INTERNAL DISEASES
An Introductory Course
Edited by V.Vasilenko and A.Grebenev
Translated from the Russian by Alexander Rosinkin
Mir Publishers Moscow
PREFACE
ISBN 5-03-001686-4
First published 1987
Second edition 1990
Revised from the 1989 Russian edition
PHnted in the Union of Soviet Socialist Republics Ha am/iuiicKOM A3biKe
© H3;iaTejn>cTBo «MeimuHHa», 1989,
C H3MeHeHI}aMH
© English translation, A.Rosinkin, 1990
Internal medicine is the major branch of medical practice and research because internal diseases are the most common and run a grave and protracted course involving many complications and impairing the patient's objective condition and his working capacity. Internal diseases have the highest mortality rates as well. Therefore prophylaxis of internal diseases is the main concern in the health care system of all countries, and the study of internal diseases is the leading subject of medical training.
The term "internal diseases" came into use in the 19th century to stand alongside with the then-popular term "therapy". The development of new, complicated methods of diagnosis and treatment, requiring specialized skills and training on the part of the physician, has led to the formation of separate branches of medicine such as cardiology, gastroenterology, endocrinology, and haematology. This by no means indicates the division of the concept of "internal medicine" into "daughter subjects". Clinical medicine of the second half of this century is characterized by parallelism of differentiation and integration. Therefore, despite a further separation of special branches, general medical training and education, and the integrating research into internal diseases and related subjects are now even more important.
It should also be noted that the new offshoots of medicine develop at the "interface" of several clinical subjects. Thus cardiology, which was formerly only a branch of internal medicine, gave rise to heart surgery and anaesthesiology.
At the present time the knowledge of internal diseases has improved greatly: many new diseases have been described, the aetiology and pathogenesis of the known diseases and their clinical course studied, and new methods of diagnosis and treatment have been developed and improved. Therefore, despite the branching of internal medicine into special subjects, the amount of knowledge that is necessary today for a practitioner is much greater than say 20 or even 10 years ago. The requirements for adequate medical training have thus increased accordingly.
The course in internal diseases is given differently in various countries: the student may be educated at one clinic during his entire course of studies, or he may take classes in different departments consecutively. But in all cases there exists a certain optimum sequence in the studies. During their first years (usually the third year) the students study the main methods of examination, symptoms of internal diseases, and the main principles of
6 Foreword
their management. This book is a course in diagnostic principles and special pathology. In other words, this is an introduction to therapy, ox propaedeutics to internal diseases. This course is given to students after they have studied the fundamentals of medicine, such as anatomy, physiology, biochemistry, etc.
During their further studies the students broaden and improve their knowledge of all major internal diseases, their differential diagnoses, and their treatment. The students start managing patients independently. Future physicians are thus trained in stages.
This particular manual is intended for third-year medical students. It describes symptoms and syndromes, the main methods of examination used by internists and methodology of diagnosis. It helps students master the practical diagnosis of internal diseases and their management. The authors hope that this manual will help the student in his further detailed study of internal diseases and that it may also be useful to those who master other special medical subjects. The authors believe also that this book may be helpful to a practitioner.
The contributors to this manual are members of the staff of the Moscow First Medical Institute named after I. Sechenov.
The authors would gladly accept any criticisms or comments which would improve this manual.
Contributing Authors
Golochevskaya, V. S. Grebenev, A. L.
| Mikhailova, N. P. |
Pletneva, N. G. Sheptulin, A. A.
|
Shirokova, K. I. |
| Vasilenko, V. Kh. | Yakovleva, V. S.
|
Zaikin, M.D.|
Contents
GENERAL PART 11
Chapter 1. Internal Medicine: Subject Matter, Purpose and Objectives 11
General Concepts 11
Admitting Medical Students to the Clinic and Fundamentals of Medical
Deontology .. 17
Chapter 2. History of Diagnosis 23
A Short History Survey 23
The Role of Russian and Soviet Scientists in Development of Diagnosis and the
General Therapy of Internal Diseases 27
Soviet Public Health System: A New Stage in Medicine 30
Chapter. 3. Methods of Clinical Examination of Patients and General Symptoma tology of Diseases of the Internal Organs 32
Inquiry 33
The Present Complaints 34
History of the Present Disease 35
Anamnesis Vitae 35
Physical Examination 40
General Inspection 41
Palpation 53
Percussion 54
Auscultation 57
Laboratory and Instrumental Methods of Examination 60
Anthropometry 61
Thermometry ... 63
X-ray Study 69
Endoscopy, Biopsy, and Cytological Studies 71
Instrumental-Functional Methods of Examination 72
Radioisotope Methods 72
Ultrasound Echography 73
Laboratory Methods of Examination 76
Chapter 4. General Methodology of Diagnosis 77
The Importance of Medical Theory for Development of Diagnostics 77
Planning Diagnostic Examination 82
Special Features of Diagnostic Examination 83
Diagnostic Observation and Examination 84
Recording Form 87
Types of Diagnosis . 87
Methods and Theory of Diagnosis 87
Prognosis 99
SPECIAL PART Ill
Chapter 5. Respiratory System Ill
Methods of Examination Ill
Inquiry Ill
Physical Examination 116
Instrumental and Laboratory Methods 143
Main Clinical Syndromes 159
Special Pathology 164
Bronchitis 165
Contents
Bronchial Asthma 168
Acute Pneumonia 171
Pulmonary Abscess 178
Pleurisy 181
Chronic Pneumonia 186
Bronchiectasis 187
Emphysema of the Lungs 190
Chapter 6. Blood Circulatory System 192
Methods of Examination 192
Inquiry 192
Physical Examination 195
Physical and Instrumental Studies of the Vessels 220
Instrumental Study of the Heart 234
Major Clinical Syndromes 256
Cardiac Rhythm Disorders (Arrhythmias) 256
Circulatory Insufficiency 256
Special Pathology 257
Rheumatism 285
Bacterial (Septic) Endocarditis 290
Heart Valvular Diseases 292
Myocarditis 311
Cardiomyopathy 312
Pericarditis 314
Essential Hypertension 316
Atherosclerosis 319
Ischaemic Heart Disease 322
Angina Pectoris 322
Myocardial- Infarction 325
Cardiosclerosis 330
Chapter 7. Digestive System 332
Oesophagus 332
Methods of Examination ….. 332
Inquiry 332
Physical Examination 333
Laboratory and Instrumental Methods 334
Special Pathology 334
Achalasia of the Cardia 334
Oesophagitis 335
Stomach 337
Methods of Examination 337
Inquiry 337
Physical Examination 342
Laboratory and Instrumental Methods 345
Special Pathology 355
Gastritis 355
Peptic Ulcer Disease (Gastric and Duodenal Ulcer) 358
Intestine 364
Methods of Examination 364
Inquiry 364
Physical Examination 368
Laboratory and Instrumental Methods 378
Major Clinical Syndromes 385
The Acute Abdomen 385
Inadequate Digestion Syndrome 387
Contents 9
Malabsorption Syndrome 389
Special Pathology 390
Acute Enterocolitis 391
Chronic Enteritis 391
Chronic Colitis 392
Liver and Bile Ducts 394
Methods of Examination 394
Inquiry 394
Physical Examination 396
Laboratory and Instrumental Methods 406
Main Clinical Syndromes 430
Jaundice 430
Portal Hypertension 433
Hepatolienal Syndrome 434
Hepatic Insufficiency and Coma 435
Special Pathology 438
Chronic Hepatitis 438
Cirrhosis of the Liver 441
Cholelithiasis 447
Cholecystitis 452
Pancreas…………………………………………………………………… 456
Methods of Examination ……………………………………………………456
Inquiry 456
Physical Examination 457
Laboratory and Instrumental Methods 458
Major Clinical Syndromes 463
Exocrine Pancreatic Insufficiency 463
Special Pathology 464
Pancreatitis 464
Chapter 8. Urinary System 468
Methods of Examination 468
Inquiry 468
Physical Examination 473
Instrumental and Laboratory Methods 478
Main Clinical Syndromes 495
Renal Oedema 495
Nephrotic Syndrome 498
Renal Hypertension 500
Renal Eclampsia 503
Renal Failure 504
Special Pathology 508
Diffuse Glomerulonephritis 508
Toxic Kidney 515
Amyloidosis of the Kidney (Amyloid Kidney) 515
Nephrolithiasis 517
Pyelonephritis 520
Chapter 9. Diseases of the Blood 522
Methods of Examination 522
Inquiry 522
Physical Examination 524
Instrumental and Laboratory Methods 528
Special Pathology ..... 545