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Arthrocentesis
43%
3/7
Azithromycin, ceftriaxone, and vancomycin
57%
4/7
Ibuprofen and observation
0%
0/7
Methotrexate
MRI
Select Answer to see Preferred Response
This patient likely has a sexually transmitted disease (given his urethral discharge and dysuria) and a migratory arthritis that has localized suggesting a diagnosis of reactive arthritis, gonococcal arthritis, or septic arthritis. He should first be managed with arthrocentesis prior to treating his condition. Reactive arthritis, also called Reiter syndrome, is the most common type of inflammatory polyarthritis in young men. It is more common in those with the HLA-B27 genotype and occurs in those with infections with organisms such as Chlamydia trachomatis (though Salmonella, Shigella, and Campylobacter are less frequent causes). It commonly presents with polyarthritis, conjunctivitis, uveitis, and genitourinary symptoms such as dysuria, polyuria, and penile discharge. The differential for a red, hot, tender, and inflamed joint includes gonococcal arthritis or septic arthritis. Prior to treatment, any patient with a red and hot joint should have arthrocentesis and fluid analysis performed and have a swab for gonorrhoae and chlamydia sent off. Subsequently, the patient can be treated with broad-spectrum antibiotics and surgical washout (if indicated). Incorrect Answers: Answer 2: Azithromycin, ceftriaxone, and vancomycin are broad-spectrum antibiotics that cover both for this patient's STD and a septic arthritis. These antibiotics may be started after arthrocentesis and GC/chlamydia testing have been performed. Answer 3: Ibuprofen and observation is appropriate management of osteoarthritis which presents with cool/normal skin in a weight bearing joint typically in an obese patient. Answer 4: Methotrexate is a disease-modifying antirheumatic drug (DMARD)that is indicated for long-term management to improve outcomes and reduce the incidence of permanent joint deformity in rheumatoid arthritis which presents in a middle-aged woman with symmetric joint pain that is worse in the morning and improves throughout the day. Answer 5: MRI is an appropriate diagnostic test for osteomyelitis which may present with focal bone pain, a fever, and an elevated ESR/CRP. It would not offer culture results and a gram stain/crystal analysis necessary to diagnose this patient's possible septic arthritis. Bullet Summary: A red, hot, inflamed, and tender joint is concerning for septic arthritis and must initially be managed with arthrocentesis.
4.5
(8)
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