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DivisionofGeneralMedicalSciences

JamesA.Giles,MD

Fellow DivisionofNeurology

AnneC.Goldberg,MD

ProfessorofMedicine DivisionofEndocrinology,Metabolism,andLipidResearch

SethGoldberg,MD

AssociateProfessorofMedicine DivisionofNephrology

RamaswamyGovindan,MD

ProfessorofMedicine DivisionofMedicalOncology

MartinH.Gregory,MD

Fellow DivisionofGastroenterology

RodrigoVazquezGuillamet,MD

AssociateProfessorofMedicine DivisionofPulmonaryandCriticalCareMedicine

C.PrakashGyawali,MD

ProfessorofMedicine DivisionofGastroenterology

LauraHalverson,MD

AssistantProfessorofMedicine DivisionofPulmonaryandCriticalCareMedicine

KatrinaHan,MD

Fellow DivisionofEndocrinology,Metabolism,andLipidResearch

JustinC.Hartupee,MD

AssistantProfessorofMedicine CardiovascularDivision

CynthiaJ.Herrick,MD,MPHS

AssociateProfessorofMedicine DivisionofEndocrinology,Metabolism,andLipidResearch

https://t.me/med1917

SueLinHilbert,MD,MPH

AssociateProfessorofEmergencyMedicine DepartmentofEmergencyMedicine

WutYiHninn,MD,MBBS

Fellow TransplantNephrology

DanielT.Ilges,PharmD,BCIDP

PharmacyResident DivisionofInfectiousDiseases

EricJohnson,MD

AssistantProfessorofMedicine DivisionofHospitalMedicine

KaiJones,MD

Resident DepartmentofInternalMedicine

PaulKannarkat,MD

InstructorinMedicine DivisionofPulmonaryandCriticalCareMedicine

PhillipM.King,MD

Fellow CardiovascularDivision

NigarKirmani,MD

ProfessorofMedicine DivisionofInfectiousDiseases

MarinH.Kollef,MD

ProfessorofMedicine DivisionofPulmonaryandCriticalCareMedicine

JamesG.Krings,MD,MSCI

AssistantProfessor DivisionofPulmonaryandCriticalCareMedicine

MarkD.Levine,MD

AssociateProfessorofEmergencyMedicine DepartmentofEmergencyMedicine

StephenY.Liang,MD,MPHS

https://t.me/med1917

AssociateProfessorofMedicine DivisionofInfectiousDiseases

MichaelLin,MD

AssociateProfessor DivisionofHospitalMedicine

CalineMattar,MD

AssistantProfessorofMedicine DivisionofInfectiousDiseases

JanetB.McGill,MD

ProfessorofMedicine DivisionofEndocrinology,Metabolism,andLipidResearch

CarlosMejia-Chew,MD

AssistantProfessorofMedicine DivisionofInfectiousDiseases

JenniferM.Monroy,MD

AssociateProfessorofMedicine DivisionofAllergyandImmunology

DanielMorgensztern,MD

ProfessorofMedicine DivisionofMedicalOncology

NathanielMoulton,MD

Fellow DivisionofPulmonaryandCriticalCareMedicine

MichaelE.Mullins,MD

AssociateProfessorofEmergencyMedicine DepartmentofEmergencyMedicine

BlessingOsondu,MD

Fellow DivisionofPulmonaryandCriticalCareMedicine

BindiyaG.Patel,MD

Fellow DivisionofMedicalOncology

MaryE.Petrulis,MD

ClinicalFellow

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DivisionofNeurology

RachelM.Presti,MD,PhD

AssociateProfessorofMedicine DivisionofInfectiousDiseases

NishathQuader,MD

AssociateProfessorofMedicine CardiovascularDivision

AndreaRamirezGomez,MD

Fellow DivisionofRheumatology

DominicReeds,MD

ProfessorofMedicine DivisionofGeriatricsandNutritionalScience

SanaSaifUrRehman,MD

AssistantProfessor DivisionofHematology

HilaryE.L.Reno,MD,PhD

AssociateProfessorofMedicine DivisionofInfectiousDiseases

AmyE.Riek,MD

AssistantProfessorofMedicine DivisionofEndocrinology,Metabolism,andLipidResearch

DavidJ.Ritchie,PharmD

ClinicalPharmacistSpecialist InfectiousDiseases,Barnes-JewishHospital

RebeccaRoediger,MD

Fellow DivisionofGastroenterology

DavidB.Rose,MD

Fellow DivisionofPulmonaryandCriticalCareMedicine

TonyaD.Russell,MD

ProfessorofMedicine DivisionofPulmonaryandCriticalCareMedicine

https://t.me/med1917

MaryamSaleem,MD

Fellow DivisionofNephrology

KristenM.Sanfilippo,MD

AssistantProfessorofMedicine DivisionofHematology

RowenaDelosSantos,MD

AssociateProfessorofMedicine DivisionofNephrology

EvanS.Schwarz,MD

AssociateProfessorofMedicine DepartmentofEmergencyMedicine

GabrielSchroeder,MD

Fellow DivisionofPulmonaryandCriticalCareMedicine

DeepaliSen,MD

AssociateProfessorofMedicine DivisionofRheumatology

ParthShah,MD

Fellow DivisionofGastroenterology

AdrianShifren,MD

AssistantProfessorofMedicine DivisionofPulmonaryandCriticalCareMedicine

MarcA.Sintek,MD

AssistantProfessorofMedicine CardiovascularDivision

SandeepS.Sodhi,MD,MBA

AssistantProfessorofMedicine CardiovascularDivision

KaharuSumino,MD

AssociateProfessorofMedicine DivisionofPulmonaryandCriticalCareMedicine

JustinM.Vader,MD

https://t.me/med1917

AssociateProfessorofMedicine CardiovascularDivision

DayneVoelker,MD

Fellow DivisionofAllergyandImmunology

Tzu-FeiWang,MD

AssistantProfessorofInternalMedicine DivisionofHematology,TheOhioStateUniversity

DominiqueS.Williams,MD

AssistantProfessorofMedicine CardiovascularDivision

NoahN.Williford,MD

Fellow CardiovascularDivision

BinQ.Yang,MD

Fellow CardiovascularDivision

RogerD.Yusen,MD,MPH

AssociateProfessorofMedicine DivisionofPulmonaryandCriticalCareMedicine

RayZhang,MD,PhD

AssistantProfessorofMedicine DepartmentofPathology&Immunology,DivisionofLaboratory&GenomicMedicine

AmyZhou,MD

AssistantProfessorofMedicine DivisionofMedicalOncology

https://t.me/med1917

InpatientCareinInternalMedicine

MichaelLin,EricJohnson,CrystalAtwood

GeneralCareoftheHospitalizedPatient

GENERALPRINCIPLES

Althougha generalapproachtocommon problemscanbeoutlined,therapy must be individualized.

All diagnostic and therapeutic proceduresshould be explainedcarefullytothe patient, includingthe

potentialrisks,benefits,andalternatives.

The period of hospitalizationrepresents a complexinterplayofmultiple caregivers that subjects the

patienttopotentialharmbymedicalerrorsandiatrogeniccomplications.Everyeffortmustbemade

tominimizetheserisks.Basicmeasuresincludethefollowing:

Useofstandardizedabbreviationsanddosedesignations Excellentcommunicationbetweenphysiciansandothercaregivers Institutionofappropriateprophylacticprecautions Prevention of nosocomial infections, including attention to hygiene and discontinuation of unnecessarycatheters Medicinereconciliationatalltransfersofcare

Hospitalorders

Admissionordersshouldbeenteredpromptlyafterevaluationofapatient. Daily rounds should include assessment for ongoing need of IV fluids, telemetry, catheters, and supplementaloxygen,allofwhichcanlimitmobility. Theneedfordailylabsshouldbereassessedeachdaywhilepatientsareadmittedinthehospital.

Discharge

Dischargeplanningbeginsatthetimeofadmission.Assessmentofthepatient’ssocialsituationand

potentialdischargeneedsshouldbeplanned. Earlycoordinationwithnursing,socialwork,andcase coordinators facilitatesefficientdischarge andacompletepostdischargeplan. Patient education should occur regarding changes in medications and other new therapies. Adherenceisinfluencedbythepatient’sunderstandingofthetreatmentplan. Prescriptionsshouldbewrittenforallnew medication,andthe patientshouldbeprovided witha completemedicationlistincludinginstructionsandindications. Communicationwithphysicianswhowillberesumingcareofthepatientis importantforoptimal follow-upcareandshouldbeacomponentofthedischargeprocess.

ProphylacticMeasures

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VenousThromboembolismProphylaxis

GENERALPRINCIPLES

Epidemiology

Venousthromboembolism(VTE)isapreventablecauseofdeathinhospitalizedpatients.Inthelargest observationalstudytodateattemptingtorisk-stratifymedicalpatients,1.2%ofmedicalpatients developedVTEwithin90daysofadmission.Atotalof10%–31%ofpatientsweredeemedtobeathigh riskforVTE,definedashavingtwoormorepointsbyweightedriskfactorslistedbelow1:

Threepoints:previousVTE,thrombophilia

Onepoint:cancer,age>60years

Prevention

Ambulationseveraltimesadayshouldbeencouraged.

Pharmacologicprophylaxisresultsina50%decreaseinVTErisk.Nooverallmortalitybenefitfrom

prophylaxishasbeendemonstrated.

AcutelyillpatientsathighriskofVTE,withoutbleedingorhighriskofbleeding,canbetreatedwith

low-dose unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) such as

enoxaparin,dalteparin,orfondaparinux.

Betrixabanandrivaroxabanaretheonlydirectoralanticoagulantapprovedfordeepvenousthrombosis

DVTprophylaxisinnonsurgicalhospitalizedpatients.

Aspirinaloneisnotsufficientforprophylaxisinhospitalizedpatients.

At-risk patients with contraindications to anticoagulation prophylaxis may receive mechanical

prophylaxis with intermittent pneumatic compression or graded compression stockings, although

evidenceofbenefitislacking.

DecubitusUlcers

GENERALPRINCIPLES

Epidemiology

Decubitusulcerstypicallyoccurwithinthefirst2weeksofhospitalizationandcandevelopwithin2–6 hours.Oncetheydevelop,decubitusulcersaredifficulttohealandhavebeenassociatedwithincreased mortality.5Themostimportantriskfactorsforthedevelopmentofdecubitusulcersareimmobility, malnutrition,reducedskinperfusion,andsensoryloss.

Prevention

Preventioniskeytomanagementofdecubitusulcers.Itisrecognizedthatnotalldecubitusulcersare avoidable.Preventativemeasuresincludethefollowing:

Advancedstaticmattressesoroverlaysshouldbeusedinat-riskpatients.

Skin care includes daily inspection with particular attention to bony prominences including heels,

minimizingexposuretomoisture,andapplyingmoisturizerstodrysacralskin.

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Nutritionalsupplementsmaybeprovidedtopatientsatrisk.

Frequentrepositioning(minimumofevery2hours)issuggested.

Multilayerfoamdressingshavebeenshowntoreducetheratesofpressureinjuries.

DIAGNOSIS

NationalPressureUlcerAdvisoryPanelStaging:

Suspecteddeeptissueinjury:Localizedareaofpurpleormaroon intactskin or blood-filledblister

becauseofdamageofunderlyingsofttissuefrompressureand/orshear.

Stage I: Intact skinwithnonblanching redness ofa localizedarea usuallyover a bony prominence.

Darklypigmentedskinmayobscurefindings.

StageII:Partial thickness lossofdermispresenting as a shallowopenulcerwith a redpinkwound

bedwithoutslough.Mayalsopresentasablister.

StageIII:Full-thicknesstissueloss.Subcutaneousfatmaybevisible,butthebone,tendon,ormuscle

is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include

underminingandtunneling.

StageIV: Full-thicknesstissueloss withexposedbone,tendon, or muscle.Sloughorescharmaybe

presentonsomepartsofthewoundbed.Oftenincludesunderminingandtunneling.

Unstageable:Full-thicknesstissuelossinwhichthebaseoftheulcer iscovered byslough(yellow,

tan,gray,green,orbrown)and/oreschar(tan,brown,orblack)inthewoundbed.

TREATMENT

Optimaltreatmentofpressureulcersremainspoorlydefined.Thereisevidencetosupportthefollowing:

Hydrocolloidorfoamdressingsmayreducewoundsize.

Electricalstimulationmayacceleratehealing.

Otheradjunctivetherapieswithlesssupportingevidenceincluderadiantheat,negativepressure,and

platelet-derived growth factor. Topical agents (Santyl, Xenaderm) may optimize healing or lead to

minorsloughdébridement.

OtherPrecautions

Fallprecautionsshouldbewrittenforpatientswhoareathighriskofafall(e.g.,dementia,weakness,

orthostasis).Fallsarethemostcommonaccidentinhospitalizedpatients,frequentlyleadingtoinjury.

Fallriskshouldnotbeequatedwithbedrest,whichmayleadtodebilitationandhigherriskoffuture

falls.

Seizure precautions, which include padded bed rails andan oral airwayatthe bedside, should be

consideredforpatientswithahistoryofseizuresorthoseatriskofseizing.

Restraintordersarewrittenforpatientswhoareatriskofinjuringthemselvesorinterferingwiththeir

treatment becauseofdisruptive or dangerousbehaviors. Physical restraintsmayexacerbateagitation.

Bedalarms,sitters,andsedativesarealternativesinappropriatesettings.

AcuteInpatientCare

Anapproachtoselectedcommoncomplaintsispresentedinthissection.Anevaluationshouldgenerally includeadirectedhistoryandphysicalexamination,reviewofthemedicalproblemlist,reviewof medicationswithattentiontorecentmedicationchanges,andconsiderationofrecentprocedures.

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ChestPain

GENERALPRINCIPLES

Commoncausesofchestpainrangefromlife-threateningcausessuchasmyocardialinfarction(MI)and pulmonaryembolism(PE)toothercausesincludingesophagealreflux,pepticulcerdisease,pneumonia, costochondritis,shingles,trauma,andanxiety.

DIAGNOSIS

HistoryandPhysicalExamination

History should include previous cardiac or vascular disease history, cardiac risk factors, and risk

factorsforVTE.

Physicalexaminationisideallyconductedduringanepisodeofpainandincludesvitalsigns(bilateral

bloodpressure[BP] measurementsifconsidering aorticdissection),cardiopulmonaryandabdominal

examination,andinspectionandpalpationofthechest.

DiagnosticTesting

Assessmentofoxygenationstatus,CXR,andECGisappropriateinmostpatients.Serialcardiac biomarkersshouldbeobtainedifthereissuspicionofischemia.SpiralCTandventilation/perfusion scanscanbeusedtodiagnosePE.

TREATMENT

Ifcardiacischemiaisaconcern,seeChapter4,IschemicHeartDisease,fordetails.

MusculoskeletalpaintypicallyrespondstoacetaminophenorNSAIDtherapy.

PrompttreatmentisnecessaryifthereishighsuspicionforMIorPE.

Dyspnea

GENERALPRINCIPLES

Dyspneaismostcommonlycausedbyacardiopulmonaryabnormality,suchascongestiveheartfailure (CHF),cardiacischemia,bronchospasm,PE,infection,mucusplugging,andaspiration.Dyspneamustbe promptlyandcarefullyevaluated.

DIAGNOSIS

HistoryandPhysicalExamination

Initial evaluation should include a review of the medical history for underlying pulmonary or

cardiovasculardiseaseandadetailedhistoryofpresentillness.

Adetailedcardiopulmonaryexaminationshouldtakeplace.

DiagnosticTesting

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