Date:
Patient:
Reason for Visit:
Follow-up for sickle cell disease (SCD)
Assessment of pain crisis or other complications
Evaluation of response to treatment (if applicable)
Management plan discussion
History:
Presenting Illness:
Current symptoms (pain location, severity, duration) – for pain crisis
Frequency of pain crises
Other presenting complaints (fatigue, shortness of breath, fever, cough)
Recent hospitalizations or emergency department visits for SCD complications
Past Medical History (PMH):
Genotype (if known) – влияет (vliyaet) on disease severity (influences disease severity) in Russian
History of major complications (e.g., acute chest syndrome, splenic sequestration, stroke)
Prior treatments for pain crises and other complications
Vaccinations (up-to-date influenza and pneumococcal vaccines are crucial)
Use of hydroxyurea (common medication to reduce SCD complications)
Pregnancy history (if female) – SCD can pose risks during pregnancy
Social History:
Adherence to medications and follow-up appointments
Pain management strategies
Psychosocial stressors and access to social support
Physical Exam:
General: Assess for signs of pain, dehydration, fever, jaundice.
Vital Signs: Temperature, heart rate, respiratory rate, blood pressure, oxygen saturation (may be low during crisis).
Pulmonary: Evaluate for chest pain, shortness of breath, wheezing (signs of acute chest syndrome).
Abdominal: Palpate for splenomegaly (enlarged spleen).
Neurologic: Assess for confusion, focal deficits (possible signs of stroke).
Diagnostic Tests (may be ordered depending on clinical suspicion):
Complete blood count (CBC): May show anemia, elevated white blood cells (infection), reticulocytosis (increased red blood cell production).
Reticulocyte count: Elevated levels suggest recent hemolysis (destruction of red blood cells).
Lactate dehydrogenase (LDH): Increased levels indicate ongoing hemolysis.
Blood cultures (if fever present): To rule out infection as a complication.
Chest X-ray (if acute chest syndrome suspected): May show infiltrates (fluid in the lungs).
Abdominal ultrasound (if splenic sequestration suspected): Can detect an enlarged spleen.
Assessment:
Pain crisis severity: Based on pain location, intensity, duration, and response to initial treatment.
Presence of acute complications: Evaluate for acute chest syndrome, splenic sequestration, stroke, or other potential complications.
Adherence to treatment plan: Assess medication adherence and effectiveness of pain management strategies.
Psychosocial well-being: Evaluate for signs of depression, anxiety, or difficulty coping with SCD.
Plan:
Acute pain management:
Intravenous fluids for hydration.
Pain medication regimen tailored to severity (e.g., opioids, non-steroidal anti-inflammatory drugs).
Oxygen therapy (if needed for acute chest syndrome).
Blood transfusion (may be necessary in severe cases).
Long-term management:
Continue hydroxyurea (if tolerated) to reduce future complications.
Regular monitoring with laboratory tests to assess for anemia and other complications.
Pain management education and strategies for self-management.
Vaccinations (ensure up-to-date influenza and pneumococcal vaccines).
Address psychosocial concerns with counseling or support groups (if needed).
Consider referral to a hematologist specializing in SCD for complex cases.
Patient education: Provide information about SCD, its complications, and self-management strategies.
Discuss the importance of hydration, pain management techniques, and medication adherence.
Explain the risks and benefits of hydroxyurea and other treatment options.
Encourage healthy lifestyle choices (balanced diet, exercise, stress management).
Follow-up:
Schedule for follow-up appointments based on severity:
More frequent visits during pain crises or for monitoring complications.
Regular visits (every 3-6 months) for stable patients on hydroxyurea.
Monitor for response to treatment, complications, and adherence to recommendations.
Consider additional imaging or specialist consultations if necessary.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of sickle cell disease