Febrile Neutropenia Evaluation Note (Pediatric Oncology)

FN Timeline

(Time-critical section. Include explicit timestamps with date and 24-hour time. If any element is unknown, state "unknown." Maintain chronological order. Always include antibiotic order and first-dose start times and calculate TTA.)

• Fever onset: [Date/time] — [home / ED / inpatient]; Tmax [temperature with units] via [oral / tympanic / temporal / rectal]; [Antipyretic given: agent, dose, time / none given]
• Arrival/triage or recognition time: [Date/time of ED arrival or inpatient recognition]
• Blood cultures collected: (Enumerate every lumen and peripheral draw. Indicate whether obtained before vs after antibiotics.)
  • CVC lumen A: [Date/time] — [before / after] antibiotics
  • CVC lumen B: [Date/time / not obtained] — [before / after] antibiotics (Include only lumens present.)
  • Peripheral: [Date/time / not obtained] — [before / after] antibiotics
• Empiric antibiotic ordered: [Agent(s)] at [Date/time]
• First-dose antibiotic administration started: [Agent(s)] at [Date/time] (If not yet given, state "not yet administered" and document reason.)
• Time-to-antibiotics (TTA): [Minutes] from [triage / recognition] to first-dose start (If unable to compute, state which timestamp is missing.)
• Hemodynamic instability interventions: (Include only if unstable; otherwise omit.)
  • Fluid bolus: [Fluid type, volume mL/kg] at [Date/time]; response [improved / unchanged / worsened]
  • Vasopressor initiation: [Agent, dose] at [Date/time]
  • Oxygen escalation: [Device, flow/FiO2] at [Date/time]

Encounter Information

• Location: [ED / inpatient unit]
• Patient age: [Age]
• Weight: [kg]
• Primary oncologist/service: [Name / team]
• Consulting services notified: [Oncology / Infectious Diseases / PICU / Pharmacy] at [Date/time] (Include only those contacted.)
• Central line status: [Port / PICC / tunneled catheter], [number] lumens; [accessed / not accessed]; [line draws possible / not possible]
• Isolation/precautions: [None / neutropenic / contact / droplet / airborne]

Chief Complaint

[Fever in oncology patient / Fever and neutropenia / Concern for sepsis in neutropenic patient]

Oncology and Immunocompromise Context

[Cancer diagnosis and current therapy phase: induction / consolidation / maintenance / relapse]. [Transplant status if applicable: auto / allo HCT, day post-transplant, GVHD status, immunosuppression]. [Most recent chemotherapy agents and dates]. [Steroid exposure if clinically relevant: agent, dose, duration]. [Current prophylaxis: antibacterial, antifungal (mold-active vs non-mold-active), antiviral, PJP]. [Prior microbiology of concern: resistant organism colonization, prior bloodstream infections, invasive fungal disease history]. (If any detail is unknown, state "unknown" rather than inferring.)

History of Present Illness

[Fever details: location measured, highest temperature with route, timing of onset, duration, response to antipyretics]. FN criteria: ANC [value with time / pending]; [if pending, state treating as possible FN due to recent chemotherapy or high-risk status]. [Symptom review for infectious sources: respiratory (cough, dyspnea), GI (abdominal pain, diarrhea, mucositis, odynophagia), GU (dysuria), skin/soft tissue (rash, cellulitis, perirectal symptoms), line-related (pain, erythema, drainage, flushing difficulty), neurologic (headache, mental status changes)]. [Relevant exposure history]. (If fever onset time is unknown, explicitly document this. Use direct caregiver quotes sparingly for key times or measurements.)

High-risk clinical features screen: Ill/toxic appearance [present / absent]; altered mentation [present / absent]; hypotension or poor perfusion [present / absent]; respiratory distress or hypoxemia [present / absent]; severe abdominal pain [present / absent]; new focal neurologic changes [present / absent].

Background

• Allergies: [Allergen — reaction type] (Critical for antibiotic selection.)
• Relevant PMH: [Prior FN episodes, ICU admissions, other relevant conditions]
• Home medications: [Prophylaxis, immunosuppressants, others impacting infection risk]
• Baseline organ function: [Renal and hepatic status if dosing-relevant]
• Outpatient pathway considerations: [Distance to hospital, caregiver reliability, ability to return urgently] (Include only if considering outpatient management.)

Physical Examination

• General: [Well-appearing / uncomfortable / ill-appearing / toxic]; hydration [adequate / dehydrated]
• HEENT: [Mucositis/oral lesions: present / absent]; [pharynx and nasal findings]
• Cardiovascular/perfusion: HR [value], pulses [normal / diminished], capillary refill [seconds], extremities [warm / cool], mental status [alert / lethargic], BP [value]
• Respiratory: [Work of breathing]; [breath sounds]; [focal findings]; SpO2 [value] on [room air / oxygen device]
• Abdomen: [Soft / distended]; [tenderness location / none]; [guarding / rebound: present / absent]
• Skin: [Rash / cellulitis / lesions]; [perianal inspection findings if indicated] (No routine rectal exam.)
• Central line site: [Dressing integrity]; [erythema / tenderness / drainage: present / absent]; [flushing/draw function]
• Neurologic: [Baseline mental status]; [focal deficits: present / absent]

Objective Data

Vitals and Monitoring

• Latest vitals: Temp [value] at [time]; HR [value]; RR [value]; BP [value]; SpO2 [value] on [device]
• Trend: [Brief trend description from arrival to current with timestamps]
• Weight: [kg]
• Monitoring: [Continuous pulse ox / cardiac monitor / BP cycling frequency]
• I/O: [Intake/Output with timeframe] (Include for inpatients if available.)

Labs

• CBC with differential: [Date/time] — WBC [value], Hgb [value], Plt [value], ANC [value — resulted / pending] (ANC status must be documented as value with time or explicitly "pending".)
• Metabolic/organ function: [BMP values]; [renal and hepatic panel if relevant to dosing]
• Additional labs if instability: [Lactate / blood gas / coagulation studies] — indication: [hemodynamic concern / respiratory failure] (Include only if obtained.)

Microbiology

• Blood cultures: (Specify source, time, and relation to antibiotics.)
  • CVC lumen A — [Date/time] — [before / after] antibiotics — [pending / organism and susceptibilities]
  • CVC lumen B — [Date/time] — [before / after] antibiotics — [pending / organism and susceptibilities]
  • Peripheral — [Date/time / not obtained] — [before / after] antibiotics — [pending / organism and susceptibilities]
• Other specimens: [Urine culture/UA, respiratory panel, stool studies, wound culture] — [collection time] — [results / pending] (Include only if obtained.)

Imaging

• Chest radiograph: [Obtained / not obtained — if not obtained, state rationale (no respiratory symptoms)] — [results]
• Additional imaging: [CT chest/sinuses/abdomen] — indication: [prolonged fever / IFD evaluation] — [results / pending] (Include only if obtained.)

Assessment

[Age]-year-old [pediatric oncology / HCT] patient presenting with fever. Neutropenia status: ANC [value with time / pending]. Risk category: [High-risk / low-risk] FN based on [validated tool or institutional criteria with key elements documented]. Hemodynamic status: [Stable / unstable]; sepsis [suspected / not suspected] based on [supporting findings]. Likely source or differential: [Line-associated bacteremia / pneumonia / mucositis-translocation / UTI / typhlitis / SSTI / viral illness / unknown]. (Do not infer low-risk without documenting criteria. Label assessment as provisional when ANC pending.)

Plan

Febrile Neutropenia

• Risk stratification: [High-risk / low-risk] per [tool/criteria used with key elements]
• Diagnostics: Blood cultures from all CVC lumens [A, B]; peripheral [obtained / not obtained]; [other indicated cultures/tests]. Chest radiograph [obtained for respiratory symptoms / not indicated].
• Empiric antimicrobials:
  • [Agent] — IV — [dose mg/kg, max dose] — ordered [Date/time] — first dose started [Date/time]
  • [Additional agent if indicated] — IV — [dose mg/kg] — ordered [Date/time] — first dose started [Date/time]
  • Rationale: [Antipseudomonal beta-lactam selection]; [indication for added gram-positive or double gram-negative coverage if used]; [allergy considerations]; [resistant organism risk factors]
  • De-escalation: [Reassessment criteria and timeframe at 24–72 hours]
• Monitoring: Vitals [frequency]; [continuous monitoring orders]; repeat labs [CBC/ANC timing, renal function if nephrotoxic agents]; culture follow-up [timing]; escalation triggers [criteria]
• Consults/communication: [Oncology / ID / ICU / Pharmacy] notified at [Date/time] (Include only those contacted.)

Hemodynamic Instability or Sepsis

(Include only if applicable; otherwise omit this section.)

• Recognition time: [Date/time]
• Perfusion/organ dysfunction findings: [Supporting findings]
• Interventions:
  • Fluids: [Type, volume mL/kg] at [Date/time]; response [improved / unchanged / worsened]
  • Oxygen: [Device, flow/FiO2] at [Date/time]
  • Vasopressors: [Agent, dose] at [Date/time]
• Disposition escalation: [PICU consult/transfer criteria and timing]

Source-Specific Problems

(Add subsections only when supported by findings; otherwise omit.)

• Suspected line infection: [Supporting evidence]; [diagnostics]; [therapy adjustments]
• Pneumonia: [Symptoms/imaging]; [microbiologic tests]; [antibiotic adjustments]
• Mucositis/translocation: [Findings]; [nutrition/support]; [antimicrobial considerations]
• UTI: [UA/culture]; [therapy]
• Typhlitis: [Abdominal findings/imaging]; [bowel rest, antibiotics, surgery consult]
• SSTI: [Lesion description]; [drainage/culture]; [coverage]

Prolonged Fever in Neutropenia

(Include only if fever persists ~96 hours or per institutional definition; otherwise omit.)

• Duration: [Days/hours] despite [current antibiotics]
• IFD risk assessment: [Host factors, prophylaxis status, prior fungal disease]
• Imaging/biomarkers: [CT chest/sinuses/abdomen, galactomannan/β-D-glucan] with timing
• Antifungal approach: [Empiric / pre-emptive] — [agent, dose mg/kg] — rationale: [criteria]

Supportive Care

• Antipyretics: [Agent, dose mg/kg, frequency]
• Hydration/electrolytes: [IVF type/rate]; [electrolyte repletion plan]
• Transfusion thresholds: [PRBC/platelet thresholds] (Include if relevant.)
• Neutropenic precautions: [Diet, isolation, visitor guidance]

Disposition

• Decision: [Admit / Discharge]
• If admitting: Level of care [floor / step-down / PICU]; monitoring orders [specify]; antibiotic continuation [plan]; reassessment [timepoints]
• If outpatient management (low-risk FN only): Low-risk criteria [documented]; follow-up infrastructure [confirmed]; oral antibiotic [agent, dose, duration]; return precautions [specified]; follow-up [timing]. (If eligibility cannot be confirmed, default to admission with documented reasoning.)

(Meta-instructions: Timestamps are critical safety elements—if unavailable, explicitly label as "unknown." ANC must always be documented as a numeric value with time or as "pending." Culture sites and lumens must be explicitly enumerated. Antibiotic administration start time is required; if not yet given, document reason. Hemodynamic assessment is required and determines whether to include the sepsis section. Omit inapplicable sections rather than leaving empty placeholders, except for safety-critical items above. Do not auto-populate contradictory findings between sections.)