Board Basics 3 - An Enhancement to MKSAP

An Enhancement to MKSAP

®

What’s Inside:

• Don’t Be Tricked: Incorrect answers that may masquerade as correct choices

• Test Yourself: Abbreviated case histories found in Board exam questions, providing “word association” links to the correct answers

• Study Tables: Key associations that tie concepts together to prepare you for related questions

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E n h a n c e m e n t

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M K S A P

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Essential Facts and Strategies for Passing the Internal Medicine Certification and Maintenance of Certification Examinations

Plus other vital information to help you pass the Boards Download the Board Basics 3 app Go to http://mksap.acponline.org/bb3 and download the Board Basics 3 app for iPads, Android-based tablets, Macs, PCs, iPhones, and Android-based smart phones.

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9 781938 245138

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ISBN 978-1-938245-13-8

9/27/12 1:59 PM

Your Last Stop before the Boards For the third consecutive edition of MKSAP, we bring you Board Basics, the only publication that compiles the essential facts and strategies for passing the Internal Medicine Certification and Maintenance of Certification (MOC) Exam into one book and digital application. (You can access the app at http://mksap.acponline.org/16/apps.) We are confident that this volume will meet your needs. A total of 84% of surveyed Board Basics 2 users told us that Board Basics 2 effectively helped them prepare for the Certification or MOC exams. As many as 97% found this resource to be user-friendly and three quarters said they would recommend it to a colleague.

How to Use Board Basics 3 The goal of this enhancement to MKSAP 16 is to prepare you for the Boards after you have completed a systematic review of MKSAP 16 and its more than 1200 multiplechoice questions. Once again, we have combed through volumes to produce a concise compilation of only the information that you will most likely see in the exam.

Our intention has not been to create a concise guide to patient care but to develop an exam preparation tool to help you quickly recognize the most likely answers on a multiplechoice exam. Drug dosages are not included since they are rarely, if ever, tested. You will also see many sections where information has been omitted because the omitted material is difficult to test or is otherwise unlikely to appear on the exam.

Broad differential diagnoses are not provided for most problems. Instead, Board Basics focuses on the entities that have the highest probability of appearing on the exam as the “correct answers.” Critical points that appear on the exam are often presented here in isolation, stripped of context that is not relevant to answering a multiple-choice question. If you review these points shortly before your exam, you will have the best chance of remembering what you need to know to do well. Knowing that most Board questions are prefaced with the words “most likely,” we have tried to be very directive, skipping important steps in the patient evaluation. When you see the words “select” or “choose,” think in terms of selecting or choosing a particular answer, not an intervention in the practice of medicine. Remember that board Basics is not a patient care resource.

Content Organization Abbreviations, spelled out in a convenient list at the back of the book, are used frequently to increase reading efficiency.

Content is organized by topic and in consistent categories, such as Prevention, Screening, Diagnosis, and Therapy.

Special components have been designed to enhance learning and recall. Look for: • Don’t Be Tricked: Incorrect answers that may masquerade as correct choices.

• Test Yourself: Abbreviated case histories and answers found in Board exam questions.

• Study Tables: Key concepts to prepare you for specific types of questions.

• Yellow highlighting: We applied our own “marker” to call your attention to important phrases.

Why This Text Makes Sense For Board Basics 3, MKSAP 16 authors reviewed the latest literature and produced a concise syllabus and 1200-plus Board-like multiple-choice questions. Next, the content was turned over to 13 carefully selected chief residents, fellows, instructors, and professors of medicine who have expertise in Board preparation and the subspecialties of internal medicine. These physicians strained the essential points from MKSAP 16 and added their insights to update the content of Board Basics. Board Basics 3 editors also added information requested by readers of the second edition. Insights gleaned from ACP’s Internal Medicine In-Training Examination were also added.

Board Basics includes core information to supplement MKSAP 16, information that is likely testable material for board examinations. Joining me in this effort were Associate Editors Edward R. Bollard, MD, DDS, FACP, of the Penn State College of Medicine, and Joyce E. Wipf, MD, FACP, of the University of Washington.

Patrick Alguire, MD, FACP, Senior Vice President of the Medical Education Division of the American College of Physicians and Editor-in-Chief of MKSAP 16, pulled all of the content together, eliminating overlap and excessive material to focus the text as sharply as possible. The end product is what you have in your hands—the best Board prep tool that you will find anywhere. We hope you enjoy it and benefit from your study. Best wishes on your exam.

Douglas S. Paauw, MD, MACP Editor Board Basics

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Table of Contents

Allergy Allergic Rhinitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Urticaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Angioedema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Food Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Drug Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Immunodeficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Complement Deficiency . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Cardiovascular Medicine Acute Coronary Syndromes . . . . . . . . . . . . . . . . . . . . . . . 10 Chronic Stable Angina . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Heart Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Heart Failure with Preserved Ejection Fraction . . . . . . . . 17 Dilated Cardiomyopathy . . . . . . . . . . . . . . . . . . . . . . . . . 18 Peripartum Cardiomyopathy . . . . . . . . . . . . . . . . . . . . . . 19 Hypertrophic Cardiomyopathy . . . . . . . . . . . . . . . . . . . . 19 Restrictive Cardiomyopathy . . . . . . . . . . . . . . . . . . . . . . . 21 Pericardial Tamponade and Constriction . . . . . . . . . . . . . 22 Acute Pericarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Rheumatic Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Heart Murmurs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Aortic Stenosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Aortic Regurgitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Mitral Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Mitral Regurgitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Mitral Valve Prolapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Tricuspid Regurgitation . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Prosthetic Heart Valves . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Atrial Septal Defect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Ventricular Septal Defect . . . . . . . . . . . . . . . . . . . . . . . . . 33 Arrhythmia Recording . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Atrial Fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Atrial Flutter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Supraventricular Tachycardia . . . . . . . . . . . . . . . . . . . . . . 36 Wolff-Parkinson-White Syndrome . . . . . . . . . . . . . . . . . . 39 Heart Block. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Ventricular Tachycardia . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Sudden Cardiac Death . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Aortic Atheroemboli . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Coarctation of the Aorta . . . . . . . . . . . . . . . . . . . . . . . . . 47 Thoracic Aortic Aneurysm and Dissection . . . . . . . . . . . . 47

Abdominal Aortic Aneurysm . . . . . . . . . . . . . . . . . . . . . . 48 Peripheral Arterial Disease . . . . . . . . . . . . . . . . . . . . . . . . 49 Preoperative Cardiac Risk Assessment . . . . . . . . . . . . . . . 50

Dermatology Cellulitis and Soft Tissue Infection . . . . . . . . . . . . . . . . . . 52 Dermatophyte and Yeast Infections . . . . . . . . . . . . . . . . . 54 Pityriasis Rosea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Scabies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Leishmaniasis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Herpes Zoster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Eczemas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Acne and Rosacea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Pemphigus Vulgaris and Pemphigoid . . . . . . . . . . . . . . . . 63 Molluscum Contagiosum. . . . . . . . . . . . . . . . . . . . . . . . . 64 Warts (Verruca Vulgaris) . . . . . . . . . . . . . . . . . . . . . . . . . 65 Seborrheic Keratosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Actinic Keratosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Squamous Cell Carcinoma. . . . . . . . . . . . . . . . . . . . . . . . 66 Basal Cell Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Dysplastic Nevi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Melanoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Erythema Multiforme . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Dermatologic Signs of Systemic Disease. . . . . . . . . . . . . . 69

Endocrinology and Metabolism Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Hyperglycemic Hyperosmolar Syndrome . . . . . . . . . . . . . 75 Diabetic Ketoacidosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Diabetes Care for Hospitalized Patients . . . . . . . . . . . . . . 76 Pregnancy and Diabetes Screening. . . . . . . . . . . . . . . . . . 76 Hypoglycemia in Patients Without Diabetes . . . . . . . . . . 77 Hyperlipidemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Hyperthyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Hypothyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Thyroid Nodules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Pituitary Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Hypopituitarism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Diabetes Insipidus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Hyperparathyroidism and Hypercalcemia . . . . . . . . . . . . . 88 Hypocalcemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Osteomalacia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 ix

Paget Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Hypercortisolism (Cushing Syndrome) . . . . . . . . . . . . . . 92 Hypoadrenalism (Addison Disease) . . . . . . . . . . . . . . . . . 93 Adrenal Incidentaloma. . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Pheochromocytoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Primary Hyperaldosteronism . . . . . . . . . . . . . . . . . . . . . . 95 Male Hypogonadism . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

Gastroenterology and Hepatology Dysphagia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Achalasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 GERD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Esophagitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Nonulcer Dyspepsia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Peptic Ulcer Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Gastroparesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Celiac Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Malabsorption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Acute Pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Chronic Pancreatitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Differentiating Cholestatic and Hepatocellular Diseases . . 105 Gallstones, Acute Cholecystitis, and Cholangitis. . . . . . . 105 Hepatitis A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Hepatitis B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Hepatitis C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Hemochromatosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Autoimmune Hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . 110 Primary Biliary Cirrhosis . . . . . . . . . . . . . . . . . . . . . . . . 110 Primary Sclerosing Cholangitis. . . . . . . . . . . . . . . . . . . . 111 Alcoholic Hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Nonalcoholic Steatohepatitis . . . . . . . . . . . . . . . . . . . . . 112 Acute Liver Injury and Acute Liver Failure. . . . . . . . . . . 113 Cirrhosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Liver Disease Associated with Pregnancy . . . . . . . . . . . . 116 Irritable Bowel Syndrome . . . . . . . . . . . . . . . . . . . . . . . 116 Inflammatory Bowel Disease . . . . . . . . . . . . . . . . . . . . . 117 Diverticular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Mesenteric Ischemia and Ischemic Colitis . . . . . . . . . . . 119 Acute Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Traveler’s Diarrhea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 C. difficile Antibiotic-Associated Diarrhea . . . . . . . . . . . 121 Amebiasis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Chronic Diarrhea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Upper GI Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Lower GI Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Bleeding of Obscure Origin . . . . . . . . . . . . . . . . . . . . . . 124

General Internal Medicine Biostatistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 x

Screening and Prevention . . . . . . . . . . . . . . . . . . . . . . . 128 Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Involuntary Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . 131 Pressure Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Hypertension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Syncope. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Falls. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Chronic Cough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Pharyngitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 Sinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 Hearing Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 External Otitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 Red Eye. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 Chronic Fatigue. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 Benign Prostatic Hyperplasia . . . . . . . . . . . . . . . . . . . . . 143 Acute Prostatitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 Male Sexual Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . 144 Acute Scrotal Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 Medical Ethics and Professionalism . . . . . . . . . . . . . . . . 145 Patient Safety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146

Hematology Aplastic Anemia, Pure Red Cell Aplasia, and Paroxysmal Nocturnal Hemoglobinuria. . . . . . . . . . 148 Normocytic Anemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Microcytic Anemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 Macrocytic Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Hemolytic Anemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Sickle Cell Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Thalassemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Thrombocytopenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 Thrombocytopenia in Pregnancy . . . . . . . . . . . . . . . . . . 157 Thrombotic Thrombocytopenic Purpura–Hemolytic Uremic Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 HIT and HITT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 Approach to Bleeding Disorders . . . . . . . . . . . . . . . . . . 159 Common Acquired Bleeding Disorders . . . . . . . . . . . . . 159 Hemophilia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 von Willebrand Disease . . . . . . . . . . . . . . . . . . . . . . . . . 160 Transfusion Medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Thrombophilia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 Multiple Myeloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 Chronic Myeloid Leukemia . . . . . . . . . . . . . . . . . . . . . . 164 Essential Thrombocythemia. . . . . . . . . . . . . . . . . . . . . . 165 Polycythemia Vera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 Myelofibrosis with Myeloid Metaplasia. . . . . . . . . . . . . . 167 Myelodysplastic Syndromes . . . . . . . . . . . . . . . . . . . . . . 167 Chronic Lymphocytic Leukemia . . . . . . . . . . . . . . . . . . 168 Hairy Cell Leukemia . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

Acute Lymphoblastic Leukemia/Lymphoma. . . . . . . . . 169 Acute Myeloid Leukemia . . . . . . . . . . . . . . . . . . . . . . . . 169

Infectious Disease Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 Sepsis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 Toxic Shock Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . 173 Catheter-Associated UTIs . . . . . . . . . . . . . . . . . . . . . . . 173 Hospital-Acquired and Ventilator-Associated Pneumonia . . 174 Clostridium difficile Antibiotic-Associated Diarrhea . . . 175 Catheter-Related Intravascular Infections . . . . . . . . . . . . 175 Smallpox and Varicella . . . . . . . . . . . . . . . . . . . . . . . . . . 176 Infective Endocarditis . . . . . . . . . . . . . . . . . . . . . . . . . . 177 Epstein-Barr Virus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 Influenza Virus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 Community-Acquired Pneumonia . . . . . . . . . . . . . . . . . 181 Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 Pneumocystis jirovecii Pneumonia . . . . . . . . . . . . . . . . . 185 Anthrax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 Botulism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 Rocky Mountain Spotted Fever . . . . . . . . . . . . . . . . . . . 187 Leptospirosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 Malaria and Babesiosis . . . . . . . . . . . . . . . . . . . . . . . . . . 187 Ehrlichiosis and Anaplasmosis . . . . . . . . . . . . . . . . . . . . 188 Osteomyelitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 Cystitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190 Pyelonephritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 Neisseria gonorrhoeae Infection . . . . . . . . . . . . . . . . . . . 192 Syphilis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 Herpes Simplex Virus Infection . . . . . . . . . . . . . . . . . . . 194 HIV Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196 Toxoplasmosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198 Candida Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199 Aspergillosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200 Cryptococcal Infection. . . . . . . . . . . . . . . . . . . . . . . . . . 200 Endemic Mycosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 Posttransplantation Infections . . . . . . . . . . . . . . . . . . . . 201

Nephrology Glomerular Filtration Rate. . . . . . . . . . . . . . . . . . . . . . . 203 Urinalysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 Alcohol Poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206 Hyponatremia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207 Hypernatremia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208 Hyperkalemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208 Hypokalemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209 Hypomagnesemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209 Hypophosphatemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210 Acute Kidney Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . 211 Chronic Kidney Disease . . . . . . . . . . . . . . . . . . . . . . . . . 213

Nephrotic Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 Nephritic Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . 216 Glomerulonephritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216 Pulmonary-Renal Syndromes. . . . . . . . . . . . . . . . . . . . . 218 Renal-Dermal Syndromes . . . . . . . . . . . . . . . . . . . . . . . 219 Renal Tubular Acidosis . . . . . . . . . . . . . . . . . . . . . . . . . 219 Nephrolithiasis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220 Autosomal-Dominant Polycystic Kidney Disease . . . . . . 221

Neurology Ischemic Stroke and Transient Ischemic Attack . . . . . . . 222 Subarachnoid Hemorrhage . . . . . . . . . . . . . . . . . . . . . . 224 Intracerebral Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . 225 Dementia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226 Delirium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227 Myelopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228 Multiple Sclerosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228 Amyotrophic Lateral Sclerosis . . . . . . . . . . . . . . . . . . . . 229 Parkinson Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230 Hyperkinetic Movement Disorders . . . . . . . . . . . . . . . . 231 Migraine Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231 Epilepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233 Peripheral Neuropathy. . . . . . . . . . . . . . . . . . . . . . . . . . 235 Myasthenia Gravis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236 Vertigo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236 Viral Encephalitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237 Meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238 Metastatic Brain Tumors . . . . . . . . . . . . . . . . . . . . . . . . 239 Meningioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240 Coma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240

Oncology Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242 Cervical Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243 Endometrial Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . 244 Ovarian Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244 Prostate Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245 Testicular Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247 Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248 Hepatocellular Carcinoma . . . . . . . . . . . . . . . . . . . . . . . 250 Gastric Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250 Carcinoid Tumor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251 Lung Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251 Pancreatic Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253 Renal Cell Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . 254 Thyroid Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255 Hodgkin Lymphoma. . . . . . . . . . . . . . . . . . . . . . . . . . . 256 Non-Hodgkin Lymphoma. . . . . . . . . . . . . . . . . . . . . . . 257 Carcinoma of Unknown Primary Origin . . . . . . . . . . . . 258 Cancers of Infectious Origin . . . . . . . . . . . . . . . . . . . . . 259 xi

Febrile Neutropenia. . . . . . . . . . . . . . . . . . . . . . . . . . . . 260 Cancer Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . 261 Effects of Cancer Therapy . . . . . . . . . . . . . . . . . . . . . . . 263 Palliative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263 Cancer Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263

Carbon Monoxide Poisoning. . . . . . . . . . . . . . . . . . . . . 300 Poisoning with Therapeutic Agents . . . . . . . . . . . . . . . . 301 Hyperthermia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301 Nutritional Support During Critical Illness. . . . . . . . . . . 302 Critical Illness Neuropathy. . . . . . . . . . . . . . . . . . . . . . . 302

Psychiatry

Rheumatology

Alcohol Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265 Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267 Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267 Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269 Generalized Anxiety Disorder . . . . . . . . . . . . . . . . . . . . 270 Panic Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270 Posttraumatic Stress Disorder. . . . . . . . . . . . . . . . . . . . . 270 Social Anxiety Disorder . . . . . . . . . . . . . . . . . . . . . . . . . 271 Obsessive-Compulsive Disorder . . . . . . . . . . . . . . . . . . . 271 Borderline Personality Disorder . . . . . . . . . . . . . . . . . . . 271 Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272 Somatoform Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . 272 Autism Spectrum Disorders . . . . . . . . . . . . . . . . . . . . . . 273 Attention-Deficit/Hyperactivity Disorder . . . . . . . . . . . 273

Septic Arthritis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303 Lyme Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304 Osteoarthritis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305 Rheumatoid Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . 307 SjĂśgren Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309 Spondyloarthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310 Gout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313 Calcium Pyrophosphate Deposition Disease. . . . . . . . . . 314 Hypertrophic Osteoarthropathy. . . . . . . . . . . . . . . . . . . 315 Systemic Lupus Erythematosus . . . . . . . . . . . . . . . . . . . 315 Systemic Sclerosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317 Idiopathic Inflammatory Myopathies . . . . . . . . . . . . . . . 318 Vasculitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320 Relapsing Polychondritis . . . . . . . . . . . . . . . . . . . . . . . . 321 Regional Pain Syndromes. . . . . . . . . . . . . . . . . . . . . . . . 322 Complex Regional Pain Syndrome. . . . . . . . . . . . . . . . . 325 Familial Mediterranean Fever . . . . . . . . . . . . . . . . . . . . . 326 Adult-Onset Still Disease . . . . . . . . . . . . . . . . . . . . . . . . 326 Serologic Studies in Rheumatologic Disorders . . . . . . . . 327

Pulmonary and Critical Care Medicine Pulmonary Function Tests . . . . . . . . . . . . . . . . . . . . . . . 274 Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275 Occupational Asthma and Reactive Airways Dysfunction Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . 278 Chronic Obstructive Pulmonary Disease . . . . . . . . . . . . 278 Cystic Fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280 Pleurisy and Pleural Effusion . . . . . . . . . . . . . . . . . . . . . 281 Pneumothorax. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282 Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283 Obstructive Sleep Apnea . . . . . . . . . . . . . . . . . . . . . . . . 284 Solitary Pulmonary Nodule . . . . . . . . . . . . . . . . . . . . . . 285 Hemoptysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286 Pulmonary Arteriovenous Malformation . . . . . . . . . . . . 286 Sarcoidosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287 Idiopathic Pulmonary Fibrosis . . . . . . . . . . . . . . . . . . . . 288 Asbestos-Associated Lung Diseases . . . . . . . . . . . . . . . . 290 Mountain Sickness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291 Chronic Hypercapnic Respiratory Failure. . . . . . . . . . . . 291 Acute Respiratory Distress Syndrome. . . . . . . . . . . . . . . 292 Preoperative Pulmonary Assessment. . . . . . . . . . . . . . . . 293 Noninvasive Positive-Pressure Ventilation. . . . . . . . . . . . 294 Mechanical Ventilation. . . . . . . . . . . . . . . . . . . . . . . . . . 294 Venous Thromboembolic Disease . . . . . . . . . . . . . . . . . 296 Pulmonary Hypertension. . . . . . . . . . . . . . . . . . . . . . . . 298 Organophosphate Poisoning . . . . . . . . . . . . . . . . . . . . . 299

xii

Women’s Health Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328 Cervical Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328 Vaginitis and Cervicitis. . . . . . . . . . . . . . . . . . . . . . . . . . 329 Genital Herpes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330 Pelvic Inflammatory Disease . . . . . . . . . . . . . . . . . . . . . 331 Primary Amenorrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . 332 Secondary Amenorrhea . . . . . . . . . . . . . . . . . . . . . . . . . 332 Polycystic Ovary Syndrome . . . . . . . . . . . . . . . . . . . . . . 333 Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334 Abnormal Uterine Bleeding . . . . . . . . . . . . . . . . . . . . . . 334 Premenstrual Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . 335 Menopause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335 Primary Dysmenorrhea . . . . . . . . . . . . . . . . . . . . . . . . . 335 Endometriosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336 Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336 Urinary Incontinence. . . . . . . . . . . . . . . . . . . . . . . . . . . 338 Domestic Violence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339 Breast Lump . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340 Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341 Gestational Diabetes Mellitus. . . . . . . . . . . . . . . . . . . . . 341

Allergy Allergic Rhinitis Diagnosis Rhinitis is an inflammation of the nasal mucosal membranes that causes rhinorrhea, nasal itching, sneezing, nasal congestion, and postnasal drainage.

Allergic rhinitis can be seasonal or perennial. Diagnosis of allergic rhinitis is usually made by history and confirmed with empiric treatment. If empiric treatment fails, diagnostic allergy testing may be appropriate to guide allergen avoidance or immunotherapy. In this setting, allergy skin testing is preferred to in vitro specific IgE antibody assay (or RAST).

Other causes of rhinitis include acute viral infections, pregnancy, hypothyroidism, atrophic rhinitis (occurring in elderly patients), Îą-blockers, mechanical obstruction (nasal septal deviation, nasal polyps), and rhinitis medicamentosa. Chronic nonallergic rhinitis (vasomotor rhinitis) is described as a syndrome of sneezing, rhinorrhea, congestion, or postnasal discharge in the absence of an identified cause. Chronic nonallergic rhinitis generally has a later age of onset than allergic rhinitis, with perennial symptoms that are often exacerbated by weather and irritants rather than allergens.

In allergic rhinitis, the nasal mucosa is edematous and pale. Select CT for cases of persistent or refractory rhinitis.

S T U D Y T A B L E : Mimics of Allergic Rhinitis

Look for‌

Diagnose‌

Systemic illness with saddle nose deformity, nasal ulceration, or chronic sinusitis

ranulomatosis with polyarteritis (Wegener G granulomatosis)

Young person, nasal polyposis, chronic sinusitis, malnourishment, infertility, and chronic or recurrent bronchitis

Cystic fibrosis

Nonseasonal rhinitis with negative skin tests

Chronic nonallergic rhinitis (vasomotor rhinitis)

Refractory congestion after chronic use of topical nasal decongestants

Rhinitis medicamentosa

Nasal congestion in the last 6 or more weeks of pregnancy

Pregnancy rhinitis

Rhinitis, nasal polyps, asthma, and aspirin intolerance (respiratory symptoms)

Aspirin sensitivity (triad asthma or Samter syndrome)

Therapy Therapy includes the select removal of pets, animals, and carpet; allergy encasements for bedding; and small-particle filters for air conditioning. Most patients will require the addition of pharmacotherapy or immunotherapy. Intranasal corticosteroids are used as first-line therapy. The following can be used as second-line agents: intranasal antihistamines, oral combination antihistamines/decongestants, oral montelukast, or intranasal cromolyn. Ipratropium bromide is effective for severe rhinorrhea.

Choose skin testing and allergen immunotherapy if symptoms are not well controlled by intranasal corticosteroids with supplemental antihistamines or decongestants.

The most consistently effective treatments for chronic nonallergic rhinitis are topical intranasal corticosteroids, topical intranasal antihistamines, and topical ipratropium bromide. Patients with chronic rhinitis, nasal polyps, asthma, and aspirin intolerance may improve following aspirin desensitization.

1

Allergy

u DON’T

BE TRICKED

• Do not select antibiotics for URI-related rhinitis, because such therapy does not reduce symptoms compared with placebo but significantly increases the risk of adverse events.

• Do not refer patients with allergic rhinitis for skin testing/immunotherapy without a trial of empiric therapy.

v Test Yourself For the past 2 months, a 30-year-old man has had nasal congestion that began with rhinorrhea, coughing, and sore throat. His only medication is oxymetazoline nasal spray BID. ANSWER: The diagnosis is rhinitis medicamentosa. Stop the topical decongestant and select a short course of prednisone or intranasal corticosteroid.

Urticaria Diagnosis The hallmark of urticaria (hives) is the wheal, a superficial itchy swelling of the skin. Wheals involving the skin around the mouth are considered an emergency, requiring careful observation and investigation for airway obstruction. Concomitant angioedema and urticaria occur in 40% of patients, with another 40% experiencing urticaria alone and 20% developing angioedema but no urticaria.

Acute urticaria lasts less than 24 hours but may recur. β-Lactams, sulfonamides, NSAIDs, opioids, insect stings, contrast dyes, latex (including condoms), nuts, fish, and eggs are common causes. Urticaria can also be initiated by pressure, cold, heat, vibration, water, or sunlight. Chronic urticaria is defined as having symptoms most days for >6 weeks.

Evaluate most patients with chronic urticaria with a CBC, ESR or CRP, and TSH (higher incidence of hypothyroidism).

Lesions persisting >24 hours with purpura/ecchymoses upon resolution are likely due to urticarial vasculitis. In this situation, definitive diagnosis is made by skin biopsy. If urticaria is associated with a travel history and prominent eosinophilia, select parasitic infection.

u DON’T

BE TRICKED

• Do not select ANA testing for acute or chronic urticaria.

ST U D Y T A B L E : Differential Diagnosis of Urticaria

If you see this…

Select this…

↑ESR, ↑CRP, lesions persisting >24 hours

asculitic urticaria; perform skin biopsy and obtain serum V complement levels, hepatitis B and C serology, cryoglobulins, and serum protein electrophoresis.

Fever, adenopathy, arthralgias, and antigen or drug exposure

Serum sickness; measure IgE level (elevated).

Features of anaphylaxis, obvious allergen exposure

I mmediate hypersensitivity reaction; treat emergently with epinephrine, corticosteroids, and antihistamines.

Marked eosinophilia

arasitic infection, possibly strongyloidiasis, filariasis, or P trichinosis (especially with periorbital edema).

Therapy Avoid aspirin and other NSAIDs. Select nonsedating antihistamines as first-line therapy. If no response is seen, add an H2-blocker (cimetidine, ranitidine), although evidence for effectiveness is mixed. Doxepin blocks H1, H2, and serotonin receptors and is often effective. Short-term oral corticosteroids are indicated in very symptomatic patients with acute urticaria. Patients who have chronic autoimmune urticaria may require methotrexate, azathioprine, or cyclosporine.

2

Allergy

u DON’T

BE TRICKED

• Systemic and topical corticosteroids are not beneficial for patients with chronic urticaria.

• Measurement of C1 inhibitor levels is not indicated in patients with urticaria, because deficiency of C1 inhibitor is associated with angioedema, not with hives.

v Test Yourself A 31-year-old man has a 2-week history of hives. Individual lesions persist for less than 24 hours and are not worsened by cold, sunlight, or pressure. He has been taking diphenhydramine without relief.

ANSWER: The diagnosis is acute urticaria. Additional diagnostic studies are not indicated. Add an H2 blocker.

Urticaria: Urticaria is characterized by small white, pink, or flesh-colored pruritic papules.

Angioedema Diagnosis Angioedema is characterized by a sudden, temporary edema of a localized area of skin or mucosa, usually the lips, face, hands, feet, penis, or scrotum. Abdominal pain may be present owing to bowel wall edema.

Mast cell–mediated angioedema is often associated with urticaria, bronchospasm, or hypotension. This can be due to allergic reaction (peanuts, shrimp, latex, or insect stings) or to direct mast cell stimulation (NSAIDs, radiocontrast media, or opiates).

Bradykinin-mediated angioedema is NOT associated with urticaria. In the setting of angioedema without urticaria, consider a limited differential diagnosis.

S T U D Y T A B L E : Differential Diagnosis of Bradykinin-Mediated Angioedema

Condition

Historical Clues/Disease Associations

Laboratory Studies

Hereditary angioedema

Family history of angioedema

Low C1 inhibitor and C4 levels

Acquired C1 inhibitor deficiency

Lymphoma, MGUS, or SLE

L ow C1q levels (in addition to low C4 and C1 inhibitor levels)

ACE inhibitor effect

Medication history

Low C1 inhibitor and C4 levels

u DON’T

BE TRICKED

• In patients with urticaria and angioedema, diagnose food or drug allergy, food additive sensitivity, or urticarial vasculitis. Do not diagnose HAE.

Therapy Select epinephrine, antihistamines, and corticosteroids for acute episodes of mast cell–mediated (allergic) angioedema with airway compromise or hypotension. Epinephrine is effective in racemic nebulized form or by subcutaneous or IM injections. Patients should carry an epinephrine autoinjector. Use antihistamines and corticosteroids alone in cases of allergic angioedema that is not part of an anaphylaxis syndrome (absent airway compromise or hemodynamic instability).

Select IV C1 inhibitor concentrate for acute episodes of bradykinin-mediated angioedema (hereditary or acquired angioedema); use FFP in an emergency. For long-term management of HAE, select danazol and stanozolol to elevate hepatic synthesis of C1 esterase inhibitor protein.

3

Allergy

u DON’T

BE TRICKED

• Epinephrine is not effective for HAE.

v Test Yourself A 40-year-old man has a 1-year history of cramping abdominal pain and 2- to 3-day episodes of face and hand swelling that have not responded completely to epinephrine and antihistamines. His mother died suddenly of “suffocation.”

ANSWER: The patient has probable HAE. Order serum C4 and C1 inhibitor levels (functional and antigenic).

Treat severe acute episodes of swelling with C1 inhibitor concentrate.

Angioedema: Angioedema differs from urticaria in that it covers a larger surface area and involves the dermis and subcutaneous tissues.

Anaphylaxis Diagnosis Anaphylaxis is a life-threatening syndrome caused by the release of mediators from mast cells and basophils triggered by an IgE-allergen interaction (termed an anaphylactic reaction) or by a non–antibody-antigen mechanism (termed an anaphylactoid reaction). The most common causes are peanut/nut ingestion, insect stings, latex, and medications (penicillin, NSAIDs, and aspirin). Flushing, urticaria, conjunctival pruritus, bronchospasm, nausea, and vomiting usually develop within 30 minutes to 1 hour if the antigen was injected or up to 2 hours if ingested. Anaphylactic shock is caused by severe hypovolemia (fluid shifts owing to increased vascular permeability) and vasodilatation. Shock may occur without prominent skin manifestations or a history of exposure; therefore, anaphylaxis is part of the differential diagnosis for patients who present with shock and no obvious cause. The diagnosis of anaphylaxis is made clinically, but elevated urine and serum histamine and plasma tryptase concentrations are supportive. Death occurs from refractory bronchospasm, respiratory failure with upper airway obstruction, and cardiovascular collapse.

Therapy Epinephrine is first-line therapy even if the only presenting signs are hives or pruritus. Corticosteroid therapy prevents lateonset reactions. Use inhaled bronchodilators for bronchospasm and IV saline for shock or hypotension. Treat refractory hypotension with repeated doses of epinephrine or a continuous epinephrine infusion. Anaphylaxis may progress over 12 hours and requires observation for late recurrence (biphasic anaphylaxis). β-Blockers may blunt the effect of epinephrine, but epinephrine remains the drug of first choice; reserve glucagon for epinephrine-refractory anaphylaxis. Patients with diffuse rash or anaphylaxis from hymenoptera sting (bee, yellow jacket, and wasp) should undergo venom skin testing and immunotherapy.

u DON’T

BE TRICKED

• Don’t confuse SC with IV dosages of epinephrine. IM or SC epinephrine (0.3-0.5 mg of 1:1000) is first-line treatment for classic anaphylaxis. IV epinephrine (1:10,000) is reserved for anaphylactic shock or refractory symptoms.

v Test Yourself A 25-year-old woman has shortness of breath and wheezing after a bee sting 1 hour ago. Her blood pressure is 80/50 mm Hg and heart rate is 110/min.

ANSWER: Treat anaphylaxis with epinephrine and IV fluids. Observe for at least 12 hours. Discharge with selfadministered epinephrine.

Also look for anaphylaxis during surgery or anaphylaxis in a woman during coitus and consider latex allergy.

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