Orthopaedic station 4

Setting:

You are a Foundation Year doctor working in an emergency unit. The patient has presented with pain in their arm after a fall.

Name: Stephen Titchmarsh

Tasks:

1. Take a history from the patient.

2. Interpret the investigation to the examiner.

3. Explain the diagnosis and treatment to the patient.

You are not required to examine the patient.

Briefing

Diagnosis: distal radius fracture.
You are Stephen Titchmarsh, a 48 year old male
You have presented to the emergency department after you fell whilst carrying a heavy objects at work.

Opening statement

“I was in the farm yard and I think I tripped on an uneven bit of pavement whilst carrying a scarecrow which needed planting in the nearby field. I fell forwards and landed on my right hand. It hurt as soon as I fell and I think I’ve broken something.”

Presenting complaint

You fell forward, you had a scarecrow purched on your left shoulder so could only reach out with your right hand. As you fell forward all your weight went through your right arm.
Site - pain in the right forearm
Onset - immediate, the incident happened about 2 hours ago
Character - as you fell it was a sudden sharp pain. Now it is an achey pain that won’t go away.
Radiation - none
Associated symptoms -

• you think the wrist is in a "funny position" (it appears displaced)
• there is no numbness
• there is no weakness and you can move your fingers
• there is some swelling of the wrist and forearm
• the hand has not changed colour

Timing - nil
Exacerbating/relieving factors - you had Methoxyflurane with the ambulance crew and it helped a lot
Severity - 9/10 initially, now 7/10
You are right handed.

Past Medical History

Previous similar episodes - nil
PMH - hashimotos thyroiditis (well controlled on medication), hypertension
Previous surgeries - nil

Drug History

Prescribed - nil
Over the counter - levothyroxine, omeprazole, rampiril
Allergies - no known allergies

Family History

Mother - osteoarthritis

Social History

Smoking history - nil
Alcohol - special occasions only
Drug use - never used any illicit drugs
Employment - works as a farmer
Fully independent
You live alone in a bungalow after your wife died of cancer 2 years ago, you work a lot.
You enjoy playing the piano in your spare time and are quite good

Systems Review

General/red flags - NO head strike or loss of conciousness
Syncopal symptoms - NO dizziness, NO shortness of breath, NO palpitation, NO chest pain
Systemic - NO fevers or rashes
Resp - NO cough or sputum
GI - NO bowel upset
GU - NO urinary symptoms
Joints - NO pain in any other joints

Ideas / Concerns / Expectation

Ideas - “Have I broken my wrist?”
Concerns - “Will I need an operation?”
Expectations - “I’m in a lot of pain so could I get something for it?”

Discussion / Questions

After the history the candate will explain the diagnosis to you, recieve this in an understanding manor. Please ensure if they fail to address your concerns initially, to mention this once more prior to moving on. If they mention an operation ask when the operation will be scheduled for.

Please interpret these results

Name: Stephen Titchmarsh

Age: 48

Date of Scan:

Time of Scan: 09:30am

Location: Radiology Department, City Hospital