Approach to Internal Medicine (eBook)

David Hui, MD, MSc, FRCPC, Clinical Research Fellow, Supportive and Palliative Oncology, M.D. Anderson Cancer Center, recent recipient of the Arnold Gold Foundation Humanism and Excellence in Teaching Award and The A.M. Edwards Award for Medical Education.

Disclaimer 6
Preface 7
Section Editors 9
Contributors 10
Contents 11
Pulmonary Medicine 18
Asthma Exacerbation 18
Differential Diagnosis of Wheezing 18
Pathophysiology 18
Clinical Features 18
Investigations 18
Acute Management 18
Long-Term Management 19
Treatment Issues 19
Specific Entities 20
COPD Exacerbation 20
Differential Diagnosis of Acute Dyspnea 20
Pathophysiology 20
Clinical Features 20
Investigations 21
Prognostic Issues 21
Acute Management 21
Long-Term Management 21
Treatment Issues 22
Specific Entities 22
Pneumonia 23
Types of Pneumonia 23
Pathophysiology 23
Clinical Features 23
Investigations 23
Diagnostic and Prognostic Issues 24
Management 24
Treatment Issues 24
Specific Entities 25
Pulmonary Embolism 25
Differential Diagnosis of Acute Dyspnea 25
Pathophysiology 25
Clinical Features 25
Investigations 26
Diagnostic Issues 26
Management 26
Treatment Issues 26
Specific Entities 27
Pleural Effusion 27
Differential Diagnosis 27
Clinical Features 27
Investigations 28
Diagnostic Issues 28
Management 28
Specific Entities 28
Chronic Cough 29
Differential Diagnosis 29
Pathophysiology 29
Investigations 29
Management 29
Specific Entities 29
Hemoptysis 29
Differential Diagnosis 29
Pathophysiology 30
Clinical Features 30
Investigations 30
Management 30
Specific Entities 30
Solitary Pulmonary Nodule 30
Differential Diagnosis 30
Clinical Features 30
Investigations 30
Diagnostic Issues 30
Management 31
Specific Entities 31
Pulmonary Hypertension 31
WHO Classification of Pulmonary Hypertension 31
Pathophysiology 32
Clinical Features 32
Investigations 32
Management 32
Specific Entities 32
Interstitial Lung Disease 32
Differential Diagnosis 32
Clinical Features 33
Investigations 33
Diagnostic Issues 33
Management 33
Specific Entities 33
Obstructive Sleep Apnea 34
Differential Diagnosis of Sleep Disorders 34
Pathophysiology 34
Clinical Features 34
Investigations 34
Management 34
Treatment Issues 35
Specific Entities 35
Respiratory Acidosis: Hypoventilation 35
Differential Diagnosis 35
Pathophysiology 35
Investigations 35
Management 35
Respiratory Alkalosis: Hyperventilation 36
Differential Diagnosis 36
Pathophysiology 36
Investigations 36
Management 36
Approach to Chest Imaging 36
Approach to Chest X-Ray Intepretation 36
Chamber Enlargement 37
Lung Cavities 37
Focal Infiltrate 37
Diffuse Airspace Disease 37
Reticular Pattern 37
Nodular or Reticulonodular Pattern 37
Pleural-Based Disease 38
Hilar Enlargement 38
Mediastinal Masses 38
Signs for Disease Processes 38
CT Chest Protocols 38
Approach to Pulmonary Function Tests 38
Overall Approach to PFT Interpretation 38
Classification of Pulmonary Diseases 38
Terminologies 38
Flow-Volume Loop Patterns 39
Spirometry and Lung Volume Patterns 39
Analyzing DLCO 40
Notes 41
Cardiology 42
Aortic Dissection 42
Differential Diagnosis 42
Pathophysiology 42
Clinical Features 42
Investigations 43
Diagnostic and Prognostic Issues 43
Management 43
Acute Coronary Syndrome 43
Differential Diagnosis of Chest Pain 43
Pathophysiology 43
Clinical Features 44
Investigations 44
Diagnostic and Prognostic Issues 44
Acute Management 45
Long-Term Management of Coronary Artery Disease 47
Treatment Issues 47
Pericardial Diseases: Pericarditis and Tamponade 49
Differential Diagnosis 49
Clinical Features 49
Investigations 50
Management 50
Specific Entities 50
Heart Failure 50
Differential Diagnosis of HF Exacerbation/Dyspnea 50
Pathophysiology 50
Clinical Features 51
Investigations 54
Diagnostic and Prognostic Issues 54
Acute Management 54
Long-Term Management 54
Treatment Issues 54
Specific Entities 55
Digoxin Intoxication 55
Differential Diagnosis 55
Pathophysiology 55
Clinical Features 56
Investigations 56
Diagnostic Issues 56
Management 56
Treatment Issues 56
Atrial Fibrillation 56
Differential Diagnosis of Palpitations 56
Differential Diagnosis of Narrow Complex Tachycardia 57
Differential Diagnosis of Irregularly Irregular Rhythm 57
Pathophysiology 57
Clinical Features of Narrow Complex Tachycardia 57
Clinical Features 57
Investigations 58
Acute Management 58
Long-Term Management 59
Treatment Issues 59
Syncope 60
Cardiac Examination 60
Pulse 60
Blood Pressure 60
Jugular Venous Pressure 60
Precordial Examination 61
Heart Sounds 61
Murmurs 62
Investigations 64
Aortic Stenosis 64
Differential Diagnosis 64
Pathophysiology 64
Clinical Features 64
Investigations 65
Diagnostic and Prognostic Issues 65
Management 65
Treatment Issues 65
Aortic Regurgitation 66
Differential Diagnosis 66
Pathophysiology 66
Clinical Features 66
Investigations 67
Prognostic Issues 67
Management 67
Mitral Stenosis 67
Clinical Features 67
Investigations 67
Diagnostic and Prognostic Issues 68
Management 68
Specific Entities 68
Mitral Regurgitation 68
Differential Diagnosis 68
Pathophysiology 68
Clinical Features 68
Investigations 68
Management 69
Specific Entities 69
Endocarditis 69
Differential Diagnosis 69
Pathophysiology 70
Clinical Features 70
Investigations 70
Diagnostic and Prognostic Issues 70
Management 71
Treatment Issues 71
Peripheral Vascular Disease 71
Differential Diagnosis of Claudication 71
Clinical Features 72
Investigations 73
Diagnostic Issues 73
Management 73
Treatment Issues 73
Specific Entities 73
Hypertension 74
Differential Diagnosis 74
Pathophysiology 74
Clinical Features 74
Investigations 74
Diagnostic Issues 75
Acute Management 75
Long-Term Management 75
Treatment Issues 75
Specific Entities 77
Hyperlipidemia 78
Differential Diagnosis of Hypercholesterolemia 78
Differential Diagnosis of Hypertriglyceridemia 78
Differential Diagnosis of Low HDL 78
Clinical Features 78
Investigations 78
Management 78
Specific Entities 79
Smoking Issues 79
Approach to ECG 79
Ten Steps to ECG 79
Chest Leads Placement 79
Rate and Rhythm 80
Tachycardia 80
Bradycardia and Prolonged PR 80
Prolonged QRS-Bundle Branch Block and Hemiblock 80
Prolonged QT 80
Hypertrophy Criteria 80
Ischemia/Infarct Morphology 81
Voltage Criteria 81
Differential Diagnosis of ST Elevation 81
Special Conditions 82
Notes 83
Nephrology 84
Acute Renal Failure: Pre-renal 84
Differential Diagnosis 84
Pathophysiology 84
Investigations 84
Diagnostic Issues 84
Management 85
Treatment Issues 85
Acute Renal Failure: Renal 85
Differential Diagnosis 85
Clinical Features 85
Investigations 85
Management 86
Specific Entities 86
Acute Renal Failure: Post-renal 87
Differential Diagnosis 87
Investigations 87
Diagnostic Issues 87
Management 87
Glomerulopathies 87
Pathophysiology of Glomerulopathies 87
Clinical Features 87
Nephrotic Syndrome 88
Nephritic Syndrome 88
Specific Entities 88
Chronic Kidney Disease 90
Differential Diagnosis 90
Pathophysiology 90
Clinical Features 90
Investigations 90
Diagnostic Issues 90
Management 91
Treatment Issues 91
Specific Entities 91
Proteinuria 91
Differential Diagnosis 91
Pathophysiology 91
Clinical Features 92
Investigations 92
Management 92
Specific Entities 92
Hematuria 92
Differential Diagnosis 92
Pathophysiology 92
Clinical Features 92
Investigations 92
Diagnostic Issues 92
Management 93
Specific Entities 93
Cystic Kidney Diseases 93
Causes 93
Investigations 93
Management 93
Specific Entities 93
Metabolic Acidosis 94
Differential Diagnosis 94
Investigations 94
Diagnostic Issues 94
Management 95
Specific Entities 95
Metabolic Alkalosis 95
Differential Diagnosis 95
Pathophysiology 96
Investigations 96
Diagnostic Issues 96
Management 96
Specific Entities 96
Hyponatremia 96
Differential Diagnosis of Hypoosmolar Hyponatremia 96
Pathophysiology 97
Investigations 97
Diagnostic Issues 97
Management 97
Treatment Issues 97
Specific Entities 97
Hypernatremia 98
Differential Diagnosis 98
Pathophysiology 98
Clinical Features 98
Investigations 98
Diagnostic Issues 98
Management 98
Hypokalemia 98
Differential Diagnosis 98
Pathophysiology 98
Clinical Features 99
Investigations 99
Diagnostic Issues 99
Management 99
Hyperkalemia 99
Differential Diagnosis 99
Pathophysiology 99
Clinical Features 99
Investigations 99
Diagnostic Issues 99
Management 100
Hypomagnesemia 100
Differential Diagnosis 100
Pathophysiology 100
Clinical Features 100
Investigations 100
Diagnostic Issues 100
Management 100
Hypophosphatemia 100
Differential Diagnosis 100
Pathophysiology 100
Clinical Features 100
Investigations 101
Diagnostic Issues 101
Management 101
Ureteral Calculi 101
Causes 101
Pathophysiology 101
Investigations 101
Diagnostic Issues 101
Management 101
Hypertension 101
Approach to Dialysis 102
Hemodialysis 102
Continuous Renal Replacement Therapy 102
Peritoneal Dialysis (PD) 102
Notes 104
Critical Care 106
Intensive Care Issues 106
ICU Admission Criteria 106
Preventative Strategies 106
Sedation, Analgesia, Paralysis in the ICU 106
Differential Diagnosis for Weakness in the ICU 106
Procedures 106
Central Venous Saturation 107
Prognostic Issues 107
Cardiopulmonary Resuscitation 107
Brain Death 108
Hypoxemia 109
Differential Diagnosis 109
Pathophysiology 109
Investigations 109
Diagnostic Issues 109
Management 110
Treatment Issues 110
Specific Entities 110
Acute Respiratory Distress Syndrome 110
Differential Diagnosis 110
Pathophysiology 110
Investigations 110
Diagnostic and Prognostic Issues 111
Management 111
Ventilation Issues 111
Mechanical Ventilation 111
Assessment of Airway 112
Artificial Airways 112
Ventilatory Settings 112
Weaning Ventilation 113
Ventilator-Associated Pneumonia 114
Shock 114
Differential Diagnosis 114
Pathophysiology 114
Clinical Features 115
Investigations 115
Diagnostic Issues 115
Management 116
Treatment Issues 116
Sepsis and Septic Shock 116
Pathophysiology 116
Investigations 117
Management 117
Lactic Acidosis 118
Differential Diagnosis 118
Pathophysiology 118
Investigations 118
Management 118
Rhabdomyolysis 118
Differential Diagnosis 118
Pathophysiology 118
Investigations 118
Diagnostic Issues 118
Management 118
Specific Entities 119
Toxicology 119
Approach to Overdose 119
Anticholinergic Syndromes 119
Sympathomimetic Syndromes 119
Cholinergic Syndromes 120
Methanol and Ethylene Glycol Overdose 120
Acetaminophen Overdose 120
Salicylate Overdose 120
Opiate, Sedative or Ethanol Intoxication Syndromes 120
Blocker Overdose 120
Calcium Channel Blockers Overdose 121
Lithium Toxicity 121
Diagnostic Issues for Overdose 121
Management of Overdoses 121
Alcohol Withdrawal and Complications of Alcoholism 122
Pathophysiology 122
Clinical Features 122
Investigations 123
Acute Management of Alcohol Withdrawal 123
Long-Term Management of Alcoholism 123
Treatment Issues for Alcohol Withdrawal 123
Specific Entities 124
Hypothermia 124
Causes 124
Pathophysiology 125
Clinical Features 125
Investigations 125
Management 125
Specific Entities 125
Smoke Inhalation 125
Pathophysiology 125
Clinical Features 125
Investigations 126
Management 126
Specific Entities 126
Anaphylaxis 126
Notes 127
Gastroenterology 128
Nausea and Vomiting 128
Differential Diagnosis 128
Pathophysiology 128
Investigations 128
Management 128
Dysphagia 129
Differential Diagnosis 129
Clinical Features 129
Investigations 129
Management 130
Specific Entities 130
Dyspepsia 130
Differential Diagnosis 130
Pathophysiology 130
Clinical Features 130
Investigations 131
Management 131
Specific Entities 131
Acute Abdominal Pain 132
Differential Diagnosis 132
Pathophysiology 132
Clinical Features 132
Investigations 133
Diagnostic Issues 134
Management 134
Specific Entities 134
Upper GI Bleed 135
Differential Diagnosis 135
Clinical Features 135
Investigations 136
Prognostic Issues 136
Management 136
Treatment Issues 136
Lower GI Bleed 137
Differential Diagnosis 137
Clinical Features 137
Investigations 137
Diagnostic Issues 137
Management 137
Inflammatory Bowel Disease Exacerbation 137
Differential Diagnosis 137
Pathophysiology 137
Investigations 138
Management 138
Treatment Issues 139
Acute Diarrhea 139
Differential Diagnosis 139
Pathophysiology 139
Clinical Features 140
Investigations 140
Management 140
Specific Entities 140
Chronic Diarrhea 141
Differential Diagnosis 141
Clinical Features 141
Investigations 141
Investigation Issues 141
Management 141
Specific Entities 141
Malabsorption Syndromes 142
Differential Diagnosis 142
Pathophysiology 142
Clinical Features 142
Investigations 142
Management 143
Specific Entities 143
Constipation 143
Differential Diagnosis 143
Investigations 143
Diagnostic Issues 143
Management 143
Specific Entities 143
Acute Liver Failure 145
Differential Diagnosis 145
Pathophysiology 145
Investigations 145
Diagnostic and Prognostic Issues 146
Management of Acute Liver Failure 146
Treatment Issues 146
Specific Entities 146
Hepatitis B 147
Pathophysiology 147
Clinical Features 147
Investigations 147
Diagnostic Issues 147
Management 148
Treatment Issues 148
Hepatitis C 148
Pathophysiology 148
Clinical Features 148
Investigations 149
Prognostic Issues 149
Management 149
Treatment Issues 149
Chronic Liver Disease: Cirrhosis 149
Differential Diagnosis 149
Pathophysiology of Chronic Liver Disease 149
Clinical Features 150
Investigations 150
Management 151
Specific Entities 151
Hepatic Encephalopathy 152
Differential Diagnosis 152
Pathophysiology 152
Clinical Features 152
Investigations 152
Management 153
Ascites 153
Differential Diagnosis 153
Clinical Features 153
Investigations 153
Diagnostic Issues 154
Management 154
Specific Entities 154
Jaundice 155
Differential Diagnosis of Jaundice/Hyperbilirubinemia 155
Pathophysiology 155
Clinical Features 155
Investigations 155
Management 155
Specific Entities 155
Acute Pancreatitis 156
Causes 156
Pathophysiology 156
Clinical Features 156
Investigations 156
Diagnostic and Prognostic Issues 156
Management 156
Specific Entities 157
Notes 158
Hematology 160
Polycythemia 160
Differential Diagnosis 160
Pathophysiology 160
Clinical Features 160
Investigations 160
Diagnostic Issues 160
Management 160
Microcytic Anemia 161
Differential Diagnosis 161
Pathophysiology 161
Clinical Features 161
Investigations 161
Diagnostic Issues 161
Management 161
Specific Entities 161
Normocytic Anemia 162
Differential Diagnosis 162
Pathophysiology 162
Clinical Features 162
Investigations 162
Diagnostic Issues 162
Management 162
Specific Entities 163
Macrocytic Anemia 163
Differential Diagnosis 163
Pathophysiology 163
Clinical Features 163
Investigations 163
Management 163
Sickle Cell Disease 164
Pathophysiology 164
Clinical Features 164
Investigations 164
Management 164
Specific Entities 165
Neutropenia 165
Differential Diagnosis 165
Pathophysiology 165
Investigations 165
Management 165
Treatment Issues 165
Specific Entities 165
Eosinophilia 165
Differential Diagnosis 165
Pathophysiology 166
Clinical Features 166
Investigations 166
Diagnostic Issues 166
Management 166
Specific Entities 166
Thrombocytosis 167
Differential Diagnosis 167
Pathophysiology 167
Clinical Features 167
Investigations 167
Diagnostic Issues 167
Management 167
Thrombocytopenia 168
Differential Diagnosis 168
Pathophysiology 168
Clinical Features 168
Investigations 168
Diagnostic Issues 168
Management 168
Specific Entities 168
Pancytopenia 170
Differential Diagnosis 170
Investigations 170
Diagnostic Issues 170
Management 170
Specific Entities 170
Bleeding Diathesis 170
Differential Diagnosis 170
Pathophysiology 171
Clinical Features 171
Investigations 172
Management 172
Specific Entities 172
Hypercoagulable States 173
Differential Diagnosis 173
Pathophysiology 173
Investigations 173
Diagnostic Issues 173
Management 173
Treatment Issues 173
Specific Entities 174
Deep Vein Thrombosis 175
Differential Diagnosis of Unilateral Leg Swelling/Deep Vein Thrombosis 175
Pathophysiology 175
Investigations 175
Diagnostic Issues 175
Management 176
Treatment Issues 176
Specific Entities 176
Notes 176
Approach to Anticoagulation Therapies 177
Contraindications to Warfarin Therapy 178
Warfarin-Induced Skin Necrosis 178
Correction of Supratherapeutic INR due to Warfarin Use 178
Transfusion Reactions 179
Investigations 180
Indications for Specially Prepared Blood Products 180
Approach to the Peripheral Blood Smear 180
Terms 180
RBC Intracellular Inclusions 180
TellTale Morphologies 180
Splenomegaly 181
Differential Diagnosis 181
Clinical Features 181
Investigations 182
Management 182
Specific Entities 182
Myeloproliferative Disorders 182
Differential Diagnosis 182
Pathophysiology 182
Clinical Features 182
Investigations 182
Diagnostic and Prognostic Issues 182
Management 183
Treatment Issues 183
Acute Myelogenous Leukemia 183
Hematologic Malignancies Overview 183
Pathophysiology 184
Clinical Features 184
Investigations 184
Diagnostic and Prognostic Issues 184
Management 184
Treatment Issues 185
Specific Entities 185
Acute Lymphoblastic Leukemia 186
Pathophysiology 186
Clinical Features 186
Investigations 186
Prognostic Issues 186
Management 186
Treatment Issues 187
Chronic Lymphocytic Leukemia 187
Differential Diagnosis of Lymphocytosis 187
Pathophysiology 187
Clinical Features 187
Investigations 187
Diagnostic and Prognostic Issues 187
Management 188
Treatment Issues 188
Specific Entities 188
Hodgkin’s Lymphoma 188
Pathophysiology 188
Clinical Features 189
Staging 189
Investigations 189
Prognostic Issues 190
Management 190
Treatment Issues 190
Non-Hodgkin’s Lymphoma 190
Differential Diagnosis of Lymphadenopathy 190
Pathophysiology 190
Clinical Features 191
Staging 192
Investigations 192
Diagnostic and Prognostic Issues 192
Management 192
Treatment Issues 193
Specific Entities 193
Multiple Myeloma 195
Types of Plasma Cell Dyscrasias 195
Pathophysiology 195
Clinical Features 195
Investigations 195
Diagnostic and Prognostic Issues 196
Management 197
Treatment Issues 197
Specific Entities 197
Febrile Neutropenia 197
Hematopoietic Stem Cell Transplant 197
Terminologies 197
Common Indications 198
Allogeneic Transplantation 198
Autologous Transplantation 199
Notes 200
Oncology 202
Lung Cancer 202
Pathophysiology 202
Clinical Features 202
Staging 203
Investigations 203
Diagnostic and Prognostic Issues 203
Management 204
Treatment Issues 204
Mesothelioma 205
Pathophysiology 205
Clinical Features 205
Staging 205
Investigations 205
Prognostic Issues 205
Management 205
Thymoma and Thymic Carcinoma 206
Pathophysiology 206
Clinical Features 206
Staging 206
Investigations 206
Management 206
Treatment Issues 206
Breast Cancer 206
Differential Diagnosis of Breast Mass 206
Pathophysiology 206
Clinical Features 207
Investigations 207
TNM Staging 207
Diagnostic and Prognostic Issues 208
Management 208
Breast Surgery Overview 209
Hormonal Therapy Overview 209
Adjuvant Chemotherapy Overview 210
Palliative Chemotherapy Overview 211
Biological Therapy Overview 211
Management of Brain Metastases 212
Esophageal Cancer 212
Pathophysiology 212
Clinical Features 212
Staging 213
Investigations 213
Diagnostic and Prognostic Issues 213
Management 213
Treatment Issues 213
Gastric Cancer 214
Pathophysiology 214
Clinical Features 214
Staging 214
Investigations 214
Diagnostic and Prognostic Issues 214
Management 215
Treatment Issues 215
Colorectal Cancer 215
Pathophysiology 215
Clinical Features 216
Staging 216
Investigations 216
Management of Colon Cancer 216
Management of Rectal Cancer 217
Treatment Issues 217
Carcinoid Tumors 218
Pathophysiology 218
Clinical Features 218
Investigations 218
Management 219
Treatment Issues 219
Gastrointestinal Stromal Tumor 219
Pathophysiology 219
Clinical Features 220
Investigations 220
Prognostic Issues 220
Management 220
Anal Cancer 220
Pathophysiology 220
Clinical Features 220
Staging 220
Investigations 221
Management 221
Cancer of the Exocrine Pancreas 221
Pathophysiology 221
Clinical Features 221
Staging 221
Investigations 222
Diagnostic Issues 222
Management 222
Treatment Issues 222
Hepatocellular Carcinoma 222
Differential Diagnosis of Focal Liver Lesion (by Ultrasound) 222
Pathophysiology 222
Clinical Features 222
Staging for Hepatocellular Carcinoma or Intrahepatic Bile Duct Cancer 223
Investigations 223
Diagnostic Issues 223
Management 223
Treatment Issues 223
Specific Entities 223
Renal Cancer 224
Differential Diagnosis of Solid Renal Mass 224
Pathophysiology 224
Clinical Features 224
TNM Staging 224
Investigations 225
Diagnostic and Prognostic Issues 225
Management 225
Specific Entities 225
Bladder Cancer 225
Pathophysiology 225
Clinical Features 226
TNM Staging 226
Investigations 226
Prognostic Issues 226
Management 226
Prostate Cancer 227
Pathophysiology 227
Clinical Features 227
Staging 227
Investigations 227
Diagnostic and Prognostic Issues 227
Management 228
Treatment Issues 229
Testicular Cancer 229
Pathophysiology 229
Clinical Features 230
Staging 230
Investigations 230
Diagnostic and Prognostic Issues 230
Management 231
Treatment Issues 231
Brain Tumors 232
Ovarian Cancer 232
Pathophysiology 232
Clinical Features 232
Staging 232
Investigations 232
Diagnostic and Prognostic Issues 233
Management 233
Treatment Issues 233
Endometrial Cancer 233
Pathophysiology 233
Clinical Features 234
Prognostic Issues 234
Staging 234
Investigations 234
Management 234
Treatment Issues 235
Cervical Cancer 235
Pathophysiology 235
Clinical Features 235
TNM Staging 235
Investigations 235
Management 235
Cancer of Unknown Origin 236
Pathophysiology 236
Investigations 236
Management 236
Tumor Markers 237
Pathophysiology 237
Prostate Specific Antigen (PSA) 237
Carcinoembryonic Antigen (CEA) 237
CA 19-9 238
CA 15-3 238
CA 125 238
Cancer Screening 239
Principles of Screening 239
Prostate Cancer Screening 239
Colon Cancer Screening 239
Breast Cancer Screening 240
Ovarian Cancer Screening 240
Cervical Cancer Screening 240
Hereditary Cancer Syndromes 241
Hallmarks of Hereditary Cancer 241
BRCA Syndromes 242
Li-Fraumeni Syndrome 242
Von Hippel-Lindau Syndrome 242
Hereditary Malignant Melanoma 242
Hereditary Diffuse Gastric Cancer (HDGC) 242
Hereditary Non-polyposis Colorectal Cancer (HNPCC, Lynch Syndrome) 242
Familial Adenomatous Polyposis (FAP) 243
Antineoplastic Agents 243
Oncologic Emergencies 245
Infusion Reactions 245
Malignant Spinal Cord Compression 245
Malignant Cauda Equina Syndrome 245
Superior Vena Cava Syndrome 245
Hypercalcemia 246
Tumor Lysis Syndrome 246
Febrile Neutropenia 246
Chemotherapy-Induced Nausea and Vomiting 246
Pathophysiology 246
NCI-CTC Grading v4.0 246
Emetogenic Levels of Intravenously Administered Antineoplastic Agents 247
Management 247
Treatment Issues 247
Oral Mucositis 247
Pathophysiology 247
NCI-CTC Grading v4.0 247
Management 248
Chemotherapy-Induced Diarrhea 248
Pathophysiology 248
NCI-CTC Grading v4.0 248
Management 248
Notes 249
Infectious Diseases 250
Fever of Unknown Origin 250
Differential Diagnosis 250
Pathophysiology 250
Clinical Features 250
Investigations 250
Diagnosis and Prognostic Issues 251
Management 251
Fever and Rash 251
Differential Diagnosis 251
Clinical Features 251
Investigations 252
Management 252
Specific Entities 252
Fever and Joint Pain 253
Sepsis 253
Febrile Neutropenia 253
Differential Diagnosis 253
Pathophysiology 253
Clinical Features 254
Investigations 254
Management 254
Treatment Issues 254
Specific Entities 255
Fever with Travel History 255
Differential Diagnosis 255
Clinical Features 256
Investigations 256
Pre-Travel Considerations 256
Specific Entities 256
Pneumonia 258
Endocarditis 258
Meningitis 258
Differential Diagnosis for Fever and Neurological Symptoms 258
Pathophysiology 259
Investigations 259
Diagnostic and Prognostic Issues 260
Management 260
Specific Entities 260
Urinary Tract Infections and Sexually Transmitted Infections 261
Differential Diagnosis of Dysuria 261
Pathophysiology of Urinary Tract Infections 261
Clinical Features of Urinary Tract Infections 261
Investigations for Urinary Tract Infections 262
Diagnostic Issues for Urinary Tract Infections 262
Management of Urinary Tract Infections 262
Vaginitis 262
Sexually Transmitted Infections (STIs) 262
Soft Tissue Infections 264
Differential Diagnosis 264
Pathophysiology 264
Investigations 264
Management 264
Specific Entities 264
Osteomyelitis 265
Differential Diagnosis 265
Pathophysiology 265
Clinical Features 265
Investigations 266
Diagnostic Issues 266
Management 266
Specific Entities 266
Septic Arthritis 267
Tuberculosis: Pulmonary 267
Pathophysiology 267
Clinical Features 267
Investigations 268
Diagnostic Issues 268
Management 268
Treatment Issues 269
Approach to Gram Stain, Culture, and Sensitivity 269
Gram-Positive Cocci 269
Gram-Positive Bacilli 269
Gram-Negative Cocci 269
Gram-Negative Bacilli 269
Specific Organisms 270
Antibiotic Susceptibility and Resistance 270
Antibiotics 271
Gentamicin and Tobramycin Dosing 273
Once-Daily Gentamicin and Tobramycin Dosing 273
Vancomycin Toxicity and Dosing 273
Penicillin Allergy 274
Approach to Empiric Antibiotics 274
General Approach 274
Specific Infections and Empiric Antibiotic Choices 274
Hepatitis B 275
Hepatitis C 275
Herpes Simplex Virus Infection 275
Human Immunodeficiency Virus 276
Risk Factors for HIV 276
Acute HIV Infection 276
Natural History of HIV 276
CNS Lesions in HIV Patients 276
Chronic Meningitis in HIV Patients 277
Respiratory Infections in HIV Patients 277
Esophagitis in HIV Patients 277
Hepatitis/Cholangitis/Pancreatitis in HIV Patients 277
Colitis/Diarrhea in HIV Patients 277
AIDS-Associated Malignancies 277
Education, Prophylaxis, and Immunization for HIV Patients 278
Antiretroviral Therapy for HIV Patients 278
Therapeutic Decisions in HIV 278
Immune Reconstitution Inflammatory Syndrome (IRIS) in HIV Patients 279
Viral Hepatitis in HIV Co-infected Patients 279
Influenza 279
Differential Diagnosis 279
Pathophysiology 279
Clinical Features 280
Investigations 281
Management 281
Treatment Issues 281
Antiviral Agents 282
Fungal Infections 282
General Approach 282
Candidiasis 282
Aspergillosis 283
Zygomycetes (Mucormycosis) 283
Histoplasmosis 283
Cryptococcosis 284
Coccidioidomycosis 284
Blastomyces 284
Antifungal Agents 285
Indications for Voriconazole 285
Indications for Caspofungin 286
Treatment Definitions 286
Infection Control 286
Nosocomial Infections 286
Needle Stick Injury 286
Immunization for Adults 287
Principles 288
Notes 289
Rheumatology 290
Septic Arthritis 290
Differential Diagnosis of Monoarthritis 290
Pathophysiology 290
Clinical Features 290
Investigations 291
Diagnostic Issues 291
Management 291
Gout 292
Causes 292
Pathophysiology 292
Clinical Features 292
Investigations 292
Diagnostic Issues 292
Management 292
Treatment Issues 292
Specific Entities 293
Polyarticular Joint Pain and Fever 293
Differential Diagnosis 293
Clinical Features 293
Investigations 293
Management 294
Specific Entities 294
Rheumatoid Arthritis 294
Differential Diagnosis of Polyarthritis 294
Pathophysiology 294
Clinical Features 294
Investigations 295
Diagnostic and Prognostic Issues 295
Management 295
Specific Entities 295
Systemic Lupus Erythematosus 296
Pathophysiology 296
Clinical Features 296
Investigations 297
Management 297
Specific Entities 297
Seronegative Spondyloarthropathies 299
Differential Diagnosis of Oligoarthritis 299
Clinical Features 299
Investigations 299
Diagnostic Issues 299
Management 300
Specific Entities 300
Back Pain 301
Differential Diagnosis 301
Clinical Features 301
Investigations 301
Diagnostic Features 301
Management 301
Specific Entities 302
Osteoarthritis 303
Differential Diagnosis 303
Pathophysiology 303
Clinical Features 303
Investigations 303
Diagnostic Issues 303
Management 303
Specific Entities 303
Fibromyalgia 304
Differential Diagnosis of Diffuse Body Pain 304
Pathophysiology 304
Clinical Features 304
Investigations 304
Management 305
Specific Entities 305
Vasculitis 305
Differential Diagnosis 305
Pathophysiology 305
Clinical Features 305
Investigations 306
Management 306
Specific Entities 306
Approach to Serologies 309
Inflammatory Markers 309
Rheumatoid Arthritis 309
Lupus 309
Scleroderma 309
Sjogren’s Syndrome 309
Inflammatory Myopathies 310
Vasculitis 310
Joint Examination 311
Notes 313
Neurology 314
Brain Tumors 314
Pathophysiology 314
Clinical Features 314
Investigations 315
Prognostic Issues 315
Management 315
Treatment Issues 315
Specific Entities 315
Acute Stroke Syndromes 316
Differential Diagnosis 316
Pathophysiology 316
Clinical Features 317
Investigations 319
Diagnostic and Prognostic Issues 319
Management 319
Treatment Issues 319
Specific Entities 320
Cranial Nerve Examination 321
Specific Entities 322
Diplopia 323
Differential Diagnosis 323
Pathophysiology 323
Clinical Features 323
Investigations 324
Management 324
Specific Entities 324
Bell’s Palsy 324
Causes of Facial Droop 324
Pathophysiology 324
Clinical Features 324
Investigations 324
Diagnostic and Prognostic Issues for Bell’s Palsy 324
Management of Bell’s Palsy 325
Specific Entities 325
Multiple Sclerosis 325
Differential Diagnosis 325
Pathophysiology 325
Clinical Features 325
Investigations 325
Diagnostic and Prognostic Issues 325
Management 326
Dementia 326
Delirium 326
Seizures 326
Differential Diagnosis 326
Pathophysiology 327
Clinical Features 327
Investigations 327
Diagnostic Issues 327
Management 327
Treatment Issues 328
Syncope 329
Differential Diagnosis 329
Clinical Features 329
Investigations 329
Management 329
Treatment Issues 329
Specific Entities 329
Neurocardiogenic (Vasovagal) Syncope 329
Neurogenic Orthostatic Hypotension 329
Migraine Headaches 330
Differential Diagnosis of Headaches 330
Clinical Features 330
Investigations 331
Diagnostic Issues 331
Management of Migraine Headaches 331
Specific Entities 331
Meningitis 332
Dizziness and Vertigo 332
Differential Diagnosis 332
Clinical Features 332
Investigations 332
Diagnostic Issues 333
Management 333
Specific Entities 333
Hearing Impairment 334
Differential Diagnosis 334
Clinical Features 334
Investigations 334
Management 334
Myasthenia Gravis 335
Differential Diagnosis of Ptosis 335
Pathophysiology 335
Clinical Features 335
Investigations 336
Management of Myasthenia Gravis 336
Specific Entities 336
Ataxia 336
Differential Diagnosis 336
Clinical Features 336
Investigations 337
Management 337
Subacute Combined Degeneration 337
Parkinson’s Disease 337
Classification of Movement Disorders 337
Pathophysiology 337
Clinical Features 338
Investigations 339
Investigations for Hyperkinetic Movement Disorders 339
Management 339
Specific Entities 339
Radiculopathy 340
Pathophysiology 340
Clinical Features 340
Investigations 340
Treatment of Cervical Radiculopathy 340
Specific Entities 340
Dermatomes 341
Myotomes 341
Brachial Plexus 342
Muscle-Nerve Function Correlation 342
Differentiating between Nerve Root and Peripheral Nerve Lesions 342
Specific Considerations 344
Peripheral Neuropathy 344
Differential Diagnosis 344
Clinical Features 344
Investigations 344
Management 344
Specific Entities 345
Peripheral Nerves 346
Muscle Weakness 349
Differential Diagnosis 349
Clinical Features 349
Investigations 349
Management 350
Specific Entities 350
Approach to Neuroimaging 350
Modalities 350
Approach to CT Head 350
Head CT Findings in the Elderly 351
Head CT Findings in Stroke 351
Notes 352
Notes 353
Endocrinology 354
Diabetes Mellitus 354
Classification 354
Pathophysiology 354
Clinical Features 354
Investigations 355
Diagnostic Issues 355
Acute Management of Diabetic Ketoacidosis 355
Specific Entities 356
Long-Term Management 356
Oral Hypoglycemic Agents 357
Principles of Insulin Use 358
Starting Insulin for New Patients 358
Regular Insulin Dose Adjustment Principles 358
Sample Sliding Scale Template 359
Treatment Issues 359
Hypoglycemia 359
Differential Diagnosis 359
Pathophysiology 359
Clinical Features 359
Investigations 359
Management 359
Hypothyroidism 360
Differential Diagnosis 360
Clinical Features 360
Investigations 360
Diagnostic Issues 360
Management 360
Treatment Issues 360
Specific Entities 360
Hyperthyroidism 361
Differential Diagnosis 361
Pathophysiology 361
Clinical Features 361
Investigations 361
Diagnostic Issues 362
Management 362
Treatment Issues 362
Specific Entities 362
Solitary Thyroid Nodule 362
Differential Diagnosis 362
Clinical Features 362
Investigations 362
Diagnostic Issues 363
Management 363
Treatment Issues 363
Pituitary Tumors 363
Differential Diagnosis of Pituitary Tumors 363
Differential Diagnosis of Hyperprolactinemia 363
Clinical Features 363
Investigations 363
Diagnostic Issues 363
Management 364
Specific Entities 364
Polyuria 364
Differential Diagnosis 364
Pathophysiology 364
Investigations 364
Management of Diabetes Insipidus 365
Adrenal Incidentaloma 365
Differential Diagnosis 365
Pathophysiology 365
Clinical Features 365
Investigations 365
Diagnostic Issues 365
Management 366
Specific Entities 366
Adrenal Insufficiency 366
Differential Diagnosis 366
Clinical Features 366
Investigations 367
Diagnostic Issues 367
Management 367
Cushing’s Syndrome 367
Differential Diagnosis 367
Clinical Features 367
Investigations 367
Diagnostic Issues 368
Management 368
Treatment Issues 368
Specific Entities 369
Hypocalcemia 369
Differential Diagnosis 369
Pathophysiology 369
Clinical Features 369
Investigations 369
Management 369
Specific Entities 369
Hypercalcemia 370
Differential Diagnosis 370
Pathophysiology 370
Clinical Features 370
Investigations 370
Diagnostic Issues 370
Management 370
Treatment Issues 371
Specific Entities 371
Osteoporosis 371
Causes 371
Pathophysiology 371
Clinical Features 371
Investigations 372
Diagnostic and Prognostic Issues 372
Management 372
Treatment Issues 372
Specific Entities 372
Hypertension 373
Hyperlipidemia 373
Amenorrhea 373
Differential Diagnosis 373
Pathophysiology 373
Clinical Features 373
Investigations 374
Management 374
Hirsutism 374
Differential Diagnosis 374
Pathophysiology 374
Clinical Features 374
Investigations 374
Management 375
Specific Entities 375
Notes 376
Dermatology 378
Eczema 378
Differential Diagnosis of Pruritus 378
Pathophysiology 378
Clinical Features 378
Investigations 378
Management 378
Specific Entities 378
Psoriasis Vulgaris 379
Differential Diagnosis of Papulosquamous Lesions 379
Pathophysiology 379
Clinical Features 379
Investigations 379
Management 379
Specific Entities 379
Acne Vulgaris 380
Differential Diagnosis of Acneiform Lesions 380
Pathophysiology 380
Clinical Features 381
Investigations 381
Management 381
Treatment Issues 381
Specific Entities 381
Exanthematous Lesions 381
Differential Diagnosis of Exanthematous Lesions 381
Clinical Features 381
Management 381
Specific Entities 382
Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis 382
Differential Diagnosis of Vesicles/Bullous Lesions 382
Pathophysiology 382
Clinical Features 382
Investigations 383
Prognostic Issues 383
Management 383
Specific Entities 383
Ulcers 384
Differential Diagnosis of Ulcers 384
Investigations 384
Management 384
Specific Entities 384
Melanoma and Skin Tumors 385
Differential Diagnosis of Pigmented Lesions 385
Pathophysiology 385
Clinical Features 385
Investigations 386
Diagnostic and Prognostic Issues 386
Management 386
Specific Entities 387
Cutaneous Lupus Erythematosus 388
Differential Diagnosis of Photosensitivity 388
Clinical Features 388
Investigations 388
Management 388
Specific Entities 388
Drug Eruptions 389
Differential Diagnosis 389
Investigations 389
Management 389
Specific Entities 389
Erythema Nodosum 390
Differential Diagnosis of Painful Nodules 390
Pathophysiology 391
Clinical Features 391
Investigations 391
Management 391
Clubbing 391
Differential Diagnosis 391
Pathophysiology 391
Clinical Features 391
Investigations 391
Management 391
Specific Entities 392
Dupuytren’s Contracture 392
Differential Diagnosis 392
Pathophysiology 392
Clinical Features 392
Management 392
Notes 393
Geriatrics 394
Geriatric-Specific Issues 394
The Frail Elderly 394
Comprehensive Geriatrics Assessment 394
Comprehensive Geriatric Management 394
Health Care and Financial Proxy 395
Competency Assessment 395
Dementia and Cognitive Impairment 395
Differential Diagnosis 395
Pathophysiology 395
Clinical Features 396
Investigations 396
Diagnostic Issues 396
Management 397
Specific Entities 397
Delirium 397
Differential Diagnosis 397
Pathophysiology 398
Clinical Features 398
Investigations 398
Diagnostic Issues 399
Management 399
Treatment Issues 399
Falls 399
Differential Diagnosis 399
Pathophysiology 399
Clinical Features 400
Investigations 400
Management 400
Osteoporosis 400
Urinary Incontinence 400
Differential Diagnosis of Chronic Urinary Incontinence 400
Differential Diagnosis of Transient Urinary Incontinence 401
Pathophysiology 401
Investigations 401
Management of Chronic Urinary Incontinence 401
Hearing Impairment 402
Pharmacological Issues in the Elderly 402
Principles of Drug Use in the Elderly 402
Under-Prescribing in the Elderly 402
Over-Prescribing in the Elderly 402
Common Adverse Drug Reactions and Drug-Drug Interactions 402
Notes 404
Palliative Care 406
Palliative Care-Specific Issues 406
Introduction 406
Symptom Complex and Assessment 406
Depression in the Palliative Setting 407
Care for Caregivers 407
Communication in the Palliative Setting 407
Decision Making in the Palliative Setting 407
Spirituality in the Palliative Setting 407
Diagnosis of Dying 408
Medication Administration in the Palliative Setting 408
Principles of Pain Control 408
Types of Pain 408
Pathophysiology 408
Management 409
Treatment Issues 409
Delirium 411
Cancer-Related Fatigue 411
Causes 411
Pathophysiology 411
Clinical Features 411
Investigations 411
Management 411
Dyspnea in the Palliative Setting 411
Differential Diagnosis of Acute Dyspnea 411
Pathophysiology 412
Investigations 412
Management 412
Treatment Issues 412
Specific Entities 412
Nausea and Vomiting in the Palliative Setting 412
Investigations 412
Management 413
Specific Entities 413
Constipation in the Palliative Setting 413
Differential Diagnosis 413
Pathophysiology 413
Investigations 413
Diagnostic Issues 413
Management 414
Anorexia-Cachexia 414
Differential Diagnosis 414
Pathophysiology 414
Differential Diagnosis 414
Investigations 415
Management 415
Treatment Issues for Anorexia-Cachexia 415
Communication Issues 416
Communication Techniques 416
Discussing Resuscitation Status 416
Breaking Bad News-The Gentle Art of Truth Telling 416
Prognostication in Far Advanced Cancer Patients 417
Reasons for Discussing Prognosis 417
Prognostic Factors 417
Prognostic Tools 417
Notes 419
Nutrition 420
Obesity 420
Complications and Associated Disorders 420
Pathophysiology 420
Investigations 420
Management 420
Treatment Issues 421
Malabsorption Syndromes 421
Anorexia-Cachexia 421
Vitamin B12 Deficiency 422
Differential Diagnosis 422
Pathophysiology 422
Clinical Features 422
Investigations 422
Management 422
Diet and Supplemental Nutrition 423
Introduction 423
Nutritional Assessment 423
Hospital Diet Types 423
Enteral Nutrition Overview 423
Routes for Enteral Feeds 423
Administration of Enteral Feeds 423
Enteral Nutrition Formulas 424
Additions to Enteral Feeds 424
Complications of Enteral Feeds 424
Parenteral Nutrition Overview 424
Components of Total Parenteral Nutrition 424
Refeeding Syndrome 424
Notes 425
Obstetric Medicine 426
Preeclampsia/Eclampsia/HELLP Syndrome 426
Differential Diagnosis of Hypertension in Pregnancy 426
Pathophysiology 426
Clinical Features 426
Investigations 426
Management 426
Pulmonary Diseases in Pregnancy 427
Asthma 427
Venous Thromboembolism 427
Amniotic Fluid Embolism 427
Cardiac Diseases in Pregnancy 428
Pathophysiology 428
Valvular Disorders 428
Myocardial Disorders 428
Rhythm Disorders 428
Hepatic Diseases in Pregnancy 428
Differential Diagnosis 428
Clinical Features 429
Investigations 429
Management 429
Specific Entities 429
Infectious Diseases in Pregnancy 429
Urinary Tract Infections 429
Human Immunodeficiency Virus (HIV) 430
TORCHES Infections 430
Tuberculosis 430
Antibiotics 430
Endocrine Disorders in Pregnancy 430
Diabetes in Pregnancy 430
Hypothyroidism in Pregnancy 431
Hyperthyroidism in Pregnancy 431
Other Disorders in Pregnancy 431
Seizures in Pregnancy 431
Lupus in Pregnancy 432
Breast Cancer in Pregnancy 432
Pain Control in Pregnancy 432
Thrombocytopenia in Pregnancy 432
Antiphospholipid Antibody Syndrome in Pregnancy 432
Notes 433
General Internal Medicine 434
Approach to Diagnostic Tests and Clinical Trials 434
Diagnostic Tests 434
Therapeutic Interventions 435
Smoking Cessation 435
Complications and Smoking-Associated Disorders 435
Pathophysiology of Smoking 435
Management of Smoking Cessation 436
Treatment Issues 436
Prognostic Issues 436
Multisystem Disorders 437
Selected MultiSystem Disorders 437
Hemochromatosis 437
Sarcoidosis 437
Amyloidosis 437
Cryoglobulinemia 438
Porphyria 438
Whipple’s Disease 439
Perioperative Assessment for Non-cardiopulmonary Surgery and Postoperative Complications 439
Perioperative Cardiac Risk Assessment 439
Perioperative Pulmonary Risks 440
Investigations for Perioperative Patients 440
Management of Perioperative Patients 441
Postoperative Complications 442
Medical Fitness to Drive 443
General Principles 443
Obtaining Consent for Medical Procedures 444
Consenting Process 444
Biomedical Ethics Issues 444
Ethics Judgment 444
Truth Telling 444
Informed Consent 444
Capacity 444
Battery and Negligence 445
Confidentiality 445
Futility 445
Euthanasia 445
Resource Allocation 445
Research Ethics 445
Conflict of Interest 445
Hospital Admission and Discharge Issues 446
Principles of Medical Management 446
Reasons for Admission 446
Rehabilitation Criteria 446
Discharge Criteria 446
Disposition 446
Notes 447
Appendix A Advanced Cardiac Life Support 448
Appendix B List of Common Abbreviations 449
Appendix C Common Laboratory Values And Unit Conversion 453
Appendix D History Template 457
Index 458
Selected Internal MedicineTopics 474