History of Present Illness and Examination

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A 53-year-old man with a history of diabetes and hypertension for which he takes metformin and furosemide presents to the emergency department with 1 month of migratory bilateral ankle pain that is worse on the left side. He has seen many clinicians, underwent radiographic examination, and has been using orthotics, but the pain persists.  He reports being unable to work for the past 2 weeks due to worsening ankle pain. He denies fever, injury, increase in activity prior to symptom onset, calf swelling, chest pain, shortness of breath, or other complaints.

Physical examination is normal except for elevated blood pressure at 172/98 mm Hg and mild bilateral diffuse ankle tenderness.  The patient is obese; therefore, it is difficult to determine if his ankles are swollen or normal for his body habitus. However, his ankles do appear symmetric.  There is no redness, but there appears to be slight warmth on the left ankle compared with the right.

Differential diagnoses include arthritis, gout, infection, and forgotten injury.

Initial Testing

Radiographic examination of the ankles demonstrates symmetric bilateral mild osteoarthritis.

The patient provided written consent, and aspiration of the left ankle joint was attempted; no fluid was obtained.  After removal of the needle, the plunger was pulled back further to ensure no fluid existed in the needle lumen or hub, and none was found.   Before the clinician discarded the syringe, however, a small (approximately 1 x 1 mm) pellet of white paste was visualized (Figure). 

What does the case image show? What is the next best step in this patient’s management?   

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