Download the full version and explore a variety of ebooks

or textbooks at https://ebookmass.com

Ferri's Clinical Advisor 2021: 5 Books in 1 Fred

F. Ferri MD FACP Fred F. Ferri Md Facp

_____ Tap the link below to start your download _____

https://ebookmass.com/product/ferris-clinical-
advisor-2021-5-books-in-1-fred-f-ferri-md-facp-fred-f-ferri-
md-facp/

Find ebooks or textbooks at ebookmass.com today!

 We believe these products will be a great fit for you. Click
the link to download now, or visit ebookmass.com
to discover even more!

Ferri’s Clinical Advisor 2019 Fred F. Ferri

https://ebookmass.com/product/ferris-clinical-advisor-2019-fred-f-
ferri/

Ferri's Clinical Advisor 2021: 5 Books in 1 1st Edition

Fred Ferri

https://ebookmass.com/product/ferris-clinical-advisor-2021-5-books-
in-1-1st-edition-fred-ferri/

Ferri’s Clinical Advisor 2018 20th Edition Fred F. Ferri

https://ebookmass.com/product/ferris-clinical-advisor-2018-20th-
edition-fred-f-ferri/

Ferri's Clinical Advisor 2022 1st Edition Fred F. Ferri

https://ebookmass.com/product/ferris-clinical-advisor-2022-1st-
edition-fred-f-ferri/
Cecil Essentials of Medicine 10th Edition Edward J. Wing
Md Facp Fidsa (Editor)

https://ebookmass.com/product/cecil-essentials-of-medicine-10th-
edition-edward-j-wing-md-facp-fidsa-editor/

Cecil Essentials of Medicine (Cecil Medicine) 10th Edition

Edward J. Wing Md Facp Fidsa (Editor)

https://ebookmass.com/product/cecil-essentials-of-medicine-cecil-
medicine-10th-edition-edward-j-wing-md-facp-fidsa-editor/

Diagnostic Ultrasound: Musculoskeletal 2nd Edition James

F. Griffith Md Mrcp Frcr (Author)

https://ebookmass.com/product/diagnostic-ultrasound-
musculoskeletal-2nd-edition-james-f-griffith-md-mrcp-frcr-author/

Essentials of Nuclear Medicine and Molecular Imaging:

Expert Consult - Online and Print 7th Edition Fred A.
Mettler Jr. Md Mph
https://ebookmass.com/product/essentials-of-nuclear-medicine-and-
molecular-imaging-expert-consult-online-and-print-7th-edition-fred-a-
mettler-jr-md-mph/

Advances in Ophthalmology and Optometry, 2021 (Volume 6-1)

(Advances, Volume 6-1) Myron Yanoff Md (Editor)

https://ebookmass.com/product/advances-in-ophthalmology-and-
optometry-2021-volume-6-1-advances-volume-6-1-myron-yanoff-md-editor/
CLINICAL DISORDERS Ventricular fibrillation I, III Verrucous lesions II
CARDIOVASCULAR DISEASES SECTION Ventricular tachycardia I Vitiligo I
Acute coronary syndromes I Wolff-Parkinson-White syndrome I Warts I
Aneurysm, abdominal aorta I
Angina pectoris I DERMATOLOGY ENDOCRINOLOGY
Aortic coarctation I Acne vulgaris I Adrenal incidentaloma I, III
Aortic dissection I Actinic keratosis I Adrenal insufficiency I
Aortic regurgitation I Alopecia I Adrenal mass, clinical algorithm III
Aortic stenosis I Angioedema I Adrenocortical hyperfunction II
Arrhythmogenic right ventricular cardiomyopathy I Angular cheilitis I Adrenocortical hypofunction II
Atrial enlargement, left atrium II Atopic dermatitis I Aldosteronism I
Atrial fibrillation I Balanitis I Androgen excess, reproductive-age woman II
Atrial flutter I Basal cell carcinoma I Anhydrosis II
Atrial myxoma I Bedbug bite I Bone density, decreased, generalized II
Atrial septal defect I Calcifications, cutaneous II Bone density, decreased, localized II
Atrium enlargement, right atrium II Candidiasis, cutaneous I Bone mass, low II
Atrioventricular dissociation I Contact dermatitis I Breast, nipple discharge evaluation III
Bicuspid aortic valve I Cutaneous infections, athletes II Calcifications, abdominal, nonvisceral on x-ray II
Branch bundle block I Cutaneous occlusion syndromes III Calcifications, adrenal gland on x-ray II
Bradycardia III Cyanosis, algorithm III Calcifications, genital tract, female on x-ray II
Brugada syndrome I Dermatitis herpetiformis I Calcium stones II
Calcifications, cardiac on x-ray II Discoid lupus I Cushing's disease and syndrome I
Calcifications, valvular on x-ray II Eosinophilic dermatoses III Delayed puberty I
Cardiac death, sudden II Epidermolysis bullosa (EB) I Diabetes insipidus I
Cardiac tamponade I Erosions, genitalia II Diabetes mellitus I
Cardiac tumors II Erysipelas I Diabetic foot I
Cardioembolism II Erythema elevatum diutinum I Diabetic gastroparesis I
Cardiomegaly on chest x-ray III Erythema multiforme I Diabetic ketoacidosis I
Cardiomyopathy, chemical-induced I Erythroderma II Diabetic nephropathy I
Cardiomyopathy, dilated I Eyelid neoplasm II Erectile dysfunction I
Cardiomyopathy, hypertrophic I Fifth disease (parvovirus infection) I Exocrine pancreatic insufficiency (EPI) I
Cardiomyopathy, ischemic, surgical management III Finger lesions, inflammatory II Flushing III
Cardiomyopathy, restrictive I Flushing III Foot lesion, ulcerating II
Cardiorenal syndrome I Folliculitis I Galactorrhea I
Carotid sinus syndrome I Foot dermatitis II Genitourinary syndrome of menopause (GSM) I
Cervical artery dissection I Genital lesions or ulcers III Goiter evaluation and management III
Chronic urticaria I Granuloma, algorithm III Graves disease I
Cirrhotic cardiomyopathy I Granuloma annulare I Gynecomastia I
Congestive heart failure I Granulomatous dermatitides II Hirsutism I
Congestive heart failure and cardiomyopathy II Hand-foot-mouth disease I Hot flashes I
Connective tissue disease–associated I Herpes simplex I Hypercalcemia, clinical algorithm IV
vasculitis Herpes zoster I Hypercalcemia, laboratory differential diagnosis II
Coronary artery disease I Hidradenitis suppurativa I Hypercalcemia, malignancy-induced II
Cor pulmonale I Hyperhydrosis I Hyperlipoproteinemia, primary I
Cyanosis II Hyperpigmentation III Hyperosmolar hyperclycemic syndrome I
Early repolarization syndrome I IgA vasculitis I Hyperostosis, cortical bone II
Ejection sound or click II Impetigo I Hyperparathyroidism I
Giant cell myocarditis I Jaundice, neonatal, algorithm III Hyperthyroidism I
Heart block, second-degree I Kaposi sarcoma I Hypoaldosteronism I
Heart failure, acute I, II Leg ulcer III Hypocalcemia, laboratory differential diagnosis II
Heart failure, pregnancy II Lichen planus I Hypoglycemia II
HIV-associated cardiomyopathy I Lichen sclerosus I Hypogonadism I
Hypercholesterolemia I Lichen simplex chronicus I Hypoparathyroidism I
Hyperlipoproteinemia, primary I Malar eruption III Hypopituitarism I
Hypertension I Mastocytosis I Hypothyroidism I
Hypertension, in children II Melanoma I Infertility I
Hypotension III Melanonychia II Menopause I
Intraventricular conduction defect (IVCD) I Molluscum contagiosum I Metabolic syndrome I
Junctional rhythm I Mucormycosis I Osteoporosis I
Long QT syndrome I Myositis III Osteoporosis, secondary causes II
Mesenteric arterial embolism, associated II Nail dystrophy III Paget disease of the bone I
factors Neurofibromatosis I Pancreatic islet cell tumors III
Mitral regurgitation I Onycholysis III Paraneoplastic syndromes I
Mitral stenosis I Oral hairy leukoplakia I Pheochromocytoma I
Mitral valve prolapse I Panniculitis I Pituitary adenoma I
Multifocal atrial tachycardia I Papulosquamous disorders, pediatric patient III Pituitary region tumors II
Murmur, diastolic III Paronychia I Polycystic ovary syndrome I
Murmur, systolic III Pediculosis I Primary ovarian insufficiency I
Myocardial infarction I Pemphigus vulgaris I Prolactinoma I
Myocarditis I Photosensitivity III Pseudohermaphroditism III
Orthostatic hypotension I Pinworms I Sexual dysfunction III
Palpitations III Pityriasis rosea I Sexual precocity, female breast development III
Paroxysmal supraventricular tachycardia I Porphyrias I Sexual precocity, female pubic hair development III
Patent ductus arteriosus I Premature graying, scalp hair II Sexual precocity, male III
Pericardial effusion, malignant III Pruritus, generalized, clinical algorithm III Short stature III
Pericarditis I Pruritus vulvae II Syndrome of inappropriate antidiuresis I
Pleural effusion, malignant III Psoriasis I Thyroid nodule I
Pleural effusions, malignancy-associated II Purpura, nonpalpable II Thyroid, painful, clinical algorithm III
Postural hypotension, nonneurologic causes II Purpura, non-purpuric disorders simulating II Thyroiditis I
Premature ventricular contractions and II purpura Thyromegaly II
ventricular tachycardia Purpura, palpable II
Pulmonary edema I Purpura, palpable, clinical algorithm III ENVIRONMENTAL MEDICINE
Pulmonary edema, non-cardiogenic II Reactive erythema, pediatric patient III Amebiasis I
Pulseless electrical activity I Rocky Mountain spotted fever I Babesiosis I
Renal artery stenosis I Rosacea I Bite wounds I
Rib notching on x-ray II Roseola I Bites and stings, arachnids I
Short QT syndrome I Scabies I Bites and stings, insect I
Sick sinus syndrome I Scarlet fever I Bites, snake I
Syncope I Scleroderma (systemic sclerosis) I Botulism I
Tachycardia III Skin blisters III Burns I
Tachycardia, narrow complex III Stevens-Johnson syndrome I Contact dermatitis I
Tachycardia, wide complex III Tinea capitis I Diarrhea, acute III
Takayasu's arteritis I Tinea corporis I Drowning I
Takotsubo cardiomyopathy I Tinea cruris I Ehrlichiosis I
Thrombotic microangiopathies, diagnosis III Tinea pedis I Electrical injury I
Torsades des pointes I Tinea versicolor I Envenomation, marine III
Valvular heart disease II Varicella I Food poisoning, bacterial I
Venous ulcers I Venous insufficiency, chronic I Frostbite I
Ventricular septal defect I Venous ulcers I Giardiasis I
Heat exhaustion and heat stroke I Helicobacter pylori infection I Cervicitis I
High-altitude sickness I Hematemesis II Chlamydia genital infections I
Hypothermia I Hemochromatosis I Condyloma acuminatum I
Lyme disease I Hemoperitoneum II Contraception I
Malaria I Hemoptysis I Cystitis, acute III
Microsporidosis I Hepatic encephalopathy I Delayed passage of meconium II
Mushroom poisoning I Hepatitis A I Dysmenorrhea I
Radiation exposure I Hepatitis, acute II Dyspareunia I
Rocky Mountain spotted fever I Hepatitis B I Dysuria and/or urethral/vaginal discharge III
Salmonellosis I Hepatitis B prophylaxis V Eclampsia I
Shigellosis I Hepatitis C I Ectopic pregnancy I
Southern tick-associated rash illness (STARI) I Hepatitis D I Endometrial cancer I
Tapeworm infestation I Hepatitis E I Endometriosis I
Vaccinations for international travel V Hepatitis, viral III Endometritis I
Zika virus I Hepatomegaly, algorithm III Erosions, genitalia II
Hepatomegaly, by shape of liver II Fallopian tube cancer I
GASTROENTEROLOGY Hepatopulmonary syndrome I Fertility preservation in women I
Abdominal compartment syndrome I Hepatorenal syndrome I Fibrocystic breast disease I
Abdominal pain, chronic lower II Hookworm I Genital lesions or ulcers, algorithm III
Abdominal pain, nonsurgical causes II Hypergastrinemia II Genitopelvic pain/penetration syndrome I
Achalasia I Hypersplenism, associated conditions II Gonococcal urethritis I
Acute colonoic pseudo-obstruction I Hypoglycemia II Gonorrhea I
Acute liver failure I Incontinence, fecal II Groin masses II
Acute lower gastrointestinal bleeding I Inguinal hernia I Heart failure, pregnancy II
Acute mesenteric ischemia I Irritable bowel syndrome I Heavy menstrual bleeding I
Alcoholic hepatitis I Ischemia, colon III Hereditary breast and ovarian cancer syndrome I
Anal abscess and fistula II Ischemic colitis I Herpes simplex I
Anorectal fistula I Ischemic hepatitis I Hot flashes I
Anorectal stricture I Jaundice, classification II Hyperemesis gravidarum I
Anorexia II Jaundice in the adult patient I Hypoactive sexual desire disorder I
Aphthous ulcers I Jaundice, neonatal II Hypogonadism III
Appendicitis I Jaundice, neonatal, algorithm III Immunizations during pregnancy V
Ascariasis I Lactose intolerance I Incontinence (urinary) I
Ascites I Large bowel obstruction I Infertility I
Autoimmune hepatitis I Large bowel stricture II Mastitis I
Bacterial overgrowth, small intestine II Levator ani syndrome I Mastodynia I
Barrett esophagus I Liver abscess I Meigs syndrome I
Bile duct, dilated II Liver disease, pregnancy II Menopause I
Bleeding, gastrointestinal, algorithm III Liver lesions, benign II Molar pregnancy I
Bleeding, rectal II Liver transplantation I Nipple lesions II
Bleeding, variceal III Lynch syndrome I Nongonococcal urethritis I
Budd-Chiari syndrome I Malabsorption II Ovarian cancer I
Calcifications, liver on x-ray II Malabsorption algorithm III Ovarian neoplasm, benign I
Calcifications, pancreas on x-ray II Mallory-Weiss tear I Paget's disease of the breast I
Calcifications, spleen on x-ray II Microscopic colitis I Pelvic abscess I
Celiac disease I Nonalcoholic fatty liver disease I Pelvic congestion syndrome I
Cholangiocarcinoma I Non-celiac disease gluten sensitivity I Pelvic inflammatory disease I
Cholangitis I Nutrition assessment and intervention in cancer III Pelvic mass, algorithm III
Cholecystitis I patient Pelvic organ prolapse (uterine prolapse) I
Choledocholithiasis I Odynophagia II Pelvic pain, causes in women II
Cholelithiasis I Pancreas transplantation I Pelvic pain, reproductive-age woman III
Chronic pancreatitis I Pancreatic calcifications II Perirectal abscess I
Cirrhosis I Pancreatic cancer (exocrine) I Placenta previa I
Cirrhosis, primary biliary I Pancreatitis, drug-induced II Polycystic ovary syndrome I
Cirrhotic cardiomyopathy I Peptic ulcer disease I Postpartum depression I
Colic, acute abdominal II Perianal pain II Postpartum hemorrhage I
Colorectal cancer I Peritonitis, secondary I Preeclampsia I
Colostridium difficile infection I Peutz-Jeghers syndrome and other polyposis I Premature rupture of membranes I
Constipation, adult patient II syndromes Premenstrual syndrome I
Constipation I, III Pinworms I Preterm labor I
Crohn disease I Pneumatosis intestinalis in neonate and older child II Primary ovarian insufficiency I
Cryptosporidium infection I Portal hypertension I Pruritus, pregnant patient III
Delayed passage of meconium II Portal vein thrombosis I Pruritus vulvae I, II
Diarrhea, acute III Primary sclerosing cholangitis I Rh incompatibility I
Diarrhea, acute watery and bloody II Rectal mass, palpable II Sexual assault I
Diarrhea, chronic III Retropharyngeal abscess I Sexual dysfunction III
Diarrhea, chronic, in patients with HIV infection, III Shigellosis I Sexual dysfunction in women I, II
algorithm Short bowel syndrome I Spontaneous abortion I
Diarrhea, infectious II Small bowel masses II Syphilis I
Diarrhea, non-infectious II Small bowel obstruction I Thrombocytopenia, in pregnancy II
Diarrhea, persistent I Small bowel intestinal bacterial overgrowth I Toxic shock syndrome I
Diverticular disease (diverticulosis, I Small intestine ulceration II Urinary tract infection I
diverticulitis) Spontaneous bacterial peritonitis I Uterine fibroids I
Drug-induced liver injury I Subphrenic abscess I Uterine malignancy I
Dyspepsia III Tapeworm infestation I Vaginal bleeding during pregnancy I
Dyspepsia, nonulcerative I Toxic megacolon I Vaginal discharge, algorithm III
Dysphagia, oropharyngeal II Traveler's diarrhea I Vaginal fistulas I
Echinococcosis I Ulcerative colitis I Vaginal cancer I
Eosinophilic esophagitis I Vitamin deficiency (hypovitaminosis) I Vaginal prolapse III
Epigastric pain II Vaginitis, estrogen-deficient I
Esophageal tumors I GYNECOLOGY AND OBSTETRICS Vaginitis, fungal I
Esophageal varices I Abruptio placentae I Vaginitis, prepubescent I
Esophagitis II Abnormal uterine bleeding I Vaginitis, Trichomonas I
Familial adenomatous polyps and Gardner I Acute fatty liver of pregnancy I Vaginosis, bacterial I
syndrome Acute pelvic pain in women I
Fetal alcohol spectrum disorder I Adnexal masses I HEMATOLOGY/ONCOLOGY
Food poisoning, bacterial I Amniotic fluid alpha-fetoprotein elevation II Acute lymphoblastic leukemia I
Functional gallbladder disorder I Bartholin gland abscess I Acute myeloid leukemia I
Gallbladder carcinoma I Bleeding, early pregnancy III Anemia, algorithm III
Gastric cancer I Bleeding neonate III Anemia, aplastic I, II
Gastric dilatation II Bleeding, vaginal III Anemia, aplastic due to drugs and chemicals II
Gastric emptying, delayed II Bone mineral density, increased II Anemia, autoimmune hemolytic I
Gastritis I Breast cancer I Anemia, hypochromic II
Gastroenteritis I Breastfeeding difficulties III Anemia, inflammatory I
Gastroesophageal reflux disease I Breast, nipple discharge evaluation III Anemia in newborn III
Giardiasis I Breast, radiologic evaluation III Anemia, iron deficiency I
Gilbert disease I Breast, routine screen or palpable mass evaluation III Anemia, macrocytic III
Glossitis I Cervical cancer I Anemia, microcytic III
Glossodynia II Cervical dysplasia I Anemia, pernicious I
Anemia with reticulocytosis III Pancytopenia II Endometritis I
Anorexia-cachexia syndrome associated with I Paraneoplastic neurologic syndromes II Epididymitis I
malignancy Pericardial effusion, malignant III Epidural abscess I
Antiphospholipid antibody syndrome I Pheochromocytoma I Epiglottitis I
Astrocytoma I Pigmenturia II Epstein-Barr virus infection I
Atypical lymphocytosis, heterophil negative, II Pituitary adenoma I Erysipelas I
infectious causes Pituitary region tumors II Esophagitis II
Basal cell carcinoma I Pleural effusion, malignant III Fever and infection in high-risk patient without III
Bladder cancer I Pleural effusions, malignancy-associated II obvious source
Bleeding, congenital disorder III Polycythemia II Fever and neutropenia, pediatric patient III
Bleeding neonate III Polycythemia, algorithm III Fever in the returning traveler I
Bleeding time (modified Ivy method) IV Polycythemia, relative versus absolute II Fever of undetermined origin I
Bone marrow failure syndromes, inherited II Polycythemia vera I Fifth disease (parvovirus infection) I
Bone tumor, primary malignant I Postthrombotic syndrome I Folliculitis I
Brain metastases I Prolactinoma I Food poisoning, bacterial I
Brain neoplasm I Prostate cancer I Foot lesion, ulcerating II
Brain neoplasm, benign I Pulmonary infiltrates, immunocompromised host II Genital lesions or ulcers III
Brain neoplasm, glioblastoma I Purpura, nonpalpable II Giardiasis I
Breast cancer I Purpura, non-purpuric disorders simulating II Gonococcal urethritis I
Cancer of unknown primary site I purpura Granulomatous dermatitides II
Cervical cancer I Purpura, palpable II Groin masses II
Chemotherapy-induced nausea and vomiting I Renal cell adenocarcinoma I Hand-foot-mouth disease I
Cholangiocarcinoma I Reticulocyte count IV Helicobacter pylori infection I
Chronic lymphocytic leukemia I Retinoblastoma I Hepatitis A I
Chronic myeloid leukemia I Rh incompatibility I Hepatitis, acute II
Chylothorax II Salivary gland neoplasms I Hepatitis B I
Cobalamin deficiency II Sickle cell disease I Hepatitis C I
Colorectal cancer I Spine tumor III Hepatitis D I
Conjunctival neoplasm II Splenomegaly, algorithm III Hepatitis E I
Cryoglobulinemia I Splenomegaly and hepatomegaly II Hepatitis, viral III
Deep vein thrombosis I Splenomegaly, children II Herpes simplex I
Disseminated intravascular coagulation I Squamous cell carcinoma I Herpes simplex keratitis I
Endometrial cancer I Superior vena cava syndrome I Herpes zoster I
Erythrocytosis II Testicular cancer I HIV-associated cardiomyopathy I
Erythrocytosis, acquired III Thalassemias I Histoplasmosis I
Esophageal tumors I Thrombocytopenia, differential diagnosis II HIV cognitive dysfunction I
Eyelid neoplasm II Thrombocytopenia, inherited disorders II HIV: Recommended immunization schedule for V
Fallopian tube cancer I Thrombocytopenia, in pregnancy II HIV-infected children
Fetal alcohol spectrum disorder I Thrombocytosis I Hookworm I
Fever and neutropenia, pediatric patient III Thrombosis or thrombotic diathesis II Human immunodeficiency virus I
Fever, non-infectious causes II Thrombotic thrombocytopenic purpura I Impetigo I
Folate deficiency II Thyroid carcinoma I Immunization schedule, childhood, accelerated V
Gallbladder carcinoma I Transfusion reaction, hemolytic I if necessary for travel
Gastric cancer I Tumor lysis syndrome I Immunization schedule, childhood and V
Graft-versus-host disease (GVHD) I Tumor markers elevation II adolescence
Groin masses II Upper extremity deep vein thrombosis I Immunization schedule, contraindications and V
Head and neck squamous cell carcinoma I Uterine malignancy I precautions
Hemolysis, mechanical II Vaginal cancer I Immunization schedule, HIV-infected children V
Hemolytic-uremic syndrome I Von Willebrand disease I Immunizations for adults V
Hemophilia I Waldenström macroglobulinemia I Immunizations during pregnancy V
Hemoptysis I Immunizations for immunocompromised infants V
Heparin-induced thrombocytopenia I INFECTIOUS DISEASES and children
Hepatocellular carcinoma I Acquired immunodeficiency syndrome I Immunizing agents and immunization schedules V
Hereditary breast and ovarian cancer syndrome I Acute bronchitis I for health-care workers
Hodgkin lymphoma I Amebiasis I Influenza I
Hypercalcemia, malignancy-induced II Anaerobic infections I Ischemic hepatitis I
Hypercoagulable state I Anal abscess and fistula II Kaposi sarcoma I
Hypercoagulable state, associated disorders II Ascariasis I Laryngitis I
Hypersplenism I Aspergillosis I Laryngotracheobronchitis I
Hypersplenism, associated conditions II Aspiration, oral contents III Legionnaires' disease I
Immune thrombocytopenic purpura I Aspiration pneumonia I Lemierre syndrome I
Intraocular neoplasm II Atypical lymphocytosis, heterophil negative, II Listeriosis I
Iron overload II infectious causes Liver abscess I
Kaposi sarcoma I Babesiosis I Lung abscess I
Lead poisoning I Bacterial overgrowth, small intestine II Lyme disease I
Liver lesions, benign II Bacterial pneumonia I Lymphangitis I
Lung cancer, occupational causes II Balanitis I Lymphocytosis, atypical II
Lung neoplasms, primary I Bartholin gland abscess I Malaria I
Lymphadenopathy, generalized, algorithm III Bedbug bite I Mastoiditis I
Lymphocytes IV Bite wounds I Mediastinitis I
Lymphocytosis, atypical II Botulism I Mediastinitis, acute II
Macrothrombocytopenia, inherited II Brain abscess I Meningitis, bacterial I
Medical marijuana I Breast abscess I Meningitis, viral I
Meigs syndrome I Candidiasis, cutaneous I Meningitis, recurrent II
Melanoma I Candidiasis, invasive I Mesenteric adenitis I
Meningioma I Cat-scratch disease I Methicillin resistant Staphylococcus aureus (MRSA) I
Mesothelioma, malignant I Cavernous sinus thrombosis I Microsporidiosis I
Microangiopathic hemolytic anemia I Cellulitis I Middle East respiratory syndrome I
Monoclonal gammopathy of renal significance I Cervicitis I Molluscum contagiosum I
(MGRS) Childhood and adolescent immunizations V Mononucleosis I
Monoclonal gammopathy of undetermined I Chlamydia genital infections I Mononucleosis, monospot negative II
significance Cholangitis I Mucormycosis I
Monocytosis II Cholecystitis I Multidrug-resistant gram-negative rods I
Mononucleosis, monospot negative II Clostridium difficile infection I (MRD-GNRs)
Multiple endocrine neoplasia I Colorado tick fever I Mumps I
Multiple myeloma I Condyloma acuminatum I Necrotizing fasciitis I
Myelodysplastic syndrome I Conjunctivitis I Necrotizing pneumonias II
Nasopharyngeal carcinoma I Cryptococcosis I Nongonococcal urethritis I
Neutropenia II Cryptosporidium infection I Orchitis I
Neutropenia with decreased marrow reserve II Cysticercosis I Osteomyelitis I
Neutrophilia II Cytomegalovirus infection I Otitis externa I
Non-Hodgkin lymphoma I Diarrhea, infectious II Otitis media I
Nutrition assessment and intervention in cancer III Ear pain III Paronychia I
patient Echinococcosis I Pediculosis I
Ovarian cancer I Ehrlichiosis I Pelvic abscess I
Ovarian neoplasm, benign I Empyema I Pelvic inflammatory disease I
Paget's disease of the breast I Encephalitis, acute viral I Perirectal abscess I
Pancreatic cancer (exocrine) I Endocarditis, infective I Peritonitis, secondary I
Pancreatic islet cell tumors III Endocarditis prophylaxis V Pertussis I
Pharyngitis/tonsillitis I Calcium stones II Convulsive disorder, pediatric age III
Pinworms I Cardiorenal syndrome I Daytime sleepiness II
Pneumonia, mycoplasma I Chronic kidney disease I Delirium I
Pneumonia, pnuemocystis jiroveci I Contrast-associated acute kidney injury I Delirium, agitated II
Pneumonia, viral I Dehydration correction, pediatric patient III Delirium, dialysis patient II
Prostatitis I Edema, generalized, algorithm III Dementia, algorithm III
Pyelonephritis I End-stage kidney disease I Dementia with Lewy bodies I
Reactive arthritis I Glomerulonephritis, rapidly progressive II Diabetic polyneuropathy I
Renal abscess l Glomerulopathies, thrombotic, microangiopathic II Dilated pupil III
Rocky Mountain spotted fever I Glomerulosclerosis, focal segmental II Diplopia, monocular II
Roseola I Goodpasture syndrome I Diplopia, vertical II
Salmonellosis I Hematuria, in children II Dissociative disorders I
Scabies I Hemolytic-uremic syndrome I Dizziness II
Scarlet fever I Hepatorenal syndrome I Dystonia I
Sepsis I Hydronephrosis I Elbow pain II
Septic arthritis I Hypercalcemia, algorithm IV Encephalomyelitis, nonviral causes II
Shigellosis I Hyperkalemia I Encephalopathy I
Sialadenitis I Hypermagnesemia, algorithm IV Epidural abscess I
Sinusitis I Hypernatremia, algorithm IV Epidural hematoma I
Sore throat II Hyperuricemia I Esotropia II
Southern tick-associated rash illness (STARI) I Hypocalcemia, laboratory differential diagnosis II Essential tremor I
Spinal epidural abscess I Hypokalemia, algorithm IV Febrile seizures I
Spontaneous bacterial peritonitis I Hypokalemia, differential diagnosis II Focal seizures I
Stomatitis I Hypokalemic periodic paralysis I Footdrop II
Stye (hordeolum) I Hypomagnesemia I Frontotemporal dementia I
Syphilis I Hypomagnesemia, algorithm IV Generalized tonic-clonic seizures I
Tapeworm infestation I Hypomagnesemia, differential diagnosis II Guillain-Barré syndrome I
Thrombophlebitis, superficial I Hyponatremia I, II Hallucinogenic overdose I
Tinea corporis I Hypoparathyroidism I Headache, acute II
Tinea cruris I Hypophosphatemia, algorithm IV Headache, chronic II
Tinea unguium I IgA nephropathy I Hearing loss, algorithm III
Tinea versicolor I Interstitial nephritis I Hereditary neuropathy I
Toxoplasmosis I Kidney enlargement, unilateral II HIV cognitive dysfunction I
Tuberculosis, miliary I Microscopic polyangiits I Horner syndrome I
Tuberculosis, pulmonary I Monoclonal gammopathy of renal significance I Huntington chorea I
Urinary tract infection I (MGRS) Hydrocephalus, normal pressure I
Urosepsis II Nephrocalcinosis II Inclusion body myositis I
Vaccinations for international travel V Nephrotic syndrome I Inflammatory myopathies I
Vaccinations, recommendations for persons V Oliguria, algorithm III Intracerebral hemorrhage, nonhypertensive II
with medical conditions Pigmenturia II causes
Vaginitis, fungal I Pyelonephritis I Labyrinthitis I
Vaginitis, Trichomonas I Relapsing polychondritis I Leg movement when standing, involuntary II
Vancomycin resistant Enterococcus (VRE) I Renal abscess I Leptomeningeal lesions II
Varicella I Renal artery stenosis I Memory loss symptoms, elderly patients II
Viral bronchiolitis I Renal cell adenocarcinoma I Meniere disease I
Zika virus I Renal cystic disorders II Meningioma I
Renal disease, ischemic management III Mental status changes and coma II
MISCELLANEOUS Renal failure, acute, pigment-induced II Migraine headache I
Abdominal wall masses II Renal mass III Mild cognitive impairment I
Anaphylaxis I Renal parenchymal disease, chronic II Mononeuropathies, isolated II
Anorexia II Renal tubular acidosis I Motion sickness I
Cyanosis II Renal vein thrombosis I Multiple sclerosis I
Deep vein thrombosis I Rhabdomyolysis I Muscle disease II
Dehydration correction, pediatric patient III Scombroid poisoning I Muscle weakness, algorithm III
Delayed passage of meconium II Statin-induced muscle syndromes I Muscular dystrophy I
Drowning I Tension-type headache l Myasthenia gravis I
Familial Mediterranean Fever I Tumor lysis syndrome I Myelin disorders II
Fever, non-infectious causes II Uric acid stones II Myoclonus I
Food allergies I Urinary retention II Myotonia I
Graft-versus-host disease (GVHD) I Urine color abnormalities II Narcolepsy I
Groin lump II Urolithiasis I Neurocognitive disorders I
Hallucinogenic overdose I Neuromuscular junction dysfunction II
Iliac fossa pain, left sided II NEUROLOGY Neuronopathies, sensory (ganglionopathies) II
Iliac fossa pain, right sided II Absence seizures I Neuropathic bladder II
Lactic acidosis I Acoustic neuroma I Neuropathic pain I
Malignant hyperthermia I Alzheimer's disease I Neuropathies, peripheral, asymmetrical II
Mediastinitis I Amaurosis fugax I proximal/distal
Mediastinal compartments, anatomy and II Amblyopia I Neuropathies with facial nerve involvement II
pathology Amyotrophic lateral sclerosis I New onset seizures I
Medical marijuana I Anisocoria III Nystagmus, monocular II
Methanol and ethylene glycol poisoning I Anoxic brain injury I Opsoclonus II
Opioid overdose I Antibody-mediated autoimmune encephalitis I Optic atrophy II
Opioid use disorder I Astrocytoma I Optic neuritis I
Paralytic shellfish poisoning I Ataxia, acute or recurrent II Osteosclerosis, diffuse II
Paraneoplastic syndromes I Ataxia, cerebellar, adult onset II Paraneoplastic neurologic syndromes II
Pleurisy I Ataxia, cerebellar, children II Paraparesis, acute or subacute II
Postthrombotic syndrome I Ataxia, chronic or progressive II Paraparesis, chronic progressive II
Sarcoma I Ataxia, progressive III Parkinsonism-plus syndromes II
Shift work disorder I Autistic spectrum disorders I Parkinson disease I
Sore throat II AV malformations, cerebral I Periodic limb movement disorder I
Statin-induced muscle syndromes I Ballism II Polyneuropathies, demyelinating II
Substance use disorder I Bell palsy I Polyneuropathies, distal, sensorimotor II
Synthetic cannabinoids I Benign paroxysmal positional vertigo I Postconcussive syndrome I
Tracheobronchial narrowing on x-ray II Blindness, monocular, transient II Postherpetic neuralgia I
Upper extremity deep vein thrombosis I Brain neoplasm I Primary angiitis of the central nervous system I
Vitamin D deficiency I Brain neoplasm, benign I Ramsay Hunt syndrome I
Vitamin deficiency (hypovitaminosis) I Brain neoplasm, glioblastoma I Restless legs syndrome I
Carotid artery stenosis I Sciatica I
NEPHROLOGY Carpal tunnel syndrome I Seizures, mimics II
Acid-base homeostasis III Cerebral infarction secondary to inherited II Shaken baby syndrome I
Acidosis, metabolic, algorithm III disorders Smell disturbance II
Acute glomerulonephritis I Cerebrospinal fluid (CSF) IV Spasticity I
Acute kidney injury I Charcot-Marie-Tooth disease I Spinal cord compression I
Acute tubular necrosis I Chronic inflammatory demyelinating I Spinal cord compression, epidural II
Acute urinary retention (AUR) I polyneuropathy Spinal cord dysfunction, non-traumatic II
Alkalosis, metabolic, algorithm III Chronic traumatic encephalopathy (CTE) I Spinal cord ischemic syndromes II
Autosomal dominant polycystic kidney disease I Cluster headache I Spinal stenosis I
AV malformations, cerebral I Complex regional pain syndrome I Status epilepticus I
Calcium-alkali syndrome I Concussion I Stroke, acute ischemic I
2021
Ferri’s
CLINICAL
ADVISOR
FRED F. FERRI, MD, FACP
Clinical Professor
Department of Medicine
Warren Alpert Medical School
Brown University
Providence, Rhode Island
Elsevier
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

FERRI'S CLINICAL ADVISOR 2021 ISBN: 978-0-323-71333-7

Copyright © 2021 by Elsevier, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher's permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Notice

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds or experiments described herein. Because of rapid advances
in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be
made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or con-
tributors for any injury and/or damage to persons or property as a matter of products liability, negligence
or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in
the material herein.

ISBN: 978-0-323-71333-7

Publisher: Sarah Barth

Senior Content Development Specialist: Mary Hegeler
Publishing Services Manager: Catherine Jackson
Senior Project Manager: Kate Mannix
Design Direction: Bridget Hoette

Printed in the United States

Last digit is the print number: 9 8 7 6 5 4 3 2 1

 Section Editors
Manuel F. DaSilva, MD Gregory L. Fricchione, MD
Director, Medical Student Education Associate Chief of Psychiatry
Department of Orthopedic Surgery Director, Benson Henry Institute for
Warren Alpert Medical School of Mind Body Medicine
Brown University Director, Pierce Division of Global
Providence, Rhode Island Psychiatry
Massachusetts General Hospital
Mind Body Medical Institute Professor
of Psychiatry
Harvard Medical School
Boston, Massachusetts

Fred F. Ferri, MD, FACP Corey Elam Goldsmith, MD

Clinical Professor Assistant Professor of Neurology
Department of Medicine Neurology Residency Program Director
Warren Alpert Medical School of Baylor College of Medicine
Brown University Chief of Neurology Outpatient Clinics
Providence, Rhode Island Ben Taub Hospital—Harris Health
System
Houston, Texas

Glenn G. Fort, MD, MPH, Joseph S. Kass, MD, JD,

FACP, FIDSA FAAN
Clinical Associate Professor of Associate Dean of Student Affairs
Medicine Professor of Neurology, Psychiatry,
Warren Alpert Medical School of and Medical Ethics
Brown University; Director, Alzheimer’s Disease and
Chief, Infectious Diseases Memory Disorders Center
Our Lady of Fatima Hospital and Baylor College of Medicine
Landmark Medical Center Ben Taub General Hospital
Providence, Rhode Island Houston, Texas

iii
iv Section Editors
Bharti Rathore, MD Iris L. Tong, MD
Program Director, Hematology/ Associate Professor
Oncology Fellowship Department of Medicine
Roger Williams Medical Center Warren Alpert Medical School of
Providence, Rhode Island; Brown University;
Assistant Professor of Medicine Attending Physician
Boston University School of Women’s Primary Care
Medicine Women’s Medicine Collaborative
Boston, Massachusetts Providence, Rhode Island

Daphne Scaramangas- John Wylie, MD, FACC

Plumley, MD Director, Cardiac Electrophysiology
Rheumatologist Steward Health Care System;
Attune Health Associate Professor of Medicine
Cedars-Sinai Medical Center Tufts University School of Medicine
Beverly Hills, California Boston, Massachusetts

Anthony Sciscione, DO Jerry Yee, MD

Professor of Obstetrics and Clinical Professor of Medicine
Gynecology Department of Internal Medicine
Jefferson Medical College Wayne State University School of
Philadelphia, Pennsylvania; Medicine;
Residency Program Director Division Head, Nephrology and
Director of Maternal-Fetal Hypertension
Medicine Henry Ford Hospital
Department of Obstetrics and Detroit, Michigan
Gynecology
Christiana Care Health System
Newark, Delaware
 Contributors
Alexandra Abrams-Downey, MD Maria Andrievskaya, MD
Professor of Medicine Nephrology Fellow
Icahn School of Medicine at Mount Sinai Henry Ford Hospital
New York, New York Detroit, Michigan

W. Peyton Adkins, MD Kathryn Taylor Anilowski, MS, PT, CLT-LANA

Resident Physician Physical Therapist
Emergency Medicine Saratoga Springs, New York
University of Tennessee Health Science Center
Memphis, Tennessee Anngene Anthony, MD, MPH, FAAFP
Teaching Faculty
Maxwell Eyram Afari, MD Family Medicine
Advanced Heart Failure and Transplant Cardiologist Hackensack Meridian Health
Department of Cardiovascular Medicine Mountainside Medical Center
Maine Medical Center Montclair, New Jersey
Portland, Maine
Joe Aoun, MD
Sandeep Agarwal, MD Cardiovascular Medicine Fellow
Associate Professor of Medicine Houston Methodist DeBakey Heart and Vascular Center
Division of Nephrology and Hypertension Houston, Texas
Drexel University College of Medicine
Philadelphia, Pennsylvania Erick A. Argueta, MD
Department of Internal Medicine
Mhd Hussam Al Jandali, MD Warren Alpert Medical School of Brown University
Nephrology Fellow Providence, Rhode Island
Department of Internal Medicine, Nephrology
Henry Ford Health System Pinar Arikan, MD
Detroit, Michigan Resident Physician
Internal Medicine
Maad M. Alhudairy, MD, MAS Warren Alpert Medical School of Brown University
Resident Physician Providence, Rhode Island
Internal Medicine
St. Elizabeth’s Medical Center Zuhal Arzomand, MD
Tufts University School of Medicine Rheumatology Fellow
Boston, Massachusetts Warren Alpert Medical School of Brown University
Providence, Rhode Island
Tanya Ali, MD
Clinical Assistant Professor of Medicine Daniel K. Asiedu, MD, PhD, FACP
Warren Alpert Medical School of Brown University Staff Physician
Providence, Rhode Island Internal Medicine
Coastal Medical, Inc.
Stephanie Michelle Allen, MS Lincoln, Rhode Island
Baylor College of Medicine
Houston, Texas Sudeep K. Aulakh, MD
Director, Ambulatory Education, Baystate Internal Medicine Residency
Ihab Alomari, MD Assistant Professor
Interventional Cardiologist University of Massachusetts Medical School—Baystate
Assistant Professor of Medicine Baystate Health
University of California, Irvine Springfield, Massachusetts
Orange, California
Rupali Avasare, MD
Rasha B. Alqadi, MD Physician
Rheumatologist Nephrology and Hypertension Department
Providence Sacred Heart Medical Center and Children’s Hospital Oregon Health and Science University
Spokane, Washington Portland, Oregon

Jordan Anderson, MD Sarah Aziz, DO Candidate

Rhode Island Hospital Rowan University School of Osteopathic Medicine
Departments of Neurology and Psychiatry Stratford, New Jersey
Providence, Rhode Island
v
vi Contributors
Tania B. Babar, MD Vicky H. Bhagat, MD, MPH
Electrophysiologist Gastroenterology Fellow
Division of Electrophysiology Robert Wood Johnson University Hospital
Charleston Area Medical Center New Brunswick, New Jersey
Charleston, West Virginia
Harikrashna B. Bhatt, MD
Emelia Argyropoulos Bachman, MD Assistant Professor of Medicine
Assistant Professor of Clinical Obstetrics and Gynecology Warren Alpert Medical School of Brown University
Division of Reproductive Endocrinology and Infertility Chief of Endocrinology
Hospital of the University of Pennsylvania Providence VA Medical Center
Philadelphia, Pennsylvania Providence, Rhode Island

T. Caroline Bank, MD Danish Bhatti, MD

Resident Physician Assistant Professor
Obstetrics and Gynecology Department of Neurological Sciences
Christiana Care Health System University of Nebraska Medical Center
Newark, Delaware Omaha, Nebraska

Trace Barrett, MD Jiaying Bi, MA

Cardiovascular Disease Fellow Center for Health Profession Studies
University of Vermont Medical Center University of Delaware City
Burlington, Vermont Newark, Delaware

Ailin Barseghian, MD Courtney Clark Bilodeau, MD, FACP

Assistant Clinical Professor Assistant Clinical Professor of Obstetric Medicine
Department of Internal Medicine Warren Alpert Medical School of Brown University
Division of Cardiology Attending Physician, Women’s Medicine Collaborative
University of California, Irvine Providence, Rhode Island
Orange, California
Stefani Bissonette, MD
Craig L. Basman, MD Resident Physician
Structural Heart Disease Fellow Obstetrics and Gynecology
Department of Cardiothoracic Surgery Christiana Care Health System
Lenox Hill Hospital Newark, Delaware
Northwell Health
New York, New York Ghamar Bitar, MD
Resident Physician
Lee Baumgarten, MD Obstetrics and Gynecology
Resident Physician Christiana Care Health System
Vattikuti Urology Institute Newark, Delaware
Henry Ford Health System
Detroit, Michigan Craig Blakeney, MD
Emergency Medicine Physician
Jennifer Bell, MD Department of Emergency Medicine
St. Elizabeth’s Medical Center University of Tennessee Health Science Center
Tufts University School of Medicine Memphis, Tennessee
Boston, Massachusetts
Brad Blankenhorn, MD
Deanna Benner, MSN, APRN Assistant Professor
Nurse Practitioner Department of Orthopedic Surgery
Christiana Care Health System Brown University/Rhode Island Hospital
Obstetrics and Gynecology Providence, Rhode Island
Newark, Delaware
Christopher P. Blomberg, DO
Michael Bergen, MD Cardiovascular Medicine
Resident Physician Southern Maine Health Care
Department of Orthopedic Surgery Maine Health
Brown University/Rhode Island Hospital Biddeford, Maine
Providence, Rhode Island
Steven L. Bokshan, MD
Arnaldo A. Berges, MD Orthopedics
Director, Division of Inpatient Psychiatry Warren Alpert Medical School of Brown University
Rhode Island Hospital Providence, Rhode Island
Assistant Clinical Professor
Warren Alpert Medical School of Brown University Alex F. Borchert, MD
Providence, Rhode Island Vattikuti Urology Institute
Henry Ford Hospital Health System
Detroit, Michigan
 Contributors vii

Christina M. Bortz, MD Alexandra Buffie, MD

Attending Physician Baylor College of Medicine
Assistant Professor of Medicine Houston, Texas
Clinical Educator
Department of Internal Medicine Christine Burke, MD
Warren Alpert Medical School of Brown University Resident Physician
Providence, Rhode Island Obstetrics and Gynecology
Christiana Care Health System
Alexandra Boske, MD Newark, Delaware
Director of Inpatient Neurology
Stroke Program Director Ryan J. W. Burris, MD
Saint David’s Round Rock Medical Center Cardiology Fellow
Round Rock, Texas Department of Medicine/Cardiology
University of California, Irvine
Tara C. Bouton, MD, MPH, TM Orange, California
Research Fellow
Division of Infectious Diseases D. Brandon Burtis, DO
Miriam Hospital Assistant Professor of Neurology
Warren Alpert Medical School of Brown University University of Florida
Providence, Rhode Island Gainesville, Florida

Lynn A. Bowlby, MD Kate Cahill, MD

Medical Director, Duke Outpatient Clinic Assistant Professor of Medicine, Clinician Educator
Department of General Internal Medicine Division of Internal Medicine
Duke University Medical Center Warren Alpert Medical School of Brown University
Durham, North Carolina Providence, Rhode Island

Amanda Box, MD, MS Rebecca Cangemi, MD

Resident Physician Resident Physician
Emergency Medicine Department of Internal Medicine
University of Tennessee Rhode Island Hospital/Lifespan, Brown University
Memphis, Tennessee Providence, Rhode Island

Mark F. Brady, MD, MPH, MMSc Caleb Cantrell, BS

Assistant Professor MD Candidate (2021)
Department of Emergency Medicine University of Tennessee Health Science Center
University of Tennessee Health Science Center Memphis, Tennessee
Memphis, Tennessee
Andrew Caraganis, MD
Russell E. Bratman, MD Internal Medicine
Fellow Boston University School of Medicine
Department of Endocrinology Roger Williams Medical Center
Warren Alpert Medical School of Brown University Providence, Rhode Island
Providence, Rhode Island
Ashlie Sewdass Carter, MD
Keith Brennan, MD Resident Physician
Geriatric Medicine Obstetrics and Gynecology
Stony Brook University Christiana Care Health System
Stony Brook, New York Newark, Delaware

Gavin Brown, MD Valerie Carter, MD

General Neurologist Assistant Professor
Laureate Medical Group, Northside Hospital Internal Medicine
Atlanta, Georgia Hospital Medicine/Division of General Internal Medicine
Froedtert & the Medical College of Wisconsin
Neal Bucher, MD Milwaukee, Wisconsin
University of Toledo College of Medicine and Life Sciences
Toledo, Ohio Ana Castaneda-Guarderas, MD
Assistant Professor
Jennifer Buckley, MD Emergency Medicine Department
Clinical Instructor of Family Medicine University of Tennessee Regional One Physicians
Warren Alpert Medical School of Brown University Memphis, Tennessee
Providence, Rhode Island
Family Medicine
Memorial Hospital of Rhode Island
Pawtucket, Rhode Island
Kent Memorial Hospital
Warwick, Rhode Island
viii Contributors
Jorge J. Castillo, MD Sarah L. Chisholm, MD
Associate Professor Resident Physician
Division of Hematologic Malignancies Department of Obstetrics and Gynecology
Dana-Farber Cancer Institute University of Colorado Hospital
Harvard Medical School Denver, Colorado
Boston, Massachusetts
Chandrika Chitturi, MD
Andreea M. Catana, MD Attending Staff
Department of Gastroenterology and Hepatology Division of Nephrology and Hypertension
Beth Israel Deaconess Medical Center Henry Ford Hospital
Boston, Massachusetts Detroit, Michigan

Carolina S. Cerezo, MD, FAAP George Cholankeril, MD

Medical Director Transplant Hepatology
Division of Pediatric Gastroenterology, Nutrition and Liver Diseases University of Tennessee Health Science Center
Hasbro Children’s/Rhode Island Hospital Memphis, Tennessee
Associate Professor
Department of Pediatrics Rosann Cholankeril, MD
Warren Alpert Medical School of Brown University Boston University School of Medicine
Providence, Rhode Island Roger Williams Medical Center
Providence, Rhode Island
Joshua Chalkely, DO, MS
Department of Neurology Seth Clark, MD, MPH
University of Kentucky Medical Center Addiction Medicine Fellow
Lexington, Kentucky Warren Alpert Medical School of Brown University
Rhode Island Hospital
Paul D. Chamberlain, MD Providence, Rhode Island
Department of Neurology
Baylor College of Medicine Brian Clyne, MD
Houston, Texas Interim Chair, Assistant Professor
Department of Emergency Medicine
Philip A. Chan, MD, MS Warren Alpert Medical School of Brown University
Associate Professor Providence, Rhode Island
Department of Medicine
Warren Alpert Medical School of Brown University Debbie L. Cohen, MD
Providence, Rhode Island Professor of Medicine
Renal Electrolyte and Hypertension Division
Anjulika Chawla, MD University of Pennsylvania
Associate Medical Director, Bluebird Bio Philadelphia, Pennsylvania
Attending Physician
Division of Pediatric Hematology Lisa Cohen, PharmD
Hasbro Children’s Hospital Associate Professor of Pharmacy
Associate Professor University of Rhode Island
Warren Alpert Medical School of Brown University Kingston, Rhode Island
Providence, Rhode Island
Zachary Cohn, MD
Dhruti P. Chen, MD Fellow
Fellow Department of Hematology and Oncology
Division of Nephrology and Hypertension University of Massachusetts
University of North Carolina Worcester, Massachusetts
UNC Kidney Center
Chapel Hill, North Carolina Soontharee Congrete, MD
Fellow
Vicky Cheng, MD Pulmonary and Critical Care Medicine
Assistant Professor University of Connecticut
Warren Alpert Medical School of Brown University Farmington, Connecticut
Department of Endocrinology
Providence, Rhode Island River Cook, MD
University of Kansas Medical Center
Roxana Chis, MD Wichita, Kansas
Division of Gastroenterology
University of Toronto Eddie L. Copelin II, MD, MHA
Toronto, Ontario, Canada Internal Medicine
Boston University School of Medicine
Roger Williams Medical Center
Providence, Rhode Island
 Contributors ix

James Earl Corley III, MD Kristin Dalphon, PA

Resident Physician Physician Assistant
Emergency Medicine New York University School of Medicine
University of Tennessee Health Science Center New York, New York
Memphis, Tennessee
Kristy L. Dalrymple, PhD
Rebecca Craine, MSEd, CCC-SLP Director of Adult Psychology
Speech Language Pathologist Rhode Island and The Miriam Hospitals
Bradley Children’s Hospital Associate Professor, Clinician Educator
East Providence, Rhode Island Warren Alpert Medical School of Brown University
Providence, Rhode Island
Meagan S. Cramer, MD
Fellow Gerard H. Daly, MD, MSc
Oregon Health and Science University Vascular/Structural Fellow
Obstetrics and Gynecology Cardiovascular Medicine
Portland, Oregon St. Elizabeth’s Medical Center
Boston, Massachusetts
Patricia Cristofaro, MD
Assistant Professor Shivang U. Danak, MD
Department of Infectious Diseases St. George’s University
Warren Alpert Medical School of Brown University Detroit, Michigan
Providence, Rhode Island
Rituparna Das, MD
Tess Crouss, MD Assistant Professor
Fellow Neurology
Female Pelvic Medicine and Reconstructive Surgery Baylor College of Medicine
Cooper University Health Care Houston, Texas
Camden, New Jersey
Manuel F. DaSilva, MD
Joanne Szczygiel Cunha, MD Director, Medical Student Education
Assistant Professor of Medicine Department of Orthopedic Surgery
Division of Rheumatology Warren Alpert Medical School of Brown University
Warren Alpert Medical School of Brown University Providence, Rhode Island
Providence, Rhode Island
Catherine D’Avanzato, PhD
Karlene Cunningham, PhD Psychologist
Clinical Assistant Professor Rhode Island Hospital
Department of Psychiatry and Behavioral Medicine Clinical Assistant Professor
Brody School of Medicine at East Carolina University Warren Alpert Medical School of Brown University
Greenville, North Carolina Providence, Rhode Island

Alicia J. Curtin, PhD Steven F. DeFroda, MD, MEng

Assistant Professor Department of Orthopaedic Surgery
Division of Geriatrics Warren Alpert Medical School of Brown University
Warren Alpert Medical School of Brown University Providence, Rhode Island
Providence, Rhode Island
Alexandra Degenhardt, MD, MMSc
Ganary Dabiri, MD, PhD Director
Staff Dermatologist Multiple Sclerosis Center
Roger Williams Medical Center Pen Bay Medical Center
Providence, Rhode Island Rockport, Maine

Lynn Dado, MD Ashwini U. Dhokte, MD

Primary Care Physician Resident Physician
Internal Medicine Christiana Care Hospital
Henry Ford Medical Center Newark, Delaware
Detroit, Michigan
Joseph A. Diaz, MD, MPH
Deepan S. Dalal, MD, MPH Associate Dean for Diversity and Multicultural Affairs
Assistant Professor Associate Professor of Medicine
Medicine, Rheumatology Associate Professor of Medical Science
Warren Alpert Medical School of Brown University and School of Public Warren Alpert Medical School of Brown University
Health Providence, Rhode Island
Department of Health Services, Policy, and Practice
Rhode Island Hospital
Providence, Rhode Island
x Contributors
Allison Dillon, MD Pamela Ellsworth, MD
Resident Physician Chief, Division of Pediatric Urology
Obstetrics and Gynecology Professor of Urology
Christiana Care Health System Nemours Children’s Hospital
Newark, Delaware Orlando, Florida

Thomas H. Dohlman, MD Alan Epstein, MD

Cornea Service, Massachusetts Eye and Ear Infirmary Roger Williams Medical Center
Harvard Medical School Providence, Rhode Island
Boston, Massachusetts
Patricio Sebastian Espinosa, MD, MPH
Stephen Dolter, MD Associate Professor
Pediatric Hospitalist Department of Neurology
Children’s Hospital and Medical Center Department of Clinical Biomedical Science
Pediatric Hospital Medicine Charles E. Schmidt College of Medicine, Florida Atlantic University
Omaha, Nebraska Boca Raton, Florida

David J. Domenichini, MD Danyelle Evans, MD

Clinical Instructor Baylor College of Medicine
Endocrinology and Metabolism Houston, Texas
Hartford Hospital
University of Connecticut Health Center Mark D. Faber, MD
West Hartford, Connecticut Senior Staff Nephrologist
Associate Professor
Kathleen Doo, MD Wayne State University School of Medicine
Sleep Medicine Fellow Henry Ford Hospital
New York University Detroit, Michigan
New York, New York
Matthew J. Fagan, MD, FACOC
James H. Dove, MD Attending Physician
Resident Director of Undergraduate Medical Education
Department of Orthopedic Surgery Obstetrics and Gynecology
Warren Alpert Medical School of Brown University Christiana Care Health System
Providence, Rhode Island Newark, Delaware

Andrew P. Duker, MD Ronan Farrell, MD

Associate Professor Gastroenterology Fellow
Movement Disorders Division Department of Gastroenterology and Hepatology
Director, Department of Neurology and Rehabilitation Medicine Warren Alpert Medical School of Brown University
University of Cincinnati College of Medicine Providence, Rhode Island
Cincinnati, Ohio
Timothy W. Farrell, MD, AGSF
Shashank Dwivedi, MD Associate Professor of Medicine
Resident Physician Adjunct Associate Professor of Family Medicine
Department of Orthopaedic Surgery Director, University of Utah Health
Warren Alpert Medical School of Brown University Interprofessional Education Program
Rhode Island Hospital Physician Investigator, VA Salt Lake City Geriatric Research, Education, and
Providence, Rhode Island Clinical Center
University of Utah School of Medicine
Evlyn Eickhoff, MD Salt Lake City, Utah
Resident Physician
Department of Medicine, Division of Nephrology Kevin Fay, MD
University of New Mexico Health Science Center Fellow
Albuquerque, New Mexico Renal Electrolyte and Hypertension Department
University of Pennsylvania
Christine Eisenhower, PharmD Philadelphia, Pennsylvania
Clinical Assistant Professor
Pharmacy Practice Mariam Fayek, MD
University of Rhode Island College of Pharmacy Clinical Assistant Professor
Kingston, Rhode Island Department of Medicine
Attending Physician
Amani A. Elghafri, MD, MSc, Med Ed Warren Alpert Medical School of Brown University
Resident Physician Center for Women’s Gastrointestinal Health
Department of Internal Medicine Women and Infants Hospital
University of California San Francisco Providence, Rhode Island
Fresno, California
 Contributors xi

Jason D. Ferreira, MD Gregory L. Fricchione, MD

Gastroenterologist Associate Chief of Psychiatry
University Gastroenterology, LLC Director, Benson Henry Institute for Mind Body Medicine
Providence, Rhode Island Director, Pierce Division of Global Psychiatry
Massachusetts General Hospital
Fred F. Ferri, MD Mind Body Medical Institute Professor of Psychiatry
Clinical Professor Harvard Medical School
Department of Medicine Boston, Massachusetts
Warren Alpert Medical School of Brown University
Providence, Rhode Island Michael Friedman, MD
Clinical Associate Professor
Heather Ferri, DO Department of Psychiatry and Human Behavior and Department of
Department of Medicine Neurology
Warren Alpert Medical School of Brown University Warren Alpert Medical School of Brown University
Rhode Island Hospital Providence, Rhode Island
Providence, Rhode Island
Daniel R. Frisch, MD
Barry Fine, MD, PhD Electrophysiology Section, Division of Cardiology
Assistant Professor of Medicine Thomas Jefferson University Hospital
Division of Cardiology Philadelphia, Pennsylvania
Columbia University Vagelos College of Physicians and Surgeons
New York, New York Anthony Gallo, MD
Director of ECT Service
Staci A. Fischer, MD Rhode Island Hospital
Field Director of Education and Training Clinical Assistant Professor
Clinical Learning Environment Review Program Warren Alpert Medical School of Brown University
Accreditation Council for Graduate Medical Education Providence, Rhode Island
Chicago, Illinois
Mostafa Ghanim, MD
Tamara G. Fong, MD, PhD Fellow
Assistant Professor of Neurology Cardiology
Harvard Medical School MercyOne North Iowa Medical Center
Staff Neurologist Mason City, Iowa
Beth Israel Deaconess Medical Center
Assistant Scientist Irene M. Ghobrial, MD
Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife Professor of Medicine
Boston, Massachusetts Harvard Medical School
Dana Farber Cancer Institute
Yaneve Fonge, MD Boston, Massachusetts
Resident Physician
Obstetrics and Gynecology Katarzyna Gilek-Seibert, MD, RhMUS
Christiana Care Health Systems Director, Rheumatology Division and Fellowship Training Program
Newark, Delaware Boston University Affiliated Roger Williams Medical Center
Providence, Rhode Island
Michelle Forcier, MD, MPH
Professor of Pediatrics Richard Gillerman, MD, PhD
Warren Alpert Medical School of Brown University Chief Medical Information Officer
Providence, Rhode Island Clinical Assistant Professor of Surgery
Department of Anesthesia
Frank G. Fort, MD, FACS, RPHS Warren Alpert Medical School of Brown University
Medical Director Providence, Rhode Island
Capital Region Vein Centre
Schenectady, New York Andrew Gillis-Smith, MD
Fellow
Glenn G. Fort, MD, MPH Hematology/Oncology
Clinical Associate Professor of Medicine UMass Memorial Medical Center
Division of Infectious Disease Worcester, Massachusetts
Warren Alpert Medical School of Brown University
Providence, Rhode Island Dimitri Gitelmaker, MD
Resident Physician
Justin F. Fraser, MD Internal Medicine
Assistant Professor of Cerebrovascular Roger Williams Medical Center
Endovascular, and Skull Base Surgery Boston University School of Medicine
Department of Neurosurgery Providence, Rhode Island
University of Kentucky
Lexington, Kentucky Alla Goldburt, MD
Assistant Clinical Professor
Family Medicine
Warren Alpert Medical School of Brown University
Providence, Rhode Island
xii Contributors
Danielle Goldfarb, MD Juan Guerra, DO
Neurologist/Psychiatrist Attending Physician
Banner Alzheimer’s Institute Clinical Adjunct Faculty
Phoenix, Arizona Department of Emergency Medicine
University of Tennessee Health Science Center
Jesse Goldman, MD, FASH Memphis, Tennessee
Professor of Medicine
Drexel University College of Medicine Patan Gultawatvichai, MD
Philadelphia, Pennsylvania Assistant Professor
Hematology–Oncology
Corey Goldsmith, MD University of Massachusetts Medical School
Assistant Professor of Neurology Worcester, Massachusetts
Neurology Residency Program Director
Baylor College of Medicine David Guo, MD
Chief of Neurology Outpatient Clinics Associate Urologist
Ben Taub Hospital, Harris Health System Kaiser Permanente Hospital
Houston, Texas Santa Clara, California

Maheswara Satya Gangadhara Rao Golla, MD Priya Sarin Gupta, MD, MPH
Department of Cardiovascular Medicine Adolescent Medicine Fellow
Steward Family Hospital, St. Elizabeth’s Medical Center Division of General Pediatrics and Adolescent Medicine
Brighton, Massachusetts Johns Hopkins Hospital
Baltimore, Maryland
Caroline Golski, MD
Resident Physician Nawaz K. A. Hack, MD
General Psychiatry Assistant Professor of Neurology
Warren Alpert Medical School of Brown University F. Edward Hébert School of Medicine
Providence, Rhode Island Uniformed Services University of the Health Sciences
Bethesda, Maryland
Helen B. Gomez, MD
Resident Physician Moti Haim, MD
Obstetrics and Gynecology Director, Cardiac Electrophysiology and Pacing
Christiana Care Health System Soroka Medical Center
Newark, Delaware Ben Gurion University of the Negev
Be’er-Sheva, Israel
Avi D. Goodman, MD
Orthopedic Trauma Fellow Sajeev Handa, MD, SFHM
Department of Orthopedics Chief, Hospital Medicine
Warren Alpert Medical School of Brown University Lifespan Physician Group
Providence, Rhode Island Rhode Island, Miriam, and Newport Hospitals
Clinical Assistant Professor of Medicine and Neurology
Paul Gordon, MD Warren Alpert Medical School of Brown University
Clinical Assistant Professor of Medicine Providence, Rhode Island
Division of Cardiology
Warren Alpert Medical School of Brown University M. Owais Hanif, MD
Providence, Rhode Island Senior Nephrology Fellow
Hahnemann Hospital
John A. Gray, MD, PhD Philadelphia, Pennsylvania
Assistant Professor
Department of Neurology Nikolas Harbord, MD
Center for Neuroscience Division Chief, Nephrology and Hypertension
University of California, Davis Mount Sinai Beth Israel
Davis, California Assistant Professor
Icahn School of Medicine at Mount Sinai
Simon Gringut, MD New York, New York
Cardiac Electrophysiology Fellow
Yale New Haven Hospital Sonali Harchandani, MD
New Haven, Connecticut Fellow
Hematology/Oncology
Lauren Grocott, BA University of Massachusetts Medical School
Clinical Research Assistant Worcester, Massachusetts
Rhode Island Hospital
Providence, Rhode Island Erica Hardy, MD, MMS
Director of Women’s Infectious Disease
Stephen L. Grupke, MD, MS Division of Infectious Disease and Obstetric Medicine
Assistant Professor Women and Infants Hospital
Department of Neurosurgery Providence, Rhode Island
University of Kentucky
Lexington, Kentucky
 Contributors xiii

Colin J. Harrington, MD R. Scott Hoffman, MD

Director of Consultation-Liaison Psychiatry and Neuropsychiatry Education Ophthalmology
Director of Psychosomatic Medicine Fellowship Doctors Eye Institute
Co-Director of CNS-Psychiatry Clerkship Assistant Clinical Professor
Rhode Island Hospital Department of Ophthalmology
Warren Alpert Medical School of Brown University University of Louisville
Providence, Rhode Island Louisville, Kentucky

Taylor Harrison, MD Dawn Hogan, MD

Assistant Professor of Neurology Clinical Assistant Professor of Family Medicine
Emory University Warren Alpert Medical School of Brown University
Atlanta, Georgia Providence, Rhode Island

Brian Hawkins, MD N. Wilson Holland, MD

Otolaryngologist Associate Professor of Medicine
Louisville, Kentucky Division of Geriatrics and Gerontology
Emory University School of Medicine
Don Hayes, Jr., MD, MS, MEd Acting Designated Learning Officer
Professor Atlanta Veterans Administration Medical Center
Departments of Pediatrics, Internal Medicine, Surgery, Epidemiology Atlanta, Georgia
The Ohio State University
Columbus, Ohio Siri M. Holton, MD
Resident Physician
Shruti Hegde, MD Obstetrics and Gynecology
Fellow Christiana Care Health System
Cardiovascular Medicine Newark, Delaware
St. Elizabeth’s Medical Center
Brighton, Massachusetts Anne L. Hume, PharmD
Professor of Pharmacy
Rachel Wright Heinle, MD, FACOG Department of Pharmacy Practice
Attending Physician University of Rhode Island
Obstetrics and Gynecology Kingston, Rhode Island
Christiana Care Health System
Newark, Delaware Zilla Hussain, MD
Gastroenterologist
Dwayne R. Heitmiller, MD, FAPM Lifespan Physicians Group
Attending Physician Department of Hepatology and Gastroenterology
Consultation-Liaison Division Providence, Rhode Island
Abbott Northwestern Hospital
Minneapolis, Minnesota Donny V. Huynh, MD
Staff Physician
Jyothsna I. Herek, MD McLeod Oncology and Hematology at Seacoast
Senior Staff Physician McLeod Regional Medical Center
Department of Nephrology and Hypertension Little River, South Carolina
Henry Ford Hospital
Detroit, Michigan Terri Q. Huynh, MD, MSCR
Associate Fellowship Program Director
Margaret R. Hines, MD Minimally Invasive Gynecologic Surgery
Clinical Fellow Christiana Care Health System
Female Pelvic Medicine and Reconstructive Surgery Newark, Delaware
Baylor Scott and White Health
Temple, Texas Sarah Hyder, MD
Assistant Professor of Medicine
Ashley Hodges, MD Associate Program Director, GI Fellowship
Resident Physician Department of Gastroenterology
Obstetrics and Gynecology Warren Alpert Medical School of Brown University
Christiana Care Health System Lifespan Physician Group
Newark, Delaware Providence, Rhode Island

Pamela E. Hoffman, MD Dina A. Ibrahim, MD

Assistant Director, Hasbro Psychiatric Emergency Services Kent Hospital
Assistant Professor, Clinician Educator Warren Alpert Medical School of Brown University
Department of Psychiatry and Human Behavior Providence, Rhode Island
Warren Alpert Medical School of Brown University
Providence, Rhode Island Caitlin Ingraham, MD
Resident Physician
Obstetrics and Gynecology
Christiana Care Health System
Newark, Delaware
xiv Contributors
Nicholas J. Inman, MD Michael P. Johnson, MD
University of Tennessee Health Science Center Internist, Medical Attending
Memphis, Tennessee Rhode Island and Miriam Hospitals
Providence, Rhode Island
Louis Insalaco, MD
Surgeon Angad Jolly, PhD
Massachusetts Eye and Ear Infirmary Baylor College of Medicine
Department of Otolaryngology, Head and Neck Surgery Houston, Texas
Boston, Massachusetts
Rebecca Jonas, MD
Ashley A. Jacobson, MD Resident Physician
Resident Physician Department of Internal Medicine
Department of Emergency Medicine Lenox Hill Hospital
Mayo Clinic New York, New York
Rochester, Minnesota
Kimberly Jones, MD
Koyal Jain, MD Associate Professor of Child Neurology
Assistant Professor of Medicine Department of Neurology
Division of Nephrology and Hypertension University of Kentucky
University of North Carolina, Chapel Hill Lexington, Kentucky
Chapel Hill, North Carolina
Shyam Joshi, MD
Vanita D. Jain, MD Assistant Professor of Medicine
Clinical Assistant Professor Section of Allergy and Immunology
Obstetrics and Gynecology Oregon Health Sciences University
Sidney Kimmel College of Medicine Portland, Oregon
Thomas Jefferson University
Philadelphia, Pennsylvania Siddharth Kapoor, MD
Medical Director, Perinatal Special Care Unit and Clinic Assistant Professor of Neurology
Christiana Care Health System Director, Headache Medicine
Newark, Delaware Program Director, Fellowship in Headache Medicine
Department of Neurology
Fariha Jamal, MD University of Kentucky College of Medicine
Assistant Professor of Neurology Lexington, Kentucky
Baylor College of Medicine
Michael. E. DeBakey VA Medical Center Vanji Karthikeyan, MD
Houston, Texas Nephrologist
Department of Nephrology and Hypertension
Sehrish Jamot, MD Henry Ford Hospital
Gastroenterology/Hepatology Fellow Detroit, Michigan
Chief Gastroenterology Fellow
Warren Alpert Medical School of Brown University Joseph S. Kass, MD, JD, FAAN
Lifespan Physician Group Associate Dean of Student Affairs
Providence, Rhode Island Professor of Neurology, Psychiatry, and Medical Ethics
Director, Alzheimer’s Disease and Memory Disorders Center
Robert H. Janigian, Jr., MD Baylor College of Medicine
Clinical Associate Professor of Surgery Ben Taub General Hospital
Department of Surgery/Ophthalmology Houston, Texas
Warren Alpert Medical School of Brown University
Providence, Rhode Island Emily R. Katz, MD
Associate Professor, Clinician Educator
Noelle Marie Javier, MD Department of Psychiatry and Human Behavior
Assistant Professor of Medicine Department of Pediatrics
Brookdale Department of Geriatrics and Palliative Care Warren Alpert Medical School of Brown University
Icahn School of Medicine at Mount Sinai Director, Child and Adolescent Psychiatry
New York, New York Consultation-Liaison Service
Hasbro Children’s Hospital
Michael Johl, MD Providence, Rhode Island
Cardiology Fellow
Department of Cardiology Ali Kazim, MD
University of California, Irvine Chief of Psychiatry
Orange, California Phoenix VA Health Care System
Clinical Professor of Psychiatry
Christina M. Johnson, MD University of Arizona Medical College
Minimally Invasive Gynecologic Surgeon Phoenix, Arizona
Department of Obstetrics and Gynecology
Beth Israel Lahey Health
Burlington, Massachusetts
 Contributors xv

Sudad Kazzaz, MD Nelson Kopyt, DO

Baylor College of Medicine Chief of Nephrology
Houston, Texas Lehigh Valley Hospital
Allentown, Pennsylvania
Sachin Kedar, MBBS, MD Clinical Professor of Medicine
Associate Professor Morsani College of Medicine
Neurological Sciences, Ophthalmology and Visual Sciences Tampa, Florida
University of Nebraska Medical School and Truhlsen Eye Institute
Omaha, Nebraska Lindsay R. Kosinski, MD
Resident Physician
A. Basit Khan, MD Warren Alpert Medical School of Brown University
Resident Physician Rhode Island Hospital
Neurosurgery Providence, Rhode Island
Baylor College of Medicine
Houston, Texas Katherine Kostroun, MD
Baylor College of Medicine
Bilal Shahzad Khan, MD Houston, Texas
Internal Medicine Fellow
Hypertension and Nephrology Ioannis Koulouridis, MD, MS
Henry Ford Hospital Cardiology Fellow
Detroit, Michigan St. Elizabeth’s Medical Center
Boston, Massachusetts
Rizwan Khan, MD
Cardiology Fellow Timothy R. Kreider, MD, PhD
St. Elizabeth’s Medical Center Assistant Professor
Boston, Massachusetts Department of Psychiatry
Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
Sarthak Khare, MD Hempstead, New York
Medicine Resident and Cardiology Fellow
St. Elizabeth’s Medical Center Prashanth Krishnamohan, MBBS, MD
Department of Medicine Neurocritical Care
Boston, Massachusetts Stanford University
Palo Alto, California
Hussain R. Khawaja, MD
Assistant Professor of Medicine, Clinician Educator Mohit Kukreja, MD
Warren Alpert Medical School of Brown University Clinical Fellow
Division of General Internal Medicine Shoulder and Elbow Surgery
Rhode Island Hospital Warren Alpert Medical School of Brown University
Providence, Rhode Island Providence, Rhode Island

Byung Kim, MD Lalathaksha Kumbar, MD

Department of Hematology Oncology Senior Staff Physician
Harold Alfond Center for Cancer Care Division of Nephrology and Hypertension
Augusta, Maine Henry Ford Hospital
Detroit, Michigan
Robert M. Kirchner, MD
Cardiology Fellow David I. Kurss, MD, FACOG, NCMP
Warren Alpert Medical School of Brown University Attending Physician, Clinical Assistant Professor
Providence, Rhode Island Obstetrics and Gynecology
State University of New York School of Medicine
Robert Kohn, MD Buffalo, New York
Department of Psychiatry and Human Behavior
Warren Alpert Medical School of Brown University Sebastian G. Kurz, MD
Providence, Rhode Island Associate Professor
Department of Internal Medicine
Erna Milunka Kojic, MD Division of Pulmonary, Critical Care and Sleep Medicine
Professor Mount Sinai Hospital
Division of Infectious Diseases New York, New York
Icahn School of Medicine at Mount Sinai
New York, New York Michael Kutschke, MD
Resident Physician
Aravind Rao Kokkirala, MD, FACC Department of Orthopedic Surgery
Warren Alpert Medical School of Brown University Warren Alpert Medical School of Brown University
Providence, Rhode Island Providence, Rhode Island

Yuval Konstantino, MD Peter LaCamera, MD

Cardiology Assistant Professor of Medicine
Clinical Cardiac Electrophysiology Tufts University School of Medicine
Soroka University Medical Center Boston, Massachusetts
Be’er-Sheva, Israel
xvi Contributors
Ann S. LaCasce, MD, MMSc Donita Dillon Lightner, MD
Associate Professor of Medicine Assistant Professor of Pediatric Neurology
Medical Oncology University of Kentucky
Harvard Medical School Lexington, Kentucky
Boston, Massachusetts
Stanley Linder, DO
Ashley Lakin, DO, MA Nephrology and Critical Care Fellow
Assistant Professor of Family Medicine (Clinical) Henry Ford Hospital
Warren Alpert Medical School of Brown University Detroit, Michigan
Providence, Rhode Island
Kito Lord, MD, MBA
Jayanth Lakshmikanth, MD Assistant Professor
Fellow Department of Emergency Medicine
Nephrology and Critical Care University of Tennessee Health Science Center
Henry Ford Hospital System Memphis, Tennessee
Detroit, Michigan
Elizabeth A. Lowenhaupt, MD
Uyen T. Lam, MD Associate Professor, Clinician Educator
Noninvasive Cardiology Department of Psychiatry and Human Behavior
St. Elizabeth’s Medical Center Warren Alpert Medical School of Brown University
Tufts University School of Medicine Providence, Rhode Island
Boston, Massachusetts
Curtis Lee Lowery III, MD, PhD
Jhenette Lauder, MD Resident Physician
Maternal-Fetal Medicine Fellow Emergency Medicine
Obstetrics and Gynecology University of Tennessee Health Science Center
University of Utah Memphis, Tennessee
Salt Lake City, Utah
David J. Lucier Jr., MD, MBA, MPH
Nykia Leach, BA Director of Quality and Patient Safety, Hospital Medicine
Clinical Research Assistant Division of General Internal Medicine
Rhode Island Hospital Massachusetts General Hospital
Providence, Rhode Island Boston, Massachusetts

David A. Leavitt, MD Michelle C. Maciag, MD

Associate Director of Endourology Fellow
Director of Laser Surgery Allergy and Clinical Immunology
Senior Staff Boston Children’s Hospital
Vattikuti Urology Institute Harvard Medical School
Henry Ford Hospital Health System Boston, Massachusetts
Detroit, Michigan
Susanna R. Magee, MD, MPH
Kachiu C. Lee, MD, MPH Assistant Professor
Department of Dermatology Department of Family Medicine
Warren Alpert Medical School of Brown University Warren Alpert Medical School of Brown University
Providence, Rhode Island Providence, Rhode Island

Nicholas J. Lemme, MD Marta Majczak, MD

Resident Physician Attending Psychiatrist
Department of Orthopedics Bradley Hospital
Warren Alpert Medical School of Brown University East Providence, Rhode Island
Rhode Island Hospital
Providence, Rhode Island Shefali Majmudar, DO
Rheumatologist
Beth Leopold, MD Jackson Medical Center
Resident Physician Miami, Florida
Obstetrics and Gynecology
Christiana Care Health System Gretchen Makai, MD
Newark, Delaware Clinical Assistant Professor
Obstetrics and Gynecology
Jian Li, MD, PhD Sidney Kimmel Medical College, Thomas Jefferson University
Clinical Assistant Professor Philadelphia, Pennsylvania;
Internal Medicine, Hypertension and Nephrology Director, Division of Minimally Invasive Gynecologic Surgery
Wayne State University School of Medicine Christiana Care Health System
Henry Ford Hospital Newark, Delaware
Detroit, Michigan
Pieusha Malhotra, MD, MPH
Suqing Li, MD Assistant Professor
Gastroenterology Fellow Division of Allergy, Immunology, and Rheumatology
University of Toronto Rutgers New Jersey School of Medicine
Toronto, Ontario, Canada Newark, New Jersey
 Contributors xvii

Eishita Manjrekar, PhD Jorge Mercado, MD

Postdoctoral Fellow Assistant Professor of Medicine
Rhode Island Hospital Assistant Chief of Pulmonary and Critical Care Medicine
Warren Alpert Medical School of Brown University Director of Pulmonary Section
Providence, Rhode Island NYU School of Medicine
New York, New York
Abigail K. Mansfield, PhD
Assistant Professor Scott J. Merrill, MD
Warren Alpert Medical School of Brown University Resident Physician
Providence, Rhode Island Obstetrics and Gynecology
Christiana Care Health System
Stephen E. Marcaccio, MD Newark, Delaware
Department of Orthopaedic Surgery
Rhode Island Hospital Jennifer B. Merriman, MD
Warren Alpert Medical School of Brown University Delaware Center for Maternal-Fetal Medicine of Christiana Care
Providence, Rhode Island Newark, Delaware

Lauren J. Maskin, MD Rory Merritt, MD, MEHP

Pediatric Hospitalist Emergency Medicine
Division of Pediatric Hospital Medicine Warren Alpert Medical School of Brown University/Lifespan
Children’s Hospital and Medical Center Rhode Island Hospital and Miriam Hospital
Omaha, Nebraska Providence, Rhode Island

Robert Matera, MD Brittany N. Mertz, PA-C, MMSc-PA

Resident Physician Physician Assistant
Internal Medicine Wesley Chapel, Florida
Warren Alpert Medical School of Brown University
Providence, Rhode Island Robin Metcalfe-Klaw, MD
Obstetrics and Gynecology
Kelly L. Matson, PharmD, BCPPS Christiana Care Health System
Clinical Professor Newark, Delaware
Department of Pharmacy Practice
University of Rhode Island Gaetane Michaud, MD
Kingston, Rhode Island Professor of Medicine and Cardiothoracic Surgery
NYU Langone Health
Maitreyi Mazumdar, MD, MPH, MSc New York, New York
Assistant Professor of Neurology
Harvard Medical School Taro Minami, MD
Staff Physician Associate Professor of Medicine, Clinician Educator
Department of Neurology Warren Alpert Medical School of Brown University
Boston Children’s Hospital Providence, Rhode Island
Boston, Massachusetts
Hassan M. Minhas, MD
Nadine Mbuyi, MD Clinical Assistant Professor
Assistant Professor of Medicine Department of Law and Psychiatry
Division of Rheumatology Yale University
George Washington University School of Medicine and Health Sciences New Haven, Connecticut;
Washington, DC Medical Director, Outpatient Autism Services
Hospital for Special Care
Russell J. McCulloh, MD New Britain, Connecticut
Associate Professor
Pediatrics and Internal Medicine Jared D. Minkel, PhD
University of Nebraska Medical Center Assistant Professor
Children’s Hospital and Medical Center Psychiatry and Human Behavior
Omaha, Nebraska Warren Alpert Medical School of Brown University
Providence, Rhode Island
Christopher McDonald, MD
Resident Physician Farhan A. Mirza, MD
Orthopedic Surgery Resident Physician
Rhode Island Hospital Neurosurgery
Warren Alpert Medical School of Brown University University of Kentucky
Providence, Rhode Island Lexington, Kentucky

Barbara McGuirk, MD Hetal D. Mistry, MD

Director of Surgery Resident Physician
Reproductive Associates of Delaware Internal Medicine
Newark, Delaware Warren Alpert Medical School of Brown University
Providence, Rhode Island
xviii Contributors
Jacob Modest, MD Adrienne B. Neithardt, MD
Resident Physician Reproductive Associates of Delaware
Orthopedic Surgery Newark, Delaware
Warren Alpert Medical School of Brown University
Rhode Island Hospital Peter Nguyen, MD
Providence, Rhode Island Interventional Cardiology Fellow
University of California, Irvine
Marc Monachese, MD Orange, California
Division of Gastroenterology
University of Toronto Samantha Ni, MD
Toronto, Ontario, Canada Resident Physician
Emergency Department
Eveline Mordehai, MD University of Tennessee Health Science Center
Resident Physician Memphis, Tennessee
Anesthesia
Warren Alpert Medical School of Brown University Melissa Nothnagle, MD, MSc
Providence, Rhode Island Chief of Family Medicine
Natividad Hospital
Theresa A. Morgan, PhD Salinas, California
Clinical Assistant Professor
Psychiatry and Human Behavior James E. Novak, MD, PhD
Warren Alpert Medical School of Brown University Division of Nephrology and Hypertension
Providence, Rhode Island Henry Ford Hospital
Detroit, Michigan
Aleem I. Mughal, MD
Cardiac Electrophysiologist Chloe Mander Nunneley, MD
Heart Center of North Texas Baylor College of Medicine
Fort Worth, Texas Houston, Texas

Marjan Mujib, MD Emily E. Nuss, MD

Cardiology Fellow Resident Physician
Department of Medicine, Division of Cardiology Obstetrics and Gynecology
Warren Alpert Medical School of Brown University Christiana Care Health System
Providence, Rhode Island Wilmington, Delaware

Shiva Kumar R. Mukkamalla, MD, MPH Gail M. O’Brien, MD

Attending Physician Physician
Internal Medicine/Hematology and Medical Oncology Internal Medicine/Obesity Medicine
Presbyterian Healthcare Services Lahey Hospital Primary Care
Rio Rancho, New Mexico Burlington, Massachusetts

Vivek Murthy, MD Ryan M. O’Donnell, MD

Assistant Professor of Medicine Resident Physician
Albert Einstein College of Medicine Orthopedic Surgery
Montefiore Medical Center Warren Alpert Medical School of Brown University
Bronx, New York Rhode Island Hospital
Providence, Rhode Island
Omar Nadeem, MD
Instructor in Medicine Adam J. Olszewski, MD
Department of Hematologic Malignancies, Medical Oncology Assistant Professor of Medicine
Harvard Medical School Warren Alpert Medical School of Brown University
Dana Farber Cancer Institute Providence, Rhode Island
Boston, Massachusetts
Lindsay M. Orchowski, PhD
Catherine E. Najem, MD Associate Professor (Research)
Section of Rheumatology Department of Psychiatry and Human Behavior
Lewis Katz School of Medicine at Temple University Warren Alpert Medical School of Brown University
Philadelphia, Pennsylvania Providence, Rhode Island

Hussain Mohammad H. Naseri, MD Sebastian Orman, MD

Physician, Hematology/Oncology Resident Physician
Ohio Valley Medical Center Orthopaedic Surgery
Wheeling, West Virginia Warren Alpert Medical School of Brown University/Lifespan
Providence, Rhode Island
Uzma Nasir, MD
Assistant Professor Brett D. Owens, MD
Clinical Anesthesia and Pain Management Surgeon, Orthopedic Sports Medicine
SUNY at Stony Brook University Hospital, VA Hospital Complex Shoulder and Knee Specialist
Northport, New York Warren Alpert Medical School of Brown University
Providence, Rhode Island
 Contributors xix

Paolo G. Pace, MASc, MD Brett Patrick, MD

Resident Physician University of Tennessee Health Science Center
Internal Medicine Memphis, Tennessee
Roger Williams Medical Center
Providence, Rhode Island Grace Rebecca Paul, MBBS, MD
Assistant Professor of Pediatrics
Argyro Papafilippaki, MD, FACC Division of Pulmonary and Sleep Medicine
Cardiology Fellow Nationwide Children’s Hospital
St. Elizabeth’s Medical Center Columbus, Ohio
Department of Medicine
Boston, Massachusetts E. Scott Paxton, MD
Assistant Professor
Lisa Pappas-Taffer, MD Orthopedic Surgery
Assistant Professor Warren Alpert Medical School of Brown University
Dermatology Providence, Rhode Island
University of Pennsylvania
Philadelphia, Pennsylvania Mark Perazella, MD
Professor
Marco Pares, BS (MD Candidate) Department of Internal Medicine and Section of Nephrology
Baylor College of Medicine Yale University School of Medicine
Houston, Texas New Haven, Connecticut

Anshul Parulkar, MD Lily Pham, MD

Resident Physician Resident Physician
Internal Medicine Neurology
Rhode Island Hospital Baylor College of Medicine
Warren Alpert Medical School of Brown University Houston, Texas
Providence, Rhode Island
Long Pham, MD
Birju B. Patel, MD Rheumatology Fellow
Assistant Professor of Medicine Cedars-Sinai Medical Center
Division of Geriatrics and Gerontology Los Angeles, California
Emory University School of Medicine
Atlanta Veterans Affairs Medical Center Katharine A. Phillips, MD
Atlanta, Georgia Professor of Psychiatry
DeWitt Wallace Senior Scholar
Devan D. Patel, MD Weill Cornell Medical College
Resident Physician Attending Psychiatrist
Warren Alpert Medical School of Brown University New York-Presbyterian Hospital
Rhode Island Hospital New York, New York;
Providence, Rhode Island Adjunct Professor of Psychiatry and Human Behavior
Warren Alpert Medical School of Brown University
Nima R. Patel, MD, MS Providence, Rhode Island
Program Director, TriHealth OB/GYN Residency
Division of Minimally Invasive Surgery Christopher Pickett, MD
TriHealth/Good Samaritan Hospital Associate Professor of Medicine
Cincinnati, Ohio University of Connecticut
Farmington, Connecticut
Pranav M. Patel, MD, FACC, FAHA, FSCAI
Professor of Medicine and Biomedical Engineering Justin Pinkston, MD
Chief, Division of Cardiology East Tennessee State University Quillen College of Medicine
University of California, Irvine Department of Emergency Medicine
Irvine, California Johnson City, Tennessee

Saagar N. Patel, MD Wendy A. Plante, PhD

Baylor College of Medicine Staff Psychologist
Houston, Texas Director of Outpatient Services
Division of Child and Adolescent Psychiatry
Shivani K. Patel, MD Hasbro Children’s Hospital/Rhode Island Hospital
Physician Clinical Associate Professor of Psychiatry and Human Behavior
Department of Internal Medicine/Rheumatology Warren Alpert Medical School of Brown University
St. Jude Medical Center Providence, Rhode Island
Fullerton, California
Kevin V. Plumley, MD, MPH
Shyam A. Patel, MD Physician
Resident Physician Internal Medicine
Warren Alpert Medical School of Brown University Kaiser Permanente
Rhode Island Hospital Los Angeles, California
Providence, Rhode Island
xx Contributors
Michael Pohlen, MD Neha Rana, MD
Baylor College of Medicine Physician
Houston, Texas Obstetrics and Gynecology
Hospital of the University of Pennsylvania
Sharon S. Hartman Polensek, MD, PhD Philadelphia, Pennsylvania
Assistant Professor of Neurology
Center for Dizziness and Balance Disorders Gina Ranieri, DO
Emory University Resident Physician
Atlanta, Georgia Obstetrics and Gynecology
Christiana Care Health System
Kittika Poonsombudlert, MD Newark, Delaware
Resident Physician
Internal Medicine Bharti Rathore, MD
University of Hawaii Program Director, Hematology/Oncology Fellowship
Honolulu, Hawaii Roger Williams Medical Center
Providence, Rhode Island
Donn Posner, PhD Assistant Professor of Medicine
Adjunct Clinical Associate Professor Boston University School of Medicine
Psychiatry and Behavioral Sciences Boston, Massachusetts
Stanford University School of Medicine
Palo Alto Veterans Institute for Research Ritesh Rathore, MD
Veterans Affairs Palo Alto Health Care System Associate Professor
Palo Alto, California Boston University School of Medicine
Director, Hematology/Oncology
Rohini Prashar, MD Roger Williams Medical Center
Nephrologist Providence, Rhode Island
Department of Nephrology and Hypertension
Henry Ford Hospital Neha P. Raukar, MD, MS
Detroit, Michigan Associate Professor
Emergency Medicine
Amanda Pressman, MD Mayo Clinic
Assistant Professor of Medicine Rochester, Minnesota
Department of Gastroenterology
Warren Alpert Medical School of Brown University John L. Reagan, MD
Providence, Rhode Island Assistant Professor
Internal Medicine, Hematology/Oncology
Adam J. Prince, MD Warren Alpert Medical School of Brown University
Resident Physician Providence, Rhode Island
Internal Medicine
Lennox Hill Hospital Bharathi V. Reddy, MD
New York, New York Associate Professor of Medicine
Section of Nephrology
Imrana Qawi, MD University of Chicago
Assistant Professor of Medicine Chicago, Illinois
Pulmonary/Critical Care
Tufts Medical Center Chakravarthy Reddy, MD
Boston, Massachusetts Associate Professor
Pulmonary and Critical Care
Reema Qureshi, MD University of Utah
Fellow Salt Lake City, Utah
Department of Cardiology
Rhode Island Hospital Snigdha T. Reddy, MD
Warren Alpert Medical School of Brown University Division of Nephrology and Hypertension
Providence, Rhode Island Henry Ford Hospital
Detroit, Michigan
Nora Rader, MD
University of South Carolina School of Medicine, Greenville Anthony M. Reginato, PhD, MD
Greenville, South Carolina Director, Division of Rheumatology
Associate Professor of Medicine
Jeremy E. Raducha, MD Warren Alpert Medical School of Brown University
Resident Physician Providence, Rhode Island
Orthopedic Surgery
Warren Alpert Medical School of Brown University Michael S. Reich, MD
Providence, Rhode Island Resident Physician
Emergency Medicine
Samaan Rafeq, MD University of Tennessee Health Science Center
Pulmonologist Memphis, Tennessee
NYU Langone Health
New York, New York
 Contributors xxi

James P. Reichart, MD Todd F. Roberts, MD, FRCPC

Associate Program Director Medical Director, Leukemia, Blood and Marrow Transplant Program
Division of Nephrology Medical Director, Immunotherapy Program
Lehigh Valley Health Network Roger Williams Medical Center
Allentown, Pennsylvania Providence, Rhode Island

Daniel Brian Carlin Reid, MD, MPH Gregory Rochu, MD, MPH
Resident Physician Assistant Professor of Medicine
Warren Alpert Medical School of Brown University Division of Geriatrics and Palliative Medicine
Rhode Island Hospital Warren Alpert Medical School of Brown University
Providence, Rhode Island Providence, Rhode Island

Victor I. Reus, MD Emily Rosenfeld, MD, MPH

Distinguished Professor of Psychiatry Resident Physician
University of California San Francisco School of Medicine Obstetrics and Gynecology
University of California San Francisco Weill Institute for Neurosciences Christiana Care Health Systems
Langley Porter Psychiatric Institute Newark, Delaware
San Francisco, California
Julie L. Roth, MD
Candice Reyes, MD, RhMSUS Director of Women’s Neurology
Associate Clinical Professor of Medicine Department of Neurology
Department of Rheumatology Rhode Island Hospital
University of California San Francisco Providence, Rhode Island
Fresno, California
Steven Rougas, MD, MS, FACEP
Harlan G. Rich, MD, FACP, AGAF Director, Doctoring Program
Associate Professor of Medicine and Medical Science Assistant Professor of Emergency Medicine and Medical Science
Warren Alpert Medical School of Brown University Warren Alpert Medical School of Brown University
Director of Endoscopy Providence, Rhode Island
Rhode Island Hospital
Clinical Director of the Division of Gastroenterology Breton Roussel, MD
Brown Medicine/Brown Physicians, Inc. Chief Resident
Providence, Rhode Island Department of General Internal Medicine
Warren Alpert Medical School of Brown University
Rocco J. Richards, MD Providence, Rhode Island
Roger Williams Medical Center
Department of Internal Medicine Amity Rubeor, DO, CAQSM
Boston University School of Medicine Assistant Professor
Boston, Massachusetts Department of Family Medicine
Warren Alpert Medical School of Brown University
Nathan Riddell, MD Providence, Rhode Island
Interventional Cardiology Fellow
Department of Cardiovascular Medicine Kelly Ruhstaller, MD
St. Elizabeth’s Medical Center Christiana Care Health Systems
Boston, Massachusetts Newark, Delaware

Giulia Righi, PhD Javeryah Safi, MD

Staff Psychologist Clinical Associate
Bradley Hospital Department of Pulmonary and Critical Care Medicine
East Providence, Rhode Island Tufts University
Assistant Professor (Research) Boston, Massachusetts
Warren Alpert Medical School of Brown University
Providence, Rhode Island Emily Saks, MD, MSSCE
Physician
Alvaro M. Rivera, MD Female Pelvic Medicine and Reconstructive Surgery
Internal Medicine Christiana Care Health System
Roger Williams Medical Center Newark, Delaware
Providence, Rhode Island
Milagros Samaniego-Picota, MD
Nicole A. Roberts, MD Section Head and Medical Director, Kidney Pancreas Transplantation
Assistant Professor Transplant Institute and Division of Nephrology and Hypertension
Obstetrics and Gynecology Henry Ford Health System
University of South Florida Detroit, Michigan
Tampa, Florida
xxii Contributors
Radhika Sampat, DO Christina D. Scully, MD
Instructor Consultation-Liaison Psychiatry Attending
Department of Neurology, Neuromuscular Division Providence, Rhode Island
Emory University School of Medicine
Atlanta, Georgia Peter J. Sell, DO
Associate Professor
Hemant K. Satpathy, MD Department of Pediatrics
Fellow University of Massachusetts Medical School
Division of Maternal Fetal Medicine Worcester, Massachusetts
Department of Obstetrics and Gynecology
Emory University Steven M. Sepe, MD, PhD
Atlanta, Georgia Chair, Department of Medicine
Roger Williams Medical Center
Ruby K. Satpathy, MD Clinical Professor of Medicine
Fellow Assistant Dean of Clinical Affairs
Cardiology Boston University School of Medicine
Department of Internal Medicine Boston, Massachusetts
Creighton University
Omaha, Nebraska Hesham Shaban, MD
Senior Staff
Syeda M. Sayeed, MD Division of Nephrology
Attending Physician Henry Ford Hospital System
Department of Rheumatology Detroit, Michigan
South Coast Health
Fall River, Massachusetts Ankur Shah, MD
Assistant Professor of Medicine
Daphne Scaramangas-Plumley, MD Division of Nephrology
Rheumatologist Warren Alpert Medical School of Brown University
Attune Health Providence, Rhode Island
Cedars-Sinai Medical Center
Beverly Hills, California Kalpit N. Shah, MD
Fellow
Aaron Schaffner, MD Orthopedic Trauma
Physician Department of Orthopedic Surgery
Emergency Medicine Warren Alpert Medical School of Brown University
University of Tennessee Health Science Center Rhode Island Hospital
Memphis, Tennessee Providence, Rhode Island

Paul J. Scheel, Jr., MD Shivani Shah, MD

Nephrologist Obstetrician/Gynecologist
CEO, Washington University Physicians Geisinger Health System
Associate Vice Chancellor of Clinical Affairs Wilkes-Barre, Pennsylvania
Washington University, St. Louis
Barnes-Jewish Hospital Esseim Sharma, MD
St. Louis, Missouri Fellow
Cardiology
Bradley Schlussel, MD Warren Alpert Medical School of Brown University
Rheumatologist Providence, Rhode Island
Department of Rheumatology
Greenwich Hospital Yuvraj Sharma, MD
Northeast Medical Group—Yale New Haven Health Senior Staff Physician
Greenwich, Connecticut Department of Nephrology and Hypertension
Henry Ford Hospital
Heiko Schmitt, MD, PhD Detroit, Michigan
Associate Professor of Medicine
Department of Cardiology Lydia Sharp, MD
Co-Director Cardiac Electrophysiology Assistant Professor
Director Anticoagulation Clinic Department of Neurology
UConn Health Baylor College of Medicine
Farmington, Connecticut Houston, Texas

Anthony Sciscione, DO Charles Fox Sherrod IV, MD

Professor of Obstetrics and Gynecology Resident Physician
Jefferson Medical College Internal Medicine
Philadelphia, Pennsylvania; Warren Alpert Medical School of Brown University
Residency Program Director Providence, Rhode Island
Director of Maternal-Fetal Medicine
Department of Obstetrics and Gynecology
Christiana Care Health System
Newark, Delaware
 Contributors xxiii

Jessica E. Shill, MD Irina A. Skylar-Scott, MD

Senior Staff Physician Resident Physician
Division of Endocrinology, Diabetes and Bone and Mineral Disorders Neurology
Henry Ford Health System Harvard Medical School
Clinical Associate Professor of Medicine Boston, Massachusetts
Wayne State University School of Medicine
Detroit, Michigan John Sladky, MD
Staff Neurologist
Philip A. Shlossman, MD Associate Program Director
Associate Director, Maternal and Fetal Medicine Wilford Hall Medical Center
Obstetrics and Gynecology San Antonio, Texas
Christiana Hospital
Newark, Delaware Brett Slingsby, MD
Child Abuse Pediatrician
Asha Shrestha, MD Lawrence A. Aubin Sr. Child Protection Center
Rheumatologist Assistant Professor of Pediatrics
Department of Rheumatology Warren Alpert Medical School of Brown University
St. Joseph Healthcare Providence, Rhode Island
Bangor, Maine
Jeanette G. Smith, MD
Jordan Shull, MD Assistant Professor
University of Texas Health Science Center at Houston McGovern Medical Department of Medicine
School Warren Alpert Medical School of Brown University
Houston, Texas Providence, Rhode Island

Khawja A. Siddiqui, MD Jonathan H. Smith, MD

Resident Physician Assistant Professor
Neurology Neurology
Baylor College of Medicine University of Kentucky
Houston, Texas Lexington, Kentucky

Lisa Sieczkowski, MD Matthew J. Smith, MD

Pediatric Hospitalist Physical Medicine and Rehabilitation
Children’s Hospital and Medical Center Warren Alpert Medical School of Brown University
Pediatric Hospital Medicine Rhode Island Hospital
Omaha, Nebraska Providence, Rhode Island

Mark Sigman, MD U. Shivraj Sohur, MD, PhD

Professor of Surgery, Urology Assistant Professor
Professor of Pathology and Laboratory Medicine Neurology
Warren Alpert Medical School of Brown University Harvard Medical School
Providence, Rhode Island Boston, Massachusetts

James Simon, MD Vivek Soi, MD

Assistant Professor Assistant Professor
Lerner College of Medicine Internal Medicine, Nephrology
Cleveland, Ohio Henry Ford Health System
Detroit, Michigan
Harinder P. Singh, MD
Clinical Associate Rebecca Soinski, MD
Department of Pulmonary and Critical Care Medicine Attending Rheumatology Physician
St. Elizabeth Medical Center Women’s Medicine Collaborative
Tufts University Lifespan Physician Group
Boston, Massachusetts Providence, Rhode Island

Divya Singhal, MD Maria E. Soler, MD, MPH, MBA

Medical Director Director, Education Division and Obstetric Triage
Oklahoma City VA Medical Center Residents’ Longitudinal Clinic Obstetrics and Gynecology
Vice Chair, Women’s Issues in Neurology Christiana Care Health System
American Academy of Neurology Newark, Delaware
Assistant Professor of Neurology
University of Oklahoma Sandeep Soman, MD
Epileptologist, Department of Neurology/Rehabilitation Services Associate Division Head
Oklahoma City, Oklahoma Nephrology and Hypertension
Henry Ford Hospital
Lauren Sittard, PharmD Candidate Detroit, Michigan
Department of Pharmacy Practice
University of Rhode Island
Kingston, Rhode Island
xxiv Contributors
Akshay Sood, MD Dominick Tammaro, MD
Chief Resident Associate Professor
Vattikuti Urology Institute Internal Medicine
Henry Ford Hospital Health System Warren Alpert Medical School of Brown University
Detroit, Michigan Rhode Island Hospital
Providence, Rhode Island
C. John Sperati, MD, MHS
Associate Professor of Medicine Alan Taylor, MD
Johns Hopkins University School of Medicine Assistant Professor
Division of Nephrology Emergency Medicine
Baltimore, Maryland University of Tennessee Health Science Center
Memphis, Tennessee
Johannes Steiner, MD
Assistant Professor Tahir Tellioglu, MD
Cardiology Assistant Professor
Oregon Health and Science University Psychiatry and Human Behavior
Portland, Oregon Warren Alpert Medical School of Brown University;
Medical Co-Director, Lifespan Recovery Center
Ella Stern, MD Providence, Rhode Island
Resident Physician
Obstetrics and Gynecology Edward J. Testa, MD
Christiana Care Health System Resident Physician
Newark, Delaware Orthopedic Surgery
Warren Alpert Medical School of Brown University
Philip Stockwell, MD Providence, Rhode Island
Assistant Professor of Medicine
Division of Cardiology Jigisha P. Thakkar, MD
Warren Alpert Medical School of Brown University Chief Resident
Providence, Rhode Island Neurology
University of Kentucky
Padmaja Sudhakar, MBBS Lexington, Kentucky
Assistant Professor
Neurology Anthony G. Thomas, DO, FACP
University of Kentucky Clinical Assistant Professor of Medicine
Lexington, Kentucky Hematology and Oncology
Warren Alpert Medical School of Brown University
Jaspreet S. Suri, MD Providence, Rhode Island
Department of Hepatology
Beth Israel Deaconess Medical Center Andrew P. Thome, Jr., MD
Boston, Massachusetts Resident Physician
Orthopedic Surgery
Elizabeth Sushereba, MSN, CNM Warren Alpert Medical School of Brown University
Senior Midwife Rhode Island Hospital
Obstetrics and Gynecology Providence, Rhode Island
Christiana Care Health System
Newark, Delaware Erin Tibbetts, PharmD
Clinical Pharmacist
Arun Swaminathan, MBBS Division of Pharmacy and Medical Intensive Care
Resident Physician Boston Children’s Hospital
Neurology Boston, Massachusetts
University of Kentucky College of Medicine
University of Kentucky Hospital Alexandra Meyer Tien, MD
Lexington, Kentucky Clinical Assistant Professor
Family Medicine
Joseph Sweeney, MD, FACP, FRCPath Warren Alpert Medical School of Brown University
Professor Providence, Rhode Island
Laboratory Medicine and Pathology
Warren Alpert Medical School of Brown University David Robbins Tien, MD
Providence, Rhode Island Clinical Associate Professor
Surgery, Ophthalmology
Wajih A. Syed, MD Warren Alpert Medical School of Brown University
Cardiologist Providence, Rhode Island
Kaiser Permanente
Roseville, California Helen Toma, MD, MSPH
Resident Physician
Maher Tabba, MD, FACP, FCCP Obstetrics and Gynecology
Associate Professor of Medicine and Surgery Christiana Care Health System
Department of Pulmonary, Critical Care and Sleep Medicine Newark, Delaware
Tufts Medical Center
Boston, Massachusetts
 Contributors xxv

Iris L. Tong, MD Junior Uduman, MD

Associate Professor Medical Director, Acute Dialysis
Department of Medicine Division of Nephrology and Hypertension
Warren Alpert Medical School of Brown University Henry Ford Hospital
Attending Physician Detroit, Michigan
Women’s Primary Care
Women’s Medicine Collaborative Sean H. Uiterwyk, MD
Providence, Rhode Island Clinical Assistant Professor
Community and Family Medicine
Brett L. Tooley, MD Geisel School of Medicine at Dartmouth
Resident Physician Hanover, New Hampshire
Emergency Medicine
University of Tennessee Health Science Center Nicole J. Ullrich, MD, PhD
Memphis, Tennessee Associate Professor of Neurology
Harvard Medical School;
Steven P. Treon, MD Director of Neurologic Neuro-oncology
Director, Bing Center for Waldenström’s Macroglobulinemia Boston Children’s Hospital
Dana Farber Cancer Institute Boston, Massachusetts
Boston, Massachusetts
Leo Ungar, MD
Thomas M. Triplett, MD Fellow
Assistant Professor Cardiology
Department of Emergency Medicine University of California, Irvine
University of Tennessee Health Science Center Orange, California
Memphis, Tennessee
Bryant Uy, MPH, PA-C
Hiresh D. Trivedi, MD Physician Assistant
Fellow Attune Health
Gastroenterology and Hepatology Beverly Hills, California
Beth Israel Deaconess Medical Center
Harvard Medical School Babak Vakili, MD
Boston, Massachusetts Vice-Chair, Gynecologic Surgery
Department of Obstetrics and Gynecology
Vrinda Trivedi, MBBS Urogynecology
Fellow Christiana Care Health System
Cardiovascular Diseases Newark, Delaware
Warren Alpert Medical School of Brown University
Providence, Rhode Island Emily Van Kirk, MD
Internal Medicine
Margaret Tryforos, MD Roger Williams Medical Center
Team C Leader Providence, Rhode Island
Family Medicine
Care New England Primary Care Medical Group Jennifer E. Vaughan, MD
Kent Hospital Fellow
Pawtucket, Rhode Island Neurology and Rehabilitation Medicine
University of Cincinnati College of Medicine
Hisashi Tsukada, MD, PhD Cincinnati, Ohio
Instructor in Surgery
Harvard Medical School Emil Stefan Vutescu, MD
Boston, Massachusetts Resident Physician
Orthopedics
Joseph R. Tucci, MD, FACP, FACE Warren Alpert Medical School of Brown University
Professor of Medicine Providence, Rhode Island
Boston University School of Medicine
Director, Division of Endocrinology Brent T. Wagner, MD
Roger Williams Medical Center Professor of Medicine
Boston University School of Medicine University of New Mexico Health Science Center;
Providence, Rhode Island Director, Kidney Institute of New Mexico
Albuquerque, New Mexico
Sara Moradi Tuchayi, MD
Dermatology J. Richard Walker III, MD, MS, FACEP
Massachusetts General Hospital Interim Chair and Program Director
Boston, Massachusetts Department of Emergency Medicine
University of Tennessee Health Science Center
Melissa H. Tukey, MD, MS Memphis, Tennessee
Department of Pulmonary and Critical Care
Kaiser Oakland Medical Center
Oakland, California
xxvi Contributors
Ray Walther, MD John P. Wincze, PhD
Methodist University Hospital Clinical Professor Emeritus
Memphis, Tennessee Department of Psychiatry and Human Behavior
Warren Alpert Medical School of Brown University
Connie Wang, PharmD Providence, Rhode Island
Tufts University
Boston, Massachusetts Marlene Fishman Wolpert, MPH, CIC, FAPIC
Independent Consultant and Long-Term Care Infection Preventionist
Danielle Wang, MD Miriam Hospital
Fellow Lifespan Laboratories Outreach Department
Rheumatology Providence, Rhode Island
Cedars-Sinai Medical Center
Los Angeles, California Tzu-Ching (Teddy) Wu, MD, MPH
Assistant Professor of Neurology
Jozal Waroich, MD University of Texas Medical School at Houston
Resident Physician Director of Telemedicine
Internal Medicine Mischer Neuroscience Institute
Warren Alpert Medical School of Brown University Houston, Texas
Providence, Rhode Island
John Wylie, MD, FACC
Emma H. Weiss, MD Director, Cardiac Electrophysiology
Baylor College of Medicine Steward Health Care System;
Houston, Texas Associate Professor of Medicine
Tufts University School of Medicine
Mary-Beth Welesko, MS, APRN-BC, WCC Boston, Massachusetts
Nurse Practitioner
Division of Geriatrics and Palliative Medicine Nicole B. Yang, MD
Care New England Medical Group Instructor in Medicine
Warwick, Rhode Island Harvard Medical School
Division of Rheumatology
Adrienne Werth, MD Brigham and Women’s Hospital
Resident Physician Boston, Massachusetts
Obstetrics and Gynecology
Christiana Care Health System Jerry Yee, MD
Newark, Delaware Clinical Professor of Medicine
Department of Internal Medicine
Matthew J. White, DO Wayne State University School of Medicine;
Fellow Division Head, Nephrology and Hypertension
Rheumatology Henry Ford Hospital
Roger Williams Medical Center Detroit, Michigan
Providence, Rhode Island
Gemini Yesodharan, MD
Paul White, MD Fellow
Physician Cardiology
School of Medicine Steward Family Hospital, St. Elizabeth’s Medical Center
University of North Carolina Brighton, Massachusetts
Chapel Hill, North Carolina
Agustin G. Yip, MD, PhD
Estelle H. Whitney, MD Associate Medical Director
Generalist Physician Short Term Unit
Obstetrics and Gynecology McLean Hospital
Christiana Care Health System Belmont, Massachusetts
Newark, Delaware
John Q. Young, MD, MPP, PhD
Matthew P. Wicklund, MD Professor and Vice Chair for Education
Professor Department of Psychiatry
Department of Neurology Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
Penn State College of Medicine; Hempstead, New York
Vice-Chair for Education
Department of Neurology Matthew H. H. Young, MD, JD
Milton S. Hershey Medical Center Resident Physician
Hershey, Pennsylvania Obstetrics and Gynecology
Christiana Health Care System
Jeffrey P. Wincze, PhD Newark, Delaware
Department of Psychiatry
Rhode Island Hospital Reem Yusufani, MD
Providence, Rhode Island Fellow
Nephrology and Hypertension
Henry Ford Hospital
Detroit, Michigan
 Contributors xxvii

Caroline Zahm, MD Mark Zimmerman, MD

Fellow Director, Outpatient Psychiatry and Partial Hospital Program
Cardiology Rhode Island Hospital
St. Elizabeth’s Medical Center Professor
Boston, Massachusetts Department of Psychiatry and Human Behavior
Warren Alpert Medical School of Brown University
Evan Zeitler, MD Providence, Rhode Island
Fellow
Adult Nephrology Aline N. Zouk, MD
Division of Nephrology and Hypertension Fellow
University of North Carolina at Chapel Hill New York University School of Medicine
Chapel Hill, North Carolina New York, New York

Talia Zenlea, MD
Assistant Professor of Medicine
Division of Gastroenterology
University of Toronto
Women’s College Hospital
Toronto, Ontario, Canada
 To my sons, Dr. Vito F. Ferri and Dr. Christopher A. Ferri, and my daughter-in-law,
Dr. Heather A. Ferri, for their help and constant support, and to my wife, Christina, for her
patience during manuscript preparation. A special thanks to all the readers who have
personally commented on the merits of this book and through their suggestions have helped
make this product a bestseller in the medical field.

Fred F. Ferri, MD, FACP

Clinical Professor
Department of Medicine
Warren Alpert Medical School of Brown University
Providence, Rhode Island
 Preface

This book is intended to be a clear and concise reference for physicians and abnormal results, this section facilitates the diagnosis of medical disorders
allied health professionals. Its user-friendly format is designed to provide and further adds to the comprehensive “one-stop” nature of our text. New
a fast and efficient way to identify important clinical information and to illustrations and tables have been added for this edition.
offer practical guidance in patient management. The book is divided into Section V focuses on preventive medicine. Information here includes
five sections and an appendix, each with emphasis on clinical information. screening recommendations for major diseases and disorders, patient
The tremendous success of the previous editions and the enthusiastic counseling, and immunization and chemoprophylaxis recommendations.
comments from numerous colleagues have brought about several positive The Appendix is divided into nine major sections. Appendix I con-
changes over time. Each section has been significantly expanded from tains extensive information on complementary and alternative medicine
prior editions, bringing the total number of medical topics covered in this (CAM), now expanded to include Common Herbs in Integrated Medicine,
book to more than 1200. Hundreds of new illustrations, tables, and boxes as well as Herbal Activities Against Pain and Chronic Diseases. With this
have been added to this edition to enhance recollection of clinically impor- material, we aim to lessen the current scarcity of exposure of allopathic
tant facts. The expedited claims submission and reimbursement ICD-10CM and osteopathic physicians to the diversity of CAM therapies. Appendix
codes are included in all topics. II focuses on nutrition, with an emphasis on dietary supplements, vita-
Section I describes in detail 988 medical disorders and diseases— mins, and minerals. Appendix III deals with diagnosis and treatment of
including 25 new topics this edition—arranged alphabetically and pre- acute poisoning. Appendix IV is a guide on impairment and disability
sented in outline format for ease of retrieval. Topics with an accompanying evaluation. Appendix V focuses on the protection of travelers. Appendix
algorithm are identified with an ALG icon. Similarly, those topics with an VI addresses Physician Quality Reporting System (PQRS) measures.
accompanying online Patient Teaching Guide (PTG) are identified with a Appendix VII—available in the online version of Ferri’s Clinical Advisor—
PTG symbol. Throughout the text, key quick-access information is consis- is a repository of practical patient instruction sheets, organized alpha-
tently highlighted, with clinical photographs to further illustrate selected betically and covers the majority of topics in this book. These guides
medical conditions, and relevant ICD-10CM codes listed. Most references can be easily customized and printed and serve as valuable tools for
focus on current peer-reviewed journal articles rather than outdated text- improving physician-patient communication, patient satisfaction, and
books and old review articles. ultimately quality of care. Appendix VIII and IX are both new to this edition
Topics in Section I use the following structured approach: and offer guidance related to palliative care and preoperative evaluation,
1. Basic Information (Definition, Synonyms, ICD-10CM Codes, Epidemiol- respectively.
ogy & Demographics, Physical Findings & Clinical Presentation, Etiology) I believe that we have produced a state-of-the-art information system
2. Diagnosis (Differential Diagnosis, Workup, Laboratory Tests, Imaging with significant differences from existing texts. The information offered
Studies) in all five sections and patient education guides could be sold separately
3. Treatment (Nonpharmacologic Therapy, Acute General Rx, Chronic Rx, based on their content, yet are available under a single cover, offering the
Disposition, Referral) reader tremendous value. I hope that the Clinical Advisor’s user-friendly
4. Pearls & Considerations (Comments, Suggested Readings) approach, numerous unique features, and yearly updates will make this
Section II includes the differential diagnosis, etiology, and classification book a valuable medical reference, not only to primary care physicians but
of signs and symptoms. This practical section allows the user investigating also to physicians in other specialties, medical students, and allied health
a physical complaint or abnormal laboratory value to follow a “workup” professionals.
leading to a diagnosis. The physician can then easily look up the presump-
tive diagnosis in Section I for information specific to that illness. Fred F. Ferri, MD, FACP
Section III includes more than 150 clinical algorithms to guide and Clinical Professor
expedite the patient’s workup and therapy. For the 2021 edition, we have Department of Medicine
continued to update algorithms and colorize online versions for improved Warren Alpert Medical School of Brown University
readability. Physicians describe this section as particularly valuable in Providence, Rhode Island
today’s managed-care environment.
Section IV includes normal laboratory values and interpretation of Note: Comments from readers are always appreciated and can be for-
results of commonly ordered laboratory tests. By providing interpretation of warded directly to Dr. Ferri at [email protected].

xxix
 Ferri’s Clinical Advisor 2021—How to Use This Book

Mouse icon: Indicates content with additional references, figures, or tables

available at ExpertConsult.com.

PTG icon: Indicates an accompanying Patient Teaching Guide available at

PTG ExpertConsult.com. Many additional PTGs are available online that
are not connected to topics in Section I.

ALG ALG icon: Indicates a topic with an accompanying algorithm.

xxx
 Abdominal Aortic Aneurysm 3

ETIOLOGY SCREENING AND MONITORING

BASIC INFORMATION
multifactorial. ing for AAA by ultrasonography in men ages
- A
DEFINITION 1. Degenerative: 65 to 75 who have a history of smoking, and
An abdominal aortic aneurysm (AAA) is a focal a. Alterations in vascular wall biology in those 60 yr of age or older with a history
full-thickness dilation of the abdominal aor- leading to a loss of vascular structural of AAA in a parent or sibling. These popula-
tic artery to at least 1.5 times the diameter proteins and wall strength. tions have been shown to have a higher
measured at the level of the renal arteries, or b. The most common association is ath- prevalence of AAA, and selectively screening
exceeding the normal diameter of the abdomi- erosclerosis. It is uncertain whether this group has been shown to decrease AAA-
nal aorta by 50%. The normal diameter at the atherosclerosis causes or results from specific mortality.
renal arteries is 2 cm (range 1.4 to 3.0 cm), and AAAs.
a diameter 3 cm or larger is generally consid- screening in men with a negative ultrasound

and Disorders
Diseases
ered aneurysmal. develop an AAA have smoked at some and has determined that men over the age
point in their lives. of 75 are unlikely to benefit from screen-
ICD-10CM CODES 2. Inherited: Familial clusters are common. ing. It was also concluded that the current
I71.4 Abdominal aortic aneurysm, without High familial prevalence rate is notable evidence is insufficient to assess the balance
rupture in male individuals. The nature of the of the harms and benefits of screening for
I71.3 Abdominal aortic aneurysm, ruptured genetic disorder is unclear but may be AAA in women ages 65 to 75 who have ever
linked to alpha-1-antitrypsin deficiency smoked.
I
EPIDEMIOLOGY & disorders, such as Marfan syndrome and
DEMOGRAPHICS scan should be performed every 6 months
strongly associated with AAA. for patients with AAAs measuring 5.0 to 5.4
States are attributed to AAA. 3. Inflammatory: AAA is a progressive cm in diameter, every 12 months for AAAs
inflammatory disease of the artery walls.
adults, affecting men more than women (4:1). Activated B lymphocytes promote AAA by
producing immunoglobulins, cytokines,
men in developed countries. and matrix metalloproteinases (MMPs), PHYSICAL FINDINGS & CLINICAL
≥4 cm are present resulting in the activation of macro- PRESENTATION
in 1% of men between age 55 and 64; and -
the prevalence rate increases by 2% to 4% ment pathways that lead to the degrada- incidentally discovered on imaging studies;
per decade thereafter. tion of collagen and matrix proteins and however, symptomatic aneurysms are at an
- to aortic wall remodeling. increased risk for rupture.
mately 70 yr old. 4. Infection, mycotic: Syphilis, Salmonella.
-
ers than in nonsmokers (8:1); and the risk NATURAL HISTORY
decreases with smoking cessation. physical examination is markedly diminished
and to expand, on average, at a rate of 0.2 to by obese body habitus.
for other atherosclerotic cardiovascular 0.5 cm per yr.
abdominal, back, flank, or groin pain.
race, smoking, male gender, family history, influenced by aneurysm size, rate of expan-
hypertension, hyperlipidemia, peripheral sion, and sex. Other factors associated with not be tender may be present
vascular disease, and aneurysm of other increased risk for rupture include continued
large vessels. smoking, uncontrolled hypertension, and renal or visceral arterial stenosis.
increased wall stress.
first-degree male relatives of known AAA -
patients. (together with histopathologic changes such rants. In addition, prominent femoral and
as accumulation of foam cells, cholesterol popliteal pulses warrant an abdominal ultra-
crystals, and matrix metalloproteinases) ren- sound and lower extremity ultrasound.
diabetes. ders the abdominal aortic wall more suscep-
caused by compression of adjacent bowel.
men age 65 or older.
is 25% to 40% for aneurysms >5.0 cm in occur from iliocaval venous compression.
death in men older than age 55. diameter, 1% to 7% for AAAs 4.0 to 5.0
cm, and nearly 0% for AAAs <4.0 cm. The extremity pain and discoloration.
likelihood that an aneurysm will rupture is
or renal transplants, severe obstructive increased in aneurysms with a diameter >5.5 cause flank and groin pain and lead to
lung disease, uncontrolled blood pres- cm; this size also demonstrates a faster rate obstructive renal failure.
sure, female sex, and ongoing tobacco of expansion (>0.5 cm over 6 months) and is
use. more likely to be found in those who continue abdominal or back pain, hypotension, and
to smoke and in females. a pulsatile abdominal mass in 50% of
of AAA and related mortality has been attrib- patients.
uted to reductions in tobacco use. However,
hospital in time for surgical repair. Of those infarction; arteriovenous fistulas may present
thoracic aortic aneurysms. who reach the hospital, the mortality rate is still as heart failure; aortoenteric fistulas may
50%, compared with the 1% to 4% mortality present as hematemesis or melena associ-
rate for elective repair of a nonruptured AAA. ated with abdominal and back pain.

These proofs may contain color figures. Those figures may print black and white in the final printed book if a color print product has not been planned. The color figures will appear in color
in all electronic versions of this book.
 4 Abdominal Aortic Aneurysm

Symptoms of AAA: pulsatile mass; abdominal pain radiating to back, flank, groin;
peripheral emboli; flank and/or groin pain; melena thought to be due to
RA IN
aortoenteric fistula; syncope; flank mass or discoloration; lower-extremity paralysis cm

LK

RK
Vital signs, intravenous access via 2 large-bore catheters, oxygen, complete An
blood count, serum chemistry panel, liver function panel, type and cross-match
for 6 units of blood, urinalysis, prothrombin/partial thromboplastin time,
electrocardiogram, portable chest radiograph
CIA

IIA
Unstable: low BP, tachycardia, ill-appearing Stable, but concern
for AAA EIA

FIG. 3 Three-dimensional computed tomog-

raphy image illustrates the presence of an
NS fluid boluses and un–cross-matched PRBCs; caution Spiral CT infrarenal abdominal aortic aneurysm. An,
for too aggressive fluid resuscitation that may (fastest and easiest); Aneurysm; CIA, common iliac artery; EIA, external
prevent local clot formation; be wary of potential of MRI; angiography
iliac artery; IIA, internal iliac artery; IN, infrarenal
dilutional coagulopathy; aim for SBP 90-100 mm Hg;
keep patient warm and consider level one infuser neck; LK, left kidney; RA, renal artery; RK, right
Sabiston
textbook of surgery, ed 17, Philadelphia, 2004,
Saunders.)
Bedside US

DIAGNOSIS
Aorta well Stabilized
visualized and and no clear AAA DIFFERENTIAL DIAGNOSIS
no sign of aneurysm or
aneurysm doubt as to Almost 75% of patients with AAA are asymp-
diagnosis tomatic, and the condition is discovered on
routine examination or serendipitously when
ordering studies for other symptoms. Diagnosis
Surgery Surgery of AAA should be considered in the differential
consultation consultation of the following symptoms: abdominal pain,
for operative repair
The differential diagnosis includes peptic ulcer
disease, mesenteric ischemia, renal calculi,
Consider spiral CT pyelonephritis, and diverticulitis.

LABORATORY TESTS
Consider alternative diagnosis:
musculoskeletal back pain, diverticulitis, cholecystitis, Not routinely indicated. For suspected infected
appendicitis, renal colic, pancreatitis, intestinal
ischemia, bowel obstruction, myocardial infarction; blood cultures can be considered. An elevated
epidural abscess or vertebral osteomyelitis, aortic D-dimer may indicate a thrombus within the
dissection, cauda equina aneurysm. Fig. 1 describes an algorithm for the
diagnosis and treatment of abdominal aortic
FIG. 1 Algorithm for the diagnosis and treatment of abdominal aortic aneurysms (AAAs). BP, Blood aneurysms.
pressure; CT, computed tomography; MRI, magnetic resonance imaging; NS, normal saline; PRBCs, packed
red blood cells; SBP, systolic blood pressure; US, Emergency medicine, IMAGING STUDIES
clinical essentials Fig. 2) has nearly
100% sensitivity and specificity in identify-
ing an aneurysm and estimating the size to
within 0.3 to 0.4 cm. It is not accurate in
EPI estimating the extension to the renal arteries
or the iliac arteries.
FIG. 2 Transverse image of an abdomi- Fig. 3) scan is
nal aortic aneurysm. Note the measure- recommended for preoperative aneurysm
imaging and estimates the size of the AAA to
cava is seen to the patient’s right of the within 0.3 mm. There are no false-negative
aorta, and the vertebral body is seen below results, and the scan can identify extension to
the two vessels. Note also that there appears renal vessels with more precision than ultra-
to be an echogenic flap within the aorta, sound. It is the imaging modality of choice for
possibly representing an aortic dissection. symptomatic AAA. Intravenous contrast is not
Emergency medicine,
3.33cm clinical essentials, ed 2, Philadelphia, 2013,
3.85cm wall (Fig. 4) and exclude rupture.

These proofs may contain color figures. Those figures may print black and white in the final printed book if a color print product has not been planned. The color figures will appear in color
in all electronic versions of this book.
 Abdominal Aortic Aneurysm 5

-
prospective studies and meta-analyses, the
detection and characterization of endoleaks
tional method of treatment. However, multiple
trials have shown lower mortality and shorter A
an aneurysm in calcified aortas. This is an
insensitive test for diagnosing AAA. imaging. increasingly using endovascular repair for
patients who fit certain anatomic and physi-
replaced by other noninvasive imaging ologic criteria.
TREATMENT
Intraoperative angiography is still used for
determining treatment options and post- NONPHARMACOLOGIC THERAPY versus open repair for ruptured abdominal
procedure efficacy (Fig. 5). aortic aneurysm failed to show a difference
in expansion rate through treatment of cardi-
close and lifelong imaging surveillance of ac risk factors, nonpharmacologic treatment open repair. There was a higher incidence of

and Disorders
Diseases
the aneurysm site for the timely detection of continues to focus on risk factor modification
possible complications, including endoleaks, (most importantly smoking cessation, diet, although interventions to deal with procedur-
graft migration, fractures, graft infection, and and exercise). Of note, moderate exercise al complications were generally less invasive
enlargement of aneurysm sac size with even- does not increase the rate of aneurysm and involved catheter-based approaches.
tual rupture. The rate of complications after expansion or the risk of rupture. -

rates are faster in current smokers than in

tomical issues such as tortuosity or small
caliber iliac arteries and inability to follow up I
former smokers. Patients with known AAA patients to exclude late failure of stent-grafts
or a family history of aneurysms should be and development of endoleaks.
up (Fig. 6), but it is accompanied with radia- advised to stop smoking and be offered
tion burden and renal injury because of the smoking cessation interventions. CHRONIC Rx
use of contrast media. In the past 2 decades,
several studies have shown the role of con- monitored and controlled as recommended
for patients with atherosclerotic disease.
- ACUTE GENERAL Rx Statins are associated with decreased mor-
nostic performance, absence of renal impair- tality after successful AAA repair, and are
ment, and no radiation, accompanied by low recommended for those with known AAA to
reduce the progression of atherosclerosis
considerations, operative risks, and availabil- and overall cardiovascular risk.
-
ture is the maximum diameter of the AAA.

the rate of aortic dilation and decreased the

L incidence of aortic complications in patients
with Marfan syndrome. Several studies have
T also suggested that beta-blocker therapy
may reduce the rate of expansion and risk
of rupture; however, conclusive evidence is
lacking.

with AAA found no significant association

between AAA progression and the use of
statins, beta-blockers, angiotensin-convert-
FIG. 4 Aneurysm of the abdominal aorta. A ing enzyme inhibitors, or angiotensin II recep-
large aortic aneurysm is evident. The aorta tor blockers.
FIG. 6 Completion digital subtraction angio-
exceeds 5 cm in diameter. A large amount of -
gram following endovascular aneurysm repair.
thrombus (T) partially surrounds the contrast- mycin have been shown to limit the expan-
(From Fillit HM: Brocklehurst’s textbook of geriatric
enhanced patent lumen (L). Note the atherosclerotic sion of small AAAs.
medicine and gerontology, ed 8, Philadelphia, 2017,
calcification (arrowhead) in the wall of the aneurysm.
should be performed for patients with infra-
renal or juxtarenal AAA of approximately 5.5

can be considered at diameters larger than 5

cm. Additionally, AAAs with a rate of enlarge-
ment greater than 0.5 cm over 6 months
should be considered for repair. All patients
who are symptomatic should undergo repair,
regardless of size. Timing of repair in symp-
tomatic unruptured AAA is still under debate.
A B (open or endovascular) for small asymptom-
FIG. 5 A, atic AAAs (less than 5.5 cm).
lobulated, infrarenal aortic aneurysm (arrowhead) with a 4-cm proximal neck suitable for endovascular repair.
B, An image after endovascular repair demonstrates complete exclusion of the aneurysm (arrowhead) with no grafts placed with the patient under local
Emergency radiol- anesthesia have provided an alternative
ogy: the requisites approach for patients with favorable anatomy.

These proofs may contain color figures. Those figures may print black and white in the final printed book if a color print product has not been planned. The color figures will appear in color
in all electronic versions of this book.
 6 Abdominal Aortic Aneurysm
-
specifically those with coronary artery dis- onstrate no advantage to immediate repair
endoleak, stent migration, change in aneu- ease or those with more than one clinical for small AAA (4.0 to 5.5 cm), regardless of
rysm size, and need for re-intervention. risk factor based on the American Heart whether open or endovascular repair is used
Association (AHA) guidelines, preoperative and, at least for open repair, regardless of
an alternative to open repair in the manage- administration of beta-blockers titrated to a patient age and AAA diameter. Thus, neither
ment of juxtarenal aortic aneurysms and goal heart rate of 60 have been shown to immediate open nor immediate endovascular
short-neck abdominal aortic aneurysms (the decrease incidence of death from cardiac repair of small AAAs is supported by the cur-
causes or nonfatal myocardial infarctions. rently available evidence.
renal artery to the beginning of the aneu- Beta-blockers initiated within 24 hours of -
the procedure have not shown an advantage; tive AAA repair despite advances in short-
safe and efficacious treatment, particularly however beta-blockers the patient is already term outcomes and is associated with AAA
for those deemed surgically high risk. taking should be continued. diameter and patient age at the time of
- -
to improve the life expectancy of patients
is associated with lower 30-day mortal- major clinical complications, particularly if with repaired AAA and to optimize patient
ity and MI rates, shorter hospital stays, and selection.
present in conjunction with cardiac or renal
disease. Smoking cessation for 2 months COMMENTS
has increased rates of graft-related com- before surgery has also been shown to
plications and is more costly. Additionally, decrease pulmonary morbidity. be due in part to decreased lamellar struc-
tural proteins in the vascular wall below the
mortality, showing up to as high as 41% renal arteries leading to decreased vascular
higher all-cause mortality, reintervention, and mortality in those with impaired renal func- wall strength.
tion compared with 6% in those without renal
dysfunction. coexisting coronary artery disease, pul-
reintervention and secondary rupture rates. monary disease, or chronic renal failure.
- REFERRAL
perioperative hemodynamic monitoring help
and approximately half of all early endoleaks asymptomatic patients with AAAs that are identify high-risk patients and decrease post-
resolve spontaneously within a period of 30 approximately 4.5 cm. operative complications.
days.
- over 6 months, it is reasonable to offer repair,
ferred approach for patients with a long life although small studies have shown that
expectancy. using expansion as a criterion for surgical
referral is of unclear benefit.
approach for most patients with a reasonable - SUGGESTED READINGS
life expectancy and suitable anatomy. ditions before surgical referral. Available at

elective AAA repair is not recommended.

PEARLS & RELATED CONTENT
CONSIDERATIONS Abdominal Aortic Aneurysm (Patient Information)
but abdominal ultrasound is gaining wide-
spread adoption for postprocedure monitor- Ryan J.W. Burris, MD, and
ing. Surveillance is recommended to occur 5.5 cm has not been shown to improve sur-
Pranav M. Patel, MD, FACC, FAHA, FSCAI
1 and 12 months postoperatively and then vival because the risk of rupture is lower than
annually thereafter. the risk of surgery.

These proofs may contain color figures. Those figures may print black and white in the final printed book if a color print product has not been planned. The color figures will appear in color
in all electronic versions of this book.
 Abdominal Aortic Aneurysm 6.e1

SUGGESTED READINGS Mohan PP, Hamblin MH

Badger S Cardiovasc
Cochrane Database Syst Rev Intervent Radiol 37(2):337-342, 2013.
Brewster D Norman P -
esis of aortic aneurysm, Arterioscler Thromb Vasc Biol 33(1473), 2013.
J Vasc Surg 37:1106- Ou J et al: A systematic review of fenestrated endovascular repair for juxtarenal
1117, 2003. and short-neck aortic aneurysm: evidence so far, Ann Vasc Surg
Eur J 1688, 2015.
Radiol Paravastu S Cochrane
De Bruin J - Database Syst Rev
nal aortic aneurysm, N Engl J Med 362:1863-1871, 2010.
et al: Surgery for small asymptomatic abdominal aortic aneurysms, aneurysms: a meta-analysis, JAMA
Cochrane Database Syst Rev W -
- ment of patients with peripheral artery disease (updating the 2005 guideline),
tiveness of endovascular strategies vs. open repair for ruptured abdominal J Am Coll Cardiol
BMJ Sweeting MJ
importance of longer-term outcomes and meta-analysis for 1-year mortality,
S Eur J Vasc Endovasc Surg
repair of intact abdominal aortic aneurysm among Medicare beneficiaries, Takayama T, Yamanouchi D: Aneurysmal disease: the abdominal aorta, Surg Clin
JAMA 307(15):1621-1628, 2012. N Am
Kayssi A - -
vascular abdominal aortic aneurysm repair, J Vasc Surg rysm in patients physically ineligible for open repair, N Engl J Med 362:1872-
Kent K : Abdominal aortic aneurysms, N Engl J Med 371:2101-2108, 2014. 1880, 2010.
Kent K et al: Analysis of risk factors for abdominal aortic aneurysm in a cohort of
more than 3 million individuals, J Vasc Surg abdominal aortic aneurysm, N Engl J Med 362:1863-1871, 2010.
- Thomas DM et al: Open versus endovascular repair of abdominal aortic aneurysm
rysm repair, J Vasc Surg 61(5):1350-1356, 2015. in the elective and emergent setting in a pooled population of 37,781 patients:
A a systematic review and meta-analysis, ISRN Cardiol
abdominal aortic aneurysm, N Engl J Med Wanhainen A
A, Noorbaloochi S, Nugent S, et al: Multicentre study of abdominal aortic
aneurysm measurement and enlargement, Br J Surg 102:1480-1487, 2015. Aneurysms, Eur J Vasc Endovasc Surg
A et al: Open versus endovascular repair of abdominal aortic aneurysm, , Wang Y: B lymphocytes in abdominal aortic aneurysms, Atherosclerosis
NEJM 242(1):311-317, 2015.

Ann Intern Med

et al: A systematic review and meta-analysis of the long-term outcomes of
endovascular versus open repair of abdominal aortic aneurysm, J Vasc Surg

These proofs may contain color figures. Those figures may print black and white in the final printed book if a color print product has not been planned. The color figures will appear in color
in all electronic versions of this book.
 6.e2 Abdominal Compartment Syndrome
among whom it ranges from 1% to 14%, PHYSICAL FINDINGS & CLINICAL
BASIC INFORMATION depending on the population and type of trauma PRESENTATION
studied. The incidence is the highest among -
DEFINITION critically ill patients. ing is often massive abdominal distention.
Abdominal compartment syndrome (ACS) is RISK FACTORS: The biggest risk factor for
defined by the presence of organ dysfunction developing ACS is critical illness stemming from and decreased urine output are also typical
as a result of increased abdominal pressure a wide array of medical and surgical conditions hallmarks.
or intraabdominal hypertension. The increased (Table E1). In particular, any illness that requires -
abdominal pressure reduces blood flow to inter- a patient to undergo large volume intravenous ated with poor perfusion states and hypoten-
nal organs, which can lead to multiple system fluid resuscitation can be associated with ACS; sion such as skin mottling, cool extremities,
failure and death if not promptly recognized the third-spacing of fluid can lead to increased and obtundation. Patients will often have
and treated. intraabdominal pressures secondary to tissue abdominal tenderness, signs of volume over-
edema. Due to large volume fluid resuscitation, load such as edema and elevated jugular
ICD-10CM CODE ACS is commonly seen in severe burns, trauma, venous pressures, and may present with
M79.A3 Nontraumatic compartment post-surgical patients, and sepsis. Other condi- acute respiratory decompensation.
syndrome of abdomen tions associated with ACS include intraabdomi-
nal and retroperitoneal pathologies such as sig- ETIOLOGY
EPIDEMIOLOGY & nificant bowel distention, liver transplantation, ACS can affect nearly every organ system.
DEMOGRAPHICS massive ascites, ruptured abdominal aortic High intraabdominal pressures are associated
INCIDENCE: Very few studies have examined aneurysm with resulting hemoperitoneum, pan- with increased intracranial pressures, which
the incidence of ACS outside of trauma patients, creatitis, and abdominal surgery (Table E2). can precipitate cerebral ischemia. Elevated
abdominal pressures can cause cardiac com-
pression by decreasing ventricular compliance
TABLE E1 Causes of Intraabdominal Hypertension and Abdominal and contractility as well as impairing inferior
Compartment Syndrome vena cava venous return, leading to increased
central venous and pulmonary pressures. Due
Increased Abdominal Contents Decreased Abdominal Volume to elevation of the diaphragm, patients will
often have reduced tidal volumes and lower
Ascites Reduction of large long-standing hernia chest wall compliance, which can lead to
Hemoperitoneum Direct closure of large, long-standing abdominal atelectasis, pneumonia, hypoxemia, and hyper-
wall defect carbia. Mechanically ventilated patients will also
Abdominal packs require increased airway pressures that can
lead to barotrauma. In addition, renal vein com-
Peritonitis
pression and renal artery vasoconstriction lead
Retroperitoneal edema (pancreatitis) Retroperitoneal edema (pancreatitis) to decreased urine output. Reduced mesenteric
Large pelvic, retroperitoneal hematoma Large pelvic, retroperitoneal hematoma blood flow can lead to intestinal ischemia and
Intestinal obstruction lactic acidosis.
Ileus
Gastric distention (esophageal ventilation) DIAGNOSIS
Abdominal aortic aneurysm
Severe constipation DIFFERENTIAL DIAGNOSIS
Large abdominal tumor (chronic)
Morbid obesity (chronic)
Pregnancy (chronic)
From Vincent JL et al: Textbook of critical care, ed 6, Philadelphia, 2011, Saunders.
WORKUP
Measurement of intraabdominal pressure is
TABLE E2 Independent Predictors of Postinjury Primary and Secondary required to make a definitive diagnosis. Bladder
Abdominal Compartment Syndrome pressure is the most common surrogate used
to estimate intraabdominal pressures and is
ED Model ICU Model measured using a bladder catheter. The most
accurate measurements can be obtained with
Independent Predictors Independent Predictors the patient in supine position at end expira-
tion in the absence of abdominal contractions.
Primary ACS To OR <75 min Temp ≤34° C The threshold abdominal pressure often set for
Crystalloids ≥3 L GAPco2 ≥16 research purposes to define ACS is >20 mm
Hb ≤8/dl Hg, but patients may have ACS with pressures
BD ≥12 mEq/L of >10 mm Hg and above. Oliguria tends to
Secondary ACS Crystalloids ≥3 L GAPco2 ≥16 develop at a pressure of 15 mm Hg, and anuria
occurs around 30 mm Hg. Intraabdominal pres-
No urgent surgery Crystalloids ≥7.5 L sures can also be estimated using intragastric,
PRBC ≥3 units UO ≤150 ml intracolonic, and inferior vena cava approaches
(Table E3).
ACS, Abdominal compartment syndrome; BD, arterial base deficit; CI, confidence interval; ED, emergency department; GAPco2,
carbon dioxide gap; Hb, hemoglobin concentration; ICU, intensive care unit; OR, operating room; PRBC, packed red blood cells;
Temp, temperature; UO, urine output.
From Vincent JL et al: Textbook of critical care, ed 6, Philadelphia, 2011, Saunders.

These proofs may contain color figures. Those figures may print black and white in the final printed book if a color print product has not been planned. The color figures will appear in color
in all electronic versions of this book.
 Abdominal Compartment Syndrome 6.e3

TABLE E3 Classification of
Abdominal Compartment
Syndrome

Basis of
Classification Subcategories
Time frame Acute
Chronic
Relation to peritoneal Primary
cavity Secondary
Etiology Trauma
Burn
Postoperative
Pancreatitis
Bowel obstruction FIG. E1 Open abdomen management of abdominal compartment syndrome. The sterile saline bag
was sewn to the skin edges. Closed suction drains were placed to limit fluid accumulation, and occlusive
Ileus dressing was applied to cover the abdominal wall. (Courtesy Brian J. Kimbrell, MD, In Vincent JL et al: Textbook
Abdominal aortic of critical care, ed 7, Philadelphia, 2017, Elsevier.)
aneurysm
Oncologic
Gynecologic
From Vincent JL et al: Textbook of critical care, ed 6, Philadel-
phia, 2011, Saunders.

LABORATORY TESTS
Laboratory testing is generally not helpful for
the diagnosis of ACS. The presence of lactic aci-
dosis suggests bowel ischemia, which portends
a poorer prognosis.

IMAGING STUDIES
Imaging alone has no diagnostic value in ACS,
but chest imaging can be helpful to evalu-
ate for diaphragmatic elevation and evidence
of pulmonary complications (atelectasis, vol-
ume overload, pneumonia, etc.). Abdominal FIG. E2 Open abdomen management of abdominal compartment syndrome using a vacuum-
computed tomography imaging will sometimes assisted closure (VAC) system. The bowel is covered with omentum if possible. Nonadherent dressing is
show renal displacement, inferior vena cava layered under a VAC sponge, or a smaller pore sponge is used against the viscera. Negative pressure is applied
compression, abdominal wall thickening, or to the wound closure to drain fluid, facilitate closure, and prevent evisceration. (Courtesy Brian J. Kimbrell, MD,
bowel injury related to ischemia but should not In Vincent JL et al: Textbook of critical care, ed 7, Philadelphia, 2017, Elsevier.)
be relied on to make the diagnosis of ACS.
-
TREATMENT decrease intraabdominal pressures, and sion for ACS has yet to be established; how-
some patients may require ventilatory sup- ever, data suggest that early decompression
Supportive care and, when appropriate, surgical port and chemical paralysis to maximize prior to the development of ACS may lead to
abdominal decompression are the mainstays of abdominal wall relaxation. better outcomes. If appropriate, consensus
ACS treatment. dictates that surgical decompression should
the high pressures that need to be generated to be performed on all patients with intraabdomi-
NONPHARMACOLOGIC THERAPY overcome the increased intraabdominal pres- nal pressure >25 mm Hg; however, some sur-
sures. Often a combination of low tidal volumes, geons are more aggressive and will consider
and ventilatory support, as well as techniques permissive hypercapnia, chemical paralysis, decompression with pressures of 15 to 25 mm
to improve abdominal wall compliance, are and high positive end-expiratory pressure are Hg in the right clinical setting. Surgical decom-
the foundations of ACS management. required to ensure adequate ventilatory support. pression (Fig. E1, Fig. E2) by incising vertically
through the linea alba can be performed at
will require surgical escharotomy to improve the administration of colloid may be superior the bedside in emergent situations and most
abdominal wall compliance. to crystalloid if the patient requires further surgeons will then keep the abdomen open
volume resuscitation. The administration of through the use of a temporary abdominal
will require large volume paracentesis to intravenous fluids will transiently increase closure device that retains heat/fluid and pre-
decrease intraabdominal pressures. renal blood flow, leading to increased urine vents evisceration until the time is appropriate
- output and improved organ perfusion and to attempt to close the abdomen again.
ble as any elevation of the head will increase cardiac output. Pressors may also have a
abdominal pressures. role to maintain perfusion pressures, but all ACUTE GENERAL Rx
of these measures are temporizing and sup- There are no direct pharmacologic agents
required if ACS is due to massive bowel portive until definitive action through surgical that treat ACS other than pressors, sedatives,
distention. decompression is performed. pain medications, and paralytics required for

These proofs may contain color figures. Those figures may print black and white in the final printed book if a color print product has not been planned. The color figures will appear in color
in all electronic versions of this book.
 Abdominal Compartment Syndrome 6.e4

supportive care as described above. Despite is most frequently estimated using bladder
underlying volume overload, diuretics have no PEARLS & pressure as a surrogate.
role in therapy. Definitive management is surgi- CONSIDERATIONS -
cal decompression. port with colloids, pressors, and ventilatory
COMMENTS support, is often required, but surgical decom-
DISPOSITION pression is the only definitive treatment.
-
Close inpatient monitoring, preferably in an cal patients, and its diagnosis requires both
intensive care setting, is indicated as mortality the presence of intraabdominal hypertension intraabdominal pressures >25 mm Hg; how-
can be extremely high (>40%) with ACS. and end organ dysfunction. ever, precise thresholds have not been estab-
lished, and earlier decompression may lead
REFERRAL to better outcomes.
to multisystem organ failure and is therefore
Patients with ACS often require admission to an associated with a high mortality. AUTHOR: Jason D. Ferreira, MD
intensive care setting with surgical consultation -
in case decompression is required. surement of intraabdominal pressure, which

SUGGESTED READINGS
Maluso P et al: Abdominal compartment hypertension and abdominal compartment
syndrome, Crit Care Clin 32:213-222, 2016.
Roberts DJ et al: Increased pressure within the abdominal compartment: intra-
abdominal hypertension and the abdominal compartment syndrome, Curr Opin
Crit Care 22:174-185, 2016.
Rogers WK et al: Intraabdominal hypertension, abdominal compartment syndrome
and the open abdomen, Chest 153(1):238-259, 2018.
Van Damme L et al: Effect of decompressive laparotomy on organ function in
patient with abdominal compartment syndrome: a systematic review and
meta-analysis, Crit Care 22(1):179, 2018.

These proofs may contain color figures. Those figures may print black and white in the final printed book if a color print product has not been planned. The color figures will appear in color
in all electronic versions of this book.
 ALG Abnormal Uterine Bleeding 7

EPIDEMIOLOGY & 4. Bimanual pelvic examination: Normal-

BASIC INFORMATION DEMOGRAPHICS
-
sized or enlarged uterus, regular or irreg-
ular contour
A
DEFINITION ogy (the PALM portion of the acronym).
ETIOLOGY
Abnormal uterine bleeding (AUB) describes uter-
ine bleeding that is abnormal in regularity, quanti- menstrual bleeding will be found to have a Table 2 describes many of the various causes
ty, frequency, or duration, in the nonpregnant per- coagulopathy. of AUB. The causes of AUB in the fourth and
son. Historically, AUB was described as in Table 1. fifth decade are summarized in Table 3.
The term “dysfunctional uterine bleeding” was PHYSICAL FINDINGS & CLINICAL
applied when no clear etiology could be identi- PRESENTATION and thyroid disorders, may also contribute to
fied. These terms have fallen out of favor. In 2011, heavy or irregular menstrual bleeding.
the FIGO Working Group on Menstrual Disorders example, an enlarged/irregular uterine contour

and Disorders
Diseases
released a classification system intended to may suggest fibroids, or a polyp may be seen DIAGNOSIS
simplify these definitions. It is known by the acro- on the cervix during a speculum examination.
nym PALM-COEIN, described later. Today, AUB is DIFFERENTIAL DIAGNOSIS
described according to these criteria. Although many patients complain of the
A normal menstrual cycle is typically abnormality of their cycles, some will present
with symptoms of anemia, with AUB being 1. Polyps (AUB-P)
described as lasting 21 to 35 days with 5 days
of bleeding per cycle. Total blood loss for normal
menses is thought to be less than 80 ml.
elicited only with a careful history. Patients
may note recent weight gain or on examina-
2.
3.
Adenomyosis (AUB-A)
Leiomyoma (AUB-L) I
tion, may have other findings (as noted later) 4. Malignancy/hyperplasia (AUB-M)
SYNONYMS suggestive of the etiology for their bleeding. 5. Coagulopathy (AUB-C; most commonly
von Willebrand disease)
Abnormal uterine bleeding (AUB)
exclude the other causes of abnormal bleeding: 6. Ovulatory dysfunction (AUB-O; most com-
Dysfunctional uterine bleeding
1. Includes thyroid, breast, liver (e.g., pres- monly polycystic ovarian syndrome)
ICD-10CM CODES 7. Endometrial (AUB-E)
ence or absence of ecchymotic lesions)
N92.5 Other specified irregular menstruation 8. Iatrogenic (AUB-I; e.g., anticoagulants,
2. Patient habitus: Obese and hirsute (poly-
N92.0 Excessive and frequent menstruation hormonal contraception, and some herbal
cystic ovarian disease) or thin (think eat-
with regular cycle remedies)
ing disorders or excessive exercise)
N91.5 Oligomenorrhea, unspecified 9. Not yet classified (AUB-N)
3. Presence or absence of vulvar, vaginal,
N92.1 Excessive and frequent menstruation
or cervical lesions, uterine (fibroid) or
with irregular cycle 1. Cervical neoplasia, cervicitis
ovarian tumors, urethral caruncles or
N94.6 Dysmenorrhea, unspecified 2. Vaginal neoplasia, adhesions, trauma,
diverticula, hemorrhoids, anal fissures,
colorectal lesions foreign body, atrophic vaginitis, infec-
tions, condyloma
3. Vulvar trauma, infections, neoplasia, con-
TABLE 1 Definitions of Abnormal Uterine Bleeding
dyloma, dystrophy, varices
Term Description 4. Urinary tract: Urethral caruncle, diverticu-
lum, hematuria
Oligomenorrhea Bleeding at intervals greater than 35 days 5. Gastrointestinal tract: Hemorrhoids, anal
Polymenorrhea Bleeding at intervals less than 21 days fissure, colorectal lesions
Hypermenorrhea (menorrhagia) Excessive flow or bleeding with normal intervals
Metrorrhagia Bleeding between menses 1. Exogenous hormone intake: Hormone
Menometrorrhagia Excessive flow or duration with periods and between periods replacement therapy
Withdrawal bleeding Bleeding after the withdrawal of hormones
TABLE 3 Causes of Abnormal
Crum CP et al: Diagnostic gynecologic and obstetric pathology, ed 3, Philadelphia, 2018, Elsevier. Uterine Bleeding in the Fourth and
Fifth Decades
TABLE 2 Causes of Abnormal Uterine Bleeding Cause Differential Diagnosis
Age (Years) Causes (In Order of Decreasing Frequency) Anovulation
Prepubertal Precocious puberty (hypothalamic, pituitary, ovarian)
Endometrial
Adolescence polyp

Third and fourth

decades Chronic endo-
metritis -
trium
Fifth decade

leiomyoma

Crum CP et al: Diagnostic gynecologic and obstetric pathol-

Crum CP et al: Diagnostic gynecologic and obstetric pathology, ed 3, Philadelphia, 2018, Elsevier. ogy, ed 3, Philadelphia, 2018, Elsevier.

These proofs may contain color figures. Those figures may print black and white in the final printed book if a color print product has not been planned. The color figures will appear in color
in all electronic versions of this book.
 8 Abnormal Uterine Bleeding ALG

2. Medications is used. Letrozole is superior to clomiphene

3. Coagulopathies: Von Willebrand disease, sonogram, sonohysterogram, saline infusion citrate in ovulation induction in women with
thrombocytopenia, hepatic failure sonogram, etc.) may be indicated if the
4. Endocrinopathies: Thyroid disorder, endometrium appears thickened or irregular. (HMG) can be used for women who do not
hyperprolactinemia, diabetes mellitus It distends the uterine cavity so that “fill- ovulate with oral agents or who have hypo-
5. Renal diseases: Generally causing ing defects” of the endometrium can be thalamic dysfunction.
acquired coagulopathy assessed for possible endometrial polyp,
6. Impaired nutritional status: Anorexia/ uterine fibroid, or neoplasm. 1. Anti-prostaglandins (ibuprofen or naprox-
bulimia
intracavitary fibroids or polyps. 2. Danazol (rarely used due to side-effect
vaginal bleeding abnormalities. profile).
characterize large fibroids or uterine pathol- 3. Gonadotropin-releasing hormone (GnRH)
WORKUP ogy but is rarely needed. analogues; often used to reduce bleeding
and ameliorate anemia and in preparation
1. Age of menarche for a surgical procedure.
2. Prior menstrual characteristics (newly
TREATMENT 4. Tranexamic acid (Lysteda) is an antifi-
abnormal or always so) brinolytic agent FDA approved for cyclic
NONPHARMACOLOGIC THERAPY heavy menstrual bleeding. Dosage in
normal renal function is 3900 mg daily
of other causes/contributors diet rich in iron to combat anemia. (650 mg tablets, 2 tablets tid) for up to
five days during menses.
pelvic examination (bimanual and speculum) loss, exercise, and low-carb diet, if indicated. 5. Endometrial tamponade with Foley catheter.
to exclude causes mentioned above
ACUTE GENERAL Rx 1. Dilation and curettage and operative hys-
or absence of goiter, galactorrhea, or ecchy- teroscopy
motic lesions) 1. Medroxyprogesterone acetate (oral), 10 to 2. Endometrial ablation
1. Patient habitus: Obese and hirsute (poly- 20 mg daily for 15 days 3. Uterine artery embolization
cystic ovarian disease) or thin (think eat- 2. Megestrol acetate, 40 to 120 mg daily in 4. Hysterectomy
ing disorders or excessive exercise) divided doses for 15 days
2. Presence or absence of vulvar, vaginal, 3. Oral contraceptives: One tablet tid for 5 to DISPOSITION
or cervical lesions, uterine (fibroid) or 7 days; patient should then continue on Cyclical treatment on birth control pills or
ovarian tumors, urethral caruncles or oral contraceptives daily Provera for several cycles, then discontinue pill
diverticula, hemorrhoids, anal fissures, or and watch patient for onset of regular men-
colorectal lesions 1. Conjugated estrogen 25 mg IV q4h until ses. If the patient does not want to conceive,
bleeding is under control (in cases of continued cycle management with a hormonal
LABORATORY TESTS (AS severe or life-threatening bleeding); max- contraceptive is commonly used.
INDICATED BY HISTORY AND imum 24 hr
PHYSICAL) 2. For prolonged bleeding that is not life REFERRAL
- threatening: Premarin 1.25 mg (Estrace To gynecologist in case of failure of treatment
ate for possible iron-deficiency anemia or 2 mg) q4h for 24 hr, followed by Provera
thrombocytopenia to bring on withdrawal bleeding; then
- sequential regimen of estrogen and pro- PEARLS &
tin (or PFA-100 assay) if coagulopathy is gestin (Premarin 1.25 mg qd for 24 days, CONSIDERATIONS
suspected Provera 10 mg for last 10 days) or oral
contraceptives
with heavy bleeding since menarche if initial
testing suggests coagulopathy CHRONIC Rx bleeding severe enough to warrant emergency
evaluation, there is a higher risk of a bleeding
1. Medroxyprogesterone acetate 10 mg disorder, such as von Willebrand disease.
tests daily for 12 days, then cyclically to induce
monthly withdrawal bleeding over 45 yr of age with new AUB.
2. Norethindrone 2.5 to 10 mg qd for 12
days each mo or 0.35 mg daily (marketed COMMENTS
as the “mini-pill”) Patient education material may be obtained
3. Depo-Provera 150 mg IM every 3 mo from the American College of Obstetricians and
- 4. Oral contraceptives, one tablet qd either
tage, especially in patients over 45, or in cyclically or continuously using only DC 20024-2188; phone 202-638-5577.
younger patients with a long-standing history active pills
of anovulatory bleeding with fewer than three 5. Levonorgestrel-releasing intrauterine
device (Mirena has an FDA indication for SUGGESTED READING
menstrual cycles per yr or with a high risk of
endometrial neoplasia with prolonged unop- heavy menstrual bleeding) Available at ExpertConsult.com
posed estrogen exposure -
cally a treatment for abnormal bleeding but RELATED CONTENT
may help patients with anovulatory bleeding Abnormal Uterine Bleeding (Patient Information)
who want to become pregnant. Progesterone Endometrial Cancer (Related Key Topic)
IMAGING STUDIES withdrawal may be counterproductive in Heavy Menstrual Bleeding (Menorrhagia)
patients wishing to start an ovulation induc- (Related Key Topic)
endometrial thickness in the postmenopausal tion regimen. Pregnancy rates are lower Uterine Fibroids (Related Key Topic)
woman and assessment of myometrial or endo- when patients undergo withdrawal compared
metrial defects. This is considered first line. to when random ovulation induction start AUTHOR: Nicole A. Roberts, MD

These proofs may contain color figures. Those figures may print black and white in the final printed book if a color print product has not been planned. The color figures will appear in color
in all electronic versions of this book.
Other documents randomly have
different content
détestait les Grignan, et les Grignan ne l'aimaient pas; de sorte que,
hormis ce qui avait trait à madame de Sévigné et à sa fille, il ne
désirait rien savoir de ce qui se passait autour d'elles. Voilà sans
doute le motif qui fit que Bussy interrompit pendant plus d'un an sa
correspondance avec sa cousine [696]. Mais si pourtant il négligea de
correspondre avec elle pendant le cours d'une année (depuis juillet
1672 jusqu'en juillet 1673), jamais il n'écrivit et ne reçut d'autres
personnes un plus grand nombre de lettres; jamais, quoique ayant
cinquante-cinq ans, il ne montra un plus grand désir de braver les
fatigues et les périls de la guerre, et de faire oublier son âge par ses
succès en amour. Ces passions surannées l'avaient lié avec un jeune
homme, l'abbé de Choisy, qui n'est plus connu heureusement
aujourd'hui que par de nombreux écrits non dépourvus d'agréments
et d'instruction et irréprochables sous le rapport de la religion et des
mœurs. L'abbé de Choisy avait quitté le nom de comtesse de Saincy
ou des Barres; il ne portait plus d'habits de femme, et, après un
voyage fait en Italie, il avait obtenu en 1663, par le crédit de sa
mère, l'abbaye de Saint-Seine en Bourgogne [697], ce qui le forçait à
résider souvent dans ce pays. Il avait à peine trente ans. Le temps
de ses métamorphoses en jeune et jolie fille était passé, mais non
pas les penchants qui y avaient donné lieu: seulement ils s'étaient
affaiblis. Il aimait toujours le jeu et les femmes. Lorsque le sort lui
avait été contraire, et qu'il était las de ses maîtresses, il quittait
Paris, et allait en Bourgogne se renfermer dans son abbaye avec la
résolution d'y résider pour faire des économies, et payer ses dettes.
L'ennui le prenait, et il allait continuellement à Paris et à Dijon [698].
Ses traits étaient restés délicats et mignards; mais l'âge et le soleil
d'Italie avaient donné à son charmant visage une apparence plus
mâle [699]. Il obtint sans artifice, sans aucun perfide déguisement de
nombreux succès auprès des femmes livrées à la galanterie [700]. A
Dijon, il en rencontra une à laquelle il rendit des soins, et il s'en fit
aimer; conquête plus facile à faire qu'à conserver: jeune, jolie,
spirituelle, elle avait en outre la réputation d'écrire très-bien des
lettres. Ce mérite était alors prisé dans la société et dans le monde
comme aujourd'hui celui de la musique: l'abbé de Choisy le
possédait, mais Bussy plus que personne.
La nouvelle maîtresse de l'abbé de Choisy était madame
Bossuet [701], femme de Bossuet, trésorier général des états de
Bourgogne, frère aîné de Jacques-Bénigne Bossuet. Elle était la fille
de Nicolas Dumont, gentilhomme de Bourgogne, et d'Anne-Catherine
de Hautoy, d'une maison distinguée de Lorraine. Nicolas Dumont
s'était attaché avec trois de ses frères à la fortune de Condé; il avait
suivi ce prince dans l'exil, et ce fut Condé qui, après sa rentrée en
France, maria la jeune et belle fille de Dumont, et procura à son
mari la place de trésorier général des états de Bourgogne. Ce
mariage eut lieu le 26 avril 1662; et, lors de la mort du père des
Bossuet, en 1667, madame Bossuet avait déjà deux fils. A l'époque
de son mariage, son mari était le personnage le plus notable de la
famille des Bossuet; il fut depuis intendant de Soissons et maître des
requêtes; mais, lors de sa liaison avec l'abbé de Choisy, le beau-frère
de madame Bossuet était l'évêque de Condom, le précepteur du
Dauphin, le grand Bossuet, alors à l'apogée de sa gloire et de sa
fortune [702].
Madame Bossuet désira entrer en correspondance avec Bussy, et
faire connaissance avec ce personnage célèbre dans toute la
Bourgogne. Elle manifesta ce désir à l'abbé de Choisy, qui mit
d'autant plus d'empressement [703] à la satisfaire que nulle pensée
jalouse ne le tourmentait à l'égard d'un rival dont l'âge était si fort
disproportionné avec le sien. Il écrivit à ce sujet à Bussy, qui,
toujours avide des louanges qu'on donnait à son esprit, ne manqua
pas, dans un voyage qu'il fit à Dijon pour ses affaires, de rendre
visite à madame Bossuet. Au moment de son départ ne l'ayant pas
trouvée chez elle, il lui fit ses adieux par une lettre où il lui
demandait son amitié [704]. Craignant sans doute le ridicule de se
commettre avec une si jeune et si belle femme, il mit peu
d'empressement à lui écrire; mais elle lui envoya la tragédie de
Bérénice de Racine, qui venait de paraître; et, à propos et sur le
sujet de cette pièce [705], il engagea avec elle une correspondance
suivie; de telle sorte que, peu à peu séduit par les louanges qu'elle
lui donnait, il finit par lui parler le langage de la galanterie et de
l'amour. C'est où elle avait voulu l'amener. L'abbé de Choisy était
retourné à Paris, et c'est à elle qu'il adressait les lettres qu'il écrivait
à Bussy, et qui de Dijon étaient transmises à ce dernier dans le lieu
de la Bourgogne où il se trouvait. De même Bussy faisait passer à
madame Bossuet les lettres qu'il écrivait à l'abbé de Choisy [706],
principalement pour qu'elle se procurât le plaisir d'en prendre
lecture, et qu'elles lui valussent de nouveaux éloges [707].
Comme madame Bossuet ne faisait aucun mystère des lettres que lui
écrivait Bussy, qu'elle en tirait même vanité, on sut dans toute la
Bourgogne, et même à Paris [708], que le comte de Bussy-Rabutin
entretenait une correspondance avec elle; et l'historien des Amours
des Gaules fut mis au nombre des amants de cette belle-sœur de
l'évêque de Condom. Madame de Montmorency, madame la
comtesse de la Roche et mademoiselle de Scudéry, qui recevait chez
elle l'abbé de Choisy, apprirent à Bussy que cela se disait à Paris [709].
Le 17 février 1673, madame de Scudéry écrivait [710]: «On dit que
madame Bossuet est cachée à Paris, et qu'on la fait chercher pour
l'enfermer dans un couvent. M. de Condom, son beau-frère, me loua
l'autre jour sa beauté et son esprit; mais je vois bien qu'il n'est pas
content de sa conduite. Est-il vrai, ne vous déplaise, que c'est vous
qui l'avez amenée à trois ou quatre lieues de Paris? Notre ami l'abbé
de Choisy a, dit-on, de grands soins d'elle. Il y a trois mois que je ne
l'ai vu: l'amour démonte extrêmement la cervelle.»
On pourrait croire que la beauté de madame Bossuet était connue
du roi, car madame de Scudéry termine sa lettre ainsi: «Vous me
deviez bien venir voir quand vous amenâtes madame Bossuet à
Paris. Je ne prétends pas que vous me veniez visiter malgré les
défenses du roi. Il ne pardonnerait pas un voyage qu'on ne ferait
que par amitié; mais je crois qu'il vous pardonnerait celui que vous
avez fait pour madame Bossuet, s'il le savait; car le tyran qui vous a
fait marcher est de sa connaissance [711].»
Mais en examinant cette correspondance avec attention, on
s'aperçoit qu'un certain marquis, amoureux de madame Bossuet,
s'était offert à elle pour servir d'intermédiaire entre elle et le roi, ce
qu'elle refusa, craignant des indiscrétions [712]. Bussy, qui n'était point
allé à Paris, répondit à mademoiselle Scudéry: «M. de Condom a
raison de vous louer la beauté et l'esprit de madame Bossuet, mais
surtout son esprit: personne ne l'a plus agréable qu'elle. Pour sa
conduite, ce n'est pas la même chose: elle ne plaît à personne, pas
même à ses amants en faveur, à qui elle est si mauvaise; et ce n'est
pas seulement comme beau-frère ou comme évêque que M. de
Condom y trouve à redire. Il a eu d'autres raisons; je ne sais si elles
durent encore.»
Cette perfide insinuation caractérise bien l'envie et la méchanceté de
Bussy. Il détestait Bossuet, non-seulement alors une des gloires de
la France, mais aussi une puissance en Bourgogne, par l'amitié
intime qui le liait au grand Condé, gouverneur de cette province et
ennemi déclaré de Bussy. L'amitié qui unissait Condé et Bossuet était
ancienne, et datait de la jeunesse de tous les deux. Lorsqu'âgé de
vingt et un ans Bossuet soutint sa thèse de bachelier, Condé, qui
n'en avait que vingt-six et qu'illustraient déjà les victoires de
Fribourg, de Nordlingue et de Dunkerque, avait assisté, avec tout
son état-major et les seigneurs de sa suite, au triomphe du jeune
théologien. Depuis lors il était resté son ami et son admirateur, et il
fut en toute occasion le protecteur de sa famille. Bussy avait des
moyens de donner de la consistance à ses calomnies sur l'évêque de
Condom. Il avait vu Bossuet très-jeune, avant qu'il fût entré dans les
ordres, présenté chez Fouquet par madame Duplessis-Guénégaud,
qui fut une de ses premières protectrices. Madame de Sévigné, dès
le commencement de son mariage, avait fait connaissance avec
Bossuet à l'hôtel de Rambouillet; et, depuis, elle eut des occasions
plus fréquentes encore de se lier plus familièrement avec lui, lorsqu'il
était un habitué de l'hôtel de Nevers [713]. L'historien du prélat est
obligé d'avouer qu'à cette époque le jeune Bossuet n'avait pas cette
sévérité de mœurs, cette répulsion pour les amusements mondains
qu'il manifesta depuis; qu'il fréquentait les spectacles et aimait la
comédie, bien qu'il la proscrivit depuis dans un de ses meilleurs
écrits. De dix enfants qu'avait eus le père Bossuet, Bénigne était le
septième; par conséquent son frère aîné était beaucoup plus âgé
que lui. Bénigne Bossuet était fort bel homme, et n'avait que trente-
quatre ans lors du mariage de sa belle-sœur. Mais, nonobstant ces
faits, les perfides insinuations de Bussy ne nuisaient alors qu'à lui-
même quand elles s'attaquaient à Bossuet [714]. La calomnie respecta
ce grand homme tant qu'il vécut, et elle n'osa essayer de noircir sa
vie que quand il fut descendu dans la tombe. Bussy, continuant sa
lettre, dit: «Où avez-vous appris cette belle nouvelle, que j'ai mené
madame Bossuet à Paris? Je vous assure qu'il n'y a rien de si faux.

Pour conduire un objet charmant,

Au hasard de déplaire au maître,
Il faudrait être son amant,
Et je n'ai pas l'honneur de l'être [715].

«La vérité est que je ne l'ai pas vue depuis l'année passée, au mois
d'août, que je l'ai quittée à Dijon; et quoiqu'elle fût assez de mes
amies, je n'ai appris de ses nouvelles que par le bruit public. Elle a
été à Paris et puis en Lorraine, et puis est retournée à Paris, où elle
est (dites-vous) cachée, et l'abbé de Choisy avec elle [716].»
Dans une de ses lettres, Bussy dépeint ainsi madame Bossuet:
«C'est une des plus jolies femmes que j'aie jamais vues, de quelque
côté qu'on la regarde.» Il en parle aussi comme aimant à exciter la
passion sans la partager: ce qui était vrai pour lui, mais non pour
l'abbé de Choisy [717].
Les flatteries que Bussy adressait à madame Bossuet dans les lettres
qu'il lui écrivait prouvent qu'il n'eût pas demandé mieux que d'être
son amant: s'il en fut autrement, c'est que madame Bossuet,
entourée de plus jeunes galants, ne voulait pas pousser sa
correspondance romanesque avec Bussy jusqu'au dénoûment [718].
Cette correspondance était pour elle un exercice d'esprit et un
agréable entretien de confiance amicale; mais Bussy avait voulu
donner à ses flatteries et à ses lettres un sens plus prononcé, qui
tendit plus directement au but qu'il désirait atteindre; et il lui écrivit:
«On ne peut longtemps avoir de l'amitié pour vous sans trouver que
Patry avait raison de dire
 Qu'il est malaisé
Que l'ami d'une jeune dame
Ne soit un amant déguisé [719].»

Elle répondit:
«Si Patry avait fait pour moi les vers que vous m'avez adressés, je lui
aurais répondu:

Soyez amant, si vous voulez;

Je ne le défends à personne;
Brûlez, parlez, persévérez;
Mais sachez que mon cœur se donne
Moins aisément qu'une couronne [720].»

Piqué au vif de se voir traité si lestement, Bussy se vengea de

madame Bossuet par les propos indiscrets qu'il tint sur son compte,
et leur correspondance cessa. Mais Bussy en eut regret; il reconnut
ses torts, et écrivit pour réparer sa faute à madame Bossuet, qui
n'avait pas, comme autrefois madame de Sévigné, des motifs de
parenté et de tendre affection pour lui pardonner. Elle lui répondit de
manière à le convaincre que leur rupture était définitive [721]. Il avait
donc cessé depuis quelque temps toute correspondance avec elle,
lorsqu'elle disparut de Dijon. On la fit chercher dans Paris, où l'on
crut que Bussy, rompant son ban, l'avait secrètement conduite. Sa
lettre à madame de Scudéry était donc sur cela en tout point,
conforme à la vérité. Bussy ne cacha pas même à cette amie qu'il
avait été fortement épris de madame Bossuet. «Il n'est pas vrai, lui
écrivait-il, que je sois fâché que la conduite de madame Bossuet
m'ait empêché de l'aimer, car je ne veux plus avoir de passions; mais
il est certain que, si du temps que j'en voulais, j'eusse trouvé une
femme faite comme elle, fidèle et tendre, je l'eusse aimée plus que
ma vie [722].»
Alors que Bussy permettait à son imagination de s'arrêter sur la folie
de passions si peu faites pour son âge, il cherchait à marier sa fille
aînée, celle qu'il avait eue de sa première femme. Privée de sa mère
dès son bas âge, mademoiselle de Rabutin fut élevée chez la
comtesse de Toulongeon, son aïeule, et ensuite au couvent des
sœurs de Sainte-Marie. Lors de son exil, Bussy l'emmena avec lui en
Bourgogne, où, dit-il, «je lui ai plus appris à vivre que toute autre
chose.» Avec lui, en effet, son esprit se développa, son goût se
forma; elle apprit à bien réciter des vers et même à en faire; elle
jouait la comédie avec grâce et avec naturel; enfin, elle faisait le
charme de la société que Bussy réunissait dans ses deux
châteaux [723]. C'était à elle que le P. Rapin envoyait les nouveautés
littéraires qu'il jugeait dignes d'être lues par elle et par son père. Il
lui fit parvenir surtout la comédie des Femmes savantes, de Molière,
qui lui plaisait plus que toute autre pièce de cet inimitable
auteur [724]. Parmi les divers partis qui se présentèrent, le marquis de
Coligny [725], qui devait par la suite obtenir sa main, fut d'abord
écarté par Bussy, qui donna la préférence au comte de Limoges, fils
du marquis de Chandenier, capitaine des gardes du corps [726]. Bussy
lui trouvait assez de noblesse, mais pas assez de bien; et il voulait
transmettre en héritage ce qu'il possédait à son fils aîné, et ne
donner qu'une faible dot à sa fille.
Le jeune homme, dans l'espoir d'épouser mademoiselle de Rabutin,
dont il était amoureux, s'embarqua sur l'escadre du comte d'Estrées,
pour gagner un grade à la guerre, et y fut tué [727]. Mais alors il avait
été refusé par mademoiselle de Bussy, qui épousa le marquis de
Coligny. Elle, ainsi que sa tante madame de Sévigné, parlent avec
dédain de ce comte de Limoges [728]. Cependant, tant qu'il fut
question de ce mariage, Bussy y gagna un correspondant de plus; et
quoiqu'il en eût de bien zélés et de bien notables, et que le nombre
eût été augmenté de l'abbé Fléchier, qui venait d'être reçu de
l'Académie française, et de Despréaux, qui ne devait y entrer que dix
ans plus tard, cependant les lettres qu'il reçut alors du jeune comte
de Limoges surpassent en importance historique toutes celles de
cette époque contenues dans le recueil de Bussy. Ce jeune homme
s'était trouvé au célèbre combat des flottes combinées d'Angleterre
et de France contre celles de Hollande, où, malgré la grande
inégalité des forces, Tromp et Ruyter parvinrent à sauver leur patrie
d'une ruine entière [729]. Les lettres du comte de Limoges, écrites de
Londres et des côtes de la Grande-Bretagne [730], renferment sur nos
voisins alliés, et alors alliés très-dévoués, des détails piquants et
curieux qui devaient beaucoup plaire à Bussy. Elles lui valurent aussi
des lettres du comte d'Estrées, qui commandait en chef la flotte. Le
comte d'Estrées s'intéressait au comte de Limoges, à cause de sa
bravoure. Il était brave en effet celui dont Villeroy disait que, dans
les siéges, il n'avait d'autre lit que la tranchée [731]!
Bussy ne cessait de solliciter des services et d'adresser au roi des
plaintes sur son exil, demandant qu'il lui fût permis au moins d'aller
à Paris, pour vaquer à des procès d'où dépendait une grande partie
de sa fortune. Il ne recevait point de réponse, et il se désespérait,
lorsque tout à coup la permission de se rendre dans la capitale lui fut
accordée sur une demande qu'il n'avait point écrite, dont il n'avait
aucune connaissance. C'était cette excellente amie madame de
Scudéry qui, sachant ses projets, ses désirs, l'urgence des affaires
qui lui commandaient de se rendre à Paris, avait intéressé en sa
faveur la duchesse de Noailles. Celle-ci avait sollicité son mari, et son
mari le roi. Madame de Scudéry avait elle-même dressé la requête
au nom de Bussy; elle l'avait signée et fait présenter comme de lui,
sans lui en parler. Lorsqu'elle eut réussi, elle lui envoya la lettre du
duc de Noailles, qui lui notifiait la permission du roi [732].
Bussy alors se ressouvint qu'il avait négligé d'écrire à madame de
Sévigné depuis qu'elle était en Provence [733]. Il savait que l'époque
de son retour à Paris approchait, et qu'il aurait besoin de son
intervention pour se réconcilier avec ses ennemis, et obtenir son
rappel à la cour. Il y croyait, il était gonflé d'espérance [734]. Déjà en
effet la Gazette de Hollande [735], instruite de son prochain voyage à
Paris, avait annoncé qu'il allait avoir un commandement dans
l'armée. Il avait négligé la marquise de Gouville autant que madame
de Sévigné; et, en arrivant dans la capitale, il ne pouvait se
dispenser d'aller lui rendre visite. Il résolut de renouer ces deux
correspondances, dont il avait été autrefois si fortement
préoccupé [736]. La lettre que Bussy adresse à madame de Sévigné
est courte, et telle qu'il la fallait pour provoquer une réponse plus
longue. Bussy promet d'envoyer de nouveaux projets de généalogie
des Rabutin, sur lesquels il serait bien aise d'avoir l'avis de l'abbé de
Coulanges [737]. Comme il regrettait de ne plus recevoir aucune lettre
de Corbinelli, il termine ainsi la sienne: «Madame, mandez-moi de
vos nouvelles; je suis en peine aussi de n'en avoir aucune de notre
ami. Quelqu'un m'a dit qu'il était dans une dévotion extrême. Si
c'était cela qui l'empêchât d'avoir commerce avec moi, j'aimerais
autant qu'il fût déjà en paradis.»
Bussy ne tarda pas à recevoir de madame de Sévigné une lettre
très-amicale. Elle lui disait: «Au mois de septembre j'irai à Bourbilly,
où je prétends que vous viendrez me trouver [738].»
Corbinelli fit une plus longue lettre. Son attachement pour madame
de Sévigné augmentait à mesure qu'il la voyait plus souvent, et sa
société était pour lui un besoin de tous les jours [739]. Allait-elle à
Grignan, il se rendait à Grignan; retournait-elle à Paris, il revenait à
Paris. Dans la conversation de ce savant, de cet érudit homme du
monde, madame de Sévigné trouvait des distractions sans nombre,
une intarissable source d'instruction, un empressement bien doux à
lui rendre service et à la consoler dans les chagrins qu'elle-même se
créait. Corbinelli, en effet, naturellement sensible et affectionné,
s'occupait toujours des amis qu'il s'était faits, et tous ses amis
s'occupaient de lui. Madame de la Fayette avait alors écrit à son
sujet à madame de Sévigné [740]: «Mandez-moi de ses nouvelles: tant
de bonnes volontés seront-elles toujours inutiles à ce pauvre
homme? Pour moi, je crois que c'est son mérite qui lui porte
malheur; Segrais porte aussi guignon. Madame de Thianges est des
amies de Corbinelli, madame Scarron, mille personnes, et je ne lui
vois plus aucune espérance de quoi que ce puisse être. On donne
des pensions aux beaux esprits; c'est un fonds abandonné à cela: il
en mérite mieux que ceux qui en ont. Point de nouvelles; on ne peut
rien obtenir pour lui.»
Les causes qui empêchaient Corbinelli d'augmenter sa trop modique
fortune étaient faciles à deviner, et sans doute madame de la Fayette
avait trop de pénétration pour ne pas les reconnaître; mais il devait
lui convenir de feindre l'ignorance sur ce point. La Rochefoucauld,
Marsillac, dont elle disposait, madame Scarron, madame de
Thianges, Segrais et tant d'autres avaient à la cour d'autres choses à
faire qu'à user leur crédit pour obtenir des grâces en faveur d'un ami
qui ne les sollicitait pas, qui ne flattait personne, qui restait attaché
aux grands dont il était l'ami, même lorsqu'ils étaient exilés, comme
Vardes et comme Bussy. En ne se montrant pas plus empressés que
lui de changer pour un peu d'argent son heureuse existence, ne lui
rendait-on pas service? Pouvait-on lui donner des fonctions lucratives
sans lui imposer en même temps des devoirs à remplir, sans lui ôter
l'admirable emploi qu'il faisait de ses loisirs indépendants? Lui qui
avait toujours vécu libre et heureux, lui qui donnait tous ses
moments à la satisfaction de son cœur et de son esprit, comment
eût-il pu supporter le supplice d'avoir pour pensée principale le soin
d'amasser de l'argent? Comment eût-il pu subir la torture d'assujettir
toutes ses actions à ce but unique? Un si dur esclavage eût été
incompatible avec le bonheur dont il a joui pendant sa vie séculaire.
Son calme philosophique se peint tout entier dans cette réponse à
Bussy:
«J'aurais un fort grand besoin, Monsieur, que le bruit de ma dévotion
continuât: il y a si longtemps que le contraire dure que ce
changement en ferait peut-être un dans ma fortune. Ce n'est pas
que je ne sois pleinement convaincu que le bonheur et le malheur de
ce monde ne soit le pur et unique effet de la Providence, où la
fortune et le caprice des rois n'ont aucune part. Je parle si souvent
sur ce ton-là qu'on l'a pris pour le sentiment d'un bon chrétien,
quoiqu'il ne soit que celui d'un bon philosophe.» Il informe ensuite
Bussy qu'avec madame de Sévigné et madame de Grignan ils ont lu
Tacite tout l'hiver; «et, ajoute-t-il, je vous assure que nous le
traduisons très-bien [741].» Ce nous s'applique moins à lui qu'à ses
compagnes, qui n'auraient pas entrepris de traduire Tacite sans son
secours. Il apprend de même à Bussy qu'il a fait un gros traité de
rhétorique en français, un autre de l'art historique, et un gros
commentaire sur l'Art poétique d'Horace. Mais il lui parle surtout de
la philosophie de Descartes, à l'étude de laquelle il s'est plus
particulièrement adonné depuis un an: «Sa métaphysique me plaît;
ses principes sont aisés et ses déductions naturelles. Que ne
l'étudiez-vous? Elle vous divertirait avec mesdemoiselles de Bussy
(Bussy avait ses deux filles avec lui). Madame de Grignan la sait à
miracle, et en parle divinement. Elle me soutenait l'autre jour que
plus il y a d'indifférence dans l'âme, et moins il y a de liberté. C'est
une proposition que soutient agréablement M. de la Forge dans un
traité de l'Esprit de l'homme, qu'il a fait en français et qui m'a paru
admirable [742].» Bussy, qui ne comprend rien à la philosophie de
Descartes, qui n'a pas lu le traité de la Forge, répond
spirituellement: «Puisque madame de Grignan vous soutient que
plus il y a d'indifférence dans une âme, moins il y a de liberté, je
crois qu'elle peut soutenir qu'on est extrêmement libre quand on est
passionnément amoureux [743].» Bussy avait raison de se railler de
cette proposition, parce qu'il entendait par indifférence cette faculté
positive que nous avons de nous déterminer à choisir entre deux
contraires, c'est-à-dire à affirmer ou à nier une même chose [744].
Mais Descartes entendait par indifférence cet état neutre de l'âme
dans lequel elle se trouve quand elle ne sait à quoi se déterminer;
«de sorte, disait-il, que cette indifférence que je sens lorsque je ne
suis point emporté vers un côté plutôt que vers un autre, par le
poids d'aucune raison, est le plus bas degré de la liberté, et fait
plutôt un défaut ou un manquement dans la connaissance qu'une
perfection dans la volonté; car si je voyais toujours clairement ce qui
est vrai, ce qui est bon, je ne serais jamais en peine de délibérer
quel jugement et quel choix je devrais faire; et ainsi je serais
entièrement libre sans jamais être indifférent [745].» Et, à l'aide du
copieux commentaire de Louis de la Forge sur ce texte de Descartes,
madame de Grignan prouvait victorieusement la vérité de son
prétendu paradoxe.
Descartes avait rouvert chez les modernes le champ de bataille,
fermé depuis des siècles, à cet antagonisme philosophique qui
résulte de la double nature de l'homme spiritualiste et sensualiste; il
avait renouvelé le combat entre l'idée et la sensation, entre l'esprit
et la matière. L'intelligence de l'homme est-elle pourvue d'une force
inhérente à son essence? est-elle douée de la faculté de percevoir,
ou n'est-elle que le miroir sur lequel s'empreint la perception? L'idée
pure existe-t-elle par elle-même, ou n'est-elle que la sensation
transformée? Ces doctrines opposées s'étaient autrefois
personnifiées chez les Grecs dans Aristote et dans Platon. Descartes,
en se plaçant dans le camp de ce dernier, étonna le monde par la
hardiesse des sublimes efforts de son génie scrutateur et par la
manière décisive, absolue avec laquelle il paraît résoudre les plus
difficiles problèmes de la pensée humaine. Par l'enchaînement serré
de ses idées, il semble vouloir toujours démontrer, comme a dit son
disciple de la Forge, «qu'il en est des vérités comme des êtres: elles
dépendent toutes les unes des autres; elles sont toutes jointes, ou
comme des effets à leurs causes, ou comme des causes à leurs
effets, ou comme des propriétés à leur essence [746].»
Près d'un quart de siècle s'était écoulé depuis la mort de Descartes,
et les partisans de ses doctrines n'avaient cessé de s'accroître parmi
ceux que recommandaient la profondeur de leur esprit, l'universalité
de leur savoir et la pratique des plus hautes vertus. Les théologiens
surtout, en adoptant cette philosophie, la complétèrent; ils
ajoutèrent le sentiment à l'idée, l'amour à la raison. Ainsi modifiée,
cette philosophie n'était nullement contraire à la foi et aux décisions
de l'Église, que Descartes respecta toujours, mais en plaçant le
doute comme sentinelle impitoyable aux portes de l'intelligence, et
en n'y admettant que l'absolu. Ce système tendait à accroître
l'orgueil de l'homme et sa confiance dans son intelligence, et, par
l'abus de la raison, à faire tomber l'esprit humain dans les abîmes
sans fond du scepticisme; ou, par l'excès de l'exaltation religieuse, à
vaporiser ses forces dans les nuages du mysticisme. Ce double
danger, auquel le cartésianisme ne put échapper, le discrédita, et
prépara le succès de la philosophie sensualiste du siècle suivant.
Mais, à l'époque qui nous occupe, le cartésianisme était en progrès;
et ses partisans avaient, pour le défendre contre ses antagonistes,
toute l'ardeur des néophytes. Ce qui caractérise ce siècle si différent
du nôtre, c'est que ce fut à des femmes que s'était adressé
Descartes pour hâter le succès de ses méditations ardues. La
palatine princesse Élisabeth et la reine Christine avaient été ses
disciples et ses protectrices; et, après sa mort, nombre de femmes
se glorifiaient d'apprécier sa philosophie, et se déclaraient
cartésiennes. Dans cette lettre à Corbinelli, où Bussy exprime, pour
lui et pour sa fille, le regret de n'avoir personne pour les mettre en
train sur la nouvelle philosophie, il manifeste le désir de l'apprendre,
et il ajoute: «Mais, à propos de Descartes, je vous envoie des vers
qu'une de mes amies a faits sur sa philosophie; vous les trouverez
de bon sens, à mon avis [747].» Cette pièce de vers, de l'une des plus
savantes et des plus spirituelles correspondantes de Bussy,
mademoiselle Dupré, fut imprimée dans le recueil du P. Bouhours,
avec ce titre: l'Ombre de Descartes [748]. Dans ces vers, l'ombre de
Descartes s'adresse à mademoiselle de la Vigne, comme elle
cartésienne, comme elle aussi connue par son talent pour la poésie.
Mademoiselle de la Vigne, fille d'un médecin et fort belle, pour se
livrer avec plus de liberté à ses goûts pour l'étude, ne se maria
point: elle était alors âgée de trente-neuf ans, et il paraît que ses
savants entretiens sur la philosophie cartésienne lui avaient acquis
une assez grande réputation pour que (même en accordant toute
licence à l'hyperbole poétique) mademoiselle Dupré ait osé faire
parler de la manière suivante l'ombre de Descartes:

Par vos illustres soins mes écrits à leur tour

De tous les vrais savants vont devenir l'amour;
J'aperçois nos deux noms, toujours joints l'un à
l'autre,
Porter chez nos neveux ma gloire avec la vôtre,
Et j'entends déjà dire en cent climats divers:
Descartes et la Vigne ont instruit l'univers.

L'épître à mademoiselle de la Vigne, dont Bussy envoya une copie

aux hôtes du château de Grignan, dut y être lue avec plaisir. Alors,
comme nous l'apprend Corbinelli, on s'occupait à Grignan de l'étude
de la philosophie de Descartes. Elle était le seul aliment à ce besoin
de discussion qui semble inhérent à l'esprit humain et sans lequel il
tomberait dans une ennuyeuse torpeur. Les bulles, les querelles des
jansénistes et des jésuites paraissaient suspendues, et les réguliers
de Port-Royal avaient été réintégrés dans leurs couvents. Dès
l'année 1668, le grand Arnauld avait obtenu la permission de
reparaître. Boileau, qui l'avait souvent rencontré chez le premier
président M. de Lamoignon, et s'était lié d'amitié avec ce grand
docteur de Sorbonne, lui avait courageusement adressé sa nouvelle
épître [749] sur la fausse honte qui nous empêche d'avouer que nous
sommes convaincus des vérités que nous avions repoussées: le
satirique se disposait à faire imprimer l'arrêt burlesque en faveur des
nouveautés philosophiques de Descartes, Gassendi et autres, qu'il
avait composé pour prévenir un arrêt sérieux que l'Université
songeait à obtenir du parlement contre ceux qui enseigneraient dans
les écoles d'autres principes que les principes d'Aristote. Madame de
Sévigné en avait reçu (en septembre 1671) une copie manuscrite,
tandis qu'elle était en Bretagne [750]. Cette pièce, qu'elle avait d'abord
trouvée parfaite et pleine d'esprit [751], devint pour elle admirable
quand sa fille, à laquelle elle l'avait envoyée, l'eut approuvée.
Ainsi madame de Sévigné se trouvait bien disposée pour recevoir les
leçons de Corbinelli et de sa fille, qui voulaient faire d'elle une
prosélyte de Descartes. Le livre de Louis de la Forge était
merveilleusement choisi comme moyen d'instruction: c'était un
excellent ouvrage d'exposition cartésienne; il ne contenait rien de
neuf, rien qui ne fût déjà dans Descartes, dans ses Méditations, dans
ses réponses aux objections, ses principes, son traité des passions,
ses lettres; mais tout cela était recueilli et commenté avec méthode
et clarté; et, de nos jours, le savant et véridique historien de la
philosophie du XVIIe siècle a jugé que, même après la lecture des
œuvres du maître, ce traité d'un de ses meilleurs disciples méritait
d'être connu pour lui-même et complétait sa doctrine psychologique
en quelques points secondaires [752]. La longue préface du docteur de
Saumur est peut-être la meilleure et la plus importante partie de son
ouvrage; elle en est certainement la plus adroite. Il savait que les
plus grands obstacles qui s'opposaient à l'établissement du
cartésianisme dans les écoles et dans les séminaires étaient les
doctrines d'Aristote et de saint Augustin, qui y dominaient depuis
longtemps; et il s'attache à démontrer que les points fondamentaux
de la philosophie cartésienne se retrouvent dans Aristote et dans
saint Augustin, et surtout que ce dernier «ne pensait pas autrement
que M. Descartes touchant la nature de l'âme [753].»
Pour Aristote, madame de Sévigné en faisait bon marché: elle ne
l'avait pas lu. Mais quant à saint Augustin, c'était tout différent: elle
connaissait et comprenait très-bien la doctrine de ce premier des
métaphysiciens de la chrétienté, et elle y adhérait fortement. Les
lectures qu'elle avait faites de Nicole, de Pascal, les sermons de
Bourdaloue, ses entretiens avec les Arnauld, avec Bossuet, Mascaron
l'avaient rendue très-forte en théologie.
En arrivant en Provence, elle dit à Arnauld d'Andilly: «Vous seriez
bien étonné si j'allais devenir bonne à Aix! Je m'y sens quelquefois
portée par un esprit de contradiction; et voyant combien Dieu y est
peu aimé, je me trouve chargée d'en faire mon devoir... Je suis plus
coupable que les autres, car j'en sais beaucoup [754].»
Elle faisait cet aveu à Arnauld d'Andilly plutôt par humilité que par
vanité, et pour montrer qu'elle ne voulait pas s'excuser sur ses
manquements à la religion par l'ignorance de ses devoirs. Nous
savons qu'elle cachait sa science, sous ce rapport bien différente de
sa fille [755]. On ne peut douter que, dans les entretiens qu'elle eut à
Grignan avec elle et avec Corbinelli, elle n'ait opposé de fortes
objections aux raisonnements qu'on lui produisait et qu'on puisait
dans le traité du docteur de Saumur.
Dans ces intéressants et sérieux débats, madame de Sévigné n'aura
pas oublié de faire remarquer que de la Forge dit, au début de son
ouvrage, qu'il ne prétend se servir, dans ses démonstrations,
d'aucune des vérités que la foi nous a révélées, parce que de tels
arguments ne sont pas bons à employer en philosophie, «dont le
principal but est, dit-il, de découvrir les vérités où la seule lumière
naturelle peut atteindre [756];» mais qu'ensuite, lorsqu'il veut
démontrer l'immortalité de l'âme, il n'en peut trouver d'autre preuve
certaine que les promesses de Dieu faites à l'homme par la
révélation; car Dieu, dont toutes les âmes émanent, peut, dans sa
toute-puissance, anéantir ce qu'il a lui-même créé [757].
Madame de Sévigné dut surtout faire observer que les philosophes
cartésiens, qui prétendent ne procéder que selon une méthode
rigoureuse, et avoir constamment en main la pierre de touche du
doute pour éprouver la réalité et le degré de pureté de chaque
vérité, sont, au contraire, dans leurs spéculations hardies, les plus
téméraires, les plus dogmatiques de tous les philosophes; qu'ils
étaient souvent fort obscurs dans leurs démonstrations et dangereux
pour les vérités de la foi [758]; et que surtout ils avaient le grand
défaut d'abuser du raisonnement et de fatiguer en vain l'attention,
en la fixant sur des matières qui sortent des limites imposées à
l'entendement humain et à la nature périssable de l'homme, comme,
par exemple, lorsque de la Forge entreprend d'examiner quel sera
l'état de l'âme après la mort [759]. Quels furent les résultats des
conférences tenues à Grignan sur ces graves sujets entre madame
de Sévigné, madame de Grignan et Corbinelli? Nous les connaissons
par les lettres subséquentes de madame de Sévigné; nous les avons
déjà fait entrevoir à nos lecteurs par des citations extraites de
quelques-unes de ces lettres, mais nous ne les avons pas résumés
d'une manière assez précise. Ces résultats furent que madame de
Sévigné demeura plus que jamais convaincue de l'inanité de la
philosophie cartésienne pour prouver la vérité de la foi. Cela se
montre évidemment dans ses lettres, par quelques railleries qu'elle
et sa fille s'adressent [760], et par le besoin qu'elles manifestent de se
convaincre mutuellement et de s'entretenir sur ces matières.
Madame de Sévigné parle plus souvent qu'avant son séjour à
Grignan de son père Descartes; elle se dit de plus en plus bête pour
comprendre les grandes vérités de sa doctrine; et sa fille, pour la
provoquer à son tour, lui demande si elle est toujours «cette petite
dévote qui ne vaut guère [761].»
Mais, chose remarquable, les effets de ces conférences furent tout
autres pour Corbinelli. Dans ses lettres à Bussy, il nous apprend qu'il
est philosophe; peu après, madame de Sévigné se vante que
Corbinelli ne négligera plus la religion, depuis qu'il a appris à la
connaître. En effet, il s'était converti; mais en se convertissant il
resta cartésien; et sa foi, exaltée par l'effet de ses opinions
philosophiques, le transporta dans la région du mysticisme. Madame
de Grignan fut très-mécontente de ce changement qui s'était opéré
dans l'esprit de Corbinelli; elle se permit de l'appeler le mystique du
diable [762].
«Mais je vous gronde, répondit madame de Sévigné, de trouver
notre Corbinelli le mystique du diable. Votre frère en pâme de rire
[ce frère, à la fin de sa vie, devint plus mystique que Corbinelli]; je
le gronde comme vous. Comment! mystique du diable, un homme
qui ne songe qu'à détruire son empire, qui ne cesse d'avoir
commerce avec les ennemis du diable, qui sont les saints et les
saintes de l'Église! un homme qui ne compte pour rien son chien de
corps, qui souffre la pauvreté chrétiennement, vous direz
philosophiquement; qui ne cesse de célébrer les perfections et
l'existence de Dieu!... Et vous appelez cela le mystique du diable!...
Il y a dans ce mot un air de plaisanterie qui fait rire d'abord et qui
pourrait surprendre les simples. Mais je résiste, comme vous voyez;
et je soutiens le fidèle admirateur de sainte Thérèse, de ma
grand'mère et du bienheureux Jean de la Croix [763].» Yupez, ou Jean
de la Croix, qui fut avec sainte Thérèse le législateur des carmes
déchaussés, est un des auteurs mystiques dont les ouvrages ont été
le plus répandus; et Corbinelli devait d'autant mieux se plaire à leur
lecture qu'il était familiarisé avec la langue espagnole, si
harmonieuse, si expressive, si bien adaptée à la sensation de la vive
flamme de l'amour de Dieu et des angoisses de l'âme, délices et
tourments du solitaire voué à la vie contemplative.
Cependant la mysticité de Corbinelli n'a jamais affaibli son
attachement pour ses amis, ni même diminué son estime pour la
philosophie cartésienne. Le savant Huet s'était montré, dans sa
jeunesse, partisan de Descartes; mais longtemps après il combattit
sa doctrine, et voulut jeter du ridicule sur son auteur quand ce grand
homme abandonna sa patrie pour devenir le courtisan d'une reine de
Suède [764]. Corbinelli prit à cette occasion la défense de Descartes;
et ses amis, auxquels il lut son écrit, l'engagèrent à le terminer et à
le publier; mais il n'en fit rien. Jamais il ne put se résoudre à faire
imprimer aucun de ses ouvrages; et madame de Sévigné nous en
donne la raison quand elle dit de lui: «Vous le connaissez, il brûle
tout ce qu'il griffonne: toujours vide de lui-même et plein des autres,
son amour-propre est l'intime ami de leur orgueil [765].» C'est par
cette raison que des nombreux ouvrages de Corbinelli dont il est fait
mention dans ses lettres, aucun n'a été imprimé, et qu'on a
seulement publié cinq petits volumes qui ne contiennent que des
extraits de livres de littérature légère [766]. On n'y a point admis les
extraits de livres composés sur des sujets pieux, les seuls auxquels il
se complaisait dans sa vieillesse. «Il a, dit madame de Sévigné, un
Malaval qui le charme; il a trouvé que ma grand'mère et l'amour de
Dieu de notre grand-père saint François de Sales étaient aussi
spirituels que sainte Thérèse. Il a tiré de ces livres cinq cents
maximes d'une beauté parfaite; il va tous les jours chez madame le
Maigre, très-jolie femme, où l'on ne parle que de Dieu, de la morale
chrétienne, de l'évangile du jour: cela s'appelle des conversations
saintes; il en est charmé, il y brille; il est insensible à tout le
reste [767].» Ceci se rapporte à une époque postérieure à celle dont
nous traitons. Lorsque Corbinelli était à Grignan avec madame de
Sévigné et sa fille, il s'entretenait alors du Tasse avec la première et
des Méditations de Descartes avec la seconde [768]; mais il ne se
préoccupait nullement de la Pratique facile pour élever l'âme à la
contemplation, de François Malaval.
Quand une grande ferveur de dévotion inspira à Corbinelli un goût
exclusif pour les écrits des mystiques, madame de Sévigné fut la
première qui en fut instruite; mais cette confidence d'un ami qu'elle
estimait tant n'eut sur elle qu'une faible influence. Madame de
Sévigné aimait trop ses enfants, ses amis, le monde pour aimer Dieu
à la manière de sa grand'mère et du saint évêque de Genève, qu'elle
appelle son grand-père, ne se faisant aucun scrupule de badiner
plaisamment sur l'usage qui avait prévalu de ne pas séparer les
noms vénérés de Frémyot de Chantal et de François de Sales.
Lorsqu'il fallut se résoudre à quitter Grignan, madame de Sévigné ne
pensait plus qu'avec effroi à l'instant fatal où elle se séparerait de sa
fille. Dans la Provence, elle n'avait vu qu'elle, elle ne regrettait
qu'elle; et elle n'eût pu surmonter sa douleur sans la promesse que
lui fit madame de Grignan de venir la rejoindre. La diplomatie d'une
assemblée de députés des villes et des communautés, les intrigues
du palais d'un gouverneur de province n'intéressaient que
médiocrement une femme habituée aux agitations d'une cour où
luttaient les ambitions les plus élevées, où se décidait la fortune de
tant de hauts personnages, d'une cour dont l'éclat et la splendeur
s'accroissaient chaque jour par la gloire du monarque qui y régnait.
Le pays où madame de Grignan se trouvait heureuse de dominer
plaisait peu à madame de Sévigné: la pâle verdure des oliviers, le
sombre aspect des cyprès, l'ardeur desséchante d'un ciel d'azur
fatiguaient ou attristaient ses regards. Ce château de Grignan,
exposé à tous les vents, sans abri contre les rayons brûlants du
soleil, d'où l'œil plane orgueilleusement sur des champs pierreux et
infertiles, lui faisait regretter les beaux ombrages de Livry. A cette
Provence si vantée elle préférait sa verte Bourgogne et sa Bretagne
inculte. Lyon, Aix, Marseille, Toulon avaient charmé sa curiosité, mais
ne pouvaient lui faire oublier Paris, Versailles, Saint-Germain. La
nouveauté des aspects et des objets qui s'offraient à ses regards lui
rendait plus chers encore les endroits où elle avait passé son
enfance, sa jeunesse, les plus belles années de sa vie. C'est dans ces
lieux si pleins de ses souvenirs et de ses vives émotions que nous
allons la suivre.
 NOTES
ET

ÉCLAIRCISSEMENTS.
 NOTES
ET

ÉCLAIRCISSEMENTS.
CHAPITRE PREMIER.

Chapitre I, page 1, et chapitre III, p. 67.

Sur les voyages de madame de Sévigné de Paris aux Rochers et des Rochers à
Paris.

Madame de Sévigné mit exactement le même temps pour se rendre

de Paris aux Rochers que pour retourner des Rochers à Paris; dans
ces deux fois, elle n'arriva au lieu de sa destination que le dixième
jour. Partie le lundi matin, 18 mai, de Paris (lettre du lundi 18 mai
1671 en partant, t. II, p. 76, édit. G.), elle n'arriva aux Rochers que
le mercredi de la semaine suivante (t. II, p. 85, édit. G.).
Pour retourner à Paris, elle partit le mercredi 9 décembre 1671 (t. II,
p. 307, édit. G.), et elle n'arriva que le vendredi 18 décembre de la
semaine suivante. Dans les deux fois, le calcul des distances nous
donne le même nombre de lieues: quatre-vingt-trois lieues et demie.
Elle faisait donc environ huit lieues et un quart par jour, et, en
retranchant le jour de repos, neuf lieues et un quart.
La première fois, elle ne s'était arrêtée pour séjourner qu'après un
trajet de soixante lieues, à Malicorne, chez le marquis de Lavardin.
La seconde fois, à son retour à Paris, elle part des Rochers le
mercredi; et, pour éviter le pavé de Laval, elle va coucher chez
madame de Loresse, parente de madame de Grignan (lettres des 9
et 13 décembre 1671, t. II, p. 308 et 310, édit. G.), où elle paraît
avoir séjourné. Là on la fait consentir à prendre deux chevaux de
Welcome to our website – the perfect destination for book lovers and
knowledge seekers. We believe that every book holds a new world,
offering opportunities for learning, discovery, and personal growth.
That’s why we are dedicated to bringing you a diverse collection of
books, ranging from classic literature and specialized publications to
self-development guides and children's books.

More than just a book-buying platform, we strive to be a bridge

connecting you with timeless cultural and intellectual values. With an
elegant, user-friendly interface and a smart search system, you can
quickly find the books that best suit your interests. Additionally,
our special promotions and home delivery services help you save time
and fully enjoy the joy of reading.

Join us on a journey of knowledge exploration, passion nurturing, and

personal growth every day!

ebookmasss.com