With the proliferation of subspecialities dedicated to specific areas of medicine, the class of primary care physicians and general physicians (internists) is tending to diminish in number. Majority of the young graduates and postgraduates in Medicine wish to pursue higher training in specialities which offer greater acceptance in society, comforts and financial gains.

The primary care physician and the internist who form the first contact physicians have to be abreast with the advancement in the medical field. This is absolutely necessary to provide immediate care without jeopardising the final outcome and to refer the patients who require specialist services to the appropriate specialists. The patients also expect to be under the care of the physician who is competent, empathetic and easily available for all their immediate needs. In the present day medical scenario occurring in India and neighbouring countries, the general physician has to be conversant with the basic principles of a wide spectrum of medical conditions, so as to be able to provide appropriate services demanded by the situation.

Sound knowledge of history–taking and proper head-to-foot physical examination are absolutely necessary to form the provisional (often the final) diagnosis and to plan the investigations. For several decades to come, the importance of physical examination will remain supreme. Eliciting a proper history which is the sharpest and most cost-effective tool in the diagnostic process has to be learnt with patience and the young entrant into the profession has to develop appropriate communication skill which will enable him to make the diagnosis and to gain the confidence of the patient. Unfortunately in these times of fast life where neither the patient nor the doctor bestows enough time for patient doctor interaction, the first and the most harmful casualties are the elicitation of history and proper physical examination. The lacuna is partly overcome by ordering unnecessary, often harmful and always very expensive investigations, which at least some sections of our population cannot afford.

This third edition which comes after four years of publication of the second edition is prepared, with these facts in mind. The contributors have strived hard to emphasise the importance of history and physical examination. Care has been taken to bring out the relevance of the investigations, their indications and interpretation.

Most of the sections have been revised and some have been re-written. The section on Neurology is made more elaborate, in order to cater to the need of the postgraduate students who are likely to encounter neurology cases in their examinations

It is hoped that it will serve the purpose expected of it, while upholding its mission elaborated in the preface to the first edition.

The situation in India is different from that of many of the economically developed countries. In India, a large number of patients flock to the primary care physician. Facilities for investigation are limited due to the scarcity of services. The cost of investigations is high and is unaffordable by the patients at large. The physician, therefore, has to be very careful in planning investigations which are readily available in a cost-effective manner. Detailed clinical examination is absolutely necessary to achieve this end with the least expense while providing the greatest benefit and satisfaction to the patient.

Clinical methods have been changed considerably depending on the changes in disease patterns and availability of investigative facilities. The situation in India is special. The clinical spectrum is a mixture of diseases seen in underdeveloped regions of the world such as malnutrition, infective diarrhoeas and tetanus; and those seen in higher proportion in advanced countries, such as diabetes, ischaemic heart disease, hypertension and cancer. Facilities for basic investigations are available in many parts, but large areas of the country are devoid of them. In many cases the primary care physician himself or herself has to organise investigations. Specialist facilities and commercially oriented high-technology medical institutions are springing up in many towns and cities. They mainly cater to the small affluent section of the population. These facilities are beyond the reach of large masses. Clinical methods appropriate to Indian conditions will go a long way in providing medical care to larger sections of the population. This book is the result of attempts made in this direction, on the advice of many of my peers and colleagues, and request from numerous students and young physicians, who have found my Short Textbook of Medicine quite useful.

This book is designed to provide information on complete clinical examination, correlation of clinical findings with pathological processes and guidance to select investigations in a cost-effective manner. Investigations, which the medical student or physician may himself or herself have to do are described elaborately. This book is produced in two parts. Part I includes Clinical Examination and Investigations required for training in the general medical wards. Part II contains other medical disciplines included in the undergraduate curriculum—Dermatology, Sexually transmitted diseases, Paediatrics, Obstetrics, Otorhinolaryngology, Ophthalmology, and Psychiatry. A short section on Community Medicine and Statistical Methods is also included since these are most essential for the success of any primary heatlh 12care physician. The use of computers in medicine has also been included to prepare the students for the future trends in medicine.

Compared to all other sections, on Neurology is relatively longer and more exhaustive. This has been deliberately done in spite of the apparent disproportion between the sections due to the following reasons:

In all postgraduate clinical examinations in India (MD, Dip. NB, etc.), the main clinical long case is invariably a neurological problem. This is so, since the elicitation of obvious findings, their interpretation and planning of investigations, etc. lend themselves for easier and more objective assessment. To the student who has not understood clinical neurology well, these exercises are nightmares. At present the available undergraduate books on Clinical Medicine deal with neurology in the same manner as the other sections, since these books cater to the undergraduates. As such the student going for postgraduate examinations has to resort to monographs in neurology to acquire skills required of them in the clinical examinations.

This book is intended also to cater to the needs of postgraduates in internal medicine and therefore this section had to be made comparatively more exhaustive. I wish it fulfils the need it is intended to provide.

Miss R Sreedevi helped in the preparation of the text and get it ready for the DTP firm M/s Krishnakumar Associates. Mrs Manjula Krishnakumar, Mr Ajayakumar and Mr Abraham Jacob of M/s Krishnakumar Associates did a good job in page–setting and formatting. The encouragement, patience and endurance of my wife Mrs L N Kamalam went a long way in encouraging me to complete the editorial task in time.

M/s Jaypee Brothers Medical Publishers (P) Ltd have shown considerable skill to bring out this volume. Their experience and standing as Medical Publishers in India will go a long way publish this book and popularise it among the medical student fraternity of India and the neighbouring countries.

Modern medical practice is a teamwork involving the primary care physician, i.e. the physician to whom the patient goes first for help, often referred to as the general practitioner; the specialist who practises one or other major branches of medicine such as internal medicine, general surgery, gynaecology or ophthalmology; and those who are highly skilled in a subspeciality such as cardiology, neurology, plastic surgery, and the like. In addition, members of several other disciplines such as laboratory scientists, technicians, nursing staff, physiotherapists, and health workers, constitute the health team.

The primary care physician has to depend more on his or her clinical skills, with some support from easily available investigations. He or she has to deal with a large number of patients. The specialist physician or surgeon has to rely heavily on his or her clinical skills, also has to plan more investigations and management strategy to treat complicated cases. Highly skilled specialists have to devote more time for performing specialised investigations and doing procedures which demand prolonged training. For all these categories, clinical skill is the cornerstone of success. This has to be acquired by the young physician right at the beginning of his or her career, and he or she has to keep on developing his or her skill as he or she gains wider experience.

Clinical examination is the process by which the doctor forms the first impression about the patient's illness and deliberately plans the investigations. Since the patient's illness as well as his or her biological processes keep on changing with the passage of time, clinical examination has to be repeated at appropriate intervals. Professional skill, and empathy of the doctor for the patient and involvement in his or her problems and personalised attention, help in winning the patient's confidence.

This goes a long way in improving the image of the doctor in the patient's mind and also helps the latter to overcome the illness with confidence and optimism. It is this facet of the physician's job which broadly constitutes the art of medicine.

Modern medical practice has gone a long way from its original form of purely bedside medicine. Advancements in laboratory investigations and availability of complicated and expensive machines for investigation and treatment have brought medical practice to the forefront of biological sciences. In the quest for seeking the advancing frontiers of medical science, the doctor may find his or her time and energy consumed by pursuits away from the bedside practice. Moreover, the need to involve different types of personnel in the management of a patient's illness may lead to reduction in the importance of 15the family physician who is always the first contact for the patient and whom he or she considers as his or her “friend, philosopher and guide”. This tendency has to be guarded against at all costs. It is the “doctor-patient relationship” which is the unique feature of medical practice and which makes the medical profession stand out distinctly different from many other professions.

Medical profession has an exciting future, since it is a profession that continues to provide its practitioners with great personal fulfilment through service to their fellowmen. “Work” and “continued work” is the watchword in the success of any doctor. The doctor's role does not stop with his or her skills in diagnosis of an illness or its management. It is his or her role as a healer that makes him great. William Osler, one of the greatest clinicians, the West has seen, has said “faith in gods or saints cures one, hypnotic suggestions another, and faith in a plain common doctor a third. Nothing in life is more wonderful than faith. Happiness in our profession comes primarily from service to others. Greatest reward for the true physician comes simply from service itself”. Ayurveda, the traditional medical system practised in India over several centuries, defines the qualities and outlook required to become a good doctor. It emphasises the fact that only a proper blend of the knowledge in theory and practice of medicine makes a physician successful. If any of these is lacking in the physician, he or she becomes ineffective just like a bird with only one wing which is unable to fly.

This textbook attempts to introduce the young doctor to the basic clinical skills, which he or she would develop later as he or she gains experience, and reach unsurpassed heights in the profession.