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A 23-year-old woman with sickle cell disease is brought to the emergency department after becoming obtunded; she has a 2day history of cough and fever. Her temperature is 39.3°C (102.7°F), pulse is 128/min, respirations are 28/min, and blood pressure is 98/60 mm Hg. She appears stuporous. She is intubated and mechanically ventilated. There is moderate nuchal rigidity. Right basilar crackles are heard on auscultation. Hematocrit is 21% with many nucleated erythrocytes, and leukocyte count is 24,000/mm . Which of the following is the most appropriate next step in management?
A) Administration of antibiotics
B) Administration of dopamine
C) CT scan of the head (WRONG)
D) Transfusion of 3 units of packed red blood cells
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I'm guessing that the answer is A since this is a sickle cell disease patient and despite the "obtunded," presentation it's unlikely that she had any head trauma/stroke since the presentation was not acute, the symptoms did not develop suddenly and more importantly the symptoms did not change at all as time went on. There's no history of head trauma, and there are a lot of positives signs of infection such as the elevated white count, fever, and tachycardia.
You would get a CT in a elderly patient, with a history of hypertension/cvs disease or a lot of risk factors for stroke such as smoking and a high lipid profile etc. Other clues to a stroke would be a progression in symptoms getting either better or worse depending on whether it was an ischemic or hemorrhagic stroke and the presence of focal neurological findings. While this patient does have neck rigidity, when combined with the other signs of infection and the likelihood of the patient being functionally asplenic at her age, your differential should be focusing on things like meningitis and/or acute chest syndrome.
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@mastahriz, thank you. But I was thinking the answer is likely to be D, as she is severely anemic with Sickle cell, rapidly decompensating, and would require rapid infusion of blood cells and oxygenation of tissue to prevent further decompensation?
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2. A 72-year-old man comes to the physician because of a 7-day history of increasingly severe pain around the waist. He says that it feels like a burning belt from the left midback to the umbilicus. He has a history of chronic low back pain. He has type 2 diabetes mellitus treated with glyburide and asthma treated with beclomethasone and albuterol inhalers. He completed a 10day course of corticosteroids for asthma 3 weeks ago. Examination shows numbness in the left T12 distribution. The remainder of the examination shows no abnormalities. Which of the following is the most likely explanation for these findings?
A) Ankylosing spondylitis
B) Atherosclerotic vascular disease
C) Diabetic radiculopathy
D) Epidural abscess (WRONG)
E) Low back strain
F) Lumbar radiculopathy
G) Lumbar stenosis
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For the first one, antibiotics is a very urgent step in patients with aspleenia. As a matter of fact, they are instructed to always keep antibiotics on hand and take at the slightest sign of infection, they also wear a medic bracelet, so healthcare personnel know to give them antibiotics ASAP.
Sickle cell disease patients always have anemia. A 21 % hematocrit isn't very impressive for them. It might even be the baseline in some. Even if she does eventually need to be transfused, it's not more urgent than antibiotics.
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@ doc2530 - I agree with ulum . Also in mtb 3 it is written if a sickle cell patient let's say develops fever , the first thing to be given is antibiotics. It doesnt matter what else he has , but if there is fever you best first step is antibiotics.
