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POCKET NB

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DICINE Ffh on

by ARC s. SABANE, D, P OCAE PROFEOR OF ECNE ARVAR ECA SCOO Edited

Th Mh G H  Hd  I Md11 ®Wolter Kuwer Lppincott ilam & kn Health

Phadephia Batimore New Yok· London Buenos Aies Hong Kong· Sydney Tokyo •

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 All rights reserved. T his book is protected by copyright. No part of this book may be reproduced in any form by any means, including photocopying, or utilized by any informaon s and tril sem without writn permission fm the coright owne except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their oicial duties as U.S.  government employees are not covered by the above-mentioned copyright. Printed in China Not authorised for sale in United States, Canada, Australia, New Zealand, Puerto Rico, and United States Virgin slands. Library of Congress Catalogig-in-Pubication Data

Pocket medicine (Sabatine) Pocket medicine I [edited by] Marc S. Sabatine. Fih edition. p.;cm. Preceded by Pocket medicine I edited by Marc S. Sabatine. 4th ed. c2011. Includes bibliographical references and index. ISBN3: 97845182378 ISBN0: 4518237-6 ISBN3: 97845188875 ISBN0: 45188870 I. Sabatine, Marc S., editor of compilation. I. Title. [DNLM: . Internal MedicineHandbooks. 2. Clinical MedicinHandbooks. WB 39] RC55 616dc23 201309655 DISCLAIMER Care has been taken to confirm the accuracy of the information pre

sented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied,  with respect to the currency, completeness, or accuracy of the contents of the publica  tion. Application of the information in a particular situation remains the professional responsibility of the practitione he authors, editors, and pulisher have exerted every eort to ensure that rug selection and dosage set forth in this te are in accordance with current recommendations and practice at the time of publication. owever, in view of ongoing research, changes in  government regulations, and the consnt ow of information relating to drug therapy and drug reactions, the reader is urged to check the pacage insert for each drug for any change in indications and dosage and for added warnings and precautions. his is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in the publication have Food and Drug  Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice. To purchase additional copies of this book, call our customer service department at (800) 6383030 or fax orders to (301) 2232320. International customers should call (301) 2232300. Visit ippincott Williams &  Wilkins on the Internet: at Wcom. ippincott Williams &  Wilkins customer service representatives are available from 8:30 am to 6 pm, EST. 10 9 8 7 6 5 4 3 2 

Contributig Authrs Frewrd Prefac

VI  IX 

CARDIOLOGY

Nel A. htterjee, Ad Stefesu, Willim}. Huker, Dvid M. Dudziski, Mr S. Sbtie, Mihelle O'Dghue Electrocardiography Cest Pan Noivasve Evaluaton of CAD Coroary Angography and Revascularzaton  Acute Coroary Syndromes PA Cateter and Taiored Terapy Heart Faure Cardomyopathies Valvuar Heart Dsease Percardia! Dsease Hypertension  Aortc Aeurysms  Acute Aortic Sydromes  Arrytmas  Atria Fbrllaton Sycope ntracardac Devces Cardac Rsk Assessmet for Noncardac Surgery Perperal Artery Dsease

1-1 1-3 1-4 1-5 1-6 1-12 1-14 1-17 1-20 1-25 1-28 1-30 1-31 1-32 1-35 1-37 1-39 1-40 1-41

PULMONARY

 J. Brbsh, Kthry A. Hibbert, Atul Mlhtr Dyspnea Pumoary Fucton ests  Asthma  Aaphyaxs Cronc Obstructve Pumoary Dsease Hemoptyss Brochiectasis Sotary Pulmoary Nodule Obstuctive Seep Apnea Interstita Lug Dsease Peura Euso Veous Tromboemboism Pumoary Hypertesion Respiratory alure Mechaical Ventilation  Acute Respratory Dstress Sydrome Sepss

2-1

2-1 2-2 2-4 2-5 2-7 2-7

2-8 2-8 2-9

2-11 2-13 2-16 2-18 2-19 2-22 2-23

GASTROENTEROLOGY

Zhry A. Zt Adrew S. de Lems, Lwree S. Friedm Esophagea ad Gastric Disorders Gastroitesta Bleedig Darrea, Costpato and Ieus Dvertcuar Dsease Inflammatory Bowel Dsease Intestnal scemia

3-1 3-3 3-5 3-9 3-10 3-12

Pancreatitis  Abnomal Lve Tests Hepatitis  Acute Lve Falue Crhoss Hepatic Vascla Dsease  Ascites Biiay Tract Disease

3-13 3-15 3-17 3-20 3-21 3-25 3-26 3-27

NEPHROOGY

 AndrewS. Alegrei, Andrew L Lundquist Hasan Bazari  Acd-Base Dstubances Sodium and Wate Homeostasis Potassum Homeostasis Rea aiue Gomeuar Disease Uraysis Nephrolthass

4-1 46 4-10 4-12 4-16 4-18 4-19

HEMATOOG�ONCOOGY

 Andrew M. Brunner, Shehear K Kabraji, Mark M. Awad, Andrew J. Aguirre, Daniel J DeAngelo, David P. Ryan  Anema Dsodes of Hemostass Patelet Disorders Coagopates Hypercoaguabe States Dsodes of Leukoces Trasfson T herapy Myelodysplastic Syndomes Myelopoiferatve Neopasms ekemia ympoma Pasma Cel Dyscrasias Hematopoetc Stem Cel Tansplantaton ung Cance Beast Cance Postate Cance Colorecta Cancer Chemotherapy Side Eects Pancreatic Tumors Ocologic Emegences Cancer of Uknown Pimary Site

51 5-6 5-7 5-10 5-11 5-12 5-13 5-14 5-15 5-17 5-21 5-24 5-26 528 5-30 532 5-33 534 5-35 536 5-37

INFECIOUS DSEASES

 Ana A Wei/, Emily  Hyle, Nesli Basgoz Peumoia Funga Infectons Infectons in Immunosuppressed Hosts Uay Tact Inectons So T issue and Bone Inectons Inectons of te Nevos System Bacteal Endocadtis Tbecuoss HIV/AIDS TckBone Diseases Feve Syndomes

6-1 6-3 6-4

65 6-6 6-9

6-12 615 6-17 620 6-22

ENDOCRINOLOGY

Kelly B. Lauter, Marc ituitary Disorders Thyod Disorders Adrenal Disorders Calcium Dsorders Diabetes Melitus pid Dsorders

N.

Wein, Michael Mannstadt

7-1 73 7-7 71 7-13 7-16

RHEUMTOLOGY

Zacha S Walace, E Miloslavsky, Robe P. Friday ArthtsOvervew Rheumatoid Artrtis Adut Onset Stil's Disease & Relapsng olychondrts Crystal Depostion Arthritides Seroegatve Spondyoarthritis Infectous Arthritis & Bursitis Coectve Tissue Diseases Systemc Lupus Erhematosus Vascuitis lgG4-Related Disease Cyogobuliema Amyodosis

81 83 84 85 87 89 81 8-15 817 8-20 821 822

NEUROLOGY

Michael P Bowley, Todd M. Herrington, Eyal Tracey A Cho Chage n Mental Status Sezures Alcohol Wthdrawa Stroke Weakness & Neuromuscular Dysfuction Headache Back and Spna Cord Disease

Y

Kimchi, Sarah Wahlster,

91 93 9-5

9-6 98 9-10 91

 CONS ULTS

Kirn H Lagiset, Jennifer F Tseng, Katherine T Chen, Stela K Kim Surgcal Issues Ob/Gy Issues Opthamic Issues

0-1 103 104

  EDIX

ICU Medcatos & Treatmet of Hypotenso/Shock Antibotcs Formuae and Quick Reference  BBREVTONS INDEX

11 13 1-4 12- -

HOTO INSER TS

Radology Echocardiography & Coronary Agography ephera Blood Smears & eukemas Uralysis  C LS

1 -9 13 P15 ACLS

 Andrew J. Aguirre, MD, PhD Hematology-Oncoogy Feow, Daa-Farber/Parters CancerCare ematology/Ocoogy Program  AndrewS. Aegrett, MD Iterna Medicie Resident, Massachusetts Geeral ospta Mark M.Awad, MD, PhD Hematology-Oncoogy Feow, Daa-Farber/Parters CancerCare ematology/Ocoogy Program lan J. Barbash, MD Iterna Medicie Resident, Massachusetts Geeral ospta Nesi Basgoz, MD Associate Cief ad Cliica Director, nfectious Dsease Dvision, Massacusetts General osptal Associate Professor of Medcie, Harvard Medca Scoo Hasan Bazari, MD Cliical Director, Neproogy Uit, Massacusetts Geera Hospta Program Drector, nternal edicie Resdecy, assacusetts Genera ospta Associate Professor of Medcie, Harvard Medca Scoo Mchae P Bowey, MD, PhD Neurology Resdent, Partners Neuroogy Residecy  Andrew M Brunner, MD Iterna Medicie Resident, Massachusetts Geeral ospta Nea A. Chatterjee, MD Iterna Medicie Resident, Massachusetts Geeral ospta Katherine T. Chen, MD, MPH Assocate Professor of Obstetrics, Gyecoogy, and Reproductve Sciece Associate Professor of edca Education Vce-Char of Ob/Gyn Educatio, Career Development, and entorsp ca School of Medicne at Mount Sna, New York Tracey A. Cho, MD Associate Program Director, Parters-arvard Neurology Resdency Assstant Professor of eurology, Harvard Medca Schoo Assstant Neuroogist, Massachusetts General ospita  AndrewS. de Lemos, MD Transplant Hepatology ellow, Massachusetts Genera ospta Danie J. DeAngeo, MD, PhD Adult Leukema Program, Daa-Farber Cacer nstitute & Brigam ad Women's Hospital Associate Professor of edcie, Harvard Medca Scoo

David M. Dudzinski, MD, JD Cardiology Fellow, Massachusetts General Hospital Robert P Friday, MD, PhD Attending Physician, Rheumatology Unit, assachusetts General ospital Associate Director, Rheumatology Fellowship Program, Massachusetts General ospital Instructor in edicine, Harvard edical School Lawrence S. Friedman, MD Anton R. Fried, MD, Chair, Department of Medicine, Neon-Wellesley ospital Assistant Chief of Medicine, assachusetts General Hospital Professor of Medicine, arvard Medical School Professor of Medicine, Tus University School of Medicine Todd M. Herrington, MD, PhD Neurology Resident, Partners Nerology Residency Kathry n A. Hibbert, MD Plmonary and Critical Care Fellow, arvard Medical School William J. Hucker, MD, PhD Cardiology Fellow, Massachusetts General Hospital Emily P Hyle, MD Assistant in Medicine, Infectios Disease Division, assachsetts General ospital Instructor in edicine, Harvard edical School Sheheryar K. Kabraji, BM, BCh Internal edicine Resident, assachusets General Hospital Stella K. Kim, MD Director, Clinical Research in Opthalmology Director, Opthalmology Residency Rotation Program Associate Professor of Opthalmology UT MD Anderson Cancer Center EyaY Kimchi, MD, PhD Neurology Resident, artners Nerology Residency Kiran H. Lagisetty, MD Surgical Resident, Beth srael Deaconess Medical Center Kelly B. Lauter, MD, PhD Internal edicine Resident, assachusets General Hospital Andrew L. Lundquist, MD Nephrology ellow, BWH/MGH Joint Nephrology Fellowship Program Atul Mahotra, MD Associate Physician, Divisions of Pulmonary & Critical Care and Sleep Medicine, Brigham and Women's ospital Associate Professor of edicine, Harvard edical School

Michael Mannstadt, MD Attending Physician, Endocrine Unit, Massachusetts General Hospital Assistant Professor of Medicine, Harvard edical School El Milosavsky, MD Rheumatology Fellow, Massachusetts General Hospital Michelle O'Donoghue, MD, MPH Investigator, TM  Study Group and Associate Physician, Cardiovascular Division, Brigham and Women's ospital Aliate Physician, Cardiology Division, assachsetts General ospital Assistant Professor of Medicine, Harvard edical School David P Ryan, MD Clinical Director, Massachusetts General Hospital Cancer Center Chief of ematology/Oncology, assachusetts General Hospital Associate Professor of edicine, arvard Medical School Marc S. Sabatine, MD, MPH Chairman, IMI Stdy Group and Physician, Cardiovascular Division, Brigham and Women's Hospital Aliate Physician, Cardiology Division, assachusetts General ospital Associate Professor of edicine, arvard Medical School Ada Stefanescu, MD, C M Internal Medicine Resident, Massachusetts General Hospital Jennifer F. Tseng, MD, MPH Chief, Division of Surgical Oncology, Beth Israel Deaconess Medical Center Associate Professor of Surgery, Harvard edical School Sar ah Wahster, MD Neurology Resident, Partners Neurology Residency Zachary S.Wallace, MD Internal Medicine Resident, Massachusetts General Hospital AnaA.Wei, MD, MPH Internal Medicine Resident, Massachusetts General Hospital Ma Nein MD PhD Endocrinology Fellow, Massachusets General Hospital Zachary A. Zator, MD Internal Medicine Resident, Massachusetts General Hospital

To the 1st dition

It is with the greatest enthusiasm that I introduce Pocket edicine In an era of information glut, it will logically be asked, "Why another manual for medical house officers? Yet, despite enormous information readily available in any number of  textbooks, or at the push of a key on a computer, it is oen that the harried house officer is less helped by the description of dierential diagnosis and therapies than one would wish. Pocket edicine is the joint venture between house staff and faculty expert in a number of medical specialties. This collaboration is designed to provide a rapid but thoughtful initial approach to medical problems seen by house oicers with great frequency. Questions that frequently come from faculty to the house staff on rounds, many hours aer the initial interaction between patient and doctor, have been anticipated and important pathways for arriving at diagnoses and initiating  therapies are presented. This approach will facilitate the evidence-based medicine discussion that will follow the workup of the patient. his well-conceived hand book should enhance the ability of every medical house officer to properly evalu ate a patient in a timely fashion and to be stimulated to think of the evidence supporting the diagnosis and the likely outcome of therapeutic intervention. Pocket edicine  will prove to be a worthy addition to medical education and to the care of our patients. DENNIS A.AUSIELO, MD

Physician-in-Chie Massachusetts Genel Hospital Jackson Professor of Clinical Medicine, Harvard Medical School

To my parents, Matt and Lee Sabatine, to their namesake gndchildren Matteo and Natalie, and to my wife jennifer Written by residents, fellows and attendings, the mandate for Pocket Medicine  was to provide, in a concise a manner as possible, the key information a clini cian needs for the initial approach to and management of the most common inpatient medical problems. The tremedous respose to the prevous editions suggests we were abe  to help fi a important eed for cicas. Wth this fifth edtion come severa major mprovements icludg a thorough updatig of every topic, the addton of severa new topics (ncuding treatmet of aaphylaxis, approach to inpatient nutritional issues, chemotherapy side effects, and workup of a fever in a recent  traveler), and ncusion of addtioal photomcrographs. We have also added a new section on Consults in which non-internal medicine specialists provide expert guidance in terms of establishing a differential diagnosis for common presenting symptoms and initiating an evaluation in anticipation of calling a consult. As aways, we have icopoated key efeeces to the most recent high-tier reviews and importat studies publshed right up to the time Pocket Medicine  wet to press. We welcome ay suggestios for further mprovement. Of course medce s far too vast a fied to ever summarize in a textbook of ay sze. Long moographs have bee devoted to many of the topcs discussed heren. Pocket Medicine s meat ony as a starting point to gude one durng the ital phases of diagoss ad management uti one has time to cosut more definitve resources. Although the recommedatos herei are as evdence-based as possibe, medce s both a science ad an a. As aways, soud clca judge met must be applied to every sceario. I am gateful for te suppot of te house offces, felows, and attendgs at  the Massachusetts Genera Hospital. It is a priviege to work with such a know edgeabe, dedcated, and compassonate group of physcians. I always look back o my time there as Chef Residet as oe of the best expereces I have ever had. I am grateful to several outstandg cica mentors, ncuding Hasa Bazari, Larry Friedma, Nesl Basgoz, Mort Swartz, Erc sselbacher, Bill Dec, Mke Fifer, ad Roman DeSancts, as wel as the ate Charle McCabe ad Peter Yurchak. This edito woud ot have been possbe without the hep of two idivduals i the IM I Study Group Chairman's Oce. Meida Cuerda, my academc coordia  to was a ivaluabe resource for this edtio. She shepherded every aspect of the project from start to sh, wth a ncredibe eye to detai to esure that each page of this book was the very best t could be. Pamela Melhorn, my executve assstant, expertly manages the Charma's Oce, miracuously coordinatng the compex clnical, research, and educatona mssons. Lastly, specal thaks to my parents for their perpetual encouragement ad love and, of course, to my wfe, Jenifer Tseng, who, despite beig a surgeon, s my cosest advso my best fred and the love of my fe. I hope that you find Pocket Medicine usefu throughout the arduous but icedby ewardig jouney of pacticig medicine. M S. S, MD, MPH

 Approach a systematic apprach is vital Rate (? tachy, brady) and rhythm (? relationship between P and QRS) Intervals (P R,QRS,QT) and axis (? LAD or RAD) Chamber abnormality (? L and/or RA ? LVH and/or RVH) QRST changes? Q waves,poor R -wave progresson V6,ST H or T-wave �s) Figure - QRS axs Left axis deviation (LAD) Denition: axis beyond -0° (S > R n ead II) Etiologies: VH, BBB, nferor M, WW Left anterior fascicular block: LAD -  to -90° ) and qR in aVL and QRS <20 msec and • • • •

aVR -150°

aVL -30°

• • •

no other cause of AD (eg,IMI)

Right axis deviation (RAD) Denition: axis beyond +90° (S > R in lead I) Etiologies: RVH,PE,COPD (usualy not > +0° )  • •

septal defects,atera MI,WW

aVF

m

RBBB

v

et posterior ascicular block: D 9080° ) and rS n I & aVL and qR n I & aVF and QRS <20 msec and no other cause of RAD

•

Bunl Bnh Blk (Cc :e) l .   rs s   v,    ; ,s  ) ll      l,    , l. r  sl  ).   � c ( cl)  r'   rcrl  ,2) 3          ±     I   rcl s   � c ( cl)  r,l,sc   , , (±      c) 3  s    ,     r    )        jr   5 ±  , '  r s



v

V6

=

-

=

LBBB

vf

Bfasccla block: BBB + LAB/LPB

Prolonged QT interval NEJM  wtsdsg • •

•

•

QT easured fro begnnng of RS colex o end of  ave measure longes T)  vres /  crrec / ze rul: c / (n sec), forul ccure  ery  d lo  (l c 0 sec o d 60 sec C) Q proongation a/w  risk d (esp. >00 msec); perform basene/serial CGs if usng QT prolonging meds,no estab gudelnes for stoppng  f QT proongs Etioogies: Anhyh cass Ia (rcanade,dsyrade),class I (adarone,staol) Psych drugs: antpsychotics (phenothaines,haoperdol,atypicals), i,? SSRI,TCA  Antimicroals: macroldes,unolones,azoles,enadne, aovauone,aazanavr Other: antemetcs (droerdol, H3 antagonsts),alfuzosn,metadone,ranolazne Electrolyte disturbances: hypoCa (nb, hyperCa a/w  QT),? hypoK,? hypoMg Aunm yfn  (dee I),sroke,crod edrerecoy, ec dssecon Congenital (long QT syndrome): K,Na,Ca channelopathies ( 7 Mis: CAD,CM bradycarda, hghgrade AVB, hypothyroidsm,hypothermia,BBB =

��

>120 msec

>4�sec

Left Atrial Abnormality (LAA)

ave . . 11 Cr•ter•a

 r

J 2.:m i I>1.5

Right Atrial Abnormality (RAA)

I >1mm

II

1 r V  1

Left ventricular hypertrophy (LVH) (c  • •

toogies: HTN,AS/AI,HCM coarctation of aorta Crtera (al w/ Se <0% Sp >8%; accuracy aected by age,sex,race,BMI) RomhitEstes pointscore system: 4 ponts probable, points definte i  lu   e ll): ls  r   lb leds 0       2 �0 mm R n Y or V6 �0 mm  ponts) ST dsplacement opposte to QRS deflecton: w/o dig  points); w/ dig  point) L   ponts); AD 2 points); QRS duraton �90 msec  pont) =

=

or