{"id":4225,"date":"2024-09-18T13:29:03","date_gmt":"2024-09-18T13:29:03","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=4225"},"modified":"2025-10-01T11:38:22","modified_gmt":"2025-10-01T19:38:22","slug":"usmle-step-2-question-of-the-day-arthrocentesis","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-arthrocentesis","title":{"rendered":"USMLE\u00ae Step 2 Question of the Day: Arthrocentesis"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-arthrocentesis\/#The_correct_answer_to_todays_USMLE%C2%AE_Step_2_CK_Question_is%E2%80%A6\" >The correct answer to today&#8217;s USMLE\u00ae Step 2 CK Question is&#8230;<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-arthrocentesis\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-arthrocentesis\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-arthrocentesis\/#Major_Takeaway\" >Major Takeaway<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-arthrocentesis\/#References\" >References<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><strong><em>Prepare for your USMLE Step 2 CK with a question focusing on the diagnosis of septic arthritis. How do you differentiate between various causes of joint swelling based on clinical presentation and synovial fluid analysis? Do you know the answer? Let&#8217;s find out! <\/em><\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 73-year-old man presents to the emergency department for evaluation of right knee pain and swelling for the past 2 days. &nbsp;The patient has been unable to ambulate secondary to the pain. Past medical history includes hypertension, gout, diabetes, osteoarthritis, and obesity. Temperature is 38\u00b0C (100.4\u00b0F), blood pressure is 125\/71 mmHg, pulse is 98\/min, respiratory rate is 14\/min, and oxygen saturation is 99% on room air. On physical examination, there is a palpable effusion, warmth, and marked swelling of the right knee. The patient is unable to bear weight without significant pain. An arthrocentesis is performed. The synovial fluid analysis results from later that day are shown below. Which of the following is the most likely diagnosis?&nbsp;<\/p>\n\n\n\n<figure class=\"wp-block-table\"><table class=\"has-fixed-layout\"><tbody><tr><td>Laboratory value&nbsp;<\/td><td>Result&nbsp;<\/td><\/tr><tr><td>Color&nbsp;<\/td><td>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; Opaque&nbsp;&nbsp;<\/td><\/tr><tr><td>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Culture\/Gram stain&nbsp;<\/td><td>&nbsp;Moderate polymorphonuclear cells on Gram stain&nbsp;&nbsp;No growth on culture thus far&nbsp;&nbsp;<\/td><\/tr><tr><td>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Cell Count&nbsp;&nbsp;<\/td><td>77,532 cells\/microL, 95% polymononuclear leukocytes&nbsp;<\/td><\/tr><tr><td>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Crystal Analysis&nbsp;&nbsp;<\/td><td>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; Negative&nbsp;<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A.&nbsp;Septic arthritis<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Osteoarthritis<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C.&nbsp;Rheumatoid arthritis&nbsp;<br><\/strong><br><strong>D.&nbsp;Gout&nbsp;&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E.&nbsp;Calcium pyrophosphate deposition disease<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Scroll down for the correct answer!<\/em><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_USMLE%C2%AE_Step_2_CK_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s USMLE\u00ae Step 2 CK Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A.\u00a0Septic arthritis<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Before we get to the&nbsp;<strong>Main Explanation<\/strong>, let&#8217;s see why the answer wasn&#8217;t B, C, D, or E. Skip to the bottom if you want to see the correct answer right away!<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B.\u00a0Osteoarthritis<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>&nbsp;Synovial fluid analysis from osteoarthritic joints typically have cell counts &lt;2000 cells\/microL. This patient&#8217;s synovial fluid analysis and clinical presentation are more consistent with septic arthritis.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C.&nbsp;Rheumatoid arthritis<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>Synovial fluid analysis in a patient with rheumatoid arthritis is typically inflammatory, with a&nbsp;white blood cell count &gt;2000&nbsp;cells\/microL, but generally the range is 5000-50,000&nbsp;cells\/microL.&nbsp;This patient&#8217;s synovial fluid analysis and clinical presentation are more consistent with septic arthritis.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D.&nbsp;Gout<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>Synovial fluid analysis in patients with gout is typically inflammatory, with a&nbsp;white blood cell count &gt;2000&nbsp;cells\/microL, but generally the range is 5000-50,000&nbsp;cells\/microL.&nbsp;Patients with gouty arthritis will also have evidence of negatively birefringent crystals. This patient&#8217;s synovial fluid analysis and clinical presentation are more consistent with septic arthritis.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E.&nbsp;Calcium pyrophosphate deposition disease&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>Synovial fluid analysis in patients with calcium pyrophosphate deposition disease (pseudogout) is typically inflammatory, with a&nbsp;white blood cell count &gt;2000&nbsp;cells\/microL, but generally in the range of 5000-50,000&nbsp;cells\/microL.&nbsp;Patients will also have evidence of calcium pyrophosphate crystals. This patient&#8217;s synovial fluid analysis and clinical presentation are more consistent with septic arthritis.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">This patient presents for evaluation of unilateral knee swelling and pain. Given this patient&#8217;s fever, joint effusion, limited range of motion, significant pain with range of motion, and inability to bear weight on the affected joint,&nbsp;septic arthritis&nbsp;is likely. Arthrocentesis and synovial fluid analysis shows opaque fluid with a white blood cell count of 77,532 cells\/microL, with 95% polymononuclear leukocytes which is consistent with septic arthritis.&nbsp;<\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" height=\"722\" width=\"1024\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/arthritic-synovial-fluid.png?w=1024\" alt=\"ARTHRITIC SYNOVIAL FLUID\nAnalysis \/ Non-Inflammatory Arthritis \/ Inflammatory Arthritis \/ Septic Arthritis\nColor \/ Clear\/Yellow \/ Yellow\/Cloudy \/ Cloudy\/Purulent\nCulture\/Gram Stain \/ Negative \/ Negative \/ + Growth\/Moderate Polymorphonuclear cells\/ + Gram Stain\nCell Count \/ < 2000 cells\/uL\nCrystal Analysis \/ Negative \/ +\/- Crystals \/ Negative\" class=\"wp-image-4227\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/arthritic-synovial-fluid.png 1246w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/arthritic-synovial-fluid.png?resize=300,211 300w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/arthritic-synovial-fluid.png?resize=768,541 768w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/arthritic-synovial-fluid.png?resize=1024,722 1024w\" sizes=\"auto, (max-width: 1024px) 100vw, 1024px\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">The diagnosis of septic arthritis is both clinical as well as dependent on results from synovial fluid analysis. Synovial fluid analysis can be used to differentiate between non-inflammatory causes of arthritis like osteoarthritis and inflammatory causes such as rheumatoid arthritis and septic arthritis. What separates septic arthritis is that there are typically &gt;50,000 cells\/microL with &gt;90% of those cells being polymorphonuclear cells, and gram stain and culture will be positive.&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Arthrocentis and synovial fluid analysis in patients with septic arthritis typically shows&nbsp;purulent &nbsp;fluid with leukocyte counts (most of which are neutrophils) of 50,000-150,000&nbsp;cells\/microL.&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Nair R, Schweizer ML, Singh N. Septic Arthritis and Prosthetic Joint Infections in Older Adults. Infect Dis Clin North Am. 2017 Dec;31(4):715-729. doi: 10.1016\/j.idc.2017.07.013. PMID: 29079156.&nbsp;<a href=\"https:\/\/www.sciencedirect.com\/science\/article\/pii\/S0891552017300673?via%3Dihub\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/www.sciencedirect.com\/science\/article\/pii\/S0891552017300673?via%3Dihub<\/a>&nbsp;&nbsp;<\/li>\n\n\n\n<li>Expert Panel on Musculoskeletal Imaging; Pierce JL, Perry MT, Wessell DE, Lenchik L, Ahlawat S, Baker JC, Banks J, Caracciolo JT, DeGeorge KC, Demertzis JL, Garner HW, Scott JA, Sharma A, Beaman FD. ACR Appropriateness Criteria\u00ae Suspected Osteomyelitis, Septic Arthritis, or Soft Tissue Infection (Excluding Spine and Diabetic Foot): 2022 Update. J Am Coll Radiol. 2022 Nov;19(11S):S473-S487. doi: 10.1016\/j.jacr.2022.09.013. PMID: 36436971.&nbsp;<a href=\"https:\/\/www.sciencedirect.com\/science\/article\/pii\/S1546144022006470?via%3Dihub\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/www.sciencedirect.com\/science\/article\/pii\/S1546144022006470?via%3Dihub<\/a>&nbsp;&nbsp;<\/li>\n\n\n\n<li>Tigges S, Stiles RG, Roberson JR. Appearance of septic hip prostheses on plain radiographs. AJR Am J Roentgenol. 1994 Aug;163(2):377-80. doi: 10.2214\/ajr.163.2.8037035. PMID: 8037035.https:\/\/www.ajronline.org\/doi\/10.2214\/ajr.163.2.8037035&nbsp;&nbsp;<\/li>\n\n\n\n<li>Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W, Steckelberg JM, Rao N, Hanssen A, Wilson WR; Infectious Diseases Society of America. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2013 Jan;56(1):e1-e25. doi: 10.1093\/cid\/cis803. Epub 2012 Dec 6. PMID: 23223583.\u00a0<a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/23223583\/\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/pubmed.ncbi.nlm.nih.gov\/23223583\/<\/a>\u00a0\u00a0 <\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image size-large\"><a href=\"https:\/\/www.osmosis.org\/plans\/md\" target=\"_blank\" rel=\"noreferrer noopener\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/09\/Blog_Display_Ads_MD1_2023.png?w=700\" alt=\"\" class=\"wp-image-5904\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/09\/Blog_Display_Ads_MD1_2023.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/09\/Blog_Display_Ads_MD1_2023.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><em><strong>Want more &nbsp;USMLE\u00ae Step 2 CK practice questions?&nbsp;<\/strong><\/em><em><strong>Try Osmosis by Elsevier today! Access your&nbsp;<a href=\"https:\/\/www.osmosis.org\/login?type=create\" target=\"_blank\" rel=\"noreferrer noopener\">free trial<\/a>&nbsp;and find out why millions of current and future clinicians and caregivers love learning with us.<\/strong><\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Review a clinical case of knee swelling and pain with synovial fluid results. Can you identify the most likely diagnosis and differentiate it from other arthritic conditions?<\/p>\n","protected":false},"author":202,"featured_media":4226,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[27,20,16,1370,45],"tags":[1254,1253,1259,1258,1252,1257,1256,798,1255,952],"class_list":["post-4225","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-exam-prep","category-do","category-step-2-questions","category-step-2","tag-arthritis-diagnosis","tag-arthrocentesis","tag-calcium-pyrophosphate-disease","tag-gout","tag-joint-swelling","tag-osteoarthritis","tag-rheumatoid-arthritis","tag-septic-arthritis","tag-synovial-fluid-analysis","tag-usmle-step-2-ck"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>USMLE\u00ae Step 2 Question of the Day: Arthrocentesis - Osmosis Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-arthrocentesis\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"USMLE\u00ae Step 2 Question of the Day: Arthrocentesis - Osmosis Blog\" \/>\n<meta property=\"og:description\" content=\"Review a clinical case of knee swelling and pain with synovial fluid results. Can you identify the most likely diagnosis and differentiate it from other arthritic conditions?\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-arthrocentesis\" \/>\n<meta property=\"og:site_name\" content=\"Osmosis Blog\" \/>\n<meta property=\"article:published_time\" content=\"2024-09-18T13:29:03+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2025-10-01T19:38:22+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/usmle-arthrocentesis.webp\" \/>\n\t<meta property=\"og:image:width\" content=\"1080\" \/>\n\t<meta property=\"og:image:height\" content=\"1080\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/webp\" \/>\n<meta name=\"author\" content=\"Marina Horiates Kerekes, MD &amp; Team\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":[\"Article\",\"BlogPosting\"],\"@id\":\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-arthrocentesis#article\",\"isPartOf\":{\"@id\":\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-arthrocentesis\"},\"author\":{\"name\":\"Marina Horiates Kerekes, MD &amp; 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