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CURRENT
Guidelines in
Primary Care
2020
Jacob A. David, MD, FAAFP

Associate Program Director
Family Medicine Residency Program
Ventura County Medical Center
Clinical Instructor
UCLA School of Medicine
Los Angdes, California
New York Chicago San Francisco Athens London Madrid

Mexico City Milan New Delhi Singapore Sydney Toronto
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This book is dedicated to all of our current and
former residents at the Ventura County Medical Center.
This page intentionally left blank
Contents
Contributors xv
Preface xix
SECTION 1 SCREENING
1. Behavioral Health Disorders 3

Alcohol Abuse and Dependence 3
Depression 4
Illicit Drug Use 5
Tobacco Use 6
2. cardiovascular Disorders 7
Abdominal Aortic Aneurysm 7
Atrial Fibrillation 8
Carotid Artery Stenosis (CAS) (Asymptomatic) 9
Cholesterol and Lipid Disorders 10
Coronary Artery Disease 15
Hypertension (HTN), Adults 18
Peripheral Artery Disease 20
Sleep Apnea 21
Tobacco Use 21
3. Disorders of the Skin, Breast, and Musculoskeletal System 23
Breast Cancer 23
Breast Cancer-BRCA1 and 2 Mutations 26
Oral Cancer 28
Skin Cancer (Melanoma) 29
Skin Cancer 30
Vitamin D Deficiency 30
4. Endocrine and Metabollc Disorders 31
Diabetes Mellitus (DM), Type 2 and Prediabetes 31
Obesity 33
Thyroid Cancer 33
Thyroid Dysfunction 34
5. Gastrolntestlnal Disorders 37
Barrett Esophagus (BE) 37
Celiac Disease 38
Colorectal Cancer 39
Esophageal Adenocarcinona 44
Gastric Cancer 45
Hepatocellular Carcinoma (HCC) 45
Hereditary Hemochromatosis (HH) 46
Hepatitis B Virus (HBV) Infection 47
Hepatitis C Virus (HCV) Infection 48
Pancreatic Cancer 49
CONTENTS
6. GenltourlnaryDlsorden 51
Bladder Cancer 51
Cervical Cancer 52
Endometrial Cancer 62
Ovarian Cancer 63
Pelvic Examinations 65
Prostate Cancer 66
Testicular Cancer 70
7. Infectious DlsHses 71
Gonorrhea and Chlamydia 71
Herpes Simplex Virus (HSV), Genital 72
Hwnan Immunodeficiency Vrrus (HIV) 73
Syphilis 74
Trichomonas 74
8. Pulmonary Disorders 77
Chronic Obstructive Pulmonary Disease 77
Lung Cancer 77
9. R•nal Disordars 81
Kidney Disease, Chronic (CKD) 81
1O. SpKlal Populatlon: Chlldren and Adolescents 83
Alcohol Abuse and Dependence 83
Attention-Deficit/Hyperactivity Disorder 84
Autism Spectrum Disorder 85
Celiac Disease 86
Cholesterol and Lipid Disorders 87
Depression 88
Diabetes 89
Family Violence and Abuse 89
Hwnan Immunodeficiency Vrrus {HIV) 90
Hypertension (HTN), Children and Adolescents 91
Illicit Drug Use 92
Lead Poisoning 93
Motor Vehicle Safety 94
Obesity 94
Scoliosis 95
Speech and Language Delay 95
Suicide Risk 96
Tobacco Use 97
Tuberculosis, Latent 97
Visual hnpairment 98
11. Sp•clal Population: Newborns and Infants 99
Anemia 99
Critical Congenital Heart Disease 100
Developmental Dysplasia of the Hip (DDH) 100
Growth Abnormalities 101
Hearing Impairment 101
CONTENTS
vii
Hemoglobinopathies 102
Newborn Screening 102
Phenylketonuria {PKU) 103
Thyroid Disease 104
12. Special Population: Older Adults 105
Dementia 105
Falls in the Elderly 106
Family Violence and Abuse 107
Osteoporosis 108
Visual Impairment, Glaucoma, or Cataract 109
13. Special Population: Pregnant Women 111
Anemia 111
Bacterial Vaginosis 112
Bacteriuria, Asymptomatic 112
Chlamydia and Gonorrhea 113
Diabetes Mellitus, Gestational (GDM) 113
Diabetes Mellitus {DM), Type 2 114
Fetal Aneuploidy 115
Group B Streptococcal (GBS) Disease 116
Hepatitis B Virus Infection 116
Hepatitis C Vrrus (HCV) Infection, Chronic 117
Herpes Simplex Virus (HSV), Genital 118
Human Immunodeficiency Virus (HIV) 118
Intimate Partner Violence 119
Preeclampsia 120
Lead Poisoning 120
Rh (D) Incompatibility 121
Syphilis 121
Thyroid Disease 122
Tobacco Use 123
SECTION 2 PREVENTION
14. C.rdlovucular Disorders 127

Hypertension (HTN) 127
Atherosclerotic Cardiovascular Disease (ASCVD), Aspirin Therapy 129
Atherosclerotic Cardiovascular Disease (ASCVD), Dietary Therapy 130
Atherosclerotic Cardiovascular Disease (ASCVD), Statin Therapy 131
Atherosclerotic Cardiovascular Disease (ASCVD), Specific Risk Factors 138
Stroke 141
Stroke, Atrial Fibrillation 141
Stroke, Specific Risk Factors 144
Venous Thromboembolism (VTB) Prophylaxis in Nonsurgical Patients 149
Venous Thromboembolism (VTE) in Surgical Patients 154
15. Disorders of the Skin, Brqst, and Musculoskeletal System 157
Back Pain, Low 157
Breast Cancer 158
Gout 161
CONTENTS
viii
Oral Cancer 162

Osteoporosis 163
Pressure Ulcers 165
Skin Cancer 166
16. Endocrine •nd Metllbolic Disorders 169
Diabetes Mellitus (DM), Type 2 169
Hormone Replacement Therapy to Prevent Chronic Conditions 170
Obesity 171
17. GHtrolnt•stln•I Disorden 173
Colorectal Cancer 173
Esophageal Cancer 175
Gastric Cancer 176
Hepatocellular Cancer 177
18. GenltourlmiryDlsorclen 179
Cervical Cancer 179
Endometrial Cancer 180
Ovarian Cancer 181
Prostate Cancer 182
19. Infectious DIMllHS 183
Catheter-Related Bloodstream Infections 183
Colitis, Clostridium Difficile 184
Endocarditis Prevention 185
Human ImmunodeficiencyVll"Us (HIV). Opportunistic Infections 187
Immunizations 203
Influenza, Chcmoprophylaxis 203
Influenza, Vaccination 205
20. Renal Dlsord•rs 207
Kidney Injury, Acute 207
21. Speml Popui.tion: Children and Adolescents 209
Asthma 209
Athcrosclerotic Cardiovascular Disease 210
Concussion 212
Dental Caries 213
Domestic Violence 215
Immunizations, Infants and Children 216
Influenza, Chcmoprophylaxis 216
Influenza, Vaccination 217
Motor Vehicle Injury 218
Obesity 219
Otitis Media 221
Sexually Transmitted Infections (STis) 221
Tobacco Use 222
CONTENTS
22. Specl•I Populalon: Newborns •ncl lnt.nts 223

Immunizations, Infants and Children 223
Sudden Infant Death Syndrome (SIDS) 223
Gonorrhea, Ophthalm.ia Neonatorum 224
23. Specl•I Population: Older Adults 225
Driving Risk 225
Falls in the Elderly 226
Osteoporotic Hip Fractures 227
24. Special Population: Pregn•nt Women 2:a
Cesarean Section 229
Group B Streptococcal (GBS) Infection 231
Neural Tube Defects 231
Postpartum Depression 232
Postpartum Hemorrhage 232
Preeclampsia 233
Pretenn Birth 233
Rh Alloimmunization 234
Surgical Site Infections {SSI) 234
Thromboembolism in Pregnancy 235
Tobacco Use 235
SECTION 3 MANAGEMENT
25. Behavloral HHlth Disorders 239
Adult Psychiatric Patients in the Emergency Department 239
Alcohol Use Disorders 240
Anxiety 241
Attention-Deficit Hyperactivity Disorder (ADHD) 241
Autism Spectrum Disorders 243
Depression 244
Eating Disorders 245
Opioid Use Disorder 246
Pregnancy, Substance Abuse 248
Posttraumatic Stress Disorder (PTSD) 249
Tobacco Abuse, Smoking Cessation 249
26. Cardiovascular Disorders 253
Abdominal Aortic Aneurysm (AAA) 253
Anaphylaxis 256
Atrial Fibrillation 257
Bradycardia 270
Carotid Artery Disease 271
Coronary Artery Disease (CAD) 274
Heart Failure 283
Hyperlipidemia 287
Hypertension 288
Peripheral Arterial Disease 306
Preoperative Clearance 308
Valvular Heart Disease 308
CONTENTS
27. Care of the Older Adult 313

Dementia, Feeding Tubes 313
Dementia, Almeimer Disease 313
Dementia 315
Delirium, Postoperative 315
Palliative Care of Dying Adults 316
28. Disorders of the Hud, Eye, E•r, Nose, •nd Tbro•t 31 g
Bronchitis, Acute 319
Cataract 320
Cerwnen Impaction 322
Headache 323
Headache, Migraine Prophylaxis 324
Hearing Loss, Sudden 334
Hoarseness 335
Laryngitis, Acute 336
Otitis Externa, Acute (AOE) 336
Otitis Media, Acute (AOM) 337
Pharyngitis, Acute 339
Rhinitis 340
Sinusitis 341
Sinusitis, Acute Bacterial 341
Sinusitis 342
Tinnitus 344
Tonsillectomy 345
Tympanostomy Tubes 345
Vertigo, Benign Paroxysmal Positional (BPPV) 346
29. Disorders of the Skin, Breast, and Musculoslwlehll System 347
Ankylosing Spondylitis and Spondyloarthritis 347
Atopic Dermatitis (AD) 348
Back Pain, Low 349
Lumbar Disc Herniation 351
Rotator Cuff Tears 351
Breast Cancer Follow-Up Care 352
Gout. Acute Attacks 354
Hip Fractures 356
Multiple Sclerosis (MS) 356
Muscle Cramps 357
Osteoarthritis (OA) 358
Osteoporosis 360
Osteoporosis, Glucocorticoid-Induced 362
Pressure Ulcers 364
Psoriasis, Plaque-Type 365
Psoriasis and Psoriatic Arthritis 366
Rheumatoid Arthritis (RA), Biologic Disease-Modifying Antirheumatic
Drugs (DMARDs) 368
Polymyalgia Rheumatica 369
Systemic Lupus Erythematosus (SLE, Lupus) 370
CONTENTS
30. Endocrine •nd Metllbollc Disorders 375

Adrenal lncidentalomas 375
Androgen Deficiency Syndrome (See Hypogonadism, Male) 376
Cushing's Syndrome (CS) 376
Diabetes Mellitus (DM). Type 2 379
Hypogonadism, Male 389
Menopause 392
Obesity 394
Polycystic Ovary Syndrome 395
Thyroid Disease, Hyperthyroidism 396
Thyroid Disease, Hypothyroidism 398
Thyroid Nodules 399
Transgcnder Health Care 400
Vitamin Deficiencies 403
31. c;.istrolntestinal Disorders 405
Abnormal Liver Chemistries 405
Ascites, from Cirrhosis 407
Other Complications of Cirrhosis 410
Barrett Esophagus 411
Celiac Disease 413
Colitis, Clostridium Difficile 414
Colorectal Cancer Follow-Up Care 417
Constipation, Idiopathic 419
Constipation, Opiate Induced 420
Diarrhea, Acute 421
Dyspepsia 423
Dysphagia 425
Gallstones 425
Gastrointestinal Bleeding, Lower 426
Gastrointestinal Bleeding, Upper (UGIB) 429
Helicobacter Pylori Infection 431
Hepatitis B Virus (HBV) 432
Hepatitis B Virus Infection-Treatment Specifics 435
Hepatitis C Vuus (HCV) 436
Hereditary Hemochromatosis (HH) 447
Inflammatory Bowel Disease, Crohn's Disease 448
Inflammatory Bowel Disease, Ulcerative Colitis 450
Inflammatory Bowel Disease, Ulcerative Colitis, Surgical Treatment 452
Irritable Bowel Syndrome (IBS) 452
Liver Disease, Alcoholic 454
Liver Disease, Nonalcoholic (NAFLD) 456
Pancreatitis, Acute (AP) 458
Paracentesis 460
Ulcers, Stress 460
32. Genltourln•ry Disorders 461
Benign Prostatic Hyperplasia (BPH) 461
Erectile Dysfunction (ED) 462
CONTENTS
xii
Hematuria 463
Indwelling Urinary Catheters or Intermittent Catheterization 465
Infertility, Male 465
Ovarian Cancer Follow-Up Care 466
Pap Smear, Abnormal 467
Polycystic Ovary Syndrome 468
Prostate Cancer: Active Surveillance (AS) for the Management
of Localized Disease 468
Prostate Cancer Follow-Up Care 470
Urinary Incontinence, Overactive Bladder 471
Urinary Incontinence, Stress 472
Urinary Tract Symptoms, Lower 476
Urolithiasis 476
33. H•m•tologlc Disorders 481
Anemia 481
Anemia, Chemotherapy Associated 481
Anemia, Hemolytic (HA) 483
Anemia, Iron Deficiency 485
Anemia of Chronic Disease 487
Cobalamin (B12) and Folate (B,) Deficiency 488
Sickle Cell Disease 490
hnmune Thrombocytopenia (ITP) 493
Heparin-Induced Thrombocytopenia (HIT) 498
Thrombotic Thrombocytopenia Purpura (TTP) 502
Transfusion Therapy, Red Blood Cell (RBC) Transfusion 505
Transfusion Therapy-Alternatives to Red Blood Cell Transfusion 507
Transfusion Therapy, Platelet Transfusion 508
Transfusion Therapy, Fresh Frozen Plasma (FFP) 510
Transfusion Therapy, Cryoprecipitate 511
Transfusion Therapy, Prothrombin Complex Concentrate (PCC) 512
Neutropenia Without Fever 512
Hemophilia A and B 514
Von Willebrand Disease 515
Thromboprophylaxis 517
Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) 519
Thrombophilias 530
Multiple Myeloma/Monoclonal Gammopathy of Undetermined Significance 532
34. lnr.ctlous Diseases 535
Asymptomatic Bacteriuria 535
Common Cold 535
Diabetic Foot Infections, Inpatient Management 536
Human Immunodeficiency Virus (HIV) 537
Human Immunodeficiency Virus (HIV), Antiretroviral Therapy (ART)
in Pediatrics 539
Human Immunodeficiency Virus, Antiretroviral Use in Adults 540
Identifying Risk of Serious Illness in Children Under 5 Y 541
Influenza 543
Neutropenia. Febrile (FN) 545
CONTENTS
xiii
Meningitis, Bacterial 547

Neurocysticcrcosis (NCC) 550
Respiratory Tract Infections, Lower (Community Acquired Pneumonia) 550
Respiratory Tract Infections, Upper 552
Sexually Transmitted Diseases 552
Sinutis 562
Skin and Soft Tissue Infections 562
Syphilis 563
Tuberculosis (TB), Diagnosis 564
Tuberculosis (TB), Extrapulmonary Diagnosis 564
Tuberculosis (TB), Extrapulmonary 565
Tuberculosis (TB), Management 566
Tuberculosis (TB), Management of Latent TB 568
Tuberculosis (TB), Multidrug-Resistant (MDR-TB) 569
Urinary Tract Infections (UTI) 570
35. Neurologic Disorders 573
Bell's Palsy 573
Concussions 574
Epilepsy 575
Malignant Spinal Cord Compression (MSCC) 576
Normal Pressure Hydrocephalus (NPH) 578
Pain, Chronic, Cancer Related 578
Pain, Chronic 581
Delirium 583
Pain, Neuropathic 584
Procedural Sedation 585
Restless Legs Syndrome and Periodic Limb Movement Disorders 585
Sciatica 586
Seizures 587
Seizures, Febrile 589
Stroke, Acute Ischemic 589
Stroke, Recurrence 600
Syncope 606
Traumatic Brain Injury 610
Tremor, Essential 610
36. Pr.natal and ObstWk C•re 611
Abortion 611
Contraception 612
Contraception, Emergency 614
Delivery: Trial OfLabor After Cesarean (TOLAC) 627
Delivery: Vaginal Lacerations 627
Ectopic Pregnancy 628
Diabetes Mellitus, Gestational (GDM) 630
Human lmmWlodeficiency Virus (HIV), Pregnancy 630
Hypertension, Chronic in Pregnancy 632
Pregnancy, Postpartum Hemorrhage (PPH) 633
Premature Rupture of Membranes 634
Preterm Labor 636
CONTENTS
xiv
Pregnancy, Pretcrm Labor, Tocolysis 637

Routine Prenatal Care 637
Thyroid Disease, Pregnancy and Postpartum 641
37. Pulmonary Disorders 643
Apnea, Central Sleep (CSAS) 643
Apnea, Obstructive Sleep {OSA) 643
Asthma, Exacerbations 644
Asthma, Stable 645
Chronic Obstructive Pulmonary Disease {COPD), Exacerbations 648
Chronic Obstructive Pulmonary Disease (COPD), Stable 650
Cough, Chronic 653
Non-Small Cell Lung Cancer (NSCLC) Follow-Up Care 654
Pleural Effusion, New 655
Pleural Effusion, Malignant (MPE) 656
Pneumonia 658
Pneumonia, Community Acquired: Treatment 661
Pneumothorax, Spontaneous 661
Pulmonary Nodules 662
38....... Disorders 667
Kidney Disease, Chronic-Mineral and Bone Disorders (CKD-MBDs) 667
Kidney Disease, Chronic 668
Kidney Injury, Acute 669
Renal Cancer (RCC) Follow-Up Care 670
Renal Masses, Small 677
39. Appendices 679

Estimate of 10-Y Cardiac Risk for Men 680
Estimate of 10-Y Cardiac Risk for Women 683
Estimate of 10-Y Stroke Risk for Men 686
Estimate of 10-Y Stroke Risk for Women 689
95th Percentile of Blood Pressure for Boys 692
95th Percentile of Blood Pressure for Girls 693
Body Mass Index (BMI) Conversion Table 694
Functional Assessment Screening in the Elderly 695
Geriatric Depression Scale 698
Immunization Schedule 699
Modified Checldist fur Autism in Toddlers, Revised with Follow-Up
(M-Chat-R/F) 711
Professional Societies and Governmental Agencies 712
Index 727
Contributors
David Araujo, MD, FAAFP

Program Director, Family Medicine Residency Program, Ventura County Medical
Center, Associate Clinical Professor, David Geffen School of Medicine at UCLA,
Los Angeles, California
[Chapters 6, 9, 18, 20, 32, 38]
Wallace Baker, MD, MS

Family Medicine Residency Program, Ventura County Medical Center, Ventura,
California
[Chapters 8, 28, 37]
Dorothy DeGuzman, MD, MPH, FAAFP

Core Faculty, Family Medicine Residency Program, Ventura County Medical
Center, Ventura, California
[Chapters 10, 11, 21, 22]
Gabrielle Flamm, MD
Family Medicine Residency Program, Ventura County Medical Center,
Ventura, California
[Chapters 1, 13, 24, 25, 36]
Audrey Gray, MD
Faculty, Sea Mar Marysville Family Medicine Residency Program, Marysville,
Washington
[Chapters 1, 13, 24, 25, 36]
James Helmer, Jr., MD, FAAFP

Center, Ventura, California
[Chapters 26, 35]
Neil Jorgensen, MD
Faculty, Ventura Family Medicine Residency, Ventura County Medical Center,
Ventura, California
[Chapters 2, 3, 5, 14, 15, 17]
Shadia Karim, MD
Family Medicine, Ravenswood Family Health Center, East Palo Alto, California
[Chapters 4, 7, 16, 19]
CONTRIBUTORS
Tipu V. Khan, MD, FAAFP, FASAM

Program Director, Primary Care Addiction Medicine Fellowship; Core Faculty,
Family Medicine Residency Program, Ventura County Medical Center; Assistant
Clinical Professor, UCLA School of Medicine, Los Angeles, California
[Chapters 1, 13, 24, 25, 36)
Cheryl Lambing, MD, FAAFP

Center, Assistant Clinical Professor, UCLA David Geffen School of Medicine,
[Chapters 12, 23, 27, 29)
Luyang Liu, MD
California
[Chapters 2, 3, 5, 14, 15, 17)
Eric Monaco, MD
California
[Chapters 30, 31]
Marina Morie, MD
California
[Chapters 12, 23, 27, 29)
John Nuhn, MD
California
[Chapters 8, 28, 37]
Carolyn Pearce, MD
California
[Chapters 10, 11, 21, 22)
Magdalena Reinsvold, MD
California
[Chapters 6, 9, 18, 20, 32, 38)
CONTRIBUTORS
xvii
James Rohlfing, MD
California
[Chapters 33, 34)
Kristi M. Schoeld, MD
California
[Chapters 4, 7, 16, 19)
Tanya Shah, MD
California
[Chapters 26, 35)
Ian Wallace, MD
California
[Chapters 30, 31)
Zachary M. Zwolak, DO, FAAFP

Core Faculty, Family Medicine Residency Program, Ventura Country Medical
Center, Assistant Clinical Professor of Medicine, UCLA School of Medicine,
[Chapters 33, 34)
Preface
Current Practice Guidelines in Primary Care 2020 is intended for all clinicians
interested in updated, evidence-based guidelines for primary care topics in both
the ambulatory and hospital settings. This handy reference consolidates informa-
tion from nationally recognized medical associations and government agencies into
concise recommendations and guidelines of virtually all ambulatory care topics.
This book is organized into topics related to disease screening, disease prevention,
and disease management, and further subdivided into organ systems, for quick ref-
erence to the evaluation and treatment of the most common primary care disorders.
The 2020 edition of Current Practice Guidelines in Primary Care contains
updates reflecting more than 150 new guidelines, and nearly 30 new sections on
topics including transgender health, opiate use disorder, systemic lupus erythema-
tosus, rotator cuff injury, and abortion. It is a great resource for residents, medical
students, midlevel providers, and practicing physicians in family medicine, internal
medicine, pediatrics, and obstetrics and gynecology.
Although painstaking efforts have been made to find all errors and omissions,
some errors may remain. If you find an error or wish to make a suggestion, please
e-mail us at EditorialServices@mheducation.com.
Jacob A. David, MD, FAAFP

Screening
Behavioral Health
Disorders
ALCOHOL ABUSE AND DEPENDENCE
Population
-Adults older than 18 y of age.
Recommendations
~ CDC 2018, USPSTF 2018, ASAM 1997
-Screen all adults in primary care settings, including pregnant women,
for alcohol misuse.
-If positive screen for risky or hazardous drinking, provide brief
behavioral counseling interventions to reduce alcohol misuse.
Sources
-CDC. Alcohol Screening and Brief Intervention for People Who Consume
Alcohol and Use Opioids. 2018.
-USPSTF. JAMA. 2018;320(18):1899-1909.
-ASAM. Public Policy Statement on Screening/or Addiction in Primary
Care Settings. 1997.
Comments
1. Screen regularly using a validated tool such as the AUDIT, CAGE, or
MAST questionnaires.
2. The TWEAK and the T-ACE are designed to screen pregnant women
for alcohol misuse.
Population
-Children and adolescents.
SECTION 1: SCREENING
Recommendation
~ USPSTF 2018
- Insufficient evidence to recommend for or against screening or
counseling interventions to prevent or reduce alcohol misuse by
adolescents.
Source
-USPSTF. JAMA. 2018;320(18):1899-1909.
Comments
1. Screen using a tool designed for adolescents, such as the CRAFFT,
BSTAD, or S2BI.
2. Reinforce not drinking and driving or riding with any driver under the
influence.
3. While behavioral counseling has been proven to be beneficial in
adults, data do not support its benefit in adolescents.
DEPRESSION
Population
-Children aged 11 y and younger.
Recommendation
~ USPSTF 2016
-Insufficient evidence to recommend for or against routine screening.
Source
-USPSTF. Depression in Children and Adolescents: Screening. 2016.
Population
-Adolescents.
Recommendation
~ USPSTF 2016
-Screen all adolescents age 12-18 y for major depressive disorder
(MDD). Systems should be in place to ensure accurate diagnosis,
effective treatment, and adequate follow-up.
Source
-USPSTF. Depression in Children and Adolescents: Screening. 2016.
Comments
1. Screen in primary care clinics with the Patient Health Questionnaire
for Adolescents (PHQ-A) (73% sensitivity; 94% specificity) or the
Beck Depression Inventory-Primary Care (BDI-PC) (91 % sensitivity;
91 % specificity). See Chapter 39.
BEHAVIORAL HEALTH DISORDERS
2. Treatment options include pharmacotherapy (fluoxetine and escitalo-

pram have FDA approval for this age group), psychotherapy, collabora-
tive care, psychosocial support interventions, and CAM approaches.
3. SSRI may increase suicidality in some adolescents, emphasizing the
need for close follow-up.
Population
-Adults.
Recommendation
~ USPSTF 2016
- Recommend screening adults for depression, including pregnant and
postpartum women. Have staff-assisted support systems in place for
accurate diagnosis, effective treatment, and follow-up.
Source
-USPSTF. Depression in Adults: Screening. 2016.
Comments
1. PHQ-2 is as sensitive (96%) as longer screening tools:
a. "Over the past 2 wk, have you felt down, depressed, or hopeless?"
b. "Over the past 2 wk, have you felt little interest or pleasure in doing
things?"
2. Optimal screening interval is unknown.
ILLICIT DRUG USE
Population
-Adults, adolescents, and pregnant women.
Recommendation
~ USPSTF 2008
- Insufficient evidence to recommend for or against routine screening for
illicit drug use.
Source
- USPSTF. Drug Use, Illicit: Screening. 2008.
TOBACCO USE
Population
- Adults including pregnant women.
Recommendation
AAFP 2015, USPSTF 2015
- Recommend screening all adults for tobacco use and provide tobacco
cessation interventions for those who use tobacco products.
Source
-USPSTF. Tobacco Smoking Cessation in Adults, Including Pregnant
Women: Behavioral and Pharmacotherapy Interventions. 2015.
Comment
1. Provide some type of SBIRT (Screening, Brief Intervention, and
Referral to Treatment) such as:
a. The "5-K framework is helpful for smoking cessation counseling:
i Ask about tobacco use.
ii. Advise to quit through clear, individualized messages.
iii. Assess willingness to quit.
iv. Assist in quitting.
v. Arrange follow-up and support sessions.
Population
-School-aged children and adolescents.
Recommendation
USPSTF 2013
- Recommends that primary care clinicians provide interventions
including education or brief counseling to prevent the initiation of
tobacco use.
Comment
1. The efficacy of counseling to prevent tobacco use in children and
adolescents is uncertain.
Source
- USPSTF. Tobacco Use in Children and Adolescents: Primary Care
Interventions. 2013.
Cardiovascular
Disorders
ABDOMINAL AORTIC ANEURYSM
Population
-Men age ~65y.
Recommendations
~ USPSTF 2014, ACC/AHA 2006, Canadian Society for Vascular
Surgery 2006, Society for Vascular Surgery 2018
-Screen once before age 75, with ultrasound, if they have ever smoked.
~ Canadian Society for Vascular Surgery 2018
-Screen once between age 65 and 80 y with ultrasound, regardless of
smoking history.
~ ESVS 2011
-Screen once with ultrasound at age 65 y if have smoked > 100 cigarettes
lifetime or have a family history of AAA.
~ ESVS2014
-Screen with ultrasound all men >65 y of age.
~ ACRa/AIUM/SRU 2014
-Screen with ultrasound all men ~65 y (or ;::: 50 y with family history of
aneurysmal disease) and women 2:65 y with cardiovascular risk factors.
- Patients 2: 50 y with a family history of aortic and/or peripheral
vascular aneurysmal disease.
- Patients with a personal history of peripheral vascular aneurysmal
disease.
-Groups with additional risk include patients with a history of smoking,
hypertension, or certain connective tissue diseases ( eg, Marfan
syndrome).
-ACR-AIUM-SRU Practice Parameter for the Performance of

Diagnostic and Screening lntrasound of the Abdominal Aorta in
Adults. 2014.
.... Society for Vascular Surgery 2018
-Screen once with ultrasound between age 65 and 75 if ever smoked, or
after 75 if in "good health" and never screened previously.
Sources
-Ann Intern Med. 2014;161(4):281-290.
-l Vase Surg. 2007;45:1268-1276.
-Moll FL, Powell JT, Fraedrich G, et al Management of abdominal aortic
aneurysms clinical practice guidelines of the European Society for
Vascular Surgery. Eur I Vase Endovasc Surg. 2011;(41):Sl-S58.
- Erbel R, Aboyans V, Boileau C, et al 2014 ESC guidelines on the
diagnosis and treatment of aortic diseases. Bur Heart f. doi:l0.1093/
eurheartj/ehu281
-ACR-AIUM-SRU Practice Parameter for the Performance ofDiagnostic
and Screening Ultrasound of the Abdominal Aorta in Adults. 2014.
-l Vase Surg. 2018;67(1):2-77.
-https:// canadianvascular.ca/Clinical-Guidelines
Population
-Women age 2::65 y.
Recommendation
.._ Canadian Society for Vascular Surgery 2018
-Consider screening once between age 65 and 80 y if history of smoking
or cardiovascular disease.
Source
-https:// canadianvascular.ca/Clinical-Guidelines
ATRIAL FIBRILLATION
Population
-Asymptomatic adults over age 65.
Recommendation
.... USPSTF 2018
- Insufficient evidence to recommend routine ECG screening for atrial
fibrillation to impact risk of stroke from untreated atrial fibrillation.
Source
-JAMA. 2018;320(5):478-484.
CARDIOVASCULAR DISORDERS
CAROTID ARTERY STENOS IS (CAS) (ASYMPTOMATIC)
Population
-Asymptomatic adults.
Recommendations
~ ASN 2007, USPSTF 2014, AHNASA 2011, ACCF/ACR/AIUM/
ASE/ASN/ICAVUSCAl/SCCT/SIR/SVM/SVS 2011, AAFP 2013
- Do not screen the general population or a selected population based on
age, gender, or any other variable alone.
-Do not screen asymptomatic adults.
Sources
-l Neuroimaging. 2007;17:19-47.
-USPSTF. Carotid Artery Stenosis: Screening. 2014.
-l Am Coll Cardiol. 2012;60(3):242-276.
-Choosing Wisely: American Academy of Family Physicians. 2013.
-Stroke. 2011;42(2):e26.
Recommendation
~ ACR-AIUM-SRU 2016, ACC/AHNASNACR/SVS 2011
-Indications for carotid ultrasound: evaluation of patients with a cervical
bruit, not routine screening.
Sources
-Stroke. 2011;42(8):e464-e540.
-ACR-AIUM-SPR-SRU Practice Parameter for the Performance ofan
Ultrasound Examination of the Extracranial Cerebrovascular System.
2016. http://www.acr.org/-/media/ACR/Documents/PGTS/guidelines/
US_Extracranial_Cerebro.pdf
Recommendation
~ Society of Thoracic Surgeons 2013
-Do not routinely evaluate for carotid artery disease prior to cardiac
surgery in the absence of symptoms or other high-risk criteria.
Source
-Choosing Wisely: Society of Thoracic Surgeons. 2013.
Comments
1. The prevalence of internal CAS of ;:::70% varies from 0.5% to 8%
based on population-based cohort utilizing carotid duplex ultrasound.
For population age >65 y, estimated prevalence is 1%. No risk
stratification tool further distinguishes the importance of CAS. No
evidence suggests that screening for asymptomatic CAS reduces fatal
or nonfatal strokes.
2. Carotid duplex ultrasonography to detect CAS ~60%; sensitivity, 94%;

specificity, 92%. (Ann Intern Med. 2007;147(12):860)
3. If true prevalence of CAS is 1%, number needed to screen to prevent
1 stroke over 5 y = 4368; to prevent 1 disabling stroke over 5 y =
8696. (Ann Intern Med. 2007;147(12):860)
CHOLESTEROL AND LIPID DISORDERS
Population
-Asymptomatic adults 40-79 y.
Recommendations
..... ACC/AHA2013
-Perform 10-y ASCVD Risk Score.
-High-risk categories include:
•Primary elevation of LDL-C ~190 mg/dL.
•Diabetes (type 1or2) with LDL-C 70-189 mg/dL and without
clinical ASCVD.
• Without clinical ASCVD or diabetes with LDL-C 70-189 mg/dL
and estimated 10-y ASCVD Risk Score ~7.5%.
..... ESC2016
-Perform SCORE risk assessment tool available at: www.heartscore.org
-Secondary hyperlipidemia should be ruled out.
-Total cholesterol and LDL-C primary target: goal LDL :570 mg/dL in
patients with very high CV risk, LDL :5100 mgldL in patients with high
CV risk.
-Secondary targets are non-HDL-C and ApoB.
-HDL is not recommended as a target for treatment.
...,. Canadian Cardiovascular Society 2016
-Screen all men/women over age 40, or those of any age at high risk
(clinical evidence of atherosclerosis, AAA, DM, HTN, cigarette
smoking, stigmata of dyslipidemia, family history of early CVD or
dyslipidemia, CKD, BMI >30, inflammatory bowel disease, HIV,
erectile dysfunction, COPD, hypertensive diseases of pregnancy).
-Nonfasting lipid tests are acceptable.
-Repeat a risk assessment using Framingham or Cardiovascular Life
Expectancy Model every 5 y or as clinical circumstances dictate.
Sources
-Circulation. 2013;2013;01.cir.0000437738.63853.7a.
- European Society of Cardiology. Dyslipidaemias 2016.

-Canadian Journal of Cardiology. 2016;32( 11):1263-1282.
Comment
1. Prior to initiating statin therapy, perform lipid panel, ALT, HgbAlc
to RIO DM, and baseline CK (if patient is at increased risk for muscle
events based on personal or family history of statin intolerance).
Population
-Adults with diabetes.
Recommendations
~ ADA2013
- Measure fasting lipids at least annually in adults with diabetes.
-Every 2 y for adults with low-risk lipid values (LDL-C <100 mg/dL,
HDL-C >50 mgldL, TG <150 mgldL).
Source
-Diabetes Care. 2013;36(suppl l):Sl l-S66.
Population
-Adults >20 y.
Recommendations
~ NLA2014
-Fasting lipid profile (LDL-C and TG) or nonfasting lipid panel
(non-HDL-C and HDL-C) should be measured at least every 5 y.
-Also assess ASCVD risk.
-Non-HDL-C (primary target), ApoB (secondary target) have more
predictive power than LDL-C.
-Apolipoprotein B (ApoB) is considered an optional, secondary target
for therapy. More predictive power than LDL-C, but not consistently
superior to non-HDL-C.
-HDL-C is not recommended as a target therapy.
Source
-l Clin Lipidol. 2014;8:473-488.
Comment
1. Non-HDL-C values:
a. Desirable <130 mg/dL.
b. Above desirable 130-159.
c. Borderline high 160-189.
d. High 190-219.
e. Very high ~220.
CHOLESTEROL GUIDELINES
Recommended
LIpoprotein Recommended
Measurements Upoprotein Recommended
for Risk Targets of Risk Assessment
Source Assessment Therapy Algorithm
National Cholesterol Fasting lipid panel Primary Identify number of
Education Program Calculation of non- target: LDL-C CH Drisk factors
AdultTreatment HDL-C when TG Secondary target: Framingham 10-y
Panel Ill >200mg/dl non-HDL-C absolute CHD risk
International Fasting lipid panel Non-HDL-C Lifetime risk of total
Atherosclerosis with calculation LDL-C is considered ASCVD morbidity/
Society of non-HDL-C alternative target mortality (by
of therapy Framingham, CV
Lifetime Risk pooling
project, or QRisk)
European Society of Fasting lipid Primary 10-y risk of total
Cardiology/European panel with target: LDL-C fatal ASCVD by the
Atherosclerosis calculation of Secondary targets: Systematic Coronary
Society non-HDL-C and non-HDL or ApoB Risk Evaluation
TC/HDL-C ratio in patients with (SCORE) system
ApoB or ApoB/ cardiometabolic
apoAl ratio risk
are considered
alternative risk
markers
Canadian European Society Primary 10-y risk of total
Cardiovascular of Cardiology/ target: LDL-C ASCVD events by
Society European Secondary targets: the Framingham
Atherosclerosis non-HDL-C Risk Score
Society andApoB
American Association Fasting lipid panel Primary Men: Framingham Risk
of Clinical Calculation of targets: LDL-C Score (10-y risk of
Endocrinologists non-HDL-C Secondary targets: coronary event)
isa more non-HDL-Cin Women: Reynolds
accurate risk patients with Risk Score (10-y risk
assessment ifTG ea rdiometa bol ic of coronary event,
is between 200 risk or established stroke, or other
and 500 mg/dl, CADApoB major heart disease)
diabetes, insulin recommended to
resistance, or assess success of
established CAD LDL-C-lowering
therapy
American Diabetes Stronger risk Strong 30-y/lifetime global

Association/ discrimination recommendation ASO/Drisk
American Heart provided by for ApoBand
Association non-HDL-C, non-HDL-C as
Statement on ApoB, LDL-P secondary targets
Cardiometabolic Risk
American Diabetes Fasting lipid panel LDL-C Not applicable in
Association: setting of diabetes
Standards of Medical (CHD risk equivalent)
Care in Diabetes
Kidney Disease: Fasting lipid panel None: therapy CKD considered CHO
Improving Global to screen for guided by risk equivalent
Outcomes: Clinical more severe absolute risk of Treatment with
Practice Guideline for forms of coronary event evidence-based
Lipid Management dyslipidemia based on age, statins/statin doses
in Chronic Kidney and secondary and stage of CKD based on age, and
Disease causes of oreGFR stage of CKD or eG FR
dyslipidemia
Secondary Prevention Fasting lipid panel Primary target: N/A

of Atherosclerotic Calculation of LDL-CSecondary
Cardiovascular non-HDL-C when target: non-HDL-C
Disease in Older TG >200 mg/dl
Adults: A Scientific
Statement from
the American Heart
Association
National Lipid Fasting lipid panel LDL-C Not applicable due
Association: Familial to extremely high
Hypercholesterolemia lifetime risk
Expert Panel on Fasting lipid panel Primary No risk algorithm,

Integrated Guidelines with calculation target: LDL-C treatment based
for Cardiovascular of non-HDL-C Secondary target: on the number of
Health and Risk non-HDL-C ASO/D risk factors
Reduction in Children
and Adolescents
CHOLESTEROL GUIDELINES (Continued)

Recommended
LIpoprotein Recommended
Measurements Upoprotein Recommended
for Risk Targets of Risk Assessment
Sourw Assessment Therapy Algorithm
AHA Women's Fasting lipid panel LDL-C Updated Framingham
Cardiovascular Consider hs-CRP risk profile (coronary,
Disease Prevention in women >60 cerebrovascular, and
Guidelines yand CHD peripheral arterial
risk >10% disease and heart
failure events)
Reynolds Risk Score
(10-y risk of coronary
event, stroke, or
other major heart
disease)
2013 American Fasting lipid panel LDL-C measured 0/ Risk Calculator
College of to screen for for assessment based on Pooled
Cardiology/American more severe of therapeutic Risk Equations (10-y
Heart Association: forms of response and risk of total ASCVD
Blood Cholesterol dyslipidemia compliance events)
Guidelines for ASCVD and secondary Therapy guided Lifetime risk provided
Prevention causes of by identification for individuals 20-59
dyslipidemia of 40 categories yof age
of patients who
benefit from high-
or moderate-dose
statin therapy
apoA1, apolipoprotein A1; ApoB, apolipoprotein B; ASOJD, atherosclerotic cardiovascular
disease; CAD, coronary artery disease; CHO, coronary heart disease; CKD, chronic
kidney disease; 0/, cardiovascular; eGFR. estimated glomerular filtration rate; HDL-C,
high-density lipoprotein cholesterol; hs-CRP, high-sensitivity (-reactive protein; LDL-C,
low-density lipoprotein-cholesterol; LDL-P, low-density lipoprotein particle; TC, total
cholesterol; TG, triglycerides.
Sourrt: Morris PB, Ballantyne CM, et al. Review of clinical practice guidelines for the management of LDL-related
risk.JA«. 2014;64(2):196-206.
CORONARY ARTERY DISEASE
Population
-Adults at low risk of CHD events.•
Recommendations
~ AAFP 2012, USPSTF 2018, American College of Physicians
2012, American Society of Echocardiography 2013,
American College of Cardiology 2013
-Do not routinely screen men and women at low risk for CHD riskb with
resting electrocardiogram (ECG), exercise treadmill test (ETT), stress
echocardiogram, or electron-beam CT for coronary calcium.
-Do not screen with stress cardiac imaging or advanced non-invasive
imaging in the initial evaluation of patients without cardiac symptoms,
unless high-risk markers are present.
-Do not perform annual stress cardiac imaging or advanced
non-invasive imaging as part of routine follow-up in asymptomatic
patients.
Sources
-AAFP Clinical Recommendation: Coronary Heart Disease. 2012.
-Choosing Wisely: American College of Physicians. 2012. http://www.
choosingwisely.org/societies/american-college-of-physicians/
-Choosing Wisely: American Academy of Family Physicians. 2013.
http:/ /www.choosingwisely.org/societies/american-academy-of-family-
physicians/
-Choosing Wisely. American Society of Echocardiography. 2012. http://
www.choosingwisely.org/societies/american-society-of-
echocardiography/
-Choosing Wisely: American College of Cardiology. 2014. http://www.
choosingwisely.org/societies/american-college-of-cardiology/
-Ann Intern Med. 2012;157:512-518.
-JAMA. 2018;319(22):2308-2314.
•Increased risk for CHD events: older age, male gender, high BP, smoking, elevated lipid levels,
diabetes, obesity, sedentary lifestyle. Risk assessment tool for estimating 10-y risk of developing
CHD events available online, http://cvdrisk.nhlbi.nih.gov/calculator.asp, or see Appendices VI
and VIL
•AHA scientific statement (2006): Asymptomatic persons should be assessed for CHD risk.
Individuals found to be at low risk (<103 10-y risk) or at high risk (>20% 10-yrisk) do not benefit
from coronary calcium assessment. High-risk individuals are already candidates for intensive
risk-reducing therapies. In clinically selected, intermediate-risk patients, it may be reasonable to use
electron-beam CT or multidetector computed tomography (MDCT) to refine clinical risk prediction
and select patients for more aggressive target values for lipid-lowering therapies (Circulation.
2006;114:1761-1791).
Comment
1. USPSTF recommends against screening asymptomatic individuals
because of the high false-positive results, the low mortality with
asymptomatic disease, and the iatrogenic diagnostic and treatment
risks.
Population
-All asymptomatic adults age ~20 y.
-Risk score assessment.
Recommendations
ACC/AHA 2013, ESC 2012
-ASCVD Risk Score has replaced the FRS in the United States for
patients age 40-79 y.
- Assess 10-y ASCVD Risk Score every 4-6 y.
- Framingham Risk Score (FRS), including blood pressure (BP) and
cholesterol level, should be obtained in asymptomatic adults age ~20 y.
- The SCORE Risk Score remains the screening choice in Europe.
- No benefit in genetic testing, advanced lipid testing, natriuretic peptide
testing, high-sensitivity C-reactive protein (CRP), ankle-brachia!
index, carotid intima-medial thickness, coronary artery score on
electron-beam CT, homocysteine level, lipoprotein (a) level, CT
angiogram, MRI, or stress echocardiography regardless of CHD risk.
Sources
-Circulation. 2007;115:402-426.
- l Am Coll Cardiol. 2010;56(25):2182-2199.
Population
-Adults at intermediate risk of CHD events.
Recommendations
ACC/AHA 2013, ESC 2012
- May be reasonable to consider use of coronary artery calcium
and high-sensitivity CRP (hs-CRP) measurements in patients at
intermediate risk.
- hs-CRP is not recommended in low- or high-risk individuals.
Sources
- Bur Heart f. 2007;28(19):2375-2414.
- Bur Heartf. 2012;33:1635-1701.
-l Am Coll Cardiol. 2007;49:378-402.
- Circulation. 2013;2014;129(25 Suppl 2):S49-S73.
Comment
1. 10-y ASCVD risk calculator (The Pooled Cohort Equation) can be
found at: http://tools.acc.org/ASCVD-Risk-Estimator/
Population
-Adults at high risk of CHD events.
Recommendations
~ AAFP 2012, AHA 2007, USPSTF 2012
- Insufficient evidence to recommend for or against routine screening
with ECG, ETT.
-In addition, there is insufficient evidence to recommend routine MRI.
Sources
-Arch Intern Med. 2011;171(11):977-982.
-AAFP Clinical Recommendations: Coronary Heart Disease. 2012.
-Ann Intern Med. 2012;157:512-518.
Population
-Men and women with no history of CHD.
Recommendation
~ USPSTF 2009
-Insufficient evidence to assess the balance of benefits and harms of
using the nontraditional risk factors to prevent CHD events (hs-CRP,
ankle-brachia! index [ABI], leukocyte count, fasting blood glucose
level, periodontal disease, carotid intima-media thickness, coronary
artery calcification [CAC] score on electron-beam computed
tomography, homocysteine level, and lipoprotein [a] level).
Source
- USPSTF. Coronary Heart Disease: Screening Using Non-Traditional Risk
Factors. 2009.
Comment
1. 10-y ASCVD risk calculator (The Pooled Cohort Equation) can be
found at: http://tools.acc.org/ASCVD-Risk-Estimator/
Population
-Women.
Recommendations
~ ACCF/AHA 2011
-Cardiac risk stratification by the Framingham Risk Score should be
used. High risk in women should be considered when the risk is ~10%
rather than ;:::20%.
-An alternative 10-y risk score to consider is the Reynolds Risk Score,
although it requires measurement of hs-CRP.
Source
-! Am Coll Cardiol. 2011;57(12):1404-1423.
Population
-Adults with stable CAD.
Recommendation
~ CCS2013
-Risk assessment by Framingham Risk Score should be completed
every 3-5 y for men age 40-75 y and women age 50-75 y. Frequency
of measurement should increase if history of premature cardiovascular
disease (CVD) is present. Calculate and discuss a patient's
"cardiovascular age" to improve the likelihood that the patient will
reach lipid targets and that poorly controlled hypertension will be
treated.
Source
-Can f Cardiol. 2013;29:151-167.
Recommendation
~ AAFP 2009, AHA/APA 2008
-All patients with acute myocardial infarction {MI) to be screened for
depression at regular intervals during and post hospitalization.
Sources
-Circulation. 2008;118:1768-1775.
-Ann Fam Med. 2009;7{1):71-79.
HYPERTENSION (HTN), ADULTS
Population
-Adults age >18 y.
Recommendations
~ USPSTF 2015, AAFP 2009, CHEP 2015, ESH/ESC 2013,
Canadian Task Force on Preventive Health Care 2013
-Screen for HTN.
-HTN is > 140/90 mm Hg on two or more BP readings.
-All adults should have their BP assessed at all appropriate clinical visits.
-Ambulatory BP monitoring {ABPM) is the standard to confirm
diagnosis.
-Annual F/U of patients with high-normal BP (2-y risk of developing

HTN is40%).
Sources
-Am Fam Physician. 2009;79(12):1087-1088.
-http://www.aafp.org/online/en/home/clinical/exam.html
-USPSTF. High Blood Pressure in Adults: Screening. 2015.
-Hypertension Canada: http://www.hypertension.ca/en/chep
-Can Fam Physician. 2013;59(9):927-933.
-l Hypertens. 2007;25:1105.
-Eur Heart J. 2013;34:2159-2219.
Recommendations
~ ESH/ESC 2013
-In cases of severe BP elevation, especially if associated with end-organ
damage, the diagnosis can be based on measurements taken at a
single visit.
-In asymptomatic subjects with hypertension but free of CVD,
chronic kidney disease (CKD), and diabetes, total cardiovascular risk
stratification using the SCORE model is recommended as a minimal
requirement.
Sources
-J Hypertens. 2007;25:1105.
-Eur Heart]. 2013;34:2159-2219.
Comments
1. Electronic (oscillometric) measurement methods are preferred to
manual measurements. Routine auscultatory Office BP Measurements
(OBPMs) are 9/6 mm Hg higher than standardized research BPs
(primarily using oscillometric devices). (CHEP, 2015)
2. Confirm diagnosis out-of-office before starting treatment.
3. ABPM has better predictive ability than OBPM.
4. Home BP Measurement (HBPM) is recommended if ABPM is not tol-
erated, not readily available, or due to patient preference; 15%-30% of
elevations by OBPM will have lower BP at home. (USPSTF, 2015)
5. Assess global cardiovascular risk in all hypertensive patients. Inform-
ing patients of their global risk ("vascular age") improves the effective-
ness of risk factor modification.
Population
-Age >18y.
Recommendation
JNC 8 2014
- Treatment thresholds:
• Age ~ 60: 150/90.
•Age < 60: 140/90.
• DM or CKD: 140/90.
Source
- JAMA. 2014;311 (5):507-520.
Comment
1. "Hypertension" and "pre-hypertension" are no longer defined.
Population
-Age > 65y.
Recommendation
ACCF/AHA 2011
-Identification and treatment of systolic and diastolic HTN in the very
elderly are beneficial in the reduction of all-cause mortality and stroke
death.
Source
-J Am Coll Cardiol. 2011;57(20):2037-2110.
Comments
1. Increased frequency of systolic HTN compared with younger
patients.
2. HTN is more likely associated with end-organ damage and more
often associated with other risk factors.
PERIPHERAL ARTERY DISEASE
Population
Recommendation
USPSTF 2018
- Insufficient evidence to recommend for or against routine screening
with Ankle-Brachia! Index.
Source
-JAMA. 2018;320(2):177-183.
SLEEPAPNEA
Population
Recommendation
~ USPSTF 2017, AAFP 2017
- Insufficient evidence to recommend for or against routine screening.
Sources
-AAFP. Obstructive Sleep Apnea in Adults: Screening. 2017.
-JAMA. 2017;317(4):407-414.
TOBACCO USE
Population
-Adults.
Recommendation
~ AAFP 2015, USPSTF 2015, ICSI 2014
-Recommend screening all adults for tobacco use and provide tobacco
cessation interventions for those who use tobacco products.
Sources
-AAFP Clinical Preventive Service Recommendation: Tobacco Use. 2015.
-USPSTF. Tobacco Smoking Cessation in Adults, Including Pregnant
Women: Behavioral and Pharmacotherapy Interventions. 2015.
-ICSI. Preventive Services for Adults. 20th ed. 2014.
Comment
I. The "5-K framework is helpful for smoking cessation counseling:
a. Ask about tobacco use.
b. Advise to quit through clear, individualized messages.
c. Assess willingness to quit.
d. Assist in quitting.
e. Arrange follow-up and support sessions.
Disorders of the
Skin, Breast, and
Musculoskeletal
System
BREAST CANCER
Population
-Women.
Recommendations
~ USPSTF 2016
-Age 40-49 y: Individualize assessment of breast cancer risk;
incorporate woman's preference and cancer risk profile to determine
whether to screen.
-Age ~50-75 y: Mammography every 2 y, with or without clinical breast
exam.
-Age >75 y: Inconclusive data for screening.
~ ACS2016
-Age 20-40 y: Advise women to report lumps or breast symptoms.
-Age 40-44 y: Allow women to begin annual screening if desired.
-Age 45-54 y: Mammography every year.
-Age ~55 y: Mammography every 1-2 y as long as overall health is good
and life expectancy is ~ 10 y.
-Do not use clinical breast examination for screening.
~ NCCN2018
-Age 25-40 y: Teach breast awareness.
-Age 40-80 y: Mammography and clinical encounter annually.
-Age >80 y: Do not screen.
Sources
-http://www.cancer.org
-Ann Intern Med. 2012;156:609.
-Ann Intern Med. 2014;160:864.
Another random document with
no related content on Scribd:
be in the Scheldt, struggling in his gun-boat against a gale which, in
spite of all his endeavors and seamanship, drove him ashore, under
the guns of the Belgians. A crowd of Belgian volunteers leaped
aboard, ordered him to haul down his colors and surrender. Von
Speyk hurried below to the magazine, fell upon his knees in prayer,
flung a lighted cigar into an open barrel of powder, and blew his ship
to atoms, with nearly all who were on board. If he, by this sacrifice,
prevented a Dutch vessel from falling into the enemy’s power, he
also deprived Holland of many good seamen. The latter country,
however, only thought of the unselfish act of heroism, in one who
had been gratuitously educated in the orphan house at Amsterdam,
and who acquitted his debt to his country, by laying down his life
when such sacrifice was worth making. His king and countrymen
proved that they could appreciate the noble act. The statue of Von
Speyk was placed by the side of that of De Ruyter, and the
government decreed that as long as a Dutch navy existed there
should be one vessel bearing the name of Von Speyk.
To return to the knights of earlier days, I will observe that indifferent
as many of them were to meeting death, they, and indeed other men
of note, were very far from being so as to the manner in which they
should be disposed of after death. In their stone or marble coffins,
they lay in graves so shallow that the cover of the coffin formed part
of the pavement of the church. Whittingham, the Puritan Dean of
Durham, took up many of their coffins and converted them into horse
or swine troughs. This is the dean who is said to have turned the
finely-wrought holy-water vessels into salting-tubs for his own use.
Modern knights have had other cares about their graves than that
alluded to above. Sir William Browne, for instance, one of George
II.’s knights, and a medical man of some repute, who died in 1770,
ordered by his will that when his coffin was lowered into the grave,
there should be placed upon it, “in its leathern case or coffin, my
pocket Elzevir Horace, comes viæ vitæque dulcis et utilis, worn out
with and by me.” There was nothing more unreasonable in this than
in a warrior-knight being buried with all his weapons around him.
And, with respect to warrior-knights and what was done with them
after death, I know nothing more curious than what is told us by
Stavely on the authority of Streder. I will give it in the author’s own
words.
“Don John of Austria,” says Stavely, “governor of the Netherlands for
Philip II. of Spain, dying at his camp at Buge” (Bouges, a mile from
Namur), “was carried from thence to the great church at Havre,
where his funeral was solemnized and a monument to posterity
erected for him there by Alexander Farnese, the Prince of Parma.
Afterward his body was taken to pieces, and the bones, packed in
mails, were privately carried into Spain, where, being set together
with small wires, the body was rejointed again, which being filled or
stuffed with cotton, and richly habited, Don John was presented to
the King, entire, leaning upon his commander’s staff, and looking as
if he were alive and breathing. Afterward the corpse being carried to
the Church of St. Laurence, at the Escurial, was there buried near
his father, Charles V., with a fitting monument erected for him.”
Considering that there was, and is, a suspicion that Philip II. had
poisoned his kinsman, the interview must have been a startling one.
But Philip II. was not, perhaps, so afraid of dead men as the fourth
Spanish king of that name. Philip IV., by no means an unknightly
monarch, was born on a Good Friday, and as there is a Spanish
superstition that they who are born on that day see ghosts whenever
they pass the place where any one has been killed or buried, who
died a violent death, this king fell into a habit of carrying his head so
high, in order to avoid seeing those spirits, that his nose was
continually en l’air, and he appeared to see nobody.
Romance, and perhaps faithful history, are full of details of the
becoming deaths of ancient knights, upon the field. I question,
however, if even Sir Philip Sidney’s was more dignified than that of a
soldier of the 58th infantry, recorded in Nichols’s “Anecdotes of the
Eighteenth Century.” A straggling shot had struck him in the
stomach. As he was too dreadfully wounded to be removed, he
desired his comrades would pray by him, and the whole guard knelt
round him in prayer till he died. Bishop Hurd remarked, when this
was told him, that “it was true religion.” There was more of religion in
such sympathy than there was of taste in the condolence of Alnwick,
on the death of Hugh, Duke of Northumberland—a rather irascible
officer, and Knight of the Garter. “O,” cried the Alnwick poet—
“O rueful sight! Behold, how lost to sense

The millions stand, suspended by suspense!”
But all fruitlessly were the millions so suspended, for as the minstrel
remarked in his Threnodia—
“When Time shall yield to Death, Dukes must obey.”
“Dying in harness,” is a favorite phrase in chivalric annals to illustrate

the bravery of a knight falling in battle, “clothed in complete steel.”
So to die, however, was not always to die in a fray. Hume says of
Seward, Earl of Northumberland, that there are two circumstances
related of him, “which discover his high sense of honor and martial
disposition. When intelligence was brought to him of his son
Osborne’s death, he was inconsolable till he heard the wound was
received on his breast, and that he had behaved with great gallantry
in the action. When he found his own death approaching, he ordered
his servants to dress him in a complete suit of armor, and sitting
erect on the couch, with a spear in his hand, declared that in that
position, the only one worthy of a warrior, he would patiently await
the fatal moment.”
See how the chief of many a field

Prepares to give his latest breath;
And, like a well-trimmed warrior, yield
Becomingly t’impending death—
That one, stern conqueror of all,
Of chieftain in embattled tower,
Of lord within his ancient hall,
And maiden in her trellised bower.
To meet that surest of all foes,

From off his soft and pillowed bed,
With dignity old Seward rose,
And to a couch of state was led.
Fainting, yet firm of purpose there,
Stately as monarch on his throne,
Upright he sat, with kingly air,
To meet the coming foe, alone.
“Take from these limbs,” he weakly cried,

“This soft and womanish attire;
Let cloak and cap be laid aside—
Seward will die as died his sire:
Not clad in silken vest and shirt,
Like princes in a fairy tale;
With iron be these old limbs girt—
My vest of steel, my shirt of mail.
“Close let my sheaf of arrows stand;

My mighty battle-axe now bring;
My ashen spear place in my hand;
Around my neck my buckler sling.
Let my white locks once more be pressed
By the old cap of Milan steel;
Such soldier’s gear becomes them best—
They love their old defence to feel.
“’Tis well! Now buckle to my waist

My well-tried gleaming blade of Spain
My old blood leaps in joyful haste
To feel it on my thigh again.
And here this pendent loop upon,
Suspend my father’s dagger bright;
My spurs of gold, too, buckle on—
Or Seward dies not like a knight.”
’Twas done. No tear bedimmed his eyes—

His manly heart had ne’er known fear;
It answered not the deep-fetched sighs
Of friends and comrades standing near.
Death was upon him: that grim foe
Who smites the craven as the brave.
With patience Seward met the blow—
Prepared and willing for the grave.
The manner of the death, or rather of the dying of Seward, Earl of

Northumberland, was in part, unconsciously, imitated by the great
Mansfeldt. When the career of the latter was nearly at its close, his
fragile frame was already worn out by excess of action—his once
stout soul irritated by disappointment, and his former vigorous
constitution shattered by the ravages of a disease which had long
preyed on it in secret. The erst gallant knight lay helpless in the
miserable village of Zara, in Dalmatia. As he found his last moment
drawing near, he put on one of his richest uniforms, and girded his
favorite sword to his side. It was the one he most constantly carried
in battle. Thus accoutred, he summoned his chief officers to attend
him. He was held up by the two whom he most wished to distinguish,
because of their unwavering fidelity. Thus upheld, he exhorted all to
go on, unwearied, in the path of glory; and, living or dying, never to
bate a breath of inveterate hatred for Austria—whose government
has been accursed in all time, since there has been an Austria, for
its unmitigated infamy. “With the indifference of a man preparing for a
journey of no extraordinary importance,” thus speaks Naylor, when
describing the scene, “he continued tranquilly to converse with his
friends to the latest moment of his existence. His body was interred
with military pomp at Spalatio, in Dalmatia, at the expense of the
Venetians. Thus was the emperor delivered from an enemy who,
though often defeated, never ceased to be formidable; and whose
transcendent genius was so fertile in resources, that, without the
smallest funds to support the expenses of war, he maintained an
honorable contest during seven campaigns against the most
powerful monarchs in Europe.”
His hour at length is come:

The hero of a hundred fields,
Who never yielded, only yields
To Him who rules the tomb.
He whose loud trumpet’s blast,

Carried upon the trembling gale
The voice of death o’er hill and dale,
Is struck himself at last.
The same who, but of late,

Serenely saw destruction hurled,
And slaughter sweeping through the world,
Serenely meets his fate.
The spirit of the brave,
That led him o’er the embattled plain
’Gainst lines of foes, o’er countless slain,
Waits on him to the grave.
And with his latest breath

The warrior dons his proud array,
Prepared to meet, and to obey,
His last commander—Death!
The mournful tears and sighs

Fall not for him who, like the swan,
Wears his best plumes, sings sweetly on,
Sounds his last song—and dies!
With regard to the burial of knights, we may observe that, down to a

comparatively late period the knights and barons of England were
buried with much solemn splendor. At the obsequies of a baron,
there was an official present who wore the armor of the defunct,
mounted a horse in full trappings, and carried the banner, shield, and
helmet, of the deceased. So, in Henry the Eighth’s time, Lord William
Courtney was buried with the ceremonies observed at the funeral of
an earl, to which rank it had been the king’s intention to elevate him.
On this occasion Sir Edmund Carew, a gallant knight, rode into the
church in full armor, with the point of his battle-axe downward—a
token, like a reversed torch, of death.
The latest instance I have met with of a union of ancient and modern
customs at the burial of a knight, occurred at Treves, in 1781, at the
interment of the Teutonic knight, General Frederick Casimir. This
gallant soldier’s charger was led to the brink of the grave in which
the body had just been deposited; the throat of the steed was swiftly
cut by an official, and the carcass of the horse was flung down upon
the coffin of the knight. Such sacrifices were once common enough.
At the funerals in England of cavalry soldiers, or of mounted officers,
the horse is still processionally conducted to the brink of the grave,
but we are too wisely economical to leave him there, or to fling him
into it.
Where chivalry had great perils and temptations, we need not be
surprised to find that there were many scions of noble houses who
either declined to win spurs by encountering mortal danger, or who
soon grew weary of making the attempt. Let us, then, consider the
unambitious gentlemen who grew “tired of it.”
THE KNIGHTS WHO GREW “TIRED OF IT.”
“How blest are they that waste their weary hours
In solemn groves and solitary bower
Where neither eye nor ear
Can see or hear
The frantic mirth
And false delights of frolic earth;
Where they may sit and pant,
And breathe their pursy souls;
Where neither grief consumes, nor griping want
Afflicts, nor sullen care controls!
Away false joys! Ye murder where ye kiss;
There is no heaven to that, no life to this.”
Francis Quarles.
As marriage or the cloister was the alternative submitted to most

ladies in the days of old, so young men of noble families had small
choice but between the church and chivalry. Some, indeed,
commenced with arms, won knightly honors, cared nothing for them
when they had obtained the prize, and took up the clerical
profession, or entered monasteries. There are many distinguished
examples. There was first St. Mochua or Cluanus, who, after serving
in arms with great distinction, entered a monastery and took to
building churches and establishing cities. Of the former he built no
less than thirty; and he passed as many years in one church as he
had built of churches themselves. He was the founder of one
hundred and twenty cells. He is to be looked upon with respect. Old
warriors in our own days are often moved by the same impulse
which governed Mochua; and when we see retired admirals taking
the chair at meetings where Dr. Cumming is about to exhibit; or
infirm major-generals supporting, with unabated mental energy, their
so-called Puseyite pastors, we only look upon men who, acting
conscientiously, are worthy of respect, and are such Mochuas as
modern times and circumstances will admit of.
We have another example in Adelard, the cousin of Charlemagne.
He was a gay and gallant chevalier at his imperial cousin’s court,
and there was no stouter wielder of a sword in all the army; but
Alard, or Adelard, grew weary of camp and court alike. He fled from
some very pretty temptations in the one, as well as great perils in the
other. The young prince, he was only twenty, took the monastic habit
at Corbie, where he was employed as a gardener, and spoiled
cartloads of vegetables before he got his hand and his thoughts to
his new profession. He was occasionally busy too in the kitchen, but
not to the visible gratification of the monks. Charlemagne often
insisted on his appearing at court, where at last he held one or two
high offices; and, when he left, wrote a book for the guidance of
courtiers generally, by which the latter as little profited, say wicked
wits, as other nobility, for whom a nation has long prayed that grace,
wisdom, and understanding might be their portion. St. Adelard, for
the imperial knight was canonized, lived to be the chief authority in
the monastery where he had commenced as cook and gardener, and
St. Gerard composed an office in his honor, in gratitude for having
been cured of a violent headache through the saint’s interposition.
This seems to me one of the oddest ways of showing gratitude for a
small service that I ever heard of.
I believe that St. Cedd, Bishop of London, in very early days, was
also of a family whose profession was military. When or why he
entered the church I do not know; but he has some connection with
military matters in the fact that Tilbury Fort occupies part of the site
of a monastery which St. Cedd had founded, in which he resided,
and which was the pride of all the good people in the then pleasant
and prosperous city of Tillabury.
Touching St. Aldric, Bishop of Mans, there is no doubt whatever. He
was of a noble family, and commenced life at twelve years old, as
page to Louis le Debonnaire, at the court of Charlemagne. He was
speedily sick of the court, and as speedily sick of the camp. At the
age of twenty-one he withdrew to Metz, entered the clerical
profession, and became chaplain and confessor to the sovereign
whom he had once served as page. His military training made him a
very sharp disciplinarian during the quarter of a century that he was
bishop; and it is only to be regretted that he had not some influence
over the king whose conscience he directed, and of whom a legend
will be found in another part of this volume.
There was a second son of Eric, King of Denmark, known by the
name of St. Knudt or Canute. He was Duke of Schleswig, and was
much more of a monk than a duke. He was canonized accordingly
for his virtues. He had a rough way of joking. His knights were
nothing better than robbers and pirates, and he resolved to make
them forswear violence and live peaceably. They represented, in
vain, that they had a right to live as became knights, which Canute
did not dispute; he simply dissented from the construction of the right
as set down by the knights themselves. To prevent all mistakes on
the matter, he one day condemned seven of these gentlemen to be
hanged for acts of piracy. One of these exclaimed that, “fitting as the
sentence might be for his fellows, there must necessarily be
exemption for him.” He was like the German corporal in the “Etoile
du Nord,” who can very well understand that it is quite proper that a
man should be hanged, but could not comprehend that he himself
should be the man. The Schleswig knight claimed special exemption
on the ground that he was a kinsman of Canute. The latter allowed
that this entitled him to some distinction, and the saintly duke hung
his cousin six feet higher than any of his accomplices.
We come back more immediately to a knight who grew tired of his
vocation, in the person of Nathalan, a Scottish noble of the fifth
century. He sold arms, horses, and estate, divided the proceeds
among the poor, and devoted himself to preparations for ordination,
and the cultivation of vegetables. He bears a highly respectable
reputation on the roll of Bishops of Aberdeen.
We meet with a man more famous, in Peter of Sebaste, whose
pedigree showed more heroes than could be boasted by any of
Peter’s contemporaries. He is not an example, indeed, of a man
quitting the camp for the cloister; but he and two of his brothers
exhibit to us three individuals who might have achieved great worldly
profit, by adopting arms as a vocation, but who preferred the Church,
and became, all three, bishops.
We have a similar example in the Irish St. Felan. His high birth and
great wealth would have made him the flower of Irish chivalry, but he
selected another profession, and despising chivalry, entered the
Church. He went a Mundo ad Mundum, for it was from the hands of
Abbot Mundus that he received the monastic habit. Thus, as it was
wittily said, the world (Mundus) at once drove and drew him into the
Church. It is clear, however, that, like the old war-horse, he pricked
up his ears at the sound of battle, and took an interest in stricken
fields. To such conclusion we must come, if it be true, as is asserted
of him, that the battle of Bannockburn, in 1314, was won by Bruce
through the saint’s especial intercession. The Dukes of Normandy
owed equal obligations to St. Vaneng, who unbuckled the armor from
his aristocratic loins, to cover them with a frock; and built churches
for the Normans, where he offered up continual prayer for the
Norman dukes.
Then again, there was William Berringer, of the family of the Counts
of Nevers. No persuasion could induce the handsome William to
continue in the career he had embraced, the career of chivalry and
arms. His uncle, Peter the Hermit, may have had considerable
influence over him, and his change of profession was by no means
unprofitable, for the once horse-loving William became Archbishop of
Bourges: and he defended the rights of his Church against kings and
councils with as much boldness, zeal, and gallantry, as any knight
could have exhibited against the stoutest of assailants.
Among our English saints, the one who most nearly resembles him
is St. Egwin, who was of the royal blood of the Mercian kings, and
who, after a short trial of the profession of arms, retired to the
cloister, but was ultimately raised to the see of Worcester. The spirit
of the man may perhaps be seen through the legend which says that
on setting out on a penitential pilgrimage to Rome, he put iron
shackles on his legs, the key of which shackles he flung into the
Avon. This is very possible; but when we are told that on requiring
the key at a subsequent period, he found it inside a fish, we see that
the author of the legend has plagiarized from the original constructor
of the story of Polycrates and his ring.
St. Egwin was far less a benefactor to his fellow-men than St.
Benedict Biscop, a noble knight of the court of Oswi, the pious king
of the Northumbrians. When Benedict, or Bennet, as he is familiarly
called, retired from the profession of arms to follow that of the
Church, he continued quite as active, and twice as useful, as he had
been before. He was a great traveller, spent and gave liberally, and
brought over with him, from the continent, workers in stone to erect
that monastery at Weremouth which, in its ruins, commemorates his
name and deeds. He also brought from France the first glaziers who
ever exercised the art of glass-making in England. Altogether St.
Bennet is one of those who find means to effect good to others,
whatever may be the position they are in themselves.
Aelred of Ridal was a man of similar quality. He was a young North-
of-England noble, when he figured as the handsomest cavalier at the
court of that “sair saint to the Church,” the Scottish king, David. He
was remarkable for his good temper, and was as well-disciplined a
monk as he had been a military man; for when he once happened to
inadvertently break the rule of permanent silence, which prevailed in
the monastery at Ridal, into which he entered at the age of twenty-
five, he became so horror-stricken that he was eager to increase the
penalty put upon him in consequence. He had only dropped a single
word in the garden, to a monk who, like himself, had been a knight,
but who gave him in return so edifying a scowl, that in an instant
poor Aelred felt all the depth of his unutterable iniquity, and
accounted himself as criminal as if he had set fire to the neighboring
nunnery. He never afterward allowed himself the indulgence of
reading his favorite Cicero, but confined his reading to his own work
“On Spiritual Friendship,” and other books of a similar description.
The great St. Hilary was another of the men of noble family following
arms as a vocation, who gave up the profession for that of the
Church, and prospered remarkably in consequence. St. Felix of Nola
affords us an additional illustration of this fact. This noble young
soldier found no happiness in the business of slaughtering, and all
the sophistry in the world could not persuade him that it was
honorable. “It is a disgusting business,” said the Saint, “and as I can
not be Felix [happy] in performing it, I will see if I can not be Felix in
the Church;” and the punning saint found what he sought.
There is something more wonderful in the conversion of St. Maurus.
He was the son of a nobleman, had St. Benedict for a tutor, and was
destined to the career of arms. The tutor, however, having awoke
him one night, and sent him to pick a monk out of the river, whom
Benedict, in a dream, had seen fall in, Maurus, although no
swimmer, obeyed, walked upon the surface of the water, pulled out
the struggling monk, walked back with him, arm-in-arm, to the shore,
and immediately concluded that he was called to another vocation
than that of arms. As for St. John Calybyte, he would not be a
soldier, but ran away from home before his wealthy sire could
procure him a commission, and only returned to stand, disguised as
a mendicant, in front of his father’s house, where he received alms
till he died. A curious example of idiosyncrasy. St. Honoratus was
wiser. He was of a consular family; but, in declining the military
profession, he addressed himself with sincerity to be useful in the
Church; and the well-deserved result was that he became
Archbishop of Arles. St. Anthony, the patriarch of monks, made still
greater sacrifices, and chose rather to be a hermit than a
commander of legions. St. Sulpicius, the Debonnair, was both rich
and good-looking, but he cared less for helmet and feathers than for
cord and cowl, and the archbishopric of Bourges rewarded his self-
denial. There was more than one King Canute too, who, though not
surrendering royalty and generalship of armies, seemed really more
inclined, and indeed more fitted, to be studious monks than
chivalrous monarchs. Wulstan of Worcester was far more decided,
for finding himself, one night, most warmly admiring the young lady
who was his vis-à-vis in a dance, the gallant officer was so shocked
at the impropriety, that he made it an excuse for taking to the cowl
forthwith. He did not so ill by the exchange, for the cowl brought him
to the mitre at Worcester.
St. Sebastian was a far bolder man, seeing that although he hated a
military life, he, to the very utmost, did his duty in that state of life to
which it had pleased God to call him; and if half be true of what is
told of him, there never was knight of the actual days of chivalry who
performed such bold and perilous actions as St. Sebastian. What
was a cavalier, pricking against a dragon, to a Roman officer
preaching Christianity to his men, under Diocletian?
In later days we meet with St. Raymund of Pennafort, the wealthy
young lord, who, rather than serve for pay or plunder, went about
teaching philosophy for nothing. St. John, the Patriarch of
Alexandria, might have been known as a conqueror, but he preferred
being handed down, under the title of the Almoner. He was like that
St. Cadoc who chose rather to be abbot in, than prince of, Wales. St.
Poppo of Stavelo exhibited similar humility. He was rapidly rising in
the Flandrian army when he suddenly sunk into a cell, and became a
sort of Flemish John Wesley. He preached against all tournaments,
but only succeeded in abolishing the very exciting combats between
a knight and a bear, which were greatly patronized by Flemish
ladies, and at which parties staked great sums upon their favorite
animal.
St. Francis of Sales, on the other hand, that gentlemanly saint, was
saved from the knightly career which his noble birth seemed to
promise him, by a vow made by his mother, before he was born. She
was resolved that he should be a saint and not a soldier, and as all
things went as the lady desired, she placed her son in a position
direct for the Church, and the world certainly lost nothing by the
matron’s proceeding. I respect St. Francis of Sales all the more that
he had small human failings, and did not scatter damnation over
men whom he saw in a similar concatenation. Sulpicius Severus
was, in many respects, like him, save that he had some experience
of a soldier’s life. But he laid down the sword for the pen, and gave
us that admirable historical romance, in which he details so
graphically the life of another noble warrior, who quitted the
command of soldiers, to take up the teaching of men—St. Martin of
Tours.
There was a lady, St. Aldegonde, of the royal blood of France, in the
seventh century, who at least encouraged young knights to abandon
their fancied vocation, and assume that of monks or friars. She was,
most undeservedly, I dare say, assailed by scandalizing tongues
accordingly. Indeed, I never heard of lady more persecuted in this
way, except perhaps this particular lady’s namesake, who once
belonged to the gay troupe of the Varietés, and to whom the most
rattling of chansonniers alluded, in the line of a song, which put the
significant query of
Que fait Aldegonde avec le monde entier?
One of the most remarkable features in the characters of many of

these young nobles who were disinclined to take up arms, or who
laid them down for the religious vocation, is the dread they
entertained of matrimony. In illustration of this fact, I may notice the
case of St. Silvin of Auchy. There was not a gayer or braver knight at
the court of Childeric II., nor a more welcome wooer among the
ladies. In due time he proposed to a noble maiden, who was in a
flutter of happiness at the thought of carrying off such a bachelor
from a host of competitors. The wedding was brilliant, up to the
conclusion of the ceremony. That over, no persuasion could induce
the bridegroom to go to the breakfast. As he had been brought to the
altar, there he was resolved to remain. He denounced all weddings
as wicked vanities, and darting out of the church-door, left bride and
bridal party to take what course they would. There was no end of
conjectures as to the cause of the sudden fright which had seized
upon the young bridegroom. The latter set it down to inspiration, and
as he took to the cowl and led a most exemplary life, no one
presumed to doubt it, except the bride and her relations.
The case of St. Licinius is easier of explanation. He was the most
rollicking knight-bachelor at the court of Clotaire I. It must, however,
be said for him that he sowed his wild oats early, and fought none
the less stoutly for going to mass daily, and confessing once a
quarter. He was rich, and had a maiden neighbor who was richer.
The families of knight and maiden were united in thinking that the
estates of the two, encircled in one ring fence, would be one of the
most desirable of consummations. The maiden was nothing loath,
the knight alone was reluctant. He too, had his doubts about the
excellence of marriage, and it was only with very considerable
difficulty he was brought to woo the lady, who said “Yes” before the
plume in his bonnet had touched the ground when he made his bow
to her. The wedding-day was fixed, and as the old epitaph says,
“wedding-clothes provided.” On the eve of the eventful day, however,
Licinius, on paying a visit to the bride, found her suddenly attacked
with leprosy. The doctor protested that it would be nothing, but
Licinius declared that it was a warning which he dared not neglect.
He looked at the leprous lady, muttered the word “unpleasant,” and
at once betook himself, not to active military life, but to a religious
mission. In this occupation he is alleged to have performed such
miracles as to deserve canonization, if only the half of them were
true.
Now, a bride afflicted with leprosy may fairly be said to be an
unpleasant sight. Licinius may even be considered authorized to
hesitate in performing his promise, if not in altogether declaring off.
We can not say as much in extenuation of another knight who broke
his word to a lady, and was clapped into the Roman calendar of
deified men. This gentleman in question had a rather unchristian-
sounding name. He was called Abraham of Chiduna. At tilt and
tournament, and in tented field, there was no cavalier who sat more
perfectly in saddle, or handled his lance and wielded his battle-axe
with more terrible effect. He was of noble birth, of course; was
wealthy, somewhat addicted to light living, in his salad days, but a
man who lived soberly enough when those were over. He then
resolved to marry, and he had the “good taste,” if one may use a
term which, we are told, belongs to the literary milliner’s vocabulary,
to offer himself to, and ask the hand of a very pious maiden with a
highly satisfactory dower. The required conclusion was soon come
to, and one fine spring morning saw the two principals and their
respective friends in church. The knight, it is true, was the last to
arrive, and he had been, previously, as unwilling to get up and be
married, as Master Barnardine was to get up and be hanged. He
was finally brought to the altar, and after some little delay, such as
searching for the ring which he had misplaced, and only recovered
after much search, the nuptial knot was tied. When this had been
accomplished, surrounding friends approached to offer their
congratulations; but the icy Abraham coldly waved them back, and
announced his determination, then and there, to end his short-lived
married state. As he immediately rushed into the wood which was in
the vicinity of the church, there was a universal cry that he
contemplated suicide. The bride was conveyed home amid much
sympathy, and a general but an ineffectual search was made for the
“groom.” Yet, not altogether ineffectual, for at the end of seventeen
days he was discovered, offering up his orisons, in the midst of a
marsh. There he had been, he said, for a fortnight, and there he
declared he would remain, unless those who sought him consented
to the terms he should propose. These were, that he should be
allowed to retire to a cell which should be entirely walled up, save a
small square aperture for a window. The agreement was ratified, and
Abraham was shut up according to his desire; and by a long life of
seclusion, passed in preaching to all who approached the window,
and taking in all they brought through the same aperture, Abraham
has had “Beatus” attached to his name, and that name has been
recorded upon the roll of saints.
If there be any reader who objects to this story as unnatural, I would
remark to the same, that similar incidents may be met with in our
own time. In proof thereof I will briefly relate an anecdote which was
told me by the reverend father of a legal knight, who was himself the
officiating minister at the ceremony of which I am about to speak.
To the clergyman of a pretty village in Wales, due notice had been
given, and all preliminary legal observances having been fulfilled, he
awaited in his vestry, ready to marry an ex-sergeant and one of the
girls of the village. The canonical hours were fast gliding away, and
yet the priest was not summoned to the altar. By certain sounds he
could tell that several persons had assembled in the church, and he
had two or three times seen a pretty face peeping in at the vestry-
door, with a look upon it of pleasure to see that he was still there,
and of perplexity as if there was something to be told which only
waited to be asked for. At half-past eleven the face again peeped in,
whereupon the clergyman invited the owner of it to approach nearer.
The invitation was obeyed, and the clergyman inquired the reason
for the unusual delay, remarking at the same time, that if the parties
were not speedily prepared it would be too late to perform the
ceremony that day.
“Well sir,” said the nymph, “I was about asking your advice. I am the
bride’s sister; and there is a difficulty—”
“What is it?” asked the priest.
“Just this, sir,” said Jenny. “Sergeant Jones has promised to marry
sister Winnifred if father will put down five pounds. Father agrees;
but he says that if he puts down the money before the marriage, the
sergeant will walk off. And the sergeant will not come up to be
married till the money is put down. So, you see, sir, we are in a
terrible difficulty; and we want you to propose a method to get us out
of it.”
“There is nothing easier,” said the minister; “let your father put the
money into the hands of a trusty third person, who will promise to
place it in the sergeant’s possession as soon as he has married your
sister.”
Jenny Morgan saw the excellence of the device in a moment, rushed
back to the bridal parties, and they showed their appreciation of the
clergyman’s suggestion, by crowding to the altar as soon as the
preliminary proceeding recommended to them had been
accomplished. At length the clergyman came to the words, “Wilt thou
have this woman to thy wedded wife?”
“Jack,” said the ex-sergeant, looking round at the stake-holder, “have
you got the cash?”
“All right!” nodded Jack.
“Then I will,” said the sergeant; “and now, Jack, hand over the tin.”
The agreement was rigidly fulfilled; but had not the minister thought
of the means which solved the difficulty, Sergeant Jones would have
been nearly as ungallant to his lady as Abraham, Silvin, and Licinius,
had been to theirs.
But to return to Abraham. I have said this knight, on assuming his
monkly character, had caused himself to be walled up in his cell. I
have my suspicions, however, that it was a theatrical sort of wall, for
it is very certain that the saint could pass through it. Now, there
resided near him a lady recluse who was his “niece,” and whose
name was Mary. The two were as inseparable as the priest Lacombe
and Madame Guyon; and probably were as little deserving of
reproach. This Mary was the original of “Little Red Riding Hood.” She
used to convey boiled milk and butter, and other necessary matters
to her uncle Abraham. Now it happened that the ex-knight used also
to be visited by a monk whose name was Wolf, or who, at all events,
has been so called by hagiographers, on account of his being quite
as much of a beast as the quadruped so called. The monk was wont
to fall in with Mary as she was on her way to her uncle’s cell with
pleasant condiments under a napkin, in a wicker-basket. He must
have been a monk of the Count Ory fashion, and he was as
seductive as Ponchard, when singing “Gentille Annette” to the “Petit
Chaperon Rouge,” in Boieldieu’s Opera. The result was, that the
monk carried off Mary to a neighboring city—Edessa, if I remember
rightly—and if I am wrong, Mr. Mitchell Kemble will, perhaps, set me
right, in his bland and gentleman-like way. The town-life led by these
two was of the most disgraceful nature; and when the monk had
grown tired of it, he left Mary to lead a worse, without him. Mary
became the “Reine Pomare,” the “Mogadore,” the “Rose Pomponne”
of Edessa, and was the terror of all families where there were elder
sons and latch-keys. Her doings and her whereabouts at length
reached the ears of her uncle Abraham, and not a little astonished
were those who knew the recluse to see him one morning, attired in
a pourpoint of rich stuff, with a cloak like Almaviva’s, yellow buskins
with a fall of lace over the tops, a jaunty cap and feather on his head,
a rapier on his thigh, and a steed between his legs, which curveted
under his burden as though the fun of the thing had given it
lightness. At Mary’s supper, this cavalier was present on the night of
his arrival in Edessa. He scattered his gold like a Crœsus, and Mary
considered him worth all the more penniless knights put together.
When these had gone, as being less welcome, Abraham declared
his relationship, and acted on the right it gave him to rate a niece
who was not only an ungrateful minx, but who was as mendacious
as an ungrateful niece could well be. The old gentleman, however,
had truth on his side, and finally so overwhelmed Mary with its
terrible application, that she meekly followed him back to the desert,
and passed fifteen years in a walled-up cell close to that of her
uncle. The miracles the two performed are adduced as proofs of the
genuineness of the personages and their story; matters which I
would not dispute even if I had room for it.
The next knight whom I can call to mind as having been frightened
by marriage into monkery, is St. Vandrille, Count of the Palace to
King Dagobert. During the period of his knightship he was a very
Don Juan for gallantry, and railed against matrimony as conclusively
as a Malthusian. His friends pressed him to marry nevertheless; and
introduced him to a lady with a hundred thousand golden qualities,
and prospects as auriferous as those of Miss Kilmansegg. He took
the lady’s hand with a reluctance that might be called aversion, and
which he did not affect to conceal. When the nuptial ceremony was
concluded, Knight Vandrille, as eccentric as the cavaliers whose
similar conduct I have already noticed, mildly intimated that it was
not his intention to proceed further, and that for his part, he had
renounced the vanities of this world for aye. Taking the lady apart, he
appears to have produced upon her a conviction that the
determination was one he could not well avoid; and we are not told
that she even reproached him for a conduct which seems to me to
have been a thousand times more selfish and inexcusable than that
of the clever but despicable Abelard. The church, however, did not
disapprove of the course adopted, and St. Vandrille, despite his
worse than breach of promise, has been forgiven as knight, and
canonized as saint.
Far more excusable was that little Count of Arian, Elzear, the boy-
knight at the court of Charles II., King of Sicily, whom that monarch
married at the age of thirteen years, to Delphina of Glandeves, a
young lady of fifteen. When I say far more excusable, I do Elzear
some injustice, for the boy was willing enough to be wed, and looked
forward to making his lady proud of his own distinction as a knight.
Delphina, however, it was who proposed that they should part at the
altar, and never meet again. She despised the boy, and the little
cavalier took it to heart—so much so, that he determined to
renounce the career of arms and enter the church. Thereby chivalry
lost a worthy cavalier, and the calendar gained a very active saint.

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CURRENT Practice Guidelines in

Primary Care 2020 - eBook PDF

Jacob A. David, MD, FAAFP

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1. Behavioral Health Disorders 3

14. C.rdlovucular Disorders 127

Oral Cancer 162

22. Specl•I Populalon: Newborns •ncl lnt.nts 223

27. Care of the Older Adult 313

30. Endocrine •nd Metllbollc Disorders 375

Meningitis, Bacterial 547

Pregnancy, Pretcrm Labor, Tocolysis 637

39. Appendices 679

David Araujo, MD, FAAFP

Wallace Baker, MD, MS

Dorothy DeGuzman, MD, MPH, FAAFP

James Helmer, Jr., MD, FAAFP

Tipu V. Khan, MD, FAAFP, FASAM

Cheryl Lambing, MD, FAAFP

Zachary M. Zwolak, DO, FAAFP

Jacob A. David, MD, FAAFP

ALCOHOL ABUSE AND DEPENDENCE

2. Treatment options include pharmacotherapy (fluoxetine and escitalo-

ILLICIT DRUG USE

ABDOMINAL AORTIC ANEURYSM

-ACR-AIUM-SRU Practice Parameter for the Performance of

CAROTID ARTERY STENOS IS (CAS) (ASYMPTOMATIC)

2. Carotid duplex ultrasonography to detect CAS ~60%; sensitivity, 94%;

CHOLESTEROL AND LIPID DISORDERS

- European Society of Cardiology. Dyslipidaemias 2016.

American Diabetes Stronger risk Strong 30-y/lifetime global

Secondary Prevention Fasting lipid panel Primary target: N/A

Expert Panel on Fasting lipid panel Primary No risk algorithm,

CHOLESTEROL GUIDELINES (Continued)

CORONARY ARTERY DISEASE

HYPERTENSION (HTN), ADULTS

-Annual F/U of patients with high-normal BP (2-y risk of developing

PERIPHERAL ARTERY DISEASE

“O rueful sight! Behold, how lost to sense

“When Time shall yield to Death, Dukes must obey.”

“Dying in harness,” is a favorite phrase in chivalric annals to illustrate

See how the chief of many a field

To meet that surest of all foes,

“Take from these limbs,” he weakly cried,

“Close let my sheaf of arrows stand;

“’Tis well! Now buckle to my waist

’Twas done. No tear bedimmed his eyes—

The manner of the death, or rather of the dying of Seward, Earl of

His hour at length is come:

He whose loud trumpet’s blast,

The same who, but of late,

And with his latest breath

The mournful tears and sighs

With regard to the burial of knights, we may observe that, down to a

As marriage or the cloister was the alternative submitted to most

Que fait Aldegonde avec le monde entier?

One of the most remarkable features in the characters of many of

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