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A 65-Year-Old Man Comes to the Physician Because of a 3

question 356

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A 65-year-old man comes to the physician because of a 3 day history of pain and swelling in his left knee. He also reports nausea and feeling weak earlier today. He has a long-standing history of rheumatoid arthritis (RA) and has had several previous episodes of "fluid in the knee." He currently takes methotrexate and sulfasalazine for his RA. Tumor necrosis factor inhibitor therapy was prescribed two years ago but was discontinued after six months due to frequent sinus infections and exacerbation of his congestive heart failure. His other medical problems include hypertension, hypercholesterolemia, colonic polyps, essential tremor, congestive heart failure, and a remote history of asbestos exposure. His other medications include furosemide, propranolol, lisinopril, aspirin, and simvastatin.
His temperature is 37.2 C (99 F) , blood pressure is 110/70 mm Hg, pulse is 88/min, and respirations are 16/min. He has no jugular venous distention. His heart sounds are normal and his lungs are clear. Musculoskeletal examination is notable for extensive deformities in the hands due to long-standing arthritis. His right knee is normal. The left knee is tender and swollen and he is unable to extend it due to pain.
Joint aspiration yields 20 cc of synovial fluid. Laboratory results are as follows:

Which of the following is the most appropriate next step in management?

Definitions:

Central DC

Central DC, or Central Distribution Center, is a critical logistics facility that centralizes warehousing and distribution activities for efficient goods movement.

Use Fee

A charge imposed for the use of a particular service, facility, or product, often on a rental or per-use basis.

Congestion

A situation in transportation or network systems where demand exceeds capacity, resulting in delays and inefficiencies.

Motorist

An individual who operates a motor vehicle, such as a car or motorcycle.