Pocket Medicine

P o c k e t

Pocket M e d i c i n e

Fifth Edition

Edited byMarc S. Sabatine, MD, MPHaSSociate ProfeSSor of MeDicine

HarvarD MeDical ScHool

The Massachusetts General Hospital Handbook of Internal Medicine

N ot E b o o k

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Library of Congress Cataloging-in-Publication Data

Pocket medicine (Sabatine) Pocket medicine / [edited by] Marc S. Sabatine. — Fifth edition. p. ; cm. Preceded by Pocket medicine / edited by Marc S. Sabatine. 4th ed.c2011. Includes bibliographical references and index. ISBN-13: 978-1-4511-8237-8 ISBN-10: 1-4511-8237-6 ISBN-13: 978-1-4511-8887-5 ISBN-10: 1-4511-8887-0 I. Sabatine, Marc S., editor of compilation. II. Title. [DNLM: 1. Internal Medicine–Handbooks. 2. Clinical Medicine–Handbooks. WB 39] RC55 616–dc23 2013019655

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CONTENTSContributing Authors viForeword ixPreface x

cARDIoLoGYNeal A. Chatterjee, Ada Stefanescu, William J. Hucker, David M. Dudzinski,

Marc S. Sabatine, Michelle O’Donoghue Electrocardiography 1-1Chest Pain 1-3Noninvasive Evaluation of CAD 1-4Coronary Angiography and Revascularization 1-5Acute Coronary Syndromes 1-6PA Catheter and tailored therapy 1-12Heart Failure 1-14Cardiomyopathies 1-17Valvular Heart Disease 1-20Pericardial Disease 1-25Hypertension 1-28Aortic Aneurysms 1-30Acute Aortic Syndromes 1-31Arrhythmias 1-32Atrial Fibrillation 1-35Syncope 1-37Intracardiac Devices 1-39Cardiac Risk Assessment for Noncardiac Surgery 1-40Peripheral Artery Disease 1-41

PULMoNARYIan J. Barbash, Kathryn A. Hibbert, Atul MalhotraDyspnea 2-1Pulmonary Function tests 2-1Asthma 2-2Anaphylaxis 2-4Chronic obstructive Pulmonary Disease 2-5Hemoptysis 2-7bronchiectasis 2-7Solitary Pulmonary Nodule 2-8obstructive Sleep Apnea 2-8Interstitial Lung Disease 2-9Pleural Effusion 2-11Venous thromboembolism 2-13Pulmonary Hypertension 2-16Respiratory Failure 2-18Mechanical Ventilation 2-19Acute Respiratory Distress Syndrome 2-22Sepsis 2-23

GAStRoeNteRoLoGYZachary A. Zator, Andrew S. de Lemos, Lawrence S. FriedmanEsophageal and Gastric Disorders 3-1Gastrointestinal bleeding 3-3Diarrhea, Constipation and Ileus 3-5Diverticular Disease 3-9Inflammatory bowel Disease 3-10Intestinal Ischemia 3-12


Pancreatitis 3-13Abnormal Liver tests 3-15Hepatitis 3-17Acute Liver Failure 3-20Cirrhosis 3-21Hepatic Vascular Disease 3-25Ascites 3-26biliary tract Disease 3-27

NePHRoLoGYAndrew S. Allegretti, Andrew L. Lundquist, Hasan BazariAcid-base Disturbances 4-1Sodium and Water Homeostasis 4-6Potassium Homeostasis 4-10Renal Failure 4-12Glomerular Disease 4-16Urinalysis 4-18Nephrolithiasis 4-19

HeMAtoLoGY-oNcoLoGYAndrew M. Brunner, Sheheryar K. Kabraji, Mark M. Awad, Andrew J. Aguirre,

Daniel J. DeAngelo, David P. RyanAnemia 5-1Disorders of Hemostasis 5-6Platelet Disorders 5-7Coagulopathies 5-10Hypercoagulable States 5-11Disorders of Leukocytes 5-12transfusion therapy 5-13Myelodysplastic Syndromes 5-14Myeloproliferative Neoplasms 5-15Leukemia 5-17Lymphoma 5-21Plasma Cell Dyscrasias 5-24Hematopoietic Stem Cell transplantation 5-26Lung Cancer 5-28breast Cancer 5-30Prostate Cancer 5-32Colorectal Cancer 5-33Chemotherapy Side Effects 5-34Pancreatic tumors 5-35oncologic Emergencies 5-36Cancer of Unknown Primary Site 5-37

INFectIoUS DISeASeSAna A. Weil, Emily P. Hyle, Nesli BasgozPneumonia 6-1Fungal Infections 6-3Infections in Immunosuppressed Hosts 6-4Urinary tract Infections 6-5Soft tissue and bone Infections 6-6Infections of the Nervous System 6-9bacterial Endocarditis 6-12tuberculosis 6-15HIV/AIDS 6-17tick-borne Diseases 6-20Fever Syndromes 6-22


eNDocRINoLoGYKelly B. Lauter, Marc N. Wein, Michael MannstadtPituitary Disorders 7-1thyroid Disorders 7-3Adrenal Disorders 7-7Calcium Disorders 7-11Diabetes Mellitus 7-13Lipid Disorders 7-16

RHeUMAtoLoGYZachary S. Wallace, Eli Miloslavsky, Robert P. FridayArthritis—overview 8-1Rheumatoid Arthritis 8-3Adult onset Still’s Disease & Relapsing Polychondritis 8-4Crystal Deposition Arthritides 8-5Seronegative Spondyloarthritis 8-7Infectious Arthritis & bursitis 8-9Connective tissue Diseases 8-11Systemic Lupus Erythematosus 8-15Vasculitis 8-17IgG4-Related Disease 8-20Cryoglobulinemia 8-21Amyloidosis 8-22

NeURoLoGYMichael P. Bowley, Todd M. Herrington, Eyal Y. Kimchi, Sarah Wahlster,

Tracey A. Cho Change in Mental Status 9-1Seizures 9-3Alcohol Withdrawal 9-5Stroke 9-6Weakness & Neuromuscular Dysfunction 9-8Headache 9-10back and Spinal Cord Disease 9-11

coNSULtSKiran H. Lagisetty, Jennifer F. Tseng, Katherine T. Chen, Stella K. Kim Surgical Issues 10-1ob/Gyn Issues 10-3ophthalmic Issues 10-4

APPeNDIXICU Medications & treatment of Hypotension/Shock 11-1Antibiotics 11-3Formulae and Quick Reference 11-4

ABBReVIAtIoNS 12-1

INDeX I-1

PHoto INSeRtSRadiology P-1Echocardiography & Coronary Angiography P-9Peripheral blood Smears & Leukemias P-13Urinalysis P-15

AcLS ACLS-1


CONTRIBUTING AUTHORSAndrew J. Aguirre, MD, PhDHematology-oncology Fellow, Dana-Farber/Partners CancerCare

Hematology/oncology Program

Andrew S. Allegretti, MDInternal Medicine Resident, Massachusetts General Hospital

Mark M. Awad, MD, PhDHematology-oncology Fellow, Dana-Farber/Partners CancerCare

Hematology/oncology Program

Ian J. Barbash, MDInternal Medicine Resident, Massachusetts General Hospital

Nesli Basgoz, MDAssociate Chief and Clinical Director, Infectious Disease Division,

Massachusetts General HospitalAssociate Professor of Medicine, Harvard Medical School

Hasan Bazari, MDClinical Director, Nephrology Unit, Massachusetts General HospitalProgram Director, Internal Medicine Residency, Massachusetts

General HospitalAssociate Professor of Medicine, Harvard Medical School

Michael P. Bowley, MD, PhDNeurology Resident, Partners Neurology Residency

Andrew M. Brunner, MDInternal Medicine Resident, Massachusetts General Hospital

Neal A. chatterjee, MDInternal Medicine Resident, Massachusetts General Hospital

katherine t. chen, MD, MPHAssociate Professor of obstetrics, Gynecology, and Reproductive ScienceAssociate Professor of Medical EducationVice-Chair of ob/Gyn Education, Career Development, and MentorshipIcahn School of Medicine at Mount Sinai, New York

tracey A. cho, MDAssociate Program Director, Partners-Harvard Neurology ResidencyAssistant Professor of Neurology, Harvard Medical SchoolAssistant Neurologist, Massachusetts General Hospital

Andrew S. de Lemos, MDtransplant Hepatology Fellow, Massachusetts General Hospital

Daniel J. DeAngelo, MD, PhDAdult Leukemia Program, Dana-Farber Cancer Institute & brigham

and Women’s HospitalAssociate Professor of Medicine, Harvard Medical School


David M. Dudzinski, MD, JDCardiology Fellow, Massachusetts General Hospital

Robert P. Friday, MD, PhDAttending Physician, Rheumatology Unit, Massachusetts General HospitalAssociate Director, Rheumatology Fellowship Program, Massachusetts

General HospitalInstructor in Medicine, Harvard Medical School

Lawrence S. Friedman, MDAnton R. Fried, MD, Chair, Department of Medicine, Newton-Wellesley

HospitalAssistant Chief of Medicine, Massachusetts General HospitalProfessor of Medicine, Harvard Medical SchoolProfessor of Medicine, tufts University School of Medicine

todd M. Herrington, MD, PhDNeurology Resident, Partners Neurology Residency

kathryn A. Hibbert, MDPulmonary and Critical Care Fellow, Harvard Medical School

William J. Hucker, MD, PhDCardiology Fellow, Massachusetts General Hospital

emily P. Hyle, MDAssistant in Medicine, Infectious Disease Division, Massachusetts

General HospitalInstructor in Medicine, Harvard Medical School

Sheheryar k. kabraji, BM, BchInternal Medicine Resident, Massachusetts General Hospital

Stella k. kim, MDDirector, Clinical Research in opthalmologyDirector, opthalmology Residency Rotation ProgramAssociate Professor of opthalmologyUt MD Anderson Cancer Center

eyal Y. kimchi, MD, PhD Neurology Resident, Partners Neurology Residency

kiran H. Lagisetty, MDSurgical Resident, beth Israel Deaconess Medical Center

kelly B. Lauter, MD, PhDInternal Medicine Resident, Massachusetts General Hospital

Andrew L. Lundquist, MDNephrology Fellow, bWH/MGH Joint Nephrology Fellowship Program

Atul Malhotra, MDAssociate Physician, Divisions of Pulmonary & Critical Care and Sleep

Medicine, brigham and Women’s HospitalAssociate Professor of Medicine, Harvard Medical School


Michael Mannstadt, MDAttending Physician, Endocrine Unit, Massachusetts General HospitalAssistant Professor of Medicine, Harvard Medical School

Eli Miloslavsky, MDRheumatology Fellow, Massachusetts General Hospital

Michelle O’Donoghue, MD, MPHInvestigator, TIMI Study Group and Associate Physician, Cardiovascular

Division, Brigham and Women’s HospitalAffiliate Physician, Cardiology Division, Massachusetts General HospitalAssistant Professor of Medicine, Harvard Medical School

David P. Ryan, MDClinical Director, Massachusetts General Hospital Cancer CenterChief of Hematology/Oncology, Massachusetts General HospitalAssociate Professor of Medicine, Harvard Medical School

Marc S. Sabatine, MD, MPHChairman, TIMI Study Group and Physician, Cardiovascular Division,

Brigham and Women’s HospitalAffiliate Physician, Cardiology Division, Massachusetts General HospitalAssociate Professor of Medicine, Harvard Medical School

Ada Stefanescu, MD, CM Internal Medicine Resident, Massachusetts General Hospital

Jennifer F. Tseng, MD, MPHChief, Division of Surgical Oncology, Beth Israel Deaconess Medical

CenterAssociate Professor of Surgery, Harvard Medical School

Sarah Wahlster, MDNeurology Resident, Partners Neurology Residency

Zachary S. Wallace, MDInternal Medicine Resident, Massachusetts General Hospital

Ana A. Weil, MD, MPHInternal Medicine Resident, Massachusetts General Hospital

Marc N. Wein, MD, PhDEndocrinology Fellow, Massachusetts General Hospital

Zachary A. Zator, MDInternal Medicine Resident, Massachusetts General Hospital


FOREWORD To the 1st Edition

It is with the greatest enthusiasm that I introduce Pocket Medicine. In an era of information glut, it will logically be asked, “Why another manual for medical 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 discussion that will follow the workup of the patient. this well-conceived hand-book should enhance the ability of every medical house officer to properly evalu-ate 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.

DenniS a. auSiello, MDPhysician-in-Chief, Massachusetts General Hospital

Jackson Professor of Clinical Medicine, Harvard Medical School


PREFACETo my parents, Matt and Lee Sabatine, to their namesake grandchildren Matteo and Natalie, and to my wife Jennifer

Written by residents, fellows and attendings, the mandate for Pocket Medicine was to provide, in a concise a manner as possible, the key information a clini-cian needs for the initial 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 fifth edition come several major improvements including a thorough updating of every topic, the addition of several new topics (including treatment of anaphylaxis, approach to inpatient nutritional issues, chemotherapy side effects, and workup of a fever in a recent traveler), and inclusion of additional photomicrographs. We have also added a new section on Consults in which non-internal medicine specialists provide expert guidance in terms of establishing a differential diagnosis for common presenting symptoms and initiating an evaluation in anticipation of calling a consult. 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.

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 judge-ment must be applied to every scenario.

I 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 knowl-edgeable, dedicated, and compassionate group of physicians. I always look back on my time there as Chief Resident as one of the best experiences I have ever had. I am grateful to several outstanding clinical mentors, including Hasan bazari, Larry Friedman, Nesli basgoz, Mort Swartz, Eric Isselbacher, bill Dec, Mike Fifer, and Roman DeSanctis, as well as the late Charlie McCabe and Peter Yurchak.

this edition would not have been possible without the help of two individuals in the tIMI Study Group Chairman’s office. Melinda Cuerda, my academic coordina-tor, was an invaluable resource for this edition. She 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. Pamela Melhorn, my executive assistant, expertly manages the Chairman’s office, miraculously coordinating the complex clinical, research, and educational missions.

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.

Marc S. Sabatine, MD, MPH


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