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Afebrile patient with a swollen knee… April 30, 2012

Posted by Andy Jagoda, MD in : Uncategorized , trackback

A middle-aged man with diabetes and hypertension has been waiting patiently to be seen, with a complaint of right knee pain and swelling that has gradually progressed over several hours. There is no history of trauma, recent or remote, but he describes several goutlike episodes of pain in both feet in recent years, which improved with rest and NSAIDs. He was triaged as an ESI4, and the waiting room is packed. Fortunately, the charge nurse comments on how uncomfortable he looks and he is brought into the ED for evaluation. The patient is afebrile, but the knee is hot, beefy red, and swollen. The ED is over-capacity and the patient’s history is reassuring, so you consider keeping him in a chair. But that knee looks impressive and you wonder if your plan is aggressive enough.

What do you do next?

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Comments»

1. The latest What’s Your Diagnosis… « What's Your Diagnosis? - April 30, 2012

[…] challenge, titled “Afebrile patient with a swollen knee,” has been posted on our new location; check it out here. Like this:LikeBe the first to like this […]

2. Omer - May 1, 2012

this may be acute gout

3. Kenneth Hirsch MD - May 1, 2012

I’d order labs (CBC,lytes,ESR,Lyme titer, Uric acid level), X-ray, and pain meds. Also move pt to a stretcher for better exam.

4. Else Ribbe - May 1, 2012

christalloid synovitis

5. Dr Papa - May 1, 2012

It is most likely a Bakers Cyst also called popliteal cyst. Anti-inflammatory drugs, NSAIDS are given to relieve pain and inflammation. If does not reduce and pain persists,should resolve with aspiration of excess knee fluid along with cortisone injection in the joint.

6. Dr Papa - May 1, 2012

Ruptured Bakers Cyst !

7. Judith - May 1, 2012

middle aged man with monoarthropathy being patient even though unwell: I would consider gonorrhoea, needs to be examined lying down, if an effudion is present this needs to be send for urgent gram stain

8. susan - May 1, 2012

most importantly r/o acute septic arthritis with his hx dm…cbc, crp, cmp. tap is most definitive

9. Dr.Omar Farid - May 1, 2012

the first step is to releiving the patient pain and discomforte then put pt flat on bed and flexed his knee for orthocentosis if effusion is present then see the color and send sample for lactate and wbc and synovial culture and gram stain ,after you diagnostic of septic arthritis start antibiotic(vancomycin and ceftriaxon) and prepare pt for operation and consult orthopediac surgery.

10. Adam - May 1, 2012

Septic arthritis until proven otherwise. Arthrocentesis if overlying cellulitis is not impeding the entry point. CBC, BMP, Uric acid. Indomethacin, colchicine.

11. dr. ahmad al ani - May 1, 2012

please x-ray , mri may be indicated befor suggestion of any diagnosis.my suggestion is with osteoarthrosis

12. Ron Koury - May 1, 2012

tap it. send for culture/sens/g stain/cell ct/crystals/,…,…
start IV Abx/pain meds,… and consider admission vs. solid F/U with ortho,…

13. TG - May 1, 2012

Wow, Maybe you should refer to orthopaedics? Adam & Susan are correct, an arthrocentesis. Assume the worse, a septic knee, but gout is more likely. A cell count, gram stain, C & S and a microscopic inspection for uric acid or calcium pyrophosphate crystals should be done. Omar is right start antibiotics until you know but he forgot the cryatalline exam. A CBC, uric acid level (done fasting?) are all indirect tests and not as Susan said definitive. A ruptured Bakers cyst would ordinarily present as painful and with calf swelling. If these are all negative then you have the time to workup for the unusual like Lyme’s disease, an inflammatory monarthropathy or a osteoarthrosis. Dx-Acute gout r/o septic arhtritis. TG

14. Marylène Crépin - May 2, 2012

R/o septic arthritis first, even without fever

15. dr suresh naidu - May 2, 2012

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

16. Dr santosh pathak - May 2, 2012

resp sir my diagnosis is the patient may suffering from siatica. all symtoms are looking like this

17. dr mona jawish - May 2, 2012

may be acute gout

18. dr mona jawish - May 2, 2012

even it is in knee but could be acute gout

19. Ajeet Dube - May 2, 2012

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.

20. Anda Piebalga - May 3, 2012

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

21. Dr.Arif Karagöz - May 4, 2012

I think septic arthritis first,than acute gout.

22. rita cohen - May 5, 2012

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 )

23. Rauvan Averick - May 5, 2012

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.

24. Dr.A.Lalitha - May 6, 2012

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.

25. rita cohen - May 26, 2012

Acute monoarthritis can be the initial manifestation of many joint disorders.
The first step in diagnosis is to verify that the source of pain is the joint, not the surrounding soft tissues.
The most common causes of monoarthritis are crystals (i.e., gout and pseudogout), trauma, and infection.
Examination of joint fluid often is essential in making a definitive diagnosis.
Leukocyte counts vary widely in septic and sterile synovial fluids and should be interpreted cautiously. If the history and diagnostic studies suggest an infection, aggressive treatment can prevent rapid joint destruction. When an infection is suspected, culture and Gram staining should be performed and antibiotics should be started. Fever and tachycardia may signal infection, but they are not reliable indicators.Light microscopy may be useful to identify gout crystals, but polarized microscopy is preferred.
Referral is indicated when patients have septic arthritis or when the initial evaluation does not determine the etiology.
IN this patient an arthrocentesis is required and is mandatory to rule out infection.Superimposed cellulitis is a relative contraindication to arthrocentesis.Removal of as much synovial fluid as possible offers symptomatic relief and helps to control infection.
If the knee is infected – give IV abx and addmit to orthpedic unit ( the knee might need a was and drainage) , if it is reactive – your choices are , NSAID , colchicine , IM ACTH or steroids .

26. Niko Holmen - May 27, 2012

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27. chandra Sekhar - July 19, 2012

Respected all,

My mother is 54 years old and is suffering from diabetics past 20years. Recently she is under treatment on insulin.

Recently, I observe that her right side knee has developed some swelling and pain is being felt.

Please kindly guide me in this regard so that we can take appropriate steps from further complications

regards,
Sekhar, Hyderabad.

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