Aspirin (Hives)
Sickle cell disease (HbSS), previous acute pain crises, splenic sequestration as a child.
No known surgical history
Up to date on all immunizations
Both parents are alive. Mother has sickle cell trait (AS), and father has sickle cell trait (AS). No siblings.
Hydroxyurea 1100mg PO once daily. Multivitamin PO once daily.
| Time | Provider | Notes |
|---|---|---|
| 0830 | Tony Lee M.D. | 25yo patient with history of sickle cell disease presents to the emergency department with complaints of severe joint pain, back pain, fatigue, and fever. Patient reports the pain started about a week ago. They tried to self-manage at home with rest, and fluids, but the pain has been worsening the past two days. They developed a fever yesterday that prompted them to come in for assessment and care. Patient admitted for pain management and fluids.Work up initiated for possible infection. Follow up with chest x-ray. |
| Time | 0800 | |
|---|---|---|
| Heart Rate | 116 bpm | |
| Blood Pressure | 130/85 mmHg | |
| Respiratory Rate | 22 breaths/min | |
| Pulse Ox | 116 bpm | |
| Oxygen in Liters | 94% | |
| Temperature | 101.2 F | |
| Pain | 3/10 |