Case Information
- Case ID: OA-004
- Patient Name: Susan Richards
- Age: 67
- Gender: Female
- Indigenous Status: Non-Indigenous
- Year: 2025
- ICPC-2 Codes: L89 – Osteoarthritis of the Knee
Competency Outcomes
Competency Domain | Competency Element |
---|---|
1. Communication and Consultation Skills | Establishing rapport, educating the patient on osteoarthritis, and addressing concerns about pain and function |
2. Clinical Information Gathering and Interpretation | Conducting a structured history and examination to confirm osteoarthritis and assess severity |
3. Diagnosis, Decision-Making and Reasoning | Differentiating osteoarthritis from other causes of knee pain (e.g., inflammatory arthritis, gout, bursitis) |
4. Clinical Management and Therapeutic Reasoning | Developing a multimodal treatment plan, including non-pharmacological and pharmacological options |
5. Preventive and Population Health | Encouraging weight management and exercise to slow disease progression |
6. Professionalism | Providing patient-centred care and considering the patient’s preferences and functional goals |
7. General Practice Systems and Regulatory Requirements | Assessing the need for allied health referrals (e.g., physiotherapy, exercise physiology) and potential surgical referral |
9. Managing Uncertainty | Addressing concerns about worsening symptoms and long-term prognosis |
10. Identifying and Managing the Patient with Significant Illness | Recognising when symptoms are severe enough to warrant specialist input (e.g., orthopaedic referral for joint replacement) |
Case Features
- 67-year-old retired teacher presenting with gradual onset of right knee pain over the past 2 years, worsening in the last 6 months.
- Describes stiffness in the morning lasting <30 minutes, pain with walking and stair climbing, and occasional swelling.
- BMI: 31 kg/m², sedentary lifestyle, and mild hypertension managed with amlodipine.
- Previously tried paracetamol, but now needs ibuprofen for pain relief. Concerned about long-term NSAID use.
- No history of joint trauma, gout, or inflammatory arthritis.
- Wants to discuss management options, including exercise, weight loss, and possible injections.
Candidate Information
Instructions
The candidate is expected to review the following patient record and scenario. The examiner will ask a series of questions based on this information. The candidate has 15 minutes to complete this case.
The approximate time allocation for each question:
- Question 1: 3 minutes
- Question 2: 3 minutes
- Question 3: 3 minutes
- Question 4: 3 minutes
- Question 5: 3 minutes
Patient Record Summary
Patient Details
- Name: Susan Richards
- Age: 67
- Gender: Female
- Indigenous Status: Non-Indigenous
Allergies and Adverse Reactions
- No known allergies
Medications
- Amlodipine 5 mg daily for hypertension
- Paracetamol PRN (occasional use)
- Ibuprofen 400 mg PRN, used 3-4 times per week
Past History
- Hypertension (well-controlled)
- No history of rheumatoid arthritis, gout, or previous knee injuries
Social History
- Retired teacher, lives with her husband.
- BMI 31 kg/m², acknowledges limited exercise due to knee pain.
- Non-smoker, occasional alcohol (1-2 drinks per week).
Family History
- Mother had knee osteoarthritis and had a total knee replacement at 72.
Vaccination and Preventive Activities
- Influenza vaccine: Up to date
- COVID-19 booster: Declined
- Bone health: No recent calcium or vitamin D assessment
Scenario
Susan Richards, a 67-year-old retired teacher, presents with progressive right knee pain over the past two years, now impacting mobility and daily activities. She experiences morning stiffness (<30 minutes) and worsening pain with walking, stair climbing, and prolonged sitting.
She has trialled paracetamol with some relief but now requires ibuprofen regularly. She is concerned about NSAID use and is interested in alternative options, including exercise, weight loss, and injections.
On examination:
- Knee Inspection: No redness or warmth, mild swelling
- Palpation: Bony tenderness over the medial joint line, mild effusion
- Range of Motion: Reduced flexion with crepitus, no instability
- Gait: Slightly antalgic, avoids prolonged weight-bearing on the right leg
Investigations Ordered:
- X-ray of the right knee (to confirm osteoarthritis and rule out other causes)
- Vitamin D and calcium levels (given age and risk factors)
- Renal function tests (if considering long-term NSAID use)
Examiner Only Information
Questions
Q1. What are the key features that support a diagnosis of knee osteoarthritis?
- Prompt: What symptoms and examination findings indicate osteoarthritis?
- Prompt: How do you differentiate osteoarthritis from other causes of knee pain?
Q2. What are the initial management strategies for Susan’s osteoarthritis?
- Prompt: What non-pharmacological treatments are recommended?
- Prompt: When should pharmacological therapy be considered?
Q3. How would you counsel Susan on the risks and benefits of NSAID use?
- Prompt: What are the potential side effects of long-term NSAID use?
- Prompt: What alternatives to NSAIDs could be considered?
Q4. What role do weight loss and exercise play in managing osteoarthritis?
- Prompt: How does obesity contribute to osteoarthritis progression?
- Prompt: What specific exercises are beneficial?
Q5. When would you consider referral to a specialist?
- Prompt: What are the indications for orthopaedic referral?
- Prompt: When should intra-articular corticosteroid or hyaluronic acid injections be considered?
THE COMPETENT CANDIDATE
The competent candidate should be able to:
Q1: What are the key clinical features that support a diagnosis of osteoarthritis?
The competent candidate should:
- Clinical history features:
- Gradual onset of knee pain over three years, worsening over the last eight months.
- Morning stiffness lasting <30 minutes, improving with activity (typical of OA).
- Pain aggravated by walking, stair climbing, and prolonged standing, relieved with rest.
- Intermittent swelling but no warmth or redness, reducing the likelihood of inflammatory arthritis.
- No systemic symptoms (e.g., fever, weight loss, malaise), ruling out inflammatory or infectious causes.
- Examination findings:
- Bony tenderness over the medial joint line.
- Crepitus on movement, reduced flexion but no joint instability.
- Mild effusion but no erythema or warmth, suggesting non-inflammatory effusion.
- Antalgic gait due to pain, avoiding prolonged weight-bearing on the affected leg.
- Investigations:
- X-ray findings (if available): Joint space narrowing, osteophytes, subchondral sclerosis.
- Absence of raised inflammatory markers (CRP/ESR normal if tested).
Q2: What are the initial management strategies for Helen’s osteoarthritis?
The competent candidate should:
- Non-pharmacological interventions (first-line):
- Weight loss (BMI 32 kg/m²) to reduce knee joint stress.
- Exercise therapy: Strengthening exercises (e.g., quadriceps, hip muscles), low-impact activities (e.g., swimming, cycling).
- Physiotherapy referral for supervised exercises and gait retraining.
- Joint protection strategies: Walking aids (if needed), supportive footwear.
- Pharmacological management:
- Regular paracetamol as first-line analgesic (scheduled, not PRN).
- Topical NSAIDs (diclofenac gel) as a safer option than oral NSAIDs.
- Oral NSAIDs (short-term, lowest effective dose, gastroprotection if required).
- Consider intra-articular corticosteroid injection for short-term relief if symptoms persist.
Q3: How would you counsel Helen on the risks and benefits of NSAID use?
The competent candidate should:
- Benefits:
- Effective pain relief and improved mobility.
- Reduces joint inflammation and stiffness.
- Risks:
- Cardiovascular risks: NSAIDs can increase blood pressure and heart disease risk, particularly in older adults.
- Gastrointestinal risks: Increased risk of gastritis, ulcers, and GI bleeding.
- Renal impairment, especially in those with pre-existing hypertension or kidney disease.
- Safer alternatives:
- Topical NSAIDs (lower systemic absorption, fewer side effects).
- Paracetamol as first-line analgesia.
- Non-pharmacological approaches (exercise, weight loss, physiotherapy).
- Monitoring:
- Regular blood pressure and renal function tests if long-term NSAID use is required.
Q4: What role do weight loss and exercise play in managing osteoarthritis?
The competent candidate should:
- Weight loss:
- Reducing 5-10% of body weight can significantly improve knee pain and function.
- Lessens mechanical load on joints, slowing OA progression.
- Referral to a dietitian or exercise physiologist for structured guidance.
- Exercise:
- Strengthening exercises to stabilise the joint and reduce symptoms.
- Low-impact aerobic activities: Walking, swimming, cycling.
- Avoid prolonged inactivity, as it worsens stiffness and muscle deconditioning.
Q5: When would you consider referral to a specialist?
The competent candidate should:
- Refer to an orthopaedic surgeon if:
- Severe pain not relieved by conservative measures.
- Significant functional impairment affecting daily activities.
- Severe radiographic changes (e.g., joint space obliteration, severe osteophytes).
- Refer to a physiotherapist for:
- Supervised exercise programs.
- Mobility aids (e.g., knee brace, walking aid).
- Refer to a pain specialist if:
- Persistent pain despite optimised medical therapy.
SUMMARY OF A COMPETENT ANSWER
- Identifies key clinical and radiographic features of osteoarthritis.
- Implements a multimodal approach, prioritising exercise, weight loss, and lifestyle modifications.
- Uses a stepwise pharmacological approach, starting with paracetamol and topical NSAIDs.
- Discusses NSAID risks and safer alternatives, including monitoring strategies.
- Recognises indications for specialist referral (orthopaedics, physiotherapy, or pain management).
PITFALLS
- Over-relying on NSAIDs without exploring non-pharmacological options.
- Not addressing weight loss and physical activity as core management strategies.
- Failing to assess cardiovascular or renal risks before prescribing NSAIDs.
- Delaying referral for severe disease or functional impairment.
REFERENCES
- RACGP Osteoarthritis Guidelines
- National Institutes of Health on Musculoskeletal Conditions
- Australian Commission on Safety and Quality in Health Care on Osteoarthritis Management
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 Establishes rapport and addresses patient concerns about pain management.
2. Clinical Information Gathering and Interpretation
2.1 Conducts a structured history to assess severity and functional impact.
3. Diagnosis, Decision-Making and Reasoning
3.1 Differentiates osteoarthritis from other causes of knee pain.
4. Clinical Management and Therapeutic Reasoning
4.1 Develops a personalised, evidence-based osteoarthritis management plan.
5. Preventive and Population Health
5.2 Encourages exercise and weight management to slow disease progression.
6. Professionalism
6.3 Provides patient-centred care and considers the impact on daily life.
7. General Practice Systems and Regulatory Requirements
7.2 Coordinates allied health referrals appropriately.
9. Managing Uncertainty
9.1 Addresses concerns about symptom progression and treatment options.
10. Identifying and Managing the Patient with Significant Illness
10.3 Recognises when orthopaedic referral is required.
Competency at Fellowship Level
☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD