History of Present Illness 09\/30\/2022<\/p>\n
Patient is very nice 48 years old male with history of basal cell carcinoma of the lungs, on chemotherapy, presenting with generalized weakness, left temporal and forehead pressure and pain in with nausea vomiting on and off for 3 weeks. He has a known right lower lobe mass seen in August of 2022, he now also has lymph nodes in the right axilla which are painful and bleeding. CT of the brain show a likely dural based MET(metastasis) in the left parietal lobe without midline shift with some surrounding vasogenic edema. He has a known right lower lobe mass that was discovered in August of 2022, and he now has painful and bleeding lymph nodes in the right axilla. A CT scan of the brain reveals a likely dural-based MET (metastasis) in the left parietal lobe with some surrounding vasogenic edema.<\/p>\n
Review of Systems<\/p>\n
Constitutional: No fever\/chills, no weight loss\/gain
\nEyes: No double vision, no visual changes
\nENT: No hearing loss\/tinnitus, no nasal congestion
\nCardiovascular: No chest pain, no palpitations
\nRespiratory: No shortness of breath, no cough
\nGastrointestinal: No nausea\/vomiting, no diarrhea
\nGenitourinary: No urinary incontinence, no urinary difficulty
\nMusculoskeletal: No significant joint pain, no muscle cramps
\nSkin: No rashes, no abrasions
\nNeurological: No weakness, no numbness
\nPsychiatric: No depression, no anxiety, Cooperative.
\nEndocrine: No heat or cold intolerance, no change in appetite
\nHematologic\/Lymphatic: No easy bruising, no anemia
\nAllergic\/Immunologic: No allergic response to food, no swollen lymph nodes<\/p>\n
Physical Exam On arrival on 09\/30\/2022
\nGENERAL: No acute distress. Speech fluent.
\nCHEST: Breathing comfortably on room air.
\nCARDIOVASCULAR: Regular rate
\nSKIN: Intact.
\nEXTREMITIES: Well perfused
\nPSYCH: Appropriate
\nNEURO:
\nCN:
\nPeripheral fields intact
\nPupils equal, round, reactive to light
\nExtra-ocular movements intact
\nV1-V3 intact
\nFace symmetric
\nHearing grossly intact
\nPalatal elevation symmetric
\nShoulder shrug intact
\nTongue midline
\nMOTOR:
\n5\/5 Bilateral:
\nGrip
\nBicep
\nTricep
\nDorsiflexion
\nPlantarflexion
\nSENSATION: Intact to light touch
\nREFLEXES:
\nNo hoffman
\nPatellar reflexes 2+
\nCOORDINATION:
\nFinger to nose intact<\/p>\n
Assessment\/Plan
\nAdmit for left parietal MET
\nCT C\/A\/P to r\/o METS
\nMRI Brainlab Plus\/MRV
\nDecadron 4q6\/Famotidine for Edema
\nKeppra for Sz ppx
\nAcetaminophen\/Hydrocodone prn pain
\nNPO except MEDS\/ICU admit
\nSCDs for DVT ppx<\/p>\n
. Brain metastasis C79.31
\nOrdered:MRV Head wo Contrast<\/p>\n
Current diagnosis<\/p>\n
-Brain metastasis
\n-Metastatic basal cell carcinoma
\n-Pneumonia
\n– axillary mass
\n-cancer related pain
\nCerebral brain hemorrhage<\/p>\n
Problem List\/Past Medical History<\/p>\n
Ongoing
\nAcute hypoxemic respiratory failure<\/p>\n
Acute renal failure<\/p>\n
At risk for falls<\/p>\n
Axillary mass<\/p>\n
BCC (basal cell carcinoma), back<\/p>\n
Cancer related pain<\/p>\n
Cancer-related pain<\/p>\n
Diarrhea due to drug<\/p>\n
Diarrhea with dehydration<\/p>\n
Encounter for antineoplastic immunotherapy<\/p>\n
Encounter for immunotherapy<\/p>\n
Hyponatremia<\/p>\n
Joint pain<\/p>\n
Leukocytosis<\/p>\n
Metastasis to lung<\/p>\n
Metastatic basal cell carcinoma<\/p>\n
Obesity<\/p>\n
Pain<\/p>\n
Pericardial effusion<\/p>\n
Respiratory symptoms<\/p>\n
Systemic inflammatory response syndrome<\/p>\n
Tachypnea<\/p>\n
Wheezing on expiration<\/p>\n
Historical
\n2019 novel coronavirus<\/p>\n
Anxiety<\/p>\n
Clostridium difficile<\/p>\n
Clostridium difficile<\/p>\n
Cough<\/p>\n
Lung cancer<\/p>\n
Procedure\/Surgical History
\n\u2022EXCISION OF ILEUM, ENDO, DIAGN (04\/07\/2022)
\n\u2022EXCISION OF LARGE INTESTINE, ENDO, DIAGN (04\/07\/2022)
\n\u2022AMPUTATION TOE INTERPHALANGEAL JOINT (06\/25\/2020)
\n\u2022INTRODUCE OTH ANTINEOPLASTIC IN PERIPH VEIN, PERC (09\/08\/2019)
\n\u2022EXTRACTION OF RIGHT AXILLARY LYMPHATIC, PERC APPROACH, DIAGN (08\/23\/2019)<\/p>\n
Medications<\/p>\n
Inpatient
\nacetaminophen, 650 mg= 2 tab, PO, q4h, PRN<\/p>\n
Albuterol- Ipratropium 3ml soln, nebulizer q6h for cough<\/p>\n
Hydromorphone, 4mg 1 tab, PO , q8h prn, for pain<\/p>\n
Trazodone 50mg 1 tab PO, nightly for sleep<\/p>\n
Tamsulosin 0.8mg 2 caps, po nightly BPH<\/p>\n
Dextromethorphan , 10mg syrup , q6h for cough<\/p>\n
docusate-senna 50 mg-8.6 mg oral tablet, 2 tab, PO, 2x\/day<\/p>\n
Heparin 5000U, 1ml, inj SC q8hr for DVT prophylaxis<\/p>\n
labetalol, 10 mg= 2 mL, IV Push, q30min, PRN<\/p>\n
levETIRAcetam, 500 mg= 1 tab, PO, q12h for seizure<\/p>\n
Melatonin 6mg 2tab po nightly<\/p>\n
Pentoprazole 40mg 1tab po daily for Gerd<\/p>\n
amLODIPine, 5 mg= 1 tab, PO, Daily<\/p>\n
Allergies<\/p>\n
morphine (hallucinations)<\/p>\n
Social History<\/p>\n
Smoking Status
\nNever smoker<\/p>\n
Alcohol<\/p>\n
Use: Denies.<\/p>\n
Substance Use<\/p>\n
Use: Denies.<\/p>\n
Tobacco\/Nicotine<\/p>\n
Use: Denies.<\/p>\n
Family History
\nFather: Diabetes mellitus type 1
\nMother: Diabetes mellitus type 1<\/p>\n
Second copy<\/p>\n
Progress note where you can get more information<\/p>\n
Chief Complaint<\/p>\n
brain mass<\/p>\n
History of Present Illness<\/p>\n
48M PMH oculocutaneous albinism and metastatic basal cell carcinoma to the lungs and right axilla on chemo p\/w weakness, L temporal\/forehead pressure\/pain along with nausea x2-3 weeks. CTH demonstrates L parietal dural met with surrounding vasogenic edema. He was admitted to the Neuro ICU for further management and his hospital course is as follows:
\n9\/29: CTH completed – heterogeneous destructive soft tissue lesion centered in L parietal bone with intracranial\/superficial extension (likely metastasis)
\n9\/30: Decadron given. Keppra started. CT CAP completed – increased pulm nodules size, R axilla lymphadenopathy. Palliative consulted. Discussed CTH finding with patient’s outpatient Oncology, who states there are no medical tx available for the brain met and concur with surgical intervention where a craniotomy was done. LVNX started
\n10\/1: Echo EF 55-60%
\n10\/2: EGK obtained, MRI MRV completed
\n10\/3: BUE Dopplers negative. Medicine consult for surgical clearance. Surg Onc consult for right axilla mass
\n10\/4: Deemed Low Risk for OR a\/p medicine Cx. Surg Onc rec Rad Onc Cx as not surgical candidate for right axilla mass. Rad Onc Cx placed.
\n10\/6: Consent obtained for OR.
\n10\/7: OR left craniectomy for tumor resection, reconstructive cranioplasty
\n10\/8: MRI: post surgical changes, HMV d\/c
\n10\/9: PT: outpatient. Foley d\/c. void trial Transferred to 2F for floor care
\n10\/11: New headache. CTH completed – L parietal extracranial\/intracranial hematoma with R-ward shift. CT PE (-). Trop (-). ECG (-). RRT called. OR for L crani for EDH evacuation. Intraop TEG inhibited, received 1u plts.
\n10\/12: TEG completed – AA 92.2, ADP 47.6. CTH post-op changes. HSQ started. PO diet started.
\n10\/13: CTH stable, HMV drain dc’d, transferred down to Neuro IMC. CXR (-) for acute abnl. Covid (-). PT recommend outpt PT
\n10\/14: CTH completed – stable. Decadron x24h for headache. Final pathology: basal cell carcinoma
\n10\/16: Hgb 6.0, sp 2U PRBC, Lactate 1.1, started on empiric Vanc, Zosyn. Transferred to medicine team as primary.<\/p>\n
Oncologic history and How the Patient\u2019s disease process all started.<\/p>\n
He was initially diagnosed with basal cell carcinoma in the right forearm in 2011. This was treated with liquid nitrogen but he started developing more lesions through his body including a back lesion in 2013, which was treated with surgery. Over the course of the next year or two he developed more skin cancers all over the body including his arms and forearms, his shoulders, right face and also other part of the torso. It appears that all these lesions were removed by surgery but some may have been treated with cryotherapy. In 2018, he had chest x-ray for new cough and he was found to have at least two lung lesions. He had a biopsy done at the time (7\/2018) which showed metastatic basal cell carcinoma. He was started on Erivedge (Vismodegib) and he did not tolerate that drug. He was oxygen dependent and had hemoptysis in Aug 2019 and had improved respiratory status on high dose steroid with taper, received first dose of Keytruda (flat dose of 200mg IV q3weeks) on 9\/9\/2019 in the hospital and second dose onwards he was getting it outpatient at the infusion center. Progressed (only in the chest) in late fall of 2021 and on Nivolumab 400 mg\/Ipilimumab 1 mg\/kg salvage treatment q4w.<\/p>\n
As of April 2022 and after 3 cycles of nivolumab\/ipilimumab treatment (with response), he developed checkpoint inhibitor mediated autoimmune inflammatory bowel disease. He was admitted to the hospital with intense gastrointestinal management and on steroid in the form of methylprednisolone equivalent of 100 mg of prednisone (1mg\/kg), he improved along with Imodium and Reglan.<\/p>\n
Also during the hospitalization in April 2022, CT abdomen pelvis showed multiple spiculated pulmonary nodules and masslike areas of consolidation that were unchanged from recent. Patient underwent colonoscopy on 4\/7\/2022 that showed ileitis as well as colitis. Stool cultures were negative. He was placed on IV Solu-Medrol and was discharged on prednisone with tolerance.<\/p>\n
He has been evaluated by rad\/onc during this admission and recommended palliative XRT to right axilla which can be managed at a facility closer to his home in Maryland.<\/p>\n
On Assessment, he is resting in bed, accompanied by his mother in the room. He states that he has productive cough with yellow sputum that started 3 days ago. Denies hemoptysis, SOB at rest, chest pain, palpitations, nausea\/ vomiting, abd pain, diarrhea\/ constipation.<\/p>\n
Physical Exam
\nVitals & Measurements
\nT: 37 \u00b0C (Oral) TMIN: 36.6 \u00b0C (Oral) TMAX: 37.5 \u00b0C (Oral) HR: 97(Monitored) RR: 28 BP: 125\/60 SpO2: 96% WT: 91.5 kg<\/p>\n
Oxygen Delivery Device: Nasal cannula (10\/16\/22 04:00:00)
\nOxygen Flow Rate: 2 L\/min (10\/16\/22 04:00:00)<\/p>\n
Progress note for 10\/16\/2022<\/p>\n
General: Well developed, well nourished. Denies pain. Alert and oriented, no acute distress.
\nEye: Bilateral pupils appear red, round, equal and reactive to light bilaterally. Extraocular motions intact. No sinus tenderness. Sclera are non-icteric and the conjunctiva are pink bilaterally
\nHENT: Surgical staples noted on head. Normal hearing, moist oral mucosa. Oropharynx clear and without edema, injection nor exudate.
\nNeck: Supple, non-tender, with full range of motion, no carotid bruits, no JVD.
\nLungs: Good air entry bilaterally. Coarse breath sounds with L basilar crackles.
\nHeart or Cardiovascular: Normal rate, regular rhythm, no murmur, gallop or rub. There is no peripheral edema. Distal pulses strong and equal in all limbs.
\nAbdomen: Soft, supple, non-distended. No tenderness to palpation. Bowel sounds are present and normal. No masses or organomegaly noted.
\nMusculoskeletal: No gross deformity of extremities. All extremities move well with full range of motion and strength, no tenderness or swelling.
\nSkin: Skin is warm and dry. Albinism.
\nNeurologic: Awake, alert, and oriented to person, place and time. Cranial Nerves II-XII are grossly intact. Sensation to light touch intact. No focal motor deficits. Strength and sensation are intact without any focal deficit.
\nPsychiatric: Cooperative, appropriate mood, affect, and thought.<\/p>\n
Assessment\/Plan
\n48 yoM with PMH oculocutaneous albinism, metastatic basal cell carcinoma to lungs, R axilla and bones on Chemo, admitted on 9\/30 with newly diagnosed presumed left brain mets s\/p L craniectomy transferred to medicine primary team for management of productive cough concerning for HAP.<\/p>\n
#SIRS
\n#Productive Cough
\nPatient developed productive cough with yellowish thick sputum 3 days ago. He has been afebrile, but tachypneic, tachycardiac. Leukocytosis likely reactive post surgery is downtrending. CXR 10\/15 no new infiltrative process. UA wnl.
\nEtiology: concerning for HAP vs metastatic lung disease
\n– Continue Zosyn and Vanc (dosing by pharmacy)
\n– Continue Tessalon Perles, Robitussin 400mg Q4 PRN
\n– Continue Nebulizer treatment 4x\/day PRN
\n– MRSA swab
\n– Urine for strep pneumo\/ legionella
\n– Check procalcitonin
\n– F\/u sputum culture
\n– F\/u blood culture<\/p>\n
#L Brain Met 2\/2 basal cell lung CA s\/p Left craniotomy (10\/7) s\/p emergent hematoma evacuation 10\/11
\n– Continue care in Neuro ICU
\n– Q2h neuro checks, ok sleep protocol and q2h vital signs
\n– Continue Keppra 500mg BID for seizure ppx
\n– SBP goal 100-160
\n– Na goal normonatremia
\n– Repeat CTH Monday, ordered
\n– Final path shows metastatic basal cell carcinoma
\n– Palliative care onboard for GOC and symptom management
\nPain management:
\n– Short course Decadron completed 10\/16
\n– continue Fioricet PO q4h PRN
\n– continue oxycodone 5mg PO q4h PRN pain 1-4
\n– continue oxycodone 10 mg PO q4h PRN pain 5-10<\/p>\n
#R Axillary Mass
\n-Onc surgery consulted, not recommending surgery at this time
\n-Rad Onc on board, recommended XRT to the right axilla post resection of intracranial mass<\/p>\n
#Normocytic Anemia
\nLikely etiology of acute blood loss from recent surgeries in addition to anemia of chronic disease\/ metastatic malignancy
\nHb on 10\/16: 6, transfused 2u pRBC
\n– F\/u post transfusion hb
\n– F\/u ferritin, TIBC
\n– Transfuse goal Hb >7<\/p>\n
Code: Code Status Full Code – Ordered
\nDiet: Regular Diet – Ordered
\n— 10\/12\/22 8:51:00 EDT
\nDVT PPx: Heparin SC
\nGI PPx: Protonix
\nTele: Yes
\nRestraints: None
\nIsolation\/Precaution: None
\nL\/T\/D: Lines
\nPIV Forearm Left 20 G 2.5 cm – Peripheral IV Activity: Assessed (10\/16\/22 07:00:00)<\/p>\n
PIV Forearm Right 22 G 2.5 cm – Peripheral IV Activity: Assessed (10\/16\/22 12:00:00)<\/p>\n
Some Progress note about the patient 0n 10\/16\/22. Please take note of the new changes.<\/p>\n
48M PMH HNT, known lung cancer on 2 L nasal cannula (per chart, however per sister had not been on oxygen for the past couple months) w\/brain mets now s\/p hemicrani and repeat OR for hematoma 5 days ago, now ~2 days with chills, sweats, temperatures 99.9 \u00b0F, cough with yellowish thick sputum, fatigue, poor sleep, as well as hemoglobin dropped to 6 now getting 2 units PRBCs transfused by neurosurgery. Per patient and sister at bedside, the symptoms did not start when the patient was admitted or immediately after either operation, but 3 days after her last operation. Blood culture x1 sent, lower extremity Dopplers bilateral and FOBT ordered by neurosurgery team.<\/p>\n
BP:(93 – 136)\/(53 – 72)HR:(78 – 109)RR:(18 – 30)T:(36.60 – 37.50)<\/p>\n
General: Well developed, obese. Denies pain. NAD
\nEye: PERRL. No sinus tenderness, Normal appearing conjunctiva.
\nHENT: moist oral mucosa. Oropharynx clear and without edema, injection nor exudate. Thyroid not enlarged, large cranial scar with many stitches
\nNeck: non-tender, no LAD
\nLungs: On 2 L nasal cannula, crackles at left base, coarse breath sounds, coughing
\nHeart or Cardiovascular: RRR, no M\/R\/G. No JVD. Distal pulses strong and equal in all limbs.
\nAbdomen: Soft, non-distended. No tenderness to palpation. +BS. No masses or organomegaly noted.
\nMSK: no leg swelling
\nSkin: Skin is warm, dry. No rashes or lesions. Albinism
\nNeurologic: ANOx4
\nPsychiatric: Cooperative, appropriate mood, affect, and thought.<\/p>\n
Neuro\/Psych — No pain\/sedation, ANOX4
\nResp –2 L nasal cannula, increased oxygen requirements, no large changes in x-ray possible lobar pneumonia? On antibiotics follow-up cultures procalcitonin; nebulizer Tessalon Perles
\nCardio –NAI
\nInfect –possible pneumonia on top of known metastatic lung disease
\nGastro –NAI
\nGenitourinary\/Lytes — Dose medications to GFR.
\nHeme\/Onc –getting 2 units of PRBC, follow-up post transfusion CBC
\nEndo — BG goal 140-180 mg\/dl
\nIntegumentary –hemicrania scar<\/p>\n
Lab Results<\/p>\n
CBC 10\/16\/22 02:10 10\/14\/22 05:02 10\/13\/22 12:46
\nWBC 24.92H 31.13H 32.46H
\nHgb 6.0LC 7.3L 8.2L
\nHct 18.7LC 22.2L 24.5L
\nPlt 325 318 327<\/p>\n
BMP 10\/16\/22 02:10 10\/14\/22 05:02 10\/13\/22 03:53
\nSodium 137 130L 133L
\nPotassium 4.2 4.4 4.0
\nChloride 103 95L 98
\nCO2 31 28 30
\nBUN 9 10 12
\nCreatinine 0.70 0.63 0.64
\nGlucose Random 108 133 114<\/p>\n
COAG 10\/11\/22 20:21 10\/07\/22 03:52 09\/30\/22 00:44
\nPT 13.7 13.7 13.5
\nINR 1.0 1.0 1.0
\nPTT 26.7 36.2<\/p>\n
10\/21\/2022 (please these are the most current labs)<\/p>\n
WBC = 8.24, Hgb = 9.7L, Hct = 31.1L, platelet = 333, RBC = 3.57L, RDW = 17.1H,
\nSodium = 139, Potassium = 3.9, Chloride = 104, CO2 = 28L, BUN = 8L, Creatinine = 0.70, Glucose = 139, Total protein = 6.3, calcium = 8.9, Globulin = 2.6, AST = 41H, ALT = 64H<\/p>\n
Lactate (last 3 in 48H)
\nLactic Acid Lvl: 1.1 mmol\/L (10\/16\/22 02:10:00)
\nLactic Acid Lvl: 2.6 mmol\/L High (10\/15\/22 00:38:00)
\nLactic Acid Lvl: 2.8 mmol\/L High (10\/14\/22 21:29:00)<\/p>\n
Some full Diagnostic Results<\/p>\n
ult Type:\tCT Chest Abdomen Pelvis wo IV Contrast
\nResult Date:\tSeptember 30, 2022 03:42 EDT<\/p>\n
* Final Report *<\/p>\n
Reason For Exam
\nOther (Specify)
\nHISTORY: Brain\/CNS neoplasm, staging<\/p>\n
FINDINGS:
\nAnterior right shoulder skin nodularity is partially visualized. Right axillary nodule is 1.5 cm. Calcified mediastinal and hilar lymph nodes are unchanged. No pleural or pericardial effusion is seen. The heart is normal in size.<\/p>\n
The dominant bilateral pulmonary masses are grossly stable in size though some of the nodules have enlarged. For example, nodule at the right major fissure superiorly has enlarged from 3.9 to 4.6 cm. There is extensive new interstitial thickening and nodularity within the middle lobe. The left upper lobe and right lower lobe bronchi are occluded by masses.<\/p>\n
The unenhanced liver, gallbladder, spleen, pancreas, kidneys and adrenal glands are unremarkable.<\/p>\n
The unenhanced bowel is unremarkable. The urinary bladder is thick-walled and the prostate is enlarged at 6 cm transversely. Right mesenteric lymph nodes are mildly enlarged.<\/p>\n
No suspicious osseous lesions are identifie<\/p>\n
Result Type:\tMRI Brain wo w Contrast
\nResult Date:\tOctober 02, 2022 16:38 EDT<\/p>\n
Reason For Exam
\nOther (Specify)<\/p>\n
REPORT
\nEXAM: MRI Brain with and without Contrast:<\/p>\n
CLINICAL INDICATION: Lung cancer<\/p>\n
COMPARISON STUDY: CT dated September 29, 2022<\/p>\n
FINDINGS:<\/p>\n
A destructive lesion the left parietal calvarium is again seen. There is intra and extracranial extension. The lesion extends to the superior sagittal sinus but does not compromise its lumen. The intracranial extension measures at least 70 mm x 14 mm in depth. There is no significant edema of the underlying brain.<\/p>\n
Ventricles are normal in size and position.<\/p>\n
No Intra or extra-axial bleeding is noted. The orbits, sella, and craniocervical junction have a normal appearance. Normal signal void is seen in major arterial and dural venous structures.<\/p>\n
(10\/14\/2022 00:56 EDT CT Head wo Contrast)
\nEXAM: CT of the head without contrast
\nREASON FOR EXAMINATION:, Cranioplasty<\/p>\n
COMPARISON: October 13, 2022<\/p>\n
TECHNIQUE:<\/p>\n
Axial images were obtained from the skull base to the vertex without intravenous contrast.<\/p>\n
FINDINGS:<\/p>\n
Patient is status post resection of a bony metastatic lesion in the left parietal region with subsequent cranioplasty. A small amount of blood and surrounding edema is again seen beneath the anterior aspect of the cranioplasty. This measures approximately 10 mm.<\/p>\n
Ventricles are normal in size and position. There is no shift of midline structures.<\/p>\n
IMPRESSION:<\/p>\n
Stable study. [2]<\/p>\n
[1] XR Chest 1 View Portable; Ahn, MD, Julia Y. 10\/15\/2022 12:34 EDT<\/p>\n
[2] CT Head wo Contrast; Monsein, MD, Lee Haskell 10\/14\/2022 00:56 EDT<\/p>\n
(10\/15\/2022 12:34 EDT XR Chest 1 View Portable)
\nExam: Radiograph of the chest 1 view<\/p>\n
Indication:History of lung cancer<\/p>\n
Technique: Single frontal view of the chest<\/p>\n
Comparison: 10\/13\/2022<\/p>\n
Findings:Cardiac silhouette is mildly enlarged. Redemonstrated are nodular opacities in keeping with patient’s known metastatic lung disease. Redemonstrated are bilateral perihilar masses. Left lower lobe opacities present. No discernible pneumothorax. Osseous structures are unchanged.<\/p>\n
Impression:Stable examination. [1]<\/p>\n
–<\/p>\n","protected":false},"excerpt":{"rendered":"
History of Present Illness 09\/30\/2022 Patient is very nice 48 years old male with history of basal cell carcinoma of the lungs, on chemotherapy, presenting\u2026<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[7732,7731,7739,7735,7730,7734,7737,7740,7736,7733,7738,7741],"tags":[618,576,116,631,19,473,633,630,628,450,597,594,626,636,635,639,574,638,622,624,620,621,619,623,617,625,627,573,637,634,629,632],"class_list":["post-94253","post","type-post","status-publish","format-standard","hentry","category-apps-to-help-with-writing-assignment","category-assignment-help-in-australia","category-assignment-help-website","category-assignment-helpers-for-students","category-essay-writing","category-help-students-with-assignment","category-i-will-pay-someone-to-do-my-assignments","category-looking-for-someone-to-do-my-assignments","category-pay-someone-to-do-my-assignment","category-paying-someone-to-do-assignment","category-university-assignment-hacks","category-studybay","tag-assignment-writing-services-in-usa","tag-best-dissertation-writing-services","tag-best-essay-writing-service","tag-best-paper-writing-services","tag-best-research-paper-writing-services-in-usa","tag-cheap-essay-writing-service","tag-cheap-research-paper-writing-service","tag-college-paper-writing-service","tag-dissertation-help-online","tag-dissertation-writing-services","tag-dissertation-writing-services-illegal","tag-dissertation-writing-services-near-me","tag-dissertation-writing-services-usa","tag-essay-writer","tag-essay-writing-service","tag-essay-writing-service-usa","tag-free-dissertation-writing-services","tag-free-essay-writing-service","tag-homework-essay-writer","tag-homework-essay-writer-free","tag-homework-help-global","tag-homework-help-services","tag-homework-help-usa","tag-homework-writing-help","tag-homework-writing-service","tag-legit-research-paper-writing-services","tag-legitimate-dissertation-writing-services","tag-professional-essay-writers","tag-research-essay-pro","tag-research-paper-writer-online-free","tag-research-paper-writing-services-online","tag-research-paper-writing-websites"],"_links":{"self":[{"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/posts\/94253","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/comments?post=94253"}],"version-history":[{"count":0,"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/posts\/94253\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/media?parent=94253"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/categories?post=94253"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/tags?post=94253"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}