TENNIS ELBOW

Marcus Namon

28 years, MALE

Role-play cases simulate real clinical practice to guide how candidates respond to clinical scenarios and real life practice.

Opening Line

"In a stern voice: 'I want to talk about my arm pain, I'm not happy with the wait times and the treatment I received before.'

Personal Information

Name: Marcus Namon
Age: 28 years
Gender: Male

Background

Health Status: Obese with a sedentary lifestyle.
Habits: Does not smoke or drink alcohol due to his Muslim faith.
Occupation: Professional esports (online gamer).
Living Situation: Lives alone.
Social Background: Migrated from Eritrea and feels socially isolated in the UK. Relies heavily on online interactions with friends and gamers for social connection.

History only if asked.

Current Issue: Pain around the left outer elbow.
Duration: About 2 weeks.
Onset: Gradual.
Symptoms: No redness, mildly swollen, slightly warm to touch. Pain worsens during gaming or using his arm.
Pain Characteristics: Located around the left outer elbow, mildly swollen, warm to touch.
Impact on Activities: Worse when gaming or using his arm. Daily activities at home are not significantly affected, but he has had to use his right arm more. Your Left Hand is your dominant hand.

Previous Medical Visit

First Clinic Presentation: This is his first GP visit for this issue after experiencing long wait times for appointments.
Previous Encounter: Previously saw a non-doctor healthcare provider, which added to his frustration. Now returning to see you.

Lifestyle

Living Situation: Lives alone.
Social Connection: Relies on online gaming for social interaction due to feeling isolated in the UK. Very hesitant to stop gaming as this is also a source of income and entertainment.
Physical Activity: Sedentary lifestyle contributing to obesity.
Diet and Exercise: Understands the need for more activity to address obesity but struggles due to lifestyle.

Ideas, Concerns, Expectations

Ideas: Believes the pain might be due to sleeping on his arm.
Concerns: Worried that the pain might hinder his ability to game and thus impact his income.
Expectations: Desires stronger pain medication for relief.

Behavior

General Attitude: Frustrated with the long wait for appointments and the initial non-doctor consultation.
Desired Outcome: Seeks effective pain management and timely medical attention.

Response to Doctor's Approach

Positive: If the doctor provides effective pain management, listens empathetically, and addresses the concerns, Marcus will likely be satisfied.
Negative: If the doctor dismisses his pain or does not offer a solution, Marcus may become more frustrated and demand further action.

You are a doctor in your routine clinic, ready to begin your day of consultations. A patient has been booked to see you,

Name: Mr Marcus Namon

Age: 28 years Male

Past Medical History: Obesity Stage 2, Early Osteoarthritis (both knees).

Occupation: Professional eSports (Online gamer)

Medication History: Topical analgesia. NKDA

Medical Notes:

First contact MSK clinic, Today:
Seen with left elbow pain 2weeks, worsening. No associated factor. Lives alone, little exercise – BMI 32Kg/m2. Vital signs normal.
Examination: Tender over the lateral epicondyle, worse on resisted wrist extension and supination. Left arm normal tone and power. Normal sensation and full range of movement of the wrist, elbow and shoulder.

Good ROM in the neck, no neck tenderness.

Given exercises and PIL

Appear unhappy that he wasn’t seeing a GP, asking for second opinion.

Whenever we see patients who are making a complaint, we must acknowledge their frustrations and collaboratively formulate a plan, providing a clear timeline for when they can expect a response.

Data Gathering and Diagnosis

Reviews Marcus's history, including the duration and nature of his elbow pain, and self-treatment with ibuprofen.
Excludes red flags and checks differentials for elbow pain; infective arthritis, osteoarthritis, neck pain, trauma
Enquires about any current abdominal pain, changes in bowel habits, and overall energy levels.
Reviews discharge summary if any recent hospital visits (due to ibuprofen use for previous conditions) and checks the plan for follow-up, including the use of PPI and Iron tablets.
Understanding Symptoms: Establishes Marcus's understanding of his symptoms and their potential relation to his self-treatment with ibuprofen.
Enquires about risk factors for potential complications such as GI bleed, including his dietary habits, physical activity, and any smoking or alcohol intake (acknowledging his non-use due to religious beliefs)

Marking Criteria:

Clear Pass: Thorough history review, comprehensive understanding of current health, effective communication of potential risks.
Pass: Adequate history review, covers most aspects but may miss some details.
Fail: Incomplete history review, significant gaps in understanding the patient's current health.
Clear Fail: Neglects key aspects of history, fails to understand or communicate potential risks.

Clinical Management and Medical Complexity

Discusses possible clinical options with Marcus including types/preference for analgesia, prescribing PPI, cold compress, braces, strengthening exercises and rest from vigorous activities, steroid injections.
Prescribes: Prescribes analgesia and PPI cover, supports patient with information to obtain elbow braces from local pharmacy, amazon.
Offers health promotion advice regarding physical activity and weight management.
Offers to add a note on Marcus's records to check or avoid future NSAID use.
Arranges follow-up in a few days if Marcus remains undecided on the next steps.
Provides appropriate safety netting, advising Marcus to see a GP if experiencing any signs of GI bleeding (melena) or to visit A&E if vomiting blood.

Marking Criteria:

Clear Pass: Comprehensive discussion of options, clear medication plan, effective health promotion.
Pass:Discusses most options, provides medication plan, some health promotion advice.
Fail: Misses significant options or aspects of medication plan, minimal health promotion.
Clear Fail: Fails to discuss key options, inadequate medication plan, no health promotion.

Interpersonal Skills / Relating to Others

Addressing Concerns and Apology: Explores the cue, "I'm not happy," and addresses Marcus's ideas, concerns, and expectations (ICE), including side effects of ibuprofen and issues with communication over treatment duration.
Acknowledges Marcus's anger and frustration and offers a balanced apology: "I'm sorry you had to go through this," without accepting liability for appointment delays.
Empathy and Support:
Shows a sensitive and empathetic approach, giving Marcus adequate time to speak and explain his situation.
Explains in a clear and sensitive manner the standard treatment for musculoskeletal injuries and potential side effects of NSAIDs.
Supports Marcus through non-verbal behaviors, making eye contact, actively listening, and reflecting back his concerns.
Avoids medical jargon, ensuring Marcus understands all explanations and recommendations.
Checks understanding of information provided and asked how patient would like further information (patient information leaflet).

Marking Criteria:

Clear Pass: Fully explores patient concerns, provides a balanced apology, highly empathetic and supportive.
Pass: Addresses most patient concerns, offers a reasonable apology, generally empathetic.
Fail: Misses key patient concerns, inadequate apology, limited empathy.
Clear Fail: Fails to address patient concerns, no apology, lacks empathy.

By following this structured approach, the GP can ensure a thorough and empathetic consultation, addressing Marcus Namon's concerns effectively while maintaining a high standard of care.

These are the key issues in this clinical scenario.

Key Issues:

The clinical management has to be up to date with current practice and relevant to the patient. The doctor should employ principles of shared management when offering options to the patient.
Important to note and incorporate the social history and context in your management. Factors that influenced lifestyle, and precipitated known and new medical conditions should be addressed. The patient is a professional eSports, social isolation as a migrant, income and entertainment needs of the patient.
Demonstrate understanding that professional sport people find it difficult to stop playing sports or he hesitant to take a break. It is their lifestyle and a source of income.
The doctor should be able to demonstrate and explain the various options for clinical management of tennis elbow, if the initial steps do not work.
The doctor should be show acknowledge the patient's frustrations with getting appointments and explain to patient that the clinical assessment from the non-GP staff was appropriate.

Reviews Marcus's history, including the duration and nature of his elbow pain, and self-treatment with ibuprofen.
Excludes red flags and checks differentials for elbow pain; infective arthritis, osteoarthritis, neck pain, trauma
Enquires about any current abdominal pain, changes in bowel habits, and overall energy levels.
Reviews discharge summary if any recent hospital visits (due to ibuprofen use for previous conditions) and checks the plan for follow-up, including the use of PPI and Iron tablets.
Understanding Symptoms: Establishes Marcus's understanding of his symptoms and their potential relation to his self-treatment with ibuprofen.
Enquires about risk factors for potential complications such as GI bleed, including his dietary habits, physical activity, and any smoking or alcohol intake (acknowledging his non-use due to religious beliefs)

Marking Criteria:

Clear Pass: Thorough history review, comprehensive understanding of current health, effective communication of potential risks.
Pass: Adequate history review, covers most aspects but may miss some details.
Fail: Incomplete history review, significant gaps in understanding the patient's current health.
Clear Fail: Neglects key aspects of history, fails to understand or communicate potential risks.

Clinical Management and Medical Complexity

Discusses possible clinical options with Marcus including types/preference for analgesia, prescribing PPI, cold compress, braces, strengthening exercises and rest from vigorous activities, steroid injections.
Prescribes: Prescribes analgesia and PPI cover, supports patient with information to obtain elbow braces from local pharmacy, amazon.
Offers health promotion advice regarding physical activity and weight management.
Offers to add a note on Marcus's records to check or avoid future NSAID use.
Arranges follow-up in a few days if Marcus remains undecided on the next steps.
Provides appropriate safety netting, advising Marcus to see a GP if experiencing any signs of GI bleeding (melena) or to visit A&E if vomiting blood.

Marking Criteria:

Clear Pass: Comprehensive discussion of options, clear medication plan, effective health promotion.
Pass:Discusses most options, provides medication plan, some health promotion advice.
Fail: Misses significant options or aspects of medication plan, minimal health promotion.
Clear Fail: Fails to discuss key options, inadequate medication plan, no health promotion.

Interpersonal Skills / Relating to Others

Addressing Concerns and Apology: Explores the cue, "I'm not happy," and addresses Marcus's ideas, concerns, and expectations (ICE), including side effects of ibuprofen and issues with communication over treatment duration.
Acknowledges Marcus's anger and frustration and offers a balanced apology: "I'm sorry you had to go through this," without accepting liability for appointment delays.
Empathy and Support:
Shows a sensitive and empathetic approach, giving Marcus adequate time to speak and explain his situation.
Explains in a clear and sensitive manner the standard treatment for musculoskeletal injuries and potential side effects of NSAIDs.
Supports Marcus through non-verbal behaviors, making eye contact, actively listening, and reflecting back his concerns.
Avoids medical jargon, ensuring Marcus understands all explanations and recommendations.
Checks understanding of information provided and asked how patient would like further information (patient information leaflet).

Marking Criteria:

Clear Pass: Fully explores patient concerns, provides a balanced apology, highly empathetic and supportive.
Pass: Addresses most patient concerns, offers a reasonable apology, generally empathetic.
Fail: Misses key patient concerns, inadequate apology, limited empathy.
Clear Fail: Fails to address patient concerns, no apology, lacks empathy.

By following this structured approach, the GP can ensure a thorough and empathetic consultation, addressing Marcus Namon's concerns effectively while maintaining a high standard of care.

Strategies for Effective Consultation

Patients often come with expectations and their own ideas about the cause of their problems. For Marcus Namon, the GP can use the following strategies to efficiently address his concerns and provide comprehensive care

1. Prioritize and Structure the Consultation

Agenda Setting: At the beginning of the clinical management, clearly set the agenda by acknowledging the main concerns. For example, "Marcus, I understand you have several important questions about your arm pain and how it's affecting your gaming, should we start by discussing how we can help with this"

2. Active Listening and Empathy

Show Empathy: Display understanding of his frustration and concerns. Use phrases like, "I can see why you’re worried about how this pain is affecting your gaming and daily activities."

Active Listening:Ensure Marcus feels heard by summarizing his concerns. "You’re concerned about your arm pain, the wait time for appointments, and the treatment you’ve received so far."

3. Effective Questioning

Open-Ended Questions:Start with open-ended questions to get a comprehensive view of Marcus’s concerns, then use closed-ended questions to focus on specifics. Example: "What are your main worries about your arm pain?" followed by "Have you noticed any new symptoms since you first felt the pain?"

4. Provide Clear and Concise Information

Address each concern briefly, and if running out of time, mention that the rest can be discussed in a follow-up appointment.

Arm Pain Management: "It’s possible your pain is due to overuse or strain. We can explore stronger pain relief options and other treatments."
Wait Times: "I apologize for the delays you’ve experienced. We'll work on ensuring you get timely appointments in the future."
Impact on Gaming: "We'll aim to manage your pain so you can continue your gaming activities without interruption."

5. Reassure and Plan Follow-Up

Reassurance:Reassure Marcus about the manageability of his condition. "With the right treatment, we can help reduce your pain and prevent it from affecting your gaming."

Follow-Up Plan:"We’ll schedule a follow-up in a week to review your progress and any concerns you might still have."

6. Time Management

Efficient Time Use:State at the start of the consultation that there is a lot to discuss and will try to cover all. Allocate approximately 2 minutes per major concern, leaving the last few minutes for summarizing and planning next steps.

Stay on Track:Gently steer the conversation back if it goes off-topic. "That's important, but let’s make sure we cover your main health concerns first."

7. Note Any Other Issues for Follow-Up

If unable to cover all questions, mention that you would like to book another appointment to discuss further. For example, if Marcus's sedentary lifestyle and obesity need more discussion, say, "We’ll book another appointment to focus on lifestyle management and strategies to help with your weight and activity levels."

8. Summarize Key Points

At the end of each topic, summarize the key points to ensure Marcus understands. "To recap, we’re going to try a different pain medication, and I’ll see you in a week to check on your progress."

By using these strategies, the GP can efficiently address Marcus Namon's concerns and provide comprehensive care, ensuring he feels heard, understood, and supported in managing his health issues.