EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses for Michael’s knee symptoms?

• Prompt: What is the most likely diagnosis and why?
• Prompt: What other conditions should be considered?

Q2. What red flags would indicate the need for urgent referral or further investigations?

• Prompt: What features suggest an inflammatory or serious joint condition?
• Prompt: What initial investigations would you consider?

Q3. How would you manage Michael’s condition?

• Prompt: What lifestyle and medication changes would you recommend?
• Prompt: When would you consider referral to a specialist?

Q4. Michael is concerned about worsening mobility. How would you counsel him?

• Prompt: How would you provide reassurance while discussing disease progression?
• Prompt: What strategies can help maintain function and reduce symptoms?

Q5. What preventive strategies can Michael implement to reduce his risk of further joint deterioration?

• Prompt: How can he modify his lifestyle and activities?
• Prompt: What role does exercise, weight management, and physiotherapy play?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are your differential diagnoses for Michael’s knee symptoms?

Michael’s most likely diagnosis is knee osteoarthritis, given his gradual onset of joint pain, morning stiffness lasting <30 minutes, and worsening with activity.

Key Differential Diagnoses:

1. Osteoarthritis (Most Likely) – Progressive pain with activity, mild effusion, crepitus, and no systemic symptoms.
2. Gout – Acute episodic pain, swelling, erythema, often affecting the first MTP, but can involve the knee.
3. Rheumatoid Arthritis (RA) – Symmetric polyarthritis, morning stiffness >1 hour, systemic symptoms, positive RF/anti-CCP.
4. Septic Arthritis (Emergency Diagnosis) – Acute swelling, erythema, fever, severe pain, requiring urgent joint aspiration and antibiotics.
5. Meniscal Injury or Ligamentous Tear – History of trauma or mechanical symptoms (locking, instability).

Further assessment with imaging and blood tests will clarify the diagnosis.

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Q2: What red flags would indicate the need for urgent referral or further investigations?

Red flags requiring urgent referral:

• Hot, swollen, acutely painful joint (concern for septic arthritis or gout flare).
• Persistent morning stiffness >1 hour (suggestive of inflammatory arthritis).
• Weight loss, night pain (concern for malignancy or infection).
• Instability or mechanical locking (suggesting meniscal or ligament injury).

Recommended Investigations:

• X-ray of the knee – Look for joint space narrowing, osteophytes (OA) or erosions (RA/gout).
• Serum urate – If gout is suspected.
• ESR/CRP, Rheumatoid Factor (RF), Anti-CCP – If inflammatory arthritis suspected.
• Joint aspiration – If effusion present and septic arthritis or gout is suspected.

If septic arthritis is suspected, urgent hospital referral for aspiration and IV antibiotics is required.

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Q3: How would you manage Michael’s condition?

1. Non-Pharmacological Management:

• Weight loss and exercise – Reduces joint stress and improves symptoms.
• Physiotherapy and muscle strengthening – Quadriceps exercises for knee stability.
• Use of walking aids (e.g., cane, knee brace) for symptom relief.

2. Pharmacological Management:

• Paracetamol as first-line analgesia.
• NSAIDs (e.g., ibuprofen 400mg PRN) if no contraindications (consider PPI for gastroprotection).
• Topical NSAIDs or capsaicin cream for local symptom control.
• Intra-articular corticosteroid injection for severe pain flares.

3. Referral and Long-Term Monitoring:

• Consider orthopaedic referral if severe pain despite maximal conservative treatment.
• Monitor for functional decline, discussing possible joint replacement if necessary.

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Q4: Michael is concerned about worsening mobility. How would you counsel him?

1. Acknowledge Concerns and Provide Reassurance
   • “Osteoarthritis is a chronic but manageable condition.”
   • “Many people continue to lead active lives with proper management.”
2. Explain Disease Progression and Management Options
   • “Weight loss and strengthening exercises slow disease progression and improve mobility.”
   • “If pain becomes severe, injections or surgery may be considered.”
3. Encourage an Active Role in Management
   • “Regular low-impact exercise (walking, swimming, cycling) helps maintain joint function.”
   • “Physiotherapy can help improve mobility and reduce stiffness.”
4. Safety Netting and Follow-Up
   • “We will review your symptoms in 6 weeks to assess response to treatment.”
   • “Seek urgent care if your knee becomes hot, swollen, or significantly more painful.”

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Q5: What preventive strategies can Michael implement to reduce his risk of further joint deterioration?

1. Lifestyle Modifications:
   • Weight loss (BMI 32 → target BMI <25) to reduce joint load.
   • Regular physical activity (150 min/week, low-impact) to strengthen muscles.
2. Joint Protection Strategies:
   • Modify activities to reduce joint strain (avoid high-impact sports).
   • Use ergonomic supports at work if needed.
3. Pharmacological Strategies:
   • Optimise pain management to maintain mobility.
   • Consider chondroitin or glucosamine supplements (variable benefit).
4. Regular Monitoring and Follow-Up:
   • Annual GP review for symptom progression.
   • Early referral if worsening function or severe pain.

Preventing OA progression requires a combination of lifestyle changes, medication optimisation, and activity modification.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive differential diagnosis, distinguishing osteoarthritis, gout, inflammatory arthritis, and mechanical injuries.
• Identification of red flags, ensuring urgent referral if needed.
• Structured evidence-based management plan, including lifestyle changes, medications, and possible referral.
• Clear patient-centred counselling, addressing concerns about mobility and long-term function.
• Preventive strategies, including weight loss, joint protection, and exercise programs.

PITFALLS

• Failing to assess for red flags, missing septic arthritis or inflammatory conditions.
• Overprescribing NSAIDs, without considering gastrointestinal or renal risks.
• Not emphasising lifestyle changes, focusing only on medications.
• Delaying referral when function is severely affected, missing timely surgical intervention.
• Lack of structured follow-up, leading to poor long-term management.

REFERENCES

• RACGP – RACGP Guidelines to Approach to pain management
• GP Exams – Joint symptom/complaint NOS

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Takes a detailed history to assess joint symptoms and functional impact.
1.2 Provides clear explanations of the diagnosis, investigations, and next steps.

2. Clinical Information Gathering and Interpretation

2.1 Conducts a systematic joint examination, including range of motion and special tests.
2.2 Identifies red flags requiring urgent referral.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between inflammatory and non-inflammatory joint conditions.
3.2 Determines when further investigations are warranted.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an appropriate management plan, including lifestyle, pharmacological, and referral options.
4.2 Ensures treatment is aligned with best-practice guidelines.

5. Preventive and Population Health

5.1 Provides education on risk factors for joint conditions and preventive strategies.

6. Professionalism

6.1 Acknowledges patient concerns and maintains a patient-centred approach.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate follow-up and safety-netting for joint-related symptoms.

9. Managing Uncertainty

9.1 Recognises when further assessment or specialist referral is required.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies serious conditions such as inflammatory arthritis, septic arthritis, or crystal arthropathy.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD