INTERNAL MEDICINE Just the Facts pptx

Perry MD, MS, MACP Professor of Internal MedicineDirector, Division of Hematology and MedicalOncology Department of Internal Medicine Ellis Fischel Cancer Center University of Missouri—C

Trang 2

INTERNAL MEDICINE

Just the Facts

Trang 3

Medicine is an ever-changing science As new research and clinical experience broaden our knowledge, changes in ment and drug therapy are required The authors and the publisher of this work have checked with sources believed to

treat-be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted atthe time of publication However, in view of the possibility of human error or changes in medical sciences, neither theauthors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrantsthat the information contained herein is in every respect accurate or complete, and they disclaim all responsibility forany errors or omissions or for the results obtained from use of the information contained in this work Readers areencouraged to confirm the information contained herein with other sources For example and in particular, readers areadvised to check the product information sheet included in the package of each drug they plan to administer to be certainthat the information contained in this work is accurate and that changes have not been made in the recommended dose

or in the contraindications for administration This recommendation is of particular importance in connection with new

or infrequently used drugs

Trang 4

Paul G Schmitz, MD, FACP

Professor of Internal Medicine Saint Louis University School of Medicine Department of Internal Medicine

St Louis, Missouri

Associate Editor

Kevin J Martin, MB, BCh, FACP

Professor of Internal Medicine Saint Louis University School of Medicine Director, Division of Nephrology

Trang 5

The material in this eBook also appears in the print version of this title: 0-07-146887-0.

All trademarks are trademarks of their respective owners Rather than put a trademark symbol after every occurrence of a trademarked name, we use names

in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark Where such designations appear

in this book, they have been printed with initial caps

McGraw-Hill eBooks are available at special quantity discounts to use as premiums and sales promotions, or for use in corporate training programs For more information, please contact George Hoare, Special Sales, at george_hoare@mcgraw-hill.com or (212) 904-4069

TERMS OF USE

This is a copyrighted work and The McGraw-Hill Companies, Inc (“McGraw-Hill”) and its licensors reserve all rights in and to the work Use of this work

is subject to these terms Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not pile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill’s prior consent You may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited Your right to use the work may be terminated if you fail to comply with these terms

decom-THE WORK IS PROVIDED “AS IS.” McGRAW-HILL AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO decom-THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE McGraw-Hill and its licensors do not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free Neither McGraw-Hill nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom McGraw-Hill has no responsibility for the content

of any information accessed through the work Under no circumstances shall McGraw-Hill and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise

DOI: 10.1036/0071468870

Trang 6

We hope you enjoy this McGraw-Hill eBook! If you’d like more information about this book, its author, or related books and websites,

please click here.

Want to learn more?

Trang 7

And to our patients,

whom we have been given the privilege of caring for

Trang 8

Gina L Michael, Margaret C Hochreiter,

Section 2

ASSESSING THE MEDICAL LITERATURE

Trang 9

12 Overview to Inferential Statistics: Estimation and Hypothesis Testing

16 Geriatric Syndromes: The “I’s” of Geriatrics

22 Depression in the Elderly

Section 4

ALLERGY AND IMMUNOLOGY

Section 5

CARDIOVASCULAR MEDICINE

Trang 10

36 Chronic Coronary Artery Disease

43 Aortic and Peripheral Vessel Disease

45 Congenital Heart Disease in the Adult

Section 6

ENDOCRINOLOGY AND METABOLISM

47 Disorders of the Pituitary Gland

GASTROENTEROLOGY AND LIVER DISEASE

Trang 11

Section 8

HEMATOLOGY

Krishnamohan R Basarakodu, Stephen L Graziano, Scott W McGee, Rajesh R Nair, Michael C Perry,

Trang 12

81 Sarcomas Nancy F McKinney 492

Long-Term Survivors of Cancer Treatment

Section 10

INFECTIOUS DISEASE

87 Respiratory Tract Infections

91 Genitourinary Tract Infections

92 Skin and Soft Tissue Infections

93 Bone and Joint Infections

94 Sexually Transmitted Infections

Immunodeficiency Syndrome

Musab U Saeed, Mary Abigail C Dacuycuy,

99 Rickettsiosis and Ehrlichioses

Trang 13

Section 12

PSYCHIATRIC DISORDERS

Section 13

PULMONARY MEDICINE AND CRITICAL CARE

Joseph Roland D Espiritu and

113 Interstitial Lung Disease

Trang 14

Section 14

NEPHROLOGY AND HYPERTENSION

119 Fluid, Electrolyte, and Acid-Base Disorders

Trang 15

Saint Louis University School of Medicine

Department of Internal Medicine Saint Louis University School of Medicine

St Louis, Missouri

Trang 16

Terry L Moore, MD

Professor of Internal Medicine, Pediatrics, andMolecular Microbiology and ImmunologyDirector, Division of Rheumatology andPediatric Rheumatology

St Louis VA Medical Center Saint Louis University School of Medicine

St Louis, Missouri

Interdisciplinary Medicine

Thomas J Olsen, MD, FACP

Professor of Internal Medicine Division of General Internal Medicine Department of Internal Medicine Saint Louis University School of Medicine

St Louis, Missouri

Hematology and Oncology

Michael C Perry MD, MS, MACP

Professor of Internal MedicineDirector, Division of Hematology and MedicalOncology

Department of Internal Medicine Ellis Fischel Cancer Center University of Missouri—Columbia School

of MedicineColumbia, Missouri

Nephrology and Hypertension

Paul G Schmitz, MD, FACP

Professor of Internal Medicine Saint Louis University School of Medicine Department of Internal Medicine

Trang 17

Mona Bahl, MD

Assistant Professor of Internal Medicine Division of General Internal Medicine Department of Internal Medicine Saint Louis University School of Medicine

St Louis, Missouri(Chapter 8)

Krishnamohan R Basarakodu, MD

Fellow in Hematology and Medical Oncology Division of Hematology and Medical Oncology Department of Internal Medicine

Ellis Fischel Cancer Center Columbia School of Medicine University of Missouri—Columbia School

of MedicineColumbia, Missouri(Chapters 60, 66, 67)

Bahar Bastani, MD

Professor of Internal Medicine Division of Nephrology Department of Internal Medicine Saint Louis University School of Medicine

St Louis, Missouri(Chapters 122, 124)

xvii

Trang 18

Thomas E Burroughs, PhD

Associate Professor of Internal Medicineand Health Management & Policy Executive Director, Saint Louis UniversityCenter for Outcomes Research

St Louis, Missouri(Chapters 10–14)

Jeffrey Ciaramita, MD

Fellow in CardiologyDivision of Cardiology Department of Internal Medicine Saint Louis University School of Medicine

Mary Abigail C Dacuycuy, MD

Fellow in Infectious Diseases Division of Infectious Diseases Department of Internal Medicine Saint Louis University School of Medicine

St Louis, Missouri(Chapters 88, 89, 91, 92, 94, 96, 97–99)

Patricia A Dettenmeier, ANP, MSN

Assistant Professor of Internal Medicine Division of Pulmonary, Critical Care, and SleepMedicine

Adrian M Di Bisceglie, MD

Professor of Internal Medicine Division of Gastroenterology and Hepatology Department of Internal Medicine

James Drake, MD

Mark S Dykewicz, MD

Professor of Internal Medicine Division of Allergy and Clinical Immunology Department of Internal Medicine

St Louis, Missouri(Chapters 23, 27, 28)

Joseph Roland D Espiritu, MD

Kevin Fitzgerald, MD

Fellow in Cardiology Division of Cardiology Department of Internal Medicine Saint Louis University School of Medicine

Trang 19

Daniel Friedman, MD

Fellow in Cardiology

Division of Cardiology

Department of Internal Medicine

St Louis, Missouri

(Chapter 32)

Julie Gammack, MD

Assistant Professor of Internal Medicine

Division of Geriatric Medicine

Geriatric Research, Education and Clinical

Center

St Louis VA Medical Center

Department of Neurology and Psychiatry

St Louis, Missouri

(Chapter 107)

Ramaswamy Govindan, MD

Associate Professor of Internal Medicine

Division of Medical Oncology

Alvin J Siteman Cancer Center

Washington University School of Medicine

St Louis, Missouri

(Chapter 77)

Stephen L Graziano, MD

Professor of Medicine

Regional Oncology Center

Upstate Medical University

State University of New York

Syracuse, New York

George T Grossberg, MD

Samuel W Fordyce Professor Division of Psychiatry Department of Neurology and Psychiatry Saint Louis University School of Medicine

St Louis, Missouri(Chapters 22, 108, 111)

Sahar Hachem, MD

Fellow in Endocrinology Division of Endocrinology Department of Internal Medicine Saint Louis University School of Medicine

Noah M Hahn, MD

Assistant Professor of Medicine Division of Hematology and Oncology Department of Medicine

Indiana University Cancer Center Indiana University School of Medicine Indianapolis, Indiana

(Chapter 79)

Matthew T Haren, PhD

Post Doc Fellow Division of Geriatric Medicine Department of Internal Medicine Geriatric Research, Education and ClinicalCenter

Ghazala Hayat, MD

Professor of Neurology Division of Neurology Department of Neurology and Psychiatry Saint Louis University School of Medicine

Trang 20

Robert M Heaney, MD

Professor of Internal Medicine Associate Dean, Graduate Medical Education Division of General Internal Medicine Department of Internal MedicineSaint Louis University School of Medicine

Steven C Herrmann, MD, PhD

Adjunct Assistant Professor Department of Pharmacological andPhysiological Science

St Louis, Missouri Director of Cardiovascular Services Bradford Regional Medical Center Bradford, Pennsylvania

(Chapter 29)

Margaret Hochreiter, MD, PhD

Associate Professor of Internal Medicine Division of General Internal Medicine Department of Internal Medicine Saint Louis University School of Medicine

Christopher N Hueser, DO, MS

Fellow in Hematology and Oncology Division of Hematology and Oncology Department of Internal Medicine Saint Louis University School of Medicine

Syed Huq, MD, MS

Columbia School of Medicine University of Missouri—Columbia School

of MedicineColumbia, Missouri(Chapter 72)

Catherine Iasiello, MD

Sundeep Jayaprabhu, MD

Resident in Psychiatry Division of Neurology Department of Neurology and Psychiatry Saint Louis University School of Medicine

Seema Joshi, MD

Fellow in Geriatric Medicine Division of Geriatric Medicine Department of Internal Medicine Saint Louis University School of Medicine

Jeffrey Kao, MD

Resident in PsychiatryDivision of PsychiatryDepartment of Neurology and PsychiatrySaint Louis University School of Medicine

St Louis Missouri(Chapter 111)

Donald J Kennedy, MD

Professor of Internal Medicine Division of Infectious Diseases Department of Internal Medicine Saint Louis University School of Medicine

C Daniel Kingsley, MD

of MedicineColumbia, Missouri(Chapters 61, 82, 83)

Ganesh C Kudva, MD, MRCP (UK)

Assistant Professor of Internal Medicine Division of Hematology and Oncology Department of Internal Medicine Saint Louis University School of Medicine

Trang 21

Stephen Kuehn, MD

Fellow in Cardiology

Division of Cardiology

St Louis, Missouri

(Chapter 39)

Bahaeldeen A Laz, MD

Staff Physician, St John’s Hospital

Columbia School of Medicine

University of Missouri—Columbia School

Kevin J Martin, MB, BCh, FACP

Professor of Internal Medicine Saint Louis University School of Medicine Director, Division of Nephrology

Deryk McDowell, MD

Fellow in Cardiology Department of Internal Medicine Saint Louis University School of Medicine

Scott W McGee, MD

of MedicineColumbia, Missouri(Chapters 60, 64)

Trang 22

Nancy F McKinney, MD

Ellis Fischel Cancer Center Columbia School of MedicineUniversity of Missouri—Columbia School

Gina L Michael, MD

Assistant Professor of Medicine Division of General Internal Medicine Department of Internal Medicine Saint Louis University School of Medicine

Peter Mikolajczak, MD

Fellow in CardiologyDivision of CardiologyDepartment of Internal Medicine Saint Louis University School of Medicine

Francis A Mithen, MD, PhD

Professor of Neurology Division of Neurology Department of Neurology and Psychiatry Saint Louis University School of Medicine

Terry L Moore, MD

Professor of Internal Medicine, Pediatrics, andMolecular Microbiology and ImmunologyDirector, Division of Rheumatology andPediatric Rheumatology

St Louis, Missouri (Chapters 130, 132)

John E Morley, MB, BCh

Professor of Internal Medicine Director, Division of Geriatric Medicine Geriatric Research, Education and ClinicalCenter

Joanne E Mortimer, MD

Professor of Medicine Deputy Director for Clinical Affairs Division of Hematology and Oncology Department of Internal Medicine Moores Cancer Center

University of California—San Diego School

of Medicine

La Jolla, California(Chapter 76)

Chinya Murali, MD

Staff Physician, Department of Psychiatry

Rajesh R Nair, MD

Ravi P Nayak, MD

Stacy Neff, DO

Resident in Psychiatry Division of Psychiatry Department of Neurology and Psychiatry Saint Louis University School of Medicine

Trang 23

Clinical Associate Professor of Medicine

Hebrew University Medical School

Jerusalem, Israel

Adjunct Professor

Division of Rheumatology

St Louis, Missouri

(Chapter 43)

Thomas J Olsen, MD, FACP

Professor of Internal Medicine

Division of General Internal Medicine

St Louis, Missouri

(Chapters 1, 7, 9)

M Louay Omran, MD

Division of Gastroenterology and Hepatology

St Louis, Missouri

(Chapter 53–56)

Wilman Ortega, MD

Division of Pulmonary, Critical Care, and Sleep

Medicine

(Chapter 131)

Rami Owera, MD

Peri Hickman Pepmueller, MD

Associate Professor of Internal Medicine andPediatrics

Division of Rheumatology Department of Internal Medicine Saint Louis University School of Medicine

Michael C Perry MD, MS, MACP

Professor of Internal Medicine and Director Division of Hematology and Medical Oncology Department of Internal Medicine

of MedicineColumbia, Missouri(Chapters 60, 73, 80, 84)

Marian Petrides, MD

Associate Professor of Clinical Pathology Medical Director, Transfusion Service andCoagulation Laboratory

Department of Pathology and AnatomicalSciences

Trang 24

Paul Petruska, MD

Professor of Internal Medicine Division of Hematology and Oncology Department of Internal Medicine Saint Louis University School of Medicine

Joseph Polizzi, MD

Fellow in Cardiology Division of Cardiology Department of Internal Medicine Saint Louis University School of Medicine

Nora L Porter, MD, MPH

Osama Qubaiah, MD

Arun Rajan, MD

Fellow in Hematology and Oncology Division of Hematology and Oncology Department of Medicine

Upstate Medical University State University of New York Syracuse, New York

(Chapter 60)

Hans-Joachim Reimers, MD, PhD, FAHA

Professor of Internal Medicine Division of Hematology and Oncology Department of Internal Medicine Saint Louis University School of Medicine

Timothy Rice, MD

Musab U Saeed, MD

Fellow in Infectious Diseases Division of Infectious Diseases Department of Internal Medicine Saint Louis University School of Medicine

St Louis, Missouri(Chapters 85–87, 90, 93, 95, 96, 100)

Huda Salman, MD

Assistant Professor of Internal Medicine Division of Hematology and Oncology Department of Internal Medicine Saint Louis University School of Medicine

Paul G Schmitz, MD, FACP

Professor of Internal MedicineSaint Louis University School of MedicineDepartment of Internal Medicine

Trang 25

Alan B Silverberg, MD

Professor of Internal Medicine

Division of Endocrinology

St Louis, Missouri

(Chapter 110)

Raymond G Slavin, MD, MS

Professor of Internal Medicine and Molecular

Microbiology and Immunology

Director, Division of Allergy and Immunology

St Louis, Missouri

(Chapters 24, 25, 26)

Richard E Stewart, MD

Associate Professor of Medicine

Division of Cardiovascular Medicine

University of North Texas Health Science

Center

Fort Worth, Texas

(Chapter 36)

Aaron Tang

Senior Medical Student

St Louis, Missouri

(Chapter 45)

Syed H Tariq, MD

Associate Professor of Internal Medicine

Division of Geriatric Medicine

Geriatric Research, Education and Clinical

Center

(Chapter 126)

David R Thomas, MD

Professor of Internal Medicine Division of Geriatric Medicine Department of Internal Medicine Saint Louis University School of Medicine

Florian P Thomas, MD, MA, PhD

Professor of Neurology and Psychiatry Associate Professor of Molecular Virology andMolecular Microbiology and Immunology Division of Neurology

Department of Neurology and Psychiatry Associate Chief of Staff, St Louis VA MedicalCenter

Sri Laxmi Valasareddi, MD

H Douglas Walden, MD, MPH

Trang 26

Allison P Wall, MD

Robert M Woolsey, MD

Professor of NeurologySaint Louis UniversityDirector, Spinal Cord Injury/DysfunctionService

Saint Louis VA Medical Center

Trang 27

“Just the facts, ma’am.” Stan Freburg’s parody of the police procedural drama

Dragnet is instantly recognizable five decades later, even to those who have

never seen or heard of the program Internal Medicine: Just the Facts is our

effort to provide the student, resident in training, and practicing clinician withobjective, practical information through a carefully structured format

Accordingly, this textbook reflects the core information that the busy tioner, medical student, or resident should master This text should prove espe-cially useful to healthcare providers preparing for certification andrecertification examinations The structured format necessarily lessens theemphasis on the underlying science of medicine, such as molecular biology,cell biology, and pathophysiology; however, the contributors were careful toinclude succinct discussions of these pertinent biological principles whereappropriate For an in-depth discussion of the biological basis of disease, theinterested reader is referred to standard comprehensive textbooks of internalmedicine One may rightfully think of this book as a high-yield clinical ren-dering of those standard textbooks

practi-This textbook covers the totality of internal medicine through 15 unique tions Each section was designed to maximize the acquisition of practical infor-mation involved in the everyday care of patients Sections 1 through 3 areintrinsically interdisciplinary in nature, and therefore should prove useful to allinvolved in delivering quality care The growth of evidence-based medicineprovided the stimulus for Section 2, which covers the basic principles vital tothe interpretation of the medical literature Section 3 is devoted exclusively tothe unique problems encountered in the older patient Sections 4 through 15,each expertly written and edited by leaders in the field, cover the subspecialtyareas that the practicing physician must comprehend The references for eachsection, while short in number, are designed to furnish the healthcare providerwith high-impact, evidence-based data or scholarly summaries of the clinicalproblems likely to be encountered in the practice setting With the proliferation

sec-of information available via the Internet, the authors were compelled to includeWeb site links, where appropriate The blueprint for the subspecialty sectionswas based on an exhaustive review of the medical literature, coupled withextensive feedback from academic faculty, primary care providers, residents,and medical students

Trang 28

We hope that you enjoy this focused, yet comprehensive approach to thestudy and practice of internal medicine To that end, we encourage you, thereader, to let us know what we have done right, and what we could improve on

in our commitment to creating an information resource that is useful to thebusy practitioner

Paul G SchmitzKevin J Martin

Trang 29

The editors wish to thank the many faculty, fellows, residents, and medical dents who generously contributed their suggestions and expertise to the chap-ters for this first edition Paul wishes to thank his family, Beth, Hannah, andZachary, for their unwavering support during the preparation of this manuscriptand their sublime tolerance of the chaotic nature of academia He also wishes

stu-to thank the many people who have contributed stu-to his growth as an educastu-torand academician, including Morris Davidman, William Keene, MichaelO’Donnell, Coy Fitch, and, importantly, his co-editor, Kevin Martin Manythanks to our colleagues at McGraw Hill, especially Jim Shanahan and PeterBoyle A special thanks to Diane Goebel for coordinating the overall processfrom our office in St Louis We appreciate her thoughtful attention to detailand willingness to frequently adjust her schedule to accommodate our updatesand changes

Trang 30

INTERNAL MEDICINE

Just the Facts

Trang 31

1 MEDICAL

PROFESSIONALISM

Thomas J Olsen

PHYSICIAN CHARTER

In February 2002, Medical Professionalism in the New

Millennium: A Physician Charter was published by the

European Federation of Internal Medicine, the American

College of Physicians, and the American Board of

Internal Medicine This Charter reaffirmed three

funda-mental and universal principles and values of medical

professionalism The Charter held these to be ideals that

should be pursued by all physicians and identified 10

commitments as professional responsibilities of the

physician

DEFINITION OF PROFESSION

A profession is an occupation based on mastery of a

complex body of knowledge and skills It is a vocation

in which the practice of an art is used in the service of

others Traditional professions include doctors,

teach-ers, lawyteach-ers, and members of the clergy Members of a

profession profess a commitment to competence,

integrity and morality, altruism, and promotion of the

common good These commitments form the basis of a

contract between the medical profession and society

Society grants the profession the right to autonomy in

practice and the privilege of self-regulation

A physician is a professional who has mastered special

knowledge and skills These include anatomy,

physiol-ogy, diagnosis, treatment, communication, coordination

of care, and knowledge of healthcare systems Some

believe that this knowledge is not proprietary and that

the profession holds this knowledge in trust for the good

of society The physician is granted special privileges

including interviewing, examining, and treating patients.Physicians probe the body, mind, and spirit of a patient.These special privileges also include prescription of nar-cotics and dangerous drugs and surgery Physicians havespecial responsibilities including placing the interests ofthe patient and society above their own, caring for thesick and suffering and regulating the behavior of themembers of the profession The American Board ofInternal Medicine defines medical professionalism asthose attributes and behaviors that serve to maintainpatient interest and welfare above physician self-interest.These include altruism, accountability, excellence, duty,service, honor, integrity, and respect for others

FUNDAMENTAL PRINCIPLES

PRIMACY OF PATIENT WELFARE

The medical profession commits to the education andtraining of a continuous supply of competent physi-cians Laws govern licensure and prescription of med-ications The profession oversees training, certification,accreditation, and hospital privileges Physicians arecommitted to beneficence and act in the best interest ofthe patient They promise nonmaleficence and protectpatients from harm The profession makes a commit-ment to its members and to society that it will developsystems to identify and treat impaired physicians

PATIENT AUTONOMY

Physicians demonstrate respect for individual autonomyand foster informed decision making through patienteducation Physicians recognize the autonomy of patients

to provide informed consent and informed refusal.Physicians should respect informed decisions made bypatients and families provided they are ethically soundand do not lead to demands for inappropriate care Truthtelling and confidentiality are fundamental tenets of medical

INTERDISCIPLINARY MEDICINE

1

Trang 32

care The physician respects the privacy of patients,

encourages them to seek medical care and discuss their

problems candidly and prevents discrimination on the

basis of their medical conditions

SOCIAL JUSTICE

Physicians must be committed to promoting equity in

healthcare including improving access to care and a just

distribution of finite resources Physicians must work to

eliminate discrimination of healthcare services based on

race, gender, socioeconomic status, sexual orientation,

ethnicity, or religion

PROFESSIONAL COMMITMENTS

The Physician Charter identified a set of “definitive

pro-fessional responsibilities.” These are commitments that

cross cultural, religious, and national borders These are

the means by which physicians provide for the care of

patients and meet the needs of the communities in

which they live and work

Professional competence

Honesty with patients

Patient confidentiality

Maintaining appropriate relations with patients

Improving quality of care

Improving access to care

Just distribution of finite resources

Scientific knowledge

Maintaining trust by managing conflict of interest

Professional responsibilities

Threats to professionalism

Some might ask why a profession that is thousands of

years old needs to be reminded of its fundamental

prin-ciples Threats to professionalism have come in the

form of commodification of healthcare, managed care,

and economic market forces, and emphasis on quantity

not quality of patient care In educational settings,

emphasis on service over learning and institutional

cul-ture can contribute Technologic advances challenge the

ability of the profession to appropriately integrate new

treatments in a cost effective and appropriate manner

Inequities in access to medical care affect both

individ-ual health and the health of society

Summary from the Charter on Medical Professionalism

The practice of medicine in the modern era is beset with

unprecedented challenges in virtually all cultures and

soci-eties These challenges center on increasing disparities among

the legitimate needs of patients, the available resources to

meet those needs, the increasing dependence on market forces

to transform healthcare systems, and the temptation for physicians to forsake their traditional commitment to the primacy of patients’ interests To maintain the fidelity of medicine’s social contract during this turbulent time, physicians must reaffirm their active dedication to the principles

of professionalism, which entails not only their personal commitment to the welfare of their patients but also collec- tive efforts to improve the healthcare system for the welfare

of society.

B IBLIOGRAPHY

American Board of Internal Medicine, American College of Physicians-American Society of Internal Medicine, European Federation of Internal Medicine Medical professionalism in

the new millennium: a physician charter Ann Intern Med.

2002;136(3):243–246.

Cruess RL, Creuss SR Teaching medicine as a profession in the

service of healing Acad Med 1997;72:941–952.

Pellegrino E, Thomasma D The Virtues in Medical Practice.

New York, NY: Oxford University Press; 1993:35.

Timothy Rice

“These people look, but they don’t see, and they hear, but they don’t understand.” Luke 8:10 (Contemporary English Version of the Bible)

• When examining the skin, the untrained eye can tify a rash without characterizing the salient features

iden-To illustrate this point, visualize your car dashboard

or the face of your wristwatch Without looking, sketch

as many details of each item as you can recall Whatare the numbers and interval on the speedometer?Does your dashboard have a tachometer and whatnumbers are on the tachometer or other gauges?Describe the numbers, intervals, and words on the face

of your watch These exercises illustrate the pitfalls ofthoroughly examining and describing the features of

an item (or skin finding) Accordingly, an accuratedescription of dermatologic findings requires practiceand patience By carefully examining the skin anddescribing the features of the lesions in detail the cli-nician will be prepared to render a plausible diagnosis,

or at the least communicate findings to an experiencedconsultant

Trang 33

PRIMARY SKIN LESIONS

• An understanding of terminology is essential to

accu-rately describe lesions and recognize morphology A list

of descriptive terms and examples of dermatologic

con-ditions that exhibit these findings is enumerated below:

䊊 Macule: Flat, <1-cm lesion with a color that differs

from the surrounding skin (eg, freckle, flat moles,

port-wine stains, rickettsial rash, rubella, measles,

vitiligo, tinea versicolor)

䊊 Patch: Flat >1-cm lesion with a color that differs

from the surrounding skin (eg, Café-au-lait)

䊊 Papule: Solid <1-cm raised lesion, such as a closed

comedone, or whitehead, in acne, warts, molluscum

contagiosum, psoriasis, syphilitic chancre, urticaria,

lichen planus, insect bites, contact dermatitis,

sebor-rheic keratoses, and actinic keratoses

䊊 Nodule: Solid 1- to 5-cm raised lesion (eg, dermal

nevus, xanthomas, epitheliomas, metastatic cancer)

䊊 Tumor: Solid, >5-cm raised lesion (eg, mycosis

fun-goides, small lipomas, fibromas, erythema nodosum,

larger epitheliomas)

䊊 Plaque: Raised, flat-topped >1-cm lesion (eg,

eczema-tous dermatitis, pityriasis rosea, tinea corporis,

psori-asis, seborrheic dermatitis, urticaria, condylomata

lata of secondary syphilis, gumma of tertiary syphilis,

erythema multiforme, lichen simplex chronicus)

䊊 Vesicle: Clear, fluid-filled <1-cm raised lesion; appearstranslucent (eg, allergic contact dermatitis, physicaltrauma, sunburn, thermal burn, herpes, varicella)

䊊 Bulla: Fluid-filled, >1-cm lesion; often translucent(eg, drug eruptions, pemphigus, dermatitis herpeti-formis, erythema multiforme, epidermolysis bul-losa, and bullous pemphigoid)

䊊 Pustule: Pus-filled lesion Importantly, there are manypustular lesions that are not infectious (eg, impetigo,acne, folliculitis, furuncles, carbuncles, deep fungalinfections, hidradenitis suppurativa, kerion, pustularmiliaria, and pustular psoriasis of the palms and soles)

䊊 Cyst: Soft, raised sack filled with semisolid or liquidmaterial (eg, acne, sebaceous cysts)

䊊 Wheal: Short-lived, raised, erythematous papule orplaque that migrates to adjacent areas over severalhours (eg, urticaria)

• Figure 2–1 schematically depicts several common mary skin lesions

pri-SECONDARY SKIN LESIONS

• Primary skin lesions can transform after secondarymanipulation (scratching) or as a result of superim-posed infection

䊊 Scale: Shedding of dead epidermal cells (eg, greasyscale-dandruff, dry scale; psoriasis, tinea versicolor,pityriasis rosea)

FIG 2–1 Schematic representation of several common primary skin lesions Reproduced with permission from Lawley TJ, Yancey KB: Approach

to the patient with a skin disorder In Kasper DL, Braunwald E, Fauci AS,

et al Harrison’s Principles of Internal Medicine 16th ed New York, NY:

b Blue

c Red

Trang 34

䊊 Lichenification: Thickening of the skin with

accen-tuated skin-fold markings (eg, atopic dermatitis,

lichen simplex chronicus) (Fig 2–2)

䊊 Crust: Dried exudate of body fluids—serous

(yellow) exudate or hemorrhagic (red) exudate (eg,

honey-colored crust is consistent with impetigo;

crusts are also seen in scabies, pediculosis, or

creep-ing eruption)

䊊 Erosion: Loss of the epidermis without loss of the

dermis Erosions heal without scarring (eg, herpes

virus lesions and pemphigus)

䊊 Ulcer: Extension into the dermis which promotes

scarring (eg, chancre of primary syphilis, tertiary

syphilis, stasis ulcers)

䊊 Excoriation: Scratching that produces linear,

angular erosions (eg, scratched insect

bites—sca-bies)

䊊 Atrophy: Loss of dermal or subcutaneous tissue

pro-duces a skin depression with an intact epidermis

Loss of epidermal tissue produces a shiny, delicate,

wrinkled area of the skin

䊊 Scar: Fibrous change in the skin caused by trauma

or inflammation Scaring in hair-bearing areas

pro-duce hair loss Scars may be erythematous,

hypopigmented, or hypertrophic

䊊 Pruritus: Sensation on the skin that induces

scratch-ing (eg, atopic dermatitis, allergic contact

dermati-tis, xerosis, and aged skin) Systemic conditions

associated with pruritus, without skin lesions

include uremia, cholestasis, pregnancy, malignancy,

polycythemia vera, hyperthyroidism, diabetes

melli-tus, and psychogenic

䊊 Fissure: Deep, sharp skin break (eg, tinea pedis,

congenital syphilis)

SPECIAL SKIN LESIONS

• Milia: 1-mm, firm, white papules filled with keratin(eg, may occur in newborns or in areas of trauma orinflammation)

• Telangiectasia: Small, superficial, dilated vessels (eg,rosacea, scleroderma, long-term topical steroid use,ataxia-telangiectasia, hereditary hemorrhagic telang-iectasia, basal cell carcinoma)

• Spider angioma: Red, central punctate arteriole withtelangiectatic network of dilated capillaries radiatingfrom the center On pressure, the lesion disappearsand with release of pressure the radiating capillariesfill from the center punctuate arteriole out This lesionhas been described in cirrhosis, hyperestrogenic states(pregnancy), and after oral contraceptive use

• Burrows: Tunnels in the epidermis (eg, small, shortburrows—scabies; or tortuous, long burrows—creep-ing eruption from hook worm infection)

• Comedone or blackhead: Small, flesh-colored, white,

or dark (blackhead) bumps at the opening of a ceous follicle (pore) (eg, acne)

seba-DISEASES ASSOCIATED WITH A COMBINATION OF PRIMARY AND SECONDARY SKIN FINDINGS

SCALING PAPULAR DISEASES ORPAPULOSQUAMOUS DISEASES

• These lesions are characterized by sharp margins with

no signs of epithelial disruption Papulosquamouslesions are dry without crusts, fissures, or excoriation.These lesions can be the manifestation of a primaryskin condition or can represent the dermatologicalmanifestations of systemic disease The primary papu-losquamous diseases include:

䊊 Tinea

䊊 Psoriasis

䊊 Pityriasis rosea

䊊 Lichen planus

䊊 Pityriasis rubra pilaris

• Systemic diseases that are associated with mous lesions include:

FIG 2–2 Lichenification Thickening of the skin with

accentu-ated skin-fold markings in a patient with atopic dermatitis Photo

by Timothy Rice.

Trang 35

䊊 Pediculosis

䊊 Creeping eruption from hook worm infection

COMMON BENIGN SKIN TUMORS

• Acrochordon (skin tag): Fleshy, brown, tan or skin

colored pedunculated skin polyp

• Cherry angioma: This is a blood-filled papule

• Dermatofibroma: This is a firm red to brown nodule

that produces a depression or dimple with lateral

com-pression by the thumb and index finger.

• Epidermal cyst: An epidermal cyst arises when a hair

follicle is obstructed with keratin and lipid-rich

debris This is the most common cutaneous cyst

• Seborrheic keratosis: Seborrheic keratosis lesions

are described as stuck on brown papules or plaques

with a greasy texture They are the most common of

the benign epithelial tumors These hereditary

lesions do not appear until after age 30 New

tumors continue to appear throughout the patient’s

lifetime

• Lipoma: Soft, rounded tumor that is well-defined andeasily movable both against the overlying skin and theunderlying structures Lipomas are the most commonsubcutaneous tumors

ALGORITHM FOR EVALUATING SKIN LESIONS

An algorithm for evaluating skin lesions based on tion is depicted in Fig 2–3

loca-SKIN DISEASES BY LOCATION

The distribution of some common dermatologic eases and lesions are depicted in Fig 2–4

• Bowen disease

• Superficial spreading melanoma

Ulcer

• Basal cell carcinoma

• Diabetic ulcer

• Primary chancre of syphilis

Nodular

• Metastatic cancer

Nodular

• Metastatic melanoma

• Lipomas

Pustular

• Pustular psoriasis

FIG 2–3 Algorithm for evaluating skin lesions

Reproduced with permission from Wolff K, Johnson RA, Suurmond D Fitzpatrick’s Color Atlas and Synopsis of

Clinical Dermatology 5th ed New York, NY: McGraw-Hill; 2001.

Trang 36

Pityriasis

rosea

Herpes zoster

Lichen

planus

Psoriasis Psoriasis Folliculitis Dyshidrotic eczema

Verruca plana

Tinea pedis

A

Keratosis pilaris

Verrucae vulgaris

Asteatotic eczema

Lichen simplex chronicus

Skin tags

Seborrheic keratoses Senile angioma Atopic dermatitis

Tinea or Candida cruris Actinic keratoses

Psoriasis

Dermatofibroma

Stasis ulcer Stasis dermatitis Tinea pedis

B

Herpes labialis

Lichen planus

Aphthous stomatitis

Geographic tongue

Leukoplakia Squamous cell carcinoma Oral hairy leukoplakia

Seborrheic dermatitis

Acne rosacea Xanthelasma

Seborrheic dermatitis

Perleche Acne vulgaris

C

FIG 2–4 The distribution of some common dermatologic diseases and lesions Reproduced with permission from Lawley TJ, Yancey KB:

Approach to the patient with a skin disorder In: Kasper DL, Braunwald E, Fauci AS, et al Harrison’s Principles of Internal Medicine.

16th ed New York, NY: McGraw-Hill; 2004.

Trang 37

䊊 Id reaction from tinea pedis

䊊 Secondary syphilis (soles)

• Photo/sun exposure distribution

䊊 Phototoxic dermatitis

䡲 Plants containing a furocoumarin (limes, parsley,

celery, bishop’s weed, and figs)

䡲 Drugs include thiazides, sulfonylureas,

sulfon-amides, tetracyclines, phenothiazines, psoralens,

nalidixic acid, and nonsteroidal anti-inflammatory

drugs

䊊 Photoallergic reactions

䡲 Thiazides and benzocaine

䊊 Metabolic disorders

䡲 Porphyria cutanea tarda

䊊 Polymorphous light eruption

䊊 Solar urticaria

䊊 Dermatomyositis

䊊 Porphyria cutanea tarda

䊊 Systemic lupus erythematosus

SEASONAL DERMATOLOGIC DISEASES

• The following are conditions that occur with seasonal

䡲 Contact dermatitis caused by poison ivy, insect

bites, and tinea versicolor (apparent increased

intensity is sometimes noted because the

sur-rounding skin may be tanned)

䊊 Fall

䡲 Atopic dermatitis, contact dermatitis caused by

ragweed and pityriasis rosea

䊊 Day of the week variation

• Wednesday tends to be the day that patients present

with contact dermatitis due to poison ivy These

patients are exposed while working in the yard or

garden on Saturday or Sunday The rash usually

appears after 24 to 48 hours

SKIN FINDINGS IN AILING PATIENTS

• Fever associated with a rash

䊊 Generalized red rash

䡲 Drug eruptions

䡲 Viral exanthems

䡲 Rickettsial exanthems

䡲 Bacterial infections with toxin production

• Staphylococcal scalded skin syndrome (SSSS)

• Staphylococcal toxic shock syndrome (TSS)

• Staphylococcal food poisoning (enterotoxin)

• Scarlet fever

• Streptococcal TSS

• Cutaneous anthrax (usually secondarywound infection with streptococci or staphy-lococci)

䊊 Blisters and prominent mouth lesions

䡲 Erythema multiforme (major)

䊊 Generalized pustules

䡲 Generalized acute pustular psoriasis

䡲 Drug eruptions

䊊 Generalized vesicles

䡲 Disseminated herpes simplex

䡲 Generalized herpes zoster

䡲 Bacterial infections with toxin production

䊊 Blisters and prominent mouth lesions

䡲 Erythema multiforme (major)

䡲 Toxic epidermal necrolysis

䡲 Disseminated herpes simplex

䡲 Generalized herpes zoster

䡲 Varicella

䡲 Drug eruptions

Trang 38

䊊 Generalized wheals and soft tissue swelling

䡲 Urticaria and angioedema

䊊 Scaling over the entire body

䊊 Disseminated intravascular coagulopathy

䊊 Fat embolism syndrome

• Localized skin infarcts

䊊 Calciphylaxis (calcific uremic arteriolopathy)

䊊 Atherosclerosis obliterans

䊊 Atheroembolization

䊊 Warfarin necrosis

䊊 Antiphospholipid antibody syndrome

• Facial inflammatory edema with fever

䊊 Erysipelas

䊊 Lupus erythematosus

DISTINCTIVE FEATURES OF SKIN AND

SOFT TISSUE BACTERIAL INFECTIONS

• Impetigo

䊊 Honey-colored serous crust is classically described

䊊 Variations in impetigo appearance is common, from

small vesicles to large bulla

䊊 Impetigo is the result of a superficial, cutaneous

infection that must be differentiated from ecthyma,

an infection that involves the dermis

䊊 Impetigo is caused by Staphylococcus aureus and

group A Streptococcus pyogenes (GAS).

䊊 Treatment for mild localized disease usually involves

topical application of mupirocin ointment, although

the topical approach is generally less effective than oral

antibiotics In advanced lesions or in patients not

responding to topical antibiotics, oral antibiotics

should be administered Cephalexin, 250 mg four

times daily; doxycycline, 100 mg twice daily; or

cefadroxil 500 mg twice daily Community-acquired

methicillin-resistant S aureus (CA-MRSA) may cause

impetigo In communities with a high incidence of

CA-MRSA or CA-MRSA, initial treatment options include

trimethoprim-sulfamethoxazole or doxycycline

• Erysipelas (Fig 2–5)

䊊 Sharply marginated, painful, bright red, raised, matous, indurated plaques with advancing raisedborders emanating from the surrounding normalskin Erysipelas frequently involves the central face

ede-䊊 Treatment: Intravenous antibiotics with coverage forgroup A hemolytic streptococci and staphylococcifor 24 to 48 hours With less severe disease or afterinitial intravenous (IV) therapy, oral dicloxacillin orcephalexin, 250 to 500 mg is administered four timesdaily for 7 to 10 days

• Cellulitis

䊊 Cellulitis is characterized by lesions that are poorlydemarcated, typically flat, erythematous, warm, andtender The surrounding uninvolved skin appearsnormal

䊊 Treatment: Intravenous antibiotics with activityagainst group A hemolytic streptococci and staphy-lococci for 24 to 48 hours With less severe disease

or following the initial IV therapy, oral dicloxacillin

or cephalexin, 250 to 500 mg is administered fourtimes daily for 7 to 10 days

• Folliculitis, furuncles, and carbuncles

䊊 These three conditions represent a continuum frommild involvement to severe

FIG 2–5 Erysipelas Sharply marginated, painful, bright red, raised, edematous, indurated plaque with advancing raised borders involving the ear and extending onto the face Photo by Timothy Rice.

Trang 39

䊊 Usually caused by methicillin-susceptible S aureus;

MRSA infections are increasing in frequency

䊊 Folliculitis

䡲 Infection of hair follicles

䊊 Furuncle (boil)

䡲 Firm, tender, up to 1- to 2-cm nodule with a

cen-tral necrotic plug

䡲 Occurs in an area with existing folliculitis

䡲 If recurrent consider colonization of the nose,

per-ineum, and body folds with S aureus

䊊 Carbuncles

䡲 These large lesions arise from coalescence of

sev-eral adjacent furuncles

䊊 Treatment: Incision and drainage is the mainstay of

therapy For moderate to severe lesions, the patient

should also receive oral dicloxacillin or cephalexin,

250 to 500 mg four times daily for 10 days

• Hidradenitis suppurativa

䊊 Chronic, recurring infection of the apocrine glands

䊊 Usually localized to the axillae, but may also arise

in the groin, perianal, and suprapubic area

䊊 Treatment: Drainage of the lesions and meticulous

hygiene For severe recurrent hidradenitis,

apoc-rine sweat-bearing skin may be surgically excised

• Ecthyma

䊊 A vesicle or pustule that arises from a minor

super-ficial break in the skin from excoriations, insect

bites, or minor trauma Often seen in diabetics,

eld-erly patients (>60 years of age), active military

per-sonnel, and alcoholics

䊊 Ecthyma progresses rapidly to the crusting stage

䊊 Deeper cutaneous infections may occur and extend

into the dermis

䊊 S aureus and GAS (S pyogenes) are the usual

micro-organisms associated with ecthyma

䊊 The treatment requires antibiotic administration,

usu-ally cephalexin, 250 mg four times daily, doxycycline,

100 mg twice daily, or cefadroxil 500 mg twice daily

for 5–7 days When CA-MRSA or MRSA are

sus-pected, initial antimicrobial treatment options include

䊊 The incidence of invasive GAS is increasing

• Group B Streptococcus (Streptococcus agalactiae)

䊊 Anogenital cellulitis

䊊 Puerperal sepsis following childbirth

• Streptococcus pneumoniae (Pneumococcus)

䊊 Bulla, brawny erythema, violaceous hue

• Erysipeloid (Erysipelothrix rhusiopathiae)

䊊 Painful, swollen plaques with sharply defined ular raised borders at the site of inoculation (eg,finger or hand, spreading to the wrist and forearm)

irreg-䊊 Color characteristics

䡲 Acute lesions are characterized by purple-red hue

䡲 With resolution the color changes to brown

䊊 Enlarges peripherally accompanied by central fading

䊊 Systemic symptoms are usually absent In somepatients with diffuse eruptions, systemic symptomsincluding arthritis and endocarditis may occur

䊊 Usually develops after exposure to game, poultry, orfish (eg, butchers, veterinarians, or fishermen)

䡲 The epidermis overlying the ischemic area ops into a bulla The epidermis eventually sloughs,resulting in an ulcer

devel-䡲 The distribution of the lesion(s) usually involvethe intertriginous areas: axilla, groin, perineum

䡲 Typically, there is a solitary lesion

䡲 Ecthyma gangrenosum has been described in

Pseudomonas septicemia.

䊊 Rose spot lesions of P aeruginosa

䡲 These are characterized by erythematous maculesand/or papules on trunk

䡲 Seen with Pseudomonas infection of the

gastroin-testinal tract

䊊 Small embolic lesions secondary to P aeruginosa

䡲 Characterized by multiple painful nodules

䡲 The lesions may cluster forming vesicular or lous lesions

bul-• Haemophilus influenzae

swelling

䊊 Involve the cheek and periorbital areas

䊊 Children are the most susceptible

• Vibrio vulnificus and Vibrio cholerae (non-01 and

non-0139 types)

䊊 Bulla formation and necrotizing vasculitis

䊊 Location: extremities; often bilateral

Trang 40

• Capnocytophaga canimorsus

䊊 Bites or scratches from dogs in immunosuppressed

patients (organ transplantation)

• Pasteurella multocida B

䊊 Bites from cats

• Clostridium species

䊊 Subcutaneous gas and severe systemic toxicity

䊊 Usually arises from wounds that are contaminated by

soil or feces (Mycobacterium chelonae–Mycobacterium

䊊 Rarely involves multiple noncontiguous sites

䊊 Only observed in immunocompromised patients

䊊 This organism may also be associated with

molluscum-like lesions, subcutaneous or mucosal lesions,

pus-tules, and erythematous papules

• Cutaneous Mucormycosis

䊊 Characterized by a single, painful, indurated area

䊊 Progresses into an ecthyma-like lesion

䊊 Usually occurs in individuals with uncontrolled

dia-betes, organ transplantation, or neutropenia

DERMATOLOGIC EMERGENCIES

LIFE-THREATENING CONDITIONS

• Angioedema and urticaria

䊊 Characterized by swelling of the face, lips, and

tongue which may contribute to airway

obstruc-tion

䊊 Urticaria is a localized process, whereas, angioedema is

more extensive and associated with bronchospasm and

shock

• Stevens-Johnson syndrome and toxic epidermal

necrolysis

䊊 Stevens-Johnson syndrome is characterized by

severe, intensely painful bullae and mucosal

ulcera-tions with target-like lesions on the trunk

䊊 Toxic epidermal necrolysis is characterized by

fever, pruritus, pharyngitis, and conjunctivitis

䊊 The painful rash usually begins on the upper trunk

or face Affected skin may be erythematous or

exhibit bullae The bullae may erode or the affected

skin may slough into large sheets Pressure on the

bulla produces lateral extension of the blister known

as Nikolsky sign

䊊 The mucous membranes are involved in

Stevens-Johnson syndrome and toxic epidermal necrolysis

while spared in SSSS

• Exfoliation and erythroderma

䊊 There are many underlying diseases that may beassociated with these lesions Psoriasis with its char-acteristic plaques and/or nail changes may developerythroderma Bullous pemphigoid typically pres-ents with tense bullae in addition to erythroderma.Severe drug reactions may be associated with ery-throderma These patients appear acutely ill withfever, malaise, and lymphadenopathy Other find-ings in patients with life-threatening erythro-derma include leukocytosis with eosinophilia andorganomegaly Hepatic or renal impairment mayalso occur because of volume contraction, shock,and high-output cardiac failure

• Staphylococcal scalded-skin syndrome

䊊 Staphylococcal scalded-skin syndrome may simply

be characterized by localized eruption of a few ile fluid-filled bullae surrounded by normal skin.Conversely, severe manifestations with widespreadbullae may develop in some patients Skin erosionscan involve large areas resulting in open, painfullesions A positive Nikolsky sign is present Themucous membranes are spared in SSSS

frag-POTENTIALLY LIFE-THREATENING CONDITIONS

• Cellulitis and erysipelas

䊊 If untreated, both conditions can result in septicemia,local abscess formation, gangrene, and cavernoussinus thrombosis in patients with facial erysipelas

• Pustular psoriasis

䊊 These patients manifest systemic symptoms (fever,chills) accompanied by multiple pustules and largeareas of erythema Pustular psoriasis mainly occurs

in patients with pre-existing psoriasis

䊊 Treatment involves hospitalization and emergentconsultation with a dermatologist

• Pemphigus vulgaris

䊊 Pemphigus vulgaris is characterized by superficialblistering initially in the oral mucous membranes,then extending to virtually any mucous membranearea The lesions are fragile, and easily rupture.The underlying skin may be erythematous.Importantly, the blisters often slough prior to theclinical presentation leaving only ulcerations onexamination Involvement of the lower airway mayresult in hoarseness A positive Nikolsky sign ispresent

䊊 Treatment involves hospitalization and consultationwith a dermatologist Antibiotic treatment may benecessary if secondary infection is suspected.Lifelong immunosuppressive therapy may be required

in the chronic form of this disease

Tiêu đề	Just the Facts
Người hướng dẫn	Paul G. Schmitz, MD, FACP, Kevin J.. Martin, MB, BCh, FACP
Trường học	Saint Louis University School of Medicine
Chuyên ngành	Internal Medicine
Thể loại	lecture notes
Năm xuất bản	2008
Thành phố	St. Louis

Định dạng
Số trang	832
Dung lượng	15,73 MB