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A MERICAN C OLLEGE OF P HYSICIANSC LERKSHIP D IRECTORS IN I NTERNAL M EDICINEI NTERNAL M EDICINEEssentialsforClerkshipStudents2ACP
I NTERNAL M EDICINEEssentialsforClerkshipStudents2Patrick C. Alguire, MD, FACPDIRECTOREDUCATION AND CAREER DEVELOPMENTAMERICAN COLLEGE OF PHYSICIANSEDITOR-IN-CHIEF
Associate Publisher and Manager, Books Publishing: Tom HartmanProduction Supervisor: Allan S. KleinbergSenior Production Editor: Karen C. NolanEditorial Coordinator: Angela GabellaDesign: Michael E. RipcaCopyright 2009 by the American College of Physicians. All rights reserved. No part ofthis publication may be reproduced in any form by any means (electronic, mechanical,xerographic, or other) or held in any information storage or retrieval systems withoutwritten permission from the College.Printed in the United States of AmericaPrinted by Sheridan BooksComposition by Scribe, Inc. (www.scribenet.com)ISBN: 978-1-934465-13-4The authors and publisher have exerted every effort to ensure that the drug selectionand dosages set forth in this book are in accordance with current recommendations andpractice at the time of publication. In view of ongoing research, occasional changes ingovernment regulations, and the constant flow of information relating to drug therapyand drug reactions, however, the reader is urged to check the package insert for eachdrug for any change in indications and dosage and for added warnings and precautions.This care is particularly important when the recommended agent is a new or infrequentlyused drug.09 10 11 12 13 / 10 9 8 7 6 5 4 3 2 1
Section EditorsThomas M. DeFer, MD, FACPClerkship DirectorDivision of Medical EducationDepartment of Internal MedicineWashington University School of MedicineSt Louis, MissouriSara B. Fazio, MDAssistant Professor, Harvard Medical SchoolDirector, Core I Medicine ClerkshipDivision of General Internal MedicineBeth Israel Deaconess Medical CenterBoston, MassachusettsD. Michael Elnicki, MD, FACPDirector, Ambulatory Medicine ClerkshipDirector, Section of General Internal MedicineUniversity of Pittsburgh School of MedicineUPMC ShadysidePittsburgh, PennsylvaniaJames L. Sebastian, MD, FACPDirector of Student Teaching ProgramsDepartment of MedicineMedical College of WisconsinClement J. Zablocki Veterans Affairs Medical CenterMilwaukee, WisconsinMark J. Fagan, MDClerkship DirectorDepartment of MedicineAlpert Medical School of Brown UniversityProvidence, Rhode Island
ContributorsArlina Ahluwalia, MDClinical Assistant Professor of MedicineStanford University School of MedicineClerkship Site DirectorPalo Alto VAHCSPalo Alto, CaliforniaHugo A. Alvarez, MD, FACPAssociate Professor of MedicineSub-Internship DirectorClerkship Site Director, Department of MedicineRosalind Franklin University of Medicine and ScienceMount Sinai HospitalChicago, IllinoisEyad Al-Hihi, MD, FACPAssociate Professor of MedicineClerkship Director, Ambulatory MedicineSection Chief, Division of General Internal MedicineMedical Director, Internal Medicine ClinicsTruman Medical Center-Hospital HillUniversity of Missouri-Kansas City School ofMedicineKansas City, MissouriAlpesh N. Amin, MD, MBA, FACPMedicine Clerkship DirectorAssociate Program Director, IM ResidencyUniversity of California, IrvineIrvine, CaliforniaMary Jane Barchman, MD, FACP, FASNAssociate Professor of MedicineSection of Nephrology and HypertensionDirector, Introduction to Medicine CourseClerkship Director, Internal MedicineBrody School of Medicine at East Carolina UniversityGreenville, North CarolinaErik K. Alexander, MD, FACPDirector, Medical Student EducationBrigham & Women’s HospitalAssistant Professor of MedicineHarvard Medical SchoolBoston, MassachusettsSeth Mark Berney, MD, FACPProfessor of MedicineChief, Section of RheumatologyDirector, Center of Excellence for Arthritis andRheumatologyHealth Sciences CenterLouisiana State University School of MedicineShreveport, LouisianaIrene Alexandraki, MD, FACPAssistant Professor of MedicineUniversity of Florida College of MedicineJacksonville, FloridaMark R. Allee, MD, FACPAssistant Professor of MedicineDepartment of Internal MedicineUniversity of Oklahoma College of MedicineOklahoma City, Oklahomav
vi ContributorsCynthia A. Burns, MDAssistant ProfessorClerkship Director, Inpatient Internal MedicineSection of Endocrinology and MetabolismDepartment of Internal MedicineWake Forest University School of MedicineWinston-Salem, North CarolinaAmanda Cooper, MDAssistant Professor of MedicineUniversity of Pittsburgh School of MedicineUniversity of Pittsburgh Medical CenterPittsburgh, PennsylvaniaNicole M. Cotter, MDFellow, Section of RheumatologyCenter of Excellence for Arthritis and RheumatologyHealth Sciences CenterLouisiana State University School of MedicineShreveport, LouisianaReed E. Drews, MD, FACPProgram DirectorHematology-Oncology FellowshipCo-Director, Core Medicine 1 ClerkshipBeth Israel Deaconess Medical CenterHarvard Medical SchoolBoston, MassachusettsSteven J. Durning, MD, FACPMajor, Medical Corps, US Air ForceAssociate Professor of MedicineCo-Director, Intro to Clinical Reasoning CourseUniformed Services University of the Health SciencesBethesda, MarylandRichard S. Eisenstaedt, MD, FACPChair, Department of MedicineAbington Memorial HospitalProfessor of MedicineTemple University School of MedicinePhiladelphia, PennsylvaniaJ. Michael Finley, DO, FACP, FACOIAssociate Professor and Chair of MedicineDepartment of MedicineWestern University College of Osteopathic MedicinePomona, CaliforniaJanine M. Frank, MDAssistant Professor of MedicineUniversity of Pittsburgh Medical CenterUniversity of Pittsburgh School of MedicinePittsburgh, PennsylvaniaJane P. Gagliardi, MDAssistant Clinical ProfessorDepartment of Internal MedicineDepartment of Psychiatry and Behavioral SciencesDuke University School of MedicineDurham, North CarolinaPeter Gliatto, MDAssistant Professor of MedicineDirector, Medical ClerkshipsMount Sinai School of MedicineNew York, New YorkEric H. Green, MD, MScCourse Director, Patients, Doctors, and CommunitiesAssistant Professor of MedicineMontefiore Medical CenterAlbert Einstein College of MedicineBronx, New YorkMark C. Haigney, MDProfessor of MedicineDirector of CardiologyUniformed Services University of the Health SciencesBethesda, MarylandCharin L. Hanlon, MD, FACPAssistant Professor of Internal MedicineClerkship Director, Internal MedicineWest Virginia University-Charleston DivisionCharleston, West VirginiaWarren Y. Hershman, MDDirector of Student EducationDepartment of MedicineBoston University School of MedicineBoston, MassachusettsMark D. Holden, MD, FACPEagle’s Trace Medical DirectorErickson Retirement CommunitiesHouston, Texas
Contributors viiIvonne Z. Jiménez-Velázquez, MD, FACPProfessor and Vice-Chair for EducationGeriatrics Program DirectorClerkship Director, Internal Medicine DepartmentUniversity of Puerto Rico School of MedicineSan Juan, Puerto RicoLawrence I. Kaplan, MD, FACPProfessor of MedicineSection Chief, General Internal MedicineInternal Medicine Clerkship DirectorTemple University School of MedicinePhiladelphia, PennsylvaniaAsra R. Khan, MDAssistant Professor of Clinical MedicineAssociate Program Director, Internal MedicineResidencyMedicine Clerkship DirectorUniversity of Illinois College of MedicineChicago, IllinoisSarang Kim, MDAssistant Professor of MedicineDivision of General Internal MedicineUniversity of Medicine and Dentistry of New JerseyRobert Wood Johnson Medical SchoolNew Brunswick, New JerseyChristopher A. Klipstein, MDClerkship Director of Internal MedicineAssociate ProfessorDepartment of MedicineUniversity of North Carolina School of MedicineChapel Hill, North CarolinaCynthia H. Ledford, MDClerkship Director of Internal MedicineOhio State University College of MedicineColumbus, OhioBruce Leff, MD, FACPAssociate Professor of MedicineMedicine Clerkship DirectorJohns Hopkins University School of MedicineBaltimore, MarylandFred A. Lopez, MD, FACPAssociate Professor and Vice ChairDepartment of MedicineLouisiana State University Health Sciences CenterAssistant Dean for Student AffairsLSU School of MedicineNew Orleans, LouisianaAnna C. Maio, MD, FACPDivision Chief and Associate ProfessorDivision of General Internal MedicineDepartment of Internal MedicineCreighton University School of MedicineOmaha, NebraskaBrown J. McCallum, MD, FACPAssistant ProfessorCo-Clerkship DirectorDepartment of Internal MedicineUniversity of South Carolina School of MedicineColumbia, South CarolinaKevin M. McKown, MD, FACPAssociate Professor of MedicineCo-Chief, Section of RheumatologyProgram Director, Rheumatology FellowshipCo-Clerkship DirectorDepartment of MedicineUniversity of Wisconsin School of Medicine andPublic HealthMadison, WisconsinMelissa A. McNeil, MD, MPHProfessor of Medicine and Obstetrics, Gynecology &Reproductive SciencesChief, Section of Women’s HealthDivision of General MedicineUniversity of PittsburghPittsburgh, PennsylvaniaJanet N. Myers, MD, FACP, FCCPAssociate Professor of MedicineDeputy Clerkship Director, Department of MedicineUniformed Services University of the Health SciencesBethesda, Maryland
viii ContributorsKathryn A. Naus, MDChief Fellow, Section of RheumatologyCenter of Excellence for Arthritis and RheumatologyHealth Sciences CenterLouisiana State University School of MedicineShreveport, LouisianaPriya Radhakrishnan, MDClinical Assistant ProfessorUniversity of Arizona College of MedicineClerkship Director and Associate Program DirectorDepartment of Internal MedicineSt. Joseph Hospital & Medical CenterPhoenix, ArizonaRobert W. Neilson Jr., MDAssistant ProfessorClerkship DirectorDepartment of Internal MedicineDivision of General Internal MedicineTexas Tech University Health Sciences CenterLubbock, TexasJoseph Rencic, MD, FACPAssistant Professor of MedicineClerkship Site Director, Associate Program DirectorDepartment of Internal MedicineTufts-New England Medical CenterBoston, MassachusettsKatherine Nickerson, MDVice ChairDepartment of MedicineAssociate Professor of Clinical MedicineClerkship DirectorColumbia University, P & SNew York, New YorkKathleen F. Ryan, MDAssociate Professor of MedicineClerkship DirectorDivision of General Internal MedicineDepartment of Internal MedicineDrexel University College of MedicinePhiladelphia, PennsylvaniaL. James Nixon, MDClerkship DirectorDivision of General Internal MedicineUniversity of Minnesota Medical SchoolUniversity of Minnesota Medical Center, FairviewMinneapolis, MinnesotaBrijen J. Shah, MDChief Medical Resident, Department of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBoston, MassachusettsCarlos Palacio, MD, MPH, FACPClerkship DirectorAssistant Professor of MedicineUniversity of Florida College of MedicineJacksonville, FloridaHanah Polotsky, MDAssistant Professor of MedicineClerkship DirectorMontefiore Medical CenterAlbert Einstein College of MedicineBronx, New YorkNora L. Porter, MDCo-Director, Internal Medicine ClerkshipSt. Louis University School of MedicineSt. Louis, MissouriPatricia Short, MDMajor, Medical Corps, US ArmyAssociate Professor and Associate Clerkship DirectorDepartment of MedicineUniformed Services University of the Health SciencesBethesda, MarylandMadigan Army Medical CenterTacoma, WashingtonDiane C. Sliwka, MDInstructor of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBoston, Massachusetts
Contributors ixHarold M. Szerlip, MD, FACP, FCCPProfessor and Vice-ChairmanDepartment of MedicineMedical College of GeorgiaAugusta, GeorgiaGary Tabas, MD, FACPAssociate Professor of MedicineUniversity of Pittsburgh School of MedicinePittsburgh, PennsylvaniaTomoko Tanabe, MD, FACPAssistant Professor of MedicineAssociate Clerkship DirectorUniversity of California, San DiegoSan Diego, CaliforniaDavid C. Tompkins, MDAssociate ChairDepartment of MedicineSUNY Stony Brook Health Sciences CenterStony Brook, New YorkDario M. Torre, MD, MPH, FACPClerkship DirectorDepartment of MedicineMedical College of WisconsinMilwaukee, WisconsinMark M. Udden, MD, FACPProfessor of MedicineDepartment of Internal MedicineBaylor College of MedicineHouston, TexasH. Douglas Walden, MD, MPH, FACPCo-Director, Internal Medicine ClerkshipSt. Louis University School of MedicineSt. Louis, MissouriJoseph T. Wayne, MD, MPH, FACPAssociate Professor of MedicineAssociate Professor of PediatricsClerkship Director, Internal MedicineAlbany Medical CollegeAlbany, New YorkJohn Jason White, MDAssistant Professor of MedicineNephrology SectionDepartment of MedicineMedical College of GeorgiaAugusta, GeorgiaKevin D. Whittle, MDAssistant ProfessorThird Year Clerkship Director, Internal MedicineSanford Medical School of the University of SouthDakotaSioux Falls, South Dakota
ContentsFOREWORD .xvACKNOWLEDGMENTS .xviiIIII Gastroenterology and Hepatology13 Approach to Abdominal Pain .57Priya Radhakrishnan14 Approach to Diarrhea .61Sarang Kim15 Diseases of the Gallbladder and Bile Ducts.64Nora L. Porter16 Acute Pancreatitis .67Nora L. Porter17 Gastroesophageal Reflux Disease .70Brown J. McCallum18 Peptic Ulcer Disease .72Brown J. McCallum19 Dyspepsia.74Brown J. McCallum20 Approach to Gastrointestinal Bleeding .76Warren Y. Hershman21 Viral Hepatitis .80Carlos Palacio22 Cirrhosis .83Mark J. Fagan23 Inflammatory Bowel Disease .87Brown J. McCallumCardiovascular Medicine1 Approach to Chest Pain .3Dario M. Torre2 Chronic Stable Angina .7Anna C. Maio3 Acute Coronary Syndrome.11Patrick C. Alguire4 Supraventricular Arrhythmias .15Charin L. Hanlon5 Ventricular Arrhythmias .20Steven J. Durning and Mark C. Haigney6 Heart Failure .24James L. Sebastian7 Valvular Heart Disease .28H. Douglas WaldenIIEndocrinology and Metabolism8 Diabetes Mellitus and Diabetic Ketoacidosis .37Erik K. Alexander9 Dyslipidemia .41D. Michael Elnicki and Gary Tabas10 Thryoid Disease.44Erik K. Alexander11 Adrenal Disease .48Cynthia A. Burns12 Osteoporosis .52Melissa A. McNeil and Janine M. FrankIVGeneral Internal Medicine24 Test Interpretation.93D. Michael Elnicki25 Health Promotion, Screening, and Prevention.96L. James Nixon26 Approach to Syncope .100Lawrence I. Kaplanxi
xii Contents27 Depression.103Hugo A. Alvarez28 Substance Abuse .107Mark Allee29 Approach to Low Back Pain.110Lawrence I. Kaplan30 Approach to Cough .113Patrick C. Alguire31 Smoking Cessation.116Patrick C. Alguire32 Obesity .118L. James Nixon33 Approach to Involuntary Weight Loss .121Bruce Leff34 Disorders of Menstruation and Menopause .124Sara B. Fazio35 Common Dermatologic Disorders .128Hanah Polotsky36 Comprehensive Geriatric Assessment .133Ivonne Z. Jiménez-Velásquez37 Hypertension .137Thomas M. DeFerVHematology38 Anemia .143Reed E. Drews39 Bleeding Disorders .149Diane C. Sliwka40 Sickle Cell Anemia .152Reed E. Drews41 Thrombocytopenia .155Richard S. Eisenstaedt42 Thrombophilia.158Patrick C. Alguire43 Common Leukemias .161Mark M. Udden44 Multiple Myeloma .164Mark M. UddenVIInfectious Disease Medicine45 Approach to Fever .171Joseph T. Wayne46 Sepsis Syndrome .174Charin L. Hanlon47 Common Upper Respiratory Problems .177Robert W. Neilson, Jr.48 Urinary Tract Infection .180Irene Alexandraki49 Sexually Transmitted Diseases .183Sara B. Fazio50 Human Immunodeficiency Virus Infection .186Peter Gliatto51 Health Care Associated Infections .189Brijen Shah52 Tuberculosis .193Arlina Ahluwalia53 Community-Acquired Pneumonia .197Irene Alexandraki54 Infective Endocarditis .200Fred A. Lopez55 Osteomyelitis .203David C. TompkinsVIINephrology56 Acute Kidney Injury .209Harold M. Szerlip57 Chronic Kidney Disease .213John Jason White58 Acid-Base Disorders.217Tomoko Tanabe59 Fluid and Electrolyte Disorders .220Mary Jane Barchman60 Calcium and Phosphorus Metabolism .225Mary Jane BarchmanVIIINeurology61 Approach to the Altered Mental State .231Robert W. Neilson Jr.62 Headache.234Eyad Al-Hihi63 Dementia.237Mark Allee64 Approach to Meningitis and Encephalitis .240Fred A. Lopez65 Stroke and Transient Ischemic Attack .244Jane P. Gagliardi66 Peripheral Neuropathy .247Christopher A. KlipsteinIXOncology67 Breast Cancer .253Kathleen F. Ryan68 Colon Cancer .256Kathleen F. Ryan
Contents xiii69 Lung Cancer .259Cynthia H. Ledford70 Prostate Cancer .262Eric H. Green71 Cervical Cancer .265Asra R. Khan72 Skin Cancer .268Cynthia H. Ledford73 Pain Management .271Patrick C. AlguireXPulmonary Medicine74 Approach to Dyspnea.275Mark D. Holden75 Pleural Effusion .278Dario M. Torre76 Asthma .282Patricia Short77 Chronic Obstructive Pulmonary Disease .286Carlos Palacio78 Obstructive Sleep Apnea .290Arlina Ahluwalia79 Infiltrative and Fibrotic Lung Diseases .293Janet N. Myers80 Venous Thromboembolism .297Alpesh N. Amin81 Interpretation of Pulmonary Function Tests.301Kevin D. WhittleXIRheumatology82 Approach to Joint Pain .307Thomas M. DeFer83 Approach to Knee and Shoulder Pain .309Joseph Rencic84 Crystalline Arthritis .312Katherine Nickerson85 Osteoarthritis.315Amanda Cooper86 Polymyositis and Dermatomyositis .317Kevin M. McKown87 Rheumatoid Arthritis .319Kathryn A. Naus and Seth Mark Berney88 Septic Arthritis.322J. Michael Finley89 Systemic Lupus Erythematosus .325Nicole Cotter and Seth Mark Berney90 Vasculitis .328Patrick C. AlguireINDEX .331COLOR PLATES.Back of Book
Forewordmore than 450 questions has been specifically edited bya group of clerkship directors to meet the learningneeds of students participating in the medicine clerkship. Each question comes with an answer critique thatsupplies the correct answer, an explanation of why thatanswer is correct and the incorrect options are not, anda short bibliography. We recommend that students firstread the appropriate chapter in IM Essentials, thenassess their understanding by answering the designatedquestions in MKSAP for Students 4.The content of IM Essentials is based upon The CoreMedicine Clerkship Curriculum Guide (available atwww.im.org/CDIM), a nationally recognized curriculum for the required third-year internal medicine clerkship, created and published by the CDIM and theSociety for General Internal Medicine. A collaborationof 66 authors, all of whom are either internal medicineclerkship directors or clerkship faculty, representing 45different medical schools, IM Essentials 2 is unique inthat it is created by faculty who helped design the internal medicine curriculum and who are actively involvedin teaching and advising students on the internal medicine clerkship.Internal Medicine Essentials for Clerkship Students is acollaborative project of the American College ofPhysicians (ACP) and the Clerkship Directors inInternal Medicine (CDIM), the organization of individuals responsible for teaching internal medicine tomedical students. The purpose of IM Essentials is toprovide medical students with an authoritative educational resource that can be used to augment learningduring the third year internal medicine clerkship. Muchof the content is based upon two evidence-basedresources of ACP: the Medical Knowledge SelfAssessment Program (MKSAP) and the PhysicianInformation and Education Resource (PIER); othersources include recently published practice guidelinesand review articles. IM Essentials is updated every twoyears with the best available evidence and is designed tobe read cover-to-cover during the clerkship.Based upon student feedback, IM Essentials 2 contains twice as many color plates and algorithms as itspredecessor and more than 100 extra tables to enhancelearning (and passing tests!). An index now providesfuller subject access. The most exciting addition is theBook Enhancement section found at the end of eachchapter. This section directs the reader to a book-related Web site that contains nearly 500 links to additionaltables, algorithms, color plates, and patient care tools.The Book Enhancement section also identifies specificchapter-related self-assessment questions published in aseparate companion book, MKSAP for Students 4.MKSAP for Students 4 consists of a printed and electronic collection of patient-centered self-assessmentquestions and answers. The questions begin with a clinical vignette, just as in the medicine clerkship examination and the USMLE Step 2 licensing examination. Thequestions are organized into eleven sections that matchthe eleven sections found in IM Essentials. Each of the*****Founded in 1915, the American College ofPhysicians is the nation’s largest medical specialty society. Its mission is to enhance the quality and effectiveness of health care by fostering excellence and professionalism in the practice of medicine. ACP’s 124,000members include allied health professionals, medicalstudents, medical residents, and practicing physicians. Physician members practice general internalmedicine and related subspecialties, including cardiology, gastroenterology, nephrology, endocrinology,xv
xvi Forewordhematology, rheumatology, neurology, pulmonary disease, oncology, infectious diseases, allergy and immunology, and geriatrics.The Clerkship Directors in Internal Medicine is thenational organization of individuals responsible forteaching internal medicine to medical students.Founded in 1989, CDIM promotes excellence in theeducation of medical students in internal medicine.CDIM serves internal medicine faculty and staff by:providing a forum to share ideas, generate solutions tocommon problems, and create opportunities for careerdevelopment; participating in the development and dissemination of innovations for curriculum, evaluation,and faculty development; encouraging research and collaborative initiatives among medical educators; andadvocating for issues concerning undergraduate medical education.*****Publication of Internal Medicine Essentials forClerkship Students 2 would not have been possible without the invaluable and entirely voluntary contributionsof many individuals, only some of whom are listed inthe Acknowledgments. Others, not specifically named,were representatives from a wide spectrum of constituencies and organizations such as the Executive andEducational Committees of the Clerkship Directors inInternal Medicine and the Education Committee andthe Council of Student Members of the AmericanCollege of Physicians.Patrick C. Alguire, MD, FACPEditor-in-Chief
AcknowledgmentsThe American College of Physicians and the Clerkship Directors in InternalMedicine gratefully acknowledge the special contributions to Internal MedicineEssentials for Clerkship Students 2 of Nicole V. Baptista, CDIM PolicyCoordinator, Clerkship Directors in Internal Medicine; Sheila T. Costa,Director of Meetings and Communications, Clerkship Directors in InternalMedicine; Rosemarie Houton, Administrative Representative, AmericanCollege of Physicians; Lisa Rockey, Education and Career DevelopmentCoordinator, American College of Physicians; and Helen Kitzmiller, PatientEducation Project Administrator, American College of Physicians. We alsothank the many others, too numerous to mention, who have contributed to thisproject. Without the dedicated efforts of them all, publication of this volumewould not have been possible.xvii
Section ICardiovascular MedicineChapter 1Approach to Chest PainChapter 2Chronic Stable AnginaChapter 3Acute Coronary SyndromeChapter 4Supraventricular ArrhythmiasChapter 5Ventricular ArrhythmiasChapter 6Heart FailureChapter 7Valvular Heart Disease
Chapter 1Approach to Chest PainDario M. Torre, MDCboth arms (positive likelihood ratio 7.1), an S3 (positive likelihood ratio 3.2), and hypotension (positive likelihood ratio 3.1). In contrast, a normal electrocardiogram result (negativelikelihood ratio 0.1-0.3), chest pain that is positional (negative likelihood ratio 0.3), chest pain reproduced by palpation(negative likelihood ratio 0.2-0.4), or chest pain that is sharp orstabbing (negative likelihood ratio 0.3) makes ischemic etiology less likely. Patients suspected of having acute coronary syndromeare hospitalized and evaluated with serial electrocardiograms andcardiac biomarkers, chest x-ray, and often echo- cardiography(Table 2). Low-risk patients without evidence of myocardial infarction are evaluated with an exercise or pharmacologic stress test.Coronary artery vasospasm (Prinzmetal’s angina) classicallypresents as rest pain, similar to angina, and may be associatedwith ST-segment elevation on the resting electrocardiogram.Cocaine use can cause chest pain and ST segment changes dueto ischemia or secondary to vasospasm without evidence of directmyocardial injury.Acute pericarditis (viral or bacterial) may be preceded or accompanied by symptoms of an upper respiratory tract infection andfever. Pericarditis is characterized by sudden onset of sharp, stabbing substernal chest pain with radiation along the trapezius ridge;the pain is often worse with inspiration and lying flat, and is frequently alleviated with sitting and leaning forward. A pericardialhest pain is one of the most common complaints in internal medicine. In outpatients, the most common cause ismusculoskeletal chest pain; in emergency settings, approximately 50% of patients have acute coronary syndrome (i.e.,myocardial infarction or unstable angina). Differential diagnosis ofchest pain can be approached as cardiac, pulmonary, gastrointestinal, musculoskeletal, and psychiatric causes (Table 1).Cardiac CausesAcute coronary syndrome is an important cause of chest pain.Ischemic chest pain classically presents as substernal pressure,tightness, or heaviness with radiation to the jaw, shoulders, back,or arms. The pain is typically related to exertion and relieved byrest or nitroglycerin, and may be accompanied by dyspnea,diaphoresis, and nausea. Recent onset or increasing symptoms ofchest discomfort occurring at rest without elevation of biomarkers(e.g., creatine kinase and troponin) is consistent with unstable angina. Patients with diabetes, women, or the elderly may present withatypical symptoms, such as dyspnea without chest pain. Ischemicchest pain typically lasts 20 minutes; pain of longer duration suggests myocardial infarction or an alternative diagnosis. The mostpowerful clinical features that increase the probability of myocardial infarction include chest pain that simultaneously radiates toTable 1. Differential Diagnosis of Chest PainDiseaseNotesAcute coronary syndrome (see Chapter 3)Chest pain, nausea, or dyspnea. Associated with specific ECG and echocardiographic changes. Cardiacenzymes help establish diagnosis of myocardial infarction.Aortic dissectionSubsternal chest pain with radiation to the back, mid-scapular region. Often described as “tearing” or“ripping” type pain. Chest x-ray may show a widened mediastinal silhouette, a pleural effusion, or both.Aortic stenosis (see Chapter 7)Chest pain with exertion, heart failure,
University of Pittsburgh School of Medicine University of Pittsburgh Medical Center Pittsburgh, Pennsylvania Nicole M. Cotter, MD Fellow, Section of Rheumatology Center of Excellence for Arthritis and Rheumatology Health Sciences Center Louisiana State University School of Medicine Shreveport, Louisiana Reed E. Drews, MD, FACP Program Director
