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A Symptom-Based Approach in Internal Medicine

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A Symptom-Based Approach in Internal Medicine Diagnosis A Symptom-based Approach in Internal Medicine Diagnosis A Symptom-based Approach in Internal Medicine CS Madgaonkar MBBS FCGP Consultant Family Physician Hubli, Karnataka, India Honorary National Professor Indian Medical Association College of General Practitioners Chennai (HQ), Tamil Nadu, India ® JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi • Panama City • London Published by Jaypee Brothers Medical Publishers (P) Ltd Corporate Office 4838/24 Ansari Road, Daryaganj, New Delhi - 110002, India Phone: +91-11-43574357, Fax: +91-11-43574314 Website: www.jaypeebrothers.com Offices in India • Ahmedabad, e-mail: [email protected] • Bengaluru, e-mail: [email protected] • Chennai, e-mail: [email protected] • Delhi, e-mail: [email protected] • Hyderabad, e-mail: [email protected] • Kochi, e-mail: [email protected] • Kolkata, e-mail: [email protected] • Lucknow, e-mail: [email protected] • Mumbai, e-mail: [email protected] • Nagpur, e-mail: [email protected] Overseas Offices • Central America Office, Panama City, Panama, Ph: 001-507-317-0160, e-mail: [email protected], Website: www.jphmedical.com • Europe Office, UK, Ph: +44 (0) 2031708910, e-mail: [email protected] Diagnosis: A Symptom-based Approach in Internal Medicine © 2011, Jaypee Brothers Medical Publishers All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher. This book has been published in good faith that the material provided by author is original. Every effort is made to ensure accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error (s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only. First Edition : 2011 ISBN 978-93-80704-75-3 Typeset at JPBMP typesetting unit Printed in India Dedicated to The memory of my dear brothers Ramakant and Vasant PREFACE The best physician is the one who is able to differentiate the possible and the impossible. Herophilus of Alexandria Diagnosis: A Symptom-based Approach in Internal Medicine was conceived during my practice in general internal medicine. I wrote this book because I wished it had been written for me. Although there are many textbooks and excellent manuals devoted to symptom-oriented diagnosis, I personally felt the need for a book that provides the essential information necessary in a concise and practical method, and thus relieve one from time and labor in searching through voluminous medical textbooks on the diagnostic process of symptoms presented by patients in today’s arduous ambulatory health care delivery system. A symptom is commonly defined as,”Any affection which accompanies disease; a perceptible change in the body or its functions, which indicates disease, or the kind or phases of disease”. The importance of symptoms, therefore, cannot be overemphasized because symptoms are why patients visit physicians; and based on their analysis, a physician attempts to make as accurate a clinical diagnosis as possible. Many symptoms encountered in everyday practice may suggest undifferentiated problems and many may suggest problems that are self-limited, while many symptoms are characteristic of early disease. New or serious symptoms often drive patients to overcrowded office or emergency departments. However, physicians need medical resource that can deliver timely and effective diagnostic information which, besides providing diagnosis on an established or common disease, does not ignore other possibilities. Besides, relevant diagnostic investigations and clinical aspects of related disorders are essential to support the diagnosis of any disease and treatment accordingly. Thus, in a busy ambulatory care, diagnosis has to be made without it being unrecognized until advance disease is present, treatment options are limited, and prognosis may be unfavorable. It is in this context, I have made an attempt to first project common symptoms encountered in internal medicine, especially as applicable to the epidemiological incidence to the adult patient population, and then create a framework in which a physician can arrive at a tentative diagnosis. The main features which remain constant for each symptom are: • Synopsis: A symptom introduction in brief; • Differential diagnosis of the symptom: Classified in three main groups, namely—common, occasional and rare; • Investigations: In two sections, namely—general and specific; • Clinical notes: In short paragraphs, helpful in the diagnosis of most of the diseases; • Red flags: Key points highlighted to alert serious disorders not to be missed; • Tables: To simplify and comprehensively illustrate text, wherever needed; • Selective glossary: Brief summary of assorted, common and uncommon diseases, denoted by the sign “vide infra ↓↓”; and • References: From various journals, textbooks, etc. where applicable. viii Thus, the contents of this book are focused on commonly encountered symptoms, with their differential diagnosis in a concise form, which will lead to a working diagnosis and investigations. The emphasis is on the axiom, ‘common diseases present commonly, and its converse, uncommon diseases present uncommonly’. However, pointers to ‘red flags’, i.e. uncommon manifestations of common diseases should alert the physician of serious diseases not to be missed. No attempt has been made to discuss etiology or pathology of illness, or the complexities of practice management. The frequency with which a disease is encountered by physician will depend upon its prevalence in the region from which their patients are drawn and also their specialty; therefore, regional variations in the incidence of diseases or methodology, or guidelines for investigations and diagnosis are not discussed, which can be accessed from other relevant sources. The book assumes much basic knowledge and the information it contains must be supplemented by further reading. However, my endeavor has been to cover a spectrum of symptoms, with emphasis on practical features of diagnosis, based on recent evidence-based guidelines. The contents of the book are intended for medical students, internists, and house-officers during their daily office or hospital practice, and also to physicians to boost their diagnostic skills during busy practice day, and preparation for ‘rounds’ and clinical teaching. I also anticipate that physicians of other specialties will also value this book as an easy-to-use ready-reference guide beyond their everyday experience and in various practice settings. There is no substitute for knowledge, and this book, I believe, will make symptom-based diagnostic process more accessible to many physicians, and if it prompts others to delve further and achieve sophistication in this clinical expertise, then this book has accomplished its purpose. Finally, I would welcome feedback, which can be posted to me via my website: www.drcsm.com, or email: [email protected], or to the publishers. CS Madgaonkar ACKNOWLEDGMENTS My work in writing this book has been shared among many individuals. First of all, I would like to appreciate the comments and advice of the following eminent specialists who reviewed appropriate chapters of this book: • Dr Vidya C Madgaonkar MD DA, Professor of Anesthesiology, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India. • Dr AS Guruprasad MS, Fellow Sankara Nethralaya, Head of Vitreoretinal Services, MM Joshi Eye Institute, Hubli, Karnataka, India. • Dr Shailesh E Gokavi MD, Infertility Consultant and Gynecological Endoscopic Surgeon, Hubli, Karnataka, India. • Dr Neminath R Patil MS DLO, Consulting ENT Surgeon, Shravan ENT Neuro-Otology Clinic, Hearing Aid Center, Hubli, Karnataka, India. I have received most generous assistance from the former Dean Dr YS Rai FRCS (Ed), SDM College of Medical Sciences and Hospital, Manjushree Nagar, Sattur, Dharwad, Karnataka for extending Central Library facilities, and also to the library staff, who took immense care and pains to provide innumerable references in the compilation of this book. I would also like to sincerely thank the library staff of my alma mater, Kasturba Medical College, Manipal, Karnataka, India who have been a consistent resource. My sincere thanks are extended to Shri Jitendar P Vij (Chairman and Managing Director), and Mr Tarun Duneja, (Director-Publishing), M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India who have helped me throughout and displayed patience, understanding and professionalism in publishing this book. I would also like to record my appreciation from Mr Venu Gopal V, (Bengaluru branch) for extending his cooperation at every step. I owe a debt of gratitude to my dear mother, Smt Sumitra S Madgaonkar, for her unstinted support, encouragement, and forbearance. Thanks, as ever, also goes to my other family members and friends, for their constant support, guidance and encouragement. The true kudos, however, belong to my wife, Dr Vidya, and my son, Varun, for their eternal patience and incredible support throughout, which ultimately made this book a realty. CONTENTS 1. Abdominal Distension .................................................................................................................. 1 Common 1; CBC 2; ESR 2; Urinalysis 2; Stools
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