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Contributors
JeremyS. Abramson, MD, MMSc
AssistantProfessor
DepartmentofMedicine
HarvardMedical School Director,LymphomaProgram Cancer Center
MassachusettsGeneral Hospital Boston,Massachusetts
KarinAndersson, MD Instructor
DepartmentofMedicine
HarvardMedical School
Hepatologist
MassachusettsGeneral Hospital Boston,Massachusetts
Ernie-Paul Barrette, MD, FACP
AssociateProfessor
DepartmentofMedicine
WashingtonUniversity Medical Director
PrimaryCareMedicineClinic
Barnes-JewishHospital
St.Louis,Missouri
Michael J. Barry, MD
Clinical Professor
DepartmentofMedicine
HarvardMedical School
Medical Director
JohnD.StoeckleCenter for PrimaryCareInnovation
MassachusettsGeneral Hospital
Boston,Massachusetts
HasanBazari, MD
AssociateProfessor ofMedicine
DepartmentofMedicine
HarvardMedical School
Physician,ProgramDirector
Internal MedicineResidency
MassachusettsGeneral Hospital
Boston,Massachusetts
SusanE. Bennett, MD
AssistantProfessor
DepartmentofMedicine
HarvardMedical School
AssociatePhysician
DepartmentofMedicine
MassachusettsGeneral Hospital
Boston,Massachusetts
Neil Bhattacharyya, MD, FACS
Professor
DepartmentofOtologyandLaryngology
HarvardMedical School
AssociateChief
DivisionofOtolaryngology
BrighamandWomen’sHospital
Boston,Massachusetts
Michael F. Bierer, MD, MPH
AssistantProfessor
HarvardMedical School
AssociatePhysician
DepartmentofMedicine
MassachusettsGeneral Hospital
Boston,Massachusetts
Shana L. Birnbaum, MD
Instructor
DepartmentofMedicine
HarvardMedical School
AssistantPhysician
DepartmentofMedicine
MassachusettsGeneral Hospital
Boston,Massachusetts
StephenL. Boswell, MD
AssistantProfessor ofMedicine
DepartmentofInfectiousDiseases
MassachusettsGeneral Hospital
PresidentandCEO
FenwayHealth
Boston,Massachusetts
Ilana M. Braun, MD
AssistantProfessor
DepartmentofPsychiatry
HarvardMedical School
Chief
DepartmentofPsychosocial OncologyandPalliativeCare
Dana-Farber Cancer Institute
Boston,Massachusetts
DavidC. Brewster, MD
Clinical Professor ofSurgery
DepartmentofVascular andEndovascular Surgery
HarvardMedical School
AttendingSurgeon
DepartmentofSurgery
MassachusettsGeneral Hospital
Boston,Massachusetts
W. ScottButsch, MD, MS
Instructor inMedicine
DepartmentofMedicine
HarvardMedical School
AssistantinMedicine
DepartmentofMedicine
MassachusettsGeneral Hospital
Boston,Massachusetts
Francis X. Campion, MD
Instructor
DepartmentofPopulationMedicine
HarvardMedical School
General Internist
BethIsrael DeaconessMedical Center
Boston,Massachusetts
NancyL. Cantelmo, MD
AssistantClinical Professor ofSurgery
SurgeryDepartment
HarvardMedical School
AssistantinSurgery
Vascular andEndovascular SurgeryDepartment
MassachusettsGeneral Hospital
Boston,Massachusetts
ChristopherP. Chiodo, MD
Clinical Instructor
DepartmentofOrthopedicSurgery
HarvardMedical School
FootandAnkleDivisionChief
DepartmentofOrthopedicSurgery
BrighamandWomen’sHospital
Boston,Massachusetts
JeffreyW. Clark, MD
AssociateProfessor
DepartmentofMedicine
HarvardMedical School
Medical Director,Cancer Center Protocol Office
Medical Director,Medical OncologyExperimental TherapeuticsProgram
Director oftheClinical TrialsCore,Dana-Farber/PartnersCancer Care
MassachusettsGeneral Hospital
Boston,Massachusetts
Tina Scheufele Cleary, MD
Vitreoretinal Surgeon
OphthalmicConsultantsofBoston
Boston,Massachusetts
M. Cornelia Cremens, MD
AssistantProfessor
DepartmentofPsychiatry
HarvardMedical School
GeriatricPsychiatrist
DepartmentsofPsychiatryandMedicine
MassachusettsGeneral Hospital
Boston,Massachusetts
Michael E. Dalton, OD, MBA
Optometrist
OphthalmicConsultantsofBoston
Boston,Massachusetts
BenjaminDavis, MD
AssistantProfessor
HarvardMedical School
Physician
InfectiousDiseaseDepartment
MassachusettsGeneral Hospital
Boston,Massachusetts
RichardJ. de Asla, MD
Instructor
DepartmentofOrthopedicSurgery
HarvardMedical School
Boston,Massachusetts
DepartmentofOrthopedicSurgery
Winchester Hospital
Winchester,Massachusetts
Thomas F. DeLaney, MD
Professor
DepartmentofRadiationOncology
HarvardMedical School
Medical Director,FrancisH.Burr ProtonTherapyCenter
DepartmentofRadiationOncology
MassachusettsGeneral Hospital Boston,Massachusetts
Jules L. Dienstag, MD
Carl W Walter Professor ofMedicineandDeanfor Medical Education
DepartmentofMedicine
HarvardMedical School
Physician
Gastrointestinal Unit,DepartmentofMedicine
MassachusettsGeneral Hospital
Boston,Massachusetts
DarinD. Dougherty, MD, MSc
AssociateProfessor
DepartmentofPsychiatry
HarvardUniversity
Director
DivisionofNeurotherapeutics,DepartmentofPsychiatry
MassachusettsGeneral Hospital Boston,Massachusetts
PeterJ. Fagenholz, MD
Instructor
DepartmentofSurgery
HarvardMedical School
Assistant
DepartmentofSurgery
MassachusettsGeneral Hospital
Boston,Massachusetts
Leslie S.-T. Fang, MD, PhD
AssistantProfessor
DepartmentofMedicine
HarvardMedical School
FirmChief,Walter Bauer Firm
DepartmentofMedicine
MassachusettsGeneral Hospital
Boston,Massachusetts
Laura C. Fine, MD
Clinical Instructor
DepartmentofOphthalmology
HarvardMedical School
AssistantinOphthalmology,ActiveStaff
MassachusettsEyeandEar Infirmary Boston,Massachusetts
Lawrence S. Friedman, MD
Professor ofMedicine
HarvardMedical School andTuftsUniversitySchool ofMedicine
AssistantChiefofMedicine
MassachusettsGeneral Hospital
Boston,Massachusetts
Chair,DepartmentofMedicine
Newton-WellesleyHospital Newton,Massachusetts
Nicoletta Fynn-Thompson, MD Partner
OphthalmicConsultantsofBoston Boston,Massachusetts
Ellie J. C. Goldstein, MD
Clinical Professor
DepartmentofMedicine
DavidGeffenSchool ofMedicineatUCLA Director
DepartmentofInfectionControl
Kindred-LAHospital LosAngeles,California
AnnekathrynGoodman, MD
AssociateProfessor ofObstetrics,Gynecology,ReproductiveBiology
DepartmentofObstetricsandGynecology
HarvardMedical School
Boston,Massachusetts
JohnD. Goodson, MD
AssociateProfessor
DepartmentofMedicine
HarvardMedical School
Physician
General Internal MedicineUnit,DepartmentofMedicine
MassachusettsGeneral Hospital
Boston,Massachusetts
Claus Hamann, MD, MS
Consultant,GeriatricMedicine DepartmentofMedicine
MassachusettsGeneral Hospital
Boston,Massachusetts
MarkP. Hatton, MD
SurgeoninOphthalmology,MassachusettsEyeandEar Infirmary
AssistantClinical Professor ofOphthalmology
HarvardMedical School
Boston,Massachusetts
Nicole L. Herschenhous, MD
AssistantProfessor
DepartmentofPsychiatry
DalhousieUniversity
StaffPsychiatrist
ShortStayUnit
QueenElizabethIIHealthSciencesCentre
Halifax,NovaScotia,Canada
CarolynCrimmins Hintlian, MPH, MBA, RD, LDN
ConsultingNutritionist
BostonNutritionDowntown
Senior AdministrativeManger
BiostatisticsCenter,DepartmentofMedicine
MassachusettsGeneral Hospital
Boston,Massachusetts
Theodore Hong, MD
AssistantProfessor
DepartmentofRadiationOncology
HarvardMedical School
Director,Gastrointestinal RadiationOncology
DepartmentofRadiationOncology
MassachusettsGeneral Hospital Boston,Massachusetts
James W. Hung, MD
OphthalmicConsultantsofBoston Boston,Massachusetts
Elaine M. Hylek, MD, MPH
Professor
DepartmentofMedicine
BostonUniversity
Director,ThrombosisClinicandAnticoagulationService
BostonMedical Center
Boston,Massachusetts
Ignacio Inglessis, MD
AssistantProfessor
DepartmentofMedicine
HarvardMedical School
Director of Adult Congenital Heart Disease Interventions, Interventional Cardiology
CardiologyDivision
MassachusettsGeneral Hospital
Boston,Massachusetts
Jesse B. Jupiter, MD
Professor,HansjorgWyssAOFoundation
DepartmentofOrthopaedicSurgery
HarvardMedical School
VisitingSurgeon
DepartmentofOrthopaedicSurgery
MassachusettsGeneral Hospital
Boston,Massachusetts
MihirM. Kamdar, MD
Instructor
DepartmentofMedicine
HarvardMedical School
Director,MGHCancer PainClinic
DepartmentofPainMedicineandPalliativeCare
MassachusettsGeneral Hospital
Boston,Massachusetts
Linda A. King, MD
AssistantProfessor ofMedicine
SectionofPalliativeCareandMedical Ethics
UniversityofPittsburghMedical Center
Pittsburgh,Pennsylvania
LindsayY. King, MD
Fellow
DepartmentofGastroenterology
MassachusettsGeneral Hospital Boston,Massachusetts
WilliamA. Kormos, MD, MPH
Instructor inMedicine
DepartmentofMedicine
HarvardMedical School
AssistantPhysician
General Internal Medicine
MassachusettsGeneral Hospital
Boston,Massachusetts
Eric L. Krakauer, MD, PhD
AssistantProfessor
DepartmentsofMedicineandGlobal HealthandSocial Medicine
HarvardMedical School
AttendingPhysician
DepartmentofPalliativeCareService
MassachusettsGeneral Hospital
Boston,Massachusetts
BradenKuo, MD, MSc
Instructor inMedicine
DepartmentofGastroenterology
HarvardUniversity
Director ofGIMotilityLaboratory,AssistantPhysician
DepartmentofGastroenterology
MassachusettsGeneral Hospital
Boston,Massachusetts
Irene Kuter, MD, DPhil
AssistantProfessor
DepartmentofMedicine
HarvardMedical School
Medical Oncologist
Medical Services/Cancer Center
MassachusettsGeneral Hospital Boston,Massachusetts
EdwardT. LaheyIII, DMD, MD
Instructor
DepartmentofOral andMaxillofacial Surgery
HarvardSchool ofDental Medicine
AssistantOral andMaxillofacial Surgeon
DepartmentofOral andMaxillofacial Surgery
MassachusettsGeneral Hospital
Boston,Massachusetts
Regina C. Larocque, MD, MPH
AssistantProfessor
DepartmentofMedicine
HarvardMedical School
AssistantPhysician
DepartmentofMedicine
MassachusettsGeneral Hospital
Boston,Massachusetts
ElizabethA. Lawson, MD, MSc
AssistantProfessor
DepartmentofMedicine
HarvardMedical School
AssistantinMedicine
NeuroendocrineUnit,DepartmentofMedicine
MassachusettsGeneral Hospital
Boston,Massachusetts
RichardR. Liberthson, MD
AssociateProfessor
DepartmentofMedicineandPediatrics
HarvardMedical School
Director Congenital HeartDiseaseProgram,Physician,Pediatrician
DepartmentsofMedicineandPediatrics
MassachusettsGeneral Hospital
Boston,Massachusetts
DavidA. Lovas, MD
AssistantProfessor
PsychiatryDepartment
DalhousieUniversityFacultyofMedicine
StaffChild&AdolescentPsychiatrist
PsychiatryDepartment IWKChildren’sHospital
Halifax,NovaScotia,Canada
Fremonta Meyer, MD
Instructor
DepartmentofPsychiatry
HarvardMedical School
AttendingPsychiatrist
DepartmentofPsychiatry
BrighamandWomen’sHospital
Boston,Massachusetts
KennethL. Minaker, MD
AssociateProfessor
DepartmentofMedicine
HarvardMedical School
Chief,GeriatricMedicine
DepartmentofMedicine
MassachusettsGeneral Hospital
Boston,Massachusetts
WilliamE. Minichiello, EdD
Psychologist
MassachusettsGeneral Hospital
AssociateProfessor ofPsychology
DepartmentofPsychiatry
HarvardMedical School
Boston,Massachusetts
Deanna D. Nguyen, MD
Instructor DepartmentofMedicine
HarvardMedical School
AssistantPhysician
Gastrointestinal Unit,DepartmentofMedicine
MassachusettsGeneral Hospital Boston,Massachusetts
L. Christine Oliver, MD, MPH, MS
AssociateClinical Professor ofMedicine
DepartmentofMedicine
HarvardMedical School
Co-Director,Occupational andEnvironmental Medicine DepartmentofMedicine
MassachusettsGeneral Hospital
Boston,Massachusetts
Kerri Palamara, MD
Instructor ofMedicine
DepartmentofMedicine
HarvardMedical School
AssociateProgramDirector DepartmentofMedicine
MassachusettsGeneral Hospital Boston,Massachusetts
AmyA. Pruitt, MD
AssociateProfessor
DepartmentofNeurology
UniversityofPennsylvania
DivisionChief,General Neurology DepartmentofNeurology
Hospital oftheUniversityofPennsylvania
Philadelphia,Pennsylvania
ScottL. Rauch, MD
Professor
DepartmentofPsychiatry
HarvardMedical School
Boston,Massachusetts
PresidentandPsychiatristinChief
DepartmentofPsychiatry
McLeanHospital
Belmont,Massachusetts
Claudia U. Richter, MD
Clinical Instructor
DepartmentofOphthalmology
HarvardMedical School
AssistantSurgeon DepartmentofOphthalmology
MassachusettsEyeandEar Infirmary
Boston,Massachusetts
James M. Richter, MD
AssociateProfessor ofMedicine
DepartmentofMedicine
HarvardMedical School
Physician
GastroenterologyDivision
MassachusettsGeneral Hospital
Boston,Massachusetts
NancyRidenour, PhD, APRN, BC, FAAN
DeanandProfessor
UniversityofNew MexicoCollegeofNursing
Albuquerque,New Mexico
NancyA. Rigotti, MD Professor
DepartmentofMedicine
HarvardMedical School
AssociateChief
General MedicineDivision
MassachusettsGeneral Hospital
Boston,Massachusetts
DavidRing, MD, PhD
AssociateProfessor
DepartmentofOrthopaedicSurgery
HarvardMedical School
Director ofResearch
OrthopaedicHandandUpper ExtremityService
MassachusettsGeneral Hospital
Boston,Massachusetts
Laurence J. Ronan, MD
Instructor
DepartmentofMedicine
HarvardMedical School
StaffPhysician
DepartmentofMedicine
MassachusettsGeneral Hospital
Boston,Massachusetts
JasonS. Rothman, MD
OphthalmicConsultantsofBoston
Boston,Massachusetts
EdwardT. Ryan, MD, FACP, FIDSA, FASTMH
Professor
DepartmentofMedicine
HarvardMedical School
Professor
DepartmentofImmunologyandInfectiousDiseases
HarvardSchool ofPublicHealth
Director
ImmunizationCenter,DivisionofInfectiousDiseases
MassachusettsGeneral Hospital
Boston,Massachusetts
JennyS. Sauk, MD
Instructor inMedicine
DepartmentofGastroenterology
HarvardMedical School
AssistantinMedicine
DepartmentofGastroenterology
MassachusettsGeneral Hospital
Boston,Massachusetts
PeterC. Schalock, MD
AssistantProfessor
DepartmentofDermatology
HarvardMedical School
AssistantDermatologist
DepartmentofDermatology
MassachusettsGeneral Hospital Boston,Massachusetts
Linda C. Shafer, MD
AssistantProfessor
DepartmentofPsychiatry
HarvardMedical School
Psychiatrist
DepartmentofPsychiatry
MassachusettsGeneral Hospital Boston,Massachusetts
Paul C. Shellito, MD
AssistantProfessor ofSurgery
DepartmentofSurgery
HarvardMedical School
AssociateVisitingSurgeon
SurgeryDepartment
MassachusettsGeneral Hospital
Boston,Massachusetts
DavidM. Slovik, MD
AssociateProfessor ofMedicine
HarvardMedical School
Chief
DivisionofEndocrinologyandDiabetes
Newton-WellesleyHospital
EndocrineUnit
MassachusettsGeneral Hospital
Boston,Massachusetts
ArthurJ. Sober, MD
Professor
DepartmentofDermatology
HarvardMedical School
Director for QualityandSafety
DepartmentofDermatology
MassachusettsGeneral Hospital
Boston,Massachusetts
Shane J. Volney, MD
Clinical Instructor
DepartmentofAnesthesia,Critical Care,andPainMedicine
HarvardMedical School
AssistantinAnesthesia
DepartmentofAnesthesia,Critical Care,andPainMedicine
MassachusettsGeneral Hospital
Boston,Massachusetts
E. NalanWard, MD
Instructor
DepartmentofPsychiatry
HarvardMedical School
AssociatePsychiatrist
DepartmentofPsychiatry
MassachusettsGeneral Hospital
Boston,Massachusetts
JeffreyB. Weilburg, MD
AssistantProfessor
DepartmentofPsychiatry
HarvardMedical School
AssociateinPsychiatry
DepartmentofPsychiatry
MassachusettsGeneral Hospital
Boston,Massachusetts
JohnJ. WorthingtonIII, MD
AssistantProfessor
DepartmentofPsychiatry
HarvardMedical School
StaffPsychiatrist
DepartmentofPsychiatry
MassachusettsGeneral Hospital
Boston,Massachusetts
PatrickS. Yachimski, MD, MPH
AssistantProfessor ofMedicine
Director ofPancreatobiliaryEndoscopy
AssistantProfessor ofMedicine
DivisionofGastroenterology,Hepatology&Nutrition
VanderbiltUniversityMedical Center
Nashville,Tennessee
Sonia S. Yoon, MD
ResearchFellow
HarvardMedical School
Clinical ResearchFellow inMedicine
Gastrointestinal Unit,DepartmentofMedicine
MassachusettsGeneral Hospital
Boston,Massachusetts
Acknowledgments
Over the preceding33 years and seveneditions of Primary Care Medicine, innumerable individuals have contributedgenerouslytothis textbook.Given the importance of their past contributions to the collective effort that goes into preparation of each new edition, we have always acknowledged those who completed their assignments with publication of the previous edition We remainmostgrateful tothemandlistbelow their names andthe chapters theyauthoredor coauthored:
• Katherine K. Treadway, MD: Chapters 14 (Screening for Hypertension), 19(EvaluationofHypertension),and26(ManagementofHypertension)
• G Sherry Haydock, MD, and Mason W Freeman, MD: Chapters 15 (Screening for Hyperlipidemia and Associated Coronary Heart Disease RiskFactors) and27(ApproachtothePatientwithaLipidDisorder)
•J.Andrew Billings,MD: Chapter 90,Part2(PalliativeCare)
• Charles McCabe, MD: Appendix, Chapter 197-1 (Minor Surgical Office Proceduresfor SkinProblems)
• Audrey Ahuero, MD: Chapters 201 (Evaluation of Eye Pain) and 202 (EvaluationofDryEyes)
•KristieJ.Bennett,OD: Chapter 210(CorrectionofVision)
• JohnP. Kelly, MD, DMD: Chapters 211 (Screening for Oral Cancer) and 214(EvaluationofAcuteOrofacial PainandSwelling)
• Eleanor Z. Hanna, PhD: Chapter 228 (Approach to the Patient with an Alcohol Problem)
• Arthur J. Barsky III, MD: Chapters 230 (Approach to Patients with Somatic Symptom Disorders and Health Anxiety) and 231 (Approach to DifficultPatientInteractions)
Although Primary Care Medicine is principally a work by primary care physicians for primary care physicians and team members, it depends on contributions fromour specialtycolleagues,bothininternal medicineandin
the nonmedical specialties pertinent to adult primary care. We want to acknowledge the superb efforts of our specialty section editors for this edition in authoring chapters and, in some instances, also coordinating contributionsfromtheir colleagues.
•JamesM.Richter,MD Gastroenterology
•JeffreyW.Clark,MD Oncology
•DavidM.Slovik,MD Endocrinology
•AnnekathrynGoodman,MD Gynecology
•AmyA.Pruitt,MD Neurology
•Peter C.Schalock,MD Dermatology
•ClaudiaU.Richter,MD Ophthalmology
•Neil Bhattacharyya,MD ENT
Unique to this edition of Primary Care Medicine are 1) the tables on team-basedcareanditsevidencebasecontributedbyNancyRidenour,PhD, Deanofthe College ofNursing, UniversityofNew Mexico, and 2) the web site’s interprofessional curriculum for team-based care authored by Dr. Ridenour and Leigh H. Simmons, MD of Massachusetts General Hospital. These are pioneeringefforts we are excited aboutand lookto expand inthe future.
Finally, we want to acknowledge and express our gratitude for the professionalismand commitment to publishing quality of our colleagues at Lippincott Williams & Wilkins, particularly editors Rebecca Gaertner, Sonya Seigafuse, and Kristina Oberle, assisted by the valued efforts of Thomas Conville and D. Sree Vidya. We are fortunate to have such a fine publisher over thesemanyyearsandmanyeditions.
Physicians have traditionally provided direct, initial, comprehensive care for patients as well as continuity of care. In the past two decades, the growing proportion of specialist physicians has endangered this traditional role of the physician. The development of highly technologic, tertiary, inpatient medical care has preoccupied the attention of our teaching institutions. Coping with the increased armamentarium of diagnostic and therapeutic interventions has distracted some physicians from traditional roles in patient care. The primary care movement has been a national response to this situation aimed at providing more physicians skilled in dealingwiselyand humanelywithillness intheir patients and providingthe overall supervision and continuity of medical care that we expect of good generalists. It encourages these physicians to know their patients as human and social beings as well as bearers of organ pathology. Promotion of preventionas well as the practice of curingis animportant part of primary care.
Theconcerns thathaveledtorenewedattentionofthemedical profession to primary care medicine have had a very salutary effect on our teaching institutions. There has been a resurgence of training in the ambulatory setting. Medical students and residents have learned that many illnesses formerlythoughttorequire hospitalizationcanbe effectivelymanagedinthe ambulatorysetting. As usual, this is not anoriginal discovery; rather, it is a returnto the emphasis thatwas verymucha partoftrainingprograms inthe earlier decadesofthiscentury.
Primary Care Medicine has grown out of the experiences of a group of young physicians who have pioneered in the rebirth of primary care medicine within the Harvard medical community. They have organized primarycarepractices thathaveservedas trainingsites for other physicians and healthworkers. Theyhave examined their ownpractices, as well as the
published experience of others, in order to provide within this text a synthesis of the best available information for ambulatory management of adult medical patients. Their discussions are brief and practical rather than exhaustive, but the interested reader is provided with a key annotated bibliographythatdirects himto further sources ofinformation. This bookis not meant to compete with the traditional exhaustive textbook of Medicine. Rather, its brief, clear discussions and analyses of current knowledge are prepared for the busypractitioner who dailyencounters manyproblems for whichheneedstoquicklyknow thebestavailableanswers.
To whom is the book addressed? To the primary care physician, of course. Itwill be his bible a valuable source ofguidance and ofsolace in innumerable managementsituations. Butitis becomingincreasinglyevident thatthe medical subspecialistdevotes a considerable portionofhis practice time to the provision of first contact and continuous care of the medical needs ofhis patients.This bookwill,therefore,findawelcomeplaceonthe desk of both the medical subspecialist and the medical generalist and is addressedtoeveryoneengagedintheclinical practiceofadultMedicine.
Alexander Leaf, MD Jackson Professor of Medicine
Harvard Medical School Chief, Medical Services Massachusetts General Hospital Boston, Massachusetts April 1981
