Rheumatology & Orthopaedics
CANDIDATE INSTRUCTIONS
You are the resident year 1 doctor covering the surgical ward out of hours. You get a phone call from a nurse from one of the orthopaedic wards being concerned about Ben Davies, a 68 year old man complaining of left leg swelling. She also says the patient is in a lot of pain and wants you to assess the patient as soon as possible.
The patient’s notes and observations are available if you need them.
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:
When the station time begins, please offer the candidate the following details:
Name: Ben DaviesAge: 68
Admitted after a road traffic accident today with a tibial fracture for conservative management. He had a cast put on couple of hours ago by the SHO on the ward.
Observations
NEWS 2
SpO2 96% on air
RR 18
BP 138/64 HR130
O/E: Left leg looks swollen under cast with sides. He is in a lot of pain especially when you try to move his leg. Right leg looks completely normal.
At 8 minutes, stop the candidate and ask the following questions:
Question 1: Name the most likely diagnosis.
Answer 1: Compartment syndrome
Question 2: What are the acute presentations of compartment syndrome (Name 2)?
Answer 2: Pain, paresthesia, pale, pressure, paralysis
Question 3: How to manage compartment syndrome?
Answer 3:
Escalate to orthopaedics registrar
Removing any external bandage or dressings
Elevating the leg
Emergency fasciotomy
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Acute Compartment Syndrome of the LEFT Leg
PATIENT INSTRUCTIONS
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Name: Ben Davies
Age: 68 years old
Date of Birth: 20th November 1956
Occupation: Retired salesman
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"I am in so much pain in my left leg and its all swollen up as well, I can barely move it!"
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Site: My left lower leg
Onset: Only around 30 minutes ago
Character: It’s very painful, worse than when I first came in with the fracture. It now looks like its swollen as well which it wasn’t
Radiation: Just all around the left lower leg
Assoc Sx: I can’t move my leg at all because of the pain. If asked specifically - No numbness or tingling. Looks quite red.
Timing: It’s just happened over the last half hour
Exacerbating Factors: Trying to move it
Relieving Factors: The nurses gave me some morphine which didn’t touch the pain
Pain Scale: It’s a 10/10 now
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Recent illness: None.
Recent trauma: Just the car accident I came in with, they said I broke my tibia.
Recent travel: None.
Previous episodes: Never experienced this before.
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Ideas: "I dont know what it is but the pain is really bad”
Expectations: “What’s going on?"
Concerns: “Something is definitely wrong, I wasn’t even in this much pain when I broke my bones."
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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
Fever: None
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Previous hospital admissions: None
Previous surgeries: None
Medical conditions: T2DM, COPD, obesity, Hypertension, prev ischaemic heart disease
Medications:
Amlodipine, ramipril, bisoprolol, metformin, aspirin
Allergies:
None.
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Nothing really
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Smoking: Current smoker, about 15 per day
Alcohol: Couple of beers on the weekends
Recreational drugs: Never
Diet: Usually microwaveble food
Exercise: Not really
Ill contacts: No one around me was recently ill
Home: Lives alone in flat
Active Daily Living: Family and neighbours come in to help. I do shopping online
Occupation: Retired hotel receptionist
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: /47
SCORE GUIDE
High Pass: > 38
Pass: > 28
Borderline Pass: 23 - 28
Fail: < 23
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