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Produced by ACP and the Clerkship Directors in Internal Medicine (CDIM), IM Essentials Text and IM Essentials Questions are the next. Download as PDF, TXT or read online from Scribd. Flag for .. Based upon student feedback, IM Essentials 2 con- clerkship directors or clerkship faculty, representing 45 tains twice as many Correction of dosage error in text. Crit Care Med. IM Essentials Text is part of the IM Essentials suite of study materials produced for students through a collaboration of the American College of Physicians and the Clerkship Directors in Internal Medicine. Download Best Book IM Essentials Text, PDF FILE Download IM Essentials.


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Read Online Premium E-Books IM Essentials Text American College of IM Essentials Text is an abbreviated medical textbook organized by the For Full BOOK ONLINE BEST PDF Premium E-Books IM Essentials Text. IM Essentials Text is based on the national core curriculum and written by clerkship directors to cover all of the key content needed for students to get the most. Includes FREE access to the online version of IM Essentials containing both questions and text plus flashcards! See access code inside. text.

Pulse or blood pressure differential useful but uncommonly present.

INTERNAL MEDICINE Essentials for Clerkship Students 2 pdf

Chest radiograph may show a widened mediastinal silhouette, pleural effusion, or both. Intense retrosternal pain after vomiting; often associated with ethanol use. Pneumomediastinum on CXR can be seen. Chest pain with exertion, heart failure, syncope.

Typical systolic murmur at the base of the heart radiating to the neck. May be indistinguishable from angina. Often diagnosed after a negative evaluation for ischemic heart disease. Often associated with palpitations, sweating, and anxiety.

Typically more reproducible chest pain. Includes muscle strain, costochondritis, and fracture.

Should be a diagnosis of exclusion. Burning-type chest discomfort usually precipitated by meals and not related to exertion. It is often worse upon lying down and improved with sitting. Low-risk patients without evidence of MI are evaluated with exercise or pharmacologic stress testing, as indicated.

Higher-risk patients or those with STsegment elevations undergo urgent cardiac catheterization. Cocaine use can cause chest pain and ST-segment changes due to vasospasm, even in patients without significant occlusive coronary artery disease, and may result in myocardial injury.

Pericarditis is characterized by sudden onset of sharp, stabbing, substernal chest pain with radiation along the trapezius ridge. Often, the pain is worse with inspiration and lying flat and is alleviated with sitting and leaning forward. Given the ephemeral nature of the friction rub, its absence does not rule out pericarditis.

The classic rub consists of three components: An echocardiogram may be helpful if there is suspicion of significant pericardial effusion or pericardial tamponade. Acute pericarditis secondary to infection viral or bacterial may be preceded or accompanied by symptoms of an upper respiratory tract infection and fever.

In patients with acute pericarditis, hospitalization is prompted by an associated MI, pyogenic infection, or tamponade. Outpatient management is appropriate if other potentially serious causes of chest pain are excluded, hemodynamic status is normal, and a moderate or large pericardial effusion is excluded by echocardiography.

In the absence of a specific cause for acute peri-. Although dissection is fairly rare compared to other chest pain causes an incidence of 3 per , patients per year , it can be rapidly life threatening. An early diastolic murmur due to acute aortic insufficiency may be heard, particularly if the dissection involves the ascending aorta, but the presence or absence of a diastolic murmur is not useful in ruling in or ruling out dissection. When aortic dissection is suspected, imaging the aorta is indicated.

Because of an increased risk of coronary artery dissection and tamponade with dissection progression, dissections involving the ascending aorta and. Figure 1. Electrocardiogram showing sinus rhythm with diffuse ST-segment elevation consistent with acute pericarditis. Aortic stenosis is a cause of exertional chest pain and may also be accompanied by dyspnea, palpitations, and exertional syncope due to a diminished cardiac output see Chapter 9. Physical examination reveals a systolic, crescendo-decrescendo murmur best heard at the second right intercostal space, with radiation to the right carotid artery.

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A transthoracic echocardiogram is the diagnostic test of choice for patients with suspected aortic stenosis. Patients with spontaneous esophageal rupture typically have severe retching and vomiting followed by excruciating retrosternal chest and upper abdominal pain. These symptoms are followed by the rapid development of odynophagia, tachypnea, dyspnea, cyanosis, fever, and shock.

Many cases are related to excessive alcohol ingestion. Chest radiography may show pneumomediastinum, although computed tomography is more sensitive for making this diagnosis. Patients with acute cholecystitis frequently present with right upper quadrant and lower chest pain that may radiate to the right shoulder and is associated with nausea, vomiting, and fever see Chapter On physical examination, deep palpation during inspiration can elicit pain in the right upper quadrant and cause inspiratory arrest Murphy sign.

Physical examination findings are nonspecific but may include tachypnea and tachycardia. ECG readings may also show findings of right ventricular strain, but the most common finding is sinus tachycardia.

A negative D-dimer, a test for PE with a high specificity but low sensitivity, can exclude the diagnosis when clinical suspicion is low. When suspicion is moderate or high, however, a spiral computed tomography scan or a ventilation-perfusion lung scan is an appropriate initial approach Pleuritic chest pain can also be a manifestation of pneumonia and is associated with fever, chills, cough, purulent sputum, and dyspnea see Chapter The physical examination may show wheezing or crackles and signs of consolidation, such as dullness to percussion, egophony, and bronchophony.

Chest x-ray is considered the gold standard for pneumonia diagnosis and is an appropriate initial diagnostic test for any case of chest pain with a possible pulmonary etiology. Pneumothorax should be considered in any patient with sudden onset of pleuritic chest pain and dyspnea see Chapter It is most common in smokers, especially those with chronic obstructive pulmonary disease. The physical examination may reveal decreased breath sounds on the affected side; if a tension pneumothorax is present, hypotension and tracheal deviation to the opposite side of the pneumothorax may be noted.

Chest radiography shows a lack of lung markings on the affected side. In tension pneumothorax, there is a shift of the mediastinum away from the side of the pneumothorax, whereas hydropneumothorax is identified by the presence of concomitant pleural fluid. Although sometimes difficult to differentiate from ischemic cardiac chest pain, GERD pain often lasts minutes to hours and resolves spontaneously or with antacids see Chapter Other symptoms may include heartburn, regurgitation, chronic cough, sore throat, and hoarseness.

On physical examination, patients may exhibit wheezing, halitosis, dental erosions, and pharyngeal erythema. In unclear cases, it is most appropriate to exclude cardiac causes of chest pain before evaluating gastrointestinal causes. For patients with a high probability of GERD, empiric treatment with a proton pump inhibitor for 4 to 6 weeks is an appropriate initial diagnostic and therapeutic approach.

Musculoskeletal Causes Musculoskeletal causes of chest pain are more common in women than in men. Often, the pain is worse with inspiration and lying flat and is alleviated with sitting and leaning forward.

Given the ephemeral nature of the friction rub, its absence does not rule out pericarditis. The classic rub consists of three components: occurring during atrial systole, ventricular systole, and ventricular diastole.

An echocardiogram may be helpful if there is suspicion of significant pericardial effusion or pericardial tamponade.

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Acute pericarditis secondary to infection viral or bacterial may be preceded or accompanied by symptoms of an upper respiratory tract infection and fever. In patients with acute pericarditis, hospitalization is prompted by an associated MI, pyogenic infection, or tamponade.

Outpatient management is appropriate if other potentially serious causes of chest pain are excluded, hemodynamic status is normal, and a moderate or large pericardial effusion is excluded by echocardiography. In the absence of a specific cause for acute peri- carditis, anti-inflammatory therapy with nonsteroidal anti-inflammatory drugs NSAIDs is the mainstay of treatment.

Although dissection is fairly rare compared to other chest pain causes an incidence of 3 per , patients per year , it can be rapidly life threatening.

An early diastolic murmur due to acute aortic insufficiency may be heard, particularly if the dissection involves the ascending aorta, but the presence or absence of a diastolic murmur is not useful in ruling in or ruling out dissection.

When aortic dissection is suspected, imaging the aorta is indicated. Because of an increased risk of coronary artery dissection and tamponade with dissection progression, dissections involving the ascending aorta and Figure 1. Electrocardiogram showing sinus rhythm with diffuse ST-segment elevation consistent with acute pericarditis. Aortic stenosis is a cause of exertional chest pain and may also be accompanied by dyspnea, palpitations, and exertional syncope due to a diminished cardiac output see Chapter 9.

Physical examination reveals a systolic, crescendo-decrescendo murmur best heard at the second right intercostal space, with radiation to the right carotid artery.

A transthoracic echocardiogram is the diagnostic test of choice for patients with suspected aortic stenosis.

Patients with spontaneous esophageal rupture typically have severe retching and vomiting followed by excruciating retrosternal chest and upper abdominal pain. These symptoms are followed by the rapid development of odynophagia, tachypnea, dyspnea, cyanosis, fever, and shock.

Many cases are related to excessive alcohol ingestion. Chest radiography may show pneumomediastinum, although computed tomography is more sensitive for making this diagnosis. Patients with acute cholecystitis frequently present with right upper quadrant and lower chest pain that may radiate to the right shoulder and is associated with nausea, vomiting, and fever see Chapter On physical examination, deep palpation during inspiration can elicit pain in the right upper quadrant and cause inspiratory arrest Murphy sign.

Physical examination findings are nonspecific but may include tachypnea and tachycardia. ECG readings may also show findings of right ventricular strain, but the most common finding is sinus tachycardia. A negative D-dimer, a test for PE with a high specificity but low sensitivity, can exclude the diagnosis when clinical suspicion is low.

When suspicion is moderate or high, however, a spiral computed tomography scan or a ventilation-perfusion lung scan is an appropriate initial approach Pleuritic chest pain can also be a manifestation of pneumonia and is associated with fever, chills, cough, purulent sputum, and dyspnea see Chapter The physical examination may show wheezing or crackles and signs of consolidation, such as dullness to percussion, egophony, and bronchophony.

Chest x-ray is considered the gold standard for pneumonia diagnosis and is an appropriate initial diagnostic test for any case of chest pain with a possible pulmonary etiology. Pneumothorax should be considered in any patient with sudden onset of pleuritic chest pain and dyspnea see Chapter It is most common in smokers, especially those with chronic obstructive pulmonary disease.

The physical examination may reveal decreased breath sounds on the affected side; if a tension pneumothorax is present, hypotension and tracheal deviation to the opposite side of the pneumothorax may be noted. Chest radiography shows a lack of lung markings on the affected side.

In tension pneumothorax, there is a shift of the mediastinum away from the side of the pneumothorax, whereas hydropneumothorax is identified by the presence of concomitant pleural fluid.

Although sometimes difficult to differentiate from ischemic cardiac chest pain, GERD pain often lasts minutes to hours and resolves spontaneously or with antacids see Chapter Other symptoms may include heartburn, regurgitation, chronic cough, sore throat, and hoarseness. On physical examination, patients may exhibit wheezing, halitosis, dental erosions, and pharyngeal erythema. In unclear cases, it is most appropriate to exclude cardiac causes of chest pain before evaluating gastrointestinal causes.

For patients with a high probability of GERD, empiric treatment with a proton pump inhibitor for 4 to 6 weeks is an appropriate initial diagnostic and therapeutic approach. Musculoskeletal Causes Musculoskeletal causes of chest pain are more common in women than in men. Frequent causes of musculoskeletal chest pain include costochondritis, arthritis, and shoulder rotator cuff injuries.

Musculoskeletal chest pain has an insidious onset and may last for hours to weeks. It is most recognizable when sharp and localized to a specific area of the chest; however, it can also be poorly localized. The pain may be worsened by turning, deep breathing, or arm movement. Chest pain may or may not be reproducible by chest palpation; pain reproduced by palpation does not exclude ischemic heart disease. The cardiovascular examination often is normal.

For musculoskeletal chest pain, the history and physical examination are keys to the diagnosis; selected radiographic studies and laboratory tests may be indicated depending on the clinical circumstances.

Psychiatric Causes Chest pain can be a manifestation of severe anxiety and panic attacks. Patients may complain of sweating, trembling, or shaking; sensations of choking, shortness of breath, or smothering; nausea or abdominal distress; or feeling dizzy, unsteady, or lightheaded.Echocardiography can detect very small pericardial effusions that may help with the diagnosis of pericarditis.

Patients are taken off their nitrates at night to mitigate nitrate tolerance. Outpatient management is appropriate if other potentially serious causes of chest pain are excluded, hemodynamic status is normal, and a moderate or large pericardial effusion is excluded by echocardiography.

Book Enhancement to access tools to determine the best noninvasive test for your patient, to estimate likelihood of coronary artery disease following an exercise stress test, to estimate mortality rates, and to review indications for revascularization.

Chest x-ray may show a widened mediastinal silhouette, a pleural effusion, or both.

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