DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
ADMISSION DIAGNOSIS: Neutropenic fever.
DISCHARGE DIAGNOSES:
1. Neutropenic fever.
2. Acute myelogenous leukemia, status post induction and three cycles of high-dose Ara-C.
3. Thrombocytopenia.
4. Diarrhea.
5. Vaginal bleeding.
6. Hypokalemia.
PROCEDURES PERFORMED:
1. Two-view chest x-ray.
2. One unit of PRBC transfusion.
HOSPITAL COURSE: The patient is a very pleasant (XX)-year-old female with acute myelogenous leukemia who has undergone three cycles of high-dose Ara-C. She was transferred here after she presented to an outside facility with a one-day onset of fevers and chills. She had a measured temperature at the outside hospital at that time of 102 degrees. She was transferred to this facility and admitted to the oncology service.
She was initially placed on cefepime, and blood cultures were drawn. All cultures throughout the course of her hospitalization turned out to be negative. She, however, remained febrile for the majority of her hospitalization. Upon presentation, she did complain of one-day onset of profuse watery diarrhea that was extremely foul smelling. Of note, she was on p.o. prophylactic Levaquin due to her neutropenia. She was also on prophylactic acyclovir. Due to her being on antibiotics and history of diarrhea, a stool PCR was collected but resulted negative. Before the stool PCR resulted, she was placed on Flagyl as empiric coverage for suspected C. diff colitis. After the stool PCR resulted negative, Flagyl was discontinued.
During the short 24 hours when she was on Flagyl, she seemed to have defervesced, and her fever curve trended down. However, after the Flagyl was discontinued, she started having worsened diarrhea and the fevers went back up again. For this reason, a C. diff PCR was ordered and the Flagyl was resumed. The C. diff PCR was also negative. Until that point, she remained on cefepime and the Flagyl was also decided to be continued since the patient seemed to improve with it. The thinking was that she may have had some colitis that was not related to C. diff.
Six days into her hospitalization, she continued to have fever. At this juncture, vancomycin was added to see if this would help. Repeat blood cultures were negative. Cultures were even drawn from the port that she had. There was some discussion as to whether her fevers may have been caused by the cefepime. The cefepime was discontinued. At this time, however, her fever curve had already started slightly trending down. Over the next 48 hours, she remained afebrile.
The vancomycin and Flagyl were discontinued the day before discharge, and she remained afebrile that night. Her diarrhea had resolved over the last four to five days of her hospitalization and she received Imodium for this. The remainder of her hospitalization was unremarkable and she felt well. Of note, she did complain of poor appetite. We advised her to try to eat as much as she can and at the very least remain hydrated with Gatorade, and she understood that it may take some time for her appetite to completely return to normal.
She did frequently have hypokalemia and hypomagnesemia. This was presumed to be secondary to the diarrhea. Both of these electrolytes were replaced appropriately. However, even after the diarrhea resolved, she continued to have hypokalemia despite replacement. She later notified us that this issue is not new and that she actually takes potassium supplementation at home. She reported that she had p.o. potassium chloride at home and that she did not need medication or a refill for this. She could not, however, recall the dosage. We do not know the etiology of her hypokalemia as this was not worked up while she was inpatient due to again thinking that her hypokalemia was a result of her diarrhea.
Additionally, the patient also had complaints of vaginal bleeding. She was actually admitted previously for the same complaints. OB-GYN was consulted and they recommended discontinuation of her combination oral contraceptive pills and placed her on norethindrone three times a day until her bleeding stopped and then once a day. She reported that she may not have been taking the norethindrone after she was discharged from her last hospitalization. She was placed on this medication, and her vaginal bleeding stopped within one to two days. On the day of discharge, she was advised that she could take this medication now just once a day. On the day of discharge, she was also instructed to resume her prophylactic Levaquin and acyclovir.
DISCHARGE MEDICATIONS:
1. Acyclovir 400 mg p.o. b.i.d.
2. HCTZ 25 mg p.o. daily.
3. Lopressor 25 mg p.o. b.i.d.
4. Pravastatin 10 mg p.o. at bedtime.
5. Norethindrone 5 mg p.o. daily.
6. Levaquin 500 mg p.o. daily.
7. Zofran 4 mg sublingually q.8 hours p.r.n. nausea.
8. Norco 5/325 one tablet p.o. q.4 hours p.r.n. pain.
FOLLOWUP APPOINTMENT: Dr. John Doe in one week for followup for chemotherapy.
FOLLOWUP LABS AND STUDIES: CBC, CMP before appointment with Dr. John Doe.
DISCHARGE DIET: Regular as tolerated.
DISCHARGE ACTIVITY: As tolerated.
