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You are working as an F1 in a rural GP practice. Bruce, a 67 year old gentleman, has come for an appointment because of “knee pain”. From looking at previous records, it seems Bruce does not go to the GP practice very often at all, and has very little in his medical background except asthma and type 2 diabetes mellitus. He does not have any drug allergies and only take salbutamol and metformin.

Please take a history of Bruce’s presenting complaint ensuring you cover how this has been affecting his life. Following this please perform the appropriate examination on this patient.

Your name is Bruce Ellosis, and you are stoical 67 year old gentleman who does not like going to the GP practice. Nevertheless, the pain you’ve been having in your left knee has become so bothersome you feel you should make an appointment to get some tablets for it.

HPC: You first noticed the pain whilst walking your five dogs out in the moorlands last summer. It had been a particularly long walk as one of the dogs had ran off and taken you on a massive detour, and so you put the pain down to all the hard effort you’d put in keeping your pets under control! However gradually you’ve noticed the pain has been getting worse (around 6/10, no radiation and no localised knee pain) on shorter walking distances and even around the house, and now your other knee has started hurting too. You sometimes take paracetamol but you find a shot of whiskey is a lot more effective. Your other joints have been OK, and you haven’t noticed any calf pain/skin changes and have had no recent trauma.

ICE: You live alone and love taking your beloved dogs for walks in the country-side. Recently you have been less able to do this and you feel that you’re “letting the dogs down”. You expect some “magic pill” that can make the pain go away, and a telephone number for dog-walking services to help him when the pain is too bad.

PMH: You have asthma, which bothers you very little, and diabetes which is solved by a tablet you take three times a day. You know there are diabetes clinic checks but try to avoid them as you feel your diabetes is well-controlled.

SH: You have never smoked and do enjoy your whiskey and ale – usually it’s around five pints with your friends on a Thursday at the steak-and-ale pub night, plus a shot of whiskey every night now this pain has been developing. You enjoy a hearty diet of ready meals and chocolate eclairs, but feel this is allowed as you take the dogs out for long walks. Despite all this exercise you are aware of your overweight size, but feel “a chocolate éclair a day keeps the doctor away”

FH: Your father had “a painful toe” every now and then but other than you don’t remember any medical conditions your parents had, and they both died “of old age” as far as you can remember

The student should take a detailed pain history of the joint and explore any rheumatological factors as well as red flag symptoms such as weight loss and night pain. The student should find out how this knee pain has affected the patient’s life and what his main concerns are. A knee examination would be carried out, eliciting crepitus of both knees and restricted movement s on the left side. The student’s differential diagnosis should sound something like: My differential diagnosis would include osteoarthritis, as he has bilateral knee pain worse on movement. Another cause of joint pain would include gout – this gentleman has a family history and lifestyle compatible with this condition, but often gout would affect joints unilaterally and most often the great toe. I would want to rule out septic arthritis in any patient who presents with a painful joint, although for that I would expect an acute history of a hot swollen joint. Examples for discussion may include: - How would you investigate a painful joint? - What Xray changes would you expect in an osteoarthritic joint? How does this differ from rheumatoid arthritis? - How is OA managed? - If this man had surgery on his knee, what complications should he be warned about? - This gentleman has type 2 diabetes mellitus. What pre-op and post-op care could he receive in hospital?