Lucky Break
David B. Wilson
Julie A. Steinberg
CHIEF COMPLAINT
“Fell out of bed”
HISTORY of PRESENT ILLNESS
A 4-year-old boy with sickle cell disease (Hb SS) fell from a bunk bed 3 days PTA. On the DOA, he was taken to the emergency department for evaluation of worsening arm pain and swelling. He has had no fevers and no other symptoms whatsoever.
PAST MEDICAL HISTORY
Prematurity
G-tube placement/removal
SVT, age 7 month, resolved
One episode of sickle cell pain
Medications
PCN VK 250 mg po BID
Hydroxyurea 250 mg po qD
Ibuprofen PRN
Acetaminophen/hydrocodone PRN
Miralax
Family/Social History
Diet: Picky eater; diet lacks Fe-rich foods.
FH: Sickle cell trait, both parents.
SH: Lives with grandmother, mother, and sibling.
EXAMINATION
Vitals: T = 37.6 °C; P = 126; R = 23; BP = 116/63.
Head: Atraumatic and normocephalic.
Eyes: Pupils equal, round, and reactive to light and conjunctiva clear.
Nose: Clear, no discharge.
Throat: Moist mucous membranes without erythema, exudates, or petechiae.
Neck: Supple, no lymphadenopathy.
Lungs: Clear to auscultation; no wheezing, crackles, or rhonchi; breathing unlabored.
Heart: Normal PMI. RRR with a loud II/VI systolic murmur, normal S1 and S2.
Abdomen: Soft, nontender. BS normal. No masses or organomegaly.
Neuro: Face symmetric, moves right upper and bilateral lower extremities spontaneously against gravity.
Musculoskeletal: The left arm is swollen and tender to palpation. No tenderness to palpation of right upper extremity or bilateral lower extremities.
Skin: Warm, no rashes, no ecchymosis.
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