CHIEF COMPLAINT: Left forearm swelling

PRESENT ILLNESS: 58M otherwise healthy who developed atruamatic L elbow pain 4
days prior, which he states started on his funny bone. It made
it difficult to move his elbow, and it has gotten progressively
worse.  Last night he was seen at an outside hospital where he
had an Xray and labs. He was told he had an "orthopedic problem"
and was referred to a clinic and given pain medication.
Overnight
he developed fever (Tmax 103) and shaking chills, in addition to
N/V. The pain has continued to worsen and now he can barely move
his arm. He is unable to flex or extend his wrist or his elbow
secondary to pain. EMS was called this morning for worsening
symptoms and lightheadedness. In the field he was found to be
hypotensive to the 70s. On arrival to the ED he was
normotensive.
.
He denies recent trauma or similar pain in his elbow. He denies
a known bite or abrasion over his left forearm. He denies any
wounds in the area recently. He denies abdominal pain, chest
pain or shortness of breath. He states he had cold symptoms last
week, which are improving. He has a history of bursitis in this
elbow approximatey 2 years ago, which resolved on it's own.

MEDICAL HISTORY: Esophageal ulcer (negative biosy)
.
PSH: s/p transphenoid pituitary tumor removal

MEDICATION ON ADMISSION: nexium

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: PE:
99.2-->103 100 110/62 16 99% RA
General: A&O x 3, Calm, Resting in bed.
EXT: He is uncomfortable with any movement of LUE. Skin over
medial aspect of extensor surface of forewarm erythematous and
edematous. No fluctuance noted. Tenderness over that area to
light touch. Compartment tense. Elbow held at approximately 80
degrees able to extend minimally with severe pain. Pain with
wrist extension and flexion. Grasp weak [**2-15**] pain. Capillary
refill <2 secs in all extremities. No bony tenderness in elbow.
No apparent joint effusion or significant bursa swelling.
Radial,
Median, Ulnar SILT. 2+ radial pulses.

FAMILY HISTORY: N/C

SOCIAL HISTORY: No Tob/EtOH/IVDU.  Works at a desk job
Necrotizing fasciitis,Toxic shock syndrome,Nontraumatic compartment syndrome of upper extremity,Cellulitis and abscess of upper arm and forearm,Acute kidney failure, unspecified,Cardiac complications, not elsewhere classified,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group A,Other specified hypotension,Dehydration,Other abnormal glucose,Atrial fibrillation,Other restorative surgery causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Barrett's esophagus,Personal history of benign neoplasm of the brain,Personal history of other malignant neoplasm of skin
Necrotizing fasciitis,Toxic shock syndrome,Nontraum comp syn-up ext,Cellulitis of arm,Acute kidney failure NOS,Surg compl-heart,Streptococcus group a,Hypotension NEC,Dehydration,Abnormal glucose NEC,Atrial fibrillation,Abn react-plast surg NEC,Barrett's esophagus,Hx benign neoplasm brain,Hx-skin malignancy NEC
Admission Date:  [**2141-4-24**]              Discharge Date:   [**2141-5-3**]

Date of Birth:  [**2083-4-23**]             Sex:   M

Service: PLASTIC

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 7733**]
Chief Complaint:
Left forearm swelling


Major Surgical or Invasive Procedure:
s/p multiple incision and drainage, left forearm split thickness
skin graft (donor site - L thigh) with wound vac application:
.
[**2141-4-24**]
1. Decompression fasciotomy, left arm, with epimysiotomy of
    all muscle groups.
2. Decompression fasciotomy, left forearm, epimysiotomy of
    all muscle groups.
3. Left open carpal tunnel release.
4. Application of vacuum-assisted closure dressing.
.
[**2141-4-26**]
1. Dressing change, debridement left forearm, soft tissue
    only.
2. Pulse irrigation and application of vac dressing.
.
[**2141-4-27**]
1. Irrigation and debridement of left arm wound 40 x 15 cm.
2. Placement of vacuum-assisted sponge 14 x 15 cm.
.
[**2141-4-29**]
1. Irrigation and debridement, left arm wound.
2. Partial wound closure, left arm.
3. VAC dressing change.
.
[**2141-5-1**]
1. Debridement left forearm.
2. Split-thickness skin graft left forearm (30 cm x 9.0
    cm).
3. Application of VAC dressing.


History of Present Illness:
58M otherwise healthy who developed atruamatic L elbow pain 4
days prior, which he states started on his funny bone. It made
it difficult to move his elbow, and it has gotten progressively
worse.  Last night he was seen at an outside hospital where he
had an Xray and labs. He was told he had an "orthopedic problem"
and was referred to a clinic and given pain medication.
Overnight
he developed fever (Tmax 103) and shaking chills, in addition to
N/V. The pain has continued to worsen and now he can barely move
his arm. He is unable to flex or extend his wrist or his elbow
secondary to pain. EMS was called this morning for worsening
symptoms and lightheadedness. In the field he was found to be
hypotensive to the 70s. On arrival to the ED he was
normotensive.
.
He denies recent trauma or similar pain in his elbow. He denies
a known bite or abrasion over his left forearm. He denies any
wounds in the area recently. He denies abdominal pain, chest
pain or shortness of breath. He states he had cold symptoms last
week, which are improving. He has a history of bursitis in this
elbow approximatey 2 years ago, which resolved on it's own.


Past Medical History:
Esophageal ulcer (negative biosy)
.
PSH: s/p transphenoid pituitary tumor removal

Social History:
No Tob/EtOH/IVDU.  Works at a desk job


Family History:
N/C

Physical Exam:
PE:
99.2-->103 100 110/62 16 99% RA
General: A&O x 3, Calm, Resting in bed.
EXT: He is uncomfortable with any movement of LUE. Skin over
medial aspect of extensor surface of forewarm erythematous and
edematous. No fluctuance noted. Tenderness over that area to
light touch. Compartment tense. Elbow held at approximately 80
degrees able to extend minimally with severe pain. Pain with
wrist extension and flexion. Grasp weak [**2-15**] pain. Capillary
refill <2 secs in all extremities. No bony tenderness in elbow.
No apparent joint effusion or significant bursa swelling.
Radial,
Median, Ulnar SILT. 2+ radial pulses.


Pertinent Results:
Pathology Examination

Name Birthdate    Age     Sex Pathology #     [**Hospital1 18**] [**Known lastname 76008**],[**Known firstname **]       [**2083-4-23**]    58 Male      [**Numeric Identifier 76009**] [**Numeric Identifier 76010**]
Report to:   DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by:   DR. [**Last Name (STitle) **]. [**Hospital1 **]/dif
.
SPECIMEN SUBMITTED: TENOSYNOVIUM CARPAL CANAL LEFT (1 VIAL),
Forearm Fascia, Tenosynovium Carpal Canal , Forearm muscle.
Procedure date     Tissue received     Report Date    Diagnosed
by
[**2141-4-24**] [**2141-4-25**] [**2141-4-27**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 2336**]/ttl
Previous biopsies:    [**Numeric Identifier 76011**]  GI BX (6 jars)
DIAGNOSIS:
I.  Tenosynovium, carpal canal (A):
Fibrous tissue with edema and acute inflammation; focal necrosis
and bacterial forms.
II.  Left forearm fascia (B-E):
1.  Fibroadipose and fascial type tissue with extensive necrosis
and acute inflammation.
2.  Tissue Gram's stain reveals numerous Gram's positive cocci.
III.  Left forearm muscle (F-G):
1.  Fibrous tissue and skeletal muscle with extensive necrosis
and acute inflammation.
2.  Tissue Gram's stain reveals numerous Gram's positive cocci.
IV.  Tenosynovium carpal canal (H):
Fibroadipose tissue with edema and acute inflammation; focal
necrosis and bacterial forms.
.
[**2141-4-24**]
LEFT ELBOW THREE VIEWS; FOREARM, TWO VIEWS
FINDINGS: No fracture or dislocation identified. No effusions,
subcutaneous
gas or radiopaque foreign body identified. No suspicious blastic
or lytic
lesions.
IMPRESSION: No acute process. No fracture or dislocation.
.
Final Report
CT SCAN OF THE LEFT ARM PERFORMED ON [**2141-4-24**]
Comparison with a radiograph from same day.

IMPRESSION: Diffuse edema in the left forearm, which is notable
in the deep fascial compartments which raises concern for
compartment syndrome. Please correlate clinically. No soft
tissue gas or drainable fluid collection.
.
[**2141-4-24**] 7:30 pm SWAB      LEFT FOREARM FASCIA.

                            **FINAL REPORT [**2141-4-28**]**

   GRAM STAIN (Final [**2141-4-24**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      3+  (5-10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS.

   WOUND CULTURE (Final [**2141-4-26**]):
      BETA STREPTOCOCCUS GROUP A.    MODERATE GROWTH.

   ANAEROBIC CULTURE (Final [**2141-4-28**]):    NO ANAEROBES ISOLATED.


[**2141-4-24**] 8:30 pm TISSUE      LEFT FOREARM FAT.

                            **FINAL REPORT [**2141-4-28**]**

   GRAM STAIN (Final [**2141-4-24**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS.

   TISSUE (Final [**2141-4-27**]):
      BETA STREPTOCOCCUS GROUP A.
         SPARSE GROWTH OF TWO COLONIAL MORPHOLOGIES.

   ANAEROBIC CULTURE (Final [**2141-4-28**]):    NO ANAEROBES ISOLATED.
.
[**2141-4-24**] 7:30 pm TISSUE      LEFT FOREARM FASCIA #2.

                            **FINAL REPORT [**2141-4-28**]**

   GRAM STAIN (Final [**2141-4-24**]):
      Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 76012**] #[**Numeric Identifier 76013**] @2210,
[**2141-4-24**].
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      3+  (5-10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS.

   TISSUE (Final [**2141-4-27**]):
      BETA STREPTOCOCCUS GROUP A.    SPARSE GROWTH.
         IDENTIFICATION PERFORMED ON CULTURE # [**Numeric Identifier 76014**]
([**2141-4-24**]).

   ANAEROBIC CULTURE (Final [**2141-4-28**]):    NO ANAEROBES ISOLATED.

.
[**2141-4-24**] 7:30 pm TISSUE      LEFT FOREARM FASCIA #1.

                            **FINAL REPORT [**2141-4-28**]**

   GRAM STAIN (Final [**2141-4-24**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      4+   (>10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS.

   TISSUE (Final [**2141-4-27**]):
      BETA STREPTOCOCCUS GROUP A.    MODERATE GROWTH.
         IDENTIFICATION PERFORMED ON CULTURE #  [**Numeric Identifier 76014**]
[**2141-4-24**].

   ANAEROBIC CULTURE (Final [**2141-4-28**]):    NO ANAEROBES ISOLATED.

.
[**2141-4-24**] 8:45 pm TISSUE      TENOSYNOVIUM CARPAL CANAL - L.

                            **FINAL REPORT [**2141-4-28**]**

   GRAM STAIN (Final [**2141-4-24**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS.

   TISSUE (Final [**2141-4-27**]):
      BETA STREPTOCOCCUS GROUP A.    RARE GROWTH.
         SENSI REQUESTED BY DR. [**Last Name (STitle) **],[**Doctor First Name 2482**] [**2141-4-26**].
         Sensitivity testing performed by Sensititre.
         CLINDAMYCIN.         <=0.12MCG/ML.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             BETA STREPTOCOCCUS GROUP A
                             |
CLINDAMYCIN-----------       S
ERYTHROMYCIN----------<=0.25 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------   <=1 S

   ANAEROBIC CULTURE (Final [**2141-4-28**]):    NO ANAEROBES ISOLATED
.
[**2141-4-27**] 11:41 pm TISSUE      LEFT UPPER EXTREMITY.

                            **FINAL REPORT [**2141-5-2**]**

   GRAM STAIN (Final [**2141-4-28**]):
      THIS IS A CORRECTED REPORT [**2141-4-30**].
      Reported to and read back by DR [**Last Name (NamePattern4) 76015**] [**2141-4-30**] 330PM.
      3+  (5-10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      4+   (>10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND IN SHORT
CHAINS.
      PREVIOUSLY REPORTED AS ([**2141-4-28**]).
      3+  (5-10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      4+   (>10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND IN SHORT
CHAINS.
      2+   (1-5 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      Reported to and read back by [**First Name5 (NamePattern1) 76016**] [**Last Name (NamePattern1) 76017**] 0335 ON
[**2141-4-28**].

   TISSUE (Final [**2141-5-1**]):
      BETA STREPTOCOCCUS GROUP A.    HEAVY GROWTH.
         IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 76018**]
         ([**2141-4-24**]).

   ANAEROBIC CULTURE (Final [**2141-5-2**]):    NO ANAEROBES ISOLATED.
.
[**2141-5-1**] 3:36 pm SWAB      LEFT FOREARM.

   GRAM STAIN (Final [**2141-5-1**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.

   WOUND CULTURE (Preliminary):    NO GROWTH.

   ANAEROBIC CULTURE (Preliminary):
.
ECHO - [**2141-4-27**]:
Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Transmitral and tissue
Doppler imaging suggests normal diastolic function, and a normal
left ventricular filling pressure (PCWP<12mmHg). There is no
ventricular septal defect. Right ventricular chamber size is
normal. with borderline normal free wall function. The aortic
root is mildly dilated at the sinus level. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.

IMPRESSION: Normal regional and global left ventricular systolic
function. Borderline normal RV function. No significant valvular
abnormality seen
.
Final Report
PORTABLE CHEST [**2141-4-30**]
CLINICAL INFORMATION: Infection, PICC placement.

FINDINGS:

Frontal view of the chest demonstrates a right-sided PICC
terminating at the cavoatrial junction. There is a patchy
airspace consolidation at the right lung base. There is
atelectasis at the left lung base. There is mild
eventration of the right hemidiaphragm. Remainder of the lungs
is relatively clear. Heart and mediastinum are stable.

[**2141-4-24**] 09:25AM BLOOD WBC-27.5* RBC-4.92 Hgb-15.4 Hct-44.1
MCV-90 MCH-31.3 MCHC-35.0 RDW-12.1 Plt Ct-351
[**2141-4-24**] 02:27PM BLOOD WBC-21.6* RBC-4.21* Hgb-13.3* Hct-38.4*
MCV-91 MCH-31.6 MCHC-34.7 RDW-12.1 Plt Ct-259
[**2141-4-24**] 09:56PM BLOOD WBC-23.7* RBC-4.16* Hgb-13.3* Hct-37.9*
MCV-91 MCH-31.9 MCHC-35.1* RDW-12.4 Plt Ct-302
[**2141-4-25**] 02:21AM BLOOD WBC-21.3* RBC-3.63* Hgb-11.4* Hct-33.0*
MCV-91 MCH-31.4 MCHC-34.6 RDW-12.3 Plt Ct-249
[**2141-4-25**] 05:00PM BLOOD WBC-23.2* RBC-3.91* Hgb-12.4* Hct-35.6*
MCV-91 MCH-31.8 MCHC-35.0 RDW-12.6 Plt Ct-290
[**2141-4-26**] 04:46AM BLOOD WBC-29.0* RBC-3.89* Hgb-12.2* Hct-35.3*
MCV-91 MCH-31.3 MCHC-34.5 RDW-12.4 Plt Ct-307
[**2141-4-27**] 03:24AM BLOOD WBC-29.5* RBC-3.59* Hgb-11.4* Hct-32.2*
MCV-90 MCH-31.7 MCHC-35.4* RDW-12.6 Plt Ct-302
[**2141-4-28**] 01:32AM BLOOD WBC-15.8* RBC-3.72* Hgb-11.5* Hct-33.9*
MCV-91 MCH-31.0 MCHC-34.1 RDW-12.7 Plt Ct-289
[**2141-4-29**] 05:45AM BLOOD WBC-15.3* RBC-3.88* Hgb-12.0* Hct-35.4*
MCV-91 MCH-31.0 MCHC-34.1 RDW-12.9 Plt Ct-355
[**2141-4-30**] 05:50AM BLOOD WBC-15.3* RBC-3.65* Hgb-11.4* Hct-33.1*
MCV-91 MCH-31.2 MCHC-34.4 RDW-13.2 Plt Ct-309
[**2141-5-1**] 05:52AM BLOOD WBC-14.1* RBC-3.69* Hgb-11.6* Hct-33.8*
MCV-92 MCH-31.5 MCHC-34.4 RDW-13.5 Plt Ct-329
[**2141-5-2**] 04:30AM BLOOD WBC-12.3* RBC-3.72* Hgb-11.5* Hct-34.3*
MCV-92 MCH-31.0 MCHC-33.6 RDW-13.6 Plt Ct-383
[**2141-4-24**] 09:25AM BLOOD Neuts-77* Bands-19* Lymphs-2* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2141-4-25**] 02:21AM BLOOD Neuts-80* Bands-9* Lymphs-4* Monos-3
Eos-0 Baso-0 Atyps-2* Metas-2* Myelos-0
[**2141-4-25**] 05:00PM BLOOD Neuts-97* Bands-1 Lymphs-1* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2141-4-26**] 04:46AM BLOOD Neuts-89* Bands-5 Lymphs-2* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2141-4-28**] 01:32AM BLOOD Neuts-76* Bands-1 Lymphs-15* Monos-3
Eos-0 Baso-0 Atyps-3* Metas-1* Myelos-1*
[**2141-4-29**] 05:45AM BLOOD Neuts-59 Bands-8* Lymphs-13* Monos-4
Eos-2 Baso-0 Atyps-2* Metas-8* Myelos-4*
[**2141-5-1**] 05:52AM BLOOD Neuts-60 Bands-2 Lymphs-23 Monos-7 Eos-1
Baso-0 Atyps-0 Metas-4* Myelos-2* Promyel-1*
[**2141-5-2**] 04:30AM BLOOD Neuts-66 Bands-5 Lymphs-18 Monos-7 Eos-2
Baso-0 Atyps-1* Metas-1* Myelos-0
[**2141-4-24**] 09:25AM BLOOD ESR-51*
[**2141-4-26**] 12:51PM BLOOD ESR-78*
[**2141-4-24**] 09:25AM BLOOD PT-13.5* PTT-20.4* INR(PT)-1.2*
[**2141-4-24**] 09:56PM BLOOD PT-15.7* PTT-31.2 INR(PT)-1.4*
[**2141-4-25**] 02:21AM BLOOD PT-16.2* PTT-31.8 INR(PT)-1.4*
[**2141-4-25**] 10:46PM BLOOD PT-14.3* PTT-30.0 INR(PT)-1.2*
[**2141-4-27**] 03:24AM BLOOD PT-13.0 PTT-26.2 INR(PT)-1.1
[**2141-4-28**] 01:32AM BLOOD PT-13.4 PTT-24.4 INR(PT)-1.1
[**2141-4-24**] 09:25AM BLOOD Glucose-97 UreaN-23* Creat-1.8* Na-137
K-4.4 Cl-96 HCO3-23 AnGap-22*
[**2141-4-24**] 02:27PM BLOOD Glucose-94 UreaN-20 Creat-1.4* Na-138
K-4.2 Cl-104 HCO3-19* AnGap-19
[**2141-4-24**] 09:56PM BLOOD Glucose-100 UreaN-20 Creat-1.2 Na-138
K-4.7 Cl-104 HCO3-20* AnGap-19
[**2141-4-25**] 02:21AM BLOOD Glucose-90 UreaN-17 Creat-1.0 Na-135
K-4.3 Cl-105 HCO3-20* AnGap-14
[**2141-4-25**] 05:00PM BLOOD Glucose-167* UreaN-17 Creat-1.2 Na-133
K-4.3 Cl-94* HCO3-23 AnGap-20
[**2141-4-25**] 10:46PM BLOOD Glucose-111* UreaN-20 Creat-1.1 Na-132*
K-4.4 Cl-100 HCO3-26 AnGap-10
[**2141-4-26**] 04:46AM BLOOD Glucose-134* UreaN-20 Creat-1.1 Na-130*
K-4.4 Cl-98 HCO3-28 AnGap-8
[**2141-4-26**] 12:51PM BLOOD Glucose-89 UreaN-20 Creat-1.0 Na-134
K-4.2 Cl-100 HCO3-25 AnGap-13
[**2141-4-27**] 03:24AM BLOOD Glucose-97 UreaN-17 Creat-0.9 Na-135
K-3.6 Cl-101 HCO3-26 AnGap-12
[**2141-4-28**] 01:32AM BLOOD Glucose-94 UreaN-20 Creat-0.8 Na-139
K-3.3 Cl-105 HCO3-27 AnGap-10
[**2141-4-30**] 05:50AM BLOOD Glucose-135* UreaN-12 Creat-0.8 Na-139
K-3.9 Cl-107 HCO3-26 AnGap-10
[**2141-5-1**] 05:52AM BLOOD Glucose-97 UreaN-17 Creat-0.9 Na-139
K-4.5 Cl-106 HCO3-26 AnGap-12
[**2141-4-24**] 09:25AM BLOOD CK(CPK)-154
[**2141-4-25**] 02:21AM BLOOD ALT-334* AST-204* LD(LDH)-200
AlkPhos-198* TotBili-2.6*
[**2141-4-25**] 05:00PM BLOOD ALT-300* AST-151* LD(LDH)-240
CK(CPK)-562* AlkPhos-203* TotBili-2.7*
[**2141-4-25**] 10:46PM BLOOD CK(CPK)-581*
[**2141-4-27**] 03:24AM BLOOD ALT-173* AST-93* AlkPhos-298*
TotBili-3.1* DirBili-2.4* IndBili-0.7
[**2141-4-28**] 01:32AM BLOOD ALT-152* AST-176* AlkPhos-369*
TotBili-1.8*
[**2141-4-29**] 05:45AM BLOOD ALT-144* AST-153* LD(LDH)-381*
AlkPhos-427* TotBili-1.1
[**2141-5-2**] 04:00PM BLOOD ALT-90* AST-77* LD(LDH)-282* AlkPhos-331*
TotBili-0.6
[**2141-4-27**] 03:24AM BLOOD GGT-138*
[**2141-4-29**] 05:45AM BLOOD Lipase-122*
[**2141-4-24**] 02:27PM BLOOD Calcium-7.1* Phos-3.2 Mg-1.3*
[**2141-4-24**] 09:56PM BLOOD Calcium-7.3* Phos-5.1*# Mg-2.4
[**2141-4-25**] 02:21AM BLOOD Albumin-2.3* Calcium-7.0* Phos-3.5#
Mg-2.1
[**2141-4-25**] 05:00PM BLOOD Albumin-2.6* Calcium-7.4* Phos-2.6*
Mg-2.4
[**2141-4-25**] 10:46PM BLOOD Calcium-7.7* Phos-2.7 Mg-2.6
[**2141-4-26**] 04:46AM BLOOD Calcium-7.8* Phos-3.2 Mg-2.7*
[**2141-4-27**] 03:24AM BLOOD Calcium-7.6* Phos-2.5* Mg-2.5
[**2141-4-29**] 05:45AM BLOOD Calcium-7.5* Phos-3.8 Mg-2.0
[**2141-4-30**] 05:50AM BLOOD Calcium-7.4* Phos-4.7* Mg-1.9
[**2141-5-1**] 05:52AM BLOOD Calcium-7.9* Phos-4.3 Mg-2.0
[**2141-4-29**] 05:45AM BLOOD Free T4-0.92*
[**2141-4-27**] 03:24AM BLOOD TSH-0.20*
[**2141-4-29**] 05:45AM BLOOD TSH-1.8
[**2141-4-25**] 05:00PM BLOOD Vanco-8.8*
[**2141-4-24**] 09:48AM BLOOD Lactate-7.2*
[**2141-4-24**] 11:31AM BLOOD Lactate-3.9*
[**2141-4-24**] 09:58PM BLOOD Lactate-4.9*
[**2141-4-25**] 02:50AM BLOOD Lactate-3.8*


Brief Hospital Course:
This is a 58 year-old Male who initially presented with 3-days
of left forearm swelling, redness and pain associatd with fevers
for one day. He noted the onset of bilateral axilla erythema for
2-weeks after having upper respiratory symptoms including
congestion and cough. Three days prior to presentation, the
patient developed severe left arm pain and erythema, targeting
elbow and forearm, associated with intermittent paresthesias of
the left hand. He then reported the onset of high fever, nausea
and vomiting on the night prior to arrival. He presented to the
[**Hospital1 18**] ED where his labs were notable for a lactate of 7.2, he
had evidence of mild renal insufficiency with a creatinine of
1.8 and a WBC to 27.5. He received 4L of IVF's. X-ray of the
extremity was performed and was negative for gas. CT of the
extremity was performed which showed deep fascial edema
concerning for impending compartment symdrome, without gas.

NEURO/PAIN: The patient was maintained on IV pain medication in
the immediate post-operative periods and transitioned to PO
narcotic medication with adequate pain control on POD#9 from his
initial surgical procedure. The patient remained neurologically
intact and without change from baseline. The patient remained
alert and oriented to person, location and place.

CARDIOVASCULAR: The patient remained hemodynamically stable
intra-op and in the immediate post-operative period. He did,
however, develop intermittent, paroxysmal atrial fibrillation
following his first surgical procedure with rapid ventricular
repsonse refractory to medical treatment initially with
Lopressor and Diltiazem. He Cardiology had been consulted,
recommending an Amiodarone gtt which was discontinued following
his initial procedure and following an oral loading dose. He
remains on Amiodarone, and will follow-up with cardiology as an
outpatient. He had no further episodes of atrial fibrillation
from POD#[**5-22**]. Vitals signs were closely monitored via telemetry.
He remained hemodynamically stable throughout his stay.

RESPIRATORY: The patient was extubated POD#1 from his initial
procedure, successfully. The patient had no episodes of
desaturation or pulmonary concerns. The patient denied cough or
respiratory symptoms. Pulse oximetry was monitored closely and
the patient maintained adequate oxygenations. He was extubated
without issue following his washout and debridements in the
operating room.

GASTROINTESTINAL: The patient was NPO following their procedure
and transitioned to sips and a clear liquid diet on POD#0 from
each procedure, again being made NPO past midnight for his
following procedure. The patient experienced no nausea or
vomiting. The patient was transitioned to a regular diet on
POD#[**8-22**] and IV fluids were discontinued once adequate PO intake
was established.

GENITOURINARY: The patient's urine output was closely monitored
in the immediate post-operative period. A Foley catheter was not
required and the patient was able to successfully void without
issue. The patient's intake and output was closely monitored for
> 30 mL per hour output. The patient's creatinine was 1.8, with
evidence of acute renal insufficiency on admission, however,
this improved with adequate hydration. His creatinine normalized
to 0.9 prior to discharge.

HEME: The patient remained hemodynamically stable and did not
require transfusion. The patient's coagulation profile remained
normal. The patient had no evidence of bleeding from their
incision. His hematocrit remained stable.

ID: The patient was admitted with concerns of acute compartment
syndrome versus necrotizing fasciitis. For this, he was
emergently brought to the operating room for left forearm
fasciotomy and VAC placement. At the time of his procedure,
infectious disease physicians were notified and he was
empirically begun on IV Vancomycin, Clindamycin and Zosyn. His
OR wound cultures initially speciated Beta Streptococcus group
A, as did all following cultures. He was taken to the operating
room on HOD#2, 3, 5 and 7 for subsequent debridements and
washouts with a final procedure on [**2141-5-1**] consisting of a left
forarm I&D, split thickness skin graft from the left thigh and
VAC placement. Infectious disease specialists continued to
follow the patinet, as his antibiotics were tapered to IV
Ceftriaxone 2 g IV Q24 hours. His WBC on admission was 27 and
fell steadily to around a WBC 12 prior to discharge. Serial arm
and hand examinations were continuously performed, yielding
steady improvement. His arm remained elevated, in a volar
resting splint and sling, in an elevated position at all times.

ENDOCRINE: The patient's blood glucose was closely monitored in
the post-op period with Q6 hour glucose checks. Blood glucose
levels greater than 120 mg/dL were addressed with an insulin
sliding scale.

PROPHYLAXIS: The patient was maintained on heparin 5000 units SQ
TID for DVT/PE prophylaxis and encouraged to ambulate
immediately post-op. The patient also had sequential compression
boot devices in place during immobilization to promote
circulation. The patient was encouraged to utilize incentive
spirometry, ambulate early and was discharged in stable
condition.

Medications on Admission:
nexium

Discharge Medications:
1. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day): Apply to underarms.
Disp:*1 Bottle* Refills:*1*
2. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO daily ().
3. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
One (1)  Intravenous Q24H (every 24 hours) for 5 days: last dose
[**2141-5-8**].
Disp:*5 solutions* Refills:*0*
4. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*1*
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*2*
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever: Max 12/day. Do not exceed
4gms/4000mgs of tylenol per day.
9. Outpatient Lab Work
Please draw the following labs on [**2141-5-8**]:
1) CBC w/diff
2) BUN/Cr
3) LFTs
Please fax results to Dr.[**Name (NI) 23346**] office, fax #: [**Telephone/Fax (1) 76019**]


Discharge Disposition:
Home With Service

Facility:
Critical Care Systems

Discharge Diagnosis:
Necrotizing fasciitis, left arm: BETA STREPTOCOCCUS GROUP A


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Your wound vac to your left arm skin graft site should stay
intact until Tuesday, [**5-9**], when you.  Please keep suction
at 125 mmHg.
.
You may maintain your left arm in a sling for comfort and you
should always wear your orthoplast splint.  You should continue
to actively move your fingers so that they don't become stiff.
.
You should continue to leave your left thigh donor site open to
air to dry it out.  The yellow dressings should stay in place
and dry out like a scab.  Do not get this area wet until cleared
by Dr. [**Last Name (STitle) 5385**].
.
Please follow up with your primary care physician within one
week of discharge.  You had an occurrence of atrial fibrillation
while an inpatient, and you are being discharged on Lopressor.
This needs to be managed by your PCP.
.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered.
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging. Please note that
Percocet and Vicodin have Tylenol as an active ingredient so do
not take these meds with additional Tylenol.
3. Take prescription pain medications for pain not relieved by
tylenol.
4. Your antibiotic will be given IV until [**2141-5-8**] when you will
receive your last dose.
5. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
6. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical sites, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or drain(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness,swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.


Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) 5385**]: ([**2141**]
for this Tuesday, [**2141-5-9**] at 3:30PM to have wound vac dressing
removed. Dr. [**Last Name (STitle) 5385**] is located at:
[**Apartment Address(1) 76020**]
[**Location (un) 55**], [**Numeric Identifier 3883**]
.
Please schedule a follow up with your Primary Care Provider to
[**Name9 (PRE) 76021**] the need for your 'lopressor' medication used to help
prevent the recurrence of 'atrial fibrillation' that you
experienced while you were in the hospital.  [**Last Name (LF) 76022**],[**First Name3 (LF) 8694**] C.
[**Telephone/Fax (1) 2115**]



                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 7738**]
{"Necrotizing fasciitis,Toxic shock syndrome,Nontraumatic compartment syndrome of upper extremity,Cellulitis and abscess of upper arm and forearm,Acute kidney failure, unspecified,Cardiac complications, not elsewhere classified,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group A,Other specified hypotension,Dehydration,Other abnormal glucose,Atrial fibrillation,Other restorative surgery causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Barrett's esophagus,Personal history of benign neoplasm of the brain,Personal history of other malignant neoplasm of skin"}


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: Left forearm swelling

PRESENT ILLNESS: 58M otherwise healthy who developed atruamatic L elbow pain 4
days prior, which he states started on his funny bone. It made
it difficult to move his elbow, and it has gotten progressively
worse.  Last night he was seen at an outside hospital where he
had an Xray and labs. He was told he had an "orthopedic problem"
and was referred to a clinic and given pain medication.
Overnight
he developed fever (Tmax 103) and shaking chills, in addition to
N/V. The pain has continued to worsen and now he can barely move
his arm. He is unable to flex or extend his wrist or his elbow
secondary to pain. EMS was called this morning for worsening
symptoms and lightheadedness. In the field he was found to be
hypotensive to the 70s. On arrival to the ED he was
normotensive.
.
He denies recent trauma or similar pain in his elbow. He denies
a known bite or abrasion over his left forearm. He denies any
wounds in the area recently. He denies abdominal pain, chest
pain or shortness of breath. He states he had cold symptoms last
week, which are improving. He has a history of bursitis in this
elbow approximatey 2 years ago, which resolved on it's own.

MEDICAL HISTORY: Esophageal ulcer (negative biosy)
.
PSH: s/p transphenoid pituitary tumor removal

MEDICATION ON ADMISSION: nexium

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: PE:
99.2-->103 100 110/62 16 99% RA
General: A&O x 3, Calm, Resting in bed.
EXT: He is uncomfortable with any movement of LUE. Skin over
medial aspect of extensor surface of forewarm erythematous and
edematous. No fluctuance noted. Tenderness over that area to
light touch. Compartment tense. Elbow held at approximately 80
degrees able to extend minimally with severe pain. Pain with
wrist extension and flexion. Grasp weak [**2-15**] pain. Capillary
refill <2 secs in all extremities. No bony tenderness in elbow.
No apparent joint effusion or significant bursa swelling.
Radial,
Median, Ulnar SILT. 2+ radial pulses.

FAMILY HISTORY: N/C

SOCIAL HISTORY: No Tob/EtOH/IVDU.  Works at a desk job 

### Response:
{"Necrotizing fasciitis,Toxic shock syndrome,Nontraumatic compartment syndrome of upper extremity,Cellulitis and abscess of upper arm and forearm,Acute kidney failure, unspecified,Cardiac complications, not elsewhere classified,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group A,Other specified hypotension,Dehydration,Other abnormal glucose,Atrial fibrillation,Other restorative surgery causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Barrett's esophagus,Personal history of benign neoplasm of the brain,Personal history of other malignant neoplasm of skin"}
