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General Resources
Primary Care Medicine: Office Evaluation and
Management of the Adult Patient, 7
th
Edition
Allan H. Goroll, MD, MACP • Albert G. Mulley, MD, MPP
Addresses the full spectrum of clinical problems encountered in the
adult primary care practice.
Whether it’s the answer to a question regarding screening, prevention,
evaluation, management, or a comprehensive approach to a complex
condition, you’ll find a review of the best evidence integrated with
considerations of affordability, cost-effectiveness, convenience, and
patient preference.
All chapters are completely updated with new data from nearly 3,000
of the best and latest randomized trials, systematic reviews, meta-
analyses, and cost-effectiveness studies.
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Employs a unique problem-based chapter organization that covers
the full spectrum of adult primary care, including complementary
and alternative therapies, men’s and women’s health issues, ADHD,
posttraumatic stress disorder, and biologic therapies for cancer
and autoimmune disorders
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Presents actionable, scientifically-validated guidance that allows
physicians to go beyond standard consensus guidelines and
provide highly personalized care
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Emphasizes team-based approaches to primary care delivery,
recognizing its increasing importance in achieving high levels of
practice performance
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Provides over 300 tables, figures, and photographs
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Offers quarterly updates through its digital format to provide the
most current point-of-care decision support
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Includes free, unlimited INTERACTIVE eBook access
1,648 pages
$129.99
ISBN: 9781451151497"Compared with other primary care books written for use in the office at the point of care,
Primary Care Medicine
is the one to own."
Journal of the American Medical Association
"Great resource for the primary care practitioner. Comprehensive assessment, treatment,
standards, research, and pearls."
5-Star Amazon Review
chapter 52 Approach to thePatientwithAcuteBronchitis orPneumonia in theAmbulatorySetting 441 discussion);more than85%of resistantorganisms are serotypes contained in the 23-valent vaccine. In addition,penicillin resis- tance has decreased since the introduction of the pediatric conjugate vaccine (which contains serotypes responsible for almost80%of resistantorganisms) in2000. managementof influenza If the diagnosis of influenza is confirmed or highly suspected, severalmedicationsmaybeuseful indecreasing thedurationof symptoms ifadministeredwithin the first48hoursof the illness. Previously, amantadine and rimantadine were recommended as first-line therapy,although theseagentswereonlyactiveagainst influenzaA.However, increasing resistance to these agents has occurredover the lastdecade, and in the2005 to2006 influenza season, the routineuseof these agentswas abandoned. The neuraminidase inhibitors zanamivir and oseltamivir are neweragents for the treatmentof influenza.Thesedrugsare sialic acidanalogues that inhibit theviralneuraminidaseenzyme,which is essential to replication for both influenza A and influenza B. Randomized trials of these agents show a decrease in the dura- tion of illness of 1 to 1.5 days if the drug is administeredwithin 48 hours of symptom onset, similar to the effect seen with the older agents.Zanamivir is administeredby an inhaler twicedaily; oseltamivir isgivenasapill (75mg) twicedaily. Inhigh-riskpopu- lations, these agents reduce risk of death, hospitalization, and durationof symptoms.Earlier treatment is associatedwithbetter outcomes. The advantage of these newer agents is their activity against both influenzaA and influenzaB; thedevelopmentof resistance has been documented but is of uncertain clinical significance. In addition, because the average cost of these agents is at least 10 times greater than that of influenza vaccine, vaccination is clearlythemorecost-effectivemethodforavoidingflusymptoms. Preventing influenza among health careworkers is amajor challenge.Randomized trial findswearing an everyday surgical mask provides asmuchprotection aswearing an N95 respirator. Handwashing is essential. Prophylaxis in patients and family members is a priority (seePatientEducation andPrevention). tHERaPEutic REcommEndations (50,51) antibiotictherapy for Pneumonia Treatment for lower respiratory tract infections is tailored to the clinical syndrome and likelypathogens.Table52–2 summarizes the empiric antibiotic recommendations for the various clinical syndromes, andTable 52–3 describes the recommendations for specificpathogens. tabLe 52–2 empirictreatment for Lowerrespiratorytract infections clinicalSyndrome preferredempirictreatment alternativetreatment Acutebronchitis None Doxycycline, erythromycin Acute exacerbationof chronicbronchitis Second-generation cephalosporinor amoxicillin–clavulanate Second-generationmacrolide, a trimethoprim–sulfamethoxazole Community-acquiredpneumonia Healthy young adults Macrolide Doxycycline, respiratory fluoroquinolone b Elderly (age>60 y)or comorbiddisease Second-generationmacrolide a plus β -lactam c Respiratory fluoroquinolone Hospitalizedpatient (non–intensive careunit) Third-generation cephalosporinplus second-generationmacrolide Respiratory fluoroquinolone a Second-generationmacrolides include clarithromycin and azithromycin. b Respiratory fluoroquinolones are agentswith adequatepneumococcal activity, including levofloxacin,moxifloxacin, andgemifloxacin. c β -Lactamswith adequate activity againstpotentially resistantpneumococci include amoxicillin1g three timesdaily and amoxicillin–clavulanate2g twicedaily. tabLe 52–3 pathogen-Specifictherapy for Lowerrespiratorytract infections organism First-Lineagent alternativeagents Streptococcus pneumoniae Penicillin sensitive (MIC<0.1 μ g/mL) Penicillinor amoxicillin Erythromycin, respiratory fluoroquinolone Intermediatepenicillin resistance (MIC0.1–2.0 μ g/mL) Parenteralpenicillinor ceftriaxone Respiratory fluoroquinolone Highlypenicillin resistant (MIC>2.0 μ g/mL) Ceftriaxone, cefotaxime (basedon susceptibilities) Vancomycin, respiratory fluoroquinolone Legionellosis Erythromycinor second-generation macrolide Respiratory fluoroquinolone Haemophilus influenzae,Moraxella catarrhalis Second-generation cephalosporin Second-generationmacrolide, trimethoprim–sulfamethoxazole Chlamydophila pneumoniae,Chlamydia psittaci, Mycoplasma pneumoniae Doxycyclineor erythromycin Second-generationmacrolide, respiratory fluoroquinolone Staphylococcus aureus Nafcillin Vancomycin (ifmethicillin resistant); cefazolin Klebsiella pneumoniae Second-or third-generation cephalosporin β -Lactam/ β -lactamase inhibitor, fluoroquinolone Streptococcus pyogenes Penicillin Cephalosporin, erythromycin Coxiella burnetii (Q fever) Doxycycline Chloramphenicol Mixed anaerobic–aerobic infection (aspiration) Clindamycin Penicillinplusmetronidazole Bordetella pertussis Erythromycinor second-generation macrolide Trimethoprim–sulfamethoxazole InfluenzaA Oseltamivir Zanamivir MIC,minimum inhibitory concentration.Sec04.indd 4
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