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Medicine for Dental Students
R Alagappan
CHAPTER 1:
Introduction to Clinical Medicine
HISTORY TAKING
GENERAL EXAMINATION
EXAMINATION OF THE SKIN
HAIR
Stages of Hair Follicle Growth
Phases of Hair Growth (Fig. 1.6)
Cicatricial Alopecia
Non-cicatricial Alopecia
Colour of Hair
Causes of Hypertrichosis (Excess Hair)
Decreased Body Hair Distribution (Secondary Sexual Character)
FACE
Forehead
Hypertelorism
Low Set Ears
High Arched Palate
EYES
Characteristic Types of Facies (Fig. 1.14)
CONSTITUTION
Clinical Classification
Anthropometric Classification
STATURE
Stature>Arm Span
Arm Span>Stature
Upper Segment>Lower Segment
Lower Segment > Upper Segment
Marfan's Syndrome
STATE OF NUTRITION
POSTURE
HANDS AND FINGERS
Hands
Fingers
FEET AND ‘TOES
Genu Varum (Bow Legs)
Genu Valgum (Knock Knees)
Large Feet
Pes Cavus (Claw Foot) (Fig. 1.22)
Heel Pad Thickness
NAILS IN CLINICAL MEDICINE (Figs 1.23 and 1.24)
Koilonychia (Fig. 1.25)
Beau's Line (Fig. 1.26)
White Nail (Terry Nail) (Fig. 1.28)
Plummer Nail
Lindsay Nail (Fig. 1.27)
Yellow Nail Syndrome
TEMPERATURE
FEVER
Maximum Normal Oral Temperature
Fever with Relative Bradycardia
Fever with Exanthems
Febrile Convulsions
Patterns of Fever
Drug Fever
Hyperpyrexia
Hyperthermia
Hypothalamic Fever
Pyrexia of Unknown Origin (PUO)
Durack and Street Classification of PUO
Therapeutic Trial
PAIN
CHEST PAIN
ABDOMINAL PAIN
Pain due to Disorders of GIT
PERIPHERAL VASCULAR PAIN
Arterial Occlusion
Rest Pain
Venous Pain
NEUROGENIC CLAUDICATION
OEDEMA
SHOCK
CLASSIFICATION
Cardiogenic Shock
Extracardiac Obstructive Shock
Oligemic Shock
Distributive Shock
Hypovolemic Shock
Cardiogenic Shock
Common Causes of Acute Circulatory Failure
Extracardiac Obstructive Shock
Distributive Shock
Clinical Features
Investigations
Management
Goals
Treatment
CHAPTER 2:
Nutrition
VITAMINS
VITAMIN A (RETINOL)
Functions of Vitamin A
WHO Classification of Vitamin A Deficiency
Excess Carotenes
Vitamin D
Rickets
Osteomalacia
Management
Hypervitaminosis D
Vitamin E
Vitamin K
WATER-SOLUBLE VITAMINS
Thiamine (Vitamin B1)
Riboflavin (Vitamin B2)
Niacin (Nicotinic Acid and Nicotinamide)
Pellagra
Pyridoxine (Vitamin B6)
Biotin
Vitamin B12 and Folate
Vitamin B12
Folic Acid
Vitamin C (Ascorbic Acid)
Scurvy
Hypervitaminosis C
INORGANIC NUTRIENTS
Sodium
Hyponatremia
Hypernatremia
Potassium
Hypokalemia
Hyperkalemia
Calcium
Phosphorus
Hypophosphatemia
Iron
Iodine
Zinc
Fluorine
Magnesium
Manganese (Mn)
Copper (Cu)
Cobalt
Nickel
Chromium
Selenium
Dietary Modifications—Diet therapy
Vitamins and Trace Minerals– Requirement/day–Deficiency induced Disorders
OBESITY
Type of Obesity
Aetiology
Syndromes of Obesity with Hypogonadism and Mental Retardation
Pathology
Newer Drugs
Very Low Calorie Diets
Surgery
ANOREXIA NERVOSA AND BULIMIA
Anorexia Nervosa
Bulimia
Management
CHAPTER 3:
Infectious Diseases
TYPHOID AND PARATYPHOID FEVER (ENTERIC FEVER)
PARATYPHOID FEVER
Investigations
Complications
Management of Complications
Prevention
DIPHTHERIA
VIRAL EXANTHEMS
MEASLES (RUBEOLA)
Clinical Features
Complications
Management
Prevention
SMALLPOX (Variola Major)
VARICELLA-ZOSTER VIRUS INFECTIONS
Clinical Features
Complications
Investigations
Management
RUBELLA (German Measles—3 Day Measles)
HERPES ZOSTER (SHINGLES)
HERPES SIMPLEX
Pathogenesis
Clinical Features
Various Types of Primary Infection can occur
Investigations
Management of HSV Infections
MUMPS
SEXUALLY TRANSMITTED DISEASES
SYPHILIS
GONORRHOEA
CHANCROID
DONOVANOSIS (GRANULOMA INGUINALE)
LYMPHOGRANULOMA VENEREUM
HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION AND ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS)
ORGAN-SPECIFIC SYNDROMES
Oral Lesions in HIV
Skin Diseases in HIV
GIT Diseases in HIV
Hepatobiliary Diseases in HIV
Pulmonary Disorders in HIV
CNS Diseases in HIV
Psychiatric Disorders in HIV
Haemotological Disorders in HIV
Renal Disorders in HIV
Heart Disease in HIV
Metabolic and Endocrinologic Disorders in HIV
Investigations
Laboratory Tests to Monitor the Progression of HIV Infection
Management
Antiretroviral Therapy
Complications of ART
Assessment of Clinical Benefits in Drug Therapy
Prevention
CHAPTER 4:
Clinical Pharmacology
PRINCIPLES OF DRUG THERAPY
DRUG INTERACTIONS
DRUG INTERACTIONS OUTSIDE THE BODY ON MIXING DRUGS
DRUG INTERACTIONS IN THE BODY
Pharmacokinetic Interactions
Pharmacokinetic Interactions Causing Increased Drug Delivery
Pharmacodynamic interactions
Good Way of Prescribing
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
History
Opioid Group (Narcotics)
Non-Narcotics
Chemical Classification of NSAIDs
Mechanism of Action
Half-Lives of NSAIDs
Protein Binding
SALICYLATES
Aspirin (Acetyl Salicylic Acid)
5-Amino Salicylic Acid
Sulfasalazine
Methyl Salicylate
Salicylic Acid
Sodium Salicylate
Diflunisal
PYRAZOLONE DERIVATIVES
Phenylbutazone
Apazone (Azapropazone)
Sulfinpyrazone
Piroxicam
ACETIC ACID DERIVATIVES
Indomethacin
Sulindac
Tolmetin
Diclofenac
FENAMATES (Mefenamic Acid)
PROPIONIC ACID DERIVATIVES
Naproxen
Ketoprofen
Uses of NSAIDS
ADVERSE REACTIONS TO NSAIDS
Gastrointestinal System
Renal System
Hepatic System
Central Nervous System
Haematopoietic System
Cardiovascular System
Visual System
Auditory System
Dermatological Effects
Hypersensitivity Reactions
Role of Aspirin in Pregnancy
Pregnancy Induced Hypertension (PIH)
Drug Interactions of NSAIDs with Other Drugs
PHARMACOKINETIC INTERACTIONS
NSAID Affecting Other Drugs
Other Drugs Affecting NSAID
PHARMACODYNAMIC INTERACTIONS
NSAIDs Affecting Other Drugs
Combination with Increased Risk of Toxicity
Co-morbid conditions aggravated by NSAIDs
Conclusion
NEWER ANTIBACTERIAL AGENTS
Betalactam Antibiotics
PENICILLINS
AMINO PENICILLINS
ANTIPSEUDOMONAL PENICILLINS
ANTISTAPHYLOCOCCAL PENICILLINS
β-LACTAMASE INHIBITOR COMBINATIONS
CEPHALOSPORINS (1948)
First Generation Cephalosporins
Second Generation Cephalosporins
Third Generation Cephalosporins
Fourth Generation Cephalosporins
Oral Preparation of Cephalosporins
ADVERSE EFFECTS OF CEPHALOSPORINS
Carbapenems
Monobactam (1981)
Vancomycin (1956)
Teicoplanin
Lincosamides
Tetracyclines (1950)
Chloramphenicol (1949)
Sulfonamides and Trimethoprim
Streptogramins
Metronidazole (1950)
Adverse Effects
Quinolones
Aminoglycosides
Side Effects
Risk Factors Potentiating Nephrotoxicity
OD AG Therapy in Febrile Neutropenic Patients
Topical Antibacterial Agents
Anti-Tuberculous Drugs
Rifampin
Rifabutin
INH
Ethambutol
Pyrazinamide
Streptomycin
Second Line Drugs
GENERAL PRINCIPLES OF ANTI-TB CHEMOTHERAPY
ANTIVIRAL CHEMOTHERAPY
ADAMANTANES
Amantadine
Rimantadine
Isoprinosine (Immunovir, inosiplex, inosine prabonex)
Interferons
NUCLEOSIDE ANALOGUES
Acyclovir (acycloguanosine)
Ganciclovir
Famciclovir
Vidarabine
VIDARABINE MONOPHOSPHATE
ZIDOVUDINE (ZDV AZIDOTHYMIDINE, AZT)
DIDEOXY INOSINE (Didanosine Ddi, Videx)
DIDEOXYCYTIDINE (DDC, ZALCITABINE)
Stavudine (d4T)
Lamivudine (3Tc)
TOPICAL ANTIVIRALS
PHOSPHONIC ACIDS
FOSCARNET (Phosphonoformic acid, PFA)
PHOSPHONOACETIC ACID (PAA)
IMMUNOMODULATORY AGENTS
IMUTHIOL (Sodium diethyldithiocarbamate—DTC)
THYMOPENTIN
OTHER ANTIVIRAL AGENTS
Beta-diketones (Ariloone)
AMPLIGEN
RIFABUTIN (ANSAMYCIN)
CATANOSPERMINE
CD4 ANALOGUES
ANTIFUNGAL DRUGS
Azole Derivatives
Amphotericin B (1955)
Liposomal Amphotericin B
Amphotericin B Methyl Ester
Flucytosine (1972)
Miconazole (1978)
Ketoconazole (1981)
Fluconazole (1990)
Itraconazole
Saperconazole
PRINCIPAL ADVERSE EFFECTS OF ANTIFUNGAL AGENTS
LOCAL ANAESTHETICS
Local Anaesthetics
ESTER-LINKED DRUGS
Cocaine
Procaine Hydrochloride (Novocain, Neocaine)
Amethocaine
AMIDE-LINKED DRUGS
Lignocaine Hydrochloride (Xylocaine, Lidocaine, Duncaine)
Mepivacaine
Bupivacaine
Etidocaine Hydrochloride
Prilocaine Hydrochloride
Cinchocaine Hydrochloride (Nupercaine)
Drugs used for Vasoconstriction
PREANAESTHETIC ASSESSMENT (EVALUATION OF A CASE FOR ANAESTHESIA)
History Taking
Clinical Examination
GENERAL EXAMINATION
Malnutrition
Teeth
Anaemia
SYSTEMIC EXAMINATION
Heart
Lungs
Liver
Kidneys
Endocrine Disorders
Pregnancy
Elderly
Diabetes Mellitus
Investigations
Assessment of Physical Status
CHAPTER 5:
Oral Manifestations in Systemic Disorders
HALITOSIS
CAUSES OF HALITOSIS
CAUSES OF OROFACIAL P\AIN
CHAPTER 6:
Cardiovascular System
SYMPTOMS AND SIGNS
DYSPNOEA
New York Heart Association Grading of Dyspnoea, Palpitation, Fatique and Angina in Patients with Cardiovascular Disease
Causes
Dyspnoea is the Major Symptom of Left Heart Failure
ORTHOPNOEA
Paroxysmal Nocturnal Dyspnoea (PND)
Trepopnea
Platypnoea
ANGINA PECTORIS
Canadian Heart Association
Characteristics of Anginal Pain
Levine Test
Anginal Equivalent
Second Wind Angina
Causes of Angina Pectoris
PALPITATION
Causes
SYNCOPE
Causes
CYANOSIS
Types
Causes
ARTERIAL PULSE
Pulse Rate
Rhythm
Pulse Volume (Figs 6.3A–6.3I)
Pulse Character
Hypokinetic Pulse
Anacrotic Pulse (Parvus et Tardus) (Fig. 6.3C)
Hyperkinetic Pulse (Fig. 6.3D)
Collapsing Pulse (Water-Hammer Pulse, Corrigans Pulse) (Fig. 6.3E, 6.4)
Pulsus Bisferiens (Fig. 6.3F)
Pulsus Dicroticus (Fig. 6.3G)
Pulsus Alternans (Fig. 6.3H)
Pulsus Bigeminus
Pulsus Paradoxus (Fig. 6.3I)
Reverse Pulsus Paradoxus
Radiofemoral Delay
BLOOD PRESSURE
Korotkoff Sounds
Various Cuff Sizes for BP Measurement
Auscultatory Gap
Blood Pressure in the Basal Condition
Postural or Orthostatic Hypotension
Normal Blood Pressure
JNC 7 Classification of Hypertension
Common Causes of Hypertension
Isolated Systolic Hypertension
Accelerated Hypertension
Hypertensive Urgency
Hypertensive Emergency
Pseudohypertension
Labile Hypertension
Paradoxical Hypertension
Malignant Hypertension
White Coat Hypertension
Transient Hypertension
Episodic or Paroxysmal Hypertension
Hypertensive States
Pulsus Paradoxus
Pulsus Alternans
EXAMINATION OF NECK VEINS
Jugular Venous Pressure
JVP as Indicator of Mean Right Atrial Pressure
Jugular Venous Pulse (JVP)
Abnormalities of JVP
Kussmaul's sign is an inspiratory increase in JVP
Abdominal Jugular Reflux
GENERAL EXAMINATION
EXTERNAL FEATURES OF CARDIAC DISEASE
FUNDUS IN CARDIOLOGY
AUSCULTATION
Auscultatory Areas (Fig. 6.16)
HEART SOUNDS
First Heart Sound (S1)
Second Heart Sound (S2)
Wide Variable Split
Reverse Splitting Of S2
Third Heart Sound (S3)
Fourth Heart Sound (S4)
Gallops
Opening Snap (OS)
Ejection Clicks (Vascular/Valvular)
Mid Systolic Clicks
Vascular Clicks
Pericardial Knock
Tumour Plop
Prosthetic Sounds
Pericardial Rub
HEART MURMURS
Levine and Freeman's Grading of Murmurs
Systolic Murmurs
Early Systolic Murmurs (Fig. 6.17)
Late Systolic Murmurs (Fig. 6.20)
Diastolic Murmurs
Continuous Murmurs (Fig. 6.24)
Classification of Continuous Murmurs
Approach to Continuous Murmurs
Acyanotic Heart Disease
Cyanotic Heart Disease
To and Fro Murmurs (Biphasic Murmurs)
Systolic-Diastolic Murmur
Innocent Murmurs (Fig. 6.25)
Functional Murmurs
Changing Murmurs
Dynamic Auscultation
ELECTROCARDIOGRAM
ECG IN CORONARY ARTERY DISEASE
Myocardial Necrosis (Fig. 6.35)
Myocardial Injury
Myocardial Ischaemia
Localization of MI
Right Ventricular Infarct
True Posterior Wall Infarct
Acute Pericarditis (Fig. 6.38)
Pericardial Effusion
Electrical Alternans
ECG in Electrolyte Imbalance
Causes of Tall Symmetrical T- waves
ECG in Acute Pulmonary Embolism
ECG Features of COPD
ECG Features of Hypothermia
Causes of Pathological Q- wave
ECG IN VARIOUS ARRHYTHMIAS
Tachyarrhythmias
Analysis of ECG
Rule of Hundreds for Tachycardias
A. Paroxysmal Supraventricular Tachycardia
B. Atrial Flutter (Fig. 6.40)
C. Atrial Fibrillation
Management of Narrow Complex Tachycardia (SVT)
Synchronized Cardioversion
Radiofrequency Ablation
Specific Management
Anticoagulation
Atrial
Ventricular
Broad Complex Tachycardia
Ventricular Tachycardia
Sustained Monomorphic VT
Polymorphic VT
Ventricular flutter
Ventricular Fibrillation
Management of Broad complex Tachycardia
Bradyarrhythmias
Indications for Permanent Pacemakers
CONGENITAL HEART DISEASES
CLASSIFICATION OF CONGENITAL HEART DISEASES
Gross Anomalies
Lesions without Shunts
Shunt Lesions—Left to Right (Acyanotic)
Shunt Lesions—Right to Left (Cyanotic)
Cardiac Malposition
Dextrocardia
Isolated Dextrocardia
ATRIAL SEPTAL DEFECT (ASD) (Fig. 6.53)
Clinical Features
Treatment
VENTRICULAR SEPTAL DEFECT (VSD)
Classification (Fig. 6.56)
Mechanism of Closure of Defect
Clinical Features
PATENT DUCTUS ARTERIOSUS (PDA) (Figs 6.58 and 6.59)
Clinical Features
EISENMENGER SYNDROME (Fig. 6.61)
Clinical Features
TETRALOGY OF FALLOT (TOF) (Fig. 6.62)
Embryology
Pentology of Fallot
Triology of Fallot (PS, ASD and RVH)
Clinical Features
Complications
Treatment
RHEUMATIC FEVER
Pathophysiology
Major Criteria
Minor Criteria
Essential Criteria
Prevention of Rheumatic Fever
VALVULAR HEART DISEASE
MITRAL STENOSIS (MS) (Fig. 6.65)
Causes
Asymptomatic MS
Severity
Complications
Conditions Simulating MS
Management
Closed Mitral Volvotomy / Commissurotomy
Open Mitral volvotomy/Commissurotomy
Percutaneous Balloon Valvuloplasty
Valve Replacement
MITRAL REGURGITATION (MR) (Fig. 6.69)
Causes
Severity
Complications
Management
Causes of Acute MR
Mitral Valve Prolapse Syndrome (MVPS)
Conditions Causing or Associated with MVP
Symptoms
Signs
Complications
ECG
Management
AORTIC STENOSIS (AS) (Fig. 6.71)
Symptoms
Signs
Severity
Silent AS
Complications
Investigations
Coronary Angiogram
Prognosis–Life Expectancy
Management
Surgical
AORTIC REGURGITATION (AR) (Fig. 6.72)
Causes
Signs of Wide Pulse Pressure
Other Signs
Severity
Cardiac catheterization
Management
Causes of Acute AR
Causes of Combined AS and AR
Tricuspid Stenosis (TS)
ECG
Tricuspid Regurgitation (TR)
INFECTIVE ENDOCARDITIS (IE)
Types
Predisposing Factors to Development of Infective Endocarditis
Clinical Manifestations
Clinical Consequences of Infective Endocarditis
Laboratory Diagnosis
Duke's Criteria
Indications for Endocarditis Prophylaxis
Prophylaxis Not Needed
Treatment
Indications for Surgical Management
Non-infective Endocarditis
CARDIAC FAILURE
Preload
Afterload
Classification of Cardiac Failure
High Output and Low Output Failure
Right and Left Sided Heart Failure
FEATURES OF HEART FAILURE
Investigations
Forward and Backward Heart Failure
Framingham Criteria for diagnosis of CCF
Causes of Refractory Cardiac Failure
B-Type Natriuretic Peptide (BNP)
Treatment of Cardiac Failure
A. Nonpharmacologic Measures
Dialysis and Ultrafiltration
B. Pharmacologic Therapy
Parenteral Vasodilators
Sympathomimetic Amines
Phosphodiesterase inhibitors (Amrinone, Milrinone, Enoximone, Pimobendon)
SYSTEMIC HYPERTENSION (Fig. 6.77)
Investigations
Risk Factors for Cardiovascular Diseases
Target Organ Damage (TOD)
Associated Clinical Conditions (ACC)
MANAGEMENT
General Principles
Special Considerations in Antihypertensive Therapy
Management of Hypertensive Crisis
Complications of Hypertension
ACUTE CORONARY SYNDROMES (ACS)
Unstable Angina
Pathogenesis
Management
RISK STRATIFICATION OF ACS (see Table 6.21)
Antiplatelet Therapy
GP IIb/IIIa receptor inhibitors in ACS-IV
Anticoagulant Therapy
Coronary Angiography
MYOCARDIAL INFARCTION (MI)
Incidence
Risk Factors
Syndrome X
Symptoms
CARDIAC ARREST—CAUSES
Cardiac
CARDIOPULMONARY RESUSCITATION (BASIC LIFE SUPPORT)
Cardioversion (DC Shock)
Contraindications to Cardioversion
Cardiac Transplantation
Contraindications
CHAPTER 7:
Respiratory System
RESPIRATORY DISEASES
CLASSIFICATION OF RESPIRATORY DISEASES
Obstructive Diseases
Restrictive Diseases (PAINT)
BRONCHIAL ASTHMA
Types
Factors Precipitating Asthma
Clinical Features
Gastric Asthma
Exercise-induced Asthma
Episodic Asthma
Chronic Asthma
Investigations
Treatment
Indications for Assisted Ventilation
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) (Fig. 7.26)
Chronic Bronchitis
EMPHYSEMA
Special Varieties of Emphysema
Clinical Features (Fig. 7.26)
Reid Index
Complications
Investigations
Gold Classification of COPD
Indications for Noninvasive Positive Pressure ventilation (NIPPV)
Management
BRONCHIECTASIS
Factors Predisposing to Bronchiectasis
Types
Complications
Investigations
Management
TUBERCULOSIS
Natural History of Tuberculosis
Primary Tuberculosis
Miliary Tuberculosis
Cryptic Miliary Tuberculosis
Endobronchial and Laryngeal Tuberculosis
TB Meningitis
Genitourinary Tuberculosis
Bone and Joint Tuberculosis
Investigations
Post Primary Pulmonary Tuberculosis
Investigations
Management of Tuberculosis
Reserve Antituberculosis Drugs
Treatment Regimens in Special Situations
Mode of Action in Interruption of TB Treatment
Principles of Chemotherapy
HIV and Tuberculosis
PNEUMONIA
Classification
Pathological Stages in the Development of Pneumonia
Predisposing Factors
Clinical Features
Investigations
Bad Prognostic Indicators
Complications
Causes of Unresolved Pneumonia
Causes of Recurrent Pneumonia in the Same Segment
Special Characteristics of Various Pneumonias
Management
LUNG ABSCESS
Predisposing Factors
Common Organisms
Clinical Features
Differential Diagnosis
Investigations
Management
EOSINOPHILIC PNEUMONIAS
Causes of Peripheral Blood Eosinophilia (more than 500/µl)
Classification of Pulmonary Eosinophilia/ Eosinophilic Pneumonias
Allergic Bronchopulmonary Aspergillosis
Tropical Eosinophilia
Drug Induced Eosinophilic Pneumonias
Loeffler's Syndrome
Acute Eosinophilic Pneumonia
Chronic or Cryptogenic Eosinophilic Pneumonia
Allergic Angitis and Granulomatosis of Churg and Strauss
Hypereosinophilic Syndrome
PULMONARY THROMBOEMBOLISM
Risk Factors for Deep Vein Thrombosis
Investigations
Clinical Features
Management
Management of DVT
PLEURAL EFFUSION
Mechanism of Pleural Fluid Formation
Causes of Pleural Effusion
Pleural Fluid Analysis
Clinical Features
Investigations
Parapneumonic Effusion
Empyema Thoracis
Causes
Organisms
Predisposing Factors
Clinical Features
Investigations
Treatment
Malignant Effusions
Chylothorax
Haemothorax
Causes of Bilateral Effusion
Causes of Right Sided Effusion
Causes of Left Sided Effusions
Management
PNEUMOTHORAX
Spontaneous Pneumothorax
Traumatic Pneumothorax
Types
Clinical Features
Catamenial Pneumothorax
Complications of Pneumothorax
Investigations
Management
CHAPTER 8:
Abdomen
CLINICAL EXAMINATION
GENERAL EXAMINATION
Signs of Liver Cell Failure
REGIONS OF ABDOMEN (Fig. 8.3)
Inspection (Fig. 8.4)
Skin or Surface of Abdomen
IVC Obstruction (Fig. 8.5)
Interpretation
Measurements
SURFACE MARKING OF ORGANS
Liver
Spleen
Kidneys
Gallbladder
PALPATION
Palpation by Dipping
Palpation of Liver
Palpation of Gallbladder
Courvoisier's Law
Murphy's Sign
Palpation of Spleen (Fig. 8.9)
Palpation of Kidneys (Fig. 8.10)
Palpation of Urinary Bladder
Differential Diagnosis
Tenderness
PERCUSSION
Defining Boundaries
Percussion can also be used for Detecting Fluid in the Abdomen by the following Methods
Grading of Ascites
Chronic ascites is associated with
Percussion of Cyst (Hydatid Thrill)
AUSCULTATION
Bowel Sounds
Succussion Splash
Bruit
Venous Hum
Friction Rub
CAUSES OF HEPATOMEGALY
Congestive
Degenerative and Infiltrative
Storage Disorders
Neoplasia
Toxins
CAUSES OF PAINFUL HEPATOMEGALY
CAUSES OF PULSATILE LIVER
CAUSES OF SPLENOMEGALY
Mild (upto 5 cm)
Moderate (5–10 cm)
Massive (>10 cm)
CAUSES OF HEPATOSPLENOMEGALY
Infections
Haematological Disorders
Congestive States
Storage Disorders
CAUSES OF HEPATOSPLENOMEGALY + LYMPHADENOPATHY
GASTROINTESTINAL SYSTEM
GLOSSITIS AND STOMATITIS
Gingivitis
Aphthous Ulcers
Vincent's Infection
Candidiasis
Dyspepsia
Reflux Oesophagitis
Clinical Features
Diagnosis
Treatment
DYSPHAGIA
Causes of Dysphagia
Diagnostic Approach to Dysphagia
Treatment
GASTRITIS
Acute Haemorrhagic or Erosive Gastritis
Etiology and Pathogenesis
Clinical Features
Management
Acute or Active Chronic Gastritis of H. pylori
Diagnosis of H. pylori
Chronic Gastritis
Corrosive Agents Induced Gastritis
Infectious Gastritis
Granulomatous Gastritis
Eosinophilic Gastritis
Gastritis Following Gastric Surgery (Alkaline or Bile Reflux Gastritis)
Menetrier's Disease (Hypertrophic Gastritis)
PEPTIC ULCER DISEASE
Peptic Ulcer
Helicobacter Pylori and Peptic Ulcer Disease
Pathogenesis of Ulcer Production
Stress Ulcer
Pathogenesis
Clinical Conditions Producing Stress Ulcer
Treatment
NSAID and Peptic Ulcer
Diagnosis
Endoscopic Differentiation between Benign and Malignant Ulcer
GASTROINTESTINAL BLEEDING
Haematochezia
Aetiology
Laboratory Findings
Management
DIARRHOEA
Mechanism of Diarrhoea
Osmotic Diarrhoea
Secretory Diarrhoea
Acute Diarrhoea
Chronic Diarrhoea
AMOEBIASIS
Pathogenesis
Clinical Features
Investigations
MALABSORPTION
Luminal Phase
Mucosal Phase
Transport Phase
Clinical Features
Drugs and Malabsorption
Tests of Malabsorption
Small Intestine Biopsy
Systemic Diseases Associated with Malabsorption
Principles of Management
HEPATOLOGY
LIVER FUNCTION TESTS
Serum Enzymes
Tests of Biosynthetic Function
Tests of Cholestasis
JAUNDICE
Metabolism of Bilirubin
Types
Causes
An Approach to Jaundice
CONGENITAL JAUNDICE
Crigler-Najjar Syndrome (Type I)
Crigler-Najjar Syndrome (Type II)
Gilbert's Syndrome
Dubin-Johnson Syndrome
Rotor Syndrome
VIRAL HEPATITIS
Clinical Features
Investigations
Complications
Management
Prognosis
CHRONIC HEPATITIS (CH)
Older Classification
Newer Classification
Causes of Chronic Hepatitis
PREVENTION OF HEPATITIS
For HAV
For HBV
CIRRHOSIS OF LIVER
Causes of Cirrhosis of Liver
Morphological Classification
Alcoholic Cirrhosis
Enlarged liver in Cirrhosis
Post-Necrotic Cirrhosis
Cryptogenic Cirrhosis
Biliary Cirrhosis
Treatment
Cardiac Cirrhosis
Complications of Cirrhosis
PORTAL HYPERTENSION
Classification
Collateral Circulation (Varices)
Major Sites of Collaterals
Investigations
Complications
Management
VARICEAL BLEEDING
Factors Predisposing to Bleeding
Clinical Features
Management
Prognosis
Unfavourable Signs
ASCITES
Causes of Ascites
Pathogenesis
Spontaneous Bacterial Peritonitis (SBP)
Chylous Ascites
Mucinous Ascites
Refractory Ascites
CHAPTER 9:
Haematology
HAEMAMATOPOIESIS
ANAEMIA
Causes of Anaemia
Classification
Haemolysis
Symptoms and Signs
Iron Deficiency Anaemia
Iron Metabolism
Causes of Iron Deficiency
Stages in Iron Deficiency Anaemia
Clinical Features
Investigations
Differential Diagnosis
Management
Iron Requirement
Megaloblastic Anaemia
Clinical Features
Investigations
Useful Clues for Diagnosis
Management
Megaloblastic Disease without Anaemia
HAEMOLYTIC ANAEMIA
Causes
Investigations
HAEMATOLOGICAL MALIGNANCIES
LEUKEMIAS
Acute Myeloid Leukemia
Aetiology
Classification
Clinical Features (Fig. 9.8)
Investigations
Prognostic factors in AML
Complete Remission
Management
ALL (Working Classification)
Chronic Myeloid Leukemia (CML)
Summary
Response Criteria in CML
Special Clinical Problems in CML
Acute Lymphoblastic Leukaemia
Aetilogy
Classification
Clinical Features
Management
Poor Prognostic Factors
Treatment of Relapse
Chronic Lymphocytic Leukaemia (CLL)
BLEEDING DISORDERS
An Approach to Bleeding Disorders
Excessive Anticoagulation
Duration of therapy–Anticoagulants
Qualitative Platelet Disorders
Quantitative Platelet Disorders
IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP)
Clinical Features
Investigations
Disorder due to Deficiency of Clotting Factors
Haemophilia A
Haemophilia B (Christmas Disease)
Disseminated Intravascular Coagulation (DIC)
Disorders of Lymph Nodes and Spleen
Lymph Nodes
Causes of Lymph Node Enlargement
Diseases Causing Lymphadenopathy
Important Factors while Assessing Lymphadenopathy
Disorders Causing Lymph Node Enlargement
Malignant Diseases
Investigations
Management
Disorders of the Spleen
Disorders Causing Enlargement of the Spleen
Hypersplenism
Hyposplenism/Asplenia
CHAPTER 10:
Nephrology
URINE ANALYSIS
URINARY TRACT INFECTION
Definitions
Risk Factors Associated with Urinary Tract Infection
Pathogenesis
Symptoms of UTI
Investigations
Principles of Treatment of UTI
Recommendations for Use and Care of Urinary Catheters
Treatment of Uncomplicated UTI
Treatment of Complicated UTI
Treatment of Prostatic Infection
Asymptomatic Bacteriuria
Prophylaxis for UTI
Glomerulopathies (Fig. 10.3)
Classification
NEPHROTIC SYNDROME
Causes of Nephrotic Syndrome
Clinical Features
Minimal Change Glomerulonephritis
Causes
Membranous Glomerulonephritis
Mesangial Proliferative Glomerulonephritis (Fig. 10.7)
Focal and Segmental Glomerulosclerosis (Fig. 10.5)
Diabetic Nephropathy (Fig. 10.6)
Evaluation of Nephrotic Syndrome
Treatment
Complications
GLOMERULONEPHRITIS
Acute Glomerulonephritis (AGN)
Acute Post-streptococcal GN
Post-infectious GN
ACUTE RENAL FAILURE (ARF)
Causes of ARF
ATN
Clinical Features
Course
Complications
Recovery
Management of ARF
Indications for Urgent Dialysis
Chronic Kidney Disease
CHRONIC RENAL FAILURE (CRF) (Fig. 10.8)
Common Causes
Symptoms, Signs and Consequences of CRF
Investigations
Treatment
End-Stage Renal Disease
Dialysis
CHAPTER 11:
Endocrine and Metabolic Disorders
HYPOTHALAMUS AND PITUITARY GLAND
ANATOMY
Anterior Lobe
Clinical Uses of Somatostatin
Neurohypophysis
HYPOPITUITARISM
Aetiology
Clinical Features
Investigations
Clinical Indications for Detailed Pituitary Stimulation Tests
Treatment
HYPERSECRETORY DISORDERS OF ANTERIOR PITUITARY
HYPERPITUITARISM
Acromegaly and Gigantism
Clinical Features (Fig. 11.1)
Laboratory Diagnosis
Treatment
HYPERPROLACTINAEMIA
Causes
Clinical Features
Laboratory Diagnosis
Treatment
PITUITARY TUMOURS
Secretory Tumours
Clinical Features
Laboratory Diagnosis
Treatment
DISORDER OF THE NEUROHYPOPHYSIS
DIABETES INSIPIDUS (DI)
Aetiology
Central DI
Nephrogenic DI
Dipsogenic DI
Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)
Causes of SIADH
Laboratory Diagnosis
Treatment
THYROID DISORDERS
HYPERTHYROIDISM
Causes
Clinical Features (Fig. 11.8)
Grading of Eye Signs
Investigations
Treatment
Thyrotoxic Crisis (Thyroid Storm)
Neonatal Hyperthyroidism (Neonatal Grave's disease)
Investigations
Complications
Management
HYPOTHYROIDISM
Causes
CLINICAL FEATURES
Congenital Hypothyroidism (Cretinism) (Figs 11.12 and 11.13)
Acquired Hypothyroidism
Sub-clinical Hypothyroidism
Myxedema Coma
DISORDERS OF PARATHYROID GLAND AND CALCIUM AND PHOSPHORUS METABOLISM
HYPOCALCAEMIC DISORDER
Disorder of Parathyroid Glands
Clinical Features (Fig. 11.21)
Treatment
Pseudohypoparathyroidism (Fig. 11.22) (Target Organ Resistance)
Pseudopseudohypoparathyroidism
Adrenal Glands
PRIMARY HYPERALDOSTERONISM
Causes
Clinical Features
Investigations
Management
SECONDARY HYPERALDOSTERONISM
Causes
Treatment
CUSHING'S SYNDROME
Classification of Cushing's Syndrome
Pseudo-Cushing's Syndrome
Clinical Features (Fig. 11.23 to 11.25)
Periodic Cushing's Syndrome
Evaluation to Localize Tumours
Management
ADRENAL INSUFFICIENCY (ADDISON'S DISEASE)
Causes of Addison's Disease
Clinical Features (Fig. 11.26)
Associated Other Autoimmune Diseases
Laboratory Investigations
Special Tests
Management
Adrenal Crisis
Pheochromocytoma (Fig. 11.27 to 11.30)
Pathophysiology
Clinical Features
Common Symptoms
Signs
Syndromes Associated with Pheochromocytoma
Investigations
Management
Other Drugs for Control of Hypertension
Surgical Treatment
Prognosis
DIABETES MELLITUS (DM)
ACUTE COMPLICATIONS OF DIABETES
Diabetic Ketoacidosis (DKA)
Pathophysiology of DKA
Role of Counter Regulatory Hormones
Investigations
Management
Complications of DKA
HYPEROSMOLAR COMA
Predisposing Factors
Clinical Features
Investigations
Management
LACTIC ACIDOSIS
Causes
Treatment
LONG-TERM COMPLICATIONS OF DIABETES
Diabetic Retinopathy
Background Retinopathy without Maculopathy
Preproliferative Retinopathy
Proliferative Retinopathy
Risk Factors for Diabetic Retinopathy
Rubeosis Iridis
Treatment
Limited Joint Mobility (LJM, Diabetic Hand Syndrome)
Diabetic Neuropathy
DIABETIC NEPHROPATHY (DN)
Stages in Diabetic Nephropathy
Treatment
PREGNANCY AND DIABETES
Effect of Diabetes on Pregnancy
Foetal Development
Screening and Diagnostic Criteria for Gestational DM (O’ Sullivan-Mahan Criteria)
Diagnosis of Gestational DM
Stages of Care in Diabetic Pregnancy before Conception
I. Dietary Management of Diabetic Women
II. Insulin Therapy in Pregnancy
III. Obstetric Management
Surgery and Diabetes
Modification of Chronic Therapy
Preoperative Assessment
Criteria for Simultaneous Pancreas-Kidney Transplantation
Hypoglycaemia in Adults
Glucose Homeostasis
Hormonal Response to Hypoglycaemia
Signs and Symptoms of Hypoglycaemia
1. Drugs
Treatment
2. Factitious Hypoglycaemia
3. Ethanol
4. Non β-Cell Tumour
5. Hepatic Failure
6. Adrenal Insufficiency
7. Beta Cell Tumour (Insulinomas)
Diagnostic Tests for Insulinomas
Treatment
8. Renal Failure
9. Insulin Autoantibodies
10. Insulin Receptor Autoantibodies
11. Sepsis
12. Falciparum Malaria
13. Congestive Heart Failure
Fed (Reactive) Hypoglycaemias
Treatment of Reactive Hypoglycemia
CHAPTER 12:
Central Nervous System
HIGHER FUNCTIONS
DEFINITIONS
Consciousness
Confusion
Coma
Stupor (or) Semiconsciousness
Glasgow Coma Scale (GCS)
Abbreviated Coma Scale (AVPU)
Coma Vigil (Vegetative State)
Akinetic Mutism
Abulia
Catatonia
Delirium
Dementia
Delirium
Amnesia
EXAMINATION OF HIGHER MENTAL FUNCTIONS
CONSCIOUSNESS
Causes of Coma
Endocrine and Metabolic Disturbances
Tropical Coma
APPROACH TO COMA
APPEARANCE AND BEHAVIOUR
EMOTIONAL STATE
ORIENTATION
HANDEDNESS
GENERAL INTELLIGENCE
MEMORY
Components of Memory
Types
PERCEPTION
VISUOSPATIAL FUNCTIONS
Apraxia
Types of Apraxia
Agnosia
Sleep
States and Stages of Sleep
Neuroanatomy of Sleep (Sleep Centre)
Function of Sleep
Effect of Sleep Deprivation
International Classification of Sleep Disorders
Sleep Disorders Associated with Medical or Psychiatric Disorders
Sleep Apnoea Syndromes
Parasomnias
Somnambulism (Automatic Motor Activities During Sleep)
Sleep Terrors (Pavor Nocturnus)
REM Sleep Behaviour Disorders
Narcolepsy and Cataplexy
Sleep Bruxism
Sleep Enuresis (Bed Wetting)
Sleep Disorders with Neurologic Disorders
Circadian Rhythm Sleep Disorders
Jet-Lag Syndrome
Shift-Work Sleep Disorders
SPEECH AND LANGUAGE
Definitions
Speech Areas (Fig. 12.4)
Dysarthria
Examination of Speech and Language
Lobar Functions
Frontal Lobe Functions
Frontal Lobe Lesions
Functions of Parietal Lobe
Parietal Lobe Lesions
Functions of Temporal Lobe
Lesions of Temporal Lobe
Functions of Occipital Lobe
Lesions of Occipital Lobe
Cognitive Scales
EXAMINATION OF THE CRANIAL NERVES (Fig. 12.5)
FIRST CRANIAL NERVE (OLFACTORY NERVE)
Anatomical Peculiarity
Testing Sense of Smell
Interpretation
SECOND CRANIAL NERVE (OPTIC NERVE)
Testing of Visual Acuity
Testing of Visual Fields
Monocular Visual Loss
Binocular Visual Loss
Colour Vision
Swinging Light Test for Afferent (Optic Nerve) Pupillary Abnormality
Inspection of Optic Nerve Head and Fundus by Ophthalmoscopy (Fig. 12.11)
Aetiologic Classification of Optic Atrophy
Papillitis
Retrobulbar Neuritis
Examination of the Macula
Amaurosis Fugax
THE OCULOMOTOR (THIRD), TROCHLEAR (FOURTH), AND ABDUCENT (SIXTH) CRANIAL NERVES
Anatomical Peculiarities (Fig. 12.17)
Pseudo von Grafe's Sign
Examination of III, IV and VI Cranial Nerves Inspection of the Eyes (Fig. 12.18)
Pupillary Reflexes
Ocular Movements
Strabismus or Squint
Upper Motor Neuron (Supranuclear) Lesions
Internuclear Lesions
Nystagmus
FIFTH CRANIAL NERVE (TRIGEMINAL NERVE)
Nucleus
Lesions of the Vth Cranial Nerve
Paroxysmal Facial Pain (Trigeminal Neuralgia, Tic Douloureux)
Duration of Pain
Trigger Zones
Age Incidence
Sex Incidence
Frequency
Aetiology
Differential Diagnosis
Medical Management
Surgical Management
SEVENTH CRANIAL NERVE (FACIAL NERVE)
Anatomical Peculiarity (Figs 12.29 and 12.30)
Inspection
Examination of Motor Function (Fig. 12.28)
Examination of Sensory Functions
Examination of the Secretory Functions
Examination of the Reflexes
Common Causes of VII Nerve Palsies
Bilateral
Facial Nerve Involvement in Leprosy
Bell's Palsy
THE EIGHTH CRANIAL NERVE (VESTIBULO-COCHLEAR NERVE)
Examination of Auditory Function
Caloric Testing
Abnormal Responses
THE NINTH AND TENTH CRANIAL NERVES (GLOSSOPHARYNGEAL AND VAGUS NERVES) (FIGS 12.33A AND B)
ELEVENTH CRANIAL NERVE (ACCESSORY NERVE)
Testing of Sternocleidomastoid Muscle (Fig. 12.34)
Testing of the Trapezius Muscle (Fig. 12.35)
THE TWELFTH CRANIAL NERVE (HYPOGLOSSAL NERVE)
SPINO MOTOR SYSTEM
COORDINATION (Fig. 12.41)
Methods of Testing Coordination
Involuntary Movements
Common Involuntary Movements
Gait
Abnormalities of Gait
Reflexes
Abdominal Reflexes
The Plantar Reflex
Deep Tendon Reflexes
Other Allied Reflexes
Abnormalities of Tendon Reflexes
Inverted Reflexes
Primitive Reflexes (Released Reflexes)
CEREBELLUM
THE SENSORY SYSTEM
SENSORY DERMATOMES (FIG. 12.58)
Rule of 3
Method of Examination
PROPRIOCEPTIVE SENSATIONS
Sense of Passive Movement (Joint Sense) (Fig. 12.59)
Romberg's Test for Position Sense
VIBRATION SENSE
Timed Vibration Sense
MUSCLE SENSITIVITY
Barber's Chair Sign or Lhermitte's Sign
CORTICAL SENSATIONS
Function of Sensory Cortex
Point Localisation (Tactile Localization)
Two-Point Discrimination
Stereognosis
Graphaesthesia
Sensory Dissociation
Various Sensory Lesions (Fig. 12.64)
Sacral Sparing
Loss of Sensation of Saddle Type
Glove and Stocking Anaesthesia
Loss of Vibration Sense Alone
Loss of Position and Vibration Sense Alone
Patchy Areas of Sensory Loss
Dejerine Roussy Syndrome
EPILEPSY
STATUS EPILEPTICUS
Classification
Precipitating Factors
Etiology
Complications
Management
PSEUDOSEIZURES
CEREBROVASCULAR DISORDERS
STROKE
Clinical Classification of Stroke
Risk Factors for Stroke
Pathophysiology of Stroke
Posterior Cerebral Artery
Occulsion of Anterior Inferior Cerebellar Artery (AICA)
Pontine Syndromes
Mid Pontine Syndromes
Inferior Pontine Syndromes
YOUNG STROKE
Causes
Investigations
Management
Pathophysiology
Management
2. Surgical Management
Subclavian Steal Syndrome
Lacunar Infarction
Cortical Venous Thrombosis (Dural Sinus Thrombosis)
SUBARACHNOID HAEMORRHAGE (SAH)
Causes of SAH
Common Sites of Aneurysm
Aetiopathogenesis of Aneurysm Formation
Conditions Associated with Aneurysm
Clinical Features of SAH
Complications of SAH
Causes of Thunderclap Headache
Treatment of SAH
Association
SAH Due to Other Causes
ARTERIOVENOUS MALFORMATION (AVM)
Types of AVM
Clinical Features
Investigations
Treatment
BRAIN DEATH
Essential Neurological Signs
Ancillary Diagnostic supportive Tests
Headache
Pain Sensitive Structures
Pain Insensitive Structures
Mechanisms of Production of Headache
Headache Caused by Systemic Illness
Investigations
Treatment
MENINGITIS
Causes
Clinical Features
Predisposing Factors
Investigations
CSF Glucose Decreased
Management
No Organisms Seen in CSF
Adjuvant therapy–Dexamethasone
ENCEPHALITIS
Symptoms and Signs
Investigations
Management
Prognosis
CHAPTER 13:
Substance Abuse
Alcohol
RISK FACTORS FOR ALCOHOLIC LIVER DISEASE
1. Drinking Pattern
2. Sex
3. Genetics
4. Nutrition
5. Gastric First-Pass Metabolism
Metabolism of Alcohol
Effect of Alcohol on Liver
Morphological Change
CLINICAL SYNDROMES (Fig. 13.1)
Fatty Liver
Acute Alcohol Hepatitis
ALCOHOL AND CENTRAL NERVOUS SYSTEM (CNS)
1. Acute Intoxication
2. Alcoholic Coma
3. Withdrawal Syndrome
4. Alcohol Dementia
5. Marchiafava-Bignami Syndrome
6. Cerebrovascular Disease
7. Alcoholic Cerebellar Degeneration
8. Central Pontine Myelinosis
9. Peripheral Neuropathy
10. Saturday Night Palsy
11. Alcoholic Myopathy
TOBACCO ALCOHOL AMBLYOPIA
Nutritional Deficiency Syndrome
PREGNANCY AND ALCOHOL
Foetal Alcohol Syndrome
GASTROINTESTINAL
Oesophagus
Stomach
Pancreas
Small Bowel
Haematology
Cardiovascular System
Respiratory System
Genitourinary System
Bone
Endocrine
Skin
Alcohol and Malignancy
Alcohol and Lymphatic System
Alcohol and Drug Interactions
Smoking
PACK YEAR
Smoking and Respiratory Disease
Smoking and Gastrointestinal Disorders
Smoking and Depression
Smoking and Body Weight
Smoking and Pregnancy
Passive Smoking
Smoking and Drugs
Type of Smoking
Cessation Process
Cessation Methods
Pharmacotherapy
CHAPTER 14:
Imaging Modalities in Internal Medicine
The Chest Film
Plain Abdominal Film
PLAIN X-RAY SKULL (Fig. 14.12)
Intracranial Calcification
Sella Turcica
Air Sinuses
X-RAY HANDS
Soft Tissues
Joints
Deformities
Erosion of Terminal Phalangeal Tufts (Fig. 14.13)
Coarse Trabeculations
Middle Phalanx
Contrast Studies
Therapeutic Manoeuvres
Complications
Intravenous Urography Pyelography (IVU Or IVP)
Laboratory Reference Values
Cerebrospinal Fluid
Appendix
INDEX
TOC
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