Board Review: Down the watering hole


A 78 year old male with a history of obesity, DM, HTN, and alcohol use disorder presents to the ED with fever. He appears lethargic and is unable to provide further history. VS are as follows: T38C HR 120 BP 95/55 RR 20 SpO2 98%. A nurse connects the patient to continuous monitoring and obtains IV access. While examining the patient you notice his scrotum appears darkly erythematous and edematous with crepitus. What do you do next?
A. Perform a bladder US at the bedside
B. Order a stat CT chest/abdomen/pelvis
C. Start broad spectrum antibiotics
D. Call Surgery 
















This patient is hemodynamically unstable with pertinent physical exam findings that are highly suspicious for Fournier gangrene, a rapidly progressive necrotizing polymicrobial infection of the male scrotum, penis, and perineum. The only treatment for this condition is surgical debridement, which should not be delayed by any imaging. Broad spectrum antibiotics should be started as well, but what will save this patient’s life is the OR. *This post is also your reminder to examine the entire patient in the ED, including the older and obtunded!