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Choosing Wisely — RCPSC IM MCQ

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HardGeneral IM, Ethics, CanMEDSChoosing WiselyRCPSC IM

A 64-year-old with gout and CKD presents with an acutely swollen knee, fever and rigors. The joint is intensely tender and urate is elevated. What is the next diagnostic step?

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Correct answer: A — Perform urgent arthrocentesis with microscopy and culture

The best answer is “Perform urgent arthrocentesis with microscopy and culture”. Fever and acute monoarthritis require septic arthritis exclusion even in known gout, and infection can coexist with crystals. Synovial fluid provides the decisive microbiologic and crystal assessment; imaging or serum urate cannot replace it, and intra-articular steroid before exclusion is unsafe.

Reference: Canadian Rheumatology Association, gout resources: https://rheum.ca/resources/publications/