Authors: Kenneth Akapo, OSU MS4 // Dr. Michael Barrie, OSU EM Attending
A 24 year old female with history of sickle cell disease presents with a 6 hours history of widespread pain. The pain is in her lower back but also present within the lower and upper extremities. She also endorses mild shortness of breath although she attributes this to her pain episode. She mentions being seen a week ago due to a similar episode during which she also had new onset headaches associated with blurry vision. During that episode, CT scan was unremarkable. During the current encounter, there was low concern for ischemic stroke. The headaches have persisted until now, however, she no longer endorses changes in vision. She also denies any other focal neurologic symptoms.
Upon initial examination, the patient appeared to be in mild distress. She was mentating well and exhibited no focal neurologic symptoms. She was diffusely tender to palpation although she seemed to exhibit more pain when palpating the lower extremities and back. Breath sounds were clear to auscultation bilaterally, and cardiovascular exam was normal.
Before presenting the case to the senior resident, you consider your differential diagnosis – sickle cell pain crisis, acute chest syndrome (ACS), ischemic stroke, acute coronary syndrome (the other ACS), and heart failure among others.
But what findings would help support or refute a diagnosis of acute chest syndrome? And what is the plan to manage the initial diagnosis and treatment of possible acute chest syndrome?