Frameworks for Internal Medicine

Frameworks for Internal MedicineAndré M. Mansoor, MDAssistant Professor of Medicine

Division of Hospital Medicine

Director, Procedure Service

Oregon Health & Science University

Portland, Oregon

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Library of Congress Cataloging-in-Publication Data

Names: Mansoor, André M., author.Title: Frameworks for internal medicine / André M. Mansoor.Description: Philadelphia : Wolters Kluwer, [2019] | Includes bibliographical references and index.Identifiers: LCCN 2018041461 | ISBN 9781496359308 (pbk.)Subjects: | MESH: Internal Medicine | Diagnosis, Differential | Case Reports | Problems and ExercisesClassification: LCC RC71.5 | NLM WB 18.2 | DDC 616.07/5–dc23LC record available at https://lccn.loc.gov/2018041461

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v

DEDICATION

For my mother Salma, and my father Edward. All that I have ever hoped to be, I owe to you.

vi

FOREWORD

In the end, after the “large group learning studios” have fallen silent, the “breakout” rooms are in disarray, and nobody knows that the remotes for the massive TV sets no longer work, medical students will still know 90% of the expected core knowledge. How can this be? It is because these handpicked students are surrounded by handpicked residents, fellows, and junior faculty, all of whom believe it is a fundamental obligation of the profession to teach. They teach all who thirst and most of those who should thirst. It has been this way since the “breakthrough” at Kos. More amazing, the best of these people do not expect any remuneration other than the satisfaction of doing the job well. Education is still the first of the professional expectations at most academic medical centers. These teachers bring the stringent and austere life of physicians-in-training to the task. They can be counted on to teach students what they need to know and, sometimes, what they ought to know.

This task, for which most academic centers pay nothing, is in peril. RVUs, EMRs, “rooming efficiency,” and grading scales for “patient satisfaction” all take a toll. These faculty members are expected to recognize “kaizen events” and alert the managers. Some of the managers want to teach the “silver spoon” doctors a lesson or 2 about “hard times.” Controversy abides, but the teachers persevere. They are, however, in dire need of help.

Where to start? More than anything else, they need blackboards. Blackboards have disappeared. The boards that fill the old blackboard gaps are white and can be written on only with special order pens. When the pens disappear, “informative flyers” begin to fill the space on the whiteboards. “Quiet please. No one can get well in a noisy place!” Are you sure? Sit and listen to an intensive care unit for an hour. “Wash your hands!” The sinks have all disappeared, too, and the wall “hand wash stations” deliver a foul-smelling liquid that fails to dis-patch C-diff spores. It has been labeled toxic for human beings by the FDA. Other messages of importance are

an invitation to a potluck lunch. There is an invitation to attend the next art committee meeting. The boards are covered with ephemerata. Doctors need a sacro-sanct clean board in every corridor of every ward service in every specialty. What will happen at these boards, should they appear, is an ongoing unscripted discussion of the clinical problems at hand for all to see and hear. Approaches to all of the “slings and arrows that life is heir to” show up on these boards. These challenges to health and happiness are ever-present and countless in number. More appear every day. Doctors learn much of what they know at these vestigial boards. Give them real boards and get out of the way!

This book preserves the art of Socratic teaching, a method that reaches back 2500 years. Not only does the process reveal what is known but, even more clearly, it reveals what is not known. Everybody learns. Students, teachers, and nurses learn. Laboratory per-sonnel and patients learn. All will evolve and grow. It is a powerful thing to witness.

Fifty of the most common clinical problems are illustrated in this book. The cache of questions will evolve as the anatomy of erudition points the way. This book contains frameworks that guide the discus-sion of the “chosen fifty.” The 60-year-old man with hematocrit of 32. The 29-year-old pregnant woman with pitting edema to the axillae. The acutely dyspneic long haul truck driver. The young person with fever of unknown origin. The framework prepares the teacher and the learners. It creates the environment most con-ducive to high-impact learning efficiency. In the end, it is the process rather than the framework. The process becomes generalized. Academia is back on track.

Now that we have the book, the boards will appear, hopefully!

Lynn Loriaux, MD, PhDProfessor of Medicine

Oregon Health & Science UniversityPortland, Oregon

vii

PREFACE

Twenty: The number of years the average American physician spends as a student before a degree is earned and residency training begins. Experienced physicians would respond to this notion with a grin; medicine is a dynamic field that requires ongoing refinement of those who practice it. For the physician, learning is a lifelong endeavor. It does not end after 20 years. However, 20 years does mark an important inflection point in the life of an academic physician: there begins the transi-tion from full-time student to part-time student and part-time educator. For most young doctors, this evo-lution does not happen naturally. It must be sought.

Weakness

Brain/spinal cord Anteriorhorn cell

Peripheralnerve

Neuromuscularjunction

Muscle

When I was a third-year medical student on the internal medicine clerkship, I was introduced to the “morning report” case conference, usually led by the chief residents. It was the aspect of the rotation I most enjoyed. I was drawn to the chal-lenge of solving the cases, eventually turning it into a game: I would silently record how long it took for me to guess the correct diagnosis. My record was the time needed for the presenter to finish her open-ing words, “shortness of breath, facial plethora, and upper extremity swelling” (which I immediately recognized as superior vena cava syndrome). Often I was wrong. However, no one else knew about those mistakes. Then, I became an intern and sat in the same room as before, but my role had changed. As an intern, I was obligated to share my thoughts with the group. Still, it remained simple. I would speak up only when I thought I had a pretty good idea of the correct answer. When I did not, some-one else would, and eventually we would get on the right path. On some occasions, however, no one spoke up.

One such occasion involved the case of a mid-dle-aged man with weakness. After time was spent clarifying additional history from the presenter, the chief resident advised that we begin to construct a

differential diagnosis. “Stroke,” offered a resident in the audience. “Is that all?” asked the chief. The room was quiet. My mind was scrambling to come up with more diagnoses, as it often had when confronted with a problem associated with a broad differential diagnosis. “Does anyone have an approach to weak-ness?” Meeting more silence, he offered his own method. Breaking it down anatomically, he began to write several headings on the board, including “brain/spinal cord,” “anterior horn cell,” “peripheral nerve,” “neuromuscular junction,” and “muscle.”

It was as if a light had suddenly turned on in the room. Using this structural format, new possibilities were uncovered. Below the heading “brain/spinal cord,” the chief began listing the diagnoses that were now flow-ing from the audience, including brain tumor, multiple sclerosis, and epidural abscess. Next were lesions of the anterior horn cell. Prompting the group, the chief asked, “Does anyone remember what disease Lou Gehrig had?” Of course, within seconds, ALS appeared on the list. In a similar way, the audience identified diseases of the peripheral nerve, neuromuscular junction, and mus-cle. With this framework for approaching weakness, we had achieved what seemed impossible moments before.

I left that session with an appreciation of the chal-lenges of leading case conference. When the audience is quiet, the leader must not only determine the direc-tion of the conference but also guide the audience forward. The following year, I was offered one of the future chief resident positions. With joy came some trepidation. One of the concerns on my mind was the idea of leading the case conferences that I always enjoyed as a member of the audience.

I began to strategize. During ensuing conferences, I made note of each case. I soon recognized that certain problems were often at the center of discussion. This list included entities such as dyspnea, acute kidney

viii PREFACE

injury, anemia, hypoxemia, diarrhea, fever of unknown origin, and syncope. Given the frequency with which these entities seemed to appear during case confer-ence, I reasoned that developing an approach to each of them would prove valuable, particularly in moving conference along in front of a reticent audience.

As I began to work toward this goal, I realized that having an approach to a problem in many cases is as simple as constructing a framework that divides the long differential diagnosis into shorter sublists, which are easier for our brains to store and process. Rather than memorize a long list of diagnoses, it is sufficient to remember the headings of a framework, from which many of the diagnoses can then be generated.

I began to build frameworks for all of the common clinical problems in internal medicine. I used various resources, from pages of notes I scribbled at one point or another during residency to textbooks and primary literature. Some frameworks are time-honored and commonly taught, such as those used for acute kidney injury (prerenal, intrarenal, postrenal) and vasculitis (small vessel, medium vessel, large vessel). After a few months, I had accumulated a healthy amount of mate-rial. Here is 1 example of the frameworks that I was beginning to assemble:

Arthritis

• Crystal arthropathy• Infectious (acute)• Infectious (chronic)• Early oligoarthritis

• Disseminated gonorrhea• Spondyloarthritis• Spirochetal infection• Löfgren’s syndrome• Henoch-Schönlein purpura• Cryoglobulinemia• Behçet’s disease• Early polyarthritis

Inflammatory

• Rheumatoid arthritis• Systemic lupus erythematosus• Viral infection• Polymyositis/ dermatomyositis• Still’s disease• Rheumatic fever• Serum sickness• Sarcoidosis

• Osteoarthritis• Trauma• Hemarthrosis• Charcot joint• Osteonecrosis• Hypertrophic osteoarthropathy• Episodic arthritis of cystic fibrosis• Acromegaly• Hemochromatosis

Noninflammatory

Monoarticular Oligoarticular Polyarticular

These frameworks would become the “tip of the spear” when I was faced with silence during case con-ference. I had accomplished my objective. However, I discovered something much more valuable. I had developed a collection of tools that could be used to teach learners how to approach the clinical problems of internal medicine, beyond the boundaries of case conference.

I spent the rest of my time as a resident using these tools to teach, taking advantage of every opportunity. On the inpatient medical ward, the members of my team were the audience of frequent talks. I discov-ered that the guidance from the framework alone was enough to result in a meaningful teaching session, but I began to expand the outlines with additional learn-ing points, making each talk healthier and more robust. With each passing month, I sharpened my skills as a resident-teacher. By the end of residency, I had become a nascent teacher. I hope this work can help others reach this point.

ix

REVIEWERS

The author would like to thank the following individ-uals for their time and expertise:

SECTION 3: Cardiology

Edward S. Murphy, MDProfessor of MedicineKnight Cardiovascular InstituteOregon Health & Science UniversityPortland, Oregon

Khidir Dalouk, MDAssistant Professor of MedicineClinical Cardiac ElectrophysiologistKnight Cardiovascular InstituteOregon Health & Science UniversityPortland, Oregon

SECTION 4: Endocrinology

D. Lynn Loriaux, MD, PhDProfessor of MedicineHead, Division of Endocrinology, Diabetes, and

Clinical NutritionOregon Health & Science UniversityPortland, Oregon

SECTION 5: Gastroenterology and Hepatology

Janice Jou, MD, MHSAssistant Professor of MedicineDivision of Gastroenterology and HepatologyDirector, Gastroenterology and Hepatology

FellowshipOregon Health & Science UniversityPortland, Oregon

SECTION 6: General Internal Medicine

D. Lynn Loriaux, MD, PhDProfessor of MedicineHead, Division of Endocrinology, Diabetes, and

Clinical NutritionOregon Health & Science UniversityPortland, Oregon

David Mansoor, MDAssociate Professor of PsychiatryOregon Health & Science UniversityPortland, Oregon

SECTION 7: Hematology

Thomas DeLoughery, MD, MACP, FAWMProfessor of Medicine, Pathology, and PediatricsDivision of Hematology and OncologyOregon Health & Science UniversityPortland, Oregon

SECTION 8: Infectious Diseases

Thomas Ward, MDProfessor Emeritus of MedicineDivision of Infectious DiseasesOregon Health & Science UniversityPortland, Oregon

SECTION 9: Nephrology

Pavan Chopra, MD, MSAssistant Professor of MedicineDivision of Nephrology and HypertensionDirector, Dialysis ServicesOregon Health & Science UniversityPortland, Oregon

SECTION 10: Neurology

Faheem Sheriff, MDFellow of Neurocritical CareMassachusetts General HospitalBrigham and Women’s HospitalBoston, Massachusetts

SECTION 11: Pulmonology

Alan F. Barker, MDProfessor of MedicineDivision of Pulmonary and Critical CareOregon Health & Science UniversityPortland, Oregon

SECTION 12: Rheumatology

Atul Deodhar, MD, MRCP, FACP, FACRProfessor of MedicineDivision of Arthritis & Rheumatic DiseasesDirector, Rheumatology ClinicsDirector, Immunology Infusion CenterOregon Health & Science UniversityPortland, Oregon

x REVIEWERS

Medical Editor

Margot E. Chase, MPAS, PA-CInstructor of MedicineDivision of Hospital MedicineOregon Health & Science UniversityPortland, Oregon

Additional Faculty Reviewers

Stephanie A.C. Halvorson, MD, FACPAssociate Professor of MedicineDivision of Hospital MedicineOregon Health & Science UniversityPortland, Oregon

Mary Ann Kuzma, MDAssociate Professor of MedicineClerkship Director, Internal MedicineDrexel University College of MedicinePhiladelphia, Pennsylvania

Octavian Calin Lucaciu, MD, PhDAssociate Professor of AnatomyCanadian Memorial Chiropractic CollegeToronto, Ontario, Canada

Gregory J. Magarian, MDProfessor of MedicineDivision of Hospital MedicineOregon Health & Science UniversityPortland, Oregon

Additional Student and Resident ReviewersShelby BadaniCassandra Betts, MDKaren BieraugelChristina B. CherryMichael-Hunter ClementAlexander ConnellySpencer Degerstedt, MDChristine GreippSameer Hirji, MDArthur KehasWhitney KingRebecca Levin-EpsteinAisha MohammedChristine MotzkusJennifer E. MustardAndrew Oehler, MDJayoma PereraNekeyua N. RichardsonBranden TarlowRachna UnnithanCara Varley

xi

ACKNOWLEDGEMENTS

I received an incredible amount of support over the 6 years it took me to complete this book. Above all, I am thankful for my mother Salma. I am grateful to my father Edward, siblings Sherri, Steve, Dave, Aimee, and Lori, as well as Sito (grandmother) Margareet Barhoum for encouraging me from the beginning until the end. It is amazing the impact of such a sim-ple question, “How is the book coming along?” My cousins Jamil Mansoor and Joseph Barhoum, and my friend Josh Hughes were always interested in the progress, no matter how fast or how slow.

When I first came to OHSU in 2005, I was intro-duced to the legend of Lynn Loriaux. So astute a clini-cian, it was said he needed only a handshake to make a diagnosis. Behind every legend there is a man. Often, they are nothing alike. Sometimes, the man is equal to the legend. Only seldom does he exceed it. When I met the man himself, it was clear just how rare he is. His guidance throughout this process cannot be over-stated. And we could not have done it without Julie Walvatne.

I received immeasurable support from Shangar Meman, from the earliest stages of writing until the end (she is a superb agent). The advice of my friend and

colleague Christopher “Kwonsult” Kwock was always as effective as it was sarcastic. He was available any time I needed him. This book benefited from excep-tional proofreading by Jennifer Mustard and Spencer “274” Degerstedt. Joseph Mabe provided valuable expertise in matters that are beyond me. Christopher Neck always took time to answer questions. Summer Steele contributed countless reference articles. I thank my friends and colleagues Gregory Magarian, Peter Sullivan, Sima Desai, Brian Chan, Elly Karamooz, and Margot Chase for their interest and advice over the years.

I am appreciative of the outstanding team at Wolters Kluwer, in particular Matt Hauber, Tom Conville, Andrea Vosburgh, and Lindsay Ries, first for their patience and second for their innovative ideas that enriched every facet of this book. I would also like to recognize Tari Broderick who first received my proposal and believed in this book from day one.

Finally, and most importantly, I would like to thank all of the patients I have ever had the privilege of caring for, with special attention to those presented in this book. I hope the telling of their stories will serve as a benefit to others.

xii

CONTENTS

FOREWORD VI

PREFACE VII

REVIEWERS IX

ACKNOWLEDGEMENTS XI

LIST OF COMPLETED FRAMEWORKS XIV

SECTION 1 How to Use This Book

FOR LEARNERS 1

FOR EDUCATORS 1

Internal Medicine Residents and Faculty 1

Internal Medicine Chief Residents 1

SECTION 2 The Framework System

SECTION 3 Cardiology

Chapter 1 BRADYCARDIA 5

Chapter 2 CHEST PAIN 15

Chapter 3 HEART BLOCK 29

Chapter 4 HEART FAILURE 37

Chapter 5 PERICARDITIS 55

Chapter 6 TACHYCARDIA 67

SECTION 4 Endocrinology

Chapter 7 ADRENAL INSUFFICIENCY 78

Chapter 8 CUSHING’S SYNDROME 91

Chapter 9 HYPERCALCEMIA 100

Chapter 10 HYPOCALCEMIA 112

Chapter 11 HYPOTHYROIDISM 125

Chapter 12 THYROTOXICOSIS 137

SECTION 5 Gastroenterology and Hepatology

Chapter 13 ASCITES 147

Chapter 14 CHOLESTATIC LIVER INJURY 162

Chapter 15 DIARRHEA 176

Chapter 16 GASTROINTESTINAL BLEEDING 198

Chapter 17 HEPATOCELLULAR LIVER INJURY 212

Chapter 18 INTESTINAL ISCHEMIA 223

SECTION 6 General Internal Medicine

Chapter 19 DELIRIUM 235

Chapter 20 DYSPNEA 248

Chapter 21 FEVER OF UNKNOWN ORIGIN 263

Chapter 22 HYPOTENSION 276

Chapter 23 PERIPHERAL EDEMA 288

Chapter 24 SYNCOPE 300

SECTION 7 Hematology

Chapter 25 ANEMIA 310

Chapter 26 HEMOLYTIC ANEMIA 326

Chapter 27 PANCYTOPENIA 342

Chapter 28 PLATELET DISORDERS 353

SECTION 8 Infectious Diseases

Chapter 29 ENDOCARDITIS 365

Chapter 30 MENINGITIS 382

Chapter 31 PNEUMONIA 398

xiiiCONTENTS

SECTION 9 Nephrology

Chapter 32 ACID-BASE DISORDERS 414

Chapter 33 ACUTE KIDNEY INJURY 430

Chapter 34 GLOMERULAR DISEASE 445

Chapter 35 HYPERKALEMIA 460

Chapter 36 HYPERNATREMIA 469

Chapter 37 HYPOKALEMIA 479

Chapter 38 HYPONATREMIA 487

Chapter 39 SECONDARY HYPERTENSION 501

SECTION 10 Neurology

Chapter 40 HEADACHE 510

Chapter 41 POLYNEUROPATHY 525

Chapter 42 SEIZURE 540

Chapter 43 STROKE 557

Chapter 44 WEAKNESS 578

SECTION 11 Pulmonology

Chapter 45 HEMOPTYSIS 603

Chapter 46 HYPOXEMIA 612

Chapter 47 INTERSTITIAL LUNG DISEASE 631

Chapter 48 PLEURAL EFFUSION 645

SECTION 12 Rheumatology

Chapter 49 ARTHRITIS 658

Chapter 50 SYSTEMIC VASCULITIS 673

SECTION 13 Educator’s Appendix

A Brief History of Medical Education and Introduction to the Chalk Talk 684The Seven Tenets of The Chalk Talk 687Chalk Talks and The Framework System 690

INDEX 693

xiv

LIST OF COMPLETED FRAMEWORKS

SECTION 3: CardiologyBRADYCARDIA 12

CHEST PAIN 22

HEART BLOCK 33

HEART FAILURE 51

PERICARDITIS 64

TACHYCARDIA 75

SECTION 4: EndocrinologyADRENAL INSUFFICIENCY 87

CUSHING’S SYNDROME 97

HYPERCALCEMIA 108

HYPOCALCEMIA 122

HYPOTHYROIDISM 133

THYROTOXICOSIS 143

SECTION 5: Gastroenterology and HepatologyASCITES 157

CHOLESTATIC LIVER INJURY 172

DIARRHEA 193

GASTROINTESTINAL BLEEDING 208

HEPATOCELLULAR LIVER INJURY 219

INTESTINAL ISCHEMIA 232

SECTION 6: General Internal MedicineDELIRIUM 244

DYSPNEA 259

FEVER OF UNKNOWN ORIGIN 272

HYPOTENSION 285

PERIPHERAL EDEMA 296

SYNCOPE 306

SECTION 7: HematologyANEMIA 322

HEMOLYTIC ANEMIA 338

PANCYTOPENIA 350

PLATELET DISORDERS 361

SECTION 8: Infectious DiseasesENDOCARDITIS 378

MENINGITIS 394

PNEUMONIA 410

SECTION 9: NephrologyACID/BASE DISORDERS 427

ACUTE KIDNEY INJURY 442

GLOMERULAR DISEASE 456

HYPERKALEMIA 466

HYPERNATREMIA 476

HYPOKALEMIA 484

HYPONATREMIA 497

SECONDARY HYPERTENSION 507

SECTION 10: NeurologyHEADACHE 521

POLYNEUROPATHY 535

SEIZURE 553

STROKE 574

WEAKNESS 598

SECTION 11: PulmonologyHEMOPTYSIS 609

HYPOXEMIA 627

INTERSTITIAL LUNG DISEASE 641

PLEURAL EFFUSION 654

SECTION 12: RheumatologyARTHRITIS 668

SYSTEMIC VASCULITIS 680