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The 5-Minute Clinical Consult 2025 33 rd EDITION Editor-in-Chief Frank J. Domino Associate Editors

Robert A. Baldor Kathleen A. Barry Jeremy Golding Mark B. Stephens

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The 5-Minute Clinical Consult 2025 33rd EDITION

The 5-Minute Clinical Consult 2025 33rd Edition Editor-in-Chief Frank J. Domino, MD Professor and Director of Predoctoral Education Department of Family Medicine and Community Health UMass Chan Medical School Worcester, Massachusetts Associate Editors

Robert A. Baldor, MD, FAAFP Professor and Founding Chair Department of Family Medicine UMass Chan Medical School-Baystate Springfield, Massachusetts Designated Institutional Official Baystate Franklin Medical Center

Greenfield, Massachusetts Kathleen A. Barry, MD Associate Professor UMass Chan Medical School Department of Family Medicine and Community Health Hahnemann Family Health Center Worcester, Massachusetts Jeremy Golding, MD, FAAFP Professor of Family Medicine and Obstetrics & Gynecology UMass Chan Medical School Department of Family Medicine and Community Health University of Massachusetts Memorial Health Care Hahnemann Family Health Center Worcester, Massachusetts

Mark B. Stephens, MD, MS, FAAFP Associate Dean for Medical Education Professor of Family and Community Medicine Professor of Humanities

Director, Medical Practice: Brian Brown Associate Director of Medicine Content Development: Anne Malcolm Acquisitions Editor: Joe Cho Development Editor: Cindy Yoo

Editorial Assistant: Kristen Kardoley Marketing Manager: Kirsten Watrud

Production Project Manager: Bridgett Dougherty Manager, Graphic Arts & Design: Stephen Druding

Manufacturing Coordinator: Lisa Bowling Prepress Vendor: Absolute Service, Inc.

33rd edition

All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at permissions@lww.com, or via our Web site at shop.lww.com (products and services).

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Library of Congress Cataloging-in-Publication Data available from the Publisher upon request. ISBN-13: 978-1-9752-3472-0

This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work.

This work is no substitute for individual patient assessment based on health care professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data, and other factors unique to the patient. The publisher does not provide medical advice or guidance, and this work is merely a reference tool. Health care professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments. Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made, and health care professionals should consult a variety of sources. When prescribing medication, health care professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings, and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used, or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work.

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This edition is dedicated to Lauren Evelyn Clark.

M ark B. S tephens , MD, MS, FAAFP

PREFACE

“…to know that one life has breathed easier because you lived. This is to have succeeded.”

This highly organized content online provides you with the following: • Differential diagnosis support from our expanded collection of algorithms • Current evidence-based designations highlighted in each topic cover ing 500 1 commonly encountered diseases in print, with an additional 1,000 online adult and pediatric diseases and conditions topics: • FREE point-of-care CME and CE: 1/2-hour credit for every digital search • A to Z drug database from Facts & Comparisons • Laboratory test interpretation from Wallach’s Interpretation of Diagnostic Tests • More than 3,000 patient handouts in English and Spanish • ICD-10 codes; additionally, SNOMED codes are available online. Our Web site delivers quick answers to your questions. It is an ideal resource for patient care. Integrating The 5-Minute Clinical Consult content into your workflow is easy and fast, and our patient education handouts can assist in helping you meet meaningful use compliance. The site provides an easy-to-use interface, allowing smooth maneuver ability between topics, algorithms, images, videos, and patient education materials as well as more than 1,000 online-only topics. Evidence-based health care is the integration of the best medical infor mation with the values of the patient and your skill as a clinician. We have updated our evidence-based medicine (EBM) content so you can focus on how to best apply it in your practice. The algorithm section includes both diagnostic and treatment algo rithms. This easy-to-use graphic method helps you evaluate an abnormal finding and prioritize treatment. They are also excellent teaching tools, so share them with the learners in your office. This book and Web site are a source to solve problems and to help eval uate, diagnose, and treat patients’ concerns. Use your knowledge, expressed through your words and actions, to address their anxiety. The 33rd edition means I have had the great fortune to help grow and support this content for half of its life. I am honored to play this role and hope to keep doing so for some years to come. I thank you, the reader, and the team at Wolters Kluwer for your support. The 5-Minute Clinical Consult editorial team values your observations, so please share your thoughts, suggestions, and constructive criticism through our Web site’s contact form.

This is the last line of poem attributed to Ralph Waldo Emerson. I share it with my fourth-year med students every year. And added it to this book a few years back. Very few professions offer this opportunity to help someone “breathe easier,” both literally and metaphorically. We have challenging and amazing professions. To know more about someone than their spouse; sometimes even more than they know about themselves and the opportunity to help them live physically, mentally, and emotionally better is a huge task and our “superpower.” Yet, in the hectic minutes of our busy days, we may not be aware of or mindful of all that we have and all that we do. Anthropologist Jane Goodall reminds us: “You cannot get through a single day without having an impact on the world around you. What you do makes a difference, and you have to decide what kind of difference you want to make.” Making the decision to have this impact, to make one person’s world, and the entire world, a better place comes at great personal cost and sacri fice (I know). The fulfillment of helping someone breathe easier is your gift. And maybe your payment. Thank you. Welcome to the 2025 edition of The 5-Minute Clinical Consult . Your clinical practice is full of challenges and unanswered questions. Your use of this amazing tool will provide you with the answers needed to help your patients live to their fullest. The 5-Minute Clinical Consult is here to assist in fulfilling our role as health care providers. In each patient interaction, in addition to bringing your clinical expertise, remember how your patients view you—as their advocate, someone who prioritizes their well-being unlike anyone else. Our editorial team has collaborated with hundreds of authors so that you may deliver your patients the best care. Each topic provides you with quick answers you can trust, where and when you need them most, either in print or online.

F rank J. D oMino , MD

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EVIDENCE-BASED MEDICINE

WHAT IS EVIDENCE-BASED MEDICINE? W e used to treat every otitis media with antibiotics. These recom mendations came about because we applied logical reasoning to observational studies. If bacteria cause an acute otitis media, then antibiotics should help it resolve sooner, with less morbidity. Yet, when rigorously studied (via a systematic review), we found little benefit to this intervention. The underlying premise of EBM is the evaluation of medical interventions and the literature that supports those interventions in a systematic fashion. EBM hopes to encourage treatments proven to be effective and safe. And when insufficient data exist, it hopes to inform you on how to safely proceed. EBM uses end points of real patient outcomes, morbidity, mortality, and risk. It focuses less on intermediate outcomes (bone density) and more on patient conditions (hip fractures). Implementing EBM requires three components: the best medical evidence, the skill and experience of the provider, and the values of the patients. Should this patient be screened for prostate cancer? It depends on what is known about the test, on what you know of its benefits and harms, your ability to communicate that information, and that patient’s informed choice. This book hopes to address the first EBM component, providing you access to the best information in a quick format. Although not every test or treatment has this level of detail, many of the included interventions here use systematic review literature support. The language of medical statistics is useful in interpreting the concepts of EBM. Below is a list of these terms, with examples to help take the confu sion and mystery out of their use. Prevalence: proportion of people in a population who have a dis ease (in the United States, 0.3% [3 in 1,000] people . 50 years old have colon cancer) Incidence: how many new cases of a disease occur in a population during an interval of time; for example, “The estimated incidence of colon cancer in the United States is 104,000 in 2005.” Sensitivity: percentage of people with disease who test positive; for mammography, the sensitivity is 71–96%. Specificity: percentage of people without disease who test nega tive; for mammography, the specificity is 94–97%. Suppose you saw ML, a 53-year-old woman, for a health maintenance visit, ordered a screening mammogram, and the report demonstrates an ir regular area of microcalcifications. She is waiting in your office to receive her test results; what can you tell her? Sensitivity and specificity refer to people who are known to have disease (sensitivity) or those who are known not to have disease (specificity). But what you have is an abnormal test result. To better explain this result to ML, you need the positive predictive value.

Positive predictive value (PPV): percentage of positive test re sults that are truly positive; the PPV for a woman aged 50 to 59 years is approximately 22%. That is to say that only 22% of abnormal screening mammograms in this group truly identified cancer. The other 78% are false positives. You can tell ML only 1 out of 5 abnormal mammograms correctly identi fies cancer; the other four are false positives, but the only way to know which mammogram is correct is to do further testing. The corollary of the PPV is the negative predictive value (NPV) , which is the percentage of negative test results that are truly negative. The PPV and NPV tests are population dependent, whereas the sensitiv ity and specificity are characteristics of the test and have little to do with the patient in front of you. So when you receive an abnormal lab result, especially a screening test such as mammography, understand their limits based on their PPV and NPV. Treatment information is a little different. In discerning the statistics of randomized controlled trials of interventions, first consider an example. The Scandinavian Simvastatin Survival Study (4S) ( Lancet . 1994;344[8934]:1383–1389) found using simvastatin in patients at high risk for heart disease for 5 years resulted in death for 8% of sim vastatin patients versus 12% of those on placebo; this results in a rela tive risk of 0.70, a relative risk reduction of 33%, and a number needed to treat of 25. There are two ways of considering the benefits of an intervention with respect to a given outcome. The absolute risk reduction is the difference in the percentage of people with the condition before and after the interven tion. Thus, if the incidence of myocardial infarction (MI) was 12% for the placebo group and 8% for the simvastatin group, the absolute risk reduc tion is 4% (12% 2 8% 5 4%). The relative risk reduction reflects the improvement in the outcome as a percentage of the original rate and is commonly used to exaggerate the benefit of an intervention. Thus, if the risk of MI were reduced by simvastatin from 12% to 8%, then the relative risk reduction would be 33% (4% / 12% 5 33%); 33% sounds better than 4%, but the 4% is the absolute risk reduction and reflects the true outcome. Absolute risk reduction is usually a better measure of clinical signifi cance of an intervention. For instance, in one study, the treatment of mild hypertension has been shown to have relative risk reduction of 40% over 5 years (40% fewer strokes in the treated group). However, the absolute risk reduction was only 1.3%. Because mild hypertension is not strongly associ ated with strokes, aggressive treatment of mild hypertension yields only a small clinical benefit. Don’t confuse relative risk reduction with relative risk. Absolute (or attributable) risk (AR): the percentage of people in the placebo or intervention group who reach an end point; in the 4S, the absolute risk of death was 8%.

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Evidence-Based Medicine • • • ix

BIAS Bias is anything that interferes with the truth. There are many types of bias that should be considered by the publishers of medical information. Below describes a number of bias types that often affect our care without us know ing it is present. Publication bias occurs when research is not published. The mo tivation to publish information that “didn’t work” is low. It is estimated up to 40% of all medical research never gets published. When you read of an effective intervention, wonder if other studies did not show benefit and went unpublished. Comparator bias occurs when research compares an intervention to not the standard of care. Knowing a new treatment is more effective than placebo for treating a condition is not helpful if you typically use a drug or procedure. Why not study comparing the new to the standard of care? Sometimes, the new treatment is no better than the current standard. And if a study was done to see if the new is better than the old and not published, you have an example of publication bias. Selection bias involves choosing study populations that might be different than the average patient or just reporting a just subset of study participants from a study. Either will result in the data being skewed because it can only be applied to small subset of people. Attrition bias and the concept of intention to treat. Attrition bias is when researchers address how a study deals with participants who do not adhere to the research protocol or drop out completely. Intention to treat analysis hopes to diminish attrition bias by statistically considering the nonadhering or dropped out patients as unsuccessfully benefiting from the intervention. Commercial (funder) bias involves who paid for the research being done, and do they have a vested interest in the outcome. If the developer of a new drug does a large study, or a researcher has a per sonal financial interest in seeing a study succeed, they may consciously or unconsciously alter what is reported. The data may be accurate, but until this is studied by less vested interests, it is difficult to accept the conclusions. A systematic review gathers all the literature on a topic, say using antibiotics to treat otitis media, and combines the data to determine if the sum of all the trials tells a different story than any single trial. The large number of participants in this type of research results in a much more statistically (and clinically) significant conclusion than any single paper. A meta-analysis is a quantitative systematic review and demon strates its outcomes in the form of a forest plot. The interpretation of a forest plot is to look for the diamond on the bottom. If it is totally to LEFT of the vertical line, it means risk of an outcome was reduced by the intervention. If it is fully to the RIGHT, then risk of that outcome was increased. And if the diamond touches the vertical line, it means there was no statistical influence of the intervention on the outcome. We hope this brief introduction to EBM has been informative, clear, and helpful. If any of the information above seems unclear, or if you have a ques tion, please contact us via the 5MinuteConsult Web site.

Relative risk (RR): the risk of disease of those treated or exposed to some intervention (i.e., simvastatin) divided by those in the placebo group or who were untreated • If RR is , 1.0, it reduces risk—the smaller the number, the greater the risk reduction. • If RR is . 1.0, it increases risk—the greater the number, the greater the risk increase. Hazard ratio: the probability of an event in a treatment group versus the probability of events in a control group at a given time (can be calculated at any time in the study; often applied to observa tional data); like RR, if HR is statistically , 1.0, it reduces risk; if . 1.0, increases risk. Relative risk reduction (RRR): the relative decrease in risk of an end point compared to the percentage of that end point in the placebo group If you are still confused, just remember that the RRR is an overestimation of the actual effect. Number needed to treat (NNT): This is the number of people who need to be treated by an intervention to prevent one adverse out come. A “good” NNT can be a large number (100) if risk of serious outcome is great. If the risk of an outcome is not that dangerous, then lower (25) NNTs are preferred. The NNT should be compared to a similar statistic, the number needed to harm (NNH). This is the number of people who have to be given treat ment before one excess side effect or harm occurs. When the NNT is com pared to the NNH, you and the patient can judge whether the benefit of the intervention is great enough to outweigh the risk of harm. EVIDENCED-BASED GRADING To help you interpret diagnostic and treatment recommendations within The 5-Minute Clinical Consult , we have graded the best information within the text and highlighted this content. An “A” grade means the reference is from the highest quality resource, such as a systematic review. A systematic review is a summary of the medi cal literature on a given topic that uses strict, explicit methods to perform a thorough search of the literature and then provides a critical appraisal of individual studies, concluding in a recommendation. The most presti gious collection of systematic reviews is from the Cochrane Collaboration (www.cochrane.org). A “B” grade means the data referenced comes from high-quality ran domized controlled trials performed to minimize bias in their outcome. Bias is anything that interferes with the truth; in the medical literature, it is often unintentional, but it is much more common than we appreciate. In short, always assume some degree of bias exist in any research endeavor. A “C” grade implies the reference used does not meet the A or B re quirements; they are often treatments recommended by consensus groups (such as the American Cancer Society). In some cases, they may be the standards of care. But implicit in a group’s recommendation is the bias of the author or the group that supports the reference.

ACKNOWLEDGMENTS

T his is the 33rd edition of The 5-Minute Clinical Consult , a comprehen sive point-of-care tool to assist in the care of patients. From beginning to end, one cannot find a more current and easy-to-use collection of clinically useful content. Developing and maintaining a book and Web site of this magnitude requires an equally broad effort from its supporting team. I wish to thank the dedication and tireless efforts of many: Rebecca Schmidt, product lead, medical education and medical practice; Cindy Yoo, development editor; Joe Cho, acquisitions editor; and Lisa McAllister, vice president, medical practice. This 2025 edition is the direct result of the dedication and insights of our associate editors. I wish to thank Drs. Robert A. Baldor, Jeremy Golding, Mark B. Stephens, and Kathleen A. Barry for their hard work and over whelming commitment to The 5-Minute Clinical Consult . I wish to especially thank my wife, Sylvia, and my daughter, Molly, who have given greatly for this book. The challenge of completing a book covering this broad spectrum of medicine requires insights and skills far beyond my own. Many thanks to my mentors, Bob Baldor and Mark Quirk, who have been an enormous support— always there to encourage, reassure, and impart wisdom. Many in the academic and health care worlds are due thanks for sup port, insight, and friendship: M. Diane McKee, Michele Pugnaire, Karen Rayla, Maryanne Adams, Erica White, Phil Fournier, Erik Garcia, Jeff Stovall, Jim Comes, Leah

Honor, J. Herb Stevenson, Michael Kidd, Zainab Nawab, Sanjiv and Amita Chopra, Vasilios (Bill) Chrisostomidis, James (Jay) Broadhurst, Christina Kim, Madhavi Medipally, the staff of Shrewsbury Family Medicine, Ben Babbitt, Joyce Paquette, Priscila Velez, Brittany McLean, Michelle Leboeuf, Chad Ren, Joseph Frappier, my amazing colleagues Mark Powicki, Steve Messineo, Jill Terrien, Susan Feeney, Mariyan Montaque, Jillian Joseph, Jim Nairus, Kayla Chalmers, Danielle Ferreira, Rick Watson, and Sara Floros, and the faculty and students of the University of Massachusetts Medical School. Medicine is a challenge I have fortunately not had to meet alone. Thanks to my parents, Frank and Angela (Jean); my brother, John, and his family, Marylou, Cate, and Jane; Frank, Mary Anne, Diane, and David Christian; the Diana and Hymie Lipschitz family; and the Bob and Ruth Pabreza family; they are responsible for who I am and my success in life. I am blessed with the best of friends; without them, I would not be a physician. Thanks to Bob Bacic; Ron Jautz; Richard Onorato; John Horcher; Auguste Turnier; Bob Smith; Paul Saivetz; Bob and Nancy Gallinaro; Drew and Jill Grimes; Louay Toma; Laurie, Alan, Daniel, Jenny, and Matt Bugos; Alan Ehrlich; Andy Jennings; Bill Demianiuk; John and Kathleen Polanowicz; Phil and Carol Pettine; Mark and Linda Shelton; Steve Bennett; Vicki Triolo; and Bob and Laurie Jenal, Mike Rousse, Cliff Sterns, and Conor Wallace. —F rank J. D omino , MD

CONTRIBUTING AUTHORS

Christoffer Amdahl, MD Resident Physician Department of Family Medicine HCA Medical City Arlington Arlington, Texas Khorshid Amirkhosravi, MD UT Health San Antonio, Texas Alyssa Anderson, MD Assistant Professor Department of Family and Community Medicine Penn State College of Medicine Hershey, Pennsylvania Garland E. Anderson II, MD Associate Clinical Professor Department of Rural Family Medicine Louisiana State University Health Sciences Center New Orleans New Orleans, Louisiana Justin Ryan Andrada, DO Resident Physician Department of Family Medicine St. Joseph Hospital Chicago Chicago, Illinois Rose Katherine Appel, DO Associate Program Director Department of Graduate Medical Education AdventHealth East Orlando Orlando, Florida Camille A. Archer, MD Director of Child & Adolescent Outpatient Psychiatry Department of Child & Adolescent Psychiatry Brookdale Hospital Medical Center, One Brooklyn Health Brooklyn, New York Department of Family Medicine Residency OhioHealth Riverside Methodist Hospital Columbus, Ohio Alaina Aristide, MD Resident Physician Lawrence Family Medicine Residency Lawrence, Massachusetts Ann M. Aring, MD, FAAFP Associate Program Director

Stephanie Algenio-Anciro, MD Resident Physician Department of Family Medicine David Grant Medical Center

Hanadi Abou Dargham, MD Associate Program Director Department of Family Medicine St. Joseph’s Medical Center Stockton, California Laith Abushanab, MD Emergency Medicine Resident Department of Emergency Department Rutgers Robert Wood Johnson Medical School New Brunswick, New Jersey Adel M. Abuzeid, MBBS Associate Professor, Surgery Augusta University Medical Center Augusta, Georgia Ryan Accomazzo, MD, MPH Concord, North Carolina Cyrus Adams-Mardi, MD, MS The George Washington University School of Medicine and Health Sciences Washington, District of Columbia Ronald N. Adler, MD, FAAFP Associate Professor Department of Family Medicine and Community Health University of Massachusetts Medical School Worcester, Massachusetts Adwoa A. Adu, MD University of South Carolina Greenville, South Carolina Faraz Ahmad, MD, MPH † Assistant Clinical Professor Department of Family and Community Medicine Ohio State University Columbus, Ohio Hiba Ahmad, PharmD, BCOP † Clinical Oncology Pharmacist University of Colorado Aurora, Colorado Yasir Ahmed, MD Cornea, Cataract, and Refractive Surgeon Eye Center of Texas Houston, Texas Family Medicine Core Faculty Department of Family Medicine

Travis Air Force Base, California Fozia Akhtar Ali, MD, FAAFP Diplomat of American Board of Obesity Medicine Associate Professor Family and Community Medicine Department UT Health San Antonio San Antonio, Texas Nabeel Ali, MD Associate Program Director Department of Family Medicine Baptist Memorial Medical Education Southaven, Mississippi Aya Allam, MD Department of Family Medicine Creighton University Omaha, Nebraska Richard W. Allinson, MD Associate Professor Department of Ophthalmology Texas A&M Health Science Center Bryan, Texas Senior Staff Physician Baylor Scott & White Clinic Waco, Texas Alqasem Alsaqri, MD Resident Physician Department of Family Medicine Advocate Christ Medical Center Family Medicine Program Oak Lawn, Illinois Bremmy L. Alsbrooks, DO, MPH Resident Physician Department of Graduate Medical Education HCA Medical City Arlington Arlington, Texas Maureen Alvarado, DO Assistant Professor/Clinical Department of Family and Community Medicine UT Health San Antonio San Antonio, Texas

xii • • • Contributing Authors

Michael A. Armstrong, MD Resident Physician Department of Family Medicine HCA Medical City Arlington Arlington, Texas James J. Arnold, DO, FACOFP † Director of Medical Education 96th Medical Group/Eglin Hospital

Ben Ayotte, MD Clinical Assistant Professor, Division of Hospital Medicine Department of Internal Medicine Michigan Medicine, University of Michigan Ann Arbor, Michigan Sanaa Ayyoub, MD Endocrinologist Dartmouth-Hitchcock Medical Center Manchester, New Hampshire Sultan Mahmood Babar, MD, CAQSM, FAAFP Consultant Physician Department of Emergency Medicine King Faisal Specialist Hospital & Research Centre Department of Family and Community Medicine Texas Tech University Health Sciences Center School of Medicine Lubbock, Texas Melissa E. Badowski, PharmD, MPH Clinical Associate Professor Department of Pharmacy Practice University of Illinois at Chicago College of Pharmacy Chicago, Illinois Andrew Baird, MD PGY-3 Family Medicine Resident HCA Healthcare/Mercer University School of Medicine Grand Strand Medical Center Family Medicine Residency Program Myrtle Beach, South Carolina Frederic Baker Mills IV, MD, MS Orthopaedic Surgery Resident Department of Orthopaedic Surgery Duke University Health System Durham, North Carolina Riyadh, Kingdom of Saudi Arabia Franklyn C. Babb, MD, FAAFP Professor Robert A. Baldor, MD, FAAFP Professor and Founding Chair Department of Family Medicine UMass Chan Medical School-Baystate Springfield, Massachusetts Designated Institutional Official Baystate Franklin Medical Center Greenfield, Massachusetts Kenneth A. Ballou, MD Associate Professor of Clinical Medicine Department of Family Medicine University of California at Riverside School of Medicine Riverside, California

Laurel Banach, MD Department of Family Medicine UMass Memorial Medical Center

Worcester, Massachusetts Tara Baney, MS, CRNP Nurse Practitioner Department of Family and Community Medicine Penn State Health The George Washington University Washington, District of Columbia Sophia R. Barber, DO PGY-1 Department of Family Medicine AHN Forbes Family Medicine Residency Monroeville, Pennsylvania Elise Joyce Barney, DO Clinical Assistant Professor Department of Internal Medicine University of Arizona College of Medicine Phoenix, Arizona John P. Barrett, MD, MPH, MS † COL, MC, USA Adjunct Associate Professor Deputy Director Uniformed Services University War Related Illness and Injury Study Center Washington DC VA Medical Center Washington, District of Columbia Kathleen A. Barry, MD Associate Professor UMass Chan Medical School Department of Family Medicine and Community Health Hahnemann Family Health Center Worcester, Massachusetts Tricia Bautista, MD Resident Physician Family Medicine Residency Program Adventist Health Hanford Hanford, California Orly Bell, MD, MPH Resident Physician Department of Family Medicine University of California Los Angeles Los Angeles, California Paul P. Belliveau, PharmD Professor of Pharmacy Practice Department of Pharmacy Practice Massachusetts College of Pharmacy and Health Sciences Worcester, Massachusetts State College, Pennsylvania Zeina M. Bani Hani, MBBS

Eglin Air Force Base, Florida Michael J. Arnold, MD † Assistant Professor Department of Family Medicine Uniformed Services University of the Health Sciences Bethesda, Maryland Chris Artner, MD Resident Department of Internal Medicine Residency Program University of Louisville Louisville, Kentucky Ashley Asensio, DO Resident Physician Department of Emergency Medicine Rutgers Robert Wood Johnson Medical School

New Brunswick, New Jersey Maximos Attia, MD, FAAFP Associate Professor Department of Family Medicine Guthrie Sayre, Pennsylvania Justin Atwood, MD Prisma Health Columbia, South Carolina Frantz Aubry, MD Clinical Fellow Department of Psychiatry One Brookdale Health Brooklyn, New York Sandra S. Augusto, MD, MPH Education Director

Barre, Worcester Family Residency Program Assistant Professor, UMass Chan Medical School Full Spectrum Family Medicine with OB Faculty, BFHC Department of Family Medicine and Community Health UMass Memorial Hospital Worcester, Massachusetts Sudeep K. Aulakh, MD, FACP, FRCPC Director, Ambulatory Education UMass Chan Medical School-Baystate Springfield, Massachusetts

Contributing Authors • • • xiii

Brandis Belt, MD, MPH Assistant Residency Director Department of Family Medicine Robert Wood Johnson University Hospital Somerset Somerville, New Jersey Brock A. Benedict, DO US Army Family Physician Womack Army Community Hospital

Dmitry Bisk, MD Associate Director HonorHealth Scottsdale Osborn Family Medicine Residency Program HonorHealth Scottsdale, Arizona Haley Bodette, MD Resident Physician Department of Family Medicine ProHealth Waukesha Memorial Hospital

Makenna Brezitski, MD, Med Resident Physician

Department of Family & Community Medicine Penn State Health Milton S. Hershey Medical Center Hershey, Pennsylvania Katy (Ekaterina) Brodski-Quigley, MD, EdM Physician, Urgent Care Waltham, Massachusetts David T. Broome, MD Assistant Professor Department of Internal Medicine Division of Metabolism, Endocrinology, and Diabetes University of Michigan Ann Arbor, Michigan Kathryn M. Brown, MD, MS Assistant Professor Department of Family Medicine and Community Health University of Minnesota Minneapolis, Minnesota Phillip Charles Brown, MD Assistant Clinical Professor UCLA Family Medical Department Los Angeles, California Daniella Davida Brutman, MD Physician Department of Family Medicine AMITA Health Saint Joseph Hospital Chicago

Fort Liberty, North Carolina Ambreka Benons, MD Psychiatry Resident Brooklyn, New York Ivan Berezowski, MD Resident Physician

Waukesha, Wisconsin Frances J. Boly, DO

Department of Infectious Diseases Advocate Christ Medical Center Oak Lawn, Illinois Curtis W. Bone, MD, MHS Assistant Professor

Department of General Internal Medicine The George Washington University Hospital Washington, District of Columbia Jasmine S. Beria, DO, MPH Assistant Professor Department of Medicine NYU Langone Hospital Long Island Mineola, New York Bryan G. Beutel, MD Assistant Professor Kansas City University College of Medicine Kansas City, Missouri Rajarshi Bhadra, MD Clinical Fellow Department of Nephrology University of Massachusetts Medical School Worcester, Massachusetts Prarthna V. Bhardwaj, MBBS Fellow, Department of Hematology Oncology UMass Chan Medical School-Baystate

Department of Family and Community Medicine Penn State Health Milton S. Hershey Medical Center Hershey, Pennsylvania Marie L. Borum, MD, EdD, MPH † Professor of Medicine Director of the Division of Gastroenterology and Liver Diseases Department of Medicine George Washington University School of Medicine and Health Care Sciences Washington, District of Columbia Katherine E. Bouchard, DO Department of Family Medicine Methodist Charlton Medical Center Dallas, Texas Melissa Boucher, DO, MPH Chief Resident, Ascension St. Joseph Family Medicine Residency Department of Family Medicine Ascension St. Joseph Hospital Chicago, Illinois William McCormick Bowen, MD Program Director UNM Santa Fe Family Medicine Residency Santa Fe, New Mexico Primary Care Sports Medicine Texas A&M College of Medicine College Station, Texas William B. Bradley, MD Florida State University College of Medicine Tallahassee, Florida Greg Bowlin, MD Assistant Professor

Chicago, Illinois Liz Buck, MD Department of Family Medicine University of Washington Seattle, Washington Bonnie A. Buechel, MD, MS Resident Physician

Springfield, Massachusetts Siddhi Bhivandkar, MD Department of Psychiatry St. Elizabeth’s Medical Center Boston University Boston, Massachusetts

Department of Family and Community Medicine Penn State Health Milton S. Hershey Medical Center Hershey, Pennsylvania Han Q. Bui, MD, MPH † Chief Medical Officer International SoS Houston, Texas Dylan Buller, MD Resident Department of Urology UConn Health Farmington, Connecticut

Ghazaleh Bigdeli, MD, FCCP Pulmonary Rehab Associates Youngstown, Ohio Wendy S. Biggs, MD Professor, Family Medicine Central Michigan University College of Medicine Saginaw, Michigan

Chelsea Leigh Bunce, DO New Brunswick, New Jersey

xiv • • • Contributing Authors

Samantha Carroll, MD Hospitalist

Kyle Burke, DO Department of Family and Community Medicine Penn State Health Milton S. Hershey Medical Center Hershey, Pennsylvania Liam P. Burke, MD Assistant Professor Department of Family Medicine and Community Health University of Massachusetts Medical School Worcester, Massachusetts Harold J. Bursztajn, MD Associate Professor of Psychiatry, Part-Time Department of Psychiatry Beth Israel Deaconess Medical Center Department of Family Medicine Kaweah Health Medical Center Visalia, California Jennifer W. Caceres, MD Associate Professor of Medicine Department of Medicine Schmidt College of Medicine at Florida Atlantic University Boca Raton, Florida David C. Cadena Jr., MD † Assistant Professor Department of Family and Community Medicine University of Texas Health Science Center at San Antonio San Antonio, Texas Kristen R. Canady, MD, PhD Department of Family and Community Medicine University of Texas Health Science Center at San Antonio San Antonio, Texas Justin Paul Canakis, DO Resident Doctor Department of Internal Medicine George Washington University Washington, District of Columbia Etny Raul Candelario, MD, MS Department of Family and Community Medicine University of Texas Health Science Center San Antonio, Texas Dana G. Carroll, PharmD, BCPS, CDCES, BCGP Clinical Professor Department of Pharmacy Practice Auburn University Harrison School of Pharmacy Tuscaloosa, Alabama Harvard Medical School Boston, Massachusetts Jared Caballes, MD Resident Physician

Christine Chan, MD Faculty Hawai’i Island Family Medicine Residency Hilo Medical Center Hilo, Hawaii Sangili Chandran, MD Director, Primary Care Sports Medicine Advocate Christ Medical Center Oak Lawn, Illinois Associate Professor Department of Family Medicine Chicago Medical School Roslind Franklin University of Medicine and Science Chicago, Illinois Clifford M. Chang, MD Resident Physician Department of Emergency Medicine Inspira Vineland Medical Center Vineland, New Jersey Felix B. Chang, MD, DABMA, ABIHM, ABIM Director, Inpatient Service University of Massachusetts Fitchburg Family Medicine Residency Program Hospitalist, Family Medicine University of Massachusetts Medical School Worcester, Massachusetts Hospitalist Department of Hospital Medicine University of Massachusetts Memorial Medical Group Leominster, Massachusetts Jennifer G. Chang, MD † LtCol, USAF, MC Department of Family Medicine Residency 96th Medical Group Eglin Air Force Base, Florida Juliana Chang, MD Rheumatology Fellow University of California, Irvine Irvine, California Jason Chao, MD, MS Professor Department of Family Medicine and Community Health Case Western Reserve University and University Hospitals Cleveland Medical Center Cleveland, Ohio Kathya M. Chartre, MD Department of Family Medicine AMITA Health Saint Joseph Hospital Chicago, Illinois

Department of Pediatrics AdventHealth for Children Orlando, Florida Elizabeth H. Carver, DNP, FNP-BC, CNE Nurse Practitioner Occupational Health and Wellness Duke University Affiliate Assistant Professor Clerkship Director, Pediatrics Department of Women’s and Children’s Health Charles E. Schmidt College of Medicine Florida Atlantic University Boca Raton, Florida Casandra Cashman, MD, FAAFP Assistant Director Community East Family Medicine Residency Program Indianapolis, Indiana Michelle Caster, MD Assistant Professor Department of Family Medicine University Hospitals Cleveland, Ohio Jennifer E. Cavin, MD Assistant Professor Department of Family Medicine Dell Medical School, The University of Texas at Austin Austin, Texas William E. Cayley Jr., MD, Mdiv Adjunct Clinical Professor University of Wisconsin School of Medicine and Public Health Prevea Family Medicine Residency Eau Claire, Wisconsin Jan Cerny, MD, PhD † Associate Professor of Medicine Department of Medicine Division of Hematology/Oncology University of Massachusetts Medical School Worcester, Massachusetts Morgan Lee Chambers, MD, MEd PGY2 Department of Family and Community Medicine Penn State Health Milton S. Hershey Medical Center Hershey, Pennsylvania Ronald G. Chambers Jr., MD, FAAFP † Program Director Department of Family Medicine Dignity Health Sacramento, California Durham, North Carolina Robert J. Casey, MD

Contributing Authors • • • xv

Parul Chaudhri, DO Assistant Professor, Director of Osteopathic Education Department of Family Medicine University of Toledo Toledo, Ohio Summer Chavez, DO, MPH, MPM Clinical Assistant Professor Department of Health Systems and Population Health Sciences University of Houston Houston, Texas Janet Chen, DO AdventHealth Orlando, Florida Jeffrey Chen, MD Clinical Instructor Department of Internal Medicine University of Texas at Houston, McGovern Medical School Houston, Texas Department of Family and Community Medicine Penn State Health Milton S. Hershey Medical Center Hershey, Pennsylvania Teresa M. Chirayil, MD † Resident Physician, Family Medicine Advocate Christ Family Medicine Residency Oak Lawn, Illinois Luke Thomas Chmielecki, MD Clinical Instructor Department of Internal Medicine Boston Medical Center Boston, Massachusetts Ratnesh Chopra, MD Assistant Professor of Medicine University of Massachusetts Medical School Worcester, Massachusetts Department of Emergency Medicine University of Massachusetts Memorial Healthcare Worcester, Massachusetts Megan Ann Christopher, MD, MPH Resident Physician Department of Family Medicine Dell Medical School, The University of Texas at Austin Austin, Texas Rensa Chen, DO Resident Physician Efstathia Choros, MD, CPA Emergency Medicine Physician

Justin Chu, MD Internal Medicine & Pediatrics University of Louisville School of Medicine Louisville, Kentucky Vivian Nnenna Chukwuma, MD Resident

Sabina M. Constantine, DO Clinical Assistant Professor

NYU Long Island School of Medicine NYU Langone Hospital—Long Island Mineola, New York Stephanie L. Conway-Allen, PharmD, RPh Associate Professor Department of Pharmacy Practice Massachusetts College of Pharmacy and Health Sciences University Department of Family Medicine Residency St. Mary’s Medical Center Family Medicine Residency Grand Junction, Colorado Corey J. Costanzo, DO, MPH, MS Assistant Professor Department of Family Medicine UMass Chan School of Medicine Worcester, Massachusetts Samantha Cotler, DO, MBA Family Medicine Residency AdventHealth East Orlando Orlando, Florida Benjamin Cottrell, DO Resident Physician AdventHealth East Orlando Orlando, Florida Caroline E. Cox, MD Division of Surgery Spartanburg Regional Medical Center Spartanburg, South Carolina Julie A. Creech, DO † Family Medicine Physician, Sports Medicine Physician, Primary Care Sports Medicine Fellow United States Air Force O’Fallen, Illinois Jason Cross, PharmD, BCPS, BCACP Associate Professor of Pharmacy Practice Massachusetts College of Pharmacy and Health Sciences University Worcester, Massachusetts Hongyi Cui, MD, PhD Associate Professor of Surgery, Associate Director, Acute Care Surgery Department of Surgery University of Massachusetts Memorial Medical Center Worcester, Massachusetts Shani H. Cunningham, DO, MEd, FAAP Assistant Professor AdventHealth for Children Orlando, Florida Worcester, Massachusetts Tonya M. Cook, PharmD Faculty, Clinical Pharmacist

Department of Internal Medicine Advocate Christ Medical Center Oak Lawn, Illinois S. Lindsey Clarke, MD, FAAFP †

Medical University of South Carolina Area Health Education Consortium Professor (Greenwood/Family Medicine) Director of Resident Education and Associate Program Director Self Regional Healthcare Greenwood, South Carolina Department of Family and Community Medicine Penn State Health Milton S. Hershey Medical Center Hershey, Pennsylvania Gregorio Climaco, MD PGY-2 Family Medicine Resident SouthWestern Illinois Family Medicine Resident St. Elizabeth’s Hospital O’Fallon, Illinois Cerrone A. Cohen, MD Assistant Professor Duke Psychiatry and Behavioral Sciences Duke Family Medicine and Community Health Duke University Durham, North Carolina Karl T. Clebak, MD, MHA, FAAFP † Associate Professor, Program Director

Timothy J. Coker, MD, FAAFP † United States Air Force Academy Air Force Academy, Colorado Erik Colegrove, MD Department of Family Medicine

Central Michigan University Mount Pleasant, Michigan

Irene Coletsos, MD Community Psychiatrist Department of Behavioral Health VinFen, Department of Mental Health Quincy, Massachusetts Jennifer R. Collins, PharmD Clinical Pharmacy Specialist - Ambulatory Care Community Health Network Indianapolis, Indiana Christina Conrad, DO Department of Pediatric Emergency Medicine Phoenix Children’s Hospital Phoenix, Arizona

xvi • • • Contributing Authors

Madeleine Cutrone, MD Resident Physician Department of Family Medicine Novant Health Family Medicine Residency Program Huntersville, North Carolina Tina D’Amato, DO Attending Family Physician Charlotte Family Medicine Charlotte, Vermont Darnel Viray Dabu, MD, MPH, FAAFP Faculty Department of Family Medicine Lakeside Medical Center Belle Glade, Florida Pawan Daga, MD Resident Department of Internal Medicine University of Louisville Louisville, Kentucky Heather Ann Dalton, MD, FAAFP † Hospice and Palliative Medicine Fellow Department of Internal Medicine UT Southwestern Medical Center Dallas, Texas Paul E. Daniel Jr., MD Hospitalist Thomas Jefferson University Philadelphia, Pennsylvania Amanda Kimberley Davis, MD, MBBS Department of Family Medicine Tallahassee Memorial Health Care FMRP Tallahassee, Florida Michelle A. Davis, DO Resident Physician Family and Community Medicine University of Texas Health Science Center San Antonio, Texas Ana De Diego, MD Resident Physician UMass Memorial Healthcare Division of Hospital Medicine Worcester, Massachusetts Akhil Das, MD, FACS Professor Department of Urology

Iain W. Decker, DO Resident Physician Department of Ophthalmology Kettering Health Network Grandview Medical Center Dayton, Ohio Henry Del Rosario, MD Assistant Professor Department of Family Medicine and Community Health University of Massachusetts Memorial Medical School Worcester, Massachusetts Emilee J. Delbridge, PhD, LMFT Assistant Professor of Clinical Family Medicine Department of Family Medicine Indiana University Indianapolis, Indiana Konstantinos E. Deligiannidis, MD, MPH, FAAFP Assistant Professor Department of Family Medicine Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Hempstead, New York Malhar Desai, DO, MS, BA Resident Robert Wood Johnson - Emergency Department Rutgers Robert Wood Johnson Medical School New Brunswick, New Jersey Michael DiGaetano, MD Resident Physician Department of Emergency Medicine Rutgers Robert Wood Johnson University Hospital New Brunswick, New Jersey Sherilyn DeStefano, MD Assistant Professor Department of Family Medicine Oregon Health and Science University Portland, Oregon Hillary Kieran Deveaux, MBBS Resident Department of Internal Medicine Advocate Christ Medical Center Oak Lawn, Illinois Bradley Devrieze, MD Assistant Professor Department of Internal Medicine Creighton University School of Medicine Omaha, Nebraska Gabriel J. Diaz, CRNP-BC, MS Nurse Practitioner Department of Gastroenterology The George Washington University Washington, District of Columbia

Amanda M. DiSabato, DO Resident Physician Department of Family Medicine OhioHealth Riverside Methodist Hospital Family Medicine Residency Program Columbus, Ohio Lena Dung Doan, DO Resident Physician Department of Family Medicine Texas A&M Health Science Family Medicine Residency Program Bryan, Texas Professor and Director of Predoctoral Education Department of Family Medicine and Community Health UMass Chan Medical School Worcester, Massachusetts Andrea B. Dotson, MD, MSPH Assistant Professor Department of Family Medicine and Community Health Durham, North Carolina Ian P. Downin, MD, MHA Resident Physician Department of Family and Community Medicine Penn State Health Milton S. Hershey Medical Center Hershey, Pennsylvania Joanna Drowos, DO, MPH, MBA Associate Dean for Faculty Affairs Associate Professor of Family Medicine Charles E. Schmidt College of Medicine Florida Atlantic University Boca Raton, Florida Milap Dubal, MD, MPH Assistant Professor Department of Family and Community Medicine Penn State Health Fishburn, Pennsylvania Loreal Dolar, DO Resident Physician Orlando, Florida Frank J. Domino, MD

Michelle E. Duffelmeyer, MD Director of Didactic Education

College of Health Science Westfield State University Westfield, Massachusetts Carla Dugas, DO

Department of Internal Medicine University of Miami at Holy Cross Miami, Florida Niyomi De Silva, MD Associate Program Director Department of Family Medicine HCA Medical City Arlington Arlington, Texas

Core Faculty, Attending Physician Department of Emergency Medicine

Inspira Medical Center Vineland, New Jersey

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