Manual of Clinical and Practical Medicine GS Sainani, Rajesh G Sainani
INDEX
Page numbers followed by b refer to box, f refer to figure and t refer to table.
A
Abacavir 43
Abadie’ sign 320
Abdomen 88, 114, 378, 389f, 393
auscultation of 99
examination of 85, 91, 346
inspection of 91
movements of 92
palpation of 94
percussion of 98
plain X-ray 551
quadrants of 89f
regions of 91f
shape of 91, 91f
tuberculosis of 122
Abdominal bruit 100f
Abdominal calcification 567
Abdominal colic 58
Abdominal diseases 95b
Abdominal glands 123
Abdominal lump 115
Abdominal pathologies 89
Abdominal reflexes, elicitation of 298f
Abdominal tenderness 95f
Abdominal tumors 92
Abdominal veins
dilated 106
distended 94
Abdominal wall 92
ABE antitoxin 732
Abetalipoproteinemia 691
ABO incompatibility 765
Abrams pleural biopsy needle 621f
Abscess 316
subphrenic 247
Absolute eosinophil count 668
Acanthocytes 418, 419f
Acanthosis nigricans 81f
Acarbose 402, 680
Accessory muscles 218
of respiration 700
Accessory nerve 290
examination of 285
Accommodation reaction 275
Acebutolol 659
Acetaminophen 719, 720
poisoning 724
Acetylcysteine 724
Achalasia cardia 537, 552, 553f, 554t
Achlorhydria 619
Achondroplasia 403
Acid–base balance 349
Acid-base disorders 341, 355
basic concepts of 355t
Acid-fast bacilli 192, 227, 336
Acid peptic disease 87
Acidosis 355
lactic 355
metabolic 218, 229, 355
renal tubular 355
Acne vulgaris, causes 364
Acoustic meatus, left internal 588f
Acoustic neuroma 607
Acrocyanosis 77
Acromegaly 562
Acropachy 364
ACTH-secreting pituitary adenomas 386
ACTH stimulation test 388
Activated partial thromboplastin time 429, 681
Addison's disease 69, 70f, 76, 361, 364, 366, 386388, 705, 714
management of 388
Adenocarcinoma prostate 595f
Adenolymphangitis, acute 49
Adenoma
gastrin secreting 652
pituitary 367
sebaceum 59f
Adenosine 660
Adie's tonic pupil 275, 704
Adiposogenital syndrome 361
Adrenal adenoma 586f
Adrenal crisis 388, 764
Adrenal gland
calcification of 387
left 586f
right 604f
Adrenal insufficiency 709
Adrenaline 389
Adrenocortical
deficiency, primary 386
insufficiency, secondary 387
tumor 602
Adrenocorticotropic hormone 360, 773
Adriamycin 437
Advanced life support 742
Adventitious sounds 224
Aedes aegypti mosquito 34, 35
Aedes anopheles 49
Aflatoxins 121, 122
Agranulocytosis 377
Agraphia 266
Air bronchogram 535f
Air-fluid level, causes of 537
Air hunger 129, 210, 211
Alanine aminotransferase 773
Albumin-globulin ratio 103
Albuminocyto disproportion 689
Albuminocytologic dissociation 334
Albuminuria 183
Albuterol 230
Alcohol 55, 185
abuse 56b
adverse effects of 56f
ingestion 115
Alcohol binge 389
Alcoholic hepatitis 56, 107, 121
Alcoholic liver disease 107
Alemtuzumab 435
Aleukemic leukemia 617
Alexia 266
Alkaline diuresis 719
Alimentary glycosuria 698
Alkaptonuria 67
Allergic alveolitis, extrinsic 541
Allergy testing 229
Allgrove syndrome 706
Allodynia 302
Allogenic BM transplant 433
Allopurinol 437, 439, 468
Alopecia 67, 378, 466
Alopecia, diffuse 466f
Alpha blockers 189
Alpha glucosidase inhibitors 402, 680
Alpha thalassemia 420
Alpha tocopherol 16
Alpha-fetoprotein 684
Alport's syndrome 202, 348
Alprazolam 752
Aluminum phosphide 719
poisoning 725
Alveolar cell carcinoma 537
Alzheimer's dementia 265
Alzheimer's disease 596
Amantadine 736
Amaurosis fugax 311
Ambu bag 742
Amblyopia 55, 653
Amebic liver abscess 96, 118, 118f, 210
Amebic typhlitis 98
Amenorrhea 362
American Heart Association Guidelines 188t
Aminoglycoside 350, 765
Aminophylline toxicity 714
Amiodarone 378, 659
Amoebic dysentery 691
Amoxicillin 650, 660
Amphoric breathing 253
Amprenavir 43
Amrinone 189
Amyloid deposits 68f
Amyloidosis 70, 70f
Amyotrophic lateral sclerosis 323, 323f
Anacrotic pulse 136
Anal
lesions 699
reflex 298
Analgesia 302
Anaphylactic shock 744
Anaphylaxis 738
treatment 738
Anasarca 79, 348, 349
Anemia 185, 411, 418, 424
classification of 411
in malaria, mechanisms of 643
type of 424
Anesthesia 302, 325
Aneurysm of arch 548f
Angina
grading of 128b
unstable 127
Angina pectoris 127f
classification of 658
Angle of Louis 139, 214f
Anion gap 355
Anisocytes 419f
Anita Harding's criteria 327
Ankle
clonus 296
jerk, absence of 317
reflex 296
Ankylosing spondylitis 462, 463f
Ann Arbor classification 440, 440t
Anomalous pulmonary venous connection, partial 198
Anomalies, congenital 400
Anopheles 49
Anorexia nervosa 695
Anosmia 267
causes of 267
Antiarrhythmic drugs 659
Antibodies
anti neutrophil cytoplasmic 453
anticardiolipin 477
anticentromere 470
anti-dsDNA 453
antinuclear 452
antiphospholipid 453
antithyroid peroxidase 376
Anticholinergic 719
drugs 69
Anticoagulant therapy, management of 656
Anticyclic citrullinated peptide antibody 452
Antidiphtheritic serum 25
Antidiuretic hormone 342
Antinuclear antibody 452
Antiphospholipid
antibodies 453
syndrome 446, 476, 476f
Antiretroviral
therapy 43t
treatment 43
Antisnake venom 733
Antistreptolysin O antibodies 453
Antitrypsin deficiency 233
Antitubercular drugs 666
second-line 666, 667
Antivenom 719
Antiviral agents 106
Anuria 343
Anxiety tremor 293
Aorta
abdominal 208f
aneurysm of 206
ascending 128
arch of 208f
calcification of ascending 550
coarctation of 180, 181f, 182f, 183, 550, 663, 749
dissecting aneurysm of 207f, 750, 750t
prominent ascending 178f, 182f
with calcification 548f
Aortic
aneurysm 205, 206f
types of 205f
arch, right-sided 550
catheterization 749
component 149f
dilatation 547
disease 167
dissection 749
incompetence 151, 549
knuckle 178f, 182f
prosthetic valves 161f
regurgitation 129, 167, 169f, 171, 172
sclerosis 166
stenosis 151, 165, 165f, 166f, 171, 549
valve
area 167
disease 167
surgery 749
Aortoarteritis 179, 180, 183, 206, 551
Aortography 180, 208f
Apex beat, types of 143, 144f
Aphasia 266
types 266
Apherocytes 419
Aphonia 266
Aphthous ulcer 70f, 481
tongue 451f
Aplastic anemia 411, 423
causes of 423
Aplastic crisis 422
Apnea hypopnea index 236
Apophyseal joints 464
Appendicitis 95
Appetite suppressants, types of 680
Apraxia 266
Arachnodactyly 141f
Arcus senilis 132f, 365
Argyll-Robertson pupil 275, 320
Arnold Chiari malformation 321, 324326
Arrhythmias 185, 366, 497
Arsenic poisoning 725
Artemether 29
Arterial blood 616
gas 665, 690
Arterial pulsations 137, 137t
Arterial thrombosis 761
Arteriovenous fistulae 152b
Arteritis 208f
Artery, auscultation over 152
Arthralgia 153, 444
Arthritis 155, 444
causes of 465
Articulation 265
Asbestosis 246, 247, 538
Ascaris lumbricoides 668
Ascites 99f, 107, 108f, 701
causes of 107
signs of 107
Ascitic tapping 612
Ascorbic acid 14, 16
Aspiration 240
needles 610f
pneumonia 241
Asplenia 197
Asthma
extrinsic 230t
intrinsic 230t
severe acute 750
triggers of 210
Astringent enema 626
Astrocytoma 317f
Ataxia 261
Ataxic breathing 219
Atazanavir 43, 44
Atelectasis causes 246
Athetosis 294
Atlantoaxial subluxation 322f
Atonic bladder 308
Atrial
arrhythmias 498
enlargement
left 547
right 547
fibrillation 133, 140, 366, 498, 499f, 659, 701, 746
cardioversion in 620
flutter 498, 499f, 510, 747
myxoma, left 159
premature complexes 498, 498f
septal defect 197, 197f, 549
Attack of gout, acute 468f
Auditory function, examination of 283
Auditory hallucinations 283
Augmented histamine test 619
Augmented limb leads 484
Auricular nerve, thickened greater 83f
Auscultation 222, 223b, 644
Auscultatory silent gap 66f
Austin flint murmur 700
Autoimmune
diseases 376, 453
disorders 7
rheumatic diseases 453
syndromes 693
Autonomic dysfunction 25
Autonomic nervous system 305, 305f
examination of 305
Autonomic neuropathy 363
Axial disease 464
Axial fluid-attenuated inversion recovery 352f
Axillae 72
Azathioprine 337
B
Babinski reflex 298
Baby speech 265
Baclofen 333
Bacterial infections, secondary 28
Bacterial meningitis 607
Bactericidal drugs 34
Bacteriostatic drugs 34
Balloon angioplasty 182, 651
Balloon aortic commissurotomy 166
Balloon valvotomy 166
Balloon valvuloplasty 159, 161
Band keratopathy 365
Banti's disease 113
Barbiturate 720
poisoning 721
Barium
enema
double-contrast 556f
studies 556
meal 552, 554, 555, 555f
swallow 471f, 552, 553f
Barking cough 210
Barlow's disease 163, 164, 491
Barognosis 304
Barotrauma
involves air-containing 737
sickness 737
Bartter's syndrome 716, 717
Basal acid output 619
Basal bronchiectasis, bilateral 239f
Basal ganglia 313f, 704
calcification 561f
Basal meningitis 286
Basic life support 740
Basilar artery 260
syndromes 314
Basophilic stippling 727
Bassen-Kornzweig syndrome 704
BCG vaccination, complications of 666
Beau's lines 75f
Becker's muscular dystrophy 331
Becker's sign 167
Beclomethasone 230
Beevor's sign 291, 315
Behcet's disease 261, 347, 446, 451, 451f, 643
Behcet's syndrome 481
Bell's palsy 281, 281f, 282f
Bell's phenomenon absent 696
Bence Jones proteins 436
Benedict's syndrome 277, 313
Bengal splenomegaly syndrome 647
Benzodiazepines 719
Beriberi 16, 78, 130, 135
Bernheim effect 167
Berry aneurysms 180
Berylliosis 212
Best motor response 693
Best verbal response 693
Beta-thalassemia
major 420
minor 421
Beverages 640
Biceps reflex 296
Bicuspid aortic valve 749
Biguanides 401
Bile
acid sequestrants 653
ducts 566
Biliary cirrhosis 75, 96t
Bilirubin 773
Bilirubinemias, conjugated 114
Bilot's spots 17f
Binasal
catheter 743
hemianopia 268
Biophosphonates 12
Biopsy procedure 622
Biot's irregular breathing 219
Biot's respiration 62
Biotin 16
Bitemporal hemianopia 268
Bitot spot 68f
Black stools, causes of 107
Bladder
examination of 347
neck obstruction 352
Blalock-Taussig shunt 201
Blindness, central 266
Blood 240, 412
cultures 339
gas 233, 773
analysis 778
glucose 396
half 607
loss 411
chronic 412
pH 395
pressure 64, 381, 396
diastolic 657
systolic 657
products
irradiated 685
types of 685
sugar 396, 776
transfusion 115
complications of 685
mismatch 765
urea 395
Blue granules, ring of 424f
Blue sclera 59f, 406f
Body
mass index 61f
temperature, abnormalities of 63b
Bone 456, 563
deformities, causes of 456b
disease, symptoms of 456
disorders 557
fever, break 34
forming agents 12
long 561, 563
marrow 416, 431f
aspiration needle 617f
biopsy 618
examination 616
pain, causes of diffuse 456b
Bordetella pertussis 26
Bordet-Gengou agar 26
Bornholm disease 251
Borst diet 632
Bortezomib 437
Bosentan 237
Botulism 731
Bouchard's nodes 73, 446f
Bouin's fluid 622
Boutonniere deformities 459
Bowel diarrhea
large 691
small 691
Bowman's capsule 341
Bowel, small 555
Brachial plexus lesions 694
Brachioradialis 290
Bradycardia 695
Bradykinesia 328
Brain
abscess 569
diffuse affection of 757
focal affection of 757
magnetic resonance imaging of 310f
stem syndromes 313
tuberculoma 569f
tumor 263, 759
Brassy cough 210
Braziliensis infection 48
Breast 72, 366
malignancy, right 597f
Breath
sounds 233
intensity of 223
types of 223
test, deep 305
Breathing 396
abnormal 219
ambient air 778
pattern 63f
abnormalities 62
type of 219
Brisk tendon reflexes 366
Broca's area 265
Broca's index 20
Brock's syndrome 238
Brockenbrough braunwald morrow sign 702
Bromocriptine 369, 736
Bronchial asthma 229, 230, 230t, 255
acute 230
severity of 665
treatment of 230b
Bronchial breathing 223, 224f
Bronchiectasis 238, 239f, 240f, 540
bilateral 238
basal 239f
cystic 239f
middle lobe 238
sicca 239
traction 243
upper lobe 238
Bronchitis
acute 255
chronic 190, 233t, 255
Bronchoalveolar lavage 481
Bronchogenic carcinoma 244
Bronchophony 251
Bronchoscopy 614
applications of 614
Brown-Sequard syndrome 318, 319f
Brucella 175
abortus 30
melitensis 30
suis 30
Brucellosis 30
diagnosis 31
treatment 31
Brudzinski's sign 306
Brugada syndrome 664
Brugia malayi 49
Bruit 99
Bubble humidifier 616
Budd-Chiari syndrome 106, 110, 1110f, 120, 140, 651
Budesonide 230
Buerger's disease 78, 79, 137
Buffaloe hump 22f
Buffy coat preparation 435
Bulbar
dysarthria 266
palsy, progressive 324, 692
Bulbocavernous reflex 298
Bulimia 695
Bulky hypoechoic pancreas 125f
Bull neck 24
Bullae, multiple 541f
Bullous emphysema 700
Bundle branch block 493
left 493, 493f, 510
right 494, 494f, 510
Bundle of Kent 503
Burkett's lymphoma 41
Burkett's type leukemia 430f
Burning pain 477f
Busulfan lung 700
Butterfly malar rash 466C-ANCA pattern 453
C
Cachexia of malignancy 61f
Café-au-lait spots 315
Calcification, causes of 538
Calcified fibroid 565f
Calcified lymph nodes
in axillae 538f
in neck 538f
Calcinosis universalis 471f
Calcitonin 12, 13
Calcitriol 384, 776
Calcium 12, 18, 503, 773
carbonate 352
channel blockers 189
gluconate 711, 712, 714
rich foods 633Calculi
pancreatic 391
renal 344, 351, 532, 564, 633, 715
salivary 87
Camel hump effect 502
Caplan's syndrome 536, 667
Campylobacter jejuni infection 688
Canadian Heart Association 128
Candida 175
infection 39
Caplan's syndrome 536, 667
Capreomycin 667
Capsule, internal 288
Caput medusae 106
Carbamates 719
Carbidopa 736
Carbohydrates 2
food sources of 2
high 632tCarbon monoxide poisoning 728
Carboxy-hemoglobin 774
Carcinoembryonic antigen 684
Carcinoid syndrome 244, 651
Cardiac
apex, position of 220
arrest 739
mechanisms of 740
asthma 210
cachexia 130
catheterization 157
chambers 127f, 146f
cycle 148
disorders, X-ray of 548
dullness 221
superficial 221
Cardiac
emergencies 740
enzymes 128, 191, 206, 749, 761
failure
congestive 58, 96, 186f, 630, 708
high-output 170
lesion 188
congenital 663
output
decreased 616
increased 546
shape 545
size 545
tamponade 745
Cardiogenic shock 744
Cardiomyopathy 193
Cardiopulmonary resuscitation 740
Cardioselective &-blockers 663
Cardiovascular
abnormalities 366
causes of syncope 130b
diseases 655
disorders 7
system 4, 126, 375, 376, 378, 392, 545, 629
examination of 126
Carditis 153, 155
Carey Coomb murmur 153, 155
Carina, level of 553f
Carotenemia 80, 82
Caroticocavernous fistula 381
Carotid artery
pulsations 137
stenosis 311
Carotid endarterectomy 761, 762
Carpal compression test 478
Carotido-cavernous fistula 152
Carpal tunnel syndrome 364, 366, 368, 378, 401, 477, 478f, 687
Carpopedal spasm 294, 356fCasal's collar 13
Castor oil 626
Catatonia 691
Catecholamines 774, 776
Catechol-O-methyltransferase 329
Cauda equine
lesions 308
syndrome 319, 319t
Causalgia 302
Caustic ingestion 729
Cavernous hemangioma 684
Cavernous sinus 243f, 271f
thrombosis 339
Cavity, causes of 537
Cecum 98
Celiac disease 60, 75, 687, 688
Cell carcinoma
non-small 245
small 246
Central cyanosis, causes of 78b
Central nervous system 375, 393, 629, 726
disorders 8
manifestations 720
Central pontine myelinolysis 650, 691, 709
Cereal exchanges 637
Cereal preparations 638
Cerebellar
artery, posterior inferior 313
ataxia 299, 303b, 326
disorders 299
dysarthria 266
dysfunction 293
lesion, signs of 300, 300b
syndrome 703
Cerebellopontine angle 281
left 588f
tumor 340
Cerebellum, disorders of 300
Cerebral
artery
anterior 259
middle 259
posterior 259, 260, 260f
superior 260
blood supply 259
cortex 287f
diplegia 314
edema, treatment of 757
hemisphere, left 585f
hemorrhage 313f
infarction 310f
lobes, dysfunction of 266
malaria 28, 760
thrombosis, causes of 761
Cerebrohepatorenal syndrome 673
Cerebrospinal fluid examination 431
Cerebrovascular insufficiency, causes of 311
Ceruloplasmin 20, 103, 671, 756, 774,
Cervical
cord, myelitis of 321f
rib 145, 535, 694
spine 322f, 444
X-ray 464f
spondylosis 322
vertebrae, tuberculosis of 557f
Chaddock's sign 297
Chamber enlargement 547
Charcoal 725, 726, 728, 729
Charcot's joint 320, 399, 563
Charcot-Bouchard microaneurysms 704
Charcot-Marie-Tooth disease 324, 330
Chediak-Higashi syndrome 83
Chelating agents 267, 719
Chelation, indications for 728
Chemoprophylaxis 29, 29t
Chest
barrel-shaped 216
deformities 216, 217f
diseases 257f
examination of 214
inspection of 216b
movements of 218
pain 211, 750
palpation of 219
plain X-ray of 228
regions of 213, 213f, 214f
shape of 216
veins 219
wall, vertical planes of 140
Cheyne-Stokes breathing 219
causes of 219
Chikungunya fever 35
Chilaiditi's syndrome 552, 552f
Child's classification, modified 105b
Chipmunk facies 420, 421f
Chlamydia 42
Chloasma 59, 81
Chloral hydrate 626
Chlorambucil 434
Chloroquine 445
maculopathy 445f
resistant Plasmodium falciparum 28
Cholecystitis 95, 635
Choledochal cyst 115
Cholelithiasis 635
Cholestatic jaundice 113
Cholesterol 250, 348, 397, 631
Cholinergic
crisis 767
drugs 767
Chondroitin sulfate 689
Chorea 153, 294
causes of 329
Choreoathetosis 73, 153, 294
Choroid tubercle 32, 336, 700
Choroiditis 643
Chromium 20
Churg-Strauss syndrome 667
Chvostek's sign 294, 714
Chyliform effusion 250
Chylothorax, causes of 250
Chyluria 344
Ciliospinal reflex intact 696
Circadian rhythm 648
Circinate balanitis 347
Circle of Willis 260f
Cirrhosis 96
liver, management of 105
of liver 90, 102, 635, 675
Cisternal puncture 607
Clarithromycin 650
Clasp-knife spasticity 288
Claude's syndrome 277, 313, 313f
Claw hand 290
Clitoral hypertrophy 367
Clofazimine 47
Clomiphene therapy 363
Clonus 293, 296
Clostridium botulinum 731
Clubbing
grades of 74f
of digits 245f
Clumsy hand syndrome 311
Cluster headache 263
Coagulopathy, treatment of 757
Coarctation aorta, congenital 182f
Cobalamin 16
Cobra 732
Cod fish biconvex vertebra 12f
Coeliac disease 370, 661
Cohen's law of meningitis 607
Coin sound sign 227
Cold agglutinin disease 418
Colitis
ischemic 557
pseudomembranous 755
ulcerative 556. 556f, 634Collagen vascular disorders 11
Collapse, types of 246
Collapsing pulse, causes of 135b
Colloid
cyst 588f
goiter, large 374f
Colon
ascending 124f
carcinoma 597f
Color vision 268
Colorectal cancer 557
Coma 757
causes of 757
in hypopituitarism, causes of 677
Comatose patient, management of 757
Compartment syndrome 429, 689
Compatible blood group 685
Complete blood count 42
Complete heart block, acquired 497, 497b
Complete ptosis 277f
left side 696f
Compression collapse 246
Computed tomography 568
advantages 568
disadvantages 568
of brain 310f, 313f
Confrontation test 268, 268f
Congenital disorder 317
Congenital heart diseases 477
Congestive heart failure 184, 188t, 702
Conjunctivitis 68f
Conn's syndrome 180, 361, 390
Connective tissue disease 643
Conradi-Hunermann syndrome 202
Constipation 90, 634
Constrictive pericarditis 140, 549
chronic 192, 194t
Contraceptive pill 651
oral 54
Contraction of cecum 124f
Contralateral lungs 596f
Conus 318
medularis 319, 319t
syndromes 318
Cooley's anemia 420, 421f
Coombs’ test 683
direct 683
indirect 683
Cope's pleural biopsy needle 621f
Copper 20
Cor pulmonale
causes of 231b
chronic 190, 233
Cord compression 606
symptoms of 316
Corkscrew appearance of retinal arteries 182
Corneal reflex 279
Cornelia de Lange syndrome 202
Coronal flair 579f
Coronary
angiography 168
artery
bypass graft 137
disease 654
syndrome, acute 662, 702
Corpora quadrigemina, superior 270
Corpus callosum 673Corrigan's pulse 133
Corrigan's sign 167
Cortical lesions 286
Cortical venous thrombosis 338
Corticospinal fibers, lesions of 288f
Corticospinal tracts 287f
Corticotropin releasing hormone 360
Cortisol 774
Corynebacterium diphtheriae 24
Costochondritis 128, 650
Cotton wool exudates 178f
Cough 129
barking 210
brassy 210
dry 210
early morning 210
nocturnal 210
paroxysmal 210
productive 210
seasonal 210
types of 210
whooping 210
Courvoisier's law 98, 114
Coxa vera 8f
Coxsackie B virus infection 251
Crackles 224
Cramps 295
Cranial nerve 266, 270, 271, 271f, 272f, 277, 278f, 279, 279f, 282, 282f, 283, 284, 284f, 285, 285f
bilateral palsy of 277f
divisions of 278
examination of 273, 279, 284, 286b
fibers of 284
fourth 271
palsy 272f, 277, 277b, 284f, 286
bilateral 277f
causes of 277, 281
paralysis of 279, 281
second 267
sensory connections of 278f
third 270
Craniofacial deformities 673
Craniopharyngioma 373
typical of 373f
Craniosynostosis 403
Craniovertebral
anomalies 560
junction anomalies 321
Crazy pavement dermatosa 6
C-reactive protein 452
Creatine phosphokinase 774
Cremasteric reflex 298
Crepitus 448
CREST syndrome 471
Cretinism 60, 66, 370, 378
Creutzfeldt–Jacob disease 685
Cri du chat syndrome 202
Crigler-Najjar syndrome 113
Crocodile tears 696
Crohn's disease 555, 555f, 634, 699
of ileum 124f
Crouzon syndrome 202, 403
Cruveilhier-Baumgarten syndrome 100, 106, 153
Cryoglobulinemia 78, 80, 449, 689
Cryoprecipitate 685
Cryptococcus 336
neoformans 39
Cryptogenic cirrhosis 106
Culex 49
Cullen's sign 125
Cushing's disease 386, 714
Cushing's syndrome 11, 22, 22f, 180, 183, 244, 356, 361366, 370, 384, 384f, 385, 385f, 716
Cushingoid face 445f
Cutaneous
leishmaniasis 48, 49
porphyria 81f
sensations 302
Cyanide 719
poisoning 725
Cyanocobalamin 774
Cyanosis 77, 201f, 233, 235
central 77f, 77t
Cyanotic congenital heart disease 70, 75, 438
Cyclophosphamide 437
Cycloserine 666
Cystic bronchiectasis 239f
Cysticercosis 560, 569
Cytomegalovirus 40
retinitis 40f
Cytotoxic drugs, discovery of 430
Cystourethrography 564
D
D-dimer 428, 753, 777
D-penicillamine 105, 727
Dactylitis 446, 446f
Dantrolene 736
Dapsone 47
Dark-field microscopy 646
Darunavir 43DC cardioversion 159
DC defibrillator 620
DC shock 742
De Musset's sign 167
Deafness
congenital 265
infantile 265
DeBakey's classification 207f
Decerebrate movements 295
Decerebrate posturing 721
Decubitus 58
Defibrillation 741
Deficiency disorders 411
Deformities 444
Dehydration 62, 69, 396
Dehydroascorbic acid 14
Dehydroepiandrosterone 774
Dejerine-Sottas disease 83,
Delirium tremens 264
Delusions 264, 283
Demeclocycline 709
Dementia 14
under evaluation 596f
Demyelinating disorders 333
Dengue
fever 34
types of 34
hemorrhagic fever 34
Dense pulmonary fibrosis 542
Dentatorubral pallidoluysian atrophy 705
Depression 362
Dermatitis 13
herpetiformis 690
Dermatolymphangioadenitis 50
Dermatomyositis 446, 478
Descending colon 98
Desferrioxamine 422
Desmopressin 429, 677
Developmental abnormalities 535, 560
Devic's disease 333, 688
DEXA 456
Dexamethasone 437
Dextrans 743
Dextrocardia 142, 143f, 195, 196f, 203, 549
with situs inversus 549, 549f
Dextroversion 196, 203
Diabetes 636, 679
insipidus 677
mellitus 54, 90, 351, 359, 360, 390, 391, 392f, 400, 563, 635, 636
noninsulin-dependent 391
treatment of 401t, 402t
Diabetic
amyotrophy 400
cardiomyopathy 654
cheiroarthropathy 400, 401f
foot 398, 399f
ketoacidosis 393
ketoacids 699
neuropathy, types of 398t
prayer sign 401, 401f
retinopathy 365, 398f
Dialyzable toxins ad drugs 720
Diaphragm
bilateral elevation of 539
unilateral elevation of 539
Diaphragmatic hernia 538
Diarrhea 14, 90, 116, 629, 634
acute 755
bloody 726, 727
hormone-induced 755
large bowel 90
severe 19, 755
traveler's 90
watery 726
Diastolic murmur, early 750
Dicrotic pulse 136
Didanosine 43
Dietary
deficiency 412
fiber 3
requirements, calculating normal 627
Diethylcarbamazine 50
Digitalis toxicity 501
Digoxin 237, 659, 660, 719, 720
Dihydrotestosterone 774
Diltiazem 659
Dimorphic anemia 411
Diphtheria 24
complications 24
diagnosis 24
prevention 25
treatment 25
Diplopia 274
Directly observed treatment 667
Disequilibrium syndrome 672
Disopyramide 659
Disseminated intravascular coagulation 681, 732
Distal interphalangeals 461f
Disuse atrophy 694
Diuretic 709
therapy 712
Diverticular disease 556
Dobutamine 187, 237
Dolutegravir 43
Dopamine 187, 402
Dorsal interossei, test 290
Dorsal interosseous muscles 46
Double vision 274
Down's syndrome 59f, 70, 73f, 370, 407, 408f
Doxorubicin 420, 437
Dressler's syndrome 191, 663
Drowning, near 737
Drug 719, 720
antidotes for 719
toxicity 378
Dry cough 210
Dry fibrinous pleurisy 247
Dry gangrene ischemia 399f
Dry mouth, causes of 87
Dry pericarditis, acute 191
Dubin-Johnson syndrome 114
Duchenne's muscular dystrophy 331, 454
Duodenal ulcer 86f, 95, 555, 619
Duodenum 555f
Dupuytren's contracture 74f
Durkan's test 478
Duroziez murmur 152, 167
Dysarthria 265
types of 265
Dysdiadochokinesis 293
Dysembryoblastic neuroepithelial tumor 585f
Dysentery 634
Dysesthesia 302
Dyshematopoietic anemia 411
Dyskinesia 294
Dyslipidemia 21, 54
Dysmetria 300
Dysmorphic syndromes 370
Dyspepsia 87
Dysphagia 87
causes of 88b
Dyspnea 129, 210, 729
of cardiac origin 210
severe 235
Dystonia 294
Dystrophic nails 76f
Dysuria 344
E
Ear lobe crease 67
Eaton-Lambert syndrome 244, 338, 338t, 732
Ebstein's anomaly 203, 495, 499, 503, 654
Eccentric nucleus 436f
Ecchymoses 427f
Echinococcosis of liver 113
Ectopia lentis 406f
Ectopic gastric mucosa 602f
Edema 78, 124f, 428f
of abdominal wall 92f
Edematous severe acute malnutrition 6f
Edinger-Westphal nucleus 270
Edrophonium 337
Edward syndrome 201
Efavirenz 43, 44
Egophony 227
Ehlers-Danlos syndrome 11, 11f, 82, 83f, 161, 164, 408, 409f, 426
types of 408
Eisenmenger's complex 198, 199, 202
Eisenmenger's syndrome 197, 202
Ejaculation, premature 346
Ejection systolic murmur 149
Ekbom's syndrome 669
Elbow 444
Electrical alternans 135f
Electrical axis 491
Electrocardiogram abnormalities 653
Electrocardiography 483
Electrolyte disturbances 502
Elephantiasis 50f
Elliptocytes 419f
Ellis van Creveld syndrome 202
Emaciation, causes of 61
Emboli, retinal 643
Embolic strokes 670
Emphysema 233t, 256, 540
Emphysematous
bulla 233f, 541f
chest 233f
Empty delta sign 339
Empty sella syndrome 371, 676
Empyema 247, 250
necessitans 250
Emtricitabine 43
Encephalopathy 635
Endobronchial
growth 225
metastasis, causes of 665
obstruction 539
Endocardial cushion defect 198
Endocarditis 174, 176
Endocrine
diseases 359
disorders 7, 11, 21, 179, 363, 366, 370
gigantism 367
glands 359, 360f
syndromes 693
system 4
Endomyocardial biopsy 194
Endotracheal intubation 613
Enema 626
types of 626
Enfuvirtide 43
Engorged peripheral lymphatics 186f
Entamoeba histolytica 250
Enteric fever 29
pathogenesis 29
Enterogenous cyanosis 77
Enzymatic defects 683
Enzyme defects 418
Eosinophilia, causes of 441
Ependymoma 317
Epidural hematoma 569
Epigastric
pulsations, causes of 145b
region 127f, 143, 145
Epilepsy 74, 672, 673
grand mal 384
Epileptic fit 240
Epiphyseal plates 9f
Epistaxis 36, 212, 423
Eplerenone 189
Epstein-Barr virus infection 40, 439
Erb's area 145, 150, 151, 167, 169172
Erectile dysfunction 362
management of 698
Erythema
marginatum 153, 690
nodosum 80f, 449f, 690
Erythrocyte sedimentation rate 425, 452
Erythropoiesis 410
Erythropoietin 682
level 683
Esmolol 660
Esophageal
candidiasis 553, 554f
intubation 613
spasm 129b
sphincter, lower 553f
varices 104f, 553
web 553
anterior 554f
Esophagitis 86f
Esophagogram 471f
Esophagus 86
anatomical interrelationships of 205f
carcinoma 537, 553, 554t
malignancy of 553f
Estradiol 775
Estrogen 12
Ethambutol 667
Ethanol 720, 774
Ethionamide 667
Ethylene glycol 719, 720
Etravirine 43
Eunuchoid gigantism 367
Eunuchoidism 60
Euthyroidism 374f
Evacuant enema 626
fluids 626
Ewart's sign 191
Excessive salivation, causes of 87
Exophthalmos 68f, 365
advanced stage 375f
Expectoration
mucoid 232
pink frothy 742
Extradural compression 316
Extragastric disorders 102
Extrahepatic obstruction 115t
Extraintestinal air collection 568
Extramedullary
compression 317
erythropoiesis 421f
Extraocular muscles paralysis 696
Extrapulmonary
calcification 538
manifestations 39
tuberculosis 33f
Extrapyramidal
disease 300, 328
disorders 299
Extrathyroidal disorders 373
Extreme kyphosis 456f
Exudative ascites, causes of 698
Exudative pleural effusion, causes of 701
Eye 46, 67b, 375, 481, 629
abnormalities 365
in respiratory case 700
movements 274, 277
opening 693
position of 277f
prominence of 362
Eyeball
ocular movement of 272f
tension 396
Eyebrows, loss of outer 379f
Eyelid, evert lower 469f
Ezetimibe 653
F
Fab 654
fragments 719
Face 58, 364, 469
upper part of 280f
Facial
canal 281
movements, involuntary
nerve
examination of 280
lesions 281
paralysis 703
ipsilateral 313
unilateral 285rash 466
dusky 478
photosensitive 446
Facioscapulohumeral myopathy 332
Falciparum infection, severe 29
Fallot's tetralogy 201f
Familial hypophosphatic rickets 9
Fanconi's anemia 617
Fanconi's syndrome 9
Fascial muscles 692
Fasciculations, causes of 324
Fasciola hepatica 668
Fascioscapulohumeral myopathy 332f
Fat 2
embolism 68f
exchange 637
high 632t
types of 2
Fatigue look 337f
Fatty acids 1, 631
Fatty liver 111f
Febrile neutropenia 764
Feet 79, 79b
dorsal surface of 14f
Felty's syndrome 97, 441
Female genitalia 347
Femoral hernia 100, 101f
Ferritin, decreased 690
Festinant gait 299
Fetal alcohol syndrome 202
Fetal hydantoin syndrome 202
Fever 115, 153
black 48
break bone 34
dengue 34
enteric 29
low-grade 32
quartan 27
tertian 27
types of 64, 64f
Fiberoptic bronchoscope 614f
Fibrates 653
Fibrinogen degradation products 732
Fibrocalcareous disease 497
Fibromuscular dysplasia 551f
Filarial
dance sign 50
worms, types of 49
Filariasis 49, 50f
life cycle 49
Finger
deformities 459f
flexion contracture of 470f
flexors 290
tips 470f
Finger-nose-finger test 292
Fish tapeworm infestation 415
Fissured tongue 69
Flag sign 67
Flapping tremors 717
Fleischner's sign 555
Flat chest 216
Flat T wave 486f
Flecainide 659
Flexible bronchoscopy 614
Flexor spasms 323
Floppy valve syndrome 163, 164
Fluconazole 39
Fluid 743
thrill 99
types of 649
Flunisolide 230
Fluorescence microscopy 28
Fluorine deficiency 19
Fluoroquinolones 420
Fluorosis 559, 560f
Fluticasone 230
Fogarty catheter 752
Folate
deficiency 415417
metabolism 415
Foley's catheter 625, 767
urinary 625f
Folic acid 16, 415
deficiency 681
causes of 415
levels 687
Follicle stimulating hormone 360, 774
Follicular non-Hodgkin's lymphoma 440f
Foot 562
intrinsic muscles of 291
Formoterol 230
Fosamprenavir 43
Foster Hennedy syndrome 340
Foville's syndrome 313
Framingham criteria 188t
Friedreich's ataxia 326, 327
Frohlich's syndrome 21
Froin's syndrome 669
Frostbite 736
Fruit exchange 637
Fulminant hepatic failure 756
Fundoscopy 269
Fundus 28, 104f, 333
Fungal infections 39
Fungus ball 540
left upper lobe 541f
Fusion inhibitor 43
G
Gadolinium enhancement 325
Gag reflex 615
diminished 313
Gait 299, 448
abnormalities of 300b
ataxic 300
festinant 299
hemiplegic 300
high stepping 320
hysterical 300
reeling 299
sensory ataxic 299
shuffling 378
spastic (scissors) 299, 315
stamping 299
waddling 331
Galacto-hyperprolactinemia 367
Galactorrhea 362, 367
Gallbladder 98, 566, 567
calculi 566, 566f, 572f
carcinoma 574f
disorders of 635
echogenic lesion 572f
lumen of 572f
Gallops 148f
Gallstones 566, 567
Gamma-Glutamyl transpeptidase 774
Gangrene syndrome 476f
Gardner's syndrome 651
Gastric
analysis 619
aspirate, volume of 619
emptying study 593f
ulcer 95
benign 554
malignant 554
varices 104f
Gastritis, atrophic 415
Gastroesophageal
junction 89f
reflux disease 88
Gastrointestinal
acid 716
bleeding, causes of
lower 87f
upper 86f
complications 30
diseases 701
disorders, symptoms of 85, 86
system 4, 85, 393
tract 551, 629
Gaucher's disease 112, 617
Gaze palsy 275
Genital ulcers 451b, 481
Genitalia
external 347
male 101, 347
Genitourinary
complications 30
tract 564, 567
Gerstmann's syndrome 266
Ghon's focus 31
Ghon's lesion 543
Giant cell arteritis 137, 263, 446, 670
Giardia
intestinalis 650
lamblia 650
Giardiasis 650
Gibbus 315
Gigantism 60, 367, 367f
Gilbert's syndrome 113
Gingivitis 15, 70, 71
Glabellar reflex 279, 298
Glandular tuberculosis 123
Glans penis, ulcerative lesions of 347
Glargine 403, 679Glasgow coma scale 264, 264b, 693
Glioma 317
Glomerular
disease 348
primary 674
filtration rate 341
infiltration rate 675
Glomerulonephritis 344
acute 675
Glossitis 13, 687
Glossopharyngeal nerve 283
Glucocorticosteroid 462
deficiency 386
Glucosamine sulfate 689
Glucose tolerance test 620
Glucose-6-phosphate dehydrogenase deficiency 418420
Glucosteroid treatment 686
Glycemic index 2, 3, 676, 690
Glycogen 3
storage disease 70
Glycosuria 712
Goiter, diffuse 374f
Gonda's sign 297
Goodpasture's syndrome 675
Gordon's sign 297
Gottron's papules 478
Gottron's rash over knuckles 447f
Gout 454, 633
acute 468
Gower's maneuver 300, 331
Gower's sign 455f
Gradenigo's syndrome 277
Graham Steell murmur 150, 156f
Gram stain 227
Granulocytes 685
Granulomatous disorders 96
Graphesthesia 304
Graves’ disease 362, 365, 366, 373, 376, 381, 595Ground glass appearance 247f
Growth hormone 676
secretion, control of 677
Guillain-Barré syndrome 25, 30, 269, 315, 333335, 584f, 688, 703, 704, 732, 763
Guinea worm 567
calcification 567f
Gum 70, 71b
hypertrophy 71f
Gynecological disorders 8
Gynecomastia 108f, 189, 244, 362, 366
causes of 72b
Gynoid obesity 676
H
Hacek organisms 174
Haemophilus influenzae 190, 232, 307
Haenel's sign 320
Hair 67b, 364, 629
changes 6
Hairy
cell leukemia 434
tongue 69
Hamman's sign 225
Hammer toe deformities 459f
Hand 562
deformities 470f
Hansen's disease 45
Hansen's rash 59f
Haptoglobin 775Harrison's sulcus 8, 216
Hartmann's solution 649
Harsh vesicular breathing 223
Hashimoto's thyroiditis 366, 381
Hatchet face 331
Headache 261, 362
causes of 263f
types of 261, 263b
Head tilt 273
Head tilt–chin lift 740
Healing stage 558
Heart 250
auscultation of 146f
bare area of 216f, 221
block
complete 140, 497, 510, 746
congenital complete 497
chambers of 127f
conduction system of 493, 493f
disease 131f
congenital 659, 701
failure 140, 184
acute 187
backward 184
beta-blockers in 658
causes of refractory 184
diastolic 184, 185t
left 184
management of 654
right 184, 700
severe 189
systolic 184, 185t
treatment of 163, 185, 188t
murmurs 176
shadow, normal 545
size 381, 546
sound 145, 146, 147f
abnormalities of 146
additional 147
Heat
intolerance 361
stroke 735
Heavy metals 719
Heberden's nodes 73, 446f
Heel-knee test 292
Heel-shin-ankle test 292, 292f
Heerfordt's disease 703
Heimlich valve 611
Heinz bodies 418
Helicobacter pylori 650
infections 85, 101, 102
Heliotrope rash over eyelids 447f
Hemangioma over face 697f
Hematemesis 105, 212b
Hematology 561, 777
Hematuria 344, 345b, 353, 754
types of 344b
Hemianesthesia 304
Hemianopia 268
Hemiballismus 294
Hemiblock, left
anterior 494, 494f
posterior 494, 495f
Hemic murmurs 152
Hemifacial spasms 280
Hemiplegia 295, 299, 309
Hemisection of cord 318
Hemivertebra 560
Hemochromatosis 682
Hemodialysis 353, 415
Hemoglobin 420, 777
abnormalities 683
Hemoglobinuria 733
paroxysmal nocturnal 90
Hemolytic 424
anemia 411, 417, 418b, 419f, 683
causes of 418
crises 419, 422
jaundice 113, 114b
Hemophilia 429, 562, 681
A 429
B 429
early stage 562
intermediate stage 562
late stage 562
Hemopoitic system 7
Hemoptysis 211, 212, 212b, 751
causes of 211b
Hemorrhage 15, 82f
intracerebral 312
meningitis 306
pulmonary alveolar 211
subarachnoid 261, 306
vitreous 398
Hemorrhagic pleural effusion, causes of 251
Henoch-Schönlein purpura 80f, 425, 426, 450f
Heparin
anticoagulants 620
low-molecular weight 656
unfractionated 661
Hepatic
coma 107, 698
dysfunction 28
encephalopathy 105, 635
grading of 756
lesions, multiple 595f
metastasis 566
rub 100
transplantation, indications for 724
Hepatitis 96
B 40
C 40
D 40
to anti-tuberculosis drugs
prevention of 667
treatment of 667
viruses 115t
Hepatobiliary
disorders, symptoms of 85, 86
systems 85, 90
Hepatocellular
carcinoma 105, 121, 566
jaundice 113, 114b
Hepatojugular reflux 138f
Hepatopulmonary syndrome 110
Hepatorenal syndrome 105, 109
types of 109
Hepatotoxic drugs 115
Herculean calves 331
Hereditary
cancer syndromes 693
elliptocytosis 419, 419f
hemolytic anemias 683
hemorrhagic telangiectasia 652
spherocytosis 419, 419f
Hernia, hiatus 23, 701
Herpes encephalopathy 584f
Herpes labialis 40f
Herpes simplex virus 40
Herpes zoster 44, 45f, 89
complications 45
management 45
virus 40
Hexaxial system 491, 491f
Hiatus hernia 87, 89f, 552
types of 88f
Hibernating myocardium 656
Hiccups 313
treatment of 353
High-fiber diets, types of 642
Hilar
calcification 538
enlargement, causes of 538
lymphadenopathy 244f
shadows, causes of displaced 539
Hill's sign 167, 169
Himalayan P waves 203
Hip 20, 444
arthritis 463f
extensors of 291
flexor of 291
Hirschsprung's disease 556f, 557, 731
Hirsutism 67f, 362, 695
His bundle 496
Histamine-fast achlorhydria 417
Histoplasma 175
Hockey stick
T wave 510
type depression 488f
Hodgkin's disease 64, 97, 348, 439, 440t, 441f, 643, 684
Hodgkin's lymphoma 439
Hoffman's sign 296
Hoffman's syndrome 382
Holiday heart syndrome 663
Hollander insulin test 619
Holmes Adie's syndrome 704
Holter monitoring 126
Holt-Oram syndrome 201
Homan's sign 79,
Homocystinuria 60, 692
Honeycomb
appearance 457
shadows, causes of 537
Horizontal fissure 214
Hormone therapy 12, 698
Horn cells lesion, anterior 694
Horner's syndrome 205, 275, 313, 366, 696, 700
Horseshoe kidney 564, 564f
Horseshoe-shaped dullness 99
Howell-Jolly bodies 416f, 682
Human
actrapid insulin 394
chorionic gonadotropin 684
Human cysticercosis, life cycle of 669
Human immunodeficiency virus
infection 36, 37, 669
infection, prevention of 44
nephropathy 674
rapid antibody test 41
viral load tests 42
leukocyte antigen 453
premix 679
T-lymphotropic virus 1 703
Humidification 616
Hummingbird sign 578f
Humoral immunity 37
Hung up reflex 295
Hunter's syndromes 155
Huntington's chorea 329
Hurler's syndromes 155
Hutchinson's teeth 70
Hyaline membrane disease 536
Hydatid cyst of liver 565
with septation 565f
Hydralazine 189
Hydrocele 50f
Hydrochloric acid 619
Hydrochlorothiazide 188
Hydrocortisone 27, 47, 231, 744, 746, 751, 764
Hydromyelia 705
Hydronephrosis 565f
Hydronephrotic left kidney 600
Hydropneumopericardium 538
Hydropneumothorax 253, 253f, 256, 537, 544
Hydroxychloroquine 462, 464, 482
Dihydroxycholecalciferol 342, 382, 384
Hydroxycobalamin 417
Hydroxyurea 423
Hygiene hypothesis 230
Hyperacidity 87
Hyperacusis 283
Hyperaldosteronism 717
primary 701
secondary 701
Hyperalgesia 302, 304
Hyperbaric O2 729
Hyperbilirubinemias, congenital 113
Hypercalcemia 503, 503f, 699, 714
Hypercalciuria 435
Hypercapnia 229, 236
Hypercholesterolemia 3, 132, 348, 349, 363, 449, 631
Hypercoagulable states 428
Hyperdense cystic lesion 588f
Hyperdynamic apex impulse 143
Hyperesthesia 302
Hyperflexibility 405f
Hypergammaglobulinemia 479
Hyperglycemia 188
Hyperhomocysteinemia 655
Hyperintense
cystic component 373f
mass 588f
Hyperkalemia 17, 18f, 189, 502, 502f, 710
Hyperkalemic periodic paralysis 712
Hyperlipidemia 188
Hypermagnesemia 642
Hypernatremia 17, 699, 709
Hyperosmolar non-ketotic coma 699
diabetic 395
Hyperparathyroidism 382, 383f, 563
Hyperpituitary gigantism 367
Hyperprolactinemia 372
Hyperpyrexia 63, 735
causes 735
management 735
Hypersegmented polymorph 416f
Hypersensitivity carotid sinus 659
Hypersplenism 423
Hypertelorism 132f
Hypertension 54, 177, 177f, 179b, 185, 351, 353, 366, 631
portal 754
sample diet for 631
secondary 179
Hypertensive crisis 390
Hypertensive encephalopathy 744
Hyperthermia 735
Hyperthyroidism 364, 374f, 563
causes of 373t
primary 373
secondary 373
Hypertrophic obstructive cardiomyopathy 582f
Hypertrophy, biatrial 510
Hyperuricemia 188, 702
causes of 454b
Hyperventilation, causes of 718
Hyperviscosity syndrome 435, 437, 670
Hypervitaminosis D 8
Hypervolemia, signs of 346
Hypervolemic state 346
Hypesthesia 302
Hypoalbuminemia 4, 6, 35, 348, 661, 701
Hypocalcemia 503, 503f, 699, 713
Hypochromia 420f
Hypochromic
anisocytes 413f
microcytes 413f
Hypodense nonenhancing cysts, multiple 354f, 587f
Hypoechoic ill-defined lesions, small 572f
Hypoechoic inguinal lymph node 440f
Hypoglycemia 362
symptoms 396
Hypoglycemic
agents 680, 719
coma 396, 396t, 699
Hypogonadism 60
Hypogonadotropic hypogonadism 698
Hypokalemia 18, 19f, 188, 394, 488f, 502, 502f, 712
Hypokalemic periodic paralysis 713
Hypomagnesemia 188
Hyponatremia 17, 188, 699, 708
Hypoparathyroidism 383, 383f, 687
Hypoperistaltic esophagus 471f
Hypophosphatemia 9
Hypopituitarism 370, 371f
Hypoplastic cerebellar vermis 581f
Hypopnea syndrome 236
Hypotension 366, 695
Hypothermia 63, 695
Hypothyroidism 21, 364, 378
primary 381t
secondary 381, 381t
Hypotonia 288
Hypoventilation, chronic 231
Hypovolemia, signs of 346
Hypovolemic shock 744
Hypoxia 76, 690
index 357
Hypoxic coma 699
Hysteria 269, 300
Hysterical
gait 300
tremor 293
I
Ice test 337
Ichthyosis 82
Icteric leptospirosis 35
Idiojunctional rhythm 497f, 510
Idionodal tachycardia 499
Idiopathic
pulmonary fibrosis 541, 542f
skeletal hyperostosis, diffuse 401f
thrombocytic purpura 426
acute 426
chronic 426
thrombocytopenic purpura 425, 686
Idioventricular rhythm 497f
Ileocecal tuberculosis 124f, 556f
Iliac fossa, right 602
Imatinib 433
Immotile cilia syndrome 196
Immune deficiency 36
Immunity, cell-mediated 37, 242
Immunodeficiency syndrome, acquired 36
Immunoglobulin 775
Immunosuppression 693
Inappropriate antidiuretic hormone secretion, syndrome of 708
Indian childhood cirrhosis 103
Indinavir 43
Indium-pentetreotide 652
Infarction
cerebral 309
midbrain 277
multilobar 312
splenic 438
Infections 7, 96, 185
Candida 39
filarial 49.
fungal 39
nosocomial 644
pneumococcal 28
protozoal 39
viral 40
Infectious disease 24
Infective endocarditis 173, 185
prophylaxis 163
Infective hepatitis 635
Infiltrative disorders 96
Inflammatory bowel disease 370, 634
Inflammatory demyelinating polyneuropathy, chronic 335
Infra-axillary regions 213
Infranuclear lesions 274
Inguinal
glands 100
hernia 100
anatomy of 101f
Inotropic drugs 187
Insulin 402t, 679
secretagogues 401, 680
sensitizers 401, 680
therapy 400
Insulin-dependent diabetes mellitus, development of 694
Intensity projection, maximum 428f
Intention tremor 293
Intercostal drain 544f
Intermittent arthritis, causes of 469
Intermittent episodic arthritis 445
Intermittent porphyria, acute 678
Internuclear ophthalmoplegia 276
Interstitial
edema 547
infiltrates 244f
lung disease 243f, 247f
shadows, causes of diffuse 536
Intestinal
disorders 700
enzyme 680
obstruction 552
symptoms 602f
sounds 99
tuberculosis 123, 555, 699
Intestine 86
Intracellular to extracellular compartment 710
Intracerebral hemorrhage 312, 762
causes of 312
Intracranial
calcification 560
hypertension, benign 697
pressure, raised 560, 759
tumors 339
Intrahepatic obstruction 115t
Intramedullary compression 317
Intrapleural pressure 253
Intrauterine growth restriction 476
Intravenous
nicardipine 745
therapy 608
Intrinsic sympathomimetic activity 663
Iodide 378
Iodine 20
scan, post-therapy 599f
Ipratropium 230
Iritis 40, 481
Iron 20, 775
binding capacity 412
deficiency anemia 411, 412, 424, 680
causes of 412b
dextran 414
dietary sources of 411
kinetics 413t
overload 682
poisoning 728
Irritable bowel syndrome 124, 634, 652
Ischemia, acute 489f
Ischemic
colitis 557
heart disease 54, 309, 488, 488f, 631
premature 702
pain 89
stroke 311, 761
Isolated dextrocardia 549
Isonex 667
Isoniazid 667
J
Jaccoud's arthritis 466
Jacksonian epilepsy 703
Jamshedji Swain needle 618
Janeway lesions 466, 466f
Jaundice 113, 241
severe 82f, 113f
Jaw
jerk 279
reflex 296
Jerky pulse 195, 195f
Jervell-Lange-Nielson syndrome 491
Jet lag, mechanism of 648
Jod-Basedow phenomenon 382
Joint 444
deformity 448
instability 448
mobility syndrome 400
position, sense of 303
space, loss of 461f
swelling 472f
Jug handle appearance 197, 197f
Jugular vein, prominent external 72f
Jugular venous
pressure 137, 138f
abnormalities of 140
causes of raised 140
pulsations, abnormalities of 139f
pulse waves 139f
Junctional premature complexes 499, 500f
Junctional rhythm 499, 499f
Junctional tachycardia 499
Juvenile
chronic arthritis 473f
idiopathic arthritis 451, 473
Juxtaglomerular apparatus 341
K
Kala-azar 48
Kallmann's syndrome 60
Kanamycin 667
Kaposi's sarcoma 40
Kartagener's syndrome 196, 238
Kawasaki disease 480, 648
Kayser-Fleischer rings 67, 112, 329, 671, 702
Keith and Wagner's grading 177
Kennedy syndrome 72
Keratoconjunctivitis sicca 643
Keratoderma blennorrhagica
feet 448f
hands 448f
Keratomalacia 16
Kerley's A lines 158f
Kerley's B lines 158f, 186f
Kernig's sign 306
Ketoacidosis 219
Ketoconazole 386
Ketonuria 396
Kidney 28
bilateral large 565
bilateral small 564
biopsy 482, 623
causes 766
disease 633
chronic 633
enlarged left 98t
examination of 97
functions of 342
left 98
unilateral
large 565
small 564
Killip classification 185, 187b, 658
Klebsiella pneumoniae 540
Klinefelter's syndrome 60, 72, 367, 406, 407f
Klippel-Feil
anomaly 477
malformation 560
syndrome 202
Knee 444
bilateral OA of 471f
flexor of 291
jerks 706
joints
bruising around 409f
deformities of 457f
OA bilateral 472f
reflex 296
Knock knees 8f
Knuckles, hyperpigmentation of 387f
Koilonychia 75f
Korsakoff's psychosis 668
Korsakoff's syndrome 668, 697
postalcoholic 697
Krait 732
Krönig's isthmus 221
Kussmaul's
breathing 346, 351, 356
respiration 62, 218, 219
sign 139, 191, 192
Kveim-Siltzbach test 242
Kwashiorkor 3, 5, 6, 6f, 6t, 67
Kyphoscoliosis 84, 406f
Kyphosis 83, 218
L
Labetalol 745
Labyrinthine artery 260
Lacrimation 280
Lactase deficiency 57
Lactate dehydrogenase 249
Lactic acidosis 395
Lactose 106
Lactulose 757
Lacunar infarct 704
syndromes of 670
Lacunar stroke 670
Lambert-Eaton myasthenic syndrome 672
Lamivudine 44
Landry's ascending paralysis 334
Lanreotide 369
Lantus 403, 679
Large-bowel obstruction 552
Laryngeal diphtheria 24
Laryngospasm 615
L-ascorbic acid 14
Lasegue's test 307
Lathyrism 3, 4f
Latissimus dorsi 290
Laurence-Moon-Biedl syndrome 21, 60, 695
Lead poisoning 727
Leflunomide 482
Leg 79, 448, 451
bowed 16, 79b
rash 80f
swelling of 364, 428f
ulcer 421
causes of 80b
Legionnaire's disease 644
Leishmania donovani 48
Leishmaniasis, prevention of 49
Lenegre's disease 497
Lepra reactions 645
Lepromatous leprosy 46, 46f
Leprosy 45, 83F, 90
Leptin deficiency 361
Leptospirae
canicola 646
hardjo 646
icterohemorrhagica 646
Leptospirosis fever 35
Leriche's syndrome 658
Leukemia 90, 97, 222, 348, 430, 431
acute 430
cutis 432, 432f
Leukonychia 74
Leukopenia 103, 112, 414
Leukotriene inhibitors 230
Lev's disease 497
Leveen shunt 108
Levine's grading 151
Levine's sign 702
Levine's tube 618
Levodopa 736
Levoversion 196
Leydig cell tumor of testis 72
Lhermitte's sign 333
Libido, loss of 362
Libman-Sack's endocarditis 702
Lid lag 365
Liddle syndrome 716
Lidocaine 660
Ligament calcification 560f
anterior longitudinal 464f
Ligamentum venosum 100f
Light chain myeloma 437
Light reflex
consensual 274
direct pupillary 274
indirect pupillary 274
intact 696
lost 696Limb
girdle myopathy 331, 366
peripheral nerves, upper 47f
upper 289
Lindsay lines 352
Lindsay nail 76, 76f
Linea
alba 298
nigra 92
Lip 69, 77f, 629
inner side of 70f
Lipids 653
Lipodystrophy 393f
syndrome 44
Lipoprotein 653
Liposomal amphotericin 48b
Lispro premix 679
Listeria monocytogenes 307
Lithium 714, 720
carbonate 378
Live vaccines 648
Livedo reticularis 446, 476
Liver 565
abscess 85, 116, 565
biopsy 621
carcinoma of 96
causes of enlarged 96
cirrhosis 115
cysts, multiple 354f, 587f
disease, chronic 103f
dullness 221
examination of 95
lesions 591f
metastasis 122f, 597f
palpation of 95
tissue, failure to obtain 623
Loa loa 49
Lobar pneumonia 539
Lobe tuberculosis, bilateral upper 239f
Local pain 362
Localized pulmonary fibrosis 256
Locked-in syndrome 314, 691
causes of 691
Loculated pleural effusion
bilateral 543f
posteriorly 543f
Loeffler's syndrome 667
Looser's zones 559
Lopinavir 43, 44
Lordosis 84
Low erythrocyte sedimentation rate, causes of 425
Low volume pulse, causes of 135b
Lower limb 289
peripheral nerves 47f
Lower lobe collapse, right 540f
Lower motor neuron 287, 300, 694
lesion 300
Lown-Ganong-Levine syndrome 690
Lucio phenomenon 479
Lugol's iodine 764
Lumbar
canal stenosis 317, 318b
management of 318
lordosis 84f
puncture 605
needle 606, 606f
spine 444, 560f, 562
Lumbosacral transitional vertebra 560
Lump, abdominal 115
Lung 482
abscess 240, 241f, 537, 540, 540f
biopsy 228
capacity, total 234
carcinoma of 541
types of 244
collapse of 246, 255, 539
compliance 233
diseases 190, 240, 241
fields 546
function test 234, 234t
lobe/segment 539
malignancy, right 596f
opacities, causes of uniform 539
segments of 215fvolumes 227f
Lupus anticoagulant 453, 476
Lupus nephritis 466
WHO classification of 467b
Luteinizing hormone 360, 775
releasing hormone 360
Lutembacher's syndrome 201
Lymph glands 71, 71f
Lymph node biopsy 441f
Lymphadenopathy 699
Lymphatic leukemia, chronic 433
Lymphatic obstruction, left-sided 589
Lymphoblastic leukemia, acute 430f
Lymphoblasts 430f
Lymphocytes, small 434f
Lymphocytic leukemia, chronic 434, 434f
Lymphocytopenia, causes of 441
Lymphocytosis, causes of acute 684
Lymphoma 41, 90, 430, 439
Lymphoproliferative malignancies 452
Lymphorrhea 108
Lytic lesions of skull 532
M
Machado-Joseph disease 705
Macleod's syndrome 539
Macroangiopathy 397
Macrocytic hypochromic anemia 411
Macroglossia 69, 70f
causes of 70b
Macroovalocytes 416f
Macrophage activation syndrome 474
Macula densa 342
Macular edema 398
Magnesium
deficiency 19, 642
sulfate 626
enema 626
Malabsorption 412
syndrome 555, 661
Maladie-de-Roger syndrome 202
Malaria 27
acute 28
chronic 28
types of 27t, 647
vaccine 29
Malecot rubber catheter 625f
Malecot urinary catheter 625
Malnutrition 3
Manganese 20
Mannitol 712
Mansonia 49
Mantoux test 33, 42, 112, 123
Marantic endocarditis 176, 702
Marasmic kwashiorkor 6, 6f
Marasmus 3, 5, 5f, 6, 6t
Marble bone disease 618
Marchiafava Bignami syndrome 673
Marchiafava Michel syndrome 673
Marfan's syndrome 60, 60f, 71, 161, 164, 364, 405, 406f, 664, 692, 749
Marginal osteophytes 472f
Mask-like face 58
Mass reflex 308
Massive splenomegaly, causes of 97
Massive transfusion, complications of 685
Maternal rubella syndrome 202
Maturation, sages of 432f
Maxillary division 278
McBurney's point 98
McBurney's sign 98
Meckel's diverticulum 602
Medial compartment joint spaces, loss of 472f
Mediastinal
crunch 225, 226f
mass
anterior 254
extensive superior 255f
middle 254
posterior 254
superior 254
obstruction syndrome, causes of superior 695
syndrome, superior 254f
Mediastinitis 538
Mediastinum 544f
diseases of 254
divisions of 254f
Medulla 288
Medullary syndrome 313, 314, 314f
lateral 313
medial 314
Megaloblastic anemia 414416, 416f, 417, 424, 617
Meigs syndrome 247, 251, 695, 701
Melatonin 648
Melena 54, 212, 438, 686, 754
Melkersson-Rosenthal syndrome 703
Membrane disorders 683
Memory 264
Menghini's liver biopsy needle 623f
Menghini's needle 622
Meniere's disease 671
Meningeal irritation 306
signs of 306
Meningioma 317
Meningitis 27, 607
Meningococcus 307
Menstrual cycle 381
Mercury poisoning 726
Mesencephalon, region of 275
Mesothelioma 217
Metabolic
acidosis 355, 715
primary 357
alkalosis 355, 356, 716
causes of 356, 716
coma, causes of 698
derangements 722
diseases 359
disorders 7, 28
myopathy, causes of 693
syndrome 679, 693
Metabolism 562
Meta-iodophenyl guanidine scintigraphy 389
Metamyelocytes 432f
Metastasis 316
Methanol 719
Methemoglobinemia 719
Methicillin resistant Staphylococcus aureus 765
Methotrexate 208
Methyl alcohol 720
poisoning 722
sources of 722
Methylprednisolone 230
Metolazone 188
Metoprolol 659, 660
Metyrapone 386
testing 386
Mexiletine 659
Microalbuminuria 674
Microcytes 419f
Microcytic hypochromic
anemia 411, 413t
causes of 413
cells 422f
Microcytosis 420f
Microfilariae 49, 668
Micrognathia 474f
Micronutrients 1, 3
Microstomia 470f
Micturition, frequency of 343
Midazolam 611
Midbrain 288
syndromes 313
Mid-diastolic murmur 150
Midsystolic murmur 149
Midzone lung abscess, left 240f
Migraine 3, 263
Mikulicz's syndrome 649
Miliary mottling 536f
Miliary shadows, causes of 536
Milk exchanges 636
Milking sign 329
Milkmaid's grip 329
Milkman's line 10
Milkman's syndrome 559
Millard-Gubler syndrome 313
Miller-Fisher syndrome 704
Milrinone 189, 237
bolus 187
Milroy's disease 79, 650
Miltefosine 48
Mimic facial nerve palsy 696
Mineralocorticoid excess 717
Mineralocorticosteroid deficiency 386
Minerals 16
Mitotic diseases 7
Mitral
diastolic murmur 159
facies 159
incompetence 170, 549
regurgitation 149, 151, 161, 163f, 171f
stenosis 151, 155, 157f, 158b, 158f, 170, 171f, 172, 549
planimetry 158f
severe 128
valve
area 158b
dimensions 155
prolapse 163, 164
Mobius’ syndrome 286
Molar tooth 581f
sign 581f
Monoclonal antibody 435
Monocytic leukemias, acute 71
Monosaturated fatty acids 2
Moon-shaped face 22f
Morning cough 210
Moschcowitz syndrome 427
Motor abnormalities 300
Motor cortex 288
Motor functions 279
Motor neuron
diseases 323
facial palsy
bilateral lower 696
bilateral upper 696
upper 286, 300, 694
Motor system 261, 286
examination of 288
Mouth breathing 69
Mouth-to-mouth respiration 741f
Mucocutaneous leishmaniasis 49
Mucocutaneous lymph node syndrome 480, 648
Mucopolysaccharidosis 70
Mucosal
folds, thickened 555
leishmaniasis 48
Mucus 619
Muller's sign 167
Multibacillary lepromatous 47
Multinodular goiter, large 375f
Multiple system atrophy 580f
Mumps 26, 26f, 27, 90
complications 27
diagnosis 27
treatment 27
Munchausen syndrome 649
Murdoch-Walker wrist sign 406f
Murmur 147f, 148
causes of continuous 200
continuous 150
diastolic 150, 151
functional 152t
intensity of 151
quality of 151
selective conduction of 151
systolic 148, 151, 167
Murphy's sign 98, 114
Muscarinic manifestations 720
Muscle 375
abdominal 291
atrophy 454
disease 694
primary 300
enzymes 455
inflammation 456f
mass 288
of hands, small 694
strength 289
tone, abnormalities of 288
wasting 455f
weakness 289, 444
causes of 454b
Muscular
atrophy, progressive 324
dystrophies 331
Musculoskeletal
manifestations of leprosy 478
system 7, 443, 557, 629
examination of 443
Myasthenia
crisis 337
graves 336, 337f, 338t, 703, 732, 767
Myasthenic
crisis 767
syndrome 338
Mycetoma 540
Mycobacterium leprae 45
Mycobacterium tuberculosis 238, 240, 666
Myeloblastic leukemia, acute 430
Myeloblasts 430, 431f
Myelocytes 432f
Myelofibrosis 437
Myeloid leukemia
acute 430f, 431f
chronic 431, 432f
Myeloid, chronic 431
Myeloma
multiple 435, 436f, 561, 687
with osteolytic areas, multiple 562f
Myeloproliferative disorders 438
Myelosclerosis, primary 437
Myocardial disease 488
Myocardial infarction 185, 657, 702
acute 89, 127, 127f, 476, 489f, 750, 750t
premature 702
Myocardial perfusion 590f
Myoclonic jerks 263, 717
Myoglobinuria 345, 733
Myokymia 294
Myopathy 300
types of 668
Myotonia 454, 455f
dystrophica 57
Myotonic dystrophy 455f
Myxedema 58f, 70, 378, 379f
coma 380
management of 380
signs of 378t
N
Nadolol 659
Nail 74, 76b, 629
abnormalities of 75f
Beau's lines 75, 76
bitten 76
black 76
discoloration 76
fold lesions 466f, 470f
Half and half 76
Mee's line 76
Onychia 76
patella syndrome 76, 647
pitting 76, 447f
trophic changes 76
Nasal
catheters, administration by 615
diphtheria 24
mucosa 68
Nasogastric intubation 618
Nasolabial folds 81f
sparing of 450f
National Cholesterol Education Program 694
Natriuretic peptide, B-type 185
Natural vegetable products 631
Nausea 130
causes of 87
Near drowning 737
Neck 71, 143, 145
extensors of 292
flexor of 292
lateral bending of 292
pulsations 72
rotators 292
veins 131
Necrobiosis lipoidica diabeticorum 364
Nelson's syndrome 386
Neoplastic meningitis 607
Nephritic syndrome 353t
Nephrocalcinosis 382
Nephron 341, 342f
Nephrotic syndrome 348, 349f, 353t, 632, 661, 675, 688
sample diet for 633
Nerve 83
causes of thickened 83b
conduction velocity 327
intercostal 610
palsy 696
third 696
root
clumping of 334f
entrapment, signs of 307
trigeminal 277
Nervous system 258, 378, 762
anatomy of 259
examination of 264
gross anatomy of 259f
Neuroblastoma 578f
Neurocysticercosis 561f, 570, 571f
Neuroepileptic malignant syndrome 736
Neurofibroma 255f, 317
Neurogenic
bladder 307
syndromes 308
shock, stage of 310
Neuroglycopenia 396
Neuromyelitis optica 688
Neurological manifestations of alcohol 668
Neurology 560, 569
Neuromuscular junction, diseases of 670
Neuropathic arthropathy 563
Neuropathic joint, causes of 478
Neurosyphilis 39
Neutropenia, causes of 684
Neutrophil alkaline phosphatase 438
Nevirapine 43, 44
Niacin 13, 16
Nicotinamide 13
Nicotine deaddiction 680
Nicotinic
acid 13, 653
manifestations 720
Niemann–Pick's disease 96
Nitric oxide inhalation 238
Nitrites 189
Nitrofurantoin 420
Nitroglycerin 187, 745
Nitroprusside 187
Nocturia 343
causes of 343
Nocturnal cough 210
causes of 210b
Nocturnal diarrhea 363
Nodal rhythm 499, 499f, 510
Nodular cobblestone-like appearance, multiple 124f
Nodular enhancement 243f
Nodular shadow(s), causes of 536
Nodules 243f
Nonalcoholic fatty liver disease 111
Nonautoimmune diseases 453
Noncaseating granulomatous disease 241
Noncirrhotic portal fibrosis 119
Non-dominant hemisphere, functions of 704
Non-Hodgkin's lymphoma 96
Noninsulin-dependent diabetes mellitus 390
Nonpitting edema, causes of 79b
Non-steroidal anti-inflammatory drugs 688
Noonan's syndrome 370
Noradrenaline 389
Normocytic normochromic anemias 411
Nose 69b
Nosocomial infections 644
Nutrient, deficiency 6
Nutrition 1, 414
physiology of 1
Nutritional disorders 3
Nutritional status 61, 61b
assessment of 628
Nutritional value of selenium 657
Nystagmus 276
O
OA knee, X-ray of 472f
Obese abdomen 91f
Obesity 20, 21, 21f, 62f, 629
abdominal 676
complications of 22f
pharmacotherapy in 680
secondary 21
types of 21, 676
Obstructive hydrocephalus 588f
Obstructive jaundice 113, 114b, 566
Obstructive lung disease 690
Obstructive pulmonary disease, chronic 54, 231, 233f
Obstructive sleep apnea 236
syndrome 236
Ochronosis 67
Octreotide 369
Ocular
movements, external 273
muscles, actions of external 273
Ogilvie syndrome 731
Olecranon bursitis 460f
Oligomenorrhea 362
Oliguria 130, 343
enema 626
Oliver's sign 205f, 206
Onchocerca volvulus 49
Oncology 430
Onycholysis 447f
of nail 75
Oppenheim's sign 297, 297f
Opioid 719
poisoning 723
Opisthotonus 25, 58
Oppenheim's sign 297
Opponens pollicis 289
Optic
atrophy 270f, 333, 365f
causes of 269
nerve, examination of 268
neuritis, causes of 269
Oral
acetylcysteine 724
cavity 469
mucosa 69
replacement solutions 645
ulcers 451b
vasodilators 189
Orchitis 27
Organic brain disease 264
Organic murmurs 152t
Organism, sources of 174
Organophosphates 719
Organophosphorus compound poisoning 720
Orthopnea 129
Orthostatic hypotension 305
Ortner's syndrome 159, 664
Osler's nodes 132, 142f, 466
Osler-Weber-Rendu syndrome 652
Osmotic
demyelination syndrome 709
diarrhea 116
Osseous erosions 461f
Osteitis 463
deformans 84
fibrosa cystica 563
Osteoarthritis 446, 471
Osteoarticular manifestations of tuberculosis 479
Osteogenesis imperfecta 9, 59f
Osteomalacia 9, 10f, 456f, 559, 687
symptoms of 10
Osteomyelitis 316
Osteopenia 10f
Osteoporosis 11, 12f, 456, 456f, 457f, 559, 687
circumscripta 457f
Ostium
primum 197, 198
secundum 197
O'Sullivan-Mahan criteria 678
Ovarian
cyst 92f
fibroma 701
Overdose, treatment of acute 724
Overnight fast 619
Oxalate-rich foods 633
Oxidant stress 418
Oxygen 743
partial pressure of 234
therapy 615
complications of 616
indications of 616, 664
Oxygenation 738
P
P waves, abnormal 484
Pacemaker implantation 659
Paget's disease 286, 457, 457f, 687
of bone 559
of skull 559f
Pain 88, 89, 342, 444
abdominal 115
causes of abdominal 89f
Palatal reflex 284
Palatal paralysis 284
Palate 70
Soft
Pallor 69, 71, 90, 111
Palmar vasculitis 73f
Palpable precordial sounds 144
Palpation 143
deep 94
Palpitation 129
Pamaquine 420
Pamidronate 715
Pancoast's syndrome 211, 668
Pancoast's tumor 244, 541, 542f, 668
Pancreas 390, 566
carcinoma of 567, 567f
Pancreatic calcification 567
Pancreatitis 27
acute 125, 125f, 510
chronic 566
with calcification, chronic 567f
Pancytopenia 112, 423
Panhypopituitarism 363, 364
Pansystolic murmur 148
Pantothenic acid 16
Papillary carcinoma thyroid 599f
Papillary muscle dysfunction 163
Papilledema 269, 269f, 759
causes of 269
Papillitis 269, 333
bilateral 270f
Para-amino-salicylic acid 666
Paracentesis, abdominal 612
Paraesophageal hernia 553f
Paralysis 261
Paralytic squint 274, 274t
Paramyxoviral systemic disease 26
Paranasal sinuses 213f
Paraneoplastic syndromes 693
Paraphasia 266
Paraplegia 295, 299, 314, 316t
causes 314
Parasympathetic stimulation, symptoms of 734
Parathyroid 382
adenoma, left-sided 601
scintigraphy 601f
Paratyphoid 29
Parenchymal
lung disease 231
renal diseases 180
Parenteral hyperalimentation 609
Paresthesia 302, 362
Parietal lobe
abscess 570f
sensations 303
signs of 704
Parkinson's disease 285, 289, 299, 300, 328, 703
Parkinsonian
face 58f
posture 328f
tremor 293
Parosmia 267
Parotid
calculi 90
gland 281
gland enlargement
bilateral 26f, 90f
causes of 90b
tumors 90
Paroxysmal
atrial tachycardia 498, 510
cough 210
nocturnal 129
Partial ptosis, left side 696f
Patau syndrome 202
Patchy hyperpigmentation 81b
Patellar clonus 296, 297
Patent ductus arteriosus 199, 200f, 550
Pathergy test 481
Payer's patches 440
Peak expiratory flow 234
Pectoralis major 290
Pectus carinatum 216
Pectus excavatum 216, 406f
Pel-Ebstein fever 693
Pellagra 13, 81f
dysebacea 14f
scaly patches 14f
Pelvic
calcification 567
girdle muscle weakness 455f
lymph nodes 595f
rami, bilateral pseudofractures of 456f
Pelvis X-ray 456f
Pelviureteric junction calculus, left 565f
Pencil-in-cup deformity 461
Pendular jerk 295
Penguin sign 578f
Pentagastrin test 619
Pentavalent antimonials 48
Pepper pot skull-hyperparathyroidism 563f
Peptic ulcer 554, 634
disease 652
of stomach 554t
Percussion myotonia 332f
Periarthritis 444
Pericardial
calcification 192, 193f
cyst 549
effusion 549
knock 148f
sound 192f
rub 152
Pericardiocentesis 611
Pericarditis 140, 190, 191
acute 191f, 490f
causes 191
types 190
Perifollicular hemorrhage 82f
Perimembranous ventricular septal defect, small 199f
Periodic respiratory infections 233
Periorbital heliotrope rash 478
Peripheral
blood film 420f
cyanosis 77t
causes of 78b
labyrinthine nystagmus 276b
nerve lesions 694
nervous system 479
disorders 330
neuritis 330
neuropathy 300, 366
causes of 671
smear 416f, 419f, 422f
abnormalities 418b
vascular disease 397
Perisplenitis 95
Peritoneal tuberculosis 123
Peritonitis 88
Perivascular tissues 535
Pernicious anemia 417
Peroneal muscular atrophy 330
Persistent atrial fibrillation, causes of 499
Persistent bronchial obstruction 255
Persistent collapse with patent bronchus 540
Pertechnetate thyroid scan 598f
Pertussis 26
Pes cavus 327f
Petechiae purpura 427f
Petechial hemorrhages 15
Peutz-Jegher's syndrome 70, 76, 653
Peyer's patches 29
Phagocyte deficiency 83
Phalanges 383f
Phalen's sign 478, 687
Phalen's test 478
Phantom tumor 695
Pharmacogenetics 648
Phenylketonuria 82
Pheochromocytoma 183, 388, 389, 389f
right-sided 604f
Philadelphia chromosome 431
Phosphodiesterase inhibitors 189
Photophobia 606
Phrenic nerve paralysis 254
Phyloquinone 16
Piano sign 459
Pickwickian syndrome 23
Pigeon-shaped chest 8, 8f
Pigmentary changes of skin 469f
Pigmentation, causes of 80b
Pineal gland, tumor of 275
Pinpoint pupils, causes of 721
Pitres’ sign 320
Pitting edema, causes of 78
Pituitary
adenoma 369f
gland 359, 360
nonvisualization of 371f
hormones, deficiency of 381
Pizzalo's method 365
Plantar reflex 297
Plasma
acetone 396
bicarbonate 396
catecholamines 389, 390
cell 436f
disorders 685
glucose 395
ketones 395
Plasmodium
falciparum 28, 647
malariae 647
ovale 647
vivax 28, 647
Platelet
concentrates 685
derived growth factor 690
Platonychia 629
Platybasia 322
Platypnea 129
Pleural
biopsy 621
calcification 538f
effusion 540f, 544f
causes of 701
free 543
loculation of 544
right 186f
fibrosis 544f
fluid aspiration 609
rub 226, 226f
Pleurisy 89, 247
Pleuritic chest pain, causes of 211
Pleurodesis 609
Pleuropericardial rub 226
Plummer's disease 373
Plummer's nail 75
Plummer-Vinson syndrome 424
Pluriglandular syndrome 363
Pluriglandular syndrome 363
Pneumaturia 344
Pneumococcal vaccination 665
Pneumocystis jiroveci 39, 42
infection, treatment of 39
Pneumonectomy 542
Pneumonia 89, 664
complications of 666
Pneumoperitoneum, causes of 552
Pneumothorax 251, 252f, 544
aspiration 610
causes of recurrent 695
closed 251, 253, 256
open 251, 253, 256
right-side 544f
types of 251
Podagra 467, 469
Poikilocytes 419f
Poisoning 718
acute 726
chronic 726
Poisonous snakes, common 732
Poisons, antidotes for 719
Poliomyelitis 694, 732
Pollicis brevis, abductor 289
Polyangiitis, microscopic 351
Polyarteritis nodosa 351, 451, 479, 479b
Polyarthritis 153
Polycystic kidney 353f
disease 353
Polycystic ovarian syndrome 679
Polycythemia
secondary 438
vera 438
Polydactyly 141f
Polydipsia 360, 391
Polymerase chain reaction 41
Polymyositis-dermatomyositis 668
Polyphagia 360, 391
Polysaccharides starch 3
Polyunsaturated fats 2
Polyuria 343, 360, 391
Poncet's disease 479
Pons 288
Pontine
arteries 260
myelinolysis, central 709
syndromes 313
Porphyrias 678
Porphyrins 776
Portal hypertension 119
Portal venous system, anatomy of 120f
Portex endotracheal tube 613f
Port-wine stain 673
Postherpetic neuralgia 45
Postmyocardiotomy syndrome 663
Postphlebitic syndrome 661, 662
Postprandial angina 701
Postprimary tuberculosis 32
Post-tussive
crackles 225
suction 227
Poststenotic aortic dilatation 550
Postural hypotension 366
Postures, abnormal 295
Potassium 17, 394
Potassium-containing foods, low 630
Pott's disease 32
Pott's spine 315, 479, 557
Prazosin causes postural hypotension 734
Prebiopsy screening tests 623
Precordial pulsations, abnormal 144
Precordium 139
shape of 142
Prediabetes 679
Prednisolone 230, 427
Predominant
myeloblasts 430f
neurologic disease 38
Preexcitation syndrome 503
Pregnant woman 656
management of 655
Prehepatic portal hypertension 120
Premature ovarian failure 362
Prerenal azotemia 674
Presystolic murmur 150
Pretibial myxedema 364
Primaquine 420
Prinzmetal's angina 487
Procainamide 659, 660
Procalcitonin 739
Procedures 605
Prodrome 115
Prognathism 364, 368
Progesterone 775
Prolactin releasing factor 360
Prolactinemia 360
Prominent U wave 490, 490f
Promyelocytes 432f
Pronator sign 329
Prophylaxis, secondary 155
Proprioception, loss of 668
Proptosis 67
Propylthiouracil 377
Prostate specific antigen 685
Prosthetic
mitral valve 548f
valve sounds 152
Protein 1
losing enteropathy, causes of 699
Protein-energy malnutrition 3, 5
prevention of 5
Protein-free diets 632t
Proteinuria 674
types of 673
Protodiastolic gallop rhythm 146
Proton pump inhibitor 650
Protozoal infections 39
Protruding jaw 58
Provocative test 713
Proximal
dilatation 124f
interphalangeal joints, fusiform swelling of 458f
muscle weakness 361
pulmonary arteries 550f
Proximally dilated esophagus 553f
Pseudoathetotic movements 303
Pseudobulbar
dysarthria 266
palsy 692
causes of 324
Pseudoathetotic movements 303
Pseudobulbar palsy 311
Pseudocoma 691
Pseudocholinesterase deficiency 648
Pseudo-Cushing's syndrome 706
Pseudocyst in pancreas 573f
Pseudodiarrhea 755
Pseudofractures 10f
Pseudogout 454
Pseudohemoptysis 751
Pseudohyperkalemia 711
Pseudohypertrophy in muscular dystrophies 300
Pseudohypoparathyroidism 384
Pseudomonas aeruginosa 232
Pseudotumor 695
Psoriasis 446
skin 450f
Psoriatic
arthritis 454, 461, 482
skin lesions 82f
Psychogenic polydipsia 343, 361
Ptosis 68f, 272f
Pubic symphysis 91f
Puddle sign 99
Pudendal nerve 298
Pulmonary
abnormalities 535
arterial pruning 546
artery 479
dilated 546
main 546, 550f
vasculitis 481
atresia 203
component 149f
edema 548, 734, 742
acute 127, 187
embolism 185, 428f, 550, 703, 753
acute 128, 550f
embolus 550f
eosinophilia 667
fibrosis 246
function test 227, 233
hypertension 198f, 231, 236
grades of 237
hypertrophic osteoarthropathy 245f
infarction 89, 543
lesion 699
metastasis 665
oligemia 546
opacities 535
pathology, X-ray of 539
physiology 778
plethora 546
regurgitation 151
stenosis 151
thromboembolism, chronic 551
tuberculosis 31, 33f, 542
primary 31
venous
hypertension 547
vascularity, increased 547
Pulsations 93
carotid artery 741
left ventricular 129
right atrial 131
right ventricular 93
venous 72
Pulse 62, 132, 381
and dal preparations 639
and meat exchanges 637
causes of
irregular 133b
unequal 137b
high volume 133
low volume 135
types of 134f
Pulsus
alternans 135f, 136, 193, 194f
bigeminus 136
bisferiens 136, 171, 171f
paradoxus 135, 191, 191f, 192
causes of 135
parvus 136
Punctate basophilia, causes of 682
Pupillary
light reflex 275b
reaction 275
reflex 274
Pupils 274
dilatation of 269
dilated unresponsive 721
irregular 274
small 320
Purine content of foods 633
Purkinje fibers 493
Purpura 690
causes of 425
Pursuit movements 274, 277
Pyelonephritis 95
Pyemic liver abscess 96
Pyoderma gangrenosum 690
Pyogenic
arthritis 454
liver abscess 116, 117
lung abscess 241
Pyopneumothorax 241, 251
Pyramidal tracts 286
Pyrazinamide 667
Pyrexia, causes of 643
Pyridoxine 16
Pyuria 345, 625
Q
Q waves, causes of pathological 486
QRS complex 485
voltage abnormalities 485
QT interval 490, 491
corrected 491
Quadrigeminus pulse 136
Quadriplegia 691
spastic 258
Queckenstedt's test 605, 669
Quincke's sign 167
Quinidine 659, 660
toxicity 501, 501f
Quinine 720
Quotidian fever 473f
R
Rabeprazole 650
Rachitic rosary 8
Radiating mucosal folds 555f
Radioiodine therapy 377
Rai staging 434
Raised diaphragm, causes of 539
Raltegravir 43
Ramsay Hunt syndrome 277, 283
Rapid urease test 102
Rashkind umbrella 200
Rathke's pouch 373
Raynaud's phenomenon 450b, 451f, 466, 469, 471, 689
severe 451f
Reactants
acute phase 154
types of 645
Reactive arthritis 446, 454, 475
Reaven syndrome 701
Rectal Examination 85, 348
Recurrent laryngeal nerve 159, 205, 366, 377, 664, 668
Recurrent pneumothorax 253
Red blood cells 131
Red glass test, diplopia 274
Reed-Sternberg cells 439, 441f
Referred pain 89
Reflexes
abdominal 298, 298f
types of 295
Refractory
anemia 424
heart failure 184
Refsum's disease 704
Refsum's syndrome 673
Reiter's syndrome 451, 642, 643
Relapsing polychondritis 446, 451
Relapsing polyradiculopathy, chronic 330
Renal
acid 716
and alimentary glycosuria 698
artery stenosis 551, 551f
biopsy 623
calculi 564, 633
capsules 89
cell carcinoma 354, 354f
colic 766
cyst upper pole 574f
diseases 344
failure 674, 675
acute 349, 353, 632, 632t, 674, 708
cause 675
chronic 350, 351f, 351t, 575f
prerenal acute 349
prevent 722
glycosuria 698
Renin 775
Renovascular hypertension 717
Respiration 62
Respiratory
acidosis 355, 356, 717
primary 357
alkalosis 355, 356, 718
causes of 357
diseases 255, 255t, 700
disorders 533
distress syndrome, acute 235
failure, chronic 356
rate 218
system 4, 209, 393, 533
tract, examination of upper 213
Restless leg syndrome 669
Restrictive lung disease 234t, 690
Retention enema 626
Reticulocyte count 425
Reticulocytosis, causes of 425
Retinal arteries, corkscrew appearance of 182f
Retinitis pigmentosa 22f
Retinoid etretinate 482
Retinol 16
Retinopathy 643, 670
Retroperitoneal fibrosis 350, 351
Retrosternal goiter 222, 366
Reye's syndrome 756
Rh immune globulin 685
Rhabdomyolysis 763
Rheumatic
carditis, acute 155
chorea 329
diseases 446t, 449b451b, 689
fever 153, 154f
prophylaxis 163
signs of 329
nodules 142f
Rheumatoid
arthritis 451, 454, 458, 461, 461f
disease 643
hand late stage 459f
nodule 475f
of lung 536f
Rhinocerebral mucormycosis 381
Rhyroid eye disease 68f
Rhythm control 747
Rib 562f
notching 182f, 545
Riboflavin 16
deficiency 13
Rich dietary sources 631
Rickets 8, 9f, 558, 558f
Riedel's lobe 96
Rifampicin 47, 667
Rigid bronchoscopy 615
Rinne's test 283
Risus sardonicus 25
Ritonavir 43, 44, 44
Rituximab 435
Romano-Ward syndrome 664
Romberg's sign 320, 328
Romberg's test 292, 319
Root compression, symptoms of 316
Root lesions 694
Ropy discharge eye 451f
Rose-thorn ulcers 555f
Rostacyclin 238
Rotch's sign 191
Roth's spot 175f
Rotor syndrome 114
Rough thick skin 362
Rouleaux formation 436f
Roussy-Levy disease 704
Roux-en-Y gastric bypass 23
Rubinstein-Taybi syndrome 202
Russell's viper 732
Russell-Silver syndrome 370
Ryle's tube 618, 618f
S
Saccular aneurysm 550
Sacral edema 131
Sacroiliitis, bilateral 463f
Saddle anesthesia 318
Saddle nose deformity 447f
Sagging depression 488f
Sahli's bone marrow needle 617, 617f
Sainani sign 297, 298
Salbutamol 229
Salicylate 720
poisoning 722
Salicylism 722
Saline enema, normal 626
Salmeterol 230
Saponin enema 626
Saquinavir 43
Sarcoidosis 90, 241, 242f244f, 450f, 451, 543
suggestive of 243f
Saturated fats 2
Sausage toe 446f
Saw-scaled viper 732
Scaly skin, causes of 82f
Scaphoid abdomen 91f
Scapula, winging of 406f, 455f
Scars 82, 365
pitted 470
Schaefer's sign 297
Schamroth's sign 74f
Schamroth's window test 74
Scheuermann's disease 218
Schilling test 425
Schirmer's test 280, 462f
Schistocytes 418, 419f
Schmidt syndrome 705
Sclerodactyly 470f
Sclerodegenerative disease 497
Scleroderma 76, 79, 81, 83, 116, 425
Sclerosis, multiple 333, 607, 688
Sclerotic lesions of skull 561
Scofield's calliper 61
Scoliosis 84, 218
Scorbutic rosary 15, 216
Scorpion bite (sting) 719, 734
Scratch marks, causes of 81b
Scurvy 15, 15f, 558, 558f
Sea snakes 732
Seasonal cough 210
Secretory diarrhea 116
causes of 116
Sedatives 720
Seizures 261
Selenium 20
Sella turcica 368f
causes of enlarged 369
Sengstaken-Blakemore tube 755
balloon compression 119
Senile osteoporosis 13
Sensation, areas of 47f
Sensory
ataxic gait 299
disorders 299, 300
examination 302
functions 279
innervation of face 278f
neuropathy, causes of pure 331
pathways 301f
symptoms 301
system 301
Septal aneurysm 199f
Septicemia 739
Serum
bicarbonate 395
biochemistry 773
calcium 384
abnormalities of 687
cholesterol 381
complement 452
ferritin 413
gastrin 417
iron 413
phosphate 687
potassium 395
sodium 17, 395
uric acid 453
Sexual reflexes 308
Sezary syndrome 434
Shock 743
diastolic 144, 202
treatment of 744
types of 744
Shoulder 444
abductors 290
Shrue mouth 59f
Shunt, left to right 546
Shy-Drager syndrome 329
Sickle cell 418
anemia 418, 424, 561
disease 422, 422f
trait 683
Sickness, decompression 737
Sideroblastic anemia 424, 424f
Siegert's sign 407, 408f
Sighing breathing 211
Sigmoid
colon 98
diverticulitis 95
Sildenafil 237
citrate 698
Silhouette sign 539
Silicosis 57, 212, 246, 537, 665
Silver wire appearance of arteries 178f
Simmond's cachexia 63
Sinoatrial block 495, 495f
Sinus
arrhythmia 498
bradycardia 366, 498, 510
causes of 133b
node dysfunction 659
tachycardia 366, 497, 498t
causes of 133b
thrombosis, superior sagittal 339
venosus 197, 198
Situs inversus 196
Sjogren's syndrome 67, 69, 90, 451, 451f, 462, 462f, 643
Skeletal
dysplasias 370
metastasis, multiple 593f
multiple 597f
Skin 6, 364, 381, 481
conditions 81
fold thickness 20
hyperelasticity of 11f, 409f
hyperpigmentation of 387f
inspection of 80
lesions 690
palpation of 83
plaques 243f
rash 449b
Skodaic resonance 221, 251
Skull 560, 563
changes 561
lytic lesions of 560
Sliding hiatus hernia 89f
Small-bowel loops, separation of 555
Smoking, stop 647
Snake bite 719, 732
Snellen's test 268
Sodium 16
nitroprusside 745
Soft tissue
lesions 595f
swelling 468f
Solitary plasmacytoma 562f
Solitary pulmonary nodule, causes of 537
Sotalol 659
Spastic
gait 299
paraplegia, pure 315
quadriplegia 315
Speech
cortical organization of 265
disturbances of 258, 265
slurred 324
staccato 266
stuttering 328
written 265
Spherical red cells 419f
Spherocytosis 419f
Spider nevi 93
Spina bifida 560, 560f
Spinal artery
anterior 309
syndrome
anterior 322
posterior 322
Spinal cord 288, 309, 323f, 325f, 705
causes 315
compression 316, 316f
cross-section of 309f
lesions 694
magnetic resonance imaging of 321f, 325f
tumor, magnetic resonance imaging of 317f
Spinal meningioma 317f
Spinal shock 323
Spine 83, 448, 452, 463, 563
deformities 218
tuberculosis of 557
Spinocerebellar degeneration 704
Spinothalamic tracts 335
Spleen 98
enlarged 98t
examination of 96
Splenectomy 419
Splenic abscesses 572f
Splenic rub 100
Splenomegaly
causes of mild 97
grades of 97f
Spondyloarthropathies 451, 461, 464
Spontaneous bacterial peritonitis 105, 108
Spontaneous pneumothorax, types of 252f
Spur cell anemia 418
Sputum, consistency of 210
Squamous carcinoma 245
Squint 274
concomitant 274, 274t
St Jude valve 161
Stable angina 127
Staghorn calculus 565f
Stamping gait 299
Staphylococcus aureus 399, 765
Starch opium enema 626
Starr-Edwards valve 161
Status asthmaticus 231, 750
Status epilepticus 758
Stavudine 43, 44
Steele-Richardson-Olszewski syndrome 329
Steinberg test 405f
Stem cell therapy 655
Stensen's duct 27
Sterling sign 555
Sternal angle 139
Sternoclavicular pulsations, right 145
Steroids 445
Stertorous breathing 219
Stevens-Johnson syndrome 82, 83f, 347
Stierlin's sign 123
Stiffness 444
Still's disease 247, 473, 473f, 474, 643
Stokes-Adams
attack 130, 497
syndrome 746
Stomach 86
disorders 699
malignant ulcer of 554t
Stomatitis 661
angular 13
Stool antigen test 102
Strabismus 274
Straight leg raising test 307
Streptococcal antibody test 153
Streptococcal infection 155
Streptococcus 765
Streptomycin 666, 667
Stridor 211, 225, 729
causes of 211
Stroke 310, 312, 569
acute 312
causes of 312
Sturge-Weber syndrome 673, 697
Subacute combined degeneration of cord 319, 319f
Subarachnoid hemorrhage 762
Subclavian steal syndrome 669
Subconjunctival hemorrhage 36f
Subcutaneous
emphysema 221f
nodule 153, 449b, 449f
Subdural hematoma 571f
chronic 570
Subperiosteal erosions 383f
Subtentorial lesions 757
Succussion splash 100, 226
Sucralfate 757
Sucrose lysis test 419
Sudden cardiac arrest 740
Sulfasalazine 464
Sulfonamides 420
Sulfonylureas 401, 680
Supinator reflex 296
Suppurative parotitis 90
Supranuclear palsy 275
Suprapubic
aspiration 767
catheterization 767
Suprasellar lesion 373f
Suprasternal notch 145
Suprasternal pulsations, causes of 145b
Supratentorial lesions 757
Supraventricular tachycardia 659
Suzman's sign 143, 145, 180
Swan neck 331
deformity of fingers 459f
Sweat glands 361
Swelling 444, 446
Sydenham chorea 155
Sympathetic stimulation, symptoms of 734
Sympathomimetic amines 189
Syndactyly 141f
Synovial fluid, examination of 453
Synovial joint, structure of 444f
Syphilitic chancre 101f
Syringobulbia 324
Syringomyelia 324, 325f, 705
congenital 325
fluid 325f
Systemic diseases, manifestations of 642
Systemic lupus erythematosus 351, 446, 451
Systemic rheumatic diseases 452
Systemic sclerosis 451f, 469, 470f, 471f
Systolic murmur
late 150
long 150
T
T wave inversion
primary 487f
secondary 487f
Tabes dorsalis 320, 320f
Table top test 401
Tachyarrhythmias 659
Tachypnea 62, 666, 710, 722
Tactile extinction 304
Tactile fremitus 220
Tactile vocal fremitus 220
Tadalafil 698
Taenia solium 669
Takayasu's arteritis 206, 311, 749
Takayasu's disease 137
Tall stature 60
Tall T wave 487f
causes of 487
Tardive dyskinesia 703
Target cells 418, 420f
Taste
disorders of 87
sensation 280
examination of 280
Tear drop cells 419f
Technical abnormalities 545
Teeth 70, 563
Temporal arteritis 480
Temporal lobe 266
left anterior 583f
right 585f
Tendon reflexes, deep 295
Tenofovir 43, 44
Tensilon test 337
Tension headache 263
Tension pneumothorax 251, 253, 544, 545f, 611, 752
Testicles 366
Testicular atrophy 366
Testis 46
Testosterone 776
Tetanus 25
complications 25
diagnosis 25
opisthotonus 25f, 58f
prevention 25
treatment of 26, 643
Tetany 294
causes of 643
Tetralogy of Fallot 200, 550
Thalamus 704
Thalassemia 420, 561
major 418, 420f, 421b, 421f, 424
types of 420
Thalidomide 437
Thenar muscles, wasting of 478f
Theophylline 720
Therapeutic diets 629
Thiacetazone 666
Thiamine 16
Thiazide diuretics 714
Thiazolidinediones 401
Thigh
abductors of 292
adductors of 291
rotators of 292
Thoracentesis 609
Thoracic cage
abnormalities, developmental 545
disease 231
Thoracic kyphosis 84f
Thoracic outlet syndrome 324
Thoracic spine 444
Thorax 535
Throat culture 153
Thromboangiitis obliterans 55
Thrombocythemia, primary 439
Thrombocytopenia, causes of 442
Thrombocytosis, causes of 442
Thrombolytic therapy 312, 663
Thrombotic
crisis 422
stroke 309
Thumb printing 557
Thunder clap headache 691
Thymoma 337, 545, 696
Thyroid 375, 378
crisis 377
diseases 382
disorders 185, 363, 373
eye disease 376f
gland examination 72
scan 595f
storm 377, 764
swelling 365
examination of 365
Thyroiditis 598
Thyroid-stimulating hormone 677
Thyrotoxic tremor 293
Thyrotoxicosis 374f, 375f, 375t, 595
causes of 382
Thyrotropin-releasing hormone 360
Tics 294
Tidal percussion 222
Tidal volume 717
Tietz syndrome 650
Tinel's sign 477, 478, 687
Tinel's test 478
Tinnitus 282
Tipranavir 43
Tizanidine 333
Tobacco-related diseases 55
Todd's paralysis 261
Todd's syndrome 672
Tongue 69, 77f
bald 69
geographic 69f
hemangioma of 70
lymphangioma of 70
Tonsillar diphtheria 24
Tonsils 71
Tophaceous gout 468f
chronic 467
Tophi feet 449f
Tophi fingers 468f
Tophus 468
Topognosis 304
Torsades 749f
de pointes 500, 748
Torticollis 294
Total body K excess, causes of 710
Total iron binding capacity 412
Total water deficit 710
Tower-shaped skull 424
Toxic
nodular goiter 375f
nodule 376f
Toxicity, mechanism of 726
Toxin 719, 720
Toxoplasma gondii 39
Toxoplasmosis 570, 571f
Trachea 250, 544f
palpation of 220f
position of 220
pressure necrosis of 613
Tracheal tug 206
Tracheostomy 614
indications for 614
Tractus solitaries 313
Trail's sign 219
Transient ischemic attack 261, 311, 760
Transillumination test 101, 347
Transjugular venous biopsy 623
Translucency hilar shadows, causes of increased 539
Transplant kidney scan 594f
Trans-sphenoidal surgery 369
Transudate in ascites 698
Transvenous pacing 620
Transverse
myelitis, acute 321
sinus occlusion 339
Trapezius 290
reflex 298
Traube's sign 167
Traube's space 221, 222, 222f
resonance, loss of 222
Trauma 316
Tremor 293, 396
benign 293
Trendelenburg sign 300
Trepopnea 129
Triamcinolone 230
Triceps reflex 296
Trichinella spiralis 668
Tricuspid
regurgitation 140, 149, 163, 172
stenosis 140, 151, 160, 172
Tricyclic antidepressants 719
Trientine 672
Trigeminus pulse 136
Trigeminy 510
Triglycerides 250, 612
Triradiate pelvis 10f
Trismus 25
Trisomy 140, 202
Trocar 611
Trophic ulcer 79f
Tropical eosinophilia 211, 441
Tropical spastic paraplegia 703
Tropical sprue 687
Trousseau's sign 294, 366, 714
causes of 714
Tru-cut biopsy needle 624f
Tru-cut disposable needle 624
Truncal obesity 22f, 385f
Tubercular abscess formation 583f
Tubercular effusion, secondary to old 538f
Tuberculin test 42
Tuberculoma 569
Tuberculosis 454
adult-type 32f
extrapulmonary 32
fibrocaseous 32
hematogenous 441
intestinal 699
miliary 536, 700
of abdomen 32
of spine 532
reinfection of 666
Tuberculous
lung abscess 241
meningitis 336
osteitis 557f
Tuberous sclerosis 576f
Tubes, advantages of larger 613
Tubular necrosis, acute 594, 674
Tumor flop sound 152
Tunnel vision 269
Turner's syndrome 180, 365, 370, 404, 404f
Turpentine 626
Typhlitis 98
Typhoid 29
Typical skin rash 474f
Typist's cramp 294
U
Ulcer 69, 699
aphthous 451f
crater 555f
decubitus 312
intestinal 123
malignant 554
meatal 347
oral 451b
orogenital 448
rose-thorn 555f
tiny 556f
neuropathic 399f
Ulcerative colitis 556, 556f, 634, 699
Ultrasonography 568
Umbilical hernia 93
Umbilicus 91f, 93
sunken 91f
Unconjugated hyperbilirubinemias 113
Unipolar limb leads 484
Upper medulla, cross-section of 314f
Urachal carcinoma 587f
Urea breath fest 102
Uremia 698
Ureteric causes 766
Urethra, discharge per 345
Uric acid 776
Urinary 674
bladder 98, 307
catheterization 625
neurogenic control of 308f
casts, types of 675
incontinence, causes of 345
protein 353
Urine 776
acute retention of 766
glucose 396
osmolality 674, 677
retention of 731
Urokinase 662, 753
Ursodeoxycholic acid 105
Urticaria 3
Uveitis, posterior 243f
V
Vaccine, triple 25
Valgus 459f
deformity of knees 460f
Valproic acid 386, 758
Valsalva maneuver 152
Valsalva test 305
Valvular
aortic stenosis 165
heart disease 309, 655
murmur, location of 151
Valvuloplasty 161
Vardenafil 698
Variceal bleeding 754
Varicose veins 23f
Variegate porphyria 678
Varus deformities 459f, 471f
Vascular bruits 152b
Vasculitis 451
Vegetable exchanges 637
Vein
abdominal 94f
auscultation over 153
thrombosis, deep 427, 428f
Velocardiofacial syndrome 202
Vena cava 547
filter, inferior 753
inferior 100f, 127
obstruction, superior 140
superior 127
Venepuncture 608
complications 608
procedure 608
Venesection 608
procedure 608
Venom, scorpion 734
Venoocclusive disease 651
Venous hum 100
Venous pulsations, normal 138
Venous thrombosis, deep 349
Ventilation perfusion scan 237
Ventricle, left 547
Ventricular aneurysm, left 143f, 547
Ventricular arrhythmias 499
causes of 500
Ventricular enlargement, right 547
Ventricular extrasystoles 530
Ventricular failure, acute left 129, 742
Ventricular fibrillation 500, 510
flutter 748
Ventricular hypertrophy 492
left 143, 492, 492f, 510
right 492, 493f, 510
Ventricular septal defect 149, 198, 549
Ventricular tachycardia 500, 500f, 510, 659, 748
Verapamil 659
Vertebra 561
compression of 12f
with cold abscess 557f
Vertebral artery 259
Vertebral body 309
Rugger jersey appearance of 559
Vertebral lesions 694
Vertiginous ataxia 327
Vertigo 274
causes of 671
Very low-density lipoprotein 654, 702
Vesicular breathing 223
Vessels, intercostal 610
Vestibular function, examination of 283
Vibration sense 303
Vibrio cholera 90, 691
Vidarabine 480
Viliary cirrhosis 96t
Villous atrophy 417, 661, 712
Vim-Silverman
liver biopsy needle 623f
method 622
needle 622
Vincent's angina 71
Vincristine 437
Viomycin 667
Viper, green pit 732
Viral
infections 40, 232
meningitis 607
Virchow's triad 427
Virilisation, causes of 363
Visceral
leishmaniasis 48
pain, radiation of 90b
reflexes 298
Visible peristalsis 93
Visual acuity 268, 286, 365, 393
Visual cortex 266
Visual field defects 267f, 268
Vital capacity 234
Vitamin 15, 16
A 16
deficiency 17f
B1 16
causes of 414
deficiency 415417, 668
level 683
metabolism of 414
B2 13, 16
B3 16
B5 16
B7 16
B9 16
C 16
D 6, 9, 16
causes of 7
deficiency 7, 9
forms of 7
D3, dietary sources of 7
E 16
K 16, 115, 732
Vitiligo 80f
Vocal resonance 227
Volkmann's ischemic contracture 73, 694
Vomiting 759
causes of 87
von Hippel-Lindau syndrome 354, 673
Von Willebrand factor 685
Vulvovaginitis 347
W
Waddling gait 299
Waist
circumference 20
hip ratio 20
Waldenström's macroglobulinemia 425
Waldeyer's ring 440
Wall ischemia, anterior 530
Warfarin 110, 237, 428, 620
Water content of body 62
Water-hammer pulse 366
Waterhouse-Friderichsen syndrome 388
Water-insoluble fibers 3
Water intoxication 678
Water-soluble fibers 3
Waterston-Cooley shunt 201
Weber's syndrome 277, 313, 313f
Weber's test 283
Wegener's granulomatosis 351, 381, 446, 451, 537
Weight, loss of 61
Weil's disease 36f, 96, 646
Weil's syndrome 35, 646
Wenckebach phenomenon 496, 496f
Wernicke's area 265
Wernicke's encephalopathy 668, 697
Wernicke-Korsakoff psychosis 265
Western blot test 41, 42
Wheelchair sign 703
Wheezes 225, 225f
causes of 211
Whipple's triad 396
Whispering pectoriloquy 227
White nail 76
Whooping cough 26
complications 26
diagnosis 26
Widal test 30
Widening of
superior mediastinum 545
sutures 560
Wilms’ tumor 345
Wilson's disease 67, 105, 112, 329f, 671, 672, 702
Wind angina, second 128
Wiskott-Aldrich syndrome 442
Wolfe's bottle 615
Wolff-Parkinson-White syndrome 498, 503, 503f, 510
Word deafness 266
Worm infestation 667, 681
Wormian tongue 329
Wrist
ankylosis of 461f
extensors 290
flexors 290
sign 405
Wuchereria bancrofti 49
X
X-linked spinal muscular dystrophy 72
Xanthelasma 132f, 142f, 365
Xanthochromic CSF 607
Xanthomas 132f
Xerostomia 87
Xiphisternal angle 611
Xiphisternum 91f
Yohimbine 698
Xylose absorption 776
Xylose malabsorption 687
Y
Yellow fever 648
Z
Zalcitabine 43
Zellweger syndrome 673
Zidovudine 44
Ziehl-Neelsen stain 227
Zinc 20
Zivovudine 44
Zoledronic acid 715
Zollinger-Ellison
disease 619, 652
syndrome 116, 363
Zygoma 364
×
Chapter Notes

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Nutrition Including ObesityCHAPTER 1

 
CONTENTS
  • Macronutrients (Proteins, Fats and Carbohydrates)
  • Micronutrients (Vitamins and Minerals)
  • Nutritional Disorders
  • Protein-Energy Malnutrition (Marasmus, Kwashiorkor)
  • A Case of Marasmus
  • A Case of Kwashiorkor
  • A Case of Marasmic Kwashiorkor
  • Vitamin D
  • A Case of Rickets
  • A Case of Osteomalacia
  • A Case of Osteoporosis
  • A Case of Riboflavin Deficiency
  • A Case of Pellagra
  • Ascorbic Acid
  • A Case of Scurvy
  • Vitamins
  • Minerals Sodium
  • A Case of Hyponatremia
  • A Case of Hypernatremia
  • Potassium
  • A Case of Hyperkalemia
  • A Case of Hypokalemia
  • Calcium
  • A Case of Magnesium Deficiency
  • A Case of Fluorine Deficiency
  • Obesity
 
NUTRITION
 
Introduction
To maintain good health and prevention of disease, one should have a balanced diet. Our appetite and eating behaviors are controlled by neurophysiologic mechanisms. What we eat, maintains the body needs. While we are fasting, body needs are taken care of by the release of energy from the stores. The excess amino acids, glucose and fatty acids are stored as protein, glycogen and triglycerides and are under control of insulin. Either excess or poor nutrition leads to disease.
 
Physiology of Nutrition
Nutrition broadly covers (1) Macronutrients which provide calories and energy for the body. These are proteins, fats and carbohydrates. (2) Micronutrients which are vitamins and minerals. These are taken in small amounts and are essential. They do not provide energy, and they are not synthesized in the body.
  1. Proteins
    • ▸ Proteins are the basic units of tissues. Their main role is in the formation of enzymes, hormones and transport mechanisms. Proteins are not stored in the body. During growth spurts 2(infancy and adolescents), protein requirements are high (1.5–2 g/kg body weight). Otherwise average person requires 1 g/kg/body weight of protein. There are nine essential amino acids out of total 20 amino acids. The essential amino acids are leucine, isoleucine, lysine, tryptophan, threonine, histidine, methionine + cysteine, phenylalanine + tyrosine and valine. These are termed essential because they synthesize different proteins of the body. An average person should have 10–15% calories from proteins. Proteins of animal origin meat, chicken, fish, eggs, milk have higher biological value than the proteins of vegetable origin. Children during growth, pregnant and lactating mothers require high biological proteins and more calories. Brain uses glucose at the rate of 5 g/hour.
    • ▸ Balanced diet contains macronutrients and micronutrients in adequate amounts to maintain good health.
  2. Fats
    Usually an average adult consumes 35–40% of calories as fats—1 g of fat gives 9 kcal of energy.
    Three types of fats
    1. Saturated fats—Ghee, butter palmitic acids—Consumption of saturated fats increase plasma LDL and total cholesterol and predispose to atherosclerosis.
    2. Polyunsaturated fats—Linoleic acid in plant seed oils. Its derivatives gamma linoleic acid, arachidonic acids are the essential fatty acids. Fish oils are rich in omega-3 series of polyunsaturated fatty acids. These are precursors of prostaglandins and eicosanoids. They inhibit thrombosis by antagonising thromboxane A2. For prevention of dyslipidemias, reduction of hypertriglyceridemia and coronary artery disease, polyunsaturated fatty acids are beneficial.
    3. Monosaturated fatty acids, for example, Oleic acids are useful for prevention of hyperlipidemia and CAD. One prescribes two types of dietary fats: (1) It comprises of 10% of each type of fat with daily cholesterol intake less than 300 mg (2) More strict diet advocated when diet 1 fails. It comprises of 7% of each type of fat with daily intake of cholesterol intake less than 200 mg.
  3. Carbohydrates
    The available carbohydrates, e.g. starch and sugar are broken down to monosaccharides before absorption from the gut. They supply over 50% of energy in a well-balanced diet. One gram of carbohydrates give 4 kcal. Daily intake of carbohydrates is 200 g but if it is less than 100 g daily, enhanced lipolysis results in ketosis. Intake of extrinsic sugars, e.g. sucrose, fructose, and maltose which increase the risk of diabetes mellitus, and dental cares should be restricted. It is the starches in cereals, root foods and legumes which provide the largest proportion of energy in most diets. Whereas some starches are digested promptly by salivary and pancreatic amylase delivering rapidly glucose in the blood, other starches are digested more slowly. These differences are the basis of ‘glycemic index’ of foods. The glycemic index reflects the area under curve of the rise in blood glucose in the 2 hours following ingestion of 50 g carbohydrates expressed as the percentage of the response to 50 g of glucose.
    Remember that high glycemic index foods are linked to obesity and type 2 DM.
 
Food Sources of Carbohydrates
  1. Sugars—Monosaccharides and disaccharides and polysaccharides—glycogen, starch. Intrinsic sugars—fruits and milk 3(good), Extrinsic sugars (cane sugar, beet root sugar), not good as they cause cavities.
  2. Polysaccharides starch and glycogen
    Starch is available in cereals (rice, wheat, maize) and roots (potatoes, cassava), plantains and legumes
Glycemic index is calculated as follows—
  • ▸ Two hours plasma glucose after 50 g of carbohydrates in a meal divided by curve of 50 g of glucose in water.
  • ▸ Foods with high glycemic index are—sugars, potatoes, white bread, etc.
  • ▸ Foods with low glycemic index are – whole grains, legumes.
 
Dietary Fiber
It is difficult for dietary enzymes to digest dietary fibre. These are of 2 types:
  1. Water-insoluble fibers increase bran of hemicellulose of wheat. It has water holding capacity which increases the quantity of stools, and this is good for constipation. It also prevents diverticulosis and cancer colon
  2. Water-soluble fibers—Pectin, guar gum, oat bran, beans. They induce early satiety, lower cholesterol, flatten glucose tolerance curve.
 
Micronutrients
  1. Organic micronutrients, vitamins (not synthesized in body)
  2. Inorganic micronutrients
    1. Minerals (iron, calcium, magnesium, etc).
    2. Trace elements (iodine, zinc, copper, chromium, selenium, manganese, etc.)
    3. Electrolytes (sodium, potassium, chloride).
 
Water
Daily calories requirement (Box 1.1).
 
NUTRITIONAL DISORDERS
  1. Under nutrition
    Deficiency in quantity
    • ▸ In children it causes marasmus
    • ▸ In adults, various forms of starvation, anorexia nervosa.
  2. Malnutrition
    Deficiency in quality
    • ▸ Protein deficiency—Protein-calorie malnutrition (kwashiorkor)
    • ▸ Vitamin D deficiency – Rickets
    • ▸ Vitamin C deficiency – Scurvy.
  3. Overnutrition
    • ▸ Quantitative—Obesity
    • ▸ Qualitative—Excess cholesterol intake—Hypercholesterolemia
      Excess vitamins—hypervitaminosis—A,D, etc.
 
Toxins in Food Causing Migraine, Urticaria, Lathyrism
Effect of toxins in food—Lathyrism due to consumption of lathyrus sativus, khesari dal (Fig. 1.1).
 
PROTEIN-ENERGY MALNUTRITION (PEM)
 
Introduction
Primary—It is due to inadequate intake of proteins due to famine or poverty. In young children, there are two types of malnutrition: (1) Marasmus (2) Kwashiorkor and also combined form. In adults, primary form is more of undernutrition. It is due to anorexia, poverty and insufficient food, increased demand, increased energy expenditure.4
zoom view
Fig. 1.1: Patient of lathyrism
Adults patient with PEM presents with
  • ▸ Loss of weight, generalized weakness
  • ▸ Intolerance to cold
  • ▸ Loss of libido and nocturia
  • ▸ Amenorrhea
  • ▸ Loss of hair and thinning of hair
  • ▸ Skin looses lustre and is dry, lax
  • ▸ Loss of subcutaneous fat
  • ▸ Muscle wasting
  • ▸ Bradycardia, hypotension
  • ▸ Edema feet
  • ▸ Bloated abdomen with diarrhea
  • ▸ Depressed, introverted
  • ▸ Deep tendon jerks diminished
  • ▸ Secondary infections.
 
PEM Causes Systemic Disorders by Affecting Various Systems
  1. Cardiovascular system
    • ▸ Small heart, reduced cardiac output and stroke volume
    • ▸ Atrophy and patchy necrosis of myocardium and affection of conduction tissue of the heart
  2. Gastrointestinal system—Intestinal villi are atrophied, secretions of stomach, biliary system and pancreas are reduced in quantity and quality resulting in malabsorption.
  3. Endocrine system—Various endocrine hormones, such as thyroxine, insulin are diminished but levels of growth hormone and cortisone are increased. These changes result in increased catabolism of muscle protein and increase in lipolysis. In adults, gonadal dysfunction is seen.
  4. Respiratory system—Atrophy of intercostal muscles and diaphragm
  5. Immunological functions
    • ▸ There is impairment of cell-mediated and humoral immunity
    • ▸ Total lymphocyte count is decreased
    • ▸ T and B lymphocyte function is affected
    • ▸ Tuberculin test is delayed
    • ▸ Wound healing is impaired.
 
Investigations
  1. Record body weight, calculate BMI and measure skinfold thickness
  2. CBC, ESR—Usually hemoglobin is low, leukopenia and thrombocytopenia are present but ESR is normal
  3. Hypoproteinemia and hypoalbuminemia
  4. Serum T3 and T4 levels are low
  5. Cortisol and growth hormone levels are high
  6. X-ray chest is done to detect secondary infections
  7. ECG—Bradycardia and low voltage.
 
Management
  1. Increase protein intake to 2–3 g/kg/body weight instead/of 1 g/kg (normal)
  2. Give vitamins and minerals
  3. Correct hypoglycemia, hypokalemia, dehydration, acidosis and electrolytes.5
Recommendation of National Institute of Nutrition, Hyderabad to make an energy protein rich mixture to treat protein-energy malnutrition at home (Box 1.2).
For prevention of protein-energy malnutrition (PEM), UNICEF recommendations are Mnemonic – GOBI FFF (Box 1.3)
 
PROTEIN-ENERGY MALNUTRITION IN CHILDREN
 
A Case of Marasmus
  • Marasmus (Fig. 1.2) Weight of the child is reduced below 60% of the WHO standard. It results from poor breast milk in undernourished mother, early weaning from breastfeeding and poor diet (low in protein, low calories and low essential minerals, vitamins are the causes). Also poor living conditions leading to gastroenteritis resulting in further malnutrition leads to marasmus.
  • ▸ Child is under weight, wasted, just skin and bones with little subcutaneous fat and poor muscle mass.
  • ▸ Gaseous distension of abdomen with diarrhea is seen in marasmus
In contrast to kwashiorkor, child has no skin or hair changes, no edema and no anorexia.
zoom view
Fig. 1.2: A child with marasmus
 
A Case of Kwashiorkor
  1. Kwashiorkor (Fig. 1.3)
    • ▸ Here child has pure form of protein malnutrition. It occurs in the second year of life when child is weaned from breastfeeding but is being fed with carbohydrate starchy diet with low protein. Due to unhygienic living conditions, secondary infections like malaria, measles which require high protein diet further worsens protein malnutrition.
    • ▸ Child is irritable, apathetic, lethargic, drowsy
    • ▸ There is pitting edema but subcutaneous fat is normal
    • ▸ Growth of child is stunted6
    • Skin changes are seen maximum around napkin area. These are symmetrical pigmented and thickened mosaic like appearance with fissuring of skin (crazy pavement dermatosa). Same skin changes are noticed over pressure areas
    • Hair changes—The hairs loose lustre and are thin, sparse and brownish in color. They fall off easily. There is partial correction resulting in alternate bands of pigmentation and depigmentation
    • ▸ Occasionally one may see clinical picture of marasmus and kwashiorkor in the same child.
zoom view
Fig. 1.3: Kwashiorkor—edematous severe acute malnutrition
 
A Case of Marasmic Kwashiorkor (Fig. 1.4)
In such a child, the clinical features will be combined of marasmus and kwashiorkor.
In severe cases, acute protein depletion affects liver, pancreas and intestines. Due to involvement of liver, albumin synthesis is affected resulting in hypoalbuminemia and edema. Associated deficiency of vitamins and minerals will reflect in clinical picture. See Table 1.1 for differential points between kwashiorkor and marasmus.
zoom view
Fig. 1.4: Marasmic kwashiorkor
Table 1.1   Differential points between kwashiorkor and marasmus
Parameters
Kwashiorkor
Marasmus
1. Deficiency nutrient
Protein deficiency
Proteins, other nutrients and calories
2. Facial appearance
Less degree of emaciation
Emaciated
3. Age
1–4 years
<1 year
4. Weight
<80–85% of standard weight
<60% of standard weight
5. Edema
Pitting edema
No edema
6. Skin and hair changes
marked changes
Mild changes
7. Weaning
Late and gradual
Early and fast
8. Apathy and loss of appetite
Present
Absent
9. Liver
Fatty enlarged liver
Normal
 
VITAMIN D
  1. Introduction
    • ▸ Actually vitamin D is a hormone and not a vitamin. It is important for the metabolism of calcium, phosphorus and for formation of the bone7
    • ▸ The main source of vitamin D is when skin is exposed to sunlight (UVR).
Dietary sources of vitamin D3
  • ▸ Fortified milk, fortified orange juice, fatty fishes like Salmon, mushrooms, fish liver oil, eggs, cheese, butter
  • ▸ Vitamin D enhances the absorption of calcium and phosphorus from GIT
  • ▸ It also mobilizes calcium and phosphorus from bones
  • ▸ Its rise facilitates reabsorption of calcium from bones
  • ▸ It also facilitates reabsorption of calcium and phosphorus from kidneys.
    Two forms of Vitamin D
    1. Vitamin D2 (calciferol) obtained by ultraviolet irridation of plant origin ergosterol
    2. Vitamin D3 (cholecalciferol) is formed from 7-dehydrocholesterol which is present in the epidermal cells of skin by exposure to sun light
Daily requirement varies as follows:
  • ▸ Infants, preschool children
- 400 IU/day
  • ▸ Children and adults
- 200 IU/day
  • ▸ Pregnancy and lactation
- 400 IU/day
  1. Metabolism: First hydroxylation occurs in liver and 25 hydroxyl vitamin D is formed. Further it is hydroxylated in kidney and the most active 1,25 hydroxy cholecalciferol (calcitriol) is formed. Normal vitamin D3 level should be greater than 30 preferably >40 mg.
 
Predisposing Factors for Vitamin D Deficiency
  1. Dark skinned persons
  2. Women using burqa or parda
  3. Little exposure to sunlight
  4. Infants breastfed and no supplements
  5. Pregnant women.
 
Causes of Vitamin D Deficiency
  1. Lack of exposure to sunlight
  2. Malabsorption due to pancreatic disease, coeliac disease, obstructive biliary disease
  3. Impaired production due to kidney disease
  4. Side effects of drugs, e.g. rifampin, phenytoin sodium which impair metabolism.
 
Effects of Vitamin D Deficiency
  • ▸ Vitamin D deficiency causes rickets in children and osteomalacia in adults.
  • ▸ Recent evidence has shown that vitamin D is very important. Its deficiency in Indians is very common, and it plays a very important role in various systemic disorders.
    1. Autoimmune disorders
      • Rheumatoid arthritis
      • SLE
      • Psoriasis
      • Type 1 DM
      • Inflammatory bowel disorders
    2. Cardiovascular disorders
      • CAD
      • Hypertension
      • Cardiomyopathy
      • CCF
      • Sudden cardiac death
      • Peripheral vascular disease
    3. Metabolic and endocrine disorders
      • Metabolic syndrome
      • Primary hyperparathyroidism
      • Type 1 and 2 DM
    4. Infections
      • Recurrent upper respiratory infections occur
      • Tuberculosis
    5. Hemopoitic system
      • Leukemias
      • Anemias
    6. Musculoskeletal system
      • Rickets, osteomalacia
      • Osteoporosis, fractures, myopathy
    7. Mitotic diseases
      • Ovarian cancer
      • Colon cancer
      • Prostate cancer
      • Pancreatic cancer8
    8. CNS disorders
      • Stroke
      • Headache
      • Psychiatric disorders
      • Depression, mood swings
    9. Gynecological disorders
      • Dysmenorrhea
      • Gestational diabetes mellitus.
 
Hypervitaminosis D
  • ▸ It leads to hypercalcemia. Patient presents with constipation, nausea, vomiting, and sleepiness. There is some disorder of renal function. Due to hypercalcemia, metastatic calcification is seen in different organs and tissues like kidneys, lungs, soft tissue, arteries. To avoid hypervitaminosis, serum calcium should be monitored when patient is taking high dose of vitamin D. If serum calcium is >10.5 mg, vitamin D should be stopped.
 
A Case of Rickets
  1. Clinical features
    • ▸ Occurs between 1–2 years
    • ▸ Milestones of child except speech are delayed
    • ▸ Child is irritable and has prominent abdomen (pot belly)
    • ▸ Child under first year has abnormal softening of skull in the occipital region termed craniotabes
    • ▸ In children 1 year and above have frontal and parietal bossing resembling ‘hot cross bun’ appearance
    • ▸ There is delayed closure of the anterior fontanels and head is large
    • ▸ Dentition is delayed and enamel is defective
    • ▸ Permanent teeth also show hypoplastic enamel with pitting of teeth with high risk of caries
    • ▸ Costochondral junctions are prominent, and there is beading giving an appearance of Rachitic rosary
    • Harrison's sulcus which is due to horizontal groove along the attachment of diaphragm due to contraction pulling the softened bony thoracic cage
    • ▸ There is projection of sternum causing “pigeon-shaped chest” (Fig. 1.5)
    • ▸ There may be kyphosis (Fig. 3.60), lordosis (Fig. 3.61) and scoliosis of spine
Extremities—Epiphyses of wrists and ankles are widened. Bending of long bones femur, tibia, fibula, leading to knock knees and coxa vera (Fig. 1.6).
  1. Examination of other systems
    • ▸ Frequent chest infections
    • ▸ Convulsions
      zoom view
      Fig. 1.5: Pigeon-shaped chest
      zoom view
      Fig. 1.6: Knock knees and coxa vera
      9
    • ▸ Tetany
    • ▸ Hepatosplenomegaly
Note: Rarely one may see vitamin D resistant rickets because of defective tubular clearance of phosphates.
  1. Investigations
    • ▸ Hypocalcemia
    • ▸ Hypophosphatemia
    • ▸ Elevated alkaline phosphatase
      1. X-ray findings showing irregular widening and irregular flaring of distal ends of long bones with cupping (Fig. 1.7).
      2. Decreased density and increased trabeculations of shafts with sub-periosteal osteoid formation giving double contour appearance to the shaft (Fig. 1.8)
  2. Treatment of rickets is similar to osteomalacia.
 
A Case of Osteomalacia
  1. Introduction
    The key defect is that bone matrix (osteoid) fails to get mineralized normally. In children before epiphyseal closure, it results in rickets.
      Patient presents with bone pains, weakness of proximal muscles, difficulty in climbing stairs, difficulty in getting up from sitting position, waddling gait. The bones and muscles are tender on pressure. There are pseudofractures and fracture of ribs and pelvis.
  2. Etiological factors
    1. Vitamin D deficiency
      • ▸ Lack of synthesis in the skin
      • ▸ Vegetarians as diet is deficient in vitamin D
      • ▸ Poor absorption
      • ▸ Hepatobiliary diseases
      • ▸ Pancreatic disease
      • ▸ Coeliac disease.
    2. When metabolism is defective
      • ▸ Chronic kidney failure
        zoom view
        Fig. 1.7: X-ray of rickets with bowing and wide epiphyseal plates
        zoom view
        Fig. 1.8: X-ray showing classical with double contour appearance long bones
      • ▸ Renal osteodystrophy
      • ▸ Patient taking drugs, e.g. sedatives, anticonvulsants.
    3. Hypophosphatemia with normal vitamin D
      1. Familial hypophosphatic rickets
      2. Renal tubular defects (inherited and acquired such has Fanconi syndrome), cadmium poisoning, multiple myeloma
    4. Osteomalacia occurring in a patient with normal vitamin D, calcium, phosphate
      1. Osteogenesis imperfecta
      2. Hypophosphatasia
  3. 10Presenting symptoms of osteomalacia
    • ▸ Patient presents with bone pains, weakness of proximal muscles, difficulty in climbing stairs, getting up from sitting position.
    • ▸ Severe bone and muscle pains and tenderness on pressure
    • ▸ Waddling gait due to muscle weakness
    • ▸ Tetany—Carpopedal spasm (Fig. 1.9) and twitchings of face
    • ▸ Patient can get spontaneous fractures of neck of femur, ribs and pelvis.
  4. Investigations
    • ▸ Serum calcium, phosphate are diminished
    • ▸ Rise in alkaline phosphatase.
  5. X-ray features
    There is loss of cortical bone.
      Pseudofracture or looser zone (Fig. 1.10) is seen in lateral border of scapula, pubic rami, neck of femur and ribs. Pseudofracture is apparently partial fracture without displacement (Fig. 1.11).
      Along the course of major arteries, linear zones of decalcification are seen (Milkman's line).
    Biconcave (codfish) vertebra develop due to microfracture, expansion of inter vertebral disk.
  6. Management
    • ▸ 1000–2000 IU of vitamin D along with 500–1000 mg of calcium daily should be sufficient for rickets and osteomalacia.
    • ▸ For rapid correction 60,000 IU weekly for 6 weeks followed by monthly 60,000 IU is adequate
    • ▸ Alternatively 40,000 IU IM injections once in fortnight such 4 injections.
    • ▸ For prevention of recurrence, oral daily intake of 400 IU of vitamin D are adequate.
    • ▸ Treatment of osteomalacia is similar to rickets, but if osteomalacia is due to renal disease, administer alfacalcidol 1 μg per day orally and adjust dose according to the plasma calcium.
      zoom view
      Fig. 1.9: Tetany—carpopedal spasm
      zoom view
      Fig. 1.10: X-ray pelvis showing osteomalacia with looser zones
      zoom view
      Fig. 1.11: X-ray pelvis showing osteomalacia with pseudofractures, triradiate pelvis and osteopenia
      11
    • ▸ To prevent recurrence, 400 IU of vitamin D daily is advised.
 
A Case of Osteoporosis
  1. Introduction
    Here there is loss of matrix as well as mineralization is not normal with the result that bone mass per unit volume is reduced.
  2. Etiological factors
    1. Involutional
      • ▸ Postmenopausal in women—Type I
      • ▸ Old age in both sexes—Type II.
    2. Endocrine disorders
      • ▸ Hyperparathyroidism
      • ▸ Hyperthyroidism
      • ▸ Hypogonadism
      • Cushing's syndrome
      • ▸ Diabetes mellitus.
    3. Connective tissue disorders, e.g. rheumatoid arthritis
    4. GI tract disorders—Malabsorption, anorexia
    5. Hematological—Multiple myeloma.
    6. Collagen vascular disorders
      zoom view
      Fig. 1.12: Ehlers–Danlos syndrome with hyperelasticity of skin
    7. Side effects of drugs
      • ▸ Steroids
      • ▸ Anti-seizure drugs
      • ▸ Lithium
      • ▸ Cyclosporin
      • ▸ Alcohol
      • ▸ Cytotoxic drugs.
    8. Cigarette smoking, tobacco chewing
    9. Renal disorders
      See Table 1.2 for DD of Type I and Type II osteoporosis.
  3. Presenting features
    1. Severe bone pains of acute onset in the dorsal, lumbar spine regions and often radiating to flanks and abdomen are observed.
    2. Depending upon the fracture of the bone, e.g. hip, femur, humerus, wrist, vertebrae, presentation and sequelae will vary accordingly.
    3. Important sequalae of collapse fracture of vertebral bodies is wedge-shaped deformity resulting in dorsal kyphosis and loss of height.
    4. Scoliosis is also seen commonly
    5. Loss of appetite and muscle weakness may be present.
  4. Investigations
    1. Biochemical
      • ▸ Serum calcium, phosphate and alkaline phosphatase are normal, however, after bone fracture, serum alkaline phosphatase is elevated
      • ▸ Urine hydroxyoproline is high.
        Table 1.2   Differential points of type I and type II osteoporosis
        Features
        Type I
        Postmenopausal
        Type II
        Senile
        Sex F:M
        6:1
        2:1
        Age
        45–65 years
        >65 years
        Bone
        Trabecular loss
        Trabecular and cortical loss
        Fractures
        Forearm, crush vertebra
        Hip joints, wedge vertebra
    2. 12Radiological
      • ▸ The mineral density is decreased in bones
      • ▸ Fracture usually occurs in lower dorsal and upper lumbar vertebrae. Also collapse of vertebra is common
      • ▸ In some patients you may find cod fish biconvex vertebra and compression of the vertebra (Fig. 1.13).
    3. Bone mass
      With the help of USG and quantitative CT, one can assess bone mass which is decreased.
  5. Differential diagnosis
    1. Osteomalacia
    2. Hyperparathyroidism
    3. Lymphoma
    4. Multiple myeloma
    5. Leukemia
      (See box 1.4 for WHO criteria)
  6. Management
    1. General
      1. Bed rest, locally heat (electric pad or hot water fomentation) and pain killers SOS
      2. Regular walking daily for ½–1 hours
      3. Prevent falls to avoid bone fractures.
    2. Drugs to prevent resorption
      1. Hormone therapy (estrogen plus medroxy progesterone (cyclic progestin) 5–10 mg daily for 10–14 days, progesterone should be added to prevent endometrial carcinoma
      2. Estrogen therapy is important in females with premature menopause
      3. Calcium—In women (postmenopausal) 1500 mg calcium daily and in premenopausal women 1000 mg daily
      4. Calcitonin—It increases vertebral bone density and decreases the risk of vertebral fracture, and it is given for 1–2 years. It is administered as 50 IU SC per day thrice weekly. Alternatively salmon calcitonin 200 units/day as nasal spray. The side effects are nausea, flushing.
        zoom view
        Fig. 1.13: Osteoporosis—cod fish biconvex vertebra and compression of vertebra
      5. Biophosphonates—They reduce osteoclast number and function
        1. Alendronate 5–10 mg daily
        2. Risedronate—5 mg daily
          Esophageal irritation is important side effect; hence, both should be taken with plenty of water or cold milk and patient should not lie down after taking the tablet.
    3. Bone-forming agents
      1. Anabolic steroids—Testosterone in osteoporotic men with gonadal deficiency
      2. Fluoride—75 mg daily.
    4. Vitamin D supplements and diuretics13
 
Senile Osteoporosis in Men
Due to longevity, prevalence of senile osteoporosis is increasing in men. As the bone in males is heavier than in females, and there is no loss of hormones as it occurs in women at menopause, osteoporosis in men manifests at late age.
 
Management
  • ▸ Calcium and vitamin D supplements
  • ▸ No smoking, no tobacco, alcohol in moderation if he has been taking
  • ▸ Regular exercise
  • ▸ In presence of hypogonadism, testosterone replacement.
  • ▸ For relief of pain—Ibuprofen (Cox-2 inhibitors) is helpful.
 
Bisphosphonates
  1. Mild cases (serum alkaline phosphatase (SAP) <2 times the normal
    1. Tiludronate 4000 mg/day for 3 months or Etidromate 400 mg/day for 6 weeks
  2. Moderate to severe cases
    Risedronate 30 mg/day for 6 months
    Note: Monitor response to therapy by estimating SAP every 3 months
      The therapy is repeated when SAP level rises by 25% above normal level.
  3. In very severe cases—Give palmidronate 60 mg IV in 500 mL of normal saline or dextrose over 4 hours as a single dose for rapid response. If the response is adequate, repeat the dose weekly for 1 month
    Calcitonin—It is considered when patients cannot tolerate biophosphates, injection salmon calcitonin 100 u/day SC followed by 40 units thrice weekly for maintenance. It causes suppression of SAP. In mild cases use calcitonin 200 u/day as nasal spray
 
A Case of Riboflavin Deficiency (Vitamin B2)
  • ▸ It takes part in various oxidation-reduction reactions as it is type of coenzyme, 1–2 mg is the daily requirement.
  • ▸ It is present in dairy products (milk, butter, cheese), liver, kidney, meat (for non vegetarians) and whole cereals, legumes and green leafy vegetables (for vegetarians). Deficiency occurs in persons with malnutrition and malabsorption.
  • ▸ Patient having deficiency presents with glossitis, red tongue, angular stomatitis, cheilosis, sore-throat, seborrheic dermatitis.
    Treatment—Tablet riboflavin (5 mg) TDS.
 
Nicotinic Acid and Nicotinamide (NIACIN)
  • ▸ 15–20 mg—daily is the requirement
  • ▸ It is present in pulses, cereals, nuts, fish, meat, liver, kidney and coffee.
  • ▸ Very little is synthesized from essential amino acid tryptophan (1 mg of nicotinamide is synthesized from 600 mg of tryptophan)
  • ▸ Deficiency occurs in alcoholics, in persons eating plenty of maize or jowar and in persons having chronic small bowel disorders.
 
A Case of Pellagra
  1. Clinical features
    The typical features are dermatitis, diarrhea and dementia. It is due to nicotinamide deficiency. It is a chronic wasting disease.
    1. Dermatitis—Erythema, cracking, vesiculation, crusting and ulceration. Dermatitis is symmetrical, bilateral with hyperpigmentation, desquamation, keratosis and occurring usually on exposed parts of the body to sunlight and this is due to photosensitivity. Skin changes occur over neck collar. Casal's collar, upper part of front of the chest. One should look for pellagra dysebacea on face (Fig. 1.14), pellagra scaly erythematous patches on hands (Fig. 1.15), scaly erythematous patches on dorsal surface of feet (Fig. 1.16) and scaly patches on pressure areas (Fig. 1.17)14
      zoom view
      Fig. 1.14: Pellagra dysebacea on face
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      Fig. 1.15: Pellagra scaly erythematous patches on on both hands
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      Fig. 1.16: Pellagra Scaly erythematous patches on dorsal surface of feet
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      Fig. 1.17: Pellagra scaly patches on pressure areas
    2. Diarrhea—There is involvement of mucosa of oral cavity, tongue, stomatitis, achlorhydria, gastritis, enteritis.
    3. Dementia—Dementia, apathy, insomnia, disorientation, hallucination, memory loss and organic psychosis.
    4. In addition, patient may present with palpitation, cyanosis, heart enlargement, liver enlargement and peripheral edema.
  2. Treatment
    IM/IV nicotinamide 100 mg daily for 14 days followed by oral niacin 10 mg daily.
 
Ascorbic Acid
  1. Introduction
    • ▸ Human beings cannot synthesise ascorbic acid from glucose in contrast majority animals can
    • Only dehydroascorbic acid and L-ascorbic acid have antiscorbutic activity. The ascorbic acid and other analogues have no antiscorbutic activity.
    • ▸ It has an antioxidant action like other vitamins E and A.
    • ▸ 50–100 mg is daily requirement15
    • ▸ It is available in guava, Indian gooseberry, fruits, amla, green leafy vegetables, potatoes, meat, kidney, liver and fish.
    • ▸ Its deficiency results from malnutrition, famine, poverty and situations of increased demand like pregnancy, lactation and decreased absorption, e.g. malabsorption syndrome. It is common in single elderly person as majority of them cannot look after their nutrition.
    • ▸ Total body content of vitamin C is 1.5 g.
 
A Case of Scurvy
Scurvy is the result of vitamin C deficiency. It presents as follows:
  1. Infancy and childhood
    • ▸ Gingivitis, swollen spongy gums, easy bleeding from papillae inbetween the teeth. Teeth may be lost in severe cases
    • ▸ Painful swelling over long bones due to subperiosteal hemorrhages
    • ▸ Anorexia, lethargy, lassitude
    • ▸ Separation of epiphyses is seen commonly
    • Scorbutic rosary is the result of inward sinking of sternum with prominent elevation of costochondral junctions.
    • ▸ Ecchymosis and purpura (see Figs 10.19 and 10.20) are seen in the skin
    • ▸ Joints get swollen and painful due to bleeding in the joints.
    • ▸ Other common sites of hemorrhages are subarachnoid, intracerebral and retrobulbar region.
    • ▸ Anemia (normocytic normochronic) is commonly seen.
  2. Adults
    • ▸ Swollen, spongy gums with bleeding, secondary infection and loosening of teeth
      zoom view
      Fig. 1.18: X-ray showing haematoma due to bleeding in scurvy
    • ▸ Hemorrhage into joints, nails and muscles of limbs (Fig. 1.18)
    • ▸ In skin perifollicular hyperkeratosis with hemorrhages, petechial hemorrhages in the viscera.
    • ▸ Wound healing is delayed
    • ▸ Anemia is common
    • ▸ Sometimes one may see icterus, edema, hypotension, fever and convulsions.
  1. Investigations
    • Capillary fragility is abnormal
    • ▸ Low ascorbic acid in plasma and platelets is noted
    • ▸ Serum bilirubin may be elevated.
    • ▸ X-ray of bones typical changes. X-ray changes are dense line of frankle and lateral spur of phelkan (Fig. 1.19).
  2. Treatment
    • ▸ Scurvy can be fatal if not treated
    • ▸ Give 100 mg of vitamin C tds till 4 g has been administered and later followed by 100 mg daily.
 
VITAMINS
Vitamins are organic compounds in food. These are not synthesized in body and are required in small amounts. They are (1) Water soluble (B and C), these are not stored in body 16and are excreted in urine and (2) Fat-soluble (A,D,E and K), these are stored in the liver and deficiency occurs when the stores are depleted. Excess intake of fat-soluble vitamins cause hypervitaminosis.
See Table 1.3 for other vitamins.
 
MINERALS
These are inorganic nutrients. Fourteen minerals are important and essential for life. They are sodium, potassium, calcium, magnesium, iodine, iron, copper, cobalt, zinc, sulphur phosphorous, selenium, chromium and fluorine.
 
Sodium
  • ▸ It is an important electrolyte in extracellular fluid along with chlorides, it determines osmolality of extracellular fluid.
    zoom view
    Fig. 1.19: Scurvy X-ray bone showing dense line of Frankel and lateral spur of phelkan
    Table 1.3   List of vitamins along with their daily intake and disorders due to their deficiency
    Vitamin
    Daily intake
    Disorders due to deficiency
    Vitamin A (retinol)
    5000 IU
    Night blindness, Bilot's spots, (Fig. 1.20) xerophthalmia, hyperkeratosis, keratomalacia, immune compromised
    Thiamine (vitamin B1)
    1–2 mg
    Beriberi, peripheral neuropathy, ophthalmoplegia, Werneck's encephalopathy, cardiac enlargement with or without CCF
    Riboflavin (vitamin B2)
    1–2 mg
    Angular stomatitis, magenta tongue cheilosis, seborrheic dermatitis
    Niacin (vitamin B3)
    15–20 mg
    Pellagra, sore tongue
    Pantothenic acid (vitamin B5)
    5–10 mg
    Fatigue, paraesthesia, tenderness of feet and soles
    Pyridoxine (B6)
    10–12 mg
    Cheilosis, glossitis, peripheral neuropathy, fits, pyridoxine responsive hypochromic anemia
    Biotin (vitamin B7)
    100–200 mg
    Alopecia, seborrheic dermatitis, fits, myalgia, hyperesthesia
    Folic acid (vitamin B9)
    400 mg
    Megaloblastic anemia, diarrhea, glossitis
    Cobalamin (Vitamin B12)
    5 mg
    Megaloblastic anaemia, ataxia, subacute combined degeneration, paraesthesia, dementia, diarrhea
    Ascorbic acid (vitamin C)
    100 mg
    Spongy bleeding gums, petechiae, purpura, scurvy, ecchymosis, bleeding in joints, poor wound healing, depression
    Ergocalciferal (vitamin D)
    400 IU
    Rickets, osteomalacia, rachitic rosary, bone pains, bowed legs, tetany, muscle weakness
    Alpha tocopherol (vitamin E)
    10–15 µg
    Neuropathy, retinopathy, hemolysis, abnormal clotting, spino-cerebellar ataxia.
    Phyloquinone (vitamin K)
    80 µg
    Bleeding, easy bruising
    17
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    Fig. 1.20: Bilot's spots (vitamin A deficiency)
  • ▸ 1–2 g is the daily requirement but Indians take 10–12 g daily.
 
A Case of Hyponatremia (Serum Sodium levels <130 mEq/L)
  1. Causes
    • ▸ Vomiting, diarrhea
    • ▸ Burns, peritonitis
    • ▸ Renal—Diuretics, salt loosing nephropathy, renal tubular acidosis
    • ▸ Cirrhosis liver, CCF
    • ▸ Dilutional hyponatremia
    • ▸ Syndrome of inappropriate ADH secretion (SIADH)
    • ▸ Addison's disease.
  2. Clinical presentation
    • ▸ Lethargy, confusion, cramps, dehydration
    • ▸ If sodium level is <120 mEq/L, patient becomes drowsy and may suffer from fits, hemiparesis, coma.
  3. Treatment
    • ▸ Dilutional hyponatremia—Restrict water
    • ▸ Normal saline IV in hypovolemic patients
    • ▸ SIADH—Restrict water and give demeclocycline
    • ▸ If serum sodium level <120 mEq/L, give hypertonic saline.
 
A Case of Hypernatremia (Serum Sodium >150 mEq/L)
  1. Causes
    • ▸ Hemoconcentration due to excessive fluid loss—Vomiting, diarrhea, diuretics
    • ▸ Primary aldosteronism
    • ▸ Congenital adrenal hyperplasia
    • ▸ Hypertonic saline infusion
    • ▸ Hypertonic hemodialysis
    • ▸ Diabetes inspidus.
  2. Clinical presentation
    • ▸ Twichings, seizures, confusion, coma
    • ▸ Rarely when level goes >160 mEq/L, there can be rupture of brain blood vessels causing hemorrhage and neurological deficit.
  3. Treatment
    • ▸ Hypervolemic hypernatremia—Furosemide, hypotonic fluids
    • ▸ Hypovolemic hypernatremia—IV normal saline followed by 0.45% saline
    • ▸ Central diabetes insipidus—Give desmopressin.
 
Potassium
  • ▸ Mainly it is present in intracellular compartment. Acidosis shifts potassium out of cells and alkalosis shifts potassium into the cells. It maintains intracellular osmotic pressure.
  • ▸ Normal serum potassium—3.5–4.5 mEq/L
  • ▸ It is available in fresh as well as dry fruits (almonds, dates), tender coconut water and potatoes.
Daily requirement—3–4 g/day.
 
A Case of Hyperkalemia (serum K >5.5 mEq/L)
  1. Causes
    • ▸ Renal failure (acute and chronic)
    • ▸ Hypoaldosteronism18
    • ▸ Medications—ACE-inhibitors, potassium sparing diuretics
    • ▸ Addison's disease
    • ▸ Potassium shift from tissues, e.g. acidosis, crush injury, internal hemorrhage.
  2. Clinical presentation
    • ▸ Patient complains of papilations as he is prone to get arrhythmias and conduction disturbances. ECG is typical and diagnostic of hyperkalemia
    • ▸ ECG – Tall T waves in precordial leads, wide QRS and absent P waves (Fig. 1.21).
  3. Treatment
    • ▸ Insulin glucose drip is given to shift potassium into the cells
    • ▸ Furosemide—40 mg IV, it can be repeated
    • ▸ Calcium gluconate 10% 10 mL IV stat, it can be repeated
    • ▸ To correct acidosis, administer sodium bicarbonate
    • ▸ If all above fail, hemodialysis.
 
A Case of Hypokalemia (serum K <3.5 mEq/L)
  1. Causes
    • ▸ Primary aldosteronism
    • ▸ Vomiting, diarrhea
    • ▸ Diuretics, renal tubular acidosis, metabolic alkalosis
    • ▸ Cushing's syndrome
  2. Clinical presentation
    • ▸ Muscular weakness, polyuria, ileus are the common features
    • ▸ In severe cases, hypokalemic paralysis and death has been documented
    • ▸ ECG—prominent U waves, prolonged QT interval, flat or inverted T waves, extrasystoles (Fig. 1.22).
  3. Treatment
    • ▸ Potassium chloride orally, potassium rich fruits (coconut water, fruit juices).
    • ▸ In severe cases IV potassium chloride 20–40 mEq/hour/IV, monitor potassium while on drip.
 
Calcium
  • ▸ Normal levels—9–11 mg/dL
  • ▸ Daily requirement is 500 mg (adults), Pregnant and lactating mother—1200 mg
  • ▸ Post menopausal women—1000–1500 mg
  • ▸ Diet rich in calcium—milk, yoghurt, cheese. eggs, fish, almonds, peanuts, walnuts and other dry fruits.
    zoom view
    Fig. 1.21: ECG of a patient with hyperkalemia
    19
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    Fig. 1.22: ECG of a patient with hypokalemia
  • ▸ Vitamin D and proteins in diet facilitate absorption of calcium
  • ▸ Calcium metabolism is closely connected to vitamin D, parathyroid hormone and calcitonin.
The electrocardiogram helps in differentiating case of hypercalcemia (Fig. 12.58) from cases of hypocalcemia (12.59).
 
A Case of Magnesium Deficiency
  1. Etiological causes
    • ▸ Severe diarrhea
    • ▸ Excess alcohol intake
    • ▸ Diabetic ketoacidosis
    • ▸ Patient on total parentral nutrition (weekly magnesium levels should be monitored)
    • ▸ Associated with hypokalemia (when diuretics are given)
    • ▸ Magnesium deficiency is sometime accompanied with hypocalcemia.
Total body magnesium is 20 g and 75% of magnesium is complexed with calcium in bone. Daily requirement 300 mg/day.
Sources in food: Cereals, leafy vegetables, beans and fish
It is activator of several enzymes
  1. Salient clinical features
    • ▸ Paresthesia, tetany (carpopedal spasms), fits, arrhythmias particularly it can worsen digitalis toxicity.
    • ▸ Magnesium deficiency causes decreased PTH with decrease in parathyroid action.
    • ▸ Higher magnesium levels cause kidney damage
    • ▸ Its deficiency causes neuromuscular irritability and tremors.
  2. Management
    Administer magnesium salts.
 
A Case of Fluorine Deficiency
  • ▸ The safe limit of fluorine is 1 part per million in water (1 PPM). Its main role is prevention of dental caries
  • ▸ Soft water has no fluoride, however hard water contains fluoride and sometimes is to the toxic level (10 PPM)
  • ▸ Sea fish and tea in large quantity gives fluoride level greater than 2 PPM and that causes loss of appetite and weight
  • ▸ More than 5 PPM fluoride level causes osteosclerosis, calcification of ligament and increase in bone density
  • ▸ In endemic areas, fluorosis is seen20
Table 1.4   Important trace minerals, their daily intake, deficiency disorders and evaluation
Nutrient
Intake/day
Deficiency-induced disorders
Evaluation
Iron
10–15 mg
Microcytic hypochromic anemia, hypothyroidism.
Impaired congenital development. Premature labor, increased perinatal and maternal mortality
Serum iron, total iron binding capacity, saturation index serum ferritin
Iodine
150 µg
Goitre, hypothyroidism
TSH, urine iodine estimation
Zinc
15 mg
Impaired taste and smell, alopecia, dermatitis (acro-orificial lesions), hypogonadism, delayed sexual maturation, growth retardation, dementia
Plasma zinc estimation
Copper
2 mg
Anaemia, neutropenia, defective keratinization, osteoporosis and pigmentation of hair
Serum copper, plasma ceruloplasmin estimation
Chromium
20–300 µg
Peripheral neuropathy, glucose intolerance, encephalopathy
Serum chromium estimation
Selenium
100–200 µg
Muscle weakness, cardiomyopathy
Serum selenium, blood glutathione peroxidase activity Perioxidase
Manganese
1.5 mg
Dementia, impaired growth and skeletal development, dermatitis, dementia, hypercholesterolaemia
Serum manganese estimation
  • ▸ Preventive measures for dental caries, if fluorine level in public water is low, one should add fluoride 1PPM at the sources of public water.
For trace minerals, see Table 1.4.
 
OBESITY
  1. Ideal body weight is calculated—22.5 × (height in meters)2
  2. Body mass index: BMI = Weight in kg/height in meters2
    BMI
    in men
    20–25
    in women
    18–23
    1. Overweight—BMI 25–30, weight more than 20% of IBW
    2. Underweight—In men BMI <18, weight less than 20% of IBW
      In women BMI <16, weight less than 20% of IBW
    3. Obesity BMI >30
  3. Skin fold thickness—It should be measured at biceps, triceps, subscapular and suprailiac regions. Normal triceps skin fold thickness in men is 12.5 mm, in women is 16.5 mm
  4. Broca's index—It gives rough estimate of body weight in an adult
    Height in inches = weight in kg
    Height in cm—100 = desired body weight in kg
  5. Waist circumference
    Waist circumference—Measured at narrowest circumference between iliac crest and rib cage
    Hip—It is measured at the maximal circumference of the hip over the buttocks
  6. Waist Hip Ratio
    a.
    Pear shape obesity
    0.8 or less
    Desired
    b.
    Apple shape obesity
    0.9 or more
    Enhanced morbidity
21
 
Obesity is Associated with Insulin Resistance, DM, CAD and Dyslipidemia
Waist circumference alone is enough to assess risk in obesity
Waist circumference more than 37 inches (moderate risk) >40 inches (high risk)—Men
Waist circumference more than 32 inches (moderate risk) >35 inches (high risk)—Women.
 
Types of Obesity
  1. Generalized—Deposition of fat uniformly distributed all over body
  2. Android—Predominant fat over waist (Fig. 1.24)
  3. Gynoid—Predominant deposition over buttocks and thighs (Fig. 1.23)
  4. Truncal (superior) type—Excess fat over face, neck and upper part of trunk, thin legs and knees (Cushing's syndrome)
  5. Visceral—Predominant deposition over abdomen apple shaped obesity (Fig. 1.24).
 
Causes
  1. Excess caloric intake
  2. Decreased energy expenditure in sedentary persons
  3. Behavioral changes
    • ▸ Frequent snacks in between meals
    • ▸ Excess intake of high calorie foods like sweets, icecream soft drinks
    • ▸ Excess alcohol
    • ▸ Smoking—energy expenditure is more in smokers and appetite is less. Most smokers are thin. Some put on weight on giving up smoking.
  4. Elderly persons—energy expenditure is less
  5. Familial and genetic factors
    • Lipoprotein lipase—It is synthesized in adipocytes and causes obesity
    • Leptin—This adipokine is produced in adipose tissue. Leptin levels are increased in obesity.
 
Secondary Obesity Due to Endocrine Disorders
  1. Hypothalamic disorders
    • Frohlich's syndrome
    • Laurence-Moon-Biedl syndrome—Obesity, retinitis pigmentosa (Fig. 1.25), hypogonadism
  2. Hypothyroidism—Obesity with decreased basal metabolic rate (BMR).
    zoom view
    Fig. 1.23: Types of obesity
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    Fig. 1.24: A case of apple-shaped (visceral) obesity
    22
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    Fig. 1.25: Retinitis pigmentosa
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    Fig. 1.26: Moon-shaped face, buffaloe hump (truncal obesity) in Cushing's syndrome
  3. Cushing's syndrome—Moon shaped face, buffaloes hump (Fig. 1.26).
 
Drugs Causing Obesity
Corticosteroids, sulfonylureas, contraceptives, tricyclic antidepressants.
 
Complications (Fig. 1.27)
  • ▸ Hypertension
  • ▸ Type 2 DM
  • ▸ Insulin resistance
  • ▸ Atherosclerosis
  • ▸ Coronary artery disease
    zoom view
    Fig. 1.27: Complications of obesity
    23
  • ▸ Cerebrovascular disease
  • ▸ Varicose veins (Fig. 1.28)
  • ▸ Osteoarthritis
  • ▸ Hiatus hernia
  • ▸ Sleep apnea syndrome
  • Pickwickian syndrome manifestates with sleep apnea, hypoxia, hypercapnea, cynanosis, polycythemia, pulmonary hypertension, chronic cor pulmonale
  • ▸ Infertility
  • ▸ Cancer prone—In males prostate, colon, gallbladder; in postmenopausal women, cancer breast, ovary, endometriosis
  • ▸ Depression
  • ▸ Fungal infection of skin.
zoom view
Fig. 1.28: An obese patient with varicose veins
 
Prognosis
Mortality is high (25%) if patient is 25% overweight.
 
Management
  1. Diet—Low fat, low calories according to the severity of the obesity. The aim of the diet advice should be to reduce 1 kg in 7–10 days according to the severity; 500 calories reduction in diet reduces 1 kg in 1 week.
  2. Exercise—Walking, cycling, swimming, racket games
  3. Behavioral and eating habits modification
  4. Drugs—Orlistat 60–120 mg 2–3 times a day.
 
Surgical
Bariatric surgery—gastric banding and vertical (sleeve) gastrectomy.
Roux-en-Y gastric bypass. It takes care of restriction and malabsorption and is considered by many as the gold standard.