The Little Black Book of Hospital Medicine Series Editor: Daniel K. Onion Andrew J. Dionne, MD Director, MaineGeneral Hospitalists MaineGeneral Medical Center Augusta and Waterville, Maine 73700_FMxx_i_xxxvi.indd i 7/29/10 11:36 AM World Headquarters Jones & Bartlett Learning Jones & Bartlett Learning Canada Jones & Bartlett Learning 40 Tall Pine Drive 6339 Ormindale Way International Sudbury, MA 01776 Mississauga, Ontario L5V 1J2 Barb House, Barb Mews 978-443-5000 Canada London W6 7PA [email protected] United Kingdom www.jblearning.com Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com. Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other qualifi ed organizations. For details and specifi c discount information, contact the special sales department at Jones & Bartlett Learning via the above contact information or send an email to [email protected]. Copyright © 2011 by Jones & Bartlett Learning, LLC All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner. The authors, editor, and publisher have made every effort to provide accurate information. However, they are not responsible for errors, omissions, or for any outcomes related to the use of the contents of this book and take no responsibility for the use of the products and procedures described. Treatments and side effects described in this book may not be applicable to all people; likewise, some people may require a dose or experience a side effect that is not described herein. Drugs and medical devices are discussed that may have limited availability controlled by the Food and Drug Administration (FDA) for use only in a research study or clinical trial. Research, clinical practice, and government regulations often change the accepted standard in this fi eld. When consideration is being given to use of any drug in the clinical setting, the healthcare provider or reader is responsible for deter- mining FDA status of the drug, reading the package insert, and reviewing prescribing information for the most up-to-date recommendations on dose, precautions, and contraindications, and determining the appropriate usage for the product. This is especially important in the case of drugs that are new or seldom used. Production Credits Project Management: Thistle Hill Publishing Senior Acquisitions Editor: Nancy Duffy Services, LLC Editorial Assistant: Sara Cameron Composition: Dedicated Business Solutions Production Director: Amy Rose Cover Design: Anne Spencer Associate Production Editor: Laura Almozara Cover Image: © Photos.com Associate Marketing Manager: Katie Hennessy Printing and Binding: Malloy, Inc. V.P., Manufacturing and Inventory Control: Cover Printing: Malloy, Inc. Therese Connell Library of Congress Cataloging-in-Publication Data Dionne, Andrew J. The little black book of hospital medicine / Andrew J. Dionne. p. ; cm. — (Little black book series) Includes bibliographical references and index. ISBN-13: 978-0-7637-7370-0 (pbk.) ISBN-10: 0-7637-7370-0 (pbk.) 1. Hospital care—Handbooks, manuals, etc. 2. Internal medicine— Handbooks, manuals, etc. I. Title. II. Series: Little black book series. [DNLM: 1. Hospitalization—Handbooks. 2. Clinical Medicine—Handbooks. WX 39 D592L 2011] RA972.D56 2011 362.11—dc22 2010011801 6048 Printed in the United States of America 14 13 12 11 10 10 9 8 7 6 5 4 3 2 1 73700_FMxx_i_xxxvi.indd ii 7/29/10 11:36 AM Dedication This book is dedicated to my two favorite readers, Emily Rose and Drew. 73700_FMxx_i_xxxvi.indd iii 7/29/10 11:36 AM 73700_FMxx_i_xxxvi.indd iv 7/29/10 11:36 AM Contents Dedication iii 2.2 Thyroid Disorders 94 Preface ix Myxedema (Severe Acknowledgments xiii Hypothyroidism) 94 Medical Abbreviations xv Thyrotoxicosis Journal Abbreviations xxvii (Hyperthyroidism, Thyroid Notice xxxv Storm) 96 2.3 Diabetic and Glucose Chapter 1 Cardiology 1 Disorders 99 1.1 Acute Coronary Syndromes 1 Hyperglycemia, Inpatient 1.2 Congestive Heart Failure 22 (Including Diabetes 1.3 Arrhythmias 42 Mellitus) 99 Ventricular Ectopy and Diabetic Ketoacidosis Tachycardia 42 (DKA) 105 Supraventricular Tachycardia 46 Hyperosmolar Hyperglycemic Atrial Fibrillation 50 State (HHS; Hyperosmolar 1.4 Infectious and Infl ammatory Nonketotic Coma) 111 Cardiac Diseases 61 Hypoglycemia 113 Infective Endocarditis 61 2.4 Mineral Disorders (Calcium/ Acute Pericarditis 68 Magnesium/Phosphorus) 116 Myocarditis 71 Hypocalcemia 116 1.5 Hypertensive Crisis 73 Hypercalcemia 118 1.6 Syncope 80 Hypomagnesemia 121 Hypermagnesemia 122 Chapter 2 Endocrinology 87 Hypophosphatemia 123 2.1 Adrenal Disorders 87 Hyperphosphatemia 124 Cushing’s Syndrome 87 Adrenal Insuffi ciency 90 v 73700_FMxx_i_xxxvi.indd v 7/29/10 11:36 AM Chapter 3 Gastroenterology 127 Chapter 4 Hematology 209 3.1 Abdominal Pain in Adults 127 4.1 Anemia (Including 3.2 Gastrointestinal Bleeding Transfusion Practices) 209 (Including Upper and Lower 4.2 Thrombocytopenia 222 GI Sources) 129 Heparin-Induced 3.3 Pancreaticobiliary Diseases 143 Thrombocytopenia Biliary Tract Disease (HIT) 231 (Including Cholecystitis, 4.3 Neutropenia 240 Bile Duct Obstruction, 4.4 Multiple Myeloma 247 Cholangitis) 143 Pancreatitis, Acute and Chapter 5 Infectious Disease 257 Chronic 148 5.1 Antimicrobial Medications 257 3.4 Infectious Diseases 5.2 Gastrointestinal Infections 263 of the Gut 159 Acute Diarrhea and Diverticulitis 159 Gastroenteritis 263 Appendicitis 163 Clostridium diffi cile Colitis 268 3.5 Intestinal Obstruction and 5.3 Systemic Infections 273 Pseudo-Obstruction 166 Sepsis and Septic Shock 273 3.6 Intestinal Ischemia 174 Central Venous Catheters 3.7 Liver Disease and and Associated Complications 179 Infections 287 Alcoholic Liver Disease 5.4 Soft Tissue Infections 292 (Including Hepatitis and Cellulitis (Including Cirrhosis) 179 Necrotizing Fasciitis Acute Liver Failure and Gas Gangrene) 292 (Including Acetaminophen Diabetic Foot Ulcers 299 Overdose) 187 5.5 Pulmonary Infections 302 Ascites and Spontaneous Pneumonia (Including Bacterial Peritonitis Community-Acquired, (SBP) 192 Hospital-Acquired, and Hepatic Encephalopathy 198 Ventilator-Associated) 302 Hepatorenal Syndrome 201 Evaluation of Abnormal LFTs 206 vi Contents 73700_FMxx_i_xxxvi.indd vi 7/29/10 11:36 AM 5.6 Systemic Fungal Infections 319 Chapter 7 Pulmonary 373 Antifungal Medications 319 7.1 Venous Thromboembolism Aspergillosis 320 (VTE) 373 Blastomycosis 322 Pulmonary Embolism (PE) 373 Coccidiomycosis (San Deep Venous Thrombosis Joaquin Valley Fever) 323 (DVT) 382 Cryptococcosis 324 VTE Prophylaxis in Histoplasmosis 326 Hospitalized Patients 390 Pneumocystis Pneumonia 7.2 Diseases of the Airway 399 (PCP) 327 Chronic Obstructive Systemic Candidiasis 330 Pulmonary Disease 5.7 Urinary Tract Infections 331 (COPD) Exacerbations 399 Complicated Urinary Asthma Exacerbations 411 Tract Infections and 7.3 Infl ammatory Lung Pyelonephritis 331 Disorders 417 5.8 Central Nervous System Acute Respiratory Distress Infections 336 Syndrome (ARDS) 417 Meningitis 336 Interstitial Lung Diseases Encephalitis 345 (ILDs) 429 Chapter 6 Neurology 349 Chapter 8 Renal/Urology 437 6.1 Stroke and Related 8.1 Acid-Base Disorders 437 Disorders 349 8.2 Sodium and Potassium Transient Ischemic Disorders 443 Attack (TIA) 349 Hyponatremia 443 Ischemic Stroke 351 Hypernatremia 451 6.2 Epilepsy and Seizure Hypokalemia 456 Disorders 360 Hyperkalemia 459 6.3 Guillain-Barre Syndrome 367 8.3 Acute Renal Failure 464 6.4 Parkinson’s Disease 369 8.4 Nephrolithiasis 480 Index 487 Contents vii 73700_FMxx_i_xxxvi.indd vii 7/29/10 11:36 AM 73700_FMxx_i_xxxvi.indd viii 7/29/10 11:36 AM Preface Hospital medicine is the fastest-growing specialty in the United States. Some have interpreted this as further fracturing of patient care, splitting a patient’s healthcare experiences between an out- patient and inpatient world. Others, myself included, argue that this new endeavor allows for comprehensive, patient- centered hospital care, with a team of physicians and other providers who have special expertise in hospital- based medicine. This book is not meant to be an all- inclusive text of the medical issues encountered in the hospital. I’m sure that any text aimed at inpatient adult medicine would be defi cient in some aspect of the depth and breadth of care provided by today’s hospitalists. In addition, this is not a collection of algorithms to direct the care of individual problems. In my career as a hospital- ist, I have found that not many inpatient decisions can be guided simply by an algorithm. There are too many competing interests of risks, benefi ts, patient and family wishes, local practice, and knowledge and comfort level of the physician. In The Little Black Book of Hospital Medicine, I have tried to provide a framework for managing the major problems we, as hospitalists, encounter every day. This includes thoughtful review of the issues and also an overview of the important clinical research that guides our decisions. When available, I have tried to summarize the best available evidence supporting a particular test or intervention, so that we may help our patients make an informed decision about their care.