What's Your Diagnosis? Sickle Cell Disease in the ED

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got the previous case on Emergency Department Management of Patients With Complications of Dialysis correct.

Case Presentation: Emergency Department Management of Patients With Sickle Cell Disease

An 18-year-old woman with sickle cell disease presents with bilateral hip and low back pain…

As you enter the room, the patient appears to be resting comfortably on a stretcher and is scrolling through her cell phone. Her vital signs are within normal limits and her physical examination is grossly unremarkable.
The patient reports that her pain started after a recent upper respiratory infection and has been worsening progressively for 3 days. She now rates it a 10 out of 10 in severity. She is on chronic opioid therapy with hydromorphone and has been taking oral acetaminophen, ibuprofen, and oxycodone for breakthrough pain around the clock, with minimal relief. She says this pain feels similar to prior pain crises.
The nurse has already placed a peripheral IV and sent laboratory tests. The CBC returns with a hemoglobin of 10.2 mg/dL, which is consistent with the patient’s baseline.
You wonder whether this patient is having a true pain crisis and what pain medication would be best to provide. You also wonder whether “drug seeking” is a concern…

Case Conclusion

Despite this patient’s reassuring examination and vital signs, you took her pain seriously. After she rated her current pain a 9/10 in severity, you asked her what typically helps during her acute pain crises. She reported that morphine worked best. The patient weighed approximately 60 kg, so you administered morphine 6 mg IV and reassessed her pain 30 minutes later. She required 3 additional doses of morphine 6 mg IV over the next 90 minutes, but ultimately her pain improved to 4/10 in severity.

You then transitioned the patient to oral pain medication by giving a dose of oxycodone 20 mg. The patient felt well enough for discharge and confirmed that she had enough pain medication at home. She was instructed to call her hematologist as soon as possible to arrange a follow-up appointment.