SECTION SECTION SECTION SECTION SECTION 1 1 1 1 1 CHAPTER 1 Introduction to Clinical Medicine Patient Identification It is important to make proper records so that the patient can be identified and recalled at a future date for follow-up. One of the serious handicaps in day-to-day practice is the want of a proper address and other details of identification of the patients so that many of them may be lost to follow up. Moreover many patients change their addresses frequently so that the same person may be registered under different names in the same institution or different institutions. It is therefore desirable to give the following details. Name______________ Age______Sex_______ Residential address (present)______________ Permanent address______________________ In case of those who do not have their own permanent houses, details of residence with reference to a school, post office, temple, or any other landmark may help to trace them out in future. While recording occupation, state the actual type of work, e.g. executive, technical person, manual labourer, etc. Since many diseases show close relationship to occupation, it is essential to give a brief description of the work done by the patient. Agricultural workers are more prone to develop helminthiasis, leptospirosis, and poisoning by pesticides. Workers in the carding and jinning areas of cotton mills are more exposed to cotton dust which provokes asthma. It is desirable to include other details such as ethnic group and religion. It should be noted that in India the same ethnic groups profess different religions and therefore classification based on religious faith may not reflect ethnic differences. HISTORY The doctor starts the first contact with patient during history-taking (interrogation). This is the first step which paves the way for a firm doctor- patient relationship, which is essential for mutual confidence and trust. Many parts of the history of the illness pertain to very close personal matters of the patient which he may not reveal to anyone other than a doctor. Therefore strict privacy has to be maintained during interrogation.

SECTION SECTION SECTION SECTION SECTION 2 2 2 2 2 Vital Signs Before proceeding for systemic general exami- nation, note down the vital signs. These include the pulse, respiration, blood pressure and the level of consciousness. The radial pulse should be examined and its rate, rhythm and character noted. Normal pulse rate is 80 (60-100) per minute. Tachycardia (rate above 100/mt) may occur due to anxiety, exertion, fevers, diseases such as hyperthyroidism and the specific tachyarrhythmias. In shock the pulse is rapid and thready, i.e. low volume and soft. Bradycardia (rate below 60/minute) is common in those who do hard physical labour and in trained athletes. Rates below 40/minute should raise the suspicion of heart block, especially so if there is no increase on exertion. Respiration Normal respiratory rate is 14-18/minute. Rise in respiratory rate occurs in respiratory diseases like pneumonia, pleural effusion or pulmonary embolism. In cardiac failure the respiratory rate is considerably increased. In shock, the patient has severe tachypnoea with signs of respiratory distress (air hunger). Respiratory rate is considerably diminished in narcotic poisoning, raised intra - cranial tension and in deep coma. Blood Pressure Estimation of the blood pressure gives an indication of the overall cardiovascular status since it depends upon cardiac output and peri- pheral resistance. Fall in either leads to drop in blood pressure. Normal blood pressure in adults is 100-120 mm Hg systolic and 70-84 mm Hg diastolic. Normal blood pressure (BP) differs at different ages and during pregnancy. Increase in blood pressure above normal is termed hyper- tension. Hypertension is very prevalent in many population groups in India (Table 2.1). In shock the blood pressure drops and reaches values below 80/40 in adults. Elevation of blood pressure is seen in systemic hypertension, increased intracranial tension, and several other diseases. Level of Consciousness The level of consciousness may change gradually in many chronic diseases such as dementia, CHAPTER 2 Physical Examination Vital signs-13, General examination-14, Anthropometry-16, Congenital abnormalities, Nutrition-17, Temperature, Fever-18, Pallor-22, Jaundice, Cyanosis- 23, Clubbing of fingers, Nail changes-24, Skin, Hair Distribution, Oedema-25, Lymph nodes-29, AppendixPossible clues from general examination-35 .

CHAPTER 3 Investigations in Prolonged Fever Blood Counts It comprises of h aemoglobin estimation, total leucocyte count and differential leucocyte count. Examination of blood film for parasites such as malarial parasite, microfilaria, borrelia, Leish- mania donovani, trypanosomes and bartonella. Examine the erythrocytes for evidence of haemolysis. Exclude leukaemias by a proper differential count and also examination of a buffy coat smear. If filariasis is suspected, examine a wet blood film taken at or after midnight when the patient is sleeping. Active microfilaria can be recognised easily. Examination of stained blood film helps to identify the species of filaria. Urine Examination Macroscopic, microscopic and chemical exami- nation. Highly acidic turbid urine with a fishy smell suggests the presence of urinary infection. Presence of pus cells in uncentrifuged urine is highly suggestive of inflammation of the urinary tract. Presence of bacteria (seen by a hanging drop of Gram staining) in a clean catch fresh urine strongly suggests bacteriuria. Presence of bile salts and pigments should suggest the diagnosis of hepatitis or obstructive lesions of the biliary tract. Examination of Faeces Presence of diarrhoea with blood an d mucus suggests dysentery. Diarrhoea with greenish stools is a common accompaniment of enteric fevers. Tuberculous enteritis, fulminant ulcera- tive collitis, and infective type of food poisonings may give rise to diarrhoea often with varying quantities of blood and mucus. Acquired immu- nodeficiency syndrome (AIDS) may present with fever and diarrhoea in many cases. Parasites such as Entamoeba histolytica, Strongyloides stercoralis and Giardia lamblia may cause fever under exceptional circumstances. Presence of occult blood suggests a bleeding focus in the upper gastrointestinal tract such as peptic ulcer, carci- noma or hookworm infestation. Radiological Examination Skiagram of the chest reveals pulmonary and pleural lesions, mediastinal masses, cardiac enlargement, pulmonary oedema and pericardial effusion. Upward enlargement of the right dome of the diaphragm may suggest liver abscess. Depending upon the symptoms, other parts should be imaged, e.g. paranasal sinuses in case of headache and spine if there are pain and tenderness over the vertebrae. Ultrasonography This has emerged as a very versatile, safe and cheap imaging modality to detect enlargement of organs, presence of fluid in cavities, cardiac lesions such as valvular and congenital abnorma- lities and vegetations; abscesses, abnormalities of the hepatobiliary system and urinary system Blood counts, Urine examination, Examination of faeces, Radiological exami- nation, Ultrasonography-36, Microbiological investigation, Biopsy proce- dures-37, Computed tomography (CT) scanning, Magnetic resonance imaging (MRI)-38 .

GENERAL CONSIDERA TIONS Alimentary system starts at the mouth and ends at the anus. In the baby the temporary teeth start appearing by the seventh month. With ado- lescence the deciduous teeth fall off and permanent teeth are in position, the final ones to appear are the last molars (wisdom teeth) which may erupt as late as 30 years or in some they may not erupt at all. For further details see Section 12 on Paediatrics. Number of teeth in each Jaw Temporary Permanent teeth (deciduous) teeth Incisors 4 4 Canines 2 2 Premolars - 4 Molars 4 6 Total 1 0 1 6 In health the teeth do not fall off even upto the eighth decade. Premature loss of teeth is often due to peridontal disease. Mucous membrane of the mouth and tongue is kept moist by saliva which is produced by the three pairs of salivary glandsparotid, submandibular and sublingual CHAPTER 4 Alimentary System Alimentary System Alimentary System Alimentary System Alimentary System and numerous mucous glands embedded in the oral, lingual and pharyngeal mucosa. Swallowing is initiated as a voluntary pro- cess, by concerted muscle action involving the lips, cheeks, tongue and pharyngeal muscles. Once the food passes down the oropharynx swallowing becomes a reflex act. The oesopha- gus which is 25 cm long lies deep inside the thorax and its main function is to transmit food to the stomach by active peristalsis. Gastric contents are prevented from regurgitating into the oesophagus by the intrinsic sphincter at the lower end of the oesophagus, anatomical configuration of the gastro-oesophageal junction and muscular action of diaphragm. Abnormalities at this region lead to regurgitation of acid contents into the oesophagus and ulceration. Difficulty to swallowing results from intrinsic lesions of the oesophagus, incoordination or weakness of muscle action and compression from outside. Deglutition is controlled by the swallowing center located in the medulla and pons. It has three functional components-an efferent receptor system, a coordinating region and an efferent system of motor neurons. The efferents carry sensory information from the oropharynx.

CHAPTER 5 Symptoms in Alimentary Diseases SYMPT OMS RELA TED T O MOUTH Normal flow of saliva is required to moisten the lips, tongue and cheeks, for achieving smooth movements during talking, and eating solid food. Saliva also helps to cleanse these parts and prevent infection. Dryness of the Mouth (Xerostomia) It occurs in conditions such as dehydration and diabetes mellitus where the body water is exces- sively lost. Lesions affecting the salivary glands which lead to diminution of secretion such as Sjögrens syndrome and post irradiation fibrosis result in xerostomia. Anticholinergic drugs such as atropine inhibit salivary secretion. Dryness of the mouth is a common symptom in those who sleep with their mouths open. Dryness of the mouth predisposes to infection of the gums and salivary glands. Stomatitis (inflammation of the mouth) and suppurative parotitis are common complications occurring in prolonged fevers such as typhoid, if proper mouth care is not done. This is seen only rarely at present. Ptyalism This is excessive flow of saliva. Normally saliva is just enough to moisten the oral mucosa and this is swallowed automatically. During chewing, salivary secretion is stimulated depending on the type of food eaten. Even absolutely dry food materials can be comfortably chewed and swallowed. In health there is no need to spit out saliva. Frequent spitting may develop as a compulsive habit in many. Ptyalism may occur in painful and inflammatory lesions of the mouth and presence of foreign bodies such as dentures or dental fillings. Reflex salivation may occur preceding nausea and vomiting. Peptic ulcer, parasympathomimetic drugs such as carbachol, and prostigmine excite salivation. Neurological disorders which interfere with swallowing such as motor neuron disease and lower cranial nerve palsies result in ptyalism. Conditions associated with dysphagia such as carcinoma of the oesophagus lead to retention of saliva in the mouth. Parkinsonism which is associated with parasympathetic overactivity is a frequent cause of excessive salivation. Acute infections like rabies which affect the brainstem are characterised by excessive salivation in their early stages. Halitosis This is bad odour of the breath. In healthy indivi- duals with proper hygiene and mouth care the breath is not foul. Halitosis may result from oropharyngeal lesions, infection of the paranasal sinuses or suppurative lesions in the lungs. Oropharyngeal pyorrhoea alveolaris, lesions ulcerative gingivitis, carcinoma of the oral cavity. Lesions of Sinusitis. paranasal sinuses Suppurative bronchiectasis, lung lesions i n the lung abscess, gangrene of the lung.

CHAPTER 6 Physical Examination of the Alimentary System Before proceeding to examine the alimentary system the following general points should be carefully looked for. General Examination Nutrition Proper nutrition depends on normal function of the alimentary tract. Diseases which lead to vomiting, diarrhoea or dysphagia lead to starvation and severe malnutrition. Bleeding from benign and malignant ulcers lead to iron deficiency anaemia, e.g. carcinoma stomach, ulcerative colitis, haemorrhoids and others. On the other hand several nutritional disorders such as kwashiorkor and pellagra lead to diarrhoea. Oedema Malabsorption states lead to nutri tional oedema. Cirrhosis liver may give rise to ascites and dependent oedema. In chronic congestive heart failure, hepatic enlargement, cardiac cirrhosis and ascites may develop. Pallor Anaemias resulting either from chronic blood loss or malabsorption of haematinic factors are frequent accompaniments of chronic gastro- intestinal disorders. Cyanosis Cirrhosis liver with portal hypertension may rarely give rise to central cyanosis. Clubbing of fingers This may be seen in cirrhosis, hepatic abscesses, hepatic carcinoma, chronic ulcerative colitis and Crohns disease. Jaundice It is common in hepatobiliary disease and it may be intermittent or progressive. Commonly it is hepatocellular or obstructive in type. (See also chapter - 9) Lymphadenopathy Conditions associated with generalised lymphadenopathy such as tuber- culosis and lymphomas may produce lesions in the digestive organs. More often malignancies of the lower end of the oesophagus and stomach may lead to secondary metastasis in the left supraclavicular glands ( Virchows glands ), and these may give clue to deep seated malignancy in the abdomen. Enlargement of abdominal and pelvic lymph nodes may present as masses in the abdomen. Fever Conditions like hepatitis, hepatic amoe- biasis, peritonitis, appendicitis, abdominal tuberculosis and urinary tract infection may be accompanied by fever, which may be mild or severe.

CHAPTER 7 Investigations in Alimentary Diseases Examination of faeces-77, Vomitus, Ascitic fluid examination-80, Nasogastric intubation, Gastric acid study, Radiology-82, Ultrasound scan of abdomen-86, Endoscopy-88, CT scan-90, MRI scan, Laparoscopy, H.pylori infection, Radioisotope studies-91, Tumour markers, FNAC, Investigations in pancreatic diseases-92, Malabsorption states-93 Examination of Faeces After completing the physical examination of the abdomen, faeces has to be examined in all cases preferably by the doctor himself. This helps to confirm the diagnosis in many cases e.g. haemorrhoids, dysenteries, malabsorption states, obstructive jaundice and melena. The patient is asked to collect a sample of faeces. The whole stool should be collected to detect abnormalities in quantity and other characteristics, or abnormal shape of the faecal mass as in carcinoma rectum or stricture. For microscopy and chemical examination about 1 g of faeces is collected in a suitable container. If the patient is not able to collect faeces due to constipation a laxative is given the previous night. In case of emergency, a sample can be collected by digital examination of the rectum. Macroscopy The whole stool should be examined for the amount, consistency, colour, odour, blood, mucus, helminths such as roundworms, thread worms, segments of tape worms, and flukes and undi- gested particles. Large, losse, bulky, frothy and offensive stool may suggest malabsorption. Presence of excess fat in the faeces (steatorrhoea) makes it greasy. Blood and mucus are seen in dysenteries, ulcer- ative colitis and carcinoma of the rectum. Faeces are clay coloured in obstructive jaun- dice and dark in haemolytic jaundice. Silvery stools occur if there is a combination of obstruc- tive jaundice with upper gastrointestinal bleeding. In melena the faeces are tarry in colour and consistency due to the presence of partly digested blood. Fresh blood indicates bleeding from lower gastrointestinal tract. Medicinal iron can produce blacks stools but not tarry. This should not be mistaken for melena. Microscopical Examination A match head size of faeces is mixed thoroughly with a drop of normal saline on a glass slide to make a fine emulsion and a cover slip is applied. The slide is first scanned under the low power and then under the high power of the microscope. First observe for motile parasites, e.g. vegeta- tive forms of amoeba, Trichomonas hominis, Giardia lamblia, Balantidium coli and Strongyloides sterco- ralis . Pathogenic amoebae, particularly Entamoeba histolytica should be identified from other non- pathogenic amoebae like Entamoeba coli . Points to distinguish E. histolytica from E. coli in the wet preparation.

Hepatobiliary System Hepatobiliary System Hepatobiliary System Hepatobiliary System Hepatobiliary System CHAPTER 8 General Considerations General considerations-95, Pattern of diseases affecting the liver and biliary system in India-97 INTRODUCTION Liver occupies the right hypochondrium and epi- gastrium and it weighs around 1.5 kg in adults. It is in close apposition with the diaphragm above. It is held in place by loose folds of peritoneum. The intra-abdominal pressure prevents it from dropping. Normally the lower border of the liver is just palpable as a soft edge below the right costal margin, on inspiration. In the epigastrium it is palpable 3-5 cm. When the abdominal muscles become lax, the liver may drop down and become more palpable. Liver is the main seat of metabolic activity. Hepatocytes are endowed with several enzymes, acting specifically in different metabolic pathways. When liver cells undergo injury or necrosis, intracellular enzymes are released into circulation, e.g. aspartate transaminase (SGOT) and alanine transaminase (SGPT). Following are the major functions of the liver. Carbohydrate Metabolism Glycogen formation and release of glucose from glycogen. Protein Metabolism Synthesis of albumin, deamination and transmi- nation of amino acids and peptides. Production of complement and other proteins. Conversion of ammonia into urea for excretion. Fat Metabolism Metabolism of cholesterol and lipoproteins. Secretion of Bile Bilirubin which is derived form the breakdown of haemoglobin and myoglobin by the reticulo- endothelial system is conjugated by liver cells into water soluble products (conjugated bilirubin- cholebilirubin) and excreted into bile canaliculi (entero-hepatic circulation). Ultimately these are discharged into the second part of the duodenum for elimination. The bile pigments secreted into the intestine are converted into urobilinogen by bacterial action. Part of it is absorbed passively in the portal circulation and reaches the liver cells. This pigment is re-excreted into bile canaliculi (entero- hepatic circulation). A part of urobilinogen escapes the hepatic cells and reaches the systemic circulation to be excreted in urine as urobilinogen. Bile pigment and its further metabolites give the normal colour to faeces. In their absence, the faeces are pale white comparable to china clay. The pigment present in faeces is called stercobilino- gen.

CHAPTER 9 Physical Examination in Hepatobiliary Disorders Symptoms,Vague general symptoms, Pain, Mass in abdomen, Jaundice-99, Oedema and ascites, Haematemesis and Melena, Haemorrhoids-100, Other features of hepatic failure-101, Physical examination-102 SYMPTOMS Vague General Symptoms Symptoms such as anorexia, bloated feeling of the abdomen after food, loss of weight, lethargy and fatigue are common in cirrhosis and other conditions associated with hepatic failure. Pain Enlargement of the liver and stretching of the capsule produce dull aching pain. This is seen in viral hepatitis and congestive heart failure. In hepatic amoebiasis the inflammation extends to the parietal peritoneum and the pain is sharp, often throbbing and aggravated by breathing and pressure over the right hypochondrium. Inflam- mation of the capsule especially in the sub- diaphragmatic region gives rise to pain referred to the shoulders. Amoebic liver abscess of the right lobe gives rise to pain referred to the right shoulder. In abscess of the left lobe pain may be referred to left shoulder. Colicky pain is seen in seen in gall stone disease and biliary stricture. Mass in the Abdomen Moderate or gross enlargement of the liver and spleen may give rise to feeling of mass in the upper abdomen. Hepatosplenomegaly is a common feature in cirrhosis, infiltrative diseases of the liver, lymphomas, chronic leukaemias, myelofibrosis, hepatic malignancy (primary or secondary) and hydatid cysts. Jaundice Yellow pigmentation of the sclera skin, mucous membranes and other tissues caused by excess of bilirubin in circulation is called jaundice. When the serum bilirubin level exceeds 2 mg/dL the tissues start getting stained. Collagenous tissue has great affinity to bilirubin and therefore tissues rich in collagen are stained early and most deeply e.g. sclera, palmar aponeurosis, nail beds, under aspect of the tongue and skin. To detect mild jaundice, the patient should be examined in bright daylight. When serum bilirubin rises, it takes 2-3 days to stain the tissues. Urine becomes high coloured earlier. So also when the liver recovers and serum bilirubin has fallen to normal, it still takes a few more days (up to 2 weeks) for the pigment to be released from the tissues completely. Jaundice may result from different disease processes and therefore its presence is an indication for further clinical examination and investigation. Based upon the mechanism of hyperbilirubinemia, jaundice can be classified into three major groups.

CHAPTER 10 Investigations in Diseases of the Hepatobiliary System Urine, Haemogram, Biochemical tests-103, Imaging techniques, Ultrasonography- 106, Computed tomography, Magnetic resonance imaging, Radionuclide studies, Angiography-107, Liver biopsy, Endoscopic procedures-108 Urine examination Urine examination for bile salts, bile pigments and urobilinogen are given in chapter 30. Haemogram Intense neutrophil leucocytosis (20000/cmm or more) with 80-90% neutrophils in the presence of fever, tender hepatomegaly and jaundice suggest the possibility of suppurative cholangitis, pyelephlebitis or pyogenic liver abscess. In hepatic amoebiasis and abscess there is moderate leucocytosis 10-12000/cmm with 60- 65% neutrophils. In hydatid disease and other helminthic infections like schistosomiasis, eosinophils may be increased. In viral hepatitis, total leucocyte count is usually normal or low with relative lymphocytosis. In leptospirosis the leucocyte count is elevated with neutrophil preponderence. Biochemical Tests Serum bilirubin is raised above 2 mg/dl in jaun- dice. The level of serum bilirubin gives objective evidence of the severity of jaundice and helps to assess progress with treatment. Conjugated and unconjugated bilirubin can be estimated to find out the type of jaundice. This differentiation is more important when investigating the cause of congenital hyperbilirubinaemias. Serum Proteins In liver failure, albumin level is lowered below 3.5 g/dl. The serum albumin correlates with hepatic function. Globulins are increased in cirrhosis liver. There is reversal of A/G ratio. Beta and gamma globulins contribute to this increase. In primary biliary cirrhosis, IgM is increased. Serum Sodium Values below 120 mmol/L indicate severe liver disease or excessive diuretic therapy. Enzymes Alkaline phosphatase Normal level of alkaline phosphatase (ALP) in serum is 4-13 KAU (35-125 IU/L). Hepatic alkaline phosphatase is increa- sed in obstructive jaundice. Values above 30 KA units are suggestive of obstruction to biliary drainage. ALP is a more sensitive and reliable parameter to diagnose biliary obstruction than serum bilirubin level. ALP is also elevated in hepatocellular carcinoma. Transaminases Aspartate transaminase (AST) ( serum glutamic oxaloacetic transaminase SGOT and alanine transaminase(ALT), (serum glutamic pyruvic transaminase(SGPT) are present in several tissues including the liver. In necrosis of liver cells, these are released into circulation and their values rise.

Respiratory System Respiratory System Respiratory System Respiratory System Respiratory System CHAPTER 11 General Considerations Introduction, Conducting system-airways-109, Nasal cavity and Paranasal sinuses, Larynx, Trachea and Bronchi-110, Lungs-111, Pleura-112, Physiological considera- tions-113, Air entry and production of breath sounds, Control of ventilation and respiratory rhythm-114, Surfactant, General pattern respiratory diseases in India-115 INTRODUCTION The thorax is an osseo-cartilaginous cage which extends from the root of the neck to the abdomen. It houses the principal organs of respirationthe lungs, which are separated from each other by the mediastinum. The thoracic cage is constructed in such a way that its movements result in increase and decrease of the antero- posterior and lateral diameters and its vertical height, thereby increasing or decreasing the intrathoracic volume during inspiration and expiration. In inspiration the anteroposterior and trans- verse diameters of the thorax are increased. Movements of the ribs at the costovertebral joints result in increased anteroposterior diameter (pump-handle movement). The transverse dia- meter is further increased by the ribs swinging outwards (bucket-handle movement). The dia- phragm which is attached to the lower margin of the thoracic cage acts like a piston. The vertical diameter increases by the contraction of dia- phragm which results in opening up of the costodiaphragmatic recesses, and elongation and narrowing of the mediastinum. During quiet respiration, expiration is brought about by the elastic recoil of the chest wall and the lungs. During forced expiration abdominal muscles pull the ribs down and the relaxed diaphragm is pushed up to reduce the vertical height. The Conducting SystemAirways This extends from the nose to the terminal bronchioles. This can be divided into upper and lower respiratory tracts. The upper respiratory tract consists of the nose, paranasal sinuses, nasopharynx and larynx. The lower respiratory tract includes trachea, bronchi and bronchioles upto the terminal bronchioles. The larger air passages are provided with rigid cartilaginous rings which prevent them from collapsing during strong respiratory movements. The bronchi branch repeatedly in a dichotomous manner becoming smaller and narrower progressively.

Laryngeal Cough Laryngeal cough occurs in acute and chronic laryngitis. The cough is harsh, irritative and repetitive. It may be accompanied by stridor and cyanosis. Usually there is a history or preceding attack of pharyngitis followed by hoarseness of voice or aphonia. In whooping cough, as a result of laryngeal spasm, there is a peculiar long inspiratory whoop after a prolonged bout of severe coughing. When the cough loses its explosive nature it is known as bovine cough (since it resembles cough in cattle). Bovine cough occurs in vocal cord paralysis since the laryngeal aperture cannot be closed. Tracheal Cough The cough may be dry and accompanied by retrosternal discomfort which increases on inspiration or coughing. Retrosternal pain and cough might increase on exposure to cold atmosphere. There may be a history of mild pyrexia and mucopurulent sputum which may be blood tinged. Presence of dyspnoea and wheezing are indicative of associated bronchitis. Cough that is of metallic and hard quality is termed as brassy CHAPTER 12 Examination of the Respiratory System History Main symptoms pertaining to the respi- ratory system are cough, expectoration of sputum, haemoptysis, dyspnoea, pain in the chest, and wheezing. Cough Cough is a protective reflex mechanism. It may be induced reflexly or consciously, to dispose of foreign material or accumulated secretions in the airways. In normal persons the secretions in the large airways are small in amount and they are cleared by mucociliary action of the bronchial mucosa. Cough arises as a result of irritation of the larger air passages or by the presence of excessive secretions in them. Cough may be of different types. Pharyngeal Cough The patient may present with short and dry irritative cough accompanied by pain behind the jaw or in the neck. There may be a history of nasal discharge, increase in postnasal discharge, and soreness in the throat. Pharyngeal cough is characteristic of pharyngitis and upper respira- tory tract infections. Cough-116, Expectoration of sputum-118, Haemoptysis-119, Chest pain-120, Dyspnoea-121, Abnormal patterns of respiration, Sleep apnoea-123, Wheeze, Stridor, Hoarseness of voice, Past history-124, Physical examination-125, Respiratory system examination-126, Inspection-127, Palpation-130, Percussion-132, Auscultation-135, A scheme for recording physical findings-137, Interpretation of physical findings-138, Common pathological changes in the lungs and pleura-142.

CHAPTER 13 Investigations in Respiratory Diseases Examination of Sputum-144, Radiology of the chest-146, Computed tomography- 154, Bronchoscopy, Lung biopsy-155, Investigations in pleural diseases-156, Thoracoscopy and lung biopsy-160, Pulmonary function tests-160 Examination of Sputum Examination of sputum gives invaluable infor- mation in respiratory diseases. This is manda- tory in all cases where infections or neoplasia are suspected. Collection of Sputum A clean wide mouthed bottle should be used for sputum collection. Most patients find it easier to bring out sputum early in the morning soon after waking up. Sputum brought out from the lower respiratory tract should be collected without contamination by saliva. When sputum is scanty or thick and sticky, proper hydration of the patient and administration of expectorants such as ammonium chloride or bromhexine make expectoration easier. In those with inability to cough, suitable physiotherapy such as adoption of appropriate postures and assistance to coughing helps to clear the air passages. When sputum cannot be obtained by these simple methods, more invasive procedures such as bronchoscopic aspiration, bronchoscopic lavage and transtracheal aspiration may become necessary. To assess the total daily output of sputum it should be collected for 24 hours. Inspection Note the colour, smell and quantity. The sputum is viscid and yellow in acute bronchitis, bronc- hiectasis and lung abscess. It is white and mucoid in chronic bronchitis, bronchial asthma and pulmonary tuberculosis. Rusty sputum is suggestive of pneumonia. Presence of Cursch- mans spirals which are bronchial casts suggests bronchial asthma and allergic bronchopul- monary aspergillosis. Watery and blood stained sputum suggests pulmonary oedema. Causes of haemoptysis are given on page 119. Chocolate coloured sputum may suggest amoebiasis. Serial reduction in the quantity of sputum and change in its physical characteristics are bed side parameters to monitor improvement in the condition. Intense foul smell should suggest chronic suppuration as in bronchiectasis and lung abscess. The three layer test: Allow the sputum to stand in a conical glass. In conditions such as bronchiectasis and lung abscess, it may form three distinct layersthick nummular purulent sputum below, serous fluid in the middle and froth above. Microscopy Usually sputum is examined microscopically after staining. Unstained fresh specimen can be examined as a wet-preparation to reveal Enta- moeba histolytica, and ova of Paragonimus if these infections are suspected. If the sputum is negative it can be concentrated by centrifugation and this gives higher positivity rates. Wet staining with aqueous methylene blue helps to detect malignant cells. A proper specimen of sputum should reveal alveolar macrophages.

Cardiovascular System Cardiovascular System Cardiovascular System Cardiovascular System Cardiovascular System CHAPTER 14 General Considerations Cardiac output-164, Sequence of cardiac contraction, Arterial supply of heart-165, Nerve supply, Arterial blood pressure, Heart failure, Patterns of cardiovascular diseases seen in India-166 The adult human heart weighs 250-350 g. 60% of the weight of the heart is constituted by the left ventricle. The left ventricle is 1-1.5 cm in thickness, the right ventricle is about 0.5 cm thick. The intrinsic properties of cardiac muscle include excitability, contractility, rhythmicity, conductivity and distensibility. In normal hearts, increase in fibre length by distension leads to increase in force of contraction. This is Starlings law. When the heart muscle is diseased, this relationship is deranged. Energy for the myo- cardium is derived from the metabolism of free fatty acids, glucose, lactate, pyruvate and keto- acids. Heart uses 8-10 mL of oxygen per minute. The myocardial oxygen demand during systole is three times that during diastole. Both systolic contraction and diastolic relaxation are active energy dependent processes and when the heart muscle is diseased, both these functions may be deranged in varying degrees. Cardiac Output The amount of blood ejected by the ventricles for each systole is the stroke volume. It ranges from 65-75 ml. Cardiac output is the total amount of blood ejected by each ventricle per minute and is the product of heart rate and stroke volume. In a healthy individual, it is around 5-6 L. Cardiac index is the term denoting the output of each ventricle per minute per square metre of body surface area. Normal cardiac index is 3.4 L/m 2 / min (range 2.8-4.2). Cardiac output is governed by several factors such as effective venous return, heart rate, distensibility of the ventricles to receive blood in diastole (i.e. compliance) contractile force, obstruction to atrial or ventricular outflow and blood pressure. In health the cardiac output can be increased to 20 L or more during exercise or emotional reactions. This is achieved by increa- sing the heart rate (acceleration) and contractile force (augmentation). Cardiac output may be reduced by several factors. 1 . Reduction in venous return into the atria as in hypovolemic shock. 2 . Extreme tachycardia above 150/mtThe diastolic interval is shortened so that ventri- cular filling is reduced. 3 . Extreme bradycardiaheart rate below 40/ minute. 4. Weakness of myocardial contraction. 5 . Arrhythmias such as atrial fibrillation.

CHAPTER 15 Examination of the Cardiovascular System Dyspnoea Dyspnoea is defined as an uncomfortable aware- ness of ones own breathing. Dyspnoea is a limiting factor of physical activity caused by very strenuous or unaccustomed exertion even in healthy people. This is not abnormal. When it occurs at rest or at levels of activity which are usual to the patient, it is considered abnormal. Dyspnoea is a common manifestation of cardiac and pulmonary diseases. Cardiac causes for dyspnoea are detailed below. In patients with heart disease, dyspnoea indicates pulmonary venous congestion. Eleva- tion of pulmonary venous pressure results from left ventricular failure or mitral valve disease. Left ventricular failure (LVF) is the most common cause of pulmonary venous congestion. Systemic hypertension, coronary artery disease, cardio- myopathy, myocarditis and aortic valve lesions can lead to left ventricular failure. LVF leads to rise of the left ventricular end diastolic pressure which is transmitted backwards to the left atrium and pulmonary veins. This leads to pulmonary venous congestion. When pulmonary venous pressure exceeds 22 mm Hg, dyspnoea occurs. If the resting pulmonary venous pressure is lower, dyspnoea occurs only on exertion which preci- pitates left ventricular dysfunction. In mitral stenosis, mechanical obstruction to atrial emptying causes rise in left atrial pressure which is transmitted retrograde to the pulmonary veins. Other rare causes of obstruction to left atrial outflow include left atrial myxoma and ball valve thrombi, cor triatriatum and supramitral rings. Rarer anomalies such as stenosis of the pul- monary veins can also cause pulmonary venous congestion and dyspnoea. For purposes of description and quantitation, dyspnoea is graded as follows: Grade I dyspnoea occurring at heavy, but accustomed activity Grade II dyspnoea occurring on moderate exertion Grade III dyspnoea during mild exertion or during daily routine activities Grade IV dyspnoea at rest. Occasionally patients with ischaemic heart disease may experience exertional dyspnoea instead of pain. In such cases dyspnoea is an anginal equivalent. Sudden onset of dyspnoea suggests acute pulmonary oedema, pulmonary embolism, pneumothorax or an acute obstruction to airways. In a patient with ischaemic heart disease, sudden exacerbation of dyspnoea should suggest acute myocardial infarction or its complications such as acute pulmonary oedema, Dyspnoea-168, Chest pain or cardiac origin-169, Palpitation, Haemoptysis-172, Syncope-173, Oedema-174, Cyanosis, Fatigue, Cough, Symptoms related to arteries, Symptoms related to veins-175, Past history, Physical examinationgeneral examination-176, Examination of pulse-178, Examination of jugular veins-182, Examination of chest-185, Palpation of the Precordium-186, Percussion of Precordium-190, Auscultation of the heart and blood vessels-191, Recording of blood pressure-200.

CHAPTER 16 Investigations in Cardiology ELECTROCARDIOGRAPHY The electrocardiogram (ECG) is a graphic record of the electrical activity of the heart and it is recorded by the electrocardiograph. General Considerations In modern clinical practice, the ECG has come to stay as a readily available tool to diagnose and manage many cardiac and noncardiac condi- tions. It is a part of the diagnostic equipment of all doctors ranging from the primary care phy- sician to the cardiologist. Hence it is essential that all doctors should understand its principles and application. Ionic Basis for Cardiac Electrical Activity Resting Membrane Potential In the resting state a potential difference exists across the cell membrane of myocardial cells. The basis for this resting membrane potential (RMP) is the differential distribution of ions across the cell membrane. Movement of ions across the cell membrane is influenced by 3 factors. i . The ions move from regions of higher concentration to those of lower concen- tration. i i . The electric gradient allows charged ions to diffuse along their electric gradient. iii. The cell membrane is selectively permeable permitting free passage of smaller ions like K + , while restricting movement of other ions like Na + . The interior of the cell has a high concentration of potassium ions (K + ) and protein anions, while the cell exterior is rich in sodium (Na + ) and chloride (Cl ) ions. The RMP is generated and maintained by the selective permeability of the cell membrane to potassium, which tends to diffuse out from the cell along its concentration gradient. This movement is opposed by the positive electrical charge of the cell exterior. The cell exterior has a positive charge due to the activity of the sodium- potassium ATPase pump which actively pushes out the sodium from the cell by an energy dependent process. A net equilibrium is struck between these opposing forces, so that the cell interior is negative in the resting state. In most cardiac cells the resting membrane potential is 60 to 90 millivolts (mv). Action Potential An action potential develops in response to any stimulus that produces changes in the ionic permeability of the cell membrane. Such stimuli produce alteration in the physicochemical environment which modify the permeability of the cell membrane. The action potential consists of depolarisation and repolarisation processes. Depolarisation This is also referred to as phase-O of the action potential. In response to a stimuli, the Na + chan- nels in the cells membrane open up allowing free entry of sodium into the cell.

CHAPTER 17 Cardiac Arrest and its Management Suspect cardiac arrest when there is sudden collapse in any subject. Confirm cardiac arrest by: a . absence of pulses, b . absence of heart sounds and c . absence of respiratory movements. First Aid Measures Institute cardiopulmonary resuscitation (CPR) (basic life support activities ) immediately. 1. Place the subject supine on a hard surface and loosen all clothing. 2 . Deliver a sharp blow over the front of chest on the lower third of the sternum (precordial thump version). In a few cases this may start off effective cardiac contractions. 3 . Clear the airway and establish effective ventilation. i . Tilt the head backwards, lift the chin, remove foreign bodies from the mouth and throat manually (Fig. 17.1). ii. Heimlich manoeuvre : Deliver a sharp compressive movement to the upper abdomen with the closed fists. This may dislodge any foreign body impacted in the throat. i i i . Turn the patient to one side and deliver 3-4 sharp blows over the back between the shoulder blades with the heel of the hand to dislodge foreign bodies from the airways. 4 . Mouth to mouth respiration should be started and continued until better respiratory assistance is available, either in an emergency ambulance or in the hospital. Procedure Pinch the nose, and with your mouth applied to the patients mouth, breath forcibly out, using the force generated by your cheek muscles, expiration occurs passively. 10-15 respirations should be given every minute by one member of the team. 5 . External cardiac massage: This should be undertaken by another member of the team. Place the palm of one hand over the lower sternum with the other hand over it firmly (Fig. 17.2). Depress the sternum approximately 3-5 cm with sufficient force to generate a palpable pulse. Fig. 17.

CHAPTER 18 General Considerations SECTION SECTION SECTION SECTION SECTION 7 7 7 7 7 Musculoskeletal and Musculoskeletal and Musculoskeletal and Musculoskeletal and Musculoskeletal and Locomotor System Locomotor System Locomotor System Locomotor System Locomotor System General Considerations Rheumatology is that branch of medicine con- cerned with disorders of the musculoskeletal or locomotor system including inflammatory and other joint diseases, generalized connec- tive tissue disorders, back problems and disor- ders of periarticular tissues (WHO). The targets of a proper rheumatological examina- tion are the axial and appendicular musculosk- eletal system and the related connective tissues of the body. Bones The human body has about 206 bones. Structur- ally, they can be divided into spongy and com- pact bones. In spongy bone the lamellae are stacked one above the other as trabeculae. In com- pact bone the lamellae are arranged closely in concentric circles around a central canal contain- ing the osteocyte. Spongy bones house the bone marrow whereas compact bones do not. During bone formation and repair different cells such as osteocytes, osteoblasts and osteoclasts act in a coordinated and orderly manner under the influ- ence of several humoral factors. Periosteum cov- ers bones. It has an outer fibrous layer and an inner cellular layer capable of producing bone the osteogenic layer. Long bones transmit body weight and act as levers for movement. The middle part of the tubu- lar shaft is the diaphysis which is flanked on either end by the metaphyseal regions. The ends are expanded to form the articular areas, the epi- physes. Long bones derive their blood supply from diaphyseal, metaphyseal, epiphyseal and peri- osteal nutrient arteries. Short bones like the carpal bones function as points of absorption of pressure and distribution of shearing forces. They are made of compact bone. Joints Joints may be classified as fibrous, cartilaginous or synovial. RHEUMATOLOGY General considerations-252, Disease pattern affecting the locomotor system-253 .

CHAPTER 19 Examination of the Musculoskeletal System HISTORY Pain The most important rheumatological symptom is pain. Find out the onset and duration of this symptom. Chronic joint pain occurs in osteo- arthritis (OA), rheumatoid arthritis (RA), psoriatic arthritis, ankylosing spondylitis (AS), juvenile RA and others. Acute joint pain develops in rheumatic fever, traumatic arthritis, reactive arthritis, acute gout and in the acute phases of all chronic arthropathies. Osteomalacia and osteoporosis present with chronic aching pain over the spine and weight bearing bones, aggravated by activity. Site of Pain It is important to locate the site of pain clearly, whether it is from joints, bones, periarticular tissues, muscles, nerves or vascular lesions. Ask the patient to show the exact site of pain. Localisation of pain to the enthesis should suggest periarticular lesions. Neuralgic pain over a dermatomal distribution occurs in involvement of the dorsal nerve roots. Symmetrical distribution of pain and numbness over the distal parts of the extremities is suggestive of nerve involvement, which may be mistaken for joint lesion. Joint Pain Joint pain that is worst in the morning and gets relieved as the day advances suggests inflam- matory arthritis like rheumatoid arthritis. Pain that comes on by the end of the day and aggravated by joint use suggests osteoarthritis. Brief or fleeting joint pains that move quickly, i.e. flit from joint to joint must bring rheumatic fever to mind. Acute or subacute arthritis is the presenting feature in JRA. Several infections such as viral hepatitis B, infective endocarditis, leprosy (during reactions), brucellosis, syphilis, Lyme disease and others may present with arthritis as a major symptom. Acute leukaemias in children commonly give rise to arthritic manifestations. In children, pain of insidious onset with impairment of function of single joints may be the only feature of osteo- articular tuberculosis. Pain around the hip in a child may be due to tuberculosis or Perthes disease. In the former, pain is more severe and unrelieved by rest and invariably it disturbs sleep. The latter often presents with slight pain, a limp and restricted movement. Pyoarthrosis presents as severely painful acute arthritis. Acute gouty arthritis presents as sudden onset of pain, swelling and signs of inflammation characteris- tically in the metatarsophalangeal joint of the big toe. Several other joints may also be affected. Chronic gout presents with pain, restriction of movements and deformities of several jointsbig and small. Recurrent joint pains and swelling involving whole foot, hands or digits in children should suggest dactylitis occurring in sickle cell History-255, Physical examinationGeneral examination-261, General principles of examination of joints-262, Examination of particular regions-264 .

CHAPTER 20 Investigations in Rheumatology Laboratory investigations-278, Synovial fluid examination, Determination of HLA status-281, X-ray examination-282, Other imaging techniques-282, Arthroscopy, Synovial Biopsy-284 . LABORA T O R Y INVESTIGA TIONS Acute Phase Reactants These include erythrocyte sedimentation rate and C-reactive protein. Erythrocyte sedimentation rate (ESR) Normal value is upto 10 mm/hr in men and 20 mm/hr in women. Rise in ESR suggests inflammatory processes. Levels above 100 mm/hr should suggest rheumatoid arthritis, systemic lupus erythematosus (SLE), tuberculous arthritis and pyogenic arthritis. ESR is raised in a wide range of diseases and therefore, the test is nonspecific for diagnosis. In many cases the level of ESR may reflect the severity of the inflammatory process and this can be used as an easily available laboratory parameter for follow-up of the disea- ses, provided there are no coexisting conditions which modify the ESR. Joint manifestations caused by allergic processes and osteoarthritis are not accompanied by high rise in ESR. In many instances the intensity of the pathological process and the rise in ESR do not go hand in hand. The disadvantages of ESR are that it is affected by age and gender, by red cell morphology and numbers and according to the levels of many kinds of plasma proteins all of which are not acute phase reactants. C-Reactive protein (CRP) CRP is unaffected by age or gender and reflects the value of a single acute phase protein. CRP is a beta-globulin present in serum, capable of reacting with the outer coat of pneumococci. Normally it is absent from human plasma. When inflammatory processes occur in any part of the body, the liver produces an identical protein which can be detected by a slide test using ready-made reagents. The test can be performed quickly within five minutes. It is more expensive than determining ESR. This test is also non-specific. Advantages of study of CRP are 1 . Shorter time to perform. 2 . CRP is positive even before the ESR starts rising. 3 . CRP can be quantified by determining dilution titres and 4 . It helps to distinguish between rheumatoid arthritis (RA) and SLE. In RA, CRP is ele- vated, whereas in uncomplicated SLE it is not. Routine Blood Counts Haemoglobin and erythrocyte count Reduction of haemoglobin level is seen in chronic rheumatoid disease. This anaemia may be due to impairment of utilisation of iron, haemolysis, or toxic effects of anti-rheumatic drugs. SLE may be associated with haemolytic anaemia. Leucocyte count Total leucocyte count (TLC) is elevated in the acute phase of inflammatory arthritides.

SECTION SECTION SECTION SECTION SECTION 8 8 8 8 8 CHAPTER 21 Haematology: General Considerations Haematological System Haematological System Haematological System Haematological System Haematological System General Considerations Blood, bone marrow and the lymphoreticular systems constitute haematological organs in the adult. Embryology Haemopoietic stem cells appear in the first or second week of embryonic life from the mesoderm of the yolk sac. Production of erythrocytes from the yolk sac ceases by the tenth week. Foetal liver starts haemopoiesis by sixth week, spleen by twelth week and the bone marrow by twentieth week. At birth virtually all haemopoiesis is from the bone marrow. In the foetus the haemoglobin is almost totally foetal haemoglobin (HbF-  2  2 ) (HbF) which is best suited to function in the intrauterine environment. Foetal haemoglobin falls to below 2% by the age of six months. Adult haemoglobin (Hb A-  2  2 ) starts appearing in foetal erythrocytes by the eleventh week of gestation and after birth it rapidly replaces foetal haemoglobin. The total blood volume is about 5 L in the adult (65 mL/kg) made up of plasma and the formed elements. The bone marrow is a loosely-knit semisolid tissue contained within the marrow cavity of almost all bones. The total weight of the bone marrow in adult varies from 1600-3700 g. Active red marrow constitutes approximately 1000 g. The proportion of active haemopoiesis taking place in different bones is given below: Pelvic bones 3 4 % Vertebrae 2 8 % Cranium and mandible 1 3 % Sternum and ribs 1 0 % Scapulae, humeri, and clavicles 8% Femur 4 % The cellular components of the bone marrow are: Mean Values Myeloid precursors and granulocytes 5 7 % Erythroid precursors 2 5 % Lymphocytes 1 6 % Monocytes 3 % Plasma cells 1.3% Reticulum cells 0.3% Megakaryocytes 0.1% General considerations-286, Pattern of common haematological disorders in India- 287 .

CHAPTER 22 Examination of Haematological System History Most of the points in history and physical examination which are relevant to diseases of the haemopoietic system have been described in this book under different sections. The following points in history are parti- cularly important. Nutrition Dietary history should be taken in detail. Iron deficiency anaemia and nutritional macrocytic anaemia caused by deficiency of folate or vitamin B 12 are largely due to inadequate dietary intake of these nutrients. Severe protein deficiency may also give rise to anaemia. Dietary articles rich in iron are liver, meat, fresh green vegetables, onions, grapes and jaggery. Rich sources of folic acid include liver, meat, green vegetables and fruits. Food articles rich in B 12 are liver, meat and other animal products. Dairy products (especially yoghurt and butter milk) supply small amounts of this vitamin. Vegetable sources do not contain vitamin B 12 . Vitamin C deficiency leads to scurvy in which bleeding is a prominent clinical manifestation. Rich sources of Vitamin C include citrus fruits, goose-berries ( amla ), guava, and sprouting pulses. Sources of Blood Loss Nutritional deficiency is often complicated by blood loss. Common sources of blood loss are given below: 1. Haemorrhoids 2 . Heavy infestation by hookworms or whip- worms. 3 . Excessive menstrual bleeding. Menstrual bleeding occurring for more than four days and more frequently than once a month may be taken as excessive. Normal blood loss during a menstrual period ranges around 60 mL. 4 . Repeated pregnancies at intervals shorter than three years. 5 . Ulcerating lesions of the gastrointestinal tract, e.g. gastric and colonic carcinoma, ulcerative colitis, intestinal tuberculosis, peptic ulcer- ation. In addition, lesions such as carcinoma of the stomach, colon and uterus may lead to occult blood loss and present for the first time as anaemia even when the underlying condition remains silent. In all cases of anaemia, source of blood loss if any, should be identified and corrected to get full relief. History of Drug Intake Drug intake Several drugs lead to toxic damage to the blood components and bone marrow. A few examples are given below: Agranulocytosis Analgesicsamidopyrine, phenylbutazone, antirheumatic drugs, chlorpro- mazine, anti-thyroid drugs like thiouracil and carbimazole. History-289, Physical examination-291, Involvement of other systems in haemato- logical cases-292, Systemic complications caused by drugs-293.

CHAPTER 23 Investigations in Haematological Disorders Haemoglobin estimation, Enumeration of cells-294, Staining of blood film , Abnormalities of erythrocytes-295, Reticulocytes-299, Erythrocytes sedimentation rate, Leucocytes-301, Platelets-301, Parasites-301, Diagnosis of leukaemia-302, Bone marrow examination-303, Special investigation in nutritional anaemias-305, Diagnosis haemolytic anaemias-305, Cytogenetic Analysis in haematology, Flow cytometry, Fluorescence in -situ hybridization-307, Bleeding disorders-309, Test for platelet function-310, Investigation in thrombophilia-312, Diagnosis of multiple myeloma-312 All haematological cases should have the follow- ing investigations done. Haemoglobin estimation, total erythrocyte (RBC) count. Total white cell count, differential white cell count. Platelet count, haematocrit, and erythrocyte sedimentation rate (ESR). Haemoglobin Estimation This should be done as part of general investi- gation in all patients irrespective of the complaint since anaemia is very prevalent in many commu- nities in India. Haemoglobin level has to be repeated at periodic intervals to assess the progress of the condition. The standard procedure to estimate haemo- globin is by cyanmethaemoglobin method using international standards and reliable equipment. The accuracy of the instrument has to be checked regularly. Manual methods using Sahlis haemoglobinometer give unacceptably high errors. Normal values of haemoglobin for different age groups accepted by WHO are: Children 6 months to 6 years 11 g/dL and above 6 yrs to 14 yrs 12 g/dL and above Adult males 13 g/dL and above Adult females Nonpregnant 12 g/dL and above Pregnant 11 g/dL and above Increase in haemoglobin above 17.5 g/dL in males and 15.5 g/dL in females occurs in polycy- themia and haemoconcentration. Enumeration of cells Erythrocytes, leucocytes and platelets used to be counted by manual methods till four decades ago. Even in the best hands errors upto 20% are common. These errors are minimized by using automated and semiautomated counters. These are now widely used for measuring various blood parameters. Automated counters require only appropriate samples to be fed into them. Newer counters can measure 8-20 parameters. Results are obtained immediately.

CHAPTER 24 Haematological Emergencies and their Management Severe Anaemia Haemoglobin less than 5 g/dL Complicationcardiac failure. T reatment Packed red cell transfusion or exchange transfusion to raise the haemoglobin to asymptomatic levels. Agranulocytosis Suspect the disease if there is severe throat pain, necrotic ulcerations in the mouth, high fever or toxemia in any patient receiving drugs. T reatment Withdraw the offending drug forth- with and start strong bactericidal antibiotics like gentamicin, carbenicillin, cefotaxime, ceftazidime or amikacin. Granulocytes can be replaced by giving granulocyte transfusion if available. Transfusion of fresh blood is a much less efficient alternative. Use of colony stimulating factors should be considered. Bleeding Institute local measures to arrest bleeding. In coagulopathies, local application of Gelfoam or other styptics may help. Identify the possible causes by preliminary tests and administer the necessary clotting factor parenterally. Calculation of dose of Antihaemophilic Globulin (AHG) in Haemophilia If pure AHG is not available, cryoprecipitate can be given as an alternative. As far as possible the patient or his near-relative should be trained to take self-injection at the earliest sign of bleed- ing. If both are not available first frozen plasma (FFP ) is a less efficient alternative . Disseminated Intravascular Coagulation Identify and remove the cause. Heparin in small doses and replacement of fibrinogen and clotting factors (fresh frozen plasma) help to arrest the intravascular coagulation and restore coagula- bility of blood. Immune Thrombocytopenia High dose steroids, large doses of IV immuno- globulin, platelet transfusion and emergency splenectomy may be life-saving.

SECTION SECTION SECTION SECTION SECTION 9 9 9 9 9 Endocrinology Endocrinology Endocrinology Endocrinology Endocrinology CHAPTER 25 General Considerations Introduction-315, Anatomy and functions of endocrine organs-316, Pattern of endocrine disorders in India-317 , Genetically determined endocrine abnormalities, Paraneoplastic manifestations of malignancy-319 INTRODUCTION TO ENDOCRINOLOGY Endocrine glands are ductless glands which secrete hormones. They are important regulatory influences in cellular metabolism. Hormones have different sites of action. Many act on the target tissues often distant from their glands of originendocrinologic action. Some hormones act on cells adjacent to their site of originparacrine action, while others act on their own cells of originautocrine action. Resistance to hormone action can involve any or all of those pathways. Several endocrine glands can be involved simultaneously resulting in hypersecre- tion of the hormones as in multiple endocrine neoplasiaMEN syndromes. So also hypo- function of multiple glands occurs in conditions such as autoimmune poly glandular syndromes. Endocrine disorders fall under different groups, based on their pathogenesis. 1 . Those caused by over-or under secretion of hormones, e.g. hyperthyroidism, acromegaly, gigantism, myxoedema, pituitary dwarfism. 2 . Those caused by ectopic production of hor- mones or related substances, e.g. carcinoma bronchus causing Cushings syndrome, hypernephroma causing hyperparathyroi- dism. 3 . Disorders due to the unresponsiveness of target tissues to the hormones, e.g. testicular feminisation syndrome, pseudohypopara- thyroidism, thyroid hormone resistance syndrome, insulin resistance syndrome. 4. Those due to deficiency in enzymes required for the synthesis of a hormone resulting in excess production of intermediate products, alternate products or precursors, e.g. dyshor- monogenesis in Pendreds syndrome resulting in hypothyroidism and congenital adrenal hyperplasia with adrenogenital syndrome. 5 . Abnormalities cause d by heightened tissue susceptibility to hormone action, e.g. hirsui- tism in young females with normal androgen levels. Though previously the pituitary was consi- dered to be the master endocrine gland which controlled the others, with the discovery of releasing and inhibitory hormones secreted by the hypothalamus, the pride of place has shifted to the hypothalamus at present.

CHAPTER 26 Clinical Examination in Endocrine Diseases General symptomatology-321 Physical examination-323, Examination of individual glands- Thyroid-325, Parathyroids, Adernal glands-327, Pancereatic Lesions, Reproductive system-328, Examination of the Breasts-330, Abnormalities of the Pituitiry-331 Abnormalities of the Hypothalamus, Pineal gland-332 As in the case of all other systems the steps to be followed include: 1. Proper history. 2 . Physical examination with special attention to anthropometry. Secondary sexual characteristics and abnor- malities of endocrine organs. 3. Correlating the symptoms and signs to make a provisional diagnosis, and 4 . Planning the appropriate investigations for confirmation. Though all hormones exert their effect pre- dominantly on a particular tissue, there may be several effects on other tissues as well. For example the thyroid hormone acts mainly on growth, development and metamorphosis but it has got several actions on cardiovascular system, gastro- intestinal system and on the brain. Hence the clinical features may include general symptoms as well as organ-specific symptoms. General Symtomatology in Endocrine Diseases a . Loss of Diabetes mellitus, thyroto- weight xicosis, Addisons disease, hypopituitarism. b . Obesity Prediabetic state, myxoe- dema, Cushings synd- rome, adrenal tumours, Froehlichs syndrome, Laurence-Moon- Biedle syndrome. c . Skin pigmen- Addisons disease, tation over Cushings syndrome, axillary folds, hypothyroidism, palm and sole thyrotoxicosis. creases, pres- sure points, moist surfaces and mucous membranes d . Vitiligo Hypothyroidism, Addisons disease, diabetes type first e . Increased Hyperthyroidism, hypo- sweating glycemia, pheochromocy- (hyperhidrosis) toma. Cardiovascular Symptoms a. Dyspnoea Caused by secondary hypertension, (phaeochro- mocytoma) obesity, (Cushings syndrome). b . Palpitation Thyrotoxicosis, hypoglycaemia, phaeochromocytoma.

CHAPTER 27 Investigations in Endocrine Disorders Introduction-333, General investigations, Estimation of hormone levels-334, Special tests to diagnose specific endocrine disorders- Diabetes mellitus-335, Thyroid disorders-337, Parathyroids, Adrenal cortex-339, Adernal medulla-340, Gonads- 341, Anterior pituitary, Posterior pituitary-342, Appendix normal values-343 INTRODUCTION The clinical diagnosis of endocrine disorders has to be supported by investigations. Many cases of subclinical functional defects can be confirmed only by investigations. The process of diagnosis of an endocrine disorder should aim at. 1 . Establishing the functional derangement by clinical examination and laboratory investi- gations. 2 . Locating the abnormal organ by imaging techniques such as radiology, ultrasono- graphy, CT scan, MRI, isotope imaging and selective venous catheterisation to estimate hormone levels in venous blood draining the particular gland. 3 . Establishing the etiological factor and pathological process. It should be ascer- tained whether an endocrine hyperfunction is due to hyperplasia of the gland, adenoma, carcinoma or ectopic hormone production. This is done by biochemical tests as well histology. Since treatment of endocrine disorders may involve medical measures, surgical excision, isotope administration or external irradiation, all these steps are to be followed according to specific indications.

SECTION SECTION SECTION SECTION SECTION 10 10 10 10 10 Nephrology Nephrology Nephrology Nephrology Nephrology CHAPTER 28 General Considerations Introduction, Applied anatomy-345, Applied physiology-347, General pattern of medical disorders affecting the kidney and urinary tract in India-348 . INTRODUCTION Considerable advances have been made in the understanding of the excretory system in health and disease over the last five decades. As a consequence newer modalities of treatment have also been developed. Conditions which were considered to be invariably fatal, such as chronic renal failure can be managed now by renal replacement therapy in the form of maintenance dialysis or renal transplantation. In this chapter, the steps for an adequate clinical evaluation of a patient with diseases of the excretory system are described. A patient with disease of the kidney or urinary tract may present in several ways. 1 . Remain asymptomatic with normal urine tests. 2. Remain asymptomatic with abnormalities in urine detected by investigations. 3 . Have symptoms directly referable to the excretory system and showing abnormali- ties on investigations, or 4 . Present with renal or non-renal manifes- tations of a generalised disease like diabetes mellitus or dyscollagenosis which com- monly affects the kidneys. In many instances a high index of suspicion goes a long way in the early diagnosis and timely intervention. Applied Anatomy The kidneys measure about 11 x 6 x 3 cm and weigh 125-170 g. They occupy the retroperitoneal space on either side of the vertebral column from D 12 to L 3 vertebrae with the upper poles nearer to the midline. The right kidney is lower than the left by 1.5 cm because of the liver above it. The upper pole of the left kidney reaches the transverse process of D 11 vertebra. Kidneys are placed in close apposition to the diaphragm. During respiration, the kidneys move only 1-2 cm in the vertical axis since the movement is restricted by the perine- phric fascia. Upper part of the medial border and the anterior aspect of the upper pole are in close apposition with the corresponding suprarenal gland. Enlargement of the suprarenals may cause downward displacement of the kidney. Gross enlargement of the suprarenal may mimic renal enlargement clinically. Renal tumours such as nephroblastomas and suprarenal tumours such as neuroblastomas, which reach large size are common neoplasms of childhood.

CHAPTER 29 Clinical Examination in Renal Diseases General approach, Symptoms--349, Physical examination-355 General Approach Several pathological processes may affect the kidneys, but the clinical manifestations take the form of only a limited number of distinct syn- dromes. As in the case of all other systems, a proper history, physical examination and basic investi- gations will help to identify these syndromes and find out the aetiology. As the first step, the doctor should be able to identify a problem as of renal origin. The next step is to define the problem more specifically so as to narrow down the possibilities. For example, the symptom of hematuria may be further quali- fied as painful or painless. Painful haematuria occurring towards the end of micturition, with the presence of clots, may probably suggest a bladder stone, whereas recurrent bouts of painless haematuria may be a symptom of glomerulo- nephritis. Once the symptom is identified, the next step is to fit the condition into one of the classical syndromes such as acute renal failure, chronic renal failure, nephrotic syndrome, acute glomerulonephritis, urinary infection and so on. The exact aetiology and pathology can now be determined with the help of specific investigations. Symptoms A patient with disease of the urinary system may fall into one of four categories. 1 . Clear cut symptoms of involvement of the kidneys, ureters, bladder or urethra, e.g. oedema, haematuria, oliguria, colicky pain, dysuria and others. 2 . Systemic symptoms of renal insufficiency and uraemia. 3 . Symptoms of systemic diseases which lead to renal involvement, e.g. diabetes mellitus, collagen vascular disease, chronic sepsis, malignancy and others. 4 . No symptom referable to excretory organs, but their pathology is detected incidentally in the course of a routine medical examination for other diseases or of an apparently healthy person, e.g. persistent proteinuria, elevation of blood urea or presence of abnormalities in ultrasonography. A. Symptoms referable to the kidneys include: a . Facial puffiness and oedema b . Alteration in the urinary outputoliguria or polyuria c . Alternations in the colour and transparency of urine d . Haematuria e . Abdominal mass f . Fever with chills g . Pain in the lower abdomen h . Hypertension and its complications i . Symptoms of renal failureacute or chronic renal failure and uraemia. B. Symptoms referable to the ureters Ureteric colic, haematuria, abrupt cessation of urine flow, reflex anuria, C.

CHAPTER 30 Investigations in Nephrology Urine examination-356, Haemogram, Biochemical tests blood-362, Radiology-365, Computed tomography, Endoscopy and catheterisation-367, Histopathological studies-367, Isotopic studies-368, Appendix-370 Urine Examination Volume . For measuring 24 - hour urine volume the patient should be instructed to void and discard the urine at 6 a.m. The collection time starts now. All the urine passed subsequently upto and including 6 a.m. the next day is collected in a bottle containing a preservative, usually glacial acetic acid -10 mL. The time of collection of each specimen and its volume are charted. This helps to determine the volume of urine passed during day and night respectively. Normal adult passes 700-2500 mL of urine in 24 hours. If the 24 hours urine is to be collected for special tests or estimation of 17-ketosteroids or other metabolites, a large container with an appropriate preservative has to be supplied. Specific Gravity (Sp gr) This is measured using a urinometer. The specific gravity depends upon the concentration of solutes present in the urine. Crystalloids like urea, salts and sugars raise Sp gr considerably, whereas colloids like proteins do so to a lesser extent. Method The urine is allowed to cool down to room temperatu