patient with knee pain with Family Medicine approach

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 Population 7 million Life expectancy: Males 78.6 yrs; ranked 1st Females 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 recognised  More emphasis on prevention needed  Gate-keeping role needs strengthening  More collaboration with other professionals required (occupational hazard and psychological problems rarely dealt with fully) Consequence:  Not able to achieve the best health outcome  Time and resources are at times wasted on unnecessary investigations  More 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 daily  Bilateral knee pain for 1 year  What further questions would you like to ask ? 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  Social hx: Smoker ,non drinker     Lives with wife and a daughter in public housing estate Occup: Dim Sum chef in restaurant, required to stand for > 10 hours / day The only bread winner in the family Cannot tolerate the job anymore because knees are too painful  What additional information would you like to have ?  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 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 pain Obesity inadequate BP control Smoking Loss of working ability Financial constraint  What are the differential diagnoses of his knee pain?  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  What is the most likely diagnosis ?  Dx: Osteoarthritis of knees  X ray of both knees:     Mild degenerative changes with marginal osteophytes are present Narrowed joint space are most obvious at the patellofemoral compartments of both knees No radio-opaque loose body is seen No fracture  How are you going to manage this patient? 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  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 and uselessness gradually improved Looking 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) communityoriented 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 daily  Bilateral knee pain for 1 year NOT A USUAL GRAND ROUND CASE  Problem list:       Knee pain Obesity Inadequate BP control Smoking Loss of working ability Financial constraint 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 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.