Clinical Medicine: A Textbook of Clinical Methods and Laboratory Investigations KV Krishna Das, PK Sasidharan, Mathew Thomas, S Aswini Kumar, R Kasi Visweswaran, C Sudheendra Ghosh, KR Vinaya Kumar
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Clinical Medicine: A Textbook of Clinical Methods and Laboratory Investigations
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Fourth Edition
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Clinical Medicine: A Textbook of Clinical Methods and Laboratory Investigations
Editor-in-ChiefKV Krishna Das BSc MBBS FRCP(E) FAMS DTM and H(Edin) Consultant Physician and Hematologist, Ex-Director and Professor Department of Medicine, Trivandrum Medical College Thiruvananthapuram, Kerala, India EditorsMathew Thomas MD Professor and Head, Department of Medicine, Dr Somervell Memorial CSI Medical College and Hospital, Karakonam, Thiruvananthapuram, Kerala, India PK Sasidharan MD Professor and Head, Department of Medicine, Government Medical College Kozhikode, Kerala, India S Aswini Kumar MD Professor, Department of Medicine, Trivandrum Medical College, Thiruvananthapuram, Kerala, India R Kasi Visweswaran MD DM(Nephrology) Ex-Professor, Department of Nephrology, Nephrologist, Ananthapuri Hospital and Research Institute Thiruvananthapuram, Kerala, India C Sudheendra Ghosh MD(Med) MD(Resp) Dip NB MPH(USA) Joint DME, Trivandrum Medical College, Thiruvananthapuram, Kerala, India KR Vinaya Kumar MD DM Professor and Head, Department of Gastroenterology, Trivandrum Medical College Thiruvananthapuram, Kerala, India
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© 2013, Jaypee Brothers Medical Publishers
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This book has been published in good faith that the contents provided by the author contained herein are original, and is intended for educational purposes only. While every effort is made to ensure accuracy of information, the publisher and the editor specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work. If not specifically stated, all figures and tables are courtesy of the author. Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device.
Clinical Medicine: A Textbook of Clinical Methods and Laboratory Investigations
First Edition: 1995
Second Edition: 2000
Third Edition: 2005
Fourth Edition: 2013
9789350902806
Printed at
5Dedicated to
the memory of all patients who entrusted their health and life to us and who have helped us to shape our careers as physicians caring for them6
7Contributors 9Preface to the Fourth Edition
There is great need for a textbook of clinical medicine for the use of medical students and practitioners, with due emphasis on the local conditions. Several books are available which are popular among students and teachers. All these books are highly informative and useful but emphasis is given to the conditions prevailing in their countries of origin.
The present medical scenario in addition to many of the diseases caused by poor socio-economic conditions, most of the diseases encountered in developed countries such as lifestyle-related diseases, diseases of advancing age and diseases caused by tobacco and biomass fuel smoke, disturbance in family relationships, road accidents, environmental changes, more migration to townships without adequate development of infrastructure; have all constituted to a change in disease patterns and epidemiology leading to gross change in the prevalence and pattern of diseases. There is considerable overall improvement in the financial, socioeconomic, educational and infrastructural improvement, but still vast areas of the country are deficient in infrastructure, clinical facilities and availability of appropriate modern medical care. Basic investigations such as simple laboratory tests, X-rays, electrocardiography (ECG) and even ultrasound studies are available in even remote villages and towns. There is a rapid proliferation of secondary care and tertiary care hospitals in the private sector, which provide health care on payment. These are available only to a smaller section of society.
The concept of primary care physician, which dominated till the middle of the twentieth century has given place to the era of specialists and highly skilled specialists, so that the first entrants into the medical studies proceed towards postgraduation and further acquisition of skills. Their services are available only in towns and cities, where most of the secondary and tertiary care private hospitals are located. The students and young physicians joining the medical profession have to be aware of these facts and it is their bounden duty to provide medical care to the less affluent masses too. This entails the proper acquisition of clinical skills, which alone may be adequate to diagnose and manage the vast majority of diseases occurring in the community. The doctor should use his discretion to plan the investigations which reduce cost and inconvenience to the patient. It is absolutely essential that cost-effective investigations have to be planned. All these require a thorough knowledge of the principles underlying clinical examination and the interpretation of investigations. Moreover, at the present time, when many young doctors may have to practice in remote communities single handed, many investigations have to be carried out by themselves, e.g. urine examination for glucose, acetone and deposits, examination of feces for ova of worms, or examine a blood smear for malarial parasites. The ECGs and skiagrams may have to be interpreted without help. To facilitate the establishment of such laboratory tests and empower the doctor to interpret the abnormalities, this book gives practical details to perform such simple tests. In the case of the more complicated tests, only the principles and interpretation of the findings are given.
The 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. 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—Pediatrics, Geriatrics, Pregnancy, Dermatology, Leprology and Sexually Transmitted Diseases, Psychiatry, Ophthalmology, Ear, Nose and Throat, Examination of Oral Mucosa and Teeth, Community Medicine and Statistics and Information Technology.
All the sections have been thoroughly revised and modified depending on the development in the subject so as to provide up-to-date information to the learner. Several photographs have been added to facilitate self– study by the students.10
The book is intended also to cater the needs of undergraduates throughout their course, internship, further clinical studies, preparation for postgraduate entrance examinations in internal medicine and practitioners in India. The students of others systems of medicine and practitioners of alternate systems may also find the interpretation of physical findings and planning of investigations useful. The sections on Community Medicine and Statistics and Information Technology have been specially designed to help the students to read and understand modern medical literature, interpret published material critically and plan research at the basic level. The section on information technology is intended to make the reader aware of modern developments in this field and to acquaint himself to the use of tools to get further information.
All the contributors, who are veteran teachers, have tried their utmost to bring out the book as a useful companion for studying clinical medicine.
KV Krishna Das
11Preface to the First Edition
There is great need for a textbook of clinical medicine for the use of medical students and practitioners, with due emphasis on the local conditions. At present, the vast majority of medical students depends on notes prepared during bedside clinics and supplemented by information obtained from books on clinical medicine. Though most of these books are highly informative and useful, emphasis is given to the conditions prevailing in their countries of origin. Many of them are written to cater to the young students who have access to advanced investigations at hand.
The situation is different from the economically developed countries. A large number of patients flock to the primary care physician. Facilities for investigations are limited due to the scarcity of services. The cost of investigations is high and also 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 changed considerably depending on the changes in disease patterns and availability of investigative facilities. The situation is special. The clinical spectrum is a mixture of diseases seen in underdeveloped regions of the world such as malnutrition, infective diarrheas and tetanus plus those seen in higher proportion in advanced countries, such as diabetes, ischemic 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 has to organize investigations. Specialist facilities and commercially oriented high-technolgoy 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. Appropriate clinical methods 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 my peers and colleagues, and request from numerous students and young physicians, who have found my Short Textbook of Medicine quite useful.
The 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 have to perform are described elaborately. The 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, Pediatrics, 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 health care 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 because in all postgraduate clinical examinations, the main clinical long case is invariably a neurological problem. This is 12so, 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.
The book is intented 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.
KV Krishna Das
13Acknowledgments
My editorial committee members and all the contributors have spent much time in putting considerable effort to update the material, add newer chapters demanded by the students and teaching communities and increase the number of illustrations to make the book user-friendly and attractive. Late PK Mohan had assisted in writing of chapters 31 to 34 of (Neurology). Close interaction of the members of the editorial committee and the contributors has helped to make the text up-to-date and attractive.
Mr Abraham Jacob, did the DTP work and put the illustrations in place. The encouragement, patience and endurance of my wife, Mrs LN Kamalam, went a long way in encouraging me to complete the editorial task in time. Dr S Anand (Associate Professor of Ophthalmology) read the proof of chapters in ophthalmology and did corrections.
Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director), Mr Tarun Duneja (Director-Publishing), Mr KK Raman (Production Manager), Mr Sunil Kumar Dogra (Production Executive), Mr Neelambar Pant (Production Coordinator), Manoj Pahuja (Senior Graphic Designer), Sudhir Babu (Graphic Designer), Dr Mohd Naved (Senior Proofreader), Chandra Dutt (Typesetter) and staff members of Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, extended considerable help and constructive suggestions to modify the text and make it come up to modern standards of technical details.