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Acute mania with agitation — RCPSC EM MCQ

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HardPsychiatric emergenciesAcute mania with agitationRCPSC EM

A patient with rheumatoid arthritis taking a biologic agent has a hot, swollen knee, fever and markedly raised CRP. What is the most appropriate next investigation before treating this as a disease flare?

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Correct answer: A — Perform urgent arthrocentesis for synovial fluid analysis and culture

The best answer is “Perform urgent arthrocentesis for synovial fluid analysis and culture”. A rheumatoid flare can resemble septic arthritis, but immunosuppression and fever make infection especially concerning. Diagnostic arthrocentesis with synovial analysis and culture is required when suspicion is present, before escalating immunosuppression or injecting steroid. Serology and radiography cannot exclude a septic joint, and outpatient imaging delays source identification.

Reference: Emergency Care BC: Rheumatoid Arthritis—Diagnosis, Management and ED Complications: https://emergencycarebc.ca/clinical_resource/clinical-summary/rheumatoid-arthritis-diagnosis-management-and-ed-complications/