Graber and Wilbur’s Family Medicine Examination and Board Review [5th Edition] 9781260441086

An engagingly written case-based review for the Family Medicine Board Examination and the USMLE Step 3 Widely recognized

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 9781260441086

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Table of contents :
Contributors..............................................................................................ix
Preface..................................................................................................... xiii
A Few Words on Studying and Taking the Board Examination...... xv
1 Emergency Medicine................................................................... 1
2 Cardiology......................................................................................43
3 Pulmonology.............................................................................. 105
4 Allergy and Immunology....................................................... 141
5 Nephrology................................................................................. 150
6 Hematology and Oncology................................................... 183
7 Gastroenterology...................................................................... 211
8 Infectious Diseases................................................................... 253
9 HIV/AIDS...................................................................................... 281
10 Endocrinology........................................................................... 296
11 Rheumatology........................................................................... 330
12 Orthopedics and Sports Medicine..................................... 364
13 Pediatrics..................................................................................... 395
14 Adolescent Medicine............................................................... 437
15 Obstetrics and Women’s Health.......................................... 451
16 Men’s Health............................................................................... 501
17 Dermatology.............................................................................. 525
18 Neurology.................................................................................... 551
19 Ophthalmology......................................................................... 585
20 Otolaryngology......................................................................... 607
21 Care of the Older Patient........................................................ 631
22 Care of the Surgical Patient................................................... 662
23 Psychiatry.................................................................................... 693
24 Nutrition and Herbal Medicine............................................ 729
25 Substance Use Disorders....................................................... 742
26 Ethics............................................................................................. 763
27 End-of-Life Care......................................................................... 774
28 Evidence-Based Medicine..................................................... 788
29 Patient-Centered Care............................................................. 800
30 Final Examination..................................................................... 813
Index........................................................................................................841

Citation preview

Graber and Wilbur’s

FAMILY MEDICINE EXAMINATION & BOARD REVIEW

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Graber and Wilbur’s

FAMILY MEDICINE EXAMINATION & BOARD REVIEW FIFTH EDITION Editors Mark A. Graber, MD, MSHCE, FACEP Clinical Professor Departments of Family Medicine and Emergency Medicine Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City, Iowa Brigit E. Ray, MD, MME Clinical Assistant Professor Department of Family Medicine Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City, Iowa Jason K. Wilbur, MD, FAAFP Clinical Professor Department of Family Medicine Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City, Iowa

New York/Chicago/San Francisco/Athens/London/Madrid/Mexico City/ New Delhi/Milan/Singapore/Sydney/Toronto

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Copyright © 2020 by McGraw-Hill Education. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher. ISBN: 978-1-26-044108-6 MHID: 1-26-044108-3 The material in this eBook also appears in the print version of this title: ISBN: 978-1-26-044107-9, MHID: 1-26-044107-5. eBook conversion by codeMantra Version 1.0 All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark. Where such designations appear in this book, they have been printed with initial caps. McGraw-Hill Education eBooks are available at special quantity discounts to use as premiums and sales promotions or for use in corporate training programs. To contact a representative, please visit the Contact Us page at www.mhprofessional.com. Notice Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. Readers are encouraged to confirm the information contained herein with other sources. For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is of particular importance in connection with new or infrequently used drugs. TERMS OF USE This is a copyrighted work and McGraw-Hill Education and its licensors reserve all rights in and to the work. Use of this work is subject to these terms. Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill Education’s prior consent. You may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited. Your right to use the work may be terminated if you fail to comply with these terms. THE WORK IS PROVIDED “AS IS.” McGRAW-HILL EDUCATION AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill Education and its licensors do not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free. Neither McGraw-Hill Education nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom. McGraw-Hill Education has no responsibility for the content of any information accessed through the work. Under no circumstances shall McGraw-Hill Education and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages. This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise.

To the people who make Family Medicine happen. Jogjakarta: Dr. Mora Claramita, Dr. Adi Heru Husodo, Dr. Wahyudi Istiono, and Dr. Fitriana Murriya. Moscow: Professor Dr. Gregorii Efimovich Roitberg, Dr. Olga Sharkun, Dr. Irina Slastnikova, Dr. Janna Dorosh, and Professor Timothy O’Connor. Haiphong: Dr. Hùng Nguyễn Văn, Dr. Linh Nguyễn, and Dr. Nguyễn Thuý Hiếu. —MAG To my parents, Bill and Bonnie Ray, for always loving, supporting, and encouraging me to follow my dreams to become a family physician. To all of my Family Medicine and education mentors including: Drs. George Bergus, Rick Dobyns, Jason Wilbur, Bob Tallitsch, Jeff Pettit, and Marcy Rosenbaum. Your guidance and support along this journey have shaped me into the family physician educator I have become! —BER To my many mentors in Family Medicine, including Drs. John Ely, Mark Graber, Paul James, Gerald Jogerst, and Barcey Levy; and to Dr. Kate Thoma and all the Family Medicine program directors and faculty members who work tirelessly (and mostly thanklessly) to develop the next generation of excellent family doctors. Keep teaching; keep leading! —JKW

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Contents Contributors..............................................................................................ix Preface..................................................................................................... xiii A Few Words on Studying and Taking the Board Examination...... xv

16 Men’s Health............................................................................... 501

1 Emergency Medicine................................................................... 1

19 Ophthalmology......................................................................... 585

2 Cardiology......................................................................................43

20 Otolaryngology......................................................................... 607

3 Pulmonology.............................................................................. 105

21 Care of the Older Patient........................................................ 631

4 Allergy and Immunology....................................................... 141

22 Care of the Surgical Patient................................................... 662

5 Nephrology................................................................................. 150

23 Psychiatry.................................................................................... 693

6 Hematology and Oncology................................................... 183

24 Nutrition and Herbal Medicine............................................ 729

7 Gastroenterology...................................................................... 211

25 Substance Use Disorders....................................................... 742

8 Infectious Diseases................................................................... 253

26 Ethics............................................................................................. 763

9 HIV/AIDS...................................................................................... 281

27 End-of-Life Care......................................................................... 774

10 Endocrinology........................................................................... 296

28 Evidence-Based Medicine..................................................... 788

11 Rheumatology........................................................................... 330

29 Patient-Centered Care............................................................. 800

12 Orthopedics and Sports Medicine..................................... 364

30 Final Examination..................................................................... 813

17 Dermatology.............................................................................. 525 18 Neurology.................................................................................... 551

13 Pediatrics..................................................................................... 395 14 Adolescent Medicine............................................................... 437 15 Obstetrics and Women’s Health.......................................... 451

Index........................................................................................................841

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Contributors Emad Abou-Arab, MD, CME Clinical Assistant Professor Department of Family Medicine Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City, Iowa 10. Endocrinology Daniel M. Anderson, DO Senior Associate Consultant Department of Neurology Mayo Clinic Health System Franciscan Healthcare La Crosse, Wisconsin 18. Neurology A. Ben Appenheimer, MD Clinical Assistant Professor Department of Internal Medicine Division of Infectious Diseases Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City, Iowa 8. Infectious Diseases 9. HIV/AIDS Stacey Appenheimer, MD Clinical Assistant Professor Department of Family Medicine Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City, Iowa 14. Adolescent Medicine Olivia E. Bailey, MD Clinical Associate Professor Department of Emergency Medicine Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City, Iowa 1. Emergency Medicine Maresi Berry-Stoelzle, MD Department of Family Medicine Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City, Iowa 6. Hematology and Oncology

Guru V. Bhoojhawon, MBBS, MD, FAAP Clinical Associate Professor Department of Pediatrics Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City, Iowa 13. Pediatrics Nicholas R. Butler, MD, MBA Clinical Associate Professor Department of Family Medicine Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City, Iowa 21. Care of the Older Patient Rachel R. Butler, MD Clinical Assistant Professor Department of Internal Medicine Division of Pulmonary, Critical Care, and Occupational Medicine Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City, IA 3. Pulmonology Meghan Connett, MD Clinical Assistant Professor Department of Family Medicine Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City, Iowa 15. Obstetrics and Women’s Health Dustin Z. DeYoung, MD Psychiatrist Behavioral Health Associates University of California, Los Angeles Los Angeles, California Austin R. Fox, MD Department of Ophthalmology and Visual Sciences University of Iowa Iowa City, Iowa 19. Ophthalmology ix

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x

CONTRIBUTORS

Mark A. Graber, MD, MSHCE, FACEP Clinical Professor Departments of Family Medicine and Emergency Medicine Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City, Iowa 1. Emergency Medicine 2. Cardiology 7. Gastroenterology 12. Orthopedics and Sports Medicine 26. Ethics 28. Evidence-Based Medicine 30. Final Examination Erin Hayward, MD Clinical Assistant Professor Department of Family Medicine University of Iowa Iowa City, Iowa 22. Care of the Surgical Patient Priyanka Iyer, MD, MPH Clinical Associate Professor Department of Internal Medicine Division of Immunology University of Iowa Clinics and Hospitals Iowa City, Iowa 11. Rheumatology Monika Jindal, MD Instructor, University of Colorado School of Medicine Department of Psychiatry Department of Family Medicine Denver Health Medical Center Denver, Colorado 23. Psychiatry Nicholas H. Kluesner, MD, FACEP Associate Medical Director Department of Emergency Medicine UnityPoint Health – Des Moines Des Moines, Iowa 26. Ethics Jason Kruse, DO Department of Internal Medicine Broadlawns Medical Center Des Moines, Iowa 7. Gastroenterology Bharat Kumar, MD, MME, FACP, RhMSUS Department of Internal Medicine and Division of Immunology Department of Internal Medicine Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City, Iowa 11. Rheumatology

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Aaron R. Kunz, DO, MA, MME Clinical Assistant Professor Department of Family Medicine Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City, Iowa 16. Men’s Health Victoria Linares, MD CAQ Geriatric Medicine Clinical Assistant Professor Department of Primary Care Loyola University Medical Center Maywood, IL 21. Care of the Older Patient Britt L. Marcussen, MD CAQ Sports Medicine Clinical Associate Professor Department of Family Medicine Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City, Iowa 12. Orthopedics and Sports Medicine Denise A. Martinez, MD Clinical Associate Professor Associate Dean for Diversity, Equity, and Inclusion Department of Family Medicine Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City, Iowa 29. Patient-Centered Care Patrick J. McCarthy, MD, MME Assistant Professor Section of Hospital Medicine, Department of Pediatrics Medical College of Wisconsin/Children’s Hospital of Wisconsin Milwaukee, Wisconsin 13. Pediatrics Sarah L. Miller, MD, FACEP, FAAP Clinical Associate Professor Department of Emergency Medicine Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City, Iowa 1. Emergency Medicine Megan H. Noe, MD, MPH, MSCE Instructor Department of Dermatology Brigham & Women’s Hospital Harvard Medical School Boston, Massachusetts 17. Dermatology

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Contributors

Scott R. Owen, MD Assistant Professor Director of Facial Plastic and Reconstructive Surgery Department of Otolaryngology, Head and Neck Surgery University of Iowa Iowa City, Iowa 20. Otolaryngology Juan R. Pagan-Ferrer, MD, DABIM, Ger, HPM Clinical Assistant Professor Department of Internal Medicine Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City, Iowa 27. End-of-Life Care Sanjeev Patil Assistant Professor Department of Rheumatology and Immunology University of Vermont Medical Center Burlington, VT Brigit E. Ray, MD, MME Clinical Assistant Professor Department of Family Medicine Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City, Iowa 15. Obstetrics and Women’s Health 22. Care of the Surgical Patient 30. Final Examination Wendy W. Shen, MD, PhD Clinical Associate Professor Department of Family Medicine Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City, Iowa 4. Allergy and Immunology Tameem A. Shoukih, MD Clinical Assistant Professor Departments of Emergency Medicine and Pediatrics Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City, Iowa 12. Orthopedics and Sports Medicine Kelly Skelly, MD Clinical Associate Professor Department of Family Medicine Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City, Iowa 14. Adolescent Medicine

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Melissa L. Swee, MD, MME Clinical Assistant Professor Department of Internal Medicine Division of Nephrology Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City, Iowa 5. Nephrology Teri Thomsen, MD Clinical Associate Professor Department of Neurology Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City, Iowa 18. Neurology Alka Walter, MBBS, MS Clinical Assistant Professor Department of Family Medicine Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City, Iowa 22. Care of the Surgical Patient Karolyn A. Wanat, MD, FAAD Associate Professor Department of Dermatology Medical College of Wisconsin Milwaukee, Wisconsin 17. Dermatology Jason K. Wilbur, MD, FAAFP Clinical Professor Department of Family Medicine Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City, Iowa 2. Cardiology 6. Hematology and Oncology 16. Men’s Health 24. Nutrition and Herbal Medicine 30. Final Examination Qiang Zhang, MD Movement Disorder Fellow Department of Neurology and Iowa Neuroscience Institute Physician Scientist Training Program Clinical NeuroScientist Training Program Roy J. and Lucille A. Carver College of Medicine University of Iowa Iowa City, Iowa 18. Neurology

C. Blake Sullivan, MD Resident Physician Otolaryngology – Head and Neck Surgery University of Iowa Iowa City, Iowa 20. Otolaryngology

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Preface Welcome to the fifth edition of Graber & Wilbur’s Family Medicine Examination & Board Review book. We hope that you are as excited to be here as we are. The whole book has been meticulously updated to not only serve you well as a study guide, but also to provide you with cutting edge, up-to-date, information pertinent to your practice. For those of you who love your e-readers and tablets, there is a portable, electronic version of the book. You can also now find us on “AccessMedicine.” What is new? We have added a succinct guide to the recommended health maintenances for children and adults, perfect for a quick review. We estimate that 30% of the material has been changed since our last edition: think of hepatitis C diagnosis and treatment, new cholesterol and blood pressure guidelines, new heart failure guidelines (and drugs), the everchanging anticoagulation guidelines, etc. What has not changed? Our essential style remains the same. The book is divided into 29 chapters based on body system and elements of patient care, followed by the “Final Examination” (Chapter 30). The thousands of questions in the book are woven into cases, which we hope you will find interesting, practical, and relevant. To test your acquisition of knowledge, each case ends with the learning objectives. To break the monotony of slogging through a study guide, you will find “Quick Quizzes” and “Helpful Tips” peppered throughout each chapter. A dozen years ago when we wrote the first edition, we made the decision to use the second-person voice in order to engage the reader better and to give the book a conversational appeal. We have tried to keep the book from being boring. Yes, we are aware that this is a study aid. But why must studying be an exercise in tedium and endurance? It should be enjoyable, applicable to real life and provide a surprise every now and again. You will find (sometimes feeble) attempts at humor throughout the book. We have noticed that an occasional reader does not appreciate our sense of humor. As Abraham Lincoln famously never said, “You can please some of the people all of the time, and then again, some people just won’t think you’re funny.” We have been impressed with the level of engagement of our readers. Over the years, we have received scores of e-mails from readers who have thanked us, corrected us, and sometimes chided us. No matter the intent of the message, the tone is almost universally positive—readers are invested in the book and want to offer helpful suggestions. Likewise, the comments posted online (not usually the place one goes for affirmation) have been mostly approving, constructive, and enthusiastic.

The first edition was published amid a less-than-friendly environment, with declining interest in print media and several well-known board review books already on the market. Because our book carried a different tone, readers slowly gravitated to it, and its market share grew by word-of-mouth. Engaged and supportive readers play a huge role! In preparation for work on the fifth edition, we saved all of your e-mails and scoured the Internet for reader comments and reviews. We read and considered all that we could find—which amounted to several hundred readers’ ideas. So, you, the reader, have helped shape this book. Keep those e-mails coming! With all of the board review books out there, why should you choose our text? There are two crucial differences between this book and other board review books on the market. First, we have written this book not only to help you pass the boards but also to broaden your knowledge of family medicine. The majority of questions contain a detailed explanation not only of why an answer is right but also why the other answers are wrong. In the rapidly changing world of medical knowledge, we have endeavored to provide you with the most relevant and up-todate evidence. When the current evidence is controversial and we are not certain what the American Board of Family Medicine (ABFM) will do with it, we acknowledge the uncertainty and try to help you navigate the current evidence. We have tried to make this book as broad and as comprehensive as possible. In addition to its use as a board review book for family medicine, it can be employed as a general review for primary care physicians, physician assistants, and nurse practitioners. Students and residents studying for Step 3 of the licensing examination should find the book helpful as well. However, no board review book can possibly cover the entire scope of family medicine. Use these questions as a guide: what areas are your strengths and what do you need to study further? Each answer of the “Final Examination” is referenced in the book so you can go back and review any topic that you might have missed. In this book, the use of eponymous medical terms such as Crohn disease and Wilson disease reflects the current American Medical Association recommendations for these and similar terms where the possessive form is dropped. In addition, there is a general trend toward using fewer eponyms, such as Wegener, which has been dropped completely. We have made note of both new and old terms when we have deemed the old term more recognizable. xiii

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xiv

PREFACE

We enjoyed writing this book and we hope that you enjoy using it. If you have suggestions or complaints (okay, maybe all of our jokes aren’t politically correct or even funny), do not hesitate to write us at [email protected], jason-wilbur@ uiowa.edu, or [email protected]. We take your comments seriously as we endeavor to make studying for the board examination more effective and more fun. We acknowledge and thank all our chapter authors who have brought their expertise to bear on this project. We also want to thank the good people at McGraw-Hill who have edited the book to keep errors to a minimum and created a handsome and readable layout. Mark would like to thank you, the reader, for buying this book. Thanks also to his family: Hetty, Rachel, and Abe (as always). But not to the dogs, Nietzsche and “Vash the Stampede.” They need to learn to stay either in or out of the house. No more of this back and forth. Music that has kept Mark awake: “Hellborg, Lane, and Sipe” (check out “Time is the Enemy” and “Personae” [yes, it is spelled with an “e”]), Stephane Wrembel (Barbes-Brooklyn is Mark’s favorite but you can’t go wrong), and the Kinks. Finally, thanks to his bicycle for keeping Mark sane … although some would argue this point. Jason thanks his loving and supportive family. After some initial threats, Deb has granted her patience and understanding

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to the project, and Jason simply owes her dinner every night … for a year. Jason thanks his boys, Ken and Ted, who offer a great distraction from work (like learning to drive—yikes!) and find it entertaining that their dad is some form of an author. Finally, as with every edition, Jason must acknowledge that the book would never get finished without large amounts of coffee; so, he thanks everyone involved in the worldwide production of coffee, from the pickers on the Central American fincas to the local baristas. He’s really hoping that we all do something about climate change to at least save the coffee-growing regions of the world. Brigit thanks her husband, Austin, for being so patient when she has been cranky and sleep deprived. She is so proud of her husband’s hard work and dedication in the completion of his research, residency, and fellowship. He has been an inspiration and her greatest sidekick, friend, and love, and she can’t wait to start this new chapter in their life together; by FINALLY living in the same location! She would like to acknowledge the “Academy” (no really, she’s not joking) as she has spent many hours on her couch with the movies and the AAFP editing this book and completing her CME questions. Lastly, she would like to thank the open roads, blue skies, and sunshine for always providing her with much needed “run therapy” and happiness.

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A Few Words on Studying and Taking the Board Examination Throughout the book, you will find that we give advice on what we think is likely to be on the examination. That’s what you’re paying for, right? However, the fourth edition marked the first time that we offered advice on studying for and taking the examination. We thought it worthwhile to keep this section for the fifth edition. We recommend you read this section prior to diving into the rest of the book. While we acknowledge that some people are simply better test takers than others, there is good evidence to show that anyone can improve his or her scores. In fact, examination scores are directly proportional to time spent studying for the examination (although this association grows weaker for those who have high scores already). The point is, you don’t have to be a genius who got a 36 on the ACT in order to rock the ABFM Certification/Recertification Examination. But you may need to put in the work. Your first step in studying for the examination—after purchasing this book, of course—should be to develop a study plan. Plotting out time and dedicating that time to uninterrupted study is important. How much time do you have before the examination? How many hours per week can you devote to studying? When are you most productive in your studying— morning or night? What are the chances of a worldwide failure of coffee crops? Will a new Star Wars movie open before the examination? Thinking through these questions, get a calendar, mark the examination date, and plot out days and times that you will devote to studying. If you have taken the examination before and it didn’t turn out so well, you may need to change your daily work schedule for 2 to 3 months before the examination to accommodate studying 10 to 15 hours per week. We endorse neither “cramming” for the examination nor “adding on” studying to an already full schedule. To get the most out of studying, you need to approach it like a daily devotion. In order to maximize your return on your studying and to focus on deficiencies, try taking a pre-test. The best pre-test is the ABFM In-Training Examination (ITE) — keep reading for more on this. You can use your results on the pre-test to see what areas are your weakest. Studying weak areas is less fun but will net higher yield results than studying areas of relative strength. If your practice is narrow in scope (e.g., a hospitalist),

you probably already have a sense of areas of strength and weakness. Make sure you address your weak areas with relatively more time on them. Next, know what is on the examination. The percentage of examination content devoted to various systems is posted on the ABFM website, and we recommend you review it. The top systems tested are usually cardiovascular, respiratory, and musculoskeletal systems. If you are weak in any of these areas, be certain to focus your studying on them. Now, what material should you use when studying? Some of our readers have been overly kind, suggesting in their reviews that this book is the only study tool needed for the board examination. While we would like to believe it, we cannot endorse this point of view. To get a flavor for the questions on the examination, the best strategy is to go to the source. The ABFM posts its ITE for the last 3 years on its website (www.theabfm.org). A login is required, which board-certified family physicians should all have. The ITEs are perhaps the best source for assessing your knowledge—we strongly recommend you use them. Although we do not recommend relying on the ITEs as your only study aid (obviously; we’re trying to sell books here!), you can use these as a way to measure your progress as you study. The critiques are available as well, so you can learn what the ABFM thinks you should know. The ABFM also has extensive information on what you should expect when you sit for the certifying/recertifying examination, including a tutorial that simulates the examination. If you are an anxious test-taker, be certain to check out the tutorial. While the ABFM has several useful tools, be aware that the Self-Assessment Modules are not representative of the types of questions you will find on the certifying/recertifying examination; however, the more recent Continuous Knowledge Self-Assessment activity, where the diplomate answers 25 questions per quarter, is a closer representation. Another great source for questions is the American Academy of Family Physicians (AAFP) website. If you are a member of AAFP, you can access questions for free. They are categorized by body system and can be done in chunks of ten at a time worth 0.25 CME credits. This question bank offers another opportunity to test your knowledge and determine where you need to focus your studying. xv

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xvi

A Few Words on Studying and Taking the Board Examination

Also, the AAFP markets a comprehensive board review selfstudy course, which will set you back over $1,000 if you are a member and more if you are not. Indeed, it covers everything you need to know for the examination. But so does this book! So, the choice is yours, but we doubt that you will need both our book and the AAFP board examination self-study package. What about texts and primary sources? Well, while we would admire your perseverance in slogging through whole texts preparing for the examination, we do not recommend attempting to read cover-to-cover texts like Robert Rakel’s Textbook of Family Medicine or reference material like UpToDate. Don’t get us wrong. We like these sources and recommend them to you as references as you are studying, but you should not rely on them as your sole study material. Likewise, using primary sources, like medical journals, is impractical as a study foundation but useful to expand your knowledge when you don’t understand something. As far as board review courses: to each his or her own. If you are considering attending a course, the AAFP offers comprehensive courses multiple times per year in locations all across the country. For-profit entities provide additional options. If you learn best in a live lecture setting, these courses may be a good option for you, but you need not attend a course to get all that information (c’mon—you’ve got this book!). There are some important basic things you need to know about the examination. As of the writing of this book, the examination is composed of 4 sections, each consisting of 80 multiple choice questions and 100 minutes in length. Sections 1, 3 and 4 have questions from a wide variety of family medicine topics. Section 2 consists of 40 questions from a chosen module and 40 questions pertaining to the general breadth of family medicine. It is best to choose modules with which you are more familiar. For example, if you practice primarily in an emergency department, you may want to choose Emergent/Urgent Care or Hospital Medicine rather than Maternity Care (unless you’re looking for the additional challenge). We highly recommend to check out the ABFM website (https://www.theabfm.org/continue-certification/cognitive-expertise/one-day-fmc-exam) for exam information as this may change. The examination consists entirely of four-item multiplechoice questions. You are not penalized for guessing. An unanswered question will always be wrong; whereas, a guessed question has a 25% chance of being right. If you have no idea, go ahead and guess. As a corollary to that rule, never exit the examination without first completing all the items. You cannot return to answer unmarked items.

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Read every stem and option carefully. Although we doubt that the ABFM writes “trick questions,” they do use catch words/phrases, such as “except,” “most likely,” “first step,” and “least likely.” If you are not attending to the catch phrase, you are likely to answer the question wrong. In the past, the ABFM recommended relying on evidence in place up to 2 years before the examination rather than the most recent medical evidence. Now, the ABFM recommends examinees rely on the most up-to-date evidence available. So, when you are looking at a question and thinking, “Well, the answer last year might have been ‘A’ but now the evidence points to ‘B’.” Choose “B.” Successful test-takers do not use grand strategies to outsmart the question writers; instead they tend to employ a few simple rules when answering multiple-choice questions. These simple rules that follow amount to guidelines that cannot be blindly applied to the entire test, but are often true. No secret to many of you, perhaps, but here they are: • Go with your first thoughtful choice unless you have a solid reason to change it (e.g., you misread the question). • Look for catch words in the answers, such as “always” and “never.” These will often be incorrect. • Avoid answers with unfamiliar terms (e.g., obscure disease names or rarely performed procedures). These are often incorrect. • The most detailed answer is often the correct answer. • If two answers are similar, they are probably both wrong. • Stick with family medicine principles (e.g., answers with “more history” or “shared decision making” are more likely to be correct). • If you don’t know, guess and move on. Do not waste time deliberating on a single question. Finally, we part offering advice that we know busy doctors seldom follow: get plenty of rest. Seriously! Be prepared for the examination day by getting a good night’s sleep. Don’t stop taking care of your health prior to the examination, and that includes rest. Eat a good breakfast, bring a snack for your breaks, and plan to take yourself out for a nice lunch (but skip the martini—you’ve got an examination to finish). Just like a mountain climber, wear layers. Some of those test-taking centers are freezing; some are boiling. Stay positive, take a deep breath and keep moving through it. You will pass this thing! Good luck.

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Emergency Medicine Olivia E. Bailey, Sarah L. Miller, and Mark A. Graber

▶▶ CASE 1.1 You get a call from a panicked mother because her 4-year-old drank a bottle of children’s Tylenol. She found the empty bottle in her child’s bed after a nap, and her child had been in bed for 90 minutes. She thinks there were about 3 ounces of liquid left in the bottle. She is about 35 minutes from the hospital. She states her child weighs 15 kg. Question 1.1.1 Your advice to her is: A) Induce vomiting to reduce acetaminophen absorption B) Have the child eat to slow absorption and proceed directly to the hospital C) Proceed to the hospital D) Breathe deeply and calm down; the amount of acetaminophen this child could have ingested is harmless Answer 1.1.1 The correct answer is “C.” Proceed to the hospital. “A” is incorrect for a couple of reasons. After 90 minutes, it is not likely that there is significant medication left in the stomach and induced vomiting can lead to aspiration (this is true of liquids and pills). “B” is incorrect because you do not want to delay definitive treatment. “D” is incorrect as this patient may have ingested up to 3 oz (90 mL) of 160 mg/5 mL solution (total dose of 2880 mg or 192 mg/kg). HELPFUL TIP: Acetaminophen is the most common agent involved in pediatric ED visits for over-the-counter medication exposures. Reasons for these high exposure rates include the medication’s reputation as “safe,” its ubiquity in medicine cabinets, errors in dosing, as well as co-administration of medications that also contain acetaminophen.

The patient arrives in your emergency department (ED). She is alert with stable vital signs. The mother states she now

1 believes the ingestion occurred about 50 minutes ago as her child told her she found the bottle in the bathroom when she woke up from her nap. You contemplate gastrointestinal (GI) decontamination. Question 1.1.2 Which of the following statements is true about gastric lavage? A) Except in extraordinary circumstances it should only be done in the first hour after an overdose B) Patients who have had gastric lavage have higher incidence of pulmonary aspiration than patients who have not C) Patients who undergo gastric lavage have a higher incidence of esophageal perforation D) It can push pill fragments beyond the pylorus E) All of the above are true Answer 1.1.2 The correct answer is “E.” All of the options are true. Generally, the efficacy of gastric lavage is limited. Outcome data do not support the use of gastric lavage after the first hour. In a particularly severe overdose or in an overdose that is likely to delay gastric emptying (e.g., tricyclic antidepressants), you might want to consider lavage, but such circumstances are unusual. Gastric lavage increases the risk of aspiration, esophageal perforation, and can push pill fragments beyond the pylorus. Question 1.1.3 After careful consideration, you decided not to lavage. She is now 90 minutes after the ingestion. Her physical exam is normal other than some dried sticky liquid on her face, shirt, and hands that smells like cherry flavoring. The next best step to take in this patient is to: A) Check blood acetaminophen levels and refer for hemodialysis if markedly elevated B) Administer 5 g/kg of charcoal with sorbitol C) Start treatment with N-acetylcysteine (NAC) D) Prophylactically treat this patient for seizures using phenytoin E) Observe and measure acetaminophen level at 4 hours after ingestion 1

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Answer 1.1.3 The correct answer is “E.” Giving charcoal is likely helpful only within the first hour after ingestion, and even this remains controversial. “A” is incorrect because hemodialysis is not indicated for acetaminophen (APAP) overdose and measuring levels at 90 minutes will not allow appropriate risk stratification for this child. “C” and “D” are incorrect because seizure prophylaxis is not indicated in this patient, and although NAC could be initiated for a known dose of >150 mg/kg, this child clearly had spilled medication on her skin and clothing. In order to determine the risk of APAP-induced hepatotoxicity and treatment via the Rumack–Matthew nomogram, a 4-hour APAP level is necessary. HELPFUL TIP: Although frequently given, single dose activated charcoal has limited or no effect on outcomes of poisonings. It reduces absorption by about 30% if given within 1 hour of ingestion and likely has no benefit after 1 hour. It can also cause vomiting with aspiration. For this reason, it has fallen out of favor (we don’t remember the last time we used it in our ED). We are not sure what the correct answer on the test will be.

HELPFUL TIP: Do NOT give activated charcoal to patients with an altered mental status or who are otherwise unable to protect their airway. To prevent aspiration, do not give charcoal to a patient likely to have a seizure (such as with tricyclic overdose).

Question 1.1.4 Assuming you are using charcoal, for which of these overdoses is charcoal NOT indicated? A) Acetaminophen B) Aspirin C) Iron D) Digoxin E) Opiates Answer 1.1.4 The correct answer is “C.” Charcoal will not bind iron. Charcoal will also not bind Caustics/corrosives, Heavy metals, Alcohols, Rapid-onset cyanide, Chlorine (or iodine), Other insoluble tablets, Aliphatics (hydrocarbons), or Laxatives (mnemonic: CHARCOAL). Some of you may have answered “A.” Theoretically, charcoal could interfere with the action of N-acetylcysteine, the antidote for acetaminophen ingestion by absorbing it. However, this is more of a theoretical concern than an actual one. First, the drugs should be used at different times. Charcoal should be given immediately, while N-acetylcysteine is given only after 4-hour levels are available. Second, the doses of N-acetylcysteine recommended are quite high, and you can give a higher dose if you will be using it with charcoal. Finally, intravenous (IV) N-acetylcysteine is available and is obviously not affected by

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charcoal. “B,” “D,” and “E” are all incorrect. While we do have antidotes for digoxin and opiates (Digibind, naloxone), charcoal may still be indicated to reduce absorption within the first hour. ▶▶

Objectives: Did you learn to … •

Manage a patient with an acute ingestion? Describe the appropriate use of gastric lavage and charcoal administration? • Identify situations where charcoal may not be indicated? •

QUICK QUIZ: BIOTERRORISM AND THE ATTACK OF GODZILLA Oh, no. Godzilla is attacking Tokyo. And this time it is with weapons of mass destruction. Which of the following properly describes the isolation requirements of a patient with pulmonary anthrax? A) No isolation necessary. The patient may be in the same room with an uninfected patient B) Respiratory isolation only C) Respiratory and contact isolation D) Negative pressure room (such as with tuberculosis) + ­contact isolation The correct answer is “A.” Pulmonary anthrax is NOT transmitted person to person. Contact isolation is indicated in those with cutaneous anthrax and GI anthrax (where diarrhea may be infectious). Godzilla is not done yet… Which of the following drugs should be used as prophylaxis against inhaled anthrax, should exposure to aerosolized spores be documented? A) A first-generation cephalosporin B) Trimethoprim/sulfamethoxazole C) Ciprofloxacin D) A third-generation cephalosporin The correct answer is “C.” Fluoroquinolones are the drugs of choice when treating those exposed to anthrax. Doxycycline may also be used. Cephalosporins and TMP/SMX are not active against anthrax. Godzilla, frustrated by his failed anthrax attack, is now spreading smallpox. Which of the following is NOT true about smallpox? A) Isolation is best done at home if possible B) The patient is infectious until he or she becomes afebrile C) All lesions are generally in the same stage of evolution, unlike what is seen in varicella D) Smallpox immunization causes an encephalitis in 1:300,000 of which 25% of cases are fatal The correct answer is “B.” The patient is infectious until all lesions crust over. Infectivity has nothing to do with the presence or absence of fever. “A” is true. Isolation is best done at

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home since this will limit spread (as those in the household have likely already been exposed). “C” is also true; all lesions are in a similar state of evolution. Finally, “D” is true and is the reason we do not currently immunize against smallpox—well, that and the fact we eradicated it in the wild (Way to go, humans!).

▶▶ CASE 1.2 A 22-year-old female presents to the ED with an overdose. She has a history of depression, and there were empty bottles found at her bedside. The bottles had contained clonazepam and nortriptyline. The patient is unconscious with diminished breathing and is unable to protect her airway. Question 1.2.1 The BEST next step is to: A) Intubate the patient B) Begin gastric lavage and administer charcoal C) Administer flumazenil, a benzodiazepine antagonist, to awaken her and improve her respirations D) Administer bicarbonate E) Administer lipid emulsion Answer 1.2.1 The correct answer is “A.” This patient should be intubated. Remember in any emergency situation that the ABCs (airway, breathing, and circulation) are the priority. “B” is incorrect because, as noted earlier, patients who undergo gastric lavage have a higher incidence of pulmonary aspiration—an even greater concern in the obtunded patient. In fact, airway protection is MANDATORY before undertaking lavage. “C” is incorrect. Flumazenil will reverse the benzodiazepine. However, we know from experience that seizures in patients who have had flumazenil are particularly difficult to control. This would be particularly problematic in a patient with a mixed overdose, such as with a tricyclic, where seizures are common. Thus, it is recommended that flumazenil be used only as a reversal agent after procedural sedation in patients who are not on chronic benzodiazepines. “E” is incorrect. Lipid emulsion refers to the liquid fatty acids given as part of total parenteral nutrition and theoretically can be used to bind fat-soluble drugs in the blood. Case series support consideration of lipid emulsion for calcium channel blocker, betablocker, and tricyclic antidepressant overdoses, as well as other fat-soluble drugs but only in cases of refractory cardiac arrest or cardiovascular collapse—and certainly not before the airway has been secured. Keep reading for a discussion of answer “D.” You notice that the patient begins to have an abnormal tracing on the cardiac monitor, so you order an ECG. Question 1.2.2 Which of the following findings would you expect to find in a tricyclic overdose? A) Normal QRS complex B) Second- and third-degree heart block C) Widened QRS complex D) Sinus tachycardia E) Any of the above

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Answer 1.2.2 The correct answer is “E.” All of the above findings can be seen with a tricyclic overdose. In fact, the most common presenting rhythm is a narrow-complex sinus tachycardia. As toxicity progresses, you can see a prolonged PR interval, a widened QRS complex, and a prolonged QT interval. A QRS >100 ms is predictive of seizures and QRS >160 ms is highly predictive of ventricular arrhythmia in patients with a tricyclic antidepressant overdose. Heart blocks (secondand third-degree) herald a poor outcome and may be seen late in the course. Asystole is not a primary rhythm in tricyclic overdose and tends to reflect the end stage of another arrhythmia. YIKES!! The patient becomes unresponsive and you look at the monitor. You obtain an ECG which shows the following (Fig. 1-1). Question 1.2.3 What is the patient’s rhythm? A) Monomorphic ventricular tachycardia B) Sinus tachycardia with a bundle branch block C) Paroxysmal supraventricular tachycardia D) Torsades de pointes E) Third degree heart block Answer 1.2.3 The correct answer is “D.” This is torsades de pointes which is a subtype of polymorphic ventricular tachycardia. In French, it literally means “twisting of the points,” but in every language it means “bad news.” Torsades de pointes can be recognized by the varying amplitude of the complex in a somewhat regular pattern. “A” is incorrect because the complexes are not monomorphic. “B” is incorrect for two reasons. First, there are no P waves visible. Second, sinus tachycardia should not have varied amplitude. “C” is incorrect because, again, there are no P waves and the complexes are polymorphic. “E” is incorrect because there are no P waves. Question 1.2.4 This patient needs treatment post haste. After taking care of the ABCs, what is the ONE BEST drug for the treatment of this arrhythmia in a patient with a tricyclic overdose? A) Esmolol B) Lidocaine C) Sodium bicarbonate D) Procainamide E) Amiodarone Answer 1.2.4 The correct answer is “C.” The treatment of choice for arrhythmias in patients with a tricyclic overdose is sodium bicarbonate. Raising the pH and administering sodium seem to “prime” the sodium channels in the heart, reversing the toxicity of the tricyclic. Procainamide (“D”) and quinidine should not be used because they act in similar fashion to tricyclics and may worsen the problem. Lidocaine (“B”) can be used as can amiodarone (“E”), but they are not the best choices. Betablockers such as esmolol (“A”) can worsen hypotension and should be avoided.

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FIGURE 1-1.    ECG for patient in question 1.2.3.

This is not your patient’s lucky day. She begins to seize after the administration of the bicarbonate. Question 1.2.5 The treatment of choice for this seizing patient is: A) Lorazepam (Ativan) B) Repeat the bolus of sodium bicarbonate and start a bicarbonate drip C) Phenytoin (Dilantin) D) Fosphenytoin (Cerebryx) E) None of the above Answer 1.2.5 The correct answer is “A.” Benzodiazepines are the treatments of choice in tricyclic-induced seizures. While most seizures are self-limited, it is important to control seizures because the resultant acidosis can worsen tricyclic toxicity (beyond the fact that prolonged seizures can cause CNS injury). “B” is incorrect. This patient is already alkalinized, and although sodium bicarbonate is the preferred therapy for tricyclic-induced cardiovascular toxicity, sodium bicarbonate is not particularly effective in tricyclic-induced seizures. “C,” phenytoin, can be used, but benzodiazepines and phenobarbital should be administered first if possible. In addition to not working well as an antiepileptic drug in tricyclic overdose, phenytoin is also a class Ib antiarrhythmic, which may further prolong the QRS and worsen the cardiac toxicity of the tricyclic. “D” is incorrect for two reasons. First, since fosphenytoin is metabolized to phenytoin, the concern about efficacy applies. Second, fosphenytoin is a prodrug and requires adequate circulation and renal and hepatic function to be converted into active drug. If our patient becomes hypotensive with poor liver and renal perfusion, adequate drug levels might not be achieved. Finally, both

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phenytoin and fosphenytoin can cause hypotension—not what you need in this unstable patient. You correct the arrhythmia and stop the seizures, and she is admitted to the intensive care unit. HELPFUL TIP: A patient who is entirely asymptomatic 6 hours after a tricyclic overdose is unlikely to have any serious consequences from the ingestion. They can be “medically cleared” at that point for admission to a psychiatric unit. Note that “symptomatic” may just be tachycardia or mild confusion. We mean the entirely asymptomatic patient. ▶▶

Objectives: Did you learn to … • • • • •

Understand the importance of the ABCs in an unstable patient? Describe the role of flumazenil in toxicologic emergencies? Manage a tricyclic overdose? Recognize ECG findings in a tricyclic overdose? Recognize torsades de pointes and its treatment in the context of a tricyclic overdose?

QUICK QUIZ: DESIGNER AND CLUB DRUGS An 18-year-old male presents after a party. He is having alternating episodes of combative behavior interspersed with episodes of coma. He becomes almost apneic during the episodes of coma. He has alternating bradycardia (while in coma) and

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TABLE 1-1   TOXIDROMES Drug Class

Examples

Signs and Symptoms

Anticholinergic

Tricyclics, diphenhydramine, scopolamine, loco weed (jimson weed), some mushrooms, etc.

Tachycardia, flushing, dilated pupils, low-grade temperature, and confusion. Mnemonic: Dry as a bone, red as a beet, mad as a hatter, blind as a bat

Opiates

Morphine, heroin, codeine, oxycodone, etc.

Pinpoint pupils, hypotension, hypopnea, coma, hypothermia

Cholinergic

Organophosphate or carbamate pesticides, some mushrooms

Lacrimation, salivation, muscle weakness, diarrhea, vomiting, miosis. Mnemonic: SLUDGE BBB (salivation, lacrimation, urination, diarrhea, GI upset, emesis … Bradycardia, bronchorrhea, bronchospasm)

Sympathomimetic

Cocaine, ecstasy, methamphetamine

Tachycardia, hypertension, elevated temperature, dilated pupils (mydriasis)

Gamma-hydroxybutyrate (GHB)

GHB, liquid ecstasy, etc.

Alternating coma with agitation, hypopnea while comatose, bradycardia while comatose, and myoclonus

tachycardia when awake. The patient is also having myoclonic seizures. His serum alcohol level is zero, and his pupils are miotic. The most likely drug causing this is: A) Ecstasy (MDMA) B) GHB (gamma-hydroxybutyrate aka “liquid ecstasy”) C) Methamphetamine D) LSD (lysergic acid diethylamine aka “acid”) E) Oxycodone The correct answer is “B.” The episodic coma and bradycardia interspersed with episodes of extreme agitation are almost pathognomonic of GHB overdose. GHB intoxication also causes pinpoint pupils. “A” is incorrect because MDMA causes an amphetamine-like reaction with agitation, hypertension, hyperthermia, tachycardia, etc. “C” is incorrect for the same reason. “D” is incorrect because LSD rarely (if ever) causes coma. “E” is incorrect because patients with opioid overdoses are generally somnolent or comatose without interspersed episodes of agitation, although opioids may also cause miosis (be aware that not all narcotic overdoses are associated with pinpoint pupils). GHB is odorless and has slight salty taste. Besides being a street drug, GHB is available by prescription as “sodium oxybate” for narcolepsy (Xyrem). It has become a drug of choice for “date rape” since it cannot be detected in the urine. The toxicity tends to be self-limited and can be treated with intubation if needed along with tincture of time. The half-life is only 27 minutes.

QUICK QUIZ: TOXIDROMES A patient presents to the hospital with a diphenhydramine overdose. Which of the following signs and symptoms are you likely to find in this patient? A) Bradycardia, dilated pupils, flushing, and increased bowel sounds

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B) Bradycardia, pinpoint pupils, flushing, and decreased bowel sounds C) Tachycardia, dilated pupils, diaphoresis, and increased bowel sounds D) Tachycardia, dilated pupils, flushing, and decreased bowel sounds E) Tachycardia, pinpoint pupils, flushing, and increased bowel sounds The correct answer is “D.” This patient has an anticholinergic toxidrome. Toxidromes are symptom complexes associated with a particular overdose that should be immediately recognized by the clinician. Common toxidromes are listed in Table 1-1.

▶▶ CASE 1.3 A patient presents to your office with neck pain after a motor vehicle accident. He was restrained and the airbag deployed. He notes that he had some lateral neck pain at the scene. He continues to have lateral neck pain. Question 1.3.1 Which of the following IS NOT a criterion for clearing the cervical spine clinically? A) Absence of all neck pain B) Normal mental status including no drugs or alcohol C) Absence of a distracting injury (such as an ankle fracture) D) Absence of paralysis or another “hard” sign that could be caused by a neck injury E) Absence of retrograde amnesia Answer 1.3.1 The correct answer is “A.” Patients can have lateral neck pain and still have their cervical spines cleared clinically. However, no one will fault you for obtaining radiographs in patients with lateral muscular (e.g., trapezius) neck pain. Patients with central neck pain (e.g., over the spinous processes) DO need imaging (radiographs ± CT) to clear their cervical spine. All of the other criteria are required in order to clinically clear the cervical spine (Table 1-2). These criteria have been validated in both adult and adolescent patients.

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TABLE 1-2   CLEARING THE CERVICAL SPINE CLINICALLY No central neck pain on questioning or palpation No distracting, painful injury (e.g., bone fracture) No symptoms or signs referable to the neck (paralysis, stinger-type injury, etc.) Normal mental status including no drugs or alcohol. This includes any retrograde amnesia, etc.

HELPFUL TIP: CT has pretty much replaced plain x-rays in the evaluation of the bones of the neck. If you are doing plain films, the most common cause of missed fractures is an inadequate series of radiographs. An adequate series of radiographs for the cervical spine includes an AP film, a lateral film including the top of T-1, and an odontoid film. Flexion–extension views add little and should be avoided.

The patient’s daughter, aged 4 years, was in the same motor vehicle accident and also had her cervical spine cleared by radiograph. However, you get a call from the ED 48 hours after the initial accident that she is paralyzed from just above the nipple line down (never a good thing—you quickly make a mental note to make sure your malpractice insurance premiums are paid up). You review the initial radiographs with the radiologist, which are negative as is a CT of the cervical spine bones done after the onset of the paralysis. Question 1.3.2 The most likely cause of this patient’s paralysis is: A) Missed transection of the thoracic cord B) Conversion reaction from the psychological trauma of the accident C) Subarachnoid hemorrhage D) SCIWORA syndrome E) Guillain–Barre syndrome Answer 1.3.2 The correct answer is “D.” This likely represents SCIWORA syndrome (spinal cord injury without radiologic abnormality). SCIWORA has become a bit of a misnomer in the age of MRI, as up to two-thirds of children with this diagnosis will have abnormal MRI findings. This entity occurs from stretching of the cord secondary to flexion/extensiontype movement in an accident. Patients with SCIWORA syndrome may be paralyzed at the time of initial presentation (in the event of cord transection) or may have a delayed presentation up to 72 hours after the injury. “A” is incorrect because a cord transection would present with paralysis immediately at the time of injury. “B” is incorrect because this child is 4 years old, and conversion reaction is unlikely in children. In addition, conversion reaction is always a diagnosis of exclusion. “C” and “E” are incorrect because this is neither the presentation of a subarachnoid hemorrhage (headache, stiff neck, perhaps focal neurologic symptoms) nor of Guillain–Barre

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syndrome (progressive numbness and weakness from autoimmune myelitis). Question 1.3.3 The next step in the management of this patient is: A) Avoid hypotension and hypoxia to prevent secondary insult to the cord B) Fluid restriction and diuretics to reduce cord edema C) Mannitol to reduce cord edema D) Neurosurgical intervention to decompress the cord E) Lollipop and a gift card for “service recovery” Answer 1.3.3 The correct answer is “A.” Patients with a cord injury should be monitored closely to avoid hypotension and hypoxia, both of which will further damage the already compromised spinal cord. Neither diuretics (“B”) nor mannitol (“C”) will be useful in this situation. “D” is incorrect because the process of SCIWORA involves stretching of the cord (and subsequent dysfunction) rather than cord compression such as would be seen with a bony injury. “E” might be the right choice if you are taking this test as a “patient experience expert” instead of a doctor; but doctors should choose “A.” HELPFUL TIP: Don’t use steroids for spinal cord injuries. It doesn’t work. There are also secondary complications from the steroids, including hyperglycemia, myopathy, and infections (e.g., pneumonia).

Question 1.3.4 The father is, understandably, irate that his child is now paralyzed. You can tell him that the natural history of SCIWORA syndrome in THIS CHILD is likely to be the following: A) Continued paralysis with the necessity of long-term, permanent adaptation to the injury B) Progression of the injury over the next week to include further paralysis in an ascending fashion C) Resolution of paralysis and sensory symptoms over the next several months D) Resolution of all symptoms except sensory symptoms over the next several months E) Large lawsuit payout on the way. Do not pass go; do not collect $200; go directly to a malpractice attorney Answer 1.3.4 The correct answer is “C.” Generally, patients with SCIWORA syndrome regain their strength and sensory

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