Septic Arthritis: Diagnosis and Treatment.

Septic arthritis must be considered and promptly diagnosed in any patient presenting with acute atraumatic joint pain, swelling, and fever. Risk factors for septic arthritis include age older than 80 years, diabetes mellitus, rheumatoid arthritis, recent joint surgery, hip or knee prosthesis, skin infection, and immunosuppressive medication use. A delay in diagnosis and treatment can result in permanent morbidity and mortality. Physical examination findings and serum markers, including erythrocyte sedimentation rate and C-reactive protein, are helpful in the diagnosis but are nonspecific. Synovial fluid studies are required to confirm the diagnosis. History and Gram stain aid in determining initial antibiotic selection. Staphylococcus aureus is the most common pathogen isolated in septic arthritis; however, other bacteria, viruses, fungi, and mycobacterium can cause the disease. After synovial fluid has been obtained, empiric antibiotic therapy should be initiated if there is clinical concern for septic arthritis. Oral antibiotics can be given in most cases because they are not inferior to intravenous therapy. Total duration of therapy ranges from two to six weeks; however, certain infections require longer courses. Consideration for microorganisms such as Neisseria gonorrhoeae, Borrelia burgdorferi, and fungal infections should be based on history findings and laboratory results.

Ear Pain: Diagnosing Common and Uncommon Causes.

Otalgia (ear pain) is a common presentation in the primary care setting with many diverse causes. Pain that originates from the ear is called primary otalgia, and the most common causes are otitis media and otitis externa. Examination of the ear usually reveals abnormal findings in patients with primary otalgia. Pain that originates outside the ear is called secondary otalgia, and the etiology can be difficult to establish because of the complex innervation of the ear. The most common causes of secondary otalgia include temporomandibular joint syndrome and dental infections. Primary otalgia is more common in children, whereas secondary otalgia is more common in adults. History and physical examination usually lead to the underlying cause; however, if the diagnosis is not immediately clear, a trial of symptomatic treatment, imaging studies, and consultation may be reasonable options. Otalgia may be the only presenting symptom in several serious conditions, such as temporal arteritis and malignant neoplasms. When risk factors for malignancy are present (e.g., smoking, alcohol use, diabetes mellitus, age 50 years or older), computed tomography, magnetic resonance imaging, or otolaryngology consultation may be warranted.

Hemoptysis: evaluation and management.

Hemoptysis is the expectoration of blood from the lung parenchyma or airways. The initial step in the evaluation is determining the origin of bleeding. Pseudohemoptysis is identified through the history and physical examination. In adults, acute respiratory tract infections (e.g., bronchitis, pneumonia), bronchiectasis, asthma, chronic obstructive pulmonary disease, and malignancy are the most common causes. Tuberculosis is a major cause of hemoptysis in endemic regions of the world. Although tuberculosis rates are low in the United States, they are increased in persons who are homeless or who were born in other countries; consideration for testing should be made on an individual basis. Hemodynamic instability, abnormal gas exchange, cardiopulmonary comorbidities, and lesions at high risk of massive bleeding warrant inpatient evaluation. Chest radiography is recommended as the initial diagnostic test for hemodynamically stable patients with hemoptysis. Further evaluation with computed tomography with or without bronchoscopy is recommended in patients with massive hemoptysis, those with abnormal radiographic findings, and those with risk factors for malignancy despite normal radiographic findings.