Pocket

N ot e b o o k

Pocket
Medicine
Fifth Edition

Edited by
Marc S. Sabatine, MD, MPH
Associate Professor of Medicine
Harvard Medical School

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The Massachusetts General Hospital

Handbook of Internal Medicine

14/05/13 6:52 PM

Executive Editor: Rebecca Gaertner

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Printed in China
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 MedicineHandbooks. 2. Clinical MedicineHandbooks. WB 39]
RC55
616dc23

2013019655
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CONTENTS
Contributing Authors

Foreword
Preface

vi
ix

CARDIOLOGY
Neal A. Chatterjee, Ada Stefanescu, William J. Hucker, David M. Dudzinski,
Marc S. Sabatine, Michelle ODonoghue
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
Intracardiac Devices
Cardiac Risk Assessment for Noncardiac Surgery
Peripheral Artery Disease

1-1
1-3
1-4
1-5
1-6
1-12
1-14
1-17
1-20
1-25
1-28
1-30
1-31
1-32
1-35
1-37
1-39
1-40
1-41

PULMONARY
Ian J. Barbash, Kathryn A. Hibbert, Atul Malhotra
Dyspnea
Pulmonary Function Tests
Asthma
Anaphylaxis
Chronic Obstructive Pulmonary Disease
Hemoptysis
Bronchiectasis
Solitary Pulmonary Nodule
Obstructive Sleep Apnea
Interstitial Lung Disease
Pleural Effusion
Venous Thromboembolism
Pulmonary Hypertension
Respiratory Failure
Mechanical Ventilation
Acute Respiratory Distress Syndrome
Sepsis

2-1
2-1
2-2
2-4
2-5
2-7
2-7
2-8
2-8
2-9
2-11
2-13
2-16
2-18
2-19
2-22
2-23

GASTROENTEROLOGY
Zachary A. Zator, Andrew S. de Lemos, Lawrence S. Friedman
Esophageal and Gastric Disorders
Gastrointestinal Bleeding
Diarrhea, Constipation and Ileus
Diverticular Disease
Inflammatory Bowel Disease
Intestinal Ischemia

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3-1
3-3
3-5
3-9
3-10
3-12

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Pancreatitis
Abnormal Liver Tests
Hepatitis
Acute Liver Failure
Cirrhosis
Hepatic Vascular Disease
Ascites
Biliary Tract Disease

3-13
3-15
3-17
3-20
3-21
3-25
3-26
3-27

NEPHROLOGY
Andrew S. Allegretti, Andrew L. Lundquist, Hasan Bazari
Acid-Base Disturbances
Sodium and Water Homeostasis
Potassium Homeostasis
Renal Failure
Glomerular Disease
Urinalysis
Nephrolithiasis

4-1
4-6
4-10
4-12
4-16
4-18
4-19

HEMATOLOGY-ONCOLOGY
Andrew M. Brunner, Sheheryar K. Kabraji, Mark M. Awad, Andrew J. Aguirre,
Daniel J. DeAngelo, David P. Ryan
Anemia
Disorders of Hemostasis
Platelet Disorders
Coagulopathies
Hypercoagulable States
Disorders of Leukocytes
Transfusion Therapy
Myelodysplastic Syndromes
Myeloproliferative Neoplasms
Leukemia
Lymphoma
Plasma Cell Dyscrasias
Hematopoietic Stem Cell Transplantation
Lung Cancer
Breast Cancer
Prostate Cancer
Colorectal Cancer
Chemotherapy Side Effects
Pancreatic Tumors
Oncologic Emergencies
Cancer of Unknown Primary Site

5-1
5-6
5-7
5-10
5-11
5-12
5-13
5-14
5-15
5-17
5-21
5-24
5-26
5-28
5-30
5-32
5-33
5-34
5-35
5-36
5-37

INFECTIOUS DISEASES
Ana A. Weil, Emily P. Hyle, Nesli Basgoz
Pneumonia
Fungal Infections
Infections in Immunosuppressed Hosts
Urinary Tract Infections
Soft Tissue and Bone Infections
Infections of the Nervous System
Bacterial Endocarditis
Tuberculosis
HIV/AIDS
Tick-Borne Diseases
Fever Syndromes

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6-1
6-3
6-4
6-5
6-6
6-9
6-12
6-15
6-17
6-20
6-22

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ENDOCRINOLOGY
Kelly B. Lauter, Marc N. Wein, Michael Mannstadt
Pituitary Disorders
Thyroid Disorders
Adrenal Disorders
Calcium Disorders
Diabetes Mellitus
Lipid Disorders

7-1
7-3
7-7
7-11
7-13
7-16

RHEUMATOLOGY
Zachary S. Wallace, Eli Miloslavsky, Robert P. Friday
ArthritisOverview
Rheumatoid Arthritis
Adult Onset Stills Disease & Relapsing Polychondritis
Crystal Deposition Arthritides
Seronegative Spondyloarthritis
Infectious Arthritis & Bursitis
Connective Tissue Diseases
Systemic Lupus Erythematosus
Vasculitis
IgG4-Related Disease
Cryoglobulinemia
Amyloidosis

8-1
8-3
8-4
8-5
8-7
8-9
8-11
8-15
8-17
8-20
8-21
8-22

NEUROLOGY
Michael P. Bowley, Todd M. Herrington, Eyal Y. Kimchi, Sarah Wahlster,
Tracey A. Cho
Change in Mental Status
Seizures
Alcohol Withdrawal
Stroke
Weakness & Neuromuscular Dysfunction
Headache
Back and Spinal Cord Disease

9-1
9-3
9-5
9-6
9-8
9-10
9-11

CONSULTS
Kiran H. Lagisetty, Jennifer F. Tseng, Katherine T. Chen, Stella K. Kim
Surgical Issues
Ob/Gyn Issues
Ophthalmic Issues

10-1
10-3
10-4

APPENDIX
ICU Medications & Treatment of Hypotension/Shock
Antibiotics
Formulae and Quick Reference

11-1
11-3
11-4

ABBREVIATIONS

12-1

INDEX

I-1

PHOTO INSERTS
Radiology
Echocardiography & Coronary Angiography
Peripheral Blood Smears & Leukemias
Urinalysis

ACLS

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P-1
P-9
P-13
P-15
ACLS-1

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CONTRIB U T I N G A U T H O R S
Andrew J. Aguirre, MD, PhD
Hematology-Oncology Fellow, Dana-Farber/Partners CancerCare
Hematology/Oncology Program
Andrew S. Allegretti, MD
Internal Medicine Resident, Massachusetts General Hospital
Mark M. Awad, MD, PhD
Hematology-Oncology Fellow, Dana-Farber/Partners CancerCare
Hematology/Oncology Program
Ian J. Barbash, MD
Internal Medicine Resident, Massachusetts General Hospital
Nesli Basgoz, MD
Associate Chief and Clinical Director, Infectious Disease Division,
Massachusetts General Hospital
Associate Professor of Medicine, Harvard Medical School
Hasan Bazari, MD
Clinical Director, Nephrology Unit, Massachusetts General Hospital
Program Director, Internal Medicine Residency, Massachusetts
General Hospital
Associate Professor of Medicine, Harvard Medical School
Michael P. Bowley, MD, PhD
Neurology Resident, Partners Neurology Residency
Andrew M. Brunner, MD
Internal Medicine Resident, Massachusetts General Hospital
Neal A. Chatterjee, MD
Internal Medicine Resident, Massachusetts General Hospital
Katherine T. Chen, MD, MPH
Associate Professor of Obstetrics, Gynecology, and Reproductive Science
Associate Professor of Medical Education
Vice-Chair of Ob/Gyn Education, Career Development, and Mentorship
Icahn School of Medicine at Mount Sinai, New York
Tracey A. Cho, MD
Associate Program Director, Partners-Harvard Neurology Residency
Assistant Professor of Neurology, Harvard Medical School
Assistant Neurologist, Massachusetts General Hospital
Andrew S. de Lemos, MD
Transplant Hepatology Fellow, Massachusetts General Hospital
Daniel J. DeAngelo, MD, PhD
Adult Leukemia Program, Dana-Farber Cancer Institute & Brigham
and Womens Hospital
Associate Professor of Medicine, Harvard Medical School

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David M. Dudzinski, MD, JD

Cardiology Fellow, Massachusetts General Hospital
Robert P. Friday, MD, PhD
Attending Physician, Rheumatology Unit, Massachusetts General Hospital
Associate Director, Rheumatology Fellowship Program, Massachusetts
General Hospital
Instructor in Medicine, Harvard Medical School
Lawrence S. Friedman, MD
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
Todd M. Herrington, MD, PhD
Neurology Resident, Partners Neurology Residency
Kathryn A. Hibbert, MD
Pulmonary and Critical Care Fellow, Harvard Medical School
William J. Hucker, MD, PhD
Cardiology Fellow, Massachusetts General Hospital
Emily P. Hyle, MD
Assistant in Medicine, Infectious Disease Division, Massachusetts
General Hospital
Instructor in Medicine, Harvard Medical School
Sheheryar K. Kabraji, BM, BCh
Internal Medicine Resident, Massachusetts General Hospital
Stella K. Kim, MD
Director, Clinical Research in Opthalmology
Director, Opthalmology Residency Rotation Program
Associate Professor of Opthalmology
UT MD Anderson Cancer Center
Eyal Y. Kimchi, MD, PhD
Neurology Resident, Partners Neurology Residency
Kiran H. Lagisetty, MD
Surgical Resident, Beth Israel Deaconess Medical Center
Kelly B. Lauter, MD, PhD
Internal Medicine Resident, Massachusetts General Hospital
Andrew L. Lundquist, MD
Nephrology Fellow, BWH/MGH Joint Nephrology Fellowship Program
Atul Malhotra, MD
Associate Physician, Divisions of Pulmonary & Critical Care and Sleep
Medicine, Brigham and Womens Hospital
Associate Professor of Medicine, Harvard Medical School

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Michael Mannstadt, MD
Attending Physician, Endocrine Unit, Massachusetts General Hospital
Assistant Professor of Medicine, Harvard Medical School
Eli Miloslavsky, MD
Rheumatology Fellow, Massachusetts General Hospital
Michelle ODonoghue, MD, MPH
Investigator, TIMI Study Group and Associate Physician, Cardiovascular
Division, Brigham and Womens Hospital
Affiliate Physician, Cardiology Division, Massachusetts General Hospital
Assistant Professor of Medicine, Harvard Medical School
David P. Ryan, MD
Clinical Director, Massachusetts General Hospital Cancer Center
Chief of Hematology/Oncology, Massachusetts General Hospital
Associate Professor of Medicine, Harvard Medical School
Marc S. Sabatine, MD, MPH
Chairman, TIMI Study Group and Physician, Cardiovascular Division,
Brigham and Womens Hospital
Affiliate Physician, Cardiology Division, Massachusetts General Hospital
Associate Professor of Medicine, Harvard Medical School
Ada Stefanescu, MD, CM
Internal Medicine Resident, Massachusetts General Hospital
Jennifer F. Tseng, MD, MPH
Chief, Division of Surgical Oncology, Beth Israel Deaconess Medical
Center
Associate Professor of Surgery, Harvard Medical School
Sarah Wahlster, MD
Neurology Resident, Partners Neurology Residency
Zachary S. Wallace, MD
Internal Medicine Resident, Massachusetts General Hospital
Ana A. Weil, MD, MPH
Internal Medicine Resident, Massachusetts General Hospital
Marc N. Wein, MD, PhD
Endocrinology Fellow, Massachusetts General Hospital
Zachary A. Zator, MD
Internal Medicine Resident, Massachusetts General Hospital

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F O R E WO R D
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 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.

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Dennis A. Ausiello, MD
Physician-in-Chief, Massachusetts General Hospital
Jackson Professor of Clinical Medicine, Harvard Medical School

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P R E FA C E
To 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 clinician 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 judgement 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 knowledgeable, 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 Chairmans Office. Melinda Cuerda, my academic coordinator, 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 Chairmans 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.

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Marc S. Sabatine, MD, MPH

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