1. 4 patients with pains in their legs………………

2. Mr H 65 years of age Type II Diabetes
Developed shortness of breath when walking the dog
Worse when he is climbing hills and better when he comes down
Starts to develop pain in his right leg as well

3. Medication
Ramipril
Aspirin
Atenolol
Metformin
Simvastatin

4. What are the main pathologies here?
Which symptoms need to asked when enquiring about his leg pain?
Can you explain the indications for each of the medications that are listed
Name 3 side effects of each one
What is the most likely cause of this mans leg pain?
What else can cause similar pain and how do you distinguish this?

5. Assessment How would you assess this patient on clinical examination?
Which features in the history or examination would support your diagnosis
He is referred to hospital – which investigations might help

6. Management What are the priorities for this man’s management?
What would you advise relating to his medication?
Which factors need to be taken into account relating to managing this man?

7. MR G Aged 72 Presents with aching pain in right thigh
Pain also felt in right groin and into his knee
Pain worse when he walks but also keeping him awake at night

8. Examination
What sort of assessment would you make in this man when examining him?
Can you explain /demonstrate the examination process to your colleagues?
What sort of tests might help you and why might you be doing them?

9. Test results
X ray hip – suggests early arthritic change in right hip ( subchondral sclerosis, loss of joint space and a few osteophytes)
Full blood count normal
ESR 100
Alkaline Phosphatase raised but ALT normal

10. What does the x ray report suggest?
What are the causes of a high ESR?
What might cause the raised ALP?
What else might be going on here and how would you follow this up?

11. Mr K 55 fork lift truck driver Long history of low back pain
Develops pain in low back which is causing early morning stiffness
Bends down to clip toe nails and develops sudden severe pain in the leg on the left

12. Clinical assessment What is the most likely pathology here?
How would you examine and assess this man clinically?
Can you demonstrate the examination to you colleagues?
What questions do you need to particularly need to ask this man ?

13. Tests Normal FBC but slightly raised ESR at 40 and CRP at 12
X ray – Radiologists decline to perform plain film – is this correct?
What can be seen on a plain film?
What might be a more useful method of assessing this man?

14. Red flags
What symptoms in the history might suggest that there is something more going on?
How can you make a reasonable assessment of this?
What actions are open to the primary care doctor when assessing a patient with low back pain

15. Mrs F Develops pain initially in one then both legs when walking
Initially buttocks and thighs then spreads to feet
Gets better when sits and leans forward
She gets this when walking home at the same place each night

16. Worse when she goes down hill
Last three weeks also noted that her legs get weak when she walks too far

17. What does this picture suggest?
Which of the following tests would you request?
Plain lateral x ray lumbar spine
MRI scan?
Bone scan?