Comments for What's Your Diagnosis? http://www.ebmedicine.net/empblog A diagnostic challenge for emergency clinicians Sun, 06 May 2012 15:18:57 +0000 hourly 1 http://wordpress.org/?v=3.2.1 Comment on Afebrile patient with a swollen knee… by Dr.A.Lalitha http://www.ebmedicine.net/empblog/2012/04/30/afebrile-patient-with-a-swollen-knee/#comment-155 Dr.A.Lalitha Sun, 06 May 2012 15:18:57 +0000 http://www.ebmedicine.net/empblog/?p=59#comment-155 gouty arthritis is a strong possibility in view of the age,gender,past history ,onset over few hours and the clinical signs of acute inflammation involving a single joint in the absence of fever.gout is known to present this way.so workup in the same line is indicated keeping other possibilities in mind in view of the diabetic status. gouty arthritis is a strong possibility in view of the age,gender,past history ,onset over few hours and the clinical signs of acute inflammation involving a single joint in the absence of fever.gout is known to present this way.so workup in the same line is indicated keeping other possibilities in mind in view of the diabetic status.

]]> Comment on Afebrile patient with a swollen knee… by Rauvan Averick http://www.ebmedicine.net/empblog/2012/04/30/afebrile-patient-with-a-swollen-knee/#comment-154 Rauvan Averick Sun, 06 May 2012 03:01:56 +0000 http://www.ebmedicine.net/empblog/?p=59#comment-154 Tap, tap, tap (not your feet, the patient's knee) - and guess what? Five per cent of crystalloid arthritides have positive cultures. History is important - is this simmialr to patient's previous episodes of gout-if so, you could shoot the steroid right in after you drain the joint. And do try to drain in it - the more infalmatory material you get out, the more effective yor therapy will be. This, of course, assumes swollen means there is an effusion present. If it feels like just STS, check it out with sono or X-ray. Tap, tap, tap (not your feet, the patient’s knee) – and guess what? Five per cent of crystalloid arthritides have positive cultures. History is important – is this simmialr to patient’s previous episodes of gout-if so, you could shoot the steroid right in after you drain the joint. And do try to drain in it – the more infalmatory material you get out, the more effective yor therapy will be.
This, of course, assumes swollen means there is an effusion present. If it feels like just STS, check it out with sono or X-ray.

]]> Comment on Afebrile patient with a swollen knee… by rita cohen http://www.ebmedicine.net/empblog/2012/04/30/afebrile-patient-with-a-swollen-knee/#comment-153 rita cohen Sat, 05 May 2012 08:08:54 +0000 http://www.ebmedicine.net/empblog/?p=59#comment-153 we ate discussing monoarthritis in a middle aged patient with diabetes and history of gouty arthritis well treated with NSAID . the question is if the patient have a reactive arhtritis or septic arthritis ' ---> first - i would oreder kidney fx tests + cbc + uric acid level ( nevertheless it can be normal in acute gout)+esr+crp +peripheral cultures second-i would try to aspirate fluid from the knee and send it to - microscopic evaluation for bacteria and gram stain ( the aspiration will r/o infected hemarthrosis ) -slit lamp if i have , for cristals -PMN count from the aspirate knee fluid depending on the results of the peripheral CBC+ count of PMN in the fluid + the gram stain ( and of course the physical exam ) i will treat the patient . if the PMN count in the knee is above 50000 and equivalent the peripheral cont us high + the patient looks septic --> i would addmit him and give IV ABX. if the results will be consistent with reactive erthritis I would discharge the patient with colchicine ( dose adjusted to renal fx and liver fx) as said in the guidelunes for gout / I would also r/o STD ( gonnorhea and VDRL ) we ate discussing monoarthritis in a middle aged patient with diabetes and history of gouty arthritis well treated with NSAID .
the question is if the patient have a reactive arhtritis or septic arthritis ‘ —>

first – i would oreder kidney fx tests + cbc + uric acid level ( nevertheless it can be normal in acute gout)+esr+crp +peripheral cultures
second-i would try to aspirate fluid from the knee and send it to – microscopic evaluation for bacteria and gram stain ( the aspiration will r/o infected hemarthrosis )
-slit lamp if i have , for cristals
-PMN count from the aspirate knee fluid
depending on the results of the peripheral CBC+ count of PMN in the fluid + the gram stain ( and of course the physical exam ) i will treat the patient .
if the PMN count in the knee is above 50000 and equivalent the peripheral cont us high + the patient looks septic –> i would addmit him and give IV ABX.
if the results will be consistent with reactive erthritis I would discharge the patient with colchicine ( dose adjusted to renal fx and liver fx) as said in the guidelunes for gout /
I would also r/o STD ( gonnorhea and VDRL )

]]> Comment on Afebrile patient with a swollen knee… by Dr.Arif Karagöz http://www.ebmedicine.net/empblog/2012/04/30/afebrile-patient-with-a-swollen-knee/#comment-152 Dr.Arif Karagöz Fri, 04 May 2012 07:10:47 +0000 http://www.ebmedicine.net/empblog/?p=59#comment-152 I think septic arthritis first,than acute gout. I think septic arthritis first,than acute gout.

]]> Comment on Afebrile patient with a swollen knee… by Anda Piebalga http://www.ebmedicine.net/empblog/2012/04/30/afebrile-patient-with-a-swollen-knee/#comment-149 Anda Piebalga Thu, 03 May 2012 15:58:27 +0000 http://www.ebmedicine.net/empblog/?p=59#comment-149 Could be sepsis (diabetes!) and purulent arthritis. Then it is very important to take blood culture, control sepsis source and give antibiotics as fast as possible Could be sepsis (diabetes!) and purulent arthritis. Then it is very important to take blood culture, control sepsis source and give antibiotics as fast as possible

]]> Comment on Afebrile patient with a swollen knee… by Ajeet Dube http://www.ebmedicine.net/empblog/2012/04/30/afebrile-patient-with-a-swollen-knee/#comment-148 Ajeet Dube Wed, 02 May 2012 23:02:23 +0000 http://www.ebmedicine.net/empblog/?p=59#comment-148 DDX: acute gout, septic arthritis, cellulitis, occult injury question for risk factors of gonnorrhea (urethral discharge, sexual habits) Given exam must draw blood: cbc, sed rate, cultures, uric acid (poor sensitivity/specificity), crp, knee xray, pain control. dx: likely acute gout tx: steroids, pain meds, colchicine. f/u rheum/ortho to tap or not: if labs Normal likley acute gout treat as such and recommend close f/u with ortho or return to ed in 24 hours if develop fevers or not improving. if labs Abnormal (increase wbc/sed rate) must tap - unless overlying cellulitis is prohibitive, in which case start abx vanc/unasyn, consult ortho and admit. DDX: acute gout, septic arthritis, cellulitis, occult injury
question for risk factors of gonnorrhea (urethral discharge, sexual habits)

Given exam must draw blood: cbc, sed rate, cultures, uric acid (poor sensitivity/specificity), crp, knee xray, pain control.

dx: likely acute gout tx: steroids, pain meds, colchicine. f/u rheum/ortho

to tap or not:
if labs Normal likley acute gout treat as such and recommend close f/u with ortho or return to ed in 24 hours if develop fevers or not improving.
if labs Abnormal (increase wbc/sed rate) must tap – unless overlying cellulitis is prohibitive, in which case start abx vanc/unasyn, consult ortho and admit.

]]> Comment on Afebrile patient with a swollen knee… by dr mona jawish http://www.ebmedicine.net/empblog/2012/04/30/afebrile-patient-with-a-swollen-knee/#comment-147 dr mona jawish Wed, 02 May 2012 19:42:43 +0000 http://www.ebmedicine.net/empblog/?p=59#comment-147 even it is in knee but could be acute gout even it is in knee but could be acute gout

]]> Comment on Afebrile patient with a swollen knee… by dr mona jawish http://www.ebmedicine.net/empblog/2012/04/30/afebrile-patient-with-a-swollen-knee/#comment-146 dr mona jawish Wed, 02 May 2012 19:40:13 +0000 http://www.ebmedicine.net/empblog/?p=59#comment-146 may be acute gout may be acute gout

]]> Comment on Afebrile patient with a swollen knee… by Dr santosh pathak http://www.ebmedicine.net/empblog/2012/04/30/afebrile-patient-with-a-swollen-knee/#comment-145 Dr santosh pathak Wed, 02 May 2012 19:38:05 +0000 http://www.ebmedicine.net/empblog/?p=59#comment-145 resp sir my diagnosis is the patient may suffering from siatica. all symtoms are looking like this resp sir my diagnosis is the patient may suffering from siatica. all symtoms are looking like this

]]> Comment on Afebrile patient with a swollen knee… by dr suresh naidu http://www.ebmedicine.net/empblog/2012/04/30/afebrile-patient-with-a-swollen-knee/#comment-144 dr suresh naidu Wed, 02 May 2012 13:10:35 +0000 http://www.ebmedicine.net/empblog/?p=59#comment-144 do bed side ultrasound of knee...if have effusion do needle aspiration under ultrasound guidence send it for analysis and culture. and of course analgesic before all that do bed side ultrasound of knee…if have effusion do needle aspiration under ultrasound guidence send it for analysis and culture. and of course analgesic before all that

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