A swollen knee

The patient’s treatment and outcome

The patient had a history of gastric ulcers and intolerance to NSAIDs. Therefore, he was started on oral colchicine for the probable gout. He was also given 500 mg of cephalexin po, qid, for the cellulitis and impetigo. He refused any blood tests, but accepted a follow-up appointment for the next day.

When we thought the patient had a septic joint, the optimal treatment would have involved hospitalization. The patient’s fear of hospitalization and losing his job made the choice of hospitalization a nonoption for this mentally ill homeless man. Instead of doing nothing, we began the diagnostic process in the outpatient setting.

If we had obtained purulent joint fluid it would have been incumbent upon us to press once again for hospitalization for septic arthritis. The appearance of yellow fluid and joint crystals gave us the option of attempting outpatient care.

Unfortunately, the patient never returned. Joint fluid Gram stain and culture results were negative, and the cell counts were consistent with inflammation. The hospital lab read the crystal analysis as negative even though our photograph documents the presence of crystals consistent with urate crystals.

Health care delivery must be flexible and creative in the setting of a shelter clinic. We can only hope that the oral medications he received allowed him full recovery from his acute illnesses.