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(BQ) Part 2 book Harrison''s manual of medicine presents the following contents: Cardiovascular diseases, respiratory diseases, renal diseases, gastrointestinal diseases; allergy, clinical immunology, and rheumatology; endocrinology and metabolism; neurology; psychiatric disorders and psychoactive substance use; adverse drug reactions; women’s health,... and other contents.
SECTION CARDIOVASCULAR DISEASES 117 PHYSICAL EXAMINATION OF THE HEART General examination of a pt with suspected heart disease should include vital signs (respiratory rate, pulse, blood pressure), skin color, clubbing, edema, evidence of decreased perfusion (cool and sweaty skin), and hypertensive changes in optic fundi Important findings on cardiovascular examination include: CAROTID ARTERY PULSE (Fig 117-1) • Pulsus parvus: Weak upstroke due to decreased stroke volume (hypovole- mia, LV failure, aortic or mitral stenosis) • Pulsus tardus: Delayed upstroke (aortic stenosis) • Bounding (hyperkinetic) pulse: Hyperkinetic circulation, aortic regurgitation, patent ductus arteriosus, marked vasodilatation • Pulsus bisferiens: Double systolic pulsation in aortic regurgitation, hypertrophic cardiomyopathy • Pulsus alternans: Regular alteration in pulse pressure amplitude (severe LV dysfunction) • Pulsus paradoxus: Exaggerated inspiratory fall (Ͼ10 mmHg) in systolic bp (pericardial tamponade, severe obstructive lung disease) JUGULAR VENOUS PULSATION (JVP) Jugular venous distention develops in right-sided heart failure, constrictive pericarditis, pericardial tamponade, obstruction of superior vena cava JVP normally falls with inspiration but may rise (Kussmaul’s sign) in constrictive pericarditis Abnormalities in examination include: • Large “a” wave: Tricuspid stenosis (TS), pulmonic stenosis, AV dissociation (right atrium contracts against closed tricuspid valve) • Large “v” wave: Tricuspid regurgitation, atrial septal defect • Steep “y” descent: Constrictive pericarditis • Slow “y” descent: Tricuspid stenosis PRECORDIAL PALPATION Cardiac apical impulse is normally localized in the fifth intercostal space, midclavicular line (Fig 117-2) Abnormalities A Hypokinetic Pulse B Parvus et Tardus Pulse D Bisferiens Pulse C Hyperkinetic Pulse E Dicrotic Pulse + Alternans S D FIGURE 117-1 Carotid artery pulse patterns 593 Copyright © 2005, 2002, 1998, 1995, 1991, 1988 by The McGraw-Hill Companies, Inc Click here for terms of use 594 SECTION Cardiovascular Diseases A B ECG ECG AOP CP OS S4 S1 ES SC S3 Apex LSB E RF W a a O ACG S1 S2 JVP A2 P2 c v x y FIGURE 117-2 A Schematic representation of electrocardiogram, aortic pressure pulse (AOP), phonocardiogram recorded at the apex, and apex cardiogram (ACG) On the phonocardiogram, S1, S2, S3, and S4 represent the first through fourth heart sounds; OS represents the opening snap of the mitral valve, which occurs coincident with the O point of the apex cardiogram S3 occurs coincident with the termination of the rapid-filling wave (RFW) of the ACG, while S4 occurs coincident with the a wave of the ACG B Simultaneous recording of electrocardiogram, indirect carotid pulse (CP), phonocardiogram along the left sternal border (LSB), and indirect jugular venous pulse (JVP) ES, ejection sound; SC, systolic click include: • Forceful apical thrust: Left ventricular hypertrophy • Lateral and downward displacement of apex impulse: Left ventricular dil- atation • Prominent presystolic impulse: Hypertension, aortic stenosis, hypertrophic cardiomyopathy • Double systolic apical impulse: Hypertrophic cardiomyopathy • Sustained “lift” at lower left sternal border: Right ventricular hypertrophy • Dyskinetic (outward bulge) impulse: Ventricular aneurysm, large dyskinetic area post MI, cardiomyopathy AUSCULTATION HEART SOUNDS (Fig 117-2) S1 Loud: Mitral stenosis, short PR interval, hyperkinetic heart, thin chest wall Soft: Long PR interval, heart failure, mitral regurgitation, thick chest wall, pulmonary emphysema S2 Normally A2 precedes P2 and splitting increases with inspiration; abnormalities include: • Widened splitting: Right bundle branch block, pulmonic stenosis, mitral regurgitation • Fixed splitting (no respiratory change in splitting): Atrial septal defect • Narrow splitting: Pulmonary hypertension • Paradoxical splitting (splitting narrows with inspiration): Aortic stenosis, left bundle branch block, CHF • Loud A2: Systemic hypertension • Soft A2: Aortic stenosis (AS) • Loud P2: Pulmonary arterial hypertension • Soft P2: Pulmonic stenosis (PS) CHAPTER 117 Physical Examination of the Heart 595 S3 Low-pitched, heard best with bell of stethoscope at apex, following S2; normal in children; after age 30– 35, indicates LV failure or volume overload S4 Low-pitched, heard best with bell at apex, preceding S1; reflects atrial contraction into a noncompliant ventricle; found in AS, hypertension, hypertrophic cardiomyopathy, and CAD Opening Snap (OS) High-pitched; follows S2 (by 0.06– 0.12 s), heard at lower left sternal border and apex in mitral stenosis (MS); the more severe the MS, the shorter the S2 – OS interval Ejection Clicks High-pitched sounds following S1; observed in dilatation of aortic root or pulmonary artery, congenital AS (loudest at apex) or PS (upper left sternal border); the latter decreases with inspiration Midsystolic Clicks At lower left sternal border and apex, often followed by late systolic murmur in mitral valve prolapse HEART MURMURS (Table 117-1, Fig 117-3) Systolic Murmurs May be “crescendo-decrescendo” ejection type, pansystolic, or late systolic; right-sided murmurs (e.g., tricuspid regurgitation) typically increase with inspiration Diastolic Murmurs • Early diastolic murmurs: Begin immediately after S2, are high-pitched, and are usually caused by aortic or pulmonary regurgitation • Mid-to-late diastolic murmurs: Low-pitched, heard best with bell of stethoscope; observed in MS or TS; less commonly due to atrial myxoma • Continuous murmurs: Present in systole and diastole (envelops S2); found in patent ductus arteriosus and sometimes in coarctation of aorta; less common Table 117-1 Heart Murmurs SYSTOLIC MURMURS Ejection-type Holosystolic Late-systolic Aortic outflow tract Aortic valve stenosis Hypertrophic obstructive cardiomyopathy Aortic flow murmur Pulmonary outflow tract Pulmonic valve stenosis Pulmonic flow murmur Mitral regurgitation Tricuspid regurgitation Ventricular septal defect Mitral or tricuspid valve prolapse DIASTOLIC MURMURS Early diastolic Mid-to-late diastolic Continuous Aortic valve regurgitation Pulmonic valve regurgitation Mitral or tricuspid stenosis Flow murmur across mitral or tricuspid valves Patent ductus arteriosus Coronary AV fistula Ruptured sinus of Valsalva aneurysm 596 SECTION Cardiovascular Diseases A B ECG ECG LVP LVP AOP LAP HSM S1 EDM S2 S1 ECG A2 ECG LVP AOP LVP LAP MSM S1 PSM A2 MDM S1 S2 FIGURE 117-3 A Schematic representation of ECG, aortic pressure (AOP), left ventricular pressure (LVP), and left atrial pressure (LAP) The hatched areas indicated a transvalvular pressure difference during systole HSM, holosystolic murmur; MSM, midsystolic murmur B Graphic representation of ECG, aortic pressure (AOP), left ventricular pressure (LVP), and left atrial pressure (LAP) with hatched areas indicating transvalvular diastolic pressure difference EDM, early diastolic murmur; PSM, presystolic murmur; MDM, middiastolic murmur causes are systemic or coronary AV fistula, aortopulmonary septal defect, ruptured aneurysm of sinus of Valsalva For a more detailed discussion, see O’Rourke RA, Braunwald E: Physical Examination of the Cardiovascular System, Chap 209, p 1304, in HPIM-16 118 ELECTROCARDIOGRAPHY AND ECHOCARDIOGRAPHY STANDARD APPROACH TO THE ECG Normally, standardization is 1.0 mV per 10 mm, and paper speed is 25 mm/s (each horizontal small box ϭ 0.04 s) HEART RATE Beats/min ϭ 300 divided by the number of large boxes (each mm apart) between consecutive QRS complexes For faster heart rates, divide 1500 by number of small boxes (1 mm apart) between each QRS CHAPTER 118 Electrocardiography and Echocardiography N DE VI AT Ϫ60° ϪIII N EXT RE ME Ϫ90° ϪaVF LEFT AX IS IO Ϫ120° ϪII AX I Ϫ30° ϩaVL Ϫ150° ϩaVR 0° ϩI 180° ϪI IS AL AX ϩ120° ϩIII IS D IA TI ON ϩ60° ϩII ϩ90° ϩaVF RM HT EV NO RIG ϩ30° ϪaVR ϩ150° ϪaVL AX S DE IO AT VI 597 FIGURE 118-1 Electrocardiographic lead systems: The hexaxial frontal plane reference system to estimate electrical axis Determine leads in which QRS deflections are maximum and minimum For example, a maximum positive QRS in I which is isoelectric in aVF is oriented to 0Њ Normal axis ranges from Ϫ30Њ to ϩ90Њ An axis Ͼ ϩ 90Њ is right axis deviation and Ͻ Ϫ30Њ is left axis deviation I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 RBBB LBBB LAH RBBB ϩ LAH RBBB ϩ LPH FIGURE 118-2 Intraventricular conduction abnormalities Illustrated are right bundle branch block (RBBB); left bundle branch block (LBBB); left anterior hemiblock (LAH); right bundle branch block with left anterior hemiblock (RBBB ϩ LAH); and right bundle branch block with left posterior hemiblock (RBBB ϩ LPH) (Reproduced from RJ Myerburg: HPIM-12.) Early Early ECG sequence with inferior Q wave infarction III II I aVR ECG sequence with anterior Q wave infarction aVR III II I aVL aVL aVF aVF V2 V2 V4 V4 FIGURE 118-3 Sequence of depolarization and repolarization changes with (A) acute anterior and (B) acute inferior wall Qwave infarctions With anterior infarcts, ST elevation in leads I, aVL, and the precordial leads may be accompanied by reciprocal ST depressions in leads II, III, and aVF Conversely, acute inferior (or posterior) infarcts may be associated with reciprocal ST depressions in leads V1 to V3 (After AL Goldberger, E Goldberger: Clinical Electrocardiography: A Simplified Approach, 6th ed St Louis, Mosby-Year Book, 1999.) Evolving B Evolving A V6 V6 CHAPTER 118 Electrocardiography and Echocardiography I II III aVR aVL aVF V1 V2 V3 V4 V5 599 V6 11/29 12/5 aVF V2 2 FIGURE 118-4 Acute inferior wall myocardial infarction The ECG of 11/29 shows minor nonspecific ST-segment and T-wave changes On 12/5 an acute myocardial infarction occurred There are pathologic Q waves (1), ST-segment elevation (2), and terminal T-wave inversion (3) in leads II, III, and aVF indicating the location of the infarct on the inferior wall Reciprocal changes in aVL (small arrow) Increasing R-wave voltage with ST depression and increased voltage of the T wave in V2 are characteristic of true posterior wall extension of the inferior infarction (Reproduced from RJ Myerburg: HPIM-12.) RHYTHM Sinus rhythm is present if every P wave is followed by a QRS, PR interval Ն 0.12 s, every QRS is preceded by a P wave, and the P wave is upright in leads I, II, and III Arrhythmias are discussed in Chap 125 MEAN AXIS If QRS is primarily positive in limb leads I and II, then axis is normal Otherwise, find limb lead in which QRS is most isoelectric (R ϭ S) The mean axis is perpendicular to that lead (Fig 118-1) If the QRS complex is positive in that perpendicular lead, then mean axis is in the direction of that lead; if negative, then mean axis points directly away from that lead Left-axis deviation (more negative than Ϫ30Њ) occurs in diffuse left ventricular disease, inferior MI; also in left anterior hemiblock (small R, deep S in leads II, III, and aVF) Right-axis deviation (Ͼ90Њ) occurs in right ventricular hypertrophy (R Ͼ S in V1) and left posterior hemiblock (small Q and tall R in leads II, III, and aVF) Mild right-axis deviation is seen in thin, healthy individuals (up to 110Њ) INTERVALS (Normal values in parentheses) PR (0.12– 0.20 s) • Short: (1) preexcitation syndrome (look for slurred QRS upstroke due to “delta” wave), (2) nodal rhythm (inverted P in aVF) • Long: first-degree AV block (Chap 125) Table 118-1 Leads with Abnormal Q Waves in MI Leads with Abnormal Q Waves Site of Infarction V1 – V2 V3 – V4 I, aVL, V5 – V6 II, III, aVF V1 – V2 (tall R, not deep Q) Anteroseptal Apical Anterolateral Inferior True posterior 600 SECTION Cardiovascular Diseases Table 118-2 Differential Diagnosis of Q Waves (with Selected Examples) Physiologic or positional factors Normal variant “septal” Q waves Normal variant Q waves in V1 to V2, aVL, III, and aVF Left pneumothorax or dextrocardia Myocardial injury or infiltration Acute processes: myocardial ischemia or infarction, myocarditis, hyperkalemia Chronic processes: myocardial infarction, idiopathic cardiomyopathy, myocarditis, amyloid, tumor, sarcoid, scleroderma Ventricular hypertrophy/enlargement Left ventricular (poor R-wave progression)a Right ventricular (reversed R-wave progression) Hypertrophic cardiomyopathy Conduction abnormalities Left bundle branch block Wolff-Parkinson-White patterns a Small or absent R waves in the right to midprecordial leads Source: After AL Goldberger: Myocardial Infarction: Electrocardiographic Differential Diagnosis, 4th ed St Louis, Mosby-Year Book, 1991 QRS (0.06– 0.10 s) Widened: (1) ventricular premature beats, (2) bundle branch blocks: right (RsRЈ in V1, deep S in V6) and left [RRЈ in V6 (Fig 1182)], (3) toxic levels of certain drugs (e.g., quinidine), (4) severe hypokalemia QT (Յ0.43 s; Ͻ50% of RR interval) Prolonged: congenital, hypokalemia, hypocalcemia, drugs (quinidine, procainamide, tricyclics) HYPERTROPHY • Right atrium: P wave Ն 2.5 mm in lead II • Left atrium: P biphasic (positive, then negative) in V1, with terminal negative force wider than 0.04 s Table 118-3 Clinical Uses of Echocardiography 2-D echo Cardiac chambers: size, hypertrophy, wall motion abnormalities Valves: morphology and motion Pericardium: effusion, tamponade Aorta: Aneurysm, dissection Assess intracardiac masses Doppler echocardiography Valvular stenosis and regurgitation Intracardiac shunts Diastolic filling/dysfunction Approximate intracardiac pressures Transesophageal echocardiography Superior to 2-D echo to identify: Infective endocarditis Cardiac source of embolism Prosthetic valve dysfunction Aortic dissection Stress echocardiography Assess myocardial ischemia and viability CHAPTER 118 Electrocardiography and Echocardiography 601 FIGURE 118-5 Two-dimensional echocardiographic still-frame images from a normal patient with a normal heart Upper: Parasternal long axis view during systole and diastole (left) and systole (right) During systole, there is thickening of the myocardium and reduction in the size of the left ventricle (LV) The valve leaflets ate thin and open widely Lower: Parasternal short axis view during diastole (left) and systole (right) demonstrating a decrease in the left ventricular cavity size during systole as well as an increase in wall thickening LA, left atrium; RV, right ventricle; Ao, aorta (Reproduced from RJ Myerburg in HPIM-12.) • Right ventricle: R Ͼ S in V1 and R in V1 Ͼ mm; deep S in V6; right-axis deviation • Left ventricle: S in V1 plus R in V5 or V6 Ն 35 mm or R in aVL Ͼ 11 mm INFARCTION (Figs 118-3 and 118-4) Q-wave MI: Pathologic Q waves (Ն0.04 s and Ն25% of total QRS height) in leads shown in Table 118-1; acute non-Q-wave MI shows ST-T changes in these leads without Q wave development A number of conditions (other than acute MI) can cause Q waves (Table 118-2) ST-T WAVES • ST elevation: Acute MI, coronary spasm, pericarditis (concave upward) (see Fig 121-1 and Table 121-2), LV aneurysm • ST depression: Digitalis effect, strain (due to ventricular hypertrophy), ischemia, or nontransmural MI • Tall peaked T: Hyperkalemia; acute MI (“hyperacute T”) • Inverted T: Non-Q-wave MI, ventricular “strain” pattern, drug effect (e.g., digitalis), hypokalemia, hypocalcemia, increased intracranial pressure (e.g., subarachnoid bleed) 602 SECTION Cardiovascular Diseases A C AR m/s AS Vmax ϭ 3.8 m/s B D MS m/s MR FIGURE 118-6 Schematic presentation of normal Doppler flow across the aortic (A) and mitral valves (B) Abnormal continuous wave Doppler profiles are depicted in C Aortic stenosis (AS) [peak transaortic gradient ϭ ϫ Vmax2 ϭ ϫ (3.8)2 ϭ 58 mmHg] and regurgitation (AR) D Mitral stenosis (MS) and regurgitation (MR) INDICATIONS FOR ECHOCARDIOGRAPHY (Table 118-3 and Fig 118-5) VALVULAR STENOSIS Both native and artificial valvular stenosis can be evaluated, and severity can be determined by Doppler [peak gradient ϭ ϫ (peak velocity)2] VALVULAR REGURGITATION Structural lesions (e.g., flail leaflet, vegetation) resulting in regurgitation may be identified Echo can demonstrate whether ventricular function is normal; Doppler (Fig 118-6) can identify and estimate severity of regurgitation through each valve VENTRICULAR PERFORMANCE Global and regional wall motion abnormalities of both ventricles can be assessed; ventricular hypertrophy/infiltration may be visualized; evidence of pulmonary hypertension may be obtained CARDIAC SOURCE OF EMBOLISM May visualize atrial or ventricular thrombus, intracardiac tumors, and valvular vegetations Yield of identifying cardiac source of embolism is low in absence of cardiac history or physical findings Transesophageal echocardiography is more sensitive than standard transthoracic study for this purpose ENDOCARDITIS Vegetation visualized in more than half of pts (transesophageal echo has much higher sensitivity), but management is generally Index Renal failure (Cont.): prerenal, 703, 704t, 705 treatment of, 705– 706 chronic, 707 approach to, 699 causes of, 707t differential diagnosis of, 707– 708 laboratory evaluation of, 708 renovascular disease and, 730 slowing progression of, 709 treatment of, 708– 709 edema in, 194, 195f Renal stones, 731 Renal transplant, 711 complications of, 713 contraindications to, 712t factors influencing graft survival, 712t immunosuppressive therapy for, 711– 713 infections in transplant recipients, 422 rejection of, 711 Renal tubular acidosis, 723 distal (type I), 723 drug-induced, 986t proximal (type II), 723 treatment of, 723 type IV, 723 Renal tubular disease, 720 approach to, 700t, 701 causes of, 721t transport dysfunction in, 722t Renal vein occlusion, azotemia in, 228f Renal vein thrombosis, 728 Renovascular disease, 728 arteriolar nephrosclerosis, 730 hemolytic-uremic syndrome, 730 ischemic nephropathy, 730 renal artery occlusion, 728 renal artery stenosis, 729– 730 renal vein occlusion, 228f renal vein thrombosis, 728 scleroderma, 730 sickle cell nephropathy, 731 toxemia of pregnancy, 731 vasculitis, 731 Repaglinide, for diabetes mellitus, 833t Reproductive system disorder, 393 female, 839 male, 835 Residual volume, 663, 663f, 665t Respiratory acidosis, 11f, 13– 14 treatment of, 13– 14 Respiratory alkalosis, 11f, 14 treatment of, 14 Respiratory disease See also Pulmonary disease; specific diseases in amyloidosis, 805 ARDS, 39– 40 asthma, 668– 672 Chlamydia pneumoniae, 519 COPD, 675– 678 diagnosis of, 666 drug-induced, 984t environmental, 673– 675 1073 hypersensitivity pneumonitis, 672– 673 infectious, in immunocompromised host, 419 interstitial lung disease, 687– 690 meningococcal, 463 obstructive, 664t, 665t pneumonia, 679– 685 prevention of, 993t Pseudomonas aeruginosa, 474 pulmonary embolism, 685– 687 respiratory failure, 678 restrictive extraparenchymal, 664t, 665t parenchymal, 664t, 665t in sarcoidosis, 803 sleep apnea, 697– 698 specimens for culture, 353t Staphylococcus aureus, 450 upper respiratory infections, 248 ventilatory disorders, 695– 697 viral, 533 weight loss in, 201t Respiratory failure, 20, 22, 678 acute, 22 acute or chronic, 22 chronic, 22 clinical evaluation of, 22– 23 mechanism of alveolar network dysfunction, 22– 23 controller dysfunction, 22– 23 pulmonary vascular dysfunction, 22– 23 pump dysfunction, 22– 23 treatment of, 21, 23 type I (acute hypoxemic), 20 type II, 20 type III, 20 type IV, 21 Respiratory function, disturbances of aspiration of lung in, 667 bronchoalveolar lavage in, 667 bronchoscopy in, 667 gas exchange, 665– 666 imaging in, 666 mechanisms of, 666 mediastinoscopy in, 667 pleural biopsy in, 667 pulmonary angiography in, 667 pulmonary circulation, 665 pulmonary function tests in, 667 scintigraphy in, 667 skin tests for, 666 sputum exam in, 666 thoracentesis in, 667 ventilatory, 663– 665, 663f, 664f, 664t, 665t video-assisted thoracic surgery in, 667 Respiratory muscle dysfunction, 186 Respiratory pattern, in confusion and coma, 57 Respiratory procedures, endocarditis prophylaxis for, 378t, 379t Respiratory quotient, 665 1074 Index Respiratory support, for nerve agent exposure, 127 Respiratory syncytial virus immune globulin, 538 Respiratory syncytial virus infection, 537 pneumonia, 679 treatment of, 538 Responsiveness, assessment of impaired consciousness, 56 Restless legs syndrome, 182, 184t Retching, 197 Reticulate body, 517 Reticulated lesion, 255 Reticulocyte(s), 265 Reticulocyte index, 233– 234, 233f Reticuloendothelial system hyperplasia, 238t Retinal artery occlusion, 172f Retinal vein occlusion, 172f, 173 Retinitis, herpes simplex virus, 521 Retinitis pigmentosa, 172f Retinoic acid for acne vulgaris, 263 for acute myeloid leukemia, 292 for head and neck cancer prevention, 310 for oral leukoplakia, 284 Retinopathy diabetic, 243 treatment of, 243 drug-induced, 987t Retrochiasmal lesion, 172, 172f Retroperitoneal abscess, 382 Reverse transcriptase inhibitors, 428t– 432t nonnucleoside, 439 Rewarming active, 116 passive, 116 Reye’s syndrome, 535 Rheumatic fever, acute, 455 Rheumatoid arthritis, 781 interstitial lung disease in, 690 neck pain in, 154 pain in, 162f pleural effusion in, 691 treatment of, 782– 783, 782f Rhinitis, allergic, 774 treatment of, 774– 775 Rhinovirus infection, 536 Rhizomucor infection, 560– 561 Rhizopus infection, 560– 561 Ribavirin for adenovirus infections, 539 for chronic hepatitis C, 764, 765t for hemorrhagic fever, 551 for Lassa fever, 551 for measles, 541 for respiratory syncytial virus infections, 538 for SARS, 537 for viral encephalitis, 893 for viral hemorrhagic fevers, 121t Rickettsia akari infection See Rickettsialpox Rickettsial disease, 510 Rickettsialpox, 511 treatment of, 512 Rickettsia rickettsii infection See Rocky Mountain spotted fever Rifabutin, for mycobacterial infections, 504– 505 Rifampin for anthrax, 122 for Bartonella infections, 484t for brucellosis, 480 for Clostridium difficile-associated disease, 392 for diphtheria, 461 for endocarditis, 375, 377t for Haemophilus influenzae prophylaxis, 467 for Legionella infections, 479 for leprosy, 503 mechanisms, indications, and adverse effects of, 364 for meningococcal infection prophylaxis, 464t, 887 for nontuberculous mycobacterial infections, 505 for primary biliary cirrhosis, 768 for Q fever, 516 for streptococcal carriage, 456 for tuberculosis, 498, 499t, 501t Rift Valley fever, 551 Riluzole, for amyotrophic lateral sclerosis, 918 Rimantadine for influenza, 535 for influenza prophylaxis, 536 Ringworm, 262 Rinne test, 244, 871 Risedronate, for osteoporosis, 854 Risperidone dosage and adverse effects of, 967t for schizophrenia, 958 Ritonavir, for HIV infections, 433t Rituximab for chronic lymphocytic leukemia/lymphoma, 300 for gastric cancer, 322 for idiopathic thrombocytopenic purpura, 277 Rivastigmine, for Alzheimer’s disease, 908– 909 River blindness, 585 Rizatriptan, for migraine, 143t Rocky Mountain spotted fever, 97t, 100, 510 treatment of, 511 Rodent bite, 106, 108t Rodent-borne viral infection, 548 Roman˜a’s sign, 576– 577 Romberg sign, 914 Romberg test, 873 Ropinirole for Parkinson’s disease, 913t for restless legs syndrome, 182 Roseola infantum, 527 Index Rosetting, 569 Rosiglitazone, for diabetes mellitus, 833t Ross River virus, 550 Rosuvastatin, for hyperlipidemia, 859t Rotavirus infection, diarrhea, 385 Rouleaux formation, 265 Rubella, 541 congenital rubella syndrome, 541 Rubella vaccine, 541 Rubeola See Measles Rumination, 197 Russian spring-summer encephalitis, 552t Saccades, 870 St Louis encephalitis, 552t, 893t Salicylates for osteoarthritis, 795 poisoning, 86– 87 Salicylic acid, for scabies, 590 Saline diuresis, for poisoning/drug overdose, 77 Saline therapy for hypercalcemia, 103, 849t for hyponatremia, for metabolic alkalosis, 13 for syndrome of inappropriate ADH, 815 Salmeterol for asthma, 669, 670t for COPD, 677 Salmonella infection, 387 diagnosis of, 353t reactive arthritis, 792 Salmonellosis, 387 nontyphoidal, 388– 389 treatment of, 388– 389 Salpingitis, 397 Salt wasting, 722t Saquinavir mesylate, for HIV infections, 433t Sarcoidosis, 802 acute, 803 clinical features of, 803 insidious onset, 803 treatment of, 804 Sarcoma Kaposi’s, 437, 527 paraneoplastic syndromes, 344t Sarcoptes scabiei See Scabies Scabies, 590 treatment of, 590 Scalded-skin syndrome, staphylococcal, 451 Scale, 256 Scar, 256 Scar carcinoma, 308 Scarlet fever, 456 Schistocytes, 265 Schistosomiasis, 585 acute, 586 cercarial invasion, 586 chronic, 586 diagnosis of, 359t treatment of, 586 1075 Schizoaffective disorder, 958 Schizoid personality, 962 Schizont, 569 Schizophrenia, 957 treatment of, 958 Schizophrenic-like reaction, drug-induced, 988t Schizotypal personality, 962 Schwannoma, 884 vestibular, 246 Scintigraphy, for biliary tract disease, 750t Scleroderma, 783 See also Systemic sclerosis diffuse cutaneous, 783 dysphagia in, 205 limited cutaneous, 783 pain in, 162f renovascular disease in, 730 Sclerotherapy, for esophagogastric varices, 771 Scombroid poisoning, 112 Scopolamine for nausea and vomiting, 198 for vertigo, 170t Scorpionfish, 110– 111 Scorpion sting, 113 treatment of, 113 Scotoma, 172f Screening recommendations, 991 Scrofula, 496 Scrub typhus, 513 Sea anemone envenomations, 110 Segmental signs, in spinal cord disease, 933 Seizure, 875 See also Epilepsy absence (petit mal), 875, 880t, 882t causes of, 875, 876t, 877t classification of, 875 clinical evaluation of, 876, 878f– 879f complex-partial, 875 differential diagnosis of, 877t drug-induced, 877t, 987t electroencephalography in, 876– 877 generalized, 875 neuroimaging in, 882 partial (focal), 875, 880t, 882t from poisoning/drug overdose, 76– 77 simple-partial, 875 syncope versus, 165, 877t tonic-clonic (grand mal), 875, 880t, 882t treatment of, 880t– 881t, 882, 882t Selection bias, 281 Selective serotonin reuptake inhibitors (SSRI), 963 dosage and adverse effects of, 964t Selegiline for Alzheimer’s disease, 909 for Parkinson’s disease, 911 Seminoma, 333 Sensitization, 24 Sensorineural hearing loss, 245– 246 Sensory exam, 870f, 871f, 873 1076 Index Sensory level, 102 Sensory neuronopathy, paraneoplastic, 348t Sepsis clostridial, 488 gram-negative, 96t gram-positive, 96t listerial, 465 without obvious primary infection, 95, 96t puerperal, 475 severe, 49 See also Septic shock antimicrobial therapy for, 52t infectious disease emergencies, 94 with skin manifestations, 95, 97t, 100 with soft tissue/muscle findings, 98t, 100 Staphylococcus aureus, 450 Septic arthritis brucellosis, 479 HACEK organisms, 470 Staphylococcus aureus, 450, 454 streptococcal, 458 Septic shock, 45, 49 clinical features of, 50– 51 epidemiology and risk factors for, 49– 50 treatment of, 51– 53, 52t Sequestra, 414 Serologic diagnosis, 358 Serotonin syndrome, 87 Serratia marcescens infection, 473 urinary tract, 724 Sertraline dosage and adverse effects of, 964t for panic disorder, 959 Serum sickness, 787 drug-induced, 980t Sevelamer, for hyperphosphatemia, 708 Severe acute respiratory syndrome (SARS), 537 epidemiology of, 537 treatment of, 537 Severe combined immunodeficiency (SCID), 776 adenosine deaminase deficiency, 776 Swiss-type, 776 treatment of, 777 X-linked, 776– 777 Sexual dysfunction, drug-induced, 980t Sexually transmitted disease (STD), 393 chancroid, 406– 407 Chlamydia infections, 400– 402 donovanosis, 407 enteritis, 398– 399 enterocolitis, 398– 399 epididymitis, 396 gonorrhea, 399– 400 herpes simplex virus infections, 406 human papillomavirus infections, 407– 408 mucopurulent cervicitis, 397 mycoplasmal infections, 402– 403 pelvic inflammatory disease, 397– 398 proctitis, 398– 399 proctocolitis, 398– 399 syphilis, 403– 406 ulcerative genital lesions, 398 urethral syndrome in women, 396 urethritis in men, 393– 396 in women, 396 vulvovaginal infections, 396– 397 Shigella infection, 390 diagnosis of, 353t proctocolitis, 399 reactive arthritis, 792 treatment of, 390 Shingles See Herpes zoster Shock, 20, 44 See also specific types of shock approach to, 45 forms of, 45t in GI bleeding, 214 hemodynamic profiles in, 46t laboratory evaluation of, 46 oligemic, 45, 45t, 46t physical examination for, 45– 46 treatment of, 46– 49, 47f vasopressors, 48t Shoulder adhesive capsulitis of, 802 muscles and innervation of, 868t– 869t Shoulder pain, 154, 155t Sibutramine, for obesity, 829 Sicca symptoms, 784 Sick euthyroid syndrome, 820 Sickle cell anemia, 270 clinical manifestations of, 270, 270t nephropathy in, 731 treatment of, 271– 272 Sickled cells, 265 Sideroblastic anemia, 269, 269t Sigmoidoscopy, 282t, 327 Sildenafil adverse effects of, 623, 636 for erectile dysfunction, 838 for systemic sclerosis, 784 Silent ischemia, 631 Silicosis, 674 Simple phobia, 960– 961 Simvastatin, for hyperlipidemia, 859t Sindbis virus, 550 Sinusitis, 248– 252 acute, 249 diagnosis of, 250t treatment of, 249, 250t anaerobic infection, 490 Aspergillus, 559 chronic, 249– 250 bacterial, 249 fungal, 249– 250 pneumococcal, 445 streptococcal, 460 Sinus rhythm, 599 Sinus tachycardia, 639f, 640t myocardial infarction and, 625 Sirolimus, immunosuppression for renal transplant, 713 Index Sister Mary Joseph’s nodule, 224 Sjoăgrens syndrome, 784 treatment of, 785 Skeletal disease See Bone disease; Musculoskeletal disease Skeletal muscle-central nervous system syndrome, 950 Skin biopsy of, 258 examination of, 255 Skin cancer, 307 basal cell carcinoma, 308 melanoma, 307 prevention of, 309 screening for, 282t squamous cell carcinoma, 308– 309 Skin disease See also specific diseases acne, 262– 263 in amyloidosis, 805 anaerobic infections, 490 clostridial, 488 common, 259 diagnosis of, 257– 259 drug-induced, 264, 981t– 982t eczematous, 260– 261 history in, 257 infectious, 261– 262, 408– 412 in immunocompromised host, 417 in inflammatory bowel disease, 743 larva migrans, 581 lesion characteristics arrangement and shape, 255 distribution, 255, 256f– 258f in malnutrition, papulosquamous, 259– 260 primary lesions, 255 Pseudomonas aeruginosa infections, 475 in returned traveler, 372 in rheumatoid arthritis, 781 in sarcoidosis, 803 secondary lesions, 256 staphylococcal, 449 streptococcal, 456– 457 in systemic lupus erythematosus, 780 in systemic sclerosis, 783 vascular disorders, 263– 264 Skin necrosis, drug-induced, 982t Skin tag, 257f, 258f Skin test, in respiratory disease, 666 Sleep, nonrestorative, 181 Sleep apnea, 697 central, 183, 697 mixed, 183 obstructive, 183, 184t, 697, 698t treatment of, 697– 698, 698t Sleep disorder, 181 approach to, 181 drug-induced, 988t seizures in, 877t Sleep hygiene, 183 inadequate, 182 Sleeping sickness, 577 treatment of, 578 1077 Sleep paralysis, 184t, 185 Slow-reacting substance of anaphylaxis, 773 Small-bowel tumor, 323 treatment of, 324 Smallpox as bioweapon, 121t, 123– 124 hemorrhagic, 123 malignant, 123 microbiology and clinical features of, 122 treatment of, 121t, 123 vaccination and prevention of, 121t, 123– 124 Smell, disorders of sense of, 922, 923t Smoke inhalation, 674 Smoking cessation, 37, 676, 690, 991, 992t, 993t Snakebite, venomous, 108t, 109 treatment of, 109– 110 Social phobia, 960– 961 Sodium, disorders of, Sodium bicarbonate for cardiac arrest, 42, 43f– 44f for hyperkalemia, 10t for iron poisoning, 83 for metabolic acidosis, 12 for shock, 49 Sodium nitrite, for cyanide poisoning, 82 Sodium nitroprusside, for aortic dissection, 654, 655t Sodium restriction for aldosteronism, 825 for ascites, 225 for cor pulmonale, 652 for heart failure, 649, 651 for hyponatremia, for mitral stenosis, 604 for restrictive cardiomyopathy, 611 Sodium stibogluconate, for leishmaniasis, 573– 576 Sodium thiosulfate, for cyanide poisoning, 82 Sodium valproate for migraine prophylaxis, 145t for posthypoxic myoclonus, 71 Soft tissue infection, 408– 412 anaerobic, 490 clostridial, 488 Klebsiella, 472 Pseudomonas aeruginosa, 475 streptococcal, 456– 457 Solid organ transplant, infections in transplant recipients, 422 Solitary pulmonary nodule, 314 approach to, 315f Solute diuresis, 230f Somatization disorder, 961 Somatoform disorder, 961 treatment of, 961 Somatostatin, for esophagogastric varices, 771 Somatostatinoma, 329, 330t Somatotropin, for hypopituitarism, 812 1078 Index Sotalol, for arrhythmias, 641t South American hemorrhagic fever syndrome, 551 Soy products, for menopausal symptoms, 845 Spastic paraplegia, familial, 936 Spectinomycin, for gonococcal infections, 401t Speech audiometry, 244 Speech therapy, 181 Spherocytes, 265 Sphincteric reflex, 872 Spider bite, 112 Spinal cord, anatomy of, 933f Spinal cord compression neoplastic compression, 885, 885t, 934 oncologic emergency, 102 treatment of, 102 Spinal cord disease, 932 acute, 934– 935 approach to, 934 cervical cord, 934 chronic myelopathy, 935– 936 complications of, 936 lumbar cord, 934 sacral cord, 934 specific signs by cord level, 934 symptoms and signs of, 932– 933 thoracic cord, 934 trauma, autonomic dysfunction in, 928 treatable, 932t weakness in, 176t, 177t Spinal cord infarction, 935 Spinal epidural abscess, 935 Spinal epidural hematoma, 935 Spinal shock, 933 Spinal stenosis, pain in, 148 Spinocerebellar ataxia, 915 Spirillum minor infection, 106 Spirochetal infection, 506 Spironolactone for aldosteronism, 825 for ascites, 225 for dilated cardiomyopathy, 609 for edema, 196t for heart failure, 649t, 650 for hirsutism in female, 843 Splenectomy, 240 for esophagogastric varices, 771 postsplenectomy infection, 95 treatment of, 52t Splenic abscess, 382 Splenomegaly, 236 diseases associated with, 238t– 239t mechanisms of, 238t– 239t, 239 tropical, 570 Spondylitic myelopathy, 935 Spondylolisthesis, pain in, 148 Spondylosis, cervical, pain in, 154, 156 Spondylotic myelopathy, 156 Sporotrichosis, 565 extracutaneous, 565 lymphangitis, 565 meningitis, 897t plaque, 565 treatment of, 565 Sporozoite, 569 Spotted fever, tick- and mite-born, 510 Sputum culture, 353t Sputum examination, 666, 684 Squamous cell carcinoma, 258f of esophagus, 321 of skin, 308 treatment of, 308– 309 Staghorn calculi, 731 Standard precautions, 442 Stanford classification, of aortic dissection, 654f Staphylococcal infection, 448 arthritis, 412 coagulase-negative, 451 endocarditis, 451 meningitis, 886, 891t prosthetic device-related, 451 treatment of, 454 endocarditis, 376t– 377t urinary tract, 724 Staphylococcus aureus infection, 448 from animal bites, 107t bacteremia, 450 colonization of humans, 448 diagnosis of, 449 endocarditis, 450, 454 epidemiology of, 448 epiglottitis, 254 food poisoning, 384, 451 impetigo, 261 invasive disease, 448– 449 meningitis, 886 methicillin-resistant, 448 musculoskeletal, 449, 454 nosocomial, 443 osteomyelitis, 414, 416t pneumonia, 679, 684 prevention of, 451 prosthetic-device related, 450, 454 respiratory, 450 risk factors for, 449 scalded-skin syndrome, 451 sepsis, 450 sinusitis, 249 skin and soft tissue, 449 toxic shock syndrome, 100, 451, 455 toxin-mediated disease, 449, 451 treatment of, 452t– 453t, 454– 455 urinary tract, 450 Stasis ulcer, 257f Stat DRIP (medications mnemonic), Statins, 859t Stat medications, Status epilepticus, 72 treatment of, 72, 73f Stauffers’ syndrome, 332 Stavudine, for HIV infections, 430t Stenotrophomonas maltophilia infection, 475 treatment of, 477 Stent, vascular, for angina pectoris, 634, 634t Index Stereognosis, 873 Sternoclavicular pyarthrosis, 475 Steroid injection, for psoriatic arthritis, 792 Stevens-Johnson syndrome, 263 Stiff neck, 886 Stingrays, 110– 111 Stomatitis, aphthous, 258f Stool examination diagnosis of infectious disease, 353t– 354t in diarrhea, 210 Straight-leg raising sign, 147 crossed, 147 reverse, 147– 148 Streptobacillus moniliformis infection, from animal bite, 106, 108t Streptococcal infection, 455 cellulitis, 409 dog bite, 107t group A, 455 bacteremia, 457 cellulitis, 456 epiglottitis, 254 erysipelas, 456– 457 impetigo, 456 necrotizing fasciitis, 457 nosocomial, 443– 444 pharyngitis, 253, 455– 456 pneumonia, 457, 681 poststreptococcal glomerulonephritis, 714 puerperal sepsis, 457 toxic shock syndrome, 457– 458, 457t group B meningitis, 886, 887t neonatal infection, 458– 459 pelvic inflammatory disease, 397 treatment of, 458 group C, 458 group D, 459 group G, 458 hemolytic patterns, 455 infective endocarditis, 376t nutritionally variant streptococci, 460 osteomyelitis, 415t scarlet fever, 456 skin and soft tissue, 456– 457 toxic shock syndrome, 100 viridans streptococci, 459– 460 Streptogramins, mechanisms, indications, and adverse effects of, 365 Streptokinase for myocardial infarction, 623 for thrombotic disorders, 279 Streptomycin for brucellosis, 480 for enterococcal infections, 459 for nontuberculous mycobacterial infections, 504 for plague, 121t, 483 for tuberculosis, 498, 499t for tularemia, 121t, 481 1079 Streptozotocin for carcinoid tumor, 329 for pancreatic islet-cell tumors, 331 for Zollinger-Ellison syndrome, 741 Stress testing, in coronary artery disease, 631, 632f, 633t Stroke, 58 anatomic localization in, 59t causes of, 63t determination of, 61– 62 clinical presentation of, 58– 60 drug-induced, 987t embolic, 65 hemorrhagic, 60 ischemic, 58, 60– 61, 63t prevention of, 62– 65 risk factors for, 62, 64t treatment of, 60– 61, 60t Strongyloidiasis, 582 diagnosis of, 359t treatment of, 583 Struvite stones, 732, 733t Stupor, 54 Subacute sclerosing panencephalitis, 540 Subarachnoid hemorrhage (SAH), 66 with hydrocephalus, 67 laboratory evaluation of, 66 rebleeding, 66 treatment of, 66 Subdural hematoma, 904 Substance abuse alcoholism, 972– 975 narcotic abuse, 975– 977 in women, 990 Succimer for arsenic poisoning, 80 for lead poisoning, 84 for mercury poisoning, 85 Sucralfate, for erosive gastropathy, 740 Sudden death, 41 Suicide, 955– 956, 958, 992t– 993t Sulfadiazine, for toxoplasmosis, 579 Sulfadoxine, for malaria, 571t Sulfadoxine/pyrimethamine, for malaria, 575t Sulfasalazine for ankylosing spondylitis, 790 for inflammatory bowel disease, 743 for psoriatic arthritis, 792 for reactive arthritis, 793 for rheumatoid arthritis, 783 Sulfhemoglobinemia, 192, 193t Sulfinpyrazone, for gout, 798 Sulfonamides mechanisms, indications, and adverse effects of, 363– 364 for nocardiosis, 493, 493t Sulfonylurea for diabetes mellitus, 832, 832t hypoglycemia from, 93f, 94, 94t Sulfur granules, 494 Sulfur mustard, 125– 126 treatment of exposure to, 126 1080 Index Sumatriptan for cluster headache, 146 for migraine, 143t, 144t Summer grippe, 545 Superior vena cava syndrome, 693 oncologic emergency, 101– 102 treatment of, 102 Supraventricular arrhythmia, myocardial infarction and, 625– 626 Supraventricular tachycardia, 643t from poisoning/drug overdose, 75– 76 Suramin, for sleeping sickness, 578 Surgical patient, evaluation of, 34 cardiac risk assessment, 34– 37, 34t, 35f pulmonary evaluation, 36t, 37 Susceptibility testing, diagnostic, 358 Swallowing disorder, 203 Swimmer’s ear, 252, 475 Swimmer’s itch, 586 Sympathomimetics for heart failure, 651 poisoning, 87– 88 Symphysis pubis infection, 475 Syncope, 164 approach to, 165, 167f causes of, 165, 166t seizure versus, 165, 877t treatment of, 167– 168 vasodepressor, 165 vasovagal, 165, 166t, 167 Syndrome of inappropriate ADH (SIADH), 814 causes of, 814, 814t drug-induced, 814t paraneoplastic, 103, 344t, 345– 346, 814t treatment of, 103, 815 Syndrome X, 831 Synkinesis, 922 Synovial fluid analysis, 163f, 164 in gout, 797 Syphilis, 403 cardiovascular, 404 congenital, 404 diagnosis of, 404 endemic, 507– 508 late, 403– 404 late benign, 404 latent, 403, 405t in pregnancy, 405t primary, 403, 405t secondary, 403, 405t tertiary, 936 treatment of, 404– 406, 405t Syringomyelia, 935– 936 Syrup of ipecac, 77, 88 Systemic inflammatory response syndrome (SIRS), 49 Systemic lupus erythematosus (SLE), 781 interstitial lung disease in, 690 pain in, 162f renal disease in, 714, 719t treatment of, 780– 781 Systemic sclerosis, 783 interstitial lung disease in, 690 treatment of, 784 Systolic blood pressure, 618f– 619f Tabes dorsalis, 936 Tachyarrhythmia electrocardiography in, 639f syncope and, 166t treatment of, 638 Tacrine, for Alzheimer’s disease, 908–909 Tacrolimus, immunosuppression for renal transplant, 712 Tadalafil, adverse effects of, 623, 636 Taeniasis saginata, 587 treatment of, 587 Taeniasis solium, 587 treatment of, 588 Takayasu’s arteritis, 655, 786, 788 Tamoxifen for breast cancer, 318– 319 for breast cancer prevention, 283 for endometrial cancer, 337 for melanoma, 308 Tandem walk test, 873 Tapeworm See Cestode infection Tardive dyskinesia, 969 Target cells, 265 T cell immunodeficiency, 777 treatment of, 777 T cell receptor complex deficiency, 777 Td (tetanus, diphtheria) vaccine, 368f, 370f, 994t Teardrop cells, 265 Tegaserod, for irritable bowel syndrome, 747 Telangiectasia, GI tract, 217 Telithromycin, for pneumonia, 680t Temazepam, dosage and adverse effects of, 966t Temozolamide, for melanoma, 308 Temporal arteritis See Giant cell arteritis Tendinitis, 802 calcific, 802 pain in, 162f treatment of, 802 Tendon xanthoma, 857 Tenofovir, for HIV infections, 431t Tenosynovitis, in gout, 796 Tensilon (edrophonium) test, 942 Tension headache, 140t, 144 treatment of, 146t Teratodermoid, 693 Terazosin, for prostate hyperplasia, 338 Terbinafine, 555 Terbutaline, for asthma, 669 Testicular cancer, 333 paraneoplastic syndromes, 344t treatment of, 333– 334 Testicular failure, 835 Testosterone for androgen deficiency, 836 deficiency of, 835– 836 for hypopituitarism, 812 Index Tetanus, 106, 485 generalized, 485– 486 local, 486 neonatal, 486 prevention of, 486 treatment of, 486 Tetanus booster, 109 Tetanus immune globulin, 486 Tetanus vaccine, 486, 992t, 993t, 994t Tetracycline for acne rosacea, 263 for acne vulgaris, 263 for adult inclusion conjunctivitis, 518 for cerebral malaria, 99t for Chlamydia pneumoniae infections, 519 for diverticular disease, 747 for Helicobacter pylori eradication, 739t for intestinal pseudoobstruction, 748 mechanisms, indications, and adverse effects of, 363 for Moraxella catarrhalis infections, 468 for psittacosis, 519 for trachoma prophylaxis, 518 for tularemia, 481 Tetrathiomolybdate, for Wilson’s disease, 865 Thalamotomy, for Parkinson’s disease, 914 Thalassemia, 269, 269t treatment of, 272 Thalidomide for leprosy, 503 for multiple myeloma, 304 Thallium 201 imaging, in coronary artery disease, 631 Thallium poisoning, 88 Theophylline for asthma, 670t, 671 for COPD, 677, 677t poisoning, 88 Thermoregulatory sweat test, 928 Thiabendazole, for strongyloidiasis, 583 Thiamine for alcoholism, 974 deficiency of, 16t for status epilepticus, 72 Thigh, muscles and innervation of, 868t– 869t Thioridazine, dosage and adverse effects of, 967t Thiothixene, dosage and adverse effects of, 967t Thoracentesis, 28, 667 Thoracic disease, actinomycosis, 494 Thoracic outlet syndrome arterial, 154 disputed, 154 true neurogenic, 154 Thoracic surgery, video-assisted, 667 Throat culture, 353t, 456 Thromboangiitis obliterans, 656 1081 Thrombocytopenia, 275 drug-induced, 275, 983t treatment of, 277 Thrombocytosis, 276 essential, 296 Thromboembolism, drug-induced, 984t Thrombolytic therapy for arterial embolism, 656 for myocardial infarction, 624f for stroke, 61, 62t Thrombophlebitis, superficial, 657 Thrombotic disorders, 277 Thrombotic thrombocytopenic purpura (TTP), 276 treatment of, 277 Thrush, oral, 557 Thumb, muscles and innervation of, 868t– 869t Thymectomy, for myasthenia gravis, 944 Thymoma, 348t, 693, 779, 942 Thyroid adenoma, 821 toxic, 821 Thyroid cancer, 815, 821 treatment of, 822 Thyroid disease, 815 amiodarone-related, 820 drug-induced, 980t goiter nontoxic, 820– 821 toxic multinodular, 821 hypothyroidism, 815– 817 neoplastic, 815 sick euthyroid syndrome, 820 thyrotoxicosis, 818– 820 toxic adenoma, 821 Thyroid nodule, solitary, 821 approach to, 822f Thyroid-stimulating hormone (TSH), 807, 809t, 815 deficiency of, 811– 812 replacement therapy, 812t Thyroid-stimulating hormone-secreting tumor, 809, 811 Thyroid storm See Thyrotoxic crisis Thyrotoxic crisis, 818 treatment of, 819– 820 Thyrotoxicosis, 815, 818, 821 causes of, 818 evaluation of, 818, 819f treatment of, 818– 820 Thyrotropin-releasing hormone (TRH), 815 Thyroxine, 815– 823 for hypopituitarism, 812 Tiagabine for generalized anxiety disorder, 959 for seizures, 882t Tic(s), 178– 179 Ticarcillin, for Pseudomonas aeruginosa infections, 476t Ticarcillin/clavulanate for anaerobic infections, 491t for Pseudomonas aeruginosa infections, 476t 1082 Index Ticarcillin/clavulanate (Cont.): for sepsis, 52t for urinary tract infections, 726t Tic douloureux See Trigeminal neuralgia Tick bite, 114 treatment of, 114– 115 Tick-borne relapsing fever, 509 Tick-borne spotted fever, 510 Tick paralysis, 114 Tidal irrigation, for osteoarthritis, 795 Tidal volume, 663f Tilt-table testing, 928 Timolol for glaucoma, 242– 243 for migraine prophylaxis, 145t for myocardial infarction prophylaxis, 630 Tinea capitis, 262 Tinea cruris, 257f, 262 Tinea pedis, 256f, 257f, 262 Tinea unguium, 262 Tinnitus, 247 treatment of, 248 Tirofiban, for acute coronary syndromes, 635 Tissue plasminogen activator (tPA) for myocardial infarction, 624f for stroke, 61, 62t for thrombotic disorders, 279 Tobramycin for gram-negative sepsis, 96t for osteomyelitis, 416t for Pseudomonas aeruginosa infections, 476t for sepsis, 52t Toes, muscles and innervation of, 868t– 869t Tolcapone, for Parkinson’s disease, 914 Tolnaftate, for dermatophyte infections, 262 Tolosa-Hunt syndrome, 925 Tongue, geographic, 258f Tongue paralysis, 924 Tophi, 796 Topiramate for bipolar disorder, 957 for seizures, 882t Topoisomerase inhibitors, 287t Torsades de pointes, 643t Total lung capacity, 663, 663f, 665t Toxemia of pregnancy, 731 Toxic epidermal necrolysis, drug-induced, 982t Toxic granulations, 265 Toxicologic analysis, for poisoning or drug overdose, 75 Toxic shock syndrome, 97t staphylococcal, 100, 451 treatment of, 455 streptococcal, 100, 457– 458, 457t Toxins, renal disease and, 721t Toxoplasmosis, 578 brain abscess, 894 congenital, 579 diagnosis of, 359t HIV and, 579– 580 meningitis, 897t ocular, 579 prevention of, 580 treatment of, 579 Trace minerals, reference values for laboratory tests, 1004t Tracheobronchitis Moraxella catarrhalis, 468 respiratory syncytial virus, 538 Trachoma, 518 treatment of, 518 Tramadol abuse of, 975 for osteoarthritis, 795 for pain, 27t Transaminases, blood, 220– 221, 222t Transfusion, 17 autologous, 18 complications of, 18, 18t exchange, 17, 570 for GI bleeding, 217 of plasma components, 19 platelet, 18 red blood cell, 17– 18 for shock, 47f whole blood, 17 Transient hypogammaglobulinemia of infancy, 778 Transient ischemic attack (TIA), 58 Transjugular intrahepatic portosystemic shunt (TIPS), 771 for ascites, 225 Transplant recipient cytomegalovirus infection in, 530 infections in, 421 Transurethral microwave thermotherapy (TUMT), for prostate hyperplasia, 338 Transurethral resection of prostate (TURP), 338 Tranylcypromine, dosage and adverse effects of, 965t Trastuzumab, for breast cancer, 320 Travel advice, 366 gastrointestinal illness, 366, 369 for HIV-infected traveler, 369– 371 immunization, 366, 371t malaria prevention, 366 in pregnancy, 369 problems after return, 371– 372 Traveler’s diarrhea, 384 Trazodone, 963 dosage and adverse effects of, 965t for insomnia, 183 for posttraumatic stress disorder, 960 Trematode infection, 585 liver flukes, 586– 587 lung flukes, 587 schistosomiasis, 585– 586 Tremor, 177 in Parkinson’s disease, 910 Trench fever, 483, 484t Index Trench mouth, 489 Treponema pallidum infection See Syphilis Treponematosis, endemic, 507 treatment of, 508 Treprostinil, for pulmonary hypertension, 661 Triamcinolone for asthma, 671 for cough, 189 Triamterene, for edema, 196t Triazolam dosage and adverse effects of, 966t for insomnia, 183 Triazoles, 555 Trichinellosis, 580 meningitis, 897t treatment of, 581 Trichloroacetic acid, for human papillomavirus infections, 407 Trichomoniasis, 396– 397 urethritis, 393 Triclabendazole, for liver flukes, 587 Tricuspid regurgitation, 608 treatment of, 608 Tricuspid stenosis, 608 treatment of, 608 Tricuspid valve endocarditis, 373 Tricyclic antidepressants, 963 dosage and adverse effects of, 964t Trientene, for Wilson’s disease, 864– 865 Trifluoperazine, dosage and adverse effects of, 967t Trifluorothymidine, for herpes simplex virus infections, 525t Trigeminal nerve (V), 870 disorders of, 920, 921t sensory divisions of, 921f Trigeminal neuralgia, 147, 920 treatment of, 920 Trigeminal neuropathy, 920 causes of, 920– 921, 921t Trihexyphenidyl for extrapyramidal side effects, 969 for Parkinson’s disease, 914 Triiodothyronine, 815– 823 Trimethoprim mechanisms, indications, and adverse effects of, 363– 364 for Pneumocystis infections, 567t for urinary tract infection prophylaxis, 727 Trimethoprim-sulfamethoxazole (TMPSMX) for animal bites, 107t, 108t for Aeromonas infections, 474 for brucellosis, 480 for Burkholderia cepacia infections, 477 for COPD, 677– 678 for cyclosporiasis, 387 for HACEK endocarditis, 469t for Haemophilus influenzae infections, 467 1083 for isosporiasis, 387 for Legionella infections, 479 for listeriosis, 466 for Moraxella catarrhalis infections, 468 for nephrolithiasis, 733t for nocardiosis, 493, 493t for otitis media, 251t for peritonitis prophylaxis, 381 for pertussis, 468 for Pneumocystis infections, 567, 567t for Pneumocystis prophylaxis, 568t for salmonellosis, 389 for shigellosis, 390 for sinusitis, 250t for spontaneous bacterial peritonitis, 225 for Staphylococcus aureus infections, 453t, 454 for Stenotrophomonas maltophilia infections, 477 for toxoplasmosis prophylaxis, 580 for urinary tract infection prophylaxis, 727 for urinary tract infections, 726t Trimetrexate, for Pneumocystis infections, 567t Trophozoite, 569 Troponins, cardiac-specific, 622 Trypanosomiasis, 576 Tuberculosis, 495 AIDS and, 497 brucellosis versus, 480t diagnosis of, 497– 498 epidemiology of, 495– 496 extrapulmonary, 496– 497 latent, 500, 501t– 502t miliary, 497 multidrug-resistant, 495, 499 nosocomial, 444 osteomyelitis, 414 pathogenesis of, 496 pleural effusion in, 691 prevention of, 500 pulmonary postprimary disease, 496 primary disease, 496 treatment of, 498– 500, 499t, 501t– 502t Tubular necrosis acute, azotemia in, 228f drug-induced, 986t Tubulin poisons, 287t Tubulointerstitial disease, 720 Tularemia, 95, 106, 480 as bioweapon, 121t, 124 oculoglandular, 481 oropharyngeal, 481 pulmonary, 481 treatment of, 121t, 481 typhoidal, 481 ulceroglandular, 481 Tumor lysis syndrome, 104 treatment of, 104 1084 Index Turcot’s syndrome, 325, 325t Two-point discrimination, 873 Tympanometry, 244 Typhoid fever, 388 treatment of, 388 Typhoid vaccine, 371t Typhus fever flea-borne, 512– 513 louse-borne, 512– 513 Tzanck preparation, 258, 522 Ulcer peptic See Peptic ulcer disease skin, 256, 409 Ulcerative colitis, 742 arthritis in, 799 extraintestinal manifestations of, 743 treatment of, 743– 745, 744t– 745t Ulcerative genital lesions, 398 Ulnar neuropathy, 940t, 941 Ultrasonography in abdominal pain, 139 in acute abdomen, 207 in aortic aneurysm, 653 in aortic dissection, 654 in biliary tract disease, 750t Doppler, in peripheral vascular disease, 656– 657 endoscopic, 741 in biliary tract disease, 750t hepatobiliary, 223 indications for, 32– 33 neuroimaging, 874t in osteomyelitis, 415t in pancreatitis, 754, 756 renal, 707 utility of, 32– 33 Undecylenic acid, for dermatophyte infections, 262 Upper motor neuron dysfunction, 175 weakness in, 176t, 177t Upper respiratory infection, 248 ear infections, 252– 253 larynx and epiglottis, 253– 254 nonspecific, 248 pharyngitis, 253 sinusitis, 248– 252 Urate nephrosis, 797 Urea breath test, 738t Ureaplasma urealyticum infection, 402 urethritis, 393 Ureidopenicillin, for acute cholecystitis, 751 Uremic syndrome, 708 Ureteral obstruction, 734 Urethral syndrome, in women, 396 Urethritis, 724 clinical features of, 724 gonococcal, 393– 396, 399 in men, 393 treatment of, 393– 396 nongonococcal, 393– 396, 402 in women, 396 Uric acid nephropathy, 797 Uric acid stones, 732, 733t, 797 Urinalysis in acute renal failure, 703– 705, 705t in chronic renal failure, 708 reference values for specific analytes, 1005t toxicologic analysis, 75 in urinary tract infections, 725 urine culture, 354t Urinary abnormalities approach to, 700t, 701 asymptomatic, 701, 718, 718t glomerular causes of, 718t urine composition, 230 urine volume, 228 Urinary tract infection (UTI), 724 acute, 724 approach to, 700t, 701 clinical features of, 724 complicated, 726t device-related, 442– 443 emphysematous pyelonephritis, 727 enterococcal, 459 Escherichia coli, 471 gram-negative enteric bacteria, 473 Klebsiella, 472 nephrolithiasis and, 731 nosocomial, 442– 443 papillary necrosis, 727 prevention of, 727 prostatitis, 727 Proteus, 473 Pseudomonas aeruginosa, 475 Staphylococcus aureus, 450 treatment of, 725, 726t Urinary tract obstruction, 734 approach to, 701t, 702, 735f clinical features of, 734, 735f treatment of, 706, 734– 735 Urogenital secretions, culture of, 354t Urokinase, for thrombotic disorders, 279 Ursodeoxycholic acid for cholelithiasis, 750 for primary biliary cirrhosis, 768 for primary sclerosing cholangitis, 753 Urticaria, 263– 264, 773 drug-induced, 982t treatment of, 774 Uterine bleeding abnormal, 839 treatment of, 839– 840 dysfunctional (anovulatory), 839 Vaginal infection diagnosis of, 394t treatment of, 394t Vaginitis, trichomonal, 394t– 395t Vaginosis, bacterial, 394t– 395t, 396– 397, 402 Vagotomy, for peptic ulcer disease, 739t Vagus nerve (X), 872 disorders of, 923 Index Valacyclovir for genital herpes, 406 for herpes simplex virus infections, 523, 524t– 525t for herpes zoster, 527 for viral meningitis, 892 Valganciclovir for cytomegalovirus infections, 530 for viral esophagitis, 205 Valproic acid, 969 for bipolar disorder, 957 for brain tumor, 883 dosage and adverse effects of, 968t for myoclonus, 177 for seizures, 880t– 881t, 882t Valsalva maneuver, 928 Valsartan, for myocardial infarction, 625 Valvular heart disease, 603 See also specific valves echocardiography in, 602, 602f preoperative evaluation of, 36 Vancomycin for acute bacterial endocarditis, 99t for bacterial meningitis, 890t, 891t for brain abscess, 894 for Clostridium difficile-associated disease, 392 for endocarditis, 375, 376t– 377t for endocarditis prophylaxis, 379t for enterococcal infections, 459 for gram-positive sepsis, 96t for HACEK endocarditis, 469t for hepatic encephalopathy, 772 for infectious arthritis, 413 mechanisms, indications, and adverse effects of, 362 for osteomyelitis, 416t for pneumococcal infections, 447 for pneumonia, 681t, 682t– 683t for sepsis, 52t for Staphylococcus aureus infections, 452t– 453t, 454 for streptococcal infections, 459 Varicella vaccine, 367f, 368f, 370f, 994t in immunocompromised patients, 423t Varicella-zoster immune globulin, 528t Varicella-zoster virus infection, 523 diagnosis of, 526– 527 encephalitis, 892– 893 Vascular disorders See also Cardiovascular disease abdominal pain in, 137t gastrointestinal, 748 headache with, 140t skin conditions, 263– 264 syncope in, 166t Vascular malformation, chronic myelopathy and, 935 Vascular shunting, anatomic, cyanosis in, 192, 193t Vasculitis, 264, 785 approach to, 787, 787f azotemia in, 228f cutaneous, 786 1085 definition and pathogenesis of, 785– 786 isolated, of CNS, 786 primary vasculitis syndromes, 786 renal disease and, 715, 731 secondary vasculitis syndromes, 787 treatment of, 264, 788 Vasodilators, for heart failure, 626, 650– 651, 651t Vasopressin, 813 for cardiac arrest, 43f for diverticulosis, 217 for esophagogastric varices, 771 replacement therapy, 812t for shock, 48, 48t Vasopressors, for shock, 48t Vasospasm, in subarachnoid hemorrhage, 66 Vasospastic disorders, 656 treatment of, 656 Venezuelan equine encephalitis, 552t, 893t Venlafaxine, 963 dosage and adverse effects of, 965t for pain, 27t Venous obstruction, edema in, 194, 195f Ventilatory function, disturbances in, 663, 663f, 664f, 664t, 665t, 695 extraparenchymal, 663 obstructive, 663, 664t parenchymal, 663 restrictive, 663, 664t Ventilatory support for amyotrophic lateral sclerosis, 920 for ARDS, 40 care of ventilated patient, 21 indications in critically ill patient, 20 for respiratory failure, 23, 678 weaning from mechanical ventilation, 21 Ventricular aneurysm myocardial infarction and, 630 pseudoaneurysm, 630 true, 630 Ventricular arrhythmia, myocardial infarction and, 625 Ventricular fibrillation, 639f, 642t management of cardiac arrest, 41, 43f myocardial infarction and, 625 Ventricular hypertrophy, 602 Ventricular premature beats, 642t Ventricular septal rupture, 627– 628 Ventricular tachycardia, 639f, 642t electrocardiography in, 644t management of cardiac arrest, 43f myocardial infarction and, 625 from poisoning/drug overdose, 76 Verapamil for aortic dissection, 654 for arrhythmias, 641t for hypertrophic cardiomyopathy, 611 for migraine prophylaxis, 142, 145t for mitral stenosis, 604 for supraventricular arrhythmias, 626 1086 Index Verruca peruana, 483, 484t Verruca plana, 256f Verruca vulgaris, 257f Verrucous carcinoma, 308 Vertebral fracture, 148, 852 Vertebral metastasis, back pain in, 148– 150 Vertebrobasilar insufficiency, visual loss in, 173 Vertigo, 168 approach to, 171 benign paroxysmal positional, 169t, 170 benign positional, 171 central, 168, 169t, 170 central positional, 169t pathologic, 168 peripheral, 168, 169t physiologic, 168 psychogenic, 170 treatment of, 170t, 171 Vesicants, 125– 126 Vesicle, 255, 409 Vestibular disorder, drug-induced, 987t Vestibular neuronitis, 169 Vestibular schwannoma, 246 Vibrio cholerae infection See Cholera Vibrio cholerae non-O1 infection, 385 Vibrio parahaemolyticus infection, diarrhea, 385 Vibrio vulnificus infection, 100 Vinblastine, for lung cancer, 313 Vincent’s angina, 489 Vincristine for acute lymphoid leukemia/lymphoma, 302 for multiple myeloma, 304 Vindesine, for lung cancer, 313 Vinorelban, for lung cancer, 313 Vinorelbine, for breast cancer, 320 Violence, against women, 990, 992t VIPoma, 329, 330t Viral disease, diagnosis of, 351, 357t Virilization, 843 Visceral abscess, 382– 383 Visceral disease, back pain in, 150, 151t Visceral distention, pain in, 137t Visceral spasm, pain in, 137t Vision testing, 868– 869 Visual cortex lesions, 172f Visual field mapping, 172, 172f Visual loss acute, 171, 241– 242 chronic, 242– 244 causes of, 243t transient or sudden, 173 Vital capacity, 663f, 665t Vitamin(s) reference values for laboratory tests, 1004t therapy for vitamin deficiencies, 16t Vitamin A, for measles, 540– 541 Vitamin A deficiency, 16t Vitamin B12 deficiency, 907, 936 anemia and, 269 treatment of, 271 Vitamin C for macular degeneration, 243 for nephrolithiasis, 733t Vitamin C deficiency, 16t Vitamin D for osteomalacia, 855 for osteoporosis, 854 for primary biliary cirrhosis, 768 for primary sclerosing cholangitis, 753 for psoriasis, 259 Vitamin D deficiency, 854– 855 Vitamin E for Alzheimer’s disease, 909 for macular degeneration, 243 for menopausal symptoms, 845 Vitamin E deficiency, 16t, 915 Vitamin K, for primary biliary cirrhosis, 768 Vitamin K deficiency, 16t, 276– 277 Vitreous detachment, 173 Vitreous hemorrhage, 173 Vomiting, 197 See also Nausea and vomiting von Hippel-Lindau disease, 332 von Willebrand’s disease, 276 treatment of, 277 Voriconazole, 555– 556 for aspergillosis, 559 for fusariosis, 564 for pseudoallescheriasis, 565 V/Q nuclear scan, in pulmonary hypertension, 659, 660f Vulvovaginal infection, 396 Waldenstroăms macroglobulinemia, 719t Warfarin for cor pulmonale, 652 for deep venous thrombosis, 657 for deep venous thrombosis prevention, 658 for dilated cardiomyopathy, 609 for heparin-induced thrombocytopenia, 277 for mitral stenosis, 604 for renal vein thrombosis, 728 for stroke prevention, 65, 65t for thrombotic disorders, 278t, 279 for thyrotoxicosis, 819 Warts, 262 anal, 749 treatment of, 262 Wasp sting, 114 Water restriction for hyponatremia, 5– for syndrome of inappropriate ADH, 103 Weakness, 175 See also Muscle weakness approach to, 178f causes of, 177t Index Weakness (Cont.): from different areas of nervous system, 176t Weaning, for mechanical ventilation, 21 Weaponization, 118 Weber test, 244, 872 Wegener’s granulomatosis, 715, 786, 788 Weight, ideal weight for height, 3t Weight loss, 201 causes of, 201, 201t drug-induced, 201t laboratory evaluation of, 202t Weil’s syndrome, 508 Wernicke-Korsakoff’s syndrome, 973– 974 Wernicke’s aphasia, 179, 180t Western equine encephalitis, 552t, 893t West Nile virus encephalitis, 550, 552t, 892, 893t, 894 Wet mount, 351 Wheal, 255 Whiplash injury, 154 Whipple’s disease, 799 Whipple’s triad, 92, 93f Whitlow, herpetic, 521, 524t Whole blood transfusion, 17 Whole-bowel irrigation, 77 Widow spider bite, 113 treatment of, 113 Wilson’s disease, 864 treatment of, 864– 865 Winking owl sign, 102 Winterbottom’s sign, 577 Wiskott-Aldrich syndrome, 779 Withdrawal of care, 21– 22 Wolff-Parkinson-White syndrome, 639f, 644 Women’s health, 989 Alzheimer’s disease, 989 autoimmune disease, 989 coronary artery disease, 989 diabetes mellitus, 989 drug-induced illness, 990 HIV infection, 990 hypertension, 989 osteoporosis, 990 psychiatric disorders, 990 substance abuse, 990 violence, 990 Wood’s light examination, 259 Work hardening, 151 1087 Wound infection culture of wound material, 355t nosocomial, 443 Wrist, muscles and innervation of, 868t– 869t Wuchereria bancrofti infection, 584 Xanthelasma, 258f, 857 Xanthoma eruptive, 857 tendon, 857 tuberous, 857 X-rays See also Abdominal x-ray; Chest x-ray bioterrorism, 129 in osteomyelitis, 415t Yaws, 507– 508 Yeast, 555 Yellow fever, 553 Yellow fever vaccine, 371t Yersinia pestis infection, 122– 123 See also Plague Yersiniosis, 390– 391 diagnosis of, 353t reactive arthritis, 792 treatment of, 391 Zafirlukast, for asthma, 670t, 671 Zalcitabine, for HIV infections, 429t Zaleplon, for insomnia, 183 Zanamivir for influenza, 535 for influenza prophylaxis, 536 Zap70 kinase deficiency, 777 Zidovudine, for HIV infections, 428t, 438 Zileuton, for asthma, 670t, 671 Zinc deficiency, 16t Zinc therapy for macular degeneration, 243 for Wilson’s disease, 864– 865 Ziprasidone, dosage and adverse effects of, 967t Zoledronate, for hypercalcemia, 103, 345, 849t Zollinger-Ellison syndrome, 329, 330t, 740 diagnosis of, 741, 741t treatment of, 741 Zolmitriptan, for migraine, 143t Zolpidem, for insomnia, 183, 184t Zonisamide, for seizures, 882t Zoster ophthalmicus, 526– 527 ... FIGURE 122 -2 Approach to the hypertensive patient after initiating antihypertensive drug treatment See Fig 122 -1 for initial steps and definition of risk and Table 122 -1 for initial choice of agents... aVL aVF V1 V2 V3 V4 V5 599 V6 11 /29 12/ 5 aVF V2 2 FIGURE 118-4 Acute inferior wall myocardial infarction The ECG of 11 /29 shows minor nonspecific ST-segment and T-wave changes On 12/ 5 an acute... combination therapy as initial treatment FIGURE 122 -1 Initiation of treatment in patients with hypertension See Table 122 -1 for listing of classes of agents to use initially In the initial evaluation,