Current Practice Guidelines in Primary Care 2020 Joseph S Esherick Full Chapter

CURRENT Practice Guidelines in
Primary Care 2020 Joseph S. Esherick

Visit to download the full and correct content document:
https://ebookmass.com/product/current-practice-guidelines-in-primary-care-2020-jose
ph-s-esherick/
a LANGE medical book
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
Copyright@ 2020, 2019, 2018, 2017, 2016, 2015 by McGraw Hill. All rights reserved. Except as permitted under
the United States Copyright Act of 1976, no part ofthis publication may be reproduced or distnbuted in any form
or by any means, or ston:d in a database or retrieval system, without the prior written permission of the publisher.
ISBN: 978-1-26-046985-1
MIIlD: 1-26-046985-9
The material in this eBook also appears in the print version ofthis title: ISBN: 978-1-26-046984-4,
MIIlD: 1-26-046984-0.
eBook conversion by codeMantra

Version 1.0
All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every occur-
rence of a trademarked name, we use names in an editorial fashion only, and to the benefit ofthe trademmk owner,
with no intention of infringement of the trademark. Where such designations appear in this book, they have been
printed with initial caps.
McGraw-Hill Education eBooks are available at special quantity discounts to use as premiums and sales promo-
tions or for use in corporate training programs. To contact a representative, please visit the Contact Us page at
www.mhprofessional.com.
Notice
Medicine is an ever-changing science. AB new research and clioical experience broaden our knowledge, changes
in treatment and drug therapy are required. The authors and the publisher ofthis work have checked with sources
believed to be reliable in their efforts to provide information that is complete and generally in accord with the
standards accepted at the time of publication. However, in view of the possibility of human enor or changes in
medical sciences, neither the authors nor the publisher nor any other party who has been involved in the prepa-
ration or publication of this work warrants that the information contained herein is in every respect accurate or
complete, and they disclaim all responsibility for any enors or omissions or for the results obtained from use of
the information contained in this work. Readers are encouraged to coD1irm the information contained herein with
other sources. For example and in particular, readers are advised to check the product information sheet included
in the package of each drug they plan to administer to be certain that the information contained in this work is
accurate and that changes have not been made in the recommended dose or in the contraindications for admin-
istration. This recommendation is of particular importance in connection with new or infrequently used drugs.
TERMS OF USE
This is a copyrighted work and McGraw-Hill Education and its licensors reserve all rights in and to the work. Use
of this work is subject to these terms. Except as permitted under the Copyright Act of 1976 and the right to store
and retrieve one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify,
create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any
part of it without McGraw-Hill Education's prior consent. You may use the work for your own noncommercial
and personal use; any other use of the work is strictly prohibited. Your right to use the work may be terminated if
you fail to comply with these terms.
THE WORK IS PROVIDED "AS IS." McGRAW-HILL EDUCATION AND ITS LICENSORS MAKE NO
GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF
OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT
CAN BE ACCESSED TIIR.OUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY
DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIBD, INCLUDING BUT NOT LIMITED TO IMPLIBD
WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill
Education and its licensors do not warrant or guarantee that the functions contained in the work will meet your
requirements or that its operation will be uninterrupted or error free. Neither McGraw-Hill Education nor its
licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the
work or for any damages resulting therefrom. McGraw-Hill Education has no responsibility for the content of
any information accessed through the work. Under no circumstances shall McGraw-Hill Education and/or its
licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from
the use of or inability to use the work, even if any of them has been advised of the possibility of such damages.
This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in
contract, tort or otherwise.
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:
“Goblin?” I asked quickly; for, you see, he looked so old and ugly that
I thought he must be one of the underground faeries.
“I’m not a goblin,” he replied in an angry, shrill voice, like the wind
whistling through a keyhole. “It is very rude of you to call me a goblin
—a nasty thing who lives under the earth, and only cares for gold
and silver. I’m a faery—a very celebrated faery indeed.”
“But you wear a beard,” I said doubtfully; “faeries don’t wear beards.”
“Not all faeries,” he answered, with dignity, jumping down from his
swaying flower stem; “but I do, because I am the librarian of King
Oberon.”
“Dear me! I did not know he had a library. Do let me see it!”
“You see it now,” said the librarian, waving his hand; “look at all the
books.”
I looked round, but saw nothing except a circle of trees, whose great
boughs, meeting overhead, made a kind of leafy roof, through which
could be seen the faint, rosy flush of the sunset sky. The ground, as I
said before, was covered with daisy-sprinkled turf, and there was a
still pool of shining water in the centre, upon the bosom of which
floated large white lilies.
“I must say I don’t see anything except leaves,” I said, after a pause.
“Well—those are the books.”
“Oh, are they! Well, I know books have leaves, but I didn’t know
leaves were books.”
The faery looked puzzled.
“You must have some faery blood in you,” he said at length, “or you
would never have found your way into this forest; but you don’t seem
to have enough of the elfin nature to see all the wonders of
Faeryland.”
“Oh, do let me see the wonders of Faeryland!” I asked eagerly; “now
that I am here, I want to see everything.”
“No doubt you do,” retorted the faery, with a provoking smile; “but I
don’t know if the King will let you—however, I’ll ask him when he
wakes.”
“Is he asleep?” I said in astonishment; “why, it’s day-time.”
“It’s day-time with you, not with us,” answered the librarian; “the night
is the day of the faeries—and see, there’s the sun rising.”
Looking up through the fretwork of boughs and leaves, I saw the
great silver shield of the moon trembling in the dark blue sky, from
whence all the sunset colours had died away.
“But that’s the moon,” I cried, laughing.
“The moon is our sun, stupid,” he said tartly. “I think the King will be
awake now, so I’ll ask him if you can see the books.”
He vanished,—I don’t know how; for, though I did not take my eyes
off him, he seemed to fade away, and in his place I saw the green
leaves and slender stem of a flower, with the Canterbury bell
nodding on the top.
The only thing I could do was to wait, so I sat down again on the
fallen tree, and amused myself with looking round to see what kind
of creatures lived in Faeryland.
The night was very still,—no sound of cricket or bird, not even the
whisper of the wind, or the splash of water,—all was silent, and the
moon, looking down through the leaves, flooded the glade with a
cold, pale light, turning the still waters of the pool to a silver mirror,
upon which slept the great white lilies.
Suddenly, a bat, whirring through the glade, disappeared in the soft
dusk of the trees, then I heard the distant “Tu whit, tu whoo” of an
owl, which seemed to break the spell of the night, and awaken the
sleeping faeries; for all at once, on every side, I heard a confused
murmur, the glow-worms lighted their glimmering lamps on the soft
mossy banks, and brilliant fireflies flashed like sparkling stars
through the perfumed air.
Then a nightingale began to sing; I could not see the bird, but only
heard the lovely music gushing from amid the dim gloom of the
leaves, filling the whole forest with exquisite strains. I understood the
nightingale’s song just as well as I did that of the cricket, but what it
sang was much more beautiful.
THE NIGHTINGALE’S SONG.
The Day has furled

Her banners red,
And all the world
Lies cold and dead;
All light and gladness fled.
Asleep!—asleep,
In slumber deep,
Are maid and boy;
And grief and joy,
And pleasures—pains
Are bound—fast bound in slumber’s chains.
Ah, slumbers keep
The maid who sighs,
The boy who cries,
The bee that flies,
In charmèd sleep.
See how the moon shines in the sky

Her light so pale,
O’er hill and dale;
O’er dale and hill,
So calm and still,
In splendour flinging;
And Mother Earth,
At her bright birth,
Hears me the night-bird singing.
’Tis I!
Who in the darkness cry;
The nightingale who sings, who sings on high.
I call the elves
To show themselves;
They creep from tree, from grass, from flower;
In forest-bower
At midnight hour,
They dance—they dance,
All night so bright—so light;
While I the woods with song entrance.
Singing—Singing,
My voice is ringing
Thro’ the still leaves,
Till all the dark night heaves
With pain—with pain
Again—oh, sing again;
Bring joy—bring tears,
Till o’er the lawn
The red, red dawn
Appears—appears—appears.
While the nightingale was thus singing in such a capricious manner,

paying no attention to metre or rhyme, the whole glade changed, but
I was so entranced with the bird music, that I did not notice the
transformation until I found myself in a splendid hall with a lofty
ceiling, seated on a couch of green velvet. The trees around were
now tall slender pillars of white marble, and between them hung long
curtains of emerald velvet. The pool was still in the centre, with its
broad white water-lilies asleep on its breast, but it was now encircled
by a rim of white marble, and reflected, not the blue sky, but an
azure ceiling, upon which fantastic patterns in gold reminded me
somewhat of the intricate traceries of the trees. High up in the oval
ceiling, in place of the moon, there hung a large opaque globe, from
whence a soft, cool light radiated through the apartment.
As I was looking at all these beautiful things, I heard a soft laugh,
and, on turning round, saw a man of my own height, dressed in
robes of pale green, with a sweeping white beard, a purple cap on
his head, and a long slender staff in his hands.
“You don’t know me?” he said in a musical voice. “My name is
Phancie, and I am the librarian of the King.”
“Were you the faery?” I asked, looking at him.
“I am always a faery,” he replied, smiling. “You saw me as I generally
appear to mortals; but, as the King has given you permission to learn
some of the secrets of Faeryland, I now appear to you in my real
form.”
“So this is the King’s library?” I said, looking round; “but how did I
come here?—or rather, how did the glade change to the library?”
“The glade has not changed at all,” said Phancie quietly; “it is still
around you, but your eyes have been unsealed, and you now see
beneath the surface.”
“But I don’t understand,” I observed, feeling perplexed.
“It is difficult,” assented Phancie gravely, “but I can show you what I
mean by an illustration. When you see a grub, it only looks to your
eyes an ugly brown thing; but my eyes can see below the outside
skin, to where a beautiful butterfly is lying with folded wings of red
and gold. The glade you saw was, so to speak, the skin of the library.
Now, your sight has been made keen by the command of the King.
You see this splendid room—it is still the glade, and still the room;
only it depends upon your sight being lightened or darkened.”
“It doesn’t look a bit like the glade.”
“You don’t think so, of course,” said Phancie kindly; “but I will explain.
The white pillars are the trunks of the trees; the green curtains
between are the green leaves; the ceiling is the blue sky; the white
globe that gives light is the moon; and the golden fretwork on the
ceiling is the leaves and boughs of the trees shining against the clear
sky.”
“And the books?” I asked quickly.
“Here are the books,” he replied, drawing one of the green curtains a
little on one side, and there I saw rows of volumes in brown covers,
which reminded me somewhat of the tint of the withered leaves.
“You can stay here as long as you like,” said Phancie, dropping the
curtain, “and read all the books.”
“Oh, I can’t stay long enough for that,” I said regretfully. “I would be
missed from my house.”
“No, you would not,” he replied. “Time in Faeryland is different from
time on earth—five minutes with you means five years with us—so if
you stay here thirty years, you will only have been away from earth
half an hour.”
“But I’m afraid”—
“Still unconvinced!” interrupted Phancie, a little sadly, leading me
forward to the pool of water. “You mortals never believe anything but
what you see with your own eyes—look!”
He waved his white wand, and the still surface of the water quivered
as if a breeze had rippled across it; then it became still again, and I
saw my own room, and myself seated asleep in the arm-chair in front
of a dull red fire. I closed my eyes for a moment, and when I looked
again the vision had vanished.
“How is it my body is there and I am here?” I asked, turning to
Phancie.
“What you saw is your earthly body,” he said quietly, “but the form
you now wear is your real body—like the butterfly and the grub of
which I told you. Now, you can look at the books. You will not
remember all you read, because there are some thoughts you may
not carry back to earth; but the King will let you remember seven
stories which you can tell to the children of your world. They will
believe them, but you—ah! you will say they are dreams.”
“Oh no, I won’t,” I said eagerly, “because it would not be true. This is
not a dream.”
“No, it is not a dream,” he said sadly; “but you will think it to be so.”
“Never!”
“Oh yes, you will. Mortals never believe.”
I turned angrily away at this remark, but when I looked again to reply,
Phancie had vanished—faded away like a wreath of snow in the
sunshine, and I was alone in the beautiful room.
Oh, it was truly a famous library, containing the most wonderful
books in the world, but none of which I had seen before, except the
faery tales. In one recess I found the lost six books of Spenser’s
Faerie Queene, the last tales told by Chaucer’s Canterbury Pilgrims,
the end of Coleridge’s Christabel, some forgotten plays of
Shakespeare, and many other books which had been lost on earth,
or which the authors had failed to complete. I learned afterwards that
they finished their earthly works in Faeryland, and that none of the
books they had written during their lives were in the library, but only
those they had not written.
You will not know the names of the books I have mentioned,
because you are not old enough to understand them but when you
grow up, you will, no doubt, read them all—not the faery books, of
course, but all the others which the men I mention have written.
In another recess I found nothing but faery tales—Jack and the
Beanstalk, The White Cat, The Yellow Dwarf, and many others,
which were all marked The Chronicles of Faeryland.
I do not know how long I was in the library, because there was no
day or night, but only the soft glow of the moon-lamp shining through
the room. I read many, many of the books, and they were full of the
most beautiful stories, which all children would love to hear; but, as
Phancie said, I only remember seven, and these seven I will now
relate.
I hope you will like them very much, for they are all true stories in
which the faeries took part, and there is more wisdom in them than
you would think.
The faeries understand them, and so do I, because I have faery
blood in my veins; but many grown-up people who read them will
laugh, and say they are only amusing fables. The wise children,
however, who read carefully and slowly will find out the secrets they
contain, and these secrets are the most beautiful things in the world.
So now I have told you how I was permitted to enter Faeryland, I will
relate the stories I remember which I read in the faery palace, and
the clever child who finds out the real meanings of these stories will
perhaps some day receive an invitation from King Oberon to go to
Faeryland and see all the wonders of his beautiful library.
THE RED ELF
I.
HOW THE RED ELF RAN AWAY FROM FAERYLAND.
FAERYLAND lies between the Kingdom of the Shadows and the

Country of the Giants. If you want to reach it you must sail across the
Sea of Darkness, which rolls everlastingly round these three strange
places, and separates them from our world. Then you journey first
through the Giants’ Country, the inhabitants of which are very like
ourselves, only larger and fiercer, with very little spiritual nature in
their enormous bodies; afterwards you pass into Faeryland, where
the elves are bright, graceful creatures, who possess forms like ours,
and not a little of our nature. Beyond lies the strange Kingdom of
Shadows, where dwell things which have very little in common with
our earth; they are the shadows of the past and the future, of what
has been, and what yet shall be. Mortals have strayed by chance
into the Giants’ Country, and in old stories we are told they have
lived in Faeryland, but no living man or woman has ever seen the
Kingdom of Shadows, nor will they ever see it during life.
Now, the Faeries, being afraid of the Shadows, never enter their
kingdom, but they also never enter the Country of the Giants,
because they despise them very much as being lower than
themselves, much the same as we look down upon the uncivilised
savages of Africa. Oberon, who, as you know, is the King of Faery,
made a law that no elf should ever go into the Giants’ Country, being
afraid lest the faeries should learn things there which would bring evil
on his own land. So when the faeries want to visit our earth, they do
not cross the Giants’ Country, but come in another way which is
known only to themselves. Having thus explained how these three
countries lie, I will now tell you of a naughty elf who, disobeying the
King’s command, lost himself in the Giants’ Country, and of the
difficulty he had in getting back to Faeryland.
The elf’s name was Gillydrop, a beautiful little creature all dressed in
clothes of a pale green tint, which is the favourite colour of the
faeries, as every one knows who has seen them dance in the
moonlight. Now Gillydrop was full of curiosity, which is a very bad
thing, as it leads people into a great deal of trouble, and although he
had never bothered his head about the Giants’ Country before, as
soon as he heard the proclamation of Oberon he immediately
determined to see for himself what the giants were like. Do you not
think this was a very naughty thing for him to do? it certainly was, but
he was punished for his disobedience, as all naughty people are
sooner or later.
He spoke to two or three faeries in order to get them to join him, but
they would not disobey the King’s command, and advised him to
give up his foolish idea.
“The King is very wise,” they said, “and no doubt he has a good
reason for not letting us visit the Giants’ Country, so you ought to do
as he tells you.”
“I don’t care,” replied naughty Gillydrop; “I’m sure there is something
in the Giants’ Country the King does not want us to know, and I am
determined to find out what it is.”
So, in spite of all warnings, he spread his beautiful wings, which
were spotted silver and blue, like a white-clouded sky, and flew away
through the woods. It was night-time, for, of course, that is the
faeries’ day, but the way to Giants’ Country was so long that by the
time he reached the end of the forest, and came to the boundary of
Faeryland, the red dawn was breaking, so he crept into the bosom of
a rose, and, after getting a honey supper from a friendly bumble-bee,
curled himself up to sleep.
All through the long day, while the sun was high in the blue sky, he
slept, lulled by the swaying of the flower, which rocked like a cradle,
and soothed by the whisper of the wind and the buzzing of the bees
as they hummed round his rose-house.
At last the weary, hot day came to an end, the silver moon arose in
the dark blue sky, the wind sighing through the forest made the
delicate leaves tremble with its cool breath, and the elf awoke. He
left the kind rose, which had sheltered him in her golden heart from
the heat of the day, and flew towards the rippling stream which lies
on the confines of Faeryland. Away in the distance, he could hear
the murmuring laughter of the faeries, as they danced to the sound
of elfin music, but he was too anxious to get into the Giants’ Country
to trouble himself about his old friends.
Just as he was about to cross the boundary, the leaves of the Faery
forest sighed out the word “Beware!” but, not heeding the warning,
he flew across the stream, and found himself at last in the terrible
country where dwelt the foolish giants and the evil ogres. As he
alighted upon an enormous daisy, which was as large as a
mushroom, a voice rang out from Faeryland, full and clear, like the
sound of a beautiful bell:
“Never more come back you need,
Till you’ve done some kindly deed.”
And so when Gillydrop looked back, he saw no green banks, no tall

trees, no beautiful flowers, but only a wide grey ocean sleeping in
sullen stillness under the cold light of the moon.
He was now flying over a dreary waste plain, with great circles of
upright stones standing here and there, and a bitter cold wind
blowing shrilly across the flat country towards the sullen grey sea.
Had he not been able to fly, he would never have crossed the plain,
because the grass stood up like mighty spears, and the furze bushes
were like great trees. On every side he saw immense mountains,
blue in the distance, lifting their snowy summits to the clouds, with
great trees at their foot looking like enormous hills of leaves. There
were no birds flying in the cold air, and no animals crawling on the
bleak earth; everything seemed dead and silent, except the wind,
which moaned through the mighty trees like the roaring of oceans.
There are no towns in Giantland, because the giants are not very
fond of one another, and prefer to live by themselves in lonely
castles among the mountains. Gillydrop knew this, but, although he
looked on every side, he could see no sign of any castle, until at last
he suddenly came on one which was quite in ruins, and so tumbled
down that no one could possibly dwell in it. He flew on, feeling rather
afraid, and came to another castle, also in ruins, with a huge white
skeleton lying at the foot of a high tower, which was no doubt the
skeleton of the giant who had lived there.
Then he found a third, a fourth, a fifth castle, all deserted and in
ruins. It seemed as though all the giants were dead, and Gillydrop, in
despair at the sight of such desolation, was about to fly back to
Faeryland, when he suddenly thought of the voice which had said:
“Never more come back you need,
Till you’ve done some kindly deed.”
Poor Gillydrop was now in a dreadful plight, and, folding his weary
wings, he dropped to the ground, where he sat in the hollow of a
buttercup, which was like a large golden basin, and wept bitterly. He
could never return to Faeryland until he had done some kindly deed,
but, as there was no one to whom he could do a good deed, he did
not see how he could perform any, so cried dreadfully at the thought
of living for evermore in the desolate Giants’ Country. So you see
what his disobedience had brought him to, for, instead of dancing
merrily with his friends in the Forest of Faeryland, he was seated, a
poor, lonely little elf, in a dreary, dreary land, with no one to comfort
him.
While he was thus weeping, he heard a sound like distant thunder;
but, as there were no clouds in the sky, he knew it could not be
thunder.
“It must be a giant roaring,” said Gillydrop, drying his eyes with a
cobweb. “I’ll go and ask him where all his friends have gone.”
So he flew away in the direction from whence came the sound, and
speedily arrived at a great grey castle, with many towers and
battlements, perched on the top of a very high hill. At its foot rolled
the Sea of Darkness, and round the tall towers the white mists were
wreathed like floating clouds. There was a wide road winding up the
steep sides of the rock to the castle door, which was as high as a
church; but Gillydrop, having wings, did not use the road, so flew
right into the castle through an open window.
The giant, whose name was Dunderhead, sat at one end of a large
hall, cutting slices of bread from an enormous loaf which lay on the
table in front of him. He looked thin,—very, very thin,—as though he
had not had a good dinner for a long time; and he thumped the table
with the handle of his knife as he sang this song, taking a large bit of
bread between every verse:
THE GIANT’S SONG.
Oh, if my life grows harder,

I’ll wish that I were dead!
There’s nothing in the larder
Except this crust of bread.
With hunger I am starving,

And it would give me joy
If just now I was carving
A little girl or boy.
I’ve drunk up all the coffee,

I’ve eaten all the lamb,
I’ve swallowed all the toffee
And finished all the jam.
I want to get some plum-cake—

I only wish I could;
For if I can’t get some cake
I’ll die for want of food.
Here Dunderhead stopped singing with a roar of pain, for while

cutting himself some more bread, the knife slipped and gashed his
hand in a most terrible manner. A great spout of blood gushed out
like a torrent and settled into a dark red pool on the table, while the
giant, roaring with anger, wrapped up his wounded hand in his
handkerchief, which was as large as a tablecloth.
“What are you crying about, giant?” asked Gillydrop, who had
perched himself on the table, where he sat, looking like a green
beetle.
“I’ve cut my finger,” said the giant in a sulky tone; “you’d cry, too, if
you cut your finger. Don’t call me a giant—my name is Mr.
Dunderhead. What is your name?”
“Gillydrop. I’m a faery.”
“I thought you were a beetle,” said Dunderhead crossly. “What do
you want here?”
“I’ve come to see the giants, Mr. Dunderhead,” replied Gillydrop.
“You won’t see any, then,” said Dunderhead, making a face. “They’re
all dead except me. I’m the last of the giants. You see, we ate up
every boy and girl that lived near us, and all the sheep, and all the
cattle, until there was nothing left to eat; and as none of us could
cross the Sea of Darkness, every one died except me, and I won’t
live long—this loaf is all I’ve got to eat.”
“Perhaps if I do a kindly deed to Dunderhead by getting him a meal,
I’ll be able to go back to Faeryland,” thought Gillydrop, as he listened
to the giant’s story.
“Well, what are you thinking about?” growled Dunderhead, cutting
himself another slice of bread.
“I was thinking how I could get you some food,” replied Gillydrop.
“What! you?” roared the giant; “a little thing like you get me food! Ha,
ha, ha!” and he thumped the table with his great fist.
Now, as he did this, everything on the table jumped up with the
shock, and so did Gillydrop, who had no time to spread his wings
and prevent himself falling; so when he fell he came down splash
into the pool of blood. He gave a cry of terror when he fell in, and
after crawling out with some difficulty, he found his beautiful green
clothes were all red, just as if he had been dipped in red ink.
The rude giant laughed heartily at the poor elf’s plight, but to
Gillydrop it was no laughing matter, for there is nothing the faeries
dislike so much as the colour red.
“Oh dear, dear, dear!” sighed Gillydrop, while the tears ran down his
face; “now I’ll never go back to Faeryland.”
THE RUDE GIANT LAUGHED HEARTILY AT THE
POOR ELF’S PLIGHT
“Why not?” asked Dunderhead, who was still eating.

“Because my clothes are red,” replied the elf ruefully; “no one who
wears red clothes is allowed to live in Faeryland. Cannot I clean my
clothes?”
“No,” answered the giant, taking a bit out of the loaf. “You are dyed
red with my blood, and the only way to get your clothes green again
is to wash them in my tears.”
“Oh, let me do it at once!” cried Gillydrop, jumping up and down with
delight. “Do cry, Mr. Giant, please do.”
“I can’t cry when I’m told to,” growled Dunderhead; “but if you go to
earth and bring me two nice fat children for supper, I’ll weep tears of
joy, and then you can wash in my tears and become a green beetle
again.”
“But how am I to bring the children here?” asked Gillydrop, who
never thought of the poor children being eaten, but only how he
could get his emerald suit once more.
“That’s your business,” growled Dunderhead crossly, for you see he
had eaten all the loaf, and was still hungry. “I’m going to sleep, so if
you want to clean your clothes, bring me the children, and you can
wash in the tears of joy I shed.”
So saying, the giant leaned back in his chair and fell fast asleep,
snoring so loudly that the whole room shook.
Poor Gillydrop, in his red clothes, spread his red wings, and,
alighting on the beach of the Sea of Darkness, he wondered how he
was to cross it, for he knew he was too feeble to fly all the way.
“Oh, I wish I hadn’t been naughty!” he said to himself. “I’ll never see
my dear Faeryland again.”
And he cried red tears, which is a most wonderful thing, even for a
faery to do. It was no use crying, however, for crying helps no one;
so he looked about for a boat to carry him across the Sea of
Darkness, but no boat could he see.
Gillydrop was almost in despair, when suddenly the sun arose in the
east, and a broad shaft of yellow light shot across the Sea of
Darkness like a golden bridge.
On seeing this, the Red Elf clapped his hands with glee, for, being a
faery, he could easily run along a sunbeam; so, without waiting a
moment, he jumped on to the broad golden path, and ran rapidly
across the Sea of Darkness, which heaved in black billows below.
II.
HOW THE ELF BROUGHT THE GIANT’S SUPPER.
As the sun grew stronger, the beam shot farther and farther across
the Sea of Darkness, until it quite bridged it over, and you may be
sure Gillydrop ran as hard as ever he could, so as to reach earth
quickly. It was lucky he did make haste, for, just as he alighted on a
green lawn near a village, the sun hid himself behind a cloud, and of
course the beam vanished.
Having thus arrived, Gillydrop began to look about for two naughty
children to take to the Giants’ Country for Dunderhead’s supper. He
was very tired, both with his journey across the Sea of Darkness,
and with being up all day, which was just the same to him as staying
up all night would be to us. As he was anxious to get back to
Faeryland, there was no time to be lost, so, instead of going to sleep,
he searched all through the village for two naughty children.
Now, in one of the pretty cottages there lived a poor widow, who had
two children called Teddy and Tilly, of whom she was very fond, as
they were all she had in the world to love. I am sorry to say, however,
that Teddy and Tilly were not worthy of their mother’s love, for they
were very naughty indeed, and never so happy as when engaged in
some mischief. Dame Alice, for that was the name of the poor
widow, tried very hard to improve them, but it was really a waste of
time, for the harder she tried the worse they became. They tore their
nice clean clothes, worried the cat, destroyed the flowers, ate up
everything they could lay their hands on, and altogether were a great
trouble to their poor mother, who often wondered why her children
were so much worse than any one else’s. Dame Alice, however, had
still some hope that they would improve, for, having a few friends
among the faeries, she had learned that some day both Teddy and
Tilly would receive a severe lesson, which would make them the best
and most obedient children in the world.
There was a wood, not far from the village, which was said to be
enchanted, and Teddy and Tilly were told never to enter it, but this
command only made them the more anxious to disobey, and they
constantly wandered about the wood, never thinking of the faeries,
nor of anything else, except their own pleasure. On the day Gillydrop
arrived, they had been in the wood all day, gathering nuts and
chasing the squirrels. Now, as it was sundown, they were coming
home to their supper, quarrelling dreadfully all the way, which was
very naughty of them after spending a pleasant day.
Gillydrop heard them calling each other names, so he peeped out
from behind the leaf of a tree, where he was hidden, and, seeing
their cross faces, he immediately guessed that they were two
children who would do capitally for Dunderhead’s supper, so at once
made up his mind how to act.
It was now night, and, as the faeries say, night is caused by the
overflowing of the Sea of Darkness, which rises and rises when the
sun goes down, until it rolls all over the earth, and any one abroad
during the night is in danger of being lost in its black waves. At dawn,
however, the sea subsides, and vanishes altogether when the sun
appears; but when he sets in the west, it rises once more and
spreads over the earth.
Gillydrop had brought with him a withered leaf from the Giants’
Country, which, being enchanted, would expand into a boat, and sail
across the Sea of Darkness to the Giants’ Country, for, having come
from there, it was bound to return to the tree upon which it had
grown.
The Red Elf took this leaf out of his pocket, and immediately it
spread out into a great brown carpet, which he placed under a tree in
the darkest part, and then went away to entice the children on to it.
Teddy and Tilly came through the wood, quarrelling in a noisy
manner, and calling each other ugly names; not a bit afraid of the
dark, although they certainly ought to have been.
“You’re eating all the nuts,” bellowed Teddy.
“Well, I gathered them,” shrieked Tilly.
“No, you didn’t; I got most,” whimpered her brother crossly.
“Oh, you story! You didn’t,” retorted Tilly.
And then they called each other more ugly names, and fought and
scratched until the whole wood resounded with their noise, and the
birds trembled in their nests with fear.
Suddenly, in front of them, they saw a small red ball, glowing like a
scarlet coal, and it kept dancing up and down like a restless will-o’-
the-wisp.
“Oh, Teddy,” cried Tilly, “look at that pretty ball!”
“It’s mine!” roared greedy Teddy, rushing forward. “I’ll have it.”
“You shan’t!” cried Tilly, running after him. “I’ll get it.”
But the red ball—which was none other than Gillydrop—rolled and
rolled in front of the children through the dark wood, and led them
deeper and deeper into the forest, until it bounded right on to a
brown carpet lying under a great tree, where it lay glowing like a red-
hot coal. Teddy and Tilly jumped on to the brown carpet with a
scream of delight, thinking they would now seize the ball, when
suddenly the sides of the brown leaf curled up, and it lengthened out
into a long boat. The darkness under it grew thicker and thicker, the
foliage of the tree above vanished, and the two naughty children
found themselves in a boat, rolling and tossing on the black waves,
with a gloomy, starless sky above them. Away at the end of the boat
sat Gillydrop, who had now unrolled himself, and was guiding the
magic skiff across the Sea of Darkness towards the Country of the
Giants.
“Oh, I want to go home!” cried Tilly, now very frightened.
“And so do I!” roared Teddy, sitting close to her.
As they said this, they both heard a mocking ripple of laughter, and
saw the Red Elf dancing with glee at the end of the boat.
“You’ll never go home again,” he cried mockingly, “because you have
been naughty, and must be punished.”
“I’ll never be naughty again,” sobbed Tilly.
“No more will I,” echoed Teddy; and they both wept bitterly.
“It’s too late now,” said Gillydrop, shaking his head. “Naughty
children always get punished.”
He might have said the same thing about himself; but then he was a
faery, and felt ashamed to tell two human beings that he had been
as naughty as themselves.
Teddy and Tilly cried dreadfully as they thought of their poor mother
waiting for them at home, and of the nice supper of bread and milk
which she had prepared for them; but their tears were all of no avail,
for the magic boat sailed on and on, though how it moved without
sails or oars they could not tell.
At last they saw a faint silver light away in the distance, and a cool
breeze blew steadily against them. The light grew larger and larger
until it spread everywhere, and they saw the shores of the Giants’
Country, with Dunderhead’s great castle hovering above them. The
boat ran right up on to the beach, and then, suddenly turning into a
leaf, contracted to a small size and flew away to another beech, but
this time the beech was a tree.
The Red Elf vanished as soon as the leaf, and Teddy and Tilly,
finding themselves alone in this dreary land, began to cry loudly. It
would have been better for them if they had held their tongues, for
Dunderhead, hearing two children crying, knew at once that the elf
had brought them for his supper, and came down to seize them
before they could get away.
“Ah! this is the supper my friend the elf has brought me,” he roared,
picking up the children. “I’m so pleased! Now I’ll boil them.”
You may be sure that Teddy and Tilly were in a dreadful fright on
hearing this, as they did not want to be boiled; but, in spite of all their
cries, Dunderhead took them up to the great hall of his castle, and
set them down on the table.
They were so fat and juicy that the Giant cried tears of joy at the
prospect of having a good supper, and as his tears gushed out in a
great torrent, Gillydrop, who had been waiting for this, plunged into
the torrent to get his clothes cleaned again. Much to his dismay,

Current Practice Guidelines in Primary Care 2020 Joseph S Esherick Full Chapter

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Current Practice Guidelines in Primary Care 2020 Joseph S Esherick Full Chapter

Uploaded by

Copyright:

Available Formats

CURRENT Practice Guidelines in

Primary Care 2020 Joseph S. Esherick

Jacob A. David, MD, FAAFP

New York Chicago San Francisco Athens London Madrid

eBook conversion by codeMantra

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

THE NIGHTINGALE’S SONG.

The Day has furled

See how the moon shines in the sky

While the nightingale was thus singing in such a capricious manner,

HOW THE RED ELF RAN AWAY FROM FAERYLAND.

FAERYLAND lies between the Kingdom of the Shadows and the

And so when Gillydrop looked back, he saw no green banks, no tall

THE GIANT’S SONG.

Oh, if my life grows harder,

With hunger I am starving,

I’ve drunk up all the coffee,

I want to get some plum-cake—

Here Dunderhead stopped singing with a roar of pain, for while

“Why not?” asked Dunderhead, who was still eating.

HOW THE ELF BROUGHT THE GIANT’S SUPPER.

You might also like