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Approach to internal medicine 2016

David Hui
Alexander A. Leung
Raj Padwal Editors

Approach to
Internal Medicine
A Resource Book
for Clinical Practice
Fourth Edition

123


Approach to Internal Medicine



Approach to Internal Medicine
A Resource Book for Clinical Practice

Fourth Edition

Edited by

David Hui, MD, MSc
Alexander A. Leung, MD, MPH, FRCPC, MRCP(UK), FACP
Raj Padwal, MD, MSc, FRCPC
With Assistance from
Christopher Ma, MD


Editors

David Hui, MD, MSc
The University of Texas MD Anderson
Cancer Center
Houston, TX
USA

Raj Padwal, MD, MSc, FRCPC
University of Alberta
Edmonton, AB
Canada

Alexander A. Leung, MD, MPH, FRCPC,
MRCP(UK), FACP
University of Calgary
Calgary, AB, Canada
Editors: David Hui, Alexander A. Leung, Raj Padwal
Assistant Editor: Christopher Ma
First edition, first printing, April 2006
Second edition, first printing, August 2007
Second edition, second printing, November 2007
Second edition, third printing, March 2008
Second edition, fourth printing, July 2008
Second edition, fifth printing, November 2008
Second edition, sixth printing, June 2009
Third edition, first printing, January 2011
Fourth edition, first printing, September 2015
Approach to Internal Medicine: A Resource Book for Clinical Practice
Additional material to this book can be downloaded from http://extras.springer.com.


ISBN 978-3-319-11820-8
ISBN 978-3-319-11821-5
DOI 10.1007/978-3-319-11821-5

(eBook)

Library of Congress Control Number: 2015952117
Springer Cham Heidelberg New York Dordrecht London
© Springer International Publishing Switzerland 2016
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar
methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the
relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this
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authors or the editors give a warranty, express or implied, with respect to the material contained herein
or for any errors or omissions that may have been made.
Printed on acid-free paper
Springer International Publishing AG Switzerland is part of Springer Science+Business Media
(www.springer.com)


To Ella, Rupert and Nancy
David Hui
To Miriam
Alexander A. Leung
To Stephanie and Sarah
Raj Padwal
To Bryan, Sarah, Michael, and May
Christopher Ma



Disclaimer

Approach to Internal Medicine is meant to be a practical field guide. Dosages of medications are provided for quick reference only. Readers should
consult other resources before applying information in this manual for
direct patient care. The author, editors, and publisher of Approach 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.



Preface
Practice is science touched with emotion.
Confessio Medici, Stephen Paget, 1909
In this fourth edition of Approach to Internal Medicine, we have substantially updated the content to
provide practicing clinicians and trainees with a practical, evidence-based, and concise resource for
everyday clinical use, bedside teaching and examination preparation. Approach to Internal Medicine
consists of over 250 internal medicine topics classified under 17 subspecialties.
Under each topic, the sections on differential diagnoses, investigations, and treatments are designed
for the rapid retrieval of high-yield clinical information and can be particularly useful when one is all
alone assessing a patient at 3 o’clock in the morning. Unique to Approach to Internal Medicine, we have
included multiple comparison tables aimed at highlighting the distinguishing features between various
clinical entities, and numerous clinical pearls and mnemonics (marked by ★). In addition to International
System (SI) units, this edition also provides US customary units [in square brackets] for quick reference.
For this new edition, we are very fortunate to have recruited a new assistant editor, Dr. Christopher Ma,
who brings with him a wealth of knowledge and the perspective of a chief medicine resident. The JAMA
Rationale Examination Series has now been updated with new data. We are most grateful to our section
editors and contributors for their meticulous review of each subspecialty, providing expert input on the
most up-to-date information. We also would like to thank the editorial and production teams at Springer
for their expert guidance and support throughout this mammoth project. Finally, we would like to thank all
previous and current users of this manual for their support and feedback.
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 from
application of the information contained herein. Verification of the information in this manual remains
the 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 particularly important since patterns of practice and clinical evidence evolve constantly. We welcome any
constructive feedback to help make this manual a more accurate, practical, comprehensive, and userfriendly resource.
David Hui, MD, MSc
The University of Texas MD Anderson Cancer Center
Houston, TX, USA
Alexander A. Leung, MD, MPH, FRCPC, MRCP(UK), FACP
University of Calgary,
Calgary, AB, Canada
Raj Padwal, MD, MSc, FRCPC
University of Alberta
Edmonton, AB, Canada
Christopher Ma, MD
Department of Medicine, University of Alberta,
Edmonton, AB, Canada



Section Editors
PULMONARY MEDICINE
Ashley-Mae Gillson, HBSc, MD, FRCPC
Division of Pulmonary Medicine
Department of Medicine
University of Alberta
Edmonton, AB, Canada

ONCOLOGY
Ahmed Eid, MD, MEd
Department of General Oncology
The University of Texas MD
Anderson Cancer Center
Houston, TX, USA

CARDIOLOGY
Bryan Jonathan Har, MD, MPH, FRCPC
Clinical Assistant Professor
Department of Cardiac Sciences
University of Calgary
Calgary, AB, Canada

David Ramirez, MD
Department of General Oncology
The University of Texas MD
Anderson Cancer Center
Houston, TX, USA

NEPHROLOGY
Alan W. McMahon, MD, FRCPC
Division of Nephrology and Transplant Immunology
Department of Medicine
University of Alberta
Edmonton, AB, Canada
CRITICAL CARE
Wendy Sligl, MD, MSc, FRCPC
Divisions of Critical Care Medicine
and Infectious Diseases
Department of Medicine
University of Alberta
Edmonton, AB, Canada
GASTROENTEROLOGY
Angeli Chopra, MD, FRCPC, ABIM
Division of Gastroenterology
Department of Medicine
University of Alberta
Edmonton, AB, Canada
HEMATOLOGY
Michael H. Kroll, MD, FACP
Department of Benign Hematology
The University of Texas MD Anderson
Cancer Center
Houston, TX, USA

Caren L. Hughes, PharmD, BCOP
Division of Pharmacy
The University of Texas MD
Anderson Cancer Center
Houston, TX, USA
INFECTIOUS DISEASES
Stephanie W. Smith, MD, MSc, FRCPC
Division of Infectious Diseases
Department of Medicine
University of Alberta
Edmonton, AB, Canada
RHEUMATOLOGY
Steven J. Katz, MD, FRCPC
Division of Rheumatology
Department of Medicine
University of Alberta
Edmonton, AB, Canada
NEUROLOGY
Michael M.C. Yeung, MD, FRCPC
Department of Clinical Neurosciences
Cumming School of Medicine
University of Calgary
Calgary, AB, Canada


xii
Ronak K. Kapadia, MD, BSc
Department of Clinical Neurosciences
Cumming School of Medicine
University of Calgary
Calgary, AB, Canada
ENDOCRINOLOGY
Sonia Butalia, BSc, MD, FRCPC, MSc
Division of Endocrinology
and Metabolism
Department of Medicine
University of Calgary
Calgary, AB, Canada
DERMATOLOGY
Susan Y. Chon, MD, FAAD
Division of Internal Medicine
Department of Dermatology
The University of Texas MD
Anderson Cancer Center
Houston, TX, USA
GERIATRICS
Diana Rucker, MSc, MD, FRCPC
Division of Geriatrics
Department of Medicine
University of Alberta
Edmonton, AB, Canada
PALLIATIVE CARE
David Hui, MD, MSc
Department of Palliative Care
and Rehabilitation Medicine
Department of General Oncology
Division of Cancer Medicine
The University of Texas MD
Anderson Cancer Center
Houston, TX, USA

Section Editors

NUTRITION
Raj Padwal, MD, MSc, FRCPC
Division of General Internal Medicine
Department of Medicine
University of Alberta
Edmonton, AB, Canada
Kari McKnight, RD
WholeSUM Nutrition Consulting Inc.
Edmonton, AB, Canada
OBSTETRICAL MEDICINE
Eliana Castillo, MD, MHSc, FRCPC
Division of General Internal Medicine
Department of Medicine
Cumming School of Medicine
University of Calgary
Calgary, AB, Canada
Tammy Shaw, MD, CCFP, FRCPC
Division of General Internal Medicine
Department of Medicine
St. Joseph’s Health Centre
University of Toronto
Toronto, ON, Canada
GENERAL INTERNAL MEDICINE
Peter Hamilton, MBBCh, FRCPC
Division of General Internal Medicine
Department of Medicine
University of Alberta
Edmonton, AB, Canada
Christopher Ma, MD
Department of Medicine
University of Alberta
Edmonton, AB, Canada


Contents
1

Pulmonary Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Asthma Exacerbation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
COPD Exacerbation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pulmonary Embolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pleural Effusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chronic Cough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hemoptysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Solitary Pulmonary Nodule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pulmonary Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Interstitial Lung Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Obstructive Sleep Apnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Respiratory Acidosis: Hypoventilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Respiratory Alkalosis: Hyperventilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hypoxemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ventilation Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Approach to Chest Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Approach to Pulmonary Function Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1
1
4
7
10
12
14
15
16
17
18
20
22
22
23
23
23
25

2

Cardiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Aortic Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Acute Coronary Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pericardial Diseases: Pericarditis and Tamponade . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Heart Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Digoxin Intoxication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Atrial Fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Syncope. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cardiac Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Aortic Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Aortic Regurgitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mitral Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mitral Regurgitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Endocarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Peripheral Vascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

27
27
28
35
37
43
45
49
49
54
56
57
59
60
62
65


xiv

Contents

Hyperlipidemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Smoking Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Approach to ECG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

70
73
73

3

Nephrology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Acute Renal Failure: Pre-renal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Acute Renal Failure: Renal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Acute Renal Failure: Post-renal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Glomerulopathies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chronic Kidney Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Proteinuria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hematuria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cystic Kidney Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Metabolic Acidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Metabolic Alkalosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hyponatremia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hypernatremia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hypokalemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hyperkalemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hypomagnesemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hypophosphatemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ureteral Calculi. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Approach to Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

77
77
78
80
80
83
85
85
86
87
89
90
92
92
93
94
94
95
96
96

4

Critical Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Intensive Care Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hypoxemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Acute Respiratory Distress Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ventilation Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sepsis and Septic Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Lactic Acidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Rhabdomyolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Toxicology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Alcohol Withdrawal and Complications of Alcoholism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hypothermia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Smoke Inhalation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

99
99
102
104
105
108
111
112
113
114
117
120
121
122

5

Gastroenterology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Nausea and Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dysphagia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dyspepsia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Acute Abdominal Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Upper GI Bleed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Lower GI Bleed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Inflammatory Bowel Disease Exacerbation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

123
123
124
125
128
131
134
135


Contents

xv

Acute Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chronic Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Malabsorption Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Acute Liver Failure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hepatitis B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hepatitis C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chronic Liver Disease: Cirrhosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hepatic Encephalopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ascites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Jaundice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Acute Pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

137
138
140
141
143
145
147
149
152
153
155
156

6

Hematology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Polycythemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Microcytic Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Normocytic Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Macrocytic Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sickle Cell Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Neutropenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Eosinophilia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Thrombocytosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Thrombocytopenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pancytopenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Bleeding Diathesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hypercoagulable States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Deep Vein Thrombosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Approach to Anticoagulation Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Transfusion Reactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Approach to the Peripheral Blood Smear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Splenomegaly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Myeloproliferative Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Acute Myelogenous Leukemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Acute Lymphoblastic Leukemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chronic Lymphocytic Leukemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hodgkin’s Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Non-Hodgkin’s Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Multiple Myeloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Febrile Neutropenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hematopoietic Stem Cell Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

159
159
160
161
162
163
164
165
166
167
170
170
173
176
178
180
182
182
184
185
188
189
191
193
198
201
201

7

Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Lung Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mesothelioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Thymoma and Thymic Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Esophageal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Gastric Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

203
203
206
207
208
215
217


xvi

8

Contents

Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Carcinoid Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Gastrointestinal Stromal Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Anal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cancer of the Exocrine Pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hepatocellular Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Renal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Bladder Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prostate Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Testicular Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Brain Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cancer of Unknown Origin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tumor Markers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hereditary Cancer Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Antineoplastic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Oncologic Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Febrile Neutropenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chemotherapy-Induced Nausea and Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Oral Mucositis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chemotherapy-Induced Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

219
221
223
224
225
227
228
230
231
234
237
237
239
240
243
246
253
254
254
256
257

Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Fever of Unknown Origin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Fever and Rash. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Fever and Joint Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Febrile Neutropenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Fever with Travel History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Endocarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Urinary Tract Infections and Sexually Transmitted Infections . . . . . . . . . . . . . . . . . . . . . . . .
Soft Tissue Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Osteomyelitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Septic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tuberculosis: Pulmonary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Approach to Gram Stain, Culture, and Sensitivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Approach to Empiric Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hepatitis B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hepatitis C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Herpes Simplex Virus Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Human Immunodeficiency Virus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Influenza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Antiviral Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Fungal Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Antifungal Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Infection Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Immunization for Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

259
259
260
262
262
263
265
268
268
269
272
275
277
279
279
282
289
290
290
290
291
295
297
298
302
304
305


Contents

xvii

9

Rheumatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Septic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Gout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Polyarticular Joint Pain and Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Rheumatoid Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Systemic Lupus Erythematosus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Seronegative Spondyloarthropathies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Back Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Osteoarthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Fibromyalgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Vasculitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Approach to Serologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Joint Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

309
309
311
312
314
316
319
322
324
325
326
331
333

10 Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Brain Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Acute Stroke Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cranial Nerve Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Diplopia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Bell’s Palsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Delirium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Syncope. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Migraine Headaches. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dizziness and Vertigo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hearing Impairment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Myasthenia Gravis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ataxia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Subacute Combined Degeneration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Parkinson’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Radiculopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Peripheral Neuropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Muscle Weakness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Approach to Neuroimaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

335
335
337
344
347
347
349
350
350
350
353
355
356
357
359
360
361
362
362
366
371
377
378

11 Endocrinology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Diabetes Mellitus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Principles of Insulin Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hypoglycemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hypothyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hyperthyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Solitary Thyroid Nodule. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pituitary Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Polyuria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Adrenal Incidentaloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Adrenal Insufficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

381
381
387
389
390
391
393
394
396
396
398


xviii

Contents

Cushing’s Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hypocalcemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hypercalcemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hyperlipidemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Amenorrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hirsutism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

399
401
402
403
406
406
406
407

12 Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Eczema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Psoriasis Vulgaris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Acne Vulgaris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Exanthematous Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Stevens–Johnson Syndrome/Toxic Epidermal Necrolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Melanoma and Skin Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cutaneous Lupus Erythematosus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Drug Eruptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Erythema Nodosum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Clubbing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dupuytren’s Contracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

409
409
410
412
413
414
416
418
421
422
424
425
426

13 Geriatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Geriatric-Specific Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dementia and Cognitive Impairment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Delirium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Urinary Incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hearing Impairment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pharmacological Issues in the Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

427
427
429
432
434
435
435
436
436

14 Palliative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Palliative Care-Specific Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Principles of Pain Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Delirium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cancer-Related Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dyspnea in the Palliative Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Nausea and Vomiting in the Palliative Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Constipation in the Palliative Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Anorexia–Cachexia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Communication Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prognostication in Far Advanced Cancer Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Management of Other Distressing Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

439
439
442
445
446
446
448
448
449
451
453
454


Contents

xix

15 Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Malabsorption Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Anorexia–Cachexia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Vitamin B12 Deficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Diet and Supplemental Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

457
457
459
459
459
460

16 Obstetric Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Physiologic Changes in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Preeclampsia/Eclampsia/HELLP Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pulmonary Diseases in Pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cardiac Diseases in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hepatic Diseases in Pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Infectious Diseases in Pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Diabetes in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Thyroid Diseases in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other Disorders in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

465
465
467
469
470
471
472
474
475
476

17 General Internal Medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Approach to Diagnostic Tests and Clinical Trials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Multisystem Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Perioperative Assessment for Non-cardiopulmonary Surgery
and Postoperative Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medical Fitness to Drive. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Obtaining Consent for Medical Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Biomedical Ethics Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hospital Admission and Discharge Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

479
479
480
482

Appendix A Advanced Cardiac Life Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

495

Appendix B List of Common Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

497

Appendix C Common Laboratory Values and Unit Conversion . . . . . . . . . . . . . . . . . . . . .

503

Appendix D History Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

509

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

511

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

513

484
490
492
492
494


1
PULMONARY MEDICINE
Ashley-Mae Gillson
Asthma Exacerbation
DIFFERENTIAL DIAGNOSIS OF WHEEZING

EXTRATHORACIC AIRWAY OBSTRUCTION
· OROPHARYNX—enlarged tonsils, retropharyngeal abscess, obesity, post-nasal drip
· LARYNX—laryngeal edema, laryngostenosis,
laryngocele, epiglottitis, anaphylaxis, severe
laryngopharyngeal reflux, laryngospasm
· VOCAL CORDS—vocal cord dysfunction, paralysis, hematoma, tumor, cricoarytenoid arthritis
INTRATHORACIC AIRWAY OBSTRUCTION
· TRACHEAL OBSTRUCTION—tracheal stenosis,
tracheomalacia, tracheobronchitis (herpetic,
fungal), malignancy, benign tumor, aspiration, foreign body
· 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, fungal
· OUTDOORS—respirable particulates, ozone,
sulfur dioxide, cold air, humidity, smoke
· INDOORS—smoke, dust mites, air conditioners,
humidity, perfumes, scents, mold, animal dander
· NON-ADHERENCE
CLINICAL FEATURES

HISTORY —history of asthma and any
life-threatening exacerbations, number of ER
visits/hospital admissions in the last 6 months
(or  ever), any ICU admissions, previous prednisone use, triggers for attacks, usual peak
expiratory flow rate, change in peak flow rates,
wheezing, cough, dyspnea, decreased function,
exercise limitation, nocturnal symptoms,

CLINICAL FEATURES CONT’D

absenteeism from work/school, postnasal drip,
recurrent sinusitis, GERD, past medical history,
medication history, psychosocial issues, occupational and work environment, home environment
(pets, heating source, filter changes)
PHYSICAL—HR ↑, RR ↑, pulsus paradoxus, O2
requirement, moderate-severe dyspnea, barrel
chest, cyanosis, hyperresonance, decreased
breath sounds, wheezing, forced expiratory time
TYPES OF WHEEZING—inspiratory wheeze and
expiratory wheeze are classically associated with
extrathoracic and intrathoracic airway obstruction, respectively. However, they are neither
sensitive nor specific and cannot help to narrow
differential diagnosis
INVESTIGATIONS

BASIC
·

LABS—CBCD, lytes, urea, Cr, troponin/CK

MICROBIOLOGY—sputum Gram stain/AFB/
C&S, nasopharyngeal swab for viral studies
· IMAGING—CXR
SPECIAL
· 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
post-bronchodilator suggests asthma
· METHACHOLINE
CHALLENGE
(non-acute
setting)—if diagnosis of asthma not
confirmed by spirometry alone. A decrease
of FEV1 >20% after methacholine challenge
suggests asthma. Sens 95%
· SPUTUM EOSINOPHIL COUNTS (non-acute
setting)—performed in specialized centres
for monitoring of asthma control in patients
with moderate to severe asthma
Can Resp J 2012 19:2
·

D. Hui et al. (eds.), Approach to Internal Medicine: A Resource Book for Clinical Practice,
DOI 10.1007/978-3-319-11821-5_1, © Springer International Publishing Switzerland 2016

1


2

Asthma Exacerbation

ACUTE MANAGEMENT

TREATMENT ISSUES

ASTHMA CONTROL CRITERIA

ABC—O2 to keep sat >92%, IV
BRONCHODILATORS—salbutamol 100 μg MDI
2 puffs q6h ATC + q1h PRN and ipratropium 20 μg
MDI 2 puffs q6h ATC (frequency stated is only a guide,
may increase or decrease on a case by case basis)
STEROID —prednisone 0.5–1  mg/kg PO
daily × 7–14 days (may be shorter depending on
response) or methylprednisolone 0.4–0.8 mg/kg
IV daily (until conversion to prednisone)
OTHERS—if refractory case and life-threatening,
consider IV epinephrine, IV salbutamol, theophylline, inhaled anesthetics, MgSO4
MECHANICAL VENTILATION—BiPAP, intubation

Characteristic
Daytime symptoms
Night-time symptoms
Physical activity
Exacerbations
Absence from work or
school due to asthma
Need for a SABA
FEV1 or PEF

<4 doses/week
≥90% personal
best
<10–15%
PEF diurnal variationa
Sputum eosinophils
<2–3%
a
Diurnal variation is calculated as the
difference between the highest and lowest
PEF divided by the highest PEF multiplied
by 100 for morning and night (determined
over a 2 week period)

LONGTERM MANAGEMENT

EDUCATION—smoking cessation (see p.  480).
Asthma action plan. Puffer technique education and review
ENVIRONMENTAL CONTROL—avoidance of outdoor/indoor allergens, irritants, and infections; home
environment cleanliness (e.g. steam cleaning)
VACCINATIONS—influenza vaccine annually
and pneumococcal vaccine every 5 years
FIRST LINE—SABA (salbutamol 100  μg MDI 2
puffs PRN). Proceed to second line if using more
than 2×/week or 1×/day for exercise-induced
symptoms, symptoms >2×/week, any nocturnal
symptoms, activity limitation or PEF <80%
SECOND LINE—low-dose ICS plus short-acting
β2-agonist PRN
THIRD LINE—moderate-dose ICS, combined ICS
plus LABA (note that long-acting β2-agonist
should never be used alone in asthma), or leukotriene receptor antagonist (most effective in
asthma complicated with sinus disease and
exercise-induced asthma). May also consider using
single inhaler budesonide/formoterol combination
therapy as both a controller and an acute reliever
FOURTH LINE—anti-IgE therapy (omalizumab)
for refractory allergic asthma, administered
subcutaneously q2–4 weeks, dosed by IgE level
and body weight, for add-on therapy or inadequately controlled moderate-to-severe allergic
asthma despite use of high doses of inhaled
corticosteroid therapy
NEJM 2009 360:10
Can Resp J 2012 19:2

Frequency or value
<4 days/week
<1 night/week
Normal
Mild, infrequent
None

COMMON INHALED MEDICATIONS
SHORT-ACTING β-AGONISTS (SABA)—salbutamol
MDI 100 μg 1–2 puffs PRN or 2.5 mg NEB PRN,
fenoterol MDI 100 μg 1–2 puffs PRN, terbutaline
500 μg INH PRN
· SHORT-ACTING ANTICHOLINERGICS—ipratropium
MDI 20 μg 2 puffs QID or 500 μg NEB QID
· LONG-ACTING β-AGONISTS (LABA)—formoterol
6–24  μg INH BID, salmeterol diskus 50  μg i
puff BID
· LONG -ACTING ANTICHOLINERGICS — tiotropium
18 μg INH daily
· INHALED CORTICOSTEROIDS—beclomethasone
125–250  μg INH BID, budesonide turbuhaler
200–400  μg INH BID or 0.5–1  mg NEB BID,
fluticasone 125–250  μg INH BID, ciclesonide
MDI 100–400  μg INH daily (only indicated for
asthma at this time, not COPD), mometasone
twisthaler 100–400 μg INH BID
·

Related Topics
Chronic Obstructive Pulmonary Disease (p. 4)
Pulmonary Function Tests (p. 25)


3

Asthma Exacerbation

TREATMENT ISSUES CONT’D

ADMISSION CRITERIA
FEV1 (L)
PEF (L/min)
PaO2
Action
Very severe


<90% with O2
Admit
Severe
<1.6 (<40%)
<200 (<40%)
<90%
Admit
Moderate
1.6–2.1
200–300
>90%
Admit?
Mild
>2.1 (>60%)
>300 (>60%)
>90%
Send home
DISCHARGE CRITERIA—consider discharging patient if peak flow >70% of usual (or predicted)
value for at least 1 h after bronchodilator
OXYGEN DELIVERY DEVICES
Device
Nasal cannula

Flow rates
Delivered O2
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 (non-rebreather mask)
6 L/min
60%
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
41–50%
NOTE: delivered O2 (FiO2) is approximate. Oxygen delivery can approach 100% with intubation and
mechanical ventilation
SPECIFIC ENTITIES

EXERCISEINDUCED ASTHMA
· PATHOPHYSIOLOGY—mild asthma with symptoms only during exercise due to bronchoconstriction as a result of cooling of airways
associated with heat and water loss
· DIAGNOSIS—spirometry. Exercise or methacholine challenge may help in diagnosis
· TREATMENTS—prophylaxis with salbutamol 2
puffs MDI, given 5–10  min before exercise.
Consider leukotriene antagonists or
inhaled  glucocorticoids if frequent use of
prophylaxis
TRIAD ASTHMA (Samter’s syndrome)—triad of
asthma, aspirin/NSAIDs sensitivity, and nasal
polyps. Cyclooxygenase inhibition → ↓ prostaglandin E2 → ↑ leukotriene synthesis → asthma
symptoms. Management include ASA/NSAIDs
avoidance and leukotriene antagonists
(montelukast)

SPECIFIC ENTITIES CONT’D

ALLERGIC
BRONCHOPULMONARY
ASPERGILLOSIS (ABPA)
· PATHOPHYSIOLOGY—associated with asthma
and cystic fibrosis. Due to colonization of the
airways by Aspergillus 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, CT chest findings of
central bronchiectasis, “finger-in-glove”
appearance (i.e. mucous-filled dilated bronchi)
· DIAGNOSIS—above clinical features plus
Aspergillus extract skin test, serum IgE level,
sputum for Aspergillus and/or serologic tests
(IgE and IgG against Aspergillus)
· TREATMENTS —systemic
glucocorticoids,
itraconazole


4

COPD Exacerbation

COPD Exacerbation

NEJM 2004 250:26

DIFFERENTIAL DIAGNOSIS OF ACUTE DYSPNEA

CLINICAL FEATURES CONT’D

RESPIRATORY
· AIRWAY —COPD
exacerbation, asthma
exacerbation, acute bronchitis, infectious
exacerbation of bronchiectasis, foreign body
obstruction
· PARENCHYMA —pneumonia,
cryptogenic
organizing pneumonia (COP), ARDS, acute
exacerbation of interstitial lung disease
· VASCULAR—pulmonary embolism, pulmonary hypertension
· PLEURAL—pneumothorax, pleural effusion
CARDIAC
· MYOCARDIAL—HF exacerbation, myocardial
infarction
· VALVULAR—aortic stenosis, acute aortic
regurgitation, mitral stenosis, endocarditis
· PERICARDIAL —pericardial
effusion,
tamponade
SYSTEMIC—sepsis, metabolic acidosis, anemia
OTHERS —neuromuscular,
psychogenic,
anxiety

LR+
LR–
Decreased cardiac dullness 10
0.88
Match test
7.1
0.43
Rhonchi
5.9
0.95
Hyperresonance
4.8
0.73
FEV1 >9 s
4.8

FEV1 6–9 s
2.7

FEV1 <6 s
0.45

Subxyphoid cardiac apical 4.6
0.94
impulse
Wheezing
4.4
0.88
Maximum laryngeal height 4.2
0.70
≤4 cm
Pulsus paradoxus
3.7
0.62
(>15 mmHg)
Decreased breath sounds
2.6
0.66
Accessory muscle use

0.70
Clinical Judgement
5.6

Overall Clinical Prediction
of Moderate-Severe
Disease
Overall Clinical Prediction   2.3

of Mild Disease
APPROACH—“no single item or combination of items from the clinical examination
rules out airflow limitation. The best findings
associated with increased likelihood of airflow limitation are objective wheezing, FEV1
>9 s, positive match test, barrel chest, hyperresonance and subxyphoid cardiac impulse.
Three findings predict the likelihood of airflow limitation in men: years of cigarette
smoking, subjective wheezing and either
objective wheezing or peak expiratory flow
rate”
JAMA 1995 273:4
UPDATE—multivariate ‘Rule In’ Obstructive
Disease Model (history of obstructive airways
disease, smoking >40 pack-years, age ≥45, and
laryngeal height ≤4 cm) has posterior odds of
disease of 220. Multivariate ‘Rule Out’
Obstructive Disease Model (smoking <30 years,
no wheezing symptoms, and no auscultated
wheezing) has posterior odds of disease of
0.02.
The Rational Clinical Examination.
McGraw-Hill, 2009

PATHOPHYSIOLOGY

PRECIPITANTS OF COPD EXACERBATION—
infections, lifestyle/environmental (10%
[cigarette smoke, dust, pollutants, cold air]),
non-adherence, pulmonary embolism, pulmonary edema, pneumothorax, progression of
COPD
CLINICAL FEATURES

RATIONAL CLINICAL EXAMINATION SERIES:
DOES THE CLINICAL EXAMINATION
PREDICT AIRFLOW LIMITATION?
History
Smoking >40 pack-years
Smoking ever
Sputum >1/4 cup
Chronic bronchitis Sx
Wheezing
Any exertional dyspnea
Coughing
Any dyspnea
Physical
Barrel chest

LR+

LR–

12
1.8
4
3
3.8
2.2
1.8
1.2

0.63
0.16
0.84
0.78
0.66
0.83
0.69
0.55

10

0.90


5

COPD Exacerbation

INVESTIGATIONS

BASIC
·

LABS—CBCD, lytes, urea, Cr, troponin/CK, Ca,

Mg, PO4
·

MICROBIOLOGY—sputum

Gram stain/AFB/
C&S/fungal, nasopharyngeal swab for viral
studies
· IMAGING—CXR
· ECG—left atrial enlargement, atrial fibrillation, sinus tachycardia
· SPIROMETRY/PFT—FEV1/FVC <0.7, may be
partially reversible. Severity based on FEV1
· ABG—if acute respiratory distress
SPECIAL
· BNP—if suspect HF
· D-DIMER, CT CHEST—if suspect PE
·

ECHOCARDIOGRAM

PROGNOSTIC ISSUES

PROGNOSIS OF PATIENTS WITH ACUTE
EXACERBATION OF COPD—in-hospital mortality 5–10%
GOLD CLASSIFICATION 2007—all have FEV1/
FVC <0.7
· STAGE I (MILD)—FEV1 ≥ 80% predicted
· STAGE II (MODERATE)—FEV1 50–79% predicted
· STAGE III (SEVERE)—FEV1 30–49% predicted
· STAGE IV (VERY SEVERE)—FEV1 < 30% predicted,
or <50% predicted + cor pulmonale
BODE INDEX
· BMI—0 points = >21, 1 point = ≤21
· OBSTRUCTION (post-bronchodilator FEV1)—0
points = ≥65% predicted, 1 point = 50–64%,
2 points = 36–49%, 3 points = ≤35%
· DISTANCE WALKED IN 6 MIN—0 points = ≥350 m,
1 point = 250–349 m, 2 points = 150–249 m, 3
points = ≤149 m
· EXERCISE MMRC DYSPNEA SCALE—0 points = 0–1,
1 point = 2, 2 points = 3, 3 points = 4
· SCORING—total BODE score calculated as sum
of all points. Relative risk for death (any cause)
is increased by 34% per one-point increase
in  BODE score. Relative risk for death (from
respiratory failure, pneumonia, or pulmonary
embolism) is increased by 62% per one-point
increase in BODE score
NEJM 2004 350:10

ACUTE MANAGEMENT

ABC—O2 to keep sat >90%, or 88–92% if CO2
retainer, IV
BRONCHODILATORS—salbutamol 100 μg MDI
2 puffs q4h ATC + q1h PRN and ipratropium
20 μg MDI 2 puffs q4h ATC
STEROIDS —prednisone 40–60  mg PO
daily × 5–14 days (tapering dose not always
necessary) or methylprednisolone 60–125 mg IV
q6-12 h (inpatient)
ANTIBIOTICS—give if any two of the following
criteria are met: ↑ sputum purulence, ↑ dyspnea
or ↑ sputum volume. Other considerations include
the need for non-invasive mechanical ventilation
and “at risk” for poor outcome (substantial comorbidities, severe COPD, frequent exacerbations >3/
year, recent antibiotics within 3 months); choices
depend on clinical circumstance (levofloxacin
500  mg PO daily × 7–10 days [or 750  mg PO
daily × 5 days if no renal disease], doxycycline
100  mg PO BID × 7–10 days, amoxicillin 500  mg
PO BID × 7  days, cefuroxime 250–500  mg PO
BID × 10 days, or azithromycin 500 mg PO × 1 day
then 250 mg PO daily × 4 days)
MECHANICAL VENTILATION—BiPAP, intubation
OTHERS —DVT prophylaxis (unfractionated
heparin 5000 U SC q8-12 h, enoxaparin 40 mg SC
q24h, dalteparin 5000 U SC q24h), physiotherapy
NEJM 2002 346:13
LONGTERM MANAGEMENT

EDUCATION—smoking cessation (see p.  480).
Disease-specific self-management program.
Puffer technique education and review
VACCINATIONS—influenza vaccine annually
and pneumococcal vaccine booster every 5 years
REHABILITATION—education and exercise
training (increases quality of life and exercise
tolerance); pulmonary rehabilitation associated
with ↓ risk of recurrent exacerbation in patients
with moderate to very severe COPD and recent
AECOPD (<4 weeks)
FIRST LINE—SABA or short-acting anticholinergic on an as-needed basis
SECOND LINE—LABA or long-acting anticholinergic (tiotropium 1 puff [18 μg/puff] INH daily)
plus SABA PRN. Consider early initiation of longacting agents if requiring regular PRN shortacting agents as long-acting agents are superior


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