Rheumatology & Orthopaedics
CANDIDATE INSTRUCTIONS
You are a year 2 resident doctor working in the Acute Medical Unit. Mr James Brown presents after being referred from his GP with fever and joint pain. He says his GP was concerned about there being a severe infection in his joints and told him to present for further investigations and tests.
Take a focused history
At 8 minutes you will be stopped by the examiner to ask some questions
2 Minutes Reading Time
10 Minutes Station Time
Total 12 Minutes
EXAMINER INSTRUCTIONS
Timing Instructions: At 8 minutes, stop the candidate and ask the following questions:
Question 1: What is the mostly likely diagnosis and why?
Answer 1:
Septic Arthritis
Hot, swollen joint with reduced movement (this should always make you think of septic arthritis until proven otherwise)
Question 2: Name 2 common organisms that can cause septic arthritis, starting with the common one first
Answer 2:
Staphyloccocus Aureus
Neisseria gonorrhoea (insexually active young adults)
Question 3: How is septic arthritis most commonly spread?
Answer 3: Haematogenous spread, from distant sites with recent bacterial infections
Question 4: What would be the management?
Answer 4: IV flucloxacillin or clindamycin if penn allergic (any antibiotics that cover gram positive cocci), preferably after synovial fluid sampling/ cultures obtained
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Septic Arthritis
PATIENT INSTRUCTIONS
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Name: James Brown
Age: 65 years old
Date of Birth: 30th October 1959
Occupation: Retired police man
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"My knee is swollen and painful and I cant seem to walk.”
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Site: Your left knee
Onset: Yesterday night
Character: It’s swollen, red and its very painful when I try to move it
Radiation: Nil
Assoc Sx: I’ve been feeling quite warm like when I am running a fever but not actually managed to check my temperature
Timing: It’s only got worse since it started
Exacerbating Factors: It’s not so bad just now but when I try moving it hurts and I cant bend my knee as well because of the swelling
Relieving Factors: Nothing really
Pain Scale: Maybe a 6/10
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Recent illness (only if specifically asked): I have got an ulcer on my foot which is usually very well looked after but got infected 2 weeks ago. It went away with a couple of days of antibiotics from the GP
Recent trauma: None.
Recent travel: None.
Previous episodes: Never experienced this before.
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Ideas: "Have I got another infection?"
Expectations: “Can I go home today?"
Concerns: “I havent been able to walk or drive since this came on, how long will it take to go away?"
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Bowel habits: Nil
Urinary habits: Nil
Appetite: Same as usual.
Sleep: Same as usual
Weight: No change
Pain in the chest/abdomen: None
Headaches: None
Cardiology: Normal
Respiratory: Normal
Upper limb neurology: Normal
No pain in lower limbs
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Previous hospital admissions: None
Previous surgeries: None
Medical conditions:
I’ve got diabetes which I am on insulin injections for (if leg ulcers mentioned previously, explain that diabetic control was a struggle initially which was what caused the ulcer)
Medications:
Nil
Allergies:
None.
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DIabetes
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Smoking: Never smoked
Alcohol: Occasional 1-2 pints with my mates
Recreational drugs: Never
Diet: I usually cook at home
Exercise: I enjoy walks in the park
Ill contacts: No one around me was recently ill
Home: Lives with wife in a flat on the second floor
Active Daily Living: Independent with all ADLs
Occupation: I used to work as a lawyer but retired 10 years ago
MARK SCHEME
Introduction
Ideas, Expectations & Concerns
Presenting Complaint
History of Presenting Complaint
Systems Review
Past Medical History
Drug History
Family History
Social History
Questions
Patient Scores
Enter Your Score Here: /48
SCORE GUIDE
High Pass: > 38
Pass: > 29
Borderline Pass: 24 – 29
Fail: < 24
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