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M & M

M & M. January 7, 2009 Huron Valley Hospital Brent Zamzow DO. ER 12/13/08 CC : scrotal pain, b/l leg swelling HPI : 69  c/o scrotal redness & pain x 1wk. Scrotal swelling on & off for 1yr. B/l leg swelling x 2wks. Rectal pain & fecal urgency attributed to known fistula

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M & M

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  1. M & M January 7, 2009 Huron Valley Hospital Brent Zamzow DO

  2. ER 12/13/08 • CC: scrotal pain, b/l leg swelling • HPI: 69 c/o scrotal redness & pain x 1wk. Scrotal swelling on & off for 1yr. B/l leg swelling x 2wks. Rectal pain & fecal urgency attributed to known fistula • PMH: nonrheumatoid arthritis (steroid dependent for 3 years), colitis, rectal fistula, diverticulitis, Bell’s palsy, empyema, chronic anemia, elevated LFTs • PSH: colonoscopy, thoracostomy w/ decortication, cataract, eye muscle surgery • Meds: prednisone, aspirin, motrin prn • Allx: PCN, sulfa

  3. 12/13/08 • PE • 35.9 97/57 103 20 • A&O x3, NAD • Scrotal erythema, tender, swollen; b/l thigh & perineum erythema • Rectal fistula w/ stool draining from R buttock • Labs: • WBC 12.9 • Hgb 9.6 • BUN 37, Cr 1.2 • Na 133, K 3.9, Ca 8.0 • Scrotal US – skin thickening b/l consistent with scrotal cellulitis, b/l hydrocele, dense & inhomogeneous L epididymis • Consults • Urology – scrotal pain • General Surgery – rectal fistula • GI – bloody diarrhea • Infectious Disease – scrotal cellulitis/rectal fistula

  4. 12/13/08 CT – Findings most consistent with Fournier’s gangrene. Gas forming infectious agent with cellulitis in the perineum, scrotum & rectal area. Heterogeneous enhancement of kidneys suggesting pyelonephritis.

  5. 12/13/08 • Presented to ER 11:51am • Admitted 3:12pm • Urology Consult 6:22pm • CT Scan done 7:25pm • CT Scan read 10:01pm • OR 11:50pm • Urology - I&D perineum & scrotum - Fournier’s • Gen Surgery – Lap assisted transverse loop colostomy, debridement perirectal/perianal abscess

  6. What Happened? • Sepsis • Late Presentation with rectal fistula • Lactic Acidosis - shock/hypoperfusion vs dead bowel • Wound care - wound vac • Chronic Steroids • Malnourished

  7. Fournier’s • Mortality avg 20% (7-75%) • Higher if late presentation, DM, alcoholics, colorectal source • Na, Ca, anemia (rbc production)

  8. End

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