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

z

z
z

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
z
z
z
z

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:
z
z
z
z
z
z

Knee pain
Obesity
inadequate BP control
Smoking
Loss of working ability
Financial constraint

 What are the differential diagnoses of his

knee pain?

 DDx:
z
z
z
z
z
z
z

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:

z

z
z

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:
z
z

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%
z
z
z
z

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:
z
z
z

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:
z
z
z
z
z
z

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:
z
z

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.