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 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
[email protected]

Anudeep Padakanti
MBBS MD (Internal Medicine)
Department of Medicine
Kasturba Medical College
Manipal Academy of Higher Education
Mangaluru, Karnataka, India
[email protected]

Foreword
Chakrapani M
Headquarters
Jaypee Brothers Medical Publishers (P) Ltd
4838/24, Ansari Road, Daryaganj
New Delhi 110 002, India
Phone: +91-11-43574357
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Overseas Office
J.P. Medical Ltd
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SW1H 0HW (UK)
Phone: +44 20 3170 8910
Fax: +44 (0)20 3008 6180
Email: [email protected]
Website: www.jaypeebrothers.com
Website: www.jaypeedigital.com
© 2020, Jaypee Brothers Medical Publishers
The views and opinions expressed in this book are solely those of
the original contributor(s)/author(s) and do not necessarily represent
those of editor(s) of the book.
All rights reserved. No part of this publication may be reproduced,
stored or transmitted in any form or by any means, electronic,
mechanical, photocopying, recording or otherwise, without the prior
permission in writing of the publishers.
All brand names and product names used in this book are trade
names, service marks, trademarks or registered trademarks of their
respective owners. the publisher is not associated with any product
or vendor mentioned in this book.
Medical knowledge and practice change constantly. This book is
designed to provide accurate, authoritative information about the
subject matter in question. However, readers are advised to check
the most current information available on procedures included and
check information from the manufacturer of each product to be
administered, to verify the recommended dose, formula, method and
duration of administration, adverse effects and contraindications. It is
the responsibility of the practitioner to take all appropriate safety
precautions. Neither the publisher nor the author(s)/editor(s) assume
any liability for any injury and/or damage to persons or property
arising from or related to use of material in this book.
This book is sold on the understanding that the publisher is not
engaged in providing professional medical services. If such advice or
services are required, the services of a competent medical
professional should be sought.
Every effort has been made where necessary to contact holders of
copyright to obtain permission to reproduce copyright material. If any
have been inadvertently overlooked, the publisher will be pleased to
make the necessary arrangements at the first opportunity. the
CD/DVD-ROM (if any) provided in the sealed envelope with this
book is complimentary and free of cost. Not meant for sale.
Inquiries for bulk sales may be solicited at:
[email protected]
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
[email protected]
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-and-
half-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.
Contents

1. Prerequisites for Practical Examination and Common

Examination Cases
2. General Examination
A. Case Sheet Format
B. Vitals Examination
C. Physical Examination
D. Anthropometry
3. Respiratory System Examination
A. Case Sheet Format
B. Diagnosis Format
C. Discussion on Cardinal Symptoms
D. Discussion on Examination
E. Summary of Findings in Common Respiratory Diseases
4. Cardiovascular System Examination
A. Case Sheet Format
B. Diagnosis Format
C. Discussion on Cardiac Cycle
D. Discussion on Cardinal Symptoms
E. Discussion on Examination
F. Summary of Findings in Common Cardiovascular Diseases
5. Gastrointestinal System
A. Case Sheet Format
B. Diagnosis Format
 C. Discussion on Cardinal Symptoms
D. Discussion on Examination
6. Nervous System
A. Case Sheet Format
B. Diagnosis Format
C. Discussion on Cardinal Symptoms
D. Discussion on Examination
i. General Examination in Neurology
ii. Higher Mental Functions
iii. Cranial Nerves
iv. Motor System Examination
v. Reflexes
vi. Sensory System Examination
vii. Cerebellum and Coordination
viii. Gait
ix. Approach to Involuntary Movements
x. Meningeal Signs, Skull, and Spine
E. Approach to Common Neurological Cases
7. Rheumatology
A. Case Sheet Format
B. Diagnosis Format
C. Discussion on Symptommatology and Examination
8. Comprehensive Geriatric Assessment
Case Sheet Format
Diagnosis Format
Discussion
9. Approach to Psychiatric Illness
Case Sheet Format
Diagnosis Format
Discussion on Examination
Discussion on Diseases and Diagnostic Criteria
10. Semilong Cases
A. Diabetes Mellitus
B. Hypertension
C. Chronic Kidney Disease
D. Hypothyroidism
E. Hyperthyroidism
F. Cushing’s Syndrome
G. Acromegaly
11. Simplified Approach to Ecg (Reading and Diagnosis)
12. A Systematic Approach to Chest X-rays
13. Basic instruments in Viva
14. Spotters
15. Annexures
A. Miscellaneous topics
B. Definitions
C. Grading Systems
D. Laboratory Values of Clinical Importance

Index
Abbreviations

°C : Degree celcius
°F : Degree Farenheit
ALL : Acute lymphoblastic leukemia
ABPA : Allergic bronchopulmonary aspergillosis
ACS : Acute coronary syndrome
ACR : American college of Rheumatology
ARF : Acute renal failure
ADHD : Attention deficit hyperactivity disorder
ADR : Adverse drug reaction
ARDS : Acute respiratory distress syndrome.
AGN : Acute glomerulonephritis
AION : Anterior ischemic optic neuritis
AKI : Acute kidney injury
ALL : Acute lymphoblastic leukemia
ASCVD : Atherosclerotic cardiovascular disease
ACD : Anaemia of chronic disease
ADC : Apparent diffusion coefficient
ACA : Anterior cerebral artery
ACE : Addenbrooke’s cognitive examination
ACEI : Angiotensin converting enzyme inhibitor
ARB : Angiotensin receptor blocker
ACTH : Adrenocorticotropic hormone
ADHF : Acute decompensated heart failure
AEM : Ambulatory electrocardiogram monitoring
AI : Aortic insufficiency
AIDP : Acute inflammatory demyelinating polyneuropathy
AF : Atrial fibrillation
AICA : Anterior inferior cerebellar artery
AICD : Automated implantable cardioverter defibrillator
AML : Acute myeloid leukemia
ANS : Autonomic nervous system
ARVD : Arrhythmogenic right ventricular dysplasia
ASD : Atrial septal defect
AVF : Arteriovenous fistula
AVM : Arteriovenous malformation
AVR : Aortic valve replacement
AVRT : Atrioventricular re-entrant tachycardia
AVNRT : AV nodal re-etrant tachycardia
APB : Atrial premature beat
ALS : Amyotropic lateral sclerosis
ADL : Activities of daily living
ACPA : Anticitrullinated protein antibody
APLA : Antiphospholipid antibody syndrome
AP : Anteroposterior
Bx : Biopsy
BAL : Bronchoalveolar concentration
B/L : Bilateral
BIH : Benign intracranial hypertension
BAV : Bicuspid aortic valve
BBB : Bundle branch block
BC : Bone conduction/blood culture
BCAT : Brief cognitive assessment tool
BER : Benign early repolarization
BLS : Basic life support
BSA : Body surface area
BP : Blood pressure
BT : Bleeding time
BUN : Blood urea nitrogen
BM : Bone marrow
BMI : Body mass index
BMV : Bag and mask ventilation/balloon mitral valvotomy
BVP : Biventricular pacing
B-ALL : B-cell acute lymphoblastic leukemia
BADL : Basic activities of daily living
CRP : C-reactive protein
CXR : Chest X-ray
CCA : Common carotid artery
C/L : Contralateral
CMT : Charcot Marie tooth Disease
CN : Cranial nerve
C/O : Complaints of
CT : Computed tomography
CAMCOG : Cambridge cognitive examination
COST : Cognitive state test
CPR : Cardiopulmonary resuscitation
CCF : Congestive cardiac failure
CHF : Congestive heart failure
CBC : Complete blood count
CBD : Common bile duct
CHB : Complete heart block
CKD : Chronic kidney disease
CIDP : Chronic inflammatory demyelinating polyneuropathy
CLD : Chronic liver disease
CLL : Chronic lymphoid leukemia
CML : Chronic myeloid leukemia
CMV : Cytomegalovirus
CNS : Central nervous system
CVA : Cerebrovascular accident
CNS : Central nervous system
CABG : Coronary artery bypass graft
CAD : Coronary artery disease
CAUTI : Catheter associated UTI
CBE : Clinical breast examination
CRF : Chronic renal failure
COPD : Chronic obstructive pulmonary disease
CCCU : Critical coronary care unit
CCS : Canadian cardiovascular society
CVS : Cardiovascular system
CVP : Central venous pressure
CP angle : Cerebellopontine angle
CPB : Cardiopulmonary bypass
CDC : Centers for disease control and prevention
CDAI : Clinical disease activity index
CGA : Comprehensive geriatric assessment
CSF : Cerebrospinal fluid
DDx or D/D : Differential diagnosis
DPI : Dry powder inhaler
DIC : Disseminated intravascular coagulation
DIP joint : Distal interphalangeal joint
DKA : Diabetic ketoacidosis
DLCO : Diffusion lung capacity for carbon monoxide
DM : Diabetes mellitus
DR : Diabetic retinopathy
DNR : Do not resuscitate
DTR : Deep tendon reflex
DTA : Descending thoracic aorta
DSM : Diagnostic and statistical manual of mental disorders
DVT : Deep venous thrombosis
DLE : Disseminated lupus erythematosus
DAS : Disease activity score
DWI : Diffusion weighted imaging
ECA : External carotid artery
EAT : Ectopic atrial tachycardia
ECG : Electrocardiogram
ECF : Extracellular fluid
ECHO : Echocardiogram
ECMO : Extracorporeal membrane oxygenation
EPS : Extrapyramidal system
EF : Ejection fraction
EM : Erythema multiforme
ECD : Endocardial cushion defects
EDH : Extradural hematoma
EOM : Extraocular muscles/movement
EPO : Erythropoietin
EDM : Early diastolic murmur
ESM : Ejection systolic murmur
ESRD : End-stage renal disease
ET : Endotracheal tube
ESV : End-systolic volume
EULAR : European league against rheumatism
FMS : Fibromyalgia syndome
FBS : Fasting blood sugar
FEV1 : Forced expiratory volume in first second
FTT : Failure to thrive
FVC : Forced vital capacity
GI : Gastrointestinal
GBS : Guillain–Barré syndrome
GCS : Glasgow coma scale
GERD : Gastroesophageal reflux disease
GH : Growth hormone
Hb : Hemoglobin
HMF : Higher mental functions
HOCM : Hypertrophic obstructive cardiomyopathy
HBV : Hepatitis B virus
HL : Hodgkin lymphoma
HUS : Hemolytic uremic syndrome
HAI : Hospital acquired infection
HE : Hepatic encephalopathy
HDS : Hemodynamically stable
HIT : Heparin induced thrombocytopenia
HCC : Hepatocellular carcinoma
HTN : Hypertension
HIV/AIDS : Human immunodeficiency virus/acquired immunodeficiency syndrome
HDL : C-High density lipoprotein cholesterol
HD : Huntington’s disease
IADL : Instrumental activities of daily living
IP joint : Interphalangeal joint
IGF : Insulin-like growth factor 1
ICA : Internal carotid artery
ICD : Intercostal drain
ICS : Intercostal space/inhaled corticosteroid
ICH : Intracerebral hemorrhage
IVH : Intraventricular hemorrhage
INO : internuclear ophthalmoplegia
INR : International normalized ratio
ICP : Intracranial pressure
IBD : Inflammatory bowel disease
IBS : Irritable bowel syndrome
IDDM : Insulin-dependent diabetes mellitus—Type 1 diabetes
ICSOL : Intracranial space occupying lesion
IHD : Ischemic heart disease
IJV : Internal jugular vein
ILD : Interstitial lung disease
IMN : Infectious mononucleosis
IVC : Inferior vena cava
INH : Isoniazid
IPPV : Intermittent positive pressure ventilation
ITP : Immune thrombocytopenic purpura
IV : Intravenous
JME : Juvenile myoclonic epilepsy
JRA : Juvenile rheumatoid arthritis
JVP : Jugular venous pressure
KUB : Kidney, ureters and bladder
KDIGO : Kidney disease improving global outcomes
KF Ring : Kayser fleischer ring
July

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