DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
BRIEF HISTORY AND HOSPITAL COURSE: This (XX)-year-old Hispanic woman was discharged following a three-day hospital stay occasioned by the finding of profound pancytopenia on the day of her admission. The patient is known to have recurrent follicular low-grade lymphoma, stage IIIB, and underwent therapy with a radioimmunoconjugate, Zevalin, approximately six weeks ago. Approximately two weeks following her therapy, she developed cytopenias as predicted and has been hospitalized intermittently for transfusion support, growth factor support, as well as IV antibiotics. One such admission was complicated by bilateral pulmonary hemorrhage from which she recovered uneventfully with transfusion support.
The patient was admitted to the hospital and placed on IV fluids consisting of D5 half normal saline at 84 mL per hour. Potassium chloride was added to the IV fluids for prehospital hypokalemia found in the office. The patient did well overall, and she received three single-donor apheresis units as well as three packed red blood cells. All blood products were leukodepleted and premedicated with hydrocortisone. Throughout the hospital stay, the patient had a low-grade temperature but no microbiologic documentation for infection was found.
PHYSICAL EXAMINATION: GENERAL: The patient is alert, active, in no distress. VITAL SIGNS: Normal. Blood pressure is 112/72. The temperature is 96.8 degrees. HEENT: Shows no thrush, petechia or exudate. On the lower lip, there is a distinctly characteristic lesion for herpes stomatitis, which is in the healing and crusting phases. NECK: Supple. CHEST: Clear. HEART: Regular rhythm with no murmur or gallop. ABDOMEN: Benign. There is no palpable hepatosplenomegaly, mass or ascites. EXTREMITIES: Show no cyanosis, clubbing or edema. There is no petechia.
LABORATORY DATA: Laboratory shows WBC of 2.0 with an ANC of approximately 1200. Hemoglobin 10.8 and platelets of 47,000. CMP is within normal limits. and alkaline phosphatase is slightly increased.
Chest x-ray showed clearing of the previously described right middle lobe pneumonia.
IMPRESSION:
1. Pancytopenia secondary to radioimmunoconjugate therapy.
2. Recurrent follicular lymphoma.
3. Hypertension, controlled.
4. Herpes stomatitis.
PLAN: The plan was discussed with the patient, her nurse, and the pharmacist.
1. Discharge home today. Follow up in the office next week for transfusion support and monitoring.
2. Discharge diet is regular.
3. Discharge activity is as tolerated.
4. Discharge medications include Famvir 500 mg p.o. q. 8 hours for 2 weeks, Levaquin 500 mg p.o. daily for 2 weeks, Neulasta or Neupogen in the office, and Vfend 200 mg p.o. b.i.d. for 2 weeks.
PROGNOSIS: Guarded.
