Differential Diagnosis

Differential Diagnosis
• Medicine • Surgery • Ob/Gyn. • Ophth.
• Paed. • Dental
Seventh Edition

LC Gupta
MD (Rad) MD (PSM) DMRE MAMS, D Sc (Hon)
• World record of writing 98 medical books
• Millennium author of SARC Nations-2002
• BC Roy National Awardee-1986
New Delhi

Abhitabh Gupta
MD (Physician) DMRE
New Delhi

Abhishek Gupta
MD (Physician) DRM DNB
NMR Scanning and Research Centre
Jalandhar

J AYPEE BROTHERS
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Differential Diagnosis
© 2005, LC Gupta, Abhitabh Gupta, Abhishek Gupta
All rights reserved. No part of this publication should be reproduced, stored in a retrieval
system, or transmitted in any form or by any means: electronic, mechanical, photocopy-
ing, recording, or otherwise, without the prior written permission of the editor and the
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This book has been published in good faith that the material provided by contributors
is original. Every effort is made to ensure accuracy of material, but the publisher,
printer and editor will not be held responsible for any inadvertent error(s). In case of
any dispute, all legal matters to be settled under Delhi jurisdiction only.

First Edition: 1984

Seventh Edition: 2005
ISBN 81-8061-414-X

Typeset at JPBMP typesetting unit

Printed at Replika Press Pvt Ltd., 310 EPIP, HSIDC, Kundli, Sonipat (Haryana)
 Contributors

SR Gupta MD (Med) MD (Pharm) SK Sharma MD

Ex. Prof Head Deptt of CMO (SG) BSF
Medicine, Raipur (MP) New Delhi
PG Raman MD SK Sharma MD LLB
Prof Head Deptt of Medicine Incharge Department of
MGM Medical College Emergency, Ram Manohar
Indore (MP) Lohia Hospital
Puneet Rastogi MD DM (Card) New Delhi
GR Medical College
Gwalior (MP) Jad Aoun MD
Beirut, Lebanon
Sujata MS MCh DNB
Plastic Surgeon Ramesh Gupta
Safdarjung Hospital Cardiologist
New Delhi New York

Dr N Mishra MBBS DTM&H Rachana Dayal MBBS DGO

Director BSF HQS National Board of Examination
New Delhi New Delhi
 Preface to the Seventh Edition

The overwhelming response to the sixth edition of Differential

Diagnosis from the students and general practitioners has
encouraged us to develop the seventh edition. While retaining the
text of all the topics discussed in the previous editions, we have
made necessary corresponding revisions considered necessary in
the context of fast changing scene in medical literature. Tables on
differential diagnosis, i.e. differentiating tables, have been enlarged
and updated. Special section on diagnosis based on the laboratory
findings has been updated to help the practitioners and the students
alike. A very significant additional feature in this edition is
incorporation of sub section on causes of common dental diseases.
We sincerely wish this fully revised and updated edition to be of
much practical value to the readers, who will find it a valuable book
of resource and a continuous companion for reference.
In the last we have added the seventh section of `Syndromes’.
We are thankful to all such conscientious readers who have sent
us their suggestions and comments for improving the text and
presentation.

LC Gupta
Abhitabh Gupta
Abhishek Gupta
 Preface to the First Edition

The differential diagnosis is the medical art of distinguishing one

disease from another, looking alike. During the era of adulteration
it has become difficult to give a set of symptoms, signs and
investigative findings to exclude those diseases which simulate the
actual disease of the patient, i.e. the diagnosis. All this depends on
the clinical acumen—capability of the physician.
Knowledge of the differential diagnosis expedites the process of
reaching a correct diagnosis thus avoiding lot of suffering to the
patient.
Keeping in view of the fact present handbook has been edited in
three sections, first dealing with the differential diagnosis of signs/
symptoms, second enumerating the causes of common findings/
complaints and third differentiating certain diseases closely in a table
form.
We are sure that the presentation will be useful to postgraduates
and physicians doing private practice or serving in villages. They
will be able to save time and energy in revising the medical concepts
at a glance.
 Contents

Section-1

COMMON SIGNS AND SYMPTOMS

1. Acute Abdomen ...................................................................... 1
2. Chronic Abdomen .................................................................. 2
3. Amenorrhoea ........................................................................... 4
4. Anaemia .................................................................................... 4
5. Anorexia .................................................................................... 6
6. Ascites ....................................................................................... 7
7. Backache ................................................................................. 10
8. Bleeding Gums ...................................................................... 12
9. Blood Pressure ....................................................................... 14
10. Brain Death ............................................................................ 17
11. Clubbing of Fingers ............................................................. 23
12. Colic ......................................................................................... 24
13. Coma ........................................................................................ 25
14. Complexion and Colour of the Face ................................. 28
15. Conjunctiva ............................................................................ 29
16. Constipation ........................................................................... 30
17. Cough ...................................................................................... 30
18. Cyanosis .................................................................................. 34
19. Depression ............................................................................. 35
20. Diarrhoea ................................................................................ 38
21. Dysmenorrhoea ..................................................................... 40
22. Dyspareunia ........................................................................... 41
23. Dysphagia ............................................................................... 42
24. Dyspnoea ................................................................................ 44
25. Dysuria .................................................................................... 48
26. Electrocardiogram ................................................................. 50
27. Enlargement of Heart ........................................................... 53
28. Epistaxis .................................................................................. 56
29. Face Pain ................................................................................. 57
30. Fever ........................................................................................ 58
31. Foul Smell of Breath (Halitosis) ........................................ 64
xii Differential Diagnosis

32. Fundus Changes .................................................................... 64

33. Haematemesis ........................................................................ 67
34. Haematuria ............................................................................. 71
35. Haemoptysis .......................................................................... 75
36. Hair .......................................................................................... 78
37. Headache ................................................................................ 80
38. Heart Burn .............................................................................. 82
39. Hemiplegia ............................................................................. 82
40. Jaundice .................................................................................. 84
41. Lips .......................................................................................... 88
42. Liver Enlargement ................................................................ 89
43. Lymph Node Enlargement .................................................. 92
44. Male Infertility ...................................................................... 96
45. Melaena ................................................................................. 112
46. Menorrhagia ........................................................................ 112
47. Metrorrhagia ........................................................................ 113
48. Oedema ................................................................................. 115
49. Pain in Ear ............................................................................ 116
50. Pain, Numbness, Tingling in a Limb .............................. 118
51. Painful Eye ........................................................................... 120
52. Painful Joints ....................................................................... 121
53. Palpitation ............................................................................ 123
54. Poisoning .............................................................................. 124
55. Pruritus Vulvae .................................................................... 131
56. Pulse ...................................................................................... 131
57. Pupil ...................................................................................... 135
58. Pyrexia of Long Duration .................................................. 136
59. Rigor ...................................................................................... 139
60. Saliva ..................................................................................... 141
61. Sleep ...................................................................................... 142
62. Sneezing ............................................................................... 143
63. Snoring .................................................................................. 143
64. Spinal Lesions ..................................................................... 144
65. Spleen Enlargement ........................................................... 161
66. Sputum .................................................................................. 164
67. Swelling in Right Hypochondrium ................................ 164
68. Swelling of Breast ............................................................... 166
 Contents xiii
69. Swelling Related to Bones ................................................ 167
70. Tenesmus .............................................................................. 169
71. Thyroid Swelling ................................................................ 170
72. Tongue ................................................................................... 171
73. Tremors .................................................................................. 176
74. Ulcer ....................................................................................... 185
75. Urine ...................................................................................... 186
76. Vaginal Discharge ............................................................... 188
77. Viral hepatitis ...................................................................... 190
78. Vomiting ............................................................................... 192
79. Vulval Swelling ................................................................... 195
80. Weight Loss .......................................................................... 197

Section-2

CAUSES

MEDICINE AND SURGERY

1. AV Block ............................................................................... 200

2. Abdominal Fluid ................................................................. 200
3. Abdominal Reflexes ........................................................... 201
4. Abdominal Rigidity ........................................................... 201
5. Abnormal Mediastinal Mass ............................................ 202
6. Absent Knee Jerk ................................................................ 202
7. Acne—Drug Induced ......................................................... 202
8. Acute Confusional State .................................................... 203
9. Acute Dyspnoea in Infants and Young Children ......... 204
10. Acute Follicular Conjunctivitis ........................................ 204
11. Acute Renal Failure ............................................................ 204
12. Adult Respiratory Distress Syndrome ........................... 205
13. Agranulocytosis ................................................................... 205
14. Air under Diaphragm ........................................................ 206
15. Albuminuria ........................................................................ 206
16. Alopecia ................................................................................ 206
17. Anaemia ................................................................................ 207
18. Ankylosis .............................................................................. 208
19. Anuria ................................................................................... 208
xiv Differential Diagnosis

20. Aortic Regurgitation ........................................................... 208

21. Apex Beat—Variations ....................................................... 209
22. Aphakic Glaucoma ............................................................. 209
23. Aphasia ................................................................................. 210
24. Aplastic Anaemia ................................................................ 210
25. Appetite—Increased ........................................................... 211
26. Appetite—Diminished ...................................................... 211
27. Argyl Robertson’s Pupil .................................................... 212
28. Arterial Occlusion ............................................................... 212
29. Arthritis—Terminal Interphalangeal Joint .................... 213
30. Arthritis with Spondylitis ................................................. 213
31. Ascites ................................................................................... 213
32. Aseptic Fever ........................................................................ 214
33. Ataxia ..................................................................................... 215
34. Atrial Fibrillation ................................................................ 215
35. Attacks of Apnea—Newborn ........................................... 216
36. Basal Metabolic Rate .......................................................... 216
37. Basophilia ............................................................................. 217
38. Bed Wetting .......................................................................... 217
39. Bilateral Parotid Enlargement .......................................... 217
40. Bleeding in Liver Disease ................................................. 217
41. Bone-Bending ...................................................................... 218
42. Bone Metastasis ................................................................... 218
43. Bone Tumors ........................................................................ 218
44. Breath Sounds ...................................................................... 220
45. Breathing—Noisy ............................................................... 220
46. Breathlessness— According to Rate of Onset ............... 220
47. Calcification in Abdomen ................................................. 221
48. Cardiac Arrest ...................................................................... 221
49. Cardiac Dullness—Increased ........................................... 222
50. Cardiac Enlargement .......................................................... 222
51. Cardiac Obstructive Syncope ........................................... 222
52. Cardiomegaly—Right Ventricle ....................................... 223
53. Cardiomyopathies .............................................................. 223
54. Carotenaemia ....................................................................... 224
55. Carotid Pulse—Exaggerated ............................................. 224
56. Causes of GIT Bleeding ..................................................... 224
57. Charcot’s Joint (Neuropathic Arthritis) .......................... 226
 Contents xv
58. Chest Wall Tumors .............................................................. 226
59. Chorea ................................................................................... 227
60. Choreoathetosis ................................................................... 228
61. Chronic Active Hepatitis ................................................... 228
62. Chronic Intestinal Pseudo-obstruction ........................... 228
63. Chronic Liver Diseases ...................................................... 229
64. Chronic Renal Failure ........................................................ 229
65. Cirrhosis of Liver ................................................................ 230
66. Claudication ......................................................................... 230
67. Claw Hand ............................................................................ 231
68. Conjunctival Oedema (Chemosis) .................................. 231
69. Constipation ......................................................................... 231
70. Continuous Murmur .......................................................... 232
71. Convulsions ......................................................................... 232
72. Convulsions in Children ................................................... 233
73. Corneal Ring Lesion ........................................................... 233
74. Corneal Ring Ulcer ............................................................. 234
75. Cramp in Hand .................................................................... 234
76. Crepitus ................................................................................. 234
77. Cushing’s Syndrome .......................................................... 235
78. Cutaneous Manifestations of Internal Disease ............ 235
79. Dead Fingers ........................................................................ 237
80. Deafness ............................................................................... 237
81. Decreased Blood Glucose .................................................. 238
82. Decreased Bone Density (Osteomalacia) ....................... 238
83. Decreased Pulse Pressure .................................................. 238
84. Delayed Puberty ................................................................. 239
85. Delayed Sitting and Walking ........................................... 240
86. Delayed Union—Fracture ................................................. 240
87. Diaphragmatic Paralysis ................................................... 240
88. Diarrhoea Alternating with Constipation ..................... 241
89. Diarrhoea—Drug Induced ................................................ 241
90. Diastolic Murmur ............................................................... 241
91. Different Colours of Urine ................................................ 242
92. Difficulty in Sucking and Swallowing .......................... 242
93. Diffuse Abdominal Pain ................................................... 243
94. Diplopia ................................................................................ 243
95. Discharge from Breast ........................................................ 244
xvi Differential Diagnosis

96. Distension of Abdomen .................................................... 244

97. Drop Attacks ........................................................................ 244
98. Drugs Causing Liver Damage .......................................... 245
99. Drug Eruptions .................................................................... 245
100. Drug Induced Absorption Defect .................................... 246
101. Drug Induced Extrapyramidal Disease .......................... 246
102. Drug Induced SLE .............................................................. 247
103. Dupuytren’s Contracture ................................................... 247
104. Dwarfism .............................................................................. 248
105. Dysarthria ............................................................................. 248
106. Dysphagia ............................................................................. 249
107. Dysphagia—Intermittent .................................................. 249
108. Dyspnoea in Newborn ....................................................... 250
109. Dyspnoea Posture Related ................................................ 250
110. Dystonias .............................................................................. 250
111. ECG—Low Voltage ............................................................. 251
112. ECG-ST Segment—False
Positive Exercise Response .............................................. 251
113. ECG-T Wave—Notched, Bifid .......................................... 251
114. Egg Shell Crackling ............................................................ 252
115. Elevation of Diaphragm .................................................... 252
116. Embolism—Cardiac Causes .............................................. 252
117. Empyema .............................................................................. 253
118. Enlarged Mediastinal Shadow ......................................... 254
119. Enlargement of Blind Spot ............................................... 254
120. Enuresis ................................................................................. 255
121. Eosinophilia ......................................................................... 255
122. Epigastric Pain ..................................................................... 255
123. Epigastric Pulsation ............................................................ 256
124. Erectile Impotence .............................................................. 256
125. Erythema Multiforme ........................................................ 256
126. Erythema Nodosum ............................................................ 257
127. Erythema of Fingers ........................................................... 257
128. Excessive Thirst ................................................................... 258
129. Exophthalmos ...................................................................... 258
130. Extrasystole .......................................................................... 259
131. Facial Palsy ........................................................................... 259
 Contents xvii
132. Factors Precipitating Encephalopathy in
Cirrhotic Patients ................................................................ 260
133. Failure of Urinary Excretion ............................................. 260
134. Falls in Elderly .................................................................... 261
135. Fasciculations ....................................................................... 261
136. Fat Embolism ....................................................................... 261
137. Fever with Rigor .................................................................. 262
138. Fingers—Shape ................................................................... 262
139. Fingers—Spindiriform Joints ........................................... 262
140. First Heart Sound ................................................................ 263
141. Fixed Eruptions ................................................................... 263
142. Folate Deficiency ................................................................ 263
143. Flushed Face ......................................................................... 264
144. Frequent Blinking ............................................................... 264
145. Frigidity ................................................................................ 264
146. Frozen Shoulder .................................................................. 265
147. Gait Abnormalities—Unilateral ...................................... 265
148. Galactorrhoea ....................................................................... 266
149. Gastric Dilatation ................................................................ 266
150. Gastrointestinal Bleeding ................................................. 266
151. General Backwardness ...................................................... 267
152. Generalised Pustules .......................................................... 267
153. Generalised Stiffness ......................................................... 268
154. Generalised Nephrocalcinosis ......................................... 268
155. Generalised Vesicles and Bullae ...................................... 269
156. Giddiness .............................................................................. 269
157. Gingivitis .............................................................................. 269
158. Glaucoma to be Suspected ................................................ 270
159. Glycosuria ............................................................................ 270
160. Gum Hyperplasia ................................................................ 270
161. Gynaecomastia .................................................................... 271
162. Haematemesis ...................................................................... 271
163. Haemolysis in G-6-PD Deficiency .................................. 272
164. Haemorrhagic Pericarditis ................................................ 272
165. Hair Loss ............................................................................... 273
166. Halitosis ................................................................................ 273
167. Hand—Shape ....................................................................... 273
168. Head Nodding ..................................................................... 274
xviii Differential Diagnosis

169. Headache .............................................................................. 274

170. Heart Block ........................................................................... 274
171. Heart Block—Bundle Branch Block Left ........................ 275
172. Heart Block—Intraventricular Conduction Defect ...... 275
173. Heart Sound—Fourth (S4) ................................................. 275
174. Heart Sound—Single (S2) .................................................. 275
175. Hemiplegia of Acute Onset .............................................. 275
176. Hemiplegia of Gradual Onset .......................................... 276
177. Hemiplegia— Recurrent but Transient .......................... 276
178. Hepatomegaly ...................................................................... 276
179. Hiccough ............................................................................... 277
180. Hirsutism .............................................................................. 278
181. Hoarseness of Voice ............................................................ 278
182. Homogeneous Opacity of One Hemithorax .................. 279
183. Homogeneous Rounded Opacity—Lung ....................... 279
184. Honeycomb Lung ............................................................... 280
185. Horner’s Syndrome ............................................................ 280
186. Hydrocephalus .................................................................... 280
187. Hyperamylasaemia ............................................................. 281
188. Hypercalcaemia ................................................................... 281
189. Hypercalciuria ..................................................................... 281
190. Hyperhidrosis ...................................................................... 282
191. Hypertension ....................................................................... 282
192. Hyperthyroidism ................................................................. 283
193. Hypertonia ........................................................................... 283
194. Hypertranslucency of Lung .............................................. 284
195. Hypertrichosis ..................................................................... 284
196. Hypertrophic Osteoarthropathy ...................................... 284
197. Hyperventilation ................................................................. 285
198. Hypoadrenalism .................................................................. 286
199. Hypoglycaemia .................................................................... 287
200. Hypomelanosis .................................................................... 287
201. Hypopigmented Patches ................................................... 288
202. Hypotelorism ....................................................................... 288
203. Hypotension—Chronic ...................................................... 288
204. Hypotension—Intermittent .............................................. 289
205. Hypothermia ........................................................................ 289
206. Hypothyroidism .................................................................. 290
 Contents xix
207. Hypotonia ............................................................................. 291
208. Hypouricemia ...................................................................... 291
209. Hypouricacidemia ............................................................... 291
210. Hypoventilation .................................................................. 292
211. Impotence—Due to Antihypertensive Drugs ............... 293
212. Impotence—Due to Diabetes Mellitus ........................... 293
213. Increased Appetite .............................................................. 293
214. Increased Blood Glucose ................................................... 293
215. Increased Bone Density ..................................................... 293
216. Increased SGOT .................................................................. 294
217. Increased Visibility of Cornea ......................................... 294
218. Increased Plasma Glucagon .............................................. 294
219. Inequality of Limb Length ................................................ 295
220. Infantile Convulsions ........................................................ 295
221. Insulin Resistance ............................................................... 296
222. Intention Tremor ................................................................. 296
223. Intracranial Calcification ................................................... 296
224. Intracranial Hypertension ................................................. 297
225. Intraorbital Calcification ................................................... 297
226. Inverted ‘T’ Wave ................................................................ 297
227. Involuntary Movements .................................................... 298
228. Iodine in Serum .................................................................. 298
229. Iritis ........................................................................................ 299
230. Irregular Bleeding per Vagina .......................................... 299
231. Irregularity of Pupil ........................................................... 300
232. Jugular Venous Distension ............................................... 300
233. Ketonuria .............................................................................. 300
234. Kidney Size .......................................................................... 301
235. Kinesias ................................................................................. 301
236. Knee-Instability .................................................................. 301
237. Kyphoscoliosis .................................................................... 301
238. Kyphosis ............................................................................... 302
239. Lack of Outer Third of Eyebrows .................................... 302
240. Lactic Acidosis ..................................................................... 303
241. Lagophthalmos .................................................................... 303
242. Lassitude ............................................................................... 303
243. Left Upper Quadrant Leg Ulcers ...................................... 304
244. Lengthened ‘QT’ Interval .................................................. 304
xx Differential Diagnosis

245. Leukopenia ........................................................................... 304

246. Leukoplakia ......................................................................... 305
247. Lightening Pains ................................................................. 305
248. Liver—Damage by Drugs .................................................. 306
249. Liver-Hepatitis, Chronic Persistent ................................. 306
250. Liver—Non-cirrhotic Fibrosis .......................................... 306
251. Local Muscle Wasting ........................................................ 306
252. Localised Lymphadenopathy ............................................ 307
253. Localised Oedema ............................................................... 307
254. Loss of Accommodation Reflex ....................................... 307
255. Loss of Consciousness ....................................................... 308
256. Loss of Memory ................................................................... 308
257. Loss of Smell ........................................................................ 308
258. Loss of Weight ..................................................................... 309
259. Loose Bodies—Joints .......................................................... 309
260. Lordosis ................................................................................. 310
261. Low/Flat ‘T’ Wave ................................................................ 311
262. Lung Collapse ...................................................................... 311
263. Lung—Localised Fibrosis .................................................. 311
264. Lung Metastases .................................................................. 312
265. Lung Resonance .................................................................. 312
266. Lymphoedema ..................................................................... 312
267. Male Infertility .................................................................... 313
268. Mandibular Joint—Clicking ............................................. 313
269. Mastomegaly ........................................................................ 313
270. Membranous Throat ........................................................... 314
271. Meningism ........................................................................... 314
272. Menorrhagia ........................................................................ 314
273. Menstruation—Precocious ................................................ 315
274. Metabolic Acidosis ............................................................. 315
275. Metabolic Alkalosis ............................................................ 315
276. Microcytic Anaemia ............................................................ 315
277. Micturition ........................................................................... 316
278. Miliary Mottling of Lung .................................................. 316
279. Monocular Diplopia ........................................................... 317
280. Monocytosis ......................................................................... 317
281. Monoplegia .......................................................................... 318
282. Mood Disorders .................................................................. 318
 Contents xxi
283. Mouth Breathing ................................................................. 319
284. Muscle Weakness ................................................................ 319
285. Muscle Weakness, Episodic .............................................. 319
286. Myalgias ............................................................................... 320
287. Myoclonias ........................................................................... 320
288. Myoclonus ............................................................................ 321
289. Nails ....................................................................................... 321
290. Neck Stiffness ...................................................................... 322
291. Neonatal Abdominal Distension ..................................... 322
292. Nephrocalcinosis ................................................................. 322
293. Nephrolithiasis .................................................................... 323
294. Nephrotoxic Agents ............................................................ 323
295. Neuropathic Arthritis ......................................................... 324
296. Neuropathy—Demyelinating ........................................... 324
297. Nipple Retraction ................................................................ 324
298. Nocturia ................................................................................ 324
299. Non-cirrhotic Hepatic Fibrosis ......................................... 325
300. Non-union of Fracture ....................................................... 325
301. Non-visualization of Gallbladder in
Cholecystogram ................................................................... 325
302. Nutritional Anaemia .......................................................... 326
303. Oesophageal Varices .......................................................... 326
304. Oesophagitis ........................................................................ 326
305. Opisthotonos ....................................................................... 326
306. Oral Pigmentation .............................................................. 327
307. Orbital Pain .......................................................................... 327
308. Osteomalacia ........................................................................ 327
309. Osteoporosis ........................................................................ 328
310. Osteosclerosis ...................................................................... 329
311. Overventilation ................................................................... 329
312. Painful Hip in Children .................................................... 330
313. Painful Ophthalmoplegia ................................................. 330
314. Palpitation ............................................................................ 330
315. Pancreatitis ........................................................................... 331
316. Pancytopenia ........................................................................ 331
317. Papillary Necrosis ............................................................... 332
318. Papilloedema ....................................................................... 332
319. Paradoxical Pupillary Reaction ........................................ 333
xxii Differential Diagnosis

320. Paralytic Ileus ...................................................................... 333

321. Paraplegia ............................................................................. 333
322. Paresthesias .......................................................................... 334
323. Parkinsonism ....................................................................... 334
324. Parotid Swelling .................................................................. 334
325. Passing of Blood Per Rectum ............................................ 335
326. Pathological Fracture .......................................................... 335
327. Perianal Pain ........................................................................ 336
328. Periarticular Nodules ......................................................... 337
329. Pericardial Effusion ............................................................ 337
330. Pericarditis ........................................................................... 337
331. Peripheral Neuropathy ...................................................... 337
332. Peritonitis ............................................................................. 338
333. Perverted Appetite .............................................................. 339
334. Photophobia ......................................................................... 339
335. Phrenic Paralysis ................................................................. 339
336. Pigmentation of Eyelid ...................................................... 339
337. Pigmentation of Skin ......................................................... 340
338. Pigmented Retina ............................................................... 341
339. Pigmented Skin Lesion ...................................................... 341
340. Plantar Response ................................................................. 341
341. Pneumothorax ...................................................................... 341
342. Poliosis .................................................................................. 342
343. Polyarthritis due to Inflammation .................................. 342
344. Polyarteritis Nodosa ........................................................... 343
345. Polycythaemia ..................................................................... 343
346. Polyneuritis of Hand .......................................................... 344
347. Polyuria ................................................................................. 345
348. Poor Convergence ............................................................... 345
349. Portal Hypertension ........................................................... 346
350. Postprandial Hypoglycaemia ........................................... 346
351. Positive Kahn’s Test ............................................................ 347
352. Positive ‘LE’ Cells in Blood ............................................... 347
353. Positive Rheumatoid Factor .............................................. 347
354. Potassium Depletion .......................................................... 348
355. Precordial Thrills ................................................................ 348
356. Pregnancy Collapse IN ...................................................... 349
357. Pregancy Test—Positive ..................................................... 349
 Contents xxiii
358. Priapism ................................................................................ 349
359. Prolonged Bleeding Times ................................................ 350
360. Prolonged QRS Interval .................................................... 350
361. Prostate—Nodular .............................................................. 350
362. Proteinuria ............................................................................ 350
363. Proximal Muscle Weakness of Leg .................................. 351
364. Proximal Myopathies ......................................................... 351
365. Pruritus .................................................................................. 351
366. Pruritus Ani .......................................................................... 352
367. Pruritus Vulvae .................................................................... 352
368. Pulmonary Eosinophilia .................................................... 352
369. Pulmonary Eosinophilia
(Eosinophilic Pneumonitis) .............................................. 353
370. Pulmonary Oligemia .......................................................... 353
371. Pulse Pressure Increased ................................................... 354
372. Pulse Unequal ...................................................................... 354
373. Punched-out Areas in Bones of Extremities .................. 355
374. Purpura ................................................................................. 355
375. Pyogenic Liver Abscess ..................................................... 355
376. Pyuria—Sterile and Persistent ......................................... 355
377. Raised Alkaline Phosphatase ........................................... 356
378. Raised ESR ........................................................................... 356
379. Raised Platelet Count ......................................................... 357
380. Raised Serum Cholesterol ................................................. 357
381. Raised Uric Acid .................................................................. 357
382. Raynaud’s Phenomenon .................................................... 358
383. Recurrent Abdominal Pain ............................................... 358
384. Red Scaly Patches ............................................................... 359
385. Reflexes ................................................................................. 359
386. Reflexes—Diminished ....................................................... 359
387. Renal Hypertension ........................................................... 360
388. Renal Stones and Nephrocalcinosis ................................ 360
389. Respiratory Acidosis .......................................................... 361
390. Respiratory Alkalosis ......................................................... 361
391. Respiratory Acidulous Conditions .................................. 362
392. Respiratory Arrest ............................................................... 362
393. Respiratory Rate .................................................................. 362
394. Sacroiliitis ............................................................................. 363
xxiv Differential Diagnosis

395. Salivation and Drooling .................................................... 363

396. Sclerosis ................................................................................ 364
397. Scoliosis ................................................................................ 364
398. Second Heart Sound ........................................................... 364
399. Secondary Diabetes ............................................................ 365
400. Segmental Myoclonus ....................................................... 365
401. Seizures ................................................................................. 365
402. Sexual Precocity .................................................................. 366
403. Shock ..................................................................................... 367
404. Short Stature (Proportionate) ........................................... 367
405. Short Stature having Short Limbs ................................... 368
406. Shoulder Pain ...................................................................... 368
407. Sideroblastic Anaemia ....................................................... 369
408. Single Red Hot Joint .......................................................... 369
409. Single Nodule in Lungs ..................................................... 369
410. Sinus Bradycardia ............................................................... 370
411. Size and Shape of Kidney ................................................. 370
412. Solitary Pulmonary Nodule .............................................. 371
413. Spinal Cord Compression ................................................. 371
414. Spontaneous Hyphema ..................................................... 372
415. Stiff Neck .............................................................................. 372
416. Stridor ................................................................................... 373
417. Sudden Death ...................................................................... 373
418. Supraventricular Tachycardia ........................................... 374
419. Sweating ............................................................................... 374
420. Swelling ................................................................................ 375
421. Swelling in Ileocaecal Region .......................................... 375
422. Swelling in Umbilical Region .......................................... 375
423. Swelling of Face .................................................................. 375
424. Syncope ................................................................................. 376
425. Syrinx .................................................................................... 376
426. Systolic Murmur ................................................................. 377
427. Tachycardia ........................................................................... 377
428. Taste ....................................................................................... 378
429. Telangiectasia ....................................................................... 378
430. Temperature of Hand ......................................................... 379
431. Tenderness of Chest ........................................................... 379
 Contents xxv

432. Tenderness of Spine ........................................................... 379

433. Tendon Reflexes .................................................................. 380
434. Tension of CSF Fluid .......................................................... 380
435. Thickened Nerves ............................................................... 381
436. Third Heart Sound .............................................................. 381
437. Thrombocytopenia ............................................................. 381
438. Tics ......................................................................................... 382
439. Tinnitus ................................................................................. 382
440. Toe Walking ......................................................................... 383
441. Transient Flitting Arthritis ................................................ 383
442. Transient Loss of Vision .................................................... 383
443. Tricuspid Regurgitation ..................................................... 384
444. Trismus .................................................................................. 384
445. Tunnel Vision (Peripheral Visual Constriction) ........... 384
446. Unilateral Glaucoma .......................................................... 385
447. Urinary Calculi .................................................................... 385
448. Urinary Retention ............................................................... 386
449. Vagina—Candidiasis .......................................................... 386
450. Vagina—Vaginismus .......................................................... 386
451. Valvular Aortic Stenosis .................................................... 387
452. Vasculitis—Nodular ........................................................... 387
453. Varicose Veins—Lower Limbs .......................................... 387
454. Vertebral Column—Rigidity ............................................ 388
455. Vertigo ................................................................................... 388
456. Virilism ................................................................................. 388
457. Vital Capacity Reduced ..................................................... 389
458. Vitamin B12 Deficiency ...................................................... 389
459. Vomiting ............................................................................... 390
460. Vomiting in Infancy ........................................................... 391
461. Wasting of Intrinsic Hand Muscles ................................. 391
462. Wasting of Muscles ............................................................. 392
463. Weight Gain ......................................................................... 392
464. Wheezing .............................................................................. 393
465. Xerosis ................................................................................... 394
466. Yawning ................................................................................ 394
467. Yellow Pigmentation .......................................................... 394
xxvi Differential Diagnosis

PAEDIATRICS

1. Abdominal Pain .................................................................. 395

2. Acute Ataxia ......................................................................... 395
3. Acute Convulsions .............................................................. 396
4. Acute Renal Failure ............................................................ 397
5. Acute Visual Disturbance .................................................. 398
6. Agitation and Withdrawal ................................................ 399
7. Anaemia in Newborn ......................................................... 399
8. Aphasia ................................................................................. 400
9. Bilateral Nephromegaly in Newborn ............................. 400
10. Breath Holding Spasm ...................................................... 400
11. Cardiac Arrhythmias—AV Block ..................................... 401
12. Cardiac Arrhythmias .......................................................... 401
13. Catarrhal ............................................................................... 402
14. Cerebral Palsy ...................................................................... 402
15. Chest Pain ............................................................................. 403
16. Chronic Cough .................................................................... 403
17. Coma ...................................................................................... 404
18. Congestive Heart Failure ................................................... 405
19. Constipation ......................................................................... 406
20. Convulsions—Chronic ...................................................... 407
21. Cough .................................................................................... 407
22. Crying in Early Infancy ..................................................... 407
23. Cyanosis ................................................................................ 408
24. Delayed Bilestones ............................................................. 408
25. Delirium ............................................................................... 409
26. Developmental Ataxia ....................................................... 409
27. Diarrhoea—Acute ............................................................... 411
28. Dwarfism—Congenital ...................................................... 412
29. Dysphagia ............................................................................. 412
30. Earache .................................................................................. 413
31. Faecal Soiling ....................................................................... 413
32. Fever—Common Causes ................................................... 413
33. Hematemesis ........................................................................ 414
34. Head—Frontal Bossing ...................................................... 415
35. Haeadache ............................................................................ 415
36. Haemoptysis ........................................................................ 415
 Contents xxvii
37. Hematuria ............................................................................. 416
38. Hoarseness of Voice in Infancy ........................................ 416
39. Intestinal Obstruction—Neonatal ................................... 417
40. Intracranial Raised Pressure ............................................. 417
41. Irritability ............................................................................. 417
42. Jaundice—Conjugated ....................................................... 418
43. Jaundice in Newborn ......................................................... 418
44. Joint Pain .............................................................................. 419
45. Joints Swollen ...................................................................... 419
46. Limping ................................................................................. 419
47. Liver—Cirrhosis .................................................................. 420
48. Lower Limb—Pain .............................................................. 421
49. Lymphadenopathy .............................................................. 422
50. Malabsorption Syndrome ................................................ 423
51. Mental Retardation with Enlarged Head ....................... 424
52. Myoclonic Spasms in Infants ........................................... 424
53. Napkin Rash ........................................................................ 425
54. Neck Mass ............................................................................ 425
55. Neonatal Convulsions ....................................................... 425
56. Neonatal Hypocalcemia ..................................................... 426
57. Nephrotic Syndrome .......................................................... 427
58. Neurologic Causes of Disorders of
Micturition and Defecation .............................................. 427
59. Nonepileptical Paroxysmal Disorders ............................ 428
60. Obesity .................................................................................. 428
61. Obstructive Uropathy ........................................................ 428
62. Oedema ................................................................................. 429
63. Pancreatitis ........................................................................... 429
64. Peritonitis ............................................................................. 431
65. Pica ......................................................................................... 431
66. Pleural Effusion ................................................................... 431
67. Poor School Performance .................................................. 432
68. Preauricular Lymphadenopathy ...................................... 432
69. Pulmonary Oedema ............................................................ 432
70. Recurrent Pneumonia ........................................................ 433
71. Sexual Precocity .................................................................. 434
72. Shock ..................................................................................... 434
73. Sinus Bradycardia ............................................................... 435
xxviii Differential Diagnosis

74. Sinus Tachycardia ............................................................... 435

75. Stiff Acute Neck .................................................................. 435
76. Temper Tantrums ................................................................ 436
77. Thumb Sucking ................................................................... 436

OBSTETRICS AND GYNAECOLOGY

1. Abnormal Bleeding ............................................................ 436

2. Abortion ................................................................................ 437
3. Bleeding per Vaginum ....................................................... 438
4. Breast Tumors ...................................................................... 439
5. Carcinoma Breast—Risk Factors ...................................... 439
6. Chronic Endometritis ......................................................... 439
7. Collapse during Pregnancy ............................................... 440
8. Convulsions during Pregnancy ........................................ 440
9. Delayed Labour ................................................................... 440
10. Discharge from Nipples .................................................... 441
11. Dyspareunia ......................................................................... 442
12. Eclampsia .............................................................................. 442
13. Ectopic Pregnancy ............................................................... 443
14. Enlargement of Cervix ....................................................... 443
15. Fetus Stillbirth ..................................................................... 444
16. Frigidity ................................................................................ 444
17. Hypoplasia Breast ............................................................... 445
18. Infarction of Breast ............................................................. 445
19. Insufficiency of Placenta ................................................... 445
20. Intrauterine Death of Fetus ............................................... 446
21. Leucorrhoea .......................................................................... 446
22. Mastitis .................................................................................. 447
23. Maternal Death during Delivery ..................................... 447
24. Offensive Vaginal Discharge ............................................ 448
25. Oligohydraminos ................................................................ 448
26. Oligomenorrhoea ................................................................ 448
27. Positive Test of Pregnancy ................................................ 449
28. Pregnancy—High Risk ...................................................... 449
29. Pregnancy—Hypertension ................................................ 450
30. Pregnancy—Jaundice ......................................................... 450
31. Premature Labour ............................................................... 450
 Contents xxix
32. Premature Rupture of Membranes .................................. 451
33. Primary Amenorrhoea ....................................................... 451
34. Prolapse of Umbilical Cord .............................................. 452
35. Pruritus Vulvae .................................................................... 452
36. Recurrent Abortion ............................................................. 453
37. Retarded Fetal Growth ...................................................... 453
38. Salpingo-oophoritis ............................................................ 453
39. Uterine prolapse .................................................................. 454
40. Uterus—Fixed ...................................................................... 454
41. Uterus—Ruptured ............................................................... 454
42. Vaginal Discharge ............................................................... 455
43. Vaginismus ........................................................................... 456
44. Vaginitis ................................................................................ 456
45. Vulvitis .................................................................................. 457

EYE

1. Anterior Uveitis ................................................................... 457

2. Ageing Changes of Cornea ............................................... 457
3. Apparent Divergent Strabismus ...................................... 458
4. Atrophic Bulbi ..................................................................... 458
5. Band-shaped Keratopathy ................................................. 458
6. Bitot’s Spot ........................................................................... 458
7. Blink Reflexes ...................................................................... 459
8. Bloody Tears ......................................................................... 459
9. Blue Sclera ............................................................................ 459
10. Cataract ................................................................................. 460
11. Cataract due to Metabolic Disorder ................................ 460
12. Central Scotoma .................................................................. 460
13. Cicatricial Conjunctivitis .................................................. 461
14. Coarse Eyebrows ................................................................. 461
15. Coloboma of Iris ................................................................. 461
16. Colour Blindness ................................................................ 461
17. Congenital Cataract ............................................................ 462
18. Conjunctival Bleeding ....................................................... 462
19. Conjunctival Congestion/Ciliary Congestion ............... 463
20. Cornea ................................................................................... 464
21. Corneal Opacity in Infants ............................................... 464
xxx Differential Diagnosis

22. Cotton Wool Spots on Retina ........................................... 465

23. Defective Colour Vision .................................................... 465
24. Dilated Episcleral Vessels ................................................. 465
25. Dilated and Tortuous Retinal Vessels ............................. 465
26. Diminished Corneal Sensation ........................................ 466
27. Elevated Intraocular Pressure with
Normal Optic Disc .............................................................. 466
28. Enophthalmos ...................................................................... 466
29. Excessive Tears ..................................................................... 467
30. Eye Pain ................................................................................ 467
31. Fat Herniation into Lids .................................................... 468
32. Fixed Dilated Pupil ............................................................ 468
33. Frequent Change in Refraction ........................................ 468
34. General Narrowing of Retinal Arterioles ...................... 469
35. Glaucoma .............................................................................. 469
36. Granulomatous and Non-granulomatous Uveitis ........ 469
37. Granulomatous Uveitis ...................................................... 470
38. Hyperaemia of Iris .............................................................. 470
39. Hyperaemia of Lid Margin ............................................... 470
40. Infrequent Blinking ........................................................... 470
41. Iris Atrophy .......................................................................... 471
42. Iritis/Glaucoma/Conjunctivitis ........................................ 471
43. Irregular Anterior Chamber .............................................. 471
44. Keratitis ................................................................................. 472
45. Lids ........................................................................................ 472
46. Lipids Deposit at Macula .................................................. 474
47. Liquefaction of Vitreous .................................................... 474
48. Loss of Vision ...................................................................... 474
49. Macular Hemorrhage ......................................................... 475
50. Megalocornea and Buphthalmos ..................................... 475
51. Microaneurysm of Retina .................................................. 476
52. Miosis .................................................................................... 476
53. Mydriasis .............................................................................. 476
54. Neovascular Glaucoma ...................................................... 477
55. Night Blindness .................................................................. 477
56. No Reflex from Pupil ......................................................... 477
 Contents xxxi
57. Nodule at Limbus ............................................................... 478
58. Nystagmus ............................................................................ 478
59. Oculomotor Nerve Palsy ................................................... 479
60. Oedema of Orbit ................................................................. 479
61. Ophthalmoplegia ................................................................ 480
62. Optic Atrophy ...................................................................... 480
63. Optic Neuritis ...................................................................... 481
64. Painful Ocular Movements ............................................... 482
65. Painful Ophthalmoplegia ................................................. 482
66. Papillitis ................................................................................ 482
67. Paralysis of Accommodation ............................................ 482
68. Paralysis of Orbicularis ..................................................... 483
69. Peripheral Lesions of Fundus ........................................... 483
70. Photophobia ......................................................................... 483
71. Pigmentary Glaucoma ....................................................... 484
72. Pigmented Retina ............................................................... 484
73. Pinpoint Pupil ..................................................................... 484
74. Posterior Subcapsular Opacities in Lens ....................... 484
75. Proptosis ............................................................................... 485
76. Pseudo-lip Retraction ......................................................... 486
77. Pseudo-proptosis ................................................................. 487
78. Pseudopapilloedema .......................................................... 487
79. Phthisis Bulbi ...................................................................... 487
80. Ptosis ...................................................................................... 488
81. Ptosis of Upper Eyelid ....................................................... 488
82. Puffiness of Eyelids ............................................................ 489
83. Pupil Block ........................................................................... 489
84. Red Eye ................................................................................. 489
85. Retinal Haemorrhage ......................................................... 490
86. Retinal Vascular Tortuosity ............................................... 490
87. Retinal Hemorrhage ........................................................... 490
88. Ring Lesions of Cornea ..................................................... 491
89. Scleral Rigidity .................................................................... 491
90. Scleral Staphyloma ............................................................. 491
91. Scleral Thinning .................................................................. 491
92. Scleritis .................................................................................. 492
93. Soft Eyeball .......................................................................... 492
94. Solid Oedema of Lid .......................................................... 492
xxxii Differential Diagnosis

95. Subconjunctival Haemorrhage ........................................ 493

96. Systemic Diseases Causing Scleritis ............................... 493
97. Thickened Eyelids .............................................................. 493
98. Third, Fourth and Sixth Cranial Nerve Palsies ............. 494
99. Tortuosity of Conjunctival Vessels .................................. 494
100. Toxic Amblyopia ................................................................. 494
101. Unilateral Blindness ........................................................... 495
102. Unilateral Cataracts ............................................................ 495
103. Unilateral Glaucoma .......................................................... 495
104. Uveitis ................................................................................... 495
105. Vasoproliferative Retinopathy ......................................... 496
106. Vitreous Hemorrhage ......................................................... 496
107. White Reflex from Pupil ................................................... 496

DENTAL

1. Brown Lesions of Lips ....................................................... 497

2. Burning Sensation of Tongue ........................................... 497
3. Cauliflower Like Growth of Oral Cavity ....................... 497
4. Delayed Tooth Eruption .................................................... 497
5. Diffuse Facial Swelling ..................................................... 498
6. Disorder of Taste ................................................................. 498
7. Easily Bleeding Soft Tissue of Oral Cavity ................... 499
8. Elevated Lesions of Lip ..................................................... 499
9. Facial Nerve Palsy ............................................................... 499
10. Facial Nerve Paralysis ........................................................ 500
11. Flushing of Face .................................................................. 501
12. Generalised Red Conditions and
Multiple Ulceration ............................................................ 501
13. Intraoral Brownish, Bluish or Black Conditions .......... 501
14. Intraoral Soft Tissue Swelling ......................................... 502
15. Loose Teeth ........................................................................... 502
16. Mandibular Joint Clicking ................................................ 502
17. Oral Fetor .............................................................................. 502
18. Oral Ulcer ............................................................................. 503
19. Parotid Gland Enlargement .............................................. 503
 Contents xxxiii
20. Primary Oral Condidiasis ................................................. 504
21. Non-scrapable White Lesions on Oral Mucosa ............ 504
22. Painful Salivary Gland ...................................................... 504
23. Sialorrhea ............................................................................. 505
24. Solitary Red Lesion ............................................................ 505
25. White Lesion of Lips .......................................................... 505

Section-3

DIFFERENTIATING TABLES

1. Acute Abdomen/Myocardial Infarction ......................... 506

2. Acute Gout and Acute Rheumatism ............................... 507
3. Adams-Stokes Syndrome/Epilepsy ................................. 508
4. Abdominal Pain due to Infectious Disorders ............... 509
5. Alopecia ................................................................................ 511
6. Amoebic and Bacillary Dysentery ................................... 513
7. Anaemia—Vitamin B12 Deficiency (due to
Pernicious Anaemia) and Folate Deficiency ................. 514
8. Angina Pectoris ................................................................... 515
9. Angina on Effort and Coronary Thrombosis ................ 517
10. Ankylosing Spondylitis/Osteoarthritis/Gout ............... 518
11. Ankylosing Spondylitis vs Backache ............................. 519
12. Aortic Dissection/Myocardial Infarction ....................... 520
13. Arsenic Poisoning and Cholera ....................................... 521
14. Arterial and Venous Pulsation ......................................... 522
15. Arteriosclerosis Obliterans (ASO) and
Burger’s Disease .................................................................. 523
16. Arthritis ................................................................................. 524
17. Atrial Fibrillation/Multiple Ectopics .............................. 525
18. Arthritis ................................................................................. 526
19. Ascites/Ovarian Cyst .......................................................... 527
20. Bacterial Pneumonia/Viral Pneumonia .......................... 528
21. Biliary and Portal Cirrhosis .............................................. 529
22. Bladder .................................................................................. 530
xxxiv Differential Diagnosis

23. Bradycardia .......................................................................... 531

24. Bronchial Asthma and Tropical Eosinophilia ............... 532
25. Cardiac and Bronchial Asthma ........................................ 533
26. Central and Peripheral Cyanosis ..................................... 534
27. Cerebro-vascular Accident, Diabetic
Coma and Uraemia ............................................................. 535
28. Cholera and Food Poisoning ............................................ 536
29. Chronic Bronchitis and Emphysema .............................. 537
30. Chest Diseases ..................................................................... 538
31. Chest Pain: Associated Signs ............................................ 540
32. Chronic Bronchitis, Emphysema,
Bronchial Asthma ............................................................... 545
33. Chronic Gastric Ulcer and Chronic
Duodenal Ulcer ................................................................... 546
34. Chronic Gastric Ulcer, Malignant
Disease and Chronic Gastritis .......................................... 547
35. Colic ....................................................................................... 548
36. Chronic Mitral Regurgitation/Acute MR ....................... 549
37. Chronic Nephritis and Essential Hypertension ............ 550
38. Chronic Myeloid Leukaemia/
Chronic Lymphoid Leukaemia ......................................... 551
39. Conjugated and Unconjugated Bilirubin ...................... 553
40. Colitis .................................................................................... 554
41. Colubrine Poisoning and Viperine Poisoning .............. 555
42. Conjunctival Congestion/Ciliary Congestion ............... 556
43. Conjunctivitis, Iritis and Acute Glaucoma .................... 557
44. Diabetes ................................................................................ 558
45. Diastolic Murmurs—Apex ................................................ 560
46. Diastolic Murmurs—Second
Interspace Right and Left (Base) ...................................... 562
47. Differentiating Clinical Features in
Patients with Diarrhea ....................................................... 563
48. Different Types of Jaundice .............................................. 566
49. Differentiation between Natural and
Criminal Abortion .............................................................. 568
50. Differential Diagnosis of Big Skull ................................ 569
51. Drug Addiction and Drug Habituation .......................... 570
52. Drunkenness and Concussion ......................................... 571
 Contents xxxv
53. Ear Discharge ....................................................................... 572
54. Endogenous Depression/Neurotic Depression ............. 573
55. Effort Angina/Acute Infarction ........................................ 574
56. Extrinsic Asthma/Intrinsic Asthma ................................. 576
57. Episodic Thoracic Pain ....................................................... 577
58. Endocardial and Pericardial Murmurs ........................... 579
59. Fallot’s Tetralogy and Fallot’s Triad ................................. 580
60. Functional Mitral Incompetence ...................................... 581
61. Gall Bladder Swelling/Kidney Swelling ....................... 582
62. Gaucher’s Disease/Niemann-Pick
Disease/Hand-Schüller-Christian Disease .................... 583
63. Genital Ulcers ...................................................................... 584
64. Haemoptysis and Haematemesis ..................................... 585
65. Hepatitis A/Hepatitis B ...................................................... 586
66. Headaches ............................................................................. 588
67. Heat stroke/Heat Exhaustion/Heat Cramps ................... 592
68. Hematuria ............................................................................. 593
69. Hysterical and Organic Convulsions .............................. 594
70. Hepatitis E/Hepatitis Virus ............................................... 595
71. Hysterical fit and Epileptic Fit ......................................... 596
72. Hyperglycaemic and Hypoglycaemic Coma ................. 597
73. Hospital-acquired Infections ............................................ 598
74. Hypovolemic Shock and Septic Shock ........................... 603
75. Immunity .............................................................................. 604
76. Infective Hepatitis and Serum Hepatitis ....................... 605
77. Innervation of Reflexes ..................................................... 606
78. Irregular Tachycardia ......................................................... 607
79. Lesions of Conus Medullaris/
Cauda Equina Lesions ....................................................... 608
80. Lobar Pneumonia and Broncho-pneumonia ................. 609
81. Lower Urinary Tract Obstruction ..................................... 610
82. Lungs of Infant Before Respiration and after
Onset of Respiration .......................................................... 611
83. Middle Aortic Syndrome/Congenital Syndrome ......... 612
84. Loose Motions ..................................................................... 613
85. Marasmus and Kwashiorkor ............................................ 614
86. Migraine ............................................................................... 615
87. Mitral Regurgitation/Tricuspid Regurgitation ............. 616
xxxvi Differential Diagnosis

88. Mitral Incompetence/Aortic Stenosis ............................. 617

89. Mitral Regurgitation, VSD and
Tricuspid Regurgitation ..................................................... 618
90. Migraine, Tension Headache, Psychotic Headache,
Pressure Headache, and Temporal Arteritis .................. 619
91. Muscular Dystrophies ........................................................ 620
92. Nail Discolouration ............................................................ 621
93. Nasal Discharge .................................................................. 623
94. Papillitis and Papilloedema .............................................. 624
95. Non-cirrhotic Portal Fibrosis/Cirrhosis .......................... 625
96. Oedema of the Skin ............................................................ 627
97. Oedema or Skin or Tissue in Children ........................... 628
98. Organic Psychosis/Functional Psychosis ....................... 629
99. Osteoarthritis/Frozen Shoulder ....................................... 630
100. Pain in the Umbilical Region ........................................... 631
101. Peripheral Oedema ............................................................. 632
102. Petit Mal, Temporal Lobe Epilepsy
and Grand Mal Epilepsy ................................................... 633
103. Peripheral Vascular Disease ............................................. 634
104. Pleural Effusion ................................................................... 635
105. Pericardial Effusion/Pleural Effusion ............................. 638
106. Poisoning .............................................................................. 639
107. Primary Haemostasis/Secondary Haemostasis ............. 641
108. Primary Pulmonary Hypertension and
Multiple Pulmonary Emboli ............................................ 642
109. Prostatic diseases/PR Examination .................................. 643
110. Psychoneuroses and Psychoses ........................................ 644
111. Psychosis and Neurosis ..................................................... 645
112. Pyogenic Lung Abscess/Tubercular Abscess ................. 646
113. Regular Tachycardia ........................................................... 647
114. Rheumatoid Arthritis/Rheumatic .................................... 648
115. Rheumatic and Syphilitic Incompetence ....................... 649
116. Rheumatoid Arthritis and Osteoarthritis ....................... 650
117. Severe Abdominal Pain: Associated
Symptoms and Signs .......................................................... 652
118. Sinus Bradycardia ............................................................... 655
119. Smallpox and Chickenpox ................................................ 656
120. Spleen Swelling/Kidney Swelling .................................. 657
 Contents xxxvii

121. Sinus Tachycardia/Ventricular Tachycardia ................... 658

122. Stages of Dehydration ....................................................... 661
123. Strychnine Poisoning and Tetanus .................................. 662
124. Suicidal and Homicidal Hanging .................................... 663
125. Spleen Enlargement ........................................................... 664
126. True Insanity and Feigned Insanity ................................ 665
127. Suicidal and Homicidal Wounds ..................................... 666
128. Systolic Murmurs—Apex and
Left Lower Sternal Border (LLSB) ................................... 668
129. Systolic Murmurs—Right Second Interspace ............... 670
130. Tachycardias ......................................................................... 672
131. Thyrotoxicosis ..................................................................... 674
132. Tonsillitis, Scarlet Fever and Diphtheria ....................... 675
133. Trigeminal Neuralgia, Atypical Facial Pain,
Migraine, and Postherpetic Neuralgia ........................... 676
134. Upper Motor Lesion and Lower Motor Lesion ............. 677
135. True Bruise and Artificial Bruise ..................................... 678
136. Vascular Embolism, Thrombosis and
Haemorrhage ....................................................................... 679
137. Vasovagal Fit, Hyperventilation Drop Attack,
Stokes-Adams and Hypoglycaemia ................................ 680
138. Viral Pericarditis/Myocardial Infarction ........................ 681
139. Ventricular Ectopic/Atrial Fibrillation ............................ 682
140. Ventricular Septal Defect and Pulmonary Stenosis ..... 683
141. Viral Encephalitis and Tuberculous Meningitis ........... 684

Section-4

ESSENTIALS OF DIAGNOSIS

1. Acne Vulgaris ....................................................................... 685

2. Acromegaly .......................................................................... 685
3. Acute Appendicitis ............................................................. 686
4. Acute Cholecystitis ............................................................. 686
5. Acute Gastritis ..................................................................... 686
6. Acute Glaucoma .................................................................. 687
7. Acute Miliary Tuberculosis ............................................... 687
xxxviii Differential Diagnosis

8. Acute Otitis Media ............................................................. 687

9. Acute Poliomyelitis ............................................................ 687
10. Acute Pyelonephritis .......................................................... 688
11. Acute Renal Failure ............................................................ 688
12. Addison's Disease ............................................................... 689
13. Alcoholic Liver .................................................................... 689
14. Amyloidosis ......................................................................... 689
15. Anaemia ................................................................................ 690
16. Angina Pectoris ................................................................... 690
17. Aortic Incompetence .......................................................... 690
18. Aortic Stenosis ..................................................................... 691
19. Asthma .................................................................................. 691
20. Atelectasis ............................................................................. 691
21. Atrial Septal Defect ............................................................ 692
22. Attention Deficit Hyperactivity Disorder ...................... 692
23. Bacillary Dysentery ............................................................ 693
24. Brief Reactive Psychosis .................................................... 693
25. Bronchiectasis ...................................................................... 693
26. Bronchogenic Carcinoma .................................................. 694
27. Bronchopneumonia ............................................................ 694
28. Cancer Cervix ....................................................................... 695
29. Cervicitis ............................................................................... 695
30. Chickenpox .......................................................................... 695
31. Chronic Alcoholism ............................................................ 696
32. Chronic Pyelonephritis ...................................................... 696
33. Conduct Disorder ................................................................ 697
34. Congenital Syphilis ............................................................ 697
35. Conjunctivitis ...................................................................... 698
36. Corneal Ulcer ....................................................................... 698
37. Cushing's Syndrome .......................................................... 698
38. Delirium ............................................................................... 699
39. Dementia .............................................................................. 699
40. Depression ........................................................................... 700
41. Diabetes Insipidus .............................................................. 700
42. Diabetes Mellitus ................................................................ 701
43. Dysmenorrhoea ................................................................... 701
44. Duodenal Ulcer ................................................................... 701
45. Eczema ................................................................................... 702
 Contents xxxix
46. Facial Palsy ........................................................................... 702
47. Fallot's Tetralogy ................................................................. 702
48. Fibroid Uterus ...................................................................... 703
49. Functional Enuresis ............................................................ 704
50. Gigantism ............................................................................. 704
51. Gonorrhoea .......................................................................... 704
52. Gout ....................................................................................... 705
53. Grand Mal Epilepsy ........................................................... 705
54. Herpes Zoster ....................................................................... 706
55. Hodgkin's Disease .............................................................. 706
56. Hypertension ....................................................................... 707
57. Hyperthyroidism ................................................................. 707
58. Hypothyroidism .................................................................. 708
59. Indian Childhood Cirrhosis ............................................. 708
60. Infantile Diarrhoea ............................................................. 709
61. Infective Endocarditis ........................................................ 709
62. Infective Hepatitis .............................................................. 710
63. Intestinal Amoebiasis ........................................................ 710
64. Intestinal Tuberculosis ....................................................... 710
65. Iritis ........................................................................................ 711
66. Kwashiorkor ........................................................................ 711
67. Major Depressive Episode ................................................ 711
68. Manic Episode ..................................................................... 712
69. Marasmus ............................................................................. 712
70. Measles ................................................................................. 713
71. Melancholic .......................................................................... 713
72. Menopause ........................................................................... 713
73. Mitral Incompetence .......................................................... 714
74. Mumps .................................................................................. 714
75. Myocardial Infarction ........................................................ 715
76. Nephrotic Syndrome .......................................................... 715
77. Opioid Withdrawal ............................................................. 715
78. Oppositional Defiant Disorder ........................................ 716
79. Osteoarthritis ....................................................................... 716
80. Paranoid Disorder ............................................................... 716
81. Panic Disorder ..................................................................... 717
82. Parkinsonism ....................................................................... 717
83. Patent Ductus Arteriosus ................................................... 717
xl Differential Diagnosis

84. Pericardial Effusion ............................................................ 718

85. Peripheral Neuritis ............................................................. 718
86. Petit Mal Epilepsy .............................................................. 719
87. Pleural Effusion ................................................................... 719
88. Pneumonia ........................................................................... 719
89. Pneumothorax ...................................................................... 720
90. Portal Cirrhosis .................................................................... 720
91. Pregnancy ............................................................................. 720
92. Psoriasis ................................................................................ 721
93. Psychosis ............................................................................... 721
94. Pyloric Obstruction ............................................................ 721
95. Rheumatic Fever ................................................................. 722
96. Rheumatoid Arthritis ......................................................... 722
97. Rickets ................................................................................... 723
98. Ringworm ............................................................................. 724
99. Scabies ................................................................................... 724
100. Schizophrenia ...................................................................... 724
101. Scurvy .................................................................................... 725
102. Subarachnoid Haemorrhage ............................................. 726
103. Tetany .................................................................................... 726
104. Trigeminal Neuralgia ......................................................... 727
105. Tubal Pregnancy .................................................................. 727
106. Tuberculosis ......................................................................... 728
107. Tuberculous Meningitis ..................................................... 728
108. Typhoid Fever ...................................................................... 729
109. Ulcerative Colitis ................................................................ 729
110. Ventricular Septal Defect .................................................. 730
111. Whooping Cough ................................................................ 730

Section-5

STAGING OF DISEASES
Grading and Staging ..................................................................... 732
Grading of Symptoms .................................................................. 732
• Dyspnoea .................................................................................... 732
• Exertional Dyspnoea ................................................................ 733
Grading of Signs ............................................................................ 734
 Contents xli
• Clubbing ..................................................................................... 734
• Heart Sound ............................................................................... 734
• Hill's Sign ................................................................................... 734
• Joint Tenderness ........................................................................ 734
• Level of Consciousness ............................................................ 736
• Murmur ....................................................................................... 737
• Muscle Power ............................................................................. 737
• Nystagmus .................................................................................. 738
• Parasternal Heave ..................................................................... 738
• Plantar Response ....................................................................... 738
• Splenomegaly ............................................................................ 738
• Tendon Reflexes ........................................................................ 739
Grading of Diseases ...................................................................... 739
• Acne Vulgaris ............................................................................. 739
• Acute Mountain Sickness ........................................................ 741
• Acute Pancreatitis ...................................................................... 742
• Alcohol Intoxication ................................................................. 742
• Anaemia ...................................................................................... 743
• Aplastic Anaemia ...................................................................... 743
• Angina Pectoris .......................................................................... 743
• Adult Respiratory Distress Syndrome .................................. 744
• Asphyxia ..................................................................................... 744
• Barbiturate Poisoning .............................................................. 745
• Breast Cancer .............................................................................. 745
• Bronchial Asthma ...................................................................... 745
• Bronchogenic Carcinoma ......................................................... 746
• Carcinoma Cervix ...................................................................... 748
• Chronic Bronchitis .................................................................... 749
• Chronic Cor Pulmonale ........................................................... 750
• Circulatory Decompensation in Cirrhotic Ascites .............. 750
• Factor 8-Coagulant Acitivity ................................................... 750
• Dengue Fever ............................................................................. 751
• Diabetes ...................................................................................... 752
• Endometrial Carcinoma ........................................................... 755
• Ethylene Glycol Poisoning ...................................................... 755
• Grading of Glutethimide Intoxication ................................. 755
• Grading of Open Fracture ....................................................... 756
• Haemolysis According to Life-span of RBCs ...................... 757
xlii Differential Diagnosis

• Heart Failure .............................................................................. 757

• Hepatic Encephalopathy .......................................................... 758
• Hodgkin's Lymphoma .............................................................. 759
Modified Ann Arbor Staging (As 1971 staging with the
addition of stage 3-1 and 3-2) .................................................... 759
• Hyperbilirubinaemia (Unconjugated) .................................. 760
• Hypoglycemia ............................................................................ 760
• Hypertension ............................................................................. 760
• Intelligence and Mental Retardation .................................... 763
• Intracranial Tension (Raised) .................................................. 764
• Jaundice ....................................................................................... 764
• Lathyrism .................................................................................... 764
• Chronic Lymphatic Leukaemia .............................................. 766
• Malnutrition ............................................................................... 767
• Multiple Myeloma .................................................................... 770
• Myasthenia Gravis .................................................................... 771
• Myocardial Infraction .............................................................. 772
Recovery after Nerve Injury ........................................................ 773
• Motor Recovery ......................................................................... 773
• Sensory Recovery (Precedes Motor Recovery) .................... 773
Nutrition Deficiency Syndrome ................................................. 773
Parkinsonism .................................................................................. 774
Patent Ductus Arteriosus ............................................................. 774
Plexogenic Pulmonary Arteriopathy ......................................... 774
Proteinuria ...................................................................................... 775
Pulmonary Hypertension ............................................................. 775
Pulmonary Stenosis ...................................................................... 776
a. Pulmonary Tuberculosis ........................................................ 777
b. Radiological Classification of Pulmonary
Tuberculosis ............................................................................ 778
Rabies ............................................................................................... 778
Rheumatic Carditis ........................................................................ 779
Rheumatoid Arthritis .................................................................... 779
Sarcoidosis ...................................................................................... 781
• Radiologic Staging .................................................................... 781
Sickle Retinopathy (Proliferative) ............................................. 781
Shock ................................................................................................ 782
SLE .................................................................................................... 782
 Contents xliii
Subarachnoid Haemorrhage ....................................................... 783
Syphilis ............................................................................................ 784
Tubercular Meningitis .................................................................. 784
Tetanus ............................................................................................. 785
Tuberculin Test ............................................................................... 786
Ventricular Premature Beats ........................................................ 786
Thyrotoxicosis (Wayne's Clinical Diagnostic Index) .............. 787
Ulcerative Colitis ........................................................................... 788
Ventricular Septal Defect ............................................................. 789
Yaws .................................................................................................. 790
Yellow Fever ................................................................................... 790
Severity of Psychological Stressors Scale—Adults ................ 791
Severity of Psychosocial Stressors Scale—Children and
Adolescents ................................................................................... 791

Section-6

SYNONYMS

Section-7

SYNDROMES
1. Achard Syndrome ............................................................... 804
2. Aortic Arch Syndrome ....................................................... 804
3. Arnold Chiari Syndrome ................................................... 804
4. Black Pleural Signs ............................................................. 804
5. Blind Loop Syndrome ........................................................ 804
6. Bantis Syndrome ................................................................. 805
7. Behcet’s Syndrome .............................................................. 805
8. Bernheim’s Syndrome ........................................................ 805
9. Bourneville Pringle Syndrome ........................................ 805
10. Burler-Albright Syndrome ................................................ 806
11. Caison Syndrome ................................................................ 806
12. Caplan Syndrome ............................................................... 806
xliv Differential Diagnosis

13. Carpenter Syndrome .......................................................... 806

14. Cervical Rib Syndrome ...................................................... 807
15. Cockyne Syndrome ............................................................ 807
16. Coffin Lowry Syndrome .................................................... 807
17. Conn’s Syndrome ................................................................ 807
18. Cushing’s Syndrome .......................................................... 808
19. Down’s Syndrome .............................................................. 808
20. Dumping Syndrome ........................................................... 808
21. Ebstein’s Syndrome ............................................................ 808
22. Eisenmenger Syndrome ..................................................... 809
23. Empty-Sella Syndrome ...................................................... 809
24. External Carotid Steal Syndrome .................................... 810
25. Fanconi’s Syndrome ........................................................... 810
26. Gardner’s Syndrome .......................................................... 810
27. Gaucher’s Syndrome .......................................................... 810
28. Hand and Foot Syndrome ................................................. 810
29. Hand-Schuller-Christian Syndrome ............................... 811
30. Herrmann Syndrome ......................................................... 811
31. Horner’s Syndrome ............................................................ 811
32. Hunter Syndrome ............................................................... 811
33. Hurler Syndrome ................................................................ 812
34. Hutchinson-Golford Syndrome ....................................... 812
35. Irritable Colon Syndrome ................................................. 812
36. Irritable Hip Syndrome ..................................................... 813
37. Jaccoud Syndrome .............................................................. 813
38. Kimmelsteil-Wilson Syndrome ....................................... 813
39. Klippel-Feil Syndrome ...................................................... 814
40. Larsen Syndrome ................................................................ 814
41. Laurence Moon-Biedl Syndrome ..................................... 814
42. Letterer-Siwe Syndrome .................................................... 814
43. Löffler’s Syndrome ............................................................. 815
44. Macleod Syndrome ............................................................. 815
45. Marfan’s Syndrome ............................................................ 815
46. Mikulicz’s Syndrome ......................................................... 816
47. Morgagni Syndrome .......................................................... 816
48. Morquios Syndrome .......................................................... 816
49. Nail-Patella Syndrome ....................................................... 816
50. Niemann-Pick Syndrome .................................................. 817
 Contents xlv
51. Paget’s Syndrome ................................................................ 817
52. Pancoast Syndrome ............................................................ 817
53. Pink Fallot’s Syndr ome ..................................................... 818
54. Simmond’s Syndrome ........................................................ 818
55. Simmond’s Syndrome ........................................................ 818
56. Sturge-Weber Syndrome ................................................... 819
57. Subclavian Steal Syndrome .............................................. 819
58. Trisomy-8 Syndrome .......................................................... 819
59. Turcot Syndrome ................................................................. 819
60. Turner’s Syndrome ............................................................. 820
61. Ullrich-Turner Syndrome .................................................. 820
62. `W’ Syndrome ...................................................................... 820
63. Wegener’s Syndrome .......................................................... 820
64. XXY Syndrome .................................................................... 821
65. Yellow Nail Syndrome ....................................................... 821

Section-8

INVESTIGATIONS

1. Blood Values ........................................................................ 822

• Serum Phosphorus ......................................................... 822
• Serum Triglyceride ......................................................... 822
• Serum Bilirubin .............................................................. 822
• Serum Calcium ................................................................ 823
• Serum Chloride ............................................................... 823
• Serum Cholesterol .......................................................... 823
• Serum Albumin .............................................................. 823
• Serum Globulin .............................................................. 824
• Nitrogen Compound ...................................................... 824
• Blood Urea ....................................................................... 824
• Blood Uric Acid ............................................................... 824
• Serum Alkaline Phosphatase ....................................... 825
• Serum Amylase ............................................................... 825
• Serum Iron ....................................................................... 825
• Serum Fibrinogen ........................................................... 825
• Oestrogens ....................................................................... 826
• Fasting Blood Sugar ....................................................... 826
xlvi Differential Diagnosis

• SGPT ................................................................................. 826

• SGOT ................................................................................ 826
• Lactic Acid Dehydrogenase (LDH) ............................. 827
• HDL Cholesterol ............................................................. 827
• Thyroxine Total T4 .......................................................... 827
• Triiodothyronine (T3) ..................................................... 827
• Carotene (Vit. A Retinol) ............................................... 827
• Lipase ................................................................................ 827
• Leukocytosis .................................................................... 827
• Eosinophilia ..................................................................... 828
• Lymphocytes .................................................................... 828
• Bleeding Time ................................................................. 828
• Prothrombin Time .......................................................... 829
• Platelet Count .................................................................. 829
• MCV .................................................................................. 829
• MCHC ............................................................................... 829
2. Urine Analysis ..................................................................... 829
3. Stool ....................................................................................... 834
4. Drugs ..................................................................................... 835
5. Common X-ray Findings of Chest
Diseases ................................................................................ 838
• Chronic Bronchitis ......................................................... 838
• Bronchiectasis .................................................................. 838
• Primary Childhood Type of Tuberculosis ................. 839
• Chronic Pulmonary Tuberculosis ................................ 839
• Miliary Tuberculosis ...................................................... 839
• Emphysema ..................................................................... 840
• Primary Pneumonia ....................................................... 840
• Lung Abscess ................................................................... 840
• Pleural Effusion .............................................................. 840
• Pneumothorax ................................................................. 841
• Pulmonary Oedema ....................................................... 841
• Hodgkin's Disease .......................................................... 841
• Metastasis ......................................................................... 841
• Causes of Unilateral Hilar Enlargement .................... 842
• Bilateral Hilar Enlargement ......................................... 842
• Shifting of Mediastinum Towards Opposite Side ... 842
• Shifting of Mediastinum Towards Same Side ......... 842
 Contents xlvii
• Unilateral Elevation of Diaphragm ............................ 843
• Accentuated Interstitial Markings in Lungs ............. 843
• Honeycomb Lung ........................................................... 843
• Pulmonary Oedema—Bilateral .................................... 843
• Unilateral Pulmonary Oedema .................................... 844
• 0.5 to 2 mm Multiple Opacities ................................... 844
• Solitary Pulmonary Nodule ......................................... 844
• Homogeneous Opacity of One Lung .......................... 844
6. Chest ...................................................................................... 845
• Solitary Pleural Mass ..................................................... 845
• Pleural Based Parenchymal Nodules ......................... 845
• Multiple Pleural Densities Each Greater 2 mm ....... 845
• Pleural Effusion .............................................................. 845
• Pleural Effusion Large Cardiac Silhouette ................ 845
• Pleural Effuson with Subsegmental Atelectasis ...... 845
• Pleural Effusion with Hilar Enlargement .................. 846
• Pleural Effusion with Lobar Densities ....................... 846
• Pleural Thickening ......................................................... 846
• Pleural Calcification ...................................................... 846
• Elevated Diaphragm ...................................................... 846
• Shift of Mediastinum .................................................... 846
• Anterior Mediastinal Mass ........................................... 847
• Right Cardiophrenic Angle Mass ................................ 847
• Middle Mediastinal Mass ............................................. 847
• Hilar Masses .................................................................... 848
• Unilateral Hilar Adenopathy ....................................... 848
• Bilateral Hilar Adenopathy .......................................... 848
• Posterior Mediastinal Mass .......................................... 848
7. Atelectasis ............................................................................. 849
• Large Airway Obstruction ............................................ 849
• Small Airway Obstruction ............................................ 849
• Compressive Atelectasis ............................................... 849
• Passive Atelectasis .......................................................... 849
• Adhesive Atelectasis ...................................................... 849
• Cicatrization Atelectasis ................................................ 849
• Segmental and Lobal Densities ................................... 849
• Lobar Expansion ............................................................. 850
• Diffuse Coalescing Densities ....................................... 850
xlviii Differential Diagnosis

• Non-Cardiac Pulmonary Oedema ............................... 850

• Diffuse Fine Reticular Densities ................................. 851
• Fine Reticualr Pattern and Pleural Effusion ............. 851
• Fine Reticular Pattern and Hilar Adenopathy .......... 851
• Coarse Reticular Densities ........................................... 852
• Diffuse Fine Nodular Disease ..................................... 852
• Diffuse Fine Nodular Pattern in Afebrile Patient ... 852
• Diffuse Fine Nodular Pattern in Case of Fever ........ 852
• Multifocal Ill-defined Densities ................................. 853
• Multiple Nodular Masses with Sharp Borders ........ 853
• Solitary Nodules ............................................................. 853
• Hypertranslucent Lungs ................................................ 854
• Solitary Lucent Defect ................................................... 854
• Multiple Lucent Lesions ............................................... 854
• Cavitating Nodule .......................................................... 854
• Ill-defined Densities with Holes ................................. 855
8. X-ray Features of Arthritis ................................................. 855
• Osteoarthritis ................................................................... 855
• Pyogenic Arthritis .......................................................... 855
• Tuberculous Arthritis ..................................................... 856
• Rheumatoid Arthritis .................................................... 856
• Rheumatoid Arthritis in Children
(Still's Disease) ................................................................ 856
• Gout ................................................................................... 857
• Psoriatic Arthritis ........................................................... 857
9. Intravenous Pyelography .................................................. 857
10. Causes of Urinary Tract ...................................................... 865
11. Kidney ................................................................................... 868
12. Barium Meal Studies .......................................................... 869
13. Gastrointestinal Tract ......................................................... 878
14. Practical Applications of ECG .......................................... 882
• Chamber Enlargement ................................................... 882
• Myocardial Ischaemia (Angina Pectoris) ................... 882
• Myocardial Infarction .................................................... 885
• Arrhythmias ..................................................................... 887
• Heart Block ...................................................................... 896
• Bundle Branch Block ..................................................... 898
• Drugs ................................................................................. 899
 Contents xlix
• Electrolytes ....................................................................... 902
• Miscellaneous Conditions ............................................ 906
15. Treadmill Test in Coronary Artery Disease ................... 907
• Depression of the ST Sagment:
Subendocardial Injury .................................................. 913
• Postmyocardial Infarction
Treadmill Exercise Test ................................................. 917

Index ....................................................................................... 919