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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2007  |  Volume : 18  |  Issue : 4  |  Page : 663-665
It is "Only My Knee, Doctor" Syndrome


Division of Nephrology, Hypertension and Renal Transplantation, King Abdulaziz Medical City, Riyadh; Clinical Professor of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

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How to cite this article:
Al Sayyari AA. It is "Only My Knee, Doctor" Syndrome. Saudi J Kidney Dis Transpl 2007;18:663-5

How to cite this URL:
Al Sayyari AA. It is "Only My Knee, Doctor" Syndrome. Saudi J Kidney Dis Transpl [serial online] 2007 [cited 2019 Jul 16];18:663-5. Available from: http://www.sjkdt.org/text.asp?2007/18/4/663/36532
Saleh was an 80-year old gentle soul. He lived all his life in a small village in the South. He definitely never visited the capital, Riyadh. He never saw the need, really. But he was eventually persuaded to visit Riyadh by his youngest son, Omar, who joined the army and was now stationed just outside Riyadh. Omar was living with his small family in the army camp. He wanted his father to see his new grandson.

Omar was very happy that his father has agreed to come to his home specially that he has not seen him for a while. He was parti­cularly pleased that his father looked well but he did note that his father was not as agile as before and was having difficulty standing and performing his prayers.
"What is the problem, father" asked Omar as he was walking his father back from the nearby mosque. "Oh, it is only my knee, son." "I will take you tomorrow to the hos­pital in Riyadh to be seen." "There is really no need son. I leant to live with this pain. A couple of paracetamol tablets and I am as fine as rain for hours," said the father. "Nonsense, father. We have a great army hospital with great doctors." Saleh, by his nature was never an argumentative man and became increa­singly so as he aged. So, he did not argue with his son.

Next day found Saleh and his son waiting outside one of the primary care clinics. It seemed too long a wait for Saleh who asked his son if they could leave. "It won't long, father. You know what hospitals are like."

Indeed almost immediately the nurse led them to the doctor. The interview with the primary care doctor took all of five minutes - really too short, thought Omar, considering they had waited for 2 hours to see the doctor. "We just need to do an X­ray of your knee and do a few blood tests, just general tests" said the clearly bored doctor. Saleh never had to give any of his blood for any reason before and the idea of a blood test did not quite appeal to him. "Is it really necessary to do a blood test? It is only my knee, doctor" "No, father;" Omar quickly interjected, "that will be great, doctor. My father had never had general medical check."

As they left the clinic, the father could be heard whispering "But it is only my knee, son."

Next week the doctor informed them that the father had osteoarthritis of his knee but he did mention that tests revealed his kidney function was not quite right. "I will make an appointment for you with our nephrologist" "But doctor, it is really only my knee" Saleh said.

It was a month later that I met Saleh in my clinic. That was about 6 months after I be­came a consultant. I introduced myself as a nephrologist Almost before I finished the introduction Saleh said" I really don't know why I am here, doctor. I have no pain on my kidney and my urination is perfect. You see, it is really just my knee, doctor"

I have already checked his result and noted that his serum creatinine was indeed raised - 140umol/L. The medical history really was not contributory. Neither was the physical examination except for a blood pressure 165/98 and clear evidence of osteoarthritis of the right knee. The urinalysis informed me that there was a trace of blood and 2+ protein. I asked for more blood and urine tests. "I am going to arrange or kidney ultrasound for your kidneys." "But why, doctor?" Saleh asked, clearly irritated for the first time and added "It is just my knee." "This is really a very simple test. It is completely without harm" I said.

The son was again keen that his father should have all the possible tests. After all, God only knows when he will agree to come to Riyadh again.

The kidney ultrasound report informed me that there is mild dilatation of the right kidney calyces and pelvis and suggested that there is an obstruction in the middle of the right ureter. "It appears that you have an obstructed right kidney. I need to bring you in for a day or two to put a tube in your kidney. This way we will relieve your obstruction, improve your kidney function and find out why exactly what is causing the obstruction" I told Saleh and his son. "Does that mean he will need to undergo an operation?" Omar asked. "Not really. This is usually done in the X-ray department by a radiologist. No general anaesthesia is required." "But I don't have any problem with my kidney. It is only just my knee, doctor."

The non argumentative, gentle, docile Saleh had his nephrostomy tube inserted. Within two hours he had to be transferred to the intensive care unit having dropped his blood pressure precipitously and his haemoglobin level dropped by 5 grams/dl.

Of course he received all possible supportive therapy modern medicine could provide. He developed severe septic shock which was irreversible despite all sorts of antibiotics. He also required dialytic support for acute renal failure. Three days later he was dead. His old age worked against him. My lack of sense of proportion also worked against him.

I was told by his son that among his last words were "I told you son, over and over again, it was only my knee."

Saleh's death was painful to me. It still is Saleh has taught me a long-lasting lesson. His voice still echoes in my soul "But it is only my knee, doctor."

This painful episode became a teaching lesson I have imparted to my juniors over the years. I pray to God that it is an ongoing offering for Saleh's soul (sadaqa Jarriah).

I learnt to always respect a patient's old age as working against him/her whenever even a minor procedure is done on him/her. I learnt, more importantly, to use common sense in how far to investigate. I have learnt that the point is not to reach the diagnosis for its own sake but how this will be of benefit to the patient.

I sometime wonder how many patients we have harmed in our pursuit for getting the right diagnosis not to mention the cost of all this. I hope I have also learnt to really "listen to the patient."

It was Sir William Osler over 150 years ago who said "Listen to the patient - he is trying to tell you the diagnosis."

May God bless your soul Saleh, and may you forgive me. My intentions were good as I saw them at the time.

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Correspondence Address:
Abdullah A Al Sayyari
Saudi Center for Organ Transplantation, P.O. Box 27049, Riyadh 11417
Saudi Arabia
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PMID: 17951963

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