Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Junior Doctor working in General Practice. Your next patient is a 45-year-old woman, Susan Willowson, presenting with elbow pain. Please take a history and perform an appropriate examination.
Patient History:
Susan Willowson - a 45-year-old female - farmer
You have been experiencing elbow pain for the last few months. This pain is gradually getting worse. This pain is located at the lateral side of your right elbow. The pain is sharp and constant and can radiate down the forearm. Pain is not worsened by grasping objects, wrist flexion or pronation. It is made worse when bending your right wrist upwards (extension). You tried ibuprofen which improved the pain.
You noticed the gripping strength of your right hand has reduced. You now find opening a jar of jam more difficult than usual. No known recent injuries. No abnormal sensation.
Ideas, Concerns, Expectations:
You think this might be related to your work as a farmer, as you often have to use heavy vibrating tools on the farm. You are concerned as you are beginning to have difficulty managing at home and at work due to the pain. You would like to find out what is going on and have strong painkillers.
Past Medical History:
Osteoarthritis affecting both hips and knees
COPD
Previous left Achilles tendon rupture
Drug History:
Ibuprofen as required for pain
Fostair inhaler
NKDA
Family History:
Inflammatory bowel disease
Social History:
You work on a farm involving raising animals and growing crops.
You live with your husband in a detached house.
You are usually independent at home. No carers.
You smoke ten cigarettes a day for 20+ years.
You drink a glass of wine every day during dinner.
You play tennis when you are free, but you have been playing less than usual due to elbow pain.
Examination Findings:
Tenderness at the right lateral epicondyle of the humerus on palpation.
Elbow pain is worsened on resisted dorsiflexion of the right wrist
Weak right wrist extension and reduced grip strength of the right hand
Mill's test positive
Cozen's test positive
Tinel's sign is negative
Good range of movement of the right elbow.
Normal sensation
Differentials:
Lateral epicondylitis (Tennis Elbow)
Olecranon bursitis
Elbow arthritis
Cervical nerve root entrapment
Radial tunnel syndrome
Investigations:
Clinical diagnosis
Consider Elbow XRay/MRI/US if the diagnosis is uncertain
Consider nerve conduction study and electromyography if ulnar nerve involvement is suspected in patients with golfer's elbow
Consider Infra-red thermography and laser doppler flowmetry in difficult suspected cases of tennis elbow
Management: