text:  Of note  Na 133   K 4   WBC 8.82   hematocrit 35.1   platelets 229 . PT 13.8 with an INR of 1.3   PTT 25.5 total protein was 6.2   albumin 3.4   globulin of 2.8   calcium of 9.1   phos 2.7   mag 2.1   urea 3.7 . ALT was elevated at 240   AST 85   LDH 305   alk phos 85   total bilirubin was 1.3   direct bili was .8 . Cholesterol 188   triglyceride was 127 . UA  trace protein   trace ketones   positive for bilirubin and nitrogen and also 4 to 6 wbcs with 1 bacteria . Chest x-ray  Showed a left paratracheal adenopathy and small left pleural effusion with no evidence of pneumonia . In summary   the patient is a 49 year old woman with metastatic breast cell CA   status post chemotherapy with CMSAP and PVSC and XRT who presented with fever   four days of diarrhea   nausea and vomiting and had been on Keflex for an erythema on her left chest wall . The Keflex was stopped when she developed the diarrhea . When she arrived the plan was to go ahead and treat here rythematous induration and possible cellulitis with IV antibiotics . So she was put on dicloxicillin and we did local wound care with an agent called Santyl   which is a collagenace ondebrided which worked very well for her . Also at the time of admission we were also considering palliative Taxol chemotherapy   which the patient declined . She refused the Taxol therapy so that was not done . Another major issue with this patient was pain control . She had been in a whole lot of pain from her left arm lesion . So pain control was a big issue so she was on MS Contin and MSIR at home she thought that clouded her thinking   so we tried different things for pain management . One of them was to do a subarachnoid neurologic block at C6-C7 interface on 1-6-94 . After that the patient had minimal relief of pain . However   she declined further blocks   which were offered to her . So accepted to be on dilaudid p.o. which was started at a dosage of 2-4 meg but since then we have tapered it up . She is now getting dilaudid 8 mg q2h and in addition she has been on fentanyl patch . She is now getting 75 micrograms per hour of the fentanyl patch which is changed every 72 hours . We can go up by 25 mg on the fentanyl patch as needed to control her pain and we can always go up on the dilaudid because she is still in considerable amount of pain . Other things that happened during this admission  we obtained ahead CT for her on the 8th of January because of her clouded thinking and altered mental status   which was probably due to the morphine that she was taking . We went ahead and got a head CT scanand it showed no enhancing lesions . In addition her liver transaminases were elevated   we thought about doing further work-up   but that was deferred because the patient wanted to wait on that . That has been stable . The patient on January 13 became hyponatremic . Her sodium went down to 121 and before that on admission she was 133 . A renal consult was obtained and their assessment was that this was probably a mixture of hypovolemia as well as SIADH . We proceeded to do for her hyponatremia  we gave her some fluid and her urine sodium became higher than her serum sodium  we stopped it . We had given her some normal saline and then we proceeded to just do fluid restriction . In addition we gave her a sodium chloride one gram per day and that also helped   so that now at the time of discharge   the patient &aposs sodium is between 126 and 129  prior to that it had gone down to as low 116. So that has really improved . We suggest continuing increased salt intake in her diet and also continuing with the fluid restriction of free water intake to one liter per day . On the 14th of January   the patient developed increased shortness of breath and chest x-ray was taken showed a wedge shaped infiltrate in the right upper lobe which was consistent with Hampton &aposs hump . Also a VQ scan obtained the next day showed high probability for PE . So we proceeded to put her on heparin for anticoagulation and then when she was therapeutic on heparin   we went ahead and started her on coumadin and she is currently on coumadin at 2.5 mg q.h.s. Her INR is 2.3 . We want her INR to remain between 2 and 3 . So if it goes much lower than 2   then we would consider increasing it to perhaps coumadin 2.5 and 5 alternating every other night . However   we would leave it at 2.5 for now . Other major issues  As a result of all the things happened and with her hyponatremia and also the other problems   her blood pressure was elevated also . We put her on nifedipine IR   SL and that was not enough to control her blood pressure which was in the 200s in the systolic   so we had started her on atenolol . So on discharge she is on atenolol 100 . If needed to you can give her some nifedipine SL to decrease her blood pressure . The patient also has significant edema in both arms now and also some mild edema in the lower extremities   so I think that fluid restriction should help with that . She is also a little dry . The patient is on oxygen . Ever since the pulmonary embolus she has been on oxygen . She was on 4 liters  now she is on 5 liters   sating 94 to 96 on 5 liters . We would like for her to remain on the oxygen as well . The complications that I have listed include the hyponatremia   pulmonary embolus and also the elevatd blood pressure . 