CCE-CBD-158

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your diagnosis and differential diagnosis?

• Prompt: Explain your reasoning.
• Prompt: What features support your diagnosis?
• Prompt: What other conditions should be considered?

Q2. Outline your immediate management plan.

• Prompt: What non-pharmacological and pharmacological treatments would you offer?
• Prompt: How would you address work-related issues?

Q3. How would you provide education and advice to Mark about prognosis and expectations?

• Prompt: What advice would you give regarding his return to work and activity modification?

Q4. What long-term management and referral considerations are important for Mark?

• Prompt: When would you refer, and to whom?
• Prompt: What options are available in a rural context?

Q5. Discuss any preventive health issues relevant to Mark.

• Prompt: How would you approach his cardiovascular risk?
• Prompt: Any lifestyle advice?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What is your diagnosis and differential diagnosis?

Diagnosis:

• The most likely diagnosis is lateral epicondylitis (Tennis Elbow).
  • This is supported by gradual onset of lateral elbow pain, worsened by gripping and wrist extension.
  • Pain is localised over the lateral epicondyle and exacerbated by resisted wrist extension, with no trauma history.

Differential Diagnosis:

• Radial tunnel syndrome (radial nerve entrapment): presents similarly but involves more diffuse pain extending into the forearm and may have neurological findings.
• Cervical radiculopathy: may cause referred pain to the elbow, but typically with neck symptoms and/or neurological signs.
• Osteoarthritis of the elbow: rare without a history of trauma or systemic arthritis, but should be considered.
• Posterolateral rotatory instability: uncommon, more often linked to trauma or ligamentous injuries.

Reasoning:

• Pain on resisted wrist extension with tenderness over the lateral epicondyle is highly specific to Tennis Elbow.
• Lack of neurological deficits or neck pain makes cervical radiculopathy less likely.
• No swelling or joint instability on exam decreases the likelihood of alternative diagnoses like osteoarthritis or ligament injury.

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Q2: Outline your immediate management plan.

Non-pharmacological strategies:

• Activity modification: temporarily reduce or avoid activities that exacerbate symptoms, especially repetitive gripping or lifting at work.
• Ergonomic advice: assess workplace practices, suggest modifications to lifting technique, and recommend breaks.
• Ice application: 10–15 minutes, 3–4 times daily, to reduce inflammation.
• Elbow counterforce brace: may reduce strain on the extensor tendons.

Pharmacological management:

• Simple analgesia: start with paracetamol and/or NSAIDs (e.g., ibuprofen), considering GI risks.
• Topical NSAIDs (e.g., diclofenac gel) are a good option to avoid systemic side effects.

Initial rehabilitation:

• Begin stretching and strengthening exercises, focusing on wrist extensors under guidance (possibly via telehealth if local physio unavailable).

Work considerations:

• Discuss modified duties with employer (e.g., lighter duties or fewer repetitive tasks).
• Provide a medical certificate for work modifications as needed.

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Q3: How would you provide education and advice to Mark about prognosis and expectations?

Prognosis:

• Reassure Mark that Tennis Elbow is self-limiting, with most cases resolving in 6–12 months.
• Recurrence is possible without addressing contributing factors (e.g., workplace ergonomics, technique in tennis).

Advice on activity modification:

• Encourage relative rest, not complete immobilisation.
• Recommend avoiding heavy lifting or repetitive wrist movements until pain improves.
• Modify tennis activities: lighter racket, softer grip, less frequent play.

Expectation management:

• Explain that recovery requires consistent adherence to physiotherapy and ergonomic changes.
• Pain may initially increase with exercise but should settle with time.

When to seek further help:

• Persistent or worsening pain after 6–8 weeks of conservative therapy.
• Neurological symptoms (numbness/weakness) or signs of infection/inflammation.

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Q4: What long-term management and referral considerations are important for Mark?

Referral options:

• Physiotherapy: for supervised stretching/strengthening (consider telehealth in rural settings).
• Occupational therapy: workplace ergonomic assessment if available.
• Sport and exercise physician (if elite sports or persistent symptoms).
• Orthopaedic surgeon: consider after 6 months of failed conservative management.

Long-term care:

• Graduated exercise program: build strength and endurance of wrist extensors.
• Education on injury prevention: ergonomic tools, warm-ups before sport, improving tennis technique.

Injections:

• Consider corticosteroid injection if no improvement with conservative measures. Discuss potential short-term benefit but higher long-term recurrence.
• PRP (Platelet-Rich Plasma) is an emerging option but limited evidence and access in rural areas.

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Q5: Discuss any preventive health issues relevant to Mark.

Cardiovascular risk assessment:

• BP is borderline elevated; consider a cardiovascular risk assessment (e.g., absolute CVD risk calculator).
• Discuss lifestyle: diet, weight control (BMI 26.4), physical activity (appropriate for injury recovery).
• Review family history: Father with hypertension, so monitor BP regularly.

Alcohol intake:

• Moderate, within NHMRC guidelines, but reinforce safe drinking limits.

Vaccinations:

• Confirm tetanus is up to date.
• Consider influenza and pneumococcal vaccines, especially if ongoing NSAID use increases infection risk.

Other screening:

• Skin check overdue: recommend routine skin cancer screening, given rural/occupational outdoor exposure.

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SUMMARY OF A COMPETENT ANSWER

• Accurate diagnosis of Tennis Elbow based on clinical findings
• Clear differential diagnosis reasoning
• Comprehensive management plan combining non-pharmacological and pharmacological measures
• Appropriate education on prognosis and recovery timeline
• Consideration of referral pathways in a rural context
• Discussion of preventive health, cardiovascular risk, and lifestyle modifications

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PITFALLS

• Failing to rule out cervical radiculopathy or radial tunnel syndrome
• Over-relying on pharmacological treatment without addressing ergonomics and exercise
• Not considering workplace modifications, risking prolonged recovery
• Ignoring preventive health opportunities (e.g., BP management, lifestyle advice)
• Omitting discussion of referral options in rural practice, including telehealth

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REFERENCES

• RACGP Guidelines
• Murtagh’s General Practice 8th Edition
• Therapeutic Guidelines
• NHMRC Australian Guidelines to Reduce Health Risks from Drinking Alcohol
• Australian Absolute CVD Risk Calculator

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations of healthcare and the full impact of their illness experience on their lives.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets information about health needs and issues.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises hypotheses and diagnoses.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements management plans.
4.2 Prescribes and monitors therapies appropriately.

5. Preventive and Population Health

5.1 Provides care that includes health promotion and illness prevention activities.

6. Professionalism

6.1 Adopts a patient-centred approach to care.

7. General Practice Systems and Regulatory Requirements

7.1 Practices in accordance with relevant policies and guidelines.

8. Procedural Skills

8.1 Performs procedural skills safely.

9. Managing Uncertainty

9.1 Manages uncertainty in diagnosis and management.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and manages patients with potentially serious illness.

12. Rural Health Context (RH)

RH1.1 Provides comprehensive, evidence-based care appropriate to rural settings.

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Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD