OSCE CODE A2.18 GP REGISTRAR INSTRUCTION SHEET

ELICITING CONCERNS, IDEAS AND EXPECTATIONS – MR SYKES
TASK

Your task is to carry out a normal consultation.

There is no need to examine the patient. If you need to know any examination findings, the examiner will tell you them.

The consultation will be stopped after seven minutes. For the purpose of assessment it is not necessary to complete the consultation.

SCENARIO

Apart from minor self limiting illnesses your patient who is 65 years old is an infrequent attender. He was last seen by your partner 1 month ago who wrote:

“Painful knee.

A bit of crepitus on movement. Full range of movements. Nil else.

Early OA.

Lose weight. Paracetamol prn.

MAY 2002

OSCE CODE A2.18 ASSESSOR INSTRUCTION SHEET

ELICITING CONCERNS, IDEAS AND EXPECTATIONS – MR SYKES

The aim of this station is to assess the trainee’s ability to elicit the concerns and expectation of a patient suffering from possible early osteoarthritis of the knee.

PatientMale

Approx age = 60

Slightly overweight if possible

EquipmentConsultation room

Specimen prescriptions

Routine pathology and X-ray forms – not essential but may help consultation to ‘flow’ better

INSTRUCTIONS

The patient will need coaching especially with regard to the cues. The cues listed are only suggestions. Please feel free to suggest Other cues that you feel might be appropriate. (See Assessor’s Feedback Sheet).

There are no new findings on examination.

During the consultation
  1. Using the feedback sheet, assess the trainee’s ability to elicit the patient’s concerns and expectations.
  2. Stop the consultation after 7 minutes.
After the consultation
  1. Complete the assessor’s feedback sheet and ask the patient to complete his feedback sheet.
  2. Invite the trainee to say what he/she did well and what he/she might have done differently.
  3. Invite the patient to give verbal feedback.
  4. Using the feedback sheet, give your own verbal feedback.
  5. Give the trainee both feedback sheets to take away.

OSCE CODE A2.18 PATIENT FEEDBACK SHEET

ELICITING CONCERNS, IDEAS AND EXPECTATIONS – MR SYKES
Trainee’s Name: ______

After the consultation for each question please ring the response which you feel is correct.

  1. COMMUNICATION

I had adequate opportunity to express my problem.YESNONOT SURE

The nature of my problem was explained to me.YESNONOT SURE

I was able to discuss what needed to be done to help it.YESNONOT SURE

The doctor used language I could understand.YESNONOT SURE

  1. DOCTOR/PATIENT RELATIONSHIP

I was treated with respect.YESNONOT SURE

The doctor was sensitive to my feelings.YESNONOT SURE

I felt at ease with the doctor.YESNONOT SURE

  1. PROFESSIONAL

I felt this doctor was competent.YESNONOT SURE

I trust this doctor.YESNONOT SURE

  1. OVERALL

I would consult this doctor again.YESNONOT SURE

COMMENTS:

PLEASE COMPLETE IMMEDIATELY AND HAND TO GP REGISTRAR AFTER THE FEEDBACK SESSION.

The Registrar – discuss this further with your trainer.

OSCE CODE A2.18 ASSESSOR FEEDBACK SHEET

ELICITING CONCERNS, IDEAS AND EXPECTATIONS – MR SYKES

OSCE CODE A2.18 HANDOUT SHEET

ELICITING CONCERNS, IDEAS AND EXPECTATIONS – MR SYKES

Osteoarthritis

Predisposing causes Joint malalignment, eg valgus deformity ; decreased size of joint contact (eg subluxation in congenital dislocation of the hip); osteochondral fractures; foreign bodies; torn menisci; damaged cartilage from septic arthritis or neuropathy.

PathologyEarly on there is splitting (fibrillation) of cartilage, then some breaks away, leaving exposed bone - which becomes thickened, hard and white ('eburnation'). Nodular new bone formations at joint surfaces are called osteophytes.

Presentation The patient may suffer joint pain at rest (eg at night); pain on movement. Joints may be a little thickened, but not usually inflamed. Crepitus (the grating of surfaces) may be felt on joint movement. There may be fixed deformity (inability to assume neutral position). In the hands the distal interphalangeal joints are commonly affected. Swellings at these joints are called Heberden's nodes. Rheumatoid factor is absent. The ESR is normal.

Diagnosis This is made principally on the history, signs and x-ray changes:

  1. Joint space narrowing
  2. Subchondral sclerosis
  3. Subchondral cysts
  4. 'Lipping' at joint margins (from osteophytes).

Methods of following the osteoarthritis process by tracking biochemical markers of the different processes are also being developed.3

ManagementAim to reduce pain and disability, and to increase fitness (gentle-to-moderate exercise does improve symptoms,1 but note that cycling may aggravate patello-femoral osteoarthritis, and swimming is generally good for back and hip symptoms but may worsen cervical apophyseal joint osteoarthritis). There are no panaceas. For pain, try Paracetamol 500mg-1g/6h PO alone or in combination with opioids e.g. Co-proxamol (expect constipation). Consider NSAIDs, such as Ibuprofen 400mg/8h PO pc, for inflammatory episodes (e.g. in the knee), but if needed long-term, beware GI bleeding - and consider a Misoprostol -containing tablet.

Newer agents such as Meloxicam (dose example 7.5-15mg PO once per day with food) should be used with caution, because experience is limited. These agents are said to preferentially inhibit COX-2 and to spare COX-1. Cyclo-oxygenase-1 (COX-1) produces the prostaglandins that mediate gastric cytoprotection, whereas COX-2 is produced in response to inflammatory stimuli, and leads to an increase in the prostaglandins mediating the inflammatory response. This is the rationale behind the claim that meloxicam and other COX-2 inhibitors produce anti-inflammatory effects with less risk of GI bleeding, and less risk of renal problems. NB: meloxicam is not a good cytoprotective agent and so is not suitable for arthritic patients with GI ulceration.

OSCE CODE A2.18 HANDOUT SHEET

ELICITING CONCERNS, IDEAS AND EXPECTATIONS – MR SYKES

Claims that these are the much-longed for ‘safe aspirin’ may be premature: they may not be safe and they may not be aspirin, as COX-1 inhibition may be required for full anti-inflammatory benefit.4,5 They may cause problems with fluid retention, as COX-2 is expressed in the kidney’s medulla densa. They do not have aspirin’s cardiovascular effects.

Local warmth may give relief. Physiotherapy may increase functional use of joints. Unload weight-bearing joints through weight reduction (diet) and walking aids (stick, frame, stair rail). Occupational therapists can advise on modifying tools and home. Intra-articular steroid injections are also tried, and may relieve symptoms for a month or two. When disability or pain are severe, consider surgery.

Surgery

  • Arthroscopic joint debridement, excision of osteophytes and unstable articular cartilage + drilling of exposed bone helps 60% of patients.2
  • Arthrodesis (surgical fusing of a joint) is used most commonly at the metatarsophalangeal joint of the hallux.
  • Osteotomy to realign a joint - eg to correct genu varum deformity.
  • Excision arthroplasty is used in Keller's operation.
  • Interposition arthroplasty is used at the thumb's carpometacarpal joint, when a silastin sponge is interposed between the joint surfaces.
  • Joint replacement for hips, elbows, shoulders and knees.

Arthritis of the hip Fixed flexion deformities are common. Thomas test reveals such deformity. The usual surgical treatment is replacement arthroplasty .

References:

  1. PA Kovar 1992Ann Int Med116 529 & Drug Ther Bul34 33
  2. J Bone & Joint Surg 1991 Ed 737-8 (No abstract available yet via Medline)
  3. OTM 3e p2982 [2742503]
  4. C Hawky 1999Lancet353 307 (No abstract available yet via Medline)
  5. J Wallace 1998Gastroenterology115 101 (No abstract available yet via Medline)