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| Septic arthritis resident survival guide:
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| === Complete diagnostic approach: ===
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| <div style="font-size: 90%;">
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| {{Familytree/start}}
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| {{Familytree|boxstyle=width: 700px; text-align: left; font-size: 100%; padding: 0px;| A01 | | |A01=<div style="padding: 10px;">
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| ==Common Presentation==
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| '''Symptoms in newborns or infants:'''
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| * Cries when infected joint is moved (e.g. diaper change causes crying if hip joint is infected)
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| * [[Fever]]
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| * Inability to move the limb with the infected joint (pseudoparalysis)
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| * [[Irritability]]
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|
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| '''Symptoms in children and adults:'''
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| * Inability to move the limb with the infected joint (pseudoparalysis)
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| * Intense [[joint pain]]
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| * Joint [[swelling]]
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| * Joint redness
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| * Low [[fever]]
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| * The [[tenosynovitis]] is characterized by pain, [[swelling]], and [[erythema]] around the tendon
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| ==Less common Presentation==
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| *[[Chills]]
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| </div>}}
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| {{Familytree|boxstyle=width: 700px; text-align: left; font-size: 100%; padding: 0px;| |!| | | |}}
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| {{Familytree|boxstyle=width: 700px; text-align: left; font-size: 100%; padding: 0px;| A01 | | |A01=<div style="padding: 10px;">
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| ==Focused History==
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| * Intravenous drug use
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| * Sexual activity
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| * Terminal complement deficiency
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| * Dog or cat bite
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| * Ingestion of unpasteurized dairy products
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| * Nail through shoe
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| * Soil exposure/gardening
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| * Soil or dust exposure containing decomposed wood
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| (north-central and southern United States)
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| * Southwestern United States, Central and South America
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| (primary respiratory illness)
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| * Cleaning fish tank
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| </div>}}
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| {{Familytree|boxstyle=width: 700px; text-align: left; font-size: 100%; padding: 0px;| |!| | | |}}
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| {{Familytree|boxstyle=width: 700px; text-align: left; font-size: 100%; padding: 0px;| A01 | | |A01=<div style="padding: 10px;">
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| ==Physical Examination==
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|
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| ===Appearance of the Patient===
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| * Patient with [[septic arthritis]] usually appears [[toxic]] and with [[joint pain]]
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| * children usually appear [[irritable]]
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|
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| === Vital Signs ===
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| * Low grade [[fever]]. [[Chills]] and spiking fever are very rare.
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| * [[Hyperthermia]] over the joint involved
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| * [[Tachycardia]]
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| * [[Tachypnea]]
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|
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| === Skin ===
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| * Warmth over the joint
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|
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| * [[Erythema]] over the around the joint that involved
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| * [[Disseminated gonococcal infection]] often present with [[skin]] lesions, typically multiple, painless [[macules]] and [[papules]], most often found on the arms or legs or on the [[trunk]].<ref name="pmid9449882">Goldenberg DL (1998) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9449882 Septic arthritis.] ''Lancet'' 351 (9097):197-202. [http://dx.doi.org/10.1016/S0140-6736(97)09522-6 DOI:10.1016/S0140-6736(97)09522-6] PMID: [https://pubmed.gov/9449882 9449882]</ref>
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|
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| === Extremities ===
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| Most commonly involves [[knee]] > [[hip]] > [[shoulder]] > [[ankle]].<ref name="pmid3498362">Barton LL, Dunkle LM, Habib FH (1987) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=3498362 Septic arthritis in childhood. A 13-year review.] ''Am J Dis Child'' 141 (8):898-900. PMID: [https://pubmed.gov/3498362 3498362]</ref> Other joints such as [[sacroiliac joint]] (~10%), [[sternoclavicular]] or costoclavicular joints may be involved in patient with history of intravenous drug abuse (IVDA), penetrating trauma, animal or human bites and local [[steroid]] [[injections]].
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| * [[Swelling]] of the joint that involved
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| * Decreased [[range of motion]] such as pseudo paralysis
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| * Patient hold the hip in flexed and externally rotated position if SA involving [[hip]].
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| * If child, unwillingness to bear weight on the affected joint (antalgic gait)
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|
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| </div>}}
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| {{Familytree|boxstyle=width: 700px; text-align: left; font-size: 100%; padding: 0px;| |!| | | |}}
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| {{Familytree|boxstyle=width: 700px; text-align: left; font-size: 100%; padding: 0px;| A01 | | |A01=<div style="padding: 10px;">
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| ==Laboratory Workup==
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| * [[Complete blood count|CBC with DC]]
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| * [[Basic metabolic panel|SMA-7]]
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| * [[Creatine kinase]]
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| * [[Urinalysis]] with [[Urinalysis#Microscopic examination|microscopic examination]]
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| * [[Erythrocyte sedimentation rate]]
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| * [[C-reactive protein]]
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| * Synovial fluid analysis
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| **Synovial [[White blood cells|WBC]] count with differential
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| **Crystal analysis
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| **[[Gram staining|Gram stain]]
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| **Culture and sensitivity
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| </div>}}
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| {{Familytree|boxstyle=width: 700px; text-align: left; font-size: 100%; padding: 0px;| |!| | | |}}
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| {{Familytree|boxstyle=width: 700px; text-align: left; font-size: 100%; padding: 0px;| A01 | | |A01=<div style="padding: 10px;">
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| ==Imaging Study==
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|
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| ===Plain radiographs of swollen joints===
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| *Erosions
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|
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| ===Ultrasonography of painful joints===
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| *Detect synovitis and tenosynovitis in the hands and wrists in patients with SLE
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|
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| ===Renal ultrasonography===
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| *To assess kidney size
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| *To rule out urinary tract obstruction
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|
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| ===Chest radiography===
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| *For suspected pleural effusion, interstitial lung disease, cardiomegaly
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|
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| ===Echocardiography===
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| *For suspected pericardial involvement, to assess for a source of emboli, or noninvasive estimation of pulmonary artery pressure; and for evaluation of suspected valvular lesions, such as verrucae
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|
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| ===Computed tomography (CT)===
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| *For abdominal pain, suspected pancreatitis, interstitial lung disease
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|
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| ===Magnetic resonance imaging (MRI)===
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| *For focal neurologic deficits or cognitive dysfunction
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| </div>}}
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| {{Familytree|boxstyle=width: 700px; text-align: left; font-size: 100%; padding: 0px;| |!| | | |}}
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| {{Familytree|boxstyle=width: 700px; text-align: left; font-size: 100%; padding: 0px;| A01 | | |A01=<div style="padding: 10px;">
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| ==Other Investigation==
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|
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| ===Bronchoscopy===
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| Fiberoptic [[bronchoscopy]] with [[Bronchoalveolar lavage|bronchoalveolar lavage (BAL)]] and transbronchial lung biopsies:<ref name="pmid16409858">{{cite journal |vauthors=Shen M, Wang Y, Xu WB, Zeng XJ, Zhang FC |title=[Pleuropulmonary manifestations of systemic lupus erythematosus] |language=Chinese |journal=Zhonghua Yi Xue Za Zhi |volume=85 |issue=48 |pages=3392–5 |year=2005 |pmid=16409858 |doi= |url=}}</ref><ref name="pmid9187214">{{cite journal |vauthors=Susanto I, Peters JI |title=Acute lupus pneumonitis with normal chest radiograph |journal=Chest |volume=111 |issue=6 |pages=1781–3 |year=1997 |pmid=9187214 |doi= |url=}}</ref>
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| * To substantiate the diagnosis of alveolar [[hemorrhage]]
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| === Barium swallow or esophagography ===
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| *[[Esophageal]] stricture<ref name="pmid12873055">{{cite journal |vauthors=Jiménez-Alonso J, Estev D, Vera C, Sabio JM |title=Dysphagia in patients with systemic lupus erythematosus |journal=Lupus |volume=12 |issue=6 |pages=493 |year=2003 |pmid=12873055 |doi= |url=}}</ref>
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| **Peptic strictures that appear as smooth, tapered narrowing in the distal [[esophagus]]
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| *[[Esophageal dilatation]]<ref name="pmid12873055" />
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|
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| === Biopsy ===
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| * [[Renal]] biopsies:<ref name="pmid22977215">{{cite journal |vauthors=Giannico G, Fogo AB |title=Lupus nephritis: is the kidney biopsy currently necessary in the management of lupus nephritis? |journal=Clin J Am Soc Nephrol |volume=8 |issue=1 |pages=138–45 |year=2013 |pmid=22977215 |doi=10.2215/CJN.03400412 |url=}}</ref><ref name="pmid24969191">{{cite journal |vauthors=Singh A, Ghosh R, Kaur P, Golay V, Pandey R, Roychowdhury A |title=Protocol renal biopsy in patients with lupus nephritis: a single center experience |journal=Saudi J Kidney Dis Transpl |volume=25 |issue=4 |pages=801–7 |year=2014 |pmid=24969191 |doi= |url=}}</ref>
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| ** Determining the degree of renal involvement
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| ** Delineating treatment decisions and prognosis in certain clinical scenarios
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| ** Assess activity and damage (i.e., chronicity)
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| ** Helping with classification
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|
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| * [[Endomyocardial]] biopsy:<ref name="pmid2684953">{{cite journal |vauthors=Salomone E, Tamburino C, Bruno G, Di Paola R, Silvestri F |title=The role of endomyocardial biopsy in the diagnosis of cardiac involvement in systemic lupus erythematosus |journal=Heart Vessels |volume=5 a|issue=1 |pages=52–3 |year=1989 |pmid=2684953 |doi= |url=}}</ref>
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| ** May be helpful in guiding treatment towards the use of [[corticosteroids]]
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|
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| === Paracentesis ===
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| * [[Paracentesis]] in the presence of the following conditions either for symptomatic relief (therapeutic) or fluid evaluation (diagnostic):
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| ** [[Ascites]]<ref name="pmid22324961">{{cite journal |vauthors=Prasad S, Abujam B, Lawrence A, Aggarwal A |title=Massive ascites as a presenting feature of lupus |journal=Int J Rheum Dis |volume=15 |issue=1 |pages=e15–6 |year=2012 |pmid=22324961 |doi=10.1111/j.1756-185X.2011.01659.x |url=}}</ref>
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| ** Massive [[pleural effusion]]<ref name="pmid25417677">{{cite journal |vauthors=Palavutitotai N, Buppajarntham T, Katchamart W |title=Etiologies and outcomes of pleural effusions in patients with systemic lupus erythematosus |journal=J Clin Rheumatol |volume=20 |issue=8 |pages=418–21 |year=2014 |pmid=25417677 |doi=10.1097/RHU.0000000000000179 |url=}}</ref>
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| ** Massive [[pericardial effusion]] and [[tamponade]]<ref name="pmid24579442">{{cite journal |vauthors=Kruzliak P, Novak M, Piler P, Kovacova G |title=Pericardial involvement in systemic lupus erythematosus: current diagnosis and therapy |journal=Acta Cardiol |volume=68 |issue=6 |pages=629–33 |year=2013 |pmid=24579442 |doi=10.2143/AC.68.6.8000011 |url=}}</ref>
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|
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| === Arthrocentesis ===
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| * In the presence of joint effusion to differentiate between different causes of [[arthritis]]<ref name="pmid642792">{{cite journal |vauthors=Goldenberg DL, Cohen AS |title=Synovial membrane histopathology in the differential diagnosis of rheumatoid arthritis, gout, pseudogout, systemic lupus erythematosus, infectious arthritis and degenerative joint disease |journal=Medicine (Baltimore) |volume=57 |issue=3 |pages=239–52 |year=1978 |pmid=642792 |doi= |url=}}</ref>
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| </div>}}
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| {{Familytree/end}}
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| </div>
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