Alagappan’s Clinical Medicine for Dental Students R Alagappan
INDEX
Page numbers followed by f refer to figure and t refer to table respectively
A
Abacavir 434
Abdomen left extra-adrenal paraganglioma 337f
Abdomen palpation 30f
Abdomen, regions of 28, 28f
Abdominal colic, recurrent 65
Abdominal discomfort 151
Abdominal examination, positioning for 29f
Abdominal girth 28
Abdominal pain 66, 73
colicky 59
Abdominal reflex 272, 273
method of testing 272f
Abdominal ultrasonography 36
Abdominal X-rays 36
ABO haemolytic disease 235
Ace inhibitors 154
Achalasia 45
Acid-fast bacillus 211
Acidophilic 344
Acidosis 173
Acids, retention of 83
Acinetobacter spp 196
Acipimox 355
Acquired deformities and conditions 41
Acquired immunodeficiency syndrome 43
secondary infections in 431t
Acral enlargement 341
Acromegalic facies 12
Acromegalic hand 18, 18f
Acromegaly 19
increased heel pad thickness 341f
spade-like fingers and toes 341f
ACTH and cortisol, measurement of 335
Actinomyces spp 196
Actinomycosis 69, 183, 201
Actinomycotic infections 218
Acyanotic fallot 115
Addison's disease 9, 15, 19, 334, 335f, 453, 454
manifestations of 335
Addisonian pernicious anaemia 232
Adenovirus 55
Adrenal androgen, loss of 335
Adrenal insufficiency, secondary 334
Adrenergic blockers 154
Adrenergic drugs 457
Adrenergic stimulants 190
Adrenocorticotropic hormone 9
blocking antibody 334
dependent 332
secretion, increased 335
stimulation test 335, 340
Aegophony 181
Agnosia, types of 267t
Agranulocytopenia 455
Airway obstruction 96
Alanine aminotransferase 70
Alanine transaminase 64
Alcohol 50
Algid malaria 441
Alkaline or bile reflux gastritis 52
Alkaline phosphatase 8
Alkalosis 173
Allergic 15
asthma 171
bronchopulmonary aspergillosis 171
Alopecia areata 12, 12f
Alpha interferon 248
Alpha-1 antitrypsin deficiency 219
Alpha-glucosidase inhibitors (acarbose) 354
Alpha-thalassaemia 455
Alveolar cell tumours 183
Alveolar hypoventilation 106
Amalgam tattoo 454
Amber colour urine 66
Aminoglycosides 82
AML, treatment of 245
Amoebiasis 8, 59, 69
Amoebic and bacillary dysentery, differences between 60t
Amoebic dysentery 59, 60
Amoebic liver abscess 61, 176
Amrinone 156
Amylin analog (pramlintide) 355
Amyloid kidney 85
Amyloidosis 69, 120, 183
Anabolic steroids 16
Anacrotic pulse 94
Anaemia 10, 19, 27, 83, 116, 152, 227
chronic progressive 228
classification 227
aetiological 227
cytometric 227
congenital, haemolytic 233
differential diagnosis of various 228t
haemolytic 228, 233
in malaria, causes of 440
jaundice 89, 244f
megaloblastic 230, 231
of chronic disease 228
pernicious 455
symptoms to 242
Anaesthesia 164
glove and stocking 286
Anasarca 15
Android obesity 14, 398
Aneurysm 219
ventricular 140
left 140f, 151
Aneurysmal dilatation aorta 19
Angioedema 164
Angiogram, coronary 127
Angiotensin receptor blockers 81
Angiotensin-converting enzyme 80, 99, 151, 153, 164
inhibitors 164
Angiotention-II receptor blocker 164
Ankle jerk reflex 275
Ankylosing spondylitis 90, 104, 172
Anomalies, gross 108
Anorexia 64, 76, 142
Anorexia nervosa 15, 401
and bulimia 401
Anorexia, nausea, vomiting 84, 151
Anthracyclines 245
Anthropometric classification 14
Anthropometry 394
Antibacterial drugs 458
Antibiotic treatment in meningitis based on causative organism 311t
Antibodies in patient's serum 407
Anticancer drugs 460
Anticholinergics 191
Anticoagulation indicated, life long 123
Antidiuretic hormone 73
secretion, syndrome of inappropriate 346
Antifungal drugs 459
Anti-HIV drugs prophylaxis 435
Anti-hypertensive therapy 164
Antihypertensives 77
Anti-hypertensives, centrally acting 98
Anti-inflammatory agents 191
Antilarval measures 445
Antimicrobial therapy 42
Anti-platelet drugs 303
Antiretroviral drugs 434t
Antiretroviral therapy, complications of 435
Antisecretory agents (racecadotril) 57
Antiseptics 461
Antithyroid drugs 321
Anti-tubercular drugs
dosage of first-line 207t
second-line 207t
side-effects of first-line 207t
Antiviral drugs 459
Aorta 30, 120, 123, 126, 129
coarctation of 89, 108, 109
dilatation of ascending 89
overriding of 115
preductal coarctation of 114
Aortic and pulmonary ejection clicks, differences between 101t
Aortic aneurysm 44, 89, 165
Aortic dilatation 101
Aortic dissection 127, 128, 165
Aortic murmurs 96f
Aortic prosthesis 101
Aortic regurgitation 89, 90, 91, 95, 115, 116, 127, 129f
acute 127
chronic 127
differences between acute and chronic 128t
Aortic septal defect 101
Aortic stenosis 91, 94, 102, 105, 108, 125, 150, 151
and aortic regurgitation, combined 127
Aortic thrills 92
Aortic valve
acquired calcific stenosis of bicuspid
116
congenital bicuspid 127
disease 105, 125
involvement 127
regurgitation 109
Aortic wall involvement 128
Aortic, mitral, tricuspid valves, regurgitant lesions of 100
Aortopulmonary level shunt 109
Aortopulmonary septal defect 112
Aortopulmonary window 109
Apex beat, position of 171
Apex-pulse deficit See Pulse deficit
Aphagia 44
Aphthous ulcer 43
Apical impulse 90
confirmation of 175
types of 91
Aplastic anaemia 239, 455
Apneustic breathing 174, 314
Appetite, loss of 66, 67
Arachidonic acids 373
Arachnodactyly 17, 108
Arcus senilis 89
Arrhythmias 146, 152, 164
ventricular 114
Arterial blood gas analysis 184
Arterial obstruction 107
Arterial pulse 92
Arteries, complete transposition of great 109
Arteriolar vasodilators 16
Arteriovenous fistula 95
Arteriovenous fistulae, coronary 109, 112
Artery disease, coronary 103, 146, 165
Artery, innominate See Artery, subclavian
Artery, subclavian 19
Arthralgia 119, 143
Arthritis 89, 118
Arthritis See Arthralgia
Ascariasis 183
Ascites 15, 72, 85, 151
causes of 72
chronic 34
grading of 34
pathogenesis of 73f
Ascitic fluid
analysis of 72, 73
causes of
exudate 73
transudate 72
Ascorbic acid See Vitamin C
Aspartate aminotransferase 70
Aspartate transaminase 64
Aspergillus fumigatus 200
Aspiration pneumonia 199
signs of 199t
symptoms of 199t
Aspirin 49, 303
for transient ischaemic attack 125
Asthma 184
acute severe 96, 184
diagnosis of 190
drugs in 190
drugs used for prevention of 190
extrinsic 187
nocturnal 188
pathogenesis of 189f
Asthmaticus, status 191
Astrovirus 55
Asymptomatic mitral stenosis 121
Asymptomatic neurosyphilis 423
Ataxic breathing 174, 314
Atazanavir 434
Athetosis 270
Atria origin arrhythmias 146
Atria, position of 110
Atrial beats, premature 147, 147f
Atrial ectopics 93
Atrial enlargement, left 44
Atrial failure, left 151
Atrial fibrillation 93, 105, 121, 123, 146, 146f, 151
Atrial flutter 147, 147f
Atrial level shunt 109
Atrial myxoma 19, 124
Atrial septal defect 89, 108-110, 151
device closure of 111f
types of 110f
Atrial tachyarrhythmias with varying AV blocks 93
Atrial thrombus, left 105
Atrial tumours, left 105
myxomas 105
thrombus 105
Atrium, left 219
Atrophic gastritis 51
Atropine 8
Atypical pneumonia See Viral pneumonia
Auscultation 9, 35, 96, 179, 210
Auscultatory areas 97, 179
Auscultatory gap 97
Austin Flint's murmur 92
Austin-Flint's murmur and mitral stenosis, difference between 129t
Autoimmune diseases 335
Autoimmune disorders 83
Autonomic neuropathy 98
AV malformation 183
Axillary region 171
Azotaemia 81
B
B12 deficiency 232
earliest sign 231
Babinski and pseudo-babinski sign, differences between 274t
Babinski sign in absence of pyramidal tract lesion 274
Bacillary dysentery 59, 60
Bacilli, isolation and identification of 407
Bacillus calmette-guérin See BCG vaccination
Bacillus cereus 55
Bacillus fusiformis 42
Bacteraemia 200
Bacteria and parasitic organisms 56
Bacteria into lower respiratory tract 200
Bacterial endocarditis 19
Bacterial infections 69, 73, 431, 433, 453
Bacterial peritonitis 72
Balanced diet 391
food pyramid 391f
Baldness 12
Balloon mitral valvuloplasty 123f
Balloon valvuloplasty, percutaneous 123
Barium meal series 52
Barrel chest 171
Barrett's oesophagus 48
Basal metabolic rate 7, 374
Basilar artery migraine 106
Basophil 344
BCG vaccination 206
Beau's line 19, 20f
Becker's sign 128
Bedside lung function tests 182
Bee/wasp sting 15
Behcet's syndrome 43, 450
Bell's palsy 12f, 13, 290
treatment 290
Bell's phenomenon 13
Berger's disease 76
Beriberi 152
Bernard-Soulier syndrome 251
Bernstein test 47
Beta-blockers for chest pain and tachycardia 125
Beta-thalassaemia major 238
Beta-thalassaemia trait 228
Biceps jerk reflex 275
Biceps reflex 276
methods of eliciting 276f
Bicuspid aortic valve 142
Bilateral basal crackles 151
Bilateral obstruction 85
Bilateral pleural effusion 213
Bile breakdown 63
Bile salts 62
Biliary cirrhosis 70, 71
primary 13, 71
secondary 71
Bilirubin uridine diphosphate
glucuronyltransferase 65
Binet staging system 249t
Bioprosthesis 123
Biosynthetic function, tests of 37
Biot's breathing 174
Biotin 382
causes of deficiency 382
daily requirement 382
management 382
Bisferiens pulse 95f
Bitot's spot 13, 377f
Biventricular pacing 156
Black nail 19, 20f
Blackish urine 441
Blackwater fever 441
Bladder 33
distended 30
Blalock-Taussig procedure 117
Bleeding disorders 252t
Bleeding, site of 252
Blood cells
disorders of white 242, 455
red 63, 77
Blood clot prevention 146
Blood count, complete 20, 246, 414
Blood culture 8, 143, 219, 407
Blood examination 219, 442
Blood film, peripheral 236
Blood flow from extremities,
redistribution of 107
Blood flow, altered splenic 260
Blood glucose 335
Blood grouping and typing 20
Blood in stool, gross 56
Blood investigation 57
Blood loss anaemia 228
Blood picture 408
Blood pressure 6, 79, 97, 302
in basal condition 98
measurement 6f
normal 98
record 92
Blood profile 245, 247
Blood smear, peripheral 247, 442
Blood tissues, malignancy involving 456
Blood urea nitrogen 357
Bloody diarrhoea 56
Blue nail 19
Blue sclera 13, 13f
Bluish-white membrane formations in pharyngeal diphtheria 411f
B-lymphocytes 430
BNP-nesiritide, recombinant 155
Body aches 67
Body fluid compartments, normal 15t
Body mass index 14
Body piercings and tattoos 68
Body weight, ideal 14
Bone 38
and joint tuberculosis 205
changes 341
disease 38
marrow 245
biopsy 232
examination 245, 246
picture 247
transplant 246, 247
transplant allogeneic 248
transplant, syngeneic 248
metabolism 435
remineralisation, accelerated 329
Boot shaped heart 116f
Borrelia vincentii 42
Bowel and large bowel diarrhoea, differences between small 58t
Bowel sounds 35
Bowel syndrome, irritable 57
Bowman's space
clearly illustrated 79f
obliterated 77f
Brachial arteriovenous fistula 19
Bradycardia (rare) 64, 156
Bradycardia, extreme 105
Bradypnoea 173
Brain 342f
abscess 114
in tetralogy of fallot patient 116f
sagittal section 342f
tumour 305
Brain–pituitary tumour 342f
Brain–sagittal section 342f
Brainstem injury, sign of 315
Brainstem lesion 173, 315
Breath sounds 179
Breath test 50
Breath-holding test 182
Breathing patterns 169, 174
irregular abnormal 174
regular abnormal 174
Breathing, cluster 314
Breathing, cogwheel 174
Bronchial adenoma 183
Bronchial asthma 104, 178, 179, 187, 215
natural history of 187
pathogenesis of 188f
Bronchial carcinoids, primary 56
Bronchial obstruction 219
Bronchiectasis 16, 19, 219
cylindrical 219
factors predisposing to 219
infection 19
right-sided 220f
types of 220f
Bronchiolitis infection 219
Bronchitis infection 19
Bronchitis, chronic 19, 178, 192
blue bloater 184
emphysema 104
Bronchodilators 191
Bronchogenic carcinoma 19, 183
Bronchogram–bronchiectatic changes 221f
Bronchography 181, 221
Bronchopneumonia 196, 197
versus lobar pneumonia 197f
acute 199
Bronchopulmonary segments 169, 169f, 170t
Bronchoscope, uses of 185
Bronchoscopy 185
Bronchospasm 190
Brucella 143
Brucellosis 69
Brudzinski's neck sign 309f
Brudzinski's sign 309
Bruit 35
Brush border hydrolysis, defect in 62
B-type natriuretic peptide 152, 155
Buccal mucous membrane 16
Budd-Chiari syndrome 69, 70, 72
Bulbocavernosus reflex 272
Bulimia 401
Bulla or cyst, infected 218
Bumetanide 153
Burns 50
chemical or thermal 43
C
CAD, severe 149
Café-au-lait macule 10f
Caged ball valve 123
Calcitriol, structure of 378f
Calcium 62, 384
absorption 385
by bone 326
channel blockers 16, 154
daily requirement 385
dietary sources 384
from bone, increased release of 325
functions 385
increased intestinal absorption of 326
manifestations of 385
Calorie 391
Campylobacter jejuni 55
Candida 432
albicans 421
Candidiasis 51, 451, 453
oral 452f
Caput medusae 29
Carbamazepine 297
Carbohydrate 62, 370
intolerance in pregnancy,
classification of 365t
malabsorption 56
metabolism 350
non-energy yielding 372
Carcinoid syndrome 35, 57, 120
Carcinoma (adeno) 48
Carcinoma lung 215
Cardiac and renal disease,
superimposed 75
Cardiac anomalies, congenital 142
Cardiac arrhythmias 151, 156
type of 156
Cardiac catheterisation 103, 127, 129
Cardiac causes 300
Cardiac cirrhosis 70, 72
Cardiac computed tomography 103
Cardiac failure 70, 93, 94, 150, 154t
congestive 19, 69, 113, 118, 150, 164, 211, 319
diuretics in 153t
Cardiac magnetic resonance imaging 103
Cardiac malpositions 108, 110
Cardiac oedema 15
Cardiac output, reduced 107
Cardiac resuscitation 140
Cardiac stress test 103
Cardiac tamponade 82, 95, 96
in constrictive pericarditis 152
Cardiac toxicities 156
Cardiac transplantation 141
Cardiac valves and auscultatory areas 97f
Cardiomegaly 151, 152
Cardiomyopathies 69, 104, 105, 124, 125, 150
dilated 96
Cardiovascular disorders 312, 399
Cardiovascular syphilis 424
Cardiovascular system 165
complications of 412
Cardioversion 141
contraindications to 141
Carditis 118
Caries 16
Carotenaemia 10
Carotid pulse, palpate 140
Carotid shudder See Carotid thrill
Carotid territory 301
Carotid thrill 92
Castell's method 33
Catamenial pneumothorax 216
Caudate nucleus 269
Cell count, differential 212
Cell cultures 414
Cell enzymopathy, red 236
Cell lung cancer, non-small 222
Cell volume, packed 240
Cellular extract vaccine 409
Cellulitis 15
Centriacinar emphysema 193
Cerebellar dysfunction 280
Cerebellar lesions
causes of 280
localisation of 280
Cerebellum 279
anatomy of 279f
divisions of 279
nuclei of 279
Cerebral haemorrhage 300
Cerebral infarction 299, 300, 301t, 302t
Cerebral malaria 8, 441
Cerebral oedema, treatment of 302
Cerebral thrombosis or haemorrhage, massive 50
Cerebrospinal fluid 205
analysis 309
in meningitis 310t
examination for neurosyphilis 425
Cerebrovascular accident 45
Cerebrovascular disease 312
Cerebrovascular disorders 106
Cervical lymph nodes 17f
Cervical nodes, posterior 258
Cervical spine, X-ray 305
Cervical spondylitis 44
Cervicofacial actinomycosis 453
Chaga's disease 150
Chancre, primary 422f
Chancre, primary See Syphilis, primary
Chancroid 422f, 426
Charcot's arthropathy 362f
Chediak-Higashi syndrome 455
Chemoprophylaxis 445
Chest deformities 171
Chest discomfort or heartburn 45
Chest expansion 176f
measurement of 175
Chest pain 121, 169, 210
Chest shape 171
Chest wall defects 90
Chest wall, lateral 178
Chest wall, posterior 178
Chest X-ray 8, 103, 111-113, 116, 122, 124, 127, 129, 152, 183, 189, 194, 205, 210, 213, 216, 219, 220
Chest, Cobbler's 172
Chest, CT 219
Chest, funnel 172
Chest, movement of 172
Cheyne–stokes breathing 174, 313
Chickenpox 370, 452
Childbirth 19
Childhood cirrhosis/malnutrition 70
Chlamydia psittaci 196
Chlamydia trachomatis 421
Chloramphenicol 19
Chloroquine-sensitive falciparum malaria 445
Cholangiocarcinoma 69
Cholangiography, CT 36
Cholangiopancreatography, endoscopic retrograde 37
Cholangitis 69
Cholera, pancreatic 56
Cholestasis, tests of 38
Chondroma 183
Chorea 119, 269
signs elicitable in 269
Choriocarcinoma 320
Christmas disease See Haemophilia B
Chromium 390
Chromophobes 344
Chronic excessive preload 150
Chronic obstructive pulmonary disease 151
Chvostek's sign 329
Chylothorax 213
causes of 213
Chylous ascites 72, 73
Ciliary function, assessment of 220
Circulatory failure 201
Cirrhosis, alcoholic 70
Cirrhosis, macronodular type of 71f
Clay-coloured stool 65
Clonazepam 297
Clostridium difficile 56
Clotting factors, disorders to deficiency of 254
Clotting, diseases to defect in 456
Clubbing, causes of 19t
Clubbing, types of 19
Coagulopathy 72
Coarse fibrillation 146f
Cobalt 390
Coccidioidoma 183
Coeliac disease 43, 62
Coeliac sprue 57
Coeliac sprue-gluten-sensitive
enteropathy 56
Cold antibody type 233
Cold caloric testing 314
Cold exposure 107
Collagen vascular disease 212
Collagen vascular disorders 127
Collapse, differences between active and passive 175t
Coma, approach to 312
Community-acquired pneumonia 196
Community-acquired pneumonia See Pneumonia, primary or 196
Congenital heart disease, external markers of 109f
Congenital pancytopenia 240
Congenital syphilis
early 424
late 424
Congestive cardiac failure 82, 104
Conjunctival reflex 273
Conn's syndrome 332
Consciousness 313
state of 316
Consequences of H. pylori infection 51
Consolidation, signs of 197
Constrictive pericarditis 69, 70, 72, 91, 96, 100
Contraction, premature ventricular 147
Cooley's anaemia See Beta-thalassaemia major
Coombs test, direct 234, 235
Coombs’ murmur 92
Copper foreign body, intraocular 13
Copper metabolism, disorder of 13
Cor triatriatum 108
Corneal arcus 89
Corneal reflex 273
Coronary arteries, anomalous origin of 115
Coronary artery from pulmonary artery, anomalous origin of left 109
Coronary heart disease 154
Corrigan's sign 128
Corticocerebellar 280
Corticosteroids 461
Costal cartilages 90
Costochondritis 90
Cosyntropin test See ACTH stimulation test
Cough See Tussive syncope
Cough 164, 185, 189, 210, 220
expectoration 151
mechanism of 185
nocturnal 152
types of 185
with sputum 197
Coughing frequency 169
Courvoisier's law 31
Coxiella burnetti 196
Coxiella pneumonia 201
Coxsackie virus 452
Crackles, mechanism of 181
Cremasteric reflex 273, 273f
Cricopharyngeal achalasia 45
Crigler-Najjar syndrome
type I 65
type II 65
Crohn's disease 19, 43, 44, 57, 62
and regional ileitis 56
Cryoprecipitate infusions 255
Cryptic miliary tuberculosis 205
Cryptococcosis 183
Cryptococcus neoformans 432
Cryptogenic 70
cirrhosis 13
Cryptosporidia 431
Curling's ulcer See Burns
Cushing's syndrome 9, 12f, 13, 19, 332,
332f, 333f
acne 333f
adrenal 332, 333
classification of 332
ectopic 332-334
hirsutism 333f
moon face 333f
periodic 333
Cushing's ulcer 50
Cutaneous diphtheria 411
Cyanosis 13, 89, 106, 169
case of central 106
central 10, 106
differential 106
Cyanotic congenital heart disease 19, 106
Cyanotic fallot 115
Cyclic citrullinated peptide 211
Cyst, percussion of 35
Cystic fibrosis 19, 70, 171, 215, 219
Cytarabine 245
Cytoanalysis of ascitic fluids 74t
Cytomegalovirus 198, 200, 432
infection 8
Cytotoxic drugs 50
D
D Leukotriene antagonists 191
Dark-field examination 424
Darting motility 56
De musset's sign 128
Decreased renal calcium excretion 326
Decreased vital capacity by one-third 152
Deep vein thrombosis 211
Defaecation syncope 106
Defining boundaries 33
Degenerative calcific aortic stenosis 142
Deglutition syncope 106
Dehydration 59, 95
Dejerine-Roussy syndrome 286
Delavirdine 435
Dental 329
caries 40, 171, 389
exposure 68
fluorosis 389
guidelines 435
Dentistry, drugs in 457
Dermatome pattern 283f
Dermoid cyst 183
Detecting fluid 33
Dextrocardia 110
isolated 110
situs inversus
with 96
without 96
Diabetes 351
Diabetes insipidus 344
central 345
management, central 345
Diabetes mellitus 15, 38, 70, 80f, 83, 86, 98, 151, 153, 164, 348
classification 348
type 1 349
and 2 352t
management 350
type 2 352
diet planning 353
drug therapy 353
management 353
with CRF 85
Diabetes on pregnancy, effect of 364
Diabetes, acute complications of 356
Diabetes, long-term complications of 359
Diabetic foot 363, 363t
Diabetic hand syndrome 361
Diabetic ketoacidosis 352, 356
and non-ketotic hyperosmolar state, distinguishing between 357t
complications of 357
Diabetic nephropathy 80, 84, 164, 361
manifestations of 80
Diabetic neuropathy
classification 361
different types of 362t
management 362
Diabetic pregnancy before conception 364
Diabetic proliferative retinopathy 360f
peripheral 360f
Diabetic retinopathy 359, 360
Dialysis and ultrafiltration 154
Dialysis dementia 84
Diaphoresis 113
Diarrhoea 55, 56, 59, 66, 82
Diarrhoea persisting 57
Diarrhoea to abnormal motility 57
Diarrhoea
acute 55
causes of 55t, 56t
causes of persistent 57
chronic 55, 57
idiopathic secretory 56
inflammatory 57
secretory 57
types of 55
Diastolic heart failure 151
Diastolic murmur 102
mid 101
Diastolic thrill over mitral area 120
Dicrotic pulse 95f
Didanosine 434
Diet control 42
Dietary fibre 372
water-insoluble 372
water-soluble 372
Dietary history 393
Dietary management 365
Dietary treatment of obesity 399
Digitalis 155
Digitoxicity, management of 156
Digoxin induced arrhythmias 152
Diphtheria 410
classification 410
pertussis tetanus vaccine 76
Dipsogenic diabetes insipidus 346
Dipstick testing 39
Directly-acting vasodilators 164
Directly-observed treatment-short- course
strategy 207
Disease, infectious 76
Disease, perception of 267
Diseases, malignant 72, 211, 259
Disinfectants 461
Disseminated intravascular coagulation 255
Diuretics 77, 153, 154
DNA probe 443
Dobutamine 156
Doctor-patient interrelationship 3
Doll's eye phenomenon 314
Donovania granulomatis 421
Dopamine 156
and dobutamine 156
Down's syndrome 242
Doxycycline 19
Dressler's syndrome 101
Drug therapy
biguanides 353
sulphonylureas 353
triple 50
Drug treatment of typhoid and paratyphoid fever 408t
Drug-induced diarrhoea 55
Drug-induced fever 7
Drugs 8, 15, 82, 98
adverse effects of 465
common needles for injecting 68
Drugs-causing oedema 16
Dubin-Johnson syndrome 65
Duke's criteria 143
Dullness, shifting 33, 179
Duodenal ulcer 51
Duroziez murmur 128
Duroziez's sign 128
Dynamic auscultation 102, 102t
Dysdiadochokinesia 269, 280
Dysentery 58
types 59
Dysmetria 280
Dyspepsia 36
Dysphagia 44, 46
causes of 45
mechanical 44
sideropenic 46
Dyspnoea 104, 169, 210, 213
major symptom of left heart failure 104
on exertion 152
Dyssynergia 280
Dystonia secondary 270
Dystonias 270
types 270
E
E Lipoxygenase inhibitor 191
Ear malformations 108
Earlobe creases 89
Early diastolic murmur 127
Ears, low set 108
Ebstein's anomaly 101, 110
EBV-infected B cells 446
Ecchymosis 85
Ectopia cordis 108
Eczema herpeticum 419
Efavirenz 435
Effusion, causes of bilateral 214
Ehlers-Danlos syndrome 215
Eisenmenger's syndrome 19, 114
Ejection systolic murmur 126
Electrocardiogram 122, 124-126, 129
Electroencephalography 20
Electrolyte 350
imbalance 56
Embryology 115
Emphysema 193
and chronic bronchitis, differences between 192t
diffuse 178
‘pink puffer’ 184
severe 33
types of 193, 193f
Empirical treatment of pneumonias 201t
Empyema 19, 170, 176, 212
causes of 212
or effusion pre-existing fibrosis 175
thoracis 212
Emtricitabine 434
Enalaprilat 155
Encephalopathy 84
Endobronchial 205
tuberculosis 219
Endocardial cushion defects 124
Endocarditis in intravenous drug abusers 142
Endocarditis, infective 36, 114, 116, 121, 127, 142, 152
Endocarditis, negative blood culture in infective 143
Endocarditis, non-infective 145
Endocarditis, sign of infective 143f
Endocrine and metabolic disturbances 312
Endocrine disease 259
Endometriosis 183
Endometrium, carcinoma of 19
Endoscopy 36, 47
Energy requirement, daily 373
for male and females 373t
Energy, source of 373
Energy-yielding carbohydrate 371
functions 371
Enfuvirtide 435
Enhanced external counterpulsation 156
Enlarged liver in cirrhosis 70
Enlarged thyroid gland 44
Enoximone 156
Entamoeba histolytica 55, 56, 431
Enteric fever 8
Enteric gram-negative bacteria 196
Enterobacter spp 196
Enterovirus 55
Enzyme defects, congenital 359
Enzyme-linked immunosorbent assay 50, 206, 414
Eosinophilic gastritis 51
Epididymo-orchitis 416
Epiglottitis, acute 184
Epilepsy 293
anti-epileptic drugs in 297t
classification 293
counselling women with 297
immediate treatment 296
in pregnant women 297
management 296
pathophysiology 294
Epileptics, precautions for 296
Epilepticus, status 296
Epinephrine 156
Epithelial processing, defect in 62
Epithelial transport, defect in 62
Epstein-Barr virus 432, 446, 452
specific antibody tests 448
Equivocal babinski sign 274
Erythema marginatum 89, 119
Erythema multiforme 451
Erythroblastosis foetalis 455
Erythrocyte sedimentation rate-platelet correlation 8
Erythrocytes, disorders associated with abnormal 260
Escherichia coli 55, 56, 196, 200
Essential fatty acids 373
source 373
Ethacrynic acid 153
Ethosuximide 297
Euglycaemia with increased insulin levels 352
Evan's syndrome 236
Exaggerated tendon reflexes 276
Exertional dyspnoea 151
Expiration 173
deep 102
Expiratory airflow, duration of 182
Extra-adrenal paraganglioma 337f
Extracellular fluid 82
Extracutaneous manifestations 451
Extragenital chancre 422f
Extrapulmonary tuberculosis 205
Extrapyramidal tract disease 45
Eye 449
movements, reflex 316
signs in hyperthyroidism 320
F
Face 12
hyperthyroid 12f, 13
in systemic lupus erythematosus 12f, 13
Facial features of virilisation 12f
Facial nerve 288
course of 289f
major branches of 290
palsy 289
Facial pain See Trigeminal neuralgia
Facial palsy 290
Facies in medicine 12f
Facies, type of 12
Factitial diarrhoea 57
Faeces culture 407
Faeces, hard 30
Faeco-oral route of transmission of
typhoid 406f
Falciparum malaria, complications of 442
False platelet counts 248
False positivity for ketones 357
False-negative sign 175
False-positive sign 175
Familial benign hypercalcaemia 327
Fanconi's anaemia 240
Fanconi's syndrome 70
Fasciculation causes 271
Fat 62, 372
solubilisation, defect in 62
soluble vitamins 375
Fatigue 66, 142, 151
Fatty acids
classification of 372
monounsaturated 372
oxidation inhibitors 355
unsaturated 372
Fatty liver, alcoholic 69
Febrile convulsions 7
Febrile illness, acute 19
Felbamate 297
Female anopheles mosquito 439
Female related problems 399
Fenoterol 190
Fever 7, 59, 66, 73, 119, 142, 173, 197
continuous 7
intermittent 7
patterns of 7
relapsing 7
with relative bradycardia 7
Fibre neuropathy, large 361
Fibreoptic bronchoscope 185
Fibrillation, ventricular 148
Fibroma 183
Fibrosing alveolitis 215
Fibrosis 175
and collapse, differences between 175t
Filariasis 15, 17
Finger clubbing 213
Finger flexion reflex 275
Finger-finger-nose test 268, 268f
Finger-nose test 268
Fingers, abnormalities of 17t
arachnodactyly 18f
polydactyly 18f
syndactyly 18f
Fingers, clubbing of 18
Flag sign 12
Flat chest 171
Flick or tap gently 34f
Fluid and electrolyte imbalance 54
Fluid thrill 34
Fluorescence microscopy 443
Fluorine 389
daily requirement 389
dietary sources 389
in human health, role of 389
Flutter, ventricular 148
Foetal development 364
Folate 382, 394
deficiency, causes of 231
Folic acid 62, 383
deficiency 231
Follicle-stimulating hormone 340
Follicular tonsillitis and diphtheria, differences between acute 411t
Food as therapy 370
Food based on
function 370
nutrients 370
classification of 371
macronutrients 370
micronutrients 370
water 370
Food in health and disease, importance of 369
Food in prevention of disease 369
Food, classification of 370
Food, role of 369
Foot pat test 269
Forchheimer spots 415
Foreign body 219
Friction fremitus 176
Friction rub 36
Fundal haemorrhages 244f
Funduscopic examination 316
Fungal 218
endocarditis 144
infections 432, 433, 453
Fungi See Candida albicans
Furosemide 153
Fusiform bronchiectasis 219
G
Gabapentin 297
Gait, abnormalities of 280
Galactosaemia 70
Gallbladder 29
carcinoma of 31
palpation of 31
Gallium nitrate 328
Gallops 100
Gamma-glutamyl transpeptidase 38
Ganglion blocking agents 98
Gas diffusion capacity 184
Gastric asthma 188
Gastric atrophy 51
Gastric B-cell lymphoma 51
Gastric cancer 51
Gastric outlet obstruction 54
Gastric peristalsis, visible 29
Gastric secretions 200
Gastric ulcer 51
only, malignancy with 54
Gastritis 49
acute erosive 49
chronic atrophic 51
chronic stages of 51
classification of 49
corrosive agents induced 51
gastric surgery 52
infectious 51
superficial 51
Gastrocolic fistula 54
Gastroenteritis, infectious 55
Gastroesophageal anti-reflux mechanism 46f
Gastroesophageal reflux disease 45, 46
signs of 47
symptoms of 47
Gastrointestinal bleeding 75, 83
severe 35
Gastrointestinal malignancy 19
Gastrointestinal tract 27, 153, 253
symptoms 155
Gaucher's disease 69
Genetic disorders 238
Genital herpes 419
Genital HSV 420
Genital mucosa 449
Genitourinary tuberculosis 205
Gerhardt's sign 128
Gestational diabetes mellitus 364
Giant cell arteritis 305
Giardia lambia 55, 431
Gilbert's syndrome 65
Gingival disease 41
Gingivostomatitis and pharyngitis 419
Glabellar reflex 279
Glabellar tap 279f
Gland disorders
adrenal 331
types of adrenal 331
Glasgow coma scale 265
best motor response 265
best verbal response 265
decorticate posture 265
eye opening 265
Glomerular disease, primary 76
Glomerular filtration rate 39, 79, 82
Glomerulonephritis 76, 82
acute post-streptococcal 77
mesangial hypercellularity, focal
proliferative 80f
post-infectious 77
Glomerulopathies 86
Glomerulosclerosis, focal 78
and segmental 80
Glomerulosclerosis, nodular 80
Glomerulus, normal 79f
Glossitis 46
Glossopharyngeal nerves 44
Glucagon-like peptide 1 355
Glucocorticoid 16, 328
insufficiency 334
replacement 335
Glucocorticosteroids 191
Glucose level 211
Glucose-6-phosphate dehydrogenase deficiency 236
Glycaemic index 371
Glycogen storage disease, type IV 70
Glycoprotein IIb IIIa inhibitors 303
Golden rules 90
Gonorrhoea 425, 453
disseminated gonococcal infection 426
females 425
males 425
management 426
newborn 426
Goodpasture's syndrome 76
Graham-Cole test 37
Gram-negative sepsis 255
Granulocytes in maturation 247f
Granuloma, non-specific 183
Granulomatous gastritis 51
Granulomatous liver disease 38
Graphaesthesia 285
Grasp reflex 279
Graves’ disease 320
Gravidarum See Striae atrophica
Great vessel without septal defects 114
Greenish-yellow skin 65
Grey-turner's method 29
Groins, para-aortic nodes and vessels, palpation of 32
Growth hormone 340
Guillain-Barré syndrome 76, 104
Gynoid obesity 14, 398
Gynoid type (pear-shaped) 14f
H
H pylori, diagnosis of 50
Haemangioma 35
Haematemesis 186
Haematological causes 300
Haematological investigations 20
Haematuria, minimal 79
Haemochromatosis 19, 70
Haemoconcentration 56
Haemodynamically stable ventricular tachycardia 149
Haemoglobin level 229
Haemolytic anaemias
acquired 236
treatment 236
causes of autoimmune 233t
Haemophilia A 254, 255
complications 254
management 254
treatment 255
Haemophilia B 254
Haemophilus ducreyi 421
Haemophilus influenzae 196, 253
Haemophilus parainfluenzae 143
Haemoptysis 121, 186, 197, 220
and haematemesis, differences
between 186t
causes of 185t
severe 114
Haemorrhage 82
postoperative 82
postpartum 82
subconjuctival 244f
Haemorrhagic See Gastritis, acute erosive
Haemostasis disorders 251
Haemothorax 170, 212
Hair 10
Half-half nail 20f
Hallmark of digitoxicity 156
Hamartoma 183
Hamman's mediastinal crunch 181
Hand in cardiac palpation, application of 90f
Hand-foot-and-mouth disease 452
Hands and fingers 17
Hansen's disease 19
Harrison's sulcus 172
Hashitoxicosis 320
Head and eye deviation 315
Headache 76, 304
classification 304
cluster 305
management 305
pain structures
insensitive 304
sensitive 304
types of 305t
Health 369
Heart 341
blocks 93, 105
congenital complete 108
disease
acquired 89
acquired valvular 104
congenital 89, 100, 104, 108
coronary 104
incidence of congenital 108t
ischaemic 3, 90, 100, 105, 124, 125, 150, 151, 164
mitral 146
extreme clockwise rotation of 101
failure 151t, 154, 155
acute left 104
backward 151
biventricular 150
chronic right-sided 70
diagnosis of congestive 152
forward 151
forward and backward 151
left 104
left sided 150
right sided 150
systolic and diastolic 151t
malformations, left 108
murmurs 102
rate 148
shunt, aortic root to right 109
sound 99
first 99
fourth 100
second 100
third 100, 152
Heel-knee test 269, 269f
Heinz bodies 236
Helicobacter pylori 49, 52
gastritis, acute 50
Hemiballismus 270
Hemiplegia 19
Henoch-Schönlein purpura 76
Hepatic amoebiasis 60, 69
Hepatic artery aneurysm 35
Hepatic cirrhosis 72
Hepatic encephalopathy 72
Hepatic failure 50
Hepatic oedema 15, 16
Hepatic vein thrombosis 75
Hepatic venous occlusion 72
Hepatic venous outflow obstruction 70
Hepatitis 8, 66
Hepatitis A 66
virus 66
Hepatitis B 66
virus 66, 67f, 432
pathogenesis of 67
structure of 66f
Hepatitis C 68, 68f, 432
and protein 68f
virus 68
Hepatitis D 69, 432
virus 69
Hepatitis E 69
virus 69
Hepatitis, acute alcoholic 35
Hepatitis, infective 69
Hepatobiliary system 38
Hepatocellular carcinoma 35, 69, 72
Hepatocellular jaundice 64
Hepato-jugular reflex, positive 152
Hepatoma 69, 75
Hepatomegaly 69, 69t, 152
Hepatorenal syndrome 72
Hepatotoxic drugs 75
Herditary fructose intolerance 70
Heredodegenerative dystonias 270
Heritable renal disease, family history of 83
Hernia, sliding 48
Herpangina coxsackie virus A and B 452
Herpes encephalitis 419
Herpes gladiatorum 419
Herpes infection, pathway of 418f
Herpes labialis, recurrent 452
Herpes simplex virus 198, 418, 432, 452
infections, treatment of 420
types of 419
Herpes zoster (shingles) 417, 452
complications 417
investigations 417
management 418
systemic therapy 418
analgesics 418
antivirals 418
topical therapy 418
virus 432
Herpetic gingivostomatitis 16
Herpetic keratitis 419
Herpetic whitlow 419
Heschl's transverse gyrus 266
Heterophile antibodies, test for 447
Heterophile antibody test 447
Hiatus hernia 218
Hill's sign 128
Hirsutism 12
Histiocytosis X 215
Histoplasmoma 183
Histoplasmosis 69, 432, 453
and crohn's disease 51
Hodgkin's disease 38, 79
Hodgkin's lymphoma 456
Hoffman reflex 275, 275f
Homocystinuria 17
Homozygous beta-thalassaemia 238
Honey-moon phase 350
Hormone dependent, non-adrenocorti-cotropic 332
Hormone, treatment of deficient 340t
Hormones, role of counter regulatory 356
Horner's syndrome 314
Hospital-acquired pneumonia (nosocomial) 196, 200
factors predisposing to 200
HSV, primary 420
Human cycle 439
erythrocytic stage 439
gametogony 439
pre-erythrocytic (tissue) stage 439
Human immunodeficiency virus 8, 17, 43, 79, 206, 427
and AIDS 427
immunopathogenesis of 428f
infected patients 429f
infection 15
primary 452
Human insulins 350
Human leucocyte antigen 240
Human papillomavirus 432
Humoral and cell-mediated immunity 430
Hunter's syndrome 120
Huntington's chorea 269
Hurler's syndrome 120
Hydatid cyst 183
infected 218
Hydatid thrill 35
Hydatidiform mole 320
Hydralazine 16, 154
Hydrolysis, defect in substrate 61
Hydronephrosis See Bilateral obstruction
Hydrothorax 15, 151, 170
Hydroxycarbamide See Hydroxyurea
Hydroxyurea 238
Hyperaldosteronism management
primary 332
secondary 332
Hyperalgesia and hyperaesthesia, contralateral 285
Hypercalcaemia 385
causes 385
crisis 327
in malignancy 327
causes 327
treatment 327
treatment of severe 328, 328t
Hypercholesterolaemia 79, 81
Hyperdynamic apical impulse, differences between heaving and 91t
Hyperdynamic states 89
Hyperglycaemia 435
Hyperkalaemia 83, 84, 387
causes 387
management 387
Hyperkinetic pulse 94, 94f
Hyperlipidaemia 435
Hyperlipoproteinaemia 165
Hypermagnesaemia 83, 84
Hypernatraemia 386
causes 386
management 386
Hyperosmolar coma 358
management 358
Hyperparathyroidism 326f
osteolytic lesion 326f
primary 325
secondary 327
causes 327
treatment 327
to bone resorption 19
Hyperphosphataemia 83, 84
Hyperpigmentation 85
Hyperpituitarism—acromegaly and
gigantism 341
Hyperplasia of adrenals 332
Hyperplasia, gingival 244f
Hyperpnoea 173
Hyperprolactinaemia 343
management 343
Hyperpyrexia 7, 8
causes of 8
Hypersensitive carotid sinus 106
Hypersplenism 260
management 260
Hypertelorism 13
in increased distance between medial canthuses of eyes 13f
Hypertension 76, 79, 83, 84, 86, 91, 105, 146, 150, 151
accelerated 98
causes of 98
complications of 165
drugs for control of 338
episodic or paroxysmal 99
malignant 98
with hyperlipidaemia 164
with left ventricular hypertrophy 164
Hypertensive crisis, management of 165
Hypertensive emergency 99
Hypertensive heart disease 104
Hypertensive states 99
Hypertensive urgency 98
Hyperthermia 8
causes 8
malignant 8
Hyperthyroidism 19, 38, 319, 319f
management options for 321t
Hypertonic saline infusion test 346
Hypertrichosis 12
Hypertrophic cardiomyopathy 100, 102
Hypertrophic gastritis See Menetrier's disease
Hypertrophic obstructive
cardiomyopathy 105
Hypertrophy, left ventricular 165
Hypertyelorism 108
Hyperuricaemia 83, 84
Hypervitaminosis 382
Hypervitaminosis A 377
acute toxicity 377
carotenaemia 377
chronic toxicity 378
Hypervitaminosis C 384
Hypervitaminosis D 379
prevention 380
Hypervitaminosis E 380
Hypervitaminosis K 381
Hypoalbuminaemia 19, 72, 73, 79, 214
Hypocalcaemia 83, 84
causes of 328
manifestations of 385
Hypocalcaemic disorder 328
Hypoglycaemia 351
Hypogonadism 17
Hypokalaemia 149, 387
causes 387
management 387
Hypokinetic pulse 94, 94f
Hypomagnesaemia 149
Hyponatraemia (dilutional) 84, 386
Hyponatraemia causes 386
Hypoparathyroidism—tetany 329f
Hypopituitarism 17, 339
Hypopituitarism hypothalamic 339
acquired 339
congenital 339
Hypopituitarism oral manifestations 340
Hypopituitarism pituitary 339
Hypoplastic left heart syndrome 114
Hypoproliferative marrow 228
Hypoproteinaemia 72
Hyposplenism/asplenia 260
Hypotension 82, 93, 140
Hypothalamic fever 8
Hypothermia 7
Hypothermic coma See Myxoedema coma
Hypothyroidism 19, 72, 173, 322
difference between primary and secondary 322tw
Hypotonia 280
Hypoventilation, primary alveolar 184
Hypovolaemia 81, 82, 98, 105
Hypovolaemia 93
Hypoxia 173
Hysteria 173
I
Iatrogenic-electrolyte imbalance to diuretic excess 152
Icterus 13
Idiopathic neutropenia, chronic 455
IGA nephropathy See Berger's disease
Ileus, paralytic 35, 83
Ill health, general 67
Immune cells in non-HIV-infected 429f
Immune complex mediated 233
Immune disorders 260
Immune response, normal 257
Immunisation, active 414
Immunisation, passive 415
Immunity in malaria 442
Immunity, acquired 442
Immunity, disturbed 70
Immunodeficiency syndrome 219
acquired 62, 196, 427, 430
Immunopathogenesis 429
Indinavir 434
Indwelling catheters 142
Infarction, acute
inferior wall 93
myocardial 91, 99, 101
Infection, severe 49
Infectious complications, control of 245
Infectious diseases 370
Infective endocarditis, prevention of 125
Inferior vena cava 123, 127
Inflammation, active 75
Inflammatory diseases 17
Influenza See Viral fever
Infra-axillary region 171
Infraclavicular area 171
Infrascapular region 171
Infundibular pulmonary stenosis 115
Inguinal lymph nodes, small 30
Innate immunity 442
Inspiratory tracheal descent 175
Insulin 355
actions of 350t
allergy 351
delivery, devices for 351
levels, overt diabetes with declining 352
levels, post-prandial hyperglycaemia with increased 352
oedema 352
pens 351
pump therapy
external 351
implanted 351
regimens 351
bedtime insulin 351
mixed therapy 351
multiple daily injections 351
single dose 351
resistance 351
role of 356
syringes 351
therapy 365
complications of 351
principles of 355
Insulinotropins 355
Insulinotropins excretins 355
Insulinotropins incretins 355
Intensive care unit 54
Intercostal tenderness 213
Interferon alpha 79
Interscapular region 171
Intestinal amoebiasis 60
Intestinal obstruction, advanced 35
Intestinal peristalsis, visible 29
Intestinal tract 38
Intestine, diseases of 55
Intestine, surface marking of large 28f
Intolerance, intramuscular 230
Intra-abdominal abscess 212
Intra-aortic balloon pump 156
Intracerebral haemorrhage, primary 299
Intracranial tension, seizure disorders and raised 312
Intraoral herpes simplex 452
Intrapulmonary shunts, multiple small 106
Intra-renal failure 82
Intravenous rehydration 57
Intrinsic asthma 188
Intrinsic heart muscle disease 150
Iodine 389
daily requirement 389
deficiency 389
dietary sources 389
Iron 50, 62, 387
absorption of 387
daily requirement 387
deficiency anaemia 46, 48, 228, 387
causes 388
signs 387
symptoms 387
stages in 229
treatment 388
deficiency, chronic 27
dextran-intravenous 230
dietary sources 387
excess 389
functions of 387
metabolism 228
requirement 230
sucrose 230
Iron-deficiency anaemia 19, 455
Irregular rhythm, regularly 93
Ischaemic heart disease 155
Isometric exercise 103
Isopora belli 431
Isoprenaline 156
Itching 66
Itchy skin 67
Ivy's method for BT 252
J
Janeway lesions 89, 143
Jaundice 10, 63, 64t, 66, 151
congenital 65
fluctuating 65
haemolytic 64
obstructive 27, 64, 65
physiological 65
types 64
Jaw jerk reflex 275
John cunningham virus 432
Joint sense 283
Joint swelling 89
Jug handle appearance 111f
Jugular venous pressure 151
K
Kala-azar 69
Kallmann's syndrome 339
Kartagener's syndrome 219
Kayser-Fleischer ring 13, 27, 27f
Kernig's sign 309
stage 1 309f
stage 2 309f
Ketotifen 190
Kidney 28, 165
bimanual palpation of 32f
damage, current evidence of 83
disease
chronic 83
polycystic 84, 85
stages of chronic 83
lower pole of either 30
palpation of 32
Kissing disease 446
Klebsiella pneumoniae 196, 198, 200
Klinefelter's syndrome 242
Knee jerk
of ankle jerk 278f
reflex 275
Knee reflex, inverted 278
Koilonychia 19, 20f, 27, 46
Koplik's spots 413
on buccal mucosa 414f
Korotkoff sounds 6, 97
Kupffer cells 36
Kussmaul's breathing 174
Kussmaul's sign 140
Kwashiorkor 394, 395
Kyphoscoliosis 104, 172
Kyphosis 172f
scoliosis 90
L
LA myxoma 124
Labile hypertension 99
Lactase deficiency 56
Lactic acidosis 358, 435
causes 358
treatment 359
Lactic dehydrogenase 37
Lactose intolerance 57
Laennec's cirrhosis See Alcoholic cirrhosis
Lamivudine 434
Lamotrigine 297
Landolfi's sign 128
Laryngeal diphtheria 411
Laryngeal or tracheal obstruction 104
Laryngeal stridor 181
Laryngeal tuberculosis 205
Laryngitis 48
Larynx, carcinoma of 19
Laurence-Moon-Biedl syndrome 17
Left atrium 120, 123, 124, 126, 127, 129
Left ventricle 120, 123, 124, 126, 127, 129
Left ventricular hypertrophy 123, 151
Leonine facies 12f, 13
Lesion, localisation of site of 300
Lethargy 84
Leucine aminopeptidase 38
Leucocyte abnormalities 84
Leucocyte count 408
differential 447
total 447
Leuconychia 27
Leukaemia 69
or lymphoma generalised
lymphadenopathy 27
to tissue infiltration 19
Leukaemia, acute 17, 456
lymphoblastic 242, 246
lymphoblastic classification 246
myeloid 242
Leukapheresis and splenectomy 248
Levine and Freeman's grading of murmurs 102
Levocardia 110
Lichen planus 450, 451
lacy white 450f
management of 450
violaceous 450f
Lichenoid reaction 454
Limb threatening infections 363
Limbs, testing coordination in
lower 269, 269f
upper 268
Lindsay nail 19
Lindsay nail See Half-half nail
Linoleic acid 373
Linolenic acids 373
Lipid metabolism 350
Lipid storage diseases 259
Lipodystrophy syndrome 435
Lipoid pneumonia 183
Lipoma 183
Lips, color of 16
Live oral vaccine 409
Liver 28, 33, 341
abscess 38
aspiration of 61
cirrhosis of 19, 69, 72, 152, 211
disease, model for end stage 38
diseases of 63
edge of 30
function tests 37, 448
nutmeg 72
or bone, primary or metastatic
tumour of 38
palpation of 30, 30f
span 33
surface marking of 28f
transplantation 67, 75
uptake into 63
Lobar pneumonia 197
right middle lobe 197f
Loint mobility, limited 361
Lopinavir 434
Ludwig's angina 451
management 452
treatment 451
Lumbar puncture headache 305
Luminal availability and processing, defect in 62
Luminal phase 61
Lung abscess 16, 19, 218, 219t
predisposing factors for 218
Lung cancer 222
cavitating 218
Lung disease
chronic obstructive 104
chronic restrictive 104
classification of pulmonary disease, chronic obstructive 194
interstitial 19, 104, 178
suppurative 19
Lung fields 151
crackles in 152
Lung infections, recurrent 220
Lung volume estimation 182
Lung volumes 183f
Lung, borders of 170
Lung, bronchiectasis right 220f
Lung, chronic
abscess 183
disorders 151
Lung, collapse of 175
Lungs, clear 140
Lupoid hepatitis 70
Luteinising hormone 340
Lymph node, structure of 258
Lymph nodes 17, 219, 257
and spleen, disorders of 257
Lymphadenopathy infectious diseases 258
bacterial infections 258
chlamydial infections 258
fungal infections 258
viral infections 258, 259
Lymphadenopathy management 259
Lymphadenopathy, causes of 17t
Lymphangitis, chronic 15
Lymphatic carcinomatosis 184
Lymphatic obstruction 72
Lymphatic oedema 15
Lymphatic system 257f
Lymphocytic leukaemia, chronic 242, 249, 249f
Lymphoma 17, 19, 69, 183
deposits 171
Lymphoreticular disorders 27
M
M Kansasii infection 431
M tuberculosis 431
Macrocytic-hyperchromic 227
Macrocytosis, causes of 231
Macrominerals 384
Madarosis 13
Maddrey index 38
Magnesium 62, 385
Magnesium dietary sources 385
Malabsorption 35, 61
syndromes 15
tests of 61t
Maladie-de-roger syndrome 112
Malaise 76, 142, 437
Malar flush See Mitral facies
Malaria 69, 370, 443
asexual phase 438
benign 440
changes in organs in 441f
congenital 441
control programmes 445
life cycle 438
malignant tertian 441
management of 444
regimens for treatment of 444t
sexual phase 438
transmission of 438
treatment of complicated 445
vaccine 445
Malignancy 8, 15, 54, 212, 214
Mallory's bodies 70
Malnutrition 15, 72, 75, 369, 392
complications 393
Mammary region 171
Marasmic-Kwashiorkor 394
Marasmus 394, 395
Marfan's syndrome 17, 125, 128, 215
Massive hydrothorax 152
Maturation disorder 227
Maximal expiratory flow rate 182
Maximum normal oral temperature 7
Measles 370, 413, 414f
complications of 414, 414t
infection 219
investigations 414
management 414
mumps 19
prevention 414
Mediastinal masses, posterior 44
Meglitinide 354
Meig's syndrome 72
Melanin pigmentation, diffuse 454
Melanoma, malignant 454
Melanotic macule (oral) 454
Membranoproliferative GN 78
Membranous glomerulonephritis 78, 80
Menetrier's disease 52
Meningeal syphilis 423
Meningitis 7, 308
empirical treatment of 310t
Meningococcal meningitis 8
Meningovascular syphilis 423
Menstruating women 229
Mental rest 153
Mesangial proliferative
glomerulonephritis 80
Mesangial proliferative GN 76
Mesangial sclerosis 80
Mesangiocapillary GN 76
Mesangioproliferative GN 78
Mesocardia 110
Mesothelioma 5, 19, 175
Metabolic acidosis 173
with anion gap 83
Metabolic cirrhosis (rare) 70
Metabolic coma 316
Metabolic defects 341
Metabolic disorders 399
Metabolism of
bilirubin 63, 63f
vitamin D 378f
Metaproterenol 190
Metastatic gastrointestinal carcinoid
tumours 56
Metformin 354
Methaemoglobinaemia 10
Methicillin-sensitive and methicillin-resistant S. aureus 196
Methylcobalamin 232
Methylxanthines 191
Methysergide 120
Metyrapone test 335
interpretation of 336t
Microalbuminuria 80
Microminerals 384
Micronodular type of cirrhosis 70f
Microsporidia 431
Micturition syncope 106
Mid-diastolic murmur 120
Middleton's manoeuvre 32
Midstream urine collection 39
Migraine 305
Mild fever 67
Mild mitral stenosis 101, 121
Miliary tuberculosis 17, 205, 206f
Milkmaid sign 270
Milrinone 156
Mineralocorticoid insufficiency 334
Mineralocorticoid replacement 336
Minerals 375, 384
types of 384
Minoxidil 16
Mithramycin See Plicamycin
Mitral facies 120
Mitral prosthesis 101
Mitral regurgitation 91, 89, 101, 102, 123, 123f, 150
acute 124
chronic 124
congenital 124
difference between acute and chrome 123t
late phase of VSD, PDA 151
Mitral stenosis 94, 96f, 108, 120, 122, 129t, 151
calcific 101
common 101
congenital 101
moderate 121
severe 101, 121
Mitral valve
disease 120
parachute 124
prolapse 108, 142
syndrome 101, 102, 124, 125
vegetation 144f
Mitral valvotomy/commissurotomy
closed 122
open 123
Mitral valvular abscess, large 144f
Mitral valvulotomy 125
Molluscum contagiosum, typical umbilicated papule of 11f
Monocytes/macrophages 430
Mononucleosis or glandular fever, infectious 446, 447, 448
Mononucleosis, infectious 69, 446, 452
management 448
oral manifestations 447
Moon face 12f
Mosquito cycle 439
Mosquito-borne malaria and blood transfusion malaria, difference between 442t
Motor disorder 45
Motor dysphagia 44
Mouth and pharynx 16
Mouth, angle of 16
Mucinous ascites 74
Mucocutaneous manifestations 450
Mucoid impaction 183
Mucosal disease 56
Mucous membrane pemphigoid 451
Mucous membrane, pigmentation of 16
Muller's sign 128
Multidrug-resistant tuberculosis 203
Multiple ventricular premature depolarisations 156
Multisystem disease 76
Mumps 416
management 417
prevention 417
Murmur of mitral valve prolapse syndrome 102
Murmur, conduction of 102
Murmur, intensity of 102
Murmurs, differential diagnosis of continuous 112t
Murphy's punch 33f
Murphy's sign 31
Muscle in thyrotoxicosis, thickened extraocular 321f
Muscle power 281
Muscle tone 281, 316
types of 281f
Muscle weakness 45
Muscles of expiration 173f
accessory 173
Muscles of inspiration 173f
accessory 173
Muscular defect 109
Musculoskeletal disorders 399
Musty foetor oris 42
Myasthenia gravis 45, 104
Mycetoma 183
Mycobacteria, atypical 200
Mycobacterial infections 259
Mycobacterium avium 220
complex 431
Mycobacterium bovis 203
Mycobacterium tuberculosis 198, 200, 203
Mycoplasma 196
pneumonia 201
Myeloid leukaemia
chronic 36, 242, 247, 247f, 248
classification of acute 243t
Myeloma kidney 85
Myocardial abscess 124
Myocardial infarction 19, 82, 123, 124
acute anterior wall 93
silent 151
Myocardial pump failure 98
Myocarditis 150-152
and atrial septal defect 146
Myoclonus 271
causes 271
Myokymia 271
Myopathies 45
Myotonic dystrophy 45
Myxoedema See Hypothyroidism
Myxoedema coma 324
Myxoma 183
N
Naevi 454
Naiacin 394
Nail 329
changes 19t
red 19
Nail-bed angle, normal 18f
Nails or milk spots, white 27
Narcotic drug poisoning 173
Nasal diphtheria 410
Nasal mucosa 449
Nasal polyps 171
Nasal septum, deviated 171
Nasopharyngeal, aspiration of 200
Natural killer cells 430
Nausea 66, 67
and anorexia 84
and vomiting, persistent 36
Neck 17
vein 17
distension 152
Necrosis, acute tubular 82
Necrotic tissue in lower anterior region 42f
Necrotising periodontal disease 41
Necrotising ulcerative gingivitis 42f
Nedocromil sodium 190
Neisseria gonorrhoeae 421
Nelfinavir 434
Neocerebellum 280
Neonatal herpes simplex virus infection 419
Neonatal hyperthyroidism 322
Neoplastic diseases 17, 346
Neoplastic lesions 433
Neopterin 433
Nephritic syndrome, acute 81
Nephritis, interstitial 82, 84
Nephrogenic diabetes insipidus 345
management 345
Nephrosis 72
Nephrotic and nephritic syndrome, difference between 81
Nephrotic syndrome 72, 77, 78, 81, 211
features of 79
pathogenesis of 78
Nephrotoxic drugs 75
Nerve
abducent 287, 288
assessory 288
cranial 286, 288t
disorders of cranial 289
glossopharyngeal 288
vagus 288
hypoglossal 288
oculomotor 287, 288
optic 287, 288
pathic trochlear 288
trochlear 287
types of cranial 288t
Nervous system, central 54, 165, 265, 325
disorders 346
Nervous system, complications of 412
Neuralgic headache 307
Neurogenic hyperventilation, central 313
Neurogenic tumours 183
Neurological symptoms 416
Neuromuscular See Motor dysphagia
Neuropathy (C-fibre), small fibre 361
Neuropathy, anatomical classificaiton of 362t
Neutropaenia 164
Neutropaenia, cyclic 7, 455
Neutrophils, increased 212
Nevirapine 435
Newborn, haemolytic disease of 234
Niacin 381
causes of deficiency 382
dietary sources 382
management 382
pellagra 382
Nickel 390
Nicotinamide 381
Nicotine stains on fingers and teeth 89
Nicotinic acid 381
Niemann-Pick's disease 69
Night blindness 377
Nitrates 154
Nitroglycerine 155
Nixon's method 33
Nocardiosis 183
Non-Hodgkin's lymphoma 38
Non-insulin-dependent diabetes mellitus 356
Non-ketotic hyperosmolar syndrome 352
Non-limb-threatening infections 363
Non-peristaltic contractions 45
Non-pharmacologic measures 153
Non-proliferative retinopathy 359f
Non-respiratory cause 176
Non-steroidal anti-inflammatory drug 16, 49, 82, 152, 153, 306, 457
and peptic ulcer 52
Norepinephrine 156
Nuclear defects 227
Nutrients 369
and health 369
over 392
state of 14
surveys, biochemical tests in 394t
Nutritional disorders 391, 392
classification of 392
Nutritional oedema 15, 16
Nutritional rehabilitation services 396
Nutritional status 27, 369
assessment of 393
Nystagmus 280
O
Obesity 14, 89, 104, 151, 397
danger of 399
generalised 14
grading of 14
pattern of 14f
superior or central type of 14, 398
to endocrine causes, secondary 399
types of 14, 398
Obstructive abnormality 182
Ocular motility 314, 316
Ocular movements 314
Odynophagia 44
Oedema 15, 76, 79
causes of 15t
extremity 152
generalised 15
idiopathic 16
inflammatory 15
localised 15
pedal 16
pitting 151
pedal 16f
types 15
Oesophageal manometry 47
Oesophageal rupture 212
Oesophageal smooth muscle, disorders of 45
Oesophageal spasm, diffuse 45
variants of 45
Oesophageal webs 46
Oesophagitis 48
Oesophagus
diseases of 44
rupture of 176
Oestrogens 16
Older age 83
Olfactory nerve 287, 288
Oliver's sign 174
Oophoritis 416
Opoid analgesics and antagonists 458
Oral anti-diabetic agents, pharmacology of 354t
Oral candidiasis 452t
Oral cavity 171
diseases of 40
Oral cholecystogram 37
Oral contraceptives 454
Oral hairy leucoplakia 433f
Oral hygiene 171
Oral infections 16
Oral lichen planus 68
Oral manifestations 295, 320, 396
classification of 433t
of dermatological disorders 449
of haematological disorders 455
of haemophilia 255
of infectious diseases 451
of mucocutaneous lesions 449, 451t
to vitamin deficiency 384t
Oral mucosa 449
pigmented lesions of 454t
Oral rehydration solution 57
Oral thrush 171
Oral ulcers, types of 43t
Oral vasodilators 155
Orange-tinged skin 64
Organ failure, multiple 201
Organisms causing lung abscess 218
Organisms, uncommon 196
Organs, surface marking of 28
Oropharyngeal anaesthesia 44
Orthopnoea 104
Orthostatic hypotension 98, 106
Osler's disease See Polycythaemia rubra vera
Osler's nodes 89
Osler's sign 99
Osmolarity ORS, composition of reduced 57t
Osmotic diarrhoea 57
Osteitis fibrosa cystica 325
Osteogenesis imperfecta 13f
Osteomalacia 38
Ostium primum 109, 110, 111
Ostium secundum 109, 110, 111
atrial septal defect 125
Overdiuresis 82
Oxygen 153
diffusion, impaired 106
P
Paget's disease 38
Pain, severe 48
Palatal reflex 273
Pale motions (stool) 64
Pale stool 66
Paleocerebellum 280
Pallor 10, 13
Palmo-mental reflex 279
Palpable gall bladder 65
Palpitation 105
Panacinar emphysema 193
Pancreatitis 54, 72, 82, 212, 416
acute 211
Pansystolic murmur 102, 123
Papillary muscle dysfunction 124
Paradox 99
Paradoxical hypertension 99
Paraganglioma, left extra-adrenal 337f
Paramembranous defect See Perimembranous
Parapneumonic effusion 212
complicated 212
empyema 201
Paraseptal emphysema 193
Parasites, quantification of 443
Parasitic infestations 259
Parasternal heave, left 120
Parasternal heave, method of palpation for 91f
Parasternal impulse 91
grading of 91
Parasternal thrills, left lower 92
Parathyroid adenoma 326f
Parathyroid gland disorders 325
Parathyroid hormone
deficiency 328
resistance 329
secretion, suppressed 329
Paratyphoid fever 405
Parenteral iron therapy 230
Parenteral vasodilators 155
in cardiac failure 155t
Parkinsonian face 12f, 13
Paroxysmal atrial tachycardia 156
Paroxysmal nocturnal dyspnoea 104, 105, 123, 151, 152
Partial extrahepatic bile duct obstruction 38
Partial pressure of arterial
carbon dioxide 184
oxygen 184
Partial seizures 293
Patau's syndrome 242
Patent ductus arteriosus 4, 91, 95, 101, 108, 109, 112, 113, 113f, 114f, 115, 151
Patent foramen ovale 115
Paterson-Brown-Kelly syndrome 46
Paul-Bunnell test See Heterophile antibody test
Pectus carinatum 90, 171f
Pectus carinatum See Pigeon chest
Pectus excavatum 90, 108, 172, 172f
Peld score 38
Pel-Ebstein fever 7
Pemphigus vulgaris 451
Pendular knee jerk 280
Pendular reflex 276
Pentology of Fallot 115
Pepper-pot in lateral view of skull 326f
Percuss from midline to sides 34f
Percussion note, types of 178
Percussion, types of 179
Percutaneous pleural biopsy 185
Perforation 54
Periapical abscess 41
Periapical cyst 41
Periapical granuloma 41
well-defined radiolucency 41f
Pericardial xenograft 123
Pericardial diseases 146
Pericardial effusion 15, 91, 96
Pericardial knock 101
Pericardial rub 101
Pericarditis 83
Perimembranous 109
Periodontal disease 16
Periodontal surgery in advanced cases 42
Periodontitis 41
aggressive 41
chronic 41
with endodontic lesions 41
Periodontium, abscesses of 41
Perioral tremor 270
Peripheral blood smear predominant lymphocytes 249f
Peripheral cyanosis 10, 106, 107, 151
differences between central and 107t
Peripheral neuropathy 84
Peripheral oedema 151
Peripheral pulses 93f
Peripheral vascular disease 164
Peritonitis 35, 82
Petit mal 295
Peutz-Jegher's syndrome 19, 455
pH of pleural fluid 212
Phaeochromocytoma 336
syndromes with 337
Phagophobia 44
Pharyngeal and oesophageal striated muscle, disorders of 45
Pharyngeal diphtheria 410
Pharyngeal reflex 273
Pharyngeus, globus 44
Pharynx 171
Phenobarbitone 297
Phenytoin 297
Pheochromocytoma 8, 98
Phlegmonous gastritis, acute 51
Phosphodiesterase inhibitors 156
Phosphorus 385
absorption 385
dietary sources 385
functions 385
PHT, primary 115
Phthirus pubis 421
Phylogenetically newest part of cerebellum 280
Pigeon chest 171
Pigment disorders 453
Pimobendon 156
Pitch of murmur 102
Pituitary gland disorders 339
Pituitary stimulation tests 340
Pituitary tumours 342f, 344
management 344
Pituitary, Cushing's syndrome 332, 333
Plantar reflex 272, 273, 273f
abnormal responses 272
methods of obtaining 274
Plantar response, minimal 274
Plasma catecholamine levels 338
Plasma renin activity 335
Plasmodium 437
falciparum 437, 440
ovale 440
vivax 7, 440
life cycle of 438f
Platelet disorders 251
Platelets 447
diseases of 456
Platypnoea 105
Pleura, malignancy of 212
Pleural aspiration 185
Pleural border 170
Pleural effusion 91, 152, 170, 175, 209, 209f
as per underlying pathology 211t
features of 213
Pleural fluid analysis 211
Pleural rub 181
and crackles, differences between 181t
Pleuritic pain 197
Pleuro-pericardial rub 181
Plicamycin 328
Plummer nail 19
Plummer-vinson syndrome 44, 46, 455
Pneumococcal peritonitis 81
Pneumococcal pneumonia 198, 200
Pneumoconiosis 104
cavitating 218
Pneumocystis carinii 198, 200, 431
pneumonia 198
Pneumonia 19, 104, 173, 196, 215
bad prognostic indicators of 201
causative organisms of 196t
complications of 201
in immunocompromised
host 198
patients 200
infection 219
legionella 196, 198, 201
pathology 197f
primary 196, 198
recurrent 48
rusty in pneumococcal 197
secondary 196, 199
to chlamydia 198
Pneumonias, nosocomial 200
Pneumothorax 170, 175, 176, 215
large right 33
right side with passive lung collapse 215f
secondary spontaneous 215, 216
small and large 215f
Poliomyelitis 45
Polycythaemia 89, 108
causes for 240
rubra vera 240
vera 455
Polydactyly 17, 108
Polymerase chain reaction 443
Polyneuritis, cranial 412
Polyunsaturated fatty acids 372, 380
Polyuria 82, 84
Pontine haemorrhage 8
Poor drug compliance 152
Porcine bioprosthesis 123
Porphyria 19
acute intermittent 99
Portal hypertension 72
Portein losing enteropathy 72
Positron emission tomography 36
Postmenopausal women and adult men 229
Post-nasal drip 171
Post-necrotic cirrhosis 70
Postpolio syndrome 45
Postremission management 246
Post-renal failure 82
Postural tremor 270
Posture decerebrate 315f
Posture decorticate 315f
Postvagotomy haematoma and fibrosis 44
Post-viral cirrhosis 70, 71
Potassium 386
daily requirement 387
dietary sources 386
manifestations of 387
retention 164
Potency loop, high 153
Potency potassium sparing diuretics, low 153
Potency thiazide diuretics, medium 153
Pott's procedure 117
Preanaesthetic medication drugs 460
Precordium 89
Pregnancy 38, 99, 116, 152
anti-epileptic drug during 298
Premature beats, ventricular 93
Premenstrual, cyclic 15
Pre-renal failure 82
sustained 82
Pressure symptoms 121
Primidone 297
Primitive reflexes 278
Progestins 16
Proliferative retinopathy 359, 359f
photocoagulation with laser 360f
Prophylactic measures 238
Prophylaxis 40, 58, 445
in infective endocarditis 145
Proprioceptive sensations 283
position sense 283
Prosthesis, mechanical 123
Prosthetic sounds 101
Prosthetic valve 142
dysfunction 127
Protease 193
Protein 62, 373, 394
energy malnutrition 12, 394
changes in 395t
classification of 394t
in adults 397
in young children 394
infections with 396t
prevention of 397
functions 373
losing enteropathy 72
loss of specific binding 81
metabolism 350
Proteinuria 80, 164
heavy 79
Proteus spp 196
Prothrombin time 37
Proton pump inhibitors, failure of 48
Protozoa 421
Proximal caries on premolar 40f
Pruritis 64
severe 65
Pruritus 84, 85
Pruritus-induced scratch marks 27
Pseudo-babinski sign 274
Pseudobulbar paralysis 45
Pseudo-Cushing's syndrome 332
Pseudohypercalcaemia 326
Pseudohyperkalaemia 248
Pseudohypertension 99
Pseudohypoglycaemia 248
Pseudohypoparathyroidism 330, 330f
Pseudohypoxaemia 248
Pseudomonas aeruginosa 196, 200
Pseudo-myotonic reflex 276
Psoriasis 19
Ptosis 13
Puddle's sign 34
by auscultopercussion method, eliciting 35f
manually eliciting 35f
Pulmonary angiography 185
Pulmonary arteriovenous fistula 105, 106, 110, 112
Pulmonary artery 120, 123, 126, 127
absence of left 115
dilatation 89, 101
idiopathic dilatation of 115
Pulmonary atresia 110, 114
with large systemic arterial collaterals 116
Pulmonary disease, chronic obstructive 4, 164, 192, 193, 215
Pulmonary disorders 346
Pulmonary ejection click 101
Pulmonary embolism 104, 105, 146, 151, 173, 184, 212
recurrent 115
Pulmonary fibrosis 48, 184
Pulmonary function test 182, 190, 194, 221
abnormalities on 221
Pulmonary function, impaired 106
Pulmonary haemosiderosis and ossification 121
Pulmonary hamartoma 218
Pulmonary hypercirculation 89
Pulmonary hypertension 105, 89, 100, 101, 111, 151
Pulmonary infarction 19, 114, 211, 212, 214
Pulmonary infarction See Pulmonary thrombosis
Pulmonary neoplasm 104
Pulmonary nodule
benign and malignant solitary 184t
causes of solitary 183t
Pulmonary oedema 77, 121, 184
acute 152, 173
Pulmonary osteoarthropathy, congenital hypertrophic 19
Pulmonary stenosis 105, 151, 108
Pulmonary suppuration 218
Pulmonary thrills 92
Pulmonary thrombosis 114
Pulmonary tuberculosis 203
bilateral 206f
long-standing 19
post primary 205
Pulmonary vein 120, 123, 126, 127
stenosis 108
Pulmonary venous connection, total anomalous 108, 109
Pulmonic stenosis 109, 110
Pulpitis 41
Pulsations, visible 29, 89
Pulse 6
alternans 95, 95f, 99
bigeminus 95
bisferiens 95
character 93
collapsing 94, 94f
corrigans 94
deficit 93
dicroticus 95
jerky 95
normal 93f
paradoxus 95, 96f, 99, 140
reverse 96
parvus et tardus 94f
pressure, signs of wide 128
raise arm to feel for collapsing 94f
rate 92
rhythm 93
small volume 120
volume 93
water-hammer 94
Punched out 42
Pupil reactivity 316
Pupil size 316
and reactivity 314
Pupillary defects in coma 314f
Purified protein derivative 206
Pursed lip breathing 174, 194f
Pyaemic abscess 69
Pyelonephritis, chronic 84
Pyloric stenosis 35
Pyogenic pericarditis 101
Pyrexia of unknown origin 8
causes of 8
Pyridoxine 382
daily requirement 382
deficiency 382
dietary sources 382
management 382
Q
Quadruple rhythm 100
Qualitative platelet disorders 251
acquired 251
congenital 251
Quantitative buffy coat, smear 443
Quantitative platelet disorders 251
Quartan fever 7
Quaternary syphilis 423
Quincke's sign 128
Quinidine therapy 149
Quinine 454
R
Rabies 45
Radiation 62
Radio-femoral delay 96
Radio-femoral delay, method of 96f
RAI staging system 249t
Raised intracranial tension 173
Raised intraocular pressure 93
Raised JVP 140, 151
Ranula 42
Rapid antigen detection tests 443
Rarely in mitral disease or atrial tumours 105
Rate control 146
Raynaud's syndrome 19
Reabsorption of urobilinogen 63
Reassurance 125
Rebound tenderness 33
Recrudescence and relapse, differences between 443t
Rectus abdominis 30
Red blood cells, disorders of 227, 455
Reflexes, released See Primitive reflexes
Reflexes, types of 275t
Reflexly-induced seizure 295
Refractory ascites 75
Remission consolidation 247
Remission maintenance 247
Remittent fever 7
Renal 325
Renal (kidney) function test 39
Renal artery stenosis 82
avoid in bilateral 164
Renal dialysis 72
Renal disease, end-stage 86
Renal failure 50, 56, 81, 82, 164, 201
acute 77, 82, 153
chronic 84, 84f
Renal hypoperfusion 82
Renal insufficiency 164
Renal oedema 15, 16
Renovascular hypertension 164
Repaglinide nateglinide 354
Resorcinols 190
Respiration 6, 102, 313, 316
movement with 30
Respiratory conditions 173
Respiratory disorders 399
signs in common 186t
Respiratory distress syndrome, acute 173, 184, 201, 202
Respiratory failure 50, 201
bilateral pneumothorax with 217
causes of 184t
types of 184t
Respiratory infections, lower 16
Respiratory muscle paralysis 184
Respiratory patterns
abnormal 174f
in coma 313f
Respiratory syncytial virus 198
Respiratory system, complications of 412
Respiratory tract, inspection of
lower 171
upper 171
Restrictive abnormality 182
Resynchronization therapy 156
Reticulocyte index 227
Reticulocyte production index classification 227
Retina 165
Retinal haemorrhages 253
Retinal haemorrhages, oval 143
Retinitis proliferans 237
Retinol See Vitamin A
Retinopathy without maculopathy 359
Retinopathy, pre-proliferative 359
Retropharyngeal abscess and masses 44
Reversibility tests 190f
Rh incompatibility 235
Rhabdomyolysis 82
Rheumatic and syphilitic aortic regurgitation, differences between 128t
Rheumatic fever 8, 118
acute 101, 125
markers of 89
Rheumatic heart disease 118, 120, 124, 127, 142
valve involvement in 118
Rheumatoid arthritis 101, 128
Rheumatoid disease 17, 211
Rhythm 173
control 147
Riboflavin 381, 394
causes 381
dietary sources 381
management 381
Rickety rosary 172
Rifampicin 79
Right atrium 120, 123, 124, 126, 127
Right subclavian artery 44
Right ventricle 120, 123, 124, 126, 127
Right ventricular
enlargement 91
failure 150
hypertrophy 89, 115
infarction 140, 151
outflow tract obstruction 115
Right-sided aorta 44
Rigid bronchoscope 185
Ritonavir 434
Rocker bottom foot 108
Romberg's test for position sense 284
Root canal treatment 40
Root pat test 269f
Root planning, removal of calculus and 42
Rosenbach's sign 128
Rotavirus 55
Roth's spots 143
Rotor syndrome 65
Rubella 415
complications 415
syndrome, congenital 415, 416
Rubella–risk of congenital malformation 415t
Rubeola See Measles
Rubeosis iridis 360
S
Saccular (cystic) bronchiectasis 219
Sacral sparing 286
Saddle back fever 7
Salbutamol See Saligenine
Saligenine 190
Saliva, lack of 44
Salmonella paratyphi 405
Salmonella typhi 405, 409
Salmonella, antigenic structure of 406f
Salmonellae (non-typhoidal) 55
Salt and fluid restriction 77
Saquinavir 434
Sarcoidosis 17, 19
Sarcoma 183
Sarcoptes scabiei 421
Saturated fatty acids 372
Schatzki ring 44
Schematic presentation of traub's space 178f
Schistosomiasis 69, 70
Schizogony See Human cycle
Scleroderma and related collagenvascular diseases 45
Sclerosing cholangitis 38
Scorbutic rosary 172
Scurvy 383
Sedative-hypnotic drugs 458
Segment inequality
lower 89
upper 89
Seizures, generalised 293
Selenium 390
Sensation of saddle type, loss of 286
Sensations, cortical 284
Sense alone, loss of
vibration 286
position and 286
Sense of passive movement 283
Sense, testing joint position 284f
Sense, timed vibration 284
Sense, vibration 284
Sense—medial malleolus, testing vibration 284f
Sensory cortex, function of 284
Sensory dermatomes clues 282
Sensory dissociation 285
Sensory lesions 285, 287f
Sensory loss, patchy areas of 286
Septal defect, ventricular 17, 101, 108-112, 112f
Septicaemia 8, 201
Serratia marcescens 196
Serum alkaline phosphatase 38
slightly raised 64
Serum bilirubin 38, 64
Serum creatinine 20, 39
Serum electrolytes 20
Serum enzymes 37
Serum glutamate pyruvate transaminase 70
Serum glutamic-oxaloacetic transaminase 70
Serum proteins 37
Serum sickness 76
Severity of symptoms, classification of 189t
Sex hormone replacement 336
Sexual exposure 68
Sexually transmitted diseases 421
bacterial origin 421
other origin 421
viral origin 421
Shamroth's sign 18
Sheehan's syndrome–postpartum 339
Shigella dysenteriae 55
Shigella flexneri 55
Shigella species 55
Shigella, pathogenesis of 59f
Shock 49, 94
cardiogenic 93
direct current See Cardioversion
Shunt lesions
left to right (acyanotic) 109
right to left (cyanotic) 109
Shunt, denver 75
Shunt, leveen 75
Shunt, peritoneovenous 75
Shunt, ventricular level 109
Shunts and valvular lesions 104
Shunts or stenosis with jet streams 142
Shunts, lesions without 108
Sialadenitis 68
Sialolithiasis 42
Sick sinus syndromes 147
Sickle cell anaemia 36, 236, 455
Sideroblastic anaemia 228
Sigmoidoscopy 36
Silent chest See Bronchial asthma
Silicosis 5
Simian crease 108
Sinus arrhythmia 147
Sinus bradycardia, causes of 92
Sinus of Valsalva aneurysm, rupture of 95, 109, 112
Sinus tachycardia 147
causes of 93
Sinus venosus 109, 110, 111
Sinusitis infection 19
Situs inversus totalis 110
Sjögren's syndrome 44, 320
Skeletal 325
fluorosis 389
muscle-motor response 315
Skin 9
abnormal pigmentation of 10t
carcinoma of 19
examination, prerequisites for 9
inspection of 9
lesions, types of 10, 10t
or surface 29
rashes 164
Sleep apnoea 151
Sleep patterns, normal 267t
Snake bite 255
Snap, causes of opening 101
Snider's test 182
Snout reflex 279
Sodium 386
and water overload 83
cromoglycate 190
dietary sources 386
ferric gluconate 230
functions 386
manifestations of 386
nitroprusside 155
retention 84
Soft tissue calcification 329
Solitary metastasis 183
Somatosensory 267
Sounds 176
miscellaneous 181
Speech and language 267
Speech disturbances 280
Spider fingers 17
Spinal cord lesions, manifestations of 424
Spinal deformity 172
Spinocerebellar 280
Spinoumbilical measurement 28
Spiral CT 36
Spirochaetal diseases 259
Spirometry 182
Spirometry measurements 182
Spleen 28, 33
massively enlarged 32f
moderately enlarged 32f
newer methods of percussion of 33
palpation of 31, 32f
Splenic enlargement, medial 32f
Splenic sequestration syndrome 237
Splenomegaly 259
Splinter haemorrhage 89
clubbing 89
Spontaneous bacterial peritonitis 72, 73
Spontaneous eye movements 314, 316
Spontaneous pneumothorax 215
primary 216, 215
Spoon nails See Koilonychia
Sporogony See Mosquito cycle
Sputum 185
examination 220
pink frothy 151
Squatting, standing to 103
Staging/TNM classification 222
Staphylococcal lung abscess 215
Staphylococcal pneumoniae 198, 200
Staphylococcus aureus 41, 55, 142, 196, 200, 201, 363
Stature 14
Stavudine 434
Steatorrhoeal diarrhoea 57
Steatorrhoea–stool fat exceeding 56
Stenotic mitral valve 121
Steroidal hormones 16
Steroids 50
Steven-Johnson's syndrome 449, 451
facial eruption with haemorrhagic crusting of lips 449f
mucosal lesions 449
skin lesions 449
Stomach 28
diseases of 49
surface marking of 28f
Stool antigen test 50
Straight back syndrome 90
Straight line dullness 179
Streptococcus
boris 144
mutans 40
pneumoniae (most common) 196
pyogenes 196
Stress ulcer 54
Striae atrophica 29
Striae purple 29
Strict bed rest 77
Strictures 48
Stridor 181
Stroke 299
completed 299
heat 8
Styloid process of radial bone 93f
Sub-acute infective endocarditis 142
Sub-arachnoid haemorrhage 164
Subarachnoid haemorrhage, non-traumatic 299
Subconjunctival hemorrhage 143
Subcutaneous emphysema, detection of 176
Subcutaneous nodules 89, 118
Subthalamic nucleus 270
Succussion splash 35
Sucking reflex 279
Sulphaemoglobinaemia 10
Sulphonylurea therapy, side effects of 354
Summation gallop 100
Supernumerary fingers 17
Supinator reflex 275
Supraclavicular area 171
Suprapubic aspiration 39
Suprascapular region 171
Swallowing centre, lesions of 44
Swollen glomerulus with hypercellularity 77f
Sydenham's chorea 119, 269
Sympathomimetic amines 156
Symptomatic neurosyphilis 423
Syncope 105
disorders resembling 106
situational 106
Syndactyly 17, 108
webbed fingers 17
Synthetic insulin
aspart 350
detemir 350
glargine 350
syndromes with 350
Syphilis 19, 51, 128, 421
classification 421
congenital 424, 453
constitutional symptoms, secondary 423
differential diagnosis of secondary 423
in neonates 70
latent 423
oral manifestations, secondary 423
primary 422, 453
secondary 423, 453
Weil's disease 69
Syringomyelia 19
Systemic acidosis 212
Systemic hypertension 89, 100, 101, 116, 128, 151
Systemic lupus erythaematosus 4, 17, 43, 76, 101, 154, 210, 211, 294
Systolic and diastolic failure 151
Systolic blood pressure 75
Systolic clicks, mid 101
Systolic heart failure 151
Systolic hypertension, isolated 98
Systolic murmur
ejection 102
of hypertrophic cardiomyopathy 103
T
T cells, atypical 447
Tachyarrhythmias, antiarrhythmic agents for 125
Tachyarrhythmias, supraventricular 105
Tachyarrhythmias, ventricular 105
Tachycardia 151, 152
management of broad complex 149
prevention of recurrent ventricular 149
resistant ventricular 149
sustained monomorphic ventricular 148
triple rhythm with 100
ventricular 148
Tachypnoea 113, 151, 172, 197
Tactile fremitus 176
Takayasu's arteritis 128
Tandem walking 280f
Tapping apical impulse 120
Taste, loss of 164
Technetium-sestamibi scan 326f
Temperature 7
Tender hepatomegaly 151
Tenderness of colon 59
Tenderness, shifting 33
Tendon reflexes 276
abnormalities of 276
deep 274, 277f
Tenesmus 59
Tenofovir 434
Tension headaches 305, 307
Tension pneumothorax 216, 217
Terbutaline 190
Terry nail See White nail
Tertian fever 7
Tertiary hyperparathyroidism 327
Tertiary syphilis 423, 453
oral manifestations 423
Tetanus 45
Tetralogy of Fallot 105, 108, 109, 115, 115f
Thalassaemia 238, 455
based on severity, classification of 238t
intermedia 238
major 238
minima 238
minor 238
Therapeutic paracentesis 75
Thiamine 381, 394
causes of deficiencies 381
dietary sources 381
functions 381
management 381
Thiazolidinediones 355
Thoracic expansion, anterior 176f
Thoracic movement
anterior 175
posterior 175, 176f
Thready pulse 95
Thrills 91
Thrombocytopaenia 156, 251
causes 251
Thrombocytopaenic purpura, idiopathic 253
Thrombolysis 302
Thrombophlebitis 15
Thyroid 341
diseases, primary 322
gland 17
disorders 319
hormones 319
medullary carcinoma of 56
stimulating hormone 320, 322
storm 8, 321
Thyrotoxic crisis 321
Thyrotoxic ophthalmopathy 320f
Thyrotoxicosis 8, 15, 19, 146, 151
factitia 319
Thyrotropin-releasing hormone 340
Ticlopidine 303
Tics 271
causes 271
Tidal percussion 178
Tilting disc valve 123
Tissue disease, connective 8
Tissue disorder, connective 124
Tissue hypoxia
with 358
without 359
Titubation 272, 280
Tongue
color of 16
hyperplastic candidiasis of 433f
jack in box 269
paralysis of 44
Tonsillectomy, acute 448
Tonsils 171
Tophaceous gout 19
Topical steroids 461
Torsades de pointes 149, 149f
with long QT syndrome 149
Toxic adenoma 320
Toxic multinodular goitre 320
Toxins 359
and drugs 70
and others 313
Toxoplasma gondii 431
Trachea, methods of palpating 174f
Trachea, position of 171
Tracheal position, assessing 174f
Tracheal stridor 181
Tracheal tug 174
Trail's sign 171
Transfusion 68
malaria 441
Transhepatic cholangiography,
percutaneous 37
Transient hypertension 99
Transient ischaemic attacks 299, 300
Transoesophageal echocardiography
144f
Transplacental transmission 68
Transposition of great arteries 108
Transudate and exudate ascitic fluid 72t
Transudative and exudative effusion, causative pathologies of 210t
Transudative versus exudative pleural fluid 209t
Traube's sign 128
Traube's space 178
boundaries of 178
Trauma 49, 125, 127
Traumatic herpes See Herpes
gladiatorum
Traumatic pneumothorax 215, 216
Traumatic ulcers 43
Traveller's diarrhoea 55, 58
Treadmill test 20
Treatable cerebellar lesions 281
Tremor 270
causes 271
intention 270, 280
types 270
Trench mouth 42
Treponema pallidum 421
Trepopnoea 105
Triceps jerk reflex 275
Trichomonas vaginalis 421
Tricuspid atresia 108, 109
Tricuspid insufficiency 70
Tricuspid regurgitation 72, 90, 101
Tricuspid stenosis 90
common 101
Tricuspid valve 101
Trigeminal land facial nerve 288
Trigeminal nerve 288
Trigeminal neuralgia 291
Trigger zones 291
Triology of Fallot 115
Triple stimulation test 340
Troisier's sign 27
hard and enlarged supraclavicular node 27f
Tropical coma 313
Tropical splenomegaly syndrome 441
Tropical sprue 62
Trousseau's sign 329
Truncus arteriosus 108, 109
TSH secreting pituitary tumour 320
Teeth and gum, appearance of 16
Tuberculin test 206
Tuberculoma 183
Tuberculosis 8, 15, 51, 69, 72, 73, 203, 205, 211, 212, 215, 218, 453
drugs for 207t
meningitis 205
primary 204
sites of infection in 203
Tuberculous pericarditis 101
Tumour 73, 175
adenoma/carcinoma 219
benign 44
infiltration with 176
malignant 44
pancoast 19
pancreatitis, pancreatic 44
primary 222
Turner's syndrome 17
Tussive syncope 106
Tylosis of palms in carcinoma of oesophagus 27
Typhoid 69
and paratyphoid fever 405
complications of 408t
diagnosis of 408
fever 7, 95
progression graph of 406f
Tyrosinosis 70
U
Ulcer disease, peptic 52
Ulcer on tongue, multiple aphthous 43f
Ulcer production, pathogenesis of 52
Ulcer, benign 54
strictures to peptic 44
Ulcer
coexistence of duodenal 54
differences of benign from malignant 53
endoscopic differentiation between benign and malignant 54t
malignant 54
peptic 52, 85
stress 54
treatment of peptic 53t
Ulcerative colitis 19, 57
Ulcerative gingivitis, acute necrotising 16, 42, 453
Ulcers, recurrent aphthous 43
Umbilical position 28
Umbilicus 29
Umcomplicated malaria 444
Uncertain aetiology, diarrhoea of 56
Unidigital clubbing 19
Upper gastrointestinal
endoscopy 53
radiography 52
tract 56
Upper motor neuron lesions 45
Uraemia 19, 27, 56, 101
Urease test 50
Urinary bladder
carcinoma of 5
palpation of 32
Urinary free catecholamines 338
Urinary metanephrine 337
Urinary tract infection 83
Urine analysis 39
Urine culture 407
Urine specimens, methods of collection of 39
Urine test for total metanephrine 338
Urine, dark yellow 65, 67
Urine, high-coloured 64
V
Vaccines, killed 409
Vagus nerve 288
Valproate 297
Valsalva manoeuvre 102
Valve area and symptoms 121
Valve replacement 123
Valve, replacement of 125
Valvular clicks 101
Valvular heart disease 120
Valvular stenosis, silent 152
Vanillylmandelic acid levels in urine 338
Varicella-zoster virus See Chickenpox
Varicella-zoster virus, reactivation of 452
Varicose bronchiectasis 219
Varicose veins 15
Various cuff sizes for blood pressure measurement 97t
Vascular clicks 101
Vasculitis 72, 76, 82
Vasodepressor syncope 105
Vasodilator therapy 154
Vasovagal 105
Vein thrombosis, deep 15
Veins prominence, superficial 29
Vena cava
obstruction, superior 96
superior 120, 123, 126, 127
Venacaval obstruction, superior or inferior 15
Veno-occlusive disease 70, 72
Venous hum 35
Venous hypertension, right-sided 72
Venous obstruction 107
Venous oedema 15
Ventilation perfusion
imaging 184
mismatch 106
Ventilatory capacity, patterns of abnormal 182t
Ventricle origin arrhythmias 147
Ventricular bigemini 156
Ventricular ectopics See Atrial ectopics
Ventricular fibrillation 156
depicting 148f
Ventricular flutter 149f
Ventricular S3, differences between right and left 100t
Ventricular septal defect 91, 151
Ventricular tachycardia 148f, 156
Vertebral osteophytes 44
Vertebrobasilar insufficiency 106
Vertebrobasilar territory 301
Vervous system HSV/severe
complications, central 420
Vesicular breath sound 179
Vessels, transposition of great 110
Vestibulocochlear nerve 288
Vibrio cholerae 55, 56
Vigorous See Achalasia
Vincent's infection See Trench mouth
Vinyl chloride worker to focal tissue reaction to chemical 19
Vipoma—vasoactive intestinal peptide tumour 56
Viral antigen, demonstration of 414
Viral exanthema 413
Viral fever 7
Viral hepatitis 69, 85
obstructive phase of 27
Viral infections 432, 433, 452
Viral pericarditis 101, 201
Viral pneumonia 198
Virchow's node 27
Viridans streptococci 144
Virilisation 12
Viruses 100
certain 196
Visceral infections 419
Visceral myopathy, hollow 45
Visceral reflexes 272t
Vision 267
Visuospatial functions 266
agnosia 267
apraxia 266
sleep 267
Vital capacity expired in first second, fraction of 183f
Vital capacity, forced 182
Vitamin 375
Vitamin A 62, 375, 376, 384, 394
causes of deficiency 377
daily requirement 377, 378
deficiency See Bitot's spots
dietary sources 375, 378
functions 377, 378
hypophosphataemic rickets 379
management 378, 379
metabolism 378
osteomalacia 379
prevention 378
rickets 379
skeletal manifestations 379
toxicity 377
treatment 378
Vitamin B1 376, 384
Vitamin B1 See Thiamine
Vitamin B12 62, 376, 382, 384, 394
deficiency, causes of 231
Vitamin B2 376, 384
Vitamin B2 See Riboflavin
Vitamin B3 376, 384
Vitamin B5 376
Vitamin B6 376, 384
Vitamin B6 See Pyridoxine
Vitamin B7 376
Vitamin B9 376
Vitamin C 376, 383, 384, 394
causes of deficiency 383
daily requirement 383
functions 383
sources 383
Vitamin D 62, 376, 378, 384
Vitamin E 376, 380, 384
causes of deficiencies 380
daily requirement 380
dietary sources 380
functions 380
Vitamin K 62, 376, 380, 384, 394
causes of deficiency 380
deficiency 255
manifestations of 380
dietary sources 380
management 380
Vitamin, classification of 375
Vitamin, functions of 375
Vitamin, recommended daily allowance of 376t
Vocal fremitus 176
Vocal resonance 181
Voice sounds 181
Vomiting 67, 82
von Willebrand's disease 255
von Willebrand's factor, functions of 255
Vronchitis infection 219
VSD with aortic regurgitation 109
W
Waist-hip ratio 15, 398
Warm and cold antibody, differences between 233t
Warm antibody type 233
Wartenberg's reflex 275, 276f
Water soluble vitamins 381
Water-hammer pulse 128
Waterston procedure 117
Weakness 59
Webbed neck 108
Wegener's granulomatosis 171
Weight loss 66, 113
Wheeze 188
Whipple's disease 57, 62
Whispering pectoriloquy 181
White blood cells 260
count, total 211
absence of 56
presence of 56
White chalky spot 40
White coat hypertension 99
White nail 19
Whooping cough infection 219
Wickham's striae 450
Widal test 407
Widened sella turcica 342f
Wilms’ tumour, irradiation of 76
Wilson's disease 13, 19, 70
Wilson's disease See Kayser-Fleischer ring
Wolff-Parkinson-White syndrome 147
X
Xanthelasma 89
Xanthomas 89
Xerophthalmia 377
Y
Yellow nail syndrome 19, 219
Young's syndrome 219
Z
Zalcitabine 434
Zenker's diverticulum 44
Zidovudine 434, 454
Zinc 62, 390
daily requirement 390
dietary sources 390
functions of 390
Zollinger-Ellison syndrome 57
×
Chapter Notes

Save Clear


1General Medicine2
  1. Aims, Objectives and Case History

Aims, Objectives and Case History1

Chapter Outline
  • ■ Aims and Objectives
  • ■ Doctor-Patient Interrelationship
  • ■ Case History
  • ■ General Examination
  • ■ Pulse
  • ■ Respiration
  • ■ Blood Pressure
  • ■ Temperature
  • ■ Clinical Examination
  • ■ Examination of Skin
  • ■ Examination of Face
  • ■ Constitution
  • ■ Stature
  • ■ State of Nutrition
  • ■ Oedema
  • ■ Examination of Mouth and Pharynx
  • ■ Examination of Neck
  • ■ Examination of Hands and Fingers
  • ■ Differential Diagnosis
  • ■ Investigations
  • ■ Diagnosis
  • ■ Treatment
  • ■ Prognosis
  • ■ Follow-up
 
Aims and Objectives
The term general medicine is implied to learn and analyze the health of the patient in totality, thus the knowledge of general medicine is very important for dental graduates in order to come to relevant diagnosis and treatment planning.
  • Aims: The aim of the dental student should be:
    • To identify the disease and determine its diagnosis if any underlying systemic condition.
    • To make appropriate referrals to a concerned speciality if required.
    • To render timely treatment or should be in a capacity to suggest or organize the same.
  • Objectives: The following objectives will help him in achieving his aim:
    • Complete detailed history
    • Complete clinical evaluation
    • Complete investigation
    • Differential diagnosis.
 
Doctor-Patient Interrelationship
To understand the importance of doctor-patient interrelationship, one must recall the statement of Dr Francis Peabody, ‘the significance of intimate personal relationship between physician and patient cannot be too strongly emphasized, for in an extraordinary large number of cases both the diagnosis and treatment are directly dependent on it. One of the essential qualities of clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient ’. If you listen to your patient long enough without interrupting, they will tell you what is wrong with them. Eighty per cent of accurate final diagnosis could be arrived at the end of carefully listening to the patient and only 20% more refined by physical examination and investigations. We must remind our younger generation that ‘cure rarely, comfort mostly, but console always’. Even before going into the patient's complaints, important facts can be glanced from the following data that is asked as a routine from every patient and help the consulting doctor to arrive at a most probable conclusion to the patient's problems.
 
Case History
  • Name: It gives a clue of the country, state and religion to which the patient may belong.
  • Age: Diseases occurring in childhood are occasionally congenital in origin. Degenerative, neoplastic and vascular disorders are more common in the middle aged or elderly. In women beyond the menopausal age group, the incidence of problems like ischaemic heart disease (IHD) increases in equal proportion as that in their male counterparts.4
  • Sex: Males are prone to inherit certain conditions that are transmitted as X-linked recessive disorders, e.g. haemophilia. They are more prone to develop conditions like IHD, bronchogenic carcinoma and decompensated liver disease, as they are habituated to smoking and consumption of alcohol, in larger numbers than their female counterparts.
        Females are more prone for developing autoimmune disorders like systemic lupus erythematosus (SLE), thyroid disorders, etc.
  • Religion: Jews practice circumcision soon after birth, and thus, development of carcinoma of penis is rare in them. Muslims do not consume alcohol and are less prone to develop problems related to its consumption, e.g. decompensated liver disease. Sikhs do not smoke and are less likely to develop problems related to smoking, e.g. carcinoma of lung. Certain sects of Hindus do not consume meat products and consume a high fibre diet and are therefore protected from developing carcinoma of the colon.
  • Address: People hailing from the urban region are prone to develop problems related to urbanization like exposure to constant stress and atmospheric pollutants (industrial and vehicular) and problems developing consequent to this, e.g. IHD, chronic obstructive pulmonary disease (COPD), interstitial lung disease, etc. Inhabitants of mountains or hilly regions may develop problems like primary pulmonary hypertension, may have a persistent patent ductus arteriosus (PDA) (from childhood) or may be goitrous secondary to iodine deficiency. The particular place from which the patient hails may be endemic for certain diseases, e.g. fluorosis prevalent in certain pockets in Andhra Pradesh.
  • The presenting complaint (Table 1.1): Allow the patient to tell his complaints in his own words. Do not ask leading questions to the patient. The current complaints and their duration should be noted in a chronological order.
  • History of present illness: Allow the patient to elaborate on the story of his illness from its onset to its present state. Take care so as not to ask any leading questions to the patient which may distort the patient's history. The doctor may, however, interrupt the patient to ask for the presence of ‘positive’ or ‘negative’ symptoms pertaining to patient's current problems. In analysis of the symptoms, it is important to consider the mode of onset of the illness (acute, subacute, or insidious) and the progression of the illness to the present state (gradually deteriorating, getting better, remaining the same or having remissions and exacerbations). A review of all the systems can be made by asking the patient on the presence or absence of symptoms pertaining to a particular system. Clinician should record the history of pain such as onset, type, severity and, aggravating and relieving factors.
  • History of previous illnesses: This should include all important previous illnesses, operations, or injuries that the patient might have suffered since birth. The mode of delivery and the timing of attainment of the various developmental milestones in infancy may be important in some cases. It is always wise to be cautious while accepting readymade diagnosis from the patient like ‘typhoid fever’, ‘malaria’, etc. unless the patient has records of the mentioned illness. Tactful enquiry about sexually transmitted diseases and their treatment, when considered of being possible relevance to the patient's problem, should be made.
  • The menstrual history: Following should be enquired:
    • Age of menarche
    • Duration of each cycle
    • Regular or irregular cycles
    • Approximate volume of blood loss in each menstrual cycle
      Table 1.1   Systems-related symptomatology
      System
      Symptom
      Gastrointestinal (GI) tract
      Pain, altered taste, dyspepsia, heart burn, dysphagia, diarrhoea or constipation, anorexia, nausea or vomiting, malaena, rectal bleeding, flatulence
      Hepatobiliary tract
      Pain, nausea or vomiting, jaundice, mass in abdomen, distention of abdomen, haematemesis
      Cardiovascular system
      Dyspnoea, orthopnoea, palpitation, cyanosis, cough, haemoptysis, oedema of feet, chest pain
      Respiratory tract
      Cough, sputum, dyspnoea, chest pain, haemoptysis, wheeze
      Central nervous system
      Numbness, headache, vomiting, seizures, altered sensorium/loss of consciousness, behavioural abnormalities, visual disturbances, vertigo, speech disorder, weakness of limbs, sensory disturbances, unsteady gait, abnormal movements, syncope
      Urinary system
      Pain, haematuria, oliguria, anuria, polyuria, nocturia, dysuria, hesitancy, incontinence, urethral discharge, swelling of legs, dyspnoea5
    • Age of attainment of menopause
    • Postmenopausal bleeding.
  • Obstetric history: Following should be enquired:
    • Number of times the patient conceived.
    • Number of times pregnancy was carried to term.
    • Number of abortions (spontaneous or therapeutic)
    • Number of living children, their ages and the age of the last child delivered.
    • The time interval between successive pregnancies/ abortions.
    • Mode of delivery (vaginal, forceps assisted, or caesarean).
    • Development of oedema in legs, HTN, seizures in the antenatal or postnatal period (seizure within 48 hours of delivery is due to pregnancy-induced HTN, beyond 48 hours may be due to cerebral sinus thrombosis).
    • Presence of impaired glucose tolerance in the course of pregnancy or history of having given birth to a large baby may give a clue to the presence of diabetes mellitus (DM) in the patient.
  • Family history: Enquire about the presence of consanguinity in the patient's parents, any disease states in the patient's parents, brothers, sisters and close relatives (presence of disease states like HTN, DM, IHD in the above may make the patient more prone to develop a similar problem). Presence of a hereditary disorder prevalent in the family should be enquired for. Marital status of the patient and the number of children that the patient has should also be enquired (Infertility in a patient may give a clue to the presence of immotile cilia syndrome, cystic fibrosis or Young's syndrome).
  • Social history: Enquire about the patient's family lifestyle, daily habits and diet; about the nature of the patient's work (hard work or sedentary), the possibility of overcrowding at home (overcrowding aids in the spread of communicable diseases) and the sanitation in and around the house; about the presence of pets in the house; about the use of alcohol (number of days in a week and also the quantity consumed each day), tobacco (whether chewed or smoked) and betel nut.
  • Treatment history: This should include all previous medical and surgical treatments and also any medication that the patient is continuing till date. Details of drugs taken, including analgesics, oral contraceptives, psychotropic drugs, previous surgery and radiotherapy are particularly important to find out if the patient had been allergic or had experienced any untoward reactions to any medication that he may have consumed previously. It may be helpful as the same medication can be avoided in the patient in future and the patient is also appraised of the same. Knowledge of any current therapy that the patient may be taking is necessary in order to avoid adverse drug reactions, when new drugs are introduced by the consulting doctor.
Chewing betel nut or tobacco is a habit common with people living in the rural areas, and this increases the risk of developing oral malignancies. Inquire about history of travels abroad or other places within the country, as it may give a clue to the import of a disease by the patient endemic in the place visited.
  • Occupational history: Enquiry must be made on all previous and present occupations, as it may give a clue to the presence of an occupational disease in the patient and also in planning the rehabilitation, e.g:
    • Mesothelioma: Exposure to asbestos.
    • Carcinoma of the urinary bladder: Exposure to aromatic amines in dye stuff industry.
    • Silicosis: Occurs in mine workers.
      On the other hand, the presence of disease in an individual may make him unfit for his occupation by proving to be hazardous to him as well as to others, e.g:
    • Salmonella infection or carrier state in food handlers.
    • Epilepsy in drivers of public transport vehicles.
 
General Examination
General examination of the patient is done with an objective to get an overall impression about the general state of health and draws attention to the system that is maximally deranged so that the physician can start systematic examination with that system first.6
 
Pulse
The radial pulse should be examined and its rate, rhythm and character should be noted. The right radial pulse is palpated with the tips of three fingers of the left hand. Normal pulse rate is 60–100 beats per minute. Tachycardia refers to pulse rate above 100 beats per minute and may occur due to anxiety, after exercise, fever and hyperthyroidism. Bradycardia refers to pulse below 60 beats per minute and is seen in trained athletes or may be a sign of heart block.
 
Respiration
Respiratory rate is counted by watching the movement of the abdomen. Normal respiratory rate is 14–18 breaths per minute. Increase in respiratory rate occurs in pneumonia, pulmonary oedema, asthma, pulmonary embolism and metabolic acidosis. Respiratory rate decreases in narcotic poisoning, raised intracranial tension and in deep coma.
 
Blood Pressure
The patient is seated comfortably or in lying down position, blood pressure (BP) cuff of adequate size is tied properly permitting introduction of one finger (Fig. 1.1). The cuff is tied in a way so that it is 2–3 cm above the elbow joint. The hand should be kept in a position to ensure that the cuff remains at the level of heart.
zoom view
Fig. 1.1: Schematic presentation of blood pressure (BP) measurement
7
Diastolic pressure closely corresponds to phase V. However, in aortic regurgitation, the disappearance point is extremely low, sometimes 0 mm Hg and so phase IV is taken as diastolic BP in adults as well as children. Normal BP in adults is 100–120 mm Hg systolic and 70–84 mm Hg diastolic. Normal BP differs with age and during pregnancy. Elevation of BP is seen in systemic HTN, increased intracranial tension, and several other disease. In shock, the BP decreases below 80/40 mm of Hg.
 
Temperature
By placing the dorsum of the hand on the forehead, temperature can be easily assessed if the patient is febrile or not. But the exact temperature has to be recorded by using a clinical thermometer.
The normal diurnal variation is 1°F. The normal body temperature is more towards the evening because of increased basal metabolic rate (BMR) and increased skeletal muscle activity. Rectal temperature is 0.6°C (1°F) higher than oral temperature. Oral temperature is 0.6°C (1°F) higher than temperature recorded in the axilla.
 
Fever
It is an elevation of body temperature above the normal circadian variation as a result of the change in the thermoregulatory centre, located in the hypothalamus.
Normal
37–37.6°C (98.6–99.6°F)
Febrile
Above 37.8°C (100°F)
Hyperpyrexia
> 41°C (>06°F)
Hypothermia
35°C (95°F)
 
Febrile Convulsions
It occurs in infants and children less than 5 years old. Convulsions are common at temperatures more than 40°C. It may not be a sign of cerebral disease.
 
Patterns of Fever
 
Continuous Fever
The temperature remains elevated above normal without touching the baseline and the fluctuation does not exceed 0.6°C (1°F) (diurnal variation), e.g. lobar pneumonia, infective endocarditis, enteric fever, etc.
 
Remittent Fever
The temperature fluctuation exceeds 0.6°C (1°F), but does not touch the baseline.
 
Intermittent Fever
The elevated temperature touches the baseline in between. In hectic or septic type of intermittent fever, the diurnal variation is extremely large (as in septicaemia). Quotidian fever is a hectic fever occurring daily.
 
Relapsing Fever
Febrile episodes are separated by normal temperature for more than 1 day, e.g. borrelia infection, rat bite fever.
  • Tertian fever occurs on the 1st and 3rd day, e.g. Plasmodium vivax, P. ovale, falciparum.
  • Quartan fever occurs on 1st and 4th day, e.g. P. malariae.
  • Pel-Ebstein fever: Lasts for 3–10 days followed by afebrile period of 3–10 days, e.g. Hodgkins lymphoma and other lymphomas.
  • Saddle back fever: In which initially fever lasts for 2–3 days, followed by a remission lasting for 2 days and the fever reappears and continues for 2–3 days, e.g. dengue fever.
  • In cyclic neutropenia fever occurs every 21 days.
 
Hyperpyrexia
It is an elevation of body's core temperature, above 41°C (106°F), due to inadequate dissipation of heat. It is a medical emergency, since the patient is prone to sudden cardiorespiratory arrest.
 
Causes of Hyperpyrexia
  • Heat stroke
  • Thyroid storm
  • Pontine haemorrhage
  • Rheumatic fever
  • Meningococcal meningitis
  • Drugs (atropine)
  • Septicaemia
  • Cerebral malaria.
 
Treatment
It is treated with parenteral antipyretics to set the elevated thermostat point to a lower level. Physical cooling aids in reducing the body temperature are employed. Chlorpromazine is sometimes helpful in reducing the body temperature.
 
Hyperthermia
In hyperthermia, the body temperature is raised with normal setting of thermoregulatory centre and the diurnal variation is absent. There is an uncontrolled increase in body temperature that exceeds body's ability to lose heat.
 
Causes
  • Heat stroke
  • Malignant hyperthermia
  • Thyrotoxicosis
  • Pheochromocytoma
  • Hypothalamic fever
  • Drugs: Amphetamine, atropine.
 
Pyrexia of Unknown Origin
Pyrexia of unknown origin (PUO) is defined as the presence of persistent high temperature greater than 101.2°F (38.4°C) on several occasions accompanied by more than 3 weeks of illness and failure to reach a diagnosis despite week of impatient investigations.
 
Investigations
  • Erythrocyte sedimentation rate (ESR)-platelet correlation: If ESR is more than 100 mm/hour with thrombocytosis, think of:
    • Tuberculosis
    • Malignancy
    • Connective tissue disease.
Erythrocyte sedimentation rate more than 100 mm/hour without thrombocytosis, think of viral infections.
  • Alkaline phosphatase may be elevated in biliary tract infections, alcoholic hepatitis and primary and secondary cancer of liver.
  • Blood culture
  • Serological tests (fourfold rise significant): Useful in:
    • Enteric fever
    • Hepatitis
    • Cytomegalovirus (CMV) infection
    • Amoebiasis
    • Human immunodeficiency virus (HIV).
  • Imaging techniques
    • Chest X Ray (CXR): In all patients with PUO, when initial X-ray of chest is normal, a second X-ray must be taken after 3 weeks to rule out miliary tuberculosis (time taken for radiological opacity to appear).
    • Ultrasound: Excellent imaging is procured in thin individuals and poor imaging in obese individuals.
    • Computed tomography (CT) scan: It gives excellent imaging in obese patients also.
    • Magnetic resonance imaging (MRI) scan: It gives the best resolution of tissue planes of differing intensity. It has an advantage over CT scan when studying bone, brain, pelvis, spinal cord and large vessels in thorax. MRI is contraindicated when metal clips are present.
    • Radionuclide scans: 99mTc-sulphur colloid is used for scanning liver and spleen. 111Indium–labelled leucocytes are used for detection of intra-abdominal abscess.
Ninety percent of PUOs are diagnosed by proper evaluation. The rest recover under a watchful non-interference. The duration of fever increases the likelihood of infection as the cause of PUO is remote.
 
Clinical Examination
 
Inspection
Inspection is through visualization of the patient with naked eye. During inspection all the external signs appearance, weight, skin colour, breathing pattern, walking style (Gait) and manner of speaking; and gross deviations—scars, visible lumps, swelling, postural deviations and tremor are noted.
 
Palpation
Palpation is the examination of body by hand. It is performed to determine the shape, size and texture of the tissues. It is very important in diagnosing conditions like enlargement of liver, gall bladder, and other causes of abdominal pain. Anatomical landmarks are also located by palpation for various therapeutic procedures.
 
Percussion
Percussion is the examination of body by tapping on the surface to determine the underlying structures. Percussion can be performed by two methods: directly and indirectly. Direct method is used to percuss bony areas, in which finger is directly tapped over area. In indirect method to middle finger of one hand is placed over the area to be examined and is tapped with middle finger of other hand by wrist flexion.
 
Auscultation
Auscultation is derived from the latin word ‘auscultare’ meaning ‘to listen’. It is the method of listening internal sounds of the body with the help of stethoscope. This method is mainly used to listen heart sounds, breath sounds and gastrointestinal (GI) sounds. It takes substantial clinical experience to learn the skill of auscultation. Auscultating plays an important role in making provisional diagnosis of heart and lung conditions. When auscultating heart, one should look for abnormal heart sounds like heart murmur, gallops and any other sound coinciding with normal heart sounds. When auscultating lungs, one should look for breath sounds like wheezes, crackles and crepitations. Bowel sounds are listened during auscultating of GI system.
 
Examination of Skin
 
Prerequisites for Skin Examination
 
Accessibility
An examination room where patient can be clothed only in an examination gown. If thats not possible, at least, the affected part should be properly exposed.
 
Adequate Illumination
Sunlight or a bright overhead fluorescent lighting is preferred. Penlight is used in side lighting to determine if a lesion is subtly elevated and for examining the oral cavity. A complete cutaneous examination should be made that includes:
  • Skin from head to toe
  • Mucous membrane, mouth and genitals
  • Hair and nails.
The examination includes inspection and palpation, besides percussion and auscultation.
 
Inspection of Skin
  • Pigmentation: Pigmentation of the skin varies from dark skinned to fair individuals, depending on the race to which they belong.
    • Generalised absence of skin pigmentation suggestive of albinism.
    • Patchy absence of skin pigmentation may be due to vitiligo. In the presence of vitiligo, suspect presence of DM or other autoimmune disorders (Fig. 1.2).
    • Circumscribed hypopigmented lesions of the skin may occur in Hansen's disease (tuberculoid or borderline tuberculoid types) and tinea versicolor.
    • Generalised hyperpigmentation of the skin is seen in haemochromatosis, Addison's disease, Cushing's syndrome, ectopic, adrenocorticotropic hormone (ACTH) production.
    • Patchy hyperpigmentation of the skin is seen in pellagra (in parts exposed to sunlight), café-au-lait spots (Fig. 1.3), butterfly rash over face in SLE, chloasma and acanthosis nigricans.10
      zoom view
      Fig. 1.2: Patchy absence of skin pigmentation can be seen in cases of vitiligo
      Table 1.2   Abnormal pigmentation of skin
      Pigmentation
      Condition
      Yellow
      • Jaundice
      • Carotenaemia
      Bluish
      • Central cyanosis
      • Peripheral cyanosis
      • Methaemoglobinaemia and sulphaemoglobinaemia
      Pallor
      • Anaemia
    • Abnormal skin pigmentation and the condition in which they are found are given in Table 1.2.
  • Types of skin lesions (Table 1.3, Figs 1.4 to 1.9)
zoom view
Fig. 1.3: Café-au-lait macule an example of hyperpigmentation
Table 1.3   Types of skin lesions
Morphology
Small (<0.5 cm)
Large (>0.5 cm)
Flat lesions
  • Normal
  • Indurated
Macule
Plaque
Patch
Plaque
Elevated lesions
  • Solid
  • Fluid filled
  • Pus filled
Papule
Vesicle
Pustule
Nodule
Bulla
Pustule
Indurated lesions (diameter > depth)
Plaque
Plaque
Lesions due to extravasation of blood
Petechiae
Ecchymosis
 
Examination of Hair
While examining hair, one should look for presence and colour of scalp hair. Presence and distribution of hair over body (secondary sexual character: axillary and pubic region) should also be noted.
 
Shape
Shape of hair varies depending on the race.
  • Asians—straight hair
  • Mongoloids—sparse facial and body hair
  • Negroids—curly hair
  • Europeans—wavy hair.
 
Colour
  • White hair: Albinism (due to absence of pigment)
  • Grey hair: A sign of ageing
  • Poliosis: Patchy loss of pigmentation of hair in the region of an adjoining vitiligo.11
    zoom view
    Fig. 1.4: Papule—solid elevated lesions of verruca vulgaris of less than 0.5 cm
    zoom view
    Fig. 1.5: Macule—depigmented flat lesions of variable size and shape of vitiligo and lip-tip type
    zoom view
    Fig. 1.6: Papule—dome-shaped papule, a few of them umbilicated, of molluscum contagiosum
    zoom view
    Fig. 1.7: Typical umbilicated papule of molluscum contagiosum
    zoom view
    Fig. 1.8: Violaceous coloured papules of lichen planus over the genitalia and thigh
    zoom view
    Fig. 1.9: Plaque—flat elevated lesions covered with silvery white micaceous scales of psoriasis vulgaris
    12
  • Flag sign: Brownish discolouration of hair with interspersed normal colour of hair, seen in protein-energy malnutrition (PEM).
 
Growth
  • Baldness: Temporal recession and baldness are common in males and the process is androgen dependent. Temporal recession in females may suggest virilisation. Frontal baldness is a marker for myotonic dystrophy and also seen in some cases of SLE.
zoom view
Fig. 1.10: Alopecia areata
zoom view
Fig. 1.11: Facial features of virilisation
  • Hypertrichosis: It refers to excess hair which could be familial or due to sexual precocity, hypothyroidism, adrenal hyperplasia or neoplasm and virilising ovarian tumours.
 
Examination of Face
 
Type of Facies
  • Acromegalic facies: Prominent lower jaw, coarse features, large nose, lips, ears, prominent forehead, cheekbones and widespread teeth.
    zoom view
    Figs 1.12A to G: Facies in medicine: (A) Hypothyroid face; (B) Leonine face; (C) Moon face (Cushing's syndrome); (D) Face in systemic lupus erythematosus (SLE); (E) Hyperthyroid face; (F) Parkinsonian face and (G) Bell's palsy
    13
  • Hypothyroid face: Puffy face with a dull expression and swollen eyelids and loss of hair over eyebrows (Fig. 1.12A).
  • Leonine facies: Seen in leprosy, and shows thickening of the skin and ear lobes with a flattened nasal bridge and loss of hair over the lateral aspect of eyebrows and eyelashes (madarosis) (Fig. 1.12B).
  • Cushing's syndrome: Rounded ‘moon face’ with excessive hair growth (Fig. 1.12C).
  • Face in SLE: Butterfly rash is seen over the face encompassing the upper cheeks and nasal bridge (Fig. 1.12D).
  • Hyperthyroid face: Anxious look, widely opened eyes with the upper and lower limbus being visible, associated with infrequent blinking and absence of wrinkling of the forehead (Fig. 1.12E).
  • Parkinsonian face: Immobile, fixed, expressionless face with infrequent blinking of the eyes. Normal rate of blinking is about 20 blink per minute. In parkinsonism, the rate of blinking is reduced to 10 blink per minute (Fig. 1.12F).
  • Bell's palsy: Absence of wrinkling of forehead on the side of the lesion, along with inability to close the eyes and on attempting to do so the eyeball is seen to move upwards and outwards (Bell's phenomenon). There is also loss of the nasolabial fold on the side of lesion and deviation of the angle of the mouth to the opposite healthy side on smiling. However, in long-standing Bell's palsy, when contractures of the facial muscles develop, prominent nasolabial grooves may be seen on the affected side, creating confusion as to the side of lesion (Fig. 1.12G).
 
Eyes
Look for the following features when examining the patient's eyes:
  • Ptosis (unilateral or bilateral) (Figs 1.13A and B)
  • Hypertelorism (Fig. 1.14)
  • Pallor
  • Cyanosis
    zoom view
    Figs 1.13A and B: (A) Sign sign ptosis, (B) Changes in eye due to ptosis
    zoom view
    Fig. 1.14: Hypertelorism in showing increased distance between medial canthuses of eyes
    zoom view
    Fig. 1.15: Blue sclera as seen in osteogenesis imperfecta
  • Icterus
  • Bitot's spots (Vitamin A deficiency).
  • Any corneal opacities, cataract, subconjunctival haemorrhage and corneal ulcers (seen in Bell's palsy and in trigeminal nerve palsy).
  • Kayser-Fleischer ring (KF ring) is seen in Wilson's disease (disorder of copper metabolism), primary biliary cirrhosis, cryptogenic cirrhosis and intraocular copper foreign body (uniocular KF ring).
  • Blue sclera as seen in osteogenesis imperfecta (disorder of bone metabolism) (Fig. 1.15).
 
Constitution
Constitution indicates the body type or habitus. Human race can be classified into the following somatotypes.
 
Clinical Classification
  • Asthenic: Thin, long and underdeveloped body with long neck, flat chest and slender fingers. They have a vertical heart. They are prone to have neurasthenia and visceroptosis.14
  • Normosthenic: Normal average body build.
  • Sthenic: Broad, short, fat neck, muscular chest and large stumpy fingers. They have horizontal heart.
 
Anthropometric Classification
  • Endomorph: Soft, round contours with well-developed cutaneous tissues and short stature.
  • Mesomorph: Wide, stocky, muscular individual with normal stature.
  • Ectomorph: Long narrow hands, long feet, shallow thorax, small waist and tall stature.
 
Stature
Stature is total height measured from vertex of head to soles of feet. It is a sum total of upper segment measurement (from vertex of head to the upper border of symphysis pubis) + lower segment measurement (from top of symphysis pubis to soles of feet).
 
State of Nutrition
The state of nutrition depends mainly on the distribution of adipose tissue in the body. On this basis, individuals can be classified as normal, overweight (fat or obese) and underweight. The state of nutrition can be assessed in the following ways:
  • Ideal body weight (IBW) = 22.5 × (height in metres)2. In women, the IBW is calculated as follows 0.94 × 22.5 × (height in metre)2. If the body weight more than 10% of IBW, the individual is overweight. If the body weight more than 20% of IBW, the individual is obese.
  • Body mass index is calculated as follows:
    BMI = Weight in kg/(height in metre)2.
  • The amount of subcutaneous fat can be estimated by measuring the skinfold thickness over the triceps, biceps, subscapular region and suprailiac region, by using a special pair of calipers. Normal triceps skinfold thickness: adult males—12.5 mm, adult females—16.5 mm.
  • Rough calculation of body weight (Broca's index) can be done provided the height of the individual is more than 100 cm and so is possible in adults only.
Height in cm–100 = desired body weight (in kg)
E.g. 160 cm–100 = 60 kg
Height in inches = body weight (in kg)
E.g. 66 inches = 66 kg.
 
Obesity
A person is said to be obese, if his body weight more than 20% of IBW and his BMI more than 30.
 
Types of Obesity
  • Generalised obesity: There is excess fat deposition uniformly throughout the body. Overeating is the most common cause. It is characterised by the presence of a ‘double chin’.
  • Android obesity: It is a type of obesity, which is characterised by excess deposition of fat over the region of the waists (Fig. 1.16A).
  • Gynoid obesity: It is a type of obesity, which is characterised by excess deposition of fat over the hips and thighs (Fig. 1.16B).
  • Superior or central type of obesity: In this type, there is excess fat deposition over face, neck and upper part of the trunk and the arms are thin. This is seen in Cushing's syndrome.
Type of obesity
Waist-hip ratio
Prognosis
Pear-shaped
0.8 or less
Good
Apple-shaped
0.9 or greater
Greater risk for complications of obesity
zoom view
Figs 1.16A and B: Pattern of obesity: (A) Android type (apple-shaped) and (B) Gynoid type (pear-shaped)
15
 
Waist-hip Ratio
Recent evidence suggests that regional distribution of fat may be of greater prognostic significance than absolute degree of obesity. This is assessed by measuring waist-hip ratio. Take maximal measurement of the hip over the buttocks. Take the narrowest measurement between the rib cage and the iliac crest. Calculate the waist-hip ratio.
 
Oedema
Oedema is a collection of excess fluid in the body interstitium, from the intravascular compartment.
The normal body fluid compartments are given in Table 1.4.
Table 1.4   Normal body fluid compartments
Compartment
Volume (in litres)
Percentage of lean body weight
Total body water
42
60
Extracellular water
  • Plasma
  • Interstitial
14
3–4
11
20
4–5
16
Intracellular water
28
40
 
Types
Oedema may be generalised or localised.
  • In generalised oedema (synonym: anasarca), there is retention of excessive fluid in tissues resulting in increase in total body fluids. This excessive fluid is due to transudation of fluid into the tissue spaces, increase in fluid in cells and increase of fluid volume in the venous and capillary sides of the circulation. Along with the retention of water, there is retention of sodium and chloride.
  • Localised oedema: Unlike generalised oedema, there is no accumulation of fluid in the entire body but there is accumulation in localised area with oedema confined to that region.
The causes of generalised and localised oedema are listed in Table 1.5.
Table 1.5   Causes of oedema
Generalised oedema
Localised oedema
  • Cardiac oedema
  • Renal oedema
  • Hepatic oedema
  • Nutritional oedema
  • Cyclic premenstrual
  • Idiopathic
  • Venous oedema
    • Deep vein thrombosis
    • Thrombophlebitis
    • Varicose veins
    • Superior or inferior venacaval obstruction
  • Lymphatic oedema
    • Chronic lymphangitis
    • Filariasis
    • Radiotherapy
  • Inflammatory oedema
    • Cellulitis
  • Allergic
    • Bee/wasp sting
    • Drugs
 
Clinical Features
The patient complains of tightness of the part and unusual heaviness. The skin is stretched and shiny and the normal wrinkles are obliterated. Superficial veins become less prominent. The confirmatory sign of oedema is pitting on pressure, i.e. pressure over the oedematous part displaces the fluid and this leads to the formation of a dimple (Fig. 1.17). The test is performed by exerting gentle pressure with the flat of the thumb for 10 seconds over a bony area (shin of the tibia, medial malleolus, and sacrum), and looking for pitting.
 
Characteristic Features
  • Cardiac oedema: In right-sided heart failure, there is systemic venous congestion and generalised16 oedema. The oedema is dependent in nature, i.e. it is most prominent in those parts which are the lowest. In ambulant subjects, the oedema is maximal over the ankles and feet (pedal oedema) and it is worse towards the end of day. It clears up with recumbency. In bedridden patients, oedema is most prominent over the sacrum. An early symptom of generalised fluid retention is nocturnal polyuria. The fluid which accumulates during the day is cleared at night due to improvement in cardiac output. As the condition progresses, the oedema becomes established at all times. Cardiac oedema is accompanied by other signs of cardiac failure such as exertional dyspnoea, engorged jugulars and hepatic enlargement.
    zoom view
    Fig. 1.17: Pitting pedal oedema
  • Renal oedema: Renal oedema characteristically involves the loose connective tissue, especially over the periorbital region. It is more prominent when the patient wakes up in the early morning, as the patient with renal oedema are able to lie down flat (comfortably).
  • Hepatic oedema: The pathophysiology of this oedema is that the collection of fluid occurs characteristically first in the peritoneal cavity (ascites), because of the increased portal venous pressure (portal HTN). Tense ascites leads to increased intra-abdominal pressure, thereby decreasing venous return from the lower limbs and hence development of pedal oedema.
  • Nutritional oedema: It is a generalised oedema. Causes of nutritional oedema are:
    • Decreased ingestion of proteins leading to hypoalbuminaemia and therefore, oedema.
    • Thiamine deficiency leading to beri-beri.
  • Idiopathic oedema: This constitutes the periodic episodes of oedema occurring exclusively in women. Diurnal variation of weight occurs with orthostatic retention of salt and water. This suggests an increase in capillary permeability on erect posture.
 
Examination of Mouth and Pharynx
Examination should be done with the help of torch and tongue depressor. The following things need to be examined.
  • Color of lips, tongue and buccal mucous membrane
  • Angle of mouth
  • Appearance of teeth and gum
  • Pigmentation of mucous membrane
  • Halitosis or bad breath typically emanates from oral cavity or nasal passages. Bacterial decay of food and cellular debris release volatile sulphur compounds resulting in halitosis. Poorly-fitting dentures, oral infections, and tongue coating are usual causes. Pockets of decay in the crypts of tonsils, oesophageal diverticulum, stasis of food due to achalasia or stricture can cause halitosis. Psychiatric illness can cause pseudo-halitosis or halitophobia in the absence of objectively detectable bad odour and is also indicative of certain diseases, e.g. in hepatic failure, breath has a fishy odour, in renal failure ammoniacal or urinary odour and in diabetic ketoacidosis fruity odour.
 
Examination of Neck
The neck should be examined for:
  • Thyroid gland: Size, shape, enlargement if any.
  • Neck veins: Normal or engorged, jugular venous pressure, carotid pulse.
  • Lymph nodes: Site, size, number of nodes enlarged, consistency, tenderness, mobility, fixity to skin, lesions in area of drainage, lymphoedema.
 
Lymph Nodes
Cervical nodes may be broadly divided into superficial and deep groups with reference to their relation with the deep fascia. Superficial group consists of the occipital, retro-orbital, parotid, buccal, submandibular, submental and anterior and posterior cervical nodes. Supraclavicular nodes are situated above the medial ends of the clavicles. Pretracheal (scalene) nodes are situated behind the origin of the sternal head of the sternocleidomastoid muscle, usually palpated in between the two heads of this muscle (Fig. 1.18).
zoom view
Fig. 1.18: Cervical lymph nodes
 
Lymphadenopathy
Lymph nodes are normally just palpable as small firm nontender masses less than 0.5 cm in diameter, especially in children or they are not palpable at all. Any palpable lymph node anywhere in the body is significant. In general, nodes larger than 2 cm, any lymph node in the supraclavicular region, scalene node or generalised lymphadenopathy are significant. The causes of generalised lymphadenopathy are given in Table 1.6.
Table 1.6   Causes of generalised lymphadenopathy
Infections
  • Miliary tuberculosis
  • HIV
  • Filariasis
Other inflammatory diseases
  • SLE
  • Rheumatoid disease
Neoplastic diseases
  • Lymphomas
  • Acute leukaemias
Miscellaneous
  • Sarcoidosis
Abbreviations: HIV, human immunodeficiency virus; SLE, systemic lupus erythematosus.
 
Examination of Hands and Fingers
  • The hands should be examined for general appearance, muscle wasting, any contracture, etc.
  • The fingers should be examined for their number, webbed fingers (syndactyly), absence of digits and clubbing (Table 1.7).
Table 1.7   Abnormalities of fingers
Condition
Seen in
Polydactyly (supernumerary fingers) (Fig. 1.19A)
  • Congenital
  • Familial
  • Associated with ventricular septal defect (VSD)
  • Laurence-Moon-Biedl syndrome
  • Turner's syndrome
Syndactyly (webbed fingers) (Fig. 1.19B)
  • Sometimes in normal individuals
  • Poland's syndrome
Arachnodactyly (long and thin fingers—spider fingers) (Fig. 1.19C)
  • Marfan's syndrome
  • Hypogonadism
  • Hypopituitarism
  • Homocystinuria18
zoom view
Figs 1.19A to C: Abnormalities of fingers: (A) Polydactyly; (B) Syndactyly and (C) Arachnodactyly
zoom view
Fig. 1.20: Acromegalic hand
 
Clubbing of Fingers
It is a selective bulbous enlargement of the distal portion of the digit due to increased subungual soft tissue. The normal angle between the nail and the nail-bed is 160° and is known as the Lovibond angle (Fig. 1.21A). When the dorsum of the distal phalanges of the fingers of both hands are approximated to each other, a diamond-shaped gap is made out due to the presence of the Lovibond angle (Shamroth's sign). This gap disappears with obliteration of this angle, as that occurs with clubbing. The minimum duration required for clubbing to manifest is 2–3 weeks. Clubbing first appears in the index finger (Figs 1.21B and C). The causes of clubbing are given in Table 1.8.
zoom view
Figs 1.21A to C: Clubbing: (A) Normal nail-bed angle; (B) Testing for fluctuation and (C) Clubbing of finger
19
Table 1.8   Causes of clubbing
Congenital/familial
  • Congenital hypertrophic pulmonary osteoarthropathy
Pulmonary and thoracic causes
  • Bronchogenic carcinoma
  • Suppurative lung disease
    • Bronchiectasis
    • Cystic fibrosis
    • Lung abscess
    • Empyema
  • Interstitial lung disease
  • Long-standing pulmonary tuberculosis
  • Chronic bronchitis
  • Mesothelioma
Cardiovascular causes
  • Cyanotic congenital heart disease
  • Bacterial endocarditis
  • Atrial myxoma
  • Eisenmenger's syndrome
Gastrointestinal (GI) causes
  • Cirrhosis of liver
  • Ulcerative colitis
  • Crohn's disease
  • GI malignancy
Miscellaneous
  • Syphilis
  • Syringomyelia
  • Acromegaly
  • Thyrotoxicosis
 
Examination of Nails
The various nail changes and their causes are given in Table 1.9.
Table 1.9   Nail changes
Condition
Description
Seen in
Koilonychia (Fig. 1.22)
Thinning and softening of the nail-plate resulting in spoon-shaped nail
  • Iron-deficiency anaemia
  • Haemochromatosis
  • Raynaud's syndrome
  • Porphyria
Beau's line (Fig. 1.23)
Transverse ridges in the nail-plate due to temporary alteration of nail growth rate
  • Acute febrile illness
  • Pneumonia
  • Measles, mumps
  • Myocardial infarction, pulmonary infarction
  • Childbirth
  • Drug reaction
White nail (Terry nail)
White colour in the nail bed than the nail plate
  • Anaemia
  • Hypoalbuminaemia
Plummer nail
Onycholysis of the nail (rat-bitten nail)
  • Hypothyroidism
  • Hyperthyroidism
  • Raynaud's disease
  • Porphyria
  • Drugs—doxycycline, chloramphenicol
Lindsay nail (Fig. 1.24)
Proximal dull white portion and a distal pink or brown portion with a well demarcated transverse line of separation
  • Uraemia
Red nail
  • Congestive heart failure
Blue nail
  • Wilson's disease
Black nail (Fig. 1.25)
  • Peutz-Jegher's syndrome
  • Cushing's syndrome
  • Addison's disease
Yellow nail syndrome
Yellow discolouration of finger and toe nails with clubbing and onycholysis
  • Infection—sinusitis, bronchitis, bronchiectasis
  • Carcinoma of skin, larynx, endometrium
  • Lymphoma
  • Psoriasis20
zoom view
Fig. 1.22: Koilonychia
zoom view
Fig. 1.23: Beau's line
zoom view
Fig. 1.24: Half-half nail (Lindsay nail)
zoom view
Fig. 1.25: Black nail
 
Differential Diagnosis
It is the method of reaching the diagnosis by rulling out other candidate diseases (having almost same sign and symptoms) with the help of advanced investigations.
 
Investigations
Investigation for a patient depends on the presenting complaints. Various type of investigations are as follows:
  • Haematological investigations:
    • Complete blood count
    • Serum electrolytes
    • Serum creatinine
    • Coagulation studies
    • Blood grouping and typing
    • ABG
  • Radiological examinations:
    • X-ray scan
    • CT scan
    • MRI
  • Electrocardiogram (ECG)
  • Echocardiogram
  • Treadmill test (TMT)
  • Angiography
  • Electroencephalography (EEG)
  • Endocrine study.
 
Diagnosis
It is the process of reaching a conclusion about the cause and the nature of disease after taking detailed history, examination and investigations.
 
Provisional Diagnosis
It is the process of making a tentative diagnosis with the help of history, examination and differential diagnosis.21
 
Confirmed Diagnosis
When provisional diagnosis is confirmed with the help of investigation, it is called confirmed diagnosis.
 
Treatment
Once the diagnosis is made, treatment for the diagnosed condition is started. Treatment can be symptomatic or treatment of the underlying cause/pathology. Choice of treatment depends on the type of disease, e.g. a tooth pain can be treated for its symptoms with analgesics or can be treated removing its underlying etiology.
 
Prognosis
Prognosis is the prediction of likely outcome of the course of a disease. A complete prognosis includes expected duration, function and a description of course of disease (progressive, relapsing, etc.). It is an important part of modern medicine as it helps in deciding course of treatment. It also helps patient's relative to take important decisions related to patient, e.g. decision to wean-off a patient from ventilator can be taken by the relatives in the light of prognosis.
 
Follow-up
It is the process of monitoring the progress of a patient after active treatment. Follow-up is a very important part of modern medicine. It helps in developing better doctor-patient or hospital-patient relationship with better patient satisfaction.
 
 
Systems-related details will be dealt in respective chapters.22
Protocol for Recording Case History/Sample Format for Case History
Name
………………………………………………………………………………………………………………………………………………………
Age/Sex
………………………………………………………………………………………………………………………………………………………
Occupation
………………………………………………………………………………………………………………………………………………………
Marital Status
………………………………………………………………………………………………………………………………………………………
Address:
………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………
Provisional Diagnosis:
………………………………………………………………………………………………………………………………………………………
Chief Complaint:
………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………
Present Medical History
………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………
Past Medical History
………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………
Family History
………………………………………………………………………………………………………………………………………………………
Social History
………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………
Physical Examination
General Examination
General Appearance ………………………………………………………………………………………………………………………………………………………
Built
………………………………………………………………………………………………………………………………………………………
Dehydration
………………………………………………………………………………………………………………………………………………………
Anaemia
………………………………………………………………………………………………………………………………………………………
Cyanosis
………………………………………………………………………………………………………………………………………………………
Clubbing
………………………………………………………………………………………………………………………………………………………
Jaundice
………………………………………………………………………………………………………………………………………………………
Purpura
………………………………………………………………………………………………………………………………………………………
Oedema
………………………………………………………………………………………………………………………………………………………
Exophthalmus
………………………………………………………………………………………………………………………………………………………
Puffiness
………………………………………………………………………………………………………………………………………………………
Pulse
………………………………………………………………………………………………………………………………………………………
Blood Pressure
………………………………………………………………………………………………………………………………………………………23
Fever
………………………………………………………………………………………………………………………………………………………
Lymph Nodes
………………………………………………………………………………………………………………………………………………………
Skin
………………………………………………………………………………………………………………………………………………………
Teeth and Gums
………………………………………………………………………………………………………………………………………………………
Tonsil and Pharynx
………………………………………………………………………………………………………………………………………………………
Ear
………………………………………………………………………………………………………………………………………………………
Systemic Examination
Chest
Inspection
Respiratory Rate
………………………………………………………………………………………………………………………………………………………
Shape of Chest
………………………………………………………………………………………………………………………………………………………
Movement
………………………………………………………………………………………………………………………………………………………
Palpation
………………………………………………………………………………………………………………………………………………………
Percussion
………………………………………………………………………………………………………………………………………………………
Auscultation
………………………………………………………………………………………………………………………………………………………
Heart Sounds      Murmur
…………………    …………………………
Abdomen
Inspection
………………………………………………………………………………………………………………………………………………………
Contour
………………………………………………………………………………………………………………………………………………………
Movement of Abdominal Wall
………………………………………………………………………………………………………………………………………………………
Veins
………………………………………………………………………………………………………………………………………………………
Umbilicus
………………………………………………………………………………………………………………………………………………………
Scar
………………………………………………………………………………………………………………………………………………………
Palpation
Superficial
………………………………………………………………………………………………………………………………………………………
Deep
………………………………………………………………………………………………………………………………………………………
Liver
………………………………………………………………………………………………………………………………………………………
Spleen
………………………………………………………………………………………………………………………………………………………
Kidney
………………………………………………………………………………………………………………………………………………………
Gall Bladder
………………………………………………………………………………………………………………………………………………………
Bowels
………………………………………………………………………………………………………………………………………………………
Lymph Nodes
………………………………………………………………………………………………………………………………………………………24
Other Mass
………………………………………………………………………………………………………………………………………………………
Fluid Thrill
………………………………………………………………………………………………………………………………………………………
Percussion
Upper Border of Liver
………………………………………………………………………………………………………………………………………………………
Shifting Dullness
………………………………………………………………………………………………………………………………………………………
Auscultation
Bowel Sounds
………………………………………………………………………………………………………………………………………………………
Bone and Joints
Limbs
………………………………………………………………………………………………………………………………………………………
Skull
………………………………………………………………………………………………………………………………………………………
Spine
………………………………………………………………………………………………………………………………………………………
Sternum
………………………………………………………………………………………………………………………………………………………
Ribs
………………………………………………………………………………………………………………………………………………………
Nervous System
Mental State
Consciousness
………………………………………………………………………………………………………………………………………………………
Memory
………………………………………………………………………………………………………………………………………………………
Intelligence
………………………………………………………………………………………………………………………………………………………
Mood
………………………………………………………………………………………………………………………………………………………
Fear, Anxiety, etc.
………………………………………………………………………………………………………………………………………………………
Delusions/Illusions
………………………………………………………………………………………………………………………………………………………
Temperament
………………………………………………………………………………………………………………………………………………………
Other
………………………………………………………………………………………………………………………………………………………
Orientation
Time
………………………………………………………………………………………………………………………………………………………
Place
………………………………………………………………………………………………………………………………………………………
Person
………………………………………………………………………………………………………………………………………………………
Behaviour Speech
………………………………………………………………………………………………………………………………………………………
Involuntary Movement
………………………………………………………………………………………………………………………………………………………
Differential Diagnosis
………………………………………………………………………………………………………………………………………………………
Investigations
………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………….
Diagnosis
………………………………………………………………………………………………………………………………………………………
Provisional Diagnosis
………………………………………………………………………………………………………………………………………………………
Confirmed Diagnosis
………………………………………………………………………………………………………………………………………………………
Treatment
………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………….