Sequence of Medical Care and Events for patient. 21 JAN 2011 21 JAN 2011@2330  ED  Provider: MD C/o pain, migraine, flu-like symptoms Per discharge Instructions: Febrile Illness Influenza Tx: Rest, OTC pain relievers, hydration, etc Back to barracks  23JAN20111 @ 1444  Provider:   Left upper arm pain. Day after shot started fever, HAs, body aches vomiting. Findings: Lesions: two puncture wounds superior deltoid, 2cm below that he has red, indurated, hot area which looks inflammatory pink not cellulitis red.  Dermatitis, allergy to drugs, serums or vaccines Tx:  Toradol 60 mg IM Ibuprofen Rx Roxicet Rx Back to barracks  24JAN2011@0645 in Provider: Sore upper left arm, HAs, body aches, vomiting No dx tx, sent to sick call  24JAN2011@0735 WTB Clinic: See above; left upper arm has been swollen, red streak, painful to touch, painful to motion. Spoke with vascular clinic (433 5228) & paged & spoke with (vascular) & then phoned Tripler ED & discussed pt status with Dr. : SM will be going to ED for evaluation to r/o localized phelebitis VS DVT of left upper Extremity  Limb Pain To ED for further eval and r/o DVT SM sent to medical center ED  24JAN2011@0935 MC ED: See above; labs drawn. WBCs 22.2,other abn lab findings Dx: Cellulitis of left arm Course of Care: toradol and benadryl and compazine and clindamycin iv.    Blood Cultures ordered and drawn Then abx started Discussed case with provider (who also saw pt).  Patient counseled in person regarding the patient's condition, test results and diagnosis.   Differential Diagnosis:  I considered soft tissue etiology, compartment syndrome, abscess, septic phlebitis and embolism as a possible cause of upper extremity pain in this patient. This is a partial list of diagnoses considered.    Back to Barracks Given 48 hrs qrtrs, new Rx for Clindamycin.  ED note says to see PCM the next day but SM does not remember being told this    SM not evaluated by Vascular in ED as health provider had arranged; ED did not call Vascular to consult on case.  Note  Blood Culture resulted 30 JAN (no growth) 25JAN2011 SM slept most of day but medical center finally reached him at about 1500 SM had not seen PCM, reported area of redness and tenderness continues.  SM fell asleep night before and did not take Clindamycin until about 0100 25 JAN.   SM got up and checked area in the light and noted red area was larger than pen line drawn at ED the day before.   Note to see PCM next day not seen  in the then still open encounter in AHLTA Advised SM that he should be seen again ASAP at MC ED as symptoms getting worse/not improving  25JAN2011@1705 TAMC ED: MD Now past margins in several directions.  Warm, red and tender.   WBC = 17.1  Course of Care: clearly worsening wbc improved from 22,000 to 17,000 iv vancomycin ordered FP called and case discussed (in dept) at 1840   Plan was to admit the patient, however, due to the current bed availability situation, the pt will be discharged on double strength, double dose Bactrim and walk in to FP in the afternoon tomorrow or sooner if worsening.  If not improved, likely bed available tomorrow and will admit directly.  No bed available to admit WT 26JAN2011@0900 WTB:  Area of redness extended beyond second markings made 25 JAN in ED, down to elbow and encompassing all but underside of left arm SB WTB with c/o painful swollen upper arm for s/p vaccination over a wk ago; initially was seen by me on  24 Jan '11 by PCM (SM had two visits prior to be seen by WTB) & further 2 more visits with ED in Tripler & he was treated for Cellulites over left upper arm & he was treated with IV abx while in ED & sent home with PO abx; but today with c/o his condition has got worse.   limb swelling: I spoke with Dr., Vascular clinic; accepted to see this SM  to r/o DVT or other issues (thanks); SM to be assisted to the vascular clinic for further evaluation as soon as possible    26JAN2011@1100 Vascular Clinic: Dr.  See above Doppler neg for DVT SM admitted to MC 6B2 and started on Vancomycin IV through 30 JAN.  SMs 3 FEB Ortho surgery cancelled  26JAN2011 MC  Pt was admiited by vascular surgery for cellulitis ofg LUE. Pt had been seen multiple times in various ED for LUE pain and erythema following a flu shot on 21 Jan. PT was admitted by vascular surgery for IV antibiotics following ru of DVT in LUE by US. Pt was started on IV Vanc and improved rapidly. Erythema resolved quickly, pt did note increased pain and induration in proximal lateral LUE and a CT was obtained showing a 2x1 cm fluid collection at the insetion of the deltoid on the humerous and minimal fat stranding, unconcerning for abcess. PT received 5 days of IV Vanc and was then transitioned to PO Septra and discharged. Pt had ortho procedure scheduled for later this week on opposite shoulder. ORtho was contacted and recommendation was made to delay procedure. SM discharged from MC on Bactrim DS two tabs twice a day.   CT calls into question technique during administration of immunizations 31JAN 2011 SM discharged from MC, seen by NCM Post Hospital Visit Area of redness greatly diminished, still has three areas of tenderness scattered around LUE Appt made to see PCM 1 FEB Ortho contacted to reschedule surgery OIF: o/a 28 NOV SM was promised he would have surgery on R shoulder within a week of returning to SB.  Surgery not scheduled until 2 FEB.  Have since been able to reschedule it to 23 FEB.