DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: This was one of many admissions for this (XX)-year-old male who has sickle cell anemia. He came to the emergency room complaining of neck pain. He was found to have a fever of 101.5, markedly enlarged 3+ tonsils. The patient was complaining of severe pain in the right side of his neck and throat. The examining physician in the emergency room was able to obtain a throat culture but did not see the throat well. Culture of throat and blood were sent. Empiric ceftriaxone was started. The patient was admitted for IV antibiotics and IV hydration. He had obvious poor oral intake due to the pain. Other than pain in his neck and throat, he had noted that he was tolerating only liquids, had pain on swallowing. He had decreased appetite. He denied decreased urine output. He had vomited once the day of admission. As noted, he has a history of multiple hospitalizations in the past, including acute chest syndromes and pediatric ICU admissions. He has been on hydroxyurea for some period of time.
PHYSICAL EXAMINATION: VITAL SIGNS: On admission, in the emergency room, he had a temperature of 101.5 degrees, pulse 106, respiratory rate 14, blood pressure 128/72, and oxygen saturation 98% on room air. He weighed 52 kilograms. HEENT: He was found to have markedly increased tonsils with red throat but no exudates. NECK: He had lymphadenopathy, cervical lymphadenopathy. Nodes were enlarged such that they were visible. The right posterior cervical nodes were the largest, about 1 x 1.5 cm in diameter. These were slightly mobile. They were tender. They were not fluctuant. There were a few very small anterior cervical nodes. He did not have a stiff neck. LUNGS: Clear except for questionable decreased aeration and slight dullness at the extreme right base. No wheezes, rales or rhonchi were heard. HEART: Sinus arrhythmia with no murmur appreciated. ABDOMEN: Flat, soft, unremarkable. EXTREMITIES: Very slender with no swelling, tenderness or apparent abnormality. NEUROLOGIC: Examination was unremarkable.
LABORATORY DATA: Admission CBC showed a white count of 19,600, hemoglobin 8.6 with hematocrit 26. MCV was 125.6, platelet count 486,000, differential count 72 segs, 4 bands, 14 lymphs, 9 monos, 1 eosinophil, and 3 nucleated red cells. Reticulocyte count was 29.6%. Comprehensive metabolic panel showed a bilirubin of 5.6, a normal SGPT, was otherwise unremarkable. Throat culture was negative for strep group A antigen. Chest x-ray shows no infiltrates.
HOSPITAL COURSE: The patient was continued on ceftriaxone, and the next day requested morphine for pain that was still concerning him. In response to this request, he was given one dose of 3 mg of IV morphine and a p.r.n. dose of 2 mg of morphine every 3 hours as needed for pain. He actually needed very few that night. He was starting to feel better by yesterday. He still was having occasional low-grade fevers. The antibiotics were continued. By date of discharge, blood culture was negative. Throat culture was positive for beta-hemolytic strep but not group A. By the evening of date of discharge, he was feeling much better and wanted to go home. He could now swallow with no pain. Tonsils were somewhat smaller on examination. Lungs were clear. Grade 2/6 systolic ejection murmur could be heard, but there was no gallop, and heart rate was regular. Abdomen was unremarkable.
Laboratory studies included a white count of 8700, 39% polys, 3 bands, definitely decreased from admission. Hemoglobin 7.6. Reticulocyte count of 15.6. Total bilirubin of 4. Direct bilirubin of 0.3. The EBV panel had returned showing a negative IgM, so there is no evidence for acute infection. There was evidence of past infection with EBV. He was discharged to home.
DISCHARGE MEDICATIONS: Ceftin 250 mg by mouth 2 times a day for 7 days; folic acid 5 mg per day; hydroxyurea 1000 mg per day; Tylenol with Codeine No. 4 prescription was given for 25 tablets, one tablet every 4 hours as needed for pain; and he was instructed to call for followup appointment.
