CHIEF COMPLAINT: worsening pain, weakness, and low grade fever

PRESENT ILLNESS: The patient is a 47 yo F with multiple sclerosis and metastatic
melanoma p/w FTT at home. Known metastatic disease to brain,
spleen, spine. Patient with chronic back pain secondary to
metastatic disease. The patient reports that it has been
difficult to manage at home since around [**Holiday **] when she
discovered the recurrence of the melanoma in her left axilla.
Over the past 1-2 weeks she has had persistent lower back pain
and poor PO intake. She reports low grade fevers to 99 at home
with difficulty sleeping over the last few weeks. Poor PO intake
over last few weeks. She was seen in the Pain [**Hospital 9085**] clinic
and started on oxycontin and oxycodone for her back pain without
much relief. This morning her family felt that it was becoming
too difficult to manage her symptoms at home and felt it was
necessary to bring her to the ED.
.
In the ED, initial vitals were 97.7, HR 130, BP 132/66, RR19,
96% RA. While in the ED, the patient spiked to 102. UA was
negative. Blood and urine cultures were sent. An initial lactate
was 4.0. She received 4L IVF and her lactate improved to 2.3.
She was empirically treated with vancomycin and cefepime. A CT
scan was performed and did not show any drainable abscess from
her left axilla. The patient declined central access.

MEDICAL HISTORY: # Metastatic Melamoma - [**2162-2-8**], underwent an excisional
biopsy for what was felt to be a 7.2 thick, [**Doctor Last Name 10834**] level IV,
nonulcerated melanoma with 10 mitoses/m2 on her left shoulder.
There was evidence of lymphovascular invasion and a question of
perineural invasion. She underwent a wide local excision and
left axillary sentinel lymph node biopsy on [**2162-3-12**]
with pathology revealing melanoma in 4 sentinel lymph nodes with
evidence of extracapsular extension. She underwent a completion
left axillary node dissection on [**2162-3-26**] with
pathology showing no melanoma in 3 lymph nodes identified. She
received radiation therapy to the left axilla without
difficulty, completing in [**2162-5-9**]. She was placed on
interferon alpha-1a (Rebif) for multiple sclerosis on [**2162-7-6**]. She presented to Clinic on [**2163-1-26**] with multiple
nodules in the left axilla consistent with recurrence within the
radiation field. Subsequent head MRI showed multiple CNS
metastases. About to begin a phase II clinical trial of
sorafenib + temazolomide therapy for her CNS metastatic
melanoma.
# Multiple Sclerosis - Diagnosed in [**2154**], relapsing/remitting

MEDICATION ON ADMISSION: Dexamthasone 4mg [**Hospital1 **]
Ambien 10mg PRN
Oxycontin 20mg [**Hospital1 **]
Oxycodone 5mg prn
Neurontin 300mg , uptitrating
Xanax 0.5mg PRN
Fiorinal 50-325-40mg cap 1 cap daily prn headache
Ibuprofen 600mg q8h
compazine 10mg tab q6h prn nausea

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals - 98.0 141/100 118 17 100% RA
General - ill appearing middle aged female, lying in bed
HEENT - PERRL, dry MM
Neck - supple, no lympadenopathy
CV - tachycardic, regular, no murmur appreciated
Lungs - CTA B/L
Abdomen - soft, non-tender, non-distended
Ext - extensive soft tissue nodularity in the left axilla with
venous congestion. No drainage appreciated.
Neuro - CN 2-12 intact, sensation intact upper and lower
extremities, RLE [**4-13**], LLE 4+/5, RUE/LUE 4+/5

FAMILY HISTORY: Father died of heart disease. Mother with hypertension.

SOCIAL HISTORY: The patient lives with her husband and youngest son (age 17).
She has 2 older children ages 27 (daughter) and 25 (son). She
used to work as a teachers aid. She denies ETOH/smoking/drugs.
Unspecified septicemia,Pressure ulcer, heel,Secondary malignant neoplasm of bone and bone marrow,Secondary malignant neoplasm of other digestive organs and spleen,Urinary tract infection, site not specified,Multiple sclerosis,Personal history of malignant melanoma of skin,Sepsis,Adult failure to thrive,Lumbago
Septicemia NOS,Pressure ulcer, heel,Secondary malig neo bone,Sec mal neo GI NEC,Urin tract infection NOS,Multiple sclerosis,Hx-malig skin melanoma,Sepsis,Failure to thrive-adult,Lumbago
Admission Date:  [**2163-2-20**]              Discharge Date:   [**2163-3-10**]

Date of Birth:  [**2115-7-11**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3016**]
Chief Complaint:
worsening pain, weakness, and low grade fever

Major Surgical or Invasive Procedure:
none


History of Present Illness:
The patient is a 47 yo F with multiple sclerosis and metastatic
melanoma p/w FTT at home. Known metastatic disease to brain,
spleen, spine. Patient with chronic back pain secondary to
metastatic disease. The patient reports that it has been
difficult to manage at home since around [**Holiday **] when she
discovered the recurrence of the melanoma in her left axilla.
Over the past 1-2 weeks she has had persistent lower back pain
and poor PO intake. She reports low grade fevers to 99 at home
with difficulty sleeping over the last few weeks. Poor PO intake
over last few weeks. She was seen in the Pain [**Hospital 9085**] clinic
and started on oxycontin and oxycodone for her back pain without
much relief. This morning her family felt that it was becoming
too difficult to manage her symptoms at home and felt it was
necessary to bring her to the ED.
.
In the ED, initial vitals were 97.7, HR 130, BP 132/66, RR19,
96% RA. While in the ED, the patient spiked to 102. UA was
negative. Blood and urine cultures were sent. An initial lactate
was 4.0. She received 4L IVF and her lactate improved to 2.3.
She was empirically treated with vancomycin and cefepime. A CT
scan was performed and did not show any drainable abscess from
her left axilla. The patient declined central access.


Past Medical History:
# Metastatic Melamoma - [**2162-2-8**], underwent an excisional
biopsy for what was felt to be a 7.2 thick, [**Doctor Last Name 10834**] level IV,
nonulcerated melanoma with 10 mitoses/m2 on her left shoulder.
There was evidence of lymphovascular invasion and a question of
perineural invasion. She underwent a wide local excision and
left axillary sentinel lymph node biopsy on [**2162-3-12**]
with pathology revealing melanoma in 4 sentinel lymph nodes with
evidence of extracapsular extension. She underwent a completion
left axillary node dissection on [**2162-3-26**] with
pathology showing no melanoma in 3 lymph nodes identified. She
received radiation therapy to the left axilla without
difficulty, completing in [**2162-5-9**]. She was placed on
interferon alpha-1a (Rebif) for multiple sclerosis on [**2162-7-6**]. She presented to Clinic on [**2163-1-26**] with multiple
nodules in the left axilla consistent with recurrence within the
radiation field. Subsequent head MRI showed multiple CNS
metastases. About to begin a phase II clinical trial of
sorafenib + temazolomide therapy for her CNS metastatic
melanoma.
# Multiple Sclerosis - Diagnosed in [**2154**], relapsing/remitting


Social History:
The patient lives with her husband and youngest son (age 17).
She has 2 older children ages 27 (daughter) and 25 (son). She
used to work as a teachers aid. She denies ETOH/smoking/drugs.

Family History:
Father died of heart disease. Mother with hypertension.

Physical Exam:
Vitals - 98.0 141/100 118 17 100% RA
General - ill appearing middle aged female, lying in bed
HEENT - PERRL, dry MM
Neck - supple, no lympadenopathy
CV - tachycardic, regular, no murmur appreciated
Lungs - CTA B/L
Abdomen - soft, non-tender, non-distended
Ext - extensive soft tissue nodularity in the left axilla with
venous congestion. No drainage appreciated.
Neuro - CN 2-12 intact, sensation intact upper and lower
extremities, RLE [**4-13**], LLE 4+/5, RUE/LUE 4+/5


Pertinent Results:
[**2163-2-20**] ADMISSION LABS:
WBC-9.6# RBC-4.70# Hgb-12.9# Hct-38.0# MCV-81* MCH-27.5
MCHC-34.0 RDW-16.7* Plt Ct-131* Neuts-93* Bands-1 Lymphs-0
Monos-2 Eos-0 Baso-0 Atyps-3* Metas-0 Myelos-1*
.
PT-12.0 PTT-29.7 INR(PT)-1.0
.
Glucose-127* UreaN-20 Creat-0.4 Na-136 K-4.2 Cl-99 HCO3-20*
AnGap-21* Calcium-10.0 Phos-4.3 Mg-1.8
.
ALT-13 AST-16 LD(LDH)-595* AlkPhos-119* TotBili-0.5 Albumin-3.6
.
[**2163-2-20**] 03:15PM BLOOD Lactate-4.0*
[**2163-2-20**] 08:50PM BLOOD Lactate-2.3*
.
calTIBC-177* VitB12-1831* Folate-8.1 Ferritn-1401* TRF-136*
.
[**2163-2-20**] 2:00 pm BLOOD CULTURE

                            **FINAL REPORT [**2163-2-26**]**

   Blood Culture, Routine (Final [**2163-2-26**]):    NO GROWTH.
.
[**2163-2-20**] 3:05 pm URINE     Site: CATHETER

                            **FINAL REPORT [**2163-2-21**]**

   URINE CULTURE (Final [**2163-2-21**]):    NO GROWTH.
.
[**2163-2-23**] 6:39 am URINE      Source: Catheter.

                            **FINAL REPORT [**2163-2-24**]**

   URINE CULTURE (Final [**2163-2-24**]):    NO GROWTH.
.
[**2163-2-23**] 6:39 am BLOOD CULTURE      Source: Line-picc.

                            **FINAL REPORT [**2163-3-1**]**

   Blood Culture, Routine (Final [**2163-3-1**]):    NO GROWTH.
.
[**2163-2-24**] 9:29 pm BLOOD CULTURE      Source: Line-SL PICC.

                            **FINAL REPORT [**2163-3-2**]**

   Blood Culture, Routine (Final [**2163-3-2**]):    NO GROWTH.

[**2-20**] CT CHEST/AXILLA
IMPRESSION:
1. No evidence of drainable fluid collection.
2. Extensive metastatic disease, some of which appears stable,
for example in the lungs, however, some of which appears
increased, for example in the vertebral bodies and spleen.
3. Cortical erosion at the T7 level along the posterior
vertebral body. If concern exists for neurologic change or
compromise, consider MRI imaging to help evaluate the soft
tissue encroachment on the thecal sac and/or nerve roots.
.
[**2-20**] EKG
Sinus tachycardia
Normal ECG except for rate
.
[**2163-2-21**]
IMPRESSION: Satisfactory right PICC tip placement in the
proximal SVC.
.
[**2163-2-22**] MRI L Spine
IMPRESSION:
1. Innumerable bony metastatic foci throughout the lumbar spine,
the sacrum, and the visualized ilia.
2. Apparent epidural extension of tumor at the L3-4 level
causing mild canal stenosis.
3. No definite signal abnormality within the distal spinal cord
or nerve roots.
.
[**2163-2-23**] CXR
IMPRESSION: No new pneumonia in the visualized portions of the
lungs. Multiple melanoma metastases as on prior.
.
[**2163-2-25**] MRI C+T Spine
IMPRESSION:
1. Bony metastatic disease. No evidence of cord compression.
2. Intrinsic signal abnormalities within the spinal cord
secondary to multiple sclerosis with a possible enhancing
multiple sclerosis plaque at T7-8 level. No epidural mass seen.
.
[**2163-2-26**] RLE Ultrasound
IMPRESSION: No evidence of DVT within the right lower extremity.
.
[**2163-3-4**] MRI BRAIN
IMPRESSION:
1. Several new enhancing lesions, less than 1 cm, consistent
with further progression of metastatic melanoma.
2. Stable appearance of demyelinating disease.
3. No evidence of edema, mass effect, or hemorrhage.
[**2163-3-5**] 12:00AM BLOOD WBC-3.0* RBC-3.37* Hgb-9.4* Hct-27.7*
MCV-82 MCH-27.8 MCHC-33.8 RDW-18.4* Plt Ct-127*
[**2163-3-4**] 12:00AM BLOOD Glucose-115* UreaN-15 Creat-0.4 Na-140
K-4.1 Cl-100 HCO3-31 AnGap-13

Brief Hospital Course:
MICU COURSE:
The patient was admitted initially to the ICU for pain control
and presuemd septic physiology given tachycardia and elevated
lactate in the ED. She was continued on Vanc and Cefepime for
broad coverage given her left axillary wound and she remained
hemodynamically stable. She was continued on decadron for her
spinal met and dilaudid for pain control. As she remained
stable, she was transfered to OMED on the [**Hospital Ward Name **] for
further care.

OMED COURSE:
47 F w/ metastatic melanoma to lung, liver, brain, severe MS p/w
weakness and FTT.

# Pain Control - Used a tremendous amount of pain medicine (IV
dilaudid after first arriving to floor. Pain service was
consulted. Was initially put in IV dilaudid PCA. Final
acceptable pain regimen was 6-8 mg dilaudid q3h prn, Fentanyl
Patch 150 mcg/hr TP Q72H, methadone 10mg q8h, naproxen 500mg tid
prn, Lidocaine 5% Patch 1 PTCH TD DAILY, Neurontin
100qAM/100qPM/200qHS, and duloxetine 30mg daily. Additionally,
she underwent 5 fractions of palliative XRT to the pelvis and
spine. To counteract the effects of such a large pain medicine,
an aggressive bowel regimen was pursued. Monitored for narcosis
or depressed respiratory rate. Respirations were as low as [**11-20**]
at points, but was never pathological. Pt did deomnstrate some
nocturnal confusion (see below), for which ambien was
discontinued.  By time of discharge was stablized on an adequate
regimen with an aggressive bowel regimen given her high dose
narcotics.  Extended care facility has been provided with a
complete list.

# Confusion - Briefly noted early during inpatient course.
Initially thought to be most likely a side effect of
medications, but patient has known brain metastases. MRI brain
showed small new mets c/w melanoma, also stable demyelinating
disease. Ambian discontinued and confusion resolved.  Rad-onc
was then consulted to evaluated if whole brain radiation vs
cyberknife were appropriate for new metastases.  Given that she
was assymptomatic, no further treatment was pursued while
inpatient.  If patient does become symptomatic, she's encouraged
to contact radiation oncology as needed.

# Hypertension - No history of this in the past, but pt
persistently hypertensive on the floor (although BPs were taken
in legs because L arm with invasive melanoma, R arm with PICC,
so BP likely overestimated). Hypertension was likely exacerbated
by pain, so emphasized pain control to control BP as well. BPs's
decreased as pain has come under better control but ultimately
required continued metoprolol for BP control, discharged on this
medication.

# Metastatic Melanoma w/ axillary wound - Plan to continue chemo
with TMZ 200mg per m2 at later date, currently not able [**3-12**]
compromised health. Pan Spinal MRI showed intrinsic signal
abnormalities within the spinal cord secondary to multiple
sclerosis, as well as diffuse bony metastatic disease, with no
evidence of cord compression seen. S/p palliative XRT to spine
with great improvement in pain.  Wound care was consulted for
axillary wound and followed patient throughout stay.
Continued dexamethasone with taper for CNS mets.  Appreciate SW
consult, psych and pall care consults while inpatient.

# Intermittent Fever - Most likely related to malignancy.
Patient presented with fever in ED. Unclear source for an
infection, as CT showed no axillary abscess and all cultures
either negative or with NGTD. CXRs unrevealing for infiltrate.
After ICU stay, patient spiked again early [**2-23**] despite
vanc/cefepime and steroids. Cultures and radiology from that
date were also negative.  Patient completed 5 days of vancomycin
and a 7 day course of cefepime that was completed [**2-27**].  No
further antibiotics were given and no further evidence of
infection was found.

# Multiple Sclerosis - Last med was Rebif, d/c'ed in [**Month (only) **],
with no relapses. Previously on Avonex and Tysabri. Followed by
Dr [**Last Name (STitle) 10835**]. Spoke with Dr. [**Last Name (STitle) 10835**], would defer all MS rx at
this time while undergoing chemo; a last ditch option would be
MTX or cyclophosphamide. If undergoing brain XRT may need more
steroids as higher risk for MS relapse, but this is deferred to
outpatient follow-up if patient becomes symptomatic from new
brain metastases.

# Shoulder Pain - Complained of R shoulder pain that began the
day prior to admission following upper extremity physical
therapy.  Patient was consistent with muscle strain, which
patient thought was true as well.  No [**Last Name (un) 2043**] deformity.  EKG not
indicative of cardiac origin.  Abdominal exam benign with no
signs of radiating origin.  Maintained current pain regimen with
intermittantly complete relief.

# Anxiety - Psych consulted, continued prn BZD. Duloxetine added
for pain control.

# Code - DNR/DNI - discussed with patient at time of admission

Medications on Admission:
Dexamthasone 4mg [**Hospital1 **]
Ambien 10mg PRN
Oxycontin 20mg [**Hospital1 **]
Oxycodone 5mg prn
Neurontin 300mg , uptitrating
Xanax 0.5mg PRN
Fiorinal 50-325-40mg cap 1 cap daily prn headache
Ibuprofen 600mg q8h
compazine 10mg tab q6h prn nausea

Discharge Medications:
1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply
to lower back. please remove for 12hrs in any 24 hr period  .
2. Fentanyl 75 mcg/hr Patch 72 hr Sig: Two (2) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. Hydromorphone 2 mg Tablet Sig: 3-4 Tablets PO Q3H (every 3
hours) as needed: please try to give 6mg doses during the day
and 8mg at night  .
4. Methadone 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours): hold for oversedation or confusion.
5. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
7. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed.
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
9. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. Modafinil 100 mg Tablet Sig: One (1) Tablet PO qAM ().
11. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours): continue this dosing until [**3-10**], then decrease to 2mg
daily x 1 week, then taper off, or as otherwise instructed by
MD.
12. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for nausea/vomiting/anxiety.
13. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea/vomiting.
14. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
15. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): hold for bsp <100, hr <50.
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
19. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet
Sig: One (1) Powder in Packet PO daily ().
20. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day): Hold for loose stools.
21. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q4H
(every 4 hours) as needed.
22. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
23. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours): Can discontinue once patient
is more mobile.
24. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day): hold fpr SBP<105, HR<55  .


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 2670**] - [**Location (un) 1456**]

Discharge Diagnosis:
Primary:
weakness
.
Secondary:
# Metastatic Melanoma - mets to brain, pelvis, femurs, spleen,
adrenals, and spine
# Multiple Sclerosis - Diagnosed in [**2154**], relapsing/remitting


Discharge Condition:
stable, pain under good control


Discharge Instructions:
You were admitted to the hospital with worsening lower back
pain, lower extremity weakness, and low grade fevers at home.
You were initially admitted to our ICU for close observation
because we were worried about an possible infection in your
bloodstream. However, no source for an infection was ever found
and you were then transferred to our oncology floor. You had
some intermittent fevers but again, no infection was found. The
fever may have been related to your malignancy.
.
We did an MRI of your spine which showed diffuse bony metastases
which were likely causing your pain and weakness. Our pain
service consulted and put you on an extensive pain control
regimen which lowered your pain to an acceptable level. We also
called our radiation oncologists, who provided you with a 5
session course of radiation to your spine and pelvis to further
control your pain.
.
At points you were confused, which was likely a side effect of
the large amount of pain medicine you were on. However, since
you have known brain metastases, we imaged your head to assess
for any change. This scan showed a few new small lesions that
were unlikely to be responsible for the confusion. We continued
to treat your cancer with a drug called temozolomide, as well as
with the palliative chemotherapy.
.
Our physical therapists worked with you and determined that you
need to go to rehab to work on regaining your strength.
.
Please take all of your medicines as prescribed. Please keep all
of your outpatient followup appointments. If you experience any
symptoms that disturb you, such as new weakness, fevers,chills,
please call your doctor [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the ER.

Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10837**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2163-3-22**]
2:00

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**]
date/Time:[**2163-3-22**] 2:30

Provider: [**Name10 (NameIs) 10838**] [**Name11 (NameIs) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 22**]
Date/Time:[**2163-3-22**] 2:30


                             [**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]
{'Unspecified septicemia,Pressure ulcer, heel,Secondary malignant neoplasm of bone and bone marrow,Secondary malignant neoplasm of other digestive organs and spleen,Urinary tract infection, site not specified,Multiple sclerosis,Personal history of malignant melanoma of skin,Sepsis,Adult failure to thrive,Lumbago'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: worsening pain, weakness, and low grade fever

PRESENT ILLNESS: The patient is a 47 yo F with multiple sclerosis and metastatic
melanoma p/w FTT at home. Known metastatic disease to brain,
spleen, spine. Patient with chronic back pain secondary to
metastatic disease. The patient reports that it has been
difficult to manage at home since around [**Holiday **] when she
discovered the recurrence of the melanoma in her left axilla.
Over the past 1-2 weeks she has had persistent lower back pain
and poor PO intake. She reports low grade fevers to 99 at home
with difficulty sleeping over the last few weeks. Poor PO intake
over last few weeks. She was seen in the Pain [**Hospital 9085**] clinic
and started on oxycontin and oxycodone for her back pain without
much relief. This morning her family felt that it was becoming
too difficult to manage her symptoms at home and felt it was
necessary to bring her to the ED.
.
In the ED, initial vitals were 97.7, HR 130, BP 132/66, RR19,
96% RA. While in the ED, the patient spiked to 102. UA was
negative. Blood and urine cultures were sent. An initial lactate
was 4.0. She received 4L IVF and her lactate improved to 2.3.
She was empirically treated with vancomycin and cefepime. A CT
scan was performed and did not show any drainable abscess from
her left axilla. The patient declined central access.

MEDICAL HISTORY: # Metastatic Melamoma - [**2162-2-8**], underwent an excisional
biopsy for what was felt to be a 7.2 thick, [**Doctor Last Name 10834**] level IV,
nonulcerated melanoma with 10 mitoses/m2 on her left shoulder.
There was evidence of lymphovascular invasion and a question of
perineural invasion. She underwent a wide local excision and
left axillary sentinel lymph node biopsy on [**2162-3-12**]
with pathology revealing melanoma in 4 sentinel lymph nodes with
evidence of extracapsular extension. She underwent a completion
left axillary node dissection on [**2162-3-26**] with
pathology showing no melanoma in 3 lymph nodes identified. She
received radiation therapy to the left axilla without
difficulty, completing in [**2162-5-9**]. She was placed on
interferon alpha-1a (Rebif) for multiple sclerosis on [**2162-7-6**]. She presented to Clinic on [**2163-1-26**] with multiple
nodules in the left axilla consistent with recurrence within the
radiation field. Subsequent head MRI showed multiple CNS
metastases. About to begin a phase II clinical trial of
sorafenib + temazolomide therapy for her CNS metastatic
melanoma.
# Multiple Sclerosis - Diagnosed in [**2154**], relapsing/remitting

MEDICATION ON ADMISSION: Dexamthasone 4mg [**Hospital1 **]
Ambien 10mg PRN
Oxycontin 20mg [**Hospital1 **]
Oxycodone 5mg prn
Neurontin 300mg , uptitrating
Xanax 0.5mg PRN
Fiorinal 50-325-40mg cap 1 cap daily prn headache
Ibuprofen 600mg q8h
compazine 10mg tab q6h prn nausea

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals - 98.0 141/100 118 17 100% RA
General - ill appearing middle aged female, lying in bed
HEENT - PERRL, dry MM
Neck - supple, no lympadenopathy
CV - tachycardic, regular, no murmur appreciated
Lungs - CTA B/L
Abdomen - soft, non-tender, non-distended
Ext - extensive soft tissue nodularity in the left axilla with
venous congestion. No drainage appreciated.
Neuro - CN 2-12 intact, sensation intact upper and lower
extremities, RLE [**4-13**], LLE 4+/5, RUE/LUE 4+/5

FAMILY HISTORY: Father died of heart disease. Mother with hypertension.

SOCIAL HISTORY: The patient lives with her husband and youngest son (age 17).
She has 2 older children ages 27 (daughter) and 25 (son). She
used to work as a teachers aid. She denies ETOH/smoking/drugs. 

### Response:
{'Unspecified septicemia,Pressure ulcer, heel,Secondary malignant neoplasm of bone and bone marrow,Secondary malignant neoplasm of other digestive organs and spleen,Urinary tract infection, site not specified,Multiple sclerosis,Personal history of malignant melanoma of skin,Sepsis,Adult failure to thrive,Lumbago'}
