Discover millions of ebooks, audiobooks, and so much more with a free trial

Only $11.99/month after trial. Cancel anytime.

Kochar's Clinical Medicine for Students: Sixth Edition
Kochar's Clinical Medicine for Students: Sixth Edition
Kochar's Clinical Medicine for Students: Sixth Edition
Ebook2,009 pages51 hours

Kochar's Clinical Medicine for Students: Sixth Edition

Rating: 0 out of 5 stars

()

Read preview

About this ebook

The latest edition of Kochar’s Clinical Medicine for Students includes all new editors and authors who provide critical information medical students need to succeed.

The textbook includes four sections:

• “Key Manifestations and Presentations of Diseases” describes the key symptoms and findings that clinicians look for in patients and links them to a basic understanding of physiology.

• “Diseases and Disorders” is organized by traditional organ systems. After a brief introduction on epidemiology, each chapter addresses the etiology, clinical manifestation, diagnosis, treatment and complications of the disease or disorder.

• “Ambulatory Medicine” highlights topics frequently encountered in the outpatient setting.

• “Systems-based Learning and Practice”—an entirely new section—includes topics pertinent to the current health care system in the United States.

With students now being exposed to clinical medicine early on in medical school, this newest edition will be a valuable resource from the beginning of training.

Whether you’re studying to be a doctor, nurse or physician assistant, you’ll appreciate this textbook’s detailed information on diseases and disorders as well as its guidance on practicing in the field.

LanguageEnglish
PublisheriUniverse
Release dateFeb 29, 2016
ISBN9781491781333
Kochar's Clinical Medicine for Students: Sixth Edition
Author

Mahendr S. Kochar, MD

Kochar’s Clinical Medicine for Students serves as an excellent segue for the third-year medical student who must start learning how to apply knowledge in a practical fashion on the wards. The book has 3 main sections: “Key Manifestations and Presentations of Diseases,” “Diseases and Disorders,” and “Ambulatory Medicine.” By dividing the topic of internal medicine into these main categories rather than by organ system alone, the book already has a leg up on others of its kind. It prepares the medical students to recognize the common presentations of a disease and to learn about the differential diagnosis, then provides information about the diagnosis itself. The book also separates inpatient and outpatient medicine topics, providing complete overviews of each. The chapters in the second section that discuss individual diseases are thorough and fully adequate. Rather than dishing out short quick answers to the questions that attending physicians may ask, the book provides a careful detailing of each disease. The information on the management of each disease is particularly effective, with well-balanced descriptions that provide the broad concepts of management while also providing specific details on laboratory value cutoffs and dosages only when generally applicable. (Review of the Fifth Edition, Journal of American Medical Association, January 21, 2009)

Related to Kochar's Clinical Medicine for Students

Related ebooks

Medical For You

View More

Related articles

Reviews for Kochar's Clinical Medicine for Students

Rating: 0 out of 5 stars
0 ratings

0 ratings0 reviews

What did you think?

Tap to rate

Review must be at least 10 words

    Book preview

    Kochar's Clinical Medicine for Students - Mahendr S. Kochar, MD

    Kochar’s

    Clinical

    Medicine

    for

    Students

    49889.png

    KOCHAR’S CLINICAL MEDICINE FOR STUDENTS

    Copyright © 2016 Mahendr S. Kochar, MD, MACP.

    All rights reserved. No part of this book may be used or reproduced by any means, graphic, electronic, or mechanical, including photocopying, recording, taping or by any information storage retrieval system without the written permission of the author except in the case of brief quotations embodied in critical articles and reviews.

    This publication contains information relating to general principles of medical care that should not be construed as specific instructions for individual patient care. Manufacturers’ product information and package inserts should be used for current information, including contraindications, dosage and precautions. The authors, editors and publisher are not responsible as a matter of product liability, negligence, or otherwise for any injury resulting from any material contained herein.

    The editors have made every effort to trace the copyright holders for borrowed material. If they have inadvertently overlooked any, they would be pleased to make the necessary arrangements at the first opportunity.

    iUniverse

    1663 Liberty Drive

    Bloomington, IN 47403

    www.iuniverse.com

    1-800-Authors (1-800-288-4677)

    Because of the dynamic nature of the Internet, any web addresses or links contained in this book may have changed since publication and may no longer be valid. The views expressed in this work are solely those of the author and do not necessarily reflect the views of the publisher, and the publisher hereby disclaims any responsibility for them.

    Any people depicted in stock imagery provided by Thinkstock are models,

    and such images are being used for illustrative purposes only.

    Certain stock imagery © Thinkstock.

    ISBN: 978-1-4917-8134-0 (sc)

    ISBN: 978-1-4917-8133-3 (e)

    Library of Congress Control Number: 2015921135

    iUniverse rev. date: 02/27/2016

    Kochar’s Clinical Medicine for Students

    Sixth Edition

    EDITORS

    LAWRENCE K. LOO, MD, MACP

    Professor and Vice Chairman of Medicine for Education and Faculty Development

    Assistant Dean for Continuing Medical Education

    Loma Linda University, School of Medicine

    Clinical Professor of Medicine

    University of California, Riverside, School of Medicine

    ROGER C. GARRISON, DO, FACP

    Associate Clinical Professor of Medicine

    University of California, Riverside, School of Medicine

    Vice Chairman, Department of Medicine

    Riverside University Health System, Medical Center

    RAJESH GULATI, MD, FACP

    Clinical Professor of Medicine

    University of California, Riverside, School of Medicine

    Clerkship Director

    Program Director of Internal Medicine Residency

    Riverside Community Hospital

    MICHAEL NDUATI, MD, MBA, MPH, FAAFP

    Associate Clinical Professor of Family Medicine

    University of California, Riverside, School of Medicine

    Associate Dean of Clinical Affairs

    Director of Hospital Medicine

    GEOFFREY LEUNG, MD, EdM

    Assistant Clinical Professor of Family Medicine

    University of California, Riverside, School of Medicine

    Chief of Family Medicine

    Riverside University Health System

    SUMANTA CHAUDHURI SAINI, MD

    Assistant Clinical Professor of Medicine

    University of California, Riverside, School of Medicine

    Associate Program Director of Internal Medicine Residency

    Riverside Community Hospital

    CONSULTING EDITOR

    MAHENDR S. KOCHAR, MD, MS, MACP, FRCP (LONDON), FACC

    Clinical Professor of Medicine

    Associate Dean, Graduate Medical Education

    University of California, Riverside, School of Medicine

    DEDICATION

    To our students who rejuvenate and remind us of the roads we have traveled,

    To our mentors who challenge and inspire us to travel new roads,

    Our heartfelt thanks—and most especially, to Mahendr Kochar.

    FOREWORD

    In the Preface to the first edition of the book, I quoted Sir William Osler, the pre-eminent internist of the last two centuries who said, To study the phenomenon of disease without books is to sail an uncharted sea. Some claim that books are going out of style, and a learner can obtain all the information one needs from the internet. While it may be partially true, students still need books to acquire the knowledge necessary to learn systematically and become good physicians.

    This book has evolved and changed with every edition since it was first published in 1983. The first edition, published as Textbook of General Medicine, had 22 authors; all sub-specialists in internal medicine. The second edition was called Concise Textbook of Medicine and it was again authored by sub-specialists of internal medicine. The next two editions were primarily authored by sub-specialists, but a few chapters were co-authored by general internists. The last edition was authored primarily by general internists and called Clinical Medicine for Students.

    The current edition is edited by four general internists and two family physicians who are excellent clinicians and teachers. Some of the chapters are co-authored by exceptionally qualified residents who love to teach. The book is written for medical, nurse practitioner and physician assistant students. It is being published as an electronic book which will also be available in print on demand. The price of the electronic version is significantly lower to make it more affordable for students. The book has evolved with every edition to meet the needs of the students of the time while maintaining the core tenet of professionalism in internal medicine.

    The latest scientific information is published in peer reviewed journals. It is synthesized in the form of medical knowledge in textbooks. Students are encouraged to seek more detailed information from larger textbooks and medical literature when wishing to learn about a certain topic. This textbook should provide the basic knowledge of internal medicine that every clinical student should acquire as a part of one’s education.

    I have greatly enjoyed being associated with this book for the last 35 years. This is the last edition that I am involved in editing. It has been a particular pleasure working with the editors of the sixth edition. It is my earnest hope that the future editors and authors will continue the tradition of excellence that the current and former editors have established.

    Mahendr S. Kochar, MD, MS, MACP, FRCP (London), FACC

    Clinical Professor of Medicine

    Associate Dean, Graduate Medical Education

    University of California, Riverside, School of Medicine

    PREFACE

    The Sixth Edition of Kochar’s Clinical Medicine for Students builds on the strengths of the fifth edition of the book. It has all new editors and authors who have revised and updated the chapters from the fifth edition. Every chapter of the sixth edition was read and edited by two editors after it was submitted by the author(s).

    The book has four sections. The first, Key Manifestations and Presentations of Diseases, describes the key symptoms and findings that clinicians look for in patients and links them to a basic understanding of physiology. This section is useful for students to learn clinical medicine and doctoring that is now taught in most North American medical schools starting in the first year. Every chapter in this section addresses differential diagnosis, evaluation, and specific disorders. The second section, Diseases and Disorders, is organized by traditional organ systems. After a brief introduction on epidemiology, each chapter addresses the etiology, clinical manifestations, diagnosis, treatment and complications of the disease or disorder. The third section, Ambulatory Medicine, discusses topics frequently encountered in the outpatient setting. The fourth section, Systems-based Learning and Practice, has been added to the current edition. It has topics that are of great interest in the current system of health care in the United States. At the end of each chapter there are up to three Additional Reading and Resources for the readers to access current evidence or guidelines.

    As was the case with the fifth edition, the current edition of the book contains selected topics that are emphasized by internal medicine clerkship directors in teaching and evaluating medical students during their clinical years. With students now being exposed to clinical medicine right from the beginning of medical school through Problem Based Learning sessions, the book should prove useful to medical students from the onset.

    The book is available in both electronic and printed formats. We believe that today’s technology savvy students will find the relatively inexpensive electronic edition easy to carry and use in real time when seeing patients in both the outpatient and inpatient settings. Information is more likely to be retained and applied when acquired during a patient encounter. The book is being published by iUniverse which specializes in publishing electronic books and makes them available in print on demand.

    Each chapter is authored by outstanding clinician teachers. Some chapters are co-authored by residents who are greatly interested in teaching and serve as role models for students. Although the book is written with medical students in mind, it should also prove useful for students studying to be nurse practitioners or physician assistants.

    Dr. Mahendr Kochar, Editor in Chief of the first two editions and Consulting Editor of the next three editions of the book, has again served as a Consulting Editor of the current sixth edition. His advice has been invaluable to us for which we are very grateful. Throughout its earlier editions, the book has provided exactly the information that students and residents needed to take care of their patients in a way that they could quickly access and effectively apply. This new edition does the same.

    Lawrence K. Loo

    Roger C. Garrison

    Rajesh Gulati

    Michael Nduati

    Geoffrey Leung

    Sumanta Chaudhuri Saini

    ACKNOWLEDGMENTS

    We would like to thank the authors who have worked diligently to update and revise the Sixth Edition of Kochar’s Clinical Medicine for Students.

    We would like to express our appreciation to Dr. Kochar, Associate Dean of Graduate Medication Education, University of California, Riverside, School of Medicine, for his tireless leadership and guidance on this project. Dr. Kochar has inspired and mentored the editorial staff with his experience and wonderful sense of humor. It has been an honor and privilege to work with such a recognized leader in medical education.

    A very special thanks to Victoria Tejera who kept this project organized and worked tirelessly to coordinate with the editorial staff at iUniverse and the many authors involved with this edition. Victoria demonstrated quiet grace and exceptional skill during the many months of this endeavor. The entire editorial team would like to express their sincere gratitude to Victoria and all she has done to make this project a success.

    We are also grateful to Julia De Leon for her invaluable assistance to Victoria in the final months of producing the manuscript. She is a hardworking and bright student who we wish the best.

    Finally, the editorial staff would like to thank all the authors who have contributed to earlier editions of this textbook. They created a foundation and structure which the present authors were able to build upon. Their vision has been carried forward in this edition and we pay tribute to their hard work.

    CONTRIBUTORS

    Mohamad Abu-Qaoud, MD

    Assistant Professor of Medicine

    University of California, Riverside

    School of Medicine

    Riverside University Health System, Medical Center

    Barbara C. Ackerman, RN, PhD

    Assistant Clinical Professor of Family Medicine

    University of California, Riverside

    School of Medicine

    Riverside University Health System, Medical Center

    Adolfo Aguilera, MD

    Assistant Clinical Professor of Family Medicine

    University of California, Riverside

    School of Medicine and

    Western University of Health Sciences

    Program Director, UCR Family Medicine Residency

    Riverside University Health System, Medical Center

    Olumide Makanju-ola Akingbemi, MD

    Associate Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Riverside Community Hospital

    Andrew G. Alexander, MD, FAAFP

    Associate Clinical Professor of Family Medicine

    University of California, Riverside

    School of Medicine

    Riverside Community Hospital

    Dennis B. Alters, MD, DFAPA

    Clinical Professor of Psychiatry

    University of California, Riverside

    School of Medicine

    Riverside County Department of Mental Health

    Yona R. Ardiles, DO

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    Attending Physician, Department of Medicine

    Riverside University Health System, Medical Center

    Huy Au, MA, MD

    Assistant Professor of Medicine

    University of California, Riverside

    School of Medicine

    Riverside University Health System, Medical Center

    Columbus D. Batiste, MD, FACC

    Assistant Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Chief Division of Cardiology

    Kaiser Permanente Riverside Medical Center

    Zebayel Baye, MD

    Assistant Clinical Professor

    University of California, Riverside

    School of Medicine

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    Riverside University Health System, Medical Center

    Samuel Baz, MD

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    Program Director, Internal Medicine Residency

    Loma Linda University Medical Center

    Reba K. Bindra, MD, MS

    Assistant Clinical Professor of Psychiatry

    University of California, Riverside

    School of Medicine

    Riverside County Department of Mental Health

    Brandon Brown, MPH, PhD

    Assistant Clinical Professor

    University of California, Riverside

    School of Medicine

    Susan L. Brown, MS, D. Bioethics

    Medical Social Worker/Bioethics

    Riverside University Health System, Medical Center

    Ryan J. Burris, MD, MSc

    Internal Medicine Resident

    University of California, Irvine

    School of Medicine

    John M. Byrne, DO

    Associate Professor of Medicine

    Loma Linda University School of Medicine

    Associate Chief of Staff for Education

    VA Loma Linda Healthcare System

    Marven G. Cabling, MD

    Assistant Clinical Professor of Medicine

    Loma Linda University School of Medicine

    Matthew Chang, MD

    Assistant Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Sumanta Chaudhuri Saini, MD

    Assistant Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Riverside Community Hospital

    Christina L. Chen, DO

    Internal Medicine Resident

    Loma Linda University Medical Center

    Thomas J. Chen, MD, MPH

    Assistant Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Program Director, Internal Medicine Residency

    Kaiser Permanente, Fontana Medical Center

    Ann M. Cheney, PhD

    Assistant Clinical Professor of Psychiatry

    University of California, Riverside

    School of Medicine

    Morteza Chitsazan, DO, FACP

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    Riverside University Health System, Medical Center

    Eric H. Choi, MD

    Assistant Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Riverside Medical Clinic

    David M. Chooljian, MD, JD

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    VA Loma Linda Healthcare System

    Mark J. Chou, DO

    Chief Resident of Quality and Safety, Internal Medicine

    Loma Linda University Medical Center

    VA Loma Linda Healthcare System

    Philip W. Chui, MD

    Internal Medicine Resident

    University of California, Irvine

    School of Medicine

    Takesha J. Cooper, MD

    Assistant Clinical Professor of Medicine

    University of California, Irvine

    School of Medicine

    Adrian Cotton, MD

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    President, Medical Staff

    Loma Linda University Medical Center

    Nasim Daoud, MD

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    Loma Linda University Medical Center

    Emerson M. De Jesus, MD

    Rheumatology Fellow

    Loma Linda University Medical Center

    Jerry L. Dennis, MD

    Associate Clinical Professor of Psychiatry

    University of California, Riverside

    School of Medicine

    Medical Director

    Riverside County Department of Mental Health

    Kishore Desagani, MD

    Assistant Clinical Professor of Psychiatry

    University of California, Riverside

    School of Medicine

    Riverside County Department of Mental Health

    Christine A. Duong, MD

    Assistant Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Associate Program Director, UCR Internal Medicine Residency

    Kaiser Permanente, Riverside Medical Center

    Christine Duong, RN, DNP (in progress)

    Adjunct Professor

    School of Nursing

    California Baptist University

    Maegen Dupper, MD

    Assistant Clinical Professor of Family Medicine

    University of California, Riverside

    School of Medicine

    Riverside University Health System

    Ragavi Elangovan, DO

    Internal Medicine Resident

    University of California, Riverside

    School of Medicine

    Rachid A. Elkoustaf, MD

    Cardiologist

    Kaiser Permanente, Riverside Medical Center

    Andrew Elliott, MD, MPH

    Associate Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Riverside County Department of Mental Health

    Armen Eskandari, MD

    Internal Medicine Resident

    University of California, Riverside

    School of Medicine

    Ramiz A. Fargo, MD, FCCP

    Associate Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Riverside University Health System, Medical Center

    Parastou Farhadian, MD

    Assistant Clinical Professor of Family Medicine

    University of California, Riverside

    School of Medicine

    Program Director, UCR Family Medicine Residency

    Riverside University Health System, Medical Center

    Siavash Farshidpanah, MD

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    Assistant Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Riverside University Health System, Medical Center

    Christopher Fitchner, MD

    Clinical Professor of Psychiatry

    University of California, Riverside

    School of Medicine

    Riverside County Department of Mental Health

    Alexander Friedman, DO

    Internal Medicine Resident

    University of California, Riverside

    School of Medicine

    Cynthia V. Fuentes, MD

    Internal Medicine Resident

    University of California, Riverside

    School of Medicine

    Joe R. Gamboa, MD

    Rheumatology Fellow

    Loma Linda University Medical Center

    Roger C. Garrison, DO, FACP

    Associate Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Associate Program Director, UCR Internal Medicine Residency

    Riverside University Health System, Medical Center

    Rajesh Gulati, MD, FACP

    Professor of Clinical Medicine

    University of California, Riverside

    School of Medicine

    Clerkship Director, Internal Medicine

    Program Director, Internal Medicine Residency Program

    Riverside Community Hospital

    Niraj P. Gupta, MD

    Assistant Clinical Professor of Psychiatry

    University of California, Riverside

    School of Medicine

    Riverside University Health System, Medical Center

    Wael Hamade, MD, FAAFP

    Assistant Clinical Professor of Family Medicine

    University of California, Riverside

    School of Medicine

    Riverside University Health System, Medical Center

    Kalipta Hatti, MD

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    Loma Linda University Medical Center

    Amy Hayton, MD, MPH

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    Clerkship Director, Internal Medicine

    VA Loma Linda Healthcare System

    Douglas Hegstad, MD, MACP

    Associate Professor of Medicine

    Chairman, Department of Medicine

    Loma Linda University School of Medicine

    Kathie Huang, MD, MS

    Assistant Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Riverside University Health System, Medical Center

    Michael D. Hughes, MD

    Assistant Clinical Professor of Family Medicine

    University of California, Riverside

    School of Medicine

    Desert Regional Medical Center

    Earl Ilano, MD

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    Riverside University Health System, Medical Center

    Talha H. Imam, MD

    Assistant Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Kaiser Permanente, Fontana, Medical Center

    Erum Iqbal Bajwa, MD

    Internal Medicine Resident

    University of California, Irvine

    School of Medicine

    Vida Jahangiri, MD

    Internal Medicine Resident

    University of California, Riverside

    School of Medicine

    Safwan Jaradeh, MD

    Professor of Neurology and Neurological Sciences

    Stanford University, School of Medicine

    Faheem M. Jukaku, MD, FAAFP

    Assistant Clinical Professor of Family Medicine

    University of California, Riverside

    School of Medicine

    Western University of Health Sciences

    Riverside University Health System, Medical Center

    Ilho Kang, MD

    Assistant Professor of Medicine

    Associate Clerkship Director, Internal Medicine

    Loma Linda University School of Medicine

    Riverside University Health System, Medical Center

    Amir Kashani, MD, MPH

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    Riverside University Health System, Medical Center

    Emmanuel P. Katsaros, DO

    Associate Professor of Medicine

    Western University of Health Sciences

    Chair, Department of Internal Medicine

    College of Osteopathic Medicine of the Pacific

    Sadia S. Khan, MD, MS

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    Riverside University Health System, Medical Center

    Mohammad S. Kharazmi, MD

    Assistant Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Riverside Community Hospital

    Daniel I. Kim, MD, MBA

    Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Program Director, UCR Internal Medicine Residency

    Chairman of Medicine

    Riverside University Health System, Medical Center

    Lawrence Kim, MD, MBA

    Internal Medicine Resident

    University of California, Irvine

    School of Medicine

    Walter Klein, MD

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    Riverside University Health System, Medical Center

    Shawn Koh, MD

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    VA Loma Linda Healthcare System

    Rajagopal Krishnan, MD, MRCP

    Associate Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Chief of Cardiology

    Riverside University Health System, Medical Center

    Samir Kubba, MD

    Assistant Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    St. Bernardine Medical Center

    Vincent Kwok, MD

    Assistant Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Kaiser Permanente, Riverside Medical Center

    Mimi Q. Le, MD, FACC

    Assistant Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Attending Cardiologist

    Kaiser Permanente, Riverside Medical Center

    Minh-Phuong T. Le, MD

    Internal Medicine Resident

    University of California, Irvine

    School of Medicine

    Peter J. Lee, MD, MPH

    Assistant Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Riverside University Health System

    Richard J. Lee, MD

    Assistant Clinical Professor of Psychiatry

    University of California, Riverside

    School of Medicine

    Riverside County Department of Mental Health

    Geoffrey W. Leung, MD, EdM

    Assistant Clinical Professor of Family Medicine

    University of California, Riverside

    School of Medicine

    Chief of Family Medicine

    Riverside University Health System

    Sheila Lezcano, MD

    Internal Medicine Resident

    Loma Linda University Medical Center

    Shu-Yi Liao, MD, MPH

    Internal Medicine Resident

    University of California, Riverside

    School of Medicine

    Brian S. Lim, MD, MCR

    Assistant Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Kaiser Permanente, Riverside Medical Center

    Lawrence K. Loo, MD, MACP

    Professor of Medicine

    Vice-chair for Education, Department of Medicine

    Loma Linda University School of Medicine

    Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Hector D. Ludi, MD, FACS

    Associate Clinical Professor of Surgery

    University of California, Riverside

    School of Medicine

    Assistant Professor of Surgery

    Loma Linda University School of Medicine

    Riverside University Health System, Medical Center

    Alex Ly, MD

    Assistant Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Riverside Community Hospital

    Gerald A. Maguire, MD, DFAPA

    Professor and Chair of Psychiatry

    University of California, Riverside

    School of Medicine

    Michael J. Matus, MD, MBA

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    Chief Resident, Internal Medicine

    Riverside University Health System, Medical Center

    Nathan D. McLaughlin, MD

    Assistant Clinical Professor of Family Medicine

    University of California, Riverside

    School of Medicine

    Riverside University Health System, Medical Center

    Heidi Millard, MD

    Assistant Clinical Professor of Family Medicine

    University of California, Riverside

    School of Medicine

    Riverside University Health System

    Nareg Minaskeian, MD

    Internal Medicine Resident

    University of California, Riverside

    School of Medicine

    Bahram Mirza, MD

    Assistant Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Physician Director

    Kaiser Permanente, Riverside Medical Center

    Adnan Misellati, MD

    Assistant Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Riverside Community Hospital

    Yvette Modad, MD

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    Chief Resident, Internal Medicine

    Loma Linda University Medical Center

    VA Loma Linda Healthcare System

    Ioana Moldovan, MD

    Associate Clinical Professor of Medicine

    Loma Linda University School of Medicine

    Loma Linda University Medical Center

    Hoveda Mufti, MD

    Assistant Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Riverside Community Hospital

    Ashis Mukherjee, MD, FACC

    Associate Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Associate Program Director, UCR Internal Medicine Residency

    St. Bernardine Medical Center

    Iqbal Munir, MD, PhD

    Assistant Professor of Medicine

    University of California, Riverside

    School of Medicine

    Riverside University Health System, Medical Center

    Waheed Murad, MD, MRCP

    Hematologist and Oncologist

    Kaiser Permanente, Riverside Medical Center

    Michael Nduati, MD, MBA

    Associate Dean of Clinical Affairs and Associate Clinical Professor of Family Medicine

    University of California, Riverside

    School of Medicine

    Director of Hospital Medicine

    Riverside Community Hospital

    Michelle Ngo, DO, MS

    Rheumatology Fellow

    Loma Linda University Medical Center

    Chau Lien Nguyen, DO

    Rheumatology Fellow

    Loma Linda University Medical Center

    Truclinh T. Nguyen, DO

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    Riverside University Health System, Medical Center

    Ananda Nimalasuriya, MD

    Endocrinology

    Kaiser Permanente, Riverside Medical Center

    Jillian R. Oft, MD

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    Chief Resident, Internal Medicine

    Loma Linda University Medical Center

    Edmond K. Ohanian, DO

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    Chief Resident, Internal Medicine

    Loma Linda University Medical Center

    John N. Ojinmah, MD

    Assistant Clinical Professor of Psychiatry

    University of California, Riverside

    School of Medicine

    Riverside County Department of Mental Health

    Bipin Patel, MD, FAPA

    Associate Clinical Professor of Psychiatry

    University of California, Riverside

    School of Medicine

    Chair, Department of Psychiatry

    Riverside University Health System, Medical Center

    Neha Pandey, MD

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    Riverside University Health System, Medical Center

    Mohini Pathria, MD

    Internal Medicine Resident

    Loma Linda University Medical Center

    Mark C. Patuszynski, MD

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    VA Loma Linda Healthcare System

    Jon Persichino, DO

    Associate Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Riverside University Health System, Medical Center

    Anita V. Phatak, MD

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    Chief Resident, Internal Medicine

    Loma Linda University Medical Center

    VA Loma Linda Healthcare System

    Lakshmi K. Puvvula, MD

    Assistant Clinical Professor

    University of California, Riverside

    School of Medicine

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    Riverside University Health System, Medical Center

    Francisco P. Quismorio, Jr., MD, MACR

    Professor of Medicine and Pathology

    Keck School of Medicine

    University of Southern California

    Maisara Rahman, MD

    Assistant Clinical Professor of Family Medicine

    University of California, Riverside

    School of Medicine

    Assistant Professor Family Medicine

    Loma Linda University School of Medicine

    Riverside University Health System, Medical Center

    Sarah S. Rasheed, MD

    Assistant Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Clare E. Robertson, MD

    Internal Medicine Resident

    University of California, Riverside

    School of Medicine

    Candice Ruby, MD

    Hematology-Oncology

    Kaiser Permanente, Riverside Medical Center

    Sajib Saha, MD

    Internal Medicine Resident

    University of California, Riverside

    School of Medicine

    Shivani Scharf, DO

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    University of California, Riverside

    School of Medicine

    Loma Linda University Medical Center

    Amy Schill Depew, MD

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    Associate Program Director, Internal Medicine Residency

    Loma Linda University Medical Center

    Nikhil Shah, MD

    Assistant Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Stewart Shankel, MD, MACP

    Clinical Professor of Medicine and

    Interim Chair of Medicine

    University of California, Riverside

    School of Medicine

    Ankush Sharma, MD, MPH

    Assistant Clinical Professor

    University of California, Irvine

    School of Medicine

    Gastroenterology Fellow

    Wright State University

    Boonshoft School of Medicine

    Elham Siman, MD

    Chief Resident, Family Medicine

    University of California, Riverside

    School of Medicine

    Riverside University Health System, Medical Center

    Emma Simmons, MD, MPH

    Associate Clinical Professor of Family Medicine

    Associate Dean, Student Affairs

    University of California, Riverside

    School of Medicine

    Riverside University Health System, Medical Center

    Naveenraj L. Solomon, MD, FACS

    Associate Professor of Surgery

    Loma Linda University School of Medicine

    Loma Linda University Medical Center

    Debra L. Stottlemeyer, MD, MBA

    Associate Clinical Professor of Medicine

    Loma Linda University School of Medicine

    Riverside University Health System, Medical Center

    Made Sutjita, MD, PhD

    Associate Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Associate Professor of Medicine

    Loma Linda University School of Medicine

    Riverside University Health System, Medical Center

    Benjamin Tabibian, DO

    Instructor of Medicine

    Loma Linda University School of Medicine

    Riverside University Health System, Medical Center

    Gary Thompson, DO, FACP

    Assistant Clinical Professor of Medicine

    University of California, Riverside

    School of Medicine

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    Riverside University Health System, Medical Center

    Duc To, MD, MS

    Clinical Instructor

    University of California, Riverside

    School of Medicine

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    Riverside University Health System, Medical Center

    Karina D. Torralba, MD, MACM

    Associate Professor of Medicine

    Loma Linda University School of Medicine

    Interim Division Chief

    Director, Rheumatology Fellowship Program

    Loma Linda University Medical Center

    Linh N. Tran, MD

    Instructor of Medicine

    Loma Linda University School of Medicine

    Chief Resident of Quality and Patient Safety, Internal Medicine

    Loma Linda University Medical Center

    VA Loma Linda Healthcare System

    Shunling Tsang, MD, MPH

    Assistant Clinical Professor of Family Medicine

    University of California, Riverside

    School of Medicine

    Riverside University Health System, Medical Center

    Leah A. Tudtud-Hans, MD, FACP

    Associate Professor of Medicine

    Loma Linda University School of Medicine

    Associate Program Director, Transitional Year Residency

    Loma Linda University Medical Center

    Jaswinder K. Walia, MD

    Assistant Clinical Professor of Psychiatry

    University of California, Riverside

    School of Medicine

    Riverside County Department of Mental Health

    Bruce H. Weng, DO

    Internal Medicine Resident

    Loma Linda University Medical Center

    Brian A. Wong, MD

    Associate Professor of Medicine

    Loma Linda University School of Medicine

    VA Loma Linda Healthcare System

    Charlie M. Wray, DO

    Hospitalist Research Scholar

    Clinical Associate

    University of Chicago, Medical Center

    Jeffrey C. Wu, DO

    Internal Medicine Resident

    University of California, Riverside

    School of Medicine

    Haik Yanashyan, MD

    Internal Medicine Resident

    University of California, Riverside

    School of Medicine

    Priyanka Yaramada, MD

    Internal Medicine Resident

    University of California, Riverside

    School of Medicine

    Minho Yu, DO

    Assistant Professor of Medicine

    Loma Linda University School of Medicine

    Associate Program Director, Internal Medicine Residency

    Riverside University Health System, Medical Center

    Steven Zhao, MD

    Internal Medicine Resident

    University of California, Irvine

    School of Medicine

    CONTENTS

    I. Key Manifestations and Presentation of Diseases –Douglas Hegstad, MD and Lawrence K. Loo, MD

    1 Abdominal Pain

    Andrew G. Alexander, MD

    2 Acute Gastrointestinal Bleeding

    Ilho Kang, MD

    3 Altered Mental Status

    Amy Hayton, MD

    4 Anemia

    Mark C. Patuszynski, MD

    5 Chest Pain

    Mark J. Chou, DO

    6 Cough

    Anita V. Phatak, MD

    7 Diarrhea

    Linh N. Tran, MD

    8 Dizziness and Vertigo

    Samuel Baz, MD

    9 Dyspnea

    John M. Byrne, DO

    10 Dysuria

    John M. Byrne, DO

    11 Edema

    Douglas Hegstad, MD

    12 Fever and Rash

    Yvette Modad, MD

    13 Fever and Fever of Unknown Origin

    Bruce H. Weng, DO and Brian A. Wong, MD

    14 Headache

    Parastou Farhadian, MD and Lawrence K. Loo, MD

    15 Heart Sounds and Murmurs

    Mark J. Chou, DO

    16 Hematuria

    Adrian Cotton, MD

    17 Hemoptysis

    Linh N. Tran, MD

    18 Jaundice

    Brian S. Lim, MD

    19 Joint Pain

    Adolfo Aguilera, MD

    20 Nausea and Vomiting

    Adrian Cotton, MD

    21 Shock

    Roger C. Garrison, DO

    22 Syncope

    Mark J. Chou, DO

    23 Unintentional Weight Loss

    Mark C. Patuszynski, MD

    II. Diseases and Disorders

    Cardiology – Rajesh Gulati, MD

    24 Electrocardiography

    Armen Eskandari, MD and Rajesh Gulati, MD

    25 Noninvasive Cardiac Imaging

    Armen Eskandari, MD and Rajagopal Krishnan, MD

    26 Coronary Artery Disease

    Columbus D. Batiste, MD

    27 Heart Failure

    Phillip W. Chui, MD and Rajesh Gulati

    28 Cardiomyopathies and Myocarditis

    Minh-Phuong T. Le, MD and Rajesh Gulati, MD

    29 Valvular Heart Disease

    Mimi Q. Le, MD

    30 Pericardial Disease

    Ashis Mukherjee, MD

    31 Congenital Heart Disease in Adults

    Ryan J. Burris, MD and Rajesh Gulati, MD

    32 Aortic Dissection

    Armen Eskandari, MD and Ashis Mukherjee, MD

    33 Peripheral Arterial Disease

    Morteza Chitsazan, DO

    34 Atrial Fibrillation and Flutter

    Rachid A. Elkoustaf, MD

    35 Other Cardiac Dysrhythmias

    Ryan J.Burris, MD and Rajesh Gulati, MD

    III. Endocrine and Metabolic Disorders – Iqbal Munir, MD and Roger C. Garrison, DO

    36 Diabetes Mellitus and Hypoglycemia

    Priyanka Yaramada, MD and Ananda Nimalasuriya, MD

    37 Parathyroid Diseases and Calcium Homeostasis

    Bahram Mirza, MD

    38 Vitamin D Metabolism, Osteomalacia and Rickets

    Maisara Rahman, MD and Elham Siman, MD

    39 Thyroid Diseases

    Iqbal Munir, MD

    40 Anterior Pituitary Diseases

    Iqbal Munir, MD

    41 Diabetes Insipidus and Syndrome of Inappropriate Antidiuretic Hormone

    Maisara Rahman, MD

    42 Diseases of the Adrenal Glands

    Yona R. Ardiles, DO and Truclinh T. Nguyen, DO

    43 Polycystic Ovary Syndrome and Hirsutism

    Neha Pandey, MD and Maegen Dupper, MD

    IV. Gastroenterology – Lawrence K. Loo, MD

    44 Gastroesophageal Reflux Disease

    Edmond K. Ohanian, DO

    45 Peptic Ulcer Disease

    Edmond K. Ohanian, DO

    46 Celiac Disease

    Priyanka Yaramada, MD and Amir Kashani, MD

    47 Inflammatory Bowel Disease

    Amir Kashani, MD

    48 Irritable Bowel Syndrome

    Eric H. Choi, MD

    49 Diverticular Disease of the Colon

    Eric H. Choi, MD

    50 Hepatitis

    Shawn Koh, MD

    51 Cirrhosis

    Ilho Kang, MD

    52 Nonalcoholic Fatty Liver Disease

    Charlie M. Wray, DO

    53 Biliary Disorders

    Brian S. Lim, MD

    54 Pancreatitis

    Edmond K. Ohanian, DO

    55 Malnutrition

    Ankush Sharma, MD and Huy Au, MD

    V. Geriatrics – Geoffrey W. Leung, MD

    56 Functional Decline in the Elderly

    Wael Hamade, MD

    57 Falls

    Wael Hamade, MD

    58 Urinary Incontinence

    Shunling Tsang, MD

    59 Benign Prostatic Hypertrophy

    Wael Hamade, MD and Shunling Tsang, MD

    60 Insomnia

    Nathan McLaughlin, MD

    61 Dementia

    Wael Hamade, MD

    62 Palliative Care

    Faheem M. Jukaku, MD

    VI. Hematology – Roger C. Garrison, DO and Samir Kubba, MD

    63 Acute Leukemias

    Sadia S. Khan, MD

    64 Myeloproliferative Neoplasms

    Waheed Murad, MD

    65 Iron Deficiency Anemia

    Gary Thompson, DO

    66 B12 Deficiency and Other Megaloblastic Anemias

    Kathie Huang, MD

    67 Anemia of Chronic Disease

    Daniel I. Kim, MD

    68 Sickle Cell Disease

    Huy Au, MD and Christine Duong, RN

    69 Thalassemias

    Cynthia V. Fuentes, MD and Sara Rasheed, MD

    70 Hereditary Spherocytosis

    Earl Illano, MD

    71 Autoimmune Hemolytic Anemia

    Ragavi Elangovan, DO and Candice Ruby, MD

    72 Thrombotic Thrombocytopenic Purpura and Hemolytic Uremic Syndrome

    Michael J. Matus, MD

    73 Disseminated Intravascular Coagulation

    Thomas J. Chen, MD

    74 Hemophilia and Von Willebrand Disease

    Thomas J. Chen, MD

    75 Leukopenia

    Neha Pandey, MD

    76 Reactive Leukocytosis

    Mohammad S. Kharazmi, MD

    77 Eosinophilia

    Zebayel Baye, MD

    78 Clinical Uses of Blood and Blood Products

    Duc To, MD

    79 Heparin-Induced Thrombocytopenia

    Minho Yu, DO

    80 Immune Thrombocytopenia

    Minho Yu, DO

    VII. Infectious Diseases – Lawrence K. Loo

    81 Pneumonia

    Charlie M. Wray, DO

    82 Urinary Tract Infections

    John M. Byrne, DO

    83 Cellulitis and Other Soft-Tissue Infections

    Samuel Baz, MD

    84 Meningitis, Encephalitis and Central Nervous System Infection

    Made Sutjita, MD

    85 Tuberculosis

    Kathy Huang, MD

    86 Sepsis Syndrome

    Jillian R. Oft, MD

    87 Endocarditis

    Jillian R. Oft, MD

    88 Osteomyelitis and Other Bone and Joint Infections

    Made Sutjita, MD

    89 Syphilis and Gonorrhea

    Jon Persichino, DO

    90 Other Sexually Transmitted Diseases

    Yvette Modad, MD

    91 HIV Infection

    Jon Persichino, DO

    92 Nosocomial Infections

    Leah A. Tudtud-Hans, MD

    93 Ebola

    Made Sutjita, MD

    VIII. Nephrology – Sumanta Chaudhuri Saini, MD and Vincent Kwok, MD

    94 Acute Kidney Injury

    Vincent Kwok, MD

    95 Chronic Renal Failure

    Alex Ly, MD

    96 Glomerulonephritis

    Alex Ly, MD

    97 Nephrotic Syndrome

    Alex Ly, MD

    98 Acute Interstitial Nephritis

    Alex Ly, MD

    99 Polycystic Kidney Disease

    Sumanta Chaudhuri Saini, MD

    100 Nephrolithiasis

    Alexander Friedman, DO and Talha H. Imam, MD

    101 Fluid and Electrolyte Disorders

    Leah A. Tudtud-Hans, MD

    102 Acid-Base Disorders

    Stewart Shankel, MD

    103 Renal Tubular Acidosis

    Stewart Shankel, MD

    IX. Neurology – Safwan Jaradeh, MD and Sumanta Chaudhuri Saini, MD

    104 Ischemic Stroke

    Safwan Jaradeh, MD

    105 Intracerebral and Subarachnoid Hemorrhage

    Safwan Jaradeh, MD

    106 Seizures

    Safwan Jaradeh, MD

    107 Parkinson’s Disease

    Safwan Jaradeh, MD

    108 Multiple Sclerosis

    Safwan Jaradeh, MD

    109 Peripheral Neuropathy

    Safwan Jaradeh, MD

    110 Guillain-Barré Syndrome

    Safwan Jaradeh, MD

    111 Amyotrophic Lateral Sclerosis

    Heidi Millard, MD

    112 Myasthenia Gravis

    Safwan Jaradeh, MD

    113 Migraine and Cluster Headaches

    Safwan Jaradeh, MD

    114 Coma and Brain Death

    Safwan Jaradeh, MD

    X. Oncology – Rajesh Gulati, MD

    115 Plasma Cell Dyscrasias

    Nareg Minaskeian, MD and Nikhil Shah, MD

    116 Lymphomas

    Jeffrey C. Wu, MD and Waheed Murad, MD

    117 Breast Cancer

    Hector D. Ludi, MD

    118 Colon Cancer

    Erum Iqbal Bajwa, MD and Rajesh Gulati, MD

    119 Lung Cancer

    Lawrence Kim, MD and Rajesh Gulati, MD

    120 Cervical, Endometrial, and Ovarian Cancers

    Vida Jahangiri, MD and Samir Kubba, MD

    121 Prostate Cancer

    Nareg Minaskeian, MD and Nikhil Shah, MD

    122 Pancreatic Cancer

    Naveenraj L. Solomon, MD and Hector D. Ludi, MD

    123 Thyroid Nodules and Thyroid Cancer

    Nareg Minaskeian, MD & Iqbal Munir, MD

    124 Paraneoplastic Syndromes

    Steven Zhao, MD and Rajesh Gulati, MD

    XI. Psychiatry – Gerald Maguire, MD and Sumanta Chaudhuri Saini, MD

    125 Depression

    Barbara C. Ackerman, PhD and John N. Ojinmah, MD

    126 Anxiety Disorders

    Sumanta Chaudhuri Saini, MD

    127 Schizophrenia

    Reba K. Bindra, MD

    128 Feeding and Eating Disorders

    Takesha J. Cooper, MD, Richard J. Lee, MD, and Bipin Patel, MD

    129 Somatic Disorders

    Jaswinder K. Walia, MD

    130 Substance Abuse and Dependence

    Jerry L. Dennis, MD and Kishore Desagani, MD

    131 Suicide and Overdose

    Sumanta Chaudhuri Saini, MD

    132 Trauma and Stress Related Disorders

    Niraj Gupta, MD

    133 Bipolar Disorder

    Matthew Chang, MD and Andrew Elliott, MD

    134 Attention Deficit Hyperactivity Disorder

    Bipin Patel, MD, Dennis B. Alters, MD, and Takesha J. Cooper, MD

    135 Personality Disorders

    Andrew Elliott, MD, and Richard J. Lee, MD

    XII. Pulmonary Diseases – Ramiz A. Fargo, MD and Roger C. Garrison, DO

    136 Pulmonary Function Testing

    Ramiz Fargo, MD and Shu-Yi Liao, MD

    137 Asthma

    Sumanta Chaudhuri Saini, MD

    138 Chronic Obstructive Pulmonary Disease

    Lakshmi K. Puvvula, MD and Ramiz Fargo, MD

    139 Interstitial Lung Disease

    Walter Klein, MD and Haik Yanashyan, MD

    140 Pleural Effusions

    Roger C. Garrison, DO

    141 Pneumothorax

    Mohamed Abu Qaoud, MD and Zebayel Baye, MD

    142 Obstructive Sleep Apnea

    Mohamed Abu Qaoud, DO and Siavash Farshidpanah, MD

    143 Venous Thromboembolic Disease

    Morteza Chitsazan, DO

    144 Asbestosis

    Daniel I. Kim, MD

    145 Sarcoidosis

    Earl Illano, MD

    146 The Solitary Pulmonary Nodule

    David M. Chooljian, MD and Shivani Scharf, DO

    147 Cystic Fibrosis and Bronchiectasis

    Benjamin Tabibian, DO

    148 Pulmonary Hypertension

    Ben Tabibian, DO and Siavash Farshidpanah, MD

    149 Acute Respiratory Distress Syndrome

    Walter Klein, MD

    150 Mycoses

    Made Sutjita, MD and Clare E. Robertson, MD

    XIII. Rheumatology – Karina D. Torralba, MD and Rajesh Gulati, MD

    151 Approach to Rheumatic Diseases

    Karina D. Torralba, MD

    152 Osteoarthritis

    Sajib Saha, MD and Francisco P. Quismorio Jr., MD

    153 Rheumatoid Arthritis

    Michelle Ngo, DO

    154 Systemic Lupus Erythematosus

    Adnan Misellati, MD, Chau L. Nguyen, DO, Joe R. Gamboa, MD, and Karina D. Torralba, MD

    155 Inflammatory Myopathies

    Chau L. Nguyen, DO and Kalpita Hatti, MD

    156 Systemic Sclerosis

    Alexander Friedman, DO and Rajesh Gulati, MD

    157 Vasculitis

    Mohini Pathria, MD and Emmanuel P. Katsaros, DO

    158 Sjögren’s Syndrome

    Emerson M. De Jesus, MD and Ioana Moldovan, MD

    159 Seronegative Spondyloarthropathies

    Joe R. Gamboa, MD and Nasim Daoud, MD

    160 Gout and Calcium Pyrophosphate Deposition Disease

    Marven G. Cabling, MD

    161 Infectious Arthritis

    Christina L. Chen, DO and Nasim Daoud, MD

    162 Fibromyalgia, Common Soft Tissue Disorders, and Chronic Pain Syndromes

    Sheila Lezcano, MD, Kalpita Hatti, MD, and Karina D. Torralba, MD

    163 Mixed Connective Tissue Disease

    Hoveda Mufti, MD

    164 Undifferentiated Connective Tissue Disease

    Karina D. Torralba, MD

    XIV. Ambulatory Medicine – Lawrence K. Loo, MD

    165 Disease Prevention and Screening

    Christine A. Duong, MD

    166 Smoking Cessation

    Shunling Tsang, MD and Peter J. Lee, MD

    167 Hypertension

    Philip W. Chui, MD and Rajesh Gulati, MD

    168 Obesity

    Amy Hayton, MD

    169 Dyslipidemias

    Amy Schill Depew, MD

    170 Osteoporosis

    Anita V. Phatak, MD

    171 Low Back Pain

    Lawrence K. Loo, MD

    172 Upper Respiratory Tract Infection

    Anita V. Phatak, MD

    173 Menstruation and Menopause

    Debra L. Stottlemeyer, MD

    174 Contraception

    Debra L. Stottlemeyer, MD

    175 Red Eye

    Amy Schill Depew, MD

    176 Erectile Dysfunction

    Shawn Koh, MD

    XV. Systems-Based Learning and Practice – Michael Nduati, MD

    177 Gender Differences

    Hoveda Mufti, MD and Ann M. Cheney, PhD

    178 Health Disparities

    Emma Simmons, MD and Olumide Makanju-ola Akingbemi, MD

    179 Care of LGBT Individuals

    Michael D. Hughes, MD

    180 Healthcare Delivery Systems

    Michael Nduati, MD

    181 Affordable Care Act

    Michael Nduati, MD

    182 Patient-Centered Medical Home

    Geoffrey W. Leung, MD

    183 HIPAA

    Peter J. Lee, MD and Shunling Tsang, MD

    184 Electronic Health Record

    Andrew G. Alexander, MD

    185 Medical Ethics

    Brandon Brown, PhD and Susan L. Brown, D. Bioethics

    186 Evidence-Based Medicine

    Lawrence K. Loo, MD

    187 Applied Epidemiology and Clinical Reasoning

    Lawrence K. Loo, MD

    Key Manifestations and Presentation of Diseases

    DOUGLAS HEGSTAD, MD AND LAWRENCE K. LOO, MD

    CHAPTER 1

    Abdominal Pain

    Andrew G. Alexander, MD

    Abdominal pain is one of the most common complaints seen in the outpatient, inpatient, and emergency room settings. While chronic abdominal pain does not generally carry a sense of diagnostic urgency, acute abdominal pain can have catastrophic results if diagnosis and subsequent evidence-based treatment is delayed. This chapter will predominately focus on acute abdominal pain of adults.

    ETIOLOGY AND UNDERLYING PATHOPHYSIOLOGY

    The origin of abdominal pain must be evaluated based upon its characteristics and in the context of the patient who is suffering from the pain.

    Visceral (organ) pain occurs due to stretching or inflammatory stimuli of the C-fiber and A-delta nerves within the visceral peritoneum layer surrounding the abdominal organs. Such painful stimuli are poorly localized by the patient and may be described as dull, cramping, or throbbing. Referral to the periumbilical region may also occur. Examples are appendicitis, gallstone disease, and small bowel obstruction.

    Parietal pain derives from stimulation of nerves in the peritoneum that lines the abdominal cavity. This sensation is sharp and localizes more precisely over the area of pathology. Examples include late appendicitis, cholecystitis, and diverticular abscess.

    Inflammatory responses, and therefore pain stimuli, may be blunted in geriatric patients. This reduces the symptoms and signs on initial presentation and can result in delayed diagnoses. Decreased inflammatory response can also occur in patients taking corticosteroids, tumor necrosis factor (TNF) inhibitors, patients with acquired or congenital immune defects, in organ transplant patients taking medications that inhibit host-versus graft reactions, and in patients taking chemotherapy. The individual interpretation of sensations and cultural expression of discomfort further modifies the sensation of pain. Some individuals are stoic, while others might rate a moderate discomfort as a 10 (on a 10-point pain scale). Administration of proper doses of opioid pain medications to patients with abdominal complaints was once thought to mask important physical findings, but such fears have not been confirmed in evidence-based analyses.

    The gender of the patient also modifies the differential diagnosis of abdominal pain. Many conditions occur in both sexes, while others do not. As patients age, the differential diagnosis list is again modified, with some diseases becoming less likely and others becoming more likely (Table 1.1).

    8300.png

    CLINICAL MANIFESTATIONS

    An understanding of the symptoms of acute pain is essential to a timely and accurate diagnosis. Reoccurring pain with increased symptoms over the first one to two days is commonly seen with acute appendicitis. A kidney stone may crescendo to its maximum level of discomfort within minutes to hours, while a ruptured abdominal aneurysm may begin and reach its peak within a matter of seconds.

    The location and duration of pain gives information about both the etiology as well as the stage of the disease. The initial visceral pain of an early appendicitis often presents as a vague epigastric or periumbilical pain. When the disease progresses to a transmural appendiceal inflammation sufficient to cause parietal peritoneal irritation, the pain symptom subsequently localizes to the right lower quadrant. Pain that disappears entirely, only to recur later, suggests a different differential diagnosis in a woman with episodic exacerbations of flank pain (e.g., recurrent kidney stones) compared to a woman with severe pain that regularly occurs at the time of menses. Colic is pain that quickly increases over minutes, reaches a peak, and then subsides. It is present in conditions where the smooth muscle of a hollow viscus attempts to contract proximal to a partial or complete obstruction. It is also seen in irritable bowel syndrome and any inflammatory condition of the intestine.

    Aggravating and relieving factors can give important diagnostic clues. Epigastric pain relieved by antacids is typical of acid peptic disease, but doesn’t rule out other etiologies. Epigastric pain not improved by antacids but improved by sitting forward is typical of pancreatitis. The gastric hydrochloric acid production associated with eating may worsen the abdominal pain of duodenal ulcers, yet the pain of gastric ulcers might be improved by food due to the acid diluting effect of food. If a gastric ulcer perforates through the posterior wall of the stomach, pain might radiate to the back. Blood exiting a gastric ulcer might pool in the right lower quadrant of the abdomen, imitating acute appendicitis.

    Pain that worsens after food intake is typical of gall bladder disease. Cholecystitis is the most common surgical condition of the abdomen in older Americans. Food-provoked pain can also occur with mesenteric ischemia, a condition caused by atherosclerosis with subsequent arterial insufficiency of the superior or inferior mesenteric arteries. The resultant intestinal angina results in severe generalized abdominal pain, loss of bowel sounds, and lactic acidosis. If an older patient has a tearing pain in the abdomen with radiation towards the back, strong consideration should be given to a dissecting aortic aneurysm. If the patient has cirrhosis, fever, ascites, and a tender abdomen, consider the diagnosis of spontaneous bacterial peritonitis.

    The most common diagnoses for acute abdominal pain in young adults are infectious gastroenteritis and irritable bowel syndrome. The onset of colic or cramps in waves with pain relieved in part by defecation of loose or watery stools is highly suggestive of either one. In additional, history that includes the presence of fever, nausea, vomiting, and malaise would give greater support to an infectious etiology. A history that included consumption of potato salad 6 to 12 hours prior to symptoms would add staph food poisoning to the differential diagnosis. Diarrhea with a history of antibiotic use in the past few weeks would promote the possibility of antibiotic associated colitis (Chapter 7).

    Appendicitis and cholecystitis are the most common surgical conditions that cause acute abdominal pain. Appendicitis usually presents with severe pain in the right lower abdominal quadrant. A careful history will often uncover that the pain began hours earlier as a periumbilical discomfort. Lack of appetite, decreased stooling, and low grade fevers are occasional features. The patient may walk in a bent-over position to decrease right lower quadrant (RLQ) pain. Tenderness will be confirmed during examination when a formal psoas sign may be elicited by noting increased RLQ tenderness as the examiner hyperextends the right hip, causing the iliopsoas muscle to contact an inflamed retrocecal appendix. The abdomen is typically most tender in the region one-third the distance between the right iliac crest and the umbilicus (known as McBurney’s point). Abdominal guarding is expected, but if generalized peritonitis has occurred, rebound tenderness and board like rigidity may be present.

    Gall bladder disease occurs in both sexes, but is most common in middle-aged women and the elderly. It is usually associated with gallstones (cholelithiasis) and a history of episodic post-prandial right upper abdominal pain (biliary colic). When fever is present, cholecystitis or ascending cholangitis become probable. Tenderness can be substantial with deep palpation under the right costal margin during inspiration (Murphy’s sign). If fever is absent and the complete blood count (CBC) shows no evidence of an increased white blood count (WBC), the diagnosis is more probably cholelithiasis with biliary spasm. Factors that increase the probability of gallstones and gallstone-related disease include family history, Native American ethnicity, advancing age, female gender, and obesity (Chapter 53).

    Pancreatitis presents with severe central abdominal pain that often radiates to the back. These symptoms can also be representative of other conditions, including penetrating gastric ulcer and ruptured abdominal aortic aneurysm. Pancreatitis is most often caused by an obstructing gallstone in the distal common bile duct but is also common among alcoholics and persons using combination antiretroviral therapy for HIV infection. When pancreatitis occurs, digestive enzymes are released and digest the pancreas itself. The resultant inflammation and necrosis causes extraordinary pain with central abdominal guarding, hypoactive bowel sounds, and rigidity. If substantial necrosis and hemorrhage of the pancreas has occurred, ecchymoses may be seen in the periumbilical region (Cullen’s sign) or bilateral flanks (Grey-Turner’s sign) of the patient (Chapter 54).

    Large intestine diverticula can occur anywhere throughout the colon and are common enough in elderly patients to be considered normal variants. Diverticula in the elderly can be a cause of lower gastrointestinal bleeding with vague or minimal symptoms of pain. When a diverticular outlet obstructs, it may infect and potentially perforate. The resultant diverticulitis can be a painful experience that includes fever, local phlegmon formation, and generalized lower abdominal tenderness. If inflammation reaches the parietal peritoneum, localized tenderness with guarding occurs over the site of the inflammation. Most infected or ruptured diverticula are found in the sigmoid colon, yielding pain and tenderness in the left lower quadrant. As with appendiceal ruptures, these leaks may form abscesses that become walled off with the aid of the greater omentum (Chapter 49).

    Inflammatory bowel diseases are associated with acute exacerbations of chronic pain. Ulcerative colitis may cause fever and bloody bowel movements in association with lower abdominal pain. Crohn’s disease may present with abdominal pain in the right lower quadrant (or anywhere in the abdomen) with fever, weight loss, and perhaps a bowel blockage or fistula (Chapter 47). Kidney stones cause intense colicky pain that typically starts in either the left or right costovertebral angles of the back and flanks. As the stone descends into the mid-ureter, the pain moves to the lower quadrant of the affected side and then towards the labia majora or scrotum as the renal calculus reaches the lower ureter.

    In women of child-bearing years, pain associated with ovulation, endometriosis, sexually transmitted infections (STIs), and ectopic pregnancy also cause acute abdominal pain. Ovulatory pain, called Mittelschmerz, occurs when ovarian follicular rupture is associated with enough blood and escaping fluid to irritate the peritoneum. This event causes a deep stabbing pain that occurs on day 14 of the menstrual cycle. Excruciating pain that occurs immediately before and during menses is more typical of endometriosis, while pain that occurs just after a cycle is more typical of Pelvic inflammatory disease (PID). Pain that occurs in a sexually active female of child-bearing age that has not had a menstrual period in the preceding four weeks could be due to an ectopic pregnancy (Chapter 173).

    Abdominal pain in women must include the full range of diagnoses that affect both genders. Even when the initial complaint is not pelvic in nature, tunnel vision must not diminish objectivity. Generalized peritonitis with right upper quadrant tenderness is usually GI or biliary in origin, but in women it could also be hepatic inflammation from a sexually transmitted infection (Fitz-Hugh-Curtis syndrome). When a pelvic exam is performed, pain encountered during manipulation of the cervix would suggest PID. Appropriate cultures and pelvic ultrasound should be performed. If fever, urinary frequency and flank pain are present, pyelonephritis must be considered as well.

    DIAGNOSTIC & KEY LABORATORY FINDINGS

    The initial bloodwork may confirm or categorize clinical impressions based upon the history and physical. An elevated white blood count (WBC) on a complete blood count test (CBC) should increase the clinical suspicion of infection, as is typical of acute diverticulitis, peritonitis, inflammatory bowel disease, abdominal abscess, or advanced appendicitis. Anemia (low hemoglobin) can be caused by many diseases; but, if acute, increases the likelihood for bleeding ulcers, ectopic pregnancy, or GI bleeds. Acute pancreatitis generally has a very high lipase; and, if severe, can be associated with high triglycerides, elevated C-reactive protein, and hypocalcemia. Ascending cholangitis elevates alkaline phosphatase, ectopic pregnancy gives a positive beta HCG, and a urinalysis with urine WBCs or WBC casts supports a diagnosis of urinary tract infection. An increased prothrombin time suggests longer-term dysfunction of the liver and highlights increased risks of bleeding. A high serum lactate level with a rigid abdomen could represent an ischemic or gangrenous bowel, diabetic ketoacidosis, or generalized shock. Ischemic bowel, whether from an incarcerated inguinal hernia, bowel adhesion, mesenteric artery embolism, or atherosclerotic mesenteric ischemia, requires urgent surgical intervention and carries a high mortality if not rapidly corrected.

    Imaging studies are an important part of the evaluation of the acute painful abdomen. This information is especially important since appendicitis, cholelithiasis, and bowel obstructions are often devoid of abnormalities on routine laboratory tests of serum and urine. Different imaging studies have different sensitivities and specificities for different organs. Ordering of tests, therefore, is based in part upon the regional anatomy as well as the disease processes being considered (Tables 1.1 and 1.2).

    Consideration for the effects of ionizing radiation and cost also influence selection of initial studies.

    8245.png

    TREATMENT

    Treatment should be evidence-based and linked to diagnoses. A proper diagnosis might be: right lower quadrant pain for one day, temperature of 38°, with a positive McBurney’s sign on exam, mild dehydration, low serum potassium, and normal CBC. The diagnosis may seem nebulous, but if it is stated at the Level-of Understanding, it is a correct diagnosis. The initial plan of treatment might be to get more history, order a CT of the abdomen, and to seek a surgical consult. If the abdomino-pelvic CT shows an enlarged appendix with an adjacent phlegmon and no other pathology, the updated diagnosis becomes acute appendicitis. Treatment should now include antibiotics in addition to intravenous (IV) fluids, electrolytes, and medical clearance for surgery.

    Treatment of infectious disorders of the abdomen must consider the regional bacterial flora. If perforation occurs within the foregut (proximal to the ligament of Trietz), the bacterial counts and anaerobic bacteria are less plentiful than if perforation were to occur in the ilium or colon. Antibiotic treatment for perforations of all upper and lower tract areas require coverage for gram negative, gram positive, and anaerobic organisms. Choices include ciprofloxacin plus metronidazole, imipenem, or piperacillin/tazobactam. Supportive measures include fluid administration sufficient for maintenance plus ongoing losses.

    Peritonitis quickly follows perforation of the bowel due to leakage of the air, chemicals, and bacterial contents of the GI tract. Supportive measures include sufficient IV fluid administration to account for maintenance needs plus the ongoing losses (third spacing) of fluids that rapidly leave the intravascular spaces for interstitial spaces, the peritoneal cavity, pleural cavities, or to enter the lumen of the gut itself. The patient should not eat or drink anything by mouth (NPO).

    Each treatment regimen will be specific to the diagnosis and to the patient who carries the diagnosis. Appendicitis is a surgical condition, and consultation must be obtained at the time the diagnosis is considered. IV fluids are given for the intravascular volume replacement needed to counter third-spacing. Antibiotics appropriate for gram positive, gram negative, and anaerobic bacteria are indicated.

    Cholecystitis is a surgical condition, but without significant anaerobic contamination. Antibiotic selection for cholecystitis could properly be any one of the first, second, or third generation cephalosporins. In cases of cholecystitis with sepsis, an immunocompromised state, or cholangitis, coverage would be broadened to include typical bowel perforation coverage (see above).

    Cholelithiasis with colic but without cholecystitis, is a common disorder that does not generally require surgery. It is important, therefore, to differentiate this less emergent condition from cholecystitis. Timely and accurate diagnosis often requires consultation with a gastroenterologist. Besides a skilled second opinion, the gastroenterologist can perform an esophagogastroduodenoscopy (EGD) or endoscopic retrograde cholangiopancreatography (ERCP) depending on the diagnosis suspected. Endoscopy allows visualization of the mucosa of the GI tract, the ability to coagulate bleeding vessels, biopsy tumors, and perform diagnostic tests for colonization with Helicobacter pylori. This intestinal bacterium increases the incidence of peptic ulcer disease and gastric neoplasia. H. pylori does not require immediate treatment, and can be eliminated with one of many oral antibiotic protocols after recovery from acute pain.

    Pancreatitis is treated medically, so long as ultrasound or CT does not show tumor, cysts, or obstructing gallstones. Analgesics and fluids are important in this painful disease. Elimination of food (NPO diet) and stomach acid (with IV omeprazole or similar H2 blocker) decreases the gastric stimulus to release digestive enzymes from the pancreas, thereby protecting the organ from digesting itself further. Antibiotics are not routinely indicated. If improvement is not seen within days, a feeding tube can be placed into the duodenum or jejunum to ensure proper nutrition. If an ultrasound shows gallstones in the common bile duct, an experienced gastroenterologist can perform an ERCP to delineate the anatomy of the biliary and pancreatic ducts, incise the sphincter (sphincterotomy) of Oddi to extract obstructing gallstones, sweep out retained common bile duct stones, and place a biliary stent to allow passage of more proximal retained stones. Cholecystectomy can be performed when the patient is stable.

    When treating non-gallstone pancreatitis, attention should be given to the other diagnoses. In the event of concurrent alcoholism, treatment of alcohol withdrawal and detoxification are critical. Other causes of pancreatitis include medications, infections, hyperlipidemia, trauma, and idiopathic.

    Diverticulitis causes inflammation of the bowel wall via passage of bacteria into or through the bowel wall. In either scenario, selection of antibiotics must cover gram negative, gram positive, and anaerobic bacteria. Should an abscess be seen on CT scan, the need for surgical drainage should be considered. Drainage is often performed by an interventional radiologist using a CT-guided catheter. Recurrent abscess formation from advanced diverticular disease requires a partial large bowel resection.

    Crohn’s disease and ulcerative colitis are chronic inflammatory bowel diseases with overlapping acute presentations. The fistulas and obstructions of Crohn’s disease often require surgical consultation. Ulcerative colitis is by definition a distal inflammation. Proper diagnosis often requires the colonoscopic skills of the gastroenterologist to define the extent and severity of disease. Unless bowel resection is considered, ulcerative colitis is treated medically with anti-inflammatory medications that may include steroids, mesalamine, and sometimes biologic therapies (anti-TNF, anti-integrins).

    Patients with ascites from any cause are at risk for spontaneous bacterial peritonitis (SBP). Fever, generalized abdominal tenderness, and an ascites polymorphonuclear neutrophil (PMN) count over 250 should be treated with an intravenous third generation cephalosporin, such as cefotaxime.

    Pyelonephritis often gives fever, flank tenderness, and a urinalysis demonstrating white blood cells (WBCs) and WBC casts. After urine and blood has been sent for culture, these patients should receive antibiotics that cover gram negative organisms. Initial choices include fluoroquinolones alone or ceftriaxone (with or without an aminoglycoside). If microscopic blood is seen on the urinalysis in a patient with severe colicky non-febrile flank pain, a renal calculus would top the list of possible diagnoses. An ultrasound or CT scan will show if the stone has obstructed the ureter (hydronephrosis). Antibiotics are not generally given for simple hydronephrosis, unless concurrent infection is present.

    Examination of a painful abdomen should always include a rectal examination. In addition to checking for tenderness, the presence of masses within reach of the examining glove and the presence or absence of blood as determined by stool guaiac testing provides valuable information. In females with abdominal symptoms, a bimanual pelvic exam is also indicated. Abnormal vaginal discharge, tenderness to motion of the cervix with the examining glove, tenderness in the adnexal regions, as well as discovery of masses are all important.

    Cervical motion tenderness (CMT) is an important sign in the diagnosis of pelvic inflammatory disease (PID). Treatment of uncomplicated PID is often done as an outpatient using a combination of intramuscular (IM) ceftriaxone (for gonococcus) and oral doxycycline (for chlamydia), pending receipt of cultures. Any suspicious adnexal masses, cysts, or abscesses that are found during the bimanual exam can be confirmed with ultrasonography. A pregnancy test is a must on all sexually active women of child bearing age with abdominal or pelvic pain. Early pregnancies and ectopic pregnancies are easily missed unless they are considered in the differential diagnosis.

    COMMON COMPLICATIONS

    Complications occur with every disease and will never be completely eliminated. Avoidable diagnostic delay on the part of the patient or medical team, however, is the most serious complication of acute abdominal pain. Any delay in presentation or diagnosis of a patient with acute appendicitis increases the probability of appendiceal rupture and development of peritonitis and/or a periappendiceal abscess. If the patient is elderly, using steroids, or immune modulating drugs, the inflammatory response may not be dramatic enough to cause pain until the appendix is at the bursting stage. Delayed diagnosis can occur with acute cholecystitis or any disease in which age or anti-inflammatory drugs have moderated the body’s inflammatory responses.

    The complications of pancreatitis are due in large part to the loss of endocrine and exocrine functions of the organ. Malabsorption may require digestive enzyme supplements, while hyperglycemia might require insulin shots. Protracted courses of acute pancreatitis often require total parenteral nutrition (TPN) to provide sufficient intravenous nutrition for healing. Cysts can occur within the organ and hemorrhagic pancreatitis can cause great morbidity and mortality. Pain can become chronic and recurrent.

    PID can cause chronic pelvic pain due to the scar tissue formation of adhesive bands (i.e., adhesions). Scar tissue and inflammation of the fallopian tubes can cause infertility and increase the incidence of tubal pregnancies.

    Crohn’s disease can give rise to sinuses and fistulae that pass bowel content from one segment of bowel lumen to other areas of the GI tract, as well as to the skin, vagina, or bladder. Adhesions can bind pieces of bowel together and sometimes cause partial or complete bowel obstructions. Treatment includes non-steroidal, steroidal, and biologic anti-inflammatory drugs, which themselves cause a plethora of complications. Surgery is occasionally

    Enjoying the preview?
    Page 1 of 1