LWBK634_FM[i-x].qxd 7/6/10 10:03PM Page i Aptara Inc POCKET N OT E B O O K Pocket MEDICINE Fourth Edition Edited by MARC S SABATINE, M.D., M.P.H ASSOCIATE PROFESSOR OF MEDICINE HARVARD MEDICAL SCHOOL The Massachusetts General Hospital Handbook of Internal Medicine LWBK634_FM[i-x].qxd 7/6/10 10:03PM Page ii Aptara Inc Acquisitions Editor: Sonya Seigafuse Product Manager: Kerry Barrett Production Manager: Bridgett Dougherty Senior Manufacturing Manager: Benjamin Rivera Marketing Manager: Kim Schonberger Design Coordinator: Doug Smock Production Service: Aptara © 2011 by LIPPINCOTT WILLIAMS & WILKINS, a WOLTERS KLUWER business Two Commerce Square 2001 Market Street Philadelphia, PA 19103 USA LWW.com All rights reserved.This book is protected by copyright No part of this book may be reproduced in any form by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews Materials appearing in this book prepared by individuals as part of their official duties as U.S government employees are not covered by the above-mentioned copyright Printed in China Library of Congress Cataloging-in-Publication Data Pocket medicine / edited by Marc S Sabatine.–4th ed p ; cm “The Massachusetts General Hospital Handbook of Internal Medicine.” Includes bibliographical references and index ISBN-13: 978-1-60831-905-3 (domestic : alk paper) ISBN-10: 1-60831-905-9 (domestic : alk paper) ISBN-13: 978-1-4511-0335-9 (international : alk paper) ISBN-10: 1-4511-0335-2 (international : alk paper) Internal medicine–Handbooks, manuals, etc I Sabatine, Marc S II Massachusetts General Hospital [DNLM: Internal Medicine–Handbooks Clinical Medicine–Handbooks WB 39 P7394 2011] RC55.P63 2011 616–dc22 2010024523 DISCLAIMER Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication Application of the information in a particular situation remains the professional responsibility of the practitioner The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, 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 is particularly important when the recommended agent is a new or infrequently employed drug Some drugs and medical devices presented in the publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320 International customers should call (301) 223-2300 Visit Lippincott Williams & Wilkins on the Internet: at LWW.com Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to pm, EST 10 LWBK634_FM[i-x].qxd 7/6/10 10:03PM Page iii Aptara Inc C ONT E NT S Contributing Authors Foreword Preface vi ix x CARDIOLOGY Rajat Gupta,Viviany R.Taqueti, David M Dudzinski, Rory B.Weiner, Michelle O’Donoghue, Marc S Sabatine Electrocardiography Chest Pain Noninvasive Evaluation of CAD Coronary Angiography and Revascularization Acute Coronary Syndromes PA Catheter and Tailored Therapy Heart Failure Cardiomyopathies Valvular Heart Disease Pericardial Disease Hypertension Aortic Aneurysm Acute Aortic Syndromes Arrhythmias Atrial Fibrillation Syncope Intracardiac Devices Cardiac Risk Assessment for Noncardiac Surgery 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 PULMONARY Mary Berlik Rice, Kathryn A Hibbert, Atul Malhotra Dyspnea Pulmonary Function Tests (PFTs) Asthma Chronic Obstructive Pulmonary Disease Hemoptysis Solitary Pulmonary Nodule Obstructive Sleep Apnea (OSA) Interstitial Lung Disease Pleural Effusion Venous Thromboembolism (VTE) Pulmonary Hypertension (PHT) Respiratory Failure Mechanical Ventilation Acute Respiratory Distress Syndrome Sepsis 2-1 2-1 2-2 2-5 2-7 2-7 2-8 2-9 2-11 2-13 2-16 2-18 2-19 2-22 2-23 GASTROENTEROLOGY Louis J Cohen, Andrew S de Lemos, Lawrence S Friedman Esophageal and Gastric Disorders Gastrointestinal Bleeding Diarrhea, Constipation, and Ileus Diverticular Disease Inflammatory Bowel Disease 3-1 3-3 3-5 3-9 3-10 LWBK634_FM[i-x].qxd 7/6/10 10:03PM Page iv Aptara Inc Intestinal Ischemia Pancreatitis Abnormal Liver Tests Hepatitis Acute Liver Failure Cirrhosis Hepatic Vascular Disease Ascites Biliary Tract Disease 3-12 3-13 3-15 3-17 3-20 3-21 3-25 3-26 3-27 NEPHROLOGY Andrew L Lundquist, Eugene P Rhee, Hasan Bazari Acid-Base Disturbances Sodium and Water Homeostasis Potassium Homeostasis Renal Failure Glomerular Disease Urinalysis Nephrolithiasis 4-1 4-6 4-10 4-12 4-16 4-18 4-19 HEMATOLOGY-ONCOLOGY Andrew J Aguirre, Franklin W Huang, David B Sykes, David T Ting, Daniel J DeAngelo, David P Ryan Anemia Disorders of Hemostasis Platelet Disorders Coagulopathies Hypercoagulable States Disorders of Leukocytes Transfusion Therapy Myelodysplastic Syndromes (MDS) Myeloproliferative Neoplasms (MPN) Leukemia Lymphoma Plasma Cell Dyscrasias Hematopoietic Stem Cell Transplantation (HSCT) Lung Cancer Breast Cancer Prostate Cancer Colorectal Cancer (CRC) Pancreatic Tumors Oncologic Emergencies Cancer of Unknown Primary Site 5-1 5-6 5-7 5-10 5-11 5-12 5-13 5-14 5-15 5-17 5-21 5-24 5-26 5-28 5-30 5-32 5-33 5-35 5-36 5-37 INFECTIOUS DISEASES Roby P Bhattacharyya, Rachel P Simmons, Nesli Basgoz Pneumonia Fungal Infections Infections in Susceptible Hosts Urinary Tract Infections (UTI) Soft Tissue and Bone Infections Infections of the Nervous System Bacterial Endocarditis Tuberculosis 6-1 6-3 6-4 6-5 6-6 6-9 6-12 6-15 LWBK634_FM[i-x].qxd 7/6/10 10:03PM Page v Aptara Inc HIV/AIDS Tick-Borne Diseases Fever of Unknown Origin (FUO) 6-17 6-21 6-23 ENDOCRINOLOGY Alaka Ray, Geoffrey A.Walford, Michael Mannstadt Pituitary Disorders Disorders of Multiple Endocrine Systems Thyroid Disorders Adrenal Disorders Calcium Disorders Diabetes Mellitus Lipid Disorders 7-1 7-2 7-3 7-7 7-11 7-13 7-16 RHEUMATOLOGY Gwen C Crevensten, Katherine P Liao, Robert P Friday Arthritis—Overview Rheumatoid Arthritis (RA) Relapsing Polychondritis Crystal Deposition Arthritides Seronegative Spondyloarthritis Infectious Arthritis & Bursitis Connective Tissue Diseases Systemic Lupus Erythematosus (SLE) Vasculitis Cryoglobulinemia Amyloidosis 8-1 8-3 8-4 8-5 8-7 8-9 8-11 8-15 8-17 8-21 8-22 NEUROLOGY David Y Hwang, Atul Maheshwari, Mikael L Rinne, David M Greer Change in Mental Status Seizures Alcohol Withdrawal Stroke Weakness & Neuromuscular Dysfunction Headache Back and Spinal Cord Disease 9-1 9-3 9-5 9-6 9-8 9-10 9-11 APPENDIX ACLS Algorithms ICU Medications Antibiotics Formulae and Quick Reference 10-1 10-4 10-6 10-7 ABBREVIATIONS 11-1 INDEX I-1 PHOTO INSERTS Radiology Echocardiography Coronary Angiography Peripheral Blood Smears Leukemias Urinalysis P-1 P-9 P-13 P-13 P-14 P-15 LWBK634_FM[i-x].qxd 7/6/10 10:03PM Page vi Aptara Inc C ONTR I B UT I NG A UT HOR S Andrew J Aguirre, MD, PhD 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 Attending Physician, Nephrology Unit, Massachusetts General Hospital Program Director, Internal Medicine Residency, Massachusetts General Hospital Associate Professor of Medicine, Harvard Medical School Roby P Bhattacharyya, MD, PhD Internal Medicine Resident, Massachusetts General Hospital Louis J Cohen, MD Internal Medicine Resident, Massachusetts General Hospital Gwen C Crevensten, MD Internal Medicine Resident, Massachusetts General Hospital Andrew S de Lemos, MD Gastroenterology Fellow, Massachusetts General Hospital Daniel J DeAngelo, MD, PhD Clinical Director, 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 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 David M Greer, MD, MA Director, Neurological Consultation Service, Massachusetts General Hospital Program Director, Partners Neurology Residency Program Associate Professor of Neurology, Harvard Medical School LWBK634_FM[i-x].qxd 7/6/10 10:03PM Page vii Aptara Inc Rajat Gupta, MD Internal Medicine Resident, Massachusetts General Hospital Kathryn A Hibbert, MD Pulmonary and Critical Care Fellow, Harvard Medical School Franklin W Huang, MD, PhD Internal Medicine Resident, Massachusetts General Hospital David Y Hwang, MD Neurology Resident, Partners Neurology Residency Katherine P Liao, MD, MPH Rheumatology Fellow, Brigham and Women’s Hospital Andrew L Lundquist, MD Internal Medicine Resident, Massachusetts General Hospital Atul Maheshwari, MD Neurology Resident, Partners Neurology Residency Atul Malhotra, MD Associate Physician, Divisions of Pulmonary & Critical Care and Sleep Medicine, Brigham and Women’s Hospital Medical Director of the Brigham Sleep Disorders Program Associate Professor of Medicine, Harvard Medical School Michael Mannstadt, MD Assistant Physician, Endocrine Unit, Massachusetts General Hospital Instructor in Medicine, Harvard Medical School Michelle O’Donoghue, MD, MPH Investigator,TIMI Study Group and Associate Physician, Cardiovascular Division, Brigham and Women’s Hospital Affiliate Physician, Cardiology Division, Massachusetts General Hospital Instructor in Medicine, Harvard Medical School Alaka Ray, MD Internal Medicine Resident, Massachusetts General Hospital Eugene P Rhee, MD Nephrology Fellow, BWH/MGH Joint Nephrology Fellowship Program Mary Berlik Rice, MD Internal Medicine Resident, Massachusetts General Hospital Mikael L Rinne, MD, PhD Neurology Resident, Partners Neurology Residency David P Ryan, MD Clinical Director, Massachusetts General Hospital Cancer Center Associate Chief of Hematology/Oncology, Massachusetts General Hospital Associate Professor of Medicine, Harvard Medical School LWBK634_FM[i-x].qxd 7/6/10 10:03PM Page viii Aptara Inc Marc S Sabatine, MD, MPH Vice Chair,TIMI Study Group and Associate Physician, Cardiovascular Division, Brigham and Women’s Hospital Affiliate Physician, Cardiology Division, Massachusetts General Hospital Associate Professor of Medicine, Harvard Medical School Rachel P Simmons, MD Infectious Disease Fellow, Massachusetts General Hospital and Brigham and Women’s Hospital David B Sykes, MD, PhD Hematology-Oncology Fellow, Dana-Farber/Partners CancerCare Hematology/Oncology Program Viviany R.Taqueti, MD Internal Medicine Resident, Massachusetts General Hospital David T.Ting, MD Hematology-Oncology Fellow, Dana-Farber/Partners CancerCare Hematology/Oncology Program Geoffrey A.Walford, MD Endocrinology Fellow, Massachusetts General Hospital Rory B.Weiner, MD Cardiology Fellow, Massachusetts General Hospital PHOTO INSERT P-2 LWBK634_CP[1-16].qxd 7/9/10 6:56 AM Page Aptara Inc Interstitial pulmonary edema: with Kerley A, B, and C lines and cephalization of the vascular markings (Fund Diag Radiology 3rd ed, 2006.) Alveolar pulmonary edema (Fund Diag Radiology 3rd ed, 2006.) Right upper lobe pneumonia (Radiology 101, 3rd ed, 2009.) LWBK634_CP[1-16].qxd 7/9/10 6:56 AM Page Aptara Inc PHOTO INSERT P-3 Right middle lobe pneumonia (Radiology 101, 3rd ed, 2009.) Right lower lobe pneumonia (PA) (Radiology 101, 3rd ed, 2009.) Right lower lobe pneumonia (lateral) (Radiology 101, 3rd ed, 2009.) PHOTO INSERT P-4 LWBK634_CP[1-16].qxd 7/9/10 6:56 AM Page Aptara Inc 10 Bilateral pleural effusions (curved arrows) and enlarged azygous vein (straight arrow) (PA) (Radiology 101, 3rd ed, 2009.) 11 Bilateral pleural effusions (curved arrows) (lateral) (Radiology 101, 3rd ed, 2009.) 12 Pneumothorax (Radiology 101, 3rd ed, 2009.) P-5 (Radiology 101, 3rd ed, 2009.) PHOTO INSERT 13 Normal chest CT at level of pulmonary arteries (parenchymal windows) LWBK634_CP[1-16].qxd 7/9/10 6:56 AM Page Aptara Inc PHOTO INSERT P-6 LWBK634_CP[1-16].qxd 7/9/10 6:56 AM Page Aptara Inc 14 Bilateral PE (mediastinal windows) (Radiology 101, 3rd ed, 2009.) 15 Sarcoidosis with perilymphatic nodules (Fund Diag Radiology 3rd ed, 2006.) 16 Idiopathic pulmonary fibrosis (Fund Diag Radiology 3rd ed, 2006.) PHOTO INSERT P-7 17 Normal abdomen CT at level of liver & spleen (Radiology 101, 3rd ed, 2009.) LWBK634_CP[1-16].qxd 7/9/10 6:56 AM Page Aptara Inc 18 Normal abdomen CT at level of pancreas (Radiology 101, 3rd ed, 2009.) PHOTO INSERT P-8 LWBK634_CP[1-16].qxd 7/9/10 6:56 AM Page Aptara Inc LWBK634_CP[1-16].qxd 07/22/2010 1:48 PM Page Aptara Echocardiography Right coronary cusp Ventricular septum Left ventricular outflow tract Anterior mitral leaflet Left atrium Posteromedial papillary muscle Coronary sinus Posterior mitral leaflet Parasternal long-axis view allows visualization of the right ventricle (RV), ventricular septum (VS), posterior wall (PW) aortic valve cusps, left ventricle (LV), mitral valve, left atrium (LA), and ascending thoracic aorta (Ao) *Pulmonary artery (Top: From Mayo Clinic Proceedings [Tajik AJ, Seward JB, Hagler DJ, et al.Two-dimensional real-time ultrasonic imaging of the heart and great vessels:Technique, image orientation, structure identification, and validation Mayo Clinic Proceedings, 1978;53:271–303], with permission Bottom: From Oh JK, Seward JB,Tajik AJ The Echo Manual, 3rd ed Philadelphia: Lippincott Williams & Wilkins, 2006 By permission of Mayo Foundation for Medical Education and Research All rights reserved.) P-9 Noncoronary cusp PHOTO INSERT Right ventricle PHOTO INSERT P-10 LWBK634_CP[1-16].qxd 07/22/2010 1:48 PM Page 10 Aptara Right coronary artery Right ventricular Anterior outflow tract tricuspid Right leaflet coronary Pulmonary cusp valve Left coronary artery Left atrial appendage Right atrium Noncoronary cusp Left coronary cusp Left atrium Atrial septum Inferior Coronary sinus vena cava Parasternal short-axis view at the level of the aorta: LA, left atrium; PV, pulmonary valve; RA, right atrium; RVOT, right ventricular outflow tract (Top: From Mayo Clinic Proceedings [Tajik AJ, Seward JB, Hagler DJ, et al.Two-dimensional real-time ultrasonic imaging of the heart and great vessels:Technique, image orientation, structure identification, and validation Mayo Clinic Proceedings, 1978;53:271–303], with permission Bottom: From Oh JK, Seward JB,Tajik AJ The Echo Manual, 3rd ed Philadelphia: Lippincott Williams & Wilkins, 2006 By permission of Mayo Foundation for Medical Education and Research All rights reserved.) LWBK634_CP[1-16].qxd 07/22/2010 1:48 PM Page 11 Aptara PHOTO INSERT Anterolateral free wall Left ventricle P-11 Anterolateral papillary muscle Right ventricle Posterolateral wall Ventricular septum Posteromedial papillary muscle Parasternal short-axis view at the level of the papillary muscles: AL, anterolateral papillary muscle; PM, posteromedial papillary muscle; RV, right ventricle; VS, ventricular septum; LV, left ventricle (Top: From Mayo Clinic Proceedings [Tajik AJ, Seward JB, Hagler DJ, et al.Two-dimensional real-time ultrasonic imaging of the heart and great vessels:Technique, image orientation, structure identification, and validation Mayo Clinic Proceedings, 1978;53:271–303], with permission Bottom: From Oh JK, Seward JB,Tajik AJ The Echo Manual, 3rd ed Philadelphia: Lippincott Williams & Wilkins, 2006 By permission of Mayo Foundation for Medical Education and Research All rights reserved.) PHOTO INSERT P-12 LWBK634_CP[1-16].qxd 07/22/2010 1:48 PM Page 12 Aptara Papillary muscles: Left ventricle Posteromedial Ventricular septum Right ventricular wall Anterolateral Right ventricle Septal Tricuspid valve leaflets: Anterior Posterolateral wall Mitral valve leaflets: Anterior Posterior Posterior Right atrium Left atrium Atrial Pulmonary veins septum Inferior vena cava Apical four-chamber view: Note that at some institutions the image is reversed so that the left side of the heart appears on the right side of the screen LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle (Top: From Mayo Clinic Proceedings [Tajik AJ, Seward JB, Hagler DJ, et al.Two-dimensional real-time ultrasonic imaging of the heart and great vessels:Technique, image orientation, structure identification, and validation Mayo Clinic Proceedings, 1978;53:271–303], with permission Bottom: From Oh JK, Seward JB,Tajik AJ The Echo Manual, 3rd ed Philadelphia: Lippincott Williams & Wilkins, 2006 By permission of Mayo Foundation for Medical Education and Research All rights reserved.) LWBK634_CP[1-16].qxd 7/9/10 6:57 AM Page 13 Aptara Inc Coronary Angiography RIGHT CORONARY ARTERY 6 3 7 LAO RAO LAO Left anterior descending artery (LAD) Ramus medianus artery Diagonal branches Septal branches Left circumflex artery (LCx) Left atrial circumflex artery Obtuse marginal branches 6 RAO Conus artery SA node artery Acute marginal branches Posterior descending artery (PDA) AV node artery Posterior left ventricular artery (PLV) Coronary arteries (From Grossman WG Cardiac Catheterization and Angiography, 4th ed Philadelphia: Lea & Febiger, 1991, with permission.) Peripheral Blood Smears Normal smear Hypochromic, microcytic anemia due to iron-deficiency Macrocytic anemia due to pernicious anemia; note macro-ovalocytes and hypersegmented neutrophils Spherocytes due to autoimmune hemolytic anemia P-13 2 PHOTO INSERT LEFT CORONARY ARTERY PHOTO INSERT P-14 LWBK634_CP[1-16].qxd 7/9/10 6:57 AM Page 14 Aptara Inc Sickle cell anemia Schistocytes Teardrop shaped RBC (dacrocyte) Acanthocytes Nucleated RBC 10 Rouleaux Leukemias AML with Auer rod ALL LWBK634_CP[1-16].qxd 7/9/10 6:57 AM Page 15 Aptara Inc PHOTO INSERT P-15 CML CLL All photos excluding Leukemias Fig 4: From Wintrobe’s Clin Hematol 12th ed, 2009: Leukemias Fig From Devita, Hellman, and Rosenberg’s Cancer: Princip & Prac of Oncol 8th ed, 2008 Urinalysis Granular cast (College of Am Pathologist, Hyaline cast (Clin Lab Medicine, 2nd ed, with permission.) 2002.) RBC cast (Dis of Kidney & Urinary Tract, WBC cast (Clin Lab Medicine, 2nd ed, 8th ed, 2006.) 2002.) LWBK634_CP[1-16].qxd 7/9/10 6:57 AM Page 16 Aptara Inc ... findings) Pathology • Autosomal dominant mutations in cardiac sarcomere genes (eg, -myosin heavy chain) • Myocardial fiber disarray with hypertrophy • Morphologic hypertrophy variants: asymmetric septal;... Coagulopathies Hypercoagulable States Disorders of Leukocytes Transfusion Therapy Myelodysplastic Syndromes (MDS) Myeloproliferative Neoplasms (MPN) Leukemia Lymphoma Plasma Cell Dyscrasias Hematopoietic... brash c by meals, recumbency; T by antacids EGD, manometry, pH monitoring Intense substernal pain c by swallowing, T by NTG/CCB Manometry Precipitated by vomiting EGD Precipitated by vomiting