Case Information
- Case ID: AR-031
- Patient Name: Daniel Smith
- Age: 28
- Gender: Male
- Indigenous Status: Non-Indigenous
- Year: 2025
- ICPC-2 Codes: L88 – Arthritis (excluding osteoarthritis and rheumatoid arthritis)
Competency Outcomes
| Competency Domain | Competency Element |
|---|---|
| 1. Communication and Consultation Skills | Explaining the diagnosis, prognosis, and management plan to the patient |
| 2. Clinical Information Gathering and Interpretation | Taking a structured history, including infectious and inflammatory triggers |
| 3. Diagnosis, Decision-Making and Reasoning | Differentiating between types of inflammatory arthritis |
| 4. Clinical Management and Therapeutic Reasoning | Developing a short- and long-term management plan |
| 5. Preventive and Population Health | Identifying modifiable risk factors (e.g., previous infection, STI screening) |
| 6. Professionalism | Addressing patient concerns about prognosis and long-term impact |
| 7. General Practice Systems and Regulatory Requirements | Ordering appropriate investigations under Medicare guidelines |
| 9. Managing Uncertainty | Recognising when to refer to a rheumatologist |
| 10. Identifying and Managing the Patient with Significant Illness | Recognising complications requiring escalation of care |
Case Features
- Physically active, plays soccer, now unable to exercise due to joint pain.
- 28-year-old male with a 4-week history of knee and ankle pain, swelling, and stiffness.
- Recent gastroenteritis (self-resolving diarrhoea 6 weeks ago).
- No prior joint issues, no family history of autoimmune disease.
- Mild conjunctivitis and intermittent urethral discomfort but no discharge.
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: Daniel Smith
- Age: 28
- Gender: Male
- Indigenous Status: Non-Indigenous
Allergies and Adverse Reactions
- Nil known allergies
Medications
- Nil regular medications
Past History
- No previous joint disease
- No history of autoimmune conditions
Social History
- Works as a mechanic, physically demanding job
- Plays soccer regularly, now unable due to joint pain
- Sexually active, new partner in the past 3 months
Family History
- No family history of autoimmune disease or inflammatory arthritis
Vaccination and Preventive Activities
- Up to date with general health screenings
- No prior STI screening
Scenario
Daniel Smith, a 28-year-old mechanic, presents with a 4-week history of right knee and left ankle pain, swelling, and stiffness.
He had self-limiting diarrhoea 6 weeks ago but did not seek medical attention at the time.
He also reports mild conjunctivitis and occasional urethral discomfort but denies penile discharge.
He has no prior history of joint pain or autoimmune disease.
The symptoms are impacting his ability to work and play soccer.
On Examination:
- Right knee: Warm, swollen, mildly tender, reduced range of motion
- Left ankle: Mild swelling and tenderness
- Conjunctivae: Mild redness bilaterally, no discharge
- No rash or nail changes
- No lumbar or sacroiliac tenderness
Initial Investigations Ordered:
- CRP: Elevated at 40 mg/L (normal <5)
- ESR: Elevated at 50 mm/hr
- HLA-B27: Positive
- STI screen (chlamydia, gonorrhoea PCR): Pending
- Joint aspiration (if needed): No evidence of septic arthritis
Likely Diagnosis:
- Reactive arthritis (post-infectious inflammatory arthritis).
THE COMPETENT CANDIDATE
The competent candidate should be able to:
Q1: How would you explain Daniel’s diagnosis and underlying cause?
The competent candidate should:
- Explain reactive arthritis in simple terms:
- “Reactive arthritis is a type of arthritis that develops in response to an infection. Your immune system reacts to the infection and mistakenly causes inflammation in your joints, even though the infection itself is no longer present.”
- Link the cause to his symptoms:
- “You had a gastrointestinal infection 6 weeks ago, and now your immune system is overactive, affecting your joints, eyes, and possibly the urinary tract.”
- Reassure about prognosis:
- “Most cases resolve within 3 to 6 months, but some may persist. Early treatment can help reduce symptoms and prevent long-term complications.”
Q2: What investigations are needed to confirm the diagnosis and exclude other conditions?
The competent candidate should:
- Confirm reactive arthritis with:
- CRP and ESR (elevated in inflammatory conditions).
- HLA-B27 (positive in 50–80% of cases but not diagnostic).
- STI screen (chlamydia, gonorrhoea) given urethral symptoms.
- Exclude alternative diagnoses:
- Joint aspiration if septic arthritis is suspected.
- Rheumatoid factor/anti-CCP to rule out rheumatoid arthritis.
- Uric acid if gout is a differential.
Q3: How would you manage Daniel’s condition?
The competent candidate should:
- Symptomatic treatment:
- NSAIDs (e.g., naproxen 500 mg BD) as first-line therapy.
- Intra-articular steroid injection for persistent joint swelling.
- Short course of oral corticosteroids if multiple joints involved.
- Treat underlying infection if present:
- Antibiotics if chlamydia-positive (e.g., azithromycin 1g stat or doxycycline 100mg BD for 7 days).
- Encourage gentle movement and physiotherapy:
- Joint mobilisation to prevent stiffness.
Q4: What is the prognosis for reactive arthritis, and what long-term complications should be considered?
The competent candidate should:
- Natural history:
- Most cases resolve within 3-6 months.
- 20% may develop chronic arthritis.
- Potential complications:
- Chronic inflammatory arthritis.
- Recurrent episodes with future infections.
- Anterior uveitis (requiring ophthalmology input).
Q5: When would you refer Daniel to a rheumatologist?
The competent candidate should:
- Refer to rheumatology if:
- Symptoms persist beyond 6 months despite NSAIDs.
- Multiple joints are affected severely.
- Features suggest a spondyloarthritis spectrum disease (e.g., sacroiliitis, spinal involvement).
- Consider DMARDs (e.g., sulfasalazine) for persistent arthritis.
SUMMARY OF A COMPETENT ANSWER
- Explains reactive arthritis in simple terms.
- Orders appropriate investigations to confirm diagnosis and exclude differentials.
- Manages with NSAIDs, steroids, and physiotherapy.
- Recognises when to refer for persistent or severe cases.
PITFALLS
- Not ruling out septic arthritis with joint aspiration when indicated.
- Failing to screen for STIs as a potential trigger.
- Overprescribing antibiotics without confirmed infection.
- Not discussing prognosis or long-term monitoring.
REFERENCES
- RACGP Guidelines on Reactive Arthritis
- National Institutes of Health on Rheumatology (Reactive Arthritis)
- Australian STI Management Guidelines
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 Clearly explains reactive arthritis and its impact.
2. Clinical Information Gathering and Interpretation
2.1 Identifies post-infectious arthritis triggers.
3. Diagnosis, Decision-Making and Reasoning
3.1 Differentiates reactive arthritis from other causes.
4. Clinical Management and Therapeutic Reasoning
4.1 Provides appropriate symptomatic and targeted treatment.
5. Preventive and Population Health
5.2 Screens for underlying infections contributing to arthritis.
6. Professionalism
6.3 Provides patient-centred and shared decision-making.
7. General Practice Systems and Regulatory Requirements
7.2 Ensures appropriate STI screening and management.
9. Managing Uncertainty
9.1 Recognises when to refer for persistent arthritis.
10. Identifying and Managing the Patient with Significant Illness
10.3 Detects complications requiring escalation.
Competency at Fellowship Level
☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD