Marcus Vale
Admission Snapshot
Chief Complaint
“My leg feels like something is tearing through it. I can’t put weight on it, I’m shaking, and I almost passed out.”
Marcus presents with rapidly worsening right-leg pain, swelling, fever, chills, and vomiting after a small shin wound sustained approximately 28 hours earlier. He reports dizziness and near-syncope during his shift at a Halloween haunted attraction.
Patient Profile
DOB: 03/19/1992 • 5 ft 11 in (180.3 cm) • 181 lb (82.1 kg) • BMI 25.3
Isolation Status at Arrival: Standard Precautions
Medical History
- No known chronic medical conditions.
- No previous surgeries.
- Baseline creatinine 0.9 mg/dL approximately three months before admission.
- Tetanus immunization documented in 2024.
Home Medications
- Ibuprofen 400 mg PO every 6 hours as needed — pain; took two doses today without meaningful relief of right-leg pain.
- No prescribed daily medications or reported supplements.
Recent History
Marcus works in a warehouse and performs seasonally at Black Hollow, a haunted attraction inside a closed hospital. Approximately 28 hours before arrival, he scraped his right shin on a metal edge beneath a prop table. The wound initially appeared small. He reports no animal bite, injection drug use, or freshwater or saltwater exposure involving the wound.
Tonight, Marcus played an escaped patient dragging one leg through the morgue corridor. Over approximately four hours, the dragging became real. Burning pain spread into his calf, followed by shaking chills, vomiting, and dizziness. Guests continued filming as he sank beside a prop body bag, assuming his trembling and cries were part of the performance. Costume blood concealed drainage from the actual wound.
A coworker stopped the attraction when Marcus said, “Please turn the lights on. I’m not acting.” EMS transported him to the emergency department. Last oral intake was at 1800 on 10/24/2026. He lives with his sister, Naomi Vale.
Emergency Contact
Naomi Vale • Sister
589-216-XXXX
Insurance
Commercial employer-sponsored insurance
Current Care Status
10/24/2026 • 2210 • Emergency Department, Resuscitation Bay 3. Emergency evaluation for suspected necrotizing soft-tissue infection with sepsis is underway. Initial resuscitation, antimicrobial treatment, and urgent surgical evaluation are being initiated.
Full Code; Standard Precautions at arrival. Subsequent isolation changes, transfers, and treatment updates are documented in the timeline.
Patient Timeline
The wound is small, but the pain reaches far beyond it. Marcus is febrile, tachycardic, and showing signs of impaired perfusion.
Marcus Vale • DOB: 03/19/1992 • MRN: 763184
Chief Complaint
“My leg is burning all the way up my calf. I’m freezing, and I feel like I’m going to black out.”
History of Present Illness
Marcus is a previously healthy 34-year-old man presenting after a right-shin scrape approximately 28 hours earlier. He struck a metal edge beneath a prop table while working at Black Hollow, a Halloween attraction inside a closed hospital. The initial wound was approximately 1.5 cm and appeared superficial.
During tonight’s performance, pain intensified over approximately four hours and spread into the calf. Fever, shaking chills, vomiting, weakness, and near-syncope followed. Guests initially interpreted his difficulty walking and collapse beside a prop body bag as part of the performance. Two doses of ibuprofen provided no meaningful relief. Last oral intake was 1800 today.
Past Medical History
- No known chronic medical conditions.
- No previous surgeries.
- Baseline creatinine 0.9 mg/dL approximately three months ago.
- Tetanus immunization documented in 2024.
- No known drug allergies.
- Home medication: ibuprofen 400 mg PO every 6 hours PRN; two doses today for leg pain.
Family History
- Mother with type 2 diabetes mellitus.
- No reported family history of immunodeficiency.
Social History
- Warehouse employee and seasonal haunted-attraction performer.
- Lives with sister, Naomi Vale.
- Denies injection drug use.
- No animal bite or freshwater/saltwater exposure involving the wound.
Review of Systems
Constitutional: Fever, chills, and weakness.
Neurologic: Dizziness and near-syncope; no reported loss of consciousness.
Cardiopulmonary: No chest pain or reported dyspnea.
Gastrointestinal: Vomiting; no reported diarrhea.
Musculoskeletal / Skin: Severe right-leg pain, swelling, redness, and drainage from the shin wound.
Peripheral neurologic: No foot numbness or weakness at this assessment.
Physical Examination
General: Acutely ill, shivering, and visibly uncomfortable; alert and oriented ×4, GCS 15.
Vital signs: 38.8°C / 101.8°F, HR 124, RR 24, BP 98/60, MAP 73, SpO₂ 98% on room air.
Cardiovascular: Regular tachycardia; distal pulses palpable.
Respiratory: Tachypneic; no increased oxygen requirement.
Right leg: A 1.5 cm shin wound lies within approximately 6 × 8 cm of erythema. Edema and marked tenderness extend beyond visible redness. No bullae or palpable crepitus at this assessment.
Neurovascular: Foot warm; distal movement and sensation intact.
Labs
Collected 2215: WBC 19.8, hemoglobin 14.2, platelets 184, sodium 132, bicarbonate 20, BUN 25, creatinine 1.4, glucose 146, lactate 3.8, INR 1.2, and aPTT 31 seconds. Blood cultures ×2 pending.
Diagnostics
Right tibia/fibula radiograph at 2220 shows swelling without fracture, radiopaque foreign body, or visible gas. ECG shows sinus tachycardia. Type and screen: O positive; antibody screen negative.
CT is not planned before urgent surgical evaluation because imaging could delay source control.
Assessment
Suspected right-leg necrotizing soft-tissue infection with sepsis, impaired perfusion, and acute kidney injury. Severe pain beyond visible skin changes and rapid systemic deterioration are concerning for deep infection. Absence of gas, crepitus, or extensive superficial injury does not exclude a necrotizing process.
Plan
- Immediate IV antibiotics and crystalloid resuscitation.
- Urgent orthopedic surgical consultation with Dr. Julian Carter and critical care consultation with Dr. Nadia Wells.
- NPO and preparation for urgent operative exploration.
- Frequent BP, mental-status, perfusion, respiratory, and right-leg neurovascular reassessment.
- Droplet plus Standard Precautions beginning 2230 for suspected invasive group A streptococcal infection. Add Contact if drainage is uncontained.
- Explain urgent treatment and possible repeated debridement; involve sister with patient permission.
Provider Information
Dr. Zoe Langston, MD
Emergency Medicine
Marcus Vale • DOB: 03/19/1992 • MRN: 763184
Patient arrives wearing a blood-stained hospital costume and states, “Please turn the lights on. I’m not acting.” Costume removed for assessment. Theatrical staining is present on clothing, with actual drainage visible at the right-shin wound. Wound covered with a dressing that currently contains drainage. Reports pain 10/10 and dizziness. Right calf tender beyond visible redness; erythema borders marked and timed. Distal pulses, movement, and sensation intact.
Two peripheral IVs established and assessed for patency. Continuous cardiac monitoring initiated. Blood cultures collected before antibiotics without delaying treatment. LR started 2218, piperacillin-tazobactam 2220, vancomycin 2225, and clindamycin 2230 using compatible access and appropriate line management.
Fentanyl 25 mcg IV and ondansetron 4 mg IV administered 2220. Pain decreases to 8/10 without excessive sedation. Patient remains NPO and does not ambulate.
Dr. Langston and Dr. Julian Carter informed of severe pain and systemic findings. Droplet Precautions initiated 2230 per order; Standard Precautions maintained. Sister contacted with patient permission.
Marcus Vale • DOB: 03/19/1992 • MRN: 763184
Dr. Julian Carter, MD — Urgent Surgical Consultation
Rapid progression, systemic illness, and pain extending beyond superficial skin changes are highly concerning for necrotizing soft-tissue infection. Absence of gas on radiograph does not exclude it. Recommend urgent operative exploration and debridement.
Discussed possible extensive tissue removal, repeated operations, and potential limb loss. Patient consents to operative management. Continue antibiotics and resuscitation during preparation. Imaging must not delay surgery. Critical care notified.
| Order Type | Order Details | Priority | Ordered By | Status | Comments |
|---|---|---|---|---|---|
| IV Fluids | LR 1,000 mL IV once over 30 minutes for impaired perfusion | Stat | Dr. Zoe Langston, MD | In Progress | Started 2218; expected completion 2248. Reassess perfusion and respiratory status. |
| Medication | Piperacillin-tazobactam 4.5 g IV every 6 hours over 30 minutes for suspected necrotizing infection; duration pending culture-guided review | Stat first dose | Dr. Zoe Langston, MD | Active | First dose 2220; next due 0420 on 10/25. Pharmacy to reassess renal dosing. |
| Medication | Vancomycin 2,000 mg IV loading dose once over at least 2 hours for empiric MRSA coverage | Stat | Dr. Zoe Langston, MD | In Progress | Started 2225; expected completion 0025. Further dosing per pharmacy. |
| Medication | Clindamycin 900 mg IV every 8 hours over 30 minutes for suspected toxin-producing infection; duration pending infectious disease review | Stat first dose | Dr. Zoe Langston, MD | Active | First dose 2230; next due 0630 on 10/25. |
| Medication | Fentanyl 25 mcg IV every 30 minutes PRN severe pain; maximum 100 mcg before provider reassessment; expires at anesthesia handoff | PRN | Dr. Zoe Langston, MD | Active | Given 2220. Hold for SBP <90, RR <12, or excessive sedation. |
| Medication | Ondansetron 4 mg IV every 8 hours PRN nausea/vomiting for 24 hours | PRN | Dr. Zoe Langston, MD | Active | Given 2220; next eligible 0620. Expires 10/25 at 2220. |
| Isolation | Droplet + Standard; add Contact if drainage is uncontained | Immediate | Dr. Zoe Langston, MD | Active from 2230 | Reassess organism, effective therapy, and drainage containment. |
| Nursing / Monitoring | Continuous ECG/SpO₂; BP every 5–15 minutes; right-leg neurovascular assessment every 15 minutes | Immediate | Dr. Zoe Langston, MD | Active | Increase frequency with deterioration; report hypotension, sensory loss, or confusion. |
| Laboratory | CBC, BMP, lactate, INR/aPTT, blood cultures ×2, and type and screen | Stat | Dr. Zoe Langston, MD | Collected | Collected 2215; blood cultures pending. Repeat lactate within approximately 2 hours or sooner if worsening. |
| Diagnostic / Imaging | Right tibia/fibula radiograph and ECG | Stat | Dr. Zoe Langston, MD | Completed | Swelling without visible gas; ECG shows sinus tachycardia. |
| Dietary | NPO for urgent surgery | Immediate | Dr. Julian Carter, MD | Active | Last oral intake 1800. |
| Activity | Assisted activity only; fall precautions | Immediate | Dr. Zoe Langston, MD | Active | No unassisted ambulation. |
| Consult / Procedure | Urgent orthopedic surgery and critical care evaluation; prepare for exploration and debridement | Stat | Dr. Zoe Langston, MD / Dr. Julian Carter, MD | In Progress | Do not delay operative management for CT. |
| Vital Sign | 2210 | Reference Range |
|---|---|---|
| Temperature | 38.8°C / 101.8°F | 36.1–37.2°C / 97–99°F |
| Heart Rate | 124 bpm | 60–100 bpm |
| Respiratory Rate | 24 breaths/min | 12–20 breaths/min |
| Blood Pressure | 98/60 mmHg | Resting reference: <120/<80 mmHg; assess perfusion |
| MAP | 73 mmHg | Resuscitation target ≥65 mmHg |
| Oxygen Saturation | 98% on room air | 95–100% |
| Pain | 10/10, right leg | Subjective scale 0–10 |
| Neurologic Status | GCS 15; oriented ×4 | GCS 15; baseline orientation |
| Urine Output | Not yet measured | ≥0.5 mL/kg/hr; approximately 41 mL/hr |
| Lab Test | 2215 | Reference Range |
|---|---|---|
| WBC | 19.8 ×10³/µL H* | 5–11 ×10³/µL |
| Hemoglobin | 14.2 g/dL | Male: 14–16.5 g/dL |
| Platelets | 184 ×10³/µL | 150–450 ×10³/µL |
| Sodium | 132 mEq/L L* | 135–145 mEq/L |
| Potassium | 4.2 mEq/L | 3.5–5.0 mEq/L |
| Bicarbonate | 20 mEq/L L* | 22–29 mEq/L |
| BUN | 25 mg/dL H* | 10–20 mg/dL |
| Creatinine | 1.4 mg/dL H* | 0.6–1.2 mg/dL |
| Glucose | 146 mg/dL H* | 60–100 mg/dL — fasting |
| Lactate | 3.8 mmol/L H* | 0.5–2.2 mmol/L |
| INR | 1.2 | 0.9–1.2 |
| aPTT | 31 seconds | 20–45 seconds |
| Blood Cultures ×2 | Pending | No growth |
H* = above reference range; L* = below reference range. Glucose is flagged against the fasting reference; fasting status is not confirmed and this does not establish diabetes. Previous creatinine: 0.9 mg/dL.
- 2220 — Right tibia/fibula radiograph — Completed: Soft-tissue swelling without fracture, radiopaque foreign body, or visible gas. Absence of gas does not exclude necrotizing infection.
- ECG — Completed: Sinus tachycardia without acute ischemic changes.
- Type and screen — Completed: O positive; antibody screen negative.
- Blood cultures — Pending: Collected 2215.
- CT — Not ordered: Could delay urgent operative evaluation and source control.
- 2210 — Costume removed; actual wound and pain beyond visible redness identified.
- 2215 — Laboratory specimens and blood cultures collected.
- 2218 — Initial LR bolus started.
- 2220 — Piperacillin-tazobactam, fentanyl, and ondansetron administered; radiograph completed.
- 2225 — Vancomycin loading infusion started.
- 2230 — Clindamycin started; Dr. Julian Carter recommends urgent exploration.
- 2230 — Droplet plus Standard Precautions initiated; add Contact if drainage becomes uncontained.
Review Marcus’s symptoms, assessment, laboratory results, and current plan before answering.
Rapid progression and severe pain extending beyond visible erythema are concerning for deeper tissue infection. Fever, tachycardia, low blood pressure, elevated lactate, and rising creatinine indicate systemic illness and impaired perfusion. A small wound, intact pulses, and absence of gas or crepitus do not exclude necrotizing infection. Immediate escalation, antibiotics, resuscitation, and urgent surgical assessment are required.
Give prescribed antibiotics and fluids promptly while reassessing perfusion, respiratory status, mental status, and right-leg neurovascular findings. Maintain NPO, fall precautions, ordered isolation, and coordinated handoff. CT should not delay operative evaluation when findings strongly suggest a necrotizing infection. Antibiotics and resuscitation support the patient, but urgent surgical source control is essential.
Marcus develops dusky skin, bullae, and reduced sensation at the center of the wound. His blood pressure and mental status change while fluids and antibiotics continue.
Marcus Vale • DOB: 03/19/1992 • MRN: 763184
Chief Complaint
“The middle feels dead, but everything around it is burning. I’m dizzy even lying down.”
Interval History
Right-leg erythema has expanded from approximately 6 × 8 cm to 12 × 18 cm since initial assessment. New bullae, dusky central skin, and reduced central sensation are present. Surrounding pain remains severe. Marcus is now confused and increasingly hypotensive while awaiting urgent operative exploration.
Initial 1,000 mL LR completed at 2248. Additional 1,500 mL LR started at 2248 over approximately 45–50 minutes through dedicated fluid access. Approximately 1,700 mL total crystalloid received by 2310; additional bolus remains in progress.
Norepinephrine started at 2307 for persistent hypotension. At 2310, BP is 82/46 and MAP 58 while the infusion is running at 0.07 mcg/kg/min. Resuscitation and operative preparation continue together.
Past Medical History
- No known chronic medical conditions or previous surgeries.
- Baseline creatinine 0.9 mg/dL approximately three months ago.
- Tetanus immunization documented in 2024.
- Two ibuprofen doses before arrival; no scheduled home medications.
Family History
- Mother with type 2 diabetes mellitus.
- No additional relevant family history reported.
Social History
- Warehouse employee and seasonal haunted-attraction performer.
- Lives with sister, Naomi Vale.
- No injection drug use, animal bite, or water exposure involving the wound.
Allergies
No known drug allergies.
Review of Systems
History is limited by new confusion.
Constitutional: Fever, chills, and profound weakness.
Neurologic: Persistent dizziness and new confusion.
Musculoskeletal / Skin: Severe surrounding right-leg pain, spreading redness, bullae, and central numbness.
Gastrointestinal: Earlier vomiting.
Cardiopulmonary: No new chest pain reported; tachypnea observed.
Physical Examination
General / Neurologic: Acutely ill and confused; GCS 14.
Cardiovascular / Perfusion: HR 138, BP 82/46, MAP 58. Capillary refill approximately 4 seconds.
Respiratory: RR 30 breaths/min; SpO₂ 96% on room air.
Right leg: Erythema approximately 12 × 18 cm with dusky central skin, new bullae, reduced central sensation, and marked surrounding tenderness.
Distal neurovascular: Pulses remain palpable. Serial movement and sensation assessment continues.
GU: Foley inserted at 2305 with initial return of 15 mL. A complete hourly urine-output measurement is not yet available.
Labs
Repeat specimens collected at 2300: WBC 24.6 ×10³/µL, hemoglobin 12.9 g/dL, platelets 142 ×10³/µL, sodium 131 mEq/L, bicarbonate 17 mEq/L, BUN 29 mg/dL, creatinine 1.8 mg/dL, glucose 168 mg/dL, lactate 5.6 mmol/L, INR 1.4, and aPTT 34 seconds. Blood cultures remain pending.
Diagnostics
Earlier radiograph showed swelling without visible gas. ECG showed sinus tachycardia. Type and screen completed: O positive, antibody screen negative. Operative exploration is being prepared. Deep-tissue microbiology and pathology are not yet available.
Assessment
Rapidly progressive suspected necrotizing soft-tissue infection with shock and worsening acute kidney injury. Central sensory loss with dusky skin and bullae suggests local tissue and nerve injury rather than recovery. MAP remains below the ordered target at 2310.
Plan
- Continue prescribed fluid bolus with repeated perfusion and respiratory assessment.
- Check BP measurement, infusion pump, tubing, and peripheral vasopressor site.
- Norepinephrine sequence: 0.05 mcg/kg/min at 2307; 0.07 at 2309; 0.09 at 2312. MAP remains below goal at 2314; increase to 0.11. Repeat MAP 67 at 2315.
- Continue antibiotics and urgent operative source control with Dr. Julian Carter.
- Maintain NPO, Droplet plus Standard Precautions; add Contact if wound drainage becomes uncontained.
- Measure urine output hourly and monitor mental status, renal function, coagulation studies, and lactate.
- Request Dr. Kevin Morales for infectious disease consultation.
- Arrange postoperative surgical ICU admission.
Provider Information
Dr. Nadia Wells, MD
Critical Care Intensivist
Marcus Vale • DOB: 03/19/1992 • MRN: 763184
Patient increasingly confused and asks why the center of his leg “doesn’t feel like mine.” Surrounding pain remains 9/10. Central skin dusky with new bullae and reduced sensation. No additional fentanyl administered because SBP is below the medication hold parameter.
Initial LR bolus completed 2248; additional bolus continues. Third peripheral IV established 2250 to provide separate fluid, antibiotic, and vasopressor access. Norepinephrine infusing through a dedicated proximal peripheral IV. Site patent without swelling, blanching, or reported site pain.
Foley inserted at 2305 with 15 mL initial return. Hourly output monitoring initiated. Patient remains on continuous ECG and SpO₂ monitoring. Respiratory rate 30; SpO₂ 96% on room air.
Norepinephrine started at 0.05 mcg/kg/min at 2307, increased to 0.07 at 2309. At 2310, BP 82/46 and MAP 58. BP measurement repeated; pump, tubing, and IV site checked. Dr. Wells notified. Increased to 0.09 at 2312 per titration order. MAP remains below 65 at 2314; increased to 0.11. MAP 67 at 2315.
NPO and Droplet plus Standard Precautions maintained. Dressing currently contains drainage. OR handoff includes skin progression, current norepinephrine rate of 0.11, approximately 1,700 mL crystalloid received by 2310 with bolus continuing, antibiotic timing, Foley output, and last oral intake. Sister updated with patient permission.
Marcus Vale • DOB: 03/19/1992 • MRN: 763184
Consultant
Dr. Julian Carter, MD • Orthopedic Surgeon
Reason for Consultation
Reassessment before urgent surgery following progressive skin changes and hemodynamic deterioration.
Impression
Spreading erythema, bullae, dusky tissue, reduced sensation, and systemic deterioration further support a necrotizing infection. Reduced central pain is concerning for tissue and nerve destruction rather than recovery.
Recommendations
Proceed urgently to exploration and debridement while resuscitation continues. Obtain operative tissue for Gram stain, culture, and pathology. Continue antibiotics and coordinate anesthesia and ICU handoff.
Infectious Disease
Consultation requested with Dr. Kevin Morales, MD. Formal infectious disease note pending at this timestamp.
| Order Type | Order Details | Priority | Ordered By | Status | Comments |
|---|---|---|---|---|---|
| Dietary | NPO for urgent surgery | Immediate | Dr. Julian Carter, MD | Active | Last oral intake 1800. |
| Activity | Assisted activity only; fall precautions | Immediate | Dr. Nadia Wells, MD | Active | No unassisted ambulation. |
| Monitoring | Continuous ECG and SpO₂ monitoring | Stat | Dr. Nadia Wells, MD | Active | Carry forward initial monitoring orders. |
| Nursing | BP every 2–5 minutes during vasopressor titration; right-leg neurovascular assessment every 15 minutes until operative handoff | Immediate | Dr. Nadia Wells, MD | Active | Replaces initial BP interval. Reassess mental status and perfusion frequently. |
| IV Fluids | Initial LR 1,000 mL IV once over 30 minutes | Stat | Dr. Zoe Langston, MD | Completed 2248 | Included in cumulative resuscitation volume. |
| IV Fluids | Additional LR 1,500 mL IV once over approximately 45–50 minutes for persistent impaired perfusion | Stat | Dr. Nadia Wells, MD | In Progress | Started 2248. Approximately 1,700 mL total crystalloid received by 2310. Continue bedside reassessment. |
| Medication | Norepinephrine IV infusion 0.02–0.5 mcg/kg/min; titrate by 0.01–0.02 mcg/kg/min every 2–5 minutes to MAP ≥65 | Stat | Dr. Nadia Wells, MD | Active | Started 2307 at 0.05; 2309: 0.07; 2312: 0.09; 2314: 0.11. MAP 67 at 2315. Continue until shock resolves with provider-directed weaning. Dedicated proximal peripheral IV pending central access; inspect frequently and follow extravasation protocol if indicated. |
| Medication | Piperacillin-tazobactam 4.5 g IV every 6 hours over 30 minutes for suspected necrotizing infection | Scheduled | Dr. Zoe Langston, MD; continued by Dr. Nadia Wells, MD | Active | First dose completed; next due 0420. Duration pending culture-guided review. Reassess renal dosing. |
| Medication | Vancomycin 2,000 mg IV loading dose once over at least 2 hours for empiric MRSA coverage | Stat loading dose | Dr. Zoe Langston, MD | In Progress | Started 2225; expected completion 0025. Further dosing and concentrations per pharmacy. |
| Medication | Clindamycin 900 mg IV every 8 hours over 30 minutes for suspected toxin-producing infection | Scheduled | Dr. Zoe Langston, MD; continued by Dr. Nadia Wells, MD | Active | First dose completed; next due 0630. Duration pending infectious disease review. |
| Medication | Fentanyl 25 mcg IV every 30 minutes PRN severe pain; maximum 100 mcg before provider reassessment | PRN | Dr. Zoe Langston, MD | Active; withheld for hypotension | Last given 2220. Hold for SBP <90, RR <12, or excessive sedation. Expires at anesthesia handoff. |
| Medication | Ondansetron 4 mg IV every 8 hours PRN nausea/vomiting for 24 hours | PRN | Dr. Zoe Langston, MD | Active | Last given 2220; next eligible 0620. Expires 10/25 at 2220. |
| Isolation | Droplet + Standard Precautions; add Contact if wound drainage is uncontained | Immediate | Dr. Zoe Langston, MD; continued by Dr. Nadia Wells, MD | Active | Reassess organism identification, effective therapy, and drainage containment. |
| Nursing | Insert Foley catheter and measure urine output hourly | Stat | Dr. Nadia Wells, MD | Inserted 2305; monitoring active | Initial return 15 mL. Report output below approximately 41 mL/hr and worsening trend. |
| Laboratory | Repeat CBC, BMP, INR/aPTT, and lactate now | Stat | Dr. Nadia Wells, MD | Completed 2300 | Results available in trend table. |
| Laboratory | CBC, BMP, INR/aPTT, and lactate every 4 hours postoperatively | Urgent | Dr. Nadia Wells, MD | Ordered | Adjust frequency to clinical response; repeat sooner for deterioration. |
| Laboratory | Blood cultures ×2 | Stat collection | Dr. Zoe Langston, MD | Pending results | Collected 2215; continue following results. |
| Procedure / Laboratory | Urgent right-leg exploration and debridement; operative tissue Gram stain, culture, and pathology | Stat | Dr. Julian Carter, MD | Preparing for OR | Continue resuscitation during transfer. No CT-related delay. |
| Consult | Infectious disease consultation with Dr. Kevin Morales, MD | Urgent | Dr. Nadia Wells, MD / Dr. Julian Carter, MD | Requested | Review antimicrobials after operative findings and microbiology. |
| Admission | Postoperative surgical ICU admission | Urgent | Dr. Nadia Wells, MD | Planned | Coordinate anesthesia, surgical, and ICU handoff. |
| Vital Sign | 2210 | 2310 | Reference Range |
|---|---|---|---|
| Temperature | 38.8°C / 101.8°F | 39.4°C / 102.9°F | 36.1–37.2°C / 97–99°F |
| Heart Rate | 124 bpm | 138 bpm | 60–100 bpm |
| Respiratory Rate | 24 breaths/min | 30 breaths/min | 12–20 breaths/min |
| Blood Pressure | 98/60 mmHg | 82/46 mmHg | Resting reference: <120/<80 mmHg; interpret with perfusion |
| MAP | 73 mmHg | 58 mmHg | Resuscitation target ≥65 mmHg |
| Oxygen Saturation | 98% on room air | 96% on room air | 95–100% |
| Pain | 10/10 | 9/10 surrounding wound; reduced central sensation | Subjective scale 0–10 |
| GCS | 15 | 14 | 15 |
| Urine Output | Not yet measured | 15 mL initial Foley return at 2305; full-hour measurement pending | Hourly target ≥0.5 mL/kg/hr; approximately 41 mL/hr at 82.1 kg |
| Lab Test | 2215 | 2300 | Reference Range |
|---|---|---|---|
| WBC | 19.8 ×10³/µL | 24.6 ×10³/µL | 5–11 ×10³/µL |
| Hemoglobin | 14.2 g/dL | 12.9 g/dL | Male: 14–16.5 g/dL |
| Platelets | 184 ×10³/µL | 142 ×10³/µL | 150–450 ×10³/µL |
| Sodium | 132 mEq/L | 131 mEq/L | 135–145 mEq/L |
| Potassium | 4.2 mEq/L | 4.5 mEq/L | 3.5–5.0 mEq/L |
| Bicarbonate | 20 mEq/L | 17 mEq/L | 22–29 mEq/L |
| BUN | 25 mg/dL | 29 mg/dL | 10–20 mg/dL |
| Creatinine | 1.4 mg/dL | 1.8 mg/dL | 0.6–1.2 mg/dL |
| Glucose | 146 mg/dL | 168 mg/dL | 60–100 mg/dL — fasting reference |
| Lactate | 3.8 mmol/L | 5.6 mmol/L | 0.5–2.2 mmol/L |
| INR | 1.2 | 1.4 | 0.9–1.2 |
| aPTT | 31 seconds | 34 seconds | 20–45 seconds |
Fasting status is not confirmed for either glucose specimen. Previous creatinine was 0.9 mg/dL approximately three months ago.
- Serial Right-Leg Examination — Ongoing: Erythema approximately 12 × 18 cm with bullae, dusky central skin, and reduced central sensation.
- Right Tibia/Fibula Radiograph — Previously Completed: Soft-tissue swelling without visible gas, fracture, or radiopaque foreign body.
- ECG — Previously Completed: Sinus tachycardia without acute ischemic changes.
- Type and Screen — Previously Completed: O positive; antibody screen negative.
- Blood Cultures ×2 — Pending: Collected 2215; no organism identified at this timestamp.
- Operative Exploration — Preparing: Urgent procedure planned; findings not yet available.
- Deep-Tissue Gram Stain and Culture — Ordered: Specimens to be collected during surgery.
- Tissue Pathology — Ordered: Operative tissue submission planned.
- CT — Not Ordered: Operative evaluation proceeding without imaging-related delay.
- 2248 — Initial 1,000 mL LR completed.
- 2248 — Additional 1,500 mL LR started over approximately 45–50 minutes.
- 2250 — Third peripheral IV established for separate fluids, antibiotics, and vasopressor access.
- 2255 — Dusky skin, bullae, and central sensory loss identified.
- 2300 — Repeat laboratory specimens collected; lactate 5.6 and creatinine 1.8.
- 2305 — Foley inserted with 15 mL initial return.
- 2305 — Dr. Julian Carter confirms immediate operative exploration.
- 2307 — Norepinephrine started at 0.05 mcg/kg/min.
- 2309 — Increased to 0.07 mcg/kg/min per order.
- 2310 — BP 82/46, MAP 58; measurement and infusion assessed; Dr. Wells notified.
- 2312 — Norepinephrine increased to 0.09 mcg/kg/min.
- 2314 — MAP remains below goal; increased to 0.11 mcg/kg/min.
- 2315 — MAP 67; operative handoff completed with fluid bolus continuing.
Review Marcus’s changing assessment, laboratory trends, current orders, and response to resuscitation.
Reduced central sensation in dusky, blistering tissue can reflect tissue destruction and injury to local nerves. It is not reassuring when surrounding pain, erythema, hypotension, confusion, and lactate are worsening. Assess and document skin changes, sensation, movement, pulses, and perfusion, and communicate progression immediately. Intact distal pulses do not exclude necrotizing infection or establish that the affected tissue is viable.
Confirm the BP measurement, assess perfusion and mental status, and check the pump, tubing, and IV site. Notify the provider and titrate within the order: increments of 0.01–0.02 mcg/kg/min every 2–5 minutes to MAP at least 65. Here, the infusion increases to 0.09 at 2312, then to 0.11 at 2314 after reassessment shows MAP remains below goal. Repeat MAP is 67 at 2315.
Continue prescribed fluids with repeated assessment of response and tolerance. Persistent hypotension should not remain untreated while waiting for the entire bolus to finish. Document infusion rates and responses, maintain safe peripheral vasopressor monitoring, and continue urgent operative coordination for source control.
Marcus is awake after emergency debridement, and norepinephrine has been discontinued. His right leg remains dressed, with repeat operative exploration scheduled for 1800.
Marcus Vale • DOB: 03/19/1992 • MRN: 763184
Chief Complaint
“My leg still throbs, but I’m not dizzy. Why do I have to go back to surgery?”
Interval History
Emergency right-leg exploration and debridement performed by Dr. Julian Carter from 2325 on 10/24 through 0040 on 10/25. Operative findings included gray nonviable fascia, turbid fluid, and easy separation along fascial planes, confirming necrotizing fasciitis. Skin, subcutaneous tissue, and fascia were debrided, leaving an approximately 18 × 10 cm open wound. Muscle appeared viable. Estimated blood loss was 150 mL; no transfusion administered.
Anesthesia placed a left radial arterial line at 2330 and a right IJ central line at 2340. Central-line placement and usability were confirmed before norepinephrine transitioned to central access at 2345. The additional 1,500 mL LR bolus completed at 2335, bringing initial resuscitation crystalloid to 2,500 mL, approximately 30 mL/kg. Any additional operative fluids are accounted for separately in the anesthesia record.
Returned to Surgical ICU intubated at 0100 after general anesthesia. Extubated at 0600 following recovery and readiness assessment. Norepinephrine discontinued at 1000. Repeat operative exploration is scheduled for 1800 today.
At 0100, wound drainage escaped the operative dressing. Surgical team notified and dressing reinforced per order. Contact Precautions added to existing Droplet and Standard Precautions.
Past Medical History
- No known chronic medical conditions before admission.
- No previous surgeries before this admission.
- Baseline creatinine 0.9 mg/dL approximately three months ago.
- Tetanus immunization documented in 2024.
- Current admission includes necrotizing fasciitis, shock, acute kidney injury, and emergency right-leg debridement.
Family History
- Mother with type 2 diabetes mellitus.
- No additional relevant family history reported.
Social History
- Warehouse employee and seasonal haunted-attraction performer.
- Lives with sister, Naomi Vale, who is available for support.
- No reported injection drug use or water exposure involving the wound.
- Expresses concern about repeat surgery and recovery.
Allergies
No known drug allergies.
Review of Systems
Constitutional: Reports less weakness; no current shaking chills.
Neurologic: Denies current dizziness or confusion.
Cardiovascular: Denies chest pain.
Respiratory: Denies dyspnea.
Gastrointestinal: No current vomiting; remains NPO.
Musculoskeletal / Skin: Postoperative right-leg pain. No new foot numbness reported.
Psychological: Anxiety regarding the wound and repeat surgery.
Physical Examination
General / Neurologic: Awake and oriented ×4; GCS 15. Anxious but participates in discussion.
Cardiovascular / Perfusion: HR 98, BP 112/68, MAP 83. Norepinephrine off since 1000. Distal pulses palpable.
Respiratory: Respiratory rate 18 breaths/min. SpO₂ 97% on room air. Breathing comfortably after extubation.
Right leg: Operative dressing in place with small, stable serosanguineous strike-through. No brisk bleeding. Packing not removed during this assessment.
Distal neurovascular: Right foot warm, with palpable pulses and intact movement and sensation.
Devices: Right IJ central line, left radial arterial line, and Foley catheter remain in place.
GU: Urine output 50 mL during 1100–1200.
Labs
Specimens collected at 1100: WBC 20.1 ×10³/µL, hemoglobin 11.8 g/dL, platelets 136 ×10³/µL, sodium 134 mEq/L, bicarbonate 22 mEq/L, BUN 27 mg/dL, creatinine 1.5 mg/dL, glucose 128 mg/dL, lactate 1.9 mmol/L, INR 1.3, and aPTT 32 seconds.
Random vancomycin concentration 11.2 mcg/mL. Pharmacy reviewed the concentration in relation to dose timing and changing renal function.
Diagnostics
Operative findings confirm necrotizing fasciitis. Deep-tissue Gram stain shows gram-positive cocci in chains; preliminary blood culture shows gram-positive cocci. Final organism identification, susceptibilities, and tissue pathology remain pending.
Repeat exploration is scheduled for 1800 and has not yet been performed.
Assessment
Necrotizing fasciitis after initial operative source control. Shock currently resolved off norepinephrine, with improving lactate and acute kidney injury. Residual or recurrent nonviable tissue remains possible and requires operative reassessment. Preliminary Gram stain does not establish group A streptococcus or exclude a polymicrobial infection.
Plan
- Repeat exploration with Dr. Julian Carter at 1800. Maintain NPO.
- Continue current antibiotics pending final microbiology and Dr. Kevin Morales’s recommendations.
- Continue pharmacy-directed vancomycin dosing and renal review of antimicrobial therapy.
- Continue hourly external dressing assessment, distal neurovascular checks, and urine-output monitoring.
- Report recurrent hypotension, confusion, reduced urine output, new sensory loss, spreading skin changes, or increased drainage or bleeding immediately.
- Maintain Contact, Droplet, and Standard Precautions. Earliest Droplet review is after 2220 today if therapy is confirmed effective; no automatic discontinuation.
- Review Contact duration with infection prevention, including reliable drainage containment.
- Provide pain control, explain repeat surgery, and involve sister with patient permission.
- Review fluid balance, laboratory trends, device necessity, and postoperative VTE prevention.
Provider Information
Dr. Nadia Wells, MD
Critical Care Intensivist
Marcus Vale • DOB: 03/19/1992 • MRN: 763184
Patient awake and oriented ×4. Becomes tearful when looking at the covered leg and asks whether the infection is “still moving underneath.” Explained the purpose of repeat exploration according to the surgical plan. Additional questions referred to Dr. Julian Carter. Sister present with patient permission.
Temperature 37.8°C / 100.0°F, HR 98, RR 18, BP 112/68, MAP 83, SpO₂ 97% on room air. Denies chest pain, dyspnea, and dizziness. No current vomiting. Norepinephrine off since 1000.
Reports right-leg pain 6/10 before fentanyl 25 mcg IV administered at 1130. Pain decreases to 3/10 on reassessment without excessive sedation or respiratory depression.
Operative dressing has a small, stable area of serosanguineous strike-through without brisk bleeding. Earlier drainage leakage at 0100 was reported to surgery and dressing reinforced per order. Packing remains undisturbed. Right foot warm with palpable distal pulses and intact movement and sensation.
Right IJ dressing and left radial arterial-line dressing intact; no new site bleeding or swelling. Arterial waveform appropriate after leveling and zeroing. Peripheral IV sites patent without infiltration. Foley draining; output 50 mL from 1100–1200.
Contact, Droplet, and Standard Precautions maintained. NPO for repeat surgery at 1800. Hourly assessments, assisted activity, fall precautions, and pressure-injury prevention continue. Current assessment and concerns communicated to Dr. Wells.
Marcus Vale • DOB: 03/19/1992 • MRN: 763184
Consultant
Dr. Julian Carter, MD • Orthopedic Surgeon
Reason for Consultation
Postoperative reassessment and planning for repeat exploration after initial debridement.
Impression
Initial debridement removed visibly nonviable tissue. Further tissue viability requires operative reassessment. Improved blood pressure and lactate do not exclude remaining or evolving necrosis.
Recommendations
Repeat exploration scheduled for 1800. Maintain NPO and prescribed antibiotics. Notify surgery immediately for spreading discoloration, new bullae or sensory loss, increased drainage or bleeding, recurrent severe pain, or hemodynamic deterioration. Surgical team to remove packing and assess the wound directly.
Marcus Vale • DOB: 03/19/1992 • MRN: 763184
Consultant
Dr. Kevin Morales, MD • Infectious Disease Specialist
Reason for Consultation
Antimicrobial and isolation review following operative confirmation of necrotizing fasciitis.
Impression
Deep-tissue Gram stain shows gram-positive cocci in chains; blood culture preliminarily shows gram-positive cocci. Species identification and susceptibilities remain pending. These findings do not prove group A streptococcus or exclude polymicrobial infection.
Recommendations
Continue vancomycin, piperacillin-tazobactam, and clindamycin pending final microbiology and repeat source-control findings. Pharmacy to guide vancomycin dosing and renal review. Narrow therapy when definitive results support a targeted regimen.
Continue Contact, Droplet, and Standard Precautions. For suspected group A streptococcal infection, earliest Droplet discontinuation review is after 2220 today if antimicrobial therapy is confirmed effective. Contact review also requires assessment of drainage containment and infection-prevention guidance. This is a review point, not an automatic stop order.
| Order Type | Order Details | Priority | Ordered By | Status | Comments |
|---|---|---|---|---|---|
| Admission | Continue Surgical ICU care | Urgent | Dr. Nadia Wells, MD | Active | Postoperative monitoring following necrotizing infection and shock. |
| Dietary | NPO until operative and postoperative reassessment | Immediate | Dr. Julian Carter, MD | Active | Repeat exploration scheduled at 1800. |
| Activity | Assisted activity only; no right-leg weight bearing; fall precautions | Routine | Dr. Julian Carter, MD | Active | Protect operative site and maintain pressure-injury prevention. |
| Monitoring | Continuous ECG and arterial blood-pressure monitoring | Urgent | Dr. Nadia Wells, MD | Active | Report recurrent MAP <65 or other signs of impaired perfusion. |
| Nursing | Right-leg neurovascular assessment and urine-output measurement hourly | Urgent | Dr. Nadia Wells, MD | Active | Report new sensory or motor changes, confusion, or urine output below approximately 41 mL/hr. |
| Wound Care | External dressing assessment every 1 hour until operative handoff | Urgent | Dr. Julian Carter, MD | Active | Reinforce only as ordered. Do not remove packing. Report expanding drainage, bleeding, or skin changes. |
| IV Therapy | 0.9% sodium chloride at 75 mL/hr IV while NPO until OR | Routine | Dr. Nadia Wells, MD | Active | Initial boluses completed. Reassess fluid balance, respiratory status, electrolytes, and ongoing need. |
| Medication | Piperacillin-tazobactam 4.5 g IV every 6 hours over 30 minutes for necrotizing infection | Scheduled | Dr. Nadia Wells, MD; reviewed by Dr. Kevin Morales, MD | Active | Last administered 1020; next due 1620. Duration pending microbiology and source control. Continue renal-dose review. |
| Medication | Clindamycin 900 mg IV every 8 hours over 30 minutes for suspected toxin-producing infection | Scheduled | Dr. Nadia Wells, MD; reviewed by Dr. Kevin Morales, MD | Active | Last administered 0630; next due 1430. Duration pending infectious disease review. |
| Medication | Vancomycin 1,250 mg IV once at 1400 over 90 minutes for empiric MRSA coverage | Scheduled | Dr. Nadia Wells, MD, per pharmacy dosing review | Ordered | Based on concentration, prior dose timing, and changing renal function. No automatic maintenance interval; subsequent doses and concentrations per pharmacy. |
| Medication | Fentanyl 25 mcg IV every 1 hour PRN severe postoperative pain for 24 hours from postoperative order | PRN | Dr. Nadia Wells, MD | Active | Replaces expired ED order. Given 1130; next eligible 1230 if indicated. Hold for SBP <90, RR <12, or excessive sedation. |
| Medication | Ondansetron 4 mg IV every 8 hours PRN nausea/vomiting | PRN | Dr. Zoe Langston, MD; continued by Dr. Nadia Wells, MD | Active until 2220 today | Original 24-hour order. Review MAR before dosing; no automatic extension. |
| Isolation | Contact + Droplet + Standard Precautions | Immediate | Dr. Nadia Wells, MD; reviewed by Dr. Kevin Morales, MD | Active | Contact added at 0100 for uncontained drainage. Earliest Droplet review after 2220 if therapy confirmed effective. No automatic stop; Contact review includes drainage containment. |
| Device Management | Maintain right IJ central line, left radial arterial line, and Foley per protocol | Routine | Dr. Nadia Wells, MD | Active | Arterial line placed 2330, IJ 2340, and Foley 2305 on 10/24. Assess sites and review device need daily. |
| Laboratory | CBC, BMP, and INR/aPTT after repeat operation | Scheduled | Dr. Nadia Wells, MD | Ordered | Earlier every-4-hour postoperative laboratory schedule replaced by this order. Repeat sooner for deterioration or new provider order. |
| Laboratory | Routine every-4-hour lactate monitoring | Status update | Dr. Nadia Wells, MD | Discontinued after review of 1100 result | Repeat lactate for clinical deterioration or a new provider order. |
| Laboratory | Follow blood cultures, operative tissue culture, and pathology | Routine | Dr. Julian Carter, MD / Dr. Kevin Morales, MD | Pending final results | Preliminary microbiology available; definitive identification and susceptibilities pending. |
| VTE Prevention | Sequential compression device to left leg | Routine | Dr. Nadia Wells, MD / Dr. Julian Carter, MD | Active | Pharmacologic prophylaxis held for repeat surgery and bleeding-risk reassessment. No compression device over affected wound. |
| Procedure | Repeat right-leg exploration and debridement as indicated at 1800 | Urgent | Dr. Julian Carter, MD | Scheduled | Initial operation completed at 0040. Report deterioration before scheduled procedure. |
| Patient Education | Explain repeat exploration, current treatment, and symptoms requiring immediate reporting | Routine | Dr. Julian Carter, MD / Dr. Nadia Wells, MD | In Progress | Use teach-back and involve sister with permission. Address pain and anxiety. |
| Medication — Status Update | Norepinephrine infusion | Status update | Dr. Nadia Wells, MD | Discontinued 1000 | Continue hemodynamic monitoring. Notify provider for recurrent hypotension and obtain a new or reactivated order as appropriate. |
| Medication — Status Update | ED fentanyl order: 25 mcg IV every 30 minutes PRN | Status update | Dr. Zoe Langston, MD | Expired at anesthesia handoff | Replaced by current postoperative pain order. |
| Vital Sign | 2210 (10/24) | 2310 (10/24) | 1200 (10/25) | Reference Range |
|---|---|---|---|---|
| Temperature | 38.8°C / 101.8°F | 39.4°C / 102.9°F | 37.8°C / 100.0°F | 36.1–37.2°C / 97–99°F |
| Heart Rate | 124 bpm | 138 bpm | 98 bpm | 60–100 bpm |
| Respiratory Rate | 24 breaths/min | 30 breaths/min | 18 breaths/min | 12–20 breaths/min |
| Blood Pressure | 98/60 mmHg | 82/46 mmHg | 112/68 mmHg | Resting reference: <120/<80 mmHg; interpret with perfusion |
| MAP | 73 mmHg | 58 mmHg | 83 mmHg | Resuscitation target ≥65 mmHg |
| Oxygen Saturation | 98% on room air | 96% on room air | 97% on room air | 95–100% |
| Pain | 10/10 | 9/10 surrounding wound; reduced central sensation | 3/10 following 1130 fentanyl | Subjective scale 0–10 |
| GCS | 15 | 14 | 15 | 15 |
| Urine Output | Not yet measured | 15 mL initial Foley return at 2305; full-hour measurement pending | 50 mL during 1100–1200 (50 mL/hr) | Hourly target ≥0.5 mL/kg/hr; approximately 41 mL/hr at 82.1 kg |
| Lab Test | 2215 (10/24) | 2300 (10/24) | 1100 (10/25) | Reference Range |
|---|---|---|---|---|
| WBC | 19.8 ×10³/µL | 24.6 ×10³/µL | 20.1 ×10³/µL | 5–11 ×10³/µL |
| Hemoglobin | 14.2 g/dL | 12.9 g/dL | 11.8 g/dL | Male: 14–16.5 g/dL |
| Platelets | 184 ×10³/µL | 142 ×10³/µL | 136 ×10³/µL | 150–450 ×10³/µL |
| Sodium | 132 mEq/L | 131 mEq/L | 134 mEq/L | 135–145 mEq/L |
| Potassium | 4.2 mEq/L | 4.5 mEq/L | 4.1 mEq/L | 3.5–5.0 mEq/L |
| Bicarbonate | 20 mEq/L | 17 mEq/L | 22 mEq/L | 22–29 mEq/L |
| BUN | 25 mg/dL | 29 mg/dL | 27 mg/dL | 10–20 mg/dL |
| Creatinine | 1.4 mg/dL | 1.8 mg/dL | 1.5 mg/dL | 0.6–1.2 mg/dL |
| Glucose | 146 mg/dL | 168 mg/dL | 128 mg/dL | 60–100 mg/dL — fasting reference |
| Lactate | 3.8 mmol/L | 5.6 mmol/L | 1.9 mmol/L | 0.5–2.2 mmol/L |
| INR | 1.2 | 1.4 | 1.3 | 0.9–1.2 |
| aPTT | 31 seconds | 34 seconds | 32 seconds | 20–45 seconds |
| Vancomycin Random Concentration | Not obtained | Not obtained | 11.2 mcg/mL | Interpret using dose timing, renal function, and pharmacy assessment |
Fasting status is not confirmed for the glucose specimens. Previous creatinine was 0.9 mg/dL approximately three months ago. A random vancomycin concentration is not interpreted using a universal trough target.
- Right Tibia/Fibula Radiograph — Previously Completed: Soft-tissue swelling without fracture, radiopaque foreign body, or visible gas.
- ECG — Previously Completed: Sinus tachycardia without acute ischemic changes during the initial emergency evaluation.
- Type and Screen — Previously Completed: O positive; antibody screen negative. No transfusion administered during the initial operation.
- Initial Operative Exploration — Completed 2325–0040: Gray nonviable fascia, turbid fluid, and easy fascial-plane separation confirmed necrotizing fasciitis. Debridement left an approximately 18 × 10 cm open wound. Muscle appeared viable.
- Deep-Tissue Gram Stain — Preliminary: Gram-positive cocci in chains. Final culture identification and susceptibilities pending.
- Blood Cultures — Preliminary: Gram-positive cocci. Final identification and susceptibilities pending.
- Tissue Pathology — Pending: Operative tissue submitted during initial debridement.
- Central-Line Placement — Confirmed: Right IJ placement and usability confirmed by inserting team before norepinephrine transitioned to central access.
- Repeat Exploration — Scheduled: Planned for 1800 today; not yet performed.
- CT — Not Ordered: Initial operative management proceeded without CT-related delay.
- 10/24 • 2325 — Dr. Julian Carter begins right-leg exploration and debridement; operative specimens collected.
- 2330 — Anesthesia places left radial arterial line.
- 2335 — Additional 1,500 mL LR completed. Initial resuscitation crystalloid totals 2,500 mL, approximately 30 mL/kg.
- 2340 — Right IJ central line inserted.
- 2345 — Norepinephrine transferred to central access after placement and usability confirmation.
- 10/25 • 0025 — Vancomycin loading infusion completed.
- 0040 — Initial debridement completed. Approximately 18 × 10 cm open wound remains. Estimated blood loss 150 mL; no transfusion.
- 0100 — Returns to Surgical ICU intubated following general anesthesia.
- 0100 — Drainage escapes wound dressing. Surgery notified, dressing reinforced, and Contact Precautions added.
- 0600 — Extubated following recovery and readiness assessment.
- 1000 — Norepinephrine discontinued.
- 1030 — Dr. Julian Carter confirms repeat exploration at 1800.
- 1100 — Laboratory specimens collected. Dr. Kevin Morales reviews antimicrobial and isolation plans.
- 1130 — Fentanyl administered for pain 6/10. Pain decreases to 3/10 on reassessment.
- 1200 — NPO, current precautions, postoperative monitoring, and preparation for repeat exploration continue.
Review Marcus’s complete course, response to treatment, remaining concerns, and current orders before answering.
Marcus’s MAP of 83 without norepinephrine, return to GCS 15, lactate of 1.9, and urine output of 50 mL/hr support improved perfusion. Creatinine has decreased from 1.8 to 1.5 mg/dL, although renal function has not returned to his baseline. These findings indicate a response to resuscitation and initial source control, but they do not establish that every area of nonviable tissue has been removed. Repeat exploration permits direct assessment of tissue viability and additional debridement when necessary.
Escalate recurrent hypotension, tachycardia, confusion, reduced urine output, renewed severe pain, spreading discoloration, new bullae or sensory loss, and increasing drainage or bleeding. These changes can indicate recurrent hypoperfusion, infection progression, or another postoperative complication. Maintain NPO, antibiotics, monitoring, and operative preparation rather than assuming that improved numbers eliminate the need for further source control.
No. Gram-positive cocci in chains are a preliminary finding and do not definitively identify group A streptococcus. Continue the current precautions pending organism identification and infection-prevention review. At 1200, 24 hours of effective therapy has not elapsed; the earliest Droplet review is after 2220 today if treatment is confirmed effective.
Contact review also requires assessment of whether wound drainage is reliably contained. Improved vital signs and the wound’s dimensions alone do not determine whether transmission precautions can stop. Follow the documented discontinuation order and infection-prevention guidance rather than treating the 24-hour point as an automatic stop.