SCA APPROACH

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Opening Sentence:

“Doctor, my elbow is causing me lots of pain. It’s been five weeks now, and it’s just not getting better.”

Open History (to give freely):

Has a sharp, aching pain on the outside of her right elbow. It started gradually about five weeks ago and has been getting progressively worse.

Cues to give:

“I need to get this sorted and fast, please” (If this was picked up )“I used to do a lot of pottery, and I’ve recently got back into it. I spend hours on the wheel. I know it’s probably that, but I love it, and I have a big exhibition coming up in a month.

ICE:

Ideas: “I’m pretty sure it’s tennis elbow, I looked it up online. It feels exactly like what they describe. I just don’t understand why it’s not healing.”

Concerns: “My biggest concern is that it won’t get better in time for my pottery exhibition. I’ve put so much work into it, and I need to be able to finish my pieces”

Expectation: “I want something strong to fix this. Maybe a steroid injection? Or some kind of quick fix. I can’t afford to be out of action for long.”

How to Act:

Ms. Jenkins should be assertive, direct, and slightly impatient. She should convey a sense of urgency and frustration with the pain. She might interrupt or try to steer the conversation towards her desired treatment (e.g., injection). She should be keen to get back to her activities and may express scepticism about conservative management.

More History (only if asked):

· The pain is particularly bad when she tries to lift things, grip objects, or twist her forearm, like opening a jar or turning a doorknob.

· She finds it difficult to type at work, and her new pottery hobby is impossible. She’s tried over-the-counter painkillers (paracetamol, ibuprofen), but they only offer temporary, mild relief.

· No specific injury or trauma.

· The pain feels sharp, aching, and localised to the lateral epicondyle, radiating slightly down the forearm.

· No numbness, tingling, weakness (other than pain-induced), swelling, redness, or warmth. No neck or shoulder pain.

· No systemic symptoms (fever, weight loss), no arm weakness

Social History:

Occupation: Graphic designer (right-handed, uses mouse and keyboard extensively).

Smoking: Non-smoker.

Alcohol: Social drinker.

Home situation: Lives alone.

Hobbies/Lifestyle: Recently restarted pottery (throwing clay on a wheel), enjoys gardening.

Questions to ask:

“Can I get a steroid injection today?”

“How long will it take to get better?”

“Do I need an X-ray or scan?”

“What about physiotherapy? Can I get referred straight away?”

EXAMPLE CONSULTATION SCRIPT

Explain the situation, the likely diagnosis or DD, and manage ICE:

Good morning, Ms. Jenkins. Thanks for coming in. I understand how frustrating and debilitating this elbow pain must be, especially with your pottery exhibition coming up. You’re right to suspect tennis elbow, or lateral epicondylitis, as we call it medically. It’s a very common condition, often caused by repetitive strain or overuse of the forearm muscles that attach to the outside of your elbow. Your new pottery hobby, while enjoyable, is likely contributing to this, as are activities like typing and gripping.

I can see you’re a very proactive person and keen to get this sorted quickly. It’s completely understandable that you want a quick fix, and I appreciate that you’ve done some research. While steroid injections can provide temporary relief, they aren’t usually the first line of treatment, especially for a new onset like yours, and they don’t address the underlying cause. In fact, repeated injections can sometimes weaken the tendon in the long run. My priority is to help you get better safely and effectively, and to prevent this from becoming a chronic issue.

Reassure

The good news is that tennis elbow usually responds very well to simple treatments, though it can take some time. The most important first step is to modify the activities that aggravate your elbow. This doesn’t necessarily mean stopping pottery entirely, but perhaps reducing the intensity or duration. We can discuss some strategies for that.

Self-measures:

I’d recommend starting with a combination of rest, ice, and over-the-counter pain relief. Continue with the ibuprofen if it helps, and apply ice packs to the painful area for 15-20 minutes several times a day. If this is not enough, we can also try naproxen, which is a bit stronger and helps the pain and the inflammation settle down.

We can also try a simple elbow strap, which can help reduce the strain on the tendon. I can give you some information on where to get one and how to use it.

Next step

Physiotherapy is also effective for tennis elbow. They can teach you specific exercises to strengthen the forearm muscles and improve flexibility, as well as advise on proper technique for your work and hobbies.

I can refer you to physiotherapy, and they can usually see you within a few weeks. In the meantime, I can give you some basic exercises to start at home.

Acknowledge, but stay realistic.

Regarding your pottery exhibition, I understand this is very important to you. While complete rest might be ideal, it’s not always practical. We need to find a balance. Perhaps you can focus on tasks that don’t aggravate your elbow as much, or break up your work into shorter sessions with frequent breaks.

If you find the pain is still too much, we can reconsider options like a steroid injection closer to the exhibition date, but only if conservative measures haven’t helped and you understand the risks.

Information leaflet

I’ll also provide you with some patient information leaflets on tennis elbow, which will cover everything we’ve discussed in more detail. It’s important to remember that healing takes time, often several weeks to a few months, but with consistent effort, most people make a full recovery. I’d like to review you in about 3-4 weeks to see how you’re progressing, or sooner if your symptoms worsen significantly.

Management objective

What is scenario testing?

· This scenario primarily tests the GP trainee’s ability to:

· Manage patient expectations: Deal with an aggressive patient keen for a quick fix (e.g., injection) and guide them towards appropriate conservative management.

· Explain common musculoskeletal conditions: Clearly articulate the nature of tennis elbow, its causes, and typical prognosis.

· Provide practical self-management advice: Offer actionable lifestyle modifications, ergonomic advice, and self-help measures.

· Safe prescribing/referral: Avoid unnecessary interventions (e.g., immediate steroid injection) and make appropriate referrals (e.g., physiotherapy).

· Empathy and communication: Acknowledge the patient’s frustration and impact on their life while maintaining professional boundaries and guiding them to the best course of action.

· Safety netting: Advise on when to seek further medical attention or if symptoms worsen.

Important areas in data gathering:

· Onset, duration, and character of pain: Gradual vs. sudden, specific location, radiation, aggravating/relieving factors.

· Impact on daily activities: Work, hobbies, self-care.

· Associated symptoms: Numbness, tingling, weakness, swelling, redness, warmth (to rule out other pathologies).

· Recent changes in activity/hobbies: Identification of potential causative factors.

· ICE: Crucial to understand the patient’s ideas (tennis elbow), concerns (exhibition, chronicity), and expectations (quick fix, injection).

· Red flags: Systemic symptoms, neurological deficits, signs of infection.

· Differential diagnoses (to consider and ask about): Lateral epicondylitis (tennis elbow), radial tunnel syndrome, cervical radiculopathy (less likely given localized pain), olecranon bursitis (unlikely given location).

Case F Mock 1

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