Joint Pain OSCE - Osteoarthritis

Diagnosis: Osteoarthritis

Case Overview

  • Age/Sex: 71-year-old female
  • Occupation: Retired primary school teacher
  • Setting: GP clinic / outpatient orthopedic clinic
  • Chief complaint: "Painful joints"

Patient Script

Who I Am

I'm 71, retired, I used to teach little ones and I live on my own.

What Brings Me In

My knees and some of my finger joints have been sore for months and it's getting worse — I can't do my gardening like I used to.

My Story

For about two years I've had gradually worsening pain in my knees, worse on the right, and for the last six months I've noticed bony lumps on the ends of some fingers. The knee pain is worse after walking or at the end of the day and usually eases when I rest; I sometimes limp if I've been out for a long walk. I get stiff for about 10–20 minutes in the morning, then it eases. There hasn't been a dramatic flare with fever or anything — it just comes on slowly and is getting steadily worse. I used to take ibuprofen occasionally but stopped because my daughter worried about my kidneys. I also take a herbal joint tablet (glucosamine) which I bought from the chemist and it seemed to help a bit at first.

I once had what my GP called a "gouty attack" many years ago in one toe after a weekend of heavy food and drink, but that was a one-off and it cleared with a short course of medication. I haven't had anything like that recently. I had a urinary infection treated about three months ago — nothing serious. I worry I might need knee surgery one day because I know an elderly neighbour had replacements. I do find walking increasingly difficult and I sometimes use a walking stick for longer distances.

My Medical Background

  • Type 2 diabetes for 12 years (on tablets)
  • Hypertension and high cholesterol
  • Previous single episode treated as "gout" many years ago (patient report)
  • Medications: metformin 500 mg twice daily, gliclazide 30 mg daily, lisinopril 10 mg daily, simvastatin 20 mg nightly, low-dose aspirin 75 mg daily, glucosamine (OTC)
  • Allergies: Penicillin (rash as a young adult)
  • Social: Lives alone, retired teacher, used to garden frequently, stopped driving last year, has a neighbour who helps sometimes
  • Smoking: never
  • Alcohol: 1–2 units twice a week
  • Family: Mother had "arthritis" in her knees later in life

What I Think & Worry About

  • I think it's just getting old and the wear-and-tear on my knees.
  • I'm worried I might lose the ability to look after myself or might need surgery.
  • I worry it could be something serious like "rheumatoid" or spread from something else because of that finger swelling.

If You Ask Me About Other Symptoms...

  • Pain pattern: "Knees hurt when I walk, aches at the end of the day; fingers are stiff but I can still do buttons mostly."
  • Fever/systemic: "No fevers, no sweats, I don't feel unwell generally."
  • Morning stiffness: "Yes, but only for about 10–20 minutes, then it gets better."
  • Morning function: "I can get out of bed and dress — it may be a bit slow sometimes."
  • Red swollen joints: "My knee can swell a bit after a long walk but it's not red or hot usually."
  • Nerve symptoms: "I have a bit of tingling in my toes sometimes — my diabetes nurse says it's neuropathy."
  • Recent trauma: "No falls or injuries recently, just normal daily knocks."
  • Meds use: "I took ibuprofen sometimes but stopped; I take paracetamol when it's bad."
  • Other: "I sometimes feel breathless when I climb stairs — the doctor said it's probably my heart/blood pressure."

Clinical Summary

Examination

  • General: comfortable at rest, afebrile, BMI 31 kg/m2
  • Vitals: BP 140/82 mmHg, HR 78/min, Temp 36.6°C, RR 16/min
  • Gait: antalgic on the right with reduced stride length; uses stick for longer distances
  • Knees:
    • Inspection: mild joint swelling bilaterally, no erythema or warmth
    • Palpation: bony enlargement of joint margins, tenderness at medial joint line (R > L)
    • Range of motion: reduced flexion on the right (0–100°) and left (0–110°) with crepitus
    • Stability: no obvious ligamentous laxity
  • Hands:
    • Bony nodes at the distal interphalangeal joints (Heberden's nodes) and small nodes at PIP joints (Bouchard's) bilaterally
    • No prominent synovitis, no MCP swelling
  • Other: distal sensory loss consistent with peripheral neuropathy; cardiovascular exam unremarkable

Investigations

  • Full blood count: WCC 6.2 x10^9/L (normal) (no systemic infection)
  • CRP: 5 mg/L (normal <10) (no significant inflammatory response)
  • ESR: 12 mm/hr (normal for age) (not suggestive of active inflammatory arthritis)
  • Serum uric acid: 340 µmol/L (near-normal; does not support current gout flare)
  • Renal function: serum creatinine 110 µmol/L, eGFR ~52 mL/min/1.73m2 (mild-moderate CKD)
  • HbA1c: 7.2% (55 mmol/mol) (suboptimally controlled diabetes)
  • Weight-bearing X-ray knees (AP): medial joint space narrowing (right > left), osteophyte formation, subchondral sclerosis, no erosions
  • Hand X-ray (if performed): osteophytes at DIP joints, joint space narrowing at PIP/DIP

Diagnosis

  • Primary diagnosis: Osteoarthritis (knee and hand)

    • Evidence: elderly patient with chronic, activity-related joint pain, brief morning stiffness (<30 minutes), bony enlargement (Heberden/Bouchard nodes), crepitus and reduced ROM, and characteristic radiographic changes (medial joint space narrowing, osteophytes, subchondral sclerosis).

  • Key differentials:

    • Rheumatoid arthritis — less likely: RA typically causes prolonged morning stiffness, prominent MCP/PIP synovitis, systemic inflammatory markers and erosions on X-ray; exam here shows bony nodes and no active synovitis, CRP/ESR not elevated.
    • Gout — less likely for current presentation: usually presents as acute monoarthritis with marked redness and swelling; history of a past episode is a red herring and serum urate is not elevated to a level suggesting ongoing gouty arthritis.
    • Polymyalgia rheumatica — unlikely: presents with proximal shoulder/hip girdle stiffness >45 minutes and markedly raised ESR, which are absent here.
    • Septic arthritis — unlikely: no fever, normal inflammatory markers, chronic course rather than acute monoarticular infection.

Management

  • Education and self-management:
    • Explain osteoarthritis as "wear-and-tear" causing cartilage loss; set realistic expectations about slow progression and goal of symptom control and function preservation.
    • Encourage weight loss (target modest weight reduction for BMI 31) and low-impact aerobic exercise (walking, swimming) and strengthening exercises for quadriceps; refer to physiotherapy for a structured program.
  • Analgesia and medications:
    • Start regular paracetamol (e.g., up to 3 g/day as appropriate) as first-line analgesic trial.
    • Consider topical NSAID (diclofenac gel) for knee pain to minimise systemic effects given age and CKD.
    • Avoid long-term oral NSAIDs if possible because of age, CKD and concurrent antihypertensive/aspirin use; if necessary, use lowest effective dose for shortest duration with gastroprotection and careful renal/BP monitoring.
    • Consider duloxetine if neuropathic component or persistent chronic pain despite basic measures.
    • Intra-articular corticosteroid injection for short-term relief of significant knee pain/swelling if conservative measures fail and no infection suspected.
  • Additional considerations:
    • Refer to physiotherapy and occupational therapy for aids/adaptations, gait training and home safety assessment to reduce falls risk.
    • Optimize diabetes control and review medications (assess renal function before NSAID use); discuss vaccines as per routine care.
    • If pain and functional limitation remain severe despite conservative care, consider referral to orthopedic surgery for assessment for joint replacement.

Key Learning Points

  • Osteoarthritis typically causes activity-related joint pain, brief morning stiffness (<30 minutes), bony enlargement and crepitus; radiographs show joint space narrowing and osteophytes.

  • Distinguish OA from inflammatory arthritides by symptom pattern (mechanical vs inflammatory), exam (bony nodes vs synovitis), inflammatory markers, and imaging; watch for red herrings like a remote history of gout.

  • Management focuses on non-pharmacological measures (exercise, weight loss, physio), cautious use of analgesics in older patients with comorbidities (prefer topical agents and paracetamol; avoid systemic NSAIDs when possible), and stepwise escalation including injections or surgical referral if conservative care fails.

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