CHIEF COMPLAINT: Pain in both legs.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female with a past medical history of sickle cell disease, who comes to the ER with a chief complaint of pain in both legs one day prior to admission. She complains of 10/10 pain in both legs, nonradiating, aggravated by walking, not relieved by Percocet. She says it is like her usual crisis pain. She also complains of vomiting two days prior to admission, which was mostly food, nonbloody, nonbilious. It was accompanied by 6/10 throbbing, epigastric pain. The patient still had vomiting at the time of admission. No history of eating food outside. No diarrhea. No fever. No chills. She also complains of pain in her arms and back, and she is asking for analgesics. She gives history of ICU admission. She gives history of blood transfusion. No history of acute chest syndrome. No other complaints. Her usual hemoglobin, she says, is around 8. She does not know whether she has a hemoglobin SS or SC.
PAST MEDICAL HISTORY: Sickle cell disease. No diabetes. No hypertension. No asthma. No heart disease. Previous hospitalization for sickle cell crisis.
PAST SURGICAL HISTORY: History of cholecystectomy three years back.
ALLERGIES: No known drug allergies.
CURRENT MEDICATIONS: Folic acid 1 mg orally once daily, Dilaudid 6 mg q.4 hours p.r.n. pain, and MS Contin 30 mg b.i.d. for pain.
SOCIAL HISTORY: She does not work. No alcohol. No smoking. No drug abuse. She denies cigarette smoking within the past six months. She lives alone.
FAMILY HISTORY: Mother has sickle cell trait. Father has sickle cell trait. Sibling has asthma. Hypertension and colon cancer in father’s family.
REVIEW OF SYSTEMS: No fever. No chills. Sleep and appetite normal. No weight loss, no rash, no ecchymosis, no cold, no sore throat, no chest pain, no palpitation, no shortness of breath, no wheezing, no cough. She complains of nausea and vomiting but no diarrhea, no constipation, no abdominal pain, no dysuria, no hematuria, no burning on micturition. Last menstrual period was on MM/DD/YYYY. Musculoskeletal: She complains of pain in arms, legs, and back but no depression or psychiatric history. No seizure disorder.
PHYSICAL EXAMINATION: VITAL SIGNS: At the time of admission, temperature 98.6 degrees, pulse 76 beats per minute, respirations 20 breaths per minute, blood pressure 120/72 mmHg, and saturation 98% on room air. GENERAL: The patient is alert, awake, and oriented x3. SKIN: No rash. No ecchymosis. HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light bilaterally. Muddy sclerae present bilaterally. Ears, no discharge, bilaterally normal. Nose, no congestion. Throat, moist mucous membranes are present. No exudate. NECK: Soft and supple. No lymphadenopathy. CHEST: Symmetrical. HEART: Heart sounds S1 and S2 are normal. No murmur. LUNGS: Clear to auscultation bilaterally. No rales, rhonchi, or wheezing. ABDOMEN: Soft. Bowel sounds are present. Nontender. Nondistended. Tenderness on palpation in the mid epigastric region. MUSCULOSKELETAL: No muscle or joint tenderness. EXTREMITIES: Warm. No cyanosis, clubbing, or edema. NEUROLOGIC: Neurologically intact. Deep tendon reflexes present and symmetrical at the time of admission.
HOSPITAL COURSE: The patient was admitted with the diagnosis of sickle cell crisis to the general medicine floor where she was started on folic acid 1 mg p.o. once daily, Dilaudid 4 mg IV q.4 hours p.r.n. pain, MS Contin 30 mg p.o. twice daily, Reglan 10 mg IV q.6 hours p.r.n. nausea and vomiting, Protonix 40 mg IV daily, which was later on changed to Protonix 40 mg orally once daily. The patient’s Dilaudid was increased to 4 mg IV q.3 hours. The patient also had a chest x-ray, which showed bibasilar infiltrates and cardiomegaly. Chest x-ray was reviewed. The film was underpenetrated. The patient was afebrile and clinically did not look like lung infection. Also, infiltrates could not be appreciated on the x-ray when it was reviewed. Hence, the patient was not started on any antibiotics. The patient is feeling much better today. She says her pain control is better, and she is being discharged to home on a regular diet. Activity as tolerated. Medications were folic acid 1 mg once daily orally, MS Contin 60 mg orally twice daily, and Dilaudid 4 mg orally every 6 hours as needed for breakthrough pain. She has been given the prescriptions, and the patient is being discharged with the diagnosis of sickle cell crisis. The patient wants to follow up in the medicine clinic, but with her insurance, we have informed her that she has to call her insurance company and then change her primary doctor through the clinic so that she can be seen at the clinic.
