169.A 23-year-old man presents to the ED with left lower-abdominal pain
and left testicular pain that started 1 to 2 weeks ago and has gradually
worsened. He denies nausea and vomiting. His HR is 98 beats per minute,
BP is 125/65 mm Hg, temperature is 100.9°F, and RR is 18 breaths per
minute. Physical examination reveals a tender left testicle with a firm nodu-
larity on the posterolateral aspect of the testicle. Pain is relieved slightly
with elevation of the testicle and the cremasteric reflex in normal. Which of
the following is the next best step?
a. Prescribe pain medications and penicillin for coverage of syphilis.
b. Recommend bed rest and scrotal elevation with urology follow-up.
c. Attempt to untwist the left testicle by rotating it in a clockwise direction and
order an immediate scrotal ultrasound.
d. Give ceftriaxone 250 mg intramuscularly (IM), plus a 10-day course of oral
doxycycline.
e. Confirm the diagnosis with transillumination of the testicle, and then consult
urology for surgical drainage.
170.A 40-year-old diabetic man presents to the ED with severe perineal
pain and fever as high as 103°F. Physical examination demonstrates crepi-
tus over the medial thigh and widespread discoloration with sharp demar-
cation over the scrotum. The scrotum is warm and markedly edematous.
His pain appears out of proportion to the physical examination. Which of
the following is the most likely diagnosis?
a. Epididymitis
b. Fournier gangrene
c. Scrotal edema
d. Paraphimosis
e. Testicular torsion
Fever 179