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Evaluation And Management Of Septic Arthritis Discussion

Evaluation And Management Of Septic Arthritis Discussion

please write a discussion response :Respond to at least two of your colleagues on 2 different days who were assigned different case studies than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition and justify your reasoning Evaluation And Management Of Septic Arthritis Discussion.

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The discussion post identifies essential must-not-miss diagnoses for this patient, which include osteomyelitis and septic arthritis. Septic arthritis is a severe or dangerous medical condition associated with significant morbidity and mortality (Long, Koyfman, & Gottlieb, 2019). The patient’s presentation with localized signs of inflammation, including pain, swelling, and loss of function, makes diagnosing osteomyelitis or septic arthritis imperative to rule out. However, the absence of generalized signs of infection such as fever and generalized body malaise, coupled with the fact that the disease affects both or two joints, unlike monoarticular pain that seen is in septic arthritis, makes septic arthritis and unlikely osteomyelitis diagnoses (Long, Koyfman, & Gottlieb, 2019; )Evaluation And Management Of Septic Arthritis Discussion. However, their inclusion in the list of differentials indicates the practitioner’s willingness to rule out these diseases to avoid their adverse consequences if they go untreated, and this effort is commendable.

Based on the patient’s presentation, more so concerned with the pop sound heard during active physical activity brings to mind the tearing or rupture of a tendon or a ligament (Melanson & Shuman, 2021). This presentation is more common for ankle sprains or strains. The associated features often include pain, reduced weight bearing, swelling, evident bruising on the affected side, and local warmth (Halabchi & Hassabi, 2020; Melanson & Shuman, 2021). These features would support a bilateral ankle sprain or just a right ankle sprain, as correctly identified in the discussion post. The injury is the most common lower limb injury in athletes and physically active adults (Halabchi & Hassabi, 2020). It accounts for 16%-40% of all sports-related injuries and more commonly occurs in sports such as American football and soccer, further reinforcing the diagnosis (Halabchi & Hassabi, 2020). It has various treatment modalities. However, using ankle braces and physical exercise is proven superior to other treatment modalities Evaluation And Management Of Septic Arthritis Discussion

References

Halabchi, F., & Hassabi, M. (2020). Acute ankle sprain in athletes: Clinical aspects and algorithmic approach. World Journal of Orthopedics, 11(12), 534-558. https://doi.org/10.5312%2Fwjo.v11.i12.534

Melanson, S., & Shuman, V. (2022). Acute Ankle Sprain. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459212/

Momodu, I., & Savaliya, V. (2021). Osteomyelitis. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532250/

Long, B., Koyfman, A., & Gottlieb, M. (2019). Evaluation and management of septic arthritis and its mimics in the emergency department. Western Journal of Emergency Medicine, 20(2), 331-341. https://doi.org/10.5811%2Fwestjem.2018.10.40974

Respond to at least two of your colleagues on 2 different days who were assigned different case studies than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition and justify your reasoning.

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A 46-year-old female reports pain in both of her ankles, but she is more concerned about her right ankle. She was playing soccer over the weekend and heard a “pop.” She is able to bear weight, but it is uncomfortable. In determining the cause of the ankle pain, based on your knowledge of anatomy, what foot structures are likely involved? What other symptoms need to be explored? What are your differential diagnoses for ankle pain? What physical examination will you perform? What special maneuvers will you perform? Should you apply the Ottawa ankle rules to determine if you need additional testing?Evaluation And Management Of Septic Arthritis Discussion

Patient Initials: A. M.             Age: _46_                               Gender:  Female

 

SUBJECTIVE DATA:

 

Chief Complaint (CC): “My ankles hurt but I’m more worried about my right ankle.”

 History of Present Illness (HPI): J.T. is a 46-year-old female who presented to the clinic with a 2-day history of bilateral ankle pain after hearing a pop while playing soccer. She describes the pain as a continuous “aching and throbbing” localized to the lateral sides of both ankles. At onset the pain was 2/10 to the left ankle and 4/10 to the right. At that time, she noticed minor swelling only to the right ankle. She continued to bear weight on both ankles, and within 24 hours, she noticed increased swelling and bruising to only the right ankle. Applying ice and rest tend to reduce the swelling briefly. She did take Ibuprofen 600mg every 6 to 8 hr. as needed for pain, which provided some relief. Today she reports worsen symptoms of intermittent sharp shooting pain that radiates from the right ankle across the top of the foot causing pain 6/10. The left ankle pain is 2/10. Evaluation And Management Of Septic Arthritis Discussion

 Medications: 

  • Ibuprofen 200 mg 2-3 times a day PRN for ankle pain.
  • Amlodipine 20 mg PO once daily for hypertension.
  • Omeprazole 20 mg daily for GERD.

Allergies: 

  • Erythromycin (swelling of face, eyes, and lips).
  • Sulfa drugs (hives).
  • No food, latex, or environmental allergies.

 Past Medical History (PMH):

  • Hypertension diagnosed 3 years ago, controlled with medications.
  • Gastroesophageal reflux disease (GERD) diagnosed 2 years ago, controlled with medications. Evaluation And Management Of Septic Arthritis Discussion

Past Surgical History (PSH): 

  • Cholecystectomy approximately 8 years ago, no complications (Dr. Eich, Hampton, VA).
  • Cesarean section 23 years ago, no complications reported (Dr Davies, Norfolk, VA).

Sexual/Reproductive History:

Menarche age 13, normal menstrual cycles with a 29-day interval. G2, P1, AB 1. Her last pap smear was approximately 1-year ago that was normal.  No history of sexually transmitted disease or HIV infection. Previous history of condom uses during heterosexual encounters. She is currently sexually active with only her spouse. Patient states she does not currently use condoms since spouse vasectomy 10-years ago.

 Personal/Social History: 

The patient is married and lives in a home with her spouse and mother-in-law. They have one adult child that attends a nearby university and returns home every weekend. She works full-time as an emergency room nurse at a level 1 trauma center. She reports an active work environment that requires standing and walking for 8 to 10 hour per shift. She reports a stressful work environment. She listens to inspirational music to relieve work related stress. Her family have affordable medical and dental insurance coverage though her employer. Denies alcohol, tobacco, and recreational drug use. She exercises regularly for at least 1 hour, 3 to 4 day a week. Her daily diet consists of at least 2 to 4 servings of lean proteins, whole grains, fruits, and vegetables. She drinks 48 to 56 oz of water daily. She avoids milk, caffeine, and sugary drinks. She prepares her meats grilled with olive oil. She does not require daily assistance with eating, bathing, or grooming. She never received a blood transfusion Evaluation And Management Of Septic Arthritis Discussion.

 Health Maintenance: 

  • Last complete physical exam was approximately 6 months ago.
  • Pap smear and Mammogram exam completed approximately 6 months ago, with normal results. She performs self-breast exam monthly. She has never had a colonoscopy Evaluation And Management Of Septic Arthritis Discussion.

 Immunization History:

  • Tetanus vaccine: October 2018
  • Influenza vaccine: December 2021.

Significant Family History:

  • Daughter: healthy, age 23.
  • Sister: healthy, age 49
  • Mother: congestive heart failure and peripheral neuropathy, age 76.
  • Father:  hypertension, hyperlipidemia, died of a heart attack, at age 75.
  • Maternal Grandmother: died of COPD age 70.
  • Maternal Grandfather: died of a stroke, at age 68.
  • Paternal Grandmother: former smoker, died of lung cancer, at age 61.
  • Paternal Grandfather: died of sarcoidosis at age 63.

 Review of Systems:  

General: Denies fever, chills, or weakness. Denies night sweats and sleep disturbances.

Respiratory: Denies cough, shortness of breath, and wheezing. No history of asthma, pulmonary

embolism, or TB.

Cardiovascular/Peripheral Vascular: Denies chest pain, palpations and arrythmias.

Musculoskeletal:  Moderate swelling and bruising to lateral right ankle and entire foot. Denies

ulcers, deformity, coolness, or paleness to both ankles. Limping while ambulating.

Neurological: Denies numbness, tingling, paresthesia, or loss of sensation to foot and toes.

Psychiatric: Denies, irritability, restlessness, agitation, or anxiety.

OBJECTIVE DATA: 

Vital signs: BP: 130/78; P: 88; R: 16; Temp: 98.7 F; O2 Sat: 99% on room air. Wt.: 145 lbs. Ht: 68 inches BMI: 22.0.

 General: A.M. is a pleasant, calm, and cooperative 46-year-old African American female who appears younger than her stated age. She is alert and oriented with no signs of acute distress.

Chest/Lungs: Symmetrical chest expansion. Lungs sounds clear and equal bilaterally.  

Heart/Peripheral Vascular: Regular rate and rhythm. S1 and S2 heard. No murmurs, heaves, or thrills. Bilateral dorsalis pedis pulse: +2. Bilateral tibialis pulses: +2. Capillary refills in toes: less than 3 seconds bilaterally Evaluation And Management Of Septic Arthritis Discussion.

Musculoskeletal: No redness, ecchymosis, or inflammation. No deformities or joint crepitus noted. Weight bearing more than four steps. Moderate bruising to right ankle and anterior foot. Limited dorsiflexion, and plantar flexion range of motion to right ankle. Moderate tenderness noted with ROM to right ankle. Full ROM to left ankle with minor tenderness. Tenderness noted with palpation to the right lateral ankle ligaments. Anterior drawer test: positive for right ankle and negative to the left. Positive single balance to the right ankle.

Lymphatics: Unable to palpate inguinal lymph nodes.

Psychiatric: Alert and oriented to person, place, time, and situation. Behavior is appropriate for the situation.

 Diagnostic results: 

  • Rheumatoid factor: 13 IU/ml. (Normal).
  • C-reactive protein: 6 mg/L (Normal)
  • Anti-citrullinated protein antibody: Negative.
  • Complete blood count:  WBC: 8.0, RBC: 4.0, HGB: 12.0, HCT: 30, Platelets: 250. Differential: unremarkable.
  • Anti-citrullinated antibodies: Negative.
  • Right ankle x-ray: soft tissue swelling. No evidence of fracture. Evaluation And Management Of Septic Arthritis Discussion

 ASSESSMENT:

 Diagnoses:

  • Lateral Ankle Sprain is a common sports-related injury involving the position of the foot and rotational force on the joint and ligaments (Melanson & Shurman, 2022). The mechanism of injury can cause fracture, and torn or ruptured tendons (Melanson & Shurman, 2022). A patient with a lateral ankle sprain presents with pain and bruising to the lateral joint and ligament area. Performing the anterior drawer test on an exam to assess the stability of the ATFL by stabilizing the leg while plantar flexion of the injured foot compared to the other ankle can pinpoint a diagnosis (Larkins et al., 2020). The Ottawa ankle rule is based on the inability to weight bear and tenderness to the medial malleolus to rule out a fracture.
  • Rheumatoid Arthritis (RA) is a chronic autoimmune inflammatory disorder affecting the organs, joints, ligaments, and tendons (McCance & Huether, 2019). Commonly affected joints include the finger, feet, wrist, ankles, knees, and wrist (McCance & Huether, 2019). A patient with RA presents with pain, joint deformity, nodules, loss of function, and inflammation of ligaments and joints. Applying pressure or movement to the affected joints causes pain (Chauhan et al., 2022). An elevated rheumatoid factor (RA) and positive anti-citrullinated protein antibodies may indicate the presence of RA (Chauhan et al., 2022)Evaluation And Management Of Septic Arthritis Discussion. The patient in the scenario did not present with deformity or nodules.

 

  • Osteoarthritis (OA) is a form of arthritis that causes erosion of the bone and joint. OA affects joints of the hips, knees, hands, ankles, fingers, lumbar and cervical vertebrae

Patients with OA may present with pain, swelling, tenderness, stiffness, and deformity of the joints (Sen & Hurley, 2022). The patient in the scenario did not present with stiffness or deformity.

 

  • Osteomyelitis is a bacterial bone infection caused by trauma, surgical procedure, animal bites, or decubitus ulcers (Momodu & Savaliya, 2022a). Patients with osteomyelitis present with a low-grade fever, lymphadenopathy, localized pain, and swelling (McCance & Huether, 2019)Evaluation And Management Of Septic Arthritis Discussion.  An elevated WBC count and MRI can detect the presence of an infection requiring hospitalization for IV antibiotic treatment (McCance & Huether, 2019). The patient in the scenario did have a fever, redness, or warmth to her ankles. Osteomyelitis is not the appropriate diagnosis.

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  • Septic arthritis is inflammation of the joints commonly caused by a bacterial infection (Momodu & Savaliya, 2022b). Untreated septic arthritis can lead to increased mortality and morbidity (Momodu & Savaliya, 2022b). Patients with a history of rheumatoid arthritis and IV drug users have an increased risk of developing septic arthritis. Patients with septic arthritis may present pain, joint swelling, warmth, limited range of motion, fever, tachycardia, and irritability (Momodu & Savaliya, 2022b). An elevated WBC count and positive blood cultures are used to diagnosis this disorder (Momodu & Savaliya, Evaluation And Management Of Septic Arthritis Discussion