inpatient / rheumatology and immunology

Acute Arthritis

Last Updated: 1/19/2023

# Acute Arthritis

-- ABCs: 
make sure patient is not septic with bacteremia, get ortho team involved ASAP if c/f septic joint
-- Chart Check: hardware, previous infections and culture data, h/o gout, diuretic use
-- HPI Intake: joint involved, timing of pain/stiffness, other sxs (fevers, diarrhea, urethritis, ulcers, rashes)
-- Can't Miss: septic joint
-- Admission Orders: CBC, BMP, ESR/CRP, uric acid, BCx if c/f systemic infection
-- Initial Treatment to Consider: artrhocentesis with steroid injection if less c/f septic joint; start abx and analgesia (tylenol, NSAIDs, opioids)

-- History: *** joints involved, duration, timing (AM stiffness), hardware, previous infections, h/o gout/podagra, trauma, diuretic use
-- Clinical/Exam: *** joint pain, fevers, diarrhea, conjunctivitis, urethritis, ulcers, rashes
-- Data: *** WBC, uric acid, ESR/CRP, arthrocentesis (WBC, GS, cultures, crystals), BCx
-- Etiology/DDx: *** gout, pseudogout, septic arthritis, reactice arthritis, trauma, bursitis, SSTI, DVT

The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.

-- f/u uric acid, ESR/CRP
-- f/u arthrocentesis studies - WBC, GS, culture, crystals

-- c/f Gout - colchicine 1.2 once, 0.6 1hr later, 0.6 1-2x daily until 2-3 days after sxs resolve; NSAIDS; intra-articular steroids; uric acid goal <6
-- c/f Septic arthritis - antibiotics (vanc and CTX, switch to cefepime and add metronidazole if post-procedure or injection, add doxy if risk of STI, add cefazolin if prosthetic joint) and washout with ortho; BCx, eval for endocarditis
-- c/f Reactive Arthritis - GC/Chlamydia, UCx, stool Cx if diarrhea
-- Pain - oral and topical NSAIDs

Get Template PDF

PDF coming soon!

Clinical Pearls

  • Gout has 10-100k WBC, septic joint usually 50-150k
  • WBC on tap may be lower than usual 50k cutoff for septic arthritis if there is a prosthetic joint