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Pocke t Me dicine is meant only as a starting p oint to guide one during the initial p hases of diagnosis and management until one has time to consult more de nitive resources. Although the recommendations herein are as evidence-based as p ossible, medicine is both a science and an art. As always, sound clinical judgement must be ap p lied to every scenario. I am grateful for the sup p ort of the house o cers, fellows, and attendings at the Massachusetts General Hosp ital.
It is a p rivilege to work with such a knowledgeable, dedicated, and comp assionate group of p hysicians. I always look back on my time there as Chief Resident as one of the best exp eriences I have ever had. Melinda Cuerda, my academic coordinator, was an invaluable resource for this edition. She shep herded every asp ect of the p roject from start to nish, with an incredible eye to detail to ensure that each p age of this book was the very best it could be. Lastly, sp ecial thanks to my p arents for their p erp etual encouragement and love and, of course, to my wife, Jennifer Tseng, who, desp ite being a surgeon, is my closest advisor, my best friend and the love of my life.
I hop e that you nd Pocke t Me dicine useful throughout the arduous but incredibly rewarding journey of p racticing medicine. MARC S. CCTA vs. Coronary vasodilators will reveal CAD, but not tell you if Pt ische mic : regadenoson, dip yridamole or adenosine may p recip itate bradycardia and bronchosp asm.
Risk strat. Due to mech p rob. MI Mortality benefit seen in some studies, likely only if cons.
PO convenient. Excep t for exercise-induced asthma. PO steroids may be needed for severely uncontrolled asthma. Useful in young Pts. ED visits. PEF used to follow clinical course. Mild-mod exacerbation: IV or via ETT 2. AND at least one of: IM or SC 0. IV contrast not truly an IgE-mediated mechanism. Abnormal gas exchange: PE Annals 2 Lance t 1.
S1S2 S3. R-sided strain. Obstruction FEV1: Surgical resection. CF Pts often have multip le drug-resistant organisms Pse udomonas. Burkholde ria ce pacia. UPPP of limited benefit Che st Offer if refusing CPAP. Lancet Resp Med CBC lymp hop enia. African Americans. NSIP esp. ILD of unknown cause. Churg-Strauss syndrome. RA large. Kle bsie lla. Staph aure us. Common causes: Stre p pne umo. Pe ptostre ptococcus. Hae mophilus. Stre p mille ri. Pse udomonas. PE usually exudate. SLE small.
Bacte roide s. PE RBC: Archive s 2 RA amylase: NT-p roBNPeff. NIPPV avoid chest tubes. APC resistance. R-sided S 3. Graham Steell PR murmur. Use if p retest p rob of PE high and CT not available or contraindicated.
Send p anel 2 wk after comp lete anticoagulation. Hamp ton hump wedge-shap ed density abutting p leura. P p ulmonale. Can also exclude PE if low p retest p rob. Che st Attractive op tion as outPt bridge to long-term oral anticoagulation Fondaparinux: RV dysfxn on echo.
CD No need to monitor anti-factor Xa unless concern re: Blood 2 LMWH eg. If catheter- associated. RV enlargement on CTA and low bleed risk. Chest Cochrane 2 Sup erficial venous thrombosis: Consider if extensive eg. RUQ fullness.
PR Graham Steell. RV heave. RV diam. JIM Che st 2 R-sided S 4. PAH all etiologies: COHb not true cyanosis ] p erip heral: Pulse oximeter Ox misreads COHb as. Pulse ox misreads MetHb as HbO 2. E time. Pick ventilator mode. Choose method including p otentially noninvasive ventilation.
VS stable. Methylp rednisolone 2 0 mg IV q4h starting 12 h p re-extub. HOB elevated. NPV 0. Weaning from the ventilator NEJM BDZs and p olyp harmacy are risk factors p rop ofol: R dexmedetomidine: JPEN 2 Benefit may vary by time since ARDS onset: PLoS One 2 Adverse effects include neuromuscular weakness.
CVP 8 —12 mmHg. Crit Care Me d 2 Rings lower. Fe-defic anemia. Ne urog astro 2 Diet elim milk. Drugs swallow inh steroids. Gastro 2 SSRI or baclofen Gastro 2 High-grade dysp lasia: Chemop reventive benefit of ASA under study. Am J Gastro 2 Alim Pharm The r 2 Gut 2 Trip le Rx: Gastro 8. AAA or aortic graft erodes into 3rd p ortion of duodenum. HSV or Candida if immunosup p ressed. JVP localizable abd tenderness.
VS most important. CT angio p romising Radiolog y 2 GIE 2 Obscure GIB Gastro 2 If still. Evaluation NEJM 2 If severe.
LR IV. PR vanco if ileus. PO vanco tap er for 6 wk. GI surgery. Inf Dis Clin 2 H2 RA. Gastro CNS Ds. BMJ 2 SSRI Bloating: Methylnaltrexone and alvimop an for op ioid-induced AJG 2 Must exclude mechanical obstruction absence of gas in rectum.
FHx of IBD or colon cancer. TSH Colonoscop y if alarm sx: Sitzmark study. IV fluids. Fecal calp rotectin ap p ears useful for Ddx IBD vs.
BM sup p ression. If high-grade dysp lasia or dysp lasia assoc. Exclude viral hep atitis. Other risk factors include: If sx. Dysp lasia best marker for risk. Complications of therapy Clin Gastro He p 2 Alime nt Pharmacol The r 2 Cancer screening Gastro 2 Chemop rop hylaxis: Similar for colonic CD. AAA leak. Surg 2 Ann Surg 2 Help s exclude other dx. AJG 2 IV mep eridine. Ideally NJ tube. GI hemorrhage.
FNA no longer routinely recommended Pancre as 2 Surgery in selected cases. Smoking major risk factor.
Chronic pancreatitis Lance t 2 VII is short. IgM anti-HBc. IgM anti-HAV. Evaluate for any clues to etiology 1st eg. RUQ p ain. MRI q6mo. Clin Gas He p 2 He p 2 Rx 2 4—48 wk. IL28 B genotyp e. Other viruses HGV. Africa and Mexico. Consider early transfer to transp lant ctr. NG lavage.
Clin Liv Dis 2 Pentoxifylline under study He p 2 NAFLD fibrosis score www. Liver bx remains gold standard. Budd-Chiari syndrome. Stre p. Workup He p 2 CCl 4. HCV rare. HEV esp. ARF or on vasop ressors. IV acyclovir for HSV. R-sided CHF. Kle bs. Fe and Cu studies.
Pse ud. GN or obstruction Type I: EGD req. Crit Care 2 Typ e 1: Hepatocellular carcinoma HCC He p 2 Clin Gastro He p 2 Based on Cr. Ye rsinia. C2 8 2 Y homozygotes: Europ ean Caucasians. Liste ria. In acute live r failure.
PRBC transfusion. In advance d dise ase rare: Varied p resentations: Coombs hemolytic anemia. If AMA. M is nl MZ? Trials of colchicine. Rx less clear acute: Isolated sp lenic vein thrombosis eg.
Budd-Chiari syndrome J He patol 2 LFTs usually normal. J He patol 2 IVC webs. If refractory bleed consider TIPS. He patolog y 2 Dig Dis Sci 2 Native American. NSAIDs eg. Campylobacte r. Pts p ostop major surgery. Kle bsie lla and Ente robacte r sp. RUQ tenderness. In acute cholecystitis. BD injury or retained stones. If sp hincterotomy cannot be p erformed larger stones.
Pa CO 2. HCO 3. GI causes. OG p recedes AG. Int J Clin Pract 2 HIV normal renin. K-sp aring diuretics. B 6 ethylene glycol. NaHCO 3 eg. CNS trauma. JASN 2 MDMA miscellaneous: GI losses eg.
Hypovolemic hypotonic hyponatremia ie. Pe diatr Ne phrol 2 EtOH Nephrogenic Annals 2 NGT drainage. U osm. AML crisis.
U waves. GI loss diarrhea. Workup Crit Care Me d 2 HRS or glomerulonep hritis. KI Suppl 2 NaHCO 3? Can be irreversible. Cr p oor estimate of GFR. K if oliguric or hyp erkalemic. Rx CV risk factors eg. Na if HTN. BP measurements. ITC2 For outPts. NDT 2 CHF Sigmoidal dose resp onse curve. Relatively weak natriuretic activity. Disease state specific regimens. LV mass. CVVH vs. PD vs. HCO3 requires hep arin to p revent machine from clotting vs.
Catheter removal. Filtrate discarded. Blood under p ressure p asses down one side of hig hly pe rme able membrane allowing H 2 O and solutes to p ass across membrane via TMP gradient convective clearance. Rep lacement fluid infused solute concentrations similar to p lasma. K and Ca in dialysate bath.
Fluid balance controlled by choosing dialysate [glc] higher concentrations p ull more fluid into p eritoneum. BK virus load. Called automated or continuous cycling p eritoneal dialysis APD. Pse udomonas Hyp erglycemia: BK virus. HIV collap sing variant.
Nat Me d 2 Kid Int 2 Scie nce 2 PLA2 recep t. Acute treatment NEJM 2 AJR 2 Prote us. D-p enicillamine. Dep ending on 2 4-h urine: WBC morp hology. Hb electrop horesis. RBC p arams incl. MCV nb.
BUN and Cr.. IV iron Fe-sucrose. Rare Fe refractory genetic disorder due to hep cidin dysregulation Nat Ge ne t 2 RBC Pappenheimer bodies Fe-containing inclusions. Hb electrophoresis: Ann He m 2 IVIg if p arvovirus infection. Schilling test. Lesch-Nyhan syndrome. B or C immune disorders SLE. RBC destruction p recip itated by a medication: ANA BM bx for unexp lained thrombocytop enia.
Anti-plt Ab te sts not use ful. APLA if anemia: MI thrombosis 4: LMWH prophylaxis. FFP if delay to p lasma exchange Blood 2 X and p rotein C. Also consider nep hrotic syndrome. PNH esp.
INR 3—4 vs. Ab that p rolongs p hosp holip id-dep endent coagulation reactions. Ab against cardiolip in. J Thromb Hae most 2 Lance t Oncol 2 Am J He matol 2 KIT mutations in virtually all systemic mastocytosis. Nat Re v Clin Oncol 2 BJH 2 Stratification based on IWG factors allows p rognostication at any p oint during clinical course Blood 2 MPN esp. Bloom syndrome. Treatment Blood 2 JNCCN 2 Cytarabine dose: Daunorubicin dose: JCO 2 ATO highly active as first-line therap y or in treatment of refractory disease.
T-cell immunop henotyp e. Side effects include nausea. TKI up front. CD2 0 dim. Key role for sp liceosome mutations NEJM 2 Nine significantly mutated genes. JCI 2 Binet stage C. VZV p rop hylaxis.
BR sup erior to monoRx Lance t 2 PET resp onse to Rx can be p rognostic Blood 2 NHL cardiac disease if RT or anthracycline. RS cells are clonal B-cells: ABVD doxorubicin. Lymp hoblastic lymp homa B or T cell: HHV8 driven; also can be seen in other immuno- sup p. Definition and epidemiology NEJM 2 ; Caucasian ratio 2: M p rotein concen. Proteasome inhib containing regimens incl. Timing of HSCT up front vs. Definition Blood 2 ; BM cytop enias , hep atomegaly, sp lenomegaly, lymp hadenop athy.
Transplantation of donor pluripote nt ce lls that can re constitute all re cipie nt blood line ag e s. Matche d unre late d: Auto HSCT allows higher ablative chemo doses and then rescues the hematop oietic system used mostly for lymp homa, multip le myeloma, testicular cancer. Transplantation procedure. Goal is e radication of underlying disease for which transp lant is being p erformed.
BM vs. G-CSF accelerates recovery by 3—5 d in all scenarios. Eng raftme nt syndrome: Dx of exclusion: Symp toms: Clinical grades I—IV based on scores for skin severity of maculop ap ular rash , liver bilirubin level and GI volume of diarrhea ; bx sup p orts diagnosis. NEJM ; VATS eval. Ske le tal: HER2 amp lified. Mutations in TP Rare mutations in CHEK2. Che mothe rapy Lance t 2 Prop hylactic bilat.
Gleason grade 2 — For local recurrence following RP. CA Cance r J Clin 2 BRAF mutation may guide clinical trials. COX-2 inhib. Amsterdam criteria: Pathology and genetics NEJM 2 ASA assoc.
Nature 2 Known or susp ected familial syndrome: CT colonography CTC: In high-risk Pts. Immunohisto for Hb: Rep eat q1y. Staging is comp lex and based on p athologic correlation with observed survival data. Flex sig less Se vs. At p op ulation level.
If p olyp found. Peutz-Jeghers LKB1. Offer clinical trials. Ann Oncol 2 Gemcitabine alone vs. Surgery based on age. Uncertain p rogression to cancer? Oncolog ist 2 Treatment of pancreatic adenocarcinoma NEJM 2 RLQ p ain. CBC with differential. GI mucositis. MRSA colonization. Avoid in G6PD deficiency as results in hemolytic anemia. UA level must be drawn on ice to quench e x vivo enzyme activity JCO 2 CML in blast crisis. Acta Hae matol 2 Le g ione lla. Good samp le ie. Chem-2 0. SaO2 or Pa O 2.
CID 2 Le g ione lla on BCYE. Multilobar infiltrates. Some p athogens need sp ecific cx eg.
Insufficient time: If high-risk comorbidity. Uncertain resistance p attern. RT-PCR gold standard avail. Can be esp.. M2 inhib. If from Pacific NW. AIDS most suscep tible. With any crypto dx. Sensi testing available. Other sites: India ink stain. Dosing and duration vary by host. CNS cryp tococcoma. CN abnl.. Cell counts vary. Cryptococcus CID CSF CrAg. LP all Pts. CNS rare unless immunosup p. Coccidioidomycosis CID SE and midwest U. Non-CNS disease in healthy Pts: Aspergillosis CID AIDS esp.
Se variable best for Coccidio. High mortality desp ite Rx. Pne umocystis. Aspe rg illus. Se for many fungal infxns Candida. GI necrotic ulcers. Sp limited by X-react Crypto Ag serum. Ure aplasma ure alyticum. Trichomonas vag inalis. Chlamydia trachomatis. Ne isse ria g onorrhoe ae.
In healthy. Group B strep and coag-neg stap h excep t S. Mycoplasma g e nitalium. BCx may be. CID Gram stain. EtOH abuse. If concern for strep. Charcot Ds Radionuclide imaging: PCR eg. India ink p rep..
Coxie lla. IV Ig and antilymp hocyte Ig. Jap anese. JC virus PML. Nile NEJM 2 Risk factors for severe dis: Neurology DFA is most Se from scrap e of newly unroofed vesicle.. AoV disease incl. PE if right-sided. Clinical manifestations Archives TEE if i mod-to-high susp icion. Seek ID eval Me d 2 Treatment NEJM Detailed hx: Add rifamp in for PVE due to stap h sp p.
BCx [? Seek ID eval. IVDU S. Kle bsie lla sp p. Ne isse ria less likely p athogenic: Candida sp p. Source control essential for cure and to p revent recurrence.
Can occur as new not p reviously treated infxn if exp osed in former Soviet Rep ublics. IDU or medically underserved. Mantoux tuberculin test ie. Relies on host immune fxn. HIV assoc. Constitutional sx fever. Diagnostic studies for active TB high index of suspicion is key! Does not distinguish active vs. Se limited in immunosup p. Preventive therapy Annals LAN likely due to hyp ersensitivity resp onse to killing of bacilli.
TB eg. Pts taken off immunosup p ress. If HIV. CD4 count. HIV genotyp e.
AIDS-defining illness. DHHS 2 PCP sp utum stain. HIV or med-related.