Date:
Patient:
MRN:
Clinician: (Oncologist, Hematologist)
Reason for Visit:
Febrile neutropenia evaluation
Management of fever and neutropenia
Assessment for source of infection
History of Present Illness:
Onset, duration, and severity of fever (temperature > 100.4°F (38°C))
Timing of fever in relation to chemotherapy or other immunosuppressive therapy
Presence of any localized signs or symptoms suggestive of infection (cough, shortness of breath, urinary urgency, etc.)
Chills, rigors (shaking episodes)
Past Medical History:
Underlying malignancy (type, stage)
Recent chemotherapy regimen and neutropenic nadir (lowest absolute neutrophil count)
History of prior episodes of febrile neutropenia
Other relevant medical history (comorbidities)
Medications:
Current chemotherapy regimen and other medications
Social History:
Recent hospitalizations or procedures
Travel history
Dental hygiene practices
Physical Exam:
Vital Signs: Temperature, heart rate, respiratory rate, blood pressure
General Appearance: Illness severity (signs of sepsis)
HEENT (Head, Ears, Eyes, Nose, Throat): Signs of sinusitis, pharyngitis, oral mucositis
Neck: Lymphadenopathy (swollen lymph nodes)
Chest: Auscultation for wheezing, crackles
Abdomen: Soft, distended, tenderness
Skin: Rash, petechiae (tiny red spots)
Labs:
Complete blood count (CBC): Absolute neutrophil count (ANC) to confirm neutropenia.
Blood cultures (drawn from multiple sites) to identify potential bloodstream infection.
Chest X-ray – to assess for pneumonia
Urinalysis and urine culture – to rule out urinary tract infection (UTI)
Other cultures (stool, sputum) – may be obtained depending on suspected source of infection
Imaging:
Consideration of additional imaging studies (CT scan, ultrasound) based on suspected source of infection.
Assessment:
Confirm febrile neutropenia based on clinical criteria and laboratory findings.
Assess for the severity of illness based on clinical presentation and vital signs.
Identify the potential source of infection based on history, physical exam, and laboratory results.
Plan:
Outline the treatment plan based on the severity of illness and suspected source of infection:
Empiric broad-spectrum antibiotics: Administer antibiotics to cover a broad range of bacteria while awaiting culture results.
Supportive care: Intravenous fluids for hydration, antipyretics for fever management, granulocyte colony-stimulating factor (G-CSF) to stimulate neutrophil production (if indicated)
Isolation precautions: Implement neutropenic precautions to minimize exposure to pathogens.
Prognosis:
Briefly discuss the prognosis, which depends on the underlying cause of infection, the severity of neutropenia, and the patient’s overall health. Early diagnosis and treatment of infection are crucial for a favorable outcome.
Education:
Document any education provided to the patient and caregivers regarding:
Importance of good hand hygiene to prevent infections
Warning signs of worsening infection
Importance of adhering to neutropenic precautions
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the plan and any concerns they may have.
Consider mentioning the need for close monitoring of vital signs, white blood cell count, and response to treatment.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a healthcare professional for diagnosis and treatment recommendations.