Family Medicine: Principles and Practice

Description

Since the publication of the 7th edition of this book, there has been a remarkable increase in information in several clinical areas, including cardiology, immunology and oncology.  This rapid knowledge expansion has led to practice changes for family physicians and other primary care providers.  Patients are now discharged from tertiary care hospitals to their home communities with life sustaining left ventricular assist “heart pumps”. Hepatitis C, once an incurable illness, is now routinely cured. Oncology treatment regimens are increasingly becoming ambulatory and individualized. The decreased cost and increasing availability of health monitoring devices will make it possible for physicians to remotely check on the health status of their patients in their homes. With the ongoing and worsening shortage of family physicians across the US, the practice model for family medicine in the future may tend toward a family physician supervising a cast of mid-level providers as they care for a panel of patients, versus the physician providing the majority of care.  All of these changes will require practice pattern changes and a need for up to date sources of information for the family physician.  In addition, the “family” of family medicine academic organizations is undertaking a major review of the practice, training, funding and evaluation of all aspects of family medicine. Eight family medicine organizations have launched the “Family Medicine for America’s Health” (FMAHealth) with the expressed purpose “to strategically align work to improve practice models, payment, technology, workforce and education, and research to support the triple aim”.  This project has moved past the study phase and will soon move to the implementation phased.  This book is organized into short, focused chapters almost exclusively dedicated to topics relevant to daily practice. All lead authors are themselves accomplished family physicians who can specifically address the needs, concerns, and interests of this crucial profession. As one of the key reference textbooks for family medicine, it is very important to provide the most up-to-date knowledge to support learners and practitioners of family medicine in the face of rapidly expanding clinical knowledge and the extensive self-examination of family medicine. Family Medicine: Principles and Practice, 8th Edition, is a must-have reference for medical students, residents, practicing physicians, nurse practitioners and physician assistants with an active role in patient care. Preface to the Eighth Edition Preface to the First Edition Acknowledgments Contents Contributors Abbreviations Part I: The Principles of Family Medicine 1 Family Medicine: Fifty Years of Caring for America A Short History of the Specialty Family Medicine as a Social Movement Family Medicine as a Defense of General Practice Family Medicine as a Reform Movement Within Medicine The Evolution of Family Medicine Family Medicine in the United States in 2020 Family Medicine and General Practice Around the World Academic Principles of Family Medicine Access Continuity Comprehensiveness Care Coordination Contextual Care Current Challenges and Future Practice The Unsustainable Cost of Health Care Commercialization of Medicine Sustaining Family Medicine as a Desirable Specialty Choice Information Technology and the Tension Between Personal Care and Population Health Globalization and Global Health Disparities Caring for the World Important Internet Sites References 2 Culture, Race, and Ethnicity Issues in Health Care The Context of Race, Ethnicity, and Culture Race Ethnicity Culture Population Demographic Shifts Health Status of Black or African Americans Health Status of Hispanics Health Status of American Indians and Alaska Natives Health Status of Asian-Pacific Americans Health Equity Special Populations Health Status of LGBT People Creating a Welcoming Environment LGBT Youth LGBT Elderly Health Maintenance and Screening Health Status of Deaf People Sociocultural Norms Language Barriers Health Status of Refugee Populations Common Presenting Problems Healthcare Issues of Spiritual and Religious Culture Approach to Spirituality in the Clinical Encounter Spiritual Screening Obtaining a Spiritual History Spiritual Assessment and Plan Approach to the Cross-Cultural Clinical Encounter Special Considerations Language and Working with Medical Interpreters Health Literacy Time References 3 Family Issues in Health Care Role of the Family in Health and Illness Challenges to Family-Centered Care The Role of the Family in Health-Care Reform Family-Centered Care Genograms Meeting with Family Members Principles of Family Interviewing Confidentiality Conclusion References 4 Family Stress and Counseling Introduction Theoretical Frameworks of Stress and Health Family Systems Theory Framework Mind-Body-Environment Framework Health Belief Framework Developmental Life-Cycle Framework Family Response to Crisis Framework Effects of Stress on Health Acute Stress Chronic Stress Counseling Strategies for Patients and Families Individual Treatment Approaches Motivational Interviewing Solution-Focused Brief Therapy Cognitive Behavioral Therapy Mindfulness Based Stress Reduction Family Treatment Approaches Family Psychoeducation Intergenerational Approach Group Treatment Approaches Dialectical Behavioral Therapy Psychodynamic Group Therapy Psychoeducational Groups for Families Caregiver Well-Being Healthcare Team Approach References 5 Population-Based Health Care Introduction What Is Population Health? Why Population Health? Population Medicine Individual Providers and Practices Population Health Management Health Systems, Provider Networks, and Accountable Care Organizations Population Health Community Health and Social Determinants Public Health Health Policy References Part II: Preventive Care 6 Clinical Prevention Healthy People 2020 Leading Health Indicators Screening Evidence in Clinical Prevention Health Maintenance Key Recommendations from the US Preventive Services Task Force (USPSTF) and Advisory Committee on Immunization Practices (ACIP) Prevention for Infants, Children, and Adolescents (Birth to 18 Years) Immunization Prophylaxis Counseling and Anticipatory Guidance Prenatal Screening Prevention at Ages over 18 Years Immunization Prophylaxis Counseling and Anticipatory Guidance Screening Adhering to Prevention Guidance: Barriers to Care Barriers to Provider Adherence Barriers to Patient Adherence Strategies to Improve Adherence to Prevention Guidance Special Considerations in Underserved Populations Special Considerations in Teaching Practices References 7 Health Promotion and Wellness Physical Activity Benefits of Physical Activity Physical Activity Recommendations Exercise Types/Intensity Sedentary Behavior Physical Activity Assessment and Exercise Prescriptions Nutrition Diet Types Nutrition Assessment Nutrition Prescriptions A Note on Vitamins and Supplements Motivational Interviewing Stress Management Tobacco Cessation Alcohol Consumption Alcohol Use Screening Importance of Well-Being to the Health Care Professional References 8 Health Care of the International Traveler Introduction Pre-Trip Consultation History Intake Routine Vaccinations Travel-Related Vaccinations Hepatitis A Hepatitis B Typhoid Yellow Fever Polio Meningococcus Japanese Encephalitis Rabies Traveler´s Diarrhea Prophylaxis Malaria Prophylaxis Mefloquine Doxycycline Malarone Primaquine Tafenoquine Personal Protective Measures Altitude Illness Prophylaxis Safety and Accident Prevention Emerging Diseases Post-Trip Consultation Fever in Returned Traveler GI Illness in Returned Traveler Skin Lesions in the Returned Traveler Eosinophilia Tuberculosis Screening in the Returned Traveler Reentry for Long-Term Travelers: Psychological Concerns References Part III: Pregnancy, Childbirth, and Postpartum Care 9 Preconception Care Preconception and Interconception Care Defined Ongoing Problem of Perinatal Morbidity and Mortality Need to Address Risks Prior to Pregnancy CDC Recommendations on Preconception Health Barriers Opportunities in Primary Care History Past Medical History Previous Obstetrical History Family History Social History Medication History Environmental History Physical Examination Nutritional Status The Obesity Epidemic Standard Nutritional Recommendations Vaccine Preventable Infections Sexually Transmitted Infections (STIs) Laboratory Evaluation Strategies for the Prevention of Adverse Birth Outcomes The Reproductive Life Plan Reducing Disparities Novel Approaches to Preconception Care Preconception Care and the Family Preconception Issues for Men Key Preconception Care Partnerships and Resources References 10 Normal Pregnancy, Labor, and Delivery Prenatal Care First Trimester Health Promotion/Counseling Prenatal Screening Common Screening Tests in Pregnancy Second Trimester Health Promotion/Counseling Second Trimester Screening Third Trimester Health Promotion/Counseling Third Trimester Screening Fetal Assessment Labor and Delivery Three Stages of Labor Stage One Stage Two Stage Three Support during Labor Intrapartum Analgesia Delivery References 11 Medical Problems During Pregnancy Introduction Respiratory Disorders Asthma Influenza Cardiovascular Disease Chronic Hypertension Infectious Disease Urinary Tract Infection HIV Viral Hepatitis Hepatitis A Hepatitis B Hepatitis C Cervicitis Genital Herpes Simplex Syphilis Varicella Zoster Tuberculosis Endocrine Disorders Diabetes Mellitus Pregestational Diabetes Gestational Diabetes Thyroid Disorders Hypothyroidism Hyperthyroidism Hematologic Disorders Iron Deficiency Anemia Gestational Thrombocytopenia Venous Thromboembolism Neurologic Disorders Epilepsy Migraine Headache Musculoskeletal Disorders Low Back Pain Carpal Tunnel Syndrome Psychiatric Disorders Depression Special Considerations Substance Use Disorders Obesity Bariatric Surgery and Pregnancy Diagnostic Imaging During Pregnancy References 12 Obstetric Complications During Pregnancy Spontaneous Abortion Epidemiology Etiology Diagnosis Prevention Management Ectopic Pregnancy Epidemiology Etiology Diagnosis Prevention Management Hypertensive Disorders of Pregnancy Epidemiology Etiology Diagnosis Prevention Management Placenta Previa Epidemiology Etiology Diagnosis Prevention Management Preterm Labor and Delivery Epidemiology Etiology Diagnosis Prevention Management References 13 Problems During Labor and Delivery Introduction Trial of Labor and Vaginal Birth After Cesarean Section Background Uterine Rupture Approach to the Patient Management Indications for Cesarean Delivery Breech Delivery Background General Principles Management Bleeding Complications During Labor General Principles Placental Abruption Placenta Previa Placenta Accreta Vasa Previa Premature Rupture of Membranes and Preterm Premature Rupture of Membranes General Principles Diagnosis Treatment Postterm Pregnancy General Principles Management Labor Dystocia General Principles Approach to the Patient Diagnosis Management/Prevention Infection Group B Streptococcal Disease Background Management/Prevention Intra-amniotic Infection General Principles Diagnosis Treatment Meconium-Stained Amniotic Fluid General Principles Management Shoulder Dystocia General Principles Diagnosis Management Prevention Assisted Vaginal Delivery General Principles Approach to the Patient Technique Cord Prolapse General Principles Diagnosis Prevention Management References 14 Postpartum Care Introduction Immediate Postpartum Care The Golden Hour: Maternal-Infant Bonding Immediate Postpartum Contraception Promotion of Breastfeeding Contraindications to Breastfeeding Important Noncontraindications Postpartum Complications Postpartum Hemorrhage Postpartum Gestational Hypertension, Preeclampsia, and Eclampsia Postpartum Infection Postpartum Preventive Care Immunization RhoGAM Postpartum Office Visit Postpartum Contraception Postpartum Contraceptive Options Postpartum Depression Postpartum Thyroid Dysfunction Postpartum Venous Thromboembolism Health Equity and Standardization of Maternity Care References Part IV: Care of the Infant, Child, and Adolescent 15 Genetic Disorders Introduction Basic Science of Genetics Terminology Family History Taking/Genogram Common Chromosomal and Genetic Disorders Types of Genetic Testing Clinical Testing Direct-to-Consumer Testing Result Interpretation Pharmacogenomics CYP450 PGx Guidelines Common Clinical Examples PGx Testing Clinical PGx Implementation and a Path Forward Cancer Genetics Cancer Genetic Risk Assessment Genetic Risk Reduction Epigenetics Counseling Considerations Ethics and Privacy Laws The Future of Genetics in Primary Care References 16 Problems of the Newborn and Infant Newborn Resuscitation Stabilization for Transfer to Higher Level of Care Giving Bad News to Parents After Delivery Common Problems in the Nursery Respiratory Distress Late Preterm Infants Small for Gestational Age Large for Gestational Age Neonatal Sepsis Neonatal Jaundice Primary Prevention Secondary Prevention Assessment Laboratory Assessment Treatment Hypoglycemia Metabolic Disorders Anemia Polycythemia Birth Injuries Human Immunodeficiency Virus (HIV) Infection in Newborns and Infants Guidelines for Early Hospital Discharge of the Newborn Well-Child Visits Nutrition and Feeding Breastfeeding Vitamin D Supplementation Infant Formula Advancing the Infant Diet Infant Colic Failure to Thrive Fever Neonates (0-28 Days) Ill-Appearing Infants (29-90 Days) Well-Appearing Infants (29-60 Days) Infants 61-90 Days Old Infants 3-36 Months Old Sudden Infant Death Syndrome Brief Resolved Unexplained Event Other Common Problems of the Infant Family and Community Issues Perinatal Depression Child Care Family Violence Substance-Exposed Infants Adolescent Parents References 17 Infectious Diseases in Children Introduction Common Cold General Principles Definition/Background Epidemiology Approach to the Patient Diagnosis, History, and Physical Examination Differential Diagnosis Treatment Immunizations and Chemoprophylaxis Prevention Family and Community Issues Common Pediatric Viral Exanthems General Principles Definition Classification Diagnosis History and Physical Examination Measles Epidemiology Patient Approach Clinical Presentation Complications Treatment Prevention Rubella Epidemiology Patient Approach Clinical Presentation Complications Treatment and Prevention Varicella (Chickenpox) Epidemiology Patient Approach Clinical Presentation Complications Treatment Prevention Roseola Infantum (Exanthema Subitum or Sixth Disease) Epidemiology Patient Approach Clinical Presentation Lab Investigations Complications Treatment and Prevention Erythema Infectiosum (Fifth Disease) Epidemiology Patient Approach Clinical Presentation Complications Treatment and Prevention Laryngotracheobronchitis Definition and Background Epidemiology Classification Patient Approach History Physical Examination Lab and Imaging Differential Diagnosis Treatment Epiglottitis Acute Gastroenteritis in Children Definition Epidemiology Differential Diagnosis Clinical Evaluation History and Physical Examination Lab Investigations Treatment Fluid Management Oral Rehydration Therapy Deficit Replacement Maintenance Fluids and Ongoing Losses Nutrition and Zinc Supplements Antibiotics Probiotics Prevention and Vaccination Kawasaki Disease Definition/Background Epidemiology History and Physical Examination Laboratory and Imaging Treatment Medications\Immunizations and Chemoprophylaxis, Referrals, and Counseling Patient Education and Activation Prevention Pinworms Epidemiology Transmission Clinical Presentation and Diagnosis History and Physical Examination Laboratory and Imaging Treatment Prevention References 18 Behavioral Problems of Children General Principles Attention Deficit Hyperactivity Disorder Epidemiology Diagnostic Considerations [8] Treatment of ADHD Pharmacological Treatments Behavioral Treatments for ADHD Learning Disabilities, Specific Learning Disorders, and Learning Difficulties General Principles Specific Learning Disorders (SLD) Diagnosis of Specific Learning Disorders Management of the Child with SLD Disruptive, Impulse Control, and Conduct Disorders General Principles Diagnostic Considerations Treatment Anxiety and Specific Phobias Diagnostic Considerations Treatment Tics Diagnostic Considerations Management of Tics Thumb Sucking Pica General Principles Diagnostic Considerations Management Temper Tantrums General Principles Diagnostic Considerations Management and Prevention Sleep Disturbances General Principles Management References 19 Musculoskeletal Problems of Children Generalized Musculoskeletal Conditions Common Fracture Patterns Physeal Fractures Buckle Fractures Plastic Deformation Fractures Greenstick Fractures Apophyseal Avulsion Fractures Stress Fractures Apophyseal Injuries (Apophysitis) Apophysitis of the Hip Sinding-Larsen-Johansson Syndrome Osgood-Schlatter Disease Sever´s Disease Osteochondritis Dissecans Growing Pains Regional Musculoskeletal Conditions Neck and Back Problems Spondylolysis and Spondylolisthesis Idiopathic Scoliosis Scheuermann Disease Elbow Problems Osteochondrosis of the Elbow Radial Head Subluxation Gait Abnormalities Normal Gait and Alignment Metatarsus Adductus Tibial Torsion Femoral Anteversion Genu Varus Blount´s Disease Genu Valgus Hip Problems Developmental Dysplasia of the Hip Transient Synovitis Septic Hip Slipped Capital Femoral Epiphysis Legg-Calve-Perthes Disease Foot Problems Toe Walking Talipes Calcaneovalgus Talipes Equinovarus Pes Cavus Flexible Versus Rigid Flatfoot Tarsal Coalition Freiberg Disease Kohler Disease References 20 Selected Problems of Infancy and Childhood Developmental Surveillance Approach to the Infant or Child with Motor Delay Speech Development and Speech Delay Cognitive Impairment Oral Health Pediatric Autoimmune Neuropsychiatric Disorders Associated with Group A Streptococcal Infections (PANDAS) Lead Poisoning References 21 Health Care of the Adolescent References Part V: Care of the Elderly 22 Selected Problems of Aging General Principles Definition/Background Selected Clinical Issues Frailty Pathophysiology Diagnosis Management Constipation Types and Risk Factors Evaluation Management of Constipation Nonpharmacological Management Pharmacological Management Sleep-Related Disorders in Elderly Social and Functional Issues Community-Based Assistive Services and Living Arrangements Assistive Services Alternative Living Arrangements How to Help Seniors Understand Medicare Medicare Structure Medicare Finances Covered Services Assessing Older Drivers References 23 Common Problems of the Elderly Urinary Incontinence Types of Urinary Incontinence Transient Urinary Incontinence Established Urinary Incontinence Evaluation of Urinary Incontinence Treatment of Urinary Incontinence Falls Orthostatic Hypotension Polypharmacy Strategies for Appropriate Prescribing Underutilization (Underprescribing) Pain Management WHO Analgesic Ladder Opioids Neuropathic Agents Nutrition Nutritional Assessment Treatment of Nutritional Deficiencies Pressure Ulcers Assessment and Staging of Pressure Ulcers Treatment of Pressure Ulcers Dressings Transitions of Care Determining Support Needs Community Supports Healthcare Resources Levels of Care Home Living Supportive Living Facility Living Older Drivers Evaluating Older Drivers References 24 Alzheimer Disease and Other Dementias General Principles Definition/Epidemiology Approach to the Patient History and Physical Examination Lab/Imaging Treatment Prevention and Early Detection Medications Behavioral/Psychological Issues End-Stage Dementia Summary References 25 Elder Abuse General Principles Definition and Background Categories of Abuse Risk Factors Challenges to Identification Patient-Related Challenges Physician-Related Challenges Assessment History and Physical Examination Management and Reporting Guidelines Prevention Conclusion References 26 Care of the Very Elderly Functional Impairment of Older Adults Sensory Impairment Nutrition Mobility Mood Sleep Continence Cognition Geriatric Syndromes End of Life and Goals of Care References Part VI: Family Conflict and Violence 27 Child Abuse and Neglect Introduction Prevention Neglect Medical Neglect Educational Neglect Pediatric Undernutrition Physical Abuse Patterns of Injury Fractures Abusive Head Trauma Sexual Abuse Sex Trafficking Emotional Abuse Witness to Abuse Bullying Medical Child Abuse Identification and Referral Documentation and Reporting Summary References 28 Intimate Partner Violence Background Prevalence Cycle of Abuse Subtypes of IPV Physical Violence Sexual Violence Stalking Psychological Aggression Consequences of IPV Special Populations and Considerations LGBTQ Couples Pregnant Women Children Teens HIV Immigrants Disabled Persons Public Health and Economic Burden Prevention Screening Management Resources Safety Plans Documentation Reporting References 29 Sexual Assault Introduction Occurrence Impact Female Victims Male Victims Intimate Partner Violence The Family Physicians´ Role Care of the Victim STI Prevention Emotional Reactions and Psychological Sequelae Follow-Up Prevention Conclusion References Part VII: Behavioral and Psychiatric Problems 30 Managing Mentally Ill Patients in Primary Care General Principles Definition/Background Epidemiology Approach to the Patient Diagnosis History Physical Examination Laboratory and Imaging Differential Diagnosis Treatment Medications\Immunizations and Chemoprophylaxis Referrals Community Mental Health Agencies Counseling Patient Education and Activation Prevention Family and Community Issues References 31 Anxiety Disorders Separation Anxiety Disorder Selective Mutism Specific Phobias Social Anxiety Disorder (Social Phobia) Panic Disorder Agoraphobia Generalized Anxiety Disorder Other Anxiety Disorders Obsessive-Compulsive and Related Disorders Trauma- and Stressor-Related Disorders Reactive Attachment Disorder Disinhibited Social Engagement Disorder Post-Traumatic Stress Disorder (PTSD) Screening Tools for Anxiety Disorders Treatment Complementary and Alternative Methods Yoga Exercise Acupuncture Mindfulness Summary References 32 Mood Disorders Epidemiology Risk and Prognostic Factors Diagnostic Criteria Depressive Disorders Bipolar and Related Disorders Bipolar I Disorder Bipolar II Disorder Cyclothymic Disorder Suicide Differential Diagnosis Treatment Principles Treatment Biologic Therapies Depressive Disorders Selective Serotonin Reuptake Inhibitors Serotonin-Norepinephrine Reuptake Inhibitors Tricyclic Antidepressants and Monoamine Oxidase Inhibitors Other Antidepressants Augmentation Alternative/Complementary Options Bipolar and Related Disorders Acute Treatment Maintenance Treatment Depression Bipolar Disorder Psychological Therapies Physician-Administered Counseling Strategies Other Non-pharmacological Interventions Social Treatments Opiate Use in Depressed Patients Special Populations Children and Adolescents Older Adults Pregnant and Lactating Women References 33 The Suicidal Patient General Principles Definition/Background Epidemiology Approach to the Patient Diagnosis History Risk Factors Protective Factors Laboratory and Imaging Special Testing Treatment Behavioral Medication Prevention Identification General Considerations Therapeutic Considerations Inpatient Considerations Follow-Up Care Emerging Environmental and Other Considerations Family and Community Issues References 34 Somatic Symptom and Related Disorders General Principles Introduction Epidemiology Etiology of Somatization Biological Factors Environmental and Social Factors Approach to the Patient Diagnosis Differential Diagnosis Treatment Psychotherapy Cognitive Behavioral Therapy Mindfulness-Based Therapy Pharmacotherapy Cultural Considerations to Treatment Planning References 35 Selected Behavioral and Psychiatric Problems General Principles Definition/Background Eating Disorders Anorexia Nervosa Diagnosis Treatment Prognosis Bulimia Nervosa Diagnosis Treatment Prognosis Binge-Eating Disorder Personality Disorders Cluster A Personality Disorders Paranoid Personality Disorder Schizoid Personality Disorder Schizotypal Personality Disorder Cluster B Antisocial Personality Disorder Borderline Personality Disorder Histrionic Personality Disorder Narcissistic Personality Disorder Cluster C Avoidant Personality Disorder Dependent Personality Disorder Obsessive-Compulsive Personality Disorder Management in the Family Medicine Practice References 36 Anxiety and Stress in Young Adults General Principles and Background Epidemiology Etiology Clinical Presentation Differential Diagnosis Evaluation for Anxiety Disorders Treatment Options Cognitive Behavioral Therapy Medications Other Commonly Used Medications for Treatment of Chronic Anxiety Alternative Therapies for Anxiety and Stress in Young Adults Useful Resources for Young Adult Patients References 37 Developmental Disability Across the Lifespan Introduction Role of the Family Physician in Team-Based Care Improving Outcomes with Prenatal Counseling and Care Genetic Counseling and Testing Manage Environmental Risks and Health-Related Behaviors Population-Based Developmental Screening for Children Assessment Diagnostic Evaluations Functional Evaluations Communication Evaluations Psychoeducational or Neuropsychological Assessments Effective Communication with Families Tips for Breaking Diagnostic News Practical Problem-Solving Caregiver Assessment and Support Early Intervention Prevention and Treatment of Co-occurring and Secondary Conditions Abuse and Neglect/Trauma Transition to Adulthood Aging with a Developmental Disability References Part VIII: Allergy 38 Common Allergic Disorders Allergic Rhinitis General Principles Definition and Background Epidemiology Classification Approach to the Patient Diagnosis History Physical Examination Laboratory and Imaging Special Testing Differential Diagnosis Treatment Behavioral and Family Issues Environmental Measures Medications Approach to Pharmacologic Treatment and Combination Medication Use Oral Antihistamines Intranasal Corticosteroids Intranasal Antihistamines Oral Decongestants Nasal Decongestants Oral Leukotriene Antagonists Immunotherapy Referrals Counseling and Patient Education Prevention Family and Community Issues References 39 Anaphylaxis Definition Epidemiology Pathogenesis Triggers Food Medications Venoms Anesthesia/Perioperative Exercise Diagnosis Clinical Criteria [1] History Essential History to Obtain in the Evaluation of a Patient with an Anaphylaxis Episode Physical Exam Ancillary Studies Differential Diagnosis Management of Anaphylaxis Primary Treatment Secondary Treatment Discharge Plan Follow-up Plan Prevention Confirmation of Anaphylaxis Triggers References Part IX: Infectious Diseases 40 Epstein-Barr Virus Infection and Infectious Mononucleosis General Principles Background Epidemiology Classification Approach to the Patient Diagnosis History Physical Examination Laboratory and Imaging Special Testing Differential Diagnosis Treatment Behavioral Medications\Immunizations and Chemoprophylaxis Referrals Counseling Patient Education and Activation Prevention Family and Community Issues References 41 Viral Infections of the Respiratory Tract Definition/Background Epidemiology Etiology Transmission Pathogenesis Laboratory Testing Testing Methods [9] Common Cold Definition/Background Etiology/Spread Prognosis Epidemiology Clinical Manifestations Diagnosis Treatment Complications [13] Laryngitis Definition/Background Approach to the Patient Treatment Influenza Definition/Background Clinical Manifestations Treatment Prevention Acute Bronchitis Definition/Background Approach to the Patient Treatment Coronavirus Infections Human Coronavirus Types [7] Other Human Coronaviruses (Causing More Severe Respiratory Disease) COVID-19 Definition/Background Clinical Presentation New and Emergent Respiratory Infections [39] SARS Etiology, Epidemiology, and Clinical Presentation MERS Etiology, Epidemiology, and Clinical Presentation Pandemic Influenza 2009 Etiology, Epidemiology, and Clinical Presentation Prevention Family and Community Issues References 42 Sinusitis, Tonsillitis, and Pharyngitis Sinusitis Epidemiology Risk Factors Microbiology Clinical Presentation Diagnosis Physical Exam Diagnostic Imaging and Laboratory Studies Treatment Antimicrobial Therapy Chronic Rhinosinusitis Tonsillitis and Pharyngitis Epidemiology Etiologies Infectious Inflammatory Clinical Presentation of GAS Tonsillopharyngitis Laboratory Diagnosis Complications of GAS Tonsillopharyngitis Suppurative Complications Nonsuppurative Complications Treatment of GAS Tonsillopharyngitis Chronic Carriers and Asymptomatic Contacts Tonsillectomy References 43 Sexually Transmitted Diseases General Principles Definition/Background Chlamydial Infection Screening Clinical Presentation Diagnosis Treatment Pregnancy Sexual Partners Gonorrhea Screening Clinical Presentation Diagnosis Treatment Penicillin/Cephalosporin Allergy Pregnancy Sexual Partners Trichomoniasis Screening Clinical Presentation Diagnosis Treatment Pregnancy Sexual Partners Pelvic Inflammatory Disease Clinical Presentation Diagnosis Treatment Parenteral Treatment Outpatient Treatment Options Penicillin Allergy Sexual Partners Syphilis Screening Clinical Presentation Primary Syphilis Secondary Syphilis Tertiary Syphilis Neurosyphilis Latent Syphilis Diagnosis Treatment Primary and Secondary Syphilis Tertiary Syphilis Neurosyphilis Latent Syphilis Pregnancy Sexual Partners Genital Warts Clinical Presentation Diagnosis Treatment Topical Condyloma Treatments: Patient Applied Topical Condyloma Treatments: Provider Applied Pregnancy Prevention Genital Herpes Screening Clinical Presentation Diagnosis Treatment Pregnancy Sexual Partners STD Prevention References 44 Human Immunodeficiency Virus Infection and Acquired Immunodeficiency Syndrome Natural History Screening and Diagnosis HIV Testing Symptoms by HIV Stage Acute HIV Infection Asymptomatic HIV Infection AIDS Medical Management Pre-exposure Prophylaxis (PrEP) Acute or Suspected Exposure (Post Exposure Prophylaxis [PEP]) Evaluation of Patients with HIV HAART Management of the Immunocompromised Patient Prophylaxis HIV Wasting and Fatigue Skin and Mucosa Eyes Pulmonary Cardiac Blood and Lymph GI Tract and Liver Renal Musculoskeletal Neurologic System/CNS HIV in Children HIV in Women HIV and Aging Summary of HIV for Family Physicians References 45 Bacteremia and Sepsis General Principles Public Health and Economic Burden Definitions and Classification Approach to the Patient Diagnosis Laboratory Workup and Imaging Differential Diagnosis Treatment Prevention Family and Community Issues References 46 Selected Infectious Diseases Toxoplasmosis Etiology and Epidemiology Clinical Features Laboratory Diagnosis Treatment Trichinellosis Etiology and Epidemiology Clinical Features Laboratory Diagnosis Treatment Prevention Lyme Disease Etiology and Epidemiology Clinical Presentation Treatment Ebola and Marburg Virus Etiology and Epidemiology Clinical Presentation Laboratory Diagnosis Treatment Prevention Hantaviruses Etiology and Epidemiology Clinical Presentation Laboratory Findings Treatment Prevention Giardia Etiology and Epidemiology Clinical Presentation Laboratory Diagnosis Treatment Rocky Mountain Spotted Fever (RMSF) Epidemiology Clinical Features Laboratory Diagnosis Treatment Prevention References 47 Epidemics and Pandemics Introduction Detection Surveillance Response Investigation Infrastructure and Organization Control Strategies Stopping Versus Slowing the Spread Treatment Practice Preparedness Opportunities in the Broader Response Ethical Considerations References Part X: Environmental and Occupational Health Problems 48 Occupational Health Care Introduction From Antiquity to Nanotechnology Practice Overview Epidemiology Legal Underpinnings and Entities Worker´s Compensation (WC) Occupational Health and Safety Administration National Institute of Occupational Safety and Health Americans with Disabilities Act (ADA) Family and Medical Leave Act (FMLA) General Approach to the Evaluation of the Worker The Standard for Documentation The Systematic Injury History Medications and Substances An Objective Physical Examination The Occupational History Psychosocial Factors General Approach to the Treatment of the Worker Communication Medications Return to Work Representative Occupational Medicine Challenges Conditions: Musculoskeletal Injuries Conditions: Infectious Exposures Conditions: Chemical and Environmental Exposures Latex Allergy Building-Related Illness Mold Specific Types of Occupational Examinations Post-hire, Preplacement Examinations Fit for Duty, Return to Work Examinations Commercial Driver Examinations Basic Med FAA Examinations Comprehensive Occupational Health Programs References 49 Problems Related to Physical Agents Heat Definitions Epidemiology Diagnosis Treatment Patient Education Cold Hypothermia Background Definition Treatment Patient Education Nonfreezing Cold Injury (NFCI) and Frostbite Background Definitions Approach to the Patient Radiation Classification History Patient Education and Counseling Ultraviolet Light Background History and Physical Examination Patient Education Electrical Injury Background Approach to the Patient Noise Background Counseling Carbon Monoxide Background Diagnosis Treatment Counseling References Part XI: Injury and Poisoning 50 Bites and Stings Mammalian Bites Clinical Presentation Diagnosis Management Prophylactic Antibiotics Established Infections Rabies Prophylaxis Prevention Family and Community Issues Spider Bites Clinical Presentation Diagnosis Management Prevention Hymenoptera Stings Clinical Presentation Management Prevention Snakebite Clinical Presentation Diagnosis Management Prevention Other Arthropods Clinical Presentation Diagnosis Management Prevention Marine Animal Stings Clinical Presentation Diagnosis Management Prevention References 51 Poisoning Introduction Signs and Symptoms Diagnosis Point-of-Care Testing Laboratory Evaluation Decontamination Gastric Emptying Ipecac Activated Charcoal Acetaminophen Pharmacokinetics Clinical Presentation Management Antidepressants: Tricyclic Antidepressants (TCAs) Pharmacokinetics Clinical Presentation Management Antidepressants: Selective Serotonin +/- Norepinephrine Reuptake Inhibitors (SSRIs/SNRIs) Pharmacokinetics Clinical Presentation Management Aspirin/Salicylates Pharmacokinetics Clinical Presentation Management Opiates Pharmacokinetics Clinical Presentation Management Disposition Prevention References 52 Care of Acute Lacerations Introduction Skin Anatomy and Wound Healing Wound Closure Indications/Contraindications to Primary Closure Injectable Anesthesia Wound Preparation and Further Assessment Suture Characteristics Simple Interrupted Closure Simple Running Closure Intradermal Running Closure Two-Layer Closure Horizontal Mattress Suture Vertical Mattress Suture Half-Buried Mattress Suture Dog-Ear Repair Alternatives to Sutures Tissue Adhesives Staples Adhesive Strips Antibiotics Coding and Billing References 53 Selected Injuries Drowning and Submersion Injury General Principles Definition/Background Epidemiology Approach to the Patient History Physical Exam Treatment Prevention Barotrauma General Principles Definition/Background Approach to the Patient Diagnosis History Physical Examination Laboratory and Imaging Treatment Prevention Burns General Principles Definition/Background Partial-Thickness Burns Full-Thickness Burns Approach to the Patient Physical Examination Determination of Percent Total Body Surface Area (%TBSA) Treatment Partial-Thickness Burn Full-Thickness Burn Fluid Resuscitation Prevention Swallowed Foreign Body General Principles Definition/Background Approach to the Patient Diagnosis History Physical Examination Laboratory and Imaging Treatment Prevention Fishhook Removal General Principles Treatment Removal Prevention References Part XII: Care of the Athlete 54 Medical Problems of the Athlete Introduction Physical Activity Guidelines Approach to the Athlete as a Patient Exercise Physiology Overtraining Syndrome Chronic Disease Medical Problems Asthma Cardiac Diabetes Hematological Disease Anemias Hemoglobinopathies Skin Tinea Corporis Gladiatorum Herpes Gladiatorum Tinea Pedis Staphylococcus and Streptococcus Nail Dystrophies Talon Noir/Mogul´s Palm Special Populations Women Elderly Pediatrics Transgender References 55 Athletic Injuries Introduction General Injury Management General Fracture Management Concussion Introduction Physical Exam Imaging Management Acute Back Pain History Physical Exam Imaging Management Rotator Cuff Injuries History Physical Exam Imaging Management Shoulder Instability History Physical Examination Imaging Treatment Bicep Tendon Ruptures History Physical Exam Imaging Management Lateral Epicondylitis ``Tennis Elbow´´ History Physical Exam Imaging Management Scaphoid Fracture History Physical Imaging Management Boxer´s Fracture History Physical Imaging Management Mallet Finger History Presentation and Physical Exam Imaging Management Jersey Finger History Physical Imaging Management IT Band Syndrome History Physical Exam Imaging Treatment Patella Dislocation History Physical Exam Imaging Management Knee Ligament Sprains/Tears History Physical Imaging Management Meniscus Tear History Physical Exam Imaging Management Patellofemoral Pain Syndrome Introduction Physical Exam Imaging Treatment Achilles Tendon Rupture History Physical Exam Imaging Management Achilles Tendinopathy History Physical Exam Imaging Management Ankle Sprain History Physical Exam Imaging Management Proximal Fifth Metatarsal Fracture Introduction History Physical Exam Imaging Management References Part XIII: Common Clinical Problems 56 Care of the Patient with Obesity General Principles Management of the Patient with Obesity Clinical Management History Physical Exam Laboratory Testing Treatment Diet Physical Activity Behavioral Management Pharmacological Management of Obesity Surgical Management of Obesity References 57 Care of the Challenging Patient General Principles Definition/Background Epidemiology Approach to the Patient Diagnosis Treatment Family and Community Issues Closing References 58 Care of the Patient with Fatigue General Principles Background Epidemiology Approach to the Patient Diagnosis History Physical Examination Laboratory Testing and Imaging Treatment Cognitive Behavioral Therapy Graded Exercise Therapy Medication Referrals Patient Education and Activation Chronic Fatigue Syndrome in Children Chronic Fatigue Syndrome in Elderly Adults Chronic Fatigue Syndrome in Underrepresented Minority Populations Family and Community Issues Conclusion References 59 Care of the Patient with a Sleep Disorder General Principles Definition/Background Classification Sleep Disorders: The Clinical Spectrum The Insomnias Background Diagnosis Treatment The Sleep-Associated Breathing Disorders Background Diagnosis and Treatment Excessive Daytime Sleepiness (Other Hypersomnias) Circadian-Rhythm Sleep Disorders Parasomnias Sleep-Related Movement Disorders The Family Physician and Sleep Medicine Prevention Family and Community Issues References 60 Medical Care of the Surgical Patient Introduction Preoperative History Cardiac Assessment Surgical Risk Risk Stratification Functional Capacity Pulmonary Assessment Infection Assessment Endocarditis Prophylaxis Hematologic Assessment Prevention of Deep Vein Thrombosis General Surgery Orthopedic: Hip and Knee Arthroscopy and Hip Fracture Surgery Craniotomy and Spinal Surgery Preoperative Testing Electrocardiogram (EKG) Echocardiogram Noninvasive Cardiac Testing Chest Radiography Pulmonary Function Testing Electrolytes Urine Analysis Glucose Monitoring Complete Blood Count Coagulation Testing Perioperative Medications Beta Blockers Angiotensin-Converting Enzyme Inhibitor (ACE)/Angiotensin-Receptor Blockers (ARBs) Statins Antiplatelet Medications Anticoagulation Oral Hypoglycemic Agents Insulin Postoperative Monitoring References 61 Care of the Patient with Sexual Concerns Care of the Patient with Sexual Concerns Definition of Sexual Dysfunction Approach to the Patient with Sexual Concerns Sexual History Taking Physical Exam Labs and Other Testing Approach to Diagnosing Sexual Dysfunction Treating Sexual Dysfunction: General Principles Diagnosing and Treating Sexual Dysfunction in Women Diagnosing and Treating Sexual Dysfunction in Men Referrals References 62 Care of the Alcoholic Patient Overview Prevalence Screening Diagnosis Treatment of Alcohol Use Disorder Intermittent Abuse or Binge Drinking Chronic Alcohol Abuse and Dependence Alcohol Withdrawal Syndrome Treatment of AWS When Is Medically Supervised AWS Treatment Not Necessary? Outpatient Treatment of AWS Inpatient Treatment of AWS Reducing Symptoms Preventing Complications Alternative AWS Medications: Less Effective Outpatient BZD Dosing Options Inpatient Dosing Options Monitoring Withdrawal: Outpatient Monitoring Withdrawal: Inpatient Management of DTs Long-Term Management of Alcohol Dependence Levels of Care Psychosocial and Behavioral Interventions Pharmacologic Interventions Naltrexone Acamprosate Disulfiram Other Agents Other Interventions Emerging Interventions References 63 Care of the Patient with Chronic Pain Definition and Scope of Chronic Pain Treating Acute Pain Patient Assessment Types of Pain and Treatment Options Non-opioid Pharmacologic Treatments for Pain Muscle Relaxants Role of Opioids in Chronic Pain Mitigating Opioid Risks Discontinuation of Opioids Other Interventions for Pain Management Non-pharmacologic Modalities Quality of Life and the Chronic Disease Model References 64 Care of the Dying Patient General Principles Definition/Background Palliative Care and Hospice End-of-Life Patient Communication Prognosis at End of Life End-of-Life Pain Management Physical Pain Neuropathic Pain Bone Pain Grief and Depression Nausea and Vomiting Constipation Dyspnea Recommendation for the Final Hours Advanced Directives: Living Wills/Health Care Proxy/POLST Palliative Sedation, Physician-Assisted Suicide, and Euthanasia References 65 Care of the Refugee Definition Keller Stages of Refugee Experience Approaching the Refugee Patient Sexual and Reproductive Health Taking a History Mental Health and Mental Health History: Identifying PTSD, Depression, Anxiety Disorders, and Adjustment Disorders Infectious Diseases Nutrition Oral Health Trauma and Torture Chronic Pain Chronic Health Problems Addiction Cancer Screening Refugee Children Legal Considerations Establishing a Medical Home Prevention and Public Health Patient Education References 66 Substance Use Disorders Definition and Background SUD History and Primary Care Epidemiology Classification DSM-5 Criteria for Substance Use Disorders DSM-5 Diagnostic Criteria for Substance Use Disorders General Principles Approach to the Patient Screening, Brief Intervention, and Referral to Treatment Office-Based Opioid Treatment Diagnosis History Physical Examination Laboratory and Imaging Imaging Genetic Testing Special Testing: Adolescents Differential Diagnosis Treatment Behavioral Medications/Immunizations and Chemoprophylaxis Referrals Patient Education and Activation Community Issues: Prevention from a Community Perspective Special Populations References Part XIV: Nervous System 67 Headache General Principles Definition Epidemiology Classification Approach to the Patient Diagnosis General Interview Principles Patient History Migraines Tension-Type Headaches Cluster-Type Headaches Medication Overuse Headaches (MOH) Physical Examination Laboratory and Imaging Treatment General Approach Behavioral Approaches Medication Strategies for Migraine, Tension, Cluster, and Medication Overuse Headaches Migraine Treatment Tension-Type Headache (TTH) Treatment Cluster Headache Treatment Medication Overuse Headache (MOH) Treatment Complementary and Alternative Medicine (CAM) Conclusion References 68 Epilepsy Types of Seizures and Epilepsy Generalized Seizures Clinical Manifestations Generalized Seizures Absence Seizures Typical Absence Seizure Atypical Absence Seizures Generalized Tonic-Clonic (GTC) Seizures Myoclonic Seizures Atonic Seizures Focal Seizures Focal Seizures without Impairment of Consciousness Focal Seizures with Impairment of Consciousness Focal Seizures Evolving to Bilateral Convulsive Seizures Seizure Syndromes by Age Group Seizures in Neonates and Infants Benign Familial Neonatal Seizures Early Infantile Epileptic Encephalopathy (Ohtahara) Early Myoclonic Encephalopathy Infantile Spasms Benign Myoclonic Epilepsy of Infancy Seizures in Childhood Febrile Seizures Simple Febrile Seizure Complex Febrile Seizures Dravet Syndrome or Severe Myoclonic Epilepsy of Infancy (SEMI) Rolandic Epilepsy or Benign Epilepsy with Centro-Temporal Spikes (BECTS) Lennox Gastaut Syndrome (LGS) Landau Kleffner Syndrome Seizures in Adolescence Juvenile Myoclonic Epilepsy Management of Seizures History Neurological Exam Neuroimaging Electroencephalography (EEG) Video-EEG Monitoring Other Tests Medical Treatment Epilepsy Surgery Vagal Nerve Stimulation Deep Brain Stimulation (DBS) Responsive Neural Stimulation (RNS) Status Epilepticus Specific Conditions Sudden, Unexplained Death in Epilepsy (SUDEP) Women with Epilepsy First Seizure References 69 Cerebrovascular Disease General Principles Introduction Epidemiology Pathogenesis Ischemic Hemorrhagic Risk Factors Prevention of Cerebrovascular Disease Primary Prevention Strategies Ischemic Stroke and Transient Ischemic Attack (TIA) Transient Ischemic Attacks Ischemic Stroke Early Management of Patients with Acute Ischemic Stroke Blood Pressure Management Intravenous Thrombolysis Endovascular Treatment Antiplatelet Therapy Role of Other Therapies in Acute Setting Other Considerations Complications Secondary Prevention of Stroke Intracerebral Hemorrhage (ICH) Subarachnoid Hemorrhage (SAH) Rehabilitation of Patients with Stroke Key Considerations [53, 55] References 70 Movement Disorders Introduction Initial Diagnostic Considerations Importance of Movement Disorders Initial Work-up Parkinson Disease Clinical Presentation Physical Examination Differential Diagnosis Diagnosis and Initial Work-up Treatment Initial Monotherapy Motor Fluctuations Advanced and Surgical Treatment Prognosis Referral and Education Restless Leg Syndrome Clinical Presentation Physical Examination Diagnosis Differential Diagnosis Treatment Essential Tremors Differentiating Types of Tremors Clinical Presentation Differential Diagnosis Treatment and Prognosis Dystonia Clinical Presentation Differential Diagnosis Treatment Ataxia Clinical Presentation Diagnosis Other Clinical Diagnostic Considerations Treatment References 71 Disorders of the Peripheral Nervous System Background Evaluation Cranial Neuropathies Bell´s Palsy Trigeminal Neuralgia Mononeuropathies Carpal Tunnel Syndrome Cubital Tunnel Syndrome Radial Neuropathies Lumbosacral Neuropathies Meralgia Paresthetica Femoral Neuropathy Sciatic Neuropathy Peroneal Neuropathy Interdigital Neuralgia Polyneuropathies Thoracic Outlet Syndrome Brachial Plexus Lumbosacral Plexus Infectious Neuropathies Postherpetic Neuralgia Leprosy Hepatitis C Human Immunodeficiency Virus (HIV) Infection Lyme Disease Acute Inflammatory Demyelinating Polyradiculoneuropathy (Guillain-Barre Syndrome) Chronic Inflammatory Demyelinating Polyradiculoneuropathy Metabolic Neuropathies Diabetic Neuropathy Uremic Neuropathy Toxin Induced Nutritional Neuropathies Alcoholic Neuropathy Vitamin B1 (Thiamine) Deficiency Vitamin B6 (Pyridoxine) Deficiency and Toxicity Vitamin B12 Deficiency Vitamin E Deficiency Copper Deficiency Hereditary Neuropathies Treatment References 72 Selected Disorders of the Nervous System Meningitis Background Presentation Diagnosis History Physical Examination Cerebrospinal Fluid Examination Laboratory Testing and Imaging Treatment Course and Prognosis Special Considerations Chronic Meningitis Noninfectious Meningitis Prevention Encephalitis Background Presentation Diagnosis History and Physical Exam Laboratory Testing Imaging Treatment Course and Prognosis Brain Abscess Background Presentation Diagnosis Physical Exam Laboratory Studies Neuroimaging Treatment Antibiotic Therapy Neurosurgical Intervention Adjunctive Therapy Course and Prognosis Neurosyphilis Background Presentation Diagnosis Physical Exam Laboratory Studies Treatment Antimicrobial Treatment Special Considerations Brain Tumors Background Presentation Diagnosis Treatment Symptom Treatment Course and Prognosis Multiple Sclerosis Background Presentation Diagnosis History, Physical Exam, and Diagnostic Imaging Differential Diagnosis Treatment Disease-Modifying Agents Exacerbations Symptom-Specific Management Course and Prognosis References Part XV: The Eye 73 The Red Eye General Principles Definition/Background Conjunctivitis Bacterial Conjunctivitis History Physical Examination Laboratory Findings Treatment Viral Conjunctivitis History Physical Examination Laboratory Findings Treatment Family and Community Issues Chlamydial Conjunctivitis History Physical Examination Laboratory Findings Treatment Allergic Conjunctivitis History Physical Examination Laboratory Findings Treatment Keratoconjunctivitis Sicca History Physical Examination Laboratory Findings Treatment Other Causes of Red Eyes Corneal Abrasion/Corneal Foreign Body History Physical Examination Laboratory Findings Treatment Episcleritis History Physical Examination Laboratory Findings Treatment Scleritis History Physical Examination Laboratory Findings Treatment Iritis History Physical Examination Laboratory Findings Treatment Herpes Keratitis History Physical Examination Laboratory Findings Treatment Trichiasis History Physical Examination Laboratory Findings Treatment Acute Closed-Angle Glaucoma History Physical Examination Laboratory Findings Treatment Conclusion References 74 Ocular Trauma Introduction Ocular Examination Periocular Injuries Eyelid Lacerations Orbital Fractures Subconjunctival Hemorrhage Open Globe Injury Anterior Segment Injuries Corneal Abrasions and Non-Penetrating Foreign Bodies Ultraviolet Light Injury Traumatic Iritis and Hyphema Lens Injuries Posterior Segment Injuries Retinal Detachment and Vitreous Hemorrhage Retrobulbar Hemorrhage and Ocular Compartment Syndrome Chemical Injuries References 75 Selected Disorders of the Eye The Pupil The Eyelids Congenital Abnormalities Positional Abnormalities Entropion Ectropion Blepharoptosis Inflammation Blepharitis Hordeolum Chalazion Dermatitis Conjunctiva Subconjunctival Hemorrhage Pingueculum and Pterygium Lacrimal System Epiphora Dry Eye Dacryocystitis Dacryoadenitis Orbit Retina Arterial Occlusive Retinal Disease Venous Occlusive Retinal Disease Retinal Detachment Diabetic Retinopathy Nonproliferative Diabetic Retinopathy Proliferative Diabetic Retinopathy Amaurosis Fugax Ocular Migraine Macular Degeneration Dry Age-Related Macular Degeneration Neovascular Age-Related Macular Degeneration Optic Nerve Optic Disc Edema Pseudopapilledema Lens Glaucomas Primary Open-Angle Glaucoma Angle-Closure Glaucoma Oculomotor Motility Strabismus Amblyopia Optical Defects Refractive Disorders Accommodation Loss or Presbyopia References Part XVI: The Ear, Nose, and Throat 76 Otitis Media and Externa Acute Otitis Media Epidemiology Diagnosis Treatment Analgesia Antibiotic Therapy Observation Surgical Options Complications Prevention Otitis Externa Epidemiology Pathophysiology Diagnosis Treatment Complications Prevention Chronic Otitis Externa Malignant (Necrotizing) Otitis Externa References 77 Disorders of the Oral Cavity Caries Periodontal Diseases Gingivitis Periodontitis Candidiasis Stomatitis Lichen Planus Glossitis Halitosis Temporomandibular Disorders Oral Cancer Other Oral Lesions Bony Tori Mucocele Pyogenic Granuloma References 78 Selected Disorders of the Ear, Nose, and Throat Adult Hearing Loss General Principles Pathophysiology Evaluation and Diagnosis Treatment Prevention Pediatric Hearing Loss General Principles Pathophysiology Evaluation and Diagnosis Treatment Tinnitus General Principles Pathophysiology Evaluation and Diagnosis Treatment Prevention Salivary Gland Inflammation and Salivary Stones General Principles Pathophysiology Evaluation and Diagnosis Treatment Prevention Xerostomia General Principles Pathophysiology Evaluation and Diagnosis Treatment Hoarseness General Principles Pathophysiology Evaluation and Diagnosis Treatment Prevention Epistaxis General Principles Pathophysiology Evaluation and Diagnosis Treatment Prevention Foreign Bodies in the Ear and Nose General Principles Pathophysiology Evaluation and Diagnosis Treatment References Part XVII: The Cardiovascular System 79 Hypertension General Principles Detection and Diagnosis Approach to the Patient History Physical Examination Laboratory Tests and Diagnostic Procedures Secondary Causes Management Benefits of Treatment Nonpharmacologic Interventions Pharmacologic Treatment Diuretics ACE Inhibitors Angiotensin Receptor Antagonists Calcium Channel Blockers Beta-Blockers Central Acting Drugs Alpha-Blockers Vasodilators Special Considerations Hypertensive Emergency Hypertension Treatment in Older Adults ``Race´´-Based Treatment References 80 Ischemic Heart Disease General Principles Diagnosis History Physical Exam Electrocardiogram and Biomarkers Stress Testing and Cardiac Imaging Coronary Angiography Management Acute Coronary Syndrome Stable Ischemic Heart Disease References 81 Cardiac Arrhythmias Electrophysiology of the Heart Evaluation of Patients with Arrhythmia History and Physical Exam (H&P) Evaluation of Cardiac Arrhythmia Treatment Options for Cardiac Arrhythmia Cardioversion Antiarrhythmic Drug Therapy Ablation Therapy Pacemakers and Defibrillators Surgery Referral to Cardiologist Supraventricular Tachyarrhythmias (SVT) Atrial Fibrillation (AF) Anticoagulation Atrial Flutter Atrial or Sinus Tachycardia Frequent or Premature Atrial Contractions (PACs) Wolff-Parkinson-White (WPW) Syndrome Atrioventricular Arrhythmias Sick Sinus Syndrome (SSS) Also Known as Sinus Node Dysfunction (SND) Ventricular Arrhythmias (VA) Premature Ventricular Contractions, PVCs Ventricular Tachycardia (VT) Ventricular Fibrillation (VF) QT Interval Prolongation Torsades de Pointes Summary References 82 Valvular Heart Disease Introduction The Third Heart Sound The Fourth Heart Sound Physical Exam and Diagnostic Approach Physical Maneuvers Definitions of Severity of Valve Disease Stages of Valvular Heart Disease Key Points in Treatment Aortic Regurgitation (AR) Etiology Diseases of the Valve Diseases of the Aorta Diseases Affecting Aorta and Valve Symptoms and Physical Findings Diagnosis of Aortic Regurgitation Natural History, Complications, and Follow-Up Medical Therapy and Timing for Surgery Aortic Stenosis Etiology Symptoms and Physical Findings Diagnosis of Aortic Stenosis Natural History, Complications, and Follow-Up Medical Therapy and Timing for Surgery Hypertrophic Obstructive Cardiomyopathy Etiology Signs and Symptoms Physical Findings Natural History and Complications Medical Therapy and Timing of Surgery Mitral Stenosis Etiology Signs and Symptoms Physical Examination Natural History and Complications Medical Therapy and Timing of Surgery Mitral Regurgitation Etiology Signs and Symptoms Physical Examination Natural History and Medical Therapy Cardiovascular Evaluation of the Young Athlete References 83 Heart Failure Definition Epidemiology Classification Approach to the Patient Diagnosis History Physical Examination Laboratory and Imaging B-Type Natriuretic Peptide Electrocardiogram Chest Radiograph Cardiac Imaging Special Testing Differential Diagnosis Treatment Heart Failure with Reduced Ejection Fraction Diuretics Renin-Angiotensin System Inhibition Beta-Blockers Mineralocorticoid Receptor Antagonists Hydralazine and Isosorbide Ivabradine Digoxin New Therapies Awaiting Guideline Recommendation SGLT-2 Inhibitors Vericiguat Omecantiv Mecarbil How to Initiate Therapies Adverse Therapies Implantable Devices Cardiac Resynchronization Therapy Transcatheter Mitral Valve Repair Wireless Pulmonary Artery Pressure Cardiac Rehabilitation Heart Failure with Preserved Ejection Fraction Acute Heart Failure Referrals Counseling and Patient Education Prevention References 84 Cardiovascular Emergencies General Principles Cardiogenic Shock Pathophysiology Definition Management Cardiopulmonary Resuscitation (CPR) Aortic Dissection Classification Symptoms Diagnosis Management Type A Dissections Type B Dissections Cardiac Syncope Risk Factors for Serious Adverse Events After a Syncopal Episode History and Physical Exam Testing Management Sudden Cardiac Death Primary Prevention Secondary Prevention Hypertrophic Cardiomyopathy Definition Diagnosis Management References 85 Venous Thromboembolism Introduction Pathophysiology Epidemiology Diagnosis Clinical Approach D-Dimer Testing Compression Ultrasound (CUS) Venography Computed Tomographic Pulmonary Angiography (CTPA) Ventilation-Perfusion (V/Q) Scanning and V/Q SPECT Other Diagnostic Testing Management Initial Management Long-Term Anticoagulation Length of Therapy and Extended Anticoagulation Additional Therapy Prevention Superficial Vein Thrombosis and Superficial Thrombophlebitis References 86 Selected Disorders of the Cardiovascular System Peripheral Artery Disease Presentation and Diagnosis Differential Diagnosis Intervention Pericarditis Presentation and Diagnosis Differential Diagnosis Intervention Bacterial Endocarditis Presentation and Diagnosis Differential Diagnosis Intervention Prevention Cardiomyopathy Hypertrophic Cardiomyopathy (Genetic) Presentation and Diagnosis Intervention Arrhythmogenic Right Ventricular Cardiomyopathy (Genetic) Other Genetic Cardiomyopathies Dilated Cardiomyopathy (Mixed) Primary Restrictive Nonhypertrophied Cardiomyopathy (Mixed) Myocarditis (Acquired) Presentation and Diagnosis Intervention Stress-Induced (``Takotsubo´´) Cardiomyopathy (Acquired) Peripartum Cardiomyopathy (Acquired) Tachycardia-Induced Cardiomyopathy (Acquired) Pulmonary Hypertension and Cor Pulmonale Presentation and Diagnosis Differential Diagnosis Intervention References Part XVIII: The Respiratory System 87 Obstructive Airway Disease Asthma General Principles Definition/Background Epidemiology Classification Diagnosis History Physical Examination Laboratory and Imaging Special Testing Differential Diagnosis Treatment Medications/Immunizations and Chemoprophylaxis Referrals Counseling Patient Education and Activation Prevention Family and Community Issues Chronic Obstructive Pulmonary Disease General Principles Definition and Background Epidemiology Classification Diagnosis History Physical Examination Laboratory and Imaging Special Testing Differential Diagnosis Treatment Treatment of Chronic COPD Treatment of Acute COPD Exacerbations Prevention References 88 Pulmonary Infections Introduction Bacterial Pneumonia General Principles Definition/Background/Epidemiology Classification Approach to the Patient Diagnosis History Physical Exam Laboratory and Imaging Special Testing Differential Diagnosis Treatment Medications Patient Education Prevention Immunizations Atypical Pneumonias Mycoplasma Pneumoniae General Principles Approach to the Patient Diagnosis History and Physical Laboratory and Imaging: Special Testing Treatment Prevention Chlamydial Infection General Principles Approach to the Patient Diagnosis History and Physical Laboratory and Imaging: Special Testing Treatment Prevention Viral Pneumonia General Principles Epidemiology Transmission Approach to Patient Diagnosis History Physical Examination Treatment Family and Community Issues Tuberculosis General Principles Definition Epidemiology Classification Approach to the Patient Diagnosis Screening History/Physical Examination Laboratory/Imaging Treatment Family and Community Issues Histoplasmosis General Principles Definition/Background and Epidemiology Approach to the Patient Diagnosis History Physical Examination Laboratory and Imaging Special Testing Differential Diagnosis Treatment Medications Prevention and Patient Education Coccidioidomycosis General Principles Definition/Background and Epidemiology Approach to the Patient Diagnosis History and Physical Examination Laboratory and Imaging: Special Testing Treatment Prevention Legionnaire´s Disease General Principles Definition/Background Epidemiology Approach to the Patient Diagnosis History and Physical Examination Laboratory and Imaging Special Testing Differential Diagnosis Treatment Medications Immunizations and Chemoprophylaxis Prevention Family and Community Issues Mycobacterium Avium Complex General Principles Definition/Background and Epidemiology Approach to the Patient Diagnosis History and Physical Examination Laboratory and Imaging Special Testing Management Pneumocystis Pneumonia General Principles Definition/Background and Epidemiology Approach to the Patient Diagnosis History and Physical Laboratory and Imaging: Special Testing Treatment Prevention and Community Issues References 89 Lung Cancer General Principles Prevention Primary Prevention Cigarette Smoking Occupational and Environmental Exposure Nutrition and Exercise Genetics Secondary Prevention Classifications Diagnosis Clinical Presentation Diagnostic Approach Evaluating a Lung Nodule Staging Non-small Cell Lung Cancer Staging Small Cell Lung Cancer Treatment Non-small Cell Carcinoma Small Cell Carcinoma Posttreatment Follow-Up Palliative Care References 90 Selected Disorders of the Respiratory System Pulmonary Hypertension Diagnosis Management Pneumothorax Primary Spontaneous Pneumothorax Diagnosis Management Secondary Spontaneous Pneumothorax Diagnosis Management Tension Pneumothorax Family and Community Issues Pleural Effusion Diagnosis Transudative Effusions Exudative Effusions Management Family and Community Issues Interstitial Lung Disease Diagnosis Management Lung Cancer Subtypes Screening Diagnosis Family and Community Issues Pulmonary Sarcoidosis Diagnosis Management Family/Community Problems Vaping-Induced Pulmonary Injury Diagnosis Management Prognosis References Part XIX: The Digestive System 91 Gastritis, Esophagitis, and Peptic Ulcer Disease Dyspepsia/Epigastric Pain Epidemiology Presentation General Approach Gastroesophageal Reflux Disease Presentation Diagnosis Management Peptic Ulcer Disease Presentation Diagnosis Treatment Refractory Ulcers and Maintenance Therapy Gastritis/Gastropathy Upper Gastrointestinal Bleed Causes Diagnosis and Management Gastric Cancer References 92 Diseases of the Small and Large Bowel Infectious Diarrhea Viral Gastroenteritis Bacterial Infections Traveler´s Diarrhea Clostridioides difficile Infection (CDI) Parasitic Infections Protozoa Helminths Structural Diseases Diverticular Disease General Principles Clinical Presentation Diagnosis Management Microscopic Colitis General Principles Etiology, Risk Factors, and Associated Diseases Clinical Presentation and Diagnosis Treatment Inflammatory Bowel Disease General Principles Clinical Presentation Crohn´s Disease Ulcerative Colitis Workup Laboratory Diagnosis Management A Stepwise Approach to Treatment Corticosteroids 5-Aminosalicylic Acids Immunomodulators Biologicals Microbiome Therapies Surgery Additional Primary Care Considerations Malabsorption General Principles Presentation and Workup Procedures and Imaging Treatment Irritable Bowel Syndrome General Principles Clinical Presentation Diagnosis Management References 93 Diseases of the Pancreas Acute Pancreatitis Background Etiology Diagnosis Clinical Features Laboratory Tests Imaging Differential Diagnosis Treatment Severity Prediction Fluid Therapy Nutrition Pain Management Antibiotics Causative Therapy Complication Management Chronic Pancreatitis Background Etiology Diagnosis Clinical Features Laboratory Tests Imaging Classification Differential Diagnosis Treatment Pancreatic Cysts Background Clinical Features Diagnosis Management Intraductal Papillary Mucinous Neoplasm Mucinous Cystic Neoplasm Pancreatic Cancer Background Clinical Features Diagnosis Staging Management Exocrine Pancreatic Insufficiency Background Etiology Clinical Features Diagnosis Treatment References 94 Diseases of the Liver Viral, Alcoholic, and Drug-Induced Liver Disease Hepatitis A Clinical Presentation and Diagnosis Management Prevention Hepatitis B Clinical Presentation and Diagnosis Management Prevention Hepatitis C Clinical Presentation and Diagnosis Management Prevention Other Viral Agents Alcoholic Hepatitis Clinical Presentation and Diagnosis Management Prevention Drug-Induced Liver Disease HIV Liver Disease Hepatocellular Carcinoma Clinical Presentation and Diagnosis Management Prevention Family Issues of Diseases of the Liver Conclusion References 95 Diseases of the Rectum and Anus Anatomy of the Rectum and Anal Canal Hemorrhoids Background Epidemiology Classification Diagnosis History Examination, Special Testing Treatment: Non-operative Office Procedures In-Hospital Surgery External Hemorrhoids Nonhemorrhoidal Anorectal Diseases Anal Fissure Epidemiology and Classification Diagnosis Treatment Anorectal Abscess Pathogenesis and Classification Diagnosis Treatment Anorectal Fistula Pathogenesis and Classification Diagnosis Treatment Anal Incontinence Background Diagnosis Treatment Rectal Prolapse Background Diagnosis Treatment Pruritus Ani Background Causes Diagnosis Treatment Infectious Proctitis Background Diagnosis Treatment Hidradenitis Suppurativa Background Diagnosis Treatment Condyloma Acuminatum Background Diagnosis Screening, Prevention, and Treatment Anal Canal Cancers References 96 Colorectal Cancer General Principles Risk Factors Polyps Genetics Lynch Syndrome Familial Adenomatous Polyposis Other Hereditary Syndromes Tobacco Alcohol Comorbidities Obesity Diabetes Mellitus Pathogenesis Approach to the Patient Choosing a Screening Modality Stool-Based Screening Radiographic-Based Screening Endoscopic-Based Screening Serum-Based Screening Average Risk Screening Increased Risk Screening Overview of Colonoscopy Procedure Bowel Preparations Colonoscopy Overview Quality Metrics for Colonoscopy Workup of Individual Suspected of Colorectal Cancer TMN and Anatomic Stage Treatment Endoscopic Therapy Surgery Chemotherapy and Radiation Postoperative Surveillance Prognosis Prevention Diet Lifestyle Medications Family and Community Issues References 97 Surgical Problems of the Digestive System Abdominal Pathology Some Key Terms and Maneuvers Evaluation of Patients with Abdominal Pathology History Physical Examination Additional Testing: Laboratory Tests Additional Testing: Imaging Preparing the Patient for Surgery Preoperative Testing Resuscitation Perioperative Glucose Control Laparoscopic Surgery Etiology of Acute Abdominal Pain in Patients Seeking Emergency Care Life-Threatening Causes Abdominal Trauma Background Diagnosis Management Appendicitis Background Diagnosis: History and Examination Diagnosis: Investigations Appendicitis: Differential Diagnosis Appendicitis: Treatment Cholelithiasis and Cholecystitis Background Pathophysiology Diagnosis: History and Examination Diagnosis: Investigations Differential Diagnosis Cholecystitis: Treatment Acalculous Cholecystitis Special Situations Oral Dissolution of Cholelithiasis Inguinal Hernia Background Hernia- Anatomy Inguinal Hernia: Types, Diagnosis, and Complications Differential Diagnosis Inguinal Hernia: Treatment Complications Bowel Obstruction Background Diagnosis: History and Examination Investigations Bowel Obstruction: Treatment Surgical Problems of the Digestive System: Prevention References 98 Selected Disorders of the Digestive System Acute Diarrheal Illness General Principles Approach to Patient Diagnosis Treatment Viral Infections Bacterial Infections Salmonella Enterohemorrhagic Escherichia coli (EHEC) Clostridioides Difficile Prevention/Family and Community Issues Ischemic Bowel Syndromes General Principles Approach to Patient Diagnosis Treatment Acute Mesenteric Ischemia Acute SMA Occlusion Acute Mesenteric Venous Thrombosis Nonocclusive Disease Chronic Mesenteric Ischemia Prevention and Family and Community Issues Food Allergy General Principles Approach to Patient Diagnosis Treatment Prevention/Family and Community Issues Lactose Intolerance General Principles Approach to Patient Diagnosis Treatment Prevention/Family and Community Issues Marine Poisoning General Principles Approach to Patient Diagnosis Treatment Prevention/Family and Community Issues Botulism General Principles Approach to Patient/Diagnosis Treatment Prevention/Family and Community Issues References Part XX: The Renal, Urinary, and Male Genital Systems 99 Urinary Tract Infections Asymptomatic Bacteriuria UTI in Children Diagnosis Urinalysis and Culture Imaging Evaluation Management UTI in Pregnancy Acute Uncomplicated Lower UTI in Young Women Acute Uncomplicated Pyelonephritis in Young Women Complicated UTIs Recurrent Infections (Cystitis) in Women UTIs in Younger Men Catheter-Associated UTIs Chronic UTIs in the Elderly UTI in Patients with Spinal Cord Injuries Fungal UTIs Laboratory Guides and Interpretation Pyuria Bacteriuria Urine Culture References 100 Fluid, Electrolyte, and Acid-Base Disorders Volume Overview Volume Depletion Volume Excess Sodium Disorders Hyponatremia Hypernatremia Potassium Disorders Hypokalemia Hyperkalemia Acid-Base Disorders Metabolic Acidosis Metabolic Alkalosis Respiratory Acidosis Respiratory Alkalosis Mixed Acid-Base Disturbances Miscellaneous Electrolyte Disturbances Magnesium Phosphate Calcium References 101 Diseases of the Kidney Glomerulonephritis Acute Proliferative Glomerulonephritis/Poststreptococcal Glomerulonephritis Immunoglobulin A Nephropathy Lupus Nephritis Rapidly Progressive Glomerulonephritis (RPGN) Type 1 RPGN Type 2 RPGN Type 3 RPGN Nephrotic Syndrome Clinical and Laboratory Features Etiology and Work Up Minimal Change Disease Focal Segmental Glomerulosclerosis Membranous Nephropathy Membranoproliferative Glomerulonephritis Treatment Tubulointerstitial Diseases of the Kidney Autosomal Dominant Polycystic Kidney Disease (ADPKD) Chronic Interstitial Nephritis (CIN) Acute Kidney Injury Intrinsic Renal AKI Contrast Induced AKI (CI-AKI) Postrenal AKI AKI Risk Factors Diagnostic Evaluation Prevention and Treatment of AKI Follow Up Care CKD CKD Definition and Detection Etiology Treatment Renal Cell Carcinoma Transitional Cell Carcinoma Bladder Cancer Wilms´ Tumor References 102 Benign Prostate Conditions Lower Urinary Tract Symptoms Prostatic Hyperplasia Prostatitis Acute Bacterial Prostatitis Chronic Bacterial Prostatitis Chronic Nonbacterial Prostatitis References 103 Prostate Cancer Introduction Screening African-American Men Family History of Prostate Cancer Interpreting Prostate-Specific Antigen Role of Digital Rectal Examination Diagnosis Prostate Biopsy Staging and Risk Stratification Role of Magnetic Resonance Imaging Atypical Lesions on Biopsy Treatment Survivorship Active Surveillance Vs. Watchful Waiting Monitoring after Prostate Cancer Treatment Quality of Life Prevention Risk Factors Chemoprevention When to Refer to Urology References 104 Surgery of the Male Genital Tract Neonatal Circumcision Undescended Testis Testicular Torsion Vasectomy References 105 Selected Disorders of the Genitourinary System Scrotal Mass Nontesticular Masses Hydrocele and Indirect Inguinal Hernia Varicocele Spermatocele and Epididymal Cyst Epididymitis Testicular Masses Testicular Torsion Acute Orchitis Testicular Cancer Epidemiology and Risk Factors Screening Pathology Diagnosis and Evaluation Treatment Complications of Treatment Urothelial Tumors (Bladder Cancer) Epidemiology and Risk Factors Pathology Location Screening Diagnosis and Staging Treatment Urolithiasis Epidemiology Etiology Evaluation Approach to Management Antispasmodics Analgesia Surgical Management Metabolic Evaluation Treatment Hyperoxaluria Hypercalciuria Hypocitraturia Hyperuricosuria Prevention of Urolithiasis References Part XXI: The Female Reproductive System and Womens Health 106 Family Planning, Birth Control, and Contraception Contraceptive Use in the United States What Are the Most Popular Contraceptive Methods? Teen Contraceptive Use Provider Tools CDC- US MEC WHO Medical Eligibility Criteria for Contraceptive Use The Family Planning National Training Center (FPNTC) Association of State and Territorial Health Officials (ASTHO)1 Non-English Resources for Patients Long-Acting Reversible Contraceptives (LARC) Intrauterine Device (IUD) Subdermal Contraceptive Implant Contraindications Other Considerations Injectables Emergency Contraception Combined Hormonal Contraceptives General Guidelines for Combined Hormonal Contraceptives Barrier Methods Condoms: Male and Female Diaphragm and Cervical Cap Spermicides Permanent Contraceptive Methods: Tubal Sterilization and Vasectomy Natural Family Planning References 107 Vulvovaginitis and Cervicitis Acute Cervicitis Chronic Cervicitis Office Evaluation Treatment Follow-up Special Populations Vaginitis Inflammatory Vaginitis Trichomoniasis Vulvovaginal Candidiasis Diagnosis of VVC Treatment of VVC Noninflammatory Vaginitis Bacterial Vaginosis Atrophic Vaginitis or Genitourinary Syndrome of Menopause (GSM) Desquamative Inflammatory Vaginitis (DIV) Other Causes of Inflammatory Vaginitis Approach to the Patient References 108 Menstrual Disorders Premenstrual Disorders Amenorrhea and Oligomenorrhea Primary Amenorrhea Outflow Tract Abnormalities Gonadal Anomalies Hypothalamic and Pituitary Causes Secondary Amenorrhea Hypothalamic Pituitary Axis Dysmenorrhea Abnormal Uterine Bleeding Polycystic Ovarian Syndrome (PCOS) References 109 Menopause Overview The Female Reproductive Life Span and the Menopausal Transition Stages of the Menopausal Transition Late Reproductive Years Early Menopause Transition Late Menopausal Transition Final Menstrual Period and Early Postmenopause Late Postmenopause Laboratory Testing Epidemiology Systemic Effects of Menopause Vasomotor Symptoms Sleep Disturbances Urogenital Changes Cognitive Changes Mood Changes Skin and Hair Changes Cardiovascular Disease Osteopenia and Osteoporosis Menopause Treatment Overview Hormone Therapy Indications Effectiveness of Hormone Therapy Formulations Risks of Hormone Therapy Contraindications Duration Monitoring Intravaginal Hormonal Therapy Bio-identical Hormone Therapy Nonhormonal Therapy Antidepressants Alternative Pharmacological Therapy Non-pharmacological Options References 110 Tumors of the Female Reproductive Organs Leiomyoma General Principles Definition/Background Epidemiology Classification Approach to the Patient Diagnosis History Physical Examination Laboratory and Imaging Special Testing Differential Diagnosis Treatment Behavioral Medications\Immunizations and Chemoprophylaxis Referrals Counseling Prevention Endometrial Carcinoma General Principles Definition/Background Epidemiology Classification Approach to the Patient Diagnosis History Physical Examination Laboratory and Imaging Special Testing Differential Diagnosis Treatment Behavioral Medications\Immunizations and Chemoprophylaxis Referrals Cervical Cancer General Principles Definition/Background Epidemiology Risk Factors Classification Diagnosis History Physical Examination Laboratory and Imaging Differential Diagnosis Treatment Staging Treatment Options Referrals Screening Techniques Initiation and Frequency Colposcopy Prevention Primary Prevention Medications/Immunizations and Chemoprophylaxis Secondary Prevention Ovarian Cancer General Principles Definition/Background Epidemiology Risk Factors Family History/Familial Ovarian Cancer Syndromes Reproductive/Hormonal Factors Environmental Other Diagnosis History Physical Exam Laboratory and Imaging Differential Diagnosis Staging/Treatment Referrals Medications/Chemoprophylaxis Prevention Screening References 111 Benign Breast Conditions and Disease Introduction Anatomy and Physiology History, Physical Exam, and Initial Workup History Breast Self-Examination Clinical Breast Exam Imaging Tissue Sampling The Triple Test Common Chief Complaints Breast Pain (Mastodynia/Mastalgia) Cyclic Versus Noncyclic Breast Pain Treatment of Breast Pain Nonpharmacological Interventions Pharmacological Interventions Hormonally Active Pharmacological Interventions Nipple Pain Mastitis Ectopic or Absent Breast Tissue Nipple Discharge Galactorrhea Non-galactorrheal Discharge Mammary Duct Ectasia Benign Breast Masses Nonproliferative Lesions Cysts Fibrocystic Changes Fibroadenomas Fat Necrosis Proliferative Lesions Without Atypia Usual Ductal Hyperplasia Intraductal Papilloma Sclerosing Adenosis Radial Scar Atypical Hyperplasia Breast Disease During Pregnancy Male Breast Conditions Gynecomastia References 112 Breast Cancer General Principles Background Definition and Classification Pathogenesis Epidemiology Approach to the Patient Early Detection Risk Factors and Risk Assessment Screening Models for High Risk Assessment Diagnosis Overview History and Clinical Presentation Diagnostic Workup Biopsy Treatment Overview Ductal Carcinoma In Situ Operable Stage I-III Disease Loco-Regional Treatment Systemic Therapy Inoperable Stage IV Metastatic Disease Surveillance and Follow-up Care Evolving Role of Primary Care in Breast Cancer Chemoprevention Breast Cancer and Cardiovascular Disease References 113 Selected Disorders of the Female Reproductive System Acute Pelvic Pain in Women Background History Physical Exam Labs Imaging Diagnosis/Management The Pregnant Patient Infectious Gynecologic Causes of Pelvic Pain Endometritis Pelvic Inflammatory Disease (PID) and Tubo-Ovarian Abscess (TOA) Infectious Gynecologic Causes of Acute Pelvic Pain Noninfectious Gynecologic Causes of Acute Pelvic Dysmenorrhea Ovarian Cysts Adnexal Torsion Nongynecologic Causes of Acute Abdominal Pain Gastrointestinal Urinary Tract Disorders Conclusion Toxic Shock Syndrome Chronic Pelvic Pain Background History Physical Exam Labs and Imaging Diagnosis and Management Treatment Surgical Interventions and Approach to Management of CPP Conclusion Infertility Introduction and Background Female Factor Infertility Male Factor Infertility Unexplained Infertility Endometriosis Epidemiology Pathophysiology Treatment References Part XXII: The Musculoskeletal System and Connective Tissue 114 Disorders of the Neck and Back Disorders of the Back Low Back Pain (LBP) General Principles Definition/Background Epidemiology Natural History Clinical Presentation History Physical Exam Radiographic and Laboratory Diagnosis Differential Diagnosis Nonspecific Low Back Pain Osteoarthritis Intervertebral Disk Herniation Spinal Stenosis Osteoporosis Neoplasia Facet Syndrome Ankylosing Spondylitis Visceral Diseases Management Stratified Primary Care Management Activity Bed Rest Pharmacological Nonopiate Analgesics Opiate Receptor Agonists Skeletal Muscle Relaxants Antidepressants Systemic Corticosteroids Disease-Modifying Antirheumatic Drugs (DMARDs) Exercise Back School Psychological Intervention Spinal Manipulation Acupuncture Epidural Steroid Injection Surgery Chronic Low Back Pain Disorders of the Neck Cervical Radiculopathy General Principles Presentation Diagnosis Management Acute Cervical Strain General Principles Presentation Diagnosis Management Prognosis Cervical Myelopathy General Principles Presentation Diagnosis Management References 115 Disorders of the Upper Extremity Hand and Wrist Infectious and Inflammatory Paronychia Felon Herpetic Whitlow Tenosynovitis De Quervain´s Tenosynovitis Intersection Syndrome Traumatic Mallet Finger Jersey Finger Central Slip Extensor Tendon Injury Scaphoid Fracture Hamate Fracture Elbow Radial Head Subluxation Olecranon Bursitis Lateral Epicondylitis Medial Epicondylitis Arm Humeral Fractures Supracondylar Fracture Mid-Shaft Humeral Fracture Proximal Humeral Fracture Bicep Tears Acute Tear of the Long Head of the Proximal Bicep Acute Tear of the Distal Bicep Shoulder Glenohumeral Dislocation Anterior Glenohumeral Dislocation Posterior Glenohumeral Dislocation Inferior Glenohumeral Dislocation Rotator Cuff Injuries Subacromial Bursitis Frozen Shoulder Clavicular Fracture Mid-Shaft Clavicle Fracture Distal Clavicle Fracture Proximal Clavicle Fracture References 116 Disorders of the Lower Extremity Hip Injuries Hip Fracture General Principles Diagnosis Treatment Stress Fractures General Principals Diagnosis Treatment Avulsion Fractures Hip Dislocation General Principles Diagnosis Treatment Femoroacetabular Impingement (FAI) Syndrome General Principles Diagnosis Treatment Acetabular Labral Tear (ALT) General Principles Diagnosis Treatment Greater Trochanteric Pain Syndrome (GTPS) or Trochanteric Bursitis General Principles Diagnosis Treatment Quadriceps and Hamstring Injuries General Principles Diagnosis Treatment Knee Injuries Meniscal Injuries General Principles Diagnosis Treatment Baker´s Cyst (Popliteal Cyst) General Principles Diagnosis Treatment Knee Bursitis General Principles Pes Anserine Bursitis Prepatellar Bursitis Fractures and Dislocations of the Knee General Principles Lower Leg/Ankle/Foot Injuries Calf Injuries General Principles Diagnosis Treatment Achilles Tendon Rupture General Principles Diagnosis Treatment Plantar Fasciopathy (PF) General Principles Diagnosis Treatment Metatarsalgia General Principles Diagnosis Treatment Interdigital Nerve Compression Sesamoiditis Distal Tibia/Fibula/Ankle/Foot Fractures References 117 Osteoarthritis General Principles Definition/Background Epidemiology Classification Osteoarthritis of the Knee Osteoarthritis of the Hip Osteoarthritis of the Hands Approach to the Patient Diagnosis History Physical Examination Laboratory and Imaging Differential Diagnosis Treatment Lifestyle Modifications Medications Topical Medications Acetaminophen and Anti-Inflammatories Intra-Articular Injections Opioids Other Pharmacologic Options Referrals Complementary and Alternative Therapy Surgical Options Patient Education and Activation Prognosis References 118 Rheumatoid Arthritis and Related Disorders Differential Diagnosis of Joint Pain Step 1: A Thorough Medical History Step 2: Physical Examination Rheumatoid Arthritis (RA) Background and Pathophysiology Clinical Presentation Diagnosis Laboratory and Imaging Studies Treatment Nonpharmacologic Treatment Pharmacologic Therapy NSAIDs and Corticosteroids DMARDs Surgery Clinical Course and Disease Activity Differentiating Rheumatoid Arthritis from Osteoarthritis Juvenile Idiopathic Arthritis Reactive Arthritis (Reiter´s Syndrome) Systemic Lupus Erythematosus Background and Pathophysiology Clinical Presentation Laboratory Findings Treatment Raynaud´s Disease (Primary Raynaud´s Phenomenon) Systemic Sclerosis Sjögren´s Syndrome Polymyalgia Rheumatica (PMR) Giant Cell Arteritis (Temporal Arteritis) Ankylosing Spondylitis Psoriatic Arthritis References 119 Selected Disorders of the Musculoskeletal System Fibromyalgia General Principles Definition/Background Epidemiology Diagnosis History Physical Examination Classification Differential Diagnosis Laboratory and Imaging Approach to the Patient Treatment Patient Education Exercise Behavioral and Coexisting Disorders Medications Myofascial Pain Syndrome General Principles Definition/Background Classification Approach to the Patient Diagnosis History and Physical Examination Treatment Complex Regional Pain Syndrome General Principles Background/Classification Epidemiology Approach to the Patient Diagnosis History and Physical Examination Laboratory and Imaging Diagnostic Criteria Differential Diagnosis Prognosis and Treatment Referrals Medications Neuroma General Principles Definition/Background Classification Approach to the Patient Diagnosis History and Physical Examination Imaging Treatment and Prevention Dupuytren´s Contracture General Principles Background Epidemiology Approach to the Patient Diagnosis Physical Examination Treatment Referrals Ganglion Cyst General Principles Approach to the Patient Diagnosis Physical Examination Differential Diagnosis, Imaging, and Special Testing Treatment Selected Disorders of Bone Benign Tumors General Principles Osteoid Osteoma Background History and Physical Imaging Treatment and Prognosis Osteochondroma Background History and Physical Imaging Treatment and Prognosis Enchondroma Background History and Physical Imaging Treatment and Prognosis Non-ossifying Fibroma Background History and Physical Imaging Treatment and Prognosis Malignant Tumors General Principles Approach to the Patient History and Physical Diagnosis Primary Osteosarcoma Background Imaging Treatment and Prognosis Ewing´s Sarcoma Background Imaging Treatment and Prognosis Chondrosarcoma Background Imaging Treatment and Prognosis References Part XXIII: The Skin and Subcutaneous Tissues 120 Common Dermatoses General Principles Acne Approach to the Patient Treatment Options Atopic Dermatitis Approach to the Patient Treatment Family and Community Implication of Common Dermatoses References 121 Skin Infections and Infestations Bacterial Infections of the Skin Impetigo General Principles Epidemiology Diagnosis History and Physical Examination Treatment Erysipelas General Principles Epidemiology Diagnosis History and Physical Examination Treatment Cellulitis General Principles Epidemiology Diagnosis History and Physical Examination Evaluation Treatment Folliculitis General Principles Epidemiology Diagnosis History and Physical Examination Evaluation Treatment Furuncles and Carbuncles General Principles Epidemiology Diagnosis History and Physical Examination Evaluation Treatment Hidradenitis Suppurativa General Principles Epidemiology Diagnosis History and Physical Examination Treatment Abscess of Skin General Principles Epidemiology Diagnosis History and Physical Examination Evaluation Treatment Necrotizing Fasciitis General Principles Epidemiology Diagnosis History and Physical Examination Evaluation Treatment Erythrasma General Principles Epidemiology Diagnosis History and Physical Examination Treatment Viral Diseases of the Skin Herpes Simplex General Principles Epidemiology Diagnosis History and Physical Examination Evaluation Treatment Genital Herpes General Principles Epidemiology Diagnosis History and Physical Examination Evaluation Treatment Herpes Zoster General Principles Epidemiology Diagnosis History and Physical Examination Evaluation Treatment Viral Warts General Principles Epidemiology Diagnosis History and Physical Examination Treatment Molluscum Contagiosum General Principles Epidemiology Diagnosis History and Physical Examination Treatment Fungal Infections of the Skin Dermatophytoses General Principles Epidemiology Diagnosis History and Physical Examination Evaluation Treatment Onychomycosis General Principles Epidemiology Diagnosis History and Physical Examination Evaluation Treatment Yeast General Principles Epidemiology Diagnosis History and Physical Examination Evaluation Treatment Tinea Versicolor General Principles Epidemiology Diagnosis History and Physical Examination Evaluation Treatment Infestations Lice/Pediculosis General Principles Epidemiology Diagnosis History and Physical Examination Treatment Scabies General Principles Epidemiology Diagnosis History and Physical Examination Evaluation Treatment Chiggers General Principles Epidemiology Diagnosis History and Physical Examination Treatment Bedbugs General Principles Epidemiology Diagnosis History and Physical Examination Treatment References 122 Skin Tumors General Principles Approach to the Patient History Physical Examination Keratosis Seborrheic Keratosis (SK) General Principles Definition Epidemiology Classification Diagnosis History Physical Examination Special Testing Differential Diagnosis Treatment Referrals Counseling Patient Education Actinic Keratosis (AK) or Solar Keratosis General Principles Definition Epidemiology Approach to Patient Diagnosis History Physical Examination Special Testing Differential Diagnosis Treatment Medications Referrals Counseling Patient Education/Prevention Pigmented Lesions Nevus (Mole) General Principles Definition Epidemiology Types of Nevi Junctional Nevus Dermal Nevus Compound Nevus Atypical Nevus Blue Nevus Halo Nevus Spitz Nevus Congenital Nevus Approach to Patient Diagnosis History Physical Examination Special Testing Differential Diagnosis Treatment Behavioral Medications Referrals Counseling Patient Education Prevention Solar Lentigo or Actinic Lentigo General Principles Definition Epidemiology Classification Approach to Patient Diagnosis History Physical Examination Special Testing Differential Diagnosis Treatment Medications Referrals Counseling Patient Education/Prevention Malignant Skin Tumors Melanoma General Principles Definition Epidemiology Classification Superficial Spreading Melanoma Nodular Melanoma Lentigo Maligna Melanoma Acral Melanoma Approach to Patient Diagnosis History Physical Examination Laboratory and Imaging Special Testing Differential Diagnosis Treatment Medications Referrals Counseling Patient Education Prevention Basal Cell Carcinoma (BCC) General Principles Definition Epidemiology Classification Based on Histopathology Nodular BCC Superficial BCC Sclerotic/Morphea-Form BCC Approach to Patient Diagnosis History Physical Examination Special Testing Differential Diagnosis Treatment Medications Counseling Patient Education/Prevention Squamous Cell Carcinoma (SCC) General Principles Definition Epidemiology Classification Approach to Patient Diagnosis History Physical Examination Laboratory and Imaging Special Testing Differential Diagnosis Treatment Medications Referrals Counseling Patient Education Keratoacanthoma (KA) General Principles Definition Epidemiology Approach to the Patient Diagnosis History Physical Examination Special Testing Differential Diagnosis Treatment Referrals Counseling Patient Education/Prevention Kaposi Sarcoma General Principles Definition Epidemiology Classification of KS Approach to Patient Diagnosis History Physical Examination Laboratory and Imaging Special Testing Differential Diagnosis Treatment Medications Referrals Counseling Patient Education Vascular Lesions Hemangioma General Principles Definition Epidemiology Classification Approach to the Patient Diagnosis History Physical Exam Laboratory and Imaging Differential Diagnosis Treatment Behavioral Medication Referrals Counseling Patient Education Angiokeratoma General Principles Definition Epidemiology Classification Other Vascular Malformations Approach to the Patient Diagnosis History Physical Exam Special Testing Differential Diagnosis Treatment Referrals Counseling Patient Education Venous Lake General Principles Definition Epidemiology Approach to the Patient Diagnosis History Physical Exam Special Testing Differential Diagnosis Treatment Referrals Counseling Patient Education Pyogenic Granuloma General Principles Definition Epidemiology Approach to Patient Diagnosis History Physical Examination Special Testing Differential Diagnosis Treatment Referrals Counseling Patient Education Nonpigmented Nonvascular Lesions Dermatofibroma General Principles Definition Epidemiology Approach to Patient Diagnosis History Physical Examination Special Testing Differential Diagnosis Treatment Medications Referrals Counseling Patient Education Acrochordon or Skin Tag General Principles Definition Epidemiology Approach to Patient Diagnosis History Physical Examination Special Testing Differential Diagnosis Treatment Medication Referrals Counseling Patient Education Keloids General Principles Definition Epidemiology Approach to Patient Diagnosis History Physical Examination Special Testing Differential Diagnosis Treatment Medications Referrals Counseling Patient Education Lipoma General Principles Definition Epidemiology Classification Approach to Patient Diagnosis History Physical Examination Special Testing Differential Diagnosis Treatment Medications Referrals Counseling Patient Education Epidermal Cyst General Principles Definition Classification Epidemiology Approach to Patient Diagnosis History Physical Exam Laboratory Testing Special Testing Differential Diagnosis Treatment Behavioral Medications Referrals Counseling Patient Education Oral Lesions General Principles Definition Epidemiology Classification Approach to the Patient History Physical Exam Laboratory Testing and Imaging Differential Diagnosis Treatment Behavioral Referrals Patient Education Surgical Techniques Cryotherapy Punch Biopsy Shave Biopsy Excisional Biopsy Curettage and Electrodessication Sun Exposure Protection Basic Principles References 123 Selected Disorders of the Skin Disorders of Hypopigmentation Vitiligo Management Pityriasis Alba Tuberous Sclerosis Disorders of Hyperpigmentation Pityriasis Versicolor (Tinea Versicolor) Photosensitivity Dermatitis Lichen Planus Clinical Presentation Treatment Cutaneous Lupus Erythematosus Clinical Presentation Treatment Corns and Calluses Clinical Presentation Management Nail Abnormalities Tinea Unguium (Onychomycosis) Management Ingrown Toenails Subungual Hematoma Alopecia Pathologic Hair Loss Telogen Effluvium Anagen Effluvium Alopecia Areata Cicatricial (Scarring) Alopecia Traumatic Alopecia Fungal Infection (Tinea Capitis) Physiologic Hair Loss References Part XXIV: The Endocrine and Metabolic System 124 Dyslipidemias General Principles Definition of Dyslipidemias Lipids and Lipoproteins Epidemiology Screening for Dyslipidemias in Adults Screening for Dyslipidemias in Children Classification Diagnosis of Dyslipidemias History Physical Examination Laboratory and Imaging Special Testing Differential Diagnosis Treatment Medications LDL Apheresis Nutraceuticals Referrals Prevention Family and Community Issues References 125 Diabetes Mellitus Definition Epidemiology Classification Diagnosis of Diabetes Mellitus Important Aspects in Managing Patients with Type 1 DM Management of Type 1 Diabetes: Insulin Considerations Insulin Delivery Systems Insulin Injection Technique Diabetes Education and Self-Management Glucose Monitoring Devices/Diabetes Technology Sick Day Management of Insulin Dawn Phenomenon Somogyi Phenomenon Hypoglycemia Pregnancy Planning DM Management During Pregnancy Dietary Considerations Exercise Considerations Other Routine Care for Patients with Type 1 Diabetes Management of Type 2 Diabetes Mellitus Clinical Features in Patients with Type 2 Diabetes Mellitus Pharmacologic Therapy of Type 2 Diabetes Mellitus Specific Pharmacologic Therapy for Type 2 DM Glycemic Targets Step-Wise Introduction of Therapeutic Agents Other Routine Medical Care in Type 2 Diabetes Patients Complications of Diabetes Mellitus Microvascular Complications Diabetic Neuropathy Other Considerations Diabetic Emergencies Diagnostic Testing for DKA and HHS Inpatient Diabetes Care References 126 Thyroid Disease Overview Thyroid Lab Testing Hypothyroidism Clinical Presentation Diagnostic Evaluation Treatment Myxedema Coma Hashimoto´s Thyroiditis Diagnostic Workup Treatment Iatrogenic Hypothyroidism Painless Thyroiditis, Postpartum Thyroiditis, and Subacute Thyroiditis Riedel´s Thyroiditis Thyroid Infiltration Congenital Hypothyroidism Central Hypothyroidism Hyperthyroidism Clinical Presentation Diagnostic Workup Thyroid Storm Graves´ Disease Clinical Presentation Diagnostic Workup Treatment Antithyroid Drugs Radioactive Iodine Thyroidectomy Special Populations Pregnancy Lactating Mothers Pediatrics Graves´ Ophthalmopathy Clinical Presentation Diagnosis and Treatment Toxic Adenoma Thyroiditis Causes of Acute Thyroiditis Infectious Thyroiditis Radiation Thyroiditis Traumatic Thyroiditis Causes of Subacute Thyroiditis Silent Thyroiditis Postpartum Thyroiditis Diagnostic Evaluation Treatment Subacute Painful Thyroiditis Drug-Induced Thyrotoxicosis Secondary Hyperthyroidism Factious Ingestion Rare Causes Subclinical Hyperthyroidism Summary (Table 2) Thyroid Nodule Evaluation Laboratory Studies Imaging Special Populations References 127 Osteopenia and Osteoporosis Risk Factor Assessment Lifestyle Genetics Endocrine Factors Medications Laboratory Assessment Bone Densitometry Assessment FRAX Score Diagnosis Prevention and Treatment Nonpharmacological Calcium Vitamin D Physical Activity Fall Prevention Pharmacological Treatment Bisphosphonates Alendronate (Fosamax) Risedronate (Actonel) Ibandronate (Boniva) Zoledronic Acid (Reclast) Hormonal Hormone Replacement Therapy (HRT) Estrogen Agonist/Antagonists Calcitonin Parathyroid Hormone (PTH) RANK Ligand Inhibitor Romosozumab (Evenity) Monitoring and Duration of Treatment Conclusion References 128 Disorders of Nutrition Introduction Vitamin and Mineral Deficiencies Vitamin D Deficiency Vitamin B12 Deficiency Folic Acid Deficiency Iron Deficiency Malnutrition Nutritional Requirements for Health Maintenance, Gender/Age/Disease, or Activity References 129 Selected Disorders of the Endocrine and Metabolic System The Pituitary Hyperprolactinemia and Galactorrhea Overview Clinical Presentation Diagnosis Management Hypopituitarism Overview Clinical Presentation Diagnosis Management Neuroendocrine Disorders of Water Balance Polydipsia Primary Polydipsia Secondary Polydipsia Polyuria and Central Diabetes Insipidus Clinical Presentation Diagnosis Management Disorders of Secondary Sexual Characteristics Normal Puberty Precocious Puberty Delayed Puberty Hypogonadism in Adults Hirsutism and Virilization Diagnosis Management Calcium Metabolism and Parathyroid Glands Hypercalcemia and Hyperparathyroidism Clinical Presentation Diagnosis Management Hypocalcemia and Hypoparathyroidism Clinical Presentation Diagnosis Management Adrenal Dysfunction Adrenocortical Insufficiency Clinical Presentation Diagnosis Management Adrenocortical Excess Clinical Presentation Diagnosis Management Hyperaldosteronism Hypoglycemia Overview Diagnosis Management Gout Clinical Presentation Diagnosis Management References Part XXV: The Blood and Hematopoietic System 130 Anemia Background and Introduction Clinical Presentation Symptoms History Physical Examination Laboratory Data Microcytic Anemias (Fig. 1) Iron Deficiency Anemia Thalassemia Hemoglobin E Sideroblastic Anemia Normocytic Anemias (Fig. 2) Normocytic Anemia with Elevated Reticulocytes Normocytic Anemias with Decreased Reticulocytes Macrocytic Anemias (Fig. 3) Megaloblastic Anemias Non-megaloblastic Anemias Summary References 131 Selected Disorders of the Blood and Hematopoietic System Bleeding Disorders Congenital Coagulation Disorders Von Willebrand´s Disease Hemophilia A Hemophilia B Easy Bruising Acquired Coagulation Disorders Vitamin K Deficiency Thrombocytopenia Hereditary Hemorrhagic Telangiectasia (HHT) Neutropenia Acquired Neutropenia Postinfectious Neutropenia Drug-Induced Neutropenia Congenital Neutropenia Autoimmune Neutropenia Chronic Idiopathic Neutropenia Alloimmune (Isoimmune Neutropenia) Nutritional Neutropenia Other Hematologic Disorders Hemochromatosis Polycythemia Sickle-Cell Disease Hematologic Malignancies Multiple Myeloma Myelodysplastic Syndromes Leukemias References Part XXVI: Family Medicine Applications 132 Medical Informatics, the Internet, and Telemedicine History of Medical Informatics The Role of Clinical Informaticists Artificial Intelligence (AI) and Machine Learning Medical Informatics and Electronic Health/Medical Record Systems The Internet Clinical Decision Support Emerging Internet Technologies Blockchain The Internet of Things (IoT) Telemedicine/Telehealth Conclusion References 133 Complementary and Alternative Medicine Biological Based Therapies Supplements Multivitamins Megavitamin Therapy Probiotics Herbal Medicines Diet-Based Therapies FODMAP Keto- and Paleo-Diets Juicing and Detoxification Diets Intermittent Fasting Diets Gluten-free Diets Mind-Body Medicine Deep Breathing Meditation Yoga Biofeedback Hypnosis Manual Medicine Osteopathic Manipulation Chiropractic Therapy Massage Therapy Alternative Medicine Systems Homeopathy Traditional Chinese Medicine (TCM) Acupuncture Naturopathy Energy Medicine Therapeutic Touch Reiki References 134 Patient-Centered Medical Home Definition of the Medical Home History of the Medical Home Principles and Characteristics of Medical Homes Principles The Role of Family Medicine in the Medical Home Role of the PCMH in the Health System Results and Evidence Certification, Recognition, and Accreditation In Context References 135 Chronology: The Evolution of Family Practice as a Specialty in the United States 136 Engaging the Future of Family Medicine and Healthcare Introduction The Origins and Current Role of Family Medicine The Primary Care Advantage The Challenges of the Future The Way Forward for Family Medicine Conclusion References Normal Laboratory Values/Adult Patients Clinical Chemistry Tests Lipid Panel Thyroid Function Tests Blood Gases Hematology and Coagulation Tests Index