Authors Abraham K. Sleem , MD Robert L. Schultze , MD Robert A. Eden, MD William Yang, MD
EDITORS - pe56d.s3.amazonaws.com fileEDITORS Anthony S. Fauci, MD Eugene Braunwald, MD Dennis L....
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Transcript of EDITORS - pe56d.s3.amazonaws.com fileEDITORS Anthony S. Fauci, MD Eugene Braunwald, MD Dennis L....
EDITORS
Anthony S. Fauci, MD, ScD(HON)Chief, Laboratory of Immunoregulation; Director,
National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda
Eugene Braunwald, MD, ScD(HON)Distinguished Hersey Professor of Medicine,
Harvard Medical School; Chairman, TIMI Study Group, Brigham and Women’s Hospital, Boston
Dennis L. Kasper, MD, MA(HON)William Ellery Channing Professor of Medicine,
Professor of Microbiology and Molecular Genetics, Harvard Medical School; Director, Channing Laboratory,
Department of Medicine, Brigham and Women’s Hospital, Boston
Stephen L. Hauser, MDRobert A. Fishman Distinguished Professor and Chairman,
Department of Neurology, University of California, San Francisco, San Francisco
Dan L. Longo, MDScientific Director, National Institute on Aging,
National Institutes of Health, Bethesda and Baltimore
J. Larry Jameson, MD, PhDProfessor of Medicine;
Vice President for Medical Affairs and Lewis Landsberg Dean,Northwestern University Feinberg School of Medicine, Chicago
Joseph Loscalzo, MD, PhDHersey Professor of the Theory and Practice of Medicine,
Harvard Medical School; Chairman, Department of Medicine;Physician-in-Chief, Brigham and Women’s Hospital, Boston
EDITORS
Anthony S. Fauci, MD
Eugene Braunwald, MD
Dennis L. Kasper, MD
Stephen L. Hauser, MD
Dan L. Longo, MD
J. Larry Jameson, MD, PhD
Joseph Loscalzo, MD, PhD
New York Chicago San Francisco Lisbon London MadridMexico City New Delhi San Juan Seoul Singapore Sydney Toronto
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ISBN: 978-0-07-170200-3
MHID: 0-07-170200-8
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Dr. Fauci’s and Dr. Longo’s works as editors and authors were performed outside the scope of theiremployment as U.S. government employees. These works represent their personal and profession-al views and not necessarily those of the U.S. government.
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Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xvii
SECTION 1 CARE OF THE HOSPITALIZED PATIENT
1 Initial Evaluation and Admission Orders for the General Medicine Patient . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Electrolytes/Acid-Base Balance. . . . . . . . . . . . . . . . . . . . . . . . . . 3
3 Diagnostic Imaging in Internal Medicine. . . . . . . . . . . . . . . . . . 22
4 Procedures Commonly Performed by Internists . . . . . . . . . . . . 25
5 Principles of Critical Care Medicine . . . . . . . . . . . . . . . . . . . . . . 30
6 Pain and Its Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
7 Assessment of Nutritional Status . . . . . . . . . . . . . . . . . . . . . . . 39
8 Enteral and Parenteral Nutrition . . . . . . . . . . . . . . . . . . . . . . . . 41
9 Transfusion and Pheresis Therapy. . . . . . . . . . . . . . . . . . . . . . . 44
10 Palliative and End-of-Life Care . . . . . . . . . . . . . . . . . . . . . . . . . 46
SECTION 2 MEDICAL EMERGENCIES
11 Cardiovascular Collapse and Sudden Death . . . . . . . . . . . . . . . 55
12 Shock. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
13 Sepsis and Septic Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
14 Acute Pulmonary Edema. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
15 Acute Respiratory Distress Syndrome . . . . . . . . . . . . . . . . . . . . 69
16 Respiratory Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
17 Confusion, Stupor, and Coma . . . . . . . . . . . . . . . . . . . . . . . . . . 74
18 Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
19 Subarachnoid Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
20 Increased Intracranial Pressure and Head Trauma . . . . . . . . . . 90
21 Spinal Cord Compression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
22 Hypoxic-Ischemic Encephalopathy . . . . . . . . . . . . . . . . . . . . . . 96
23 Status Epilepticus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
24 Diabetic Ketoacidosis and Hyperosmolar Coma . . . . . . . . . . . 100
25 Hypoglycemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
26 Infectious Disease Emergencies . . . . . . . . . . . . . . . . . . . . . . . 105
27 Oncologic Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
28 Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
29 Bites, Venoms, Stings, and Marine Poisonings . . . . . . . . . . . . 117
30 Hypothermia and Frostbite . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
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31 Poisoning and Drug Overdose . . . . . . . . . . . . . . . . . . . . . . . . . 130
32 Bioterrorism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
SECTION 3 COMMON PATIENT PRESENTATIONS
33 Chest Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
34 Abdominal Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
35 Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
36 Back and Neck Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
37 Fever, Hyperthermia, Chills, and Rash . . . . . . . . . . . . . . . . . . 199
38 Pain and Swelling of Joints . . . . . . . . . . . . . . . . . . . . . . . . . . 203
39 Syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
40 Dizziness and Vertigo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
41 Acute Visual Loss and Double Vision . . . . . . . . . . . . . . . . . . . 215
42 Weakness and Paralysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
43 Tremor and Movement Disorders . . . . . . . . . . . . . . . . . . . . . . 222
44 Aphasias and Related Disorders . . . . . . . . . . . . . . . . . . . . . . . 224
45 Sleep Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
46 Dyspnea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
47 Cough and Hemoptysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
48 Cyanosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
49 Edema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
50 Nausea, Vomiting, and Indigestion . . . . . . . . . . . . . . . . . . . . . 244
51 Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
52 Dysphagia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
53 Diarrhea, Constipation, and Malabsorption . . . . . . . . . . . . . . . 253
54 Gastrointestinal Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
55 Jaundice and Evaluation of Liver Function. . . . . . . . . . . . . . . . 263
56 Ascites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
57 Azotemia and Urinary Abnormalities . . . . . . . . . . . . . . . . . . . 274
58 Anemia and Polycythemia . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
59 Lymphadenopathy and Splenomegaly . . . . . . . . . . . . . . . . . . 283
60 Generalized Fatigue. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288
SECTION 4 OPHTHALMOLOGY AND OTOLARYNGOLOGY
61 Common Disorders of Vision and Hearing. . . . . . . . . . . . . . . . 293
62 Sinusitis, Pharyngitis, Otitis, and Other Upper Respiratory Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
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SECTION 5 DERMATOLOGY
63 General Examination of the Skin. . . . . . . . . . . . . . . . . . . . . . . 309
64 Common Skin Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
SECTION 6 HEMATOLOGY AND ONCOLOGY
65 Examination of Blood Smears and Bone Marrow . . . . . . . . . . 321
66 Red Blood Cell Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
67 Leukocytosis and Leukopenia . . . . . . . . . . . . . . . . . . . . . . . . . 329
68 Bleeding and Thrombotic Disorders . . . . . . . . . . . . . . . . . . . . 332
69 Cancer Chemotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
70 Myeloid Leukemias, Myelodysplasia, and Myeloproliferative Syndromes . . . . . . . . . . . . . . . . . . . . . 344
71 Lymphoid Malignancies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352
72 Skin Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364
73 Head and Neck Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
74 Lung Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368
75 Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
76 Tumors of the Gastrointestinal Tract . . . . . . . . . . . . . . . . . . . . 379
77 Genitourinary Tract Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
78 Gynecologic Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395
79 Prostate Hyperplasia and Carcinoma. . . . . . . . . . . . . . . . . . . . 399
80 Cancer of Unknown Primary Site. . . . . . . . . . . . . . . . . . . . . . . 401
81 Paraneoplastic Endocrine Syndromes . . . . . . . . . . . . . . . . . . . 405
82 Neurologic Paraneoplastic Syndromes . . . . . . . . . . . . . . . . . . 407
SECTION 7 INFECTIOUS DISEASES
83 Diagnosis of Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . 411
84 Antibacterial Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
85 Health Care–Associated Infections. . . . . . . . . . . . . . . . . . . . . . 428
86 Infections in the Immunocompromised Host . . . . . . . . . . . . . 432
87 Infective Endocarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 440
88 Intraabdominal Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . 448
89 Infectious Diarrheas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451
90 Sexually Transmitted Diseases andReproductive Tract Infections . . . . . . . . . . . . . . . . . . . . . . . . . 462
91 Infections of the Skin, Soft Tissues, Joints, and Bones . . . . . . 477
92 Pneumococcal Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 486
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93 Staphylococcal Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489
94 Streptococcal/Enterococcal Infections, Diphtheria, and Other Infections Caused by Corynebacteria and Related Species . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496
95 Meningococcal and Listerial Infections . . . . . . . . . . . . . . . . . . 504
96 Infections Caused by Haemophilus, Bordetella, Moraxella, and HACEK Group Organisms. . . . . . . . . . . . . . . . . 508
97 Diseases Caused by Gram-Negative Enteric Bacteria, Pseudomonas, and Legionella . . . . . . . . . . . . . . . . . . . . . . . . 513
98 Infections Caused by Miscellaneous Gram-Negative Bacilli . . 522
99 Anaerobic Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 528
100 Nocardiosis and Actinomycosis . . . . . . . . . . . . . . . . . . . . . . . . 535
101 Tuberculosis and Other Mycobacterial Infections . . . . . . . . . . 538
102 Lyme Disease and Other Nonsyphilitic Spirochetal Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 549
103 Rickettsial Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 554
104 Mycoplasma Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 560
105 Chlamydial Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 561
106 Herpesvirus Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 564
107 Cytomegalovirus and Epstein-Barr Virus Infections . . . . . . . . . 572
108 Influenza and Other Viral Respiratory Diseases. . . . . . . . . . . . 577
109 Rubeola, Rubella, Mumps, and Parvovirus Infections . . . . . . . 584
110 Enteroviral Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 588
111 Insect- and Animal-Borne Viral Infections. . . . . . . . . . . . . . . . 592
112 HIV Infection and AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 600
113 Fungal Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 618
114 Pneumocystis Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 633
115 Protozoal Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 636
116 Helminthic Infections and Ectoparasite Infestations . . . . . . . . 648
SECTION 8 CARDIOLOGY
117 Physical Examination of the Heart . . . . . . . . . . . . . . . . . . . . . 661
118 Electrocardiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 665
119 Noninvasive Examination of the Heart . . . . . . . . . . . . . . . . . . 669
120 Congenital Heart Disease in the Adult . . . . . . . . . . . . . . . . . . 674
121 Valvular Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 678
122 Cardiomyopathies and Myocarditis . . . . . . . . . . . . . . . . . . . . . 684
123 Pericardial Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 688
124 Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 693
125 Metabolic Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 699
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126 ST-Segment Elevation Myocardial Infarction (STEMI) . . . . . . . 700
127 Unstable Angina and Non-ST-Elevation Myocardial Infarction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 709
128 Chronic Stable Angina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 712
129 Bradyarrhythmias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 717
130 Tachyarrhythmias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 720
131 Congestive Heart Failure and Cor Pulmonale . . . . . . . . . . . . . 730
132 Diseases of the Aorta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 736
133 Peripheral Vascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . 739
134 Pulmonary Hypertension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 742
SECTION 9 PULMONOLOGY
135 Respiratory Function and Pulmonary Diagnostic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 747
136 Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 753
137 Environmental Lung Diseases . . . . . . . . . . . . . . . . . . . . . . . . . 756
138 Chronic Obstructive Pulmonary Disease . . . . . . . . . . . . . . . . . 759
139 Pneumonia and Lung Abscess. . . . . . . . . . . . . . . . . . . . . . . . . 764
140 Pulmonary Thromboembolism and Deep-Vein Thrombosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 769
141 Interstitial Lung Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 772
142 Diseases of the Pleura and Mediastinum . . . . . . . . . . . . . . . . 777
143 Disorders of Ventilation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 781
144 Sleep Apnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 783
SECTION 10 NEPHROLOGY
145 Approach to the Patient with Renal Disease . . . . . . . . . . . . . 785
146 Acute Renal Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 789
147 Chronic Kidney Disease and Uremia . . . . . . . . . . . . . . . . . . . . 794
148 Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 796
149 Renal Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 798
150 Glomerular Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 801
151 Renal Tubular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 808
152 Urinary Tract Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 815
153 Renovascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 820
154 Nephrolithiasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 826
155 Urinary Tract Obstruction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 829
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SECTION 11 GASTROENTEROLOGY
156 Peptic Ulcer and Related Disorders . . . . . . . . . . . . . . . . . . . . . 831
157 Inflammatory Bowel Diseases. . . . . . . . . . . . . . . . . . . . . . . . . 836
158 Colonic and Anorectal Diseases. . . . . . . . . . . . . . . . . . . . . . . . 840
159 Cholelithiasis, Cholecystitis, and Cholangitis . . . . . . . . . . . . . . 844
160 Pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 849
161 Acute Hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 854
162 Chronic Hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 859
163 Cirrhosis and Alcoholic Liver Disease. . . . . . . . . . . . . . . . . . . . 868
164 Portal Hypertension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 872
SECTION 12 ALLERGY, CLINICAL IMMUNOLOGY, AND RHEUMATOLOGY
165 Diseases of Immediate Type Hypersensitivity. . . . . . . . . . . . . 877
166 Primary Immune Deficiency Diseases . . . . . . . . . . . . . . . . . . . 881
167 SLE, RA, and Other Connective Tissue Diseases. . . . . . . . . . . . 885
168 Vasculitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 891
169 Ankylosing Spondylitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 895
170 Psoriatic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 897
171 Reactive Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 899
172 Osteoarthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 900
173 Gout, Pseudogout, and Related Diseases . . . . . . . . . . . . . . . . 903
174 Other Musculoskeletal Disorders . . . . . . . . . . . . . . . . . . . . . . . 907
175 Sarcoidosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 910
176 Amyloidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 913
SECTION 13 ENDOCRINOLOGY AND METABOLISM
177 Disorders of the Anterior Pituitary and Hypothalamus . . . . . . 917
178 Diabetes Insipidus and SIADH . . . . . . . . . . . . . . . . . . . . . . . . . 923
179 Thyroid Gland Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 925
180 Adrenal Gland Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 933
181 Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 939
182 Diabetes Mellitus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 942
183 Disorders of the Male Reproductive System . . . . . . . . . . . . . . 947
184 Disorders of the Female Reproductive System . . . . . . . . . . . . 952
185 Hypercalcemia and Hypocalcemia. . . . . . . . . . . . . . . . . . . . . . 959
186 Osteoporosis and Osteomalacia . . . . . . . . . . . . . . . . . . . . . . . 965
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CONTENTS
187 Hypercholesterolemia and Hypertriglyceridemia . . . . . . . . . . 968
188 Hemochromatosis, Porphyrias, and Wilson’s Disease . . . . . . . 975
SECTION 14 NEUROLOGY
189 The Neurologic Examination . . . . . . . . . . . . . . . . . . . . . . . . . . 979
190 Neuroimaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 986
191 Seizures and Epilepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 988
192 Alzheimer’s Disease and Other Dementias . . . . . . . . . . . . . . . 995
193 Parkinson’s Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1002
194 Ataxic Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1007
195 ALS and Other Motor Neuron Diseases . . . . . . . . . . . . . . . . . 1010
196 Autonomic Nervous System Disorders . . . . . . . . . . . . . . . . . 1013
197 Trigeminal Neuralgia, Bell’s Palsy, and Other Cranial Nerve Disorders . . . . . . . . . . . . . . . . . . . . 1020
198 Spinal Cord Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1026
199 Tumors of the Nervous System. . . . . . . . . . . . . . . . . . . . . . . 1031
200 Multiple Sclerosis (MS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1035
201 Acute Meningitis and Encephalitis . . . . . . . . . . . . . . . . . . . . 1042
202 Chronic Meningitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1052
203 Peripheral Neuropathies, Including Guillain-Barré Syndrome (GBS) . . . . . . . . . . . . . . . . . . . . . . . 1055
204 Myasthenia Gravis (MG) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1065
205 Muscle Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1068
SECTION 15 PSYCHIATRY AND SUBSTANCE ABUSE
206 Psychiatric Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1077
207 Psychiatric Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1085
208 Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1093
209 Alcoholism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1095
210 Narcotic Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1099
SECTION 16 DISEASE PREVENTION AND HEALTH MAINTENANCE
211 Routine Disease Screening . . . . . . . . . . . . . . . . . . . . . . . . . . 1103
212 Immunization and Advice to Travelers . . . . . . . . . . . . . . . . . 1107
213 Cardiovascular Disease Prevention . . . . . . . . . . . . . . . . . . . . 1118
214 Prevention and Early Detection of Cancer. . . . . . . . . . . . . . . 1121
215 Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1126
216 Women’s Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1128
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CONTENTS
SECTION 17 ADVERSE DRUG REACTIONS
217 Adverse Drug Reactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1131
SECTION 18 LABORATORY VALUES
218 Laboratory Values of Clinical Importance . . . . . . . . . . . . . . . 1141
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1173
xii
ASSOCIATE EDITORS
TAMAR F. BARLAM, MDAssociate Professor of Medicine Boston University School of Medicine, Boston
ANNE R. CAPPOLA, MD, SCMAssistant Professor of MedicineDivision of Endocrinology, Diabetes, and Metabolism University of Pennsylvania School of Medicine Philadelphia
S. ANDREW JOSEPHSON, MDAssistant Professor of Neurology, Director, Neurohospitalist ProgramUniversity of California, San FranciscoSan Francisco
CAROL A. LANGFORD, MD, MHSDirector, Center for Vasculitis Care and Research Department of Rheumatic and Immunologic DiseasesCleveland Clinic Foundation, Cleveland
LEONARD S. LILLY, MDAssociate Professor of MedicineHarvard Medical SchoolChief, Brigham/Faulkner CardiologyBrigham & Women’s Hospital, Boston
DAVID B. MOUNT, MDAssistant Professor of MedicineHarvard Medical SchoolAssociate Physician, Brigham & Women’s HospitalRenal Division Staff Physician, VA Boston Healthcare System, Boston
EDWIN K. SILVERMAN, MD, PHDAssociate Professor of MedicineChanning Laboratory and Pulmonary and Critical Care DivisionDepartment of Medicine, Brigham & Women’s HospitalHarvard Medical School, Boston
Numbers indicate the chapters written or co-written by the contributor.
TAMAR F. BARLAM, MD13, 26, 29, 37, 62, 83–111, 113–116, 139, 152, 212
EUGENE BRAUNWALD, MD11, 12, 14, 33, 46–49, 117–124, 126–131, 134, 143, 144, 217
ANNE R. CAPPOLA, MD, SCM7, 8, 24, 25, 30, 51, 177–188, 216
ANTHONY S. FAUCI, MD28, 32, 38, 55, 56, 63, 64, 112, 159–176
STEPHEN L. HAUSER, MD6, 17–23, 35, 36, 39–45, 61, 82, 189–207, 209, 210, 215
J. LARRY JAMESON, MD, PHD1, 3, 4, 7, 8, 24, 25, 30, 31, 51, 60, 125, 177–188, 208, 211, 216, 218
CONTRIBUTORS
xiii
CONTRIBUTORS
S. ANDREW JOSEPHSON, MD6, 17–23, 35, 36, 39–45, 61, 82, 189–207, 209, 210, 215
DENNIS L. KASPER, MD13, 26, 29, 37, 62, 83–111, 113–116, 139, 152, 212
CAROL A. LANGFORD, MD28, 32, 38, 55, 56, 63, 64, 112, 159–176
LEONARD S. LILLY, MD11, 33, 117–124, 127–133, 213
DAN L. LONGO, MD9, 10, 27, 34, 50, 52–54, 58, 59, 65–81, 156–158, 214
JOSEPH LOSCALZO, MD, PHD2, 5, 15, 16, 57, 132, 133, 135–138, 140–142, 145–151, 153–155
DAVID B. MOUNT, MD2, 57, 145–151, 153–155
EDWIN K. SILVERMAN, MD, PHD5, 15, 16, 135–138, 140–142
xiv
Harrison’s Principles of Internal Medicine (HPIM) provides a comprehensivebody of information important to an understanding of the biological andclinical aspects of quality patient care. It remains the premier medicaltextbook for students and clinicians. With the rapidly expanding base ofmedical knowledge and the time constraints associated with heavy patient-care responsibilities in modern health care settings, it is not always possible toread a comprehensive account of diseases and their presentations, clinicalmanifestations, and treatments before or even immediately after encounter-ing the patient. It was for these reasons, among others, that in 1988 theEditors first condensed the clinical portions of HPIM into a pocket-sizedvolume, Harrison’s Manual of Medicine. Similar to the prior 6 editions, thisnew edition of the Manual, drawn from the 17th edition of HPIM, presentsthe key features of the diagnosis, clinical manifestations, and treatment of themajor diseases that are likely to be encountered on a medical service.
The Editors stress that the Manual should not substitute for in-depthanalysis of the clinical problem, but should serve as a ready source of well-crafted and informative summaries that will be useful “on-the-spot” and thatwill prepare the reader for a more in-depth analysis drawn from moreextensive reading at a later time. The Manual has met with increasingpopularity over the years; its popularity and value relate in part to itsabbreviated format, which has proven to be extremely useful for initialdiagnosis, brief description of pathogenesis, and outline of management intime-restricted clinical settings. The most obvious change in this new editionof the Manual is its appearance: full-color format will increase the speed withwhich readers can locate and use information within its chapters. The Manualhas been written for easy and seamless reference to the full text of the 17th
edition of HPIM, and the Editors recommend that the full textbook—orHarrison’s On Line—be consulted as soon as time allows.
As with previous editions, this latest edition of the Manual attempts tokeep up with the continual and sometimes rapid evolution of internalmedicine practices. In this regard, every chapter has received a close reviewand has been updated from the prior edition, with substantial revisions andnew chapters provided where appropriate. In Section 1 on Care of theHospitalized Patient, a new chapter entitled “End-of-Life Care” has beenadded. Section 2 on Medical Emergencies now includes a chapter entitled“Spinal Cord Compression.” Chapters on “Tremor and Movement Disor-ders” and “Generalized Fatigue” appear in Section 3 on Common PatientPresentations. In Section 7 on Infectious Diseases, the chapter on “HIVInfection and AIDS” has been extensively revised to reflect important advanc-es in therapy since the last edition. In Section 8 on Cardiology, there are newchapters on “Noninvasive Examination of the Heart,” “Congenital HeartDisease in the Adult,” and “Metabolic Syndrome.” In Section 9 on Pulmonol-ogy, there is a new chapter on “Sleep Apnea,” and in Section 16 on DiseasePrevention and Health Maintenance, there are important new chapters on“Cardiovascular Disease Prevention” and “Smoking Cessation.”
In full recognition of the important role of digital information deliveryin alleviating the increasing time demands put on clinicians, the last 3editions of the Manual, including the current edition, have been made
PREFACE
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available in PDA format. In addition, a version of the Manual for use with theiPhone platform is available for the 17th edition.
In 2006, in recognition of the increasing use of electronic health recordssystems in hospitals, Harrison’s Practice made its debut. This innovative,digital point-of-care resource delivers substantial clinical reference data tothe bedside. Its outline format and telescopic nature make it an ideal tool forfinding and employing complex medical reference information quickly.Taken as a complete portfolio, Harrison’s is now available in a variety offormats designed to be suitable for all levels of medical training and for allvarieties of health care settings.
xvi PREFACE
ACKNOWLEDGMENTS
The Editors and McGraw-Hill wish to thank their editorial staff whoseassistance and patience made this edition come out in a timely manner:
From the Editors’ offices: Pat Duffey; Gregory K. Folkers; Julie McCoy;Elizabeth Robbins, MD; Kathryn Saxon; Kristine Shontz; and StephanieTribuna.
From McGraw-Hill: James F. Shanahan, Mariapaz Ramos Englis, Cathe-rine Saggese, M. Lorraine Andrews, and Eileen Scott who has been a part ofHMOM since the 11th edition.
The Editors also wish to acknowledge contributors to past editions of thisManual, whose work formed the basis for many of the chapters herein: JosephB. Martin, MD, PhD; Kurt Isselbacher, MD; Jean Wilson, MD; Daryl R.Gress, MD; Michael Sneller, MD; John W. Engstrom, MD; Kenneth Tyler,MD; Sophia Vinogradov, MD; Dan B. Evans, MD; Punit Chadha, MD; GlennChertow, MD; James Woodrow Weiss, MD.
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NOTICEMedicine is an ever-changing science. As new research and clinicalexperience broaden our knowledge, changes in treatment and drugtherapy are required. The authors and the publisher of this workhave checked with sources believed to be reliable in their efforts toprovide information that is complete and generally in accord withthe standards accepted at the time of publication. However, in viewof the possibility of human error or changes in medical sciences,neither the authors nor the publisher nor any other party who hasbeen involved in the preparation or publication of this work war-rants that the information contained herein is in every respectaccurate or complete, and they disclaim all responsibility for anyerrors or omissions or for the results obtained from use of theinformation contained in this work. Readers are encouraged toconfirm the information contained herein with other sources. Forexample and in particular, readers are advised to check the productinformation sheet included in the package of each drug they plan toadminister to be certain that the information contained in this workis accurate and that changes have not been made in the recommend-ed dose or in the contraindications for administration. This recom-mendation is of particular importance in connection with new orinfrequently used drugs.
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SECTION 1 CARE OF THE HOSPITALIZED PATIENT
Initial Evaluation and Admission Orders for the General Medicine Patient
Patients are admitted to the hospital when (1) they present the physician with acomplex diagnostic challenge that cannot be safely or efficiently performed inthe outpatient setting; or (2) they are acutely ill and require inpatient diagnostictests, interventions, and treatments. The decision to admit a patient includesidentifying the optimal clinical service (e.g., medicine, urology, neurology), thelevel of care (observation, general floor, telemetry, ICU), and necessary consult-ants. Admission should always be accompanied by clear communication withthe patient and family, both to obtain information and to outline the anticipatedevents in the hospital. Patients often have multiple physicians, and based on thenature of the clinical problems, they should be contacted to procure relevantmedical history and to assist with clinical care during or after admission.
The scope of illnesses cared for by internists is enormous. During a single dayon a typical general medical service, it is not unusual for physicians, especiallyresidents in training, to admit ten patients with ten different diagnoses affectingten different organ systems. Given this diversity of disease, it is important to besystematic and consistent in the approach to any new admission.
Physicians are often concerned about making errors of commission. Exam-ples would include prescribing an improper antibiotic for a patient with pneu-monia or miscalculating the dose of heparin for a patient with new deep venousthrombosis (DVT). However, errors of omission are also common and can re-sult in patients being denied life-saving interventions. Simple examples in-clude: not checking a lipid panel for a patient with coronary heart disease, notprescribing an angiotensin-converting enzyme (ACE) inhibitor to a diabeticwith documented albuminuria, or forgetting to give a patient with an osteopo-rotic hip fracture calcium, vitamin D, and an oral bisphosphonate.
Inpatient medicine typically focuses on the diagnosis and treatment of acutemedical problems. However, most patients have multiple medical problems af-fecting different organ systems, and it is equally important to prevent nosocomialcomplications. Prevention of common hospital complications, such as DVT, pep-tic ulcers, line infections, falls, delirium, and pressure ulcers, is an important as-pect of the care of all general medicine patients.
A consistent approach to the admission process helps to ensure comprehen-sive and clear orders that can be written and implemented in a timely manner.Several mnemonics serve as useful reminders when writing admission orders.A suggested checklist for admission orders is shown below and it includes sev-eral interventions targeted to prevent common nosocomial complications. Com-puterized order entry systems are also useful when designed to promptstructured sets of admission orders. However, these should not be used to theexclusion of orders tailored for the needs of an individual patient.
1
