allergies: patient recorded as having no known allergies to drugs attending: chief complaint: abdominal and back pain major surgical or invasive procedure: scrotal debridment scrotal flap history of present illness: 70 yo male who initially presented to hospital with lower abdominal pain on but left hospital against medical advice, then re-presented again at the same hospital with similar symptoms, including back pain, fatigue, acute renal failure, and testicular swelling on . he is s/p operative scrotal debridement by urology . he was transferred to for further management. past medical history: htn type ii dm family history: noncontributory physical exam: upon admission: vitals- t 101, hr 67, bp 150/81, rr 33, o2sat 99% 2l gen- moderate distress, alert head and neck- at, nc, soft, supple, no masses heart- rrr, no murmurs lungs- ctab, no rhonchi, no crackles abd- soft, nt, nd, decreased bs perineum- extensive skin and subq tissue debridement of entire scrotum and perineal region, left testicle pallorous, no obviously necrotic tissue, no emphysematous or erythema of surround skin, exquisitely tender ext- warm, well-perfused, no edema pertinent results: 06:00am blood wbc-13.3* rbc-3.17* hgb-8.5* hct-26.2* mcv-83 mch-26.8* mchc-32.5 rdw-14.9 plt ct-409 06:15am blood wbc-13.5* rbc-3.28* hgb-8.7* hct-27.0* mcv-82 mch-26.6* mchc-32.4 rdw-15.2 plt ct-528* 05:40am blood wbc-11.3* rbc-3.67* hgb-9.8* hct-30.4* mcv-83 mch-26.7* mchc-32.2 rdw-14.8 plt ct-510* 8:53 am stool consistency: loose source: stool. **final report ** clostridium difficile toxin assay (final ): feces negative for c. difficile toxin by eia. (reference range-negative). radiology report duplex dop abd/pel limited study date of 2:26 am scrotal ultrasound: the right testicle measures 2.7 x 2.8 x 3.8 cm. the left testicle measures 3.2 x 2.5 x 2.6 cm. there is no subcutaneous gas. within the tissues superior to the testicles bilaterally, heterogeneously echogenic, irregular soft tissue swelling is present. this is distinct from the testicles. the epididymis is unremarkable bilaterally. color and doppler examination of the testicles reveal normal arterial and venous waveforms in the right testicle. however, the left testicle shows an overall relative decrease in blood flow, and no arterial waveforms are identified. venous flow is present. impression: 1. no ischemic changes in the left testicle, but no arterial flow is visualized, though strangely venous flow is. this raises concern for developing ischemia of the left testicle. normal arterial and venous waveforms in the right testicle. 2. massive subcutaneous swelling superficial to the testes. no subcutaneous air. findings discussed with dr. at 10:15 a.m. radiology report scrotal u.s. study date of 4:06 pm findings: each testicle has been repositioned superiorly into the inguinal region of the ipsilateral side. the right testicle measures 3.1 x 2.0 x 2.7 cm. the left measures 3.3 x 1.7 x 2.8 cm. the right testicle again shows normal color doppler flow, as well as spectral arterial and venous waveforms. compared to the right, the left again shows less overall vascularity than the right on color doppler imaging. doppler waveforms can be obtained in the left testicle which shows venous flow as well as greater pulsatile activity suggestive of low-level arterial flow. except for the appearance of greater pulsatility suggestive of arterial flow, there has been no significant change. impression: similar appearance of reduced vascularity of the left testicle compared to the right, although there is greater pulsatility in the doppler waveforms of the left testicle suggestive of low-level arterial flow. brief hospital course: he was admitted to the surgical service under the care of dr. . he was initially taken to the surgical icu where he remained for several days. infectious disease was consulted and his antibiotics were changed to vancomycin, levofloxacin and flagyl. he did have blood cultures drawn on and they were negative; a stool for c-diff was sent and was also negative. twice daily dakin's dressing changes were continued. urology was consulted and he underwent scrotal ultrasound to assess for residual infection and for flow. he was transferred to the regular nursing unit. he continued to have ongoing pain control issues; requiring iv narcotics initially, and this was changed to pca. plastic surgery was then consulted for possible flap; he was taken to the operating room on for open wound extensive debridement of skin, subcutaneous tissue and bilateral local advancement flap elevation with baring of the scrotum in the abdominal and a suprapubic cavity. his antibiotics, levofloxacin and flagyl were continued and will need to continue for another week following the surgery. his foley catheter was removed; there was a fecal incontinence pouch system previously in place to keep open wound clean; this was also removed. his pain was much less postoperatively, he no longer required iv narcotics and was changed to an oral pain regimen using long and short acting narcotics. he was evaluated by physical therapy and they have recommended rehab after acute hospital stay. medications on admission: lisinopril 40', metformin 500", glyburide 5", humulin insulin 20 qhs, diltiazem xr 240', hctz 25', atenolol 50' medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) ml injection tid (3 times a day). 2. diltiazem hcl 240 mg capsule, sustained release sig: one (1) capsule, sustained release po daily (daily). 3. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 4. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily): hold for sbp>110. 5. levofloxacin 750 mg tablet sig: one (1) tablet po q24h (every 24 hours). 6. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po bid (2 times a day): hold for sbp<110; hr<60. 7. morphine 30 mg tablet sustained release sig: one (1) tablet sustained release po q12h (every 12 hours). 8. oxycodone 5 mg tablet sig: 2-3 tablets po q3h (every 3 hours) as needed for breakthrough pain. 9. metronidazole 500 mg tablet sig: one (1) tablet po q 8h (every 8 hours). 10. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed for constipation. 11. metformin 500 mg tablet sig: one (1) tablet po bid (2 times a day). 12. hydrochlorothiazide 12.5 mg capsule sig: one (1) capsule po daily (daily): hold for sbp<110. 13. gabapentin 100 mg capsule sig: two (2) capsule po bid (2 times a day). 14. acetaminophen 500 mg tablet sig: two (2) tablet po q6h (every 6 hours). 15. insulin nph human recomb 100 unit/ml suspension sig: forty (40) units subcutaneous qam @ breakfast. 16. insulin nph human recomb 100 unit/ml suspension sig: twenty (20) units subcutaneous hs. 17. regular insulin sliding scale sig: one (1) dose subcutaneous four times a day as needed for per sliding scale: see attached sliding scale. disposition: extended care facility: rehabilitation and nursing center - diagnosis: fournier's gangrene condition: hemodynamically stable, tolerating an oral diet, pain being adequately controlled instructions: avoid any extremes of adduction/abduction of hips in order to prevent placing pressure on the scrotum and operative site. followup instructions: follow up this friday at 1:30 p.m. in plastic's clinic with dr. . location: , bldg, surgical specialities call if the appointment needs to be changed. follow up in clinic in weeks, call for an appointment. follow up with your primary care doctor from rehab. Procedure: Other repair of testis Other repair of scrotum and tunica vaginalis Excision or destruction of testicular lesion Excision of lesion of thyroid Excision of varicocele and hydrocele of spermatic cord Diagnoses: Vascular disorders of male genital organs Rash and other nonspecific skin eruption Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Other specified types of hydrocele