Netter’s internal medicine

1242 Pages·2009·167.06 MB·English

by  Greganti

Netter's Internal Medicine
2nd Edition
By Marschall S. Runge, MD, PhD, University of North Carolina at Chapel Hill School of
Medicine, Chapel Hill, NC, USA; and M. Andrew Greganti, MD, University of North Carolina
at Chapel Hill School of Medicine, Chapel Hill, NC, USA
I. Common Clinical Challenges
1. Practicing in the Modern Environment - Patient Safety, Medical Errors, Malpractice (NEW)
2. Screening - Health Promotion and Disease Prevention/Wellness Examination" (NEW)
3. Diagnostic Testing: The Example of Thromboembolism (PE/DVT)
4.Obesity
5. Evaluation and Treatment of Chronic Pain
6. Chronic Fatigue Syndrome
7.Poisoning and Drug Overdose
II. Disorders of the Upper RespiratoryTract and Oropharynx
8.Pharyngitis
9.Rhinosinusitis
10.Rhinitis:Allergic and Idiopathic
11.Common Oral Lesions (Title Change)
12.Acute Otitis Externa
13.Acute Otitis Media
14.Hoarseness
15. Vocal Cord Dysfunction (NEW)
16. Neck Masses in Adults
III. Disorders of the Respiratory System
17.Cough
18. Community-Acquired Pneumonia
19.Pleural Effusions and Pneumothorax
20. Asthma
21. Bronchitis: Acute and Chronic (NEW)
22.Chronic Obstructive Pulmonary Disease
23. Restrictive Lung Disease, Including Interstitial Lung Disease (NEW)
24.Environmental Lung Diseases (NEW)
IV. Disorders of the Cardiovascular System
25. Hypertension
26. Hypertension Secondary to Renovascular Diseases
27. Hypertension Secondary to Diseases of the Adrenal Gland
28. Angina Pectoris
29. Myocardial Infarction
30. Electrocardiography and Functional Testing (NEW)
31. Peripheral Vascular Disease
32. Congenital and Valvular Heart Disease
33. Cardiomyopathies (NEW)
34. Heart Failure
35. Hypercholesterolemia: Evaluation and Treatment
36. Cardiac Arrhythmias
37. Atrial Fibrillation (NEW)
38. Syncope (NEW)

V. Disorders of Endocrinology and Metabolism

39. Diabetes and PreDiabetes: Diagnosis and Treatment
40. Prevention and Treatment of complications of Diabetes
41. Hypothyroidism
42. Thyrotoxicosis
43. Hyperparathyroidism
44. Disorders of the Adrenal Cortex
45. Pituitary Diseases
46. Hirsutism
47. Hypogonadism in the Male
48. Osteoporosis
49. Paget 's Disease of Bone

VI. Disorders of the Gastrointestinal Tract

50. Gastroesophageal Reflux Disease
51. Peptic Ulcer Disease
52. Helicobacter Pylori Infection and Associated Disorders
53. Gastrointestinal Bleeding (NEW)
54. Cholelithiasis
55. Pancreatitis
56. Diarrhea: Acute and Chronic
57. Constipation
58. Common Anorectal Disorders and Colonic Diseases
59. Irritable Bowel Syndrome
60. Inflammatory Diseases of the GI Tract
61. Esophageal Disorders: Dysphagia (NEW)
62. Diseases of the Liver - Non-Alcoholic Fatty Liver Disease, Drug Induced Liver Diseases,
and Abnormal Liver Function Tests (NEW)
63. Viral Hepatitis: Acute and Chronic Disease
64. Cirrhosis
65. Celiac Disease

VII. Disorders of Coagulation and Thrombosis

66. Hypercoagulable States
67. Deep Venous Thrombosis and Pulmonary Embolism
68. Disseminated Intravascular Coagulation
69. Anticoagulation Management: Periprocedural, During Pregnancy, Supratherapeutic
Levels/Complications of Therapy (NEW)
70. Bleeding Disorders

VIII. Hematologic Disorders

71. Anemias
72. Bone Marrow Failure States
73. Blood Component Therapy
74. Malignant Lymphomas
75. Leukemias
76. Multiple Myeloma/Monoclonal Gammopathy of Unknown Significance (NEW)
77. Hematopoietic Stem Cell Transplantation

IX. Oncologic Disorders

78. Lung Cancer
79. Colorectal Cancer
80. Breast Cancer
81. Prostate Cancer
82. Upper Gastrointestinal Tract Cancer
83. Skin Cancer
84. Cancer of the Oral Cavity and Oropharynx
85. Cervical Neoplasia
86. Testicular Cancer (NEW)
87. Thyroid Cancer (NEW)
88. Palliative Care for Patients with Advanced Cancer

X. Infectious Diseases

89. Fever of Unknown Origin
90. Septicemia
91. Staphylococcal Infections
92. Cellulitis (NEW)
93. Endocarditis
94. Meningitis
95. Septic Arthritis (NEW)
96. Osteomyelitis (NEW)
97. Catheter Infections (NEW)
98. Influenza
99. Infectious Mononucleosis
100. Herpes Simplex Virus Infections
101. Varicella-Zoster Infections
102. Encephalitis (NEW)
103. Pulmonary Tuberculosis
104. Fungal Infections (NEW)
105. Parasitic Infections
106. Malaria
107. Infectious Diseases in Travelers

XI. Sexually Transmitted Diseases

108. Acquired Immune Deficiency Syndrome (AIDS)
109. Nongonococcal Urethritis and Mucopurulent Cervicitis
110. Gonorrhea
111. Pelvic Inflammatory Disease (NEW)
112. Genital Warts
113. Syphilis

XII. Disorders of the Reproductive System

114. Contraception (NEW)
115. Common Problems in Pregnancy
116. Diabetes in Pregnancy
117. Menstrual Disorders
118. Endometriosis
119. Menopause
120. Erectile Dysfunction

XIII. Neurologic Disorders

121. Disorders of Consciousness: Persistent Vegetative State, etc. (NEW)
122. The Radiculopathies: Cervical, Lumbar, Spinal Stenosis (NEW)
123. Peripheral Neuropathy
124. Migraine Headache
125. Stroke and Transient Ischemic Attacks
126. Vertigo
127. Sleep Disorders
128. Epilepsy
129. Tremor
130. Parkinson's Disease
131. Bell's Palsy
132. Trigeminal Neuralgia
133. Multiple Sclerosis
134. Myasthenia Gravis

XIV. Disorders of the Kidney and Urinary Tract

135. Urinary Tract Infection
136. Bladder Function Disorders
137. Microscopic Hematuria (NEW)
138. Urinary Stone Disease (Nephrolithiasis)
139. Chronic Kidney Disease
140. Acute Renal Failure
141. Glomerulonephritis
142. Nephrotic Syndrome

XV. Disorders of the Immune System, Connective Tissue and Joints

143. Osteoarthritis
144. Low Back Pain in Adults
145. Fibromyalgia/Regional Pain Syndromes (NEW)
146. Gout
147. Calcium Crystal Diseases
148. Autoinflammatory Syndromes (NEW)
149. Vasculitis
150. Polymyalgia Rheumatica and Giant Cell Arteritis
151. Systemic Lupus Erythematosus
152. Antiphospholipid Syndrome (NEW)
153. Rheumatoid Arthritis
154. Scleroderma
155. Spondyloarthropathies
156. Polymyositis and Dermatomyositis (NEW)

XVI. Ocular Diseases

157. Myopia and Common Refractive Disorders
158. Common Eye Diseases (NEW)
159. Glaucoma
160. Diabetic Retinopathy

XVII. Psychiatric Disorders

161. Personality Disorders (NEW)
162. Anxiety and Panic
163. Depression
164. Grief
165. Posttraumatic Stress Disorder (PTSD) (NEW)
166. Obsessive-Compulsive Disorders
167. Schizophrenia
168. Emotional and Behavioral Problems Among Adolescents and Young Adults
169. Alcohol and Substance Dependence and Abuse

XVIII. Disorders of the Skin

170. Urticaria
171. Eczema and Other Common Dermatoses
172. Contact Dermatitis (NEW)
173. Psoriasis
174. Bullous Skin Disease
175. Alopecia
176. Scabies and Pediculosis

XIX. Geriatric Medicine

177. Drug Therapy in the Elderly: Appropriate Prescribing for the Older Patient
178. Falls (NEW)
179. Hypertension in the Elderly
180. Delirium
181. Dementia
182. End of Life Decision Making (NEW)
1
Brian P. Goldstein • Lawrence K. Mandelkehr • Celeste M. Mayer
Practicing in the Modern
Environment: Improving
Outcomes and
Patient Safety
Introduction
In this fi rst decade of the 21st century, medicine in the United States remains a learned profession. Patients,
and the public at large, continue to hold doctors in relatively high regard. Physicians preside over an ever-
expanding array of diagnostic and therapeutic tools that are more targeted and therefore more successful,
and many tests and procedures are less invasive than those available in the past. In general, the care available
to individuals has never been more potentially powerful or more effi cacious.
At the same time, Americans have lately become much practice by the government, by payors and their customers
more conscious of practitioners’ imperfections, and they (employers), and by the public is here to stay.
are especially aware of the shortcomings of the system Before the mid-1990s, payors, policy makers, and the
that they must navigate to obtain care. The public now profession gave scant attention to the shortcomings of the
knows that the health care system often falls short of its health care system. To be sure, the U.S. tort system has
potential; that medical care sometimes causes avoidable long permitted compensation for individual victims of neg-
harms; and that the system includes wide variations in ligence. For a plaintiff to be compensated, a defendant
practice and cost without apparent differences in benefi t must be judged as failing to meet a standard of care and
to patients. Caregivers, and the organizations in which therefore blamed for “more likely than not” causing harm.
they practice, are increasingly tasked to demonstrate that Medicine weathers periodic crises of rising insurance pre-
their respective practices meet available standards and miums, and a few states have enacted reforms, but the U.S.
avoid potential harms. malpractice system remains fundamentally unchanged in
As doctors well know, we remain limited in our ability structure, and it has contributed little if anything to the
to collect valid and reliable data and to appropriately real evolution of the scrutiny of clinical practice.
compare different types of practice behaviors and different The attention to the quality and safety of medical care
types of patients. Just as important, reimbursement models is the result of several other trends. From roughly the
are fundamentally misaligned from the goals of optimizing 1960s to the 1980s, what we now call health services
performance and patient safety. Public and private pres- researchers gradually standardized the methods for evalu-
sures to change practice are, for now, modest, and physi- ating the structure of health care delivery models, the
cians will face these demands while continuing to cope processes of care delivery, and clinical outcomes. Advances
with others that at times will seem more pressing—such as in information technology have gradually brought the
billing regulations, staff shortages, and declining income. computing power to apply these methods for evaluating
Despite these additional pressures, scrutiny of physician care, processes, and outcomes. Federal support for the
3
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4 SECTION I (cid:2) Common Clinical Challenges
evaluation of medical practice was boosted by the creation measure. Process measures also avoid the complications of
in 1990 of the Agency for Health Care Policy and Research socioeconomic mix of the population and severity adjust-
(now the Agency for Health Research and Quality). Mean- ment. Hospital-based measures of outcomes tend to be
while, a multitude of groups—from employers who fund reported to discipline-specifi c or specialty-specifi c national
health insurance, to federal and state governments who databases, or as research fi ndings. Examples include the
also pay for an increasing share of health care, to managed Vermont-Oxford database for neonatal care, the Society
care insurers and coalitions of consumer groups—all have for Thoracic Surgeons database, and data sets collected by
steadily turned more of their attention to the quality of hospital-sponsored groups such as the University Health-
health care services and to the value of the services received System Consortium.
in proportion to their cost. Physician-specifi c measurement has been slower to take
Most recently, the medical profession has aggressively shape in the United States but is now emerging as another
(if somewhat belatedly) lent its voice to the need for sys- important component of the fi eld. CMS initiated in 2006
temic change in the way doctors, hospitals, and others a voluntary reporting system for a fi nite set of process
provide medical care. The Institute for Healthcare measures in the doctor’s offi ce. In December 2006, Presi-
Improvement (IHI) is a private not-for-profi t organization dent Bush signed the Tax Relief and Health Care Act of
founded in 1991 by a pediatrician, Donald Berwick, MD, 2006, mandating establishment of a physician quality
and has always included physicians in its leadership. IHI reporting system and authorizing a payment incentive (at
began as a lonely voice within the health care professions least initially). At this time, physician participation in the
advocating for fundamental changes in care delivery. Over CMS quality reporting initiative is still voluntary, but
the ensuing years, IHI has been joined by a growing chorus beginning in the second half of 2007, physicians who share
of voices from “offi cial” medicine, including many spe- data about their care of certain conditions will receive a
cialty societies, the American Medical Association, and the 1.5% fi nancial incentive from Medicare. Private insurers
Institute of Medicine (IOM). Indeed, the IOM’s serial have also initiated a few programs to encourage individual
reports on the fl aws and the potential for improvements to physicians to report data about their practice. An example
the health care system represent a watershed in both raising is the Bridges to Excellence program, which offers bonus
national consciousness about these matters and stimulating payments to doctors who meet standards for the care of
real movement toward change, both within the profession several chronic diseases. Efforts to more closely align pro-
and in public policy. vider payments with quality and safety measures remain
In this decade, widespread measurement of care has the exception but will continue to expand.
become a reality. The Joint Commission (TJC) has adopted Other important contributors to the movement toward
a broadening set of performance measures that hospitals transparency and accountability in the health care system
are required to collect and report. The data are posted to have focused less on tying performance to accreditation
a public website. The Centers for Medicare and Medicaid or payment, and more on emphasizing peer-stimulated
Services (CMS) has now joined TJC in this effort; as of and evidence-supported incremental change. A prominent
2005, hospitals that wish to receive their full annual infl a- example is the 2005 IHI 100,000 Lives Campaign. Partici-
tion update from CMS must report their performance pating hospitals (3,000 ultimately enrolled) and their
measures. CMS has proposed the long-anticipated conver- medical staff volunteered to commit resources to imple-
sion of its program from “pay for accurate reporting” to ment a series of practices that the medical literature has
“pay for performance,” with some fraction of a hospital’s unequivocally shown will reduce in-hospital deaths. The
payments adjusted according to its success in improving IHI evidence suggests that most hospitals were successful
care as determined by these measures. The Leapfrog in improving clinical outcomes and safety in one or more
Group, a consortium of large employers founded in 1998 of the six suggested interventions. Most participants con-
to press for changes in health care delivery, has its own tinue to work on these interventions. In December 2006,
scorecard to track hospitals’ performance. Participation in the IHI launched a new drive to reduce avoidable morbid-
the Leapfrog survey is voluntary, but payors and the public ity in hospitalized patients. Another organization, the
increasingly look to this data set for information about National Quality Forum (NQF), has focused on creating,
hospital performance. The Leapfrog and the TJC/CMS codifying, and disseminating standards of clinical practice
instruments measure processes (e.g., whether a hospital that represent the best clinical evidence (and expert con-
ensured that an aspirin was prescribed after an acute myo- sensus). The NQF serves a valuable function by accelerat-
cardial infarction) as opposed to clinical outcomes (e.g., the ing the endorsement of consensus-based national standards
proportion of patients with a prior acute myocardial infarc- for measurement and public reporting of data about spe-
tion who have a second heart attack). Process measures cifi c clinical diagnostic and therapeutic interventions.
tend to be easier to track because they typically represent Other groups, such as Leapfrog, TJC, CMS, and specialty
a behavior that is occurring at a snapshot in time, whereas societies, can adopt these standards rather than having to
outcomes may take much longer to assess. It is also easier create their own and can thereby focus on helping pro-
to achieve expert consensus on the validity of a process viders to improve care.
Ch001-X4417.indd 4 2/14/2008 6:11:44 PM
1 (cid:2) Practicing in the Modern Environment 5
Although the ultimate impact of the initiatives outlined This fi rst report of the Committee on the Quality of Health Care in
on the quality of care rendered to individual patients America is the source of the oft-quoted fi gure of “98,000 deaths from medical
errors each year.” This fi gure is based on scant data, but the assertion drew
remains to be established, few can dispute that the central
attention to the remainder of this document, which focuses on all parties’
goal of improving our health care delivery system is worth
obligation to prevent and mitigate harm in the course of trying to do good for
any effort required. The hesitancy of some providers to patients.
embrace and participate in quality-enhancing initiatives National Quality Forum. Available at: http://www.qualityforum.org.
often refl ects the time constraints of a busy clinical practice Accessed February 4, 2007.
The NQF has evolved as the best developer of consensus standards for
rather than a lack of interest. To deal with the realities of
medical care. Expect its publications to continue to serve as the basis for P4P
the modern time- and resource-constrained clinical prac-
programs and Joint Commission goals.
tice environment, policymakers must acknowledge the U.S. Department of Health and Human Services, Centers for Medicare
need for clinicians to have more infrastructure support to and Medicaid Services: Physician Voluntary Reporting Program.
comply with new guidelines. In many cases, that will Available at: http://www.cms.hhs.gov/PQRI. Accessed February 4,
2007.
require an increase in hospital and professional fees to
This website reviews the requirements, expectations, and general organiza-
cover the additional overhead costs.
tion of this program.
EVIDENCE
Additional Resources
1. Committee on Quality of Health Care in America, Institute of
Donabedian A: Evaluating the quality of medical care. Milbank Mem Medicine: Crossing the Quality Chasm: A New Health System for
Fund Q 44:166-206, 1966. the 21st Century. Washington, DC, National Academy Press,
This article provides a good general review. 2001.
Donabedian A: Explorations in Quality Assessment and Monitoring, An excellent summary of the state of the health care system at the start
vols I-III. Ann Arbor, MI, Health Administration Press, 1980, 1985. of this century, and still the defi nitive consensus summary of the funda-
This text is considered the “bible” of the preferred methodologic approach mental changes that physicians and health care organizations can make
for health services research. to improve care. The document’s Six Aims for Improvement are the most
Institute for Healthcare Improvement. Available at: http://www.ihi.org. widely cited defi nition of quality: health care should be safe, effective,
Accessed February 4, 2007. patient centered, timely, effi cient, and equitable.
The IHI’s website is an excellent source of information about U.S. and 2. U.S. Department of Health and Human Services: Hospital
international care improvement activities. Some areas of the site are for Compare—A quality tool for adults, including people with Medi-
members only, and some publications are available for sale, but a great deal care. Available at: http://www.hospitalcompare.hhs.gov/. Accessed
of the information is free and available. February 4, 2007.
Kohn LT, Corrigan JM, Donaldson MS (eds), for the Committee on This consumer-friendly website provides data submitted by more than
Quality of Health Care in America, Institute of Medicine: To Err is 90% of U.S. hospitals, allowing the viewer to make comparisons among
Human: Building a Safer Health System. Washington, DC, National these hospitals.
Academy Press, 2000.
Ch001-X4417.indd 5 2/14/2008 6:11:44 PM