EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses for James’s hip pain?

• 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 urgent or serious hip pathology?
• Prompt: What initial investigations would you consider?

Q3. How would you manage James’s condition?

• Prompt: What lifestyle, pharmacological, and non-pharmacological treatments would you recommend?
• Prompt: When would referral to orthopaedics be considered?

Q4. James is concerned about needing a hip replacement. How would you counsel him?

• Prompt: What are the indications for hip replacement?
• Prompt: What are the non-surgical options before considering surgery?

Q5. What preventive strategies can James implement to reduce further hip deterioration?

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

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are your differential diagnoses for James’s hip pain?

James’s most likely diagnosis is hip osteoarthritis (OA), given his gradual onset of pain, worsening with activity, morning stiffness <30 minutes, and reduced internal rotation.

Key Differential Diagnoses:

1. Hip Osteoarthritis (Most Likely) – Progressive joint pain and stiffness, worse with movement, relieved by rest.
2. Trochanteric Bursitis – Lateral hip pain, worsened by pressure (e.g., sleeping on side), no joint stiffness.
3. Avascular Necrosis (AVN) – Consider if progressive pain with no clear trigger, risk factors (steroid use, diabetes).
4. Hip Labral Tear – Younger patients, mechanical symptoms (clicking, catching), pain with hip flexion and rotation.
5. Referred Pain (Lumbar Spine Pathology, Sacroiliac Joint Dysfunction) – Back pain, radicular symptoms, positive straight leg raise.

Further assessment, including imaging (X-ray, MRI if required), functional limitations, and red flag symptoms, will refine 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:

• Acute severe pain with inability to weight-bear – Consider fracture or avascular necrosis.
• Fever, night sweats, unexplained weight loss – Evaluate for infection or malignancy.
• Progressive neurological symptoms (weakness, numbness, bowel/bladder changes) – Consider lumbar spine pathology.
• Severe joint deformity or instability – Suggests advanced OA or hip pathology requiring urgent orthopaedic assessment.

Recommended Investigations (if red flags present):

• X-ray hip (AP and lateral views) – Assess for joint space narrowing, osteophytes, AVN signs.
• MRI hip – If concern for soft tissue injury or AVN.
• Blood tests (CRP, ESR, FBC) – If suspected septic arthritis, inflammatory arthritis, or malignancy.

James has no immediate red flags, so routine X-ray and conservative management are appropriate.

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Q3: How would you manage James’s condition?

1. Conservative Management (First-Line):

• Weight loss (target BMI <25) – Reduces joint load and pain.
• Regular low-impact exercise (swimming, cycling, physiotherapy) – Strengthens supporting muscles.
• Walking aids (e.g., cane in opposite hand) – Improves mobility.

2. Pharmacological Management:

• Paracetamol 1g QID – First-line for mild pain.
• NSAIDs (e.g., ibuprofen 400mg PRN) – If no contraindications (monitor renal function, GI effects).
• Topical NSAIDs (e.g., diclofenac gel) – If systemic NSAIDs not tolerated.

3. When to Consider Invasive Treatment:

• Corticosteroid injection – If persistent pain despite conservative therapy.
• Total hip replacement (THR) – If severe pain limiting daily activities, X-ray confirms advanced OA.

4. Follow-Up and Specialist Referral:

• Review in 6–8 weeks – Assess response to conservative treatment.
• Refer to orthopaedics if severe functional impairment or failed conservative therapy.

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Q4: James is concerned about needing a hip replacement. How would you counsel him?

1. Acknowledge Concerns & Provide Reassurance
   • “Hip osteoarthritis is progressive but manageable with the right treatment approach.”
   • “Many patients avoid or delay surgery with lifestyle changes, physiotherapy, and pain management.”
2. Explain Indications for Hip Replacement
   • “Surgery is considered when pain significantly limits daily activities and does not respond to conservative treatment.”
   • “We assess your function, pain severity, and X-ray findings before making a decision.”
3. Discuss Non-Surgical Options
   • Weight loss, physiotherapy, walking aids, pain relief are first-line treatments.
   • Corticosteroid injections may provide temporary relief if symptoms worsen.
4. Outline Surgery Expectations
   • “Total hip replacement is highly effective, with a 90% success rate and lifespan of 15–20 years.”
   • “Rehabilitation post-surgery is crucial for best outcomes.”

Providing a clear management plan reduces anxiety and empowers the patient.

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Q5: What preventive strategies can James implement to reduce further hip deterioration?

1. Weight Management:
   • Aim for BMI <25 – Reduces joint stress and slows OA progression.
2. Exercise and Joint Protection:
   • Low-impact activities (swimming, cycling, Tai Chi) maintain mobility.
   • Physiotherapy to strengthen muscles and improve balance.
3. Pain and Function Management:
   • Use of a walking aid if needed.
   • Proper footwear with cushioned soles.
4. Medication Optimisation:
   • Avoid long-term NSAID use if possible due to gastrointestinal and renal risks.
5. Regular Monitoring:
   • Annual GP review to assess pain progression and functional decline.

Preventing further joint deterioration requires a combination of weight control, exercise, and symptom management.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive differential diagnosis, distinguishing hip OA, bursitis, AVN, and referred pain.
• Identification of red flags, ensuring urgent referral if needed.
• Structured evidence-based management plan, including lifestyle changes, physiotherapy, and medication optimisation.
• Clear patient-centred counselling, addressing concerns about hip replacement and non-surgical options.
• Preventive strategies, including weight loss, exercise, and joint protection.

PITFALLS

• Failing to assess for red flags, missing serious conditions like AVN or malignancy.
• Overprescribing NSAIDs long-term, without considering renal and cardiovascular risks.
• Not emphasising lifestyle modifications, such as weight loss and physiotherapy.
• Delaying orthopaedic referral when needed, leading to prolonged functional impairment.
• Lack of structured follow-up, missing disease progression.

REFERENCES

• RACGP – RACGP Osteoarthritis Management Guidelines
• GP Exams – Hip symptom/complaint

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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 structured musculoskeletal history, including functional limitations.
1.2 Provides clear explanations about the diagnosis, management, and prognosis.

2. Clinical Information Gathering and Interpretation

2.1 Conducts a systematic hip examination, including range of motion and special tests.
2.2 Differentiates between mechanical, inflammatory, and referred hip pain.

3. Diagnosis, Decision-Making and Reasoning

3.1 Diagnoses hip pathology based on clinical features.
3.2 Determines when further investigations or specialist referral is required.

Competency at Fellowship Level

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