Differential Diagnosis in Clinical Medicine Differential Diagnosis in Clinical Medicine R Deenadayalan MD (Gen Med) Formerly Professor of Medicine Stanley Medical College and Hospital Chennai, Tamil Nadu, India Meenakshi Medical College Hospital and Research Institute Enathur, Kancheepuram, Tamil Nadu, India Forewords T Gunasagaran S Shiva Kumar L Pari ® JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi • Panama City • London ® Jaypee Brothers Medical Publishers (P) Ltd Headquarter Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: jaypee@jaypeebrothers.com Overseas Offices J.P Medical Ltd 83 Victoria Street, London SW1H 0HW (UK) Phone: +44-2031708910 Fax: +02-03-0086180 Email: info@jpmedpub.com Jaypee-Highlights Medical Publishers Inc City of Knowledge, Bld 237, Clayton Panama City, Panama Phone: 507-301-0496 Fax: +507-301-0499 Email: cservice@jphmedical.com Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2012, Jaypee Brothers Medical Publishers All rights reserved No part of this book may be reproduced in any form or by any means without the prior permission of the publisher Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com This book has been published in good faith that the contents provided by the author contained herein are original, and is intended for educational purposes only While every effort is made to ensure accuracy of information, the publisher and the author specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work If not specifically stated, all figures and tables are courtesy of the author Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device Differential Diagnosis in Clinical Medicine First Edition: 2012 ISBN: 978-93-5025-768-5 Printed at Dedicated to My Children and Grandson Who are a Great Source of Inspiration Dr T Gunasagaran Vice Chancellor Meenakshi University Enathur, Kancheepuram 631 552 Foreword Every book is meant to bring concept to those who care to read them Books on medical subjects are vast in number and every author strives to fill a need that he himself has felt Some authors achieve this objective, but others, their intentions though are genuine meander into a dreary desert of words Prof R Deenadayalan MD (Gen Med) has made a serious attempt in trying to help a hard pressed medical student by presenting him with a work based on two decades of experience superimposed on those of his teachers Thus, a simple but a very useful glossary of differential diagnosis of clinical signs and entities has been created Though this cannot replace a formal textbook, it will serve as a ready reckoner to the beleaguered medical student who labors under an ever increasing load of information and changing priorities The faculty of the Meenakshi University, I am sure, will find this contribution very useful and I am definite that they will recommend it to their students and colleagues This book will be a bedside companion to students and staff alike Dr T Gunasagaran Vice Chancellor Meenakshi University Enathur, Kancheepuram Tamil Nadu, India Dr S Shiva Kumar MD Professor of Medicine (Retd.) Stanley Medical College and Hospital Chennai-600 001 Res: 3362/O, AE, 8th Street, Anna Nagar, Chennai 600040 Phone: 26212522 Mobile: 9840224019 Foreword Dr R Deenadayalan has a reputation as an excellent teacher of clinical medicine to both undergraduate and postgraduate medical students In this era, where modern diagnostic facilities are easily available, clinical medicine has unfortunately taken a back seat But medicine is not an exact science, as even with all the modern diagnostic facilities, diagnosis can be difficult In many rural areas diagnostic facilities are not available and clinician has to rely only on clinical methods for diagnosis It is, therefore, apt that Dr R Deenadayalan has written this book on Differential Diagnosis in Clinical Medicine which would be of immense benefit to undergraduates, postgraduates and clinicians to refer to a particular system and look for differential diagnosis It should be remembered that clinical medicine is an art as well as science and one cannot replace clinical medicine even in this present era I congratulate Dr R Deenadayalan for the immense efforts to bring this book and wish him good luck in his endeavors Dr S Shiva Kumar Professor of Medicine (Retd.) Stanley Medical College and Hospital Chennai, Tamil Nadu, India 246 Differential Diagnosis in Clinical Examination Hematogenous spread of pyogenic infection from distant organs Fungus infection – Actinomyosis Secondary infection of pleural effusion after tapping Lung abscess Mediastinal infection 10 Infection of bronchopleural fistula 153 Causes of bilateral pleural effusion CCF: Here, the right side fluid collection more than the left If the fluid is more on left or only on left side, other causes should be excluded Nephrotic syndrome Hypoproteinuria Cirrhosis liver SLE Myxedema 154 Rare causes of pleural effusion Yellow nail syndrome Familial paroxysmal (familial mediterranean fever) Sarcoidosis 155 Syndromes associated with pleural effusion Meig’s syndrome Yellow nail syndrome Oculomecocutaneous syndrome 156 Causes of transient mild pleural effusion Rheumatic fever Familial mediterranean fever Drugs: Methysergide / Nitrofurantion 157 Features of TB effusion Can occur at any stage of disease Rare before puberty Respiration 247 Can be hemorrhagic also Can occur unilaterally or bilaterally 158 Centrifuge chylous effusion, the upper column will be thick, whereas in exudates due to WBCs after centrifuge the upper column will be clear 159 When to suspect empysema clinically? Pt is toxic/febrile with constitutional symptom Intercostals bulge + Percussion tenderness + High pleural fluid WBC level PMN leukocytes High pleural fluid protein Pleural fluid pH 600 mg/dl Pleural fluid glucose