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Fifth Edition
Edited by
The Massachusetts General Hospital
Handbook of Internal Medicine
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Executive Editor: Rebecca Gaertner
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All rights reserved. This book is protected by copyright. No part of this book may
be reproduced in any form by any means, including photocopying, or utilized by any
information storage and retrieval system without written permission from the copyright
owner, except for brief quotations embodied in critical articles and reviews. Materials
appearing in this book prepared by individuals as part of their official duties as U.S.
government employees are not covered by the above-mentioned copyright.
Printed in China
Library of Congress Cataloging-in-Publication Data
Pocket medicine (Sabatine)
Pocket medicine / [edited by] Marc S. Sabatine. Fifth edition.
p. ; cm.
Preceded by Pocket medicine / edited by Marc S. Sabatine. 4th ed.
Includes bibliographical references and index.
ISBN-13: 978-1-4511-8237-8
ISBN-10: 1-4511-8237-6
ISBN-13: 978-1-4511-8887-5
ISBN-10: 1-4511-8887-0
I. Sabatine, Marc S., editor of compilation. II. Title.
[DNLM: 1. Internal MedicineHandbooks. 2. Clinical MedicineHandbooks. WB 39]
DISCLAIMER Care has been taken to confirm the accuracy of the information pre-
sented and to describe generally accepted practices. However, the authors, editors, and
publisher are not responsible for errors or omissions or for any consequences from
application of the information in this book and make no warranty, expressed or implied,
with respect to the currency, completeness, or accuracy of the contents of the publica-
tion. Application of the information in a particular situation remains the professional
responsibility of the practitioner.
The authors, editors, and publisher have exerted every effort to ensure that drug
selection and dosage set forth in this text are in accordance with current recommendations
and practice at the time of publication. However, in view of ongoing research, changes in
government regulations, and the constant flow of information relating to drug therapy and
drug reactions, the reader is urged to check the package insert for each drug for any change
in indications and dosage and for added warnings and precautions. This is particularly
important when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in the publication have Food and Drug
Administration (FDA) clearance for limited use in restricted research settings. It is the
responsibility of the health care provider to ascertain the FDA status of each drug or
device planned for use in their clinical practice.
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Contributing Authors vi
Foreword ix
Preface x
Neal A. Chatterjee, Ada Stefanescu, William J. Hucker, David M. Dudzinski,
Marc S. Sabatine, Michelle ODonoghue
Electrocardiography 1-1
Chest Pain 1-3
Noninvasive Evaluation of CAD 1-4
Coronary Angiography and Revascularization 1-5
Acute Coronary Syndromes 1-6
PA Catheter and Tailored Therapy 1-12
Heart Failure 1-14
Cardiomyopathies 1-17
Valvular Heart Disease 1-20
Pericardial Disease 1-25
Hypertension 1-28
Aortic Aneurysms 1-30
Acute Aortic Syndromes 1-31
Arrhythmias 1-32
Atrial Fibrillation 1-35
Syncope 1-37
Intracardiac Devices 1-39
Cardiac Risk Assessment for Noncardiac Surgery 1-40
Peripheral Artery Disease 1-41
Ian J. Barbash, Kathryn A. Hibbert, Atul Malhotra
Dyspnea 2-1
Pulmonary Function Tests 2-1
Asthma 2-2
Anaphylaxis 2-4
Chronic Obstructive Pulmonary Disease 2-5
Hemoptysis 2-7
Bronchiectasis 2-7
Solitary Pulmonary Nodule 2-8
Obstructive Sleep Apnea 2-8
Interstitial Lung Disease 2-9
Pleural Effusion 2-11
Venous Thromboembolism 2-13
Pulmonary Hypertension 2-16
Respiratory Failure 2-18
Mechanical Ventilation 2-19
Acute Respiratory Distress Syndrome 2-22
Sepsis 2-23
Zachary A. Zator, Andrew S. de Lemos, Lawrence S. Friedman
Esophageal and Gastric Disorders 3-1
Gastrointestinal Bleeding 3-3
Diarrhea, Constipation and Ileus 3-5
Diverticular Disease 3-9
Inflammatory Bowel Disease 3-10
Intestinal Ischemia 3-12
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Pancreatitis 3-13
Abnormal Liver Tests 3-15
Hepatitis 3-17
Acute Liver Failure 3-20
Cirrhosis 3-21
Hepatic Vascular Disease 3-25
Ascites 3-26
Biliary Tract Disease 3-27
Andrew S. Allegretti, Andrew L. Lundquist, Hasan Bazari
Acid-Base Disturbances 4-1
Sodium and Water Homeostasis 4-6
Potassium Homeostasis 4-10
Renal Failure 4-12
Glomerular Disease 4-16
Urinalysis 4-18
Nephrolithiasis 4-19
Andrew M. Brunner, Sheheryar K. Kabraji, Mark M. Awad, Andrew J. Aguirre,
Daniel J. DeAngelo, David P. Ryan
Anemia 5-1
Disorders of Hemostasis 5-6
Platelet Disorders 5-7
Coagulopathies 5-10
Hypercoagulable States 5-11
Disorders of Leukocytes 5-12
Transfusion Therapy 5-13
Myelodysplastic Syndromes 5-14
Myeloproliferative Neoplasms 5-15
Leukemia 5-17
Lymphoma 5-21
Plasma Cell Dyscrasias 5-24
Hematopoietic Stem Cell Transplantation 5-26
Lung Cancer 5-28
Breast Cancer 5-30
Prostate Cancer 5-32
Colorectal Cancer 5-33
Chemotherapy Side Effects 5-34
Pancreatic Tumors 5-35
Oncologic Emergencies 5-36
Cancer of Unknown Primary Site 5-37
Ana A. Weil, Emily P. Hyle, Nesli Basgoz
Pneumonia 6-1
Fungal Infections 6-3
Infections in Immunosuppressed Hosts 6-4
Urinary Tract Infections 6-5
Soft Tissue and Bone Infections 6-6
Infections of the Nervous System 6-9
Bacterial Endocarditis 6-12
Tuberculosis 6-15
Tick-Borne Diseases 6-20
Fever Syndromes 6-22
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Kelly B. Lauter, Marc N. Wein, Michael Mannstadt
Pituitary Disorders 7-1
Thyroid Disorders 7-3
Adrenal Disorders 7-7
Calcium Disorders 7-11
Diabetes Mellitus 7-13
Lipid Disorders 7-16
Zachary S. Wallace, Eli Miloslavsky, Robert P. Friday
ArthritisOverview 8-1
Rheumatoid Arthritis 8-3
Adult Onset Stills Disease & Relapsing Polychondritis 8-4
Crystal Deposition Arthritides 8-5
Seronegative Spondyloarthritis 8-7
Infectious Arthritis & Bursitis 8-9
Connective Tissue Diseases 8-11
Systemic Lupus Erythematosus 8-15
Vasculitis 8-17
IgG4-Related Disease 8-20
Cryoglobulinemia 8-21
Amyloidosis 8-22
Michael P. Bowley, Todd M. Herrington, Eyal Y. Kimchi, Sarah Wahlster,
Tracey A. Cho
Change in Mental Status 9-1
Seizures 9-3
Alcohol Withdrawal 9-5
Stroke 9-6
Weakness & Neuromuscular Dysfunction 9-8
Headache 9-10
Back and Spinal Cord Disease 9-11
Kiran H. Lagisetty, Jennifer F. Tseng, Katherine T. Chen, Stella K. Kim
Surgical Issues 10-1
Ob/Gyn Issues 10-3
Ophthalmic Issues 10-4
ICU Medications & Treatment of Hypotension/Shock 11-1
Antibiotics 11-3
Formulae and Quick Reference 11-4
Radiology P-1
Echocardiography & Coronary Angiography P-9
Peripheral Blood Smears & Leukemias P-13
Urinalysis P-15
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Andrew J. Aguirre, MD, PhD
Hematology-Oncology Fellow, Dana-Farber/Partners CancerCare
Hematology/Oncology Program
Andrew S. Allegretti, MD
Internal Medicine Resident, Massachusetts General Hospital
Mark M. Awad, MD, PhD
Hematology-Oncology Fellow, Dana-Farber/Partners CancerCare
Hematology/Oncology Program
Ian J. Barbash, MD
Internal Medicine Resident, Massachusetts General Hospital
Nesli Basgoz, MD
Associate Chief and Clinical Director, Infectious Disease Division,
Massachusetts General Hospital
Associate Professor of Medicine, Harvard Medical School
Hasan Bazari, MD
Clinical Director, Nephrology Unit, Massachusetts General Hospital
Program Director, Internal Medicine Residency, Massachusetts
General Hospital
Associate Professor of Medicine, Harvard Medical School
Michael P. Bowley, MD, PhD
Neurology Resident, Partners Neurology Residency
Andrew M. Brunner, MD
Internal Medicine Resident, Massachusetts General Hospital
Neal A. Chatterjee, MD
Internal Medicine Resident, Massachusetts General Hospital
Katherine T. Chen, MD, MPH
Associate Professor of Obstetrics, Gynecology, and Reproductive Science
Associate Professor of Medical Education
Vice-Chair of Ob/Gyn Education, Career Development, and Mentorship
Icahn School of Medicine at Mount Sinai, New York
Tracey A. Cho, MD
Associate Program Director, Partners-Harvard Neurology Residency
Assistant Professor of Neurology, Harvard Medical School
Assistant Neurologist, Massachusetts General Hospital
Andrew S. de Lemos, MD
Transplant Hepatology Fellow, Massachusetts General Hospital
Daniel J. DeAngelo, MD, PhD
Adult Leukemia Program, Dana-Farber Cancer Institute & Brigham
and Womens Hospital
Associate Professor of Medicine, Harvard Medical School
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David M. Dudzinski, MD, JD
Cardiology Fellow, Massachusetts General Hospital
Robert P. Friday, MD, PhD
Attending Physician, Rheumatology Unit, Massachusetts General Hospital
Associate Director, Rheumatology Fellowship Program, Massachusetts
General Hospital
Instructor in Medicine, Harvard Medical School
Lawrence S. Friedman, MD
Anton R. Fried, MD, Chair, Department of Medicine, Newton-Wellesley
Assistant Chief of Medicine, Massachusetts General Hospital
Professor of Medicine, Harvard Medical School
Professor of Medicine, Tufts University School of Medicine
Todd M. Herrington, MD, PhD
Neurology Resident, Partners Neurology Residency
Kathryn A. Hibbert, MD
Pulmonary and Critical Care Fellow, Harvard Medical School
William J. Hucker, MD, PhD
Cardiology Fellow, Massachusetts General Hospital
Emily P. Hyle, MD
Assistant in Medicine, Infectious Disease Division, Massachusetts
General Hospital
Instructor in Medicine, Harvard Medical School
Sheheryar K. Kabraji, BM, BCh
Internal Medicine Resident, Massachusetts General Hospital
Stella K. Kim, MD
Director, Clinical Research in Opthalmology
Director, Opthalmology Residency Rotation Program
Associate Professor of Opthalmology
UT MD Anderson Cancer Center
Eyal Y. Kimchi, MD, PhD
Neurology Resident, Partners Neurology Residency
Kiran H. Lagisetty, MD
Surgical Resident, Beth Israel Deaconess Medical Center
Kelly B. Lauter, MD, PhD
Internal Medicine Resident, Massachusetts General Hospital
Andrew L. Lundquist, MD
Nephrology Fellow, BWH/MGH Joint Nephrology Fellowship Program
Atul Malhotra, MD
Associate Physician, Divisions of Pulmonary & Critical Care and Sleep
Medicine, Brigham and Womens Hospital
Associate Professor of Medicine, Harvard Medical School
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Michael Mannstadt, MD
Attending Physician, Endocrine Unit, Massachusetts General Hospital
Assistant Professor of Medicine, Harvard Medical School
Eli Miloslavsky, MD
Rheumatology Fellow, Massachusetts General Hospital
Michelle ODonoghue, MD, MPH
Investigator, TIMI Study Group and Associate Physician, Cardiovascular
Division, Brigham and Womens Hospital
Affiliate Physician, Cardiology Division, Massachusetts General Hospital
Assistant Professor of Medicine, Harvard Medical School
David P. Ryan, MD
Clinical Director, Massachusetts General Hospital Cancer Center
Chief of Hematology/Oncology, Massachusetts General Hospital
Associate Professor of Medicine, Harvard Medical School
Marc S. Sabatine, MD, MPH
Chairman, TIMI Study Group and Physician, Cardiovascular Division,
Brigham and Womens Hospital
Affiliate Physician, Cardiology Division, Massachusetts General Hospital
Associate Professor of Medicine, Harvard Medical School
Ada Stefanescu, MD, CM
Internal Medicine Resident, Massachusetts General Hospital
Jennifer F. Tseng, MD, MPH
Chief, Division of Surgical Oncology, Beth Israel Deaconess Medical
Associate Professor of Surgery, Harvard Medical School
Sarah Wahlster, MD
Neurology Resident, Partners Neurology Residency
Zachary S. Wallace, MD
Internal Medicine Resident, Massachusetts General Hospital
Ana A. Weil, MD, MPH
Internal Medicine Resident, Massachusetts General Hospital
Marc N. Wein, MD, PhD
Endocrinology Fellow, Massachusetts General Hospital
Zachary A. Zator, MD
Internal Medicine Resident, Massachusetts General Hospital
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To the 1st Edition
It is with the greatest enthusiasm that I introduce Pocket Medicine. In an era of
information glut, it will logically be asked, Why another manual for medical house
officers? Yet, despite enormous information readily available in any number of
textbooks, or at the push of a key on a computer, it is often that the harried house
officer is less helped by the description of differential diagnosis and therapies than
one would wish.
Pocket Medicine is the joint venture between house staff and faculty expert in
a number of medical specialties. This collaboration is designed to provide a rapid
but thoughtful initial approach to medical problems seen by house officers with
great frequency. Questions that frequently come from faculty to the house staff on
rounds, many hours after the initial interaction between patient and doctor, have
been anticipated and important pathways for arriving at diagnoses and initiating
therapies are presented. This approach will facilitate the evidence-based medicine
discussion that will follow the workup of the patient. This well-conceived hand-
book should enhance the ability of every medical house officer to properly evalu-
ate a patient in a timely fashion and to be stimulated to think of the evidence
supporting the diagnosis and the likely outcome of therapeutic intervention. Pocket
Medicine will prove to be a worthy addition to medical education and to the care
of our patients.
Physician-in-Chief, Massachusetts General Hospital
Jackson Professor of Clinical Medicine, Harvard Medical School
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To my parents, Matt and Lee Sabatine, to their namesake
grandchildren Matteo and Natalie, and to my wife Jennifer
Written by residents, fellows and attendings, the mandate for Pocket Medicine
was to provide, in a concise a manner as possible, the key information a clini-
cian needs for the initial approach to and management of the most common
inpatient medical problems.
The tremendous response to the previous editions suggests we were able
to help fill an important need for clinicians. With this fifth edition come several
major improvements including a thorough updating of every topic, the addition
of several new topics (including treatment of anaphylaxis, approach to inpatient
nutritional issues, chemotherapy side effects, and workup of a fever in a recent
traveler), and inclusion of additional photomicrographs. We have also added a
new section on Consults in which non-internal medicine specialists provide
expert guidance in terms of establishing a differential diagnosis for common
presenting symptoms and initiating an evaluation in anticipation of calling a
consult. As always, we have incorporated key references to the most recent
high-tier reviews and important studies published right up to the time Pocket
Medicine went to press. We welcome any suggestions for further improvement.
Of course medicine is far too vast a field to ever summarize in a textbook
of any size. Long monographs have been devoted to many of the topics discussed
herein. Pocket Medicine is meant only as a starting point to guide one during the
initial phases of diagnosis and management until one has time to consult more
definitive resources. Although the recommendations herein are as evidence-based
as possible, medicine is both a science and an art. As always, sound clinical judge-
ment must be applied to every scenario.
I am grateful for the support of the house officers, fellows, and attendings at
the Massachusetts General Hospital. It is a privilege to work with such a knowl-
edgeable, dedicated, and compassionate group of physicians. I always look back on
my time there as Chief Resident as one of the best experiences I have ever had.
I am grateful to several outstanding clinical mentors, including Hasan Bazari, Larry
Friedman, Nesli Basgoz, Mort Swartz, Eric Isselbacher, Bill Dec, Mike Fifer, and
Roman DeSanctis, as well as the late Charlie McCabe and Peter Yurchak.
This edition would not have been possible without the help of two individuals
in the TIMI Study Group Chairmans Office. Melinda Cuerda, my academic coordina-
tor, was an invaluable resource for this edition. She shepherded every aspect of the
project from start to finish, with an incredible eye to detail to ensure that each page
of this book was the very best it could be. Pamela Melhorn, my executive assistant,
expertly manages the Chairmans Office, miraculously coordinating the complex
clinical, research, and educational missions.
Lastly, special thanks to my parents for their perpetual encouragement and
love and, of course, to my wife, Jennifer Tseng, who, despite being a surgeon, is my
closest advisor, my best friend and the love of my life.
I hope that you find Pocket Medicine useful throughout the arduous but
incredibly rewarding journey of practicing medicine.
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