Knee injury - Torn Cartilage 1

Knee injuries are common and easy to diagnose. There are a limited number of problems with a knee, these are relatively easy to diagnose and satisfying to treat

This site is helpful Click here - the site sells knee surgery, if their surgeons are as good as their website, you are in safe hands! worth travelling to Yorkshire.  There is a lot of useful information about knee inuries and knee anatomy

Normal Knee function 
 

The knee does two things - it flexes and straightens and it also rotates, to allow you to twist and turn as you walk and run. It is this rotation that seems to cause the problems, probably because we encase our feet in concrete and walk on flat surfaces most of the time, we rarely turn at the knee, and when we do, it causes problems. Everyone knows they can bend and straighten their knee, but not everyone appreciates that knees can also "rotate". When the rotation goes wrong, you end up with a "twisting injury" of the knee and when extension and flexion go wrong, you have a hyperextension injury or dislocation.

When your knee is straight, it locks in place and cannot rotate but as soon as you start to bend your knee, you can start to turn it. Sit down and bend you knee slightly, move your foot inwards, and outwards - most peoples' knees allow the foot to twist inwards and outwards about 60 degrees (the same amount as a decent sized slice or segment of cake). The knee does not just bend and straighten, it also allows the foot to turn in and out. This movement allows you to walk on rough ground where the surface is uneven and every step is different.

The first step in making a diagnosis is understanding the problem, and if you want to be a doctor, you have to understand the human mind and body. We all have one readily available patient and that is ourselves, learning from ourselves means it sticks in your mind and  you always have a reference point.

Knee injuries

1 - Making a diagnosis.

The Medical History 


The diagnosis is almost always in the history. By understanding what happened and how the patietn felt you  can work out what happened. And once you know what happened, you can work out what has gone wrong, and that is your diagnosis. Knowi what has gone wrong and you can put it right

Occasionally, you cannot find out what has happened, that is, you may  not have a medical history, for example, the patient may have had other major injuries at the same time and just not know what happened to their knee, but this is rare.

It is useful to know whether the injury is a twisting injury, whether the knee hyperextended, or was hit directly.

Today's case is of a man in his late thirties, early forties, not particularly fit, who lost his footing on a path and fell heavily. He landed heavily on his shoulder and hip and twisted his knee. I saw him three months after his original injury. His shoulder was better and his hip was better but his knee had not improved.

And if you are a patient stick to the point - we don't need smart ass patients! The answer to the question "What seems to be the problem?" is not "Well you are the doctor, you tell me" On the other hand saying "It is my cartilage" is equally unhelpful. As a doctor, you want to hear facts and then put the relevant facts together to make a medical history which leads you to the diagnosis.

My patient was helpful, he told me that he had twisted his knee as he fell and that his knee had immediately swollen up a bit, not massively. It was immediately painful and from the time of his accident he could not put weight on that leg without excruciating pain. He saw his GP the next day because he couldn't walk and he didn't want to make a fuss.

The skill in taking a medical history is in being able to tease out what details are medically relevant and which details are just padding.

Accident Prevention

Many people nowadays are extremely unfit, with little sense of balance and even when they do exercise it is in a gym and  not outside in the real world

1 - Keep fit and practice good balance - that means moving around a little more, preferably without keeping your feet in blocks of concrete, otherwise called "Trainers". The weight alone should put you off!

2 - Be more mindful - if you are walking on rough ground - be aware of it!

3 - Make sure you walk straight and your posture is good - this keeps your joints aligned and means when you do fall, you fall "naturally" rather than in a heap and your joints bend where they should and not where you land. When footballer Mike Owen's injured his knee you could see it flapping about before he landed on it and destroyed it. He already had a knee problem and falling on his knee, finished it off.

Injury after minor falls are far too common - I worked with the Fire Service, and because many firefighters are not as fit as they should be, after every major incident there were always injuries. If Hannibal's men had been as unfit as that lot, Hannibal would never have left Carthage, never mind crossed the Alps with a platoon of elephants in the middle of winter and wiped out three Roman armies!

Copyright (c) Dr. Liz Millerwww.lizmiller.info

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Diagnosis and The Medical History

The medical history is the most important part of any medical consultation. Taking a good medical history is key to being a good doctor, and the key to a good medical history is listening to the patient.

The medical history lets your patient explain to you what has happened to them and help you understand their problem. Medical diagnosis is the process of working out what has caused the problem.

Doctors ask a series of questions in order to get the information they need to help make a diagnosis. Sometimes the diagnosis, or cause of the problem is obvious, sometimes it can be hard to find.

Medical information is set out in the following way so as to make sense of large amount of information, some of which is relevant and some of which is not.


The Presenting Complaint
This describes the problem. At this stage open questions are best to allow the patient to use their own words to describe what has happened to them.

History of the Illness
This describes the background to the problem

Other illnesses
What else has the person suffered from?

Treatment history
What treatment has the person had, both for the Presenting complaint and for Other illnesses. All too often treatment can be as damaging as the original condition


Family History
What traits, tendencies and conditions run in the family? What do relatives suffer from?

Social and Occupational History
What work does the patient do or not do? what jobs have they had in the past that may have had a significant impact on their health and wellbeing? What kind of company does the person keep? do they live relatively separate life or are they always surrounded by friends?

and finally a
Systems Inquiry

This is a detailed inquiry into each system of the body, for example, the cardiovascular system, the respiratory system - that is how well do their heart and lungs function?, the genito urinary system, for women a gynaecological history, for men, the male equivalent asking how well their urinary system works and whether their sexual function is satisfactory, mental health and psychiatric symptoms, and gastrointestinal symptoms

These questions are more intimate and need to be handled much more sensitively than general questions. It is important before asking intimate questions that the patient and doctor trust each other. Although many people can quickly build an illusion of trust, if someone is going to trust you with the honest and intimate details of their bodily functions, they know they can trust you or whoever is asking the questions. Most people still feel that doctors can be trusted, although when people rarely see the same doctor twice, such trust is reasonably being eroded.

Future posts will look at each of these questions so as to explain exactly what information is medically required at each point in the process of making a diagnosis. As a medical student, "taking a history" was a ritual, I hated doing it, and couldn't understand why we were doing it. Now it is the most interesting part of the consultation and I understand what I am looking for and why I am doing it.

Recording a medical history

The questions above give a lot of information, which takes effort, experience and discipline to record accurately and in a way that is useful. At all times it helps for the doctor to make clear what they are thinking about and why they have made their decisions and taken action. We were taught as medical students "No notes, no Defence!"

More often patients are given a handout and asked to tick boxes instead of talking to a doctor.

There are good and bad points to a "tick the box" approach

Good points -

"Tick the box" medical histories allow doctors etc to focus on important problems immediately

Useful to screen large numbers of people and record data on a computer.

The recorded data can be manipulated to produce research papers which enable the government and other official bodies to show how much the health of the population is improving year on year

Bad points
Patients tick the wrong box - I have yet to meet anyone who answers "Yes" to the question "Are your bowels normal?", largely because people do not know what is normal bowel function.

"Tick the box" only allow Yes and No answers. It is useful for specific questions, such as "does it hurt everytime you pass urine?" but even this does not allow for the answer "sometimes"

"Tick the box" questions are almost completely useless for broader questions, such as "Are you satisfied with your consultation, town council, or the way the government communicates with you".

"Tick the box" questions do not allow a person to give background to their problem. On the other hand there are only so many hours in the day, and the amount of information that any specific doctor or expert can manage is limited.

Finally, it is easier for people to make a mistake completing a form, compared to answering questions directly. Not because the person is lying but because they may not have understood the form correctly, or because they may be embarrassed or think something is not relevant.

The role of experience

An experienced doctor can take a history quickly because their experience tells them what is important. With time, doctors develop a range of styles and it is important both for doctors to find what type of patients they can help the most. Equally, patients need to find a doctor whom they can trust and whose style suits them.

Traditional diagnosis follows the path

1 - Medical History
2 - Examination, both of the problem area and of the person generally
3 - Differential diagnosis - or list of possible diagnosis
4 - Tests and Investigations - both general and specific tests
and finally
5 - The Diagnosis, that is what has caused the problem
6 - Management plan, this includes specific treatment and general plan of how best to manage this person's medical problems

Nowadays tests and investigations are often more reliable and cheaper than doctors. It is often quicker and more efficient to go straight to the tests and come back and ask further questions depending on the results of the tests.

Even so, the pathway

History -> Examination -> Differential Diagnoses -> Tests and Investigations -> Diagnosis

remains firmly embedded in medical culture. This pathway was started by Galen, over 1,500 years ago and it remains a useful way to organise medical information.

However it cannot be easily computerised! because at each step there are mental processes going on which cannot easily be recorded on a computer. I find written notes more useful than notes on a computer - because I see a page of medical notes as a "picture" which tells me about the doctors' state of mind, their reaction to the patient, as well as the patients responses.

If you are familiar with a doctor's style, it is possible to understand what they meant, where their concerns were and how best to deal with a particular patient. This is harder if not impossible with computerised records. Personally I prefer hand written notes, scanned into a computer at the end of the consultation.

This has been a long post, well done if you have reached the end! no one said studying medicine was easy, but I hope it can also be fun



Copyright (c) Dr. Liz Miller
www.lizmiller.info

Find out more!
Buy the book!

www.moodmapping.com
www.lizmiller.co.uk