An Insider's Guide to CLINICAL MEDICINE
An Insider's Guide to CLINICAL MEDICINE
Archith Boloor Saha MBBS MD (Internal Medicine)
Associate Professor Department of Medicine Kasturba Medical College Manipal Academy of Higher Education
Mangaluru, Karnataka, India archithb@gmail.com
Anudeep Padakanti MBBS MD (Internal Medicine)
Department of Medicine Kasturba Medical College Manipal Academy of Higher Education
Mangaluru, Karnataka, India anudeeppadakanti.aigcm@gmail.com
Foreword Chakrapani M
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An Insider's Guide to Clinical Medicine
First Edition: 2020
9789389587876
Printed at
In fond memory of
Dr Sitamahalakshmi
Medicine is a science and an art. Clinical examination is fast becoming a forgotten art in the face of technological onslaught. This book is an important step in bringing the students back to the basics of clinical medicine. This book will be valuable for examination preparations. It is a comprehensive compilation of clinical signs for students of internal medicine—both undergraduates and postgraduates. Illustrations are self-explanatory and help in understanding difficult concepts.
Dr Archith has been actively and extensively involved in the clinical teaching of undergraduate and postgraduate students for many years. He has been a popular teacher among medical students and has received “best teacher award” many times at Kasturba Medical College, Mangaluru, Karnataka, India. He has understood the limitations of the present clinical examination books and also identified the knowledge gap that needs to be cleared for undergraduate and postgraduate students. His student Dr Anudeep, an enthusiastic learner and teacher has initiated the process of compiling this wonderful book.
Many common concepts which are very pertinent and relevant for university clinical examinations are discussed in detail in this book. Coverage of the topics are comprehensive, contemporary, and clear.
The authors have done extensive research while compiling the details in the book and has presented it in a very convenient to understand format by giving the details of many of these concepts in the form of tables and bullet notes. This will help the student in remembering the important points. They have explained the basic concepts, and this will help the student in understanding and then performing the clinical examinations.
Information compiled in the book is evidence-based and experience enhanced by an eminent teacher. They have taken the feedback from all the stakeholders including teachers and students before finalizing the final version of this book. This book can be strongly recommended for students, teachers and practising physicians.
Chakrapani M MD
Professor
Department of Medicine
Formerly, Head and Associate Dean
Kasturba Medical College
Manipal Academy of Higher Education
Mangaluru, Karnataka, India
Preface
The clock had struck a solid 1:30 PM. The examiner was hungry, the last student was jittery and in between them lay a central nervous system (CNS) case that was going to determine whether a four-and-half-year ripe child of medicine would be prefixed with a “Dr” or not.
The examiner was more bored than he could care to admit. Lakshman, aged 32, hailing from Shivamogga, Karnataka with chief complaints of bilateral lower limb weakness was being presented for the 14th time that day. The same boring questions had been asked in the same uninspired fashion.
“List the causes of neck pain”, the examiner asked.
A little taken aback but the student realized that the question was within the realm of a CNS case. After gathering his thoughts for a moment, he began listing out, “Meningitis causing neck muscle spasm, cervical spondylosis, cervical spondylolisthesis.” his voice trailing off in response to the examiner's unimpressed face.
”Go ahead, what else?”
Not to lose face in front of the examiner, the student once again reset his thoughts, and a few umms and ahhs later continues:
”Sir, other cervical causes like cervical intraepithelial neoplasia, cervical cancer, etc. can also cause neck pain”.
Jokes apart, getting psyched for an exam is an absolutely normal and foreseeable predicament. We often notice the most brilliant students fumbling to show off years’ worth of hard work simply because the psyche overpowers their preparation. As the saying goes “For most diagnoses, all that is needed is an ounce of knowledge, an ounce of intelligence, and a pound of thoroughness.” With that very thought in mind, it is our pleasure to present to you a simple, comprehensive and exam-oriented clinical manual: A compass to guide you through the art of clinical medicine.
The practical examinations pose a real challenge to the medical student: He has to finish writing an entire case sheet, elicit the expected clinical findings and finally arrive at a proper diagnosis. All this to be done before the examiner has even made eye-contact with the student. The catch here being the limited availability of what we all take for granted: Time. One asks the wrong questions, examines the wrong systems, latches on to the wrong points and before we realize, we are knee-deep in heaps of unorganized information that has no head or tail. Having been in the same shoes at some point in the past, this book was made to solve those problems: complete case sheets on all organ systems, with added emphasis on the common examination cases have been incorporated. We hope it will teach the reader to anticipate questions that are asked in different contexts. The book is as visually charged as we could possibly make it because we believe that seeing is learning. We have dealt with spot and short cases which are meant to test a student's take on the bigger picture of diseases. The diagnostic clues given in this book will help the student to arrive at a definitive decision sooner. X-rays, spotters and instruments are dealt with extensively and in exquisite detail.
We have read several clinical books in an attempt to make this one different. In doing so, we have found that this is one single guide which can be safely relied upon to deal with the practicals of Final MBBS Part II. We hope that the fruit of our labor becomes as close to your bookshelf as it is to our hearts. Any suggestions and/or constructive criticism is always welcome, and we hope you enjoy reading An Insider's Guide to Clinical Medicine.
Archith Boloor
Anudeep Padakanti
Remembering the Father of Modern Medicine
Medicine is a science of uncertainty and an art of probability.
The best preparation for tomorrow is to do today's work superbly well.
Every patient you see is a lesson in much more than the malady from which he suffers. Listen to your patient. He is telling you the diagnosis.
He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.
The good physician treats the disease; the great physician treats the patient who has the disease.
We are here to add what we can to life. Not to get what we can from life. Too many men slip early out of the habit of studious reading and yet that is essential.
One of the duties of the physician is to educate the masses not to take medicine.
The practice of medicine is an art. Not a trade; a calling. Not a business: A calling in which your heart will be exercised equally with your head.
Happiness lies in the absorption in some vocation which satisfies the soul. To have striven. To have made the effort. To have been true to certain ideals‑‑‑‑‑ this alone is worth the struggle.
Acquire the art of detachment, the virtue of method and the quality of thoroughness but above all the grace of humility.
Sir William Osler,
(July 12, 1849 – December 29, 1919)
Acknowledgments
It was our long-standing dream to write a clinical book that would encompass all the relevant matter needed for a student with due emphasis on clinical methods. Incorporating many years of clinical teaching and an astute understanding of the actual needs of a medical student, this book has been compiled to cater to their unmet needs. It has been a Herculean task of reading, writing, rewriting and editing this vast amount of information into this concise textbook.
When we began this work, almost a year ago, little did we anticipate the shape our ideas would finally take in the form of this “An Insider's Guide to Clinical Medicine”. This endeavor of ours would have been impossible without the constant support and encouragement of our well wishers.
Firstly, we thank all our students : undergraduates, postgraduates for having kindled in us this idea, for compiling our notes and most importantly, for asking the questions whose answers have taken the form of this book.
This book would not have seen the light of day without the constant persuasion of Dr Vivek Koushik, Dr Abu Thajudeen and Dr Nikhil Kenny Thomas. They are and will continue to be the pillars of strength on whom our life and this book would gain sustenance… Thank you.
We profusely thank Dr Chakrapani M, for writing the foreword for this edition. Sir is the embodiment of a true teacher of clinical medicine and we thank him for his constant support and inputs during this process.
We thank Dr Sheetal Raj for the chapter on Comprehensive Geriatric assessment. We thank Dr Sriraksha Nayak and Dr Vaddi Rohit, for compiling the chapter Approach to Psychiatric Illness.
We thank Dr Kaushiki Kirty, Dr Vishnu B Chandran, Dr Rama Kishore Yalampati and Dr Navyashree HC, for helping us with inputs and proofreading.
Also, we convey our sincere thanks to Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director), Mr MS Mani (Group President), Dr Madhu Choudhary (Publishing Head–Education), Ms Pooja Bhandari (Production Head), Ms Sunita Katla (Executive Assistant to Group Chairman and Publishing Manager), Dr Aakanksha Shukla Sirohi (Development Editor), Mr Rajesh Sharma (Production Coordinator), Ms Seema Dogra (Cover Visualizer), Mr Laxmidhar Padhiary (Proofreader), Mr Kapil Dev Sharma (Typesetter), Mr Manoj Pahuja (Graphic Designer) and their team members, for publishing the book in the same format as wanted, well in time.
Special thanks to Dr Ashwini MV, Dr G Suresh Reddy, Dr Lakshmi Nivedana B Dr Sriram M, Dr Pranjal Sharma, Dr Tejaswini Lakshmikeshava, Dr Nagendra C, Dr Thejus Bhaskar, Dr Mohammed Shaheen, Dr Jane Mendonca and Dr Madhav Hande, for helping us with the clinical images, editing, proofreading and designing of this book. They have lived our dream with us.
We are especially grateful for the ongoing encouragement from the management and administration of our university, the Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, India.
We are grateful to our family members, colleagues and friends who have supported us all along the way.
A very special gratitude goes out to all our teachers, who are solely responsible for what we are today and for having ignited the passion of teaching in us.
Lastly, we thank God Almighty, for making us what we are, guiding us through our life, and helping us in bringing this book to you all.
Abbreviations
°C
: Degree Celcius
°F
: Degree Farenheit
ALL
: Acute lymphoblastic leukemia
ABPA
: Allergic bronchopulmonary aspergillosis
ACS
: Acute coronary syndrome
ACR
: American College of Rheumatology
ARF
: Acute renal failure
ADHD
: Attention deficit hyperactivity disorder
ADR
: Adverse drug reaction
ARDS
: Acute respiratory distress syndrome.
AGN
: Acute glomerulonephritis
AION
: Anterior ischemic optic neuritis
AKI
: Acute kidney injury
ALL
: Acute lymphoblastic leukemia
ASCVD
: Atherosclerotic cardiovascular disease
ACD
: Anaemia of chronic disease
ADC
: Apparent diffusion coefficient
ACA
: Anterior cerebral artery
ACE
: Addenbrooke's cognitive examination
ACEI
: Angiotensin converting enzyme inhibitor
ARB
: Angiotensin receptor blocker
ACTH
: Adrenocorticotropic hormone
ADHF
: Acute decompensated heart failure
AEM
: Ambulatory electrocardiogram monitoring
AI
: Aortic insufficiency
AIDP
: Acute inflammatory demyelinating polyneuropathy
AF
: Atrial fibrillation
AICA
: Anterior inferior cerebellar artery
AICD
: Automated implantable cardioverter defibrillator
AML
: Acute myeloid leukemia
ANS
: Autonomic nervous system
ARVD
: Arrhythmogenic right ventricular dysplasia
ASD
: Atrial septal defect
AVF
: Arteriovenous fistula
AVM
: Arteriovenous malformation
AVR
: Aortic valve replacement
AVRT
: Atrioventricular re-entrant tachycardia
AVNRT
: AV nodal re-etrant tachycardia
APB
: Atrial premature beat
ALS
: Amyotropic lateral sclerosis
ADL
: Activities of daily living
ACPA
: Anticitrullinated protein antibody
APLA
: Antiphospholipid antibody syndrome
AP
: Anteroposterior
Bx
: Biopsy
BAL
: Bronchoalveolar concentration
B/L
: Bilateral
BIH
: Benign intracranial hypertension
BAV
: Bicuspid aortic valve
BBB
: Bundle branch block
BC
: Bone conduction/blood culture
BCAT
: Brief cognitive assessment tool
BER
: Benign early repolarization
BLS
: Basic life support
BSA
: Body surface area
BP
: Blood pressure
BT
: Bleeding time
BUN
: Blood urea nitrogen
BM
: Bone marrow
BMI
: Body mass index
BMV
: Bag and mask ventilation/balloon mitral valvotomy
BVP
: Biventricular pacing
B-ALL
: B-cell acute lymphoblastic leukemia
BADL
: Basic activities of daily living
CRP
: C-reactive protein
CXR
: Chest X-ray
CCA
: Common carotid artery
C/L
: Contralateral
CMT
: Charcot Marie tooth disease
CN
: Cranial nerve
C/O
: Complaints of
CT
: Computed tomography
CAMCOG
: Cambridge cognitive examination
COST
: Cognitive state test
CPR
: Cardiopulmonary resuscitation
CCF
: Congestive cardiac failure
CHF
: Congestive heart failure
CBC
: Complete blood count
CBD
: Common bile duct
CHB
: Complete heart block
CKD
: Chronic kidney disease
CIDP
: Chronic inflammatory demyelinating polyneuropathy
CLD
: Chronic liver disease
CLL
: Chronic lymphoid leukemia
CML
: Chronic myeloid leukemia
CMV
: Cytomegalovirus
CNS
: Central nervous system
CVA
: Cerebrovascular accident
CNS
: Central nervous system
CABG
: Coronary artery bypass graft
CAD
: Coronary artery disease
CAUTI
: Catheter associated UTI
CBE
: Clinical breast examination
CRF
: Chronic renal failure
COPD
: Chronic obstructive pulmonary disease
CCCU
: Critical coronary care unit
CCS
: Canadian Cardiovascular Society
CVS
: Cardiovascular system
CVP
: Central venous pressure
CP angle
: Cerebellopontine angle
CPB
: Cardiopulmonary bypass
CDC
: Centers for disease control and prevention
CDAI
: Clinical disease activity index
CGA
: Comprehensive geriatric assessment
CSF
: Cerebrospinal fluid
DDx or D/D
: Differential diagnosis
DPI
: Dry powder inhaler
DIC
: Disseminated intravascular coagulation
DIP joint
: Distal interphalangeal joint
DKA
: Diabetic ketoacidosis
DLCO
: Diffusion lung capacity for carbon monoxide
DM
: Diabetes mellitus
DR
: Diabetic retinopathy
DNR
: Do not resuscitate
DTR
: Deep tendon reflex
DTA
: Descending thoracic aorta
DSM
: Diagnostic and statistical manual of mental disorders
DVT
: Deep venous thrombosis
DLE
: Disseminated lupus erythematosus
DAS
: Disease activity score
DWI
: Diffusion weighted imaging
ECA
: External carotid artery
EAT
: Ectopic atrial tachycardia
ECG
: Electrocardiogram
ECF
: Extracellular fluid
ECHO
: Echocardiogram
ECMO
: Extracorporeal membrane oxygenation
EPS
: Extrapyramidal system
EF
: Ejection fraction
EM
: Erythema multiforme
ECD
: Endocardial cushion defects
EDH
: Extradural hematoma
EOM
: Extraocular muscles/movement
EPO
: Erythropoietin
EDM
: Early diastolic murmur
ESM
: Ejection systolic murmur
ESRD
: End-stage renal disease
ET
: Endotracheal tube
ESV
: End-systolic volume
EULAR
: European League Against Rheumatism
FMS
: Fibromyalgia syndome
FBS
: Fasting blood sugar
FEV1
: Forced expiratory volume in first second
FTT
: Failure to thrive
FVC
: Forced vital capacity
GI
: Gastrointestinal
GBS
: Guillain–Barré syndrome
GCS
: Glasgow Coma Scale
GERD
: Gastroesophageal reflux disease
GH
: Growth hormone
Hb
: Hemoglobin
HMF
: Higher mental functions
HOCM
: Hypertrophic obstructive cardiomyopathy
HBV
: Hepatitis B virus
HL
: Hodgkin lymphoma
HUS
: Hemolytic uremic syndrome
HAI
: Hospital acquired infection
HE
: Hepatic encephalopathy
HDS
: Hemodynamically stable
HIT
: Heparin induced thrombocytopenia
HCC
: Hepatocellular carcinoma
HTN
: Hypertension
HIV/AIDS
: Human immunodeficiency virus/acquired immunodeficiency syndrome
HDL
: C-High density lipoprotein cholesterol
HD
: Huntington's disease
IADL
: Instrumental activities of daily living
IP joint
: Interphalangeal joint
IGF
: Insulin-like growth factor 1
ICA
: Internal carotid artery
ICD
: Intercostal drain
ICS
: Intercostal space/inhaled corticosteroid
ICH
: Intracerebral hemorrhage
IVH
: Intraventricular hemorrhage
INO
: internuclear ophthalmoplegia
INR
: International Normalized Ratio
ICP
: Intracranial pressure
IBD
: Inflammatory bowel disease
IBS
: Irritable bowel syndrome
IDDM
: Insulin-dependent diabetes mellitus—Type 1 diabetes
ICSOL
: Intracranial space occupying lesion
IHD
: Ischemic heart disease
IJV
: Internal jugular vein
ILD
: Interstitial lung disease
IMN
: Infectious mononucleosis
IVC
: Inferior vena cava
INH
: Isoniazid
IPPV
: Intermittent positive pressure ventilation
ITP
: Immune thrombocytopenic purpura
IV
: Intravenous
JME
: Juvenile myoclonic epilepsy
JRA
: Juvenile rheumatoid arthritis
JVP
: Jugular venous pressure
KUB
: Kidney, ureters and bladder
KDIGO
: Kidney disease improving global outcomes
KF Ring
: Kayser Fleischer ring
LSM
: Late systolic murmur
LV
: Left ventricle
LVH
: Left ventricular hypertrophy
L\A
: Local anesthetic
LDL
: C-Low density lipoprotein cholesterol
LP
: Lumbar puncture
LMN
: Lower motor neuron
LVE
: Left ventricular enlargement
LVF
: Left ventricular failure
LOC
: Loss of consciousness
LQTS
: Long QT syndrome
LGIB
: Upper gastrointestinal bleed
MAP
: Mean arterial pressure
MAT
: Multifocal atrial tachycardia
MoCA
: Montral cognitive assessment
MMSE
: Mini-mental state examination
MCA
: Middle cerebral artery
MCP joint
: Metacarpophalangeal joint
MDS
: Myelodysplastic syndrome
MDM
: Mid-diastolic murmur
MLF
: Medial longitudinal fasciculus
MND
: Motor neuron disease
MS
: Mitral stenosis/multiple sclerosis
MVP
: Mitral valve prolapse
MVR
: Mitral valve replacement
MSA
: C-Multisystem atrophy—cerebellar
MSA
: P-Multisystem atrophy—Parkinson's
MCTD
: Mixed connective tissue disease
MI
: Myocardial infarction
MRC
: Medical Research Council
mMRC
: Modified Medical Research Council
MRI
: Magnetic resonance imaging
MDI
: Metered dose inhaler
MODS
: multiorgan dysfunction syndrome
NHL
: Non-Hodgkin lymphoma
NASH
: Non-alcoholic steatohepatitis
NCV
: Nerve conduction velocity
NMJ
: Neuromuscular junction
NPPV
: Noninvasive positive pressure ventilation
NPH
: Normal pressure hydrocephalus
NTS
: Nucleus Tractus solitarius
REM
: Rapid eye movement
NREM
: Non rapid eye movement
NST
: Non-stress test
NSTEMI
: Non-ST-Elevation myocardial infarction
NSAIDs
: Nonsteroidal anti-inflammatory drugs
NYHA
: New York heart association
NG Tube
: Nasogastric tube
O/E
: On examination
OSA
: Obstructive sleep apnea
OA
: Osteoarthritis
OP
: Organophosphorus
PA
: Posteroanterior
PAN
: Polyarteritis nodosa
PDA
: Patent ductus arteriosus
PAH
: Pulmonary Artery Hypertension
PCI
: Percutaneous Coronary Intervention
PCA
: Posterior cerebral artery
PCV
: Packed Cell Volume
PCWP
: Pulmonary Capillary Wedge Pressure
PD
: Parkinson's Disease
PE
: Pulmonary Embolism
PEEP
: Positive End Expiratory Pressure
PEFR
: Peak Expiratory Flow Rate
PAH
: Pulmonary Artery Hypertension
PIP Joint
: Proximal interphalangeal joint
PICA
: Posterior inferior cerebellar artery
PLS
: Progressive Lateral Sclerosis
PND
: Paroxysmal Nocturnal Dyspnea
PUO/FUO
: Pyrexia (fever) of Unknown Origin
PVC
: Premature Ventricular Contractions
pO2/paO2
: Partial pressure of oxygen
paCO2
: Partial pressure of carbon dioxide
PMI
: Point of maximal impulse
PPBS
: Post-prandial Blood Sugars
qSOFA
: Quick sequential organ failure assessment
QSART
: Quantitative sudomotor axon reflex test
RA
: Rheumatoid Arthritis
RF
: Rheumatoid factor
RAI scan
: Radioactive iodine scan
RAS
: Reticular activating system
RAPD
: Relative apparent pupillary defect
RCM
: Restrictive cardiomyopathy
RCC
: Renal cell carcinoma
RDW
: Red cell distribution width
RS
: Respiratory system
RSOV
: Ruptured sinus of valsalva
RHD
: Rheumatic heart disease
RLN
: Recurrent laryngeal nerve
RR
: Respiratory rate
RV
: Right ventricle
RVH
: Right ventricular hypertrophy
RVF
: Right ventricular failure
REMS
: Regional examination of musculoskeletal system
SAAG
: Serum–ascites albumin gradient
SAH
: Subarachnoid hemorrhage
SACD
: Subacute combined degeneration of cord
SANRT
: Sinoatrial node re-entrant tachycardia
SLRT
: Straight leg raise test
SOFA
: Sequential organ failure assessment
SIRS
: Systemic inflammatory response syndrome
SSPE
: Subacute sclerosing pan-encephalitis
SDAI
: Simplified disease activity index
STMS
: Short test of Mental status
SV
: Stroke volume
SVT
: Supraventricular tachycardia
SMA
: Spinal muscular atrophy
SDH
: Subdural haematoma
SCM
: Sternocleidomastoid
SLE
: Systemic lupus erythematosus
STEMI
: ST-Elevation myocardial infarction
SVC
: Superior vena cava
SSR
: Sympathetic skin response
SLICC
: Systemic Lupus International Collaborating Clinics
TAPVC
: Total anomalous pulmonary venous connection
TIA
: Transient ischemic attack
TB
: Tuberculosis
TBI
: Traumatic brain injury
TIN
: Tubulointerstitial nephritis
TG
: Triglycerides
TST
: Thermoregulatory sweat test
TMJ
: Temporomandibular joint
TSH
: Thyroid stimulating hormone
U/L
: Unilateral
UA
: Unstable angina
UMN
: Upper motor Neuron
UIP
: Usual interstitial pneumonitis
UGI
: Upper gastrointestinal
UGIB
: Upper gastrointestinal bleed
URTI
: Upper respiratory tract infection
UTI
: Urinary tract infection
US/USG
: Ultrasonogram
VA
: Visual acuity
VAP
: Ventilator acquired pneumonia
VC
: Vital capacity
VDRL
: Venereal Disease Research Laboratory
VPC
: Ventricular premature contractions
VSD
: Ventricular septal defect
VT
: Ventricular tachycardia
V/Q scan/ratio
: Ventilation/perfusion
VUR
: Vesicouretreric reflux
WHO
: World Health Organisation
WPW
: Wolff–Parkinson–White syndrome
ZES
: Zollinger ellison syndrome