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Sickle Cell Disease Case Presentation Form

Virginia Sickle Cell Disease ECHO: De- Identified Case Study Submission

Thank you for submitting a case study!

Some benefits to submitting and presenting are...

-You will recieve valuable feedback regarding your case from our participating experts during the ECHO clinic

-A list of suggestions provided during the ECHO clinic will be sent to you as a reference after the clinic

-Your organization will be able to utilize suggestions and improve patient care!

- You will receive $200 per case presented

- Phyiscans, APPs, social workers and any other staff working with patients can submit a case presentation.

DO NOT provide any patient specific information nor include any Protected Health Information.

Please complete the survey below.

Thank you!

Case Presenter First name

Case presenter last name

Presenter Email:

Patient Age

Patient Genotype

HbS/beta0

HbSS

HbSC

HbS/beta+

Other

Unknown

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Specify

Date of Admission:

Reason for Admission:

Any admissions in 30 days prior to this?

Yes

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How Many

Approximate number of admissions in the last year?

Level of Care

Outpatient Hematologist

Yes

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Outpatient Hematologist Name

Primary Care Provider

Yes

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Primary Care Provider Name

Current pain locations

Current Pain Score

Daily chronic pain locations (if any)

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Outpatient long-acting opioid regimen

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Typical use of outpatient short-acting opioids (total daily intake)

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Other outpatient medications

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Inpatient medications: Opioids, psychiatric and Antibiotics only

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IV pain medication- Total within last 24 hrs

Bowel Regimen?

Yes

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Acute Chest Syndrome

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Stroke

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DVT/PE

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Surgical History

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Pulmonary Hypertension

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Renal Disease

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Iron Overload

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Major Depressive Disorder

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Bipolar Disorder

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Substance Use Disorders (other than suspicion of aberrant opioid use for pain)

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Suspicion of aberrant opioid use for pain?

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Other Psychiatric History

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In psychiatric care?

Yes

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Currently on HU?

Yes

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Dose

ANC

Currently on Chronic Transfusion Therapy?

Yes

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History of Red Cell Alloimmunization/Antibodies?

Yes

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Is there an active sample in blood bank?

Yes

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Date of Last Transfusion

M-D-Y

Pulse

Blood Pressure

Temperature

O2 Stat

Oxygen Requirement

Baseline Hemoglobin/Hematocrit

Most recent Hemoglobin/Hematocrit

WBC

Neutrophil Count

MCV

Platelet count

Retic/ absolute reticulocyte

Hgb Variant/Electrophoresis

Creatinine

Total Bilirubin

Urine toxicology

Optional/Pertinent- Additional abnormal lab values :

Chest X-Ray

CT w/ contrast

CT w/o contrast

Educational Level

Occupation/Source of Support

Other relevant social history

Insurance

Housing - with whom is the patient living

Childcare

Transportation

Additional Information:

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Case Questions

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