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Chief complaint/History of Present Illness:

Chief complaint/History of Present Illness: You are admitting Tia who is a 14-year-old young woman with Sickle Cell disease who presented to the emergency room early this morning with a 2-week history of worsening headache and 2-day history of diffuse back pain. The headache started after she participated in a week of basketball camp. Tia reports that she has been “sensitive to light.” She denies having had any vision change, although Tia reports that yesterday while still at home she had some tingling in the right side of her face and in her right arm and leg. She has not had any respiratory symptoms and she has not had fever. She had a CBC, UA with culture, and type and crossmatch in the ER. She is to receive packed cells when the blood is ready.

What data is relevant to this patient that must be recognized as clinically significant to the nurse?

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The worsening headache, the back pain, the sensitivity to light and tingling at the right side of face and arm and leg.

Rationale:

These symptoms are those associated with stroke. Ischemic stroke may occur due to inadequate supply of oxygen to the brain due to the defective red blood cells in sickle cell disease.

Personal/Social History: Lives with parents. Is in the eighth grade.

PMH: Mother reports that Tia’s sickle cell clinical course has been mild. She has never had a painful crisis per Mom. She has never had acute chest syndrome. Tia has a history of recurrent urinary tract infections and nasal allergies.

Current Medications: Tia and Mother report that Tia’s medications are Tylenol; an iron supplement; Allegra; and folic acid.

What is the relationship of your patient’s past medical history (PMH) and current medications?

(Which medication treats which disease? Connect PMH disease with the correct medication)

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