Acute Rheumatic Fever ■ Essentials of Diagnosis • A systemic immune process

complicating group A beta-hemolytic streptococcal pharyngitis • Usually affects

children between the ages of 5 and 15; rare after 25 • Occurs 1–5 weeks after
throat infection • Diagnosis based on Jones’ criteria (two major or one major and
two minor) and confirmation of recent streptococcal infection • Major criteria:
Erythema marginatum, migratory polyarthritis, subcutaneous nodules, carditis,
and Sydenham’s chorea; the latter is the most specific, least sensitive • Minor
criteria: Fever, arthralgias, elevated erythrocyte sedimentation rate, elevated C-
reactive protein, PR prolongation on ECG, and history of pharyngitis ■ Differential
Diagnosis • Juvenile or adult rheumatoid arthritis • Endocarditis • Osteomyelitis •
Systemic lupus erythematosus • Lyme disease • Disseminated gonococcal
infection ■ Treatment • Bed rest until vital signs and ECG become normal •
Salicylates and nonsteroidal anti-inflammatory drugs reduce fever and joint
complaints but do not affect the natural course of the disease; rarely,
corticosteroids may be used • If streptococcal infection is still present, penicillin is
indicated • Prevention of recurrent streptococcal pharyngitis until 18 years old (a
monthly injection of benzathine penicillin is most commonly used) Acute
Respiratory Distress Syndrome (ARDS) ■ Essentials of Diagnosis • Rapid onset of
dyspnea and respiratory distress, commonly in setting of trauma, shock,
aspiration, or sepsis • Tachypnea, fever; crackles heard by auscultation • Arterial
hypoxemia refractory to supplemental oxygen, frequently requiring positive
pressure ventilation; hypercapnia and respiratory acidosis due to increase in dead
space fraction and decrease in tidal volume (lungs become stiff and difficult to
expand) • Diffuse alveolar and interstitial infiltrates by radiography, often sparing
costophrenic angles • No clinical evidence of left atrial hypertension; pulmonary
capillary wedge pressure < 18 mm Hg • Acute lung injury defined by a Pao2:Fio2
ratio < 300; ARDS is defined by Pao2:Fio2 ratio < 200 ■ Differential Diagnosis •
Cardiogenic pulmonary edema • Primary pneumonia due to any cause • Diffuse
alveolar hemorrhage • Acute interstitial pneumonia (ie, Hamman-Rich syndrome)
• Cryptogenic organizing pneumonia ■ Treatment • Mechanical ventilation with
supplemental oxygen; positive endexpiratory pressure often required • Low-tidal-
volume ventilation, using 6 mL/kg predicted body weight, may reduce mortality •
A conservative fluid strategy targeting an even total body fluid balance (requires
daily diuretics) decreases both time on the ventilator and time in the ICU •
Supportive therapy including adequate nutrition, vigilance for other organ
dysfunction, and prevention of nosocomial complications (eg, catheter-related
infection, UTI, ventilator-associated pneumonia, venous thromboembolism, stress
gastritis) • Mortality rate is 30–60%

Alcoholic Hepatitis ■ Essentials of Diagnosis • Onset usually after years of alcohol

intake; anorexia, nausea, abdominal pain • Fever, jaundice, tender hepatomegaly,
ascites, encephalopathy • Macrocytic anemia, leukocytosis with left shift,
thrombocytopenia, abnormal liver function tests (AST about double ALT,
increased bilirubin, prolonged prothrombin time), hypergamma globulinemia; AST
rarely exceeds 300 U/L despite severity of illness • Liver biopsy if diagnosis is in
doubt ■ Differential Diagnosis • Cholelithiasis, cholecystitis, cholangitis • Cirrhosis
due to other causes • Nonalcoholic fatty liver • Viral hepatitis • Drug-induced
hepatitis • Autoimmune liver disease ■ Treatment • General supportive measures
including nutritional support, withdrawal of alcohol, avoidance of hepatotoxins
(especially acetaminophen) • Treat any ascites, hepatic encephalopathy • Screen
for bacterial infections (CBC, blood and urine cultures, ascites fluid cell count and
culture if present, chest x-ray) • Methylprednisolone (32 mg/d for 4 weeks) or
pentoxifylline (400 mg three times a day for 4 weeks) may be beneficial in severe
acute disease when discriminant function (4.6 [PT – control] + bilirubin [mg/dL]) is
> 32 (study exclusion criteria: active GI bleeding, infection) Acute Liver Failure ■
Essentials of Diagnosis • Severe liver injury in a person with previously normal
liver function, associated with development of hepatic encephalopathy and
evidence of hepatic synthetic dysfunction • Patients often present with new-
onset jaundice, anorexia, nausea, vomiting, flulike symptoms, or altered mental
status • Etiologies include acetaminophen overdose, idiosyncratic drug reaction,
acute viral hepatitis, exposure to hepatotoxins, autoimmune hepatitis, Wilson’s
disease, complications of pregnancy, and vascular disorders • Markedly abnormal
liver function tests: Elevated bilirubin, AST/ALT > 1000, elevated international
normalized ratio. • Prognosis depends on etiology, rapidity of onset and degree of
encephalopathy, and development of complications ■ Differential Diagnosis •
Acute decompensation of chronic liver disease • Acute viral hepatitis; alcoholic
hepatitis; sepsis • Idiopathic drug reaction ■ Treatment • Prompt recognition of
acute liver failure key • Consider giving N-acetylcysteine to all cases of acute liver
failure, not just patients with acetaminophen overdose • After resuscitation and
stabilization, transfer to a transplant center • Surveillance for infection; consider
prophylactic antibiotics in patients with advanced encephalopathy, systemic
inflammatory response syndrome, or awaiting liver transplantation •
Management of complications: hepatic encephalopathy, cerebral edema, acute
renal failure, acute respiratory distress syndrome, cardiovascular compromise,
metabolic disturbances, bleeding • Liver transplantation in select patients

Peptic Ulcer ■ Essentials of Diagnosis • Epigastric pain 45–60 minutes following

meals or nocturnal pain, both relieved by food or antacids, sometimes by
vomiting; symptoms chronic and periodic; radiation to back common; patients
may complain of weight gain • Iron deficiency anemia, positive fecal occult blood;
amylase elevated with posterior penetration • Radiographic or endoscopic
evaluation will demonstrate ulcer crater or deformity of duodenal bulb, and
exclude other diagnoses such as malignancy • Caused by Helicobacter pylori in
70% of cases, NSAIDs in 20–30%, Zollinger-Ellison syndrome in < 1%; H. pylori
infection may be diagnosed serologically, with biopsy or by breath test •
Complications include hemorrhage, intractable pain, penetration, perforation,
and obstruction ■ Differential Diagnosis • Reflux esophagitis • Gastritis •
Pancreatitis • Cholecystitis • Other peptic disease (eg, Zollinger-Ellison syndrome
[1% of patients with peptic ulcer disease] or gastric ulcer) ■ Treatment • Eradicate
H. pylori when present • Avoid tobacco, alcohol, xanthines, and ulcerogenic
drugs, especially NSAIDs • H2 blockers, proton pump inhibitors, and sucralfate •
Endoscopic therapy for actively bleeding ulcers • Surgery—now far less common
—may be needed for ulcers refractory to medical management (rare) or for the
management of complications (eg, perforation, uncontrolled bleeding);
supraselective vagotomy preferred unless patient unstable or is obstruct Gastric
Ulcer or H. pylori ■ Essentials of Diagnosis • Epigastric pain unpredictably
relieved by food or antacids; weight loss, anorexia, vomiting • Iron deficiency
anemia, fecal occult blood positive • Ulcer demonstrated by barium study or
endoscopy • Caused by Helicobacter pylori (in 70% of cases), NSAIDs, gastric
malignancy, or rarely, Zollinger-Ellison syndrome • Endoscopic biopsy or
documentation of complete healing necessary to exclude malignancy •
Complications include hemorrhage, perforation, and obstruction ■ Differential
Diagnosis • Other peptic ulcer disease • Gastroesophageal reflux • Gastric
carcinoma • Cholecystitis • Esophagitis • Gastritis • Irritable or functional bowel
disease such as nonulcer dyspepsia ■ Treatment • Eradicate H. pylori when
present • Avoid tobacco, alcohol, xanthines, and ulcerogenic drugs, especially
NSAIDs • Proton pump inhibitors, sucralfate, H2-receptor antagonists •
Endoscopic therapy for actively bleeding ulcers • Surgery may be needed for
ulcers refractory to medical management (rare, and must exclude cancer if ulcer
not healing) or for the management of complications (eg, perforation,
uncontrolled bleeding)

Paroxysmal Supraventricular Tachycardia (PSVT) ■ Essentials of Diagnosis • A

group of arrhythmias including atrioventricular nodal reentrant, atrioventricular
reentrant tachycardias, automatic atrial tachycardia, and junctional tachycardia •
Attacks usually begin and end abruptly, last seconds to hours • Patients often
asymptomatic with transient episodes but may complain of palpitations, mild
dyspnea, or chest pain • Electrocardiography between attacks normal unless the
patient has Wolff-Parkinson-White syndrome or a very short PR interval • Unless
aberrant conduction occurs, the QRS complexes are regular and narrow; P wave
location helps determine the origin; electrophysiologic study establishes the exact
diagnosis ■ Differential Diagnosis No P: • Atrioventricular nodal reentry
tachycardia Short RP: • Typical atrioventricular reentrant tachycardia •
Orthodromic atrioventricular reentrant tachycardia • Atrial tachycardia with 1st
degree AV delay • Junctional tachycardia Long RP: • Atrial tachycardia • Sinus
tachycardia • Atypical atrioventricular nodal reentry tachycardia • Permanent
junctional reciprocating tachycardia ■ Treatment • Many attacks resolve
spontaneously; if not, first try vagal maneuvers such as carotid sinus massage or
adenosine to transiently block the AV node and break the reentrant circuit •
Prevention of frequent attacks can be achieved by calcium channel blockers, beta-
blockers, or antiarrhythmics if necessary • Electrophysiologic study and ablation
of the abnormal reentrant circuit or focus, when available, is the treatment of
choice Chronic Obstructive Pulmonary Disease (COPD) ■ Essentials of Diagnosis •
Primarily consisting of emphysema and chronic bronchitis • Dyspnea or chronic
productive cough or both are characteristic; COPD is nearly always a disease of
heavy smokers (80–90%) • Tachypnea, barrel chest, distant breath sounds,
wheezes or rhonchi, cyanosis; clubbing unusual • Hypoxemia and hypercapnia
more pronounced with chronic bronchitis than with emphysema, whereas
pulmonary hypertension is more common in patients with emphysema •
Hyperexpansion with decreased markings by chest radiography • Airflow
obstruction by spirometry (FEV1/FVC ratio < 0.70); reduced diffusing capacity
(DLCO) in emphysema ■ Differential Diagnosis • Asthma • Bronchiectasis • β1-
Antitrypsin deficiency • Bronchiolitis ■ Treatment • Stopping smoking is most
important intervention • Inhaled anticholinergic agents improve symptoms and
decrease exacerbations (inhaled tiotropium may be superior to ipratropium) •
Long-acting β-agonists decrease exacerbations • Chronic inhaled glucocorticoids
may increase pneumonia risk; use only if patient has clear symptomatic
improvement • Pneumococcal vaccination; yearly influenza vaccination •
Supplemental oxygen for hypoxemic patients (Pao2 < 55 mm Hg or O2 saturation
< 88%) reduces mortality • For exacerbations, treat with bronchodilators,
antibiotics, systemic glucocorticoids with taper over 2 weeks • Inpatients with
ventilatory failure have a mortality benefit from the institution of early
noninvasive positive pressure ventilation • Lung reduction surgery in selected
patients with emphysema