Orthopaedics Station 2

Setting:

You are a Foundation Year doctor working in the Emergency Department. This patient has presented with pain in their legs.

Sheena Thomas

Tasks:

1. Take a history from the patient.

2. State your preferred diagnosis and a differential to the examiner.

3. Outline the investigations you would like to carry out to the examiner.

4. Outline your management to the examiner.

Briefing

Diagnosis: Lumbar spinal stenosis presenting as leg pain.
You are Sheena Thomas (Age 63)
You have presented to the Emergency Department with pain in your buttocks and legs.

Appearance and Behaviour

You are well kept in appearance and trying to be polite but given the duration of the symptoms it's really starting to annoy you so you should be as insistent as possible that you want it sorted whilst remaining calm.

Opening statement

“I’m getting this awful pain in my buttocks and legs when I’m walking, please could you find out what’s causing it.

Information to Give Freely

It started a couple of months ago. You noticed it would start when you were walking, but go away again if you stopped to rest. It’s been getting worse since then and now you can barely walk 50m without it starting.

Presenting Complaint

Site - Both buttocks and the back of the legs
Onset - about 2 months ago. Did not have a sudden trigger e.g.g sneezing or picking something up
Character – It’s a crampy aching pain (NOT a burning pain if candidate attempts to clarify further)
Radiation – All the way down your thighs and calves (point down the back of your legs). Does not spread up your back.
Associated symptoms – Your husband says that you've been looking unsteady with your walking, you have felt a bit unsteady at times.
Timing – It’s not worse at any particular time in the day and some days it's not as bad but it is becoming more frequent and brought on with less activity than before
Exacerbating/relieving factors - Worse when walking or standing for a long time. Better when sitting, bending forwards, using your indoor cycling machine at home but the pain takes a while to get better (10-20 minutes)
Severity – When it start 2-3/10. Now 8/10 and it’s really affecting your ability to get around and do things around the house.

Past Medical History

Previous similar episodes - Happening with increasing frequency since it started 2 months ago (now happening every day multiple times). Prior to 2 months ago you’d never experienced anything like this.
Other medical conditions - Type 2 diabetes - on insulin. Your GP keeps telling you you need to control it better but you find it all very tedious.
Previous surgeries - Cholecystectomy in your 40s. No complications or ongoing concerns about this.

Drug History

Prescribed - metformin, lantus (16 units) at night and then novorapid with breakfast lunch and dinner (12 with breakfast, 8 with lunch and dinner).
Over the counter - Trying paracetamol and ibuprofen but they don’t help much.
Allergies - Levofloxacin. If specifically asked - you get a widespread rash and trouble breathing.

Family History

Your mum used to get sciatica which caused leg pain.

Social History

Smoking - Never smoked
Alcohol - Drinks a small glass of port in the evenings on weekends.
Home - you live in a 2 floor house with your husband.
Mobility - Normally completely independent but you’re feeling a bit more unsteady since this started.
ADLs - you and your husband normally manage well and the young neighbor next door is always available to help out with things if needed.

Systems Review

General/red flags - NO fevers or weight loss, NO night sweats
Neuro - NO loss of consciousness. NO weakenss or numbeness. No dizziness
Resp - Nil
Cardio - Nil
GI - Bowels last opened yesterday - normal for you. No sensation changes when wiping (no saddle anaesthesia). No incontinence of bowel or bladder

Ideas / Concerns / Expectation

Ideas - My friend had similar symptoms and had a clot in her leg - is that what this is?
Concerns - Will it get worse so I won’t be able to walk?
Expectations - The pain is terrible, I’d love some better pain relief.

Discussion / Questions

When talking about your concerns you should expect the candidate to reassure you that this does not sound like a DVT/blood clot. They should offer to look into some stronger pain relief options.