tennis elbow
Doctor Information
Johanna Nash, age 38
PMH:
Obesity
Knee pain
Gastric ulcer 5 years ago.
Medication:
Orlistat 120mg
Cocodamol 8/500 2 tablets qds prn
No known allergies
PMH:
Obesity
Knee pain
Gastric ulcer 5 years ago.
Medication:
Orlistat 120mg
Cocodamol 8/500 2 tablets qds prn
No known allergies
Patient Information
Johanna Nash, age 38
History: You have arm and elbow pain that started about a week ago and is getting steadily worse. The pain is much worse with certain movements - for example when you are coming home with your shopping in hand, or after a day at work.
If asked only: you work the checkout at Morrisons - you have noticed that after a whole day of scanning items with your right arm, the pain is excruciating. You took some ibuprofen which helped, but every day you go and do the same job and the same thing happens.
There is occasional pins and needles in your fingers, and sometimes your hand feels weaker. No neck or shoulder pain.
You live with your partner Paul, don’t have many hobbies apart from darts, and drink about 2-3 cans of lager 3 times a week. You are a lifelong non smoker. You have 3 children aged 12, 10 and 6. Your finances are not the best, as Paul is struggling to find work at the moment, after recently being made redundant.
You are obese and take orlistat - you come and see the nurse every three months to get weighed
You also have arthritis in your knee and take cocodamol when you need to. You had a gastric ulcer 5 years ago.
Ideas: you wonder if you have pulled a muscle in your arm
Concerns: the pain is affecting your job, and you are already on a caution because you missed so many days last year from knee pain - you cant afford to lose this job, as you are the main earner for your family at the moment.
Expectation: anything it takes to continue working
History: You have arm and elbow pain that started about a week ago and is getting steadily worse. The pain is much worse with certain movements - for example when you are coming home with your shopping in hand, or after a day at work.
If asked only: you work the checkout at Morrisons - you have noticed that after a whole day of scanning items with your right arm, the pain is excruciating. You took some ibuprofen which helped, but every day you go and do the same job and the same thing happens.
There is occasional pins and needles in your fingers, and sometimes your hand feels weaker. No neck or shoulder pain.
You live with your partner Paul, don’t have many hobbies apart from darts, and drink about 2-3 cans of lager 3 times a week. You are a lifelong non smoker. You have 3 children aged 12, 10 and 6. Your finances are not the best, as Paul is struggling to find work at the moment, after recently being made redundant.
You are obese and take orlistat - you come and see the nurse every three months to get weighed
You also have arthritis in your knee and take cocodamol when you need to. You had a gastric ulcer 5 years ago.
Ideas: you wonder if you have pulled a muscle in your arm
Concerns: the pain is affecting your job, and you are already on a caution because you missed so many days last year from knee pain - you cant afford to lose this job, as you are the main earner for your family at the moment.
Expectation: anything it takes to continue working
Examination Findings
Pulse 88
BP 148/80
Right arm normal tone and power.
Tender over the lateral epicondyle, worse on resisted wrist extension and supination
Normal sensation and full range of movement of the wrist, elbow and shoulder.
Good ROM in the neck, no neck tenderness.
BP 148/80
Right arm normal tone and power.
Tender over the lateral epicondyle, worse on resisted wrist extension and supination
Normal sensation and full range of movement of the wrist, elbow and shoulder.
Good ROM in the neck, no neck tenderness.
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Organised and systematic in gathering information from history taking, examination and investigation Identifies abnormal findings or results and/or recognises their implications Data gathering does appears to be guided by the probabilities of disease Undertakes physical examination competently Uses an incremental approach using time and accepting uncertainty |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. Fails to identify abnormal data or correctly interpret them Appears disorganised/unsystematic in the application of the instruments or the conduct of physical examinations |
Clinical Management Skills
|
POSITIVE INDICATORS
Makes appropriate diagnosis Develops a management plan (including prescribing and referral) that is appropriate and in line with current best practice Makes plans that reflect the natural history of common problems Management approaches reflect an appropriate assessment of risk Makes appropriate prescribing decisions Encourages improvement, rehabilitation, and, where appropriate, recovery. Encourages the patient to participate in appropriate health promotion and self-help strategies Follow-up arrangements and safety netting are adequate |
NEGATIVE INDICATORS
Fails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve Fails to make the patient aware of relative risks of different approaches Decisions on whether/what to prescribe are inappropriate or idiosyncratic. Decisions on whether & where to refer are inappropriate. Follow-up arrangements are absent or disjointed Unable to enhance patient’s health perceptions and coping strategies |
Inter Personal Skills
|
POSITIVE INDICATORS
Identify patient’s agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues. Works with the patient to develop a shared management plan or clarify the roles of doctor and patient Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination Does not allow own views/values to inappropriately influence dialogue |
NEGATIVE INDICATORS
Doesn't enquire about patients ICE Takes a doctor centered approach towards management Uses an explanation that is filled with jargon, or forgets to explain at all Doesn't show any sympathy / empathy towards the patient's situation Fails to empower patient Inappropriately influences patient interaction through own views/values |
Management
Explanation: you have a condition called tennis elbow - it is soreness and swelling on the outside part of your elbow, in particular the strap that connects the muscles to the bone. The most common cause is overuse, for example if you use you arm frequently to do the same movement. There are various treatments available, but for most people, the pain resolves over time by simply avoiding the activity that led to the pain.
As this is a simple musculoskeletal station, you will be expected to examine the patient. Range of movement of the elbow is usually normal. There is localised tenderness over the lateral epicondyle which can be reproduced with resisted wrist extension and supination. Make sure you exclude shoulder and neck problems. The diagnosis is clinical so there is no need to request any investigations.
First and foremost, try to pinpoint the activity that has led to the pain - in this case it is the repetitive movements of scanning items at the till. Reducing the exacerbating factor can make a big difference to symptoms. Discuss this with the patient - she is obviously keen to continue working but perhaps there is another job she can do within the supermarket? You could offer an ‘amended duties’ med 3 note suggesting this, or perhaps even to take more frequent breaks.
With regards to analgesia. Oral NSAIDs are likely to be the best option. However here his previous gastric ulcer means that this is unlikely a good idea. You could consider topical NSAIDs however their effectiveness is uncertain.
If symptoms persist you could consider a corticosteroid injection which will help the pain, but is falling out of favour as they increase the time it takes to recover from the condition.
Home exercise leaflets can be given to individuals, and they are available online. A physio referral can also be undertaken,
If the he patient wishes to continue to work, doing the same movements that initially exacerbated the problem, then often a forearm band/support is often a great way of reducing symptoms. It works by spreading the load from the tendon that's causing the pain, to the other muscles across the forearm. These can be obtained on through the nhs by referring to the physiotherapists usually. Alternatively they can be purchased online from places like Amazon for a small fee.
As this is a simple musculoskeletal station, you will be expected to examine the patient. Range of movement of the elbow is usually normal. There is localised tenderness over the lateral epicondyle which can be reproduced with resisted wrist extension and supination. Make sure you exclude shoulder and neck problems. The diagnosis is clinical so there is no need to request any investigations.
First and foremost, try to pinpoint the activity that has led to the pain - in this case it is the repetitive movements of scanning items at the till. Reducing the exacerbating factor can make a big difference to symptoms. Discuss this with the patient - she is obviously keen to continue working but perhaps there is another job she can do within the supermarket? You could offer an ‘amended duties’ med 3 note suggesting this, or perhaps even to take more frequent breaks.
With regards to analgesia. Oral NSAIDs are likely to be the best option. However here his previous gastric ulcer means that this is unlikely a good idea. You could consider topical NSAIDs however their effectiveness is uncertain.
If symptoms persist you could consider a corticosteroid injection which will help the pain, but is falling out of favour as they increase the time it takes to recover from the condition.
Home exercise leaflets can be given to individuals, and they are available online. A physio referral can also be undertaken,
If the he patient wishes to continue to work, doing the same movements that initially exacerbated the problem, then often a forearm band/support is often a great way of reducing symptoms. It works by spreading the load from the tendon that's causing the pain, to the other muscles across the forearm. These can be obtained on through the nhs by referring to the physiotherapists usually. Alternatively they can be purchased online from places like Amazon for a small fee.