mebooksfree.com mebooksfree.com mebooksfree.com mebooksfree.com Executive Editor: Rebecca Gaertner Digital Product Development Editor: Leanne Vandetty Production Project Manager: Bridgett Dougherty Design Coordinator: Joan Wendt Manufacturing Coordinator: Beth Walsh Marketing Manager: Rachel Mante Leung Prepress Vendor: Absolute Service, Inc. 27th edition Copyright © 2019 Wolters Kluwer All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at [email protected], or via our website at lww.com (products and services). 9 8 7 6 5 4 3 2 1 Printed in China Library of Congress Cataloging-in-Publication Data available from the Publisher upon request. ISBN-13: 978-1-9751-0512-9 This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work. This work is no substitute for individual patient assessment based on health care professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data, and other factors unique to the patient. The publisher does not provide medical advice or guidance, and this work is merely a reference tool. Health care professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments. Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and health care professionals should consult a variety of sources. When prescribing medication, health care professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings, and side effects, and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used, or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work. LWW.com mebooksfree.com No work such as The 5-Minute Clinical Consult comes about without the dedicated and creative work of an entire team. I am deeply grateful for the critical analysis and collegiality of my 5MCC coeditors (and especially to Frank Domino, MD, who is the model of an evidence-based, practical, compassionate, and delightfully iconoclastic leader). I wish to thank our editorial staff at Wolters Kluwer—Rebecca Gaertner and Leanne Vandetty—who make this fun while getting the job done. I also thank and acknowledge my wife, Michele Roberts, MD, PhD, whose skills as a medical editor surpass my own and whose love, patience, and determination inspire and sustain me daily. To our team and to my wife of 30 years, I dedicate this book. JEREMY GOLDING, MD, FAAFP mebooksfree.com PREFACE “With most men, unbelief in one thing springs from blind belief in another.” —GEORG LICHTENBERG “Intelligence requires that you don’t defend an assumption.” —DAVID BOHM T wo quotes this year underscore the pressures of the last 12 months. In our personal, political, and medical lives, misinformation and opinion have risen from the shadows to medical society “guidelines,” and even to the law of the land. Take the 2017 American Heart Association/American College of Cardiology Hypertension Guidelines (http://hyper.ahajournals.org/content/guidelines2017). The “executive summary” was over 190 pages in length, and much of the guideline is expert opinion rather than scientific fact. Rational thought, logic, respect for honesty, for individuals, and for the greater good have, in some ways, been replaced by the opportunity to influence. If one says something often enough and loudly enough, it is seen as “fact,” no matter how absurd. Those who care for patients must remain firm in their approach; patient- centered and transparent. Leave the pejorative, in medicine and in politics, aside. You are the patient’s advocate. Think carefully about putting a 68-year-old on a statin for primary prevention. Understand the possible harms from aggressive blood pressure lowering. Be good stewards of both antibiotics and opioids. We have the potential to give wonderful care that benefits our patients AND society. But we can be easily confused, distracted, and “misguided” by vested interests and external pressures. One last quote, from a fellow New Jerseyan: “Someday we’ll look back on this and it will all seem funny.” —BRUCE SPRINGSTEEN I certainly hope so. Till then, the answer is to do no harm and put the patient (not some guideline or quality score fear) first. mebooksfree.com Welcome to the 2019 edition of The 5-Minute Clinical Consult. This is a book of diseases, diagnostic methods, and treatment recommendations. Much of the work provided by primary care providers is focused on helping the patients help themselves to be healthier. Diet, exercise, safety, and prevention are the interventions that provide the greatest number of people with the greatest return on longevity and its enjoyment. This year’s The 5-Minute Clinical Consult is here to assist in fulfilling our role as health care providers. In each patient interaction, in addition to bringing your clinical expertise, remember how others view you, as a leader, and the power of your words and actions. Encourage them to dream more, learn more, do more, and to be more. Our editorial team has collaborated with hundreds of authors so that you may deliver your patients the best care. Each topic provides you with quick answers you can trust, where and when you need them most, either in print or online at www.5MinuteConsult.com. This highly organized content provides you with the following: Differential diagnosis support from our expanded collection of algorithms Current evidence-based designations highlighted in each topic 540+ commonly encountered diseases in print, with an additional 1,500 online topics, including content from The 5-Minute Pediatric Consult FREE point-of-care CME and CE: 1/2 hour credit for every digital search Thousands of images to help support visual diagnosis of all conditions Video library of procedures, treatment, and physical therapy A to Z drug database from Facts & Comparisons Laboratory test interpretation from Wallach’s Interpretation of Diagnostic Tests More than 3,000 patient handouts in English and Spanish ICD-10 codes and DSM-5 criteria; additionally, SNOMED codes are available online. Our website, www.5MinuteConsult.com, delivers quick answers to your questions. It is an ideal resource for patient care. Integrating The 5-Minute Clinical Consult content into your workflow is easy and fast. And our patient education handouts can assist in helping you meet meaningful use compliance. If you purchased the Premium Edition, your access includes 1 year FREE use of our expanded website; the Standard Edition includes a free 10-day trial! The site promises an easy-to-use interface, allowing smooth maneuverability between topics, algorithms, images, videos, and patient education materials as well as more than 1,500 online-only topics. Evidence-based health care is the integration of the best medical information mebooksfree.com with the values of the patient and your skill as a clinician. We have updated our evidence-based medicine (EBM) content so you can focus on how to best apply it in your practice. The algorithm section includes both diagnostic and treatment algorithms. This easy-to-use graphic method helps you evaluate an abnormal finding and prioritize treatment. They are also excellent teaching tools, so share them with the learners in your office. This book and website are a source to solve problems; to help evaluate, diagnose, and treat patients’ concerns. Use your knowledge, expressed through your words and actions, to address their anxiety. The 5-Minute Clinical Consult editorial team values your observations, so please share your thoughts, suggestions, and constructive criticism through our website, www.5MinuteConsult.com. FRANK J. DOMINO, MD mebooksfree.com EVIDENCE-BASED MEDICINE WHAT IS EVIDENCE-BASED MEDICINE? R emember when we used to treat every otitis media with antibiotics? These recommendations came about because we applied logical reasoning to observational studies. If bacteria cause an acute otitis media, then antibiotics should help it resolve sooner, with less morbidity. Yet, when rigorously studied (via a systematic review), we found little benefit to this intervention. The underlying premise of EBM is the evaluation of medical interventions and the literature that supports those interventions, in a systematic fashion. EBM hopes to encourage treatments proven to be effective and safe. And when insufficient data exist, it hopes to inform you on how to safely proceed. EBM uses end points of real patient outcomes, morbidity, mortality, and risk. It focuses less on intermediate outcomes (bone density) and more on patient conditions (hip fractures). Implementing EBM requires three components: the best medical evidence, the skill and experience of the provider, and the values of the patients. Should this patient be screened for prostate cancer? It depends on what is known about the test, on what you know of its benefits and harms, your ability to communicate that information, and that patient’s informed choice. This book hopes to address the first EBM component, providing you access to the best information in a quick format. Although not every test or treatment has this level of detail, many of the included interventions here use systematic review literature support. The language of medical statistics is useful in interpreting the concepts of EBM. Below is a list of these terms, with examples to help take the confusion and mystery out of their use. Prevalence: proportion of people in a population who have a disease (in the United States, 0.3% [3 in 1,000] people >50 years have colon cancer) Incidence: how many new cases of a disease occur in a population during an interval of time; for example, “The estimated incidence of colon cancer in the United States is 104,000 in 2005.” Sensitivity: percentage of people with disease who test positive; for mebooksfree.com mammography, the sensitivity is 71–96%. Specificity: percentage of people without disease who test negative; for mammography, the specificity is 94–97%. Suppose you saw ML, a 53-year-old woman, for a health maintenance visit, ordered a screening mammogram, and the report demonstrates an irregular area of microcalcifications. She is waiting in your office to receive her test results, what can you tell her? Sensitivity and specificity refer to characteristics of people who are known to have disease (sensitivity) or those who are known not to have disease (specificity). But, what you have is an abnormal test result. To better explain this result to ML, you need the positive predictive value. Positive predictive value (PPV): percentage of positive test results that are truly positive; the PPV for a woman aged 50 to 59 years is approximately 22%. That is to say that only 22% of abnormal screening mammograms in this group truly identified cancer. The other 78% are false positives. You can tell ML only 1 out of 5 abnormal mammograms correctly identifies cancer; the four are false positives, but the only way to know which mammogram is correct is to do further testing. The corollary of the PPV is the negative predictive value (NPV), which is the percentage of negative test results that are truly negative. The PPV and NPV tests are population-dependent, whereas the sensitivity and specificity are characteristics of the test and have little to do with the patient in front of you. So when you receive an abnormal lab result, especially a screening test such as mammography, understand their limits based on their PPV and NPV. Treatment information is a little different. In discerning the statistics of randomized controlled trials of interventions, first consider an example. The Scandinavian Simvastatin Survival Study (4S) (Lancet. 1994;344[8934]:1383–1389) found using simvastatin in patients at high risk for heart disease for 5 years resulted in death for 8% of simvastatin patients versus 12% of those on placebo; this results in a relative risk of 0.70, a relative risk reduction of 33%, and a number needed to treat of 25. There are two ways of considering the benefits of an intervention with respect to a given outcome. The absolute risk reduction is the difference in the percentage of people with the condition before and after the intervention. Thus, if the incidence of myocardial infarction (MI) was 12% for the placebo group