Station 56
Mohammed Khan
Age: 56 years old male
Full Case
Patient’s Data
Patient’s name: Mohammed Khan
Age: 56-year-old male
Past medical history
- Asthma
- Bilateral Knee Osteoarthritis
- Chronic Kidney Disease (CKD) Stage 3a – EGFR stable over the past 2 years (range: 55–59). Most recent EGFR: 55 (2 weeks ago)
Drug and Allergy History
- Symbicort 100/6: 1 puff twice daily for maintenance, plus 1 puff as needed for symptom relief, up to a maximum of 8 inhalations per day (includes both maintenance and reliever use)
- No known drug allergy
Recent Notes/Consultation
Seen by Dr Native (Clinical practitioner role) 4 weeks ago
Presenting complaint: Patient reports worsening Knee pain bilaterally, known to have osteoarthritis. No red flags
Examination findings: Crepitus on both knee joint movements, no lumps or bumps noted, Normal systemic examination.
Plan:Referred for physiotherapy, repeat knee X-rays arranged, safety netting and worsening advice given.
X-ray Report – Bilateral Knees
Findings:
Right Knee:
There is worsening narrowing of the medial joint space compared to previous Xray, consistent with severe osteoarthritis.
Subchondral sclerosis is noted in the medial compartment.
Osteophyte formation is observed along the joint margins.
There is evidence of mild patellofemoral joint involvement with small osteophytes noted at the patellar margins.
No acute fracture or dislocation is seen.
Left Knee:
Similar to the right knee, there is narrowing of the medial joint space.
Subchondral sclerosis is present in the medial compartment.
Osteophyte formation is also seen along the joint margins.
The patellofemoral joint shows severe osteoarthritic changes with osteophyte formation at the patellar margins.
No acute fracture or dislocation is seen.
Conclusion:
Bilateral severe knee osteoarthritis is noted, more prominent in the medial compartments of both knees. The patellofemoral joints also show involvement. No evidence of acute bony injury.
Recent Investigations done 2 weeks ago
Blood tests including FBC, LFTs, CRP, ESR, and Rheumatoid screen – all within normal limits
EGFR: 62 – filed as satisfactory
Patient booked routine appointment to discuss results.
Patient's Story (Role player’s brief)
Patient’s Story
You are Mohammed Khan, a 56-year-old self-employed tradesman working on building sites. You recently saw the GP a few weeks ago because your knee pain has been getting worse. The GP arranged a knee X-ray, which you’re now calling to discuss.
The pain is starting to interfere with your work. As the sole breadwinner for your household, taking time off is financially difficult.
There is no swelling, redness, or fever and no other joints are affected
You’ve been managing the pain with ibuprofen, which gives some relief. Paracetamol alone does not take away your pain.Your asthma is well controlled, and you haven’t had a flare-up in over three years. You also haven’t experienced any allergic reactions to ibuprofen in the past
Social History: Self-employed tradesman working on building sites; non-smoker; you do not drink alcohol; you live with wife and three children.
Ideas: You suspect there may be a fracture or something serious going on, even though you haven’t had any trauma.
Concerns: You are worried the pain will impact his ability to work, which would affect his income and family responsibilities.
Expectations: You want to know the results of the X-ray and what is causing the pain. You hope for a treatment option that will allow you to keep working.
If the doctor discusses referral for a knee replacement, say you’re not ready at this time due to ongoing work commitments.
Say NO to any other questions asked outside of the details already provided in the scenario. Accept anything else offered to you by the doctor.
Marking Scheme
Data Gathering and Diagnosis
- Ask where the pain is located
- Ask if the pain has gotten worse, better, or remained the same
- Ask if there is any swelling, redness, stiffness or fever
- Ask if the joint can be moved or if he is able to weight bear
- Ask about night pain or whether it wakes him from sleep
- Ask if any other joints are affected (e.g. joint above or below)
- Ask about psychosocial history including occupation, smoking status, alcohol intake, and activity level.
- Ask how this has affected daily activities and functioning
- Ask if the patient has ever experienced asthma symptoms after taking ibuprofen.
- Explain knee x-ray results that shows worsening osteoarthritis
Example of explanation to patient
Mr Khan, thank you for taking your time to explain all that has been going on. I’ve reviewed your knee X-ray, and it confirms that the pain you’re experiencing is due to worsening osteoarthritis in both knees. The good news is there’s no fracture or break in the bones, which you were understandably worried about.
As you may already know, osteoarthritis means the smooth cushioning between your joints is wearing away. This can lead to pain, stiffness, and difficulty moving, especially if you do a physical job like yours.
I see you’ve been taking ibuprofen for the pain, and it’s good to hear that it hasn’t triggered any asthma symptoms for you. That said, ibuprofen can sometimes affect asthma and may not be the best option for your kidneys, especially as they’re not working at full strength. A safer option would be to use ibuprofen gel that you rub directly onto your knees instead. It can still help with the pain but is much gentler on the rest of your body. If that’s not enough, we can also try a short course of stronger pain relief like co-codamol to help you stay comfortable. What are your thoughts?
Although the ibuprofen gel is generally a safer option than tablets, especially for your kidneys and asthma, using large amounts can still sometimes cause problems. It can affect your kidneys and may trigger asthma symptoms in some people. We’ll keep a close eye on your kidney function with regular blood tests, and if you notice any asthma symptoms, stop using the gel straight away and let us know.
There are other options too. One is a steroid injection into the joint, which can help reduce the inflammation and pain. This usually works well for a few months, but like any treatment, it has some risks, including temporary pain after the injection, skin changes, or rarely, an infection.
We can consider a referral to an orthopaedic specialist for knee replacement surgery. But I understand from what you said that now may not be the right time because of work. That’s completely fine, we can explore other options in the meantime.
Physiotherapy can also help with improving strength and mobility, things like swimming or walking can be great low-impact ways to support your knees.
Since your knee pain is making work more difficult, there’s a scheme called ‘Access to Work’ that might be able to help, there is a scheme called ‘Access to Work’. It helps people get support with workplace adaptations and allowances if their health condition affects their job. Our social prescriber can help guide you through that.
Management
Management
- Advise that oral ibuprofen may worsen both asthma and kidney function; recommend switching to topical ibuprofen gel as a safer alternative. Explain that although the gel is generally better tolerated, it can still trigger asthma symptoms if used in large amounts. Ensure renal function is monitored regularly, and advise the patient to stop using the gel and seek medical advice if any asthma symptoms occur.
- Offer a short course of co-codamol (codeine with paracetamol) if additional pain relief is needed
- Discuss the option of a steroid joint injection for symptom relief and discuss risks associated with it such as, temporary pain and swelling at the injection site, skin changes at the injection site and rare complications like infection.
- Explain the option of referral to orthopaedics to assess suitability for knee replacement, and discuss risks associated with operation, including infection, blood clots, persistent pain or stiffness and implant failure.
- Refer to physiotherapy for tailored exercise advice, including low-impact activities such as swimming, walking, and strength training
- As he is self-employed and symptoms are impacting his ability to work, advise referral to the Department for Work and Pensions under the “Access to Work” scheme. Explain that this scheme may support workplace adaptations, mobility aids, equipment, or other forms of allowance; refer to the social prescriber for further assistance with this
- Safety net regarding red flag symptoms such as worsening pain, inability to weight bear, or signs suggestive of septic arthritis
- Arrange follow-up in 4 weeks to reassess symptoms and review progress
Learning point from this station:
This station highlights the importance of taking a holistic approach when managing chronic conditions like osteoarthritis. It is essential to consider not only the physical symptoms but also how the condition affects the patient’s ability to work and carry out daily activities. Medication safety must be carefully considered, especially in patients with comorbidities such as asthma and chronic kidney disease. Management should be individualised and include a range of options; conservative measures, medication, joint injections, and potential surgical referral, while respecting the patient’s preferences and circumstances
Topical ibuprofen can generally be used with caution in patients with chronic kidney disease (CKD), but regular monitoring of renal function is advised. It should be avoided in cases of severe renal impairment, specifically when the estimated glomerular filtration rate (eGFR) is less than 30 mL/min/1.73 m². Although systemic absorption from topical formulations is lower than oral NSAIDs, applying large amounts can still lead to systemic effects, such as hypersensitivity reactions or asthma exacerbations. Therefore, it is best avoided in asthmatic patients who have never taken NSAIDs, those with a known hypersensitivity reaction to NSAIDs, or those with co-existing nasal polyps. In this case, the patient has previously taken ibuprofen without any worsening of his asthma, suggesting it may be safe to trial topical ibuprofen under supervision.