DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DIAGNOSES:
1. Neutropenic sepsis.
2. Metastatic breast cancer.
3. Fever.
4. Diabetes.
5. Thrush.
HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old female patient well known to us with history of breast CA, who in the past has been treated with chemotherapy and radiation. She was found to have an abnormal CT of the chest with a left chest wall mass noted. The patient underwent mediastinoscopy, and pathology revealed a metastatic poorly differentiated adenocarcinoma. Subsequent to this, she has undergone treatment with chemotherapy and radiation. She presented to the office recently with complaint of fever, chills, headache, dry cough, and intermittent nausea. She was admitted for further evaluation and treatment.
HOSPITAL COURSE: Upon admission, the patient was placed on IV fluids. Labs were obtained. Blood and urine culture were obtained. Chest x-ray, PA and lateral, were obtained. She was started immediately on IV Avelox and Diflucan. A consult was made to the infectious disease specialist with regard to further medical management of the patient with neutropenic fever.
Upon admission, white blood cell count was 1.8, RBC 2.88, hemoglobin 8.7, hematocrit 26.2, and platelet count of 184,000. The patient was supported with growth factor as well as underwent transfusion of blood. Chest x-ray, PA and lateral, on day of admission revealed mild cardiomegaly, bilateral small pleural effusion, and right central venous catheter tip in the superior vena cava. CT of the brain obtained revealed no abnormality demonstrated. CT of the neck soft tissue revealed abnormality not demonstrated. CT of the sinus revealed no abnormality demonstrated. CT of the chest revealed an anterior mediastinal left brachiocephalic vein and anterior chest wall mass, diminished significantly in size from comparison study. Multiple new ill-defined peripheral pulmonary opacities could represent metastatic disease, inflammatory lesions, also in the differential diagnosis.
Evaluation by the infectious disease specialist provided the following impression. The patient is receiving chemotherapy and possibly also actively receiving radiation with febrile illness with no clear-cut source. Her cough does not appear to be due to pneumonia but appears to be more of an irritative cough, perhaps from radiation changes to the upper airways or compression of upper airways due to the patient’s mass that had been previously present, although has decreased in size. The patient also has a port placed, that is certainly the source of her fever, and for this reason, she will be covered with broad-spectrum antibiotics using vancomycin and fluconazole until blood cultures are negative.
She will also be initiated on cefepime 2 grams IV q. 8 h., while laboratory findings are in progress. Blood cultures obtained were positive for coagulase-negative Staphylococcus, and the patient was then initiated on vancomycin therapy. Her blood glucose levels were closely monitored with Accu-Cheks with sliding scale coverage. The patient was also found to be low on potassium and was treated on potassium protocol. The patient responded well to medical management, and once stable, she was made ready for discharge to home.
Per recommendation of the infectious disease specialist, the patient will be discharged to home, continuing on IV vancomycin with IV vancomycin peak and trough levels obtained by home health care nursing. She will also be on moxifloxacin 400 mg p.o. q.d. for 7 days with followup in the office of the infectious disease specialist. The patient was then instructed with discharge instructions. She will follow up in 1 week in our office, and she will continue with home health care nursing, Ambien, home health for continuation of IV antibiotics. She is to notify us for any change in her condition such as increased fever and chills, nausea, vomiting, shortness of breath or difficulty breathing.
