HISTORY
Identifying Data:
Full Name: TK
Address: Queens, NY
Date of Birth: 12/19/1950, 71 years old
Date and Time: 1/24/22 2:00 PM
Location: NYP Queens
Sex: Male
Age: 71
Race: Caucasian
Religion: None
Marital Status: Married
Source of Information: Self
Reliability: Reliable
PMD: Dr. Duke
Source of Referral: Outpatient Urologist, Dr. Amirian
Chief Complaint: “scrotal abscess drainage” x 3 days
HPI:
TK is a 71 y/o male PMH HTN, HLD, DM2, COPD, BLLE cellulitis, and obesity who presented to ED ℅ drainage of a scrotal abscess x 3 days. He states that he began to have scrotal pain and swelling on Friday night, which “broke” on Saturday when he noticed a lot of “black colored drainage” from his scrotum. He described the scrotal pain as “burning,” non-radiating, 5/10 severity, intermittent, no aggravating/ alleviating factors. He admits that he took 3 tablets of ibuprofen (unknown dosage) to alleviate the pain, which helped, states he never experienced anything like this before. Pt saw Dr. Amirian in the outpatient office this morning due to the drainage and was immediately sent to the ER. Pt denies fever/chills, dysuria, hematuria, or incomplete bladder emptying. Denies fever, chills, CP.
Past Medical History
PMH – HTN x 8 years, HLD x 8 years, DM2 x 8 years, COPD x 1 year, BLLE cellulitis x a few months, obesity
Immunizations – immunizations up to date-pneumococcal, Zoster recombinant, COVID vaccine, Influenza vaccine
Screening Tests and Results – Flexible sigmoidoscopy in 12/21, found and removed polyp in rectosigmoid colon .
Past Surgical History
Inguinal hernia repair, 1968, at NYPQ
Denies past injuries or blood transfusions.
Medications- all taken at nighttime
- Glimepiride 2 mg tablet, 1 tablet PO QD, for DM2
- Lisinopril-hydrochlorothiazide 20-12.5 mg tablet, 1 tablet PO QD, for HTN
- Furosemide 80 mg tablet, 1 tablet PO QD, for HTN
- Simvastatin 40 mg tablet, 1 tablet PO QHS, for HLD
- Clobetasol 0.05% ointment, apply one application on skin BID
- Mupirocin 2% ointment, apply one application on skin TID
Denies taking any OTC’s, vitamins, or herbal supplements
PMD Dr. Duke, Urologist, Dr. Amirian, denies Endocrinologist, does not recall name of Pulmonologist
Allergies
No known drug, food, or seasonal allergies.
Family History
Mother-HTN, DM2
Father- no known medical history
Denies any other family history of medical illnesses, known family history of gastric cancer or colorectal cancer
Social History
Pt is a married male who lives in a house in Queens, NY with his family. Pt has been retired since age 55, worked in insurance prior to retirement.. He is currently sexually active with his wife only and denies any past hx of STI’s.
Habits- Pt admits to smoking 2 pk/day x 50 years (100 pk/yr smoker.) Admits to occasional ETOH use- about 2-3 drinks per week. Denies e-cigarette use or illicit substance use.
Travel – Denies any recent travel or sick contacts.
Diet – Pt states he usually eats oatmeal for breakfast, and a “light” lunch and dinner, consisting of soup, chicken, rice, and/or vegetables.
Exercise – Pt admits he does not exercise much, and walks for about 15 minutes a day
Sleep – Pt states he sleeps variable amounts of time a day, has been having trouble sleeping recently due to cellulitis and ulcer
Review of Systems
General – Denies generalized fatigue, unintentional weight loss, fever, chills, or sweats.
Skin, Peripheral Vascular – Denies changes in skin texture/temperature, ulcerations, discolorations, rashes, erythema, or pruritus. Denies intermittent claudication, pallor, paresthesia, numbness/tingling, or edema.
Head & Neck – Denies any headaches, lightheadedness, LOC, or head trauma. Wears prescription glasses for reading. Denies visual disturbances, photophobia, sore throat, neck stiffness/mass.
Pulmonary – Admits to SOB. Denies cough, hemoptysis, wheezing
Cardiovascular – Denies chest pain, syncope, edema
GI – Denies abdominal pain, nausea, vomiting, hematemesis, constipation, diarrhea, decreased appetite, dysphagia, eructation, rectal bleeding, blood in stool, or abnormal color/odors of stool.
GU – Admits to nocturia, urinary frequency and urgency. Denies oliguria, polyuria, dysuria, or flank pain.
MSK – Denies any muscle/joint pain
Hematological – Denies easy bruising or bleeding, lymph node enlargement, blood transfusions
Endocrine – Denies polyuria, polydipsia, polyphagia, heat/cold intolerance, excessive sweating, goiter
Psychiatric – Denies depression/sadness, anxiety, agitation, or ever seeing a mental health professional
Neurological – Denies any changes in memory/cognition, weakness, abnormal or uncontrollable movement, unsteady gait, or LOC.
Vital Signs – in office- 1/24/22 8:54 AM → in ER 13:52→ ER 15:45
BP 132/63 (left arm, seated) → 117/68→ 147/67
HR 100 bpm regular rhythm→102→89
Temp 36.4 C (oral) → 36.7→37.3
SpO2 95% on RA→ 93% on RA→ 96% on 2 L nasal cannula
RR 18 unlabored→ 18→ 16
Height 69 in. Weight 103.9 kg (229 lbs) BMI 32.82
PHYSICAL EXAM
General – Obese male, ill-appearing, looks appropriately his stated age of 71, has slight difficulty ambulating. The patient is resting supine in ER bed, he is A/O x 3, in no acute distress.
Skin – Skin is warm and dry with no diaphoresis. Good turgor. Skin discoloration and cellulitis present on bilateral lower legs, with stage 2 ulcer on left lateral calf.
Left lateral calf, hyperpigmentation, healing ulcer-give size, drainage or not-drainage, if there is erythema surrounding
HEENT – Head is normocephalic, atraumatic, and nontender throughout. PERRL, sclera white with no icterus, cornea and conjunctiva clear, full visual fields, EOMs intact. Mucous membranes are pink and moist, with no signs of cyanosis. No exudates, erythema or swelling of pharynx.
Neck: Supple with no masses, tenderness, thrills or bruits, FROM. Carotid pulses are 2+ bilaterally with no bruits, no JVD
Heart – mildly tachycardic, regular rhythm,. S1 and S2 distinct without any murmurs, rubs or gallops appreciated
Lungs – Lung sounds clear bilaterally in all lung fields, with no wheezing, rales, or rhonchi appreciated. Respirations are normal and unlabored with no accessory muscle use.
Abdomen –Small scar in left lower quadrant/ perineal region from left inguinal hernia surgery. Abdomen is soft, non-distended, and non-tender to palpation in all 4 quadrants with no guarding or rebound, no palpable/pulsatile masses, no CVA tenderness, tympanic throughout
Bowel sounds are present and normoactive throughout all 4 quadrants.
Genitourinary Exam-Penis- uncircumcised, + swelling, + phimosis, no discharge
Scrotum- + marked swelling, + erythema and induration from left posterior scrotum extending to left perineum and left anterior buttock. Small sinus tract on left perineum with 2×2 cm open wound with no active drainage. Left anterior buttock- 1×1 cm open wound with necrotic tissue. + crepitus at left perineum, foul odor.
R perineum and buttock slightly erythematous, no open wounds/ drainage/ necrotic tissue
Dimension, drainage, skin around it
Rectal- deferred
Extremities – 2+ peripheral pulses. No edema, clubbing, cyanosis, or ulcerations. Full ROM
Psych – A/O x 3, no agitation.
Neuro – No focal deficits, no gait abnormalities
DIFFERENTIAL DIAGNOSIS
- Fournier’s Gangrene- pt has severe pain and swelling in perineal area, as well as erythema and signs of necrosis (areas of black discoloration), crepitus, foul odor, draining
- Scrotal Abscess-pt has pain, swelling, and erythema of scrotum, as well as draining
- Cellulitis- pt has pain, swelling, and erythema of the scrotum, but no streaking
- Strangulated Hernia- pt has pain, swelling and erythema of scrotum, but not caused by straining or certain activity.
LABS (1/24/22 @ 14:25)
CBC :
WBC- 23.77
Hemoglobin/ Hematocrit- 15.9/ 46.2
MCV-88.8
MCH- 30.6
RDW- 12.9
RBC-5.3
Platelets-298
Neutrophils- 95%
Lymphocytes-1%
Monocytes-4%
Electrolytes
Na- 129
K-4.0
Cl-87
CO2-24
HCO3-24.8
BUN-38.7, Cr-1.15, BUN/Cr ratio- 34
Glucose- 396
Anion Gap-18
Calcium– 1.07
Magnesium- 1.8
Phosphorus-4.3
VBG:
PH- 7.36
PCO2-43
PO2-79
Liver Function Tests:
Protein-6.3
C-reactive Protein-23.44
Albumin- 3.2
Globulin-3.1
Total bilirubin-0.8
Direct bilirubin-0.6
Indirect Bilirubin-0.2
AST-20
ALT-23
Alkaline Phosphatase-186
Coags:
PT-15.9
PTT-30.7
INR-1.38
Lactate-6.8
COVID – negative, 1/24/22
Urinalysis:
Glucose- 500, trace ketones, specific gravity- 1.032, blood-negative, PH-5.0, Protein-30, nitrite-negative, leukocyte esterase- negative, WBCs-3, RBCs-2, Bacteria-negative, Squamous epithelial cells- 3, hyaline casts- 4
IMAGING/TESTS
CT Abdomen/Pelvis with IV Contrast
Findings: Diffuse scrotal wall thickening and infiltration, air/gas within left scrotum also involving adjacent perineum and medial upper thigh
DIAGNOSIS: Fournier’s Gangrene
ASSESSMENT
71 y/o male PMH HTN, HLD, DM2, COPD, BLLE cellulitis, and obesity who presented to ED ℅ drainage of a scrotal abscess x 3 days. Pt was seen by outpatient urologist today and sent to ER. Upon ER examination and subsequent CT scan, found to have Fournier’s Gangrene. Plan for urgent surgical debridement of left scrotum, perineum, and possible buttock.
PLAN
- Fournier’s Gangrene
- Admit to urology under Dr. Amirian’s service, for Fournier’s Gangrene, send to OR for urgent left scrotal, perineal, and possible buttock debridement
- Broad Spectrum IV antibiotics- Clindamycin IVPB 900 mg in 50 mL D5W, Zosyn 4500 mg in 100 mL D5W, Vancomycin 1,00 mg
- Diet- NPO except meds
- IV Fluids- NaCl .9% infusion continuous solution 125 mL/hr
- Check urine culture, and blood culture
- Pain Control- Fentanyl
- Foley catheter- strict I’s/O’s
- Repeat labs after surgery, trend WBC’s, H/H, lactate
- Hyperglycemia-insulin sliding scale
- DVT prophylaxis – Enoxaparin 40mg SQ QD
- Obesity- when stable, discuss with patient about the importance of healthy eating and exercise, potential dangers of obesity
- 100 pk/yr smoker- Discuss with patient the dangers associated with smoking and options available to assist with smoking cessation
- Leg Ulcer- perform wound care
- Urinary symptoms- refer to outpatient urologist for evaluation for BPH
- BLLE Cellulitis- continue clobetasol and mupirocin
- Hypertension-well-controlled, continue lisinopril-hydrochlorothiazide and furosemide
- Hyperlipidemia- well-controlled, continue simvastatin
- Disposition- patient to remain in SICU after surgery for observation and possible repeat surgical debridement
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