CURRENT Practice Guidelines in Primary Care 2023 20th

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 This book is dedicated to all of our current and
former residents at the Ventura County Medical Center.
 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 Metabolic Disorders 31
Diabetes Mellitus ( DM ) , Type 2 and Prediabetes 31
Obesity 33
Thyroid Cancer 33
Thyroid Dysfunction 34
5. Gastrointestinal 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. Genitourinary Disorders 51
Bladder Cancer 51
Cervical Cancer 52
Endometrial Cancer 62
Ovarian Cancer 63
Pelvic Examinations 65
Prostate Cancer 66
Testicular Cancer 70
7. Infectious Diseases 71
Gonorrhea and Chlamydia 71
Herpes Simplex Virus ( HSV ), Genital 72
Human Immunodeficiency Virus ( HIV ) 73
Syphilis 74
Trichomonas 74
8. Pulmonary Disorders 77
Chronic Obstructive Pulmonary Disease 77
Lung Cancer 77
9. Renal Disorders 81
Kidney Disease, Chronic ( CKD ) 81
10. Special Population: Children 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
Human Immunodeficiency Virus ( 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 Impairment 98
11. Special 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

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 Virus ( 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. Cardiovascular 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 ( VTE ) Prophylaxis in Nonsurgical Patients 149
Venous Thromboembolism ( VTE ) in Surgical Patients 154
15. Disorders of the Skin, Breast, and Musculoskeletal System 157
Back Pain, Low 157
Breast Cancer 158
Gout 161
 CONTENTS

Oral Cancer 162

Osteoporosis 163
Pressure Ulcers 165
Skin Cancer 166
16. Endocrine and Metabolic Disorders 169
Diabetes Mellitus ( DM ) , Type 2 169
Hormone Replacement Therapy to Prevent Chronic Conditions 170
Obesity 171
17. Gastrointestinal Disorders 173
Colorectal Cancer 173
Esophageal Cancer 175
Gastric Cancer 176
Hepatocellular Cancer 177
18. Genitourinary Disorders 179
Cervical Cancer 179
Endometrial Cancer 180
Ovarian Cancer 181
Prostate Cancer 182
19. Infectious Diseases 183
Catheter- Related Bloodstream Infections 183
Colitis, Clostridium Difficile 184
Endocarditis Prevention 185
Human Immunodeficiency Virus ( HIV ), Opportunistic Infections 187
Immunizations 203
Influenza, Chemoprophylaxis 203
Influenza, Vaccination 205
20. Renal Disorders 207
Kidney Injury, Acute 207
21. Special Population: Children and Adolescents 209
Asthma 209
Atherosclerotic Cardiovascular Disease 210
Concussion 212
Dental Caries 213
Diabetes Mellitus ( DM ), Type 2 215
DomesticViolence 215
Immunizations, Infants and Children 216
Influenza, Chemoprophylaxis 216
Influenza, Vaccination 217
Motor Vehicle Injury 218
Obesity 219
Otitis Media 221
Sexually Transmitted Infections (STIs) 221
Tobacco Use 222
 CONTENTS

22. Special Population: Newborns and Infants 223

Immunizations, Infants and Children 223
Sudden Infant Death Syndrome (SIDS ) 223
Gonorrhea, Ophthalmia Neonatorum 224
23. Special Population: Older Adults 225
Driving Risk 225
Falls in the Elderly 226
Osteoporotic Hip Fractures 227
24. Special Population: Pregnant Women 229
Cesarean Section 229
Group B Streptococcal ( GBS ) Infection 231
Neural Tube Defects 231
Postpartum Depression 232
Postpartum Hemorrhage 232
Preeclampsia 233
Preterm Birth 233
Rh Alloimmunization 234
Surgical Site Infections ( SSI ) 234
Thromboembolism in Pregnancy 235
Tobacco Use 235

SECTION 3 MANAGEMENT
25. Behavioral Health 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 , Alzheimer Disease 313
Dementia 315
Delirium , Postoperative 315
Palliative Care of Dying Adults 316
28. Disorders of the Head, Eye, Ear, Nose, and Throat 319
Bronchitis, Acute 319
Cataract 320
Cerumen 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 Musculoskeletal System 347
Ankylosing Spondylitis and Spondyloarthritis 347
Atopic Dermatitis ( AD ) 348
Back Pain, Low 349
Lumbar Disc Herniation 351
RotatorCuffTears 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 and Metabolic Disorders 375

Adrenal Incidentalomas 375
Androgen Deficiency Syndrome (See Hypogonadism, Male ) 376
Cushing’s Syndrome ( CS ) 376
Diabetes Mellitus ( DM ), Type 1 376
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
Transgender Health Care 400
Vitamin Deficiencies 403
31. Gastrointestinal 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 Virus ( 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. Genitourinary Disorders 461
Benign Prostatic Hyperplasia ( BPH ) 461
Erectile Dysfunction ( ED ) 462
 CONTENTS

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 Hematologic Disorders 481
Anemia 481
Anemia, Chemotherapy Associated 481
Anemia , Hemolytic ( HA ) 483
Anemia, Iron Deficiency 485
Anemia of Chronic Disease 487
Cobalamin ( B ] 2 ) and Folate ( B„ ) Deficiency 488
Sickle Cell Disease 490
Immune 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. Infectious 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

Meningitis, Bacterial 547

Neurocysticercosis ( 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. Prenatal and Obstetric Care 611
Abortion 611
Contraception 612
Contraception, Emergency 614
Delivery: Trial Of Labor After Cesarean (TOLAC ) 627
Delivery: Vaginal Lacerations 627
Ectopic Pregnancy 628
Diabetes Mellitus, Gestational ( GDM ) 630
Human Immunodeficiency Virus ( HIV ), Pregnancy 630
Hypertension , Chronic in Pregnancy 632
Pregnancy, Postpartum Hemorrhage ( PPH ) 633
Premature Rupture of Membranes 634
Preterm Labor 636
 CONTENTS

Pregnancy, Preterm 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. Renal 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 Checklist for 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

Core Faculty, Family Medicine Residency Program , Ventura County Medical
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

Core Faculty, Family Medicine Residency Program , Ventura County Medical
Center, Assistant Clinical Professor, UCLA David Geffen School of Medicine,
Los Angeles, California
[ Chapters 12, 23, 27, 29]

Luyang Liu, MD
Family Medicine Residency Program , Ventura County Medical Center, Ventura,
California
[ Chapters 2, 3, 5, 14, 15, 17]

Eric Monaco, MD
Family Medicine Residency Program , Ventura County Medical Center, Ventura,
California
[ Chapters 30, 31]

Marina Morie, MD
Family Medicine Residency Program , Ventura County Medical Center, Ventura,
California
[ Chapters 12, 23, 27, 29]

John Nuhn, MD
Family Medicine Residency Program , Ventura County Medical Center, Ventura,
California
[ Chapters 8, 28, 37]

Carolyn Pearce, MD
Family Medicine Residency Program, Ventura County Medical Center, Ventura,
California
[ Chapters 10, 11, 21, 22 ]

Magdalena Reinsvold, MD
Family Medicine Residency Program , Ventura County Medical Center, Ventura,
California
[ Chapters 6, 9, 18, 20, 32, 38]
 CONTRIBUTORS

James Rohlfing, MD
Family Medicine Residency Program , Ventura County Medical Center, Ventura,
California
[ Chapters 33, 34 ]

Kristi M. Schoeld, MD
Family Medicine Residency Program , Ventura County Medical Center, Ventura,
California
[ Chapters 4, 7, 16, 19]

Tanya Shah, MD
Family Medicine Residency Program , Ventura County Medical Center, Ventura,
California
[ Chapters 26, 35]

Ian Wallace, MD
Family Medicine Residency Program , Ventura County Medical Center, Ventura,
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,
Los Angeles, California
[ Chapters 33, 34]
 Preface
Current Practice Guidelines in Primary Care 2023 is intended for all clinicians interested
in updated evidence-based guidelines for primary care topics in ambulatory and hospital
settings. This handy reference consolidates information from national medical
associations and government agencies into concise recommendations and guidelines
covering virtually all primary care topics. This book is organized into topics related to
disease screening and prevention for the general population, for specific population
groups, and disease management, and further subdivided into organ systems for quick
reference to the evaluation and treatment of the most common primary care disorders.
The 2023 edition of Current Practice Guidelines in Primary Care contains updates
reflecting more than 140 new guidelines. There are significant updates to several
guidelines including cervical cancer screening, colorectal cancer screening, management
of sexually transmitted infections, HIV prevention, headache, chronic pain, and gout. This
edition also includes several new topics including coronavirus disease, trauma-informed
care, vaginitis, vulvar diseases, pyelonephritis, abnormal uterine bleeding, and acne.
Residents, medical students, midlevel providers, and practicing physicians in family
medicine, internal medicine, pediatrics, and obstetrics and gynecology alike will find it a
great resource.
Several guidelines include race as a consideration in their approaches to care. As race is a
primarily social construct and purportedly scientific mechanisms to explain racial
differences in outcomes are rooted in biased data, guidelines that suggest differentiating
care by race should be considered with caution. Drs. Vyas, Einstein, and Jones offer a
thoughtful assessment at NEJM 2020;383:847-882 (https://www-nejm-org-
ssl.access.hanyang.ac.kr:8443/doi/full/10.1056/NEJMms2004740).
Although painstaking efforts have been made to find all errors and omissions, some may
remain. If you find an error or wish to suggest a change, please e-mail at
[email protected].
Evidence-based guidelines such as those reviewed in this book are wonderful tools. They
enable management strategies to be standardized and disseminated to a broad swath of the
medical profession. At their best, they offer immediate access to the wisdom and analytical
approach to data-driven medical care employed by the experts, elevating the quality of our
care. But, as with any human endeavor, they are susceptible to bias and misunderstanding.
While evidence-based guidelines increasingly dictate the standards for our clinical
practice, the highest quality medical care will always derive from a clinician’s experience,
curiosity, critical thinking, compassion, and personal relationship with a patient. In that
spirit, please use the tools in this book to further hone your craft.

Jacob A. David, MD, FAAFP

 Section
Screening