A 9-year-old boy with a known history of sickle cell anemia is brought to the emergency de… — USMLE Step 2 CK

A 9-year-old boy with a known history of sickle cell anemia is brought to the emergency department by his parents due to fever, cough, and severe chest pain that started yesterday. His temperature is $38.9^\circ\text{C}$ ( $102.0^\circ\text{F}$ ), heart rate is $120/\text{min}$ , blood pressure is $105/65\text{ mmHg}$ , and respiratory rate is $30/\text{min}$ . Oxygen saturation is $89\%$ on room air. Physical examination reveals crackles and decreased breath sounds in the right lower lung field. A chest radiograph demonstrates a new right lower lobe infiltrate. Which of the following is the most appropriate next step in management?

A
Immediate administration of intravenous furosemide and strict fluid restriction
B
Observation and withholding of antibiotics until sputum and blood culture sensitivities are finalized
Admission to the hospital for supplemental oxygen, pain management, and empiric intravenous antibioticsAnswer
D
Discharge home with a prescription for oral amoxicillin and a short-acting beta-agonist inhaler
E
Administration of the live-attenuated intranasal influenza vaccine prior to discharge

Answer

Admission to the hospital for supplemental oxygen, pain management, and empiric intravenous antibiotics

The patient's presentation of fever, chest pain, hypoxemia, and a new pulmonary infiltrate is the classic diagnostic criteria for Acute Chest Syndrome (ACS) in the setting of sickle cell disease. ACS is a medical emergency driven by a combination of infection, fat embolism, and vaso-occlusion in the pulmonary microvasculature. The most appropriate immediate management is hospital admission, correction of hypoxemia with supplemental oxygen, aggressive pain management (which also helps prevent splinting and hypoventilation), and empiric intravenous antibiotics (typically a third-generation cephalosporin and a macrolide) to cover common pathogens like Streptococcus pneumoniae and atypical organisms.

Step-by-Step Solution

Identify the primary diagnosis based on the clinical triad in a patient with sickle cell disease.

Fever, chest pain, and a new pulmonary infiltrate on chest X-ray in a sickle cell patient confirm the diagnosis of Acute Chest Syndrome (ACS).

ACS is a leading cause of morbidity and mortality in sickle cell disease and requires immediate clinical recognition.

Determine the required treatment protocol for the identified emergency.

Management includes prompt hospitalization, supplemental oxygen to correct hypoxia, aggressive pain control, and broad-spectrum intravenous antibiotics.

Hypoxia and pain exacerbate red blood cell sickling, creating a vicious cycle of vaso-occlusion. Empiric antibiotics are necessary because infection is a major trigger for ACS.

Key Concept

Acute Chest Syndrome requires emergent hospitalization, supportive care (oxygen, pain control), and empiric antibiotics to break the cycle of hypoxia and vaso-occlusion.

Question

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Topics

More questions from this topic