Jacob is a 30-year-old black man with a history of sickle cell disease. He presents with a three-day history of pain in both elbows. The pain is sharp and the patient rates it as a "9" on a scale of 1-10. He has a low-grade fever
He was started on NS IV fluids and morphine was administered for the pain.
PMH—aside from the sickle cell disease, his past medical history is unremarkable.
FH/SH—Both parents are alive and well. He has no siblings. He is not married. No known relatives with a history of sickle cell disease.
Vital signs—T – 101.4 P – 89 R – 18 BP – 112/66 O2 sats – 90% on room air.
HEENT—PERRLA; scleral icterus; remainder of exam in unremarkable. Cranial nerves grossly intact; normal sensation.
Neck—No LAD or masses; no lymph nodes appreciated.
Cardiac—RRR, S1 and S2 are normal.
Lungs—Decreased breath sounds bilaterally. Crackles and rales heard on ausulcation.
Abdomen—Normal bowel sounds; no rebound tenderness or guarding. Spleen slightly enlarged.
Extremities—No cyanosis or clubbing.
Musculoskeletal—Both elbows swollen, red, hot to the touch; tenderness on palpation and painful on extension. Limited ROM in both elbows.
GU—Normal male.
Rectal exam deferred.
Impression: Sickle cell crisis. I am also concerned about the crackles, rales, and diminished breath sounds in the lungs. There could be a pneumonia starting.
Plan: Admit for treatment of the sickle cell crisis. Get a CXR to see what is going on in the lungs. Continue IV fluids; consider Hydrea; consider transfusion, depending on H&H.
Addendum: CXR is positive for pneumonia. Will do a forced sputum culture and start on antibiotics.
First-listed diagnosis: ________
Secondary diagnosis: ________
Fill in the blank with correct word.
First-listed diagnosis: ________
Answer: Sickle cell crisis – D57.00
Secondary diagnosis: ________
Answer: Pneumonia – J18.9
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