Let’s review the second case.

A 48-year-old female, five days s/p round 3 of systemic chemotherapy for metastatic breast cancer, was admitted to the hospital for “suspect infection.”

At the time of admission, the patient demonstrated a T 100.6°F, HR 99 and regular, BP 120/71, R 16 and non-labored, Pox 99% on RA.

Detailed examination was unremarkable. Labs demonstrated a WBC of 1,200 with absolute neutrophil count (ANC) 480, Hgb 9.3 with normal indices, platelets 137,000. 

Comprehensive metabolic profile was unremarkable, and the patient was placed on broad spectrum antibiotics including IV vancomycin and IV ceftazidime, as well as GCSF. 

Evaluation during her 6-day hospitalization included two sets of blood cultures daily through day 3 of hospitalization, CXR and urine culture on admission, CT of chest/abdomen/pelvis, chest CT angiography, bilateral lower extremity doppler ultrasonography and serum viral cultures. All were negative. 

On day 2 of hospitalization, the patient became afebrile. IV antibiotics were discontinued on day 4 of hospitalization, at which time the patient’s absolute neutrophil count was 1,500. 

GCSF was discontinued on day 5, and the patient remained afebrile. 

The patient was discharged to home on day 6 with no antiobiotics.

Based on the information above, what is the best documentation for this case? Click the best answer.

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