Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine (2 page)

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 Women’s Hospital Associate Professor of Medicine, Harvard Medical School

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 Women’s Hospital Associate Professor of Medicine, Harvard Medical School

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 O’Donoghue, MD, MPH

Investigator, TIMI Study Group and Associate Physician, Cardiovascular Division, Brigham and Women’s 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 Women’s 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

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 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.

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

PREFACE

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 Chairman’s 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 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

ELECTROCARDIOGRAPHY

Approach (
a systematic approach is vital
)

•
Rate
(? tachy, brady) and
rhythm
(? relationship between P and QRS)

•
Intervals
(PR, QRS, QT) and
axis
(? LAD or RAD)

•
Chamber abnormality
(? LAA and/or RAA, ? LVH and/or RVH)

•
QRST changes
(? Q waves, poor R-wave progression V
₁
–V
₆
, ST ↑/↓ or T-wave Δs)

Figure 1-1 
QRS axis

Left axis deviation (LAD)

•
Definition
: axis beyond –30° (S > R in lead II)

•
Etiologies
: LVH, LBBB, inferior MI, WPW

•
Left anterior fascicular block
: LAD (–45 to –90°)
and
qR in aVL
and
QRS <120 msec
and
no other cause of LAD (eg, IMI)

Right axis deviation (RAD)

•
Definition
: axis beyond +90° (S > R in lead I)

•
Etiologies
: RVH, PE, COPD (usually not > +110°), septal defects, lateral MI, WPW

•
Left posterior fascicular block
: RAD (90–180°)
and
rS in I & aVL
and
qR in III & aVF
and
QRS <120 msec
and
no other cause of RAD