Volume 1

Manual Of
Clinical
Medicine
Cordiology
Acid-Bose Disorder ond Electrolyte Imbolonces
Endocrine Disorders
Gosfrointestincl Disorders
Hemofology

Ashis Kumor Scho

C E S Dedicated to Education

CBS Publishers & Distributors Pvt Ltd

 Contents i

Manual of
1
Clinical
Medicine
 ii Clinical Medicine

Manual of
ClinicalMedicine 1

Two-volume set

Volume 1: Chapters 1–5

Volume 2: Chapters 6–14, Index
 Contents iii

Manual of
1
Medicine
Clinical Chapters 1–5

Ashis Kumar Saha

MD (Cal), DTM & H (Cal), FICP, FACP (USA), FRCP (EDINBURGH), FRCP (GLASGOW), MNAMS (INDIA)

Professor and Head

Department of General Medicine
KPC Medical College and Hospital
Jadavpur, Kolkata
West Bengal

CBS Publishers & Distributors Pvt Ltd

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Bhubaneswar • Hyderabad • Jharkhand • Nagpur • Patna • Pune • Uttarakhand
 iv Clinical Medicine

Disclaimer
Science and technology are constantly changing fields. New
research and experience broaden the scope of information and
knowledge. The author has tried his best in giving information
available to him while preparing the material for this book.
Although all efforts have been made to ensure optimum
accuracy of the material,yet it is quite possible some errors might
have been left uncorrected. The publisher, the printer and the
author will not be held responsible for any inadvertent errors or
inaccuracies.

Manual of
1
Medicine
Clinical

Two-volume set
ISBN: 978-93-86478-31-3
Copyright © Author and Publisher

First Edition: 2018

All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means,electronic
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Published by Satish Kumar Jain and Produced by Varun Jain for

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 Contents v

to

my parents, my wife, my teachers,

my beloved students and sons, lastly
my philosopher and guide
Dr KP Chowdhury
 vi Clinical Medicine

Foreword

t is with great pleasure I introduce the great and prognosis where a knowledge-base
I endeavour by Prof (Dr) Ashis Kumar Saha in writing
this Manual of Clinical Medicine. The book which covers
exists. Wherever possible, the discussions
are basedin on
available world
latest medical
literature. Theevidence
chapter
altogether 14 chapters will be full of fun to read and
foster the understanding of difficult diagnoses and and
students.
of gene therapy is anadatabase
bibliographic
However, added will add
furtherinclusion
elaboration
for
common pitfalls in diagnoses of difficult clinical
scenarios related to medicine. Each chapter is lucidly
depicted with innumerable pictorials—needless to say flavour to this daunting effort by the author.
students and practitioners will be benefitted immensely. I understand that time is precious and, therefore, the
author wanted to create a resource that is precise and
Sir William Osler said “To study the phenomenon of
disease without books is to sail an uncharted sea, while trustworthy. This can never be a substitute of textbook
to study books without patients is to not go to sea at all”. and that was not the intention of the author either. This
The chapters in this book represent “real-life” treatise is easy to follow, unpretentious and above all
experiences in the life of a physician. The most poignant helpful.
questions in the mind of a physician “how does this I hope the readers will enjoy reading this book. Both
information help us to devise a treatment plan?” and undergraduates and postgraduates will be benefitted
“what is the precise relationship about the anticipated and this book will find a place in the library of medical
course and prognosis?” The questions are raised in each practitioners at large.
section and follows in a beautiful way to incorporate
answers in relation to pathogenesis, diagnosis, treatment
Prof Anup Kr Bhattacharya MD, DM, FRCP(Edinburgh)
Past Hony Editor, JIMA 2014–15
President, Indian Science Congress–Medical Section
105th Indian Science Congress–2018
 Contents vii

Foreword

tart
gives
by me
a a great pleasure to present this work of to hematology. He is just the prototype
I prolific author of present day—Prof (Dr)
Ashis Kumar Saha. I have known Dr. Saha for the last 10
internist who takes responsibility of
whole human organism. I sincerely hope
years. His contribution to internal medicine is simply that this book will certainly create ripples
astounding. Despite being practicing gastro all over the world of academic medicine.
enterologist, his footsteps remain equally in nephrology

(Prof) Dr Nirmalya Roy

viii Clinical Medicine

Preface
riting a book on internal medicine is currently
W the most daunting task, more so when a single
author makes such an attempt. Nevertheless I have made
this Herculean attempt. It has to be understood that
patients would certainly appreciate when a single
physician takes the charge of their whole body. Even
though it is not quite practical, an astute internist should
be capable to deal with most common problems that a
patient encounters. This book is a challenge to factory
line medicine that has become vogue currently where
Contents ix
each subspecialist takes care of individual organ while
neglecting the human face of the sick patient. Every
attempt has been made to make the information as up
to-date as possible when the book was sent to press. I
sincerely believe that internists are lifelong students and
would be highly grateful if this Manual becomes one of
the most thumbed books in a physician’s library. I
believe this Manual will upgrade the knowledge of
undergraduate as well as postgraduate students.
Ashis Kumar Saha
 x Clinical Medicine
Acknowledgements
tbook
last I Manual
finishedofmy
Clinical Medicine
herculean workand
of writing
I this
A kept the
word given to my mother Late Radharani Saha of being
within the mindframe of teacher and student community
all over the world. My father, my lifelong inspiration
Prof (Dr) Tushar Kanti Saha, has always been with me
during my work.
Our Chairman Dr KP Chowdhury always inspired
and guided me in my work throughout the teaching
profession at our renowned KPC Medical College and
Hospital. He loved me very much and inspired me to do
more and more academic work for the students as well
as for the hospital—the result is this book. He always
tells me what is right and what is wrong and Ishould try
to follow his word.
Our Medical Director, Dr Sourav Ghosh, and our
Principal, Prof Siddhartha Chakraborty, have also
inspired me to do new innovative work for the students.
So I thought this was the way by which I could help my
students, and I started writing this book and finished it.
I also acknowledged teacher and guide Prof Maloy
Maitra, cheerful endocrinologist Prof Anirban
Majumdar, my respected guide Prof Debasish Basu, Prof
PK Ganguly, Prof Sagar Basu, retired Prof Subhas
Chandra Hazra, my colleague Prof Santanu Bhakta, and
Dr Rishad Ahmed. Prof Nirmalya Roy helped me to edit
and add new part in my book and gave constant
inspiration for writing this book.
Dr SKSaha, my father-in-law, constantly inspired me
to do more and more new academic work.
A human being has two lungs and one heart. He can
breathe fresh air and continue his life by the composite
functions of the above three organs. Here two lungs are
my two sons, Subhra Kanti beloved and Abhra Kanti
beloved, and heart is my wife Mrs Kalyani most Saha.
So, without their constant inspiration, support and a lot
of sacrifice, I could not take breath and it was not
possible for me to write the book of more than one
thousand pages.
I do not like praise but constant inspiration will help
me in making progress further and achieve the summit.
Ashis Kumar Saha
 Contents xi

Contents

Foreword by Prof. Anup Kr. Bhattacharya vi

Foreword by Prof Dr. Nirmalya Roy vii
Preface ix

VOLUME 1
Acute coronary syndrome (acs) 152
1. Cardiology 1
Lown-Ganong-Levine syndrome 169
Valvular Disease 1 Pericardial disease 169
Mitral stenosis 1 Rheumatic fever 176
Mitral regurgitation 7
Aortic stenosis 14
Aortic regurgitation 23 2. Acid-Base Disorder and
Mitral valve prolapse 30
Tricuspid regurgitation 33
Electrolyte Imbalances 180
Tricuspid stenosis 35 Acid–base disorders 180
Congenital cardiac disease 37 Hypernatremia 183
Atrial septal defect 37 Hyponatremia 185
Ventricular septal defect 41 Hyperkalemia 188
Tetralogy of Fallot 46 Hypokalemia 190
Patent ductus arteriosus 50 Metabolic alkalosis 192
Pulmonary stenosis 55 Respiratory acidosis and alkalosis 193
Congenitally corrected transposition 57
Eisenmenger syndrome 59
Ebstein anomaly 64 3. Endocrine Disorders 196
Lutembacher syndrome 68
Pituitary disorders 196
Sinus of valsalva aneurysm 69
Growth hormone axis 196
Arrhythmias 71
Acromegaly and gigantism 197
Sinus node dysfunction 71
Growth hormone deficiency in children 198
Atrial flutter 76 Posterior pituitary disorders 199
Atrial fibrillation 80 Thyroid gland disorders 203
Accelerated idioventricular rhythm 88 Thyroid gland: Anatomy and physiology 203
Brugada syndrome 90 Thyroid function tests 205
Atrioventricular conduction disease 91 Hypothyroidism 206
Carotid sinus hypersensitivity 100 Myxedema
Thyrotoxicosis
Evaluation of
coma
thyrotoxicosis
211 211 217
Ventricular tachycardia 103
Ventricular fibrillation 109
Wolf-Parkinson-White syndrome 113 Thyrotoxic crisis 218
Coarctation of aorta 118 Thyroiditis 218
Cardiomyopathies 123 Parathyroid gland disorders 220
Heart failure 136 Parathyroid gland 220
Infective endocarditis 145 Pancreas 232
xii Clinical Medicine

Hypoglycemia
Glycosylated
Hyperglycemic
Diabetic
Complications
Diabetesretinopathy
neuropathy
ketoacidosis
mellitus
hemoglobin
of
256
hyperosmolar
diabetes
232 253
252
249 255
mellitus
state 252
255 Cirrhosis 388
Portal hypertension 400
Congenital liver diseases 413
Hepatic artery 415
Hepatic encephalopathy 417
Hepatorenal syndrome 429
Spontaneous bacterial peritonitis 431
Hepatocellular carcinoma 432
Adrenal
Congenital
Pheochromocytoma
Mineralocorticoid
Mineralocorticoid
Adrenal
Cushing
disorders
insufficiency
cortex
syndrome
adrenal
259
and
excess
260
hyperplasia
264
270
glucocorticoid
267 267 synthesis 267 Iron overload states 436
Primary biliary cirrhosis 440
Wilson’s disease 443
Diseases of pancreas 446
Acute pancreatitis 450
Chronic pancreatitis 465
Tumor of pancreas 474

4. Gastrointestinal Disorders 272 5. Hematology 477

Iron metabolism and iron deficiency anemia 477
Luminal
Tropical
Whipple’s
Acute
Eosinophilic
Short
Large
Zollinger-Ellison
Small
Intestinal
Celiac
Protein-losing
Mesenteric
Inflammatory
Diverticular
Esophagus
Esophageal
Stomach
Gastritis
Peptic
Menetrier’s
Stress
Chronic
Ischemic
Irritable
Barrett’s
Esophagitis
bowel
gastroenterology
intestinal
ulcers
intestine
bowel
infective
ulcer
disease
bowel
sprue
intestinal
esophagus
280
malabsorption
colitis
280
disease
vascular
disease
272
gastroenteritis
276
syndrome
carcinoma
motor
disease
292
disease
enteropathy
bowel
304
syndrome
bacterial
syndrome
294
302
diarrhea
324
ischemia
304
disorders
of
292
ischemia
disease
276
281
322
colon
307
272
278
overgrowth
299
294
325
293
298
307
306
272
322
309
305 308 Megaloblastic anemia 481
Main groups of anemia classified according
to the underlying causes 484
Autoimmune hemolytic anemia 485
Fanconi anemia 486
Hemolytic anemia 488
Thalassemias 491
Genetic control of hemoglobin production 496
Drug-induced haemolytic anemia 497
Methemoglobinemia 497
Glucose-6-phosphate dehydrogenase
deficiency 498
Cryoglobulinemia 499
Cold hemagglutinin disease 500
Hereditary elliptocytosis 500
Hereditary spherocytosis 501
Paroxysmal cold hemoglobinuria 502
Paroxysmal nocturnal hemoglobinuria 502
Sickle cell disease 503
Bone marrow failure syndrome 507
Myelodysplastic syndrome 512
Acute lymphoblastic leukemia 517
Acute myeloid leukemia 519
Chronic myeloid leukemia 525
Chronic lymphocytic leukemia 527
Hairy cell leukemia 530
Paraproteinemias 531
Monoclonal gummopathy of undetermined
significance 535
Hepatology
Liver
Hepatitis
HBV
Ascites
Nonalcoholic
Alcohol
Non-A-E
Acute viral
function
liver
374
and
viral
A
hepatitis
C
D
337
329
virus
failure
348
liver
hepatitis
tests
fatty
337
353
366
357
338
liver
329 356
disease 370 Smoldering multiple myeloma 536
Mycosis fungoides 536
Hodgkin’s lymphoma 537
Non-Hodgkin’s lymphoma 542
Burkitt’s lymphoma 548
Polycythemia vera 548
Primary myelofibrosis 553
Chediak-Higashi syndrome 555
Clotting system in our body 555
Coagulation system 555
Fibrinolytic systems 556
Hypofibrinogenemia 557
Autoimmune hepatitis 383 Hemophilia A and B 557
 Contents xiii

Disseminated intravascular coagulation 559 Thrombotic thrombocytopenic purpura/HUS 570

Essential thrombocytosis 561 Rendu-Osler-Weber disease (hereditary
Flowchart in hematology 563 hemorrhagic telangiectasia) 571
Platelets 567 von Willebrand disease 572
Thrombocytopenia 567 White blood cells 573

VOLUME 2
Diabetic nephropathy 720
6. Infectious Disease 577
Myeloma kidney 723
Virus disease 577 Nephrotic syndrome 724
Acquired immunodeficiency syndrome 577 Reflux nephropathy 726
Dengue 585 Urinary tract infection 727
Bacteria 595 Complications of dialysis 729
Anthrax 595 Iron therapy in CKD 730
Brucellosis 597 Renal replacement therapy 731
Cholera 602 Urinary abnormalities (albumin/creatinine ratio) 733
Diphtheria 604
Leprosy 609
Leptospirosis 613
Meningococcal infections 616 8. Neurology 737
Plague 620
Salmonellosis 622 Acute inflammatory demyelinating
Shigellosis 626 polyneuropathy 737
Tetanus 630 Aseptic meningitis 739
Whooping cough 633 Brain abscess 741
Tuberculosis 635 Cauda equina and conus medullaris syndrome 744
Cavernous sinus thrombosis 748
Viruses 650
Cerebellar hemorrhage 752
Chickenpox 650
Cerebrovascular accident 753
Herpes zoster 653
Cluster headache 769
Influenza 655
Cysticercosis 771
Measles (rubeola) 657
Encephalitis 774
Mumps 661
Facioscapulohumeral dystrophy 777
Rabies 663
Guillain-Barre syndrome 777
Smallpox 667
Intracerebral hemorrhage 781
Parasite 670
Subarachnoid hemorrhage 785
Leishmaniasis (kala-azar) 670 Japanese encephalitis 793
Malaria 673 Meningitis 796
Typhus 679 Migraine 809
Multiple sclerosis 816
7. Nephrology 683 Muscular dystrophy 824
Myasthenia gravis 826
Acute glomerulonephritis 683 Normal pressure hydrocephalus 833
Poststreptococcal glomerulonephritis 687 Parkinson disease 835
Focal and segmental glomerulosclerosis 689 Seizures 842
Glomerular lesions 690 Status epilepticus 863
Goodpasture syndrome 692 Subarachnoid hemorrhage 867
IgA nephropathy 693 Syringomyelia 874
Lupus nephritis 695 Vitamin
diseases
B12 deficiency
877 associated neurologic
Membranous nephropathy 697
Mesangiocapillary glomerulonephritis
[membranoproliferative glomerulonephritis] 698
Minimal change disease 699
9. Poisoning 881
Acute kidney injury 701
Hemolytic uremic syndrome 708 Acid poisoning 884
Thrombotic thrombocytopenic purpura 709 Alkali ingestion 886
Acute nephritic syndrome 709 Organophosphorus poisoning 886
Chronic kidney disease 711 Snake bite 887
xiv Clinical Medicine
10. Respiratory Disease 892
Anaerobic infection in lung 892
Asbestosis 893
Aspergillus lung diseases 897
Aspiration lung syndrome 901
Atypical pneumonia 903
Bronchial asthma 905
Bronchiectesis 918
Carcinoid 921
Chronic lipoid pneumonia 923
Chronic obstructive pulmonary disease 923
Coal worker pneumoconiosis (CWP) 936
Community-acquired pneumonia 938
Cryptogenic organizing pneumonia 943
Cystic fibrosis 944
Desquamative interstitial pneumonia 951
Haemophilus influenzae infections 951
Hospital-acquired pneumonia 953
Hypersensitivity pneumonitis (HP) 955
Idiopathic interstitial pneumonia 956
Klebsiella pneumoniae 958
Lung abscess 959
Lung cancer 960
Lymphoid interstitial pneumonia 969
Malignant mesothelioma 970
Non-specific interstitial pneumonia (NSIP) 973
Obstructive sleep apnea syndrome 974
Paraneosplastic syndrome 977
Pleural effusion 978
Pneumococcal pneumonia 983
Pneumothorax 985
Pulmonary hypertension 988
Sarcoidosis 992
Silicosis 996
Staphylococcaland streptococcal pneumonia 998
Thromboembolic disease 999
11. Vitamins 1005
12. Osteoporosis 1010
13. Rheumatology 1018
Approach to a patient with vasculitis 1018
Antiphospholipid antibody syndrome 1021
Behcet’s disease 1023
Churg-Strauss syndrome 1024
Cogan syndrome 1026
Dermatomyositis, polymyositis 1027
Giant cells arteritis 1030
Gout 1031
Juvenile idiopathic arthritis 1037
Juvenile psoriatic arthritis 1040
Kawasaki disease 1041
Microscopic polyangiitis (MPA) 1043
Mixed cryoglobulinemia 1045
Osteoarthritis 1046
Polyarteritis nodosa 1051
Polymyalgia rheumatica 1053
Primary Sjogren syndrome 1054
Pseudogout (calcium pyrophosphate
dehydrate crystal deposition disease) 1057
Psoriatic arthritis 1058
Reactive arthritis 1061
Relapsing polychondritis 1063
Rheumatoid arthritis 1065
Spondyloarthropathies 1072
Systemic lupus erythematosus (SLE) 1076
Takayasu arteritis 1085
Vasculitis 1087
Wegener granulomatosis 1088
14. Gene Therapy 1092
Index 1093
 Contents xv

Volume 1

1. Cardiology
2. Acid-Base Disorder and Electrolyte Imbalances
3. Endocrine Disorders
4. Gastrointestinal Disorders
5. Hematology
 Volume 1

Manual Of
Clinical Medicine
Medicine ds d dynomic science is developing so fosſ thof it requires upddtion periodicolly. In the lost
severol yeors there hove been vost ond mojor dovonces in the moddlifies in diognosis. With doily
biomedicol improvement, newer moddlifies of investigofions cre coming on. With the modern
equipment ond instruments, the disedses con be didgnosed very edsily, very methodicolly ond
precisely. There dre diso vost improvements in phormocology. Wide vorieties of interventional
theropeutic procedures cre ovdiloble to us which moke the disedse more freofdble. There ore clso
prominent dovoncements in fields of genetics ond moleculor.pdfhogenesis.
As the subject of medicine is widening doily, if mdy not remdin possible for the clinicion to remember
ond refoin dll the defoils dbout the disedse. On the other hond, the undergroducte ds well ds
postgroducte courses ore time-bound, so if is not possible to recollect the defoils of ony disedse of d
point offime.
Redlising these difficulties, the duthor hos prepored the moteriol of this Manuol which dodresses the
point-wise description of the common disedses os well opprooch to the systems. If presents mony
pictures, tobles, dnd flowchorts which cre very informotive ond edsily memoroble, ond d lorge volume
ofessentiol, cruciolos wellos indispensdble moteriol on medicine.
The Manual dims to serve ds d hondy guide for oll the undergroducte ond postgroducte students
during their time-scheduled courses. It is diso designed to be on essentiol clinic-foble reference for ol
the physicidns in theirddy-to-doy proctice.

Ashis Kumdr. Schd MD cop, Dm a H cop, rich facp usa) frce edin) is currently Professor and Head,
Deportment of Generol Medicine, KPC Medicol College ond Hospitol, Jodovpur, Kolkofo, West Bengol.
He hos writtend monogroph Updates in Dengue Fever, d book Clinical Methods and Interpretations, dnd
37 origindl orticles in the lost five yeors published in different indexed notional dnd infernotional journols.
He is dssociote editor of two infernotional dnd two notional journols, dnd editor of two monogrophs
Chronic Diarrhed ond Heddache under Indidn College of Physicidns. He is reviewer of more thon 12 interndtional
ond notional journols. He hos received “Sobito & Boldi Chotterjee Distinguished Choir of Innovation' dword for
innovction dnd ddvoncement in medicine, hedlth core ochiever dword “Best Hedlth Core Speciclist in Medicine in
West Bengol" in 2016, “Bhdrof Jyoti Aword" in 2017, dnd “Ambossodor of Asidin Council of Scientific Editors"
recognition in 2016. He hos been dworded FICP (Indid), FACP (USA) ond FRCP (Edinburgh) in 2015 dnd FRCP
(Glosgow) fellowships in 2016 for his extensive work. He hos received two certificotes on ‘bosic ond ddvonced
bioethics’ conducted by UNESCO, dnd two certificofes- 'Bosic’dnd ‘ddvonced certificote in certificotion of dedih"
by ICMR. He is Public Hedlth Foundotion of Indid certified resedrch methodologist. Recently, he hos received “Best
Citizen of Indid" dword given by Inferndtional Publishing House ond "Inferndtional Exemplory Resedrch ond
Performonce Aword” for excellence in medicine in 2018.

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