Orthopaedic station 3

Setting:

You are a Foundation Year doctor working in GP. This patient has presented with knee pain.

Name: Christian White

Tasks:

1. Take a history from the patient.

2. Interpret the provided investigations.

3. Give your leading diagnosis to the examiner.

4. Answer any examiner questions.

You are not required to examine the patient.

Briefing

Diagnosis: Diagnosis: osteoarthritis in the LEFT knee
You are Christian White, a 64 year old male
You have presented to the GP with a flare of long standing knee pain

Opening statement

“Doctor, I've had knee pain for years and it’s been progressing for a while but over the past few weeks it’s pretty unbearable.”

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 - left knee, the pain feels like it’s inside the knee.
Onset - your chronic knee pain has got slowly worse over years, but in the past few weeks associated with increased activity it’s got worse.
Character - constant aching pain.
Radiation - sometimes it radiates to your left hip but mainly it’s in the knee.
Associated symptoms -

• slight swelling for years but there’s been no acute change
• mild stiffness for 30 minutes in the morning or when you rest for a long period, this loosens off when you get moving
• some “creaking and crackling” in the knee when you bend down
• no redness
• no heat
• no locking or give way

Timing - It’s worse when you wake up, especially the stiffness, it actually improves within 30 minutes of waking up but is still severe and you can’t cope.
Exacerbating/relieving factors - walking or moving the knee makes it worse. You’ve not done anything to try and improve the pain, you’ve not tried much past irregular paracetamol.
Severity - 7/10
Other details

• No trauma

Past Medical History

Previous similar episodes - You have had chronic left knee pain which has been slowly worsening for about 5 years, you’ve never seen your GP for this because you’re a busy farmer and you don’t have time to worry about a “silly bit of knee pain”. You’ve been ignoring it hoping it would improve, it has not. Other medical conditions

• central obesity with a BMI of 32 at a recent men's wellness clinic (your favorite snack is bread with a thick covering of farmhouse butter)
• NO gout history
• Previous surgeries - nil

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.