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Why the Lady With Knee Pain Got a Pelvic Exam

It was a busy night in the emergency department, so the patient had to wait for  to be seen. By the time the doctor got in the room, she was in obvious pain. Her knee was killing her.

It bothered her a little two days prior. The pain got worse a day later. By the time she woke up that morning, she wasn’t able to walk on her knee. She hadn’t injured it as far as she could remember, but it looked like the kneecap was missing whenever she straightened it out. And did she mention that it was killing her?

In all fairness, the patient’s knee was definitely warm and swollen. It wasn’t that her kneecap was missing, but rather that the effusion in her knee was making her kneecap disappear.
Really couldn’t do much of an exam on her knee because the pain was just too bad. Whenever she moved it, she yelled in pain. She got some pain medications and an x-ray. A couple of “unnecessary” lab tests were added just in case.

Of course, the xrays were normal and the labs were all abnormal. White count 20,000. Sed rate 65. CRP 19.
The patient was getting a knee tap.

The orthopedist didn’t want to hear about the case. “It’s gout. Don’t you know how to treat gout in the emergency department?”
Sorry. The emergency department staff forgot to bow and pay homage before asking the secretary to dial your cell phone number. Forgive them.
In answer to your question, “Yes, we do know how to treat gout in the emergency department. Would you prefer that we use Ancef 1 gram or 2 grams?”
So after paying further homage and sacrificing a psychiatry intern to please the Bone Gods, the knee tap proceeds against the orthopedic recommendations.
Even without orthopedic guidance and an intraoperative CT scan to prove proper placement, 130 ccs of yellow cloudy fluid is able to be retrieved. Lab analysis shows no crystals. Obviously that will be considered a lab error when the orthopedist reviews the slide in the morning, but for now, the white count of 28,000 with 98% segs must be addressed. The patient gets a dose of vancomycin and Levaquin.

Knowing one of the more common etiologies of acute monoarticular infections in young adults, then the doctor breaks the news to the patient.
“Unfortunately, we have to do a pelvic exam.”
“Whaaat? Are you high or something?”
“Well, one of the more common causes of arthritis in situations like this is … well … a sexually transmitted disease. So we need to check to see whether or not you have an asymptomatic infection.”
Sure enough, there was yellow discharge and cervical motion tenderness.

The staff engages in a moment of silence, bows toward the orthopedic wing of the hospital, and the secretary re-dials the orthopedist’s pager to relay the findings.

“What do you want me to do about it? Obviously, it’s a gyne problem. Call a gynecologist.”
Ahhhh, yes. Again, how dumb could the emergency medical staff be? It is common knowledge that women have babies in their knees. Heck, by the size of this patient’s knee, she’s probably six months pregnant.
Another collective bow before hanging up the phone, then the gynecologist is called. He makes some comment about having a urologist look up the orthopedist’s nose, but agrees to accept the admit.

The patient’s boyfriend came to visit her at about the six hour mark. As they talked, eventually he complained enough about his sore throat that the patient convinced him to register to be seen in the emergency department. He had already been to the clinic and his strep test was negative, so the nurse practitioner gave him Zithromax and told him that there was nothing else they could do.
“Give him a love dart and a few days of Suprax,” the emergency doctor says.
“But why? We already know it’s viral from his clinic visit,” said the nurse.
“Humor me.”
“But ….”
“Go Google the terms ‘Michael Douglas’ and ‘throat’ then come talk to me.”
“You guys are so weird sometimes.”

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This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on DrWhitecoat.com, please e-mail me.

5 comments

  1. An longtime ED department secretary of my acquaintance was once heard to assure someone that it’s unethical to put @$$clown’s cell numbers in every day’s block of the month-long on-call M.D. sheet for after hours notification, even if one is familiar with the department’s word processing software and printer, and no one was looking.

    No points for guessing how the conversation came up, or whether either party to said conversation paid any attention to the advice.

    And hey, nice catch to whoever.

  2. Interesting post.

    I Was wondering how the patient was going to get into the Bajingoland position with that sore swollen knee – but mystery solved as I read on. I also thought that it was a mistake – that someone mistook her a pelvic patient and she was just being the compliant patient. Because a patient had come into the ED one night with an ankle injury and when the Doc came in to examine her he told her to put the wrong ankle up so he could examine her. But when he asked her questions about it, she told him that wasn’t the injured ankle. “Why did you put give me this ankle then?” Because you told me to. :)

    “sacrificing a psychiatry intern to please the Bone Gods,” Hahaha! :)

    I don’t get the urologist remark about looking up the orthopaedist’s nose. I should I guess being a once upon a time frequent flier uro patient, but nope ..right over my head. Sounds funny tho. :)

    Enjoyed the entire post – very funny.

    Did the NP ever get back to you after googling? :)

    • I am guessing the orthopod’s “nose” would be the one in his boxer shorts, and the look would be with the biggest, baddest indwelling catheter anyone can find. :-)

    • Urologist deals with GU. On men, it’s the penis. Look up his nose – is his head a penis? Is there a slang term for a person who acts in a certain way, utilizing a slang term for the penis, which sounds also like a nickname for “Richard”, and the word “head” in combination?

      (Doing my best to not be crass.)

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