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Netter’s internal medicine PDF

1242 Pages·2009·167.06 MB·English
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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 Ch001-X4417.indd 3 2/14/2008 6:11:43 PM 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

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