Sickle Cell and Acute Chest Syndrome — History and Physical Exam — Clinical Pathway: Inpatient

Sickle Cell and Acute Chest Syndrome Clinical Pathway — Inpatient

History and Physical Exam

Nearly half of all episodes of ACS have been reported in SCD patients admitted for another indication including, pain or fever. The majority of patients present with fever and a cough. Clinical presentation may vary; younger children may have symptoms similar to viral bronchiolitis; older children may present with cough and wheezing similar to an asthma exacerbation. The physical exam is often unremarkable. ACS may be missed in up to 40% of patients with ACS if no CXR is obtained. Frequent assessment is important as half of patients develop this complication during hospitalization.

History
  • Fever
  • Recent antibiotics
  • Respiratory symptoms
  • Baseline SpO2
  • Asthma history
    • Beta-agonist use during this episode, last treatment, spacer use
    • Inhaled steroid use, last dose, use of oral steroids
  • Pain
    • Location, severity
    • Medications used, last dose
  • Hydration
    • GI symptoms
    • PO intake, UO
  • Other infectious symptoms
  • SCD Specific Therapy
    • Folate, PCN
    • Hydroxyurea
    • Transfusion therapy, Port
    • Crizanlizumab, Voxelotor, L-Glutamine
  • Recent hospitalizations
    • VOC, bacteremia, stroke, previous ACS
  • Other medications, health problems
  • Allergies
  • Immunizations
Physical Exam
  • Mental Status
  • HR, BP RR, SpO2, temperature
  • Pain level
  • WOB, focal lung findings (crackles or wheeze)
  • Rhythm, murmur, perfusion

Differential Diagnosis

  • Upper respiratory viral illness
  • Viral bronchiolitis
  • Acute exacerbation of asthma with RML syndrome
  • Pulmonary embolism
  • Pleuritis
  • Pleural effusion/empyema
  • VOE affecting ribs
  • Osteomyelitis
  • Myocarditis
  • Cardiomyopathy
  • Pericarditis
  • Acute cardiac failure
  • Sepsis