CHIEF COMPLAINT: Sickle cell crisis.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gentleman with a longstanding history of sickle cell anemia. He has pretty well-controlled pain. He takes Dilaudid and Valium at home. He has been dealing with this current crisis for approximately two months. He states that as the weather changes, his symptoms typically get worse, and he is dealing with infections in his ears and his throat. He has specifically, pain in his low back and into his bilateral lower legs. He has only minimal chest discomfort. No shortness of breath.
PAST MEDICAL HISTORY:
1. Sickle cell disease.
2. Chronic low back pain.
3. Gastritis.
MEDICATIONS:
1. Dilaudid.
2. Valium.
3. Cipro.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient denies alcohol, tobacco or illicit drug use.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: As mentioned, otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 116/72, pulse 94, respirations 18, temperature 98.6, O2 sats 92% on room air.
GENERAL: The patient is awake, alert, and oriented, in no acute distress.
HEENT: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact.
NECK: No lymphadenopathy, no carotid bruits. Neck veins are flat.
CHEST: Good breath sounds bilaterally with no wheezes, rales, or rhonchi.
HEART: Regular rate and rhythm with no murmurs, rubs, or gallops.
ABDOMEN: Soft, nontender, nondistended. Good bowel sounds with no organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema.
NEUROLOGIC: Cranial nerves are intact. Reflexes are normal. Sensation is grossly intact.
EMERGENCY DEPARTMENT COURSE: This patient was seen and evaluated for sickle cell crisis. He was given Dilaudid per his sickle cell protocol, and he has received good relief of symptoms. He did do a chest x-ray for further evaluation of his chest discomfort, and it did show a patchy airspace consolidation and atelectasis in the right lower lung. He currently is on Cipro for infectious process. At this time, he is stable for discharge.
PLAN: The patient should follow up with his primary care physician in the next couple of weeks. Return to the emergency department if he has any increased pain, shortness of breath, or fevers.
DISPOSITION: The patient was discharged home in stable condition.
