張貼日期：2018/7/8 上午 04:08:33
A 58 y/o F
[Major past history]
1. DLBCL, ABC type, stage IIIB, s/p R-CHOP(C4D1: 2017/9/13), in CR(2017/9/7 PET)
2. HBV carrier
[History summary & assessments]
This is a 58-year-old female patient with history of DLBCL s/p R-CHOP(C4D1: 2017/9/13) in complete remission. The patient received prophylatic G-CSF infusion 5mcg/kg/day during 9/19-9/22.
This time, the patient had intermittent fever with sorethroat since 9/19. The associated symptoms included cough with few sputum production, sore throat, bone pain, fatique and poor appetite. There as no abdominal discomfort, dysuria or diarrhea. Due to the fever, the patient visited NTUH ER on 2017/9/23. We were consulted for further evaluation.
[PE]
GCS: E4V5M6
HEENT
Head: trauma (-), scar(-)
Eye& Ear: pale conjunctiva (-), icteric sclera (-)
Mouth: ulcer(-), thrush(-)
Neck: supple, lymph adenopathy (-), jugular vein engorgement(-)
Axillary lymph nodes (-)
Chest
Inspection: symmetric expansion, Accessory muscle exertion(-)
Auscultation: bilateral clear, wheezing(-)
Abdomen
Inspection: soft, flat
Auscultation: bowel sound(normo-active)
Palpation: peritoneal sign(-), tenderness(-), hepatomegaly(-), splenomegaly(-)
Percussion: normo-tympanic, shifting dullness(-)
Inguinal area: lymphadenopathy(-)
Limbs: warm, edema(-)
Skin: skin turgor fine(-), petechiae(-), ecchymosis(-), rash(-)
[Blood exams]
9/23
WBC(165.7 K/μL) HB(12.0 g/dL) PLT(54 K/μL)
Normoblast(0 /100) Blast(0 %) Promyl.(0 %)
Myelo.(0 %) Meta(0 %) Band( 0 %)
Seg(67.5 %) Eos.(2.0 %) Baso.(5.0 %)
Mono.(2.5 %) Lym.(3.0 %) Aty.Lym.(0 %) PlasmaCell(0 %)
→ ANC(1484/uL)
Bil-T( mg/dL), CRE(1.1 mg/dL) Na(132 mmol/L) K(3.7 mmol/L) ALT(22 U/L)
Urine analysis: Epi(0-2/HPF), RBC(0-2/HPF), WBC(0-2/HPF), WBC esterase(-)
CxR: no obvious pneumonia patch
Hema and related diagnosis:
1. Febrile neutropenia syndrome
2. DLBCL, ABC type, stage IIIB, s/p R-CHOP(C4D1: 2017/9/13), in CR(2017/9/7 PET)
3. HBV carrier
1. Component therapy with 減白加電血品 to keep Hb > 8.0 and PLT > 20 K if no active bleeding
2. Keep empiric antibiotics as cefepime, adjust according to culture report.
3. Give NHI reimbursed G-CSF(5mcg/kg) SC daily until WBC>4000/uL or ANC > 2000/uL
4. Consider GM admission(無隔離，3>2)
Options:
Check pneumococcal urine antigen, legionella urine antigen.
Check serum mycoplasma IgM, chlamydia IgM at next blood sampling.