H&P:
Identifying Information:
Name – HS
Sex – Male
DOB – 4/5/1965, 56 y/o
Date – 1/31/22, 11:00 am
Location – Woodhull ER
Source of Information – Self
Source of referral/transportation – Self
Chief Complaint: genital pain and swelling x 2 weeks
HPI:
HS is a 56 y/o M with a PMHx of HTN, asthma and arthritis c/o scrotal pain and swelling x2 weeks. Patient states the swelling and pain came out of nowhere, has been gradual and worsening in the past 4 days. Pain and swelling is associated with dysuria and for the past 48 hours has been unable to pass urine. The pain is mainly in his scrotum, radiates to his perineum, is constant, 9/10 in severity. Patient has never experienced this before. Reports that he hasn’t taken any medications to alleviate his sx, nothing makes it significantly worse. Patient admits to a h/o of inguinal hernia for which he was supposed to get surgery in September but didn’t. Denies fever, chills, trauma to the groin, pruritus, hematuria, insect bite, chest pain or any other acute symptoms or concerns.
Past Medical History:
Arthritis, Asthma, HTN
Past Surgical History:
L hip arthroplasty – 2015
Allergies:
No known food, drug or seasonal allergies
Family History:
Father – alcohol abuse
Brother – drug abuse
Medications:
Albuterol (Proventil HFA; Ventolin HFA) 108 mcg/act inhaler – inhale 2 puffs prn
Losartan (Cozaar) 50 mg tablet – 50 mg PO qd
Sertraline (Zoloft) 100 mg tablet – 100 mg PO qd
Aripiprazole (Abilify) 20 mg tablet – 20 mg PO qd
Fluticasone 110 mcg/act inhaler – inhale 1 puff BID
Gabapentin (Neurontin) 300 mg capsule – 300 mg qd
Social History:
HS is a 56 y/o single male, lives with his brother. Works in maintenance. Patient admits to cocaine and alcohol use (3 standard drinks/week), denies tobacco use or other illicit drug use. Patient is not currently sexually active but admits to using protection when he is. Denies recent travel. Patient sleeps well, usually 7 hours a night. Makes effort to exercise and eat well.
Review of Systems:
General –Denies fever, chills, night sweats, fatigue, weakness, recent weight loss or loss of appetite.
Skin, Hair, Nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or change in hair distribution.
Head – Denies headache, vertigo, head trauma, unconsciousness, coma or fracture.
Eyes – Denies contacts, glasses, visual disturbances, fatigue, lacrimation, photophobia or pruritus. Pt doesn’t know when her last eye exam was.
Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.
Nose/Sinuses – Denies discharge, epistaxis or obstruction.
Mouth and Throat – Denies bleeding gums, sore throat, sore tongue, mouth ulcers, voice
changes, dentures. Pt’s last dental exam was 6 months ago.
Neck – Denies localized swelling/lumps or stiffness/decreased range of motion.
Breast – Denies lumps, nipple discharge or pain.
Pulmonary System – Denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea or PND.
Cardiovascular System – Denies chest pain, HTN, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur.
Gastrointestinal System – Denies abdominal pain, change in bowel habits, change in appetite, intolerance to foods, N/V, dysphagia, pyrosis, flatulence, eructation, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, blood in stool, stool guaiac/colonoscopy/sigmoidoscopy or pain in flank.
Genitourinary – Admits to oliguria, difficulty voiding, dysuria, penile swelling and scrotal swelling. Denies urinary frequency, change in color of urine, incontinence, nocturia, urgency, or polyuria.
Sexual History – Denies sexual activity, impotence, sexually transmitted infections or the use of contraception/protection.
Musculoskeletal System – Admits to hx of arthritis. Denies any pertinent muscle/joint pain or muscle wasting.
Peripheral Vascular System – Denies intermittent claudication coldness or trophic changes, varicose veins, peripheral edema or color change.
Hematologic System – Denies anemia, easy bruising or bleeding, lymph node enlargement or history of DVT/PE.
Endocrine System – Denies polydipsia, polyphagia, polyuria heat or cold intolerance, goiter or hirsutism.
Nervous System – Denies seizures, loss of consciousness, sensory disturbances (numbness, paresthesia, dysesthesias, hyperesthesia), ataxia, loss of strength, change in cognition/mental status/memory or weakness (asymmetric).
Psychiatric – Admits to seeing a mental health professional. Denies depression/sadness (feelings of helplessness, feelings of hopelessness, lack of interest in usual activities, suicidal ideation), anxiety, obsessive/compulsive disorder.
Physical Exam:
General:
56 y/o M is A&O x3, interactive, in acute distress and ill-appearing.
Vital signs:
BP: 130/81 (R arm, supine)
RR: 16 breaths/min, unlabored
Pulse: 100 beats/min, regular rhythm
Temp: 99.7 F
SpO2: 96% on room air
Height: 5’7”
Weight: 230 lb
BMI: 36.02 kg/m2
Cardiovascular:
Normal rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.
Pulmonary:
No obvious deformities or trauma to the chest. Pulmonary effort is normal, respirations unlabored, no use of accessory muscles. Lat to AP diameter is 2:1, non-tender to palpation. Lungs are clear to auscultation bilaterally, normal breath sounds, no adventitious sounds.
Abdominal:
Bowel sounds are normoactive, mainly tympanic to percussion with hyperresonance in the lower abdominal wall. Lower abdomen has tenderness and shows diffuse erythema induration confluent with perineal changes (see perineum/genitalia exam). Abdomen is soft, no guarding or rebound noted, no peritoneal signs, no hepatosplenomegaly, no CVA tenderness appreciated. All special tests negative.
Genitourinary:
Tanner stage 5 male, circumcised. Marked erythema, blisters and induration to the scrotum and perineum. Marked swelling and tenderness to palpation of the perineum and genitalia. No bowel sounds appreciated on auscultation of the scrotum.
Neurological:
Mental status – pt is A&O x3. No slurred speech or aphasia. Complete comprehension and insight into medical problems. Memory intact, reliable historian.
Differential Diagnoses:
1. Necrotizing fasciitis, Fournier’s Gangrene – patient is in acute distress and ill-appearing, presents with excruciating scrotal pain and swelling for 2 weeks which has worsened in the past few days. Significant amount of swelling, erythema, blisters on inspection and tenderness on palpation involving the scrotum, penis, perineum.
2. Incarcerated inguinal hernia – patient presents with genital pain and swelling, admits to a history of inguinal hernia for which he was supposed to get surgery for but didn’t. Patient has scrotal swelling on physical exam. Potentially incarcerated as patient is ill-appearing and in acute distress.
3. Orchitis/epididymitis – patient presents with scrotal pain, swelling and tenderness which appeared suddenly but was gradual in onset. Patient also presents with associated symptom of dysuria. Patient is not nauseated and hasn’t vomited. Less likely as patient’s signs/symptoms are bilateral, the whole scrotum is tender and erythematous not just the epididymal region (posterior and superior to the testicle).
4. Testicular torsion – patient presents with scrotal pain. Patient’s scrotum is swollen and tender. Less likely as this dx is most commonly seen in males 10-20 years old and in neonates. The pain with testicular torsion is more abrupt in onset and the testicle is retracted, potentially a horizontal lie, on physical exam. Consider anyway due to it being a true urologic emergency.
5. Acute cystitis – patient presents with scrotal pain and swelling a/w dysuria and difficulty passing urine. Less likely as patient has no other irritative symptoms, no hematuria.
Labs: WBC – 11.40, abs neut – 10.38, CO2 – 19, anion gap – 19, lactic acid – 2.2, PT/INR 15.9/1.34
CBC:
WBC – 11.40
RBC – 4.91
HgB – 14.3
HCT – 43.2
PLT – 276
Neutrophil Abs – 10.38
CMP:
Na – 140
K – 5.0
Cl – 102
CO2 – 19
BUN – 39
Cr – 1.75
eGFR – 42.6
Glucose – 144
Ca – 8.9
Anion gap – 19
Albumin – 3.3
Total protein – 5.4
Total bilirubin – 0.8
Alk phos – 97
ALT – 12
AST – 16
Lipase – 7
Lactic acid – 2.2
PT – 15.9
INR – 1.34
aPTT – 31.1
Imaging:
ECG – WNL
CT Abdomen and Pelvis –
Findings: There is extensive subcutaneous edema anterior to the pelvis soft tissue and proximal thigh with extensive subcutaneous air tracking in the perineum, scrotal area with marked scrotal edema, air in the scrotum along with large hydroceles b/l. There is also calcification at the glans penis. There is also subcutaneous edema extending through the R inguinal canal which is patent and spermatic cord vessels in the R internal canal being dilated and edematous but no herniated loops of bowel. No evidence of bowel obstruction. Bladder is distended and smooth in contour.
Impression: Fournier’s gangrene. R inguinal hernia containing fat and edematous spermatic cord vessels but no herniated loop of bowel. No evidence of appendicitis, diverticulitis or GI obstruction.
Assessment:
HS is a 56 y/o M with a PMHx of HTN, asthma and arthritis c/o scrotal pain and swelling x2 weeks. Likely Fournier’s gangrene – necrotizing soft tissue infection of the perineum requiring urgent surgical exploration and debridement.
Plan:
Booked with urology for emergent surgical exploration
Rapidly administer broad spectrum abx (Vanco and Zosyn)/bolus fluids
EKG stat
Patient Education:
Patient educated on need for emergent surgical exploration and risks and benefits of such. Patient demonstrated understanding and consents to surgery.
Procedure: Penoscrotal, groin, thigh and abdominal wall exploration and wound debridement, insertion of suprapubic tube
– Copious necrotic and purulent gaseous and liquid material was evacuated
– Finger dissection of all purulent pockets within the scrotum, penis, perineum, thigh, groin and tracked all the way up to the abdominal wall up to nearly the nipples.
– All necrotic skin and tissue debrided down to healthy appearing viable tissue.
– Pt kept intubated and brought to ICU for management and resuscitation.
– Will likely require another exploration in 48-72 hours with further debridement.
