Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Foundation Year Doctor working in general practice. Your next patient is Jamie Tooth, a 35-year-old woman presenting with joint pain. Please take a history and conduct a relevant examination.
Patient History:
Jamie Tooth, 35 y/ F, dog trainer.
For 8 months, you have been getting worsening knee pain in both knees. The pain is present on most days and worsens towards the end of the day. You spend most of the day on your feet as part of your job, and recently you have been progressively becoming less able to keep up with the demands of your work. To seek relief from the pain, you have to take frequent breaks throughout your work day, and this slows you down so much that you have been forced to cut down on the number of clients you see daily. You try to keep off your feet on the weekend and find that this helps limit the pain.
Besides brief stiffness in your knees lasting less than 30 minutes in the morning, you don't have any other symptoms. You deny symptoms of locking or giving way, shortness of breath, chest pain, palpitations, rashes, visual problems, or changes in bowel habits. You have not had any recent short-lived episodes of illness.
Ideas, Concerns, Expectations:
You are worried that you have rheumatoid arthritis, as this is what your mother has. She is currently fully dependent on others for activities of daily living - this terrifies you as you do not want to be in her position when you reach her age. You would like to begin treatment as soon as possible to preserve your independence.
Past Medical History:
Obstructive sleep apnoea
Polycystic ovarian syndrome
Asthma – well-controlled. You haven’t used an inhaler in years!
If asked about previous trauma, reveal that you tore your right knee meniscus during a hockey game as a teenager.
Drug History:
Lansoprazole
No known drug allergies.
Family History:
Mother has rheumatoid arthritis.
Father has oesophageal cancer.
Social History:
Non-smoker
No recreational drug use
You live at home with 3 dogs. You are independent in activities of daily living like shopping, cooking and cleaning.
You work full-time as a dog trainer. As working has become increasingly difficult, lately you have been considering engaging in part-time work instead.
Examination Findings:
On general inspection:
Large body habitus
Gait is slow but symmetrical.
On examination of the knees:
There is no evidence of redness, swelling or heat bilaterally.
No effusions can be detected on the patellar tap or sweep tests.
Bilateral crepitus is ascertained on passive movement.
There is pain in passive and active movement throughout the range of motion of both knees.
Differentials:
Osteoarthritis of the knees
Rheumatoid arthritis
Referred pain from the hip joint e.g. osteoarthritis of the hip, greater trochanteric pain syndrome
The above history and examination are strongly suggestive of osteoarthritis. This is the most likely diagnosis despite the family history of rheumatoid arthritis. The presence of a past meniscal tear and current obesity can confer a higher risk of developing early-onset osteoarthritis – do not be deceived by the patient's age or family history!
Investigations:
Bedside:
Measurement of BMI (obesity is associated with the development of osteoarthritis)
Bloods:
Inflammatory markers (usually normal in osteoarthritis)
Serum autoantibodies (serum autoantibodies like rheumatoid factor and anti-CCP antibodies are negative in osteoarthritis )
Imaging:
X-rays of affected joints
The 4 radiological features of osteoarthritis are:
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
Other investigations:
Synovial fluid aspiration - carried out to investigate painful effusions
Management:
Conservative: