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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Building a Healthy Tomorrow
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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Building a Healthy Tomorrow
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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Building a Healthy Tomorrow
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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Building a Healthy Tomorrow
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.