Primary care clinic
A 15 yr old African American male presents to the primary care clinic with low grade fever that has persisted for 2 days accompanied with dull abdominal pain. He has a history of Sickle Cell Disease (SCD) and was recently diagnosed with iron deficiency anemia. His temperature is 100.7, blood pressure 128/78, heart rate is 100, SatO2 is at 98%, capillary refill is 3 seconds, extremity pulses are a 3+. Abdominal pain is rated as 7 out of 10 on the numeric pain scale.
1. What is the priority physical assessment for this patient?
Priority physical assessment for this patient should include a thorough GI exam since this patient is c/o abdominal pain rated 7/10 on the pain scale. When inspecting the patient’s abdomen, note any vascular variability, asymmetry, peristalsis, pulsations, signs of trauma, etc. Abdominal auscultation that confirms absent bowel sounds can indicate an ileus or peritonitis and hyperactive bowel sounds can indicate possible obstruction. When palpating the abdomen note any guarding or rebound tenderness that can indicate peritonitis. It is important to palpate the liver and spleen, noting hepatosplenomegaly or any other abdominal masses. Splenomegaly, LUQ abdominal pain, pallor, and fatigue are symptoms suggestive of splenic sequestration (Kane, et al. 2023). Physical exam positive for RUQ pain, hepatomegaly, and worsening jaundice indicate likelihood that the patient is experiencing acute intrahepatic cholestasis (AIC) (Mangla, 2023). Other priority assessment should focus on the cardiovascular and respiratory systems noting pallor, tachycardia, increased capillary refill time (CRT), or decreased breath sounds. His VS show mild tachycardia and a low-grade fever suggestive of possible infection.
2. What would your top three differential diagnoses be? Include rationale and ICD-10 code.
Vaso-occlusive crisis – D57.00 – Hb-SS disease with crisis, including vaso-occlusive pain. Vaso-occlusive crisis can present with moderate to severe abdominal pain and fever and is the most common complication of sickle cell disease (Maakaron, 2023).
Splenic sequestration crisis – D57.02: Hb-SS disease with splenic sequestration. Possible diagnosis d/t mild tachycardia, fever, abdominal pain, and anemia.
Acute intrahepatic cholestasis (AIC) – D57.218: Sickle-cell/Hb-C disease with crisis and other specified complication, such as cholelithiasis or priaprism. Possible diagnosis d/t abdominal pain, fever, and mild tachycardia, but is less common to occur (Adkins et al., 2019).
3. What are the top three priority diagnostic screening test(s) applicable for this case? Provide an evidence-based rationale for each.
Complete blood count (CBC) with reticulocyte count – to assess how severe the drop in Hb is, determine reticulocyte count, nucleated red-blood cells, and detect possible infection.
Complete metabolic panel (CMP) – to assess ALT, AST, and bilirubin levels, which would be elevated in cholestasis.
Abdominal ultrasound – to detect hepato/splenomegaly, thickened gallbladder walls/ductal inflammation.
4. What would be your approach to pain management? Is this different for someone with Sickle Cell Disease?
For any sickle cell crisis, the patient is treated with morphine 0.05 to 0.1 mg/ kg orally every 2 to 4 hours if the pain is not severe. Rehydration therapy is used to slow down the sickling process which is a known cause of vaso-occlusive crisis.
5. What is the CPT code(s) appropriate for this patient visit?
76700 – Complete abdominal ultrasound
80053 – Complete metabolic panel
85007 – Complete blood count with differential; 85045 – Reticulocyte hemoglobin equivalent
References
Adkins, B. D., Savani, B. N., & Booth, G. S. (2019, September 1). Management of sickle cell intrahepatic cholestasis: An argument in favor of automated exchange transfusion. Clinical hematology international. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8432363/#:~:text=Acute%20sickle%20cell%20intrahepatic%20cholestasis,and%20subsequent%20ischemia%20%5B6%5D.
Joseph E Maakaron, M. (2023, December 12). Sickle cell disease (SCD) clinical presentation. History, Physical Examination. https://emedicine.medscape.com/article/205926-clinical#:~:text=The%20mortality%20rate%20of%20such,of%20bone%20weakened%20by%20infarction.
Kane, I., Kumar, A., Atalla, E., & Nagalli, S. (2023, June 5). Splenic sequestration crisis. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK553164/
Mangla, A. (2023, September 4). Sickle cell anemia. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK482164/
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