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Contents
Part IX Genitourinary
29 Dysuria � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 561
Martin Fried
30 Acute Kidney Injury � � � � � � � � � � � � � � � � � � � � � � � � � � � � 577
Valerie Jorge Cabrera
31 Prostate Problems � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �591
Martin Fried
Part X Gastroenterologic
32 Abdominal Pain � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 609
Rosemarie L. Conigliaro and Sreekala
Raghavan
33 Abnormal Liver Tests � � � � � � � � � � � � � � � � � � � � � � � � � � � 623
Sreekala Raghavan and Rosemarie L.
Conigliaro
Part XI Psychiatric
34 Depression/Anxiety � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 639
Daniel Pomerantz and Ashutosshh Naaraayan
35 Insomnia� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 649
Aaron D. Storms and Shadi Dowlatshahi
36 Memory Loss and Cognitive Impairment � � � � � � � � � � � 667
Jarrod A. Carrol and Zaldy S. Tan
Index � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 681
Part I
General Considerations
Chapter 1
Screening/Physical Exam/
Health Maintenance
JosephConigliaro andSandeepKapoor
Introduction
Traditional medical pedagogy stresses the importance of a
complete patient history and physical exam. Though this is
extremely relevant for the purposes of learning and perfecting skills, the reality of clinical practice does not allow the
clinician to complete a full examination at each patient visit.
Therefore, clinicians need to decide how to narrow the focus.
When is it appropriate to perform focused history taking and
examinations? What can the clinician use to guide these decisions? Evidence-based recommendations for screening can
support the decision process and help guide the content of
the encounter with the patient and the care provided. This
chapter will highlight the importance of prevention, harm
reduction, and thoughtful screening to better inform the
physical examination and health maintenance planning.
J. Conigliaro
Zucker School of Medicine at Hofstra/Northwell,
Hempstead, NY, USA
e-mail: Jconigliaro@northwell.edu
S. Kapoor (*)
Northwell Health, New Hyde Park, NY, USA
e-mail: skapoor@northwell.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
E. Sydney et al. (eds.), Handbook of Outpatient Medicine,
https://doi.org/10.1007/978-3-031-15353-2_1
3
4
J. Conigliaro and S. Kapoor
Intersection ofPublic Health
andPrimaryCare
Public health and epidemiology provide insights into the
prevalence of diseases and conditions in different populations.
Public health focuses on prevention of disease and health promotion rather than the diagnosis and treatment of diseases.
The equation of one’s overall well-being is now understood to
be influenced by many factors, including but not limited to the
social, environmental and economic, as well as one’s education,
employment, healthcare access, genetics, and health behaviors.
The intersection of public health and primary care is one that
requires exploration, reflection, strategy, and action.
Social Determinants ofHealth (SDOH) [1]
Chapter 1. Screening/Physical Exam/Health…
The World Health Organization (WHO) defines social determinants of health as “The conditions in which people are
born, grow, work, live, and age, and the wider set of forces and
systems shaping the conditions of daily life. These forces and
systems include economic policies and systems, development
agendas, social norms, social policies and political systems”
[2]. Addressing social determinants is an important and everdeveloping area of practice that entails starting earlier and
broadening the scope of interventions, thus making entire
families and communities healthier [3].
Evidence and personal experiences have validated that
quality of life, physical and mental health, and overall wellbeing are impacted by SDOH and that healthcare teams have
the power to manifest equity of care. To do so demands
understanding, compassion, and skill. The following domains
can be explored in a timely fashion to better understand a
patient’s circumstances: housing, transportation, and neighborhoods; racism, discrimination, and violence; education, job
opportunities, and income; access to nutritious foods and
physical activity opportunities; purity of air and water; and
language and literacy skills [1]. Acknowledgment of individuals, in a holistic manner, is key to partnership and conavigation toward better health outcomes.
5
Prevention
Prevention activities are crucial in defining policies, guidelines, and clinical approaches. The Centers for Disease
Control and Prevention (CDC) deconstructs the landscape of
prevention into three categories [4]:
• Primary prevention: intervening before health effects
occur, through measures such as vaccinations, altering
risky behaviors (poor eating habits, tobacco use), and ban-
ning substances known to be associated with a disease or
health condition [4].
• Secondary prevention: screening to identify diseases in the
earliest stages, before the onset of signs and symptoms,
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J. Conigliaro and S. Kapoor
through measures such as mammography and regular
blood pressure measurement [4].
• Tertiary prevention: managing disease post-diagnosis to
slow or stop disease progression through measures such as
chemotherapy, rehabilitation, and continued screening for
complications [4].
Harm Reduction
Harm reduction refers to interventions aimed at reducing the
negative effects of health behaviors without necessarily extinguishing the problematic health behaviors completely or
permanently. The term “harm reduction” is tightly and traditionally associated with substance and tobacco use [5, 6];
however the philosophy of harm reduction can be applied to
all health behaviors where reduction of harm can be sought
via mitigated and measured behavioral change.
The principles of harm reduction in healthcare settings [7]
can serve to orient one’s personal mindset on how to
approach this perspective (Table 1. 1 ) and how to apply to a
prevalent health disorder such as obesity (Table1.2).
Chapter 1. Screening/Physical Exam/Health…
7
(continued)
produce positive health outcomes
• Moral judgments made against patients do not
dignify patients as individuals
T . Harm reduction principles, denitions, and approaches for healthcare settings [7]
Principle Definition Approaches
1. Humanism • Providers value, care for, respect, and
patients’ needs
• Grudges are not held against patients
• Services are user-friendly and responsive to
• Providers accept patients’ choices
do things for a reason; harmful health
behaviors provide some benefit to the
individual, and those benefits must be
assessed and acknowledged to understand
the balance between harms and benefits
• It is important to recognize that people
decisions is empowering for providers
• Understanding why patients make
harm reduction can present experiences of
moral ambiguity, since they are essentially
supporting individuals in health behaviors that
to be the goal of the patient
• Abstinence is neither prioritized nor assumed
behaviors
patients as opposed to moral or societal standards
• A range of supportive approaches is provided
• Care messages should be about actual harms to
• It is valuable for providers to understand that
change them are influenced by social and
community norms; behaviors do not occur
within a vacuum
are likely to result in negative health outcomes
• Health behaviors and the ability to
2. Pragmatism • None of us will ever achieve perfect health
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J. Conigliaro and S. Kapoor
patient, and no assumptions are made based
on harmful health behaviors
• Strengths and needs are assessed for each
• There is not a universal application of protocol
and these are exemplified by patient-driven
care, shared decision-making, and reciprocal
learning
or messaging for patients Instead, providers
tailor messages and interventions for each
patient and maximize treatment options for
each patient served
• Provider- patient partnerships are important,
state of the patient
• Care negotiations are based on the current
needs and strengths
• People present with spectrums of harm
T . (continued)
3. Individualism • Every person presents with his/her own
Principle Definition Approaches
and receptivity and therefore require a
spectrum of intervention options
education regarding patients’ medications
and treatment options, individuals
ultimately make their own choices about
medications, treatment, and health
4. Autonomy • Though providers offer suggestions and
behaviors to the best of their abilities,
beliefs, and priorities
Chapter 1. Screening/Physical Exam/Health…
positive movement
all people experience plateaus or negative
• It is important to recognize that at times,
trajectories
• Providing positive reinforcement is valuable
• Providers can help patients celebrate any
impact of their choices and behaviors is
valuable, backward movement is not penalized
• While helping patients to understand the
9
improved health, and positive change can
5. Incrementalism • Any positive change is a step toward
backward movements
take years
• It is important to understand and plan for
• Patients are responsible for their choices
6. Accountability
and health behaviors
goals
• Patients are not “fired” for not achieving
without
termination
harmful health decisions, and providers
• Individuals have the right to make
can still help them to understand that the
consequences are their own
J. Conigliaro and S. Kapoor
10
may include lack of access to healthy food or unhealthy eating habits that are rooted in
family traditions or local culture
overweight or assume that weight loss is the patients’ prioritized goal
again
or high-fat, low-nutrition foods
work with patients to establish realistic eating goals, which may or may not include weight
goals
• Providers strive to understand underlying factors contributing to patients’ obesity, which
Principle Example
1. Humanism • Providers do not shame or think less of patients with obesity
T . Examples of application of harm reduction principles for patients who are obese [7]
• Clinicians do not impose their personal beliefs about diet upon patients who are
• Behavioral interventionists encourage patients to reduce their consumption of processed
2. Pragmatism • Providers do not expect that the obese patient will never eat processed or sugary foods
• Rather than mandating that patients must lose a specific amount of weight, providers
experience and how it contributes to suboptimal health and then offer appropriate
3. Individualism • In working with patients who are obese, providers might strive to understand the patient’s
interventions. For example, food vouchers or referrals to food pantries with fresh produce
might be a useful support for patients without access to healthy food