NYPQ Internal Medicine Rotation

Identifying Data:

Full Name: Ms. C. C.

Address: 108-79 184^th street Jamaica Queens, NY

DOB: 11/08/1995

Date & Time: August 11, 2020 at 0730

Location: Internal Med 2-N NYPQ

Religion: Unknown

Source of Information: Self

Source of Referral: Self

Mode of Transport: EMS

HPI
24y/o African American female with PMHx sickle cell anemia, cholecystectomy 2012, 2 months postpartum presents to the ED c/o for back pain that radiates down the back of the legs, which is typical for her pain crisis x 2 days. The pain started at her back and “moved down” her legs and became really painful. The pain is sharp and is 8/10 and she states the left leg feels worse than the right. She tried taking her prescribed medication (APAP and gabapentin) without relief. She came to emergency room because “this episode is the worst” she has had in several years. Dilaudid 12mg given in emergency room with some pain relief. Denies chest pain, palpitations, dyspnea, fever, cough, pregnancy, trauma, numbness/tingling, paralysis or urinary symptoms.

PMH:

• cholecystectomy 2012- no complications
• Sickle Cell Anemia dx at age 6

Family History:

• Mother: Alive Age: 52. HTN DM.
• Father: unknown- sickle cell
• Social History:
  Lives with mother in Jamaica Queens. Single Denies TOB use or ETOH use or illicit drug use. States she tries to exercise when she can but with newborn its difficult. Not sexually active, monogamous relationship with boyfriend. Denies STIs.

Review of Systems:
General: Denies weakness, recent weight loss or gain, loss of appetite, fever or chills, or night sweats.

• Skin, hair, nails: denies discoloration, texture, excessive dryness/sweating, changes in pigmentation, moles/rashes, pruritus.
• Head: denies lightheadedness, vertigo, and head trauma
• Eyes: denies blurring, diplopia, halos, lacrimation,
• photophobia, pruritus and glasses use.
• Ears: denies deafness, discharge, tinnitus and hearing aid use.
• Nose: denies discharge, epistaxis, rhinorrhea.
• Mouth/throat: denies dental complaints, bleeding gums, sore throat, mouth ulcers, voice
• changes and dentures.
• Neck: denies edema, masses, stiffness.
• Pulmonary: See HPI
• Cardiovascular: See HPI.
• Gastrointestinal: Denies constipation, intolerance to certain foods, N/V, dysphagia, loss of appetite, pyrosis, abdominal pain, flatulence, eructation, diarrhea, jaundice, rectal bleeding, blood in stool, hx of GI bleed
• GU: Denies nocturia, dysuria, frequency, oliguria, polyuria, change in color of urine,
• incontinence and flank pain.
• Musculoskeletal: Admits to back pain, and lower extremity pain. Denies joint stiffness, muscle fatigue, arthritis, muscle deformity/swelling and redness.
• Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema or color changes.
• Hematological system: Sickle Cell, easy bleeding, anemia hx of DVT/PE.
• Endocrine system: denies heat or cold intolerance, polyuria, polydipsia, polyphagia, goiter, excessive sweating, hirsutism.

Allergies: Baclofenà urticaria

Cyclobenzaprineà urticaria

Ketorolacà urticaria

Peanutsà urticaria

Medications:

• Acetaminophen 975mg q6hours
• Gabapentin 300mg q8h
• Famotidine 20mg qd

VITALS:
Tc: 36.7
HR: 82
BP: 116/78
RR: 17

SpO2: 100%

Physical Exam:
General: patient lying in bed, A&OxIII, NAD.
skin: no cyanosis/erythema, skin lesions
head/neck: normocephalic without evidence of trauma, neck supple. No edema
Eyes: PERRL.  EOMIs without nystagmus.
ENT: patent airway. Tongue uvula midline. Swallowing intact.
Heart: RRR without gallops, skips or murmurs.
Chest/lungs: chest normal in appearance, no use of accessory muscles, decrease breath sounds b/l
Abdomen: Bowel sounds in all 4 quadrants, soft, non-distended, non-tender to palpation throughout, no guarding or rebound tenderness
Extremities: +2 pulses in the extremities, no cyanosis, edema or ecchyomsis.

Musculoskeletal: Noted TTP over lumbar and sacral region radiating to lateral paraspinal muscles. TTP over quadraceps and hamstrings bilaterally. Full ROM of back with flexion, extension, abduction and adduction. Full ROM with lower extremities with flexion, extension, abduction, adduction and rotation. Muscle strength 5/5.

Neuro: CN II-XII grossly intact. DTRs +2
Lab Results:
LABS
PT: 12.6 / PTT: 27.7 / INR: 1.10

142 | 105 | 6.1
——————–< 101   Ca: 9.2   Anion Gap: 12
4.0 |  25 | 0.46

WBC: 10.59 / Hb: 7.2 (MCV: 84.2) / Hct: 21.8 / Plt: 410

Diff: N:51.2%  L:26.70%  Mo:13.3%

Prot: 6.6 / Alb: 4.7 / Bili: 3.5 / AST: 35 / AlkPhos: 71

Imaging:

MRI: MRI results revealed left femoral head avascular necrosis with no subchondral collapse. Bone infarct extends into the left femoral neck.

Bone infarct within the right superior acetabulum.

Assessment/Plan:
#Sickle cell crisis
-s/p dilaudid 12mg given in ED (4mg x 3) with some improvement as per pt, however states pain still returned
-f/u CXR
-cont folic 2mg daily

-hem/onc consult
-IV fluids for hydration
-Monitor H/H; keep active T&S, transfuse if needed
-Anesthesia/pain consult called – recommend PCA pump

#Back/leg pain

x-ray showed mixed lytic and sclerotic lesion within the R superior acetabulum and left femoral head, uncertain etiology.

Ortho is following

#DVT/GI ppx
-pepcid
-lovenox subcutaneous

COVID negative, low risk

Discussed with Dr. Pulijaal.

hem/onc consult

ASSESSMENT
24yo F with hx of SCD requiring multiple hospitalizations over lifespan, now 2m post-partum without resumption, presents with severe pain to lower back and R hip, hgb at baseline btw 7-8, stable on repeat. Pain appears to be well managed on PCA, though patient continues to experience reduced pain to R hip.

As patient is afebrile and in no resp distress suspicion for ACS low. Hgb at baseline and stable on repeat, Indirect bilirubin elevated and reticulocyte elevated above baselines suggestive of intravascular hemolysis, though appears no more than mild. Will recommend further hemolysis w/u to place current presentation in context of previous hospitalizations. Patient currently refusing CXR and imaging though following conversation states that she will allow, therefore obtain b/l CXR and imaging of b/l hip and pelvis as pain localized to hip to r/o avascular necrosis fem head. Considering hx of frequent hospitalizations during recent pregnancy, will assess for Fe overload, no signs to suggest at this time, will obtain Direct Antiglobulin Test as well to screen for antiRBC antibodies.

Patient indicates that her prior hematologist recently retired and she would like to f/u with hematology at local clinic. Review of prior data reveals HbgS levels between 40-60%, HgbF 1-3%, though unclear relation to blood transfusions. Expect HgbS >80 in SS disease so possibly SC disease. MCV wnl suggests against concurrent thalassemia B0, B+ remains possibility. Notably she will be moving to SF early next year as her husband is marine and will be redeployed. Will obtain additional w/u in anticipation of continuing care of patient following discharge.

Plan:
– recommend 2L NC O2 to limit sickling stimulus
– recommend CBC q24
– pain control with Dilaudid PCA, supplement with PO as needed, high dose as outpatient so assuredly tolerant and likely dependent
– Agree with ancillary opoid sparing agents such as gabapentin and acetaminophen, appreciate pain service guidance
– Obtain Haptoglobin, LDH, UA
– c/w folate at home dose 2mg qD at this time
– obtain CXR, patient states she is now amenable
– obtain XR b/l hip and pelvis, ap, lateral, and frogleg
– defer PT until after XR obtained
– obtain Hgb Electrophoresis, unclear if prior values in system were shortly after transfusion
– will consider restarting hydroxyurea as outpatient as pregnancy now complete and ongoing frequency of pain crises (>3/y), will hold during acute pain crisis
– Recommend that patient follow up with Kings County Hospital Sickle Cell Clinic in interim prior to departure for SF

Plan discussed with attending Dr. Hyun and with Patient at bedside

Attending Addendum:
24/F 2 months post-partum, sickle cell disease patient with pain crisis with no clear cause. Initially pain was localized in the hip without erythema or edema, but now pain is in “whole body”, and pt can bear weight in her hips. Patient’s vitals are stable including O2 Sat, however no labs last two days. Continue pain control, hydration, folate  and trend hemolytic measures (CBC, LDH, retic count and haptoglobin). Please do not transfuse unless she is symptomatic from anemia. Pt would benefit from following up with Sickle cell clinic who could provide comprehensive care for her. I would recommend Sickle Cell clinic in Kings County Hospital with Dr. Muthu upon discharge.
Her appointment at KCHC C41 (sickle cell clinic) is set for 8/27/2020 @10:20AM.

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Typhon Report:

Internal Med Typhon

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Peer-Reviewed Article:

Sickle Cell Management

This article provided updated treatment options for patients suffering from sickle cell anemia. Sickle cell disease has a major burden on the healthcare industry and the targeted therapies provided in this article help to mitigate that cost. The article explains in detail the origin of sickle cell disease and the painful episodes associated with that and the quality of life goals to help mitigate that pain. The article focused on the medications that specifically help patients improve survival rates. Stem cell transplant is the only cure available for sickle cell disease, yet this article finds that the patient’s who would benefit from the transplantation is controversial. Further research is needed on the use of gene therapy, the unique genomic sequence of the patients involves only certain nucleotides, but the human trial commenced in 2017 and with the use of stem cells patients have been able to remain sickle cell disease free for 6 months. More studies are needed for this complex treatment options.

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Site evaluation:

My site evaluation went really well. I was able to have a thorough conversation about my cases with my site evaluator. Mr. Combs did give me some good advice when it came to differential diagnosis, which I know is a weakness among students practicing medicine. Mr. Combs focused on my life experience and reiterated the importance of applying that to the everyday medicine.

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Summary:

Internal medicine was a tough and rewarding rotation. The complex list of patients with comorbidies and the list of diagnosis is extensive with the patients. The patients were generally in their 60s and I noticed that the emergency room had a low threshold to admit someone. I was able to witness the whole admission process which involved evaluating the patient in the emergency room, bringing the patient up to the inpatient floor and following some of providers that were seeing the patient as consults. I Noticed that the PAs would carry anywhere from 12-20 patients at a time and that did not include admissions that were throughout the day.

There were numerous opportunities to assist with procedures or do procedures on your own. For example, I would work with the nurses in the morning and offer to start IVs or draw blood for daily labs. This was good experience because it allowed me to practice my skills. I was able to place NG tubes and perform several ABGs which was a great experience. On occasion I was able to perform foley catheter placements and assist with lumbar punctures. The first LP on a patient was to rule out “Mad Cow Disease” Cruetzfeldt-Jakob Disease and it turns out he had contracted the disease. This case was an interesting read and I was able to follow the patient until palliative took over the case.

Overall, it was a great learning experience and it is a field of medicine I could see myself working in.