NU 665 Week 8 Assignment 1: i-Human Simulation

Sample Answer for NU 665 Week 8 Assignment 1: i-Human Simulation

Assessment

• Anemia, sickle cell (SCA) ICD 10 D57.1 – is an inherited autosomal recessive hemoglobinopathy involving a mutation when glutamine gets replaced by valine at the 6^th position of the beta-globin chain (Kavanagh, Fasipe & Wun, 2022).  In SCA, there’s a vaso-occlusive crisis and hemolysis resulting from intravascular hemolysis, polymerization of HbS and oxidative stress. Patients mostly present with complications; vaso-occlusive crises with pain, history of blood transfusions, or a familial history. Physical exam findings are highly dependent on the crisis for instance, in splenic sequestration, a patient will have a tender, rapidly enlarging spleen/liver. In ACS, patients will have tachypnea, pleuritic chest pain, fever, and hypoxemia (Kavanagh, Fasipe & Wun, 2022). For this patient, a clinical history of recurrent hand & foot symptoms, anemia, dactylitis, splenomegaly, and an enlarged spleen are highly suggestive of sickle cell disease.  
• Arthritis, psoriatic ICD10 L40.52 – a diagnosis of psoriasis precedes the development of psoriatic arthritis which can take an average of 10 years to occur (Merola, Espinoza & Fleischmann, 2018). It is immune-mediated, associated with the human leukocyte antigen (HLA) and involves inflammatory responses with macrophages and activated T-cells that stimulate the production of inflammatory cytokines, interleukins, and chemokines to propagate chronic inflammation (Merola, Espinoza & Fleischmann, 2018). Patients will demonstrate a familial or personal history of psoriasis and clinically, may present with synovitis, fusion of peripheral joints, osteolysis, sacroiliitis, dactylitis, or nail dystrophy (Merola, Espinoza & Fleischmann, 2018). However, joint involvement can be either polyarticular or oligoarticular and worsens with prognosis. Besides, the most affected joints are the large joints of the lower extremities, the distal interphalangeal joints of the feet and hands.
• Arthritis, septic ICD10 M00.80 – describes inflammation of a joint secondary to an infectious pathogen. The most causative infectious agents are; Staphylococcus aureus in adults, Salmonella in sickle cell patients, Pseudomonas aeruginosa, and Neisseria gonorrhea (Long, Koyfman & Gottlieb, 2019). Besides having a male predominance, its incidence peaks between 2-3 years of age. It may result from a puncture wound, direct injury, or intraarticular injections leading to an inflammatory process with joint destruction (Long, Koyfman & Gottlieb, 2019). However, the joint pain has an acute onset and is associated with swelling, fever, and reluctance to use the affected joint. The most affected joints are the ankle, knee, and hip joints.
• Rheumatoid arthritis, juvenile ICD10 M08.20 – is a chronic inflammatory diseasethat persists for atleast six weeks with an onset before 16 years of age. Its pathogenesis is associated with genetics and environmental factors and is more prevalent among Native American Indian populations (Merola, Espinoza & Fleischmann, 2018). As an autoimmune systemic inflammatory disease, JRA is primarily characterized by damage to cartilage, synovitis, and bony erosions. However, joint involvement is symmetric with polyarthritis. The most affected joints include; wrist, elbow, shoulder, knee, hip, ankle, metacarpophalangeal, and metatarsophalangeal joints (Merola, Espinoza & Fleischmann, 2018). The absence of arthritic changes on hand and foot x-rays also rules out JRA diagnosis.

Final Diagnosis: anemia, sickle cell   

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NU 665 Week 6 Assignment 1: iHuman Simulation

Management Plan

Pharmacology

• Pain management with acetaminophen 10-15 mg/kg PO q 4-6 hr for 5 days maximum.
• Initiate lifelong treatment with hydroxyurea starting at 20 mg/kg/day upon discharge and increasing every 8 weeks upon re-evaluating clinical response (Kavanagh, Fasipe & Wun, 2022).  
• If there’s evidence for sepsis, initiate treatment with ceftriaxone 75 mg/kg IV q 24 hr (2 gm max single dose) until culture results are ready (Kavanagh, Fasipe & Wun, 2022).  

Non-Pharmacological

• Admit to the pediatric unit
• Close monitoring of vital signs and intervene when there are elevated temperatures, hypotension, or signs of acute distress.
• Close monitoring for complications including; acute chest syndrome (ACS), ischemic stroke, pulmonary hypertension, avascular necrosis, nephropathy & retinopathy (Kavanagh, Fasipe & Wun, 2022).
• Ensure adequate hydration (orally or intravenously) for dactylitis management  

Diagnostics

• Blood and bone biopsy for culture & sensitivity.
• Daily CBC to monitor for splenic sequestration as demonstrated by platelet count and hemoglobin (Hgb <6mg/dl) and transfuse when necessary (Kavanagh, Fasipe & Wun, 2022).

Consults/Referrals

• Referral to a hematologist for further evaluation and management
• Consider referral to a psychotherapist for psychosocial support and care.

Patient Education

• Educate mother about SCD, etiology, pathophysiology, signs & symptoms, management options, complications, and prognosis. According to Kavanagh, Fasipe & Wun (2022), the education should also include potential complication triggers, how to identify crises and what to do during a crisis.

Follow Up

• Upon discharge (afebrile >24hr), can tolerate oral fluids and can take oral medications, negative cultures, no pulmonary symptoms, stable hematocrit & hemoglobin), to return for evaluation of progress in 8 weeks.

References

Kavanagh, P. L., Fasipe, T. A., & Wun, T. (2022). Sickle cell disease: a review. Jama, 328(1), 57-68.

Long, B., Koyfman, A., & Gottlieb, M. (2019). Evaluation and management of septic arthritis and its mimics in the emergency department. Western Journal of Emergency Medicine, 20(2), 331. https://doi.org/10.5811%2Fwestjem.2018.10.40974

Merola, J. F., Espinoza, L. R., & Fleischmann, R. (2018). Distinguishing rheumatoid arthritis from psoriatic arthritis. RMD open, 4(2), e000656. https://doi.org/10.1136/rmdopen-2018-000656