Approach to Internal Medicine A Resource Book for Clinical Practice Third Edition ppt

Approach to Internal Medicine

Approach to Internal Medicine
A 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
13
Pulmonary Medicine
Pages 1–24
Cardiology
Pages 25–66
Nephrology
Pages 67–88
Critical Care
Pages 89–110
Gastroenterology
Pages 111–142
Hematology
Pages 143–184
Oncology
Pages 185–232
Infectious Diseases
Pages 233–272
Rheumatology

Pages 273–296
Neurology
Pages 297–336
Endocrinology
Pages 337–360
Dermatology
Pages 361–376
Geriatrics
Pages 377–388
Palliative Care
Pages 389–402
Nutrition
Pages 403–408
Obstetric Med
Pages 409–416
General Med
Pages 417–430
ACLS
Page 431
Index
Pages 443–458
David Hui MD, M.Sc., FRCPC
The University of Texas M.D. Anderson
Cancer Center
Houston, TX 77030 USA

Author: David Hui
Associate editors: Alexander Leung, Raj Padwal
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
Approach to Internal Medicine: A Resource Book for Clinical Practice
Additional material to this book can be downloaded from .
ISBN 978-1-4419-6504-2 e-ISBN 978-1-4419-6505-9
DOI 10.1007/978-1-4419-6505-9
Springer New York Dordrecht Heidelberg London
Library of Congress Control Number: 2010933485
# Springer ScienceþBusiness Media, LLC 2006, 2007, 2011
All rights reserved. This work may not be translated or copied in whole or in part without the written
permission of the publisher (Springer ScienceþBusiness Media, LLC, 233 Spring Street, New York, NY
10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection
with any form of information storage and retrieval, electronic adaptation, computer software, or by
similar 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 are
not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject
to proprietary rights.
While the advice and information in this book arebelievedtobe true and accurate at the date of going to
press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any
errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect
to 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. 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 con
tained within this manual.
vii

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 to
significantly expand and update the content and substantially improve the layout, while maintaining
the same conciseness and practicality found in previous editions.
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 inthe morning. Other sections contain many clinical pearls that are intended
to help one to excel in patient care. We also included many comparison tables aimed at highlighting the
distinguishing features between various clinical entities and numerous mnemonics (marked by w). In
additionto everyday practice, Approach to Internal Medicine can be effectively used as an examination study
guide and teaching script.
For this new edition, we are very fortunate to have recruited a new associate editor, Dr. Alexander
Leung, 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 each
subspecialty, providing expert input on the most up to date information. We would also like to take

this opportunity to thank Jean Claude Quintal as a resident reviewer and the Canadian Federation of
Medical Students for its support of the previous edition. Finally, we would like to thank all previous and
current 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 its
quality in preparation for international release. In addition to International System (SI) units, this edition
also provides US customary units [in square brackets] for quick reference. We would particularly like to
thank Laura Walsh, senior editor, and Stacy Lazar, editorial assistant, from Springer for their expert
guidance and support throughout this mammoth project from design to production. We would also like
to thank Walter Pagel, director of scientific publishing at M.D. Anderson Cancer Center, for believing in
this 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 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 appro
priate clinical resources prior to applying information in this manual for direct patient care. This is
ix
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 user
friendly resource.
David Hui, MD, M.Sc., FRCPC(Med Onc)
Author, Approach to Internal Medicine
Assistant Professor (tenure track), The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
Alexander Leung, BSc(Med), MD(STIR), DABIM, MRCP(UK), FRCPC
Associate Editor, Approach to Internal Medicine
Clinical Scholar, Division of General Internal Medicine University of Calgary, Calgary, AB, Canada
Research Fellow, Division of General Internal Medicine Brigham and Women’s Hospital and Harvard
Medical School, Boston, MA, USA
Raj Padwal, MD, M.Sc., FRCPC
Associate Editor, Approach to Internal Medicine
Associate Professor, Clinical Pharmacology, Clinical Epidemiology and General Internal Medicine,

University of Alberta Edmonton, AB, Canada
x Preface
Section Editors
PULMONARY MEDICINE
Mohit Bhutani, MD, FRCPC, FACP
Assistant Professor of Medicine
Division of Pulmonary Medicine
Department of Medicine
University of Alberta
Edmonton, AB, Canada
CARDIOLOGY
Mustafa Toma, MD, FRCPC
Fellow, Advanced Heart Failure
and Cardiac Transplantation
Cleveland Clinic Foundation
Cleveland, OH, USA
Jason Andrade, MD, FRCPC
Fellow, Cardiology
Division of Cardiology
University of British Columbia
Vancouver, BC, Canada
NEPHROLOGY
Alan McMahon, MD, FRCPC
Associate Professor of Medicine
Division of Nephrology and Transplant
Immunology, Department of Medicine
University of Alberta
Edmonton, AB, Canada
CRITICAL CARE
Wendy Sligl, MD, FRCPC

Assistant Professor of Medicine
Divisions of Infectious Diseases
and Critical Care Medicine, Department of
Medicine
University of Alberta
Edmonton, AB, Canada
GASTROENTEROLOGY
Winnie Wong, MD, FRCPC
Associate Professor of Medicine
Director, Gastroenterology Subspecialty
Training Program
President Elect
Canadian Association for Study of Liver
Division of Gastroenterology
Department of Medicine
University of Alberta
Edmonton, AB, Canada
HEMATOLOGY
Michael H. Kroll, MD, FACP
Professor of Medicine and Chief
Benign Hematology
The University of Texas M.D. Anderson
Cancer Center
Houston, TX, USA
ONCOLOGY
Sharlene Gill, MD, FRCPC
Associate Professor of Medicine
Division of Medical Oncology,
British Columbia Cancer Agency
University of British Columbia

Vancouver, BC, Canada
INFECTIOUS DISEASES
A. Mark Joffe, MD, FRCPC
Professor of Medicine
Division of Infectious Diseases,
Department of Medicine
University of Alberta and Royal
Alexandra Hospital
Edmonton, AB, Canada
RHEUMATOLOGY
Elaine Yacyshyn, MD, FRCPC
Assistant Professor of Medicine
Director, Rheumatology Subspecialty
Training Program
Division of Rheumatology
Department of Medicine
University of Alberta
Edmonton, AB, Canada
xi
NEUROLOGY
Brian Thiessen, MD, FRCPC
Assistant Professor of Medicine
Department Of Medical Oncology
British Columbia Cancer Agency
Division of Neurology
Vancouver General Hospital
Vancouver, BC, Canada
ENDOCRINOLOGY
Laurie E. Mereu, MD, FRCPC
Associate Professor of Medicine

Division of Endocrinology
Department of Medicine
University of Alberta
Edmonton, AB, Canada
DERMATOLOGY
Susan Y. Chon, MD, FAAD
Assistant Professor of Medicine
Department of Dermatology
Division of Internal Medicine
The University of Texas
M.D. Anderson Cancer Center
Houston, TX, USA
GERIATRICS
Fiona Lawson, MD, FRCPC
Assistant Professor of Medicine
Division of Geriatrics
Department of Medicine
University of Alberta
Edmonton, AB, Canada
PALLIATIVE CARE
Eduardo Bruera,MD
Professor of Medicine and Chair
Department of Palliative Care
and Rehabilitation Medicine
Division of Cancer Medicine
The University of Texas
M.D. Anderson Cancer Center
Houston, TX, USA
Sriram Yennurajalingam,MD
Assistant Professor of Medicine

Department of Palliative Care
and Rehabilitation Medicine
Division of Cancer Medicine
The University of Texas
M.D. Anderson Cancer Center
Houston, TX, USA
NUTRITION
Raj Padwal, MD, M.Sc., FRCPC
Associate Professor of Medicine
Divisions of Clinical Epidemiology
Clinical Pharmacology and General Internal
Medicine, Department of Medicine
University of Alberta
Edmonton, AB, Canada
OBSTETRICAL MEDICINE
Winnie Sia, MD, FRCPC
Assistant Professor of Medicine
and Obstetrics and Gynecology
Divisions of General Internal Medicine
and Maternal Fetal Medicine
University of Alberta
Edmonton, AB, Canada
GENERAL INTERNAL MEDICINE
Peter Hamilton, MBBCh, FRCPC
Professor of Medicine
Division of General Internal Medicine
Department of Medicine
University of Alberta
Edmonton, AB, Canada
Contributors

GENERAL: Jean-Claude Quintal,MD
ONCOLOGY: Francine Aubin, MD; Anna Tinker, MD; Emma Beardsley, MD; Robyn Macfarlane, MD;
Sophie Sun,MD
DERMATOLOGY: Elizabeth Farley, MD; Catherine Riddel, BA; Glynda Caga-Anan,BA
NUTRITION: Leanne Mulesa, RD; Miranda Wong,RD
xii Section Editors
Contents
Pulmonary Medicine 1
Asthma Exacerbation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
COPD Exacerbation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Pulmonary Embolism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Pleural Effusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Chronic Cough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Hemoptysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Solitary Pulmonary Nodule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Pulmonary Hypertension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Interstitial Lung Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Obstructive Sleep Apnea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Respiratory Acidosis: Hypoventilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Respiratory Alkalosis: Hyperventilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Hypoxemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Ventilation Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Approach to Chest Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Approach to Pulmonary Function Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Cardiology 25
Aortic Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Acute Coronary Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Pericardial Diseases: Pericarditis and Tamponade. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Heart Failure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Digoxin Intoxication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Atrial Fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Cardiac Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Aortic Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Aortic Regurgitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Mitral Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Mitral Regurgitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Endocarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Peripheral Vascular Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Hyperlipidemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Smoking Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Approach to ECG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
xiii
Nephrology 67
Acute Renal Failure: Pre renal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Acute Renal Failure: Renal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Acute Renal Failure: Post renal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Glomerulopathies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Chronic Kidney Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Proteinuria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Hematuria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Cystic Kidney Diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Metabolic Acidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Metabolic Alkalosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Hyponatremia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Hypernatremia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Hypokalemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Hyperkalemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

Hypomagnesemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Hypophosphatemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Ureteral Calculi. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Approach to Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Critical Care 89
Intensive Care Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Hypoxemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Acute Respiratory Distress Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Ventilation Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Sepsis and Septic Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Lactic Acidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Rhabdomyolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Toxicology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Alcohol Withdrawal and Complications of Alcoholism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Hypothermia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Smoke Inhalation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Gastroenterology 111
Nausea and Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Dysphagia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Dyspepsia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Acute Abdominal Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Upper GI Bleed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Lower GI Bleed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Inflammatory Bowel Disease Exacerbation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Acute Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Chronic Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Malabsorption Syndromes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

Constipation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Acute Liver Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Hepatitis B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Hepatitis C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Chronic Liver Disease: Cirrhosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
xiv Contents
Hepatic Encephalopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Ascites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Jaundice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Acute Pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Hematology 143
Polycythemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Microcytic Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Normocytic Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Macrocytic Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Sickle Cell Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Neutropenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Eosinophilia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Thrombocytosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Thrombocytopenia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Pancytopenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Bleeding Diathesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Hypercoagulable States. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Deep Vein Thrombosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Approach to Anticoagulation Therapies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Transfusion Reactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Approach to the Peripheral Blood Smear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Splenomegaly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Myeloproliferative Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Acute Myelogenous Leukemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166

Acute Lymphoblastic Leukemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Chronic Lymphocytic Leukemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Hodgkin’s Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Non Hodgkin’s Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Multiple Myeloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Febrile Neutropenia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Hematopoietic Stem Cell Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Oncology 185
Lung Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Mesothelioma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
Thymoma and Thymic Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Esophageal Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Gastric Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
Carcinoid Tumors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Gastrointestinal Stromal Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
Anal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Cancer of the Exocrine Pancreas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
Hepatocellular Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Renal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Bladder Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Prostate Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
Testicular Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
Brain Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Ovarian Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Contents xv
Endometrial Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
Cervical Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Cancer of Unknown Origin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219

Tumor Markers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Hereditary Cancer Syndromes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
Antineoplastic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
Oncologic Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
Febrile Neutropenia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
Chemotherapy Induced Nausea and Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
Oral Mucositis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
Chemotherapy Induced Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Infectious Diseases 233
Fever of Unknown Origin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
Fever and Rash. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
Fever and Joint Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
Sepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
Febrile Neutropenia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
Fever with Travel History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
Endocarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
Meningitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
Urinary Tract Infections and Sexually Transmitted Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
Soft Tissue Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
Osteomyelitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
Septic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
Tuberculosis: Pulmonary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
Approach to Gram Stain, Culture, and Sensitivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
Approach to Empiric Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Hepatitis B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
Hepatitis C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
Herpes Simplex Virus Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258

Human Immunodeficiency Virus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Influenza. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
Antiviral Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
Fungal Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
Antifungal Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
Infection Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Immunization for Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270
Rheumatology 273
Septic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Gout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
Polyarticular Joint Pain and Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
Rheumatoid Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
Systemic Lupus Erythematosus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
Seronegative Spondyloarthropathies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282
Back Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
Osteoarthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
Fibromyalgia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
xvi Contents
Vasculitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288
Approach to Serologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
Joint Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294
Neurology 297
Brain Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
Acute Stroke Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
Cranial Nerve Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304
Diplopia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
Bell’s Palsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Delirium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309

Seizures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
Migraine Headaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
Meningitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
Dizziness and Vertigo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
Hearing Impairment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
Myasthenia Gravis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
Ataxia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
Subacute Combined Degeneration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320
Parkinson’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320
Radiculopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
Peripheral Neuropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
Muscle Weakness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332
Approach to Neuroimaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
Endocrinology 337
Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
Principles of Insulin Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
Hypoglycemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
Hypothyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
Hyperthyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344
Solitary Thyroid Nodule. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
Pituitary Tumors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346
Polyuria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
Adrenal Incidentaloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348
Adrenal Insufficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
Cushing’s Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350
Hypocalcemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352
Hypercalcemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353
Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 354
Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356

Hyperlipidemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356
Amenorrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356
Hirsutism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
Dermatology 361
Eczema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361
Psoriasis Vulgaris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362
Acne Vulgaris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
Contents xvii
Exanthematous Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364
Stevens Johnson Syndrome/Toxic Epidermal Necrolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
Melanoma and Skin Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368
Cutaneous Lupus Erythematosus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
Drug Eruptions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372
Erythema Nodosum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373
Clubbing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
Dupuytren’s Contracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
Geriatrics 377
Geriatric Specific Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377
Dementia and Cognitive Impairment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 378
Delirium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380
Falls. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383
Urinary Incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383
Hearing Impairment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
Pharmacological Issues in the Elderly. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
Palliative Care 389
Palliative Care Specific Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
Principles of Pain Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
Delirium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394

Cancer Related Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394
Dyspnea in the Palliative Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394
Nausea and Vomiting in the Palliative Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395
Constipation in the Palliative Setting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396
Anorexia Cachexia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
Communication Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399
Prognostication in Far Advanced Cancer Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400
Nutrition 403
Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403
Malabsorption Syndromes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404
Anorexia Cachexia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404
Vitamin B12 Deficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405
Diet and Supplemental Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406
Obstetric Medicine 409
Preeclampsia/Eclampsia/HELLP Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409
Pulmonary Diseases in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 410
Cardiac Diseases in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411
Hepatic Diseases in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411
Infectious Diseases in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412
Endocrine Disorders in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413
Other Disorders in Pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414
General Internal Medicine 417
Approach to Diagnostic Tests and Clinical Trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417
Smoking Cessation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418
Multisystem Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 420
Perioperative Assessment for Non cardiopulmonary Surgery and Postoperative Complications . . 422
xviii Contents
Medical Fitness to Drive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426
Obtaining Consent for Medical Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
Biomedical Ethics Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427

Hospital 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

1
PULMONARY 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 laryn
gopharyngeal reflux, and laryngospasm

VOCAL CORDS vocal cord dysfunction, paralysis,
hematoma, tumor, cricoarytenoid arthritis
INTRATHORACIC AIRWAY OBSTRUCTION

TRACHEAL OBSTRUCTION tracheal stenosis, tra
cheomalacia, tracheobronchitis (herpetic), malig

nancy, benign tumor, aspiration

TRACHEAL COMPRESSION goiter, right sided aor
tic 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 threaten
ing exacerbations, number of ER visits/hospital
admissions in the last 6 months or ever, any ICU
admissions, previous prednisone use, triggers for
attacks, normal peak expiratory flow rate, change in

peak flow rates, wheezing, cough, dyspnea,
decreased function, exercise limitation, nocturnal
symptoms, absenteeism from work/school, post
nasal drip, recurrent sinusitis, GERD, occupational
and work environment, past medical history, medica
tion history, psychosocial issues, home environment
(pets, heating source, filter changes)
CLINICAL FEATURES (CONT’D)
PHYSICAL HR ",RR", pulsus paradoxus, O
2
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

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
bronchodilators suggest asthma

METHACHOLINE CHALLENGE (non acute setting) if
diagnosis of asthma not confirmed by spirome
try alone. A decrease of FEV1 >20% after metha
choline challenge suggests asthma. Sens 95%
ACUTE MANAGEMENT
ABC O
2
to keep sat >92%, IV
BRONCHODILATORS salbutamol 2.5 5.0 mg NEB
q6h + q1h PRN and ipratropium 0.5 mg NEB q6h
(frequency stated is a guide, can 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, MgSO
4
MECHANICAL VENTILATION BIPAP, intubation
D. Hui, Approach to Internal Medicine, DOI 10.1007/978 1 4419 6505 9 1,

Ó Springer ScienceþBusiness Media, LLC 2006, 2007, 2011
1
LONG TERM MANAGEMENT
EDUCATION smoking cessation (see p. 418).
Asthma action plan. Puffer technique education
and review
ENVIRONMENTAL CONTROL avoidance of out
door/indoor allergens, irritants, and infections;
home environment cleanliness (e.g. steam cleaning)
VACCINATIONS influenza vaccine annually and
pneumococcal vaccine booster at 5 years
FIRST LINE short acting b2 agonist (salbutamol
2 puffs PRN). Proceed to second line if using more
than 2/week or 1/day for exercise induced symp
toms, symptoms >2/week, any nocturnal symp
toms, activity limitation or PEF <80%
SECOND LINE inhaled corticosteroids plus short
acting b2 agonist PRN
THIRD LINE inhaled corticosteroid plus long acting
b2 agonist (note that long acting b2 agonist should
never be used alone in asthma), leukotriene receptor
antagonist (most effective in asthma complicated with
sinus disease and exercise induced asthma)
FOURTH LINE anti IgE therapy (omalizumab) for
refractory allergic asthma, administered subcuta
neously q2 4weeks, 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

TREATMENT ISSUES
COMMON INHALED MEDICATIONS

SHORT-ACTING b AGONISTS salbutamol metered
dose inhaler (MDI) 100 mg 1 2 puffs PRN or
2.5 mg NEB PRN, fenoterol MDI 100 mg 1 2 puffs
PRN, terbutaline 500 mg INH PRN

SHORT-ACTING ANTICHOLINERGICS ipratropium MDI
20 mg 2 puffs QID or 500 mg NEB QID

LONG-ACTING b AGONISTS formoterol 6 24 mg INH
BID, salmeterol diskus 50 mg i puff BID

LONG-ACTING ANTICHOLINERGICS tiotropium 18 mg
INH daily

INHALED CORTICOSTEROIDS beclomethasone 50 400
mg INH BID, budesonide turbuhaler 20 0 400 mg
INH BID or 0.5 1 mg NEB BI D, fluticasone
125 250 mg INH BID, ciclesonide MDI 100 400
mg INH daily (only indicated for a sthma at this
time, not COPD)
Related Topics
Chronic Obstructive Pulmonary Disease (p. 3)
Pulmonary Function Tests (p. 21)
ADMISSION CRITERIA
FEV1 (L) PEF (L/min) PaO
2
Action

Very severe <90% with O
2
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 Flow rates Delivered O
2
Nasal 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 O
2
(FiO
2
) is approximate. Oxygen delivery can approach 100% with intubation and

mechanical ventilation
2 Asthma Exacerbation
SPECIFIC ENTITIES
EXERCISE INDUCED ASTHMA

PATHOPHYSIOLOGY mild asthma with symptoms only
during exercise due to bronchoconstriction as aresult of
cooling of airways associated with heat and w ater loss

DIAGNOSIS spirometry. Exercise or methacholine
challenge may help in diagnosis

TREATMENTS prophylaxis with salbutamol 2 puffs,
given 5 10 min before exercise. Consider leuko
triene 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 E
2
!"
leukotriene synthesis ! asthma symptoms. Manage
ment include ASA/NSAIDs avoidance and leukotriene
antagonists (montelukast)
SPECIFIC ENTITIES (CONT’D)
ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS
(ABPA)

PATHOPHYSIOLOGY associatedwith asthma and cys
tic fibrosis. Due to colonization of the airways by

Aspergillus fumigatus, leading to an intense, immedi
ate hypersensitivity type reaction in the airways

CLINICAL FEATURES history of as thma, recurrent epi
sodes of fever, dyspnea, and productive cough
(brownish sputum). Peripheral eosinophilia. CXR find
ings of patchy infiltrates and central bronchiectasis

DIAGNOSIS above clinical features plus Aspergillus
extract skin test, serum IgE level, sputum for Asper
gillus and/or serologic tests (IgE and IgG against
Aspergillus)

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 of
bronchiectasis, foreign body obstruction

PARENCHYMA pneumonia, cryptogenic organiz
ing pneumonia, 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 regurgi
tation, mitral stenosis, endocarditis

PERICARDIAL pericardial effusion, tamponade
SYSTEMIC sepsis, metabolic acidosis, anemia
OTHERS neuromuscular, psychogenic, anxiety
PATHOPHYSIOLOGY
PRECIPITANTS OF COPD EXACERBATION infec
tions, lifestyle/enviro nmental (10%, cigarette smoke,
dust, pollutants, cold air), non adherence, pulmonary
embolism, pulmonary edema, pneumothorax, progres
sion of COPD
CLINICAL FEATURES
RATIONAL CLINICAL EXAMINATION SERIES:
DOES THE CLINICAL EXAMINATION PREDICT
AIRFLOW LIMITATION?
Sens Spc LR+ LR
History
Smoking >70 pack year 40% 95% 8 0.63
Smoking ever 92% 49% 1.8 0.16
CLINICAL FEATURES (CONT’D)
Sens Spc LR+ LR
Sputum >1/4 cup 20% 95% 4 0.84
Chronic bronchitis Sx 30% 90% 3 0.78
Wheezing 51% 84% 3.8 0.66

Any exertional dyspnea 27% 88% 2.2 0.83
Coughing 51% 71% 1.8 0.69
Any dyspnea 82% 33% 1.2 0.55
Physical
Wheezing 15% 100% 36 0.85
Barrel chest 10% 99% 10 0.90
Decreased cardiac
dullness
13% 99% 10 0.88
Match test 61% 91% 7.1 0.43
Rhonchi 8% 99% 5.9 0.95
Hyperresonance 32% 94% 4.8 0.73
FEV1 >9 s 4.8
FEV1 6 9 s 2.7
FEV1 <6 s 0.45
Subxyphoid cardiac apical
impulse
8% 98% 4.6 0.94
Pulsus paradoxus
(>15 mmHg)
45% 88% 3.7 0.62
Decreased breath sounds 37% 90% 3.7 0.70
Accessory muscle use 24% 100% 0.70
APPROACH ‘‘no single item or combination of
items from the clinical examination rules out air
flow limitation. The best findings associated with
increased likelihood of airflow limitation are objec
tive wheezing, FEV1 >9 s, positive match test,
barrel chest, hyperresonance and subxyphoid car
diac 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
COPD Exacerbation 3
CLINICAL FEATURES (CONT’D)
STEREOTYPES (not useful clinically)

BLUE BLOATER (more chronic bronchitis) cough
and sputum, hypoxemia, CO
2
retention, pulmon
ary hypertension, right sided heart failure

PINK PUFFER (more emphysema) cachexia, rela
tively preserved blood gases, dyspnea even at rest
PREDICTION RULE FOR OBSTRUCTIVE AIRWAY
DISEASE

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 <4 CM [<1.6 IN.]
di
stance between the top of thyroid cartilage

and suprasternal notch at end of expiration. LR+ 2.8
JAMA 2000 283:14
INVESTIGATIONS
BASIC

LABS CBCD, lytes, urea, Cr, troponin/CK, Ca, Mg,
PO
4

MICROBIOLOGY sputum Gram stain/AFB/C&S/
fungal

IMAGING CXR

ECG left atrial enlargement, atrial fibrillation,
sinus tachycardia

SPIROMETRY/PFT FEV1/FVC <0.7, partially rever
sible. Severity based on FEV1

ABG if acute respiratory distress
SPECIAL

BNP if suspect HF

D dimer if suspect PE

ECHOCARDIOGRAM
PROGNOSTIC ISSUES
PROGNOSIS OF PATIENTS WITH ACUTE EXACERBA

TION 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= >21, 1= 21

OBSTRUCTION (post bronchodilator FEV1) 0 65%
predicted, 1=50 64%, 2=36 49%, 3= 35%

DISTANCE WALKED IN 6 MIN 0=350 m,
1=250 349 m, 2=150 24 9 m, 3= 149 m

EXERCISE MMRC DYSPNEA 0=0 1, 1=2, 2=3, 3=4

SCORING hazard ratio for death from any cause
per one point increase in BODE score is 1.34
NEJM 2004 350:10
ACUTE MANAGEMENT
ABC O
2

to keep sat >90%, or 88 92% if CO
2
retai
ner, IV
BRONCHODILATORS salbutamol 2.5 5 mg NEB
q4h ATC + q1h PRN and ipratropium 0.25 0.5 mg
NEB q4h. Puffers preferable for acute management if
proper technique used
STEROIDS prednisone 40 60 mg PO daily 14
days (tapering dose not necessary in all cases) or
methylprednisolone 60 125 mg IV daily
(inpatient)
ANTIBIOTICS give if any two of the following
criteria are met: " sp utum purulence, " dyspnea o r
" sputum volume. Other considerations include the
need for non invasi ve mechanical ventilation and
‘‘at risk’’ for poor outcome (substantial c omorbi
dities, severe COPD, frequent exacerbations
>3/year, recent antibiotics within 3 months);
choices depend on clinical circumstance (levoflox
awcin 500 mg PO daily 7days,doxycycline 100 mg
PO BID 7 1 0 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 4days)
MECHANICAL VENTILATION BIPAP, intubation
OTHERS DVT prophylaxis (heparin 5000 U SC BID),
physiotherapy
NEJM 2002 346:13
LONG TERM MANAGEMENT

EDUCATION smoking cessation (see p. 418). Dis
ease specific self management program. Puffer
technique education and review
VACCINATIONS influenza vaccine annually and
pneumococcal vaccine booster at 5 years
REHABILITATION exercise training (increases
quality of life and exercise tolerance)
FIRST LINE short acting b2 agonist or short act
ing anticholinergic on an as needed basis
SECOND LINE long acting b2 agonist or long
acting anti choline rgic (tio tropium 1puff[18mg/
puff] INH d aily) plus short acting b2 agonist PRN.
Consider early initiation of long acting agents if
requiring regular PRN sh ort acting agents as long
acting agents are superior
THIRD LINE long acting b2 agonist plus long
acting anticholinergic,withshortactingb2 agonist
PRN
FOURTH LINE long acting anticholinergic plus
long acting b2 agonist/inhaled corticosteroid
combination (e.g. Advair, Symbicort). No role for
inhaled corticosteroid alone in COPD
FIFTH LINE fourth line plus theophylline 400 mg
PO daily 3 days, then 400 600 mg PO daily, ther
apeutic level 10 20 mg/mL
SIXTH LINE fifth line plus home O
2
4 COPD Exacerbation