HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who presented with a three-day history of lower abdominal pain, radiating to the patient’s left flank. Also, reporting gross hematuria for the past one week, initially subsided, then resumed. The patient reports having a history of renal stones with similar symptoms, so the patient this time was under the assumption that he was passing a kidney stone.
However, when the patient’s pain became intolerable, he decided to come to the hospital. The patient is also reporting scrotal swelling with gradual worsening. He has been taking Tylenol for pain and fever relief and had some response, but the pain did not respond fully to the Tylenol. He denies any cough, chest pain, shortness of breath, or palpitation, but he reports having nausea, vomiting, dysuria, and subjective fever. He denies any trauma.
PAST MEDICAL HISTORY: Significant for nephrolithiasis, status post lithotripsy.
MEDICATIONS: On admission, Tylenol and Advil at home.
SOCIAL HISTORY: The patient has a history of one-pack-year, social drinking of alcohol.
FAMILY HISTORY: Significant for diabetes in the patient’s brother and sister.
PHYSICAL EXAMINATION:
VITAL SIGNS: Upon admission, temperature of 101.4 degrees Fahrenheit, blood pressure of 126/78, pulse of 104, respirations 18, and oxygen saturation of 93% on room air.
HEENT: Essentially unremarkable with pupils round and reactive to light. Extraocular movements intact. Sclerae anicteric and conjunctivae clear. Moist mucous membranes. Oropharynx was without any exudate or erythema.
NECK: Supple. No jugular venous distention. No lymphadenopathy.
CARDIAC: S1, S2 with regular rate and rhythm. No murmurs, rubs, or gallops appreciated.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft and nondistended. Positive normoactive bowel sounds. However, tenderness to palpation over the lower abdomen.
EXTREMITIES: Without any clubbing, cyanosis, or edema, 2+ dorsalis pedis and posterior tibial pulses bilaterally.
GENITOURINARY: Examination revealed left scrotum warm, erythematous, tender, firm, indurated upon palpation with extensive edema. No discharge was noticed from the urethra. Positive inguinal lymphadenopathy in the left inguinal region.
RECTAL: Examination indicated severely enlarged prostate, stool guaiac negative.
NEUROLOGICAL: Cranial nerves II through XII grossly intact. No focal deficits, 5/5 power in all extremities.
LABORATORY DATA: White blood cell count of 20,200, hemoglobin 14.6, hematocrit 41.4, and platelets 312,000. Sodium 134, potassium 3.6, chloride 96, and bicarbonate 24. BUN 12 and creatinine 0.8. Glucose levels were high at 330. Urine dipstick indicated positive heme, positive nitrites, 10-25 wbc’s.
The patient was sent for an ultrasound of his scrotum, which indicated left epididymal orchitis given the heterogeneous appearance of the left testicle; however, neoplastic involvement could not be ruled out at that time. There was no evidence of urinary stone or obstruction.
The patient also had a CT scan of the abdomen and pelvis, which indicated that there was no stone within the kidneys, ureters, or bladder. There was a 1.7 cm area of low attenuation, involving the mid pole of the right kidney anteriorly compatible with a cyst. There was no evidence of hydronephrosis or perinephric stranding. The ureters were normal in caliber and course. Also, it indicated an enlarged prostate measuring approximately 6.6 x 6.8 cm. Prostate demonstrated posterior impressions on the bladder. There was no free pelvic fluid. A small left inguinal hernia was also noted. There were inflammatory changes involving the scrotal base, extending to the surface.
Prostate demonstrated posterior impressions on the bladder. There was no free pelvic fluid. A small left inguinal hernia was also noted. There were inflammatory changes involving the scrotal base, extending to the surface.
HOSPITAL COURSE: Based on the patient’s presentation and lab data, the patient was admitted to the medical floor and was put on IV antibiotics, including initially intravenous Levaquin 500 mg as well as intravenous Zithromax 500 mg. Of note, the patient’s oxygen saturation, as mentioned before, was on the low side initially, so a chest x-ray was ordered to evaluate for possible pneumonic process. The lungs were clear and cardiomediastinal shadow was unremarkable. Later on, the patient’s antibiotic regimen was changed a bit. He was continued on IV Levaquin; however, the Zithromax was discontinued, and the patient was put on Bactrim. The patient was seen by the Urology group, who agreed with antibiotic course as well as recommended continued jock support or scrotal support and advised on awaiting urinary cultures and sensitivities and adjust intravenous IV treatment accordingly. The urine cultures came back positive for Klebsiella pneumoniae, which was sensitive to Levaquin and Bactrim. The patient was continued on the above antibiotics, and concomitantly, the patient’s newly diagnosed diabetes was being entertained.
Later on, the patient’s antibiotic regimen was changed a bit. He was continued on IV Levaquin; however, the Zithromax was discontinued, and the patient was put on Bactrim. The patient was seen by the Urology group, who agreed with antibiotic course as well as recommended continued jock support or scrotal support and advised on awaiting urinary cultures and sensitivities and adjust intravenous IV treatment accordingly. The urine cultures came back positive for Klebsiella pneumoniae, which was sensitive to Levaquin and Bactrim. The patient was continued on the above antibiotics, and concomitantly, the patient’s newly diagnosed diabetes was being entertained.
Lab work was done, and hemoglobin A1c came back 9.8. Lipid profile was also done, indicating cholesterol of 122, triglycerides 154, HDL of 12, and LDL of 80. The patient was put on Accu-Chek as well as sliding scale coverage with regular insulin as well as Glucotrol 5 mg daily. The patient’s glucose levels remained stable while in the hospital. PSA level was also sent in light of the fact that the patient’s prostate was enlarged. Levels came back at 8.82.
The patient continued to improve clinically as well as remained hemodynamically stable with stable vital signs, afebrile, with scrotal swelling improving gradually. The patient remained stable, and it was decided to discharge the patient to home with followup in three weeks as well as followup with Urology. The patient was put on ciprofloxacin 500 mg twice daily for three weeks as well as Bactrim DS one tablet twice daily for three weeks in addition to Motrin 600 mg three times daily and glyburide 5 mg once daily. Recommendations for scrotal support and, as mentioned before, follow up with Urology, perhaps in one week to reassess the patient’s epididymal orchitis as well as further followup for high PSA levels as mentioned before, which perhaps could be due to the inflammatory process that was going on at the time of admission. The patient’s pain remained under control initially with Percocet tablets, and later on, it was changed to Motrin 600 mg three times daily.
FINAL DIAGNOSES:
1. Left-sided epididymal orchitis.
2. Newly diagnosed diabetes mellitus.
