Essentials of Internal Medicine

638 Pages·2017·12.504 MB·English

by  Ardhendu Sinha Ray

h Edition
Ardhendu Sinha Ray
Abhise Si a a.v
Essentials of
INTERNAL MEDICINE
Essentials of
INTERNAL MEDICINE
Fourth Edition
Ardhendu Sinha Ray MD
Ex-Professor
Department of Medicine
Kolkata Medical College
RG Kar Medical College
Kolkata, West Bengal, India
Burdwan Medical College
Burdwan, West Bengal, India
Kalinga Institute of Medical Sciences
Bhubaneswar, Odisha, India
Abhisekh Sinha Ray MD (NY)
Staff Nephrologist
Department of Nephrology and Hypertension
Good Samaritan Medical Center
NE, USA
Formerly, Fellow
Kidney Institute, University of Kansas Medical Center
Kansas, USA
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Essentials of Internal Medicine
The first three editions have been published by other publisher
Fourth Edition: 2017
ISBN: 978-93-52700-72-1
Dedicated to
Memory of my parents
Late Sital Prasad Singha Roy
and
Late Namita Singha Roy
Preface
When we envisioned this book Essentials of Internal Medicine, our primary aim was to develop a compelling basic
textbook in internal medicine which would provide a solid understanding of the pathophysiology of diseases, help in
the development of strong clinical acumen in approach of common clinical syndromes and make one confident about
management of different diseases of various organ-systems. In this fourth edition, Essentials of Internal Medicine, we
have followed the same core principles that inspired us in our approach to the last three editions. We are grateful to
our students and colleagues, for their encouraging words and constructive criticisms. As per the feedback, suggestion
and comments we have received, cardiology, nephrology, neurology, and respiratory sections of the book have been
thoroughly updated in this edition. New chapters on general physical examination and examinations of different systems
like neurology, respiratory, gastrointestinal are added. Revised and improved fourth edition contains all essential points
of internal medicine in a student-friendly format.
We believe, this book will continue to be a useful companion to the undergraduate students as well as postgraduate
trainees.
Your feedback and suggestions are welcomed.
Ardhendu Sinha Ray
Abhisekh Sinha Ray
Contents
SECTION I CARDIOVASCULAR SYSTEM SECTION IV RESPIRATORY SYSTEM
1. Electrocardiogram 3 31. Approach to a Patient of Hemoptysis 201
2. Rheumatic Fever 29 32. Approach to a Patient of Dyspnea 203
3. Infective Endocarditis 32 33. Bronchial Asthma 205
4. Valvular Heart Disease 36 34. Chronic Obstructive Pulmonary Disease 209
5. Heart Failure 47 35. Pneumonia 213
6. Hypertension 55 36. Pleural Effusion 216
7. Congenital Heart Diseases 63 37. Respiratory Failure 221
8. Cardiomyopathy 71 38. Cor Pulmonale 223
9. Tachyarrhythmias 74 39. Acute Respiratory Distress Syndrome 225
10. Ischemic Heart Diseases 85 40. Bronchogenic Carcinoma 227
41. Pneumothorax 230
SECTION II CENTRAL NERVOUS SYSTEM
SECTION V GASTROINTESTINAL SYSTEM
11. Coma and Related Disorders 101
42. Viral Hepatitis 235
12. Meningitis 105
43. Chronic Hepatitis 242
13. Epilepsy 109
44. Alcoholic Liver Disease 247
14. Hemiplegia 114
45. Nonalcoholic Steatohepatitis 249
15. Cerebrovascular Accident 119
46. Cirrhosis and its Complications 251
16. Spinal Cord Disease (Paraparesis and
47. Approach to a Patient of Upper Gastrointestinal
Quadriparesis) 129
Bleeding 261
17. Guillain-Barré Syndrome 136
48. Budd-Chiari Syndrome 265
18. Peripheral Neuropathy 138
49. Acute Pancreatitis 267
19. Myasthenia Gravis 145
50. Approach to a Patient with Malabsorption 272
20. Myopathy and Myotonia 149
51. Inflammatory Bowel Diseases 275
21. Parkinsonism 152
22. Motor Neuron Diseases 155
SECTION VI RHEUMATOLOGY
23. Multiple Sclerosis 158
24. Polymyositis, Dermatomyositis, Inclusion Body 52. Approach to a Patient of Monoarthritis 285
Myositis 163 53. Approach to a Patient of Polyarthritis 288
54. Approach to a Patient of Low Back Pain 292
55. Gout 295
SECTION III NEPHROLOGY
56. Rheumatoid Arthritis 298
25. Acute Glomerulonephritis 169 57. Felty’s Syndrome 305
26. Nephrotic Syndrome 173 58. Still’s Disease 306
27. Acute Renal Failure/Acute Kidney Injury 179 59. Sjögren’s Syndrome 307
28. Chronic Renal Failure 185 60. Juvenile (Rheumatoid) Idiopathic Arthritis 309
29. Urinary Tract Infection 194 61. Systemic Lupus Erythematosus 310
30. Interstitial Nephritis 196 62. Antiphospholipid Antibody Syndrome 316
x Essentials of Internal Medicine
63. Seronegative Spondyloarthritis 319 SECTION XI INFECTIVE DISEASES
64. Ankylosing Spondylitis 321
98. Dengue 453
65. Reactive Arthritis 324
99. Rabies 455
66. Psoriatic Arthropathy 327
100. Tetanus 458
67. Progressive Systemic Sclerosis 330
101. Diarrhea 460
68. Mixed Connective Tissue Disorder 335
102. Typhoid and Paratyphoid (Enteric) Fever 464
69. Hemolytic Uremic Syndrome 336
103. Leptospirosis (Weil’s Disease) 466
70. Thrombotic Thrombocytopenic Purpura 338
104. Malaria 468
71. Vasculitis Syndrome (Vasculitides) 339
105. Leishmaniasis (Kala-azar) 472
72. Antineutrophil Cytoplasmic Antibody 345
106. Approach to a Patient of Fever with Rash 475
107. Management of Helicobacter pylori Infection 480
SECTION VII HEMATOLOGY
108. Human Immunodeficiency Virus, Acquired
73. Approach to a Patient of Anemia 349 Immunodeficiency Syndrome 481
74. Hemolytic Anemia and Its Investigations 352 109. Tuberculosis 488
75. Thalassemia 354
76. Hypoproliferative Anemia 358 SECTION XII MISCELLANEOUS
77. Myelodysplastic Syndrome 361
78. Leukemias 364 110. Pyrexia of Unknown Origin 499
79. Lymphoid Cells Malignancy (Lymphoma) 371 111. Metabolic Syndrome X and Acanthosis
80. Approach to a Patient with Bleeding Disorder 384 Nigricans 502
81. Thrombocytopenic Purpura 386 112. Emergencies in Clinical Medicine and Its
82. Hemophilia 388 Management 503
83. von Willebrand Disease 390 113. Acid-Base and Electrolyte Disorder 515
84. Disseminated Intravascular Coagulation 391 114. Paraneoplastic Endocrine Syndrome 521
85. Thrombotic Disorder/Thrombophilia 392
86. Kikuchi-Fujimoto Disease 394
SECTION XIII PSYCHIATRY
SECTION VIII ENDOCRINE
115. Psychiatry 525
87. Thyroid Gland Disorders 397
88. Adrenal Gland Disorders 404
SECTION XIV EXAMINATIONS
89. Acromegaly 412
90. Syndrome of Inappropriate Antidiuretic 116. Examination of Cardiovascular System 535
Hormone 415 117. Examination of Central Nervous System 543
118. Examination of Upper Gastrointestinal Tract 571
SECTION IX DIABETES (ENDOCRINE) 119. Examination of Lower Gastrointestinal Tract 573
120. Approach to a patient of Lymphadenopathy 579
91. Diabetes Mellitus 419
121. Jaundice 582
122. Cyanosis 585
SECTION X DERMATOLOGY
123. Clubbing 587
92. Scabies 435 124. Arterial Pulse 589
93. Fungal Infection of the Skin 437 125. Neck Vein 592
94. Psoriasis 439 126. General Examination/Survey 595
95. Vitiligo and Leukoderma 442 127. Examination of Respiratory System 602
96. Acne Vulgaris 446
97. Leprosy 448 Index 609
I
SECTION

CARDIOVASCULAR SYSTEM
• Electrocardiogram
• Rheumatic Fever
• Infective Endocarditis
• Valvular Heart Disease
• Heart Failure
• Hypertension
• Congenital Heart Diseases
• Cardiomyopathy
• Tachyarrhythmias
• Ischemic Heart Diseases
1
Chapter
Electrocardiogram
IntroductIon • V on posterior scapular line on the same plane of
8
VVVV.
An electrocardiogram is a graphical record of the change 4 5 6 7
In case of dextrocardia precordial leads are placed on
in membrane potential generated during cardiac muscle
the corresponding position on the right side of the chest
depolarization and repolarization.
and are called VR to VR respectively.
The ECG records the depolarization (stimulation) and 2 6
repolarization (recovery) potentials generated by atrial and
EsophagEal lEads
ventricular myocardium and spread all over body.
This electric signals are detected by means of electrode Apart from these leads there is special lead called esoph-
(called lead) attached to the extremities and chest wall and ageal lead where the recording electrode is placed in
are amplified and recorded on a (millimeter) graph paper. esophagus 27 cm down from incisor teeth for recording of
The graph paper is divided into 1 mm2 grid-like boxes. the potential from the posterior aspect of heart.
Since the universal ECG paper speed is 25 mm/sec, the Standard ECG has the following wave and P, Q, R, S,
smallest 1 mm horizontal division corresponds to 0.04 T and U wave, and the following interval PR, QRS and QT
second with heavier line at interval of 5 small square which interval (Figs 1.1 and 1.2).
is equal to 0.2 second. Vertically the ECG graph measure the During examination of ECG we have to look for follow-
amplitude of a specific wave 1 mV = 10 mm with standard ing point. (1) Heart rate, (2) rhythm, (3) electrical axis of
calibration. QRS complex, (4) P-wave, (5) P-R interval, (6) Q-wave,
The conventional ECG is recorded by 12 lead of which (7) QRS complex, (8) ST-segment, (9) Q-T interval,
6 are extremity limb lead and 6 are precordial or chest lead. (10) T-wave and (11) U-wave.
Out of 6 limb leads. Three are bipolar lead [lead-I, lead-
II, lead-III] and three are unipolar (aVR, aVL, aVF). hEart ratE
Bipolar leads are It can easily be calculated from an ECG by counting the
• Lead-I → Left arm potential – Right arm potential number of small square in between two consecutive
• Lead-II → Left leg potential – Right arm potential R-wave. And dividing 1500 by the number of small square
• Lead-III → Left leg potential – Left arm potential.
Unipolar limb leads are—aVR, aVL and aVF.
In these unipolar leads potential of right arm, left arm
and left leg are recorded against ‘zero’ potential which is
made within machine by joining the lead of all four limb
and passing it through in resistance.
Standard six precordial lead are V – V. These are uni-
1 6
polar lead and one electrodes is placed on the following
position and the second electrode is zero potential.
• V on 4th intercostal space just right of sternum.
1
• V on 4th intercostal space just left of sternum.
2
• V on midway between V–V.
3 2 4
• V on midclavicular line on 5th space.
4
• V on anterior axillary line on the same plane of V.
5 4
• V on midaxillary line on the same plane of V and V.
6 4 5
• V on posterior axillary line on the same plane of VVV Fig. 1.1: Normal ECG
7 4 5 6.