KneeA Patient With Knee Pain Family Medicine Approach

8/10/2019 KneeA Patient With Knee Pain Family Medicine Approach

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A patient with knee pain

Family Medicine approach

Drs K Cheung and TP Lam

Family Medicine Unit

Department of Medicine

The University of Hong Kong


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Population 7 million

Life expectancy:

Males 78.6 yrs; ranked 1st

Females 84.6; ranked 2nd


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2004-05, $30.2 billion (13% of the total

government expenditure of $248

billion) spent on public health care.


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Building a Healthy TomorrowHealth and Medical Development AdvisoryCommittee

Of every $100 received from tax revenue,

$22 spent on public health care.

If the trend continues, 50% of the total tax

revenue would be spent on health care by

2033.


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Consequence:

Not able to achieve the best health outcome Time and resources are at times wasted on

unnecessary investigations

More expenditure


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Recommendations:

Promote the family doctor concept


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Family Medicine

is a distinct medical discipline which dealsspecifically with the delivery of primary,

continuing, comprehensive and whole-patient

care to the individual and the family in theirnatural environment.

Hong Kong College of Family Physicians


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Mr Chan

42 y.o. chef, attends for regularhypertension FU, on natrilix 1 tab daily

Bilateral knee pain for 1 year


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What further questions would you like toask ?


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Further history

insidious onset

Aggravated by walking and prolonged standing

No fever, no malaise Not affecting other joints

Morning stiffness sometimes, but improved after

15 min of movement

No rash


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Social hx: Smoker ,non drinker Lives with wife and a daughter in public

housing estate

Occup: Dim Sum chef in restaurant, required tostand for > 10 hours / day

The only bread winner in the family

Cannot tolerate the job anymore because knees

are too painful


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What additional information would you liketo have ?


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P/E: BP 158/95 p 91

Weight 97.3 kg , Height 1.56 m

BMI : 39.98 kg/m2

Walk with limping gait Both knees: not swollen, not hot , no effusion

Mild genu varum , no muscle wasting

Tenderness around patella , and over both medial andlateral collateral ligament

Crepitus +

ROM: 0 90 deg ( active) , 0- 100 deg( passive) Both hips and back : NAD


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What are his problems ?


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Problem list:

Knee pain Obesity

inadequate BP control

Smoking

Loss of working ability

Financial constraint


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What are the differential diagnoses of hisknee pain?


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DDx: Osteoarthritis

Ligament strain/sprain

Gout/pseudogout

Rheumatoid arthritis/ connective tissue disease

Septic arthritis Referred pain : e.g. from hip or back

Bone neoplasia/ metastasis


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What is the most likely diagnosis ?

Dx: Osteoarthritis of knees


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X ray of both knees: Mild degenerative changes with marginal

osteophytes are present

Narrowed joint space are most obvious at thepatellofemoral compartments of both knees

No radio-opaque loose body is seen

No fracture


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How are you going to manage this patient?


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Management Weight reduction advised, group arranged

Advise for exercise e.g. swimming/aquatic

Medication:

Voltaren SR 100 mg daily prn

Viatril-S 500 mg bd

Referred dietitian

Referred physiotherapy and occupational therapy

Referred O&T Monitor BP

Observe mood


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Mr Chan was last seen on 4/11/05

Bilateral knee pain : subjectively improving for 60% Pain adequately controlled by oral analgesics prn

Still on physiotherapy

Weight: 97.3 kg (4/05) 95.3 kg ( 11/05) BP better controlled after adjusting medication

Psychosocial:

Wife finds a job in supermarket He looks after his daughter at home

Earlier mild depressive symptoms e.g. worthlessness anduselessness gradually improved

Looking forward to recovery and going back to work


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Who is in the best position to look

after Mr Chan?


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Building a Healthy Tomorrow

recommends to promote the family doctorconcept.


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A family doctor can be a generalpractitioner, a family medicine specialist orany other specialist.

The important point is for the patient tohave a continuing relationship with thedoctor of his/her choice

The doctor has the mindset and training ofmanaging problems at the primary carelevel in a holistic way.


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A family doctor can be a general

practitioner, a family medicinespecialist or any other specialist.

Misleading to the profession and the public


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The family physician is the physician

generalist who takes professionalresponsibility for the comprehensive primary

care of unselected patients with

undifferentiated problems and who is

committed to the person regardless of age,

gender , illness, or organ system.

Phillips & Haynes Family Medicine 2001


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Primary care

Is the first contact of health services Some specialists may provide primary care

but their scope of service is limited to

particular groups of patients or diseases.

They are not family doctors.


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At present, the community is notsufficiently aware of the merit of and

opportunities for receiving preventive

services in primary medical care.

Preventive services like screening for risk

factors, and assessments and correctionsof health risk are not often given sufficient

emphasis by both doctors and patients.


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1996 US Preventive Services Task Force

issued guidelines that primary care physicians

have the responsibility to deliver preventive

care service. However, actual adoption of the

guidelines into practice has been slow.A qualitative study shows that physicians

own perceived role in daily practice was a

significant barrier to primary preventive care.

Mirand et al. BMC Public Health 2003


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Training community responsive physicians

who have a population health perspective andare prevention orientated can be achieved by

a longitudinal curriculum designed to teach

the four domains of physician-community

involvement: (1) insight into sociocultural

aspects of patient care, (2) familiarity withcommunity health resources, (3) community-

oriented primary care skills, and (4)

community involvement.

Brill et al. Academic Medicine 2002


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Gate keeping role needs strengthening


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Approximately 95% of cases in

immunocompetent patients, a chronic coughof over 2 months duration results from

postnasal drip due to conditions of the nose

and sinuses, asthma, gastroesophageal refluxdisease, chronic bronchitis due to smoking or

other irritants, or the use of ACE I.

Irwin & Madison: The diagnosis andtreatment of cough. NEJM 2000


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Psychological problems rarely dealt withfully


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Among patients with chronic

diseases who had an individual

physician as their usual source of

care, family physicians managed

62% of anxiety/depression

Jimbo Keio J Med 2004


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Mr Chan

42 y.o. chef, attends for regular hypertensionFU, on natrilix 1 tab daily

Bilateral knee pain for 1 year

NOT A USUAL GRAND ROUND CASE


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Problem list:

Knee pain

Obesity

Inadequate BP control

Smoking Loss of working ability

Financial constraint


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Management Weight reduction advised, group arranged

Advise for exercise e.g. swimming/aquatic

Medication:

Voltaren SR 100 mg daily prn

Viatril-S 500 mg bd

Referred dietitian

Referred physiotherapy and occupational therapy

Referred O&T Monitor BP

Observe mood


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Who is in the best position to look

after Mr Chan?


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Ways to have a quality health care

service which is sustainable, affordableand accessible?


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The private sector should be able to

attract young members of theprofession.

KneeA Patient With Knee Pain Family Medicine Approach

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