Date:
Patient:
MRN:
Clincian: (Urologist, General Surgeon)
Reason for Visit:
Evaluation and management of Fournier’s gangrene
Surgical intervention (may be documented in a separate operative note)
Assessment of response to treatment and monitoring for complications
History of Present Illness:
Onset and duration of symptoms (perineal pain, swelling, erythema, crepitus – gas under the skin)
Urinary symptoms (dysuria – painful urination, urinary retention)
Presence of fever or chills
Underlying condition(s) potentially contributing to Fournier’s gangrene (diabetes, immunocompromise, recent surgery)
Past Medical History:
Diabetes mellitus (significant risk factor)
History of genitourinary procedures or infections
Other medical conditions (e.g., peripheral vascular disease)
Social History:
History of intravenous drug use (risk factor for skin infections)
Physical Exam:
Vital Signs: Fever, tachycardia (rapid heart rate) suggestive of infection.
Genitourinary: Inspection for perineal erythema, edema, induration (hardening), crepitus.
Rectal exam (if feasible): Evaluate for rectal involvement.
Imaging:
Urgent imaging studies to assess the extent of tissue involvement:
CT scan with contrast (preferred modality) to visualize soft tissue involvement, gas pockets, and potential abscess formation.
Consider mentioning other imaging studies performed in specific situations:
Doppler ultrasound – to assess blood flow in the affected area
Labs:
Blood tests:
Complete Blood Count (CBC) with differential: Elevated white blood cells suggest infection.
Basic Metabolic Panel (BMP): Evaluate for electrolyte imbalances and potential diabetic ketoacidosis if uncontrolled diabetes is present.
Blood cultures: Identify the causative organism(s) guiding antibiotic selection.
Assessment:
Confirm the diagnosis of Fournier’s gangrene based on clinical presentation, imaging findings, and laboratory tests.
Stage the severity of Fournier’s gangrene using a scoring system (e.g., Fournier’s Gangrene Severity Index [FGSI]).
Identify the potential source of infection (e.g., skin abscess, genitourinary infection).
Assess the hemodynamic status and potential for sepsis.
Plan:
Outline the urgent treatment plan:
Aggressive surgical debridement: Removal of all necrotic and infected tissue to prevent further spread.
Broad-spectrum intravenous antibiotics: Empiric therapy to cover potential pathogens while awaiting culture results.
Fluid resuscitation and hemodynamic support: Correct dehydration and ensure adequate blood flow to healthy tissues.
Consideration of hyperbaric oxygen therapy: May be used to improve tissue oxygenation and promote healing (may not be available in all facilities).
Prognosis:
Briefly discuss the prognosis. Fournier’s gangrene is a life-threatening condition with significant morbidity and mortality. Early diagnosis and aggressive treatment are crucial for improved outcomes.
Potential complications include sepsis, organ failure, and death.
Mention the need for prolonged hospitalization, potential for multiple surgeries, and extensive wound care.
Education:
Document any education provided to the patient and/or family regarding:
The seriousness of Fournier’s gangrene and the need for immediate surgical intervention.
The importance of strict adherence to antibiotic therapy and wound care protocols.
The potential for long-term complications and functional limitations.
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they or their family may have.
Consider mentioning the importance of ongoing monitoring for signs of infection and potential need for additional surgical procedures.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a urologist or general surgeon for diagnosis, treatment recommendations, and prognosis.