ContentsContents 1. Introduction to Internal Medicine ..... 1 • History Taking 2 • General Examination 4 Examination of the Skin 4 Hair 6 Face 8 Eyes 9 The Tongue 9 Characteristic

Contents

1. Introduction to Internal Medicine ........... 1 • History Taking 2 • General Examination 4

♦ Examination of the Skin 4 ♦ Hair 6 ♦ Face 8 ♦ Eyes 9 ♦ The Tongue 9 ♦ Characteristic Types of Facies 12 ♦ Constitution 12 ♦ Stature 13 ♦ State of Nutrition 16 ♦ Posture 17 ♦ Hands and Fingers 18 ♦ Feet and Toes 20 ♦ The Skin in Clinical Medicine 21 ♦ Nails in Clinical Medicine 23

• Temperature 25 ♦ Normal Temperature Regulation in the Body 25 ♦ Factors Determining Rate of Heat Production 25 ♦ Fever 26

• Pain 31 ♦ Chest Pain 31 ♦ Abdominal Pain 33 ♦ Pain due to Disorders of GIT 33 ♦ Renal Pain 35 ♦ Peripheral Vascular Pain Arterial Occlusion 35 ♦ Venous Pain 35 ♦ Neurogenic Claudication 35

• Oedema 35 ♦ Aetiology and Types of Oedema 36 ♦ Pathophysiology of Oedema 36 ♦ Characteristic Features of Oedema of Various

Aetiologies 36 • Shock 38

♦ Control of Arterial Blood Pressure 38 ♦ Control Mechanism 38 ♦ Classification 38

• Fundamentals in Genetics 40 ♦ Normal Chromosome Number and Structure 41 ♦ Chromosomal Abnormalities 41 ♦ Single Gene Disorders 42 ♦ Mosaicism 43 ♦ Chimerism 43 ♦ Multifactorial or Polygenic Inheritance 43 ♦ Genomic Imprinting 44 ♦ Trinucleotide Repeat 44 ♦ Mitochondrial Disorders 44 ♦ Common Chromosomal Disorders 44

• Immunology 45 ♦ The Immune System and the Basis of Immunity 45 ♦ Clinical Aspects of Immunology 46 ♦ Immunoglobulins 46 ♦ Disorders of Immunoglobulins 48 ♦ Immunodeficiency States 48 ♦ Hypersensitivity Reactions 49

♦ Histocompatibility Antigens 50 ♦ Transplant Rejection 50 ♦ Autoimmune Diseases 50 ♦ Immunology and Malignancy 50

2. Nutrition .................................................. 51 • Classification of Nutrients 52

♦ Water 52 ♦ Macro-nutrients 52

• Classification of Nutritional Disorders 53 ♦ Pathological Causes of Nutritional Disorders 54 ♦ Effects of Malnutrition 54 ♦ Protein–Energy Malnutrition 54

• Vitamins 56 ♦ Vitamin A (Retinol) 56 ♦ Vitamin D 58 ♦ Vitamin E 60 ♦ Vitamin K 61 ♦ Thiamine (Vitamin B1) 61 ♦ Riboflavin (Vitamin B2) 62 ♦ Niacin (Nicotinic Acid and Nicotinamide) 62 ♦ Pyridoxine (Vitamin B6) 63 ♦ Biotin 63 ♦ Vitamin B12 and Folate 63 ♦ Vitamin C (Ascorbic Acid) 63

• Inorganic Nutrients 65 ♦ Sodium 65 ♦ Potassium 65 ♦ Calcium 66 ♦ Phosphorus 66 ♦ Iron 67 ♦ Iodine 67 ♦ Zinc 67 ♦ Fluorine 67 ♦ Magnesium 68 ♦ Manganese 68 ♦ Copper 69 ♦ Cobalt 69 ♦ Nickel 69 ♦ Chromium 69 ♦ Selenium 69

• Obesity 69 ♦ Types of Obesity 70 ♦ Aetiology 70 ♦ Pathology 71 ♦ Prognosis 71

• Anorexia Nervosa and Bulimia 72 ♦ Anorexia Nervosa 72 ♦ Bulimia 72

3. Infectious Diseases ................................. 73 • Bacterial Infections 74

♦ Staphylococcal Infections 74 ♦ Streptococcal Infections 76 ♦ Meningococcal Meningitis 78 ♦ Gonococcal Infection 78

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Manual of Practical Medicinex

♦ Diphtheria 79 ♦ Tetanus 80 ♦ Botulism 81 ♦ Gas Gangrene (Clostridial Myonecrosis) 82 ♦ C. difficile Infection (Pseudomembranous Colitis) 82 ♦ Listeriosis 82 ♦ Anthrax 83 ♦ Haemophilus influenzae 84 ♦ Legionella (Legionnaires Disease) 84 ♦ Whooping Cough (Pertussis) 85 ♦ Gram-negative Enteric Bacteria 85 ♦ Escherichia coli 85 ♦ Campylobacter 86 ♦ Enteric Fever 86 ♦ Shigellosis: Bacillary Dysentery 88 ♦ Cholera 88 ♦ Brucellosis (Undulant Fever) 90 ♦ Plague 90 ♦ Helicobacter pylori 91 ♦ Anaerobic Infections 92 ♦ Nocardiosis 93 ♦ Atypical Mycobacteria 94 ♦ Extrapulmonary Tuberculosis 95 ♦ Leprosy (Hansen’s Disease) 96 ♦ Chancroid 98 ♦ Granuloma Inguinale 99 ♦ Chlamydial Infections 99 ♦ Mycoplasma Infections 102

• Spirochetal Diseases 103 ♦ Syphilis 103 ♦ Yaws (Framboesia) 107 ♦ Endemic Syphilis (Bejel) 107 ♦ Pinta 107 ♦ Leptospirosis (Weil’s Disease) 107 ♦ Relapsing Fever 108 ♦ Rat-bite Fever 109 ♦ Lyme Borreliosis 109

• Rickettsial Infections 110 ♦ Epidemic Louse-Borne Typhus 110 ♦ Endemic Flea-Borne Typhus (Murine Typhus) 110 ♦ Scrub Typhus (Tsutsugamushi Fever) 111 ♦ Rocky Mountain Spotted Fever 111 ♦ Rickettsialpox 111 ♦ Tick Typhus (Rickettsial Fever) 111 ♦ Ehrlichiosis and Anaplasmosis 111 ♦ Diagnosis of Rickettsial Infections 111 ♦ Q-Fever 111 ♦ Kawasaki Disease 112

• Viral Diseases 112 ♦ Classification of Viral Disorders 112 ♦ Viral Infections and Cancer 113 ♦ Viral Pathogenesis 113 ♦ Immunity-Viral Diseases 113 ♦ Diagnostic Virology 113 ♦ Viral Respiratory Disorders 114 ♦ Parainfluenza 114 ♦ Influenza 114 ♦ Respiratory Syncytial Virus Infections 114 ♦ Herpes Virus Infections 115 ♦ Varicella Zoster Infections 117 ♦ Epstein-Barr Virus (HHV-4) and Infectious

Mononucleosis 119 ♦ Cytomegalovirus 121

♦ Human Herpesviruses Types—6, 7 and 8 122 ♦ Human Papillomavirus and Parvovirus Infections 122 ♦ Parvovirus Infections 123 ♦ Variola (Small Pox) 124 ♦ Measles (Rubeola) 124 ♦ Rubella (German Measles) 125 ♦ Mumps 126 ♦ Poliomyelitis 126 ♦ Rabies 127 ♦ Dengue Fever (Break-bone Fever) 129 ♦ Yellow Fever 129 ♦ Japanese B Encephalitis 130 ♦ Chikungunya Virus Infection 130 ♦ Gastrointestinal Virus Infections 130 ♦ Hepatitis Viruses (A–E) 130 ♦ Coxsackie Virus Infections 130 ♦ Human Immunodeficiency Virus (HIV) Infection and

Acquired Immunodeficiency Syndrome (AIDS) 132 • Protozoal Infections 141

♦ Malaria 141 ♦ Amoebiasis 146 ♦ Giardiasis 147 ♦ Cryptosporidiosis 148 ♦ Trichomoniasis 148 ♦ Balantidiasis 149 ♦ Isosporiasis 149 ♦ Leishmaniasis 149 ♦ Trypanosomiasis 151 ♦ Toxoplasmosis 154 ♦ Pneumocystis jiroveci 155

• Helminthic Infestations 156 ♦ Classification of Helminths that Infest Humans 156 ♦ Ankylostomiasis (Hookworm) 156 ♦ Ascariasis 156 ♦ Strongyloidiasis 159 ♦ Enterobius Vermicularis (Threadworm or

Pinworm) 160 ♦ Trichuris Trichiura (Whipworm) 161 ♦ Tissue-dwelling Human Nematodes 161 ♦ Lymphatic Filariasis 163 ♦ Tropical Pulmonary Eosinophilia 164 ♦ Loiasis 165 ♦ Onchocerciasis (River Blindness) 165 ♦ Dracunculiasis (Guinea Worm Infection) 166 ♦ Zoonotic Nematodes 166 ♦ Trichinosis (Trichinellosis) 166 ♦ Cutaneous Larva Migrans (CLM) 167 ♦ Trematodes (Flatworms/Flukes) 168 ♦ Schistosomiasis (Blood Flukes) 168 ♦ Hepatobiliary Flukes 170 ♦ Intestinal Flukes 170 ♦ Lung Flukes 170 ♦ Cestodes (Tapeworms) 170 ♦ Taenia Saginata 170 ♦ Taenia Solium and Cysticercosis 171 ♦ Echinococcosis 174 ♦ Hymenolepiasis Nana 175 ♦ Diphyllobothrium latum 175

• Fungal Infections 176 ♦ Candidiasis 176 ♦ Histoplasmosis 178 ♦ Coccidioidomycosis 179


Contents xi

♦ Pneumocystosis (Pneumocystis jiroveci Pneumonia) 180

♦ Cryptococcosis 181 ♦ Aspergillosis 181 ♦ Mucormycosis (Zygomycosis/Phycomycosis) 183 ♦ Penicillium Marneffei Infections 184 ♦ Mycetoma (Maduromycosis and

Actinomycetoma) 184 • Immunisation Against Infectious Diseases 185

♦ Milestones in Vaccine Evolution 185 ♦ Adult Immunisation 185

4. Cardiovascular System ......................... 189 • Symptoms and Signs 190

♦ Dyspnoea 190 ♦ Angina Pectoris 191 ♦ Palpitation 192 ♦ Syncope 192 ♦ Cyanosis 193 ♦ Arterial Pulse 194 ♦ Blood Pressure 198

• Examination of Neck Veins 201 ♦ Jugular Venous Pressure 201 ♦ Jugular Venous Pulse 202

• General Examination 204 ♦ External Features of Cardiac Disease 204 ♦ Eyes in Cardiology 204 ♦ Inspection 205 ♦ Palpation 205 ♦ Percussion 208 ♦ Auscultation 208 ♦ Heart Sounds 209 ♦ Heart Murmurs 213 ♦ Dynamic Auscultation 217

• Electrocardiogram 218 ♦ Electrical Axis 218 ♦ Left Atrial Enlargement 219 ♦ Right Atrial Enlargement 219 ♦ Left Ventricular Hypertrophy 219 ♦ Right Ventricular Hypertrophy 221 ♦ Biventricular Hypertrophy 222 ♦ Right Bundle Branch Block 222 ♦ Left Bundle Branch Block 222 ♦ Hemiblocks (Fascicular Blocks) 223 ♦ Bi-fascicular Block 223 ♦ Tri-fascicular Block 223 ♦ ECG in Coronary Artery Disease 224 ♦ ECG in Electrolyte Imbalance 226 ♦ ECG Changes with Drug Intoxication 228 ♦ ECG in Acute Pulmonary Embolism 229 ♦ ECG Features of COPD 229 ♦ ECG Features of Hypothermia 229 ♦ ECG in Various Arrhythmias 229

• Congenital Heart Diseases 239 ♦ Classification of Congenital Heart Diseases 239 ♦ Cardiac Malposition 240 ♦ Cardiac Abnormalities with Various Genetic

Disorders 243 ♦ Maternal Disease causing CHD 243 ♦ Atrial Septal Defect 244 ♦ Ventricular Septal Defect 245 ♦ Patent Ductus Arteriosus 247 ♦ Eisenmenger Syndrome 248

♦ Tetralogy of Fallot 249 ♦ Pulmonary Stenosis 252 ♦ Congenital Aortic Stenosis 253 ♦ Coarctation of the Aorta 254 ♦ Anomalous Pulmonary Venous Connection 256 ♦ Ebstein’s Anomaly 257 ♦ Complete Transposition of the Great Vessels

(D-Transposition) 258 ♦ Congenitally Corrected Transposition of the Great

Vessels 259 ♦ Truncus Arteriosus 259 ♦ Tricuspid Atresia 260 ♦ Congenital Complete Heart Block 260 ♦ Idiopathic Dilatation of the Pulmonary Artery 261 ♦ Congenital Abnormalities of the Coronary

Arteries 261 ♦ Rheumatic Fever 262

• Valvular Heart Disease 264 ♦ Mitral Stenosis (MS) 264 ♦ Mitral Regurgitation (MR) 268 ♦ Mitral Valve Prolapse Syndrome (MVPS) 270 ♦ Aortic Stenosis (AS) 271 ♦ Aortic Regurgitation (AR) 273 ♦ Tricuspid Stenosis (TS) 275 ♦ Tricuspid Regurgitation (TR) 277 ♦ Pulmonary Stenosis (PS) 277 ♦ Pulmonary Regurgitation (PR) 277 ♦ Infective Endocarditis (IE) 278

• Cardiac Failure 281 ♦ Aetiology 282 ♦ Pathophysiology 282 ♦ Classification of Cardiac Failure High Output and Low

Output Failure 282 ♦ Treatment of Cardiac Failure 284

• Systemic Hypertension 290 ♦ Recommendations of the Eighth Joint National

Committee (JNC 8) 290 ♦ Strategies in the usage of Antihypertensive Drugs 291 ♦ Causes of Isolated Systolic Hypertension 291 ♦ Factors Influencing Prognosis 292 ♦ Non-drug Therapy 293 ♦ Drug Therapy 293 ♦ Special Considerations in Antihypertensive

Therapy 298 • Acute Coronary Syndrome (ACS) 300

♦ Unstable Angina 300 • Myocardial Infarction (MI) 304

♦ Incidence 304 ♦ Risk Factors 304 ♦ Symptoms 305 ♦ Signs 305

• Myocarditis 312 ♦ Giant Cell Myocarditis 313

• Cardiomyopathies 313 ♦ Dilated (Congestive) Cardiomyopathy 313 ♦ Tako Tsubo Cardiomyopathy 314 ♦ Arrhythmogenic Right Ventricular Dysplasia

(ARVD) 314 ♦ Restrictive (Obliterative) Cardiomyopathy 314 ♦ Hypertrophic Obstructive Cardiomyopathy 315 ♦ Primary Cardiomyopathies 317 ♦ Secondary Cardiomyopathies 317 ♦ Peripartum Cardiomyopathy (PPCM) 317


Manual of Practical Medicinexii

• Pericarditis 318 ♦ Aetiologic Classification 318

• Cardiac Tamponade 320 ♦ Causes 320

• Cardiac Arrest 320 ♦ Causes 320 ♦ Cardiopulmonary Resuscitation (Basic Life

Support) 321 ♦ Cardioversion (DC Shock) 322

• Cardiac Surgery 323 • Cardiac Transplantation 323

♦ Contraindications to Cardiac Transplantation 323

5. Respiratory System ............................... 325 • Anatomical Landmarks 326 • Bronchopulmonary Segments 326

♦ Borders of the Lung 326 ♦ Pleural Border 326

• Pulmonary Circulation 327 • Systemic Circulation (Bronchial Circulation) 327 • Symptoms and Signs 327

♦ Cough 327 ♦ Sputum 327 ♦ Haemoptysis 328 ♦ Dyspnoea 329 ♦ Chest Pain 330

• General Examination 330 ♦ Clubbing 330

• Examination of the Neck 332 ♦ Scalene Lymph Node 332 ♦ Significant Node 332 ♦ Lymphatic Drainage of

the Lung and Pleura 332 ♦ Presence of Veins over the Chest Wall 333

• External Manifestations of Respiratory Diseases 333 • Examination of the Respiratory System 333

♦ Inspection of Upper Respiratory Tract 333 ♦ Inspection of Lower Respiratory Tract 333 ♦ Position of Trachea 334 ♦ Position of Apex Beat 334 ♦ Symmetry of Chest 334 ♦ Chest Deformities 334 ♦ Spinal Deformity 335 ♦ Movement of the Chest 335

• Palpation 337 ♦ Tracheal Tug-Oliver’s Sign 337 ♦ Inspiratory Tracheal Descent 337 ♦ Confirmation of Apical Impulse 337 ♦ Measurement of the Chest Expansion 338 ♦ Assessing Symmetry of Chest Expansion 338 ♦ Assessment of Anterior Thoracic Movement 338 ♦ Assessment of Posterior Thoracic Movement 338 ♦ Tenderness over the Chest Wall 339 ♦ Detection of Subcutaneous Emphysema 339 ♦ Tactile Fremitus 339 ♦ Friction Fremitus 339 ♦ Vocal Fremitus 339

• Percussion of the Lung Fields 339 ♦ General Principles 339 ♦ Areas of Percussion 340

• Auscultation 342 ♦ General Principles of Auscultation 342 ♦ Auscultatory Areas 342

♦ Technique of Auscultation 342 ♦ Importance of Auscultation 342 ♦ Breath Sounds 342 ♦ Added Sounds 343 ♦ Voice Sounds 344 ♦ Miscellaneous Sounds 344 ♦ Other Features of Clinical Significance 345 ♦ Others 345

• Cavity 346 ♦ Thick-walled Cavity 346 ♦ Thin-walled Cavity 346

• Fibrosis 347 ♦ Types of Fibrosis 347

• Investigations 347 ♦ Sputum Examination 347 ♦ Lung Function Tests 347 ♦ Bed Side Lung Function Tests 347 ♦ Spirometry 347 ♦ Lung Volume Estimation 348 ♦ Peak Expiratory Flow Rate 349

• Chest X-ray 349 ♦ Causes of Bilateral Hilar Enlargement 349 ♦ Causes of Unilateral Hilar Enlargement 349 ♦ Unilateral Hypertransradiant Hemithorax 349 ♦ Hemithorax Opacity 349 ♦ Widespread Alveolar Opacities 350 ♦ Honeycomb Lung (Air Containing Cysts 0.5–2.0 cm

in Diameter) 350 ♦ Miliary Mottling (0.5–2 mm Opacities) 350 ♦ Solitary Pulmonary Nodule 350 ♦ Multiple Medium Sized Pulmonary Nodules

(5–10 mm) 351 ♦ Lung Cavities 351 ♦ Unilateral Elevated Hemidiaphragm 351 ♦ Bilateral Elevated Hemidiaphragm 351

• CT Scan 352 • Ultrasound Scan 352 • MRI Scan 352 • Gas Diffusion Capacity 352

♦ Arterial Blood Gas Analysis 352 ♦ Ventilation-Perfusion Imaging 352 ♦ Pulmonary Angiography 352 ♦ Bronchoscopy 352 ♦ Pleural Aspiration and Percutaneous

Pleural Biopsy 353 ♦ Oxygen Therapy 353

• Respiratory Diseases 353 ♦ Classification of Respiratory Diseases 353 ♦ Bronchial Asthma 353 ♦ Obstructive Sleep Apnoea-Hypopnoea Syndrome

(OSAHS) 358 ♦ Chronic Obstructive Pulmonary Disease (COPD) 360 ♦ Bronchiectasis 363 ♦ Cystic Fibrosis 366 ♦ Tuberculosis 368 ♦ Pneumonia 374 ♦ Lung Abscess 377 ♦ Pleural Effusion 378 ♦ Pneumothorax 383 ♦ Interstitial Lung Disease 384 ♦ Bronchogenic Carcinoma 385 ♦ Mediastinal Mass 387 ♦ Acute Respiratory Distress Syndrome (ARDS) 389


Contents xiii

♦ Pulmonary Hypertension 392 ♦ Cor Pulmonale 395 ♦ Pulmonary Thromboembolism 396

• Lung Transplantation 399 ♦ Indications 399 ♦ Types 399 ♦ Prognosis 399

6. Abdomen ............................................... 401 • Clinical Examination 402

♦ Signs and Symptoms 402 ♦ General Examination 404 ♦ Signs of Liver Cell Failure 404 ♦ Regions of Abdomen 405 ♦ Inspection 405 ♦ Palpation 408 ♦ Percussion 411 ♦ Auscultation 413 ♦ Causes of Hepatomegaly 414 ♦ Causes of Painful Hepatomegaly 414 ♦ Causes of Pulsatile Liver 414 ♦ Causes of Splenomegaly 415 ♦ Causes of Hepatosplenomegaly 415 ♦ Causes of Hepatosplenomegaly +

Lymphadenopathy 415 • Gastrointestinal System 415

♦ Dysphagia 415 ♦ Achalasia Cardia 418 ♦ Gastro-oesophageal Reflux Disease 418 ♦ Peptic Ulcer Disease 418 ♦ Zollinger-Ellison Syndrome 422 ♦ Endoscopy 422 ♦ Gastrointestinal Bleeding 422 ♦ Diarrhoea 424 ♦ Malabsorption 426 ♦ Tuberculosis of Abdomen 427 ♦ Inflammatory Bowel Disease 429 ♦ Irritable Bowel Syndrome 432 ♦ Ischaemic Colitis 433 ♦ Carcinoid Tumours 433 ♦ Gastric Ulcer and Malignancy 434

• Hepatology and Pancreas 435 ♦ Hepatic Segments 435 ♦ Liver Function Tests 435 ♦ Jaundice 437 ♦ Congenital Jaundice 438 ♦ Familial Defects in Hepatic

Excretory Function 440 ♦ HIV and the Liver 441 ♦ Pregnancy and the Liver 441 ♦ Viral Hepatitis 441 ♦ Chronic Hepatitis 444 ♦ Prevention of Hepatitis 447 ♦ Autoimmune Hepatitis 447 ♦ Polycystic Liver Disease 448 ♦ Liver Abscess 448 ♦ Amoebic Abscess 449 ♦ Steatosis 449 ♦ Nonalcoholic Fatty Liver Disease 449 ♦ Cirrhosis of Liver 450 ♦ Variceal Bleeding 455 ♦ Ascites 457 ♦ Fulminant Hepatic Failure 459 ♦ Hepatic Coma (Hepatic Encephalopathy) 460

♦ Hepatorenal Syndrome 461 ♦ Hepatocellular Carcinoma (Hepatoma) 462

• Metabolic Liver Disease 463 ♦ Wilson’s Disease 463 ♦ Haemochromatosis 465 ♦ Reye Syndrome (Fatty Liver with

Encephalopathy) 466 ♦ Budd-Chiari Syndrome 466 ♦ Acute Pancreatitis 467 ♦ Chronic Pancreatitis 470 ♦ Tropical Pancreatitis 471

• Liver Transplantation 471 ♦ Cadaver Donor Selection 471 ♦ Indications 471 ♦ Contraindications 472 ♦ Immunosuppression 472 ♦ Live Donor Transplantation 472 ♦ Auxiliary Liver Transplantation 472 ♦ Split Liver Transplantation 472 ♦ Bioartificial Liver 473 ♦ Success Rate 473 ♦ Molecular Adsorbent Recirculating System

(MARS) 473

7. Haematology ......................................... 475 • Haematopoiesis and Haematopoietic Growth

Factors 476 ♦ Cell Divisions 476 ♦ Haematopoiesis 476 ♦ Normal Haematopoiesis 476 ♦ Antigen Designation—Cellular Distribution 477 ♦ Haematopoietic Stem Cells 477 ♦ Haematopoietic Stem Cell Differentiation 477 ♦ Nature of the Marrow Stem Cell 478 ♦ Stem Cell Diseases 478 ♦ Therapeutic Application of Stem Cells 478 ♦ Haematopoietic Growth Factors 478 ♦ Major Growth Factors 478

• Normal Reference Values in Haematology 480 ♦ Absolute Reticulocyte Count 480 ♦ Reticulocyte Index 481 ♦ Peripheral Film Morphology 481 ♦ WBC Count 482 ♦ Erythrocyte Sedimentation Rate 482 ♦ Automated Full Blood Analysis 482

• Anaemia 482 ♦ WHO Definition 482 ♦ Practical Classification of Anaemia 482 ♦ Classification of Anaemia (Based on Reticulocyte

Index) 483 ♦ Symptoms and Signs 483 ♦ Iron Deficiency Anaemia 483 ♦ Megaloblastic Anaemia 486 ♦ Anaemia of Chronic Disease (ACD) (Sideropenic

Anaemia, Simple Anaemia) 489 ♦ Haemolytic Anaemia 490 ♦ Hereditary Spherocytosis (HS) 491 ♦ Sickle Cell Disease 492 ♦ Thalassaemia 494 ♦ Pancytopenia 495 ♦ Aplastic Anaemia 495

• Blood Transfusion 497 ♦ Indications 497 ♦ Manipulation of Blood Products 497


Manual of Practical Medicinexiv

• Disorders of the White Cells 498 ♦ Neutrophils 498 ♦ Lymphocytes 498 ♦ Eosinophils 499 ♦ Monocytes 499 ♦ Basophils 500

• Myeloproliferative Disorders 500 ♦ WHO Classification of Myeloid Leukemia 500 ♦ Polycythaemia Vera 500 ♦ Essential Thrombocythaemia (Primary

Thrombocytosis) 502 ♦ Primary Myelosclerosis (Myelofibrosis) 503 ♦ Myelophthisic Anaemia 503

• Haematological Malignancies 504 ♦ Lymphoid Malignancies 504 ♦ Leukaemias 504 ♦ Myelodysplastic and Preleukaemic Syndromes

(MDS and PLS) 514 ♦ Lymphomas 515

• Plasma Cell Dyscrasias 519 ♦ Plasma Cell Disorders 519

• An Approach to Bleeding Disorders 522 ♦ History 522 ♦ Examination 522 ♦ Bleeding Disorders 524 ♦ Immune Thrombocytopenic Purpura (ITP) 524 ♦ Thrombotic Thrombocytopenic Purpura (TTP) 525 ♦ Haemolytic Uraemic Syndrome (HUS) 526 ♦ HIT—Heparin-induced Thrombocytopenia (White Clot

Syndrome) 526 ♦ Disorder due to Deficiency of Clotting Factors 527

• Bone Marrow Transplantation 529 ♦ Indications 529 ♦ Types of Bone Marrow Transplantation 530 ♦ Selection of the Donor 530 ♦ Preparation of the Patient 530 ♦ Marrow Aspiration and Infusion 530 ♦ Bone Marrow Transplantation (BMT) in

Leukaemia 531 ♦ Autologous BMT 531

• Haematopoietic Stem Cell Transplantation 531 ♦ Allogeneic Stem Cell Transplant 531 ♦ Autologous Stem Cell Transplant 531 ♦ Peripheral Blood Stem Cell

Transplantation (PBSCT) 532

8. Nephrology ........................................... 533 • Urine Analysis 534

♦ Methods of Collection of Urine Specimens 534 ♦ Dipstick Testing 534 ♦ Microscopic Analysis 534 ♦ Haematuria 534 ♦ Urinary Casts 535 ♦ Leucocytes in Urine 536 ♦ Renal Tubular Cells 536 ♦ Crystals 536 ♦ Proteinuria 536 ♦ Reducing Substances in Urine 538 ♦ 24-hour Urine Studies 538 ♦ Blood Tests for Evaluating Glomerular Disorders 539 ♦ Serum and Urine Protein Electrophoresis 539 ♦ Urine Eosinophils 539 ♦ Renal Ultrasonography 539

♦ IV Urography 539 ♦ Radionuclide Scanning 539 ♦ MRI Imaging and Angiography 539 ♦ Creatinine Clearance (ClCr) 539

• Urinary Tract Infection 539 ♦ Definitions 539 ♦ Risk Factors Associated with Urinary Tract

Infection 540 ♦ Pathogenesis 540 ♦ Symptoms of UTI 540 ♦ Principles of Treatment of UTI 541 ♦ Recommendations for Use and Care of Urinary

Catheters 541 ♦ Urinary Antiseptics 543 ♦ Prophylaxis for UTI 543

• Glomerulopathies 543 ♦ Classification 543 ♦ Classification of Nephritic Syndrome Based on

Complement Levels 543 ♦ HIV-associated Nephropathy 543 ♦ Nephrotic Syndrome 544 ♦ Glomerulonephritis 547 ♦ Alport Syndrome 549 ♦ Fanconi Syndrome 549 ♦ Chronic GN 550 ♦ Tubulointerstitial Disease of Kidney 550 ♦ Acute Interstitial Nephritis 551 ♦ Renal Biopsy—Indications 551 ♦ Contraindications to Renal Biopsy 551 ♦ Chronic Interstitial Nephritis 551 ♦ Polycystic Kidney Disease 551

• Acute Kidney Injury/Acute Renal Failure (ARF) 552 ♦ Causes of ARF 553 ♦ Acute Tubular Necrosis 553 ♦ Renal Tubular Acidosis (RTA) 555

• Chronic Kidney Disease 556 ♦ Chronic Renal Failure (CRF) 556

• Dialysis 560 ♦ Haemodialysis (HD) 560 ♦ Haemofiltration 560 ♦ Intermittent Peritoneal Dialysis 560 ♦ Continuous Ambulatory Peritoneal Dialysis

(CAPD) 560 • Renal Transplantation 561

♦ Rejection 561 ♦ Immunosuppressive Therapy in Renal

Transplant ation 561 • Fluid and Electrolyte Imbalance 561

♦ Sodium 561 ♦ Potassium 563

• Acid-Base Balance and its Disorders 564 ♦ Definitions 565 ♦ Hydrogen Ion Homeostasis 565 ♦ Approach to Acid-Base Disorders 567

9. Nervous System .................................... 569 • Higher Functions 570

♦ Definitions 570 • Examination of Higher Mental Functions 572

♦ Consciousness 572 ♦ Causes of Coma 572 ♦ Approach to Coma 573 ♦ Appearance and Behaviour 577


Contents xv

♦ Emotional State 577 ♦ Orientation 577 ♦ Handedness 577 ♦ General Intelligence 577 ♦ Memory 578 ♦ Perceptions 578 ♦ Visuospatial Functions 578 ♦ Sleep 579 ♦ Speech and Language 583 ♦ Cognitive Scales 588

• Examination of the Cranial Nerves 589 ♦ First Cranial Nerve (Olfactory Nerve) 589 ♦ Second Cranial Nerve (Optic Nerve) 590 ♦ The Oculomotor (Third), Trochlear (Fourth), and

Abducent (Sixth) Cranial Nerves 597 ♦ Fifth Cranial Nerve (Trigeminal Nerve) 605 ♦ Seventh Cranial Nerve (Facial Nerve) 607 ♦ The Eighth Cranial Nerve (Vestibulocochlear Nerve) 611 ♦ The Ninth and Tenth Cranial Nerves (Glossopharyngeal

and Vagus Nerves) 615 ♦ Eleventh Cranial Nerve (Accessory Nerve) 615 ♦ The Twelfth Cranial Nerve (Hypoglossal Nerve) 617

• Spinomotor System 617 ♦ Corticobulbar and Corticospinal (Pyramidal)

System 618 ♦ Extrapyramidal System 619 ♦ Neuromuscular System (Lower Motor Neurons) 620 ♦ Cerebellum 640

• Sensory System 643 ♦ Positive Phenomena 643 ♦ Negative Phenomena 643 ♦ Cutaneous Afferent Innervation 643 ♦ Sensory Pathways 644 ♦ Modalities of Sensation to be Tested 645 ♦ Arrangement of Sensory Fibres 645 ♦ Sensory Dermatomes 645 ♦ Proprioceptive Sensations 647 ♦ Vibration Sense 648 ♦ Muscle Sensitivity 648 ♦ Cortical Sensations 649

• Epilepsy 652 ♦ Classification of Seizures 652 ♦ Precipitating Factors for Epilepsy 652 ♦ Causes 653 ♦ Age-related Causes of Seizures 653 ♦ Status Epilepticus 657 ♦ Epilepsy in Pregnant Women 659 ♦ Psychogenic Seizures 660

• Neurocutaneous Syndromes 660 ♦ Neurofibromatosis 660 ♦ Tuberous Sclerosis 661 ♦ Von Hippel-Lindau Syndrome 661 ♦ Sturge-Weber Syndrome 661 ♦ Ataxia Telangiectasia 661

• Cerebrovascular Disorders 662 ♦ Stroke 662 ♦ Young Stroke 669 ♦ Subclavian Steal Syndrome 673 ♦ Lacunar Infarction 673 ♦ Cortical Venous Thrombosis (Dural Sinus

Thrombosis) 674 ♦ Intracerebral Haemorrhage (ICH) 675 ♦ Subarachnoid Haemorrhage (SAH) 678

• Brain Death 681 ♦ Essential Neurological Signs 681

• Headache 681 ♦ Pain Sensitive Structures 681 ♦ Pain Insensitive Structures 682 ♦ Mechanisms of Production of Headache 682 ♦ Headache Caused by Systemic Illness 682

• Neoplastic Disease of the Central Nervous System 685 ♦ Spinal Cord Tumours (Excluding Secondaries) 685 ♦ Cerebral Tumours 685 ♦ Ring Enhancing Lesion—Differential Diagnosis 687

• Movement Disorders 688 ♦ Classification 688 ♦ Parkinson’s Disease 688 ♦ Parkinsonism Plus Syndromes 691

• Motor Neuron Disease 691 ♦ Genetic Classification 691 ♦ Amyotrophic Lateral Sclerosis 692 ♦ Progressive Muscular Atrophy (Predominant LMN

Involvement) 692 ♦ Progressive Bulbar Palsy 693 ♦ Primary Lateral Sclerosis (Predominant UMN

Involvement) 693 ♦ Pseudobulbar Palsy (UMN Fibres Corticobulbar Tracts)

of Cranial Nerves 693 ♦ Variants of Motor Neuron Disease 693 ♦ Spinal Muscular Atrophy (SMA) 695

• Ataxic Disorders (Cerebellar and Spinocerebellar) 695 ♦ Hereditary Ataxia 695

• Congenital Ataxias 696 • Ataxic Disorders with Known Metabolic or Other

Causes 697 • Ataxic Disorders of Unknown Aetiology of Early

Onset 698 • Ataxic Disorders of Unknown Aetiology of Late

Onset 699 ♦ Multiple Sclerosis 702 ♦ Clinical Features not Suggestive of MS 704 ♦ Features that Differentiate MS from Other

Demyelinating Disorders 704 ♦ Meningitis 706 ♦ Types of CNS TB 706 ♦ Complications of TB Meningitis 708 ♦ Corticosteroids in CNS Tuberculosis 708 ♦ Encephalitis 708 ♦ Slow Virus Disease 709 ♦ Autonomic Nervous System 712 ♦ Horner’s Syndrome 713

• The Spine 713 ♦ Curvature Disorders 713

• Spinal Cord 715 ♦ Vascular Syndromes of Spinal Cord 716 ♦ Spinal Cord Disorders 717 ♦ Traumatic Lesions of the Spinal Cord 718 ♦ Tuberculosis 718 ♦ Syphilis 719 ♦ Epidural Abscess 719 ♦ Epidural Haemorrhage and Haematomyelia 719 ♦ Cervical Spondylosis 720 ♦ Lumbar Canal Stenosis 721 ♦ Paraplegia 723 ♦ Syringomyelia 730


Manual of Practical Medicinexvi

♦ Subacute Combined Degeneration (Posterolateral Sclerosis of the Spinal Cord) 731

♦ Other Causes of Posterolateral Column Syndrome 732

• Craniovertebral Junction (CVJ) Anomalies 732 ♦ Classification 732

• Peripheral Neuropathy 735 ♦ Pathogenesis 735 ♦ Classification of Peripheral Neuropathy 735 ♦ Symptoms 736 ♦ Guillain-Barré Syndrome 738 ♦ Chronic Inflammatory Demyelinating

Polyneuropathy 739 ♦ Hereditary Sensory Motor Neuropathy (Charcot-Marie

Tooth Disease) 740 • Polymyositis 741

♦ Classification 741 • Muscular Dystrophies 742

♦ Classification 742 ♦ Mitochondrial Myopathy 744

• Congenital Myopathies 744 ♦ Central Core Disease 744 ♦ Nemaline Myopathy 744 ♦ Centronuclear Myopathy 744 ♦ Myotonia Congenita (Thomson’s Disease) 745 ♦ Paramyotonia Congenita 745 ♦ Myasthenia Gravis 746 ♦ Myasthenic Syndrome (Eaton-Lambert

Syndrome) 748

10. Endocrine and Metabolic Disorders .... 749 • Hypothalamus and Pituitary Gland 750

♦ Anatomy 750 ♦ Anterior Lobe 750 ♦ Neurohypophysis 750

• Hypopituitarism 750 ♦ Aetiology 750

• Hypersecretory Disorders of Anterior Pituitary 752 ♦ Acromegaly and Gigantism 752 ♦ Hyperprolactinaemia 755 ♦ Pituitary Tumours 756 ♦ Pituitary Hyperplasia 757 ♦ Empty Sella Syndrome 757 ♦ Craniopharyngioma 757

• Disorder of the Neurohypophysis 757 ♦ Diabetes Insipidus 757 ♦ Syndrome of Inappropriate Antidiuretic Hormone

Secretion 760 • Thyroid Disorders 761

♦ Anatomy and Physiology of Thyroid Gland 761 ♦ Hyperthyroidism 762 ♦ Hypothyroidism 767 ♦ Thyroiditis 770 ♦ Malignant Tumours of the Thyroid 773 ♦ Medullary Carcinoma 774

• Disorders of Parathyroid Gland and Calcium and Phosphorus Metabolism 774

♦ Anatomy and Physiology 774 ♦ Actions of Parathormone 774 ♦ Actions of Calcitonin 774 ♦ Parathormone Related Peptide (PTHrp) 775 ♦ Causes of Hypercalcaemia 775 ♦ Primary Hyperparathyroidism 776

♦ Hypercalcaemia in Malignancy 778 ♦ Endocrine Causes of Hyperparathyroidism 778 ♦ Secondary Hyperparathyroidism (Increased PTH and

Calcium may be Normal or Low) 778 ♦ Tertiary Hyperparathyroidism 778 ♦ Hypocalcaemic Disorder 778

• Adrenal Glands 780 ♦ Anatomy and Physiology 780 ♦ Primary Hyperaldosteronism 780 ♦ Secondary Hyperaldosteronism 781 ♦ Cushing’s Syndrome 781 ♦ Adrenal Insufficiency 784 ♦ Adrenal Crisis 787 ♦ Phaeochromocytoma 788 ♦ Sexual Disorders 790

• Diabetes Mellitus (DM) 792 ♦ Aetiologic Classification of Diabetes Mellitus 793 ♦ Risk Factors for Type 2 Diabetes Mellitus (Statistical Risk

Disease) 794 ♦ Diagnosis 795 ♦ Insulin Therapy 795 ♦ Type 2 Diabetes Mellitus 802 ♦ Acute Complications of Diabetes 810 ♦ Long-term Complications of Diabetes 816 ♦ Diabetic Foot 823 ♦ Diabetic Nephropathy (DN) 824 ♦ Pregnancy and Diabetes 825 ♦ Surgery and Diabetes 827 ♦ Hypoglycaemia in Adults 828 ♦ Fed (Reactive) Hypoglycaemias 832

• Hyperlipoproteinaemias 833 ♦ Structure 833 ♦ Classification of Lipoproteins and their

Composition 833 • Osteomalacia 838

♦ Aetiology 838 • Osteoporosis 839

♦ Aetiology 839 ♦ Male Osteoporosis 841 ♦ Paget’s Disease 842

11. Connective Tissue Disorders ................ 843 • Arthritis 844

♦ Approach to Musculoskeletal Pain 844 ♦ Classification 844 ♦ Rheumatoid Arthritis 844 ♦ Drug Therapy 849 ♦ Osteoarthritis (OA) 853 ♦ Spondyloarthropathy 853 ♦ Systemic Lupus Erythematosus (SLE) 857 ♦ Mixed Connective Tissue Disease 861 ♦ Progressive Systemic Sclerosis 862 ♦ Vasculitis Syndromes 865 ♦ Polyarteritis Nodosa 866 ♦ Churg-Strauss Disease (Allergic Angiitis or

Granulomatosis) 868 ♦ Wegener’s Granulomatosis (WG) 868 ♦ Temporal Arteritis (Giant Cell Arteritis, Cranial

Arteritis) 869 ♦ Takayasu’s Arteritis (Aortic Arch Syndrome) 870 ♦ Kawasaki Disease (Mucocutaneous Lymph Node

Syndrome) 870 ♦ Behçet’s Syndrome 871


Contents xvii

♦ Sjogren’s Syndrome (SS) (Autoimmune Exocrinopathy/Autoimmune Epithelitis) 871

♦ Antiphospholipid Antibody Syndrome (APS) 872

12. Oncology ............................................... 875 • Basic Concepts 876

♦ Genes and Cancer 876 ♦ Tumour Suppressor Genes and Familial Cancers 876 ♦ Cell Biology of Cancer 876

• Aetiology of Cancers 878 ♦ Carcinogens 878

• Clinical Features of Cancer 880 ♦ General Features 880 ♦ Specific Clinical Features 881 ♦ Investigations 883 ♦ Diagnosis 884 ♦ Staging 884 ♦ Performance Status 885 ♦ Cancer Screening 885 ♦ Complications 886 ♦ Vaccination of Cancer Patients 886

• Paraneoplastic Syndromes 887 ♦ Endocrine Syndromes 887 ♦ Haematologic Syndromes 888 ♦ Neurologic Syndromes 889

• Oncologic Emergencies 890 ♦ Superior Vena Caval Obstruction 890 ♦ Increased Intracranial Pressure (Brain Metastasis) 891 ♦ Meningeal Carcinomatosis 891 ♦ Intracerebral Leucocytostasis (Ball’s Disease) 891 ♦ Seizures 891 ♦ Spinal Cord Compression 891 ♦ Malignant Effusions 892 ♦ Airway Obstruction 892 ♦ Haemoptysis 892 ♦ Intestinal Obstruction 893 ♦ Urinary Obstruction 893 ♦ Biliary Obstruction 893 ♦ Other Emergencies 893

• Metastatic Cancer of Unknown Primary Site 894 ♦ Biologic Behaviour 894 ♦ Clinical Evaluation 895 ♦ Pathological Evaluation or Biopsy 895

• Principles of Cancer Therapy 896 ♦ Surgery 896 ♦ Radiation Therapy 896 ♦ Chemotherapy 897 ♦ Therapy of Selected Cancers 905

• Symptom Control in Severe Cancer 907 ♦ Pain 907 ♦ Nausea and Vomiting 907 ♦ Pruritus 908 ♦ Hiccup 908 ♦ Breathlessness 908 ♦ Cachexia/Anorexia 908 ♦ Constipation 908 ♦ Complications of Therapy 908 ♦ Late Effects of Cancer Therapy 910

13. Geriatric Medicine ................................ 913 • Ageing 914

♦ Postulated Mechanisms for Ageing 914 ♦ Some Physiological Effects of Ageing 914

♦ Characteristics of Disease in Old Age 914 ♦ Giants of Geriatric Medicine 916 ♦ Principles of Management of Geriatric Problems 918 ♦ Drugs Cleared by the Kidney which should be Closely

Monitored in the Elderly 919

14. Substance Abuse ................................... 921 • Alcohol 922

♦ Risk Factors for Alcoholic Liver Disease 922 ♦ Effect of Alcohol on Liver 922 ♦ Alcohol and Central Nervous System (CNS) 924 ♦ Tobacco Alcohol Amblyopia 925 ♦ Nutritional Deficiency Syndrome 925 ♦ Pregnancy and Alcohol 926 ♦ Gastrointestinal 926 ♦ Haematology 926 ♦ Cardiovascular System 926 ♦ Respiratory System 926 ♦ Genitourinary System 926 ♦ Bone 927 ♦ Endocrine 927 ♦ Skin 927 ♦ Alcohol and Malignancy 927 ♦ Alcohol and Lymphatic System 927 ♦ Alcohol and Drug Interactions 927 ♦ Psychological 927 ♦ Social 927 ♦ Alcoholic Coma 927 ♦ Alcohol Withdrawal 927 ♦ Alcohol Dependence—Drugs Used for

Management 928 • Smoking 928

♦ Contents of Cigarette Smoke 928 ♦ Pharmacology of Cigarette Smoke 928 ♦ Characteristics of Smokers 929 ♦ Clinical Correlations 929 ♦ Passive Smoking 930 ♦ Smoking and Drugs 930 ♦ Types of Smoking 930 ♦ Cessation Process 931 ♦ Cessation Methods 931

15. Imaging Modalities in Internal Medicine .................................. 933

• X-ray 934 ♦ Chest Film 934 ♦ Plain Abdominal Film 934 ♦ Plain X-ray Skull 938 ♦ X-ray Hands 940

• Contrast Studies 941 ♦ Intravenous Urography Pyelography (IVU or IVP) 941 ♦ Angiography 942

• Radioisotope Scanning 942 ♦ Cardiac Scanning 942 ♦ Brain Scanning with 99mTc 942 ♦ Ventilation/Perfusion Scan (V/Q Scan) 943 ♦ 99mTc Bone Scan 943 ♦ Renal Scan 943 ♦ Adrenal Scan 943 ♦ Hepatobiliary Scan 943 ♦ Thyroid Scan 943 ♦ White Cell Scan 943 ♦ Gallium-67 Scan 944


Manual of Practical Medicinexviii

♦ Positron Emission Tomography (PET) 944 ♦ Single Photon Emission Computed Tomography

(SPECT) 944 • Ultrasound 944

♦ Abdominal Scan 944 • Echocardiography 945

♦ Thyroid Scan 947 ♦ Orbit and Eye 947 ♦ Large Veins and Arteries 947 ♦ Special Techniques 947

• Computed Tomography (CT) Scan 947 ♦ CT Brain 947 ♦ CT Chest 948

• CT Angiography 948 ♦ Benefits 950 ♦ Risks 951 ♦ CT Coronary Angiography 951 ♦ CT—Abdomen 951

• Magnetic Resonance Imaging (MRI) 953 ♦ Advantages of MRI 954 ♦ Diffusion-weighted MRI 954 ♦ Disadvantages of MRI 955

16. Procedures ............................................ 957 • Pleural Aspiration 958

♦ Indications for Pleural Aspiration 958 ♦ Indications for Therapeutic Aspiration 958 ♦ Site of Aspiration 958 ♦ Pleural Aspiration Needle 958 ♦ Procedure 958

• Pleural Biopsy 958 • Lumbar Puncture 959

♦ Indications 959 ♦ Contraindications 959 ♦ Lumbar Puncture Needle 959 ♦ Procedure 959

• Queckenstedt’s Test 960 ♦ Procedure 960 ♦ Cisternal Puncture 960

• Pericardiocentesis 960 ♦ Indications 960 ♦ Needle 960 ♦ Procedure 960 ♦ Aftercare 961

• Ascitic Fluid Aspiration (Paracentesis) 961 ♦ Indications 961 ♦ Procedure 961 ♦ Aftercare 962

• Bone Marrow Aspiration 962 ♦ Indications 962 ♦ Contraindication 962 ♦ Needles 962 ♦ Procedure 962

• Trephine Biopsy 963 • Liver Biopsy 963

♦ Indications 963

♦ Contraindications 963 ♦ Liver Biopsy Needles 963 ♦ Procedure 963 ♦ Aftercare 964

• Kidney Biopsy 964 ♦ Contraindications 964 ♦ Procedure 965 ♦ Aftercare and Complications 965

• Setting up a Drip 965 ♦ Indications 965 ♦ Precautions 966 ♦ Procedure 966

• Administration of Intravenous Cytotoxics 966 ♦ Procedure 966 ♦ Contraindications for Cytotoxic Therapy 967 ♦ Problems 967

• Percutaneous Central Venous Cannulation 967 ♦ Procedure 967 ♦ Maintenance of Central Venous Cannulation 969

• Passing a Nasogastric Tube 969 ♦ Procedure 969 ♦ Problems 969 ♦ Aftercare and Complications 969

• Urethral Catheterisation 970 ♦ Indications 970 ♦ Contraindications 970 ♦ Choice of Catheters 970 ♦ Procedure 970 ♦ Problems 971

• Arterial Puncture 971 ♦ Contraindications 971 ♦ Site of Puncture 971 ♦ Procedure 971

• Tracheostomy 971 ♦ Indications 971 ♦ Types 971 ♦ Tracheostomy Tubes 972 ♦ Procedure 972 ♦ Postoperative Care 972 ♦ Removal of Tube 972

• Endotracheal Intubation 972 ♦ Types 972 ♦ Procedure 973

Laboratory Reference Values............... 975 ♦ Serum Biochemistry 975 ♦ Serum Enzymes 975 ♦ Haematologic Values 976 ♦ Urine 976 ♦ Stool 976 ♦ Sweat 976 ♦ Hormones 976

• Cerebrospinal Fluid 977

Index ......................................................................979


Documents

ContentsContents 1. Introduction to Internal Medicine ..... 1 • History Taking 2 • General Examination 4 Examination of the Skin 4 Hair 6 Face 8 Eyes 9 The Tongue 9 Characteristic