Approach to septic arthritis.

(IM.30) A 42-year-old male with a history of gout and hypertension presents to his family physician with a complaint of increased left knee pain over the past 2 days. He also reports swelling and redness of the left knee and is unable to bear weight on that side. He denies any prior surgery or inciting trauma to the knee, reporting that the only strenuous activity he performed was mowing the lawn 5 days ago. His vital signs are as follows: T 38.5, HR 96, BP 110/78, RR 16, O2 99%. Physical examination reveals a left knee that is erythematous, swollen, warm-to-touch, and extremely tender to palpation and attempted flexion/extension movement. His left knee range of motion is markedly reduced compared to the contralateral side. Joint aspiration of the left knee is performed, with synovial fluid analysis showing turbid fluid with 95,000 WBC, 88% neutrophils, and low glucose. Gram stain of the synovial fluid was negative. Results from synovial fluid culture are pending. Which of the following is the best pharmacologic treatment regimen for this patient?

(IM.33) A 66-year-old male presents to his family physician with a complaint of increasing right knee pain over the past several weeks. The patient underwent a right total knee arthroplasty 4 months ago and, until recently, had been progressing well without complications since his surgery. He describes the knee pain as persistent, stating that it is present both with movement and while sedentary. The patient denies any fevers. A radiograph of the right knee is obtained and shows a well seated implant without any obvious abnormalities. Joint aspiration is performed and is significant for synovial fluid WBC count of 7,000 WBC/uL and a neutrophil predominance. Which of the following organisms is most likely responsible for this patient's presentation?

(IM.8) A 61-year-old man with hypertension and rheumatoid arthritis (RA) schedules a same-day appointment with his primary care physician for worsening pain in his right wrist. He was diagnosed with RA 8 years ago and has been doing fairly well. Both of his wrists, fingers, and knees have been affected for several years, but today his pain is much worse than baseline. His medications include methotrexate, naproxen, atenolol, and lisinopril. The patient's vital signs are as follows: T 100.9 F, HR 95 bpm, BP 110/71 mmHg, and RR 16 rpm. On exam you note tender, swollen wrists bilaterally. The right wrist is slightly warm to touch and resists passive movement. There is mild ulnar deviation of the digits on both hands. The metacarpalphalangeal joints are mildly tender. Which of the following is the most appropriate course of management?