A MERICAN C OLLEGE OF P HYSICIANS C LERKSHIP D IRECTORS IN I NTERNAL M EDICINE I NTERNAL M EDICINE Essentials for Clerkship Students ACP I NTERNAL M EDICINE Essentials for Clerkship Students Patrick C Alguire, MD, FACP DIRECTOR EDUCATION AND CAREER DEVELOPMENT AMERICAN COLLEGE OF PHYSICIANS EDITOR-IN-CHIEF Associate Publisher and Manager, Books Publishing: Tom Hartman Production Supervisor: Allan S Kleinberg Senior Production Editor: Karen C Nolan Editorial Coordinator: Angela Gabella Design: Michael E Ripca Copyright © 2009 by the American College of Physicians All rights reserved No part of this publication may be reproduced in any form by any means (electronic, mechanical, xerographic, or other) or held in any information storage or retrieval systems without written permission from the College Printed in the United States of America Printed by Sheridan Books Composition by Scribe, Inc (www.scribenet.com) ISBN: 978-1-934465-13-4 The authors and publisher have exerted every effort to ensure that the drug selection and dosages set forth in this book are in accordance with current recommendations and practice at the time of publication In view of ongoing research, occasional changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, however, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions This care is particularly important when the recommended agent is a new or infrequently used drug 09 10 11 12 13 / 10 Section Editors Thomas M DeFer, MD, FACP Clerkship Director Division of Medical Education Department of Internal Medicine Washington University School of Medicine St Louis, Missouri Sara B Fazio, MD Assistant Professor, Harvard Medical School Director, Core I Medicine Clerkship Division of General Internal Medicine Beth Israel Deaconess Medical Center Boston, Massachusetts D Michael Elnicki, MD, FACP Director, Ambulatory Medicine Clerkship Director, Section of General Internal Medicine University of Pittsburgh School of Medicine UPMC Shadyside Pittsburgh, Pennsylvania James L Sebastian, MD, FACP Director of Student Teaching Programs Department of Medicine Medical College of Wisconsin Clement J Zablocki Veterans Affairs Medical Center Milwaukee, Wisconsin Mark J Fagan, MD Clerkship Director Department of Medicine Alpert Medical School of Brown University Providence, Rhode Island Contributors Arlina Ahluwalia, MD Clinical Assistant Professor of Medicine Stanford University School of Medicine Clerkship Site Director Palo Alto VAHCS Palo Alto, California Hugo A Alvarez, MD, FACP Associate Professor of Medicine Sub-Internship Director Clerkship Site Director, Department of Medicine Rosalind Franklin University of Medicine and Science Mount Sinai Hospital Chicago, Illinois Eyad Al-Hihi, MD, FACP Associate Professor of Medicine Clerkship Director, Ambulatory Medicine Section Chief, Division of General Internal Medicine Medical Director, Internal Medicine Clinics Truman Medical Center-Hospital Hill University of Missouri-Kansas City School of Medicine Kansas City, Missouri Alpesh N Amin, MD, MBA, FACP Medicine Clerkship Director Associate Program Director, IM Residency University of California, Irvine Irvine, California Mary Jane Barchman, MD, FACP, FASN Associate Professor of Medicine Section of Nephrology and Hypertension Director, Introduction to Medicine Course Clerkship Director, Internal Medicine Brody School of Medicine at East Carolina University Greenville, North Carolina Erik K Alexander, MD, FACP Director, Medical Student Education Brigham & Women’s Hospital Assistant Professor of Medicine Harvard Medical School Boston, Massachusetts Seth Mark Berney, MD, FACP Professor of Medicine Chief, Section of Rheumatology Director, Center of Excellence for Arthritis and Rheumatology Health Sciences Center Louisiana State University School of Medicine Shreveport, Louisiana Irene Alexandraki, MD, FACP Assistant Professor of Medicine University of Florida College of Medicine Jacksonville, Florida Mark R Allee, MD, FACP Assistant Professor of Medicine Department of Internal Medicine University of Oklahoma College of Medicine Oklahoma City, Oklahoma v vi • Contributors Cynthia A Burns, MD Assistant Professor Clerkship Director, Inpatient Internal Medicine Section of Endocrinology and Metabolism Department of Internal Medicine Wake Forest University School of Medicine Winston-Salem, North Carolina Amanda Cooper, MD Assistant Professor of Medicine University of Pittsburgh School of Medicine University of Pittsburgh Medical Center Pittsburgh, Pennsylvania Nicole M Cotter, MD Fellow, Section of Rheumatology Center of Excellence for Arthritis and Rheumatology Health Sciences Center Louisiana State University School of Medicine Shreveport, Louisiana Reed E Drews, MD, FACP Program Director Hematology-Oncology Fellowship Co-Director, Core Medicine Clerkship Beth Israel Deaconess Medical Center Harvard Medical School Boston, Massachusetts Steven J Durning, MD, FACP Major, Medical Corps, US Air Force Associate Professor of Medicine Co-Director, Intro to Clinical Reasoning Course Uniformed Services University of the Health Sciences Bethesda, Maryland Richard S Eisenstaedt, MD, FACP Chair, Department of Medicine Abington Memorial Hospital Professor of Medicine Temple University School of Medicine Philadelphia, Pennsylvania J Michael Finley, DO, FACP, FACOI Associate Professor and Chair of Medicine Department of Medicine Western University College of Osteopathic Medicine Pomona, California Janine M Frank, MD Assistant Professor of Medicine University of Pittsburgh Medical Center University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania Jane P Gagliardi, MD Assistant Clinical Professor Department of Internal Medicine Department of Psychiatry and Behavioral Sciences Duke University School of Medicine Durham, North Carolina Peter Gliatto, MD Assistant Professor of Medicine Director, Medical Clerkships Mount Sinai School of Medicine New York, New York Eric H Green, MD, MSc Course Director, Patients, Doctors, and Communities Assistant Professor of Medicine Montefiore Medical Center Albert Einstein College of Medicine Bronx, New York Mark C Haigney, MD Professor of Medicine Director of Cardiology Uniformed Services University of the Health Sciences Bethesda, Maryland Charin L Hanlon, MD, FACP Assistant Professor of Internal Medicine Clerkship Director, Internal Medicine West Virginia University-Charleston Division Charleston, West Virginia Warren Y Hershman, MD Director of Student Education Department of Medicine Boston University School of Medicine Boston, Massachusetts Mark D Holden, MD, FACP Eagle’s Trace Medical Director Erickson Retirement Communities Houston, Texas Contributors • vii Ivonne Z Jiménez-Velázquez, MD, FACP Professor and Vice-Chair for Education Geriatrics Program Director Clerkship Director, Internal Medicine Department University of Puerto Rico School of Medicine San Juan, Puerto Rico Lawrence I Kaplan, MD, FACP Professor of Medicine Section Chief, General Internal Medicine Internal Medicine Clerkship Director Temple University School of Medicine Philadelphia, Pennsylvania Asra R Khan, MD Assistant Professor of Clinical Medicine Associate Program Director, Internal Medicine Residency Medicine Clerkship Director University of Illinois College of Medicine Chicago, Illinois Sarang Kim, MD Assistant Professor of Medicine Division of General Internal Medicine University of Medicine and Dentistry of New Jersey Robert Wood Johnson Medical School New Brunswick, New Jersey Christopher A Klipstein, MD Clerkship Director of Internal Medicine Associate Professor Department of Medicine University of North Carolina School of Medicine Chapel Hill, North Carolina Cynthia H Ledford, MD Clerkship Director of Internal Medicine Ohio State University College of Medicine Columbus, Ohio Bruce Leff, MD, FACP Associate Professor of Medicine Medicine Clerkship Director Johns Hopkins University School of Medicine Baltimore, Maryland Fred A Lopez, MD, FACP Associate Professor and Vice Chair Department of Medicine Louisiana State University Health Sciences Center Assistant Dean for Student Affairs LSU School of Medicine New Orleans, Louisiana Anna C Maio, MD, FACP Division Chief and Associate Professor Division of General Internal Medicine Department of Internal Medicine Creighton University School of Medicine Omaha, Nebraska Brown J McCallum, MD, FACP Assistant Professor Co-Clerkship Director Department of Internal Medicine University of South Carolina School of Medicine Columbia, South Carolina Kevin M McKown, MD, FACP Associate Professor of Medicine Co-Chief, Section of Rheumatology Program Director, Rheumatology Fellowship Co-Clerkship Director Department of Medicine University of Wisconsin School of Medicine and Public Health Madison, Wisconsin Melissa A McNeil, MD, MPH Professor of Medicine and Obstetrics, Gynecology & Reproductive Sciences Chief, Section of Women’s Health Division of General Medicine University of Pittsburgh Pittsburgh, Pennsylvania Janet N Myers, MD, FACP, FCCP Associate Professor of Medicine Deputy Clerkship Director, Department of Medicine Uniformed Services University of the Health Sciences Bethesda, Maryland viii • Contributors Kathryn A Naus, MD Chief Fellow, Section of Rheumatology Center of Excellence for Arthritis and Rheumatology Health Sciences Center Louisiana State University School of Medicine Shreveport, Louisiana Priya Radhakrishnan, MD Clinical Assistant Professor University of Arizona College of Medicine Clerkship Director and Associate Program Director Department of Internal Medicine St Joseph Hospital & Medical Center Phoenix, Arizona Robert W Neilson Jr., MD Assistant Professor Clerkship Director Department of Internal Medicine Division of General Internal Medicine Texas Tech University Health Sciences Center Lubbock, Texas Joseph Rencic, MD, FACP Assistant Professor of Medicine Clerkship Site Director, Associate Program Director Department of Internal Medicine Tufts-New England Medical Center Boston, Massachusetts Katherine Nickerson, MD Vice Chair Department of Medicine Associate Professor of Clinical Medicine Clerkship Director Columbia University, P & S New York, New York Kathleen F Ryan, MD Associate Professor of Medicine Clerkship Director Division of General Internal Medicine Department of Internal Medicine Drexel University College of Medicine Philadelphia, Pennsylvania L James Nixon, MD Clerkship Director Division of General Internal Medicine University of Minnesota Medical School University of Minnesota Medical Center, Fairview Minneapolis, Minnesota Brijen J Shah, MD Chief Medical Resident, Department of Medicine Beth Israel Deaconess Medical Center Harvard Medical School Boston, Massachusetts Carlos Palacio, MD, MPH, FACP Clerkship Director Assistant Professor of Medicine University of Florida College of Medicine Jacksonville, Florida Hanah Polotsky, MD Assistant Professor of Medicine Clerkship Director Montefiore Medical Center Albert Einstein College of Medicine Bronx, New York Nora L Porter, MD Co-Director, Internal Medicine Clerkship St Louis University School of Medicine St Louis, Missouri Patricia Short, MD Major, Medical Corps, US Army Associate Professor and Associate Clerkship Director Department of Medicine Uniformed Services University of the Health Sciences Bethesda, Maryland Madigan Army Medical Center Tacoma, Washington Diane C Sliwka, MD Instructor of Medicine Beth Israel Deaconess Medical Center Harvard Medical School Boston, Massachusetts Contributors • ix Harold M Szerlip, MD, FACP, FCCP Professor and Vice-Chairman Department of Medicine Medical College of Georgia Augusta, Georgia Gary Tabas, MD, FACP Associate Professor of Medicine University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania Tomoko Tanabe, MD, FACP Assistant Professor of Medicine Associate Clerkship Director University of California, San Diego San Diego, California David C Tompkins, MD Associate Chair Department of Medicine SUNY Stony Brook Health Sciences Center Stony Brook, New York Dario M Torre, MD, MPH, FACP Clerkship Director Department of Medicine Medical College of Wisconsin Milwaukee, Wisconsin Mark M Udden, MD, FACP Professor of Medicine Department of Internal Medicine Baylor College of Medicine Houston, Texas H Douglas Walden, MD, MPH, FACP Co-Director, Internal Medicine Clerkship St Louis University School of Medicine St Louis, Missouri Joseph T Wayne, MD, MPH, FACP Associate Professor of Medicine Associate Professor of Pediatrics Clerkship Director, Internal Medicine Albany Medical College Albany, New York John Jason White, MD Assistant Professor of Medicine Nephrology Section Department of Medicine Medical College of Georgia Augusta, Georgia Kevin D Whittle, MD Assistant Professor Third Year Clerkship Director, Internal Medicine Sanford Medical School of the University of South Dakota Sioux Falls, South Dakota Contents FOREWORD xv ACKNOWLEDGMENTS xvii I III Gastroenterology and Hepatology 13 Approach to Abdominal Pain 57 Priya Radhakrishnan 14 Approach to Diarrhea 61 Sarang Kim 15 Diseases of the Gallbladder and Bile Ducts 64 Nora L Porter 16 Acute Pancreatitis 67 Nora L Porter 17 Gastroesophageal Reflux Disease 70 Brown J McCallum 18 Peptic Ulcer Disease 72 Brown J McCallum 19 Dyspepsia 74 Brown J McCallum 20 Approach to Gastrointestinal Bleeding 76 Warren Y Hershman 21 Viral Hepatitis 80 Carlos Palacio 22 Cirrhosis 83 Mark J Fagan 23 Inflammatory Bowel Disease 87 Brown J McCallum Cardiovascular Medicine Approach to Chest Pain Dario M Torre Chronic Stable Angina Anna C Maio Acute Coronary Syndrome 11 Patrick C Alguire Supraventricular Arrhythmias 15 Charin L Hanlon Ventricular Arrhythmias 20 Steven J Durning and Mark C Haigney Heart Failure 24 James L Sebastian Valvular Heart Disease 28 H Douglas Walden II Endocrinology and Metabolism Diabetes Mellitus and Diabetic Ketoacidosis 37 Erik K Alexander Dyslipidemia 41 D Michael Elnicki and Gary Tabas 10 Thryoid Disease 44 Erik K Alexander 11 Adrenal Disease 48 Cynthia A Burns 12 Osteoporosis 52 Melissa A McNeil and Janine M Frank IV General Internal Medicine 24 Test Interpretation 93 D Michael Elnicki 25 Health Promotion, Screening, and Prevention 96 L James Nixon 26 Approach to Syncope 100 Lawrence I Kaplan xi