Health History Assessment Summary

Health History Assessment Summary

Patient Name :           Johnson Bernard

CC                  :           Diagnosed with Bilateral Knee Pain

HPI:

The patient is a 26 year old gentleman with an African-American descent. The man has previously been diagnosed with h/o sickle cell. As at reporting time, the patient suffered from a bilateral knee pain that began at lunch break on the 20/10 while the patient worked at a distribution store. As reported by the patient, the pain started mildly and escalated gradually to the extent the patient could not sleep on the night of 20/10 through to 21/10. Ultimately, the pain was so exacerbated to the extent the patient had challenges standing and walking. However, the patient denied experiencing any trauma on the knee, cough, pains on the chest, any abdominal pain, and coughs. In sum, the pain was intense and localized on the knee without spreading to other parts of the body. The patient received prescriptions and started taking morphine (6mg).

 

PMH:

Medical and Surgical History

  1. H/o stuttering priapism: abnormal cavernous blood gases and perineal trauma
  2. H/o the patient has also been previously diagnosed with ulcers of the lower extremities.
  3. The patient was previously diagnosed and on treatment of the Sickle Cell Disease with the last event of pains being experienced over two years ago at XXXXX clinic in XXXXX city.
  4. The patient was hospitalized a year ago in October after being hit by a hockey ball while playing hockey. The patient had been hit on the chest and developed difficulties in breathing. Latter, the patient developed fevers and ended up being admitted for at least three days. Nonetheless, it is not clearly indicated whether or not these conditions were related to pneumonia or not.

 

Family History

There are no histories of individuals suffering from arthritis, heart diseases, liver, or kidney diseases. Currently, the patient has one sibling with sickle cell disease. An uncle of the patient out of three also had sickle cell disease. Similarly, a step grandfather had been diagnosed with the sickle cell disease.

 

Social History

Patient lives with the family of mother and father, and three siblings. They have lived in the same locality at XXXXXX for approximately five years. The patient admitted engaging in social drinking occasionally but denied using tobacco or smoking other drugs and stimulants.

 

Allergy

NKDA

 

Current Medications

  • 5mg qd of folic acid
  • 6mg of morphine
  • 5/325mg of percocet

 

 

Review of Systems

Constitutional: Experiencing intermittent chills without fever. No recorded weight loss and decrease in appetite.

ENT: The patient had no mouth ulcers in the mouth. There was also no dysphagia and URI elements.

SKIN: Normal skin with no symptoms.

PSYCHOLOGY: Absence of insomna, anxiety or depression

NEUROLOGIC: Absence of weakness or forms of numbness

 

Physical Examination

 

General: Patient inable to stand or walk, lies in bed with general symptoms of weakness and thin appearance.

Lymph Nodes: Absence of cervical LAD

Cardiovascular: Normal and prominen heartbeat sounds with equality on both sides, S1 and S2 normal

Lungs: General good air movement with decreased bulateral breath sounds.

Neurologic: Grossly intact cranial nerves, with ordinary cerebellar function

Psychiatry: Alert and oriented to person, place, and time

Discussion

Defined as an autosomal recessive disorder, the sickle cell disease causes the β-globin gene to undergo a point mutation that leads to the alteration of the structural system of the hemoglobin molecule. This subsequently leads to deoxygenation. Additionally, Aggregation and polymerization of resulting from the same process reduce the lifespans of hemoglobin molecules by causing chronic hemolytic anemia. It is highly likely that the pain on the knee was caused by a vasoocclusive event leading to periarticular infarction.

 

 

References

Hoffman, R. Hematology: basic principles and practice. 4th edition, pp. xxix, 2821 p. Philadelphia, Pa.: Churchill Livingstone, 2005.

Stuart, M. J. and Nagel, R. L. Sickle-cell disease. Lancet, 364: 1343-1360, 2004.

Benjamin, L. J., Swinson, G. I., and Nagel, R. L. Sickle cell anemia day hospital: an approach for the management of uncomplicated painful crises. Blood, 95: 1130-1136, 2000.

Charache, S., Terrin, M. L., Moore, R. D., Dover, G. J., Barton, F. B., Eckert, S. V., McMahon, R. P., and Bonds, D. R. Effect of hydroxyurea on the frequency of painful crises in sickle cell anemia. Investigators of the Multicenter Study of Hydroxyurea in Sickle Cell Anemia. N Engl J Med, 332: 1317-1322, 1995.

 

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