Section 13 Educator’s Appendix

SECTION 13 Educator’s Appendix

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A Brief History of Medical Education and Introduction to the Chalk Talk

began in ancientfEgypt with Imhotep, the world’s first recognized Islam, where groundbreaking innovations were felt across the Arabf Medicine blossomed in the Renaissance, making Europetthetcenter of The practice o medicine has evolved over thousands of years. It physician. In the 5th century bc , medicine made epochal strides in the Hippocratic School. The fall of Rome gave way to the Golden Age o Empire, from Baghdad to Damascus to Córdoba, and beyond. medical advance until the 20th century ad when it migra ed o America, where, among other places, it has flourished. Evolution of this kind requires “high-fidelity” transference of current knowledge a from one generation to the next. Physicians have viewed teaching as duty since the 5th century Hence the term “doctor,” which derives from the Latin “docere,” meaning “to teach.” The methods of medical education have undergone complex bc. 1-5 important changes over centuries. At the present time, 2 pillarsand basic science and clinical medicine. The Age of Enlightenment led to impact of scientific discovery onithe practice of clinical medicine dioxide was identified by Joseph Black, nitrogen byiDaniel Rutherford, Lavoisier, leading to the discovery of the nature of respiration. To this thThe synergetic relationship5between basic science and clinical andtHungerford discovered the chromosomallabnormality underlying support the curricular structure of most American medical schools: the experimental method and the birth of the basic sciences. The began to burgeon. For example, n the mid-to-late 18th century, important respiratory gases were discovered in the laboratory: carbon and oxygen by Carl Wilhelm Scheele and Joseph Pr estley. These scientific breakthroughs were integrated by Antoine-Laurent day, clinical decision-making is influenced by the measurement of ese gases in arterial blood. 3- medicine can be illustrated in a more recent example. In 1960, Nowell the erminal illness chronic myelogenous leukemia (CML). An aberrant reciprocal translocation between the ong arms of chromosomes 9 and 22 (Philadelphia chromosome) produces a persistently activated protein tyrosine kinase that functions in the

control of cellular replication. This leads to uninhibited replication of white blood cells, manifesting in the disease known as CML. In the

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1990s, scientists envisioned a molecule capable of specifically targeting cellular replication, thereby shutting this process down. Following when imatinib, a tyrosine kinase inhibitor, was approved for clinical chemotherapeutic agents that produce numerous side effects related to the abnormal protein tyrosine kinase responsible for uninhibited years of research in the laboratory, this vision was realized in 2001 use. This new approach to cancer therapy diverges from conventional indiscriminant toxic effects on healthy cells in the body. The mechanism by which imatinib targets cancer cells is a paradigm for

future therapies. The application of basic sciences to the practice of clinical medicine will continue to grow. 6-8 Despite the powerful connection between basic science and clinical ancientlMesopotamian civilization, where the medical traditions of medicine, the integration of these 2 pillars into medical school curricu a has been a contentious process. A chasm existed even in Sumer were divided into “scientific” and “practical” schools. In ancient Greece, there was disagreement about the most worthy candidates to learn the discipline o medicine. Plato and others

advocated that those with interestsfin philosophy and science rather physicians. This debate continued centuries later during the latter part with the establishment and rise of the universities, including the than those with practical experience were more suitable to become of the Middle Ages when medical education became more formalized Schola Medica Salernitana, regarded as the world’s first modern medical school. These institutions paved the way for the medical

programs established in Europe during the 18th century. However, other hand, pioneered theiconcept of hospital schools,,which focused advised to “read little, see much, do much.”1,3,5 depending on location, the methods of these programs differed in important ways. Early medical education in Germany for example, focused mostly on the bas c sciences. The French and British, on the education around clinical teaching. French medical students were It was not until the 19th century in Germany that the relationship between basic science and clinical medicine was formally developed. the integration of scientific laboratories into both the preclinical and s This occurred after Wilhelm von Humboldt redesigned the medical education system in Germany. One important step in the process wa clinical years of medical training. This established correspondence between the two. Under Humboldt’s leadership, medical schools

remained part of the university. This system rose to preeminence and served as the model for many early American medical institutions,

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planted the seeds of clinical instruction in America during the 18thad the direction of WilliamiOsler, students were brought into the hospital medicalistudents became in large part the responsibility of clinicians.l9 most notably Johns Hopkins University. Although Thomas Bond h century at Pennsylvania Hospital, it was Johns Hopkins that formally integrated clinical teach ng into American medical education. Under to learn directly from the care of patients. The formal education of 3, Since first modeled in the United States by Johns Hopkins, an equa emphas s on basic science and clinical acumen has been central to American medical education. Since the early 20th century, the curriculum of most American medical schools has been divided into 2

halves. The first 2 yearsiconsist of lecture-based courses and laboratory followed by 2 years of clinical-baseditraining, mostly occurring in the Doctor of Medicine (MD). Despite sharing responsibility for nearly all reCarl Ludwig, a German physician, professor of,anatomy and experience designed to nstruct students in the basic sciences. The instructors of these courses typically hold a Doctor of Philosophy (PhD) and are trained and involved n basic science research. This is hospital and the outpatient clinics. Most clinical instructors hold a of medical education, these groups of instructors usually do not ceive any formal training in the art of teaching. 3 10 physiology, and renowned teacher, once wrote in a letter to a former pupil, “Destiny has conferred on us professors the favor of helping the responsive heart of youth to find the right path. In the seemingly

insignificant vocation of the schoolmaster there is enclosed a high, blessed calling; I know no higher.” 11 le In the early years of formal clinical medical education, students interacted directly with students. Osler spent hours with students at medical education in the early 20th century. The substantial growth of latter half of the 20th century, generated a shift in focus from teaching arned by directly observing and working alongside attending physicians. Ludwig was lauded as a gifted clinical teacher who the bedside. This focus on learners was a hallmark of American academic medical centers across the United States, beginning in the to productivity, which has had a significant erosive effect on the education of medical students. The growing chasm betweentattending physicians and medical students has shifted the responsibili y of clinical teaching to resident physicians. Coincident with the growing preoccupation of clinicians with 3,10,12-14

nonteaching responsibilities, academic medical centers began to rely on team-based systems to educate medical students in the clinical

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environment. The internal medicine clerkship is the quintessential learners with various levels of training, including residents, interns, al sciences were studied during the first 2 years, these students are nowc experience become the primary vehicles of education. As leaders of model of this relationship. Inpatient ward teams are comprised of third-year medical students, and physician assistant students. Medic students are introduced into this new environment with little prior experience. Having been removed from the classroom where the basi expected to learn clinical medicine in new ways. Observation and the team, resident physicians must guide these learners through the clerkship. Residents must be able to discuss and illustrate the clinical problems that learners observe in patients. Residents must teach. Within the discipline of internal medicine, there are myriad 12-14

approaches to clinical teaching. The communication of ideas through Paleolithic period, where aicave painting in Spain depicted thetoutline illustration is deeply rooted in human history. One of the first recorded uses of this techn que related to medicine dates back o the of a mammoth with a dark spot in the center, thought to represent the beast’s heart (Figure A-1). There was almost certainly an audience intended to benefit from th s anatomic drawing. In 1801, a teacher in

Scotland.used a large pieceiof slate to illustrate concepts to a group of students On the medical ward, this technique is known as a “chalk talk.” 3,15-17

FIGURE A-1 A cave painting from the Paleolithic period (circa 15000 bc) depicting the heart of a mammoth, thought to be the first anatomic drawing.

Modern approaches to teaching include the use of computer programs to project prearranged lecture material. This technique is

most suitable for the classroom-based lectures of the preclinical years s of medical training. The dynamic nature of the medical ward demand

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a more flexible teaching modality. For internal medicine residents who must teach at a moment’s notice, often during a rare period of

downtime, the ability to pick up a writing instrument and begin teaching within a matter of seconds is essential. A chalk talk can be described as the use of a writing instrument canvas in real time to facilitate discussion between a leader and a 16 audience. In medicine, chalk talks have particular qualities. Mostnon a canvas is a whiteboard. The leaders are attending physicians or physician assistant students, and interns, in various combinations.nd found.iThe6ability totdeliver an informative and effective chalk talk is commonly, the writing instrument is a dry-erase marker and the residents, and the audience usually consists of medical students, Typical venues include physician workrooms, conference rooms, a anywhere else on the medical ward where a whiteboard may be an acquired skill tha requires understanding, preparation, and repetit on. 1

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References Magner LN. A History of Medicine. 2nd ed. Boca Raton, FL: Taylor & Francis Group; 2005. Osler W. The Evolution of Modern Medicine: A Series of Lectures Delivered at Yale University on the Stillman Foundation in April 1913. New Haven, CT: Yale University Press; 1921.

Smith JJ, Shaker LS. Looking Back Looking Ahead: A History of American Medical Education. Chicago, IL: Adams Press; 2003.

Major RH. A History of Medicine. Springfield, IL: Charles C. Thomas; 1954. Porter R. The Greatest Benefit to Mankind: A Medical History of Humanity from Antiquity to the Present. New York, NY: W. W. Norton & Company; 1999. ruker BJ, Tamura S, Buchdunger E, et al. Effects of a selective inhibitor of the Abl

D tyrosine kinase on the growth of Bcr-Abl positive cells. Nat Med. 1996;2(5):561-566. Iqbal N, Iqbal N. Imatinib: a breakthrough of targeted therapy in cancer. Chemother Res Pract. 2014;2014:357027.

Nowell PC, Hungerford DA. A minute chromosome in human chronic granulocytic leukemia. Science. 1960;132:1497. exner A. Medical education in the United States and Canada. From the Carnegie

Fl Foundation for the Advancement of Teaching, Bulletin Number Four, 1910. Bull World Health Organ. 2002;80(7):594-602.

Ludmerer KM. Time and medical education. Ann Intern Med. 2000;132(1):25-28. Lombard WP. The life and work of Carl Ludwig. Science. 1916;44(1133):363-375. Chokshi BD, et al. A “Resident-as-Teacher” curriculum using a flipped classroom approach: can a model designed for efficiency also be effective? Acad Med.

2017;92(4):511-514. Hill AG, et al. A systematic review of resident-as-teacher programmes. Med Educ. 2009;43(12):1129-1140.

Jafri W, et al. Improving the teachingfskills of residents as tutors/facilitators anduc. addressing the shortage of faculty acilitators for PBL modules. BMC Med Ed 2007;7:34.

Hajar R. Medical illustration: art in medical education. Heart Views. 2011;12(2):83-91. Muttappallymyalil J. et al. Evolution of technology in teaching: blackboard and beyond in medical education. Nepal J Epidemiol. 2016;6(3):588-592.

Orlander JD. Twelve tips for use of a white board in clinical teaching: reviving the chalk talk. Med Teach. 2007;29(2-3):89-92.

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The Seven Tenets of the Chalk Talk

Timeliness Time is volatile on the inpatient medical ward; it must be maximized when possible. However, a talk must be of reasonable length. Fo the average audience, attention reaches a nadir after

around 20rminutes (Figure A-2). Therefore, the maximum length of a talk should not stretch far beyond this limit. If we give medical learners more credit than the average audience, 30 minutes is a

reasonable constraint. If time and energy for teaching remain after 30 minutes, it may be helpful to move on to a new topic that can recapture the full attention of the audience. Certain factors can prolong a talk beyond the optimal t meframe. It will be necessary to redirect the discussion at times, as questions from the audience, whil

encouraged, can occasionally derailithe process. Strong leadership ise necessary to ensure a timely talk. 1,2

FIGURE A-2 Average audience attention as a function of time. (From Mills HR. Techniques of Technical Training. 3rd ed. London: Macmillan; 1977.)

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Relevance yeUnlike the predictabletlecture-based curriculum of the preclinical ars of medical school, he dynamic nature of the clerkship creates variable experiences. Some of the factors that define a learner’s

experience on the medical ward are not governable. For example, diseases affecting the patients on the ward. However, over the period variable. This gives rise to heterogeneity as students are dispersed into pneumonia, heart failure, and delirium. It is most helpful to,learners learning principally derives from the observation and study of of a given clerkship, the breadth and severity of illness can be highly different milieus. However, certain medical problems are pervasive. Examples include Acute Kidney Injury, anemia, hypoxemia when talks are focused on these and other common problems. It may be tempting to discuss with the team matters of personal plastic and metal biliary stents in patients with cholangiocarcinomaes is unlikely to strike a chord with learners on the medicine clerkship.ts the clerkship. It is particularly effective when a chalk talk is focused on energized by the proximity of patients with the condition.3 interest. For example, a resident involved in research comparing may wish to give a talk on this subject. Although important, it focus on a small subset of patients suffering from an uncommon disease and On the other hand, a discussion of anemia, for example, which affec up to one-third of the world’s population, is immediately applicable to active problems in patients cared for by the team. Students will be

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Participation

Tell me, and I will forget. Show me, and I may remember. Involve me, and I will understand. —Confucius, circa 450 bc4

discussion. The Socratic method should be used to engage learnershe It is important for the audience of a chalk talk to be involved in t and increase participation. Retention improves when audience members are actively engaged. For example, in a talk on arthritis, when the framework divides into inf ammatory and noninflammato

categories, the audience should havelthe opportunity to identify thery characteristics of inflammatory arthritis.

leader should ask the audience, “How do you establishtwhether there will supply hints until the correct answers are identified. For example, physical findings indicative of inflammation?” At this point, someone Rather than announce what the features of inflamma ion are, the is an inflammatory process?” If the audience is stuck, the skilled leader the original question might be followed with another, “Are there in the audience might use this hint and offer answers such as “erythema” or “edema,” which are, of course, both correct. Using this

strategy, the leader can go on to extract the bulk of the discussion from the audience. 2

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Verbalization The majority of information discussed during a chalk talk should be spoken, not written. The canvas is simply an aid to highlight key

points. If the leader transcribes all that is discussed during a talk, 2 slow process of writing. Second, the leadertwillispend too much time things will occur. First, the volume of information must be unfavorably condensed to compensate for he t me consumed by the facing the whiteboard, leading to a loss of audience engagement. The leader must verbally expand on components of the framework

as it unfolds. As an example, recall the framework for arthritis, which divides into inflammatory and noninflammatory categories. During the talk, the skilled leader does more than simply write these

categories on the board; the verbal discussion about the features of inflammatory arthritis must be richer than what is illustrated.

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Reliability ongoing research exploring thelfrontier, making discoveries that pavee There are many questions in the field of medicine that have yet to b answered. At academic medica centers all over the world, there is the way for new and sometimes confusing questions. The edge of

discovery gives rise to debate, of which there is no shortage in opinions of experts. For example, what is the role of prostate specific the diagnosis of endocarditis, is it more cost-effective to obtain a transthoracic echocardiogram (TTE) in some patients? Discussing information that supports different theories. However, for then established that iron-deficiency anemia is associated with Decreased debatable or controversial. Based on MCV, a construct can be designed built using these reliable principles.5 medicine. When the evidence is not clear, physicians rely on the antigen (PSA) screening in the primary care clinic? When considering transesophageal echocardiogram (TEE) before obtaining a these questions is healthy and challenges learners to explore the purposes of a chalk talk, it is best to focus on “hard” findings i medicine that are widely accepted. For example, it has long been mean corpuscular volume (MCV) of red blood cells; this is not to approach anemia. Foundations of medical knowledge should be

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Adaptability that may includeistudents, interns, residents, nurses, and faculty. The Internal medic ne chalk talks are usually given to diverse audiences talk should be pitched at the appropriate level. Certain aspects of

clinical problems are best discussed with learners at a particular level year medical students, time spent identifying the physical findings of residents may instead want to focus on more complex concepts, such for heart failure can be used to facilitate entirely different discussions, appropriately. This adaptabilitylensures that all audience members of training. For example, in a discussion of heart failure with third- heart failure will be worthwhile. Advanced internal medicine as inotropic support or ventricular assist devices. The same framework depending on the audience. When the group is mixed, as it often is, the leader should try to reach al learners by directing questions benefit from the talk.

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Completeness A chalk talk must be timely, but it must also be complete. The talk should have a beginning and an end. With the large space of a clean whi eboard available, it is easy to become distracted by various ideas

thattarise during a talk, taking the discussion into directions that may will allow some flexibility but will quickly recover direction, to ensure be primed with an outline before the talk begins. This will ensure that, components of the talk are addressed and a complete picture is only be narrowly related to the topic at hand. The disciplined leader that completeness is not sacrificed. To remain organized, a leader must despite how extensive or tangential the discussion may be, the core provided. The frameworks found in this text have been assembled to provide

complete overviews of each topic. Certain elements of the talk may be respecting the framework for the talk should ensure that the audience expanded on if desired. Whether these liberties are taken or not, is left with a complete outline of the topic.

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References Mills HR. Techniques of Technical Training. 3rd ed. London: Macmillan; 1977. Prince M. Does active learning work? A review of the research. J Eng Educ. 2004;93(3):223-231.

Sankaran VG, Weiss MJ. Anemia: progress in molecular mechanisms and therapies. Nat Med. 2015;21(3):221-230.

Ende J, ed. Theory and practice of teaching medicine. Philadelphia, PA: American College of Physicians; 2010.

Guyatt GH, Oxman AD, Ali:M, Willan A,.Mcllroy W, Patterson C. Laboratory diagnosis of iron-deficiency anemia an overview J Gen Intern Med. 1992;7(2):145-153.

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Chalk Talks and the Framework System

presenter, it is not difficult to discuss a topic for any length of timee challenging, even if only for 5 to 10,minutes. Indeed, some readers whiteboard without significant preparation is a realistic proposition. recollect the framework itself. The majority of the discussion, although knowledge. As entities appear within the framework during a talk, the teaching points. Importantly, these discussion items are not scripted resulting from any given talk is dynamic, bound only by the outline of uniquely suited to whiteboard teaching. Modern technology-based lectures are guided by prearranged material, usually in the form of slides on a computer screen. For th because there are prompts to reinforce order and cue certain discussion points. Without that aid lecturing becomes more may have questioned whether discussing a topic for 30 minutes on a The framework system makes it possible. The presenter need only guided by the framework, originates from the presenter’s own fund of presenter will draw on this knowledge base to illuminate various and are subject to the discretion of the presenter. The discourse the framework. The latitude afforded by the framework system is At the end of a successful chalk talk, the whiteboard will contain various remnants of the discussion. At the very least the associated framework should be intact and clearly displayed. If,nothing else, this alone is valuable for students. However, it is important to understand provides the audience with an approach to a clinical problem. This that a chalk talk is more than a simple illustration on a whiteboard. The teaching points found between the lines of the framework should generate most o the discussion. It is the responsibility of the leader to

illuminate thesefteaching points. Using hintsiand questions, the leader should allow the audience members to ident fy as much of the content within a framework as possible. Going further, whenever a new concept is introduced on the board, the presenter should discuss it at

the desired level of expertise. For example, during a talk on dyspnea, leader can then review that condition more closely. when the audience identifies cardiomyopathy as an etiology, the

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America?” “Whatiphysical findings are associated with heart failure?” “What are the most common causes of cardiomyopathy in When these quest ons are asked, the leader is facing and engaging the audience rather than simply writing on the whiteboard. Parts of the framework are used to launch segments of the talk that are entirely

verbal.fThese questions are not etched inlthe framework; rather they erudition and mustiselect.high-yield pointsito emphasize. The leader example, consider the framework for hypotonic hyponatremia, which are generated from the presenter’s know edge base. In this way, the tenet o verbalization is realized. The number of teaching points that can be found within a single framework is aston shing The leader is lim ted only by time and should direct questions to appropriate audience members. For is largely based on volume status.

At this point in the talk, the medical students in the audience might hypovolemia and hypervolemia. While later in the talk, the residents differentiate primary polydipsia from the syndrome of inappropriate be asked to identify the physical findings associated with might be asked to identify the laboratory studies that help antidiuretic hormone, a more challenging inquiry. Here, the tenet of adaptability is exercised. When the audience initially struggles to

identify the correct answer, the leader must provide guidance. Hints can be offered until the audience has enough information to achieve success. Not only does this interplay provide positive einforcemen

for the audience, but it also ensures that there is activerparticipation,t which benefits learning and retention. When an en ity arises within a framework and the presenter decide 1 to discuss it intmore detail, there are many options on which to focus.s physical examination,ilaboratory tests, imaging, and other studies (eg, For most entities, it works well to generate questions from several fixed domains, includ ng epidemiology, history of presentation,

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electrocardiography, echocardiography). Consider the diagnosis of framework, there are many potential high-yield teaching points to gout, for example. When this entity arises within the arthritis discuss with the audience.

p The leader can test the audienceton the typical presentation of gout, epidemiologic risk factors; the common historical narrative expressed chronic gout; the relevant laboratory or radiographic findings of gout; entity is introduced, following thisrsimple order to generate questions while maintaining the fluidity of the talk. The quantity and quality of presenter, the types of patients being cared for, and the degree of Without the outline ofia talk in mind, discussing a topic on an empty memorized, its adaptability to an individual audience is lost. This is nce a scripted 30-minute talk puts a limit on the spontaneity with which it ulling from each of the aforemen ioned domains. Specifically, the audience can be asked to describe the prototypical patient in terms of by patients with an acute gout flare; the physical findings of acute and and, finally, the unique tests associated with gout, such as the characteristics of synovial fluid du ing an acute flare. Whenever a new for discussion is an effective way to raise key teaching points naturally questions should be adapted to the time available, the goals of the training of the audience members. A framework is a cr tical component of a successful chalk talk. whiteboard is a futile endeavor. Even if a presentation were particularly true when facing a mixed audience, a common occurre in medicine. Moreover, the amount of preparation required to deliver can occur and essentially requires the availability of preplanned didactic time. In reality, on the medical ward, residents and attending

physicians are virtually never provided such luxury. Instead, teaching the other hand, it is relatively easy to memorize or simply become didactics must be cut, shaped, and carved to fit the available time. On

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serves as the catalyst for a discussion that develops mostly from the familiar with a framework moments before delivering a talk, which presenter’s own knowledge base.

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Using the Chapters Yet, alone, it is not enough for a successful presentation. The leader. A framework is effective when used as an outline for a chalk talk must improvise and create content between the lines of the framework. The final presentation depends on factors related to the

presenter, the audience, the patients being cared for, and the amount should be basic. If the amount of time available forithe talk isilimited, clinical problem. Included in each aretsuggested high-yield, evidence-and interns. Ultimately, the leader can choose to use or disregard these focusion entities within a framework that are relevant to the patientsto hypertension, the leader maylchoose to spend more time discussing The breadth and depth of these peripheral discussions are ultimately teaching. There is a delicate balance to be achieved. On the one hand, there must be consideration of.the tenet of timeliness, or there is a risk of time available. For example, if the audience consists of new learners, then the questions and content explored by the facil tator then the facilitator must tailor the extent of discuss on. In this way, chalk talks are customizable. Each chapter in this book is a proto ype of a talk on a particular based concepts to discuss with an audience assumed to be students suggestions. The leader may ask original questions to emphasize teach ng points thought to be more suitable. The leader may choose under the team’s care. For example, if a patient on the team presents with dyspnea and is ultimate y diagnosed with pulmonary that particular entity when it arises within the dyspnea framework. influenced by a number of factors, including the time available for when time is short, the leader must be mindful of the limitations the clock has set on the discussion On the other, when time is plentiful, of losing the attention of the audience. The formula for the chapters is simple. Each begins with the top of using hints and questions. This is the general way in which a chalk the framework, which is then built over the course of the chapter talk should flow. From the moment the topic is introduced on the whiteboard, there must be dialogue between the presenter and audience. Opportuni ies to identify the next part of the framework

whether a diagnostictstudy, a differential diagnosis, or otherwise, , suggested hints and questions to askiof the audience along the way. should be given to the audience. To this end, the chapters offer When a concept is introduced, there s opportunity for deeper

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discussion. This interaction between presenter and audience drives the explicitly. With repetition, educators will begin to discovertand use the experience is gained, most will become so familiar with the formula discussion forward. Nascent educators may find it helpful to follow the chap ers more questions and hints that bring out the best in audiences. After that they will begin to generate original discussion points to supplement those that are tried and true. With enough experience,

original frameworks may be built for other clinical problems within FoFor the first 20 scholastic years, physicians are primarily students. bestowed. This transition begins during residency training. It is therey internal medicine resident as the chalk talk. As burgeoning teachers, heIn academic medicine, there is no.higher calling. internal medicine or other disciplines. r all physicians this role continues throughout life. Upon the academic clinician, the additional responsibility of teaching is that the skills of teaching are learned, practiced, and sharpened. Man tools are available to the educator, but few are as important for the residents must begin to “provide the favor of helping the responsive art of youth to find the right path ” 2

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References Prince M. Does active learning work? A review of the research. J Eng Educ. 2004;93(3):223-231.

Lombard WP. The life and work of Carl Ludwig. Science. 1916;44(1133):363-375.

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Index

inNote: Page numbers followed by “f ” indicate figures and “t” dicate tables.

A A-a gradient, 615, 615f elevated mechanisms of, 619 ventilation-perfusion (V/Q) ratio, 620, 620f normal, reduced Pio2 causes of, 616 high altitude, 617, 617f polluted air inhalation, 616 suffocation, 616–617 Aanatomic shunt, hypoxemia, 627–628, 627f Acetylcholinesterase inhibitor, 192 Acid-base disorders acidemia, 416 alkalemia, 416 arterial pH, 415 carbonic anhydrase, 414 diagnosis, 415 extracellular buffer, 414 Henderson-Hasselbalch equation, 414 homeostasis, 417 metabolic acidosis anion gap, 417, 420–422 development of, 418, 418f lung function, 418 non-anion gap, 418–420, 420f metabolic alkalosis, 426–428 minute ventilation, 417 persistent respiratory disorder, 417

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with polyuria, 414 primary acid-base disorder, 416, 416f respiratory acidosis, 422–424, 422f respiratory alkalosis, 424–426 serum concentration, 416 types, 414 volatile and nonvolatile acid elimination, 415, 415f Acidemia, 101, 416 “Acid-loving” cells infiltration, 48 Acquired hemolytic anemia, 327 immunologic, 333–335, 334f infectious, 337–339, 339f mechanisms, 332 toxic, 335–336 traumatic, 336–337 Acromegaly, 43, 107, 662 cause of, 108 clinical characteristics, 663 high-output physiologic state, 44 Acute biliary obstruction, 219–220 Acute bronchitis, 607 dyspnea, 253–254 Acute chest syndrome, 22 chest imaging, 22 Acute coronary syndrome (ACS) acute myocardial infarction vs. myocardial ischemia, 16 causes of coronary artery dissection, 18–19 coronary artery embolism, 18–19 coronary artery vasospasm, 18–19 premature coronary artery disease, 19 risk factors, 18 stent thrombosis, 18–19 unrelated to, 19–21, 20f unstable atherosclerotic plaque rupture, 18, 18f characteristic symptoms, 16 clinical syndromes, 16

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contiguous ECG leads, 17 diagnosis, 16 ischemia, electrocardiographic features, 17 non–ST-elevation myocardial infarction (NSTEMI), 16 electrocardiographic findings, 17, 17f mycoardial injury, 17 ST-elevation myocardial infarction (STEMI), 16 electrocardiographic manifestation of, 16–17, 17f unstable angina (UA), 16 electrocardiographic findings, 17, 17f mycoardial injury, 17 Acute hypersensitivity pneumonitis, 637 Acute interstitial nephritis (AIN), 439–441, 440f Acute interstitial pneumonia (AIP), 634–635 Acute Kidney Injury (AKI) biochemical laboratory definition, 431 blood urea nitrogen levels, 430 with blue toes, 430, 430f causes of, 431 classification, 432 definition, 430 history of, 431 intrarenal acute interstitial nephritis (AIN), 439–441, 440f acute tubular necrosis (ATN), 437–439, 438f classification, 435 cross-section of, 435, 435f vascular, 436–437 physical findings, 431 postrenal, 441–442 prerenal, 432–434, 433f renal replacement therapy, 431 risk factors, 431 sequelae of, 431 serum creatinine concentration, 431 structures, 432 symptoms of, 431

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Acute (fulminant) liver failure, 151, 153 Acute mesenteric ischemia biochemical laboratory abnormalities, 225 causes of, 225 computed tomography (CT) imaging, 225 diagnosis, 225 mechanisms, 225 nonocclusive, 227 occlusive arterial embolism, 226 arterial thrombosis, 226 venous thrombosis, 226–227 physical findings, 224 prognosis of, 225 symptoms of, 224 Acute myocardial infarction, definition, 16 Acute pancreatitis, 23, 120, 167, 653, 655 characteristics of, 121 diagnosis of, 24 Acute pericarditis, 19 electrocardiographic findings, 20 Acute pulmonary arterial hypertension, 605 Acute respiratory distress syndrome (ARDS), 624 Acute rheumatic fever, 668, 670 Acute septic arthritis, 663 Acute tubular necrosis (ATN), 437–439, 438f Adenoviruses, 57 gastroenteritis, 179 Adrenal cortical tissue, 81 Adrenal hyperplasia, 97 types of, 98 Adrenal insufficiency, 107 with acute abdominal pain, 78, 78f adrenocorticotropic hormone (ACTH) stimulation, 80 causes of, 81 cortisol deficiency, 80 false-negative result, 80

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primary vs. central, 80 results of, 80 androgens, 79 catecholamines, 79 central central process, 87 glucocorticoids, 88 hypothalamic dysfunction, 87 hypothalamus recovery, 88 mechanism of, 87 mineralocorticoid deficiency, 87 pituitary gland dysfunction, 87 characteristics of, 108 clinical condition, 80 clinical manifestations acute, 80 chronic, 79 corticotropin-releasing hormone (CRH) stimulants, 79 definition, 79 glucocorticoids, 79 hypothalamic-pituitary-adrenal axis, 79, 79f incidence of, 79 mineralocorticoids, 79 primary adrenal cortical tissue, 81 adrenoleukodystrophy (ALD), 86–87 autoimmune causes, 81–82 bilateral adrenalectomy, 86–87 causes of, 81 external beam radiation, 87 hemorrhagic causes, 83–85 infectious causes, 82–83 infiltrative causes, 85–86 mechanism of, 81 medication, 86–87 mineralocorticoid deficiency, 81 radiotherapy, 86

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serum cortisol levels, 79 Adrenal tumor, 97 characteristics of, 98 Adrenocortical hormones, 79 Adrenocorticotropic hormone (ACTH) -dependent Cushing’s syndrome, 94–97 diagnosis, 94 ectopic production, 95–97 eutopic production, 94–95 hypercortisolism, 94 prevalence of, 94 -independent Cushing’s syndrome, 97–98 stimulation, 80 causes of, 81 cortisol deficiency, 80 false-negative result, 80 primary vs. central, 80 results of, 80 Adrenoleukodystrophy (ALD), 86–87 Adrenomyeloneuropathy (AMN), 87 Adult-onset Still’s disease (AOSD), 668, 670 fever of unknown origin (FUO), 267 Afterload, 46 Aging, sinus bradycardia, 8 Agoraphobia, 25 Airways constriction, 623–624 dyspnea acute bronchitis, 253–254 anaphylaxis, 254 asthma, 253–254 bronchiectasis, 253–254, 253f chronic obstructive pulmonary disease, 253–254 foreign body aspiration, 254–255 tracheomalacia, 254–255 hemoptysis acute bronchitis, 607

1054

bronchiectasis, 607 bronchovascular fistula, 607–608 causes of, 606 foreign body aspiration, 607–608 iatrogenic, 607–608 malignancy, 607 Alcohol consumption, 41 cardiomyopathy development, 42 chronic, 95, 122 Alcoholic hepatitis, 271–272 Alkalemia, 101, 121, 416 mechanism of, 122 Alloimmune hemolytic anemia, 333–334 Altered mental status, 236 Alveolar gas equation, 614 carbon dioxide, partial pressure of, 615 Aminotransferases, 212 abnormal level, 213 elevation, 213 severity of, 213 Amphetamines, 41 Amyloidosis, 48, 85, 115, 132–133, 193–194 characteristics of, 116 with renal involvement, 86 Anal fissure, 206 Anaphylaxis, dyspnea, 254 Androgens, 79 Anemia conditions, 313 definition, 311 dyspnea, 258–259 macrocytic anemia megaloblastic. See Megaloblastic anemia nonmegaloblastic, 321–323, 322f mean corpuscular volume (MCV), 313–314, 314f microcytic anemia iron deficiency, 314–315

1055

lead poisoning, 314, 316 sideroblastic anemia, 314, 316 thalassemia, 314–315, 315f normal hemoglobin concentration, 311 normocytic anemia bone marrow, 316 hyperproliferative, 318–319 hypoproliferative, 316–318 reticulocytes, 316 physical findings, 313 physiologic adaptations, 313 with pleuritic chest pain, 310, 310f prevalence, 313 red blood cell indices, 313 red blood cell production, 312, 312f red blood cell, role of, 311 severity of, 311 symptoms of, 313 tissue oxygenation, 311 Angiodysplasia, 205, 206–207 Angiotensin-converting enzyme (ACE) inhibitors coarctation, 46 hypertension, 46 reduced left ventricular systolic function, 39–40 Angiotensin II receptor blockers (ARBs) coarctation, 46 hypertension, 46 reduced left ventricular systolic function, 39–40 Angiotensin receptor-neprilysin inhibitor (ARNi), 39–40 Ankylosing spondylitis, 667 Anorexia nervosa, 7 symptoms and signs, 142 Anthracycline chemotherapeutic agents, 41 treatment with, 42 Antiarrhythmic agents, 8 Anti–glomerular basement membrane (anti-GBM) disease, 680–681 Antineutrophil cytoplasmic antibodies (ANCA)

1056

glomerulonephritis ANCA-positive patients, 451 c-ANCA, 452–453 characteristic findings, 452 p-ANCA, 453–454 small vessel systemic vasculitis eosinophilic granulomatosis with polyangiitis (EGPA), 678–679 granulomatosis with polyangiitis, 678–679, 679f microscopic polyangiitis, 678–679 secondary causes of, 679 Antiretroviral therapy (ART), 43 Antisynthetase syndrome, 670 α-1 Antitrypsin deficiency, 218–219 Anxiety (panic disorder), 25 treatment for, 25 Aorta coarctation, 46 Aortic dissection, 19, 62, 62f mechanism of, 63 risk factors, 20 Aortic regurgitation, 40–41 Aortic stenosis, 19 dyspnea, 250–251 echocardiographic criteria, 47 patient survival, without treatment, 20 Aortic valve endocarditis, 11 Arachnodactyly, 62, 62f Arboviruses, 385–386 Arterial embolism, 226 Arterial thrombosis, 226 Arteriovenous malformation (AVM), 606 Arthralgia, 658 Arthritis vs. arthralgia, 658 articular structures, 658 inflammatory arthritis blood tests, 660 classification, 663

1057

crepitus, 659 dactylitis, 660 enthesitis, 659 historical features, 659 imaging studies, 660 migratory arthritis, 660 monoarticular, 663–664 oligoarticular, 664–667, 665f physical findings, 659 polyarticular, 668–670, 669f procedure, 660 spondyloarthritis, 660 subluxation, 659 symmetric arthritis, 660 synovial fluid findings, 661 synovitis, 659 tenosynovitis, 659 mimics of, 659 noninflammatory arthritis acromegaly, 662, 663 causes of, 661–662 charcot joint, 661–662 episodic arthritis, cystic fibrosis, 661, 663 hemarthrosis, 661–662 hemochromatosis, 662, 663 hypertrophic osteoarthropathy, 661–662 osteoarthritis (OA), 661–662 osteonecrosis, 661–662 trauma, 661–662 periarticular structures, 659 physical examination, 659 with subcutaneous nodules, 658, 658f types, 659 Arthrocentesis, 660 Asbestos, 654–655 Asbestosis, 638–639 Ascariasis, 165–166

1058

Ascites, 43 classification, 148 cytologic examination, 149 definition, 148 differential cell count, 149 fluid characteristics, 149 Gram stain and culture, 149 gross appearance, 149 lactate dehydrogenase (LDH) concentration, 149 peritoneal fluid volume, 148 physical findings, 148 portal hypertension, 148 classification, 150 clinical sequelae, 150 diagnosis, 150 hepatic, 151–153, 152f mechanism of, 149 posthepatic, 154–155 prehepatic, 150–151 unrelated to, 155–159, 156f severity of, 148 with shortness of breath, 147, 147f spontaneous bacterial peritonitis, 149 symptoms of, 148 total protein concentration, 149 ultrasonography, 148, 148f Aseptic meningitis, 393–394 Aspergillus, 59–60 Aspiration pneumonia cause of, 410–411 clinical characteristics, 409, 409f definition, 409 mechanism of, 408 methods, 410 risk factors, 409 treatment, 410 Asterixis, 63

1059

Asthenia, 579 Asthma dyspnea, 253–254 exacerbation, 618–619 Astrovirus gastroenteritis, 179 Atelectasis, 623–624, 649 Atherosclerotic plaque, 228 stable angina, 20, 20f unstable rupture, 18, 18f Atonic activity, 541 Atrial fibrillation characteristics of, 71 coronary artery embolism, 19 irregular supraventricular tachycardia (SVT), 74 mitral stenosis, 47 with slow ventricular rate, 9 causes of, 10 tachyarrhythmia-induced cardiomyopathy, 41 Atrial flutter, 69 Atrioventricular (AV) conduction ratio, 8 bradycardia, 7, 7f characteristics of, 69 irregular supraventricular tachycardia (SVT), 74 with variable AV block, 9 Atrioventricular (AV) conduction ratio, 10, 72 irregular bradycardia, 12 Atrial septal defect (ASD), 50 Atrial tachycardia, 69 with Atrioventricular (AV) block, 8 characteristics of, 71 definition, 8 prognosis of, 10 with variable Atrioventricular (AV) block, 9 Atrioventricular (AV) block with atrial flutter, 7, 7f Atrioventricular (AV) conduction ratio, 8 with atrial tachycardia, 8

1060

Atrioventricular nodal reentrant tachycardia (AVNRT), 69 characteristics of, 70 dual AV nodal pathways physiology, 70, 70f Atrioventricular reentrant tachycardia (AVRT), 69 characteristics of, 70 short PR interval and delta wave, 70, 70f Aura, 541 Autoimmune adrenalitis, 81–82 Autoimmune causes, primary adrenal insufficiency, 81–82 Autoimmune encephalitis, 238–239 Autoimmune hemolytic anemia (AIHA), 333–334, 334f Autoimmune hepatitis, 219 Autoimmune-related hypoparathyroidism, 114–115 Automatisms, 541

B Bacillus cereus, 180–181 Bacterial meningitis atypical, 389–391 typical, 386–389, 388f Bacterial pericarditis characteristics of, 58 management of, 58 mechanisms of, 58 Mycobacterium tuberculosis (TB), 58–59 Staphylococcus aureus, 58–59 Streptococcus pneumoniae, 58–59 zoonoses, 58–59 Bare metal stents, 19 Becker muscular dystrophy, 44 Behçet’s disease, 62, 665, 680–681 characteristics of, 667 Bernard-Soulier syndrome (BSS), 355–356, 356f Berylliosis, 106–107 Bilateral adrenalectomy, 86, 98 hormone replacement, 87 Bilateral macronodular adrenal hyperplasia, 98

1061

Biliary colic, 23–24 Biliary system, extrahepatic cholestasis anatomy of, 164, 164f ascariasis, 165–166 biliary stricture, 165–166 choledochal cyst, 165–166 choledocholithiasis, 165, 165f liver flukes, 165–166 malignancy, 165–166 Bird fancier’s lung, 637–638 β-Blockers, 8 coarctation, 46 hypertension, 46 reduced left ventricular systolic function, 39–40 Boerhaave syndrome, 23–24 Bone marrow hypoplasia, pancytopenia antithyroid medication, 345 arsenic poisoning, 345 characteristics of, 346 definition, 344 idiopathic aplastic anemia, 345, 347 infections, 346 inherited aplastic anemia, 345–346, 346f medications, 345 paroxysmal nocturnal hemoglobinuria (PNH), 345–346 parvovirus B19 infection, 345 pregnancy, 345 Bone marrow infiltration, 348–349, 348f Brachial-femoral pulse delay, 46 Bradycardia coronary artery supplies Atrioventricular (AV) node, 6 sinoatrial (SA) node, 6 definition, 6 electrical conduction, normal heart, 6, 6f heart rate and cardiac output (CO), 6

1062

regulation, 6 hypothyroidism, 125, 125f narrow-complex bradycardia. See Narrow-complex bradycardia pacemakers, 12 physical findings, 7 QRS complex classification, 7 definition, 7 resting heart rate, in adults, 6 rhythm disturbance, 5, 5f during sleep in elderly patients, 6 in young healthy patients, 6 symptoms, 7 wide-complex bradycardia. See Wide-complex bradycardia Bradykinesia, 579 Brain abscess, 243–244 Brain tumor, 237–238 “Broken-heart” syndrome, 43 Bronchiectasis, 607 dyspnea, 253–254, 253f Bronchoscopy, 607 hemoptysis, 605 Bronchovascular fistula, 607–608 Bronze diabetes, 49 Brugada criteria, 73, 73f Budd-Chiari syndrome, 154, 217 Bundle branch block, 11, 12, 74

C Calcimimetics, 114 Calcium channel blockers, 8 Calcium chelators, 101 Calcium pyrophosphate dihydrate (pseudogout) crystals, 664 Calcium-sensing receptor (CaSR), 116 clinical manifestations, 117 negative feedback loop, 115

1063

Cameron lesion, 203–204 Campylobacter species, 183, 185 Candida, 59–60 Capillary hydrostatic pressure, peripheral edema characteristics of, 290 chronic venous insufficiency, 291–292, 292f cirrhosis, 290–291 constrictive pericarditis, 291–292 deep vein thrombosis (DVT), 290–291 mechanisms, 290, 290f medication, 291 pregnancy, 291–292 renal failure, 290–291 right-sided heart failure, 290–291 superior vena cava (SVC) syndrome, 291–292 systemic arterial hypertension, 290 Capillary oncotic pressure, peripheral edema albumin synthesis, 293, 293f characteristics of, 293 liver disease and malnutrition, 293 nephrotic syndrome, 293–294 plasma proteins, 292 protein-calorie malnutrition, 293 protein-losing enteropathy, 293–294 Capillary permeability, peripheral edema, 295–297 Carbonic anhydrase, 414 Carcinoid tumor, 96, 191–192 Cardiac chest pain acute coronary syndrome (ACS). See Acute coronary syndrome (ACS) causes, 15 Cardiac conduction system, 6, 6f Cardiac dysrhythmia dyspnea, 250–251 hyperkalemia, 461 hypokalemia, 480 Cardiac output (CO), 6 and heart rate, 29

1064

hypotension, 276 Cardiac tamponade dyspnea, 250, 252 malignant pericarditis, 60 Cardiogenic hypotension acute aortic regurgitation, 281 acute inferior ST-elevation myocardial infarction, 281 acute pulmonary embolism (PE), 281–282 cardiogenic shock, 280–281 cardiomyopathy, 281 dysrhythmia, 281 left ventricular outflow tract obstruction, 281 mechanism, 280 patterns of, 280 primary pulmonary hypertension, 281 Cardiogenic shock, 227 Cardiology bradycardia. See Bradycardia chest pain. See Chest pain heart block. See Heart block heart failure. See Heart failure pericarditis. See Pericarditis tachycardia. See Tachycardia Cardiomyopathy, dyspnea, 250–251 Cardiothoracic ratio, 39 Cardiovascular causes, heart failure, 40–41 Carpal tunnel syndrome, 43 Carvallo’s sign, 47 Case study acid-base disorders. See Acid-base disorders Acute Kidney Injury (AKI). See Acute Kidney Injury (AKI) adrenal insufficiency. See Adrenal insufficiency anemia. See Anemia arthritis. See Arthritis bradycardia. See Bradycardia chest pain. See Chest pain cholestatic liver injury. See Cholestatic liver injury

1065

Cushing’s syndrome. See Cushing’s syndrome delirium. See Delirium diarrhea. See Diarrhea dyspnea. See Dyspnea endocarditis. See Endocarditis fever of unknown origin (FUO). See Fever of unknown origin (FUO) Gastrointestinal (GI) bleeding. See Gastrointestinal (GI) bleeding glomerular disease. See Glomerular disease headache. See Headache heart block. See Heart block heart failure. See Heart failure hemolytic anemia. See Hemolytic anemia hepatocellular liver injury. See Hepatocellular liver injury hypercalcemia. See Hypercalcemia hyperkalemia. See Hyperkalemia hypernatremia. See Hypernatremia hypocalcemia. See Hypocalcemia hypokalemia. See Hypokalemia hyponatremia. See Hyponatremia hypotension. See Hypotension hypothyroidism. See Hypothyroidism hypoxemia. See Hypoxemia interstitial lung disease (ILD). See Interstitial lung disease (ILD) intestinal ischemia. See Intestinal ischemia meningitis. See Meningitis pancytopenia. See Pancytopenia pericarditis. See Pericarditis peripheral edema. See Peripheral edema platelet disorders. See Platelet disorders pleural effusion. See Pleural effusion pneumonia. See Pneumonia polyneuropathy. See Polyneuropathy secondary hypertension. See Secondary hypertension seizure. See Seizure stroke. See Stroke syncope. See Syncope systemic vasculitis. See Systemic vasculitis

1066

tachycardia. See Tachycardia thyrotoxicosis. See Thyrotoxicosis weakness. See Weakness Catamenial hemoptysis, 609 Catecholamines, 79, 465 Cavotricuspid isthmus, 69 Celiac disease, 189–190, 219–220 Central adrenal insufficiency central process, 87 glucocorticoids, 88 hypothalamic dysfunction, 87 hypothalamus recovery, 88 mechanism of, 87 mineralocorticoid deficiency, 87 pituitary gland dysfunction, 87 Central hypothyroidism, 133 Central nervous system (CNS) vasculitis, 238–239 Cerebral hypoxia, 238 Cervical angina, 24–25 Chagas disease, 42 acute and chronic, 43 Charcot joint, 661–662 Chest pain cardiac acute coronary syndrome (ACS). See Acute coronary syndrome (ACS) causes, 15 electrocardiogram (ECG), 15, 15f noncardiac, 15 anxiety (panic disorder), 25 causes, 21 Gastrointestinal, 23–24 herpes zoster, 25 musculoskeletal, 24–25 pulmonary, 21–22 pericarditis. See Pericarditis sources of, 15 Chest wall trauma, 24–25

1067

Chest wall tumor, 24–25 Choledochal cyst, 165–166 Choledocholithiasis, 165, 165f Cholelithiasis, 24 Cholerheic diarrhea, 189–190 Cholestatic liver injury aminotransferases, 163 bilirubin, 163 classification, 163 clinical manifestations, 163 computed tomography (CT), 164 elevated serum levels, 163 evaluation of, 164 extrahepatic cholestasis, 163 biliary tree, 164–166, 164f–165f classification, 164 imaging modality, 163 life-threatening condition, 164 mechanism of, 163 pancreas, 164, 164f, 167–168, 168f intrahepatic cholestasis, 163 clinical features of, 168 diagnosis, 168 imaging modality, 163 infection, 172–173, 173f mechanisms of, 168 obstruction, 169–170 toxicity, 171–172 laboratory pattern, 162 serum alkaline phosphatase levels, 162 hepatic metabolism, 163 laboratory result, 163 sources of, 162 woman with pruritis, 162, 162f Chronic anemia and shunt, 40–41 Chronic dilated cardiomyopathy, 43 Chronic eosinophilic pneumonia (CEP), 634–635

1068

Chronic hypersensitivity pneumonitis, 637 Chronic kidney disease (CKD), 118, 431 Chronic mesenteric ischemia atherosclerotic disease, 228 epidemiology of, 228 fibromuscular dysplasia, 228–229 imaging modalities, 228 indications, 228 physical finding, 228 symptoms of, 228 vasculitis, 228–229 Chronic obstructive pulmonary disease (COPD), 607 dyspnea, 253–254 Chronic pancreatitis, 167 Chronic systolic heart failure, 19 Chvostek’s sign, 113 Chylothorax, 653, 654 Chylous ascites, 157–158 Cirrhosis, 43, 650 hepatic portal hypertension, 151–152, 152f high-output physiologic state, 44 Citrate, 121 mechanism of, 122 Clonic activity, 541 Clonidine, 8 Clonus, 579 Clostridium difficile, 180–181 Clostridium perfringens, 180–181 Cluster headache, 511–512 Coagulopathy, 84 Coal worker’s pneumoconiosis, 638–639 Cocaine, 41 myocardial ischemia/infarction, 42 Coccidioides immitis, 59 Cogan’s syndrome, 676 Cognitive dysfunction, 102 Colchicine, 191

1069

Collagen vascular diseases, 8 Colon cancer, 269, 271 Colorectal polyps, 206–207 Community-acquired pneumonia (CAP) atypical pathogens, 401–403 causes, 399 endemic pathogens, 403–405, 404f typical pathogens, 400–401, 401f Concentric hypertrophy, 39, 39f preserved left ventricular systolic function, 45 valvular disease, heart failure, 47 Concussion, 237 Conduction abnormalities, 461 Confusion, hypercalcemia, 100, 100f Congestive hepatopathy, 217 Connective tissue disease (CTD) mixed connective tissue disease (MCTD), 61 prevalence, 60 rheumatoid arthritis, 60–61 scleroderma, 61 seronegative spondyloarthritides, 61–62 systemic lupus erythematosus (SLE), 60–61 vasculitis, 61–62 Constrictive pericarditis, 51, 56, 154, 649 dyspnea, 250, 252 Kussmaul’s sign, 56 Corkscrew-shaped organisms, 665, 665f Coronary artery dissection, 18 in peripartum period, 19 Coronary artery embolism, 18 risk factor, 19 Coronary artery vasospasm, 18, 19 cause of, 21 risk factor, 19 substances with, 21 Cor pulmonale, 46 Corticotropin-releasing hormone (CRH), 79, 92

1070

stimulants, 79, 92 Costochondritis, 24–25 Coxsackieviruses, 57 Crepitus, 659 Crescendo-decrescendo systolic murmur, 47 Crohn’s disease, 106–107 Cryoglobulinemia, 665, 680 Cryptogenic organizing pneumonia (COP), 634 Cryptosporidiosis, 183 Crystal arthropathy, 663 types, 664 Culture-negative endocarditis, 264 Cushing’s syndrome ACTH-dependent process, 94 diagnosis, 94 ectopic production, 95–97 eutopic production, 94–95 hypercortisolism, 94 prevalence of, 94 ACTH-independent process, 97–98 clinical evaluation, 92 clinical manifestations, 92, 92f corticotropin-releasing hormone (CRH), 92 stimulants, 92 definition, 92 delirium, 241, 243 with delusions, 91, 91f exogenous glucocorticoids, 93 hypothalamic-pituitary-adrenal axis, 92 metabolic syndrome, obesity, 92 negative confirmatory test, 93 positive confirmatory test, 93 probability of, 92 serum cortisol levels, 92 urine free cortisol (UFC) test, 92 false-negative result, 93 Cyanosis, 49

1071

Cyclospora cayetanensis, 182–183 Cystic fibrosis, 169–170, 668 Cystoisospora belli, 182–183 Cytomegalovirus (CMV), 57–58, 184, 186, 214–215

D Dactylitis, 660 Dead space, hypoxemia anatomic and alveolar dead space, 621, 621f causes of, 621–622 definition, 621 inhaled oxygen, 621 mechanism, 621 Deconditioning, 259–260 Delirium altered mental status, 236 causes of, 237 clinical examination, 236 clinical features, 236 definition, 236 electroencephalography (EEG), 237 encephalitis, 236 with flushed skin, 235, 235f hypertensive encephalopathy, 244–245 incidence of, 236 infectious, 243–244 insomnia, 244–245 limbic encephalitis, 236 lumbar puncture, 237 management, 237 metabolic Cushing’s syndrome, 241, 243 hepatic encephalopathy, 241–242 hypercarbia, 241–242 hyperosmolar hyperglycemic state, 241–242 hyperthermia, 241, 243 hypoglycemia, 241

1072

hypothermia, 241, 241f, 243 refeeding syndrome, 241–242 uremia, 241–242 Wernicke’s encephalopathy, 241–242 neuroimaging, 236 neurologic brain tumor, 237–238 central nervous system (CNS) vasculitis, 238–239 cerebral hypoxia, 238 concussion, 237 hydrocephalus, 237, 239, 239f immune-mediated encephalitis, 238–239 intracranial hemorrhage, 237–238 seizure, 237–238 stroke, 237–238 pharmacologic agents, 237 posterior reversible encephalopathy syndrome (PRES), 244–245, 245f predisposing factors, 236 psychosis, causes of, 236 toxic, 240–241 Delusions, 91, 91f Dermatomyositis (DM), 668, 670 secondary interstitial lung disease, 640, 640f, 642 Desquamative interstitial pneumonia (DIP), 639–640 Diabetes mellitus, 192–193 Dialysis-related pericarditis, 63–64 Diarrhea definition, 177 with dyspnea, 176, 176f inflammatory diarrhea. See Inflammatory diarrhea intestinal dysmotility, 192–194 mechanisms of, 177 osmotic diarrhea celiac disease, 189–190 cholerheic diarrhea, 189–190 lactose intolerance, 188–189 laxatives, 188

1073

medications, 189 pancreatic exocrine insufficiency, 189–190 short bowel syndrome, 189–190 small intestinal bacterial overgrowth, 189–190 sugar alcohol, 188, 190 tropical sprue, 189–190 secretory diarrhea, 191–192 water absorption, 177 Diastolic murmur, 603, 603f Dietary fortification, 130 Dieulafoy’s lesion, 203–204 Diffuse alveolar hemorrhage, 623, 625 Diffuse lymphadenopathy, 85 Digital clubbing, 662 Digoxin, 8 Dilated cardiomyopathy, 19, 39 Disseminated fungal infection, 82–83 Disseminated gonorrhea, 664 clinical features of, 665 Distributive hypotension, 282–283 Diuretics, 39 Diverticulosis, 206–207 Dressler’s syndrome, 63 Drug-eluting stents, 19 Drug-induced immune hemolytic anemia, 333–334 Drug-induced thyroiditis, 129 Duchenne muscular dystrophy, 44 Duodenitis, 204–205 Dysfunctional hypothalamic-pituitary axis, 81 Dysmorphic red blood cell, 451, 451f Dyspnea anemia, 258–259 breathing regulation, 249, 249f cardiac aortic stenosis, 250–251 cardiac dysrhythmia, 250–251 cardiac output (CO) determinants, 250

1074

cardiac tamponade, 250, 252 cardiomyopathy, 250–251 constrictive pericarditis, 250, 252 intracardiac shunt, 251–252 mechanisms, 250 myocardial ischemia, 250 myocarditis, 250, 252 oxygen delivery, 250 superior vena cava (SVC) syndrome, 251–252 deconditioning, 259–260 definition, 249 with facial edema, 248, 248f heart and lungs, roles, 249 hyperventilation, 249 metabolic acidosis, 259–260 myasthenia gravis, 259 panic attack, 258–259 pregnancy, 259–260 pulmonary airway, 253–255, 253f causes of, 252 gas exchange, 252 mechanisms, 252 parenchyma, 255–256, 255f pleura, 258 vasculature, 257–258 reduced partial pressure of inspired oxygen, 258, 260 tachypnea, 249 thyrotoxicosis, 259–260 Dystonic activity, 541

E Eccentric hypertrophy, 39, 39f on chest radiography, 39 Echoviruses, 57 Ectopic ACTH production carcinoid tumor, 96

1075

diagnosis, 97 electrolyte disturbance, 95 hypokalemia, 95 medullary thyroid carcinoma, 96 multiple endocrine neoplasia types 2a and 2b, 97 pancreatic islet cell tumor, 96 characteristics of, 97 pheochromocytoma, 96 multiple endocrine neoplasia types 2a and 2b, 96 small cell lung cancer, 96 source of, 97 Ectopic 1,25(OH)2D secretion, 105 Electrolyte disturbances, 8 Embolism infarction pattern, 572 mechanisms, 566, 572–573 Emery-Dreifuss muscular dystrophy, 44 Emphysema, 621–622 Empyema, 647 Encephalitis, 236 delirium, 243–244 Endobronchial biopsy, 607 Endocardial fibrosis, 49 Endocarditis, 266 classification, 365 definition, 365 Infective endocarditis classification, 370 clinical manifestations, 369 complications, 370 definition, 367 diagnosis, 369 heart valves, 367 intravenous drug use (IVDU), 377–379, 377f Janeway lesions, 368, 368f modified Duke criteria, 369, 369t

1076

native valve, 370–373 physical findings, 368 prognosis of, 370 prosthetic valve, 373–377 Roth spots, 368, 368f splinter hemorrhage, 368, 368f symptoms of, 368 therapy, 369 Noninfective endocarditis definition, 366 nonbacterialtthrombotic endocarditis (NBTE). See Nonbacterial thrombotic prevalence of, 366 endocardi is (NBTE) with pulsating nail beds, 365, 365f Endocrine disorders, 132 Endocrinology adrenal insufficiency. See Adrenal insufficiency Cushing’s syndrome. See Cushing’s syndrome hypercalcemia. See Hypercalcemia hypocalcemia. See Hypocalcemia hypothyroidism. See Hypothyroidism PTH-independent hypercalcemia, 107–108 thyrotoxicosis. See Thyrotoxicosis End-stage renal disease, 102 Entamoeba histolytica, 184–185 Enterohemorrhagic Escherichia coli (EHEC), 183, 185 Enteroinvasive Escherichia coli (EIEC), 183, 185 Enteropathic arthritis, 664 types, 666 Enterotoxigenic Escherichia coli (ETEC), 180–181 Enteroviruses, 384–385 Enthesitis, 659 Eosinophilia, 48–49 Eosinophilic granulomatosis with polyangiitis (EGPA), 62 ANCA-associated small vessel systemic vasculitis, 678–679 Eosinophilic myocarditis. See Löffler endocarditis Epilepsy

1077

antiepileptic drugs, 543 causes of, 542 definition, 542 nonpharmacologic long-term treatment, 543 prevalence, 542 triggers for, 542 types, 543 Episodic arthritis, cystic fibrosis, 661, 663 Epstein-Barr virus (EBV), 57–58, 214–215 Erythema nodosum, 664 Erythematous base, 25 Esophageal cancer, 201–202 Esophageal rupture, 23 cause of, 24 Esophageal spasm, 23 diagnosis of, 24 Esophagitis, 201–202 Essential hypertension, 502 Ethylenediaminetetraacetic acid (EDTA), 121 mechanism of, 122 Eutopic ACTH production, 94–95 Euvolemic hypernatremia, 475 Euvolemic hyponatremia, 493–495 Exogenous glucocorticoids, 93 Exogenous thyroid hormone, 142 External beam radiation therapy, 131–132 Extracranial secondary headache disorders, 520–522 Extraglandular production, 142–143 Extrahepatic cholestasis, 163 biliary system anatomy of, 164, 164f ascariasis, 165–166 biliary stricture, 165–166 choledochal cyst, 165–166 choledocholithiasis, 165, 165f liver flukes, 165–166 malignancy, 165–166

1078

classification, 164 imaging modality, 163 life-threatening condition, 164 mechanism of, 163 pancreas acute pancreatitis, 167 anatomy of, 164, 164f chronic pancreatitis, 167 pancreatic cancer, 167–168 pancreatic pseudocyst, 167–168, 168f Extrarenal hyperkalemia catecholamines, 465 concentration gradient, 465 factors, 465 insulin effect, 465 mechanism, 464, 465f medications, 466 transcellular shift, 464–465, 465f Extravascular consumption, 120–121 Extrinsic vessel compression, 227 Exudative pleural effusion causes of, 652 infectious, 652–653 mechanisms of, 651 noninfectious, 653–655 types, 651

F Fabry disease, 49–50 Facial weakness, 583 Factitious disorder, 271–272 Familial dilated cardiomyopathy, 43 diagnosis, 44 Familial hypocalciuric hypercalcemia (FHH), 102 mechanism of, 103 Familial Mediterranean fever (FMF), 267, 269 Fanconi anemia, 345–346, 346f

1079

Farmer’s lung, 637–638 Fever of unknown origin (FUO) alcoholic hepatitis, 271–272 causes of, 264 definition, 263 drug fever, 271–272 factitious disorder, 271–272 incidence of, 263 infectious causes of, 264 culture-negative endocarditis, 264 endocarditis, 266 intra-abdominal abscess, 264–265 leptospirosis, 265, 265f miliary tuberculosis (TB), 264, 266 osteomyelitis, 265–266 viral infection, 265–266 zoonotic infection, 266 intra-abdominal hematoma, 271–272 malignant atrial myxoma, 269, 271 causes of, 269 colon cancer, 269, 271 hepatocellular carcinoma (HCC), 269, 271 leukemia, 269–270 lymphoma, 269–270 metastatic breast cancer, 269 myelodysplastic syndrome (MDS), 269–270, 270f renal cell carcinoma, 269, 271 noninfectious inflammatory adult-onset Still’s disease (AOSD), 267 causes of, 266 familial Mediterranean fever (FMF), 267, 269 inflammatory bowel disease (IBD), 267, 269 polyarteritis nodosa, 267 polymyalgia rheumatica (PMR), 267, 269 reactive arthritis, 267–268

1080

rheumatoid arthritis (RA), 267–268, 268f sarcoidosis, 267–268, 268f systemic lupus erythematosus (SLE), 267–268 with oral ulcers, 263, 263f postpartum thyroiditis, 271 prevalence of, 264 prognosis of, 264 venous thromboembolism, 271–272 Fibromuscular dysplasia, 228–229 First-degree Atrioventricular (AV) block atria and ventricles conduction, 30 causes of, 30 coronary artery supplies, 30 electrocardiographic findings, 30, 30f nonconducted beats, 30 prevalence of, 30 PR interval measures, 30 prognosis of, 31 symptoms of, 30 treatment for, 31 Focal seizures, 543–544, 543f subtypes, 544–545 Foreign body aspiration, 607–608 dyspnea, 254–255 Foscarnet, 121 mechanism of, 122 Fungal meningitis, 391–393, 392f Fungal pericarditis, 59–60

G Gain-of-function genetic mutations, 117 α-Galactosidase A, 49 Gallavardin phenomenon, 47 Gastric antral vascular ectasia (GAVE), 203–204 Gastric cancer, 203–204 Gastric varices, 203–204 Gastrinoma, 191–192

1081

Gastritis, 202–203 Gastroenterology and hepatology ascites. See Ascites cholestatic liver injury. See Cholestatic liver injury diarrhea. See Diarrhea Gastrointestinal (GI) bleeding. See Gastrointestinal (GI) bleeding hepatocellular liver injury. See Hepatocellular liver injury intestinal ischemia. See Intestinal ischemia Gastroesophageal reflux disease (GERD), 23 lifestyle modifications, 23 Gastrointestinal (GI) bleeding capsule endoscopy, 200 catheter angiography, 200 characteristics, 199 classification, 199 coffee-ground emesis, 199 CT angiography, 200 deep enteroscopy, 201 definition, 198 hematemesis, 198 hematochezia, 199 upper Gastrointestinal bleeding, 200 with hypotension, 198, 198f incidence of, 199 lower Gastrointestinal tracts, 199. See also Lower Gastrointestinal bleeding management, 199 melena, 199, 199f lower Gastrointestinal bleeding, 200 push enteroscopy, 201 radionuclide imaging, 200 source of, 200 upper Gastrointestinal tracts, 199. See also Upper Gastrointestinal bleeding Gastrointestinal calcium absorption, 117 Gastrointestinal malabsorption, 118, 120 Gastrointestinal noncardiac chest pain, 21 acute pancreatitis, 23–24 biliary colic, 23–24

1082

esophageal rupture, 23–24 esophageal spasm, 23–24 gastroesophageal reflux disease (GERD), 23 peptic ulcer disease (PUD), 23–24 Gastropathy, 202, 204 Generalized lymphadenopathy, 48 Generalized seizures, 543–544, 543f subtypes, 545–546 Genetic disorders, heart failure congenital heart disease, 49 Fabry disease, 49–50 glycogen storage disease, 49 hemochromatosis, 49 hypertrophic cardiomyopathy, 49 Giant cell arteritis, 62 large vessel systemic vasculitis, 675–676, 675f Giant cell myocarditis, 44 Giardia lamblia, 182 Giardiasis, 183 Glomerular disease clinical syndromes, 446 definition, 446 effects of, 446 glomerulus, anatomy, 446, 446f with hematuria, 445, 445f nephritic syndrome characteristic urinary findings, 447 glomerulonephritis. See Glomerulonephritis nephrotic syndrome characteristic urinary findings, 446 classification, 448 infection, 447 laboratory features, 447 pathophysiology, 447 pharmacologic agents, 448 physical findings, 447 primary, 448–449

1083

secondary, 449–450 symptoms, 447 thromboembolism, 447 renal biopsy, 447 Glomerulonephritis ANCA, 451–454 anti-GBM antibodies, 454 classification, 451 dysmorphic red blood cell, 451, 451f Henoch-Schönlein purpura (HSP), 456–457 immunoglobulin A nephropathy, 456–457 laboratory findings, 451 low serum complement levels, 454–456 physical findings, 450 secondary hypertension, 506–507 symptoms, 450 Glucagonoma, 191–192 Glucocorticoids, 79, 87 Glucose-6-phosphate dehydrogenase (G6PD) deficiency, 330, 330f Glycogen storage disease, 49 hypoglycemia, 50 Graft-versus-host disease (GVHD), 169–170 Graham Steell murmur, 48 Granulomatosis with polyangiitis, 678–679, 679f Granulomatosis with polyangiitis (GPA), 62, 106 prognosis of, 107 Granulomatous disease, 48, 85, 115 hypoparathyroidism, 116 polyarticular inflammatory arthritis, 668 PTH-independent hypercalcemia berylliosis, 106–107 Crohn’s disease, 106–107 granulomatosis with polyangiitis (GPA), 106–107 histoplasmosis, 106–107 sarcoidosis, 106 tuberculosis (TB), 106–107 Graves’ disease, 131

1084

diffusely Increased radioactive iodine uptake, 140–141 Guillain-Barré syndrome, 618–619

1085

H Hamman-Rich syndrome, 634 Hashimoto’s thyroiditis, 128 diagnosis of, 129 HCV-associated cryoglobulinemia, 667 Headache classification, 511 prevalence, 510 primary disorders, 511. See also Primary headache disorders secondary disorders, 511. See also Secondary headache disorders with tinnitus, 510, 510f Heart block abnormal jugular venous waveform, 29, 29f definition, 29 electrical conduction path, normal heart, 29 first-degree Atrioventricular (AV) block, 30–31, 30f heart rate and cardiac output (CO), 29 regulation, 29 physical findings, 30 second-degree Atrioventricular (AV) block, 31–33, 31f–33f symptoms of, 29 third-degree Atrioventricular (AV) block, 34, 34f types, 30 with ventricular escape rhythm, 11 Heart failure definition, 38 hemoptysis, 605–606 left-sided heart failure physical findings, 38 pulmonary lymphatic vessel dilation, 38 left ventricular function, 38 with orthostatic hypotension, 37, 37f preserved systolic function, 38. See also Preserved left ventricular systolic function prognosis of, 38

1086

reduced systolic function, 38. See also Reduced left ventricular systolic function right-sided heart failure, physical findings, 38 risk factors, 38 symptoms of, 38 Heart rate and cardiac output (CO), 29 regulation, 29 HELLP syndrome, 219–220 Hemangioma, 206–207 Hemarthrosis, 661 causes of, 662 Hematemesis, 198, 604 Hematochezia, 199–200 Hematology anemia. See Anemia hemolytic anemia. See Hemolytic anemia pancytopenia. See Pancytopenia platelet disorders. See Platelet disorders Hematopoiesis, 343, 343f ineffective, 347 Hemiparesis, 583 Hemochromatosis, 49, 85, 662 characteristics of, 86 clinical characteristics, 663 primary hypothyroidism, 132 treatment, 50 Hemoglobin C disease, 328–329 Hemolytic anemia acquired hemolytic anemia, 327 immunologic, 333–335, 334f infectious, 337–339, 339f mechanisms, 332 toxic, 335–336 traumatic, 336–337 average life span, 326 causes of, 327 clinical sequelae, 327

1087

with dark urine, 326, 326f definition, 326 inherited hemolytic anemia, 327 Cell Membrane Defects, 331–332, 332f classification, 328 hemoglobin defects, 328–329, 329f intracellular enzyme defects, 330–331, 330f intravascular hemolysis, 326 laboratory features, 327 mechanisms, 327 physical findings, 327 symptoms of, 327 Hemoperitoneum ascites, 157–158 Hemoptysis arterial system, 604 bronchoscopy, 605 cardiovascular causes arteriovenous malformation (AVM), 606 heart failure, 605–606 infarction, 605, 605f pulmonary embolism (PE), 605–606, 605f valvular disease, 606 vasculitis, 606 catamenial hemoptysis, 609 chest radiography, 605 computed tomography (CT) imaging, 605 definition, 604 with diastolic murmur, 603, 603f historical features, 604 idiopathic pulmonary hemosiderosis, 609 mimic conditions, 604 pulmonary arteries, blood supply, 604, 604f pulmonary causes acute bronchitis, 607 bronchiectasis, 607 bronchovascular fistula, 607–608 causes of, 606

1088

foreign body aspiration, 607–608 iatrogenic, 607–608 lung abscess, 608–609 malignancy, 607 pneumonia, 608 pulmonary aspergillosis, 608–609 pulmonary paragonimiasis, 608–609 pulmonary tuberculosis (TB), 608–609 quantity of, 605 severity of, 604 Hemorrhagic causes, primary adrenal insufficiency bilateral adrenal hemorrhage, 83 adrenal vein thrombosis, 84 causes of, 84 critical illness, 84 diagnosis of, 83 immune thrombocytopenic purpura, 84 prognosis of, 84 traumatic injuries, 84–85, 85f Waterhouse-Friderichsen syndrome, 84–85 vascular anatomy, 83 Hemorrhagic stroke causes and treatment, 559 intracerebral hemorrhage, 560–562, 560f occurence, 559, 559f relative rates, 560 subarachnoid hemorrhage, 562–564, 563f Hemorrhoids, 206 Hemothorax, 653, 655 Henderson-Hasselbalch equation, 414 Henoch-Schönlein purpura (HSP), 456–457, 665 characteristics of, 667 non-ANCA-associated small vessel systemic vasculitis, 680 Hepatic encephalopathy, 241–242 Hepatic hydrothorax, 651 Hepatic portal hypertension acute (fulminant) liver failure, 151, 153

1089

cirrhosis, 151–152, 152f hepatocellular carcinoma, 151, 153 idiopathic noncirrhotic portal hypertension, 151, 153 primary biliary cholangitis (PBC), 151, 153 primary sclerosing cholangitis (PSC), 151, 153 schistosomiasis, 151, 153 sinusoidal obstruction syndrome (SOS), 152, 153 Hepatic tuberculosis (TB), 172–173, 173f Hepatitis A and B viruses, 57 Hepatitis A virus (HAV), 213–214 Hepatitis B virus (HBV), 213–214 Hepatitis C virus (HCV), 213, 215 Hepatitis D virus (HDV), 214–215 Hepatitis E virus (HEV), 213–214 Hepatocellular carcinoma (HCC), 169–170, 269, 271 hepatic portal hypertension, 151, 153 Hepatocellular liver injury abnormal aminotransferase level, 213 acute biliary obstruction, 219–220 aminotransferases, 212 elevation, 213 severity of, 213 autoimmune hepatitis, 219 biochemical laboratory pattern, 212 causes of, 213 Celiac disease, 219–220 HELLP syndrome, 219–220 hereditary, 218–219, 218f infectious, 213–215 laboratory tests, 213 life-threatening condition, 213 nonalcoholic fatty liver disease (NAFLD), 219 with skin rash, 212, 212f toxic, 216–217 vascular, 217 Hepatopulmonary syndrome, 623, 625 Hereditary elliptocytosis, 331–332, 332f

1090

Hereditary hemochromatosis, 218 Hereditary hemorrhagic telangiectasia (HHT), 606, 628 Hereditary polyneuropathy, 535–536, 536f Hereditary spherocytosis, 331 Hereditary stomatocytosis, 331–332 Hereditary xerocytosis, 331–332 Herpes simplex virus (HSV), 57, 214–215 Herpes simplex virus types 1 (HSV-1) and 2 (HSV-2), 384–385, 385f Herpes zoster, 25 High-altitude pulmonary edema (HAPE), 259 His-Purkinje system, 32 Histoplasma capsulatum, 59, 107 Histoplasmosis, 106–107 Holosystolic murmur, 40–41 Hormonal cycle, 79 Hospital-acquired pneumonia (HAP), 405–407 Human chorionic gonadotropin (hCG), 140–141 Human immunodeficiency virus (HIV), 42 antiretroviral therapy (ART), 43 primary adrenal insufficiency, 82–83 viral meningitis, 384, 386 viral pericarditis, 57–58 Hungry bone syndrome, 120–121 Hydrocephalus, delirium, 237, 239, 239f 11β-Hydroxysteroid dehydrogenase type 2, 95 Hyperalbuminemia, 101 Hypercalcemia calcium distribution, 100 clinical manifestations, 102 cognitive dysfunction, 102 with confusion, 100, 100f electrocardiographic manifestations, 102 etiology of, 102 Gastrointestinal symptoms, 102 ionized calcium, 101 neuropsychiatric symptoms, 102 PTH actions, 101, 101f

1091

PTH-dependent familial hypocalciuric hypercalcemia (FHH), 102–103 mechanism of, 102 primary hyperparathyroidism, 102–103 secondary hyperparathyroidism, 103 tertiary hyperparathyroidism, 102–103 PTH-independent causes of, 103 Endocrinopathy, 107–108 granulomatous disease, 106–107 immobility, 108 malignancy, 105 mechanism of, 103 medication, 104 rhabdomyolysis, 108–109 renal symptoms, 102 total serum calcium concentration, 100 measurement of, 101 vitamin D, 101 Hypercarbia, delirium, 241–242 Hypercortisolism, 94 ACTH-dependent Cushing’s syndrome, 94 Hypereosinophilic syndrome (HES), 49 Hyperkalemia cardiac dysrhythmias, 461 classification, 461 conduction abnormalities, 461 with dark urine, 460, 460f electrocardiographic manifestations, 461, 461f extrarenal catecholamines, 465 concentration gradient, 465 factors, 465 insulin effect, 465 mechanism, 464, 465f medications, 466 transcellular shift, 464–465, 465f

1092

glomerular filtration rate, 462 normal serum K+ concentration, 460 regulation, 461 pseudohyperkalemia, 460 renal function, 462 Decreased renal clearance, 462–463 normal renal clearance, 463–464, 464f serum creatinine concentration, 462 symptoms, 461 Hypermagnesemia, 116 Hypernatremia acute and chronic, 472, 472f adaptive mechanisms, 471 clinical manifestations, 472 definition, 469 euvolemic, 475 hypervolemic, 475–476 hypovolemic, 473–475, 474f physical findings, 472 with polyuria, 469 serum Na+ concentration, 469 effects of, 471 water homeostasis, 470, 470f Hyperosmolar hyperglycemic state, 241–242 Hyperphosphatemia, 120 mechanism of, 121 Hyperproliferative normocytic anemia, 318–319 Hypersensitivity pneumonitis (HP) antigens classes, 636 bird fancier’s lung, 637–638 bronchoscopy, 637 characteristics, 637 clinical course, 637 definition, 636 farmer’s lung, 637–638 high-resolution CT imaging, 637 prevalence, 636

1093

serologic testing, 637 treatment for, 637 Hypersplenism, 333–334, 349–350 Hypertension encephalopathy, 244–245 preserved systolic function, 46 Hyperthermia, delirium, 241, 243 Hypertonic/isotonic hyponatremia, 490 Hypertrophic cardiomyopathy, 49 without outflow obstruction, 50 Hypertrophic obstructive cardiomyopathy (HOCM), 19 preserved systolic function, 46 squatting position, murmur quality change, 21 Hypertrophic osteoarthropathy, 661–662 Hyperventilation, dyspnea, 249 Hypervolemic hypernatremia, 475–476 Hypervolemic hyponatremia, 495–497 Hypoalbuminemia, 101 Hypocalcemia calcium distribution, 112 in blood, 112 with chest pain, 112 Chvostek’s sign, 113 clinical manifestations, 113 etiology of, 113 PTH-dependent autoimmune causes, 114–115 calcium-sensing receptor, 116–117 causes of, 113 iatrogenic causes, 114 infiltrative causes, 115–116 laboratory pattern, 113 magnesium derangement, 116 mechanism of, 113 PTH-independent causes of, 117 extravascular consumption, 120–121

1094

hypomagnesemia, 122 intravascular consumption, 121–122 laboratory pattern, 117 mechanism of, 117 medication, 122 pseudohypoparathyroidism, 122 vitamin D deficiency, 117–120, 118f–119f serum ionized calcium concentration, 113 serum PTH value, 113 total serum calcium concentration, 112 hypoalbuminemia, 112 ionized calcium, 112 Trousseau’s sign, 113 Hypoglycemia, 50 delirium, 241 Hypokalemia, 95 cardiac dysrhythmias, 480 with dry mouth, 479, 479f electrocardiographic manifestations, 480, 480f extracellular K+ concentration, 479 mechanisms, 480 normal serum K+ concentration, 479 potassium excess loss, 481, 481f extrarenal loss, 482–483 low oral intake, 480–481 renal loss, 481–482 transcellular shift, 483–484 symptoms, 480 Hypomagnesemia, 116, 122 Hyponatremia acute and chronic, 489 adaptive mechanisms, 488, 488f clinical manifestations, 489 definition, 487 with hemoptysis, 487, 487f hypertonic/isotonic, 490

1095

hypotonic, 489 cause of, 490 euvolemic, 493–495 hypervolemic, 495–497 hypovolemic, 491–493 laboratory test, 491 physical findings, 491 laboratory definitions, 489 serum Na+ concentration, 487 effects of, 488 serum osmolality vs. tonicity, 489 severity of, 487 water homeostasis regulation, 488 Hypoparathyroidism autoimmune causes, 114–115 calcium-sensing receptor, 116–117 causes of, 113 iatrogenic causes, 114 infiltrative causes, 115–116 laboratory pattern, 113 magnesium derangement, 116 mechanism of, 113 Hypoproliferative normocytic anemia, 316–318 Hypotension, 621–622 blood pressure measurement, 277 regulation, 277, 277f cardiac output (CO), 276 cardiac tamponade, 56, 56f cardiogenic, 280–282 with cool extremities, 276, 276f distributive, 282–284 hypotensive shock, 278 hypovolemic, 278–280, 279f Korotkoff sounds, 277 mean arterial pressure (MAP), 276 mechanisms, 278

1096

obstructive, 284–285, 285f physical findings, 278 prevalence of, 278 symptoms of, 278 Hypotensive shock, 278 Hypothalamic-pituitary-adrenal axis, 79, 79f Cushing’s syndrome, 92 Hypothalamic-pituitary-thyroid axis, 126, 126f Hypothermia, 8 delirium, 241, 241f, 243 Hypothyroidism, 8 with bradycardia, 125, 125f causes of, 127 central, 133 clinical condition, 127 clinical entity, 127 definition, 126 function, 127 hypothalamic-pituitary-thyroid axis, 126, 126f life-threatening complication, 127 overt hypothyroidism, 127 pericarditis, 63–64 physical findings of, 127 prevalence of, 126, 128 primary causes of, 128 iatrogenesis, 131–132 infiltrative disorders, 132–133 iodine, 130–131 mechanism of, 128 thyroiditis, 128–130 subclinical, 127 symptoms of, 126 T3 and T4, 126 thyroid-releasing hormone (TRH), 126 thyroid-stimulating hormone (TSH), 126

1097

treatment, 127 Hypotonic hyponatremia cause of, 490 euvolemic, 493–495 hypervolemic, 495–497 hypovolemic, 491–493 laboratory test, 491 physical findings, 491 Hypovolemic hypernatremia, 473–475, 474f Hypovolemic hyponatremia, 491–493 Hypovolemic hypotension Gastrointestinal losses, 279 hemorrhagic shock, 279 hypovolemic shock, 278 isotonic fluid, 279, 279f mechanisms, 278 patterns of, 278 poor oral intake, 279 renal salt wasting, 279–280 severe burn injury, 279–280 Hypoxemia A-a gradient, 615, 615f elevated, 619–620, 620f normal, 616, 616t. See also A-a gradient alveolar gas equation, 614 partial pressure of, 615 anatomic shunt, 627–628, 627f barometric pressure, 615 causes of, 615 dead space anatomic and alveolar dead space, 621, 621f causes of, 621–622 definition, 621 inhaled oxygen, 621 mechanism, 621 definition, 612 hypoventilation

1098

A-a gradient, 618 asthma exacerbation, 618–619 drugs and toxins, 618–619 Guillain-Barré syndrome, 618–619 inhaled oxygen, 618 kyphoscoliosis, 618–619 obesity hypoventilation syndrome (OHS), 618–619 obstructive sleep apnea (OSA), 618–619 partial pressure of carbon dioxide, 618 primary metabolic alkalosis, 619 hypoxia, 614 impaired diffusion capacity, 625–626, 625f inspired oxygen fraction, 615 invasive test, 613 oxygen content, arterial blood, 614 determinants, 614 oxygen delivery, 614 oxyhemoglobin dissociation curve, 613, 613f partial pressure of carbon dioxide, 615 partial pressure of oxygen, 613 physiologic conditions, 613 physiologic shunt acute respiratory distress syndrome (ARDS), 624 airway constriction, 623–624 atelectasis, 623–624 definition, 623 diffuse alveolar hemorrhage, 623, 625 hepatopulmonary syndrome, 623, 625 inhaled oxygen, 623 pneumonia, 623–624 pulmonary edema, 623–624 with positional dyspnea, 612, 612f pulse oximetry, 612 conditions, 613 respiratory quotient (RQ), 615 tissue oxygen extraction, 614 water vapor pressure, 615

1099

I Iatrogenesis, 86 hypoparathyroidism, 114 primary hypothyroidism external beam radiation therapy, 131–132 Graves’ disease, 131 lithium, 131–132 thyroidectomy/radioactive iodine ablation, 131 Idiopathic dilated cardiomyopathy, 44 Idiopathic interstitial lung disease acute interstitial pneumonia (AIP), 634–635 chronic eosinophilic pneumonia (CEP), 634–635 cryptogenic organizing pneumonia (COP), 634 definition, 633 idiopathic pulmonary fibrosis (IPF), 633–634 lymphoid interstitial pneumonia (LIP), 634–635 non-specific interstitial pneumonia (NSIP), 633–634 pattern of, 633 Idiopathic noncirrhotic portal hypertension, 151, 153 Idiopathic pulmonary fibrosis (IPF), 633–634 Idiopathic pulmonary hemosiderosis, 609 Idiopathic restrictive cardiomyopathy, 50 prognosis of, 51 Immune-mediated encephalitis, 238–239 Immune-mediated inflammatory diseases, 660 Immune-mediated parathyroid destruction, 115 Immunoglobulin A nephropathy, 456–457 Immunoglobulin light chain (AL) amyloidosis, 48 Impaired diffusion capacity, 625–626, 625f Impaired sensitivity, 143–144 Infarction, hemoptysis, 605, 605f Infarct pericarditis, 63 Infectious colitis, 208–209 Infectious diseases, 8 endocarditis. See Endocarditis heart failure, 42–43 meningitis. See Meningitis

1100

pneumonia. See Pneumonia primary adrenal insufficiency, 82–83 Infectious exudative pleural effusion, 652–653 Infectious pericarditis bacterial pericarditis, 58–59 causes of, 57 clinical presentation, 57 fungal pericarditis, 59–60 viral pericarditis, 57–58 Infectious thyroiditis, 129 risk factors for, 130 Infective endocarditis classification, 370 clinical manifestations, 369 complications, 370 definition, 367 diagnosis, 369 heart valves, 367 intravenous drug use (IVDU), 377–379, 377f Janeway lesions, 368, 368f modified Duke criteria, 369, 369t native valve, 370–373 physical findings, 368 prognosis of, 370 prosthetic valve, 373–377 Roth spots, 368, 368f splinter hemorrhage, 368, 368f symptoms of, 368 therapy, 369 Inferior vena cava (IVC) obstruction, 154–155 Infiltrative causes, primary adrenal insufficiency, 85–86 Infiltrative disorders, 169–170 amyloidosis, 48 eosinophilia, 48–49 iron overload, 48–49 lymphoma, 48–49 primary hypothyroidism

1101

amyloidosis, 132–133 hemochromatosis, 132 Riedel’s thyroiditis, 132–133 sarcoidosis, 132–133 thyroid gland, 133 sarcoidosis, 48–49 sinus bradycardia, 8 Inflammatory bowel disease (IBD), 267, 269 Inflammatory diarrhea diagnosis, 178f, 187 historical features, 177 invasive infectious diarrhea, 183–186 life-threatening complication, 178 mechanism of, 177 noninfectious inflammatory diarrhea, 186–188, 186f noninvasive bacterial diarrhea, 180–182 noninvasive infectious diarrhea, 178 noninvasive protozoal diarrhea, 182–183 noninvasive viral diarrhea, 178–179 stool study, 177 Inflammatory polyneuropathy causes of, 532 classification, 532 infectious causes, 532–533 noninfectious causes, 533–535 pathophysiologic/electrophysiologic pattern, 532 Influenza A and B viruses, 57 Inherited hemolytic anemia, 327 Cell Membrane Defects, 331–332, 332f classification, 328 hemoglobin defects, 328–329, 329f intracellular enzyme defects, 330–331, 330f In situ occlusion ischemic stroke of large vessel, 567–569 mechanisms, 566 of small vessel, 570–571, 570f Insomnia, delirium, 244–245

1102

Internal medicine delirium. See Delirium dyspnea. See Dyspnea fever of unknown origin (FUO). See Fever of unknown origin (FUO) hypotension. See Hypotension peripheral edema. See Peripheral edema syncope. See Syncope Interstitial lung disease (ILD) bronchoscopy, 633 classification, 633 CT imaging, 632 characteristics, 633 definition, 632 histologic findings, 633 idiopathic, 633–635 microscopic elements, pulmonary parenchyma, 632, 632f physical findings of, 632 pulmonary function testing, 633 radiography, 632 secondary causes of, 635 desquamative interstitial pneumonia (DIP), 639–640 exposures, types, 635 hypersensitivity pneumonitis (HP), 636–638 iatrogenic exposure, 636 pneumoconiosis, 638–639 pulmonary Langerhans cell histiocytosis (PLCH), 639–640 respiratory bronchiolitis–associated interstitial lung disease (RB-ILD), 639–640 systemic disease, 640–642, 640f symptoms of, 632 with tight skin, 631, 631f Interstitial oncotic pressure, peripheral edema, 294–295, 295f Intestinal ischemia definition, 223 ischemic colitis, 224. See also Ischemic colitis mesenteric ischemia, 224 acute. See Acute mesenteric ischemia

1103

blood vessels supply, 224, 224f chronic, 228–229 subtypes of, 224 with testicular pain, 223, 223f types, 223 Intra-abdominal abscess, 264–265 Intracardiac shunt, 627 dyspnea, 251–252 Intracerebral hemorrhage stroke, 560–562, 560f Intracranial hemorrhage, 237–238 Intracranial secondary headache disorders cerebrospinal fluid, 518–519, 518f infectious, 515–517 post-traumatic headache, 519–520 trigeminal neuralgia, 519–520 tumor, 517–518 vascular, 513–515 Intrahepatic cholestasis, 163 clinical features of, 168 diagnosis, 168 imaging modality, 163 infection, 172–173, 173f mechanisms of, 168 obstruction, 169–170 toxicity, 171–172 Intrarenal Acute Kidney Injury acute interstitial nephritis (AIN), 439–441, 440f acute tubular necrosis (ATN), 437–439, 438f classification, 435 cross-section of, 435, 435f vascular, 436–437 Intrathoracic malignancy, 654 Intravascular consumption, 121–122 Intravenous drug use (IVDU), 377–379, 377f Invasive infectious diarrhea, 183–186 Iodine-induced hypothyroidism cause of, 131

1104

characteristics of, 131 dietary fortification, 130 Wolff-Chaikoff effect, 130 Ionized calcium, 101 Ionizing radiation therapy, 114 Iron deficiency, 314–315 Iron infiltration, 115–116 Iron overload, 48 causes of, 49 Irritable bowel syndrome (IBS), 192–193 Ischemia cardiomyopathy, 40 electrocardiographic features, 17 sinus bradycardia, 8 Ischemic colitis, 208–209, 209f, 224 biochemical laboratory abnormalities, 230 blood vessels supply, 229, 229f collateral circulation, 229 diagnosis, 230 endoscopy, 230 epidemiology of, 230 mechanism, 229–230 nonocclusive, 231 occlusive, 231–232 physical findings, 230 prognosis of, 230 symptoms of, 230 Ischemic hepatitis, 217 Ischemic stroke anterior and posterior circulations, 565 classification, 566 embolism infarction pattern, 572 mechanisms, 566, 572–573 internal carotid arteries (ICAs), 565, 565f in situ occlusion of large vessel, 567–569

1105

mechanisms, 566 of small vessel, 570–571, 570f treatment, 567 Watershed causes of, 574 clinical manifestations, 573–574 mechanisms, 566 prevalence, 573

J Janeway lesions, 368, 368f Jaundice, 43 Jod-Basedow phenomenon, 142–143 Jugular venous waveform constrictive pericarditis, 51 tricuspid regurgitation, 48 tricuspid stenosis, 48 Junctional escape rhythm, 8 rate of, 9 Junctional tachycardia, 69 digitalis toxicity, 71

K Kaposi sarcoma, 206–207 Kawasaki disease, 676 treatment for, 677 Kussmaul’s sign, 56 Kyphoscoliosis, 618–619

L Lactate, 121 mechanism of, 122 Lactose intolerance, 188–189 Lancisi’s sign, 48 Large vessel systemic vasculitis Cogan’s syndrome, 676 giant cell arteritis, 675–676, 675f

1106

physical findings, 675 secondary causes of, 676 Takayasu arteritis, 675–676 Laxatives, 188 Lead poisoning, microcytic anemia, 314, 316 Leptospirosis, 265, 265f Leukemia, 269–270 Limb-girdle muscular dystrophy, 44 Limbic encephalitis, 236 Listeria monocytogenes, 180–181 Lithium-induced hypercalcemia, 104, 131–132 Liver disease, 118 Liver flukes, 165–166 Loculated pleural effusion, 647, 647f Löffler endocarditis, 49 Löfgren’s syndrome, 665 prognosis of, 667 Long-chain fatty acids, 86 Lower Gastrointestinal bleeding classification, 205 diagnostic modality, 205 inflammatory, 208–209, 209f structural, 206–207 vascular, 207–208 Lower motor neuron lesions anatomic structures, 588 anterior horn cell, 589–591 definition, 588 motor nerve fibers, 589, 589f peripheral nerve, 593–594 root/plexus, 591–593 Lung abscess, 608–609 Lyme disease, 663, 667 Lymphocytic choriomeningitis virus (LCMV), 385–386 Lymphoid interstitial pneumonia (LIP), 634–635 Lymphoma, 48, 85, 105 clinical syndrome, 49

1107

fever of unknown origin (FUO), 269–270

M Macrocytic anemia megaloblastic. See Megaloblastic anemia nonmegaloblastic, 321–323, 322f Macroglossia, 48 Major depression, 25 Malignancy, 653–654 extrahepatic cholestasis, 165–166 fever of unknown origin (FUO) atrial myxoma, 269, 271 causes of, 269 colon cancer, 269, 271 hepatocellular carcinoma (HCC), 269, 271 leukemia, 269–270 lymphoma, 269–270 metastatic breast cancer, 269 myelodysplastic syndrome (MDS), 269–270, 270f renal cell carcinoma, 269, 271 lower Gastrointestinal bleeding, 206 PTH-independent hypercalcemia, 105 Malignant pericarditis, 60 Mallory-Weiss tear, 201–202 Marfan syndrome, 62, 62f Mean arterial pressure (MAP), 276 Mean corpuscular volume (MCV), 313–314, 314f Mediastinal radiation therapy, 50–51 Medium vessel systemic vasculitis Kawasaki disease, 676 treatment for, 677 physical findings, 676 polyarteritis nodosa (PAN), 676 arteriographic findings of, 677, 677f secondary causes, 677 Medullary thyroid carcinoma, 96 multiple endocrine neoplasia types 2a and 2b, 97

1108

Megaloblastic anemia on bone marrow evaluation, 320 copper deficiency, 320–321 definition, 319 features, 320, 320f folate deficiency, 320–321 nitrous oxide inhalation, 320–321 vitamin B12 deficiency, 320–321 Meigs’ syndrome, 654–655 Melena, 199–200, 199f Meningitis with agitated delirium, 382, 382f antimicrobial therapy, 383 aseptic meningitis, 393–394 bacterial meningitis atypical, 389–391 typical, 386–389, 388f characteristics, 383, 384t classification, 383 definition, 382 delirium, 243–244 diagnostic procedure, 383 vs. encephalitis, 383 fungal meningitis, 391–393, 392f meningoencephalitis, 383 neuroimaging, 383 physical findings of, 383 pleocytosis, 384 symptoms of, 382 viral meningitis arboviruses, 385–386 characteristic cerebrospinal fluid, 384 diagnosis, 384 enteroviruses, 384–385 herpes simplex virus types 1 (HSV-1) and 2 (HSV-2), 384–385, 385f human immunodeficiency virus (HIV), 384, 386 lymphocytic choriomeningitis virus (LCMV), 385–386

1109

with lymphocytic pleocytosis, 384 mumps, 385–386 pressure of, 384 treatment, 384 Meningococcemia, 84 Meningoencephalitis, 383 Mesenteric ischemia, 224 acute. See Acute mesenteric ischemia blood vessels supply, 224, 224f chronic, 228–229 subtypes of, 224 Mesenteric vasospasm, 227 Mesotheliomas, 60 Metabolic acidosis, 416 anion gap, 417, 420–422 development of, 418, 418f dyspnea, 259–260 lung function, 418 non-anion gap, 418–420, 420f Metabolic alkalosis, 416, 426–428 Metabolic pericarditis, 63–64 Metabolic polyneuropathy, 528–530, 529f Metabolic provoked seizure, 552–553, 552f Metastatic breast cancer, 269 Metastatic infiltration, 86 Methamphetamine-associated cardiomyopathy, 42 Microcytic anemia iron deficiency, 314–315 lead poisoning, 314, 316 sideroblastic anemia, 314, 316 thalassemia, 314–315, 315f Micronodular adrenal hyperplasia, 98 Microscopic polyangiitis, 678–679 Migraine headache, 511–512 Migratory arthritis, 660 Miliary tuberculosis (TB), 264, 266 Milk-alkali syndrome, 104

1110

Mineralocorticoid, 79, 87, 81 receptor, 95 Minute ventilation, 417 Mitral regurgitation, 40–41 Mitral stenosis, 47 atrial fibrillation, 47 Mitral valve prolapse (MVP), 19 symptoms, 21 Mixed connective tissue disease (MCTD), 61 secondary interstitial lung disease, 641–642 Mobitz type II second-degree Atrioventricular (AV) block, 9 AV conduction ratio, 33 block location, 32 bundle branch blocks, 12 causes of, 32 electrocardiographic findings, 32, 32f prognosis of, 32 symptomatic AV block, 12 symptoms of, 32 treatment for, 32 wide QRS complex, 10 with myocardial infarction, 32 Mobitz type I second-degree Atrioventricular (AV) block, 9 AV conduction ratio, 33 block location, 31 causes of, 32 electrocardiographic findings, 31, 31f with myocardial infarction, 31 nonconducted P wave, 10 prognosis of, 32 symptoms of, 32 treatment for, 32 Modified Duke criteria, 369, 369t Monoarticular inflammatory arthritis acute infectious, 664 acute septic arthritis, 663 chronic infectious, 664

1111

crystal arthropathy, 663 types, 664 Lyme disease, 663 Neisseria gonorrhoeae, 664 under polarized light calcium pyrophosphate dihydrate (pseudogout) crystals, 664 monosodium urate (gout) crystals, 664 Staphylococcus aureus, 664 Monomorphic wide-complex tachycardia irregular rhythm, 72 regular rhythm, 72 causes of, 72–74 types, 72 Mononeuritis multiplex, 527 Mononeuropathy, 526 Monosodium urate (gout) crystals, 664 Multifocal atrial tachycardia (MAT) characteristics of, 71 Multiple myeloma, 85, 101 Mumps, 385–386 Muscular dystrophy, 44 types, 44 Musculoskeletal noncardiac chest pain, 21, 24–25 Myasthenia gravis, dyspnea, 259 Mycobacterium tuberculosis, 58, 83 characteristics of, 59 Myelodysplastic syndrome (MDS), 269–270, 270f Myocardial infarction coronary artery vasospasm, 19 Mobitz type I second-degree Atrioventricular (AV) block, 31 Mobitz type II second-degree Atrioventricular (AV) block, 32 Myocardial ischemia, 16–17, 250 vs. acute myocardial infarction, 16 Myocardial oxygen demand, 20 Myocardial scar, 72 Myocarditis, 19, 42 acute, 43

1112

dyspnea, 21, 250, 252 Myoclonus, 540 Myopathy, weakness, 597–599 Myotonic dystrophy, 8, 44 Myxedema, 650–651 ascites, 157–158 coma, 127 interstitial oncotic pressure, 294–295, 295f

N Narrow-complex bradycardia with Irregular Rhythm, 7 causes, 9–10, 10f with regular rhythm causes, 7–9, 7f electrocardiographic characteristics, 7 Narrow-complex tachycardia irregular rhythm, 68, 71–72 regular rhythm causes of, 69–71, 70f electrocardiographic characteristics, 68 Native valve Infective endocarditis acute, 371–372 clinical differences, 371 diagnosis, 370 subacute, 372–373 types, 370 Negative cardiac stress test, 19 Neisseria gonorrhoeae, 664 Nephritic syndrome characteristic urinary findings, 447 glomerulonephritis. See Glomerulonephritis Nephrology acid-base disorders. See Acid-base disorders Acute Kidney Injury (AKI). See Acute Kidney Injury (AKI) glomerular disease. See Glomerular disease hyperkalemia. See Hyperkalemia

1113

hypernatremia. See Hypernatremia hypokalemia. See Hypokalemia hyponatremia. See Hyponatremia secondary hypertension. See Secondary hypertension Nephrotic syndrome, 155–156, 650 characteristic urinary findings, 446 classification, 448 infection, 447 laboratory features, 447 pathophysiology, 447 pharmacologic agents, 448 physical findings, 447 primary, 448–449 secondary, 449–450 symptoms, 447 thromboembolism, 447 Neurally-mediated reflexes, 8 Neuroendocrine tumor, 96 Neurology headache. See Headache polyneuropathy. See Polyneuropathy seizure. See Seizure stroke. See Stroke weakness. See Weakness Neuromuscular junction (NMJ), 595–597, 595f Neuropathy, definition, 526, 526f Nonalcoholic fatty liver disease (NAFLD), 219 Non-ANCA-associated small vessel systemic vasculitis anti–glomerular basement membrane (anti-GBM) disease, 680–681 Behçet’s disease, 680–681 cryoglobulinemia, 680 Henoch-Schönlein purpura (HSP), 680 secondary causes of, 681 urticarial vasculitis (UV), 680–681 Nonbacterial thrombotic endocarditis (NBTE) autoimmune conditions, 367 clinical manifestations, 366

1114

heart valves, 366 infection, 366–367 lung cancer, 366 malignancies, 367 systemic lupus erythematosus (SLE), 366 treatment options, 366 Noncardiac chest pain, 15 anxiety (panic disorder), 25 causes, 21 Gastrointestinal, 21 acute pancreatitis, 23–24 biliary colic, 23–24 esophageal rupture, 23–24 esophageal spasm, 23–24 gastroesophageal reflux disease (GERD), 23 peptic ulcer disease (PUD), 23–24 herpes zoster, 25 musculoskeletal, 21, 24–25 pulmonary acute chest syndrome, 22 pleurisy, 21–22 pneumonia, 21–22 pneumothorax, 21–22 pulmonary embolism (PE), 21–22 pulmonary hypertension, 22 Noncaseating granulomas, 132 Noninfectious exudative pleural effusion, 653–655 Noninfectious inflammatory diarrhea, 186–188, 186f arsenic poisoning, 187–188 colorectal cancer (CRC), 186–187 external beam radiation therapy, 187 inflammatory bowel disease, 186–187, 186f ischemic colitis, 186–187 Noninvasive bacterial diarrhea, 180–182 Noninvasive infectious diarrhea, 178 Noninvasive protozoal diarrhea, 182–183 Noninvasive viral diarrhea, 178–179

1115

Nonmegaloblastic macrocytic anemia, 321–323, 322f Non-specific interstitial pneumonia (NSIP), 633–634 Non–ST-elevation myocardial infarction (NSTEMI), 16 electrocardiographic findings, 17, 17f mycoardial injury, 17 Normal pressure hydrocephalus (NPH), 237, 239, 239f Normocytic anemia bone marrow, 316 hyperproliferative, 318–319 hypoproliferative, 316–318 reticulocytes, 316 Norovirus gastroenteritis, 178–179

O Obesity hypoventilation syndrome (OHS), 618–619 Obliterative bronchiolitis, 624 Obstructive hypotension, 284–285, 285f Obstructive sleep apnea (OSA), 618–619 secondary hypertension, 506–507 Oligoarticular inflammatory arthritis, 61 ankylosing spondylitis, 667 Behçet’s disease, 665 characteristics of, 667 causes of, 664 cryoglobulinemia, 665 disseminated gonorrhea, 664 clinical features of, 665 enteropathic arthritis, 664 types, 666 HCV-associated cryoglobulinemia, 667 Henoch-Schönlein purpura (HSP), 665 characteristics of, 667 Löfgren’s syndrome, 665 prognosis of, 667 Lyme disease, 667 nonmusculoskeletal inflammatory conditions, 666 psoriatic arthritis, 666

1116

reactive arthritis, 667 spirochetal arthritis, 665, 665f spondyloarthritides, 666 syphilis, 667 systemic vasculitides, 667 Orthostatic hypotension, heart failure, 37, 37f Osmotic diarrhea celiac disease, 189–190 cholerheic diarrhea, 189–190 lactose intolerance, 188–189 laxatives, 188 medications, 189 pancreatic exocrine insufficiency, 189–190 short bowel syndrome, 189–190 small intestinal bacterial overgrowth, 189–190 sugar alcohol, 188, 190 tropical sprue, 189–190 Osteoarthritis (OA), 659, 661–662 Osteoblastic bone metastases, 120 characteristics of, 121 Osteolytic metastases, 105, 105f Osteomalacia, 118 Osteomyelitis, 265–266 Osteonecrosis, 661 location of, 662 Overlap syndrome, 61 Overt hypothyroidism, 127

P Pacemaker-facilitated tachycardia, 72 mechanisms of, 74 Pacemakers, 12 Paget disease, 43 high-output physiologic state, 44 Painless thyroiditis, 129 characteristics of, 130 Palpable purpura, 61

1117

Pancreas, extrahepatic cholestasis acute pancreatitis, 167 anatomy of, 164, 164f chronic pancreatitis, 167 pancreatic cancer, 167–168 pancreatic pseudocyst, 167–168, 168f Pancreatic islet cell tumor, 96 characteristics of, 97 Pancreatic pseudocyst, 167–168, 168f Pancreatitis ascites, 157–158 Pancytopenia bone marrow evaluation, 344, 344f bone marrow hypoplasia antithyroid medication, 345 arsenic poisoning, 345 characteristics of, 346 definition, 344 idiopathic aplastic anemia, 345, 347 infections, 346 inherited aplastic anemia, 345–346, 346f medications, 345 paroxysmal nocturnal hemoglobinuria (PNH), 345–346 parvovirus B19 infection, 345 pregnancy, 345 bone marrow infiltration, 348–349, 348f bruising, 342, 342f definition, 343 hematopoiesis, 343, 343f ineffective, 347 hypersplenism, 349–350 investigation of, 344 mechanisms, 344 physical findings, 343 symptoms of, 343 Panic attack, dyspnea, 258–259 Paragonimus westermani, 609 Paralysis, 580

1118

Paraneoplastic encephalitis, 239 Paraparesis, 583 Parasympathetic nervous system, 6, 29, 67 Parathyroid hormone (PTH) -dependent hypercalcemia familial hypocalciuric hypercalcemia (FHH), 102–103 mechanism of, 102 primary hyperparathyroidism, 102–103 secondary hyperparathyroidism, 103 tertiary hyperparathyroidism, 102–103 -dependent hypocalcemia autoimmune causes, 114–115 calcium-sensing receptor, 116–117 causes of, 113 iatrogenic causes, 114 infiltrative causes, 115–116 laboratory pattern, 113 magnesium derangement, 116 mechanism of, 113 -independent hypercalcemia causes of, 103 Endocrinopathy, 107–108 granulomatous disease, 106–107 immobility, 108 malignancy, 105 mechanism of, 103 medication, 104 rhabdomyolysis, 108–109 -independent hypocalcemia causes of, 117 extravascular consumption, 120–121 hypomagnesemia, 122 intravascular consumption, 121–122 laboratory pattern, 117 mechanism of, 117 medication, 122 pseudohypoparathyroidism, 122

1119

vitamin D deficiency, 117–120, 118f–119f Parathyroid hormone–related peptide (PTHrP), 96, 105 Paresis, 580 Paroxysmal nocturnal hemoglobinuria (PNH), 333, 335, 345–346 Parvovirus B19 infection, 345, 668, 670 Peptic ulcer disease (PUD), 23, 202–204 with pain, 24 Perforated viscus, 157, 159 Pericardial coccidioidomycosis, 59 Pericardial disease, 50–51 Pericardiocentesis, 56 Pericarditis acute characteristic features, 55 diagnosis, 64 electrocardiographic manifestations, 55 occurence ratio, 56 with pericardial effusion, 56 physical findings, 55 symptoms of, 55 cardiac causes, 62–63 cardiac tamponade, 56, 56f chest radiography, 56 connective tissue disease (CTD), 60–62 constrictive pericarditis, 56 Kussmaul’s sign, 56 definition, 55 infectious causes, 57–60 malignant causes, 60 medications, 64 metabolic causes, 63–64 pericardiocentesis, 56 pleuritic chest pain, 55 with positional chest pain, 55, 55f radiation therapy, 64 Peripartum cardiomyopathy, 43–44 during pregnancy, 44

1120

Peripheral edema capillary hydrostatic pressure characteristics of, 290 chronic venous insufficiency, 291–292, 292f cirrhosis, 290–291 constrictive pericarditis, 291–292 deep vein thrombosis (DVT), 290–291 mechanisms, 290, 290f medication, 291 pregnancy, 291–292 renal failure, 290–291 right-sided heart failure, 290–291 superior vena cava (SVC) syndrome, 291–292 systemic arterial hypertension, 290 capillary oncotic pressure albumin synthesis, 293, 293f characteristics of, 293 liver disease and malnutrition, 293 nephrotic syndrome, 293–294 plasma proteins, 292 protein-calorie malnutrition, 293 protein-losing enteropathy, 293–294 capillary permeability, 295–297 definition, 288 dependent edema, 289 fluid balance, regulation factors, 289, 289f generalized edema, 289 interstitial oncotic pressure, 294–295, 295f mechanisms, 289 with palmar erythema, 288, 288f pitting edema, 288 total body water distribution, 289 Peripheral neuropathy, 526 Peritoneal dialysis, 651 Persistent respiratory disorder, 417 Pes cavus with hammertoes, 536, 536f Pheochromocytoma, 96, 107

1121

mechanisms of, 108 multiple endocrine neoplasia types 2a and 2b, 96 Phlebotomy, 50 Physiologic shunt, hypoxemia acute respiratory distress syndrome (ARDS), 624 airway constriction, 623–624 atelectasis, 623–624 definition, 623 diffuse alveolar hemorrhage, 623, 625 hepatopulmonary syndrome, 623, 625 inhaled oxygen, 623 pneumonia, 623–624 pulmonary edema, 623–624 Pickwickian syndrome, 618 Pituitary adenoma, 94, 143–144 characteristics of, 95, 95f Pituitary gland dysfunction, 87, 133 Pituitary macroadenomas, 133 Platelet disorders classification, 355 clinical manifestations, 354 with fever and skin rash, 353, 353f function of, 354, 354f laboratory tests, 355 petechiae and purpura, 354 production, 354 qualitative platelet disorders mechanisms, 355 platelet adhesion, 355–356, 356f platelet aggregation, 358 platelet secretion, 356–357 quantitative platelet disorders Decreased platelet production, 359–360 Increased platelet destruction, 360–361 normal peripheral platelet count, 358 pseudothrombocytopenia, 359 Plegia, 580

1122

Pleocytosis, 384 Pleural effusion abnormal fluid accumulation, 646, 646f chest radiography, 646 computed tomography (CT) imaging, 646 criteria for, 647 cytologic examination, 648 definition, 646 differential cell count, 648 dyspnea, 258 empyema, 647 exudative causes of, 652 infectious, 652–653 mechanisms of, 651 noninfectious, 653–655 types, 651 fluid characteristics, 647 glucose concentration, 648 Gram stain and culture, 648 gross appearance of, 648 hemithorax opacification, 646 incidence of, 646 large pleural effusion, 646 loculated pleural effusion, 647, 647f mechanisms of, 646 operating characteristics, Light’s criteria, 647 physical findings, 646 with pleuritic chest pain, 645, 645f symptoms of, 646 thoracentesis, 647 transudative capillary oncotic pressure, 648 diaphragm, 648 diaphragmatic defects, 651 hydrostatic pressure, 648, 649–650 intrapleural pressure, 648

1123

mechanisms of, 648 oncotic pressure, 650–651 types, 647 pleurisy, 21–22 Plexopathy, 526 Pneumoconiosis, 638–639 Pneumocystis jirovecii (PJP), 624 Pneumonectomy, 649–650 Pneumonia, 21, 608 aspiration pneumonia cause of, 410–411 clinical characteristics, 409, 409f definition, 409 mechanism of, 408 methods, 410 risk factors, 409 treatment, 410 cardiac events, 399 clinical presentation, 398 community-acquired pneumonia (CAP) atypical pathogens, 401–403 causes, 399 endemic pathogens, 403–405, 404f typical pathogens, 400–401, 401f definition, 398 delirium, 243–244 hospital-acquired pneumonia (HAP), 405–407 infectious exudative pleural effusion, 652 microbial pathogens, 399 noninfectious conditions, 399 pericardial coccidioidomycosis, 59 physical findings of, 398 physiologic shunt, hypoxemia, 623–624 with shaking chills, 398, 398f Streptococcus pneumoniae, 58 symptoms of, 398 tactile fremitus, 22

1124

ventilator-associated pneumonia (VAP), 407–408 Pneumothorax, 21 dyspnea, 258 treatment for, 22 Polyarteritis nodosa (PAN), 62, 676 arteriographic findings of, 677, 677f fever of unknown origin (FUO), 267 Polyarticular inflammatory arthritis acute rheumatic fever, 668, 670 adult-onset Still’s disease, 668, 670 dermatomyositis (DM), 668, 670 parvovirus B19, 668, 670 polymyositis (PM), 668, 670 rheumatoid arthritis, 668–669, 669f sarcoidosis, 668, 670 serum sickness, 668 clinical manifestations, 670 systemic lupus erythematosus (SLE), 668 characteristics of, 670 Polyglandular autoimmune syndrome type 1 (PAS-1), 82 Polyglandular autoimmune syndrome type 2 (PAS-2), 82 Polymorphic wide-complex tachycardia polymorphic ventricular tachycardia (VT), 74 characteristics of, 75 Torsades de pointes, 75, 75f ventricular fibrillation (VF), 75 Polymyalgia rheumatica (PMR), 267, 269 Polymyositis (PM), 668, 670 secondary interstitial lung disease, 641–642 Polyneuropathy autonomic dysfunction, 528 axonal degeneration and demyelinating disease, 527, 527f causes of, 528 classification, 528 definition, 527 diagnosis, 528 electrodiagnostic testing, 528

1125

genetic studies, 528 hereditary causes, 535–536, 536f inflammatory causes of, 532 classification, 532 infectious causes, 532–533 noninfectious causes, 533–535 pathophysiologic/electrophysiologic pattern, 532 metabolic, 528–530, 529f motor disturbance, 528 neurologic examination, 527 painful tongue, 525, 525f pathophysiologic and electrophysiologic patterns, 527 physical findings of, 528 symptoms of, 527 toxic, 530–531, 530f Portal hypertension ascites, 148 classification, 150 clinical sequelae, 150 diagnosis, 150 hepatic, 151–153, 152f mechanism of, 149 posthepatic, 154–155 prehepatic, 150–151 unrelated to, 155–159, 156f Portal vein thrombosis (PVT), 150–151 Positive pressure ventilation (PPV), 621–622 Postcardiac injury syndrome (PCIS), 62, 653, 655 causes of, 63 Posterior reversible encephalopathy syndrome (PRES), 244–245, 245f Posthepatic portal hypertension ascites, 154–155 Postpartum thyroiditis, 128 fever of unknown origin (FUO), 271 Postrenal Acute Kidney Injury, 441–442 Posttransplant complications, 169–170 Post-traumatic headache, 519–520 Potassium

1126

excess loss, 481, 481f extrarenal loss, 482–483 low oral intake, 480–481 renal loss, 481–482 transcellular shift, 483–484 Pregnancy dyspnea, 259–260 secondary hypertension, 506–507 Prehepatic portal hypertension ascites, 150–151 Prerenal Acute Kidney Injury, 432–434, 433f Preserved left ventricular systolic function afterload, 46 causes of, 45 concentric hypertrophy, 45 enlarged cardiac silhouette, chest radiograph, 45 genetic causes, 49–50 idiopathic restrictive cardiomyopathy, 50–51 infiltrative causes, 48–49 mediastinal radiation therapy, 50–51 pericardial disease, 50–51 restrictive cardiomyopathy, 45 scleroderma, 50–51 S4 gallop, 45, 45f treatment for, 45 valvular causes, 47–48 Primary adrenal insufficiency adrenal cortical tissue, 81 adrenoleukodystrophy (ALD), 86–87 autoimmune causes, 81–82 bilateral adrenalectomy, 86–87 causes of, 81 external beam radiation, 87 hemorrhagic causes, 83–85 infectious causes, 82–83 infiltrative causes, 85–86 mechanism of, 81 medication, 86–87

1127

mineralocorticoid deficiency, 81 radiotherapy, 86 Primary biliary cholangitis (PBC), 169–170 hepatic portal hypertension, 151, 153 Primary headache disorders cluster headache, 511–512 migraine headache, 511–512 tension headache, 511 trigeminal autonomic cephalalgias (TACs), 512 Primary hyperparathyroidism, 102 characteristics of, 103 clinical features, 103 parathyroid carcinoma, 103 Primary hypothyroidism causes of, 128 iatrogenesis external beam radiation therapy, 131–132 Graves’ disease, 131 lithium, 131–132 thyroidectomy/radioactive iodine ablation, 131 infiltrative disorders amyloidosis, 132–133 hemochromatosis, 132 Riedel’s thyroiditis, 132–133 sarcoidosis, 132–133 thyroid gland, 133 iodine cause of, 131 characteristics of, 131 dietary fortification, 130 Wolff-Chaikoff effect, 130 mechanism of, 128 thyroiditis definition, 128 drug-induced thyroiditis, 129 Hashimoto’s thyroiditis, 128–129 infectious thyroiditis, 129

1128

medications, 130 painless thyroiditis, 129 phase of, 128 postpartum thyroiditis, 128 radiation-induced thyroiditis, 129 subacute thyroiditis, 129 Primary metabolic alkalosis, 619 Primary sclerosing cholangitis (PSC), 169–170 hepatic portal hypertension, 151, 153 Prinzmetal’s angina, 19 Prosthetic valve Infective endocarditis diagnosis, 374 early, 374–375 late, 376–377 mechanical valves, 373 microbiological differences, 374 mortality rate, 373 time course, 374 types, 374 Protein-calorie malnutrition, 155–156, 156f Protein-losing enteropathy (PLE), 155–156, 650–651 Protein-poor ascites capillary oncotic pressure, 155 mechanism, 155 nephrotic syndrome, 155–156 protein-calorie malnutrition, 155–156, 156f protein-losing enteropathy, 155–156 Protein-rich ascites chylous ascites, 157–158 hemoperitoneum, 157–158 intraperitoneal malignancy, 157 mechanisms, 157 myxedema, 157–158 pancreatitis, 157–158 perforated viscus, 157, 159 tuberculosis, 157–158 Provoked seizure, 542

1129

causes of, 546 infectious, 551–552 metabolic, 552–553, 552f nonstructural conditions, 546 structural, 550 toxic, 549–550 vascular, 546–549, 547f Pseudohyperkalemia, 460 Pseudohypoparathyroidism, 122 Psoriatic arthritis, 660, 660f, 666 Psychogenic pseudosyncope syncope, 306–307 Psychosis, causes of, 236 Pulmonary arteriovenous malformation, 627 Pulmonary aspergillosis, 608–609 Pulmonary capillaritis, 621–622 Pulmonary causes, hemoptysis airways acute bronchitis, 607 bronchiectasis, 607 bronchovascular fistula, 607–608 causes of, 606 foreign body aspiration, 607–608 iatrogenic, 607–608 malignancy, 607 pulmonary parenchyma lung abscess, 608–609 pneumonia, 608 pulmonary aspergillosis, 608–609 pulmonary paragonimiasis, 608–609 pulmonary tuberculosis (TB), 608–609 Pulmonary edema, 623–624 Pulmonary embolism (PE), 21, 621–622, 653–654 acute, electrocardiographic findings, 22 hemoptysis, 605–606, 605f Pulmonary hypertension, 22, 46, 621–622 diagnosis, 22

1130

Pulmonary Langerhans cell histiocytosis (PLCH), 639–640 Pulmonary noncardiac chest pain acute chest syndrome, 22 pleurisy, 21–22 pneumonia, 21–22 pneumothorax, 21–22 pulmonary embolism (PE), 21–22 pulmonary hypertension, 22 Pulmonary paragonimiasis, 608–609 Pulmonary parenchyma lung abscess, 608–609 pneumonia, 608 pulmonary aspergillosis, 608–609 pulmonary paragonimiasis, 608–609 pulmonary tuberculosis (TB), 608–609 Pulmonary tuberculosis (TB), 608–609 Pulmonic stenosis, 47 causes, 48 Pulmonology hemoptysis. See Hemoptysis hypoxemia. See Hypoxemia interstitial lung disease (ILD). See Interstitial lung disease (ILD) pleural effusion. See Pleural effusion Pulse oximetry, 612 conditions, 613 Pulsus parvus et tardus, 19 Pyruvate kinase deficiency, 330–331

Q Quadriparesis, 583 Qualitative platelet disorders mechanisms, 355 platelet adhesion, 355–356, 356f platelet aggregation, 358 platelet secretion, 356–357 Quantitative platelet disorders Decreased platelet production, 359–360

1131

Increased platelet destruction, 360–361 normal peripheral platelet count, 358 pseudothrombocytopenia, 359

R Radiation coloproctitis, 208–209 Radiation-induced thyroiditis, 129 types of, 130 Radiculopathy, 24–25, 526 Radioactive iodine ablation, 131 Radioactive iodine uptake, 140–143, 140f Rash, 25 Reactive arthritis, 667 fever of unknown origin (FUO), 267–268 Reduced left ventricular systolic function acromegaly, 43–44 cardiovascular causes, 40–41 causes of, 40 cirrhosis, 43–44 dilated cardiomyopathy, 39 eccentric hypertrophy, 39f on chest radiography, 39 familial dilated cardiomyopathy, 43–44 giant cell myocarditis, 44 idiopathic dilated cardiomyopathy, 44 infectious causes, 42–43 muscular dystrophy, 44 myocardial hypertrophy, types, 39, 39f Paget disease, 43–44 peripartum cardiomyopathy, 43–44 pharmacologic agents improved patients survival, 40 improved symptoms, 39 S3 gallop, 39, 39f Takotsubo cardiomyopathy, 43–44 thiamine deficiency, 43–44 toxic causes, 41–42

1132

Refeeding syndrome, 241–242 Regular rhythm, definition, 7 Relative bradycardia, 8 pacemaker-dependent patient, 12 Renal cell carcinoma, 269, 271 Renal replacement therapy, 431 Respiratory acidosis, 416, 422–424, 422f Respiratory alkalosis, 416, 424–426 Respiratory bronchiolitis–associated interstitial lung disease (RB-ILD), 639–640 Respiratory quotient (RQ), 615 Respiratory syncytial virus, 57 Restrictive cardiomyopathy, 45 Rhabdomyolysis, 108–109 Rheumatoid arthritis (RA), 60, 668–669, 669f clinical features, 60 fever of unknown origin (FUO), 267–268, 268f secondary interstitial lung disease, 640, 642 Rheumatology arthritis. See Arthritis systemic vasculitis. See Systemic vasculitis Rib fracture, 24–25 Rickets, 118, 118f Riedel’s thyroiditis, 132–133 “Ripping” chest pain, 19 Rotavirus gastroenteritis, 178–179 Roth spots, 368, 368f

S Saddle nose deformity, 106 Salmonella species, 183–184 Sarcoidosis, 48–49, 106, 668, 670 characteristics of, 86 fever of unknown origin (FUO), 267–268, 268f primary hypothyroidism, 132–133 secondary interstitial lung disease, 640 Sarcomas, 60 Schistosomiasis, 151, 153

1133

Scleroderma, 50–51, 61, 193–194 secondary interstitial lung disease, 640–641 Secondary headache disorders causes of, 512 classification, 512 extracranial, 520–522 intracranial cerebrospinal fluid, 518–519, 518f infectious, 515–517 post-traumatic headache, 519–520 trigeminal neuralgia, 519–520 tumor, 517–518 vascular, 513–515 Secondary hypertension blood pressure regulation, 502 causes of, 502 clinical characteristics, 502 with discordant peripheral pulses, 501, 501f endocrinologic causes, 503–505 essential hypertension, 502 glomerulonephritis, 506–507 obstructive sleep apnea (OSA), 506–507 pregnancy-associated hypertension, 506–507 prevalence, 502 toxic causes, 505–506 vascular causes, 502–503, 503f white-coat hypertension, 506–507 Secondary interstitial lung disease causes of, 635 desquamative interstitial pneumonia (DIP), 639–640 exposures, types, 635 hypersensitivity pneumonitis (HP) antigen classes, 636 bird fancier’s lung, 637–638 bronchoscopy, 637 characteristics, 637 clinical course, 637

1134

definition, 636 farmer’s lung, 637–638 high-resolution CT imaging, 637 prevalence, 636 serologic testing, 637 treatment for, 637 iatrogenic exposure, 636 pneumoconiosis, 638–639 pulmonary Langerhans cell histiocytosis (PLCH), 639–640 respiratory bronchiolitis–associated interstitial lung disease (RB-ILD), 639–640 sarcoidosis, 640–641 systemic disease dermatomyositis (DM), 640, 640f, 642 mixed connective tissue disease (MCTD), 641–642 polymyositis (PM), 641–642 rheumatoid arthritis (RA), 640, 642 sarcoidosis, 640–641 scleroderma, 640–641 Sjögren’s syndrome, 641–642 systemic lupus erythematosus (SLE), 641–642 vasculitis, 641–642 Second-degree Atrioventricular (AV) block Mobitz type I (Wenckebach), 31–32, 31f Mobitz type II, 32–33, 32f second-degree 2:1 AV block, 33, 33f types, 31 Seizure atonic activity, 541 aura, 541 automatisms, 541 classification, 542 clonic activity, 541 conditions, 540 definition, 540 delirium, 237–238 dystonic activity, 541 electroencephalography (EEG), 541

1135

emergency neuroimaging, 541 focal seizures, 543–544, 543f subtypes, 544–545 generalized seizures, 543–544, 543f subtypes, 545–546 myoclonus, 540 pharmacologic treatment, 541 physical examination, 541 postictal state, 541 with pronator drift, 540, 540f provoked seizure, 542 causes of, 546 infectious, 551–552 metabolic, 552–553, 552f nonstructural conditions, 546 structural, 550 toxic, 549–550 vascular, 546–549, 547f status epilepticus, 541 symptoms and signs, 540 tonic activity, 541 unprovoked seizure, 542 epilepsy, 542 Sepsis, 42 delirium, 243–244 intrahepatic cholestasis, 172 prognosis of, 43 Seronegative spondyloarthritides, 61 reactive arthritis, 62 Serum sickness, 668 clinical manifestations, 670 S3 gallop, 39, 39f, 154 S4 gallop, 45, 45f Sheehan’s syndrome, 87 Shigella species, 183, 185 Short bowel syndrome, 189–190 Sickle cell anemia, 22, 169–170

1136

inherited hemolytic anemia, 328–329, 329f Sideroblastic anemia, 314, 316 Silicosis, 638–639 Sinoatrial exit block, 9 definition, 10 type I, 10 type II, 10, 10f Sinus arrest, 9 definition, 10 Sinus arrhythmia, 9 Sinus bradycardia, 7 bundle branch block, 11 causes of, 8 mechanism of, 8 medications of, 8 pulse-temperature pattern, 8 ventricular escape rhythms, 11 Sinusoidal obstruction syndrome (SOS), 152, 153 Sinus tachycardia, 69 Sjögren’s syndrome, 653 secondary interstitial lung disease, 641–642 Skin hyperpigmentation, 662 Slapped-cheek syndrome, 668 Small cell lung cancer, 96 Small vessel systemic vasculitis ANCA-associated eosinophilic granulomatosis with polyangiitis (EGPA), 678–679 granulomatosis with polyangiitis, 678–679, 679f microscopic polyangiitis, 678–679 secondary causes of, 679 manifestations of, 677 non-ANCA-associated anti–glomerular basement membrane (anti-GBM) disease, 680–681 Behçet’s disease, 680–681 cryoglobulinemia, 680 Henoch-Schönlein purpura (HSP), 680 secondary causes of, 681

1137

urticarial vasculitis (UV), 680–681 palpable purpura distribution, 677 physical findings, 677 serological testing, 678 Smoking, 96 Soft tissue sarcoma, 25 Spider angiomas, 43 Spirochetal arthritis, 665, 665f Splanchnic arteriovenous fistula, 150–151 Splenic vein thrombosis, 150–151 Splinter hemorrhage, 368, 368f Spondylitis, 660 Spondyloarthritides, 666 Spondyloarthritis, 660 Spur cell anemia, 333, 335 Stable angina pectoris, 19 mechanism of, 20, 20f Staphylococcus aureus, 58–59, 180–181, 664 Status epilepticus, 541 ST-elevation myocardial infarction (STEMI), 16 electrocardiographic manifestation of, 16–17, 17f Stent thrombosis, 18 timing of, 19 Streptococcus pneumoniae, 58–59 Stroke CT imaging, 559 definition, 557 delirium, 237–238 with flank pain, 557, 557f hemorrhagic, 559. See also Hemorrhagic stroke ischemic, 559. See Ischemic stroke mechanisms of, 558, 558f prevalence, 558 prognosis of, 558 relative rates, 558 risk factors, 558 transient ischemic attack (TIA), 557

1138

conditions, 558 risk of, 558 types, 558 Structural provoked seizure, 550 Subacute hypersensitivity pneumonitis, 637 Subacute thyroiditis, 129 Subarachnoid hemorrhagic stroke, 562–564, 563f Subclavian steal syndrome, 303, 303f Subcutaneous emphysema, 23 Subluxation, 659 Subphrenic abscess, 652–653 Substance abuse, 25 Sugar alcohol, 188, 190 Superior vena cava (SVC) syndrome, 649 dyspnea, 251–252 Supraventricular rhythm irregular, 12 regular, 11 Supraventricular tachycardia (SVT) irregular, 74 wide QRS complex, 74 regular, 72 vs. baseline wide QRS complex, 73 Surgical trauma, 8 Surreptitious thyroid hormone ingestion, 142 Symmetric arthritis, 660 Symmetric hypertrophy, 39, 39f Symmetric inflammatory polyarticular arthritis, 60 Sympathetic nervous system, 6, 29, 67 Syncope α-blocker medication, 306 cardiovascular, 301–303, 303f causes of, 300 definition, 300 enlarged cardiac silhouette, 300, 300f hyperventilation, 306 hypoxemia and anemia, 306

1139

incidence of, 300 mechanism of, 300 neurocardiogenic, 303–305 neurologic, 305 prognosis of, 300 psychogenic pseudosyncope, 306–307 tension pneumothorax, 306–307, 307f Syndrome of inappropriate antidiuretic hormone (SIADH), 96 Synovial fluid, 661 Synovitis, 659 Syphilis, 667 Systemic disease dermatomyositis (DM), 640, 640f, 642 mixed connective tissue disease (MCTD), 641–642 polymyositis (PM), 641–642 rheumatoid arthritis (RA), 640, 642 sarcoidosis, 640–641 scleroderma, 640–641 Sjögren’s syndrome, 641–642 systemic lupus erythematosus (SLE), 641–642 vasculitis, 641–642 Systemic lupus erythematosus (SLE), 60, 653, 668 characteristics of, 670 clinical features, 61 fever of unknown origin (FUO), 267–268 nonbacterial thrombotic endocarditis (NBTE), 366 secondary interstitial lung disease, 641–642 Systemic mastocytosis, 191–192 Systemic vasculitides, 667 Systemic vasculitis classification, 674 conditions, 674 definition, 674 with hemoptysis, 673, 673f laboratory features of, 674 large vessel, 675–676 limited systemic vasculitis, 674

1140

medium vessel, 676–677, 677f occurrence of, 674 small vessel ANCA-associated, 678–679, 679f manifestations of, 677 non-ANCA-associated, 680–681 palpable purpura distribution, 677 physical findings, 677 serological testing, 678 Systolic ejection murmur, 19

T Tachyarrhythmia-induced cardiomyopathy, 40–41 Tachycardia definition, 68 electrical conduction, normal heart, 67 heart rate and cardiac output (CO), 68 regulation, 67 mechanisms of, 68 narrow QRS complex, 68. See also Narrow-complex tachycardia physical findings of, 68 resting heart rate, adults, 68 symptoms of, 68 wide QRS complex, 68. See also Wide-complex tachycardia definition, 68 woman with palpitations, 67, 67f Tachypnea, 249 Tactile fremitus, 22 Takayasu arteritis, 675–676 Takotsubo cardiomyopathy, 43 echocardiographic finding, 44 sepsis, 43 Telangiectasias, 206–207 Tenosynovitis, 659 Tension headache, 511 Tension pneumothorax, 22

1141

syncope, 306–307, 307f Tertiary hyperparathyroidism, 102–103 Thalassemia, 115 inherited hemolytic anemia, 328–329 microcytic anemia, 314–315, 315f Thiamine deficiency, 43–44 Thiazide diuretics, 104 Third-degree Atrioventricular (AV) block, 34, 34f Thoracentesis, 647 Thrombocytopenia clinical manifestations, 359 Decreased platelet production, 359–360 immature platelets, 359 Increased platelet destruction, 360–361 laboratory test, 359 mechanisms, 359 normal peripheral platelet count, 358 pseudothrombocytopenia, 359 Thromboembolism, nephrotic syndrome, 447 Thymic carcinoid tumors, 96 Thyroid adenomas, 142 Thyroidectomy, 131 Thyroiditis, 142–143 Thyroid-releasing hormone (TRH), 126, 137 Thyroid-stimulating hormone (TSH), 126, 137 -dependent thyrotoxicosis impaired sensitivity, 143–144 mechanism of, 143 pituitary adenoma, 143–144 -independent thyrotoxicosis with Decreased radioactive iodine uptake, 142–143 diagnosis, 139 diffusely Increased radioactive iodine uptake, 140–141 with focally Increased radioactive iodine uptake, 141–142 Increased radioactive iodine uptake, 140, 140f mechanism of, 139 Thyrotoxicosis, 41, 107, 127, 192, 194

1142

cardiovascular conditions, 42 characteristics, 139 characteristics of, 108 clinical evaluation, 138 definition, 137 dyspnea, 259–260 hypothalamic-pituitary-thyroid axis, 137 life-threatening complication, 138 with palpitations, 137, 137f physical findings of, 138, 138f prevalence, 138 serum thyroid hormone levels, 139 symptoms of, 138 T3 and T4, 137, 139 thyroid function, 139 thyroid-releasing hormone (TRH), 137 thyroid-stimulating hormone (TSH), 137 -dependent thyrotoxicosis, 143–144 -independent thyrotoxicosis, 139–143, 140f Thyrotoxicosis factitia, 142 Tissue ischemia, 121 Tissue oxygen extraction, 614 Tonic activity, 541 Torsades de pointes, 75, 75f characteristics of, 75 Total parenteral nutrition (TPN), 171–172 Toxic adenoma, 141 Toxic causes, heart failure, 41–42 Toxic multinodular goiter (TMNG), 141 Toxic polyneuropathy, 530–531, 530f Toxic provoked seizure, 549–550 Tracheomalacia, 254–255 Transient ischemic attack (TIA), 557 conditions, 558 risk of, 558 Transsphenoidal adenectomy, 95

1143

Transthyretin amyloidosis, 48 Transudative pleural effusion capillary oncotic pressure, 648 diaphragm, 648 diaphragmatic defects, 651 hydrostatic pressure, 648, 649–650 intrapleural pressure, 648 mechanisms of, 648 oncotic pressure, 650–651 Transverse incision scar, 114 Trapped lung, 649–650 Traumatic arthritis, 661 clinical features, 662 Tricuspid regurgitation, 47 Lancisi’s sign, 48 Tricuspid stenosis, 47 jugular venous waveform, 48 Trigeminal autonomic cephalalgias (TACs), 512 Trigeminal neuralgia, 519–520 Tropheryma whipplei, 180, 182 Trousseau’s sign, 113 Tuberculosis (TB), 82, 85, 106 antimicrobial treatment, 106 percentage of, 83 pleuritis, 652–653 protein-rich ascites, 157–158

U Ultraviolet B radiation, 119 Unprovoked seizure, 542 epilepsy, 542 Unstable angina (UA), 16 electrocardiographic findings, 17, 17f mycoardial injury, 17 Unstable hemoglobins, 328–329 Upper Gastrointestinal bleeding blood urea nitrogen (BUN) level, 201

1144

classification, 201 diagnostic modality, 201 duodenal, 204–205 esophageal, 201–202 gastric, 202–204 procedure, 201 Upper motor neuron lesions, 580 anatomic structures, 581 of brain, 583–584 characteristics, 582 definition, 581 effects of, 581 facial weakness, 583 hemiparesis, 583 ipsilateral cranial nerve signs, 583 neurologic manifestations, 583 paraparesis, 583 pathways, 582, 582f quadriparesis, 583 restricted weakness, 583 of spinal cord, 584–588 Uremia, 654–655 delirium, 241–242 pericarditis, 63 Urinary tract infection, 243–244 Urine calcium concentration, 102 Urine free cortisol (UFC) test, 92 false-negative result, 93 Urinothorax, 651 Urticarial vasculitis (UV), 680–681

V Valvular disease heart failure aortic stenosis, 47 concentric hypertrophy, 47 mitral stenosis, 47

1145

pulmonic regurgitation, 47–48 pulmonic stenosis, 47–48 tricuspid regurgitation, 47–48 tricuspid stenosis, 47–48 hemoptysis, 606 Variceal hemorrhage, 201–202 Varicella-zoster virus (VZV), 214–215 Vascular provoked seizure, 546–549, 547f Vasculitis, 61–62 chronic mesenteric ischemia, 228–229 clinical manifestations of, 674 definition, 673 etiology, 674 hemoptysis, 606 leukocytoclastic vasculitis (LCV), 674 physical findings of, 674 secondary interstitial lung disease, 641–642 single-organ vasculitides, 674 vs. vasculopathy, 673 Venous thromboembolism, 271–272 Venous thrombosis, 226–227 Ventilation-perfusion (V/Q) ratio, 620, 620f Ventilator-associated pneumonia (VAP), 407–408 Ventricular escape rhythm heart block with, 11 rate of, 11 sinus bradycardia, 11 Ventricular fibrillation (VF), 75 Ventricular tachycardia (VT), 72 Brugada criteria, electrocardiographic (ECG) algorithm, 73, 73f monomorphic, characteristics of, 73 Vesicular skin lesions, 25 Vibrio cholerae, 180–181 Vibrio parahaemolyticus, 184, 186 VIPoma, 191–192 Viral hepatitis, 172–173 Viral infection, 265–266

1146

Viral meningitis arboviruses, 385–386 characteristic cerebrospinal fluid, 384 diagnosis, 384 enteroviruses, 384–385 herpes simplex virus types 1 (HSV-1) and 2 (HSV-2), 384–385, 385f human immunodeficiency virus (HIV), 384, 386 lymphocytic choriomeningitis virus (LCMV), 385–386 with lymphocytic pleocytosis, 384 mumps, 385–386 pressure of, 384 treatment, 384 Viral pericarditis causes of, 57 characteristics, 58 incidence of, 58 occurence, 57 Vitamin A, 101 Vitamin D, 101, 104 deficiency antiepileptic medication, 118 calcium resorption, 117 chronic kidney disease, 118 D2 and D3, 117, 120 Gastrointestinal calcium absorption, 117 Gastrointestinal malabsorption, 118, 120 liver disease, 118 measurement of, 117 mechanism of, 120 osteomalacia, 118 rickets, 118, 118f sunlight deprivation, 118–119, 119f Von Willebrand disease (VWD), 355–356

W Water homeostasis, 470, 470f Watershed stroke

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causes of, 574 clinical manifestations, 573–574 mechanisms, 566 prevalence, 573 Weakness asthenia, 579 bradykinesia, 579 characteristics, 581 classification, 580, 580f clonus, 579 fatigability, 579 grade muscle strength, 580 lower motor neuron lesions anatomic structures, 588 anterior horn cell, 589–591 definition, 588 motor nerve fibers, 589, 589f peripheral nerve, 593–594 root/plexus, 591–593 motor unit, 579, 579f muscle bulk, 579 muscle fasciculation, 579 muscle fibrillation, 579 muscle tone, 579 muscle weakness, 578 myopathy, 597–599 neuromuscular junction (NMJ), 595–597, 595f paralysis, 580 paresis, 580 physical examination, 581 plegia, 580 resistance testing, 580 upper motor neuron lesions, 580 anatomic structures, 581 of brain, 583–584 characteristics, 582 definition, 581

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effects of, 581 facial weakness, 583 hemiparesis, 583 ipsilateral cranial nerve signs, 583 neurologic manifestations, 583 paraparesis, 583 pathways, 582, 582f quadriparesis, 583 restricted weakness, 583 of spinal cord, 584–588 “waddling” gait, 578, 578f Wernicke’s encephalopathy, 241–242 Wet beriberi, 43 Whipple disease, 180, 182 White-coat hypertension, 506–507 Wide-complex bradycardia classification, 10 with Irregular Rhythm, 10 causes, 12 with regular rhythm, 10 causes, 11 Wide-complex tachycardia uniform QRS morphology, 72. See also Monomorphic wide-complex tachycardia variable QRS morphology, 72. See also Polymorphic wide-complex tachycardia Wide QRS complex, definition, 7 Wilson’s disease, 218, 218f Wolff-Chaikoff effect, 130 Wolff-Parkinson-White syndrome, 69

X X-linked disease, 86 X-linked lysosomal storage disorder, 49

Y Yellow nail syndrome, 654–655 Yersinia species, 184–185

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Z Zoonoses, 58–59 Zoonotic infection, 266

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