Orthopaedics Station 1

Setting:

You are a junior doctor working in A&E. This patient has presented with a sore knee.

Name: Toby Snow

Tasks:

1. Take a focussed history from the patient.

2. Present your history to the examiner.

3. Interpret the investigations to the examiner.

4. Give your diagnosis and management plan to the examiner.

You are not required to examine the patient.

Briefing

Diagnosis: Septic arthritis presenting with knee pain
You are Toby Snow, a 40 year old male.
You have presented to A&E with pain in your left knee

Appearance and Behaviour

You should act as if you are in pain throughout, and getting annoyed at how much this has impacted your life.

Opening statement

“Well Doctor, it’s my knee. The last few days it has gotten so painful I can barely get around the house”

Information to Give Freely

It’s been all red and swollen over the last few days after I fell over at work and cut it.

Presenting Complaint

Site – Left knee
Onset – 4 days ago.
Character – it’s a throbbing pain in the left knee.
Radiation – You haven’t noticed any radiation of this pain, and no other joints have been affected.
Associated symptoms – Redness, swelling, knee feels hot and you’re having trouble weight bearing (ie loss of function). If specifically asked, you’ve noticed a fever (last measured at 38.2) over the last few days with shaking and chills. No discharge from the knee or laceration.
Timing – It’s been getting increasingly painful and inability to weight bear has been worsening.
Exacerbating/relieving factors – Ice packs helped a little, but the pain always comes back. Moving the knee makes it worse but you can’t think of anything specifically that may have caused it.
Severity – Pain has increased day by day and is now 9/10 (vs 5/10 to start), becoming unbearable. It’s massively affecting your life and ability to work.

Past Medical History

Previous similar episodes - None. No previous injuries to the knee
Other medical conditions - Type 2 Diabetes, Hypertension
Previous surgeries – Nil. You have no prosthetic joints.

Drug History

Prescribed – Metformin 500mg BD, Ramipril 5mg OD.
Over the counter – You’ve tried paracetamol and ibuprofen as regular but they didn’t help.
Allergies – Penicillin. Only if asked, you get a generalised rash but no difficulty breathing.

Family History

Osteoarthritis, diabetes and hypertension run in the family. No autoimmune or rheumatological conditions.

Social History

Smoking history - Smokes 10/day with a 20 pack year history.
Alcohol – A glass of wine or 2 on weekends.
Recreational drugs – you’ve never used recreational drugs of any type – IV or by other methods.
Sexual history (only answer these if explicitly asked) – You’ve only been with your husband (who is also from the UK and neither of you have ever travelled abroad) in the last 6 months and always use condoms. You’ve had both anal and oral sex. Neither of you have had other partners since getting married 15 years ago and were screened for HIV and sexually transmitted infections (blood tests) prior to this – all of which came back clear.
Occupation – Carpenter so I’m often kneeling
Activity - You’re typically quite active due to work.
Home:

Type: Semi-detached house with 2 floors

Who’s at home: Your husband and 2 kids.

Mobility - fully independent prior to this, now can barely walk.

ADLs – Typically fully independent

Miscellaneous – you’ve never had any tattoos.

Systems Review

General/red flags – Noticed fever (as per PC), NO weight loss, NO night sweats
Neuro – NO changes in sensation. NO change in power of muscles above or below joint. NO neuropathic (burning) pain. NO sensitivity to light.
Resp – Nil
Cardio - Nil
GI – Nil
GU – NO lower urinary tract symptoms, NO urethral discharge.
Derm – NO new rashes or lesions.

Ideas / Concerns / Expectation

Ideas – “I know arthritis runs in my family, is it that?”
Concerns – “I’m concerned I won’t be able to work properly if it doesn’t get sorted”
Expectations – “Please help the pain”

Fluid Sample: Left knee joint aspirate

Name: Toby Snow

DoB: 10/06/1981

Date of Study:

Appearance	Purulent
WBC Count	70,000
Gram stain	Positive
Crystals	Nil seen