Nội dung

P. J. MEHTA'S p �T ME I SP Mehta • SR Joshi • Nihar P Mehta 20 NATIONAL CONTENTS PART I - CLINICAL CASES 1. HISTORY TAKING AND SYMPTOMATOLOGY 1. Weight loss 2 24. Heart burns 5 2. Weight gain 2 25. Vomiting 6 3. Anorexia 2 26. Hematemesis 6 4. Fever 2 27. Constipation 6 5. Chest pain 2 28. Flatulence 6 6. Dyspnea 3 29. Diarrhea 6 7. Cough 3 30. Bleeding per rectum 6 8. Hemoptysis 3 31. Jaundice 6 9. Palpitations 3 32. Epistaxis 6 10. Syncope 3 33. Bleeding Gums 6 11. Polyuria 3 34. Hoarse Voice 7 12. Pyuria 4 35. Itching 7 13. Frequency of Micturition and Nocturia 4 36. Hirsutism 7 14. Hesitancy and Precipitancy of Urine 4 37. Gynecomastia 8 15. Retention of urine 4 38. Backache 8 16. Hematuria 4 39. Hiccough 8 17. Anuria 4 40. Headache 8 18. Pain in the Loin 5 41. Tinnitus 9 19. Abdominal Pain 5 42. Tingling and Numbness 9 20. Dysphagia 5 43. Cramps 9 21. Water brash 5 44. Intermittent Claudication 9 22. Indigestion 5 45. Vertigo 9 23. Eructation 5 2. GENER AL EXAMINATION 1. Built 10 11. Skin and its Appendages 27 2. Body Proportions 14 12. Vertebral Column 31 3. Nutrition 14 13. Thickened nerves 32 4. Decubitus 15 14. Joints 32 5. Clubbing 15 15. Temperature 36 6. Cyanosis 16 16. Pulse 39 7. Jaundice 19 17. Jugular Venous Pulse (JVP) 43 8. Pallor 22 18. Blood pressure 46 9. Lymphadenopathy 23 19. Hypertension 48 25 20. Hypotension 53 10. Edema 3.ABDOMEN 1. Proforma 55 10. Alcoholic Liver Disease 87 2. Examination 56 11. Malaria 90 95 3. Hepatomegaly 65 12. Kala Azar 4. Splenomegaly 67 13. Typhoid 98 5. Ascites 70 14. Leukemia 102 6. Abdominal Lump 72 15. Malignant lymphoma 106 7. Acute Viral Hepatitis 77 8. Cirrhosis of Liver 82 9. Portal Hyp ertension 84 16. Human Immunodeficiency Virus (HIV) Disease Acquired Immune Deficiency Syndrome (AIDS) 109 4. RESPIRATORY SYSTEM 1. Proforma 122 2. Examination 124 3. Pleural Effusion 135 4. Collapse / Atelectasis of Lung 143 5. Pulmonary Fibrosis / Interstitial Lung Diseases 145 6. Pneumothorax 149 7. Pulmonary cavity 154 8. Bronchogenic Carcinoma 155 9. Pulmonary Tuberculosis 158 10. Chronic Obstructive Pulmonary Disease (COPD) (Emphysema and Chronic Bronchitis) 168 11. Pneumonia 172 12. Bronchiectasis 175 13. Lung Abscess 178 14. Solitary Pulmonary Nodule (SPN) 180 15. Obstructive Sleep Apnoea 182 16. Hepatopulmonary Syndrome 185 17. Allergic Bronchopulmonary Asperigillosis (ABPA) 187 5. CARDIOVASCULAR SYSTEM 1. Proforma 188 12. Cyanotic Congenital Heart Disease 243 2. Examination 189 13. Patent Ductus Arteriosis (PDA) 250 3. Rheumatic fever 203 14. Ventricular Septa! Defect (VSD) 252 4. Infective Endocarditis 205 15. Atrial Septa! Defect (ASD) 253 5. Ischemic Heart Disease 208 16. Coarctation of Aorta 255 6. Cardiac Failure 220 17. Aneurysm of Aorta 257 7. Mitra! Stenosis (MS) 225 18. Pericardia! Effusion 259 8. Mitral Regurgitation (MR) 232 19. Cardiomyopathy 260 9. Mitra! Valve Prolapse (MVP) 236 20. Fitness for surgery (Pre-operative Evaluation) 263 10. Aortic Regurgitation (AR) 237 11. Aortic Stenosis (AS) 241 6. CENTRAL NERVOUS SYSTEM I. Proforma 264 8. Myasthenia Gravis 340 2. Examination 266 9. Cerebellum 341 3. Cranial Nerves 298 10. Tuberculosis of Nervous System 344 4. Bulbar Palsy 321 11. Cerebrovascular Diseases 349 5. Hemiplegia 322 12. Parkinsonism 357 6. Paraplegia 326 13. Coma 365 7. Quadriplegia 336 14. Syphilis of Nervous System 370 PART II-TABLE-WORK 7. MEDICAL EMERGENCIES 1. Cardiac Arrest 374 28. Acute Retention of Urine 395 2. Cardiac Failure 377 29. Acute Renal Failure (ARP) 395 3. Ischemic Heart Disease 377 30. Diabetic Ketoacidosis 396 4. Stokes Adams Syndrome 377 31. Hypoglycemia 397 5. Hypertensive Crisis 377 32. Respiratory Acidosis 398 6. Hypertensive Encephalopathy 378 33. Metabolic Acidosis 399 7. Shock 379 34. Respiratory Alkalosis 399 8. Anaphylactic Shock 380 35. Metabolic Alkalosis 399 9. Pulmonary Embolism and Deep Vein Thrombosis 380 36. Dehydration 400 37. Hypernatremia 400 10. Hemoptysis 382 11. Bronchial Asthma 383 12. Respiratory Failure 385 13. Tension Pneumothorax 386 14. Hematemesis 387 15. Acute Gastroenteritis / Food poisoning 388 16. Acute Pancreatitis 389 17. Hepatic Coma 389 18. Coma 390 19. Meningitis 390 20. Cerebrovascular Diseases 391 21. Subarachnoid Hemorrhage 391 22. Epilepsy 391 23. Sickle Cell Crisis 393 24. Acute Hemolytic Crisis 393 25. Aplastic Anemia 394 26. Hemophilia 27. Renal Colic 38. Hyponatremia 400 39. Hyperkalemia 401 40. Hypokalemia 401 41. Acute Hypercalcemia 401 42. Amebic Dysentery 401 43. Bacillary Dysentery 402 44. Cholera 402 45. Typhoid 403 46. Dengue 403 47. Leptospirosis 404 48. Diphtheria 405 49. Tetanus 405 50. Rabies 406 51. Cerebral Malaria 406 52. Acute Poisonings 406 394 53. Organophosphorous Compound Poisoning 407 394 54. Acute Alcoholic Intoxication 408 59. Snake Bite 55. Barbiturate Poisoning 408 56. Acute Salicylate Poisoning 409 60. Scorpion Bite 411 57. Carbon Monoxide Poisoning 409 61. Hyperpyrexia 413 58. Carbon Dioxide Narcosis 410 62. Drowning 413 410 8. ELECTROCARDIOGRAPHY 1. Introduction 415 2. Normal ECG 415 3. Waves and Complexes 416 4. Myocardial Infarction 421 5. Ventricular Enlargement 421 6. Rhythm Disturbances 422 7. Conduction Defects Atrioventricular Block (AV Block) 429 8. Effect of Drugs and Electrolytes 430 9. RADIOLOGY 432 5. Barium studies X-ray Chest - Heart 437 6. X-ray of Bones 447 Plain X-ray Abdomen 438 7. X-ray Skull 452 Urogenital System 440 1. X-ray chest 2. 3. 4. 443 10. INSTRUMENTS 1. Endotracheal Tube 455 20. Urosac Bag 465 2. Tracheostomy Tube 456 21. Stomach Tube 466 457 3. Laryngoscope 4. Oxygen Mask and Oxygen Cannula (Nasal Prongs) 458 5. Nebulizer Chamber 458 6. Metered Dose Inhaler 458 7. Spacehaler 459 8. Rotahaler 459 9. Nelson's Inhaler 459 10. Ambu Bag (Self-inflating Ventillation Bag) 460 11. Airway 460 12. Mouth Gag 461 13. Tongue Depressor 462 14. Trocar and Cannula 462 15. Asepto Syringe and Bulb 462 16. Simple Rubber Catheter 462 17. Foley's Self-retaining Catheter 463 18. Malecot's Catheter 465 19. Condom Catheter 465 22. Ryle's Tube (RT) or Nasogastric Tube 466 23. Sengstaken Blakemore Tube (S.B. Tube) 467 24. Infant Feeding Tube 468 25. Record Syringe and Needle 469 26. B.D. Syringe and Needle 469 27. Tuberculin Syringe 470 28. Insulin Syringe 470 29. Lumbar Puncture Needle 471 30. Cisternal Puncture Needle 471 31. Vim-Silverman's Needle 471 32. Menghini's Needle and Syringe 471 33. Bone Marrow Aspiration Needle 471 34. Pleural Biopsy Needle 472 35. Trucut Needle 472 36. Southey's Tube and Needle 472 37. Tourniquet 472 38. Venesection Needle 473 39. Scalp Vein Needle 473 475 40. Pleural or Ascitic Aspiration Needle 473 44. Clinical Thermometer 41. Intravenous Cannulas (Venflow or Angiocath) 473 45. Flatus Tube 476 42. Three Way 474 46. Proctoscope 476 43. I.V. Set 474 47. Stethoscope 477 48. Central Venous Catheter 477 11. PROCEDURES 1. Transvenous Pacing 479 11. Ascitic Tapping 490 2. Cardioversion 479 12. Gastric Analysis 491 3. Lumbar Puncture 480 13. Glucose Tolerance Test (G.T.T.) 492 4. Cisternal Puncture 484 14. Intravenous Therapy 493 5. Liver Biopsy 484 15. Subcutaneous Infusions 495 6. Kidney Biopsy 486 16. Tracheostomy 495 7. Bone- marrow Aspiration 487 17. Oxygen Therapy 496 8. Pleural Fluid Aspiration 488 18. Enema 497 9. Aspiration ofPneumothorax Cavity 489 19. Parenteral Hyperalimentation 499 490 10. Pericardia! Aspiration 12. HEMATOLOGY 1. Blood Collection 501 11. Electronic Cell Counters 514 2. Preparation ofBlood 502 12. Red Cell Indices 514 3. Hemoglobin Estimation 505 13. Red Cell Morphology 515 4. Packed Cell Volume (PCV ) 507 14. Anemias 517 5. Erythrocyte Sedimentation Rate (E.S.R.) 507 15. Differential Leucocyte Count 522 6. Reticulocyte Count 509 16. Leukemias 525 7. Osmotic Fragility ofRBCs 510 17. Parasites in Blood 525 8. Total Red Cell Count 510 18. Multiple Myeloma 526 9. Total White Cell Count 511 19. Coagulation studies 526 513 20. Normal Hematological Values 613 10. Platelet Count 13. CLINICAL PATHOLOGY 1. Urine Examination 533 3. Feces Examination 539 2. Sputum 539 4. Helminthic Infections 541 14. PATHOLOGY SP ECIMENS L_ 1. Central Nervous System 546 5. Large Intestines 553 2. Cardiovascular System 547 6. Liver 553 3. Lung 549 7. Kidney 555 4. Small Intestine 552 15. DRUGS 1. 2. Cardiovascular Drugs 557 Antibacterial Agents 585 a) Inotropic Drugs 557 a) 585 b) Anti-arrhythmic Drugs 558 b) Quinolones c) Anti-angina! Agents 560 c) d) Anti-hypertensive Agents 561 d) Macrolides 588 e) Anti-thrombotic Agents 566 e) Aminoglycosides 589 e) Heparins/Aprotinin 566 f) Tetracyclines 589 f) Diuretics 567 g) Chloramphenicol 590 Autonomic Nervous System a) Catecholamines 590 568 7. Anti-leprosy Drugs 591 8. Anti-amoebic Drugs 592 9. Drugs for Kala- azar 593 572 10. Anti-malarial Drugs 593 a) 570 572 11. Anti-helminthic Agents 594 d) Serotoninergic Agents 573 12. Anti-fungal Agents 597 Drugs in Central Nervous System Diseases 573 13. Anti-viral Agents 598 a) 573 14. Anti-retroviral Agents for HIV Infection 599 b) Analgesics and Anti-inflammatory Drugs 574 15. Alcohol 601 c) 16. Anti-malignancy Agents 601 17. Hemopoietic Drugs 603 c) 4. Anti-allergic Drugs 586 Anti-tuberculous Drugs 570 b) Agents for Cough and Expectoration 586 Beta-lactams 6. Drugs in Respiratory Diseases Anti-asthma Agents Sulfonamides 568 b) Cholinergic and Anti-cholinergic Agents 569 3. 5. Opioids Drugs in Migraine 576 d) Drugs in Gout and Arthritis 576 e) Anti-epileptic Drugs 577 f) Muscles Relaxants 579 18. Chelating Agents 604 g) Anti-psychotic Drugs 579 19. Drugs in Endocrine Disorders 605 h) Sedatives / Hypnotics 580 20. Drugs for Diabetes 607 i) Anti-depressants 582 j) Anti-parkinsonism Drugs 583 21. Lipid Lowering Agents 608 k) Drugs in Stroke 584 22. Gastro-intestinal Drugs 609 I) Drugs in Degenerative Brain Disorders 584 23. Electrolytes 611 25. Plasma Expanders 612 List of Contributors for the 20th Edition Dr. Hardik Shah Dr. Sunita Iyer Dr. Nikesh Jain Dr. Rajiv Shah H istory taking is an art, which a doctor learns over the years by repeated practice and ex­ perience. History is the record of medical events that have already taken place in the patient. Since every disease has a pattern of behavior, a good history combined with a sound knowledge of medicine would help the doctor to judge the likely cause(s) that may be responsible for the patient's problems. In over 80% cases the most likely diagnosis can be reached by a proper history. On clinical examination, the clinical state of the patient is determined at that given time. However, nothing is usually known of the past problems. Hence, without an appropriate history, an incorrect interpretation of the physical findings may be made. E.g. a person has brisk reflexes and extensor plantar: a recent history of transient ischemic attack would suggest recent stroke, whereas an old history of stroke a few years ago would suggest residual effect of a past stroke. with their time ofoccurrence, duration and results should be noted. Childhood illnesses (eruptive fevers, per tussis, influenza), tuberculosis, diabetes, hyp ertesnion, asthma, heart disease, jaundice, joint swelling, etc. must be inquired into. Past injuries, accidents, operations or hospital stay and blood transfusion history must also be noted in details. 5. type of diet, bowel and micturition habits, sleep and addictions like alcohol, smoking, tobacco chewing, charas, ganja, marijuana etc., must be inquired into. Loss of appetite and weight may suggest an active disease process. Similarly improper sleep due to other symptoms would suggest that those symptoms require urgent attention. Alcohol, tobacco, smoking and other intoxicants can adversely affect many systems in the body and the role of these substances in the patient's problems can be easily judged by the history. E.g. alcohol may be responsible for liver cell failure and cirrhosis as well as acute gastritis. Heavy smoking may be responsible for precipitating coronary artery disease or hypertension in the young. A good history must record the following information in a systematic order. 1. Biodataofthe patient: This should include name, age, sex, address, occupation, religion and marital status of the person. 2. Complaintsofthepresentillness: The complaints with which the patient has come should be recorded in chronological order and the duration should be noted. 3. Origin, duration and progress: Details of each symptom must be recorded separately. The mode of onset, whether sudden or gradual, the duration of each symptom and its progress and finally the present status of the symptom must be noted. Associated symptoms must also be inquired into and recorded. 4. History of past illness: Similar illness in the past Personal history: Patient's appetite, food habits, 6. Family history: Any illness in the family must be recorded. The state of health of parents, peers and children should be noted. If any member is deceased, the cause of death should be noted. Some genetically transmitted diseases are: a. X-linked recessive diseases (e.g. Duchenne muscular dystrophy, hemophilia, G6PD deficiency, ichthyosis). Women are carriers and do not suffer from the disease, whereas males suffer from the disease. Hence, in such illnesses, the family history would suggest similar illnesses in the patient's brothers, PRACTICAL MEDICINE sister's sons, mother's brother and mother's sister's sons. b. Autosomal dominant disorders ( e.g. familial hyperlipidemias, polycystic kidney, Huntington's disease, neurofibromatosis, congenital spherocytosis, myotonia dystrophica). There will be a family history of similar illness in either of the parents and/ or grandparents. c. Autosomal recessive disorders (e.g. beta thalassemia, sickle cell anemia, spinal muscular dystrophy, phenylketonuria, cystic fibrosis, congenital adrenal hyperplasia). There is usually no history of similar illness in the parents since they may be heterozygous and hence only carriers. However, history of consanguineous marriage in the parents (marriage between cousins or brother and sister or uncle and niece) may be present and may be responsible for the homozygous state in the patient and thus the manifestation of the disease. 7. Menstrual and obstetric history: In females, the date of onset of menstruation, date of last menstruation and the amount of blood flow, regularity and pain during menstruation should be noted. In a woman who has conceived, details of past abortions, premature births and normal or abnormal deliveries should be noted. Some of the common symptoms which the patients present with and their causes are given below: 1 - 1. 2. 3. 4. 5. 6. 7. 2 - Weight - Loss Caloric malnutrition: Fasting, inappropriate diet Infections (chronic): Infective endocarditis, tuberculosis, amebic liver abscess, fungal infections, H.I.V. infection, etc. Acute infections: Viral hepatitis, typhoid, septicemia Malignancy Malabsorption syndrome Endocrine diseases: Diabetes m ellitus, thyrotoxicosis, panhyp opituitarism, Addison's disease, etc. Anorexia nervosa 2 > Weigc.___ht_ G_ai__ n __ _ _ 1. Increased water retention: Cardiac failure, cirrhosis of liver, nephrotic syndrome, hyp oproteinemia, edema states, etc. 2. Increased tissue mass: a) Obesity b) Endocrine diseases: Cushing's disease, hyp othyroidism, acromegaly, etc. c) Hypothalamic diseases: Craniopharyngi-oma, Frohlich's syndrome, hamartoma, etc, d) Drugs: e.g. steroids 3 > Anorexia 1. 2. 3. 4. 5. 6. 4 Viral hepatitis including anicteric hepatitis Tuberculosis Carcinoma of stomach and other malignancies Endocrine diseases: Addison's disease, panhypopituitarism Chronic wasting diseases: Uremia, cirrhosis of liver, chronic alcoholism, chronic smoking etc. Drugs: Digitalis, quinine, metronidazole, etc. Fever (Refer Pg. 36: Temperature) 5 > Chest Pain 1. Cardiac: Ischemic heart disease, pericarditis, infective endocarditis, cardiomyopathy, valvular heart disease, dissecting aneurysm of aorta, etc. 2. Respiratory: Pleurisy, pneumothorax, pulmonary embolism, pulmonary hypertension, malignancy 3. Musculoskeletal: Rib fracture, vertebral collapse, costochondritis, myositis of pectoral muscle, etc. Functional Miscellaneous: Herpes zoster of intercostal nerves, esophagitis, pancreatitis, peptic ulcer, cholecystitis, splenic flexure syndrome, etc. 4. 5. ( 1 > History Taking and Symptomatology � s_ B>Hemop�ysi� 6>D s nea 1. 2. 3. 4. 5. 6. P hysiological: Mountaineers, exercise, hyperpyrexia, anemia Respiratory: Airway obstruction, bronchial asthma, chronic obstructive lung disease, pulmonary infections, pulmonary edema, pulmonary embolism, bronchogenic carcinoma, pleural effusion, pneumothorax, etc. Cardiac: Acute myocardial infarction, valvular heart disease, left ventricular failure, congenital cyanotic heart disease, etc. Metabolic: Diabetes, uremia, hypokalemia Neurological: Respiratory center depression as in syringobulbia, motor neuron disease, Guillain Barre syndrome, bulbar polio, myasthenia gravis Psychogenic (For ATS Dyspnea Scale: Refer pg. 125) h 7>Coug� 1. 2. 3. 4. 5. �- (Refer Pg. 382) 9 > Palpitations 1. 2. 3. 4. 5. 6. 7. (For NYHA Classification: Refer pg. 211) � Respiratory: a. Laryngeal and pharyngeal infections and neoplasms b. Tracheobronchial: Tracheobronchitis, bronchial asthma, bronchiectasis, bronchogenic carcinoma, pressure over the trachea and bronchus from outside, aspiration, etc. c. Lung: Pneumonia, tuberculosis, lung abscess, tropical eosinophilia, pulmonary edema and infarction, interstitial fibrosis, etc. d. Pleural: Pleural effusion, pneumothorax, etc. Cardiac: Left ventricular failure, mitral stenosis, aneurysm of aorta, etc. Mediastinum: Enlarged lymph nodes, mediastinal tumors, etc. Psychogenic Reflex: Wax or foreign body in the ear, subphrenic or liver abscess, etc. _ _ _ Physiological: Exercise, emotional or sexual excitement, etc. Excessive tea, coffee, tobacco, alcohol consumption Anxiety state High output state: Anemia, beriberi, thyrotoxicosis, A-V fistula, Paget's disease, etc. Cardiac arrhythmia: Extrasystoles, paroxysmal tachycardia, atrial fibrillation, heart block, etc. Drugs: Sympathomimetic agents, nitrates, overdose of digoxin or insulin M i s ce l l a n e o u s : P h e o c h r o m o c y to m a , hypoglycemia, etc. 1 O > si_n_co__.p_e___ 1. 2. 3. 4. 5. 6. Vasovagal syncope Postural hypotension Cardiac arrhythmia: Stokes Adam's syndrome Stenotic lesions of the heart: Aortic stenosis, hypertrophic subaortic stenosis, pulmonary and mitral stenosis, Fallot's tetrad, ball valve thrombus in left atrium. Cerebrovascular insufficiency: Vertebrobasilar insufficiency, carotid sinus syncope, etc. Miscellaneous: Massive myocardial infarction, pericardial tamponade, left atrial myxoma, micturition syncope, cough syncope, internal bleeding, etc. 11 > Poli�u.:...: ri-=a____ 1. 2. _ _ Transient: Excessive water drinking, diuretic therapy, cold weather, stress Persistent: a. Diabetes mellitus 3