POCKET NOTEBOOK , POE EDICINE _ Seventh Edition Edited by >) Marc S. SaBATINE, MD, MPH >, Professor of Medicine ~ Harvard Medical School > The Massachusetts General Hospital ey) Handbook of Internal Medicine ~ . ®.wolte rs Kluwer Philadelphia Baltimore - New York « London Buenas Aires + Hong Kong ~ Sydney « TokyoSenior Acquisitions Editor: Sharon Zinner Development Editor: Ashley Fischer Production Project Manager: Sadie Buckallew Editorial Coordinator: Ingrid Greenlee ‘Manufacturing Coordinator: Kathy Brown Design Coordinator: Stephen Druding Prepress Vendor: $4Carlisle Publishing Services Copyright © 2020, 2017, 2014, 201 1, 2008, 2004, 2000 by Wolters Kluwer All rights reserved. This book is protected by copyright. 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This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments. Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer's package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the ‘maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as-a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work. shop.tww.comContributing Authors Foreword Preface CARDIOLOGY ~ Rachel Frank, Shilpa Sharma, Nino Mihatov, Nilay Patel, Marc S. Sabatine, Michelle L. "Donoghue Electrocardiography ™\ Chest Pain Noninvasive Evaluation of CAD Coronary Angiography and Revascularization >) Acute Coronary Syndromes PA Catheter and Tailored Therapy Heart Failure > Cardiomyopathies Valvular Heart Disease Pericardial Disease Hypertension Aortic Aneurysms Acute Aortic Syndromes > Arrhythmias Atrial Fibrillation Syncope >) Cardiac Rhythm Management Devices Cardiac Risk Assessment for Noncardiac Surgery Peripheral Artery Disease PULMONARY ‘Miranda Theodere, Jason Maley, Walter J. O'Donnell Dyspnea Pulmonary Funetion Tests Asthma Anaphylaxis Chronic Obstructive Pulmonary Disease Solitary Pulmonary Nodule _~_ Hemoptysis Bronchiectasis Cystic Fibrosis _~<,_ Interstitial Lung Disease Pleural Effusion Venous Thromboembolism Pulmonary Hypertension Respiratory Failure Mechanical Ventilation -s, Acute Respiratory Distress Syndrome Sepsis and Shock Toxicology Lung Transplant GASTROENTEROLOGY Stephanie M, Rutledge, Emily Walsh Lopes, Lawrence S, Friedman Esophageal and Gastric Disorders Gastrointestinal Bleeding Diarrhea Dysmotility & Nutrition Disorders of the Colon 2 2 22 14 25 27 27 28 28 29 211 2.13 2-16 2-18 2-24Inflammatory Bowel Disease Intestinal Ischemia Pancreatitis Abnormal Liver Tests Hepatitis Acute Liver Failure Cirrhosis Hepatic Vascular Disease Ascites Biliary Tract Disease NEPHROLOGY Alexander Blair, Harish Seethapathy, Andrew S.Allegretti Acid-Base Disturbances Sodium and Water Homeostasis Potassium Homeostasis Renal Failure Glomerular Disease Urinalysis Nephrolithiasis HEMATOLOGY-ONCOLOGY ‘Melissa Lumish, Arielle Medford, fanya E. Keenan, Harshabad Singh, Jean M. Connors, Daniel J. DeAngelo, David P Ryan Anemia Disorders of Hemostasis Platelet Disorders ‘Coagulopathies Hypercoagulable States. Disorders of Leukocytes Transfusion Therapy Myelodysplastie Syndromes Myeloproliferative Neoplasms Leukemia Lymphoma Plasma Cell Dyscrasias Hematopoietic Stem Cell Transplantation Lung Cancer Breast Cancer Prostate Cancer Colorectal Cancer Pancreatic Turnors Hepatocellular Carcinoma (HCC) ‘Oncologic Emergencies Chemotherapy & Immunotherapy Side Effects INFECTIOUS DISEASES Alison C. Castle, Kristen Hysell,Kimon C. Zachary Pneumonia Fungal Infections Infections in Immunosuppressed Hosts Urinary Tract Infections Soft Tissue and Bone Infections Infections of the Nervous System Bacteremia & Endocarditis Tuberculosis HIVIAIDS 3-10 3-12 3-13 3-15 3-17 3-20 3-21 3-25 3-26 3-27 41 4-10 412 4.17 Aly 4-20 5-1 5-6 5-10 5-11 5-12 5-13 5-14 S-18 5-17 5-20 5-24 5-26 5-28 5-30 5-32 5-33 5-34 5-35 5-35 5-37 6-1 63 64 65 6-6 6-9 6-12 6-15 6-17Tick-Borne Diseases Fever Syndromes ENDOCRINOLOGY Caitlin Colling,Armen Yerevanian, Michael Mannstadt Pituitary Disorders Thyroid Disorders Adrenal Disorders Calcium Disorders Diabetes Mellitus Lipid Disorders RHEUMATOLOGY Isaac D. Smith, Mazen Nasrallah, Robert P. Friday Approach to Rheumatic Disease Rheumatoid Arthritis Adult-Onset Sull’s Disease & Relapsing Polychondritis, Crystal Deposition Arthritides Seronegative Spondyloarthritis Infectious Arthritis & Bursitis Connective Tissue Diseases Systemic Lupus Erythematosus Vasculitis igG4-Related Disease Cryoglebulinemia Amyloidosis NEUROLOGY Omar Al-Louzi, Leeann Brigham Burton, Kristin Galetta, ‘Morgan Prust, Michael P. Bowley Change in Mental Status Seizures hol Withdrawal Dizziness Stroke Weakness & Neuromuscular Dysfunction Headache Back and Spinal Cord Disease CONSULTS Sarah J. Carlson, Jennifer F. Tseng, Katherine T. Chen, Stella K. Kim Surgical Issues Ob/Gyn Issues Ophthalmic Issues APPENDIX ICU Medications & Treatment of Hypotension/Shock Antibiotics Formulae and Quick Reference ABBREVIATIONS INDEX PHOTO INSERTS Radiology Echocardiography & Coronary Angiography Peripheral Blood Smears & Leukemias Urinalysis ACLS 6-20 6-22 7 73 7-7 7-1 7-13 7-16 8-3 8-4 8-5 8-9 eit 8-15 8-17 8-20 8-21 8-22 91 9.3 9-5. 9-5 9-6 9-8 9-10 oN 10-1 10-3 10-4 Wel 113 11-5 12-1 I Pal P13 P15, ACLS-1| | CONTRIBUTING AUTHORS Andrew S.Allegretti, MD, MSc Director of ICU Nephrology, Attending Physician, Nephrology Division, and Principal Investigator, Kidney Research Center, Massachusetts General Hospital Instructor of Medicine, Harvard Medical School Omar Al-Louzi, MD Neurology Resident, Partners Neurology Residency Alexander Blair, MD Internal Medicine Resident, Massachusetts General Hospital Michael P. Bowley, MD, PhD Instructor in Neurology, Massachusetts General Hospital Associate Program Director, Partners Neurology Residency Program Leeann Brigham Burton, MD Neurology Resident, Partners Neurology Residency Sarah J. Carlson Assistant Professor of Surgery, Boston University of Medicine Attending Surgeon, Boston Veterans Affairs Healthcare = Alison C. Castle, MD Internal Medicine Resident, Massachusetts General Hospital = Katherine T. Chen, MD, MPH Vice-Chair of Ob/Gyn Education, Career Development, and Mentorship Professor of Obstetrics, Gynecology,and Reproductive Science Professor of Medical Education Icahn School of Medicine at Mount Sinai, New York ~ Caitlin Colling, MD Internal Medicine Resident, Massachusetts General Hospital ~ Jean M. Connors, MD Medical Director, Anticoagulation Management Services ~ Hematology Division, Brigham and Women's Hospital & Dana-Farber Cancer Institute Associate Professor of Medicine, Harvard Medical School Daniel J. DeAngelo, MD, PhD Chief of the Division of Leukemia, Dana-Farber Cancer Institute » Professor of Medicine, Harvard Medical School Rachel Frank, MD > Internal Medicine Resident, Massachusetts General Hospital Robert P. Friday, MD, PhD 7 Chief, Division of Rheumatology, Newton-Wellesley Hospital Afiliate Physician, Rheumatology Unie, Massachusetts General Hospital Instructor in Medicine, Harvard Medical SchoolLawrence S. Friedman, MD The Anton R. Fried, MD, Chair, Department of Medicine, Newton-Wellesley Hospital Assistant Chief of Medicine, Massachusetts General Hospital Professor of Medicine, Harvard Medical School Professor of Medicine, Tufts University School of Medicine Kristin Galetta, MD Neurology Resident, Partners Neurology Residency Kristen Hysell, MD Infectious Disease Fellow, Massachusetts General Hospital Tanya E. Keenan, MD, MPH Hematology-Oncology Fellow, Dana-Farber/Partners CancerCare Stella K. Kim, MD Joe M. Green Jr: Professor of Clinical Ophthalmology Ruiz Department of Ophthalmology and Visual Sciences Robert Cizik Eye Clinic University of Texas McGovern School of Medicine Emily Walsh Lopes, MD Gastroenterology Fellow, Massachusetts General Hospital Melissa Lumish, MD Internal Medicine Resident, Massachusetts General Hospital Jason Maley, MD Pulmonary Fellow, Massachusetts General Hospital Michael Mannstadt, MD Chief, Endocrine Unit, Massachusetts General Hospital Associate Professor of Medicine, Harvard Medical School Arielle Medford, MD Internal Medicine Resident, Massachusetts General Hospital Nino Mihatov, MD Cardiology Fellow, Massachusetts General Hospital Mazen Nasrallah, MD, MSe Rheumatology Fellow, Massachusetts General Hospital Walter J. O’Donnell, MD Staff Physician, Pulmonary/Critical Care Unit, Massachusetts General Hospital Assistant Professor of Medicine, Harvard Medical School Michelle L. O'Donoghue, MD, MPH Senior Investigator, TIMI Study Group: Associate Physician, Cardiovascular Division, Brigham and Women’s Hospital Affiliate Physician, Cardiology Division, Massachusetts General Hospital Associate Professor of Medicine, Harvard Medical SchoolNilay Patel, MD Cardiology Fellow, Massachusetts General Hospital Morgan Prust, MD Neurology Resident, Massachusetts General Hospital Stephanie M. Rutledge, MBBCh, BAO, MRCPI Internal Medicine Resident, Massachusetts General Hospital David P. Ryan, MD Clinical Director, Massachusetts General Hospital Cancer Center Chief of Hematology/Oncology, Massachusetts General Hospital Professor of Medicine, Harvard Medical School Marc §. Sabatine, MD, MPH Chairman,TIMI Study Group Lewis Dexter, MD, Distinguished Chair in Cardiovascular Medicine, Brigham and Women’s Hospital Affliate Physician, Cardiology Division, Massachusetts General Hospital Professor of Medicine, Harvard Medical School Harish Seethapathy, MBBS Nephrology Fellow, BWH/MGH Joint Nephrology Fellowship Program Shilpa Sharma, MD Internal Medicine Resident, Massachusetts General Hospital Harshabad Singh, MBBS Instructor, Gastrointestinal Cancer Treatment Center, Dana-Farber Cancer Institute Isaac D, Smith, MD Internal Medicine Resident, Massachusetts General Hospital Miranda Theodore, MD Internal Medicine Resident, Massachusetts General Hospital Jennifer F. Tseng, MD, MPH Utley Professor and Chair, Boston University School of Medicine Surgeon-in-Chief, Boston Medical Center Armen Yerevanian, MD Endocrinology Fellow, Massachusetts General Hospital Kimon C. Zachary, MD Assistant Professor of Medicine, Infectious Disease Division, Massachusetts General HospitalSe Eee ae To the Ist Edition It is with the greatest enthusiasm that | introduce Pocket Medicine. In an era of information glut it wll logically be asked, Why another manual for med- ical house officers?” Yet, despite enormous information readily available in any number of textbooks, or at the push of a key on a computer; it is often that the harried house officer is less helped by the description of —, differential diagnosis and therapies than one would wish. Pocket Medicine is the joint venture between house staff and faculty expert in a number of medical specialties. This collaboration is designed to provide a rapid but thoughtful initial approach to medical problems seen by house officers with great frequency. Questions that frequently come from faculty to the house staff on rounds, many hours after the initial interaction between patient and doctor; have been anticipated and important pathways for arriving at diagnoses and initiating therapies are ~~. presented.This approach will facilitate the evidence-based medicine dis- cussion that will follow the workup of the patient. This well-conceived handbook should enhance the ability of every medical house officer to properly evaluate a patient in a timely fashion and to be stimulated to think of the evidence supporting the diagnosis and the likely outcome of therapeutic intervention. Pocket Medicine will prove to be a worthy: addition to medical education and to the care of our patients. a Dennis A.AusieLLo, MD Physician-in-Chief, Massachusetts General Hospital Jackson Professor of Clinical Medicine, Harvard Medical SchoolTo my parents, Matthew and Lee Sabatine, to their namesake grandchildren Matteo and Natalie, and to my wife Jennifer sa Written by residents, fellows, and attendings, the mandate for Pocket Medicine was ide,in a concise a manner as possible, the key information a clinician needs | approach to and management of the most common inpatient medical > problems. The tremendous response to the previous editions suggests we were able to help fill an important need for clinicians. With this seventh edition come several major improvements We have updated every topic thoroughly. In particular, we have included the newest diagnostic algorithms and pharmacotherapy for acute coronary syndromes, the revolutionary data for transcatheter aortic valve replacement (TAVR), and distilled the most recent guidelines for the classification and treatment of hypertension. We have added a dedicated section for the management of cystic fibrosis and updated the treatment of sepsis and shock. We continue to revise the approach to malignancies based on molecular classification and the corresponding biologic therapies, including dedicated sections on immunotherapy. We have incorporated the paradigm-shifting data for diabetes medications that lower cardiovascular risk and cover the newest classes of lipid-lowering therapies. As always, we have incorporated key references to the most recent high-tier reviews and important studies published right up to the time Pocket Medicine went to press. > We welcome any suggestions for further improvement. This edition builds on the work of the many contributors to prior editions of Pocket Medicine. In addition, we appreciate the advice on specific topics from additional attendings including Dr.Adam Sperling, Of course, medicine is far too vast a field to ever summarize in a textbook of any size. Long monographs have been devoted to many of the topics discussed herein. Pocket Medicine is meant only as a starting point to guide one during the initial phases of diagnosis and management until one has time to consult more definitive resources, Although the recommendations herein are as evidence-based —», as possible, medicine is both a science and an art. As always, sound clinical judgement must be applied to every scenario. | am grateful for the support of the house officers, fellows, and attendings — at the Massachusetts General Hospital. It is a privilege to work with such a knowledgeable, dedicated, and compassionate group of physicians. | always look back on my time there as Chief Resident as one of my best experiences. | am ~ grateful to several outstanding clinical mentors, including Hasan Bazari, Larry Friedman, Nesli Basgoz, Bric Isselbacher, Mike Fifer,and Roman DeSanctis, as well as the late Charlie McCabe, Mort Swartz, and Peter Yurchak. ~ This edition would not have been possible without the help of Melinda Cuerda and Abby Cange, my academic coordinators, They shepherded every aspect of the project from start to finish, with an incredible eye to detail to ensure that each page | — of this book was the very best it could be. Lastly, special thanks to my parents for their perpetual encouragement and love and, of course, to my wife, Jennifer Tseng, who, despite being a surgeon, is my _— closest advisor, my best friend, and the love of my life. I hope that you find Pocket Medicine useful throughout the arduous but incredibly rewarding journey of practicing medicine. sa Marc S. Sasatine, MD, MPH