POCKET

NOTEBOOK

Po

DICINE
Fifth Edition

Edited by

MARC s. SABATINE, MD, MPH

ASSOCIATE PROFESSOR OF MEDICINE
HARVARD MEDICAL SCHOOL

The Massachusetts General H_ospital

.
\ Handbook if Internal Med1c1ne
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Pocket medicine (Sabatine)
Pocket medicine I [edited by] Marc S. Sabatine.- Fifth edition.
p.;cm.
Preceded by Pocket medicine I edited by Marc S. Sabatine. 4th ed.
c2011.
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. T itle.
[DNLM: 1. Internal Medicine-Handbooks. 2. Clinical Medicine-Handbooks.

WB 39]

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Contributing Authors

VI

Foreword

IX

Preface

CARDIOLOGY
Neal A. Chatterjee, Ada Stefanescu, William}. Hucker, David M. Dudzinski,
Marc S. Sabatine, Michelle O'Donoghue
Electrocardiography
Chest Pain
Noninvasive Evaluation of C AD
Coronary Angiography and Revascularization
Acute Coronary Syndromes
PA Catheter and Tailored Therapy
Heart Failure
Cardiomyopathies
Valvular Heart Disease
Pericardia! Disease
Hypertension
Aortic Aneurysms
Acute Aortic Syndromes
Arrhythmias
Atrial Fibrillation
Syncope
lntracardiac Devices
Cardiac Risk Assessment for Noncardiac Surgery
Peripheral Artery Disease

1-1
1-3
1-4
1-5
1-6
1-12
1-14
1-17
1-20
1-25
1-28
1-30
1-31
1-32
1-35
1-37
1-39
1-40
1-41

PULMONARY
fan J. Barbash, Kathryn A. Hibbert, Atul Malhotra
Dyspnea
Pulmonary Function Tests
Asthma
Anaphylaxis
Chronic Obstructive Pulmonary Disease
Hemoptysis
Bronchiectasis
Solitary Pulmonary Nodule
Obstructive Sleep Apnea
Interstitial Lung Disease
Pleural Effusion
Venous Thromboembolism
Pulmonary Hypertension
Respiratory Failure
Mechanical Ventilation
Acute Respiratory Distress Syndrome
Sepsis

2-1
2-1
2-2
2-4
2-5
2-7
2-7
2-8
2-8
2-9
2-11
2-13
2-16
2-18
2-19
2-22
2-23

GASTROENTEROLOGY
Zachary A. Zator, Andrew S. de Lemos, Lawrence S. Friedman
Esophageal and Gastric Disorders
Gastrointestinal Bleeding
Diarrhea, Constipation and Ileus
Diverticular Disease
Inflammatory Bowel Disease
Intestinal Ischemia

3-1
3-3
3-5
3-9
3-10
3-12

Pancreatitis
Abnormal Liver Tests
Hepatitis
Acute Liver Failure
Cirrhosis
Hepatic Vascular Disease
Ascites
Biliary Tract Disease

3-13
3-15
3-17
3-20
3-21
3-25
3-26
3-27

NEPHROLOGY
AndrewS. Allegretti, Andrew L Lundquist, Hasan Bazari
Acid-Base Disturbances
Sodium and Water Homeostasis
Potassium Homeostasis
Renal Failure
Glomerular Disease
Urinalysis
Nephrolithiasis

4-1
4-6
4-10
4-12
4-16
4-18
4-19

HEMATOLOGONCOLOGY
Andrew M. Brunner, Sheheryar K. Kabraji, Mark M. Awad, Andrew J. Aguirre,
Daniel J. DeAngelo, David P. Ryan
Anemia
Disorders of Hemostasis
Platelet Disorders
Coagulopathies
Hypercoagulable States
Disorders of Leukocytes
Transfusion T herapy
Myelodysplastic Syndromes
Myeloproliferative Neoplasms
Leukemia
Lymphoma
Plasma Cell Dyscrasias
Hematopoietic Stem Cell Transplantation
Lung Cancer
Breast Cancer
Prostate Cancer
Colorectal Cancer
Chemotherapy Side Effects
Pancreatic Tumors
Oncologic Emergencies
Cancer of Unknown Primary Site

5-1
5-6
5-7
5-10
5-11
5-12
5-13
5-14
5-15
5-17
5-21
5-24
5-26
5-28
5-30
5-32
5-33
5-34
5-35
5-36
5-37

INFECTIOUS DISEASES
Ana A. Wei/, Emily P. Hyle, Nesli Basgoz
Pneumonia
Fungal Infections
Infections in Immunosuppressed Hosts
Urinary Tract Infections
Soft T issue and Bone Infections
Infections of the Nervous System
Bacterial Endocarditis
Tuberculosis
HIV/AIDS
T ick-Borne Diseases
Fever Syndromes

6-1
6-3
6-4
6-5
6-6
6-9
6-12
6-15
6-17
6-20
6-22

ENDOCRIN OLOGY
Kelly B. Lauter, Marc N. Wein, Michael Mannstadt
Pituitary Disorders
Thyroid Disorders
Adrenal Disorders
Calcium Disorders
Diabetes Mellitus

7-1
7-3
7-7
7-11
7-13

Lipid Disorders

7-16

RHEUMATOLOGY
Zachary S. Wallace, Eli Miloslavsky, Robert P. Friday
Arthritis-Overview
Rheumatoid Arthritis
Adult Onset Still's Disease & Relapsing Polychondritis
Crystal Deposition Arthritides
Seronegative Spondyloarthritis
Infectious Arthritis & Bursitis
Connective Tissue Diseases
Systemic Lupus Erythematosus
Vasculitis
lgG4-Related Disease
Cryoglobulinemia

8-1
8-3
8-4
8-5
8-7
8-9
8-11
8-15
8-17
8-20
8-21

Amyloidosis

8-22

NEUROLOGY
Michael P. Bowley, Todd M. Herrington, Eyal Y. Kimchi, Sarah Wahlster,
Tracey A. Cho
9-1
9-3
9-5

Change in Mental Status

Seizures
Alcohol W ithdrawal
Stroke
Weakness & Neuromuscular Dysfunction
Headache

9-6
9-8
9-10

Back and Spinal Cord Disease

9-11

CONS ULTS
Kiron H. Lagisetty, Jennifer F. Tseng, Katherine T. Chen, Stella K Kim
Surgical Issues
Ob/Gyn Issues

10-1
10-3

Ophthalmic Issues

10-4

AP PENDIX
ICU Medications & Treatment of Hypotension/Shock
Antibiotics

11-1
11-3

Formulae and Quick Reference

11-4

ABBREVIATIONS

12-1

INDEX

1-1

PHOTO INSER TS
Radiology
Echocardiography & Coronary Angiography
Peripheral Blood Smears & Leukemias

P-1
P-9
P-13

Urinalysis

P-15

ACLS

ACLS-1

Andrew J. Aguirre, MD, PhD

Hematology -Oncology Fellow, Dana-Farber/Partners CancerCare
Hematology /Oncology Program
AndrewS. Allegretti, MD
Internal Medicine Resident, Massachusetts General Hospital
Mark M.Awad, MD, PhD
Hematology -Oncology Fellow, Dana-Farber/Partners CancerCare
Hematology /Oncology Program
lan 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, Gy necology, and Reproductive Science
Associate Professor of Medical Education
Vice-Chair of Ob/Gy n Education, Career Development, and Mentorship
lcahn 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
AndrewS. de Lemos, MD
Transplant Hepatology Fellow, Massachusetts General Hospital
D aniel

J. D eAngelo,

MD, PhD

Adult Leukemia Program, Dana-Farber Cancer Institute & Brigham

and Women's Hospital
Associate Professor of Medicine, Harvard Medical School

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
Hospital
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
Kathry n A. Hibbert, MD
Pulmonary and Critical Care Fellow, Harvard Medical School
William J. Hucker, MD, PhD
Cardiology Fellow, Massachusetts General Hospital
Emily P. Hy le, 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
EyaiY. 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, BW H/MGH Joint Nephrology Fellowship Program
Atul Malhotra, MD
Associate Physician, Divisions of Pulmonary & Critical Care and Sleep
Medicine, Brigham and Women's Hospital
Associate Professor of Medicine, Harvard Medical School

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 O'D onoghue, MD, MPH

Investigator, TIMI Study Group and Associate Physician, Cardiovascular
Division, Brigham and Women's Hospital
Affiliate Physician, Cardiology Division, Massachusetts General Hospital
Assistant Professor of Medicine, Harvard Medical School

D avid P. Ry an, MD
Clinical Director, Massachusetts General Hospital Cancer Center
Chief of Hematology/Oncology, Massachusetts General Hospital
Associate Professor of Medicine, Harvard Medical School

Mar c S. Sabatine, MD, MPH

Chairman, TIMI Study Group and Physician, Cardiovascular Division,
Brigham and Women's Hospital
Affiliate Physician, Cardiology Division, Massachusetts General Hospital
Associate Professor of Medicine, Harvard Medical School

Ada Stefanescu, MD, C M

Internal Medicine Resident, Massachusetts General Hospital

Jennifer F. Tseng, MD , MPH

Chief, Division of Surgical Oncology, Beth Israel Deaconess Medical
Center
Associate Professor of Surgery, Harvard Medical School

Sar ah Wahlster, MD
Neurology Resident, Partners Neurology Residency

Zachary S.Wallace, MD
Internal Medicine Resident, Massachusetts General Hospital

AnaA.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

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 pathway s 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.

DENNIS A.AUSIELLO, MD

Physician-in-Chief, Massachusetts General Hospital

Jackson Professor of Clinical Medicine, Harvard Medical School

To my parents, Matt and Lee Sabatine, to their namesake

grandchildren Matteo and Natalie, and to my wife jennifer
W ritten 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. W ith this fifth edition come several
major improvements including a thorough updating of ever y 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 ever y 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, Larr y
Friedman, Nesli Basgoz, Mort Swartz, Eric lsselbacher, 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 TIM I Study Group Chairman's 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 ver y best it could be. Pamela Melhorn, my executive assistant,
expertly manages the Chairman's 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.
MARC S. SABATINE, MD, MPH

Approach

(a systematic approach is vital)

Rate (? tachy, brady) and rhythm (? relationship between P and QRS)

Intervals (P R, QRS, QT) and axis (? LAD or RAD )

LAA and/or RAA, ? LVH and/or RVH)

Chamber abnormality (?

QRST changes(? Q waves,poor R -wave progression v,-V6,ST iH or T-wave s)

Figure 1-1 QRS axis

Left axis deviation (LAD)

Definition: axis beyond -30 (S > R in lead II)

Etiologies: LVH, LBBB, inferior Ml,WPW

aVR

aVL

-150

Left anterior fascicular block: LAD -45 to

-30

-90 and qR in aVL and QRS <120 msec

no other cause of LAD (eg, IMI)

and

Right axis deviation (RAD)

Definition: axis beyond +90 (S > R in lead I)

septal defects,lateral MI,WPW

aVF

Etiologies: RVH,P E,COPD (usually not > +110 ,

Left posterior fascicular block: RAD 90--180

and rS in I & aVL and qR in Ill & aVF and

QRS <120 msec and no other cause of RAD
Bundle Branch Blocks (Circ 2009;119:e235)

Normal

RBBB

v1

I Initial depol. is left-to-right across septum (r in v, & q in V6;

nb,absent in LBBB) followed by LV & RV free wall,with LV

dominating (nb,RV depol. later and visible in RBBB).

-Jv'-

vflv

LBBB
I

1. QRS 120 msec 110-119

incomplete)
2. r SR' in R precordial leads ry,,V2)
=

3. Wide S wave in I and V6

4.

STJ, or T WI in R precordial leads

1. QRS 120 msec 110-119

incomplete)
2. Broad,slurred,monophasic R in I,a VL,Vs-V6
=

( RS in

Vs-V6 if cardiomegaly)

3. Absence of Q in I,Vs and V6 (may have narrow q in a VL)

4. Displacement of ST & Tw opposite major QRS deflection
5.

PRWP, LAD,Qw 's in inferior leads

Bifascicular block: RBBB + LAFB/LPFB

Prolonged QT interval (NEJM 2008;358:169; www.torsades.org

QT measured from beginning of QRS complex to end of T wave (measure longest QT)
QT varies w/ HR correct w/ Bazett formula: QTc

QT/-vRR (in sec),

formula inaccurate at very high and low HR (nl QTc <440 msec o and <460 msec

C()

QT prolongation a/w i risk TdP (esp. >500 msec); perform baseline/serial ECGs if using
QT prolonging meds,no estab guidelines for stopping Rx if QT prolongs

Etiologies:

Antiarrhythmics: class Ia (procainamide,disopyramide),class Ill (amiodarone,sotalol)

Psych drugs: antipsychotics (phenothiazines,haloperidol,atypicals), Li,? SSRI,TCA
Antimicrobials: macrolides,quinolones,azoles, pentamidine, atovaquone,atazanavir
Other: antiemetics (droperidol, S-HT3 antagonists),alfuzosin, methadone,ranolazine
Electrolyte disturbances: hypoCa (nb,hyperCa a/w J, QT),? hypoK,? hypoMg

Autonomic dysfxn: ICH (deep TWI),stroke,carotid endarterectomy,neck dissection

Congenital (long QT syndrome): K,Na,Ca channelopathies (Circ 2013;127:126)
Mise: CAD,CMP, bradycardia,high-grade AVB,hypothyroidism,hypothermia,BBB

. ave.

Crtera

Left Atrial Abnormality (LAA)

>4

>120 msec

11

or

V
1

sec
r

I >1mm

Right Atrial Abnormality (RAA)

II

Jt :

2. mm

or

i'v

>1.5mm

Left ventricular hypertrophy (LVH) (Circ 2009;119:e251)

Etiologies: HTN,A S/A I,HCMP, coarctation of aorta

Criteria (all w/ Se <50%, Sp >85%; accuracy affected by age,sex,race,BMI)
Romhilt-Estes point-score system: 4 points

probable,5 points

definite

i Amplitude (any of the following): largest R or S in limb leads 20 mm

30 mm orR in Ys or V6 30 mm 3 points)

or

S in V, or V2

ST displacement opposite to QRS deflection: w/o dig 3 points); w/ dig 1 point)

LAA (3 points); LAD (2 points); QRS duration 90 msec (1 point)