Diagnosis and Assessment: Patient Presenting Knee Pain

Diagnosis and Assessment: Patient Presenting Knee Pain Stephen Chiang Presenting Complaint Mr X is a 72 year old man who presented to the GP clinic with worsening right knee pain for the past 3 weeks. History of Presenting Complaint Pain has worsened over the past 3 weeks. Pain is around the patella with no radiation of pain. Described as a constant dull ache that worsens at the end of the day after activities. Not relieved by any pain medication. Previous trial on NSAIDs and panadolosteo. Pain and movement does not improve during the day. Denies any morning stiffness. Complains of knee being swollen and restricting the range of movement. Denies any locking or catching of the knees. Pain has restricted his movement causing him to lose balance. No history of falls. Denies any recent injury or trauma to the knee. Past Medical History Abdominal aortic aneurysm2014 Pulmonary Fibrosis2014 COPD infective exacerbation2012 GORD Medications Metoprolol 50mg Panadol Osteo SR665mg Vytorin10mg/20mg Rabeprazole10mg Prednisolone25mg Allergies/ Adverse Reactions Penicillins skin rash Immunisation -VAXIGRIP provided Family History nil known Social History Lives alone in Collie. No support services required. Non-smoker. 1 standard drink several times a week. Limited physical activities No history of substance abuse Examination Pleasant looking elderly man. Not in any obvious distress. Alert and oriented to time, place and person. Good mobility Vitals BP 155/88 mmHg, HR 78bpm and regular, RR 17, afebrile Cardiovascular Heart sound dual, nil added. JVP not elevated, all peripheral pulses are palpable Respiratory symmetrical rise and fall of chest with respiration, bibasal crepitations heard, no wheeze. Not in respiratory distress Abdomen – no scars noted, abdomen soft, non tender, bowel sound present Knee – no deformities, swelling or muscle wasting noted. No obvious signs of effusion. Bulge test and patellar tap negative. No erythema and not warm. Crepitations heard with movement of knee. Not tender on palpation. Full range of movement with active and passive movement with pain. (extension, flexion, rotation). Ligament stability test NAD Investigations Ordered Bilateral Knee X-ray Murtagh’s Diagnostic Model Factors in initial history / examination supporting diagnosis Factors in initial history / examination NOT supporting diagnosis Factors in subsequent history / examination / investigation influencing diagnosis PROBABLE diagnosis Osteoarthritis Swelling of the knee Age, Chronic Pain, Asymmetrical, Weight bearing joint, Worse with movement, Crepitus on movement Ligament strains No previous injuries or trauma Asymmetrical knee pain Serious disorders not to miss Neoplasia primary in bone metastases No night sweats, no weight loss, no indication of previous X-ray constant ache day and night Severe infections septic arthritis No fever, no redness, warmth or swelling of joint. No hx of trauma Vascular disorders deep venous thrombosis superficial thrombophlebitis No long periods of immobilisation No previous hx of clots Nil tenderness around muscle unilateral pain Pitfalls Gout/ pseudogout No previous hx of gout Referred pain back or hip Denies any pain of the back and hip Masquerades Diabetes No polyuria, polydipsia, Normal Fasting BSL Spinal dysfunction Another agenda? Depression Lives on his own, poor supportive relationship, Management Plan (Whole person) 1. Knee pain RICE therapy, Weight loss knee X-ray Adequate pain management Referral to orthopaedic surgeons for review Referral to physiotherapist – strengthen quadriceps 2. Pulmonary Fibrosis/ COPD Prevent infective exacerbations Continue follow up with respiratory physicians in Perth Yearly influenza vaccination/ 5 yearly pneumovax Referral to chest physiotherapist 3. Abdominal Aortic Aneurysm Yearly monitoring of AAA Continue follow up with vascular surgeon in Perth Preventative Health Activities 1. Nutrition – patient education on maintaining healthy diet. Referral to dietician 2. Weight – review 6 monthly to ensure BMI 2 3. Physical activity – education on appropriate exercise routine. Referral to physiotherapist 4. Alcohol intake – reduction of alcohol intake 5. General – monitor BP 6 monthly, yearly monitoring of FBC UEC Lipid profile 6. Cancer screening – colorectal every 2 years 7. Vision, hearing and fall risk assessment Unable to follow up with patient as patient returned to GP in Collie while I was based in Bunbury. No access to patient’s result from Bunbury. Clinical Evidence Base In patients with osteoarthritis of the knee (OAK), is intra-articular steroid injection more effective compared to other pharmacological treatment such as NSAIDs and glucosamine in terms of efficacy and managing pain? Osteoarthritis is the most common joint disease affecting adults older than 65 years old. In Australia alone, osteoarthritis affects more than 1.3million adults.1 Osteoarthritis can significantly impact the quality of life because of the restriction in mobility caused by the pain. In osteoarthritis of the knee (OAK), the main form of treatment remains partial or total knee replacement.4 However, there are still a large number of patients who are unable to undergo such intervention. In such patients, treatments are limited to safer alternatives such as NSAIDs, opioids, glucosamine supplements and intra-articular steroid injection. The OneSearch UWA library database was searched and keywords used were â€Å"osteoarthritis†, â€Å"knee†, â€Å"pharmacological†, â€Å"NSAIDs†, â€Å"steroid†. Other related terms were included in the search. One study was identified, â€Å"short term efficacy of pharmacotherapeutic interventions in osteoarthritis knee pain by Jan Magnus Bjordal, Atle Klovning, Anne Elisabeth Ljunggren and Lars Slordal.2 The study is a meta-analysis of randomised placebo controlled trials with a sample study size of 14,060 patients in 63 trials measuring pain intensity within 4 weeks of treatment and at 8-12 weeks follow up using the visual analogue scale (VAS).2 Results Within 4 weeks oral NSAIDs, pain relief measured 10.2mm on the VAS (95% CI8.8-11.6). Steroid injection showed 14.5mm (95% CI9.7-19.2), paracetamol 3.0mm (95% CI1.4-4.7), glucosamine 4.7mm (95% CI 0.3-9.1), chondroitin sulphate 3.7mm (95% CI0.3-7.0).2 8-12 weeks follow up – oral NSAIDs and steroid injection showed decline in efficacy 9.8mm. Paracetamol did not show change in efficacy. Glucosamine showed 3.8mm efficacy and chondroitin sulphate showed an increase in efficacy of 10.6mm.2 Strength and Weaknesses of this study: 1. Level 1 evidence based on NHMRC 2. Outcome and methods of measure was clearly explained and defined. 3. Inclusion and exclusion criteria were clear. 1. Measuring of pain intensity with the visual analogue scale (VAS) is very subjective. 2. Bias in terms of NSAIDs users selection in certain trials. 3. Comparing different treatment options by assessing separate meta-analyses for each treatment may have different baseline data and prognostic factors. 4. All steroid injection trials were performed in a fixed setting limiting their application into primary care context. Duration of trial of 4 weeks may be too short to analyse efficacy of some treatments. Findings showed that there is better short term pain relieve when using steroid injection compared to the other treatment options. However, steroid and oral NSAIDs have the same efficacy in long term. Chondroitin sulphate also showed a minimal pain relieve in the long term. Application – This study was done in Norway and it showed that there is minimal pain relieve by using current treatment options such as steroid injections, oral NSAIDs and supplements. Further studies should be performed to compare patients in Australia. Patients should be educated about the efficacy of such pharmacological treatment to lower their expectations. We should start reconsidering the role of these treatments in future pain management of osteoarthritis. This patient was started on many treatments that did not offer any pain relieve that corresponds to the results of the study stated above. Hence, he was referred to an orthopaedic surgeon for further review and management plan. References 1. Australian Institute of Health and Welfare. A Picture of Osteoarthritis.Department of Health and AgeingOctober 2007; Arthritis Series Number 5 2. Jan Magnus Bjordal a,*, Atle Klovning a , Anne Elisabeth Ljunggren a , Lars Slà ¸rdal b. Short-term efficacy of pharmacotherapeutic interventions in osteoarthritic knee pain: A meta-analysis of randomised placebo-controlled trials.European Journal of Pain8 May 2006; 11, 125-138 3. Carlos J Lozada, MD Director of Rheumatology Fellowship Training Program, Professor of Clinical Medicine, Department of Medicine, Division of Rheumatology and Immunology, University of Miami, Leonard M Miller School of Medicine.Osteoarthritis. http://emedicine.medscape.com/article/330487-overview (accessed 17/06/2015) 4. S.P. Krishnana, , J.A. Skinnerb. Novel treatments for early osteoarthritis of the knee.Current OrthopaedicsDecember 2005; Volume 19(Issue 6), Pages 407-414

Kfc in China Essay

Is Tony Wang correct in assuming that China is an ideal market for KFC? Should KFC be pursuing the Chinese market at the present time? Considering China as a strategic location was based from a SWOT analysis. Availability of Supply (Strength) There is ready access of quality poultry in the major metropolitan areas such as Shanghai, Guangzhou and Beijing. Poultry industry is one of the top priority categories in China’s agriculture modernization and it is highly encourage by the government. Thus, the company can ensure a reliable supply of high quality chicken. Low Competitive Pressure (Strength) Potential competitors such as MacDonald’s face major barriers to enter the China market due to poor beef supply while KFC, aside from availability of high quality chicken supply, has the clear advantage since its main product-chicken- is eaten almost everywhere in the world. Furthermore, chicken is already familiar in China and even much cheaper. Company’s Control Measures (Strength) KFC s control mechanisms are designed to ensure standard levels of quality, service and cleanliness (QSC) at all of the restaurant’s chain stores. This fits the positive image in Asia of American fast food restaurants as famous, air-conditioned, and hygienic. Product Consumption (Strength) Chicken has long been regarded as a kind of nutritious food, which is especially good for the patients, the elders and children. An increase in health conscious consumers also raises the consumption of chicken. Moreover, chicken is a more popular meal than hamburgers in most Asian countries and KFC has the opportunity to offer an American style experience that is different from most other food establishments. Drawing Area (Opportunity) In late 1978, China began implementing economic reforms to modernize its economy by lessening the government’s control of the economy. This reform referred as a socialist market economy boosted the national wealth and the consequent increase in individual’s income has led to steady changes in Chinese consumer patterns prevalent in pre-Mao era. As the world’s most populous nation with over 1 billion inhabitants, the potential size and growth for KFC makes the Chinese market very attractive. Not to mention, the possibility of establishing the first Western style fast-food operation in China as a historic opportunity for the company. Scarce Human Resources (Weakness) Managerial resources are precious because of the scarcity of Chinese-speaking KFC managers. There are also possible conflicts between KFC-appointed managers and local employees. Lack of Local connections (Weakness) Pioneering in the fast-food field would find KFC very difficult to form local and personal networks between businesses and government agencies, which are crucial in providing access to the local market and domestic suppliers and eventually, to the company’s success. Entering into a relatively unknown market, KFC, as a new entrant will have to get in touch with the local business customs and laws as well as with knowledge of culture and language. Quality of Government (Threat) A communist government with strict foreign investment laws rules China. Setting up here requires heavy investment expenses and high levels of resource commitment. The risk of domestication measures may be imposed by the host government, often leading to major financial losses for the foreign investor. Overcoming Threats and Weaknesses KFC has three options of entering the China market thru, namely: Franchising, Wholly owned subsidiary and Joint venture. The traditional franchising strategy, in markets where political risk and cultural unfamiliarity exists, certainly would reduce financial risks. However, KFC had already encountered problems in the past with the aligning of corporate planning with the franchisee’s short-term focus on profitability. In addition, KFC will be pioneering in the fast-food service and thus needs to be highly sensitive to cultural demands. In such case, franchising is not feasible. On the other hand, a wholly owned subsidiary would rely upon total control over competitive advantages and ensures complete operational and strategic control. It also involves high financial risk and little country-level flexibility and responsiveness. This option is not recommended. Entering into a joint venture is highly recommended. Such an international business strategy will attempt to solve many logistics problems such as access to good quality chicken and other supplies, ease the access to Chinese market, share risk with a local entity, utilize ways to cut bureaucratic red-tape and finally, serve as a sign of commitment to the host government increasing goodwill. In addition, due to the complexity of many barriers to entry into China, a potential partner with sufficient contacts or networks with the government officials may smoothen the process of setting-up operations in the country. The potential joint-venture partner should be large, well established, provide excellent distribution channels and have personal network access to government officials. It is recommended that a partner be found by backward integration- that is, a good domestic supplier of poultry. In order to ensure total commitment, the set-up of the joint venture should be with KFC as the dominant partner. This way, cost, quality and strategic control measures are maintained. By building on each partner’s core competencies, knowledge, and efficiencies, a mutually beneficial synergy effect could be achieved as a result of joint venture activities. For instance, the local partner can learn from KFC how to produce a better product at a lower cost and further expand on its new competitive positioning. KFC, on the other hand, can maintain quality supply, which is critical to its success. RECOMMENDATION: The Chinese market represents a great opportunity for KFC where Tony Wang is correct in his assumptions. By finding an appropriate domestic business partner via backward integration, it is possible to further build on opportunities and significantly reduce risk throughout financial sharing, cultural sensitivity and favorable treatment from the host government. KFC should start pursuing this strategy at the present time and develop a coherent international strategy linking the China operations with the other markets. Which of the three cities being investigated should the company choose if it decides to enter China? The capital city, Beijing, is recommended as the preferred location for KFC’s entry into the Chinese market. Beijing is the center for most political activities and provides the necessary access to government agencies and business regulatory bodies. Also, it has a large population of nearly 9 million inhabitants. The numerous universities located in the city contributes to more affluent and educated people that may make them more open to foreign ideas including Western fast-food. More importantly, plenty of Western tourists are attracted to Beijing’s many tourist attractions, increasing the potential for generating foreign currency sales. Furthermore, supplies of poultry are readily available. Beijing can serve as the initial platform of KFC’s operations and later expand into other potential areas such as Shanghai and Guangzhou. One or two initial outlets should be set-up to get an insight of how KFC will be perceived in the Chinese capital. Both dine-in and take-out facilities much in line with most KFC’s international operations ought to be offered in large, clean and well-serviced outlets to cater for the customers with above-average disposable incomes. In order to serve large numbers of customers due to the sheer size of the population, the right cultural fit of the business restaurants must be highly functional and effective. Special menu-substitutions may also have to be facilitated to cater to consumers taste for traditional Chinese meals. Lessons Learned Capitalizing on Strengths and Opportunities In the initial period of KFC’s entry into China market, few of Chinese onsumers were really impressed with the food itself since the country is known to have the best culinary culture in the world. Instead, they were more fascinated with the eating experience: the encounter with friendly employees, quick service, spotless floors climate-controlled and brightly-lit dining areas, and smiling Colonel Sanders standing in front of the main gate. Having experienced the initial surprises brought by a never-seen western lifestyle, Chinese consumers have gradually calmed down and their consumption attitudes towards foreign products are getting more reasonable. Since Chinese people are more concerned with the nutrition and tastes of the fast food, KFC taken advantage of McDonald’s. By offering poultry food that is more acceptable to Chinese people compared with beef, have taken consumers needs and competition with other brands into account. Knowing the market The most prominent success of KFC in China is not only the outcome of KFC’s persistent tenets â€Å"quality, service and cleanliness† but also the achievements of its keen perception of cross-cultural marketing and its understanding of Chinese culture. Based on its scrutiny and adoption of Chinese traditional culinary arts, KFC has developed a series of products that are specially designed for the tastes of Chinese consumers. Moreover, in purpose of maintaining its image of a U. S. brand and keeping consistent with its globalization strategy, most of KFC s Chinese side dishes are defined as short-term products and would be replaced by new products. KFC’s product strategies are categorized into two aspects: 1)To meet consumers desire for novelty by introducing western style products like Mexican Chicken Warp and New Orleans Barbeque Wings. This means can satisfy young consumers who are more open and acceptable to the foreign flavors. 2)To cater to consumers taste for traditional Chinese meal by offering Chinese style fast food from time to time, say, Old Beijing Chicken Roll, a wrap modeled after the way Peking duck is served, but with fried chicken inside and accompanied with green onions and hoi sin sauce, and Sichuan Spicy Chicken which absorbs the spicy flavor of Sichuan dish. This measure can attract older consumers who are fond of Chinese food and in need of the convenience of fast food service as well.

What Ways Did Pastoral Societies Differ From Their...

1) In what ways did pastoral societies differ from their agricultural counterparts? Pastoral societies differed from their agricultural because pastoral societies supported less people, since they had generally less productive economies, and the lived in scattered areas. They also generally offered women higher status, fewer restrictions, and a greater role in public life because they were needed, since people did not tend to specialize in things. Pastoral societies were also far more mobile, whereas in agricultural societies, people would have large populations because of their environment and their ability to grow food. They also lived in one area, and had had people who specialized in different things which brought down the status of women. 2) In what ways did pastoral societies interact with their agricultural neighbor’s? Pastoral socities interacted with their agricultural neighbor’s economically, because nomads needed access to the food, and other luxury items that they could only get from their agricultural neighbor’s. They also interacted politically and militarily, because pastoral people come together sometimes, to trade, or raid aagrcicultural societies. Pastoral societies also interacted culturally with their agricultural neighbor’s. Members of some pastoral socities were known to have adopted religions of their agricultural neighbors, such as Judaism, Buddhism, Christianity, Islam, and even Manichaeism, which included different elements of Zoroastrianism,Show MoreRelatedChapter 13 Margin Review Questions2220 Words   |  9 PagesIs there value in asking this kind of â€Å"what if† or counterfactual question? Or is it an irrelevant waste of time? 2. How does this chapter distinguish among the various kinds of societies that comprised the world of the fifteenth century? Are there other ways of categorizing the worlds peoples that might work as well or better? 3. What would surprise a knowledgeable observer from 500 C.E., were he or she to make a global tour in the fifteenth century? What features of that earlier world mightRead MoreMoney and Its Functions in Modern Economy8915 Words   |  36 Pagesrole of money. 22 Conclusion. 25 The list of references. 26 Introduction Money is one of the greatest inventions of a human thought. Perhaps, the whole structure of today’s economy is predetermined by the existence of money. But when did money occur and what was the reason for its occurrence? Money is a public institution, which increases wealth buy reducing the cost of exchange and contributing to greater specialization in occupation o, according to ones comparative advantage. Money appearedRead MoreTrade Unions in Malawi13087 Words   |  53 PagesTRADE UNIONS FREDRICK BANDA INTRODUCTION This chapter examines democracy from another angle that is the way democracy is rooted in the collective action of citizens outside of the formal institutions of democratic government. The trade union movement in Malawi dates as far back as the end of the Second World War. It has undergone a process of growth, decline and growth again over the past seven decades or so. To understand how trade unionism has developed in any country, we need to considerRead MoreRastafarian79520 Words   |  319 PagesRastafari This page intentionally left blank Rastafari From Outcasts to Culture Bearers Ennis Barrington Edmonds 2003 198 Madison Avenue, New York, New York 10016 Oxford University Press is a department of the University of Oxford It furthers the Universitys objective of excellence in research, scholarship, and education by publishing worldwide in Oxford New York Auckland Bangkok Buenos Aires Cape Town Chennai Dar es Salaam Delhi Hong Kong Istanbul Karachi Kolkata KualaRead MoreFundamentals of Hrm263904 Words   |  1056 Pagessave money From multiple study paths, to self-assessment, to a wealth of interactive visual and audio resources, WileyPLUS gives you everything you need to personalize the teaching and learning experience.  » F i n d o u t h ow t o M A K E I T YO U R S  » www.wileyplus.com ALL THE HELP, RESOURCES, AND PERSONAL SUPPORT YOU AND YOUR STUDENTS NEED! 2-Minute Tutorials and all of the resources you your students need to get started www.wileyplus.com/firstday Student support from an experienced

Humes Wide Construal of the Virtues Essay - 3865 Words

Humes Wide Construal of the Virtues ABSTRACT: The term virtue has traditionally been used to designate morally good character traits such as benevolence, charity, honesty, wisdom, and honor. Although ethicists do not commonly offer a definitive list of virtues, the number of virtues discussed is often short and their moral significance is clear. Humes analysis of the virtues departs from this tradition both in terms of the quantity of virtues discussed and their obvious moral significance. A conservative estimate of the various virtues Hume refers to in his moral writings would put the number at around seventy, with the more untraditional ones including wit, good manners, and dialog. Unsurprisingly, Humes critics have attacked†¦show more content†¦Humes analysis of the virtues departs from this tradition both in terms of the quantity of virtues he discusses and their obvious moral significance. A conservative estimate of the various virtues Hume refers to in his moral writings would put the number at around se venty, with the more untraditional ones including wit, good manners, and dialog. Not surprisingly, Humes critics, past and present, have attacked him for making nonsense of the concept of virtue by construing it so widely. For example, Philippa Foot argues that, ... one does not find in Hume an account of the difference between skills or talents and virtues and he even says that there is no reason to consider virtue as something distinct. I suppose it is partly due to Humes influence that this important topic, which was splendidly treated by Aristotle and Aquinas, is hardly discussed by modern moral philosophers. (1) Hume was aware that his broad understanding of virtue was controversial and he offered several defenses for his position. After presenting the neglected attacks of his contemporaries, and Humes response, I will argue that a problem remains: by failing to distinguish between degrees of virtue, Hume also fails to distinguish between degrees of vice. But, some vices such as malevolence clearly deserve punishment whereas other alleged vices such as uncleanliness clearly do not. Thus, for adequate retribution, a distinction is needed between important and less