POCKET •

NOTEBOOK

Po DICINE

Fifth Edition

Edited by MARC s. SABATINE, MD, MPH ASSOCIATE PROFESSOR OF MEDICINE HARVARD MEDICAL SCHOOL

� The Massachusetts General.H_ospital

\� Handbook if Internal Med1c1ne

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Pocket medicine (Sabatine) Pocket medicine I [edited by] Marc S. Sabatine.- Fifth edition.

p.;cm. Preceded by Pocket medicine I edited by Marc S. Sabatine. 4th ed.

c2011. Includes bibliographical references and index. ISBN-13: 978-1-4511-8237-8 ISBN-1 0: 1-4511-8237-6 ISBN-13: 978-1-4511-8887-5 ISBN-1 0: 1-4511-8887-0

I. Sabatine, Marc S., editor of compilation. II. T itle. [DNLM: 1. Internal Medicine-Handbooks. 2. Clinical Medicine-Handbooks. WB 39] RC55 616-dc23

2013019655

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10 9 8 7 6 5 4 3 2 1

Contributing Authors Foreword Preface

CARDIOLOGY

Neal A. Chatterjee, Ada Stefanescu, William}. Hucker, David M. Dudzinski, Marc S. Sabatine, Michelle O'Donoghue

Electrocardiography Chest Pain Noninvasive Evaluation of C AD Coronary Angiography and Revascularization Acute Coronary Syndromes PA Catheter and Tailored Therapy Heart Failure Cardiomyopathies Valvular Heart Disease Pericardia! Disease Hypertension Aortic Aneurysms Acute Aortic Syndromes Arrhythmias Atrial Fibrillation Syncope lntracardiac Devices Cardiac Risk Assessment for Non cardiac Surgery Peripheral Artery Disease

PULMONARY

fan J. Barbash, Kathryn A. Hibbert, Atul Malhotra

Dyspnea Pulmonary Function Tests Asthma Anaphylaxis Chronic Obstructive Pulmonary Disease Hemoptysis Bronchiectasis Solitary Pulmonary Nodule Obstructive Sleep Apnea Interstitial Lung Disease Pleural Effusion Venous Thromboembolism Pulmonary Hypertension Respiratory Failure Mechanical Ventilation Acute Respiratory Distress Syndrome Sepsis

GASTROENTEROLOGY

Zachary A. Zator, Andrew S. de Lemos, Lawrence S. Friedman

Esophageal and Gastric Disorders Gastrointestinal Bleeding Diarrhea, Constipation and Ileus Diverticular Disease Inflammatory Bowel Disease Intestinal Ischemia

VI

IX

X

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

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

3-1 3-3 3-5 3-9

3-10 3-12

Pancreatitis Abnormal Liver Tests Hepatitis Acute Liver Failure Cirrhosis Hepatic Vascular Disease Ascites Biliary Tract Disease

NEPHROLOGY

AndrewS. Allegretti, Andrew L Lundquist, Hasan Bazari

Acid-Base Disturbances Sodium and Water Homeostasis Potassium Homeostasis Renal Failure Glomerular Disease Urinalysis Nephrolithiasis

HEMATOLOG�ONCOLOGY

Andrew M. Brunner, Sheheryar K. Kabraji, Mark M. Awad, Andrew J. Aguirre, Daniel J. DeAngelo, David P. Ryan

Anemia Disorders of Hemostasis Platelet Disorders Coagulopathies Hypercoagulable States Disorders of Leukocytes Transfusion T herapy Myelodysplastic Syndromes Myeloproliferative Neoplasms Leukemia Lymphoma Plasma Cell Dyscrasias Hematopoietic Stem Cell Transplantation Lung Cancer Breast Cancer Prostate Cancer Colorectal Cancer Chemotherapy Side Effects Pancreatic Tumors Oncologic Emergencies Cancer of Unknown Primary Site

INFECTIOUS DISEASES

Ana A. Wei/, Emily P. Hyle, Nesli Basgoz

Pneumonia Fungal Infections Infections in Immunosuppressed Hosts Urinary Tract Infections Soft T issue and Bone Infections Infections of the Nervous System Bacterial Endocarditis Tuberculosis HIV/AIDS T ick-Borne Diseases Fever Syndromes

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

3-27

4-1 4-6

4-10 4-12 4-16 4-18

4-19

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

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 N. Wein, Michael Mannstadt

Pituitary Disorders Thyroid Disorders Adrenal Disorders Calcium Disorders Diabetes Mellitus Lipid Disorders

RHEUMATOLOGY

Zachary S. Wallace, Eli Miloslavsky, Robert P. Friday

Arthritis-Overview Rheumatoid Arthritis Adult Onset Still's Disease & Relapsing Polychondritis Crystal Deposition Arthritides Seronegative Spondyloarthritis Infectious Arthritis & Bursitis Connective Tissue Diseases Systemic Lupus Erythematosus Vasculitis lgG4-Related Disease Cryoglobulinemia Amyloidosis

NEUROLOGY

Michael P. Bowley, Todd M. Herrington, Eyal Y. Kimchi, Sarah Wahlster, Tracey A. Cho

7-1 7-3 7-7

7-11 7-13 7-16

8-1 8-3 8-4 8-5 8-7 8-9

8-11 8-15 8-17 8-20 8-21 8-22

Change in Mental Status 9-1 Seizures 9-3 Alcohol Withdrawal 9-5 Stroke 9-6 Weakness & Neuromuscular Dysfunction 9-8 Headache 9-10 Back and Spinal Cord Disease 9-11

CONS ULTS

Kiron H. Lagisetty, Jennifer F. Tseng, Katherine T. Chen, Stella K Kim

Surgical Issues Ob/Gyn Issues Ophthalmic Issues

APPENDIX

ICU Medications & Treatment of Hypotension/Shock Antibiotics Formulae and Quick Reference

ABBREVIATIONS

INDEX

PHOTO INSER TS

Radiology Echocardiography & Coronary Angiography Peripheral Blood Smears & Leukemias Urinalysis

ACLS

10-1 10-3 10-4

11-1 11-3 11-4

12-1

1-1

P-1 P-9

P-13 P-15

ACLS-1

Andrew J. Aguirre, MD, PhD Hematology-Oncology Fellow, Dana-Farber/Partners CancerCare

Hematology/Oncology Program

Andrew S. Allegretti, MD Internal Medicine Resident, Massachusetts General Hospital

Mark M.Awad, MD, PhD Hematology-Oncology Fellow, Dana-Farber/Partners CancerCare

Hematology/Oncology Program

lan J. Barbash, MD Internal Medicine Resident, Massachusetts General Hospital

Nesli Basgoz, MD Associate Chief and Clinical Director, Infectious Disease Division,

Massachusetts General Hospital Associate Professor of Medicine, Harvard Medical School

Hasan Bazari, MD Clinical Director, Nephrology Unit, Massachusetts General Hospital Program Director, Internal Medicine Residency, Massachusetts

General Hospital Associate Professor of Medicine, Harvard Medical School

Michael P. Bowley, MD, PhD Neurology Resident, Partners Neurology Residency

Andrew M. Brunner, MD Internal Medicine Resident, Massachusetts General Hospital

Neal A. Chatterjee, MD Internal Medicine Resident, Massachusetts General Hospital

Katherine T. Chen, MD, MPH Associate Professor of Obstetrics, Gynecology, and Reproductive Science Associate Professor of Medical Education Vice-Chair of Ob/Gyn Education, Career Development, and Mentorship lcahn School of Medicine at Mount Sinai, New York

Tracey A. Cho, MD Associate Program Director, Partners-Harvard Neurology Residency Assistant Professor of Neurology, Harvard Medical School Assistant Neurologist, Massachusetts General Hospital

AndrewS. de Lemos, MD Transplant Hepatology Fellow, Massachusetts General Hospital

Daniel J. DeAngelo, MD, PhD Adult Leukemia Program, Dana-Farber Cancer Institute & Brigham

and Women's Hospital Associate Professor of Medicine, Harvard Medical School

David M. Dudzinski, MD, JD Cardiology Fellow, Massachusetts General Hospital

Robert P. Friday, MD, PhD Attending Physician, Rheumatology Unit, Massachusetts General Hospital Associate Director, Rheumatology Fellowship Program, Massachusetts

General Hospital Instructor in Medicine, Harvard Medical School

Lawrence S. Friedman, MD Anton R. Fried, MD, Chair, Department of Medicine, Newton-Wellesley

Hospital Assistant Chief of Medicine, Massachusetts General Hospital Professor of Medicine, Harvard Medical School Professor of Medicine, Tufts University School of Medicine

Todd M. Herrington, MD, PhD Neurology Resident, Partners Neurology Residency

Kathryn A. Hibbert, MD Pulmonary and Critical Care Fellow, Harvard Medical School

William J. Hucker, MD, PhD Cardiology Fellow, Massachusetts General Hospital

Emily P. Hyle, MD Assistant in Medicine, Infectious Disease Division, Massachusetts

General Hospital Instructor in Medicine, Harvard Medical School

Sheheryar K. Kabraji, BM, BCh Internal Medicine Resident, Massachusetts 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

EyaiY. Kimchi, MD, PhD Neurology Resident, Partners Neurology Residency

Kiran H. Lagisetty, MD Surgical Resident, Beth Israel Deaconess Medical Center

Kelly B. Lauter, MD, PhD Internal Medicine Resident, Massachusetts General Hospital

Andrew L. Lundquist, MD Nephrology Fellow, BW H/MGH Joint Nephrology Fellowship Program

Atul Malhotra, MD Associate Physician, Divisions of Pulmonary & Critical Care and Sleep

Medicine, Brigham and Women's Hospital Associate Professor of Medicine, Harvard Medical School

Michael Mannstadt, MD Attending Physician, Endocrine Unit, Massachusetts General Hospital Assistant Professor of Medicine, Harvard Medical School

Eli Miloslavsky, MD Rheumatology Fellow, Massachusetts General Hospital

Michelle O'Donoghue, MD, MPH Investigator, TIM I Study Group and Associate Physician, Cardiovascular

Division, Brigham and Women's Hospital Affiliate Physician, Cardiology Division, Massachusetts General Hospital Assistant Professor of Medicine, Harvard Medical School

D avid P. Ryan, MD Clinical Director, Massachusetts General Hospital Cancer Center Chief of Hematology/Oncology, Massachusetts General Hospital Associate Professor of Medicine, Harvard Medical School

Mar c S. Sabatine, MD, MPH Chairman, TIM I Study Group and Physician, Cardiovascular Division,

Brigham and Women's Hospital Affiliate Physician, Cardiology Division, Massachusetts General Hospital Associate Professor of Medicine, Harvard 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 Medical School

Sar ah Wahlster, MD Neurology Resident, Partners Neurology Residency

Zachary S. Wallace, MD Internal Medicine Resident, Massachusetts General Hospital

AnaA.Weil, MD, MPH Internal Medicine Resident, Massachusetts General Hospital

Marc N.Wein, MD, PhD Endocrinology Fellow, Massachusetts General Hospital

Zachary A. Zator, MD Internal Medicine Resident, Massachusetts General Hospital

To the 1st Edition

It is with the greatest enthusiasm that I introduce Pocket Medicine. 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 often that the harried house

officer is less helped by the description of differential diagnosis and therapies than

one would wish.

Pocket Medicine 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 officers with

great frequency. Questions that frequently come from faculty to the house staff on

rounds, many hours after 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. This 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

Medicine will prove to be a worthy addition to medical education and to the care

of our patients.

DENNIS A.AUSIELLO, MD

Physician-in-Chief, Massachusetts General Hospital Jackson Professor of Clinical Medicine, Harvard Medical School

To my parents, Matt and Lee Sabatine, to their namesake

grandchildren 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 tremendous response to the previous editions suggests we were able

to help fill an important need for clinicians. W ith this fifth edition come several

major improvements including a thorough updating of ever y topic, the addition

of several new topics (including treatment of anaphylaxis, approach to inpatient

nutritional issues, chemotherapy side effects, and workup of a fever in a recent

traveler), and inclusion of additional photomicrographs. 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 always, we have incorporated key references to the most recent

high-tier reviews and important studies published right up to the time Pocket

Medicine went to press. We welcome any suggestions for further improvement.

Of course medicine is far too vast a field to ever summarize in a textbook

of any size. Long monographs have been devoted to many of the topics discussed

herein. Pocket Medicine is meant only as a starting point to guide one during the

initial phases of diagnosis and management until one has time to consult more

definitive resources. Although the recommendations herein are as evidence-based

as possible, medicine is both a science and an art. As always, sound clinical judge­

ment must be applied to every scenario.

I am grateful for the support of the house officers, fellows, and attendings at

the Massachusetts General Hospital. It is a privilege to work with such a knowl­

edgeable, dedicated, and compassionate group of physicians. I always look back on

my time there as Chief Resident as one of the best experiences I have ever had.

I am grateful to several outstanding clinical mentors, including Hasan Bazari, Larry

Friedman, Nesli Basgoz, Mort Swartz, Eric lsselbacher, Bill Dec, Mike Fifer, and

Roman DeSanctis, as well as the late Charlie McCabe and Peter Yurchak.

This edition would not have been possible without the help of two individuals

in the TIM I Study Group Chairman's Office. Melinda Cuerda, my academic coordina­

tor, was an invaluable resource for this edition. She shepherded every aspect of the

project from start to finish, with an incredible eye to detail to ensure that each page

of this book was the very best it could be. Pamela Melhorn, my executive assistant,

expertly manages the Chairman's Office, miraculously coordinating the complex

clinical, research, and educational missions.

Lastly, special thanks to my parents for their perpetual encouragement and

love and, of course, to my wife, Jennifer Tseng, who, despite being a surgeon, is my

closest advisor, my best friend and the love of my life.

I hope that you find Pocket Medicine useful throughout the arduous but

incredibly rewarding journey of practicing medicine.

MARC S. SABATINE, MD, MPH

Approach (a systematic approach is vital) • Rate (? tachy, brady) and rhythm (? relationship between P and QRS) • Intervals (P R, QRS, QT) and axis (? LAD or RAD) • Chamber abnormality (? LAA and/or RAA, ? LVH and/or RVH) • QRST changes(? Q waves, poor R -wave progression v,-V6, ST iH or T-wave �s)

Figure 1-1 QRS axis Left axis deviation (LAD)

aVR

• Definition: axis beyond -30° (S > R in lead II) • Etiologies: LVH, LBBB, inferior Ml, WPW

-150° aVL -30° • Left anterior fascicular block: LAD (-45 to

-90°) and qR in aVL and QRS <120 msec and no other cause of LAD (eg, IMI)

Normal

RBBB

LBBB

aVF

Right axis deviation (RAD) • Definition: axis beyond +90° (S > R in lead I) • Etiologies: RVH, PE, COPD (usually not > + 11 0°),

septal defects, lateral MI,WPW • Left posterior fascicular block: RAD (90--180°)

and rS in I & aVL and qR in Ill & aVF and QRS <120 msec and no other cause of RAD

Bundle Branch Blocks (Circ 2009;119:e235)

I v1 v� I Initial depol. is left-to-right across septum (r in v, & q in V6;

V 6 nb, absent in LBBB) followed by LV & RV free wall, with LV

I dominating (nb, RV depol. later and visible in RBBB).

1. QRS �120 msec (11 0-119 = incomplete)

� -Jv'- 2. r SR' in R precordial leads ry,,V2) 3. Wide S wave in I and V6

I 4. ± ST J, or T WI in R precordial leads

1. QRS �120 msec (11 0-119 = incomplete)

vflv 2. Broad, slurred, monophasic R in I, a VL,Vs-V6 (± RS in

Vs-V6 if cardiomegaly) 3. Absence of Q in I,Vs and V6 (may have narrow q in a VL) 4. Displacement of ST & Tw opposite major QRS deflection

I 5. ± PRWP, LAD, Qw's in inferior leads

Bifascicular block: RBBB + LAFB/LPFB

Prolonged QT interval (NEJM 2008;358:169; www.torsades.org) • QT measured from beginning of QRS complex to end of T wave (measure longest QT) • QT varies w/ HR �correct w/ Bazett formula: QTc = QT/-vRR (in sec),

formula inaccurate at very high and low HR (nl QTc <440 msec o and <460 msec C() • QT prolongation a/w i risk TdP (esp. >500 msec); perform baseline/serial ECGs if using

QT prolonging meds, no estab guidelines for stopping Rx if QT prolongs • Etiologies:

Antiarrhythmics: class Ia (procainamide, disopyramide), class Ill (amiodarone, sotalol) Psych drugs: anti psychotics (phenothiazines, haloperidol, atypicals), Li,? SSRI, TCA Antimicrobials: macrolides, quinolones, azoles, pentamidine, atovaquone, atazanavir Other: antiemetics (droperidol, S-HT3 antagonists), alfuzosin, methadone, ranolazine Electrolyte disturbances: hypoCa (nb, hyperCa a/w J, QT),? hypoK,? hypoMg Autonomic dysfxn: ICH (deep TWI), stroke, carotid endarterectomy, neck dissection Congenital (long QT syndrome): K, Na, Ca channelopathies (Circ 2013;127:126) Mise: CAD, CMP, bradycardia, high-grade AVB, hypothyroidism, hypothermia, BBB

1 Left Atrial Abnormality (LAA) Right Atrial Abnormality (RAA)

��ave 11

>120 msec V

>4�sec

I Jt2.: mm i'v I C . . � or 1 � r II 1 or V1 >1.5mm

r•ter•a v I >1 mm

Left ventricular hypertrophy (LVH) (Circ 2009;119:e251) • Etiologies: HTN,AS/AI, HCMP, coarctation of aorta • Criteria (all w/ Se <50%, Sp >85%; accuracy affected by age, sex, race, BMI)

Romhilt-Estes point-score system: 4 points = probable, 5 points = definite i Amplitude (any of the following): largest R or S in limb leads �20 mm or S in V, or V2 �30 mm orR in Ys or V6 �30 mm (3 points) ST displacement opposite to QRS deflection: w/o dig (3 points); w/ dig (1 point) LAA (3 points); LAD (2 points); QRS duration �90 msec (1 point)