Medicine

SPECIALITY CASE HISTORY
: :
GENERAL MEDICINE NEPHROTIC SYNDROME
Swelling of face, hands and legs Frothy urine Diabetes mellitus History towards Syhilis, Malaria, Tuberculosis and HIV History of Cancers- reast cancer, !ung cancer and Hodge"in#s lym$homa Collagen %ascular diseases& !u$us'- s"in lesions, oral ulcers, (oint $ains, $rolonged fe%er lood transfusion- He$aitis He$atitis C and HIV Drug history-)S*IDs, D +encillamine, heroin, *lternati%e and com$limentary medicines &Hea%y metals' +ersonal history- STD- Sy$hilis, HIV and He$atitis Family History- ,enal diseases CLINICAL EXAMINATION -eneral ./am-*nasarca, Malar ,ash Swelling of tissues around the eyes &$eriobital edema 0 Swelling of feet and an"les Scrotal edema Dysnoea & fluid o%erload- $ulmonary edema' Dry S"in CVS- +ericardial effusion ,S- +leural effusion * D- *scites, genital edema C)S- Diabetic retino$athy and neuro$athy INVESTIGATIONS aselinelood sugar 1rinanalysis- $rotein cast, li$id cast 23 hour urinary $rotein -4567gm8day !FT- Serum albumin9 560 gm8dl ,FT !i$id +rofile&increased cholesterol and T-!' !ow Iron and Vitamin-D le%els S$ecial-*)*,*nti dsD)*, Hbsag, HCV, Serum $rotein electro$horesis *S: titre 1S--.nlarged "idneys- Dimensions ,enal %ein thrombosis ,enal bio$sy COMPLICATIONS Infections- +eritonitis, Cellulitis and Se$is 1
National Board of Examinations, cases Medicine
Hy$ercoagubality- DVT, +ulmonary .mbolism and ,enal Vein Thrombosis Hy$erli$edemia Chronic ;idney disease -rowth delay in children DIFFERENTIAL DIAGNOSIS )e$hritic syndrome Cardiac Failure He$atic Failure Hy$othyroidism Cushings syndrome In children Fluid o%erload mista"en as lung allergic conditions TREATMENT If systemic causes of ne$htric syndrome is $resent thera$y should be instituted for the systemic disease Diet !ow +rotein !ow Salt-<-2 gms ,esticted fluid Corticosteroids to reduce the $roteinurea and edema Salt free *lbumin- to restore the blood %olume Diuretics- to maintain fluid balance and caution to a%oid hy$o%olemia Cyclo$hos$hamide when bot res$onding to steroids *C. inhibitors, *, reduce the rate of $rogression of the renal disease COMPLICATIONS .dema- Diuretics Dysli$edemia- statins Thromboembolic $henomena- If renal %ein thrombosis- He$arin Vitamin-D su$$lementation
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SPECIALITY CASE
:- GENERAL MEDICINE :EXTRA PYRAMIDAL DISORDER
Extra Pyramidal di !rd"r ar" *ssociated with abnormalities in basal ganglia constituted by fi%e $aired nuclei namely candate nucleus, $utamen , globus $allidus , sub-thalmic nuclei and substantia nigra6 The common mo%ement disorders are= <6+ar"insonism 26Tremors 56 Chorea 36 *thetosis 76 Dystonia >6 Hemi ballismus HISTORY <6 H8: of ,heumatic fe%er, $ast H8o ence$halitis &%iral', H8o e$ile$sy6 26 H8o drug inta"e &methyldo$a, $henothia?ines, :6C6 $ills etc6' 56 Family history of similar com$laints 36 +sychological history 76 H8o e/$osure to to/ics li"e carbon mono/ide, manganese etc6 >6 Duration and $rogress of the disease6 @6 H8o associated Aaundice or any e%idence of Chronic !i%er disorder &for Bilson#s disease'6 C6 H8o %asculitis, arthralgia, low grade fe%er&for S6I6.6' D6 *ny aggra%ating or relie%ing factors6 CLINICAL EXAMINATIONS Most im$ortant In a case of +ar"insonism, loo" for the following features= <6 !ac" of facial e/$ression& Mas"-li"e' 26 :n the face )ote tremors, absence of blin"ing, dribbling of sal%ia, glabellar- ta$, ocular mo%ements , for su$ra nuclear ga?e $alasy, feel for a greasy or sweaty blow & due to autonomic dysfunction' 2 S$eech=- Monotonus, soft , $oorly articulated and faint6 5 *s" the $atient to write & !oo" for microgra$hia' 3 +aucity of mo%ements 7 *s" the $atient to wal", turn Euic"ly and sto$ and restart6 & )ote the difficulty in starting, stuffing ,free?ing and festination' > !oo" for $ro$ulsion and retro$ulsion & with care' @ ,esting tremors with the arms rela/ed &F$ill rollingG mo%ement'- on finger- nose testing, the resting tremors disa$$ears6 C Test for wrist tone , for cog-wheel or lead- $i$e rigidity6 3
EXAMINATION OF A PATIENT #ITH #ITH OTHER EXTRA PYRAMIDAL MOVEMENT DISORDERS <6 Higher mental functions 26 Chorea- gremacing of face, (er"ing of head6 56 ./amination of the $atient#s arms for chorei from mo%ement, *thetosis *nd hemi Hbellimus and tremors & descri$tion of the mo%ements of the arms is %ery im$ortant6 36 Sha"e hands with the $atient FMil"-maid gri$G- lac" of sustained gri$6 76 *s" the $atient to hold hands out and loo" for the classical choreic $osture6 &Finger and thumb hy$er restricted and wrist fle/ed due to hy$otonia' >6 ,efle/es @6 Con(ucti%al in(ection &ata/ia telengec tasia' C6 ;6F6 ring &wilson#s disease' D6 ./amination of cardio-%ascular system INVESTIGATIONS <6 Com$lete Haemogram 26 !6F6T6 56 Detailed :$thalmic e/amination 36 *S!: titres 76 Bor" u$ for S!. >6 Thyroid function tests if autoimmune thyroidities is sus$ected @6 Serum co$$er and cerulo$lasmin le%els6 C6 !6+6 D6 CT Scan rain <06 M,I S can of rain <<6 ..- if reEuired <26 .stimation of drug le%els& if reEuired' <56 .CH: TREATMENT Par$i% !%i m <6 Sym$tomatic, su$$orti%e and $alliati%e6 26 +hysical thera$y and $sycho-thera$y 56 ,eEuirement of lifelong medications 36 Treatment $rogramme to be $ersonali?ed 76 Medical treatment for com$ensated $hase and decom$ensated $hase6 >6 Medications under e%aluation @6 ,ole of surgery TREATMENT OF OTHER MOVEMENT DISORDERS <6 Drug treatment of Tremors 26 treatment of Dystonia 56 ,ole of surgery 36 1se of botulinum to/in
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SPECIALITY CASE
:- GENERAL MEDICINE :- RHE&MATOLOGICAL DISEASES
M&ST 'E COVERED POINTS IN RHE&METOLOGICAL DISEASES INTROD&CTION The diagnosis and assessment of articular disease are based on the clinical $rocesses of history- ta"ing and e/amination6 history- ta"ing and e/amination of the $atient6 o%er-diagnosisand o%er-treatment6 lood tests and radiological 1nnecessary in%estigations are in%estigations are often useful, and may be essential , but they cannot re$lace careful e/$ensi%e , may cause an/iety to $atients, and if ta"en out of clinical conte/t, lead to The initial history and e/amination may lead immediately to the diagnosis of a s$ecific disorder, such as rheumatoid arthritis, or may indicate a $athological $rocess such as %as ulitisor syno%itis, or may suggest that the condition is self-limiting or non- $athological6 *$$ro$riate assessing the $atient and the results of the in%estigations, the $hysician should be able to offer the $atient an e/$lanation of his sym$toms in terms the $atients can understand and formulate with the $atient a $lan for treatment6 THE HISTORY The $atient should be as"ed first about the nature of the main $roblem and it#s im$act on their daily life6 Factor#s such as the $atient#s age, se/, race and em$loyment are often rele%ant6 The mode of the onset of the sym$toms and any $reci$itating factors such as trauma should be as"ed about6 The de%elo$ment of sym$toms, their e%olution o%er time, and $attern of remission and rela$se are also im$ortant6 The effect of $re%ious thera$ies, the $atient#s com$liance with them and any ad%erse reaction are im$ortant in $lanning future treatment6 Pai% +ain is a cardinal sym$tom of rheumatic disease and should be enEuired about in detail6 Sit" It is im$ortant, and sometimes sur$risingly difficult, to establish whether the $ain arises from a (oint, muscle, bone or other tissue, in general, $ain arising in a (oint is worse when the (oint is mo%ed, whereas $ain arising elsewhere will not be affected by (oint mo%ement6 *ssociated sym$toms such as (oint swelling suggesting
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inflammatory (oint disease or $araesthesiae and wea"ness, suggesting a neurological cause for the $ain, may also hel$6 It is hel$ful to as" $atients to demonstrate on their own bodies the site where $ain is felt6 ()ality !r *+ara*t"r +ain is notoriously difficult to describe in words, but some features are %ery useful6 +ain, which is worse at night, disturbs slee$ and is unrelenting and unaffected by $osition, is strongly suggesti%e of serious disease such as malignancy and reEuires urgent in%estigation6 The $ain of malignancy is usually less acutely se%ere than the $ain of an acute inflammatory condition such as gout6 The se%ere shooting $ain of ner%e root entra$ment, which tra%els down a limb or around the trun", is often characteristic enough to be diagnostically useful iii, R"li"-i%. a%d "xa*"r/ati%. 0a*t!r Aoint $ain due to mechanical $roblems without inflammation is ty$ically worsened by mo%ement and ra$idly reli%ed by rest6 Inflamed (oints are often $ainful at rest and somewhat better after a few minutes of use6 +atients with acti%e inflammatory (oint disease are often troubled by se%ere night $ain and stiffness6 Sti00%" a%d r" tri*ti!% !0 m!-"m"%t Stiffness is highly sub(ecti%e and %ariable sensation of tightness and resistance to mo%ement6 +atients may eEuate stiffness with fatigue, $ain, wea"ness, loss of range of mo%ement or swelling6 Most $atients with (oint $ain e/$erience an initial, shot-li%ed sensation of stiffness after immobility6 This needs to be differentiated from the se%ere stiffness e/$erienced with $atients with inflamed (oints when they begin to mo%e after slee$ or rest6 This stiffness ty$ically F wears offGafter minutes or hours, and $atient can often Euantify this time Euite accurately6 The duration of Fearly morning stiffnessG on first arising after the night#s slee$ may be used to assess the changing se%erity of inflammatory disease6 * duration of more than 50 minutes of morning stiffness remains one of the *merican ,heumatism *ssociation criteria for rheumatoid arthritis6 S1"lli%. +atients may notice swelling, but it is unwise to assume that what the $atient is describing is syno%ial swelling or (oint infection unless the descri$tion is %ery clear, or there is e%idence of syno%itis or effusion on e/amination, Stiffness , $araesthesiae from ner%e entra$ment, malallignment, discolouration or $ain itself may lead the $atient to a $erce$tion of swelling which is not confirmed by
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e/amination6 If swelling or deformity is $resent, it is necessary to determine whether it is due to fluid, soft-tissue or bone6 Family Hi t!ry The family history may be usefulI a history of similar $roblems in other family members may gi%e a clue to H!* 2@- related arthro$athies, $soriatic arthritis, gout or some autoimmune rheumatic diseases6 Sy t"mi* ym2t!m Sym$toms of systemic illness such as fe%er, weight loss and malaise may be due to acti%e inflammatory (oint disease, but should also alert the doctor to the $ossibility of an underlying infection, malignancy or tuberculosis, may be rele%ant6 )on- articular sym$toms associated with (oint disease such as an"ylosing s$ondylitis should be s$ecifically as"ed for I $atients will seldom associate a history of a $ainful red eyeI s"in rash or urethral discharge with their $ainful swollen "nee6 Tact, and a$$ro$riate e/$lanation, are needed when enEuiring about se/ually transmitted diseaseand genital sym$toms, but failure to as" the rele%ant Euestions may result in misdiagnosis6 E "%tial 2!i%t i% t+" +i t!ry 3 +ain :nset ite and radiationI referred $ain character effect of mo%ement and rest night $ain and unremitting $ain morning- duration Immobility stiffness and gelling Swelling and deformity Disability and handica$ Systemic illness, e/tra-articular features, slee$ and de$ression o Social and family history +atients should be as"ed s$ecifically about slee$ disturbance de$ression, which are commonly features of chronic $ainful conditions6 systemic lu$us erythematosus6 Exami%ati!% !0 t+" l!*!m!t!r y t"m S1"lli%. Fatigue is a characteristic sym$toms of autoimmune disease such as reheumatoid arthritis and
J Stiffness o o o
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Swelling around a (oint may be cause by fluid, as in an intra-articular effusion or effusion into an inflamed bursa, by soft tissues such as syno%ium or e/traarticular fat $ads, or by bony enlargement as in the osteoarthritis6 Sublu/ation, as the metacar$o$halangeal (oint, may also gi%e an im$ression of swelling6 Intraarticular fluid $roduces a swelling defined by the margins of the (oint ca$sule6 The syno%ial lining layer is normally too thin to be $ala$able but the thic"ened inflamed syno%ium in chronic syno%itis such as rheumatoid arthritis may ha%e a FboggyG consistency and be easily felt6 .ffusion without syno%ial thic"ening, where the (oint line can be clearly felt , is usually due to trauma or osteoarthritis6 Fluid can often be shifted from one area of the (oint to another by com$ressing one side of the swollen (oint6 T"%d"r%" 4 r"d%" a%d 1armt+
Inflammed (oints are tender along the (oint line6 +a$lation may also locali?e tenderness to the sites of attachment of tendons or ligaments, bursae, muscles or fat $ads 6 Inflammed (oints are usually warmer than the surrounding tissues6 ,edness o%er the (oint is a sign of intense inflammation, usually due to gout, $seudogout or infection6 Limitati!% !0 m!-"m"%t4 d"0!rmity a%d i% ta/ility !imitation of a mo%ement is a common sym$tom of (oint disease6 :lder $eo$le ha%e less mobile (oints than the young, women are generally more fle/ible than men and (oint mobilityis greater in some races than others6 It is im$ortant to de%elo$ a feeling for the normal for a $articular race, age and se/ so that generali?ed hy$ermobility, as well as restriction of mo%ement at s$ecific (oints may be detected6 !imitation of mo%ement of a (oint may be due to swelling, soft-tissue contracture, tendon ru$ture, muscle wea"ness, (oint sublu/ation or dislocation as well as $ain , the commonest cause6 The e/tent of loss of function resulting from limitation of mo%ement should be assessed6 The $attern of loss of mo%ement may indicate whether it is due to inflammation of the (oint itself or to another cause such as ru$ture of tendon6 There may be a greater range of $assi%e than acti%e mo%ement6 This is commonly due to $ain but may be due to muscular wea"ness or tendon ru$ture6 Deformity of a (oint may result from contracture of the ca$sule or surrounding soft tissue , sublu/ation, an"ylosis in an abnormal $osition or bony or soft tissue swelling6 Deformity usually results in some loss of function and $lacing of
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the abnormal stresses on the (oint6 * (oint is said to be unstable if a greater than normal range of $assi%e mo%ement is $ossible6 If there is $artial loss of congruity of the (oint surfaces the (oint is sublu/edI if there is com$lete loss of cartilage-tocartilage contact the (ont is located6
5, L!!$
6, F""l
7,M!-"
8, F)%*ti!%
+osition in which the (oint is held Swelling Deformity *ssociated tissues-s"in changes, muscle wasting nails6 Barmth Tenderness swellingI bone, soft-tissue&syno%ium or other 0 or fluidK Cre$itusI soft-tissue&syno%ial' or bonyK *CTIV. M:V.M.)T assess the range, rhythm and ease of mo%ement the $atient can achie%e6 +*SSIV. mo%ement Com$are the range of mo%ement when you mo%e the (oint *ssess the stability of the (oint6 *ssess the degree &or loss' of useful function egI of the hand or arm6
Extra-arti*)lar ma%i0" tati!% !0 *!mm!% r+")mati* di "a " S$i% )odules ,ash Still#s , cutaneous Vasculitides, drugs !yme arthritis, %iral infection, ;awasa"i#s disease, HIV H related arthritis6 .rythema nodosum T , drugs, stre$tococcoal sore throat, ehcets, sarcoidosis, fungal infections, idio$athic, inflammatory bowel disease, le$rosy & erythema nodosum le$rosum' Inflammatory bowel disease, S!., Beber-Christian Disease, malignancy6 ,ehematic fe%er, rheumatoid arthritis, gout, Hy$erli$idaemias Systemic lu$us erythematosus, rheumatic Disease, $soriasis, ,eiter#s dermatomyositis, fe%er,
:ther $anniculitis , ,aynaud#s Sclerodactyly
+rogressi%e systemic scelrosis, $olymyositis H dermatomyositis, S!. , rheumatoid arthritis, %asculitis6 +rogressi%e systemic sclerosis, C,.ST, o%erla$6 syndromes
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!eg ulcers
Fetly#s syndrome, behcet#s systemic %asculitis, inflammatory bowel disease6 S!., $olyarteritis nodosa S!., drugs &cytoto/ic' hu$othyroidism -onococcaemia, ehcet#s +rimary osteoarthritis +rimary osteoarthritis
!i%edo reticularis Hairloss S"i $ustules Heberden#s nodes ouchard#s nodes
Oral *a-ity *$theous ulcers ehcet#s inflammatory bowel disease Su$erficial $ainless 1lcers Dry mouth O*)lar Con(uncti%itis Scleritis- e$iscleritis *nterior u%eitis Iritis Dry eyes ,eacti%e arthritis S(ogren#s syndrome H $rimary, secondary reacti%e arthritis, rela$sing $olychondritis ,heumatoid arthritis, rela$sing $olychondritis Au%enile chronic arthritis, seronegati%e s$ondyloarthritis S$ondylarthritis, ehcet#s S(ogren#s syndrome
S)mmary !0 t+" S*r""%i%. Exami%ati!% !0 t+" 9!i%t <6 Gait Batch the $atient as he stands, wal"s and sits6 +ain, stiffnessor deformity of the lower limb (oints or bac" may lead to a lim$6 *n abnormal gait, a lim$, or abnormal $osture may indicate disease in the s$ine, hi$, "nees or feet6 2 Bith the $atient sitting, e/amine %"*$- range of mo%ement and lym$h nodes "l/!1- range of mo%ement *nd swelling 1ri t-range of mo%ement and swelling
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+a%d - for s"in, nails, (oint swelling, deformity, $inch and $ower gri$s 56 Bith the $atient lying, e/amine +i2- rotation $%"" - for effusion, range of mo%ement 0""t- for deformity and MT+A sEuee?e $ain Bith the $atient lying, e/amine S2i%"- for abnormal contour and range of lumbar mo%ement6 INVESTIGATIONS N!% 2"*i0i* T" t The tests included are com$leted blood counts and .S,, routine urinalysis, total $roteins with albumin and globulin le%els, C-reacti%e $rotein &C,+' and a host of acute-$hase rectant &*+,'6 The time $rofile of each *+, is different, e6g6 C,+ %alues can change within 23 hours while .S, ta"es a few days6 This difference allows (udicious use of the tests6 Their serial estimation hel$s to monitor disease acti%ity between clinical acti%ity and .S,6 .S, should be measured by the Bestergren method6 High .S, is a feature of inflammatory rheumatic disorders6 Very high .S,&4<00mm in < st hour' is commonly seen in infections &T ', rhematic diseases &S!., Still#s disease' and malignancies &myeloma, leu"aemias, lym$homas'6 C,+ estimation is not reEuired routinely6 In normal healthy $ersons the le%els are com$lement $athway is acti%ated6 )ormal C3 and lowered C5 le%els indicate acti%ation of the alternate $athway6 -enetically determined low le%els of indi%idual com$lement com$onents are sometimes seen6 These indi%iduals may de%elo$ S!. or other rheumatic diseases6 Imm)%!.l!/)li% ,ise in immunoglobulin le%els is a nons$ecific findings and hence is the routine estimation is not essential6 Multi$le myeloma and agammaglobulinaemia are the two main indications fro estimation of indi%idual immunoglobulins6 The same can be said of routine $rotein electro$horesis6 Ot+"r imm)%!l!.i*al t" t Circulating immune com$le/es are of research interest6 Howe%er, in routine $ractice their detection has not been found to be of great hel$6 Further, no single method has found uni%ersal acce$tance6 Cryoglobulins, +.- $reci$itation, ClE binding and ,a(i cell assay are some of the better "nown6
36
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N!%- S)r.i*al Ma%a."m"%t <6 26 56 36 76 )on Hsteoridal anti-inflammatory drugs6 ,econstructi%e hand surgery *rtho$lasty *nti-cyto"ine agents Immunosu$$ressi%e thera$y
S)r.i*al ma%a."m"%t
1.
26 56 36
:$en on arthrosco$ic syno%ectomy ,econstructi%e hand surgery *rthro$lasty Total Aoint ,e$lacement
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SPECIALITY CASE
=- GENERAL MEDICINE :- THYROTOXICOSIS
Bhat is the difference between the terms thyroto/icosis and hy$erthyroidismK P!i%t i% t+" +i t!ry <6 Male= Female 26 *ge 56 StressK 36 Smo"ing 76 +regnancy >6 Hy$eracti%ity8 irritability @6 Heat intolerance8 Sweating C6 +al$itations D6 Beight loss with increased a$$etite <06 Diarrhoea <<6 +olyuria <26 !oss of libido P!i%t <6 26 56 36 76 >6 @6 C6 D6 t! /" *!-"r"d i% *li%i*al "xami%ati!% Tachycardia, *F Tremor -oiter Muscles wasting, $ro/imal myo$athy without fasciculation,chorea H++ .ye signs -ynaecomastia S"in Lchanges#8Thyroid dermo$athy6 Scoring of orbital changes6 ): S+.CS scheme
P!i%t i% i%-" ti.ati!% <6 26 56 36 76 >6 @6 TSH, uncombined TSH, uncombined T5 T+: antibiotics T ll or TSI measurement ,adionuclide scar6 !i%er function tests S6 Ferritin le%els Haemogram8 + S for microcytic anaemia M thrombocyto$enia
P!i%t i% Di00"r"%tial Dia.%! i <' )odular thyroid disease 2' Destructi%e thyroiditis 5' .cto$ic thyroid tissue 3' Factitious thyroto/icosis 7' TSH-secreting $ituitary tumor6 >' +anic attac"s, mania @' +haeochromocytoma
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P!i%t i% Ma%a."m"%t <6 *ntithyroid drugs 26 Surgery-subtotal thyroidectomy a6 Thyroto/ic crisis b6 Com$lications of surgery
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S2"*ialty Ca "
==-
Medicine Diabetes Mellitus
D"0i%iti!%:- The national diabetes data grou$ MBH: ha%e issued diagnostic Criteria for D6M6 Sym$toms of Diabetes $lus random blood glucose concentration 4 200mg8d! or Fasting $lasma or glucose4<2>mg8d! or Two hour $lasma -lucose4 200mg8d! during an oral glucose tolerance test6 Hi t!ry=+olyuria, +olydi$sia, +oly$hagia, weight loss6 lurred %ision, lower e/tremity $aresthesias, yeast infection, $articularly Voluo%aginitis in women, balanitis in men6 :bese $atients, +atient first degree relati%e with ty$e 2 diabetes mellitus6 +atients with hy$ertension, +atients with high triglyceride or HD!- Cholesterol 957mg8d!6 +olycystic o%ary disease Exami%ati!%: :besity *nthro$ometric data -Height -Beight -Baist-hi$ ratio -Fat fold thic"ness S"in Changes Hair loss +rominent %eins Callus formation Crac"ers and fissures 1lcers in the foot and deformities +eri$heral $ulses lood $ressure recording &both recumbent and standing' *uscultations for bruits o%er carotid and femoral arteries )eurological e/amination cranial ner%es Dee$ tendon refle/es *utonomic function Di00"r"%tial : Diabetes inci$idus Insulin resistance :besity 15
Maturity onset diabetes mellitus !atent autoimmune diabetes of adults&!*D*' Stein- !e%enthal syndrome I%-" ti.ati!%: Fasting $lasma glucose &f$g' greater than or eEual to <2>M-8d! or random glucose greater than or eEual to 200mg8d! and classic sym$toms $olyuria, $olydi$isia, $oly$hagia, weight loss Hemoglobin *lc &Hb*lc or *lc' or glycosylated hemoglobin &-Hb' Screening urine microralbumin measurements is recommended Measuring insulin or C-+e$tide Concentrations *ntibodies to insulin, islet cells, or glutmatic acid decarbo/ylase &-D*'
- )on- Sulfonylurea - ,e$aglinide )ateglinide & ' iguanides Metformin &C' !6glucosidace inhibitor -*carose - Meglitol &D' Thia?olidinedione - ,osiglilata?one - +ioglita?one Ii<sulin=&*' Short *cting - !is$ro - Insulin *s$art 16
- ,egular & ' Intermediate acting - )+H !ente &C' !ong *cting - 1ltralente - -largine Com$lication monitoring SM Surgery=- Bhole $ancreas trans$lantation Di"t:- Beight reduction &in obese' -Hy$ocaloric Diet - Total calories between <000-<200 "cal8 day - For obese- 20 "cal8"g ideal weight N - For normal adults &sedentary'- 50 "cal8"g ideal body weight - for normal adults& manual wor"er' and growing children 30"cal 8"g ideal body weight6 - Carbohydrate- 70->0 O of total calories6 - Fibers - 27 gm of fibres $er <000 "cal - +roteins- 27-50O of total calories6 - Fats - 27-50O of total calories Ex"r*i ":- Isotonic e/ercise li"e bris" wal"ing, swimming or cycling are recommended6 - *erobic e/ercise for 50-37 minutes8 day, 7 times $er wee" should be ad%ocated6 - ./ercise regimen should start with warm u$ stretching for <0 minutes, aerobic e/ercise for 50- 37 mintues, and cool down streching for 7-<0 minutes6
Hy2!.ly*"mia 5, Hi t!ry:- Tremor - Sweating - *n/iety 17

- +allor -)ausea - Shi%ering - +al$itation - Im$aired concentration - Confusion - Ina$$ro$riate beha%ior - Difficulty in s$ea"ing - *ggression or non- coo$eration - Focal8generali?ed sei?ure -Hunger - Bea"ness - .$igastric discomfort - lurred Vision 6 6, Exami%ati!%:-Tachycardia -Increased +ulse $ressure - Focal neurological deficit including transient nemi$legia6 - Drowsiness $rogressing to coma - +ermanent neurological change, if $rolonged hy$oglycemia6 - Gradi%.: - Clinically, hy$oglycemia may be usefully graded as follows =-rade <=- iochemical hy$oglycemia in the absence of sym$toms -rade 2=- Mild sym$tomatic- treated successfully by the $atient6 -rade 5=- Se%ere- assistance reEuired from another $erson6 -rade 3=- Very se%ere- causing coma or con%ulsion6 Di00"r"%tial:J )on"etotic Hy$ersomolar State J Diabetic ;etoacidosis J Metabolic ence$halo$athy I%-"ti.ati!%:J,andom blood sugar J* J Chest / rays
7,
8,
:, Ma%a."m"%t:I% ty2" 5 OM -rade <-2 Hy$oglycemia= 2-3 De/trose tablets 2 tsfSugar &<0 gm', honey or (am &ideally in water' * small glass of carbonated sugar- containing soft drin"6 -rade 5-3 Hy$oglycemia= uccal glucose gel=-+ro$rietary thic" glucose gel &e6g6 Hy$osto$' :r honey, can be smeared on the buccal mucosa &%ariable efficacy' 18
I% ty2" 6 DM:
Intra%enous glucose=- *dminister 27ml of 70O glucose &or <0:ml :f 20ODe/trose' into a large %ein, ideally after cannulation6 -lucagon= - < mg can be gi%en I6 V , SIC or I6M
Intra%enous de/trose =- Mandatory continuous infusion of 7O or <0O may be reEuired for se%eral days6 Dia? o/ide Hydrocortisone -lucagon Mannitol =- to reduce cerebral odema :ctriotide= - for $re%ention of sul$honylurea - induced hy$oglycemia6 Howe%er, clinical e/$erience is %ery limited6 Dia/"ti* ;"t!a*id! i
5, Hi t!ry:J )ausea, Vomiting J Thirst, +olyurea J *bdominal +ain6 J Shortness of breath6 J Confusion, Drowsiness, Coma6 J *cute weight !oss6 J -enerali?ed muscular wea"ness6 J Visual Disturbances6 J Muscular Cram$s6 6, P+y i*al Exami%ati!%:J Tachycardia6 J Dry Mucous Membranes, ,educed S"in turgor J Dehydration, Hy$otension6 J Tachy$noea, ;ussmaul ,es$iration8,es$iratory distress6 J *bdominal Tenderness6 J !ethargy, :btundation, Cerebral :dema, Coma6 7, Di00"r"%tial Dia.%! i : *lcoholic ;etoacidosis6 *cute *$$endicitis Hy$erosmolar Hy$erglycemic )on"etotic coma Salicylate To/icity6 Hy$onatremia Hy$othermia6 !actic *cidosis6 19
Metabo<ic *cidosis6
8, I%-" ti.ati!%:J ,andom lood Sugar6 J 1rine for ;etones6 J * -6 J S6 .lectrolytes &;P, )aP, MgPP, CI-, icarbonate, +hos$hate' J *cid-base status-+H, Hco5-, +co2, Q-Hydro/ybutyrate6 J ,enal Function test6 J lood Culture6 J Chest R-,ays6 J .C-6 :, Ma%a."m"%t:- Fl)id a%d El"*tr!lyt" J Volumes= - l!8h R 5, thereafter ad(ust according to reEuirements6 J Fluids= )ormal Saline &<70mmol8!' is routine6 - Hy$otonic &SHalf- normalS' Saline &@7 mmol8!', if serum Sodium e/ceeds <70mmol8!6 - 7O De/trose < ! 3-> hrly when blood glucose has fallen to <7mmol8!6 J +otassium= $otassium )o $otassium in first <! unless initial $lasma 9567 mmo<8!6Thereafter, add 30mmol8! ;C! 567-767 mmo<8!, add 20mmol ;C! 4 767 mmo<8!, 30mmol ;C! se%ere hy$o "alemia may reEuire more aggressi%e
;C!
re$lacement Jlnsulin=-<6 y continuous intra%enous infusion= - regular insulin is administrated as I6V&06< 18;g' or <6M &06318;g', then 06< 18;g8hr continuous I6 V infusionI increase 2-<0 fold if no res$onse by 2-3hour6 26 *dminister intennediate or long acting insulin as soon as $atient is eating6 *llow for o%er la$ in insulin infusion and subcutaneous insulin in(ection6 :, Ot+"r P!i%t :J Search for and treat $reci$itating cause &e6g6 infection, MI' J Hy$otension usually res$onds to adeEuate fluid re$lacement6 20
J CV+ monitoring in elderly $atients or if cardiac disease $resent6 J )- tube, if conscious le%el im$aired to a%oid as$iration of gastric content6 J1rinary Catheter6 J Continuous .C- monitoring may warn of hy$er or hy$o"alemia J *,DS mechanical %entilation &<00O 02I I++V' a%oid fluid o%erload6 J Mannitol &u$ to < gm 8"g I6 V' if cerebral odema sus$ected6 J Meticulously u$dated clinical M biochemical record using a $ur$ose designed flow chart6
Hy2"r! malar C!ma <6 Hi t!ry:J .lderly with "nown history of ty$e 2 DM J +olyuria J Beight loss J Diminished oral inta"e that culminates in mental confusion, lethargy, and coma6 J +rior hos$itali?ation for hy$erglycemia J Increasing thirst with $olyuria, $olydi$sia, and weight loss J Drowsiness and lethary - Delirium -Coma - Sei?uers - Visual8Disturbance J Clues to underlying DM=- )eedle $ric"s or calluses on finger ti$s6 - :besity - *onthosis nigricans J Diabetic dermo$athy J )ecrobiosis on the $retibial surface J lower e/tremety infections,&e6g6 cellulites , carbuncles' J alanities J Val%o%aginitis J Thrush J -ingi%itis J Tachycardia J Hy$otension J Sei?ures, Hemi$aresis J * $ositi%e abins"i sign J Myoclonic (er"s J Change in muscle tone J )ystagmus, di$lo$ia and altered mental status 6 Di00"r"%tial :J Diabetes insi$idus JDiabetic ;etoacidosis J Myocardial Infarction 21
J *$hasia J +ulmonary .mbolism
7, I%-" ti.ati!%:J +lasma glucose J *rterial blood gases &$H,+co2,Hco5-,;P,)aP' J +lasma "etones J Serum osmolality and calculated serum osmolality J 1rinalysis J +lasma .lectrolytes J Calculated *nion -a$ J Creatinine and 1) J Com$lete blood count and differential J Creatine ;inase &,habdomyolysis' J Chest radiogra$h J CT scan of the head J .lectrocardiogram 8, Tr"atm"%t:J Intra%enous fluid hydration and electrolyte hemoeostasis J Corrections of hy$erglycemia J Treatment of underlying diseases J Cardio$ulmonary monitoring )eurological Monitoring
DIA'ETIC NE&ROPATHY 5, Hi t!ry:J Sensory Sym$toms=)egati%e or +ositi%e Diffuse or Focal J)egati%e Sensory Sym$toms are feelings of numbness or deadness6 !oss of alance .s$ecially with eyes closed6 +ainless in(uries J +ositi%e Sensory Sym$toms may be describe as urning +ric"ing $ain Tingling Sensation +ins M )eedles Feeling *ching, tightness Hy$ersensiti%ity to touch J Motor +rombles=- Distal, $ro/imal 22
- More focal wea"ness 6 - Fine hand coordination and difficulty with tas"s - Foot sla$$ing and toe scuffing or freEuent tri$$ing - Bea"ness - !imb wea"ness - Difficulty climbing u$ the stairs and getting u$ from a seated or su$ine $osition, falls6 J *utonomic Sym$toms=-Dry s"in due to lac" of sweating or e/cess defined areas -+oor dar" ada$tation, sensiti%ity to bright light -Cardio%ascular $ostural hy$otension lightheadedness, fainting6 -1rinary &1rgency, incontinence, dribbling' --astrointestinal &nocturnal diarrhea, consti$ation, nausea, or %omiting' -Se/ual &.rectile im$otence and e(aculatory ability to reach se/ual clima/ in woman' 3 Exami%ati!%:- Symmetrical or *symmetric neuro$athies in%ol%ed6 J Symmetric $olyneuro$athies= - multi$le ner%es diffusely and symmetrically in%ol%ed6 - Distal symmetric $olyneuro$athy - Small Fiber neuro$athy - Diabetic autonomic neuro$athy - Diabetic neturonathic cache/ia *symmetric neuro$athy= - Single or multi$le cranial mononeuro$athies - Cranial Mononeuro$athy - Somatic Mononeuro$athy - Diabetic +olyradiculo$athy -Diabetic radiculo$le/o$athy -Chronic inflammatory dymyelinating $olyneuro$athy6
6, P+y i*al:great toes6 - !oss of an"le (er"s or loss of %ibratory sensation o%er the - Bea"ness of small foot muscles6 7, Di00"r"%tial :- *lcohol & .thanol' related neuro$athy - Chronic Inflammatory Dymyelinating +olyradiculoneuro$athy )utritional )euro$athy - Sarcoidosis and )euro$athy - Thyroid Disease - To/ic )euro$athy - 1remia )euro$athy - Vasculitic )euro$athy 8, I%-" ti.ati!%:- Com$lete blood count &C C' 6 - Com$lete metabolic $anel &.lectrolytes and li%er function $anel' 23
- Vitamin -<2 and folate le%els - Thyroid-stimulating hormone and thyro/ine - .rythrocyte sedimentation rate - Serum $rotein electro$horesis with immunofi/ation electro$horesis6 *ntinuclear antibody - ,heumatoid factor - +arane$lastic antibodies - .le%ated hemoglobin *lc le%els4CO - M,I of the cer%ical, thoracic, and lumbar regions - .lectro $hysiologic studies&.lectromyogra$hy and ner%e conduction studies'6 :, Tr"atm"%t: Medical care =- -eneral as$ects of treatment - .ducation on foot care - regular foot e/aminations J Current treatments for $ain=Tight and stable glycemic control is $robably the most im$ortant - -aba$entin, +regabalin, To$ical lidocaine, and dulo/etine +henytoin, lamotrigine, and o$ioids - To$ical thera$y with ca$saicin Treatments for autonomic dysfunction - For .rectile im$otence - +a$a%erine Sildenafil -lyco$yrrolate *ldose reductase inhibitors &e6g6, *lrestatin, sorbinil, tolrestat' *l$ha-li$oic acid -amma- !inolenic acid )er%e growth factor&)-F'
24
Dia/"ti* %"2+r!2at+y Hi t!ry J History of Diabetes=J +assing of foamy urine J :therwise une/$lained $roteinuria in a $atient with diabetes Exami%ati!%:* Foot edema secondary to hy$oalbumineia J other associated disorders such as $eri$heral %ascular disease J Hy$ertension J .%idence of diabetic retino$athy after fundusco$y or fluorescein angiogra$hy J +eri$heral %ascular occlusi%e disease J .%idence for diabetic neuro$athy J .%idence for fourth heart sound during cardiac auscultation J )onhealing s"in ulcers8osteomyelitis Di00"r"%tial :JMulti$le Myeloma J)e$hritis, interstitial J)e$hrosclerosis J)e$hrotic Syndrome J,enal artery stenosis J ,enal Vein Thrombosis J ,eno%ascular Hy$ertension I%-" ti.ati!% :3 1rinalysis J Microalbuminuria J 23- hour urinalysis for urea J Microsco$ic urinalysis J,enal ultrasound - ;idney si?e - :bstruction - .chogenicity studies J Serum and urinary electro$horesis J ,enal bio$sy Tr"atm"%t:JMedical care=- -lycemic control J *ntihy$ertensi%e treatment 25
J ,*S inhibition -*C.66I M *, J S$ecific thera$ies= - includes modification M8or to treatment of ris" factors - +eritoneal dialysis - Hemdialysis - C*+D - Continuous ,enal ,e$lacement thera$y &*' Continuous arterio%enous hemodiafittration with or without dialysis & ' Continuous %eno-%enous hemodaifiltration with or without dialysis6 J Surgical -,enal re$lacement thera$ies ;idney $ancreas trans$lantation - *6 V fistula Di"t:J *D* suggests diets of %arious energy inta"e &caloric %alues'6 J Bith ad%ancing renal diseases, $rotein restriction of as much as 06C- < gm8"g8day may retard the $rogression of ne$hro$athy6 A*ti-ity:)o restriction in acti%ity, unless associated com$lication of diabetes li"e coronary artery disease or $eri$heral %ascular disease6
OPHTHALMOLOGIC COMPLICATIONS 5, Hi t!ry:J Transient disturbance of refraction6 J -radual loss of %ision - suggesti%e of maculo$athy or cataract6 J Sudden $ainless loss of %ision-%itreous hemorrhage6 ,etinal arterial M %enous thrombosis may also occur in diabetic $atients6 J *$$earance of TfloatersT- $ossible small8recurrent %itreous hemorrhage6 J Chronic $air M redness- rubeosis M secondary glaucoma6 J Field defects and im$aired night %ision6 6, Exami%ati!%:J Visual acuity, maculo$athy, cataract, glaucoma6 J Fundus ./amination - ac"ground retino$athy - +re-$roliferati%e retino$athy - +roliferati%e retino$athy - *d%anced diabetic eye disease - Maculo$athy 26
7, Di00"r"%tial Dia.%! i :J ranch retinal %ein occlusion J Central retinal %ein occlusion J :cular ischemia syndrome 6 J ,etino$athy, haemoglobino$athy J Sic"le cell disease6 8, I%-" ti.ati!%:3 lood sugar JFundus, Slit -!am$ ./amination J1ltrasound .ye, Flurescein angiogra$hy &for macular edema' :, Ma%a."m"%t:J ac"ground retino$athy -./$lanation -Search for other com$lication -,e%iew of glycemia control J +roliferati%e retino$athy - !aser +hotocoagulation &$an-retinal $hotocoagulation' J *d%anced diabetic eye ds &,etinal detachment owing to fibrin traction, ,ubeosis iridis &new %essels on the iris' +an- retinal $hotocoagulation Surgical %asectomy H .nucleation J Maculo$athy - +hotocoagulation Control of hy$ertension J Cataract -Surgical e/traction with I:! im$lantation, once the cataract has matured6
DIA'ETIC FOOT DISEASE < PEREPHERAL VASC&LAR DISEASE 5, Hi t!ry:J Intermittent claudication J ,est $ain J !eriche Syndrome &buttoc" M leg claudatcation, erectile im$otence as a result of ma(or stenosis of the aortofemoral %essels'6 J Foot ulceration- $ast or $resent J Smo"ing habits6 J Family history of atherosclerotic disease6 J :ther manifestations of atherosclerosis- i6e of MI, TI*, stro"e and li$id status6 6, Exami%ati!%:J +al$ation of $eri$heral $ulses 6 J *uscultation for bruits6 J Tro$hic changes in s"in 27
J !imb tem$erature &!imb is $ale M cold in the $resence of significant ischemia but may a$$ear red with critical im$airment of blood flow &TSunset FootT'6 J uergerTs Sign J ./amination of ulcer- ase, .dge, $ainful or +ainless J Dry and warm J Callus formation J -angrene 7, Di00"r"%tial Dia.%! i :3 Cellulites J Dee$ s"in and soft tissue infections--angrene J *cute :steomyditis J Chronic :steomyelites6 8, I%-" ti.ati!%:J Com$lete Haemogram J lood Sugar J +us culture M Sensiti%ity J R-rays feet M (oints6 J Do$$ler Studies J Du$le/ scanning J :/ygen tension J *ngiogra$hy J )uclear medicine bone scans J M,I of foot, one bio$sy Culture :, Ma%a."m"%t:&*' +eri$heral Vascular ds J *s$irin J Foot care=- Ins$ect feet daily - Chec" foot wear for forigen ob(ects before wearing - Ha%e feet measured carefully when $urchasing shoes - ;ee$ feet away from heaters, Fires and hot water bottles6 - Chec" feet tem$erature of bathwater before bathing - *%oid wal"ing barefoot es$ecially outdoors6 - *%oid unaccustomed lengthy wal"s when on holiday6 J Vasodilators J Surgical Sym$atheotomy- !umbar sym$athecto J ,econstructi%e surgery6 J *ngio$lasty6 J *m$utation6 6 J ,ehabitation=& ' Diabetic Foot=J High ris" $atients should be identified during routine foot e/amination $erformed on all $atients with DM6 J+atient .ducation=28
66
<6 Carefull selection of foot wears6 26 Daily ins$ection of feet to detect early sign of $oor fitting foot wears8 minors trauma6 56 Daily foot hygine to "ee$ the s"in clean and moist6 36 *%oidance of self treatment of foot abnormalities and high beha%ior &e6g6 Bal"ing barefoot' 76 +rom$t consultation with a health care $ro%ider if an
ris" abnormalities
arise6 J,is" factor modification=<6 :rthotic shoes and de%ices6 26 Callus management 56 )ail Care6 36 +ro$lylactic measures to reduce increased s"in $ressure from abnormal bony architecturesmo"ing, dysli$idemia, hy$ertension6 7 *ntibiotic &IV M oral'=- *ccording to culture senti%ity re$ort6 Bound debridement6 > :steomyelitis is best treated by a combination of $rolonged antibiotic &IV M :ral' and +ossible debridement of infected bone6 @ * recent consensus statement from *D* identified si/ inter%entions with demonstrated efficacy in diabetic foot wound=-6 <6 :ff- loading 26 Debridement6 56 Bound dressings6 36 *$$ro$riate 1se of antibiotics6 76 ,e%asculari?ation >6 !imited am$utation
J Hy$erbaric o/ygen6
29
Er"*til" Dy 0)%*ti!% <6 Hi t!ry:J Through se/ual medical and $sychosocial history J Difficulty obtaining erection J ,a$id &$remature' e(aculation J :btain information about current medications and $rior surgeries, J*ny h8o of $el%ic surgery, trauma, $rior $rostate surgery, or radiation to the $rostate6 J Tobacco use, alcohol inta"e, caffeine inta"e, and illicit drug J Stress factors and tension at wor" and at home J Indication of de$ression, J loss of libido J +roblems and tension in the se/ual relationshi$ lethargy, moodiness Stress from wor" or other sources6 6, Exami%ati!%:J+enile $laEues J Small tsetse J .%idence of $ossible $rostate cancer J +rostatitis, %ascular disorder J enign $rostatic hy$er$lasia JStatus of the genitalia and $rostate J Si?e and te/ture of the testes J*bnormalities of the $enis such as hy$os$adias and $eyronie $lagues6 7, Di00"r"%tial : *bdominal trauma *therosclerosis Cirrhosis li%er De$ression Haemo chromatosis Hy$ertension Hy$erthyroidism Hy$o$ituitarism &+anhy$o$ituitarisum' Hy$othyroidism )on bacterial $rostatitis +eri$heral arterial occlusi%e disease +eyronie Disease +ria$ism +rostate Cancer 30
+rostatitis .ndo%ascular Hy$ertension Sclerodema Sic"le Cell *nemia6
J *ntide$ressant medication J *nti$sychotic J *ntihy$ertensi%e J Hy$erli$idemia medications 8, I%-" ti.ati!%:J .%aluation of the $atientTs hormone status J Measuring morning serum testosterone le%el, total and free J Measurement of luteini?ing hormone, $rolactin J .%aluating the $atient for diabetes with a hemoglobin *lc measurement J !i$id $rofile, and $rostate s$ecific antigen J In%estigate the hy$othalamic-$ituitary- gonadal a/is by e%aluating testosterone le%el J Serum thyroid- stimulating hormone e%aluation J 1rinalysis loo"ing for , Cs, B Cs, $rotein and glucose J )octurnal $enile tumescence testing, testing for $enile blood flow studies J *ngiogra$hy J Du$le/ ultraSonogra$hy J 1ltrasonogra$hy of testes :, Tr"atm"%t:J Medical care=- 6 -1se of oral +D.-7 inhibitor - most common $ractice -Combination thera$y with one of the +D.-O Inhibitors $lus Uohimbine, M1S. or intraca%emosal in(ection, in selected cases J Drugs are +D.-7 inhibitors - Sildenafil &Viagra' - Vardenafil &!e%itra' - Tadalafil &Clalis' - Vasodilators &nitroglycerine' - +ento/ifylline &trental' J Uohimbine J *$omor$hine &1$rima' J +hentolamine &Vasoma/' J *ndrogens 31
- *l$rostaladill, +:. < - small su$ossity that can be introduced in to the uretha6 J Intraurethral thera$y &M1S.' J Hormonal &testosterone' thera$y - Hy$ogonadotro$hic hy$onganadism- $arenteral testosterone 200mg I6M =, S)r.i*al :J +enile im$lants - Semirigid or malleable rod im$lants -Fully inflatable im$lants - Self- contained inflatable unitary im$lants - Vascular ,econstructi%e surgery - Micro%ascular arterial by$ass surgery >, Ot+"r J +sychological care6 J Vaccume de%ices- to draw blood in to $enis J +enile in(ection thera$y
D"rmat!l!.i* Ma%i0" tati!% &<' Diabetic dermo$athy-& $igmented $retibial $a$ules'- erythematous area and e%ol%es in to an area of circular hy$er$igmentation, more common in elderly men with DM6
&2'
)erobiosis li$oidica diabeticorum= - young women with ty$e IDM6 1sually begins in the $retibial region as an erthemations $laEue or +a$ules that gradually enlarge dar"een and de%elo$ irregular margins, with atro$hic centers and ulceration6
&5' *canthosis nigricans- &hy$er $igmented %el%ety $laEues seen on the nec", a/illa or e/trensor surfaces'- features of se%ere insulin resistance and accom$anying diabetes &3' &7' -ramuloma annulare- erthematous $laEues on the e/tremities or trun"6 Sclerdema- areas of s"in thic"ening on the bac" or nec" at the site of , $re%ious su$erficial infections6 !i$oatro$hy and !i$ohy$ertro$hy at insulin in(ection sities but are unusual with use of human insulin6 -Rerosis M $ruritus6 32
&>' &@'
I%0"*ti!% J +neumonia J 1rinary Tract infection J S"in and soft tissue infection - Furuncles - Carbuncles - Cellu<ites - -as gangrene J .m$hysematous $yelone$hrities J .m$hysematous cystitis J Su$erficial and dee$ candidial infection J Vul%o%aginitis, alanitis J +ost o$erati%e wound infection J ,hino cerebral mucormycosis J .m$hysematous infection of gallbladder J SMalignantS or in%asi%e otitis e/tema, osteomyelitis and meningitis J +ulmonary tuberculosis Ma*r!-a *)lar C!m2li*ati!% ?A@C!r!%ary art"ry di "a ":- &Silent ischemia, myocardial infarction' Hi t!ry:J Chest $ainV chest discomfort 33
- ,etrostemal - ,adiating to bac" left arm, nec", (aw - Hea%y, sEuee?ing, Crushing, Stabbing or burning6 J .$igastric discomfort J Bea"ness J Fatigue J reathlessness J )ausea, Vomiting J *n/iety J Sweating J Sudden loss of consciousness J Confusional state J +al$itation J ,is" factor &Hy$ertension, cigarette smo"ing, alcohol, family history etc' Exami%ati!%:J *n/ious J ,estless J +allor J +ers$iration J Coolness of e/tremities J TachycardiaV radycardia, *rrhythmia TI J Hy$ertensionV hy$otension J +recordium Euiet J *$ical im$ulse difficult to $al$ate J Fourth heart sound and third heart sound J Decrease intensity of first heart sound J +arado/ical s$litting of second heart sound J Transient midsystolic or late systolic a$ical systolic murmur J +ericardial friction rub J Carotid $ulse J .le%ated tem$erature &u$ to 5CWc' J *rterial $ulse Di00"r"%tial Dia.%! i :J -astro-.so$hageal reflu/ disease J +neumonitis, *sthma6 J Mediastinitis J Dissection of aorta J +ericarditis J Myocarditis J :eso$hageal ru$ture J Cafe coronary J +ulmonary embolism I%-" ti.ati!% :34
&<' .C&2' Cardiac iomar"ers J Myoglobin J Creatine $hos$ho"inase &c"' - C;M J Cardiac s$ecific tro$onin- T and I J !actate Detrydrogenase J *ST &S::T' J !eu"ocytosis J .S, &5' Cardiac Imaging J Two- dimensional echocardiogra$hy J ,adionuclide imaging techniEues - Myocardial $erfusion imaging with 20< TI or DDm Tc- sestamibi6 - ,adionuclide %entriculogra$hy &3' *ngiogra$hy Ma%a."m"%t:J Medical - :/ygen - *s$irin - Clo$edogerel, He$arin8low molecular weight He$arin &!MMH' - Mor$hine -)itroglycerine - eta bloc"ers - *C. Inhibitor - Calcium Channel loc"er - Statins - Thrombolysis &stre$to"inase, 1ro"inase, tenecte$lase and rete$lase' - -+ nb8liA,a inhibitor - -lycemia control &insulin' S)r.i*al:J C* - &Coronary artery by$ass -rafting' Ot+"r :- Diet - ./ercise8acti%ity - owel &consti$ation' - Sedation
35
Ma*r!-a *)lar C!m2li*ati!% ?'@ C"r"/r!-a *)lar a**id"%t : - &:cclusi%e stro"e and transient ischemic attac"s' Hi t!ry:J Sudden onset of loss of sensation &one side of body' J Sudden onset wea"ness &one side of body' J Change in %ision J -ait disturbance J Inability to s$ea"8understand J Sudden, se%ere headache J Sei?ure J Fe%er8se$sis J ,is" factors &hy$ertension, cigarette, smo"ing, alcohol, family history etc' Exami%ati!%:J High motor function J Cranial ner%es J Motor e/amination J Sensory tests J -ait J Coordination J Carotid bruit Di00"r"%tial Dia.%! i :J Intracranial hemorrhage J Subarachnoid hemorrhage J Migrane J Meningitis J Metabolic .nce$halo$athy J Cerebal Venous thrombosis J Subdural Hematoma, )eo$lasm J Head In(ury J ToddTs $aralysis J Multi$le Scletosis 36
J Vestibular disorder J Hysteria I%-" ti.ati!%:J Com$lete haemogram with $latlet count J .S,
J leeding time, clotting time and $rothrombin time J Sic"le cell test J *nticardio$li$in antibodies J C-reacti%e $rotein J !i$id $rofile J 1ric acid and electrolytes J Serum $rotein C and S le%el J Homocystein le%el in blood J Chest / ,ays J .C-, Hotler monitoring J 2D .chocardiogra$hy J CSF J VD,! of blood and CSF J Fluorescent tre$onemal antibody absor$tion test &FT*- * S' JHIV JCom$uted tomogra$hy JCarotid Do$$ler J M,I of rain JM,* or digital subtraction angiogra$hy JS+.CT of brain Ma%a."m"%t: J Medical J Maintenance of %itals Tem$erature +ulse - ,es$iration &%entilation' - lood $ressure - Fluid and electrolytes J +re%ention of com$lications li"e $ulmonary as$iration, sei?ures, thrombo$lebitis and bedsores6 J -lycemic control J Mannitol, De/amethasone J *s$irin 37
J Clo$idogreal J He$arin 8 low molecular weight he$arin &!MBH' J Thrombolytic thera$y &,T -+ *- ,ecombinant tissue $lasminogen acti%ator' J )euro$rotecti%e agents S)r.i*al:J Carotid endarterectomy J ./tracranial to intracranial by$ass surgery J *ngio$lasty and stenting Ot+"r :J Diet J ./erciseV acti%ity J Stro"e $re%ention &modification of ris" factors'
38
SPECIALITY :- M"di*i%" CASE :- 9a)%di*" Hi t!ry :<6 *lcohol inta"e & Euantity and duration' 26 !ength of history of li%er disease &+8H He$atitis, Aaundice including contact, H8o during addiction &i8V', Tatoos, transfusions6 H8o drug inta"e, o%erseas tra%el, H8o fe%er'6 56 H8o D6M, Cardiac failure, arthro$athy6 36 Treatment history 76 History suggesti%e of com$lication, &e6g6' any +8H ence$halo$athy, -6I6 bleeding, abdominal $ain, distention of abdomen secondary to ascites6 >6 +8H any o$erations6 @6 H8o tra%el to endemic areas & for malaria, le$tos$irosis!oo" for signs of ' .R*MI)*TI:)= <6 )ote the $atient#s racial origin &for He$atitis and He$atitis c' 26 chronic li%er disease& S$ider )ea%e, -ynaecomasia, +almar erythema, $etichae, etc6' 56 !oo" for signs of !i%er failure, fla$$ing , breath, confusion , stu$or, 36 Small of alcohol 76 *naemia8 BT loss8Tatoos8 body $iercing, needle $ric"s8scratch mar"s8oedema /anthelesma8 ;6F6 rings8 Du$utren#s contractures8 lym$hode lubbing6 >6 ./amination of the *bdomen @6 ./clude se%ere ,t6 Heart failure, Tricus$id ,egurgitation, Constricti%e +ericarditis6 C6 ,ectal ./amination6 INVESTIGATIONS :The following list co%ers all the causes for Aaundice6 :ne could narrow it down to the selected one#s de$ending on the $ro%isional diagnosis made6 <6 Full Haemogram including $eri$herial smear and reticulocyte count6 26 !6F6T6 including +6T8I), 56 *uto immune wor"u$ 36 *scitic Ta$ 76 *bdomino-+el%ic 18S Scan >6 He$atitis- and He$atitis-C @6 *bdominal Do$$ler Studies- *rterial C6 CT scan *bdomen D6 arium Series <06 .ndosco$y <<6 *l$ha Feto +rotein <26 F)*C and !i%er bio$sy if indicated <56 .,C+8M,C+ &Diagnostic and Theara$etic' <36 Serum *mmonia le%els and co$$er le%els6 <76 Serum .lectrolyte 39
DIFF.,.)TI*! DI*-):SIS &F.B :F TH.M' <6 Haemolytic Disease 26 He$atitis8 Cirrhosis of !i%er 56 -6I 6 Malignancy with Metastastasis 36 +rimary biliary cirohosis 76 Bilson#s disease >6 :bstructi%e Aaundice @6 Hemolysis due to infection ):) S1,-IC*! M*)*-.M.)T &Conser%ati%e '-' & De$ends on the diagnosis made' <6Diuretics 26Salt restriction 56,emo%al of $reci$itating causes 36 Treatment of infections 76 Treatment of Haemolysis > Treatment of chronic He$ato cellular failure @6 Treatment of -6I6 leeding C6 Steroids in s$ecific auto immune he$atitis6 D6i8% :ctreoatide, eta loc"ers S1,-IC*! T,.*TM.)T <6Sclerothera$y 26.so$hageal banding &Su$erior to Sclerothera$y' 56+eritoneal shunts 36Various s$ecific surgical $rocedures for obstructi%e (aundice6 76S$lenectomy6
40
S2"*ialty Ca "
==-
Medicine Diabetes Mellitus
D"0i%iti!%:- The national diabetes data grou$ MBH: ha%e issued diagnostic Criteria for D6M6 Sym$toms of Diabetes $lus random blood glucose concentration 4 <2>mg8d! during on oral glucose tolerance test6 Hi t!ry= +olyuria, +olydi$sia, +oly$hagia, weight loss6 lurred %ision, lower e/tremity $aresthesias, yeast infection, $articularly Voluo%aginitis in women, balanitis in men6 :bese $atients, +atient first degree relati%e with ty$e 2 diabetes mellitus6 +atients with hy$ertension, +atients with high triglyceride or HD!- Cholesterol 957mg8d!6 +olycystic o%ary disease Exami%ati!%: :besity *nthro$ometric data -Height -Beight -Baist-hi$ ratio -Fat fold thic"ness S"in Changes Hair loss +rominent %eins Callus formation Crac"ers and fissures 1lcers in the foot and deformities +eri$heral $ulses lood $ressure recording &both recumbent and standing' *uscultations for bruits o%er carotid and femoral arteries )eurological e/amination cranial ner%es Dee$ tendon refle/es *utonomic function Di00"r"%tial : Diabetes inci$idus Insulin resistance :besity Maturity onset diabetes mellitus !atent autoimmune diabetes of adults&!*D*' Stein- !e%enthal syndrome In%estigation=41
Fasting $lasma glucose &f$g' greater than or eEual to <2>M-8d! or random glucose greater than or eEual to 200mg8d! and classic sym$toms $olyuria, $olydi$isia, $oly$hagia, weight loss
42
SPECIALTY CASE
=- MEDICINE :- HYPOTHYROIDISM
History= 1. A." : Sim$le -oitre= is commonly seen in girls a$$roaching $ubertal age, Hashimoto#s thyroiditis= middle aged human6 *utoimmune Hy$othyroidism 38<000 women= <8<000men6 2. S"x: ma(ority of thyroid disorder common in females4men6 3. Pla*"= endemic area for goiter6 8, A%y +i t!ry !0 1"lli%. i% %"*$, Bhen was the swelling <st sightedK Has the si?e of swelling remained same8gradually increasingK *ny $ain at the sight of swellingK &In Hasimoto#s thyroiditis there will be some discomfort in the nec"' *ny history of $ainful enlargement of thyroid gland with fe%erK &Thyroiditis' X Initially there will be thyroto/ic state-4 Hy$othyroid stateY 76 Hi t!ry !0 ym2t!m SA! Hy2!t+yr!idi m a' History of tiredness, wea"ness b' History of loss of a$$etite with weight gain c' History of cold intolerance d' ,ecent e/cessi%e loss of hair e' History of any change in %oice&hoarseness of %oice' f' History of $arasthesia suggested by tingling numbness in limb, any loss of sensations suggested by inability to feel foot wear &this com$lication8sym$tom is %ery rare8late' g' *ny history of dys$onea on e/ertion and effort angina h' History s8o consti$ation >6 P"r !%al Hi t!ry:i' Decrease in a$$etite ii'History of consti$ation iii'History of loss of libido >, M"% tr)al +i t!ryA O/ t"tri* +i t!ry: Com$lete obstetric history- -+! status *s" s$ecifically for history of any congenital Hy$othyroidism in baby6 Suggested by= a6 +rolonged (aundice b6 Feeding $roblem c6 Flaccidity d6 Macroglossia e6 Delayed bone maturation f6 1mbilical hernia g6 +ermanent neurological deficits in the child6 43
M"% tr)al +i t!ry= History of increase flow &menorrhagia' followed by decrease flow6 &oligomenorrhea' and then amenorrhoea6 History of recurrent abortions6 8 Dr).A Tr"atm"%t +i t!ry= *Y H8o recent thyroid surgery or treatment with radio iodine in recent $ast6 Y iodine e/cess Zeg= contrast imaging[ C[ Drug history= -*miodarone -lithium -*ntithyroid drugs +ara amino salicyclic acid6 Interferon alfa D6 Family Hi t!ry= H8o similar illness in the family6 +ast history of sna"e bite & causing $an hy$o$itutariam' $ituitary disease or surgery, ./cessi%e $ost $artum hemorrhage6 C!I)IC*! .R*MI)*TI:) <6 -eneral e/amination= *[ uild and nourishment= +atient is obese and o%erweight6 +atient a$$ears lethargic M tired6 [ Facies= Dull e/$ressionless facies, $eriorbital $uffiness with boggy eyelid6 Coarse hair, $atchy alo$ecia Dry and rough s"in6 Facial $allor6 C[ +ulse= Sinus bradycardia6 D[ lood $ressure= Diastolic $ressure may be high due to hy$ercholesterolemia M artherosclerosis6 .[ +allor= Moderate to se%ere6 1sually a normocytic normochromic anemia6 F[ Sclera may be lemon yellow tinged s8o carotenemia6 -[ .dema of feet= )on $itting edema6 +uffiness of face, su$racla%icular fossa, nec"6 X due to de$osition of mucinuous material, Muco$olysacharides hyaluronic acid M chondroitin sul$hateY SUST.MIC .R*MI)*TI:) <Y Cardio%ascular system= a' +ulse= Sinus bradycardia6 X mention rate, %olume, character, $eri$herial $ulses condition of %essel wall Y 44
b'
lood $ressure= Mention in which limbM which $osition6 Diastolic hy$erten c' Heart sounds, may be muffled , features due to $ericardial effusion6 &50O' 2Y Central ner%ous system= *Y Higher mental function= Shows memory im$airment M mental slowing6 De$ression My/edema coma Slow and sluggish s$eech XbradylaliaY with hoarse %oice6 Y Carnial ner%e=Cthner%e deafness6 There may be conducti%e deafness due to fluid accumulation in middle ear ca%ity6 Xserious ca%ityY CY Tone = Hy$otonia DY +ower = usually normally6 .Y ,efle/es = Sluggish6 FY Sensory- .ntra$ment syndromes6 .g= car$al tunnel syndrome- tingling numbness in the distribution of the median ner%e6 -Y Myo$athy = +ainful muscles cram$s X Hoffman#s syndrome[ Calf muscle hy$ertro$hy HY Cerebellar ata/ia 56 -IT = Macroglossia= Decreased bowel sounds +resence of free fluid 36 ,es$iratory system= Vocal cord edema- hoarseness of %oice +leural effusion ,es$iratory muscle fatigue 76 ./amination of thyroid= aY Ins$ection= +i??ilo#s method= *s" $atient to "ee$ $atients behind head and to $ress head against clas$ed hand6 *s" $atient to swallow-thyroid swelling mo%es with degulgition6 !oo" for any dilated %eins o%er swelling6 !oo" for any scar o%er the anterior $art of nec" s8o any $re%ious thyroid surgery6 Y +al$ation= - *lways $al$ate with $atient#s head fle/ed -land is $al$ated from behind by four fingers with thumb at na$e +al$ate for any swelling6 If $resent- note for -!ocal8entire gland in%ol%ed - $osition si?e 45
sha$e e/tent consistency mobile8fi/ed +al$ate indi%idual lobe-lahey#s method +lace thumb on the thyroid Mas" $atient to swallow Xrile#s methodY To $al$ate whether swelling mo%es with deglutition6 >' :ther associate conditions= autoimmune conditions li"e Vitiligo +ernicious anaemia *ddison#s disease Ty$e < DM *lo$ecia areata Differential Diagnosis Differential diagnosis will de$end on what sym$tom is $resenting with and accordingly the discussion will go on $ertaining to the e%aluation of that $articular sym$tom6 INVESTIGATIONS <6 Com$lete hemogram= !ow Hb- *naemia usually normocytic anaemia X*naemia may be due to menorrhagiaY 26 Serum electrolytes- Hy$onatremia 56 Serum cholesterol- Total cholesterol usually4 270mg -High triglycerides 36 .C-- Sinus radycardia !ow %oltage com$le/es Xheight of , wa%es in limb leads97mmM that of $recordial leads9<0mmY )on s$ecific ST-T wa%e changes 76 Thyroid function test= -TSH usually420mu8<
CLINCAL SUSPICION OF HYPOTHY OIDIS! DETE !INE TSH " free T# FreeT3 MTSH )ormal .uthyroid InTH ,Y 46
Free T3low TSH High +rimary Hy$othyroidism
FreeT3low TSH normal or low Secondary Hy$othyroidism
FreeT3High TSH high Thyroidhormone resistance Xdefect
) = During early stages of hy$othyroidism T\ MFT3 lie (ust below the normal range6 T5 is normal M TSH is barely ele%ated6 This is sub clinical hy$othyroidism or failing thyroid syndrome6 )ormal hy$erthyroid Hy$erthyroid T\Xug8dlY 367-<267 4<267 9367 FT3Xng8dl 06D-260 4260 906D TsXng8dlY C0-220 4220 9C0 TSHXu18mmlY 065->60 9065 4>60 76 Demonstration of autoantibodies= *ntimicrosomal antibody for which Thyroid +ero/idase antigen is $ositi%e in C0Ocases of Hashimoto#s thyroiditis6 *ntithyroglobuin antibodies $ositi%e in >0O cases of Hashimoto#s thyroiditis6 >6 ,adio Iodine u$ta"e scan= Decrease u$ta"e of radio iodine6 @6 F)*C and usage of thyroid= .%idence of inflammatory infiltrate Min Hashimoto hel$s to differentiate a thyroid mass sus$ected of Hashimoto#sM e8o Hurthle cells6 F)*C hel$s to differentiate a thyroid mass sus$ected of Hashimoto#s from lym$homa6 C6:thers= Increase in creatine "inase Increase in !DH Increase in *ST D6Chest R-,ay M.CH: Increase in cardiac silhouette s8o $ericardial effusion6 <06 in%estigations for other associated endocrine disorders lide addison#s disease etc6 TREATMENT <6 If there is no thyroid residual thyroid function the daily re$lacement dose of le%othyro/ine is <6> ug8"g8body wtX<00-<70 ug8dayY 26 If there is underlying autonomous function Xeg= de%elo$ing hy$othyroidism or after treatment of -ra%e#s diseaseY the dose will be @7-<27ug8day S$ecial consideration= *Y In elderly $atient4 >0 years es$ with C*D starting dose is <2,7-27 ug8day Xangina may de%elo$Y Y *dults under >0years without e8o C*D starting dose is 70<00ug8day6 CY In the $regnancy the dose may be increased 470O during $regnancy M returned to $re%ious le%els after deli%ery6 DY There are no uni%ersally acce$ted guidelines for the management of mild or subclinical hy$othyroidism which is defined as biochemical e%idence of thyroid hormone deficiency in $atients without any clinical features8o hy$othyroidism6 In $atients with subclinical or mild 47
hy$othyroidism es$6 if TSH4 >mu8! M T+: antibodies are increased the starting dose will be 27-70 ug8day6 ) = The tablets to be ta"en in the morning in em$ty stomach with water6 +atient who miss doses can be ad%ised to ta"e u$ 5 doses of the s"i$$ed doses at once because T3 has along life X@daysY F:!!:B-1+= TSH res$onse is gradual M should be measured about 2 months after instituting the thera$y6 *d(ustment of the dose is made in <267 or 27 ug increments if TSH is high e%ery 2-5 wee"s6 ) = In $atients with $ituitary hy$othyroidism re$lacement should be made only after re$lacement of hydrocortisone has been initiated6 Xas it may result in adrenal crisisY MUR:.D.M* C:M*=<6 !e%othyro/ine- 700ug i% bolus followed by70-<00 ug8day6 X It can be gi%en through )-T if i% $re$aration not a%ailableY 26 *n alternati%e is to gi%e !iothyronine XT5Y in the dose of <0-<7ug i% ]Cthor ]<2th6 :, 56 Combination of !-thyro/ine X200ugY M !iothyronine X27ugY single i% bolus followed by daily treatment with le%othyro/ine 70-<00ug8day M T5 <0 ug ]Cth6 4. In(6 Hydrocortisone 700mg i% >th or Cth hrly as there is concomitant im$airment of adrenal reser%e6 S&PPORTIVE MEAS&RES: 5, ./ternal warming with s$ace blan"ets if tem$rature,50dC 6, +reci$itating factors should be corrected6 7, Hy$ertonic saline for hy$onatremia6 8, i% glucose for hy$oglycemia :, Sedati%es should be a%oided if $ossible or sused in reduced doses6 =, Ventilatory su$$ort with regular * - may be needed in the initial 3C hrs6 >, Medication should be continued lifelong6 B, If $atients with a dose of4 200ug8 day M still ele%ated TSH, other causes must be e/cluded6 .g6 Malabsor$tion, estrogen thera$y M drugs that interfere with T3 absor$tion or clearance such as cholestyramine, ferrous sul$hate, calcium su$$lements, lo%astain, aluminium hydro/ide, rifam$icin, amiodarone, carbama?e$ine $henyotin6 S&RGICAL TREATMENT:)ot indicated unless there is tracheo eso$hageal com$ression or for cosmetic $ur$ose6 X-oitreY
48
NEONATAL SCREENING AND PREVENTION )eonatal screening by measurement of TSH or T\ le%els in heel $ric" blood sam$le 6 when diagnosis is confirmed thyroid su$$lements are gi%en6 Iodine su$$lements to $re%ent iodine deficiency6 ,.F.,.)C.S= <' Harissons $rinci$les of internal medicine <> ed6 2' Current Medical Diagnosis *nd Treatment 2007= Hy$othyroidism $g no= <0DC-<<026 3! Cecil te/t boo" of Internal Medicine 2<st ed= The thyroid gland $gno= <25<-<2336 3' Da%idson#s Te/tboo" of medicine6 7' S6Das= clinical methods in surgery6 6! Internet ref6 www6 )e(m6org www 6 .medicine6com www6 Medsca$e6com
49

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SPECIALITY CASE HISTORY

GENERAL MEDICINE NEPHROTIC SYNDROME

:- GENERAL MEDICINE :EXTRA PYRAMIDAL DISORDER

:- GENERAL MEDICINE :- RHE&MATOLOGICAL DISEASES

:ther $anniculitis , ,aynaud#s Sclerodactyly

!i%edo reticularis Hairloss S"i $ustules Heberden#s nodes ouchard#s nodes

=- GENERAL MEDICINE :- THYROTOXICOSIS

Medicine Diabetes Mellitus

Hy2!.ly"mia 5, Hi t!ry:- Tremor - Sweating - n/iety 17

J *$hasia J +ulmonary .mbolism

+rostatitis .ndo%ascular Hy$ertension Sclerodema Sic"le Cell *nemia6

Medicine Diabetes Mellitus

Free T3low TSH High +rimary Hy$othyroidism

FreeT3low TSH normal or low Secondary Hy$othyroidism

FreeT3High TSH high Thyroidhormone resistance Xdefect

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