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Rheumatology & Orthopaedics

Ankle Pain

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CANDIDATE INSTRUCTIONS

You are resident doctor working in a renal clinic this afternoon and your next patient is Mrs Scott who is a patient with end stage CKD being considered for renal transplant. During consultation, she mentions that she has been having a sore ankle for the last 2 days. 

You think it can most likely be referred to her GP for follow up but will need to explore a bit more about her presentation.

  1. Take a focused history

  2. At 8 minutes you will be stopped by the examiner to ask some questions

2 Minutes Reading Time

10 Minutes Station Time

Total 12 Minutes

EXAMINER INSTRUCTIONS

Timing Instructions: At 8 minutes, stop the candidate and ask the following questions:

Question 1: Name 2 differential diagnosis.

Answer 1: 

  • Septic arthritis

  • Gout/ pseudogout

Question 2: Why is Mrs Scott being a patient with CKD relevant to her presentation?

Answer 2: There is decreased renal secretion of uric acid in patients with CKD, causing hyperuricaemia and gout

Question 3: Name 2 investigations and what you would expect to find from them.

Answer 3:

  • Blood tests - High uric acid levels

  • Synovial fluid analysis - needle shaped negatively birefringent monosodium urate crystals

  • X- Ray - joint effusion, soft tissue tophi, well-defined 'punched-out' erosions with sclerotic margins

Question 4: What would be the management in the acute phase

Answer 4: NSAIDs and colchicine

  • Gout

PATIENT INSTRUCTIONS

  • Name: Ellen Scott

    Age: 57 years old

    Date of Birth: 3rd May 1967

    Occupation: Supermarket cashier

  • "My left ankle has been in agony since this morning, it even woke me up in the night!"

    • Site: My left ankle

    • Onset: Woke me up from sleep around 3am this morning

    • Character: I have never felt pain this bad, I even had to lift the covers off my foot because it hurt so bad!

    • Radiation: No

    • Assoc Sx: Theres a bit of redness and swelling around the ankle as well

    • Timing: It’s been getting a lot worse

    • Exacerbating Factors: Just anything touching it really

    • Relieving Factors: I tried taking paracetamol which does not work at all

    • Pain Scale: It’s a 9/10 now

    • Recent illness: None.

    • Recent trauma: None. 

    • Recent travel: None.

    • Previous episodes: Never experienced this before.

    • Ideas: "I dont know what it is but the pain is really bad”

    • Expectations: “Can I please get something for the pain?"

    • Concerns: “One of my friends said it might be a sign that my kidneys are failing, is that true?"

    • Bowel habits: Nil

    • Urinary habits: Nil

    • Appetite: Same as usual.

    • Sleep: Same as usual

    • Weight: No change 

    • Pain in the chest/abdomen: None

    • Headaches: None

    • Fever: None

    • No focal neurology

  • Previous hospital admissions: None

    Previous surgeries: None

    Medical conditions:

    • CKD

    Medications:

    • Paracetamol

    Allergies:

    • None.

  • Nothing really

    • Smoking: I stopped smoking 20 years ago

    • Alcohol: Not really

    • Recreational drugs: Never

    • Diet: Just whatever is easiest, most of the time I get meal deals from work

    • Exercise: Not really

    • Ill contacts: No one around me was recently ill

    • Home: Lives alone in flat

    • Active Daily Living: Independent with all ADLs

    • Occupation: Cashier at tesco

MARK SCHEME

Introduction

Ideas, Expectations & Concerns

Presenting Complaint

History of Presenting Complaint

Systems Review

Past Medical History

Drug History

Family History

Social History

Questions

Patient Scores

Enter Your Score Here: /50

SCORE GUIDE

High Pass: > 40

Pass: > 30

Borderline Pass: 25 - 30

Fail: < 25

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