Arthur Pathy
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You are a junior doctor working in A and E, this 60yr old gentleman has presented with a painful knee. Please take a history from him, and perform a relevant examination. His regular medication includes: Simvastatin 40mg ON Aspirin 75mg OD Furosemide 40mg BD Bisoprolol 2.5mg OD Ramirpril 5mg OD Paracetamol 1g QDS Codeine 30mg PRN Ibuprofen 400mg TDS
You are a 60yr old man called Arthur Pathy, your DOB is 13/2/1955. You are presenting with a swollen and painful knee. Mark is a very friendly guy, he thinks the NHS is going a great job and doesn’t like to waste their time with things. He would only come to A&E when he is really struggling with things. He is very forthcoming with information in an effort to help, but this can come across as over talkative, occasionally giving un related information. He is an overweight, jovial guy, who likes going to the pub with his mates.
PC: Painful and swollen right knee
HPC: It all started 5 days ago when you noticed your right knee was much more painful than normal. At first you just thought it was your arthritis playing up, but when you woke up the next day you noticed it was much more swollen than normal. Swelling isn’t a problem you’ve really had before, and that’s when you first thought that something else was going on. Since then its just been getting more swollen and painful, and over the day or so its now got very red (if the student asks directly – feels hot to the touch). Its getting in the way of you sleeping at night, and stopping you getting about. You haven’t actually been out of the house in the last 3 days, which is unusual for you as most nights you go to the pub with your friends. You’re finding the problems with walking really hard, because you felt that side of things had been getting much better, as you recently saw your heart doctor who upped your medications and your breathing has been feeling better for it. The biggest problem is the pain, its really bad when you move it. It feels like someone is stabbing you in the knee with a hot pin. Your normal painkillers help, but only to make it just bearable. Resting it helps, but the pain never goes away. You’ve got quite a high pain threshold, and you’re used to the arthritis pain, but this is something different. You haven’t injured the knee at all recently or fallen over. You did have a steroid injection to that knee about a week ago, but have never had an operation on it. Apart from the pain, you’ve been feeling well in yourself. No fevers, nausea or vomiting. No other joints are any worse than usual. The joint is just as strong, but it does feel very stiff. But you haven’t been moving it much, and you know that can make stiffness a lot worse. Never had anything as bad as this before.
ICE: At first just thought it was his arthritis playing up again, but its never been this bad before. Worried something else is going on. Concerned that he may need to have an operation, older sister had her knee operated on and it was never the same afterwards. Looking for some reassurance that it will get better, and wont need surgery.
PMH: Heart failure ‘big heart’ Arthritis – ‘wear and tear’ kind, in both knees, starting in the hips High blood pressure, but you never feel anything from it. Had a heart attack 4yrs ago Overweight – or so the wife keeps telling you!
DH and Allergies: Nothing else from the list. Your furosemide and ramipril were recently increased. Allergic to penicillin, not really sure what happened, you were always told by your mum ever since you were a child though.
FH: Heart disease runs in the family, your dad and uncle both had heart failure and heart attacks. Mum has thyroid problems.
SH: Lives with wife and son. Had to retire after the heart attack as job was too stressful, used to work as manager of taxi firm , but they all decided that it was just too much strain on his heart. Cope just fine at home, wife does most of the shopping and cooking. Slow to get about, what with the breathing and arthritis, but manages fine. Ex smoker, stopped the day of the heart attack. Smoked 20-30 a day for over 40 yrs. Never felt tempted to go back on them either! Drinks 3-4 pints a night, which you know is probably too much, but going to the pub with your friends is your great joy in life and you would never give that up.
SE: Exertional chest pain rarely SOBOE, worse when lying flat Swollen feet, long term, ever since heart attack. Chronic pain in knees.
The student should take a focussed history of the problems with Mr Pathy’s knee. They should perform an examination of the knee, fully exposing the patient and comparing both knees. The student’s summary should sound something like this: ‘This is Mr Pathy, a 60yr old man presenting with a 5 day history of a painful swollen and hot right knee. He has a background of IHD, heart failure and osteoarthritis. There is no recent trauma or surgery to the knee, although he did receive a steroid injection just before the problems started. He is an ex smoker with a significant alcohol intake.’ The student’s differential should sound something like this: ‘My top differential for this patient would be gout, given his risk factors and current medication. However, given the recent steroid injection to the joint, it would be important to rule out septic arthritis as well’ Examples for discussion may include: • Initial investigation and management of this patient in A&E • Long term management of this patient as an outpatient/by GP • Different cause of mono arthroparthies/acutely swollen joint • Risk factors for gout in this gentleman • Gout vs pseudo gout, differences in pathology and how to diagnose them • Management of gout (if not dealt with in earlier questions) • Risk factors for septic arthritis, is it a likely differential in this case? • Management of septic arthritis (if not dealt with in earlier questions)
