Medical Report: Sickle Cell Anemia Patient Case Study Analysis

This medical report presents a comprehensive analysis of a 10-year-old patient diagnosed with sickle cell anemia. The report details the patient's history, including recent discharge for acute chest syndrome and the onset of symptoms like weakness and pain. It covers the physical examination findings, such as scleral icterus and abnormal blood vessels, along with diagnostic tests, including DNA and hemoglobin electrophoresis, which confirmed sickle cell anemia. The report outlines various treatment options, including hydroxyurea, L-glutamine, crizanlizumab, pain-relieving medications, voxelotor, red blood transfusions, and stem cell transplant. It concludes with a recommended plan of action, advising folic acid supplements, hydration, avoidance of temperature extremes, and regular exercise to manage the condition. The report references several studies supporting the discussed treatments and management strategies.

Running head: MEDICAL REPORT 1
Medical Report
Name of Author
Institution of Affiliation
Date of Submission

MEDICAL REPORT 2
Medical Report
Patient: Mrs. Jane
DOB:1/2/2010
Date of visit: 25/3/ 2020
Reasons for the visit/ history of symptoms
This paper presents a medical report of a 10-year old patient who presented to the
hospital a feeling of tired and heart problems. She had just been discharged the previous week
for acute chest syndrome. She ate his breakfast wand spent his day watching television but at
about 5.00 pm when she went to the bathroom, she notices that she was unable to pull up his
trousers since his left arm was too weak. On walking out of the bathroom, Jane also noticed she
was walking with a lot of difficulties as his legs were very weak. She went to rest in bed and
started experiencing shocking pains on his sides of the neck which were like unusual pain. These
events transpired him to call for emergency medical services and were transported to a nearby
hospital.
On arriving in the emergency clinic, she was alert and arranged cranial nerves. She had likewise
flabby loss of motion of the respective upper and lower furthest points. Besides, she had a
reflexia in the biceps, triceps, and brachioradialis reciprocally. The patient additionally had fever,
vaso-occlusive emergency, intense chest disorder, stroke, and priapism. The patient further had
intense splenic sequestration and aplastic crisis.
Medical history
Basing on the medical history, the patient had duration of fever, pain, lethargy, and
pallor. The patient had also a history of provoking factors such as fever, procedures and had
recently been hospitalized for chest pain. She had also the history of chest crises and

MEDICAL REPORT 3
management in ICU ventilation. The doctors also noted that the patient had a medical history of
bone pain especially on his arms, legs and on his abdominal pain. Other medical histories of Jane
that the doctors were able to note are that she had a history of asthma and a chronic transfusion
program. Also, the doctors noted that Jane’s parents had a history of sickle cell anemia.
Physical Examination
The physical examinations were done guided by signs and symptoms of the patient. The
physical examination showed the presence of scleral icterus. When examined with
ophthalmoscopy of the conjunctiva with +40 lenses the doctor was able to record an abnormal
and corkscrew-shaped blood vessel. The physical examination also showed a mucous membrane
that was pale in color. A systolic murmur was also able to be heard over the entire precordium.
Furthermore, the doctor was able to record tachycardia and hypotension which might be the
signs of splenic sequestration crisis or septic shock.
Furthermore, on arrival to our clinic, doctor noted the client had vaso-occlusive crisis
which normally occurs when the microcirculation is hindered by sickled red blood cells. This is
understood to cause ischemic injury to the organ supplied thus resulting into pain (Stettler et al.,
2015).
Testing/Diagnostics
A blood test for hemoglobin was done using a DNA test to determine whether Jane has
normal hemoglobin or altered hemoglobin. According to (Archer, Galacteros & Brugnara, 2015),
normal hemoglobin tests will mean Jane has no sickle cell anemia and altered or abnormal
hemoglobin will mean Jane has a sickle cell anemia. If a gene is mutated or altered it can change

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how hemoglobin behaves thus abnormal hemoglobin will show sickle-shaped to SCD (Stettler et
al., 2015). The DNA test showed positive to SCD thus sickle cell anemia.
After testing positive with DNA test, the doctor took a second test known as hemoglobin
electrophoresis which showed two abnormal hemoglobin genes thus Jane was confirmed to be
suffering from sickle cell anemia (Xu et al., 2017).
Treatment Option
Various options can be taken to treat and manage Jane’s health condition. These treatment
options are aimed at avoiding episodes of pain, relieving of sickle cell anemia symptoms and
preventing any complications that are linked with the condition (Piel, Steinberg & Rees, 2017).
Some of the treatment options for Jane’s conditions include:
 Prescription of hydroxyurea will be aimed at reducing the frequency of pain crises. It will
also be able to reduce the need for blood transfusion and hospitalization.
 Administration of L-glutamine oral powder which will help in lowering the frequency of
Jane’s pain crises.
 Prescription of crizanlizumab administered via a vein and helpful in reducing the
frequency of pain crises as well as reducing the side effects such as back pain, fever, and
nausea.
 Prescriptions of pain-relieving medications such as narcotics that will help relieve pain
during pain crises.
 Administration of voxelotor, an oral medication that will be able to relieve side effects
such as fever, fatigue, nausea, and headache.

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 Red blood transfusion through a vein which can increase the number of normal red blood
cells thus reducing symptoms and complications associated with sickle cell anemia
(McGann & Ware, 2015).
 Stem cell transplant also referred to as bone marrow transplant. The procedure can
involve replacing affected bone marrow with healthy bone marrow from the donor. It is
crucial as it will reduce the symptoms linked to sickle cell anemia.
Recommended Plan of action
The patient should be advised to take folic acids supplements daily together with a
healthy diet. Folic acid together with other vital vitamins will help in making new red blood cells
thus preventing symptoms and complications of sickle cell anemia. The patient should also be
advised to drink plenty of water as dehydration can increase the risk of sickle cell crisis (Ware,
2015).
Also, the patient should be ready to avoid being exposed to temperature extremes.
Exposure to cold or hot temperatures is understood to increase the risk of sickle cell crisis.
Furthermore, the patient should be encouraged to exercise regularly with control as it helps in
lowering the pain crisis linked to sickle cell (Bernaudin et al., 2015). Also, the doctor should
support the patient by talking to him and discussing ways that can help Jane to cope with the pain
that is linked to his current condition.

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References
Archer, N., Galacteros, F., & Brugnara, C. (2015). 2015 Clinical trials update in sickle cell
anemia. American journal of hematology, 90(10), 934-950.
Bernaudin, F., Verlhac, S., Arnaud, C., Kamdem, A., Vasile, M., Kasbi, F., ... & Epaud, R.
(2015). Chronic and acute anemia and extracranial internal carotid stenosis are risk
factors for silent cerebral infarcts in sickle cell anemia. Blood, The Journal of the
American Society of Hematology, 125(10), 1653-1661.
McGann, P. T., & Ware, R. E. (2015). Hydroxyurea therapy for sickle cell anemia. Expert
opinion on drug safety, 14(11), 1749-1758.
Piel, F. B., Steinberg, M. H., & Rees, D. C. (2017). Sickle cell disease. New England Journal of
Medicine, 376(16), 1561-1573.
Stettler, N., McKiernan, C. M., Adejoro, O. O., & Walczak, N. B. (2015). Proportion of adults
with sickle cell anemia and pain crises receiving hydroxyurea. Jama, 313(16), 1671-
1672.
Ware, R. E. (2015). Optimizing hydroxyurea therapy for sickle cell anemia. Hematology 2014,
the American Society of Hematology Education Program Book, 2015(1), 436-443.
Xu, M., Papageorgiou, D. P., Abidi, S. Z., Dao, M., Zhao, H., & Karniadakis, G. E. (2017). A
deep convolutional neural network for classification of red blood cells in sickle cell
anemia. PLoS computational biology, 13(10).