DIAGNOSIS & TREATMENT - PART 1 docx

Whooley, MD Assistant Professor of Medicine University of California, San Francisco Section of General Internal Medicine Veterans Affairs Medical Center San Francisco, California Lange M

Essentials of

DIAGNOSIS & TREATMENT

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S e c o n d E d i t i o n

a LANGE medical book

Lawrence M Tierney, Jr., MD

Professor of Medicine

University of California, San Francisco

Associate Chief of Medical Services

Veterans Affairs Medical Center

San Francisco, California

Sanjay Saint, MD, MPH

Assistant Professor of Medicine

Division of General Medicine

University of Michigan Medical School

Research Scientist

Ann Arbor Veterans Affairs Medical Center

Ann Arbor, Michigan

Mary A Whooley, MD

Assistant Professor of Medicine

University of California, San Francisco

Section of General Internal Medicine

Veterans Affairs Medical Center

San Francisco, California

Lange Medical Books/McGraw-Hill

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Essentials of

DIAGNOSIS & TREATMENT

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To Camilla Payne

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Contributors ix

Preface xiii

1 Cardiovascular Diseases 1

2 Pulmonary Diseases 37

3 Gastrointestinal Diseases 64

4 Hepatobiliary Disorders 90

5 Hematologic Diseases 106

6 Rheumatologic & Autoimmune Disorders 143

7 Endocrine Disorders 174

8 Infectious Diseases 198

9 Oncologic Diseases 243

10 Fluid, Acid-Base, & Electrolyte Disorders 266

11 Genitourinary & Renal Disorders 282

12 Neurologic Diseases 305

13 Geriatric Disorders 324

14 Psychiatric Disorders 333

15 Dermatologic Disorders 349

16 Gynecologic, Obstetric, & Breast Disorders 400

17 Common Surgical Disorders 418

18 Common Pediatric Disorders 431

19 Selected Genetic Disorders 450

20 Common Disorders of the Eye 456

21 Common Disorders of the Ear, Nose, & Throat 471

22 Poisoning 481

Index 499 Tab index Back Cover

For more information about this book, click here.

Copyright 2002 The McGraw-Hill Companies, Inc Click Here for Terms of Use

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Pediatric Resident, Department of Pediatrics, University of

Washington School of Medicine, Seattle

Assistant Professor of Medicine, Division of Occupational &

Environmental Medicine and Division of Pulmonary & Critical

Care Medicine, Department of Medicine, University of California,San Francisco

eisner@itsa.ucsf.edu

Pulmonary Diseases

Neal Fischbach, MD

Clinical Fellow, Division of Hematology and Oncology, University

of California, San Francisco

fischba@itsa.ucsf.edu

Hematologic Diseases; Oncologic Diseases

Rebecca Ann Jackson, MD

Assistant Professor, Department of Obstetrics, Gynecology, and

Reproductive Sciences, University of California, San Francisco;Medical Director, Gynecologic Ambulatory Services,

San Francisco General Hospital

jacksonr@obgyn, ucsf.edu

Gynecologic, Obstetric, & Breast Disorders

Copyright 2002 The McGraw-Hill Companies, Inc Click Here for Terms of Use

Common Disorders of the Ear, Nose, & Throat

Catherine Bree Johnston, MD, MPH

Assistant Clinical Professor of Medicine, Division of Geriatrics,Department of Medicine, University of California, San Francisco;Program Director, Geriatric Fellowship, San Francisco VeteransAffairs Medical Center

kewlee@itsa.ucsf.edu

Psychiatric Disorders

Joan Chia-Mei Lo, MD

Assistant Professor of Medicine, University of California, SanFrancisco; Staff Physician, San Francisco General Hospitaljlo@itsa.ucsf.edu

Endocrine Disorders

Rajesh S Mangrulkar, MD

Lecturer, Division of General Medicine, Department of InternalMedicine, University of Michigan Health System, Ann Arbor, andAnn Arbor Veterans Affairs Medical Center

rajm@umich.edu

Fluid, Acid-Base, & Electrolyte Disorders

x Essentials of Diagnosis and Treatment

V Raman Muthusamy, MD

Assistant Clinical Professor of Medicine, Division of

Gastroenterology, University of California, San Francisco

Gastrointestinal Diseases; Hepatobiliary Disorders

Kurt Robert Oelke, MD

Rheumatology Fellow, Department of Rheumatology, University ofMichigan Medical School, Ann Arbor

Chief Resident, Department of Dermatology, University of

California, San Francisco

Common Genetic Disorders

Lawrence.Tierney@med.va.gov

Pearls

Contributors xi

Genitourinary & Renal Disorders

xii Essentials of Diagnosis and Treatment

This second edition of Essentials of Diagnosis Treatment adds a feature

which we believe is unique in medical texts—a Clinical Pearl for eachmain entity The Pearl as it has come to be known in medical parlance

is a brief aphorism or maxim capsulizing and emphasizing some tant principle of diagnosis, treatment, or prognosis—often adorned withintended humor and expressed in colloquial idiom A Pearl should ifpossible be “pithy” and memorable, thus expressed sometimes withmore certainty than perhaps is warranted by the facts of every case.Some Pearls are truly unforgettable, such as, “A stroke is never a strokeuntil it’s had 50 of D50.” One of the authors was offered this Pearl over

impor-30 years ago by an older doctor, and what it means is that focal logic deficits may be due to metabolic abnormalities—in particular,severe hypoglycemia—and that appropriate interventions may there-fore restore normal nervous system function While all the Pearls in thisbook are not as catchy or compelling as that one, they are nonethelessuseful teaching aids and we hope the reader enjoys picking them andlooking at them We should be grateful if our readers would send usPearls of their own for possible inclusion in subsequent editions—and

neuro-if any of ours seem off the point or unclear, we want to know that, too.Our modest goal has been to provide a slim volume summarizingthe crucial points in diagnosis, differential diagnosis, and treatment ofselected diseases One clinical reference is provided in each case as astarting point for further study

We want to thank our editor at Lange/McGraw-Hill, Shelley hardt, for support, encouragement, and exhortation without limit in thedevelopment of this book

Rein-Lawrence M Tierney, Jr., MDSanjay Saint, MD, MPHMary A Whooley, MD

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hyper-• Type A involves the ascending aorta or arch; type B does not

• Sudden onset of chest pain with interscapular radiation in at-riskpatient

• Unequal blood pressures in upper extremities; new diastolic mur of aortic insufficiency occasionally seen in type A

mur-• Chest x-ray nearly always abnormal; ECG unimpressive unlessright coronary artery compromised

• CT, transesophogeal echocardiography, MRI, or aortography ally diagnostic

• Nitroprusside and beta-blockers to lower systolic blood pressure

to approximately 100 mm Hg, pulse to 60/min

• Emergent surgery for type A dissection; medical therapy for type

B is reasonable, with surgery or percutaneous intra-aortic stentingreserved for high-risk patients

• Left ventricular failure

due to any cause

• Left-sided valvular disease

• Primary pulmonary

hypertension

• Chronic pulmonary embolism

• All patients require endocarditis prophylaxis

• Symptomatic patients with gradients > 50 mm Hg: percutaneousballoon or surgical valvuloplasty; asymptomatic patients withgradients > 75 mm Hg and right ventricular hypertrophy: evalu-ate for treatment

• Prognosis for those with mild disease is good

• Eisenmenger’s syndrome

• Femoral pulses delayed and decreased, with pulsatile collaterals

in the intercostal areas; a harsh, late systolic murmur may be heard

in the back; an aortic ejection murmur suggests concomitant cuspid aortic valve

bi-• Electrocardiography with left ventricular hypertrophy; chest x-raymay show rib notching inferiorly due to collaterals

• Transesophageal echo with doppler or MRI is diagnostic; raphy confirms gradient across the coarctation

angiog-■ Differential Diagnosis

• Essential hypertension

• Renal artery stenosis

• Renal parenchymal disease

• Pheochromocytoma

• Surgery is the mainstay of therapy; balloon angioplasty in ected patients

sel-• All patients require endocarditis prophylaxis even after correction

• Twenty-five percent of patients remain hypertensive after surgery

Atrial Septal Defect

• Right ventricular lift, widened and fixed splitting of S2, and tolic flow murmur in the pulmonary area

sys-• Electrocardiography may show right ventricular hypertrophy andright axis deviation (in ostium secundum defects), left anteriorhemiblock (in ostium primum defects); complete or incompleteright bundle branch block in 95%

• Atrial fibrillation commonly complicates

• Echo-doppler with agitated saline contrast injection is tic; radionuclide angiogram or cardiac catheterization estimatesratio of pulmonary flow to systemic flow (PF:SF)

diagnos-■ Differential Diagnosis

• Left ventricular failure

• Left-sided valvular disease

• Small defects do not require surgical correction

• Surgery or percutaneous closure devices indicated for patientswith PF:SF > 1.7 or even smaller PF:SF shunts if there is evi-dence of right ventricular failure

• Surgery is contraindicated in patients with pulmonary sion and right-to-left shunting

• Eisenmenger’s syndrome

• Pulmonary stenosis

Ventricular Septal Defect

• Small shunts in asymptomatic patients may not require surgery

• Mild dyspnea can be treated with diuretics and preload reduction

• PF:SF shunts over 2 are repaired to prevent irreversible nary vascular disease

pulmo-• Surgery if patient has developed shunt reversal (Eisenmenger’ssyndrome) without fixed pulmonary hypertension

• Prophylaxis for infective endocarditis

Patent Ductus Arteriosus

• Ventricular septal defect

If pulmonary hypertension dominates the picture, consider:

• Primary pulmonary hypertension

• Chronic pulmonary embolism

• Prophylaxis for infective endocarditis

• Right ventricular lift in many; opening snap occasionally palpable

• Crisp S1, increased P2, opening snap; these sounds often easier toappreciate than the characteristic low-pitched apical diastolicmurmur

• Electrocardiography shows left atrial abnormality and, commonly,atrial fibrillation; echo confirms diagnosis, quantifies severity

■ Differential Diagnosis

• Left ventricular failure

due to any cause

• Mitral valve prolapse

(if systolic murmur present)

beta-• Valvuloplasty or valve replacement in symptomatic patients withmitral orifice of less than 1.2 cm2; valvuloplasty preferred in non-calcified valves

• Prophylaxis for beta-hemolytic streptococcal infections until age

25 and for infective endocarditis for lifetime

• Left atrial myxoma

• Cor triatriatum (in patientsunder 30)

• Tricuspid stenosis

Mitral Regurgitation

■ Essentials of Diagnosis

• Causes include rheumatic heart disease, infectious endocarditis,mitral valve prolapse, ischemic papillary muscle dysfunction,torn chordae tendineae

• Acute: immediate onset of symptoms of pulmonary edema

• Chronic: asymptomatic for years, then exertional dyspnea andfatigue

• S1usually reduced; a blowing, high-pitched pansystolic murmurincreased by finger squeeze over the apex is characteristic; S3

commonly seen in chronic regurgitation; murmur is not tolic and less audible in acute

pansys-• Left atrial abnormality and often left ventricular hypertrophy onECG; atrial fibrillation typical in chronic cases

• Echo-doppler confirms diagnosis, estimates severity

• Mild to moderate symptoms can be treated with diuretics, sodiumrestriction, and afterload reduction (eg, ACE inhibitors); digoxin,beta-blockers, and calcium channel blockers control ventricularresponse with atrial fibrillation, and warfarin anticoagulationshould be given

• Atrial septal defect

• Ventricular septal defect

Aortic Stenosis

■ Essentials of Diagnosis

• Causes include congenital bicuspid valve and progressive senilecalcification of a normal three-leaflet valve; rheumatic fever rarely,

if ever, causes isolated aortic stenosis

• Dyspnea, angina, and syncope singly or in any combination; den death in less than 1% of asymptomatic patients

sud-• Weak and delayed carotid pulses; a soft, absent, or paradoxicallysplit S2; a harsh diamond-shaped systolic ejection murmur to theright of the sternum, often radiating to the neck

• Electrocardiography shows left ventricular hypertrophy, and x-raymay show calcification in the aortic valve

• Echo confirms diagnosis and estimates valve area and gradient;cardiac catheterization confirms severity, documents concomi-tant coronary atherosclerotic disease, present in 50%

■ Differential Diagnosis

• Mitral regurgitation

• Hypertrophic obstructive or even dilated cardiomyopathy

• Atrial or ventricular septal defect

• Syncope due to other causes, eg, ventricular tachycardia

• Percutaneous balloon valvuloplasty for temporary (6 months)relief of symptoms in poor surgical candidates

Aortic Regurgitation

■ Essentials of Diagnosis

• Causes include congenital bicuspid valve, endocarditis, tic heart disease, Marfan’s syndrome, aortic dissection, ankylos-ing spondylitis, reactive arthritis, and syphilis

rheuma-• Acute aortic regurgitation: acute onset of pulmonary edema

• Chronic aortic regurgitation: asymptomatic until middle age, whenchest pain or symptoms of left heart failure develop

• Acute aortic regurgitation: reduced S1and an S3along with signs

of acute pulmonary edema

• Chronic aortic regurgitation: reduced first heart sound, wide pulsepressure, water-hammer pulse, subungual capillary pulsations(Quincke’s sign), rapid rise and fall of pulse (Corrigan’s pulse),and a diastolic murmur over a partially compressed femoral artery(Duroziez’s sign)

• Soft, high-pitched, decrescendo diastolic murmur in chronic aorticregurgitation; occasionally, an accompanying apical low-pitcheddiastolic rumble (Austin Flint murmur) in nonrheumatic patients;

in acute aortic regurgitation, the diastolic murmur can be short

• ECG shows left ventricular hypertrophy, and x-ray shows left tricular dilation

ven-• Echo-doppler confirms diagnosis, estimates severity

■ Differential Diagnosis

• Pulmonary hypertension with Graham Steell murmur

• Mitral or, rarely, tricuspid stenosis

• Left ventricular failure due to other cause

• Dock’s murmur of left anterior descending artery stenosis

• Acute regurgitation caused by aortic dissection or endocarditisrequires surgical replacement of the valve

Tricuspid Stenosis

■ Essentials of Diagnosis

• Usually rheumatic in origin; rarely, seen in carcinoid heart disease

• Almost always associated with mitral stenosis when rheumatic

• Evidence of right-sided failure: hepatomegaly, ascites, peripheral

edema, jugular venous distention with prominent (a) wave

• A diastolic rumbling murmur along the left sternal border, creasing with inspiration

• Valve replacement in severe cases

• Balloon valvuloplasty may prove to be useful in many patients

Tricuspid Regurgitation

■ Essentials of Diagnosis

• Causes include infective endocarditis, right ventricular heartfailure, carcinoid syndrome, systemic lupus erythematosus, andEbstein’s anomaly

• Most cases secondary to dilation of the right ventricle from sided heart disease

left-• Edema, abdominal discomfort, anorexia; otherwise, symptoms ofassociated disease

• Prominent (v) waves in jugular venous pulse; pulsatile liver,

• Atrial septal defect

• Ventricular septal defect