Favorite Quotes
"For every complex problem, there is a solution that is simple, neat, and wrong." - HL Mencken
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"The good physician treats the disease; the great physician treats the patient who has the disease" - Sir William Osler
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" The best test of a person's character is how he or she treats those with less power." - Bob Sutton
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"Anyone can make the simple complicated. Creativity is making the complicated simple." - Charles Mingus
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"Not everything that can be counted counts, and not everything that counts can be counted." - Albert Einstein
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"A foolish consistency is the hobgoblin of little minds, adored by little statesman and philosophers and divines. With consistency a great soul has simply nothing to do." - Ralph Waldo Emerson
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"What is hateful to you, do not do to your neighbour. This is the whole Torah; all the rest is commentary. Go and learn it." - Hillel, Talmud, Shabbath 31a
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"You will never understand bureaucracies until you understand that for bureaucrats procedure is everything and outcomes are nothing." - Thomas Sowell
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"If you only have a hammer, you tend to see every problem as a nail." - Abraham Maslow
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"A great teacher is one who realizes that he himself is also a student and whose goal is not to dictate the answers, but to stimulate his students creativity enough so that they go out and find the answers themselves." - Herbie Hancock
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"There are no facts, only interpretations." - Nietzsche
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"An education isn't how much you have committed to memory, or even how much you know. It's being able to differentiate between what you do know and what you don't." - Anatole France
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"In character, in manner, in style, in all things, the supreme excellence is simplicity." - Henry Wadsworth Longfellow ====
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A patient care puzzle
23 Feb2009
50 something male was admitted 3 weeks ago for a septic right knee and subsequent endocarditis – MSSA. His knee has no problems, but he needs 6 weeks of IV antibiotics. Social work has worked on finding an intermediate care facility, and they find one! But we get called during rounds because the patient has a fever of 102 (afebrile for 2 weeks.)
Discharge is delayed, and a fever workup begins. The next morning on rounds he has tender hot joints – left elbow and right ankle. He is in obvious pain.
What do you do? What diagnosis do you suspect? Do you start treatment?
We have a clear answer – and a controversy coming.
More tomorrow …
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5 Responses to A patient care puzzle
Jared
February 23rd, 2009 at 11:59 am
Well, sadly, I begin questioning compliance and dirty IV access. However, the differential for migrating polyarthritis including rheumatic fever, gonococcal arthritis, Lyme Dz, HIV, Henoch-Schonlein purpura, Hepatitis B/C, and Sarcoidosis. Fever of unknown origin also includes TB and neoplasms.
HPE, admitted 3 wk prior with septic R knee and endocarditis. Febrile 1 week following admission, afebrile 2 weeks, currently febrile again at 102.
I’m assuming that since it was MSSA, the antibiotic used was dicloxacillin. My first thought is to perform and arthrocentesis and do a susceptibility study while changing treatment to IV clindamycin and metronidazole. I would also do sputum studies, detailed medical history and social history. Also, test Hepatitis and C. diff status.
Mehmet Karaca
February 23rd, 2009 at 12:34 pm
Pseudogout (Calcium Pyrophosphate Deposition Disease) is definitely a possibility. CPDD can present as a febrile oligoarticular disease, given this patient’s recent hospitalization and coexisting medical conditions he is at risk for crystal disease. I would check his synovial fluid and look for intracellular crystals and would try to rule out hematogenic spread of his MSSA.
The Happy Hospitalist
February 23rd, 2009 at 4:09 pm
Common things being common, I would like to know why he got endocarditis in the first place. The fact that it took three weeks to find a rehab joint suggests the guy has no insurance. Perhaps he has no insurance because he is spending all his money on meth.
Check a drug screen on him. Maybe he’s shooting up in his room.
CHenry
February 23rd, 2009 at 9:11 pm
Herx?
3+speckled
February 23rd, 2009 at 10:38 pm
Common things being common, gout would be top of the list, but fever of 102 shouldn’t have preceded the onset of synovitis. Inappropriate drug choice, dose or inadequate joint drainage could lead to recurrence but wouldn’t happen on your watch I’m sure and should have recurred in the same joint as well. Antibiotic related drug fever followed by a reactive type arthritis or beginning of a serum sickness. Serum sickness is usually polyarticular though. Therefore, a new infection as suggested by HH seems likely but I’ll give the patient the benefit of doubt and blame a line-associated MRSA infection. Still, don’t see much room for controversy there.
Joint tap to R/O crystal, if neg, broader spectrum until gram/cultures back.