Atlas

For General Practitioners

to accompany the Book

GENERAL PRACTICE
A P R A C T I C A L M A N UA L
BY
D R . G H A N A S H YA M VA I D YA

SECTION-2

GENERAL MEDICAL
Published by : BHALANI PUBLISHING HOUSE,
Mumbai
 Atlas
For General Practitioners

Every patient is a Jigsaw puzzle.

Some have 2-3 pieces
While some have 500
But
Unless you collect all the pieces
You cannot complete the picture.

A Good Physician first collects all his pieces

Through History, Examination and Deductions
And then sits down to put them in place.

The Atlas helps you to identify some of the important pieces

And
Solve some one piece puzzles – known as the Spot Diagnosis
© Dr. Ghanashyam Vaidya
 Section -1
3

GENERAL
EXAMINATION

© Dr. Ghanashyam Vaidya

 4

Note the pale white

colour of the nails on
the right, compared
with the normal pink
nails on the left. The
extreme pallor of the
nails is unmistakable.

You will also note the

yellowish tinge that
comes with the
severe pallor. This is
the reason - laymen
often bring the
patient to the doctor,
thinking he is having
jaundice!!
Anemia
(Pallor)

© Dr. Ghanashyam Vaidya

 5

Note the concavity of

the nails on the right
compared with a
normal nail on the
left.

This condition of
concave spoon
shaped nails is
termed as
Koilonychia, and is
diagnostic of Iron
Deficiency Anemia.

Koilonychia

© Dr. Ghanashyam Vaidya

 6

This is another
photograph, showing
Koilonychia – ie
spoon shaped
concave nails.

The lower picture

shows a drop of
water in the spoon!

Koilonychia

© Dr. Ghanashyam Vaidya

 7

Observe the nail and

its contour carefully.
The nail is pale; and
it has lost its
convexity & is
showing a flat, plain
surface.

This is termed as
Platynychia.

Platynychia is seen in
Iron Deficiency
Anemia, and you
could say it is one
stage before
concavity or
Koilonychia. Platynychia

© Dr. Ghanashyam Vaidya

 8

Compare the nails on

the right with the
normal nail on the
left. Note the
increased convexity
which is termed as
clubbing.

In the second picture,

note the club like
enlargement of the
tip of the finger.

Clubbing
3rd degree

© Dr. Ghanashyam Vaidya

 9

This is another case

of Cyanosis of nails.

In adults, cyanosis
may also be seen due
to reduced
pulmonary function
in lung diseases.

If cyanosis is seen
only in nails, not in
the tongue, it is
Peripheral cyanosis.

Cyanosis

© Dr. Ghanashyam Vaidya

 10

Observe the colour of

the nails of this child,
and compare it with
the normal adult
nails.

There is a bluish
colour to the nails,
which is due to
deoxygenated blood
in the capillaries of
the nailbed.

This is Cyanosis.

In children , it is due
to Congenital
Cyanotic Heart
Diseases like Fallot’s
Tetralogy. Cyanosis
(Blue nails)

© Dr. Ghanashyam Vaidya

 11

Note how a space is

created between the
nail & its bed. I am
able to pass a pin
under the nail in this
space. This is termed
as Onycholysis.

Onycholysis is the
separation of the nail
plate from the
nailbed.

This is commonly
seen in fungal nails.
Sometimes in
Psoriasis.
Onycholysis

© Dr. Ghanashyam Vaidya

 12

Onychogryphosis :
The nail plate is
greatly thickened,
and the nail curves
steeply forwards.

Onychogryphosis

© Dr. Ghanashyam Vaidya

 13

Note the transverse

groove-like line on all
the nails, at the same
level. Theses are
Beau’s lines, which
are sometimes seen
after a major illness.

Details in next slide.

Beau’s lines

© Dr. Ghanashyam Vaidya

 14

During major
illnesses like,
Typhoid fever or
Septicemia, the nail
growth is temporarily
slows down or stops
for a few days, till the
patient has
recovered. The nail
shows a depression,
representing this
period.

This depressed line

termed as Beau’s line
moves forwards as
the nail grows and
reaches the anterior
end in about 3
months. Beau’s Lines

© Dr. Ghanashyam Vaidya

 15

Note the roughening,

thickening and
irregular surface of
the nails of the right
hand.

These are typical

Fungal nails – or
Taenia Unguium.

Early cases are cured

with Medical
treatment, but severe
infections where the
nail and nailbed are
badly destroyed, the
nail has to be
removed and then
the nailbed is Fungal Nails
treated, so that a
healthy new nail
grows.
© Dr. Ghanashyam Vaidya
 16

Crushing injury of
the tip of fingers
often results in a
hematoma under the
nail, termed as
Subungual
hematoma.

It is a sharply
demarcated clot of
blood, and it moves
forwards over next 3
months as the nail
grows.

If painful, it may be
drained by drilling a
tiny hole in the nail
over it. Subungual Hematoma

© Dr. Ghanashyam Vaidya

 17

Note the pallor – the

pale pink colour of
the tongue - due to
anemia.

Then note the

irregular black-
brown pigmentation
of the tongue, which
is of no clinical
significance.

Pale + Pigmented Tongue

© Dr. Ghanashyam Vaidya

 18

The top surface of

the tongue shows the
typical red stain,
seen in a significant
number of our
population, due to
chewing of paan. This
patient needs your
lecture on bad effects
of tobacco, chuna &
paan.

Now observe the

right tongue margin,
which shows multiple
apthous ulcers, the
proximal one being
large – almost 1 cm Paan stains + Aphthous ulcers
size.

© Dr. Ghanashyam Vaidya

 19

This tongue shows

black patchy,
irregular
pigmentation, which
is present since birth.

This has no clinical

significance.

Pigmented tongue

© Dr. Ghanashyam Vaidya

 20

You must have seen

this black coating of
the tongue many
times. This is seen in
patients taking oral
iron preparations,
specially liquid iron
tonics.

Black coating due to oral Iron

© Dr. Ghanashyam Vaidya

 21

Observe the tongue

which shows some
areas which have no
papillae, and hence
look bald & smooth.
The bald areas look
pink and there is an
overall look of a
world map with the
bald areas marking
countries. Hence the
name – Geographic
tongue.

There is no clinical
significance, and the
bald areas may
change their sites Geographic tongue
with time.

© Dr. Ghanashyam Vaidya

 22

Note the deep

fissures in this
tongue. They are
present since birth,
and painless. They do
not bear any clinical
significance.

This is a fissured
tongue.

Fissured Tongue

© Dr. Ghanashyam Vaidya

 23

On protrusion, this
tongue deviates to
the right side.

Observe and compare

the two halves of the
tongue. The right half
of the tongue is
atrophic and smaller.

This is twelfth cranial

nerve palsy.

The affected side

muscle has
atrophied, and on
protrusion, the
tongue deviates to
the affected side. Deviation of tongue

© Dr. Ghanashyam Vaidya

 24

Note the typical

Aphthous ulcer on the
right tongue margin in
the first picture and
over the lip mucosa in
the second picture.

It is a superficial, painful
ulcer – and gives severe
pain when it comes in
contact with chillies or
hot / sour food.

Aphthous ulcers are

treated by xylocaine/
metronidazole locally
and high doses of
Vitamin B complex.

Aphthous Ulcer

© Dr. Ghanashyam Vaidya

 25

Note the loss of

papillae over the
tongue (Except in the
central part in the
first photograph).

Bald tongue is due to

vitamin B complex
deficiency. Give
injections and oral
tablets of B complex.

Bald Tongue

© Dr. Ghanashyam Vaidya 2

 26

Observe the sclera of

this patient. There is
a yellow
discolouration of the
sclera due to
jaundice.

Early jaundice can be

appreciated only in
natural sunlight. So
you must take the
patient to the window
and observe in
sunlight, if jaundice
is suspected. Sclera
being pure white
under the upper
eyelid, jaundice is
appreciated best in Icterus
this area. (Jaundice)
As depth of jaundice
increases, it may be
© Dr. Ghanashyam Vaidya
seen in oral mucosa,
 27

This is another case

of Jaundice. Observe
the sclera under the
upper eyelid. The
yellow colour is
unmistakable.

Icterus
(Jaundice)

© Dr. Ghanashyam Vaidya

 28

Note the greenish

yellow colour of the
sclera of this patient.
This colour is
characteristic of
Obstructive Jaundice.

If you observe the

colour shade in
Jaundice carefully
everytime, you will
be able to suspect
obstructive jaundice,
from the colour of the
sclera.

Icterus

© Dr. Ghanashyam Vaidya

 29

Extreme Emaciation
– is due to loss of all
body fat, followed by
loss of muscle mass –
seen in extreme
cases of malnutrition
& starvation, and
systemic diseases
like Tuberculosis,
AIDS, & advanced
Malignancies.

Emaciation

© Dr. Ghanashyam Vaidya

 30

White or Yellowish
white coating of the
tongue is seen many
G.I. Disorders, and it
does not signify any
specific disorder.

Coated Tongue

© Dr. Ghanashyam Vaidya

 Section-2

31

GENERAL MEDICAL
CASES

© Dr. Ghanashyam Vaidya

 32

Observe the eyes of

this child. There is
edema around the
eyes, more so under
the lower eyelid. The
edema is much more
in the morning when
the eyes become slit
like.

In this age group,

most likely causes
are – nephrotic
syndrome, and Acute
Glomerulo-nephritis.
Renal Edema

© Dr. Ghanashyam Vaidya

 33

Note the slight

edema of the space
under the lower
eyelids.

This is typical renal

edema (mild).

Renal Edema-2

© Dr. Ghanashyam Vaidya

 34

Note the puffy

edematous face. Note
the coarse & dry
skin. Note the dull
look.

The lady has slow

husky voice. And
deep tendon jerks
show slow relaxation.

This is Myxoedema
face – in
Hypothyroidism.

Myxoedema Face

© Dr. Ghanashyam Vaidya

 35

I am pressing my
finger in an
intercostal space
over the right lower
chest. It is painful as
seen on the patient’s
expression.

Intercostal
tenderness is
typically seen in
Empyema (Pus
collection in pleural
cavity). On the right
side, it is also seen in
Amoebic Liver
abscess.

This patient had high

fever with chills, and Intercostal Tenderness
hepatomegaly, and
ultrasonography
confirmed Amoebic
© Dr. Ghanashyam Vaidya
Liver Abscess.
 36

Note the cluster of

few vesicles, filled
with clear fluid, and
slight skin redness,
at the border of the

l
upper lip.

This is Herpes
Simplex.

The infection stays

dormant, and
whenever the patient
gets fever, the
vesicles erupt again.

Herpes Simplex

© Dr. Ghanashyam Vaidya

 37

Note the forward

protrusion of the
sternum and costo-
chondral junctions,
giving the chest a
forward bulge like a
Pigeon’s chest.

Pigeon Chest

© Dr. Ghanashyam Vaidya

 38

Note the depression

of the sternum
inwards, producing a
concavity in the
anterior chest wall,
in midline.

This is termed as a
Funnel chest or Pes
Excavatum

Pes Excavatum
(Funnel Chest)

© Dr. Ghanashyam Vaidya

 39

Note the grossly

increased antero-
posterior diameter of
the chest.

Normally, the chest is

oval with shorter AP
diameter. But in
emphysema, the
cross-section of the
chest becomes round.

This is termed as
Barrel chest.

Barrel chest

© Dr. Ghanashyam Vaidya

 40

Observe the
edematous face of
this breathless
patient, and the
cyanosis of the
tongue (central
cyanosis).

In chronic bronchitis,
in advanced stage,
the face is puffy due
to edema (due to cor
pulmonale), the
tongue is cyanosed,
and the patient blows
out the air by
blowing through the
cheeks & lips.
Blue bloater
This is the Blue
bloater – in chronic
bronchitis.
© Dr. Ghanashyam Vaidya
 41

Note the sharp spiky

papules on the skin
over the front of the
knee.

This is typical skin

change in Vitamin A
deficiency – termed
as Phrynoderma.

Phrynoderma

© Dr. Ghanashyam Vaidya

 42

In alcoholic cirrhosis,
look for red tiny
spots upto 1 cm in
size, which blanch on
pressing and then fill
from the center.

These are Spider

Naevi. The other
estrogen effects seen
in cirrhosis are –
Gynaecomastia,
Palmar erythema.

Spider Naevi-1

© Dr. Ghanashyam Vaidya

 43

Spider Naevus - is a
spider-like cutaneous
vessel, with a dilated
arteriole in the
center anad its
branches spreading
like the legs of a
spider.

When compressed, it
blalnches, and then it
fills from the center
towards periphery.

Spider Naevus - 2

© Dr. Ghanashyam Vaidya

 44

Another classic
spider naevus.

They are often much

smaller than this one,
and are seen over the
upper chest, neck,
upper back and arm.
An effect of increased
estrogen levels in
Cirrhosis of Liver.

Spider Naevus - 3

© Dr. Ghanashyam Vaidya

 45

Note the red

edematous rash over
both the cheeks .

This is the typical

butterfly rash over
the cheeks, in
Systemic Lupus
Erythematosus.

Butterfly rash
in SLE

© Dr. Ghanashyam Vaidya

 46

Note the ulcerations

over the tips of the
fngers. This occurs in
vasculitis due to
diseases like SLE.

In the lower picture,

observe the tips of
the fingers. They are
tapering and narrow.

Vasculitis - fingers

© Dr. Ghanashyam Vaidya

 47

Note the uniform

distension of the
abdomen in ascitis.
In lying down
position, the fluid
gravitates backwards
and the flanks are
more distended.

Ascitis

© Dr. Ghanashyam Vaidya

 48

If you inspect the

abdomen carefully,
upper abdomen is
distended more on
the left side, while
lower abdomen is
distended more on
the left.

On palpation, it was a
huge and firm
splenomegaly, as
marked over the
abdomen.

Such massive
splenomegaly is seen
in Chronic Myeloid
Leukemia.
Ascitis

© Dr. Ghanashyam Vaidya

 49

Observe the typical

position of the hand
fingers in the first
picture on the
emergency room trolley.

This is carpopedal
spasm due to calcium
deficiency. Intravenous
Calcium injection is
being given .

In the second picture at

the end of the injection,
the spasm is seen

1
relieved and the fingers
are relaxed.

Carpopedal spasm in Tetany

2
© Dr. Ghanashyam Vaidya
 50

Note the face of this

child, who is crying, but
the face looks as if he is
laughing.

This is the typical Risus

sardonicus of Tetanus.

In the second picture,

you will appreciate the
stiffness of the muscles –
I am lifting the head
only, but the whole neck
& back is raised like a
log of wood. The child
also had trismus.

Risus Sardonicus

© Dr. Ghanashyam Vaidya

 51

This is another case of

Tetanus, showing
trismus – one of the
early signs.

When I insert a tongue

depressor, the mouth is
tightly closed. This is an
involuntary movement
and the patient cannot
open the mouth.

Second photograph
shows the same patient
after 7 days, after
treatment, when there is
no trismus.

Trismus in Tetanus

© Dr. Ghanashyam Vaidya

 52

This is a case of Cobra

bite.

I have asked the patient

to look upwards. As the
patient attempts, the
eyebrows are raised, but
the eyelids do not open.
The upper eyelid is
paralysed.

Ptosis is the earliest sign

seen in neurotoxic
snakebite.

The bite mark below

shows two puncture
marks about 1 cm apart,
and ecchymosis around
the bite – as there is
hemolytic component
also.
Ptosis in snakebite - 1

© Dr. Ghanashyam Vaidya

 53

This is another case

of neurotoxic
snakebite.

Typical bilateral
ptosis is diagnostic.
This is the first stage.
In the second stage
there is difficulty in
swallowing. Later in
the third stage there
is respiratory
paralysis.

But the progress to

respiratory paralysis
can be rapid – within
a few minutes –
depending on the
amount of venom
injected. So, when
Ptosis in snakebite – 2
ptosis is seen, rush
the patient to a
© Dr. Ghanashyam Vaidya
hospital. Ambu bag
 54

Note the dilated

tortuous veins
running vertically
from the thigh to the
neck.

On testing the
direction of flow, the
blood is flowing from
below upwards.

These are dilated

superficial veins in
Inferior Vena Cava
Obstruction.

IVC Obstruction

© Dr. Ghanashyam Vaidya

 55

Note the dilated

superficial veins,
radiating outwards
from the umbilicus.

The direction of
blood flow is away
from umbilicus in all
directions.

These are the

classical veins in
Portal Hypertension,
representing Porta-
Systemic
anastomosis, and are
termed as Caput
Medusae. Caput Medusae

© Dr. Ghanashyam Vaidya

 Section -3
56

NEUROLOGICAL SIGNS

© Dr. Ghanashyam Vaidya

 57

Observe the Right eye of

this patient, as she looks Sixth
to the right & left.
Crani
You will have noticed that
the right eye does not
al
turn to the right and the
lady complains of
Nerve
diplopia; On looking Palsy
straight forwards, the eye
is turned slightly medially
– which means that the
lateral rectus muscle is
paralysed.

This is a case of Right

sixth nerve (Abducens)
Palsy.

The importance of
recognising this condition
is that in any intracranial
disease raising
intracranial tension, 6th
nerve is affected first.
This patient needs a CT /
MRI of Brain.
© Dr. Ghanashyam Vaidya
 58

Third Cranial
Nerve Palsy (R)

Note the ptosis on

the right side.

Unilateral ptosis
should make you
think of third cranial
nerve palsy.

In the second picture,

I have lifted the
eyelid – the eye is
normal, but with a
slightly lateral
squint.

Now see the next

slide.

© Dr. Ghanashyam Vaidya

 59
Looking
Towards
Third Cranial Right

Nerve Palsy
(R)
The lateral Rectus
supplied by the sixth Looking
nerve is normal. So the Towards
eye can turn laterally. left

But it does not move to

right, or upwards and
downwards.

When the patient is Looking

looking forwards, the Upwards
eye will be slightly
divergent laterally.

The pupil is slightly

smaller on the affected
side, which is not Looking
appreciated in the Downwar
photographs. ds

© Dr. Ghanashyam Vaidya

 60

Observe the typical

Facial (VII) Nerve Palsy
features of Left Facial
Nerve Palsy (Bell’s Palsy).

1. On looking upwards,
the horizontal lines on
the forehead are
absent on left side.

2. On closing the eye, the

upper lid does not
close fully, and the
eyeball is seen to turn
upwards.

3. On smiling, the left 1 2

angle of mouth does
not move. So the face
is drawn towards the
healthy side ie to
right.

4. On blowing the cheeks,

the left cheek does not
fill and air leaks out
through the left angle
of mouth. 3 4
© Dr. Ghanashyam Vaidya
 61

This patient had a

viral fever for 4-5
days, and then he
observed that, when
he drinks water, part
of it comes out from
the nose.

This is due to Psedo-

bulbar palsy –
affecting IX, X, XI
cranial nerves.

There is weakness of
the palatal muscles,
with nasal
regurgitation while
swallowing liquids.

Note the water

Pseudo-bulbar Palsy
dripping through the
nose, as he drinks it
©from the glass.Vaidya
Dr. Ghanashyam
 62
IX &
XII
cranial
The first picture
shows XII nerve nerve
palsy. The tongue palsy
shows atrophy of the
left side and on
protrusion it bends to
the affected – left
side.

The second picture

shows IX nerve palsy
in the same patient.
On saying ‘Ah”, the
uvula and the soft
palate is pulled to the
right – ie towards the
normal side.

© Dr. Ghanashyam Vaidya

 63

I have asked this

patient of backache,
to extend his toes
against resistence.

The left toe can be

easily flexed,
indicating weakness
of EHL – Extensor
Hallusis Longus.

This test must be

done in every case of
severe or chronic
backache. Because
this is usually the
earliest neurological
sign in all
compressive spinal EHL Weakness
pathologies.

© Dr. Ghanashyam Vaidya

 64

Scissors gait in a
child of cerebral
palsy.

Note the legs,

crossing across the
midline with each
forward step. This
occurs due to excess
adductor tone.

Scissors gait

© Dr. Ghanashyam Vaidya

 65

Note the Calf

muscles of this child.
There is a

g
hypertrophy of the
calf muscles, but the
child has weakness of
the muscles, and
finds it difficult to
climb stairs and to
get up from a sitting
position.

This is a case of
Pseudohypertrophic
Muscular Dystrophy
(Duschene’s type).

Hypertrophic calf

© Dr. Ghanashyam Vaidya

 66

This is the most

severe form of
reaction to a drug
affecting all skin and
mucosa. Oral mucosa
shows ulceration.
Conjunctiva is badly
inflammed, and there
may be corneal
ulcers. Skin all over
the body shows
allergic rashes. There
may be hypotension.

This is Steven-
Johnson’s Syndrome :
most severe form of
allergic reaction to
any drug and may Steven-Johnson’s Syndrome
occur after
swallowing a single
tablet.
© Dr. Ghanashyam Vaidya
 67

Note the bilateral

large lymph nodes on
both sides of the
neck.

Large lymph nodes

on both sides of neck
or at multiple sites
should make you
suspect Lymphoma.

A biopsy or FNAC
will confirm the
diagnosis.

But note a small scar

of sinus on the left
side. A sinus is
suggestive of
Tuberculosis, and Cervical Lymphadenopathy
never a lymphoma.
The final diagnosis
was Tuberculosis.
© Dr. Ghanashyam Vaidya
 68

This lady has

presented with fever
since 4 days and pain
and swelling of both
cheeks.

Bilateral swelling of
the parotid glands
with fever is
diagnostic of mumps
– of course more
common in children.

In adult males, it may

also causes orchitis,
with resultant
decrease in sperm
count. In children, it Mumps
is harmless.

© Dr. Ghanashyam Vaidya

 69

The yellow arrow

points to a
subcutaneous
ecchymosis.

The second picture

shows the face, with
epistaxis.

Bleeding Disorders

© Dr. Ghanashyam Vaidya

 70

Bleeding disorders with

deficiency of platelet
factors show skin
hemorrhages – purpura
(<2 mm), petechiae (2-5
mm) and ecchymosis
(>5 mm).

This patient’s forearm

shows patches of
ecchymosis.

The second patient

shows a patch of
ecchymosis over the
upper arm.

Ecchymosis

© Dr. Ghanashyam Vaidya

 71

This is a case of a
Bleeding disorder –
Idiopathic
Throbocytopenic
Purpura.

This is a purpuric
rash due to tiny skin
haemorrhages. They
are larger in the
upper thigh where
they could be called
Petechiae.

Purpura

© Dr. Ghanashyam Vaidya

 72

Dehydration
Note the face of this
patient who has come
with H/O watery
diarrhoea. Note the
sunken eyeballs –
retracted deep into
the sockets. The
tongue (not seen) is
dry.

In the pictures below,

I have pinched the
skin over the
abdomen and
released. The skin
fold remains so
raised for several
seconds, indicating
severe dehydration.

© Dr. Ghanashyam Vaidya

 73

When a bee-hive is
disturbed, the honey
bees start attacking
everyone around. If
you cannot cover
yourself or flee, then
hundreds of bees
may bite you.

Note the large

number of Bee
stings, where the
bees have left their
sting behind.

Honey bee bites

© Dr. Ghanashyam Vaidya

 THE END

ALL PHOTOGRAPHS
H AV E B E E N C L I C K E D F O R Y O U
BY
D R G H A N A S H YA M VA I D YA

Special Thanks to my mother Institute –

The Karnatak Health Institute, Ghataprabha
For permitting me to publish the photographs.

For comments & suggestions for the Book, write to : gmvaidya1 @ gmail.com