sprint123
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An 18-year-old woman is evaluated because of a 10-day history of joint pain. She has had fever followed by pain and swelling in the knuckles of both hands for 3 days. Her left wrist subsequently became swollen and painful, followed by her left knee. She has a sore throat and two small skin lesions. She is currently menstruating.
Her temperature is 38.6ºC (101.5ºF), pulse rate is 100/min, and blood pressure is 110/70 mm Hg. The posterior oropharynx is slightly red without exudate. There is a red papular skin lesion 0.5 cm in diameter on the left forearm and a small pustule on the left upper chest. There is a large right knee effusion; the knee is red, warm, and tender to palpation and painful on movement. The remainder of the examination, including pelvic, was normal.
Arthrocentesis of the right knee obtained 35 mL of cloudy yellow fluid. No organisms are seen on Gram's stain, synovial fluid leukocyte count is 15,000/μL with 90% polymorphonuclear cells; glucose level is 48 mg/dL (serum glucose is 125 mg/dL); protein is 45 g/dL.
Which of the following is the most likely diagnosis?
( A ) HIV infection
( B ) Acute rheumatic fever
( C ) Hepatitis B virus infection
( D ) Disseminated gonococcal infection
( E ) Lyme arthritis
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| new_n_lost
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( B ) Acute rheumatic fever
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| muna
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D
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| Justice
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Very tempting to choose (D)
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| doc_clotaire
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Young female with polyarthritis ( hand and knee ) and dematologic lesions ( red papules )
D----------------Disseminated Gonoccocal Infection
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| sprint123
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The answer is D...i WAS WONDERING HOW COULD SORE THROAT FIT IN??Any comments?
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| doc_clotaire
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just a distractor to screw us up LOL  ( like Goljan would say )
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| mdwannabe
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Classical presentation of one of the two forms of Gonnococcal Arthritis
1. Tenosynovitiis + Polyarthragia + painless Dermatitis, pustulo-vesicular Joint tap- tipically negative.
2. Septic arthritis... you know what the fluid looks like.
in Hep B .. rash ussualy itchy.
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| sprint123
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Still  ...Why can't it be ARF :
fEATURES SUGGESTING :
Migrating joint pain x 10 days
Fever,sore throat
Joint tap-No gram stain,plenty of neutrophils
Why can't rash be a distractor in this question to rule out gonorhea?!Just curious...
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| new_n_lost
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yup i focused more on the Synovial Fluid pic n sore throat otherwise her entire history is consistent with DGI Got Distracted 
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| mdwannabe
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To Sprint... It is the type of rash that is described, that makes the difference. Take a quick tour of different rashes in different conditions... these things sometime pop up on boards.
Vesicular rash...several locations...not very numerous... less than 40 vesicles...charactesitic.
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| sprint123
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You are right..mdwannabe...Pretty weak in the type of rashes...Can u suggest a source to improve?Eager to look into that
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| mdwannabe
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hmm...tough to say... use google images...Mayo clinic review for IM boards...Derm books... all for quick look up of the rashes and associations. Thats what I did.
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| AAAAA
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D
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| dr_ayyad
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sore throat fits in
the gurl was...........................
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