Student Instructions
You are a junior doctor working in general practice.
Mrs Betts complains of painful joints. As she walks into your clinics office you notice she is limping.
Please take a focused history from her and formulate a management plan.
The examiner will stop you at 7 minutes to ask you a few questions.
Patient Instructions
Name: Mrs Julie Betts
Age: 63 years old
Job: Retired clothes shop owner
PC
You attend your GP practice today with a rather painful limp.
For the last few months, you have noticed increasing pain in your left hip and right knee which is usually worse at the end of the day, particularly if you have been on your feet a lot or have been cooking for your grandchildren at home.
None of your joints are red or swollen although the knee pain is worse when you touch your knee. It is very difficult to be specific about which areas of tender to touch as you feel the whole knee can be achy at the end of the day and it really doesn't matter where you touch it.
In addition, your granddaughter, who was only eight years old, says that when she tries to massage your knee, she can hear crackling in it as she moves it. You wonder if you have bits of bones in your joint but can't think how they got in there.
You deny any recent falls, injury or trauma to the affected areas. None of your other joints are affected and you have not noticed any swelling or lumps anywhere else in your body.
You do not have any rashes. You have not had red eyes and have not noticed any dryness in your mouth or eyes. You have not had any diarrhoea and have not lost weight. You do not have any mouth or genital ulcers. You do not have any neurological symptoms.
PMH
None
DH
NKDA
Paracetamol 1mg po prn
Ibuprofen 400mg po prn
SH
You do not smoke or drink. You have one son who is always at work and very busy. His wife is also very career orientated so you are usually left with your two granddaughters to look after when they come home from school. You enjoy playing with them but find it hard to keep up with their antics as your joint pain gets worse with excessive movements.
You used to do a lot of exercise as a youngster and ran 3 marathons in your day. You never had any sporting injuries but do feel you have overused your joints a bit and are paying the price now. Many of your friends have recently had joint replacement surgeries and you know they have not had great results so would like to put this off for as long as possible.
ICE
You did not want to bother the doctor but the pain is getting the better of you so you wanted to check what is wrong.
Questions
What is the likely diagnosis?
Osteoarthritis
What are the differentials?
Rheumatoid arthritis
Crystal arthropathy
What investigations & management would you do?
Arrange X-rays of hands and knee.
Encourage regular exercise.
Prescribe regular analgesics such as paracetamol/codeine/NSAIDs.
Reduce weight, BMI is 28.
Intra-articular steroid injections may temporarily alleviate severe symptoms.
Joint replacement is indicated for severe OA.