A patient with knee pain –Family Medicine approach

Drs K Cheung and TP LamFamily Medicine Unit

Department of MedicineThe University of Hong Kong

Population 7 millionLife expectancy:

Males 78.6 yrs; ranked 1stFemales 84.6; ranked 2nd

2004-05, $30.2 billion (13% of the total government expenditure of $248

billion) spent on public health care.

“Building a Healthy Tomorrow”Health and Medical Development Advisory Committee

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.

“Building a Healthy Tomorrow”Health and Medical Development Advisory Committee

Importance of continuity of care not fully recognisedMore emphasis on prevention neededGate-keeping role needs strengtheningMore collaboration with other professionals required (occupational hazard and psychological problems rarely dealt with fully)

Consequence:

Not able to achieve the best health outcomeTime and resources are at times wasted on unnecessary investigationsMore expenditure

Recommendations:

Promote the family doctor concept

Family Medicine

is a distinct medical discipline which deals specifically with the delivery of primary, continuing, comprehensive and whole-patient care to the individual and the family in their natural environment.

Hong Kong College of Family Physicians

Mr Chan

42 y.o. chef, attends for regular hypertension FU, on natrilix 1 tab dailyBilateral knee pain for 1 year

What further questions would you like to ask ?

Further history

insidious onsetAggravated by walking and prolonged standingNo fever, no malaiseNot affecting other jointsMorning stiffness sometimes, but improved after 15 min of movementNo rash

Social hx: Smoker ,non drinkerLives with wife and a daughter in public housing estateOccup: Dim Sum chef in restaurant, required to stand for > 10 hours / dayThe only bread winner in the familyCannot tolerate the job anymore because knees are too painful

What additional information would you like to have ?

P/E: BP 158/95 p 91Weight 97.3 kg , Height 1.56 m BMI : 39.98 kg/m2Walk with limping gaitBoth knees: not swollen, not hot , no effusion

• Mild genu varum , no muscle wasting• Tenderness around patella , and over both medial and

lateral collateral ligament• Crepitus +• ROM: 0 – 90 deg ( active) , 0- 100 deg( passive)• Both hips and back : NAD

What are his problems ?

Problem list:Knee painObesityinadequate BP controlSmokingLoss of working abilityFinancial constraint

What are the differential diagnoses of his knee pain?

DDx: OsteoarthritisLigament strain/sprainGout/pseudogoutRheumatoid arthritis/ connective tissue diseaseSeptic arthritisReferred pain : e.g. from hip or backBone neoplasia/ metastasis

What is the most likely diagnosis ?

Dx: Osteoarthritis of knees

X ray of both knees: Mild degenerative changes with marginal osteophytes are presentNarrowed joint space are most obvious at the patellofemoral compartments of both kneesNo radio-opaque loose body is seenNo fracture

How are you going to manage this patient?

ManagementWeight reduction advised, group arrangedAdvise for exercise e.g. swimming/aquaticMedication:

Voltaren SR 100 mg daily prnViatril-S 500 mg bd

Referred dietitianReferred physiotherapy and occupational therapyReferred O&TMonitor BPObserve mood

Mr Chan was last seen on 4/11/05Bilateral knee pain : subjectively improving for 60%

Pain adequately controlled by oral analgesics prnStill on physiotherapyWeight: 97.3 kg (4/05) 95.3 kg ( 11/05)BP better controlled after adjusting medication

Psychosocial: Wife finds a job in supermarketHe looks after his daughter at homeEarlier mild depressive symptoms e.g. worthlessness and uselessness gradually improvedLooking forward to recovery and going back to work

Who is in the best position to look after Mr Chan?

“Building a Healthy Tomorrow”

recommends to promote the family doctor concept.

“Building a Healthy Tomorrow”

• A family doctor can be a general practitioner, a family medicine specialist or any other specialist.

• The important point is for the patient to have a continuing relationship with the doctor of his/her choice

• The doctor has the mindset and training of managing problems at the primary care level in a holistic way.

A family doctor can be a general practitioner, a family medicine specialist or any other specialist.

• Misleading to the profession and the public

The family physician is the physician generalist who takes professional responsibility 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

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.

“Building a Healthy Tomorrow”

• At present, the community is not sufficiently 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 corrections of health risk are not often given sufficient emphasis by both doctors and patients.

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

“Training community responsive physicians”who have a population health perspective and are 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 with community health resources, (3) community-oriented primary care skills, and (4) community involvement.

• Brill et al. Academic Medicine 2002

“Building a Healthy Tomorrow”

• Gate keeping role needs strengthening

Approximately 95% of cases in immunocompetent patients, a chronic cough of over 2 months’ duration results from postnasal drip due to conditions of the nose and sinuses, asthma, gastroesophageal reflux disease, chronic bronchitis due to smoking or other irritants, or the use of ACE I.

Irwin & Madison: The diagnosis and treatment of cough. NEJM 2000

“Building a Healthy Tomorrow”

• Psychological problems rarely dealt with fully

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

Mr Chan

42 y.o. chef, attends for regular hypertension FU, on natrilix 1 tab dailyBilateral knee pain for 1 year

NOT A USUAL GRAND ROUND CASE

Problem list:Knee painObesityInadequate BP controlSmokingLoss of working abilityFinancial constraint

ManagementWeight reduction advised, group arrangedAdvise for exercise e.g. swimming/aquaticMedication:

Voltaren SR 100 mg daily prnViatril-S 500 mg bd

Referred dietitianReferred physiotherapy and occupational therapyReferred O&TMonitor BPObserve mood

Who is in the best position to look after Mr Chan?

Ways to have a quality health care service which is sustainable, affordable

and accessible?

The private sector should be able to attract young members of the

profession.