allergies: patient recorded as having no known allergies to drugs attending: chief complaint: altered mental status major surgical or invasive procedure: none history of present illness: 61 yo woman h/o breast cancer s/p resection, metastatic poorly differentiated sarcoma went for right pneumonectomy for mets ( ), now presents with several weeks of intermittent ams/confusion/occasional speech difficulty, worsen today. for the past few weeks she has developed some confusion and aphasia according to the family. pt herself states that she does notice that she can't find correct words. denies any respiratory sx, headaches, changes in the vision or balance. she recently had pet which did not show any activity. family called dr who referred her to ed for evaluation. when she arrived, cxr found to have loculated l pleural fluids, ua is unimpressive, head ct showed spherical lesions, c/w metastatic disease - widespread. neurosurg report no emergent surgical therapy likely, did not recommend steroids now given infection of unclear type (ie. elevated wbc). heme-onc aware of the patient. she was noted to be persistently tachycardic after 2 l. . initial vitals, pain temp 100.4 hr 123 bp 143/93 rr18 sat 98 on 2l. given acetaminophen, piperacillin-tazob, vancomycin, morphine sulfate in ed. pain controlled. prior to transfer vitals were: 98.5 114 119/78 22-26 98% nc. ua unimpressive, ucx sent. ekg twi in v3. . on the floor, 98 104/66 rr 10 sat 100. comfortable, able to answer questions appropriately. past medical history: past medical history: breast cancer felt to be due to a variant brca2 mutation htn endometriosis depression psh: b/l oophorectomy, lumpectomy x3, b/l mastectomy social history: the patient is married and lives with her husband in . she works as a bookkeeper for a construction company, but is not currently working due to her illness. she smoked tobacco socially in the past, but has not smoked regularly. she has two daughters. she drinks alcohol socially. family history: the patient has no ashkenazi heritage in her family. her mother had pancreatic cancer in her 60s. her first cousin, her maternal uncle's daughter, had breast cancer in her 60s and died of an mi at 67. the patient's paternal grandmother had breast cancer in her 70s. physical exam: general: alert, oriented, mild distress, cachetic heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: abscent lung sounds on right, left no wheezes, rales, ronchi cv: tachy, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: 09:00pm blood wbc-28.3*# rbc-4.11* hgb-9.8* hct-32.4* mcv-79* mch-23.9* mchc-30.3* rdw-16.6* plt ct-913* 03:16am blood wbc-21.0* rbc-3.41* hgb-8.4* hct-26.6* mcv-78* mch-24.6* mchc-31.5 rdw-16.1* plt ct-719* 03:00pm blood hct-28.2* brief hospital course: mrs. is a 61 yo woman with a h/o breast cancer s/p resection that is metastatic and poorly differentiated sarcoma s/p right pneumonectomy for mets ( 4/). she now presents with several weeks of intermittent ams, confusion and occasional speech difficulty that had worsened on presentation. . ams: on admission, the patient had difficulty with speech and was confused to the point where she couldn't remember her daughter's names. she had a ct scan and mri of the head that showed multiple brain mets (~14 spherical lesions). her acute mental status change was secondary to brain metastasis from her sarcoma. the patient was followed by radiation oncology during her hospitalization. they recommended whole brain radiation. she completed brain mapping and completed 4 radiation treatments. her mental status improved and she was able to communicate clearly by the day of discharge. . leukocytosis/infection: the elevated wbc count with fever was suggestive of infectious etiology, however we believe this is a paraneoplastic phenomemnon. blood cultures and urine cultures were sent and there was no growth. no antibiotics were used at this time. the patient continued to have persistent leukocytosis on the day of discharge. we suspect that the leukocytosis is related to her tumor burden. . thrombocytosis, anemia: appears to be presistent after diagnosis of her sarcoma. there was no need for transfusions during her hospitalization. . pain medication: no complaints about pain. we continued her on the following regimen throughout her hospitalization: - continue morphine sulfate 2-4 mg iv q4h:prn pain and morphine sulfate ir 15 mg po/ng q4h:prn pain. - continue lidocaine 5% patch 1 ptch td daily 12 hrs. . palliative care had a meeting with the family and patient today. the family is very protective of the mother. they were all aware of her prognosis, but they want to limit discussion about end of life issues around the patient. the family would like many of the services offered by hospice, but were not willing to agree to accept these services at this time. the family was comfortable with accepting services. medications on admission: gabapentin 600 mg po tid lisinopril 5 mg po daily lorazepam 0.5 mg tablet tablet(s)po q4-6 hours as needed morphine 15 mg tablet po q 4-6 hours as needed for pain ascorbic acid n aspirin aspirin] 81 mg tablet daily. discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). 3. gabapentin 300 mg capsule sig: two (2) capsule po tid (3 times a day) for 1 weeks. disp:*42 capsule(s)* refills:*1* 4. morphine 15 mg tablet sustained release sig: one (1) tablet sustained release po q12h (every 12 hours) for 2 weeks. disp:*28 tablet sustained release(s)* refills:*1* 5. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 6. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily) for 1 weeks. disp:*7 adhesive patch, medicated(s)* refills:*0* 7. morphine 15 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain for 1 weeks. disp:*84 tablet(s)* refills:*0* 8. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for fever. 9. famotidine 20 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 1 weeks. disp:*14 tablet(s)* refills:*2* 10. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed for constipation. 11. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 12. bisacodyl 10 mg suppository sig: one (1) suppository rectal hs (at bedtime) as needed for constipation. 13. polyethylene glycol 3350 17 gram/dose powder sig: one (1) po daily (daily) as needed for constipation. 14. dexamethasone 4 mg tablet sig: one (1) tablet po as directed for 17 doses: please take 4mg three times a day for three days, then taper down to 4mg two times a day for three days. disp:*17 tablet(s)* refills:*0* 15. lorazepam 0.5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for anxiety/insomnia for 1 weeks. disp:*28 tablet(s)* refills:*1* 16. dexamethasone 2 mg tablet sig: one (1) tablet po as directed for 9 doses: please take 2mg for three days and then taper down to 2mg daily for three days. disp:*9 tablet(s)* refills:*0* discharge disposition: home with service facility: discharge diagnosis: lung sarcoma brain metastases discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: it was a pleasure working with you during your hospital admisssion. you were admitted for confusion and mental status changes. we found two metstatic lesions in the brain that explain your symptoms. during your hospital admission, you were started on radiation therapy. you received your first dose on friday morning and you completed 3 treatments this week. we encourage you to continue your home medications on discharge. in addition, we recommend that you continue your steroid, dexamethasone. over the next few days, you will need to taper your steroid dose. the instructions will be included in your discharge paperwork and can be given to your visiting nurses. please follow-up with your primary oncologist in the next few weeks. followup instructions: provider: scan phone: date/time: 11:15 provider: , md phone: date/time: 10:00 provider: , md phone: date/time: 9:40 md Procedure: Other radiotherapeutic procedure Diagnoses: Unspecified pleural effusion Unspecified essential hypertension Personal history of malignant neoplasm of breast Depressive disorder, not elsewhere classified Secondary malignant neoplasm of brain and spinal cord Secondary malignant neoplasm of lung Anemia in neoplastic disease Essential thrombocythemia Personal history of malignant neoplasm of other sites