Footballer, had right knee injury 30

years ago, had knee operation that

he has no idea about, developed
worsening right knee pain 4 months
ago . Please take history from this
patient.
Introduction
• Hello. I am one of the exam candidate
• May I confirm your name and age please?
• Nice to meet you Mr. …. Today I’ve been asked to ask
you few questions regarding your condition, are you
OK with this?
• How can I help you today?
• I am so sorry to hear that.
Hx of Pain • (Site, Onset, course, duration, character, radiation, timing, severity,
aggravating and relieving factors and associated factors)
• Where did you feel that pain? Could please point to the site?

• Does it move anywhere?

• When did you first notice that pain?

• Did it start suddenly or gradually?

• Did it come and go? Has this changed recently?

• Is there any specific time during the day that the pain increase?

• Is there anything makes this pain stops?

• Is there anything makes that pain increases?

• Could please describe that pain for me? Is it colicky, cramping, or stabbing?

• How badly is this affecting your day-to-day life?

• If you had to rate the pain from 1 to 10, with 10 being the worst pain you can
imagine, how would you rate it?
DD • 1. Osteoarthritis
• Does the pain present all the day and increase at night?
• Did you notice any changes in the shape of your knee?
• Was there any history of trauma?
• 2. ACL injury
• Did you experience giving away when walking?
• 3. Meniscus injury
• Did you experience locking of your knee?
• 4. Rheumatoid arthritis
• Have you noticed any stiffness in your joint(s) when you wake
up in the morning? How long does that last for?
 • 5. Septic arthritis
• Have you noticed swelling of your knee? Or redness?
DD • Is there any discharge?
• 6. Referred from the back
• Have you noticed weak or numb legs?
• Do you have back pain?
• 7. Extra intestinal manifestation of IBD
• Have you noticed any rashes anywhere on your body?
• Have you had any diarrhoea?
• Have you had painful or red eyes?
• 8. Malignancy
• Have you noticed any significant weight loss over the past
few months?
• How is your appetite?
 • Do you have any other medical conditions, see your GP for anything, ever had surgeries?

• Do you take any medications? Dose? Do you have any allergy against any drug?

• Do you mind if I ask personal questions?

(Past medical or • What is your occupation?
surgical history, • Who is at home with you?
Drug history, • Do you have any difficulty with the stairs?
Family history, • Do you smoke? How many packs/ day?

Ideas, concerns • Do you drink alcohol? How many units/ week

and • Is there anyone else in the family has had a similar problem?

expectations, • Before I go any further, could I ask?

other system • What do you think the cause is?

review) • What are you the most concerned about?

• What are you hoping us to do for you?

• Urogenital Abdominal pain, F of micturition, dysuria, urgency, polyuria, haematuria

• Rheumatic: any muscle or joint pain?

• Anything else you want to add?

• Thank you
Summarization • Mr... is a ... year-old gentleman who has been referred with increasing pain
from his right knee. This started approximately … years ago and has been
increasing in severity over the past 4 months. He is experiencing a dull
constant ache that is increased on exertion and at the end of the day. However,
the joint does not swell, lock or become unsteady on walking. The pain is
limiting his daily routine. The patient has a past history of knee trauma and
surgery
• My main differentials will be:
• • OA (traumatic)
• • RA
• • Meniscal injury
• • Referred pain from hip or spine pathology
Investigations?
• FBC, U/E , LFT ,CRP, Uric Acid , Joint fluid analysis.
• Knee x-ray (standing and weight bearing), AP and
lateral views.
• MRI knee
What changes • There are four main radiographic signs in
would you osteoarthritis:

expect to see
on a radiograph • Narrowing of the joint space
of an • Subchondral sclerosis
osteoarthritic • Cyst formation
knee? • Osteophyte formation
What are the
indications for a • Pain relief
knee replacement?
• Improvement of mobility
• Correction of deformity
 • Conservative

Treatment • • Maintain or achieve a healthy weight i.e. aim to decrease weight, and therefore force,
going through a joint
• • Regular exercise, with particular attention to strengthening the muscles around the joint.
For example in OA of the knee, cycling is beneficial
• • Analgesia: care to be taken with NSAID's with relation to gastric irritation

• • Heat application to the joint may offer relief

• • Physiotherapy

• • Intra-articular steroids

• Surgical:

• Arthroscopy and arthrocentesis

• • Realignment osteotomy

• • Total or partial knee replacement

• Will the patient be likely to play soccer in 9 months? No