A 63-Year-Old Man with Recent Elective Right Inguinal Hernia Repair

question 124

Multiple Choice

A 63-year-old man with recent elective right inguinal hernia repair comes to the emergency department with pain and swelling of the right thigh.  The pain began the night before and he could not sleep well despite taking oxycodone and acetaminophen.  The patient has mild hypertension and type 2 diabetes requiring daily long-acting insulin.  He also suffers from resistant fungal infection of the toenails.
His temperature is 38.4° C (101° F) , blood pressure is 110/72 mm Hg, and pulse is 124/min and regular.  His lungs are clear to auscultation.  A faint systolic murmur is heard at the base.  His abdomen is soft and nontender.  The surgical incision looks clean with minimal amount of gray discharge.  The right inner thigh has a large area of erythema and swelling that is very tender on superficial palpation.  Several small vesicles containing pink fluid with surrounding purpura are also present.
Laboratory results are as follows:

Which of the following is the best next step in management of this patient?

• A)Duplex ultrasound of the lower extremities
• B)Intravenous penicillin G and metronidazole
• C)Surgical consultation
• D)Transesophageal echocardiogram
• E)Valacyclovir

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