory abnormalities include:
Hb 8.4, WBC 13,000


1.  Calculate this patient's A-a gradient assuming an FiO2 of 21% (room air) and an Atm pressure of 760 (sea level.)
a) 10
b) 30
c) 5
d) 20
e) 40

2.  Of the following, which is the most common complication of acute chest syndrome?
a) Arrythmia
b) Mesenteric ischemia
c) Seizures
d) Acute kidney injury
e) Myocardial infarction

3.  Which of the following pathogens is most likely associated with acute chest syndrome?
a) Chlamydia pneumoniae
b) Legionella
c) Streptococcus pneumoniae
d) Staph aureus
e) Neisseria meningitidis

4.  Imagine you're lost in the woods, have sickle cell, get dehydrated, and develop an acute chest syndrome. Which of the following devices would you most wish you had brought? Also, it's 1910.
a) Horace P. Winterbottom's Patented Roentogram Generator
b) A tank of phlogisticated laughing anesthetic
c) Bayer Pharmaceutical's “Mother's Relief” Infant Teething Aide with Heroin
d) “Poseidon's Bane” Drowning Resuscitation Tobacco Smoke Enema Kit
e) A hearty sample of mandrake root and a crossroads in which to bury it, post-haste

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