Summary of Common Conditions seen in OSCEs
| Condition | Key points | Investigations and management |
| Osteoarthritis | Primary or secondary to earlier joint disease (trauma, obesity) Pain on movement Worse at the end of the day Stiffness after rest Heberden’s nodes (distal interphalangeal) Bouchard’s nodes (proximal interphalangeal) Joints: distal interphalangeal, thumb metacarpophalangeal, knees | X-ray:
Physiotherapy Analgesia (paracetamol/NSAIDs) Intra-articular steroid injection Joint replacement |
| Rheumatoid arthritis (Aletaha et al. 2010) | Symmetrical Swollen Morning stiffness Hands and feet Metacarpophalangeal, proximal interphalangeal, wrist, metatarsophalangeal Carpal tunnel syndrome Ulnar deviation Dorsal subluxation | Rheumatoid factor positive (70%) Anti-CCP (98%) Anaemia of chronic disease C-reactive protein, ESR, platelets (all raised) X-ray:
|
| Boutonnière deformity Swan neck deformity Z thumb Elbow nodules Felty syndrome: rheumatoid arthritis + neutropenia + splenomegaly Increased cardiovascular risk – ask about risk factors (e.g. smoking) | 28 Joint Disease Activity Score (DAS28) DMARDs : ask about history of tuberculosis (personal and in family; reactivation on biological treatments) Steroids (oral or intra-articular) NSAIDs Exercise Joint replacement | |
| Gout | Monoarthropathy Metatarsophalangeal joints Pain Inflammation Diuretics Alcohol Tumour lysis syndrome Renal disease | Polarised light microscopy of joint fluid: negatively birefringent Raised urate X-ray:
|
| Pseudogout (CPPD) | Similar to gout Knee, hip, wrist Diabetes mellitus Hypothyroidism Hyperparathyroidism Wilson’s disease | Polarised light microscopy of joint fluid: positively birefringent X-ray: chondrocalcinosis Analgesia NSAIDs |
| Ankylosing spondylitis | Spine Sacroiliac joints HLA B27 Gradual onset of low back pain Worse at night Morning stiffness Improves during day Question mark posture Enthesitis (inflammation at tendon insertion into bone): Achilles tendon Iritis Aortic regurgitation Apical lung fibrosis | X-ray: bamboo spine (syndesmophytes) Normocytic anaemia C-reactive protein, ESR (raised) Exercise Physiotherapy NSAIDs Anti-tumour necrosis factor alpha (etanercept, adalimumab) |
| Systemic sclerosis | Limited: CREST (calcinosis, Raynaud’s syndrome, oesophageal dysmotility, sclerodactyly, telangiectasias):
| Diffuse: echocardiogram, spirometry Intravenous cyclophosphamide Angiotensin-converting enzyme inhibitor Gloves, hat Prostacyclin |
| Relapsing polychondritis (rare but somehow finds its way into OSCEs) | Floppy ears Stridor (nasal septum, larynx) Aortic valve disease Polyarthritis Vasculitis | Steroids Immunosuppression |
| Polymyositis, dermatomyositis (same as polymyositis + skin) | Symmetrical Proximal muscle weakness May be paraneoplastic phenomenon (lung) Fever Raynaud’s disease Lung fibrosis Myocarditis Skin:
| Creatine kinase (raised) EMG (fibrillation potentials) Muscle biopsy Anti-Mi-2 Anti-Jo-1 (acute onset) Chest X-ray (? malignancy) CT (chest, abdomen, pelvis) Prednisolone Immunosuppression |
| SLE | Women of child-bearing age Afro-Caribbean Relapsing and remitting Fever, malaise, myalgia Malar rash Discoid rash Photosensitivity Mouth ulcers Serositis (pleura, pericardia) Renal Central nervous system (seizures, psychiatric) Drugs: isoniazid, hydralazine, phenytoin | Anti-dsDNA (60%) C3, C4 (low) ESR (raised) C-reactive protein (normal) ANA (95%) ENA (20%):
Anti-histone antibodies (drug-induced SLE) False-positive VDRL Blood:
|
| Reactive arthritis | Lower limbs After infection: sexually transmitted disease: Chlamydia, Ureaplasma; gastroenteritis: Campylobacter, Salmonella, Shigella, Yersinia Reiter’s syndrome:
Keratoderma blenorrhagica (palms and soles) Circinate balanitis Mouth ulcers Enthesitis | ESR C-reactive protein Stool culture Referral to genitourinary medicine clinic X-ray |
| Psoriatic arthritis | Presentations:
| Dactylitis (sausage fingers) X-ray: pencil-in-cup deformity NSAIDs Sulfasalazine Methotrexate Ciclosporin Anti-tumour necrosis factor alpha |
| Septic arthritis | Fever Pain – cannot move joint Swelling Acute onset Intravenous drug user | Joint fluid aspiration and culture Intravenous antibiotics Joint washout under general anaesthetic |
| Behçet’s disease | Mediterranean Oral ulcers Genital ulcers Uveitis Erythema nodosum Central nervous system Pathergy test: papule forms after needle prick | Immunosuppression, steroids |
| Charcot’s joint | Peripheral neuropathy (diabetes mellitus) Deformed joint | X-ray Analgesia Surgery |
| Wegener’s granulomatosis | Medium-vessel vasculitis Upper airways (epistaxis, saddle-nose, sinusitis) Lungs (cough, haemoptysis) Kidneys (rapidly progressive glomerulonephritis) Eyes | cANCA PR3 Urinalysis (proteinuria, haematuria) Chest X-ray Steroids Cyclophosphamide Plasma exchange Azathioprine, methotrexate |
| Trauma | Important to know mode of injury (high- or low-energy) Bones, ligaments torn, dislocations – knee/hip trauma is common in the history | ‘RICE’ (rest, ice, compression, elevation) Analgesia Physiotherapy Steroid injection Surgery |
‘Surgical Sieve’
| Vitamin C D E | |
| Vascular | Haemophilia |
| Infective/inflammatory | Staphylococcus, Streptococcus, Neisseria gonorrhoeae, tuberculosis |
| Trauma | Fracture, secondary osteoarthritis |
| Autoimmune | Rheumatoid arthritis, SLE, rheumatic fever |
| Metabolic | Gout, pseudogout |
| Iatrogenic | High-dose steroids (avascular necrosis) |
| Neoplastic | Osteosarcoma |
| Congenital | Congenital dislocation of the hip |
| Degenerative | Osteoarthritis |
| Endocrine | Diabetes (pseudogout), postmenopausal osteoporosis |
Hints and Tips for the Exam
Taking a history for joint pain is quite straightforward. As with any pain, you will gain marks by running through SOCRATES (site, onset, character, radiation, alleviating factors/associated symptoms, timing, exacerbating factors, severity/signs/symptoms) and then following up with a standard history proforma. The marks to separate you from other candidates will come from asking about extra-articular manifestations of disease (assess this in the body systems) and the effect of the condition on the patient’s life and work. If faced with an elderly patient presenting with worsening pain in the hip due to osteoarthritis, you should aim to address their social and safety issues. Are they at risk of falls? Do they need help around the house? How has their mood been affected?
Remember to ask about the joint above and the one below in all cases. For example, pain in the knee can be referred pain from the hip and vice versa.
Do not forget occupation – more often than not, the patient’s job will involve use of their affected joint. Opening the station for questioning on how they are coping and what their employer feels about the situation can bring out the patient’s concerns early and build a stronger rapport. Hobbies and sports activities should also be addressed.
Management will require an multidisciplinary approach with involvement of a physiotherapist (depending on the level of dysfunction), occupational therapist, surgeons (if replacement of the joint is considered), rheumatologist and GP. If there is chronic illness such as rheumatoid arthritis, mention that there are support groups and charities that the patient can contact.
Questions You Could Be Asked
Q. What are the features of seronegative arthritides?
A. Absence of rheumatoid factor, HLA B27-positive, involvement of the axial skeleton, enthesitis, dactylitis, extra-articular features such as oral ulcers, aortic regurgitation and anterior uveitis, and asymmetrical oligoarthritis/large joint monoarthritis (e.g. in the knee).
Q. What are the differential diagnoses of seronegative arthritides?
A. Psoriatic arthritis, reactive arthritis, enteropathic arthritis, osteoarthritis, rheumatoid arthritis, haemochromatosis, SLE and septic arthritis.
Q. What are the diagnostic criteria for rheumatoid arthritis?
A. New criteria were released in 2010 from the American College of Rheumatology:
- Presence of synovitis in at least one joint
- Absence of an alternative diagnosis better explaining the synovitis
- Score greater than 6/10 on:
- Number and site of involved joints (range 0–5)
- Serological abnormality (range 0–3)
- Elevated acute-phase response (range 0–1)
- Symptom duration (two levels; range 0–1)
- Number and site of involved joints (range 0–5)
Q. How can you monitor disease activity in rheumatoid arthritis?
A. Frequent follow-up, 28 Joint Disease Activity Score (DAS28) – repeat monthly, C-reactive protein and joint X-ray.
Q. How do you manage rheumatoid arthritis?
A. The answers can be found in the summary table above.
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