 , FBC; blood level at Glucose, CMP, LFT, INR, ABG, PT/PTT/INR, HCO 3 4 h postingestion If <8 h since overdose and plasma acetaminophen is above the line on the graph in Figure 20.3 , start N -acetylcysteine. If >8 h and suspicion of large overdose (>7.5 g) err on the side of caution and start acetylcysteine, stopping it if acetaminophen level is below the treat ment line and INR and ALT are normal. Acetylcysteine is given by IV: 140 mg/kg in 200 mL of 5% dextrose over 15 min. Then 50 mg/kg in 500 mL of 5% dextrose over 4 h. Then 100 mg per kg/16 h in 1 L of 5% dextrose. Rash is a common SE: Treat with diphenhydramine and observe; do not stop unless anaphylaxis (i.e., shock, vomiting, wheeze occurs [<10%]). If ingestion time is unknown, it is staggered, or presentation is >15 h from ingestion, treatment may h elp. Get advice. \206\223 ), if long-acting The graph may mislead if HIV positive(hepatic glutathione acetaminophen has been taken, in the presence of preexisting liver dis- ease, o r if induction of liver enzymes has occurred. Beware glucose \206\223 ; bedside glucose/1h r; INR/12 h. Next day, do PT, PTT, INR, CMP, LFT. If INR rising, continue acetyl- cysteine until <1.4. If continued deterioration, discuss with the liver team. \212 \212 \212 \212 \212 \212 \212 Do not hesitate to get expert advice. Criteria for transfer to ICU: \212Encephalopat hy or ICP \206\221 . Signs of CNS edema: BP >160/90 (sustained) or brief rises (systolic > 200 mm Hg), bradycardia, decerebrate posture, extensor spasms, poor pupil responses. ICP mo nitoring can help. INR>2.0 at <48 h or >3.5 at <72 h (so measure INR q12h). Peak elevation: 72 \200\22396 h. LFTs are not good markers of hepatocyte death. If INR is normal at 48 h, the patient may go home. \212 \212Renal impairment (creatinine >2.2 mg/dL). Monitor urine flow. Daily CMP and serum creatinine (use hemodialysis if >2.4 mg/dL). \212Blood pH <7.3 (lactic acidosis \206\222 tissue hypoxia) \212Systolic BP <80 mm Hg 792 e n i c i d e m y c n e g r e m E Figure 20.3 Patients whose plasma-acetaminophen concentrations are above the nor- mal treatment line sh ould be treated with acetylcysteine by IV infusion (or, provided the overdose has been take n within 10 \200\223 12 h, with methion- ine by mouth). Patients on enzyme-including drugs (e.g., carbamazepine, phenobarbital, phenytoin, rifampicin, alcohol) or who are malnourish ed (e.g., in anorexia, in alcoholism, or those who are HIV-positive) should be treated if t heir plasma-acetaminophen concentrations are above the high-risk treatment line (We thank D r. Alun Hutchings for permission to reproduce this graph.) 793 Burns Resuscitate and arrange transfer for all major burns. (>25% partial thick- ness in ad ult and >20% in children). Assess site, size, and depth of the burn. Referral is still warr anted in cases of full thickness burns >5%, partial thick- ness burns >10% in adults or >5% in children or the elderly, burns of special sites, chemical and electrical burns, and bur ns with inhalational injury. Assessment Burn size is important to assess (see Figure 20.4) as it influences the magnitude of the inflammatory response (vasodilatation, \206\221 vasc ular permeability) and thus the fluid shift from the intravascular volume. The size must be estimated to calculate fluid requirements. Ignore erythema. Burn depth determines healing time/scarring; assessing this may be difficult, even when experienced. The big distinction is whether the burn is partial thickness (painful, red, and blistered) or full thickness (i nsensate/painless and white/gray). NB: Burns can evolve, particularly over the first 48 h. Resuscitation Airway: Beware of upper airway obstruction developing if hot gasses inhaled. See Table 20.28. Suspect if history of fire in enclosed space, soot in oral/nasal cavity, s inged nasal hairs, or hoarse voice. A flexible laryngeo/bronchoscopy is useful. Involve ane sthesiologist early and consider early intubation. Breathing: Exclude life-threatening ches t injuries (e.g., tension pneumotho- rax) and constricting burns. Give 100% O 2 if carbon m onoxide poison- ing is suspected (mostly from history; may have cherry-red skin. Measure ca rboxyhemoglobin (COHb) and compare to nomograms. With 100% O 2 , t of COHb falls from 25 0 min to 40 min (consider hyperbaric oxygen if pregnant; CNS signs; >20% COHb). SpO2 measur ed by pulse oximeter is unreliable. Do escharotomy if thoracic burns impair chest excursion . Circulation: Partial thickness burns >10% in a child and >15% in adults re- quire IV flui d resuscitation. Insert two large-bore (14 or 16 g) IV lines. Do not worry if you have to p ut these through burned skin; intraosseous ac- cess is valuable in infants. Secure them wel l: They are literally lifelines. Use a burns calculator flow chart or a formula, such as th e Parkland formula (popular): 4 \227 weight (kg) \227 % burn = mL lactated Ringer \200 \231s in 24 h, half given in first 8 h. Modi \201 ed Brooke formula: 2 mL/kg for each % bu rn = ml lactated Ringer \200\231s in 24 h. Either formula is acceptable and the modified Br ooke has been shown to require less fluids without increasing harm. Replace fluid from the time of burn, not from the time first seen in hospital. See Figure 20.4. Formulas are only guides : Adjust IV infusion according to clinical response and urine output; aim for >0.5 m L/kg/h (>1 mL/kg/h in children), 50% more in electrical burns and inhalation injury. Monit or temperature (core and surface); catheterize the bladder. Treatment Do not apply cold wat er to extensive burns: This may intensify shock. If transferring to a burn unit, do not bur st blisters or apply any special creams as this can hinder assessment. Simple saline gauze or Vaseline gauze is suitable; cling movie is useful as a temporary measure and relieves pain. Use morphine in IV aliquots and titrate for good analgesia. Ensure tetanus immunity. Antibiotic prophylaxis is not routine. Definitive dressings There are many dressings for pa rtial thickness burns, including biological (pigskin, cadaveric skin), synthetic (Mepitel , DuoDERM ), and silver sulfadiazine cream (Flamazine ). Major full thickness burns benef it from early tangential excision and split-skin grafting as the burn wound is a major sour ce of inflammatory cytokines causing SIRS (systemic inflammatory response syndrome) and are an ideal medium for bacterial growth. 794 e n i c i d e m y c n e g r e m E Table 20.28 Smoke inhalation Initially, laryngospasm leads to hypoxia and straining (leading to pete- chiae), then hypox ic cord relaxation leads to true inhalation injury. Free radicals, cyanide compounds, and c arbon monoxide accompany thermal injury. Cyanide compounds (generated from burning plastic in particular) bind reversibly with ferric ions in enzymes, thus stopping oxidative phos- p horylation and causing dizziness, headaches, and seizures. Tachycardia and dyspnea soon giv e way to bradycardia and apnea. Carbon monoxide is generated later in the fire as oxygen is depleted; the COHb level does not correlate well with the severity of poisoning. \212 2 i s given to elute both cyanide and CO. \212 100% O Involve ICU/anesthesiologist early: Early ventilation may be useful; con- sider repe ated bronchoscopic lavage. Enroll expert help in cyanide poisoning. There is no single regi men suit- able for all situations. Clinically mild poisoning may be treated by rest, O 2 , and amyl nitrite 0.2 \200\2230.4 mL via an Ambu bag. IV antidotes may be used for moderat e poisoning: Sodium thiosulphate is a common first choice. More severe poisoning may requir e hydroxocobalamin, sodium nitrite, and dimethylaminophenol. \212 Figure 20.4 Lund & Browder charts 795 Hypothermia Have a high index of suspicion and a low-reading thermometer . Most patients ar e elderly and do not complain of being or feel cold, so they have not tried to warm themsel ves up. In the young, hypothermia is usually either from cold exposure (e.g., near-drowning ), or it is secondary to impaired level of consciousness (e.g., following excess alcohol or drug overdose). Definition Hypothermia implies a core (rectal) temperature <35 C. Causes In the elderly, hypothermia is often caused by a combination of: \212 \212 \212 \212 \212 \212 \212 \212 \212 The patient Don \200\231t assume that if vital signs seem to b e absent, the patient must be dead: Rewarm (see below) and reexamine. If temperature <32 C , this sequence may occur: Drop in BP \206\222 coma \206\222 bradycardia \206\222 AF \206\222 VT \206\222 VF. If >32 C, there may simply be pallor apathy. Diagnosis Check oral or axillary temperatures. If ordinary thermometer shows <36.5 C, use a low-reading on e rectally. Is the rectal temperature <35 C? Tests Urgent CMP, plasma glucose, and amylase . Thyroid function tests, CBC, blood cultures. Consider blood gasses. The ECG may show J-wa ves or Osborn waves. See Figure 20.5. Treatment \212 \212 \212 \212 Impaired homeostatic mechanisms: Usually age-related Low room temperature: Poverty, poor ho using Disease: Impaired thermoregulation (pneumonia, MI, heart failure) Reduced metabolism (immobility, hypothyroidism, diabetes mellitus) Autonomic neuropathy (e.g., diabetes mellit us, Parkinson \200\231s) Excess heat loss (psoriasis) Decreased cold awareness (dementia, c onfusion) Increased exposure to cold (falls, especially at night when cold) Drugs (major tr anquilizers, antidepressants, diuretics), alcohol Ventilate if comatose or respiratory insufficiency. Warm IV(for access or to correct electr olyte disturbance) Cardiac monitor (both VF and AF can occur during warming) Consider antib iotics for the prevention of pneumonia. Give these rou- tinely in patients >65 with a tempe rature <32 C. Consider urinary catheter (to assess renal function). Do not reheat too quic kly, which causes peripheral vaso- Slowly rewarm. dilatation, shock, and death. Aim for a r ise of C/h. Elderly conscious patients should sit in a warm room taking hot drinks. The rmal blankets may cause too rapid warming in older patients. The first sign of too rapid wa rming is falling BP. Rectal temperature, BP, pulse, and respiratory rate every half hour. \212 \212 \212 NB: Advice is different for victims of sudden hypothermia from immersion. Here, if th ere has been a cardiac arrest and T <30 C, mediastinal warm lavage, peritoneal or hemodi alysis, and cardiopulmonary bypass (no heparin if trauma) may be needed. Complications Arrh ythmias (if there is a cardiac arrest, continue resuscitating until temperature is >33 C, as cold brains are less damaged by hypoxia); pneumonia, pancreatitis, acute renal failure, intravascular coagulation. Prognosis Depends on age and degree of hypothermia. If age >70 a nd temperature <32 C then mortality >50%. Before hospital discharge Anticipate problems. W ill it happen again? What is her network of support? Review medication ( could you stop tra nquilizers )? How is progress to be monitored? Coordinate with physician/ social worker. 796 e n i c i d e m y c n e g r e m E Figure 20.5 V4 \200\230J-wave \200\231 Kindly supplied by Drs. Richard Luke and EM McLachlan. Major disasters Planning All hospitals should have a detailed disaster plan . At the scene Call the police and activate EMS. Safety is paramount: Your own and others. Be visible (lum inous mono- grammed jacket) and wear protective clothing where appropriate (safety helmet, waterproofs, boots, respirator in chemical environment). Triage: Label RED if victim will d ie in a few minutes with no treatment. Label YELLOW if victim will die in 2 h with no trea tment; label GREEN if victim can wait for treatment. (BLACK = dead). Communications are ess ential: Each emergency service will dispatch a con- trol vehicle and have a designated offi cer for liaison. Support medical staff from hospital report to the medical safety officer: He is usually the first doctor on the scene. His job is to assess then communicate to the r eceiving hospital the number and severity of casualties, organize resupply of equip- ment, and replace fatigued staff. He must resist the temptation to treat casualties as this compr omises his role. Equipment: Must be portable and include intubation and cricothyrotomy set, IV fluids (colloid), bandages and dressings, chest drain (+ flutter valve), amputation kit (when used, ideally two doctors should concur), drugs ( analgesic : Morphine; anesthetic: Ketamine 2 mg/kg IV over >60 sec [0.5 mg/kg is a powerful analgesic without respiratory dep ression]), limb splints (may be inflatable), defibrillator/monitor pulse oximeter. Evacu ation: Remember: With immediate treatment on scene, the priority for evacuation may be redu ced (e.g., a tension pneumothorax [patient la- beled RED], if relieved [now patient labeled YELLOW], can wait for evacu- ation), but those who may suffer by delay at the scene must g o first. Send any severed limbs to the same hospital as the patient, ideally chilled, but n ot frozen. At the hospital a \200\234major incident \200\235 is declared. The first receiv ing hospital will take most of the casualties; the support hospital(s) will cope with overf low and may provide mobile teams so that staff is not depleted from the first hospital. A c ontrol room is established, and the medical coordinator ensures that staff have been summon ed, nominates a triage 797 officer, and supervises the best use of inpatient beds and ICU/operating room resources. Bl ast injury may be caused by domestic (e.g., gas explosion) or industrial (e.g., mining) acc idents or by terrorist bombs. Death may occur without any obvious external injury (air embo li). Injury occurs in six ways: Blast wave 1 A transient (milliseconds) wave of overpressur e expands, rapidly produc- ing cellular disruption, shearing forces along tissue planes (su bmucosal/ subserosal hemorrhage) and reexpansion of compressed trapped gas: Bowel perforati on, fatal air embolism. 2 Blast wind This can totally disrupt a body or cause avulsive amputa- tions. Bodies can be thrown and sustain injuries on landing. 3 Fragments Penetration or laceration from blast fragments are by far the most common injur ies. These arise from the source of explosion (e.g., bomb) or are secondary (e.g., flying g lass). 4 Flash burns These are usually superficial and occur on exposed skin. 5 Crush Injuries: Be ware of sudden death or renal failure after release. 6 Psychological injury E.g.,post-traum atic stress disorder Treatment Approach the same as any major trauma. Have patient rest; ob serve others for any suspected exposure to significant blast but without other injury. 798 This page intentionally left blank Index Page numbers followed by t and f indicate tables and figures, respectively acetazolamide, 348 Achilles tendonitis, 403t acid-base balance, 660 \200\2234 Acinetobacter , 160, 582 acoustic neuromas, 356, 357 acquired thrombophilia, acute intestinal ischemia, A abacavir, 573 abatacept, 406t A. baumannii, 582 ABCDEFGHI causes of vomiting, 84 ABC \200 \231s of airway 468 \200\2239 acute kidney injury (AKI), 251, 267, 268 \200\22371, 276 \200\2237, 665 acute lower tract 638 obstruction, 260 acute lymphoblastic leukemia, 626 \200\2237 acute myeloid leukemia, acromegaly, 145t, 320t, breathing, 360 324 \200\2235 abdomen ACTH-dependent acute abdomen, 466 \200\2238, 547 Cushing \200\231s syndrome, 310, 320t ACTH-independent 203, 627 \200\2238 acute myocardial infarction, auscultation, 60t, 469 bloating, 242 calci \201 cation, 698 distension, 70, 242 free air, chest \201 lm, 692 inspection, 60t intra-abdominal infections, 539t pain, 70, 82, 242, 28 2, 361, 732, 749 \200\22350, 751t Cushing \200\231s syndrome, 310 acute myocarditis, 144 acute-on-chronic hepatic ACTH-secreting pituitary adenoma, 320t failure, 224 acute pancreatitis, 186t acute pericarditis, 146 \200\2237 acute-phase respons e, 678 acute poisoning, 787 \200\22391, Actinomyces, 169 actinomycosis, 582 acute abdomen, 464 \200\2236, 547 acute chest syndrome, 788t 411, 468 618 \200\22319 acute porphyrias, 682 acute pyelonephritis, 251, percussion and acute cholecystitis, 84, 485 acute coronary syndrome, 113 \200\22315, 740, 745, 752, 753t palpation, 60t \200\22361t 257, 258 positive abdominojugular acute radiation nephritis, re \202 ux sign, 45 277 rebound abdominal acute renal failure, 251, 549, 635, 784 \200\2235, 786t acute respiratory distress syndrome (ARDS), 185 \200\2236, 186t, 488 acute severe asthma, 177 \200\2238, acute CPPD monoarthritis, pain, 82 abdominal bruits, 60 abdominal films, 696, 697f, 699f \200\223701f, 711f abdominal ultrasound, 222 Abiotrophia defectiva, 520t acalculous cholecystitis, 485 acanthocytes, 61 1 acarbose, 290t accelerated 409 acute crystal nephropathy, 277 acute cyanosis, 73 acute dyspnea, 74 acute eosinophilic 761, 762t acute strokes, 360 acute upper tract pneumonia, 194 acute glomerulonephritis, obstruction, 260 279 acute gout, 408 acute heart failure, 130 acute hepatic failure, 224, acute vasculitis, 279 acyclovir, 258, 372, 538t adalimumab, 242t Addisonian crisis, 783 Add ison \200\231s disease, 43, 80, 84, 210t, 211, 312, 745 atherosclerosis, 267 accelerated (malignant) hypertension, 278 ACE-inhibitors, 29 \200\2233 0, 226t acute immune 114, 130, 131t \200\223132t, 134 \200\2235, 216t, 263, 278t, 280t, 293 thrombocytopenia, 620 acute infectious adenocarcinomas, 196, 209, 211, 244, 266, 500, 501t, 502, 502t adenoma sebaceum, 281 adenov irus, 522t, 544t adrenal carcinomas, 316 acetaminophen, 224, 452, glomerulonephritis, 265 792, 793f 800 acetaminophen related fulminant hepatic failure, 226t acute intermittent porphyria, 682 allopurinol, 276, 277, amylase, 679 amyloidosis, 77, 145t, 210t, 282, 283, 635 \200\2236 adrenal crisis, 312 adrenal hyperplasia, 316 adrenal insufficiency, 76, 285, 295, 312 \200 \22313, 321 409, 430 1-antitrypsin deficiency, anabolic steroids, 237 Anaerobic streptococci, 233 \200\2234, 264 adrenal scan, 707 adrenocorticotropic 1 zone, 678 2 zone, 678 -fetoprotein, 680 alpha-blockers, 135 alpha-thalassemia major , 619 Alport syndrome, 265 alteplase, 622f, 750 aluminum toxicity, 275 alveolar-arterial O2 concentration gradient, 155, 156t alveolar hemorrhage, with hypoxemia, 185 Alzheimer \200 \231s disease, 71, 520t anal cancer, 493 anal fissure, 82, 492 \200\2233 analgesia, epidural, 452 analgesia, n on-narcotic, 452 analgesia, pain-controlled, hormone (ACTH), 173, 285 adrenoleukodystrophy, 312 adult immunizations, 539 \200\22340 452 adult-onset Still \200\231s disease, analgesic ladder, 432t analgesic nephropathy, 277 anal ulcers, 493, 576 anal warts, 493 ana phylactic shock, 745, 405 Adult Treatment Panel III (cholesterol management), 108 advance directives/living 748 \200\2239 wills, 21 ANCA-associated advanced sclerosing lupus nephritis, 264t African trypanosomiasis (sleeping sickness), 592 \200\2233 aganglionosis, 214t agranulocytosis, 301t AIDS infection, 202 air travel and DVT, 454t airway management difficulties, 443 alanine-amino transferase, 377 \200\2238, 651 amaurosis fugax, 330 ambulatory ECG granulomatosis with polyangiitis/ microscopic polyangiitis, 265 monitoring, 100 amebiasis, 211, 591 American trypanosomiasis, ANCA-associated vasculitis, 416t Anderson-Fabry disease, 592 \200\2233 amikacin, 532t, 556t, 582 amiloride, 327 aminoaciduria, 282 aminoglycosides, 278t, 532, 281 androgen replacement therapy, 322 532t, 536t, 582 androgen-secreting adrenal 679 albumin, 678 albuminuria, 678 albuterol, 177, 178t, 761, aminophylline, 177 \200\2238 aminosalicylates, 239, 242t amiodarone, 55, 116, 184, hormones, 316 anemia, 608 \200\22311 aplastic anemia, 380, 198t 618, 632 762t alcohol, 17, 84 alcoholic hepatitis, 215, amitriptyline, 75, 216t, autoimmune hemolytic anemia, 617, 629 of chronic disease, 610 hemolytic anemias, 609, 294, 352 amlodipine, 117 amoebic colonic abscess, 230t alcoholism, 69, 78, 164, 166, 591 615 \200\22317 229 \200\22330 amoebic dysentery, 591 amoebic liver abscess, iron-de \201 ciency anemia, 209, 221, 248, 609 \200\22310 aldosterone antagonists, 130 547, 591 amoeboma, 591 amox-clavulanate, 582 amoxicillin, 162t, 529t amoxicillin/clavulanat e, leukoerythroblastic aldosterone-producing adrenal adenomas, 314 anemia, 611 macrocytic anemia, 613 \200\22314 aldosterone receptor blockers, 314 alendronate, 307t, 308 alfuzosin, 647 alkaline phosphata se, 679 Alkhurma virus, 523t allergic bronchopulmonary aspergillosis, 168, 169 \200\22370, 172f, 194, 594 megaloblastic anemia, 632 pernicious anemia, 232, 530t, 537t amoxicillin/sulbactam, 614 \200\22315 530t, 538t refractory anemia, 610 sickle-cell anemia, 617 \200\22319 sideroblastic anemia, amphotericin, 143t, 170, 171, 268, 269, 278t, 280, 640 610 \200\22311 801 ampicillin, 143t, 529t, 538t amputations, lower- extremity, 295 symptoms, signs, 70, 330 tropical travel allergic rhinitis, 176 evaluation, 547 anticonvulsants, 347, aphthous ulcers, 202 aplastic anemia, 380, 618, 632 appendicitis, 258 apraxia, 66 arbovirus , 372 ARBS (angiotensin II angina pectoris, 102, 117 \200\22318 angiodysplasia, 217, 470 angioedema, 29 \200\22330, 13 1t, 352, 452 anti-cyclic citrullinated peptide, 404 468, 688 angiofibromas, 281 angiokeratoma corporis diffusum, 281 anticytokine therapy, 406t antidepressants, 352, 452 antidiuretic hormone (ADH), 173 antiem etics, 353 antifungals, 216t anti-GAD (anti-glutamic acid decarboxylase antibodies), 286 an tiglomerular basement membrane, 262 \200\2233 receptor antagonists), 135, 278t, 280, 293 Argyll Robertson pupil, 81 arrhythmias, 102, 116 , angioplasty, 101 angiosarcoma, 237 angular cheilitis, 203 animal exposure 118 \200\22319, 192, 274, 298 artemether/lumefantrine, infections, 578 \200\2239 viruses, 578 551t arterial blood gas (ABG) animal exposure viruses, analysis, 155, 187t, 188, 218, 660, 661t 523t antihypertensive anion exchange resins, 109 anisocytosis, 611 anistreplase, 622f ankle brachial index (ABI), 45 ankle edema, 134 ankylosing spondylitis, 145t, medication, 352, xx antimicrobials, 278t, 525 antineutrophil cytoplasmic antibody (ANCA)+, 370 arterial thromboembolism, 239 arterioportal fistula, 220 arteriovenous fistula (AVF), 272 arthralgias, 276 arthritis. See also antinuclear antibodies (ANA), 232, 414t antiphospholipid antibody syndrome, 411, 638 \200 \2239 198t, 398 rheumatoid arthritis Ankylostoma duodenale, 598 anomic aphasias, 66 anorectal abscess/fistula, 493 anorectal dis ease, 214t anorexia, 243, 245, 271 anorexia nervosa, 305 anterior cruciate ligament axial arthritis, 403t crystal-induced arthritis, antiplatelet drugs, 112 antiproliferative agents, 275 anti-smooth muscle antibodies, 232 408 \200\2239 degenerative arthritis, 79 enthesitis-related arthritis, 407t anti-soluble liver antibodies (anti-dsDNA Ab), 232 extra-articular RA, 404 in \202 ammatory, 399 \200\223400 oligoarthritis, 403t, 407t osteo arthritis, 43, 100, (ACL), 716 anthrax, 519t, 580 antiandrogen therapy, 318 antibiotics, 534t \200\223536t antispasmodics, 452 antisynthetase syndrome, 414 anti-T cell antibodies, 275 antithyroid dr ugs, 301t antitubercular agents, 556t anti-tuberculosis 203, 205, 306, 399, 408 allergies, 276 aminoglycosides, 278t, palindromic RA, 404 pediatric chronic arthritis, 407t polyarthritis, 407t poststreptococcal 532, 532t bacterial susceptibility, medications, 216t antitumor necrosis factor, 557t \200\223558t carbapenems, 534t cephalosporins, 167t, 276, 278t, 358, 445, 530 \200\2232 170 reactive arthritis, 399 psoriatic arthritis, 43t, antiviral agents, 572 \200\2234 antivirals, 216t anxiety, 68, 355 aortic aneurysm, 77 aorti c aneurysm, ruptured, 399, 407t reactive arthritis, 398, 399 septic arthritis, 400 seronegative arthritis, macrolides, 533, 533t penicillins, 137, 143t, 167t, 276, 278t, 529t \200\223530t 74 636 aortic dissection, 279 aortic regurgitation, 139 aortic root disease, 139 aortic sclerosis, 139 aortic stenosis, 139 aortic valve disease, 139 aortoenteric fistula, 217 apex beat, 71 aphasia, 65, 66 spondyloarthritis, 399, preoperative use, 445 quinolones, 257, 533, 533t 402 \200\2233 antibiotics, preoperative systemic arthritis, 407t use, 445 arthropod-borne anticholinergics, 178, 209, infections, 519t, 525, 589 \200\22390 802 214t anticoagulants, 188 \200\2239, 361, asbestosis, 196, 198t Ascaris lumbricoides, 598 452, 623 \200\2235 atrial tachycardia, 760 atrioventricular block, 120t atrophic glossitis, 610 auditory neuro mas, 425t aura, 61 \200\2232, 346, 350 \200\2231, bacterial cholangitis, 235 bacterial cystitis, 252 bacterial endocarditis, ascites, 59, 61, 129, 244, 464 ascites with portal hypertension, 70 446, 637 \200\234ash leaf \200\235 hypomelanic macules, 281 aspartate-amino empiric treatment, 538t bacterial meningitis, 370, 356, 363 auricular-cartilage 371t transferase, 679 calcification, 312 autoimmune adrenalitis, 302 autoimmune connective tissue diseases, 410 a utoimmune hemolysis, 232 autoimmune hemolytic empiric treatment, 538t aspergilloma, 170 Aspergillus fumigatus, bacterial vaginosis, 578 bacteriuria, 257 Bacteroides, 160 Bactrim DS tablets, 228 bagassos is, 194 Balantidium coli, 545t balloon tamponade, 524, 594 Aspergillus infections, 141, 143t, 169 \200\22370 aspiration pneumonia, 160 aspirin, 452 aspirin overdose, 186t aspirin therapy, 114t, 117, 3 61, 405, 633 anemia, 617, 629 autoimmune hepatitis, 215, 224, 232 Sengstaken-Blakemore tube, 221t balsalazide, 239 barbiturates, 382, 639 barium enema, 223, 238 \200\2239 barrel chest, 71 Barrett esophagus, 209 bartholinitis, 578 Bartholin \200\231 s gland cyst, autoimmune-mediated hypothyroidism, 297t associations and causality, autoimmune thyroiditis, 28 232, 302 asterixis, 58, 224, 227, 268, autologous bone marrow transplant, 635 271, 358 asthma, 169, 176 \200\2237, 177 \200\2238, 186, 189, 190, 233, 761, 762t asthmatic bronchit is/ automated peritoneal dialysis, 274 autonomic neuropathy, 80, 84, 210t, 211, 294 autonomy of patients, respect of doctor for, 2 515 Bartonella quintana, 590 bartonellosis, 589 Bartter \200\231s syndrome, 281 basal cell nevu s syndrome, refractory asthma, 177 \200\2238 asymptomatic microscopic hematuria, 515t asystemic sclerosis, 203 ataxia, 360 atazanavir, 5 73 atheromatous vascular disease, 276 autosomal dominant 425t basal ganglia polycystic kidney disease, 281 avascular necrosis, 374 avoidance behavior, 68 AV reentry ta chycardia, 757 axial arthritis, 403t azathioprine, 184, 242t, 391, anatomy, 335 degeneration, 233 lesion, 72 basophilic stippling, 611 basophils, 613 B-cell depletion, 407t Beau \200\231s lines (of na ils), 43t beclomethasone (Qvar ), atherosclerosis, 279, 294, 698 atherosclerosis, accelerated, 267 atherosclerosis and statins, 411, 639 azithromycin, 162t, 533t, 537t, 546t, 578, 582 111 177, 178t atherosclerotic renal artery azithromycin IV, 162t aztreonam, 527t, 534t, 582 Beh et \200\231s disease, 145t, 368, 370, 399, 417, 468 disease, 279 atherothromboembolism, belimumab, 411 Bell \200\231s palsy, 65t, 192, 389, 359 B babesiosis, 519t Babinski reflex, 63t, 332t bacillary dysentery, 585 Bacillus spp., 520t, 544t, 580 backache, 366 back pain, 401 \200\2232 baclofen, 347 bacteremia, 166 bacteria, a ntibiotic susceptibility, 527t \200\223528t athetosis, 71, 335, 358 atopic dermatitis, 176 atovaquone, 525, 551t atrial arrhythmias, 29 8 atrial fibrillation, 123, 124f, 138, 165, 359, 361, 624 \200\2235 390t Bence Jones proteinuria, 678 \200\2239 beneficence of doctors for patients, 2 benign paroxysmal positional vertigo, 355 atrial flutter, 102, 116, 803 123, 124t benzathine PCN-G, 577t benzodiazepines, 89, 229, atrial septal defect, 45, 148 atrial tachyarrhythmias, 760 354t, 431 sodium: hypernatremia, bowel ischemia, 680 bowel preparation, Berger \200\231s disease (IgA 671 nephropathy), 263 sodium: hyponatremia, preoperative, 445 beriberi, 245 Bernard-Soulier disorder, 668 \200\2239, 670t bowel strangulation, 468 bradycardias, 116, 119, 120t, trace elements, 677 tumor markers, 680, 681t urate and the kidney, 620 302, 732 bradykinesia, 335 brain death, 19 \200\22320 brain natriuretic peptide (BNP), 667t \200\223668t berry aneurysms, 365 berylliosis, 193t, 198t beryllium exposure, 196 \200\2237 2-adrenore ceptor agonists, 177 2-agonists, 177, 182t 2-microglobulin 665 \200\2236 ward tests, 656 \200\2237, 657t \200\223658t bioterrorism/biowarfare, potential agents, 519t bird fancier \200\231s lung, 194, 198t bisp hosphonates, 277, 307t, brainstem anatomy, 335 infarction, 356, 360 lesions, 84, 331, 390t amyloidosis, 275 -agonists, 62 -blockers, 55, 114, 115, 308, 430, 634 branch retinal vein occlusion, 368 breast cancer, 28, 35t, 71, bitemporal hemianopia, 64t bites, from animals, 578 \200\2239 BK virus, 521t blackwater fev er, 549 bladder cancer, 80 bladder tumor, 258, 514 \200\22315 blast injuries, 798 Blastomyc es dermatitidis, 116, 117, 130, 134, 138, 267, 301t 307, 319, 422, 425t, 427, 497 \200\2239 breast pain, 73 breathlessness dyspnea, -Hemolytic streptococci, 520t -lactam, 536t, 538t -thalassemia major, 619 -thalassemia minor, 619 beta zone, 678 be zafibrate, 109 biases in screening, 73, 150 \200\234brittle \200\235 diabetes, 286 Broca \200\231s (expressive) aphasia, 65 524 Blastomycosis, 169 blasts, 611 bleeding disorders, 620 \200\2231 bleomycin, 198t blepharosp asm, 359 blindness, 64t blood coagulation bromocriptine, 261, 323, 34 \200\2235 324 bicuspid aortic valve, 148 biguanides, 290 bilateral, symmetrical hilar lymphadenopathy, 19 2, 193t bronchial adenocarcinoma, 196 bronchial adenoma, 174 bronchiectasis, 76, 167, 168 \200\2239, 176, 692 bronchiolitis oblit erans, 198t bronchoalveolar lavage anticoagulants, 188 \200\2239, 361, 452, 623 \200\2235 pathways, 621f \200\223622f tests, 6 22, 623t blood gasses, 657t blood glucose, 657 blood transfusion, 456 \200\2238, 457t \200 \223458t, 609 bilateral edema, 453 \200\2234 biliary colic, 485 biliary obstruction, 248 biliary tract, b enign (BAL), 157 bronchodilators, 168, 182t bronchogenic carcinoma, diseases, 485 \200\2236, 487f bilirubin, 657 biochemistry, 654 \200\22382 173 Brown-S quard syndrome, acid-base balance, 660 \200\2234 calcium: physiology, 674 electrolyte physiology, 666 \200 \2237, 667t \200\223668t hypercalcemia, 675, 676t hyperkalemia, 671 \200\2233 hypocalcemia, 675, 677 hypokalemia, 673 \200\2234 IV \202 uid therapy, 658 \200\2239, blue bloaters, 179 bone cancer, 452 bone cysts, terminal phalangeal, 192 bone marrow failur e, 632 bone scan, 706 Bordetella pertussis, 583 Bornholm \200\231s disease, 71 Borrelia her msii, 588 bortezomib, 635 botulinum toxin, 331 botulism, 519t Bouchard \200\231s \200\234n odes, \200\235 in osteoarthritis, 43t 333 brucellosis, 519t, 583 brush border enzyme deficiencies, 248 Budd-Chiari syndrome, 215, 220 , 224 budesonide, 232 budesonide (Pulmicort ), 659t \200\223660t 177, 178t laboratory basics, bulbar palsy, 66 bulking agents, 213 bundle branch block, 732 bupropion, 89 Burkitt \200 \231s leukemia, 631 Burkitt \200\231s lymphoma, 560, 655t \200\223656t magnesium, 677 plasma enzymes, 679 \200\22380 plasma proteins, 678 \200 \2239 porphyrias, 682 potassium, 671 804 Boutonni re finger deformities, 404 631 cardiac conduction defects, cefotaxime, 162t, 530, 582 cefotetan, 531t ceftaroline, 532t ceftazidime, 530, 582 ceftriax one, 162t, 258, 530, 531t, 537t, 538t cefuroxime, 162t, 445, 531t celiac disease, 210t, 248 , burr cells, 611 busulfan, 198t butterfly rash, 412t byssinosis, 196 281 cardiac hemolysis, 617 cardiac myxoma, 145 cardiac pacemaker (temporary) insertion, 732, 733f C CA 153- (tumor marker), cardiac-related dyspnea, 74 cardiac risk assessment, 680 305, 610 CA 199- (tumor marker), 443 \200\2235 cardiac scan, 706 cardiac surgery, 94, 102, cellulitis, 294 \200\2235, 453, 478, 680 529t, 537t CA 125 (tumor marker), central (secondary) adrenal insufficiency, 312 central cyanosis, 186 central diabetes insip idus, 680 117, 118, 125, 127, 138 \200\2239, 140, 141t cardiac tamponade, 117, cabergoline, 323, 325 cachexia, 73, 190, 245 CAGE questions (in 147 326 alcohol abuse), 229 cardiac transplantation, 140 cardiogenic shock, 116, 745, 750, 755 \200\2236, 757t central growth hormone deficiency, 322 central nervous system calcineurin inhibitor nephrotoxicity, 276 calcineurin inhibitors, cardiomegaly, 113, 271 cardiomyopathies, 101, 129, (CNS) disorders, 84 268, 275 calcitriol, 305 calcium antagonists, 117 calcium channel blockers, 116, 134, 165, 216t calcium chloride infusions, central retinal artery 138, 144 \200\2235, 192 occlusion, 362 central retinal vein occlusion, 368 central vein thrombosis, cardiorespiratory symptoms, in ROS, 40 cardiovascular medicine, 88 \200\223149 461 305 cardiovascular system, 44 \200\2238, 50 \200\2233 central venous catheter cannulation, 721 \200\2232, 733f calcium pyrophosphate dihydrate arthritis, 409 cardioversion, 112, 116, 121, 123, 361, 731 cephalexin, 531t, 537t cephalic herpes zoster, 390t cephalosporins, 167t, 276, 278t, 358, 4 45, 530 \200\2231, 530 \200\2232, 531t \200\223532t cerebellar tonsil herniation, Campylobacter spp., 524, carditis, 137 Carey Coombs \200\231 murmur, 544t, 546t cancer. See oncology; individual cancers 137 Carney complex, 310, 425t carotid artery, 337f carotid artery stenosis, 361 carotid bruits, 73 carpal tunnel syndrome, Candida, 141, 461 Candida spp., 524 candidiasis (thrush), 203 canicola fever, 588 Caplan \200\231s syndrome, 196 capreomycin, 556t capsaicin ointment, 75, 294 carbamazepine, 75, 21 6t, 778 cerebellopontine angle lesions, 65t, 390t 324 cerebellum caspofungin, 170 catecholamine-secreting neoplasms, 315 catheterizing bladders, anatomy, 335 cerebellar disease, 66 cerebello-pontine angle 294, 347, 380, 639 tumors, 65t cerebral abscess, 168 cerebral artery carbapenems, 534t carbenoxolone, 664t carcino-embryonic antigen, 720 \200\2231 cat scratch disease, 193t, 584, 589 anatomy, 338f territories, 336 \200\2237, 680 cat scratch fever, 193t, 584 cauda equina tumors, 401 causality, establishing carcinoid, malignant, 138 carcinoid syndrome, 210t, 337f \200\223338f cerebral blood supply, 245 \200\2236 338 \200\2239 (in epidemiology), 29 carcinoid tumors, 245 \200\2236 carcinoma of the pancreas, cerebral edema, 226t, 778 cerebral hemisphere infarcts, 359 cerebral venous cavernous sinus thrombosis, 367, 368 244 \200\2235 cardiac arrest, 116 cardiac catheterization, 805 cefazolin, 531t, 537t cefepime, 532t, 582 cefixime, 531t, 578 thrombosis, 368 101 \200\2232 cholestyramine, 109, 228, cidofovir, 280 ciguatera poisoning, 543t cilastatin, 534t cimetidine, 323 ciprofloxacin, 16 7t, 228, 235, 257, 258, 533t, 536t, 546t, 582 cirrhosis, 43, 89, 167, 193t, 220, 227 \200 \2238, 228t, 232, 238t cisplatin, 278t clarithromycin, 533t, 537t, cerebrospinal fluid (CSF), 235, 248 171 \200\2232, 348 \200\2239, 371t, 773t chondrocalcinosis, 231, 409 chorea, 72, 335, 358 chronic allograft certolizumab, 241, 242t, 407t nephropathy, 276 chronic bronchitis, 179 chronic cholecystitis, 485 \200\2236 chronic dyspn ea, 74 chronic eosinophilic pneumonia, 194 chronic glomerulonephritis, cervical cancer, 80, 516 \200\22317 cervical cord lesion, 186 cervical radiculopathy, 71 ce rvicitis, 516 Cestodes (tapeworms), 600 \200\2231 CHADS2 score, 26 Chagas disease, 144, 214t, 271 583 chronic heart failure, 130 chronic hepatitis, 238t chronic immune 592 chancroid, 519t Charcot-Marie-Tooth clindamycin, 445, 534t, 537t clinical skills cardiovascular system, thrombocytopenia, 620 syndrome, 387t, 388t cheese washer \200\231s lung, 194 chemical cystitis, 258 chemotherapy, 55, 161, 173, 236, 393, 433, 630, 635 44 \200\2235, 46f, 47t chronic interstitial gastrointestinal system, nephritis, 277, 279 chronic intestinal ischemia, 58 \200\2239 genitourinary history, 469 59 \200\22360, 60t \200\22361t chronic kidney disease chest deformity, 71 chest films, 691 \200\2232, 693f \200\223696f chest MRI, 711 chest pain s, 40, 44, 90 chest radiographs, 151 \200\2232, history taking, 37 \200\2238, 39t neurological system, (CKD), 251, 271 \200\2233, 276, 279, 295, 710 61 \200\2234, 64t \200\22365t chronic leukoblastic physical examination, 42 \200\2233 psychiatric assessment, leukemia, 264 chronic leukoblastic 65t, 68 \200\2239, 69t leukemia (CLL), 264 170, 184 respiratory system, 54 \200\2237 review of systems, 40 \200\2231 speech, higher mental func tion, 65 \200\2236, 67f, 67f, 67t chronic liver disease, 58, 190 chronic liver disease, signs chest x-ray, 55, 75, 76, 86, 90, 113, 127, 129, 138, 160, 161, 164, 182, 185, 188, 190, 218 , 360 Cheyne-Stokes respiration, of, 58 chronic lower tract obstruction, 261 chronic lymphocytic clitoral enlargement, 318 clomiphene citrate, 318 Clonorchis, 601 clonus, 332t Clostridia s pp., 160, 520t, 544t, 545t, 581 71, 778 leukemia, 629 Cheyne-Stokes respiration- chronic myeloid leukemia, Cyanosis, 72 628 \200\2239 Chlamydia spp., 141, 163t, 164 \200\2235, 516, 574 \200\2235 chlordiazepoxide, 229 chloride -channel (CIC-2) activators, 213 chronic obstructive pulmonary disease (COPD), 74, 176, 179 \200\22380, 186, 189, 190, 198, 763, 764t clotting disorder, 452 clubbing, of fingernails, 72, 73f, 167 \200\2238, 190 cluster headac he, 346t, 347 CMV retinitis, 571t CNS hemorrhage, 359 Coagulase-negative/ chloroquine, 525, 550 chlorpromazine, 323, 411 cholangiocarcinoma, 237 cholangitis, 486 cho lecystectomy, 486 cholecystitis, 84, 485 \200\2236 cholera, 519t, 585 \200\2236 cholestasis , 679 cholestatic (obstructive) jaundice, 215, 234, 244 chronic pancreatitis, 210t, 248 chronic paronychia (of nails), 43t chronic pulmonary edema, intermediate, 520t 198t Coagulase-positive chronic radiation nephritis, staphylococci, 520t 277 coagulation disorders, 621 coal-worker \200\231s chronic upper tract obstruction, 260 chronic urate nephropathy, pneumoconiosis, 196 coarctation of the aorta, 806 cholesterol absorption inhibitors, 109 cholesterol emboli, 280 149 277 Churg-Strauss syndrome, 177, 194, 416t Coccidioides immitis, 193t, 524, 595 congenital valve disease, Coxiella burnetii, 141, 143t cramp (painful muscle cramp), 72 cranberry juice, 258 cranial nerve examination, 63 \200\2234, 64t \200\22365t, 330t cranial nerve lesions, 64t C-reactiv e protein (CRP), 26, 111, 636, 678, 679t coccidioidomycosis, 169, 139 519t, 542 Congo-Crimean HF virus, Cockcroft-Gault equation, 523t 250, 274 codeine, 214t, 323 codeine phosphate, 211 colchicine, 184, 234, 408 cold (common c old), 561 colistin, 582 collapsing pulses (water hammer pulses), 48 colonic adenocarcinoma, conjunctivitis, 192 connective tissue disorders, 305, 399, 410, 413, 542 Conn \200\231s syndrome, 314 constipation, 213 \200\22314, 214t, 244, 352 crescentic constrictive pericarditis, glomerulonephritis, 283 Creutzfeldt-Jacobs disease, 48, 147 constructional apraxia, 66 continuous ambulatory 358 211 cricothyroidotomy, 729 \200\22330 Crigler-Najjar \200\231s syndrome, colonic ischemia, 469 colonic neoplasia, 324 colonoscopy, 213, 222, peritoneal dialysis, 274 continuous glucose 215 monitoring (CGM), 286 Crohn \200\231s disease, 193t, 222, 241 \200\2232, 242t, 248, 368, 398, 403t, 636 239, 426t colorectal adenocarcinoma, continuous murmurs, 53 contraceptives, oral, 237, 500 cromolyn, 178 Crossing the Quality Chasm: A New Health System for the 21st Century (IOM), 1 5 colorectal cancer, 210t,