Date of Admission: 10/8/2023    Date of Discharge: 10/10/2023    Primary Care Physician: MD   Issues to be Addressed in Follow-up: Continue outpatient biweekly CBC's, with Oncology management of chemotherapy   Reason for Hospital Admission (Admitting Diagnosis):  Neutropenic fever and mild diarrhea, likely mild viral illness   HPI on admission: Patient is a 65 Y  female with history of multiple myeloma on talquetamab and zometa, pancytopenia on prophylactic acyclovir, Bactrim and Entecavir who presents secondary to fever. History obtained from combination of chart review and from patient and sister who explained that patient had a temperature of 100.7 °F.  Advised by a oncologist that if she has fever, she should seek attention in the ED.  Denies any headache, sore throat, recent cough but did note 1 episode of diarrhea this morning.  Denies any shortness of breath, abdominal pain or urinary symptoms.  Denies any nausea, chills, diaphoresis, appetite changes or weakness.    Hospital Course/Significant Findings: Patient was admitted and started on Vanco/Zosyn for neutropenic fever. Patient had no more fevers after admission. Patient had mild diarrhea but was negative for C. Diff. Diarrhea resolving by time of discharge. Blood cultures NGTD. Because of patient's quick improvement and mild symptoms, likely mild viral infection causing diarrhea. Loperamide prescribed. Discharge on course of PO Levofloxacin. Patient (+) for COVID, but likely residual from previous (+) test last month. No s/s respiratory symptoms. Patient received transfusions - 2U PRBC, 1U platelets.   Complications: None   Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) NEUTROPENIC FEVER, UNSPECIFIED   ? RIGHT FEMUR FX   ? SEPTIC SHOCK   ? COVID-19 DISEASE   ? LACTIC ACIDOSIS, UNSPECIFIED   ? THROMBOCYTOPENIA, UNSPECIFIED (UNKNOWN ETIOLOGY)   ? ANEMIA   ? LEFT WRIST FX       Added automatically from request for surgery    ? MULTIPLE MYELOMA W HYPOGAMMAGLOBULINEMIA   ? OSTEOPOROSIS       Pt defers bisphosphonate      Resolved Hospital Problems No resolved problems to display.   Procedures: None   Consults:  None   Condition on Discharge:  Stable    Code Status at Time of Discharge: DNR   Smoker: No.   Discharge Disposition:  Home   Discharge Medications: Medications, instructions, follow up information: See patient instructions (or SNF Admission orders if applicable).    Future Appointments    Appointment Date & Time Visit Type Provider Department/Facility   Oct 11, 2023 To Be Determined Hh Aide Home Visit HHA HOME HEALTH AGENCY    Oct 11, 2023 To Be Determined Sn Home Visit (R.N.) HOME HEALTH AGENCY    Oct 12, 2023 To Be Determined Pt Home Visit (P.T.)         HOME HEALTH AGENCY    Oct 13, 2023 To Be Determined Hh Aide Home Visit (H H Aide) HOME HEALTH AGENCY    Oct 13, 2023 To Be Determined Pt Home Visit (P.T.) HOME HEALTH AGENCY    Oct 13, 2023 To Be Determined Sn Home Visit (R.N.) HOME HEALTH AGENCY    Oct 14, 2023  2:45 PM  Infusion GENERAL INFUSIONS INFUSION CENTER    Oct 16, 2023 To Be Determined Sn Home Visit (R.N.) HOME HEALTH AGENCY    Oct 16, 2023 10:45 AM  Office Visit (M.D.) DERMATOLOGY    Oct 17, 2023 11:10 AM  Telephone Visit (M.D.) ADULT/FAMILY MEDICINE    Oct 17, 2023 To Be Determined Sn Home Visit (R.N.) HOME HEALTH AGENCY    Oct 17, 2023 To Be Determined Hh Aide Home Visit (H H Aide) HOME HEALTH AGENCY   Oct 17, 2023 To Be Determined Sn Home Visit (R.N.) HOME HEALTH AGENCY    Oct 18, 2023 To Be Determined Pt Home Visit (P.T.) HOME HEALTH AGENCY    Oct 18, 2023 To Be Determined Sn Home Visit (R.N.) HOME HEALTH AGENCY    Oct 21, 2023 To Be Determined Pt Home Visit (P.T.) HOME HEALTH AGENCY    Oct 21, 2023  2:45 PM Infusion GENERAL INFUSIONS INFUSION CENTER    Oct 23, 2023 To Be Determined Pt Home Visit (P.T.) HOME HEALTH AGENCY   Oct 23, 2023 To Be Determined Sn Home Visit (R.N.) HOME HEALTH AGENCY    Oct 24, 2023 To Be Determined Sn Home Visit (R.N.) HOME HEALTH AGENCY    Oct 24, 2023 To Be Determined Pt Home Visit (P.T.)         HOME HEALTH AGENCY    Oct 24, 2023 To Be Determined Sn Home Visit (R.N.) HOME HEALTH AGENCY    Oct 24, 2023 To Be Determined Hh Aide Home Visit (H H Aide) HOME HEALTH AGENCY    Oct 25, 2023 To Be Determined Sn Home Visit (R.N.) HOME HEALTH AGENCY        Physical Exam on Day of Discharge: BP 113/73  | Pulse 94  | Temp 98 °F (36.7 °C)  | Resp 18  | Wt 48 kg (105 lb 14.4 oz)  | SpO2 98%  | Breastfeeding No  | BMI 20.68 kg/m²      Intake/Output Summary (Last 24 hours) at 10/10/2023 1500 Last data filed at 10/10/2023 1400  Gross over last 24 hours Intake 3476.67 ml Output ? Net 3476.67 ml   General - A&Ox3. Resting comfortably in no acute distress. Hard of hearing Head - Normocephalic. Atraumatic Eyes - PERLA. EOMI Mouth - Oropharynx moist. No injection Neck - No lymphadenopathy. No JVD Lungs - Clear to auscultation. No wheezes, no crackles Heart - Regular rate and rhythm. No murmurs, no gallops Abdomen - Soft, nontender, nondistended, no guarding, no rebound Extremities - Good pulses bilaterally, no edema Musculoskeletal - Good strength bilaterally, no spinal tenderness Neuro - CN II-XII grossly intact, no sensory deficits Psych - Patient is of sound mind and proper affect   Selected Lab Results:  Recent Labs   10/10/23 1411 10/10/23 0542 10/09/23 0520 10/08/23 2024 10/07/23 0920 WBC  --  0.7* 0.9* 0.8* 0.8* HGB 9.2* 6.9* 7.5* 6.4* 7.4* HCT 26.8* 21.1* 22.7* 19.0* 22.3* PLT  --  DECREASE* | 45* | NORMAL DECREASE* | 64* | NORMAL 15* 29* MCV  --  91 92 90 91      Recent Labs   10/10/23 0542 10/09/23 0520 10/08/23 2024 10/07/23 0834 NA 139 138 132*  --  K 3.6 4.2 3.8  --  CO2 18* 20* 21*  --  CL 112* 110 103  --  BUN 10 11 10  --  CR 0.72 0.67 0.69 0.70 RBS 95 111 109  --  CA  --   --   --  9.2      Recent Labs   10/08/23 2024 10/07/23 0834 AST 14 13 ALT 12 12 ALKP 106  --  TBILI 0.6 0.6 LIPASE 24  --       Lab Results Component Value Date   PT INR 1.0 12/16/2022   PT INR 1.0 12/15/2022   PT INR 0.9 10/27/2019   PT INR 1.0 04/22/2019   PT INR 0.9 06/05/2015   PT INR 1.0 10/09/2009   Time spent on discharge: > 35 minutes   Discussed with the patient and sister. All questions fully answered.   DO   10/10/2023 3:00 PM    Note Details  Author (D.O.) File Time 10/10/2023  3:06 PM Author Type PHYSICIAN (D.O.) Status Signed Last Editor (D.O.) Specialty Hospital Medicine Hospital Acct #  Admit Date 10/8/2023  ED to Hosp-Admission (Discharged) on 10/8/2023  ED to Hosp-Admission (Discharged) on 10/8/2023   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders Procedures   Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Hospital Problem List   OSTEOPOROSIS  NEUTROPENIC FEVER, UNSPECIFIED  MULTIPLE MYELOMA W HYPOGAMMAGLOBULINEMIA  LEFT WRIST FX  SEPTIC SHOCK  COVID-19 DISEASE  LACTIC ACIDOSIS, UNSPECIFIED  THROMBOCYTOPENIA, UNSPECIFIED (UNKNOWN ETIOLOGY)  ANEMIA  RIGHT FEMUR FX Care Timeline  10/09   Admitted from ED (Observation) 0248 10/10   Discharged 1620  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 10/10/2023) Medication List at Discharge   0.9 % sodium chloride 0.9% intraVENOUS Outpatient (Back Office) @ 20 mL/hr, STANDING OR CONDITIONAL: Administer intravenously at 20 mL/hr TKO to clear line for transfusion  acetaminophen   325 mg Tab, Take 2 tablets by mouth every 4 hours as needed for mild pain or fever (temperature > 100.4). Do not exceed 10 tablets in 24 hours. Do not exceed 4,000 mg of acetaminophen per day from all sources  500 mg Oral EVERY 6 HOURS AS NEEDED, Take 2 tabs by mouth every 6 hrs as needed for fever (temperature > 100'F) or mild pain  acyclovir 400 mg Oral EVERY 12 HOURS  carboxymethyl/gly/poly80/PF 0.5-1-0.5 % 1 Drop Both eyes 4 TIMES A DAY  CHEMOTHERAPY REGIMEN AND TREATMENT INSTRUCTIONS 1 Each Miscell. (Med.Supl.;Non-Drugs) Outpatient (Back Office)  entecavir 0.5 mg Oral DAILY  lactulose 20 g Oral DAILY  levofloxacin 500 mg Oral DAILY  loperamide HCl 2 mg Take 2 tablets by mouth after the first loose stool, then 1 tablet after each subsequent loose stool. Do not exceed 4 tablets in 24 hours. Take with 4 to 8 ounces of water  menthol/zinc oxide 0.44-20.6 % Topical 2 TIMES A DAY  ondansetron HCl 4 mg Oral EVERY 6 HOURS AS NEEDED  sulfamethoxazole/trimethoprim 800-160 mg 1 tablet Oral DAILY