Clinical Case Presentation: Young Adult/ Inpatient/ Teaching Rounds P3-2 Group 16

00:08:22
https://www.youtube.com/watch?v=PrxpxtpbMt0

摘要

TLDRThe case study discusses Jonathan, a 24-year-old African-American male experiencing severe knee pain, a common presentation for someone with his history of sickle cell disease. His symptoms include bilateral knee pain rated at 8 out of 10, chills, and mild shortness of breath. Jonathan's vital signs reflect an elevated heart rate and low O2 saturation. Physical examination shows mild knee swelling, but no serious abnormalities in heart or lung sounds. The differential diagnosis includes possibilities like vaso-occlusive disease, periarticular infarct, septic arthritis, or gout, with a greater likelihood towards vaso-occlusive due to his lack of fever and history of sickle cell complications. Treatment recommendations emphasize oxygenation and fluid administration alongside pain management using EDS and morphine. The discussion further delves into the significance of sickle cell disease versus trait, implications of Jonathan's medical history, and his healing capabilities, refining the diagnosis pathway.

心得

  • 👨‍⚕️ Jonathan is a 24-year-old male with sickle cell disease.
  • 🦵 He presented with severe bilateral knee pain.
  • 💊 Pain management with EDS and morphine was considered.
  • 💉 Luciisanerdrome, splenic infarct, and other related conditions were ruled out.
  • 🩺 A differential diagnosis included vaso-occlusive crisis and other joint issues.
  • 💧 Administering fluids and oxygen was recommended to improve his condition.
  • 📈 Vital signs included a heart rate of 120 and O2 saturation of 89%.
  • 👨‍👩‍👧‍👦 He lives with family members who also have sickle cell disease.
  • 🔬 The case highlighted the difference between sickle cell disease and trait.
  • 📊 The importance of monitoring and charting patient progress was discussed.

时间轴

  • 00:00:00 - 00:08:22

    The video discusses a 24-year-old African-American male named Jonathan who visited the emergency department (ED) with bilateral knee pain rated 8 out of 10, unrelieved by Percocet. Jonathan has a history of sickle cell disease. The pain started while working the night shift and worsened. He experiences chills and mild shortness of breath but denies fever and chest pain. Jonathan has a history of priapism and lower extremity ulcers, and he had a pain crisis a year ago. He lives with his family, some of whom have sickle cell disease. Notably, he does not smoke, use drugs, or regularly drink alcohol. His vitals are normal except for an elevated heart rate and low oxygen saturation, which is typical in his case. Examination shows discomfort and mild issues in his right knee, but no serious abnormalities in his heart, lungs, or testicles are noted. Initial assessment includes the possibility of vasoocclusive disease, periarticular infarction, septic arthritis, or gout, and treatment might involve pain management and monitoring oxygen levels.

思维导图

视频问答

  • What symptoms did Jonathan present with?

    He presented with bilateral knee pain, chills, mild shortness of breath, and a history of sickle cell disease.

  • What was Jonathan's pain level and response to medication?

    Jonathan rated his pain as 8 out of 10, and it was not relieved by Percocet.

  • What is Jonathan's medical history?

    He has a history of sickle cell disease, stuttering priapism, and lower extremity ulcers.

  • What were Jonathan's vital signs?

    Jonathan had an elevated heart rate of 120 and low O2 saturation at 89%.

  • What did the physical exam reveal?

    The exam showed mild swelling in the right knee, tenderness upon full extension, and a scaly rash on the elbow flexor side.

  • What are the differential diagnoses considered?

    Differentials include vaso-occlusive disease, periarticular infarct, septic arthritis, or gout.

  • What treatment plan was suggested for Jonathan?

    The plan included providing oxygen, fluids, and managing pain with EDS and morphine.

  • Why is vaso-occlusive disease less likely?

    Because Jonathan can heal from ulcers, and many arteries serve the knees, making occlusion less probable.

  • What is the importance of CLE cell disease in the diagnosis?

    CLE cell disease suggests a genetic component and indicates severe symptoms compared to sickle cell trait.

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  • 00:00:08
    okay narissa let's hear about this
  • 00:00:10
    patient that you've been seeing so we
  • 00:00:12
    have Jonathan who is a 24-year-old male
  • 00:00:15
    African-American male who presented to
  • 00:00:17
    the Ed last night with bilateral pain in
  • 00:00:20
    both knees he has a history of CLE cell
  • 00:00:22
    disease um he said that the pain started
  • 00:00:25
    two days ago while he was working the
  • 00:00:27
    night shift and has gradually gotten
  • 00:00:29
    worse um the pain is an8 out of 10 and
  • 00:00:32
    has not been relieved with his Percocet
  • 00:00:34
    it is also worse upon standing and
  • 00:00:37
    walking um he reports chills U mild
  • 00:00:41
    shortness of breath but he does deny
  • 00:00:43
    having a fever um any chest pain nausea
  • 00:00:46
    vomiting and abdominal pain um his past
  • 00:00:48
    medical history does include um history
  • 00:00:52
    of stuttering prism and lower extremity
  • 00:00:56
    ulcers uh he also has his last pain
  • 00:00:58
    crisis about a year ago
  • 00:01:01
    um he also lives with his mom and four
  • 00:01:03
    siblings two of which also have CLE cell
  • 00:01:06
    disease um he doesn't smoke he doesn't
  • 00:01:08
    do any drugs but he does drink alcohol
  • 00:01:11
    socially and the last time was last
  • 00:01:13
    weekend um his review of systems was
  • 00:01:16
    unremarkable except for some
  • 00:01:18
    intermittent left hand pain uh his
  • 00:01:20
    vitals were also normal except for an
  • 00:01:22
    elevated heart rate and his O2 SATs were
  • 00:01:25
    actually pretty low at 89% what was the
  • 00:01:27
    heart rate elevated at at 98
  • 00:01:30
    okay
  • 00:01:31
    yes sorry at at 120 it was at 120 that
  • 00:01:35
    would fit with pain yes think of that
  • 00:01:38
    okay so yeah his heart rate was at 120
  • 00:01:40
    um his O2 stats were also at
  • 00:01:43
    89% uh but that's normal for him for his
  • 00:01:46
    history so um on physical exam he was
  • 00:01:50
    lying in his bed uh in obvious
  • 00:01:52
    discomfort he also appeared thin but his
  • 00:01:55
    heart sounds were normal uh no murmurs
  • 00:01:57
    his lungs were clear to oscilation and
  • 00:01:59
    percussion
  • 00:02:00
    um he did have a scaly rash on his fle
  • 00:02:03
    the flexor side of his elbow uh his
  • 00:02:05
    testies were normal no prisms noted um
  • 00:02:09
    and then his right knee had mild
  • 00:02:11
    swelling um and a small affusion but no
  • 00:02:15
    athema uh it was non- tender to
  • 00:02:17
    palpation but upon full extension there
  • 00:02:19
    was some tenderness uh his left knee
  • 00:02:23
    there was no swelling no tenderness
  • 00:02:25
    noted and both knees had full range of
  • 00:02:27
    motion
  • 00:02:30
    so what are you what else you going to
  • 00:02:31
    do at this
  • 00:02:33
    point well um at this point for the
  • 00:02:36
    assessment is that is that what you the
  • 00:02:38
    assessment remember how we talked about
  • 00:02:40
    car what's the next step is you you want
  • 00:02:42
    to decide what you need to do to
  • 00:02:44
    finalize your diagnosis what else
  • 00:02:45
    additional tests things like that right
  • 00:02:47
    so we did order the
  • 00:02:49
    CBC okay um and we decided we didn't
  • 00:02:54
    need to take an s or x-ray because
  • 00:02:55
    they're usually not really conclusive
  • 00:02:58
    and don't really show much
  • 00:03:00
    good choice um so again for his
  • 00:03:03
    assessment we did we have this
  • 00:03:05
    24-year-old male who has a history of
  • 00:03:07
    CLE cell disease um and so the
  • 00:03:10
    differentials could include
  • 00:03:11
    vasoocclusive disease periarticular
  • 00:03:14
    infar septic arthritis or gout um
  • 00:03:18
    because he's a febal the vasoocclusive
  • 00:03:19
    disease or the periarticular infar are
  • 00:03:21
    more likely than not um so how are we
  • 00:03:24
    going to treat him we are going to give
  • 00:03:27
    him EDS for the pain is what I would
  • 00:03:29
    think um and then morphine for any
  • 00:03:31
    breakout pain uh if his CBC comes back
  • 00:03:34
    with any Market
  • 00:03:40
    lucyisanerd
  • 00:03:50
    Drome uh splenic infar and sorry a
  • 00:03:54
    plastic crisis and splenic
  • 00:03:56
    sequestration um and then we can monitor
  • 00:04:00
    his O2 sets and if he becomes
  • 00:04:01
    symptomatic also administer that would
  • 00:04:04
    you give him fluids and oxygen now or
  • 00:04:06
    are you going to wait we well we might
  • 00:04:08
    as well since his O2 stats are pretty
  • 00:04:10
    low at 89% so it wouldn't be a bad idea
  • 00:04:12
    to start him on any on oxygen why why
  • 00:04:14
    would this be would not be vasil
  • 00:04:17
    inclusive
  • 00:04:19
    disease think a little bit of vasil you
  • 00:04:22
    said he had some ulcers in the past but
  • 00:04:24
    he doesn't have them now okay what does
  • 00:04:27
    that tell you about his vascular system
  • 00:04:30
    he can heal yes okay okay so
  • 00:04:34
    vasoocclusive disease or necrosis where
  • 00:04:37
    would that occur when you think of Bones
  • 00:04:39
    where's the easiest place your hip hip
  • 00:04:42
    cuz remember there's one artery serving
  • 00:04:44
    that how many arteries are serving the
  • 00:04:46
    knees many okay would be hard to olude
  • 00:04:50
    that right see that's that's part of the
  • 00:04:52
    way so see that's part of the way I want
  • 00:04:53
    you to take your anatomy and bring that
  • 00:04:54
    in as you're thinking and talking about
  • 00:04:56
    it now Gap what would you expect to see
  • 00:04:59
    with gaps well a podagra and your big
  • 00:05:02
    toe yeah you con Cur in other
  • 00:05:04
    joints but it's what usually happens
  • 00:05:07
    with
  • 00:05:08
    gap remember in a joint very hot swollen
  • 00:05:12
    it will swollen yes and red that kind of
  • 00:05:16
    that takes that out plus it's highly
  • 00:05:18
    unusual in a large joint I mean you can
  • 00:05:20
    see it in ankle and the the the toe you
  • 00:05:23
    might see it in fingers but usually the
  • 00:05:25
    larger joints you don't with that or
  • 00:05:28
    something um
  • 00:05:30
    one of the things you've given a history
  • 00:05:31
    of CLE cell and let's little a little
  • 00:05:34
    bit let's talk a little bit about CLE
  • 00:05:36
    cell disease what does that mean when
  • 00:05:38
    you say disease versus
  • 00:05:40
    trait well with the disease he act so
  • 00:05:43
    both I guess both his parents had to
  • 00:05:45
    have had it um with a trait only his
  • 00:05:48
    mother or his father would have had it
  • 00:05:49
    usually trait is
  • 00:05:51
    asymptomatic generally yeah um so
  • 00:05:54
    because he has a disease he got a
  • 00:05:55
    trouble they generally can't sickle that
  • 00:05:57
    significance cells are very mild where
  • 00:05:59
    whereas with the disease they are and
  • 00:06:02
    you know what a peripheral smear would
  • 00:06:03
    look like on this describe a peripheral
  • 00:06:05
    smear the the cells would be sickle
  • 00:06:07
    shaped yeah that's where it gets its
  • 00:06:09
    name and what occurs with that as it
  • 00:06:11
    flows why the prism that you
  • 00:06:14
    see so with the prism basically it's a
  • 00:06:19
    prolonged erection and so with the
  • 00:06:22
    sickling it kind of blocks the blood
  • 00:06:23
    from being able to flow in and out
  • 00:06:26
    properly so that's why it's a stuttering
  • 00:06:28
    prism sometimes come sometimes it goes
  • 00:06:30
    just because it gets stuck per se
  • 00:06:32
    stuttering because it can be there and
  • 00:06:34
    kind of resolve on its own and the
  • 00:06:36
    sickling of the cells sludges so it's
  • 00:06:38
    difficult to pass through the you
  • 00:06:40
    remember your anatomy and in the
  • 00:06:41
    corporate
  • 00:06:42
    spongiosum the I mean the Corpus
  • 00:06:44
    cavernosum and the spongious areas
  • 00:06:45
    they'll poorly flow they usually will
  • 00:06:49
    reverse um if you don't you have to do
  • 00:06:52
    find your friendly urologist and he'll
  • 00:06:53
    teach you how to take care of those
  • 00:06:55
    things um but I think you've got a good
  • 00:06:58
    understanding of that the fact that he
  • 00:07:00
    doesn't have one now tells us he's
  • 00:07:02
    probably not at a
  • 00:07:04
    significanty cycling problem uh with
  • 00:07:07
    with the CLE cells crushing it the one
  • 00:07:10
    thing I would suggest in there is
  • 00:07:11
    probably go ahead and use the oxygen and
  • 00:07:13
    the fluids because that helps
  • 00:07:15
    oxygenating helps increase the oxygen
  • 00:07:18
    level so they function better the fluids
  • 00:07:20
    keeps from getting as acidotic so they
  • 00:07:21
    won't sickle as much we're worried that
  • 00:07:23
    there may be a component of CLE cell
  • 00:07:25
    inflammation or changes with this that
  • 00:07:27
    minimizes that it can happen what are
  • 00:07:29
    you going to do over the next few days
  • 00:07:31
    to see where he goes um we we'll
  • 00:07:35
    definitely monitor him for all the
  • 00:07:37
    things that could happen because of his
  • 00:07:38
    Sickle Cell
  • 00:07:42
    um sounds good I think you did a very
  • 00:07:45
    good presentation at this point you were
  • 00:07:47
    suin in your areas and for what we want
  • 00:07:49
    now this is the way I want you to do it
  • 00:07:51
    you're covering a lot of detail now on
  • 00:07:53
    the months ahead as we go on rounds so
  • 00:07:55
    other things you'll learn how to
  • 00:07:56
    compress that down to where it's a more
  • 00:07:58
    succinct because we'll already know
  • 00:08:00
    about the patient right but overall very
  • 00:08:02
    good NIS very good
标签
  • sickle cell disease
  • knee pain
  • vaso-occlusive crisis
  • patient assessment
  • oxygen therapy
  • pain management
  • peripheral smear
  • diagnosis