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.
“Go Google the terms ‘Michael Douglas’ and ‘throat’ then come talk to me.”
“You guys are so weird sometimes.”
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.