Orthopaedic station 3

Setting:

You are a Foundation Year doctor working in a GP practice. This patient has presented with neck and shoulder stiffness.

Name: Julie Martin

Tasks:

1. Take a history from the patient.

2. Give your leading diagnosis to the examiner.

3. Give your initial investigations to the examiner.

3. Answer any examiner questions.

You are not required to examine the patient.

Briefing

Diagnosis: Polymyalgia Rheumatica.
You are Julie Martin, a 56 year old female.
You have presented to the GP surgery with neck and shoulder stiffness.

Opening statement

“I have had this stiffness in my neck and shoulders for about the last 15 days, I thought I’d pulled a muscle as it came on quite suddenly but it’s not getting any better”

Information to Give Freely

You have chronic knee pain but over the past few weeks it’s been much worse. You’ve not had any trauma but you’ve been working extra shifts to try and complete a project at work (as a Farmer). You think this is why it’s more sore and you think you’ve “overdone it”.

Presenting complaint

Site - initially in the neck but now spreading to the shoulders.
Onset - 15 days ago. You were sat at your desk working when it came on over hours. You haven’t lifted anything heavy or done any unusual exercise.
Character - constant aching pain.
Radiation - neck and both shoulders.
Associated symptoms -

• you feel very fatigued
• there is stiffness all day
• no swelling
• no crepitus
• no redness
• no heat
• no locking

Timing - worse in the morning for about 2 hours however there is constantly an element of stiffness throughout the night and day
Exacerbating/relieving factors - you tried paracetamol and it's not helped.
Severity - it’s interfering with your life as you work in a laboratory and need to use your arms for your work 7 or 8/10
Other details

• No trauma

Past Medical History

Previous similar episodes - Never
PMH - Previous treated breast cancer, you were given the all clear 7 years ago.
Previous surgeries - mastectomy

Drug History

Prescribed - nil
Over the counter - you occasionally take paracetamol when your wife prompts you (for knee pain)
Allergies - no known allergies

Family History

Nil

Social History

Smoking history - nil
Alcohol - you never drink
Drug use - never used any illicit drugs
Employment - works as a farmer
Fully independent

Systems Review

General/red flags - NO fevers
Neuro - NO numbness or weakness (around or distal to the knee)
Systemic - NO fevers or rashes
Resp - NO resp symptoms
Skin - NO rashes or psoriasis
Eyes - NO symptoms related to iritis / scleritis
GI - NO bowel upset
GU - NO urinary symptoms or penile discharge
Joints - Other joint involvement = mild right hip pain present for years (although this is not causing you any trouble and if asked about it change the subject back to your knee), NO calf pain or swelling

Ideas / Concerns / Expectation

Ideas - “I have no idea what it is but i’d like it solved today so I can get back to work”
Concerns - “I don’t have time to rest, the harvest is coming up”
Expectations - “I’ll be going back to work once I’ve left the clinic”

Discussion / Questions

There is no further interaction after the history in this station. Please ensure you play up that this has been chronic pain but it’s got worse with increased activity recently. The candidate's history should focus on asking a series of questions to rule our more serious pathologies such as septic arthritis or gout.