Kochar's Clinical Medicine for Students: Sixth Edition
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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.
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)
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Kochar's Clinical Medicine for Students - Mahendr S. Kochar, MD
Kochar’s
Clinical
Medicine
for
Students
49889.pngKOCHAR’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.
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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.pngCLINICAL 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.pngTREATMENT
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