Table Of ContentAMERICAN COLLEGE OF PHYSICIANS
CLERKSHIP DIRECTORS IN INTERNAL MEDICINE ACP
INTERNAL MEDICINE
Essentials
for
Clerkship
Students
2
INTERNAL MEDICINE
Essentials
for
Clerkship
Students
2
Patrick C. Alguire, MD, FACP
DIRECTOR
EDUCATION AND CAREER DEVELOPMENT
AMERICAN COLLEGE OF PHYSICIANS
EDITOR-IN-CHIEF
Associate Publisher and Manager, Books Publishing: Tom Hartman
Production Supervisor: Allan S. Kleinberg
Senior Production Editor: Karen C. Nolan
Editorial Coordinator: Angela Gabella
Design: Michael E. Ripca
Copyright 2009 by the American College of Physicians. All rights reserved. No part of
this publication may be reproduced in any form by any means (electronic, mechanical,
xerographic, or other) or held in any information storage or retrieval systems without
written permission from the College.
Printed in the United States of America
Printed by Sheridan Books
Composition by Scribe, Inc. (www.scribenet.com)
ISBN: 978-1-934465-13-4
The authors and publisher have exerted every effort to ensure that the drug selection
and dosages set forth in this book are in accordance with current recommendations and
practice at the time of publication. In view of ongoing research, occasional changes in
government regulations, and the constant flow of information relating to drug therapy
and drug reactions, however, the reader is urged to check the package insert for each
drug for any change in indications and dosage and for added warnings and precautions.
This care is particularly important when the recommended agent is a new or infrequently
used drug.
09 10 11 12 13 / 10 9 8 7 6 5 4 3 2 1
Section Editors
Thomas M. DeFer, MD, FACP Sara B. Fazio, MD
Clerkship Director Assistant Professor, Harvard Medical School
Division of Medical Education Director, Core I Medicine Clerkship
Department of Internal Medicine Division of General Internal Medicine
Washington University School of Medicine Beth Israel Deaconess Medical Center
St Louis, Missouri Boston, Massachusetts
D. Michael Elnicki, MD, FACP James L. Sebastian, MD, FACP
Director, Ambulatory Medicine Clerkship Director of Student Teaching Programs
Director, Section of General Internal Medicine Department of Medicine
University of Pittsburgh School of Medicine Medical College of Wisconsin
UPMC Shadyside Clement J. Zablocki Veterans Affairs Medical Center
Pittsburgh, Pennsylvania Milwaukee, Wisconsin
Mark J. Fagan, MD
Clerkship Director
Department of Medicine
Alpert Medical School of Brown University
Providence, Rhode Island
Contributors
Arlina Ahluwalia, MD Hugo A. Alvarez, MD, FACP
Clinical Assistant Professor of Medicine Associate Professor of Medicine
Stanford University School of Medicine Sub-Internship Director
Clerkship Site Director Clerkship Site Director, Department of Medicine
Palo Alto VAHCS Rosalind Franklin University of Medicine and Science
Palo Alto, California Mount Sinai Hospital
Chicago, Illinois
Eyad Al-Hihi, MD, FACP
Associate Professor of Medicine Alpesh N. Amin, MD, MBA, FACP
Clerkship Director, Ambulatory Medicine Medicine Clerkship Director
Section Chief, Division of General Internal Medicine Associate Program Director, IM Residency
Medical Director, Internal Medicine Clinics University of California, Irvine
Truman Medical Center-Hospital Hill Irvine, California
University of Missouri-Kansas City School of
Medicine Mary Jane Barchman, MD, FACP, FASN
Kansas City, Missouri Associate Professor of Medicine
Section of Nephrology and Hypertension
Erik K. Alexander, MD, FACP Director, Introduction to Medicine Course
Director, Medical Student Education Clerkship Director, Internal Medicine
Brigham & Women’s Hospital Brody School of Medicine at East Carolina University
Assistant Professor of Medicine Greenville, North Carolina
Harvard Medical School
Boston, Massachusetts Seth Mark Berney, MD, FACP
Professor of Medicine
Irene Alexandraki, MD, FACP Chief, Section of Rheumatology
Assistant Professor of Medicine Director, Center of Excellence for Arthritis and
University of Florida College of Medicine Rheumatology
Jacksonville, Florida Health Sciences Center
Louisiana State University School of Medicine
Mark R. Allee, MD, FACP Shreveport, Louisiana
Assistant Professor of Medicine
Department of Internal Medicine
University of Oklahoma College of Medicine
Oklahoma City, Oklahoma
v
vi • Contributors
Cynthia A. Burns, MD Janine M. Frank, MD
Assistant Professor Assistant Professor of Medicine
Clerkship Director, Inpatient Internal Medicine University of Pittsburgh Medical Center
Section of Endocrinology and Metabolism University of Pittsburgh School of Medicine
Department of Internal Medicine Pittsburgh, Pennsylvania
Wake Forest University School of Medicine
Winston-Salem, North Carolina Jane P. Gagliardi, MD
Assistant Clinical Professor
Amanda Cooper, MD Department of Internal Medicine
Assistant Professor of Medicine Department of Psychiatry and Behavioral Sciences
University of Pittsburgh School of Medicine Duke University School of Medicine
University of Pittsburgh Medical Center Durham, North Carolina
Pittsburgh, Pennsylvania
Peter Gliatto, MD
Nicole M. Cotter, MD Assistant Professor of Medicine
Fellow, Section of Rheumatology Director, Medical Clerkships
Center of Excellence for Arthritis and Rheumatology Mount Sinai School of Medicine
Health Sciences Center New York, New York
Louisiana State University School of Medicine
Shreveport, Louisiana Eric H. Green, MD, MSc
Course Director, Patients, Doctors, and Communities
Reed E. Drews, MD, FACP Assistant Professor of Medicine
Program Director Montefiore Medical Center
Hematology-Oncology Fellowship Albert Einstein College of Medicine
Co-Director, Core Medicine 1 Clerkship Bronx, New York
Beth Israel Deaconess Medical Center
Harvard Medical School Mark C. Haigney, MD
Boston, Massachusetts Professor of Medicine
Director of Cardiology
Steven J. Durning, MD, FACP Uniformed Services University of the Health Sciences
Major, Medical Corps, US Air Force Bethesda, Maryland
Associate Professor of Medicine
Co-Director, Intro to Clinical Reasoning Course Charin L. Hanlon, MD, FACP
Uniformed Services University of the Health Sciences Assistant Professor of Internal Medicine
Bethesda, Maryland Clerkship Director, Internal Medicine
West Virginia University-Charleston Division
Richard S. Eisenstaedt, MD, FACP Charleston, West Virginia
Chair, Department of Medicine
Abington Memorial Hospital Warren Y. Hershman, MD
Professor of Medicine Director of Student Education
Temple University School of Medicine Department of Medicine
Philadelphia, Pennsylvania Boston University School of Medicine
Boston, Massachusetts
J. Michael Finley, DO, FACP, FACOI
Associate Professor and Chair of Medicine Mark D. Holden, MD, FACP
Department of Medicine Eagle’s Trace Medical Director
Western University College of Osteopathic Medicine Erickson Retirement Communities
Pomona, California Houston, Texas
Contributors • vii
Ivonne Z. Jiménez-Velázquez, MD, FACP Fred A. Lopez, MD, FACP
Professor and Vice-Chair for Education Associate Professor and Vice Chair
Geriatrics Program Director Department of Medicine
Clerkship Director, Internal Medicine Department Louisiana State University Health Sciences Center
University of Puerto Rico School of Medicine Assistant Dean for Student Affairs
San Juan, Puerto Rico LSU School of Medicine
New Orleans, Louisiana
Lawrence I. Kaplan, MD, FACP
Professor of Medicine Anna C. Maio, MD, FACP
Section Chief, General Internal Medicine Division Chief and Associate Professor
Internal Medicine Clerkship Director Division of General Internal Medicine
Temple University School of Medicine Department of Internal Medicine
Philadelphia, Pennsylvania Creighton University School of Medicine
Omaha, Nebraska
Asra R. Khan, MD
Assistant Professor of Clinical Medicine Brown J. McCallum, MD, FACP
Associate Program Director, Internal Medicine Assistant Professor
Residency Co-Clerkship Director
Medicine Clerkship Director Department of Internal Medicine
University of Illinois College of Medicine University of South Carolina School of Medicine
Chicago, Illinois Columbia, South Carolina
Sarang Kim, MD Kevin M. McKown, MD, FACP
Assistant Professor of Medicine Associate Professor of Medicine
Division of General Internal Medicine Co-Chief, Section of Rheumatology
University of Medicine and Dentistry of New Jersey Program Director, Rheumatology Fellowship
Robert Wood Johnson Medical School Co-Clerkship Director
New Brunswick, New Jersey Department of Medicine
University of Wisconsin School of Medicine and
Christopher A. Klipstein, MD Public Health
Clerkship Director of Internal Medicine Madison, Wisconsin
Associate Professor
Department of Medicine Melissa A. McNeil, MD, MPH
University of North Carolina School of Medicine Professor of Medicine and Obstetrics, Gynecology &
Chapel Hill, North Carolina Reproductive Sciences
Chief, Section of Women’s Health
Cynthia H. Ledford, MD Division of General Medicine
Clerkship Director of Internal Medicine University of Pittsburgh
Ohio State University College of Medicine Pittsburgh, Pennsylvania
Columbus, Ohio
Janet N. Myers, MD, FACP, FCCP
Bruce Leff, MD, FACP Associate Professor of Medicine
Associate Professor of Medicine Deputy Clerkship Director, Department of Medicine
Medicine Clerkship Director Uniformed Services University of the Health Sciences
Johns Hopkins University School of Medicine Bethesda, Maryland
Baltimore, Maryland
viii • Contributors
Kathryn A. Naus, MD Priya Radhakrishnan, MD
Chief Fellow, Section of Rheumatology Clinical Assistant Professor
Center of Excellence for Arthritis and Rheumatology University of Arizona College of Medicine
Health Sciences Center Clerkship Director and Associate Program Director
Louisiana State University School of Medicine Department of Internal Medicine
Shreveport, Louisiana St. Joseph Hospital & Medical Center
Phoenix, Arizona
Robert W. Neilson Jr., MD
Assistant Professor Joseph Rencic, MD, FACP
Clerkship Director Assistant Professor of Medicine
Department of Internal Medicine Clerkship Site Director, Associate Program Director
Division of General Internal Medicine Department of Internal Medicine
Texas Tech University Health Sciences Center Tufts-New England Medical Center
Lubbock, Texas Boston, Massachusetts
Katherine Nickerson, MD Kathleen F. Ryan, MD
Vice Chair Associate Professor of Medicine
Department of Medicine Clerkship Director
Associate Professor of Clinical Medicine Division of General Internal Medicine
Clerkship Director Department of Internal Medicine
Columbia University, P & S Drexel University College of Medicine
New York, New York Philadelphia, Pennsylvania
L. James Nixon, MD Brijen J. Shah, MD
Clerkship Director Chief Medical Resident, Department of Medicine
Division of General Internal Medicine Beth Israel Deaconess Medical Center
University of Minnesota Medical School Harvard Medical School
University of Minnesota Medical Center, Fairview Boston, Massachusetts
Minneapolis, Minnesota
Patricia Short, MD
Carlos Palacio, MD, MPH, FACP Major, Medical Corps, US Army
Clerkship Director Associate Professor and Associate Clerkship Director
Assistant Professor of Medicine Department of Medicine
University of Florida College of Medicine Uniformed Services University of the Health Sciences
Jacksonville, Florida Bethesda, Maryland
Madigan Army Medical Center
Hanah Polotsky, MD Tacoma, Washington
Assistant Professor of Medicine
Clerkship Director Diane C. Sliwka, MD
Montefiore Medical Center Instructor of Medicine
Albert Einstein College of Medicine Beth Israel Deaconess Medical Center
Bronx, New York Harvard Medical School
Boston, Massachusetts
Nora L. Porter, MD
Co-Director, Internal Medicine Clerkship
St. Louis University School of Medicine
St. Louis, Missouri
Contributors • ix
Harold M. Szerlip, MD, FACP, FCCP H. Douglas Walden, MD, MPH, FACP
Professor and Vice-Chairman Co-Director, Internal Medicine Clerkship
Department of Medicine St. Louis University School of Medicine
Medical College of Georgia St. Louis, Missouri
Augusta, Georgia
Joseph T. Wayne, MD, MPH, FACP
Gary Tabas, MD, FACP Associate Professor of Medicine
Associate Professor of Medicine Associate Professor of Pediatrics
University of Pittsburgh School of Medicine Clerkship Director, Internal Medicine
Pittsburgh, Pennsylvania Albany Medical College
Albany, New York
Tomoko Tanabe, MD, FACP
Assistant Professor of Medicine John Jason White, MD
Associate Clerkship Director Assistant Professor of Medicine
University of California, San Diego Nephrology Section
San Diego, California Department of Medicine
Medical College of Georgia
David C. Tompkins, MD Augusta, Georgia
Associate Chair
Department of Medicine Kevin D. Whittle, MD
SUNY Stony Brook Health Sciences Center Assistant Professor
Stony Brook, New York Third Year Clerkship Director, Internal Medicine
Sanford Medical School of the University of South
Dario M. Torre, MD, MPH, FACP Dakota
Clerkship Director Sioux Falls, South Dakota
Department of Medicine
Medical College of Wisconsin
Milwaukee, Wisconsin
Mark M. Udden, MD, FACP
Professor of Medicine
Department of Internal Medicine
Baylor College of Medicine
Houston, Texas
Contents
FOREWORD ..............................................................xv III Gastroenterology and Hepatology
ACKNOWLEDGMENTS ..............................................xvii
13 Approach to Abdominal Pain ............................57
Priya Radhakrishnan
I Cardiovascular Medicine 14 Approach to Diarrhea ......................................61
Sarang Kim
1 Approach to Chest Pain ......................................3 15 Diseases of the Gallbladder and Bile Ducts........64
Dario M. Torre Nora L. Porter
2 Chronic Stable Angina ........................................7 16 Acute Pancreatitis ............................................67
Anna C. Maio Nora L. Porter
3 Acute Coronary Syndrome................................11 17 Gastroesophageal Reflux Disease ......................70
Patrick C. Alguire Brown J. McCallum
4 Supraventricular Arrhythmias ............................15 18 Peptic Ulcer Disease ........................................72
Charin L. Hanlon Brown J. McCallum
5 Ventricular Arrhythmias ....................................20 19 Dyspepsia..........................................................74
Steven J. Durning and Mark C. Haigney Brown J. McCallum
6 Heart Failure ....................................................24 20 Approach to Gastrointestinal Bleeding ..............76
James L. Sebastian Warren Y. Hershman
7 Valvular Heart Disease ......................................28 21 Viral Hepatitis ..................................................80
H. Douglas Walden Carlos Palacio
22 Cirrhosis ..........................................................83
Mark J. Fagan
II Endocrinology and Metabolism 23 Inflammatory Bowel Disease ............................87
Brown J. McCallum
8 Diabetes Mellitus and Diabetic Ketoacidosis ....37
Erik K. Alexander
9 Dyslipidemia ....................................................41 IV General Internal Medicine
D. Michael Elnicki and Gary Tabas
10 Thryoid Disease................................................44 24 Test Interpretation............................................93
Erik K. Alexander D. Michael Elnicki
11 Adrenal Disease ................................................48 25 Health Promotion, Screening, and Prevention....96
Cynthia A. Burns L. James Nixon
12 Osteoporosis ....................................................52 26 Approach to Syncope......................................100
Melissa A. McNeil and Janine M. Frank Lawrence I. Kaplan
xi
