OXFORD AMERICAN HANDBOOK OF CLINICAL MEDICINE Second Edition Published and upcoming Oxford American Handbooks Oxford American Handbook of Clinical Medicine Oxford American Handbook of Anesthesiology Ox ford American Handbook of Cardiology Oxford American Handbook of Clinical Dentistry Oxford American Handbook of Clinical Diagnosis Oxford American Handbook of Clinical Drugstore Oxfo rd American Handbook of Critical Care Oxford American Handbook of Disaster Medicine Oxford American Handbook of Emergency Medicine Oxford American Handbook of Endocrinology and Diabe tes Oxford American Handbook of Geriatric Medicine Oxford American Handbook of Hospice and Palliative Medicine Oxford American Handbook of Infectious Diseases Oxford American Handboo k of Nephrology and Hypertension Oxford American Handbook of Neurology Oxford American Hand book of Obstetrics and Gynecology Oxford American Handbook of Oncology Oxford American Hand book of Otolaryngology Oxford American Handbook of Pediatrics Oxford American Handbook of P hysical Medicine and Rehabilitation Oxford American Handbook of Psychiatry Oxford American Handbook of Pulmonary Medicine Oxford American Handbook of Radiology Oxford American Handbo ok of Reproductive Medicine Oxford American Handbook of Rheumatology Oxford American Handbo ok of Sports Medicine Oxford American Handbook of Surgery Oxford American Handbook of Urolo gy OXFORD AMERICAN HANDBOOK OF CLINICAL MEDICINE Second Edition EDITED BY JOHN A. FLYNN, MD, MBA, MED GENERAL INTERNAL MEDICINE AND RHEUMATOLOGY JOHNS HOPKINS UNIVERSITY MICHAEL J. CHOI, MD MEDICINE AND NEPHROLOGY JOHNS HOPKINS UNIVERSITY L. DWIGHT WOOSTER, MD MEDICINE AND PULMONARY DISEASE JOHNS HOPKINS UNIVERSITY 3 1 Oxford University Press is a department of the University of Oxford. It furthers the Univer sity \200\231s objective of excellence in research, scholarship, and education by publishin g worldwide. Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melb ourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Japan Poland Po rtugal Singapore Italy Guatemala Hungary South Korea Switzerland Thailand Turkey Ukraine Vi etnam Oxford is a registered trademark of Oxford University Press in the UK and certain other cou ntries. Published in the United States of America by Oxford University Press 198 Madison Avenue, Ne w York, NY 10016 Oxford University Press, 2013 All rights reserved. No part of this publication may be reproduced, stored in a retrieval s ystem, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms a greed with the appropriate reproduction rights organization. Inquiries concerning reproduct ion outside the scope of the above should be sent to the Rights Department, Oxford Universi ty Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquirer. Library of Congress Cataloging-in-Publication Data Oxford American handbook of clinical med icine / edited by John A. Flynn, Michael J. Choi, L. Dwight Wooster. \200\224 2nd ed. p. ; cm. \200\224(Oxford American handbooks) Adapted from: Oxford handbook of clinical medicine / Murray Londmore, et al. 8th ed. 2010. Includes bibliographical references and index. ISBN 978 \200\2230 \200\22319 \200\223991494 \200\2234 (alk. paper) \200\224ISBN 978 \200\2230 \200\22319 \200\223998515 \200\2239 (alk. paper) \200\224 ISBN 978 \200\2230 \200\22319 \200\223998516 \200\2236 (alk. paper) I. Flynn, John A., MD. Dwight) IV. Oxford handbook of clinical medicine. V. Series: Oxford American handbooks. [DNLM: 1. Clinical Medicine \200 \224Handbooks. WB 39] LC Classification not assigned 2012038115 616 \200\224dc23 II. Choi, Michael J. III. Wooster, L. Dwight (Lyman 9 8 7 6 5 4 3 2 1 Printed in the United States of America on acid-free paper Preface The Hippocratic Oath is a pledge by all physicians to practice medicine ethically and hones tly. As part of that oath, our beliefs hold a promise \200\234to teach (our students) this art, if they desire to learn it, without fee or covenant; to give a share of precepts and oral instruction and all the other learning to \200 pupils who have signed the covenant a nd have taken an oath according to the medical law \200 \200\235. Clearly, as we were emba rking on writing and editing this medical text, we were not dwelling on the magnitude of th is late 5th-century Greek work. We were, nonetheless, thinking about and motivated by the l ong-standing tradition in medicine of sharing medi- cal knowledge with colleagues, especial ly with our students of medicine. In contrast to the early days of medicine, this sharing o f medical knowledge is distributed to all cultures and all countries and is incredibly more open to all who \200\234desire to learn it. \200\235 The Oxford American Handbook of Clin ical Medicine is particularly writ- ten for physicians-in-training; students in medical sch ool and physicians in their residency. The tradition of teaching and sharing medical inform ation had its beginnings at our hospital more than 120 years ago. It is here that Sir Willi am Osler wrote and published, in 1892, The Principles and Practice of Medicine . This book was heralded as the most current work of clinical management of patients based on known sci entific principles. In addition to his review of the science of medicine, Osler \200\231s t ext provided sage advice on the art of compassionate patient care. Unlike in the days of Os ler, we now have access to current medical information at the speed of electrons with our v arious hand-held devices, search engines, and electronic medical records. As a result, now more than ever, our trainees must assiduously balance the science of medicine with the art of medicine. Although this handbook is replete with medical information, as authors and edi tors we also worked diligently to balance the art and compassionate delivery of medicine wi th the facts of clinical decisions. We are acutely aware of new health care policies, both local and national, of clinical cost containment, of the importance of quality medical outc omes with high efficiency, and with goals of professionalism. In this new edition, we have attempted to incorporate these aspects into medical decision-making processes and rec- omme ndations for accurate diagnosis and treatment. This book aims to present both the science a nd the art of patient man- agement. Our trainees are challenged in their clinical years to remember and assimilate an enormous volume of medical information; additionally, students o f medicine are applying and synthesizing this material within the context of their care of patients in the hospital and the outpatient envi- ronment. The process of integrating medic al knowledge with patient care is a repetitive one, in which learning will come in many for ms and from numerous sources. This book is one of those sources. The Oxford American Handbo ok of Clinical Medicine is designed as a reference when contemplat- ing symptoms and signs and medical conditions. Although relatively small and constructed to fit into pockets or ba ckpacks, this text is formatted to accommodate the growth and development of your medical k nowledge. The contributors of this manual have the understanding and experience to emphasiz e one of the grandest sources of medical knowledge \200\224your patients. As you interact w ith each patient, questions will arise; use each clinical question and each patient experie nce to stimulate your quest for medical knowledge. Allow your patients to become the founda tions of this knowledge; allow your patient \200\231s illnesses and their reactions to thei r ill- nesses and treatments to formulate your compassion and your art of medi- cine. Relis h the journey; it will last a lifetime. v This page intentionally left blank Acknowledgments We, the three editors of the Oxford American Handbook of Clinical Medicine , express our mo st profound gratitude to all of the authors who have con- tributed to this book. These cont ributors are highly respected colleagues from the Johns Hopkins School of Medicine. They ha ve been fastidious in their development of these chapters, incorporating the most recent ev i- dence-based guidelines into clinical practice. We also have the distinct privilege of pa rticipating in the care of our patients while teaching physicians-in-training within Johns Hopkins Medicine. The care of patients, the recognition of their ills, the definition of th eir clinical problems, and the provision of their care are the foundations of the prac- tic e of medicine. This privilege of caring, cemented by medical knowledge, is commonly a bilat eral interaction shared mutually whether with our patients or with our students. Through th ese interactions we have learned as much as we have imparted. The sharing of medical inform ation with our colleagues, our students, and our patients is imperative for successful heal th care. The presentation of current, accurate, and dependable medical knowledge is essenti al for suc- cessful, evidence-based quality outcomes for our patients. Our participation in writing and editing this medical text was motivated by our indebtedness to our patients an d our students. We also wish to acknowledge all of the efforts provided by Oxford Universit y Press, in particular Andrea Seils, Senior Editor of Clinical Medicine. She has served thr oughout this effort as a steadfast advocate for the excellence and clarity of this text. He r many hours of dedication and profound patience are greatly appreciated. JF would like to thank his children, Emilee, John, Sarah, Jayne, Christian, Patrick, and W. Andrew for their constant support of one another as our family advances. He also wishes to thank Bill Baumg artner for his mentor- ship. Most importantly he must thank Monica \200\224his wife, his li fe \200\224for her infinite support and strength during the past 35 years of being together . MC would like to thank his wife Mia, his son Chris, and his daughter Julia for their endl ess support and infinite patience. They have forgiven him far too many things. He would lik e to thank his parents for always doing their best for him. He would also like to thank his mentor Pedro Fernandez, on behalf of all of his mentees, for simply making us better docto rs. DW extends his appreciation to his fianc e, Tina Blasi, who has unequivo- cally supp orted his decision to work on this text; she has been his cor- nerstone and source of encou ragement. Tina \200\231s love and devotion are his emotional foundations from which he chan ged professional paths and expanded his professional and personal horizons. Additionally, h is children Ashley, Margaux, and Tyler are universally helpful in contributing to his energ y and ideas, and to his wish for better health care for them and for their children. He als o wishes to thank Mike Weisfeldt for giving him the opportunity to join the faculty of John s Hopkins \200\231 Medicine. Finally, we wish to dedicate this book to Dr. Frederick L. Bra ncati for being a constant source of strength, courage, and guidance to us, through not onl y his words but through his actions. vii This page intentionally left blank Contents Preface v Acknowledgments vii List of contributors xi Symbols and abbreviations xiii 1 26 36 70 88 150 202 250 284 328 398 420 438 518 608 642 654 684 718 734 1 Thinking about medicine 2 Epidemiology 3 Clinical skills 4 Symptoms and signs 5 Cardiovascular medicine 6 Pulmonary medicine 7 Gastroenterology 8 Renal medicine 9 Endocrinology 10 Neurology 11 Rheumatology and musculoskeletal conditions 12 Oncology 13 Surgery 14 Infectious diseases (ID) 15 Hematology 16 Geriatric medicine 17 Biochemistry 18 Radiology 19 Practical procedures 20 Emergency Medicine Index 800 This page intentionally left blank List of Contributors Sumera Ali, M.D. Johns Hopkins University Radiology Rodney Omron, M.D., M.P.H. Johns Hopkins University Emergency Medicine Arjun S. Chanmugam, M.D. Johns Hopkins University Emergency Medicine Gregory P. Prokopowicz, M.D., M.P.H. Johns Hopkins University Epidemiology Colleen Christmas, M.D. Johns Hopkins University Geriatric Medicine Jason Rosenberg, M.D. Johns Hopkins University Neurology April Fitzgerald, M.D. Johns Hopkins University Signs and Symptoms Stuart Russell, M.D. Johns Hopkins University Cardiovascular Medicine John A. Flynn, M.D., M.B.A., M.ED. Johns Hopkins University Rheumatology Paul E. Segal, D.O. Johns Hopkins University Biochemistry Matthew Foy, M.D. Louisiana State University Renal Medicine Shmuel Shoham, M.D. Johns Hopkins University Infectious Disease Susan L. Gearhart, M.D. Johns Hopkins University Surgery Lanaya W. Smith, M.D. Johns Hopkins University Rheumatology Mark T. Hughes, M.D., M.A. Johns Hopkins University Thinking About Medicine Ellen M. Stein, M.D. Johns Hopkins University Gastroenterology Joshua D. King, M.D. University of Virginia Biochemistry C. Matthew Stewart, M.D., PH.D. Johns Hopkins University Practical Procedures Daniel Laheru, M.D. Johns Hopkins University Oncology Rosalyn W. Stewart, M.D., M.S. Johns Hopkins University Practical Procedures L. David Martin, M.D. Johns Hopkins University Signs and Symptoms Sumeska Thavarajah, M.D. Johns Hopkins University Renal Medicine Alison R. Moliterno, M.D. Johns Hopkins University Hematology Clifford R. Weiss, M.D. Johns Hopkins UniversityRadiology Kendall F. Moseley, M.D. Johns Hopkins University, Endocrinology L. Dwight Wooster M.D. Johns Hopkins University Pulmonary Medicine xi This page intentionally left blank Symbols and abbreviations 1 2 \200\223ve; +ve 6-MP A 2 A 2 A Ab ABC ABG ABI ABPA ac ACE ACS ACTH AD ADH Ad lib A DL AF AFB AFP Ag AIDS AIH AIN AKI alk phos ALL AMA AML AMP ANA ANCA APTT AR ARB ARDS ARF AR T AS ASD ASO(T) AST Primary Secondary negative and positive, respectively thiopurine aortic component of second heart sound angiotensin-2 receptor antagonist (AT-2, A2R, and AIIR) antibody airway, breat hing, and circulation: basic life support \200\223) arterial blood gas measurement ( P aO2 , P aCO2, pH, HCO3 ankle brachial index allergic bronchopulmonary aspergillosis ante cibum (before food) angiotensin-converting enzyme acute coronary syndrome adrenocorticotropic hor mone Alzheimer \200\231s disease antidiuretic hormone ad libitum; as much/as often as wante d (Latin for at pleasure ) activities of daily living atrial fibrillation acid-fast bacillu s (and -FP) -fetoprotein antigen acquired immunodeficiency syndrome autoimmune hepati tis acute interstitial nephritis acute kidney injury alkaline phosphatase (also ALP) acute lymphoblastic leukemia antimitochondrial antibody acute myeloid leukemia adenosine monophos phate antinuclear antibody antineutrophil cytoplasmic antibody activated partial thrombopla stin time aortic regurgitation angiotensin receptor blocker acute respiratory distress synd rome acute renal failure antiretroviral therapy aortic stenosis atrial septal defect antist reptolysin o (titer) aspartate transaminase xiii AT-2 ATN ATP AV AVM AVNRT AVRT AXR AZA AZT Ba BAL BET BHL BID BKA BMD BMI BNP BP bpm BUN ca Ca CABG CAD cAMP CAP CAPD CBC CBD CC CCPD CCU CDC CEA CF CGM CHB CHD CHF Chol CI CIPD CK angiotensin-2 receptor blocker (also AT-2, A2R, and AIIR) acute tubular necrosis adenosine triphosphate atrioventricular arteriovenous malformation(s) AV nodal reentry tachycardia AV reentry tachycardia abdominal x-ray (plain) azathioprine zidovudine barium bronchoalveolar lavage benign essential tremor bilateral symmetrical hilar lymphadenopathy bis die (twice a day) below-knee amputation bone mineral density body mass index brain natriuretic peptide blood pressure beats per minute (e.g., pulse) blood urea nitrogen carcinoma calcium corona ry artery bypass graft coronary artery disease cyclic adenosine monophosphate (AMP) communi ty-acquired pneumonia continuous ambulatory peritoneal dialysis complete blood count common bile duct creatinine clearance continuous cyclic peritoneal dialysis coronary care unit Ce nters for Disease Control, U.S. carcino-embryonic antigen cystic fibrosis continuous glucos e monitoring complete heart block coronary heart disease (related to ischaemia and atheroma ) congestive heart failure (i.e., left and right heart failure) cholesterol contraindicatio ns chronic inflammatory demyelinating polyradiculoneuropathy creatine (phospho)kinase (also CPK) xiv CKD CLL CML CMV CNS CONS COPD COX CPAP CPPD CPR CRC CrCl CRF CRP CRRT CSF CT CVD CVP CVS CX R d DC DIC DIP dL DEXA DLCO DM DOT DTPA DU D&V DVT EAA EBM EBV ECG Echo EDTA EEG EKG EGD EL ISA chronic kidney disease chronic lymphocytic leukemia chronic myeloid leukemia cytomegaloviru s central nervous system coagulase-negative Staphylococcus chronic obstructive pulmonary di sease cyclo-oxygenase continuous positive airways pressure calcium pyrophosphate dihydrate cardiopulmonary resuscitation colorectal cancer creatinine clearance chronic renal failure C-reactive protein continuous renal replacement therapy cerebrospinal fluid computed tomogr aphy cardiovascular disease central venous pressure cardiovascular system chest x \200\223r ay day(s) (also expressed as /7) direct current disseminated intravascular coagulation di stal interphalangeal deciliter dual energy x-ray absorptiometry diffusing capacity of lung diabetes mellitus directly observed therapy diethylenetriamine penta-acetic acid duodenal u lcer diarrhea and vomiting deep venous thrombosis extrinsic allergic alveolitis evidence-ba sed medicine Epstein \200\223Barr virus electrocardiogram echocardiogram ethylene diamine t etraacetic acid (e.g., in a CBC bottle) electroencephalogram electrocardiogram; also ECG es ophagogastric-duodenoscopy enzyme linked immunosorbent assay xv EM EMG ENT ERCP ESR ESRD EUA EUS EVAR FB FDA FDP FEV 1 FFP FGF FH FHF F i O 2 FNA FROM FSH FUO FVC g GA GB GC GCA GCS GERD GFR GGT GH GI G6PD GN GPA GTT GU h HAART HAP HAV Hb HBsAg/H BV hepatitis B surface antigen/hepatitis B virus electron microscope electromyogram ear, nose, and throat endoscopic retrograde cholangiopan creatography erythrocyte sedimentation rate end-stage renal disease examination under anest hesia endoscopic ultrasonography endovascular aneurysm repair foreign body U.S. Food and Dr ug Administration fibrin degradation products forced expiratory volume in first second fres h frozen plasma fibroblast growth factor family history fulminant hepatic failure partial p ressure of O2 in inspired air fine needle aspiration full range of movements follicle-stimu lating hormone fever of unknown origin forced vital capacity gram general anesthetic gall b ladder gonococcus giant cell arteritis Glasgow Coma Scale gastroesophageal reflux disease g lomerular filtration rate gamma glutamyl transpeptidase growth hormone gastrointestinal glu cose-6-phosphate dehydrogenase glomerulonephritis granulomatosis with polyangiitis glucose tolerance test (also OGTT: oral GTT) genitourinary; also gastric ulcer hour highly active a ntiretroviral therapy hospital-acquired pneumonia hepatitis A virus hemoglobin xvi HBIG HCAP HCC Hct HCV HD HDL HDV HELLP hepatitis B immune globulin health care acquired pneumonia hepatocellular cancer hematocrit hepatitis C virus hemodialysis high-density lipoprotein hepatitis D virus hemolysis, eleva ted liver enzymes, low platelet count syndrome hereditary hemochromatosis hyperosmolar hype rglycemic state hereditary hemorrhagic telangiectasia human herpes virus hepatic iminodiace tic acid heparin-induced thrombocytopenia human immunodeficiency virus human leukocyte anti gen hypertrophic obstructive cardiomyopathy hyperosmolar nonketotic (diabetic coma) human p apilloma virus high-resolution computed tomography hepatorenal syndrome hormone replacement therapy Herpes simplex virus hypertension hemolytic uremic syndrome inflammatory bowel dis ease irritable bowel syndrome intracranial pressure intercostal space intensive care unit i ron-deficiency anemia insulin-dependent diabetes mellitus interferon infective endocardi tis impaired fasting glucose immunoglobulin interferon gamma release assay impaired glucose tolerance ischemic heart disease interleukin intramuscular immune-mediated necrotizing myo pathy indinavir HH HHS HHT HHV HIDA HIT HIV HLA HOCM HONK HPV HRCT HRS HRT HSV HTN HUS IBD IBS ICP ICS ICU IDA IDDM IFN- IE IFG Ig IGRA IGT IHD IL IM IMNM IND xvii INR IPPV ISH ITP iu IVC IVDU IVIG IVF IV(I) IVU JVP K kg L LA LAD LBBB LDH LDL LFT LH LLQ L MN LMWH LMP LP LR LRD LTOT LUQ LV LVF LVH LVOT g MAI MAOI MC & S MCP MCV MDCT MDMA MDRD M ELD international normalized ratio (prothrombin ratio) intermittent positive pressure ventilati on isolate systolic hypertension idiopathic thrombocytopenic purpura international unit inf erior vena cava intravenous drug user intravenous immunoglobulin intravenous (infusion) intravenous urography jugular venous pressure potassium kilogram lit er left atrium of heart left axis deviation on the ecg left bundle branch block lactate deh ydrogenase low-density lipoprotein liver function test luteinizing hormone left lower quadr ant lower motor neuron low-molecular-weight heparin last menstrual period lumbar puncture l actated Ringer \200\231s living related donor long term oxygen therapy left upper quadrant left ventricle of the heart left ventricular failure left ventricular hypertrophy left vent ricular outflow tract microgram Mycobacterium avium intracellulare monoamine oxidase inhibi tors microscopy, culture, and sensitivity metacarpophalangeal joints mean cell volume multi detector computed tomography 3,4-methylenedioxymethamphetamine Modification of Diet in Rena l Disease model for end-stage liver disease xviii MET mg Mg MI min(s) mL mm Hg MEN MMSE MND MPA MR MRA MCRP MRI MRSA MS MSM MSSA MSU Na NAAT NAD ND ng NG(T) NHANES National Health and Nutrition Examination Survey National Institute for Health and Clinical Excellence NICE noninsulin-dependent diabetes mellitus NIDDM night intermittent peritoneal dialysis NIPD n -methyl- d -aspartate NMDA non-nucleoside reverse t ranscriptase inhibitor NNRTI number needed to treat, for 1 extra satisfactory result NNT no thing by mouth NPO normal range \200\224the same as reference interval NR nucleoside revers e transcriptase inhibitor NRTI normal saline NS nonsteroidal anti-inflammatory drugs NSAIDs nitroglycerin (also TNG) NTG nausea and/or vomiting N&V New York Heart Association NYHA os teoarthritis OA overdose OD oral glucose tolerance test OGTT opening pressure OP maximal exercise test milligram magnesium myocardial infarction minute(s) milliliter millim eters of mercury multiple endocrine neoplasia Mini-Mental Status Examination motor neuron d isease microscopic polyangiitis mitral regurgitation magnetic resonance angiography magneti c resonance cholangiopancreatography magnetic resonance imaging methicillin-resistant Staph ylococcus aureus multiple sclerosis (do not confuse with mitral stenosis) men who have sex with men methicillin sensitive Staphylococcus aureus midstream urine sodium nucleic acid am plification test nothing abnormal detected notifiable disease nanogram nasogastric (tube) xix OPD ORh \200\223 OT P 2 P a CO 2 PAD PAN P a O 2 PAS PBC PCN PCOS PCR PCV PD PDGF PE PEEP P ERLA PEF(R) PET PFT PI PID PIP PMH PMR PND PO POEM PPF PPI PR PRN PSA PSC PTCA PTH PTT PTU PUD qd qid outpatient department blood group O, Rh negative occupational therapist pulmonary component of second heart sound partial pressure of carbon dioxide in arterial blood peripheral arte ry disease polyarteritis nodosa partial pressure of oxygen in arterial blood periodic acid- Schiff primary biliary cirrhosis penicillin polycystic ovary disease polymerase chain react ion (DNA diagnosis) packed cell volume peritoneal dialysis; also Parkinson \200\231s diseas e platelet-derive growth factor pulmonary embolism positive end-expiratory pressure pupils equal and reactive to light and accommodation peak expiratory flow (rate) positron emission tomography pulmonary function tests protease inhibitor pelvic inflammatory disease proxima l interphalangeal (joint) past medical history polymyalgia rheumatica paroxysmal nocturnal dyspnea per os (by mouth) peroral endoscopic myotomy purified plasma fraction (albumin) pro ton pump inhibitor; e.g., omeprazole, lansoprazole, etc. per rectum (by the rectum) pro re nata (as required) prostate specific antigen primary sclerosing cholangitis percutaneous tr ansluminal coronary angioplasty parathyroid hormone prothrombin time propylthiouracil pepti c ulcer disease each day quater in die (4 times a day); qqh: quarta quaque hora (every 4h) right rheumatoid arthritis; also right atrium of heart R RA xx RAD RBBB RBC RCT RF R/O RLQ RUQ RV RVF RVH \202 s or sec S1, S2 SARS SBE right axis deviation on the ECG right bundle branch block red blood cell randomized control led trial renal failure rule out right lower quadrant right upper quadrant right ventricle of heart; also residual volume of lung right ventricular failure right ventricular hypertro phy recipe (treat with) second(s) first and second heart sounds severe acute respiratory sy ndrome subacute bacterial endocarditis (IE, infective endocarditis , is better) spontaneous bacterial peritonitis subcutaneous spontaneous compression device standard deviation side effect(s) Surveillance Epidemiology and End Results program systolic ejection murmur sublin gual systemic lupus erythematosus short of breath single positron emission computed tomogra phy subcutaneous slow-release (also called modified-release) serotonin-norepinephrine reupt ake inhibitor selective serotonin reuptake inhibitor statim (immediately; as initial dose) sexually transmitted disease; sexually transmitted infection superior vena cava supraventri cular tachycardia syndrome temperature biological half-life type 1 diabetes mellitus type 2 diabetes mellitus triiodothyronine thyroxine tuberculosis transitional cell carcinoma thyr oid function tests (e.g., tsh) SBP SC SCD SD SE SEER SEM SL SLE SOB SPECT SQ SR SNRI SSRI stat STD/STI SVC SVT sy(n) T t T1DM T2DM T3 T4 TB TCC TFTs xxi TIA TIBC Tid TEE TENS TGF TLC TLS TMP/SMX trimethoprim/sulfamethoxazole TNF TPR TR TRH Trig TSH TSST TTE TTP TUIP TURP U UC U&E transient ischemic attack total iron binding capacity ter in die (3 times a day) trans-esop hageal echocardiogram transcutaneous electrical nerve stimulation tumor growth factor total lung capacity tumor lysis syndrome tumor necrosis factor temperature, pulse, and respirations count tricuspid regurgitation th yroid-releasing hormone triglycerides thyroid-stimulating hormone toxic shock syndrome toxi n trans-thoracic echocardiogram thrombotic thrombocytopenic purpura transurethral incision of the prostate transurethral resection of the prostate units ulcerative colitis urea & ele ctrolytes & creatinine in plasma, unless stated otherwise ursodeoxycholic acid upper motor neuron upper respiratory tract upper respiratory tract infection ultrasound (scan) urinary tract infection ventilator-acquired pneumonia video-assisted thorascopy Venereal Diseases R esearch Laboratory vascular endothelial growth factor UDCA UMN URT URTI US(S) UTI VAP VAT VDRL VEGF VISA/VRSA vancomycin intermediate/resistant S taphylococcus aureus VF VLDL VMA V./Q. VSD VT WBC WCC wk(s) WPW WHO ventricular fibrillation very low density lipoprotein vanillyl mandelic acid (HMMA) ventila tion/perfusion ratio ventriculo-septal defect ventricular tachycardia white blood cell whit e cell count week(s) Wolff-Parkinson-White syndrome World Health Organization xxii WR yr(s) ZN Wassermann reaction year(s) Ziehl \200\223Neelsen (stain for acid-fast bacilli; e.g., mycob acteria) Other abbreviations are given on pages where they occur: consult the index . xxiii e Thinking about medicine n i c i d e m Mark T. Hughes , M.D., M.A. Contents Ideals 1 Ideal and less than ideal methods of care 1 Health and medical ethics 1 T he bedside manner and communication skills 3 Asking questions 4 What is the mechanism? Find ing narrative answers 6 Medicine, art, and the humanities 7 The art and science of diagnosi ng 9 Prevention 10 Prescribing drugs 12 Is this new treatment any good? (Analysis and meta- analysis) 13 Resource allocation and distributive justice 14 Quality and safety 15 Psychiat ry on medical and surgical wards 17 Difficult patients 18 Death: Diagnosis and management 1 8 Facing death 20 Palliative care 22 Surviving residency 23 On being busy: Corrigan \200 \231s secret door 24 t u o b a g n k n h T i i 1 Ideals Decision and intervention are the essence of action. Reflection and conjec- ture are the essence of thought. The essence of medicine is combining these realms of decision and intervention in the service of others. We offer these ideals to stimulate both thought and action: Like the stars, these ideals are hard to reach \200\224but they serve for navigatio n during the night. \212 Remember the goal of healing is to make the person whole: This ap plies whether the aim is cure, relief of symptoms in an acute or chronic illness, preventio n of complications in a chronic disease, or comfort in an incur- able disease. \212 Do not blame the sick for being sick: They come to you for help. You are there for them, not the other way around. \212 If the patient \200\231s wishes are known, comply with them . \212 Work for your pat ients, not your attending . \212 Use ward rounds to boost the patient \200\231s morale , n ot your own. \212 Treat the whole patient , not the disease. \212 Admit people \200\224n ot \200\234strokes, \200\235 \200\234infarcts, \200\235 \200\234shooters, \200\235 or \200\234gomers. \200\235 \212 Spend time with the bereaved ; you can help them shed their tears. \212 Question your conscience \200\224however strongly it tells you to act. \212 Respect the opinions of nurses; they know the patient, spend the most time with the patient, and are usually right. \212 Work as a team member; everyone on the interdisciplinary team has a valuable role in the patient \200\231s care. \212 Be kind to yourself \200\224you are not an inexhaustible resource. \212 Give the pa tient (and yourself) time : Time to ask questions, time to reflect, time to allow healing to take place, and time to gain autonomy. \212 Give the patient the benefit of the doubt . If you can, be optimistic : Patients want physicians to be realistic but also to instill hope. While these ideals speak to our actions \200\224 what we do \200\224we also have to be min dful of who we are . None of us is perfect and will never be perfect, but we can strive to reach asymptotically for perfection. This entails trying to develop habits of character tha t lead to virtues \200 and a virtuous life. The virtues especially important in medicine i nclude honesty and integrity, cour- age and fortitude, phronesis (practical wisdom), temper ance and equanimity, justice, self-effacement, compassion, and care. 1 e n i c i d e m t u o b a g n k n h T Ideal and less than ideal methods of care The story of Ivan Ilyich illustrates the options: \200\234Special foods were prepared for him on the doctor \200\231s orders, but these bec ame more and more unpalat- able, more and more revolting \200 Special arrangements, too, w ere made for his bowel movements. And this was a regular torture \200\224a torture because of the filth, the unseemliness, the stench, and the knowledge that another person had to as sist him \200 Yet it was precisely through this unseemly busi- ness that Ivan Ilyich deriv ed some comfort. The pantry boy, Gerasim, always came to carry out the chamber pot. Gerasim was a clean, ruddy-faced young peasant who was thriving on town food. He was always bright and cheerful \200 \200\230Gerasim, \200\231 said Ivan Ilyich in a feeble voice \200 \200\230This must be very unpleasant for you. You must forgive me. I can \200\231t help it. \200\231 \200 \200\230Oh no, sir! \200\231 said Gerasim as he broke into a smile, his ey es and strong white teeth gleam- ing. \200\230Why shouldn \200\231t I help you? You \200 \231re a sick man. \200\231 Gerasim did everything easily, willingly, simply, and with a go odness of heart that moved Ivan Ilyich. Health, strength, and vitality in other people offe nded Ivan Ilyich, whereas Gerasim \200\231s strength and vitality had a soothing effect on him. \200\235 2 It was the pantry boy who was his true healthcare provider and caregiver, w ho took him on his own terms, cared for him, and gave him time and dignity. While Ivan Ilyi ch \200\231s physicians and others cooperated in the \200\234lie \200\235 that he was ill but not dying, \200\234Gerasim was the only one who understood and pitied him. \200\235 Ge rasim did not find his work burdensome, because he understood he was doing it for a dying m an. As T. S. Eliot said, \200\234 there is, at best, only a limited value in the knowledge derived from experience \200\235 (e.g., the knowledge encompassed in this book). The pantr y boy had the innate understanding and the natural compassion that we all too easily lose a mid the science, the knowledge, and our stainless steel universe of organized healthcare. T he oft-quoted advice of Francis Peabody nearly a century ago still pro- vides guidance: \200\234for the secret of the care of the patient is in caring for the patient. \200\235 3 i i 1 Health and medical ethics Medicine has its own internal morality. This derives from a patie nt \200\231s illness and his or her subsequent vulnerability, coupled with the physician \200\231s intent to help the patient improve. Each time a physician asks of the patient, \200\234How can I help you? \200\235 there is an implicit understanding that the physician will use his or her expertise to serve the best interests of the patient. As members of a p rofession, physicians declare publicly that they will put aside their self-interest in the service of others. Although society grants physicians certain privileges (e.g., prescribing medication, determining 1 Pellegrino ED, Thomasma DC. The Virtues in Medical Practice . New York: Oxford University Press; 1993. 2 Tolstoy L. The Death of Ivan Ilyich. New York: Bantam Books; 1981. 3 Peabod y F. 1927, The care of the patient . JAMA. 1927;8812):877 \200\223882. disability), it also expects certain duties of the profession, namely that physicians be th e stewards of valuable societal resources. Professionalism is our contract with society and entails certain commitments on the part of physicians. 4 In the sphere of ethics, physicia ns are called upon to lead as often as to follow. To do this, we need to return to basic pr inciples and put society \200\231s expectations temporarily to one side. Our analysis start s with our aim: To do good by promoting people \200\231s health. Health entails being sound in body and mind, and having powers of growth, development, healing, and regeneration. How many people have you made healthy (or at least healthier) today? Good is the most general term of commendation and entails four chief duties: \212 Not doing harm (nonmaleficence). We owe this duty to all people, not just our patients. \212 Doing good by positive actions (beneficence). We particularly owe this to our patient s. There are four ways by which the patient \200\231s good can be defined: (1) the ultimate good, that which has the highest meaning for the patient; (2) the biomedical good, obtaine d by treatment of the disease; (3) the patient \200\231s perception of the good based on hi s or her life plan; and (4) the good of the patient as a person, deserving respect and the freedom to make reasoned choices. 5 2 \212 Respecting the person. Autonomy respecting (self-determination) is not universally recognized; in some cultures, such as those facing starvation, it may be irrelevant or even subversive. But re specting persons and their inherent dignity is to be found across cultures. This is manifes ted in medicine by upholding patients \200\231 rights to be informed, to be offered all the options, to be told the truth, and to have their confidentiality protected. autonomy or \212 Promoting justice \200\224distributing scarce resources fairly and treating people fairly, such as when we respect their legal rights. The point of having these guiding principles is to provide a context for our negotiations w ith patients. If we want to be better doctors, a good starting point is trying to put these principles into action. Inevitably, when we try, there are times when the principles seem to conflict with each other. What should guide us when these principles conflict? It is not just a case of decid- ing off the top of one \200\231s head. It requires further inquiry, deliberation, and aspiring to a synthesis \200\224if you have the time (time will so often be what you do not have; but, in retrospect, when things have gone wrong, you realize that they would not have done so if you had made time). Synthesis When we must act in the face of two conflicting duties, one of the duties will take precedence. How do we tell which one ? Trying to find out involves getting to know our patients and asking some questions: \212 Are the patient \200\231s wishes being complied with? \212 What do the patient \200\231s loved ones (family and/or friends) think? First, ask the patient \200\231s permission to sp eak to the loved ones. Do the patient \200\231s loved ones have his or her best interests a t heart? \212 What do colleagues think? Often having the input of other clinicians can help sort out the complexities of a difficult case. 4 ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American Colle ge of Physicians-American Society of Internal Medicine; European Federation of Internal Med icine. Medical professionalism in the new millennium: A physician charter. Ann Intern Med. 2002;136(3): 243 \200\223246. 5 Pellegrino ED, Thomasma DC. For the Patient \200\231s Good: The Restoration of Beneficence in Healthcare. New York: Oxford University Press; 1988. \212 Is it desirable that the reason for an action be universalizable? (That is, if I say this person is too old for such-and-such an operation, am I happy to make this a general ru le for everyone? \200\224Kant \200\231s \200\234law. \200\235) 6 e n i c i d e m \212 What would the man on the street say? These opinions are valuable as they are readily available, and they can stop decision making from becom- ing dangerously medicalized. Seek ing these opinions also prompts one to think about the \200\234reasonable person \200\235 standard when getting informed consent. t u o b a g n k n h T \212 If an investigative journalist were to sit on a sulcus of mine, having full knowledge of my thoughts and actions, would she be bored or would she be composing vitriol for tomor row \200\231s newspapers? If so, can I answer her, point for point? Am I happy with my answ ers? Or are they tactical cerebrations designed to outwit her? i \212 What would I do if nobody were watching? Would I act the same way if there were no co nsequences in terms of public scrutiny? Will I be able to face myself in the mirror the nex t morning? i \212 Do I need the input of the hospital ethics committee? In some cases, eth- ics consult ants can help to facilitate discussion among interested parties, sort out the ethical issue s at stake, and provide an opinion about ethically permissible options for resolution of th e problem. 3