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PRIMARY CARE MEDICINE Office Evaluation and Management of the Adult Patient EIGHTH EDITION

40 TH ANNIVERSARY EDITION

Allan H. Goroll Albert G. Mulley

PRIMARY CARE MEDICINE Office Evaluation and Management of the Adult Patient

PRIMARY CARE MEDICINE Office Evaluation and Management of the Adult Patient EIGHTH EDITION

Allan H. Goroll, MD, MACP Professor of Medicine Harvard Medical School Physician, Medical Service Massachusetts General Hospital Boston, Massachusetts

Albert G. Mulley Jr, MD, MPP Managing Director Global Health Care Delivery Science The Dartmouth Institute for Health Policy and Clinical Practice Professor of Medicine Geisel School of Medicine at Dartmouth Hanover, New Hampshire

Executive Editor : Sharon Zinner Development Editor : Thomas Celona Editorial Coordinator : Cody Adams Editorial Assistant : Victoria Giansante Marketing Manager : Phyllis Hitner

Senior Production Project Manager : Alicia Jackson Manager, Graphic Arts & Design : Stephen Druding Senior Manufacturing Coordinator : Beth Welsh Prepress Vendor : SPi Global Eighth Edition Copyright © 2021 Wolters Kluwer © 2014 Wolters Kluwer Health © 2009 by LIPPINCOTT WILLIAMS & WILKINS, a Wolters Kluwer business © 2006 and 2000 by Lippincott Williams & Wilkins © 1995, 1987, and 1981 by JB Lippincott All rights reserved. This book is protected by copyright. No part of this book may be repro duced 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 copy right. 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 website at shop.lww.com (products and services). 9 8 7 6 5 4 3 2 1 Printed in China 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 upon healthcare profession als’ 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. Healthcare 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. Cataloging-in-Publication Data available on request from the Publisher ISBN: 978-1-4963-9811-6

Given continuous, rapid advances in medical science and health information, independent pro fessional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should con sult a variety of sources. When prescribing medication, healthcare 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 admin istered 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. shop.lww.com Copyright © 2020 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited.

Dedicated to our students, who continue to inspire, humble, and amaze us, and to the memory of Mark Herzog, one of the best.

IN MEMORIAM

John D. Stoeckle, MD 1922–2020

John Stoeckle, our mentor and one of the fathers of modern primary care in the United States, was a deeply caring and compassionate physician, a wise and generative teacher, and a discerning and critical scholar. His gentle humility made patients from all backgrounds—as well as his students and colleagues—feel welcome, respected, and known in his presence. John’s “plain doctoring” approach to learning from patients what contributed to their health and well-being was unique. It made manifest in every encounter his passionate commitment to health equity. That the first edition of Primary Care Medicine was dedicated to John was a fitting expression of gratitude from those who learned so much from him. Forty years later, the learning and gratitude are all the greater.

CONTRIBUTORS

Fredrick M. Abrahamian, DO, FACEP, FIDSA Health Sciences Clinical Professor of Emergency Medicine David Geffen School of Medicine at UCLA Los Angeles, California Jeremy S. Abramson, MD, MMSc Assistant Professor Department of Medicine Harvard Medical School Director, Lymphoma Program Cancer Center Massachusetts General Hospital Boston, Massachusetts Audrey Ahuero, MD Ophthalmic Plastic Surgeons of Texas Houston, Texas Karin L. Andersson, MD, MPH Instructor Department of Medicine Harvard Medical School Staff Hepatologist Department of Gastroenterology Department of Medicine Harvard Medical School Director, Informed Medical Decisions Program Division of General Internal Medicine Massachusetts General Hospital Boston, Massachusetts Ernie-Paul Barrette, MD, FACP Associate Professor Department of Medicine Washington University School of Medicine Primary Care Medicine Clinic Barnes-Jewish Hospital Massachusetts Hospital Boston, Massachusetts Michael J. Barry, MD Professor

Susan E. Bennett, MD Assistant Professor

Ilana Braun, MD Assistant Professor

Department of Medicine Harvard Medical School Physician Department of Medicine Massachusetts General Hospital Boston, Massachusetts Nakul Bhardwaj, DO, MPH Department of Internal Medicine Cleveland Clinic Cleveland, Ohio Neil Bhattacharyya, MD, FACS Professor Department of Otolaryngology

Department of Psychiatry Harvard Medical School Chief, Division of Adult Psychosocial Oncology Dana Farber Cancer Institute Boston, Massachusetts David C. Brewster, MD Clinical Professor Department of Surgery Harvard Medical School Clinical Professor Department of Surgery Massachusetts General Hospital Boston, Massachusetts Kristin Burke, MD Clinical Fellow Division of Gastroenterology Massachusetts General Hospital Boston, Massachusetts Winfield Scott Butsch, MD, MSc, FTOS Director of Obesity Medicine Bariatric & Metabolic Institute Gastroenterology Fellow Department of Medicine Harvard Medical School Gastroenterology Fellow Division of Gastroenterology, Hepatology, & Endoscopy Department of Medicine Brigham and Women’s Hospital Boston, Massachusetts David J. Cangemi, MD Research Fellow Harvard Medical School Clinical Research Fellow Medicine Gastrointestinal Unit Department of Medicine Massachusetts General Hospital Boston, Massachusetts Cleveland Clinic Cleveland, Ohio Jennifer X. Cai, MD, MPH Department of Medicine Harvard Medical School Gastroenterology Fellow

Harvard Medical School Boston, Massachusetts Michael F. Bierer, MD Assistant Professor

Department of Medicine Harvard Medical School Physician Department of Medicine Massachusetts General Hospital

Boston, Massachusetts Shana Birnbaum, MD Assistant Professor

Department of Medicine Harvard Medical School Associate Physician Department of Medicine Massachusetts General Hospital Boston, Massachusetts Liliana Bordeianou, MD, MPH Associate Professor of Surgery Department of Surgery Harvard Medical School Chief, Colorectal Surgery Center Department of Surgery Massachusetts General Hospital Boston, Massachusetts Stephen T. Boswell, MD (at time of writing) Assistant Professor of Medicine Harvard Medical School Physician Beth Israel Deaconess Medical Center Boston, Massachusetts

St. Louis, Missouri Hasan Bazari, MD Associate Professor

Department of Medicine Harvard Medical School Physician

Division of Nephrology Department of Medicine Massachusetts General Hospital Boston, Massachusetts

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Contributors

Nancy L. Cantelmo, MD Assistant Clinical Professor Department of Surgery, Vascular Harvard Medical School Assistant in Surgery Department of Surgery, Vascular Massachusetts General Hospital Boston, Massachusetts Angela Catic, MD, MEd

Benjamin Davis, MD Assistant Professor Department of Medicine Harvard Medical School Physician

Laura C. Fine, MD Clinical Instructor Department of Ophthalmology Harvard Medical School Department of Ophthalmology Tufts University School Medicine Clinical Associate Massachusetts Eye and Ear Infirmary Associate Staff

Department of Infectious Disease Massachusetts General Hospital Boston, Massachusetts Thomas F. Delaney, MD Andres Soriano Professor of Radiation Oncology Department of Radiation Oncology Harvard Medical School Attending Physician Department of Radiation Oncology Massachusetts General Hospital Boston, Massachusetts Jules L. Dienstag, MD Carl W. Walter Professor of Medicine Department of Medicine Harvard Medical School Physician Department of Medicine Massachusetts General Hospital Boston, Massachusetts Darin D. Dougherty, MD Associate Professor Department of Psychiatry Harvard Medical School Direction, Division of Neurotherapeutics Department of Psychiatry Massachusetts General Hospital Boston, Massachusetts Kamryn T. Eddy, PhD Codirector Eating Disorders Clinical and Research Program Massachusetts General Hospital Boston, Massachusetts Associate Professor of Psychology Department of Surgery Harvard Medical School Associate Visiting Surgery Department of Surgery Massachusetts General Hospital Boston, Massachusetts Leslie S. T. Fang, MD, PhD John R. Gallagher III and Katherine A. Gallagher Endowed Chair Clinical Excellence in Nephrology Firm Chief, Walter Bauer Firm Medical Services Massachusetts General Hospital Department of Psychiatry Harvard Medical School Cambridge, Massachusetts Peter J. Fagenholz, MD Assistant Professor

Assistant Professor Section of Geriatric Department of Internal Medicine Baylor College of Medicine Staff Physician Geriatric and Extended Care Michael E. DeBakey VA Medical Center Houston, Texas Christopher P. Chiodo, MD Assistant Professor Department of Orthopedic Surgery Harvard Medical School Chief, Foot and Ankle Division Department of Orthopedic Surgery Brigham and Women’s Hospital Boston, Massachusetts Jeffrey William Clark, MD Associate Professor Department of Medicine Harvard Medical School Medical Director, Cancer Center Protocol Office Department of Medicine (Hematology–Oncology) Massachusetts General Hospital Boston, Massachusetts Tina Scheufele Cleary, MD Assistant Professor of Ophthalmology Department of Ophthalmology Tufts University School of Medicine Vitreoretinal Surgeon Ophthalmic Consultants of Boston Boston, Massachusetts M. Cornelia Cremens, MPH, MD Assistant Professor Department of Psychiatry Harvard Medical School Geriatric Psychiatrist Department of Psychiatry Massachusetts General Hospital Boston, Massachusetts Michael E. Dalton, OD, MBA Optometrist Ophthalmic Consultants of Boston Boston, Massachusetts

Tufts Medical Center Boston, Massachusetts Angela K. Fitch, MD Faculty Member

Department of Medicine Harvard Medical School Cambridge, Massachusetts Associate Director Endocrinology Massachusetts General Hospital Weight Center Boston, Massachusetts Nicoletta Fynn-Thompson, MD Partner Cornea, Cataract, and Refractive Surgery Ophthalmic Consultants of Boston Boston, Massachusetts Lawrence S. Friedman, MD Professor of Medicine Harvard Medical School Professor of Medicine Tufts University School of Medicine Boston, Massachusetts Alexandra K. Gold, MA Clinical Psychology Doctoral Student Department of Psychology and Brain Sciences Boston University Boston, Massachusetts Ellie J. C. Goldstein, MD Clinical Professor of Medicine UCLA School of Medicine Director

Infection Prevention and ASP Kindred Hospital Los Angeles Los Angeles, California Mark Allan Goldstein, MD Associate Professor

Shinjita Das, MD Clinical Instructor Department of Dermatology Harvard Medical School Assistant in Dermatology Department of Dermatology Massachusetts General Hospital Boston, Massachusetts

Department of Pediatrics Harvard Medical School Chief Division of Adolescent and Young Adult Medicine Massachusetts General Hospital Boston, Massachusetts

Harvard Medical School Boston, Massachusetts

Contributors

Annekathryn Goodman, MD, MPH, MS, MA Full Professor Department of Obstetrics, Gynecology, and Reproductive Biology Harvard Medical School Gynecologic Oncologist Department of Obstetrics & Gynecology Massachusetts General Hospital Boston, Massachusetts John D. Goodson, MD Associate Professor Department of Medicine Harvard Medical School Physician Division of General Internal Medicine Department of Medicine Massachusetts General Hospital Ophthalmic Consultants of Boston Massachusetts General Hospital Massachusetts Eye & Ear Infirmary Boston, Massachusetts Mark Herzog, MD, MPP Harvard Medical School Boston, Massachusetts Aaron R. Hoffman, DO, MPH Instructor Department of Medicine Harvard Medical School Assistant Department of Medicine Massachusetts General Hospital Boston, Massachusetts Theodore S. Hong, MD Associate Professor Department of Radiation Oncology Harvard Medical School Director, Gastrointestinal Radiation Oncology Department of Radiation Oncology Massachusetts General Hospital Boston, Massachusetts James W. Hung, MD Ophthalmic Consultants of Boston Boston, Massachusetts Elaine M. Hylek, MD, MPH Professor Department of Medicine Boston University Director Thrombosis Service Boston, Massachusetts Mark P. Hatton, MD

Ignacio Inglessias-Azuaje, MD Assistant Professor Department of Medicine Harvard Medical School Associate Physician Department of Medicine Massachusetts General Hospital Boston, Massachusetts Jesse B. Jupiter, MD Hansjorg Wyss/AD Professor Department of Orthopedic Surgery Harvard Medical School Orthopedic Hand Surgeon Massachusetts General Hospital Boston, Massachusetts Mihir M. Kamdar, MD Associate Director Division of Palliative Care Massachusetts General Hospital Boston, Massachusetts Hamed Khalili, MD, MPH Assistant Professor Department of Gastroenterology Harvard Medical School Associate Director Clinical and Translational Epidemiology Unit Massachusetts General Hospital Boston, Massachusetts Linda A. King, MD Assistant Professor Division of General Internal Medicine University of Pittsburgh Associate Chief Section of Palliative Care and Medical Ethics University of Pittsburgh Medical Center Pittsburgh, Pennsylvania Gustavo Kinrys, MD Instructor Department of Psychiatry Harvard Medical School Massachusetts General Hospital Boston, Massachusetts Eric L. Krakauer, MD, PhD Associate Professor Department of Medicine Harvard Medical School Attending Physician Division of Palliative Care & Geriatrics Massachusetts General Hospital Boston, Massachusetts

Hiroko Kunitake, MD, MPH Assistant Professor Department of Surgery Harvard Medical School Assistant Department of Surgery Massachusetts General Hospital

Boston, Massachusetts Braden Kuo, MD, MSc Assistant Professor

Department of Medicine Harvard Medical School Assistant Physician Department of Internal Medicine Gastrointestinal Unit Boston, Massachusetts Irene Kuter, MD, DPhil Assistant Professor Department of Medicine Harvard Medical School Physician Department of Hematology & Oncology Massachusetts General Hospital Boston, Massachusetts Edward T. Lahey III, DMD, MD Assistant Professor Oral and Maxillofacial Surgery Harvard Medical School Quality and Safety Chair and Medical Director Oral and Maxillofacial Surgery Massachusetts General Hospital Boston, Massachusetts Regina C. LaRocque, MD Assistant Professor of Medicine Department of Medicine Harvard Medical School Assistant Professor of Medicine Department of Medicine Massachusetts General Hospital Boston, Massachusetts Elizabeth A. Lawson, MD, MMSc Associate Professor of Medicine Harvard Medical School Director, Interdisciplinary Oxytocin Research Program Neuroendocrine Unit Massachusetts General Hospital Boston, Massachusetts Richard R. Liberthson, MD Associate Professor Harvard Medical School Physician, Pediatrician, Cardiologist Massachusetts General Hospital Founder and Director Emeritus Adult Congenital Heart Disease Program Massachusetts General Hospital Boston, Massachusetts

Department of Medicine Boston Medical Center Boston, Massachusetts

Contributors

L. Elizabeth Lincoln, MD Instructor Department of Medicine

Molly Perencevich, MD Instructor Department of Medicine Harvard Medical School Physician

David Ring, MD, PhD Professor of Surgery and Psychiatry Associate Dean for Comprehensive Care Dell Medical School The University of Texas at Austin Austin, Texas Patricia L. Roberts, MD Professor of Surgery Tufts University School of Medicine Boston, Massachusetts Chair Emeritus Department of Surgery Lahey Hospital and Medical Center Burlington, Massachusetts Rodrigo Tavares Rodrigues, MD Instructor of Medicine Department of Medicine Harvard Medical School Assistant in Medicine Massachusetts General Hospital Boston, Massachusetts Laurence J. Ronan, MD Staff Physician Massachusetts General Hospital Boston, Massachusetts Edward T. Ryan, MD Professor Department of Immunology and Infectious Diseases Harvard T.H. Chan School of Public Health Professor Director, Immunization Center Division of Infectious Diseases Massachusetts General Hospital Boston, Massachusetts Theodor C. Sauer, MD Fellow Department of Ophthalmology Ophthalmic Consultants of Boston/ Tufts New England Eye Center Boston, Massachusetts Peter C. Schalock, MD Adjunct Associate Professor Department of Surgery (Dermatology) Geisel School of Medicine at Dart mouth Medical Director Boston Red Sox Department of Medicine Harvard Medical School

Harvard University Attending Physician Department of Medicine Massachusetts General Hospital Boston, Massachusetts Chris Langhammer, MD, PhD Fellow–Hand Surgery Department of Orthopaedic Surgery Harvard Medical School Fellow–Hand Surgery Orthopaedic Hand Service Massachusetts General Hospital Boston, Massachusetts Andrew Lundquist, MD, PhD Assistant in Medicine Division of Nephrology Massachusetts General Hospital Boston, Massachusetts Melissa Mattison, MD Associate Professor of Medicine Department of Medicine Harvard Medical School Chief, Hospital Medicine Unit Department of Medicine Massachusetts General Hospital Department of Psychiatry Harvard Medical School Staff Psychiatrist Department of Psychiatry Brigham and Women’s Hospital Boston, Massachusetts William E. Minichiello, EdD Psychologist Massachusetts General Hospital Associate Professor of Psychology Department of Psychiatry Harvard Medical School Boston, Massachusetts L. Christine Oliver, MD, MPH, MS Adjunct Professor Department of Occupational Environmental Health Dalla Lana School of Public Health University of Toronto Toronto, Ontario, Canada Kerri Palamara McGrath, MD Assistant Professor Department of Medicine Harvard Medical School Director, Primary Care Program Department of Medicine Massachusetts General Hospital Boston, Massachusetts Boston, Massachusetts Fremonta Meyer, MD Assistant Professor

Department of Gastroenterology Brigham and Women’s Hospital Boston, Massachusetts Kurt J. Pfeifer, MD Professor of Medicine Department of Medicine Medical College of Wisconsin Milwaukee, Wisconsin Christine Prifti, MD PGY-3 Department of Medicine Harvard University PGY-3 Department of Medicine Massachusetts General Hospital Boston, Massachusetts Amy A. Pruitt, MD Professor of Neurology Department of Neurology Perelman School of Medicine

University of Pennsylvania Philadelphia, Pennsylvania Rocco Ricciardi, MD Associate Professor of Surgery Harvard Medical School Chief, Section of Colon & Rectal Surgery Massachusetts General Hospital Boston, Massachusetts Claudia U. Richter, MD Part-Time Instructor in Ophthalmology Department of Ophthalmology

Harvard Medical School Boston, Massachusetts

James M. Richter, MD, MA Associate Professor of Medicine

Department of Medicine Harvard Medical School Physician

Division of Gastroenterology Massachusetts General Hospital Boston, Massachusetts Nancy Ridenour, PhD, APRN, BC, FAAN President Barnes Jewish College

St. Louis, Missouri Nancy Rigotti, MD Professor Hanover, New Hampshire Sherry D. Scovell, MD Assistant Professor of Surgery– Part-Time Vascular & Endovascular Surgery Harvard Medical School Massachusetts General Hospital Boston, Massachusetts Copyright © 2020 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. Department of Medicine Harvard Medical School Director, Tobacco Research & Treatment Center Massachusetts General Hospital Boston, Massachusetts

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Contributors

David M. Slovik, MD Associate Professor of Medicine Harvard Medical School Chief Division of Endocrinology and Diabetes Newton-Wellesley Hospital

Arthur J. Sober, MD Professor Department of Dermatology Harvard Medical School Dermatologist Department of Dermatology Massachusetts General Hospital Boston, Massachusetts Ada C. Stefanescu Schmidt, MDCM, MSc Clinical and Research Fellow Department of Medicine Harvard Medical School Clinical and Research Fellow Department of Adult Congenital Heart Disease

Jeffrey B. Weilburg, MD Assistant Professor of Psychiatry MGH Department of Psychiatry Harvard Medical School Associate Psychiatrist Department of Psychiatry Massachusetts General Hospital Boston, Massachusetts John Winkelman, MD, PhD Professor of Psychiatry Department of Psychiatry Harvard Medical School Psychiatrist Department of Psychiatry Massachusetts General Hospital Boston, Massachusetts John J. Worthington III, MD Assistant Professor of Psychiatry Harvard Medical School Assistant Professor of Psychiatry Department of Psychiatry Boston, Massachusetts Patrick Yachimski, MD, MPH Associate Professor Division of Gastroenterology, Hepatology, and Nutrition Vanderbilt University Medical Center Nashville, Tennessee

Boston, Massachusetts Linda C. Shafer, MD Assistant Professor

Department of Psychiatry Harvard Medical School Psychiatrist Department of Psychiatry Massachusetts General Hospital Boston, Massachusetts Paul C. Shellito, MD Assistant Professor of Surgery, Emeritus Department of Surgery Harvard Medical School Visiting Surgeon, Emeritus

Massachusetts General Hospital Brigham and Women’s Hospital Boston Hospital Combined Program

Boston, Massachusetts Shane J. Volney, MD Private Practice New York, New York E. Nalan Ward, MD Assistant Professor

Department of Surgery Massachusetts General Hospital Boston, Massachusetts Leigh H. Simmons, MD Assistant Professor Department of Medicine Harvard Medical School Associate Physician Massachusetts General Hospital Boston, Massachusetts

Department of Psychiatry Harvard of Medical School Medical Director Outpatient Addiction Services Department of Psychiatry Massachusetts General Hospital Boston, Massachusetts

PREFACE

T his eighth edition of Primary Care Medicine (PCM), like the first edition 40 years ago, comes at a critical moment for primary care, as health care delivery both in the United States and around the world faces enormous challenges of access, affordability, and quality. With accumulating evidence and a growing appreciation for primary care’s foundational role comes the expectation that it will deliver on cost, quality, access, and patient experience. This is a tall order for a field that has struggled for decades to attract trainees and to receive adequate funding. Fortunately, the situation is changing dramatically with calls to transform and revitalize primary care. It is in this context that we offer the eighth edition of PCM to provide the knowledge base and strategies for delivery of robust primary care. The good news is that there is so much more we can do today for our patients than when PCM was first published in 1981. The bad news is that the knowledge base of primary care medicine has exploded—it once could be contained in a big-print book one third the size of the eighth edition. As daunting as this may seem, we have worked hard to make the content more accessible and up-to-the minute through complementary electronic delivery while holding true to our original design found so useful for learning and practicing primary care. All chapters are problem-based and action-oriented, addressing the clinical challenges one faces daily in primary care practice. The chapters are divided into key sections and subsections addressing basic elements of the care process (diagnosis, differential diagnosis, screening, workup, management strategies, prevention, patient education, and indications for referral). Chapters conclude with bulleted, actionable recommendations based on best available evidence. Important details and frequently raised questions and dilemmas are considered—content relevant to the beginner as well as the experienced clinician is included. Everything needed for decision making is included in one place, with a minimum of referring readers to other sections of the book (except for more detail). For four decades, PCM has sought to promote better personalized health care and better health at lower cost (themes that are particularly relevant in today’s environment) through application of best available evidence—the content of nearly 3,000 new references has been incorporated into this fully rewritten edition. Cost-effectiveness, team care, patient and family education, and coordination have always been central considerations and features of our recommendations. We seek to take the reader beyond the “right answer” to present the “why” as well as the “what,” so that users of PCM will under stand the evidence and rationale behind a recommendation, facilitating both customization of care and coping with a rapidly changing knowledge base. Besides being a decision-support tool for clinical practice, PCM also serves as a textbook, contain ing the essential knowledge needed to understand the scientific basis of primary care practice. Toward this end, we provide a web-based curriculum of core material for learners with reference to specific chapters in PCM. Given the importance of knowledgeable interdisciplinary team delivery to achieving high-performance primary care, such content is meant to be shared at some level by all members of the primary care team. Whether a student or resident in medicine, nursing, nurse partitioning, physician assistantship, pharmacy, or mental health, there is content in PCM relevant to your role in primary patient care. Although handbooks can provide answers, we feel it is critical that you understand the basis for the answer and thus include the supporting evidence and rationale. Yes, it entails a bit more reading than handbooks, but the investment in time should pay dividends in terms of enhanced understanding, which enables you to better personalize care and achieve more meaningful outcomes for the patients you serve. In addition to the book’s full text, quarterly updates, and interdisciplinary curriculum, the Web site also includes materials to support shared decision-making, helping patients make personally meaning ful, informed decisions about their care. We encourage a genuinely collaborative approach between patients and caregivers, an essential feature of patient-centered primary care. The practice of primary care has never been more challenging nor more rewarding. Our goal is to help PCM readers master the knowledge base and use it skillfully. We continue to be humbled and gratified by the responses of our readers over the decades who have found our book helpful in their learning and practice of primary care. It is to them and an exciting new generation of highly motivated future primary care clinicians that we dedicate this edition.

Allan H. Goroll, MD, MACP Albert G. Mulley Jr, MD, MPP Boston, Massachusetts and Hanover, New Hampshire February, 2020

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FOREWORD TO THE FIRST EDITION

P hysicians have traditionally provided direct, initial, comprehensive care for patients as well as continuity of care. In the past two decades, the growing proportion of specialist physicians has endangered this traditional role of the physician. The development of highly technologic, tertiary, inpatient medical care has preoccupied the attention of our teaching institutions. Coping with the increased armamentarium of diagnostic and therapeutic interventions has distracted some physicians from traditional roles in patient care. The primary care movement has been a national response to this situation aimed at providing more physicians skilled in dealing wisely and humanely with illness in their patients and providing the overall supervision and continuity of medical care that we expect of good generalists. It encourages these physicians to know their patients as human and social beings as well as bearers of organ pathology. Promotion of prevention as well as the practice of curing is an important part of primary care. The concerns that have led to renewed attention of the medical profession to primary care medicine have had a very salutary effect on our teaching institutions. There has been a resurgence of training in the ambulatory setting. Medical students and residents have learned that many illnesses formerly thought to require hospitalization can be effectively managed in the ambulatory setting. As usual, this is not an original discovery; rather, it is a return to the emphasis that was very much a part of training programs in the earlier decades of this century. Primary Care Medicine has grown out of the experiences of a group of young physicians who have pioneered in the rebirth of primary care medicine within the Harvard medical community. They have organized primary care practices that have served as training sites for other physicians and health workers. They have examined their own practices, as well as the published experience of others, in order to provide within this text a synthesis of the best available information for ambulatory manage ment of adult medical patients. Their discussions are brief and practical rather than exhaustive, but the interested reader is provided with a key annotated bibliography that directs him to further sources of information. This book is not meant to compete with the traditional exhaustive textbook of Medicine. Rather, its brief, clear discussions and analyses of current knowledge are prepared for the busy practitio ner who daily encounters many problems for which he needs to quickly know the best available answers. To whom is the book addressed? To the primary care physician, of course. It will be his bible—a valuable source of guidance and of solace in innumerable management situations. But it is becoming increasingly evident that the medical subspecialist devotes a considerable portion of his practice time to the provision of first contact and continuous care of the medical needs of his patients. This book will, therefore, find a welcome place on the desk of both the medical subspecialist and the medical generalist and is addressed to everyone engaged in the clinical practice of adult Medicine. Alexander Leaf, MD Jackson Professor of Medicine

Harvard Medical School Chief, Medical Services Massachusetts General Hospital Boston, Massachusetts April 1981

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ACKNOWLEDGMENTS

A lthough Primary Care Medicine is principally a work by primary care physicians for primary care physicians and clinician team members, it depends on contributions from our specialty colleagues, both in internal medicine and in the nonmedical specialties pertinent to adult primary care. We want to acknowledge the superb efforts of our specialty section editors for this edition in authoring chapters and, in some instances, also coordinating contributions from their colleagues. • • James M. Richter, MD—Gastroenterology • • Jeffrey W. Clark, MD—Oncology • • David M. Slovik, MD—Endocrinology • • Annekathryn Goodman, MD—Gynecology • • L. Elizabeth Lincoln, MD—Medical Gynecology • • Amy A. Pruitt, MD—Neurology We are also grateful to Nancy Ridenour, PhD, Dean of the Goldfarb College of Nursing at Barnes Jewish College for her contributions on team-based care and the Web site’s interprofessional curricu lum for team-based care coauthored with Leigh H. Simmons, MD, of Massachusetts General Hospital. Over the preceding 40 years and seven editions of Primary Care Medicine , innumerable individuals have contributed generously to this textbook. Given the importance of their past contributions to the collective effort that goes into preparation of each new edition, we have always acknowledged those who completed their assignments with publication of the previous edition. We remain most grateful to them and list below their names and the chapters they authored or coauthored: • • Shana Birnbaum (Chapter 111. Approach to the Woman with Abnormal Vaginal Bleeding; Chapter 112. Evaluation and Symptomatic Management of Secondary Amenorrhea; Chapter 114. Evaluation of Vulvar Pruritus; Chapter 116. Approach to the Patient with Pelvic Pain; Chapter 117. Approach to the Patient with an Abnormal Vaginal Discharge; Chapter 118. Approach to the Menopausal Woman; Chapter 121. Approach to the Woman with an Unplanned Pregnancy) • • Francis Campion (Chapter 61. Approach to the Patient with Heartburn and Reflux (Gastroesopha geal Reflux Disease) • • Ann H. Johnson, John Kwon, Richard J. de Asla (Chapter 154. Approach to Common Problems of the Foot and Ankle) • • Carolyn Crimmins Hintlian (Chapter 233. Approach to Eating Disorders) • • Claus Hamann (Chapter 239. Primary Care Geriatrics—Optimizing Cognitive and Physical Func tion in Older Adults and Caring for the Vulnerable) • • Nicole L. Herschenhous (Chapter 230. Approach to the Patient with Somatic Symptoms and Behav ioral Disturbance: Somatic Symptom Disorder) • • Lindsay Y. King (Chapter 68. Management of Peptic Ulcer Disease) • • William A. Kormos (Chapter 52. Outpatient Approach to Acute Lower Respiratory Tract Infec tion—Acute Bronchitis and Pneumonia; Chapter 219. Approach to the Patient with Sinusitis; Chap ter 220. Approach to the Patient with Pharyngitis) • • David A. Lovas (Chapter 230. Approach to the Patient with Somatic Symptoms and Behavioral Dis turbance: Somatic Symptom Disorder) • • Kenneth L. Minaker (Chapter 239. Primary Care Geriatrics—Optimizing Cognitive and Physical Function in Older Adults and Caring for the Vulnerable) • • Deanna D. Nguyen (Chapter 73. Management of Inflammatory Bowel Disease) • • Scott L. Rauch (Chapter 227. Approach for the Patient with Depression) • • Jason S. Rothman (Chapter 202. Evaluation of Dry Eyes) We want to acknowledge and express our gratitude for the professionalism and commitment to pub lishing quality of our colleagues at Lippincott Williams & Wilkins, particularly editors Sharon Zinner and Rebecca Gaertner, assisted by the valued efforts of Cody Adams, Thomas Celona, and Arunmozhi varman Shenbagakutti. We are fortunate to have such a fine publisher and publishing teams over these many years and many editions. Last but not least, our deepest thanks to our Harvard Medical student reviewers Andrew Foley, Danika Barry, Jun Lieu, and the late Mark Herzog. Mark was reviewing page proofs on top of a mountain in New Zealand the night before sustaining a tragic life-ending fall. • • Peter C. Schalock, MD—Dermatology • • Claudia U. Richter, MD—Ophthalmology • • Neil Bhattacharyya, MD—ENT • • Jenny S. Sauk (Chapter 64. Evaluation and Management of Diarrhea) • • Sonia S. Yoon (Chapter 59. Evaluation of Nausea and Vomitinga)

CONTENTS

Contributors viii Preface xiii Foreword to the First Edition xiv Acknowledgments xv

Chapter 15 Screening for Hyperlipidemia and

Associated Coronary Heart Disease Risk Factors 102

Chapter 16 Infective Endocarditis Prophylaxis 109

Chapter 17 Prevention of Rheumatic Fever and Rheumatic Heart Disease 112

SECTION I Principles of Primary Care

SECTION III Cardiovascular Problems

Chapter 1

The Purpose and Practice of Primary Care 1

Chapter 18 Primary Prevention of Coronary Heart Disease 115

Chapter 2

Selection and Interpretation of Diagnostic Tests 9 Health Maintenance and the Role of Screening 18 Estimating and Communicating Risk and Prognosis 23

Appendix 18-1: Medical Screening of Potential Exercisers 127

Chapter 3

Appendix 18-2: The Exercise Prescription 130

Chapter 4

Chapter 19 Evaluation of Hypertension 134

Chapter 5

Choosing among Treatment Options 26

Chapter 20 Evaluation of Chest Pain 144

Chapter 6

Immunization 29

Chapter 21 Evaluation of the Asymptomatic Systolic Murmur 158

Appendix 6-1: Vaccination for Travel 44

Chapter 22 Evaluation of Leg Edema 164

SECTION II Systemic Problems

Appendix 22-1: Screening for Occult Malignancy in Persons with Unprovoked Deep Vein Thrombosis 171 Appendix 22-2: Evaluation for Upper Extremity DVT 172

Chapter 7

Screening for HIV Infection 47

Chapter 8

Evaluation of Chronic Fatigue 50

Chapter 9

Evaluation of Weight Loss 56

Chapter 23 Evaluation of Arterial Insufficiency of the Lower Extremities 172

Chapter 10 Evaluation of Overweight and Obesity 62

Chapter 24 Evaluation of Syncope 178

Chapter 11 Evaluation of Fever 70

Chapter 25 Evaluation of Palpitations 187

Appendix 25-1: Evaluation of Atrial Fibrillation in the Outpatient Setting 195

Chapter 13 Approach to the Patient with Human Immunodeficiency Virus (HIV) Infection 85

Chapter 26 Management of Hypertension 200

Chapter 27 Approach to the Patient with a Lipid Disorder 221

Chapter 14 Screening for Hypertension 99

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Contents

Chapter 28 Outpatient Management of Atrial Fibrillation 247

Chapter 43 Evaluation of Pleural Effusions 425

Chapter 44 Evaluation of the Solitary Pulmonary Nodule 431

Chapter 29 Management of Ventricular Irritability in the Ambulatory Setting 262

Appendix 44-1: Evaluation of Multiple Incidental Pulmonary Nodules 436

Chapter 30

Management of Chronic Stable Angina 273

Chapter 31 Secondary Prevention of Coronary Heart Disease after a Recent Acute Coronary Syndrome 296 Chapter 32 Approach to the Patient with Chronic Congestive Heart Failure 310

Chapter 45 Evaluation of Clubbing 436

Chapter 46 Approach to the Patient with Obstructive Sleep Apnea 439 Chapter 47 Management of Chronic Obstructive Pulmonary Disease 447

Appendix 32-1: Managing Disorders of Serum Potassium in Congestive Heart Failure 332

Chapter 48 Management of Asthma 468

Chapter 49 Approach to the Patient with Tuberculosis 489

Chapter 33 Management of Valvular Heart Disease 334

Appendix 49-1: Approach to the Patient With Nontuberculous Mycobacterial Lung Disease 496

Appendix 33-1: Approach to Hypertrophic Cardiomyopathy and Patent Foramen Ovale 347

Chapter 50 Approach to Acute Uncomplicated Respiratory Tract Infection 497

Chapter 34 Management of Peripheral Artery Disease (PAD) 350 Chapter 35 Management of Peripheral Venous Disease 357 Chapter 36 Noninvasive Studies for Coronary Heart Disease 370

Chapter 51 Management of Sarcoidosis 504

Appendix 55-1: Evaluation of Interstitial Lung Disease 508

Chapter 52 Outpatient Approach to Acute Lower Respiratory Tract Infection— Acute Bronchitis and Pneumonia 514 Chapter 53 Approach to the Patient with Lung Cancer 529

Appendix 36-1: Perioperative Medical Evaluation 382

SECTION IV Respiratory Problems

Chapter 54 Smoking Cessation 537

Appendix 54-1: Pulmonary Consequences of Other Forms of Smoking 545

Chapter 37 Screening for Lung Cancer 395

Chapter 38 Tuberculosis Screening and Prophylaxis 399

SECTION V Gastrointestinal Problems Chapter 55 Screening and Case Finding for Gastrointestinal Cancers 547

Chapter 39 Evaluation and Prevention of

Chapter 56 Screening for Colorectal Cancer 550

Chapter 40 Evaluation of Chronic Dyspnea 410

Appendix 56-1: Examination of the Anorectum and Sigmoid Colon with Digital Rectal Examination, Anoscopy, and Sigmoidoscopy 556

Chapter 41 Evaluation of Subacute and Chronic Cough 415

Chapter 42 Evaluation of Hemoptysis 422

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Contents

Chapter 57 Screening for and Prevention of Viral Hepatitis 560

Chapter 75 Management of Diverticular Disease 716

Chapter 76 Management of Gastrointestinal Cancers 720

Chapter 58 Evaluation of Abdominal Pain 570

Appendix 58-1: Management of the Abdominal Aortic Aneurysm 581

SECTION VI Hematologic and Oncologic Problems

Chapter 59 Evaluation of Nausea and Vomiting 582

Chapter 60 Evaluation of Dysphagia and Suspected Esophageal Chest Pain 588 Chapter 61 Approach to the Patient with Heartburn and Reflux (Gastroesophageal Reflux Disease) 593

Chapter 77 Screening for Anemia 739

Chapter 78 Screening for Sickle Cell Disease and Sickle Cell Trait 741

Chapter 79 Evaluation of Anemia 743

Chapter 62 Evaluation of Jaundice 600

Chapter 80 Evaluation of Erythrocytosis (Polycythemia) 754

Appendix 62-1: Evaluation of the Asymptomatic Patient with an Incidental Elevation in a Liver Function Test 603

Appendix 80-1: Other Myeloproliferative Disorders—Primary Myelofibrosis 758

Chapter 63 Evaluation of Gastrointestinal Bleeding 607 Chapter 64 Evaluation and Management of Diarrhea 612 Chapter 65 Approach to the Patient with Constipation 626 Chapter 66 Approach to the Patient with Anorectal Complaints 632 Chapter 67 Approach to the Patient with an External Hernia 640

Chapter 81 Evaluation of Bleeding Problems and Abnormal Bleeding Studies 759

Chapter 82 Management of Common Anemias 771

Appendix 82-1: Management of Asplenia 778

Chapter 83 Outpatient Oral Anticoagulant Therapy 780 Chapter 84 Approach to the Patient with Lymphoma 790

Chapter 85 Approach to the Patient with Metastatic Cancer of Unknown Primary Origin 801

Chapter 68 Management of Peptic Ulcer Disease 643

Chapter 86 Approach to Staging and Monitoring 807

Chapter 69 Management of Asymptomatic and Symptomatic Gallstones 655

Chapter 87 Comprehensive Care of the Cancer Patient 810

Chapter 70 Management of Hepatitis 661

Appendix 87-1: Cancer Prevention 816

Appendix 70-1: Recommended Direct Acting Antiviral (DAA ) Programs for Hepatitis C Virus Infection 680

Chapter 88 Principles of Cancer Drug Therapy 818

Chapter 89 Principles of Radiation Therapy 829

Chapter 90 Assessment and Relief of Chronic Cancer Pain and Palliative Care 834 Chapter 91 Managing the Gastrointestinal Complications of Cancer and Cancer Treatment 848 Chapter 92 Complications of Cancer: Oncologic Emergencies, Malignant Effusions, and Paraneoplastic Syndromes 854

Chapter 72 Management of Pancreatitis 691

Chapter 73 Management of Inflammatory Bowel Disease 695 Chapter 74 Approach to the Patient with Functional Gastrointestinal Disease 707

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Contents

SECTION VII Endocrinologic Problems

Chapter 111 Approach to the Woman with Abnormal Vaginal Bleeding 991

Chapter 112 Evaluation and Symptomatic Management of Secondary Amenorrhea 998

Chapter 93 Screening for Type 2 Diabetes Mellitus 861

Appendix 93-1: Screening for Gestational and Type 1 Diabetes 868

Chapter 113 Evaluation of Breast Masses and Nipple Discharges 1005

Chapter 94 Screening for Thyroid Cancer 870

Chapter 114 Evaluation of Vulvar Pruritus 1009

Chapter 95 Evaluation of Thyroid Nodules 872

Chapter 115 Medical Evaluation of Female Sexual Dysfunction 1013 Chapter 116 Approach to the Patient with Pelvic Pain 1017

Chapter 96 Approach to the Patient with Hypercalcemia 879

Chapter 97 Evaluation of Hypoglycemia 885

Chapter 98 Evaluation of Hirsutism 890

Appendix 116-1: Premenstrual Syndrome/Premenstrual Dysphoric Disorder 1022

Appendix 98-1: Approach to an Incidentally Encountered Adrenal Mass 895

Chapter 117 Approach to the Patient with an Abnormal Vaginal Discharge 1024

Chapter 99 Evaluation of Gynecomastia 897

Chapter 118 Approach to the Menopausal Woman 1030

Chapter 100 Evaluation of Galactorrhea and Hyperprolactinemia 901 Chapter 101 Evaluation of Suspected Diabetes Insipidus 905 Chapter 102 Approach to the Patient with Diabetes Mellitus 908

Appendix 118-1: Evaluation of Flushing 1038

Chapter 119 Approach to Fertility Control 1039

Chapter 120 Approach to the Infertile Couple 1049

Chapter 103 Approach to the Patient with Hyperthyroidism 940 Chapter 104 Approach to the Patient with Hypothyroidism 949

Chapter 121 Approach to the Woman with an Unplanned Pregnancy 1057

Chapter 122 Management of Breast Cancer 1063

Chapter 123 Management of the Woman with Genital Tract Cancer 1076

Chapter 105 Glucocorticoid Therapy 959

SECTION VIII Gynecologic Problems

SECTION IX Genitourinary Problems

Chapter 106 Screening for Breast Cancer 967

Chapter 124 Screening for Syphilis 1083

Chapter 107 Screening for Cervical Cancer 975

Chapter 125 Screening for Chlamydia and Gonorrhea Infection 1086

Chapter 109 Screening for Endometrial Cancer 984

Chapter 126 Screening for Prostate Cancer 1090

Chapter 110 Screening for and Prevention of Intimate Partner Violence 987

Chapter 127 Screening for Asymptomatic Bacteriuria and Urinary Tract Infection 1095

Appendix 110-1: Screening for Firearm Risk 989

Chapter 128 Screening for Urothelial Cancers 1098

Contents

Chapter 129 Evaluation of the Patient with Hematuria 1101 Chapter 130 Evaluation of the Patient with Proteinuria 1107

Chapter 145 Evaluation of Acute Monoarticular Arthritis 1217

Chapter 146 Evaluation of Polyarticular Complaints 1221

Chapter 131 Evaluation of Scrotal Pain, Masses, and Swelling 1113 Chapter 132 Medical Evaluation and Management of Erectile Dysfunction 1116 Chapter 133 Approach to Dysuria and Urinary Tract Infections in Women 1130

Chapter 147 Approach to the Patient with Back Pain 1233

Chapter 148 Evaluation of Neck Pain 1251

Chapter 149 Approach to the Patient with Muscle Soreness or Cramps 1255 Chapter 150 Approach to the Patient with Shoulder Pain 1259

Apendix 133-1: Evaluation of Sterile Pyuria 1140

Chapter 151 Evaluation of Hip Pain 1266

Chapter 134 Approach to Urinary Incontinence 1141

Chapter 152 Evaluation of Knee Pain 1271

Chapter 135 Approach to the Patient with Nephrolithiasis 1150

Chapter 153 Approach to Minor Orthopedic Problems of the Elbow, Wrist, and Hand 1278 Chapter 154 Approach to Common Problems of the Foot and Ankle 1283

Chapter 136 Approach to the Male Patient with Urethritis 1157 Chapter 137 Approach to the Patient with Gonorrhea 1161 Chapter 138 Approach to Benign Prostatic Hyperplasia 1165 Chapter 139 Management of Acute and Chronic Prostatitis 1170 Chapter 140 Management of Urinary Tract Infection in Men 1176 Chapter 141 Management of Syphilis and Other Sexually Transmitted Diseases 1181 Chapter 142 Management of the Patient with Chronic Kidney Disease 1185 Appendix 139-1: Urine and Prostatic Fluid Collections in Men 1175

Chapter 155 Approach to the Patient with

Asymptomatic Hyperuricemia 1289

Chapter 156 Management of Rheumatoid Arthritis 1293

Chapter 157 Management of Osteoarthritis 1313

Chapter 158 Management of Gout 1325

Chapter 159 Approach to the Patient with Fibromyalgia 1334

Chapter 160 Approach to the Patient with Lyme Disease 1343

Chapter 161 Approach to the Patient with

Polymyalgia Rheumatica or Giant-Cell (Temporal) Arteritis 1353

Chapter 143 Management of Genitourinary Cancers 1195

Chapter 162 Management of Paget Disease 1360

SECTION X Musculoskeletal Problems

Chapter 163 Approach to the Patient with Raynaud Phenomenon 1364

Chapter 164 Prevention and Management of Osteoporosis 1369

Chapter 144 Screening for Osteoporosis in Postmenopausal Women 1213

Appendix 164-1: Management of Osteoporosis in Men 1384

Appendix 144-1: Screening for Osteoporosis in Men 1216

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