Sickle cell disease
The patient in this case study has a history of sickle cell disease (SCD). Priority physical assessment for this patient is to evaluate for potential complications related to SCD and signs of infection. I would assess this patient for abdominal tenderness, guarding, rebound tenderness, or splenomegaly, which could suggest complications such as splenic sequestration. His heart rate is 100 at the time of assessment, I would keep monitoring his heart rate for tachycardia which could indicate dehydration, pain or early signs of sepsis. I will ensure that the patient does not show signs of acute chest syndrome, which is a common and severe complication of SCD.
Differential Diagnoses
Vaso-Occlusive Crisis (G8.0)
Rationale: The most common complication of SCD, often triggered by infection, dehydration, or stress. The patient has abdominal pain, fever, and a history of SCD which could cause this complication (Kanter et al., 2018).
Splenic Sequestration Crisis (D57.02)
Rationale: A potentially life-threatening condition where the spleen suddenly enlarges and traps red blood cells, leading to anemia and hypovolemia. The patient’s abdominal pain and history of SCD are consistent with this condition (Kato et al., 2018)
Appendicitis (K35.80)
Rationale: The patient is c/o abdominal pain, and it has other signs and symptoms of appendicitis such as fever and elevated heart rate. As discussed by Ruddy et al. (2020), the dull nature of the pain could represent an early or atypical presentation. We would need to rule out appendicitis with a detailed history and a thorough physical exam.
Diagnostic Screening Tests
Complete Blood Count (CBC)
Rationale: This test helps assess the severity of anemia, presence of infection (leukocytosis), and reticulocyte count, which is critical in evaluating the bone marrow response, especially in patient with history of SCD and recent iron deficiency anemia diagnosis (Kavanagh et al., 2017).
Abdominal Ultrasound
Rationale: An ultrasound can identify splenomegaly, gallstones, or other abdominal pathology. Kato et al. (2018) mentioned that abdominal ultrasound is crucial in evaluating the potential for splenic sequestration or cholecystitis in a patient with SCD.
Blood Cultures and Inflammatory Markers (CRP, ESR)
Rationale: Given the low-grade fever, it\’s essential to rule out infection, which could precipitate a vaso-occlusive crisis. Blood cultures, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) can help assess for systemic infection or inflammation (Field & Nathan, 2020).
Pain Management
Pain management in this patient would be aggressive due to his history of SCD. We would ensure adequate hydration, which is vital in preventing further sickling of red blood cells. For pain control he may need NSAIDS or opioid analgesics depending on his pain tolerance. Other adjunctive therapies such as heat application or physical therapy may be helpful.
CPT Code(s)
99214: This code is for an established patient visit with moderate complexity.
References
Kanter, J., Liem, R., Bernaudin, F., Colombatti, R., Inusa, B., Kang, G., … & Yawn, B. P. (2018). American Society of Hematology 2018 guidelines for sickle cell disease: Transfusion support. Blood Advances, 2(22), 3418-3431. https://doi.org/10.1182/bloodadvances.2018025624
Kavanagh, P. L., Sprinz, P. G., Vinci, S. R., Bauchner, H., & Wang, C. J. (2017). Management of children with sickle cell disease: A comprehensive review of the literature. Pediatrics, 140(6), e20170461. https://doi.org/10.1542/peds.2017-0461
Kato, G. J., Piel, F. B., Reid, C. D., Gaston, M. H., Ohene-Frempong, K., Krishnamurti, L., … & Ware, R. E. (2018). Sickle cell disease. Nature Reviews Disease Primers, 4(1), 1-22. https://doi.org/10.1038/s41572-018-0006-8
Field, J. J., & Nathan, D. G. (2020). Advances in sickle cell therapies in the modern era. Blood, 136(4), 433-441. https://doi.org/10.1182/blood.2019000932
Ruddy, C., Bui, P., & Nguyen, V. (2020). Appendicitis in pediatric sickle cell patients: A case series and review of the literature. Journal of Pediatric Surgery, 55(12), 2653-2657. https://doi.org/10.1016/j.jpedsurg.2020.06.009
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