Approach to Internal Medicine

Approach to Internal MedicineA Resource Book for Clinical Practice

Third Edition

by

David Hui, MD, M.Sc., FRCPC

Edited by

Alexander Leung, BSc(Med), MD(STIR ),DABIM, MRCP(UK ), FRCPC

and

Raj Padwal, MD, M.Sc., FRCPC

1 3

Pulmonary MedicinePages 1–24

CardiologyPages 25–66

NephrologyPages 67–88

Critical CarePages 89–110

GastroenterologyPages 111–142

HematologyPages 143–184

OncologyPages 185–232

Infectious DiseasesPages 233–272

RheumatologyPages 273–296

NeurologyPages 297–336

EndocrinologyPages 337–360

DermatologyPages 361–376

GeriatricsPages 377–388

Palliative CarePages 389–402

NutritionPages 403–408

Obstetric MedPages 409–416

General MedPages 417–430

ACLSPage 431

IndexPages 443–458

David Hui MD, M.Sc., FRCPCThe University of Texas M.D. AndersonCancer CenterHouston, TX 77030 USAdhui@mdanderson.org

Author: David HuiAssociate editors: Alexander Leung, Raj Padwal

First edition, first printing, April 2006Second edition, first printing, August 2007Second edition, second printing, November 2007Second edition, third printing, March 2008Second edition, fourth printing, July 2008Second edition, fifth printing, November 2008Second edition, sixth printing, June 2009

Approach to Internal Medicine: A Resource Book for Clinical Practice

Additional material to this book can be downloaded from http://extras.springer.com.

ISBN 978-1-4419-6504-2 e-ISBN 978-1-4419-6505-9DOI 10.1007/978-1-4419-6505-9Springer New York Dordrecht Heidelberg London

Library of Congress Control Number: 2010933485

# Springer ScienceþBusiness Media, LLC 2006, 2007, 2011All rights reserved. This work may not be translated or copied in whole or in part without the writtenpermission of the publisher (Springer ScienceþBusiness Media, LLC, 233 Spring Street, New York, NY10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connectionwith any form of information storage and retrieval, electronic adaptation, computer software, or bysimilar or dissimilar methodology now known or hereafter developed is forbidden.The use in this publication of trade names, trademarks, service marks, and similar terms, even if they arenot identified as such, is not to be taken as an expression of opinion as to whether or not they are subjectto proprietary rights.While the advice and information in this book are believed to be true and accurate at the date of going topress, neither the authors nor the editors nor the publisher can accept any legal responsibility for anyerrors or omissions that may be made. The publisher makes no warranty, express or implied, with respectto the material contained herein.

Printed on acid free paper

Springer is part of Springer ScienceþBusiness Media (www.springer.com)

Third edition, first printing, 2011January

To Ella and Rupert

David Hui

Disclaimer

Approach to Internal Medicine is meant to be a practical field guide.Dosages of medications are provided for quick reference only. Readersshould consult other resources before applying information in thismanual for direct patient care. The author, editors, and publisher ofApproach to Internal Medicine cannot be held responsible for any harm,direct or indirect, caused as a result of application of information contained within this manual.

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Preface

Practice is science touched with emotion.Confessio Medici, Stephen Paget, 1909

The third edition of Approach to Internal Medicine builds upon previous efforts to create a practical,evidence based, and concise educational resource for everyday clinical use and examination preparation.Approach to Internal Medicine now has an expanded repertoire of over 250 internal medicine topics,classified under 17 subspecialties. With the input of a new editor and publisher, we were able tosignificantly expand and update the content and substantially improve the layout, while maintainingthe same conciseness and practicality found in previous editions.

Under each topic, the sections on differential diagnoses, investigations, and treatments are designedfor the rapid retrieval of high yield clinical information and can be particularly useful when one is all aloneassessing a patient at 3 o’clock in the morning. Other sections contain many clinical pearls that are intendedto help one to excel in patient care. We also included many comparison tables aimed at highlighting thedistinguishing features between various clinical entities and numerous mnemonics (marked by w). Inaddition to everyday practice, Approach to Internal Medicine can be effectively used as an examination studyguide and teaching script.

For this new edition, we are very fortunate to have recruited a new associate editor, Dr. AlexanderLeung, who brings with him a wealth of knowledge and outstanding commitment to medical education.We are most grateful to our section editors and contributors for their meticulous review of eachsubspecialty, providing expert input on the most up to date information. We would also like to takethis opportunity to thank Jean Claude Quintal as a resident reviewer and the Canadian Federation ofMedical Students for its support of the previous edition. Finally, we would like to thank all previous andcurrent users of this manual for their support and feedback.

We are pleased that Springer has taken this title under its direction and has helped to improve itsquality in preparation for international release. In addition to International System (SI) units, this editionalso provides US customary units [in square brackets] for quick reference. We would particularly like tothank Laura Walsh, senior editor, and Stacy Lazar, editorial assistant, from Springer for their expertguidance and support throughout this mammoth project from design to production. We would also liketo thank Walter Pagel, director of scientific publishing at M.D. Anderson Cancer Center, for believing inthis work and making this collaboration possible.

While every effort has been made to ensure the accuracy of information in this manual, the author,editors, and publisher are not responsible for omissions, errors, or any consequences that result fromapplication of the information contained herein. Verification of the information in this manual remainsthe professional responsibility of the practitioner. Readers are strongly urged to consult other appropriate clinical resources prior to applying information in this manual for direct patient care. This is

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particularly important since patterns of practice and clinical evidence evolve constantly. We welcome anyconstructive feedback to help make this manual a more accurate, practical, comprehensive, and userfriendly resource.

David Hui, MD, M.Sc., FRCPC(Med Onc)Author, Approach to Internal MedicineAssistant Professor (tenure track), The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA

Alexander Leung, BSc(Med), MD(STIR), DABIM, MRCP(UK), FRCPCAssociate Editor, Approach to Internal MedicineClinical Scholar, Division of General Internal Medicine University of Calgary, Calgary, AB, CanadaResearch Fellow, Division of General Internal Medicine Brigham and Women’s Hospital and HarvardMedical School, Boston, MA, USA

Raj Padwal, MD, M.Sc., FRCPCAssociate Editor, Approach to Internal MedicineAssociate Professor, Clinical Pharmacology, Clinical Epidemiology and General Internal Medicine,University of Alberta Edmonton, AB, Canada

x Preface

Section Editors

PULMONARY MEDICINEMohit Bhutani, MD, FRCPC, FACPAssistant Professor of MedicineDivision of Pulmonary MedicineDepartment of MedicineUniversity of AlbertaEdmonton, AB, Canada

CARDIOLOGYMustafa Toma, MD, FRCPCFellow, Advanced Heart Failureand Cardiac TransplantationCleveland Clinic FoundationCleveland, OH, USA

Jason Andrade, MD, FRCPCFellow, CardiologyDivision of CardiologyUniversity of British ColumbiaVancouver, BC, Canada

NEPHROLOGYAlan McMahon, MD, FRCPCAssociate Professor of MedicineDivision of Nephrology and TransplantImmunology, Department of MedicineUniversity of AlbertaEdmonton, AB, Canada

CRITICAL CAREWendy Sligl, MD, FRCPCAssistant Professor of MedicineDivisions of Infectious Diseasesand Critical Care Medicine, Department ofMedicineUniversity of AlbertaEdmonton, AB, Canada

GASTROENTEROLOGYWinnie Wong, MD, FRCPCAssociate Professor of MedicineDirector, Gastroenterology Subspecialty

Training ProgramPresident ElectCanadian Association for Study of LiverDivision of GastroenterologyDepartment of MedicineUniversity of AlbertaEdmonton, AB, Canada

HEMATOLOGYMichael H. Kroll, MD, FACPProfessor of Medicine and ChiefBenign HematologyThe University of Texas M.D. AndersonCancer CenterHouston, TX, USA

ONCOLOGYSharlene Gill, MD, FRCPCAssociate Professor of MedicineDivision of Medical Oncology,British Columbia Cancer AgencyUniversity of British ColumbiaVancouver, BC, Canada

INFECTIOUS DISEASESA. Mark Joffe, MD, FRCPCProfessor of MedicineDivision of Infectious Diseases,Department of MedicineUniversity of Alberta and RoyalAlexandra HospitalEdmonton, AB, Canada

RHEUMATOLOGYElaine Yacyshyn, MD, FRCPCAssistant Professor of MedicineDirector, Rheumatology SubspecialtyTraining ProgramDivision of RheumatologyDepartment of MedicineUniversity of AlbertaEdmonton, AB, Canada

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NEUROLOGYBrian Thiessen, MD, FRCPCAssistant Professor of MedicineDepartment Of Medical OncologyBritish Columbia Cancer AgencyDivision of NeurologyVancouver General HospitalVancouver, BC, Canada

ENDOCRINOLOGYLaurie E. Mereu, MD, FRCPCAssociate Professor of MedicineDivision of EndocrinologyDepartment of MedicineUniversity of AlbertaEdmonton, AB, Canada

DERMATOLOGYSusan Y. Chon, MD, FAADAssistant Professor of MedicineDepartment of DermatologyDivision of Internal MedicineThe University of TexasM.D. Anderson Cancer CenterHouston, TX, USA

GERIATRICSFiona Lawson, MD, FRCPCAssistant Professor of MedicineDivision of GeriatricsDepartment of MedicineUniversity of AlbertaEdmonton, AB, Canada

PALLIATIVE CAREEduardo Bruera, MDProfessor of Medicine and ChairDepartment of Palliative Careand Rehabilitation MedicineDivision of Cancer Medicine

The University of TexasM.D. Anderson Cancer CenterHouston, TX, USA

Sriram Yennurajalingam, MDAssistant Professor of MedicineDepartment of Palliative Careand Rehabilitation MedicineDivision of Cancer MedicineThe University of TexasM.D. Anderson Cancer CenterHouston, TX, USA

NUTRITIONRaj Padwal, MD, M.Sc., FRCPCAssociate Professor of MedicineDivisions of Clinical EpidemiologyClinical Pharmacology and General InternalMedicine, Department of MedicineUniversity of AlbertaEdmonton, AB, Canada

OBSTETRICAL MEDICINEWinnie Sia, MD, FRCPCAssistant Professor of Medicineand Obstetrics and GynecologyDivisions of General Internal Medicineand Maternal Fetal MedicineUniversity of AlbertaEdmonton, AB, Canada

GENERAL INTERNAL MEDICINEPeter Hamilton, MBBCh, FRCPCProfessor of MedicineDivision of General Internal MedicineDepartment of MedicineUniversity of AlbertaEdmonton, AB, Canada

Contributors

GENERAL: Jean-Claude Quintal, MDONCOLOGY: Francine Aubin, MD; Anna Tinker, MD; Emma Beardsley, MD; Robyn Macfarlane, MD;Sophie Sun, MDDERMATOLOGY: Elizabeth Farley, MD; Catherine Riddel, BA; Glynda Caga-Anan, BANUTRITION: Leanne Mulesa, RD; Miranda Wong, RD

xii Section Editors

Contents

Pulmonary Medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Asthma Exacerbation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1COPD Exacerbation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Pulmonary Embolism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Pleural Effusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Chronic Cough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Hemoptysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Solitary Pulmonary Nodule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Pulmonary Hypertension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Interstitial Lung Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Obstructive Sleep Apnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Respiratory Acidosis: Hypoventilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Respiratory Alkalosis: Hyperventilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Hypoxemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Ventilation Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Approach to Chest Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Approach to Pulmonary Function Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Cardiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Aortic Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Acute Coronary Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Pericardial Diseases: Pericarditis and Tamponade. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Heart Failure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Digoxin Intoxication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Atrial Fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Cardiac Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Aortic Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Aortic Regurgitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49Mitral Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50Mitral Regurgitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51Endocarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52Peripheral Vascular Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Hyperlipidemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Smoking Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62Approach to ECG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

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Nephrology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67Acute Renal Failure: Pre renal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67Acute Renal Failure: Renal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68Acute Renal Failure: Post renal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70Glomerulopathies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70Chronic Kidney Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73Proteinuria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74Hematuria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75Cystic Kidney Diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76Metabolic Acidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77Metabolic Alkalosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78Hyponatremia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79Hypernatremia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81Hypokalemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81Hyperkalemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82Hypomagnesemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83Hypophosphatemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83Ureteral Calculi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84Approach to Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Critical Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89Intensive Care Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89Hypoxemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92Acute Respiratory Distress Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93Ventilation Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97Sepsis and Septic Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99Lactic Acidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101Rhabdomyolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101Toxicology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102Alcohol Withdrawal and Complications of Alcoholism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105Hypothermia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107Smoke Inhalation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

Gastroenterology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111Nausea and Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111Dysphagia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112Dyspepsia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113Acute Abdominal Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115Upper GI Bleed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118Lower GI Bleed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120Inflammatory Bowel Disease Exacerbation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120Acute Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122Chronic Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124Malabsorption Syndromes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125Constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126Acute Liver Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128Hepatitis B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130Hepatitis C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131Chronic Liver Disease: Cirrhosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132

xiv Contents

Hepatic Encephalopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135Ascites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136Jaundice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138Acute Pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

Hematology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143Polycythemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143Microcytic Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144Normocytic Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145Macrocytic Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146Sickle Cell Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147Neutropenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148Eosinophilia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148Thrombocytosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150Thrombocytopenia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151Pancytopenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153Bleeding Diathesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153Hypercoagulable States. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156Deep Vein Thrombosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158Approach to Anticoagulation Therapies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160Transfusion Reactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162Approach to the Peripheral Blood Smear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163Splenomegaly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164Myeloproliferative Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165Acute Myelogenous Leukemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166Acute Lymphoblastic Leukemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169Chronic Lymphocytic Leukemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170Hodgkin’s Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171Non Hodgkin’s Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173Multiple Myeloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178Febrile Neutropenia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180Hematopoietic Stem Cell Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180

Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185Lung Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185Mesothelioma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188Thymoma and Thymic Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189Esophageal Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195Gastric Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198Carcinoid Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201Gastrointestinal Stromal Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202Anal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203Cancer of the Exocrine Pancreas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204Hepatocellular Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205Renal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207Bladder Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208Prostate Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210Testicular Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212Brain Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215Ovarian Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215

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Endometrial Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216Cervical Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218Cancer of Unknown Origin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219Tumor Markers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222Hereditary Cancer Syndromes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224Antineoplastic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226Oncologic Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228Febrile Neutropenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229Chemotherapy Induced Nausea and Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229Oral Mucositis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230Chemotherapy Induced Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231

Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233Fever of Unknown Origin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233Fever and Rash. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234Fever and Joint Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236Sepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236Febrile Neutropenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236Fever with Travel History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241Endocarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241Meningitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241Urinary Tract Infections and Sexually Transmitted Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244Soft Tissue Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247Osteomyelitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248Septic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250Tuberculosis: Pulmonary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250Approach to Gram Stain, Culture, and Sensitivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254Approach to Empiric Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257Hepatitis B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258Hepatitis C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258Herpes Simplex Virus Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258Human Immunodeficiency Virus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259Influenza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262Antiviral Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265Fungal Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265Antifungal Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268Infection Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269Immunization for Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270

Rheumatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273Septic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273Gout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275Polyarticular Joint Pain and Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276Rheumatoid Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277Systemic Lupus Erythematosus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279Seronegative Spondyloarthropathies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282Back Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284Osteoarthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286Fibromyalgia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287

xvi Contents

Vasculitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288Approach to Serologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292Joint Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294

Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297Brain Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297Acute Stroke Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299Cranial Nerve Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304Diplopia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306Bell’s Palsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309Delirium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309Seizures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309Syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312Migraine Headaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313Meningitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315Dizziness and Vertigo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315Hearing Impairment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317Myasthenia Gravis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318Ataxia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319Subacute Combined Degeneration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320Parkinson’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320Radiculopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323Peripheral Neuropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327Muscle Weakness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332Approach to Neuroimaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333

Endocrinology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337Principles of Insulin Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341Hypoglycemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342Hypothyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343Hyperthyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344Solitary Thyroid Nodule. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345Pituitary Tumors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346Polyuria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347Adrenal Incidentaloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348Adrenal Insufficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349Cushing’s Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350Hypocalcemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352Hypercalcemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353Osteoporosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 354Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356Hyperlipidemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356Amenorrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356Hirsutism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357

Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361Eczema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361Psoriasis Vulgaris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362Acne Vulgaris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363

Contents xvii

Exanthematous Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364Stevens Johnson Syndrome/Toxic Epidermal Necrolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367Melanoma and Skin Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368Cutaneous Lupus Erythematosus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371Drug Eruptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372Erythema Nodosum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373Clubbing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374Dupuytren’s Contracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375

Geriatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377Geriatric Specific Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377Dementia and Cognitive Impairment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 378Delirium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380Falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382Osteoporosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383Urinary Incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383Hearing Impairment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385Pharmacological Issues in the Elderly. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385

Palliative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389Palliative Care Specific Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389Principles of Pain Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391Delirium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394Cancer Related Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394Dyspnea in the Palliative Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394Nausea and Vomiting in the Palliative Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395Constipation in the Palliative Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396Anorexia Cachexia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397Communication Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399Prognostication in Far Advanced Cancer Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400

Nutrition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403Malabsorption Syndromes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404Anorexia Cachexia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404Vitamin B12 Deficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405Diet and Supplemental Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406

Obstetric Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409Preeclampsia/Eclampsia/HELLP Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409Pulmonary Diseases in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 410Cardiac Diseases in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411Hepatic Diseases in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411Infectious Diseases in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412Endocrine Disorders in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413Other Disorders in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414

General Internal Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417Approach to Diagnostic Tests and Clinical Trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417Smoking Cessation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418Multisystem Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 420Perioperative Assessment for Non cardiopulmonary Surgery and Postoperative Complications . . 422

xviii Contents

Medical Fitness to Drive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426Obtaining Consent for Medical Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427Biomedical Ethics Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427Hospital Admission and Discharge Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429

Appendix I. Advanced Cardiac Life Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431

Appendix II. List of Common Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433

Appendix III. Common Laboratory Values And Unit Conversion . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437

Appendix IV. History Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443

Selected Internal Medicine Topics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Contents xix

459

1PULMONARY MEDICINE

Section Editor: Dr. Mohit Bhutani

Asthma Exacerbation

DIFFERENTIAL DIAGNOSIS OF WHEEZING

EXTRATHORACIC AIRWAY OBSTRUCTION� OROPHARYNX enlarged tonsils, retropharyngeal

abscess, obesity, post nasal drip� LARYNX laryngeal edema, laryngostenosis, lar

yngocele, epiglottitis, anaphylaxis, severe laryngopharyngeal reflux, and laryngospasm

� VOCAL CORDS vocal cord dysfunction, paralysis,hematoma, tumor, cricoarytenoid arthritis

INTRATHORACIC AIRWAY OBSTRUCTION� TRACHEAL OBSTRUCTION tracheal stenosis, tra

cheomalacia, tracheobronchitis (herpetic), malignancy, benign tumor, aspiration

� TRACHEAL COMPRESSION goiter, right sided aortic arch

� LOWER AIRWAY OBSTRUCTION asthma, COPD,bronchiolitis, bronchiectasis, carcinoid tumor,aspiration, malignancy

� PARENCHYMA pulmonary edema� VASCULAR pulmonary embolism

PATHOPHYSIOLOGY

EXACERBATORS OF ASTHMA� INFECTIONS viral, bacterial� OUTDOORS respirable particulates, ozone, sulfur

dioxide, cold air, humidity, smoke� INDOORS smoke, dust mites, air conditioners,

humidity, perfumes, scents, smoke� NON-ADHERENCE

CLINICAL FEATURES

HISTORY history of asthma and any life threatening exacerbations, number of ER visits/hospitaladmissions in the last 6 months or ever, any ICUadmissions, previous prednisone use, triggers forattacks, normal peak expiratory flow rate, change inpeak flow rates, wheezing, cough, dyspnea,decreased function, exercise limitation, nocturnalsymptoms, absenteeism from work/school, postnasal drip, recurrent sinusitis, GERD, occupationaland work environment, past medical history, medication history, psychosocial issues, home environment(pets, heating source, filter changes)

CLINICAL FEATURES (CONT’D)

PHYSICAL HR ", RR ", pulsus paradoxus, O2requirement, moderate severe dyspnea, barrelchest, cyanosis, hyperresonance, decreased breathsounds, wheezing, forced expiratory timeTYPES OF WHEEZING inspiratory wheeze andexpiratory wheeze are classically associated withextrathoracic and intrathoracic airway obstruction,respectively. However, they are neither sensitive norspecific and cannot help to narrow differentialdiagnosis

INVESTIGATIONS

BASIC� LABS CBCD, lytes, urea, Cr, troponin/CK� MICROBIOLOGY sputum Gram stain/AFB/C&S� IMAGING CXRSPECIAL� ABG if acute respiratory distress� PEAK FLOW METER need to compare bedside

reading to patient’s baseline� SPIROMETRY/PFT (non acute setting) " FEV1>12% and an absolute " by 200 mL postbronchodilators suggest asthma

� METHACHOLINE CHALLENGE (non acute setting) ifdiagnosis of asthma not confirmed by spirometry alone. A decrease of FEV1>20% after methacholine challenge suggests asthma. Sens 95%

ACUTE MANAGEMENT

ABC O2 to keep sat >92%, IVBRONCHODILATORS salbutamol 2.5 5.0 mg NEBq6h + q1h PRN and ipratropium 0.5 mg NEB q6h(frequency stated is a guide, can increase or decreaseon a case by case basis)STEROID prednisone 0.5 1 mg/kg PO daily�7 14days (may be shorter depending on response) ormethylprednisolone 0.4 0.8 mg/kg IV daily (untilconversion to prednisone)OTHERS if refractory case and life threatening,consider IV epinephrine, IV salbutamol, theophylline,inhaled anesthetics, MgSO4MECHANICAL VENTILATION BIPAP, intubation

D. Hui, Approach to Internal Medicine, DOI 10.1007/978 1 4419 6505 9 1,� Springer ScienceþBusiness Media, LLC 2006, 2007, 2011

1

LONG TERM MANAGEMENT

EDUCATION smoking cessation (see p. 418).Asthma action plan. Puffer technique educationand reviewENVIRONMENTAL CONTROL avoidance of outdoor/indoor allergens, irritants, and infections;home environment cleanliness (e.g. steam cleaning)VACCINATIONS influenza vaccine annually andpneumococcal vaccine booster at 5 yearsFIRST LINE short acting b2 agonist (salbutamol2 puffs PRN). Proceed to second line if using morethan 2�/week or 1�/day for exercise induced symptoms, symptoms >2�/week, any nocturnal symptoms, activity limitation or PEF 70% of usual (or predicted) value for atleast 1 h after bronchodilator

OXYGEN DELIVERY DEVICESDevice Flow rates Delivered O2Nasal cannula 1 L/min 21 24%

2 L/min 25 28%3 L/min 29 32%4 L/min 33 36%5 L/min 37 40%6 L/min 41 44%

Simple oxygen face mask 6 10 L/min 35 60%Face mask with oxygen reservoir 6 L/min 60%

(non rebreather mask) 7 L/min 70%8 L/min 80%9 L/min 90%10 15 L/min 95+%

Venturi mask 4 8 L/min 24 40%10 12 L/min 40 50%

NOTE: delivered O2 (FiO2) is approximate. Oxygen delivery can approach 100% with intubation andmechanical ventilation

2 Asthma Exacerbation

SPECIFIC ENTITIES

EXERCISE INDUCED ASTHMA� PATHOPHYSIOLOGY mild asthma with symptoms only

during exercise due to bronchoconstriction as a result ofcooling of airways associated with heat and water loss

� DIAGNOSIS spirometry. Exercise or methacholinechallenge may help in diagnosis

� TREATMENTS prophylaxis with salbutamol 2 puffs,given 5 10 min before exercise. Consider leukotriene antagonists or inhaled glucocorticoids iffrequent use of prophylaxis

TRIAD ASTHMA (Samter’s syndrome) triad ofasthma, aspirin/NSAIDs sensitivity, and nasal polyps.Cyclooxygenase inhibition!# prostaglandin E2!"leukotriene synthesis! asthma symptoms. Management include ASA/NSAIDs avoidance and leukotrieneantagonists (montelukast)

SPECIFIC ENTITIES (CONT’D)

ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS(ABPA)� PATHOPHYSIOLOGY associated with asthma and cys

tic fibrosis. Due to colonization of the airways byAspergillus fumigatus, leading to an intense, immediate hypersensitivity type reaction in the airways

� CLINICAL FEATURES history of asthma, recurrent episodes of fever, dyspnea, and productive cough(brownish sputum). Peripheral eosinophilia. CXR findings of patchy infiltrates and central bronchiectasis

� DIAGNOSIS above clinical features plus Aspergillusextract skin test, serum IgE level, sputum for Aspergillus and/or serologic tests (IgE and IgG againstAspergillus)

� TREATMENTS systemic glucocorticoids, itraconazole

COPD Exacerbation NEJM 2004 250:26

DIFFERENTIAL DIAGNOSIS OF ACUTE DYSPNEA

RESPIRATORY� AIRWAY COPD exacerbation, asthma exacerba

tion, acute bronchitis, infectious exacerbation ofbronchiectasis, foreign body obstruction

� PARENCHYMA pneumonia, cryptogenic organizing pneumonia, ARDS, acute exacerbation ofinterstitial lung disease

� VASCULAR pulmonary embolism, pulmonaryhypertension

� PLEURAL pneumothorax, pleural effusionCARDIAC� MYOCARDIAL HF exacerbation, myocardial

infarction� VALVULAR aortic stenosis, acute aortic regurgi

tation, mitral stenosis, endocarditis� PERICARDIAL pericardial effusion, tamponadeSYSTEMIC sepsis, metabolic acidosis, anemiaOTHERS neuromuscular, psychogenic, anxiety

PATHOPHYSIOLOGY

PRECIPITANTS OF COPD EXACERBATION infections, lifestyle/environmental (10%, cigarette smoke,dust, pollutants, cold air), non adherence, pulmonaryembolism, pulmonary edema, pneumothorax, progression of COPD

CLINICAL FEATURES

RATIONAL CLINICAL EXAMINATION SERIES:DOES THE CLINICAL EXAMINATION PREDICTAIRFLOW LIMITATION?

Sens Spc LR+ LRHistorySmoking >70 pack year 40% 95% 8 0.63Smoking ever 92% 49% 1.8 0.16

CLINICAL FEATURES (CONT’D)

Sens Spc LR+ LRSputum >1/4 cup 20% 95% 4 0.84Chronic bronchitis Sx 30% 90% 3 0.78Wheezing 51% 84% 3.8 0.66Any exertional dyspnea 27% 88% 2.2 0.83Coughing 51% 71% 1.8 0.69Any dyspnea 82% 33% 1.2 0.55PhysicalWheezing 15% 100% 36 0.85Barrel chest 10% 99% 10 0.90Decreased cardiac

dullness13% 99% 10 0.88

Match test 61% 91% 7.1 0.43Rhonchi 8% 99% 5.9 0.95Hyperresonance 32% 94% 4.8 0.73FEV1 >9 s 4.8FEV1 6 9 s 2.7FEV1 15 mmHg)

45% 88% 3.7 0.62

Decreased breath sounds 37% 90% 3.7 0.70Accessory muscle use 24% 100% 0.70APPROACH ‘‘no single item or combination ofitems from the clinical examination rules out airflow limitation. The best findings associated withincreased likelihood of airflow limitation are objective wheezing, FEV1 >9 s, positive match test,barrel chest, hyperresonance and subxyphoid cardiac impulse. Three findings predict the likelihoodof airflow limitation in men: years of cigarettesmoking, subjective wheezing and either objectivewheezing or peak expiratory flow rate’’

JAMA 1995 273:4

COPD Exacerbation 3

CLINICAL FEATURES (CONT’D)

STEREOTYPES (not useful clinically)� BLUE BLOATER (more chronic bronchitis) cough

and sputum, hypoxemia, CO2 retention, pulmonary hypertension, right sided heart failure

� PINK PUFFER (more emphysema) cachexia, relatively preserved blood gases, dyspnea even at rest

PREDICTION RULE FOR OBSTRUCTIVE AIRWAYDISEASE� AGE �45 YEARS LR+ 1.3� SMOKING >40 PACK YEAR LR+ 8.3� SELF-REPORTED HISTORY OF CHRONIC OBSTRUCTIVE AIR-

WAY DISEASE LR+ 7.3� MAXIMUM LARYNGEAL HEIGHT

LONG TERM MANAGEMENT (CONT’D)

SEVENTH LINE lung volume reduction surgery(may be beneficial if upper lobe involvement andpoor functional capacity) or lung transplant

Canadian Thoracic Society Guidelines 2003

TREATMENT ISSUES

FACTORS FOR IMPENDING INTUBATION cardiacor respiratory failure, hemodynamic instability, markedly elevated respiratory rate (>35/min), fatigue andlabored respiration, use of accessory muscles, worsening hypercapnia, acidosis (especially lactic), stridor(impending upper airway obstruction), agonalbreathing (impending respiratory arrest)LIFE PROLONGING MEASURES FOR COPD smoking cessation, supplemental O2INDICATIONS FOR SUPPLEMENTAL HOME O2ABG done in room air. PaO2

Pneumonia NEJM 2002 345:25; NEJM 2001 344:9

TYPES OF PNEUMONIA

COMMUNITY ACQUIRED PNEUMONIA� BACTERIAL Streptococcus pneumoniae, Staphy

lococcus aureus, Haemophilus, Moraxella� ATYPICAL Mycoplasma, Chlamydia, Legionella,

TB, community acquired MRSA� VIRAL influenza, parainfluenza, metapneumo

virus, RSV, adenovirus� FUNGAL blastomycosis, cryptococcus, histoplasmosisASPIRATION PNEUMONIA� POLYBACTERIAL INCLUDING ANAEROBES Bacter

oides, Peptostreptococcus, Fuso bacterium species and other Gram positive bacilli

� CHEMICAL PNEUMONITIS

PNEUMONIA IN THE IMMUNOCOMPROMISED(see p. 259)NOSOCOMIAL PNEUMONIA� POLYBACTERIAL Staphylococcus aureus, MRSA,

Pseudomonas aeruginosa, Enterobacteriaceae(Klebsiella, Escherichia coli, Serratia), Haemophilus, Acinetobacter

� VIRAL influenzaVENTILATOR ASSOCIATED PNEUMONIANURSING HOME ACQUIRED PNEUMONIA

PATHOPHYSIOLOGY

COMPLICATIONS OF PNEUMONIA� PULMONARY ARDS, lung abscess � cavitary for

mation, parapneumonic effusion/empyema, pleuritis � hemorrhage

� EXTRAPULMONARY purulent pericarditis, hyponatremia, sepsis

CLINICAL FEATURES

RATIONAL CLINICAL EXAMINATION SERIES:DOES THIS PATIENT HAVE COMMUNITYACQUIRED PNEUMONIA?

LR+ LRHistoryCough 1.8 0.31Sputum 1.3 0.55Dyspnea 1.4 0.67Fever 1.7 2.1 0.59 0.71Asthma 0.10 3.8Dementia 3.4 0.94Immunosuppression 2.2 0.85PhysicalRR >25 1.5 3.4 0.78 0.82Dullness to percussion 2.2 4.3 0.79 0.93Decreased breath sounds 2.3 2.5 0.64 0.78

CLINICAL FEATURES (CONT’D)

LR+ LRCrackles 1.6 2.7 0.62 0.87Bronchial breath sounds 3.5 0.90Egophony 2.0 8.6 0.76 0.96PREDICTION RULE Diehr (rhinorrhea 2, sorethroat 1, night sweats +1, myalgias +1, sputumall day +1, RR>25 +2, temp�37.88C [�1008F] +2.If cut off = 1 (i.e. �1 suggests pneumonia), LR+ 5,LR 0.47. If cut off = 3, LR+ 14, LR 0.82), Singal,HeckerlingAPPROACH ‘‘individual or combinations ofsymptoms and signs have inadequate test characteristics to rule in or rule out the diagnosis ofpneumonia. Decision rules that use the presenceor absence of several symptoms and signs to modify the probability of pneumonia are available, thesimplest of which requires the absence of any vitalsign abnormalities to exclude the diagnosis. If diagnostic certainty is required in the management of apatient with suspected pneumonia, then chestradiography (gold standard) should be performed’’

JAMA 1997 278:17

SURFACE LUNG MARKINGS� INFERIOR MARGIN OF THE LUNGS level of 6th rib at the

mid clavicular line, level of 8th rib at the mid axillaryline, and level of 10th rib at the mid scapular line

� OBLIQUE (MAJOR) FISSURES draw a line diagonallyfrom T3 vertebral body posteriorly to the 6th ribanteriorly

� HORIZONTAL (MINOR) FISSURE draw a horizontalline at the level of right anterior 4th rib

Related TopicsHypoxemia (p. 92)Parapneumonic Effusion and Empyema (p. 10)Ventilator Associated Pneumonia (p. 96)

INVESTIGATIONS

BASIC� LABS CBCD, lytes, urea, Cr, troponin/CK, AST,

ALT, ALP, bilirubin, urinalysis� MICROBIOLOGY blood C&S, sputum Gram stain/

AFB/C&S/fungal, urine C&S� IMAGING CXR � CT chest� ABG if respiratory distress, and for PSI if decid

ing on possible hospitalization

6 Pneumonia

INVESTIGATIONS (CONT’D)

SPECIAL� BRONCHOSCOPY� NASOPHARYNGEAL SWAB if suspect viral infec

tion, check for influenza A/B, parainfluenza,human metapneumovirus, RSV, adenovirus

� MYCOPLASMA IGM� URINE FOR LEGIONELLA ANTIGEN

DIAGNOSTIC AND PROGNOSTIC ISSUES

PNEUMONIA SEVERITY OF ILLNESS (PSI) SCORE� SCORING age, female ( 10), nursing home (+10),

cancer (+30), liver disease (+20), heart failure(+10), CVA (+10), renal failure (+10), altered mental status (+20), RR >30 (+20), SBP 408C [>1048F] (+15), HR >125(+10), pH 10.7 mmol/L[>30 mg/dL] +20, Na13.9 mmol/L [>250 mg/dL] +10, hematocrit

TREATMENT ISSUES (CONT’D)

DISCHARGE DECISION clinical stabilization usuallytakes 2 3 days. When symptoms have significantlyimproved, vital signs are normalized, and patient hasdefervesced, patients at low risk may be safely discharged on the day of switching to oral therapywithout adverse consequences. Time to radiographicresolution is variable, with up to 5 months for pneumococcal pneumonia associated with bacteremia

IDSA Guidelines 2003Note: consider vancomycin or linezolid if MRSA suspected; emergence of community acquired MRSAassociated with serious necrotizing infections

SPECIFIC ENTITIES

CAUSES OF NON RESOLVING PNEUMONIA noninfectious (malignancy especially bronchoalveolarcarcinoma or lymphoma, cryptogenic organizing pneumonia, hemorrhage), non bacterial (viral, fungal),immunocompromised host, antibiotic resistance,pneumonia complications (abscess, empyema, ARDS)

SPECIFIC ENTITIES (CONT’D)

CAUSES OF RECURRENT PNEUMONIA� IMMUNOCOMPROMISED wSADDISTw Suppressants

(steroids, chemotherapy, transplant medications,alcohol), AIDS, Diabetics, Decreased nutrition,Immunoglobulin (hypogammaglobulinemia), Solidorgan failure (renal, liver, splenectomy), Tumors

� PULMONARY bronchiectasis, COPD, cystic fibrosis,abnormal anatomy

� GI aspirationLUNG ABSCESS� CAUSES anaerobes (Peptostreptococcus, Prevotella,

Bacteroides, Fusobacterium), Gram positive (S. milleri,microaerophilic streptococcus, S. aureus), Gramnegative (Klebsiella, Haemophilus, Legionella). Nocardia and actinomycosis can rarely cause lung abscess

� TREATMENTS clindamycin until radiographicimprovement and stabilization (usually severalweeks to months, can be completed with oralantibiotics once patient is stable). No need forpercutaneous drainage. If complicated abscess,consider lobectomy or pneumonectomy

Pulmonary Embolism NEJM 2008 359:26

DIFFERENTIAL DIAGNOSIS OF ACUTE DYSPNEA

RESPIRATORY� AIRWAY COPD exacerbation, asthma exacerba

tion, acute bronchitis, infectious exacerbation ofbronchiectasis, foreign body obstruction

� PARENCHYMA pneumonia, cryptogenic organizing pneumonia, ARDS, acute exacerbation ofinterstitial lung disease

� VASCULAR pulmonary embolism, pulmonaryhypertension

� PLEURAL pneumothorax, pleural effusionCARDIAC� MYOCARDIAL HF exacerbation, myocardial infarction� VALVULAR aortic stenosis, acute aortic regurgi

tation, endocarditis� PERICARDIAL pericardial effusion, tamponadeSYSTEMIC sepsis, metabolic acidosis, anemiaOTHERS neuromuscular, psychogenic, anxiety

PATHOPHYSIOLOGY

VIRCHOW’S TRIAD risk factors for venous thromboembolism� INJURY fracture of pelvis, femur, or tibia� HYPERCOAGUABILITY obesity, pregnancy, estrogen,

smoking, cancer (high suspicion of occult malignancy in patients who develop pulmonary embolism while on anticoagulation), autoimmune disorders (anticardiolipin antibody syndrome, lupusanticoagulant, IBD), genetics (history of DVT/PE,

PATHOPHYSIOLOGY (CONT’D)

factor V Leiden, antithrombin III deficiency, proteinC/S deficiency, prothrombin G20210A mutation,hyperhomocysteinemia)

� STASIS surgery requiring >30 min of anesthesia,prolonged immobilization, CVA, HF

CLINICAL FEATURES

HISTORY dyspnea (sudden onset), pleuritic chest pain,cough, hemoptysis, pre/syncope, unilateral leg swelling/pain, past medical history (previous DVT/PE, active cancer, immobilization or surgery in last 4 weeks, miscarriages), medications (birth control pill, anticoagulation)PHYSICAL vitals (tachycardia, tachypnea, hypotension, fever, hypoxemia), respiratory examination (pulmonary hypertension if chronic PE), cardiac examination (right heart strain), leg swelling

RATIONAL CLINICAL EXAMINATION SERIES:DOES THIS PATIENT HAVE PULMONARYEMBOLISM?PREDICTION RULES Wells, PISA PED, Geneva ruleAPPROACH ‘‘use of clinical prediction rulesrecommended. Not enough evidence to suggestany of the rules as superior. Clinical gestalt ofexperienced physician similar to use of rules. Ddimer can be used to rule out pulmonary embolismfor patients with low pre test probability’’

JAMA 2003 290:21

8 Pulmonary Embolism

INVESTIGATIONS

BASIC� LABS CBCD, lytes, urea, Cr, PTT, INR, troponin/CK�3, D dimer (if low probability for PE or outpatient), bhCG in women of reproductive age

� IMAGING CXR, duplex U/S of legs, V/Q scan, CTchest (PE protocol)

� ECG may see normal sinus rhythm (most common), sinus tachycardia (most common abnormality), atrial fibrillation, right ventricular strain(T wave inversion in anterior precordial leads),non specific ST T wave changes, right axis deviation, right bundle branch block and/or S1Q3T3(tall S wave in lead I, Q wave and inverted T wavein lead III)

� ABG if respiratory distressSPECIAL� ECHOCARDIOGRAM to check for right heart strain

(dilated RV and elevated RVSP). Particularlyimportant if hemodynamic changes

� PULMONARY ANGIOGRAM gold standard� THROMBOPHILIA WORKUP factor V Leiden, pro

thrombin G20210A, anticardiolipin antibody,lupus anticoagulant, protein C, protein S, antithrombin III, fibrinogen; consider homocysteinelevel and workup for paroxysmal nocturnal hemoglobinuria and antiphospholipid syndrome incases of combined arterial venous thrombosis

DIAGNOSTIC ISSUES

CXR FINDINGS IN PULMONARY EMBOLISMnormal, atelectasis, unilateral small pleural effusion, enlarged central pulmonary artery, elevatedhemidiaphragm, Westermark’s sign (abrupt truncation of pulmonary vessel), Hampton’s hump(wedge infarct)D DIMER (sens 85 96%, spc 45 68%, LR+ 1.7 2.7, LR0.09 0.22) can rule out PE if low clinical suspicionV/Q SCAN (sens high, spc high) useful but resultoften not definitive (intermediate probability) becauseof other intraparenchymal abnormalitiesCT PE PROTOCOL (sens 57 100%, spc 78 100%) canbe very helpful as it provides clues to other potentialdiagnoses/pathologies as well. Not good for subsegmental pulmonary emboliLEG VEIN DOPPLER (sens 50%, spc moderate)serial dopplers may be used for diagnosis of DVT ifCT or V/Q scan failed to demonstrate PE but clinicalsuspicion still highWELL’S CRITERIA FOR PULMONARY EMBOLISM� SCORING signs/symptoms of DVT (+3), alternative

diagnosis less likely (+3), HR >100 (+1.5), immobilization or surgery in last 4 weeks (+1.5), previousDVT/PE (+1.5), hemoptysis (+1), active cancer (+1)

� LOW SUSPICION (sum 0 1, 6, >70% chance) CT orV/Q scan ! if negative but suspicious, legdoppler ! if negative but still suspicious, pulmonary angiogram

NEJM 2003 349:13

Related TopicsAnticoagulation Therapy (p. 160)DVT (p. 158)Hypercoagulable States (p. 156)Pulmonary Embolism in Pregnancy (p. 410)

MANAGEMENT

ACUTE ABC, O2 to keep sat >94%, IV, considerthrombolysis (must be done in ICU) for massive PE(hemodynamic instability, right ventricular strain)ANTICOAGULATION if moderate to high risk ofdeveloping PE, consider initiating anticoagulationwhile waiting for investigations. Heparin (unfractionated heparin 5000 U IV bolus, then 1000 U/h andadjust to 1.5 2.5� normal PTT), LMWH (enoxaparin1 mg/kg SC BID or 1.5 mg/kg SC daily), or fondaparinux 5 mg SC daily (100 kg). Startwarfarin 5 mg PO daily within 72 h and continueheparin/LMWH/fondaparinux until INR is between 2and 3; ensure overlap of heparin and coumadin withtherapeutic INR for at least 48 hTHROMBOLYTICS controversial as increased riskof intracranial bleed and multiple contraindications(see below). Consider only if hemodynamicallyunstable or life threatening pulmonary embolism.TPA 100 mg IV over 2 h, or streptokinase250,000 IU over 30 min, the 100,000 IU/h over12 24 h or 1.5 million IU over 2 h. Unfractionatedheparin may be used concurrentlySURGICAL embolectomy. Consider if thrombolysisfailed or contraindicated or if hemodynamicallyunstableIVC FILTER if anticoagulation contraindicated

TREATMENT ISSUES

CONTRAINDICATIONS TO THROMBOLYTICTHERAPY� ABSOLUTE CONTRAINDICATIONS history of hemor

rhagic stroke or stroke of unknown origin, ischemicstroke in previous 3 months, brain tumors, majortrauma in previous 2 months, intra cranial surgeryor head injury within 3 weeks

Pulmonary Embolism 9

TREATMENT ISSUES (CONT’D)

� RELATIVE CONTRAINDICATIONS TIA within 6 months,oral anticoagulation, pregnancy or within 1 weekpostpartum, non compressible puncture sites,traumatic CPR, uncontrolled hypertension (SBP>185 mmHg, DBP >110 mmHg), advanced liverdisease, infective endocarditis, active peptic ulcer,thrombocytopenia

ANTICOAGULATION DURATION� FIRST PULMONARY EMBOLISM WITH REVERSIBLE OR

TIME-LIMITED RISK FACTOR anticoagulation for atleast 3 months

� UNPROVOKED PE at least 3 months of treatment. Ifno obvious risk factors for bleeding, consider indefinite anticoagulation

� PE AND MALIGNANCY treatment with SC LMWHbetter than oral warfarin. Treatment should be continued until eradication of cancer as long as there areno significant contraindications to anticoagulation

� PE AND PREGNANCY SC LMWH is preferred foroutpatient treatment. Total duration of therapyshould be 6 months unless patient has risk factorsfor hypercoagulable state

SPECIFIC ENTITIES

FAT EMBOLISM� PATHOPHYSIOLOGY embolism of fat globules to

lungs, brain, and other organs ! metabolized tofatty acids leading to inflammatory response. Commonly caused by closed fractures of long bones,but may also occur with pelvic fractures, orthopedic procedures, bone marrow harvest, bone tumorlysis, osteomyelitis, liposuction, fatty liver, pancreatitis, and sickle cell disease

� CLINICAL FEATURES triad of dyspnea, neurologicalabnormalities (confusion), and petechial rash(head and neck, chest, axilla). May also havefever, thrombocytopenia, and DIC

� DIAGNOSIS clinical diagnosis (rash is pathognomonic). Investigations may include CXR, V/Q scan,CT chest, and MRI head

� TREATMENTS supportive care as most patients willfully recover. Mortality is 10%. Primary prophylaxisincludes early mobilization and maybe steroids

Pleural Effusion NEJM 2002 346:25

DIFFERENTIAL DIAGNOSIS

EXUDATIVE malignancy, infections, connectivetissue disease, pulmonary embolism, hemothorax,pancreatitis, chylothoraxTRANSUDATIVE HF, hypoalbuminemia (GI losingenteropathy, cirrhosis, nephrotic syndrome, malnutrition), SVC obstruction, hepatohydrothorax, urinothorax, atelectasis, trapped lung, peritoneal dialysis, hypothyroidism, pulmonary embolismNote: pulmonary embolism, malignancy, and sarcoidosis can present as either exudative or transudative effusions. HF following diuresis may become‘‘pseudo exudative’’ (check albumin gradient)

CLINICAL FEATURES

HISTORY dyspnea, cough, hemoptysis, chest pain,weight loss, fever, trauma, occupational exposures,past medical history (pneumonia, liver disease, kidney disease, thyroid disease, cancer, HF, thromboembolic disease, connective tissue disease, smoking),medicationsPHYSICAL vitals, cyanosis, clubbing, tracheal deviation away from side of effusion (if no collapse ortrapped lung), peripheral lymphadenopathy, Horner’ssyndrome, respiratory examination (decreased breathsounds and tactile fremitus, stony dullness to percussion), cardiac examination, leg swelling (HF or DVT)

RATIONAL CLINICAL EXAMINATION SERIES: DOES THE PATIENT HAVE PLEURAL EFFUSION?AUSCULTATORY PERCUSSION auscultate with the diaphragm of the stethoscope over the posterior chestwall while gently tapping over the manubrium with the distal phalanx of one finger. Diminished resonancesuggests effusion

Sens Spc LR+ LRPhysicalAsymmetric chest expansion 74% 91% 8.1 0.29Auscultatory percussion 77% 92% 7.7 0.27Crackles 56% 62% 1.5 0.71Diminished breath sounds 42 88% 83 90% 4.3 5.2 0.15 0.64Dullness to conventional percussion 73% 91% 8.7 0.31Pleural friction rub 5.30% 99% 3.9 0.96

10 Pleural Effusion

CLINICAL FEATURES (CONT’D)

Sens Spc LR+ LRReduced tactile fremitus 82% 86% 5.7 0.21Reduced vocal resonance 76% 88% 6.5 0.27APPROACH ‘‘dullness to percussion and tactile fremitus are the most useful findings for pleural effusion. Dullchest percussion makes the probability of a pleural effusion much more likely but still requires a CXR to confirm thediagnosis. When the pretest probability of pleural effusion is low, the absence of reduced tactile fremitus makespleural effusion less likely so that a CXR might not be necessary depending on the overall clinical situation’

JAMA 2009 301:3

INVESTIGATIONS

BASIC� LABS CBCD, lytes, urea, Cr, LDH, total protein,

AST, ALT, ALP, bilirubin, INR, PTT, albumin� IMAGING CXR (PA, lateral, decubitus), CT chest� THORACENTESIS send pleural fluid for cell count

and differential, Gram stain, C&S, AFB and fungalcultures, LDH, total protein, pH, and cytology.Under special circumstances, also consider amylase, glucose, cholesterol, adenosine deaminase(for TB), albumin

SPECIAL� BIOPSY closed pleural biopsy, medical thoraco

scopy, bronchoscopy, surgical biopsy (videoassisted thoracic surgery)

DIAGNOSTIC ISSUES

OVERALL APPROACH generally, if the effusion is>1/4 of hemithorax, enough fluid is present fordiagnostic thoracentesis; obtain decubitus film toassess for loculation. In the absence of loculation,and with >10 mm [0.4 in.] layering of fluid ondecubitus film, bedside thoracentesis can beattempted; otherwise, request U/S guided thoracentesis. If only a small amount of fluid is present(0.6, fluid LDH >2/3 upperlimit of normal serum levelTHORACENTESIS PROCEDURE see NEJM 2006355:e16PLEURAL FLUID ANALYSIS� FLUID ACIDOSIS (pH

SPECIFIC ENTITIES (CONT’D)

during thoracentesis. Treat by lung re expansion,sometimes requiring thoracotomy with decorticationHEPATOHYDROTHORAX suspect if cirrhosisand portal hypertension, even in the absence ofascites. Pleural effusion results from passage of

SPECIFIC ENTITIES (CONT’D)

peritoneal fluid into pleura because of negativeintrathoracic pressures and diaphragmatic defects.Do not insert chest tube. Treat with diuresis, saltrestriction, and consider liver transplantation/TIPSprocedure

Chronic Cough

DIFFERENTIAL DIAGNOSIS

NON PULMONARY post nasal drip, GERD, ACEinhibitors, occult congestive heart failurePULMONARY� AIRWAY asthma, chronic bronchitis, bronchiec

tasis, neoplasm, foreign body, post viral� PARENCHYMA occult infection, occult aspira

tion, interstitial lung disease, lung abscess� VASCULAR early pulmonary hypertension

PATHOPHYSIOLOGY

DEFINITION OF CHRONIC COUGH >3 weeksCOMPLICATIONS OF CHRONIC COUGH exhaustion, insomnia, anxiety, headaches, dizziness, hoarseness, musculoskeletal pain, urinary incontinence,abdominal herniasCOUGH REFLEX� AFFERENT chemical or mechanical stimuli !

cough receptors in the epithelium of the upperand lower respiratory tracts, pericardium, esophagus, diaphragm, and stomach ! afferent nerves(vagus, glossopharyngeal, trigeminal, and phrenic)! cough center in the medulla

� EFFERENT cough center with cortical input! efferent signals travel down the vagus, phrenic, and spinalmotor nerves! expiratory muscles! cough

INVESTIGATIONS

BASIC� MICROBIOLOGY sputum Gram stain/AFB/C&S

INVESTIGATIONS (CONT’D)

� IMAGING CXR (order inspiratory and expiratoryviews if foreign body aspiration or endobronchial lesion suspected)

� SPIROMETRY/PFTSPECIAL� SINUS IMAGING� METHACHOLINE CHALLENGE� ESOPHAGEAL PH MONITORING

MANAGEMENT

SYMPTOM CONTROL codeine 20 mg PO q4h PRN,dextromethorphan 20 mg PO q4h PRNTREAT UNDERLYING CAUSE switch to ARB if ACEinhibitor suspected as cause of chronic cough

SPECIFIC ENTITIES

POST NASAL DRIP� PATHOPHYSIOLOGY secretions in the upper airway

stimulate cough receptors within the pharyngealor laryngeal mucosa

� CAUSES allergic, perennial non allergic, vasomotor rhinitis, acute nasopharyngitis, sinusitis

� DIAGNOSIS non specific findings� TREATMENTS reduce irritant exposure, antihista

mine decongestant combinations (diphenhydramine 25 50 mg PO q4 6h PRN, pseudoephedrine,ipratropium nasal spray 0.03% 2 sprays/nostril BIDTID, nasal corticosteroids, nasal saline rinses BID),surgical correction for anatomical abnormalities

Hemoptysis

DIFFERENTIAL DIAGNOSIS

NON CARDIOPULMONARY epistaxis, upper GIbleed, coagulopathyCARDIAC HF, mitral stenosisPULMONARY� AIRWAY bronchitis (acute, chronic), bronchiec

tasis, malignancy, foreign body, trauma� PARENCHYMA� MALIGNANCY lung cancer, metastasis

DIFFERENTIAL DIAGNOSIS (CONT’D)

� INFECTIONS necrotizing pneumonia (Staphylococcus, Pseudomonas), abscess, septicemboli, TB, fungal

� ALVEOLAR HEMORRHAGE Wegener’s granulomatosis, Churg Strauss, Goodpasture disease, pulmonary capillaritis, connective tissue disease

� VASCULAR pulmonary embolism, pulmonaryhypertension, AVM, iatrogenic

12 Hemoptysis

PATHOPHYSIOLOGY

MASSIVE HEMOPTYSIS 100 600 mL blood in 24 h.Patients may die of asphyxiation (rather thanexsanguination)

CLINICAL FEATURES

HISTORY characterize hemoptysis (amount, frequency, previous history), cough (productive),dyspnea, chest pain, epistaxis, hematemesis,weight loss, fever, night sweats, exposure, travel,joint inflammation, rash, visual changes, pastmedical history (smoking, lung cancer, TB,thromboembolic disease, cardiac disease), medications (warfarin, ASA, NSAIDs, naturalsupplements)PHYSICAL vitals, weight loss, clubbing, cyanosis,lymphadenopathy, Horner’s syndrome, respiratoryand cardiac examination, leg swelling (HF or DVT),joint examination, skin examination

INVESTIGATIONS

BASIC� LABS CBCD, lytes, urea, Cr, INR, PTT, urinalysis� MICROBIOLOGY blood C&S, sputum Gram stain/

AFB/fungal/C&S/cytology� IMAGING CXR, CT chest (warranted in most

patients unless obvious explanation)� BRONCHOSCOPY warranted in most patients

unless obvious explanation

INVESTIGATIONS (CONT’D)

SPECIAL� ETIOLOGY WORKUP ANA, p anca (myeloperoxi

dase MPO antibodies), c anca (antiproteinase 3PR3 antibodies), anti GBM antibody, rheumatologicscreen

� ABG if respiratory distress

MANAGEMENT

ACUTE ABC, O2, IV, intubation to protect airway ifsignificant hemoptysisSYMPTOM CONTROL cough suppressants, sedatives, stool softeners. Transfusions. Urgent interventional bronchoscopy (topical epinephrine, cold saline, cautery). Angiographic arterial embolization.Lung resectionTREAT UNDERLYING CAUSE correct coagulopathy (vitamin K 10 mg SC�1 dose or FFP); antibiotics;radiation for tumors; diuresis for HF; immunosuppression for vasculitis

SPECIFIC ENTITIES

GOODPASTURE DISEASE� PATHOPHYSIOLOGY antibasement membrane

antibodies ! attack pulmonary and renal basement membrane

� CLINICAL FEATURES hemoptysis and hematuria,with respiratory and renal failure if severe

� DIAGNOSIS lung/kidney biopsy� TREATMENTS steroids, cyclophosphamide, plasma

pheresis

Solitary Pulmonary Nodule NEJM 2003 348:25

DIFFERENTIAL DIAGNOSIS

MALIGNANT bronchogenic, carcinoid, metastatic cancerBENIGN healed infectious granuloma, benigntumors (hamartoma), AVM, rheumatoid nodule,Wegener’s granulomatosis, hydatid cyst, round at