12/15/1976 - Laserfiche WebLink

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SEBASTIAN RIVER MEDICAL CENTER SEBASTIAN, FLORIDA 32958 SUMMARY: This 53 year old black male came to the Emergency Room with a history of fever and chills which started all of a sudden and his fever had gone up to 1030. The patient looked toxic and then he disclosed in the history that he had pain in the right testicle, radiating to left inguinal b left epididymis area. He also gave a history of dysuria with frequency or urination and revealed that his urine has been very dirty looking. His past history is unremarkable except that he was admitted to Indian River Memorial Hospital for a knife wound a few years ago. He denies any history of diabetes, hypertens iort..or heart disease. 1 Physical examination on admission revealed a colored male toric looking. His pulse was 108 per minute and blood pressure was 152/80. His respirations were 40 and his temperature was �. 101.20. His head was normocephalic. His right eye is enucleated. His left eye pupil was ! reacting to light and accommodation. There was no neck vein distention. Chest was symmetri- cal. The lungs were clear on percussion and auscultation. Heart was not enlarged and the rhythm was regular. S-1 and S-2 were normal. Abdomen was soft and there was marked tenderness in the left inguinal area and the right testicle area. Prostate was tender. The rest of the physical examination was unremarkable. The IMPRESSION on admission ,.;s Acute Epididymo-orchitis with acute Prostatitis. LABORATORY DATA: On admission his hemoglobin was 16.2; hematocrit 48; WBC was 7,000 with 42 segmented, 20 stabs, 38 lymphos. On 9-1-76 his WBC went up to 22,000 with 72 segmented, 15 stabe, 5 lymphos and 3 monos. His urinalysis on admission showed 4+ bacteruria, 40-45 WBCs. The SMA 12 done on admission showed elevated SGOT, elevated Alkaline Phosphatase of 38, LDH was elevated to 165, BUN was 37, Uric Acid was 8.7, Albumin was 2.8 and Inorganic Phosphorus was 1.9 and Cholesterol was down to 75. The EKG was within normal limits except for sinus tachycardia. VDRL was positive and so was the FTA. Chest x-ray was clear. HOSPITAL COURSE: The patient was admitted and treated as acute epididymo-orchitis. On ..9-1-76 he was noted to have increased swelling of his penis area and began to have severe tenderness with abscess in his pelvic area. He was unable to pass urine and the supra -pubic Cystoscopy had to be done, and the drainage of abscess. Patient was seen in consultation by Dr. McCrystal on 9-1-76 and he found that the patient had a large peri- urethral or peri -rectal abscess extending into the scrotum, both groin and extending midway between symphysis pubic and umbilicus. He was taken to the Operating Room on the same day and a Supra -Pubic Cystostomy and I and D of both inguinal areas was done. An I and D of 1 the perineum was also performed.' The patient drained a huge amount of abscess fluid from that area which showed Proteus Mirabilis on culture. In view of his positive VDRL patient was also treated with penicillin. For his abscess he was put on Nebcin and Bicillin by Dr. McCrystal. The wound was left open.for the drainage to continue and a Supra -pubic Cyststomy was draining to a closed system. The patient had a long course and his healing was secondary granulation tissues. Finally the patient started to get better, his fever came under control and the infection healed very slowly. The healing of his supra -pubic wound as mentioned was by granulation tissue which took a long time to heal. The patient had to kept in the hospital because of his draining wound and continued need for anti- biotic therapy. rFINAL DIAGNOSIS: Peri -urethral abscess, Urethral stenosis secondary to syphilis and gonorrhea. (CONTINUED) PATIENT NXME; 1110SPITAL NUML3ER INNETT, OSCAR 002-445 ADMIZSION DATE: DISCIIARGE LATE; •28-76 10-7-76 J FK/ch d: 11-1-76 A,,n n.....,.. DEL 151976 F. KHAWAJA,M,D. Attending Physician PArg 1 , 480