An Insider’s Guide to

CLINICAL MEDICINE

An Insider’s Guide to

CLINICAL MEDICINE

Archith Boloor

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

ISBN 978-93-89587-87-6

Printed at

In fond memory of

Dr Sitamahalakshmi

Foreword

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

chakrapani.m@manipal.edu

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-andhalf-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.

1.

2.

A.

B.

C.

D.

3.

A.

B.

C.

D.

E.

4.

A.

B.

C.

D.

E.

F.

5.

A.

B.

Contents

Prerequisites for Practical Examination and Common

Examination Cases

General Examination

Case Sheet Format

Vitals Examination

Physical Examination

Anthropometry

Respiratory System Examination

Case Sheet Format

Diagnosis Format

Discussion on Cardinal Symptoms

Discussion on Examination

Summary of Findings in Common Respiratory Diseases

Cardiovascular System Examination

Case Sheet Format

Diagnosis Format

Discussion on Cardiac Cycle

Discussion on Cardinal Symptoms

Discussion on Examination

Summary of Findings in Common Cardiovascular Diseases

Gastrointestinal System

Case Sheet Format

Diagnosis Format

C.

D.

6.

A.

B.

C.

D.

i.

ii.

iii.

iv.

v.

vi.

vii.

viii.

ix.

x.

E.

7.

A.

B.

C.

8.

9.

Discussion on Cardinal Symptoms

Discussion on Examination

Nervous System

Case Sheet Format

Diagnosis Format

Discussion on Cardinal Symptoms

Discussion on Examination

General Examination in Neurology

Higher Mental Functions

Cranial Nerves

Motor System Examination

Reflexes

Sensory System Examination

Cerebellum and Coordination

Gait