Differential Diagnosis Of Joint Disorders

Differential Diagnosis Of Joint DisordersDisorders of joint is one of the common problem a family physician comes across. Here is a list of differential diagnosis for joint disorders with brief description of each disorder:

1. Congenital Causes

– Achondroplasia: Premature osteoarthritis may occur in achondroplasia.

– Ehlers-Danlos syndrome: a genetic disorder of connective tissues in which patients have hypermobile joints and hyperextensible skin. they may present with joint subluxation, dislocations and swelling due to effusions.

– Marfan Syndrome: Patients have generalized joint laxityand present with joint pain and swelling due to effusions.

– Osteogenesis Imperfecta: Patients have brittle bones that lead to easy joint dislocations.

2. Accquired Causes

– Infective:

  • Septic or pyogenic arthritis usually present as a monoarthritis with a red , swollen, painful, immobile joint. Usually a single joint is involved.
  • Viral arthritis may occur following viral illness like rubella, mumps, hepatitis etc.
  • In rheumatic fever which usually follows a streptococcal infection. There is a migratory poly arthritis together with carditis, erythematous skin lesions and sub cutaneous nodules.

– Inflammatory:

  • Rheumatoid arthritis presents initially with swollen, painful, stiff hands and feet. Later characteristic deformities develop. Most commonly swelling is seen at metacarpophalangeal joints.
  • Psoriatic arthropathy usually follows several years after skin lesions.
  • Reiter’s disease may present with arthritis in a single or few joints. There will be a history of sexual contact, urethritis and conjunctivitis.
  • Ankylosing spondylitis presents in young males and initially presents with morning stiffness in the spine. The sacroilliac joints are involved. Continue reading “Differential Diagnosis Of Joint Disorders”

Introduction To SLE

Introduction To SLEDefinition

Systemic lupus erythematosus (SLE) is a chronic inflammatory autoimmune disorder that affects the connective tissues. SLE is characterized by recurring remissions and exacerbations, which are especially common during the spring and summer.


It strikes women 8 times as often as it does men, increasing to 15 times as often during childbearing years.

EtiologyThe direct cause is unknown but it can be predisposed by certain factors

Predisposing factors

Physical or mental stress
Streptococcal or viral infections
Exposure to sunlight or ultraviolet light
Abnormal estrogen metabolism
Drugs, including procainamide, hydralazine, anticonvulsants; less commonly, penicillins, sulfa drugs, oral contraceptives


Autoimmunity is believed to be the prime mechanism in SLE. The body produces antibodies against components of its own cells, such as the antinuclear antibody (ANA), and immune complex disease follows. Patients with SLE may produce antibodies against many different tissue components, such as red blood cells (RBCs), neutrophils, platelets, lymphocytes, or almost any organ or tissue in the body. Continue reading “Introduction To SLE”

A Brief Summary Of Insomnia


Insomnia is defined as inadequate or poor-quality sleep characterized by one or more of the following: difficulty falling asleep, difficulty maintaining sleep, waking up too early in the morning, or sleep that is not refreshing. Insomnia also involves daytime consequences such as fatigue, difficulty concentrating, and irritability.

Acute Insomnia

Periods of insomnia lasting between 1 night and a few weeks are defined as acute insomnia.

Chronic Insomnia

Chronic insomnia refers to sleep difficulty occurring at least 3 nights per week for 1 month or more.


Insomnia may be associated with specific sleep disorders, including restless legs syndrome, periodic limb movement disorder, sleep apnea, and circadian rhythm sleep disorders.

  • Restless legs syndrome is characterized by unpleasant sensations in the legs or feet that are temporarily relieved by movement. Symptoms are worse in the evening, especially when a person is lying down and remaining still. The sensations cause difficulty falling asleep and are often accompanied by periodic limb movements.
  • Periodic limb movement disorder is characterized by bilateral repeated and rhythmic, small-amplitude jerking or twitching movements in the lower extremities and, less frequently, in the arms. These movements occur every 20 to 90 seconds and can lead to awakenings, which are usually not noticed by the patient. Often the patient reports that sleep is not refreshing. In many cases, the bed partner is more likely to report the movement problem.
  • Obstructive sleep apnea is most commonly associated with snoring, daytime sleepiness and obesity but occasionally presents with insomnia. Continue reading “A Brief Summary Of Insomnia”

Approach To Elderly Patient

Family physicians are responsible for caring increasing number of elderly patients.Older patients have co morbidities, functional, psychological and social problems that need to be considered by the the family physician.

Goals of Geriatric Assessment

1. Focus on preventive medicine rather than acute medicine.
2. Focus on improving or maintaining functional ability and not necessarily on a “cure.”
3. Provide a long-term solution for “difficult to manage” patients with multiple physicians, recurrent emergency department visits, and hospital admissions with poor follow-up.
4. Aid in the diagnosis of health-related problems.
5. Develop plans for treatment and follow-up care.
6. Establish plans for coordination of care.
7. Determine the need and site of long-term care as appropriate.
8. Determine optimal use of health care resources.
9. Prevent readmission into the hospital.

The geriatric assessment can be divided into four categories: medical, functional, psychological, and social.

Medical Assessment 

The medical assessment includes a review of the patient’s medical record, medication history (past and present), and a nutritional evaluation. On average, elderly patients have four to six diagnosable disorders, which may require the use of several medications. One disorder can affect another, and in turn a collective deterioration of both can lead to overall poor outcomes.

During the medical assessment, the review of systems should be completed with special emphasis on sensory impairment, dentition, mood, memory, urinary symptoms, falls, nutrition, and pain.

Hearing loss is the third most prevalent chronic condition in elderly people, after hypertension and arthritis, and its prevalence and severity increase with age.

Review of the patient’s current medication list, including over-the-counter (OTC) medications, as well as any drug allergies or previous adverse drug reactions, is a necessary component of the geriatric assessment. Polypharmacy is defined as taking more than four medications and is an independent risk factor for both delirium and falls. Patients or family members should be asked to bring in all the patient’s prescription medications and supplements at the initial visit and periodically thereafter. Continue reading “Approach To Elderly Patient”

Introduction To Bradycardia

BradycardiaBradycardia is defined as heart rate of less than 60 beats per minute.

Clinical Presentation

  • Often patients do not have any symptoms and it is detected as an incidental finding on routine physical examination.
  • Some patients may present with faints or blackouts, drop attacks, dizziness, breathlessness or lack of energy.
  • Findings on examination are slow pulse rate; normal or low BP with or without an evedence of secondary heart failure.
  • Sometimes there may be symptoms and signs of any associated disease that may help in diagnosing the cause of bradycardia.


A patient presenting with bradycardia with or without any associated symptoms should have following basic investigations done:

  • ECG: Ambulatory ECG may help with diagnosis of intermittent bradycardia as in sick sinus syndrome.
  • Blood tests: Thyroid function tests, Complete blood count, ESR, Urea, creatinine, LFTs, and digoxin levels (if pt taking digoxin).

Types Of Bradycardia

1. Sinus Bradycardia

There is a constant bradycardia and ECG shows normal P waves and P-R interval is <0.2 sec. Causes of sinus bradycardia are:

Causes Of Dysphagia

Dysphagia means difficulty in swallowing. It may or may not be associated with pain on swallowing. Dysphagia may be associated with ingestion of solids or liquids or both. It is important to know different medical conditions that lead to dysphagia and a simple list is given here:

Causes Of Dysphagia


  • Oseophageal atresia


1.In the lumen

  • Food bolus
  • Foreign body

2. In the wall

  • Inflammatory stricture
  • Gastroesopahgeal reflux
  • Caustic stricture
  • Candidiasis
  • Achlasia
  • Carcinoma
  • Plummer vinson syndrome
  • Irradiation
  • Scleroderma
  • Chagas disease (rare)

3. Outside the wall

  • Pharyngeal pouch
  • Mediastinal tumors
  • Bronchial carcinoma
  • Lymphadenopathy
  • Enlarged left artium (mitral stenosis)
  • Aortic aneurysm
  • Paraesopahageal (rollingl) hiatus hernia

4. Neuromuscular disorders Continue reading “Causes Of Dysphagia”

Diabetes- Patient Monitoring,Care And Education

Diabetes- Patient Monitoring,Care And EducationDiabetes mellitus is a common disease affecting a large number of population. It is characterized by increased blood sugars and abnormalities of carbohydrate and lipid metabolism.Diabetes can be managed by family physicians as effectively as in hospital clinics.

Aims Of Diabetic Care

  • Alleviation of symptoms.
  • Minimization of complications.
  • Reduction of early mortality.
  • Quality of life enhancement.
  • Education of the patient and family.
  • Features of well organized care
  • Use of a register and well maintained records.
  • Regular review , following a proper protocol and provision of adequate time  and open access for patients to review advice.
  • Multidisciplinary team covering all aspects of diabetes care- GPs, diabetes nurses/assistants and educators.
  • Continuing education for professional staff.

Routine diabetic review

Each diabetic patient requires 6 monthly review or more frequently as necessary. This should include a through annual review of all aspects of disease and care.

Review include

  • The indices of blood sugar control e.g HbA1c
  • Dietary behaviors, physical activity and injection techniques.
  • Foot care.
  • Immunizations – infuenza and pneumococcal vaccination.
  • Depression screening.
  • Any complications like cardiovascular disease, nephropathy, neuropathy, eye disease, errectile dysfunction etc. Continue reading “Diabetes- Patient Monitoring,Care And Education”

Approach to Patient With Amenorrhoea

It is common in general practice that patients may come with amenorrhoea and it needs a proper diagnostic approach.

Primary Amenorrhoea

Defined as when a girl have never started menstruation and sexual characteristics have not developed by the age of 14 years OR no menstruation by age 16 years when growth and sexual development is normal.


1. Outflow Abnormalities: Mullerian agenesis, transverse vaginal septum, androgen insensitivity, imperforate hymen.

2. Ovarian Disorders: Gonadal dysgenesis due to chromosomal abnormalities e.g Turner’s syndrome

3. Pitutary Disorders:  Prolactinoma

4. Hypothalamic disorders: Kallman’s syndrome.

Secondary Amenorrhoea

Defined as absence of menses for more than 6 months in a previously menstruating woman.


1. Always consider the possibility of pregnancy.

2. Stress

3. Starvation , anorexia or excessive exercise.

4. Hypo/ Hyperthyroidism

5. Hyperprolactinaemia

6. Polycystic ovarian syndrome

7. Premature menopause.

History And Physical Examination.

Rule out the possibility of pregnancy.

Ask for: Continue reading “Approach to Patient With Amenorrhoea”