Graber andWilbur’s

Fa mil y meDiCiNe
exa miNat io N
& Bo a r D r eview
Graber andWilbur’s
Fa mil y meDiCiNe
ex a miNa t io N
& Bo a r D r ev iew
Fo u r t h Ed it io n
Editors

Jas K. W lb , Md
Clinical Associate Professor
Department of Family Medicine
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa

Ma k A. G abe , Md , MSh CE, 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

B g E. r ay, Md , MME
Faculty Associate Physician
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa

New Yor /Chicago/San Francisco/Athens/London/Madrid/Me ico City

Milan/New Delhi/Singapore/Sydney/Toronto
Graber and Wilbur’s Family Medicine Examination & Board Review, Fourth Edition

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Library o Congress Cataloging-in-Publication Data

Names: Wilbur, Jason K., editor. | Graber, Mark A. (Mark Alan), editor. |
Ray, Brigit E., editor.
itle: Graber and Wilbur’s amily medicine examination & board review /
editors, Jason K. Wilbur, Mark A. Graber, Brigit E. Ray.
Other titles: Family practice examination and board review. | Family medicine
examination and board review
Description: Fourth edition. | New York : McGraw-Hill Education Medical,
[2017] | Preceded by Family practice examination and board review /
editors, Jason K. Wilbur, Mark A. Graber. 3rd ed. 2013. | Includes
bibliographical re erences and index.
Identi iers: LCCN 2016011464| ISBN 9781259585333 (pbk. : alk. paper) |
ISBN 1259585336 (pbk. : alk. paper) | ISBN 9781259589775 (ebook) |
ISBN 1259589773 (ebook)
Subjects: | MESH: Family Practice | Examination Questions
Classi ication: LCC R834.5 | NLM WB 18.2 | DDC 610.76–dc23 LC record available at
https://lccn.loc.gov/2016011464

McGraw-Hill books are available at special quantity discounts to use as premiums and sales promotions, or or use in corporate training
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To Russell and Aurelia Weil, who treated me with loving kindness rom
the moment they met me and have accepted me into their amily with
open arms.
—JKW

To Eastern Virginia Medical School which, in a strange warp o

reality, actually admitted me despite my grades. And to the staf o the
Prescriber’s Letter, who have put up with me or all these years.
—MAG

To my late Grandma Trudy and Grandpa Leon Rees who supported

me in my endeavors to become a physician and who made all things
possible by encouraging a well-rounded education.
—BER
Contents
Contributors........................................................................................... ix
Preface ...................................................................................................xiii
AFew Words on Studying and Taking the Board Examination .....xv
1 Emergency Medicine................................................................... 1
2 Cardiology .....................................................................................40
3 Pulmonology................................................................................97
4 Allergy and Immunology ...................................................... 131
5 Nephrology ................................................................................ 140
6 Hematology and Oncology.................................................. 173
7 Gastroenterology..................................................................... 200
8 Infectious Diseases .................................................................. 237
9 HIV/AIDS ..................................................................................... 258
10 Endocrinology .......................................................................... 271
11 Rheumatology .......................................................................... 303
12 Orthopedics and Sports Medicine .................................... 334
13 Pediatrics .................................................................................... 362
14 Adolescent Medicine .............................................................. 396
15 Obstetrics and Women’s Health ......................................... 409
16 Men’s Health .............................................................................. 454
17 Dermatology ............................................................................. 475
18 Neurology................................................................................... 498
19 Ophthalmology ........................................................................ 526
20 Otolaryngology ........................................................................ 548
21 Care of the Older Patient ....................................................... 569
22 Care of the Surgical Patient .................................................. 598
23 Psychiatry ................................................................................... 626
24 Nutrition and Herbal Medicine ........................................... 660
25 Substance Use Disorders ...................................................... 672
26 Ethics ............................................................................................ 688
27 End-of-Life Care ........................................................................ 698
28 Evidence-Based Medicine .................................................... 712
29 Patient-Centered Care ............................................................ 724
30 Final E amination .................................................................... 736
Index .....................................................................................................761
v
Contributors
Vijay Aluri, MD David A. Bedell, MD
Rheumatology Fellow Clinical Associate Pro essor
Division o Immunology Department o Family Medicine
Department o Internal Medicine Roy J. and Lucille A. Carver College o Medicine
University o Iowa Hospital and Clinics University o Iowa
Iowa City, Iowa Iowa City, Iowa
11. Rheumatology 25. Substance Use Disorders

A. Ben Appenheimer, MD Julia Buchkina, MD, MPH

Fellow Physician Upstream Functional Medicine
Department o In ectious Diseases Iowa City, Iowa
Roy J. and Lucille A. Carver College o Medicine 24. Nutrition and Herbal Medicine
University o Iowa
Iowa City, Iowa Chris Buresh, MD, MPH, FAAP, FACEP
9. HIV/AIDS Associate Pro essor
Department o Emergency Medicine
Stacey Appenheimer, MD University o Iowa
Clinical Assistant Pro essor Iowa City, Iowa
Department o Family Medicine 20. Otolaryngology
Roy J. and Lucille A. Carver College o Medicine
University o Iowa Nicholas R. Butler, MD, MBA
Iowa City, Iowa Clinical Assistant Pro essor
5. Nephrology Department o Family Medicine
Roy J. and Lucille A. Carver College
Olivia E. Bailey, MD, FACEP
o Medicine
Clinical Associate Pro essor
University o Iowa
Clerkship Director
Iowa City, Iowa
Department o Emergency Medicine
21. Care o the Older Patient
Roy J. and Lucille A. Carver College o Medicine
University o Iowa
Iowa City, Iowa Rachel R. Butler, MD
1. Emergency Medicine Pulmonary Critical Care Fellow
Department o Internal Medicine
David Baumgartner, MD, MBA Roy J. and Lucille A. Carver College
Resident Physician o Medicine
Department o Emergency Medicine University o Iowa
University o Iowa Healthcare Iowa City, Iowa
Iowa City, Iowa 3. Pulmonology
22. Care o the Surgical Patient
Meghan Connett, MD
Martin O. Bazelak, MD Clinical Assistant Pro essor
Fellow Physician Department o Family Medicine
Department o Internal Medicine and Hospice Roy J. and Lucille A. Carver College
and Palliative Medicine o Medicine
University o Iowa University o Iowa
Iowa City, Iowa Iowa City, Iowa
27. End-o -Li e Care 14. Adolescent Medicine
x
x CONTRIBUTORS

Elizabeth S. Cramer, MD Bharat Kumar, MD

Clinical Assistant Pro essor Rheumatology Fellow
Department o Family Medicine Allergy/Immunology Fellow
Roy J. and Lucille A. Carver College o Medicine Division o Immunology
University o Iowa Department o Internal Medicine
Iowa City, Iowa Roy J. and Lucille A. Carver College o Medicine
15. Obstetrics and Women’s Health University o Iowa
Iowa City, Iowa
Kimberly S. Delcour, DO 11. Rheumatology
Clinical Assistant Pro essor, Department
o Internal Medicine Ye-Jin Lee, MD
Division o Cardiovascular Disease, Fellow Physician
Interventional Cardiology Division o Gastroenterology/Hepatology
University o Iowa Heart & Vascular Clinic Department o Internal Medicine
University o Iowa Hospitals & Clinics Roy J. and Lucille A. Carver College o Medicine
Iowa City, Iowa University o Iowa
2. Cardiology Iowa City, Iowa
7. Gastroenterology
Nicholas Edwards, MD
Resident Physician Britt L. Marcussen, MD
Department o Emergency Medicine Clinical Associate Pro essor
University o Iowa Department o Family Medicine and Sports Medicine
Iowa City, Iowa Roy J. and Lucille A. Carver College o Medicine
12. Orthopedics and Sports Medicine University o Iowa
Iowa City, Iowa
Mark A. Graber, MD, MSHCE, FACEP 12. Orthopedics and Sports Medicine
Clinical Pro essor
Departments o Family Medicine and Emergency Medicine Denise A. Martinez, MD
Roy J. and Lucille A. Carver College o Medicine Clinical Assistant Pro essor
University o Iowa Department o Family Medicine
Iowa City, Iowa Assistant Dean
1. Emergency Medicine; 2. Cardiology; 7. Gastroenterology; O ce o Cultural A airs and Diversity Initiatives
26. Ethics; 28. Evidence-Based Medicine; 30. Final Examination Roy J. and Lucille A. Carver College o Medicine
University o Iowa
Erin R. Howe, MD Iowa City, Iowa
Clinical Assistant Pro essor 29. Patient-Centered Care
Stead Family Department o Pediatrics
Roy J. and Lucille A. Carver College o Medicine Ross E. Mathiasen, MD
University o Iowa Assistant Pro essor
Iowa City, Iowa Department o Emergency Medicine
13. Pediatrics Department o Orthopaedic Surgery
University o Nebraska Medical Center
Monika Jindal, MD Omaha, Nebraska
Chie Resident 12. Orthopedics and Sports Medicine
Departments o Family Medicine and Psychiatry
Roy J. and Lucille A. Carver College o Medicine Megan H. Noe, MD, MPH
University o Iowa Clinical Instructor
Iowa City, Iowa Department o Dermatology
23. Psychiatry University o Pennsylvania
Philadelphia, Pennsylvania
Brian R. Kirschling, OD, FAAO 17. Dermatology
Clinical Assistant Pro essor
Department o Ophthalmology and Visual Sciences Spriha Pavuluri, MD
Roy J. and Lucille A. Carver College o Medicine Neurology Resident
University o Iowa Hospitals and Clinics Department o Neurology
Iowa City VA Medical Center Roy J. and Lucille A. Carver College o Medicine
Iowa City, Iowa University o Iowa
19. Ophthalmology Iowa City, Iowa
18. Neurology
 CONTRIBUTORS x

Brigit E. Ray, MD, MME Jack . Stapleton, MD

Faculty Associate Physician Pro essor
Department o Family Medicine Departments o Internal Medicine and Microbiology
Roy J. and Lucille A. Carver College Director, Helen C. Levitt Center or Viral Pathogenesis
o Medicine Roy J. and Lucille A. Carver College o Medicine
University o Iowa University o Iowa
Iowa City, IA Iowa City, Iowa
15. Obstetrics and Women’s Health; 22. Care o the 9. HIV/AIDS
Surgical Patient; 30. Final Examination
Rebecca uetken, MD, PhD
Sandra R. Rosen eld-O’ ool, MD Clinical Associate Pro essor
Clinical Assistant Pro essor Department o Internal Medicine, Division o Immunology
Department o Family Medicine Roy J. and Lucille A. Carver College o Medicine
Roy J. and Lucille A. Carver College o Medicine University o Iowa
University o Iowa Iowa City, Iowa
Iowa City, Iowa 11. Rheumatology
15. Obstetrics and Women’s Health
Jon N. Van Heukelom, MD
Margo Schilling, MD Clinical Associate Pro essor
Clinical Pro essor Department o Emergency Medicine
Department o Internal Medicine Roy J. and Lucille A. Carver College o Medicine
Roy J. and Lucille A. Carver College o Medicine University o Iowa
University o Iowa Iowa City, Iowa
Iowa City, Iowa 12. Orthopedics and Sports Medicine
8. In ectious Diseases
Karolyn A. Wanat, MD
Adam B. Schlichting, MD, MPH Assistant Pro essor
Clinical Assistant Pro essor Associate Program Director
Department o Emergency Medicine Department o Dermatology, Pathology, In ectious Diseases
Department o Internal Medicine University o Iowa
Division o Pulmonary, Critical Care and Iowa City, Iowa
Occupational Medicine 17. Dermatology
Roy J. and Lucille A. Carver College o Medicine
University o Iowa Michelle . Weckmann, MD, MS
Iowa City, Iowa Assistant Pro essor
1. Emergency Medicine Departments o Family Medicine, Psychiatry, and
Palliative Medicine
Victoria J. A. Sharp, MD, MBA Roy J. and Lucille A. Carver College o Medicine
Clinical Pro essor o Urology and Family Medicine University o Iowa
Roy J. and Lucille A. Carver College o Medicine Iowa City, Iowa
University o Iowa 27. End-o -Li e Care
Iowa City, Iowa
16. Men’s Health Natasha B. Wheaton, MD
Clinical Assistant Pro essor
Wendy Shen, MD, PhD Department o Emergency Medicine
Clinical Associate Pro essor Roy J. and Lucille A. Carver College o Medicine
Department o Family Medicine University o Iowa
Roy J. and Lucille A. Carver College o Medicine Iowa City, Iowa
University o Iowa 22. Care o the Surgical Patient
Iowa City, Iowa
4. Allergy and Immunology; 6. Hematology and Oncology Jason K. Wilbur, MD
Clinical Associate Pro essor
Brian X. Shian, MD Department o Family Medicine
Clinical Assistant Pro essor Roy J. and Lucille A. Carver College o Medicine
Department o Family Medicine University o Iowa
Roy J. and Lucille A. Carver College o Medicine Iowa City, Iowa
University o Iowa 4. Allergy and Immunology;
Iowa City, Iowa 5. Nephrology; 6. Hematology and Oncology; 16. Men’s Health;
10. Endocrinology 21. Care o the Older Patient; 30. Final Examination
Preface
Welcome to the ourth edition! We hope that you are as excited
to be here as we are. First, let’s start with a quick tour o the
book. You will notice some new things as well as amiliar aspects
rom the previous editions. What has changed? In order to keep
up with the times, we have altered the title slightly to Graber &
Wilbur’s Family Medicine Examination & Board Review. Okay,
big deal. But wait; there’s more. In addition, you will see a new
and attractive layout. T e whole book is in color, so you do not
have to ip to the glossy pages in the middle o the book to see
the color versions o photos and gures. For those o you who
love your e-readers and tablets, there is now an online version
o the book complete with explanations or the Final Examina-
tion questions. We added 50 more questions to the last chapter,
“Final Examination.” Each chapter now ends with a list o quick
clinical pearls, which amount to several evidence-based one-liners
per chapter to help consolidate high-yield in ormation. O course,
we have updated everything, so that you will have the most recent
medical in ormation. Last but not least, we have a new editor, Brigit
Ray, who has brought a resh perspective to the book.
What has not changed? Our essential style remains the same.
T e book is divided into 29 chapters based on body system and
elements o patient care, ollowed by the “Final Examination”
(chapter 30). T e thousands o questions in the book are woven
into cases, which we hope you will nd interesting, practical,
and relevant. o test your acquisition o knowledge, each case
ends with the learning objectives. o break the monotony o
slogging through a study guide, you will nd “Quick Quizzes”
and “Help ul ips” peppered throughout each chapter.
A dozen years ago when we wrote the rst 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 rom being boring. Yes, we are
aware that this is a study aid. But why must studying be an exer-
cise in tedium and endurance? It should be enjoyable, appli-
cable to real li e and provide a surprise every now and again.
You will nd (sometimes eeble) attempts at humor throughout
the book. We have noticed that an occasional reader does not
appreciate our sense o humor. Well, we’re doctors, not writers
or Saturday Night Live (but i Lorne Michaels is reading this—
give Jason a call).
We have been impressed with the level o engagement our
readers possess. Over the years, we have received scores o emails
rom readers who have thanked us, corrected us, and sometimes
chided us. No matter the intent o the message, the tone is almost
universally positive—readers are invested in the book and want to
o er help ul suggestions. Likewise, the comments posted online
(not usually the place one goes or a rmation) have been mostly
approving, constructive, and enthusiastic.
T e rst edition was published amid a less-than- riendly
environment, with declining interest in print media and several
well-known board review books already on the market. Because
our book carried a di erent tone, readers slowly gravitated to it,
and its market share grew by word-o -mouth. As o 2015, the
third edition was the best-selling board review book in print
and made Amazon’s top 10 list o general medicine books. o
what do we attribute this success? Engaged and supportive read-
ers play a huge role!
In preparation or work on the ourth edition, we saved all o
your emails and scoured the Internet or reader comments and
reviews. We read and considered all that we could nd—which
amounted to several hundred readers’ ideas. So, you, the reader,
have helped shape this book. Keep those emails coming!
With all o the board review books out there, why should you
choose our text? T ere are two crucial dif erences 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 o amily medicine. T e major-
ity o questions contain a detailed explanation not only o why
an answer is right but also why the other answers are wrong.
In the rapidly changing world o medical knowledge, we have
endeavored to provide you with the most relevant and up-to-
date evidence. When the current evidence is controversial and
we are not certain what the American Board o 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 compre-
hensive as possible. In addition to its use as a board review
book or amily medicine, it can be employed as a general
review or primary care physicians, physician assistants, and
nurse practitioners. Students and residents studying or Step
3 o the licensing examination should ind the book help ul
as well. However, no board review book can possibly cover
the entire scope o amily medicine. Use these questions as a
guide: what areas are your strengths and what do you need
to study urther? Each answer o the “Final Examination” is
re erenced in the book so you can go back and review any
topic that you might have missed. For the online version, we
realize it may be hard to switch back and orth through the
book so we have included the answer explanations in a sec-
tion or you.
x
xv PREFACE
In this book, the use o eponymous medical terms such as
Crohn disease and Wilson disease, re ects the current Ameri-
can Medical Association recommendations or these and simi-
lar terms where the possessive orm is dropped. In addition,
there is a general trend toward using ewer eponyms, such as
Wegener, which has been dropped completely. We have made
note o both new and old terms when we have deemed the old
term more recognizable.
We enjoyed writing this book and we hope that you enjoy using
it. I you have suggestions or complaints (okay, maybe all o our
jokes aren’t politically correct or even unny), do not hesitate to
write us at jason-wilbur@uiowa.edu or mark-graber@uiowa.edu.
We take your comments seriously as we endeavor to make studying
or the board examination more e ective and more un.
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.
Jason thanks his loving and supportive amily. Af er some
initial threats, Deb has granted her patience and understanding
to the project, and Jason simply owes her dinner every night . . .
or a year. Jason thanks his boys, Ken and ed, who o er a great
distraction rom work and nd it entertaining that their dad is
some orm o an author. Finally, as with every edition, Jason
must acknowledge that the book would never get nished with-
out large amounts o co ee; so, he thanks everyone involved
in the worldwide production o co ee, rom the pickers on the
Central American ncas to the local baristas.
Mark would like to thank Jason and Brigit; this has been a
collaborative e ort, which has made it easier or all o us. T anks
to you or buying this book. T anks also to his amily: Hetty,
Rachel, and Abe (as always). But not to the dogs, Nietzsche and
Dante. T ey need to learn to stay either in or out o the house.
No more o this back and orth. Music that has kept him awake:
Faith No More, the Beach Boys (actually amazingly good . . .
check out “T e Sounds o Summer: T e Very Best o the Beach
Boys”), and the Kinks. Finally, thanks to his bicycle or keeping
him sane . . . although some would argue this point.
Brigit has been using the Family Medicine Board Review text
to study or years and thanks Jason and Mark or including her
as a new editor in this project! T is was an honor or her and
she enjoyed working on their team. Foremost, she would like
to thank her ance, Austin, and her amily or being so patient
when she has been cranky and sleep deprived juggling every-
thing. It’s not easy juggling a master’s degree program with clini-
cal duties, two busy schedules in the medical pro ession, and
long distance relationships! In act, she eels she is getting the
hang o juggling so much that she may start to study how to
actually do it!
AFewWords on Studying and
Taking the Board Examination
T roughout the book, you will nd that we give advice on what
we think is likely to be on the examination. T at’s what you’re
paying or, right? However, in previous editions, we have not
advised readers on study habits or test-taking strategies. Here,
we o er our humble suggestions on how to prepare or the
examination and enhance your overall per ormance. We rec-
ommend you read this section prior to diving into the meat o
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 act, examination scores are directly
proportional to time spent studying or the examination (although
this association grows weaker or those who have high scores
already). T e point is, you don’t have to be a genius who got a 36 on
the AC in order to rock the ABFM Certi cation/Recerti cation
Examination. But you may need to put in the work.
Your rst step in studying or the examination—af er pur-
chasing this book, o course—should be to develop a study
plan. Plotting out time and dedicating that time to uninter-
rupted study is important. How much time do you have be ore
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 o a worldwide ailure
o co ee crops? Will a new Star Wars movie open be ore the
examination? T inking through these questions, get a calendar,
mark the examination date, and plot out days and times that
you will devote to studying. I you have taken the examination
be ore and it didn’t turn out so well, you may need to change
your daily work schedule or 2 to 3 months be ore the exami-
nation to accommodate studying 10 to 15 hours per week. We
endorse neither “cramming” or the examination nor “adding
on” studying to an already ull schedule. o get the most out o
studying, you need to approach it like a daily devotion.
In order to maximize your return on your studying and to
ocus on de ciencies, try taking a pre-test. T e best pre-test is
the ABFM I E (keep reading or more on this). You can use
your results on the pre-test to see what areas are your weakest.
Studying weak areas is less un but will net higher yield results
than studying areas o relative strength. I your practice is nar-
row in scope (e.g., a hospitalist), you probably already have a
sense o areas o strength and weakness. Make sure you address
your weak areas with relatively more time on them.
Next, know what is on the examination. T e percentage o
examination content devoted to various systems is posted on
the ABFM website, and we recommend you review it. T e top
systems tested are usually cardiovascular, respiratory, and mus-
culoskeletal systems. I you are weak in any o these areas, be
certain to ocus your studying on them.
Now, what material should you use when studying? Some o
our readers have been overly kind, suggesting in their reviews
that this book is the only study tool needed or the board exami-
nation. While we would like to believe it, we cannot endorse this
point o view.
o get a avor or the questions on the examination, the best
strategy is to go to the source. T e ABFM posts its In- raining
Exams (I E) or the last 3 years on its website (www.theab m.
org). A login is required, which board-certi ed amily physi-
cians should all have. T e I Es are perhaps the best source
or assessing your knowledge—we strongly recommend you
use them. Although we do not recommend relying on the I Es
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. T e critiques are available as well, so you can learn
what the ABFM thinks you should know. T e ABFM also has
extensive in ormation on what you should expect when you sit
or the certi ying/recerti ying examination, including a tutorial
that simulates the examination. I you are an anxious test-taker,
be certain to check out the tutorial. While the ABFM has sev-
eral use ul tools, be aware that the Sel -Assessment Modules are
not representative o the types o questions you will nd on the
certi ying/recerti ying examination.
Another great source or questions is the American Academy
o Family Physicians (AAFP) website. I you are a member o
AAFP, you can access questions or ree. T ey are categorized by
body system and can be done in chunks o ten at a time worth
0.25 CME credits. T is question bank o ers another opportu-
nity to test your knowledge and determine where you need to
ocus your studying.
Also, the AAFP markets a comprehensive board review sel -
study course, which will set you back about $1,000 i you are a
member and more i you are not. Indeed, it covers everything
you need to know or 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 sel -study package.
xv
xv A FEW WORDS ON STUDYING AND TAkING THE BOARD ExAMINATION
What about texts and primary sources? Well, while we would
admire your perseverance in slogging through whole texts prepar-
ing or the examination, we do not recommend attempting to read
cover-to-cover texts like Robert Rakel’s Textbook o Family Medi-
cine or re erence material like UpToDate. Don’t get us wrong. We
like these sources and recommend them to you as re erences 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 oundation but use ul to expand your knowl-
edge when you don’t understand something.
As ar as board review courses: to each his own. I you are
considering attending a course, the AAFP o ers comprehensive
courses multiple times per year in locations all across the coun-
try. For-pro t entities provide additional options. I you learn
best in a live lecture setting, these courses may be a good option
or you, but you need not attend a course to get all that in orma-
tion (c’mon—you’ve got this book!).
T ere are some important basic things you need to know
about the examination. First, the examination is composed o
our sections, two o which are general in nature and two o
which are modules that you will select on the day o the exami-
nation. It is best to choose modules with which you are more
amiliar. For example, i you practice primarily in an emer-
gency department, you may want to choose Emergent/Urgent
Care and Hospital Medicine rather than Maternity Care (unless
you’re looking or the additional challenge).
T e examination consists entirely o our-item multiple-
choice questions. You are not penalized or guessing. An unan-
swered question will always be wrong; whereas, a guessed
question has a 25% chance o being right. I you have no idea,
go ahead and guess. As a corollary to that rule, never exit the
examination without rst completing all the items. You cannot
return to answer unmarked items.
Read every stem and option care ully. Although we doubt
that the ABFM writes “trick questions,” they do use catch
words/phrases, such as “except,” “most likely,” “ rst step,” and
“least likely.” I 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 be ore the examination rather than the most
recent medical evidence. Now, the ABFM recommends exam-
inees 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.”
Success ul test-takers do not use grand strategies to outsmart
the question writers; instead they tend to employ a ew simple
rules when answering multiple-choice questions. T ese simple
rules that ollow amount to guidelines that cannot be blindly
applied to the entire test but are of en true. No secret to many o
you, perhaps, but here they are:
• Go with your rst thought ul choice unless you have a solid
reason to change it (e.g., you misread the question).
• Look or catch words in the answers, such as “always” and
“never.” T ese will of en be incorrect.
• Avoid answers with un amiliar terms (e.g., obscure disease
names or rarely per ormed procedures). T ese are of en
incorrect.
• T e most detailed answer is of en the correct answer.
• I two answers are similar, they are probably both wrong.
• Stick with amily medicine principles (e.g., answers with
“more history” or “shared decision making” are more likely
to be correct).
• I you don’t know, guess and move on. Do not waste time
deliberating on a single question.
Finally, we part o ering advice that we know busy doctors
seldom ollow: get plenty o rest. Seriously! Be prepared or
the examination day by getting a good night’s sleep. Don’t stop
taking care o your health prior to the examination, and that
includes rest. Eat a good break ast, bring a snack or your breaks
and plan to take yoursel out or a nice lunch (but skip the mar-
tini—you’ve got an examination to nish). Just like a mountain
climber, wear layers. Some o those test-taking centers are reez-
ing; some are boiling. Stay positive, take a deep breath and keep
moving through it. You will pass this thing! Good luck.
EmergencyMedicine
Adam B. Schlichting, Olivia E. Bailey, and Mark A. Graber
CASE 1.1
You get a call rom a panicked mother because her 4-year-old
took some o her theophylline. She thinks it may have been as
many as 10 pills but is not clear on the actual number. She is
about 35 minutes rom the hospital.
Question 1.1.1 Your advice to her is:
A) Give i ec c to ro ote sto ch e tying nd reduce
theo hylline bsor tion.
B) Do not give i ec c nd roceed directly to the hos it l.
C) C ll oison control nd then roceed to the hos it l.
D) Bre the dee ly nd c l down; theo hylline is h r less.
Answer 1.1.1 The correct answer is “B.” Do not give i ec c
but roceed to the hos it l. “A” is incorrect or cou le o
re sons. First, i ec c is not rticul rly e ective ethod o
e tying g stric contents. More i ort ntly, i the tient
should st rt to seize while vo iting s result o the i ec c,
she could s ir te the vo itus c using n s ir tion neu o-
nitis. “C” is incorrect bec use you do not w nt to del y de ni-
tive tre t ent. You c n c ll oison control while the tient is
on the w y.
HELPFUL TIP:
Ipecac is ine ective and possibly harm ul. It causes my-
opathy and cardiac problems when used chronically
(such as in those with anorexia nervosa). The Food and
Drug Administration (FDA) has considered making ip-
ecac available by prescription only, and many pharma-
cies currently do not stock it.
T e patient arrives in your emergency department (ED).
She is alert but with a tachycardia o 160 beats per minute
and a stable blood pressure (BP). T e ingestion occurred
about 50 minutes ago. You contemplate gastrointestinal (GI)
decontamination.
1
Question 1.1.2 Which o the ollowing statements is true
about gastric lavage?
A) Exce t in extr ordin ry circu st nces it should only be
done in the rst hour er n overdose.
B) P tients who h ve h d g stric l v ge h ve higher incidence
o ul on ry s ir tion th n tients who h ve not.
C) P tients who undergo g stric l v ge h ve higher incidence
o eso h ge l er or tion.
D) It c n ush ill r g ents beyond the ylorus.
E) All o the bove re true.
Answer 1.1.2 The correct answer is “E.” All o the o tions re
true. Gener lly, the e c cy o g stric l v ge is li ited. Out-
co e d t do not su ort the use o g stric l v ge er the rst
hour. In rticul rly severe overdose or in n overdose th t is
likely to del y g stric e tying (e.g., tricyclic ntide ress nts),
you ight w nt to consider l v ge, but such circu st nces re
unusu l. G stric l v ge incre ses the risk o s ir tion, eso h-
ge l er or tion, nd c n ush ill r g ents beyond the
ylorus.
Question 1.1.3 A ter care ul consideration, you decided not
to lavage. She is now 55 minutes a ter the ingestion. The next
best step to take in this patient is to:
A) Check blood theo hylline levels nd re er or he odi lysis
i rkedly elev ted.
B) Ad inister 1 g/kg o ch rco l with sorbitol.
C) Pro hyl ctic lly tre t this tient or seizures using lor z-
e .
D) Pro hyl ctic lly tre t this tient or seizures using henyt-
oin.
E) C ll the Child Li e Activities T er ist to distr ct the child
while you settle in or 4-hour observ tion eriod.
Answer 1.1.3 The correct answer is “B.” Giving ch rco l is
likely hel ul only within the rst hour af er ingestion. “A” is
incorrect bec use the tient’s situ tion could deterior te by
the ti e blood levels return. “C” nd “D” re incorrect bec use
seizure ro hyl xis is not indic ted in this tient. Although
1
2 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
seizures re jor ni est tion o theo hylline toxicity,
they re ore likely to occur in tients who t ke theo hylline
chronic lly nd h ve toxic blood levels. Acute ingestions re less
worriso e. Observ tion lone (“E”) is not the best choice here.
HELPFUL TIP:
Although requently given, single dose activated char-
coal has limited or no e ect on outcomes. It reduces
absorption by about 30% i given within 1 hour o in-
gestion and likely has no bene it a ter 1 hour. It can also
cause vomiting with aspiration. For this reason, it has
allen out o avor (I don’t remember the last time I used
it in our ED [MG]). We are not sure what the correct an-
swer 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 For which o these overdoses is charcoal
NOT indicated?
A) Acet ino hen.
B) As irin.
C) Iron.
D) Digoxin.
E) O i tes.
Answer 1.1.4 The correct answer is “C.” Ch rco l will not bind
iron. Ch rco l will lso not bind C ustics/corrosives, He vy
et ls, Alcohols, R id-onset cy nide, Chlorine (or iodine),
Other insoluble t blets, Ali h tics (hydroc rbons), or L x tives
(mnemonic: CHARCOAL). So e o you y h ve nswered
“A.” T eoretic lly, ch rco l could inter ere with the ction o
N- cetylcysteine, the ntidote or cet ino hen ingestion by
bsorbing it. However, this is ore o theoretic l concern th n
n ctu l one. First, the drugs should be used t di erent ti es.
Ch rco l should be given i edi tely, while N- cetylcysteine is
given only er 4-hour levels re v il ble. Second, the doses o
N- cetylcysteine reco ended re quite high, nd you c n give
higher dose i you will be using it with ch rco l. Fin lly, intr -
venous (IV) N- cetylcysteine is v il ble nd is obviously not
ected by ch rco l. “B,” “D,” nd “E” re ll incorrect. While we
do h ve ntidotes or digoxin nd o i tes (Digibind, n loxone),
ch rco l is still indic ted to reduce bsor tion within the rst
hour.
Objectives: Did you learn to . . .
• Manage a patient with an acute ingestion?
• Describe the appropriate use o gastric lavage and charcoal
administration?
• Identi y situations where charcoal may not be indicated?
QUICK QUIZ: BIOTERRORISM
Oh no. Godzill is tt cking okyo. And this ti e it is with
we ons o ss destruction. Which o the ollowing ro erly
describes the isol tion require ents o tient with ul o-
n ry nthr x?
A) No isol tion necess ry. T e tient y be in the s e roo
with n unin ected tient.
B) Res ir tory isol tion only.
C) Res ir tory nd cont ct isol tion.
D) Neg tive ressure roo (such s with tuberculosis) + cont ct
isol tion.
The correct answer is “A.” Pul on ry nthr x is not tr ns it-
ted erson to erson. Cont ct isol tion is indic ted in those
with cut neous nthr x nd GI nthr x (where di rrhe y
be in ectious).
Godzill is not done yet . . . Which o the ollowing drugs should
be used s ro hyl xis g inst inh led nthr x should ex osure
to erosolized s ores be docu ented?
A) A rst-gener tion ce h los orin.
B) ri etho ri /sul ethox zole.
C) Ci ro ox cin.
D) A third-gener tion ce h los orin.
The correct answer is “C.” Fluoroquinolones re the drugs o
choice when tre ting those ex osed to nthr x. Doxycycline
y lso be used. Ce h los orins nd MP/SMX re not ctive
g inst nthr x.
Godzill , rustr ted by his iled nthr x tt ck, is now s re d-
ing s ll ox. Which o the ollowing is NO true bout s ll-
ox?
A) Isol tion is best done t ho e i ossible.
B) T e tient is in ectious until he or she beco es ebrile.
C) All lesions re gener lly in the s e st ge o evolution,
unlike wh t is seen in v ricell .
D) S ll ox i uniz tion c uses n ence h litis in 1:300,000
o which 25% o c ses re t l.
The correct answer is “B.” T e tient is in ectious until ll le-
sions crust over nd in ectivity h s nothing to do with the res-
ence or bsence o ever. “A” is true. Isol tion is best done t
ho e since this will li it s re d (those in the household h ve
likely lre dy been ex osed). “C” is lso true; ll lesions re in
si il r st te o evolution. Fin lly, “D” is true nd is the re son
we do not currently i unize g inst s ll ox—well, th t nd
the ct we er dic ted it (W y to go, hu ns!).
CASE 1.2
A 22-year-old emale presents to the ED with an overdose.
She has a history o depression, and there were empty bottles
ound at her bedside. T e bottles had contained clonazepam

and nortriptyline. T e patient is unconscious with dimin-
ished breathing and is unable to protect her airway.
Question 1.2.1 The BEST next step is to:
A) Intub te the tient.
B) Begin g stric l v ge nd d inister ch rco l.
C) Ad inister u zenil, benzodi ze ine nt gonist, to w ken
her nd i rove her res ir tions.
D) Ad inister bic rbon te.
E) Ad inister li id e ulsion.
Answer 1.2.1 The correct answer is “A.” T is tient should
be intub ted. Re e ber in ny e ergency situ tion th t the
ABCs ( irw y, bre thing, nd circul tion) re the riority. “B”
is incorrect bec use, s noted e rlier, tients who undergo g s-
tric l v ge h ve higher incidence o ul on ry s ir tion— n
even gre ter concern in the obtunded tient. In ct, irw y
rotection is MANDA ORY be ore undert king l v ge. “C” is
incorrect. Flu zenil will reverse the benzodi ze ine. However,
we know ro ex erience th t seizures in tients who h ve
h d u zenil re rticul rly di cult to control. T is would
be rticul rly roble tic in tient with ixed overdose,
such s with tricyclic, where seizures re co on. T us, it is
reco ended th t u zenil be used only s revers l gent
er rocedur l sed tion in tients who re not on chronic
benzodi ze ines. “E” is incorrect. Li id e ulsion re ers to the
liquid tty cids given s rt o tot l renter l nutrition nd
theoretic lly c n be used to bind t-soluble drugs in the blood.
C se series su ort consider tion o li id e ulsion or c lciu
ch nnel blocker, bet -blocker, tricyclic ntide ress nt overdose,
nd other t-soluble drugs but only in c ses o re r ctory c rdi c
rrest or c rdiov scul r coll se— nd cert inly not be ore the
irw y h s been secured.
FIGURE 1-1. ECG or patient in question 1.2.3.
CHAPTER 1 • EMERGENCY MEDICINE 3
You notice that the patient begins to have an abnormal trac-
ing on the cardiac monitor, so you order an ECG.
Question 1.2.2 Which o the ollowing ndings would you
expect to nd in a tricyclic overdose?
A) Nor l QRS co lex.
B) Second- nd third-degree he rt block.
C) Widened QRS co lex.
D) Sinus t chyc rdi .
E) Any o the bove.
Answer 1.2.2 The correct answer is “E.” All o the bove nd-
ings c n be seen with tricyclic overdose. In ct, the ost co -
on resenting rhyth is n rrow-co lex sinus t chyc rdi .
As toxicity rogresses, you c n see rolonged PR interv l,
widened QRS co lex, nd rolonged Q interv l. A QRS
>100 s is redictive o seizures nd QRS >160 s is highly
redictive o ventricul r rrhyth i in tients with tricyclic
ntide ress nt overdose. He rt blocks (second nd third degree)
her ld oor outco e nd y be seen l te in the course. Asys-
tole is not ri ry rhyth in tricyclic overdose nd tends to
re ect the end st ge o nother rrhyth i .
YIKES!! T e patient becomes unresponsive and you look at the
monitor. You obtain an ECG which shows the ollowing: (Fig. 1-1).
Question 1.2.3 What is the patient’s rhythm?
A) Mono or hic ventricul r t chyc rdi .
B) Sinus t chyc rdi with bundle br nch block.
C) P roxys l su r ventricul r t chyc rdi .
D) ors des de ointes.
E) T ird degree he rt block.
4 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Answer 1.2.3 The correct answer is “D.” T is is tors des de
ointes (in French it liter lly e ns “twisting o the oints,” but
in every l ngu ge it e ns “ hysici n’s stress test”), which is
subty e o oly or hic ventricul r t chyc rdi . ors des de
ointes c n be recognized by the v rying litude o the co -
lex in so ewh t regul r ttern. “A” is incorrect bec use the
co lexes re not ono or hic. “B” is incorrect or two re -
sons. First, there re no P w ves visible. Second, sinus t chyc r-
di should not h ve v ried litude. “C” is incorrect bec use,
g in, there re no P w ves nd the co lexes re oly or hic.
“E” is incorrect bec use there re no P w ves.
Question 1.2.4 This patient needs treatment post haste.
A ter taking care o the ABCs, what is the ONE BEST drug
or the treatment o this arrhythmia in a patient with a tri
cyclic overdose?
A) Es olol.
B) Lidoc ine.
C) Sodiu bic rbon te.
D) Proc in ide.
E) A iod rone.
Answer 1.2.4 The correct answer is “C.” T e tre t ent o
choice or rrhyth i s in tients with tricyclic overdose is
sodiu bic rbon te. R ising the H nd d inistering sodiu
see to “ ri e” the sodiu ch nnels in the he rt, reversing
the toxicity o the tricyclic. Proc in ide (“D”) nd quinidine
should not be used bec use they ct in si il r shion to tricy-
clics nd y worsen the roble . Lidoc ine (“B”) c n be used
s c n iod rone (“E”), but they re not the best choices. Bet -
blockers such s es olol (“A”) c n worsen hy otension nd
should be voided.
T is is not your patient’s lucky day. She begins to seize a er
the administration o the bicarbonate.
Question 1.2.5 The treatment o choice or this seizing
patient is:
A) Lor ze . co . He beco es l ost neic during the e isodes o co .
B) Re e t the bolus o sodiu bic rbon te nd st rt bic r-
bon te dri .
C) Phenytoin (Dil ntin).
D) Fos henytoin (Cerebryx).
E) None o the bove.
Answer 1.2.5 The correct answer is “A.” Benzodi ze ines re
the tre t ents o choice in tricyclic-induced seizures. While
ost seizures re sel -li ited, it is i ort nt to control sei-
zures bec use the result nt cidosis c n worsen tricyclic tox-
icity (beyond the ct th t rolonged seizures c n c use CNS
injury). “B” is incorrect. T is tient is lre dy lk linized, nd
lthough sodiu bic rbon te is the re erred ther y or tricy-
clic-induced c rdiov scul r toxicity, sodiu bic rbon te is not
rticul rly e ective in tricyclic-induced seizures. “C,” henyt-
oin, c n be used, but benzodi ze ines nd henob rbit l should
be d inistered rst i ossible. In ddition to not working well
s n ntie ile tic drug in tricyclic overdose, henytoin is lso
cl ss Ib nti rrhyth ic, which y urther rolong the QRS nd
worsen the c rdi c toxicity o the tricyclic. “D” is incorrect or
two re sons. First, since os henytoin is et bolized to henyt-
oin, the concern bout e c cy lies. Second, os henytoin is
rodrug nd requires dequ te circul tion nd ren l nd he tic
unction to be converted into ctive drug. I our tient beco es
hy otensive with oor liver nd ren l er usion, dequ te drug
levels ight not be chieved. Fin lly, both henytoin nd os-
henytoin c n c use hy otension—not wh t you need in this
unst ble tient.
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 a ter a
tricyclic overdose is unlikely to have any serious con-
sequences rom the ingestion. They can be “medically
cleared” at that point or admission to psychiatric unit.
Note that “symptomatic” may just be tachycardia or
mild con usion. We mean the entirely asymptomatic
patient.
Objectives: Did you learn to . . .
• Understand the importance o the A–B–Cs in an unstable
patient?
• Describe the role o umazenil in toxicologic emergencies?
• Manage a tricyclic overdose?
• Recognize ECG ndings in a tricyclic overdose?
• Recognize torsades de pointes and its treatment in the
context o a tricyclic overdose?
QUICK QUIZ: DESIGNER AND CLUB DRUGS
An 18-ye r-old le resents er rty. He is h ving ltern t-
ing e isodes o co b tive beh vior inters ersed with e isodes o
He h s ltern ting br dyc rdi (while in co ) nd t chyc rdi
when w ke. T e tient is lso h ving yoclonic seizures. His
seru lcohol level is zero, nd his u ils re iotic.
T e ost likely drug c using this is:
A) Ecst sy (MDMA).
B) GHB (g -hydroxybutyr te k “liquid ecst sy”).
C) Meth het ine.
D) LSD (lysergic cid diethyl ine k “ cid”).
E) O i te overdose.
The correct answer is “B.” T e e isodic co nd br dy-
c rdi inters ersed with e isodes o extre e git tion re
l ost thogno onic o GHB overdose. GHB intoxic tion
lso c uses in oint u ils. “A” is incorrect bec use MDMA
c uses n het ine-like re ction with git tion, hy er-
tension, hy erther i , t chyc rdi , etc. “C” is incorrect or
the s e re son. “D” is incorrect bec use LSD r rely (i ever)
 CHAPTER 1 • EMERGENCY MEDICINE 5

TABLE 1-1 TOXIDROMES

Drug Class Examples Signs and Symptoms
Anticholinergic Tricyclics, diphenhydramine, scopolamine, Tachycardia, ushing, dilated pupils, low-grade temperature, and
loco weed (jimson weed), some con usion. Mnemonic: Dry as a bone, red as a beet, mad as a hatter, blind
mushrooms, etc. as a bat

Opiates Morphine, heroin, codeine, oxycodone, etc. Pinpoint pupils, hypotension, hypopnea, coma, hypothermia

Cholinergic Organophosphate or carbamate Lacrimation, salivation, muscle weakness, diarrhea, vomiting, miosis.
pesticides, some mushrooms 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, liquid ecstasy, etc. Alternating coma with agitation, hypopnea while comatose, bradycardia
(GHB) while comatose, and myoclonus

c uses co . “E” is incorrect bec use tients with o i te
overdoses re gener lly so nolent or co tose without in-
ters ersed e isodes o git tion, lthough o i te use may lso
c uses iosis (be w re th t not ll n rcotic overdoses re s-
soci ted with in oint u ils). GHB is odorless nd h s slight
s lty t ste. It h s beco e drug o choice or “d te r e.” T e
toxicity tends to be sel -li ited nd c n be tre ted with intu-
b tion i needed long with tincture o ti e. T e h l -li e is
only 27 inutes.
QUICK QUIZ: TOXIDROMES
A tient resents to the hos it l with di henhydr
overdose.
Which o the ollowing signs nd sy to s re you likely to
nd in this tient?
A) Br dyc rdi , dil ted u ils, ushing, nd incre sed bowel
sounds.
B) Br dyc rdi , in oint u ils, ushing, nd decre sed bowel
sounds.
C) chyc rdi , dil ted u ils, di horesis, nd incre sed
bowel sounds.
D) chyc rdi , dil ted u ils, ushing, nd decre sed bowel
sounds.
E) chyc rdi , in oint u ils, ushing, nd incre sed bowel
sounds.
Question 1.3.1 Which o the ollowing IS NOT a criterion or
clearing the cervical spine clinically?
A) Absence o ll neck in.
B) Nor l ent l st tus including no drugs or lcohol.
C) Absence o distr cting injury (such s n nkle r cture).
D) Absence o r lysis or nother “h rd” sign th t could be
c used by neck injury
E) Absence o retrogr de nesi .
Answer 1.3.1 The correct answer is “A.” P tients c n h ve l t-
er l neck in nd still h ve their cervic l s ines cle red clini-
c lly. However, no one will ult you or obt ining r diogr hs
in tients with l ter l uscul r (e.g., tr ezius) neck in.
ine P tients with centr l neck in (e.g., over the s inous rocesses)
DO need i ging (r diogr hs ± C ) to cle r their cervic l
s ine. All o the other criteri re required in order to clinic lly
cle r the cervic l s ine ( ble 1-2). T ese criteri h ve been
v lid ted in both dult nd edi tric tients.
HELPFUL TIP:
The most common cause o missed ractures is an in-
adequate series o radiographs. An adequate series o
radiographs or the cervical spine includes an AP ilm,
a lateral ilm including the top o T-1, and an odontoid
ilm. CT should be done i radiographs are negative
and there is still clinical suspicion o a racture. Flexion–
extension views add little and should be avoided.

The correct answer is “D.” T is tient h s n nticholiner-

gic toxidro e. oxidro es re sy to co lexes ssoci-
TABLE 1-2 CLEARING THE CERVICAL
ted with rticul r overdose th t should be i edi tely
SPINE CLINICALLY
recognized by the clinici n. Co on toxidro es re listed
in ble 1-1. No central neck pain on questioning or palpation

No distracting, pain ul injury (e.g., bone racture)

CASE 1.3
No symptoms or signs re erable to the neck (paralysis, stinger-type
A patient presents to your o ce with neck pain a er a motor injury, etc.)
vehicle accident. He was restrained and the airbag deployed.
He notes that he had some lateral neck pain at the scene. He Normal mental status including no drugs or alcohol. This includes any
retrograde amnesia, etc.
continues to have lateral neck pain.
6 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
T e 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 rom the ED 48 hours
a er the initial accident that she is paralyzed rom 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 C o the cervical spine bones done a er the onset o the
paralysis.
Question 1.3.2 The most likely cause o this patient’s paral
ysis is:
A) Missed tr nsection o the thor cic cord.
B) Conversion re ction ro the sychologic l tr u o the
ccident.
C) Sub r chnoid he orrh ge.
D) SCIWORA syndro e.
E) Guill in–B rre syndro e.
Answer 1.3.2 The correct answer is “D.” T is likely re resents
SCIWORA syndro e (s in l cord injury without r diologic
abnor lity). T is occurs ro stretching o the cord second-
ry to exion/extension-ty e ove ent in n ccident. P tients
with SCIWORA syndro e y be r lyzed t the ti e o ini-
ti l resent tion (in the event o cord tr nsection) or y h ve
del yed resent tion u to 72 hours er the injury. “A” is incor-
rect bec use cord tr nsection would resent with r lysis
i edi tely t the ti e o injury. “B” is incorrect bec use this
child is 4 ye rs old, nd conversion re ction is unlikely in chil-
dren. In ddition, conversion re ction IS ALWAYS di gnosis
o exclusion. “C” nd “E” re incorrect bec use this is neither
the resent tion o sub r chnoid he orrh ge (he d che, sti
neck, erh s oc l neurologic sy to s) nor o Guill in–
B rre syndro e ( rogressive nu bness nd we kness ro
utoi une yelitis).
Question 1.3.3 The next step in the management o this
patient is:
A) Avoid hy otension nd hy oxi to revent second ry insult
to the cord
B) Fluid restriction nd diuretics to reduce cord ede .
C) M nnitol to reduce cord ede .
D) Neurosurgic l intervention to deco ress the cord.
E) Lolli o nd gi c rd or “service recovery.”
Answer 1.3.3 The correct answer is “A.” P tients with cord
injury should be onitored closely to void hy otension nd
hy oxi , both o which will urther d ge the lre dy co ro-
ised s in l cord. Neither diuretics (“B”) nor nnitol (“C”)
will be use ul in this situ tion. “D” is incorrect bec use the ro-
cess o SCIWORA involves stretching o the cord ( nd subse-
quent dys unction) r ther th n cord co ression such s would
be seen with bony injury. “E” ight be the right choice i you
re t king this test s “ tient ex erience ex ert” inste d o
doctor; but doctors should choose “A.”
HELPFUL TIP:
There is currently controversy regarding treatment o
acute spinal cord injuries with IVmethylprednisolone 30
mg/kg bolus (3 g in an adult) ollowed by a 5.4 mg/kg
drip or 24 hours. The e icacy o this therapy in spinal
cord injury is limited (i it exists at all), and its e icacy in
SCIWORA is unknown. There are also secondary compli-
cations rom the steroids including hyperglycemia, my-
opathy, and in ections (e.g., pneumonia). We don’t use it.
Question 1.3.4 The ather is, understandably, irate that his child
is now paralyzed. You can tell him that the natural history o
SCIWORA syndrome in THIS CHILD is likely to be the ollowing:
A) Continued r lysis with the necessity o long-ter , er -
nent d t tion to the injury.
B) Progression o the injury over the next week to include ur-
ther r lysis in n scending shion.
C) Resolution o r lysis nd sensory sy to s over the next
sever l onths.
D) Resolution o ll sy to s exce t sensory sy to s o the
next sever l onths.
E) L rge l wsuit yout on the w y. Do not ss go; do not col-
lect $200; go directly to l r ctice ttorney.
Answer 1.3.4 The correct answer is “C.” Gener lly, tients
with SCIWORA syndro e reg in their strength nd sensory
bilities over ti e. However, this depends on when they pres-
ent with symptoms! P tients who resent with r lysis right
er the ccident y h ve co lete cord tr nsection nd
thus will not reg in unction. For this re son, it is i ort nt to
obt in n MRI on ll tients with SCIWORA syndro e ( nd
ny tr u -induced r lysis or th t tter).
Objectives: Did you learn to . . .
• Clinically “clear” the cervical spine and decide when to order
cervical spine radiographs?
• Understand the physiology, natural history, and management
o SCIWORA syndrome?
CASE 1.4
A patient with an extensive history o alcohol use presents to
the ED a er drinking a bottle o automobile winter gas treat-
ment (Rothschild Vintage, 1954). He is intoxicated, has a
headache, and describes a “misty” vision, “like a snowstorm”
(i you live in southern Florida or Cali ornia, call one o us
in Iowa or a description). He is tachycardic and tachypneic.
You start an IV and administer saline. You obtain a blood
gas, which shows a mild metabolic acidosis.
Question 1.4.1 A metabolic acidosis is consistent with all o
the ollowing ingestions EXCEPT:
A) Ethylene glycol.
B) Meth nol.
C) Eth nol (e.g., vodk , gin).
D) Petroleu distill tes (e.g., non- lcohol cont ining g soline
roducts).
 CHAPTER 1 • EMERGENCY MEDICINE 7

Answer 1.4.1 The correct answer is “D.” Ethylene glycol, eth- TABLE 1-3 CAUSES OF ACIDOSIS
nol, nd eth nol c n ll c use et bolic cidosis. Hydroc r-
Causes o an Lactic acidosis
bons (e.g., g soline roducts) do not c use et bolic cidosis.
elevated anion gap Diabetic ketoacidosis
T e in ni est tion o hydroc rbon toxicity is second ry to acidosis Ingestions such as ethanol, methanol, etc.
the inh l tion nd s ir tion o the hydroc rbon nd the result-
Uremia
ing neu onitis.
Alcoholic ketoacidosis

T is patient’s electrolytes are as ollows: sodium 135 mEq/L, Causes o a normal GI bicarbonate loss (e.g., chronic diarrhea)
bicarbonate 12 mEq/L, chloride 108 mEq/L, BUN 12 mg/dL, anion gap acidosis Renal tubular acidosis (types I, II, and IV)
Cr. 1.0 mg/dL. Interstitial renal disease
Ureterosigmoid loop
Question 1.4.2 This patient’s anion gap is: Acetazolamide and other ingestions
A) 13. Small bowel drainage
B) 15.
C) 23.
D) Un ble to c lcul te the nion g with the in or tion A) Hy o ne .
rovided. B) O tic disk bnor lities.
C) Abdo in l in nd vo iting.
Answer 1.4.2 The correct answer is “B.” By convention, the D) B s l g ngli he orrh ge.
nion g is c lcul ted without using jor c tion, ot ssiu . E) Meninge l signs, such s nuch l rigidity.
T us, the nion g is c lcul ted s ollows:
Answer 1.4.4 The correct answer is “A.” Hy o ne is not
sodiu − (chloride + bic rbon te). co only seen in eth nol oisoning until the tient is close
to de th. In ct, the reverse is true. chy ne is requent
In this tient, the nion g = 135 − (108 + 12) = 15. nding in eth nol overdose. T is kes sense. T e tient
is trying to co ens te or et bolic cidosis by blowing o
T e nor l nion g is ty ic lly considered to be 12 or less. CO2. O tic disk bnor lities, bdo in l in nd vo iting,
However, since lbu in is the jor un e sured nion in the b s l g ngli he orrh ge, nd eninge l signs re ll seen s
seru , the nion g should be djusted or hy o lbu in- rt o eth nol toxicity. It is thought th t ny o these signs
e i . Every 1 g decre se in lbu in will incre se the nion nd sy to s re second ry to centr l nervous syste (CNS)
g by bout 3. T ere ore, you should subtr ct (3 × [nor l he orrh ge.
lbu in- ctu l lbu in]) to get the “re l” nion g . T e
nor l lbu in is considered to be 4. So, let us s y we c l- You can test or ethanol at your hospital but do not have a
cul te n nion g o 16 but the lbu in is 2. In this c se test or methanol on a stat basis and want to be sure that this
the corrected nion g will be (16 − [3 × (4 − 2)] = 16 − 6), patient is not just saying he has a methanol ingestion in order
or 10. to obtain alcohol (a treatment or methanol ingestion—break
out the single malt scotch!).

HELPFUL TIP: Question 1.4.5 What test is most likely to help you deter
In methanol ingestions, the severity o acid–base distur- mine i the patient has methanol ingestion?
bance is generally a better predictor o outcome than A) Co lete blood cell count (CBC).
serum methanol levels. B) BUN/cre tinine.
C) Liver enzy es.
D) Seru os ol lity.
Question 1.4.3 All o the ollowing are causes o an anion E) A yl se nd li se.
gap acidosis EXCEPT:
A) L ctic cidosis. Answer 1.4.5 The correct answer is “D.” With e sured
B) Di betic keto cidosis. seru os ol lity, you c n c lcul te the os ol r g . o do
C) Ren l tubul r cidosis. so, subtr ct the tot l measured seru os oles ro the
D) Ure i . os oles known to be due to eth nol (e ch 100 g/dL o eth -
E) Ingestions such s eth nol. nol ccounts or roxi tely 22 os oles). I there is n ele-
v ted os ol r g , it is evidence o circul ting, un e sured
Answer 1.4.3 The correct answer is “C.” See ble 1-3 or ore os ole. A nor l os ole g is so ewhere between −10 nd
on c uses o nion g cidosis. 20 Os /kg.
In this c se, or ex le:
Question 1.4.4 Which o the ollowing ndings IS NOT
requently seen in patients with methanol ingestion? Me sured seru os ol lity = 368.
8 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Blood lcohol = 200 g/dL or bout 44 os oles.
C lcul ted os ol lity = 2(N ) + BUN/2.8 + glucose/18 =
280 + 6 + 8 = 294.
So, os ol r g = 368 − (294 + 44) = 30.
T is e ns th t there re 30 un e sured os oles th t could, in
the clinic l context o the c se, re resent eth nol. T us, we know
th t the tient did not si ly overindulge on eth nol ( eth nol,
such s “g s dry,” will ke one intensely drunk . . . but h s obvi-
ous downsides).
You decide that there is su cient evidence that this patient
has ingested methanol to institute treatment.
Question 1.4.6 Appropriate treatment(s) or this patient
include:
A) Fo e izole (4-MP).
B) Acetyls licylic cid.
C) Eth nol.
D) A nd C.
E) All o the bove.
Answer 1.4.6 The correct answer is “D.” Both Fo e izole
(4-MP) nd eth nol re used or eth nol ingestion. T e ide
is to slow down the et bolis o the eth nol. T e toxicity
o eth nol is c used by or ic cid, which is by- roduct
o eth nol et bolis . Eth nol is et bolized by lcohol
dehydrogen se, the s e enzy e th t bre ks down eth nol.
T us, eth nol et bolis is co etitively inhibited by eth -
nol. T e s e holds true or o e izole, which is co etitive
inhibitor o lcohol dehydrogen se. Fo e izole nd eth nol
c n both be used or ethylene glycol ingestion s well. “B” is
incorrect. Acetyls licylic cid (ASA), or s irin, h s no role in
eth nol ingestion, nd would likely worsen ny g stritis or
he orrh ging.
HELPFUL TIP:
Hemodialysis should be available or any patient who
has ingested methanol. Indications or hemodialysis in-
clude methanol level >50 mg/dL, severe and resistant
acidosis, and renal ailure.
Objectives: Did you learn to . . .
• Recognize mani estations o alcohol ingestion?
• Identi y causes o metabolic acidosis with elevated and
normal anion gaps?
• Use the osmolar gap to narrow down the dif erential diagno-
sis o metabolic acidosis?
QUICK QUIZ: BETA-BLOCKER OVERDOSE
Which o the ollowing h s been shown to be use ul in bet -blocker
overdose when convention l, drenergic ressors re ine ective?
A) C lciu chloride.
B) Gluc gon.
C) Milrinone.
D) High-dose insulin.
E) All o the bove.
The correct answer is “E.” In bet -blocker overdoses, the ol-
lowing ndings y be observed: br dyc rdi , AV block, hy o-
tension, bronchos s , n use , e esis, nd hypoglycemia. T is
is very si il r to the resent tion o c lciu ch nnel blocker
overdose, but c lciu ch nnel blocker overdose o en l cks
bronchos s nd tients re hyperglycemic s insulin rele se
ro the islet cells is c lciu de endent. When bet -blocker
overdose h s been identi ed, the usu l tre t ents re e loyed
(e.g., IV uids, v so ressors, irw y rotection, ch rco l). I
convention l v so ressors h ve iled, gluc gon in dose o 3
to 5 g IV bolus nd dri t 1 to 5 g/hr y be e ective
in tre ting bet -blocker overdose. It is gener lly re erred over
tro ine in this situ tion. Milrinone nd other hos hodiester-
se inhibitors y lso be used but re considered third-line
gent. Like-wise, c lciu is considered third-line gent in
bet -blocker overdose. C lciu chloride y otenti te the c-
tion o gluc gon. T ere is lso growing body o liter ture su -
orting use o high dose insulin-euglycemia or bet -blocker,
c lciu ch nnel blocker, or co bin tion overdoses. T e insulin
is st rted t 0.5 units/kg/hr nd titr ted to s high s 10 units/
kg/hr, titr ted by he odyn ic i rove ent (see Clin Toxicol
(Phila). 2011;49(4):277–283, or ex le). Does it see coun-
terintuitive to give gluc gon nd insulin? Both e r to iti-
g te the deleterious e ects o bet -blockers on c rdi c yocyte
et bolis , lthough the ech nis is not co letely under-
stood. Both c n be given (usu lly in sequence with the gluc gon
rst) to the s e tient or bet -blocker overdose. Remember
to maintain euglycemia i using insulin or beta-blocker or
calcium channel blocker overdose.
QUICK QUIZ: TOXICOLOGY 1
Which o the ollowing c n be used to incre se the et bolis
o lcohol in n intoxic ted tient?
A) IV uids.
B) Ch rco l.
C) Forced diuresis.
D) GABA nt gonists such s u zenil.
E) None o the bove.
The correct answer is “E.” Drunk tients, no tter how
uch they nnoy you, will just h ve to slee it o . T e r te o
lcohol et bolis is xed with zero-order kinetics t lower
doses ( xed et bolic r te) nd rst-order kinetics t higher
doses (r te ro ortion l to levels). In gener l, this r te is in
the r nge o 9 to 36 g/dL/hr with 20 g/dL/hr being the
cce ted nor . At this oint, there re no v il ble gents to
incre se the et bolis o eth nol. “B” is incorrect bec use
eth nol is too r idly bsorbed or ch rco l to be o ny ben-
e t.

QUICK QUIZ: TOXICOLOGY 2
T e best ther y or seizures second ry to isoni zid ingestion is:
A) Lor ze .
B) Phenytoin.
C) Pyridoxine.
D) T i ine.
E) Phenob rbit l.
The correct answer is “C.” Isoni zid is vit in B6 nt gonist.
T us, yridoxine (in ssive doses!) is the drug o choice in
isoni zid-induced seizures. T ese seizures re o en resist nt to
convention l ther y. Look or this ty e o overdose in tients
who re being tre ted or tuberculosis (either ctive or l tent
dise se).
CASE 1.5
A amily o our comes into your ED a er being exposed to
carbon monoxide (CO). T ey were in an idling car and were
running the engine and heater to stay warm. You want to get
a carboxyhemoglobin level on the whole amily but cannot
get an arterial blood gas rom the youngest child.
Question 1.5.1 What is your response?
A) Check ulse oxi etry, nd i the oxygen s tur tion is nor l,
be re ssured.
B) Check end-tid l c rbon dioxide.
C) Check venous c rboxyhe oglobin level.
D) Check venous c rboxyhe oglobin nd correct or the di -
erence between venous nd rteri l s les.
Answer 1.5.1 The correct answer is “C.” A venous c rboxyhe-
oglobin is just s ccur te s n rteri l c rboxyhe oglobin—
in ct, no correction is needed, which is why “D” is wrong— nd
it is uch less in ul to dr w. “A” is incorrect bec use the ulse
oxi eter does not re ect hy oxi in c rbon onoxide oison-
ing. T us, st nd rd ulse oxi etry is useless in deter ining
the c rboxyhe oglobin level. “B” is incorrect bec use end-tid l
c rbon dioxide is e suring CO2 nd not CO.
Question 1.5.2 When determining which patients need
hyperbaric oxygen on the basis o a carboxyhemoglobin
level, the level to rely upon is:
A) T e c rboxyhe oglobin level on rriv l to the ED.
B) T e c rboxyhe oglobin level t 4 hours er ex osure.
C) T e c rboxyhe oglobin level rojected to “ti e zero” (e.g.,
t the ti e o ex osure).
D) None o the bove.
Answer 1.5.2 The correct answer is “C.” A jor consider-
tion reg rding the initi tion o hy erb ric oxygen ther y is
the tient’s clinic l situ tion. More severely ill tients with
CO oisoning (e.g., severe cidosis, unconscious, unres onsive)
should be considered c ndid tes or hy erb ric oxygen, nd
so e hy erb ric oxygen centers will tre t reg rdless o e sured
CHAPTER 1 • EMERGENCY MEDICINE 9
c rboxyhe oglobin level in these tients. I the tre t ent deci-
sion is de b sed on the c rboxyhe oglobin level, the level
rojected to ti e zero gives the ost ccur te in or tion bout
the degree o ex osure. T e rest o the nswers re incorrect.
T e ather has a headache and a time zero carboxyhemoglo-
bin level o 12%. T e mother, who is pregnant, is asymptom-
atic and has a time zero carboxyhemoglobin level o 18%.
Both o the children are asymptomatic. T e 6-year-old has
a time zero carboxyhemoglobin o level o 18% while the
8-year-old has a level o 23%.
Question 1.5.3 The rst step in the treatment o these
patients is:
A) St rt n IV nd d inister s line.
B) St rt N- cetylcysteine, which is ree r dic l sc venger.
C) St rt continuous ositive irw y ressure (CPAP) to xi-
ize ir ow by kee ing the irw ys ro coll sing.
D) Ad inister 100% oxygen.
E) Intub te the ost severe tient, 100% oxygen or the others.
Answer 1.5.3 The correct answer is “D.” Bec use CO co eti-
tively binds to he oglobin in l ce o oxygen nd in ct h s
gre ter nity or he oglobin th n oxygen, high- ow 100%
oxygen is the cornerstone o tre ting CO oisoning. T e h l -
li e o CO in tient bre thing roo ir is roxi tely 300
inutes; this is reduced to 90 inutes when bre thing high ow
oxygen nd reduced to 30 inutes when bre thing 100% hy er-
b ric oxygen. T us, the rst step in CO poisoning is to administer
100% oxygen. T e rest o the nswers re incorrect. I the tient
is not ventil ting well nd requires intub tion, this would be
ro ri te, nd the FiO2 should be set to 100%, reg rdless o
the tient’s ulse oxi etry or rteri l oxygen re dings. How-
ever, in our tients who re bre thing without di culty, there
will be no dv nt ge ( nd uch higher risk) to intub tion.
Question 1.5.4 Which o the ollowing can be seen with
carbon monoxide poisoning?
A) Rh bdo yolysis.
B) C rdi c ische i .
C) Long-ter neurologic sequel e, including de enti .
D) Pul on ry ede .
E) All o the bove.
Answer 1.5.4 The correct answer is “E.” All o the bove c n
be seen with c rbon onoxide oisoning. Addition l ndings
include l ctic cidosis, seizures, synco e, nd he d che. “C”
deserves bit ore discussion. Long-ter neurologic sequel e
c n develo ro d ys to onths er the ex osure nd include
cognitive de cits, oc l neurologic de cits, ove ent disor-
ders, nd erson lity ch nges. It e rs th t using hy erb ric
oxygen in the ro ri te tient c n reduce long-ter neuro-
logic sequel e.
Your closest diving chamber is about 90 minutes away and
will hold only one patient at a time. You need to make a deci-
sion about who to send or hyperbaric oxygen.
10 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Question 1.5.5 Which patient will bene t most rom hyper
baric oxygen therapy?
A) Asy to tic regn nt other, ti e zero c rboxyhe o-
globin o 18%.
B) Asy to tic 6-ye r-old, ti e zero c rboxyhe oglobin o
18%.
C) Asy to tic 8-ye r-old, ti e zero c rboxyhe oglobin o
23%.
D) Adult le with ild he d che only, ti e zero c rboxyhe-
oglobin level o 12%.
Answer 1.5.5 The correct answer is “A.” Gener lly cce ted
criteri or hy erb ric oxygen include: ent l st tus ch nges,
sy to tic c rboxyhe oglobin levels >25%, cidosis, c rdio-
v scul r dise se, nd ge >60. Obviously, these re rel tive criteri .
An otherwise nor l 61-ye r-old with ild ex osure need not
h ve HBO. Pregnancy is an indication or HBO therapy bec use
et l he oglobin h s high nity or c rbon onoxide, with
the etus cting s “sink” or CO. T e high erobic et bolic
ctivity o et l develo ent is i cted gre tly by ex osure to
the n erobic environ ent cre ted by c rbon onoxide.
Question 1.5.6 All o the ollowing are well established
consequences o hyperbaric oxygen EXCEPT?
A) Seizures.
B) Psychosis.
C) Myo i .
D) E r nd ul on ry b rotr u s.
E) Direct ul on ry oxygen toxicity.
Answer 1.5.6 The correct answer is “B.” All o the rest re
ound s result o hy erb ric oxygen. “C,” yo i , is ctu lly
ound in u to 20% o tients being tre ted with hy erb ric
oxygen. It is due to direct toxicity o oxygen on the lens nd usu-
lly recovers within weeks to onths.
Objectives: Did you learn to . . .
• Diagnose and manage patients with carbon monoxide
poisoning?
• Describe complications o carbon monoxide poisoning?
• Identi y patients who may bene t rom hyperbaric oxygen
therapy?
• Describe the complications o hyperbaric oxygen therapy?
CASE 1.6
A 50-year-old man comes to your ED a er being bitten by a
stray dog outside your hospital. Apparently, there is a prob-
lem with roving packs o eral dogs in your part o town. T e
bite was unprovoked and is on the abdomen. T e patient has
no other health history o note and has not taken antibiotics
or over a year. T ere is a 3-cm laceration on the abdomen.
Question 1.6.1 All o the ollowing are true about dog bites
EXCEPT:
A) T ey tend to be ri rily crush-ty e injuries.
B) In gener l, the in ection r te is si il r to l cer tion ro ny
other ech nis (e.g., kni e cut), exce t on the h nds nd eet.
C) A co on org nis in in ected dog bites is Staphylococcus
aureus.
D) Pri ry closure o dog bite wounds is n cce t ble o tion
(exce t erh s on the h nds nd eet).
E) T ey lw ys require ntibiotics.
Answer 1.6.1 The correct answer is “E.” All o the rest re
true st te ents. Dog bites (exce t, erh s, or those ro
te cu oodles n ed Fi ) tend to be crush injuries ( s con-
tr sted with c t bites, which re ri rily uncture wounds).
T e in ection r te is bout the s e s other l cer tions. Bites
on the h nds nd eet tend to h ve higher r te o in ection.
Most dog bite in ections re oly icrobi l with ixed erobic
nd n erobic b cteri . S. aureus is o en resent, long with
other org nis s including Pasteurella nd Capnocytophaga (s y
th t one ten ti es st). Other org nis s include Streptococcal
s ecies nd Gr -neg tive s ecies. Dog bites do not gener lly
require ntibiotic ro hyl xis, exce t under cert in circu -
st nces (e.g., resent >9 hours er bite, i unoco ro ised,
l rge, or co lic ted wound).
Question 1.6.2 You are concerned about rabies prophylaxis.
Which o the ollowing is the best next step?
A) Isol te the sus ect ni l or 3 d ys.
B) S cri ce the sus ect ni l nd ex ine the liver.
C) Ad inister r bies i une globulin IM.
D) Ad inister r bies i une globulin IV ollowed by r bies
v ccin tion series.
E) Ad inister r bies i une globulin by in ltr ting it round
the wound ollowed by r bies v ccin tion series.
Answer 1.6.2 The correct answer is “E.” You should in ltr te
r bies i une globulin round the wound nd then begin the
r bies v ccin tion series. In ltr te s uch o the i une glob-
ulin s ossible round the wound nd d inister the re inder
IM t di erent site. Do not give more than the recommended
dose o immunoglobulin. T is can reduce the immunogenic-
ity o the vaccine. “A” is incorrect bec use ni ls need to be
isol ted or 10 days, not 3. “B” is incorrect. I c tured, the ni-
l c n be s cri ced but the br in should be ex ined—not
the liver. “C” nd “D” re both incorrect ethods o d inis-
tering the v ccine nd i une globulin. Note th t the ver ge
incub tion eriod o r bies is 85 d ys. So, i unizing u to
3 onths (90 d ys) er the bite-event is indic ted.
Question 1.6.3 Which o the ollowing requires rabies pro
phylaxis in all cases?
A) Str y r bbit bites.
B) Str y r t bites.
C) Str y b t bites.
D) Str y squirrel bites.
E) Str y sn ke bites.
Answer 1.6.3 The correct answer is “C.” All b ts should be
considered r bid unless v il ble or observ tion nd testing.
See ble 1-4 or det iled reco end tions. Also, see the CDC
website or in or tion bout r tes o in ection in wild ni ls

TABLE 1-4 GUIDELINES FOR RABIES PROPHYLAXIS
General Rule Animals
Always assume rabid unless Foxes, bats, raccoons, skunks, dogs,
available or testing cats, errets, other carnivores
Judge on an individual basis Rodents (rats, mice, etc.),
lagomorphs (rabbits, etc.), squirrels
Never require rabies Nonmammals (snakes, lizards, etc.)
prophylaxis
in your re . O note, nd true, there re r bid squirrels in Iow
City, our illustrious ho e: Google it.
HELPFUL TIP:
Patients should receive a tetanus booster every
10 years. For a contaminated wound, the tetanus boost-
er should be within the last 5 years. Patients should re-
ceive at least one dose o Tdap (tetanus, diphtheria, and
acellular pertussis) between ages 11 and 18 and a single
dose between ages 18 and 64. In addition, health-care
workers and those > 65 years o age who will be around
in ants should receive a single dose o Tdap.
HELPFUL TIP:
I a patient at risk or tetanus has not had a primary se-
ries o tetanus immunizations, administer tetanus im-
mune globulin, and start the primary tetanus series.
You decide to irrigate this patient’s wound.
Question 1.6.4 Which o the ollowing statements is true
about irrigating a wound and subsequent risk o wound
in ections?
A) Povidone-iodine s 50% irrig tion solution (e.g., Bet dine)
in the wound will decre se the in ection r te.
B) Irrig tion with nor l s line is the only reco ended
ethod o cle ning wound.
C) Irrig tion with nor l s line nd irrig tion with t w ter
re equ lly e ective in reducing wound in ection r tes.
D) Use o e ine hrine with lidoc ine in wound incre ses the
r te o in ection.
E) Irrig tion o wound with either lcohol or hydrogen er-
oxide will reduce the r te o wound in ection.
Answer 1.6.4 The correct answer is “C.” In ection r tes (in the
United St tes) re the s e whether the wound is irrig ted with
nor l s line or t w ter. “A” is incorrect. Povidone-iodine is
toxic to tissue nd oly or honucle r leukocytes nd ctu lly
y increase in ection r tes unless solution o 1% or less is
used. Full strength ovidone-iodine can be used on int ct skin
s cle nser but should not be used in wound. “B” is incor-
rect bec use other solutions ( olox er 188, b l nced s lt
CHAPTER 1 • EMERGENCY MEDICINE 11
solutions, etc.) c n be used but re ore ex ensive nd do not
o er ny bene t in reduction in in ection r tes. “D” nd “E” re
both incorrect. As with ovidone-iodine, lcohol y be used
or cle ning skin but should be ke t out o the wound. It is toxic
to tissue nd cts x tive. Hydrogen eroxide is lso toxic to
tissue nd should not be used in o en wounds—no tter wh t
gr nd s ys!
Question 1.6.5 How long a ter a laceration occurs can the
wound be closed primarily?
A) 6 hours.
B) 12 hours.
C) 18 hours.
D) 24 hours.
E) Any o the bove c n be correct de ending on the wound.
Answer 1.6.5 The correct answer is “E.” T ere is no rbitr ry
ti e li it to when wound c n be closed. F ci l wounds y
be closed u to 24 hours er injury or cos etic re sons, while
you y not w nt to close other, cont in ted wounds ore
th n 12 hours er injury. So e wounds you y not w nt
to close t ll (e.g., bites to the h nd, wounds cont in ted
with gre se, wounds cont in ted with nure, hu n bite
wounds), r ther llowing the to close by second ry intention.
Objectives: Did you learn to . . .
• Describe the indications or rabies prophylaxis?
• Recognize the issues that arise with animal bites and indica-
tions or closure and/or prophylactic antibiotics?
• List recommendations or tetanus prophylaxis?
• Use various wound irrigation solutions or cleansing
wounds?
• Decide upon the time rame or wound closure?
CASE 1.7
A 52-year-old male presents to your ED via ambulance
complaining o a headache a er a all. He was working and
ell approximately 10 . He notes no injury except or head
and neck pain. A quick survey reveals that he has a BP o
128/86 mm Hg, pulse 100 bpm, and respirations o 12. T ere
was no loss o consciousness at the scene. He “saw stars” and
was clumsy, dazed, and slow at the scene without any ocal
neurologic de cit. He is now back to his baseline.
Question 1.7.1 A concussion is de ned as:
A) Any neurologic sy to s (e.g., clu sy, d zed, or slow) er
he d injury.
B) Loss o consciousness ollowed by return to b seline.
C) Loss o consciousness with continued neurologic sy to s.
D) Con usion er he d tr u reg rdless o whether the
tient lost consciousness or not.
E) Any tr u tic injury to the he d.
Answer 1.7.1 The correct answer is “A.” A concussion is
de ned s any neurologic sy to er he d tr u . Note
th t concussion does not require loss o consciousness. For
12 FAMILY MEDICINE EXAMINATION & BOARD REVIEW

this re son, “B” nd “C” re incorrect. “D” is incorrect bec use
ni est tions o concussion re not li ited to con usion but
lso include rotr cted vo iting, tr nsient nesi , slowed
ent tion, “dizziness,” nd other neurologic sy to s. “E” is
incorrect bec use by de nition, concussion requires neuro-
logic sy to s.
Your patient opens his eyes spontaneously, ollows com-
mands, answers all orientation questions correctly, but
appears unsteady when ambulating.
Question 1.7.2 His Glasgow Coma Scale (GCS) is:
A) 5.
B) 10.
C) 14.
D) 15.
E) 20.
D) T ere is u to 4% ch nce this tient will need neurosurgi-
c l intervention.
E) None o the bove.
Answer 1.7.3 The correct answer is “D.” In ro ri tely
selected tients (e.g., those with signi c nt ech nis o
injury), bout 18% with GCS o 15 will h ve so e intr cr -
ni l lesion, nd u to 4% will eventu lly require neurosurgic l
intervention. T ese re gener lly tients who h ve de ressed
skull r cture but nor l GCS. “A” is incorrect since nor l
GCS in nd o itsel does not llow one to orgo he d C in
tients with signi c nt ech nis o injury. “B” nd “C” re
lso incorrect or the re sons noted e rlier. Re e ber th t the
GCS is not line r; GCS o 14 is b d. P tients with GCS o 14
must h ve C sc n—unless nother ctor in the clinic l deci-
sion king dict tes otherwise (e.g., the nding is re-existing
ro de enti or otherwise).

Answer 1.7.2 The correct answer is “D.” T e GCS is sc le Question 1.7.4 In an adult patient with a signi cant head
used to indic te the severity o neurologic dys unction nd is injury, which o the ollowing is NOT an indication or a
o en lied to victi s o he d tr u . Re e ber, however, head CT scan?
th t it does not redict ort lity or orbidity but is only used A) Intoxic tion with drugs or lcohol.
s descri tive sc le o the tient’s current st te. Only the x- B) Persistent vo iting.
i u score o 15 is considered nor l GCS. T ere re three C) A nesi or e ory de cit.
co onents to the GCS, listed in ble 1-5. D) Age gre ter th n 40.
E) Seizure.
HELPFUL TIP:
Your chair and re rigerator each have a GCS o 3. Remember Answer 1.7.4 The correct answer is “D.” Older tients re t
that nothing can have a GCS less than 3. gre ter risk o develo ing serious intr cr ni l injuries, nd the
ge o 60 is usu lly considered n inde endent indic tion or
he d C with signi cant injury. While there is no “u er li it
Question 1.7.3 In patients with head injury, and indepen o nor l” or vo iting er he d tr u , the best d t v il-
dent o other actors, a GCS score o 15 indicates that: ble suggest th t ny vo iting er he d tr u in n adult
A) T e tient does not require he d C sc n. indic tes the need or he d C . T e currently reco ended
B) T ere is essenti lly no ossibility th t this tient h s n criteri or C o the he d in v rious ge grou s re listed in
intr cr ni l injury requiring surgic l intervention. ble 1-6.
C) T ere is little or no ossibility th t this tient h s ny oc l
intr cr ni l bleed. You obtain the head C and nd a subdural hematoma. You
arrange to trans er this patient or neurosurgical interven-
TABLE 1-5 GLASGOW COMA SCALE tion in order to drain the subdural hematoma. It is about a
Eye opening Spontaneous = 4
4-hour drive by ambulance to the nearest acility that has a
Mnemonic: “4 eyes” To speech = 3
neurosurgeon.
To pain = 2
No response = 1
Question 1.7.5 Which o the ollowing is indicated as pro
phylaxis against increased intracranial pressure in this
Verbal response Alert and oriented = 5 patient?
Mnemonic: “Jackson 5” Disoriented conversation = 4 A) Hy erventil tion er intub tion.
Nonsensical speech = 3 B) IV nnitol.
Moaning = 2 C) rendelenburg osition.
No response = 1 D) IV dex eth sone.
Motor response Follows commands = 6
E) None o the bove.
Mnemonic: “Six Cylinders” Localizes pain = 5
Answer 1.7.5 The correct answer is “E.” None o the bove is
Withdraws rom pain = 4
indic ted s ro hyl xis or incre sed intr cr ni l ressure. “A”
Decorticate exion = 3
is incorrect or two re sons. First, this tient does not need to
Decerebrate extension = 2
be intub ted. Second, routine hy erventil tion s ro hyl xis
No response = 1
or incre sed intr cr ni l ressure is o no bene t. T is h s

TABLE 1-6 INDICATIONS FOR HEAD CT BY AGE
Indications or Head CT A ter Trauma
Patient Age with a Signi cant Mechanism
Adult • Intoxication
• Age >60
• Any memory de cit
• Vomiting (number o times unde ned)
• Seizure
• Headache
PECARN Rules for Pediatric Head Trauma and Need for CT Scan
(The La ncet. 2009;374(9696):1160–1170.)
CT needed if:
Children >2 years • GCS <15
• Signs o a basilar skull racture
• Agitation, somnolence, slow responses, or
perseveration
• Vomiting
• Loss o consciousness
• Severe headache
• Severe mechanism (Fall >5 ft, MVC with
ejection, roll over, atality)
• Bike/pedestrian vs. car without helmet
• High Impact Object
• I there are changes during observation
(MS change, worsening headache, new or
persistent vomiting) consider CT based on
clinical judgment.
Children <2 years • GCS <15
• Palpable skull racture
• Agitation, somnolence, slow responses,
perseveration
• Scalp hematoma (except or rontal)
• LOC >5 seconds
• Severe mechanism ( all >3 ft, MVC with
ejection, roll over, atality)
• Bike/pedestrian vs. car without helmet
• High impact object
• I there are changes during observation
(MS change, worsening headache, new or
persistent vomiting) consider CT based on
clinical judgment. I child <3 months o age
consider parenteral pre erence and consider
scanning
been well studied. Wh t h ens is th t hy erventil tion does
c use v soconstriction reducing intr cr ni l blood ow nd
there ore intr cr ni l ressure. However, hy erventil tion lso
c uses ische i round the re o the injury nd y worsen
outco es. “B” is incorrect bec use ro hyl ctic nnitol, like
ro hyl ctic hy erventil tion, con ers no bene t. “C” is incor-
rect. rendelenburg ositioning, or elev ting the legs bove the
he rt, would result in incre sed intr cr ni l ressure. T ere is
very li ited d t to su ort or re ute ro hyl ctic elev tion o
the he d o the bed to prevent incre sed intr cr ni l ressure;
while this will reduce intr cr ni l ressure, cerebr l er usion
ressure will lso be ildly reduced. For treatment o incre sed
intr cr ni l ressure, there is slightly ore evidence or bene t
o elev ting the he d o the bed “D” is incorrect since steroids
re not use ul cutely in he d tr u . However, steroids re
use ul in cerebr l ede second ry to tu or.
CHAPTER 1 • EMERGENCY MEDICINE 13
HELPFUL TIP:
About two-thirds o patients with a mild head injury (not
deemed severe enough to obtain a CT scan) will have
some measurable decrement in unction at 1 month
secondary to post-concussion syndrome (J Emerg Med.
2011;40:262).
Objectives: Did you learn to . . .
• Use the GCS?
• Recognize which patients with head trauma are appropriate
to obtain a head CT?
• Manage patients presenting with potential intracranial injuries?
CASE 1.8
A 23-year-old male is in a bar ght. He only had “two beers”
and was just standing there “minding my own business” when
he was jumped by those in amous “two dudes” (how can
those two dudes be in so many places at once!). He presents
to you about 1 hour a er the event with acial trauma. His
vitals are normal and he is mentating well (with the exception
o some impaired judgment secondary to the alcohol). His
blood alcohol level is 150 mg/dL, showing that he is legally
intoxicated. On examination, you notice that the patient has
some epistaxis and a quite swollen nose. In addition, there is
one avulsed tooth and one tooth that is displaced.
Question 1.8.1 The best way to transport an avulsed tooth
is:
A) In sterile w ter.
B) In the bucc l ucos er thorough w shing with so .
C) In gl ss o ilk.
D) Wr ed in s line-so ked g uze.
E) Under illow.
Answer 1.8.1 The correct answer is “C.” T e best w y to tr ns-
ort n vulsed tooth is (1) in gl ss o ilk, (2) in H nks’ b l-
nced s lt solution (good luck nding this when you need it!),
or (3) in the bucc l ucos or under the tongue in tient in
who the risk o s ir tion is not concern. “A” is incorrect
bec use sterile w ter is hy otonic nd yd ge the tooth
root decre sing the success r te o re-i l nt tion. “B” is incor-
rect bec use washing the tooth with soap is not ro ri te.
Ag in, you w nt to int in the vi bility o the root i ossible.
“D” is incorrect s well. I this is the only o tion v il ble to you,
it is better th n nothing, but gl ss o ilk or under the bucc l
ucos is re erred. “E” is cce t ble only i you re tooth iry.
You call the dentist who is (o course) out o town. A dentist
will not be available or at least 12 hours.
Question 1.8.2 Your best course o action at this point is:
A) Continue to kee the tooth vi ble in gl ss o ilk.
B) Continue to kee the tooth vi ble in the bucc l ucos .
14 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
C) Cle n the tooth nd kee it sterile nd dry or re-i l nt tion
in 12 hours re lizing th t bridge will rob bly be needed to
hold the tooth in osition.
D) Reinsert the tooth into the socket yoursel .
Answer 1.8.2 The correct answer is “D.” I there is going to
be ny del y in rei l nt tion by dentist, the best course o
ction is to reinsert the tooth into the socket yoursel . “A,” “B,”
nd “C” re ll incorrect bec use they will reduce the r te o suc-
cess ul rei l nt tion.
HELPFUL TIP:
Primary (“baby”) teeth should not be reinserted into
the socket! They ankylose to the bone preventing the
eruption o the permanent tooth and cause a cosmetic
de ormity.
HELPFUL TIP:
Any patient who is in the ED, says he only had three
beers, and was “minding his own business” is probably
not telling the truth on either account.
You now turn your attention to this patient’s bloody nose and
are trying to decide whether or not get an x-ray.
Question 1.8.3 The BEST timing or a radiograph o the
nose is:
A) As soon s ossible er the tr u once other injuries re
st bilized nd ore i ort nt roble s re ddressed.
B) As soon s ossible to ssure th t there re no bone r g-
ents thre tening the br in.
C) T ere is no need or r diogr h cutely. You c n w it or 3
or 4 d ys.
D) T ere is never ny indic tion or n s l r diogr hs.
Answer 1.8.3 The correct answer is “C.” T ere is no need or
r diogr hs cutely exce t in extr ordin ry circu st nces. T e
re sons or r diogr h re to docu ent r cture and to ssist in
reduction. Bec use o swelling, it is di cult to get good cos etic
result reducing n s l r cture cutely. T us, r diogr h is indi-
c ted in 3 to 4 d ys only i there is evidence o n s l de or ity once
swelling h s resolved. I there is good cos esis nd the tient c n
bre the through his (they re l ost lw ys le) nose, r dio-
gr h is unnecess ry just to docu ent r cture. “A” nd “B” re
incorrect bec use, s noted e rlier, there is no re son to do r dio-
gr h t ll unless there is evidence o de or ity once the swelling
is resolved. “D” is incorrect or the re sons noted e rlier.
Question 1.8.4 You get the epistaxis stopped and exam
ine the nasal mucosa. Which one o these is considered an
emergency?
A) Closed n s l r cture.
B) Se t l he to .
C) r u to Kiesselb ch lexus.
D) A devi ted se tu .
Answer 1.8.4 The correct answer is “B.” A se t l he to
is considered n e ergency. T e roble is th t the erichon-
driu , which su lies nutrition to the se tu , is no longer in
cont ct with the se tu bec use o the intervening he to .
T us, the se t l c rtil ge c n necrose le ding to er or ted
se tu . Se t l he to s should be dr ined cutely nd the
nose cked to kee the erichondriu in cont ct with the
se t l c rtil ge. “A” is incorrect (see revious question). “C”
is incorrect. Kiesselb ch lexus is in the nterior nose nd is
venous lexus. Bleeding is e sily controlled nd gener lly is
sel -li ited. “D,” devi ted se tu , y indic te n underlying
r cture but in nd o itsel is not n e ergency.
You continue to evaluate this patient and note that he has the
loss o upward gaze in the right eye, the side on which he was
hit. All o the other extraocular motions are intact.
Question 1.8.5 The most likely diagnosis in this patient is:
A) Blowout r cture with entr ent o the in erior rectus.
B) Blowout r cture with dys unction o the su erior rectus.
C) Injury to cr ni l nerve III, which controls the su erior AND
in erior rectus uscles.
D) Volition l re us l to er or u w rd g ze on the right side
in this intoxic ted tient.
Answer 1.8.5 The correct answer is “A.” T e ost likely di g-
nosis is blowout r cture with entr ent o the in erior rectus.
T e orce o blow to the globe is tr ns itted to the in erior
orbit l w ll, which is the we kest oint in the orbit. T is c n
c use entr ent o the contents o the in erior orbit, includ-
ing the in erior rectus, c using n in bility to er or u w rd
g ze. Due to disconjug te g ze, tients with entr ent o the
in erior rectus uscle ro blowout r cture y co l in o
di lo i . “B” is incorrect bec use blowout r cture gener lly
re ers to the in erior orbit l w ll, which would not entr the
su erior rectus. In ddition, tients with n entr ed su e-
rior rectus would h ve di culty with downw rd g ze. “C” is
incorrect bec use it is unlikely th t being hit in the ce would
c use n injury to CN III. In ddition, CN III lesion would
ect ll extr ocul r uscles exce t or the l ter l rectus (CN
VI) nd the su erior oblique (CN IV). “D” is incorrect bec use
it is i ossible to ove the eyes inde endently o one nother
unless you re ch eleon or rticul rly t lented.
HELPFUL TIP:
Note that a blowout racture may be a good thing. Hav-
ing the racture allows pressures to equilibrate and pre-
vents orbital compartment syndrome (proptosis, visual
loss, etc.). Proptosis with visual loss is a surgical emer-
gency mandating an immediate lateral canthotomy
(easy to do . . . . check YouTube).
T e patient has had a long night o partying, and it is 3:00
AM Saturday morning when you call your consultant about
the blowout racture. T e consultant is not happy and re uses

to see the patient acutely. He wants you to send him to the
o ce in 3 days ( uesday morning).
Question 1.8.6 Your response is:
A) o c ll nother consult nt; blowout r cture should be
ttended to i edi tely.
B) Do nothing; ev lu tion in 2 to 3 d ys or blowout r cture,
even with in erior rectus entr ent, is ro ri te.
C) St rt steroids to reduce uscle ede to cilit te the s on-
t neous rele se o the entr ed uscle.
D) St rt ntibiotics nd hos it lize the tient so th t he c n be
seen in the orning when the consult nt kes rounds.
E) Stick ins in voodoo doll o your consult nt.
Answer 1.8.6 The correct answer is “B.” While blowout r c-
tures with uscle entr ent require close ollow-u , there is
no need to intervene cutely. In ct, decision to o er te y
be del yed or u to 14 d ys. I the entr ent s ont neously
resolves when the swelling goes down (not unco on) nd
there is no di lo i or other co lic ting sy to s, surgery
is not needed. T e other nswers re ll incorrect bec use cute
intervention is not required in this tient. “E,” however, y be
o so e bene t . . . de ending on your voodoo skills.
HELPFUL TIP:
Caveat to the above: In the pediatric population, im-
mediate surgical repair should be undertaken in trap-
door fractures. A trapdoor racture is one in which there
is signi icant entrapment o the in erior rectus muscle. I
the muscle is le t entrapped in the pediatric population,
restriction and ibrosis may occur, so immediate evalua-
tion by a surgeon is warranted. Oral steroids at a dose o
1 mg/kg may decrease edema in the irst 7 days limiting
ultimate ibrosis. In patients with signi icant sinus dis-
ease, antibiotics may be considered, usually a penicillin
or cephalosporin.
T e patient mentioned above has a “ riend” who was also in
the altercation. He, too, was just “minding his business”—
like everyone in the bar—until there was a gentleman’s dis-
agreement that could only be resolved with a broken bottle.
He has a simple laceration o the chin, which you repair. T is
patient has a blood alcohol level o 150 mg/dL (the legal limit
in most states is 80 mg/dL). Since he is intoxicated, the nurses
are reluctant to allow the patient to leave because o liability
issues. He seems initially very cooperative and competent.
However, the nurse manager reminds you o the legal issues.
T e patient is getting more agitated; he wants to go home.
Question 1.8.7 Your response is:
A) Sed te the tient with h lo eridol nd observe hi until
sober.
B) Sed te the tient with benzodi ze ine nd observe hi
until sober.
CHAPTER 1 • EMERGENCY MEDICINE 15
C) C ll the olice to re ove this tient ro your ED.
D) Use restr ints on the tient nd observe hi until sober, s
sed tive drugs y rolong ti e in the ED.
E) Let the tient le ve the ED with co etent dult.
Answer 1.8.7 The correct answer is “E.” T e tient w s ini-
ti lly coo er tive nd co etent. Co etence is not b sed on
blood lcohol level but r ther on your judg ent o the tient’s
bility to ke r tion l decisions. We llow tients on n r-
cotics to ke decisions bout their own c re ll o the ti e
des ite h ving n rcotics on bo rd. T ere re tients who will
h ve c city nd re s e t blood lcohol o 200 g/dL nd
others who y be i ired t 80 g/dL. So, judge c city
individu lly.
Objectives: Did you learn to . . .
• Treat acute dental trauma?
• Diagnose and manage nasal and periorbital trauma?
• Care or the intoxicated patient with minor trauma?
CASE 1.9
A 17-year-old emale ell asleep with her contact lenses in her
eyes last evening. T is morning she notes quite a bit o eye
pain and photophobia. You evert the eyelids (something that
should be done in all cases o possible oreign body) and nd
no evidence o a oreign body. When you stain her eye, you
nd a corneal ulcer.
Question 1.9.1 The treatment or this patient is:
A) Debride ent with burr nd syste ic ntibiotics.
B) Debride ent with cotton sw b nd syste ic ntibiotics.
C) o ic l ntibiotics, cyclo legi , nd re err l to o hth l ol-
ogy.
D) Co ious irrig tion, syste ic ntibiotics, nd cyclo legi .
Answer 1.9.1 The correct answer is “C.” T is is n o hth l o-
logic e ergency th t requires to ic l ntibiotics, cyclo legi
( or in control), nd re err l to n o hth l ologist. T ese
ulcers c n beco e quite dee nd result in ru tured globe.
You consult with your ophthalmologist who would like you
start a cycloplegic agent in this patient prior to trans er.
Question 1.9.2 The drug you would choose or a cycloplegic
agent is:
A) Piloc r ine eye dro s.
B) i olol eye dro s (e.g., i o tic).
C) etr c ine eye dro s.
D) Cyclo entol te eye dro s.
Answer 1.9.2 The correct answer is “D.”Cyclo entol te is the only
cyclo legic gent listed bove. Cyclo legic gents r lyze the cili-
ry uscle so the eye c nnot cco od te. Piloc r ine is iotic
gent. i olol is bet -blocker used in the tre t ent o gl uco .
etr c ine eye dro s re to ic l nesthetic. T us, “D” is the only
16 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
correct nswer. Other cyclo legic gents include ho o tro ine
nd tro ine. However, these h ve rolonged e ect.
Question 1.9.3 I your patient just had a simple corneal
abrasion, you would not have had to think so hard! Regard
ing corneal abrasions, you realize that:
A) P tching n eye er corne l br sion reduces in nd
ro otes he ling.
B) I to ic l ntibiotic is needed er l rge corne l br sion,
gent icin o hth l ic oint ent is the drug o choice.
C) etr c ine is good to ic l nesthetic nd should be consid-
ered or ho e use in tients with in ul corne l br sion.
D) P tients should void we ring cont ct lenses until the eye
h s been he led or t le st week.
Answer 1.9.3 The correct answer is “D.” “A” is incorrect
bec use tching n eye y ctu lly incre se in nd decre se
he ling. Whether or not to use tch should be tter o
tient co ort only. “B” is incorrect bec use gent icin o h-
th l ic oint ent ( s well s other to ic l inoglycosides)
ctu lly reduces he ling o the corne , nd ntibiotics re not
necess ry unless there re signs o in ection. “C” is incorrect
bec use tients should never be sent ho e with to ic l nes-
thetic. T ey reduce he ling nd c n le d to urther injury i
the tient, whose eyes re now insens te, continues h r ul
ctivity, rubs his/her eyes, etc.
HELPFUL TIP:
To di erentiate a topical ophthalmologic problem rom
iritis, put in some tetracaine. I the pain resolves, it is
likely, but does not prove, that the problem is su-
per icial (e.g., corneal abrasion). Posttraumatic iritis is
mani ested by ciliary lare, anterior chamber cells, and
marked photophobia. These patients really need a slit
lamp examination.
Objectives: Did you learn to . . .
• Recognize a corneal ulceration and treat it appropriately?
•
Treat corneal abrasions?
• Understand the proper use o cycloplegic agents?
QUICK QUIZ: EYE TRAUMA
You re on c ll or your grou nd welder who w s welding
nd grinding resents t 2:00 a m with severe bil ter l eye in.
When he le work t 5:00 pm the d y be ore, he did not notice
ny roble . He notes th t he w s we ring his d rk goggles
so e o the ti e while he w s welding but did quite bit o
work without goggles s well.
T e ost likely di gnosis in this tient is:
A) Foreign body.
B) Ultr violet (UV) ker titis.
C) Globe enetr tion second ry to the welding nd oreign body.
D) Iritis.
The correct answer is “B.” T is tient likely h s UV ker titis.
T e others re not likely bec use they gener lly resent unil t-
er lly. In ddition, in the c ses o “A” nd “C,” they should res-
ent directly er the event r ther th n 9 hours l ter, s in our
tient.
UV ker titis is ound in tients who re welders or h ve
been out in the sun or n extended eriod o ti e ( t the be ch,
snow skiing [“snow blindness”], t nning bed, etc.). UV ker ti-
tis gener lly resents s severe, bil ter l, eye in bout 6 to
10 hours ollowing the ctivity. It is tre ted with cyclo legic
gents nd in edic tion, o en requiring n rcotics.
HELPFUL TIP:
Patients who have a oreign body in the eye ollowing
a high-speed injury (e.g., grinding wheel) should be as-
sumed to have a globe per oration until proven other-
wise.
QUICK QUIZ: ORTHOPEDIC EMERGENCIES
Which o the ollowing is ost co only ssoci ted with sig-
ni c nt v scul r injury?
A) Pubic r us r cture.
B) Knee disloc tion.
C) Shoulder disloc tion.
D) Elbow disloc tion.
E) Ankle disloc tion.
The correct answer is “B.” In u to 33% o knee disloc tions
(not patellar dislocations), o lite l rtery injury c n be iden-
ti ed. It is deb ted s to whether ll tients with knee dislo-
c tions require ngiogr hy or C ngiogr hy or i hysic l
ex in tion nd nkle-br chi l indices re su cient to rule out
o lite l rtery injury, but v scul r injury is jor c use o
li b loss nd orbidity. “A” is incorrect bec use ubic r us
r ctures re rel tively inor injuries without v scul r involve-
ent, requiring only in control. Shoulder disloc tions (“C”)
re co only ssoci ted with injury to the xill ry nerve.
Elbow disloc tions (“D”) c n be ssoci ted with injury to the
edi n nerve nd br chi l rtery. However, rteri l injuries re
uch less co on th n with knee disloc tions. Ankle disloc -
tions (“E”) re r rely ssoci ted with v scul r injury.
CASE 1.10
A 55-year-old male armer is injured by a grass- ed cow
that pins him against a ence. His leg was trapped against
the ence or a several minutes. Being a typical Midwestern
armer, he ignores the injury until his wi e convinces him
later that a ernoon to have it evaluated. He presents to your
o ce complaining o severe pain in the cal area. A radio-
graph is normal, and the patient has normal distal pulses.
T e cal (his leg, not the cow) is tender with increased pain
on passive stretch. His pain seems to be out o proportion to
 CHAPTER 1 • EMERGENCY MEDICINE 17

his injury. T e cal (the cow) may also be tender and USDA co gul tion studies y be ro ri te de ending on the clini-
grade prime. c l situ tion but re not use ul in est blishing the resence o
yoglobinuri .
Question 1.10.1 Which o the ollowing is true?
A) Since the tient h s excellent ulses, co rt ent syn- HELPFUL TIP:
dro e is not likely. Myoglobin can be measured in the urine. However,
B) Co rt ent syndro e is de ned s co rt ent res- many laboratories have stopped doing this test avor-
sure >30 Hg. ing the positive dipstick/negative microscopic exami-
C) Co rt ent syndro e is only ssoci ted with signi c nt nation approach. There can be other causes of a heme
crush injuries or r ctures. positive dipstick. Thus, always check a CPK as well i
D) P in out o ro ortion to the injury is red g or co rt- rhabdomyolysis is a consideration.
ent syndro e.

Answer 1.10.1 The correct answer is “D.” P in out o ro or-
tion to the injury is red g or co rt ent syndro e. “A”
is incorrect bec use ulses c n be int ined until there is
signi c nt incre se in co rt ent ressures nd signi c nt
injury to uscle nd nerves. “B” is incorrect bec use it is di -
cult to de ne s eci c cut o or co rt ent syndro e.
So e tients toler te higher ressures nd others c nnot
toler te 30 Hg (nor l co rt ent ressure is zero).
However, when the ressure gets bove 20 to 30 Hg, strong
consider tion should be given to the resence o co rt ent
syndro e. “C” is incorrect. Co rt ent syndro e c n be
due to nu ber o ctors including electric l injury, exces-
sive uscle use, tet ny, re er usion er ische i , ggressive
volu e resuscit tion, etc.
HELPFUL TIP:
The classic indings o arterial insu iciency (the “5 Ps” be-
ing pulselessness, paresthesia, pallor, pain, and paralysis)
are o ten considered necessary or compartment syn-
drome to be diagnosed. This is incorrect. O these, pain is
o ten the only symptom; the second most requent would
be paresthesia. I your patient has compartment syndrome
with the 5 Ps present, there is likely extensive injury.
T e patient has a positive dipstick or blood with no red blood
cells on microscopic examination (presumptive myoglobin-
uria). His serum CPK is 32,000 U/L, which is well above ve
times the upper limit o normal (the cuto or consideration
o rhabdomyolysis, although levels o > 15,000 U/L are com-
mon when one has symptomatic rhabdomyolysis), so you
make the diagnosis o rhabdomyolysis.
Question 1.10.3 The most common adverse consequence
and greatest danger o rhabdomyolysis is:
A) Disse in ted intr v scul r co gul tion.
B) Acute kidney injury.
C) Seizure ro hy oc lce i .
D) Acute gout ro hy erurice i .
E) C rdi c rrhyth i ro hy erk le i .
Answer 1.10.3 The correct answer is “B.” Myoglobin reci i-
t tes in the ren l tubules c using cute kidney injury. “A,” DIC,
c n occur but is r re. “C,” seizures ro hy oc lce i , h ve not
been re orted in this condition, nor h s “D,” gout. T e ot s-
siu elev tion ro rh bdo yolysis y re ch level su cient
to c use rrhyth i s; this is ex cerb ted by ossible coexistent
hy oc lce i .

Question 1.10.4 The primary treatment or rhabdomyolysis

is:
You decide that it is likely that this patient has a compart- A) M nnitol in usion.
ment syndrome. B) S line in usion.
C) Furose ide.
Question 1.10.2 Which o the ollowing labs will be the D) Di lysis.
most help ul in guiding treatment or this patient?
A) CBC. Answer 1.10.4 The correct answer is “B.” T e ost i or-
B) Urin lysis. t nt tre t ent or rh bdo yolysis is s line in usion. L ct ted
C) Glucose. Ringers should be voided s it cont ins ot ssiu , which y
D) Sodiu . urther contribute to hy erk le i s entioned bove. T ere
E) P /P . h s reviously been deb te i lk liniz tion o the urine (using
IV sodiu bic rbon te) h s ny dditive bene t or revent-
Answer 1.10.2 The correct answer is “B.” One o the jor ing cute kidney injury over s line lone, but there is no evi-
co lic tions o co rt ent syndro e is rh bdo yolysis. dence th t su orts this r ctice. “A,” nnitol, c n be used to
T is will ni est itsel s urine which is di stick ositive incre se urine ow, but this is re lly tre t ent th t is second-
or blood but with neg tive icrosco ic ex in tion or red ry to good hydr tion nd y c use hy ovole i co ound-
blood cells. T e ositive di stick is icking u yoglobin in ing the roble “C,” urose ide, is controversi l nd h s no
the urine. Rh bdo yolysis c n be con r ed by seru level outco e bene t but c n be used or uid overlo d. “D,” di lysis,
o cre tine hos hokin se (CPK). CBC, glucose, sodiu , nd is wh t we re trying to void using s line.
18 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
HELPFUL TIP:
In adult patients with rhabdomyolysis, the goal is to
maintain urine output o 200 to 300 cc/hr.
T e patient is able to maintain urine output a er you insti-
tute saline.
Question 1.10.5 What treatment are you going to suggest
or the underlying compartment syndrome?
A) F scioto y.
B) I obiliz tion nd tr ction.
C) Hot cks nd elev tion o the ected li b.
D) Ice nd elev tion o the ected li b.
Answer 1.10.5 The correct answer is “A.” T e tre t ent o
co rt ent syndro e is scioto y. A r id surgic l or
ortho edic consult tion is critic l in the tre t ent o co rt-
ent syndro e.
T e patient does well and everyone is happy . . . except or the
cow, who nds his way onto the table as the centerpiece o
Christmas dinner.
Objectives: Did you learn to . . .
• Recognize mani estations o compartment syndrome and
understand that compartment syndrome can be present
with pain alone?
• Identi y patients at risk or compartment syndrome and
rhabdomyolysis?
• Manage compartment syndrome?
• Diagnose and treat rhabdomyolysis?
CASE 1.11
A 24-year-old A rican-American male presents to the ED
complaining o ever, chills, and dyspnea. He has chest pain
that is respirophasic (“pleuritic”) in nature. He is noted to be
tachypneic with a respiratory rate o 36 and an oxygen satu-
ration o 90%. He has a history o sickle cell disease and has
had a number o sickle cell crises in the past. He is up to date
on immunizations, including Streptococcus pneumoniae and
Haemophilus inf uenzae vaccines.
Question 1.11.1 The patient’s current symptoms are MOST
concerning or and suggestive o :
A) Pneu othor x.
B) Pul on ry e bolis .
C) Acute chest syndro e.
D) Sickle cell-rel ted eric rditis.
E) T or cic ortic neurys dissection.
Answer 1.11.1 The correct answer is “C.” T is tient likely h s
cute chest syndro e, which is ssoci ted with sickle cell ne-
i and may be indistinguishable rom pneumonia. Acute chest
syndro e is ch r cterized by leuritic chest in, ever, cough,
chills, dys ne , r les, nd rhonchi. T e etiology is unknown, but
it y be second ry to in rction o the lung nd/or t e boli.
All o the other di gnoses should lso be entert ined t this
oint, but cute chest syndro e is ost likely. Sickle cell-rel ted
eric rditis (“D”) is r re co lic tion o the dise se.
Question 1.11.2 All o the ollowing are recommended in
the initial treatment o acute chest syndrome EXCEPT:
A) Hydroxyure .
B) Oxygen.
C) IV nor l s line.
D) Mor hine.
Answer 1.11.2 The correct answer is “A.” Hydroxyure , while
use ul or the chronic tre t ent o sickle cell ne i , is not
indic ted or the tre t ent o cute chest syndro e. However,
it c n reduce the incidence o cute chest syndro e by 50%
when used chronic lly. M n ge ent o cute chest syndro e
includes llevi ting hy oxi (“B”), IV uid resuscit tion (“C”),
nd ro ri te n lgesi (“D”). Other tre t ents include
IV ntibiotics to cover or co unity- cquired neu oni
( lthough cute chest syndro e is not bacterial). It is rudent
to cover these tients with ntibiotics bec use dult tients
with sickle cell re de cto s lenecto ized nd the initi l re-
sent tion o cute chest syndro e c n be e sily con used with
neu oni .
T e patient continues to be hypoxic despite your therapy. His
CBC shows a slight elevation in the WBC count and a hemo-
globin o 9 g/dL. A chest radiograph indicates progression o
in ltrates.
Question 1.11.3 The next step in treating this patient is:
A) Fresh rozen l s .
B) Pentoxi ylline.
C) P cked red blood cells.
D) Exch nge tr ns usion.
E) Any o the bove.
Answer 1.11.3 The correct answer is “D.” P tients with cute
chest syndro e who re in hy oxic with rogressing in l-
tr tes re c ndid tes or exch nge tr ns usion to bring the level
o HbS to <30% o the tot l. Si ly d inistering blood (“C”)
will not resolve the roble bec use HbS will still be resent in
signi c nt ounts. I this tient h d ore signi c nt ne-
i , cked red cell tr ns usion would be ore vi ble o tion.
But tr ns usion t level o 9 g/dL o he oglobin is not indi-
c ted (gener lly the threshold is 7 g/dL in the he odyn i-
c lly st ble tient). “A” nd “B” re lso incorrect. Fresh rozen
l s h s no role in the tre t ent o cute chest syndro e,
nor does entoxi ylline.
Your patient recovers rom this episode. He has had numer-
ous pain crises in the past, as well as hospitalizations or other
reasons. You have an opportunity to provide some patient
education. You answer a ew o your patient’s questions and
then review potential mani estations o sickle cell disease.
 CHAPTER 1 • EMERGENCY MEDICINE 19

Question 1.11.4 Which o the ollowing may be a mani es

tation o sickle cell disease? CASE 1.12
A) Joint nd bone in. A 52-year-old truck driver presents to your ED a er being out
B) Acute bdo in l in. in subzero temperatures or several hours trying to repair his
C) Acute sequestr tion syndro e. truck. He is hypothermic when you use a low-reading rectal
D) A l stic crisis. thermometer with appropriate calibration (“T anks or
E) All o the bove. getting the most accurate temperature, doc!”). His initial core
temperature is noted to be 28◦ C. He has a pulse o 24 bpm, a
Answer 1.11.4 The correct answer is “E.” All o the bove c n BP o 70/30 mm Hg, and slow mentation. However, he is awake,
be ssoci ted with sickle cell ne i (kee re ding or ddi- and thus able to joke about a thermometer in his rectum.
tion l in or tion).
Question 1.12.1 The appropriate rst line treatment or
Question 1.11.5 Which o the ollowing in ections is a this patient’s pro ound bradycardia is:
common cause o aplastic crisis in sickle cell anemia? A) Atro ine.
A) P rvovirus B-19. B) E ine hrine.
B) In uenz virus. C) Do ine.
C) CMV virus. D) Lidoc ine.
D) P r in uenz virus. E) Re-w r ing.
E) None o the bove.
Answer 1.12.1 The correct answer is “E.” T e hy other ic
Answer 1.11.5 The correct answer is “A.” P tients with sickle he rt is gener lly resist nt to drugs. T us, the best tre t ent or
cell ne i c n develo l stic ne i in res onse to rvo- this tient is re-w r ing. Br dyc rdi ro other c uses c n
virus B-19 in ection. E stein–B rr virus nd so e b cteri h ve be tre ted with tro ine 0.5 g IV ush or in usion o e ine h-
lso been re orted to c use l stic crisis in tients with sickle rine or do ine.
cell ne i .
Question 1.12.2 All o the ollowing are acceptable meth
Question 1.11.6 Acute sequestration syndrome is a mani ods o re warming THIS patient EXCEPT:
estation o sickle cell anemia. In which group does acute A) Active extern l re-w r ing (e.g., hot cks).
sequestration syndrome occur? B) I ersion in 40°C w ter.
A) Younger th n 5 ye rs. C) P ssive extern l re-w r ing (e.g., bl nkets).
B) 5 to 12 ye rs old. D) He ted, hu idi ed oxygen.
C) 12 to 25 ye rs old. E) T or cic l v ge with w r uids.
D) Older th n 25 ye rs.
E) Older th n 65 ye rs. Answer 1.12.2 The correct answer is “C.” P tients with te -
er ture o below 30°C gener lly do not h ve enough endog-
Answer 1.11.6 The correct answer is “A.” Acute sequestr tion enous he t roduction to e ectively re-w r the selves.
syndro e occurs when the s leen sequesters red blood cells, le d- T us, extern l or intern l active re-w r ing is indic ted. All
ing to dro in he oglobin. T e resent tion c n be quite dr - o the other o tions re cce t ble ethods o re-w r ing this
tic with severe le u er qu dr nt in, s leno eg ly, nd tient. Extr cor ore l blood w r ing vi ECMO or di lysis
ro ound ne i , so eti es resulting in hy ovole ic shock nd long with thor cic c vity l v ge vi chest tubes nd w r crys-
de th. Bec use it requires unction l s leen, it is ost co on in t lloid re lso e ective. G stric, rect l, nd bl dder l v ge with
children younger th n 5 ye rs. P tient with sickle cell ne i who wr uids re gener lly not very e ective bec use o the li -
re older th n 5 ye rs gener lly do not h ve unctioning s leen; ited sur ce re involved nd c n c use l rge electrolyte shi s.
ost o en it h s in rcted so th t cute sequestr tion syndro e
no longer occurs. T e ort lity is 15% er e isode nd 50% recur. Question 1.12.3 Rapid re warming o the extremities is
associated with:
HELPFUL TIP: A) Alk losis, hy ok le i .
Exchange trans usions to reduce the percent o HbS to B) Acidosis, hy ok le i .
<30% is also indicated in stroke. Also keep the hemoglo- C) Acidosis, hy erk le i .
bin >9.0 g/dL in those with a sickle cell–related stroke. D) Alk losis, hy erk le i .
E) Mixed cid–b se disorder.
Objectives: Did you learn to . . . Answer 1.12.3 The correct answer is “C.” Re-w r ing o the
• Recognize acute chest syndrome? extre ities c n le d to return o cold blood to the core le ding
• Manage a patient with acute chest syndrome? to r doxic l dro in body te er ture. In ddition, hy o-
• Use exchange trans usion in a patient with sickle cell anemia? ther i c uses l ctic cidosis with hy erk le i in the extre -
• Recognize various other mani estations o sickle cell anemia? ities. As the eri her l blood is re-w r ed nd eri her l
20 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
v sodil tion occurs, the hy erk le ic, cidotic blood is obi-
lized to the tient’s centr l circul tion, with result nt syste ic
et bolic cidosis nd hy erk le i .
Question 1.12.4 Which o the ollowing is NOT associated
with an increased risk o hypothermia?
A) Di betes ellitus.
B) Obesity.
C) Alcohol use.
D) Old ge.
E) Chronic illness.
Answer 1.12.4 The correct answer is “B.”In Iow , we st rt to work
on our winter t l yer in October or just this re son. Why do you
think we e t ll th t c ndy corn? Obese tients h ve s ller
body ss to sur ce re r tio nd do not h ve n incre sed risk
o hy other i . “C,” lcohol use, c uses tients to be rel tively
insens te to cold (thus the ter “liquid j cket”), c uses eri h-
er l v sodil t tion, incre sing he t loss, nd c uses oor choices
(like not we ring re l j cket. Just t ke look t those young col-
lege ootb ll ns in Nove ber without shirts!). T er oregul -
tion is i ired s we ge. T us, “D,” old ge, is ssoci ted with
gre ter ro ensity tow rd hy other i . Di betes (“A”) nd ny
chronic illness (“E”) c n lso redis ose to hy other i .
T e patient’s mental status clears and he complains that his n-
gers and toes, which were numb and cold, are now quite pain-
ul. You note that there is probably reezing o tissue ( rostbite).
Question 1.12.5 The best method o re warming the rost
bite is:
A) Slowly in te id w ter.
B) R idly in the hottest w ter he c n st nd (tested by you, o
course, to ensure th t there will be no burns).
C) Using hot ir source such s h ir dryer.
D) Using oist he t vi he ting d.
E) We ring ittens.
Answer 1.12.5 The correct answer is “B.” Frostbitten rts
should be re-w r ed s quickly s ossible in hot w ter between
37°C nd 40°C. W ter te er ture cooler nd hotter th n this
c n le d to incre sed tissue loss. T e other ethods “A,” “C,”
“D,” nd “E” re not reco ended. Do not re-warm parts that
may become rozen again (e.g., i you re in the eld). Re- reez-
ing will c use ddition l d ge.
T e patient has a lot o pain a er thawing and reper usion.
You control the pain with morphine.
Question 1.12.6 Which o the ollowing is the most appro
priate dose o morphine in this hemodynamically stable
100 kg male?
A) 2 g IV.
B) 4 g IV.
C) 6 g IV.
D) 8 g IV.
E) 10 g IV.
Answer 1.12.6 The correct answer is “E.” T e ro ri te
dosing o or hine in cute in is never-ending source o
ze ent to our resident hysici ns who re er to st rt with
1 to 2 g IV. Nonetheless, the correct dose o IV or hine is
0.1 g/kg or 10 g in this 100 kg le. Si il rly, the correct
dose o ent nyl is 1 µg/kg (100 µg in 100-kg dult) nd the
dose o hydro or hone is 0.015 g/kg (1 to 2 g in 100-kg
dult). However, there re lly is no “ xed” dose o n rcotic in
edic tion in the ED. itr te the dose until you obt in in
relie —with the tient still bre thing, we ho e.
It is 2 days later. T e patient is noted to have black eschar on
multiple ngers and toes. T ere is no obvious per usion to
these areas.
Question 1.12.7 The best course at this point is:
A) Debride ent o the nonvi ble tissue.
B) Skin gr ing over o en re s er debride ent.
C) Observ tion or nu ber o weeks des ite the bl ck esch r.
D) A ut tion o the nonvi ble dist l digits.
Answer 1.12.7 The correct answer is “C.” It c n t ke weeks or
the ro er de rc tion line or debride ent nd gr ing to
beco e rent. T us, ggressive intervention t this oint is
counter roductive nd y le d to ddition l tissue loss. For
this re son, “A” nd “D” re incorrect. Skin gr ing is lso not
ro ri te t this ti e bec use debride ent o the esch r is
not ro ri te.
Objectives: Did you learn to . . .
• Identi y severe bradycardia in hypothermia and treat it
appropriately?
• Manage a patient with hypothermia?
• Use methods o re-warming and identi y complications o
re-warming?
• Recognize risk actors or hypothermia?
• Diagnose and manage rostbite?
QUICK QUIZ: DANGER IN THE LAUNDRY ROOM
Which o the ollowing is true bout the ingestion o household
ble ch?
A) P tients who drink household ble ch re t high risk o
eso h ge l nd g stric burns.
B) Or l burns re good redictor o eso h ge l burns.
C) All tients who ingest household ble ch should be re erred
or u er endosco y to rule out burns.
D) Household ble ch ingestions re gener lly benign nd re-
quire no tre t ent i the tient is not sy to tic.
The correct answer is “D.” Most household ble ch ingestions
re benign nd need no ther y i the tient is sy to tic.
However, this does not extend to industrial bleach or drain
cleaner. T ere is high risk o eso h ge l nd g stric burns
with industri l ble ch. “B” is incorrect. T e or l ucos y
be nor l in industri l ble ch or dr in cle ner ingestion nd

there y still be signi c nt eso h ge l nd g stric burns. For
this re son, ll tients with dr in cle ner or industri l ble ch
ingestion should undergo u er endosco y. “C” is incorrect;
tients with household ble ch ingestions do not require u er
endosco y.
CASE 1.13
An 18-year-old male was working outside in the heat and
humidity. T e outside temperature reached 105°F with 90%
humidity. He usually lives in northern Canada and works or
the government tracking the migration o caribou—but he is
here in Iowa on a job detasseling corn. (Don’t believe it? Look
at www.teamcorn.com—seasonal hard work that pays well.)
His riends noticed that he became con used, complained o
a headache and muscle cramps, and became light-headed. On
arrival to your ED, he is not sweating and is lethargic. His
rectal temperature is 41.5°C. He says with a smile, “Guess I
just can’t handle the heat, eh?”
Question 1.13.1 All o the ollowing are indicated in the
treatment o this patient EXCEPT:
A) P ck the tient in ice to reduce core te er ture.
B) IV uids.
C) Use n nd s r y w ter on the tient to ro ote ev o-
r tive cooling.
D) Ad inister glucose i the tient is hy oglyce ic.
Answer 1.13.1 The correct answer is “A.” P cking tients in
ice is contr indic ted. ot l body i ersion in ice water is use-
ul but cking the erson in ice ctu lly reduces cooling or
two re sons. First, it c uses cut neous v soconstriction. Second,
it does not llow conductive cooling such s would be seen in ice
w ter sub ersion: solid ice does not h ve s uch skin cont ct
s w ter or the circul tion to conduct w y the he t. Re e ber
th t sub ersion in ice is lso ssoci ted with c using hypother-
i .T e ro ri te tre t ent o he t exh ustion/he t stroke
(he t stroke being de ned s CNS dys unction with ch nge
in the level o consciousness) is cool w ter-so ked bl nkets
nd towels with ns i ed t the tient. T is llows ev or -
tive cooling nd lso conductive he t loss (to the w ter in the
towels). Anti yretics re gener lly not e ective bec use by this
oint, the tient’s endogenous ther oregul tion is k ut.
Question 1.13.2 Which o the ollowing IS NOT a contribut
ing actor to heat exhaustion/heat stroke?
A) Use o sti ul nts such s e hedr or het ines.
B) Dehydr tion.
C) Anticholinergic drugs.
D) T in body h bitus.
E) Extre es o ge.
Answer 1.13.2 The correct answer is “D.” T is is why Iow ns
st rt to work on their swi suit gures in A ril—it’s t-
ter o li e-or-de th, not n rcissis . A thin body h bitus is not
risk ctor or he t stroke/exh ustion; the o osite is true.
Obesity redis oses to he t stroke/exh ustion bec use there
CHAPTER 1 • EMERGENCY MEDICINE 21
is less ev or tive sur ce re er kilogr o weight. All o
the others redis ose to he t-rel ted illness. “A” nd “C” reduce
swe ting nd, in the c se o “A,” incre se et bolic r te. Both
o these redis ose to he t-rel ted dise se. O rticul r note is
“E.” S ll children swe t less re dily th n do dults. T is redis-
oses the to he t-rel ted dise se, but kes the less stinky
th n dults. T e elderly do not h ve the s e co ens tory
bility s younger eo le.
HELPFUL TIP:
Up to 80% o patients with heat stroke will not have a
prodrome o nausea, lightheadedness, con usion, head-
ache, etc., which is seen in heat exhaustion. Make sure
you check hepatic enzymes in patients in whom you
suspect heat stroke. They are almost uni ormly elevated
(beware they may take several hours to rise) and nor-
mal liver enzymes should cause you to question your
diagnosis.
Objectives: Did you learn to . . .
• Recognize and manage heat exhaustion/heat stroke?
• Recognize risk actors or heat exhaustion/heat stroke?
CASE 1.14
A 19-year-old emale presents to the ED with complaints o
wheezing. She has a history o asthma and you have been
ollowing her since her eighth birthday, when her mother
noticed that she couldn’t blow out her candles. In general,
she has mild asthma not requiring an inhaled steroid. How-
ever, over the past several months, things have accelerated so
that she now uses her rescue inhaler daily. On examination,
she is tachypneic, using accessory muscles o respiration with
a respiratory rate o 30 and wheezing in all elds. Her oxy-
gen saturation is 95% and pulse is 110 bpm with a normal
BP. Her blood gas is as ollows: pH 7.40, CO2 40 mm Hg, O2
80 mm Hg, and HCO3 24 mEq/L.
Question 1.14.1 A normal blood gas in this patient sug
gests that:
A) T is is ild ex cerb tion th t should res ond well to ther-
y.
B) She h s res ir tory cidosis.
C) She h s res ir tory lk losis.
D) T is is severe ex cerb tion th t will require ggressive
ther y.
E) T is is nor l blood g s; she c n be disch rged.
Answer 1.14.1 The correct answer is “D.” A H o 7.4 with
CO2 o 40 Hg in tient who is sth tic nd t chy neic
is b d sign. T e CO2 should be low in t chy neic tient
bec use they will be blowing o CO2. T us, nor l CO2 nd
nor l H indic te th t the tient is ret ining CO2. T is is
just nother c se where looking t the tient is ore i or-
t nt th n looking t the l bs. Even though the blood g s itsel is
22 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
technic lly within nor l li its, this tient clinic lly e rs
sick. “B” nd “C” re both incorrect, since the blood g s indi-
c tes neither n cidosis nor lk losis.
Question 1.14.2 Which o the ollowing tests are indicated in
routine evaluation o a patient with an asthma exacerbation?
A) Chest x-r y.
B) CBC.
C) Arteri l blood g s.
D) All o the bove.
E) None o the bove.
Answer 1.14.2 The correct answer is “E.” None o the bove
tests re indic ted in the routine ev lu tion o n sth ex c-
erb tion. A chest x-r y should be reserved or those tients in
who neu oni or other ul on ry rocess is sus ected. A
CBC is not going to ch nge your ther y in the routine sth
ex cerb tion nd is not indic ted. Likewise, n ABG is unnec-
ess ry in ost sth ex cerb tions. It c n be used to ssist in
your clinic l ev lu tion to deter ine whether or not the tient
is ret ining CO2; however, even in the “cr shing tient,” n
ABG is not necess ry bec use intubation is a clinical decision
and should not be based on the blood gas.
Question 1.14.3 You decide to initiate therapy or this
patient. O the ollowing options, the initial treatment o
this patient is:
A) Subcut neous e ine hrine.
B) Albuterol MDI ( etered-dose inh ler) with s cer.
C) Nebulized i r tro iu .
D) Or l steroids.
E) IV steroids.
Answer 1.14.3 The correct answer is “B.” T e initi l tre t ent
or this tient— nd ny tient resenting with n sth
ex cerb tion—is bronchodil tor. A bet - gonist is re erred,
in this c se lbuterol. It kes little di erence whether this is
vi nebulizer or MDI, s long s one uses dequ te doses. One
lbuterol nebuliz tion is equ l to bout 8 to 10 u s o n lb-
uterol MDI with s cer. “A” is incorrect bec use subcut neous
e ine hrine is second or third line in the tre t ent o sth .
“C” is incorrect. While i r tro iu is e ective in sth , it is
second ry to lbuterol in the tre t ent o sth . “D” nd “E”
re incorrect. Steroids re indic ted, but bronchodil tor ther y
is the ri ry tre t ent in cute sth ex cerb tions.
T ere is no albuterol MDI available to you in your ED, so the
patient receives nebulized albuterol. However, she continues
to wheeze.
Question 1.14.4 How many albuterol treatments can this
patient sa ely receive?
A) One every other hour.
B) One er hour.
C) wo er hour.
D) T ree er hour.
E) Continuous nebuliz tion o lbuterol is s e.
Answer 1.14.4 The correct answer is “E.” Albuterol c n be
d inistered vi nebulizer continuously i needed, even in the
edi tric ge grou . chyc rdi , one o the in side e ects
o lbuterol tre t ent, will o en improve with continuous
lbuterol. T is occurs bec use the tient’s t chyc rdi is o en
driven by hy oxi . Once the sth is dequ tely tre ted, oxy-
gen tion i roves, nd the ulse co es down.
T e patient does not respond well to albuterol alone, so you
request the addition o ipratropium. At this point, you also
want to order steroids.
Question 1.14.5 Which o the ollowing statements about
steroid use in asthma exacerbation is true?
A) IV steroids re su erior to PO steroids in the tre t ent o
sth .
B) All tients who re steroid de endent should h ve ddi-
tion l syste ic steroids even i they h ve lre dy t ken their
dose or the d y.
C) T e e ective dose r nge or steroids in sth is well est b-
lished.
D) Only tients requiring d ission should h ve or l or r-
enter l steroids.
Answer 1.14.5 The correct answer is “B.” All tients who re
steroid de endent should get steroids i they resent to the ED
with n cute ex cerb tion o sth . “A” is incorrect. IV ste-
roids nd or l steroids h ve the s e e c cy in cute sth
ex cerb tions. T us, the choice o route de ends ostly on
convenience nd cost. “C” is incorrect. Multi le steroid dosing
regi ens nd r nges o doses h ve been used in sth with
success. “D” is incorrect. Disch rged tients who h ve ny-
thing ore th n inor sth ex cerb tion should receive
steroids.
HELPFUL TIP:
When compared with oral steroids, IV steroids may in-
crease hospitalizations, cost, and treatment ailure in
those with chronic obstructive pulmonary disease. Use
oral steroids whenever possible; the bioavailability is
high (JAMA. 2010;303(23):2359–2367).
Question 1.14.6 Which o the ollowing is true about the
role o theophylline in the treatment o acute asthma
exacerbation?
A) heo hylline/ ino hylline should be used in c ses
unres onsive to two to three doses o nebulized lbuterol
since it h s dded bene its when used with n inh led
bet - gonist.
B) P tients who get theo hylline/ ino hylline h ve ore
side e ects th n do tients who get continuously nebulized
lbuterol nd get no bene t ro the drug.
C) I you choose to use theo hylline/ ino hylline, the ther -
eutic go l is seru level o 150 µg/dL.
D) T eo hylline/ ino hylline h s side e ect ro le su e-
rior to bet - gonists like lbuterol.

Answer 1.14.6 The correct answer is “B.” P tients who re
tre ted with theo hylline h ve ore side e ects, including
t chyc rdi , n use , nd rrhyth i s, th n do tients who get
continuously nebulized lbuterol (“D” is incorrect). T eo hyl-
line/ ino hylline h s essenti lly no role in the tre t ent o
cute sth ex cerb tions. T ere is no bene t to theo hyl-
line or ino hylline over optimal bet - gonist ther y (e.g.,
continuous nebulized lbuterol i required). “C” is incorrect
bec use i used t ll, the ther eutic go l or theo hylline is
seru level o 15 µg/dL.
HELPFUL TIP:
Magnesium sul ate (2 g over 10 minutes in adults,
25 mg/kg in children) can be used in patients with sta-
tus asthmaticus. Magnesium is a direct smooth muscle
relaxant. Not all patients will respond, and in patients
who will respond, you can expect a 60- to 90-minute
e ect. Avoid using magnesium in patients with renal
ailure since they may become toxic.
T e patient responds to nebulizers and steroids. You decide
to send her home.
Question 1.14.7 Which o the ollowing is true?
A) You should disch rge the tient on 2 u s o n lbuterol
MDI vi s cer to be used PRN.
B) You should l ce the tient on steroid, t ering the dose
over 3 weeks.
C) You should disch rge the tient on 8 to 10 u s o n lb-
uterol MDI vi s cer to be used every 6 hours round the
clock.
D) You should st rt the tient on steroid inh ler.
E) You should st rt the tient on long- cting bronchodil tor
inh ler.
Answer 1.14.7 The correct answer is “D.” T e tient should be
st rted on steroid inh ler to revent recurrent ex cerb tions.
She h s been using her lbuterol d ily, indic ting oor control.
Overl ing this with or l steroids will give the inh led steroid
ch nce to work while the tient is being covered with the or l
steroids. “A” is incorrect. One nebuliz tion is equ l to 8 to 10
u s o n MDI. I you si ly go b ck to low-dose lbuterol, the
tient is ore likely to do oorly. We tend to underdose lb-
uterol inh lers; tients c n s ely t ke ore th n 2 u s. “B” is
incorrect bec use tients do not need a steroid taper i they re
not on chronic steroids nd will not be t king steroids or ore
th n 10 d ys. You c n si ly tre t the tient (e.g., with red-
nisone 40 g PO QD or 5–10 d ys) nd then sto . No t er is
needed. Note that this is not true or patients on chronic steroids
who clearly do need a taper. “C” is incorrect bec use scheduled
lbuterol is not s e ective s PRN use. In ddition, lbuterol
c n cert inly be used ore th n every 6 hours. “E” is incorrect
bec use long- cting inh led bronchodil tor ther y should not
be used lone in sth due to the otenti l to incre se ort l-
ity; it should only be used with n inh led steroid.
CHAPTER 1 • EMERGENCY MEDICINE 23
Objectives: Did you learn to . . .
• Recognize clinical and blood gas mani estations o a severe
asthma exacerbation?
• Evaluate a patient presenting with an asthma exacerbation?
• Initiate treatment or asthma in the ED?
• Recognize the pit alls in using theophylline/aminophylline
or asthma?
• Formulate a plan or discharging an asthma patient rom the
ED?
CASE 1.15
A 7-year-old presents to the ED with wheezing and hives a er
being stung by a “bee.” He was evidently throwing rocks at
a yellow-jacket nest when he was stung, so at least he hope-
ully learned something. On examination, the patient has
hives and wheezing with a normal BP or his age. He is mildly
tachycardic.
Question 1.15.1 Potentially use ul treatments or this patient
include all o the ollowing EXCEPT:
A) IV di henhydr ine.
B) Intr uscul r (IM) e ine hrine.
C) Subcut neous (SC) di henhydr ine.
D) IV ci etidine.
Answer 1.15.1 The correct answer is “C.” Subcut neous
di henhydr ine c n c use skin necrosis nd is contr indi-
c ted. Either IV or IM di henhydr ine c n be used. O the
others, intramuscular (not SC) e ine hrine should be used in
the tient with n hyl xis; it is the drug o choice or n hy-
l xis. Re e ber th t di henhydr ine will not reverse bron-
chos s or hy otension. Subcut neous e ine hrine is err ti-
c lly bsorbed. I hy otension ersists des ite IM e ine hrine
nd IV uids, IV e ine hrine should be d inistered. Intr ve-
nous H2 blockers (e.g., ci etidine, r nitidine) re rticul rly
e ective in the tre t ent o n hyl xis nd should be used
routinely in these tients, lso.
HELPFUL TIP:
Only honeybees generally leave a stinger. Remove it by
any means possible. The amount o envenomation is
directly proportional to the amount o time the stinger
is in the skin and not to how you remove it (credit card,
orceps, etc.).
T e patient responds well to the therapy as noted earlier. You
are going to discharge him and want to write his prescriptions.
Question 1.15.2 The patient should be discharged with
which o the ollowing?
A) Di henhydr ine Q 6 hours or the next 48 hours.
B) Ci etidine Q 12 hours or the next 48 hours.
C) An n hyl xis (“bee sting”) kit.
D) All o the bove edic tions.
24 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Answer 1.15.2 The correct answer is “D.” P tients c n h ve
bi h sic re ction edi ted by “slow re cting subst nce o n -
hyl xis” which is now believed to be neutro hil che ot ctic
ctor. T is recurrence y occur u to 48 hours er the initi l
event. T us, rescribing edic tions to revent the recurrence
is rudent. Also, the tient should h ve “bee sting” kit v il-
ble, which should include re- lled syringe or e ine hrine
injection (e.g., E i-Pen or E i-Pen Junior). It is reco ended
th t tients h ve two syringes v il ble t ho e s the ilure
r te with one injection is irly high.
T e parents are concerned about this child who likes to play
outside. T ey worry that he will get stung again.
Question 1.15.3 You let them know that:
A) Any sting should be tre ted s n e ergency.
B) He will continue to be llergic to “bee stings” in the uture.
C) He should t ke ro hyl ctic edic tion be ore going out to
l y in the woods or other re s where he ight get stung.
D) None o the bove.
Answer 1.15.3 The correct answer is “D.” Here is why. P tients
who re llergic to one s ecies o hy eno ter n re not neces-
s rily llergic to others. In gener l, the llergy is s ecies s eci c.
T us, ost stings will be benign in n llergic tient unless it is
sting ro the o ending s ecies. “B” is incorrect. M ny chil-
dren tend to “outgrow” “bee sting” llergies. T is is in contr st
to dults in who re ctions tend to get worse over ti e. “C” is
incorrect. Obviously the child should be c re ul not to irrit te
yellow j ckets (did ny o you hurl rocks t w s nests s kid?),
but ro hyl ctic tre t ent is not routinely indic ted.
HELPFUL TIP:
Adults with a systemic allergic reaction to an insect
sting have a 30% to 60% risk o experiencing another
systemic reaction upon being stung again. There ore,
adults are more likely to bene it rom venom testing
and prophylaxis (which can reduce the risk to 5%). All
patients with a history o anaphylaxis should be pro-
vided with an anaphylaxis kit.
Objectives: Did you learn to . . .
• Describe the physiology and natural course o bee sting
reactions?
• Treat a patient with an anaphylactic reaction to a bee sting?
CASE 1.16
A 14-year-old otherwise healthy male presents to the ED
with acute onset le testicular pain when running 1 hour
prior to presentation. He denies any trauma to the region. He
states that his pain is severe and only on the le . T e pain is
increased with ambulation and movement. He has had nau-
sea and vomiting. He denies diarrhea, ever, chills, dysuria,
hematuria, or penile discharge.
Vital signs: temperature 37.0°C, pulse 110 bpm, respira-
tions 18, and BP 120/85 mm Hg. He is in distress secondary
to pain. Abdomen: normal bowel sounds, nontender, so , no
masses. Genitourinary: circumcised male, no penile lesions,
no discharge. T e le testicle is tender to palpation and has a
normal lay in the scrotum. T e cremasteric ref ex is normal
bilaterally.
Question 1.16.1 What is the signi cance o the normal lay
and cremasteric ref ex?
A) T e cre steric re ex should be bnor l in e ididy itis.
B) T e resence o cre steric re ex e ectively rules out tes-
ticul r torsion.
C) T e nor l l y o the testicle in the scrotu e ectively rules
out testicul r torsion.
D) T e resence or bsence o cre steric re ex is not hel ul
in ruling out testicul r torsion.
Answer 1.16.1 The correct answer is “D.” T e resence or
bsence o cre steric re ex (cre steric contr ction with
elev tion o the testis in res onse to stroking o the s e side
u er thigh) is neither sensitive nor s eci c enough to con r
or rule out the resence o testicul r torsion. Likewise, the l y o
the testicle c n be nor l in tients with testicul r torsion. An
bnor l testicul r l y nd the bsence o the cre steric re ex
y oint tow rd testicul r torsion. However, you c nnot rely
on these ndings to rule out testicul r torsion.
Question 1.16.2 The LEAST likely diagnosis in this patient
is:
A) orsion o testis.
B) E ididy itis.
C) orsion o endix testis.
D) orsion o endix e ididy is.
E) esticul r tu or.
Answer 1.16.2 The correct answer is “E.” esticul r torsion is
ch r cterized by cute onset o unil ter l testicul r in, o en
during ctivity such s running. It h s bi od l ge distribution,
during the rst ye r o li e nd g in during uberty. T e di er-
enti l di gnosis is de endent on the tient’s ge. I the tient is
younger th n 15 ye rs, the di erenti l consists o testicul r tor-
sion, e ididy itis, torsion o endix testis or endix e idid-
y is, orchitis, hydrocele, nd v ricocele. In tients older th n
15 ye rs, the di erenti l includes ll o these di gnoses lus tes-
ticul r tu or. However, testicul r tu ors re gener lly inless.
Question 1.16.3 What is the most reliable method or diag
nosing testicular torsion?
A) Do ler (Du lex color).
B) R dionuclide sc n.
C) Surgic l ex lor tion.
D) X-r y.
E) MRI.
Answer 1.16.3 The correct answer is “C.” Every patient with
suspected testicular torsion should have surgical exploration o
 CHAPTER 1 • EMERGENCY MEDICINE 25

the scrotum. All o the other studies re djunctive. For ex -
le, r dionuclide sc n y result in lse-neg tive nd t kes
sever l hours to er or . Ultr sound h s sensitivity s low s
82%. Surgic l ex lor tion is the only de nitive di gnostic tool.
T e window o o ortunity or surgery is bout 6 hours, er
which the testicle y not be s lv ged. Orchio exy should be
er or ed on the involved nd uninvolved sides to revent tor-
sion. M nu l detorsion c n be tte ted nd requires sed tion
nd in edic tions. wist testis like you re o ening book
(the right testis counterclockwise nd the le clockwise). I in
resolves, you h ve detorsed the testis.
Objectives: Did you learn to . . .
•
Examine a patient presenting with acute scrotal pain?
• Generate a dif erential diagnosis or scrotal pain based on
the patient’s age?
• Evaluate a patient with suspected testicular torsion?
hematuria, ever, chills, vaginal discharge, nausea, vomiting,
or diarrhea. Her last menses was 2 weeks ago, and she states
she is not sexually active. She is on oral contraceptives to treat
menstrual cramps and denies any allergies.
Question 1.17.1 A urine beta HCG is NOT indicated or
which o the ollowing patients who presents with abdomi
nal pain?
A) A 32-ye r-old e le who h s h d tub l lig tion.
B) A 16-ye r-old e le who by history h s never been sexu lly
ctive.
C) A 25-ye r-old e le who h s h d nor l eriod 1 week
go nd swe rs on st ck o Bibles th t she couldn’t ossibly
be regn nt.
D) A 24-ye r-old, rried, ro ession l e le who is t king
or l contr ce tives nd h d nor l l st enses.
E) A 25-ye r-old le.

QUICK QUIZ: UROLOGIC INFECTION 1 Answer 1.17.1 The correct answer is “E.” O course les do
not need regn ncy test ( lthough the HCG y be elev ted
in testicul r c ncer). All e le tients o re roductive ge,
Wh t is the ost co on gent c using e ididy itis in
exce t or those who h ve h d hysterecto y, ust h ve reg-
21-ye r-old le?
n ncy test s rt o the ev lu tion o bdo in l in. T ere re
A) Escherichia coli.
sever l re sons or this osition. First, ny tients y not be
B) Neisseria gonorrhoeae.
c ndid bout their sexu l ctivity. In ct, in one study, l ost
C) Chlamydia trachomatis.
one-third o tients who s id “they could not ossibly be reg-
D) Pseudomonas s ecies.
n nt,” including one who denied ever h ving intercourse, were
E) Ureaplasma urealyticum.
regn nt. Second, the ilure r te o tub l lig tion is u to 5%
over 10 ye rs de ending on the technique used (l rosco ic
The correct answer is “C.” In young les, e ididy itis is
tub l lig tion is the le st reli ble). o r ise your concern little
usu lly the result o sexu lly tr ns itted dise ses. O these,
higher, l ost ll o the regn ncies in tients who h ve h d
C. trachomatis is currently the ost co on etiologic gent.
tub l lig tion re ecto ic.
N. gonorrhoeae is second ost co on in this ge grou . It is
there ore essenti l to tre t or both gents when the di gnosis o
e ididy itis is sus ected.
HELPFUL TIP:
When examining a patient whose history is consistent
QUICK QUIZ: UROLOGIC INFECTION 2 with vulvovaginitis, remember that a KOH preparation
is only 65% to 80% sensitive or Candida and treatment
Wh t is the ost co on gent c using e ididy itis in based on symptoms and physical indings is certainly
55-ye r-old le? reasonable.
A) E. coli.
B) N. gonorrhoeae.
C) C. trachomatis.
You get a urinalysis (UA) on this patient, mostly out o habit.
D) Pseudomonas s ecies.
T e UA shows 5 to 10 WBCs/HPF, 2 + bacteria, 2 + leukocyte
E) U. urealyticum.
esterase, and 1 + nitrite.
The correct answer is “A.” Gr -neg tive rods re the ost
Question 1.17.2 Which o the ollowing antibiotic regimens
co on c use o e ididy itis in older en. O these, E. coli
IS NOT indicated or the treatment o simple cystitis?
is the ost co on etiologic gent, ollowed by Klebsiella nd
A) 3-d y course o tri etho ri –sul ethox zole ( MP–SMX).
Pseudomonas s ecies.
B) 3-d y course o uoroquinolone.
C) 5-d y course o nitro ur ntoin.
D) Single dose o os o ycin.
CASE 1.17 E) Single dose o ce h lexin.
A 22-year-old otherwise healthy emale college student pres-
ents to the ED with dysuria and urinary requency o 2 days Answer 1.17.2 The correct answer is “E.” T e usu l c us tive
duration. She denies any abdominal/pelvic pain, f ank pain, gents or unco lic ted cystitis re Gr -neg tive org nis s
26 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
such s E. coli. In re s th t h ve high r tes o resist nce to
MP–SMX (>30% or ore o isol ted E. coli b cteri resist nt),
it is wise to use quinolone s the rst-line gent; however, qui-
nolones re ore costly nd quinolone resist nce is rising. All
o the bove regi ens re usu lly e ective or tre ting cystitis
exce t single dose o ce h lexin. Ce h lexin is e ectively used
in regn nt e les, lthough 7-d y course is reco ended.
Fos o ycin h s lower cure r te th n the other regi ens nd
is ore ex ensive.
HELPFUL TIP:
A alse-negative urinalysis is common in women with
uncomplicated cystitis. Empiric treatment o urinary
tract in ection (UTI) is reasonable in a emale o child-
bearing years presenting with one or more typical
symptoms (urgency, requency, dysuria) and no vaginal
discharge.
Question 1.17.3 All o the ollowing patients with pyelone
phritis should be admitted EXCEPT:
A) A 22-ye r-old G1 P0 e le <24 weeks o gest tion, he o-
dyn ic lly st ble.
B) A 22-ye r-old e le un ble to toler te PO uids or edic tions.
C) A 22-ye r-old e le with unreli ble soci l situ tion nd/or
co li nce.
D) A 22-ye r-old e le with n uncle r di gnosis or extre e
in.
Answer 1.17.3 The correct answer is “A.” T e old d ge th t ll
regn nt tients with yelone hritis ust be d itted h s gone
out o vor. It is s e to send tients ho e who re <24 weeks
o gest tion, co li nt, h ve st ble vit l signs, nd re cces-
sible by tele hone. P tients should be given cle r instructions to
return or ny co lic tions. All o the other situ tions require
in-hos it l c re.
Objectives: Did you learn to . . .
• Decide which patients should have a urine beta-HCG in the ED?
• Provide appropriate antibiotic treatment to a patient with an
uncomplicated UTI?
• Identi y patients with pyelonephritis who require hospital
admission?
CASE 1.18
A 63-year-old male presents to the ED with a 2-day history o
ever, urinary requency, dysuria, and di culty initiating the
urinary stream. He also relates having some perineal pain.
On examination, his vitals are stable except or a temperature
o 38.5°C. His rectal examination is remarkable or a tender,
warm, edematous prostate. T ere are no perirectal masses
and the stool is heme negative. He has no penile lesions, dis-
charge, scrotal masses, or tenderness. He does not exhibit
any costovertebral angle tenderness. His UA is positive or
10 WBCs/HPF, 1+ nitrite, 1+ leukocyte esterase.
Question 1.18.1 What is the most likely diagnosis in this
patient?
A) Pyelone hritis.
B) Perirect l bscess.
C) E ididy itis.
D) Acute rost titis.
E) Cystitis.
Answer 1.18.1 The correct answer is “D.” T is tient’s sy -
to s ost closely t those o so eone with cute rost titis.
Although his UA is lso consistent with yelone hritis or cysti-
tis, his ex in tion ndings re ore suggestive o cute ros-
t titis. He l cks costovertebr l ngle tenderness ( yelone hri-
tis), nd he h s signi c nt te er ture th t rgues g inst
si le cystitis. In the st, rost tic ss ge w s reco ended
when obt ining urine s eci en; but this r ctice is to be
voided since it is quite in ul nd b cteri l seeding into the
bloodstre y occur. In the bsence o scrot l tenderness,
e ididy itis is lso quite unlikely.
Question 1.18.2 What should be included in the treatment
regimen or this patient?
A) Or l uoroquinolone or MP–SMX or t le st 3 weeks.
B) Instructions or hydr tion, sitz b ths, stool so eners, nd
nonsteroid l nti-in tory drugs (NSAIDs).
C) Ad ission or IV ntibiotics i he e rs toxic or he ody-
n ic lly unst ble.
D) Foley or su r ubic c theter i urin ry retention is rob-
le .
E) All o the bove.
Answer 1.18.2 The correct answer is “E.” P tients with cute
rost titis should be tre ted or t le st 3 weeks with or l ntibi-
otics to revent chronic rost titis; so e suggest u to 42 d ys.
re t ent should be initi ted with quinolone while urine cul-
tures re ending, since sul resist nce is high in so e re s o
the country.
While this patient is still in the ED, he develops acute uri-
nary retention. A Foley catheter is placed without di culty
and 300 cc o slightly cloudy urine is obtained. Your patient
eels much better and thanks you or alleviating his pain.
You decide to discharge him home with the Foley catheter
and a leg bag a er discussion with a urologist and ollow-up
arrangement.
Question 1.18.3 Which o the ollowing cause urinary reten
tion in men?
A) Phi osis, urethr l stricture, benign rost tic hy er l si
(BPH), c lculi.
B) Anticholinergics, sy tho i etics, n rcotics, nti sychotics.
C) Psychogenic.
D) C ud equin syndro e, di betes, s in l cord injuries.
E) All o the bove.
Answer 1.18.3 The correct answer is “E.” All o the bove c n
c use urin ry retention in en. By r, the ost co on c use

o cute urin ry retention is BPH. T e c tegories o cute urin ry
retention y be divided into neurogenic (s in l cord injuries,
c ud equin syndro e, di betes, syringo yeli , etc.), obstruc-
tive (BPH, hi osis, r hi osis, c lculi, urethr l stricture,
etc.), h r cologic ( nticholinergics, ntihist ines, n rcot-
ics, nti sychotics, tricyclics, etc.), nd sychogenic, which is
di gnosis o exclusion.
HELPFUL TIP:
Sending patients home on an alpha-blocker (e.g., doxa-
zosin, tamsulosin) may reduce the need or re-catheter-
ization a ter the catheter is removed.
Objectives: Did you learn to . . .
• Recognize the clinical presentation o prostatitis?
• Treat a patient with prostatitis?
• Identi y causes o urinary retention in a male?
QUICK QUIZ: FORBIDDEN FORESKIN
Which o the ollowing is ch r cterized by swollen, in ul
oreskin th t c nnot be reduced b ck to its nor l osition?
A) Phi osis.
B) P r hi osis.
C) B l no osthitis.
D) Me t l stenosis.
The correct answer is “B.” P r hi osis is condition in which
the oreskin is retr cted, swollen, nd un ble to reduce into its
nor l osition. Ice nd ste dy nu l co ression o en er-
its reduction. Surgery is indic ted i nu l reduction ils. “A,”
hi osis, is condition in which the dist l oreskin is too tight
to be retr cted to llow ex osure o the gl ns. It is o en con used
with enile dhesions in those younger th n 2 ye rs. “C,” b l no-
osthitis, is or o cellulitis involving the oreskin nd gl ns in
the uncircu cised le ssoci ted with oor hygiene. re t ent
is with w r so ks, ntibiotics, nd ossible circu cision. “D,”
e t l stenosis, is co on in circumcised les, ssoci ted with
n in tory re ction involving the e tus. Sy to s th t
indic te the need or surgic l tre t ent include s r ying o the
urine stre or dors l de ection o the stre .
QUICK QUIZ: FORESAKEN FORESKIN
Until wh t ge is it nor l to h ve dhesions between the gl ns
nd oreskin in uncircu cised les?
A) Adhesions re lw ys bnor l.
B) Age 6 onths.
C) Age 1 ye r.
D) Age 2 ye rs.
E) Age 3 ye rs.
The correct answer is “E.” So e dhesions re nor l in young
children. However, the oreskin should be ully retr ct ble in
CHAPTER 1 • EMERGENCY MEDICINE 27
uncircu cised les by the ge o 3 to 5 ye rs. Be ore this, no
ction need be t ken.
CASE 1.19
A 20-year-old emale presents to your ED complaining o
lower quadrant abdominal pain. She is on “the ring” or con-
traception and has been aith ully using it. She has had regu-
lar menses and has not noticed any change in her pattern o
menses. Her pain had a sudden onset but is not associated
with any vaginal bleeding. On vaginal examination, you nd
marked cervical motion tenderness but no palpable adnexal
mass.
Question 1.19.1 Based on this in ormation you decide that:
A) T e bsence o n dnex l ss e ectively rules out ecto ic
regn ncy.
B) I tient beco es regn nt, ll or s o contr ce tion
reduce the risk o ecto ic regn ncy.
C) T e ct the tient h s h d nor l eriods e ectively rules
out n ecto ic regn ncy.
D) Cervic l otion tenderness e ectively clinches the di gno-
sis o elvic in tory dise se.
E) None o the bove is true.
Answer 1.19.1 The answer is “E,” none o the above. “A” is
incorrect bec use only 10% o tients with n ecto ic reg-
n ncy will h ve l ble ss in the dnex . “B” is incorrect
bec use both intr uterine devices nd tub l lig tion increase
the risk o ecto ic regn ncy i the tient beco es regn nt.
“C” is incorrect bec use 15% to 20% o tients with ecto ic
regn ncy h ve no history o issed enses. “D” is incorrect
bec use cervic l otion tenderness c n be resent not only in
elvic in tory dise se but lso in other illnesses such s
ov ri n torsion, ecto ic regn ncy, etc.
Question 1.19.2 Risk actors or ectopic pregnancy include
all o the ollowing EXCEPT:
A) Prior ecto ic regn ncy.
B) Or l contr ce tive use.
C) History o elvic in tory dise se.
D) re t ent or in ertility.
E) Current intr uterine device use.
Answer 1.19.2 The correct answer is “B.” All o the others
incre se the risk o n ecto ic regn ncy. Other risk ctors
include cig rette s oking, recent elective bortion, revious
tub l surgery, nd tub l lig tion.
You decide that this patient may have an ectopic pregnancy.
A urine HCG test is positive or pregnancy.
Question 1.19.3 The signi cance o a positive pregnancy
test is that:
A) An ultr sound will be ble to detect n ecto ic regn ncy i
one is resent.
B) T e seru level o HCG is at least 1,000 IU/ L.
28 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
C) Co bined with the tient’s bdo in l in nd cervic l
otion tenderness, it e ectively rules in n ecto ic regn ncy.
D) T e urine HCG is 98% sensitive or regn ncy 7 d ys er
i l nt tion.
Answer 1.19.3 The correct answer is “D.” “A” is incorrect. T e
regn ncy test is ositive very e rly nd ultr sound y not be
ositive by n ex erienced o er tor until 6 weeks o regn ncy.
“B” is incorrect. T e urine y be ositive t seru HCG lev-
els o 25 to 50 IU/L. P tients y not h ve n HCG level o
1,000 IU/L until 6 weeks o regn ncy. “C” is incorrect bec use
tients with nor l regn ncy y lso h ve bdo in l
in nd cervic l otion tenderness.
T e patient’s serum HCG is 440 IU/L. You order an ultra-
sound and nd no evidence o an intrauterine or ectopic
pregnancy.
Question 1.19.4 Your next step is to:
A) Re ssure the tient th t she does not h ve n ecto ic reg-
n ncy.
B) Recheck the HCG in 48 hours.
C) Re er or l rosco y to rule out ecto ic regn ncy.
D) Recheck n HCG in 1 to 2 weeks.
E) Follow the tient clinic lly.
Answer 1.19.4 The correct answer is “B.” T e HCG should
double in nor l regn ncy every 1.8 to 3 d ys. I the HCG is
not doubling in this ti e r e, it is likely n ecto ic regn ncy.
Re e ber, the ct th t you did not see n ecto ic regn ncy
on ultr sound is irrelev nt. T e seru HCG is gener lly at least
1,500 IU/L be ore nything is seen on ultr sound. By n HCG o
6,500 IU/L, n ex erienced ultr sonogr her should cert inly
be ble to see regn ncy on ultr sound; i not seen, n ecto ic
should be reconsidered. “A” is incorrect bec use o the bove.
“C” is incorrect. T is is inv sive nd not needed. “D” is incorrect
bec use o the ti e r e; the HCG should be rechecked in 24
to 48 hours. An ecto ic y well ru ture within 1 to 2 weeks.
“E” is incorrect. I you ollow the tient clinic lly, you re b si-
c lly s ying th t you will w it until the ecto ic ru tures be ore
ddressing the roble .
Question 1.19.5 You re check the HCG in 48 hours and it is
now 1,000 IU/L (prior level 440 IU/L). Your interpretation is
that:
A) T is tient does not likely h ve n ecto ic regn ncy.
B) T is tient h s ol r regn ncy.
C) T is tient h s blighted ovu .
D) T e tient h s et l de ise o n intr uterine regn ncy.
E) All o the bove re ossible.
Answer 1.19.5 The correct answer is “A.” Since the HCG dou-
bled s ex ected in nor l regn ncy, it is not likely th t this
is n ecto ic regn ncy, blighted ovu (“C”) or intr uterine
et l de ise (“D”). In ll o these conditions, the HCG would
not double. “B” is lso not likely bec use in ol r regn ncy,
the HCG would rise dr tic lly
Objectives: Did you learn to . . .
• Evaluate a ertile emale with pelvic pain?
• Diagnose an ectopic pregnancy?
QUICK QUIZ: TWISTED SISTER
Which o the ollowing is ty ic l o ov ri n torsion?
A) Periu bilic l in gr du lly igr ting to both the right nd
le qu dr nts.
B) Sudden onset o colicky bdo in l in with v gin l bleed-
ing.
C) Sudden onset o colicky bdo in l in in one o the lower
qu dr nts.
D) Sudden low b ck in with r di tion to the erineu .
The correct answer is “C.” P tients with ov ri n torsion resent
with sudden onset o severe lower bdo in l in. T e in is
requently colicky. Since only one ov ry is involved, the in
is loc ted in one side or the other. S ont neous torsion/detor-
sion y lso occur so th t the in y re it s ont neously.
Ov ri n torsion c n be di gnosed by Do ler ultr sound th t
ex ines ow to the ov ries. M ny gynecologists consider this
clinic l di gnosis, so obt in consult tion e rly or sus ected
ov ri n torsion c ses.
CASE 1.20
A middle-aged unresponsive, disheveled patient is brought
by emergency medical services (EMS) to your ED. T ey had
been called by his girl riend who had seen him lying in the
grass outside his home this morning. He has spontaneous
respirations and has shallow respirations o 20 per minute
and a weak but palpable pulse at 110 beats per minute.
Question 1.20.1 What should be your rst steps in assess
ment and treatment?
A) Oxygen by nonrebre ther sk (NRB), st t seru glucose,
n loxone, nd thi ine.
B) Oxygen by NRB, ECG, he d C .
C) Oxygen by NRB, intub te, ECG, he d C .
D) Intub te, ECG, he d C .
Answer 1.20.1 The correct answer is “A.” T ere re sever l
c uses o unres onsiveness th t c n be i edi tely corrected.
A hel ul lgorith to rec ll in the initi l tre t ent or n unre-
s onsive tient is “DON’ ”: Dextrose, Oxygen, N loxone,
hi ine (the so-c lled “co cockt il”). Answer “A” is correct
bec use n loxone nd oxygen re d inistered nd glucose is
checked. I r id blood sug r is un v il ble, e iric l d in-
istr tion o dextrose would be ro ri te. R id tre t ent
o hy oxi , hy oglyce i , nd n rcotic overdose c n i rove
ent l st tus nd thus void intub tion. ECG nd he d C y
be indic ted l ter in the ev lu tion. You could rgue or intub -
tion in this tient since he is unres onsive (“C” nd “D”) but
the next ste s would not be ECG nd he d C . So “A” is the ost
correct nswer.

T e patient is ound to be hypothermic, hypoglycemic, and
hypoxic. He is placed on oxygen and given warm normal saline,
an amp o D50W, and naloxone. T e patient now is saturating
at 98%on NRB. He is responding to pain ul stimuli by moan-
ing and withdrawing his extremities but is not opening his
eyes. He has gurgling respirations and still has no gag ref ex.
Question 1.20.2 What is your next step?
A) Intub te.
B) Obt in he d C .
C) Obt in ECG.
D) Continue on NRB.
E) Obt in n ABG.
Answer 1.20.2 The correct answer is “A.” Although the tient
h s i roved nd h s nor l oxygen s tur tion, his level o
consciousness is still too low to rotect his irw y. T us, he
should be intub ted be ore urther di gnostic studies re er-
or ed. A si le ethod to deter ine the need or intub tion
is the GCS ( ble 1-5). P tients with GCS o 8 or less should be
intub ted, s they c nnot rotect their irw y ro s ir tion o
or l secretions nd/or e esis. T e rhy e “GCS o 8, intub te”
ssists in recollection o this rule. T is tient h s GCS o 7
(eyes 1, verb l 2, ove ent 4). He h s gurgling res ir tions,
nd you c nnot ensure he is ble to rotect his irw y. T ere-
ore he should be intub ted be ore other studies or interven-
tions. “D” is incorrect bec use he c nnot rotect his irw y. “E”
is incorrect because the decision to intubate is a clinical one
and not tied directly to the blood gas!
T e girl riend arrives and gives urther history that the
patient is an alcoholic and had told her he had quit drinking
2 days ago. She states he has had a seizure in the past when he
stops drinking. He starts to seize be ore your eyes.
Question 1.20.3 What should you do now?
A) Give lor ze nd d it or rob ble deliriu tre ens
(D s).
B) Give lor ze , obt in he d C , blood cultures, nd ECG.
C) Give lor ze , extub te, nd d it or rob ble D s.
D) Give henytoin nd d it or rob ble D s.
Answer 1.20.3 The correct answer is “B,” give lorazepam to
abort the seizure. Even though it is e sy to ssu e th t the
tient h d seizure ro D s, which y h ve resulted in
hy oxi , hy other i , nd hy oglyce i , this kind o think-
ing c n le d to errors. It is still ossible th t the tient h s
s ont neous or tr u tic br in he orrh ge, thus the need or
he d C . It is lso ossible th t the tient is se tic; re e -
ber th t hy other i c n be seen with se sis. T us, blood cul-
tures should be obt ined nd ossibly n LP er or ed. Fin lly,
n ECG c n show yoc rdi l in rction or rrhyth i th t
y lso result in seizure. “D” is incorrect bec use henytoin
is not the drug o choice or n ctively seizing tient; ben-
zodi ze ine such s lor ze should be d inistered. And,
henytoin does not work in lcohol withdr w l seizures. “C” is
CHAPTER 1 • EMERGENCY MEDICINE 29
incorrect; the tient still h s GCS o less th n 8 nd is un ble
to rotect his irw y so he should not be extub ted.
Objectives: Did you learn to . . .
• Rapidly assess and treat an unresponsive patient?
• Use the GCS to determine need or intubation?
CASE 1.21
You are working in a rural ED and get a call that the volun-
teer ambulance service is bringing an unresponsive, adult
male patient status post motor vehicle collision. T ey bring
the patient on a backboard with a c-collar.
Question 1.21.1 The primary survey o a trauma patient
includes all o the ollowing EXCEPT:
A) Check or ulses.
B) I obilize the c-s ine, ev lu te the irw y, nd listen or
bre th sounds.
C) GCS.
D) Abdo in l ex in tion.
E) Unclothe the tient.
Answer 1.21.1 The correct answer (and what you do
not want to do in the primary survey) is “D.” T e ri ry
survey is the initi l ev lu tion er or ed on every tr u
tient by the lgorith “ABCDE.” A: Airw y ssess ent
includes c-s ine i obiliz tion; o ening the irw y by j w
thrust/chin li ; nd, when indic ted, b g-v lve sk, intub -
tion, or cricothyroto y. B: Bre thing includes listening or
bre th sounds, d inistering oxygen, nd tre ting neu o-
thor ces. C: Circul tion requires ssess ent o BP, checking
ulses nd tre t ent o hy otension nd t chyc rdi with
cryst lloids nd blood. D: Dis bility is the r id neurologic
ex in tion or otenti l cord injury nd GCS. E: Ex osure
involves disrobing the tient nd rolling the to ssess ny
injury to the b ck.
On the primary survey, the patient was not protecting his
airway and was intubated with an 8-mm endotracheal tube
(E ) with rapid sequence intubation (RSI). T e patient
is noted to have breath sounds on the right but no breath
sounds on the le .
Question 1.21.2 What is the next best step in evaluation
and treatment o this patient?
A) Re ove the E ; you ust be in the eso h gus.
B) Get chest x-r y to con r tube l ce ent.
C) Do needle deco ression o le chest.
D) Insert le chest tube.
E) Check E or de th t the teeth nd osition.
Answer 1.21.2 The correct answer is “E.” T is tient h s
bre th sounds on the right; there ore, eso h ge l intub tion is
unlikely, king “A” incorrect. T e ost likely nd e sily rec-
ogniz ble source o bsent bre th sounds on the le is right
in ste bronchus intub tion. T us, looking t the de th o
30 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
l ce ent o the E t the teeth (“E”) is the initi l ev lu tion
indic ted. T e E should be l ced t bout three ti es the
size o the E (i.e., 3 × 8 = 24 c ) ssu ing th t the size o
E w s correctly chosen. T is is n i ort nt c lcul tion to
re e ber, s it lso lies to edi tric tients. A chest x-r y
c n lso ev lu te or right in ste intub tion but should not
be the rst ste . A neu othor x y be the c use o unil ter l
bre th sounds, but right, or less co only, le , in ste intu-
b tion should be considered rst.
Question 1.21.3 You now note that there is an open chest
wound to the le t lateral rib cage. Funny . . . you didn’t
notice that be ore. What is the initial treatment o this new
nding?
A) Needle thor costo y.
B) Chest tube l ce ent.
C) Occlusive dressing.
D) Chest x-r y.
Answer 1.21.3 The correct answer is “C.” T is tient h s n
o en “sucking” chest wound. E ch ti e the tient ins ires, ir
c n be sucked into the chest c vity cting s one-w y v lve.
T is c n result in tension neu othor x. T us, the initi l
tre t ent is to ly n occlusive dressing to the wound (e.g.,
such s etrol tu g uze).
Following the placement o the occlusive dressing the patient
continues to have absence o breath sounds on the le , is now
hypotensive, and has distended neck veins. T e presumed
diagnosis is a tension pneumothorax.
Question 1.21.4 What should you do now?
A) Chest x-r y.
B) Chest tube l ce ent through wound.
C) Chest tube l ce ent through se r te site.
D) Re ove occlusive dressing.
Answer 1.21.4 The correct answer is “D.” T e occlusive dress-
ing itsel y c use tension neu othor x, so its l ce ent
should be i edi tely ollowed by chest tube l ce ent. I
tension neu othor x develo s be ore the tube is l ced,
re oving the dressing (“D”) c n usu lly llevi te the tension
co onent. E ergency edic l technici ns will o en l ce
dressing th t is closed only on three sides to serve s rele se
v lve nd void this ossibility. T e di gnosis o tension neu-
othor x is clinic l. T e ti e required to obt in chest x-r y
y result in the de th o the tient. When l cing chest tube
in tient with n o en wound, never pass the tube through
the wound, s it is likely to ollow the th o the initi l enetr -
tion into lung renchy .
HELPFUL TIP:
Needle thoracostomy is also use ul in a tension
pneumothorax and should be the initial step in most
cases.
T e patient now has a chest tube in place but remains hypo-
tensive. wo large bore (18 gauge or larger) IVs were estab-
lished. No external source o bleeding is identi ed.
Question 1.21.5 When should blood be administered?
A) I edi tely.
B) I tient is hy otensive.
C) I ersistent hy otension er 1 L o nor l s line.
D) I ersistent hy otension er 4 L o nor l s line.
E) I FAS ex in tion shows intr bdo in l ree uid.
Answer 1.21.5 The correct answer is “C.” I tient rrives
hy otensive with no signs o extern l bleeding, 1 L o cryst lloid
(nor l s line) should be given i edi tely. T e tr dition l
te ching h s been to st rt blood er hy otension unres onsive
to 2 liters o s line. T is h s ch nged in the ost recent A LS
guidelines; we don’t know which will be the correct nswer
on the test. I the tient continues to be hy otensive, cked
red blood cells should be st rted long with ddition l nor l
s line. T e FAS ex in tion is r id bedside ultr sound to
identi y ree uid in the tr u tient’s bdo en nd eric r-
di l s c. Persistent hy otension with ositive FAS ex in tion
is n indic tion or e ergent ex lor tory l roto y.
Objectives: Did you learn to . . .
• Employ the primary assessment o a trauma patient?
• Treat an open chest wound?
• Resuscitate an unstable trauma patient?
HELPFUL TIP(S):
Tranexamic acid can be used as a hemostatic agent in
hypotensive trauma patients. I you are going to trans-
use a large amount o blood the best evidence sug-
gests blood:FFP:platelets in a 1:1:1 ratio.
QUICK QUIZ: CHEST PAIN
A 54-ye r-old e le resents to your ED with chie co l int o
chest in. She st tes it c e on suddenly while she w s trying to rid
her g rden o l gue o thistles (or g rlic ust rd–your choice).
She describes it s “sh r ” nd it r di tes through to her b ck. She
re orts di culty bre thing. Her st edic l history is ertinent or
hy ertension, bre st c ncer, nd obesity. She is s oker.
B sed on this history, wh t di gnosis c n be excluded ro
your di erenti l?
A) Acute yoc rdi l in rction.
B) Aortic dissection.
C) Pul on ry e bolis .
D) Pneu othor x.
E) None o the bove.
The correct answer is “E.” T e tient’s history is ost sugges-
tive o ul on ry e bolis with her co l int o sh r chest
in, trouble bre thing, c ncer history, nd s oking. However,
t this oint in ti e, ll o the etiologies listed— nd ore—

ust be considered. Wo en o en h ve ty ic l resent tions
o c rdi c chest in. In ddition, tients o en use the ter
“sh r ” to describe “intense” or “strong” in.
QUICK QUIZ: AORTIC DISSECTION
In ortic dissection, the BP is di erent between the extre ities
in less th n 30% o c ses. I you diagnose thoracic aortic dis-
section, and the patient’s BP is di erent in the upper extremi-
ties, what limb should you use to guide BP management?
A) Right r .
B) Le r .
C) Either lower extre ity.
D) T e li b with the highest BP.
E) T e li b with the lowest BP.
The correct answer is “D.” An ortic dissection yi ir the
blood ow to cert in extre ities due to the lse lu en. T e
BP should be int ined t systolic BP o 100 to 120 Hg
(or bit lower) in the extre ity with the highest BP. T is will
decre se the orces ro g ting the dissection.
HELPFUL TIP:
Patients with an aortic dissection should be started
on a beta-blocker (e.g., esmolol) and vasodilator drip
(nitroglycerin, nitroprusside) to control BP and mini-
mize stress to the aortic wall. The goal is a pulse o
approximately 60 bpm and a blood pressure o 100
to 120 mm Hg systolic. Remember that lowering the
pulse rate is just as important as reducing the blood
pressure.
CASE 1.22
A mother brings her 3-year-old child into the ED. She states
that the child has been vomiting and complaining o abdom-
inal pain all a ernoon. He has had between 8 and 10 epi-
sodes o emesis; the last two have contained small amounts
o bright red blood. He has had a little nonbloody diarrhea.
He has not been tolerating f uids. On examination, you
nd the child to be moderately ill appearing with normal
color, but he seems less interactive than you would expect.
His vitals reveal a temperature o 36.5 degrees C, a pulse
o 170 bpm, a respiratory rate o 28, and a BP o 98/58 mm
Hg. His abdomen is slightly and di usely tender. He has dry
mucous membranes.
Question 1.22.1 In general (not speci cally in this patient)
what is the initial treatment o a moderately dehydrated
child?
A) 20 cc/kg bolus o D5 1/2 NS.
B) 10 cc/kg bolus o isotonic cryst lloid uid.
C) Or l ch llenge o s ll ount o electrolyte solution.
D) 12.5 g ro eth zine su ository.
CHAPTER 1 • EMERGENCY MEDICINE 31
Answer 1.22.1 The correct answer is “C.” M ny children who
re vo iting nd h ve di rrhe will be ble to toler te s ll
(5 cc) si s o uid d inistered every ew inutes. Or l u-
ids should be tte ted rior to IV ther y. One ight lso
d inister ond nsetron to hel reduce vo iting (2 g in those
<15 kg, 4 g in those >15 kg). In children who re severely
dehydr ted, s evidenced by ltered ent l st tus or ch nge in
skin turgor, IV uid resuscit tion should begin i edi tely. I
IV rehydr tion is considered ro ri te, use nor l s line in
20 cc/kg liquots. T ere ore, nswers “A” nd “B” re not cor-
rect. Pro eth zine (“D”) is n ntie etic th t h s been used
in children in the st. However, ro eth zine h s received
“bl ck box” w rning ro the FDA or children younger th n
2 ye rs, s there is risk o res ir tory de ression.
You obtain some lab work and notice that the child has nor-
mal renal unction but low serum bicarbonate, indicating a
possible metabolic acidosis. In speaking with his mother, you
discover that earlier in the day, he was playing unsupervised
in the bathroom, where she keeps her prenatal vitamin. Upon
questioning the child, he states that he ate a bunch o “candy”
in the bathroom about 3 hours ago (all the more reason to
keep things up high and away rom children!).
Question 1.22.2 What component o prenatal vitamins is
most concerning or toxicity?
A) Folic cid.
B) Iron.
C) C lciu .
D) Vit in D.
Answer 1.22.2 The correct answer is “B.” Folic cid, c lciu ,
nd vit in D re ll toler ted well in high doses, s their
bsor tion ro the GI tr ct is li ited. Iron, however, c n con-
tinue to be bsorbed while it re ins in the GI tr ct. Iron is
direct irrit nt to the GI ucos (there ore, the bloody e esis
nd di rrhe ) nd inter eres with the electron tr ns ort ch in
nd erobic et bolis .
Question 1.22.3 The nurse asks i you should add on an iron
level to the blood that was drawn 3 hours a ter the inges
tion. You respond:
A) “No th nks. Iron levels re not hel ul.”
B) “No th nks. It’s too e rly. We need to w it until t le st
12 hours h ve el sed.”
C) “Yes, le se. I it’s nor l, we don’t need ny urther tre t ent.”
D) “Yes, le se. It y hel us deter ine the severity o toxicity.”
Answer 1.22.3 The correct answer is “D.” T e iron level
between 2 nd 4 hours er ingestion is the ost ccur te;
beyond this eriod, the jority o the iron is oving intr cel-
lul rly nd c nnot be e sured. For slow-rele se iron, seru
concentr tions should be e sured t 6 to 8 hours er inges-
tion. T ese e sures will give you e k seru iron concentr -
tion th t correl tes well with the severity o toxicity. However, a
low serum level o iron does not mean the symptomatic patient is
OK. Treatment is based on clinical ndings and NOT on serum
32 FAMILY MEDICINE EXAMINATION & BOARD REVIEW

iron levels. Once the iron oves into the eri hery, the seru TABLE 1-7 MANIFESTATIONS OF IRON TOXICITY
levels c n be low des ite signi c nt toxicity.
First (or early) Hours 0–6 Vomiting and diarrhea, o ten
phase (rarely > 6 bloody
Question 1.22.4 How do patients with an iron overdose hours) Metabolic acidosis
present?
Shock
A) Abdo in l in, vo iting, nd di rrhe .
B) He te esis, shock, nd co . Second (or 3–48 hours Resolving acidosis
C) Rel tively sy to tic. quiescent) (time variable) Resolving hypovolemia
phase
D) All o the bove. Frequently, asymptomatic

Third phase 12–48 hours GI hemorrhage

Answer 1.22.4 The correct answer is “D.” P tients who h ve (time variable) Lethargy, coma, shock
h d n iron overdose cl ssic lly ss through ive di erent
Cardiovascular collapse
h ses. he irst h se is ch r cterized by n use , vo iting,
Metabolic acidosis
di rrhe , nd bdo in l in. here y be he te esis
Renal ailure (variable)
nd he tochezi s the GI ucos beco es irrit ted. he
second h se is rel tively sy to tic eriod s the GI Fourth phase 2 days or Hepatotoxicity
sy to s resolve. During this quiet h se, iron is bsorbed more Hepatic necrosis
nd tr ns orted to the eri hery where it c uses the inter- Coma
ru tion o erobic et bolis . In the next (third) h se,
Fi th phase 2–4 weeks GI obstruction due to strictures
tients beco e hy otensive, cidotic, nd c n develo and scarring
ultisyste org n ilure nd co . It is this shock th t is
the usu l c use o de th in iron toxicity. he ourth h se
is her lded by he tic necrosis. Liver ilure, which does
not occur in ll tients, is the second ost requent c use HELPFUL TIP:
o de th in c ses o iron toxicity. Fin lly, the tient y Patients who are entirely asymptomatic 6 hours a ter
develo bowel obstructions 2 to 4 weeks or longer ter the iron ingestion and do not have any radiographic evi-
ingestion due to stricture or tion t the site o ucos l dence o iron in the GI tract are not at risk or toxicity.
irrit tion. See ble 1-7. They can be sa ely discharged with close ollow-up.
The caveat is that chewable multivitamins are not radi-
Question 1.22.5 Abdominal lms reveal radiopaque pills opaque and will not show up on x-ray.
in the stomach. What is the best next step in treatment or
this patient?
A) Whole bowel irrig tion with olyethylene glycol solution.
B) G stric l v ge. Question 1.22.6 The patient is symptomatic (vomiting and
C) Activ ted ch rco l. diarrhea), acidotic, and also has an iron level 650 µg/dL,
D) Syru o i ec c. which puts him at signi cant risk or toxicity. What is your
next step?
Answer 1.22.5 The correct answer is “A.” G stric l v ge nd A) Correction o cid–b se disturb nce nd ggressive uid
vo iting induced by syru o i ec c both ent il ir ount resuscit tion.
o risk nd neither h s been shown to be bene ci l. In ddi- B) ED A.
tion, there is the risk o s ir tion nd subsequent neu oni- C) De erox ine.
tis. T ere ore, “B” nd “D” re not correct. Iron, lithiu , nd D) A nd B.
le d will not dsorb to ctiv ted ch rco l; there ore, it is o E) A nd C.
no bene t in such c ses, nd “C” is incorrect. re t ent or
iron toxicity involves whole bowel irrig tion with olyethyl- Answer 1.22.6 The correct answer is “E.” In ddition to sy -
ene glycol solution to ush the iron out o the GI tr ct. T ere to s nd cidosis, n iron level >500 µg/dL or ingestion o
re v rious doses nd r tes o d inistr tion ublished, but ore th n 60 g/kg o ele ent l iron re considered high-risk
10 to 15 L/kg/hr, u to 2,000 cc/hr, see s to be re son ble situ tions, nd chel tion with de erox ine is w rr nted. De -
l ce to st rt. T is requires the l ce ent o n sog stric erox ine is used to chel te iron, while ED A is chel tion
tube. I tient does not toler te the volu e o the in usion, tre t ent or le d oisoning. F stidious su ortive c re, with
the r te should be decre sed by 50%. T e irrig tion should correction o the tient’s volu e nd cid–b se disturb nces,
continue until the rect l ef uent is cle r nd there re no is i er tive. Ensuring th t the tient is euvole ic is es e-
visible ill r g ents. I ollow-u r diogr hs de onstr te ci lly i ort nt when using chel tion ther y, given th t the
ersistent iron t blets in the sto ch, consider the ossibility jor side e ect o de erox ine is hy otension. T e dose o
o bezo r h ving or ed, which y require endosco ic or de erox ine is 15 g/kg/hr or 24 hours, but y be slowed
surgic l intervention or re ov l. down i the tient beco es hy otensive.

HELPFUL TIP:
Dialysis does not remove iron rom the blood stream
nor the intracellular space, where the majority o it will
be ound. Dialysis may be indicated to treat renal ailure
or persistent pro ound acidosis.
HELPFUL TIP:
The much touted “de eroxamine challenge” to see i
there is ree iron in the blood is not an accurate predic-
tor o toxicity. The test is done by giving an individual a
single challenge dose o de eroxamine and seeing i the
urine changes to a “vin rose” color re lecting circulat-
ing ree iron. However, this does not predict who needs
therapy, since the iron may already be working its evil
in the periphery.
Objectives: Did you learn to . . .
• Rehydrate a child with GI symptoms?
• Recognize the mani estations o iron poisoning?
• Manage a child with an iron ingestion?
CASE 1.23
A 25-day-old emale newborn is brought to the ED by her
parents. T ey state that she has not been breast- eeding well
this morning and has elt warm. T ey measured her axillary
temperature as 100.6°F with an axillary digital thermom-
eter at home. T ey have not noticed any rhinorrhea, cough,
or rashes. T e baby is having ve to six wet diapers per day
and ve to six yellow seedy stools per day. T e child has not
had any sick contacts. She slept normally last night, but was a
little hard to wake up rom her morning nap today. T e baby
was the 7 lb 8 oz product o an uncomplicated term gestation,
born via normal spontaneous vaginal delivery to a group B
streptococcus (GBS)-negative mother. T ere were no compli-
cations in the early neonatal period, and the baby was dis-
charged with the mother at 2 days o li e a er receiving rou-
tine neonatal care. At her 2-week weight check, she seemed to
be gaining weight well and her doctor had no concerns.
Question 1.23.1 Which o these is NOT a common cause o
serious in ections in children younger than 1 month?
A) Listeria monocytogenes.
B) Neisseria meningitides.
C) GBS.
D) Pseudomonas aeruginosa.
Answer 1.23.1 The correct answer is “D.” “A,” L. monocyto-
genes, is n oblig te intr cellul r n erobe th t is tr ns itted
tr ns l cent lly ro other to child. “B,” N. meningitides, is
Gr -neg tive di lococcus th t colonizes the res ir tory
tr ct o u to 15% o he lthy individu ls. It is usu lly s re d
through close cont ct. “C,” GBS, is Gr - ositive org nis th t
CHAPTER 1 • EMERGENCY MEDICINE 33
colonizes the genit l tr ct o nor l he lthy wo en. GBS y
be the ost co on c use o b cteri l in ection in the newborn.
T e e k incidence o GBS dise se is in the rst 7 d ys o li e, but
there y be del yed resent tion out to 30 d ys. Pseudomonas
in ections re not co only seen in the neon t l eriod.
HELPFUL TIP:
Look care ully or cold sores or other vesicular lesions on
children with rashes. Also try to get a history o any close
contacts between the patient and people with cold sores.
Herpes virus in ection can be devastating to the newborn,
and they may require treatment with antiviral medication.
T e child is seen in her ather’s arms. She appears to have
normal color and tone. She is sleeping, but arouses a er some
stimulation. She seems ussy, but can be consoled by her par-
ents. Vitals: temperature 38.7°C rectally, pulse 165 bpm, and
respiratory rate 32. She appears to be well hydrated, and oth-
erwise has a completely normal physical examination.
Question 1.23.2 What urther evaluation is indicated now?
A) CBC, blood cultures, c theterized urine or n lysis nd culture.
B) CBC, blood cultures, b g urine or n lysis nd culture.
C) CBC, blood cultures, chest r diogr h, c theterized urine
or n lysis nd culture.
D) CBC, blood cultures, c theterized urine or n lysis nd cul-
ture, lu b r uncture, nd chest r diogr h.
Answer 1.23.2 The correct answer is “D.” It is i ort nt th t
co lete ev lu tion nd se tic work-u be er or ed on ll
children younger th n 28 d ys old without de nite source o
in ection. T is includes CBC, blood cultures, c theterized urine
s eci ens or n lysis nd culture, nd lu b r uncture. A
chest x-r y need not be done in the tient without res ir tory
sy to s but is highly reco ended. LP is nd tory. Even i
you sus ect neu oni or U I, n LP should still be consid-
ered, s it is i ossible to tell i the b cteri h ve s re d he -
togenously to the eninge l s ce.
HELPFUL TIP:
Do not delay antibiotic therapy to obtain a lumbar punc-
ture. Lumbar punctures per ormed within 2 to 4 hours
o receiving antibiotics should still yield valid results.
HELPFUL AND CONTROVERSIAL TIP:
Some would argue that a bag urine should be done as
the initial urine examination. While not as speci ic as
a catheterized urine, it is more sensitive or UTI. I the
bag UA comes back positive, a catheterized specimen
should be sent or culture.
Question 1.23.3 You are awaiting lab results. Should you
play World o Warcra t, Minecra t or start antibiotics? You
34 FAMILY MEDICINE EXAMINATION & BOARD REVIEW

decide to start antibiotics. Which antibiotics are most
appropriate or empiric therapy in this patient?
A) A icillin nd gent icin.
B) Ce ri xone.
C) V l cyclovir.
D) A oxicillin with or without cl vul n te.
E) Any o the bove re equ lly v lid choices.
Answer 1.23.3 The correct answer is “A.” A icillin nd gen-
t icin cover ll o the co on c uses o serious b cteri l
in ection in the newborn, nd both ntibiotics enetr te into
the cerebros in l uid (CSF) well. Ce ri xone lso enetr tes
the CSF well, but is highly bound to lbu in nd y dis l ce
bilirubin. T ere h ve been c se re orts o kernicterus ollow-
ing the d inistr tion o ce ri xone in newborns, so its use is
not reco ended in children younger th n 1 onth. I there
is concern or her es virus in ection, cyclovir IV would be
re erred over v l cyclovir, but neither o these is used on n
e iric b sis routinely. A oxicillin, with or without cl vul -
n te, does not enetr te the CSF s well s icillin nd is
thus not re erred when eningitis is ossibility.
Question 1.23.4 What is the appropriate disposition or this
child?
A) Ad ission to the gener l edi trics oor.
B) Ad ission to the edi tric intensive c re unit.
C) Monitor or 3 hours in the ED, nd decide b sed on l bor -
tory results.
D) Disch rge with 24-hour ollow-u .
Answer 1.23.4 The correct answer is “A.” T is child does
not look toxic nd c n rob bly be n ged ro ri tely
on gener l edi trics oor inste d o n intensive c re unit.
T is child should be d itted, reg rdless o wh t the l bor -
tory results de onstr te. So e ex erienced r ctitioners will
disch rge nontoxic ebrile child ro the ED i he or she is
older th n 2 onths nd h s ollow-u within 24 hours. How-
ever, there is so e risk inherent in this r ctice—n ely, th t
deterior tion in the tient’s condition y go unrecognized t
ho e nd th t the ily will il to ollow-u . T e st nd rd o
c re is to d it ll children who h ve ever when they re less
th n 30 d ys old.
HELPFUL TIP:
With the advent o the polyvalent pneumococcal vac-
cine and the implementation o universal screening or
GBS, the incidence o occult serious bacterial in ection is
alling. It may be that in the near uture, the way in which
ebrile in ants younger than 3 months are evaluated and
treated will change. However, the practice outlined in
Table 1-8 represents the current standard o care.
HELPFUL TIP:
Even when present, otitis media is not considered
a source o ever when evaluating the neonate. You
should continue with your clinical and laboratory evalu-
ation as i you did not even see the ears!
Objectives: Did you learn to . . .
• Describe common bacterial agents causing in ection in the
early neonatal period?
• Evaluate the ebrile newborn?
• Manage the ebrile newborn?

TABLE 1-8 CURRENT RECOMMENDATIONS FOR EVALUATING THE FEBRILE CHILD

Age ≤ 28 days
• These neonates are assumed to have bacteremia and potential seeding o the CSF, even i a source is discovered.
• Work-up should include cultures o blood, urine, CSF, and stool (i GI symptoms present) and CXR (i respiratory symptoms present).
• CBC and/or CRP can be obtained, but the decision about whether or not to proceed with evaluation should not be based on these results!
• The child should be admitted or IV antibiotics until cultures are negative.

Age 1–3 months

• It is sa est to assume they are still unable to contain bacterial in ections at this age.
• Patients at low risk o having a serious bacterial in ection have the ollowing labs:
• WBC >5,000, <15,000/mm 3 with band count <1,500/mm 3
• Normal urinalysis
• Normal CSF
• Stool microscopy <5 WBC/HPF i diarrhea present
• I no source is ound on examination, it is reasonable or patients meeting these low-risk criteria to be managed with intramuscular ce triaxone in the
ED/clinic—i ollow-up can be arranged to receive a second dose in 24 hours.
• It should be emphasized that these in ants are still vulnerable to dissemination o bacterial in ections. There ore, those with an obvious source, those
who appear clinically ill, or those who do not meet the low-risk criteria should be cultured and admitted or IV antibiotics until cultures are negative.

Age 3–36 months

• Management o ever in this group is somewhat controversial, as the advent o Prevnar (pneumococcal vaccine) and continued use o HIB vaccine will
presumably reduce the risk o invasive bacterial disease.
• It is generally accepted that well-appearing children with evers less than 39°C do not require urther evaluation or antibiotics.
• Up to 5% o children with temperature >39°C who appear clinically well will have positive blood cultures (occult bacteremia), putting them at risk or
serious in ections. One approach is to obtain screening WBC on those with evers >39°C. I WBC <5,000 or >15,000/mm 3 or bands >l,500/mm 3, then
urther evaluation o blood, urine, and CSF should be considered.

CASE 1.24
A 6-month-old male is brought to the ED by his ather. He
has had a little bit o rhinorrhea or the last 36 hours but no
evers. A ew hours ago, he began coughing and seemed to
be having some di culty breathing. He has been taking his
bottle and rice cereal well. His ather states that there have
been no changes in his stools. He is ully vaccinated, has no
signi cant past medical history, and has had no known sick
contacts.
Question 1.24.1 What is the most common cause o respi
ratory distress in a 6 month old (and not necessarily the
diagnosis in this child)?
A) Pneu oni .
B) Foreign body s ir tion.
C) Bronchiolitis.
D) Second-h nd s oke ex osure.
Answer 1.24.1 The correct answer is “C.” Bronchiolitis is very
co on, es eci lly in the winter onths. It is usu lly c used
by the res ir tory syncyti l virus, but c n lso be c used by
r in uenz , in uenz , nd hu n et neu ovirus. Bron-
chiolitis is usu lly ssoci ted with ro use rhinorrhe , broncho-
s s , nd ucus lugging o the bronchiole tree. Although,
“A,” neu oni is serious c use o res ir tory roble s, it is
not terribly co on in in nts. “B,” oreign body s ir tion, is
so ething th t ust be lw ys considered in n in nt, es e-
ci lly 6- onth-old who is beco ing ore obile ( nd to
who everything looks like ood). Second-h nd s oke ex o-
sure c n c use chronic irrit tion to the res ir tory tr ct nd c n
ex cerb te bronchos s , but it is in requently the sole c use o
res ir tory distress.
As you examine the child, you note that he is mildly tachy-
pneic with some suprasternal, subcostal, and intercos-
tal retractions. He makes a whistling, wheezing sound on
inspiration (stridor) that seems to get worse the harder he
breathes. He also has a brassy-sounding cough that does not
seem to be productive.
Question 1.24.2 What is the most likely diagnosis at this
point?
A) Pneu oni .
B) Crou .
C) L ryngo l ci .
D) Asth .
Answer 1.24.2 The correct answer is “B.” Crou , or l ryngotr -
cheobronchitis, is co on in ection o the u er nd lower
res ir tory tr ct. It is ost co only c used by r in uenz
virus, but y lso be c used by in uenz nd res ir tory syn-
cyti l virus. Cl ssic lly, this ects children younger th n 5
ye rs, lthough it is occ sion lly seen in older children. As the
glottis swells, children develo wheeze/whistle on ins ir tion
(ins ir tory stridor) nd ch r cteristic br ssy “se l-like” b rk-
ing cough. T e v st jority o c ses re ild. Occ sion lly,
CHAPTER 1 • EMERGENCY MEDICINE 35
however, children y require control o the irw y due to
hy oxi . “A,” neu oni , is n in ection o the lower irw ys th t
c n be either b cteri l or vir l in n ture. T ese children gener lly
h ve ever nd roductive cough. T ey y be t chy neic nd
h ve n incre sed work o bre thing, but they usu lly do not h ve
ins ir tory stridor. “C,” l ryngo l ci , is congenit l disorder.
T ese children usu lly develo sy to s t ew weeks o ge
nd resent with ins ir tory stridor th t gets worse with crying. It
tends to be little better when the child is c l nd in the su ine
osition. L ryngo l ci resolves s ont neously in the jor-
ity o children s the l rynx beco es ore r nd the irw y
di eter incre ses, but so e children will require surgic l inter-
vention to cilit te eeding nd growth. T e child in this vignette
is resenting with new roble , s o osed to chronic one, so
this is not l ryngo l ci . “D,” sth , is nother dise se o the
lower irw ys, nd wheezing is ex ir tory in n ture.
You decide to do a radiograph o this child’s neck to aid in the
diagnosis (although this is certainly not necessary nor advo-
cated in most cases—but this is a board review book, not real
li e).
Question 1.24.3 You are most likely to see which o the
ollowing on cervical radiograph?
A) T u b sign.
B) Quincke sign
C) S ine sign.
D) Retro h rynge l s ce swelling.
E) Stee le sign.
Answer 1.24.3 The correct answer is “E.” R diogr hs in
crou show the “stee le sign,” which is subglottic n rrowing
o the tr che ro ede , giving it stee le-like e r nce.
“A,” the thu b sign, is seen in e iglottitis. “B,” Quincke sign is
incorrect, s it h s nothing to do with r diology. Quincke sign
is the ungu l c ill ry uls tion ssoci ted with ortic insu -
ciency—it’s r re, not seen in children, nd ne rly useless knowl-
edge . . . but th t is wh t you re ying us or! “C,” the s ine
sign, is loss o rogressive r diolucency o the s ine on l ter l
chest r diogr h. T is is seen when so ething—cl ssic lly
n in ltr te indic tive o neu oni —is overl ying the lower
thor cic s ine king the vertebr l bodies e r ore dense.
Fin lly, “D,” retro h rynge l s ce swelling, is seen in retro h -
rynge l bscess.
Question 1.24.4 What is the most appropriate de nitive
therapy or this patient at this time?
A) E ine hrine 0.01 g SQ.
B) Nebulized lbuterol.
C) Dex eth sone 0.6 g/kg PO/IM/IV.
D) High ow oxygen nd re re to intub te.
Answer 1.24.4 The correct answer is “C.” Corticosteroids hel
to decre se the glottic ede . One dose o dex eth sone 0.3
to 0.6 g/kg ( xi u o 10 g) c n be given vi ulti le
routes (PO/IM/IV) nd is usu lly su cient to i rove the ir-
w y swelling enough to llow the child to bre the co ort bly.
36 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
T e dv nt ge o dex eth sone over rednisone or nother
corticosteroid is th t its long h l -li e obvi tes the need or ur-
ther dosing t ho e. While w iting or the dex eth sone to
work, e ine hrine y be d inistered vi nebulizer or severe
c ses. T is usu lly le ds to signi c nt clinic l i rove ent nd
gives ti e or the steroid to begin to t ke e ect. Subcut neous
e ine hrine is usu lly unnecess ry. Albuterol, while hel ul or
bronchos s , does not do nything to tre t the glottic ede
th t is c using the jority o the res ir tory distress. Intub -
tion is not indic ted t this oint i the child is not in i ending
res ir tory ilure, hy oxic, or ini lly res onsive.
HELPFUL TIP:
While classically we have used racemic epinephrine, the
“d” isomer is inactive. In addition, racemic epinephrine is
more expensive and must be kept re rigerated i a multi-
dose vial is used. L-epinephrine, 5 cc o 1:1,000, delivered
by nebulizer is as—i not more—e ective, than racemic
epinephrine, is cheaper, and (our avorite since we can’t
do simple math!) is the same dose or everyone.
You administer the appropriate dose o dexamethasone to
the child along with a treatment o nebulized epinephrine.
He improves markedly. You watch him or 2 hours. He is able
to tolerate oral f uids well, and is active and play ul. He still
has a brassy cough, but no inspiratory stridor.
Question 1.24.5 What should his disposition be?
A) Ad it or 23 hours o observ tion.
B) Ad inister second dose o r ce ic e ine hrine nd re-
ev lu te.
C) Disch rge to ho e with close out tient ollow-u .
D) Ad inister lbuterol nd re-ev lu te.
Answer 1.24.5 The correct answer is “C.” A er d inister-
ing dex eth sone nd e ine hrine, it is i er tive to observe
children or t le st 2 hours. I child redevelo s stridor t rest,
he/she should receive second dose o e ine hrine. Any child
who needs second tre t ent h s ore severe crou , is t
higher risk o h ving co lic tions, nd should be considered
or hos it l d ission. I the child is ree o stridor 2 hours er
nebulized e ine hrine, she c n be s ely disch rged with close
out tient ollow-u (within 24 hours) s long s the rents re
reli ble, ble to onitor the child, co ort ble with the l n,
nd ble to return i the child’s condition should deterior te.
HELPFUL TIP:
Remember that an oxygen saturation o less than 95% is
singularly abnormal in a child.
Objectives: Did you learn to . . .
• Describe common causes o respiratory distress in children?
• Manage pediatric airway problems?
• Treat children with croup?
QUICK QUIZ: FOREIGN BODY
A 3-ye r-old boy nd his 5-ye r-old sister were being silly,
voiding bedti e, nd ju ing on their rent’s bed. N tur lly,
he h d nickel in his outh th t he’d ound on the oor. When
their other w lked in to wr ngle the into their j s, they
redict bly collided in id- ir nd both ell o the bed nd onto
the oor. She w s un ble to nd the nickel er the incident.
Coincident lly, the 3-ye r-old eels like he h s so ething stuck
in his thro t—so ething with T o s Je erson’s he d on it.
When the ily rrives in your o ce, he t kes liquids
without uch trouble, but won’t t ke nything solid. He s ys
his “thro t hurts.” He’s not drooling or h ving ny trouble
bre thing.
How do you con r th t the coin is not in the irw y?
A) C o the l rynx nd chest without IV contr st.
B) C o the l rynx nd chest with IV contr st.
C) AP nd l ter l l in l s o the neck.
D) Direct l ryngosco y.
E) C ll ul onologist or e ergent bero tic bronchosco y.
The correct answer is “C.” Fortun tely coins re r dio que—
t le st s o the rinting o this book ( ybe we’ll h ve wood-
en coins g in so ed y!). So e l stic toys leg lly cont in
b riu nd re r dio que while others re in dvertently
r dio que (like those de in Chin cont in ted with
le d . . . ixed blessing t best!). T e eso h gus tends to col-
l se ro nterior to osterior when there is nothing in the
lu en. T ere ore, coin in the eso h gus should look round
on n AP x-r y. By contr st, the tr che is su orted by c rti-
l ginous rings round ost o its circu erence. T e osterior
rt o the tr che , however, buts the eso h gus nd h s no
c rtil ge. T ere ore, coins th t ll into the tr che gener lly
h ve n end-on e r nce on AP r diogr hs nd look like
disc on l ter l l .
T e coin ell into the stomach on the way to x-ray and the
little boy eels better.
Wh t oreign bodies in the stomach need to be re oved e er-
gently?
A) A button b ttery.
B) A ercli th t is olded in its origin l or .
C) wo s ll gnets.
D) A doll’s shoe.
The correct answer is “C.” wo gnets c n ttr ct e ch other
through o osing loo s o bowel, c using bowel necrosis nd
er or tion. One gnet should not c use ny trouble, but
two should be t ken seriously. Button batteries lodged in the
esophagus need to be removed emergently. However, once a
button battery transitions to the stomach, it will likely pass
without causing any di culty. However, it should be re-
moved i it remains in the stomach or more than 48 hours

or is ≥ 15 mm. Other s ooth or rounded objects re unlikely to
c use ny trouble. Even s ll sh r objects ( ush ins) gener lly
ss without c using er or tion or other signi c nt d ge.
CASE 1.25
A 67-year-old emale with a history o dialysis presents
slumped over and complaining o generalized weakness.
By the time she is in a room, her eyes are closed, she is non-
verbal, withdraws rom pain ul stimuli and does not ollow
commands but has a palpable pulse at 80 beats per minute.
Her husband notes that she has been using “light salt,” which
contains potassium. You remember the “coma cocktail”
rom earlier in this chapter: glucose, naloxone, thiamine and
oxygen. You also remember that not all narcotic overdoses
are associated with pinpoint pupils. You treat her appropri-
ately. T e patient’s blood sugar is 211 mg/dL. T e patient’s
husband states that dialysis was not per ormed today. T e
patient also missed her last dialysis appointment 2 days ago
because she elt ill at home. Her mental status is unchanged
a er the “coma cocktail”; she is unable to protect her airway.
Husband con rms patient is ull code. You decide to proceed
with intubation.
Question 1.25.1 The best medications to use in this patient
are (induction agent/paralytic agent):
A) Eto id te/succinylcholine.
B) Eto id te/ket ine.
C) Eto id te/rocuroniu .
D) An induction gent nd r lytic re unnecess ry in this
tient since she is only res onsive to dee sti uli.
Answer 1.25.1 The correct answer is “C.” Rocuroniu would be
the r lytic o choice in this tient. In tient with end-st ge
ren l dise se on he odi lysis, ssu e the resence o hy erk -
le i until roven otherwise. Succinylcholine y c use hy er-
k le i ( nd c rdi c rrest) so it is contr indic ted in tients
with high likelihood o hy erk le i . Succinylcholine should
lso be voided in crush injuries, neurologic injuries/ yo -
thies, nd burn tients where it y c use lign nt hy er-
ther i . A sed tive should be used or induction to revent in
nd either eto id te or ket ine y be used—not both.
You secure the irw y. A S A ot ssiu returns t 7.9.
D rn! You look t the onitor nd notice the QRS is looking
little wide. Double d rn!
Question 1.25.2 While you are waiting or an ECG to be
obtained, you administer:
A) K yex l te.
B) Sodiu bic rbon te.
C) C lciu glucon te.
D) Insulin/glucose.
E) Albuterol nebulizer.
Answer 1.25.2 The correct answer is “C.” In hy erk le i
with evidence o ECG ch nges ( e ked w ves, wide QRS,
sine w ve), c lciu needs to be d inistered i edi tely. T e
CHAPTER 1 • EMERGENCY MEDICINE 37
c lciu st bilizes c rdi c cell e br nes within 1 inute.
C lciu glucon te 1 g or c lciu chloride 1 g y be given.
C lciu chloride is irrit ting to veins nd y c use necrosis
i it extr v s tes: centr l line d inistr tion is re erred. All o
the other nswers do lower ot ssiu levels (including continu-
ously nebulized lbuterol), but when there is evidence o ECG
ch nges, giving c lciu is your to riority. T e other gents
y t ke s long s 30 to 60 inutes to ct. As note, bic rbon-
te y not be rticul rly e ective in tients with end-st ge
ren l dise se, nother re son to use c lciu rst in this tient.
A er two doses o calcium gluconate, the QRS narrows and
you want to get the excess potassium out o your patient’s
body.
Question 1.25.3 Which o the ollowing removes potassium
rom the body?
A) He odi lysis.
B) Insulin/glucose.
C) K yex l te (sodiu olystyrene)
D) Albuterol.
E) A nd C.
Answer 1.25.3 The correct answer is “E.” Both he odi lysis
nd sodiu olystyrene will re ove ot ssiu ro the body.
Insulin/glucose will drive it intr cellul rly in 30 to 60 inutes
but does not rid the body o ot ssiu . Be c re ul: sodiu oly-
styrene exch nges sodiu or ot ssiu nd thus y worsen
congestive he rt ilure. T e use o sodium polystyrene with
sorbitol is discouraged. It is ssoci ted with bowel ische i
nd necrosis. In addition, be care ul using sodium polysty-
rene in those with GI problems (ileus, stricture, etc.) or the
same reason. Note th t tiro er, new ot ssiu binder, h s
recently been roved or use in the United St tes. However, it
y not lower ot ssiu or u to 7 hours er d inistr tion
nd is NO roved or the cute lowering o ot ssiu .
T e patient does well and, in the uture, knows to avoid
“light” salt (KCl) (o course, “light” is now spelled “lite” or
some unknown reason).
Objectives: Did you learn to . . .
• Describe contraindications o succinylcholine in intubation?
• Treat hyperkalemia in the acute situation?
CASE 1.26
A 24-year-old male presents to your ED complaining o
“dental pain.” He reports a long history o poor dental hygiene
and has not seen a dentist in several years. He smokes two
packs o cigarettes per day (and proudly wears a “Marlboro”
hat) and admits drinking a 2 liter bottle o “Hillbilly Holler”
every day at work (it includes a ree coupon or dental service
a er 100 bottles, but he has never availed himsel o this). T e
pain is described as constant and throbbing in nature located
in the right lower jaw area.
38 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Question 1.26.1 What ndings during your examination
would raise your concern regarding the patient’s clinical
condition?
A) L rge ounts o secretions.
B) Decre sed bility to o en his outh or the ex in tion.
C) Swollen nd elev ted tongue.
D) P in nd decre sed r nge o otion o the neck.
E) All o the bove.
Answer 1.26.1 The correct answer is “E.” I tient is h v-
ing trouble sw llowing secretions (“A”), it should r ise concern
or swelling in the osterior h rynx which c n co ro ise
not only the bility to sw llow one’s s liv but c n lso sign l
high risk or u er irw y occlusion second ry to swelling.
ris us (“B”) is lso concerning bec use it y indic te dee er
in ection involving the uscles o stic tion. “C,” swollen
nd elev ted tongue, y indic te the develo ent o Ludwig
ngin , li e-thre tening in ection o the oor o the outh,
which c n s re d to the dee er tissues o the sub ndibu-
l r nd sub xill ry s ces. “D,” in nd decre sed r nge o
otion o the neck, could indic te the ossibility o retro h -
rynge l bscess.
HELPFUL TIP:
Adult epiglottitis o ten presents with sore throat and
neck tenderness. So, i the patient has neck tenderness
out o proportion to what you would expect, consider
epiglottitis or a retropharyngeal abscess.
Luckily, the patient is otherwise clinically stable aside rom
the ocal dental pain. Your examination shows the tissues
around tooth number 29 (we can never remember that pesky
numbering scheme either) to be swollen and inf amed with
signs o f uctuance and severe tenderness on palpation. An
orthopantogram shows a periodontal abscess.
Question 1.26.2 Which antibiotic is NOT an appropriate
choice or this clinical condition?
A) Penicillin VK.
B) Clind ycin.
C) A oxicillin/cl vul n te.
D) ri etho ri –sul ethox zole.
Answer 1.26.2 The correct answer is “D.” Penicillin VK,
clind ycin, nd oxicillin/cl vul n te ll rovide good cov-
er ge or n erobic b cteri including n erobic Gr -neg tive
cocci, which re the in cul rits in dent l in ections. MP–
SMX h s so e Gr -neg tive cover ge but l cks the n erobic
cover ge needed to tre t in ections o the or l c vity.
T e same gentleman returns to you 3 weeks later complaining
o a sore throat. On examination, he looks toxic and has ever,
chills, dyspnea/cough, and unilateral neck swelling. His throat
looks similar to a streptococcal tonsillitis. However, the neck
is tender and this guy really looks sick. Pulse is 130 bpm and
BP is 80/50 mm Hg. He was seen last week by someone else
or a mild sore throat and given a “Z-Pak” (azithromycin—
mostly on a whim). He has gotten progressively worse. Chest
x-ray shows in ltrates and small abscesses.
Question 1.26.3 Your presumptive diagnosis is:
A) Mononucleosis.
B) Fusobacterium.
C) Arcanobacterium hemolyticum.
D) Vir l URI
Answer 1.26.3 The correct answer is “B.” Fusobacterium is
n n erobic in ection th t h s been ound with incre sing
requency in dolescent/college ge tients. It c n initi lly
resent si il rly to stre thro t but y go on to “Le ierre
syndro e,” which is se tic thro bo hlebitis o the intern l
jugul r vein. T is c n then le d to se tic e boli to the lungs,
se sis, nd ultiorg n ilure. T e oint here is th t enicillin
is still the drug o choice or stre thro t, nd it covers Fusobac-
terium, which the crolides do not. As or the other nswers,
this is not likely ononucleosis (“A”), since the neck swelling is
unil ter l nd tients with ono usu lly re not this toxic nor
h ve in ltr te on chest x-r y. “C,” A. hemolyticum, is lso co -
on in college ge students nd is initi lly clinic lly indistin-
guish ble ro stre thro t. However, 50% o tients will h ve
culo ul r or sc rl tini or r sh st rting on the extre i-
ties nd involving the trunk nd b ck but s ring the he d; s
o osed to the r sh o sc rlet ever the r sh does not eel. It
r rely c uses inv sive dise se such s neu oni or eningitis.
It will res ond to erythro ycin or clind ycin nd less so to
enicillin. “D” is obviously incorrect nd i you chose this one,
b ck to edic l school or you!
T e patient spends 3 weeks in the ICU and eventually suc-
cumbs to his disease. Not good (way or us to end on a
“downer” you say, but at least you get the message that
“Z-paks” aren’t always the answer!).
Objectives: Did you learn to . . .
• Identi y Fusobacterium and Arcanobacterium in ections?
• Initial treatment o dental abscesses?
Clinical Pearls
Avoid CT scans in patients with known urolithiasis who have
the same symptoms again unless you suspect a postobstruc-
tive in ection or have reason to believe it could be an aortic
problem (e.g., at-risk patients over 50 years old).
Avoid the use o narcotics or migraine headaches i possible.
Prochlorperazine or metoclopramide work well with pro-
chlorperazine IV being the pre erred agent.
Do not do a chest CT i a patient is PERC negative or is low
risk or a PE and has a negative d-dimer. Besides the expense,
the cancer risk or a 20-year-old emale rom a single 64 slice
chest CT is approximately 1 in 250.
Do not do a head CT or patients with simple syncope: syn-
cope is not a brain disease. It is generally a problem o CNS

per usion; you have to knock out both hemispheres simulta-
neously to lose consciousness.
Do not do a head CT in low risk patients with head trauma.
Use a prediction rule. However, it is reasonable to CT those
on anticoagulants.
Do not do a head CT looking or the cause o vertigo; it is
almost always useless. I you need imaging, do an MRI but
recognize that and MRI will be negative or posterior circula-
tion stroke in 30% o cases within the irst 24 hours.
Do not do a head CT o children with a irst uncomplicated
seizure.
Do not get back imaging or acute low back pain unless there
are red lags, such as: ever, cancer history, signi icant trauma
(not just twisting or picking something up), neurologic symp-
toms or signs.
Only give as much blood as is necessary. Giving one unit is
ine. As a general rule, don’t trans use a stable patient with a
hemoglobin o 7.0 g/dL or greater.
Phenytoin and osphenytoin do not work or alcohol with-
drawal seizures, seizures caused by drug overdose or with-
drawal (in general). Use a benzodiazepine.
BIBLIOGRAPHY
Benson BE, et l; A eric n Ac de y o Clinic l oxicology;
Euro e n Associ tion o Poisons Centres nd Clinic l
oxicologists. Position er u d te: g stric l v ge or
g strointestin l decont in tion. Clin Toxicol (Phila).
2013;51(3):140–146.
Brown CV, et l. Preventing ren l ilure in tients with
rh bdo yolysis: do bic rbon te nd nnitol ke
di erence? J Trauma. 2004;56(6):1191–1196.
C rr ro S, et l. Bronchiolitis: ro e iricis to scienti c
evidence. Minerva Pediatr. 2009;61:217–225.
Diercks DB, et l; ACEP Clinic l Polices Co ittee. Clinic l
Policy: critic l issues in the ev lu tion nd n ge ent o
dult tients with sus ected cute nontr u tic thor cic
ortic dissection. Ann Emerg Med. 2015;65:32–42.
Engebretsen KM, et l. High-dose insulin ther y in bet -
blocker nd c lciu ch nnel-blocker oisoning. Clin
Toxicol (Phila). 2011;49(4):277–283.
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Frithsen IL, Si son WM Jr. Recognition nd n ge-
ent o cute edic tion oisoning. Am Fam Physician.
2010;81:316–323.
Green NE, Allen L. V scul r injuries ssoci ted with disloc -
tion o the knee. J Bone Joint Surg Am. 1977;59:236–239.
Herz AM, et l. Ch nging e ide iology o out tient b ctere-
i in 3- to 36- onth-old children er the introduction
o the he t v lent-conjug ted neu ococc l v ccine.
Pediatr In ect Dis J. 2006;25:293–300.
Hu JS, et l; ACEP Clinic l Policies Co ittee. Clinic l
Policy: critic l issues in the ev lu tion nd n ge ent
o dult tients resenting to the e ergency de rt ent
with seizures. Ann Emerg Med. 2014;63:437–447.
Isbister GK, Ku r VV. Indic tions or single-dose ctiv ted
ch rco l d inistr tion in cute overdose. Curr Opin Crit
Care. 2011;17:351–357.
Leung AK, Sig let DL. Acute bdo in l in in children. Am
Fam Physician. 2003;67:2321–2326.
M rx J, et l. Rosen’s Emergency Medicine Concepts and Clinical
Practice. 8th ed. St. Louis, MO: Mosby Elsevier He lth
Sciences; 2010.
Mokhlesi B, et l. Adult toxicology in critic l c re: P rt II:
S eci c oisonings. Chest. 2003;123:897–922.
Mosc ti RM, et l. A ulticenter co rison o t w ter ver-
sus sterile s line or wound irrig tion. Acad Emerg Med.
2007;14(5):404–409.
Nikk nen H, Skolnik A. Di gnosis nd n ge ent o c rbon
onoxide oisoning in the e ergency de rt ent. Emerg
Med Pract. 2011;13:1–14.
P nju AA, et l. T e r tion l clinic l ex in tion. Is this tient
h ving yoc rdi l in rction? JAMA. 1998;280:1256–1263.
Rogers RL, McCor ck R. Aortic dis sters. Emerg Med Clin
North Am. 2004;22:887–908.
Steiner RW. re ting cute bronchiolitis ssoci ted with RSV.
Am Fam Physician. 2004;69:325–330.
ouger M, et l. Rel tionshi between venous nd rteri l
c rboxyhe oglobin levels in tients with sus ected c rbon
onoxide oisoning. Ann Emerg Med. 1995;25(4):481–483.
Wol SJ, et l; ACEP Clinic l Policies Co ittee. Clinic l Poli-
cy: critic l issues in the n ge ent o dult tients re-
senting to the e ergency de rt ent with cute c rbon
onoxide oisoning. Ann Emerg Med. 2008;51:138–152.
Yucesoy K, Yuksel KZ. SCIWORA in MRI er . Clin Neurol
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Cardiology
K mbe S. De c u and Ma k A. G abe
CASE 2.1
A 35-year-old emale presents with a 1-hour history o chest
pain, which resolved spontaneously. T e pain is described
as a chest pressure radiating to both arms. T e patient is a
smoker but has no other risk actors (no amily history o car-
diac disease, hypertension, diabetes, hyperlipidemia, etc.).
T e patient is diaphoretic and has a normal blood pressure.
Physical examination reveals that the patient has tenderness
to palpation o the anterior chest wall that reproduces the
chest pressure. She is now otherwise ree o chest pain and all
her lab assays, including cardiac enzymes, are normal.
Question 2.1.1 Which o the ollowing is true about this
patient’s physical ndings and history?
A) Pain radiating to both arms makes it unlikely that this
patient’s pain is cardiac.
B) T e physical ndings that are most highly associated with
an acute myocardial in arction (AMI) include hypotension,
diaphoresis, and a new S3 gallop.
C) T e absence o risk actors makes it unlikely that this patient
has cardiac disease.
D) T e act that the pain is reproducible on palpation o the
chest wall e ectively rules out cardiac disease.
E) Based on the in ormation available, urther cardiac evalua-
tion is unnecessary.
Answer 2.1.1 The correct answer is “B.” T e ndings that
are most likely to be associated with an AMI are hypoten-
sion, diaphoresis, and a new S3 gallop. “A” is not true because
pain radiating to both arms can still be associated with car-
diac disease. In act, compared with le arm radiation, right
arm radiation or bilateral arm radiation doubles the likeli-
hood o the pain being cardiac (LR 2.3 or radiation to the le
arm vs. LR 4.1–4.7 or radiation to the right or bilateral arms).
(JAMA. 2005;294(20):2623–2629.) Women with AMI o en pres-
ent atypically and may experience more chest pain radiating to the
right arm/shoulder and the anterior neck or with abdominal
pain as compared with men. “C” is incorrect. T e absence o
40
2
risk actors is only one consideration in the evaluation o this
patient. Smoking, hypertension, amily history, etc., do not
change the prior probability o cardiac disease enough to allow
them to be used to rule out or rule in cardiac disease. O note,
male gender and diabetes DO increase the pretest probabil-
ity o coronary artery disease (CAD) (luckily our patient is a
woman!). Evaluation o pretest probability is important in the
diagnostic algorithm, but should be used in addition to, not in
exclusion o , clinical judgment and ndings. “D” is incorrect. It
is true that chest pain reproduced by palpation o the chest wall
makes cardiac disease less likely. However, 15% o patients with
cardiac disease and 17% o patients with a pulmonary embolism
(PE) will have their pain reproduced by chest wall pressure. T is
does not mean that you are making their cardiac pain worse. It is
likely because o the patient’s inability to discriminate between
the types o pain (cardiac vs. chest wall).
You decide that urther testing is warranted, including an
ECG and cardiac enzymes.
Question 2.1.2 Which o the ollowing statements is TRUE?
A) A normal initial ECG in the emergency department (ED)
e ectively rules out cardiac disease.
B) Creatine phosphokinase MB raction (CPK-MB) is more
sensitive but less speci c than troponin.
C) Serum troponin is an unreliable marker o cardiac ischemia
in patients with renal ailure.
D) T e serum troponin is 100% speci c or myocardial in arc-
tion.
E) A normal troponin and CPK in the ED cannot be used to
make decisions about who to admit.
Answer 2.1.2 The correct answer is “E.” Except in cases where
the chest pain has been continuous or over 12 hours, normal
cardiac enzymes (troponin, CPK-MB) do not rule out cardiac
disease. I they did, we would not admit patients or a “rule out”
but would rather rely on the single level drawn in the ED. “A” is
incorrect since 9% o patients with AMI will have a normal ini-
tial ECG in the ED. In act, only about 50% o those with AMI

have a diagnostic ECG in the ED. Even a normal ECG obtained
during chest pain does not reliably rule out AMI (Acad Emerg
Med. 2009;16:495). “B” is incorrect since the CPK-MB is over-
all less sensitive than a high sensitivity troponin. CPK-MB and
myoglobin may become positive earlier than the troponin.
However, CPK-MB and myoglobin add little, i anything, to the
troponin; many labs no longer per orm these assays in house.
Eighty percent o AMIs will have one positive marker within the
rst 3 hours o ED arrival (but 20% will not). “C” is incorrect.
Patients with renal disease may have a mildly elevated troponin
at baseline due to poor clearance, but troponin can still be use-
ul in these patients i it continues to rise. It may be use ul to
have knowledge o the patient’s baseline troponin in renal ail-
ure, but this is NO an indication to start drawing a baseline
troponin on all o your patients with renal ailure. “D” is incor-
rect because we now know that other processes, such as PE, can
elevate the serum troponin.
HELPFUL TIP:
E evated t p n n eve s ma be due t c nd t ns the
than AMi, nc ud ng hea t a u e, PE, bu ns, seps s
the c t ca ness, st ke, and m e.
HELPFUL TIP:
The new u t a-sens t ve t p n n ma be p s t ve w th n
3 h u s. y u need t kn w what test u h sp ta s
d ng. T p n n eve s peak n ab ut 36 h u s a te an
n a ct and ma sta e evated 7 t 10 da s, s the
n a ct ma have ccu ed an whe e w th n th s t me
ame. F w the t end the t p n n t he p dete -
m ne when the n a ct ccu ed.
Question 2.1.3 All o the ollowing statements are true
EXCEPT:
A) All myocardial in arctions present with chest pain.
B) Dyspnea may be the only presenting symptom o myocar-
dial in arction.
C) Patients with myocardial in arction can present with syn-
cope.
D) Females, the elderly, and diabetic patients are more likely to
present with atypical symptoms o myocardial in arction.
Answer 2.1.3 The correct answer is “A.” As the saying goes,
“Never say never, and never say always.” Many elderly and
diabetic patients (“D”) will present with atypical symptoms or
painless, “silent” myocardial in arctions. In act, up to 30% o
myocardial in arctions are pain ree. “B” is a correct statement
because, especially in the elderly, dyspnea may be the only pre-
senting symptom due to le ventricular ailure secondary to
ischemia. “C” is a correct statement because syncope (as well as
lightheadedness and atigue) can be presenting symptoms o a
myocardial in arction.
Her ECG shows nonspeci c S - changes.
CHAPTER 2 • CAr Dio l o Gy 41
Question 2.1.4 Which o the ollowing drug(s) is/are indi
cated in the initial management o this patient?
A) Aspirin.
B) T rombolytic such as tPA or streptokinase.
C) Heparin.
D) Glycoprotein IIb/IIIa inhibitor (e.g., apciximab [ReoPro]).
E) All o the above.
Answer 2.1.4 The correct answer is “A.” Immediate therapy
in the ED requires ASA 325 mg orally (chewed). Since we are
not sure that this patient has AMI or unstable angina, there is
no indication or thrombolytic therapy (“B”), heparin (“C”) or
glycoprotein IIb/IIIa inhibitor (“D”). Since she is currently pain
ree, heparin carries more o a risk than a bene t at this junc-
ture and is not recommended. However, all patients with pos-
sible angina or an AMI should have aspirin unless they are truly
allergic (hives, anaphylaxis). “B” is incorrect because thrombo-
lytics are indicated or acute S elevation myocardial in arctions
(S EMI), not or a simple chest pain evaluation.
HELPFUL TIP:
Sh u d “Mo NA (m ph ne, x gen, n t g ce n, as-
p n) g eet a pat ents,” as the ed t s ea ned n med
sch ? Pe m e ecent 2010 C ch ane Database S s-
temat c r ev ew, the e cac x gen n AMi has been
quest ned and ma even be det menta n th se w th
a n ma x gen satu at n (94% g eate , C ch ane
Database S st r ev. 2010;6:CD007160). S , w thh d x-
gen un ess the x gen satu at n s <94%. M ph ne
sh u d be used n a te a pat ent a s spec c the a-
p , such as asp n and n t g ce n. And n t g ce n
d es n t change n a ct s ze.
HELPFUL TIP:
Cu ent use wa a n asp n sh u d not p ec ude
the adm n st at n asp n n the ED a pat ent
w th chest pa n that ma be ca d ac n g n. y u neve
kn w whethe the pat ent s actua tak ng t n t. S ,
un ess the e s a ea a e g t asp n, t must be g ven
t chest pa n pat ents n the ED.
T e patient tells you that she is allergic to aspirin, which
causes hives and bronchospasm. She can, however, take other
nonsteroidal anti-in ammatory drugs (NSAIDs) without
di culty. Oh, great. Now you need to go to plan B (no, not
the “morning a er pill”).
Question 2.1.5 Which o the ollowing is an acceptable
substitute or aspirin in this situation?
A) Dipyridamole.
B) Clopidogrel (Plavix).
C) Ibupro en or naproxen.
D) Celecoxib (Celebrex).
E) Salsalate.
42 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW
Answer 2.1.5 The correct answer is “B.” Clopidogrel in a
loading dose o 600 mg can be used as a substitute or aspi-
rin in the setting o unstable angina or AMI. “A” is incorrect
because dipyridamole (in combination with aspirin) is indi-
cated only or stroke prevention. Dipyridamole itsel is a rela-
tively weak platelet inhibitor. “C” is incorrect because ibupro-
en and naproxen are reversible platelet inhibitors that do not
give adequate platelet inhibition and have NO been shown to
be o bene t in angina/AMI. In addition, both ibupro en and
naproxen can block the e ect o aspirin by making its binding
sites on platelets unavailable. In act, stopping NSAIDs in any
patient being admitted or possible CAD is considered good
practice; they increase the risk o a cardiac event. “D” and “E”
are both incorrect because celecoxib and salsalate have not been
shown to inhibit platelets to a signi cant degree and thus would
be o no use in this situation.
HELPFUL TIP:
N te that the ad ng d se c p d g e has been n-
c eased m 300 t 600 mg. But e the s ke an accept-
ab e answe n the b a d exam nat n (and n p act ce).
Newe ant p ate et agents, such as p asug e (E ent) and
t cag e (B nta) a e bec m ng m e w de used as
ad ng agents. H weve , b eed ng sks a e h ghe w th
the newe agents.
HELPFUL TIP:
o the NSAiDs (except asp n), nap xen appea s t
ca the west ca d ac sk. H weve , t has m e Gi
s de e ects. C x-2 nh b t s, such as ce ec x b, and
d c enac a e Gi end but have m e adve se ca -
d ac events. ibup en acts m e ke nap xen (l ancet.
2013;382(9894):769–779). Guidelines suggest stop-
ping all NSAIDs except aspirin upon admitting a
patient for ACS or a question of ACS. Please do not
use ketorolac to treat chest pain as this is also an
NSAID.
Well, not all chest pain is cardiac, and this patient may have
another cause or hers.
Question 2.1.6 Which o the ollowing is TRUE?
A) Giving a “GI cocktail” (e.g., combination o Maalox and
viscous lidocaine) can reliably di erentiate cardiac rom
esophageal/GI causes o chest pain.
B) A normal chest radiograph and symmetrical pulses in the
upper extremities reliably rules out a thoracic aortic dissec-
tion.
C) Most patients with a spontaneous pneumothorax should be
treated with a chest tube.
D) I nitroglycerin relieves the chest pain, then the pain is cer-
tainly cardiac.
E) Pain is a nding in only about 60% o patients with a PE.
Answer 2.1.6 The correct answer is “E.” Only a small majority
(59%) o patients with pulmonary emboli have pain as a eature.
“A” is incorrect because about 20% o patients with cardiac pain
will have their pain relieved by a GI cocktail. Conversely, “D” is
incorrect because nitroglycerin can relieve pain rom esopha-
geal spasm as it is a nonselective smooth muscle relaxer. “B” is
incorrect because only 50% o patients with an aortic dissec-
tion will have unequal pulses and blood pressures, and only
75% will have an abnormal chest x-ray. T e consideration o an
aortic dissection mandates a chest C scan with contrast, trans-
esophageal echo, or angiogram. Remember that about 20% o
the population will have unequal blood pressures in the upper
extremities at baseline. “C” is incorrect because most patients
with spontaneous pneumothorax can be treated with a “pigtail”
catheter with a Heimlich valve. T is type o treatment reduces
the morbidity associated with a chest tube.
HELPFUL TIP:
Chest x- a nd ngs n pat ents w th th ac c a t c d s-
sect n ma nc ude w dened med ast num, b te ated
a t c kn b, p eu a “capp ng,” t achea dev at n, de-
p ess n e t ma n stem b nchus, es phagea dev a-
t n, and ss the pa at achea st pe.
T e patient’s pain recurs in the ED. You suspect that she is
having a myocardial in arction, but do not yet have unequiv-
ocal proo , such as ECG changes or elevated cardiac enzymes.
T e patient becomes markedly hypotensive in response to
another dose o sublingual nitroglycerin.
Question 2.1.7 Which o the ollowing is TRUE?
A) Intravenous nitroglycerin is contraindicated in this patient.
B) Hypotension caused by nitroglycerin is usually unrespon-
sive to IV saline.
C) Hypotension caused by nitroglycerin may be indicative o a
right ventricular in arction, which is most commonly asso-
ciated with an in erior wall myocardial in arction (IAMI).
D) Hypotension caused by nitroglycerin is diagnostic o car-
diogenic shock, suggesting that this patient will have a poor
outcome.
Answer 2.1.7 The correct answer is “C.” Hypotension in
response to nitroglycerin may be indicative o a right ventricu-
lar in arct, which is most commonly associated with an in erior
wall MI (IAMI). Since the right ventricle is dependent on lling
pressure (preload), nitroglycerin, which drops the preload, will
requently result in hypotension in those with a right ventricu-
lar in arct. “A” is incorrect because hypotension rom sublingual
nitroglycerin is not a contraindication to additional nitrates
once the patient’s blood pressure is stable. A typical sublingual
dose is 400 µg (0.4 mg). A typical IV dose starts at 20 µg/min.
T us, the sublingual dose is quite a bit larger than the IV dose.
In such a situation, you could consider starting IV nitroglycerin
at 10 to 20 µg/min and titrating up as the blood pressure allows.
“B” is incorrect because hypotension rom nitroglycerin will

generally respond to a saline bolus. “D” is incorrect. Certainly,
patients with cardiogenic shock will be hypotensive, but hypo-
tension with nitroglycerin is a common result o the drug itsel
and does not de ne cardiogenic shock.
HELPFUL TIP:
C ns de h d ng beta-b cke s n n e wa acute
Mi (iAMi), as these pat ents ten have b ad ca d a and
hea t b ck. A s , bewa e at p ca p esentat ns
iAMi such as nausea, v m t ng, and the Gi s mpt ms.
H d beta-b cke s n th se w th h p tens n, hea t
b ck hea t a u e.
Question 2.1.8 Which o the ollowing is TRUE o patients
with an IAMI?
A) T ey will likely continue to have problems with right ven-
tricular unctioning in the uture.
B) T ey will need to increase their salt intake in order to
increase preload and right ventricular lling pressure.
C) T eir right ventricular unction should return to normal or
close to normal ollowing their in arction.
D) A and B.
Answer 2.1.8 The correct answer is “C.” Most patients will
have return o right ventricular unctioning ollowing a myo-
cardial in arction. “B” is incorrect because there will be no need
to increase right ventricular lling pressure (which is what IV
FIGURE 2-1. ECG pat ent n quest n 2.1.9.
CHAPTER 2 • CAr Dio l o Gy 43
saline does acutely) once right ventricular unction returns to
normal.
T e patient’s pain continues despite treatment with nitro-
glycerin, and you obtain another ECG (Fig. 2-1).
Question 2.1.9 Which o the ollowing is TRUE regarding
this ECG?
A) T is injury pattern on ECG is most consistent with an ante-
rior wall MI.
B) In this situation, intervention in the cath lab with percuta-
neous transluminal coronary angioplasty (P CA) and stent
placement is superior to tPA or other thrombolytic.
C) T is injury pattern on ECG is most consistent with pericar-
ditis.
D) T is injury pattern on ECG proves that this patient does not
have an aortic dissection.
E) T is pattern on ECG is totally ne. What, me worry?
Answer 2.1.9 The correct answer is “B.” Intervention in the cath
lab with P CA and/or stent placement is superior to thrombo-
lytic therapy in the treatment o AMI, provided that the “door to
balloon” time is 90 minutes or less. In cases where the patient is
located in a acility without a cardiac catheterization laboratory,
the patient may receive thrombolytic therapy. “A” is incorrect
because this pattern is indicative o an in erior wall, not an ante-
rior wall, MI. You will note that this ECG shows S elevations
in leads II, III, and aVF (in erior leads) along with reciprocal S
segment depression in leads V1 and V2. An anterior wall MI is
44 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW
de ned by S elevations in leads V3, V4, and V5, and an antero-
septal MI shows S elevations in leads V1, V2, and V3. For IAMI
concerning or RV in arction, consider “right-sided chest leads.”
“D” is incorrect because patients with pericarditis should have
S elevations in all leads (although an ECG is only 80% sensitive
or pericarditis). “D” is incorrect because patients with an aortic
dissection can present with an abnormal ECG that looks simi-
lar to an in arct pattern. So, ECG changes do not prove that the
patient does not have an aortic dissection. “E” is just plain wrong
and you should be worried i you see this pattern!
You now have all the evidence that you need to show that this
patient is indeed having an ongoing myocardial in arction.
Since your rural hospital is “just around the corner rom
nowhere,” stenting is not going to happen within 90 minutes.
You decide to initiate thrombolytic therapy.
Question 2.1.10 All o the ollowing are true statements
EXCEPT:
A) Patients who are candidates or thrombolytics must have at
least 1 mm o S -segment elevation in at least 2 contiguous
limb leads or at least 1 to 2 mm o S -segment elevation in
at least 2 contiguous precordial leads.
B) Patients who are candidates or thrombolytics must have an
absence o prior history o hemorrhagic stroke within the
past year.
C) Patients who are candidates or thrombolytics should have
no active bleeding, including menstrual bleeding.
D) Patients who are candidates or thrombolytics should have
no history o recent head trauma.
E) Patients who are candidates or thrombolytics should not be
pregnant.
Answer 2.1.10 The correct answer is “C.” While active inter-
nal bleeding is a contraindication to the use o thrombolytics,
menstrual bleeding is not. While there are no controlled trials,
anecdotal evidence suggests that thrombolytics are sa e with
menstrual bleeding. “A” is correct. In addition to these ECG
criteria, the presence o a new complete le bundle branch
block (LBBB) with characteristic MI pain also indicates that the
patient may bene t rom thrombolysis. Patients with only S -
segment depression or a normal ECG, even with symptoms, do
not bene t. “B,” “D,” and “E” are all true statements. Patients
are not candidates or thrombolytics i they have recent head
trauma, are pregnant, or have had a hemorrhagic stroke in the
last year. T ere are additional criteria or and contraindications
to the use o thrombolytics. See ables 2-1A and 2-1B.
HELPFUL TIP:
“Fac tated PCi,” that s, adm n st at n th mb t cs
w th the ntent t pe m PCi w th n 2 m e h u s
g v ng th mb t cs has ve m xed (and m st nega-
t ve) data. o utc mes a e w se (and n t just because PCi
s a “ escue” techn que at th s p nt). it ce ta n s NOT
the standa d ca e and, n act, s n nge c ns de ed
as pa t the t eatment a g thm. i th mb t cs
TABLE 2-1A ACC/AHA GUIDELINES FOR THE
MANAGEMENT OF PATIENTS WITH ST-ELEVATION
MYOCARDIAL INFARCTION
C ass 1 ec mmendat ns the use th mb t cs n
m ca d a n a ct n nc ude an o NE the w ng th ee
ECG nd ngs:
• ≥1 mm ST-segment e evat n n at east 2 c nt gu us mb
eads
• 1–2 mm ST-segment e evat n n at east 2 c nt gu us p ec d a
eads
• New c mp ete bund e b anch b ck that bscu es the ST segment
ana s s p us a h st suggest ve Mi
And
• P esent ng 12 h u s s nce the nset pa n, age <75 ea s (a th ugh
t eat ng th se >75 ea s age s st a c ass 2 ec mmendat n
be w)
C ass 2 ec mmendat ns the use th mb t cs n m ca d a
n a ct n nc ude an o NE the w ng:
• ≥1 mm ST-segment e evat n n at east 2 c nt gu us mb
eads and age >75 ea s o r p esent ng 12–24 h u s a te nset
n a ct n
• 1–2 mm ST-segment e evat n n at east 2 c nt gu us p ec d a
eads and age >75 ea s o r p esent ng 12–24 h u s a te the nset
n a ct n
• B d p essu e >180 mm Hg s st c and >100 mm Hg d ast c
n a pat ent w th a “h gh- sk” m ca d a n a ct n (e.g., the h gh
sk the Mi m t gates the wa n ng ab ut th mb t c use n
unc nt ed h pe tens n)
r ep duced m Antman EM, et a . ACC/AHA gu de nes the
management pat ents w th ST-e evat n m ca d a n a ct n—
execut ve summa . J Am C Ca d . 2004;44(3): 671–719. C p ght 2004,
w th pe m ss n m E sev e .
TABLE 2-1B ACC/AHA GUIDELINES FOR THE
MANAGEMENT OF PATIENTS WITH ST-ELEVATION
MYOCARDIAL INFARCTION
Class 3 “Absolute” contraindications to the use of thrombolytic
therapy in MI
• P ev us hem hag c st ke at an t me st ke w th n the ast
12 m nths
• Kn wn nt ac an a ne p asm
• Act ve nte na b eed ng (but n t menst ua b eed ng)
• Suspected a t c d ssect n
Relative contraindications to the use of thrombolytic therapy in MI
• Unc nt ed h pe tens n (>180/110 mm Hg) at the t me
p esentat n.
• H st b eed ng d athes s, ng ng ant c agu at n (iNr >2–3)
• T auma, nc ud ng t aumat c CPr w th n 2–4 weeks, maj su ge
w th n 3 weeks
• N nc mp ess b e vascu a punctu es (e.g., subc av an ne)
• inte na b eed ng w th n the ast 2–4 weeks
• P egnanc
• Pept c u ce d sease (b eed ng n t)
• Seve e, ch n c h pe tens n
r ep duced m Antman EM, et a . ACC/AHA gu de nes the management
pat ents w th ST-e evat n m ca d a n a ct n—execut ve summa . J Am C
Ca d . 2004;44(3): 671–719. C p ght 2004, w th pe m ss n m E sev e .

ve sus p ma PCi s be ng c ns de ed, t s va uab e t
c ntact the ca d g st at the cath cente t dete m ne
whethe he/she w u d ke th mb t cs be e t ans-
e —t m ng (b th m s mpt m nset and t ans e )
s cent a t the dec s n mak ng p cess. “r escue PCi”
a ed epe us n a te th mb t c the ap sh u d
be pe med as s n as g st ca p ss b e, dea
w th n the st 24 h u s, but No T w th n the st 2 t
3 h u s p stth mb t c the ap .
HELPFUL TIP:
r emembe t epeat the ECG after th mb t cs t
p ve that ST e evat ns have es ved. Ev dence suc-
cess u epe us n a te th mb t cs s suggested b :
nea sudden and c mp ete e e chest pa n, >70%
ST e evat n es ut n n the ndex ead sh w ng the
g eatest deg ee e evat n, p us m nus the p es-
ence epe us n a h thm a.
A er con erring with your closest cath center, you give a
thrombolytic—and cross your ngers. Un ortunately, the
patient develops a new LBBB. In addition, the ECG shows
evidence o a rst-degree heart block (a prolonged PR inter-
val), although the heart rate remains normal at 80 bpm.
Question 2.1.11 The proper response to this is to:
A) Insert a Swan–Ganz catheter to monitor central pressures.
B) Insert a temporary pacemaker regardless o the heart rate.
C) Administer atropine to this patient.
D) Administer isoproterenol to this patient.
E) Do nothing, other than observe this patient.
Answer 2.1.11 The correct answer is “B.” For patients with
an AMI, a transvenous pacemaker should be inserted i she
develops (1) complete heart block, (2) second-degree heart
block type II (Mobitz II), or (3) new LBBB with rst-degree AV
block. See ables 2-2 and 2-3 or more on arrhythmia and pace-
makers in the setting o AMI. “A” is incorrect because a Swan-
Ganz catheter will be o no help in arrhythmias. “C” is incor-
rect because atropine is indicated or symptomatic bradycardia
and not or a bundle branch block. “D” is incorrect or the same
reason as “C.” In addition, isoproterenol is arrhythmogenic and
is no longer recommended. “E” is incorrect because the patient
may rapidly progress into a complete heart block. O note and
TABLE 2-2 TYPE OF HEART BLOCK ASSOCIATED
WITH INFARCTION
Ante m ca d a Bund e b anch b cks
n a ct n M b tz t pe ii sec nd-deg ee hea t b ck
in e m ca d a B ad ca d a m:
n a ct n • M b tz t pe i sec nd-deg ee hea t b ck
• Th d-deg ee hea t b ck
CHAPTER 2 • CAr Dio l o Gy 45
TABLE 2-3 CLASS I INDICATIONS FOR PACEMAKER IN
PATIENTS WITH AN ACUTE MYOCARDIALINFARCTION
New e t bund e b anch b ck + st-deg ee AV b ck
New ght bund e b anch b ck + e t ante p ste asc cu a
b ck + st-deg ee AV b ck
M b tz t pe ii hea t b ck
Th d-deg ee hea t b ck
S mpt mat c b ad ca d a un esp ns ve t at p ne.
importantly, the placement o a transvenous pacemaker should
not delay trans er or catheterization since a pacemaker may be
placed in the cath lab. However, apply an external pacemaker
as required.
T e patient requires heparin with the thrombolytic that you
choose (and is indicated, by guidelines, or a minimum o
48 hours and pre erably or the duration o the index hospital-
ization, up to 8 days or until revascularization is per ormed).
Question 2.1.12 Which o the ollowing dosing regimens is
the best accepted or use in AMIs?
A) Enoxaparin 30 mg subcutaneously (SC) every 12 hours.
B) Enoxaparin 1 mg/kg SC every 12 hours.
C) Heparin 5,000 units bolus and a drip at 1,000 units per hour.
D) Heparin 100 unit/kg bolus with a drip at 25 units/kg/hr.
E) None o the above represents the best dosing option in this
situation.
Answer 2.1.12 The correct answer is “B.” For anticoagulation
in AMI, the dose o enoxaparin is 1 mg/kg SC every 12 hours.
“A” is incorrect since 30 mg SC every 12 hours is the dose or
DV prophylaxis, not or anticoagulation. “C” is incorrect. T is
is the classic way that heparin has been dosed but it is not the
best option listed. “D” is incorrect as well. T e correct dose or
heparin when given with a thrombolytic is 60 units/kg bolus
(maximum o 4,000 units) with a drip o 15 units/kg/hr (maxi-
mum dose o 1,000 units/hr), with rate adjusted to achieve an
activated partial thromboplastin time (aP ) o 1.5 to two
times control ( or 48 hours or until revascularization). T e bot-
tom line here is that either enoxaparin or heparin can be used in
this setting, and they are more or less equivalent. I you choose
to use heparin, do not use f xed dose heparin but rather weight-
based dosing. Also, keep in mind that in the United States, it is
likely that most interventional cardiologists would pre er hepa-
rin over enoxaparin, due to both amiliarity with dosing as well
as drug pharmacology in the cath lab.
HELPFUL TIP:
D d u kn w that ST-e evat n Mi, an n t a d se
30 mg IV enoxaparin (that’s ght— nt aven us)
sh u d be g ven w th the first and only the first d se
th se age <75 ea s. The iV d se sh u d be g ven at
the same t me as the st 1 mg/kg subcutane us d se.
D t!
46 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW
T e patient receives her thrombolytic, enoxaparin, and trans-
venous pacing, and she is admitted to the hospital to a moni-
tored bed. You get a call rom the nursing staf 5 hours later.
T e rhythm strip shows 3 PVCs per minute. Your patient
remains pain ree and is hemodynamically stable.
Question 2.1.13 The nurse (who has more than a ew gray
hairs) would like an order or lidocaine. Your response is:
A) “Do it. Give the lidocaine.”
B) “Give amiodarone—it works better than lidocaine.”
C) “Give no antiarrhythmic at this point in time.”
D) “Check labs including potassium and magnesium.”
E) C and D.
Answer 2.1.13 The correct answer is “E.” T e use o lidocaine
in this setting incurs no bene t and is proarrhythmic. T e same
is true or prophylactic amiodarone, which can cause torsades
de pointes, albeit at a lower requency versus other antiar-
rhythmics (such as quinidine, procainamide, sotalol, and newer
Class III antiarrhythmic agents). In the setting o AMI, antiar-
rhythmics may be indicated only or complex arrhythmias (PVC
couplets, triplets, nonsustained ventricular tachycardia [<30
seconds], or >10 PVCs per minute). More than 90% o patients
will have isolated PVCs in the peri-in arct period, and there is
no association with increased mortality. Correcting hypokale-
mia and hypomagnesemia can help to reduce arrhythmias, and
checking these labs is prudent.
T e patient remains pain ree while in the hospital. She is
ready to be discharged 4 days later.
Question 2.1.14 Which o the ollowing tests is the most
appropriate or this patient prior to discharge?
A) Coronary angiography.
B) Submaximal stress test.
C) Full Bruce protocol, symptom limited, stress test.
D) Spiral C to assess or coronary artery calci cation.
E) Family Medicine Board Examination.
Answer 2.1.14 The correct answer is “B.” Submaximal stress
testing is considered the standard o care. Patients with a posi-
tive submaximal stress test should be re erred or catheter-
ization. Patients with a borderline stress test can be sent or a
radionuclide study. Coronary angiography is not routinely rec-
ommended or all patients who have had a myocardial in arc-
tion unless they are considered to be at high risk (continued
symptoms, positive screening test such as submaximal stress
test, heart ailure, cardiogenic shock, etc.). “C” is incorrect
because a symptom-limited, ull-protocol stress test should be
done only 14 to 21 days a er an in raction. Finally, spiral C
(“D”) to assess or coronary artery calci cation has no role in
risk strati cation a er a myocardial in arction . . . their risk is
100%! Also, keep in mind that the weight o the clinical evidence
avors trans er or early catheterization, especially or higher
risk patients. “E” is the test YOU are studying or . . . right? Dis-
oriented already? It’s only Chapter 2!
Question 2.1.15 The patient passes her stress test with y
ing colors (and you pass your Board Examination). Patients
a ter a myocardial in arction should be routinely discharged
on all o the ollowing medications EXCEPT:
A) Aspirin.
B) Beta-blocker.
C) Continuous nitroglycerin (e.g., patch or isosorbide).
D) HMG-CoA reductase inhibitor (“statin”).
E) Sublingual nitroglycerin or PRN use.
Answer 2.1.15 The correct answer is “C.” T ere is no ben-
e t to scheduled nitrates unless needed or a speci c indica-
tion (e.g., recurrent angina). All postmyocardial in arction
patients should be discharged on aspirin, beta-blocker, statin,
nitroglycerin PRN, and an angiotensin-converting enzyme
(ACE) inhibitor (i tolerated, o course). Also, per ACC NS E-
ACS guidelines, individuals treated with an ischemia-guided
strategy (vs. early invasive strategy), a P2Y12 inhibitor should
be continued or up to 12 months i there are no contrain-
dications (options include clopidogrel 75 mg daily, ticagrelor
90 mg BID). Finally, per ACC guidelines, all patients with
S -elevation MI or non-S EMI/unstable angina should be
discharged on an intensive lipid-lowering regimen with an
HMG-CoA reductase inhibitor (“statin”), such as atorvastatin
40 to 80 mg per day.
HELPFUL TIP:
in pat ents w th a h st acute c na s nd me
(ACS), stat n the ap we s the sk ecu ent Mi,
st ke, CAD- e ated death, and the need c na
evascu a zat n. Stat n the ap a te ACS s bene c a
n Al l pat ents, nc ud ng th se w th a base ne l Dl
<70 mg/dl . D scha ge ACS pat ents n a stat n.
Question 2.1.16 I this patient had a STEMI (or “Q wave” MI),
which o the ollowing statements would be TRUE?
A) Patients with a non-S EMI have the same, or perhaps a
bit worse, outcomes long term than do patients with a
S EMI.
B) Patients with a non-S EMI have worse in-hospital outcomes
when compared with patients with a S EMI.
C) Unstable angina and non-S EMI can be readily di erenti-
ated rom one another on presentation.
D) None o the above is true.
Answer 2.1.16 The correct answer is “A.” Patients with a
non-S EMI actually have the same, or perhaps even slightly
worse, outcomes long term as do patients with a S EMI. T is
makes sense; there is still myocardium le to in arct a er a
non-S EMI. As to the other answers, patients with a S EMI
do have worse in-hospital outcomes, and unstable angina and
non-S EMI look similar on ECG with -wave inversion, etc.,
but without the S elevations that are classically seen in a trans-
mural in arction.

Objectives: Did you learn to . . .
• De ne the accu ac the n t a h st , ECG, and abs n the
d agn s s ca d ac d sease n the ED ce?
• r ec gn ze the e and s gn cance ( ack the e ) sk
act s, such as d abetes, am h st , sm k ng, and h pe -
tens n, n the dec s n whethe n t t adm t a pat ent
t the h sp ta chest pa n?
• Gene ate a d f e ent a d agn s s chest pa n?
• ident the es va us d agn st c tests n the eva uat n
chest pa n?
• T eat a pat ent w th an AMi?
QUICK QUIZ: Co r o NAr y CAl CiUM
You are seeing a 47-year-old male patient. His presenting com-
plaint is chest pain. T e chest pain is right sided and is not
associated with exertion. T e patient looks well conditioned
and admits (well, beams . . . the jerk) he exercises daily without
any chest pain. On clinical examination, you nd that the chest
pain is reproducible on palpation o the anterior chest wall. He
smokes one pack o cigarettes per day and has a blood pressure
o 135/87 mm Hg, a total cholesterol o 179 mg/dL, and HDL o
30 mg/dL. He takes no medication.
Which o the ollowing is RUE regarding the role o a coronary
calcium score in this patient?
A) Coronary calcium score may be a help ul tool in the evalu-
ation o this patient in combination with the Framingham
risk score.
B) Coronary calcium score is a help ul tool in the evaluation o
this patient independent o the Framingham risk score.
C) Coronary calcium score is only use ul in evaluating this
patient once he has had an echocardiogram.
D) Coronary calcium score cannot provide use ul in ormation
regarding cardiac unction.
The correct answer is “A.” T e patient presented with a Fram-
ingham risk score o 13%, which places him in the intermedi-
ate-risk category or 10-year cardiac risk. Coronary calcium
scores may be use ul in those with an intermediate risk to help
strati y risk (e.g., between 10% and 20% risk by Framingham
per JAMA. 2010 28;303:1610 and JACC Cardiovasc Imaging.
2015;8(5):579–596). T is remains controversial, however. Won-
der why we are talking about Framingham rather than the more
recent and more popular ACC/AHA 2013 cholesterol guideline
(which we discuss later)? Coronary calcium scores have not (as
o the time o this writing) been studied using the new ACC/
AHA guideline.
QUICK QUIZ: Giib/iiia iNHiBiTo r S
You are seeing a patient in the ED with chest pain. T e ECG
shows elevated S segments in leads V1, V2, and V3 with recip-
rocal changes in eriorly. You have run through the “standard”
CHAPTER 2 • CAr Dio l o Gy 47
medications, but the patient continues to have pain. You con-
sult a cardiologist who suggests the use o a glycoprotein IIb/IIIa
inhibitor.
Which o the ollowing is true about the glycoprotein IIb/IIIa
inhibitors?
A) T ey are best used in patients who are not candidates or
P CA and stenting.
B) T ey cause no increase in the rate o intracranial bleeding.
C) T ey are use ul in all groups o patients with ACS.
D) T ey are most e ective in patients going to P CA and/or
stenting.
The correct answer is “D.” T e glycoprotein IIb/IIIa inhibi-
tors are most e ective in patients who are undergoing P CA or
stenting. T e GUS O V trial showed NO di erence in 30-day
mortality in patients who were not scheduled or catheteriza-
tion. T us, “A” is incorrect. “B” is incorrect because glycoprotein
IIb/IIIa inhibitors do increase rates o intracranial and other
bleeding. “C” is incorrect because patients who have an ACS
that is well-controlled with other drugs (e.g., heparin, metopro-
lol, and ASA) are not likely to bene t rom glycoprotein IIb/IIIa
inhibitors.
CASE 2.2
A 53-year-old male with a history o hypertension and smok-
ing, but no amily history o cardiac disease, presents to your
o ce complaining o a chest pain. T e pain is substernal,
radiates to his le arm, and is associated with exertion. T e
patient notes that this same pain has been going on or the
last 6 months and has not changed at all in duration, inten-
sity, or characteristic. It generally lasts 5 minutes or so and
resolves with rest.
Question 2.2.1 You tell the patient that:
A) Without doing any test, you know that the probability that
this pain is cardiac is greater than 85%.
B) I his ECG in the o ce is normal, his pain is unlikely to rep-
resent cardiac disease.
C) Even with risk actors, his probability o having CAD with
“typical angina” is still only 50% or so.
D) T e only intervention indicated at this point are li estyle
modi cations (e.g., stop smoking) and addressing his cho-
lesterol and hypertension.
E) It is likely that he has unstable angina.
Answer 2.2.1 The correct answer is “A.” A 50-year-old male
with “classic” angina symptoms has greater than a 90% prob-
ability o having CAD. “B” is incorrect because patients with
angina who are pain ree may have a normal electrocardiogram
(as will many patients with active angina or even a myocardial
in arction). T us, his pain could still be cardiac in origin. “C” is
incorrect because, based on demographic data, his risk o CAD
is much higher than 50%. “D” is incorrect because he needs a
urther evaluation and treatment o his chest pain. “E” is incor-
rect since this pain represents “stable angina.” T ere has been
48 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW
no change in quality, duration, amount o exertion required to
bring on symptoms, etc., eliminating unstable angina as a diag-
nosis. Use o tools such as the IMI Risk Score and/or Grace
Risk Model can assist in estimation o the level o risk and to
help guide management decisions (see 2014 AHA/ACC NS E-
ACS Guideline).
HELPFUL TIP:
Kn w u p etest p bab t ca d ac d sease be e
emba k ng up n test ng chest pa n. Th s va es b
age and t pe chest pa n. An app x mat n the
p bab t ca d ac d sease s as ws:
Ma e, at p ca ang na: age 30 t 39 = 34%, age 40 t 49 =
51%, age 50 t 59 = 65%, age 60 t 69 = 72%.
Ma e, typica l a ngina : age 30 t 39 = 76%, age 40 t 49 =
87%, age 50 t 59 = 93%, age 60 t 69 = 94%.
Fema e, at p ca ang na: age 30 t 39 = 12%, age 40 t
49 = 22%, age 50 t 59 = 31%, age 60 t 69 = 52%.
Fema e, typica l a ngina : age 30 t 39 = 26%, age 40 t
49 = 55%, age 50 t 59 = 73%, age 60 t 69 = 86%.
You send the patient home on aspirin with a prescription or
sublingual nitroglycerin or PRN use and arrange or a stress
test.
Question 2.2.2 All o the ollowing are considered absolute
contraindications to exercise stress testing EXCEPT:
A) Le bundle branch block (LBBB).
B) Presence o severe heart ailure.
C) Critical aortic stenosis.
D) Myocarditis.
E) Unstable angina.
Answer 2.2.2 The correct answer is “A.” An LBBB is a rela-
tive—not absolute—contraindication to stress testing. In the
setting o LBBB, there are already repolarization abnormalities
that limit the use ulness o the stress test. One should add an
imaging modality, such as myocardial per usion scanning, in
cases o LBBB. T e same holds or any baseline ECG pattern
that would inter ere with S segment interpretation (baseline
S changes, LBBB, LVH with repolarization changes involv-
ing the S - wave, intraventricular conduction delay, paced
rhythm, preexcitation, or S - changes due to digoxin therapy);
the stress test SHOULD include an imaging modality. T e rest
are all “absolute” contraindications to exercise stress testing. See
able 2-4 or a list o contraindications to stress testing.
Question 2.2.3 Exercise stress testing is best suited to which
group o individuals?
A) Men with an intermediate probability o cardiac disease.
B) Women with a high risk o cardiac disease.
C) Men at a high risk o cardiac disease.
D) Men at a low risk o cardiac disease.
E) Women with a low risk o cardiac disease.
TABLE 2-4 CONTRAINDICATIONS TO EXERCISE
STRESS TESTING
Abs ute • Acute m ca d a n a ct n w th n 2 da s
c nt a nd cat ns • D ssect ng aneu sm
• r ecent pu m na emb sm
• Act ve th mb ph eb t s
• BP > 200/120 mm Hg
• Hem d nam ca s gn cant a h thm as
• Seve e CHF
• Seve e a t c sten s s
• Act ve m ca d t s, pe ca d t s, end -
ca d t s
• inab t t c mp ete test
• Unstab e ang na
r e at ve • l e t bund e b anch b ck
c nt a nd cat ns • M de ate a t c sten s s
• H pe t ph c ca d m path
• E ect te d stu bance
• H gh g ade AV b ck
• Tach a h thm as b ad a h thm as
nc ud ng unc nt ed at a b at n
Answer 2.2.3 The correct answer is “A.” Stress testing is best
suited to patients with an intermediate pretest probability o
cardiac disease (between 25% and 75%). “B” and “C” are incor-
rect since patients with a high risk o cardiac disease should go
directly to another study, such as thallium testing and stress
echocardiography. “D” and “E” are incorrect since these are
not the best groups in whom to use exercise stress testing;
there will be a greater proportion o alse-positive results in
these low-risk patients. Exercise stress testing in these groups
is best used to allay patient ears that they do not have cardiac
disease, not to prove they do have cardiac disease. However, a
alse-positive stress test may lead to other unnecessary inva-
sive testing!
You decide to do an exercise stress test on this patient. It
turns out to be negative.
Question 2.2.4 Your next step is to:
A) Reassure the patient that he does not have cardiac disease.
B) Suggest a chest C scan to rule out possible aortic aneu-
rysm.
C) Schedule the patient or another cardiac test such as stress
echocardiogram, exercise myocardial per usion test, or
angiography.
D) Schedule the patient or endoscopy to rule out gastroesoph-
ageal disease as a cause o these symptoms.
E) Start an anxiolytic to treat the panic disorder, which is the
underlying cause o his chest pain.
Answer 2.2.4 The correct answer is “C.” T is patient who is
in his 50s and who has a “classic” history or angina has greater
than a 90% pretest probability o cardiac disease. T us, it is
likely that the negative stress test is a alse negative. T us, a
stress test probably should not have been done in this patient

in the rst place, since a negative test just leads to urther
testing (as would have a positive test, probably resulting in
angiography). For this reason, “A” is incorrect. “B,” “D,” and “E”
are incorrect. Initiating evaluation and management or another
cause o chest pain is premature, since we still have not proven
that this patient does not have cardiac disease.
You are considering whether to do a thallium stress test or a
stress echocardiogram.
Question 2.2.5 Which o the ollowing is true?
A) Stress echocardiography is more sensitive or cardiac disease
than is a thallium test.
B) Stress echocardiography is more speci c than is stress thal-
lium.
C) T allium testing is more speci c or cardiac disease than is
stress echocardiography.
D) None o the above is true.
Answer 2.2.5 The correct answer is “B.” Stress echocardiogra-
phy is more speci c or cardiac disease than is thallium test-
ing. Alternatively, thallium testing is more sensitive. able 2-5
summarizes this data. Remember that positive and negative
predictive values o these tests will vary depending on the pre-
test probability o disease in the patient and severity o disease.
Numbers given above are overall.
You decide to send the patient or a thallium stress test.
However, since his exercise capacity is limited, you choose to
stress him chemically. T e patient is taking theophylline or
chronic obstructive pulmonary disease (a pox on the doctors
still prescribing that drug!).
Question 2.2.6 The LEAST desirable method o stressing
this patient is:
A) Adenosine.
B) Dobutamine.
C) Dipyridamole.
D) All o the above are equally acceptable methods o chemi-
cally stressing this patient.
E) Neither A nor C is desirable.
Answer 2.2.6 The correct answer is “E.” heophylline (and
ca eine) interacts with both adenosine and dipyridamole,
attenuating their e ect; thus, neither is a good choice or
TABLE 2-5 OVERALL SENSITIVITY AND SPECIFICITY
OF NONINVASIVE CARDIAC TESTING
Sensitivity Speci city
(%) (%)
Exe c se st ess test ng 45–68 77
Tha um st ess test ng (SPECT) 88 77
St ess ech ca d g aph 76 88
CHAPTER 2 • CAr Dio l o Gy 49
stressing this patient. Dobutamine is an acceptable method
o chemically stressing those on theophylline or ca eine
(like us).
Question 2.2.7 The patient’s thallium stress test shows an
anteroapical nonreversible (“ xed”) de ect. The best inter
pretation o this is that it indicates:
A) Attenuation arti act rom breast tissue.
B) Prior myocardial in arction.
C) Angina.
D) Anomalous cardiac circulation.
E) It is not signi cant and there ore adds no value to this test.
Answer 2.2.7 The correct answer is “B.” A nonreversible
(“ xed”) de ect suggests prior myocardial in arction. A revers-
ible de ect suggests inducible ischemia. “A” is incorrect since
breast attenuation occurs mostly in women (but can also be
seen in obese males, which is part o the rationale or per orm-
ing PE in patients with BMI > 35 kg/m 2 since PE uses a
higher-energy isotope to mitigate so tissue attenuation). “C”
is incorrect since angina would likely be mani ested by a revers-
ible de cit.
Since a reversible de ect was not ound on the thallium
stress test, you conclude that there is no myocardium cur-
rently at risk. However, the patient continues to have chest
pain and now at an increasing requency with less exer-
tion. He is asymptomatic when he presents to your o ice.
He was noted at the last visit to have an elevated glucose at
350 mg/dL.
Question 2.2.8 What is the next step in the evaluation or
treatment o this patient?
A) Stress echocardiogram to document what segments are
involved.
B) Start the patient on insulin to control his blood sugars.
C) Proceed directly to cardiac catheterization.
D) Since there were no reversible de cits on thallium stress,
schedule the patient to see a gastroenterologist.
E) Give a trial o NSAIDs to help di erentiate chest wall pain
rom other causes.
Answer 2.2.8 The correct answe r is “C.” “A” is incorrect
since we already have done a noninvasive test. We already know
what segment was previously in arcted, as noted on the thal-
lium stress test. “B” is incorrect or two reasons. First, address-
ing his diabetes will not address the immediate problem o what
you must presume is unstable angina. Second, insulin is not
necessarily the rst drug to use in this patient who presumably
has type 2 diabetes. Certainly, the blood glucose needs to be
addressed and so does the chest pain. Which is going to kill him
rst? “D” is incorrect. T e sensitivity o thallium testing is in the
88% range (see able 2-5), so it will miss 12% o disease. T us,
we still have not proven in this high-risk patient that he does
not have treatable cardiac disease causing his chest pain. “E” is
incorrect or the same reason.
50 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW
T e patient has a catheterization done that shows three-vessel
disease including le main CAD. T e cardiologist calls you
with the report the next day and suggests P CA with stent-
ing, since, in his opinion, “this is the best modality or dia-
betics and diabetics are high-risk candidates when it comes
to surgery.”
Question 2.2.9 Your opinion is that:
A) Patients generally have better outcomes in terms o con-
trol o angina with stenting when compared with coronary
artery bypass gra ing (CABG).
B) Diabetic patients do particularly well with stenting when
compared with CABG.
C) Medical control o symptoms is indicated as the best man-
agement in this diabetic patient with three-vessel disease.
D) You would like to send this patient or CABG.
Answer 2.2.9 The correct answer is “D.” T is patient should
probably have surgery or his three-vessel disease because dia-
betic patients generally have worse outcomes with stenting than
do nondiabetic patients in terms o angina relie and need or
repeat revascularization. “A” is incorrect because a proportion
o patients with stents have to go on to have an open CABG due
to in stent restenosis or incomplete revascularization with per-
cutaneous revascularization. “B” is incorrect. Diabetic patients
have a much higher rate o in stent restenosis or secondary
occlusion (meaning a narrowing/stenosis somewhere else in
the diseased vessel). “C” is incorrect. T e indications or CABG
are signi cant le main CAD (>50%), three-vessel disease with
evidence o LV dys unction (ejection raction <50%), or ori-
gin/proximal LAD/LCX disease (le main equivalent). T is
patient has le main vessel disease and thus medical control
is NO the best option or this patient. He is also young and,
rom the available data, appears to be a good surgical candi-
date. T ere ore, CABG is the guideline-recommended option
is this patient.
HELPFUL TIP:
D ug-e ut ng stents (DES) dec ease ve a e cc us n
ates n c mpa s n t ba e meta stents (BMS). W men
wh have mu t p e stents and mu t -vesse d sease a e
at a h ghe sk esten s s, as a e pat ents w th a sma
p ststent ng umen s ze. Ea e cc us n sec nda
t th mb s s s h ghe w th DES ve sus BMS, and the
m ta t sk due t stent th mb s s s h gh ( ange 20–
45%). Th s s because t takes the b d nge t c ve
these stents w th nt ma ( .e., end the a zat n). Thus,
c p d g e , t cag e p asug e (n t u av te)
1 ea PLUS asp n e sh u d be used n pat ents
wh have a d ug-e ut ng stent nse ted. F ba e meta
stents, the ec mmendat n s t use ne the ant -
p ate et agents 3 to 6 months PLUS asp n e.
(N te: the sk stent th mb s s w th a ba e meta
stent s h ghest n the st 14–30 da s.)
HELPFUL TIP:
A p ea m u ed t s. D n’t c nt nue c p d g e ,
etc., uts de the t me ame n wh ch the have been
sh wn t be use u (3–6 m nths a bea meta stent,
1 ea a d ug e ut ng stent) un ess the e s ng ng
ACS. The b eed ng sk s nc eased n m n ma ben-
e t. C nt nue asp n nde n te , c u se (N Eng J Med.
2014;371:2225–2226). F pat ents n wa a n an the
a ant c agu ant, c ns de at n sh u d be g ven t e-
duc ng the du at n t p e the ap ( a ant c agu ant +
ASA + c p d g e , examp e) due t b eed ng sk w th-
ut s gn cant bene t. D p ne the ant p ate et d ugs.
H weve , the pt mum du at n the ap has n t been
estab shed. it ma be sa e t st p t p e the ap as ea as
4 t 6 weeks a te a DES (J Am C Ca d . 2015;65:1619).
Your patient has a CABG and comes into your o ce com-
plaining o chest pain and ever 3 weeks a er the surgery. He
has had the pain and ever or 4 days and does not seem to
be getting any better. He has no cough, no sputum produc-
tion, and the pain seems to be worse when he breathes or lies
down. He reports no dyspnea and has 97%oxygen saturation
on room air. T e wound rom the surgery is well healed, and a
chest radiograph shows no evidence o abnormalities.
Question 2.2.10 Which o these studies is LEAST likely to be
abnormal in this patient?
A) ECG.
B) V/Q scan.
C) Echocardiogram.
D) Sedimentation rate.
Answer 2.2.10 The correct answer is “B.” A V/Q scan is not
likely to be positive in this patient. T is patient is unlikely to have
a PE given the duration o symptoms, the act that the patient has
chest pain that worsens with inspiration ( ound in only 59% o
those with PE), ever, absence o dyspnea, and has normal oxy-
gen saturation. Certainly, this could still be a PE, but it would
be less likely than other, more plausible, explanations. T e most
likely diagnosis in this patient, given the lack o other symptoms,
is postpericardotomy syndrome. T is is similar to Dressler syn-
drome, which occurs a er a myocardial in arction and presents
with ever and chest pain several days to weeks a er the inciting
event. T e white blood count is o en elevated, as is the sedimen-
tation rate. T e ECG can be help ul as can an echocardiogram.
You obtain an ECG on this patient that shows a pattern con-
sistent with pericarditis.
Question 2.2.11 Which o the ollowing patterns can be
seen in a patient with pericarditis?
A) Di use S segment elevation.
B) Normal ECG.
C) LBBB.
D) A and B.
E) All o the above.

Answer 2.2.11 The answer is “D.” Both di use S segment
elevations and a normal ECG can be seen with pericarditis.
T e initial ECG is only 80% sensitive or pericarditis. Small
(low voltage) QRS complexes or electrical alternans can also
be seen i there is a pericardial e usion. “C” is incorrect since
bundle branch blocks have nothing to do with pericarditis. You
will have a chance to look at an ECG o pericarditis later in the
chapter. Note: PR depression accompanying di use S eleva-
tion +/– sinus tachycardia may also be seen in pericarditis.
A er a complete history, physical examination, ECG and
echocardiogram, you determine that he has pericarditis.
Question 2.2.12 Which o the ollowing drugs might be
help ul in this patient?
A) Heparin.
B) War arin.
C) Furosemide.
D) Indomethacin.
Answer 2.2.12 The correct answer is “D.” Didn’t we just tell
you not to use NSAIDs in patients who have CAD? Well, yes.
However, in this particular case, an NSAID is indicated. Vari-
ous doctors weighing risks and bene ts o NSAIDs in this
case might come to di erent conclusions, but o the available
options, “D” is the only one which is a treatment or pericarditis.
o treat pericarditis, you can use aspirin, another NSAID, ste-
roid, or colchicine. Generally, indomethacin or aspirin are con-
sidered rst-line drugs with steroids being reserved or those
who ail NSAID therapy. Colchicine is becoming increasingly
popular as a second-line treatment a er an NSAID. Do not use
anticoagulation, either heparin or war arin, in patients with
pericarditis. T is can cause bleeding into the pericardial space
and tamponade. T us, “A” and “B” are incorrect. “C” is incorrect
because urosemide will likely make this patient worse. Patients
with increased pericardial pressures are dependent on circulat-
ing preload volume in order to ll the right heart. Decreasing
the preload may cause dyspnea in this patient. Steroids are not
rst line and are typically reserved or recurrence a er treat-
ment with NSAIDs and colchicine.
T e patient returns the next day and is now eeling short
o breath. On examination, you notice JVD and peripheral
edema.
Question 2.2.13 The best initial treatment o this patient is:
A) Furosemide.
B) Nitroglycerin.
C) IV saline.
D) Morphine.
Answer 2.2.13 The correct answer is “C.” T is patient is in
“pure” right heart ailure secondary to possible cardiac tampon-
ade (eek! Let’s get him a cardiac inpatient bed!). He is preload
dependent. T e treatment is to increase his preload by using IV
saline. All the other options reduce the preload and will worsen
this patient’s symptoms.
CHAPTER 2 • CAr Dio l o Gy 51
He gets admitted to a cardiac inpatient bed and you give a
bolus o IV saline. Despite this, he remains dyspneic with
elevated neck veins and has a pulsus paradoxus o 14 mm Hg
(normal <10 mm Hg).
Question 2.2.14 The next step or this patient is:
A) Change the patient to steroids rom indomethacin.
B) Per orm a pericardiocentesis.
C) Start a positive inotrope (e.g., dopamine) to improve right
heart unction.
D) Start an a erload reducer to reduce cardiac demand.
Answer 2.2.14 The correct answer is “B.” T e patient is clearly
not doing well i he is getting more short o breath and not
responding to your treatment. T e pulsus paradoxus is 14 mm Hg.
T is is indicative o possible cardiac tamponade, but it may be
seen in constrictive pericarditis, severe asthma, or anything else
that reduces right heart lling (e.g., tension pneumothorax).
T is patient’s clinical picture is consistent with decompensated
cardiac tamponade, and drastic action is indicated to relieve the
symptoms o right heart ailure. T e de nitive treatment is peri-
cardiocentesis. “A” is incorrect because more drastic action is
required. You would be correct to change the patient to predni-
sone or to add colchicine. Colchicine is being increasingly used
or pericarditis. “C” is incorrect since an inotrope will do little
to help this problem. “D” is incorrect or two reasons: the rst
is that this is a right heart problem and reducing a erload (sys-
temic vascular resistance) will not help the right heart, which
pumps against pulmonary resistance; second, most drugs that
reduce systemic vascular resistance will also decrease preload to
some degree, worsening the symptoms o tamponade.
HELPFUL TIP:
Be awa e that up t 25% pat ents w th ca d ac tam-
p nade w NOT dem nst ate an e evated pu sus pa a-
d xus. S , a n ma pu sus pa ad xus d es n t u e ut
ca d ac tamp nade.
HELPFUL TIP:
Measu ng pu sus pa ad xus: Pump up the BP cu
t g eate than the s st c BP. De ate de ate BP cu
s w and sten the st K tk s und hea d
only du ng exp at n; c nt nue s w de at ng unt
u hea the K tk s unds w th nsp at n as we .
The d e ence s the pu sus pa ad xus.
You per orm a pericardiocentesis and the patient gets better.
O course, a good outcome never protected anyone rom a
lawsuit . . .
Objectives: Did you learn to . . .
• Eva uate a pat ent w th t p ca ang na chest pa n?
• Desc be the test cha acte st cs va us t pes n n nva-
s ve ca d ac test ng?
52 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW
• Bec me am a w th the nte p etat n n n nvas ve
ca d ac test ng?
• r ec gn ze va us nd cat ns PTCA w th stent p acement
ve sus CABG?
• Unde stand the ph s g , p esentat n, and t eatment
p stpe ca d t m s nd me?
• T eat pe ca d t s and ca d ac tamp nade?
QUICK QUIZ: CAr DiAC CT SCAN
When planning or treatment or diagnosing (i.e., “ruling out”
MI/acute ACS) based on a cardiac C angiogram (CC A),
which o the ollowing is true?
A) CC A is associated with better long-term clinical outcomes
than is cardiac per usion (thallium) scanning.
B) T e radiation exposure or C angiogram is less than that o
thallium scanning.
C) T e downstream radiation exposure a er thallium scanning
is less than that o C angiogram.
D) T e C angiogram is best done in those with a pulse o 70 to
80 bpm.
E) A creatinine o 1.6 mg/dl is a contraindication to the use o
C angiogram because o the contrast load.
The correct answer is “B.” T e radiation exposure o CC A
is less than that o thallium scanning, both initially and down-
stream (thus, “C” is wrong). More patients who have thallium
scanning go on to angiogram and additional radiation ex-
posure. “D” is incorrect. T e slower the heart rate, the better
the images (within reasonable limits, o course . . . . as pulse o
12 BPM isn’t so good). So, patients are o en pretreated with
metoprolol to slow the heart rate be ore CC A. “E” is also in-
correct. It turns out that IV contrast is less o a actor in renal
ailure than we have thought (Radiology. 2014;273(3):714). I
you eel the patient really needs the C and has a creatinine o
1.7 mg/dl or less, go ahead with the C .
What about answer “A”? It turns out that even though CCTA
is better at identi ying cardiac disease (CCTA is more sensi-
tive) and leads to more interventions than is thallium scanning
and echo, its use is not associated with better outcomes. T is is
true even though more patients who have had a CC A go on to
have revascularization (N Engl J Med. 2015 Mar 14). Feel ree to
do that thallium test . . . .
QUICK QUIZ: HyPEr TENSio N
According to the members o the Eighth Joint National
Committee (JNC 8), the blood pressure goal in a patient with
diabetes is:
A) <100/50 mm Hg.
B) <110/70 mm Hg.
C) <130/80 mm Hg.
D) <140/90 mm Hg.
E) None o the above.
The correct answer is “D.” According to JNC 8, the goal or a dia-
betic patient (or any patient age 30–59 years, including those with
chronic kidney disease) is <140/90. ighter control does not seem
to con er any bene t. T e BP goal in those over age 60 is <150/90.
T ese goals are consistent with the best current evidence at the
time JNC 8 was published. In act, tight blood pressure control in
diabetics increases mortality (JAMA. 2010;304(1):61–68).
HELPFUL TIP:
r ec mmendat ns t eat ng h pe tens n n the
e de va a tt e based n the gan zat n pub sh-
ng the g a s. F pat ents ve age 80 ea s, the e s
un ve sa ag eement (ACC/AHA, JNC 8, ASH, ESH/ESC)
that <150/90 sh u d be the g a . F pat ents age
60 t 79 ea s, JNC 8 ec mmends a g a <150/90
wh e the the gan zat ns ec mmend a g a
<140/ 90—but w th a s st c p essu e ema n ng g eat-
e than 115 mm Hg.
CASE 2.3
A 24-year-old male presents to your clinic with a 50-hour
history o an irregular heart rate. He is generally well but
has a history o hypertension (too many super-jumbo burg-
ers . . . with bacon . . . he’s been “supersized”), which he has
been trying to control with exercise and diet (he switched
to to u burgers yesterday). T ere is no prior history o car-
diac disease or palpitations. He did “have a bit to drink” cel-
ebrating . . . well, whatever, just celebrating . . . who needs
a reason! He was embarrassed about his drinking and thus
waited 2 days to seek care. T ere is no amily history o heart
disease and the patient does not smoke. Vital signs reveal an
irregular pulse o 130 bpm and a blood pressure o 160/100
mm Hg. T e patient is a ebrile and has normal respirations.
He has no heart murmur. T e ECG is shown below (Fig. 2-2).
Question 2.3.1 The most appropriate diagnosis is:
A) Multi ocal atrial tachycardia (MA ).
B) Wandering atrial pacemaker.
C) Atrial brillation.
D) Ventricular tachycardia.
E) Accelerated junctional rhythm.
Answer 2.3.1 The correct answer is “C,” atrial brillation.
T is is characterized by the lack o P waves and an irregularly
irregular rhythm. “A” and “B” are incorrect. While both MA
and a wandering atrial pacemaker are irregularly irregular, both
have P waves. “D” is incorrect. Ventricular tachycardia is a wide
complex tachycardia and is regular. “E” is incorrect. While there
are no P waves in an accelerated junctional rhythm, it should be
a regular, organized rhythm.
Question 2.3.2 What is the most likely cause o this patient’s
dysrhythmia?
A) Congenital prolonged Q syndrome.
B) Hypertrophic cardiomyopathy.

FIGURE 2-2. ECG pat ent n quest n 2.3.1.
C) Alcohol.
D) Marijuana use.
E) Ischemic cardiac disease.
Answer 2.3.2 The correct answer is “C.” T e most likely cause
o atrial brillation in this 24-year-old is alcohol. T is is also
known by the moniker “holiday heart.” It occurs a er episodes
o signi cant alcohol intake. T e underlying mechanism is not
known, but alcohol is known to be cardiotoxic at higher vol-
umes which varies per individual. “A” is incorrect because pro-
longed Q typically causes polymorphic ventricular tachycar-
dia (torsades de pointes). “B,” hypertrophic cardiomyopathy, is
unlikely since the patient has never had a murmur, and hyper-
trophic cardiomyopathy generally presents with signs o aortic
outlet obstruction (syncope or angina with exercise) although
a subset o patients do not have obstructive physiology. “D” is
incorrect because marijuana is not implicated in causing atrial
brillation, and “E” is incorrect because a patient who is 24
years old is unlikely to have ischemic cardiac disease.
Question 2.3.3 Other states that can cause atrial brillation
include all o the ollowing EXCEPT:
A) Valvular disease, especially mitral disease.
B) Hyperthyroidism.
C) Stroke.
D) Heart ailure.
E) Acute PE.
Answer 2.3.3 The correct answer is “C.” Stroke does not
generally cause atrial brillation but can be a result o atrial
CHAPTER 2 • CAr Dio l o Gy 53
brillation. Certainly, stroke and other intracranial injuries can
be associated with arrhythmias. However, these are generally
isolated PVCs. Stroke may also be associated with heart ailure
and ischemic changes on the ECG, but it is rarely an isolated
cause o atrial brillation. Valvular heart disease, hyperthyroid-
ism, heart ailure, and PE are all causes o atrial brillation.
Valvular heart disease, heart ailure, and PE all have a similar
mechanism: stretching o the atrium leading to atrial irritability.
Atrial brillation is ound in 10% to 20% o those with hyper-
thyroidism, especially in the elderly.
T e patient con des that he was indeed at a bachelor party
several days ago (so that was what he was celebrating) and
had a bit too much to drink. T is is quite unusual or the
patient. He generally drinks 2 to 3 beers per week, but on
this particular night had 12 or more (hmm . . . we’re wonder-
ing). T e patient’s pulse increases to 160 bpm, but he remains
asymptomatic.
Question 2.3.4 The INITIAL goal or this patient with
50 hours o atrial brillation is:
A) Anticoagulation.
B) Immediate cardioversion (DCCV).
C) ransesophageal echocardiogram to rule out vegetations.
D) Rate control.
E) Blood pressure lowering
Answer 2.3.4 The correct answer is “D.” Since this patient has
had >48 hours o atrial brillation, rate control is the goal. I
the onset o atrial brillation is indeterminate or >48 hours,
54 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW
one should withhold cardioversion. For those with <48 hours o
atrial brillation, cardioversion is a viable option. Anticoagula-
tion is also important to initiate while attempting to achieve rate
control. See more on whom to anticoagulate below.
T e patient’s heart rate remains elevated at 160 bpm with
occasional orays into the 170 bpm range.
Question 2.3.5 Which o the ollowing is the best drug to
administer to this patient?
A) Digoxin.
B) Lidocaine.
C) Amiodarone.
D) Adenosine.
E) Diltiazem.
Answer 2.3.5 The correct answer is “E.” “A” is incorrect.
Digoxin will be o limited use since it takes at least 30 minutes
to have an e ect. It can be used in those with atrial brillation
secondary to heart ailure but will still not signi cantly help
with rate control—especially in younger patients with robust
sympathetic tone. “B” is incorrect because lidocaine is indicated
or a wide complex tachycardia. “C” is incorrect. Amiodarone
will work as a treatment o atrial brillation but is a second-line
drug because it can cause torsades de pointes. It can be used
in patients with atrial brillation and congestive ailure, where
verapamil or diltiazem might be contraindicated. Amiodarone
is considered to be advantageous in maintaining sinus rhythm,
especially when given as pretreatment prior to cardioversion,
but is not as e cacious in prompt heart rate control due to
longer onset o action. “D” is incorrect. Adenosine is ultra-
short-acting, blocks the AV node, and can be used to convert a
paroxysmal supraventricular tachycardia (PSV ) or slow down
the rate o the arrhythmia temporarily i you are not sure what
the diagnosis is (e.g., a rapid atrial f utter vs. PSV ). However,
adenosine will not reduce the ventricular rate in atrial bril-
lation since atrial brillation does not require the AV node to
propagate. A beta-blocker could also be used in this situation.
Being the astute clinician that you are, you realize that 50%o
atrial brillation will spontaneously convert to normal sinus
rhythm, especially i present <72 hours. A transthoracic
echocardiogram was per ormed and did not demonstrate any
structural heart disease. T us, you choose to give verapamil
and watch the patient. At 24 hours, he still is in atrial brilla-
tion, although the rate is controlled well with verapamil and
he is now normotensive.
Question 2.3.6 I the patient desires cardioversion, the next
step in the management o this patient is:
A) Start war arin.
B) Start heparin and rivaroxaban at the same time.
C) Start heparin.
D) Start aspirin.
Answer 2.3.6 The correct answer is “A.”We may want to cardio-
vert this patient in the uture. “A” is the most reasonable option
provided. Some physicians will start heparin or low-molecular-
weight heparin at the same time as initiation o war arin; how-
ever, the combination is not strictly necessary in patients with
non-valvular atrial brillation. T is scenario is much di erent
than when patients have a PE/DV . For non-valvular atrial
brillation, starting war arin alone is su cient. “B” is incor-
rect. T ere is no need to bridge patients starting rivaroxaban
with heparin; rivaroxaban’s anticoagulant e ect is “immediate”
and there is no transient hypercoagulable state. However, note
that since he gave a history o an “irregular heart beat or 50
hours” on presentation, he has now presumably been in atrial
brillation or >48 hours (approximately 74 hours at this point),
so immediate cardioversion is contraindicated (see next ques-
tion). Heparin (“C”) or aspirin (“D”) alone would not be the
best choices in this case.
Question 2.3.7 How long must you wait a ter the patient
has been anticoagulated be ore cardioverting him?
A) 1 week.
B) 3 weeks.
C) 3 months.
D) Only until therapeutic on war arin.
E) T ere is no need to wait be ore cardioversion in this patient.
Answer 2.3.7 The correct answer is “B.” I the patient has been
in atrial brillation or more than 48 hours, one should wait
or cardioversion until the patient has been anticoagulated or
3 weeks with war arin (target INR 2–3) or standard dose riva-
roxaban (Xarelto), apixaban (Eliquis), or dabigatran (Pradaxa).
I atrial brillation has been present or less than 48 hours, you
can proceed directly to cardioversion. Some physicians may
order a transesophageal echocardiogram to assess or throm-
bus ormation be ore cardioversion; this approach is acceptable.
T e patient will also need anticoagulation or 4 weeks a er
success ul cardioversion.
HELPFUL TIP:
r va xaban, ap xaban ( act Xa nh b t s) and dab -
gat an (a d ect b n nh b t ) a e a app ved use
n n n-va vu a at a b at n. The ch ce d ugs
s up t u. The e s tt e c n ca d e ence between
utc mes w th wa a n, ap xaban and dab gat an (a -
th ugh wa a n s ess expens ve, even when check ng
iNr s). The e ma s me s ght c n ca advantage t va-
xaban. But, the e s n c mpe ng ev dence t av
ne ve the the . We n w have a eve sa agent
dab gat an but n t the the s (as Feb ua , 2016).
The sh u d be ava ab e s n, th ugh. y u sh u d
av d ed xaban (Sava sa). The utc me data sn’t as
g d as w th the act Xa nh b t s.
Question 2.3.8 All o the ollowing can be used to cardiovert
atrial brillation EXCEPT:
A) Ibutilide.
B) Electrical cardioversion.
 CHAPTER 2 • CAr Dio l o Gy 55

C) Quinidine. His atrial brillation has not been addressed since it was
D) Digoxin. picked up by the surgeon at a pre-op visit. His heart rate is
E) Procainamide. 80 bpm when you see him, his rhythm is irregularly irregular,
and he has no signs o heart ailure.
Answer 2.3.8 The correct answer is “D.” Digoxin does not
work to cardiovert atrial brillation. Digoxin may acilitate Question 2.4.1 Which o the ollowing options would be
cardioversion in patients with heart ailure by reducing atrial appropriate or this patient?
stretching. However, it does not convert atrial brillation. All A) Anticoagulate the patient with war arin and allow him to
o the other answers are correct. Because o potential induction stay in atrial brillation.
o arrhythmias with the other agents, electrical cardioversion B) Place the patient on aspirin and allow him to stay in atrial
is becoming the pre erred method o restoring normal sinus brillation.
rhythm. C) Give digoxin to cardiovert the patient.
D) Strongly suggest cardioversion to this patient since sus-
Objectives: Did you learn to . . .
tained normal sinus rhythm yields the best long-term
• r ec gn ze the c n ca and ECG p esentat n at a
outcomes.
b at n?
E) Add urosemide to prevent the development o heart ailure
• Use ate-c nt ng d ugs t t eat a pat ent w th at a
and edema.
b at n?
• App p ate emp ant c agu at n n at a b at n
Answer 2.4.1 The correct answer is “B.” T is patient’s CHA2-
a pat ent unde g ng ca d ve s n?
DS2-VASC (see able 2-6A) score is “1” allowing him to take
• ident app p ate s tuat ns ca d ve s n at a
aspirin rather than being ully anticoagulated with oral antico-
b at n?
agulants in the presurgical setting. A CHA2-DS2-VASC score o
“1” corresponds to what we used to call “lone atrial brillation.”
It is reasonable to allow the patient to remain in atrial bril-
QUIZ: ANTiHyPEr TENSiVE AGENTS
lation, as long as they are rate-controlled with the knowledge
that antiplatelet agents alone or in combination are in erior to
A 70-year-old male complains o erectile dys unction and oral anticoagulants or stroke prophylaxis. Outcomes o patients
requests sildena l (Viagra) or erectile dys unction, which you who stay in atrial brillation and are given appropriate therapy
believe is secondary to vascular disease. are the same (or a bit better) than in patients in whom one tries
to maintain sinus rhythm with drugs such as amiodarone, etc.
Which o the ollowing antihypertensive drugs can cause T us, “D” is wrong.
prolonged hypotension when used with sildena l?
A) Peripheral alpha-blockers.
B) Calcium channel blockers (CCBs).
C) An ACE inhibitor. TABLE 2-6A CALCULATING THE
D) Diuretics. CHA2DS2-VASc SCORE
E) Beta-blockers.
Criteria Points

The correct answer is “A.” T e peripheral alpha-blockers C ngest ve Hea t Fa u e 1

(doxazosin, prazosin, and tamsulosin) can cause symptomatic H pe tens n (t eated 1
hypotension when combined with sildena l or other drugs o ab ve 140/90 mm Hg)
this class (Cialis [tadala l], Levitra [vardena l]). T is hypoten-
Age >75 2
sive e ect is more severe when these drugs are combined with
a nitrate. Nitrates should not be administered within 24 hours D abetes 1
(or longer in patients with renal or hepatic dys unction) o these
St ke, TiA 2 Score and Risk of CVA
drugs, as the combination has reportedly resulted in strokes.
th mb emb c d sease ( n %/ )
None o the other drugs (“B”–“E”) cause this hypotensive e ect
2 = 2.2%/
when combined with sildena l.
3 = 3.2%/
4 = 4%/
CASE 2.4 5 = 7%/
6 = 10%/
A 55-year-old male with a history o newly identi ed atrial
brillation is re erred to you or “medical clearance” or sur- Vascu a d sease (CAD, 1
PAD, a t c p aque)
gery. He has a history o hypertension and hypercholesterol-
emia (calculate his CHA2-DS2-VASC score, see able 2-6A). Age 65–74 1
He has normal cardiac unction otherwise with a normal
Sex Categ Fema e 1
ejection raction and no valvular disease on echocardiogram.
56 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

TABLE 2-6B TREATMENT OF ATRIAL FIBRILLATION T e 75-year-old patient has his surgery and returns to your
BASED ON THE CHA2DS2-VASc SCORE clinic or a postoperative check-up 1 month a er his surgery.
CHA2DS2 VASc Score Recommended Treatment You check his INR and it is noted to be 5.2. T ere is no active
0–1 (ma e) Asp n 81–300 mg/da (0.5–0.7% bleeding.
st ke sk/ )
Question 2.4.3 The most appropriate action at this point
1 ( ema es) Asp n 81–300 mg/da (0.1–0.2%
is to:
st ke sk/ )
A) Hospitalize the patient or observation since he is at a high
(N te that w men aut mat ca have a
sc e 1 based n gende ) risk o bleeding.
B) Give the patient 5 mg o vitamin K orally.
2 g eate , ma e Ant c agu at n w th wa a n ( the C) Give the patient 2 units o resh rozen plasma to reverse his
ema e ant c agu ant)a
anticoagulation.
a
Xa e t ( va xaban), E qu s (ap xaban) and P adaxa (dab gat an).
D) Hold the next war arin dose and reduce the maintenance
dose.
E) A, B, and C.

HELPFUL TIP: Answer 2.4.3 The correct answer is “D.” T e risk o bleeding
H w sh u d u app the CHA2-DS2-VASC sk sc e t in a relatively healthy patient with an INR o 5.2 is very low.
the ap ? Check ut Tab e 2-6B. T us, simply holding the next one to two doses o war arin and
reducing the maintenance dose o war arin is appropriate. “A”
is incorrect because the patient does not need hospitalization.
T e patient returns at age 75. He is older. You, however, have “B” is incorrect because it will be di cult to reanticoagulate the
not aged a day because doctors are immortal, right? He is now patient a er vitamin K is administered. “C” is incorrect because
hypertensive, has diabetes, and he needs surgery to remove there is no active bleeding.
his gallbladder. His CHA2-DS2-VASC score is now 4 and he is
on anticoagulation war arin. T e patient misunderstands your instructions and takes an
extra dose o war arin that evening and or the next 2 days.
Question 2.4.2 Which o the ollowing approaches is the He returns to your clinic and his INR is now 13.
best or controlling his anticoagulation given that he needs
surgery? Question 2.4.4 What is the best option or therapy at this
A) Stop the war arin several days be ore surgery to allow his point?
INR to normalize. Restart the war arin a er surgery. A) Vitamin K 5 mg IV × 1.
B) Hospitalize the patient a couple o days ahead o time and B) Fresh rozen plasma.
start heparin. T en stop his war arin. Restart the war arin C) Vitamin K 5 mg PO × 1.
a er surgery. D) Vitamin K 10 mg IV × 1.
C) Use low-molecular weight heparin at home and stop the
war arin once this is started. Restart the war arin a er sur- Answer 2.4.4 The correct answer is “C.” Giving this patient
gery. 5 mg o PO vitamin K is the best solution. T is has been ound
D) Stop the war arin several days be ore surgery to allow his to reduce the INR while still allowing the patient to be anticoag-
INR to normalize. Start heparin a er surgery and simulta- ulated relatively easily a er treatment. “B” is incorrect because
neously restart war arin. there is no call or FFP in this asymptomatic patient. T e other
answers are incorrect because there is no advantage to higher
Answer 2.4.2 The correct answer is “A.” For patients with doses or IV doses o vitamin K in this patient, and the higher
nonvalvular atrial brillation who are undergoing surgery doses will make continued anticoagulation more di cult.
or invasive diagnostic procedures, it is reasonable to inter-
rupt anticoagulation or up to 1 week without substituting HELPFUL TIP: r EVEr SiNG WAr FAr iN
heparin (assuming they haven’t had a recent stroke or other in pat ents wh a e n t b eed ng:
thromboembolic event). “Bridge” therapy with IV heparin or • i the iNr s <4.5 s mp educe the d se wa a n
low-molecular weight heparin con ers no bene t (Circulation. h d the next d se wa a n.
2015;131(5):488). T e risk o perioperative bleeding with hepa- • i the iNr s 4.5 t 10 u have seve a pt ns. i the e
rin is actually greater than the risk o thromboembolism rom s n b eed ng: h d ne tw d ses wa a n.
atrial brillation. “B,” “C,” and “D” are incorrect because the r ut ne v tam n K s n t ec mmended. i the pat ent
patient does not need heparin. Bridging therapy is typically w equ e su ge s at h gh b eed ng sk, adm n-
indicated or patients at higher risk or thromboembolic events ste v tam n K ≤ 5 mg w th an the 1 t 1.5 mg n
such as those with mechanical heart valves, prior stroke, or 24 h u s.
CHA2DS2-VASc score >5.

• i the iNr s >10 adm n ste 2.5 t 5 mg v tam n K
even the e s n b eed ng.
in pat ents wh a e b eed ng:
• Adm n ste p th mb n c mp ex c ncent ate (e.g.
Kcent a . . . sh u d the bu a v we ? The can a d t!).
Th s s p e e ed ve esh zen p asma, wh ch s sec-
nd ne. in add t n, adm n ste 5 t 10 mg v tam n K.
See A g thm m P esc be ’s l ette ava ab e at: http://
pha mac sts ette .the apeut c esea ch.c m/p /A t c eDD.
aspx?n dchk=1&cs=&s=Pl &pt=2& pt=2&dd=280509
Objectives: Did you learn to . . .
• We gh the advantages and d sadvantages ate c nt
ve sus h thm c nt st ateg es at a b at n?
• Manage ant c agu at n and at a b at n v s-à-v s
su ge ?
• Manage the ve -ant c agu ated pat ent?
CASE 2.5
A 62-year-old emale presents to your o ce with a history o
occasional palpitations that are o great concern to her. She
notes that she eels a racing heart that lasts or a matter o sec-
onds and occurs every 7 days or so. However, when she has the
symptoms, she will generally get our to ve episodes during
that day. She denies any chest pain, dyspnea, lightheadedness,
or other associated symptoms. You order an event monitor
and it shows that the patient is having nonsustained episodes
o monomorphic ventricular tachycardia lasting 4 beats or less
each.
Question 2.5.1 The best approach at this point is to:
A) Start an antiarrhythmic such as quinidine or mexiletine to
control the heart rhythm.
B) Re er the patient to a cardiologist or an EP study to deter-
mine the best drug to control this rhythm.
C) Implant an automatic de brillator to prevent sudden death.
D) Implant a pacemaker.
E) Check serum potassium, magnesium, SH.
Answer 2.5.1 The correct answer is “E.” T e rst step in deter-
mining the treatment o this patient is to make sure that there is
not an underlying metabolic abnormality that could predispose
to this rhythm abnormality.
You check a panel o laboratory studies including thyroid
unction tests, electrolytes, magnesium, glucose, and CBC.
T ey are all within normal limits. You suggest that the
patient avoid potential triggers such as caf eine and sympa-
thomimetics. “Darn,” she sighs. “I have to quit my crystal
meth?”
Question 2.5.2 The next step or this patient is to:
A) Start an antiarrhythmic such as quinidine or mexiletine to
control the heart rhythm.
CHAPTER 2 • CAr Dio l o Gy 57
B) Re er the patient to a cardiologist or an EP study to deter-
mine the best drug to control this rhythm.
C) Implant an automatic de brillator to prevent sudden death.
D) Start a beta-blocker.
E) Order transthoracic echocardiogram to rule out structural
heart disease.
Answer 2.5.2 The correct answer is “E.” Nonsustained ventric-
ular tachycardia may have an adverse prognosis in the presence
o structural heart disease such as hypertrophic cardiomyopathy
or ischemic heart disease. An echocardiogram as well as stress
test may be help ul in ruling them out. T ere is no evidence that
nonsustained, asymptomatic ventricular tachycardia worsens
outcomes as long as the patient has no underlying cardiac
disease. In an otherwise healthy, asymptomatic patient, the risk
o trying to use antiarrhythmic drugs to suppress ventricular
ectopy leads to worse outcomes than doing nothing. Quinidine,
mexiletine, amiodarone, and other antiarrhythmics all have
proarrhythmic e ects. In general, there is more sudden death in
these patients i they are treated with antiarrhythmic drugs than
i they are watched. T ere ore, “A” is incorrect because these
drugs will actually increase mortality. “B” is incorrect since the
patient has asymptomatic, sel -limited episodes. T e reason to
do an EP study is to see i there is an inducible arrhythmia and
to determine treatment. T is patient does not need treatment.
“C” is incorrect because this patient has asymptomatic nonsus-
tained ventricular tachycardia. T us, an implantable de bril-
lator is not indicated. A er your evaluation is complete, you
may prescribe a beta-blocker (“D”) or symptomatic relie . T is
patient is overall asymptomatic so this would not be the best
option at this time.
T e echocardiogram is normal, and the patient does well or
the next 3 months but then becomes symptomatic with pro-
longed episodes o ventricular tachycardia. While all o the
episodes are sel -limited, the patient has had two episodes o
syncope.
Question 2.5.3 Which o the ollowing is the next best step
in treating this patient?
A) Sotalol.
B) Implantable de brillator.
C) Amiodarone.
D) Electrophysiologic study.
E) ocainide (an oral lidocaine equivalent).
Answer 2.5.3 The correct answer is “D.” An electrophysiologic
study is indicated to induce and characterize the ventricular
tachycardia. Certain types o ventricular tachycardia respond
very well to radio requency ablation. Some o you may have
answered “B.” T is is true in patients with ischemic heart
disease, le ventricular dys unction and symptomatic ven-
tricular tachycardia. T ese patients should get an implant-
able de brillator as should “all” heart ailure patients with an
ejection raction o <30% to 35% (there are literally over 200
variations o this based on heart ailure class, QRS duration, etc.,
but this is the basic idea).
58 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW
Objectives: Did you learn to . . .
• Eva uate a pat ent w th pa p tat ns?
• Manage n nsusta ned, as mpt mat c, vent cu a
tach ca d a?
CASE 2.6
A 22-year-old emale presents to your o ce with a history o
palpitations. You are able to capture the arrhythmia on the
monitor in your o ce: the rhythm strip shows evidence o
isolated premature atrial contractions (PACs). She is other-
wise healthy and taking no medications, and there is no am-
ily history o heart disease.
Question 2.6.1 All o the ollowing are salient points o the
history with regard to PACs EXCEPT:
A) Aged cheese consumption.
B) Ca eine use.
C) obacco use.
D) Alcohol use.
E) COPD.
Answer 2.6.1 The correct answer is “A.” Aged cheese can cause
problems in combination with monoamine oxidase inhibitors
(MAOIs). In combination with an MAOI, aged cheese and
other sources o tyramine can cause a hypertensive emergency.
However, this patient is not taking any medications. All o the
other conditions and drugs listed can cause PACs. While there
are conf icting data about the strength o the association ca -
eine, it is clear that COPD, tobacco, and alcohol can all cause
an increase in sympathetic tone, leading to PACs. Neurologic
abnormalities (e.g., stroke) can also be associated with PACs, as
can some drugs (e.g., theophylline).
HELPFUL TIP:
y u have t eat 2 p unds chedda cheese n ha an
h u n de t deve p a h pe tens ve c s s w th an
MAo i. in stud es whe e the e was ee access t cheese,
the max mum an ne was ab e t eat was 1.9 p unds n
2 h u s. Be eve t n t, s me ne stud ed th s (p b-
ab s mewhe e n W sc ns n).
Question 2.6.2 Which o the ollowing statements about
PACs is true?
A) Mitral valve prolapse is associated with PACs.
B) Mitral valve stenosis is associated with PACs.
C) Bicuspid aortic valve is associated with PACs.
D) None o the above is true.
Answer 2.6.2 The correct answer is “B.” Anything that can
cause an increase in le atrial pressures (and there ore atrial
wall stretching) is associated with an increase in the number
o PACs. Mitral stenosis causes increased pressures in the le
atrium, wall stretching, and enlargement and thus predisposes
to PACs. “A” is incorrect. Even though multiple problems have
been blamed on mitral valve prolapse, a study done as part o
the Framingham study showed that the symptoms blamed on
mitral valve prolapse (anxiety, PACs, tachycardia, etc.) are no
more prevalent in those with mitral valve prolapse than in those
without it. “C” is incorrect. A bicuspid aortic valve may cause
PACs as a result o heart ailure when the patient decompensates
and has increased le -sided heart pressures. However, a bicus-
pid aortic valve itsel is not a source o PACs. Similarly, hyper-
trophic cardiomyopathy, other causes o heart ailure, drugs
(e.g., theophylline and digoxin), and neurologic diseases can be
associated with PACs.
T is patient is bothered by her PACs. She is rather aware o
them and nds them disconcerting.
Question 2.6.3 What is the best pharmacologic therapy to
consider at this point?
A) Sotalol.
B) Metoprolol.
C) rasylol.
D) Amiodarone.
E) Mountain Dew—lots o it.
Answer 2.6.3 The correct answer is “B.” A beta-blocker may
help to reduce this patient’s PACs. “A” is incorrect because,
while sotalol can be used or both atrial and ventricular
arrhythmias, it is proarrhythmic and can cause torsades de
pointes. T us, it should be initiated in the hospital with moni-
toring and reserved or those with severe arrhythmias. “C” is
incorrect because rasylol is the trade name or aprotinin, an
enzyme that is used to reduce bleeding during surgical pro-
cedures. “D” is incorrect because, like sotalol, amiodarone is
proarrhythmic, and its use should be limited to those with sig-
ni cant arrhythmias.
Objectives: Did you learn to . . .
• r ec gn ze causes PACs?
• T eat a pat ent w th b the s me PACs?
QUICK QUIZ: VAl VUl Ar DiSEASE
Surgery is indicated in which o these patients with valvular
disease?
A) An asymptomatic patient with severe mitral regurgitation
and a le ventricular ejection raction (LVEF) o less than
60%.
B) An asymptomatic patient with a bicuspid aortic valve.
C) Asymptomatic aortic regurgitation with an LVEF o less
than 50% on echocardiogram.
D) Only symptomatic valvular lesions should be approached
surgically.
E) A and C.
The correct answer is “E.” Once patients with mitral regur-
gitation and aortic regurgitation become symptomatic,
the morbidity and mortality increases signi cantly. T us,
these patients should be operated on be ore they become

symptomatic. Patients should have routine echocardiogra-
phy yearly i they have severe valvular disease. In addition to
evaluating the valve, echocardiography allows you to evalu-
ate ventricular size and unction. Importantly, proper man-
agement o patients with valvular heart disease depends on
accurate diagnosis o the cause as well as proper staging o the
disease process, which is based on valvular anatomy, valvular
hemodynamics, severity o le ventricular dilation and sys-
tolic unction, and patient symptoms. (NO E: le ventricular
systolic unction and patient symptoms are only part o the
decision making process regarding management and timing
o re erral to surgery).
CASE 2.7
A 74-year-old male presents to your o ce with a chie
complaint o a “long cold” with an intermittent cough or
5 months. He has also noticed that he gets up to urinate twice
a night although he has no trouble with his urine stream,
starting urination, or dribbling a erward. He has been a bit
more tired lately and notices that his exercise tolerance has
decreased to several blocks, limited mainly by shortness o
breath. He has not had any chest pain. He has no history o
asthma or COPD and has not had any exposures to drugs or
chemicals. He has a history o hypertension and noncompli-
ance with medical recommendations. In act, he is taking no
medications except or an aspirin a day. His pulse is 100 bpm
with a blood pressure o 160/95 mm Hg. He looks pretty well.
On examination, you nd only trace pitting edema o the
lower extremities.
Question 2.7.1 Which o the ollowing is NOT a possible
cause o cough in this patient?
A) Heart ailure.
B) Asthma.
C) Deconditioning.
D) COPD.
E) GERD.
Answer 2.7.1 The correct answer is “C.” Deconditioning
may cause dyspnea on exertion but should not cause a cough.
T e purpose o this question is to point out the act that a
“chronic cold” or “chronic cough” in an elderly person can
be due to a myriad o causes, including “occult” heart ailure
(systolic or diastolic HF). Do not make the assumption that
the patient’s diagnosis (e.g., a “chronic cold”) is necessarily
the correct diagnosis.
HELPFUL TIP:
S st c hea t a u e (sec nda t n a ct n, etc.)
s n w te med “Hea t Fa u e w th a educed Ejec-
t n F act n” (HF EV). D ast c hea t a u e s n w
te med “Hea t Fa u e w th a p ese ved Eject n F ac-
t n (HFpEF). in th s b k we use b th the “ d” and
new n tat ns.
CHAPTER 2 • CAr Dio l o Gy 59
You decide that this patient may have heart ailure. An ECG
shows no evidence o prior or ongoing ischemia. T ere are no
signs o atrial enlargement or ventricular hypertrophy.
Question 2.7.2 The proper conclusion rom this is:
A) he patient does not have cardiac chamber enlargement
or hypertrophy and there ore is unlikely to have heart
ailure.
B) T e absence o evidence or prior in arct makes heart ailure
unlikely.
C) Regardless o the ECG results, clinical judgment alone is su -
cient to make the diagnosis o heart ailure, being correct
85% o the time.
D) T e patient’s edema is likely rom venous insu ciency.
E) Despite a normal ECG, urther testing is needed in this
patient to evaluate or heart ailure.
Answer 2.7.2 The correct answer is “E.” “A” is not correct
because only 30% to 60% o moderate-to-severe le ventricu-
lar hypertrophy (LVH) is detectible on ECG. “B” is incorrect
because patients with diastolic dys unction (discussed later)
may not have any evidence o prior ischemia or MI. “C” is
incorrect. T e clinical diagnosis o heart ailure is incorrect up
to 50% o the time. For this reason, con rmation is required
be ore embarking upon a therapeutic adventure or heart ail-
ure. “D” is unlikely, since the patient has other symptoms o
heart ailure (exertional dyspnea, cough, etc.) that make simple
venous insu ciency unlikely.
Question 2.7.3 You decide on urther testing. Assuming
every test is easily available to you (which might not be the
case depending on the setting in which you work), what is
the one best test that you would use to determine i this
patient has heart ailure?
A) Echocardiography.
B) Brain natriuretic peptide (BNP) level.
C) Chest radiograph looking or evidence o pulmonary edema
(Kerley B lines, etc.).
D) SPEC thallium test.
E) Positron emission tomography (PE ) testing.
Answer 2.7.3 The correct answer is “A.” Echocardiography is
the procedure o choice or the diagnosis o heart ailure. T is
is or two reasons. First, you can assess le ventricular systolic
unction as well as look or diastolic dys unction to determine
i this is systolic or diastolic heart ailure (i.e. heart ailure with
reduced ejection raction, HFrEF or heart ailure with preserved
ejection raction, HFpEF respectively). Second, you can evalu-
ate the potential causes o heart ailure including valvular heart
disease, ischemic heart disease, pericardial disease, deposition
disease (amyloidosis, hemochromatosis) etc. “B” is incorrect
because the BNP will give you less concrete in ormation about
the patient versus echocardiography. In this patient, with a high
pretest probability o heart ailure, BNP will most likely be ele-
vated. “D” and “E” are incorrect because SPEC thallium and
PE testing are best used to diagnose ischemia due CAD.
60 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW
HELPFUL TIP:
in a w- sk pat ent, a BNP <100 pg / ml e ect ve
u es ut hea t a u e. A BNP 100 t 500 pg/ml s n-
dete m nate and ma n t be e ated t ca d ac d sease.
A BNP >500 pg/ml s e at ve spec c hea t a -
u e ( the ca d ac and n nca d ac causes a e exc ud-
ed). A te nate ca d ac causes nc ude ACSs, hea t musc e
d sease, va vu a hea t d sease, pe ca d a d sease, at a
b at n, m ca d t s, ca d ac su ge , and status-p st
DC ca d ve s n.
(LESS) HELPFUL TIP:
N nca d ac causes an e evated BNP nc ude ena a -
u e, anem a, advanced age, seps s/ Sir S, pu m na ( b-
st uct ve s eep apnea, pu m na h pe tens n, seve e
pneum n a), c t ca ness, seve e bu ns, t x cmetab -
c events (cance , chem the ap , enven mat n). o be-
s t can cause a a se w BNP. BNP-d ected the ap
may be use u n s me pat ents. H weve , m st data at
th s p nt suggests that t eat ng based n s mpt ms
and t eat ng based n BNP have s m a utc mes (Eu
Hea t J. 2014;35(1):16–24).
T e patient has an echocardiogram that shows a le ven-
tricular ejection racture (LVEF) o 35% and a regional wall
motion abnormality (RWMA).
Question 2.7.4 This is the most consistent with a diagnosis
o :
A) Systolic heart ailure secondary to myocarditis.
B) Systolic heart ailure secondary to CAD.
C) Diastolic heart ailure.
D) Systolic heart ailure secondary to constrictive pericarditis.
E) Age-related changes; there ore, a normal variant.
Answer 2.7.4 The correct answer is “B.” A regional wall
motion abnormality (RWMA) suggests that this patient has
ischemic or in arcted myocardium. “A” is not the best choice
since those with myocarditis ( ulminant or acute) typically
have global hypokinesis (although RWMA has been reported)
and the patient would typically appear more clinically ill. “C”
is incorrect by de nition. Diastolic heart ailure (HFpEF)
requires a LVEF o at least 50%, recognizing that this group
may not have an entirely normal LVEF, but the major abnor-
mality is not a reduction in LV systolic unction. Systolic heart
ailure (HFrEF) is de ned by an LVEF o <40%. Diastolic heart
ailure (HFpEF) is associated with a hypertrophied le ven-
tricle and a preserved LVEF. T e echocardiogram in constric-
tive pericarditis (“D”) generally shows normal le ventricular
systolic unction. It may reveal pericardial thickening, dilated
in erior vena cava or hepatic veins, and abnormal mitral and
tricuspid in-f ow Doppler.
HELPFUL TIP:
T x ns such as methamphetam ne, c ca ne, a c h ,
and ant ne p ast c chem the apeut c d ugs can cause
a ca d m path and sh u d be c ns de ed as a p s-
s b e et g CHF n the app p ate pat ent.
Question 2.7.5 Which o the ollowing is the most appro
priate next strategy to work up this patient’s systolic heart
ailure (HFrEF)?
A) Cardiac MRI to assess myocardial viability.
B) Coronary angiogram.
C) Measure serial troponins to rule out ACS.
D) Electrophysiologic study to assess or inducible ventricular
arrhythmia.
E) C to assess calcium scores.
Answer 2.7.5 The correct answer is “B.” Ischemic heart disease
is the most common etiology or heart ailure associated with
systolic dys unction. I you can reverse the ischemia, mortal-
ity is decreased rom 16% annually to 3.2% annually. O all the
options listed above, coronary angiography remains the gold
standard to evaluate or CAD in this setting. Coronary angio-
grams provide in ormation about anatomy and easibility o
revascularization but do not predict recovery o unction. T is
patient does not have chest pain or ECG changes to suggest
acute cardiac syndrome (ACS); there ore, “C” is incorrect. “D”
is incorrect, as there is no indication or an electrophysiologic
study in the absence o any arrhythmia. “E” is incorrect as the
presence or absence o coronary calci cation would not change
the overall management plan or this patient. C calcium scor-
ing may be used as an additional risk strati cation tool in inter-
mediate-risk patients (similar to CRP, in addition to traditional
risk actors such as hypertension, dyslipidemia, vascular or
renal disease, etc.) but not in high-risk, symptomatic patients.
T e coronary angiogram shows dif use CAD; no coronary
lesions are considered to be amenable to angioplasty and
there are no vessels considered to be viable targets or bypass
surgery. You decide to initiate medical therapy in this patient.
In addition, you advise the patient regarding the nonphar-
macologic therapies or heart ailure treatment.
Question 2.7.6 Nonpharmacologic therapies or systolic
heart ailure (HFrEF) include all o the ollowing EXCEPT:
A) Fluid restriction o <2 L/day.
B) Sodium restriction o <2 g/day.
C) Dietary consultation.
D) Cardiac risk actor modi cation.
E) Monthly weight monitoring.
Answer 2.7.6 The correct answer is “E.” Prior to initiation o
therapy, it is important to determine the patients NYHA classi-
cation and ACC/AHA stage o HF, which in orms the clinician
regarding guideline-directed medical therapy. T e keystone o
an e ective heart ailure treatment regimen is sodium and f uid

balance as well as management o comorbidities. Frequently over-
looked, these are the most common causes o heart ailure exac-
erbation. It is imperative to get a dietary consultation or every
patient with newly diagnosed heart ailure. Cardiac risk actors,
including: hypertension, diabetes, hyperlipidemia, sleep apnea,
obesity, sedentary li estyle, smoking/alcohol/drug use, need to be
treated with the same aggressiveness as in a patient with an ACS.
Patient should be advised about daily weight monitoring rather
than monthly monitoring. A weight gain o more than 3 to 5 lb
may necessitate additional doses o a diuretic. NO E: signi cant
f uid restriction to 1.5 to 2.0 L/day is typically, though not exclu-
sively, reserved or Stage D advanced HF patients who are hypo-
natremic or diuretic resistant. Both sodium and f uid balance
recommendations are best implemented in the context o a struc-
tured daily weight and symptom sel -monitoring home program.
You wish to start an appropriate drug regimen or this patient’s
heart ailure.
Question 2.7.7 All o the drugs below have been shown
to reduce mortality in patients with systolic heart ailure
(HFrEF) EXCEPT:
A) Digoxin.
B) Metoprolol succinate.
C) ACE inhibitors.
D) Hydralazine and long-acting nitrates used in combination in
patients intolerant o ACE inhibitors.
E) Spironolactone.
Answer 2.7.7 The correct answer is “A.” Digoxin is an inotro-
pic agent, and as such, would intuitively make sense as an e ec-
tive drug or HFrEF. However, digoxin has not been shown to
increase survival and in act may worsen outcomes, especially
in women. Its use is primarily or symptomatic relie . I using
digoxin in HFrEF, the therapeutic target is a dose that achieves
a plasma concentration o drug in the range o 0.5 to 0.9 ng/mL.
T e common daily dosage to achieve that target is typically
0.125 to 0.25 mg/day in patients <70 years o age with normal
renal unction and body mass. For patients with abnormal
renal unction, low body mass or age >70, low doses (0.125 mg
daily or every other day) are recommended initially, and the
dose then titrated to the target therapeutic range. Digoxin
does reduce hospitalizations and improve symptoms in those
with HFrEF who are symptomatic despite use o other maxi-
mal guideline directed therapy. Digoxin may also be utilized
in addition to beta-blockers or controlling the ventricular
response in HFrEF patients with atrial brillation (though
it is generally not very e ective in ambulatory patients). It is
ine ective at treating atrial brillation in those with a nor-
mal EF. Avoid digoxin in patients with signi cant sinus or AV
nodal block unless they have a pacemaker. NO E: Other car-
diac medications such as amiodarone, dronedarone, verapamil,
propa enone and quinidine as well as noncardiac meds such as
clarithromycin, erythromycin, itraconazole and cyclosporine
can increase the serum digoxin concentrations and may pre-
cipitate digoxin toxicity.
CHAPTER 2 • CAr Dio l o Gy 61
All o the others options, including the combination o iso-
sorbide dinitrate and hydralazine, have been shown to reduce
mortality. However, hydralazine and isosorbide dinitrate are
generally reserved or those patients who are unable to toler-
ate ACE inhibitors or angiotensin receptor blockers (ARBs) or
remain symptomatic despite maximal medical therapy with the
other medications, especially in A rican Americans. Enalapril
reduces mortality by 28% when compared with hydralazine and
nitrates. T us, hydralazine and nitrates are second line. None o
the “traditional” loop diuretics such as urosemide, bumetanide,
etc., have been shown to positively a ect mortality.
You start this patient on urosemide or diuresis and lisinopril
or HFrEF. You also decide to initiate metoprolol succinate or
its survival bene ts. However, the patient’s symptoms worsen.
Question 2.7.8 Which o these is true about the use o
metoprolol in HFrEF?
A) It is the only beta-blocker indicated or use in HFrEF.
B) Its best use is in those patients who are still symptomatic
since it will help to control symptoms.
C) It should only be initiated in patients with well-controlled
HFrEF who are not currently having signi cant symptoms
(i.e., decompensated).
D) Beta-blockers can lead to signi cant hypokalemia when
combined with diuretics, so potassium levels should be
monitored closely.
E) Beta-blockers are contraindicated in patients who have a
combination o COPD and HFrEF.
Answer 2.7.8 The correct answer is “C.” Beta-blockers should
not be initiated in patients who are signi cantly symptomatic
or decompensated. While beta-blockers do reduce mortality,
they can increase symptoms and urther exacerbate heart ail-
ure. T ere ore, they are best initiated in the stable patient (as
an outpatient or 24 to 48 hours prior to hospital discharge and
on a stable drug regimen). Even then some patients cannot tol-
erate the introduction o beta-blockers without worsening o
symptoms, which may require additional diuresis, discontinua-
tion o the beta-blocker, a reduction in dose, or other measures.
“A” is incorrect. Other beta-blockers have been used in HFrEF,
including carvedilol. “B” is incorrect because beta-blockers may
actually worsen heart ailure symptoms. “D” is incorrect since
beta-blockers do not cause hypokalemia. “E” is incorrect. Beta-
blockers can be used in patients with COPD with the same cave-
ats that apply to any other patient: i the patient is becoming more
symptomatic on the beta-blocker, reduce the dose or discontinue
the drug. In act, beta-blockers may improve survival in COPD
(BMJ. 2011;342:d2549; BMC Pulmonary Medicine. 2012;12:48).
HELPFUL TIP:
When sta t ng a beta-b cke HF EF, sta t w and
g s w! When sta t ng d g x n HF EF, m n t
h p ka em a, h p magnesem a, h p th d sm t
av d d g x n t x c t , even w th w d ses.
62 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW
You reduce the dose o metoprolol succinate and consider
starting this patient on another medication.
Question 2.7.9 Which o the ollowing patients is/are good
candidates or spironolactone?
A) A patient with NYHA Class I and Class II heart ailure.
B) A patient with NYHA Class III and Class IV heart ailure.
C) Both A and B.
D) Neither A nor B.
Answer 2.7.9 The correct answer is “B.” Spironolactone has
been shown to reduce mortality in patients with New York Heart
Association (NYHA) Class III and Class IV heart ailure. It has
not been studied in Class I (thus “A” is wrong), However, it may
be use ul in symptomatic patients with Class II with an EF o
<30%. Serum potassium needs to be monitored closely a er ini-
tiation o spironolactone, especially since it will generally be used
with an ACE inhibitor or ARB, both o which can increase the
serum potassium. T is drug should be avoided in patients with
renal insu ciency or patients with serum potassium >5 mEq/L.
Spironolactone is indicated or patients with NYHA Classes II–
IV and who have LVEF ≤ 35% and a creatinine o <2.5 mg/dL
in males or <2.0 mg/dL in emales (or estimated GFR >30 mL/
min/1.73 m 2). Eplerenone is another aldosterone inhibitor but is
much more expensive with little, i any, advantage.
HELPFUL TIP:
A sk en (Tektu na), a en n nh b t , is contraindicat-
ed w th an Ar B ACE nh b t . it w sens utc mes
and causes h pe ka em a. it a s w sens utc mes
n pat ents w th d abetes. it d esn’t ea have a we -
de ned p ace n the ap .
You treat this patient with metoprolol succinate, lisinopril,
urosemide, and aspirin. T is regimen seems to help, and the
patient’s symptoms improve. However, a ew weeks later, he
presents to the ED with increased dyspnea. T ere have been
no changes in his medications, and he assures you that he is
taking his medications as directed. His examination reveals
that he has elevated JVD, rales over the lower hal o his lung
elds bilaterally, and pedal edema.
Question 2.7.10 Common causes o decompensation in
patients with otherwise stable heart ailure include all o
the ollowing EXCEPT:
A) Inactivity.
B) Fever.
C) Arrhythmia.
D) Dietary indiscretion.
E) Ischemia.
Answer 2.7.10 The correct answer is “A.” Inactivity will
not generally cause an exacerbation o HF. T e major causes
o increased HF include dietary indiscretion (increased salt
intake—“Say, can you pass the potato chips?”—increased f uid
consumption and f uid retention), increased metabolic demand
(e.g., rom in ection), anemia, medication noncompliance,
arrhythmia, and ischemia. T e inappropriate use o medica-
tions, such as some calcium channel blocker and the institution
o beta-blockers when CHF is decompensated, are also com-
mon causes o exacerbations o HF.
T e patient notes that he did have some chest pain earlier in
the day. You want to initiate therapy. You take his vitals, and
his pulse is 100 bpm, blood pressure 140/95 mm Hg, oxygen
saturation 89%on room air, and respiratory rate 32.
Question 2.7.11 Besides oxygen, the one best drug to initi
ate rst in the ED to treat this patient with an acute exacer
bation o his chronic HFrEF is:
A) Furosemide.
B) Digoxin.
C) A positive inotrope, such as dobutamine.
D) Nitroglycerin.
E) An ACE inhibitor
Answer 2.7.11 The correct answer is “D.” T is patient will ben-
e t rom nitroglycerin or several reasons. First, the patient has
told you that he had chest pain earlier today. T us, it is possible
that this patient’s HF exacerbation is due to ischemic disease.
Nitroglycerin will help this via vasodilation. T e second rea-
son is that the goal here is to restore normal cardiac unction
by causing vasodilation and decreasing preload and a erload.
Nitroglycerin will do both o these. “A,” urosemide, is also a
good choice but not the one best choice. By inducing diuresis,
urosemide will also signi cantly decrease preload and provide
symptomatic relie . But remember not all HF patients are f uid-
overloaded (such as with f ash edema rom ischemia). “B” is
incorrect because it will take some time or digoxin to have a
signi cant impact on this patient’s symptoms. “C” is incorrect
because dobutamine is a second-line drug reserved or those
not responding to more conservative therapy and it would not
be indicated in active ischemia due to increasing myocardial
oxygen demand. “E” is technically not incorrect, but it is not
the best answer. T ere is ample evidence that ACE inhibitors,
which work as a erload reducers, can be used in acute HF exac-
erbations either IV (e.g., enalaprilat) or sublingual (e.g., capto-
pril). However, these drugs should be reserved as second-line
therapy or patients who do not respond to more appropriate
initial measures, and they would not be the rst line to address
ischemia among choices listed.
You treat the patient with nitroglycerin, he improves, and
you admit him to the oor. While in the hospital, the patient
develops some additional chest pain that lasts or 10 min-
utes and responds to additional sublingual nitroglycerin. His
BNP is noted to be elevated. His hemoglobin (Hb) is 7.2 g/dL
and hematocrit (HC ) is 22%. He is still in congestive ail-
ure. T e pathologist tells you that there is blood available in
the blood bank to trans use this gentleman i you so choose.
T ere is a problem, o course: he is in HF and now is some-
what tachycardic at 110.

Question 2.7.12 You tell the pathologist that:
A) T e Hb o 7.2 g/dL is not an indication or trans usion.
B) rans using this gentleman is inappropriate since he is
already in HF and may become more f uid-overloaded with
a blood trans usion.
C) You would like to go ahead with trans using this patient.
D) Making this patient’s blood more viscous with a trans usion
will increase the stress on his heart.
E) Erythropoiesis-stimulating agents (ESAs), such as darbe-
poetin (Aranesp), are sa er and more e ective than blood
trans usions or patients with HF.
Answer 2.7.12 The correct answer is “C.” T is patient should
be trans used. Guidelines suggest triggering trans usion in heart
disease when the Hb is <8 g/dL and i the patient is symptomatic
(i.e., tachycardic, chest pain). T ere is no bene t to trans using
patient with a higher Hb (Ann Intern Med. 2013;159:770). Use
clinical judgment o course, as there are no guidelines or trans-
usion in an individual with ACS. ESAs (“E”) seems to increase
thromboembolic events without providing any bene t in those
with stable HF and mild to moderate anemia. T ey should gen-
erally be avoided in this population.
T ere are no o cial ACC/AHA recommendations regarding
trans usion. However, the mortality at 30 days is increased i the
Hb is <11 mg/dL in a patient with a non-S EMI. Whether or
not trans usion will help this is not known: it may just be that
patients with anemia are sicker at baseline. Patients with an HC
o <20% to 24% likely bene t rom a trans usion while those
with an HC > 27% to 30% do not. For 25% to 26% use your
judgment. HF is di erent. Blood trans usion should be reserved
or patients with heart ailure that are severely anemic and the
trans usion be undertaken slowly and with the concurrent use
o diuretics to avoid volume overload (Am Heart J. 2009;158:
653–658). “A” and “B” are incorrect because this patient should
be trans used care ully as noted above. “D” is incorrect since
trans using this patient to a normal Hb and HC will not cause
excess blood viscosity.
HELPFUL TIP:
Nes t de (Nat ec ), a BNP ana g, can be used
HF EF but s expens ve, c nt butes t ena a u e, and
ke nc eases m ta t . Nes t de can p duce p -
nged h p tens n, wh ch m ts the d se that can be
used. Th s s a the ap ast es t . . . and that ma be
t cha tab e. Just d n’t use t.
Objectives: Did you learn to . . .
• r ec gn ze at p ca p esentat ns hea t a u e w th e-
duced eject n act n n the e de ?
• Desc be the sens t v t and spec c t an ECG l VH?
• Eva uate a pat ent w th hea t a u e w th educed eject n
act n?
• Manage a pat ent w th hea t a u e w th educed eject n
act n and unde stand the e beta-b cke s, ACE
CHAPTER 2 • CAr Dio l o Gy 63
nh b t s, Ar Bs, d g x n, and sp n act ne n the t eat-
ment HF EF?
• Desc be the e BNP measu ement n the eva uat n
hea t a u e w th educed eject n act n and nes t de
n the t eatment hea t a u e?
CASE 2.8
Your patient with heart ailure does well and is discharged
rom the hospital a er a couple o days. You are just beginning
to think that the authors are tired o writing questions about
heart ailure . . . but you are wrong. T e patient’s 70-year-old
wi e shows up with shortness o breath. Her physical exami-
nation is consistent with heart ailure. Since you have learned
so much rom this case already, you send her to get an echo-
cardiogram. You also order the recommended tests: CBC,
electrolytes, ECG, thyroid unctions, etc.
Question 2.8.1 The results o the echocardiogram show a
concentric thickening o the le t ventricle with an ejection
raction o 75%. This is most consistent with:
A) Ischemic cardiomyopathy.
B) Diastolic dys unction (HFpEF).
C) Viral cardiomyopathy.
D) Hypertrophic cardiomyopathy.
E) None o the above.
Answer 2.8.1 The correct answer is “B.” “A” is incorrect since
there would likely be evidence o RWMA i there had been an
old myocardial in arction. Also, this patient has a preserved
ejection raction, which is consistent with diastolic dys unc-
tion (HFpEF) rather than the decreased ejection raction
associated with ischemic cardiomyopathy. “C” is incorrect.
Viral cardiomyopathy is associated with a dilated ventricle
rather than a hypertrophic one, and there would be global
dyskinesia with decreased ejection raction. “D” is incor-
rect; hypertrophic cardiomyopathy is usually associated with
asymmetric hypertrophy, o en septal, rather than concentric
hypertrophy o the le ventricle. Hypertrophic cardiomyopa-
thy may lead to HFpEF in addition to le ventricular outf ow
tract obstruction.
Question 2.8.2 Diastolic dys unction (HFpEF) is associated
with which o the ollowing?
A) A prolonged history o untreated hypertension.
B) Poor relaxation o the ventricular wall.
C) T yroid disease.
D) A and B.
E) B and C.
Answer 2.8.2 The correct answer is “D.” HFpEF is o en associ-
ated with long-standing hypertension as well as a sti ventricu-
lar wall that does not relax to allow good lling during diastole
(there ore “diastolic dys unction”). “C” is not correct because
hyper- and hypothyroidism are usually associated with a dilated
cardiomyopathy.
64 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW
Question 2.8.3 HFpEF represents approximately what
percentage o HF?
A) <5%.
B) Approximately 10%.
C) Approximately 25%.
D) Approximately 50%.
E) >75%.
Answer 2.8.3 The correct answer is “D.” HFpEF represents
between 40% and 60% o cases o HF when looking at the
population as a whole. T e other answers are incorrect. T e
point here is that, as discussed earlier, patients with HF need
an echocardiogram to determine what type o heart ailure
they have.
HELPFUL TIP:
HFpEF ccu s m e c mm n n e de p pu at ns.
Question 2.8.4 Which o the ollowing drugs is the LEAST
desirable in patients with HFpEF?
A) Diuretics.
B) ACE inhibitors.
C) Nitrates.
D) Digoxin.
E) Negative inotropes such as beta-blockers and CCBs.
Answer 2.8.4 The correct answer is “D.” Digoxin and other
positive inotropes (e.g., milrinone) are not very use ul in dia-
stolic dys unction. T is makes sense. T e problem here is not a
lack o contractility but alternatively a lack o muscle relaxation.
While there has not been a superior therapeutic regimen identi-
ed by randomized control trials, the goals o therapy are blood
pressure control, the use o diuretics to relieve congestion and
edema, treatment o ischemia i present, and control o the heart
rate to avoid tachycardia.
Question 2.8.5 Which o the ollowing drugs or drug classes
is theoretically the best choice or the treatment o HFpEF?
A) ACE inhibitors.
B) Beta-blockers.
C) Diuretics.
D) Hydralazine.
E) ARBs.
Answer 2.8.5 The correct answer is “B.” Beta-blockers, espe-
cially metoprolol succinate, are use ul as initial therapy in
HFpEF. Beta-blockers (1) slow down the heart to permit lon-
ger LV lling duration during diastole and (2) help to relax
the myocardium to promote a less restrictive lling pattern. I
a patient ails beta-blockers, try a CCB (e.g., verapamil, diltia-
zem). Unlike systolic dys unction, the treatments o diastolic
dys unction are not well established, and there is no convinc-
ing evidence that beta-blockers or ACE inhibitors reduce
mortality.
HELPFUL TIP:
Hea t a u e s a te m na ness w th a 5- ea su v va
n 50%. Th s s w se than man cance s.
Objectives: Did you learn to . . .
• Unde stand the path ph s g HFpEF d ast c?
• T eat a pat ent w th HFpEF?
CASE 2.9
Your “congestive heart ailure couple,” as they now call them-
selves, are doing so well that the wi e re ers her cousin to
you (we still aren’t tired o writing heart ailure questions).
Her cousin, a 65-year-old male, arrives at your o ce and
you immediately notice the smell o tobacco leaching rom
his clothing. T e small burns in his clothing con rm to you
that he smokes, and he in orms you that he has smoked
three packs per day “since birth.” He recently has noticed
some swelling in his eet and increased shortness o breath.
He denies a history o cardiac disease. An ECG per ormed
in the o ce shows right axis deviation and a right bundle
branch block (RBBB). An echocardiogram shows that he has
normal le ventricular unction but a hypertrophied right
heart with paradoxical bulging o the ventricular septum
into the le ventricle was noted.
Question 2.9.1 This clinical picture is most consistent with
which o the ollowing?
A) Constrictive pericarditis.
B) Chronic mitral valve prolapse.
C) Cor pulmonale.
D) Old right ventricular in arction with subsequent dys unction.
E) Chiari network.
Answer 2.9.1 The correct answer is “C.” A typical picture o
cor pulmonale is right ventricular hypertrophy (RVH) with
paradoxical bulging o the septum into the le ventricle, right
axis deviation on ECG, and partial or complete RBBB. “A” is
incorrect. Constrictive pericarditis is associated with pericar-
dial thickening, dilated in erior vena cava or hepatic veins, and
abnormal mitral and tricuspid f ow. “B” is incorrect because
mitral valve prolapse in the absence o severe mitral regurgi-
tation is not likely to be hemodynamically signi cant. “D” is
incorrect because with a right ventricular in arct, you would
expect to see a poorly unctioning right ventricle. “E” is incor-
rect because a Chiari network is normal vestigial variant in the
right atrium and would not cause RVH.
Question 2.9.2 Cor pulmonale (not right ventricular ailure)
may result rom all o these disease processes EXCEPT?
A) Sickle cell anemia.
B) Le ventricular ailure.
C) PE.
D) Chronic obstructive lung disease.
E) Interstitial lung disease.

Answer 2.9.2 The correct answer is “B.” Cor pulmonale is the
term used or right heart ailure caused by diseases primarily
a ecting the lungs and pulmonary vasculature. T e chronic pres-
sure overload o the right ventricle as it ejects in to the high resis-
tance pulmonary vasculature results initially in RVH with normal
RV systolic unction but over time, the RV contractility declines
leading to RV dilation and right-sided heart ailure with associ-
ated signi cant tricuspid regurgitation and right atrial dilation.
Question 2.9.3 A possible nding on the ECG o this patient
would include:
A) P-mitrale (an “m” shaped, notched P wave in lead II).
B) P-pulmonale (an enlarged, peaked, P wave in lead II).
C) Absent P waves.
D) Inverted P waves.
Answer 2.9.3 The correct answer is “B.” Patients with cor pul-
monale o en have an enlarged and peaked P wave in lead II
ref ecting right atrial enlargement. “P-mitrale” is ound in le
atrial enlargement.
Question 2.9.4 Besides stopping smoking, the best treat
ment o this patient’s cor pulmonale and pulmonary hyper
tension (PHTN) is:
A) Continuous prostacyclin in usion.
B) Continuous, low f ow oxygen.
C) CCBs.
D) Nitroglycerin.
E) Antibiotics to reduce pulmonary inf ammation secondary
to in ection.
Answer 2.9.4 The correct answer is “B.” In this patient who is a
smoker with cor pulmonale, the best drug is continuous, low-f ow
oxygen. T is will help to reverse the pulmonary vasoconstriction
caused by chronic hypoxia. It should go without saying that you
must do everything you can to get him to stop smoking. His dis-
ease process will progress much aster i he continues to smoke.
“A” is incorrect because prostacyclin in usion is use ul in primary
pulmonary hypertension (PH N), not this type o cor pulmonale.
“C” is incorrect. In some cases o primary PH N, CCBs, PDE5
inhibitors (e.g., sildena l), and several other medications, which
serve as direct vasodilators to dilate the pulmonary vascular bed,
can be use ul. However, this is not the best choice or this patient
with COPD. “D” is incorrect because patients with cor pulmonale
are dependent on high right heart lling pressures to get blood
through the pulmonary vasculature. Nitroglycerin will reduce pre-
load, thereby lowering right ventricular pressure and resulting in
worsening o his symptoms. “E” is also incorrect. Antibiotics might
be needed in this patient or pneumonia, bronchiectasis, etc., but
they are not going to help with the treatment o cor pulmonale.
HELPFUL TIP:
r emembe s eep apnea as a cause c pu m na e. N c-
tu na x gen desatu at n causes nc eased pu m na
vascu a es stance caus ng e evated ght vent cu a
p essu e and p ss b ght-s ded a u e seve e and
unt eated.
CHAPTER 2 • CAr Dio l o Gy 65
Objectives: Did you learn to . . .
• D agn se c pu m na e?
• Desc be causes c pu m na e?
• T eat a pat ent w th c pu m na e?
CASE 2.10
A 65-year-old male presents to your clinic or a complete his-
tory and physical examination. You notice that his abdomi-
nal examination reveals a pulsatile mass, which you sus-
pect may represent an aortic aneurysm (now we are tired o
writing heart ailure questions). T is nding is con rmed
by ultrasound. T e radiologist reports that the patient has a
3.5-cm abdominal aortic aneurysm without evidence o leak
or thrombus ormation.
Question 2.10.1 The best advice to this patient is:
A) Have the aortic aneurysm xed now while he is still
healthy.
B) Have a ollow-up ultrasound every 3 months.
C) Have a stent placed to prevent urther aortic dilatation.
D) Have an angiogram in the next several days to rule out vas-
cular disease below the aorta ( emoral arteries, iliac arteries,
etc.).
E) Have a repeat ultrasound at 1 year.
Answer 2.10.1 The correct answer is “E.” Patients with an
abdominal aortic aneurysm less than 4 cm in diameter should
have an ultrasound yearly to check progression. T ose with an
aneurysm 4 to 5 cm in diameter should have an ultrasound
every 6 months. An ultrasound on an every 3 to 6 months basis
is also indicated or aneurysms that are growing >0.5 cm per
year. Bottom line: the larger the aneurysm, the more requently
should do an ultrasound. “A” is incorrect (see next question or
an explanation). “C” is incorrect since a stent is not indicated at
this point. “D” is incorrect. T e only reason to do an angiogram
at this point is i the patient is symptomatic or i you are plan-
ning surgical intervention.
Question 2.10.2 The patient is really worried that this aneu
rysm will rupture and kill him. You educate him that the
bene t o having the aneurysm repaired is greater than the
risk o the surgery when the aneurysm reaches:
A) ≥4.5 cm.
B) 5.0 to 5.5 cm.
C) 5.5 to 6.0 cm.
D) >6.0 cm.
E) No repair is indicated until the patient becomes symptom-
atic.
Answer 2.10.2 The correct answer is “B.” T e risk o the sur-
gery outweighs the bene ts until the aneurysm reaches some-
where between 5.0 and 5.5 cm. T e rest are incorrect. It would
be an especially bad idea to wait until an aneurysm is symptom-
atic, as a ruptured aortic aneurysm can be lethal in a matter o
minutes.
66 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW
HELPFUL TIP:
Pe cutane us end vascu a stent g a t epa s bec m-
ng the p cedu e ch ce as c mpa ed t pen epa .
But the e a e t ade s: 30 da m ta t m an end -
vascu a g a t s 1.6% ve sus 3.2% pen epa , but at
8 ea s uptu e ate was 5.4% ve sus 1.4%. o ve a 8- ea
m ta t s the same (N Eng J Med. 2015;373:328).
T e patient goes to exas (or Arizona or Florida—somewhere
warmer than Iowa) or the winter as part o the re-establish-
ment o human annual migration. When he returns, he calls
you complaining o back pain that is somewhat sharp and
radiating into his legs. You meet him in the ED and suspect
that he is having a dissection o his aneurysm.
Question 2.10.3 All o the ollowing are true regarding aor
tic dissection EXCEPT:
A) A substantial number o patients will have palpable pulses
below the level o the dissection.
B) Patients may have an elevated LDH and microangiopathic
ndings on RBC examination.
C) Blood pressure should be kept on the high side to ensure
per usion below the area o the aneurysm.
D) T e pain may migrate down rom the chest to the lower
abdominal area over time.
E) T e pain may be episodic.
Answer 2.10.3 The correct answer is “C.” One does not want
to keep the blood pressure on the high side. In act, reducing
the blood pressure is the initial treatment o choice or a dissect-
ing aneurysm. “A,” “B,” “D,” and “E” are all correct statements.
Patients may have an elevated LDH and microangiopathic nd-
ings on RBC smear as a result o trauma and cell lysis. “D” is a
correct statement, but patients o en do not have this “classic”
migrating pattern o pain. “E” is o en true o pain in aortic dis-
section—it may be episodic.
T e patient has a blood pressure o 160/105 mm Hg. Clearly,
this is too high in a patient who has an ongoing dissection.
You decide to treat this patient be ore trans erring him to a
tertiary care center where he can be surgically managed.
Question 2.10.4 The best medication(s) to use in this
patient to control his blood pressure is/are:
A) Sublingual ni edipine plus metoprolol.
B) Amlodipine.
C) Intravenous hydralazine.
D) Intravenous esmolol plus nitroprusside.
E) Intravenous nitroglycerin.
Answer 2.10.4 The correct answer is “D.” T e goal o ther-
apy here is not only blood pressure reduction but also control
o shear orces on the aorta, which requires the prevention
o tachycardia. Intravenous beta-blockers such as labetalol,
propranolol, metoprolol, or esmolol are the rst-line agents.
Esmolol is pre erred because o the short hal -li e; you easily can
turn it o i there is hypotension. Nitroprusside (or our avor-
ite, IV nitroglycerin) can be added i the blood pressure control
remains suboptimal even a er beta-blockade. In this scenario,
nitroprusside should never be given without beta-blockade, as
it may cause ref ex tachycardia induced by vasodilation and
thus urther aortic shear stress. T e same rationale is true or
not using intravenous hydralazine without beta-blockers in
this scenario. “A” is incorrect or two very good reasons. First,
ni edipine should never be used sublingually. Syncope, heart
block, MI, stroke, and other serious adverse consequences have
been reported. Second, ni edipine increases heart rate causing
an increase in shear orces on the aorta. “B” is incorrect since
amlodipine does nothing to reduce heart rate, is not titratable to
any use ul degree, and the onset o action is too slow to be used
when prompt blood pressure lowering is desired. “E” is incor-
rect because nitroglycerin alone causes ref ex tachycardia.
HELPFUL TIP:
Sc een an a t c aneu sm once n men age 65 t
75 wh have eve sm ked (pe USPSTF and ACC/AHA
gu de nes).
Objectives: Did you learn to . . .
• ident the t eatment pt ns and t m ng t eatment an
abd m na a t c aneu sm?
• Manage a pat ent w th a d ssect ng aneu sm?
CASE 2.11
A 60-year-old male presents with dizziness and palpitations.
T e patient has a blood pressure o 100/60 mm Hg and a
pulse o 160. His ECG is shown in Figure 2-3.
Question 2.11.1 Which o the ollowing interventions are
appropriate options in the treatment o this patient?
A) Amiodarone, lidocaine, de brillation, metoprolol.
B) Amiodarone, lidocaine, de brillation, diltiazem.
C) Amiodarone, lidocaine, cardioversion, diltiazem.
D) Procainamide, lidocaine, adenosine, de brillation.
E) Amiodarone, procainamide, lidocaine, cardioversion.
Answer 2.11.1 The correct answer is “E.” T e rhythm is stable
ventricular tachycardia. Procainamide, lidocaine, amiodarone,
and synchronized cardioversion can all be used or ventricular
tachycardia. “A” is incorrect or two reasons. T e rhythm is ven-
tricular tachycardia and is stable, and neither metoprolol nor
de brillation is appropriate. De brillation could be appropriate
i the patient was unstable, pulseless (including pulseless ven-
tricular tachycardia) or had ventricular brillation. “B” is incor-
rect because o the inclusion o diltiazem and de brillation. “C”
is incorrect because o the inclusion o diltiazem. “D” is incor-
rect because adenosine, which is used or atrial arrhythmias, is
useless in ventricular arrhythmias and because, again, de bril-
lation is inappropriate.
 CHAPTER 2 • CAr Dio l o Gy 67

FIGURE 2-3. ECG pat ent n quest n 2.11.1.

HELPFUL TIP: HELPFUL TIP:

P ca nam de s n nge n the ACl S p t c s. it s F defibrillation, esca at ng d ses e ect c t a e
st a ea g d d ug u have the t me t ad t. ut the new p t c s. Sta t w th a s ng e sh ck at
360 j u es w th a m n phas c de b at 150 t 200
Question 2.11.2 The patient does not respond to IV amio j u es us ng a b phas c de b at .
darone and you choose to cardiovert him. Which o the ol
lowing is the recommended energy (in joules) or an initial
attempt at synchronized cardioversion?
A) 200 joules, monophasic. You cardiovert the patient, and the rhythm in Figure 2-4 is on
B) 360 joules, monophasic. the monitor. Is it getting hot here, or is it just you?
C) 200 joules, biphasic.
D) 360 joules, biphasic. Question 2.11.3 O the ollowing, what is the rst step you
E) None o the above. will take (while maintaining good compressions and venti
lations, o course)?
Answer 2.11.2 The correct answer is “A.” For cardioversion o A) Reshock the patient at the same energy level.
stable ventricular tachycardia, start with 100 to 200 joules or B) Check another lead to assure the readout is accurate.
monophasic wave orms and 100 joules or biphasic wave orms. C) Give epinephrine, 1 mg IV.
T e rest are incorrect. D) Give atropine, 1 mg.

FIGURE 2-4. ECG pat ent n quest n 2.11.3.

68 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW
Answer 2.11.3 The correct answer is “B.” T is rhythm is asys-
tole. It is important to quickly check another lead and make
sure that all o the leads are connected properly. “A” is incorrect
because cardioversion/de brillation is not routinely indicated
in the treatment o asystole. “C” and “D” are incorrect because
it is important to ensure that the patient actually is in asystole.
HELPFUL TIP:
W th ega d t ACl S, d ng c mp ess ns and vent a-
t ns a e pa t cu a mp tant. The e s n need t n-
tubate the pat ent he/she can be eas bagged. The
c ect numbe vent at ns (10–12/m n) and c m-
p ess ns (100 bpm w th 2 n depth) n a at 15
c mp ess ns: 2 b eaths tw p v de CPr 30:1
s ng e p v de s mp tant. The Bee-Gees “Sta -
ng A ve” has the c ect ate c mp ess ns. Queen
“An the o ne B tes the Dust” a s has the c ect ate
but s c ns de ed ess dec us n the c de s tuat n (
c u se, u d n’t have t s ng t ut ud!). i u kn w
ne the th se s ngs, u a e n t qu te as d as we a e.
HELPFUL (AND VERY IMPORTANT) TIP:
The 2010 and 2015 AHA gu de nes ACl S emphas ze the
mp tance sta t ng w th chest c mp ess ns (C–A–B) and
NEVEr nte upt ng chest c mp ess ns du ng esusc tat n
( ea that means m n m z ng nte upt ns—the ee that
t ten chest c mp ess ns a e ha ted ess mp tant
nte vent ns such as ntubat n, ven us access, etc.).
FIGURE 2-5. ECG pat ent n quest n 2.12.1.
Question 2.11.4 The new lead placement continues to show
asystole. Which o the ollowing drugs and doses are con
sidered appropriate in asystole?
A) Epinephrine 1 mg.
B) Atropine 0.5 mg.
C) Atropine 1 mg.
D) Epinephrine 10 mg.
E) A and C.
Answer 2.11.4 The correct answer is “A.” Atropine is no
longer in the ACLS guidelines or asystole. Older ACLS rec-
ommendations or asystole included both epinephrine and
atropine.
Objectives: Did you learn to . . .
• r ec gn ze and manage vent cu a tach ca d a and as st e?
• App the cu ent Ame can Hea t Ass c at ns ACl S gu de-
nes t a pat ent n as st e?
CASE 2.12
A 75-year-old emale presents to your o ce complaining o
episodic palpitations with episodes o lightheadedness that
are not concurrent with the palpitations. You per orm an
electrocardiogram in your o ce, and the rhythm is shown
in Figure 2-5.
Question 2.12.1 What rhythm does this represent?
A) First-degree heart block.
B) Second-degree heart block type I (Wenckebach).

C) Second-degree heart block type II.
D) T ird-degree heart block.
E) Atrial f utter with variable block.
Answer 2.12.1 The correct answer is “C.” Your patient’s ECG
shows a second-degree heart block, type II (Mobitz II). T is is
characterized by a xed PR interval with an intermittently non-
conducting P wave and resultant dropped beats. “A” is incor-
rect. First-degree heart block is characterized by a prolonged
PR interval without any blocked beats (meaning every QRS is
preceded by a P wave conducted with a long PR interval). T e
upper limit o normal o the PR interval is 0.2 seconds (and we
admit that this one is darn close, but Mobitz II is the issue here).
A second-degree heart block, Mobitz type I (Wenckebach), is
de ned by a progressively prolonged PR interval ending with a
nonconducted P wave and a dropped beat. A third-degree heart
block is characterized by no consistent pattern between the P
waves and the QRS complex. “E” is incorrect because, by de -
nition, atrial f utter is represented by a rapid atrial rate. In this
patient, the rate is slow.
By the time the patient arrives at the hospital, she is having a
rapid, chaotic rhythm, which appears to be atrial brillation
on the monitor. It seems as though there are also episodes o
atrial utter with 2:1 block.
Question 2.12.2 The most likely diagnosis in this patient
with varying rate is:
A) Sick sinus syndrome (bradycardia–tachycardia syndrome).
B) Hypothyroidism.
C) Hyperthyroidism.
D) Hyperkalemia.
Answer 2.12.2 The correct answer is “A.”T e most likely diagno-
sis in this patient is “sick sinus syndrome,” also known as “tachy–
brady” syndrome and “bradycardia–tachycardia” syndrome. T is
syndrome is most common in elderly individuals and ref ects the
replacement o the SA node with brous tissue. “B” is incorrect
because hypothyroidism should cause bradycardia without inter-
mittent tachycardia. “C” is incorrect because hyperthyroidism
should cause tachycardia without bradycardia. “D” is incorrect
because hyperkalemia generally causes a widened QRS complex
on ECG and eventually ventricular tachycardia. Note: With Mob-
itz type II second degree heart block, the problem is in ra-nodal,
below the AV node and can result in complete heart block. Sick
sinus syndrome is due to disease o the SA node.
Question 2.12.3 De nitive treatment o this syndrome
generally includes which o the ollowing?
A) Mexiletine.
B) Hydralazine.
C) Quinidine.
D) Pacemaker.
E) Implantable de brillator.
Answer 2.12.3 The correct answer is “D.” In general, patients
with sick sinus syndrome become symptomatic because o the
CHAPTER 2 • CAr Dio l o Gy 69
bradycardia episodes. T us, pacing is necessary. (Note: A pace-
maker would also be indicated in patients with Mobitz type II
second-degree heart block without tachy-brady syndrome).
“A” and “C” are incorrect because these two drugs are aimed
primarily at ventricular arrhythmias; sick sinus syndrome is a
problem with the SA node. “B” is incorrect because hydralazine
is an a erload reducer with no direct e ect on cardiac rhythm.
“E” is incorrect because patients with sick sinus syndrome do
not have ventricular brillation or ventricular tachycardia, and
thus there is no need or a de brillator.
HELPFUL TIP:
in s ck s nus s nd me, n add t n t the pacemake , t
s ten necessa t add a beta-b cke , d g x n, a
CCB (d t azem ve apam ) t add ess the tach ca d a
(e.g., PSVT at a b at n).
Objectives: Did you learn to . . .
• ident and d f e ent ate sec nd-deg ee hea t b cks?
• D agn se and t eat s ck s nus s nd me?
CASE 2.13
A 58-year-old male smoker with a history o type 2 diabetes
mellitus presents with complaints o easy atigability and
pain in his thighs when exerting himsel . T e le leg is worse
than the right. T e pain resolves a er resting and is no worse
going downhill than uphill. He works as a carpenter, and the
leg pain is now limiting his ability to work. He will not quit
smoking (“It’s the only thing I truly love, Doc”). T e patient
states that his symptoms are better when he hangs his leg over
the side o the bed at night.
Question 2.13.1 The etiology o this patient’s leg pain is
most likely:
A) Peripheral venous disease (e.g., venous insu ciency, vari-
cose veins).
B) Spinal stenosis.
C) Diabetic neuropathy.
D) Peripheral arterial disease (e.g., arterial stenosis).
E) None o the above.
Answer 2.13.1 The correct answer is “D.” Intermittent claudi-
cation is the classic presenting symptom o peripheral arterial
disease. When rest pain is present, relie o symptoms occurs by
making the a ected area dependent (e.g., hanging the legs over the
side o the bed), letting gravity help increase blood f ow. T e pain
associated with diabetic neuropathy begins distally, has a burning
quality, and is not typically relieved with rest. In act, patients o en
notice it more at rest (e.g., during the night). Patients with periph-
eral venous disease will o en have worsening o their symptoms
when their legs in a dependent position. Spinal stenosis is o en
made worse by walking downhill and better when walking uphill
or leaning orward (a kyphotic/ orward f exed position opens up
the oramen thereby decreasing nerve root compression).
70 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW
His examination shows decreased pulses in the lower extrem-
ities bilaterally. You would like to con rm your suspicion
that this patient has peripheral vascular disease.
Question 2.13.2 What is the rst study you would order in
this patient?
A) Spiral C to con rm vascular calci cation.
B) Ankle-brachial index (ABI).
C) Color Doppler to assess f ow.
D) Catheter based arteriography.
E) None o the above is the recommended rst test.
Answer 2.13.2 The correct answer is “B.” T e ABI is sensitive and
speci c or peripheral arterial disease in the lower extremity. T e
pressure in the ankle should be higher than that in the brachial
artery in a normal person. T e highest sensitivity is achieved by
measuring pressures in both brachial arteries, both dorsalis pedis,
and both posterior tibial arteries. Neither spiral C or color Dop-
pler are recommended as the initial screening test or the presence
o peripheral vascular disease (although C angiogram may be
use ul in the uture to de ne the degree and location o narrowing).
Catheter based arteriography is an option but should be reserved
or patients with known peripheral artery disease in whom inter-
vention (percutaneous or surgical) is being considered.
T e ABI results are normal. However, you strongly suspect
claudication.
Question 2.13.3 The next step should be:
A) Catheter based arteriography.
B) Repeat ABI a er an exercise stress test.
C) Magnetic resonance arteriography.
D) C arteriography.
E) None o the above.
Answer 2.13.3 The correct answer is “B.” In patients in whom
you strongly suspect peripheral vascular disease, ankle-brachial
indices a er exercise can be positive when a resting test is nega-
tive. T is would be the least invasive and most cost-e ective test
o the options given.
T e postexercise ankle-brachial indices are as ollows: 0.9 in
the right leg, 0.4 in the le leg.
Question 2.13.4 The proper interpretation o this in orma
tion is:
A) 95% probability o some degree o occlusive disease in the
right leg, severe occlusive disease in the le .
B) No occlusive disease in the right leg, mild disease in the le .
C) Moderate occlusive disease on both sides.
D) No occlusive disease in either leg.
Answer 2.13.4 The correct answer is “A.” A normal ABI
should be 0.95 to 1.29. An ABI o 0.9 is 95% sensitive or nding
some degree o occlusive disease on arteriography (although it
may not be hemodynamically signi cant). An ABI o 0.81 to
0.94 represents mild arterial disease that may or may not be
associated with claudication. An ABI o 0.41 to 0.80 is classi-
ed as moderate arterial disease and is usually associated with
some degree o claudication. An ABI o ≤0.4 represents severe
disease and may be associated with rest pain. Paradoxically, an
ABI > 1.30 represents noncompressible arteries and may be a
marker or arterial calci cation. In these cases, a toe-brachial
index should be measured (really). (Don’t ask us . . . we don’t
know where to nd a toe BP cu either. Maybe you can use a
ull-sized gnome or pixie cu . We’d love to sell you one).
You decide to start the patient on a medication to help control
his claudication.
Question 2.13.5 Which o the ollowing statements is
correct?
A) Pentoxi ylline is relatively contraindicated in heart ailure.
B) Cilostazol is the best choice or claudication in patients with
heart ailure.
C) Beta-blockers are good arterial dilators and are thus use ul
in claudication.
D) T e main mechanism o action o pentoxi ylline and cilo-
stazol is selective vasodilation.
E) obacco smoking paradoxically alleviates claudication.
Answer 2.13.5 The correct answer is “A.” Cilostazol (Pletal)
and pentoxi ylline ( rental) are phosphodiesterase inhibitors.
T eir mechanism o action in improving walking distance is
poorly understood. Other phosphodiesterase inhibitors (such
as milrinone) increase mortality in patients with heart ailure.
T us, pentoxi ylline and cilostazol should be used with extreme
caution, i at all, in patients with heart ailure. Selective beta-
blockers actually cause peripheral arterial constriction, not
arterial dilation. “C” is also incorrect. T e purported bene t o
pentoxi ylline is to increase RBC malleability and thus reduce
the viscosity o blood in the microcirculation. It has no vasodi-
lative e ects. However, cilostazol does have some vasodilative
e ects. T erapeutic bene t with these drugs may take several
weeks. A dedicated and supervised walking program is o para-
mount importance and underutilized. Given the strong associa-
tion between smoking and peripheral artery disease, smokers
should be encouraged to quit, so “E” is incorrect. Pharmaco-
logic therapy o PAD should include antiplatelet therapy and
cardiovascular risk actor modi cation.
HELPFUL TIP:
r emembe that pe phe a a te d sease s c ns de ed
a CAD equ va ent.
Question 2.13.6 In and o themselves, indications or ur
ther intervention or peripheral artery disease (e.g., bypass,
stenting) include all o the ollowing EXCEPT:
A) Rest pain.
B) Persistent pain that inter eres with day-to-day unctioning.
C) issue loss.
D) 80% occlusion o the emoral artery.
 CHAPTER 2 • CAr Dio l o Gy 71

Answer 2.13.6 The correct answer is “D.” Classic indications
or invasive treatment o lower extremity PAD are (1) salvage
o a threatened limb (rest pain, nonhealing ulceration, or gan-
grene) and (2) improvement in unctional capacity. An 80%
occlusion o the emoral artery, in and o itsel , is not an indica-
tion or percutaneous or surgical revascularization in a patient
who is asymptomatic.
T e patient sees the light, but does not go into it, and quits
smoking. T e case ends happily . . .
HELPFUL TIP:
N ant c agu at n eg men seems t p event e cc u-
s n we ext em t a te es a te stent ng. Pat ents
sh u d, h weve , c nt nue n the cu ent ant th m-
b t c eg men as nd cated ca d vascu a d sease
(ASA, wa a n, etc.).
Objectives: Did you learn to . . .
• r ec gn ze s mpt ms and s gns pe phe a vascu a d sease?
• o de app p ate d agn st c tests a pat ent suspected
hav ng pe phe a vascu a d sease?
• Deve p an unde stand ng the agents used t t eat pe-
phe a vascu a d sease?
Answer 2.14.1 The correct answer is “D.” As a general rule, aor-
tic stenosis is repaired when it becomes symptomatic. Repair o
asymptomatic severe aortic stenosis is indicated in the ollowing
scenarios: undergoing CABG or other valve or aorta surgery, LVEF
< 50%, hypotension in response to exercise, or high likelihood o
rapid progression. “A” is incorrect because the loudness o the
murmur does not always correlate with its unctional signi cance.
“B” is incorrect as well. As long as the lesion is not hemodynami-
cally signi cant, the patient should tolerate prostate surgery. “C” is
incorrect because surgery is not usually necessary even in severe
valvular disease without symptoms as long as the le ventricular
unction is normal. (Note: it is not uncommon that patients with
severe aortic stenosis report that they are asymptomatic, but they
have modi ed their activity to avoid symptoms which may have
occurred gradually so that they don’t recognize the decline.)
Question 2.14.2 The patient would like to know how o ten
he should have a repeat echocardiogram given that he has
mild disease. Your answer is:
A) Every 3 to 5 years.
B) Every year.
C) Every 6 months.
D) When he develops symptoms.
E) None o the above.

Answer 2.14.2 The correct answer is “A.” Patients with mild

CASE 2.14
A 75-year-old male presents to your o ce or a complete
physical examination be ore prostate surgery. On examina-
tion, you notice a 3/6 harsh, mid-systolic ejection murmur
hard best at the upper right sternal border and radiating to
the neck. S1 and S2 are normal. An echocardiogram notes
mild aortic stenosis. Currently he is asymptomatic.
aortic stenosis who are asymptomatic can be ollowed by echo-
cardiogram every 3 to 5 years. Patients with severe disease
should have yearly echocardiography to evaluate or le ven-
tricular dys unction. See able 2-7.
wo years later, the patient returns or a checkup and states
that he believes he has been having symptoms rom his aortic
stenosis.

Question 2.14.1 The indications or valve replacement Question 2.14.3 All o the ollowing can occur with symp
surgery include: tomatic aortic stenosis EXCEPT:
A) Grade 4/6 murmur. A) Le -to-right intracardiac shunt.
B) Requirement or major, semi-elective surgery such as pros- B) Exertional dyspnea.
tatectomy. C) Syncope.
C) Severe aortic stenosis without symptoms and normal LV D) Angina.
unction. E) Lightheadedness.
D) Severe aortic stenosis in a patient undergoing coronary
bypass gra ing. Answer 2.14.3 The correct answer is “A.” Intracardiac shunts
E) All o the above. don’t occur with aortic stenosis. I you got this one wrong, back

TABLE 2-7 RECOMMENDED INTERVALS FOR ECHOCARDIOGRAPHIC EVALUATION

FORVALVULAR DISEASEa
Lesion Mild Disease Moderate Disease Severe Disease
A t c sten s s Eve 3–5 ea s Eve 2 ea s Eve 6–12 m nths

M t a sten s s Eve 3–5 ea s Eve 1–2 ea s Eve 1–2 ea s

A t c egu g tat n Eve 3–5 ea s Eve 1–2 ea s Eve 6–12 m nths

M t a egu g tat n Eve 3–5 ea s Eve 1–2 ea s Eve 6–12 m nths

a
r ec mmendat ns va .
72 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW
to anatomy or you! An isolated, xed valvular lesion as an adult
cannot cause intracardiac shunting. Exertional dyspnea, light-
headedness (presyncope), syncope, and chest pain are common
symptoms in severe aortic stenosis.
Question 2.14.4 Which o the ollowing statements about
aortic valve disease is INCORRECT?
A) Aortic stenosis can be treated quite e ectively with valvu-
lotomy (balloon aortic valvuloplasty).
B) T ere are no known medical treatments that reduce the
need or aortic valve replacement.
C) Risk actors or the development o aortic stenosis are simi-
lar to CAD.
D) Valve replacement surgery is the pre erred treatment o
symptomatic aortic stenosis.
Answer 2.14.4 The correct answer (and what doesn’t work)
is “A.” Valvulotomy (balloon aortic valvuloplasty) is not a long-
term solution or the management o severe symptomatic aortic
stenosis. While it may be indicated as a “bridge” to de nitive
treatment (surgery or transcatheter aortic valve replacement
[ AVR]), durability o the valvulotomy results are poor, only
lasting 3 to 6 months. T e procedure carries the attendant risk
o cerebral embolism causing stroke, aortic rupture, or acute
severe aortic insu ciency. Valve replacement surgery is pre-
erred although AVR (see below) can be considered in the
nonsurgical candidate. T e epidemiological risk actors or aor-
tic stenosis and CAD are similar (as is the pathophysiology).
Un ortunately, there are no drugs that are e ective at reducing
the need or valve replacement. You can provide symptomatic
relie but that is all.
HELPFUL TIP:
in pat ents wh a e n t cand dates pen su g ca
a t c va ve ep acement, a cathete -based app ach
ep acement the a t c va ve (t anscathete a t c
va ve ep acement “TAVr ”) s ava ab e. TAVr appea s
t educe ve a m ta t c mpa ed w th standa d
n nsu g ca ca e but nc eases the sk st ke.
Objectives: Did you learn to . . .
• r ec gn ze s mpt ms a t c sten s s?
• Manage a pat ent w th a t c sten s s?
• Eva uate a t c va ve d sease and dete m ne ng-te m
w-up v s-à-v s pe d c ech ca d g ams?
CASE 2.15
A 35-year-old male presents to the o ce with upper respi-
ratory symptoms. He is taking no medications except or a
bit o pseudoephedrine or his cold. You notice when look-
ing at his vital signs that his blood pressure is 180/106 mm
Hg. Repeat measurement con rms that the blood pressure is
elevated at 175/103 mm Hg.
Question 2.15.1 What is your initial approach to this
patient?
A) Start a chronic antihypertensive since he is at risk or a stroke
within the next couple o days with a blood pressure at this
level.
B) Administer clonidine in the o ce to reduce the blood pres-
sure to a sa e level o about o 150/100 mm Hg.
C) Watch the patient over the next 2 weeks and get additional
blood pressure readings be ore deciding what to do and
instruct him to discontinue pseudoephedrine.
D) Schedule the patient or outpatient labs and electrocardio-
gram.
E) Fire the patient rom your practice. He’s messing up your
quality measures.
Answer 2.15.1 The correct answer is “C.” T e diagnosis o
hypertension requires two elevated blood pressures on two di -
erent occasions. T is patient’s elevated blood pressure could be
situational, related to decongestants and current illness. Neither
“A” nor “B” is correct because a blood pressure o 175/103 mm
Hg does not pose a risk o acute stroke, and the pressure need
not be lowered acutely unless there is evidence o end-organ
injury (e.g., angina, heart ailure, hypertensive encephalopathy).
“D” is incorrect because you cannot de nitively establish that
this patient has hypertension based on only one in o ce blood
pressure measurement. As or “E” . . . really? Is this why we went
into medicine?
T e patient returns to your o ce with blood pressures mea-
sured six times over a period o 2 weeks at a local pharmacy.
Only three o the six readings suggest that the patient is
hypertensive. T e patient states that the elevated blood pres-
sures were while he was under stress at work.
Question 2.15.2 Your best response at this point is to:
A) Start an antihypertensive.
B) Send the patient or a 24-hour ambulatory blood pressure
measurement.
C) Don’t worry about the blood pressure since the majority o
the readings were within a normal range.
D) Get a nephrology consult to help in decision making.
E) Make another o ce visit so you can buy that Porsche.
Answer 2.15.2 The correct answer is “B.” One way to deter-
mine i a patient with contradictory readings is hypertensive
is to per orm 24-hour ambulatory blood pressure monitoring.
T is can be use ul in patients who have elevated blood pres-
sures in the o ce but not at home or vice versa. It can also be
used i you do not trust the blood pressure readings taken out-
side o your o ce. “A” is incorrect since we have not yet estab-
lished that this patient is hypertensive. “C” is incorrect since we
have not yet established that this patient is not hypertensive.
“D” is incorrect because you are smarter than that and should
be able to work through this kind o case yoursel ! As to “E,”
whoops, we orgot. We’re amily physicians, not radiologists.
No Porsche or us!

Question 2.15.3 The ollowing are all well accepted indica
tions or 24 hour ambulatory blood pressure monitoring
EXCEPT:
A) Suspected white coat hypertension.
B) Patients with di cult-to-control hypertension.
C) Patients having hypotensive symptoms on their antihyper-
tensive treatment.
D) Follow-up a er initiating antihypertensive treatment.
E) Evaluation o patient or autonomic dys unction.
Answer 2.15.3 The correct answer is “D.” One need not do
24-hour ambulatory blood pressure monitoring to document
response to antihypertensive therapy in patients in whom
most or all measurements posttreatment are normal. All o the
other answer choices are considered reasonable indications or
24-hour ambulatory blood pressure monitoring.
Elevated blood pressure in response to stress (especially in
the doctor’s o ce) is called “white coat hypertension.”
Question 2.15.4 Which o the ollowing statements is true
about white coat hypertension?
A) As long as the majority o blood pressure readings are nor-
mal, the patient does not require treatment because there is
no increased risk o adverse cardiac outcomes.
B) Patients with white coat hypertension have an intermedi-
ate risk or adverse outcomes when compared with patients
with normal blood pressure and those with chronically ele-
vated blood pressure.
C) White coat hypertension is more common in young patients.
D) Patients with white coat hypertension have an elevated le
ventricular mass when compared to patients with normal
blood pressures.
E) B and D.
Answer 2.15.4 The correct answer is “E.” Patients with white
coat hypertension have outcomes that are intermediate between
normotensive and hypertensive patients. In addition, they have
an elevated le ventricular mass. Surprisingly, white coat hyper-
tension is more common in the elderly.
Question 2.15.5 Hypertension is de ned as an ambulatory
24 hour monitor average blood pressure o :
A) 135/85 mm Hg during the day and 125/75 mm Hg at night.
B) 140/90 mm Hg during the day and 130/85 mm Hg at night.
C) 130/85 mm Hg over 24 hours.
D) 140/90 mm Hg over 24 hours.
Answer 2.15.5 The correct answer is “A.” Patients with an
average blood pressure o >135/85 mm Hg during the day and
>125/75 mm Hg at night are de ned by JNC 7 as being hyperten-
sive; JNC 8 has not changed this. Another published criterion is
a blood pressure o >140/90 mm Hg more than 40% o the time.
T e ambulatory blood pressure monitor reveals that the
patient’s blood pressure is >140/90 mm Hg more than 40%o
the time, indicating that he is indeed hypertensive.
CHAPTER 2 • CAr Dio l o Gy 73
Question 2.15.6 The initial evaluation o the hypertension
includes the ollowing:
A) History, physical, CBC, urinalysis, glucose, BUN, creatinine,
electrolytes, ECG, and lipids.
B) History, physical, CBC, uric acid, glucose, BUN, creatinine,
electrolytes, and lipids.
C) History, physical, CBC, urinalysis, glucose, BUN, creatinine,
electrolytes, ECG, lipids, and echocardiography.
D) History, physical, and labs only as indicated by history and
physical.
Answer 2.15.6 The correct answer is “A.” History, physical,
CBC, urinalysis, glucose, BUN, creatinine, electrolytes, ECG,
and lipids are the generally agreed-upon initial work-up o the
hypertensive patient. Do we really need all o these? T at is
an interesting question, but we’re just stating what is recom-
mended by the experts. “C” includes echocardiography, which
is not recommended as part o the routine evaluation but may
be indicated i signs o cardiac disease are present.
T e patient’s ECG comes back showing evidence o LVH.
Question 2.15.7 This nding suggests that:
A) You should initiate this patient’s therapy with an ACE inhib-
itor since ACE inhibitors prevent disadvantageous cardiac
remodeling.
B) T e patient has heart ailure.
C) You should recommend an echocardiogram or this patient.
D) You should order a BNP level to screen or LVH and early
heart ailure.
Answer 2.15.7 The correct answer is “C.” T e sensitivity o
ECG or LVH is only in the 30% to 60% range with a speci city
o 80%. T us, a “positive” ECG is not a strong enough indication
to initiate therapy or LVH. For this reason, an echocardiogram
should be done to con rm the diagnosis o LVH. “A” is incor-
rect since an ACE inhibitor is not necessarily the rst drug one
would start. In addition, we really don’t know i this patient has
LVH yet, though ACE inhibitors do prevent harm ul cardiac
remodeling. “B” is incorrect. Certainly, long-standing hyperten-
sion and signi cant LVH can cause heart ailure. However, we
cannot conclude that this patient has heart ailure on the basis
o an ECG, especially in the absence o symptoms. “D” is incor-
rect since the sensitivity o the BNP as a screening tool in an
asymptomatic population is poor.
T e echocardiogram is normal. You have decided to start this
patient on treatment or his hypertension.
Question 2.15.8 Based on outcome data, the LEAST ef ec
tive drug to start on this patient?
A) An ACE inhibitor, such as lisinopril.
B) An ARB, such as losartan.
C) An alpha-blocker, such as doxazosin.
D) A thiazide diuretic, such as chlorthalidone.
E) A CCB, such as amlodipine
74 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW
Answer 2.15.8 The correct answer is “C.” Alpha-blockers have
worse outcomes in hypertension when compared to other anti-
hypertensives. T e JNC 8 recommendations suggest that the
rst line agent, in the general nonblack population, including
those with diabetes, could appropriately be a thiazide-type
diuretic, CCB, ACEI or ARB. Notice that beta-blockers do not
make the list o rst-line antihypertensives either. For the gen-
eral black population, including those with diabetes, the ini-
tial antihypertensive treatment should include a thiazide-type
diuretic or a CCB.
Question 2.15.9 Time to digress a bit. Which o the ollow
ing drugs is the best choice as your initial agent or the
treatment o hypertension in a patient with diabetes and
known microalbuminuria?
A) Lisinopril.
B) Metoprolol.
C) Losartan.
D) Verapamil.
E) Amlodipine.
Answer 2.15.9 The correct answer is “A.” In a diabetic patient
who has proteinuria, an ACE inhibitor is indicated to slow down
the progression o renal disease. An ARB or nondihydropyridine
CCB (verapamil, diltiazem) are viable alternatives or those who
cannot tolerate an ACE inhibitor. (Note: Some elderly patients
may not tolerate verapamil or diltiazem due to bradycardia or
may not be candidates due to LV systolic dys unction). However,
ACE inhibitors are still rst line. T ese recommendations stem
rom the renal and cardiac bene ts o ACE inhibitors.
HELPFUL TIP:
A th ugh th az de d u et cs dec ease the e t vent cu a
d amete (due t d u es s), beta-b cke s, CCBs, and ACE
nh b t s all eve se l VH.
HELPFUL TIP:
Expe ts (and the te atu e) g back and th between
ch s ng the d standb , h d ch th az de (HCTZ),
and the even de d ug, ch tha d ne. H p ka em a
s m e equent seen w th ch tha d ne than w th
HCTZ. P tass um sh u d be m n t ed pe d ca w th
d u et cs an wa , and h p ka em a ten c mp cates
h pe tens n.
Question 2.15.10 Digressing a bit urther . . . Which o the
ollowing drugs might you want to use6 as your initial
agent or the treatment o hypertension in a 72 year old
male who you also diagnosed with symptomatic benign
prostatic hypertrophy?
A) Amlodipine.
B) Doxazosin.
C) Captopril.
D) Losartan.
E) Verapamil.
Answer 2.15.10 The correct answer is “B.” Doxazosin is an
alpha-blocker that is use ul in the treatment o symptomatic
BPH. None o the other choices can be used or this indication.
O course, alpha-blockers are also antihypertensives, and thus
serve a use ul purpose by killing two birds with one stone (Why
would you want to kill two birds? And why with stones? Isn’t
there a better way?). Note: T ere is some evidence that alpha-
blockers do not con er as much bene t or the hypertensive
patient as other classes o drugs. T us, alpha-blockers are not
the best choice in general but could be used as the initial agent
i you have a compelling reason.
T e point o these digressions is that you should look at the
patient’s other underlying illnesses when deciding what to rec-
ommend at initial therapy. Another example would be a patient
with CAD and angina starting on a beta-blocker as initial treat-
ment rather than a thiazide (since the beta-blocker may improve
angina symptoms and is indicated or CAD). Recall that not all
beta-blockers are created equal. Atenolol is least pre erred and
metoprolol succinate is among the best. I the patient has renal
disease, consider an ACE inhibitor as rst-line treatment or
hypertension.
HELPFUL (AND IMPORTANT) TIP:
Beta-b cke s have a en ut av as a st- ne
ch ce h pe tens n. The d n’t seem t c n e as
much su v va bene t as the ant h pe tens ve c asses.
The ne except n s n pat ents w th CAD CHF.
Remember the 35-year-old guy? You start him on chlortha-
lidone, but his blood pressure does not respond at a dose o
12.5 mg/day (have your patients cut the 25-mg tabs in hal ).
His blood pressure on ollow up is 148/96 mm Hg.
Question 2.15.11 The best approach or such a patient is to:
A) Push his chlorthalidone to 25 mg daily be ore starting
another medication.
B) Stop the chlorthalidone and start another medication.
C) Rely on exercise and diet to normalize the blood pressure.
D) Start a second drug be ore you have maximized the dose o
the rst drug.
E) Start a work-up or secondary causes o hypertension.
F) A or D.
Answer 2.15.11 The correct answer is “F.” Per the JNC 8
guidelines, both “A” and “D” are acceptable strategies; you
could push up the dose o a rst drug or add a second drug.
T ere is a lack o randomized controlled trials to guide these
recommendations. JNC 8 urges us to tailor therapy based on
individual circumstances, clinician and patient pre erence, and
drug tolerability. Low-dose chlorthalidone (12.5 mg) provides
the greatest blood pressure reduction per mg o drug, and
there is little clinical bene t o utilizing >25 mg daily o HC Z
or chlorthalidone. Higher doses are associated with increased
adverse e ects with minimal clinical gain in hypertension

management. “B” is incorrect because a patient with this level
o blood pressure elevation will generally require more than
one drug to achieve a normalized blood pressure. “C” is incor-
rect because the majority o patients are unable to maintain
an adequate diet or exercise regimen to e ectively treat blood
pressure. Exercise and dietary change are certainly laudable
goals and should be encouraged in all patients. However, they
are not likely to normalize blood pressure in most hyperten-
sive patients. “D” is also correct as it represents one o the
acceptable JNC 8 guideline strategies to dose antihypertensive
drugs. “E” is incorrect since this patient has not yet proven to
be resistant to treatment.
HELPFUL TIP:
An the st ateg the n t a t eatment h pe ten-
s n, depend ng n the pat ent’s b d p essu e, s t
sta t the ap w th tw d ugs at submax ma d ses (e.g.,
s n p 10 mg and HCTZ 12.5 mg), ec gn z ng that
m st pat ents w eventua need tw d ugs.
You decide to start this patient on diltiazem as a second agent.
Question 2.15.12 Which o the ollowing side ef ects is most
characteristic o diltiazem and other CCBs?
A) Dehydration.
B) Cough.
C) Dependent edema.
D) Hypokalemia.
E) Elevated cholesterol.
Answer 2.15.12 The correct answer is “C.” As a class, CCBs
tend to cause peripheral edema. Dehydration and hypoka-
lemia can be caused by diuretics. Cough and hyperkalemia
are characteristic o ACE inhibitors and ARBs. Diuretics
can increase cholesterol, while beta-blockers can increase
triglycerides.
Despite the act that the patient is on two medications, he
remains hypertensive. In act, the blood pressure has barely
moved. With your thorough history taking, you have ruled
out excess alcohol intake (o en an “occult” cause o hyper-
tension). T e patient is compliant with his medications.
Question 2.15.13 Further investigations that might be
help ul in determining the cause o hypertension in this
patient include all o the ollowing EXCEPT:
A) Checking the potassium level while the patient is taking his
current medications to rule out hyperaldosteronism.
B) Assessing or renal artery stenosis (RAS).
C) Checking a 24-hour urine or glucocorticoids.
D) Checking a 24-hour urine or catecholamines.
Answer 2.15.13 The correct answer is “A.” Hypertension is
secondary to another cause in about 1% o patients with mild
hypertension but in 10% to 45% o those with severe, di cult
CHAPTER 2 • CAr Dio l o Gy 75
TABLE 2-8 CAUSES OF SECONDARY HYPERTENSION
D ugs, nc ud ng ve -the-c unte med cat ns
S eep apnea
End c ne:
• H pe a d ste n sm
• Phe ch m c t ma
• Th d d sease
• Cush ng s nd me ( nnate at gen c)
Vascu a :
• r ena a te sten s s
• C a ctat n the a ta
int ns c ena d sease
to control hypertension. Secondary causes o hypertension
include: hyperaldosteronism, RAS, pheochromocytoma, Cush-
ing disease, untreated obstructive sleep apnea, primary hyper-
parathyroidism, medications (OCP), and others. “A” is the thing
to avoid because when checking the serum potassium level or
hyperaldosteronism, the patient must be o all diuretic medi-
cations and have an unrestricted salt intake. All o the others
choices can be a part o a work-up or secondary hypertension
caused by RAS (“B”), Cushing disease (“C”), and pheochromo-
cytoma (“D”), respectively (see able 2-8).
Question 2.15.14 You decide to check this patient or RAS.
The best choice or a screening test or RAS is:
A) Doppler ultrasound.
B) Captopril renal scan.
C) Serum renin level.
D) MR or C angiography.
E) Both A and D.
Answer 2.15.14 The correct answer is “E.” Per the ACC/AHA
guideline or diagnosing RAS, duplex ultrasonography, C A
in patients with normal renal unction, and MRA are the rec-
ommended screening tools or diagnosis o RAS (Class I Level
o Evidence B). T e captopril renal scintigraphy, selective renal
vein renin measurements, plasma renin activity and the cap-
topril test (which includes measurement o plasma renin lev-
els at baseline and a er captopril administration) are consider
Class III or screening tests or establishing the diagnosis o
RAS.
HELPFUL TIP:
C ns de an eva uat n r AS n a pat ent wh has a
“p s t ve” c n ca ( nadve tent) “capt p cha enge.” i
u sta t an ACE nh b t and see a d amat c dec ne
n ena unct n n a ew da s, r AS, espec a b ate a
r AS, ma be the cu p t.
Your patient does not have any identi able cause or second-
ary hypertension. You add a third agent, and his blood pres-
sure comes under control. Sometimes, you just have to be
persistent!
76 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

Question 2.16.2 Which o the ollowing is true?

HELPFUL TIP:
A) Many patients with hyperaldosteronism have normal serum
Add ng sp n act ne t the eg men a pat ent
potassium.
w th d cu t t c nt b d p essu e can ten
B) In hyperaldosteronism, the plasma aldosterone-to-renin
be he p u even n the p esence an the d u et c.
ratio is usually high.
Watch h pe ka em a when sp n act ne s used
C) All antihypertensives should be stopped be ore checking a
w th ACE nh b t s. Ep e en ne s an acceptab e
plasma renin level.
a te nat ve.
D) I a con rmatory 24-hour urine is done, the urine potassium
should be low to con rm the diagnosis o hyperaldosteronism.
Objectives: Did you learn to . . . E) A and B.
• Eva uate a pat ent w th n t a h gh b d p essu e ead ngs?
• Se ect n t a ant h pe tens ve the ap ?
Answer 2.16.2 The correct answer is “E.” Many patients with
hyperaldosteronism will have normal serum potassium levels.
• App p ate ta the t eatment h pe tens n, based n
pat ent-spec c cha acte st cs?
In addition, the plasma aldosterone-to-renin level is usually
high. “C” is incorrect because, although ACE inhibitors and
• Use and nte p et 24-h u ambu at b d p essu e m n -
t ng?
spironolactone (and perhaps all diuretics) should be stopped
be ore renin and aldosterone levels are drawn, other antihy-
• Unde stand the c ncept wh te c at h pe tens n?
pertensives (e.g., CCBs) will have little e ect on plasma renin
• Gene ate a d f e ent a d agn s s and an app p ate eva ua-
levels. “D” is incorrect because hyperaldosteronism causes
t n sec nda h pe tens n?
potassium wasting, so the urine potassium should be elevated.

You diagnose this patient with hyperaldosteronism.

CASE 2.16
You have a patient who is mildly hypertensive and decide
to check baseline labs. On no medications whatsoever, the
patient’s potassium is low at 3.0 mEq/L. You re-check the
potassium be ore getting too excited. It is 2.9 mEq/L.
Question 2.16.1 O the ollowing, the MOST LIKELY cause
o low potassium in this patient is:
A) Hyperaldosteronism.
B) Hypoaldosteronism.
C) Spuriously low potassium because o an elevated glucose.
D) Metabolic acidosis.
Answer 2.16.1 The correct answer is “A.” Hyperaldosteron-
ism can cause hypokalemia and hypertension. Aldosterone
increases the secretion o potassium, which leads to hypokale-
mia. “B” is incorrect because hypoaldosteronism, such as that
seen with adrenal ailure secondary to adrenal destruction,
causes hyperkalemia and hypotension. “C” is incorrect because
elevated glucose does not result in a spuriously low potassium;
i you answered “C,” maybe you were thinking o sodium (the
sodium goes down by approximately 1.6 to 2 mEq/L or every
100 mg/dL increase in the glucose). Finally, “D” is incorrect
because a metabolic acidosis should cause an elevated potas-
sium rather than a low one.
HELPFUL TIP:
The se um p tass um g es up b app x mate
1 mEq/l eve 0.1 dec ease n the pH m 7.4. Thus,
the p tass um w u d g m 4 t 6 mEq/l the pH
changes m 7.4 t 7.2.
You suspect that the patient has hyperaldosteronism.
Question 2.16.3 The most common cause o hyperaldoste
ronism is:
A) Adrenal adenoma.
B) Idiopathic.
C) Pituitary adenoma.
D) Aldosterone-secreting tumor such as small-cell carcinoma.
E) RAS.
Answer 2.16.3 The correct answer is “A.” Adrenal adenomas
are the most common cause o hyperaldosteronism. T e second
leading cause is idiopathic.
Question 2.16.4 Accepted approaches to the treatment o
hypertension caused by hyperaldosteronism include all o
the ollowing EXCEPT:
A) Unilateral adrenalectomy in the case o adrenal adenoma.
B) Liberalized sodium intake.
C) Use o a potassium-sparing diuretic.
D) Use o a combination o amiloride and H CZ.
Answer 2.16.4 The correct answer is “B.” Liberalizing sodium
intake will actually cause volume expansion, which is counter-
productive and can lead to urther hypokalemia. Once the patient
is hypervolemic, there will be a spontaneous diuresis (the so-
called “aldosterone escape”) leading to increased hypokalemia.
T e exact mechanism o aldosterone escape is not known, but it
occurs a er a weight gain o approximately 3 kg rom f uid reten-
tion. I you want to sound smart, just say it is “neurohumeral.”
You will probably be right and it makes you sound cool.
Objectives: Did you learn to . . .
• ident ab at abn ma t es that ccu n h pe a d ste-
n sm?
• Eva uate a pat ent suspected hav ng h pe a d ste n sm?
• in t ate t eatment h pe a d ste n sm?

FIGURE 2-6. r h thm st p pat ent n quest n 2.17.1.
QUICK QUIZ: ACE iNHiBiTo r S
Which o the ollowing side e ects is/are associated with the use
o ACE inhibitors?
A) Cough.
B) Dependent edema.
C) Hypokalemia.
D) Angioedema.
E) A and D.
The correct answer is “E.” Both chronic dry cough and angio-
edema (more common in blacks or in patients with hereditary
angioedema) are side e ects o ACE inhibitors. Hyperkalemia
is another potential concern. T ese side e ects may not occur
immediately. Hence, you should be wary o these symptoms
in any patient on an ACE inhibitor or any period o time.
CASE 2.17: Rhythm Strips
Question 2.17.1 What is the rhythm on the rhythm strip
shown in Figure 2 6?
A) Second-degree heart block, type I.
B) Second-degree heart block, type II.
C) T ird-degree heart block with junctional escape rhythm.
D) Sinus rhythm with nonconducted PACs.
Answer 2.17.1 The correct answer is “A.” T is is a Wenckebach
block, also known as second-degree heart block type I or Mob-
itz type I AV block. Note the progressive prolongation o the PR
interval be ore a nonconducted P wave on the rhythm strip in
Figure 2-7 (arrows indicate P waves).
Question 2.17.2 The proper treatment o an asymptomatic
patient with this rhythm is:
A) reat any underlying causes identi ed and observe.
B) Place temporary pacemaker ollowed by permanent pace-
maker.
C) Give atropine ollowed by permanent pacemaker.
D) Re er or an electrophysiologic study.
Answer 2.17.2 The correct answer is “A.” Wenckebach/
second-degree heart block type I can be treated with
FIGURE 2-7. A ws sh w P waves w th p g ess ve nge Pr nte va .
CHAPTER 2 • CAr Dio l o Gy 77
observation as long as any underlying cardiac disease is
treated. You should also stop any medications that might be
contributing to this rhythm disturbance, such as digoxin,
beta-blockers and other AV node blocking agents. Pacemaker
is appropriate or a ew select patients, usually those with
symptoms. Atropine is used in the emergent setting or treat-
ment o bradycardia.
Question 2.17.3 What is the proper diagnosis o the ECG
shown in Figure 2 8?
A) Anterior wall myocardial in arction.
B) Posterior wall myocardial in arction.
C) Pericarditis.
D) Hyperkalemia.
E) In erior wall myocardial in arction (IMI).
Answer 2.17.3 The correct answer is “E.” T is is an IAMI. Note
the S elevations in leads II and III, and aVF with reciprocal
changes in leads V2–V5 (see indicator arrows in Fig. 2-9).
A patient presents with a history o lightheadedness when he
stands and has the ECG shown in Figure 2-10.
Question 2.17.4 What is the rhythm?
A) Atrial f utter with 4:1 block.
B) Atrial brillation with slow ventricular response.
C) Atrial tachycardia with third-degree heart block.
D) Mobitz type I (Wenckebach).
Answer 2.17.4 The correct answer is “C.” T is is an atrial
tachycardia with a third-degree heart block. T e P wave pre-
ceding each QRS complex is indicated with an arrow on the
ECG shown in Figure 2-11. Note that there is no consistent
relationship between the P waves and the QRS complexes (i.e.,
the PR interval varies and there is no predictability), giving the
diagnosis third-degree heart block.
Question 2.17.5 The appropriate treatment o this patient
with atrial tachycardia and third degree block is:
A) Pacemaker.
B) Isoproterenol.
C) Lidocaine.
D) Atropine.
78 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

FIGURE 2-8. ECG pat ent n quest n 2.17.3.

FIGURE 2-9. A ws sh w ST segment dep ess ns n ii, iii and aVF w th ec p ca dep ess ns n V2, V3 and V4.
 CHAPTER 2 • CAr Dio l o Gy 79

FIGURE 2-10. ECG pat ent n quest n 2.17.4.

FIGURE 2-11. A ws sh w P waves p t each Qr S. N te the unp ed ctab e va at n n Pr nte va s.

80 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW
Answer 2.17.5 The correct answer is “A.” T e treatment o a
third-degree heart block is a pacemaker. Atropine will increase
the atrial rate, but that is not the problem here. T e problem is
AV conduction. Isoproterenol will increase the ventricular rate
but is arrhythmogenic and may cause hypotension. Lidocaine is
not indicated in this patient.
HELPFUL TIP FOR THE RHYTHM CONNOISSEUR:
At a tach ca d a w th b ck s “c ass c” d g ta s nt x-
cat n. i th s pat ent we e n d g x n, u w u d t eat
w th D g b nd.
Question 2.17.6 The drug o choice or the rhythm in
Figure 2 12 is:
A) Atropine.
B) Procainamide.
C) Quinidine.
D) Metoprolol.
E) Lidocaine.
Answer 2.17.6 The correct answer is “D.” T is is an acceler-
ated junctional rhythm that generally occurs only in the set-
ting o cardiac ischemia. Note the absence o P waves. Using a
Class I antiarrhythmic can extinguish this rhythm, causing asys-
tole (usually considered a bad outcome . . . ). T e patient also
has in erior wall ischemia (see Fig. 2-13, with indicator arrows
showing depressed S segments in the in erior leads). Slowing
down this rhythm with metoprolol is acceptable, but you should
FIGURE 2-12. ECG pat ent n quest n 2.17.6.
treat the ischemia rst. I the rhythm is not causing any problem,
observation is good or now.
Question 2.17.7 The rhythm shown in Figure 2 14 is best
described as:
A) Atrial f utter with 2:1 block.
B) 2:1 second-degree heart block, Mobitz type II.
C) Sinus bradycardia.
D) T ird-degree heart block.
Answer 2.17.7 The correct answer is “B.” T is rhythm strip
represents second-degree heart block, Mobitz type II. Notice
that the PR interval is constant and there are dropped beats (see
Fig. 2-15, with indicator arrows showing P waves with no asso-
ciated QRS complexes). T is patient needs a pacemaker.
Question 2.17.8 The electrocardiogram shown in Figure 2 16
is consistent with which o the ollowing?
A) Pericardial e usion.
B) Pneumothorax.
C) PE.
D) Cardiac contusion.
E) None o the above.
Answer 2.17.8 The correct answer is “A.” T is is an example
o electrical alternans. Note the low QRS voltages that alternate
in height rom beat to beat. T is type o pattern is seen with
pericardial e usion. It is a late nding and one should be very
concerned about tamponade.

FIGURE 2-13. Acce e ated junct na h thm; a ws sh w n e
Question 2.17.9 The ECG in Figure 2 17 is consistent with
which o the ollowing?
A) Anterior myocardial in arction.
B) Anterolateral myocardial in arction.
C) Pericarditis.
D) Early repolarization.
E) Everywhere in arction
Answer 2.17.9 The correct answer is “C.” his ECG is
consistent with pericarditis. his ECG demonstrates several
indings that indicate pericarditis, including sinus tachy-
cardia, di use S elevations, and PR depression (see also
Fig. 2-18).
FIGURE 2-14. r h thm st p pat ent n quest n 2.17.7.
FIGURE 2-15. Sec nd deg ee hea t b ck, M b tz t pe ii.
CHAPTER 2 • CAr Dio l o Gy 81
ST segment dep ess n.
Objectives: Did you learn to . . .
• ident seve a t pes ca d ac a h thm as, nc ud ng hea t
b ck and junct na h thm?
• D agn se iMi b ECG?
• Desc be ECG eatu es pe ca d a ef us n and pe ca d t s?
CASE 2.18: More Rhythm Strips
A 24-year-old emale presents to the ED with a history o
tachycardia and the rhythm strip shown in Figure 2-19. Her
blood pressure is 115/70 mm Hg with an oxygen saturation o
98%on room air. T ere are no associated symptoms o chest
pain, dyspnea, etc.
82 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

FIGURE 2-16. ECG pat ent n quest n 2.17.8.

FIGURE 2-17. ECG pat ent n quest n 2.17.9.

 CHAPTER 2 • CAr Dio l o Gy 83

FIGURE 2-18. ECG c ns stent w th pe ca d t s.

Question 2.18.1 The appropriate treatment o this patient is: Question 2.18.2 This ECG represents:
A) Adenosine 6 mg IV ollowed by 12 mg IV. A) Normal ECG.
B) Diltiazem 5 mg/kg IV. B) Wol –Parkinson–White (WPW) syndrome.
C) Verapamil 25 mg IV. C) RBBB.
D) Digoxin 0.5 mg IV. D) Right axis deviation.
E) De brillation. E) LVH.

Answer 2.18.1 The correct answer is “A.” T is rhythm is
PSV . T ere are several treatment options or PSV , which
include adenosine, diltiazem, and verapamil. However, “B”
and “D” are incorrect because the dose or diltiazem is 0.25
mg/kg IV, not 5 mg/kg, and the dose or verapamil is 2.5 to 5
mg IV, not 25 mg IV. While cardioversion is also an option
in a hemodynamically stable patient, medication should be
tried rst. De brillation is never recommended or a per us-
ing rhythm.
You treat the patient with adenosine but there is no
response. T us, you choose to try a CCB. Un ortunately,
the patient rapidly deteriorates with the CCB, and her
heart rate actually increases, so you success ully cardiovert
the patient. T e ECG done a er cardioversion is shown in
Figure 2-20.
Answer 2.18.2 The correct answer is “B.” T is is an ECG dem-
onstrating WPW pattern. When combined with documented
tachyarrhythmia, it is re erred to as WPW syndrome. Note the
short PR interval as well as the delta wave (Fig. 2-21).
Let’s say this patient comes back to the ED with atrial brilla-
tion in the upcoming week. T is time you suspect WPW and
want to choose a rate-controlling medication.
Question 2.18.3 Which is the BEST medication choice or
this patient in light o her diagnosis o WPW?
A) Procainamide.
B) Sotalol.
C) Diltiazem.
D) Verapamil.
E) Metoprolol.

FIGURE 2-19. r h thm st p pat ent n quest n 2.18.1.

84 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

FIGURE 2-20. ECG pat ent n quest n 2.18.2.

FIGURE 2-21. ECG c ns stent w th W -Pa k ns n-Wh te s nd me.

 CHAPTER 2 • CAr Dio l o Gy 85

FIGURE 2-22. ECG pat ent n quest n 2.18.4.

Answer 2.18.3 The correct answer choice is “A.” Patients with and aVL. Because the QRS is narrow, neither LBBB nor RBBB
WPW deteriorate with beta-blockers and CCBs (“B”–“E”). T e can be correct. Le posterior block is quite uncommon due to
drug o choice is procainamide in patients with WPW who the size o the posterior ascicle.
presents with PSV , including atrial brillation/f utter. T e
other alternative is ibutilide. T e reason is that the AV node Question 2.18.5 The ECG shown in Figure 2 23 represents
is protective since it helps block most re-entrant conductions which o the ollowing?
( or re-entrant arrhythmias that rely on the AV node). I you A) LBBB.
block the AV node with beta-blockers or CCBs, the re-entrant B) RBBB.
loop is allowed to go “wild” (just like you’ve probably seen that C) LAFB.
reality show, “Rhythms Gone Wild”). T e clues to look or to D) Le posterior ascicular block.
help identi ying patients with WPW are a young patient with E) None o the above.
previous episodes o palpitations, rapid heart rate, or syncope.
Answer 2.18.5 The correct answer is “A.” T is ECG represents
Question 2.18.4 The ECG shown in Figure 2 22 represents an LBBB. Criteria include QRS width ≥ 0.12 ms, upright (mono-
which o the ollowing? phasic) QRS in leads I and V6, and a mostly negative QRS in V1.
A) LBBB.
B) RBBB. HELPFUL TIP:
C) Le anterior ascicular block (LAFB). We d n’t suggest that u e n th s but . . . The r –r
D) Le posterior ascicular block. p me s n the right s de the ECG n an r BBB (V1, V2,
E) None o the above. V3). The r –r p me s n the left s de the ECG n an
l BBB ( ead i).
Answer 2.18.4 The correct answer is “C.” For those o us who
are visually challenged, any patient with a net negative orce in Question 2.18.6 The ECG shown in Figure 2 24 represents
lead II will have le axis deviation and likely le anterior as- which o the ollowing?
cicular block (LAFB) (provided proper lead placement). Also, A) First-degree block.
look or net negative def ection in leads III and aVF. For those B) RBBB.
who like the numbers, LAFB is present when the QRS axis is C) LAFB.
−45 to −90 degrees, there is an rS pattern (with small r waves) in D) All o the above.
leads II, III, and aVF and a qR pattern (with small q waves) in I E) None o the above.
86 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW

FIGURE 2-23. ECG pat ent n quest n 2.18.5.

FIGURE 2-24. ECG pat ent n quest n 2.18.6.


Answer 2.18.6 The correct answer is “D.” T is ECG represents
a rst-degree AV block, an RBBB, and an LAFB. T e RBBB is
de ned by a QRS width o ≥0.12 ms (>3 small blocks) and an
rsR (“rabbit ears”) in chest leads V1–V3. T is patient also has an
LAFB (see the ECG in Fig. 2-22 or criteria).
Objectives: Did you learn to . . .
• ident PSVT b ECG and p esc be n t a t eatment?
• Desc be ECG nd ngs WPW?
• D f e ent ate between d f e ent t pes hea t b ck based n
ECG nd ngs?
CASE 2.19
A 75-year-old patient with chronic kidney disease and diabe-
tes presents to your ED or chest tightness, atigue, and palpi-
tations, and has the ECG shown in Figure 2-25.
Question 2.19.1 What is the most likely electrolyte abnor
mality in this patient?
A) Hypokalemia.
B) Hyperkalemia.
C) Hyponatremia.
D) Hypermagnesemia.
E) Hypercalcemia.
Answer 2.19.1 The correct answer is “B,” hyperkalemia. Note
the peaked -waves across the precordium. Note also that the
patient has early repolarization. “A” is incorrect, and many o the
FIGURE 2-25. ECG pat ent n quest n 2.19.1.
CHAPTER 2 • CAr Dio l o Gy 87
opposite ECG ndings occur with hypokalemia. ECG ndings o
hypokalemia include decreased amplitude o -waves, progressing
to -wave inversions associated with S segment depression, ol-
lowed by increased PR interval and increased P-wave amplitude.
T e U-wave is a late and inconsistent nding o hypokalemia.
Question 2.19.2 All o the ollowing are potential causes o
this patient’s hyperkalemia EXCEPT:
A) Metabolic acidosis.
B) ACE inhibitors.
C) ARBs.
D) Renal ailure.
E) Furosemide.
Answer 2.19.2 The correct answer is “E.” Furosemide will
cause hypokalemia rather than hyperkalemia. All the other
answer choices are potential causes o hyperkalemia. Other
causes o hyperkalemia include a potassium load rom muscle
breakdown (e.g., rhabdomyolysis, burns, trans usion o old
blood), tumor lysis syndrome, and other exogenous sources o
potassium such as penicillin, potassium supplements, “lite” salt,
and water so eners. Consider also Addison disease and hypoal-
dosteronism. Digoxin toxicity is also a possibility.
Question 2.19.3 What is the rhythm shown in Figure 2 26?
A) Atrial brillation.
B) Normal sinus rhythm with multiple PACs.
C) T ird-degree heart block with rapid rate.
D) Multi ocal atrial tachycardia (MA ).
88 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW
FIGURE 2-26. ECG pat ent n quest n 2.19.3.
Answer 2.19.3 The correct answer is “D.” T is is a MA . Note
the multiple morphologies o the P waves indicated by arrows
in Figure 2-27 as well as the irregularity o the rhythm. Here are
help ul tips in diagnosing and treating MA : three or more di -
erent P-wave morphologies with varying PR intervals. Causes
include theophylline, pulmonary disease, and abnormal electro-
lytes (K+ or Mg). Digoxin may worsen MA ! Rarely, AV nodal
ablation with permanent pacing can be considered in re ractory
cases.
Question 2.19.4 All o the ollowing are treatments o MAT
EXCEPT:
A) Nondihydropyridine CCB (verapamil, diltiazem).
B) Beta-blocker.
C) Magnesium.
D) Improving pulmonary unction and reducing hypoxia.
E) Adenosine.
Answer 2.19.4 The correct answer is “E.” All o the others are
indicated in the treatment o MA . Adenosine may slow down
the rhythm temporarily but is not considered a treatment o this
rhythm.
Objectives: Did you learn to . . .
• r ec gn ze ECG nd ngs ass c ated w th h pe ka em a and
h p ka em a?
• Desc be ECG nd ngs and t eatment pt ns MAT?
CASE 2.20
A 28-year-old woman with no signi cant past medical his-
tory presents to clinic with complaints o progressive short-
ness o breath; she becomes dyspneic with less activity than
1 year ago. I she exerts hersel beyond a brisk walk, she
becomes lightheaded, presyncopal, and eels tightness in her
chest. She also notes generalized atigue. Your examination
discloses a heart rate o 105 bpm and normal blood pressure.
FIGURE 2-27. A ws sh w P waves va ng m ph g , c ns stent w th MAT.
Resting transcutaneous oximetry is 92% at rest. BMI is
24 kg/m2. She has JVD but clear lungs. A grade 2/6 mid-
systolic murmur is heard over the le upper sternal border.
Electrocardiogram is shown (Fig. 2-28).
Question 2.20.1 What is the most likely diagnosis?
A) CAD.
B) Pulmonary hypertension.
C) Asthma.
D) Congenital aortic stenosis.
E) Mitral valve prolapse.
Answer 2.20.1 The correct answer is “B.” T e physical exami-
nation is consistent with right ventricular pressure overload.
T is is supported by the electrocardiogram demonstrating
right atrial enlargement, right axis deviation, and RVH. CAD
is almost unheard o in a woman younger than 30 years with-
out any risk actors. Asthma may cause her symptom com-
plex but is not supported by her examination. Aortic stenosis
causes neither resting hypoxemia nor RVH. Because they have
a xed cardiac output (limited by lung vascular pressures),
patients with pulmonary hypertension o en get presyncopal
with exertion.
Note: Findings that suggest RVH on the ECG: right axis devi-
ation, right atrial abnormality (P-wave >2.5 boxes tall in lead
II), RVH (tall R in V1), and strain pattern in leads II and III.
O en patients with pulmonary hypertension will have an intra-
ventricular conduction delay with R–R′ in V1 (not shown on
this electrocardiogram, Fig. 2-29).
Question 2.20.2 The ollowing tests may be help ul in eluci
dating the cause o pulmonary hypertension EXCEPT:
A) Chest x-ray and pulmonary unction studies.
B) C scan.
C) ANA, HIV antibody/antigen testing and liver unction studies.
D) Nasopharyngoscopy.
E) Polysomnogram.
 CHAPTER 2 • CAr Dio l o Gy 89

FIGURE 2-28. ECG pat ent n quest n 2.20.1.

Answer 2.20.2 The correct answer is “D.” An important part history and physical examination. Chest radiography and PF s
o the work-up or pulmonary hypertension is de ning the eti- can identi y chronic lung disease causing (or contributing to)
ology and potentially reversible causes. T ere is no cookbook pulmonary hypertension. A C scan is done to exclude chronic
approach, and diagnostic work-up should be tailored by the thromboembolic pulmonary disease and to evaluate or brosis,

FIGURE 2-29. ECG c ns stent w th r VH. N te a ge r wave n V1 and ght ax s dev at n.

90 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW
sarcoidosis, etc. Connective tissue disease, HIV, and cirrhosis
are known to cause pulmonary hypertension. Sleep apnea is an
important, treatable cause o PH N. Nasopharyngoscopy has
no role in this work-up.
An echocardiogram con rms ndings suggestive o severe
pulmonary hypertension and changes consistent with right
ventricular pressure overload (a right heart catheterization is
required or diagnosis). No intracardiac shunt is identi ed by
echo. T e remainder o her diagnostic work-up ails to identi y
a secondary cause o pulmonary hypertension. A right heart
catheterization con rms severe pulmonary hypertension but
also ails to identi y a shunt. A vasodilator challenge (with ade-
nosine) is per ormed and no change in pulmonary pressure is
elicited. She is given a diagnosis o idiopathic pulmonary arte-
rial hypertension.
T e treatment o pulmonary hypertension is, in general,
very specialized and a cardiologist should be involved. Excep-
tions include pulmonary hypertension rom chronic hypoxia
(smoking, sleep apnea) that are amenable to primary care
management. Chronic PE can also be managed by the primary
care practitioner, although the patient should still ollow with
a cardiologist due to the potential or right heart ailure.
HELPFUL TIP:
Add t na the ap pu m na h pe tens n ma
nc ude p stac c n and ph sph d este ase nh b t s
(e.g., s dena , tada a , va dena ). S me pat ents e-
qu e ant c agu at n. Management sh u d be d ected
b a pu m na h pe tens n spec a st.
CASE 2.21
A 54-year-old male presents to your clinic complaining o dys-
pnea and evers. His temperature in the o ce is 38.5°C and
heart rate is 113 bpm with pulse oximetry o 93%. On physical
TABLE 2-9 REVISED DUKE CRITERIA FOR ENDOCARDITIS DEFINITIVE DIAGNOSIS: TWO MAJOR
CRITERIA OR ONE MAJOR + THREE MINOR CRITERIA. POSSIBLE DIAGNOSIS: ONE MAJOR + ONE
MINOR CRITERION OR THREE MINOR CRITERIA
Major Criteria
• Tw p s t ve b d cu tu es gan sms t p ca
end ca d t s
• Th ee p s t ve b d cu tu es gan sms c ns stent w th
end ca d t s
• Se g c ev dence Coxiella burnetii
• Ech ca d g aph c ev dence end ca d a nv vement:
o sc at ng nt aca d ac mass n a hea t va ve, n supp t ng
st uctu es, n the path egu g tant jets, n mp anted
mate a w th ut an the anat m c exp anat n; ca d ac
abscess; new deh scence p sthet c va ve; new va vu a
egu g tat n
examination, you notice that he had nodules on his ngertips
and notice a slight reddish discoloration under his ngernails.
On urther questioning, he tells you that he recently moved
here rom a major city and had used IV drugs in the very dis-
tant past, by which he means as recently as last month.
Question 2.21.1 Your next step in management is:
A) Order a chest x-ray and start empiric levof oxacin.
B) Order a chest x-ray and start empiric ce riaxone and
azithromycin.
C) Order a chest x-ray, echocardiogram, draw blood cultures.
D) Order a chest x-ray and start empiric piperacillin and vanco-
mycin.
E) Order a chest x-ray and do nothing, it is probably viral.
Answer 2.21.1 The correct answer is “C.” Although the
chest x-ray is overkill or a case o endocarditis, it may iden-
ti y other causes o ever and help evaluate or heart ailure.
he patient is presenting with IV drug use history, Osler
nodes, and Janeway lesions (nail-bed hemorrhages), as well
as ever. hese easily meet three minor Duke criteria (see
able 2-9), quali ying or a “possible diagnosis o endocardi-
tis.” Now what you need is one major criterion to de initively
diagnose endocarditis. A positive echocardiogram or blood
culture would quali y. Once the blood cultures are drawn, i
your suspicion is high, you may start empiric antibiotics or
endocarditis.
Question 2.21.2 Which valve(s) are most commonly af ected
by endocarditis?
A) Aortic valve.
B) Mitral valve.
C) Pulmonic valve.
D) Demonic valve.
E) A and B.
Answer 2.21.2 The correct answer is “E.” T e aortic and mitral
valves are most commonly a ected. T ere is no demonic valve,
we hope, but there is the tricuspid, o course.
Minor Criteria
• P ed sp s ng hea t d s de
• iV d ug abuse
• Feve ≥38°C
• Vascu a phen mena: a te a emb sm, sept c pu m na emb sm,
m c t c aneu sm, nt ac an a hem hage, c njunct va petech ae,
Janewa es ns
• immun g c phen mena: g me u neph t s, o s e n des, r th sp ts,
heumat d act
• Mc b g c ev dence n ect n c ns stent w th but n t meet ng maj
c te a
• Se g c ev dence n ect n w th gan sms c ns stent w th end ca d t s

Question 2.21.3 Which o the ollowing organisms is most
common in acute endocarditis?
A) Staphylococcus aureus and group B streptococci.
B) Alpha-hemolytic streptococci or enterococci.
C) Enterovirus.
D) Fungi.
E) Elmo muppetl (can you tell we are getting tired . . . the jokes
are getting weaker).
Answer 2.21.3 The correct answer is “A.” Staph and group
B strep are generally responsible or acute endocarditis while
alpha-hemolytic streptococci and enterococci are more com-
mon with subacute endocarditis. Fungi may be present in IV
drug abusers. As to E. muppetl, it is a new species recently
described by us. We groveled it in Big Bird cultures.
Objectives: Did you learn to . . .
• in t ate eva uat n and management bacte a
end ca d t s?
QUICK QUIZ: yET ANo THEr HEAr T FAil Ur E
QUESTio N (y u th ught we we e d ne)
Cardiac resynchronization or heart ailure is indicated in which
o the ollowing patients?
A) A patient who has an ejection raction o 30% and is in atrial
brillation that is rate-controlled.
B) A patient who has an ejection raction o 30% and is in atrial
brillation that is not rate-controlled (say a rate o 110–115
bpm).
C) A patient who has an ejection raction o 30% and in normal
sinus rhythm who has an LBBB.
D) A patient with an underlying arrhythmia such as PSV who
is symptomatic.
E) A or B.
The correct answer is “C.” Bet we got you on this one, huh?
T e idea behind cardiac resynchronization is to put blood
into the ventricle at the optimum time or unction. T is re-
quires the atrium to be working properly. T us, “A” and “B” are
wrong. T e concept is to pace the atrium and then also pace
the ventricle so that the ventricle depolarizes at the optimum
moment or blood ejection a er the blood is sent to the LV
by the atrium. T is optimal blood ejection is disordered by a
LBBB where depolarization o the ventricle is delayed caus-
ing a “dyssynchrony” (as it were) between the timing o atrial
unctioning and the timing o the ventricular depolarization.
Cardiac resynchronization is “only” or patients with heart ail-
ure who are in normal sinus rhythm. So, the basic criteria or
cardiac resynchronization include a QRS o >150 ms, with a
LBBB, a LV ejection raction o 30% or less, and sinus rhythm
who have class III or class IV heart ailure (J Am Coll Cardiol.
2013;61(3):e6–75). It seems to improve the overall absolute
survival by about 2%; it also reduces readmissions (Ann Intern
Med. 2014;160:603).
CHAPTER 2 • CAr Dio l o Gy 91
QUICK QUIZ: WHAT Ar E yo U . . . A HEAr T
FAil Ur E SPECiAl iST?
Which o the ollowing has been shown to improve mortality in
patients with systolic heart ailure (HFrEF)?
A) Valsartan + Sacubitril (Entresto).
B) Ivabradine (Corlanor).
C) Azumumumab (Coregulator).
D) A and B.
E) B and C.
The correct answer is “A.” First you need to know what these
things are. Entresto combines an ARB plus a neprilysin inhibi-
tor. Inhibiting neprilysin increases vasodilatation and sodium
loss. It has been shown to be e ective at reducing mortality rom
HFrEF. T is can replace an ACE inhibitor or ARB though how
it per orms against an ACE inhibitor is not known. It cannot be
given with an ACE inhibitor because o the risk o angioedema.
O course you already know that an ACE inhibitor and an
ARB should not be used together . . . right?
Corlanor reduces heart rate without lowering BP and is only
indicated in heart ailure patients who do not reach their target
heart rate with a beta-blocker. Corlanor would be added to an
ACE inhibitor or ARB, a beta-blocker, and aldosterone antago-
nist. It does not replace the beta-blocker and does not improve
mortality. It supplements the beta-blocker in patients with heart
rate >70 bpm a er maximizing other medications. Corlanor can
also be used in patients who do not tolerate a beta-blocker. We
made up “C,” though it wouldn’t surprise us to see this drug
name at some point in the uture.
CASE 2.22
A new patient presents or his annual examination and has
some questions about cardiovascular disease risk. He also
wants to chat about his avorite sports team (Iowa Hawk-
eyes, we hope), but you gently steer him back to the matter
at hand.
Question 2.22.1 The ollowing are all considered cardiac
risk actors when calculating target cholesterol EXCEPT:
A) Male > 45 years old.
B) First-degree emale relative with CAD >65 years old.
C) Smoking.
D) Hypertension.
E) HDL cholesterol o <40 mg/dL.
Answer 2.22.1 The correct answer is “B.” It should be emale
relative with CAD at <65 years o age, not >65 years o age. See
able 2-10 or a listing o cardiac risk actors. Just to be com-
plete, i the patient has an HDL > 60 mg/dL, this counts as a
protective actor and “cancels out” one o the risk actors. Recall
that we are talking about primary prevention only here. None
o this applies to the patient who has already had a myocardial
in arction.
92 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW
TABLE 2-10 RISK FACTORS FOR CORONARY
ARTERY DISEASE
• F st-deg ee ma e e at ve w th CAD at age <55 st-deg ee
ema e e at ve w th CAD at age <65
• Sm k ng
• HDl <40 mg/dl
• D abetes
• H pe tens n
• Age: ma es >45, ema es >55
• E evated l Dl
T is 55-year-old gentleman says, “All my riends take a medi-
cine or cholesterol. Shouldn’t I take one too?” You are wor-
ried that he is susceptible to peer pressure, but you are also
thinking about protecting him rom atherosclerotic cardio-
vascular disease (ASCVD).
Question 2.22.2 According to the 2013 ACC/AHA Blood
Cholesterol Guideline, all o the ollowing automatically
quali y as patients who would bene t rom statin therapy
EXCEPT:
A) A patient with known cardiovascular disease.
B) A 40-year-old patient with an LDL o 200 mg/dL.
C) A 55-year-old diabetic patient with an LDL o 130 mg/dL.
D) A 55-year-old nondiabetic patient without known cardio-
vascular disease whose 10-year ASCVD risk is calculated as
10%.
E) A 35-year-old smoker with hypertension.
Answer 2.22.2 The correct answer is “E.” T e 35-year-old
patient might be a candidate or a statin (HMG-CoA reductase
inhibitor) but is not an automatic candidate based on the in or-
mation given. All other options describe patients who would
bene t rom statin therapy according to the 2013 ACC/AHA
guideline. T e 2013 ACC/AHA guideline relies on a risk cal-
culator or primary prevention (located online at: http://tools.
cardiosource.org/ASCVD-Risk-Estimator/). See able 2-11 or
a summary o the 2013 cholesterol guidelines.
In order to use the ASCVD risk calculator or this patient,
you need to input some in ormation.
Question 2.22.3 Which o the ollowing actors is included
in the ACC/AHA ASCVD risk calculator?
A) LDL cholesterol level.
B) Serum triglyceride level.
C) Hb A1c.
D) Systolic blood pressure.
E) Diastolic blood pressure.
Answer 2.22.3 The correct answer is “D.” T e risk actors
included in the ASCVD risk calculator include age, sex, race, sys-
tolic blood pressure, total cholesterol, HDL cholesterol, smok-
ing status, presence or absence o diabetes, and treatment or
hypertension. Unlike many Caribbean resort destinations, the
calculator is not all-inclusive. Many known risk actors or heart
TABLE 2-11 2013 AMERICAN HEART ASSOCIATION
(AHA)/AMERICAN COLLEGE OF CARDIOLOGY (ACC)
LIPID GUIDELINES
Qua a h gh- 1. l Dl >190 mg/dl or
d se stat n. 2. HX CAD ( equ va ent) or
3. DM age 40–79
Qua a P ma p event n 10- ea sk s >7.5%
m de ate-d se stat n and the pat ent has an l Dl 70–189 mg/dl
(use sk ca cu at )a and age 40–75.
Qua a w- Th se wh qua a stat n but d n’t
d se stat n. t e ate h gh- m de ate-d se stat n.
Goals of Therapy
1. The primary goal is to reach the appropriate dose of statin.
2. r educt n l Dl b 50% m base ne.
3. The e a e n xed l Dl g a s (such as past g a s l Dl <100 mg/dl ).
Drug Doses
1. H gh-d se stat n = at vastat n 40–80 mg suvastat n 20–40 mg.
2. M de ate-d se stat n = at vastat n 10–20 mg QD, p avastat n
40–80 mg BiD, and suvastat n 5–10 mg QD, am ng the s.
a
F nd a ca d vascu a sk ca cu at at http://t s.ca d s u ce. g/
ASCVD-r sk-Est mat /
disease (e.g., amily history, obesity) are not taken into account.
T e risk calculator is a tool; you must continue to apply clinical
judgment. Also, the calculator, as well as the entire guideline, is
not meant to be used to manage all orms o dyslipidemias.
T e patient then asks you about something he read about
“crap.” A light bulb goes of and you realize he wants to know
about C-reactive protein (CRP).
Question 2.22.4 Which o the ollowing best represents the
role o CRP in cardiac disease in 2015?
A) CRP should be measured in all patients in whom cardiac
disease is suspected.
B) CRP should be measured only in patients with intermediate
cardiac risk actors (e.g., those with a 10-year risk o CAD o
10–20%).
C) CRP should be measured in patients with known heart dis-
ease in order to monitor inf ammation and risk.
D) CRP should be measured in low-risk (<10% risk o CAD
in next 10 years) patients who have no known cardiac dis-
ease. An elevated CRP suggests that these patients should be
treated with a lipid-lowering therapy.
E) CRP has not been shown to be use ul and does not contrib-
ute signi cantly to cardiac risk strati cation.
Answer 2.22.4 The correct answer is “E.” Although, high-
sensitivity CRP (hsCRP) was initially thought to be a possible
biomarker or cardiac risk assessment, it has been shown to be
o marginal bene t. T e use o hsCRP led to minimal reclassi -
cation o patients (a maximum o 11% o intermediate patients
were reclassi ed in one study). T e Class IIa recommendation
to use hsCRP was published by the AHA in 2003, prior to ur-
ther studies that have questioned its use ulness.

HELPFUL TIP:
We d n t use hsCr P. H weve , t we e use u , t w u d
be n the nte med ate- sk pat ents.
Per the ACC/AHA guideline, you recommend assessing his
lipid pro le.
Question 2.22.5 Well, what does the USPSTF recommend
or screening or lipid disorders?
A) Screen all adults annually starting at age 25.
B) Screen men age 35 years and older.
C) Screen women age 35 years and older.
D) Screen all patients age 25 years and older whose BMI is
>25 kg/m 2.
Answer 2.22.5 The correct answer is “B.” As o the writing o
this book, the USPS F is in the process o updating the screen-
ing recommendation or lipid disorders. Published in 2008, the
USPS F gave a “grade A” recommendation or screening or
lipid disorders in two groups: (1) men 35 years o age and older
and (2) women 45 years o age and older at increased risk or
ASCVD.
T e USPS F gave a “grade B” recommendation or (1) men
age 20 to 35 years at increased risk or ASCVD and (2) women
age 20 to 45 years at increased risk or ASCVD. BMI > 25 kg/m 2.
For the purposes o the recommendation, the USPS F con-
siders the ollowing to be signi cant risk actors: personal his-
tory o ASCVD, diabetes, amily history o CAD be ore age 50
in male relative and be ore age 60 in emale relatives, tobacco
use, hypertension and obesity (BMI > 30 kg/m 2). “A” is wrong
because the USPS F does not speci y the optimal screening
interval.
T e next day, you obtain asting labs. T e patient has normal
electrolytes and the ollowing cholesterol panel: total choles-
terol 175 mg/dL, LDL 110 mg/dL, HDL 35 mg/dL, triglycer-
ides 150 mg/dL. He is a 55-year-old A rican-American male,
nonsmoker, and nondiabetic who takes no medications. His
systolic blood pressure is 132 mm Hg. You plug all these
data into the ASCVD risk calculator and generate a 10-year
ASCVD risk o 7.5%.
Question 2.22.6 Given the ASCVD risk you calculated, and
being consistent with the 2013 ACC/AHA guideline, you
recommend:
A) No changes. Keep calm and carry on.
B) A treadmill stress test.
C) A high ber diet.
D) Low-intensity statin therapy (e.g., simvastatin 10 mg daily).
E) Moderate-to-high-intensity statin therapy (e.g., atorvastatin
20–40 mg daily).
Answer 2.22.6 The correct answer is “E.” Did you think this
patient was a candidate or moderate-to-high-intensity statin
therapy prior to this guideline? I not, you are not alone. T e
CHAPTER 2 • CAr Dio l o Gy 93
2013 ACC/AHA guideline has changed the way we determine
risk, expanding the use o statins. Patients whose 10-year
ASCVD risk is 7.5% or greater should be on moderate-to-high-
intensity statin therapy.
Question 2.22.7 Your astute patient appears to be goal
oriented and asks you what his target LDL should be. You
reply:
A) “ argets are so 2012. T e goal is to get you on a moderate-
to-high-intensity statin. T ere is no speci c LDL goal.”
B) “Your target LDL is <100 mg/dL.”
C) “Your target LDL is about 70 mg/dL.”
D) “Your target LDL is simply as low as we can get without
causing rhabdomyolysis . . . . Well, maybe just a little rhabdo
will be OK.”
Answer 2.22.7 The correct answer is “A.” T e 2013 ACC/AHA
guideline does not recommend treating to speci c LDL targets.
Instead, appropriate statin therapy should be selected based
on risk category as previously indicated. Your goal is to get the
patient to a maximal dose o statin and not a speci c LDL. T at
said, the LDL should be reduced by 50% even i that is a starting
point o 400 mg/dL and the patient ends up at 200 mg/dL.
HELPFUL TIP:
The e s n ev dence that “t t at ng up” the d se a
stat n s necessa he p u n p event ng s de e ects.
Just sta t the na app p ate d se a stat n n da 1
t eatment.
You advise your patient to start atorvastatin 20 mg daily.
You check baseline transaminases, which are normal. When
your patient returns 3 months later and sees your partner
(because you took a “vacation” to study or the board exami-
nation), she checks his lipids and transaminases out o habit.
I only you had been there! You know that the FDA no longer
recommends periodic liver enzyme testing while on a statin.
Statin-related hepatotoxicity is an idiosyncratic reaction
that is extremely rare and completely unpredictable, so there
is no point in routinely checking transaminases. Well, your
partner didn’t get the memo, and you return to nd your
patient’s AL and AS have both doubled while on atorv-
astatin and are now almost twice the upper limit o normal
or your lab.
Question 2.22.8 When you nd transaminases are twice
the upper limit o normal while on a statin, the proper
response is to:
A) Stop the statin because o the elevated liver enzymes.
B) Start a di erent statin since this is not a “class e ect.”
C) Continue the statin and consider other causes or the ele-
vated liver enzymes.
D) Add cholestyramine to help ease the burden on the liver.
E) Re er or liver biopsy to rule out other causes o elevated
liver enzymes.
94 FAMil y MEDiCiNE EXAMiNATio N & Bo Ar D r EViEW
Answer 2.22.8 The correct answer is “C.” Statins can be contin-
ued as long as the elevation o liver enzymes is less than three
times the upper limit o normal. Never assume that this is a
drug e ect i there is a reason to believe that the patient could
have another disease, such as hepatitis C.
You are compelled to per orm the requisite history and
physical examination to assess or other causes o liver dis-
ease. In the course o your investigations, other labs and
imaging may be in order. However, liver biopsy (“E”) would
be taking your duciary duty to the extreme. “A” is incorrect
since the levels are only two times the upper limit o nor-
mal. “B” is incorrect or two reasons. First, there is no need
to act to change the drug at this point. Second, elevated liver
enzymes are a class ef ect. “D” is incorrect because you do not
need to add another drug at this time, and cholestyramine
will do nothing to “ease the burden on the liver,” whatever
that means.
A er a thorough history, examination, appropriate lab and
imaging tests, you determine that the liver enzyme elevation
was due to atty in ltration. A month later the enzymes have
come down to the upper limits o normal. When you see your
patient back, he complains o pain and tenderness in his legs,
shoulders and back. He also reports generalized atigue and
weakness.
Question 2.22.9 What is the most appropriate next step in
the evaluation and management o this complaint?
A) Stop his atorvastatin and replace it with rosuvastatin.
B) Double the dose o atorvastatin.
C) Check liver enzymes.
D) Check CPK.
E) Start coenzyme-Q10 (ubiquinone).
Answer 2.22.9 The correct answer is “D.” T is patient is pre-
senting with symptoms that may be attributable to statin-induced
myopathy. Statins have been associated with myalgia and rhab-
domyolysis. Prior to making any decisions about therapy, the
next step would be to con rm your suspicions by checking the
CPK level. I this patient has statin-induced muscle symptoms,
he is unlikely to improve by switching to rosuvastatin (“A”) and
increasing the stating dose (“B”) is the wrong thing to do. While
it may be reasonable to check liver enzymes (“C”) due to his
complaint o atigue, myopathy is more likely given his constel-
lation o symptoms. O course, in your real medical practice, you
could order liver enzymes and CPK, but an examination is not
real li e! Finally, “E” is incorrect. Coenzyme Q10 has not been
shown to prevent or treat statin related myopathy (Mayo Clin
Proc. 2015;90:24).
You check a CPK level, and it is . . . normal. Darn. You thought
you had this mystery wrapped up.
Question 2.22.10 From this normal CPK, you can conclude
that:
A) He does not have statin-induced myopathy since the CPK is
within normal limits.
B) His atigue and aches are a mani estation o depression and
sleep disturbance.
C) You can sa ely increase the dose o his statin.
D) He still may have statin-induced myopathy despite a normal
CPK.
E) Your lab has a serious quality control issue.
Answer 2.22.10 The correct answer is “D.” He still may
have statin-induced myopathy despite a normal CPK, so “A”
is incorrect. T ere are several crossover trials that demon-
strate myopathy in patients with normal muscle enzymes. T e
mechanism is thought to be a mitochondrial dys unction. “B”
is incorrect, and the reverse may actually be true (myopathy
causing poor sleep and anhedonia). “C” is incorrect because
he may indeed have a myopathy, and a trial o one or both
drugs is warranted. Remember that gem brozil (and less so
eno brate), which you might prescribe or hypertriglyceride-
mia, interact with statins to increase the risk o statin-induced
myopathy/rhabdomyolysis. Remember also that there is no evi-
dence treating with gem brozil or eno brate improves cardio-
vascular outcomes.
You stop his atorvastatin. A ew weeks later, he returns and
eels great! You consider starting a dif erent agent to treat his
lipids.
Question 2.22.11 Which o the ollowing is classi ed as a
bile acid sequestrant?
A) Ezetimibe.
B) Colestipol.
C) Colesevelam.
D) B and C.
E) All o the above.
Answer 2.22.11 The correct answer is “D.” Ezetimibe (Zetia)
is not a bile acid sequestrant but rather reduces cholesterol
absorption by blocking at the brush border o the small intes-
tine. T is is a mechanism that is di erent rom any o the other
lipid-lowering agents. It is relatively sa e but expensive and less
potent than the statins.
HELPFUL RANT:
D n’t ee b gated t “just d s meth ng.” There is no
data suggesting any anti-lipid drugs other than the
statins reduce cardiovascular outcomes. Some, such
as niacin, may actually worsen outcomes.
You nd yoursel staring out the examination room window,
ruminating on cholesterol medications.
Question 2.22.12 Side ef ects o ezetimibe include which
o the ollowing?
A) Diarrhea.
B) Arthralgia.
C) Angioedema.

D) Liver enzyme elevation.
E) All o the above.
Answer 2.22.12 The correct answer is “E.” “C” deserves spe-
cial mention. As with ACE inhibitors, angioedema has been
reported with the use o ezetimibe during postmarketing
research. T e rate o occurrence is not known. However, it can
be li e-threatening although no deaths have been reported to
date. All o the other side e ects are known to occur at a rate
greater than with placebo.
HELPFUL TIP:
Ev dence ezet m be s weak, nc ud ng a much-
t uted 2015 stud (N Eng J Med 2015;372:2387). F st,
the stud s awed and ks at a ve na w g up
pat ents (th se h sp ta zed w th kn wn CAD, the e e
sec nda p event n). it sa s n th ng ab ut p ma
p event n. Sec nd, man the pat ents we e n t
even n a stat n, the standa d ca e. F na , u have
t t eat 50 pat ents 7 ea s t p event ne ca d -
vascu a event—n t a g w ng end sement, espec a
s nce the we en’t n a stat n.
HELPFUL TIP:
Metamuc the ps um p ducts a e use u n e-
duc ng se um ch este and p v de a “n nd ug” a -
te nat ve. H weve , at east 7 g s ub e be da s
equ ed.
HELPFUL TIP:
Can’t u gu s eave ch este beh nd a ead ? N . The
new k ds n the b ck a e the PCSK9 (p p te n c n-
ve tase subt s n kex n t pe 9 nh b t s), wh ch p event
the b nd ng and the deg ad ng l Dl ecept s. S ,
the e a e m e ecept s ava ab e t em ve l Dl
the b d. The st tw a e Praluent (a cumab)
and Repatha (ev cumab). The a e wa expens ve
($10,000/ ea ), a e njectab e, and have No utc me
data (l Dl s a su gate ma ke , c u se . . . we ca e
h w the pat ent s d ng and n t the eve l Dl . Th s
has been made abundant c ea ). The a e a s n
used n pat ents wh have ess than a 50% l Dl educ-
t n w th stat ns and the d ugs.
Objectives: Did you learn to . . .
• Dete m ne sk act s ASCVD?
• l st the sc een ng ec mmendat ns p d d s de s?
• Desc be the e p d- we ng the ap n the p event n
ca d ac d sease?
• ident s me the p tent a s de ef ects p d- we ng
med cat ns?
CHAPTER 2 • CAr Dio l o Gy 95
Clinical Pearls
A a se-p s t ve t p n n can be caused b a PE, hea t a u e,
bu ns, seps s, st ke, and m e.
A n ma ECG du ng chest pa n d es n t u e ut ACS. in
act, 10% pat ents w th an Mi w have an n t a n ma
ECG w th pa n.
Agg ess ve b d p essu e we ng n pat ents w th d abetes
ma be ha m u . Use the same g a as a m st eve ne
e se, <140/90. The JNC 8 ep t suggests a g a <150/90 n
th se 60 ea s age and de .
Av d the c mb nat n a stat n and gem b z en -
b ate; t can cause habd m s s. The sk s we w th
en b ate, h weve .
D n t c nt nue n nasp n ant p ate et agents (e.g., c p d -
g e ) nde n te a te stent p acement. Dete m ne a ta get
end date (e.g., 1 ea dua asp n-c p d g e a te p ace-
ment a DES).
D n td ut ne st ess test ng as mpt mat c pat ents
p e pe at ve . in act, d n’t pe m st ess-test ng n an
as mpt mat c pat ents.
D n t use beta-b cke s a ne as ant h pe tens ve the ap
un ess the e s an the nd cat n (e.g., p st-Mi, hea t a u e).
D n t use hsCr P t assess ca d ac sk.
D n t use n nstat n d ugs t we ca d ac sk n pat ents.
i us ng a beta-b cke p e pe at ve t educe ca d ac sk,
sta t t we n advance the su ge and get the pat ent n
a stab e d se be e su ge .
Pe m an ech ca d g am when c ns de ng the d agn s s
hea t a u e. it w d e ent ate s st c hea t a u e m
d ast c hea t a u e.
Pe m ECG and adm n ste asp n 325 mg mmed ate
t a pat ents p esent ng w th s mpt ms m ca d a
n a ct n.
P esc be ACE nh b t s ve Ar Bs n pat ents w th h pe ten-
s n, ca d vascu a d sease and/ ch n c k dne d sease.
m P esc be stat ns a pat ents w th a h st CAD. The
2013 ACC/AHA gu de ne e m nated an l Dl g a . The g a
s t use h gh-d se stat ns n th se wh a e h gh sk (e.g.,
h st m ca d a n a ct n).
St p a NSAiDs (except asp n) when adm tt ng a pat ent
p ss b e ACS. NSAiDs nc ease ca d ac sk.
Use the CHA2-DS2-VASC sc e when dete m n ng the need
ant c agu at n n at a b at n. W men w th a sc e 2
and men w th a sc e 1 a e cand dates ant c agu at n.
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Pulmonology
R h R. B r
3
note, there is a strong association between OD S and devel-
CASE 3.1 opment o chronic bronchitis.
A 42-year-old male who works in a hog con nement area
presents to your o ce complaining o cough, ever, wheeze, Question 3.1.2 Appropriate treatment or this patient
and dyspnea. He and some other workers were cleaning the includes:
con nement area with high-pressure hoses (which aerosol- A) Antibiotics.
ized hog waste), and they all developed the same symptoms, B) Intubation and mechanical ventilation.
which started between 4 and 8 hours a er work. On examina- C) Supportive care.
tion, he is ebrile with a respiratory rate o 28. He is able to D) A and B.
talk in complete sentences. T ere are slight crackles when you E) A and C.
auscultate the lungs. His chest x-ray is normal.
Answer 3.1.2 The correct answer is “C.” Supportive care is the
usual treatment o OD S. Antibiotics are not needed because
Question 3.1.1 The most likely diagnosis is:
the syndrome is mediated by endotoxins rather than direct
A) “Farmer’s lung” (hypersensitivity pneumonitis).
in ection. “B” is incorrect because this patient is not in signi -
B) Organic dust toxicity syndrome.
cant respiratory distress.
C) Reactive airway disease.
D) Hydrogen sul de poisoning.
E) Bronchiolitis obliterans. HELPFUL TIP:
R b r h h r rk p s r s s r,
Answer 3.1.1 The correct answer is “B.” Organic dust tox- “ r” ( br b h h
icity syndrome (OD S) occurs when moldy or decomposed k, r s s h k r r h
hay and other organic material (such as hog manure) is h rk k) s b z .
moved. Endotoxins are aerosolized and inhaled, leading to
the symptoms. T e tip o here is that everyone on the job site
was a ected. Since hypersensitivity pneumonitis (“A”) is spe-
Keep reading to get to the objectives or this case.
ci c to the individual, generally only one worker at the site
will have symptoms. Compared with OD S, hypersensitivity
pneumonitis may present with an abnormal chest x-ray with
micronodular or reticular opacities. “C” is incorrect because
CASE 3.2
everyone is involved and ebrile, which is not consistent with T is patient’s brother, who also works on a arm, notes that
reactive airway disease. “D” is not correct. Hydrogen sul de every time he unloads hay he has ever, cough, dyspnea, and
poisoning presents as a toxic pneumonitis with pulmonary sputum production. It tends to resolve in 2 to 5 days but reoc-
edema, dyspnea, hypoxia, and loss o consciousness. Hydro- curs when he is re-exposed to hay. Does he wear a mask? Well,
gen sul de also acts as a direct cellular toxin that binds to no. He would look silly and the guys would poke un at him.
cytochrome oxidase system, similar to cyanide. In addition, Besides, none o the other workers on the arm are a ected, and
hydrogen sul de exposure comes rom cleaning manure pits they are beginning to wonder i he is malingering. His examina-
(as anyone in Iowa would know). Finally, “E,” bronchiolitis tion reveals tachypnea and ne rales. T ere is no wheezing pres-
obliterans, is a chronic illness rather than an acute one. O ent. A chest radiograph shows bilateral interstitial opacities.

97
98 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

Question 3.2.1 The most likely cause o this patient’s symp Question 3.2.4 Further evaluation will most likely reveal:
toms is: A) Bronchogenic carcinoma.
A) T ermoactinomyces candidus (an actinomyces species). B) Air space disease (e.g., a pneumonia-like picture).
B) . sacchari. C) Decreased carbon monoxide di using capacity (decreased
C) Botrytis cinerea. DLCO).
D) Cryptostroma corticale. D) Markedly abnormal bronchoalveolar lavage (BAL) with
E) None o the above. lymphocytosis.
E) Obstructive changes on pulmonary unction testing.
Answer 3.2.1 The correct answer is “A.” T is patient pres-
ents with classic symptoms o hypersensitivity pneumonitis Answer 3.2.4 The correct answer is “C.” Hypersensitivity pneu-
or, in this case, “Farmer’s lung.” T is is caused by exposure to monitis can become chronic i exposure is not limited. In these
the Actinomyces species. Acute ndings include ever, chills, cases, patients will generally have systemic complaints such as
cough, dyspnea, and chest tightness. Occasionally, the radio- atigue and possibly weight loss; ever will be absent. Dyspnea
graph is normal. High-resolution chest computed tomography and clubbing o the ngers are also generally noted, re ecting
(C ) should then be obtained, which commonly shows cen- chronic pulmonary disease. Along with this nding, pulmonary
trilobular micronodules and ground-glass opaci cation. “B,” . brosis can occur and the DLCO may be decreased. “A” is incor-
sacchari, is involved in hypersensitivity pneumonitis rom sug- rect. Hypersensitivity pneumonitis does not lead to lung cancer.
arcane (so-called Bagassosis). “C,” Botrytis cinerea, is involved “B” is incorrect. While acute hypersensitivity pneumonitis causes
in hypersensitivity pneumonitis rom grapes (so-called Spat- an alveolitis, chronic hypersensitivity pneumonitis causes pul-
lese lung). Finally, “D,” Cryptostroma corticale, is involved in monary brosis with an occasional micronodular pattern. “D”
“Maple bark stripper’s lung,” another type o hypersensitivity is incorrect. BAL in chronic hypersensitivity pneumonitis does
pneumonitis. not contain the markedly elevated lymphocyte count that is seen
with acute hypersensitivity pneumonitis. Finally, “E” is incorrect.
Question 3.2.2 The correct treatment or this patient with One would see a restrictive pattern on pulmonary unction test-
Farmer’s lung includes: ing re ecting the brosis and not an obstructive pattern.
A) Antibiotics.
B) Inhaled steroids. HELPFUL TIP:
C) Oral steroids. i h p hr rr “p ,” -
D) Leukotriene inhibitors. s r h p rs s p s. i h s s s
E) Bronchoalveolar lavage (BAL). r , s p h p 25%
s s.
Answer 3.2.2 The correct answer is “C.” Oral steroids are e ec-
tive in the treatment o hypersensitivity pneumonitis. Neither
Objectives: Did you learn to . . .
antibiotics (“A”) nor inhaled steroids (“B”) are o any bene t.
• R z h pr s s o dt S h p rs s-
“E,” bronchoalveolar lavage, is not a treatment. However, it can
p s?
be used as a diagnostic tool. One would expect to see lympho-
• m p s h s s r r r
cytes on BAL.
p s r s?

Question 3.2.3 You would advise this patient to:

A) Get a new job.
B) Apply or disability.
C) Use a respirator at work and avoid exposure to this toxin i
possible.
D) Sue the employer.
E) ake up worm arming or monoculture in rhubarb.
Answer 3.2.3 The correct answer is “C.” Wearing an appropri-
ate respirator at work can be bene cial. Avoiding exposure is
even better. As or the other answers, you are a doctor not a
lawyer or career counselor. Stick with what you know!
T e patient is unable to change jobs or wear a respirator
because it itches and he “keeps orgetting it.” But he’s per-
sistent (or brave or thickheaded or unable to learn a new
skill), and keeps arming. T ree years later, he returns with
a chronic cough, weight loss, dyspnea, atigue, and clubbing
o the ngers.
QUICK QUIZ: a St Hma
All o the ollowing populations are at increased risk or devel-
oping asthma EXCEP :
A) Obese children.
B) Female children.
C) Children exposed to tobacco.
D) Children with atopy.
E) City children.
The correct answer is “B.” Male children have a greater prev-
alence o asthma. Interestingly, adult women “catch up” so
that there is gender equity in young adulthood. A er age 40,
the prevalence is higher in emales. O note, requent respira-
tory in ections seem to be protective. T ere is an inverse asso-
ciation between children living on arms and asthma incidence
(another eather in the cap o Iowa). Presumably, this is related
to the greater variety o antigen exposure.
 Ch Apt Er 3 • Pu l mo n o l o g y 99

Answer 3.3.2 The correct answer is “C.” Patients with asthma

CASE 3.3 will have a decreased FEV1. T e FVC may all as well, but FEV1
A 20-year-old woman with no signi cant past medical his- alls rst and to a greater degree as the lung becomes obstructed.
tory presents with a 2-month history o episodic shortness T e ratio o FEV1/FVC is very sensitive to air ow limitations, and
o breath. T ese symptoms began with an upper respiratory FEV1/FVC < 0.7 (not predicted, just the ratio o the two numbers)
tract in ection. She has ts o coughing and trouble catching is generally considered diagnostic o obstructive airway disease.
her breath with exertion. She states that her breath “sounds T e rest are incorrect. LC is not measured by spirometry (which
like whistles” at times. She tried a riend’s albuterol inhaler is why “E” is incorrect); but i it were, LC may be increased in
with some improvement and wonders i she has asthma. On patients with obstructive airway disease due to air trapping.
examination, she is breathing com ortably at 16 times per
minute and her oxygen saturation is 96% on room air. Her Your patient’s o ce spirometry shows the ollowing:
lungs are clear to auscultation, and the remainder o her Normal FVC.
examination is unremarkable. You want to better categorize FEV1 82% predicted.
this patient’s disease. FEV1/FVC 0.68.
Question 3.3.3 These ndings are most consistent with
Question 3.3.1 Which o the ollowing tests is most appro which o the ollowing?
priate to order now? A) Normal spirometry.
A) Spirometry. B) Obstructive lung disease.
B) Chest x-ray. C) End-stage emphysema.
C) Arterial blood gas (ABG). D) Interstitial brosis.
D) Methacholine challenge. E) Obesity-hypoventilation syndrome.
E) Chest C .
Answer 3.3.3 The correct answer is “B.” Always go rst to the
Answer 3.3.1 The correct answer is “A.” Since this patient has FEV1/FVC ratio. In this case, it is < 0.70, which is suggestive
symptoms o bronchospasm, spirometry will be essential in o airway obstruction. T e in ormation provided here lacks
determining i there is objective evidence o obstructive lung data regarding reversibility, so you could not really di erenti-
disease. However, spirometry results are o en normal in mild ate between chronic obstructive pulmonary disease (COPD)
cases o asthma, especially when the patient is asymptomatic. and asthma. But this is clearly not end-stage emphysema, so
Bronchoprovocation testing, with methacholine or histamine, “C” is incorrect. “D” is incorrect. Interstitial brosis is generally
may be use ul in such cases, but should ollow basic spirometry. marked by a restrictive pattern on spirometry and decreased
Although chest radiography (x-ray or C ) may reveal an unsus- LC. Both ow rate (e.g., FEV1) and FVC are decreased in inter-
pected process, it is not indicated in otherwise healthy patients stitial lung diseases but in proportion to each other. T us, the
with symptoms o bronchospasm. Bacterial pneumonia is a FEV1/FVC is o en normal or elevated. See able 3-1 or more
potential precipitant o bronchospasm that may be diagnosed on interpreting spirometry results.
on chest x-ray, but this patient has no constitutional symptoms
(like ever) associated with serious bacterial in ection. Obtain- Six months a er you discuss her ndings and prescribe
ing an ABG may be help ul when a patient presents with respi- inhaled beta-agonist therapy, she returns with complaints o
ratory distress but certainly not in the of ce setting. continued wheezing and di culty breathing. Her symptoms
are brought on by cold weather and exercise and she uses her
inhaler two times per week or less. She woke up two nights
HELPFUL TIP:
over the last 6 months with shortness o breath and coughing.
a r b s p h sh -
Her albuterol still works or these symptoms, but she nds
rb h p s s s h s -
them bothersome and asks, “Why haven’t I gotten over this?”
s p r sp r r r .th rb
(P c o 2) sh b p h h p . Question 3.3.4 How would you categorize this patient’s
t h s, r pp r a Bg h r rb - respiratory state?
s r sp r r s A) Intermittent asthma.
r r sp r r r . B) Mild persistent asthma.
C) Moderate persistent asthma.
D) Severe persistent asthma.
Question 3.3.2 I this patient has mild asthma, which o
E) Recurrent lower respiratory tract in ections.
the ollowing pulmonary unction test results would you
expect to nd? Answer 3.3.4 The correct answer is “A.” According to the
A) Forced vital capacity (FVC) 50% o predicted. National Asthma Education and Prevention Program (2007
B) Forced expiratory volume in 1 second (FEV1) 100% o predicted. NHLBI/NAEPP guidelines; able 3-2), your patient meets the
C) FEV1/FVC ratio < 0.7. criteria or intermittent asthma. In such patients, mild symp-
D) otal lung capacity ( LC) 50% o predicted. toms correspond to an FEV1 (not an FEV1/FVC ratio) that is
E) FEV1/ LC < 0.7. greater than 80% predicted.
100 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

TABLE 3-1 GENEr AL INt Er pr Et At ION OF pULMONAr Y FUNCt ION t ESt

r ESULt S COMpAr ING OBSt r UCt IVE AND r ESt r ICt IVE DISEASE (MAY NOt BE
AppLICABLE FOr ALL FOr MS OF LUNG DISEASE)
PFT Result Obstructive Pattern Restrictive Pattern
Fev 1 < 80% pr d r s pr p r ss

Fvc d r s < 80% pr

Fev 1/Fvc < 0.7 > 0.7

FeF25–75% < 60% pr d r s pr p r ss

t lc n r r d r s

d lco n r r sh ; d r s r s r sr s s ;
r r r s c o Pd r r s r r s sk
r sr s s

Fev 1, r pr r 1s ; Fvc , r p ; FeF25–75, r pr r

25–75% p ;t l c , p ;d l co , s p h r rb ;
c o Pd , hr bs r p r s s .

TABLE 3-2 CAt EGOr IZAt ION OF SEVEr It Y OF ASt h MA AND St EpWISE Appr OACh t O t h Er ApY

Determine Severity When Initiating Therapy

Classification of Asthma Severity (≥12 years of age)
Components of Severity Persistent
Intermittent
Mild Moderate Severe
Symptoms ≤2 days/week >2 days/week but not daily Daily Throughout the day
)
C
Nighttime awakenings ≤2×/month 3–4×/month >1×/week but not nightly Often 7×/week
V
F
SABAa use for symptom >2 days/week but not daily
/
1
≤2 days/week Daily Several times per day
V
control (not prevention of EIBb) and more than 1× on any day
E
F
l
Interference with normal activity None Minor limitation Some limitation Extremely limited
a
m
r
o
• Normal EFV1
N
(
between
t
n
Lung function exacerbations
e
m
• EFV1 > 80% • EFV1 > 80% predicted • EFV1 > 60% but • EFV1 < 60% predicted
r
i
pa
predicted <80% predicted
m
I
• EFV1/FVC normal • EFV1/FVC normal • EFV1/FVC reduced 5% • EFV1/FVC reduced > 5%

0–1/year ≥2/year
Exacerbations requiring
k
oral systemic corticosteroids Consider severity and interval since last exacerbation
s
i
R
Frequency and severity may fluctuate over time for patients in any severity category
Relative annual risk of exacerbations may be related to FEV1
Recommended step for Step 1 Step 2 Step 3 Step 4 or 5
initiating therapy and consider short course of
See bar chart in Figure 3–1 oral systemic corticosteroids
for treatment steps In 2–6 weeks, evaluate level of asthma control that is achieved and adjust therapy accordingly.
a
Sa Ba , sh r - h b -2 s ; b eiB, r s - br h sp s .
R pr r g s r h d ss m as h .n as h e Pr Pr r ,n i s s
H h. e p r P R p r 3, p s 305–310, 343–345. h p:// . h b . h. / s/ s h .
 Ch Apt Er 3 • Pu l mo n o l o g y 101

Inte rmitte nt Persistent Asthma: Daily Medication

As thma Consult with asthma specialist if Step 4 care or higher is required. Consider consultation at Step 3.

Step 6
Step 5 Step up
Step 4 Preferred
Preferred
if needed
Step 3 High-dose
Preferred High-dose (first, check
Step 2 Preferred Medium-dose ICS + LABA
ICS + LABA +
adherence,
Step 1 oral
Preferred Low-dose ICS + LABA environmental
AND corticosteroid
Preferred Low-dose ICS + LABA§ Alternative control, and
Consider
SABA* PRN ICS† OR Medium-dose AND comorbid
Alternative omalizumab for
Medium-dose ICS ICS + either Consider conditions)
Cromolyn, patients who
Alternative LTRA, omalizumab for Assess
LTRA,‡ have allergies
Low-dose ICS + theophylline, patients who control
nedocromil, or either LTRA, or zileuton have allergies Step down
theophylline theophylline, or if possible
zileuton (and asthma is
Patient Education, Environmental Control, and Management of Comorbidities at Each Step well controlled
Cons ide r s ubcuta ne ous a lle rge n immunothe ra py for pa tie nts who have a lle rgic a s thma a t S te ps 2 through 4 at least
3 months)
Quick-Relief Medication for All Patients
• SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at
20-minute intervals as needed. Short course of oral systemic corticosteroids may be needed
• Use of SABA >2 days a week for symptom relief (not prevention of EIBµ) generally Indicates inadequate control and
the need to step up treatment
† ‡ ‡ µ
* Short-acting inhaled beta2-agonist. Inhaled corticosteroid. Leukotriene receptor antagonist. Long-acting inhaled beta2-agonist. Exercise-incluced bronchospasm.

FIGURE 3-1. t k s p s r ppr h sh .

Question 3.3.5 Which o the ollowing is most appropriate Answer 3.3.6 The correct answer is “A.” Your patient now has
or this patient given that she has intermittent asthma? mild persistent asthma and should be started on an inhaled
A) Add theophylline. steroid. When asthma symptoms become more persistent (i.e.,
B) Add montelukast. when they occur > 2 days per week or the patient awakens rom
C) Continue albuterol as needed. sleep > 2 times per month), the in ammatory component o the
D) Schedule albuterol every 4 hours. disease should be addressed while simultaneously treating the
E) Prednisone 5 mg daily. bronchospastic component with short-acting beta-2 agonists.
Anti-in ammatory drugs are the mainstay o chronic asthma
Answer 3.3.5 The correct answer is “C.” As already discussed, therapy, and inhaled corticosteroids are the most ef cacious
this patient appears to have intermittent asthma. She is in with the ewest side e ects. Although ipratropium, cromolyn
no respiratory distress, is oxygenating normally, and is still sodium, and montelukast have a place in asthma treatment,
responding well to albuterol by her report. Although there is none o these medications is a rst-line agent. Ipratropium works
some debate about the role o inhaled steroids in intermittent through its bronchodilatory e ects, while cromolyn sodium is
asthma, the NAEPP and most experts do not recommend their a mast cell stabilizer. Montelukast is a leukotriene inhibitor. T e
use. Oral prednisone is certainly not indicated in this case. She long-acting inhaled beta-2 agonists, such as salmeterol, are only
should be continued on a short-acting inhaled beta-2 agonist, recommended at Steps 3 and higher o persistent asthma con-
such as albuterol, without the addition o another medication. trol ( able 3-2, Fig. 3-1; NHLBI recommendations, 2007).
“D” is incorrect. Scheduled albuterol actually yields less e ective
symptom control than does PRN use.
HELPFUL TIP:
Your patient goes on to develop more requent recurrent symp- R b r h “r s”: p h h s>2
toms, such that she is using her albuterol inhaler more than three sh rb sp r kr q r r s -
times per week, although her nighttime symptoms are rare. r h k s h r s p s> 2 s
p r h sh b - r r , pr -
Question 3.3.6 Which medication is the most appropriate r b h r s r . as h ss
next step in treating this patient’s asthma? r h s r s p —
A) Inhaled triamcinolone. 74 p s h( hss h s r rs !). y
B) Inhaled salmeterol. r h s, h ps://
C) Inhaled cromolyn sodium. . h b . h. /h h-p r / s/ rr /
D) Inhaled ipratropium. sh - s/s r -r p r -2007
E) Oral montelukast.
102 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

A) Inhaled triamcinolone and inhaled albuterol as a “rescue.”

HELPFUL TIP:
B) Inhaled triamcinolone, oral montelukast, and inhaled
th k r h b rs ( . ., k s, z r -
albuterol as a “rescue.”
k s) r h z h s r
C) Oral montelukast and inhaled albuterol as a “rescue.”
h r p .i , h r r s s -
D) Inhaled albuterol as a “rescue.”
h s r s. t h sh b s p
E) Inhaled salmeterol and inhaled triamcinolone.
h s h s r s sh b h
r ; h r s bs r h s r s.
Answer 3.3.8 The correct answer is “B.” Leukotriene inhibitors
(e.g., montelukast, za rlukast) have demonstrated e ectiveness
Your patient does quite well over the next year, having very ew in reducing symptoms and improving peak ow in patients with
exacerbations. During one o her visits, you note slightly edem- aspirin sensitive asthma. Leukotriene inhibitors should be
atous nasal mucosa and nasal polyps. You prescribe intranasal used only in asthma patients who are already using a corticoste-
steroids. roid inhaler—or those who cannot tolerate inhaled corticoste-
roid therapy. T ere ore, “C” is not an appropriate choice. “D” is
One night when you are on call, she comes in severely dys- incorrect because there is no anti-in ammatory. Although “E”
pneic with audible wheezing. She talks in two- or three-word o ers an anti-in ammatory agent, there is no rescue inhaler,
phrases. She reports a headache today, which she treated with and patients with asthma must always have access to a short-
aspirin (something she never takes but a riend gave it to her acting inhaled bronchodilator.
thinking it was acetaminophen). Her asthma attack started
about an hour a er the aspirin dose. She has been otherwise
HELPFUL TIP:
well. She denies ever, rhinorrhea, nasal congestion, and sore
o h r n Sa id s h b p “ sp r - r-
throat. Her respiratory rate is 40, heart rate 120 bpm, and
b ” s h .th h r s h h r s b
oxygen saturation 88% on room air. She has poor air move-
b pr - - r rs h s
ment on auscultation o her lung elds.
rb b c o x-1 h b .

Question 3.3.7 Which o the ollowing is the most likely

reason or this patient’s acute exacerbation o asthma? Question 3.3.9 Which o the ollowing medications, when
A) Viral upper respiratory in ection (URI). used alone as maintenance therapy in persistent asthma,
B) Sinusitis. is associated with an increased risk o asthma related
C) Noncompliance with inhaled albuterol. mortality?
D) Sensitivity to aspirin. A) Inhaled uticasone.
E) Noncompliance with nasal steroids. B) Inhaled salmeterol.
C) Oral za rlukast.
Answer 3.3.7 The correct answer is “D.” It is likely that this D) Oral prednisone.
patient has aspirin sensitivity. Up to 10% o adults with asthma
have the clinical triad o asthma, aspirin sensitivity, and nasal Answer 3.3.9 The correct answer is “B.” Inhaled salmeterol,
polyposis. Patients with asthma should be warned about the when used alone as a controller agent or asthma, has been asso-
potential or exacerbations resulting rom consumption o aspi- ciated with a two- to our- old increase in the risk o death related
rin and nonsteroidal anti-in ammatory drugs (NSAIDs). T e to asthma or other respiratory conditions. T us, the Food and
drug-induced bronchial constriction caused by these medica- Drug Administration (FDA) has mandated a “black box” warn-
tions can have an abrupt onset with severe symptoms. Patients ing be applied to salmeterol-containing products. It is not known
with aspirin sensitivity can be desensitized with daily admin- whether inhaled steroid therapy is protective, but NHLBI/
istration o small amounts o aspirin, but this should be done NAEPP guidelines recommend adding long-acting inhaled beta-
care ully with close supervision. Although viral URIs requently agonists only a er inhaled steroids are already in use.
cause exacerbations o asthma, your patient did not report ante-
cedent symptoms o such an in ection. Further discussion o HELPFUL TIP:
the treatment o an acute asthma exacerbation can be ound in th p r p sh -
Chapter 1, “Emergency Medicine.” b rs . P s s h sh
sh r r p , h
A er a brie hospitalization, your patient recovers nicely. r s b -2 s s h s r r
Prior to this incident involving aspirin, she had been ree o s r . wh h r s pr b h p k
exacerbations or about a month. r , hs s r p s r
h r ss. a h p k
Question 3.3.8 In addition to a short course o oral ste r b s s p r h
roids, which o the ollowing medication regimens do you pr ss h b h
prescribe or this patient with aspirin sensitive asthma at h h r pr r h p .
discharge?
 Ch Apt Er 3 • Pu l mo n o l o g y 103

Me as ure Ac tual % Pre dic te d How do you interpret these ndings?

12
FVC 3.66 L 103 A) Chronic obstructive lung disease.
10 B) Restrictive lung disease.
FEV1 2.30 L 83
8 C) Fixed upper airway obstruction.
6
FEV1 /FVC 0.63 D) Poor patient e ort.
FEF(25–75) 2.15 L 51 E) Within normal range.
4
2 The correct answer is “C.” T e attened ow/volume loop is
S
/
L
0 consistent with a xed upper airway obstruction. In this case,
w
1 2 3 4 5 6
FEV1 and the FEV1/FVC ratio may look like other obstruc-
o
l
–2
F
tive diseases (i.e., asthma, COPD), so you have to look at the
–4
ow/volume loop (always a good idea). Some examples o
–6 ow/volume loops are given below (Fig. 3-3).
–8
–10 CASE 3.4
–12
Volume (L)
You are seeing a 65-year-old male in the emergency depart-
ment (ED) where he presented with complaint o increasing
FIGURE 3-2. Sp r r r s s. shortness o breath. He has obvious di culty breathing and
cannot speak in ull sentences. However, you are able to elicit
that he has been having increasing respiratory problems over
Objectives: Did you learn to . . . the last 3 to 4 days. He has known COPD with FEV1 o “less
• i r rs br h sp s ? than one” (normal FEV1 is about 4 L or a 50-year-old male
• e s p s h z sp ? and 3 L or a 50-year-old emale— or the calculations based
• c ss sh ? on age, etc., see www.hankconsulting.com/Re Cal.html). He
• Pr s r b ppr pr s r r has been using his inhalers much more than usual but with
p rs s sh ? minimal improvement. He has smoked one pack per day
• d s rb h r s h , sp r s s , s since age 18 (but proudly points out he quit 2 days ago) and
p p s s? has a past medical history o high cholesterol, obesity, and
hypertension.
On examination, he has a respiratory rate o 26 to 28,
QUICK QUIZ: SPiRo met Ry heart rate o 100 bpm, blood pressure o 130/90 mm Hg,
and temperature o 37.7°C. His O2 saturation is 84% on
A 60-year-old emale who smokes two packs o cigarettes per room air. On auscultation, you do not appreciate much
day complains o shortness o breath and ullness in her throat. due to his body habitus but you still manage to hear some
You obtain spirometry in the of ce and the results are given wheezing. He has a normal cardiac examination and no
above along with the ow/volume loop (Fig. 3-2). lower extremity edema.

Flow Flow
Flow 8 8
8
6 6
6
4 4
4
2 2
2
0 0
0

–2 –2 –2

–4 –4 –4

–6 –6 –6
–1 0 1 2 3 4 –1 0 1 2 3 4 –1 0 1 2 3 4
Volume Volume Volume
Norma l pa tte rn Obs tructive pa tte rn Re s trictive pa tte rn
FIGURE 3-3. Sp r r r s s.
104 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

Question 3.4.1 What is the next best step to help this patient?
A) Per orm emergent endotracheal intubation.
B) Administer supplemental O2 via nasal cannula.
C) Administer Solu-Medrol, 1 g IV.
D) Start antibiotics IV.
E) Obtain a chest x-ray.
now you cannot tell easily whether his O2 needs are going up
or down. “D” is o special note. Patients with COPD who look
com ortable may be becoming hypercapnic and developing CO2
narcosis. T us, while com ort is a goal, it may not be the best
judge o clinical status in patients with COPD exacerbations. o
assess CO2 levels, you will need an ABG or VBG.

Answer 3.4.1 The correct answer is “B.” T is patient is hypoxic, Your patient is now on 5 liters per minute (LPM) o oxygen via
and your rst priority should be to improve his oxygenation. nasal cannula. You obtain an ABG: pH 7.29, PCO2 74 mm Hg,
T ere exists a theory that oxygenating patients with COPD will PO2 58 mm Hg. T e patient is awake and alert but says that he
suppress their respiratory drive. T e classical teaching (mostly still eels “like dirt.” He remains tachypneic, in obvious respi-
incorrect) is that COPD causes a switch rom carbon dioxide ratory distress, with a respiratory rate o 28. Albuterol and
levels driving respiration to oxygen levels driving respiration. ipratropium are given via nebulizer.
While this may be partly true, urther study has suggested that
the main reason COPD patients are at risk o worsening hyper- Question 3.4.3 What is the best next step?
capnia is due to loss o hypoxic pulmonary vasoconstriction A) Clearly, he is ailing therapy—emergently intubate.
and worsening ventilation–per usion mismatch that occurs B) Increase his O2 to 100% via ace mask.
with excess oxygen delivery. Regardless o that, you need to rst C) Initiate noninvasive positive pressure ventilation
worry about this patient’s oxygenation. (e.g., BiPAP).
“A” is incorrect. T e patient is protecting his airway and you D) Start IV antibiotics.
have not attempted improving his oxygenation with less inva- E) Obtain a chest C with PE protocol (you are barking up the
sive methods yet. Administering steroids, IV or PO, will have wrong bronchial tree).
no immediate e ect on his respiratory status. In act, IV steroids
might be worse than PO steroids (there is question o whether Answer 3.4.3 The correct answer is “C.” T is patient is retain-
higher IV doses cause immunosuppression and subclinical ing CO2 despite tachypnea and is in impending respiratory
myopathy; see Am J Respir Crit Care Med. 2014;189:1052). Anti- ailure. He is also not oxygenating well despite low- ow oxy-
biotics and a chest x-ray may be reasonable, but with low O2 gen. Noninvasive positive pressure support (BIPAP) can relieve
saturations, your priority is to quickly improve your patient’s hypercapnia and improve oxygenation by decreasing work o
oxygen status. breathing without requiring intubation and its associated mor-
bidity. O en IV antibiotics (“D”) are used or empiric therapy in
severe exacerbations o COPD, but again, improving the respi-
HELPFUL TIP:
ratory status comes rst. He is hypoxic, but his main problem
P s h sp r c o Pd rb
is CO2 retention—increasing his O2 delivery will not alleviate
(h r rz b r s sp , sp pr -
that (thus, “B” is incorrect). Although his respiratory status is
sp p r ) sh b r h r-
tenuous, he is not in imminent respiratory ailure, and intu-
s r s ( r pr s s q iv s r s),
bation (“A”) is not warranted at this time. Chest C (“E”) can
b h rs r sp r r r p h s
rule out a PE in this hypoxic patient and may con rm COPD
( r s b s r p b , z hr -
changes including emphysema but will greatly delay treatment
, , , h rs) -
and would not change your immediate course o action.
h br h rs. S pp r h r p h s pp -
s r q r s .
A er several hours o noninvasive positive pressure ventila-
tion, your patient is doing well and he is trans erred out o
Question 3.4.2 When initiating supplemental oxygen by the intensive care unit (ICU). When you see him the next day,
nasal cannula, you instruct the nurse to keep the patient’s his medications include inhaled bronchodilators, ce riax-
oxygen saturation: one, azithromycin, and prednisone. A chest x-ray shows no
A) Between 96% and 100%. evidence o in ltrate. He is weaned rom the positive pres-
B) Between 90% and 95%. sure support and is now on 2 LPM o oxygen by nasal can-
C) Between 85% and 89%. nula. He appears com ortable, with a respiratory rate o 14
D) At whatever saturation he looks most com ortable. and an oxygen saturation o 95%.

Answer 3.4.2 The correct answer is “B.” T e primary goal o
supplemental oxygen is to reduce the risk o tissue hypoxia.
Maintaining oxygen saturations above 90% (or PaO2 60–65 mm)
will ensure tissue oxygenation. Higher oxygen saturations may
result in CO2 retention and hypercapnia, as noted earlier. Also,
aiming at 100% with excessive levels o O2 supplementation
takes away an important patient assessment parameter because
Question 3.4.4 Now you know that he has COPD, what
would be the best treatment or him?
A) Inhaled long-acting beta-agonist (LABA) + albuterol.
B) Inhaled steroid + albuterol.
C) Inhaled steroid + LABA + albuterol as needed.
D) Albuterol.
E) Albuterol and theophylline.
 Ch Apt Er 3 • Pu l mo n o l o g y 105

Answer 3.4.4 The correct answer is “C.”T is is a bit tricky, but due Answer 3.4.5 The correct answer is “E.” Aside rom oxygen, no
to the severity o his exacerbation, “C” is the best choice. Compared medical therapy has clearly demonstrated a mortality bene t or
with patients with asthma, where long acting bronchodilators are stable COPD (see Fig. 3-4 or stage o COPD and appropriate
not indicated as rst-line therapy, COPD patients have a clear symp- treatment). Another therapy to consider in advanced COPD is
tomatic bene t rom long-acting bronchodilators. T e two available pulmonary rehabilitation (PR). While having no de nite e ect
choices are anticholinergics (e.g., tiotropium) or LABAs (e.g., sal- on survival, PR improves dyspnea and quality o li e scores
meterol or ormoterol). Either choice is ne. An inhaled steroid while reducing the number o hospitalizations and days in hos-
does not modi y the long-term decline in FEV1 in patients with pital. Finally, there is a new oral phosphodiesterase inhibitor,
COPD. However, it will reduce the requency o exacerbations ro umilast (Dalisrep), or severe COPD. As you probably
and thus improve health status. Current guidelines recommend already know, your authors are curmudgeons who don’t like
addition o inhaled steroids with FEV1< 50% predicted and re- anything new. But ro umilast is particularly on our bad list. It
quent exacerbations (e.g., three in the last 3 years), see Figure 3-4. increases FEV1 by 45 mL over placebo. It has no e ect on qual-
ity o li e and exacerbations are 1.3/year with placebo and 1.2/
year with rol umilast. It also causes diarrhea and depression/
HELPFUL TIP:
a r th r S (a t S) s rz
suicidality. Nonetheless, you should know about it.
bs r r s s b s h p r pr -
Fev 1
Note: Long-acting bronchodilators can be either a beta agonist
h p . t h r sp s br h -
r s s rz b a t S. t s h h r s
or an anticholinergic.
s r sp s br h r, h r h s b
r s b h 200 r s s HELPFUL TIP:
12% h Fev 1. n h h s r s sh b s h s h
S 3 S 4( r s r ) c o Pd b s
h g b r o bs r l ds s
Holding his inhalers and smiling toothlessly, your patient (g o l d ) s. t h r s b p s h
asks, “Which o these is going to keep me alive—just in case I S 1 rS 2( ) c o Pd h r s s
can’t a ord both?” ( r s p ).

Question 3.4.5 Which o the ollowing medication regimens

has demonstrated decreased mortality in the treatment o Later that year, the same patient gets admitted to the hospital
stable COPD? or community-acquired pneumonia. During his stay in the
A) Inhaled tiotropium (a long-acting anticholinergic). hospital, the hospitalist orders a C chest “to rule out other
B) Inhaled salmeterol (LABA). things.” T e patient recovers rom his in ection and returns to
C) Inhaled ipratropium (a short-acting anticholinergic). you with the CD o his C chest images. T e reading o the C
D) Inhaled corticosteroid. chest describes a 2-cm pulmonary nodule in the right upper
E) None o the above. lobe along with extensive subcarinal lymphadenopathy.

S ta ge 1 S ta ge 2 S ta ge 3 S ta ge 4
FEV1/FVC<70% FEV1/ FEV1/ FEV1/FVC <70%
FEV1>80% FVC <70% FVC <70% FEV1 <30% or
pre dicte d FEV1 <80% FEV1 <50% <50% with
but >50% but >30% chronic re s p
fa ilure

Mild COP D Mode ra te S e ve re COP D Ve ry S e ve re

COP D COP D

Influe nza va ccine , s moking ce s s a tion, s hort a cting bronchodila tor

Long a cting bronchodila tor, P ulmona ry re ha bilita tion

Inha le d Glucocorticoids if fre que nt

e xa ce rba tions
Long te rm
Oxyge n, S urge ry

FIGURE 3-4. g b bs r s s c o Pd s r h r p .
106 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

Question 3.4.6 What is the next best step in management spontaneously combusting right and le (like Spinal ap
o this patient? drummers).
A) Repeat C chest in 3 months. D) Low- ow O2 used at least 15 hours a day signi cantly enhances
B) Repeat C chest in 6 months. survival.
C) Re er or bronchoscopy with endobronchial ultrasound- E) Low- ow O2 is a well-tolerated and e ective treatment or
guided biopsy. obstructive sleep apnea.
D) Re er to an oncologist.
E) Re er or a mediastinoscopy. Answer 3.4.8 The correct answer is “D.” Patients who use low-
ow O2 at home or 24 hours a day have an improved rate o sur-
Answer 3.4.6 The correct answer is “C.” T is patient probably vival. Patients should be encouraged to use O2 at least 15 hours
has a malignant disease and tissue is needed to either diagnose a day i possible. “B” is incorrect because patients need at least
it or rule it out. Bronchoscopy with endobronchial ultrasound 15 hours o O2 per day to have any signi cant bene t with regard
(EBUS)-guided ne-needle biopsies is a minimally invasive pro- to pulmonary hypertension. “C” is incorrect. Clearly, smoking
cedure that can relatively sa ely obtain a tissue sample or the while on O2 is not a good idea, but patients can turn o their O2
pathologist. T ere is good evidence that EBUS has high sensitiv- supply while smoking.
ity and speci city compared with PE scanning. “A” and “B” are
incorrect as this patient has a nodule that is larger than 1 cm along
with mediastinal lymphadenopathy. T is needs to be worked up HELPFUL (AND IMPORTANT) TIP:
and cannot wait 3 to 6 months. “D” is incorrect. Your patient will d s ss h p 20% p s h sp z
likely need to see an oncologist, but you need to rst provide a h c o Pd rb k r -
tissue diagnosis. “E,” mediastinoscopy, would likely provide you h Pe. d ’ rr r r s !
with the diagnosis, but it is a ar more invasive procedure than
bronchoscopy and carries higher mortality and morbidity.
Objectives: Did you learn to . . .
• R z p pr s hs s s p s
HELPFUL TIP: c o Pd ?
i r s h p alf p s treated r c o Pd • d s rb s s r r r c o Pd ?
’ h .S b r . c h k PFt s (c h s .
• d p p h p h p r p ?
2015;147:369).
• m s r rb s c o Pd ?
• dr h r p r hr c o Pd ?
Your patient returns with increasing dyspnea now at rest. His • i s s sp h r h c o Pd pr s
p hk c o Pd ?
biopsy was negative. Despite both o you being blue in the
ace, he has not quit smoking.
QUICK QUIZ: c o Pd
Question 3.4.7 Criteria or the use o continuous low ow oxy
gen in those with COPD include all o the ollowing EXCEPT:
A) PO2 < 55 mm Hg. In a patient with COPD, a lung transplantation re erral can be
B) Oxygen saturation < 88%. considered:
C) PO2 o < 59 mm Hg with evidence o cor pulmonale. A) Once the patient requires oxygen.
D) Episodic sleep apnea-related desaturations at night. B) When you eel you have run out o interventions.
C) Once insurance accepts your re erral.
Answer 3.4.7 The correct answer is “D.” Episodic sleep apnea– D) A er the patient meets strict criteria or the re erral.
related oxygen desaturations, while a cause or concern and ame- E) I the patient’s amily keeps asking or the re erral.
nable to treatment (e.g., CPAP), is not one o the criteria or the
use o continuous low- ow oxygen. T e other choices are cor- The correct answer is “D.” T e International Society or Heart
rect. “C” deserves some special attention. Evidence o cor pul- and Lung ransplantation created a set o criteria or when to
monale can include “p-pulmonale” on ECG, peripheral edema, consider transplantation and, more importantly, when should
or a hematocrit > 55%. you consider re erral or a lung transplant consultation. In COPD
patients, the indication or re erral is easy to remember and con-
Question 3.4.8 Concerning hypoxemic patients with COPD, sists o BODE index > 5 (BODE stands or Body-mass-index,
which o the ollowing is true? air ow Obstruction, Dyspnea, and Exercise, which are the char-
A) Patients on continuous, low- ow O2 become oxygen depen- acteristics used in the index). T e BODE index is an alternative
dent and cannot unction without it. to the GOLD criteria. T e BODE index incorporates unctional
B) Continuous low- ow O2 used or at least 8 hours a day helps criteria such as breathlessness and 6-minute walking distance.
to reverse pulmonary hypertension. Find a BODE calculator here: http://www.qxmd.com/calculate-
C) Concurrent smoking is a contraindication to the prescrib- online/respirology/bode-index. Criteria or transplantation in
ing continuous low- ow home O2 because patients are COPD are more complex and are beyond the scope o this book.

CASE 3.5
Ms. Sarah Bellum (i you’re not smiling, try saying the name
out loud or the joke is just lame . . .) is a 32-year-old Caucasian
emale who presents to your ED with shortness o breath. She
just returned home a er the International Con erence on
Coordination in London. Immediately a er walking through
her ront door, she became acutely short o breath (not attrib-
utable to the Justin Bieber poster in her living room). T is
is associated with some moderately sharp chest pain located
along the le side o her chest. T e pain seems worse when
she attempts to breathe deeply.
Question 3.5.1 Which important question(s) do you next
ask Ms. Bellum?
A) Do you smoke cigarettes?
B) When was your last menstrual period?
C) Have you had surgery recently?
D) Do you have a history o kidney disease?
E) All o the above.
Answer 3.5.1 The correct answer is “E.” Each o these questions
addresses risk actors associated with pulmonary embolism (PE)
and/or deep vein thrombosis (DV ). Smoking cigarettes and
recent surgery are strong risk actors, as is an active pregnancy.
Addressing a patient’s menstrual cycle serves as a natural segue
to a discussion about the use o oral contraceptives, which, too, is
a prominent risk actor. As or renal disease, nephrotic syndrome
has been associated with an increased risk o PE.
A er urther verbal probing, you discover that Ms. Bel-
lum recently completed her menstrual cycle and the other
presented questions turned up no risk actors. However,
your smooth segue did reveal that she takes low-dose estro-
gen or birth control. During this discourse, you also learn
that her aunt had a blood clot in her leg once. She has no
urther details but does not think that her aunt had any
urther complications rom this condition. Regardless, PE
just took a violent leap to the top o your di erential. You
glance at her vitals (temperature 37.1°C, heart rate 92 bpm,
blood pressure 129/68 mm Hg, respiratory rate 21, SpO2 95%
on room air) and notice that she appears mildly uncom ort-
able but not in any acute distress. Her physical examination
is entirely unremarkable. You order an ECG on the patient
to evaluate or potential cardiac etiologies or her symptoms.
Question 3.5.2 Assuming Ms. Bellum does have a PE, what
is her ECG most likely to show?
A) S1Q3 3.
B) Nonspeci c S - wave changes.
C) Sinus tachycardia.
D) Normal sinus rhythm.
E) Multi ocal atrial tachycardia.
Answer 3.5.2 The correct answer is “D.” T e most common
ECG nding associated with the diagnosis o PE remains nor-
mal sinus rhythm. With that said, the most common arrhythmia
Ch Apt Er 3 • Pu l mo n o l o g y 107
ound in patients with a PE is sinus tachycardia. But alas, Sarah
had a normal heart rate. T e other choices can certainly be ound
with this condition but are ar less requent. O note, the “text-
book” S1Q3 3 ECG rarely occurs and historically traces back to
a hand ul o patients in the 1930s that had massive pulmonary
emboli. Even i you do spot this pattern on an ECG, it is not
speci c enough to con rm the diagnosis. In the end, the clini-
cal signs attributed to pulmonary emboli (such as the shortness
o breath and chest pain) are requently more valuable than any
abnormal ECG nding.
As you attempt to rule out other potential etiologies or the
patient’s symptoms (e.g., pneumonia, atelectasis, and pneu-
mothorax), you order a trusty chest radiograph.
Question 3.5.3 What is the most common radiographic nd
ing in a patient with a PE?
A) Pleural e usion.
B) No acute cardiopulmonary processes.
C) Westermark sign.
D) Hilar/mediastinal enlargement.
E) Hampton hump.
Answer 3.5.3 The correct answer is “B.” Admittedly, this one is
a bit tricky. Approximately 75% o the chest radiographs in the
setting o PE are abnormal. However, there are numerous causes
or these abnormalities and none o them individually surpass
the requency o the normal chest radiographs. Speci cally, the
“textbook” ndings o Westermark sign (loss o peripheral vas-
cular markings) and Hampton hump (a wedge-shaped opacity
due to pulmonary in arction) are in requent, and both have a
low sensitivity and low speci city. In short, all the other options
can be seen as the result o a PE but none are more requent than
a normal chest radiograph.
ECG and chest radiograph in hand, you turn your attention
toward ordering the appropriate laboratory tests to solidi y
your presumptive diagnosis. You are working with a medical
student who suggests a number o lab tests. You agree with
most o them, but shoot him down on one.
Question 3.5.4 Which test should you AVOID ordering?
A) CBC.
B) D-dimer.
C) P /P .
D) Basic metabolic panel (Na+ , K+ , Cl− , CO2− , BUN, Cr − , and
glucose).
E) Urine pregnancy test.
Answer 3.5.4 The correct answer is “B.” T e D-dimer can be a
blessing or some but is the bane o existence or others. In this
patient, a D-dimer is not use ul. T is test has great sensitivity
but poor speci city. It is positive in ar more conditions than
PE. Used as a “rule-out” test or PE, it only applies in low-risk
patients. Ms. Bellum is not a low-risk patient as suggested by the
pulmonary embolism rule-out criteria (PERC) rules (see Help-
ul ip) due to her use o exogenous estrogen. T e Wells criteria
108 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

or PE place her in the moderate-risk group (16.2% risk o PE). TABLE 3-3 WELL’S SCOr E FOr pEa
As such, even a negative D-dimer is insuf cient or ruling out
c s sp d vt 3p s
the diagnosis. As or the other tests, they all serve a valuable
role in her evaluation. For instance, the CBC could provide evi- n r ss r k h Pe 3p s
dence o anemia, while the P /P may reveal a coagulopathy.
t h r > 100 1.5 p s
Assessing her renal unction may be needed or her evaluation
moving orward, and the same can be said or veri ying her i b z r≥3 s rs r r h 1.5 p s
nongestational status. Plus, a urine pregnancy test is per ormed pr s4 ks
on almost every woman in an ED. It might as well be part o the
Hs r d vt r Pe 1.5 p s
triage process.
m h 6 hs 1p
T at pesky med student seemed to know a lot about the PERC Pr s h p ss 1p
rules and Wells criteria. But when he listed the Wells criteria,
he got one wrong. S r >6: h h pr b b Pe (78%)
S r 2–6: r pr b b Pe (27.8%)
Question 3.5.5 The Wells criteria or PE include all o the S r <2: pr b b Pe (<3.4%).
a
- r s only s r h pr b b p .o h r s ,
ollowing EXCEPT: h p s - s pr b b h r - r s h h
A) Estrogen use. h r sk r Pe.
B) Pulse > 100.
C) Previous history o venous thromboembolism.
D) Clinical symptoms and signs consistent with PE.
E) Hemoptysis. T e CBC, coagulation studies, and basic metabolic panel all
return within normal limits. In addition, Ms. Bellum is not
Answer 3.5.5 The correct answer is “A.” While an important pregnant. T us, you wish to ( nally) solidi y that diagnosis
risk actor or PE, estrogen use is not included in the Wells crite- you have suspected or quite some time.
ria. All the others count in the Wells criteria ( able 3-3). Using a
medical calculator website, such as www.medcalc.com, is most Question 3.5.6 Since you do not put her in the low risk cat
help ul. egory by your clinical judgment, what diagnostic study
should you order?
A) VQ (ventilation–per usion) scan.
B) C scan o the chest without contrast.
HELPFUL TIP:
C) C scan o the chest with contrast.
t h PeRc r s r s r s h -
D) Pulmonary angiogram.
rz p -r sk r p r
E) Compressive Dopplers o the lower extremities.
Pe .i h p s all h , Pe s
r ( ss b h p s r sk):
Answer 3.5.6 The correct answer is “C.” T e American College
1) a < 50.
o Radiology (ACR) lists the C scan o the chest with contrast
2) H r r < 100.
(i.e., C angiography or C A) as the modality o choice in
3) S o 2 > 94%.
stable patients with a suspected PE. T e C A is considered
4) n r s .
to be the standard o care. Its bene ts include the act that it
5) n h p s s.
is noninvasive, cheaper than pulmonary angiography, and ar
6) n r hs r r rs r r .
more available than VQ scans. It should be noted that pulmo-
7) n pr r d vt r Pe.
nary angiography still remains the “gold standard” or diag-
8) n h r s .
nosing pulmonary emboli, but that is more o an academic
point. As or VQ scans, they are not available in many locales
and o en return nondiagnostic. However, they can be used in
HELPFUL TIP: a patient with a normal chest x-ray. A chest C without con-
R b r d- r -r sk p s. t h s trast (“B”) will not enhance the pulmonary arteries, making
s p r s s h ct r p s r s- the diagnosis o a PE ar more dif cult, i not impossible. Since
s r r . th r r 20- r- most pulmonary emboli are believed to arise rom the lower
r 64-s h s c t s 1:142 (r ) extremity venous system, “E,” Dopplers o the legs, could be
(Ja ma . 2007;298:317–323)! S s l . 2009;374: considered i the patient was a poor candidate or both C A
1160 JP r. 2009;154:912 h rs. P s, and VQ scan (e.g., COPD and Stage 4 chronic kidney disease).
25% “p s ”c t s -r sk p s r s p s- But this approach is obviously not diagnostic o PE; it would
, h h h (Am just help you determine i the patient has an active thrombo-
J Roentgenol. 2015;205:271). sis, and you would manage the same whether she has a PE or
DV or both.
 Ch Apt Er 3 • Pu l mo n o l o g y 109

the American College o Chest Physicians (ACCP), published

HELPFUL TIP:
online in January 2016, recommends novel oral anticoagulants
S pr rs s Pe b s ct a
(e.g., dabigatran, apixaban, and others) over war arin or treat-
h b d pp rs h s. w h b h? i
ment o PE in patients without cancer; however, the ACCP
d vt Pe, r h s s
grades this recommendation as “weak with moderate quality
r h h r. a r h s
evidence.” Continue to look at the whole patient when making
Pe, b h .S h d vt .
anticoagulation decisions.

HELPFUL TIP:
Question 3.5.8 How long are you going to maintain this
i pr , b h h s ct v/Q s r -
patient on anticoagulation?
p b p s p b r -
A) 3 months.
s (o bs g . 2011;118:718).
B) 6 months.
C) 9 months.
D) Li etime.
As keenly suspected, Ms. Bellum’s C A o the chest reveals a
Answer 3.5.8 The correct answer is “A.” For a PE that has a
moderate-sized pulmonary embolus in the le pulmonary
reversible cause (oral contraceptive pills in this patient with a
artery. Her vital signs are still stable and her pain is well-
long airplane trip), 3 months o anticoagulation is adequate. For
controlled with intravenous morphine. She is surprised by the
those with a second PE, li etime anticoagulation is warranted.
diagnosis you give her but appears to be taking it in stride.
For those with a cryptogenic PE or PE rom an acquired or
Question 3.5.7 What is the optimal management plan or inherited thrombophilia (e.g., Factor V Leiden), recommenda-
the patient moving orward? tions are all over the place rom 3 months to li e. Nine months
A) Bolus her with un ractionated heparin (UFH), start her on is likely adequate or a patient with a PE rom an irreversible
oral war arin, and discharge her to home. cause, although patients go back to their pre-treatment risk as
B) Administer a dose o enoxaparin in the ED, provide educa- soon as you stop anticoagulation. And, a rst PE trumps every-
tion, and discharge the patient to home with primary care thing else in terms or risk actors or a second PE—including
ollow-up in the next 2 to 3 days. all those ancy thrombophilia tests! So, nding that thrombo-
C) Start the patient on low–molecular-weight heparin (LMWH), philia does not necessarily help your decision-making process.
initiate oral war arin therapy, and admit the patient to the Note that some guidelines suggest anticoagulation or li e a er
amily medicine service. a rst cryptogenic/unprovoked PE i bene t seems to outweigh
D) Bolus her with UFH, initiate a UFH drip, and admit the risks. T is should be decided a er 3 months o anticoagulation.
patient to the amily medicine service. (Chest. 2012;141(2)(Suppl):7S–47S.)
E) Start her on oral war arin and discharge her to home with
primary care ollow-up in the next 2 to 3 days.
HELPFUL TIP:
Answer 3.5.7 The correct answer is “C.” Full anticoagulation a a– r s ss /
is considered mandatory or all patients with a PE. While dis- p r s s h rs b r -
charging a patient with only a DV is considered standard o s, s s, r h - - sh ,
care, this is not (yet) true or PE. T us, any plan that centers r sp r r s r ss s r (a Rd S), r b s ,r -
on a discharge to home is incorrect (a 2014 Cochrane Data- s s r s h , c o Pd h r ,
base review concluded that the available evidence is insuf cient br h ss h p r s h . t h s,
to recommend outpatient therapy and that more studies are a– r s sp r Pe. l k s ,
needed). With regard to selecting an anticoagulant, current r a– r r s r
evidence does not support the use o one agent over another; r Pe! i , p s h r
UFH, LMWH, and ondaparinux are all appropriate. Regard- s s , h Pio Ped s r
less o the selected anticoagulant, the current recommenda- h s r a– r p s
tions stipulate the initiation o war arin at the time o diagnosis h h Pe.
as well. T e UFH, LMWH, or ondaparinux should be contin-
ued until the patient’s INR has been therapeutic (2–3) or at
least 24 hours and at least 5 days. Note that apixaban, dabi- HELPFUL TIP:
gatran, and rivaroxaban can all be used to treat and prevent o 88% p s h Pe r h p , 70% h
PE. Like war arin, dabigatran requires 5 days o overlap with sp r h p , 65% h p r p , s
LMWH when used as treatment. Avoid edoxaban (Savaysa) i s 30% r h r .th p h r s h
possible. It can only be used in those with a CrCl o less than h h s sp h r h s sp
95 mL/min. And, it requires dose adjustment or those with a h k h ss r . t k h s rs , h
CrCl o between 50 and 15 mL/min (do not use under CrCl r p Bn P b p s h Pe.
15 mL/min). Note that the most recent available guideline rom
110 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

• a ppr h PeRc r s w s r r h h
HELPFUL TIP: b s r Pe?
c pr ss s k s pr p s hr b
• i p r pr r Pe?
s r , h r rr s
• u rs h a– r ?
r d vt — r !e s -
. c s r pr s r b pr ss s k s r -
h s p s. t hr b s s pr d vt s QUICK QUIZ: ven a c a va l Fil t eRS
s pr p s hr b s r h -
b r r (n n t ) 7 r pr d vt s. t h s
Which statement best describes the use o vena caval lters in
s h b r h r (n n H) 1 22
preventing PE?
p sr q r b r s s , n n H 1 11
A) T ey reduce the risk o PE but only in patients who are
p Pe, nnH 1 5r q r
maintained on anticoagulation.
r. (Ja ma i r m . 2014;174(9):1494–1501.)
B) Retrievable vena caval lters have been shown to have a
short-term advantage while the patient is in the hospital;
they should be removed as soon as possible.
Your patient does well, completes her course o war arin, and C) T ey unequivocally reduce PE risk in both anticoagulated
has no urther episodes over the next 2 years. She develops and nonanticoagulated patients.
gallstones and plans to have an elective laparoscopic chole- D) One need not work-up a patient or a PE in the presence o a
cystectomy. A surgeon colleague sends her back to see you or vena caval lter since they are close to 100% e ective.
a preoperative evaluation. You nd no evidence o cardiac,
pulmonary, or hematologic disease. She is no longer on war- The correct answer is “B.” All o the rest are wrong. All evi-
arin and is doing well. dence suggests that vena caval lters are essentially useless in
preventing PE (e.g., JAMA. 2015:28;313(16):1627–1635). In
Question 3.5.9 Which o the ollowing postoperative man addition, they can break with strut migration to the heart or
agement strategies do you recommend? through the vena cava. 2016 ACCP guidelines recommend
A) Aspirin 81 mg PO daily. against vena caval lters in patients who can be anticoagulant
B) War arin 5 mg PO daily. even aster a recurrent PE. T ey may have some short-term ben-
C) UFH 5,000 units subcutaneously daily. e t or inpatients such as with trauma.
D) Enoxaparin 40 mg subcutaneously daily.
E) No antiplatelet or anticoagulant drugs. CASE 3.6
A 50-year-old male who is a heavy drinker with a history
Answer 3.5.9 The correct answer is “D.” Even or a relatively o squamous cell carcinoma o the neck presents to your
minor surgical procedure where anesthesia is used or 30 o ce complaining o abdominal pain. He has been cough-
minutes or less and the postoperative recovery is usually quick, ing and expectorating bloody sputum and notes a low grade
your patient is at moderate risk or venous thromboembolism. ever, chills, and mild dyspnea starting about 1 week ago.
Her history o PE puts her in a higher risk category, and she He denies nausea, emesis, and chest pain. His squamous cell
requires prophylaxis. O the choices available, enoxaparin would carcinoma was treated with external beam radiation several
be the most appropriate. LMWH and UFH are both acceptable years ago. Examination reveals an a ebrile male in mild dis-
or prevention o DV /PE in the postoperative period, but “C” tress. His vital signs are normal, and his lungs sound clear.
is wrong because UFH must be dosed every 8 to 12 hours rather T e abdominal examination reveals only mild epigastric
than daily. “A” is incorrect. Aspirin is sometimes used postoper- tenderness.
atively, but the dose should be 160 mg/day or greater. Also, com- T e chest x-ray is available or your review (see Fig. 3-5).
pared with heparin and its derivatives, aspirin is less ef cacious Your colleague, who is on call today, walks by and asks i you
in the prevention o thrombus. “B” is incorrect. War arin alone have any admissions or her.
is not appropriate in this setting due to its slow onset o action.
Question 3.6.1 You consider this 50 year old with a cough
HELPFUL TIP: and reply:
th p h h p s r q r pr - A) “Yes. T is gentleman will need the ICU.”
ph s r s hr b b s rs r r s B) “Yes. T is gentleman will need a respiratory isolation
k .ar s b r pr ph s room.”
h p s b s r h r p r . C) “No. I’m sending this gentleman home with metronidazole.”
D) “No. I’ll work-up this gentleman as an outpatient.”

Objectives: Did you learn to . . . Answer 3.6.1 The correct answer is “B.” Because he is expec-
• R z r sk rs r Pe? torating bloody sputum and has a cavitary lesion on chest x-ray
• u rs h r b s p s s s Pe? (right upper lobe), this patient should be admitted to a respiratory
 Ch Apt Er 3 • Pu l mo n o l o g y 111

Chest C urther con rms a parenchymal abscess in the right

upper lobe with cavitation and air within the cavity. Bron-
choscopy reveals pus in the airway and extrinsic compression
o the bronchi. A lavage sample is obtained, but biopsies are
not taken due to the clinical impression that this is a lung
abscess.

Question 3.6.3 What organisms are most commonly

isolated in lung abscesses?
A) Anaerobic bacteria.
B) Aerobic bacteria.
C) uberculosis.
D) Mixed aerobic/anaerobic bacteria.

Answer 3.6.3 The correct answer is “A.” Anaerobes are isolated

most o en, ollowed by mixed anaerobic/aerobic bacteria, ol-
lowed by aerobic bacteria alone (especially staphylococci).

Gram stain o sputum demonstrates Gram-positive cocci and

Gram-negative rods. Cultures are pending. uberculin skin
FIGURE 3-5. P ’s h s -r . test is negative.

Question 3.6.4 What is the most appropriate therapy or

isolation room until tuberculosis is ruled out. He will need this patient?
urther evaluation and possibly intravenous antibiotic therapy, A) Re er or surgical drainage.
both o which may be accomplished during his hospitalization. B) Oral levo oxacin.
“A” is incorrect. T ere is no need to send this patient to the ICU C) Intravenous clindamycin.
based on his current picture. “C” is also incorrect. Metronida- D) Intravenous metronidazole.
zole alone is not an appropriate therapy or this patient even i E) Intravenous ce riaxone.
this is bacterial (see below).
Answer 3.6.4 The correct answer is “C.” Most lung abscesses
Question 3.6.2 What is the best next step in the diagnosis are polymicrobial, but the most important aspect in treatment
o this process? appears to be the use o an antibiotic active against anaerobes.
A) Bronchoscopy. Intravenous clindamycin is the usual choice or lung abscess
B) Sputum cultures. due to its coverage o anaerobes and Streptococcus pneumoniae.
C) Blood cultures. Metronidazole is less e ective, ailing in up to 50% o cases o
D) Chest C . putrid lung abscess. A beta-lactam with beta-lactamase inhibi-
E) Open-lung biopsy. tor (e.g., piperacillin/tazobactam) is another good choice.
Ce riaxone and levo oxacin o er poor coverage o anaerobes.
Answer 3.6.2 The correct answer is “D.” T e chest x-ray dem- Surgical drainage o lung abscesses is needed in only 5% to 10%
onstrates a cavitary lesion in the right upper lobe. Chest C is o cases. Most resolve with just antibiotics.
warranted or urther characterization o the lesion. From his-
tory, examination, and chest x-ray, it is not possible to deter- Objectives: Did you learn to…
mine whether the lesion is an abscess or a malignant process. • R z h pr s r s h s -r ?
An indolent course with low-grade ever is characteristic o • i h s s r s s?
lung abscess. However, the pre-existing squamous cell carci- • d h p p r sp r r s ?
noma has potential to have spread to the lungs, and squamous • m p h bs ss?
cell carcinoma is known to cause cavitations. Culture o sputum
and blood, including evaluation o rst morning sputum or
acid- ast bacilli (AFB), will be an essential part o the assess-
CASE 3.7
ment but may not yield as much in ormation as chest C , and A 53-year-old male is accompanied by his wi e to your o ce
sputum culture should be done in conjunction with cytology and complains o a cough or 6 weeks. It is worse at night and
and Gram stain. Bronchoscopy should be postponed until C any time he lies down. He denies sputum production, short-
results are available. Bronchoscopic biopsy is potentially detri- ness o breath, chest pain, and wheezing. He takes an antacid
mental i the lesion is an abscess since the airway could ood once or twice per day to settle his stomach and notes very bad
with pus i the entire cavity wall is penetrated. heartburn. He smoked three packs o cigarettes per day until
112 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

1 year ago, when he quit “cold turkey.” He takes only hydro- Question 3.7.2 Which o the ollowing is your next step in
chlorothiazide or hypertension and a daily aspirin. He has managing this patient’s cough?
no cardiac disorders. His wi e reports that he snores at night, A) Start a proton pump inhibitor.
and she adds, “He’s always hacking and clearing his throat— B) Start an inhaled steroid.
all night.” T e review o systems is negative. In order to sleep C) Order 24-hour esophageal pH monitoring.
better, he has recently started having a shot (or 2 . . . or 3 . . .) o D) Obtain spirometry.
whiskey be ore going to bed. E) Obtain a chest C .

Question 3.7.1 What is the most likely cause or the cough? Answer 3.7.2 The correct answer is “A.” An empiric trial o an
A) Gastroesophageal re ux. e ective gastric acid-suppressing medication in this symptom-
B) Lung cancer. atic patient is likely to relieve the cough i the diagnosis is accu-
C) Antihypertensive medication. rate. T e ACCP recommends starting therapy with a proton
D) Alcohol abuse. pump inhibitor rather than an H 2-blocker. T e usual anti-re ux
E) Congestive heart ailure (CHF). measures, such as avoiding atty oods, alcohol, and ood be ore
bedtime, should be instituted as well. Prescribers must be aware
Answer 3.7.1 The correct answer is “A.” T is patient appears that sometimes a complete resolution o cough takes months. A
to have a chronic cough that is most likely due to gastroesoph- 24-hour pH monitor (“C”) is invasive and o en not necessary
ageal re ux disease (GERD). He takes antacids and exhibits i an empiric trial o gastric acid suppression resolves the prob-
throat clearing, which can be a subtle sign and is not typically lem. Starting the evaluation o chronic cough with a chest x-ray
identi ed by patients as re ux. In addition, he drinks alcohol is part o the ACCP recommendations, but C scan (“E”) is
at bedtime, urther predisposing to re ux. He has a history o not indicated with a negative chest x-ray. I the cough does not
smoking, which does place him at increased risk or develop- resolve with empiric therapy, spirometry should be considered.
ing a bronchogenic carcinoma, but a lung mass would not be a
common cause or cough. Aspirin is associated with broncho- He does not respond a er 2 months o empiric treatment, and
spasm in some people, but it would not usually present as cough he is becoming more concerned. T e examination is unchanged.
in a patient with no history o asthma. Hydrochlorothiazide is Spirometry is normal with a normal f ow volume loop.
not known to cause cough (although angiotensin-converting
enzyme [ACE] inhibitors are). Also, it is unlikely that symptoms Question 3.7.3 Which o the ollowing management options
would be isolated to nighttime i his cough were medication- is LEAST likely to bene t this patient?
related. A) Combination antihistamine and decongestant.
B) Inhaled corticosteroid.
C) Inhaled beta-2 agonist.
HELPFUL TIP:
D) Antibiotics.
R b r h a c e h b rs s h 5%
20% p s k h .F rp s h -
Answer 3.7.3 The correct answer is “D.” T is patient has no signs
p h r a c e h b r, br r
or symptoms o sinusitis or bacterial pulmonary in ection, so
h s s rk- p r hr
treating with an antibiotic is inappropriate and unlikely to help.
h. u s ,s p sr s h 1 kb
However, some orm o empiric therapy might be tried. He could
p rs s r 1 h. c h ace h b r
have postnasal drainage without signs on physical examination,
rs r p 6 hs rs r h ace
and empiric therapy with combination antihistamine and decon-
h b r.
gestant may improve the cough. Inhaled corticosteroids and beta-2
agonists are the mainstay o chronic asthma therapy and may help
relieve this patient’s chronic cough. T is patient could yet have
HELPFUL TIP: “cough-variant asthma” despite normal spirometry results.
as p r s s s rb s h-
.S , ’b sh s p r Question 3.7.4 The three most common causes o chronic
r . (a J R sp r c r c r m . 2009;180:809 n cough (cough lasting longer than 8 weeks) are:
e J m . 2009;360:1487.) A) Postnasal drip, asthma, GERD.
B) GERD, COPD, congenital lung disease.
C) Lung cancer, postnasal drip, COPD.
On physical examination, you note a mildly overweight male D) Obstructive sleep apnea, respiratory in ections, asthma.
in no distress. His vital signs are normal. His lungs are clear
to auscultation. T e nasal and oropharyngeal mucosae are Answer 3.7.4 The correct answer is “A.” Epidemiologic stud-
intact, moist, and not inf amed. T e remainder o the exami- ies have demonstrated that most cases o chronic cough are
nation is unremarkable. Chest x-ray shows f attened dia- due to postnasal drainage (o en termed “upper airway cough
phragms but is otherwise negative. You suspect GERD, but syndrome”), asthma, or symptomatic GERD. Most cases o
also entertain other diagnoses. chronic cough seem to have only a single cause, although some
 Ch Apt Er 3 • Pu l mo n o l o g y 113

TABLE 3-4 SELECt ED COMMON CAUSES OF ACUt E CASE 3.8

AND Ch r ONIC COUGh
You see a 38-year-old emale in ollow-up or a recent epi-
a u Ri, p r ss s, r rh s, c o Pd rb ,
sh , s s s sode o sinusitis. T e illness has been present or about
6 weeks and has not responded to 2 weeks o appropriate
c hr g eRd , p s s r p, s h , hr s s s, antibiotics. She continues to have intermittent nosebleeds,
r / s r rh s, a c e h b rs, s ph
atigue, arthralgias, low grade evers, and night sweats.
br h s, hr br h s, p s s, s h
wo new complaints have sur aced: she has a cough pro-
u Ri, pp r r sp r r ; c o Pd , hr bs r p r ductive o white sputum and she occasionally expectorates
s s ; g eRd , s r s ph r s s ; a c e, s - quarter-sized clots o blood. She has pleuritic chest pain,
r z .
but denies dyspnea, tobacco use, and cardiac or pulmonary
disease.
will have more than one cause. Empiric therapy should be aimed She is a ebrile with a respiratory rate o 16, blood pressure
at these top three causes. O course, in ection (pertussis in par- 120/74 mm Hg, and pulse rate 92 bpm. Her oxygen saturation
ticular), malignancy, and other causes o cough are important to is 98%on room air. T ere is dried blood in the nares, but the
consider—and potentially rule out—as well. oropharynx is clear. Cardiac and pulmonary examinations
T e evaluation o chronic cough should proceed in a logi- are unremarkable.
cal manner. Usually, history and physical examination will nd
the cause. I this is unrevealing, consider a stepwise evaluation
addressing each o the chronic etiologies in able 3-4 in order. I Question 3.8.1 Which initial test is most appropriate?
this still does not give you an answer, consider a methacholine A) Chest x-ray.
challenge test to see i you can reproduce the symptoms that B) Sputum cytologic analysis.
would lead you to a presumptive diagnosis o asthma with nor- C) Bronchoscopy.
mal spirometry. D) Chest C .
E) CBC.

HELPFUL TIP:
l k h rs— r p s hr Answer 3.8.1 The correct answer is “A.” Hemoptysis is alarm-
h s r k .R b r s, ing to the patient and the physician—we hope. A stepwise
sp a c e h b rs ( s b ); h r r s h approach is warranted with chest x-ray as the rst step. Sputum
s h r , z p , s or cytology might help i the suspicion or lung cancer was sub-
sh s ( . ., b r , k s ). stantial, but the yield is likely to be low here. She may eventually
require bronchoscopy i suggested by initial studies. Chest C
is likely to be part o the evaluation, but a chest x-ray should be
Objectives: Did you learn to . . . per ormed rst. Obtaining blood or a CBC is also important,
• R z h s s s hr h? although likely to be normal in the setting o minor hemoptysis.
• e p h hr h?
• d p p r hr h? You obtain the chest x-ray pictured in Figure 3-6.

FIGURE 3-6. P ’s h s -r .
114 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

You get the ollowing laboratory results back: Question 3.8.3 Which o the ollowing is NOT a radiographic
CBC: Leukocytosis, thrombocytosis and normochromic, nding o granulomatosis with polyangiitis?
normocytic anemia. A) Nodules that may be cavitary.
ESR: 70 mm/hr. B) Alveolar opaci cation.
Urine dipstick: Positive or protein, heme, and red C) Pleural opacities.
cells. D) Widened mediastinum.

Question 3.8.2 Which o the ollowing tests will best assist Answer 3.8.3 The correct answer is “D.” A widened medias-
you in the diagnosis o this patient? tinum is not one o the classic ndings in GPA. However, one
A) Antineutrophil cytoplasmic antibody (ANCA). may, on occasion, see hilar adenopathy. All o the other choices
B) Antiglomerular basement membrane antibody. can be ound in GPA. In the patient’s x-ray (Fig. 3-6), a right
C) Antinuclear antibody (ANA). upper lobe mass is easily distinguished. In a young, nonsmok-
D) A and B. ing emale presenting with these symptoms, such a lung mass
E) A and C. should lead to the consideration o GPA or possibly an in ec-
tious process. She is less likely to have a malignant process.
Answer 3.8.2 The correct answer is “D.” T is patient is pre-
senting with the classic triad o granulomatosis with polyangi- HELPFUL TIP:
itis (GPA), a disease o the upper respiratory tract, lower respi- a j r, pr b b h s s , h -
ratory tract, and kidneys. (T is disease was ormerly known as p s s s br h s. t h s s sp r s k rs
Wegener’s granulomatosis. As a response to Wegener’s associa- h r .
tion with the Nazi Party, pro essional bodies and journals have
replaced his name with a descriptive name.) She has some o
the additional signs and symptoms associated with GPA, as T e diagnostic evaluation is in progress. Laboratory tests are
well. Common ndings include: pleuritic chest pain, myalgias, pending, and a chest C is scheduled. You have arranged or
arthralgias, ptosis, ever, weight loss, and purpuric skin lesions, a pulmonologist to see her. When you are on call, the phy-
among others. sician covering the ED calls you to admit her or “massive
ANCA, and especially c-ANCA that is more speci c or hemoptysis.” When you arrive, the patient looks com ort-
GPA, is present in up to 90% o patients with GPA. An ANA able and has normal vital signs. She begins a t o coughing,
is not help ul in diagnosing GPA. An antiglomerular basement expectorating several ounces o bright red blood. Her systolic
membrane antibody (anti-GBM) may be help ul in diagnos- blood pressure alls to 80 mm Hg. Her respiratory rate is 40.
ing Goodpasture syndrome (named or an American patholo- Her work o breathing has increased considerably. T e situa-
gist—not a Nazi—so he gets to keep the eponym). Goodpasture tion does not improve a er 5 minutes o observation, and her
syndrome can be clinically easily con used with GPA; they both O2 saturation is now 83%.
present with respiratory and renal involvement. T us, anti-
GBM antibody will be help ul in di erentiating these two (but Question 3.8.4 Remembering the movie Moulin Rouge
about 10% o patients with Goodpasture syndrome will also (which has nothing to do with this case except or hemop
have GPA—just to add to the con usion). For a partial list o tysis), what is your rst action in this situation?
causes o hemoptysis, see able 3-5. A) Arrange emergent bronchoscopy.
B) rans use 2 units o blood.
C) Per orm endotracheal intubation.
D) Provide bolus IV normal saline.
TABLE 3-5 CAUSES OF h EMOpt YSIS E) ell her, “T e show must go on!”
v s r Pe, s s (g p s r s r ,
Answer 3.8.4 The correct answer is “C.” Massive hemopty-
r ss hp s),
r r s r sis is variably de ned as 100 to 600 mL o blood expectorated
per day, and it can result in hemodynamic compromise and
n p s Br h r , s s s asphyxiation. Quanti cation o the blood loss by the patient is
c ss l p s, rh r hr s usually unreliable. T e main cause o mortality with hemopty-
sis is not hypovolemia but rather asphyxiation rom blood in
c r c HF, r s ss the lungs. As with any patient in acute respiratory distress, the
i s t B, br h s, p , bs ss airway must be controlled rst. T e best choice here is to per-
orm intubation. Since this patient is known to have a poten-
dr s a s, ,s s tial source or bleeding in the right lung, intubation o the le
ms s tr , r b , ps s, h ss mainstem bronchus may protect the le lung rom the blood.
Also, placing this patient on her right side (so that the bleed-
Pe, p r b s ; c HF, s h r r . ing source is dependent) may protect the le lung. I available,
 Ch Apt Er 3 • Pu l mo n o l o g y 115

emergent bronchoscopy may allow identi cation o the bleed- C) Bronchogenic carcinoma.
ing site and selective lung intubation. However, bronchoscopy D) Pneumonia.
is not well suited or stopping the hemorrhage. T e most that E) Microscopic polyangiitis.
a bronchoscopist can do is place an endobronchial blocker and
seal o the bleeding lobe. Interventional radiology should usu-
ally be the rst treatment once the bleeding site has been local- Answer 3.9.1 The correct answer is “B.” T e ndings o hilar
ized. Emergent surgery is indicated i the bleeding remains brisk lymphadenopathy and a restrictive pattern on spirometry are
and not responsive to other interventions. Fluid resuscitation most consistent with sarcoidosis. T e chest x-ray ndings do
is important. However, be ore any o these other measures is not support the diagnosis o granulomatosis with polyangiitis.
undertaken, the airway must be protected. Besides, it can’t be “A”—we just did that case (and when would
you see two GPA cases in a row on a test—let alone in your
career?). “E” is incorrect. Microscopic polyangiitis is a systemic
HELPFUL TIP: vasculitis related to GPA, presenting with similar eatures as
i s p r rs h p s hh p- GPA but without granulomatous disease. Bronchogenic carci-
ss s b r h r r noma is unlikely in this relatively young nonsmoker who does
h r b — h h ss h r p s . not demonstrate ndings o carcinoma on x-ray. T e clinical
th b s sph s history is not typical o pneumonia, and chest x-ray shows no
s rpr s h r r h s h gi in ltrate. uberculosis ( B), although not an answer option,
b rs s . a s , s r r should also be considered, and the appropriate history and test-
b r h h h b . ing should be completed. In act, B and sarcoidosis o en pres-
th r r , s r h b s k s s ent in a similar ashion.
h p ssp s.
Question 3.9.2 Which o the ollowing is NOT commonly
associated with sarcoidosis?
A) Hypercalcemia.
T e patient stabilizes in the ICU. You plan to start treatment B) Elevated ACE levels.
or her granulomatosis with polyangiitis. She does better and C) Reduced di usion capacity.
is discharged in 2 days. D) Hypothyroidism.
E) Facial or peripheral nerve palsy.
HELPFUL TIP:
t h 5- r r r r ss h Answer 3.9.2 The correct answer is “D.” Sarcoidosis is marked
p s s 90%. t h s p s r ss by the presence o noncaseating granulomas. While sarcoid can
r .c ph sph + s r ss b in ltrate the thyroid, it rarely, i ever, causes hypothyroidism.
h b s b . Pulmonary sarcoidosis includes a decreased di usion capacity
and decreased vital capacity. Other laboratory ndings include
hypercalcemia, hypercalciuria, elevated liver and pancreatic
Objectives: Did you learn to . . . enzymes, and elevated ACE levels. Neurologic involvement
• P r r ppr pr p h occurs in up to 5% o patients and requently presents as acial
h p s s? paralysis but may present as any central nervous system lesion.
• R z h j r s s h p s s? Peripheral nerves may also be involved.
• d s r ss hp s?
• i r ss h p s s? Question 3.9.3 Which o the ollowing is NOT ound as a
part o sarcoidosis?
A) Erythema nodosum.
CASE 3.9 B) Myocardial in arction.
A 35-year-old A rican-American emale presents with dys- C) Cardiac arrhythmias.
pnea worsening over the last 2 months. She also complains D) Elevated liver enzymes.
o cough, generalized atigue, and intermittent low-grade E) Vision loss.
evers. She does not smoke. Chest x-ray shows hilar adenopa-
thy and small bilateral pleural e usions. Spirometry is con- Answer 3.9.3 The correct answer is “B.” Sarcoidosis does not
sistent with a restrictive pattern. cause myocardial in arctions. While there is cardiac involve-
ment with sarcoidosis, the mani estations are bundle branch
Question 3.9.1 O the ollowing, which is the most likely block, cardiac arrhythmias, and sudden death. Many organs can
diagnosis? be a ected by sarcoidosis, including the skin, eye (iritis), heart,
A) Granulomatosis with polyangiitis. lung, liver, nervous system—essentially anywhere granulomas
B) Sarcoidosis. orm.
116 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

Question 3.9.4 Which o the ollowing is true about ACE is dullness to percussion and decreased tactile remitus over
levels in sarcoidosis? the right lower lung eld.
A) An elevated ACE level is speci c or sarcoidosis.
B) ACE levels o en correlate with disease severity in sarcoidosis. Question 3.10.1 Based on this patient’s history and physi
C) ACE inhibitors are e ective in the treatment o sarcoidosis. cal examination, what do you expect to nd on chest x ray?
D) All o the above. A) Normal chest x-ray.
B) Cavitary lung lesion.
Answer 3.9.4 The correct answer is “B.” One can ollow ACE C) Pleural e usion.
levels to track the progress o the disease. However, since treat- D) Expanded lung elds.
ment is based on symptoms, ollowing ACE levels is not recom- E) Pneumothorax.
mended. “A” is incorrect. ACE levels may be elevated in silicosis,
miliary B, and asbestosis, among others. “C” is incorrect. ACE Answer 3.10.1 The correct answer is “C.” T is patient’s nd-
inhibitors are not used to treat sarcoidosis. ings suggest pleural e usion. Everything is diminished in pleu-
ral e usion: there is dullness to percussion, decreased breath
T is patient is ound to have only pulmonary sarcoidosis sounds, decreased tactile remitus, and decreased voice trans-
with some mild systemic symptoms. mission. A cavitary lung lesion presents with either a normal
examination or ndings similar to an in ltrate (e.g., crackles,
Question 3.9.5 Which o the ollowing is the best initial increased remitus, and dullness to percussion). Expanded lung
choice or management? elds on chest x-ray are o en seen in patients with COPD or
A) Observation. asthma, and examination ndings include prolonged expiratory
B) Oral corticosteroids. phase, wheezing, and resonance to percussion. Pneumothorax
C) Oral antibiotics. presents with hyperresonance to percussion, decreased breath
D) Inhaled corticosteroids. sounds, and decreased remitus.
E) Methotrexate.
HELPFUL TIP:
Answer 3.9.5 The correct answer is “A.” T is patient has ch s r r phs h s s r rb r -
apparent pulmonary-limited disease and has minimal sys- r s. H r, h s s r pr b . t h pr s-
temic symptoms. Nearly 50% o patients with sarcoidosis may r bs rb r r s r r .
have spontaneous resolution o their symptoms without treat- wh r r s s h h r r h r s -
ment. In act, treatment may actually prolong the disease pro- h r h rb r r ,s h s p r
cess. I her pulmonary or systemic symptoms worsen or are s rh h r .
causing major li e problems, she should be started on oral
steroids. Systemic corticosteroid therapy is the mainstay o
treatment or sarcoidosis. Methotrexate and other immune- Your suspicions are con rmed. T e chest x-ray shows oblit-
modulating drugs may be employed as well and o er a steroid- eration o the right hemidiaphragm, and the posterior costo-
sparing e ect, but these are not rst-line agents. Evidence or phrenic angle is obscured on the lateral view, consistent with
the use o inhaled corticosteroids is lacking. Antibiotics are pleural e usion. T ere is also a right upper lobe lung mass.
not e ective.
Objectives: Did you learn to . . . Question 3.10.2 Which o the ollowing will provide the
• R z h s s s r s s? most in ormation and guidance or your thoracentesis?
• m p h s r s s? A) Supine chest x-ray.
B) Chest C .
C) Lateral decubitus chest x-ray.
CASE 3.10 D) Chest ultrasound.
A 57-year-old male with no prior medical history comes in E) Apical view chest radiograph.
to clinic with a 1-week history o right rib pain and low-back
pain. T e rib pain is worse with deep breaths and especially Answer 3.10.2 The correct answer is “D.” Prior to per orming
bothers him at night. T ere has been no trauma. He has a thoracentesis, you must know whether the e usion is locu-
lost 20 lb in the last 3 months. He has a cough productive o lated or reely owing. Portable ultrasound has become a vali-
white sputum. He denies any other symptoms. He smokes dated and widely accepted modality to diagnose and access a
one to two packs o cigarettes per day but does not drink pleural e usion. Also, ultrasonography has been ound to be
alcohol. more sensitive or detection o pleural uid than a chest radio-
Vital signs: temperature 36.5°C, pulse rate 95 bpm, blood graph. Chest C is somewhat more sensitive but ar more cum-
pressure 110/70 mm Hg, respiratory rate 16. On room air, his bersome and does not allow a bedside diagnosis and treatment.
oxygen saturation is 96%. T ere is no adenopathy. His lung A decubitus lm, with the a ected side down, would allow you
sounds are clear on the le and decreased on the right. T ere see the e usion “layer out” unless it is loculated but again is less
 Ch Apt Er 3 • Pu l mo n o l o g y 117

sensitive. A supine chest x-ray may cause the e usion to “layer TABLE 3-6 CAt EGOr IZAt ION OF pLEUr AL FLUID AS
out” too, but you will not be able to see it as well, which is why AN EXUDAt E Or t r ANSUDAt E
e usions may be missed when a patient is unable to stand or sit
Exuda e h r rz b
upright or his x-ray.
• P r s r pr r > 0.5
Question 3.10.3 Relative and absolute contraindications to • P r s r l dHr > 0.6
• P r ldH r r h 150 / l ( -hr s h pp r
thoracentesis include all o the ollowing EXCEPT: r s r l d H)
A) Herpes zoster in the area o needle placement.
B) Coagulopathy.
C) Diaphragmatic rupture.
D) Positive pressure ventilation. Answer 3.10.5 The correct answer is “D.” Pleural e usions
E) History o recurrent laryngeal nerve injury or compromise. are broadly categorized as exudates and transudates (see
ables 3-6 and 3-7). Such a categorization helps to narrow the
di erential diagnosis. In this case, several elements o the pleu-
Answer 3.10.3 The correct answer is “E.” Absolute contrain-
ral uid are consistent with an exudate. LDH and protein can
dications include chest wall compromise (e.g., burn, cellulitis,
be used to determine whether the pleural uid is transudative
herpes zoster, ruptured diaphragm) and cases where chest tube
or exudative. Per Light’s criteria, a pleural e usion is suggestive
thoracostomy would be more appropriate. Relative contraindi-
o an exudative process i two o any o the ollowing criteria are
cations are poor patient cooperation, coagulopathy, anticoagu-
met: pleural uid LDH > 2/3 the upper limit o normal serum
lation therapy, very small e usions (< 10 mm on decubitus lm
LDH, a pleural LDH:serum LDH ratio o > 0.6, and a pleural
view), positive pressure ventilation, and pleural adhesions.
protein:serum protein ratio o > 0.5. All three o these indicators
point to an exudate in this case. Also, exudative e usions tend to
Question 3.10.4 On ultrasound, the ef usion appears ree have a higher degree o cellularity than transudative e usions.
owing and not loculated. What is the most appropriate With the in ormation given, it is dif cult to determine i the e u-
next step? sion is related to in ection, cancer, or some other process.
A) Re erral or surgical drainage.
B) Place a chest tube to drain the e usion. T e pleural f uid cytology comes back negative. T e patient’s
C) Per orm an ultrasound-guided diagnostic thoracentesis at symptoms and examination have not changed. Repeat radio-
the bedside. graph still shows an upper lobe mass.
D) Order two pizzas, one or you and one or the patient (you
have both had a long day and are hungry). Question 3.10.6 What is the most appropriate next step in
approaching this pleural ef usion?
Answer 3.10.4 The correct answer is “C.” T e patient has a A) Await pleural uid culture results.
relatively large pleural e usion. Ultrasound-guided thoracen- B) Per orm bedside chest tube drainage o the e usion.
tesis is a good rst step in evaluating this e usion. Ultrasound C) Re er or surgical evacuation o the e usion.
guidance is quickly becoming the standard o care as it has D) Re er or bronchoscopy.
been shown to decrease complications o pneumothorax as well E) Place a chest tube or chemical pleurodesis.
as the number o unsuccess ul clinical attempts or “dry taps.”
Re erral to a thoracic surgeon may eventually be necessary, but
this would not be the rst step. Placing a chest tube into an e u- TABLE 3-7 CAt EGOr IZAt ION OF pLEUr AL EFFUSIONS
sion is not recommended at this point, and the diagnostic study BY CLASS (t r ANSUDAt IVEVEr SUS EXUDAt IVE)a
should be obtained rst.
Type o Ef usion Potential Causes
Ultrasound-guided thoracentesis is success ul in obtaining tr s s s H r r , rrh s s, phr
f uid. T e f uid is amber and cloudy, with a pH 7.3, lactate s r , s s, ,
p r b s , r h r
dehydrogenase (LDH) 800 IU/L, glucose 65 mg/dL, total pro-
tein 5.5 g/dL, WBC 1,300/mm3, RBC 50,000/mm3. Serum stud- e s s Br h r , s
ies done the same day include LDH 155 IU/L, glucose 99 mg/dL, p s , s h ,p ,
and total protein 7.0 g/dL. Cytology, Gram stain, and culture t B, h h r ,p r s, s ph
r p r , s r s s s
o the pleural f uid are pending.
(rh r hr s, Sj r s r ),
r , r s( r r ,
Question 3.10.5 Which o the ollowing is the most accurate r , h r ), h r
statement regarding the pleural uid analysis? r h r h r p ,p r
b s
A) T e uid is due to in ection.
B) T e uid is due to cancer. Note: H r r p r b s s
C) T e uid is a transudate. r s s s.
D) T e uid is an exudate. a
S exudate r r t b 3-5. e r h s s r s .
118 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

Answer 3.10.6 The correct answer is “D.” T e e usion is clearly

exudative, and the patient appears to have a lung mass. Biopsy
o the lung mass via bronchoscopy is indicated. A negative pleu-
ral uid cytology does not rule out lung cancer. Positive cytol-
ogy indicates advanced stage lung cancer. Chest tube drainage
o a pleural e usion is not recommended except under extraor-
dinary circumstances. Intermittent thoracentesis is pre erred
and has lower morbidity. Surgical evacuation o the uid would
be indicated i the patient were symptomatic, the e usion was
loculated and/or related to in ection. I the e usion grows, or is
drained and recurs, it may respond to pleurodesis. Otherwise,
pleurodesis is not indicated at this time.
HELPFUL TIP:
P s h p r s s r
b r s r r s h r s
s r s b b h sp .l - r
h p r s r b k.
Now that you have gained expertise with ultrasound o a
pleural e usion, your colleague sends you a patient that has
a pleural e usion on chest x-ray. Your colleague asks you
whether you could “tap” the f uid or him as he does not eel
com ortable with the portable ultrasound. Also, he has a tee
time in 30 minutes.
Question 3.10.7 On ultrasound, you quickly visualize the
chest and see a septated and loculated pleural ef usion.
What is the best next step?
A) Return the patient back to his doctor—the e usion is too
small to access.
B) Per orm ultrasound-guided needle thoracentesis.
C) Re er to a thoracic surgeon.
D) Place a small-bore chest tube.
E) Head to the gol course with your colleague. Nothing you
can do here.
CASE 3.11
A 60-year-old male presents to the ED or a cough. His symp-
toms began with a cold 2 weeks ago, and the other symp-
toms have improved, but the cough has persisted. He has
mild production o white sputum with no hemoptysis. T e
patient denies evers, night sweats, chills, and weight loss.
He’s had no chest pain or dyspnea. He smokes one pack o
cigarettes per day, works in construction, and does not have
a regular doctor. In act, with some pride, he says, “I haven’t
seen a doctor in over 30 years.” On physical examination, you
nd a t-appearing male in no acute distress. His vital signs
are normal. His lung sounds are diminished bilaterally, but
the remainder o the examination is unremarkable. While
k breathing ambient air, the patient’s oxygen saturation is 94%.
z You obtain a chest x-ray, which is shown in Figure 3-7.
s
Question 3.11.1 Your next step is to:
A) Prescribe a 5-day course o azithromycin.
B) Re er the patient to a pulmonologist.
C) Order a high-resolution C scan o the chest.
D) Have the patient return to you in 3 months to repeat a chest
x-ray.
E) Reassure the patient and have him return as needed.
Answer 3.11.1 The correct answer is “C.” T e chest x-ray in
Figure 3-7 shows a single nodule in the right lower lobe. T e
nodule is round, less dense than bone, and appears to be > 1 cm
in diameter. T ese are sometimes called “coin lesions.” T ere are
no other abnormalities. T e most appropriate next step in the
evaluation is to order a high-resolution C scan o the chest.
reatment with azithromycin is inappropriate in this setting, as
this patient has no signs o pulmonary in ection on examination
or chest x-ray. Re erral to a pulmonologist is premature with-
out rst investigating the nodule by C scan. Delaying urther

Answer 3.10.7 The correct answer is “C.” A loculated and sep-

tated pleural e usion can very o en be seen in empyema and
evacuation usually requires surgical intervention. T oracentesis
would unlikely be success ul and would expose the patient to
an unnecessary procedure a er which he would still need to see
a surgeon. Placing a chest tube blindly into a loculated pleural
e usion is unsa e. T at procedure should be done under visual-
ization; most commonly, video-assisted thoracic surgery would
be utilized.
Objectives: Did you learn to . . .
• R z h hs r ph s f s
p r s ?
• l s p s p r s ?
• n rr h r ssb s p r
f s?
• d h p r r s h r p
h r s s?
• d h p r r h s b r ? FIGURE 3-7. P ’s h s -r .
 Ch Apt Er 3 • Pu l mo n o l o g y 119

TABLE 3-8 r ECOMMENDAt IONS FOr FOLLOW-Up AND MANAGEMENt

OF NODULES SMALLEr t h AN 8 mm DEt ECt ED INCIDENt ALLY At
NONSCr EENING Ct
Nodule
Size (mm) Low Risk Patients High Risk Patients
4 n - p F - p 12 hs. i h ,
rh r

> 4–6 F - p 12 hs. i h , i - p c t 6–12 hs

rh r h 18–24 hs h

> 6–8 i - p c t 6–12 hs i - p c t 3–6 hs

h 18–24 hs h h 9–12 24 hs h

>8 F - p cts r 3, 9, 24 S s r -r sk p s
hs. d r s h
c t , Pet , / r b ps

Notes: t h s s pp r s p rs s 35 rs r r.
l -r sk p sh r bs hs r s k h rk r sk rs. H h-r sk
p sh hs r s k r h rk r sk rs.

imaging and evaluation is also inappropriate since 15% to 75% I the diameter is < 8 mm, the risk o cancer is low. When the
o solitary pulmonary nodules (SPNs) ≥ 8 mm are ultimately diameter is ≥ 3 cm, the SPN is now re erred to as a “pulmonary
diagnosed as cancer. mass” and is highly likely to be cancerous. SPN > 3 cm in diam-
eter should be considered cancer until proven otherwise.
Question 3.11.2 Which o the ollowing is NOT considered a T e Fleischner Society has published a set o widely accepted
benign pattern o calci cation on CT scan? recommendations regarding ollow-up o single pulmonary
A) Di use, homogeneous calci cation. nodules noted on C chest that are < 8 mm in diameter (see
B) Central calci cation. able 3-8).
C) Laminar calci cation.
D) Spiculated, irregular calci cation.
E) “Popcorn” calci cation. HELPFUL TIP:
th r s h s (b s ) s r -
Answer 3.11.2 The correct answer is “D.” We are accustomed s r SPn s. S c h s . 2013 m r; 143:840
to thinking o calci ed nodules as being benign, but that is not h p r . P r s b-s s
always the case. Irregular, spiculated calci cation is not reas- <5 - p s h r k b
suring. T e other options are considered indicative o a benign (< 2% r sk s k r). t h r s -
lesion. wo patterns on C are relatively speci c or cancer: a r h p r h r sk h r :
scalloped border and the corona radiata sign, which is com- h p://r r . s p . / r/s r -p -
posed o ne linear strands extending out rom the nodule. r - -r sk. H s ss h rp .
Question 3.11.3 All o the ollowing are use ul to help assess
the risk o cancer in a patient with an SPN EXCEPT:
A) Smoking status. Later that week, your patient returns with his C scan in
B) Age. hand. His cough is somewhat better (therapeutic C scan
C) Diameter o the nodule. radiation therapy . . . you know, like those C scans in Cali-
D) Gender. ornia that were cooking people’s brains accidentally?). You
review the C scan with him. It shows a round, smooth nod-
Answer 3.11.3 The correct answer is “D.” Determining the ule measuring 2 cm in diameter and located in the periphery
probability o cancer in patients with an SPN is an inexact sci- o the right lower lobe. T ere are no calci cations in the nod-
ence. T e risk o cancer is generally assessed as low, interme- ule and no other abnormalities.
diate, or high based on patient and radiograph characteristics.
Although men are slightly overrepresented in lung cancer diag- Question 3.11.4 Which o the ollowing is the most appro
noses, this is generally thought to be due to greater smoking priate next step?
rates in men and to occupational hazards. Gender itsel does not A) Re erral or bronchoscopy.
help to risk-strati y patients with an SPN. Smoking increases the B) High-resolution C scan every 3 months.
risk o an SPN being cancer, with greater use increasing the risk C) Chest x-ray every 3 months.
o cancer. As with most cancers, increasing age is associated D) Bone scan.
with a higher risk. T e diameter o the nodule is also important. E) Re erral to a thoracic surgeon.
120 Fa mil y med ic in e exa min a t io n & Bo a Rd Review
Answer 3.11.4 The correct answer is “E.” T is patient needs a
biopsy. T ere are several actors that put your patient at higher
risk o having a malignant cause or the SPN, including his
age and tobacco use. T ese put him into an intermediate- to
high-risk category or cancer. Although the nodule is smooth
on C , its size is > 8 mm and there are no calci cations. T is
patient should be re erred or transthoracic ne-needle biopsy
or open biopsy. “A” is tempting but incorrect. Bronchoscopy is
insensitive in the peripheral lung, especially when the lesion
is relatively small. “B” and “C” are also wrong here but are
appropriate in other settings. In this case, repeat imaging over
time may delay a diagnosis o malignancy. Without symptoms
o bone pain or con rmation that the SPN is a cancer that
might metastasize to bone, a bone scan will have a very low
yield.
Your patient returns rom the surgeon much relieved. Fine-
needle biopsy proved the SPN to be a hamartoma. Now your
patient wants to quit smoking or good, and he thinks that he
will need some assistance. You recommend nicotine replace-
ment products and bupropion, but your patient claims to
have had an allergic reaction to bupropion. Fortunately, you
know o an e ective alternative (unless he is a homicidal
maniac . . . it happens you know).
Question 3.11.5 To assist with tobacco cessation, you pre
scribe which o the ollowing?
A) Varenicline.
B) Fluoxetine.
C) Olanzapine.
D) Metoprolol.
E) Clonidine.
Answer 3.11.5 The correct answer is “A.” Randomized trials
have demonstrated the e ectiveness o the nicotine partial ago-
nist, varenicline (Chantix M). T is FDA-approved medication
appears to be at least as e ective as bupropion as an aid to smok-
ing cessation. Fluoxetine and other selective serotonin reuptake
inhibitors have not demonstrated a bene t. In schizophrenic
patients, the use o atypical antipsychotic medications may aid
in smoking cessation when compared with typical antipsychot-
ics. Clonidine is sometimes used to help patients who are with-
drawing rom narcotics, and it may have some limited role in
smoking cessation but is not very e ective. Depression, very
vivid dreams or nightmares, aggressive behavior, etc., are a well-
described side e ect o varenicline, and your patients should be
in ormed o that prior to prescribing the drug.
As you are walking out o your patient’s room, your patient
says, “Hey Doc, my brother smokes too, is there a test you can
do to make sure he doesn’t have lung cancer?”
Question 3.11.6 You respond:
A) “Sure, I’ll put in an order or him to get an outpatient chest
x-ray.”
B) “ ell him to make an appointment and we will discuss the
risks/bene ts o low-dose C scan.”
C) “Here have him spit in this cup, and I’ll send his sputum or
cytology.”
D) “Nah, we don’t recommend lung cancer screening at this
time.”
Answer 3.11.6 The correct answer is “B.” In 2013, the USP F
issued a grade B recommendation or annual lung cancer
screening with low-dose C scan in adults aged 55 to 80 years
who have a 30 pack-year smoking history and currently smoke
or have quit within the past 15 years. Screening should be dis-
continued once a person has not smoked or 15 years or devel-
ops a health problem that substantially limits li e expectancy or
the ability or willingness to have curative lung surgery. T ese
recommendations are based on the National Lung Screening
rial that showed that or every 1,000 people who got screening
or lung cancer, 3 ewer died o lung cancer because o screen-
ing. About 300 people need to be screened to save one li e rom
lung cancer. Patients should be given the risks/bene ts o lung
cancer screening since approximately 365/1,000 patients will
have a alse-positive result (usually because o a benign pul-
monary nodule) that leads to more C scans (extra radiation),
more invasive procedures (biopsies and surgeries), and patient
stress and anxiety. Con used yet? Don’t worry, the Ameri-
can T oracic Society has developed a patient decision guide
ound at http://www.thoracic.org/patients/patient-resources/
resources/decision-aid-lcs.pd . Your patient’s brother can read
the 20 pages while on his next smoke break! Just kidding. It
is important to stress that this lung cancer screening should
not take the place o e orts to stop smoking! O note, “A” and
“C” are incorrect because neither plain chest radiographs nor
sputum cytology have been shown to improve lung cancer
mortality.
Objectives: Did you learn to . . .
• w h r sk rs h SPn ?
• d p p r SPn ?
• a ss s p hs k ss ?
• l r h r sks/b f s rs r h
ppr pr p p p ?
CASE 3.12
A 74-year-old male presents to your ED or weakness, cough,
and atigue. His wi e relates an incomplete recovery since
his myocardial in arction last year. He continues to have
poor appetite and listlessness, and she thinks that he may be
depressed. He is short o breath and con used. His wi e says
that yesterday he developed a ever, chills, and a new cough
productive o white sputum. His past medical history is oth-
erwise remarkable or a cholecystectomy. He is taking aspi-
rin, metoprolol, and atorvastatin.
Vitals: temperature 39°C, respiratory rate 30, pulse 90
bpm, blood pressure 140/80 mm Hg. Oxygen saturation on
room air is 90%. He is thin, pale, and oriented to person only.
T e lung examination is remarkable or rales in the le lower
eld, with dullness to percussion and increased tactile remi-
tus. T e remainder o the examination is normal.
 Ch Apt Er 3 • Pu l mo n o l o g y 121

T e chest x-ray shows a le lower lobe in ltrate. Other Question 3.12.2 Based on patient speci c characteristics
laboratory data currently available: hemoglobin 12.4 g/dL, and your knowledge o causative actors involved in pneu
WBC 14,100/mm3, platelets 340,000/mm3, creatinine 1.9 mg/ monia, which o the ollowing is LEAST likely to be the
dL, BUN 50 mg/dL, and normal electrolytes, troponin, and agent causing this patient’s in ection?
CK. An ECG shows normal sinus rhythm. A) Mycoplasma pneumoniae.
B) S. pneumoniae.
Question 3.12.1 What is your next step in managing this C) Haemophilus in uenzae.
patient’s medical condition? D) Pseudomonas aeruginosa.
A) Place a chest tube on the le .
B) Per orm chest C . Answer 3.12.2 The correct answer is “D.” When a pathogen is
C) Administer inhaled bronchodilators. identi ed in adult community-acquired pneumonia, it is usually S.
D) Administer parenteral antibiotics. pneumoniae. In act, S. pneumoniae makes up 40% to 60%o all cases
E) Per orm intubation and mechanical ventilation. o community-acquired pneumonia in the elderly. Nontypeable
H. in uenzae composes about 5% to 10% o cases. Mycoplasma is
Answer 3.12.1 The correct answer is “D.” Given the clinical implicated in 5% o all cases o pneumonia in adults, and it is more
picture and chest x-ray ndings, the patient most likely has common in young adults. P. aeruginosa pneumonia is uncommon
community-acquired pneumonia. T ere ore, the administra- in healthy elders and more likely to occur in patients with serious
tion o parenteral antibiotics is the best choice. “A” is incorrect. underlying lung disease or immunode ciency. Approximately 5%
Since there is no e usion, a chest tube would be useless. “B” o patients or more are in ected with multiple agents.
is incorrect. C is not required in this straight orward case o
pneumonia. “C” is incorrect. T e patient is not wheezing and Question 3.12.3 On the basis o your assessment o his risk,
there is no indication or bronchodilators at this time. As or you decide to admit this patient to the hospital. An IV is in
“E,” since your patient’s respiratory status is stable, he does not place. Which o the ollowing IV antibiotic regimens do you
require intubation. choose?
A) Penicillin.
HELPFUL TIP: B) Azithromycin.
R b r h s p ss b “ p ” rs s C) Penicillin and gentamicin.
“ p ”p b r r ph. d b s D) Azithromycin and ce riaxone.
r h r p r - q r p E) Piperacillin/tazobactam and cipro oxacin.
h r r ph pp r .a p r s s
s b r s p p s Answer 3.12.3 The correct answer is “D.” T e 2007 In ec-
pp r s .n h r s k tious Disease Society o America / American T oracic Society
r r ph pp r . (IDSA/A S) guideline or pneumonia recommends that or
community-acquired pneumonia treated in the hospital set-
ting the optimal antibiotic regimen must o er good coverage
HELPFUL TIP: o S. pneumoniae, H. in uenzae, and atypical organisms such
th p s r s p p r as Mycoplasma and Chlamydia species. Most S. pneumoniae
s r h h r r p h bacteria are resistant to penicillin and about 20% to 30% are
p .H r, s s b rs h b resistant to macrolides such as azithromycin. T ere ore, these
r b r .l k p (h p:// r . agents should not be used alone in the treatment o pneumo-
s . /p r / p/10675. ). nia in hospitalized patients. Gentamicin has no activity against
S. pneumoniae but has a role in P. aeruginosa in ections. Ce ri-
axone o ers good Gram-negative coverage and activity against
HELPFUL TIP: S. pneumoniae. Azithromycin covers atypical organisms. For
a s p rb ss - ss r r- these reasons, “D” is the best choice. An alternative regimen
sp s p hp —h would be monotherapy with a respiratory uoroquinolone, such
“c u RB-65.” c h , , h? H r r h r b s: as moxi oxacin or levo oxacin. T e combination o piperacil-
C s
(b s sp s r s r - lin/tazobactam with cipro oxacin is reserved or patients with
p rs , p , r ). more severe pneumonia, requiring ventilation and ICU care.
Ur (Bu n ) > 20 / l.
R sp r r r > 30 br hs/ . Initial blood cultures grow S. pneumoniae. Sputum Gram
B pr ss r < 90/60. stain and culture are negative. T e patient initially does well
a > 65 rs. and de ervesces a er 2 days o IV antibiotics. However, on
P s h s r 0 r1h r sk day 3, he again spikes a ever. He looks moderately ill. Your
h r r s r p - examination reveals increased dullness to percussion on the
. le . T ere is no jugular venous distention (JVD) or periph-
eral edema. T e radiograph is shown in Figure 3-8.
122 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

FIGURE 3-8. P ’s h s -r .

Question 3.12.4 The most likely diagnosis at this point is: D) Prescribe amoxicillin/clavulanate.
A) Anaerobic abscess. E) Re er or bronchoscopy.
B) Development o resistant S. pneumoniae.
C) Parapneumonic e usion. Answer 3.12.5 The correct answer is “C.” T ere are no clear
D) ransudate secondary to heart ailure. guidelines regarding ollow-up chest x-ray in patients who had
E) Drug-induced transudate. pneumonia. T e British T oracic Society published recommen-
dations in 2007 where it advised repeating chest x-ray in 6 weeks
Answer 3.12.4 The correct answer is “C.” T e most likely prob- in patients with a smoking history. T e reason or that recom-
lem in this patient is a parapneumonic e usion. “A,” an anaero- mendation is a chance that the in ltrate would obscure an under-
bic abscess, is unlikely given that there are no air/ uid levels lying malignancy. T ose over age 50 should also have ollow-up
and the act that the uid appears to be in the pleural space. “B” x-ray. Bacteremic pneumococcal pneumonia has been associated
is unlikely. Development o resistance should take more than with very slowly clearing x-rays, up to 3 to 5 months in some
3 days, especially since this patient is on two drugs. “D” is cases. T us, repeating the chest x-ray in 2 weeks is unlikely to
unlikely given that this patient does not have a history o heart show resolution, so “B” is incorrect. In elderly patients, the chest
ailure, is ebrile, and has no JVD, etc. “E” is unlikely. None o x-ray takes longer to normalize than in younger patients.
the drugs that he is on is known to cause pleural e usions. T e patient is clinically doing well, and does not require treat-
ment or a persistent pulmonary in ection, so “D” is incorrect.
You place a chest tube to drain the pleural e usion ( ree f ow- Chest C (“A”) and bronchoscopy (“E”) would give more in or-
ing on ultrasound) and continue the current antibiotic regi- mation, but in the absence o systemic symptoms, such as weight
men. T e patient does well and is discharged 1 week later on loss, persistent cough, hemoptysis, or ever, they are not indicated.
clarithromycin a er sensitivities conclude that his organism It is important to consider the act that this “in ltrate” may rep-
is susceptible to that drug. resent a neoplastic process i it does not resolve within several
Six weeks a er the onset o illness, he returns or ollow- months.
up to ensure clearing o the chest x-ray. He is eeling well. He
is alert and oriented, and his lung examination is now nor- HELPFUL TIP:
mal. T ere is no lymphadenopathy in the neck or supracla- e h s (b r , sp
vicular areas. T e x-ray still shows le lower lobe in ltrate, r , .), s s
unchanged in size rom the initial x-ray. T e pleural e usion 50% s s p . t h s, r s s
has resolved. p r . Sp r s r b h r p
r s s s p s hp ,
Question 3.12.5 Which o the ollowing is the most appro 30% p s h p r b
priate next step in the evaluation and management o this pr sp .B r s r r
patient? p b r s r s -
A) Chest C . s r h sp z p s. i p ss b , b -
B) Chest x-ray in 2 weeks. r sb r h r p .
C) Chest x-ray in 6 weeks.
 Ch Apt Er 3 • Pu l mo n o l o g y 123

Your patient returns a week later looking ill. He has dyspnea, HELPFUL TIP:
ever, and worsening cough. His temperature in the o ce is S r s b h p h sp z p h
39°C, and he has a new in ltrate on chest x-ray. - q r p h r s r
s ppr ss , r hr s r s
Question 3.12.6 This situation is best described as: ’ h r b s( r r -
A) Community-acquired pneumonia. s r s). S l . 2015;385(9977):1511–
B) Double pneumonia. 1518 r hs h ( , h h sp ).
C) Hospital-acquired pneumonia.
D) Healthcare-associated pneumonia.
E) riple pneumonia.
In one o li e’s unny little coincidences, the next day you
Answer 3.12.6 The correct answer is “D.” T e 2007 IDSA/ diagnose this patient’s 36-year-old healthy son with a com-
A S guidelines de ne high-risk pneumonia based on setting. munity-acquired pneumonia. He has a ever, cough, and le
Healthcare-associated pneumonia is de ned as pneumonia lower lobe in ltrate on chest x-ray, but he is hemodynami-
occurring in a nonhospitalized patient who has had exten- cally stable. You determine that he’s t or outpatient man-
sive healthcare contact (meaning IV therapy or chemotherapy agement.
within the last 30 days, residence in a nursing home, attendance
at a hemodialysis center within the last 30 days, or 2 or more Question 3.12.8 Which o the ollowing drug regimens is
days in an acute care hospital in the last 90 days). Your patient appropriate or the treatment o this patient in the outpa
meets this de nition due to his recent hospitalization. “C,” tient setting?
hospital-acquired pneumonia, is one that develops 48 hours A) Cephalexin 250 to 500 mg PO QID or 10 days.
or more a er admission to a hospital and did not appear to B) Penicillin V 250 mg ID or 10 days.
be brewing at the time o admission. T e guidelines also dis- C) Clarithromycin 500 mg BID or 10 days.
tinguish ventilator-associated pneumonia, which occurs in D) Doxycycline 100 mg BID or 10 days.
patients 48 hours or more a er endotracheal intubation. “B” E) C or D.
and “E” are ake oils. Sorry!
Answer 3.12.8 The correct answer is “E.” T e treatment o
Question 3.12.7 Now that he has healthcare associated community-acquired pneumonia requires coverage o “typical”
pneumonia, you order the appropriate antibiotic regimen and “atypical” organisms. Neither “A” nor “B” covers atypical
consisting o : organisms. Guideline-recommended choices or the outpatient
A) Linezolid and amphotericin B. treatment o community-acquired pneumonia include doxycy-
B) Ce epime. cline and macrolides such as clarithromycin. Additional options
C) Gentamicin and vancomycin. include the respiratory uoroquinolones such as moxi oxacin,
D) Cipro oxacin. gemi oxacin, or levo oxacin. However, respiratory uoroqui-
nolones should not be used in all cases. T e IDSA/A S consen-
Answer 3.12.7 The correct answer is “B.” Since he has sus guidelines recommend that respiratory uoroquinolones
received antibiotics in the last 90 days, an anti-pseudomonal be reserved or patients with serious underlying disease (e.g.,
cephalosporin is indicated. Depending on circumstances, COPD, diabetes, immunocompromised states). O the appro-
other antibiotics may be added to broaden empiric coverage. priate regimens, doxycycline and erythromycin are the least
For example, i there are high levels o resistance to Gram- expensive, but erythromycin is associated with a high rate o
negative bacilli in the area, add an aminoglycoside. I MRSA gastrointestinal intolerance.
is suspected, add linezolid or vancomycin. I legionella is
likely, add a uoroquinolone. In this scenario, “A” is incorrect
HELPFUL TIP:
because it does not cover pseudomonas and a ungal in ec-
2007 id Sa /a t S s r r p -
tion is not likely in this immunocompetent patient. T e same
s h - q r p r h
is true o “C.” “D” may be arguable but is not the pre erred
r 5 s. H r, pr r s -
empiric choice according to the 2007 IDSA/A S guidelines.
r , h sh s b br r
Most important: know your local resistance patterns and your
48 72 h rs sh h r h h
patient’s speci c characteristics.
r r s b :h r r > 100 bp ,
r sp r r r > 24, s s b pr ss r < 90
H ,o2 s r < 90% r r, P o 2 < 60 H
HELPFUL TIP: r r, b r k , s .
Pr p p h b rs H2-b k rs r ss Sh h p h r h h s r r ,
h r s r sk p .S p h h r r b h r p s ( h p
. s h h h !).
124 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

Objectives: Did you learn to . . .

sr sh b p r h p s. t h r s
• R z h pr s - q r
h sh s h s h j r s r
p r p p p s?
pr vil i s sr s b r
• d r h ppr pr sp s r p h
6 8 l /k pr b h p s.
- q r p ?
i ,p s h sh r c o Pd q k
• i p p r r -
p h p r h h h r -
q r p ?
s. v p s h bs r s s -
r r r h .
CASE 3.13
While you are covering the ED, a 60-year-old emale comes
in by ambulance. She is unresponsive, and her husband states Your patient is on assist-control mode o ventilation. A
that he ound her 30 minutes ago surrounded by bottles nasogastric tube, 2 IVs, and a bladder catheter are in place.
o pills and an empty bottle o vodka. She has a history o She was given IV N-acetylcysteine. Her blood pressure has
COPD, hypertension, osteoarthritis, and depression. T e improved to 112/67 mm Hg, and her oxygen saturation
EM s brought in her pill bottles, which include lorazepam, is 99%. Her chest x-ray shows an endotracheal tube ter-
acetaminophen/hydrocodone, hydrochlorothiazide, aspirin, minating 3 cm above the carina and no in ltrates. T irty
and sertraline. Only a ew tablets are le in the bottle o minutes a er you intubated her, with the ventilator rate at
hydrochlorothiazide. She is wearing a nonrebreather ace- 14 breaths/min, FiO2 100%, and tidal volume at 400 mL,
mask with 50% oxygen. Her respirations are shallow with you obtain another ABG: pH 7.35, PaCO2 45 mm Hg, PaO2
a rate o 8. T e remainder o her vitals: temperature 36°C, 130 mm Hg. She takes 6 to 8 spontaneous, assisted breaths,
blood pressure 90/50 mm Hg, and pulse rate 90 bpm. Oxygen while the ventilator provides the remaining breaths. She
saturation is 88% and increases to 94% with some assisted appears to be per using her periphery well.
breaths. One nurse is obtaining a blood gas while another
gives naloxone. You decide that this patient cannot protect Question 3.13.2 Your next action is to:
her airway and choose to intubate her. A) Decrease the tidal volume to allow or permissive hypercapnia.
T e blood gas drawn just be ore intubation shows pH 7.16, B) Increase the tidal volume to achieve a pH o 7.45 to 7.50.
PaCO2 60 mm Hg, PaO2 40 mm Hg. C) Reduce FiO2 while maintaining oxygen saturations at or
above 90%.
Question 3.13.1 These ndings imply which o the ollow D) Change to pressure support ventilation.
ing processes?
A) Metabolic acidosis. Answer 3.13.2 The correct answer is “C.” Your patient is per-
B) Metabolic alkalosis. using well, and her PaO2 and measured oxygen saturation are
C) Respiratory alkalosis. much improved. You should now decrease the FiO2, with the
D) Mixed metabolic/respiratory acidosis. goal being to achieve an FiO2 o less than 60% while maintain-
E) Mixed metabolic/respiratory alkalosis. ing adequate per usion and oxygen saturation. An FiO2 o 100%
is somewhat toxic and can lead to airway injury. “A” is incorrect.
Answer 3.13.1 The correct answer is “D.” T e pH is acidotic However, permissive hypercapnia (the CO2 may be allowed to
(< 7.4). In a patient whose baseline PaCO2 is not known to you, rise to > 80 mm Hg as long as the patient tolerates it) may be
you might assume her PaCO2 is usually 40 mm Hg, which is the use ul in ventilated patients with COPD, ARDS, or asthma.
accepted normal or most patients. But remember that you still need to maintain oxygenation.
I the acidosis is purely due to acute respiratory changes and “B” is incorrect. Your patient is doing reasonably well with her
CO2 retention, a rise in PaCO2 o 10 should be accompanied slightly acidotic pH, which has corrected very quickly. It may be
by a all in pH equal to 0.08. In this case, the change in PaCO2 inadvisable to attempt to increase her pH beyond 7.40, as she
is 20. So, 20/10 × 0.08 = 2 × 0.08 = 0.16 resulting in a pH o may develop respiratory alkalosis that can then lead to cardiac
7.4 − 0.16 = 7.24. arrhythmias. Because o her low respiratory rate, she should
However, this patient’s pH is measured at 7.16, lower than remain on some type o assisted volume-cycled ventilation.
expected or a pure respiratory acidosis presenting acutely. T us, Pressure support ventilation, as its name implies, only aug-
you can determine that the acidosis is both metabolic (perhaps ments patient-triggered breaths with increased airway pressure.
rom lactic acidosis rom hypoper usion) and respiratory.
HELPFUL TIP:
HELPFUL TIP: P r ss h p r p s ppr h h
i s r h s r pr p - p h r h pr r s co 2 b p -
s h r sp r r s r ss s r / r s pH ( s 7.1) r r pr -
j r (a Rd S/a l i) pr vil i ( r- pr r s
j r ). i s r h h r h s pr h p r r bs r .
 Ch Apt Er 3 • Pu l mo n o l o g y 125

Question 3.13.3 In this patient, which o the ollowing venti

HELPFUL TIP:
lator management techniques will unequivocally decrease
RSBi s h pr rs s ss b .i
her FiO2 requirement?
s b r sp r r r b
A) Increase the respiratory rate.
rs h p s pr ss r s pp r
B) Increase the positive end-expiratory pressure (PEEP).
h s s (pr ss r 5–10, PeeP 5–8). F r
C) Decrease the tidal volume.
p ,p br h 20 sp r h
D) Addition o inhaled nitric oxide (NO).
500 l h s RSBi 20/0.5 = 40. P
br h 34 sp r h 210
Answer 3.13.3 The correct answer is “B.” wo standard tech-
l h s RSBi 34/0.21 = 161 s b s r
niques are usually employed to improve a patient’s oxygenation:
b b .
increasing FiO2 and PEEP. PEEP maintains positive pressure
in the airways at the end o expiration. Its use increases lung
compliance and decreases ventilation/per usion mismatching, HELPFUL TIP:
resulting in better oxygenation. Since FiO2 > 60% over peri- ic u s s h r h o R; b s
ods longer than 48 hours may result in oxygen toxicity, PEEP h ic u rr h h r r sk r .d b r
may be employed to reduce the need or high levels o FiO2. “A” p s b r - b . th r s p r
and “C” are incorrect. Increasing respiratory rate or tidal vol- pr r s ss ic u b sh
ume will cause increases in minute ventilation, which reduces h p 15% ic u p s r q r r - b
PaCO2, but has little e ect on PaO2. Decreasing minute ventila- sp pr rs s ss b .
tion, through decreased respiratory rate or tidal volume, causes
CO2 retention and increased PaCO2. “D” is incorrect. Nitric
oxide has been shown to improve oxygenation in select patients HELPFUL TIP:
with severe pulmonary hypertension and ARDS, but its use is m ( r h p )s b -
not appropriate in this patient. p r sp r r r b . t h s, p rs
20 br hs/ r h r 400 l /
You ollow the patient during her hospitalization. T e next br h r s = 20 × 400 =
day she is more alert and is able to ollow commands. Her 8l/ .
ventilator requirements have decreased. You consider extu-
bation.

Question 3.13.4 All o the ollowing parameters predict a Objectives: Did you learn to . . .
poor outcome or attempted weaning rom ventilation • R z r sp r r / b s s?
EXCEPT: • c p pH h s r sp r r s s?
A) Minute ventilation supplied by ventilator is < 10 L/min. • i s h ppr pr rs -
B) PaO2 < 55 mm Hg while on FiO2 > 35%. s?
C) Rapid shallow breathing index (RSBI) o 140. • i p p s ?
D) Physical examination ndings o increased respiratory • w p r h r?
e ort.

Answer 3.13.4 The correct answer is “A.” Preparing to with-

draw a patient rom mechanical ventilation—typically called
weaning or liberation—relies considerably on judgment, but
a ew objective parameters can be help ul. In general, the
patient to be liberated must be awake, alert, and coopera-
tive. She should have reasonably good oxygenation on a lower
FiO2, have PEEP < 8 cm H 2O, and be able to generate adequate
inspiratory pressures. Minute ventilation rom the ventilator
o less than 10 L/min is associated with greater success with
weaning.
Poor prognostic indicators include a minute ventilation
rom the ventilator > 10 L/min, PaO 2 < 55 with FiO 2 > 35%,
and RSBI (see Help ul ip) > 105. Patients with poor cardio-
pulmonary reserve or who have signi cant underlying disease
may also have dif culty weaning. Allow patients a period o
breathing on their own (e.g., a -piece) be ore extubating. T is
way, i the patient ails, you can simply hook her back up to the
ventilator.
CASE 3.14
A 52-year-old male smoker presents or a 3-month history o
productive cough. He reports multiple episodes o pneumo-
nia, but he appears healthy now. Chest x-ray is unremarkable.
Chest C shows enlarged peripheral airways with thickened
airway walls in the lower lobes bilaterally. Sputum culture
grows several types o bacteria, including P. aeruginosa.
Question 3.14.1 Which o the ollowing do you recommend
as initial therapy?
A) Corticosteroids.
B) Antibiotics.
C) Chemotherapy.
D) Supplemental oxygen.
E) Wedge resection o the a ected lung tissue.
Answer 3.14.1 The correct answer is “B.” T is patient’s nd-
ings are consistent with the diagnosis o bronchiectasis, a
126 Fa mil y med ic in e exa min a t io n & Bo a Rd Review

chronic in ammatory disease o the medium-sized bronchi. O the ollowing tests, which is the most likely to con rm or
Appropriate initial therapy consists o prolonged courses alter the diagnosis?
o antibiotics, usually 2 weeks o a narrow-spectrum anti- A) Spirometry, di using capacity, lung volumes.
biotic ollowed by reassessment. Doxycycline, amoxicillin, B) Spirometry, ABG, di using capacity.
clarithromycin, amoxicillin/clavulanate, and trimethoprim/ C) ABG, di using capacity, lung volumes.
sul amethoxazole are o en used. Respiratory quinolones D) ABG, lung volumes, chest C .
demonstrate some limited use in patients with Pseudomonas.
Patients should be directed to discontinue tobacco use and The correct answer is “A.” T is case demonstrates a commonly
take inhaled bronchodilators. Resection o the a ected lung seen phenomenon: patients who smoke and have dyspnea are
tissue may be necessary, but should not be the initial therapy. assumed to have obstructive lung disease, particularly emphy-
Supplemental oxygen therapy is used i oxygenation is poor. sema. However, pulmonary unction tests are required to make
Chemotherapy and prolonged oral corticosteroids are not the diagnosis o obstructive disease. Furthermore, this patient’s
used to treat bronchiectasis. chest x-ray shows increased interstitial markings in the lower
lung elds suggesting interstitial lung disease. T is disease pro-
cess is associated with a restrictive pattern on pulmonary spi-
HELPFUL TIP: rometry. However, lung volumes and di using capacity will
P s h br h ss r r h provide a more complete picture. T us, spirometry, di using
r r b s pr - capacity, and lung volumes would allow you to make the diag-
rb s. o r s r b r- nosis. In interstitial lung disease, spirometry shows a FEV1/FVC
h pr /s h z , k ratio > 0.7, a decreased di using capacity, and decreased total
h s b s r h rs 10 14 s h lung capacity (the hallmark o restrictive lung disease). ABG is
h. t h ss hs r s unlikely to help di erentiate restrictive rom obstructive lung
s . disease, so options “B” through “D” are not correct.

Question 3.14.2 In most adults with bronchiectasis, its HELPFUL TIP:

cause is: th s p , s s r b dl co , s
A) Genetic. h s s s s: ph s , rs
B) Pseudomonas in ection. s s ( . ., s r , s, p r r -
C) obacco smoking. ,p r r r ss h s r ,
D) Allergic bronchopulmonary aspergillosis (ABPA). p r br s s), P s sp , p -
E) Unknown. r s r s s .a s s
d l c o —s h b rh r sh s
Answer 3.14.2 The correct answer is “E.” T ere are limited b r r h dl co .
data regarding the etiology o bronchiectasis, but many condi-
tions and environmental exposures seem to have an association.
In most patients, no cause is identif ed. Children are more likely HELPFUL TIP:
than adults to have an identi ed etiology o their bronchiecta- dl co b r s b p r h rrh ,
sis, and the most common causes in kids are oreign body aspi- p h , ss b s , - -r h r r
ration, cystic brosis, and gastroesophageal re ux. Identi ed sh , sh , h r r ( r s p -
etiologies in adults include those mentioned or children and r h s).
pulmonary in ections, ABPA, COPD, rheumatic diseases, and
cigarette smoking.
Objectives: Did you learn to . . . QUICK QUIZ: Pu l mo n a Ry in Fec t io n S
• i f s ss h br h s s?
• tr p h br h s s? A 72-year-old woman you admitted to the hospital or pneu-
monia is having worsening dyspnea and hypoxemia. She is
decompensating despite 3 days o antibiotic therapy with intra-
QUICK QUIZ: d ySPn ea venous levo oxacin. According to her husband, the couple
had been working on their Iowa arm, and made a trip to an
A 75-year-old gentleman presents to your of ce with emphy- old barn to collect manure a week be ore the patient developed
sema diagnosed elsewhere. He reports dyspnea on exertion a er a cough and ever (so this is not hypersensitivity pneumonitis
1 to 2 blocks. He smokes 10 cigarettes per day and does not have nor organic toxic dust syndrome). T e barn was noted to be
underlying cardiac disease. Physical examination is remarkable the home o numerous birds. Her respiratory rate is 32, and her
or ne crackles in both lung bases. Chest x-ray shows increased oxygen saturation is 89% on 5 L/min o oxygen by nasal can-
interstitial markings in the lower lobes. He has no pulmonary nula. Chest x-ray reveals a di use interstitial in ltrate, enlarged
unction testing on record. mediastinal nodes, and normal heart size.

Which o the ollowing is the most likely culprit or the cause o
her current illness?
A) S. pneumoniae.
B) H. in uenzae.
C) Coxiella burnetii.
D) Histoplasma capsulatum.
E) Blastomyces dermatitidis.
The correct answer is “D.” T e case described here is classic or
an environmental exposure to a large dose o Histoplasma organ-
isms. Histoplasmosis is o en transmitted by bird or bat drop-
pings. Histoplasma occurs most commonly in the Mississippi
and Ohio River valleys, causing a sel -limited disease in most
persons. Patients who have Histoplasma in ection requently de-
velop calci ed mediastinal lymph nodes a er resolution o the
in ection. Diagnosis can be made by urinary antigen or broncho-
scopic biopsy. T e bacterial causes are unlikely to be important
actors here, as she was on a broad-spectrum antibiotic or 3 days
with no improvement. C. burnetii, the agent causing Q ever, is
rare and tends to a ect workers exposed to resh animal material,
such as placentas. Blastomyces is ound in the same regions as
Histoplasma, but the site o exposure tends to be more moist, un-
like the dry environment inside a barn. We all have granulomas
rom histoplasmosis on CXR in Iowa.
CASE 3.15
A 42-year-old emale comes to your o ce with a history o
asthma that has been di cult to control. She relates symp-
toms that have been worsening over the last 4 to 6 weeks.
She received two courses o oral corticosteroids during that
time. Her symptoms improved with this therapy but quickly
returned a er completing the steroids. She denies ever,
chills, and night sweats, but complains o a chronic cough
productive o brownish-colored sputum. She is a homemaker
in a suburban area and has no pets. Physical examination
reveals wheezing throughout all lung elds but is otherwise
normal. Laboratory evaluation includes CBC with increased
eosinophils, normal C-reactive protein, and an elevated IgE
level o 1250 ng/mL. A high-resolution C scan o the chest
reveals central bronchiectasis.
Question 3.15.1 What is the most likely diagnosis?
A) Hypersensitivity pneumonitis.
B) Acute eosinophilic pneumonia.
C) Allergic bronchopulmonary aspergillosis (ABPA).
D) Bacterial pneumonia.
E) Churg–Strauss vasculitis.
Answer 3.15.1 The correct answer is “C.” T is patient’s history
points to the diagnosis o ABPA, which is characterized by the
presence o severe asthma, brownish mucus plugs, peripheral
eosinophilia above 10%, elevated serum IgE, and central bronchi-
ectasis. IgE elevation is required to be greater than 1,000 ng/mL.
“A” is unlikely but a bit tricky. First, there is no history o
exposure to a causative agent. Second, let’s ocus on symptoms.
Constitutional symptoms—o en ever—are present in the acute
Ch Apt Er 3 • Pu l mo n o l o g y 127
orm o hypersensitivity pneumonitis. However, they need not
be present in the subacute and chronic orms o the disease.
So, based on symptoms, this could be hypersensitivity pneu-
monitis. However, the radiologic ndings o hypersensitivity
pneumonitis would include interstitial lung disease, rather than
central bronchiectasis. T us, this is not likely hypersensitivity
pneumonitis.
“B” and “D” are incorrect. Note that she has no signi cant
constitutional symptoms that might be more typical o acute
eosinophilic pneumonia or bacterial in ection. You would also
expect an in ltrate on the chest C . “E” is incorrect. Churg–
Strauss vasculitis is characterized by transient patchy intersti-
tial in ltrates, ever, weight loss, elevated sedimentation rate,
abnormal liver enzymes, and a peripheral blood eosinophilia
> 1,000 cells/µL. T is is o en related to using an oral steroid
and a leukotriene inhibitor simultaneously. It seems, but isn’t,
related to inhaled steroids because once the patient is on a ste-
roid inhaler, the oral steroid is usually tapered unmasking the
vasculitis. Extrapulmonary mani estations distinguish Churg–
Strauss rom other eosinophilic pulmonary conditions.
Question 3.15.2 Which o the ollowing would be the next
best step in con rming the diagnosis?
A) Sputum cultures.
B) ransbronchial biopsy.
C) Methacholine challenge.
D) Allergy skin testing or Aspergillus species.
E) p-ANCA.
Answer 3.15.2 The correct answer is “D.” Most but not all o
the ollowing criteria ( able 3-9) need to be present in order to
make the diagnosis o ABPA. ransbronchial biopsy is unneces-
sarily invasive, and the other tests will not help to con rm the
diagnosis.
Question 3.15.3 The most appropriate treatment or this
patient with ABPA would include which o the ollowing?
A) Antibiotics.
B) Oral corticosteroids.
C) Leukotriene receptor antagonist.
D) Itraconazole.
E) Inhaled ipratropium bromide.
Answer 3.15.3 The correct answer is “B.” Oral corticosteroids
are the treatment o choice or ABPA. Patients are typically
treated or several months with tapering doses rather than short
TABLE 3-9 Cr It Er IA FOr t h E DIAGNOSIS OF ALLEr GIC
Br ONCh OpULMONAr Y ASpEr GILLOSIS (ABpA)
• as h
• c r br h ss
• e s r i e > 1,000 / l
• i sk s r Aspergillus
• e s r -sp f i e / r i g Aspergillus fumigatus
• P r ph r b s ph > 10%
• P r f r s
128 Fa mil y med ic in e exa min a t io n & Bo a Rd Review
courses o steroids. Serum IgE levels and chest x-rays are used to
monitor response to treatment. Please note that “D” is incorrect,
and azoles are not the mainstay therapy in ABPA. T e goal o
treatment is suppression o the immune system responding to
the ungal antigen. T ere are studies that show bene t o adding
an anti ungal agent as a steroid-sparing agent. However, there
are risks associated with concomitant use o steroids and azoles,
namely, marked adrenal suppression. Hence, oral corticoste-
roids should be your rst choice.
Objectives: Did you learn to . . .
• i h pr s a BPa ?
• d s r p h a BPa ?
CASE 3.16
A 16-year-old emale comes to your o ce with complaints o
sneezing spells, itchy watery eyes, and nasal congestion or
the past 2 years. T ese symptoms are worse during the spring
and all and when she plays with her cat. She denies any other
constitutional symptoms and has no other past medical his-
tory. She has tried over-the-counter loratadine without relie .
She has lived in the same residence or the past 6 years and
denies any other environmental exposures. Her examination
reveals pale nasal mucosa and swollen nasal turbinates bilat-
erally. Her lungs and skin are clear.
Question 3.16.1 You are not clear i this is allergic rhinitis
or nonallergic rhinopathy (previously known as vasomo
tor rhinitis). The most ef ective way to determine i this is
allergic is to:
A) Do a methacholine challenge test.
B) Do a Hansel stain o nasal mucus.
C) Check overall IgE levels.
D) Per orm a nasal mucus electrophoresis to visualize allergic
bands.
E) Wa hot peppers under her nose . . . see what happens.
Answer 3.16.1 The correct answer is “B.” T e best way to tell
i this is allergic is to do a Hansel stain o the nasal mucous.
T is will show eosinophils i it is allergic. I this is nonallergic
rhinopathy, eosinophils will be absent. I it is in ectious, there
will likely be a predominance o neutrophils. “A” is incorrect. A
methacholine challenge test is help ul in diagnosing asthma, not
allergic rhinitis. Neither “C,” IgE levels, nor nasal mucus electro-
phoresis have any use here (and nasal mucus electrophoresis has
no use anywhere that we know o . . . and it is disgusting). IgE
is only elevated in 40% o patients with allergic rhinitis. Does
anyone ever actually do a Hansel stain? Probably not, but once
again, this is or the Board Examination, not real li e.
Question 3.16.2 The Hansel stain shows eosinophils. “Eureka!”
you shout. Which o the ollowing would be the most appro
priate next step in managing her symptoms?
A) Recommend allergen-impermeable encasements or
mattress and pillow.
B) Use topical decongestant sprays.
C) Change classes o antihistamines.
D) Re er or allergy evaluation, including percutaneous
aeroallergen skin testing.
E) Recommend a high ef ciency particulate air lter or the
home.
Answer 3.16.2 The correct answer is “C.” Although all o the
above choices may provide relie or allergic symptoms, the best
rst step would be to try changing the class o antihistamines.
Antihistamines (and NSAIDs or that matter) are grouped into
classes based on chemical structure. One class may be help ul
or a patient when another class does not work.
T e other choices are suboptimal. Without skin testing,
avoidance measures may be needless, costly, and ine ective.
Skin testing alone (“D”) would not immediately improve her
symptoms, and you would still need to do something with
therapy (we hope) while waiting 3 months to see an allergist.
Allergen-impermeable encasements (“A”) are currently recom-
mended or patients with dust mite allergy. Although lters
(“E”) are o en recommended or pet allergies, the data regard-
ing their e ectiveness in reducing allergic symptoms is contra-
dictory. opical decongestant sprays (“B”) are an inappropriate
choice secondary to the addictive nature o these medications
and the risk o causing rebound symptoms. Removing a pet
rom the bedroom may reduce—but not eliminate—allergen
exposure. Further evaluation should be per ormed prior to rec-
ommending any such li estyle modi cations. Another reason-
able option would be a trial o intranasal corticosteroid. Finally,
you could also put an allergen impermeable encasement around
the cat . . .
Your patient’s 17-year-old brother is in the next examination
room. He is a Boy Scout who just returned rom a backpack-
ing trip in the our corners area o New Mexico, Arizona, Col-
orado, and Nevada (. . . did you catch that? I you know your
geography, you know one o those is wrong). He has noted
myalgias, ever, and chills. He knows that you are reviewing
pulmonary medicine or your upcoming Board Examina-
tion, so he presents to your o ce complaining o dyspnea
that has been getting markedly worse over the past several
days. He has no URI symptoms such as coryza, rhinorrhea,
ear pain, etc. He has noticed nausea, vomiting, and diarrhea
with severe abdominal pain. His respiratory rate is 40 with
an oxygen saturation o 88%. (“See,” he says, “I told you I’m
sick.”) You place him on nasal oxygen and order a chest x-ray,
which shows bilateral pulmonary edema.
Question 3.16.3 Based on the epidemiology and chest x ray
appearance, your best guess at this point in the disease is:
A) Plague.
B) Coccidiodomycosis.
C) Hantavirus rom Sin Nombre (No Name) strain.
D) Noncardiogenic pulmonary edema rom smoking para-
quat (you never know what is going on at those Boy Scout
camps).
E) Ischemic cardiomyopathy rom cocaine use (you never
know what is going on at those Boy Scout camps).
 Ch Apt Er 3 • Pu l mo n o l o g y 129

Answer 3.16.3 The correct answer is “C.” T is is a typical his-

B j s h r s r hs r s; s h
tory and physical examination or hantavirus. T e absence o h s p s r s r r r b b h p .
URI symptoms, the presence o GI symptoms, and the noncar- th pr h rs h s s .
diogenic pulmonary edema are all symptoms/signs o hantavi-
B r s r r h p p (b
rus. In act, it may present as an acute abdomen. It is spread
s h ).
by aerosolization o mouse excrement or urine. “B” is incor-
rect. Although coccidiodomycosis, “Valley Fever,” is ound in d s - b - s sh h
h s r .i rs s s.
the same geographical region, it presents with lower respira-
tory symptoms, a thin walled cavitary lesion, erythema nodo- d s h s r s r c o Pd . t h
sum (10%), and eosinophilia. Coccidiomycosis is generally a r s p r b .
low grade, subacute process that lasts weeks to months. It does F r c o Pd p s, r s p
not cause noncardiogenic pulmonary edema. “A,” pneumonic p s h sh r - h br h r ( . .,
plague, while also ound in the same area, causes high ever, b r ) h - h br h r
bloody sputum, pleuritic chest pain, and develops over hours to ( . ., r p ) s p s r r .
days. It can be rapidly atal i not recognized and treated within i s p ss b r b r “ p ”r
the rst day. “D” and “E” are wrong or so many reasons that we “ p ”p b -r .
won’t bother to enumerate them here, but you never do know wh s h r p , k s r h r s
what goes on at camp. s r q r s h
ss h br h h p h h sp .
Question 3.16.4 Laboratory ndings suggestive o hantavi
rus include all o the ollowing EXCEPT:
A) T rombocytopenia. BIBLIOGRAPHY
B) Leukocytosis with a le shi .
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agement, and prevention o chronic obstructive pulmo-
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• d s h r s ? Ege MJ, et al. Exposure to environmental microorganisms and
childhood asthma. N Engl J Med. 2011;364:701–709.
Gibson PG, et al. Allergic bronchopulmonary aspergillosis.
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r s s r. v s s sh r ss. nitis. Am J Respir Crit Care Med. 2003;168:952–958.
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s s s s s p sh c o Pd ; h guidance rom the A S/ERS ask Force. T orax. 2006;61:
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American T oracic Society consensus guidelines on the
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CF bronchiectasis. T orax. 2010;65:i1–i58.
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Allergyand Immunology
Wendy Shen and Jason K. Wilb r
CASE 4.1
A 15-year-old girl has a history o acute di culty breathing
when playing basketball. Her symptoms include inspiratory
wheezing/stridor, increased respiratory rate, throat tight-
ness, and chest discom ort. Premedication with adequate
doses o albuterol has no e ect.
Question 4.1.1 What is the most likely diagnosis?
A) Exercise-induced asthma.
B) Gastroesophageal re ux disease.
C) Musculoskeletal chest pain.
D) Hyperventilation.
E) Vocal cord dys unction.
Answer 4.1.1 The correct answer is “E.” Vocal cord dys-
unction (VCD) is one o the most common asthma mim-
ics. Patients with VCD present with hoarseness, coughing,
dyspnea, and loud inspiratory wheezing/stridor, along
with other symptoms mentioned above. Pulmonary unc-
tion testing indicates airway obstruction due to an extra-
thoracic component. It appears that paradoxical inspiratory
vocal cord adduction causes air ow restriction at the level
o the larynx, resulting in a attened inspiratory loop on
ow–volume diagram. VCD presents a diagnostic challenge,
and o en leads to unnecessary treatment o asthma. In this
patient, a β 2-agonist was ine ective, even though she displays
symptoms with exertion. T is argues against answer “A.” T e
distinction between VCD and asthma may be less clear in
other patients, since the two disorders sometimes coexist.
T e clinical history does not support the diagnoses o gas-
troesophageal re ux disease, musculoskeletal chest pain, or
hyperventilation.
You make the diagnosis o VCD. However, the patient also
complains o rhinorrhea, itchy eyes, sneezing, and itchy nose.
Because you realize that we need to discuss it in this book,
you kindly re er her or allergy testing (thank you!).
4
Question 4.1.2 With regard to radioallergosorbent testing
(RAST) or allergic rhinitis, which o the ollowing is true?
A) RAS is less expensive than traditional skin testing.
B) RAS is more sensitive than traditional skin testing.
C) RAS has a limited role in testing those with allergic rhinitis.
D) Antihistamine use is a contraindication to the use o RAS .
Answer 4.1.2 The correct answer is “C.” RAS will be nega-
tive in up to 25% o those with a positive skin test, has poorly
reproducible results, and is more expensive. T us, skin testing
remains the procedure o choice or identi ying allergens. RAS
can be used i skin testing is unavailable.
Question 4.1.3 Which o the ollowing medications does
NOT need to be discontinued prior to aeroallergen skin
testing?
A) Intranasal steroid spray.
B) Atenolol.
C) Amitriptyline.
D) Cyproheptadine.
E) Azelastine nasal spray.
Answer 4.1.3 The correct answer is “A.” Intranasal steroid
sprays do not need to be discontinued prior to skin testing as
they do not inter ere with immediate-type hypersensitivity
reactions. T ey are not antihistaminic in nature, as opposed
to amitriptyline, cyproheptadine, or azelastine, which may all
blunt dermal reactivity. Although azelastine is administered
as a nasal spray, its administration may inter ere with skin test
reactivity within 2 days o usage. Beta-blockers, such as ateno-
lol, have been shown to a ect skin test reactivity and should be
avoided in patients undergoing skin testing.
Aeroallergen skin prick and intradermal testing reveals posi-
tive reactions to dust mites, cat, ragweed, and tree pollens.
T e patient relates that she gets considerable nasal conges-
tion and has tried over-the-counter decongestants with no
relie .
131
132 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Question 4.1.4 Which o the ollowing interventions would
provide the most relie or her nasal symptoms?
A) Diphenhydramine 25 mg PO BID.
B) Montelukast 10 mg PO QHS.
C) Intranasal steroid spray daily.
D) Ipratropium bromide nasal spray BID.
E) Getting rid o the cat. No one should have a cat. T ey are
evil.
Answer 4.1.4 The correct answer is “C.” Intranasal corticoste-
roids would provide the most relie in this patient by addressing
nasal congestion in addition to the other nasal symptoms men-
tioned. Although antihistamines are very help ul in relieving
nasal symptoms such as rhinorrhea, nasal itching, and sneezing,
they are generally not as e ective or nasal congestion. Likewise,
montelukast is a leukotriene modi er, which is approved or the
treatment o allergic rhinitis, but studies suggest that intranasal
steroids are superior. In addition, nasal steroids are not systemic
(although a bit may be absorbed). Ipratropium is mainly e ec-
tive or rhinorrhea only, while nasal saline irrigations promote
thinning o nasal secretions and drainage, but neither predict-
ably improves nasal congestion. As to “E,” yes, cats are evil and
shed. But as amily doctors we are supposed to be accepting o
our patient’s quirks.
HELPFUL (AND REALLY COOL) TIP:
Nasal steroids also seem to improve oc lar symptoms.
Whether some o the dr ets p the nasolacrimal
d cts or is otherwise aerosolized into the eye is nclear.
Obvio sly, do not p t nasal steroids directly in the eye.
For moderate-to-severe aller ic rhinitis, combination o
intranasal steroid and intranasal antihistamine is more
e ective than either alone.
She returns to you a year later, having tried intranasal ste-
roid sprays and high-dose antihistamines, without gaining
signi cant relie . She has instituted appropriate avoidance
measures during the interim (there goes the cat), also with-
out improvement in symptoms. You recommend allergen
immunotherapy.
Question 4.1.5 All o the ollowing statements are true
regarding allergen immunotherapy EXCEPT:
A) Patients should carry emergency epinephrine to all immu-
notherapy shot appointments.
B) It is unnecessary to stop beta-blocker therapy prior to start-
ing immunotherapy.
C) Patients should be observed in the of ce or at least 30 min-
utes a er immunotherapy injections.
D) At least 3 years o immunotherapy should be given to avoid
recurrence o symptoms.
Answer 4.1.5 The correct answer is “B.” It has been shown that
patients taking beta-blockers may be at increased risk o having
more severe systemic reactions to immunotherapy. Patients
should be treated with an alternative antihypertensive during
immunotherapy. T e current practice parameters or aller-
gen immunotherapy recommend that emergency epinephrine
should be readily available or the treatment o systemic aller-
gic reactions associated with immunotherapy. o monitor or
these immediate reactions, patients should be observed in the
of ce setting or at least 30 minutes a er immunotherapy shots
are administered. Based on studies o seasonal symptom scores,
it is generally recommended that allergen immunotherapy be
continued or 3 to 5 years.
Your next patient has a history o ragweed and grass allergy.
He states that he is “allergic” to needles. Accordingly, you
decide to use sublingual (SL) desensitization instead o sub-
cutaneous (SQ) routes. Luckily, there are FDA-approved sub-
lingual preparations or desensitization to ragweed, imothy
grass and a 5-grass combination.
Question 4.1.6 Which o the ollowing is true regarding SL
desensitization?
A) It is more e ective than SQ desensitization.
B) It is overall sa er than SQ desensitization; there are ewer
adverse systemic reactions than with SQ desensitization.
C) It can cause airway obstruction by causing tongue and phar-
ynx edema.
D) It is well studied as a combination therapy with SQ desensi-
tization.
E) B and C.
Answer 4.1.6 The correct answer is “E.” SL desensitization
can causes ewer anaphylactic reactions but can cause airway
obstruction rom local edema. “A” is incorrect. T e great major-
ity o studies show that SQ desensitization is more e ective than
SL desensitization. “D” is also incorrect. T e use o SL therapy
in combination with SQ desensitization is contraindicated and
may increase the rate o anaphylactic reactions. As a nal note,
most patients who require desensitization need desensitization
to more than just imothy grass or ragweed or the 5-grass com-
bination limiting the use ulness o SL therapy. Patients are o en
also allergic to tree pollen, animal dander, and other allergens
that cannot be treated with SL therapy.
HELPFUL TIP:
Beta-blockers sho ld be stopped in patients with a his-
tory o anaphylaxis i possible. Beta-blockers ampli y
anaphylaxis and make it more di ic lt to treat.
Objectives: Did you learn to . . .
• Reco nize symptoms o vocal cord dys nction?
• Reco nize symptoms o aller ic rhinitis?
• Provide appropriate mana ement or aller ic rhinitis?
• Describe the role o imm notherapy in treatin aller ic rhinitis?
 CHAPTER 4 • ALLERg Y AND IMMu NOLOg Y 133

TABLE 4-1 CLASSIFICATION OF IMMUNOLOGIC REACTIONS

Reaction Type Mechanism Clinical Features Timing
Type I—Immediate Anti en expos re ca ses cross-linka e o I E antibodies Anaphylaxis Less than an ho r
that are bo nd to s r aces o mast cells and basophils, An ioedema a ter expos re
with s bseq ent release o mediators s ch as histamine. Bronchospasm
u rticaria

Type II—Cytotoxic I g or I M antibodies are directed a ainst anti ens on g ra t rejection At least 5 days b t
the individ al’s own tiss es, and s bseq ent complement Hemolytic anemia sometimes many
activation leads to cell destr ction. Ne tropenia weeks a ter expos re
Thrombocytopenia

Type III—Imm ne complex I g or I M anti en–antibody complexes orm and deposit Localized arth s reaction 1 week or more a ter
within blood vessels and tiss es, ca sin complement Ser m sickness expos re
activation and ne trophil recr itment, ltimately res ltin
in tiss e dama e.

Type IV— Delayed Anti en expos re to sensitized T cells ca ses a reaction. Contact dermatitis 24–72 ho rs a ter
Stevens–Johnson syndrome expos re

The correct answer is “A.” Celery is so boring; it can’t even

QUICK QUIZ: ALLERg IC REACTIONS
A 52-year-old man with common variable immunode ciency
(CVID) receives his rst in usion o intravenous immunoglobu-
lin (IVIG) therapy. en minutes into the in usion, he complains
o dif culty breathing and generalized pruritus.
Based on the traditional classi cation o hypersensitivity
reactions, which o the ollowing best categorizes this patient’s
reaction?
A) ype I—Immediate hypersensitivity reaction.
B) ype II—Cytotoxic reaction.
C) ype III—Immune complex reaction.
D) ype IV—Delayed-type reaction.
The correct answer is “A.” Based on the clinical history and
timing o the above event, you should suspect an immediate
hypersensitivity reaction ( ype I). ype I reactions typically
occur within seconds to minutes a er exposure to the o end-
ing agent and are due to cross-linkage o IgE antibodies that are
bound to sur aces o mast cells or basophils, with subsequent
release o mediators such as histamine. Pruritus, urticaria,
angioedema, laryngeal edema, and possible generalized ana-
phylaxis can occur. o see why ypes II to IV are incorrect, re er
to able 4-1 or de nitions o the immunologic reaction types.
QUICK QUIZ: CAN I HAVE THAT BANANA OR NOT?
cause an allergic reaction in those with latex allergy! Symptoms
o oral allergy syndrome can include oral pruritus with or with-
out angioedema o the lips, tongue, palate, and posterior oro-
pharynx. Cross-reactivity has been reported between:
• Ragweed antigens and the gourd amily and banana.
• Birch pollen allergy may result in sensitivity to apple, carrots,
parsnips, celery, hazelnuts, and potatoes.
• Latex- ruit cross-reactivity may occur with banana, avocado,
passion ruit, kiwi, and chestnut, but not celery. Your patient
should be warned about these potential reactions.
HELPFUL TIP:
The vast majority o patients who report penicillin (and
other) aller ies are not tr ly aller ic. In the case o peni-
cillin, 0.5% o those with reported penicillin aller y had
skin reactions and less than 10% had any reaction to a
ll dose o penicillin. Many patients misinterpret an ad-
verse reaction (s ch as na sea) as an aller y.
HELPFUL TIP:
There is essentially no cross-reactivity between penicil-
lin and third- eneration cephalosporins. As lon as the
patient did not have tr e anaphylaxis, eel com ortable
sin these dr s in penicillin-aller ic patients.

A slightly deranged patient o yours has a serious latex allergy

and wants to play “ ruit roulette.”
QUICK QUIZ: CONTRAST ALLERg Y
You tell her that all o the ollowing may be associated with
cross-reactivity in latex allergic patients EXCEP : A 57-year-old man with chest pain is scheduled or an elective
A) Celery. cardiac catheterization. You remember that the patient has a
B) Banana. history o generalized urticaria with lip and tongue angioedema
C) Avocado. shortly a er receiving contrast dye or a C scan several years
D) Kiwi. back.
134 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Which o the ollowing interventions should be recommended
or this patient prior to undergoing the planned procedure?
A) Use o higher-osmolality radiocontrast media i possible.
B) Give a test dose o radiocontrast media and proceed as usual
i testing is negative.
C) Administration o prednisone and diphenhydramine as pre-
medications.
D) Percutaneous and intradermal skin testing with radiocon-
trast media.
E) Desensitization procedure or radiocontrast media.
The correct answer is “C.” Anaphylactoid reactions to radio-
contrast material are typically non–IgE-mediated; however,
they look very similar to a ype I immunologic reaction and
can be severe and li e threatening. T is patient will require
the premedication or this elective procedure. T e appropri-
ate premedication regimen or contrast dye allergy includes
(1) diphenhydramine 50 mg IM/PO 1 hour be ore the pro-
cedure and (2) prednisone 50 mg PO 13 hours, 7 hours, and
1 hour be ore the procedure. “A” is incorrect. T e use o lower-
osmolality radiocontrast media is associated with ewer adverse
reactions and is appropriate or contrast-allergic patients. “B”
is incorrect. est dosing or radiocontrast media should not
be done; patients with no reaction to test doses have had severe
reactions to ull doses. In addition, test doses themselves have
been reported to result in atalities. Skin testing (“D”) can
be done, especially within a window o a ew months a er the
reaction. In the past, skin testing was not recommended, but its
role is evolving, and may become available in the near uture.
T ere is no desensitization procedure available.
HELPFUL TIP:
There is no cross-reaction between shellfish and
iodine-based contrast material. The aller y to sea-
ood is an aller y to the protein (tropomyosins) in the
sea ood, not the iodine. Think abo t it or a second.
How many people have yo seen droppin dead rom
an anaphylactic reaction to iodized salt?
CASE 4.2
An 18-month-old boy comes to clinic with a history o eczem-
atous rash covering his extremities and ace. His parents state
that it worsens af er the ingestion o certain oods. He has
had increased ussiness over the last several months, as well
as some di culty gaining weight. Food allergy is suspected.
Question 4.2.1 Which o the ollowing oods is NOT com-
monly implicated in ood allergy?
A) Milk.
B) Corn.
C) Wheat.
D) Soy.
E) Egg.
Answer 4.2.1 The correct answer is “B.” Corn is not o en
implicated in ood allergies (a good thing too, since we are writ-
ing this in Iowa, surrounded by corn). Although many oods
are potentially antigenic, the great majority o ood allergies
involve only a ew oods. Studies have shown that eight oods
account or 93% o reactions, and these oods are, in order o
requency: egg, peanuts, milk, soy, tree nuts, sh, crustacean,
and wheat. Although these ood allergies may be outgrown,
sensitivity to peanuts, tree nuts, sh, and crustaceans tend to
be li e-long.
HELPFUL TIP:
The peak incidence o ood aller ies occ rs aro nd
a e 1 year, with most aller ies identi ied by the a e o
2 years. Cow’s milk and e aller ies tend to resolve by
ad lthood. The 2013 ideline rom American Academy
o Aller y, Asthma and Imm nolo y recommended in-
trod ction o hi hly aller enic ood as early as 4 months
o a e, which has shown to red ce ood aller y later.
wo months later, this patient required an emergency room
visit af er developing increased work o breathing, wheezing,
and an urticarial rash af er eating. You re er him or testing.
He is tested by both percutaneous skin testing and RAS and
is ound to have egg allergy.
Question 4.2.2 Which o the ollowing vaccinations should
NOT be given to this patient in light o his egg allergy?
A) MMR vaccine.
B) Inactivated polio vaccine.
C) Haemophilus inf uenzae B vaccine.
D) Conjugated pneumococcal vaccine (Prevnar).
E) raditional in uenza vaccine.
Answer 4.2.2 The correct answer is “E.” raditional in uenza
vaccine should not be given to individuals with egg allergy. O
particular note is “A.” “A” is incorrect. It had been common prac-
tice to withhold measles vaccination rom children with a his-
tory o anaphylactic reaction to egg; the measles vaccine is pre-
pared in chick-embryo broblast cultures. However, the MMR
is sa e to use in children with an egg allergy. Options “B,” “C,”
and “D” do not contain egg-related products and can there ore
be given sa ely to this patient.
HELPFUL TIP:
There are two preparations o e - ree in l enza
vaccine licensed in the u nited States. These are
Fl celvax®and Fl blok®. These are pre erred in e -
aller ic patients.
Objectives: Did you learn to . . .
• Identi y common ood aller ens?
• Reco nize important associations between ood aller y and
selected vaccines?

CASE 4.3
A 34-year-old emale establishes care in your clinic. Her
medical history consists o intermittent colicky, abdominal
pain, and episodes o angioedema in the past with unclear
etiology. She has not noticed urticaria with those episodes.
She has received multiple laparoscopic procedures that were
unrevealing. During the initial interview, she relates several
past episodes o lip and tongue swelling, or which she has
not sought medical assistance. She has tried diphenhydr-
amine without signi cant improvement. T e swelling epi-
sodes resolve without intervention af er 3 to 4 days.
Question 4.3.1 Which o the ollowing laboratory tests
would be most help ul in establishing the diagnosis in this
patient?
A) ANA.
B) C3 complement level.
C) C4 complement level.
D) Complete blood count (CBC).
E) SS-A and SS-B.
Answer 4.3.1 The correct answer is “C.” T is patient’s presen-
tation should raise concern or hereditary angioedema (HAE),
or C1-esterase inhibitor de ciency. T is entity is clinically char-
acterized by recurrent episodes o angioedema involving any
part o the body. T us, it can present with laryngeal angioedema
(the major cause o death) or recurrent abdominal pain (gener-
ally with a normal white count and “always” without peritoneal
signs). Urticaria is not a eature o this disorder. HAE is caused
by a C1-esterase inhibitor de ciency; C1-esterase is a protease
that normally acts on C4. I there is an absence o C1-esterase
inhibitor, C4 levels will be low as C1-esterase will continue to
degradate C4. It is possible that a patient with HAE will have a
normal level o C1-esterase inhibitor but will have a non unc-
tional allele. So always check a C-1 esterase inhibitor level and
C-1 esterase activity as well as a C4 level. I there is a non unc-
tional allele, the C-1 esterase inhibitor level will be normal but
C-1 esterase inhibitor unction will be decreased.
While awaiting the test results, you discuss HAE with your
patient.
Question 4.3.2 In order to minimize uture attacks o angio-
edema, you recommend which o the ollowing?
A) Avoidance o estrogen containing medications.
B) Avoidance o ACE inhibitors.
C) esting and treatment o Helicobacter pylori.
D) All o the above.
Answer 4.3.2 The correct answer is “D.” Education is the cor-
nerstone o treatment o HAE. Patients need to know what
triggers to avoid and how to identi y symptoms early. Most
attacks are precipitated by trauma (o en head and upper air-
way trauma), medical procedures (dental and oral surgery in
particular), emotional stress, in ections, menstruation, or the
CHAPTER 4 • ALLERg Y AND IMMu NOLOg Y 135
use o medications, especially oral contraceptives and ACE
inhibitors. Interestingly, H. pylori in ection has been associated
with HAE, and H. pylori eradication reduces the requency o
angioedema attacks.
Your patient is ultimately diagnosed with HAE.
Question 4.3.3 In this particular patient, which medication
would be most help ul in preventing uture episodes?
A) Emergency epinephrine.
B) Oral diphenhydramine.
C) Fresh rozen plasma (FFP).
D) Androgens (e.g., danazol).
E) No prophylactic treatment is available.
Answer 4.3.3 The correct answer is “D.” Emergency epineph-
rine and antihistamines have not generally been e ective, as
HAE is not allergic in nature. Prophylactic treatment in the
orm o attenuated androgens (danazol) is available. Attenu-
ated androgens appear to work by up-regulating the synthetic
capability o hepatic cells that make C1-esterase inhibitor,
thus decreasing the e ect o C1 esterase and raising the C4
level. T is, in turn, reduces the number and severity o acute
exacerbations.
wo puri ed C1-esterase inhibitor replacement protein
products (Cinryze® and Berinert®) were approved by the FDA
in 2010 or the treatment and prevention o HAE exacerba-
tions. However, they are costly and lack strong ef cacy data.
reatment o acute episodes o HAE includes FFP that contains
C1-esterase inhibitor, the C1-esterase inhibitor replacement
protein products, and bradykinin/kallikrein inhibitors (ecal-
lantide and icatibant). In addition, these three options could be
used as prophylactic treatment in short-term situations, such as
prior to surgery in a high-risk patient. However, FFP would not
be a long-term preventive measure, so “C” is incorrect.
HELPFUL TIP:
Make s re patients with HAE receive the hepatitis B vac-
cination series as they may req ire blood prod cts or
ac te treatment o an ioedema.
Objectives: Did you learn to . . .
• Identi y a patient presentin with hereditary an ioedema?
• Mana e a patient with hereditary an ioedema?
CASE 4.4
Your patient’s sister (her biologic sister, not her step-sister or
BFF) presents to clinic the next day with a similar history o
angioedema symptoms, only less requent and less severe.
Question 4.4.1 What is the likelihood that she has HAE as
well?
A) In nitesimally small because HAE is a rare disorder.
B) About 25% because HAE is autosomal recessive.
136 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
C) About 50% because HAE is autosomal dominant.
D) Almost 100% because you can tell that she’s got bad luck.
E) Unknown because multiple gene involvement renders a
simple calculation impossible.
Answer 4.4.1 The correct answer is “C.” HAE is transmit-
ted in an autosomal dominant ashion with incomplete pen-
etrance, which may be why the patient’s sister is less symp-
tomatic. New mutations do arise and cause a minority o
cases.
Later that same night, you are called to the ED to see a
patient with acial swelling. “Really?” you ask. “Yeah,
really. Get in here,” replies Happy Nurse. T is patient is a
35-year-old emale riend o your patient with HAE (so,
her BFF not her biologic sister). She is worried that she too
has HAE. T is is the rst ever episode o lip and ace swell-
ing, associated with itching in her mouth and a ew hives
on her arm and torso. She had shrimp gumbo or dinner,
but has never had a reaction to shrimp be ore. She denies
any recent trauma, surgery, or medication use. She is in no
respiratory distress. Her O2 sat is 99% on room air and BP
is 118/76 mm Hg. On lung examination, there is no stridor
or wheezing.
Question 4.4.2 The most appropriate next step in the treat-
ment o this patient is:
A) Supportive care and monitoring overnight in the intensive
care unit (ICU).
B) Administration o FFP.
C) Administration o epinephrine IM × 1.
D) Administration o diphenhydramine, cimetidine, and pred-
nisone PO.
E) Prophylactic intubation.
Answer 4.4.2 The correct answer is “D.” T is patient is di -
erent rom your HAE patient. It is unlikely that she has HAE
or several reasons: she’s never had this reaction be ore, she
has urticaria associated with the angioedema, and she did not
experience an inciting event. T is episode o angioedema and
urticaria is more likely to have been caused by a typical aller-
gic reaction and mast-cell release. For these types o reactions,
antihistamines and steroids are the mainstay o therapy. How-
ever, the ef cacy o steroids, antihistamines, and epinephrine is
limited in angioedema (but it is worth a try). “A” is incorrect
because it is overkill to admit her to the ICU, and you should
be treating her rather than just monitoring her. “B” is incorrect
because FFP treats HAE not allergic angioedema. “C” is incor-
rect because this patient is not having a ull anaphylactic reac-
tion. Epinephrine would be appropriate i she had wheezing,
airway compromise, or hypotension. I you chose “E” or a walk-
ing, talking patient with no airway compromise, well . . . that just
makes us sad.
Objectives: Did you learn to . . .
• Di erentiate HAE rom aller ic an ioedema?
• Mana e an anaphylactoid reaction?
Warning: T e next section is about immunode ciency syn-
dromes. As Dante would say: “Abandon hope all ye who enter
here.” (One o the editors has a dog named Dante and she [the
dog] says this all the time . . . to squirrels). See able 4-2 or a
quick review.
T e main points and the most important cases are men-
tioned below. For those o you who are gluttons or punishment
(gluttony is only Dante’s 3rd circle), look at the table.
T e main points:
• Rule out the obvious: Does the patient have HIV, cancer, dia-
betes, lupus, or other chronic disease or is he/she on immu-
nosuppressing drugs that predispose to recurrent in ections?
• 1% to 3% o patients are heterozygous or an IgG subtype
de ciency, the most common type o immunoglobulin de -
ciency. T ese patients may be asymptomatic or may present
with recurrent sinusitis, otitis, skin in ections, etc. IgG de -
ciency can be diagnosed by immunoglobulin electrophore-
sis. T ese patients o en do not have an appropriate response
to vaccinations.
• 1 in 700 patients are IgA de cient. Most are hereditary, but
it can also be caused by several drugs (including captopril
and thyroxine). Usually this resolves upon stopping the
drug. Most patients with IgA de ciency are asymptomatic,
although some have recurrent sinus and GI in ections. Also,
these patients requently develop autoimmune disease and
may have anaphylaxis to blood products.
• Symptomatic immunoglobulin de ciencies can be treated
with IVIG. T e most common side e ects o IVIG admin-
istration include renal ailure, anaphylaxis, and thromboem-
bolic disease.
CASE 4.5
A 35-year-old male is seen by you in the hospital setting, af er
being admitted or pneumonia. Blood cultures reveal Strep-
tococcus pneumoniae. T e patient was well until age 25 when
he began having recurrent in ections and developed an auto-
immune hemolytic anemia. He also relates requent sinus
in ections (real ones . . . not the kind we so of en see) requir-
ing antibiotics 8 to 10 times a year. His last bout o pneumo-
nia required a stay in the ICU.
Question 4.5.1 You suspect an immunodef ciency in this
individual. What is the most use ul test in making the diag-
nosis in this patient?
A) Complement levels.
B) Immunoglobulin levels.
C) CBC and di erential.
D) Bone marrow biopsy.
E) Nitroblue tetrazolium test.
Answer 4.5.1 The correct answer is “B.” T e clinical picture or
this patient is most consistent with common variable immune
de ciency (CVID). CVID, or acquired agammaglobulinemia,
is similar to X-linked agammaglobulinemia, but generally has
a later age o onset. In addition, it is associated with various
 CHAPTER 4 • ALLERg Y AND IMMu NOLOg Y 137

TABLE 4-2 IMMUNODEFICIENCY SYNDROMES

De ect/Laboratory Organisms Likely to
Syndrome Age o Onset Findings Mani estations Cause In ection
Humora l
X-linked Late rst year o li e b t Low I g , almost M ltiple, rec rrent in ections Streptococcus,
a amma lob linemia p to a e 50 (in very mild ndetectable I M, ( enerally start at 6–18 months) Haemophilus, Giardia
disease) I D, I E, and I A. No especially l n , sin ses, ears,
B cells CSF. Event ally bronchiectasis
and p lmonary ins ciency

Common variable Variable b t >2 years o Low levels o ser m Sin s and respiratory in ections. Pneumococcus,
imm node ciency a e and mostly by a e 30. imm no lob lins g I in ections especially Giardia. Haemophilus,
May be older Enhanced chance o lymphoma Mycoplasma, Giardia
as ad lt. A toimm ne disorders

Hyper I M syndrome First 2 years o li e Elevated I M, no I g , Rec rrent severe sinop lmonary Encapsulated bacteria,
I A, I E (altho h ew in ections. A toimm ne Giardia, Pneumocystis,
may have very low disorders Cryptosporidium,
level I A, I E) Histoplasmosis

I A de ciency Not be ore a e o 6 Low I A levels, normal Most asymptomatic. May have Haemophilus,
months; more severe imm no lob lins respiratory tract in ections. Pneumococcus
disease presents by a e 5. otherwise Watch or anaphylaxis with
blood prod cts

Cellular
Myeloperoxidase Variable Poor pha ocytic None except in the presence o Candida
de ciency killin other de ects (e. ., diabetes),
systemic candidiasis

Chronic In ant, toddler b t Ne trophil Rec rrent li e-threatenin Staphylococcus,

ran lomato s occasionally in late li e dys nction meas red illnesses especially p lmonary, Aspergillus
disease by nitrobl e hepatic, skin, and lymphatic
tetrazoli m testin abscesses
(and other tests)

Le kocyte adhesion Early (poor separation o Poor adhesion Periodontal and dental Pseudomonas and other
de ciency mbilical st mp) or later o le kocytes to in ections, rec rrent in ections g ram-ne ative rods,
i mild disease. Those with endotheli m, etc. o skin, pper and lower airways, Staphylococcus
mild disease rarely have bowel, perirectal area
li e-threatenin illnesses

Hyper I E (Job First weeks to month Elevated I E levels, Facial abnormalities M ltiple or anisms, b t
syndrome) o li e poor le kocyte (hypertelorism; prominent, especially Staphylococcus,
chemotaxis protr din trian lar mandible; Haemophilus, Candida
broad, somewhat b lbo s
nose). Eczema, m coc taneo s
candidiasis, sin s, p lmonary,
and skin in ections.
Rec rrent “cold abscesses”
in skin secondary to lack o
inf ammation

Wiskott–Aldrich Early. Fatal by a e 10 Low I M, dimin tion Eczema, thrombocytopenia with Encaps lated or anisms
witho t bone marrow o cell lar imm nity p rp ra, rec rrent in ections
transplant ability to respond
to polysaccharide
caps les

Severe combined Early, by 6 months. Death Le kopenia, no mat re Colon and l n in ections M ltiple or anisms,
imm node ciency by 2 years T cells, low ser m incl din diarrhea, abscesses incl din viral
syndrome imm no lob lin levels

(continued)
138 FAMILY MEDICINE EXAMINATION & BOARD REVIEW

TABLE 4-2 IMMUNODEFICIENCY SYNDROMES (Continued)

De ect/Laboratory Organisms Likely to
Syndrome Age o Onset Findings Mani estations Cause In ection
Dig eor e syndrome Early—in in ancy Absent thym s, Rec rrent in ections b t Pneumococcus,
Red ced T3 + cells variable in penetrance. Some Haemophilus
have normal or near-normal
imm ne nction. Cranio acial
abnormalities, con enital
heart disease, chromosomal
abnormalities, hypocalcemia

gastrointestinal disorders, autoimmune disorders, and malig-

nancy. Immunoglobulin levels are decreased secondary to
inadequate B-cell di erentiation. T ere ore, the most use-
ul laboratory test or the diagnosis o CVID would be serum
immunoglobulin levels. With regard to the other options and
other tests you might do to evaluate otherwise unexplained
immunode ciency:
• Immunode ciency can be secondary to complement disor-
ders and complement levels will be low in these patients.
• Nitroblue tetrazolium test will be abnormal in patients with
phagocytic disorders.
• Response to vaccines will be muted or absent in humoral im-
munode ciency (e.g., immunoglobulin de ciency).
• Delayed hypersensitivity skin testing (e.g., candida and
mumps) may indicate a -cell de ect.
Question 4.5.2 Which o the ollowing is the most appropri-
ate treatment plan or this patient?
A) Prophylactic antibiotics.
B) Bone marrow transplantation.
C) Gene therapy.
D) IVIG replacement.
E) No treatment needed.
Answer 4.5.2 The correct answer is “D.” T e treatment o
choice or CVID includes replacement IVIG, especially in this
patient who has a history o li e-threatening in ections. Prophy-
lactic antibiotics may be required in addition to IVIG in some
patients. Gene therapy is not currently possible because the
genetic de ect has not been identi ed. Although bone marrow
transplantation is use ul in other immunode ciency states, it is
not indicated in CVID.
HELPFUL TIP:
Patients with CVID may develop lymphoproli erative
disorders (e. ., non-Hod kin lymphoma). New adenop-
athy sho ld be taken serio sly.
Objectives: Did you learn to . . .
• Describe presentin symptoms o common variable imm -
node ciency?
• Reco nize treatment options or CVID?
QUICK QUIZ: I A DEFICIENCY
A 37-year-old emale is incidentally ound to have an IgA level
o 3 mg/dL (below the normal range).
What is the most likely clinical picture in this patient?
A) Pyogenic in ections.
B) T rush.
C) Cold abscesses.
D) Aphthous ulcers.
E) No clinical abnormalities.
The correct answer is “E.” IgA de ciency is present in approxi-
mately 1 in 700 Caucasians in the United States and is the sec-
ond most common immunode ciency described. Most o these
patients are asymptomatic, but some IgA-de cient patients may
present with an increased rate o respiratory tract in ections.
HELPFUL TIP:
The eval ation o imm node iciency sho ld NOT stop
when I A de iciency is discovered since I A de iciency
is o ten asymptomatic and may be accompanied by a
more serio s orm o imm node iciency.
QUICK QUIZ: IVIg
Which o the ollowing patients is most likely to develop an ana-
phylactic reaction in response to the administration o IVIG?
A) A patient with IgA de ciency.
B) A patient with IgG de ciency.
C) A patient with sickle cell anemia.
D) A patient with gra -versus-host disease.
E) A pregnant patient.
The correct answer is “A.” Patients with IgA de ciency have
pre- ormed IgG or IgE antibodies against IgA, and thus may
develop an anaphylactic reaction in response to IVIG (and
blood and FFP, or that matter). Patients with IgG de ciency
may have a similar problem but it is much less common. Not all
patients with IgA de ciency will develop anaphylaxis, but the
risk is high enough to be prepared and to reduce the risk by
using IgA-depleted IVIG and giving the IVIG slowly.
 CHAPTER 4 • ALLERg Y AND IMMu NOLOg Y 139

BIBLIOGRAPHY
Clinical Pearls Azar AE. Evaluation o the adult with suspected immunode -
An extensive eval ation or an nderlyin ca se o chronic ciency. Am J Med. 2007;120(9):764.
rticaria is very low yield and sho ld not be done. Tar et the Bowen , et al. 2010 International consensus algorithm or the
eval ation to the patient. diagnosis, therapy and management o hereditary angio-
Beta-blockers sho ld be sed with ca tion in a patient who edema. Allergy Asthma Clin Immunol. 2010;6(1):24.
has had a severe anaphylactic reaction (e. ., req irin epi- Calderon MA, et al. Allergen injection immunotherapy or sea-
nephrine). Beta-blockers increase the incidence and severity sonal allergic rhinitis. Cochrane Database Syst Rev. 2007,
o anaphylaxis and bl nt the response to therape tic doses Issue 1. Art. No.: CD001936.
o epinephrine. Cooper MA. Primary immunode ciencies. Am Fam Physician.
Do not se nontar eted I E testin in the eval ation o 2003;68(10):2001–2008.
asthma. Do testin or speci ic anti ens as indicated based Fleischer DM, et al. Primary prevention o allergic disease
on the patient’s history. through nutritional interventions. J Allergy Clin Immunol
I A imm node iciency is o ten asymptomatic and sho ld
In Pract. 2013;1(1):29–36.
not be considered the ca se o imm node iciency nless no Quillen DM. Diagnosing rhinitis: Allergic versus non-allergic.
other ca se is o nd. Am Fam Physician. 2006;73(9):1583–1590.
Intranasal steroids are irst line or aller ic rhinitis and will
Scurlock AM. Food allergy in children. Immunol Allergy Clin
also improve aller ic eye symptoms (when iven intrana-
North Am. 2005;25(2):369–388, vii–viii.
sally).
It is enerally sa e to se third- eneration cephalosporins in
a patient with penicillin aller y—as lon as the reaction was
not anaphylaxis.
RAST testin or aller y has a 25% alse-ne ative rate. Skin
testin remains the old standard.
The reat majority o patients who are reportedly “aller ic” to
penicillin do not have a tr e penicillin aller y.
There is no cross-reactivity between shell ish and iodinated
radiocontrast.
Vocal cord dys nction is an asthma mimic. Patients s ally
have inspiratory stridor.
Nephrology
Stac A n im and Jas n K. Wi bu
5
CASE 5.1 HELPFUL TIP:
N t n t min . T t m “mic a buminu ia” as
A 49-year-old, emale with a 5-year history o diabetes melli-
b n ac d wit “m d at inc as d a bumin-
tus type 2, presents or an initial visit. She has no known com-
u ia,” but t d initi n mains t sam (30–300 m
plications o diabetes. She takes met ormin, glyburide, and
t in in t u in 24 u s). C m a t is t “s -
aspirin. On examination, you nd a pleasant, obese emale
v inc as d a buminu ia,” d in d as at t an
in no distress. Her blood pressure is 136/86 mm Hg. As you
300 m t in in t u in 24 u s.
discuss monitoring her diabetes, you recommend screening
or early kidney disease.

Question 5.1.1 Which o the ollowing ap p roaches is
the recommended way to screen or diab etic kidney
disease?
A) Obtain a 24-hour urine collection or albumin now and
again in 3 years.
B) Obtain a spot urine albumin every year.
C) Obtain a spot urine albumin/creatinine ratio every year.
D) Obtain a urinalysis every year.
E) Obtain a serum creatinine every year.
Answer 5.1.1 The correct answer is “C.” Moderately increased
albuminuria (previously known by the misnomer “microalbu-
minuria”) is a marker or increased risk o uture kidney dis-
ease in diabetic patients. T e best test to evaluate or moderately
increased albuminuria is the urine albumin/creatinine ratio.
Its advantages include ease o use, relatively low cost, and good
correlation with 24-hour urine collections. Some o you may
have chosen “B.” A “spot microalbumin” (now a spot albumin)
is a common but less accurate way to provide screening and may
still be in use in some areas. As a practical matter, many physi-
cians use urine albumin alone as a method o screening, but this
method does not allow or corrections or variations in urine
volume and dilution. A random spot urine albumin/creatinine
ratio is normally less than 30 mg/g. Values above 30 mg/g are
consistent with 24-hour measures showing abnormal amounts
o albumin. Answers “D” and “E” o er measures o kidney unc-
tion that simply are not sensitive enough to use or screening
purposes.
Question 5.1.2 Her albumin/creatinine ratio is 42 mg/g. The
next step to con rm moderately increased albuminuria is:
A) Repeat urine albumin/creatinine ratio.
B) Urine dipstick or protein.
C) 24-hour urine collection or total protein excretion.
D) Serum creatinine.
E) Re erral to a nephrologist.
Answer 5.1.2 The correct answer is “A.” Veri cation by repeat
urine albumin/creatinine ratio is su cient or a diagnosis o
moderately increased albuminuria, so 24-hour urine collections
need not be per ormed or con rmation. O note, the diagnosis
o moderately increased albuminuria requires 2 o 3 urine speci-
mens showing > 30 mg/g albumin/creatinine over a 6-month
period. Since protein excretion must exceed 300 to 500 mg/
day or a urine dipstick to detect proteinuria, urinalysis (“B”) is
not sensitive enough to be diagnostic. Serum creatinine eleva-
tion may be a marker or diabetic kidney disease, but it would
develop late in the process. Nephrology re erral is premature—
you went to medical school; you can do this!
Question 5.1.3 Which o the ollowing can cause a alse -
negative albumin/creatinine ratio?
A) Vigorous exercise.
B) Fever.
C) Cachexia.
D) Poor glycemic control.
E) Large muscle mass.

140

Answer 5.1.3 The correct answer is “E.” Patients with a large
muscle mass have a high rate o creatinine excretion, which
may result in a alsely negative albumin/creatinine ratio (as
the urine creatinine goes up, the ratio obviously goes down).
Cachectic patients have the opposite problem, with low
amounts o creatinine excretion, resulting in alse-positive
albumin/creatinine ratio. Fever, vigorous exercise, heart ail-
ure, and poor glycemic control can cause transient increases
in albuminuria, potentially resulting in alse-positive albumin/
creatinine ratios.
Your patient’s other laboratory studies reveal the ollow-
ing: hemoglobin A1c 6.4%, serum creatinine 1.4 mg/dL, and
normal electrolytes. A month later, your patient returns.
Her blood pressure is 138/84 mm Hg. Her urine albumin/
creatinine remains elevated on a second measurement.
According to an eye examination yesterday, she has nonpro-
li erative diabetic retinopathy.
Question 5.1.4 Because your patient has type 2 diabetes
mellitus and moderately increased albuminuria, you real-
ize that her likelihood o progressing to overt nephropathy
is:
A) Almost zero.
B) About hal that o a similar patient with type 1 diabetes.
C) Nearly equal to that o a similar patient with type 1 diabetes.
D) More than twice that o a similar patient with type 1 diabetes.
E) Absolutely certain (100% chance).
Answer 5.1.4 The correct answer is “C.” Although earlier stud-
ies showed a greater progression to overt nephropathy in type
1 diabetics, more recent studies demonstrate a nearly equal rate
o progression in types 1 and 2. About 20% to 40% o Caucasian
patients with diabetes type 2 and moderately increased albu-
minuria will progress to diabetic nephropathy. T e rate o pro-
gression to nephropathy in non-Caucasian populations is even
higher.
Question 5.1.5 What is the most appropriate next step in
the evaluation and management o this patient’s moder-
ately increased albuminuria?
A) Start an angiotensin-converting enzyme (ACE) inhibitor.
B) Start an angiotensin receptor blocker (ARB).
C) Order renal ultrasound with Doppler o the renal arteries.
D) Start insulin.
E) Order a 24-hour urine collection or total protein.
Answer 5.1.5 The correct answer is “A.” ACE inhibitors should
be the rst-choice drugs unless there is a contraindication to
their use. “B,” an ARB, should be second-line choice in the event
that the patient cannot tolerate an ACE inhibitor. “C,” a renal
ultrasound, is not indicated at this point in time. “D” is also
incorrect. Your patient already has good glucose control (HbA1c
o 6.4%). As previously stated, a 24-hour urine collection is not
necessary or diagnosis.
CHAPTER 5 • Neph r o l o g y 141
HELPFUL (AND VERY IMPORTANT) TIP:
Ar Bs a n t just an ACe in ibit wit ut t c u .
A a m ta-ana sis s w d t at Ar Bs, w i w -
in b d ssu , av n a ciab ct n MI
ca di vascu a m ta it versus pla cebo (BMJ. 2011;342:
d2234; JAMA Int n M d. 2014;174:773). But t at’s a t
dis as in diab tics (w ic is kind im tant). Back t
na dis as . . . T n stud (t dat ) t di ct c m-
a an ACe in ibit ( na a i ) t an Ar B (t misa tan)
na t cti n in diab t s did n t d m nst at
a statistica si ni icant di nc b tw n t tw ,
at u t was a t nd in av t ACe in ibit
(N en J M d. 2004;351(19):1952). h w v , t is was a
sma stud (250 individua s) wit a i d ut at .
An t stud 4,000 subj cts s w d t at w i Ar Bs
d duc t inu ia, t av n b n it n m ta -
it (N en J M d. 2011;364:907), w ic is w at w a
ca ab ut.
T e patient has a ull urinalysis to rule out renal in amma-
tion (e.g., nephritis) and overt proteinuria (nephrotic syn-
drome). T e urinalysis is entirely negative.
Question 5.1.6 What urther investigations must your
patient undergo to eliminate other potential causes o
proteinuria?
A) Renal biopsy.
B) Renal ultrasound with Doppler o the renal arteries.
C) ANA, ESR, CRP.
D) All o the above.
E) None o the above.
Answer 5.1.6 The correct answer is “E.” No urther evaluation
is necessary in this patient with moderately increased albumin-
uria. T e combination o diabetic retinopathy (a marker or
diabetic renal disease), hypertension (BP > 140/90 mm Hg in
a diabetic patient), and abnormal protein in the urine as mea-
sured by the urine albumin/creatinine ratio is su cient to make
the diagnosis o early diabetic nephropathy. Renal biopsy is
quite invasive and unlikely to change management. ANA, ESR,
CRP, and ultrasound are unlikely to o er new in ormation. I
things change (e.g., nephritic urine and gross proteinuria), ur-
ther evaluation may be indicated.
You continue to ollow this patient or several years. She ulti-
mately is admitted or chest pain, rules out or myocardial
in arction, but has a positive stress test. She will need to have
a cardiac catheterization. Her creatinine is now 1.5 mg/dL,
and her glomerular ltration rate is in the range o stage 3
chronic kidney disease.
Question 5.1.7 In addition to holding her met ormin,
which o the ollowing interventions would be most
142 FAMIl y MeDICINe eXAMINATIo N & Bo Ar D r eVIeW

likely to reduce her risk o developing contrast-induced

HELPFUL (AND VERY IMPORTANT) TIP:
nephropathy?
T us Mr I c nt ast ( ad inium) in ati nts wit -
A) N-acetylcysteine and IV saline.
na dis as as b n ass ciat d wit a sc d ma- ik
B) N-acetylcysteine and mannitol.
s nd m (n nic s st mic ib sis). g ad inium
C) IV saline.
s u d b av id d in t s wit a C C < 30 ml /min.
D) Sodium bicarbonate and mannitol.
T data a ss c m in in t s wit a C C 30
E) Mannitol and IV saline.
t 60 ml /min. Sinc n nic s st mic ib sis can
a ct m t an just t kidn s, a dia sis ma
Answer 5.1.7 The correct answer is “C.” For patients at risk
v nt t is dis as b ducin t a -i t
o contrast-induced nephropathy, contrast studies should be
ad inium.
avoided i possible (see help ul tip below). I a contrast study
Fu t , it as c nt b n disc v d t at at-
must be done, stop aggravating medications like nonsteroidal
d us Mr I c nt ast ma main in t CNS and m
anti-in ammatory drugs (NSAIDs-–this patient shouldn’t be
d sits. W at a ct t is as n c niti n, tc. is un-
on these anyway since she has CKD!). Hydration, usually with
kn wn, but is b in inv sti at d b t FDA. FDA M d-
IV saline, should be given i there are no contraindications (e.g.,
Watc su sts imitin t us Mr I c nt ast ( tt ://
heart ailure). Nonionic lower osmolality (or even iso-osmolar)
www. da. v/Sa t /M dWatc /Sa t In mati n/
contrast agents should be used, and we recommend discussing
Sa t A ts h umanM dica p ducts/ucm456012.
these cases individually with your radiologist, cardiologist or
tm).
whomever is per orming the procedure.
Sodium bicarbonate and N-acetylcysteine do not have good
evidence or e ectiveness, but they also do not appear to do
harm. Sodium bicarbonate (isotonic sodium bicarbonate solu- Upon cardiac catheterization, she is ound to have several
tion at 3 mL/kg or 1 hour be ore the procedure and continue lesions. She undergoes coronary artery bypass gra ing and is
at 1 mL/kg or 6 hours af er the procedure) can be used as cur- discharged. Her creatinine remains stable at 1.5 mg/dL.
rent evidence indicates that it has similar e cacy to IV saline. A ew months later, she presents with gradually increasing
N-acetylcysteine needs to be started the day be ore the proce- dyspnea and cough. Her urine output is reported to be normal.
dure and the evidence is con icting. T e diuretics (mannitol, Her vitals show temperature 37°C, pulse 76 bpm, respiratory
urosemide, etc.) may be associated with an increased risk o rate 24, and blood pressure 92/46 mm Hg. You note crackles
nephropathy, and mannitol in particular has an undesirable at both lung bases. Her heart rhythm is regular and an S4 is
side e ect pro le. audible. She has JVD o 9 cm and 2+ pitting pretibial edema.
T e ECG shows sinus tachycardia but no evidence o
potassium toxicity (peaked -waves). Laboratory results:
HELPFUL TIP: troponin- and CK normal, BUN 70 mg/dL, Cr 2.0 mg/dL
T d t ac in ab ut na t xicit and i dinat d c n- (her baseline was 1.5 mg/dL), Na 128 mEq/L, K 5.5 mEq/L
t ast as c nt b n ca d int qu sti n (r adi . (re erence range 3.5–5.0), HCO3 19 mEq/L, WBC 14,500 per
2014;273(3):714–725; r adi . 2014;271(1):65–73). mm3, remainder o the CBC is normal. Urinalysis shows pro-
T s w d n a tic s av b n am c an s. D tein and glucose and a speci c gravity > 1.030, but there are
n t sta t usin c nt ast wit wi d aband n in na dis- ew cells and no casts. Cultures and a chest x-ray are pending.
as . h w v , i it is a n d d, it s ms t at t isk
na inju is w. o n cav at; w ati nts in t s Question 5.1.8 You suspect that her elevated creatinine is
studi s ad a c atinin > 3 m /dl . primarily due to which o the ollowing processes?
A) Adverse toxic e ects o drugs on the kidney.
B) Heart ailure or other prerenal cause o renal ailure such as
HELPFUL TIP: dehydration.
h m i t ati n and m dia sis av b n studi d C) Sudden progression o diabetic nephropathy.
in t v nti n c nt ast-induc d n at D) Urinary obstruction.
ati nts at isk. T d sn ta a t b a b n- E) Urinary tract in ection.
it v m c ns vativ a ac s. A s , t is
a m v t dia z ati nts w a a ad n dia sis Answer 5.1.8 The correct answer is “B.” Your patient has clini-
wit in 24 u s a c nt ast stud . T is n d cal evidence o heart ailure (HF), including edema and rales.
data, w v , and studi s s w t ntia a m. T i With a BUN/Cr ratio greater than 20 and an elevated urine-
kidn s a a ad s t . . . t a n dia sis. W at speci c gravity, she appears to have a prerenal azotemia, likely
additi na a m can u d t t i kidn s? (T is secondary to insu cient cardiac output. Drugs (“A”) may play
s m a um nt ati nts w c ntinu t duc a role in her dehydration, but the BUN/Cr ratio o > 20 argues
u in d s it avin nd-sta na dis as and b in against a renal cause o her elevated creatinine. T ere ore, the
n m dia sis). most likely culprit is HF. Diabetes should not cause a sudden
worsening o renal disease. Although it has not been eliminated
 CHAPTER 5 • Neph r o l o g y 143

as a cause, urinary obstruction (“D”) is not likely since she has

HELPFUL TIP:
good urine output. Answer “E” is incorrect since the urinalysis
In a ati nt wit ka mia and eCg c an s ( a
does not support diagnosis o in ection, and CHF explains the
tassium 7.5 m /dl ), it w u d b tim a u c ut
overall clinical picture much better.
ss: ca cium, insu in, uc s , s dium st n su -
nat (Ka xa at ), n bu iz d a but , tc. N t t
HELPFUL TIP: abs nc bica b nat . It ik d sn’t w k and its us
r m mb t at a BUN/C ati > 20 n a (but n t as a n ut av . Fina , d n’t us Ka xa at wit
a wa s!) indicat s a na caus az t mia. T s s bit and b ca u usin v n ain Ka xa at in
caus s inc ud d d ati n and na usi n individua s wit g I d s uncti n. Ka xa at as b n as-
(s ck suc as s sis, h F, and t nsi n). A BUN/ s ciat d wit , and is ik t caus ,b w a-
C ati < 20 is su stiv int insic na dis as ti n (J Am S c N . 2010;21:733).
u ina ut t bst ucti n. T s b ad n a izati ns
a t adu ts n —us c inica jud m nt. Question 5.1.11 Because her creatinine clearance is low
(and she is in HF) you should also discontinue:
A) Insulin.
Question 5.1.9 Given her diabetes and renal disease, which B) Metoprolol.
o the ollowing is the most likely cause o her hyperkale - C) Met ormin.
mia? D) Aspirin.
A) Renal tubular acidosis (R A) type 1. E) Simvastatin.
B) R A type 2.
C) R A type 3. Answer 5.1.11 The correct answer is “C.” Your patient’s cre-
D) R A type 4. atinine increased rom 1.5 to 2.0 mg/dL, corresponding to a
E) R A type 5. 33% reduction in creatinine clearance—a rough measurement
o glomerular ltration rate (GFR). When creatinine clearance
Answer 5.1.9 The correct answer is “D.” R A type 4 is due to decreases, patients on met ormin are at higher risk o devel-
aldosterone de ciency or resistance to the activity o aldoste- oping the rare adverse e ect o lactic acidosis. T ere is some
rone. T e most common cause o R A type 4 is hyporeninemic evidence that patients with mild HF or slight elevations in creat-
hypoaldosteronism, which is of en seen in diabetic nephropa- inine can sa ely take the drug, but stopping met ormin in renal
thy. T e disorder is recognized by hyperkalemia and mild aci- ailure continues to be the standard o care.
dosis. R A types 1 and 2 usually are hypokalemic and these
orms o R A are not associated with diabetes. R A type 3 is HELPFUL TIP:
a rare autosomal-recessive disorder. R A type 5 does not exist. M t min is t n disc ntinu d in diab tic ati nts
wit mi d-t -m d at na dis as . As t manu-
Question 5.1.10 In an ef ort to reduce her serum potassium actu , m t min is c nt aindicat d in m n wit s -
level (not temporize), you should do which o the ollowing? um c atinin ≥ 1.5 m /dl and in w m n wit s um
A) emporarily hold her urosemide and ACE inhibitor. c atinin t ≥ 1.4 m /dl . T is is du t t isk actic
B) Increase her urosemide and temporarily hold her ACE inhi- acid sis. h w v , t isk actic acid sis is xt m
bitor. sma and d s n t v n s m t b at d di ct
C) Administer IV calcium gluconate. t t d na d s uncti n. Unit d Kin d m
D) Bolus IV normal saline 1 to 2 L. uid in s (2008) and Am ican Diab t s Ass ciati n
E) Give albuterol by nebulizer. uid in s (2011) c mm nd c ntinuin m t min in
ati nts wit mi d-t -m d at c nic kidn dis as
Answer 5.1.10 The correct answer is “B.” Ah, test-taking— and m nit in na uncti n v 3 t 6 m nt s.
clearly not real li e! T e best answer here is to increase renal
clearance o potassium with urosemide while holding the ACEI.
Because ACE inhibitors can increase serum potassium, you HELPFUL TIP:
should stop hers. “But what about her heart ailure?” you ask. A u stimat t c atinin c a anc can b
Well, good question. Given that her potassium is only slightly ca cu at d usin t C ckc t–g au t mu a:
elevated, the ACEI could be continued while monitoring her estimat d c atinin c a anc = (140 −
serum potassium. “A” is incorrect; stopping the urosemide may a [ a ])(b d w i t [k ])/(72 × (s um
lead to worsening HF symptoms and worsening hyperkalemia. c atinin [m /dl ]))
In hyperkalemia, calcium gluconate (“C”) is used to protect F w m n, mu ti t is i u b 0.85. o n cav at is
cardiac conduction, but it is not e ective or reducing potas- t at t is mu a ma n t ct a na inju b -
sium concentrations. A bolus o normal saline (“D”) is contra- caus c m nsat t t mainin
indicated in a patient with an acute HF exacerbation. Albuterol m u i. Normal a t adu t is 94 t 140 ml /min
(“E”) is a temporizing measure, reducing serum potassium by m n and 72 t 110 ml /min w m n.
orcing potassium into the intracellular space.
144 FAMIl y MeDICINe eXAMINATIo N & Bo Ar D r eVIeW

A) Add isosorbide dinitrate.

HELPFUL TIP:
B) Add a nondihydropyridine calcium channel blocker (e.g.,
T is n ct quati n ca cu atin t g Fr .
diltiazem, verapamil).
T abb viat d m di i d di t in na dis as (MDr D)
C) Add a dihydropyridine calcium channel blocker (e.g., amlo-
ca cu ati n is inc asin us d b caus it s ms t b
dipine, ni edipine).
an accu at s ntati n kidn uncti n in adu ts
D) Restrict protein in the diet.
wit na dis as . Un ik t C ckc t–g au t quati n,
E) Aim or a higher A1C target, around 8%.
t MDr D mak s an adjustm nt A ican-Am ican
ac but d s n t tak w i t int acc unt. B t qua-
Answer 5.1.13 The correct answer is “B.” Nondihydropyridine
ti ns adjust nd . A t u t quati n is a itt
calcium channel blockers reduce protein excretion in diabetic
c m icat d, man abs n w ca cu at t MDr D g Fr .
patients with nephropathy and slow down the progression o
I u want t ca cu at it u s , us t Nati na
renal disease—but not to the degree o ACE inhibitors. “A,” a
Kidn F undati n w bsit at tt ://www.kidn . /
long-acting nitrate, would be e ective or angina and will lower
ssi na s/KDo QI/ _ca cu at .
blood pressure but does not demonstrate an e ect on diabetic
F m t aut s’ s ctiv , an t s a o K.
nephropathy. T e dihydropyridine calcium channel blockers
W d n’t n d 2 ml /min accu ac in t C C . Just mak
(“C”) do not slow down progression to nephropathy to the same
su u us n t m.
degree as some other antihypertensive drugs. T e e ect o pro-
tein restriction (“D”) on nephropathy is controversial and not
clearly bene cial; there ore, more e ective therapies should be
You administer intravenous urosemide. T e night a er initiated rst. Finally, “E” is incorrect since better glycemic con-
admission she starts vomiting, and your partner inserts a trol is associated with renal protection.
nasogastric tube, which is inadvertently le to continuous
suction overnight (don’t do this . . . there is almost no indica-
tion or an NG tube—especially on continuous suction). T e HELPFUL TIP:
next morning, your patient’s laboratory results are as ollows: F diab tic n at , a wa s sta t wit an ACe
BUN 49 mg/dL, Cr 2.0 mg/dL, Na 132 mEq/L, K 3.5 mEq/L, in ibit and t t maximiz t d s . Fu d s ACe
and HCO3 35 mEq/L (normal 23–29 mEq/L). in ibit t atm nt is ass ciat d wit im v d su -
viva in diab tic n at c m a d wit w-d s
Question 5.1.12 On the basis o history and laboratory data ACe in ibit . T d s ACe in ibit ma b imit d
provided, you strongly suspect: b s um tassium v t ati nt’s b d s-
A) Metabolic acidosis. su . Sodium restriction added to an ACE inhibi-
B) Respiratory acidosis. tor is actually more e ective than adding an ARB
C) Metabolic alkalosis. or proteinuria and blood pressure control. (BMJ.
D) Respiratory alkalosis. 2011;343:d4366). In t is stud , t actua s dium in t
di t was 2,500 m (a t u t a was 1,200 m ).
Answer 5.1.12 The correct answer is “C.” Loss o gastric acid, D s it initia nt usiasm ( d u c m an ma k t-
through emesis or gastric suction, can result in a metabolic alka- in ), an Ar B us an ACe is n t us u in ss ntia an
losis. Although no pH is available to con rm alkalosis, you are ati nt and su ts in inc as d sid cts; t is c mbi-
able to in er the diagnosis based on the elevation in serum HCO3. nati n s u d b av id d.

HELPFUL TIP:
Diu tics wi t n caus a c mic, “c nt ac-
ti n,” a ka sis m v um c nt acti n. Watc t is
in u ati nts n a diu tic.
Your patient recovers surprisingly well rom her heart ail-
ure. Her creatinine returns to baseline (1.5 mg/dL). You try
to re-challenge the patient with an ACE inhibitor. However,
her hyperkalemia recurs and she is unable to tolerate either
ACEI or ARB. With beta-blocker and loop diuretic therapy,
her average blood pressure is 130/80 mm Hg. At a ollow-up
visit, you nd no signs or symptoms o HF.
Question 5.1.13 You want to lower your patient’s risk o
progressing to end-stage renal disease. To reduce protein-
uria, which o the ollowing strategies is best?
Over the next year, your patient experiences increasing di -
culties with glycemic control. Despite your e orts, her pro-
teinuria and serum creatinine increase. As you discuss re er-
ral to a nephrologist, she asks about dialysis.
Question 5.1.14 Which o the ollowing is NOT an indication
or dialysis?
A) Severe hyperkalemia due to renal ailure.
B) Accelerated hypertension.
C) Malnutrition.
D) Persistent nausea and vomiting despite treatment.
E) Bleeding secondary to uremia.
Answer 5.1.14 The correct answer is “C.” In chronic renal
ailure due to any cause, absolute clinical indications or
 CHAPTER 5 • Neph r o l o g y 145

initiating dialysis include: persistent nausea and vomiting, albuminuria and diabetic retinopathy. You point out that
pericarditis, uid overload, uremic encephalopathy, accelerated her renal unction has progressively declined, which alarms
hypertension, bleeding due to uremia, serum creatinine greater her since her mother is on hemodialysis. Her creatinine was
than 12 mg/dL, and severe electrolyte abnormalities that can- 1.2 mg/dL 3 years ago, and now it is 1.9 mg/dL. Her GFR is
not be otherwise handled. T ese are potentially li e-threatening 36 mL/min/1.73 m2. She weighs 100 kg, and her blood pres-
situations that must be dealt with acutely. Malnutrition is a rela- sure is 120/76 mm Hg.
tive indication that occurs more indolently.
Question 5.2.1 Which o the ollowing is the most appropri-
ate description o her renal unction?
HELPFUL (AND VERY IMPORTANT) TIP: A) Stage 1 chronic kidney disease (CKD).
Counter to what you might expect, early dialy- B) Stage 2 CKD.
sis increases mortality (or at least is o no bene it). C) Stage 3 CKD.
D n t initiat dia sis unti t g Fr is 5 t 7 ml /min/ D) Stage 4 CKD.
1.73 m 2 or t ati nt is avin c inica b ms t at can- E) Stage 5 CKD.
n t b t wis mana d (N en J M d . 2010;363(7):
609–619). pati nts n a dia sis di m in cti n, Answer 5.2.1 The correct answer is “C.” She has stage 3 CKD.
c m icati ns m dia sis ( t nsi n), b ms wit able 5-1 de nes the various stages o CKD. Not all patients will
t i a ts (a ain adin t in cti n), tc. progress through all o the stages o CKD. On the basis o age
alone, many elderly patients may be classi ed as having stage
1 or 2 CKD, and they may never progress. Knowledge o a
Objectives: Did you learn to . . . patient’s CKD stage is use ul in determining how to treat, what
• Sc n m d at inc as d a buminu ia in diab tic drugs to avoid, etc.
ati nts?
• eva uat and t at m d at inc as d a buminu ia and
v t t inu ia in diab tic ati nts? HELPFUL TIP:
• Id nti na acut kidn inju ? pati nts wit CKD, wit wit ut diab t s, a at in-
• D sc ib t atu s r TA t 4? c as d isk c na a t dis as , s t isk ac-
• Id nti ast ic sucti nin as a caus m tab ic a ka sis t s a t dis as s u d b t at d a ssiv . In
in t s ita ? act, man x ts b i v t at CKD s u d b t at d
• Discuss w n t initiat dia sis in a ati nt wit c nic as a “c na a t dis as quiva nt.” At t ast,
na ai u ? CKD is an ind nd nt isk act CAD.

CASE 5.2
A 49-year-old A rican-American emale with diabetes mel-
litus type 2, hypertension and hyperlipidemia returns or a
ollow-up visit. She’s had diabetes or 15 years, and her con-
trol has been variable over that time. Now, her glycosylated
hemoglobin is 8%. She has developed moderately increased
You increase the patient’s insulin and lisinopril doses, con-
rm that she is taking aspirin, and convince her to quit
smoking (you are very persuasive—not to mention good
looking and strong . . . and humble!). One month later, your
patient returns with typical symptoms o a urinary tract
in ection (U I) without systemic symptoms (e.g., ever,

TABLE 5-1 STAGES OF CHRONIC KIDNEY DISEASE

Stage GFR (mL/min/1.73 m 2) Comments
1 ≥90 Sta 1 d n d b vid nc kidn dama
( . ., st uctu a dama , a buminu ia) wit n ma g Fr

2 60–89 Mi d d c in in na uncti n; ab ut 5.4% US

u ati n

3 30–59 M d at d c in in na uncti n; ab ut 5.4% US

u ati n ( s, sam c nt as sta 2)

4 15–29 S v d c in in na uncti n; a ac in n d
dia sis

5 <15 end-sta dis as

g Fr , m ua t ati n at .
146 FAMIl y MeDICINe eXAMINATIo N & Bo Ar D r eVIeW
nausea). Her urine culture grows Escherichia coli resistant to
trimethoprim/sul amethoxazole but susceptible to all other
antibiotics tested.
Question 5.2.2 The most appropriate antibiotic regimen
or this patient’s UTI is:
A) Cipro oxacin 250 mg PO every other day or two doses.
B) Cipro oxacin 250 mg PO once.
C) Cipro oxacin 250 mg PO BID or 3 days.
D) Levo oxacin 750 mg PO daily or 7 days.
Answer 5.2.2 The correct answer is “C.” T is patient’s GFR
is 36 mL/min/1.73 m 2 and her creatinine clearance is 56 mL/
min (using the Cockcrof –Gault equation given earlier).
T ere ore, the usual cipro oxacin dose o 250 mg PO BID
or U I is sa e and appropriate. Less requent dosing may
be required or a lesser GFR or creatinine clearance. T e
important thing here is to recall that CKD may require dos-
age adjustments or many medications. Numerous drugs are
renally cleared, so it’s always prudent to know the GFR or
creatinine clearance and check or dosage adjustments be ore
prescribing.
You assume the U I cleared because you do not hear rom
her or a ew months. T en her sister brings her in or an
acute illness including nausea, emesis, con usion and gen-
eralized weakness. T ese symptoms began yesterday. T e
only other thing new with her health is heartburn which she
has been sel -treating with increasingly larger amounts o
ums® (calcium carbonate), taking “hand uls” over the last
ew days. Her laboratory results now include creatinine
2.5 mg/dL, calcium 14 mg/dL (normal range 8.9–10.5 mg/dL),
and HCO3 37 mEq/L (normal 22–28 mEq/L).
Question 5.2.3 The most appropriate treatment or her now
includes:
A) Hydrochlorothiazide (HC Z).
B) Furosemide.
C) Normal saline IV.
D) A and C.
E) B and C.
Answer 5.2.3 The correct answer is “C.” Your patient is now
presenting with a classic case o milk-alkali syndrome. T e diag-
nosis should be recognized by the triad o hypercalcemia, meta-
bolic alkalosis, and renal insu ciency in combination with the
history o typical symptoms (described in the case) and exces-
sive calcium carbonate ingestion. reatment includes removal
o the o ending agent and treatment o the hypercalcemia with
IV saline (to improve renal per usion and metabolic alkalosis).
“A,” thiazide diuretics, results in reabsorption o calcium—the
opposite o what you want to achieve in a patient with hyper-
calcemia. “B,” urosemide, has allen out o avor and requires
the establishment o euvolemia rst. Even then you need 10 L
o saline per day with 100 mg o IV urosemide every 1 to
2 hours. T is is usually impractical and hasn’t been shown to
add anything.
HELPFUL TIP:
C m a d wit diu tics, t iazid diu tics a
n a b tt at w in b d ssu . h w v-
, at a g Fr < 30 ml /min/1.73 m 2, t iazid s a ss
ctiv as anti t nsiv a nts. F ati nts
wit CKD sta s 4 sta 5, s cia t s wit
v mia, c nsid usin a diu tic m t -
az n (w ic acts at mu ti na sit s) inst ad a
t iazid .
You get the patient through her episode o hypercalcemia
and advise her to lay o the calcium-based antacids, avor-
ing an H2-antagonist instead. As your patient’s renal disease
progresses over the years, you nd that she has become ane-
mic with a hemoglobin o 9.9 g/dL. She takes a multivitamin.
Her iron studies are consistent with anemia o chronic dis-
ease and her screening colonoscopy last year was normal. T e
anemia is normocytic and normochromic.
Question 5.2.4 I you were to treat her with an erythropoi-
etic agent (e.g., erythropoietin or darbepoetin), her target
hemoglobin would be:
A) 9 to 10 g/dL.
B) 10 to 11 g/dL.
C) 13 to 14 g/dL.
D) > 15 g/dL.
Answer 5.2.4 The correct answer is “B.” For patients with
CKD and anemia o chronic disease (when other causes o
anemia have been ruled out and/or treated), erythropoietic
agents should NO be used to achieve “near normal” hemo-
globin levels. arget levels are determined on an individual
basis but in general will be about 10 to 11 g/dL. Higher
hemoglobin levels—in particular, attempts to “normalize”
the hemoglobin concentration—are associated with a greater
risk o adverse events, including increased risk o mortality,
need or dialysis, heart ailure, graf thrombosis, uncontrolled
hypertension, etc. T ese ndings are consistent with a simi-
lar nding in cancer patients (JAMA. 2010;303(9):857–864;
N Engl J Med. 2009;361:2019–2032). I the patient is an appro-
priate candidate, the initial erythropoietin dose is approxi-
mately 50 to 100 units/kg per week. Because o the need to
preserve veins or uture hemodialysis access, we recommend
that erythropoietin be administered subcutaneously. T e
FDA suggests withholding erythropoietin or hemoglobin
> 12 g/dL or i the hemoglobin increases by > 1 g/dL in any
2-week period.
Objectives: Did you learn to . . .
• Sta CKD?
• Adjust m dicati n d s s bas d n na uncti n?
• r c niz and t at mi k-a ka i s nd m ?
• r c niz a iat ta ts t t atm nt wit t -
i tic a nts?
 CHAPTER 5 • Neph r o l o g y 147

Question 5.3.2 In your evaluation o this patient, you

CASE 5.3
A 55-year-old male presents to your of ce or evaluation o
blood in his urine. It turns out that he had a li e insurance
physical and the urinalysis showed 2+ blood on urine dip-
stick and 2 RBC/hp . T e remainder o the urinalysis and
microscopic examination was normal.
Question 5.3.1 A ter an appropriate history and physical
examination, your rst step in the evaluation o this urine
abnormality is to:
A) Repeat the urinalysis and microscopic examination.
B) Obtain urine or culture.
C) Order a renal ultrasound.
D) Order a C scan o the abdomen.
E) Order an intravenous pyelogram (IVP).
Answer 5.3.1 The correct answer is “A.” According to the uri-
nalysis, there is a small amount o blood in your patient’s urine,
but the number o RBCs is actually normal (< 3 RBC/hp ). Your
rst step should be to repeat the urinalysis and urine micro-
scopic examination to determine i this patient actually meets
the criteria or microscopic hematuria (≥ 3 RBC/hp on two o
the three properly collected urine specimens, according to the
American Urological Association). A urine culture may prove
use ul later in the evaluation process but is not necessary now.
Likewise, ordering imaging studies is premature because the
diagnosis o microscopic hematuria has not been made.
HELPFUL TIP:
Kidn st n s a a v c mm n caus ss and
mic sc ic matu ia. h w v , ca t at 20%
ati nts wit kidn st n s wi av n b d in t i
u in and a n ma u ina sis. I A n at is n
t m st c mm n int insic na dis as s t caus mi-
c sc ic matu ia; kidn c sts, inc udin c stic
kidn dis as , a c mm n caus s as w . N astic
dis as s, in a ticu a b add canc and na c ca -
cin ma, ma a s b disc v d du in t inv sti a-
ti n mic sc ic matu ia.
include all o the ollowing tests EXCEPT:
A) Urine cytology.
B) CBC.
C) Serum creatinine.
D) C scan o the abdomen and pelvis with particular note o
the kidneys.
E) Renal biopsy.
Answer 5.3.2 The correct answer is “E.” In most cases o micro-
scopic hematuria, renal biopsy is not indicated. However, i an
intrinsic renal cause o hematuria is suspected, renal biopsy may
prove necessary. Intrinsic renal disease is more likely i there
is proteinuria, hypertension, elevated serum creatinine, or an
active urinary sediment (e.g., nephritic, dysmorphic red cells,
red cell casts).
T ere is no completely standardized evaluation o micro-
scopic hematuria, and recommendations vary depending on
the author. However, the recommendations always include
serum creatinine and usually include CBC, coagulation stud-
ies, and serum chemistries. Depending on the patient’s age, ur-
ther studies may be indicated. For patients older than 40 years,
you should consider studies to evaluate or urinary tract can-
cers. Urine cytology has low sensitivity but high speci city or
bladder cancer and may be quite use ul in conjunction with
cystoscopy. Imaging o the urinary system is an absolute require-
ment in the work-up o microscopic hematuria in older patients
(generally, those over age 40 years). C scan appears to have the
greatest sensitivity or detecting masses, but ultrasound, IVP, or
the combination o the two may also be employed. Cystoscopy
should be considered i the C scan is normal since C is poor
at visualizing bladder abnormalities. See able 5-2 or a sug-
gested work-up or microscopic hematuria.
Question 5.3.3 The US Preventive Services Task Force rec-
ommends which o the ollowing screening strategies or
detecting microscopic hematuria?
A) Annual urinalysis af er age 50.
B) Urinalysis every 2 years af er age 50.

HELPFUL TIP: TABLE 5-2 EVALUATION OF MICROSCOPIC

C m a d wit mic sc ic matu ia, gross hematu- HEMATURIA
ria is m c mm n ass ciat d wit ma i nanc and, A t mic sc ic matu ia as b n id nti d (2 3 u in sam s
nc c n i m d, s u d m tat u va uati n. wit 3 m r BC/ ), t Am ican U ica Ass ciati n (AUA)
B ni n caus s microscopic hematuria in adu ts in- c mm nds t win va uati n:
c ud : vi us x cis , m nst uati n, s xua activit , • In cti n id nti d → t at wit antibi tics and at u ina sis
vi a i n ss, and t auma. • r BC casts, t inu ia, vat d c atinin → b in va uati n
m u n itis and c nsid a t an ist
• N in cti n ima na dis as id nti d in st 2 st s →
u in c t , b add c st sc (i at isk b add canc
Further history reveals that he smokes one to two packs o bas d n nvi nm nta x su s and/ a > 40), and CT scan
cigarettes per day. He has a normal blood pressure and the ( ica CT i st n s sus ct d, c nt ast- n anc d CT i st n s n t
remainder o the physical examination is unrevealing. On sus ct d)
• I nti t u dia n stic va uati n n ativ → w-u
two urine samples, you nd microscopic hematuria, with a u ina sis, u in c t ,b d ssu , and s um c atinin
positive dipstick and 5 RBC/hp . T e rest o the urinalysis is v 6–12 m nt s.
normal, and there are no red cell casts.
148 FAMIl y MeDICINe eXAMINATIo N & Bo Ar D r eVIeW
C) Annual urinalysis af er age 65.
D) Annual urinalysis in all high-risk patients older than 65 years.
E) No screening at any age.
Answer 5.3.3 The correct answer is “E.” he USPS F recom-
mends against routine screening or microscopic hematuria
to detect urinary tract cancers. In one-time urine specimens
in healthy adults, the presence o abnormal numbers o RBCs
(≥ 3 RBCs/hp ) can be as high as 39%. In up to 70% o
patients, even a ter imaging o the upper and lower urinary
tract, the source o microscopic hematuria cannot be ound.
In a low-risk population, the alse-positive rate o micro-
scopic hematuria ound on urinalysis would be unaccept-
ably high. Also, there is no evidence that early detection o
urinary tract cancers through screening urinalysis improves
prognosis.
Your patient returns to discuss his laboratory and radiol-
ogy results. His serum creatinine is 1.1 mg/dL, and his CBC,
chemistries, and coagulation studies are normal. His urine
cytology was negative, as was cystoscopy per ormed by your
riendly neighborhood urologist. C scan o the abdomen
and pelvis reveals normal size kidneys and no masses, but
three stones, measuring 2 to 3 mm in diameter, are noted in
the le renal pelvis. T ere does not appear to be any obstruc-
tion. Your patient denies any history o renal colic.
Question 5.3.4 Regarding the nding o stones in the le t
renal pelvis, which o the ollowing interventions is war-
ranted at this time?
A) Observation.
B) Lithotripsy.
C) Ureteral stent placement.
D) Ketorolac and uids by IV.
E) Prophylactic nephrectomy.
Answer 5.3.4 The correct answer is “A.” he inciden-
tal inding o stones during the evaluation o microscopic
hematuria is common. he stones may be the reason or
your patient’s hematuria. Since the stones are small, they
may pass without intervention. Most stones less than 5 mm
in diameter will pass spontaneously. No urther intervention
is warranted in asymptomatic patients. “D” is o particular
note. Ketorolac and other NSAIDs are e ective in treating
the pain o urolithiasis. However, luid is not help ul in treat-
ing acute ureteral colic (unless the patient is dehydrated).
Fluid does nothing to “push” the stone out: luid increases
pain and the body simply shi ts the excess luid to the non-
obstructed kidney.
HELPFUL TIP:
D sm ssin (DDAVp), w ic d c as s u in v -
um s, can b us d t c nt ain in t s wit u i-
t iasis (a t u w d n’t c mm nd it utin
us —t a nt d ana sics ut t ).
Your patient does well or a year. When you see him next, he
presents to your of ce as a late a ernoon add-on and com-
plains o severe abdominal pain that woke him rom sleep at
3 AM. He describes the pain as “sharp” or “crampy,” occur-
ring in his le lower quadrant and radiating to the le tes-
ticle. Although the pain has waxed and waned, it has never
resolved completely. He is also nauseated and has been vom-
iting. On examination, he is a ebrile and tachycardic and has
a blood pressure o 110/56 mm Hg. He appears uncom ort-
able and is writhing in pain. T ere is le lower quadrant,
ank, and costovertebral angle tenderness.
Question 5.3.5 Your next action is to:
A) Prescribe oral ibupro en and morphine and arrange ollow-
up tomorrow.
B) Give IM ketorolac and arrange ollow-up tomorrow.
C) Bolus 1 L IV saline, administer IV cef riaxone, and arrange
ollow-up tomorrow.
D) Send him to the emergency department (ED) or pain man-
agement, uids, and possible admission.
Answer 5.3.5 The correct answer is “D.” In a patient with
known kidney stones presenting with classic ndings o uro-
lithiasis, the most likely diagnosis is renal colic due to stones.
T is patient is nauseated and vomiting requently and may not
do well at home overnight. He is unlikely to tolerate oral medi-
cations and could become dehydrated. In addition, we don’t
have a urinalysis, and a postobstructive U I is an indication or
admission and possibly stenting. For these reasons, the most
appropriate action is aggressive pain management, which can
be accomplished in the ED. I the patient is unable to keep down
oral pain medications af er treatment in the ED, admission to
the hospital is warranted. Narcotic analgesics, IV NSAIDs (e.g.,
ketorolac), and IV uids to maintain euvolemia are all appropri-
ate. T e role o antibiotics will depend on urinalysis ndings,
but most cases o acute renal colic do not require antibiotics.
HELPFUL (AND VERY IMPORTANT) TIP:
U it iasis and abd mina a tic an u sm can av
t sam s ntin s m t ms and si ns (inc udin
matu ia). F t at as n, ima in is mandat in
t d individua in w m an abd mina a tic an-
u sm is a c nsid ati n. A s , k t sticu a t si n
n t di ntia un ma ati nts s ntin
wit na c ic s m t ms—t s ati nts n d a ni-
ta xaminati n (but u kn w t at, i t?).
You admit the patient to the ED; start IV saline to maintain
hydration; and administer narcotics, NSAIDs (ketorolac)
and antiemetics. C scan shows a 5-mm stone in the proxi-
mal ureter. T ere is no hydronephrosis. Serum electrolytes,
BUN, creatinine, and CBC are all normal. Urinalysis reveals
2+ blood, 1+ leukocyte esterase, trace protein, pH 6, speci c
gravity 1.025, 20 RBC/hp , ew calcium oxalate crystals, and
otherwise normal.

Question 5.3.6 Which o the ollowing is the most appropri-
ate management at this point in time?
A) Add antibiotics to the current therapy.
B) Continue the current therapy and observe.
C) Re er or extracorporeal shock wave lithotripsy.
D) Re er or endoscopic lithotripsy.
Answer 5.3.6 The correct answer is “B.” T ere is no reason to
change management at this point in time. Many 5-mm stones
will pass spontaneously. Although leukocyte esterase is detected
on the urine dipstick, there is no compelling evidence o in ec-
tion (e.g., ever, elevated WBC count, and WBCs on microscopic
examination), so antibiotics are not necessary. But culturing the
urine would be prudent.
HELPFUL TIP:
St n s 6 mm at wi ass s ntan us n
10% t tim and t s 4 t 6 mm 50% t tim .
T s ss t an 4 mm ass t at maj it t
tim . I ain sists t st n d s n t ass wit in
72 u s, c nsid u ic int v nti n suc as n -
st m , st nt ac m nt, and/ it t i s . r na in-
ju m bst ucti n n a d s n t ccu at
ast 72 u s (and, amazin n u ,t is n a
20% c anc c m icati ns i a n n bst uctin st n
mains 4 w ks).
HELPFUL TIP:
pati nts disc a d m t eD wit u it iasis s u d
b ac d n an NSAID in additi n t a na c tic. T is
duc s ain and “b unc back” visits.
Question 5.3.7 Your patient—a man possessing incred-
ible oresight—asks how he can avoid kidney stones in the
uture. Which o the ollowing tests will be most use ul in
determining the treatments that may prevent uture stone
ormation?
A) Urine culture.
B) Stone recovery and analysis.
C) Urinary calcium excretion.
D) Urinary oxalate excretion.
E) Serum uric acid.
Answer 5.3.7 The correct answer is “B.” T e prevention o ur-
ther stone ormation is aided by knowledge o the stone type.
You should always attempt to recover the stone and send it or
analysis—unless the patient is a well-known stone ormer and
the composition o his or her stones is already known. T e other
studies listed may have value. Struvite stones orm during bac-
terial in ections o the urinary tract and a urine culture (“A”)
will help direct therapy when these stones are identi ed. Cal-
cium oxalate stones are the most common and 24-hour urine
collection to determine calcium and oxalate excretion (“C”) can
lead to diagnoses o metabolic disturbances (hyperoxaluria and
CHAPTER 5 • Neph r o l o g y 149
hypercalciuria). Patients with uric acid stones (“D”) should be
evaluated or symptoms o gout and undergo serum uric acid
measurements.
Your patient passes the stone, his pain completely resolves,
and he is discharged rom the hospital within 24 hours o his
admission. T e stone is pure calcium oxalate. Studies o his
24-hour urine collection are pending.
Question 5.3.8 In order to reduce his risk o orming more
stones, you tell him to incorporate all o the ollowing li e -
style changes EXCEPT:
A) Restrict calcium intake.
B) Restrict oxalate intake (e.g., lea y green vegetables, chocolate).
C) Increase daily water intake.
D) Add a glass o orange juice daily.
E) Reduce meat and sh consumption.
Answer 5.3.8 The correct answer is “A.” o prevent recur-
rent urolithiasis, restricted calcium intake was encouraged in
the past. Now, moderate calcium intake (1 g/day) is recognized
as bene cial and should be encouraged. Patients should take
calcium with meals, which will bind oxalate and prevent its
absorption. A low-calcium diet actually leads to an increased
risk o urolithiasis. Increase in urine oxalate greatly increases
the risk o stone ormation. Restriction o oxalate (“B”) in the
diet may help to reduce the risk o recurrent urolithiasis. Foods
high in oxalate include spinach, rhubarb, nuts, and legumes.
Un ortunately, oxalate is also the end product o numerous
metabolic pathways, and signi cant reduction in urinary oxa-
late levels of en proves di cult (good news or you rhubarb
ans! We like rhubarb pie and chocolate . . . say, I eel a stone
coming on).
Increased uid intake (“C”) to achieve a urine volume
> 2 L/day reduces stone ormation. Water and citrus juices
(“D”) are traditionally recommended (hypocitraturia is associ-
ated with stone ormation), but most uids consumed are asso-
ciated with a positive e ect, including drinks with ca eine.
Red meat, sh, and poultry (“E”) are sources o purine, which
is metabolized to uric acid. A uric acid crystal can orm a pure
uric acid stone or serve as a nidus or calcium stone ormation.
T ere ore, a general recommendation to avoid recurrent uroli-
thiasis is to reduce purines (e.g., meat) in the diet.
Question 5.3.9 Your patient is wondering i he should have
his urolithiasis worked up to determine an etiology. All o
the ollowing are reasons to pursue a urther evaluation in
this patient EXCEPT:
A) A strong amily history o stones.
B) A rican ancestry.
C) Chronic diarrhea.
D) Hypertension.
E) Bariatric surgery.
Answer 5.3.9 The correct answer is “D.” Simply having hyper-
tension is not a reason to work-up a patient or renal stones.
All o the other choices are correct. O note is “B.” Patients o
150 FAMIl y MeDICINe eXAMINATIo N & Bo Ar D r eVIeW

A rican ancestry are less likely to have stones. T ere ore, the
work-up is more likely to reveal a pathologic process in these
patients. “C” and “E” are also o note. Anything that can cause
malabsorption including bowel surgery, history o in amma-
tory bowel disease, etc., can increase the risk o stones. T us,
evaluation is indicated in these patients.
Answer 5.3.11 The correct answer is “D.” While dehydration
predisposes patients to a second stone (and thus “E”), maintain-
ing optimal hydration lowers the risk but is not a oolproo rem-
edy. Kidney stones are more common in men and have a peak
incidence at age 30. About 60% to 80% o patients with a kidney
stone will su er a recurrence.

Because o his strong amily history, you decide to proceed Question 5.3.12 Which o these patients with urolithiasis
with evaluation. Results o your patient’s 24-hour urine have requires hospitalization?
returned and are as ollows (normal values): A) A patient with a high-grade obstruction.
B) A patient with intractable pain or vomiting.
Volume 1.6 L.
C) A patient with an associated urinary tract in ection.
pH 6.5.
D) A patient with a solitary kidney or transplanted kidney.
Creatinine clearance normal.
E) All o the above.
Calcium 410 mg (re erence range 100–300 mg).
Uric acid 410 mEq (re erence range 250–750 mEq).
Answer 5.3.12 The correct answer is “E.” All o the patients
Oxalate 42 mg (re erence range 7–44 mg).
listed above should be admitted. Obviously, patients having
Citrate 560 mg (re erence range 100–800 mg).
uncontrollable pain or vomiting will do poorly as outpatients.
Magnesium 3.1 mEq (re erence range 3–5 mEq).
Urolithiasis with a coexistent U I is a signi cant problem due
Question 5.3.10 Which o the ollowing medications is most to the risk o abscess ormation, bacteremia, and renal paren-
likely to reduce his risk o developing kidney stones in the chymal destruction. T ese patients require IV antibiotics and
uture? immediate urologic consultation, particularly in the presence o
A) Allopurinol. comorbidity. Patients with solitary or transplanted kidneys or in
B) Potassium citrate. whom the diagnosis o renal colic is unclear should be admitted
C) Hydrochlorothiazide. or monitoring o renal unction and urther evaluation.
D) Sodium bicarbonate.
E) Furosemide.
HELPFUL TIP:
T m st c nt, i qua it , data su sts t at n it
Answer 5.3.10 The correct answer is “C.” According to the
a a-b ck s ( . ., tamsu sin, d xaz sin) n ca cium
24-hour urine studies, your patient has hypercalciuria, sub-
c ann b ck s ( . ., ni di in ) a us in -
optimal urine volumes (the goal or urine output in urolithi-
in st n x u si n (l anc t. 2015;386(9991):341–349).
asis should be 2 L/day or more), and no other abnormalities.
p vi us m ta-ana s s t at s w d a b n it w
Patients with urolithiasis and hypercalciuria bene t rom the
sma , ativ qua it , studi s. T is is sti c nt -
long-term treatment with thiazide diuretics, such as hydro-
v sia and w sus ct t answ n t t st wi b t
chlorothiazide, which decrease calcium excretion and there ore
us x u siv t a wit an a a-b ck ca cium
stone ormation. Furosemide increases calcium excretion and
c ann b ck .
has the potential to increase stone ormation.
Even though it seems counterintuitive, patients with calcium
stones and hyperuricosuria may bene t rom allopurinol. It is HELPFUL TIP:
thought that hyperuricosuria predisposes to calcium stones. r m mb t at mu ti d u s can m adi uc nt
Also, allopurinol is use ul in the treatment o patients with uric st n s t at wi n t s w u n a CT scan. Am n st
acid stones. Patients with uric acid stones and hyperuricosuria t s a indinavi , ac c vi , and t iamt n .
may bene t rom alkalinization o the urine with sodium bicar-
bonate or potassium citrate. In general, dietary citrate should be
maximized. Oral potassium citrate is indicated or patients with
hypocitraturia. Objectives: Did you learn to . . .
• D n mic sc ic matu ia?
T e patient is wondering whether he can expect to get another • eva uat a ati nt wit mic sc ic matu ia bas d n isk
stone. and di ntia dia n sis?
• D sc ib t di cu ti s in nt in m in u in studi s
Question 5.3.11 All o the ollowing are true EXCEPT: t sc n u ina t act canc s?
A) T e peak incidence o kidney stones occurs at age 30. • eva uat a ati nt wit u it iasis?
B) Kidney stones are more common in men than in women. • Id nti caus s u it iasis bas d n t c a act istics
C) T e rate o a second kidney stone is 60% to 80%. t st n ?
D) Only people who become dehydrated can expect to have a • Mana a ati nt wit s m t matic u it iasis?
second stone. • Us st at i s t v nt st n mati n bas d n t c a -
E) Living in a hot climate can predispose to a second stone. act istics t st n ?

CASE 5.4
A 19-year-old emale presents to your of ce concerned about
protein in her urine. As a college student, she has a part-time
job in a medical laboratory. She “repurposed” a ew urine
dipsticks rom the laboratory—you know, “just checking
her urine”—and ound that she had 2+ protein on her dip-
stick. She has no urinary symptoms and denies ever, weight
changes and edema. She is a ebrile with a blood pressure o
118/68 mm Hg. Examination is otherwise unremarkable.
Repeat urinalysis in the of ce con rms 2+ protein, speci c
gravity 1.020, pH 6.5, and no blood. T e urine microscopic
examination is normal.
Question 5.4.1 Which o the ollowing is the most appropri-
ate next action in evaluating this patient?
A) Repeat urinalysis and urine culture.
B) Ultrasound o the kidneys.
C) 24-hour urine collection or protein and creatinine.
D) Random urine protein/creatinine ratio.
Answer 5.4.1 The correct answer is “D.” Did you go or “C”?
A random urine is much easier than collecting a 24-hour urine
and correlates well with 24-hour collections. You could ask the
patient to collect urine or 24 hours or protein and creatinine
measurements, but why? Who wants to lug around a jug o their
own urine all day? What will she tell her riends and co-workers?
Your patient already has protein on urinalysis twice. Another
urinalysis (“A”) will not help to determine i this is truly a wor-
risome nding or not. T ere is no evidence o a U I (no leu-
kocyte esterase, nitrites, etc., and no symptoms); thus, culture
would be very low yield. T ere is no indication or renal ultra-
sound (“B”) at this point.
HELPFUL TIP:
C nc nt at d a ka in u in can su t in v stima-
ti n u in t in n di stick. N t t at t is ati nt’s
u in s ci ic avit was n ma .
Question 5.4.2 Which type(s) o protein are detected on a
urine dipstick?
A) Albumin.
B) Amino acids.
C) Immunoglobulin light chains.
D) A and B.
E) A and C.
Answer 5.4.2 The correct answer is “A.” T e urine dipstick only
detects large–molecular-weight proteins—generally this means
albumin. Amino acids are not detected. Immunoglobulin light
chains, such as Bence Jones proteins, are also not detected on
urine dipstick.
Her urine protein/creatinine ratio is equivalent to 1 g o urine
protein per day. Creatinine clearance is normal. Serum cre-
atinine, BUN, albumin, glucose, and electrolytes are normal.
CHAPTER 5 • Neph r o l o g y 151
Question 5.4.3 Which o the ollowing is the best next step
in your evaluation and management?
A) Start her on a low-protein diet.
B) Order C scan o abdomen and pelvis.
C) Measure recumbent urine protein level.
D) Re er or renal biopsy.
Answer 5.4.3 The correct answer is “C.” Proteinuria may be
either transient or persistent. ransient proteinuria is of en due
to ever, exercise, or other causes and is not associated with sig-
ni cant kidney disease. ransient proteinuria is ound in 7%
o women and 4% o men. It of en resolves spontaneously, and
subsequent urine tests will probably be negative. However, at
this point you don’t know i this case will be transient or persis-
tent proteinuria.
Orthostatic proteinuria is a common type o transient pro-
teinuria seen in young, healthy persons. Up to 5% o adolescents
have orthostatic proteinuria, and young adults may present
with it as well. Protein is spilled in the urine when the patient is
upright, but not when recumbent. T ere are two ways to deter-
mine recumbent urine protein: an easy way and a hard way.
T e easy way is to have the patient void be ore going to bed,
stay supine all night (8 hours), and collect urine immediately
upon waking. T is urine is checked or protein/creatinine ratio.
Another urine sample must be checked or protein/creatinine
ratio af er the patient has been upright. I the upright is abnor-
mal and the recumbent is normal, you have diagnosed ortho-
static proteinuria (and impressed your colleagues). T e “hard
way” involves splitting a 24-hour urine collection—two jugs
o urine and the required arithmetic. Orthostatic proteinuria
is a benign condition that usually resolves as the patient ages,
requiring no additional evaluation.
A nding o 1 g o protein in a 24-hour urine collection is
abnormal (normal < 0.15 g/day), but it does not yet reach the
nephrotic range (> 3 g/day). Regardless, a low-protein diet
(“A”) is not help ul. C scan o the abdomen and pelvis (“B”) is
unlikely to add any new in ormation. Re erring or renal biopsy
(“D”) is premature.
T e patient collects urine in upright and recumbent positions,
and both have abnormal amounts o protein. You re er the
patient to a nephrologist who recommends ollow-up rather
than biopsy. Annual ollow-up will include blood pressure,
serum creatinine, and spot urine protein/creatinine ratio.
Question 5.4.4 In order to prevent worsening proteinuria,
the nephrologist also recommends which o the ollowing
medications?
A) Amlodipine.
B) Diltiazem.
C) Furosemide.
D) Benazepril.
E) Aspirin.
Answer 5.4.4 The correct answer is “D.” Patients with protein-
uria tend to respond well to ACE inhibitors. ACE inhibitors have
been shown to reduce proteinuria by 35% to 40%. T is e ect is
152 FAMIl y MeDICINe eXAMINATIo N & Bo Ar D r eVIeW

true in nondiabetic patients with proteinuria as well as in dia- TABLE 5-3 CRITERIA FOR NEPHROTIC SYNDROME
betic patients. ACE inhibitors appear to be superior to other
Required or the diagnosis o nephrotic syndrome
antihypertensives, including calcium channel blockers (“A”
• A buminu ia > 3 /da
and “B”). Furosemide (“C”) would be indicated i your patient • h a bumin mia (s um a bumin < 3 /dl )
develops edema, but loop diuretics should not be used primarily • p i a d ma
or the treatment o hypertension or proteinuria. Aspirin (“E”) Other (nondiagnostic but supportive) f ndings:
may be indicated or protection against coronary artery disease • h i id mia
in patients with risk actors, including CKD, but it is not a pri- • T mb tic v nts
mary treatment o proteinuria or hypertension. Remember that
NSAIDs can adversely a ect renal unction.
Answer 5.4.6 The correct answer is “C.” Urine sediment in
HELPFUL (AND IMPORTANT) TIP:
nephrotic syndrome is typically bland. T ere is little cellular
W i ACe in ibit s a i st- in t atm nts -
matter. Oval at bodies and atty casts occur in the urine o
t inu ia, t a s can caus cts n t tus du in
patients with heavy proteinuria and hyperlipidemia. Fat bod-
nanc . Us is n t c nt aindicat d wit in w m n
ies re ect the increased permeability o the glomeruli and sug-
c i d-b a in a , but s u d b und tak n wit
gest some type o glomerular disease (including nephrotic syn-
cauti n. ensu s is n a iab s u c c nt ac -
drome) albeit not necessarily active disease. However, at can
ti n ( a s n -actin v sib c nt ac ti n suc
also be seen in patients with polycystic kidney disease and at
as IUD N x an n) and t at s is c uns d n t
embolism syndrome.
isks t t tus i s w t t nant. I s d s
Red cell casts (“A”), the hallmark o glomerulonephritis,
b c m nant, mak su s disc ntinu s t ACe
are absent in nephrotic urine. White cell casts (“B”) are asso-
in ibit i t awa .
ciated with interstitial nephritis and pyelonephritis. Uric acid
crystals (“D”) are sometimes seen in gout, hyperuricemia and
urate stone disease. Granular casts (“E”) are not speci c to any
Un ortunately, over the next ew years, your patient develops particular pathologic process and may be ound in acute tubu-
hypertension. You maximize the dose o benazepril and need lar necrosis, glomerulonephritis, and other renal diseases. See
to add another drug to control her pressure. Her proteinuria able 5-4 or more details on urine sediment.
increases to 3.5 g/day, and her plasma creatinine increases
to 2 mg/dL. She develops edema, and her serum albumin is Question 5.4.7 Nephrotic syndrome is not a speci c disease
2.8 g/dL. T e urine shows only protein and no in ammatory entity but can be the end result o a number o processes.
components. Which o the ollowing cause(s) nephrotic syndrome?
A) Diabetes.
Question 5.4.5 This patient’s current clinical condition is B) Minimal change disease.
most appropriately described as: C) Amyloidosis.
A) Hypertensive nephropathy. D) Systemic lupus erythematosus.
B) Acute renal ailure. E) All o the above.
C) Focal nephritic glomerulonephritis.
D) Nephrotic syndrome. TABLE 5-4 URINE SEDIMENT FINDINGS AND
E) Floating kidney. ASSOCIATED CONDITIONS
Sediment Finding Associated Condition
Answer 5.4.5 The correct answer is “D.” While identi ying no e it ia c casts ATN, acut m u n itis
speci c disease state, the term nephrotic syndrome re ers to a
constellation o signs and laboratory abnormalities. A num- Fat b di s, att casts Massiv t inu ia (n tic s nd m ),
at mb i, c stic kidn dis as ,
ber o diseases may lead to nephrotic syndrome (keep read-
m u a dis as (ma n t b activ as in
ing or more on this). When urine protein exceeds 3 g/day, it n tic s nd m )
is of en re erred to as “nephrotic range” proteinuria. Complete
nephrotic syndrome is characterized by nephrotic range pro- g anu a casts N ns ci c—man na dis d s
teinuria, edema, hypertension, hypoalbuminemia, and hyper- h a in casts C nc nt at d u in , diu tic us , n ma
lipidemia ( able 5-3). ndin

r dc casts g m u n itis, vascu itis (v s ci c

Question 5.4.6 Which o the ollowing ndings in urine sed-
t t s )
iment is associated with nephrotic syndrome?
A) Red cell casts. Wax casts Advanc d na ai u
B) White cell casts.
W it c casts p n itis, acut int stitia n itis,
C) Oval at bodies. va i us m u a dis as s
D) Uric acid crystals.
E) Granular casts. ATN, acut tubu a n c sis.
 CHAPTER 5 • Neph r o l o g y 153

TABLE 5-5 CAUSES OF NEPHROTIC SYNDROME Question 5.4.9 Absolute contraindications to renal biopsy
include which o the ollowing?
• Diab t s
A) Hypertension.
• Am id sis
• S st mic u us t mat sus B) Use o war arin or other anticoagulant or atrial brillation.
• Minima c an dis as (“Ni ” dis as ) C) Pyelonephritis.
• Di us m u n itis D) Solitary renal cyst.
• M mb an us n at E) All o the above.
• I An at
• p stin cti us m u n itis ( . ., st-st t c cca g N)
• M mb an i ativ m u n itis Answer 5.4.9 The correct answer is “C.” T e presence o renal
• Va i us n astic dis as s ( m ma, mu ti m ma, un or perirenal in ection is a contraindication to renal biopsy.
canc , tc.) None o the others are absolute contraindications. However,
• p c am sia uncontrollable hypertension, irreversible coagulopathy, mul-
• Fami ia kidn dis as (A t dis as , Fab dis as )
tiple bilateral cysts, hydronephrosis, small kidneys (indicative
• F ca and s m nta m u sc sis
• M dicati ns (NSAIDs) o chronic, irreversible disease), known renal tumor, and lack o
• Misc an us consent are all contraindications to renal biopsy. Simply being
on war arin or another anticoagulant, which can be stopped or
reversed, is not a contraindication to biopsy.
Answer 5.4.7 The correct answer is “E.” All o the above can
be a cause o nephrotic syndrome. Remember that many causes Question 5.4.10 Which o the ollowing is an indication or
o nephrotic syndrome can present initially with nephritic renal biopsy?
urine. Causes o nephrotic syndrome are summarized in A) Persistent hematuria in a patient with normal renal unction
able 5-5. and an otherwise negative work-up.
B) Persistent low-grade proteinuria (1–2 g/day range) with
Question 5.4.8 Which o the ollowing tests is NOT indi- normal blood pressure and creatinine.
cated in most patients with nephrotic syndrome? C) Suspected case o IgA nephropathy.
A) Hepatitis B and C serology. D) Nephrotic syndrome likely rom diabetes mellitus.
B) ANA. E) Persistent low-grade proteinuria with elevated blood pres-
C) Serum and urine protein electrophoresis. sure and/or elevated creatinine.
D) Antistreptococcal antibodies (e.g., ASO titer).
E) CA-125 antigen. Answer 5.4.10 The correct answer is “E.” Patients with low-
grade proteinuria and elevated serum creatinine and/or hyper-
Answer 5.4.8 The correct answer is “E.” Evaluation or cancer tension should have a renal biopsy in order to determine the
should be done i there is a speci c reason to believe the patient etiology o their disease. Indications or biopsy are listed in
has a malignancy (weight loss, mass on examination, etc.). able 5-6.
CA-125 is a marker or ovarian cancer (among others . . . colon, Objectives: Did you learn to . . .
pancreatic, etc.) and need not be done routinely. Plus, it’s not a • eva uat and w a a t -a a in ati nt wit -
use ul screening test or ovarian cancer. In addition to a thor- t inu ia?
ough history and physical routine evaluation o patients with • D n and dia n s t static t inu ia and und stand
nephrotic syndrome (and nephritis and glomerulonephritis) its si ni canc ?
include the ollowing: • Mana a ati nt wit ssiv t inu ia?
• Hepatitis B and C serology. • D n and va uat n tic s nd m ?
• ANA. • Id nti caus s n tic s nd m ?
• Serum and urine protein electrophoresis.
• ASO titer.
• Cryoglobulins. TABLE 5-6 INDICATIONS FOR RENAL BIOPSY
• Serum complement levels. • N tic s nd m without a s st mic ti und n t
t stin .
• ANCA. • h matu ia m a m u a s u c with t nsi n inc as-
• Serum calcium (to rule out sarcoid). in c atinin .
• Antiglomerular basement membrane antibodies. • p sist nt w ad t inu ia with t nsi n inc asin
c atinin .
Use clinical judgment to guide your work-up. However, • N itis without a s st mic x anati n ( . ., n u us, d u
this evaluation will nd the cause o most cases o nephritis/ x su ).
nephrotic syndrome. • Sus ici n anu mat sis wit an iitis ( m W n
dis as ) a t itis n d sum w t tissu is n t avai ab .
• Acut subacut na ai u wit ut an t x anati n
T e diagnosis in your patient is unclear despite the work-up (a t u ist wi usua su t in a sum tiv dia n sis).
noted above. It is time to consider a renal biopsy.
154 FAMIl y MeDICINe eXAMINATIo N & Bo Ar D r eVIeW

CASE 5.5 HELPFUL TIP:

T su ts a v n us and a t ia b d as a ss n-
While covering the ED, a 62-year-old emale you have known tia t sam xc t t x n, w ic u can ad
or several years presents with her husband. She appears t t anscutan us x n satu ati n m nit . And,
lethargic and is unable to give a coherent history. Her hus- a v n us as u ts ss. W a d a t ia b d as s
band tells you that she began having stomach pain, nausea, and t n a m st xc usiv in ati nts n a v nti at .
and diarrhea 2 days ago. Although she has not been vomit-
ing, she has been unable to drink or eat much due to nausea.
She takes urosemide or edema and albuterol/ipratropium While you are providing supportive care, the patient’s labora-
(Combivent) or chronic obstructive pulmonary disease tory results are completed: Na 134 mEq/L, K 2.1 mEq/L, Cl
(COPD). She smokes a pack o cigarettes per day. 112 mEq/L, HCO3 10 mEq/L, BUN 29 mg/dL, Cr 1.1 mg/dL,
On physical examination, her respiratory rate is 30, pulse Ca 9.1 mg/dL; CBC: WBC 16,100 cells/mm3, Hgb 13.9 g/dL,
104 bpm, blood pressure 112/64 mm Hg, and temperature platelets 167,000 cells/mm3; urinalysis: speci c gravity 1.030,
37.9°C. She is somnolent and disoriented (maybe she’s post- remainder normal. roponin- , CK, and liver enzymes are
call?). Oral mucosa is dry. Lung examination demonstrates normal.
diminished air movement bilaterally. Her abdomen is di -
usely tender, but there is no rebound. Rectal examination is Question 5.5.2 All o the ollowing may be contributing to
negative or occult blood. hypokalemia in this patient EXCEPT:
T e rst laboratory test you have available is a room air A) Hypomagnesemia.
arterial blood gas (although venous would have been ne, B) Furosemide.
right?): pH 7.12, PaCO2 33 mm Hg, PaO2 80 mm Hg, HCO3 C) Acidosis.
10 mEq/L, and oxygen saturation 92%. D) Beta-agonists such as albuterol.
E) Diarrhea.
Question 5.5.1 This blood gas is most consistent with which
o the ollowing processes? Answer 5.5.2 The correct answer is “C.” Acidosis should cause a
A) Compensated metabolic acidosis. spurious elevation in potassium—not hypokalemia. Magnesium
B) Compensated respiratory acidosis. (“A”) depletion promotes potassium loss. T us, hypomagnesemia
C) Poorly compensated metabolic acidosis. can contribute to hypokalemia. “B,” urosemide and other loop
D) Poorly compensated respiratory acidosis. diuretics, causes renal potassium wasting. “D,” beta-agonists
E) Pure respiratory alkalosis. shif potassium into cells thereby lowering the serum potassium.
Diarrhea (“E”) causes direct gastrointestinal losses o potassium.
Other causes o hypokalemia include thiazide diuretics,
Answer 5.5.1 The correct answer is “C.” T is patient is clearly metabolic alkalosis (of en rom protracted emesis—although
acidotic, as her pH is well below the normal range o 7.35 to 7.45. this represents a shif o potassium intracellularly and not a true
So, obviously, whatever she has, it will be poorly compensated, hypokalemia), hyperaldosteronism, and R A types 1 and 2.
ruling out “A” and “B.” Based on the bicarbonate (HCO3) level
and the history o gastrointestinal losses due to diarrhea, you
would suspect a metabolic acidosis. In order to have appropriate INTERESTING (BUT USELESS) TIP:
respiratory compensation, the PaCO2 should all 12 points or Unti 1970, “ i t sa t” c ntain d it ium c id . y u
every 10-point drop in the HCO3 below the normal level (nor- c ud andma’s t nsi n and mania at t
mal HCO3 is around 24 mEq/L). sam tim ! A as in Ja an wit i it ium c nt nt
In this case, the HCO3 is 10 mEq/L (14 points below nor- in t s i av w at s d ssi n and suicid .
mal); there ore, the PaCO2 is expected to drop by about (1.2 ×
14 = 16.8) or approximately 17. However, the PaCO2 is not
23 mm Hg; it is 33 mm Hg (close to the normal range o 35–45). HELPFUL TIP:
T e patient’s PaCO2 is too high to appropriately compensate or Acid sis wi s u i us vat a ati nt’s tassium.
her metabolic acidosis, and she thus has a poorly compensated T s um tassium s u b ab ut 1 meq/l v-
metabolic acidosis. d c as in h 0.1. A ka sis wi caus an quiv-
a nt ka mia. S , i t h is 7.3, 1 meq/l t
vat d tassium is du t t acid sis.
T ere is another way to do this:
T e pH should change by 0.08 or every 10 change in CO2. So, i
a patient’s CO2 is 50, the pH should be 7.32 i it is an uncompen- Question 5.5.3 Since your administration likes to keep
sated respiratory acidosis. I they are more acidotic (e.g., 7.24), the hospital at 99% capacity, there are currently no
they have a mixed respiratory and metabolic acidosis. I they cardiac-monitored beds available or this patient. The most
are less acidotic (e.g., 7.39), they have a compensated respira- appropriate initial therapy to correct her hypokalemia
tory acidosis. (2.1 mEq/L) is to give your patient:
 CHAPTER 5 • Neph r o l o g y 155

A) KCl 40 mEq orally. • Discuss caus s ka mia?

B) KCl 80 mEq orally. • Mana a ati nt wit m tab ic acid sis and ka mia?
C) KCL 20 mEq per hour IV.
D) KCl 20 mEq push IV.
E) KCl 60 mEq per hour IV. QUICK QUIZ: r h ABDo Myo l ySIS

Answer 5.5.3 The correct answer is “C.” Remember that this T e primary mechanism by which renal ailure occurs in rhab-
patient is nauseated and lethargic and has been unable to eat. domyolysis is:
T us, oral potassium replacement is not going to work. Couple A) Glomerular destruction.
this with the act that she is pro oundly hypokalemic, and IV B) Acute tubular necrosis (A N).
replacement becomes the treatment o choice. One should not C) Interstitial nephritis.
give more than 20 mEq KCl IV per hour without a cardiac mon- D) None o the above.
itor. It should be given through a large bore peripheral IV or a
central line due to venous irritation. I you chose “D,” you just The correct answer is “B.” Myoglobin deposits in the renal
ailed your test. IV push KCl is atal. tubules, causing local damage and ischemia, which results in
Most commonly, the chloride salt o potassium (KCl) is admin- acute tubular necrosis. Findings in the urinary sediment that
istered to replete potassium stores. In the conscious patient with support acute tubular necrosis include renal tubular epithelial cells
a unctional gastrointestinal tract, oral KCl should be adminis- and dark brown casts o granular material (“muddy” brown casts).
tered. Oral and intravenous bioavailability is very similar, but oral
doses greater than 40 to 60 mEq may not be well tolerated.
HELPFUL TIP:
pati nts wit abd m sis wit c atin kinas (CK)
HELPFUL TIP: < 5,000 U/l and c a u in a un ik t d v acut
T a n iab ducib wa s t au tas- tubu a n c sis but s u d b m nit d t assu
sium d ti n and am unt n d d t mak a ati nt d in CKand ad quat na uncti n.
uka mic. T b st t in t d is sta t acin wit KC
and m nit s um tassium v s, adjustin t KC
d s as u . B ca u w n d in tassium -
ac m nt: ka mia is m st c mm n iat nic. QUICK QUIZ: l UMpy KIDNeyS

Which o the ollowing is/are associated with autosomal domi-

Question 5.5.4 In addition to KCl repletion, which o the ol- nant polycystic kidney disease (ADPKD)?
lowing interventions do you initiate now in an attempt to A) Liver cysts.
correct the acidosis? B) Cerebral aneurysms.
A) Bolus normal saline. C) Colonic diverticula.
B) Sodium bicarbonate. D) Cardiac valvular disease.
C) Bolus 5% dextrose. E) All o the above.
D) Intubation and mechanical ventilation.

Answer 5.5.4 The correct answer is “A.” On the basis o his-
tory, physical examination, and BUN/creatinine ratio, your
patient is dehydrated. T e rst step is to correct the dehydra-
tion with intravenous uids. Normal saline is pre erred over
dextrose (“C”), which might lead to urther hyponatremia and
hypokalemia. In addition, dextrose will not stay intravascular
and will actually precipitate a diuresis by making the serum
hypotonic. “B” is incorrect. T ere is no evidence that bicar-
bonate improves outcomes in metabolic acidosis. T e best
initial approach is to correct the underlying problem. In most
cases, volume replacement will lead to improvement in acidosis
without needing to resort to bicarbonate. Although she is oxy-
genating well now, i your patient’s respiratory condition deteri-
orates, she may require intubation (“D”) and ventilator settings
could be adjusted to aid in correcting the acid/base disorder.
Objectives: Did you learn to . . .
• D n acid sis and distin uis c m nsat d m A 79-year-old emale nursing home resident with moderate
c m nsat d acid sis?
The correct answer is “E.” All o the above are associated with
polycystic kidney disease. O particular importance is the pos-
sibility o cerebral aneurysms (5–20%) leading to subarachnoid
hemorrhage. However, aneurysm rupture remains airly rare
(but does seem to run in amilies—and seems to result in a
really bad day or your patient). Currently, screening or sub-
arachnoid aneurysms in asymptomatic patients with ADPKD is
not recommended.
ADPKD occurs in 1 in every 400 to 2,000 live births and is,
as the name implies, autosomal dominant. Common extrarenal
mani estations o ADPKD include cerebral aneurysms, hepatic
cysts, cardiac valve disease, colonic diverticula, and abdominal
and inguinal hernias.
QUICK QUIZ: To o SAl Ty
dementia presents or worsening con usion over the last 2 days.
156 FAMIl y MeDICINe eXAMINATIo N & Bo Ar D r eVIeW

She just nished antibiotics or a urinary tract in ection. Her tem-

HELPFUL TIP:
perature is 38.1°C, pulse 110 bpm, respiratory rate 18 breaths/
Ca cu at s a avai ab t stimat wat d icit in
minute, and blood pressure 118/60 mm Hg. She is disoriented
v mic nat mic ati nts. T a s v a
and lethargic. Examination o the heart, lungs, and abdomen is
quati ns and it’s n t c a t at n is su i t an-
unremarkable.
t . h w v , t s must b vi w d as u uid s.
Laboratory studies are as ollows: Na 165 mEq/L, K
As uids a ac d, ass ss t ati nt qu nt
4.6 mEq/L, Cl 118 mEq/L, HCO3 28 mEq/L, BUN 31 mg/dL, Cr
usin c inica and ab at m asu s.
1.1 mg/dL. Urine speci c gravity is > 1.030 and urine osmolality
is 700 mmol/kg (elevated, re ecting reabsorption o ree water).
Her CBC is normal.
CASE 5.6
Initial treatment or this patient should be: A surgical colleague asks you to consult on a patient because
A) Normal saline IV bolus. o increasing creatinine (yes, we know this will never happen
B) Dextrose 5% IV bolus. with a surgeon—just consider this a thought experiment). A
C) Sterile water IV bolus. 63-year-old woman was admitted or an elective cholecystec-
D) Loop diuretics. tomy. She is on postoperative day 3 and has ever and delir-
E) DDAVP. ium. Her current medications are morphine, ce otetan, and
acetaminophen as needed. She takes nothing by mouth, but
The correct answer is “A.” Demented or delirious patients with
has intravenous uids (5% dextrose/0.45% saline) running
an acute ebrile illness may not be able to consume enough ree
at 100 cc/hr . . . continuously . . . since surgery. Plasma studies
water to avoid hypernatremia. Several mechanisms may be at
rom the day o surgery and this morning are available:
work: ree water loss due to illness, impaired thirst, and inability
to respond to thirst due to cognitive or physical impairments.
Just as with hyponatremia, the hypernatremic patient should Laboratory Test Be ore Surgery Day o Consultation
not be corrected too quickly. Sudden changes in plasma sodium
S dium (meq/l ) 138 130
may result in cerebral edema. Although there are no standard-
ized guidelines to direct the correction o hypernatremia, most p tassium (meq/l ) 4.5 5.8
authorities recommend a maximal correction o 0.5 to 1 mEq/L/
C id (meq/l ) 103 105
hr. In this patient who appears hypovolemic, the primary con-
cern is to give volume. T e administration o normal saline h Co 3 (meq/l ) 24 18
will allow you to administer volume while lowering her plasma
BUN (m /dl ) 15 30
sodium. Dextrose 5% solution will likely lower the sodium too
quickly. Sterile water should never be administered IV because C atinin (m /dl ) 1.1 2.0
it will cause massive local hemolysis.
“E” is incorrect. T is patient’s kidney unction is appropriate
or her hypernatremia. She is concentrating her urine, as evi- Question 5.6.1 The BUN/Cr ratio on the day o consultation
denced by her high urine speci c gravity and urine osmolality. suggests that:
T ere ore, she does not have diabetes insipidus, which is char- A) She is dehydrated.
acterized by large volumes o dilute urine. DDAVP is an appro- B) She has a prerenal cause o her increased creatinine, such as
priate treatment or central diabetes insipidus. See able 5-7 or hypoper usion.
more on causes o hypernatremia. C) Intrinsic kidney disease is more likely than a prerenal cause
o her increased creatinine.
D) None o the above.
TABLE 5-7 CAUSES OF HYPERNATREMIA
Answer 5.6.1 The correct answer is “C.” A BUN/Cr ratio
• g I ss wat
• o sm tic diu sis < 20 generally indicates an intrinsic renal cause o renal ailure
• exc ss x cis and sw atin (increasing Cr) while a BUN/Cr ratio > 20 indicates a prerenal
• Diab t s insi idus cause such as hypoper usion (e.g., CHF, dehydration). In this
• D c as d acc ss t wat patient, the BUN/Cr ratio is 15, suggesting intrinsic renal disease.

Question 5.6.2 Which o the ollowing is the most appro-

HELPFUL TIP: priate rst step in determining the nature o this patient’s
g n a , u at m c anisms wi maintain a n - elevated creatinine?
ma s um s dium. h w v , t is qui s acc ss t A) Give a trial bolus o normal saline.
wat . Imm bi ati nts ( s cia t d ) a B) C scan o the abdomen.
a ticu a n t b ms b caus t i imit d C) Determine volume o urine output.
m bi it and inabi it t ind nd nt acc ss wat . D) Obtain urine or culture.
E) Give a trial dose o urosemide.
 CHAPTER 5 • Neph r o l o g y 157

Answer 5.6.2 The correct answer is “C.” Currently, all you
know about this patient’s kidney unction is that it has declined
since her admission and that it is not likely rom a prerenal
cause. It is important to know i this patient is oliguric/anuric
or has adequate urine output. T is is important because it can
a ect the treatment. For example, oliguric or anuric patients
may become volume overloaded easily in response to IV uids.
Although hospital measurements o intake and output are of en
plagued by errors, you should start this evaluation by analyzing
the patient’s urine output, as well as uid intake. Urine culture
and C scan may eventually play a role in your evaluation. T e
decision to give uids or diuretics cannot be made until more
in ormation is gathered.
HELPFUL TIP:
r ativ sma c an s in s um c atinin ma
ct acut kidn inju ( vi us t m d “acut
ai u ”). A ati nt wit a bas in c atinin 0.7 m /
dl as st hal na uncti n w n c atinin
inc as s t 1.4 m /dl , v n t u t is numb ma
sti b in t n ma an a a ticu a ab—t us,
t n d t ca cu at a c atinin c a anc and/
MDr D g Fr . T a a numb d initi ns acut
kidn inju ( . ., r IFl e, AKIN, and KDIg o c it ia), but
t basic mis is t at b s m bj ctiv m asu
( . ., c atinin , u in ut ut), kidn uncti n as a -
id d c in d.
Question 5.6.3 You have now determined that your patient
has become oliguric. Which o the ollowing is most likely
to help you narrow the dif erential diagnosis o renal
ailure?
A) Calculation o creatinine clearance.
B) Arterial blood gases.
C) C scan o the abdomen.
D) Fractional excretion o sodium (FENa).
E) Furosemide challenge.
Answer 5.6.3 The correct answer is “D.” In this patient, you
know that her BUN/Cr ratio is < 20, pointing you toward intrin-
sic renal disease. But this ratio is not speci c enough to rely
upon. In oliguric renal ailure, the FENa is a use ul tool to help
di erentiate prerenal causes o renal ailure rom intrinsic renal
causes. I the FENa is less than 1%, the kidney is unctioning
-
appropriately to conserve sodium and water to better per use
na
the kidney, and a prerenal cause o ailure is more likely such
as hypoper usion rom shock, dehydration, heart ailure, etc. I
the FENa is greater than 1%, salt and water losses are excessive,
suggesting intrinsic kidney dys unction. T is calculation is most
meaning ul in oliguric renal ailure (urine output < 400 cc/day),
but can also be used with any acute kidney injury in order to
help determine the possible underlying cause. Also, FENa may
be inaccurate in the elderly, patients receiving diuretics, and in
chronic renal ailure. T e equation used to calculate FENa is:
FENa (%) = [(urine Na/plasma Na)/
(urine Cr/plasma Cr)] × 100.

HELPFUL TIP: HELPFUL TIP:

l ik acut kidn inju , t is n sin numb t at W at i t ati nt is n a diu tic and u cann t mak
d in s i u ia. h w v , n c mm n us d d ini- us t FeNa? Us t FeU a, as u a xc ti n is n t
ti n i u ia is: ss t an 1 ml /k / in in ants, ss a ct d b diu tics. h ’s t quati n:
t an 0.5 ml /k / in c i d n, and ss t an 400 ml / FeU a (%) = [(u in u a/ asma u a)/
da adu ts. o c u s , anu ia is d in d as n u in (u in C / asma C )] × 100.
ut ut.
I t FeU a is <35%, a na caus is m ik . I
FeU a is > 50%, acut tubu a n c sis is m ik .
Cav at: c mic diu sis inc as s xc ti n
Vital signs, intake, and output have been recorded by the u a v n in v mic stat s ( . ., 3 + uc s in t
nurses or each shi since admission and are provided in u in can iv ua as i FeU a).
able 5-8.

TABLE 5-8 VITAL SIGNS, INTAKE, AND OUTPUT

Day 1 Day 1 Day 1 Day 2 Day 2 Day 2 Day 3 Day 3 Day 3
Shi t 1 Shi t 2 Shi t 3 Shi t 1 Shi t 2 Shi t 3 Shi t 1 Shi t 2 Shi t 3
Bp 118/60 117/63 102/57 80/42 92/48 102/67 105/60 102/61 102/79

pu s 84 82 92 124 117 106 100 102 93

Tm 37.3 37.0 37.7 40.0 39.1 37.1 38.0 36.9 36.8

rr 12 14 13 15 20 18 20 12 12

IV in (cc) 1,800 800 800 800 800 800 800 800 800

U in ut (cc) 1,650 1,000 750 850 600 400 180 100 80

158 FAMIl y MeDICINe eXAMINATIo N & Bo Ar D r eVIeW
On examination, you nd a mildly disoriented emale in no
acute distress. She has lower extremity and sacral edema.
You obtain urine studies, showing a speci c gravity o 1.020,
pH 6, 3 RBCs/hp , 2 WBCs/hp , and muddy brown granular
casts. T e urine creatinine is 6.5 mg/dL and the urine sodium
is 45 mEq/L. You calculate the FENa at > 1%.
Question 5.6.4 Given the clinical course and urine ndings,
which o the ollowing is the best diagnosis?
A) Acute tubular necrosis (A N).
B) Acute interstitial nephritis (AIN).
C) Vasculitis.
D) Heart ailure (HF).
E) Lactic acidosis.
Answer 5.6.4 The correct answer is “A.” A N is a major cause
o acute kidney injury in hospitalized patients. A N is the result
o toxic and/or ischemic e ects on the kidney tubules. Meta-
bolic derangements in A N include progressive hyponatre-
mia, hyperkalemia, and metabolic acidosis with a high anion
gap, all o which are present in this case. ypically patients with
A N have a FENa > 1% (or FEUrea > 50%) and a urine sodium
> 40 mEq/L (Remember, the unctioning kidney should be
retaining sodium to increase its per usion with extrinsic AKI).
T is is not happening here. So it is an intrinsic renal problem.
In this case, FENa is 9.9%. In addition, “muddy” brown casts
(renal tubular cell casts) are of en ound in the urinary sediment
o patients with A N. All o these ndings point to A N as the
cause o renal ailure in this patient.
Question 5.6.5 Based on the available data (including the
vital signs in Table 5-8 and urine values), you suspect that
ATN in this patient is the result o :
A) Acetaminophen.
B) Hypotension.
C) Intrinsic renal in ection.
D) Ce otetan.
E) Any o the above is equally likely.
Answer 5.6.5 The correct answer is “B.” As you review the vital
signs, intake, and output, you will notice that the patient had a
hypotensive period associated with tachycardia and ever (day
2, shif s 1 and 2). She then developed progressively lower urine
output despite stable IV intake. It is likely that she has had an
ischemic insult to her kidneys as a result o hypotension and
decreased per usion. While many medications can cause A N,
ce otetan and acetaminophen are relatively sa e. More of en,
cephalosporins cause acute interstitial nephritis ( ever, + /−
rash, white cell casts, and eosinophils in the urine and perhaps
in the peripheral blood).
HELPFUL TIP:
In additi n t xic insu t (s ck, usi n,
h F, tc.), c mm n caus s ATN inc ud m dicati ns
suc as tac imus, va i us ACe in ibit s, s m t
nici in d ivativ s, ntamicin, t b am cin, c c -
s amid , s v a anti- j cti n d u s, and m .
When you go to check on the patient later in the a ernoon, she
has become more tachypneic and has rales on examination.
Question 5.6.6 Which o the ollowing recommendations
do you make or this patient’s continuing care?
A) Administer dopamine.
B) Increase IV uids to 200 cc/hr, using 5% dextrose/0.45%
saline.
C) Hemodialysis.
D) Administer hydrochlorothiazide.
E) Administer urosemide.
Answer 5.6.6 The correct answer is “E.” T e treatment o acute
renal ailure due to A N is largely supportive. In this oliguric
patient with signs o volume overload, a trial o a loop diuretic
is appropriate. Intravenous urosemide dosed at 20 to 100 mg
every 6 to 12 hours is a reasonable way to start. O note, uro-
semide will of en improve the symptoms o volume overload
even i there is no diuresis; it has some direct vasodilating a ect
which decreases pulmonary artery pressure. “A,” dopamine, is
not e ective in the treatment o A N (it is not “renal sparing”
and does not increase GFR). “B,” more uid, is clearly not indi-
cated in this patient who is already uid overloaded. Why not
dialysis you ask (“C”)? Early dialysis in A N is associated with
greater mortality and increased kidney damage rom hypoten-
sion, in ection, and complement activation in the kidney. “D,”
HC Z, is less likely than urosemide to achieve a good diuretic
e ect in the setting o a low GFR.
HELPFUL TIP:
W i t aditi na tau t, t in t “c nv t” i u ic t
n n i u ic na ai u (b in t kidn s wit
diu tics) is n t u and is ssib amu.T
is a t nd t wa d at m ta it in ati nts w a
t at d t is wa . T ’s m : it can caus d a n ss
( ?), v ti , and tinnitus. r m mb , it d sn’t
t a d ad s ai in kidn s. W did w t ink
it w k d in t ast? p bab t w w
ab t duc u in in s ns t diu tics w ss
sick t b in wit .
Your patient has very little response to urosemide, but you
match her input and output and she has enough insensible
loss to resolve her rales. She begins to eat, and you monitor
her uid intake care ully. You match her uid intake with
output, giving normal saline to match her urine output and
suspected insensible losses. You treat her hyperkalemia with
sodium polystyrene sul onate without sorbitol (Kayexalate),
which is e ective. Her BUN and creatinine continue to rise
over the next two days and reach 60 and 4 mg/dL, respec-
tively. T e plasma HCO3 is 18 mEq/L.
Question 5.6.7 You now recommend:
A) Hemodialysis.
B) Sodium bicarbonate.
 CHAPTER 5 • Neph r o l o g y 159

C) Strict protein restriction.

D) Continuing to match intake and output. CASE 5.7
E) All o the above. While on call, you admit a 75-year-old emale or con usion.
One month ago, she started HC Z or hypertension. Her
Answer 5.6.7 The correct answer is “D.” At this point, there medications include HC Z 25 mg daily, levothyroxine 125
is no reason to change your therapeutic approach. In particu- mcg daily, aspirin 81 mg daily, sertraline (Zolo ) 50 mg daily,
lar, hemodialysis is not necessary. Indications or hemodialysis and atorvastatin (Lipitor) 40 mg daily. She has a 50-pack-year
in this patient might include symptomatic uremia (e.g., coma, history o tobacco use and continues to smoke.
pericarditis), severe hyperkalemia or acidosis unresponsive to On examination, you nd an irritable, con used emale in
other therapies, and complications o volume overload (e.g., no acute distress. Her admission vitals: BP 100/60 mm Hg,
pulmonary edema). Dialysis is actually associated with worse P 120 bpm, RR 12 breaths/minute, 36.1°C, weight 50 kg.
outcomes and prolonged renal disease (complement xation Her oral mucosa is dry and she has poor skin turgor. She has
in the kidney produces additional injury, episodic hypoten- clear lungs, an S4 on heart examination, and no edema. Her
sion rom dialysis increases kidney injury). Sodium bicarbon- neurological examination is non ocal.
ate is used orally in patients with signi cant chronic acidosis in Laboratory results: Na 110 mEq/L (low), K 3.0 mEq/L
end-stage renal disease, but many patients can tolerate the tem- (low), Cl 70 mEq/L (low), HCO3 33 mEq/L (high), BUN
porary mild acidosis associated with acute kidney injury. Dra- 30 mg/dL, Cr 1.0 mg/dL, glucose 110 mg/dL. Plasma osmo-
matic protein restriction will probably help to control uremia, lality 220 mOsm/L (normal 270–299 mOsm/L).
but lower BUN should not be your primary goal. Your patient is
recovering rom surgery and was probably septic. She requires Question 5.7.1 Which o the ollowing statements is true
good nutrition to continue to heal. regarding the etiology o her hyponatremia?
A) She has pseudohyponatremia.
B) She has isovolemic hyponatremia.
HELPFUL TIP:
C) She has hypovolemic hyponatremia.
Acut kidn inju du t ATN t ica asts 7 t
D) She has hypervolemic hyponatremia.
21 da s, wit na uncti n tu nin as t tubu a
c s n at . h w v , t c u s is i va iab
Answer 5.7.1 The correct answer is “C.” T e de nition o hypo-
and d nds n t ati nt’s n a a t and t
natremia is a plasma sodium concentration below 135 mEq/L.
n t and d t initia inju .
T e evaluation o hyponatremia begins with the determination
o the validity o the plasma sodium measurement. First ques-
Question 5.6.8 In patients with acute tubular necrosis, the tion: is this pseudohyponatremia (“A”)? Look at the measured
most common cause o death is: serum osmolality. I it is low (as it is here), the patient does
A) Hemorrhage. not have pseudohyponatremia. Pseudohyponatremia is caused
B) Adverse event o hemodialysis. by either hyperlipidemia or hyperproteinemia decreasing the
C) In ection. water content o plasma. T is distinction was more important
D) rans usion reaction. in the past; newer laboratory techniques compensate or pseu-
E) Heart ailure secondary to uid overload. dohyponatremia.
Hyperglycemia and severe uremia can cause hyponatremia
Answer 5.6.8 The correct answer is “C.” In patients with A N (not called “pseudohyponatremia” or reasons that the editors
who die, in ection is the usual culprit. It is critical to avoid sepsis don’t ully understand). In an instance where a patient’s mea-
in these patients. Also, serious in ection resulting in sepsis is a sured sodium concentration is hyponatremic and his glucose
common cause o A N. It’s the circle o li e . . . or death, in this is 800 mg/dL, the measured serum osmolality may be normal
instance. or elevated (due to the elevated glucose, which “counts” as
osmoles) and should be compared to the calculated osmolality
en days a er her surgery, your patient’s urine output using the equation:
increases markedly. Her BUN and creatinine return to their
premorbid levels. T e National Kidney Foundation makes Osmolality = 2 (sodium) + glucose/18 + (BUN/2.8)
you an honorary nephrologist and awards you the Bronze
I the calculated osmolality approximates the measured osmo-
Nephron.
lality, then much o the “hyponatremia” will autocorrect when
Objectives: Did you learn to . . . the hyperglycemia is corrected. T ere ore, you would not want
• eva uat a s ita iz d ati nt acut kidn inju ? to aggressively correct the serum sodium concentration without
• Us u in studi s, inc udin u in s dium and FeNa, t assist consideration o the patient’s hyperglycemia. When in doubt,
in t dia n sis acut kidn inju ? requent sodium monitoring is advisable.
• Id nti acut tubu a n c sis? T e next step in the evaluation o hyponatremia is to deter-
• D sc ib c mm n caus s acut tubu a n c sis, its t at- mine the patient’s volume status. T is patient has no signs o vol-
m nt, and its n sis? ume overload, such as edema or crackles, making hypervolemia
160 FAMIl y MeDICINe eXAMINATIo N & Bo Ar D r eVIeW

unlikely. She is tachycardic with a low blood pressure, dry hypoosmolality). T us, the urine should have a speci c gravity
mucous membranes, and a BUN/Cr ratio greater than 20, sug- less than 1.005 and osmolality less than 100 mmol/kg.
gesting she is hypovolemic. Most likely, she has a hypovolemic Inappropriately concentrated urine (osmolality > 100 mmol/
hyponatremia. kg) occurs when there is limited excretion o uid and may be
observed in SIADH, HF, cirrhosis, and renal ailure. T is is also
re ected in the urine sodium. I the kidneys respond to hypona-
HELPFUL TIP:
tremia as expected, urine sodium concentration should be low,
A wa s c nsid “b t mania” ( n u av it
typically less than 20 mmol/L and of en less than 10 mmol/L (the
dis as nam s . . . n t t m nti n n u av it
kidneys are attempting to retain sodium to increase the serum
d u s). h is w at a ns: t muc b (
osmolarity). In the setting o hypovolemia, i the urine sodium
an a c ) us t itt s ut qua wat
concentration is inappropriately high, something is inappropri-
xc ti n and nat mia.
ately spurring the kidney to excrete sodium (e.g., diuretic use,
hypoaldosteronism). In this patient, the elevated urine sodium
Question 5.7.2 What urther in ormation will help you is likely due to the diuretic. Diuretic use is the most common
narrow the dif erential diagnosis o hyponatremia in this cause o hypovolemic hypoosmolality, and thiazides are more
patient? commonly associated with hyponatremia than are loop diuret-
A) FENa. ics ( urosemide, etc.). Your patient is hypovolemic and hypona-
B) Urine osmolality and urine sodium concentration. tremic, with a high urine sodium concentration and the history
C) Urine creatinine concentration. o diuretic use: most likely, her hyponatremia is diuretic induced.
D) Urine potassium and calcium concentration. “D,” a reset osmostat, requires special mention. A reset
osmostat, which is responsible or 20% to 30% o hyponatremia,
Answer 5.7.2 The correct answer is “B.” Urine osmolality occurs when the patient’s body “adapts” to hyponatremia and
can be used to distinguish between impaired water excretion gives up trying to correct the problem: the kidneys just throw in
caused by SIADH (syndrome o inappropriate secretion o anti- the towel. Patients with a reset osmostat will present like SIADH
diuretic hormone), and pathologic water intake (polydipsia). (hyponatremia, euvolemia or slight hypervolemia, and inappro-
In SIADH, the urine will be inappropriately concentrated with priately concentrated urine) but will be resistant to treatment.
urine osmoles o > 100 mosmol/kg (the patient is unable to I a patient with apparent SIADH does not respond to the usual
retain sodium). FENa is discussed earlier; although the word treatment, consider a reset osmostat. Since patients with a reset
“sodium” is in it, FENa is not help ul or discovering the etiol- osmostat generally have mild hyponatremia (125–130 mg/dL)
ogy o hyponatremia. Concentration o potassium and calcium and are generally asymptomatic, trying to correct the sodium by
is not likely to add any use ul in ormation. limiting water intake is unnecessary and utile.

You order urine studies. Urinalysis: speci c gravity 1.025, pH HELPFUL TIP:
5.0, trace protein, 0 to 1 RBC/hp , 0 to 1 WBC/hp , otherwise W n u nc unt a ati nt wit nat mic
negative. Spot urine Na 70 mEq/L (elevated) and urine osmo- sm a it , a s k at t asma tassium
lality = 700 mmol/kg (elevated). c nc nt ati n. Diu tic us is a c mm n caus -
nat mia, ka mia, c mia, and s-
Question 5.7.3 Given the patient’s history, urine studies,
m a it ccu in simu tan us .
and hypovolemic status, what is the most likely diagnosis?
A) Syndrome o inappropriate secretion o anti-diuretic hor-
mone (SIADH). Question 5.7.4 In addition to discontinuing her diuretic,
B) Heart ailure (HF). which o the ollowing approaches is the best initial ther-
C) Diuretic-induced hyponatremia. apy or her hyponatremia?
D) Hyponatremia due to reset osmostat. A) Saline 0.9% 1 L bolus ollowed by 150 cc/hr.
E) Potato chip de ciency (hypopringlism). B) Fluid restriction to 1,500 cc/day.
C) Saline 3% 100 cc/hr or 24 hours.
Answer 5.7.3 The correct answer is “C.” In order to be use ul D) Saline 0.45% 100 cc/hr or 24 hours.
in the diagnosis o hyponatremia, urine studies must be viewed E) Saline 3% at 60 cc/hr and urosemide 40 mg IV.
in the context o volume status, plasma osmolality, and electro-
lyte levels. T is patient’s laboratory results are consistent with Answer 5.7.4 The correct answer is “A.” T is patient is hypo-
SIADH. However, patients with SIADH should be euvolemic or tensive and tachycardic and thus needs volume somewhat
slightly hypervolemic. T us, her laboratory results and clinical quickly to address her abnormal vital signs. I this patient was
picture are most consistent with diuretic-induced hyponatre- not hemodynamically compromised, you could orgo the uid
mia. Note that she also has a contraction alkalosis (low chloride, bolus. Excessively rapid correction o hyponatremia may lead to
elevated bicarbonate). pontine myelinolysis.
T e appropriate response o the kidney to hypoosmolality is Sodium concentrations less than 120 mEq/L are considered
to make maximally dilute urine (retain sodium to correct the severe hyponatremia. Patients with acute, severe hyponatremia

are almost always symptomatic as a result o the low sodium. By
de nition, acute hyponatremia has been present or 48 hours
or less and chronic hyponatremia or more than 48 hours. As
previously discussed, your patient’s hyponatremia is due to a
diuretic, which she started 1 month ago. T ere ore, her hypona-
tremia is more likely to be chronic.
As a general rule, hypovolemic hyponatremia should be cor-
rected by volume in usion, usually with 0.9% (normal) saline.
Fluid restriction (“C”), while good treatment or SIADH, is
not appropriate in this patient who is already volume depleted.
Likewise, a loop diuretic is not a good approach (“E”). Both
“C” and “E” will exacerbate the problem. Hypo-osmolar solu-
tions, like 0.45% saline (“D”), will lead to more severe hypo-
natremia.
Your patient has chronic hyponatremia, which needs to be
corrected more slowly than acute hyponatremia. Chronic hypo-
natremia should be corrected no aster than 0.5 mEq/hr or 12
mEq/day. For signi cantly symptomatic patients with acute
hyponatremia, sodium can be corrected more quickly with
maximum increases in plasma sodium concentration o 1 mEq/
hr or 20 mEq/day.
In order to determine how quickly sodium concentrations
will rise, you must know the concentrations o the solution
being in used and the patient’s plasma sodium. A liter o saline
will a ect the serum sodium by the ollowing calculation:
Na increase = (solution Na − plasma Na)/
(total body water + 1).
Patient’s Na = 110 mEq/L.
Na in 3% saline = 513 mEq/L.
Na in 0.9% saline = 154 mEq/L.
otal body water = weight (kg) × 0.5 ( emales) or 0.6 (males).
When using 3% saline solution, 1 L will increase the plasma
sodium as ollows:
Na increase = (513 – 110)/[(50 × 0.5) + 1]
= 15.5 mEq/L.
At 100 cc/hr, the plasma sodium will increase at a rate o
1.55 mEq/hr.
T is correction is too rapid or chronic hyponatremia.
When using normal saline (0.9%), 1 L will increase the
plasma sodium as ollows:
Na increase = (154 – 110)/[(50 × 0.5) + 1] = 1.7 mEq/L.
T ere ore, 1 L o normal saline will increase the plasma sodium
by 1.7 mEq initially, and 150 cc/hr will increase the plasma
sodium by 0.25 mEq/hr, well within the sa e range.
HELPFUL TIP:
W n v c ctin s dium, w t wit na-
t mia nat mia, c ck s um s dium c nc n-
t ati ns qu nt — v 6 u s is as nab in t
initia t atm nt i d.
CHAPTER 5 • Neph r o l o g y 161
Question 5.7.5 In addition to HCTZ, which medication
should you discontinue because o its potential role in
hyponatremia in this patient?
A) Aspirin.
B) Atorvastatin.
C) Levothyroxine.
D) Sertraline.
Answer 5.7.5 The correct answer is “D.” Serotonin reuptake
inhibitors (SSRIs) and tricyclic antidepressants, among other
medications, can stimulate the release o ADH rom the pitu-
itary gland, ultimately causing hyponatremia with an SIADH-
type presentation. T e association between SSRIs and hypona-
tremia is strong enough to consider measuring plasma sodium
levels in elderly patients be ore and af er starting an SSRI. T e
other medications are not associated with hyponatremia to any
signi cant degree.
Your patient does well, recovers rom her hyponatremia, and
is discharged. In place o HC Z, you start an ACE inhibitor
or hypertension. You next see her a ew months later when
she starts to have problems with mild con usion. Her am-
ily reports that she is de nitely not taking any diuretics. Her
vitals are normal. Clinically, she appears euvolemic, and her
examination is non ocal. Her plasma sodium is 120 mEq/L,
creatinine 1.1 mg/dL, plasma osmolality 240 mmol/kg, and
urine osmolality 320 mmol/kg. Urinalysis shows speci c
gravity o 1.030 but is normal otherwise.
Question 5.7.6 In addition to the laboratory tests already
available to you, which o the ollowing laboratory tests
should be done in patients with hyponatremia?
A) CBC.
B) ESR.
C) SH.
D) Liver enzymes.
E) ADH.
Answer 5.7.6 The correct answer is “C.” Hyponatremia with
hypoosmolality and a normal volume status is of en the result
o SIADH. However, SIADH is a diagnosis o exclusion. Both
hypothyroidism and glucocorticoid de ciency present with
similar eatures and should be ruled out. Hypothyroidism is
more common, and at a minimum you must check SH. O
special note is option “E.” Most o the time, ADH levels are not
help ul in the diagnosis o SIADH because up to 20% o patients
with diagnosable SIADH do not have elevated plasma ADH lev-
els. SIADH is diagnosed on clinical grounds, with characteristic
laboratory data, and lack o a better explanation.
HELPFUL TIP:
In an iv n ati nt wit nat mia, w at mak s SI-
ADh ik ? A t win data a us d t su t
t dia n sis SIADh : d c as d asma sm a it ; in-
a iat c nc nt at d u in ( . ., a u in sm a it
162 FAMIl y MeDICINe eXAMINATIo N & Bo Ar D r eVIeW
> 100 m sm /k ); c inica uv mia mi d - HELPFUL TIP: C niva tan (Va is ®) and t va tan
v mia; vat d u in s dium xc ti n (u in s dium
> 20 meq/l ); and t abs nc diu tic us , t -
idism, and ad na d s uncti n.
You order a number o laboratory tests, including SH, CBC,
and electrolytes. In addition to the laboratory tests men-
tioned above, abnormal tests include plasma Cl 90 mEq/L
(low), urine Na 50 mEq/L (high) (and urine osmoles, as noted
above, are 320 mmol/kg). T yroid unction tests are normal.
You diagnose SIADH.
Question 5.7.7 As initial treatment, you prescribe:
A) Demeclocycline.
B) Lithium.
C) Saline 0.9% bolus.
D) Furosemide.
E) Water restriction.
Answer 5.7.7 The correct answer is “E.” T e labora-
tory results and clinical picture are consistent with SIADH
(euvolemia, elevated urine sodium excretion, elevated urine
osmolarity). Water restriction is the mainstay o therapy in
SIADH. Free water should be restricted to 1 to 2 L/day. Dem-
eclocycline and lithium inter ere with the activity o ADH at
the collecting tubules, but these drugs are reserved or SIADH
patients with severe hyponatremia unresponsive to water
restriction. Saline in usion corrects hypovolemic hyponatre-
mia, and urosemide is used in hypervolemic hyponatremia
(e.g., CHF, renal insu ciency). Neither o these conditions is
present in this patient.
Question 5.7.8 The patient ails water restriction. The next
step in the treatment o this patient is:
A) Demeclocycline.
B) Lithium.
C) Sodium chloride tablets.
D) IV urea.
E) None o the above.
Answer 5.7.8 The correct answer is “C.” Increasing salt intake
and adding a loop diuretic are other ways to treat SIADH in
patients who cannot or will not maintain uid restriction. T e
aggressiveness o the intervention will depend on patient-
speci c actors, including symptoms and comorbidities. In an
outpatient who is minimally symptomatic or asymptomatic,
oral salt supplementation is most reasonable. IV urea (“D”),
which causes an osmotic diuresis, could be considered as the
next step af er sodium chloride tablets. Demeclocycline and
lithium should be reserved or patients who ail the other treat-
ments. In more severe hyponatremia and those with signi -
cant symptoms, admission or more aggressive therapy may be
warranted.
(Samsca) b t a ADh anta nists t at can b us d
SIADh . T a t i d- in a nts. p t ntia b ms
inc ud xac bati ns a t ai u , t static -
t nsi n, and ka mia. T must b sta t d in t
s ita b caus t t ntia sid cts and a id
s um s dium c an s.
Objectives: Did you learn to . . .
• g n at a di ntia dia n sis nat mia?
• Id nti m dicati ns t at a c mm n ass ciat d wit
nat mia?
• Us u in sm a it t id nti im ai d na wat and in ?
• Ca cu at s dium c cti n usin di nt c nc nt ati ns
sa in ?
• Dia n s , va uat , and t at a ati nt wit SIADh ?
CASE 5.8
A 65-year-old male with a new diagnosis o heart ailure
returns to your of ce a er starting several new medications
within the last month. A cardiologist at Ivory ower Aca-
demic Medical Center 100 miles away started these medica-
tions but never sent a note, and neither you nor your patient
knows what drugs he’s taking (“Well, there’s a little white one
and an oval one and . . .”). Over that same time period, he
states that he has elt “worse than I did a er my heart attack.”
At rst he was just atigued, but in the last ew days, he has
developed nausea, vomiting, and body aches.
On examination, his vitals are 37.1°C, P 70 bpm, RR
8 breaths/minute, BP 100/58 mm Hg. He has trace pedal
edema. His lungs are clear, and his abdomen is di usely ten-
der. When you stand him up to check his blood pressure, he
loses consciousness but quickly recovers when placed supine
( ortunately, you are strong and possess quick re exes and
caught him on the way down).
Your nurse draws blood, starts an IV, and obtains a venous
blood gas on room air. VBG: pH 7.52, PaCO2 49 mm Hg,
PaO2 40 mm Hg, and HCO3 39 mEq/L. His oxygen saturation
on monitor is 95%.
Question 5.8.1 The blood gas is consistent with the diag-
nosis o :
A) Metabolic alkalosis with respiratory compensation.
B) Respiratory alkalosis with metabolic compensation.
C) Mixed metabolic/respiratory alkalosis.
D) Mixed metabolic alkalosis and respiratory acidosis.
Answer 5.8.1 The correct answer is “A.” Your patient appears
to have a pure metabolic alkalosis with respiratory compensa-
tion. His pH is above the upper limit o normal (7.45), and his
plasma bicarbonate is elevated as well. In metabolic alkalosis,
you can expect the PaCO2 to rise in proportion to the rise in
HCO3. PaCO2 should increase by 0.5 to 0.75 times the increase
in HCO3 rom baseline (about 24 mEq/L). In this case, the
HCO3 has increased by 15 (39 – 24 = 15), and the PaCO2 has
 CHAPTER 5 • Neph r o l o g y 163

appropriately increased by 9 (9/15 = 0.6). And remember, you TABLE 5-9 CAUSES OF METABOLIC ALKALOSIS
cannot overcorrect your pH (although it is quite possible simul- DIVIDED BY URINE CHLORIDE LEVELS
taneously to have two processes—an acidosis and an alkalosis
Low Urine Chloride
resulting in a normal pH). T us, the primary process has to be
(<25 mEq/L) High Urine Chloride (>40 mEq/L)
an alkalosis.
V mitin h ka mia (s v )
Question 5.8.2 Which o the ollowing urine tests will aid in
Nas ast ic sucti nin Diu tics ( t iazid ; a ct)
determining the cause o this patient’s metabolic alkalosis?
A) Urine sodium. Factiti us dia a A ka i ad
B) Urine potassium. ( axativ abus )
C) Urine chloride. C stic b sis Ba tt /g it man s nd m s
D) Urine bicarbonate.
E) Urine creatinine. l wc id intak p ima min a c tic id xc ss
( a d st nism, c tic st ids)
Answer 5.8.2 The correct answer is “C.” You can approach the
p st ca nia
di erential diagnosis o metabolic alkalosis by measuring the
urine chloride (see next question). T e other urine studies Diu tics (
are less use ul in metabolic alkalosis. O course, an appropri- t iazid ; at ct)
ate history and physical as well as plasma tests are required to
determine the correct diagnosis and treatment.

You have admitted the patient and are on your way to the hos-
pital to see him when the laboratory tests return (you aren’t
driving and talking on the phone at the same time are you?).
Plasmastudies:Na140 mEq/L, K2.5 mEq/L(low), Cl 102 mEq/L
(normal), BUN 18 mg/dL, creatinine 0.9 mg/dL, Ca 8.4 mg/dL,
Mg 1.7 mg/dL (marginally low).
Urine studies: speci c gravity 1.025, chloride 45 mEq/L
(elevated).
Question 5.8.3 O the ollowing choices, which is NOT likely
to contribute to metabolic alkalosis in this patient?
A) Corticosteroids.
B) Diuretics.
C) Hypokalemia.
D) Vomiting.
Answer 5.8.3 The correct answer is “D.” T is makes intuitive
sense. I there is vomiting (or NG suctioning), the patient will
have low plasma chloride and thus will have little in the urine,
where it is being re-absorbed. All o the rest o the answers will
cause an elevated urine chloride and thus are consistent with
this patient’s picture. With mineralocorticoid excess (aldoste-
rone or extrinsic corticosteroids, “A,” one excretes potassium,
causing hypokalemia. Hypokalemia prevents the kidneys rom
optimally re-absorbing chloride (“C”). See able 5-9 or more
on causes o metabolic alkalosis.
It only took your nurse 40 minutes, but now you have the car-
diologist’s notes and the medication list. Your patient started
taking atorvastatin, captopril, urosemide, isosorbide dini-
trate, aspirin, and metoprolol in the last month—and you are
not surprised he has orthostatic hypotension.
Question 5.8.4 All o the ollowing are appropriate inter-
ventions in this patient EXCEPT:
A) Discontinue urosemide.
B) Administer potassium chloride.
C) Administer hydrochloric acid through an NG tube.
D) In use normal (0.9%) saline.
E) Administer ranitidine.
Answer 5.8.4 The correct answer is “C.” Chloride-responsive
metabolic alkalosis is usually secondary to volume contraction.
Your patient has renal salt and water losses due to a diuretic
and has gastrointestinal volume losses due to emesis. Physical
examination (except trace edema—but remember that he has
heart ailure) and laboratory ndings support hypovolemia. T e
diuretic should be discontinued and volume should be replaced.
An isotonic solution, such as normal saline, is an appropriate
choice. However, you must monitor your patient’s volume status
closely due to his heart ailure. Because his potassium is low, he
requires KCl. An H 2-blocker, like ranitidine, is a good choice or
a patient with alkalosis and gastrointestinal illness: it will reduce
acid secretion in the stomach (and thus urther acid loss) and
may o er some symptomatic relie as well.
Hydrochloric acid is an option in severe metabolic alkalosis
unresponsive to other therapies. However, it is not given by NG
tube. HCl is very corrosive and should only be in used centrally.
Question 5.8.5 Your patient is not responding to the KCl you
are administering. You give which o the ollowing electro-
lytes to aid in repleting his potassium stores?
A) Sodium.
B) Bicarbonate.
C) Calcium.
D) Phosphate.
E) Magnesium.
Answer 5.8.5 The correct answer is “E.” Give magnesium
be ore giving more potassium. Recall that his plasma mag-
nesium level was slightly low at 1.7 mg/dL. Even i a patient’s
magnesium is only slightly low or even low-normal, contin-
ued hypokalemia in the ace o KCl repletion may indicate
164 FAMIl y MeDICINe eXAMINATIo N & Bo Ar D r eVIeW
whole-body magnesium depletion. Serum magnesium levels
may not accurately re ect whole-body magnesium stores, espe-
cially in patients with heart ailure. Furosemide causes urther
magnesium wasting. None o the other electrolytes listed earlier
is as important to potassium repletion.
With correction o uid and electrolyte status, your patient
recovers quickly. You try to convey to the cardiologist the
importance o good communication. However, as noted by
George Bernard Shaw, “T e single biggest problem in com-
munication is the illusion that it has taken place.”
Objectives: Did you learn to . . .
• Id nti m tab ic a ka sis?
• Uti iz u in c id in t va uati n m tab ic a ka -
sis?
• r c niz va i us caus s m tab ic a ka sis?
• r c niz t ma n s mia in t atin ka-
mia?
QUICK QUIZ: h eMATUr IA
A 25-year-old male medical student presents with blood in his
urine. When asked urther about this nding, he admits that he
was using urine dipsticks at home to check his urine. (Did you
know that 20% o medical students meet the criteria or somati-
zation disorder—now known as “somatic symptom disorder” in
DSM V—at some time during medical school? It’s true.) He has
no gross hematuria, just 1+ blood on his urine sel -test. He has
no symptoms otherwise. His major concern is that his ather
had a renal transplant at age 30 or Alport syndrome.
Given that his ather had Alport syndrome, what is the prob-
ability that this student has it?
A) Certain (100% chance).
B) One in two.
C) One in our.
D) Less than 1 in 20.
The correct answer is “D.” Alport syndrome, also known as
hereditary nephritis, typically presents with microscopic hema-
turia and progresses to complete renal ailure. Alport syndrome
has a heterogeneous inheritance pattern: 80% o cases are due to
X-linked disease, about 15% are autosomal recessive, and about
5% are autosomal dominant. Since most cases are X-linked,
males are a ected more severely and earlier than emales. I
your medical student’s ather had Alport syndrome, it was most
likely X-linked, and the patient could not possibly have inher-
ited it. However, there is a 5% chance that the ather had autoso-
mal-dominant disease and then a 50% chance that the trait was
passed on to the patient; there ore, “D” is correct.
CASE 5.9
A 33-year-old male presents to the ED complaining o
shortness o breath and cough o 10 days duration. He now
sleeps in a chair due to orthopnea. He has severe atigue and
a mild, di use headache. Four days ago, he was seen in an
urgent care clinic and diagnosed with bronchitis. He reports
no medical problems or surgeries. He quit smoking 1 year
ago and denies alcohol and drug use. He has a strong amily
history o hypertension. T e review o systems is otherwise
negative.
On physical examination, his vitals are 36.8°C,
P 104 bpm, RR 16 breaths/minute, and BP 200/118 mm Hg.
T ere are bibasilar crackles with dullness to percussion at
the lung bases. T e heart, abdomen, and extremities are
unremarkable.
His chest x-ray shows cardiomegaly, cephalization o lung
markings, and bilateral small pleural e usions. An ECG
shows sinus tachycardia with le atrial enlargement and le
ventricular hypertrophy. Laboratory results: troponin- neg-
ative, hemoglobin 9.1 g/dL (low), WBC count and platelets
normal, Na 136 mEq/L, K 4.4 mEq/L, Cl 96 mEq/L, HCO3
19 mEq/L (low), BUN 108 mg/dL (high), Cr 11.9 mg/dL
(high), glucose 104 mg/dL, calcium 7.8 mg/dL (low), albumin
4 g/dL (normal).
Question 5.9.1 Which o the ollowing is the most appropri-
ate next step?
A) Prescribe levo oxacin and discharge patient with ollow-up
the next day.
B) Prescribe urosemide and discharge patient with ollow-up
the next day.
C) Administer a bolus o normal saline intravenously and
admit the patient.
D) Administer urosemide intravenously and admit the patient.
E) Per orm thoracentesis or diagnostic purposes.
Answer 5.9.1 The correct answer is “D.” T e proper disposi-
tion o this patient is the hospital. His uremia is quite severe,
and he is symptomatic rom his renal ailure. He needs urther
diagnostic tests and requires urther monitoring. He has signs
and symptoms o volume overload, and he may yet respond to
loop diuretics. A trial o IV urosemide is reasonable. Even i
it doesn’t cause a diuresis, as noted previously urosemide can
decrease pulmonary capillary wedge pressure. T e initial diag-
nosis o bronchitis was most likely erroneous and switching to
another antibiotic will only perpetuate that error. As he is vol-
ume overloaded, you certainly do not want to administer more
volume. I you are willing to attribute his pleural e usions to
volume overload due to kidney ailure, a thoracentesis is not
necessary.
Question 5.9.2 The patient’s ECG is normal. How should the
low calcium be approached in the ED?
A) Administer calcium gluconate intravenously.
B) Obtain a serum parathyroid hormone level.
C) Monitor or signs and symptoms o hypocalcemia.
D) Obtain an ionized calcium level.
Answer 5.9.2 The correct answer is “C.” Currently, your
patient does not have signs and symptoms o hypocalcemia;

there ore, he does not need IV calcium replacement in the ED
(“A”). He should be observed or the development o signs and
symptoms. Symptoms are mostly neurological—generalized
seizures, perioral paresthesias, and carpopedal spasms. T e two
best-known signs o hypocalcemia are Chvostek and rousseau
signs. Chvostek sign is present i a grimace occurs in response
to tapping the acial nerve. rousseau sign is evoked by in ating
a blood pressure cu above the systolic pressure or 3 minutes
and observing or hand spasms.
Since you expect that the patient’s hypocalcemia is secondary
to renal disease and hyperphosphatemia and you will treat him
symptomatically, serum P H level (“B”) is not required. It is not
necessary to measure ionized calcium (“D”). You have access to
both the total serum calcium level and the serum albumin, you
can calculate the corrected calcium. In addition, no correction
is required since the albumin level is normal.
HELPFUL TIP:
I t ati nt d s n t s nd t u s mid , IV
nit c in wi ik b succ ss u at ducin t is
ati nt’s u m na d ma b d c asin ad and
at ad.
Your patient is admitted. Initially, his urine output increases
slightly with loop diuretics, but then he becomes oliguric.
You ask or a nephrology consult to assist in management
o this case. T e nephrologist plans to place an IV catheter
or dialysis and is considering a renal biopsy. I the patient
develops bleeding with these procedures, hemostasis may be
impaired because o his uremia.
Question 5.9.3 Which o the ollowing treatments is LEAST
likely to reduce the risk o bleeding in this patient?
A) Hemodialysis.
B) DDAVP.
C) Cryoprecipitate.
D) Platelet trans usion.
E) Conjugated estrogens.
Answer 5.9.3 The correct answer is “D.” T e cause o bleed-
ing dys unction in uremia appears to be the e ect o uremic
toxins on platelet unction. Giving a uremic patient more plate-
lets—especially when there is no thrombocytopenia—will not
improve the situation, as the platelet dys unction due to ure-
mia will occur with the new platelets as well. “A,” hemodialysis,
will remove toxins related to uremia, improving platelet unc-
tion. “B,” DDAVP, is of en the rst-line treatment in a bleeding
patient with uremia. DDAVP is not generally toxic and quickly
reduces bleeding time. It acts by causing the release o actor
VIII:vWF multimers rom endothelial storage sites. Un or-
tunately, patients rapidly develop tachyphylaxis to DDAVP;
once the multimers are depleted rom the endothelial cells,
DDAVP will not work until these multimers are replaced (usu-
ally a process o several days). “C,” cryoprecipitate, enhances
CHAPTER 5 • Neph r o l o g y 165
platelet aggregation and will reduce bleeding time or about
24 hours af er administration. Estrogen is another option or
renal ailure-related bleeding and has been used in men or short
durations and seems to be well tolerated.
Question 5.9.4 In order to reduce the risk o renal osteo-
dystrophy (elevated serum parathyroid hormone with
mobilization o calcium rom bone), which o the ollowing
medications will you prescribe initially?
A) Calcium carbonate.
B) Aluminum hydroxide.
C) Magnesium hydroxide.
D) Sevelamer (Renagel®).
E) Vitamin D.
Answer 5.9.4 The correct answer is “A.” Renal osteodystrophy
occurs when parathyroid hormone levels are elevated and bone
is mobilized. T is occurs because patients with renal ailure can-
not clear phosphate. T e body tries to compensate by increasing
parathyroid hormone secretion, which reduces phosphate and
increases serum calcium. However, it also is detrimental to bone
and leads to demineralization.
Gastrointestinal binding o phosphate requires large doses o
a cation such as calcium (2 g/day). Calcium carbonate is associ-
ated with the least potential toxicity; there ore, it is the initial
choice or treating hyperphosphatemia to reduce the risk o
renal osteodystrophy. Also, you may consider calcium acetate,
which is as sa e as calcium carbonate and is a more potent phos-
phate binder but more expensive. Avoid aluminum and magne-
sium products in renal ailure as these ions accumulate and can
cause toxicity.
Sevelamer is a cationic polymer that binds phosphate in the
gastrointestinal tract and avoids the problems that can occur
with the calcium, magnesium, and aluminum compounds. It is
expensive and does not seem to be superior to calcium, so cal-
cium products should be tried rst.
Patients with chronic renal ailure or end-stage renal disease
on dialysis should also receive vitamin D. However, vitamin D
causes increased gastrointestinal absorption o phosphate, so
it should be given only af er hyperphosphatemia has been
controlled.
HELPFUL TIP:
W n v sc ibin ca cium na st d st -
, av ati nts tak it wit m a s— t wis it wi
n t bind s at . A s , ca cium is abs b d b tt
w n tak n wit d.
HELPFUL TIP:
Cinaca c t (S nsi a ) is an t ti n t atin -
na st d st . B mimickin ca cium in t a a-
t id, it st a at id int t inkin t at t
s um ca cium is n ma and t us duc s t ut ut
166 FAMIl y MeDICINe eXAMINATIo N & Bo Ar D r eVIeW

C) Post-streptococcal glomerulonephritis.
a at id m n . S unds c , but t ’s a ic
D) IgA nephropathy.
b in c —in t is cas s v a t usand d a s
E) Membranoproli erative glomerulonephritis.
m nt (in 2015). T a s v a t n w s at
bind s inc udin ic cit at (Au xia), w ic a s in-
Answer 5.10.2 The correct answer is “A.” Minimal change
c as s s um i n v s, and ant anum ca b nat
disease usually presents with clinical signs and symptoms o
(F s n ), w ic qui s w i s t an t ti ns
nephrotic syndrome and not gross hematuria. All o the other
but must b c w d c m t (makin it a ss att ac-
diseases are associated with hematuria, either microscopic or
tiv ti n u ati nts wit ut t t ). B t t s
gross. Henoch–Schönlein purpura, post-streptococcal glo-
a ativ x nsiv (a ximat $800/m nt ).
merulonephritis, IgA nephropathy, and membranoproli era-
tive glomerulonephritis all have more “nephritic” eatures with
“active” urinary sediments (dysmorphic red cells, red cell casts,
Objective: Did you learn to . . .
granular casts, white cells, and protein in the urine). T ese dis-
• Antici at c m icati ns na ai u , inc udin -
v mia, ca c mia, at t d s uncti n, and na eases also have a similar pathologic process in which immune
st d st ? complexes deposit in the glomeruli, resulting in glomerulone-
phritis.
CASE 5.10 CBC, coagulation studies, and electrolytes are all normal.
A 10-year-old male presents with his mother, who appears You are suspicious that he may have had streptococcal phar-
very anxious. She reports several episodes o red-brown yngitis that was unrecognized.
urine this morning. T e patient reports eeling a bit tired,
but otherwise has no complaints. His past medical history Question 5.10.3 Which o the ollowing statements best
is unremarkable and he takes no medications. On review o describes the usual course o post-streptococcal glomeru-
systems, he reports about 10 days o a sore throat that com- lonephritis?
pletely resolved a ew days ago. A) Most patients progress to renal ailure.
On examination, you nd a pleasant young male in B) Af er resolution o the initial episode, recurrent episodes o
no acute distress. He is a ebrile. His blood pressure is gross hematuria are common.
140/94 mm Hg, and he has trace pretibial edema. T e remain- C) In most cases, hypertension and uremia subside within 1 to
der o the examination is unrevealing. 2 weeks.
D) In most cases, hypertension is persistent and requires treat-
Question 5.10.1 All o the ollowing tests are likely to be ment.
help ul in the work-up o this patient EXCEPT: E) Adults tend to recover more quickly than children.
A) Urinalysis.
B) Abdominal X-ray. Answer 5.10.3 The correct answer is “C.” Post-streptococcal
C) CBC. glomerulonephritis, characterized by immune complex deposi-
D) Plasma electrolytes. tion in the glomeruli, is a sel -limited disease in most patients.
E) BUN and creatinine. T ere is a latent period, averaging 10 days, between pharyngitis
and the development o hematuria. Recovery is expected in 1 to
Answer 5.10.1 The correct answer is “B.” Abdominal plain 2 weeks. Unlike IgA nephropathy, recurrent episodes o gross
lms are not use ul in almost any situation unless looking or hematuria are rare in post-streptococcal glomerulonephritis.
constipation or bowel obstruction. (What did you say? Free air? Post-streptococcal glomerulonephritis is more common in chil-
An upright chest is the most sensitive lm or ree air—save dren and tends to be more severe when it a ects adults. Hyper-
or C .) I this patient had a presentation consistent with uro- tension and uremia resolve relatively quickly, but microscopic
lithiasis, an abdominal C scan may be indicated, although an hematuria may persist or 6 months.
ultrasound would be the pre erred rst study or urolithiasis in
a pediatric patient. All o the other laboratory tests should be
ordered.
HELPFUL TIP:
Urinalysis shows 2+ blood, 2+ protein, speci c gravity r na bi s is a indicat d in c i d n wit n -
1.015, and numerous red blood cells with red cell casts. BUN itic u in and mi d na ai u b caus t di -
is 35 mg/dL and creatinine is 1.8 mg/dL. CBC, coagulation ntia dia n sis can b na w d b t c inica
studies, and electrolytes are pending. s ntati n and b caus man t dis as s a
s - imit d. In m s v cas s, na bi s ma
Question 5.10.2 At this point, all o the ollowing should be b n c ssa t dia n s and t at a iat . S
considered in the dif erential diagnosis EXCEPT: Tab 5-10 a a tia ist caus s matu ia in
A) Minimal change disease. c i d n.
B) Henoch–Schönlein purpura.
 CHAPTER 5 • Neph r o l o g y 167

TABLE 5-10 CAUSES OF GROSS HEMATURIA blood pressure stabilizes. T is patient may also require an RBC
IN CHILDREN trans usion given her anemia. Although she has had diarrhea,
her potassium is currently in the normal range, probably due to
Idi at ic (usua b ni n wit s uti n v tim )
U ina t act in cti n
decreased glomerular ltration. Given her renal ailure, potas-
T auma sium should not be in her IV uids.
C n nita an ma Consideration o dialysis (“B”) is premature. A platelet count
U t a i itati n t auma o 50,000 is adequate or hemostasis, so answer “C” is incorrect.
N it iasis T e schistocytes suggest a microangiopathic hemolytic anemia.
Sick c dis as /t ait
C a u at
Steroids are not generally help ul or this, so “D” is incorrect.
g m u a dis as ( . ., st-st t c cca m u n itis) Finally, antibiotics (“E”) may (or may not) be bene cial i the
Ma i nanc ( . ., Wi m tum ) patient has bacterial enteritis, but IV uids should be adminis-
M dicati ns ( . ., m a ic c stitis m c c s amid ) tered rst.

Question 5.11.2 Based on the available in ormation, which

Objectives: Did you learn to . . . o the ollowing is the most likely diagnosis?
• eva uat a c i d wit ss matu ia? A) T rombotic thrombocytopenic purpura.
• g n at a di ntia dia n sis matu ia and t in- B) Hemolytic uremic syndrome.
u ia in a c i d? C) Postin ectious glomerulonephritis.
• D sc ib t usua c u s st-st t c cca m u - D) Henoch–Schönlein purpura.
n itis? E) Autosomal-recessive polycystic kidney disease.

CASE 5.11
T e parents o a 2-year-old emale bring her in to your of ce
or a week-long history o diarrhea. Initially, her stools were
loose and watery, but over the last 2 days, they have become
bloody. T e patient has appeared to have abdominal pain on
occasions, and her appetite is depressed. Despite bloody diar-
rhea, her parents attempted to care or her at home until she
became more lethargic (well, that didn’t work . . . probably the
same parents who re used vaccines). T ey are also worried
about some bruising on her extremities.
Vital signs: 37.2°C, P 145 bpm, BP 88/47 mm Hg, RR 40
breaths/minute. T e patient appears pale, with slight scleral
icterus. You note petechiae and purpura on the extremities.
Her abdomen is di usely tender. She responds to commands
but appears very lethargic.
While you are arranging her admission to the hospital,
some laboratory tests return: Hgb 8 g/dL, Hct 24%, WBC
14,000/mm3, platelets 50,000/mm3, Na 128 mEq/L, K 3.9
mEq/L, HCO3 14 mEq/L, BUN 38 mg/dL, creatinine 2.1 mg/
dL. T e peripheral blood smear shows schistocytes, “Burr”
cells, and grossly reduced number o platelets.
Question 5.11.1 Which o the ollowing is the most appro-
priate initial management o this patient?
A) Intravenous uids.
B) Dialysis.
C) Platelet trans usion.
D) Corticosteroids.
E) Antibiotics.
Answer 5.11.2 The correct answer is “B.” Hemolytic uremic
syndrome (HUS) is the most likely diagnosis. T is patient pres-
ents with a classic history o uremia, hemolysis and thrombo-
cytopenia preceded by 5 to 7 days o diarrhea. Patients tend to
become oliguric and sometimes anuric.
“A,” thrombotic thrombocytopenic purpura ( P), is related
to HUS but is rare in children. T e average age o a patient with
P is 41 years with women making up about 70% o all cases.
Being Black is also a risk actor or P. In contrast to HUS,
patients with P may present with the classic pentad: throm-
bocytopenia, ever, mental status changes, renal insu ciency,
and hemolytic anemia. Usually, there is a prodrome viral illness
with P but diarrhea occurs only rarely. See Chapter 6 or
more details.
“C,” postin ectious glomerulonephritis, usually occurs af er
pharyngitis or skin in ection with group A beta-hemolytic strep-
tococci. Common symptoms include edema and hematuria but
not thrombocytopenia or diarrhea. “D,” Henoch–Schönlein
purpura, is a (usually) transient IgA vasculitis ollowing upper
respiratory in ections in children and adolescents. Autosomal-
recessive polycystic kidney disease is a rare disorder that pres-
ents early in childhood with abdominal masses, hypertension,
urinary tract in ections, and renal ailure but not hemolytic
anemia.
HELPFUL TIP:
h US ma ccu wit ut dia a. T is subt h US
ccu s ss qu nt , is ass ciat d wit St t c ccus
in cti ns, and ca i s a w s n sis.

Answer 5.11.1 The correct answer is “A.” T e proper initial

management consists o supportive therapy. T is patient has Question 5.11.3 From the blood culture, you expect to nd:
signs o dehydration, which would be expected rom the history A) Shigella species.
o prolonged diarrhea. She is hyponatremic, and isotonic (0.9%) B) E. coli.
saline is the IV uid o choice. Use 20 cc/kg boluses until her C) Streptococcus pneumoniae.
168 FAMIl y MeDICINe eXAMINATIo N & Bo Ar D r eVIeW
D) Haemophilus inf uenzae.
E) None o the above.
Answer 5.11.3 The correct answer is “E.” Although HUS is the
result o bacterial enteritis, patients are not bacteremic. Instead,
the endothelial damage and hemolysis are caused by Shiga
toxin, released rom E. coli or Shigella dysenteriae.
Question 5.11.4 All o the ollowing are true regarding
Shiga toxin HUS in children EXCEPT:
A) I dialysis is needed, renal unction rarely returns.
B) Hal or more o the cases occur in the summer months.
C) Ingestion o contaminated meat is a common source o
E. coli O157:H7 in ection.
D) Cattle are the main vectors o E. coli O157:H7.
E) Antibiotics do not reduce the risk o HUS in patients with
con rmed E. coli O157:H7 in ections.
Answer 5.11.4 The correct answer is “A.” All the other state-
ments are true. T e prognosis o Shiga toxin HUS in children
is generally quite avorable, even i renal ailure requires dialy-
sis. While 50% will have some residual renal damage, only 4%
go on to require long-term dialysis. HUS is more common in
rural areas and in the summer. Cows are the culprits (T ey
get the blame or everything). “E” is o special note. T ere is
controversy over whether or not antibiotics may increase the
risk o HUS developing in patients with E. coli O157:H7 in ec-
tions; however, it is airly clear that antibiotics do not reduce the
risk. T e idea is that bacterial death rom antibiotics releases
more Shiga toxin leading to HUS. Remember that most cases o
bacterial gastroenteritis—E. coli O157:H7 included—will clear
without antibiotic therapy.
HELPFUL TIP:
ot subt s e. c i as w as S i a can b -
s nsib h US. T abs nc t o 157:h 7 subt
e. c i d s n t u ut h US.
Objectives: Did you learn to . . .
• eva uat and mana a c i d wit v mia and na
ai u ?
• r c niz a c inica ist and ab at ndin s su s-
tiv m tic u mic s nd m ?
• Id nti caus s m tic u mic s nd m ?
CASE 5.12
A 45-year-old emale presents to your clinic complaining o
urinary requency, “bladder” pain, and urinary urgency.
T ere is no dysuria, however. She has had hematuria on dip-
stick several times with UA showing microscopic hematuria
on more than three occasions. T is has been going on or sev-
eral months and other practitioners (less skilled than yoursel )
have treated with a number o antibiotics without any relie .
On questioning, she also notes bladder pain during inter-
course and some chronic, vague, lower pelvic pain distinct
rom the bladder pain. A urinalysis and pelvic examination
are unremarkable except or tenderness over the bladder area.
Question 5.12.1 The MOST IMPORTANT next step is:
A) Urine culture.
B) rial o 4 weeks o antichlamydial therapy.
C) Pelvic ultrasound.
D) Psychiatry consult and/or SSRI therapy or somatization dis-
order (now called somatic symptom disorder).
Answer 5.12.1 The correct answer is “C.” T is patient is
describing typical symptoms o “pain ul bladder syndrome,” the
disease ormerly known as “interstitial cystitis.” Pain ul bladder
syndrome does not involve in ammation. T ere ore, “intersti-
tial cystitis” is, and always has been, a misnomer. Pain ul bladder
syndrome consists, appropriately enough, o pain re erable to the
bladder that cannot be attributed to another cause. Patients gen-
erally note pain with lling o the bladder and relie o symptoms
af er urination. T e pain may be described as urethral, as a supra-
pubic pressure, as a pressure or a burning pain. Pain ul bladder
syndrome is a diagnosis o exclusion and now treated as a chronic
pain syndrome. It is critical to rule out other pelvic pathology that
might cause the same symptoms such as an enlarged uterus sitting
on the bladder, broids, or ovarian cancer. Other causes o similar
symptoms could be bladder irritants (ca eine, alcohol), a urethral
diverticulum, an sexually transmitted in ection, etc. While less
common, pain ul bladder syndrome can be seen in men. In this
case prostate pathology must be ruled out (you can pretty much
rule out prostate pathology in the emale patients a priori).
Question 5.12.2 All o the ollowing are mandatory at this
point EXCEPT:
A) Urine cytology in a high-risk patient (smoker, etc.).
B) Postvoid residual.
C) Cystoscopy and hyperdistention o the bladder.
D) Ruling out a bladder stone.
Answer 5.12.2 The correct answer is “C.” Cystoscopy and
hyperdistention are NO required in order to make the diag-
nosis o pain ul bladder syndrome. As noted above, pain ul
bladder syndrome is a clinical diagnosis o exclusion: Is there
anything else causing the symptoms? I not, as Sherlock Holmes
said, “Once you eliminate the impossible, whatever remains, no
matter how improbable, must be the truth.” It is important to
rule out tumor (i indicated), stones, and neurogenic bladder
(thus the postvoid residual).
HELPFUL TIP:
T atm nt ain u b add s nd m ma inc ud -
a t a ain c inic, su t u s, t atm nt an
t und in b ms (in ammat b w dis-
as , tc.), t ic c ics, aba ntin, int av sicu a DMSo ,
cu nt d dist nti n t b add , tc. W at
ab ut nt san su at s dium (e mi n)? It is v
x nsiv , ma tak u t 6 m nt s t w k, and t
b n it is m d st at b st.

HELPFUL TIP:
W n t c nic naz idin ( . ., p idium)
ain u b add s nd m ? W , u can c nsid it. But
t is a dan m t m bin mia.
Objectives: Did you learn to . . .
• eva uat and mana a ati nt wit ain u b add
s nd m ?
QUICK QUIZ: ACID–BASe DISo r Der
While covering your local ED, a 15-year-old emale presents
with her ather. He reports that he came home rom work,
ound her asleep on the couch, and had di culty in waking
her up. She is lethargic and complains o nausea, dizziness, and
abdominal pain. Apparently, she had muscle aches af er gym-
nastics practice and then took “hand uls” o aspirin to relieve
her pain. She was taking three to our tablets every hour today
but is not sure about her total ingestion. She denies other inges-
tions.
On physical examination, her vitals are: 39°C, P 110 bpm,
RR 18 breaths/minute, BP 104/68 mm Hg. She is diaphoretic.
T e neurological examination is non ocal, but she becomes
progressively more lethargic during the examination. A
venous blood gas on room air shows pH 7.38 (normal), PaCO 2
23 mm Hg (low), PaO 2 40 mm Hg (her oxygen saturation is
98% on transcutaneous monitoring), and HCO 3 15 mEq/L
(low). Other laboratory data: Na 140 mEq/L, K 3.1 mEq/L, Cl
101 mEq/L, HCO3 15 mEq/L (low), BUN 19 mg/dL, creatinine
1.1 mg/dL.
T e venous blood gas results are best described as:
A) Metabolic acidosis.
B) Metabolic acidosis and metabolic alkalosis.
C) Metabolic acidosis and respiratory alkalosis.
D) Metabolic alkalosis and respiratory acidosis.
E) Just dandy! Look at the pH, pro essor.
The correct answer is “C.” Although the pH is in the normal
range, there is an acid–base disorder present. First, there appears
to be a metabolic acidosis with an elevated anion gap. T e mea-
sured HCO3 is 15 mEq/L, consistent with an acidosis, and the
anion gap is 24 (based on the calculation o Na − (Cl + HCO3),
in this case: 140 − (101 + 15) = 24). T is patient has taken an
inadvertent overdose o aspirin. In salicylate overdoses, a high
anion gap metabolic acidosis is of en observed. Since salicylates
directly stimulate the CNS respiratory center, there is usually a
concurrent respiratory alkalosis.
In a compensated metabolic acidosis, the PaCO2 should
drop by 1.25 mm Hg or every 1 mEq/L drop in HCO3. In this
case, the serum HCO3 is 9 mEq/L below normal (i the normal
is counted as 24), so PaCO2 should be about 29 mm Hg (40 −
(9 × 1.25)). However, the measured PaCO2 is 23 mm Hg, indi-
cating the presence o a respiratory alkalosis. Also, the pH is
CHAPTER 5 • Neph r o l o g y 169
nearly normal despite the presence o a disturbance in mea-
sured HCO3, which only occurs when a mixed disorder is
present.
HELPFUL TIP:
It is im ssib t v c ct a m tab ic abn ma it .
T us, a ati nt wit a m tab ic acid sis wi n t b -
c m a ka tic n ma un ss t is an t ima-
c ss s nt ( . ., s i at a ka sis). l ik wis ,
a ati nt wit a s i at acid sis m t t nti n
Co 2 wi n t b c m a ka tic n ma un ss t
is a s c nda ima c ss in n ( . ., m tab ic
a ka sis).
Proper treatment o salicylate overdoses includes supportive
therapy, urine alkalinization with sodium bicarbonate, and pos-
sibly hemodialysis.
QUICK QUIZ: DySUr IA
Your nurse comes to you with a patient request. A 25-year-old
emale called in complaining o 2 days o burning with urina-
tion, urgency to urinate, and increased requency. She has no
ever, nausea, abdominal pain, ank pain, or vaginal discharge.
T e patient wants to know, “Can’t I just get some antibiotics?”
She’s sure this is a bladder in ection, just like the one she had
last year. Oh, by the way, she’s leaving or Europe tomorrow or
her honeymoon.
Your response is to:
A) Prescribe cipro oxacin 250 mg BID or 3 days.
B) Prescribe trimethoprim/sul amethoxazole BID or 14 days.
C) Ask her to come in or a urinalysis.
D) Ask her to come in or a urine culture.
E) Recommend cranberry juice.
The correct answer is “A.” Although you could argue that
the diagnosis o U I should be con rmed by urinalysis, there
is plenty o evidence that history alone is su ciently accurate
in the right population (in this case, women o child-bearing
years—but not children, pregnant women, men, or the elderly).
I a woman complains o dysuria and increased requency with-
out vaginal discharge, the likelihood ratio o U I is about 25 and
“pretest” probability is greater than 90% that she has a urinary
tract in ection (JAMA. 2002;287(20):2701–2710). I her urinaly-
sis were completely normal, she may still have an in ection and
likely has a alse-negative dipstick urine. T us, certain symp-
toms and historical elements are more use ul than urinalysis.
For this patient, empiric antibiotic therapy with an appropriate
antibiotic (nonrespiratory uoroquinolone, trimethoprim/sul-
amethoxazole or other, depending on regional susceptibilities
or enteric organisms) or 3 days is reasonable. Fourteen days
o trimethoprim/sul amethoxazole is overkill. O course, urine
culture is the gold standard or diagnosing U I, but she will
170 FAMIl y MeDICINe eXAMINATIo N & Bo Ar D r eVIeW

be in Europe by the time you get the results—and we’re pretty TABLE 5-11 COMMON DRUGS ASSOCIATED WITH
sure your medical license does not extend to Paris (though ACUTE INTERSTITIAL NEPHRITIS
maybe she needs someone to carry her bags).
• p nici ins
T ere is some evidence that cranberry products may reduce
• As i in
the requency o recurrent U I (maybe), but cranberry juice • Ci f xacin (and ik t fu quin n s)
does not seem to work or treatment. rials o cranberry prod- • A u in
ucts or U I su er rom high dropout rates and variability in • NSAIDs
products and measurements. • S m ACe in ibit s
• e t m cin

ACe, an i t nsin-c nv tin nz m ; NSAIDs, n nst ida anti-

HELPFUL TIP:
Wit t ica UTI s m t ms ( . ., d su ia, qu nc ) and
a n ativ u in cu tu n s ns t antibi tics,
c nsid t caus s: ain u b add s nd m , c a-
m dia u t itis, statitis (in m n), vic in amma-
t dis as (in w m n), vic mass, s nita is,
and d u s ( . ., diu tics, ca in , and t in ).
CASE 5.13
You are asked to consult on a patient who is hospitalized
by an orthopedic surgeon (consulted by a surgeon twice in
a chapter!!). T e patient is a 25-year-old emale who has a
history o osteomyelitis rom an open racture sustained in
a skiing accident. She has recently begun to spike a ever to
38.5°C and have a rapid increase in her creatinine.
Medications: na cillin, ibupro en, morphine, lactated Ringer
solution IV 100 cc/hr.
Labs: Cr 3.5 mg/dL, BUN 25 mg/dL.
CBC shows mild WBC count o 12,500/mm3 and di eren-
tial shows eosinophilia.
Question 5.13.1 All things being equal, what would you
expect to nd?
A) FENa > 2%, urine sodium < 20 mg/dL.
B) FENa < 1%, urine sodium < 20 mg/dL.
C) FENa > 2%, urine sodium > 40 mg/dL.
D) FENa < 1%, urine sodium > 40 mg/dL.
Answer 5.13.1 The correct answer is “C.” Remember . . . her
BUN/Cr < 20; there ore, it is likely not prerenal disease (and
she’s receiving volume and has no history o heart ailure).
T us, the patient likely has intrinsic kidney disease. T is means
that the FENa should be > 2% and the urine sodium > 40 mg/
dL. In this scenario, the kidney is not trying to hold on to
sodium in an attempt to correct a prerenal cause o increasing
creatinine.
T e patient’s examination shows a di use rash and the urine
contains white cell casts. T ere are no red cells in the urine.
Question 5.13.2 The most likely diagnosis is:
A) Acute tubular necrosis (A N).
B) Acute interstitial nephritis.
C) Renal in arction.
inf ammat d u s.
D) Glomerulonephritis.
E) Nephrotic syndrome.
Answer 5.13.2 The correct answer is “B.” T e combination o
ever, rash, mild eosinophilia, exposure to a new drug (na cillin)
and white cell casts in the urine essentially makes the diagnosis o
acute interstitial nephritis. “A” is incorrect. T e patient with A N
may have the same FENa and urine sodium as this patient but
should have renal tubular cells and/or granular casts in the urine.
Also, A N does not cause ever, eosinophilia, or rash. “C,” renal
in arction, is unlikely in a young patient and the rest o the clini-
cal picture is more consistent with acute interstitial nephritis. “D,”
glomerulonephritis, is a possibility (e.g., lupus could cause a rash
and ever). However, glomerulonephritis is associated with red
cell casts and not white cell casts. Finally, as you already learned
above, nephrotic syndrome presents with a bland urinary sedi-
ment. See ables 5-11 and 5-12 or more details.
Question 5.13.3 How long a ter drug exposure does acute
interstitial nephritis generally begin?
A) 2 to 3 days.
B) 10 to 14 days.
C) Several months.
D) A and B.
E) Any o the above.
Answer 5.13.3 The correct answer is “E.” Patients can
develop acute interstitial nephritis anywhere rom 1 day to
several months af er beginning a drug. Ri ampin can cause
acute interstitial nephritis on day 1. Interstitial nephritis can
begin within 2 to 5 days i there has been a prior exposure
to the drug, will typically begin within 10 to 14 days on rst
exposure to a drug, and may delayed or months in the case o
NSAID exposure.
TABLE 5-12 SYMPTOMS/SIGNS/LABORATORY
FINDINGS IN ACUTE INTERSTITIAL NEPHRITIS
• F v
• r as (va iab , ma n t b s n in a )
• Acut is in asma c atinin
• Activ u in s dim nt t at inc ud s w it c casts
• p i a sin i ia and u in sin i s (in m st cas s)
• r na tubu a acid sis
Note: Int stitia n itis s c nda t NSAIDs ma ccu wit ut v ,
as , sin i ia.
 CHAPTER 5 • Neph r o l o g y 171

HELPFUL TIP: BUN/C ati > 20 n a indicat s t at an acut kidn

pati nts wit acut int stitia n itis wi t n av inju is s c nda t xt a na caus s ( usi n m
sin i s in t u in and i a sm a , but d d ati n Ch F, tc.). T is u d s n t a t c i d n,
sin i s ma b abs nt s cia in t s wit t s wit g I b ds, and t xc ti ns.
NSAID-induc d acut int stitia n itis. T atm nt is Ca cium (di ta su m nta ) tak n wit m a s duc s
t st t ndin d u . I t is d sn’t w k, st ids t isk ca cium xa at st n s b bindin xa at in t
c t t xic d u s ma b n d d. g I t ack.
g ad inium can caus a sc d ma- ik dis as in t s
wit a c atinin c a anc < 30 m /ml /min.
Objectives: Did you learn to . . .
• r c niz t s ntin s m t ms acut int stitia In an t wis at ma wit ut a va ina disc a ,
n itis? t s m t ms d su ia, qu nc and u nc av a 90%
sitiv dictiv va u UTI, b tt t an t at a UA.
• D sc ib caus s and n sis acut int stitia n itis?
pati nts wit u it iasis s u d av an NSAID as a t
t i ain c nt im n un ss it is c nt aindicat d.
QUICK QUIZ: SAVe Th o Se Neph r o NS! r ac ma n sium in t ka mic ati nt w is n t
s ndin as x ct d t t atm nt. T sam is t u in t
A 45-year-old male comes to your o ce to establish care. He reports ati nt wit ca c mia.
a history o hypertension treated with verapamil and chlorthali- S dium bica b nat and N-ac t c st in d n t t ct t
done. His blood pressure today is 130/78 mm Hg. You order some kidn s m i dinat d c nt ast. h w v , t isk na
laboratory tests and nd that his creatinine is 2.5 mg/dL. inju wit c nt ast is sma ; d at t ati nt wit n ma
sa in .
You recommend which strategy to preserve his renal unction? T a initiati n dia sis in ati nts wit c nic kidn
A) Start a low-dose ACE inhibitor. dis as ads t w s utc m s. Sta t dia sis n w n
B) Start a high-dose ACE inhibitor. ati nt m t acc t d indicati ns.
C) Start urosemide.
D) Start amlodipine.
BIBLIOGRAPHY
The correct answer is “A.” Even in patients with renal dys-
unction as evidenced by elevated creatinine, ACE inhibi- Azadi R, et al. Hemolytic uremic syndrome caused by Shiga
tors can reduce the rate o progression o renal disease. More toxin-producing Escherichia coli 0111. J Am Osteopath
importantly, ACE inhibitors can be used sa ely in patients with Assoc. 2010;110(9):538–544.
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atinine and potassium, ACE inhibitors should be started at a myocardial in arction: meta-analyses and trial sequential
low dose and increased slowly, checking creatinine and potas- analyses o 147020 patients rom randomised trials. BMJ.
2011;342:d2234.
sium levels within 1 to 2 weeks o making a dose adjustment.
Furosemide and amlodipine have not been shown to preserve Barnett AH, et al. Angiotensin-receptor blockade versus
converting-enzyme inhibition in type 2 diabetes and
renal unction.
nephropathy. N Engl J Med. 2004;351(19):1952–1961.
Bent S, et al. Does this woman have an acute uncomplicated
HELPFUL TIP: urinary tract in ection? JAMA. 2002;287(20):2701–2710.
ACe in ibit s av b n s wn t b us u in duc- Brookhart MA, et al. Comparative mortality risk o anemia
in ssi n na dis as v n w n t a- management practices in incident hemodialysis patients.
ti nt’s c atinin is 5.0 m /dl . But b v ca u in JAMA. 2010;303(9):857–886.
t is u . Sta t w, s w, and c ck tassium and Cheng J, et al. E ect o angiotensin-converting enzyme inhibi-
c atinin . In ati nts wit CKD sta 3 4 sta t d n tors and angiotensin II receptor blockers on all-cause mor-
and ACe in ibit , a mi d inc as in c atinin is t ica tality, cardiovascular deaths, and cardiovascular events in
and x ct d and s u d n t su t in disc ntinuati n patients with diabetes mellitus: A meta-analysis. JAMA
t ACe in ibit . Intern Med. 2014;174(5):773–785.
Cooper BA, et al. A randomized, controlled trial o early versus
late initiation o dialysis. N Engl J Med. 2010;363(7):609–
Clinical Pearls 619.
Gill N, et al. Renal ailure secondary to acute tubular necrosis:
ACe in ibit s a t d u s c ic na t cti n. epidemiology, diagnosis, and management. Chest. 2005;
Ar Bs and v a ami di tiaz m a t ti ns. 128(4):2847–2863.
Av id NSAIDs in ati nts wit c nic na dis as m an Haller H, et al. Olmesartan or the delay or prevention o
caus , Ch F t nsi n. microalbuminuria in type 2 diabetes. N Engl J Med.
2011;364:907–917.
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Hou FF, et al. E cacy and sa ety o benazepril or advanced
chronic renal insu ciency. N Engl J Med. 2006;354:
131–140.
Kellum J, et al. Acute renal ailure. Am Fam Physician. 2007;
76(3):418–422.
Kohlstadt I, Frassetto L. reatment and prevention o kidney
stones: An update. Am Fam Physician. 2011;84(11):
1234–1242.
Levey AS, et al. K/DOQI clinical practice guidelines or
chronic kidney disease: evaluation, classi cation, and
strati cation. Am J Kidney Dis. 2002;39(Suppl 1):S1–S266.
Available at https://www.kidney.org/sites/de ault/ les/
docs/ckd_evaluation_classi cation_strati cation.pd ;
accessed on October 25, 2015.
Martinez-Bianchi V, Halstater BH. Urologic chronic pelvic
pain syndrome. Prim Care. 2010;37:527–546.
McDonald JS, et al. Risk o intravenous contrast material-
mediated acute kidney injury: a propensity score- matched
study strati ed by baseline-estimated glomerular ltration
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Strippoli GF, et al. Angiotensin converting enzyme inhibitors
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Hematologyand Oncology
Wendy Shen and Jason K. Wilbur
CASE 6.1
A 6-month-old boy presents to your o ce a er his mother
notices swelling and ecchymosis over his anterior right thigh.
She does not recall any trauma to the area. T e mother denies
any history o bleeding problems, including during his cir-
cumcision. On physical examination the child has a large
hematoma over his thigh. T ere are no obvious bony de or-
mities and the child otherwise looks well. You suspect the
child may have an inherited coagulation disorder.
Question 6.1.1 Which o the ollowing statements is NOT
correct?
A) Child abuse should be included in the di erential diagnosis.
B) T e child did not bleed during circumcision, so the possibil-
ity o hemophilia need not be considered.
C) A care ul amily history is important in the work-up.
D) Coagulation studies (P , P ) and CBC should be obtained.
Answer 6.1.1 The correct answer is “B.” T e absence o bleed-
ing during circumcision in no way rules out hemophilia. Up to
hal o hemophiliac patients do not bleed a er circumcision.
Depending on the severity o actor de ciency, the diagnosis
may not be made until the child is very active or even in adult-
hood, a er surgery, etc.
Question 6.1.2 Which o the ollowing is NOT TRUE about
hemophilia A?
A) It is an X-linked disorder.
B) It is the result o actor VIII de ciency.
C) It generally leads to mucosal bleeding.
D) It occurs most o en in males.
E) It can be treated with actor VIIa
Answer 6.1.2 The correct (and wrong) answer is “C.” Hemo-
philia A is an X-linked de ciency o actor VIII, which presents
with hematomas, bleeding, and hemarthrosis (and not gener-
ally mucosal bleeding or petechiae). De ciency o actor IX,
or hemophilia B, also known as “Christmas Disease,” is also
6
X-linked but is much less common. “D” deserves special men-
tion. Hemophilia rarely occurs in emales but can occur in two
situations: (1) the emale patient is a heterozygote who has early
inactivation o the second X chromosome during embryogen-
esis or (2) i both parents are carriers—in which case the ather
would have the disease overtly. “E” is true. Factor VIIa can be
used in most cases o hemophilia A and B to stop bleeding. It is
mostly used in patients who have actor inhibitors in the blood
(developed as a response to repeated exposure to actor VIII or
actor IX [Christmas disease]).
HELPFUL TIP:
Generally speaking, petechiae and mucosal bleeding re-
sult rom platelet problems (e.g., mild von Willebrand dis-
ease [VWD] and thrombocytopenia); while hemarthrosis
and hematomas result rom actor de iciency. Severe
VWD may present with hemarthrosis and hematomas.
HELPFUL TIP:
Von Willebrand disease may be autosomal domi-
nant (Type I), variable (Type II), or autosomal recessive
(Type III). There is o ten a amily history o Von Will-
ebrand actor (vWF) de iciency or bleeding, but a per-
centage o cases occur spontaneously.
Question 6.1.3 Which o the ollowing is indicated when
evaluating or a suspected inherited coagulopathy?
A) Prothrombin time (P ).
B) Partial thromboplastin time (P ).
C) Platelet count.
D) PFA-100.
E) All o the above.
Answer 6.1.3 The correct answer is “E.” T e P is actually
the most sensitive test or hemophilia. “D” deserves special
mention. T e PFA-100 (Platelet Function Analyzer) tests or
(appropriately enough) platelet unctioning and will be abnor-
mal in diseases o platelet dys unction, such as VWD.
173
174 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
HELPFUL TIP:
The PFA-100 can help you make a diagnosis o VWD but
it doesn’t necessarily correlate with the risk o clinical
bleeding.
You diagnose this patient with hemophilia A, and he grows up
under your excellent tutelage. As a junior high school student,
he attends summer camp or hemophiliacs in ransylvania. For
some bizarre reason, the councilors decide to have the kids play
tackle ootball (just in case you think we made this up, this sce-
nario was seen by one o your authors while working in the emer-
gency department (ED)—but not at the University o Iowa). T e
patient presents to the ED with bleeding into two o his joints.
Question 6.1.4 What is the initial step in the management
o this patient’s hemarthroses?
A) Joint aspiration.
B) Desmopressin.
C) Factor VIII in usion.
D) Heparin in usion.
E) Leeches.
Answer 6.1.4 The correct answer is “C.” While joint aspiration
and desmopressin may be help ul, this patient needs to be treated
with actor VIII in order to stop the bleeding. Joint aspiration may
play a role in preventing blood-induced arthritis, a risk with recur-
rent joint bleeds. Desmopressin is use ul in some cases o VWD
and in some mild cases o hemophilia. Desmopressin releases
vWF rom platelets transiently increasing circulating vWF. Anti -
brinolytic therapy may also be o use: tranexamic acid or amino-
caproic acid is commonly used to prevent clot breakdown.
Question 6.1.5 What actor level target is appropriate when
treating this patient?
A) 5% to 10%
B) 30% to 40%.
C) 75% to 80%.
D) 100%.
Answer 6.1.5 The correct answer is “B.” For a hemarthrosis or
other “minor” bleeding, you should maintain a actor level o
30% to 40% or 72 hours. For more serious bleeding (intracra-
nial, or example), maintain a level o 80% to 100% or 10 days.
HELPFUL TIP:
Von Willebrand disease Type I will respond to desmo-
pressin (as noted above). Type II has variable response
to desmopressin. A trial at the time o diagnosis is rec-
ommended. Type III VWD requires in usion o actor VIII
and vWF (such as Humate-P). Remember that actor
VIII is not enough, you need a preparation that also in-
cludes vWF. I you do not have a actor VIII + vWF actor
available, or i the bleeding continues a ter replacement
therapy, you can always trans use normal platelets as a
last option. These will have adequate vWF.
Question 6.1.6 In 2015 (as opposed to 1992) which o the
ollowing likely scenarios may be seen in a patient with
hemophilia?
A) Hemarthrosis with signi cant arthritis and joint dys unc-
tion.
B) An extremely low risk o HIV/AIDS rom multiple trans u-
sions o FFP.
C) Maturational delay i anti actor antibodies are present.
D) Reduced risk o coronary artery disease (CAD).
E) All o the above are ound with hemophilia.
Answer 6.1.6 The correct answer is “E.” “A” is true. Patients
still get recurrent hemarthrosis leading to arthritis and joint
dys unction. “B” is true. Screening and the use o recombinant
actor VIII has led to a marked reduction in HIV in hemophili-
acs rom a high o 50% in the 1990s. Patients with hemophilia
do have delayed maturation, especially i anti actor antibodies
are present. And nally, they do have a reduced risk o CAD.
T is is also seen in carriers o hemophilia genes.
Note: In this chapter, objectives are listed a er several short cases,
so keep reading.
CASE 6.2
A 4-year-old girl is brought to you a er she is noted to have
small pink spots on her lower extremities and bleeding rom
her gums. She had a URI a couple o weeks ago. She also
recently got her second dose o her MMR vaccine (mom par-
ticularly wants to make sure she is protected rom the recent
resurgence in measles and mumps). You note petechiae on her
lower extremities and purpura in her oropharynx. T e mother
and patient deny any other bleeding. You obtain a CBC,
which is normal except or a platelet count o 15,000/mm3.
You suspect immune thrombocytopenic purpura (I P, also
known as idiopathic thrombocytopenic purpura).
Question 6.2.1 Which o the ollowing may have led to this
patient’s ITP?
A) MMR vaccine.
B) In ection.
C) Food allergy.
D) Autoimmune hemolytic anemia.
E) A and B.
Answer 6.2.1 The correct answer is “E.” Both in ections and
the MMR vaccine have been linked to I P (not autism . . . got
that? . . . not autism). Food allergy does not cause I P and i you
chose “D,” time to study some more. An autoimmune hemolytic
anemia is just that; an autoimmune hemolytic anemia. It is a di -
erent disease process entirely and typically presents with signs
and symptoms o an anemia (pallor, atigue, dyspnea, ailure to
thrive). Peripheral smear with a hemolytic process will typically
show schistocytes, “bite cells” or even spherocytes; it depends
on the etiology o the hemolysis (more later) T is patient’s CBC
was normal aside rom a low platelet count so answer “D” is not
correct.

Question 6.2.2 Which o the ollowing is NOT likely to lead
to a sustained (let’s say at least 2 days) increase in the
patient’s platelet count?
A) IVIG.
B) Steroids (e.g., prednisone).
C) Platelet trans usion.
D) Splenectomy.
Answer 6.2.2 The correct answer (and what will not yield a
sustained increase in platelet count) is “C.” rans used plate-
lets will just be chomped up by “Mr. Spleen.” However, platelets
can be used to temporize i a patient must go to the OR, etc.
Most children can simply be observed. T e only indication or
treatment is bleeding. All o the treatments have a downside.
Splenectomy is associated with a risk o sepsis. I possible, delay
splenectomy until a er the child is over 5 years old. Steroids
may cause behavioral problems and long-term problems such as
avascular necrosis. IVIG leads to a temporary increase in plate-
lets that may last several weeks but can be associated with renal
injury and anaphylaxis among other possible adverse e ects.
HELPFUL TIP:
I a child suspected o having ITP looks sick, you need to
expand your di erential diagnosis. Sepsis with dissemi-
nated intravascular coagulopathy (DIC) and thrombotic
thrombocytopenic purpura—hemolytic uremic syn-
drome (TTP–HUS) are also in the di erential. ITP is most
common in children between the ages o 2 and 4 years,
with a small peak incidence in adolescence. ITP o ten
resolves without speci ic therapy; 80% to 90% o pedi-
atric patients are back to normal within a ew months,
and ewer than 20% o children will remain thrombocy-
topenic or greater than 12 months. Only 0.1% to 0.5%
develop intracranial bleeding.
HELPFUL TIP:
Do not bother checking or antiplatelet antibodies in
those with ITP. Patients without ITP may have antiplate-
let antibodies and the presence o these antibodies is
not predictive o outcome.
HELPFUL TIP:
For adults with ITP, treatment is generally indicated.
Treatment includes (in order) steroids, Rho(D) immuno-
globulin for Rh-positive patients, IVIG (which causes
a transient rise in platelet numbers), and splenectomy.
Other treatment options or re ractory cases include
rituximab or various immunosuppressive agents. The
thrombopoietin-receptor agonists, romiplostim and
eltrombopag (real names and not Icelandic vocabulary
words) stimulate platelet production and can also be
used in ITP.
CHAPTER 6 • HEMATOLOGY AND ONCOLOGY 175
HELPFUL TIP:
Failure o ITP to respond to splenectomy may be due to
the presence o an accessory spleen, which can o ten be
identi ied by a liver–spleen radionuclide study.
Keep reading or the objectives . . . We swear there is a common
theme and that we didn’t orget them!
CASE 6.3
A 24-year-old emale G1 P0 at 39 weeks o gestation pres-
ents to your o ce with a bruise on her anterior tibia, which
she noticed a er bumping into a co ee table. She has been
healthy be ore and during her pregnancy and takes only pre-
natal vitamins. Her physical examination is unremarkable
with the exception o an 8-cm bruise over her right anterior
tibia. Her vital signs are normal. Her physical examination
is remarkable or a gravid abdomen consistent with 39 weeks
o gestation, etal heart tones auscultated at 140 bpm,
absence o right upper quadrant pain, and absence o periph-
eral edema. You obtain the ollowing laboratory tests: CBC,
which demonstrates white blood cell (WBC) 9,000/mm3,
hemoglobin (Hgb) 11.8 g/dL, and platelet count 95,000/mm3;
normal P and P /INR; negative urinalysis; and normal
liver enzymes.
Question 6.3.1 What is your next step?
A) Recommend immediate delivery by cesarean section as the
in ant likely has thrombocytopenia as well and is at high risk
or intracranial hemorrhage.
B) Recommend immediate delivery by cesarean section as this
disorder will likely progress to eclampsia.
C) Recommend close observation and reassure the patient that
this is typically a sel -limited condition.
D) Start prednisone, 1 mg/kg daily, and taper slowly over the
next 6 weeks.
E) Recommend splenectomy as soon as possible a er delivery.
Answer 6.3.1 The correct answer is “C.” T is patient likely
has gestational thrombocytopenia, a condition that occurs
in up to 5% o pregnant women. It is characterized by mild
thrombocytopenia occurring in late gestation; the plate-
let count is usually > 70,000/mm 3 (two-thirds are between
130,000/mm 3 and 150,000/mm 3). T e condition resolves a er
delivery and is not associated with severe neonatal throm-
bocytopenia. No speci c change in routine obstetrical care
is warranted, although the anesthesiologist placing an epi-
dural may want a ollow-up platelet count closer to the time
o delivery.
HELPFUL TIP:
A platelet count o > 20,000 to 50,000/mm 3 is generally
considered adequate or appropriate clotting.
176 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Objectives (see, we told you we didn’t orget them!): Did
you learn to . . .
• Obtain a thorough bleeding history?
• Use laboratory testing to assist in the diagnosis o a bleeding
disorder?
• Identi y and treat common inherited bleeding disorders?
• Identi y and treat common acquired bleeding disorders?
QUICK QUIZ: COAGULATION STUDIES
Which o the ollowing conditions should be considered i both
the P and P are prolonged in a patient noted to be oozing
rom a surgical incision?
A) Severe liver disease, DIC, actor X de ciency.
B) Heparin e ect, VWD, actor XII de ciency.
C) War arin e ect, actor VII de ciency, vitamin K de ciency.
D) All o the above.
The correct answer is “A.” T e three actor de ciencies that
may prolong both P and P are II, V, and X. Both P and
P may be prolonged due to severe liver disease and DIC as
well. Mild vitamin K de ciency or mild liver disease generally
a ects the P only. Generally, heparin a ects P , and war arin
a ects P . Remember that the newer agents (rivaroxaban, dabi-
gatran, etc.) cause bleeding without prolonging the P or P .
HELPFUL TIP:
Why does vitamin K work to improve the PT in liver
disease i the problem is not related to war arin, which
reduces vitamin K dependent actors, or to the liver,
which o ten responds to vitamin K even in those with
cirrhosis? Because most alcoholics and others with liver
ailure are vitamin K de icient (poor absorption, poor
nutritional intake, antibiotic use—recall that vitamin
K is made in the gut by bacteria). Paradoxically, those
with liver ailure are o ten hypercoagulable leading to
thrombotic complications such as hepatic vein throm-
bosis.
CASE 6.4
A 42-year-old gentleman presents to the ED with a gastro-
intestinal (GI) bleeding due to ibupro en use. His Hgb is
6.8 g/dL and he is hemodynamically unstable at this point.
You remember that blood actually increases mortality i used
incorrectly.
Question 6.4.1 Which o the ollowing is an indication or
trans usion?
A) Hemodynamic instability in a trauma patient due to bleed-
ing unresponsive to no less than 5 L o saline.
B) Preoperative Hgb o 7 to 8 g/dL with expected intraoperative
blood loss.
C) Hemoglobin o 9.5 g/dL in a patient with angina.
TABLE 6-1 BLOOD TRANSFUSION INDICATIONS
Indication Trans usion Threshold
Otherwise stable adult Hgb ≤ 7 g/dL
and pediatric intensive
care patients
Hemodynamically stable Hgb ≤ 8 g/dL OR or symptoms o
postoperative patients chest pain, orthostatic hypotension,
tachycardia unresponsive to IVF
boluses, or CHF
Hemodynamically stable Hgb ≤ 8 g/dL OR or symptoms o
patients with pre-existing chest pain, orthostatic hypotension,
cardiovascular disease tachycardia unresponsive to IVF
boluses, or CHF
Hemodynamically stable Unable to make a recommendation
patients with acute against liberal or restrictive trans usion.
coronary syndrome (ACS)
Adapted rom Carson JL, Grossman BJ, Kleinman S, et al. Red blood cell
trans usion: a clinical practice guideline rom the AABB. Ann Intern Med.
2012;157(1):49–58.
D) A stable ICU patient with an Hgb o 8.7g/dL.
E) All o the above.
Answer 6.4.1 The correct answer is “B.” In general, a restric-
tive policy or blood trans usion has been shown to improve
outcomes. “A” is incorrect because blood should be given to the
hemodynamically unstable trauma patient a er at most 2 L o
saline (and per new A LS recommendations a er 1 L o saline).
“B” is correct. A restrictive preoperative trans usion policy lim-
ited trans usions to those with an Hb o < 8 g/dL has shown sur-
vival bene t. “C” is incorrect. rans usion should be considered
in the patient with CAD only when the hemoglobin reaches 7
to 8 g/dL. Finally, “D” is incorrect. rans usions should be with-
held rom a nonbleeding, hemodynamically stable ICU patient
until the Hb reaches 7 g/dL. A more liberal trans usion policy
is associated with higher mortality. As an aside, some would
trans use postoperative patients with an Hgb o less than 10 g/
dL i they are at high risk or ischemic disease (ischemic bowel,
CAD, etc.). rans usion or indications other than these are
not bene cial and have been proven harm ul. See able 6-1
or a list o trans usion indications.
HELPFUL TIP:
Erythropoietin may worsen outcomes in anemic patients
with CHF. It seems to have no bene it and increases
thrombotic events (Ann Intern Med . 2013;159:746).
You decide to trans use one unit o packed red blood cells
(PRBCs). A er 30 minutes, the patient complains o dyspnea
and back pain. Repeat examination o this patient reveals
a diaphoretic man with a pulse o 130 and BP o 88/50. His
lung elds are clear (initial vitals be ore the trans usion were
a pulse o 110 and BP o 94/52.

Question 6.4.2 What is your next step?
A) Stop the blood trans usion and begin normal saline through
the IV.
B) Increase the rate o trans usion.
C) Administer acetaminophen 650 mg PO.
D) Administer urosemide 40 mg IV.
E) Place a nasogastric tube or lavage.
Answer 6.4.2 The correct answer is “A.” T e trans usion must
be stopped. T e patient is exhibiting signs and symptoms o a
hemolytic trans usion reaction, which is generally the result o
an ABO incompatibility. Patients may exhibit nausea, ushing,
dyspnea, oliguria, back pain, and hypotension. Other ndings
include markers o hemolysis: hemoglobinuria, elevated serum-
ree Hgb, reduced haptoglobin, and elevated bilirubin. Patients
are positive or direct antiglobulin (Coombs) test. T erapy
includes IV saline at a high enough rate to initiate a brisk diure-
sis and prevent Hgb rom precipitating in the kidneys causing
acute tubular necrosis.
HELPFUL TIP:
Additional trans usion reactions include
• Anaphylaxis (especially in those with IgA de iciency)
• Febrile, nonhemolytic reactions (which respond to
meperidine and acetaminophen—“Finally, a use or
meperidine!” you exclaim)
• Trans usion related lung injury, which presents as
ARDS with dyspnea and hypoxia.
• Don’t orget that luid overload rom trans usions
may cause dyspnea.
HELPFUL TIP:
Why did we always order “2 units o packed red cells?”
In a nonbleeding patient, the trans usion o one unit o
PRBCs can be expected to raise the hematocrit by 3%
to 4% (1 g/dL or Hb). Current guidelines recommend
giving one unit and reassessing the patient. Every unit
o blood has its own risk o mismatch, contagion, etc.
CASE 6.5
A 56-year-old male presents to the ED with an acute abdo-
men, likely rom a per orated diverticulum. He is taking war-
arin or a DV that occurred a er a total knee arthroplasty.
He weighs 65 kg. You are evaluating him or surgery and
nd the ollowing laboratory results: Hgb 14.3 g/dL, platelet
count 478,000/mm3, INR 3.5, and P 28 seconds.
Question 6.5.1 Which o the ollowing statements about his
preoperative management is correct?
A) Platelet trans usion perioperatively will produce the most
immediate reduction in risk o bleeding rom war arin.
B) Fresh rozen plasma (FFP) trans usion will produce the
most immediate reduction in risk o bleeding rom war arin.
CHAPTER 6 • HEMATOLOGY AND ONCOLOGY 177
C) Vitamin K administration orally will produce the most
immediate reduction in risk o bleeding rom war arin.
D) Vitamin K administration subcutaneously will produce the
most immediate reduction in risk o bleeding rom war arin.
E) Cryoprecipitate trans usion will produce the most immedi-
ate reduction in risk o bleeding rom war arin.
Answer 6.5.1 The correct answer is “B.” T e patient above
would bene t most immediately rom the administration o
FFP. FFP contains all the soluble plasma proteins ound in
whole blood, including the vitamin K-dependent actors that
are depleted by war arin. I more sustained reversal is desired,
the simultaneous administration o vitamin K is e ective. T e
pre erred route o administration o vitamin K is oral. Giving
vitamin K IV is second best—lowers INR the same degree as
oral vitamin K at 24 hours, but the IV route may be pre erred in
instances where GI absorption is questionable. Avoid vitamin K
SQ or IM, which are less e ective than PO and IV routes. T e
e ects o FFP rarely last 24 hours; the e ects o vitamin K are
usually not apparent or 12 to 24 hours. T e use o cryoprecipi-
tate will not provide the appropriate actors depleted by war a-
rin. Cryoprecipitate contains vWF, actor VIII, actor XIII, and
brinogen. Platelet trans usion would not bene t this patient
since war arin does not a ect platelet unction.
HELPFUL TIP:
REVERSING WARFARIN—The most recent recommen-
dations suggest using a 4- actor prothrombin complex
concentrate (e.g., Kcentra) or reversing li e-threatening
bleeding secondary to war arin. A 3- actor prothrombin
complex concentrate plus FFP is an alternative; 3- actor
PCCs lack actor VII. I these are not available, FFP is still
an option.
HELPFUL TIP:
The INR o FFP is 1.5. No matter how hard you try, you
cannot reduce the INR to less than 1.5 with FFP.
Objectives: Did you learn to . . .
• Decide when blood trans usion is appropriate?
• Recognize hemolytic trans usion reactions?
• Treat war arin-induced hypocoagulability?
CASE 6.6
A 20-year-old emale with acute myeloid leukemia completed
her second cycle o consolidation chemotherapy 5 days ago.
She presents to the ED complaining o atigue and ever.
She denies cough, dysuria, abdominal pain, sinus drain-
age, or redness around her Hickman catheter. Her physical
examination reveals a temperature o 38.4°C, pulse 100 bpm,
BP 120/58 mm Hg, and respirations 14 breaths per min-
ute. Her examination is otherwise unremarkable, including
no redness or tenderness at the Hickman site. Your magic
crystal ball tells you she does not have a line in ection. Her
178 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
laboratory results reveal the ollowing: WBC 200/mm3, Hgb
9 g/dL, hematocrit 27%, and platelet count 47,000/mm3.
Blood cultures have been drawn.
Question 6.6.1 What is your next step, and what is your
rationale?
A) Administer IV amphotericin B; a Candida urinary tract
in ection is most likely.
B) Administer IV ce epime; she requires empiric coverage or
both Gram-negative and Gram-positive organisms.
C) Administer IV na cillin; a Gram-positive bacterial in ection
is most likely and broader antibiotic coverage will encourage
growth o resistant bacteria.
D) Administer IV vancomycin; she most likely has an MRSA
sinus in ection.
E) Close observation; there is no ocus o in ection and she
looks well.
Answer 6.6.1 The correct answer is “B.” T is patient has a
neutropenic ever, which is a medical emergency. Prompt treat-
ment with broad-spectrum antibiotics has drastically improved
the survival o patients with neutropenic ever. Neutropenia is
usually de ned as neutrophils plus bands (absolute neutrophil
count, ANC) < 500/mm 3 or < 1,000/mm 3 when the nadir has
not been reached. Most myelosuppressive chemotherapeutic
agents produce a reduction in WBCs 4 to 10 days a er com-
pletion and nadir at 10 to 14 days. Fever is de ned as a single
oral temperature > 101°F (38.3°C) or a temperature > 100.4◦ F
(38°C) persisting or 1 hour or more. T is patient does not need
vancomycin since the absence o a line in ection was stipulated
in the history (via crystal ball that always works in our experi-
ence). Broad-spectrum coverage o Gram-positive and Gram-
negative organisms, including Pseudomonas, is the cornerstone
o therapy with speci c therapy or any localizing symptoms or
risk signs. See able 6-2 or common antibiotic regimens.
HELPFUL TIP:
Patients with a neutropenic ever can have any in ec-
tion seen in normal hosts, but you should also con-
sider IV catheter in ections, perirectal in ections and
abscesses, and necrotizing enteritis (aka “typhlitis”).
Remember that they may not have an in lammatory
reaction around a catheter site, abscess ormation, in-
iltrate on chest x-ray, or WBCs in the urine because o
the neutropenia. The absence o signs or symptoms
should not dissuade the physician rom starting empiric
antibiotic therapy. Similarly, the absence of fever in a
neutropenic patient with focal infection should be
approached as a high-risk situation.
CASE 6.7
A 63-year-old male with a diagnosis o non–small-cell lung
cancer, undergoing weekly chemotherapy and radiation to a
le upper lobe mass, presents to your o ce. He complains
TABLE 6-2 SUGGESTED ANTIBIOTIC REGIMENS
FOR NEUTROPENIC FEVER
High-Risk Patients (ANC ≤ 100/mm 3 or expected duration o
neutropenia > 7 days or signi cant comorbidity)
Comorbidities = hypotension, pneumonia, new onset abdominal pain or
neurologic changes
Single Agents
Antipseudomonal β -lactam
• Ce epime
• Ce tazidime
• Piperacillin-tazobactam
Carbapenem
• Imipenem-cilastatin
• Meropenem
Combination Agents
Add one of the following to the above regimen for management
of complications or suspected/proven resistance:
• Aminoglycoside
• Fluoroquinolone (cipro oxacin or levo oxacin)
• Vancomycin
Additional considerations:
• Add vancomycin i a line in ection is suspected, MRSA is likely, skin
or so t tissue in ection, patient is clinically more ill (hypotension,
hemodynamically instable, etc.), or i no improvement a ter
3–5 days o empiric therapy.
• Add linezolid or daptomycin or VRE, or patient intolerant to
vancomycin.
• Add metronidazole or abdominal symptoms or suspected
Clostridium dif cile in ection.
• Add anti ungal ( uconazole, voriconazole, amphotericin B) i still
ebrile 4–7 days a ter a broad-spectrum antibacterial regimen and
no identi ed source o ever. The risk o ungal in ection is increased
by this point.
• Add acyclovir and/or uconazole i there is oral ulceration.
Low-Risk Patients (anticipated neutropenia < 7 days, able to take PO,
hemodynamically stable, no comorbid conditions, able to comply with
daily ollow-up):
• PO cipro oxacin and amoxicillin-clavulanate
OR
• Hospital admission and any o the above regimens or persistent
ever or worsening symptoms.
Data rom In ectious Diseases Society o America. Frei eld AG, et al. Clinical
practice guideline or the use o antimicrobial agents in neutropenic
patients with cancer: 2010 update by the In ectious Diseases Society o
America. Clin In ect Dis. 2011;52(4):e56–e93.
o dull, nonradiating back pain in the lower thoracic/upper
lumbar area. He denies trauma or any new activities. He has
no associated weakness or paresthesias. He denies di culties
with bowel or bladder unction.
Question 6.7.1 What is your initial diagnostic and/or thera-
peutic approach to this patient?
A) MRI o thoracic and lumbar spine.
B) Plain lms o the thoracic and lumbar spine and a COX-2
inhibitor with a 2-week ollow-up.

C) Plain lms o the thoracic spine and NSAIDs.
D) Prescription or physical therapy and NSAIDs.
E) Urinalysis with culture and antibiotics.
Answer 6.7.1 The correct answer is “A.” T is is not your aver-
age back pain. Any patient with active malignancy complain-
ing o back pain should be investigated or metastasis. While a
plain lm o the spine may be use ul, the gold standard is MRI.
T e real emergency is spinal cord impingement. Spinal cord
compression may occur rom direct extension o metastatic
disease rom the vertebrae or extension rom retroperitoneal or
paravertebral disease. Frequently, the pain predates neurologi-
cal symptoms, and because o the potential or severe, adverse
outcomes, you want to catch the disease early to prevent chronic
impairment.
T e patient undergoes MRI o the spine, which demonstrates
a lesion compressing the cord at L1.
Question 6.7.2 Which o the ollowing is NOT an appropri-
ate therapeutic modality?
A) Decompression surgery.
B) Dexamethasone 10 mg bolus IV, ollowed by 6 mg every
6 hours.
C) Observation with pain control (e.g., with morphine PCA).
D) Radiation therapy to the a ected area.
Answer 6.7.2 The correct answer is “C.” Patients with spinal
cord compression who have aggressive interventions are more
likely to retain unction, including ambulation and bowel and
bladder control. Steroids will help reduce edema surround-
ing the tumor and hope ully will relieve pressure on the cord.
Radiation can o en provide symptomatic relie and reduce the
likelihood that the tumor will spread locally to impinge on the
cord. Surgical decompression is another option. O course, i
this patient opted or a palliative care approach and had decided
upon hospice, “C” might be appropriate, but he is still getting
active therapy, and his remaining time could be spent with less
pain and better unction i one o the other options were chosen.
CASE 6.8
A 32-year-old woman presents to your o ce with com-
plaints o dyspnea, constipation, menorrhagia, and atigue
that are new over the last ew weeks. She has a distant his-
tory o Hodgkin lymphoma treated with chemotherapy and
radiation to the chest. Her physical examination reveals a
well-developed woman, who appears com ortable at rest with
normal vital signs. She has no adenopathy and the remainder
o her examination is unremarkable. Her CBC with WBC di -
erential is normal.
Question 6.8.1 Which o these diagnoses can be absolutely
ruled out based on this patient’s history?
A) Coronary ischemia.
B) Hypothyroidism.
C) Lung cancer.
CHAPTER 6 • HEMATOLOGY AND ONCOLOGY 179
D) Relapse o the Hodgkin lymphoma.
E) None o the above.
Answer 6.8.1 The correct answer is “E.” T e point here is that
patients with a history o Hodgkin lymphoma and chest radia-
tion are at risk or a wide range o complications—even years
a er the disease has been success ully treated. Even though 80%
o Hodgkin lymphoma patients have long-term disease- ree sur-
vival, one in six patients can be expected to die rom late e ects
o therapy. T e key late e ects o radiotherapy or Hodgkin
lymphoma include secondary malignancy and accelerated car-
diac disease at a younger age. Other delayed complications that
have been associated with radiation therapy include thyroid
dys unction, pulmonary brosis, noncoronary atherosclerotic
disease, and muscle atrophy.
Although coronary artery disease (“A”) would be extremely
unusual in a normal 32-year-old, a patient with a history o
chest radiation has a relative risk o coronary disease o 5 to
10 times that o age-matched controls. “B,” thyroid disease, is
highly likely, with over 50% o patients treated with chest radia-
tion requiring thyroid hormone replacement. A SH would be
adequate screening. T ere is a high risk or secondary malig-
nancy, including breast cancer, lung cancer (“C”), leukemia, sar-
coma, and non-Hodgkin lymphoma (NHL). Finally, you should
always be concerned about recurrence (“D”).
T e patient has a normal chest radiograph and ECG.
However, her SH is markedly elevated, and you start her
on levothyroxine. You plan to see her back in 8 weeks or
re-evaluation and will provide additional counseling at that
time.
Question 6.8.2 Which o the ollowing preventive health
issues is/are necessary to address at ollow-up?
A) Early intervention by a ertility specialist i the patient
desires pregnancy.
B) Smoking cessation.
C) Yearly mammograms.
D) All o the above.
E) None o the above.
Answer 6.8.2 The correct answer is “D.” Female patients who
were treated or Hodgkin lymphoma with chemotherapy and
radiation prior to age 20 have up to a 35% incidence o breast
cancer by the age o 40. T e typical latency period is 15 years.
National guidelines recommend that annual breast cancer
screening o Hodgkin lymphoma survivors treated with chest
irradiation should begin 5 to 8 years post-treatment, or age 40,
whichever comes rst. Breast cancer screening or these high-
risk patients includes breast MRI in addition to mammography.
Smokers with a history o Hodgkin lymphoma have a 20- old
increased chance o developing lung cancer when compared to
nonsmokers with a history o Hodgkin lymphoma. Also, emale
patients with Hodgkin lymphoma have a 69% incidence o pre-
mature ovarian ailure i treated or their cancer be ore the age
o 29 and up to 96% i treated a er the age o 30. While these
statistics are improving with newer chemotherapy regimens, a
180 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
patient should seek early re erral to a ertility specialist i she
desires pregnancy but is unable to conceive.
CASE 6.9
A 40-year-old male who has just received his rst course o
chemotherapy or non-Hodgkin lymphoma (NHL) presents
to your ED complaining o weakness, cramps, and decreased
urine output. He has no other medical problems and takes
no medications except or prochlorperazine as needed or
nausea. He has been eating and drinking well. His physical
examination reveals a tired-appearing male, with normal
vital signs. His head and neck examination reveals bilateral
palpable cervical lymph nodes (2 cm). His lungs are clear in
the upper lung elds with crackles bilaterally at the bases.
Muscle strength is normal, and ref exes are 3+ and symmet-
ric. He exhibits 6 beats o clonus at the ankles. Chest radio-
graph shows evidence o early pulmonary edema.
Question 6.9.1 What is the most likely set o laboratory val-
ues you will f nd or this patient (re erence ranges: potas-
sium 3.5 to 5 mg/dL, phosphate 2.4 to 4.1 mg/dL, uric acid
3.5 to 7.2 mg/dL, calcium 8.5 to 10.2 mg/dL).
A) Potassium 2.3 mEq/L, phosphorus 3.1 mg/dL, uric acid
4 mg/dL, calcium 9 mg/dL.
B) Potassium 2.6 mEq/L, phosphorus 6 mg/dL, uric acid 5 mg/
dL, calcium 12 mg/dL.
C) Potassium 6.5 mEq/L, phosphorus 7 mg/dL, uric acid
18 mg/dL, calcium 6 mg/dL.
D) Potassium 6 mEq/L, phosphorus 6.8 mg/dL, uric acid 5 mg/
dL, calcium 6.7 mg/dL.
E) Potassium 4.5 mEq/L, phosphorus 3.2 mg/dL, uric acid
9 mg/dL, calcium 8 mg/dL.
Answer 6.9.1 The correct answer is “C.” T is patient most
likely has tumor lysis syndrome, which can occur in a patient
with a highly responsive leukemia or a bulky lymphoma being
treated with chemotherapy (it rarely occurs without treatment).
umor lysis syndrome occurs when there is rapid release o
intracellular contents into the bloodstream. It is characterized
by high potassium, high phosphorus, high uric acid, and low
calcium. Patients may experience renal ailure, arrhythmias,
atigue, muscle cramps, and tetany.
T e patient is ound to have a creatinine o 8 mg/dL.
Question 6.9.2 What is the most likely cause o this patient’s
renal ailure?
A) Dehydration.
B) Heart ailure.
C) Hemoglobinuria.
D) Rhabdomyolysis related to chemotherapy.
E) Uric acid nephropathy.
Answer 6.9.2 The correct answer is “E.” Patients with tumor
lysis syndrome have renal ailure secondary to uric acid
nephropathy. T is is caused by the precipitation o uric acid in
the kidney, and it can be prevented by starting allopurinol prior
to the administration o chemotherapy. Although dehydration
(“A”) is not the cause o renal ailure, it certainly will exacerbate
the situation.
Question 6.9.3 Which o the ollowing is MOST LIKELY to
help this patient’s current condition?
A) Allopurinol 300 mg orally.
B) Calcium carbonate 500 mg orally.
C) Emergent hemodialysis.
D) IV D5W with 2 amps bicarbonate.
E) IV normal saline 200 mL/hr.
Answer 6.9.3 The correct answer is “C.” T e horses are already
out o the barn, and in act they’re probably over the hills and
through the woods. Allopurinol and oral calcium will not help
this situation. T e patient already has renal ailure rom his
tumor lysis syndrome. While he may bene t rom preventive
measures, including aggressive hydration and allopurinol prior
to undergoing chemotherapy, none o these measures are
going to help his current renal ailure. In addition, the patient
may develop worsening pulmonary edema i given too much
volume with IV uids.
While awaiting hemodialysis, you should treat the patient’s
hyperkalemia. reatment may include IV calcium gluconate,
insulin and dextrose, and oral sodium polystyrene sul onate
(Kayexalate). Note that sodium bicarbonate or hyperkale-
mia has allen out o avor. See Chapter 1 or more in orma-
tion on hyperkalemia.
HELPFUL TIP:
Rasburicase has also been approved or the preven-
tion o tumor lysis syndrome. It converts uric acid into
a nontoxic, excretable metabolite allantoin. It can also
be used a ter tumor lysis syndrome has started. It has
several black box warnings, including anaphylaxis, he-
molysis, and methemoglobinemia. Its use is considered
high risk in pregnancy. Except or the side e ects noted
above, it is well-tolerated, acts rapidly, and is e ective.
The need o dialysis secondary to tumor lysis syndrome
has substantially declined since the introduction o
Rasburicase.
Objectives: Did you learn to . . .
• Recognize and initiate treatment o some oncologic emer-
gencies, including spinal cord compression, tumor lysis
syndrome, and neutropenic ever?
• Recognize late complications o cancer and cancer therapy,
including distant radiation and chemotherapy?
QUICK QUIZ: TOO MUCH OF A GOOD THING
A 60-year-old gentleman presents to your of ce with complaints
o atigue. He has a history o alcoholic cirrhosis, diet-controlled

diabetes, and hypertension and currently takes hydrochlorothi-
azide, enalapril, and monthly testosterone injections. He smokes
two packs o cigarettes daily and consumes 6 to 8 beers nightly.
His physical examination reveals an obese, ruddy- aced man
with a temperature o 37°C, pulse 90 bpm, BP 164/80 mm Hg,
and respirations 14 bpm. He is ound to have a hematocrit o
54%.
Which o the ollowing items in his history is LEAS likely to
explain the elevated hematocrit?
A) Alcoholic cirrhosis.
B) Diabetes.
C) Antihypertensive medications.
D) estosterone injections.
E) Smoking.
The correct answer is “B.” Diabetes should not cause an
elevated hematocrit and o en causes anemia secondary to
renal disease and reduced responsiveness to erythropoietin.
Approach an elevated hematocrit with two questions: (1) Is it
due to increased RBC mass or decreased plasma volume? (2) Is
it primary erythrocytosis or secondary?
T is patient has many potential secondary causes o an
elevated hematocrit. “A,” alcoholic cirrhosis can lead to hepa-
tocellular carcinoma which, along with other malignancies, can
result in overproduction o erythropoietin, causing an elevated
hematocrit. Diuretics (“C”) decrease plasma volume, causing an
apparent elevation o hematocrit. estosterone injections (“D”)
may cause polycythemia. Finally, he has a signi cant smoking
history (“E”) that may produce a secondary polycythemia due
to hypoxia and cor pulmonale.
CASE 6.10
A 30-year-old emale presents to your o ce or a routine
visit. She was hospitalized or an appendectomy and at the
time o surgery, her platelet count was ound to be 1,400,000/
mm3, which her surgeon elt was most likely reactive. She has
no other past medical history, is asymptomatic, and exercises
three times per week. You repeat the CBC, showing WBC
5000/mm3, Hgb 13 g/dL, and platelet count 800,000/mm3.
Question 6.10.1 What is your next step in managing this
patient?
A) Anticoagulation with war arin to a goal INR o 2 to 3.
B) Counseling against becoming pregnant.
C) Initiation o hydroxyurea 500 mg BID.
D) No urther evaluation or ollow-up necessary.
E) Observation and periodic evaluation o her CBC.
Answer 6.10.1 The correct answer is “E.” T is patient likely
has essential thrombocythemia (E ), which is the most com-
mon myeloproli erative disorder in the United States. E is
more common in emales. Patients are typically older when
diagnosed with median age o 60. It is rare in children younger
than 14 years o age. Patients with E have a higher rate o mor-
tality than matched controls due to risk o thrombosis (arterial
CHAPTER 6 • HEMATOLOGY AND ONCOLOGY 181
> venous) and bleeding events. In order to diagnose E , other
causes o thrombocytosis (e.g., in ammation, iron de ciency,
recent surgery, in ection, bleeding, and malignancy) must be
excluded. A bone marrow biopsy may be help ul in establishing
the diagnosis by demonstrating adequate iron stores and ruling
out chronic myelogenous leukemia (CML) or myelodysplasia.
“A” is incorrect. War arin would not be appropriate prophy-
lactic therapy and would not be used unless the patient had a
thromboembolic event. Aspirin can be used especially or the
vasomotor symptoms associated with essential thrombocythe-
mia (erythromeralgia [a burning pain in the hands and eet],
acral paresthesias, headache, lightheadedness, etc.). Aspirin
should also be considered i the platelet count is greater than
1.5 million. “B” is incorrect. Although patients with E have
a high rate o spontaneous abortion, many can have normal,
healthy pregnancies. T e patient should be counseled regarding
pregnancy risks. “C” is also incorrect. T e patient is at low risk
or thromboembolic events (platelet count < 1.5 million/mm 3,
young age, no comorbid illness, or prior events). Hydroxyurea
could be considered i the patient was at high risk or thrombo-
embolic events or symptomatic.
HELPFUL TIP:
The most common cause o an abnormally high platelet
count is reactive thrombocytosis, which can result rom
iron de iciency, in ection, in lammation, or malignancy.
There is no increase in bleeding or clotting risk in pa-
tients with reactive thrombocytosis. The diagnosis o ET
can only be made once reactive thrombocytosis and the
presence other chronic myeloproli erative disorders are
ruled out.
CASE 6.11
A 15-year-old emale presents to your o ce complaining o
atigue. She reports menarche at age 13 and complains of heavy
menses. Her physical examination reveals a well-developed,
well-nourished, pale emale. You nd no hepatosplenomeg-
aly. Her laboratory results reveal a WBC 6,000/mm3, Hgb
8.9 g/dL, hematocrit 27%, platelet count 400,000/mm3, MCV
72 L, red blood cell distribution width (RDW) 16. You order
more laboratory tests.
Question 6.11.1 What are the expected f ndings in this
patient?
A) Increased iron, decreased erritin, increased total iron bind-
ing capacity.
B) Decreased iron, decreased erritin, decreased total iron
binding capacity.
C) Increased iron, increased erritin, increased total iron
binding capacity.
D) Decreased iron, increased erritin, decreased total iron bind-
ing capacity.
E) Decreased iron, decreased erritin, increased total iron bind-
ing capacity.
182 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
TABLE 6-3 CAUSES OF ANEMIA BY RED CELLVOLUME
Low MCV (usually < 80 L) Normal MCV (usually 80–100 L)
Anemia o chronic disease Acute blood loss
Copper de ciency Anemia o chronic disease
Iron de ciency anemia Chronic renal insu ciency
Lead poisoning Early iron de ciency
Sideroblastic anemias Endocrine (e.g., hypothyroidism)
Thalassemias Primary bone marrow disorders
Answer 6.11.1 The correct answer is “E.” T is patient likely
has iron de ciency anemia related to her heavy menses. Iron
de ciency anemia is characterized by anemia along with a
decreased serum iron, decreased erritin, increased total iron
binding capacity ( IBC), and decreased trans errin saturation.
T e decrease in serum erritin is proportional to the decrease in
total body iron stores. Hypochromic microcytic RBCs are ound
on peripheral smear. See able 6-3 or a general guide to the
causes o anemia based on red cell indices.
HELPFUL TIP:
The prevalence o VWD in women with menorrhagia
ranges rom 5% to 20%. Always make sure to take a
good personal and amily bleeding history.
HELPFUL TIP:
Even i it looks like iron de iciency anemia, always con-
sider other causes o anemia such as B12 de iciency,
olate de iciency, and thalassemia. O ten patients will
have more than one cause or their anemia. Mixed vita-
min B12 and iron de iciencies may present with normo-
cytic anemia with an elevated RDW.
You start iron supplementation therapy in this patient.
Question 6.11.2 Which o the ollowing tests will be the f rst
to indicate that you have instituted appropriate therapy
and that the patient is responding?
A) Increase in hematocrit.
B) Increase in reticulocyte count.
C) Increase in serum- ree Hgb.
D) Decrease in erritin.
E) Decrease in trans errin saturation.
Answer 6.11.2 The correct answer is “B.” T e patient’s retic-
ulocyte count will increase rst—be ore the hematocrit (“A”).
T is should start soon a er treatment and maximize at 7 to
10 days. Pica (i present) should also resolve airly early. “C”
is incorrect. Only in exceptional circumstances (intravascular
High MCV (usually > 100 L)
Alcohol ef ects
B12 de ciency
Drug ef ect (e.g., Hydroxyurea, AZT)
Folate de ciency
Hemolytic anemia
Hypothyroidism (less commonly macrocytic,
usually normocytic)
Liver disease
Primary bone marrow disease
Reticulocytosis (hemolytic anemia, response to
blood loss)
hemolysis) will there be ree hemoglobin in the blood. “D” is
incorrect because the erritin is low in iron de ciency anemia
and should increase with therapy. Finally, trans errin saturation
(“E”) should increase in patients once you start to treat their
anemia, but the reticulocyte count increases rst.
HELPFUL TIP:
Ferritin is not a use ul test or iron de iciency in hospital-
ized patients or in those who are chronically ill. Ferritin
is an acute-phase reactant and thus may be elevated in
these patients even when the patient has iron de icien-
cy anemia (where the erritin should be low). However,
you can check a soluble trans errin receptor. See below
or more.
HELPFUL TIP:
There may be no reticulocytosis with treatment o iron
de iciency i the patient is simply iron de icient without
anemia.
Question 6.11.3 How long should you continue iron sup -
plementation once the patient’s labs have normalized?
A) Stop immediately once anemia has resolved.
B) Continue 3 to 6 months a er the anemia has resolved.
C) Continue or 1 year a er the anemia has resolved.
D) Inde nite iron supplementation is indicated.
Answer 6.11.3 The correct answer is “B.” Continue iron or
3 to 6 months once the anemia has resolved. Also address the
underlying problem, in this patient her heavy periods, which
may respond to hormonal contraception, tranexamic acid, etc.
T e patient returns in 2 months but her labs, i anything, are
worse than at rst presentation. T e patient swears that she
has been taking the iron aith ully.
Question 6.11.4 Which o the ollowing can lead to a ailure
o iron therapy or iron def ciency anemia?
A) Proton pump inhibitors (PPIs).
B) Incorrect diagnosis.

C) Oral antacids (e.g., calcium carbonate).
D) Atrophic gastritis, celiac disease, or Helicobacter pylori in ec-
tion.
E) All o the above.
Answer 6.11.4 The correct answer is “E.” Anything that neu-
tralizes the stomach pH will inter ere with absorption including
PPIs, antacids, and loss o acid producing cells (e.g., pernicious
anemia). Other GI diseases (celiac disease, H. pylori) can also
inter ere with iron absorption. ea and some green lea y veg-
etables can also reduce iron absorption.
HELPFUL TIP:
Vitamin C (supplements or orange juice) enhances iron
absorption and should be considered i a patient is not
responding to iron therapy. Meat can also increase iron
absorption (which we hate to say because one o us is a
vegetarian . . . however, the truth hurts).
HELPFUL TIP:
A widened RDW and an elevated platelet count are typi-
cal o iron de iciency anemia. Conversely, the RDW will
be normal in thalassemias.
T e patient returns to your o ce and nally admits she
has not been able to take the iron because o side e ects.
Her hemoglobin is now down to 7.2 g/dL. She still eels
atigued. T e patient will not agree to take any urther iron
orally. However, she is willing to consider other sugges-
tions.
Question 6.11.5 What is your next step?
A) Encourage the patient to take the iron preparation along
with calcium carbonate ( ums) to reduce the GI side e ects.
B) Continue her prenatal vitamin only and encourage her to eat
more red meat.
C) Give iron sucrose 200 mg IV weekly or 4 weeks.
D) rans use 2 units o PRBCs immediately.
Answer 6.11.5 The correct answer is “C.” I oral iron prepara-
tions are not tolerated, IV iron preparations are available. Intra-
muscular preparations are best avoided due to pain at the injec-
tion site, skin discoloration, and risk or in ection. T e most
commonly used options or IV replacement include iron dex-
tran and iron sucrose. Iron dextran carries a risk o anaphylaxis
in 0.6% to 2.3% o patients and other side e ects in up to 25%
o patients, including bronchospasm, ushing, headache, ever,
urticaria, nausea, vomiting, hypotension, seizures, myalgias,
arthralgias, and increased thromboembolic events. Iron sucrose
has a lower incidence o side e ects—typically nausea, constipa-
tion, diarrhea, or a transient minty taste—and may be given to
patients who have had a previous reaction to iron dextran. “A”
CHAPTER 6 • HEMATOLOGY AND ONCOLOGY 183
is incorrect because calcium will inter ere with iron absorption.
Not only that but also she has already said she would not take
additional oral iron. “B” is incorrect because she needs more
iron than can be provided through prenatal vitamins and her
diet. Finally, “D” is incorrect as trans usion carries potential
risks that could be avoided i she responds to IV iron replace-
ment.
HELPFUL TIP:
Any adult patient with microcytic anemia should be
evaluated urther to clari y the etiology. In adults, GI
blood loss is a common cause o microcytic anemia.
Colitis, malignancy, or malabsorption rom in lamma-
tory disease should be considered in the di erential di-
agnosis. Tailor your work-up to the patient’s symptoms.
I he has symptoms re erable to the upper GI tract (e.g.,
dyspepsia), consider an upper GI endoscopy in addition
to colonoscopy.
CASE 6.12
A 52-year-old woman with a history o rheumatoid arthritis
is in your clinic or a 1-month ollow-up a er having a knee
prosthesis removed secondary to a joint in ection and osteo-
myelitis (Staphylococcal aureus). You obtain a CBC, revealing
a WBC 8,000/mm3, Hgb 9.5 g/dL, hematocrit 28%, platelet
count 450,000/mm3, and MCV 83 L (normal). Serum iron
levels are low with a normal serum trans errin receptor and
increased erritin.
Question 6.12.1 What is the most likely diagnosis?
A) Iron de ciency anemia due to rheumatoid arthritis.
B) Anemia o chronic disease due to rheumatoid arthritis and
osteomyelitis.
C) Hemolytic anemia induced by antibiotics.
D) Acute blood loss during surgery.
E) Myelodysplastic syndrome (MDS) associated with rheuma-
toid arthritis.
Answer 6.12.1 The correct answer is “B.” Anemia o chronic
disease is a hypoproli erative anemia that occurs in the setting
o chronic in ection, in ammation, malignancy, heart ailure,
diabetes, and other serious health conditions. T e anemia is
usually mild and characterized by low serum iron, increased
erritin (remember that erritin is an acute-phase reactant and
these patients o en have in ammation), decreased serum trans-
errin, normal (or low) serum soluble trans errin receptor level,
and decreased trans errin saturation (see below or more on the
soluble trans errin receptor). In addition, the reticulocyte count
is typically low, the erythropoietin may be mildly elevated, and
the peripheral smear may show hypochromic, microcytic RBCs
or normochromic, normocytic RBCs. I di erentiation between
iron de ciency anemia and anemia o chronic disease is not
apparent, a bone marrow biopsy can be obtained to assess iron
stores.
184 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
HELPFUL TIP:
What is that trans errin receptor anyhow? The trans er-
rin receptor can help to di erentiate between iron de-
iciency anemia and anemia o chronic disease. The se-
rum trans errin receptor level is inversely correlated to
iron storage levels. When the iron is low, the soluble
transferrin receptor level is high. Thus, high serum
transferrin receptor levels are associated with iron
deficiency but not with anemia of chronic disease in
which iron stores are adequate. One caveat, the serum
trans errin receptor level will also be elevated in states
in which there is rapid cell turnover (hemolytic anemia,
or example). However, it should not be checked in this
situation so you shouldn’t get con used.
CASE 6.13
A previously healthy 3-year-old emale with a history o
anorexia and irritability or 3 days is brought to your ED by
her mother. On the day o admission, the child is di cult to
arouse. You learn that her 6-year-old brother has had some
di culty reaching appropriate developmental milestones,
and is a “ ussy eater.”
Physical examination reveals a slightly pale-appearing
child, who responds to tactile stimuli but not to voice. Vitals
are normal and her examination is unremarkable except
or her decreased level o consciousness. Laboratory stud-
ies include a WBC 8,000/mm3, Hgb 10 g/dL, platelet count
300,000/mm3, and MCV 75 L (microcytic). Her urine dipstick
is normal, except or 1 + glucose; there are no ketones in the
urine. Her blood chemistries are within normal limits, with
the exception o a phosphorous o 2.0 mg/dL. Her peripheral
blood smear shows red cells with coarse basophilic stippling.
Question 6.13.1 What is the best working diagnosis at this
time?
A) Acute lead poisoning.
B) Anemia o chronic disease.
C) Early diabetic ketoacidosis (DKA).
D) Severe iron de ciency anemia.
E) Unrecognized bacteremia secondary to pyelonephritis.
Answer 6.13.1 The correct answer is “A.” Lead poisoning
should be considered in a child presenting with symptoms
o encephalopathy and anemia with basophilic stippling on
RBCs. Basophilic stippling occurs when ribosome precipitates
litter the RBCs. Basophilic stippling can be seen in alcohol
abuse, thalassemias, and heavy metal poisoning. “B,” anemia
o chronic disease, is unlikely because this illness is acute. “C,”
DKA, is unlikely because urine ketones are 99% sensitive or
DKA and her urine ketones are normal. “D” is unlikely because
there should be no neurologic symptoms associated with iron
de ciency anemia. “E,” pyelonephritis, is unlikely because the
patient is a ebrile and has a normal white count and negative
urine. We could have tipped you o to the answer with a “Flint,
Michigan” re erence but that would have been no un.
HELPFUL TIP:
Lead levels > 10 mcg/dL may cause developmental
delay, loss o milestones (especially language), encepha-
lopathy, seizures, cerebral edema, and cognitive impair-
ment. CNS e ects are especially problematic in children
< 6 years old who have an incomplete blood–brain bar-
rier. Lead paint in houses built be ore the 1970s and use
o imported products such as pottery, solder, cosmetics,
and crayons (and some toys made in China) still provide
sources o lead ingestion. Children born in a oreign
country and/or with recent oreign residence may also
be at risk.
HELPFUL TIP:
Other symptoms o lead intoxication include: anorexia,
decreased activity, irritability, insomnia, hearing loss,
peripheral neuropathy, SIADH, decreased renal unc-
tion, and anemia. Laboratory indings may include: ane-
mia, signs o hemolysis, coarse basophilic stippling on
RBCs, glycosuria, hypophosphatemia, positive qualita-
tive urine coproporphyrin, and moderate increases in
ree erythrocyte protoporphyrin.
T e patient’s lead level is 70 mcg/dL. Because o your concern
about acute lead intoxication and resulting encephalopathy,
you decide to admit the child and treat her with dimercaprol.
Question 6.13.2 All o the ollowing are true EXCEPT:
A) Dimercaprol should not be given i the child has a peanut
allergy.
B) T e child’s diet should be monitored or adequate intake o
calories, iron, and calcium.
C) T e child’s sibling should be tested, and arrangements
should be made or close ollow-up or both children.
D) T e dose o dimercaprol should be tripled or patients with
glucose-6-phosphate dehydrogenase (G6PD) de ciency.
Answer 6.13.2 The correct answer is “D.” Dimercaprol is a
lead chelator used to treat elevated lead levels. It is adminis-
tered intramuscularly, is water insoluble, and must be given in a
peanut oil vehicle. It may cause hemolysis in individuals with
G6PD de ciency, so these patients should be monitored closely
and not receive larger doses o dimercaprol. It is important to
test siblings o an a ected child, because the source o lead is
o en in the house. Close ollow-up o a ected children is essen-
tial to monitor or increasing blood lead levels a er treatment,
which may indicate the source o lead has not been removed.
T e absorption o lead can be made worse by malnutrition,
iron de ciency, and poor intake o calcium. Iron de ciency
requently occurs in a ected patients and may worsen anemia.

Another mainstream chelating agent is calcium disodium
ED A. It is recommended to use a combination o dimercap-
rol and ED A or children with severe lead intoxication. Other
chelating agents include d-penicillamine and succimer.
HELPFUL TIP:
A large percentage o lead is absorbed into bone with
a hal -li e o greater than 25 years. In periods o physi-
ologic stress, the inert pool o lead can be mobilized
and released into the bloodstream, producing signs
and symptoms o lead intoxication years a ter the initial
exposure.
CASE 6.14
A 6-month-old male in ant is brought to you or a well-baby
check-up. His mother reports that the child has had di culty
with eeding, has requent colds, and is o en irritable. She
has noted recurrent episodes o jaundice, especially when he
is sick. His physical examination reveals a small child, aintly
jaundiced. His temperature is 37.5°C, pulse 160 bpm, BP
85/50 mm Hg, and respirations 30 bpm. His abdomen is so
with palpable splenomegaly. T e remainder o the examina-
tion is unremarkable. Laboratories reveal a WBC 13,000/mm3,
Hgb 9 g/dL, platelet count 260,000/mm3, and MCV 60 L (low).
He is noted to have target cells on peripheral blood smear.
Question 6.14.1 Which one o the ollowing is the most
appropriate next step?
A) Order P /P .
B) Order Hgb electrophoresis.
C) rans use with 1 unit o PRBCs.
D) est or G6PD de ciency.
E) est or sickle-cell anemia.
Answer 6.14.1 The correct answer is “B.” T e clinical and
laboratory presentation is consistent with a hereditary hemo-
globinopathy, most likely a thalassemia. T e splenomegaly, sig-
ni cant anemia, target cells, and the pro oundly low MCV are
all suggestive o thalassemia; patients with thalassemia o en
have recurrent episodes o jaundice re ecting hemolysis. He has
no history o abnormal bleeding, so “A” would not be indicated.
Also, as the child does not appear to be in distress, “C” would
be an incorrect answer. G6PD-de cient patients experience epi-
sodes o hemolytic anemia. Peripheral smear review at that time
may reveal bite or blister cells, rather than target cells, so “D” is
not the right answer. “E” is incorrect since the peripheral smear
would reveal sickle cells i the patient had sickle disease.
Beta thalassemia major is con rmed by Hgb electrophoresis.
Question 6.14.2 Which o the ollowing regarding his man-
agement is NOT true?
A) Untreated, mortality may approach 80% by 5 years o age.
B) Frequent blood trans usions may be required.
CHAPTER 6 • HEMATOLOGY AND ONCOLOGY 185
C) T e condition will improve with age.
D) T e child is likely to have growth retardation and delayed
sexual maturation.
E) Without iron chelation therapy, there is a high incidence o
mortality with this disease.
Answer 6.14.2 The correct answer is “C.” Beta thalassemia
re ers to the disease state in which there are mutations in
both genes that code or beta globin. Without treatment,
mortality rom thalassemia major approaches 80% by 5 years
o age. Patients with beta thalassemia will eventually develop
iron overload, even without blood trans usions. he use o
trans usions and concurrent chelation therapy with de er-
oxamine has reduced long-term complications related to
the disease. De erasirox (Exjade), an oral chelating agent,
is available as an alternative to de eroxamine. Bone marrow
transplant can be curative. Beta thalassemia minor (or beta
trait) is much less severe and occurs when only one o the
genes is de ective.
HELPFUL TIP:
The FDA has approved de eriprone as an alternative
chelating agent in trans usion-acquired iron overload.
It is second line but can be administered orally. It can
be considered when de erasirox is not e ective and the
patient is unable to use de eroxamine, the parenteral
option.
HELPFUL TIP:
Alpha thalassemia has a more variable course. There are
our alpha globin genes. I all our genes are de ective,
intrauterine etal demise is the rule. When one gene is
de ective, there is a silent carrier state. When two genes
are de ective, there is a mild microcytic anemia. Here is
a memory aid: there are our alpha globin genes and
“4” looks kind o like the Greek letter alpha; beta is the
second letter in the Greek alphabet and beta globin has
two genes.
HELPFUL TIP:
Because o the persistence o etal hemoglobin (HbF) in
the circulation up to 6 months o age, hemoglobinopa-
thies might not be apparent until that time.
HELPFUL TIP:
Thalassemias may be erroneously diagnosed as iron de-
iciency anemia due to a low MCV. Consider testing or
thalassemia in a patient with microcytic anemia, normal
or increased iron levels, a normal RDW (less reliable),
and appropriate ethnic background (e.g., Mediterra-
nean or A rican descent).
186 FAMILY MEDICINE EXAMINATION & BOARD REVIEW

HELPFUL TIP:
In other Hgb synthesis related news . . . when you see
that middle-aged emale with abdominal pain and psy-
chiatric symptoms or the tenth (or twentieth or thirti-
eth) time, think o acute intermittent porphyria be ore
you make the diagnosis o somatization disorder.
CASE 6.15
A woman brings her 10-week-old in ant or evaluation.
T e child is colicky and irritable a er eeding. She was
born ull term but has not been gaining weight appropri-
ately. T e patient’s sister has sickle-cell trait, so you obtain
an Hgb electrophoresis, which ultimately demonstrates SS
genotype.
Question 6.15.1 Which o the ollowing is INCORRECT
regarding the child’s care?
A) T e patient should remain on prophylactic antibiotics until
the age o 5 years due to a high risk o pneumococcal sepsis.
B) T e child may develop splenomegaly and lymphadenopathy
related to her disease.
C) T e disease provides protection against in ection with par-
vovirus.
D) T e child may not develop pain crisis until she is older due
to protection rom HbF.
E) T e child is likely to have a delay in puberty.
Answer 6.15.1 The correct answer is “C.” T e patient has
homozygous SS sickle-cell disease. T is child’s mother should
be counseled regarding the importance o continuing antibiotic
prophylaxis until the age o 5 years because her child is at high
risk or pneumococcal sepsis. Sickle-cell disease is protective
against malaria, not parvovirus (“C”). In act, parvovirus in ec-
tion can be li e-threatening in these patients due the develop-
ment o aplastic anemia.
During in ancy, children may be noted to have reticulocy-
tosis, hemolytic anemia, and sickling by 10 to 12 weeks. At 5 to
6 months, splenomegaly may be noted, and lymphadenopathy
may be prominent between 6 months and 5 years. T e earliest
pain crisis o en involves hands and eet (dactylitis), and occurs
a er the HbF decreases to adult values; this usually does not
occur until a er the age o 4 years. T e spleen involutes by 5 to
8 years. Puberty is delayed by an average o 2.5 years.
T e child ollows regularly with you or years, and she begins
to develop more requent pain crises in college. She is ound
to have an elevated C-reactive protein, increased LDH, and
decreasing Hgb. You explain to her that some measures can
be taken to reduce the requency o pain crises.
Question 6.15.2 These measures include all o the ollowing
EXCEPT:
A) Initiation o hydroxyurea therapy.
B) Avoidance o hot showers.
C) Prompt treatment o in ections.
D) Adequate hydration and nutrition.
E) Avoidance o emotional stress.
Answer 6.15.2 The correct answer is “B.” wo main eatures
o sickle-cell disease are shortened RBC survival and vasooc-
clusion due to poorly de ormable RBC membranes. Pain epi-
sodes occur due to acute episodes o tissue hypoxemia and
microin arction. Crises can be precipitated by stress, atigue,
cold weather (not hot showers, which cause problems in mul-
tiple sclerosis patients), in ection, dehydration, acidosis, and
poor nutrition. T e use o hydroxyurea promotes increased
levels o HbF, and HbF is associated with decreased requency
and severity o pain crises.
HELPFUL TIP:
Acute chest syndrome (ACS) should be suspected when
a sickle-cell patient presents with ever, cough, chest
pain, and pulmonary in iltrates on chest x-ray. ACS may
be due to in ection or pulmonary in arction. Treatment
involves aggressive pain management, antibiotics or
respiratory pathogens, supplemental oxygen, cautious
hydration, and blood trans usion i the patient is sig-
ni icantly anemic. Exchange trans usion may also be
required in more severe cases.
HELPFUL TIP:
For patients with sickle-cell disease, simply replacing
volume is usually appropriate. However or primary and
secondary stroke prevention, trans use/exchange trans-
use so that the HbS is < 30%. For presurgical patients,
simply getting the Hbg to 10 g/dL seems adequate.

Since you rst met that little baby girl, 22 years have elapsed,
and she is getting married—and you are getting old (the alter-
HELPFUL TIP:
native is worse, o course). She is concerned about signi cant
Sickle trait, the condition in which a patient is hetero-
illness related to her disease. You counsel her regarding the
zygous or Hb S, is associated with a normal li e expec-
most common causes o morbidity and mortality.
tancy and no symptoms other than occasional hema-
turia and inability to concentrate urine. Pain crises are
Question 6.15.3 All o the ollowing statements are true
extremely rare, and occur only in the settings o a low
EXCEPT:
oxygen atmosphere (e.g., very high altitude) or extreme
A) ACS and pain crises are the most common causes or hospi-
physical activity (e.g., running a marathon).
tal admission or patients with sickle-cell disease.

B) Eighty percent o patients develop cholelithiasis by the age o
35 years.
C) Strokes may occur in 8% o patients by the age o 14 years,
may be either symptomatic or clinically silent, and tend to
be recurrent.
D) Heart ailure, pulmonary brosis, pulmonary hypertension,
and renal ailure complicate uid management, trans u-
sions, and maintenance o adequate oxygenation.
E) Pregnancy should be avoided under any circumstance.
Answer 6.15.3 The correct answer is “E.” T e average li e
expectancy in patients with Hb SS is 42 years or men and
48 years or women. Maternal mortality occurs in about 1% o
pregnancies. All o the rest are true including cerebrovascular
events causing seizures and possible cognitive dif culty early in
li e. O particular note, renal ailure may be the cause o death in
up to 10% o cases. Avascular necrosis and osteomyelitis (clas-
sically as a result o Salmonella in ection), chronic skin ulcers,
and priapism are also common.
Objectives: Did you learn to . . .
• Recognize the presentation and implication o essential
thrombocytosis?
• Evaluate a patient with an elevated Hgb or platelet count?
• Obtain a thorough history in an anemic patient?
• Use laboratory parameters to identi y the etiology o
anemia?
• Initiate treatment o various causes o anemia?
• Identi y certain anemias, especially iron de ciency, thalas-
semias, and sickle-cell disease, based on clinical and labora-
tory mani estations?
QUICK QUIZ: THE CURIOUS CASE OF THE
MISSING VITAMIN
A 72-year-old gentleman is brought to your of ce because
a home health nurse noted he was becoming progressively
weaker and more atigued. He has a history o celiac disease
or which he ollows a strict gluten- ree diet, but he has not
been eating well. He also has a history o a seizure disor-
der and takes phenytoin. His review o systems is positive
or dyspnea on exertion and mild anorexia. He has no other
symptoms.
Physical examination reveals a thin, pale-appearing man with
normal vital signs. His conjunctivae are pale and his tongue is
smooth, with moist mucosa and no oropharyngeal lesions. T e
remainder o the examination is unremarkable. A CBC reveals
a WBC 4,500/mm 3, Hgb 9 g/dL, hematocrit 28%, platelet count
140,000/mm 3, MCV 102 L, RDW 14, and B12 level 900 ng/L
(normal).
Which o the ollowing statements is most likely FALSE?
A) T e patient may have a high homocysteine level.
B) T e patient’s condition could be made better with a trial o
olate replacement.
C) T e patient may have a low RBC olate level.
CHAPTER 6 • HEMATOLOGY AND ONCOLOGY 187
D) T e patient’s condition will likely require chronic blood
trans usions.
E) T e patient may have a normal serum olate level.
The correct answer is “D.” T is patient likely has olate de -
ciency, given a normal B12, macrocytic anemia, and risk ac-
tors or olate de ciency—old age, poor diet, avoidance o glu-
ten ( our is normally orti ed with olate), use o phenytoin,
and possible malabsorption due to GI disease (celiac disease in
this case, but also any other in ltrating or in ammatory process
o the bowel). Dietary de ciency is uncommon in the United
States due to supplementation o grain products with olate.
Foods naturally high in olate include melons, bananas, lea
vegetables, asparagus, and broccoli. T e recommended intake is
400 µg/day, and the body stores approximately a 4-month sup-
ply. I he has had recent adequate olate intake, the serum olate
level may be normal, but the RBC olate will still be low, re ect-
ing the de ciency (think o it as the HbA1C o olate).
o di erentiate olate rom B12 de ciency, check serum
homocysteine and methylmalonate levels. Both will be elevated
with B12 de ciency, while only homocysteine will be elevated in
olate de ciency. Remember, you must exclude B12 de ciency
be ore replacing olate because olate replacement can reverse
the anemia but will permit progression o neurologic e ects o
B12 de ciency, so “B” is true.
HELPFUL TIP:
Folate replacement is dosed as 1 to 5 mg daily or
1 to 4 months or until complete hematologic recovery
occurs. I macrocytic anemia persists, other causes must
be considered.
QUICK QUIZ: REMEMBER THAT TAPEWORM
FROM MEDICAL SCHOOL? HERE IT IS AGAIN
A 47-year-old woman presents to your of ce complaining o
tongue soreness, atigue, and dyspnea with exertion. She denies
unusual bleeding, weight loss, evers, and night sweats. Her past
medical history includes hypothyroidism, or which she takes
levothyroxine. She does not drink alcohol or smoke. Physical
examination reveals a tired-appearing woman with lemon-
yellow colored skin, temperature 37°C, pulse 110 bpm, BP 120/
74 mm Hg, and respirations 12 bpm. T e examination is otherwise
unremarkable. A CBC demonstrates a WBC count 4000/mm 3,
Hgb 9 g/dL, platelet count 140,000/mm 3, and an MCV o 105 L.
Her B12 level is 100 pg/mL (normal > 300 pg/mL) and olate
40 ng/mL.
Which o the ollowing historical elements is LEAS likely to
contribute to her condition?
A) History o working as a park ranger in Canada.
B) History o Zollinger–Ellison syndrome.
C) History o hypothyroidism.
D) History o new vegetarian diet started last month.
E) History o GI surgery.
188 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
The correct answer is “D.” Most likely, this woman has perni-
cious anemia caused by B12 de ciency. Pernicious anemia is
caused by immune destruction o parietal cells in the stomach,
resulting in decreased absorption o B12. It typically develops
in people over the age o 40 and is more common in people o
northern European descent or in A rican Americans, as well as
people with type A blood. Laboratory ndings include antipa-
rietal cell antibodies in 90% o a ected patients (5% o normal
individuals also have the antibody) and antibodies to intrinsic
actor in 70% o patients. Individuals commonly have other
autoimmune diseases such as thyroid disease, diabetes, and vit-
iligo. Individuals may complain o paresthesias, GI symptoms,
sore tongue, or weight loss. T e lemon-yellow appearance o the
skin is due to anemia and mild jaundice.
Other causes o cobalamin (B12) de ciency include gastrec-
tomy, Zollinger–Ellison syndrome (inability to alkalinize the
small intestine), blind loop syndrome, bacterial overgrowth
rom previous surgery, and ingestion o undercooked sh
in ested with the tapeworm Diphyllobothrium latum ( ound in
Canada, Alaska, and the Baltics—hence, the history o working
as a park ranger). Although a strict vegetarian diet can cause
B12 de ciency, there are suf cient stores to last 3 to 5 years (in
other words, more than 1 month).
QUICK QUIZ: SAY, DID HE SWALLOW A PENNY?
A 21-year-old college student is brought to the ED by his
riends because o bizarre behavior. His riends state that he
has been acting “a little odd” lately, but they are unaware o
any drug abuse. He does drink alcohol but is not known as
a binge drinker—at least not by modern NCAA Division I
Drinking standards. His riends do not know his medical his-
tory but state he was taking a prescription drug or a “meta-
bolic disorder,” which he stopped several months ago. He is
uncooperative, paranoid, and disoriented. You note brownish
pigmentation o his corneas on physical examination. T is
may be the rst—and last—case o Wilson disease you have
ever seen.
Regarding this patient, which o the ollowing is INCORREC ?
A) T e patient has likely had episodes o hemolytic anemia in
the past.
B) T e patient has likely discontinued penicillamine.
C) T e patient likely has an elevated ceruloplasmin level on
blood test.
D) T e patient likely has hepatolenticular degeneration.
E) T e patient is at risk or hepatic ailure.
The correct answer is “C.” T is patient likely has Wilson disease
(an autosomal-recessive de ect in cellular copper export), which
presents with decreased levels o ceruloplasmin, increased liver
enzymes, and signs o hemolysis ( rom the direct toxic e ect o
copper on the cell). Symptoms typically present in the teens and
early 20s. Presenting symptoms may include Kayser–Fleischer
rings (golden-brown pigmentation o the cornea), hemolytic
anemia, or neurologic symptoms, o en mimicking psychiatric
illness. reatment o the disease includes li elong therapy with
penicillamine or trientine (chelating agents), and should be
considered even or asymptomatic individuals known to have
the disease. By the way, pennies are primarily zinc and contain
little copper.
QUICK QUIZ: “HOLE-Y BONES”
A 50-year-old man presents to your of ce with low-back pain o
8 weeks duration. He denies any history o trauma or overexer-
tion. He notes the pain is constant and does not improve with
positioning. Also, he has noticed some atigue. He has no other
complaints.
Physical examination reveals a well-nourished male with nor-
mal vital signs. His neurologic examination is normal. On mus-
culoskeletal examination, he has midline point tenderness over
12. Plain lms reveal a compression racture at 12. A serum
total protein level is 9 mg/dL (elevated), but the remainder o an
evaluation or endocrine causes o osteoporosis is normal.
All o the ollowing are necessary or the diagnosis o this
patient EXCEP :
A) Bone scan.
B) Serum and urine protein electrophoresis with immuno xa-
tion.
C) Bone marrow aspirate and biopsy.
D) Quantitative immunoglobulins.
E) Skeletal survey.
The correct answer is “A.” A spontaneous vertebral racture in
a 50-year-old male is de nitely not normal. Multiple myeloma
should be considered in patients with this presentation. Mul-
tiple myeloma is a clonal disorder o plasma cells. Risk actors
include A rican-American race, male sex, and advancing age
(median age o 60–65 at presentation). Work-up or the diag-
nosis o multiple myeloma requires a serum and urine protein
electrophoresis with immuno xation (“B”). T is will help to
identi y a monoclonal protein. Quantitative immunoglobulins
(“D”) will help to assess whether this patient has an elevation
o immunoglobulins in the range required or the diagnosis o
multiple myeloma. A skeletal survey (“E”) and bone marrow
biopsy (“C”) complete the diagnostic work-up. A bone scan is
not use ul because the lytic lesions characteristic o multiple
myeloma do not take up radioisotope.
CASE 6.16
On a routine insurance physical examination, a 55-year-old
man was ound to have a total protein o 9 g/dL (elevated).
T e remainder o his serum chemistries and his CBC were
normal. He is active, eels well, and is not taking any medi-
cations. His physical examination is unremarkable. You
order a serum and urine electrophoresis with immuno xa-
tion and quantitative immunoglobulins. He has a monoclo-
nal spike with 1,400 g/dL o IgG kappa (elevated). His other
immunoglobulins are within normal limits. A skeletal survey

demonstrates no lytic lesions, and his bone marrow aspirate
and biopsy demonstrate 6% plasma cells (normal is 1–4%).
A er the bone marrow biopsy, the hematologist sends him
back to you or ollow-up.
Question 6.16.1 What is your next step in the management
o this patient?
A) Monitor blood, including serum immunoglobulins, every 3
to 6 months and, i stable a er 1 year, annually therea er.
B) Monitor blood, including serum immunoglobulins, every
4 weeks inde nitely.
C) Start on chemotherapy or multiple myeloma.
D) Obtain yearly bone marrow biopsy and skeletal survey.
E) No ollow-up is necessary.
Answer 6.16.1 The correct answer is “A.” T is patient has
monoclonal gammopathy o undetermined signi cance, or
MGUS, which is ound in up to 3% o asymptomatic older (over
50 years old) individuals (mostly Caucasian). A bone marrow
biopsy indicating 10% plasma cells is required to make the diag-
nosis o multiple myeloma; this patient only has 6%. In addi-
tion, this patient has a normal CBC and is asymptomatic (no
atigue, bone pain suggestive o lesions, etc.). T us, this patient
has MGUS. Patients with MGUS typically do well, with only 1%
per year progressing to multiple myeloma.
While patients should be reassured o the typically benign
nature o this condition, up to 30% will have complications
(multiple myeloma, amyloidosis, other myeloproli erative
disorders). A er several unchanged immunoglobulin levels
and normal CBCs within the 6 months o the initial diagno-
sis, annual or biannual evaluation should be adequate. Any
changes in the patient’s condition, such as unexplained anemia,
increased immunoglobulin levels, renal insuf ciency, or bony
pain, should prompt urther evaluation. An increase in immu-
noglobulin does not necessarily mean the monoclonal protein
is increasing, and a serum protein electrophoresis and immu-
no xation should be obtained. Repeat bone marrow biopsy is
indicated only i the clinical picture is con using.
CASE 6.17
A 63-year-old woman presents to your o ce with complaint
o atigue. She states she elt like she spent the winter tak-
ing antibiotics because she developed “one in ection a er the
other.” Prior to this past winter, she had been well and did not
take any prescription drugs regularly. Physical examination
demonstrates a slightly pale, thin woman. Her temperature
is 37.5°C, pulse 90 bpm, BP 120/58 mm Hg, and respirations
12 bpm. Her oropharynx demonstrates purpuric lesions. Her
abdominal examination shows no organomegaly, and the
remainder o the physical examination is unremarkable.
You obtain blood tests: WBC 2,100/mm3, Hgb 8.4 g/dL,
and platelet count 20,000/mm3. A bone marrow aspirate and
biopsy are obtained, which demonstrate a hypercellular mar-
row with 4%blasts, 4%ringed sideroblasts, and megakaryo-
cytes. You talk to the hematologist, who suspects that your
patient has a myelodysplastic syndrome (MDS).
CHAPTER 6 • HEMATOLOGY AND ONCOLOGY 189
Question 6.17.1 Which o the ollowing statements is
INCORRECT?
A) T e small number o blasts in the bone marrow indicates a
good prognosis.
B) T e patient cannot have MDS because she has pancytopenia.
C) T e patient may bene t rom administration o erythropoi-
etin.
D) T e patient may develop acute myeloid leukemia.
E) T e patient’s gender may result in a better prognosis.
Answer 6.17.1 The correct answer is “B.” Patients with MDS
can be pancytopenic. MDS includes a number o clonal stem
cell disorders characterized by dysplasia and ine ective hema-
topoiesis o one or more cell lines. T e disease is typically one
o older adults, with a median age o 65 to 70 years at onset;
however, a better prognosis is associated with age < 60 years
and emale gender. T ere is an increased risk o MDS in smok-
ers, those exposed to benzene or alkylating agents, and with
some hereditary disorders. Prognosis depends on the num-
ber o blasts, the number o lineages a ected, and cytogenetic
abnormalities. Median survival ranges rom 10 to 66 months,
and progression to acute leukemia ranges rom 6% to 33% o
patients, depending on the subtype o MDS.
Depending on the age and overall per ormance status o the
individual MDS patient, treatment can range rom supportive
care with blood or platelet trans usions, to treatment with gran-
ulocyte colony stimulating actor (GCSF), to chemotherapeutics
such as azacytidine, or even to bone marrow transplantation.
Objectives: Did you learn to . . .
• Recognize the presentation o multiple myeloma?
• Identi y MGUS?
• Identi y pancytopenia as a presentation o MDS?
QUICK QUIZ: IT’S JUST KIDS’STUFF
All o the ollowing are accurate statements about neutrophil
counts in children EXCEP :
A) A rican-American children may have a normal ANC o
1,000/mm 3.
B) Children over the age o 6 should be expected to have a nor-
mal ANC o 1,500 to 8,000/mm 3.
C) Neonates typically have a normal ANC o <500/mm 3 at birth.
D) In ants typically have 20% to 30% neutrophils on WBC di -
erential.
E) Five-year-old children have 50% neutrophils on WBC di -
erential.
The correct answer is “C.” In the pediatric population, neutro-
penia is typically described as an ANC o < 1,500/mm 3. Up to
30% o A rican-American children have an asymptomatic ANC
o < 1,000/mm 3 (e.g., no increased risk o in ection). At birth,
neutrophils make up the majority o the WBC di erential, and
this decreases to 20% to 30% a er the rst ew days o li e. At
5 years o age, neutrophils comprise approximately 50% o the
di erential, and this reaches 70% by puberty.
190 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
CASE 6.18
A 49-year-old male presents to your o ce complaining o
joint pain, atigue, and increased urination. T ere is a am-
ily history o cirrhosis o the liver, apparently not related
to alcohol. He does not take any medications and does not
smoke but drinks two glasses o wine each night. Physical
examination reveals a thin male with tanned skin (in the
dead o winter in Iowa, so he is either rich or sick, take your
choice) and normal vital signs. His heart and lung examina-
tions are unremarkable. T e abdomen is so , nontender, and
nondistended, and his liver edge is palpable 2 cm below the
costal margin. He has pain with range o motion in his hips,
knees, and M P joints. T e remainder o the examination is
unrevealing. Serum electrolytes are normal, but his glucose is
282 g/dL. His transaminases are elevated.
Question 6.18.1 O the ollowing, what is the most likely
diagnosis?
A) Alcoholic hepatitis.
B) Colon cancer.
C) Hemochromatosis.
D) Vitamin B12 de ciency.
Answer 6.18.1 The correct answer is “C.” T is patient pres-
ents with a “classic” history o hemochromatosis. Symptoms
start during or a er the h decade o li e, are initially mild,
and progress slowly. “Bronze diabetes” (bronze or tan skin color
due to iron deposition accompanied by hyperglycemia) is some-
times noted. Most organs can eventually be involved, but most
commonly symptoms are due to liver, cardiac, joint, and testicu-
lar involvement. “A,” alcoholic hepatitis, is a consideration, but
his reported use is unlikely to result in disease. You also would
not expect to see some o the other symptoms (e.g., diabetes and
arthritis) in relation to alcoholic hepatitis. “B,” colon cancer, is
unlikely to present in this way. “D,” vitamin B12 de ciency, typi-
cally presents with anemia and neurologic symptoms.
Question 6.18.2 Which o the ollowing laboratory values
are most consistent with this patient’s presentation?
A) Decreased iron, decreased erritin, decreased trans errin
saturation.
B) Decreased iron, decreased erritin, increased trans errin
saturation.
C) Increased iron, decreased erritin, increased trans errin
saturation.
D) Increased iron, increased erritin, decreased trans errin sat-
uration.
E) Increased iron, increased erritin, increased trans errin
saturation.
Answer 6.18.2 The correct answer is “E.” All o these iron
studies (serum iron level, erritin and trans errin saturation)
are elevated in patients with hereditary hemochromatosis.
A normal person maintains approximately 3 to 4 g o iron in
the body. Normal individuals absorb about 1 mg/day o iron
(10% o what is ingested), which is precisely balanced with loss
through sweat, sloughing o cells, and GI losses. In hereditary
hemochromatosis, 2 to 4 mg o iron is absorbed daily, resulting
in the accumulation o iron.
T e patient’s diagnosis is con rmed, and you counsel him
regarding his disease.
Question 6.18.3 All o the ollowing statements are true
EXCEPT:
A) T is is an autosomal-dominant disease.
B) A ected emales typically present later in li e due to
increased iron losses.
C) Patients may bene t rom phlebotomy even a er develop-
ment o symptomatic disease.
D) Patients are susceptible to unusual in ections.
E) Patients are at high risk or hepatocellular carcinoma.
Answer 6.18.3 The correct answer is “A.” Hereditary hemo-
chromatosis is an autosomal-recessive disorder. Approxi-
mately 10% o Caucasians are heterozygous, and 5/1,000 are
homozygous or the gene mutation. Patients are at increased
risk or in ections due to Listeria, Vibrio vulnif cus (sorry, no
sushi!), and Yersinia enterocolitica. A ected emales may pres-
ent later in li e due to increased iron losses rom menstrua-
tion, pregnancy, and lactation.
reatment includes phlebotomy or chelation therapy i phle-
botomy is contraindicated. Patients should be monitored closely
or development o hepatoma, since therapy does not reduce the
risk o hepatocellular carcinoma once cirrhosis is present. Fam-
ily members should be screened or the disease so they can be
started on therapy early, in order to prevent the development o
cirrhosis.
HELPFUL TIP:
Hemochromatosis is a genetic disease; there ore, iden-
ti ying a de ect in the HFE gene makes the de initive di-
agnosis. Patients may have high erritin levels or many
reasons, including many causes o in lammation and
liver disease. To con irm the diagnosis, test or the two
genetic de ects known to cause the disease: C282Yand
H63D. In persons o northern European descent, het-
erozygosity is remarkably prevalent with about 10%
o these patients carrying C282Y and 15% to 20% car-
rying H63D. However, the disease is autosomal reces-
sive and will only mani est with two copies o C282Y
or one copy o each (C282Y/H63D). H63D alone (and
other mutations) appear less deleterious compared
to C282Y.
HELPFUL TIP:
Other causes o iron overload include thalassemia, sid-
eroblastic anemia, and requent blood trans usions.

CASE 6.19
A 56-year-old man undergoes a laryngoscopy. In an out-
dated move that is generally not recommended now, his
doctor used extra doses o benzocaine spray (like gallons o
the stu ) to overcome a strong gag ref ex. T e patient tol-
erated the procedure well, but a erward he started to have
cyanosis around the lips. You are now seeing him in the ED,
and he has a bluish discoloration o his lips and ngertips
and is complaining o a headache. You administer oxygen
by nasal cannula with no improvement in his cyanosis. You
draw venous blood or labs, and nd that it has an unusual
chocolate color.
Question 6.19.1 All o the ollowing statements are likely to
be true about this patient EXCEPT:
A) A measured arterial blood gas will demonstrate a normal
PaO2.
B) T e pulse oximeter will show high-normal oxygen satura-
tion.
C) T e patient may require therapy with methylene blue.
D) T e patient should not be treated with methylene blue i he
has a history o G6PD de ciency.
E) Additional doses o benzocaine can be lethal.
Answer 6.19.1 The correct answer is “B.” T is patient has
methemoglobinemia, which in his case was likely a result o
the benzocaine spray. Methemoglobinemia results when iron
in Hgb is oxidized rom the errous to the erric state and the
Hgb becomes incapable o binding and transporting oxygen.
T e blood gas oxygen may look normal because the RBCs can-
not release oxygen (and thus remain oxygenated). However, the
pulse oximeter will show a low O2 saturation. So, there is o en
a gap between what you see on the blood gas and what the
pulse oximeter suggests.
In a normal patient, less than 1% o Hgb is ound in the met-
hemoglobin orm. Depending on the percentage o methemo-
globin, presentations will vary. At methemoglobin levels o 10%
to 20%, patients present with cyanosis re ractory to oxygen. T e
arterial blood gas may show a normal PaO2 with low oxygen
saturations. When methemoglobin levels are > 30%, patients
present with headache, dizziness, dyspnea, and tachypnea (signs
o moderate hypoxemia). At > 50%, patients develop stupor and
obtundation (signs o severe hypoxemia), and levels > 70% may
be lethal.
Certain drugs such as nitroprusside, sul onamides, some
local anesthetics, and acetaminophen have been ound to cause
methemoglobinemia.
reatment o methemoglobinemia is methylene blue. How-
ever, patients with G6PD de ciency should not be given methy-
lene blue, and hyperbaric oxygen therapy should be considered
instead. Remember, when patients have been exposed to cyanide,
you want to cause methemoglobinemia. T e exact mechanism
by which this protects against cyanide is unknown, since patients
begin to improve prior to the presence o methemoglobinemia.
CHAPTER 6 • HEMATOLOGY AND ONCOLOGY 191
HELPFUL TIP:
Children with diarrhea may develop methemoglobin-
emia, although it is rarely clinically signi icant.
HELPFUL (AND SOMEWHAT USEFUL) TIP:
Methylene blue, as a potent inhibitor o monoamine
oxidase, can also cause a serotonin syndrome i used in
those on SSRIs or other serotoninergic drugs.
CASE 6.20
A 16-year-old sub-Saharan A rican male presents to your
o ice or progressive atigue and dyspnea over the last
ew days. He also has some mild upper respiratory symp-
toms that are being “treated” with sul amethoxazole—tri-
methoprim. ( he doctor down the street is known to treat
all respiratory in ections with antibiotics.) On examina-
tion, you ind a well-nourished male in no distress. He
is a ebrile but slightly tachycardic. You note mild scleral
icterus and pallor o the palmar creases, but the remain-
der o the examination is unremarkable. A CBC shows
normal WBC count and platelets, with Hgb 10.2 g/dL.
On peripheral smear, “bite cells” and rare Heinz bodies
are reported. he LDH and bilirubin are elevated and the
serum haptoglobin is low, but the other serum chemistries
are normal.
Question 6.20.1 Which o the ollowing is the most likely
diagnosis?
A) Hereditary spherocytosis.
B) G6PD de ciency.
C) Sickle-cell disease (homozygous).
D) Sickle-cell trait (heterozygous).
E) Iron de ciency anemia.
Answer 6.20.1 The correct answer is “B.” T e most likely
cause o this patient’s anemia is G6PD de ciency. He appears
to have a hemolytic anemia, as evidenced by the elevated LDH,
bite cells, elevated bilirubin, low haptoglobin, and the acute
onset o symptoms. Heinz bodies are inclusions in red cells
seen on peripheral smear within the rst ew days o an oxi-
dative stress in patients with G6PD de ciency. Bite cells are
ormed as the red cells pass through the spleen and the Heinz
bodies are removed. T e other diagnoses are less likely. Heredi-
tary spherocytosis (“A”) is caused by an inherited de ect in the
red cell membrane, and episodes o hemolytic anemia may be
brought on by environmental stress. However, patients gener-
ally have a baseline anemia, and spherocytes should be seen
on peripheral smear. Sickle-cell disease and trait are discussed
in more detail elsewhere. “E,” iron de ciency anemia, does not
generally present acutely and is not associated with ndings o
hemolysis.
192 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
HELPFUL TIP:
G6PD de iciency is the most common inherited RBC
enzyme de ect, a ecting 10% o the black male popula-
tion. It occurs more commonly in A rican and Mediter-
ranean populations.
Hemolytic anemia in G6PD de ciency is caused by oxidative
stress on red cells, most commonly as the result o in ection
or administration o certain drugs.
Question 6.20.2 Which o the ollowing can precipitate a
hemolytic crisis in G6PD def ciency?
A) Sul a antibiotics.
B) Fresh ava beans.
C) Nitro urantoin.
D) Some antimalarial drugs.
E) All o the above.
Answer 6.20.2 The correct answer is “E.” All o the above can
cause a hemolytic crisis in G6PD de ciency. Multiple other
drugs can be involved as well, including vitamin C, salicylates,
isoniazid, and phenytoin.
HELPFUL TIP:
Fresh ava beans aren’t worth the bother. First you have
to shell them and then peel each and every bean. A ter all
that work, you just end up with a hemolytic crisis i you
have G6PD de iciency. Get the canned ones.
Question 6.20.3 Which o the ollowing is the most appro-
priate intervention or this patient with G6PD def ciency at
this point?
A) Admit to the hospital and observe.
B) Admit to the hospital and trans use 2 units o packed red
cells.
C) Recommend supportive care and ollow-up in a ew days.
D) Recommend splenectomy and re er to a general surgeon.
Answer 6.20.3 The correct answer is “C.” T e hemolytic ane-
mia o G6PD de ciency is sel -limited and will resolve. T is is
because in most cases o G6PD de ciency, only about 25% o
the RBCs (the older cells) are susceptible to oxidative stress.
Severe episodes should be treated in the hospital setting, but
most episodes can be managed as an outpatient. Patients should
be educated on the drugs and stressors that may precipitate an
episode o hemolytic anemia. Splenectomy may limit hemolysis
in patients with more severe disease.
HELPFUL TIP:
I you check a G6PD level during or just a ter a hemolytic
crisis it will likely be normal even in those with G6PD
de iciency. The cells that have low levels o G6PD have
hemolyzed. The younger cells that are le t (those that
are tested) have normal levels o G6PD.
Objectives: Did you learn to . . .
• Describe symptoms and signs o hemochromatosis?
• Recognize complications related to iron overload?
• Describe ndings and treatment o methemoglobinemia?
• Identi y clinical and laboratory mani estations o G6PD
de ciency and describe its management?
QUICK QUIZ: TOO MANY LYMPHOCYTES
A 72-year-old man presents to your of ce or ollow-up a er a
recent hospitalization or pneumonia. While he was in the hos-
pital, he had an increased WBC with lymphocytosis. You repeat
his CBC and nd a WBC o 18,000/mm 3, with 80% lympho-
cytes, Hgb o 14 g/dL, and a platelet count o 200,000/mm 3. You
review of ce records rom a visit 1 year ago and nd a WBC
o 14,000/mm 3 with 76% lymphocytes. You send his peripheral
blood or ow cytometry, which is consistent with a diagnosis o
chronic lymphocytic leukemia (CLL).
Which o the ollowing statements about this patient is
INCORREC ?
A) T is patient is at risk or the development o hemolytic
anemia.
B) T is patient is at risk or serious in ection.
C) T is patient is likely to experience a relatively benign disease
course.
D) T is patient should be started on chemotherapy.
E) T is patient may develop “B symptoms” ( ever, night sweats,
weight loss).
The correct answer is “D.” CLL is characterized by progres-
sive accumulation o long-lived lymphocytes. It is more com-
mon in men and tends to be a disease o older adults (median
age at diagnosis is 65 years); however, up to 20% o cases occur
in patients < 60 years o age. Diagnosis is made i a patient has
> 5,000/mm 3 mature-appearing lymphocytes in the blood rep-
resenting a clonal line. With the use o immunophenotyping,
bone marrow biopsy is not necessary or diagnosis, but may be
use ul or prognosis.
T is patient has a low-stage CLL (the only nding is lym-
phocytosis) and does not require immediate treatment with
chemotherapy. He should be monitored every 6 to 12 months or
sooner i he develops symptoms, such as in ections, atigue, bulky
lymphadenopathy, or bleeding. Patients with CLL are at risk or
developing autoimmune diseases, including hemolytic anemia,
autoimmune thrombocytopenia, pure red cell aplasia, and auto-
immune neutropenia.
QUICK QUIZ: TOO MANY NEUTROPHILS
A 46-year-old woman presents to your of ce or a preoperative
evaluation. She is planning an elective hysterectomy or uterine
broids. She has no signi cant past medical history. Her review
o systems is positive only or sweats. Her physical examination

is unremarkable except or a palpable spleen tip. You obtain a
CBC, showing a WBC 50,000/mm 3, Hgb 11 g/dL, and a plate-
let count 350,000/mm 3. On her peripheral blood smear, she
has mostly neutrophils and bands, with some metamyelocytes,
myelocytes, and basophils as well.
All o the ollowing are likely to be true EXCEP :
A) T e patient has an underlying in ection with leukemoid
reaction.
B) T e patient has a balanced translocation between chromo-
somes 9 and 22.
C) T e patient will likely develop progressive leukocytosis,
evers, anemia, and thrombocytopenia i untreated.
D) T is condition may be treated with oral tyrosine kinase in-
hibitors.
The correct answer is “A.” Although a leukemoid reaction is a
possibility, it would be unusual to see a ull range o maturation
o myeloid cells (e.g., metamyelocytes and myelocytes) in the
peripheral blood along with increased basophils and a palpa-
ble spleen. Rather, this patient likely has chronic myelogenous
leukemia (CML), which is a clonal myeloproli erative disorder,
characterized by the “Philadelphia chromosome” (translocation
between chromosomes 9 and 22), which encodes or an abnor-
mal tyrosine kinase protein. T is protein is the target or the
tyrosine kinase inhibitors, such as imatinib (Gleevec), which
have resulted in signi cant improvement in survival. Patients
with CML typically present between the ages o 40 and 60. Up to
40% o patients are asymptomatic at presentation. Others com-
plain o weight loss, atigue, abdominal pain, night sweats, and
ever. Five-year overall survival can be up to 85% depending on
the age at diagnosis.
QUICK QUIZ: ACUTE LEUKEMIA
You have a ebrile 37-year-old male with a very high WBC
count, most o which are blasts. Most likely, he has an acute leu-
kemia. A bone marrow has not yet been done, and it is unknown
i this is an acute myeloid leukemia or an acute lymphoblastic
leukemia.
Which o the ollowing statements is INCORREC ?
A) T e patient’s ever is likely due to the leukemic cells, and
antibiotics should be started only i you identi y a speci c
in ection.
B) T e patient is at risk or tumor lysis syndrome and should be
started on allopurinol.
C) Aggressive inpatient chemotherapy is required or both the
treatment o acute myeloid leukemia and acute lymphoblas-
tic leukemia.
D) You should consult a hematologist/oncologist as soon as
possible.
The correct answer is “A.” Patients with acute leukemia
and ever should be cultured, and antibiotics should be
started as soon as possible since a ever is o ten the result
CHAPTER 6 • HEMATOLOGY AND ONCOLOGY 193
o a concurrent in ection. hese patients should be kept well
hydrated and given allopurinol to prevent tumor lysis syn-
drome, which can occur even without chemotherapy i the
tumor burden is high enough. reatment o acute leukemias
requires intensive chemotherapy and should be started as
soon as possible, so prompt evaluation by a hematologist/
oncologist is imperative.
CASE 6.21
A 65-year-old male who is on quinine or leg cramps (a non–
FDA-approved indication) is brought into the ED. Last night
he was complaining o a headache, ever, and numbness on
the right side o his ace. T is morning, he was acting errati-
cally.
His physical examination demonstrates a con used male,
with a temperature o 39°C, pulse 110 bpm, BP 180/94 mm Hg,
and respirations 14 bpm. He has a ew petechiae on his palate.
He is tachycardic and lungs are clear to auscultation bilater-
ally. His abdomen is so , without organomegaly. His neuro-
logic examination is di cult to complete due to his inability
to cooperate.
Laboratory ndings include WBC 6,000/mm3, Hgb
8.4 g/dL, and platelet count 50,000/mm3. Schistocytes are
noted on a peripheral blood smear.
Question 6.21.1 All o the ollowing may be expected in
this patient EXCEPT:
A) Creatinine o 3.2 mg/dL.
B) LDH o 640 IU/L.
C) Elevated haptoglobin.
D) Elevated indirect bilirubin.
E) Negative direct antiglobulin test (direct Coombs).
Answer 6.21.1 The correct answer is “C.” An elevated hap-
toglobin would suggest the absence o active hemolysis. T e
presence o schistocytes suggests ongoing microangiopathic
hemolysis, in this case due to thrombotic thrombocytope-
nic purpura ( P). P is due to the lack o activity o the
ADAM S13 enzyme either via inheritance o a aulty enzyme
(inherited) or via antibodies produced against the enzyme
(acquired). It is classically described by a pentad o ndings:
microangiopathic hemolytic anemia (suggested by schisto-
cytes on peripheral smear), thrombocytopenia, ever, renal
insuf ciency, and mental status changes. Not all ve eatures
need to be present or the diagnosis, but your patient seems to
have the pentad. An otherwise unexplained microangiopathic
hemolytic anemia in the presence o thrombocytopenia is
enough to trigger treatment or P; ever, renal insuf ciency
and mental status changes are not necessary to make the pre-
sumptive diagnosis o P. T e negative direct antiglobulin
test (direct Coombs), “E,” suggests that the hemolytic anemia
is not due to an autoimmune process. Note that the patient is
on quinine, one o the drugs that can cause P. Clopidogrel
and ticlopidine can also cause P although it is less common
with clopidogrel.
194 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
HELPFUL TIP:
Schistocytes are the result o intravascular trauma to
RBCs. Any microangiopathic hemolytic anemia can re-
sult in schistocytes as can other intravascular trauma
such as that secondary to arti icial heart valves, HELLP
syndrome, malignant hypertension, some malignan-
cies, transjugular intrahepatic portosystemic shunts
(TIPS), eclampsia, etc.
Question 6.21.2 Which o the ollowing laboratory f ndings
would you expect to see in this patient with TTP?
A) Normal P /INR.
B) Elevated P .
C) Elevated brin degradation products.
D) Low level o brinogen.
Answer 6.21.2 The correct answer is “A.” Patients with P lar coagulation (DIC), which is characterized by the disordered
should have a normal P /INR. T is is important because P regulation o coagulation. It can be precipitated by a sepsis,
can be con used with DIC, in which the P /INR should be ele-
vated and brinogen should be low.
Your patient is started on plasma exchange. You note that he
has not had any change in his Hgb or platelet count, and his
renal unction is worsening.
Question 6.21.3 Which o the ollowing may mimic TTP and
should be considered in a poorly responsive patient?
A) Rocky Mountain spotted ever.
B) Disseminated aspergillosis.
C) Disseminated malignancy.
D) Malignant hypertension.
E) All o the above.
Answer 6.21.3 The correct answer is “E.” When patients are
poorly responsive to therapy, an alternative diagnosis should be
sought. In pregnant patients, preeclampsia or HELLP syndrome
can mimic P. Autoimmune disease (e.g., systemic lupus ery-
thematosus and scleroderma), malignant hypertension, and dis-
seminated malignancy may also mimic P. In ections that can
be con used with P include Rocky Mountain spotted ever,
disseminated aspergillosis, as well as any other disease that can
cause mental status changes and a low platelet count such as
Ehrlichiosis, Anaplasmosis, West Nile virus, etc.
HELPFUL TIP:
Therapy with plasma exchange has reduced the mortal-
ity rate or TTP rom 90% to less than 25%. Other treat-
ments may include glucocorticoids and splenectomy in
re ractory cases. Platelet trans usion should be avoided
as it can worsen the patient’s condition.
CASE 6.22
A 23-year-old G1 P0 term emale goes to emergency cesarean
section a er she is noted to have placental abruption. She
has no other signi cant medical history. A er the delivery,
you note that she is having brisk vaginal bleeding and ooz-
ing rom her venipuncture sites. You obtain laboratories:
WBC 9,000/mm3, Hgb 8.2 g/dL, platelet count 80,000/mm3,
INR 2.4, P 22 seconds, and brinogen 80 mg/dL (normal
190–420 mg/dL). Fibrin degradation products are elevated. A
CBC at admission was normal.
Question 6.22.1 Which o the ollowing statements is
INCORRECT?
A) T e patient may bene t rom platelet trans usion.
B) T e patient may bene t rom cryoprecipitate trans usion.
C) T e patient may bene t rom FFP trans usion.
D) T e patient may bene t rom crystalloid in usion.
Answer 6.22.1 The correct answer (and what not to do) is
“A.” T is patient is exhibiting signs o disseminated intravascu-
malignancy, CNS trauma with release o tissue plasminogen
activator, obstetrical problems (preeclampsia, retained products
o conception, amniotic uid embolism), ABO incompatibility
with hemolysis, extensive burns, snake bites, etc. T rombin also
activates platelets, causing platelet aggregation and consump-
tion. Antithrombin, previously known as antithrombin III, is
consumed in this process as well. reatment is directed at cor-
recting the underlying cause o DIC whenever possible. Don’t
treat the numbers; patients may have a low-grade DIC and be
relatively asymptomatic. I this is the case, reversing the underly-
ing process is enough. I the patient is bleeding, she may ben-
e t rom platelet trans usion to maintain a platelet count above
20,000/mm 3, but trans usion at higher levels can worsen platelet
aggregation. rans usion o FFP will replace consumed actors.
Patients with low brinogen levels will bene t rom trans usion
o cryoprecipitate. T e use o heparin is generally limited to
those with low grade, chronic DIC with thrombotic complica-
tions. It may also be considered acutely i there are prominent
thrombotic complications.
HELPFUL TIP:
Laboratory indings in DIC include low platelets, pro-
longed PT/INR, normal or prolonged PTT, low ibrino-
gen, and increased ibrin degradation products. Fur-
ther, D-dimer and thrombin time are also increased,
antithrombin may be low, and peripheral blood smear
will reveal schistocytes. An elevated D-dimer in isolation
is not help ul since D-dimer is elevated in many states,
including DVT/PE.
Objectives: Did you learn to . . .
• Recognize the clinical presentation o TTP?
• Treat a patient with TTP?
• Develop a dif erential diagnosis or a patient with microan-
giopathic anemia?
• Distinguish DIC rom TTP?

CASE 6.23
A 22-year-old emale college student presents to your o ce
with complaints o an enlarged cervical lymph node and
sore throat. She has elt everish on and o or several weeks
but never measured her temperature. She is a ebrile today, a
rapid strep test is negative, and there is no evidence o lymph-
adenitis; you treat her symptomatically. You ask her to return
i her symptoms do not resolve within 2 to 4 weeks.
She returns 4 weeks later. T e sore throat has resolved;
however, she now complains o intense pruritus and sweats
at night. T e cervical lymph node now measures 3 cm. T e
remainder o her physical examination is negative.
Question 6.23.1 What is the most appropriate next step?
A) Direct laryngoscopy.
B) Empiric antibiotic trial.
C) Lymph node biopsy.
D) MRI o the neck.
E) Observation or another 4 weeks.
Answer 6.23.1 The correct answer is “C.” T e prolonged
(> 1 month) presence o a large (> 1 cm) lymph node deserves
a biopsy. MRI o the neck and laryngoscopy may be indicated
depending on the biopsy results. Empiric antibiotic therapy
(“B”) is inappropriate and unlikely to be help ul, as you have no
source o primary in ection. At this point in time, observation
(“E”) will just delay the diagnosis. Note that delaying the biopsy
or 1 month a er initial presentation does not change outcomes
even i the node is malignant.
You obtain a lymph node biopsy that is consistent with nodu-
lar sclerosing Hodgkin lymphoma.
Question 6.23.2 Which o the ollowing statements is
INCORRECT?
A) T e patient has B symptoms.
B) Further staging is necessary.
C) Chemotherapy is palliative only in this patient.
D) reatment includes both radiation and chemotherapy.
Answer 6.23.2 The correct answer is “C.” Chemotherapy
regimens or Hodgkin lymphoma have resulted in response
rates o more than 90%, with ewer long-term complications
than prior regimens. Despite the act that it is well-known,
Hodgkin lymphoma is an uncommon disease, with about
8,000 cases occurring each year in the United States. It is a dis-
ease o young people, occurring typically in patients in their
20s. Patients o en present with lymphadenopathy. Symp-
toms, known as “B symptoms,” include weight loss, ever, and
drenching night sweats. T e presence o B symptoms correlates
with more advanced disease. Other symptoms may include
pruritus, di use pain a er consuming alcoholic beverages and
symptoms related to the development o a mediastinal mass.
A er a diagnostic lymph node biopsy, urther staging (“C”)
includes C scans, bone marrow biopsy, and routine labora-
tory tests.
CHAPTER 6 • HEMATOLOGY AND ONCOLOGY 195
HELPFUL TIP:
Non-Hodgkin lymphoma (NHL) is increasing in inci-
dence and is more common than Hodgkin lymphoma.
Risk actors or NHL include HIV in ection and advanc-
ing age.
HELPFUL TIP:
The di erential diagnosis o generalized lymphade-
nopathy is broad and a good history is imperative. The
initial evaluation should include a CBC and CXR. I these
are negative and lymphadenopathy persists, consider
obtaining an RPR and ANA and testing or TB and HIV.
Also, consider testing or Epstein–Barr virus (antibody
test or heterophile) as appropriate. Some medications
can cause generalized lymphadenopathy secondary to
serum sickness.
Objectives: Did you learn to . . .
• Recognize presentation o a patient with Hodgkin lympho-
ma?
• Describe “B symptoms?”
CASE 6.24
A 34-year-old woman presents to your o ce with cal pain
and swelling. She denies trauma to the leg. She has no other
signi cant medical history and takes only oral contracep-
tives. She smokes hal a pack o cigarettes daily but does not
drink alcohol. Her physical examination is also unremark-
able, with the exception o swelling and tenderness o the le
cal . A lower extremity Doppler study demonstrates a new
thrombus occluding the common emoral vein.
Question 6.24.1 Which o the ollowing would NOT be
appropriate in this patient?
A) Start the patient on heparin or a heparinoid and war arin to
maintain an INR o 2 to 3 or start a actor Xa inhibitor (e.g.,
rivaroxaban) or a direct brin inhibitor (e.g., dabigatran).
B) Have the patient scheduled or placement o an in erior vena
cava lter.
C) Discontinue hormonal contraceptives.
D) Encourage the patient to stop smoking.
E) Obtain urther history regarding her amily.
Answer 6.24.1 The correct answer is “B.” T is patient has
an acute DV and risk actors or developing a DV , includ-
ing smoking and hormonal contraceptive use. You should start
her on heparin (or low–molecular-weight heparin) and war a-
rin with a goal INR o 2 to 3. Heparin should be used or at
least 5 days and overlapped with therapeutic doses o war arin
that have reached the target INR or at least 48 hours. Alterna-
tively you can start rivaroxaban (Xarelto), apixaban (Eliquis),
or dabigatran (Pradaxa). Dabigatran requires an overlap with
low–molecular-weight heparin; rivaroxaban and apixaban do
not. Avoid edoxaban (Savaysa) as it is less e ective and more
196 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
problematic when adjusting or renal disease. She should be
anticoagulated or at least 3 months. Encourage her to stop
smoking and to nd an alternative orm o birth control. “B”
deserves special mention. T ere is no evidence that vena caval
lters are o bene t in patients that can be anticoagulated except
as a temporary measure or inpatients where the vena caval lter
will be removed prior to discharge. T ere is no reduction in PE
risk with vena caval lters in those who can be anticoagulated,
and there is likely an increased risk o DV . T e role in those
who cannot be anticoagulated is unclear; there is scant data.
HELPFUL TIP:
Homan sign is neither sensitive nor speci ic enough to
allow it to be used to rule in or rule out DVT. Don’t both-
er. However, use o a clinical prediction tool (e.g., Well’s
criteria) can reduce unnecessary testing.
HELPFUL TIP:
All o the new anticoagulants (dabigatran, rivaroxaban,
and apixaban) are essentially equivalent to war arin in
terms o outcomes. There may be a bit less bleeding
but there is no overwhelming rationale to argue that
the newer anticoagulants are superior to war arin. The
2016 Chest guidelines suggest the newer anticoagu-
lants with a grade 2B evidence (weak recommendation
based on the data). Certainly the new anticoagulants
are more convenient. Note that dabigatran cannot be
removed rom blister packs or bottles in order to put it
in a pillbox or pill organizer. It quickly loses potency.
HELPFUL TIP:
Work-up o an inherited or acquired hypercoagu-
lable state is controversial because the treatment o
the patient is o ten not going to change whatever the
outcome. The greatest risk or having another DVT is
having a irst DVT. When a thromboembolic event is un-
provoked, it is probably prudent to screen the patient
or hypercoagulable states. When there is a provoked
event (e.g., surgery, prolonged immobilization, preg-
nancy, and oral estrogen), the role o such a work-up is
less well de ined.
T e patient returns 3 months later. She has been relatively easy
to anticoagulate (somebody has to be, right?), maintaining a
stable INR. She stopped smoking and knows to avoid hormonal
contraception. She has learned that her mother had a DV and
her maternal aunt died o a pulmonary embolus. Now, the
patient wants to know how this new in ormation will a ect her
long-term care. You decide to screen her or thrombophilia.
Question 6.24.2 Which o the ollowing sets o tests should
NOT be per ormed while she remains on war arin?
A) Factor V Leiden mutation.
B) Antiphospholipid antibodies.
C) Homocysteine.
D) Protein C.
E) Prothrombin gene mutation.
Answer 6.24.2 The correct answer is “D.” T ere are essen-
tially seven types o thrombophilia or which you might ini-
tially test: actor V Leiden mutation, antithrombin (previously
antithrombin III) de ciency, prothrombin gene mutation, pro-
tein C de ciency, protein S de ciency, antiphospholipid anti-
body syndrome, and hyperhomocysteinemia. Not all causes o
thrombophilia can be tested or while on anticoagulant therapy.
Factor V Leiden gene mutation, prothrombin gene mutation,
homocysteine, and antiphospholipid antibodies are not a ected
by war arin. However, war arin can reduce protein C and S lev-
els (giving alse-positive test results) and increase antithrombin
levels (giving a alse-negative result).
Factor V Leiden mutation is the most common cause o
inherited thrombophilia, being ound in 3% to 6% o non-
Black blood donors. Antithrombin de ciency is less common,
occurring in 1/1,000 to 1/5,000 individuals. T e homozygous
condition is atal in utero. Heterozygotes have a 30% chance
o developing a thromboembolic event by the age o 30 years.
Protein C de ciency occurs in 1/200 to 1/300 people; however,
ewer than 1/1,000 heterozygotes develop venous thromboses.
Protein S de ciency is estimated to occur in 1/750 to 1/3,000
o persons and has a clinical presentation similar to protein C
de ciency. T e prevalence o prothrombin gene mutation var-
ies widely and occurs most commonly in persons o southern
European descent. Unlike the other thrombophilias discussed
thus ar, antiphospholipid antibody syndrome is an acquired
disorder that is associated with arterial as well as venous throm-
boembolic events. Finally, hyperhomocysteinemia is associated
with the development o venous thrombosis and atherosclerotic
heart disease.
HELPFUL TIP:
How long should I anticoagulate this patient? Glad that
you asked. For patients on estrogen or other modi iable
actor with a irst DVT (s/p surgery, bedrest, pregnancy,
etc.), 3 months is probably adequate. For others (cancer,
etc.) the recurrence rate is approximately 7% per year
(Ann Intern Med. 2015;162:27). So, i the bleeding risk
is low, it is reasonable to continue anticoagulation in
these patients or li e (Chest Guidelines, 2016). Everyone
agrees that a second unprovoked DVT mandates treat-
ment “ or li e.” Finally, there is no evidence that prophy-
lactic anticoagulation in those with cancer who have
not had a thromboembolic event is use ul.
HELPFUL TIP:
Should I stop oral anticoagulation or the proce-
dures? I I do should I bridge war arin patients with
heparin? There is no need to stop anticoagulation or
many procedures such as dental procedures, colonos-
copy, etc. But just try to get this past the dentist or

gastroenterologist. Importantly, bridging atrial fibril-
lation patients on warfarin with heparin increases
the bleeding risk while doing nothing to prevent
stroke, PE, etc. Be selective in whom you bridge.
Bridge patients with a CH2ADS2-VASC score o > 5 (see
cardiology chapter or more on the CH2ADS2-VASC
score), those with a prosthetic mitral valve or metal aor-
tic valve, those with a history o thromboembolic events
while o anticoagulation, etc. For “normal” risk patients
bridging with heparin adds nothing and has signi icant
downsides (see N Eng J Med. 2015 and Circulation.
2015;131:488–494). Note that it isn’t necessary to bridge
patients who are on dabigatran, rivaroxaban, apixaban,
etc. They are short acting enough that just holding one
dose prior to surgery is adequate; there is a minimal
window or clot ormation. See below or urther discus-
sion o heparin bridging in those who have had a recent
thromboembolic event.
CASE 6.25
A 19-year-old gravid emale presents during her second tri-
mester and complains o le cal swelling. With the help o
Doppler studies, you diagnose her with a DV .
Question 6.25.1 Which o the ollowing statements is
correct?
A) DV occurs most commonly in the right lower extremity in
pregnant women.
B) DV is common in pregnancy due to increased venous sta-
sis and increased levels o brinogen, actor VIII, and vWF.
C) Anticoagulation with heparin introduces no risk to the etus
or mother.
D) DV is most common in the third trimester.
Answer 6.25.1 The correct answer is “B.” DV , and the
broader category o venous thromboembolism (V E), occurs
two to our times more o en in pregnant women compared to
nonpregnant controls. Increased risk is ound with cesarean
delivery versus vaginal delivery. T e majority o DV s occur in
the le lower extremity o pregnant women, likely due to the
compression o the le iliac vein by the right iliac artery as they
cross. T e increased incidence o V E is multi actorial, includ-
ing the presence o all three components o Virchow’s triad:
venous stasis, endothelial injury (increased venous distension
secondary to increased estrogen), and a hypercoagulable state
(increased levels o brinogen, actor VIII, and vWF).
V E occurs equally during all three trimesters, but the high-
est risk is postpartum (2–5 times the risk during pregnancy).
reatment o V E with anticoagulation is more dif cult during
pregnancy. War arin crosses the placenta and has teratogenic
e ects in addition to increased risk o etal bleeding. Heparin
and danaparoid do not cross the placenta, but are associated
with a 2% risk o maternal bleeding. Heparin also carries the
risks o heparin-induced thrombocytopenia with thrombosis,
CHAPTER 6 • HEMATOLOGY AND ONCOLOGY 197
osteoporosis, and bleeding at the uteroplacental junction.
Dosing o un ractionated heparin is dif cult during pregnancy,
and low–molecular-weight heparin (e.g., enoxaparin) is prob-
ably the best choice or anticoagulation. Heparin and war arin
are sa e or lactating mothers.
CASE 6.26
A 52-year-old woman presents to the ED with shortness o
breath and pleuritic chest pain. She has been on war arin
or atrial brillation. Despite her anticoagulation, you sus-
pect pulmonary embolism (PE) and obtain a spiral C scan,
which shows a thrombus in the right pulmonary artery.
Prior to the initiation o any therapy, her coagulation studies
return and show INR o 2.8 (normal = 1) and P 49 seconds
(prolonged).
Question 6.26.1 Which o the ollowing is the most appro-
priate next step?
A) est the patient or antiphospholipid antibodies.
B) Place an in erior vena cava lter.
C) Repeat the INR and P since the patient’s sample was
probably contaminated with heparin.
D) Con ront the patient about her noncompliance with war arin.
E) T row up your hands in disgust. Aren’t they done with the
hematology chapter yet?
Answer 6.26.1 The correct answer is “A.” Patients who have a
new V E while on appropriate anticoagulation therapy should
be evaluated or antiphospholipid antibody syndrome. T is
patient has a prolonged P , which is also suspicious or an
antiphospholipid antibody. Remember that war arin prolongs
the P , not the P . She was an outpatient prior to having her
blood drawn and was not taking heparin, so contamination
with heparin is unlikely (although heparin de nitely causes
an increase in the P ). T e increased INR suggests that the
patient has been compliant with her war arin. As to “B,” see the
note above about vena caval lters above.
HELPFUL TIP:
Previously, retrospective studies resulted in the rec-
ommendation that patients with an antiphospholipid
antibody and VTE be maintained at an INR o 3 to 4. This
recommendation has changed with newly available
prospective data, and these patients should have a tar-
get INR o 2 to 3. Some patients with antiphospholipid
antibody syndrome may have marked INR luctuations
that make monitoring anticoagulation di icult.
HELPFUL TIP:
Genetic testing is now available or war arin sensitivity
that can help predict which patients will need higher (or
lower) doses o war arin to maintain adequate antico-
agulation. However, these tests are very expensive and
contribute little to the care o most patients.
198 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
CASE 6.27
A 50-year-old male is admitted to the hospital with a rac-
tured tibia a er a motor vehicle collision. You are asked to
assist in his perioperative management. T e patient is gener-
ally healthy but is taking war arin or a DV that he devel-
oped a er a total knee arthroplasty 3 weeks ago. His INR is
1.8, and he is scheduled or open reduction/internal xation
tomorrow.
Question 6.27.1 Which o the ollowing statements is
INCORRECT?
A) T e patient has an approximate 50% risk o recurrent V E
without appropriate therapy.
B) Heparin should be started preoperatively.
C) Heparin should be continued postoperatively.
D) Resumption o war arin alone postoperatively is adequate
anticoagulation.
Answer 6.27.1 The correct answer is “D.” Perioperative man-
agement o a patient with recent V E is complicated. While
there are established guidelines or V E prophylaxis depend-
ing on the type o surgery planned, this patient already has an
active thrombotic event. Discontinuing war arin may result in a
rebound hypercoagulable state, and surgery creates a prothrom-
botic state.
Patients who have a V E within 1 month o surgery have a
50% risk o a second V E i not treated aggressively with anti-
coagulation. T ese recurrent events carry a mortality rate o
approximately 6%. Such patients should be placed on heparin
be ore and a er surgery i they are on war arin. I they are on
one o the newer anticoagulants, hold a dose o dabigatran,
apixaban, or rivaroxaban and then restart the drug postopera-
tively.
Patients with a V E within 1 to 3 months be ore a scheduled
surgery should be considered or postoperative heparin/war arin
or dabigatran, apixaban, or rivaroxaban. A V E > 3 months
be ore the scheduled surgery should not pose signi cant addi-
tional risk, and established prophylaxis guidelines should be ol-
lowed. See above or a discussion o heparin bridging in atrial
brillation and heart valves.
Objectives: Did you learn to . . .
• Obtain an appropriate history in a patient with clotting prob-
lems?
• Recognize common inherited and acquired hypercoagulable
risk actors?
• Recognize the risks o VTE in the pregnant patient?
• Identi y a patient presenting with antiphospholipid antibod-
ies and understand the management o such patients?
• Describe anticoagulation approaches in perioperative care?
OK, you knew this was coming. A quick primer on the
newer anticoagulants. By the time you read this, reversal
agents or dabigatran and the Xa inhibitors should be avail-
able. So, concerns about uncontrollable bleeding should be
resolved.
Pradaxa (dabigatran): A direct thrombin inhibitor.
Approved or nonvalvular atrial brillation or stroke preven-
tion. Contributes to less bleeding overall than war arin, but pre-
vents ewer myocardial in arctions and causes more GI bleeds.
T e dose must be decreased in those with renal disease.
Xarelto (rivaroxaban): An oral actor Xa inhibitor (similar
to enoxaparin). Indicated or the treatment o DV and PE,
DV prophylaxis ollowing surgery and nonvalvular atrial
brillation and does not require heparin at initiation. T ere are
multiple drug interactions (though ewer than with war arin).
Not indicated in those with severe renal disease and those with
moderate liver disease.
Eliquis (apixaban): An oral direct actor Xa inhibitor. Indi-
cated or the treatment o DV and PE, DV prophylaxis ol-
lowing surgery and nonvalvular atrial brillation. Does not
require heparin at initiation. Not recommended or patients
with moderate hepatic impairment. Dose must be decreased
in renal impairment. May cause hypercoagulable state when
stopped, increasing the risk o stroke i stopped without ade-
quate continuous anticoagulation.
Annexa (Andexanet al a, Portola Phamaceuticals): A
new recombinant modi ed actor Xa to work as an antidote
or patients receiving Xa inhibitors. Phase 2 trials have dem-
onstrated reversal o direct actor Xa inhibitors Eliquis and
Xarelto. Phase 3 trials o ANNEXA-R and ANNEXA-A have
also shown promise. Keep an eye out or these agents in the
next ew years!
Clinical Pearls
A platelet count o >20,000/mL is adequate or hemostasis.
Do not use plasma or a prothrombin complex concentrate to
reverse anticoagulation unless there is signi icant bleeding
(e.g., intracranial bleed).
Do not use venocaval ilters to prevent a second PE in a
patient with a prior history o DVT. They do not work.
Heparin can cause a thrombocytopenia associated with
thrombotic complications (HITTS).
I a patient is on war arin and the INR is 10 or less and the
patient is asymptomatic, do not treat with vitamin K; simply
hold the war arin. I the INR is >10, give 1 to 5 mg o PO vita-
min K.
It is not necessary to anticogulate patients with a irst DVT
that can be explained by a reversible cause (e.g., estrogen,
surgery, immobilization) or more than 3 months.
The PTT is the most use ul single test when screening or
coagulopathy.
Trans use stable patients to a hemoglobin o 7 to 8 mg/dL. A
higher target can worsen outcomes.
Trans using platelets will not work in ITP. The platelets will
just get destroyed.
With iron de iciency anemia, the reticulocyte count should
go up within 10 days when appropriately treated with iron. I
this doesn’t happen reconsider your diagnosis.
 CHAPTER 6 • HEMATOLOGY AND ONCOLOGY 199

BIBLIOGRAPHY o Chest Physicians Evidence-Based Clinical Practice

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Allen GA, Glader B. Approach to the bleeding child. Pediatr
Clin North Am. 2002;49(6):1239–1256.
Bain BJ. Diagnosis rom the blood smear. N Engl J Med.
2005;353:498–507.
Booth KK, et al. Systemic in ections mimicking thrombotic
thrombocytopenic purpura. Am J Hematol. 2011;86(9):
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Brandhagen DJ, et al. Recognition and management o
hereditary hemochromatosis. Am Fam Physician. 2002;
65(5):853.
Carson JL, et al. Red blood cell trans usion: a clinical practice
guideline rom the AABB. Ann Intern Med. 2012;157(1):
49–58.
Crownover BK, Covey CJ. Hereditary hemochromatosis. Am
Fam Physician. 2013;87(3):183–190.
Frei eld AG, Bow EJ, Sepkowiz KA. Clinical practice guideline
or the use o antimicrobial agents in neutropenic patients
with cancer: 2010 update by the In ectious Diseases Soci-
ety o America. Clin In ect Dis. 2011;52(4):e56–e93.
Ganetsky M, et al. Dabigatran: review o pharmacology and
management o bleeding complications o this novel oral
anticoagulant. J Med Toxicol. 2011;7(4):281–287.
Guyatt GH, et al., or the American College o Chest Physi-
cians Antithrombotic T erapy and Prevention o T rom-
bosis Panel. Executive summary: antithrombotic therapy
and prevention o thrombosis, 9th ed: American College
Guidelines. Chest. 2012;141(2)(Suppl):7S–47S.
Killip S, Bennett JM, Chambers MD. Iron de ciency anemia.
Am Fam Physician. 2007;75(5):671–678.
Landgren O. Monoclonal gammopathy o undetermined
signi cance and smoldering myeloma: new insights into
pathophysiology and epidemiology. Hematology Am Soc
Hematol Educ Program. 2010;2010:295–302.
Moake J. T rombotic thrombocytopenia purpura ( P) and
other thrombotic microangiopathies. Best Pract Res Clin
Haematol. 2009;22(4):567–576.
National Institutes o Health. What causes thrombotic
thrombocytopenic purpura? Available at https://www.
nhlbi.nih.gov/health/health-topics/topics/ttp/causes;
accessed on 26 March, 2014.
O’Connell X, Horita J, Kasravi B. Understanding and inter-
preting serum protein electrophoresis. Am Fam Physician.
2005;71(1):105–112.
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Short MW, Domagalski JE. Iron de ciency anemia: evalua-
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98–104.
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Other help ul of ce resource links:

American Society o Clinical Oncology. www.asco.org.
American Society o Clinical Oncology. www.plwc.org. (Web-
site or patients living with cancer.)
American Society o Hematology. www.hematology.org. (Links
to many blood disease websites.)
American Association or Clinical Chemistry. www.labtestson-
line.org. (In ormation on general hematology/oncology
subjects and laboratory testing.)
Multiple Myeloma Research Foundation. www.themmr .org.
(Everything about myeloma.)
Gastroenterology
Mark A. Graber a d Ye-Ji Lee
CASE 7.1
A 43-year-old woman complains o a burning pain in the
retrosternal area. Her symptoms started about 2 years ago
and initially responded to sel -medication with antacids or
histamine-2 receptor antagonists (H2 blockers). However,
within the last 4 months, she has had nearly daily problems.
She requently wakes up in the middle o the night with
retrosternal, burning pain, radiating to her neck. She also
requently notices an acidic taste in her mouth. While ant-
acids help somewhat, they only provide transient relie . She
has otherwise been healthy. She currently takes up to 800 mg
o cimetidine per day plus the antacids. She denies tobacco or
alcohol use. Her physical examination is normal.
Question 7.1.1 Which o the ollowing is NOT considered
a “red ag” when it comes to patients with acid re ux/
dyspepsia?
A) Weight loss.
B) rouble sw llowing liquids.
C) rouble sw llowing solids.
D) A cr ving or doughnuts.
Answer 7.1.1 The correct answer is “D.” OK, we will give you
this one. One o the ost critic l p rts o p tient ssess ent is
to ke sure there re no “red g” sy pto s th t y indi-
c te ore th n si ple g stroesoph ge l re ux dise se (GERD).
Red g sy pto s include dysph gi , weight loss, ne i ,
spir tion, e rly s tiety or vo iting, nd cough. A cr ving or
doughnuts is benign ( lthough e ting the is not) nd y be
seen ong the book editors, police, college students, V sh the
St pede, nd others.
Question 7.1.2 Which o the ollowing statements is true?
A) All p tients with GERD need endoscopy.
B) Routine endoscopy in p tients with GERD rkedly reduces
the risk o esoph ge l c ncer.
C) T e di gnostic sensitivity nd speci city o typic l sy p-
to s o GERD is > 90%.
200
7
D) P tients over the ge o 45 with new onset sy pto s re
considered to be t high risk.
E) C nd D.
Answer 7.1.2 The correct answer is “E.” Bec use o the high
sensitivity nd speci city o sy pto s (> 90%), ost p tients
do not need endoscopy or ny other procedure or test to ke
the di gnosis o GERD. P tients with re r ctory GERD or
those with new sy pto s over the ge o 45 ye rs (50 by so e
sources) w rr nt endoscopy. “B” is incorrect. Screening or the
presence o B rrett esoph gus in p tients with GERD is low
yield. rgeted, not routine, endoscopy y be bene ci l. Even
then, the bene t is li ited (J Natl Cancer Inst. 2011;103:1049).
T is is still tter o ctive deb te nd reco end tions y
ch nge.
HELPFUL TIP:
The li k betwee Helic bacter pyl ri a d GERD i p r-
ly de i ed. There i g d evide ce t upp rt eradi-
cati H. pyl ri r the treatme t GERD. The ame
i true r ulcer dy pep ia.
T e patient denies any “red ags.” Based on the history, you
assume that this patient has GERD.
Question 7.1.3 You recommend:
A) B riu sw llow study.
B) Esoph ge l no etry.
C) Esoph gog stroduodenoscopy (EGD).
D) A bul tory pH study o the esoph gus.
E) ri l o o epr zole nd li estyle odi c tions.
Answer 7.1.3 The correct answer is “E.” As noted bove, the
sensitivity nd speci city o cl ssic l sy pto s llows or the
di gnosis o GERD without ddition l studies. esting is ctu-
lly less sensitive th n sy pto s or GERD with the sensitivity
o tests v rying between 50% nd 70%. M ny p tients h ve
 CHAPTER 7 • GAs TRo En TERo Lo GY 201

lse-neg tive EGD. H2 blockers can be used as the rst-line Question 7.1.5 All o the ollowing are true regarding
treatment in patients with GERD, but this p tient h s lre dy Barrett esophagus EXCEPT:
iled ci etidine. St rting proton pu p inhibitor (PPI), like A) M les re ore likely to h ve B rrett esoph gus th n
o epr zole, is the next step nd is pre erred s the rst-line e les.
ther py in p tients with severe sy pto s. Li estyle odi c - B) B rrett esoph gus is due to ch nge in the esoph ge l
tions should be de including weight loss (i overweight); ucos ro colu n r to squ ous.
void nce o c rbon ted bever ges, c eine, excessive lcohol, C) B rrett esoph gus occurs in 10% to 15% o p tients with
nd l rge or l te evening e ls; void nce o nti-cholinergics, erosive esoph gitis.
c lciu ch nnel blockers, NSAIDs, nd sed tive drugs; s ok- D) B rrett esoph gus incre ses the risk o denoc rcino by
ing cess tion; nd elev tion o the he d o the bed using 6-in up to 30- old.
blocks. E) P tients with B rrett esoph gus should undergo periodic
screening EGD.

HELPFUL TIP: Answer 7.1.5 The correct answer is “B.” B rrett esoph gus is
M t patie t with GERD will have egative e d c pic di gnosed histologic lly when esoph ge l ucos l et pl si
i di g (termed er ive re lux di ea e [n ERD]— h s occurred and the usual squamous epithelial cells have
really, we did ’t make thi e up). s ympt m d t changed to columnar epithelium. Risk ctors or B rrett
c rrelate well with the pre e ce r degree e pha- include long-st nding re ux, le gender (6:1 le: e le pre-
geal i lammati r er i . ponder nce), iddle ge, tob cco use, nd white r ce. B rrett
esoph gus occurs in 10% to 15% o p tients with erosive esoph-
gitis, nd it dr tic lly incre ses the risk o esoph ge l de-
noc rcino by up to 30- old (N Engl J Med. 2011;365:1375).
Your patient is willing to try the PPI you prescribe, but she However, the bsolute risk o denoc rcino is still s ll,
also wants to know about surgery that a riend had. bout 0.12% to 2% nnu lly. Surveill nce or B rrett depends on
the level o dyspl si ound on initi l ex in tion, nd guide-
Question 7.1.4 Regarding surgery or GERD, you can tell her: lines exist th t dict te the requency with which repe t EGD
A) Blo ting nd in bility to belch do not occur with ntire ux should be per or ed.
surgery.
B) Antire ux surgery should be thought o s the rst-line
bec use it is v stly superior to edic l ther py. HELPFUL TIP:
C) Ye rs er ntire ux surgery, ny p tients will require Pr ki etic age t , like met cl pramide (Regla ), ca be
edic tion or GERD sy pto s. u e ul i the treatme t GERD. I additi t pr m t-
D) L p roscopic undoplic tion will ruin her bulous bikini i g t mach emptyi g, met cl pramide i crea e ga -
body by le ving l rge idline sc r. tr e phageal phi cter t e. Remember that met -
cl pramide ca cau e extrapyramidal ide e ect with
Answer 7.1.4 The correct answer is “C.” Surgery y be n chr ic u e.
option in select p tients with re ux dise se. T e usu l indic -
tions or ntire ux surgery include ilure o edic l ther py
to control sy pto s nd ilure o edic l ther py to prevent
co plic tions (e.g., stricture nd pneu oni ). T e ost co - HELPFUL TIP:
only per or ed surgery is undoplic tion, in which the lower C mplicati chr ic GERD i clude er ive e ph-
esoph ge l sphincter is “wr pped” to enh nce its co petency. agiti , peptic tricture, a d ade carci ma the
While undoplic tion will llevi te sy pto s in 80% to 95% o e phagu . H wever, the ab e ce heartbur ymp-
p tients, there is progressive loss o e ectiveness over ti e (only t m d e t rule ut re lux-related c mplicati
40% re without edic tion er 10 ye rs). Adverse e ects o i ce appr ximately e- urth patie t with peptic
surgery include persistent dysph gi (requiring ddition l inter- tricture (a tricture the e phagu , which re ult
ventions in 3–7%), g s, blo ting, nd in bility to belch. “D” is r m the heali g ulcerative e phagiti ) a d e-
incorrect bec use l p roscopic procedure should result in just third th e with ade carci ma the e phagu
ew s ll sc rs. had heartbur pri r t diag i . Barrett e phagu
ca regre with the adequate treatme t GERD.
A er a trial o your avorite PPI (that her insurance will
cover a er you play “Guess What’s on Our Formulary”),
your patient continues to have symptoms. You review li e- Objectives: Did you learn to . . .
style modi cations with her, and she assures you that she • De cribe the diag i a d ma ageme t GERD?
has made these changes. You re er her or EGD. T e esopha- • U e H2 bl cker a d PPI i the ma ageme t GERD?
geal biopsy is consistent with the visual report, which shows • Rec g ize c mplicati GERD a d ri k act r r Bar-
Barrett esophagus. rett e phagu ?
202 FAMILY MEDICIn E EXAMIn ATIo n & Bo ARD REVIEW
CASE 7.2
A 53-year-old woman comes to your o ce complaining o chest
pain and problems swallowing. She says ood seems to hang up
in the retrosternal area. T is started several years ago, has grad-
ually worsened, and now occurs at least twice per week. Gen-
erally, only solid oods cause problems. She has become very
care ul, only taking small bites and chewing them well be ore
swallowing. Should she experience problems, she has ound
that drinking additional liquids alleviates her symptoms within
minutes. She does not regurgitate ood and has not lost weight.
Question 7.2.1 What is the symptom this patient is com
plaining o ?
A) Dysph gi .
B) Globus sens tion.
C) Odynoph gi .
D) Aeroph gi .
E) Ph gophobi .
Answer 7.2.1 The correct answer is “A.” Dysph gi , ro the
Greek dys ( e ning “with dif culty” . . . s opposed to “Dis,”
which is city in D ntes’s Hell in ddition to being neologis )
nd phagia ( e ning “to e t”), re ers to the sens tion th t ood
is being hindered in its p ss ge ro the outh to the sto -
ch. Odynoph gi re ers to p in upon sw llowing, eroph gi
to sw llowing o ir, nd globus sens tion to perception o
lu p or ullness in the thro t th t is te por rily relieved by
sw llowing. Ph gophobi is just wh t you think it is: e r o e t-
ing or sw llowing.
HELPFUL TIP:
Aer phagia i a c mm a d u derdiag ed cau e
abd mi al ympt m . Ge erally, patie t will c mplai
belchi g a ciated with abd mi al bl ati g, e pecial-
ly a ter meal . It i t u c mm r patie t t me ti
that they have t l e their belt a ter meal . Aer phagia
i exacerbated by gum chewi g (which cau e reque t
wall wi g air), eati g quickly, dri ki g carb ated
beverage , a d m ki g. Aer phagia ca be mitigated by
eati g m re l wly, av idi g carb ated beverage , etc.
Question 7.2.2 Given the above patient’s description o
symptoms and the location o her discom ort ( ood stick
ing in the retrosternal esophagus), what type o dysphagia
is she most likely to su er rom?
A) Oroph rynge l dysph gi .
B) Esoph ge l dysph gi .
C) Function l dysph gi .
D) Aberr nt dysph gi .
Answer 7.2.2 The correct answer is “B.” Dysph gi c n be di -
erenti ted by where the sy pto s see to occur. Oroph ryn-
ge l dysph gi , lso known s “tr ns er dysph gi ,” rises ro
dif culty in the upper esoph gus nd ph rynx. P tients co -
pl in o ood getting stuck i edi tely upon sw llowing, nd
when sked to point to the loc tion, p tients requently identi y
the cervic l region. P tients with oroph rynge l dysph gi o en
h ve ore proble s with liquids th n solids nd y co pl in
th t liquid co es out o their nose when they try to sw llow.
Esoph ge l dysph gi is usu lly described s beginning sever l
seconds er sw llowing, nd p tients requently point to the
supr stern l notch or retrostern lly when trying to loc lize the
re c using sy pto s. P tients in who no c use c n be ound
er det iled investig tion re o en c tegorized s h ving unc-
tion l dysph gi . T ere is no such thing s berr nt dysph gi .
A complete review o systems and physical examination is
unrevealing. She is not taking pills that can cause erosive
esophagitis such as doxycycline or bisphosphonates, she
is not HIV positive making candidal and HSV esophagitis
unlikely, and she again notes progressive dysphagia, initially
to solids and now to liquids.
Question 7.2.3 Which o the ollowing is the single best test
to arrive at a diagnosis in this patient?
A) B riu sw llow.
B) Esoph ge l no etry.
C) EGD.
D) A bul tory pH study o the esoph gus.
E) Di gnostic tri l o high-dose PPI.
Answer 7.2.3 The correct answer is “C.” Visu liz tion o the
esoph gus is critic l in p tients with dysph gi . Our p tient
presents with esoph ge l dysph gi or solids, which is ost
consistent with structur l proble , such s stricture, web, or
neopl s . Endoscopy is the best di gnostic study to ev lu te the
esoph ge l ucos s it llows one to obt in biopsies nd per-
or endoscopic interventions such s dil tions, i indic ted. B r-
iu sw llows re second best nd h ve llen out o vor when
endoscopy is v il ble. Should the endoscopy co e b ck neg -
tive, esoph ge l no etry (“B”) y be use ul s it will help
deter ine i otility disorder is the c use o sy pto s. While
“di gnostic” tri l with PPI (“E”) is n ppropri te str tegy in
p tients with typic l GERD, the presence o n l r sy pto ,
such s dysph gi , requires urther testing. “D,” n bul tory
pH study, does not help in de ning the etiology o the dysph gi .
HELPFUL TIP:
Ma y patie t have breakthr ugh pai at ight eve
whe a PPI. The rea r thi i that PPI ly act
cell that have bee activated ( uch a by a meal). PPI
h uld be take 30 mi ute be re eati g. Try addi g
a H2 bl cker at ighttime r patie t havi g break-
thr ugh pai .
HELPFUL TIP:
Reb u d acid hyper ecreti ca lead t ympt m re-
curre ce i p te t a ti ecret ry age t , uch a PPI , are
t pped abruptly. Ma y expert rec mme d teppi g
d w t H2 bl cker pri r t ce ati . H wever, eve H2
bl cker ca al cau e a le er degree reb u d acid
hyper ecreti . s , c ider taperi g the e drug a well.
 CHAPTER 7 • GAs TRo En TERo Lo GY 203

TABLE 7-1 CAUSES OF ESOPHAGEAL DYSPHAGIA

Mechanical Lesions
Intrinsic Extrinsic
Be ig tum r Aberra t ubclavia
Cau tic e phagiti / tricture artery
Radiati e phagiti / tricture Cervical te phyte
Peptic e phagiti / tricture E larged a rta
E i philic e phagiti E larged le t atrium
Diverticula Media ti al ma
Malig a cy P t pi al urgery
P t-GI urgery
Ri g a d web
F reig b die
Motility Disorders
Achala ia
FIGURE 7-1. Chaga di ea e (Trypanosoma cruzi)
Di u e e phageal pa m
Hyperte ive l wer e phageal phi cter
T e patient returns rom her endoscopy. According to the n peci c e phageal m tility di rder
report, she had severe esophagitis with con uent erosions n utcracker e phagu
in the distal esophagus. During your physical examination, s cler derma
you nd the skin changes shown in Figure 7-1. When you ask
about these, the patient reports a history o bluish ngertip cre ted by undoplic tion. H. pylori tre t ent h s no role in the
discoloration with cold temperatures. She also complains n ge ent o this illness. Steroids could cert inly worsen the
that her ngers eel “tight” at times. g strointestin l (GI) sy pto s by irrit ting the g stric ucos .
Other c uses o esoph ge l dysph gi re listed in ble 7-1.
Question 7.2.4 With this new in ormation, which o the
ollowing diagnoses are you considering?
A) CRES syndro e. HELPFUL (AND IMPORTANT) TIP:
B) Esoph ge l denoc rcino . It w uld t urpri e u t ee thi e the b ard
C) Met st tic colonic denoc rcino . exami ati . A i crea i gly rec g ized cau e dy -
D) Sicc syndro e. phagia i eosinophilic esophagitis. The cla ic adult
E) Peptic ulcer dise se (PUD). patie t pre e t with dy phagia, “GERD ympt m ”
a d upper abd mi al pai u re p ive t PPI , a d
Answer 7.2.4 The correct answer is “A.” Notice the tel ngiec- p ibly d impacti . Childre te pre e t with
t si in the picture bove. CRES is n crony or syndro e eedi g pr blem (age 2), recurre t v miti g (age 8),
th t includes C lcinosis cutis, R yn ud pheno enon, Esoph - a d chr ic abd mi al pai (age 12) r d impacti
ge l dys otility, Sclerod ctyly, nd el ngiect si s. Figure 7-1 (tee age year ). A ciati with childh d a thma i
shows tel ngiect si s on the p l r digit l p d. Up to 60% o tr g a d dietary elimi ati therapy may be help ul
p tients with CRES h ve erosive esoph gitis. Dysph gi is i childre . Treatme t i adult (a d te childre ) i -
co on nd is due to esoph ge l stricture nd/or dys otility. v lve wall wi g i haled c rtic ter id (e.g., lutica-
e r bude ide), a d, i evere ca e , y temic te-
Question 7.2.5 Given her endoscopic f ndings and the act r id . s y temic e i philia i rare; m teluka t ha a
that she likely has CREST syndrome, what treatment do you checkered rec rd whe it c me t treati g e i phil-
suggest? ic e phagiti a d appear le e ective tha ter id .
A) H 2 blocker.
B) PPI.
C) High-dose corticosteroids. HELPFUL TIP:
D) H. pylori er dic tion. Dy phagia that pr gre e r m lid a d the t liq-
E) L p roscopic undoplic tion. uid i a cla ic ympt m e phageal ca cer a d ca -
t be ig red.
Answer 7.2.5 The correct answer is “B.” Severe re ux nd dys-
ph gi re h ll rks o CRES syndro e. T e esoph gus h s Objectives: Did you learn to . . .
poor otility with i p ired unction o the lower esoph ge l • Di ere tiate dy phagia r m ther GI ympt m ?
sphincter llowing re ux while poor otility reduces esoph - • Take a adequate hi t ry t evaluate the eti l gy dy pha-
ge l cle r nce. Chronic nd potent cid suppressive edic - gia?
tions, such s PPIs, re indic ted. Fundoplic tion is relatively • De cribe di ere t type dy phagia a d ide ti y vari u
contraindicated, s the poor contr ctile unction o the esoph- cau e dy phagia?
gus y not gener te enough orce to overco e the b rrier • Rec g ize that CREs T y dr me a a cau e dy phagia?
204 FAMILY MEDICIn E EXAMIn ATIo n & Bo ARD REVIEW
QUICK QUIZ: REGURGITATIo n
You see 61-ye r-old wo n in your of ce co pl ining o h li-
tosis, he rtburn, nd regurgit tion o undigested ood 4 hours
er e ting. She lso eels th t the ood is sticking in her thro t.
Wh t is the MOS LIKELY c use o her sy pto s?
A) Sch tzki ring.
B) Zenker diverticulu .
C) Ach l si .
D) Foreign body.
E) Esoph ge l web.
The correct answer is “B.” L te regurgit tion o undigested
ood is p thogno onic or Zenker diverticulu . A Zenker di-
verticulu is n cquired out-pouching o esoph ge l ucos ,
which typic lly beco es sy pto tic in iddle ge or l ter in
li e. T e di gnosis is con r ed by l ter l view o b riu sw l-
low or by visu l con r tion with EGD. T e other di gnoses
listed c n c use dysph gi nd regurgit tion but re less likely.
“A,” Sch tzki ring, is lower esoph ge l ucos l ring th t c n
“c tch” ood nd c use dysph gi . “C,” ch l si , results ro
loss o innerv tion o the lower esoph gus with i p ired esoph-
ge l otility nd gener lly occurs in young nd iddle- ged
dults. P tients with ch l si typic lly h ve dysph gi with
solids nd liquids. “D,” oreign body, should be di gnos ble by
history. Elderly dults, children, nd p tients with psychi tric
dise se re ost t risk or oreign body in the esoph gus. “E,”
esoph ge l web, is c used by thin l yer o ucos cross the
esoph ge l lu en nd presents uch like Sch tzki ring.
CASE 7.3
A 32-year-old woman presents with 3 years o intermittent GI
complaints a er eating. She describes epigastric pressure and
bloating a er ood intake. Her weight is stable. She denies
heartburn, vomiting, diarrhea, constipation, or blood in her
stools. She only takes a multivitamin and she has not tried
any speci c remedies. T e physical examination is normal.
Question 7.3.1 What is the MOST LIKELY diagnosis given
the in ormation above?
A) Pyrosis.
B) PUD.
C) Nonulcer dyspepsi .
D) Sto ch c ncer.
Answer 7.3.1 The correct answer is “C.” Nonulcer dyspepsi
is n ill-de ned condition ch r cterized recurring inter ittent
epig stric disco ort nd ullness in the bsence o ucos l
lesions or other structur l bnor lities o the GI tr ct. Non-
ulcer dyspepsi is lso known s “ unction l dyspepsi .” While
bout 20% o the gener l popul tion h s nonulcer dyspepsi ,
only bout 20% o these seek edic l ttention. Pyrosis (“A”)
e ns the s e thing s he rtburn; this p tient h s no co -
pl ints o he rtburn. Sto ch c ncer o 3 ye rs dur tion would
usu lly be cco p nied by other syste ic sy pto s (such s
tigue, weight loss or de th—is th t syste ic sy pto ?),
which the p tient denies. PUD should be cco p nied by
“he rtburn,” which is not present in our p tient.
Question 7.3.2 Which o the ollowing symptoms WOULD
NOT be an expected symptom o nonulcer dyspepsia?
A) Fullness.
B) E rly s tiety.
C) Belching.
D) Intoler nce to eggs.
Answer 7.3.2 The correct answer is “D.” Nonulcer dyspepsi is
ch r cterized by ll the other sy pto s nd lso includes such
sy pto s s bdo in l distention, borboryg i (i.e., gr nd-
p ’s tu y gurgling he rd cross the roo t T nksgiving),
epig stric or substern l p in, norexi , n use , vo iting, nd
bdo in l tenderness. “D,” intoler nce to eggs, is not p rt o
nonulcer dyspepsi . Wh t h ve you got g inst eggs? T e edi-
tors like eggs, po ched i possible nd served s eggs benedict.
While there re sever l proposed p thophysiologic ech nis s
by which nonulcer dyspepsi y occur, ood intoler nce is not
one o the .
Question 7.3.3 What is the most appropriate next step in
this patient?
A) Obt in H. pylori seru ntibodies.
B) Obt in n bdo in l ultr sound ex in tion o liver, bili-
ry tree, nd p ncre s.
C) Obt in det iled diet ry history.
D) Obt in n upper GI x-r y series.
E) Re er or g stroscopy.
Answer 7.3.3 The correct answer is “C.” Does this see to be
contr diction to the previous question? Well, we don’t e n
it to be so. Although ood intoler nce does not c use nonulcer
dyspepsi , the sy pto s o the two types o disorders overl p
to so e degree. Considering the prev lence o selective c rbo-
hydr te l bsorption syndro es, high int ke o l ctose nd
ructose-cont ining ood nd bever ges y contribute to GI
sy pto s in signi c nt nu ber o p tients. T ere ore, the
history should lw ys cont in det iled ssess ent o diet ry
h bits nd sy pto s in rel tion to ood int ke. A ore exten-
sive workup is not necess ry t this point in ti e s the p tient is
younger th n 45 ye rs o ge nd h s no l r sy pto s. While
in ection with H. pylori c uses g stritis nd peptic ulcers, sev-
er l controlled studies de onstr ted no consistent bene t o
H. pylori er dic tion in p tients with dyspepsi without ulcers.
HELPFUL TIP:
I y u ch e t te t a d treat r H. pyl ri, the pre erred
te ti g trategy i 13C urea breath te t r t l a tige
te t (keep readi g r m re).
You obtain a detailed dietary history, suggesting a potential
contribution o ructose intolerance and excessive carbonated
 CHAPTER 7 • GAs TRo En TERo Lo GY 205

beverage intake (it’s those ve Giant Gulp so drinks a day).

HELPFUL TIP:
Her symptoms persist despite appropriate diet modi cations.
F r ulcer dy pep ia, ge eral ma ageme t pri ci-
You choose to start the patient on a PPI. One week later, your
ple call r rea ura ce by the phy icia a d the av id-
nurse receives a call rom your patient about severe abdomi-
a ce repeated diag tic te ti g. Patie t h uld
nal pain and diarrhea. She has not noticed blood in her stool.
make appr priate li e tyle m di icati (av id t bac-
c , ca ei e pr duct , a d alc h l) a d limit r av id ag-
Question 7.3.4 What is the best next step?
gravati g medicati (n s AID ). Patie t h uld chew
A) She is h ving withdr w l ro the ve Gi nt Gulp sod s.
their d l wly a d eat m re reque t, mall meal .
Add b ck the ructose nd the 2,000 kc l.
Fi ally, i there i u derlyi g p ychiatric m rbidity, re-
B) Check sting g strin level.
laxati trai i g r treatme t peci ic di ea e ca
C) Add ntibiotic ther py or b cteri l overgrowth.
be help ul.
D) Discontinue the PPI.
E) Add n ntidi rrhe l.

Answer 7.3.4 The correct answer is “D.” Di rrhe , including

ro Clostridium di cile, is co on dverse e ect o PPIs HELPFUL TIP:
th t occurs in t le st 5% to 7% o p tients. Discontinu tion PPI are t be ig drug a d have bee a ciated
gener lly le ds to r pid resolution in the jority o c ses with (1) i crea ed ri k te p r i a d hip rac-
( lthough ybe not o C. di cile-rel ted di rrhe ). While ture i the elderly, (2) i crea ed ri k p eum ia,
reduced sto ch cidity ro PPIs or H 2 blockers y result (3) i crea ed ri k C. di icile c liti , (4) i ter ere ce
in b cteri l coloniz tion o the proxi l GI tr ct, the e rly with vitami a d mi eral ab rpti (B vitami , ir ,
onset nd severity o sy pto s described rgue g inst b cte- calcium), (5) diarrhea a ted ab ve, a d (6) p ible
ri l overgrowth s the etiology o this p tient’s sy pto s (“C”). i crea ed ri k deme tia i the elderly (JAMA n eur l.
While PPIs c n elev te g strin levels, the hyperg strine i seen 2016;E1–E7). s t p them a ter the treatme t i c mplet-
is not co p r ble to levels seen in Zollinger–Ellison syndro e, ed (i y u ca . . . . GERD i a chr ic di ea e a d t ppi g
which c n lso c use di rrhe . Stool studies nd e piric ther- a PPI i a ciated with reb u d acid ecreti ) a d aim
py with ntidi rrhe ls y be considered i discontinuing the r the l we t e ective d e.
PPI does not i prove sy pto s.

HELPFUL TIP: Objectives: Did you learn to . . .

There are drug that have great evide ce t upp rt
their u e i ulcer dy pep ia. PPI a d H2 bl cker
are te u ed. Pr ki etic age t may be help ul, a d i
the U ited s tate thi mea met cl pramide r eryth-
r myci . Ci apride ha bee rem ved r m the market
ec dary t cardiac arrhythmia (QT pr l gati with
t r ade de p i te ). Met cl pramide, c ur e, i a -
ciated with tardive dy ki e ia a d extrapyramidal
reacti . Erythr myci cau e GI ide e ect a d QT
pr l gati .
Question 7.3.5 Which o the ollowing IS TRUE o the natu
ral history o nonulcer dyspepsia?
A) Most p tients will not h ve sy pto - ree periods, inste d
h ving const nt dyspepsi .
B) Most p tients i prove with pl cebo tre t ent.
C) Most p tients will go on to develop ulcers.
D) Spont neous resolution o sy pto s is r re.
Answer 7.3.5 The correct answer is “B.” Up to 60% o p tients
in pl cebo controlled tri ls respond to pl cebo, king it di -
cult to prove the ef c cy o edic tions. As the bove nu -
ber suggests, spont neous resolution o sy pto s is co on,
while ny p tients will h ve chronic, inter ittent course
ch r cterized by sy pto - ree periods. Most p tients will not
develop serious p thology.
• Diag e a d ma age ulcer dy pep ia?
• Appreciate the atural hi t ry ulcer dy pep ia?
• Rec g ize imp rta t ide e ect PPI ?
CASE 7.4
A 56-year-old woman comes to the emergency department
a er a sudden episode o hematemesis. Yesterday, she had two
bowel movements that were dark, sticky, and oul smelling.
She woke up nauseated and has since twice vomited a small
amount o bright red blood. She also eels dizzy. Because o
knee pain related to skydiving 1 week ago, she started tak-
ing ve tablets o naproxen (1,100 mg) twice daily. She takes
no other medicines and denies any signi cant past medical
history.
On physical examination, you nd a pale, uncom ortable,
but alert patient. She is tachycardic (pulse o 115 bpm) and
has a drop in blood pressure rom 116/72 mm Hg supine to
93/65 mm Hg standing. Her abdomen is at with hyperactive
bowel sounds. You note epigastric tenderness but no rebound
or guarding. T ere is melena on rectal examination.
Question 7.4.1 Which o the ollowing steps will be LEAST
help ul at this point in time?
A) Ad ission to the hospit l.
B) I edi te tre t ent with n intr venous (IV) H 2 blocker.
C) Re err l or e ergent endoscopy.
206 FAMILY MEDICIn E EXAMIn ATIo n & Bo ARD REVIEW
D) IV ccess nd uid resuscit tion.
E) L bor tory tests including he oglobin, co gul tion studies,
nd blood type nd cross- tch.
Answer 7.4.1 The correct answer is “B.” T e p tient h s
sy pto s nd clinic l ndings o he odyn ic lly signi -
c nt upper GI tr ct bleed. Although she is “w lking nd t lk-
ing” just ne, uid d inistr tion nd hospit l d ission with
close onitoring in n intensive c re environ ent re indi-
c ted. A b seline he oglobin nd he tocrit (HC ) should be
obt ined. However, a normal hemoglobin does not exclude a
signi cant acute bleed, as hemodilution (in the absence o IV
uids) requires several hours. Given the present tion, blood
tr ns usion y beco e necess ry in the uture; there ore,
blood should be sent or type nd cross- tch. E rly endos-
copy should be per or ed to identi y the c use o her bleeding,
nd endoscopic ther py should be undert ken i ppropri te.
re t ent with H 2 blockers does not ect the r te o bleeding;
however, IV PPI ther py does decre se the risk o rebleeding in
high-risk p tients by incre sing g stric pH to enh nce co gu-
l tion. PPI therapy and endoscopy are standard o care or
upper GI bleeding.
HELPFUL TIP:
o rth tatic vital ig are t that u e ul i determi -
i g a patie t’ v lume tatu . Ma y hyp v lemic pa-
tie t are not rth tatic a d ma y patie t wh are
euv lemic have rth tatic cha ge (e.g., patie t
a ti-hyperte ive a d the elderly). s , u e rth tatic
vital ig t c irm y ur cli ical u pici , but d t ollowing ther py. Antisecretory drugs c n be discontinued
u e them a a ab lute guide t the patie t’ v lume
tatu (JAMA. 1999;281:1022–1029).
Question 7.4.2 What is the risk o su ering a clinically sig
nif cant GI event on NSAIDs?
A) Up to 4% per ye r.
B) Up to 10% per ye r.
C) Up to 25% per ye r.
D) Up to 50% per ye r.
E) Ne rly 99% per ye r.
Answer 7.4.2 The correct answer is “A.” T e risk o clinic lly
signi c nt NSAID-rel ted GI event, including GI bleeding, per-
or tion, or obstruction, is bout 1% to 4% per ye r.
T e patient undergoes endoscopy, which shows a small duo-
denal ulcer in the bulb with a visible vessel in the ulcer base.
Gastric biopsies show chemical gastropathy and no evidence
o H. pylori. A er endoscopic treatment, the patient recovers
nicely. T en, 3 months later, she returns to your o ce or a
ollow-up evaluation. She is asymptomatic and continues
taking a PPI. Her physical examination is normal. Labora-
tory tests show normal hemoglobin.
Question 7.4.3 What is the best next step?
A) Repe t endoscopy to docu ent he ling nd rule out lig-
n ncy.
TABLE 7-2 RISK FACTORS FOR MALIGNANCY
IN GASTRIC ULCERS
• o ccurre ce i eth ic gr up rai ed i e demic area (A ia ,
Lati , etc.)
• Helicobacter pylori i ecti
• Ab e ce rece t n s AID u e
• Ab e ce c c mita t du de al ulcer r a pri r hi t ry
du de al ulcer (du de al ulcer require higher acid ecreti ,
which i i c mpatible with the pa ga triti typical m t ga tric
ca cer )
• Gia t ulcer (> 2–3 cm)
• Ab e ce a pr tracted ulcer hi t ry—i ge eral, the l ger the
ulcer hi t ry, the l wer the ri k that a ga tric ulcer i ca cer. Ga tric
ulcer require acid a d ga tric ca cer u ually devel p i the etti g
atr phic pa ga triti
B) Upper GI x-r y series to docu ent he ling.
C) Switch to H 2 blocker.
D) Discontinue cid-suppressive edic tion.
E) H. pylori ntibody test.
Answer 7.4.3 The correct answer is “D.” While nonhe ling
ulcers y be due to neopl s , the v st jority o duodenal
ulcers re benign. T ere ore, neither endoscopic nor r diologic
docu ent tion o he ling is necess ry. See ble 7-2 or ore
on risk ctors or lign ncy in g stric ulcers. “C” is incor-
rect. P tients with unco plic ted nd s ll (< 1 c ) duode-
n l or g stric ulcers who h ve received dequ te tre t ent o
H. pylori or NSAID-induced ulcer do not need long-ter ther-
py directed t ulcer he ling s long s they re sy pto tic
er 4 to 6 weeks in these p tients. “E” is incorrect. Serology or
H. pylori will not be help ul in this p tient. First, histology is s
sensitive s other tests or H. pylori in ection nd the p tient’s
biopsies were neg tive or H. pylori. Second, serologic testing
does not tell us i the patient is currently in ected, s ny
p tients int in ntibody positivity even ye r er tre t ent.
HELPFUL TIP:
se itivity er l gic te ti g r H. pyl ri i 90% t
100%. But thi d e t i dicate curre t i ecti a d
may re lect pri r i ecti . Breath te ti g i 88% t 95%
e itive with m t al e egative the re ult the
u e a tibi tic a d a tacid , i cludi g H2 bl cker
a d PPI . Thu , make ure that the patie t ha bee
a tibi tic r at lea t a m th pri r t te ti g a d ha
t take acid uppre r r 2 week pri r t te ti g.
Thi al h ld true r CLo te ti g. s t l a tige te t-
i g (94% e itive, 92% peci ic) i al available t help
with the i va ive d cume tati H. pyl ri i ec-
ti r eradicati . Fal e- egative t l a tige a ay
may be due t rece t (withi 2 week ) u e a tibi tic
r a tacid .
Question 7.4.4 I your patient had come back H. pylori
positive, which o the ollowing combinations IS NOT indi
cated in the treatment o H. pylori?

A) O epr zole, cl rithro ycin, etronid zole.
B) Ceph lexin, o epr zole, oxicillin.
C) Metronid zole, oxicillin, o epr zole.
D) Bis uth subs licyl te, etronid zole, tetr cycline, l nso-
pr zole.
E) O epr zole, cl rithro ycin, oxicillin.
Answer 7.4.4 The correct answer (and the regimen you
would not want to use) is “B.” All o the other regi ens c n be
used to tre t H. pylori in ection. O note re regi ens “A” nd
“D.” T ere is resist nce to etronid zole, so it should only be
used when the p tient is penicillin llergic OR t king qu druple
ther py. riple ther py with PPI should be used where cl r-
ithro ycin resist nce is low. Qu druple ther py should be used
in p tients with recent or repe ted exposure to cl rithro ycin
or etronid zole or re s with high cl rithro ycin resist nce
(> 15%).
Question 7.4.5 Which o the ollowing IS NOT use ul or
testing or H. pylori eradication a ter treatment?
A) Seru IgG ntibody titers.
B) CLO test.
C) Bre th ure test.
D) R dio ctive CO2 blood test.
E) Stool ntigen test.
Answer 7.4.5 The correct answer is “A.” Re e ber the help-
ul tip bove? Only 57% o p tients re ntibody neg tive to
H. pylori ye r er success ul tre t ent. T us, ntibody titers
c nnot docu ent er dic tion. All o the other tests entioned
re unction l tests or the presence o H. pylori. T e CLO test is
done on biopsy speci ens nd docu ents the presence o ure
splitting. T e s e is true or the bre th ure test nd the r dio-
ctive CO2 blood test. In both o these tests, ure is ingested.
I H. pylori is present, r dio ctive CO2 is gener ted th t c n
be e sured in the blood or bre th. Con r tion o er dic -
tion should be considered or ll p tients receiving H. pylori
tre t ent, but de nitely should be per or ed in the ollow-
ing: (1) p tients with persistent sy pto s o dyspepsi despite
H. pylori tre t ent; (2) p tients with H. pylori ssoci ted ulcer;
(3) p tients with g stric ucos ssoci ted ly phoid tissue type
ly pho ; (4) p tients who h d resection or e rly g stric c n-
cer (N Engl J Med. 2010;362:1597–1604).
HELPFUL TIP:
n s AID-i duced ulcer ca ccur i the t mach, du -
de um, a d cca i ally i the mall b wel a d c l .
H wever, n s AID are m re reque tly u d t be the
cau e ga tric ulcer (up t 30%) tha the cau e
du de al ulcer (up t 20%).
Objectives: Did you learn to . . .
• Appreciate the r le n s AID u e i Peptic Ulcer Di ea e
(PUD)?
• Ma age a acute GI bleed?
CHAPTER 7 • GAs TRo En TERo Lo GY 207
• Ide ti y patie t at high ri k r n sAID-i duced GI t xicity?
• Lear ab ut the treatme t a d diag i H. pylori?
QUICK QUIZ: PILL PRo BLEMs
Which o these edic tions would be the LEAS likely c use o
esoph gitis i c ught in the esoph gus?
A) Pot ssiu chloride.
B) Ferrous sul te.
C) Alendron te.
D) Lor t dine.
E) etr cycline.
The correct answer is “D.” M ny edic tions c n c use “pill
esoph gitis,” including pot ssiu chloride, errous sul te,
lendron te, tetr cycline ntibiotics, nd scorbic cid. Aspirin
nd other NSAIDs c n lso c use esoph gitis. S ller pills re
less likely to c use proble s. In ddition to not being irrit ting,
lor t dine is tiny.
QUICK QUIZ: THE CAs E o F THE Ho LYs To MACH
One o your p tients presents co pl ining o di rrhe nd
epig stric p in unresponsive to H 2 blockers or PPIs. He denies
s oking tob cco, t king NSAIDs, or drinking lcohol. Endos-
copy reve ls sever l ulcers. Biopsy or H. pylori is neg tive nd
there is no lign ncy.
Which o the ollowing would be the ost ppropri te l bo-
r tory test to obt in in order to discover n etiology or the
multiple ulcers ( nd di rrhe )?
A) V so ctive intestin l peptide (VIP).
B) G strin.
C) Gluc gon.
D) So tost tin.
The correct answer is “B.” So e sort o screening test or
g strino is w rr nted in p tient who h s recurrent or re-
r ctory ulcers nd who is H. pylori neg tive nd does not use
NSAIDs. Zollinger–Ellison syndro e is the n e given to the
st te in which there is cid hypersecretion second ry to in-
cre sed g strin production, usu lly ro g strin-producing
tu or (g strino ). Up to 1% o p tients with PUD h ve
g strino . Seru g strin levels should be obt ined with the
p tient sting and of PPIs, as PPIs will increase gastrin lev-
els. I the seru g strin is elev ted (> 10 ti es upper nor l
li it), urther investig tions will need to be per or ed. Other
re sons to consider obt ining seru g strin level include ul-
cers in unusu l loc tions (dist l duoden l nd jejunu ), ily
history o ulcers, nd ulcers ssoci ted with severe esoph gitis.
“A” is incorrect. VIP ctu lly works to suppress cid secretion.
VIPo s do occur, but VIPo s re ssoci ted with w tery di-
rrhe nd hypok le i —not ulcers. “C,” gluc gon, will not be
o uch help here. Gluc gon over secretion results in hypergly-
ce i nd ne i . “D,” so tost tin, is hor one th t inhibits
208 FAMILY MEDICIn E EXAMIn ATIo n & Bo ARD REVIEW
the secretion o g strin nd thus would be protective vis-à-vis
ulcers. So tost tin secreting tu ors re very r re.
QUICK QUIZ: GI BLEEDIn G
Isol ted bright red he te esis (e.g., no t chyc rdi nd no
ever), which occurs er sever l bouts o vo iting or dry
he ves, is re erred to s:
A) Boerh ve syndro e.
B) M llory–Weiss te r.
C) C eron lesion.
D) None o the bove.
The correct answer is “B.” A M llory–Weiss te r occurs er
repe ted tr u to the lower esoph ge l nd g stric ucos ro
orce ul retching. T is c n be di erenti ted ro Boerh ve
te r by the (gener lly) sel -li ited n ture o the bleeding nd the
bsence o other sy pto s. Boerh ve syndro e is per or -
tion o the esoph gus resulting ro sudden incre se in intr -
esoph ge l pressure, c used by vo iting, retching, less requently
by coughing, childbirth, or weight li ing. It occurs higher in the
esoph gus nd is ssoci ted with edi stinitis, ever, shock, nd
de th i intervention is not orthco ing. C eron lesions re
s ll ulcers in p tients with hi t l herni , re usu lly n inci-
dent l nding, nd re likely c used by rubbing o the sto ch
g inst the di phr g s the herni slides. T ey c n bleed, but
the history given bove is cl ssic or M llory–Weiss te r.
QUICK QUIZ: ABDo MIn AL PAIn
A 35-ye r-old e le presents to your clinic co pl ining o onset
o severe idepig stric p in, weight loss, nd vo iting ollow-
ing e ls. Between e ls she is sy pto tic. T is h s been
going on or the p st 2 ye rs ever since she purpose ully lost 25 lb
to tt in he lthy weight or her height. Un ortun tely, she h s
continued to lose weight bec use o the postpr ndi l p in nd
vo iting. On her ex in tion you notice idepig stric bruit.
T e ost likely di gnosis is:
A) Aortic neurys .
B) Atherosclerotic dise se o the celi c trunk.
C) Superior esenteric rtery (SMA) syndro e.
D) Chronic p ncre titis.
E) None o the bove.
The correct answer is “C.” T is is typic l history nd physi-
c l ex in tion or SMA syndro e. SMA syndro e is ore
likely to occur in p tient who h s lost signi c nt weight, re-
sulting in thinning o the esenteric t p d. Here’s the p tho-
physiology: the SMA runs bove the duodenu nd beco es
stretched nd p rti lly occluded in response to e ls ( s the
sto ch nd duodenu exp nd), le ding to esenteric isch-
e i nd ood version. SMA syndro e c n be di gnosed using
Doppler ultr sound to de onstr te incre sed velocity o blood
in the SMA or by C - ngiogr . “A” nd “B” re unlikely in
young p tient, nd “D” should not be ssoci ted with bruit.
Celi c rtery syndro e y h ve si il r present tion to SMA
syndro e but, obviously, involves the celi c trunk.
CASE 7.5
A 54-year-old man comes to your o ce or his annual physi-
cal. He is taking naproxen or a recent ankle injury. Based on
your recommendation last year, he started taking one aspi-
rin (81 mg) daily. He does not take any other medications.
He exercises regularly, does not smoke, and drinks one glass
o wine every day. Your examination is completely normal,
except that a test or occult ecal blood is positive.
Question 7.5.1 What is the next best step?
A) Upper endoscopy.
B) CBC.
C) Colonoscopy.
D) A nd B.
E) B nd C.
Answer 7.5.1 The correct answer is “E.” Current reco en-
d tions suggest screening or colorect l c ncer in ll p tients
over the ge o 50 ye rs. esting or ec l occult blood is one o
the ccepted ethods. However, it should only be per or ed s
screening test in sy pto tic individu ls. Moreover, the use
o spirin nd/or NSAIDs nd oods such s undercooked e t
y incre se the nu ber o lse-positive tests nd should thus
be voided. Fec l i unoche ic l tests using the current gener-
tion o stool c rds detects hu n he oglobin by i unologic
e ns. T us, it circu vents ny o the we knesses o the old
gu i c test (but not bleeding second ry to NSAIDs, etc. giving
lse positive screen). I unoche ic l testing is now the
ethod o choice or detecting ec l occult blood when screen-
ing or colon c ncer. However, once you h ve he e-positive
stool, you ust proceed to colonoscopy in p tient over the
ge o 50. A CBC is lso i port nt to deter ine i the p tient is
ne ic. Since the p tient currently h s no sy pto s re er ble
to upper GI p thology, ev lu tion o the upper GI tr ct should
only be considered i the colonoscopy is neg tive.
HELPFUL TIP:
Ir uppleme t may cau e t l t darke but they
Do n o T cau e al e-p itive guaiac te t . Guaiac te t
rely the pre e ce hem gl bi i the t l, t ir .
D ’t blame a p itive guaiac a ir uppleme t.
Review o his records shows that he underwent a colonoscopy
3 years ago. T ree small adenomatous polyps were ound. He
also had scattered diverticula in the sigmoid.
Question 7.5.2 Based on this new in ormation, which strat
egy do you recommend?
A) Colonoscopy now.
B) Colonoscopy in 5 ye rs.
C) Ye rly tests or ec l occult blood.
D) Ye rly tests or ec l occult blood nd colonoscopy in 7 ye rs.
E) Colonoscopy in 7 ye rs.

Answer 7.5.2 The correct answer is “A.” Adeno tous polyps
re considered prec ncerous. Reco ended ollow-up o n
deno tous polyp is by colonoscopy every 3 to 5 ye rs. So, he
did not truly h ve “neg tive” colonoscopy 3 ye rs go. Plus,
we re not doing the colonoscopy in this c se or screening pur-
poses; it is di gnostic. We y nd nother source o his bleed-
ing. I his previous colonoscopy w s co pletely nor l (no
deno tous polyps), you could rgue or stopping the spi-
rin nd NSAIDs nd ollowing up with seri l ec l occult blood
tests (FOB s). In this ltern tive scen rio, persistently positive
gu i c tests would le d to colonoscopy s well.
HELPFUL TIP:
Ade mat u c l p lyp , either pedu culated r
e ile, are a ciated with tra rmati t ca cer.
Hyperpla tic p lyp are c idered be ig .
HELPFUL TIP:
U.s . Preve tive s ervice Ta k F rce rec mme d r uti e
cree i g r c l rectal ca cer, tarti g at the age
50 year r average-ri k patie t (thi d e n o T apply
t high-ri k patie t —p itive amily hi t ry, k w
ade mat u p lyp , etc.). A y the ll wi g m dali-
tie i acceptable: a ual Fo BT al e, Fo BT every 3 year
with igm id c py every 5 year , a d c l c py ev-
ery 10 year (with ut a ual Fo BT). Betwee the age
75 a d 85 year , r uti e cree i g i t rec mme ded
but elect patie t h uld be c u eled cree i g.
A ter the age 85, cree i g h uld be d e.
You re er the patient or a colonoscopy. T e report rom the
endoscopist shows one small tubular adenomatous polyp in
the sigmoid colon that was completely removed. T e patient
wants to know when he needs another colonoscopy.
Question 7.5.3 Your answer is:
A) In 3 onths.
B) In 1 ye r.
C) In 5 ye rs.
D) In 10 ye rs.
E) Any o the bove is n equ lly v lid reco end tion.
Answer 7.5.3 The correct answer is “C.” T e current surveil-
l nce guidelines reco end the ollowing:
1. No polyps or only rect l hyperpl stic polyps, repe t in 10 ye rs.
2. 1 to 2 tubul r deno s less th n 1 c in size with only low-
gr de dyspl si should h ve repe t colonoscopy in 5 ye rs.
3. 3 to 10 tubul r deno s, or villous e tures or high-gr de
dyspl si should h ve surveill nce in 3 ye rs.
4. P tients with > 10 deno s should be screened ore re-
quently nd ili l colon c ncer syndro es should be con-
sidered.
5. I l rge sessile polyp is re oved in piece e l shion, then
repe t ex in tion in 3 onths is ppropri te to ssure
co plete re ov l.
CHAPTER 7 • GAs TRo En TERo Lo GY 209
6. I prep is not good, repe t colonoscopy t e rliest conve-
nience is indic ted.
Question 7.5.4 Patients presenting with hereditary non
polyposis colorectal cancer (HNPCC), or “Lynch syndrome,”
are more likely than patients with sporadic colon cancer to
have which o the ollowing f ndings?
A) Le -sided colon c ncers.
B) L te ge onset o colon c ncer.
C) Multiple colon c ncers di gnosed si ult neously.
D) An unusu l desire to visit Lynchburg, ennessee, nd dedi-
c tion to ll things J ck D niels.
Answer 7.5.4 The correct answer is “C.” P tients with HNPCC
(Lynch syndro e) re t incre sed risk o developing colon c n-
cer. About 5% o colon c ncers occur in p tients with Lynch
syndro e. r ns or tion ro n deno to c ncer is
ster in p tients with Lynch syndro e. In ddition, ny o
the neopl s s re loc ted in the right colon, so “A” is incorrect.
Co p red to spor dic colon c ncer p tients, those with Lynch
syndro e re younger t the ti e o di gnosis, ore requently
present with ultiple colon tu ors, nd re ore likely to h ve
extr colonic tu ors—especi lly endo etri l c ncer. T is is
genetic disorder, nd the occurrence o colorect l nd/or endo-
metrial c ncer in three rel tives be ore the ge o 50 should sug-
gest HNPCC. T e current reco end tion is to per or sur-
veill nce colonoscopies t le st every 3 ye rs in these p tients.
HELPFUL TIP:
Curre t guideli e rec mme d earlier cree i g c l -
c py r a ympt matic patie t with a amily hi t -
ry c l ca cer, alth ugh the rec mme dati vary
by rga izati . The America Ca cer s ciety (ACs )
rec mme d cree i g c l c py at the age 40
r 10 year be re the age diag i r a y patie t
with a ir t-degree relative with c l ca cer diag ed
u der the age 60 (e.g., i m m had c l ca cer at 48,
tart y ur cree i g at 38). F r the e patie t , the ACs
rec mme d c l c py every 5 year . F r patie t
with a ir t-degree relative with c l ca cer ver the
age 60, the ACs rec mme d cree i g c l c py
at the age 40 a d the ll w-up a per average-ri k
patie t (e.g., c l c py every 10 year i c mpletely
egative).
Objectives: Did you learn to . . .
• De cribe the limitati Fo BT?
• Ch e the appr priate te t a d cree i g a d urveilla ce
i terval r c l rectal e pla ia ?
• Lear h w amily a d per al hi t ry c l rectal e pla-
ia a ect cree i g a d urveilla ce trategy?
CASE 7.6
A 28-year-old graduate student comes to your o ce com-
plaining o diarrhea. About 6 months ago, she noted a sudden
210 FAMILY MEDICIn E EXAMIn ATIo n & Bo ARD REVIEW
onset o loose stools. While she initially attributed these
symptoms to “stomach u,” her problem has persisted. She
currently has about our to six loose bowel movements per
day with nighttime de ecations. She has not seen blood in her
stool. In addition, she complains o cramps located in the le
and occasionally right lower abdomen. T e cramps are made
worse with ood intake and o en are associated with a need
to de ecate. She has lost about 8 kg unintentionally within
the last 3 to 4 months. She denies any travel or antibiotic use.
On physical examination, you notice some tenderness in the
right lower quadrant. You see a painless anal ssure in the
anterior commissure, and by the appearance, you judge that
the ssure is probably chronic in nature.
Question 7.6.1 What do you recommend as the next step in
the evaluation and management o this patient?
A) Loper ide on scheduled b sis.
B) Re err l to holistic clinic or co ee colonic cle nsing regi en
(using ir tr de, sh de grown org nic co ee only, o course).
C) Check titers o typic l ntineutrophil cytopl s ic ntibod-
ies (ANCA).
D) Colonoscopy.
E) Botulinu toxin injection into the re o the n l ssure.
Answer 7.6.1 The correct answer is “D.” T e p tient’s history
nd physic l ndings with p inless, nteriorly loc ted n l s-
sure nd di rrhe re consistent with Crohn dise se. T e best
next step in her ev lu tion is colonoscopy with inspection o the
ter in l ileu . You y w nt to do so e stool testing be ore
colonoscopy; testing or Giardia, C. di cile toxin, nd other
p thogens would be re son ble. But o the choices presented,
colonoscopy is the best option. “A” is in ppropri te since this
is long-st nding with weight loss; sy pto tic control is ne
but we need to gure out wh t is going on with this p tient.
“B” is incorrect. She h s di rrhe . . . her colon is lre dy cle n.
“C,” serologic testing, is re son ble choice but not the best.
Here is why: Crohn dise se is ssoci ted with ntibodies g inst
s cch ro yces (ASCA), while ulcer tive colitis (UC) p tients
re ore o en positive or ANCA. However, the sensitivity o
these tests is only bout 60%. Moreover, there is bout 20%
overl p (e.g., ANCA positive in Crohn dise se), r ising urther
questions bout the over ll use ulness o these tests. ASCA c n
lso be positive in celi c dise se. “E” is lso incorrect. Fissures
re one o the n l ni est tions o Crohn dise se nd should
be ppro ched by tre ting the underlying dise se r ther th n
using surgic l techniques, botulinu injection, etc. Botulinu
injections, nitroglycerin oint ent, nd ni edipine h ve ll been
used or n l ssures with success, but we need to di gnose this
p tient nd ddress the underlying dise se.
HELPFUL TIP:
I Cr h di ea e, ab ut 25% patie t have di ea e
c i ed t the c l . A ther 40% have di ea e i the
ileum a d cecum, a d 30% have di ea e c i ed t the
mall b wel. The remai der have m re di u e di ea e
a d/ r di ea e i the pr ximal GI tract.
Question 7.6.2 Which o the ollowing is true regarding the
pathophysiology and natural history o Crohn disease?
A) Crohn dise se is genetic disorder, tr ns itted in n
utoso l-do in nt shion.
B) Crohn dise se is rel psing/re itting dise se, nd 30% o
p tients will i prove spont neously.
C) P tients with Crohn dise se r rely progress to dise se requir-
ing surgery.
D) M inten nce ther py with glucocorticoids will reduce the
r te o recurrence o Crohn dise se.
E) GI stul e nd bscesses re r re co plic tions o Crohn
dise se.
Answer 7.6.2 The correct answer is “B.” Crohn dise se nd UC
re both rel psing/re itting dise ses. Up to 30% o initi l ex c-
erb tions o Crohn dise se will re it without ny intervention.
While there is genetic co ponent to in tory bowel dis-
e se (IBD) (up to 100- old incre se in risk ong rst-degree
rel tives with IBD), no single, utoso l-do in nt gene h s been
identi ed. “C” is incorrect bec use h l or ore o p tients with
Crohn dise se will ulti tely require so e sort o surgery. “D” is
incorrect. Un ortun tely, chronic glucocorticoid d inistr tion
does not lower the r te o rel pse. T ere re ny co plic tions
o IBD (see next question), nd GI bscesses nd stul e occur
with rel tively high requency (20–40%) in Crohn dise se.
HELPFUL TIP:
Alth ugh c idered a di ea e y u g adult , there
i a bim dal di tributi IBD with a ec d peak i
lder adult i their 70 .
Question 7.6.3 Extraintestinal eatures o IBD include all o
the ollowing EXCEPT:
A) Alopeci .
B) Arthritis.
C) Sclerosing chol ngitis.
D) Uveitis.
E) Cholelithi sis.
Answer 7.6.3 The correct answer is “A.” Alopeci is not n
extr intestin l ni est tion o IBD. Arthritis rel ted to IBD
(enterop thic rthritis) is irly co on nd usu lly igr tory
in n ture, involving the l rge joints. Spondylo rthrop thy y
lso be seen. Sclerosing chol ngitis nd utoi une hep titis
c n occur nd y be t l. Eye dise se y include uveitis nd
episcleritis. I port ntly, the in tre t ent o extr intestin l
ni est tions is to tre t the IBD. IBD spondylo rthrop thy nd
pyoder g ngrenosu re i port nt exceptions, s these do
not lw ys i prove with the tre t ent o the underlying IBD.
HELPFUL TIP:
T xic megac l i a p te tially deadly c mplicati
IBD that h uld be u pected i a patie t with IBD wh
pre e t with ever, abd mi al pai , a d h ck. Al ,
c ider ther cau e i te ti al b tructi .
 CHAPTER 7 • GAs TRo En TERo Lo GY 211

A) Sul llergy.
Returning to your patient, you next see her in the emergency B) Aspirin llergy.
department, where she presents with ever, abdominal pain, and C) Ane i .
bloody diarrhea. She is tachycardic and slightly hypotensive but D) A nd B.
alert and oriented. You suspect a relapse o her Crohn disease. E) B nd C.

Question 7.6.4 All o the ollowing are important aspects o

her management at this time EXCEPT:
A) Surgic l consult tion.
B) IV ccess nd uid d inistr tion.
C) Glucocorticoids.
D) T lido ide.
E) Metronid zole.
Answer 7.6.4 The correct answer is “D.” T lido ide h s been
used s chronic ther py or IBD, but it is not indic ted in the
cute setting. T e p tient should be st bilized, nd this includes
IV ccess nd uid resuscit tion. An ex cerb tion (or rel pse)
o IBD c n be tre ted with glucocorticoids in the cute setting,
nd ntibiotics re o en help ul. It ppe rs th t etronid zole
h s bene ci l e ects th t re not solely due to its nti icrobi l
properties. In this p tient, who y h ve n bscess or obstruc-
tion, urther ev lu tion (e.g., l bs nd bdo in l C ) nd sur-
gic l consult tion re necess ry.
Question 7.6.5 Which o the ollowing is indicated in the
long term treatment o IBD?
A) Az thioprine.
B) Methotrex te.
C) 5-ASA oieties.
D) Loper ide.
E) All o the bove.
Answer 7.6.5 The correct answer is “E.” All the options re
indic ted or the tre t ent o IBD. O speci l note re the
5-ASA drugs (e.g., Pent s nd As col). T ese h ve ewer side
e ects th n sul s l zine nd re the initi l drugs o choice or
inten nce, once control o sy pto s h s been obt ined.
Syste ic steroids (e.g., prednisone) re use ul cutely to induce
re ission but should be t pered nd stopped s soon s pos-
sible. Steroids re o en indic ted long-ter or Crohn dise se
limited to the stomach and duodenum.
Addition l drugs or the tre t ent o IBD include cyclospo-
rine, 6- erc ptopurine (6-MP), in ixi b, certolizu b, nd
d li u b (just s y Hu ir ®, it’s uch e sier), ong others.
Antidi rrhe l drugs such s loper ide re use ul to control
sy pto s. However, be sure to void ntidi rrhe l drugs in
p tients who y h ve i pending toxic eg colon. Probiotics
nd l ctose void nce y lso be use ul ( lthough there is less
evidence or these).
A er discussions with your patient about ongoing therapy at
discharge, you nd that cost is a major consideration or her.
T ere ore, you consider discharging her on sul asalazine.
Question 7.6.6 Which o the ollowing is an absolute con
traindication to the use o sul asalazine?
Answer 7.6.6 The correct answer is “D.” Sul s l zine cont ins
both sul nd s licyl te oieties nd thus is contr indic ted in
p tients with sul or spirin llergy.
Question 7.6.7 Which o the ollowing is LEAST likely to be
a complication o anti tumor necrosis actor (TNF) alpha
antibody therapy (e.g., in iximab [Remicade®]) or IBD?
A) Sepsis.
B) He d che.
C) Abdo in l p in.
D) Di rrhe .
E) Ane i .
Answer 7.6.7 The correct answer is “E.” Ane i will gener-
lly i prove with the tre t ent o IBD. Ane i in IBD is o en
due to co bin tion o iron de ciency nd ne i o chronic
dise se, but IBD c n c use n utoi une he olytic ne i
s well. All o the rest re co on co plic tions o in ix-
i b. In ection deserves speci l ention. P tients on nti-
NF drugs re ore prone to sepsis. In ct, ongoing in ection
is n bsolute contr indic tion to the use o nti- NF drugs.
ke ny co pl ints ttribut ble to in ection (e.g., ever) very
seriously in p tients on nti- NF drugs (not th t you don’t
t ke the seriously in ll p tients . . . just ore seriously in
these). uberculosis nd ctive hep titis B re contr indic -
tions to the use o nti- NF drugs.
Question 7.6.8 All o the ollowing characteristics di eren
tiate ulcerative colitis (UC) rom Crohn disease EXCEPT:
A) T e risk o colon c ncer is gre ter in UC th n in Crohn dis-
e se.
B) Histologic lly, UC ppe rs s tr ns ur l dise se, where s
Crohn dise se involves only the ucos l nd sub ucos l
l yers.
C) UC l ost lw ys involves the rectu , where s Crohn dis-
e se y or y not.
D) In UC, the dise sed seg ents re continuous, while “skip”
re s o he lthy bowel re seen in Crohn dise se.
Answer 7.6.8 The correct answer is “B.” Histologic lly, UC
involves only the ucos nd sub ucos l tissue, while Crohn
dise se is tr ns ur l. All o the other st te ents re true. UC
involves the rectu in 95% o c ses nd dv nces proxi lly.
HELPFUL TIP:
Medical a d urgical treatme t UC a d Cr h di -
ea e are imilar. Patie t with l g- ta di g UC with
reque t relap e are ca didate r c lect my.
212 FAMILY MEDICIn E EXAMIn ATIo n & Bo ARD REVIEW
HELPFUL TIP:
IBD i crea e the ri k c l ca cer, m re reque t
a d earlier c l c pie are rec mme ded. Rec m-
me dati vary, but m t expert guideli e rec m-
me d c l c py every 1 t 2 year i patie t with
UC a ter 8 year with di ea e. s cree i g parameter i
th e with Cr h di ea e are le well e tabli hed.
HELPFUL TIP:
I dicati r urgery i th e with IBD i clude per -
rati , b tructi , ma ive hem rrhage, t xic mega-
c l , a d evere a d per i te t di ea e that impair
u cti r quality li e. s urgical re ecti h uld be
c idered r i t lerable extrac l ic di ea e i clud-
i g arthriti a d ki le i . H wever, a kyl i g p -
dyliti ( ec dary t Cr h di ea e) a d liver dy u c-
ti d t re p d t c lect my.
Objectives: Did you learn to . . .
• Diag e IBD?
• Di ere tiate Cr h di ea e r m UC?
• Ma age a patie t with IBD?
• Rec g ize extrai te ti al ma i e tati a d c mplicati
IBD?
CASE 7.7
A 52-year-old woman complains o abdominal pain, bloat-
ing, and constipation. Her symptoms started about 5 years
ago and became more bothersome within the last 6 months.
She describes a dull pain in the le lower abdomen. T is pain
is alleviated by passing gas or having a bowel movement. T e
pain is generally related to eating, and she has had intermittent
diarrhea and constipation with constipation predominating.
wo years ago, she underwent a screening colonoscopy, which
was completely normal. Her review o systems is notable or a
weight gain o about 5 lb within the last 3 years. She is taking
only a multivitamin daily. Her physical examination is normal.
Question 7.7.1 Which is the best next step?
A) De ecogr .
B) B riu ene .
C) Anorect l no etry.
D) SH level.
E) Colonoscopy.
Answer 7.7.1 The correct answer is “D.” T e p tient’s present -
tion with p in nd constip tion eets criteri or constip tion-
predo in nt irrit ble bowel syndro e (IBS) (see ble 7-3). O
note, irrit ble bowel is not n unco on co plic tion o GI
in ections including E. coli, Campylobacter, vir l in ections, nd
Giardia (Gut. 2010;59:605). T ere is lso rel tionship between
nxiety nd the presence o irrit ble bowel. T is p tient under-
went colonoscopy or screening 2 ye rs prior to present tion,
TABLE 7-3 ROME III CRITERIA FOR IRRITABLE
BOWEL SYNDROME
C ti u u r recurre t abd mi al pai r di c m rt, at lea t
3 day per m th i the la t 3 m th , with ympt m tarti g at
lea t 6 m th pri r t diag i , and a ciated with at lea t 2 the
ll wi g:
• Relie with de ecati
• Cha ge i t l reque cy
• Cha ge i t l rm
Adapted r m L g treth GF, et al. Fu cti al b wel di rder .
Gastroenterology. 2006;130:1480. C pyright 2006, with permi i r m
El evier.
so urther ev lu tion or colon c ncer (“B” nd “E”) c n be
del yed unless there is nother indic tion. Second ry c uses o
constip tion, such s hypothyroidis , edic tion side e ects
or hyperc lce i , should be ruled out. T ere ore, SH level
should be obt ined prior to deciding on ddition l di gnostic
or ther peutic steps. At this point in ti e, norect l no etry
nd de ecogr re unnecess rily inv sive procedures, nd nei-
ther will help you to deter ine i this p tient h s IBS.
T e patient is euthyroid. Hypercalcemia and other electro-
lyte abnormalities have been ruled out. Since she does not use
medications other than the multivitamin, you decide to ini-
tiate the treatment o IBS. Based on available evidence, you
suggest using ber supplements such as psyllium.
Question 7.7.2 What do you tell your patient to expect?
A) Co plete resolution o her sy pto s.
B) Incre se in stool requency nd stool volu e with less need
or str ining.
C) Not uch. Fiber supple ent tion doesn’t work very well or
IBS.
D) Decre se in bdo in l p in nd blo ting.
E) Enlighten ent nd bsolute bliss.
Answer 7.7.2 The correct (and un ortunate) answer is “C.”
Although it h s been one o the inst ys o irrit ble bowel
ther py, the ef c cy o ber or IBS h s lw ys been in question.
A et - n lysis (Am J Gastroenterol. 2014;109:1367) suggests
NN o 7 with psylliu to bene t one p tient. Perh ps surpris-
ingly, there re only 14 r ndo ized tri ls o only 906 p tients.
While bowel h bits c n be success ully ch nged with bulking
gents or constip tion or loper ide or di rrhe -predo in nt
IBS, p in is gener lly not ected by these e sures. In ct,
incre sed ber int ke y tr nsiently worsen so e sy pto s
due to er ent tion nd gener tion o g s, potenti lly resulting
in tulence or blo ting. “E” requires speci l ention. Bliss nd
enlighten ent c n only occur with proper colon purging pro-
cedures provided t very expensive resort!
Question 7.7.3 Which o the ollowing has the best record
in treating IBS?
A) Eli in ting FODMAPs ro the diet.
B) Probiotics.

C) Ri ixin.
D) St. John’s wort.
E) Eli in ting the use o GOOGLEMAPS .
Answer 7.7.3 The correct answer is “A.” First, you need to
know wh t FODMAPs re. FODMAP st nds or “Fer ent ble,
Oligo-, Di-, Monos cch rides, And Polyols.” T ese re poorly
bsorbed c rbohydr tes th t c n c use er ent tion nd g s in
the colon. So e FODMAPs include ructose, l ctose, ruct ns
( ro whe t . . . think this is why everyone believes they h ve
gluten intoler nce?), nd others. Eli in ting FODMAPs ro
the diet see s to h ve the best NN o ny o the irrit ble bowel
tre t ents. O the others, probiotics h ve NN o 7 to 11 (Am
J Gastroenterol. 2014;109:1547), ri xi in ( t $1,200/ onth)
h s NN o 11 nd rgin l bene t t best (N Engl J Med.
2011;364:22–32), nd St. John’s wort ctu lly incre ses the sy p-
to s o IBS nd should be voided. Use o GOOGLEMAPS h s
not been shown to h ve ny e ect on IBS sy pto s side ro
perh ps decre sing nxiety nd sy pto s rel ted to it.
HELPFUL TIP:
Ab ut 4% childre diag ed with IBs wh are re-
erred t a academic GI cli ic have celiac di ea e. The
umber will be le i the ge eral patie t p pulati
(JAMA Pediatr. 2014;168(6):514–515).
HELPFUL TIP:
IBs ha a relatively g d pr g i . Up t 60% pa-
tie t impr ve with placeb treatme t i trial , maki g
it hard t h w be e it with a y treatme t. There i
i crea e i m rtality with IBs , a d ympt m u ually
impr ve ver time.
HELPFUL TIP:
s me patie t with c tipati -pred mi a t IBs will
re p d t ral s s RI medicati uch a lu xeti e r
par xeti e that eem t i crea e b wel tra it time .
The data i till ketchy, h wever. A “n 1 trial” i rea-
able, h wever.
Objectives: Did you learn to . . .
• Diag e a d ma age IBs?
• The r le Fo DMAP i irritable b wel?
• Realize that b th y u a d y ur patie t will be ru trated with
the treatme t r IBs ?
CASE 7.8
A 32-year-old male complains about atigue and episodic
abdominal pain. His pain is located in the periumbilical
region and the le lower quadrant. It is cramp-like in nature
and is associated with atulence and diarrhea. Passing gas
alleviates his symptoms. He notes that milk and other dairy
products worsen his symptoms. His weight has remained
stable. His prior medical history, amily and social history,
CHAPTER 7 • GAs TRo En TERo Lo GY 213
and physical examination are unremarkable. Laboratory
tests reveal hemoglobin o 11.5 g/dL and a normal glucose
and SH.
Question 7.8.1 What is the most appropriate next step in
your evaluation?
A) L ctose bre th test.
B) Diet ry tri l o strict l ctose void nce.
C) Enteroclysis.
D) Colonoscopy.
E) issue tr nsglut in se ntibody titer.
Answer 7.8.1 The correct answer is “B.” T e p tient’s sy p-
to s re consistent with l ctose intoler nce. He y h ve l-
bsorption second ry to l ctose intoler nce, which y be p r-
ti lly responsible or his ne i . I his sy pto s resolve with
tri l o l ctose- ree diet, you h ve your di gnosis. Follow-up
should include re-checking his CBC nd perh ps other studies,
such s stool or occult blood. I these sy pto s re new, he
could h ve second ry or o l ct se de ciency (e.g., Crohn
dise se or b cteri l overgrowth) or coincident l proble with
the bsorption o this c rbohydr te. Colon c ncer is not co -
on t this ge but endoscopy should lso be considered i ne-
i does not resolve.
T e patient tries a lactose- ree diet, but this is o no bene t
and his abdominal cramping and diarrhea continue. At this
point, you are considering additional diagnoses.
Question 7.8.2 Which o the ollowing is LEAST likely in this
patient?
A) B cteri l overgrowth syndro e.
B) Gluten-sensitive enterop thy.
C) Giardia lamblia.
D) C. di cile.
E) Whipple dise se.
Answer 7.8.2 The correct answer is “E.” It is unlikely th t this
p tient h s Whipple dise se, which is result o n in ection with
Tropheryma whippelii. Whipple dise se is ssoci ted with nonde-
or ing rthritis, weight loss, ever, di rrhe , etc. All o the oth-
ers re possibilities in this p tient. “A,” b cteri l overgrowth syn-
dro e, presents with blo ting, di rrhe , dyspepsi , nd possible
l bsorption nd weight loss. It c n occur s result o bowel
dys otility, bowel redund ncy or diverticul , chronic p ncre ti-
tis, etc. “B,” gluten-sensitive enterop thy (nontropic l or celi c
sprue), presents with sy pto s si il r to those in our p tient
including l bsorption. “C,” Giardia in ection, c n be chronic
nd presents with g s, di rrhe , nd occ sion lly constip tion.
Fin lly, C. di cile in ection (pseudo e br nous colitis) c n
lso be chronic in n ture with chronic di rrhe nd blood loss.
HELPFUL TIP:
Giardia i a c mm path ge that may be c tracted
i the day care etti g. s ympt m may c i t diar-
rhea, malai e, a d au ea. The treatme t ch ice i
metr idaz le.
214 FAMILY MEDICIn E EXAMIn ATIo n & Bo ARD REVIEW

Answer 7.8.4 The correct answer is “B.” issue tr nsglut -

You continue to work up this patient’s diarrhea with stool cul-
in se ntibodies re sensitive nd speci c or severe gluten-
tures, stool or C. dif cile toxin, direct immuno uorescence
sensitive enterop thy but y be lsely neg tive in ild-
analysis or Giardia and Cryptosporidium, and three stools or
to- oder te c ses. Antiendo ysi l IgA ntibodies re less
ova and parasites. All o the studies are negative. You now turn
sensitive th n tissue tr nsglut in se ntibodies or gluten-
your attention to possible bacterial overgrowth syndrome.
sensitive enterop thy but very speci c or gluten-sensitive enter-
op thy. Antigli din ntibodies re less sensitive nd speci c nd
Question 7.8.3 The best test(s) or bacterial overgrowth
h ve llen out o vor. T e de nitive test (“gold st nd rd”) is
syndrome is (are):
s ll bowel biopsy nd should be considered i your clinic l sus-
A) Qu ntit tive stool culture.
picion is high nd the p tient h s neg tive ntibodies. P tients
B) Stool leukocytes.
with positive ntibodies should lso h ve n endoscopy; the
C) 72-hour ec l t.
di gnosis should be con r ed by endoscopy nd biopsy be ore
D) [14-C] d-xylose bre th test.
co itting the p tient to gluten- ree diet or li e.
E) B nd D.

Answer 7.8.3 The correct answer is “D.” T e d-xylose bre th
test t kes dv nt ge o the ct th t the b cteri responsible
or b cteri l overgrowth syndro e (Gr -neg tive erobes)
c t bolize d-xylose. T e bre th test e sures r dio ctive CO2
th t is or ed s result o b cteri l bre kdown o r dio ctive
d-xylose. T e glucose bre th test, in which glucose is d in-
istered to the p tient nd bre th hydrogen is e sured, is lso
help ul nd co only used. However, it is less sensitive nd
speci c th n the d-xylose test nd h s 30% to 40% lse-
neg tive r te. Work up o b cteri l overgrowth syndro e
should lso include n upper GI endoscopy nd possible s ll
bowel biopsy. GI hypo otility, s ll bowel dil t tion, or s ll
bowel diverticul support the di gnosis o b cteri l overgrowth
syndro e. O the others, “B,” stool leukocytes re pretty useless
in gener l nd do not h ve good correl tion with in ectious
c uses o di rrhe (high lse-positive nd lse-neg tive r tes).
“C,” ec l t collection, is use ul in docu enting t l bsorp-
tion syndro es, including those second ry to severe p ncre tic
insuf ciency (e.g., cystic brosis with > 90% p ncre tic dys-
unction) nd short bowel syndro e.
HELPFUL TIP:
Up t 1:200 Cauca ia livi g i the U ited s tate may
be a ected with glute - e itive e ter pathy (while
1:20 gr cery t re ai le appear t be dev ted t glute -
ree pr duct ).
HELPFUL TIP:
Remember Fo DMAP r m earlier? s tudie patie t
wh believe that they have glute e itive e ter pa-
thy h w that elimi ati g Fo DMAP will impr ve the
ympt m ma y the e patie t (Ga tr e ter l gy.
2013;145:320). The culprit here i t the wh le wheat
bread but the eve Big-Gulp-Fruct e-Lade p p
the patie t dri k each day. T be air, wheat ha Fo D-
MAP , wheat, but t glute e itivity, may make
ympt m w r e i the e patie t . Di erentiating glu-
ten sensitive enteropathy rom FODMAP-induced
symptoms is important. Keep reading . . .

HELPFUL TIP:
A ther pti t diag e bacterial vergr wth i
empiric treatme t r 7 t 10 day with medicati
c ver aer be a d a aer be (cephalexi plu metr -
idaz le, TMP/s MX plu metr idaz le, am xicilli /
clavula ate). Ri amixi ca be u ed but i expe ive.
De i itive treatme t may require urgical i terve ti
t h rte the b wel, re ect diverticula, etc.
T is patient’s d-xylose test is negative and you consider the
possibility o gluten-sensitive enteropathy (celiac disease).
Question 7.8.4 O the ollowing, the one BEST test or the
diagnosis o gluten sensitive enteropathy is:
A) Antiendo ysi l ntibodies.
B) issue tr nsglut in se ntibodies.
C) Antigli din ntibodies.
D) R diol beled whe t our bsorption test.
E) All o the bove re equ lly ccur te or detecting celi c
dise se.
T e results o his tissue transglutaminase test are positive.
t You educate him about gluten-sensitive enteropathy (celiac
disease) and have an endoscopy per ormed. A small bowel
biopsy demonstrates blunted villi with a signi cant increase in
intraepithelial lymphocytes, consistent with gluten-sensitive
enteropathy. With a gluten- ree diet, the patient experiences
a signi cant increase in his energy level. wo years later he
comes or a routine visit. He has gradually reintroduced
some wheat products into his diet and tolerates this very well.
Question 7.8.5 What do you recommend?
A) Resu e gluten- ree diet.
B) Continue diet ry ch llenge nd repe t ex in tion in
6 onths.
C) Repe t s ll bowel biopsy.
D) Check tissue tr nsglut in se ntibody titer.
E) Avoid whe t, but try b rley or rye products.
Answer 7.8.5 The correct answer is “A.” While there is no good
d t on the bene t o long-ter gluten- ree diet in p tients

who c n toler te s ll ounts o gluten, sever l ctors rgue
or continuing gluten- ree diet. T e rst is th t ny p tients
will h ve subclinic l nutrient de ciencies i they reintroduce
gluten. For this re son, p tients with gluten-sensitive enterop -
thy should be screened or osteoporosis nd t ke ultivit -
in. T is is especi lly true in pedi tric p tients where de cien-
cies y le d to stunted growth. T e second is th t there is so e
d t th t p tients who reintroduce gluten y h ve incre sed
ort lity ro GI ly pho despite the ct th t they re tol-
er ting the gluten well (Ann Intern Med. 2013;159:169).
Question 7.8.6 All o the ollowing are gluten ree grains
EXCEPT:
A) O ts.
B) Corn.
C) Sticky rice.
D) Rice.
E) Millet.
Answer 7.8.6 The correct answer is “C.” Sticky rice is lso
known s “glutinous rice” nd cont ins gluten. T e rest re glu-
ten- ree. Other gluten- ree gr ins/st rches include buckwhe t,
x, quino , nd t pioc .
HELPFUL TIP:
With a glute - ree diet, a tib die (ti ue tra gluta-
mi a e, a tigliadi , a tie d my ial) te retur t
rmal level .
HELPFUL TIP:
Patie t with glute - e itive e ter pathy mu t be
c mpul ive ab ut their diet. Rice, c r , a d ybea -
ba ed l ur are a e t c ume. o at are te c -
tami ated with wheat.
Objectives: Did you learn to . . .
• Evaluate a patie t with diarrhea?
• Rec g ize cli ical ma i e tati glute - e itive e ter-
pathy?
• Ma age a patie t with glute - e itive e ter pathy?
CASE 7.9
A 22-year-old previously healthy male reports a 3-day his-
tory o explosive and watery diarrhea. He is having up to 6
bowel movements per day. He recalls eating at a new Mexi-
can restaurant 5 days ago. His head sinks a little low as he
recalls drinking a “ sh bowl”-sized margarita . . . or at least
he thinks he remembers drinking it! He denies ever, blood in
his stool, or recent travel. Multiple people ate the same ood
but he is the only one who is sick. His vital signs are normal
(including supine and standing blood pressures), and the
remainder o the physical examination is remarkable only or
mild, dif use abdominal tenderness.
CHAPTER 7 • GAs TRo En TERo Lo GY 215
TABLE 7-4 DIFFERENTIAL DIAGNOSIS FOR DIARRHEA
Acute Diarrhea
• Bacteria (e.g., Campylobacter, Salmonella, a d Clostridium)
• Viru e (e.g., n rwalk a d r taviru )
• Para ite (e.g., Giardia)
• Pr t z a (e pecially i HIV-i ected patie t )
• Medicati
• A ythi g that cau e chr ic diarrhea
Chronic Diarrhea
• I f ammat ry (e.g., IBD a d radiati e teriti )
• o m tic (e.g., glute - e itive e ter pathy a d lacta e de cie cy)
• s ecret ry (e.g., Z lli ger–Elli y dr me a d vill u ade ma)
• Di rdered m tility (e.g., irritable b wel y dr me a d verf w
r m ecal impacti )
Question 7.9.1 What is the most likely diagnosis?
A) Celi c sprue.
B) Vir l g stroenteritis.
C) L ctose intoler nce.
D) S ll bowel b cteri l overgrowth.
E) C. di cile colitis.
Answer 7.9.1 The correct answer is “B.” T is is lw ys
dile . It c n be dif cult to di erenti te cute g stroenteritis
ro ood poisoning. Wh t kes g stroenteritis ore likely
is th t there is no clustering o c ses ong people who te the
s e ood. With only 3 d ys o sy pto s, it would be pre -
ture to di gnose “A,” “C,” or “D.” Without recent ntibiotic expo-
sure, “E” would be unlikely in n otherwise he lthy le. See
ble 7-4 or di erenti l di gnosis or di rrhe .
Question 7.9.2 What is the MOST appropriate next step in
the care o this patient at this point?
A) Order CBC.
B) Order electrolytes.
C) Order stool ex in tion or ov nd p r sites.
D) Reco end or l hydr tion nd ntidi rrhe ls s needed.
E) Order n bdo in l l .
Answer 7.9.2 The correct answer is “D.” No workup is needed
or ild c se o cute di rrhe , since such c ses re usu lly sel -
li ited. Gener lly, the history nd physic l ex in tion should
provide the di gnosis nd indic te need or urther workup. Fur-
ther workup nd tre t ent re indic ted i the p tient h s severe
or bloody di rrhe , dehydr tion, syste ic toxicity, or severe p in.
HELPFUL TIP:
Patie t with evere, bl dy diarrhea, a d ever
(T > 101°F, > 6 t l per day) h uld be treated with a
3- t 5-day c ur e a lu r qui l e while awaiti g
t l culture re ult . Bloody diarrhea in an a ebrile pa-
tient should suggest Escherichia coli 0157:H7. The e pa-
tie t h uld not get a tibi tic becau e a i crea ed
ri k hem lytic–uremic y dr me. A alway , there i a
“except.” Patie t wh have bee traveli g t area with
re i ta t rga i m h uld be treated with azithr myci
500 mg daily r 3 day . Thi i clude m t A ia.
216 FAMILY MEDICIn E EXAMIn ATIo n & Bo ARD REVIEW
You treat the patient with oral rehydration and prochlor-
perazine or some nausea and he does well. He returns to see
you a ew weeks later a er a trip to Mexico. He liked that sh
bowl-sized margarita so much that he decided to go or an
original. He has diarrhea that began a couple o days a er his
arrival in Cancun and has now been present or 5 days. He
has had requent, watery diarrhea with nausea but no vomit-
ing. He has noticed no blood in the stool. He was very care ul
to avoid salads and water but did have some ice in a so drink
and his margarita was “on the rocks.”
Question 7.9.3 The most likely organism causing illness in
this patient is:
A) Salmonella.
B) Shigella.
C) Enterotoxigenic E. coli.
D) Enterohe orrh gic E. coli.
E) Campylobacter.
Answer 7.9.3 The correct answer is “C.” Enterotoxigenic
E. coli is the ost co on c use o tr veler di rrhe in p tients
tr veling to Mexico. Enterohemorrhagic E. coli is less likely nd
should be ssoci ted with bloody di rrhe . T e others re uch
less likely to be c uses o tr veler di rrhe .
HELPFUL TIP:
Ma y phy icia w uld t treat a patie t with s higella
u le that patie t i cli ically ill (e.g., ever). Treatme t
with a tibi tic i relatively c trai dicated i s alm -
ella becau e it pr l g the carrier tate. H wever, u e
judgme t i the patie t wh i particularly ill.
Question 7.9.4 Which o the ollowing is/are appropriate or
the treatment o this patient’s traveler diarrhea (remember,
he has no vomiting)?
A) Or l rehydr tion.
B) Antidi rrhe ls.
C) E t ny ood (e.g., no need or bl nd diet with slow dv nce-
ent).
D) All o the bove.
E) None o the bove.
Answer 7.9.4 The correct answer is “D.” T is p tient h s non-
bloody di rrhe nd no syste ic signs, so it should be s e to
tre t hi with ntidi rrhe l gents (e.g., loper ide) nd void
ntibiotics. Or l rehydr tion is the rule unless p tient is too
n use ted or h s so e other re son th t he c nnot t ke dequ te
uids by outh. Patients (including children) should eat anything
they can tolerate. T e concept o “gut rest” is isno er nd
ctu lly le ds to incre sed bowel per e bility nd ore persis-
tent di rrhe . Lactose deserves special mention. T e A eri-
c n Ac de y o Pedi trics h s ch nged their reco end tions
bout l ctose in di rrhe . T ey reco end withholding l ctose
only in children less th n 3 onths o ge. T is see s to be the
group in which tr nsient l ct se de ciency occurs.
HELPFUL TIP:
Kleb iella xyt ca ca pr duce a a tibi tic-related di-
arrhea that i i di ti gui hable r m C. di icile . I th e
with a egative t l r Cl tridium a tige , c ider
(1) al e- egative te t ( me the ewer trai
Cl tridium are t detected by traditi al t l a ti-
ge ) r (2) K. xyt ca r (3) the C. difficile toxin degen-
erates rapidly at room temperature (no toxin may
be detectable a ter 2 hours o exposure to room
temperatures) r (4) ELIs A te t ge erally ly te t r
Type A a tige . The patie t may have a a tige Type B
pr duci g trai or there may be a mutati a tige
Type A.
Objectives: Did you learn to . . .
• Evaluate a patie t with acute diarrhea?
• Treat acute diarrhea?
• Rec g ize di ere t bacterial cau e diarrhea?
CASE 7.10
A 49-year-old man comes to your o ice, requesting test-
ing or hepatitis C. He recently attended his 25-year col-
lege reunion where an old riend he had “partied” with
during experimentation with injectable drugs related that
he has cirrhosis due to hepatitis C. he patient is otherwise
healthy and denies any symptoms except or occasional
atigue a ter a long day at work. Physical examination
o the patient is unremarkable. here are no stigmata o
chronic liver disease.
Question 7.10.1 Which o the ollowing is the most appro
priate course o action?
A) Check qu ntit tive Hep titis C virus (HCV) PCR (“vir l
lo d”).
B) Order reco bin nt i unoblot ss y (RIBA).
C) Order HCV ntibody test (enzy e i uno ss y).
D) Order qu lit tive HCV PCR.
E) Order AL nd AS .
Answer 7.10.1 The correct answer is “C.” T e sensitivity nd
speci city o the present-d y HCV ntibody test re excellent;
thus, this is the best test to per or in this situ tion. R rely,
p tients with i unologic i p ir ent, such s HIV in ection,
h ve HCV vire i without detect ble ntibody, but this would
not be concern in this otherwise he lthy p tient. Qu ntit tive
HCV PCR is not reli ble e ns or di gnosing HCV in ection
bec use currently used ethods re insensitive t low levels o
vire i ; thus, in ection c nnot be ruled out i the level o HCV
vire i is below the lower li it o detection o the test. RIBA
is n old test th t is no longer used. Qualitative HCV PCR is
the ost sensitive test or the presence o HCV RNA, with
li it o detection th t is lower th n th t o qu ntit tive PCR.
It is use ul to est blish the presence o vire i , but is ore
expensive th n ntibody testing nd thus not rst-line test.
M ny p tients with chronic HCV in ection h ve nor l liver
 CHAPTER 7 • GAs TRo En TERo Lo GY 217

enzy es nd c n still h ve progressive dise se; there ore, in

A er a ew phone calls, you nd that elastography is not avail-
high-risk p tient, AL nd AS re not ppropri te or screen-
able anywhere nearby. T e patient agrees to a liver biopsy to
ing or HCV.
diagnosis cirrhosis and you make the re erral. He is still very
concerned about his situation and asks what you think the
T e patient returns several weeks later to discuss his test
chances are that he already has cirrhosis.
results. His HCV antibody test is positive. A liver panel
obtained that day shows an AL o 48 IU/L (normal range,
Question 7.10.3 Regarding the development o progres
0–20) and an AS o 39 IU/L (0–31). His albumin and total
sive liver disease in hepatitis C, all o the ollowing are true
bilirubin are within normal limits. He is extremely anxious
EXCEPT:
about his liver.
A) Approxi tely 20% o p tients with chronic HCV in ection
will develop serious liver dise se.
Question 7.10.2 To most accurately assess the degree o
B) He vy lcohol use is risk ctor or develop ent o serious
liver disease, your next step is to:
liver dise se.
A) Obt in liver–spleen sc n to ssess or evidence o cirrhosis.
C) Acquisition o HCV in ection er the ge o 40 is ssoci ted
B) Re ssure the p tient th t his ild liver test bnor lities
with incre sed risk o developing serious liver dise se.
rule out cirrhosis.
D) HCV genotype ects the prob bility o developing end-
C) Order right upper qu dr nt ultr sound with Doppler to
st ge liver dise se.
ssess or evidence o cirrhosis.
E) M les re ore likely th n e les to develop serious liver
D) Order el stogr phy or evidence o cirrhosis.
dise se.
E) Obt in n bdo in l C to ssess or evidence o cirrhosis.
Answer 7.10.3 The correct answer is “D.” While only inor-
Answer 7.10.2 The correct answer is “D.” H ving est blished
ity o persons in ected with HCV develop serious liver dise se
th t the p tient h s hep titis C with elev ted liver enzy es,
(20%), the likelihood o progression is dif cult to predict in n
the next step is to deter ine the severity o his liver dise se.
individu l p tient. Nonetheless, le gender, he vy lcohol
Although his liver unction tests re re ssuring, this does
use, nd cquisition o HCV in ection er the ge o 40 re
not exclude the possibility o dv nced brosis or even well-
ssoci ted with incre sed risk o progressive liver dise se, while
co pens ted cirrhosis. While biopsy h s been the de nitive
genotype is not. In ddition, J p nese ncestry, s oking (both
test or liver brosis in the p st ( nd you would not be wrong
cig rettes nd riju n ), nd cquiring hep titis C ro
to order biopsy i it were n option in this question), ultr -
blood tr ns usion, h ve been ssoci ted with n incre sed risk
sound el stogr phy, noninv sive technique o deter ining
o progression. T e genotype o the hep titis C cert inly kes
liver brosis, is being used ore nd ore. T e ide is th t
di erence when it co es to tre t ent but not with progres-
brotic liver is sti liver. Don’t worry bout the det ils; just
sion to cirrhosis.
know th t el stogr phy ( or ex ple FibroSc n) is noninv -
sive nd ccur te ethod or deter ining the degree o hep tic
brosis. T e “F” score, discussed below, should llow you do HELPFUL TIP:
ke decisions bout your hep titis C p tients. You would not Patie t wh have a per i te tly rmal ALT, acquired
be incorrect to order ultr sound i ging s well. hepatiti C be re the age 35, are emale, d t dri k
alc h l, a d have mi imal r ibr i liver bi p y
HELPFUL TIP: are u likely t pr gre t e d- tage liver di ea e.
Fibr i i c red r m F0 t F4, with F0 repre e ti g
ibr i a d F4 repre e ti g cirrh i . I additi t
HELPFUL TIP:
ela t graphy, a ther i va ive meth d deter-
The Us Ps TF rec mme d hepatiti C cree i g ce
mi i g the degree ibr i i the AsT/platelet rati
r all i dividual b r betwee 1945 a d 1965. o ther
i dex, abbreviated APRI. Thi i calculated a ll w :
p pulati de ervi g cree i g i clude th e with
APRI = [(patie t AsT - upper rmal lab As T)/ HIV, dialy i patie t , a d i carcerated patie t .
platelet c u t] × 100.

s ig i ica t ibr i (F2–F4) i pre e t i the APRI i 0.7 r

greater (77% e itivity, peci icity 72%) alth ugh me
urce u e 0.5 a the l wer limit r “ ig i ica t ibr i .”
A APRI 1 r greater repre e t cirrh i . Fi ally, the
Fibr s ure, Fibr te t, a d ActiTe t are pr prietary meth-
d determi i g liver ibr i —all which have ep-
arate c ri g y tem r ibr i . n te that a bi p y i
t ece ary r maki g a deci i ab ut wh t treat:
m re thi bel w.
T e patient is concerned that he may transmit the virus to his
wi e or children. T ey are tested and are ound to be negative
or HCV antibody. He is relieved but asks or advice to pre-
vent in ecting them.
Question 7.10.4 You advise all o the ollowing EXCEPT:
A) No ch nge in sexu l pr ctices is reco ended or couples
in long-ter onog ous rel tionship in which one p rt-
ner is HCV+ nd the other HCV− .
218 FAMILY MEDICIn E EXAMIn ATIo n & Bo ARD REVIEW
B) T e use o condo s is reco ended or couples in long-
ter onog ous rel tionship in which one p rtner is
HCV+ nd the other HCV− .
C) Hep titis C is not spre d by hugging, sneezing, or sh ring
drinking gl ss.
D) Household e bers o persons in ected with HCV should
not sh re ite s th t ight be cont in ted with s ll
ounts o blood such s r zors or n il clippers.
E) P renter l exposure to in ected blood is jor route o
tr ns ission o HCV.
Answer 7.10.4 The correct answer is “B.” HCV is spre d by
p renter l cont ct with in ected blood. In contr st to hep titis
B, sexu l tr ns ission o HCV is inef cient nd ppe rs to be
inor route o spre d. In ddition, the ef c cy o l tex con-
do s in preventing dise se is not known. T e NIH and the US
Public Health Service do not recommend condom use or
patients in a stable, long-term, and monogamous relation-
ship. T at said, using condoms will likely reduce an already
low risk even urther.
T e patient’s liver biopsy shows mild-to-moderate in am-
matory activity and portal and periportal brosis (stage 2).
He is relieved to nd out that he does not have cirrhosis, but
remains very concerned about his hepatitis and wants to do
everything possible to “get rid o ” the hepatitis C. He asks
about the treatment o his HCV.
Question 7.10.5 Which o the ollowing is NOT an indication
or the treatment o hepatitis C?
A) El stogr phy showing cirrhosis.
B) APRI o 0.25 (pre-cirrhosis).
C) Liver biopsy showing bridging brosis.
D) Ability to p y or the tre t ent.
Answer 7.10.5 The correct answer (and not an indication
or hepatitis C treatment) is “B.” T e cuto APRI or the tre t-
ent is 0.5 to 0.7, representing F2 brosis. F2 brosis di gnosed
by ny ethod, including biopsy or el stogr phy (e.g., Fibro-
Sure), is n indic tion or the tre t ent. You y be wonder-
ing bout “D.” St rting in 2014, w ve o new nd ore tol-
er ble hep titis C tre t ents st rted to beco e co erci lly
v il ble. However, the cost o these new drugs— t le st, in
the United St tes—is i or lly high, costing up to $100,000
or co plete 12-week tre t ent. Public nd priv te insurers
h ve been orced into outright r tioning. ( o beco e ppropri-
tely outr ged, re d this rticle: http://www.l ti es.co /busi-
ness/hiltzik/l - -hiltzik-20150621-colu n.ht l.) I the United
St tes tre ted ll o the pproxi tely 3 illion HCV in ected
persons with the new drugs, it would cost our country bout
$300 billion. Bec use o the ph r ceutic l co p nies setting
prices di erently in di erent rkets, t le st one o these new
HCV drugs costs bout 1% o the U.S. price in Egypt. So . . . One
option is to send your HCV p tients to Egypt or the tre t-
ent nd put the up in nice hotel—it would be signi c ntly
che per.
Question 7.10.6 You tell him which o the ollowing?
A) Co bin tion ther py with inter eron nd rib virin results in
sust ined virologic responses (SVR) in 40% to 70% o p tients
tre ted.
B) Co bin tion ther py with inter eron nd rib virin c n
c use nu erous side e ects including cytopeni s, u-like
sy pto s, worsening o utoi une conditions, depres-
sion, nd he olytic ne i .
C) T e HCV genotype is strong predictor o response to the
tre t ent.
D) Newer tre t ent regi ens including ledip svir/so osbuvir
re uch ore e ective th n the tr dition co bin tion o
inter eron/rib virin.
E) All o the bove.
Answer 7.10.6 The correct answer is “E.” Co bin tion ther-
py with inter eron nd rib virin is the tr dition l tre t ent
o HCV nd it is cle rly not s e ective t chieving SVR s
the newer drugs. T e HCV genotype is jor ctor deter-
ining the likelihood o chieving SVR, lthough not the
likelihood o progression to end-st ge liver dise se. Genotype
1 is responsive to the newer drugs, such s the co bin tion
o ledip svir/so osbuvir (Harvoni); n entirely or l regi en
with response r tes o 93% or better or genotype 1. A second
entirely or l tre t ent is o bit svir/p rit previr/riton vir/
d s buvir (Viekira Pak [U.S.]). However, it ust be co bined
with rib virin or genotypes 1 nd 1b i cirrhosis is present.
St ge o brosis is lso ctor, nd p tients with st ges 3 nd
4 (bridging brosis nd cirrhosis) re less likely to chieve
SVR. Higher b seline vir l levels lso tend to predict poorer
response to the tre t ent. Co bin tion ther py is expensive
nd is ssoci ted with signi c nt toxicities. T e jor con-
cerns with rib virin re he olytic ne i nd ter togenicity,
while the inter erons (st nd rd or the long- cting pegyl ted
or s) h ve long list o potenti l side e ects, o which neu-
ropsychi tric proble s, such s depression nd irrit bility, re
o en the ost troubleso e. Al ost no tre t ent regi en still
requires inter eron.
OK, now the g e ch ngers. Here is t ble ( ble 7-5) or
you to review the new hep titis C drugs nd the genotype tre ted.
T is is pretty b sic. For ore co plete su ry, see http://
www.hep titis.v .gov/pd /tre t ent-consider tions-2015–07.
pd . Side e ects o the newer drugs re he d che, GI upset, etc.,
nd gener lly uch less proble tic th n previous gener tions
o hep titis C tre t ent. Wh t h ppened to the prote se inhibi-
tors (tel previr nd boceprevir), you sk? T ey h ve gone the
w y o the dodo bird nd re no ore . . . too ny side e ects
when used or hep titis C.
Objectives: Did you learn to . . .
• Evaluate a patie t at ri k r hepatiti C?
• U der ta d the atural hi t ry the di ea e pr ce i
hepatiti C?
• De cribe the tra mi i hepatiti C?
• Di cu the treatme t i ue r a patie t with hepatiti C?
 CHAPTER 7 • GAs TRo En TERo Lo GY 219

TABLE 7-5 REGIMENS FOR HEPATITIS Ca

Genotype and Primary Response
Primary Regimens Regimens Rate (%) Note 1 Notes
a
All Ge type 1 Harv i (Ledipa vir/ buvir) 95 With ut Duration o treatment di er ba ed cirrh i v .
r Viekira Pak ( mbita vir/ cirrh i cirrh i , ailure pri r treatme t, etc.
paritaprevir/rit avir/ da abuvir) Note the oral only regimens: Harv i r all
ge type 1 a d ge type 4
Ge type 1a a d 1b Harv i r Viekira Pak plus 95 With Viekira pack r ge type 1 with ut cirrh i .
ribaviri cirrh i

Ge type 2 s bu r (s valdi) plus ribaviri 97

Ge type 3 Harv i plus ribaviri 98

Ge type 4 Viekira Pak plus ribaviri 95

Harv i
s valdi plus ribaviri

a
n te that we are u i g trade ame i thi i ta ce a ter r t me ti . Thi g ju t get c u i g therwi e . . . . . .
n te that Viekira Pak a d Tech ivie w have a war i g ab ut u e i th e with evere u derlyi g liver di ea e: they ca cau e liver i jury.
Ki d a catch 22 . . . . .

CASE 7.11
A 24-year-old emale graduate student rom China comes to
your o ce complaining o atigue or the past month. She
has also had a poor appetite and has lost about 3 lb over this
period. She reports that she was told that she had “hepati-
tis” when she was about 10 years old but does not recall what
type. She is otherwise healthy and takes no medications. She
has no history or percutaneous exposures or blood trans u-
sion. Her grand ather died o liver cancer.
Physical examination reveals a thin, tired-appearing
woman. T e liver edge is palpable 2 cm below the right costal
margin and is slightly tender. T ere is no ascites, splenomeg-
aly, or cutaneous stigmata o chronic liver disease.
Laboratory studies are remarkable or anemia (hemoglo-
bin 9.1 g/dL). Liver tests reveal elevated aminotrans erases
(AL 289 IU/L, AS 158 IU/L), albumin 3.2 g/dL, and total
bilirubin 1.5 mg/dL (normal 0.2–1.0 mg/dL).
Question 7.11.1 Diagnostic possibilities at this point
include:
A) Hep titis A.
B) Hep titis B.
C) Hep titis C.
D) Autoi une hep titis.
E) All o the bove.
Answer 7.11.1 The correct answer is “E.” Constitution l sy p-
to s such s tigue nd norexi c n be seen with ny or
o cute or chronic liver dise se; thus, they re not help ul in
est blishing speci c di gnosis. T e rst priority is to rule out
in ectious hep titis including hep titis A, B, nd cute hep ti-
tis C. Autoi une hep titis deserves consider tion, p rticu-
l rly in e le p tients. While HCV in ection is worldwide
proble , HBV in ection is ende ic in Asi nd A ric , nd the
possibility o chronic hep titis B lso w rr nts speci l ttention
in this p tient.
Question 7.11.2 Appropriate laboratory studies at this
point include which o the ollowing?
A) Qu ntit tive HCV PCR.
B) Hep titis B sur ce ntigen (HBsAg).
C) Anti-hep titis A ntibodies (IgG nd IgM).
D) B nd C.
E) All o the bove.
Answer 7.11.2 The correct answer is “D.” As discussed previ-
ously, the qu ntit tive HCV PCR is not use ul test or di g-
nosing HCV in ection. HCV ntibody testing would be better
choice. Both HBsAg nd nti-HAV re use ul tests in this p tient.
HBsAg is help ul to ssess or HBV in ection ( cute nd chronic)
nd nti-HAV ntibodies will rule out cute hep titis A in ec-
tion. A positive tot l nti-HAV (positive IgG) with neg tive IgM
would indic te p st in ection, while positive IgM would suggest
cute HAV in ection. Interpreting the HBV ntigens (Ag) nd
ntibodies (Ab) c n be con using, nd ble 7-6 y help.
T e patient’s results show a positive HbsAg, indicating ongo-
ing hepatitis B in ection. She is immune to hepatitis A and is
hepatitis C negative.
A er being out o contact or 4 months, she returns or a
ollow-up visit. She tells you that she took an herbal medicine
her mother sent rom China and has been eeling much better
recently. Her HBsAg remains positive, but her liver enzymes,
albumin, and total bilirubin are now completely normal.
Question 7.11.3 Appropriate actions at this time include:
A) re t ent with inter eron- lph 5 illion units d ily or
16 weeks.
B) Order hep titis Be ntigen, nti-HBe, nd HBV DNA level.
220 FAMILY MEDICIn E EXAMIn ATIo n & Bo ARD REVIEW

TABLE 7-6 HEPATITIS B VIRAL SEROLOGIES FOR DIFFERENT PHASES

OF INFECTION
Antigen/Antibody Acute Chronic Recovered Vaccinated/Immune
HB Ag + + − −

HBeAg + + − −

A ti-HB Ab − − + +

A ti-HBcAb + (IgM) + (IgG) + (IgG) −

A ti-HBeAb − + /− + −

HBV Dn A + + /− + /− −

Ab, a tib dy; Ag, a tige ; HBc, c re a tige r a tib dy; HBe, “e” a tige r a tib dy; HB , ur ace a tige
r a tib dy.

C) Begin periodic screening or hep tocellul r c rcino
(HCC) with ultr sound nd lph - etoprotein (AFP).
D) A nd C.
E) B nd C.
Answer 7.11.3 The correct answer is “E.” T e HBe ntigen
re ects vir l replic tion. Loss o HBeAg indic tes decre sed
vir l replic tion nd less o risk o progression to cirrhosis.
Loss o HBeAg y occur spont neously; it is lso the ther -
peutic endpoint o the ntivir l tre t ents o HBV in ection
(inter eron, l ivudine, de ovir). I she is neg tive or HBeAg
nd is nti-HBe ntibody positive ( nti-HBe + ) or h s low or
undetect ble levels o HBV DNA, she h s low level o vir l
replic tion nd will not bene t urther ro the ntivir l tre t-
ent.
Her liver p nel should be onitored periodic lly s should
the AFP nd ultr sound. Ultr sound is reco ended every
6 onths + /– AFP. An AFP lone should not be done bec use
o the poor sensitivity nd speci city. Even sy pto tic HBV
c rriers with ini l liver dise se re t risk or HCC. Screen-
ing or HCC in those who re c rriers o hep titis B is indic ted
in: Asi ns ( en > 40 ye rs old, wo en > 50 ye rs old); those
with ily history o HCC; cirrhotic p tients; nd those o
A ric n ncestry > 20 ye rs o ge. Our p tient h d positive
ily history o HCC, so onitoring or HCC is indic ted.
T e patient returns to discuss the results o her tests. Labora-
tory results show that she is positive or HBsAg and is anti-HBe
positive. Her HBV DNA is undetectable using an unampli ed
assay, making her a carrier without evidence o viral replica-
tion (no chronic, active, hepatitis B). AFP is within limits and
abdominal ultrasound is unremarkable. She continues to eel
well. She also tells you that she will be getting married in 2
months. She asks you what can be done to prevent her ancé
and uture children rom becoming in ected with HBV.
Question 7.11.4 All o the ollowing are accurate responses
to her question EXCEPT:
A) No speci l prec utions need to be t ken bec use she h s
undetect ble HBV nd is there ore not in ectious.
B) I her ncé h s not been i unized g inst HBV, he should
be tested nd v ccin ted i not i une.
C) I her ncé is not i une to HBV, they should use b rrier
contr ceptives (e.g., condo s) until he h s co pleted his
HBV v ccin tion series.
D) She should cover ny open cuts or scr tches with b nd ge
nd cle n up ny blood spills with ble ch.
E) Ad inistr tion o hep titis B i une globulin (HBIG) nd
HBV v ccin tion begun i edi tely er birth is 95% e -
ective in preventing perin t l tr ns ission o HBV.
Answer 7.11.4 The correct answer is “A.” Although p tients
with higher levels o HBV DNA re ore in ectious th n those
with lower levels o vir l DNA, the risk o tr ns ission in the
l tter c se is not zero. In the c se o this p tient, h ving “unde-
tect ble” HBV DNA si ply indic tes level o HBV DNA th t
lls below the li it o detection o n un pli ed ss y (on
the order o 105 copies/ L). Also, the positive HbsAg e ns
she is still c rrier. T us, prec utions should be t ken to pre-
vent sexu l or household tr ns ission to her ncé (use o con-
do s, i uniz tion i required, etc.) nd to her uture children
(HBIG nd HBV v ccin tion).
VERY HELPFUL (IF LONG) TIP:
ALT and AST can be elevated secondary to:
• Viral agents: Hepatiti (A, B, C, D, E), CMV, Ep tei –
Barr viru , a d ther viru e .
• Drugs and chemicals: Acetami phe verd e, the
“glitaz e ,” HMG-C A reducta e i hibit r , In H, gri -
e ulvi , a tic vul a t , n s AID , chemical (carb
tetrachl ride, etc.), alc h l, a d ma y ther age t .
• Primary liver diseases: Primary cler i g ch la -
giti , primary biliary cirrh i (p itive a timit ch -
drial a tib dy [AMA]).
• Metabolic diseases: Wil di ea e (decrea ed
cerul pla mi ), hem chr mat i , alpha 1 a titryp i
de cie cy, a d cy tic br i .
• Mechanical di culties: Ductal b tructi ec d-
ary t c mm duct t e r carci ma (e pecially

pa creatic, hepat ma, meta tatic), Budd–Chiari y -
dr me (thr mb i the hepatic vei ).
• Cholestasis r m ce tral ve u utriti (CVn ),
preg a cy, r ce triax e therapy.
• Inf ltrative processes: Fatty liver (e pecially th e
with diabete , hyp thyr idi m, be ity; determi e
by U/s ), amyl id, gra ul mat u hepatiti , liver
ab ce (i cludi g amebic r echi c ccal; diag -
i by U/s r CT; may have e i philia), AIDs -related
lymph ma, r ther e pla m.
• Other: C ge tive heart ailure, celiac prue, mu cle
di ea e (e.g., p lymy iti ).
Alkaline phosphatase may be elevated secondary
to:
• Preg a cy, a ter a atty meal i per with type o
r B bl d.
• Liver: Ch le ta i , partial b tructi the biliary
duct , primary cler i g ch la giti , adult bile duc-
t pe ia, primary biliary cirrh i , arc id i , a d
ther gra ul mat u di ea e.
• Bone diseases uch a Paget di ea e a d meta tatic
di ea e.
For elevated liver tests, workup should include (in
approximate order, which may vary depending on
patient presentation):
• Rule ut t xi exp ure (alc h l, drug ).
• Hepatiti A, B, a d C er l gy.
• s erum erriti , ir , TIBC, tra erri aturati
(hem chr mat i ).
• Ultra u d r CT imagi g (ultra u d r t).
• An A a d a ti m th mu cle a tib dy (aut immu e
hepatiti but ly 28–40% e itive).
• s erum alpha 1 a titryp i .
• s erum pr tei electr ph re i (elevated level i
aut immu e hepatiti , 80% e itive).
• A tie d my ial a tib die r ti ue tra glutami -
a e (glute - e itive prue).
• s erum cerul pla mi (Wil di ea e).
Objectives: Did you learn to . . .
• Ge erate a di ere tial diag i r patie t with ab rmal
liver e zyme ?
• Ide ti y patie t at ri k r hepatiti B?
• U e the vari u hepatiti B a tige a d a tib die t deter-
mi e a patie t’ i ecti tatu ?
• De cribe the r ute tra mi i hepatiti B?
• W rk-up elevated liver te t i a tepwi e a hi ?
CASE 7.12
A 73-year-old man comes to your o ce, complaining o
abdominal and ankle swelling, decreased energy, and poor
appetite or the past 2 months. He dates the onset o his
symptoms to a “reaction” to penicillin given or dental work.
He says that be ore taking the penicillin, he was in excellent
CHAPTER 7 • GAs TRo En TERo Lo GY 221
health and walked 3 miles per day. Now he is too weak and
tired to even care or his own yard.
His past medical history is remarkable or coronary artery
bypass surgery done 6 years ago. He also recalls having “yel-
low jaundice” (as opposed to the purple kind?) when he was
stationed in Vietnam. He has no signi cant amily history.
He “drank a bit” on the weekends when he was in the service
but has drunk very little alcohol in the past 50 years. He also
quit smoking about 50 years ago. His medications are aspirin
81 mg daily and ibupro en 600 mg as needed or knee pain
due to degenerative joint disease.
Question 7.12.1 Diagnostic considerations suggested by
the history should include which o the ollowing?
A) Adverse drug re ction to penicillin.
B) M lign ncy.
C) Cirrhosis.
D) He rt ilure.
E) All o the bove.
Answer 7.12.1 The correct answer is “E.” T e p tient’s history
o bdo in l nd lower extre ity swelling suggests uid over-
lo d. Penicillin is known to c use interstiti l nephritis nd sec-
ond ry nephrotic syndro e, which c n le d to uid retention.
Sources o uid overlo d besides the kidneys should be con-
sidered in this p tient, including liver nd he rt dise se. M lig-
n ncy, especi lly with liver involve ent, c n c use scites. He is
on n NSAID, which c n c use uid retention, lthough r rely
to this degree.
Physical examination reveals a ragile-appearing elderly man
with temporal wasting. T ere is no JVD. T e lungs are clear
to auscultation. T e heart sounds are regular, with no mur-
murs or gallops. T e abdomen is protuberant with bulging
anks. Shi ing dullness is present. T ere is 2+ ankle edema
bilaterally and scattered telangiectasias on skin examination.
He has no asterixis.
Question 7.12.2 Which o the ollowing f ndings would you
expect on laboratory examination?
A) Elev ted he oglobin nd HC (17.5 g /dL nd 55%).
3.
B) Decre sed pl telet count o 80,000/
C) Elev ted seru lbu in.
D) BUN/Cr r tio < 20.
E) All o the bove.
Answer 7.12.2 The correct answer is “B.” T is p tient likely
h s port l hypertension given his scites nd stig t o liver
dise se (spider ngio t /tel ngiect si s). Blood is shi ed
tow rd the spleen bec use o the incre sed port l pressure (the
blood, like the rest o us, t kes the p th o le st resist nce).
Shunting o blood through the spleen results in thro bocy-
topeni through incre sed pl telet destruction. “A” is wrong
since liver p tients o en h ve ne i . “C” is incorrect bec use
liver p tients requently h ve low lbu in. And, “D,” BUN/
Cr r tio < 20 is ssoci ted with intrinsic kidney dise se (see
Ch pter 5).
222 FAMILY MEDICIn E EXAMIn ATIo n & Bo ARD REVIEW
Diagnostic paracentesis is per ormed and approximately
50 mL o clear light yellow uid are obtained.
Question 7.12.3 Appropriate laboratory studies on the
ascitic uid include which o the ollowing?
A) pH.
B) Albu in.
C) L ct te.
D) riglycerides.
E) All o the bove.
Answer 7.12.3 The correct answer is “B.” T e scitic uid lbu-
in is needed to c lcul te the seru - scites lbu in gr dient
(SAAG), which is help ul to distinguish between scites result-
ing ro port l hypertension ro scites due to other c uses.
L ct te nd pH h ve been proposed s rkers or spont ne-
ous b cteri l peritonitis (SBP) but h ve proven to be unreli ble.
Me sure ent o triglycerides is use ul to con r chylous sci-
tes; however, in the bsence o grossly ilky- ppe ring uid,
there is no need to per or this test.
HELPFUL TIP:
I additi t albumi , all a citic luid h uld be e t
r cell c u t a d culture . A cell c u t h wi g ≥ 250
p lym rph uclear leuk cyte /mm 3 i pre umptive
evide ce s BP a d ma date treatme t r uch.
Gram tai i early u ele i ce a citic luid bacterial
c u t are typically l w that bacteria are rarely ee
Gram tai .
Your patient’s laboratory tests reveal an ascitic uid total
protein o 2.5 g/dL with an albumin o 1.9 g/dL. A liver panel
reveals normal aminotrans erases, normal bilirubin, serum
albumin 3.3 g/dL, and alkaline phosphatase 147 IU/L. Elec-
trolytes, BUN, and creatinine are within normal limits.
Question 7.12.4 Which o the ollowing is the most accurate
interpretation o these results?
A) T e SAAG is 1.7, which is consistent with port l hyperten-
sion s its c use.
B) T e SAAG is 1.7, which rules out port l hypertension s its
c use.
C) T e SAAG is 1.4, which is consistent with port l hyperten-
sion s its c use.
D) T e SAAG is 1.4, which rules out port l hypertension s its
c use.
E) T e seru - scites gr dient con uses e, so I don’t w nt to
do it.
Answer 7.12.4 The correct answer is “C.” T e SAAG c n tell us
whether the uid is tr nsud te or exud te. T e SAAG is si -
ply the di erence between the seru lbu in nd the scitic
uid lbu in, or 3.3 – 1.9 = 1.4, in this c se. A SAAG o ≥ 1.1
indicates portal hypertension with 97%accuracy. Re e ber
this by re e bering th t high SAAG e ns high pressure in
the port l syste .
HELPFUL TIP:
Ascites rom any cause o portal hypertension will
have a high SAAG. A ide r m cirrh i , p rtal hyper-
te i al may re ult r m chi t mia i , arc id-
i , p rtal vei thr mb i (Budd–Chiari y dr me),
c ge ital hepatic ibr i , heart ailure, myxedema, etc.
Causes o a low SAAG include er iti r m c ective
ti ue di rder , ephr tic y dr me, pa creatic-related
a cite , a d perit eal carci mat i am g ther .
Question 7.12.5 In addition to a complete evaluation to
determine the cause o his portal hypertension, which o
the ollowing is/are appropriate action(s) at this time?
A) Re er the p tient to nutritionist or instruction on low-
sodiu diet.
B) Discontinue ibupro en nd prescribe COX-2-selective
inhibitor or rthritis.
C) Prescribe spironol ctone 100 g d ily nd urose ide
40 g d ily.
D) A nd C.
E) A, B, nd C.
Answer 7.12.5 The correct answer is “D.” T e initi l ppro ch
to the n ge ent o scites due to port l hypertension is
sodiu restriction nd diuretics. T e go l is 2-g sodiu diet
(which is very dif cult to ollow—just look t c n o soup!).
T e jority o p tients will not h ve n dequ te response to
sodiu restriction lone, so it is re son ble to begin diuretics t
the outset. Spironol ctone, which is n ldosterone nt gonist,
is use ul bec use port l hypertension is st te o hyper ldoste-
ronis . Spironol ctone tends to c use hyperk le i , n e ect
th t c n be itig ted by the co d inistr tion o urose ide.
Once-d ily doses re ppropri te or initi l ther py; djust-
ents re de b sed on the p tient’s electrolytes, ren l unc-
tion, nd response to the tre t ent. NSAIDs should be voided,
due to sodiu retention nd GI bleeding. COX-2-selective
inhibitors have no advantage over nonselective NSAIDs in
this regard. Other ppro ches to the p tient’s knee p in should
be considered, including intr - rticul r injections, cet ino-
phen (up to 2 g d ily is likely s e in cirrhosis), nd n rcotics,
provided enceph lop thy is not proble .
HELPFUL TIP (AND PET PEEVE):
D ’t u e n s AIDs i liver di ea e. The patie t may
already have a c agul pathy a d a l w platelet c u t.
They may have varice pr e t bleedi g. n s AIDs ca
al cau e GI bleedi g a d are not a a e alter ative t
acetami phe .
A ew months later, your patient comes to the emergency
department “ eeling sick.” He complains o dif use abdomi-
nal pain and swelling, stating that his abdomen eels “tense.”
On examination, you nd a pale, uncom ortable male with a
temperature o 38.3°C. His other vital signs are normal. His

abdomen is tense, distended, and dif usely tender with hypo-
active bowel sounds. You per orm a paracentesis that shows
400 polymorphonuclear leukocytes/mm3.
Question 7.12.6 What is the most appropriate next step in
the evaluation and treatment o this patient?
A) Disch rge to ho e with incre sed doses o spironol ctone
nd urose ide.
B) Disch rge to ho e with oxicillin nd the s e doses o
diuretics.
C) Per or l rge-volu e p r centesis or sy pto tic relie
nd disch rge to ho e.
D) Ad it to the hospit l nd st rt IV ce ri xone.
E) Ad it to the hospit l nd pl ce peritone l tube or dr in-
ge.
Answer 7.12.6 The correct answer is “D.” T is p tient eets
3
criteri or SBP (≥ 250 poly orphonucle r leukocytes/
in the scites uid) nd h s clinic l ndings to suggest in ec-
tion. T is p tient could beco e unst ble quickly, so disch rge
ro the e ergency dep rt ent is not reco ended. Incre s-
ing doses o diuretics nd/or l rge-volu e p r centesis y be
required, but these interventions should only be considered in
the setting o hospit l d ission. Bet -blockers, which y be
used or port l hypertension, should be stopped; ort lity is
incre sed in SBP with continued use. Bro d-spectru ntibiotics
re the st nd rd o c re or SBP, nd IV third-gener tion ceph -
losporins (e.g., ce ri xone, ce ot xi e) re typic lly the rst-line
gents in hospit lized p tients. Levo ox cin is good second line
gent but should not be used in those on levof oxacin prophylaxis
as resistance is likely. A oxicillin (“B”) is not suf cient.
In ddition, lbu in in the dose o 1.5 g/kg on d y 1 ol-
lowed by 1 g/kg on d y 3 reduces the ch nce o ren l ilure,
which occurs in 30% to 40% o p tients with SBP. Albu in lso
i proves ort lity nd should be given to ll p tients with SBP.
Also, send the scitic uid or culture. Blood cultures, CBC,
seru che istries nd P /P should be obt ined s well.
Consider i ging the bdo en with ultr sound or C . Further
tests should be ordered s indic ted.
HELPFUL TIP:
The m t c mm rga i m i s BP i clude s trept -
c ccu p eum iae , E. c li, a d Kleb iella .
HELPFUL TIP:
Flu r qui l e a d TMP/sMX have bee u ed pr -
phylactically t decrea e the reque cy sBP epi de .
Pr phylaxi i i dicated i a y e with cirrh i a d ei-
ther (1) a epi de s BP or (2) a a citic luid pr tei
< 1.0 or (3) a active GI bleed. F r active GI bleed-
i g i th e with a cite , ce triax e, r r l xaci r D) Fluid nd electrolyte n ge ent.
7 day ha bee h w t reduce s BP a d m rtality.
Consider s BP pr phylaxi i th e with a a cite pr -
tei < 1.5 g/dL i the Cr > 1.2 mg/dL r n a i < 130 mg/
dL, r the BUn > 25 mg/dL r the bilirubi i > 3 mg/dL.
CHAPTER 7 • GAs TRo En TERo Lo GY 223
Objectives: Did you learn to . . .
• Ge erate a di ere tial diag i r a cite ?
• A alyze a citic f uid t determi e p te tial cau e a cite ?
• I itiate appr priate treatme t r a patie t with a cite ?
• Diag e a d ma age s BP?
CASE 7.13
A 42-year-old male with known hepatitis C who is also a
heavy drinker presents to your o ce because o increasing
con usion. He hasn’t noticed much o anything (hey, most o
his li e has been like this . . . ), but his amily states that he is
somewhat con used and on occasion di cult to wake up. He
has a known history o end-stage liver disease. He is supposed
to be on a low-protein diet but decided that it was time to
start the Atkin low-carbohydrate diet to “lose that gut” (he
even ound himsel a “low carb” beer). So, he has increased
his intake o protein.
Question 7.13.1 Which o the ollowing is NOT a common
cause o hepatic encephalopathy?
A) GI bleeding.
B) Constip tion.
C) High-c rbohydr te diet.
D) Sepsis.
E) Alter tion in gut or .
Answer 7.13.1 The correct answer is “C.” High-c rbohydr te
diets re not ssoci ted with hep tic enceph lop thy; high-
protein diet is. Si il rly, GI bleed (“A”) delivers l rge protein
lo d to the GI tr ct. T us, any patient with hepatic encepha-
lopathy should be evaluated or a GI bleed. Other c uses o
cute hep tic enceph lop thy include constip tion, sed tive use
(e.g., benzodi zepines), nd hypok le ic et bolic lk losis.
HELPFUL TIP:
A elevated amm ia level i a ciated with hepatic
e cephal pathy, alth ugh there i t a direct li ear
c rrelati betwee erum amm ia level a d me tal
tatu .
You decide to admit the patient to the hospital or treatment
o his hepatic encephalopathy.
Question 7.13.2 Which o the ollowing IS NOT part o the
treatment o hepatic encephalopathy?
A) Or l l ctulose.
B) Polyethylene glycol (e.g., GoLytely nd Mir -L x).
C) Or l ntibiotics.
E) L ctulose ene s.
Answer 7.13.2 The correct answer is “B.” Polyethylene glycol
pl ys no role in the tre t ent o hep tic enceph lop thy. While
it would ke intuitive sense th t it would work since l ctulose
224 FAMILY MEDICIn E EXAMIn ATIo n & Bo ARD REVIEW
works, this is not the c se. T e ech nis o ction o l ctulose
is dependent on b cteri l et bolis o l ctulose into l ctic
nd cetic cids. T is reduces the pH o the colon le ding to
precipit tion o non bsorb ble oni in the colon, which
reduces seru oni levels. Enemas (soap suds, etc.), on
the other hand, may help acutely by re oving colonic con-
tents. “C” is o p rticul r note. Or l ntibiotics like ri xi in,
etronid zole, or neo ycin c n be used when p tients do not
respond to l ctulose or when l ctulose is contr indic ted (e.g.,
severe di rrhe ). Ri xi in h s beco e the st nd rd in tre ting
this condition.
T e patient does well on a regimen o lactulose and oral met-
ronidazole.
Question 7.13.3 What other problems do you need to worry
about in this patient?
A) Prolonged bleeding ti e.
B) Elev ted P /INR.
C) T ro bocytopeni .
D) A nd B.
E) All o the bove.
Answer 7.13.3 The correct answer is “E.” P tients with end-
st ge liver dise se tend to h ve l ck o vit in K-dependent
clotting ctors ( nd thus elev ted P /INR nd prolonged
bleeding ti es) nd h ve thro bocytopeni due to shunting o
blood ro the liver to the spl nchnic bed bec use o elev ted
port l pressures. However, pl telet count o 50,000 is gener-
lly considered dequ te or clotting. In ddition, it is likely th t
there is pl telet dys unction in cirrhosis, lthough the clinic l
signi c nce is not cle r.
HELPFUL TIP:
Parad xically, p rtal vei thr mb i i urpri i gly
c mm i th e with cirrh i (11% ver 5 year ). It
d e t eem t cau e pr gre i cirrh i (Hepa-
t l gy. 2015;61:660). A tic agulati r acute p rtal
vei thr mb i ( ever, chill , abd mi al pai , te der
liver) i i dicated. The be e it a tic agulati i l g-
ta di g p rtal vei thr mb i , uch a that u d i -
cide tally ultra u d, i t de i ed. H wever, i the
-cirrh tic patie t p rtal thr mb i h uld pr mpt
a evaluati r a hyperc agulable tate (e.g., ca cer).
L g-term treatme t with -war ari a tic agula t
ca be u dertake but i crea e bleedi g epi de a d
ha a u certai be e it. There i a high ri k rethr m-
b i whe a tic agulati i t pped (39% i 6 week
[Cli Ga tr e ter l Hepat l. 2012;10:776]).
It turns out that this patient has also been drinking again, but
he made it through his hospital stay without going through
withdrawal. Esophageal varices were noted on EGD. He is
ready or discharge.
Question 7.13.4 Which o the options is/are indicated or
this patient at the time o discharge, assuming he is hemo
dynamically stable?
A) N dolol.
B) Propr nolol.
C) Pentoxi ylline.
D) Vit in K.
E) All o the bove.
Answer 7.13.4 The correct answer is “E.” All o the bove re
indic ted in the urther tre t ent o this p tient. Nonselective
bet -blockers (“A” nd “B”) will reduce port l pressures, decre s-
ing the risk o v rice l bleeding. It should go without s ying (but
we’ll s y it) th t only one bet -blocker should be prescribed, not
both. “C,” pentoxi ylline, reduces ort lity nd risk o develop-
ing hep toren l syndro e when used cutely ( t le st in the rst
4 weeks er n event o lcoholic hep titis). “E,” vit in K, is
indic ted bec use vit in K de ciency is co only ound in
lcoholics with lnourish ent.
HELPFUL TIP:
Pred i l e (40 mg/day) r 28 day the tapered ver
2 t 4 week may have me be e it i evere alc h lic
hepatiti . Thi i c tr ver ial a ter id ca i crea e
ri k ep i a d m t alc h lic hepatiti patie t die
ep i . I rder t determi e which patie t with al-
c h lic hepatiti are ca didate r c rtic ter id , cal-
culate the discriminant unction (DF). simply mea ure
pr thr mbi time a d t tal bilirubi a d plug the um-
ber i t a li e calculat r. I the DF ≥ 32, the patie t
may be e it r m c rtic ter id therapy.
T e patient does relatively well and abstains rom alcohol. He
is now taking propranolol, spironolactone, and urosemide as
well as ollowing a low-salt diet. He seems to be ollowing your
instructions well but returns to the clinic because o increasing
dyspnea, abdominal distention, and pain. On examination, he
has no peritoneal signs but obviously has massive ascites. You
are considering a large-volume paracentesis in your o ce.
Question 7.13.5 Which o the ollowing statements best
re ects the current thinking on large volume paracentesis?
A) A p tient who h s over 4 L o uid re oved should receive
IV lbu in.
B) T ere is no consistent d t with reg rd to the use o lbu in
in l rge-volu e p r centesis.
C) Under no circu st nce should ore th n 5 L o scites be
re oved t one ti e.
D) Given this p tient’s dyspne , l rge-volu e p r centesis is
contr indic ted.
E) I ore th n 10 L o scites uid is re oved, n equ l vol-
u e o nor l s line should be repl ced intr venously.
Answer 7.13.5 The correct answer is “B.” It is uncle r wh t
p tient ctors indic te lbu in repl ce ent. “A” is incorrect.
T ere is cle rly no need or lbu in in p tients who h ve less

th n 5 L o uid re oved. However, or p tients who h ve ore
th n 5 L o uid re oved, the st nd rd o c re is repl ce ent
with lbu in lthough the d t re li ited. “C” is incorrect.
L rge volu e p r centesis c n be done (even > 10 L) “D” is
incorrect. In ct, respir tory co pro ise is one re son to do
l rge-volu e p r centesis. Re ov l o uid will help with
di phr g tic excursion nd y help with the resolution o
pleur l e usions. “E” is wrong s lbu in repl ce ent is rec-
o ended inste d o nor l s line. Giving nor l s line will
urther induce uid shi ing nd incre se sodiu lo d.” And, it
just sounds wrong, don’t you gree? T t’s lot o uid shi ing.
HELPFUL TIP:
A meta-a aly i albumi replaceme t ll wi g
parace te i ugge t that 6 t 8 g albumi be give
per liter a cite rem ved i th e patie t havi g
m re tha 5 L a citic luid rem ved (Hepat l gy.
2012;55:1172).
You remove 4 L o uid via paracentesis, and the patient eels
better. In the meantime, however, he has had a variceal bleed
and has been hospitalized yet again. He needs something
else done, and you re er him or a transjugular intrahepatic
portosystemic shunt ( IPS) procedure to help reduce portal
pressures, prevent the re-accumulation o ascites, and hope-
ully prevent urther bleeding.
Question 7.13.6 Which o the ollowing statements best
re ects the status o TIPS?
A) IPS is ine ective in controlling cute v rice l bleeding nd
scites.
B) IPS unequivoc lly i proves surviv l ro end-st ge liver
dise se.
C) IPS is ssoci ted with n incre sed risk o hep tic enceph -
lop thy.
D) Once pl ced, IPS re ins e ective or t le st 3 ye rs.
E) IPS is only indic ted or w iters, b r tenders, b rist s, nd
c b drivers.
Answer 7.13.6 The correct answer is “C.” IPS is cle rly sso-
ci ted with n incre sed risk o hep tic enceph lop thy. “A” is
incorrect. IPS is ef ective in controlling v rice l bleeding nd
y help scites by reducing port l pressures. “B” is incorrect.
In ct there y be so e surviv l disadvantage to IPS. How-
ever, the d t is equivoc l. “D” is incorrect bec use IPS shunts
tend to clot nd y need to be ev lu ted or p tency by Dop-
pler i scites re- ccu ul tes or other sy pto s occur. Newer
devices, however, tend to clot o less o en.
HELPFUL TIP:
o ver-diure i ca lead t hepat re al y dr me, which
i characterized by liguric re al ailure. s ep i , GI bleed-
i g, etc., ca al lead t hepat re al y dr me. The
mecha i m ha m re t d with altered circulati t the
kid ey r m hepatic di ea e tha with the diure i it el .
CHAPTER 7 • GAs TRo En TERo Lo GY 225
Objectives: Did you learn to . . .
• Rec g ize cau e hepatic e cephal pathy a d ide ti y
patie t at ri k?
• Ma age a patie t with hepatic e cephal pathy?
• Di cu ri k a d be e t TIPs a d large-v lume parace -
te i ?
QUICK QUIZ: AUTo IMMUn E LIVER DIs EAs E
Which o the ollowing is rker or pri ry bili ry cirrhosis?
A) Anti- itochondri l ntibodies (AMA).
B) Antis ooth uscle ntibodies.
C) Alph 1- ntitrypsin.
D) Polyclon l ntibodies on seru protein electrophoresis.
The correct answer is “A.” Anti- itochondri l ntibodies re
ound in pri ry bili ry cirrhosis (95% sensitive nd 98% spe-
ci c). “B,” ntis ooth uscle ntibodies, re ound in utoi -
une hep titis. “C,” reduced levels o lph 1- ntitrypsin, re
ound in hep titis ro lph 1- ntitrypsin de ciency (surprise!).
“D,” polyclon l ntibodies, re ound in utoi une hep titis.
HELPFUL TIP:
scler i g ch la giti i a i lammat ry pr ce that
cau e tricture the i trahepatic a d/ r extrahepatic
duct . Bi chemically, there i evide ce ch le ta i
ma i e ted by a elevated alkali e ph phata e. Thi
pr gre e t ibr i , cirrh i , a d hepatic ailure with
a media urvival 10 year with ut a tra pla t. The
rate ch la gi carci ma i al elevated i the e pa-
tie t . The diag i cler i g ch la giti i made
by ch la gi graphy, which dem trate tricture a d
dilatati (beaded appeara ce) i tra-hepatic a d/ r
extrahepatic duct . The maj rity ca e are related t
i lammat ry b wel di ea e.
CASE 7.14
A 31-year-old man comes to your o ce or evaluation o
“abnormal liver tests.” He had labs or disability insurance
and the ollowing was noted: elevated total bilirubin (2.1 mg/
dL) with normal direct bilirubin. T e AS , AL , GG , albu-
min, and alkaline phosphatase are normal. A CBC obtained
at that time was unremarkable.
T e patient eels generally well. When you ask about jaun-
dice, he recalls that once when he was sick with the “ u” while
in college, his roommate told him that he “looked a little yel-
low.” He went to the student health service a ew days later
when he elt better and was told there was nothing to be con-
cerned about. He drinks 6 to 8 beers/week and takes ibupro-
en once or twice a month or knee pain.
Physical examination is unremarkable. A repeat liver
panel shows a total bilirubin o 2.4 mg/dL with normal conju-
gated (direct) bilirubin, an elevated unconjugated (indirect)
226 FAMILY MEDICIn E EXAMIn ATIo n & Bo ARD REVIEW
bilirubin and normal AS , AL , and alkaline phosphatase.
CBC and reticulocyte count are also normal. A blood smear,
LDH, and haptoglobin are normal.
Question 7.14.1 The most likely diagnosis is:
A) Crigler–N jj r syndro e type I.
B) Choledocholithi sis.
C) Gilbert syndro e.
D) He olytic ne i .
E) Occult cet inophen buse.
Answer 7.14.1 The correct answer is “C.” Gilbert syndro e is
the ost co on inherited disorder o bilirubin et bolis ,
ecting up to 5% o C uc si ns. It is ch r cterized by isol ted
ild unconjug ted (indirect) hyperbilirubine i , with seru
bilirubin levels usu lly less th n 3 g/dL. However, bilirubin
levels in p tients ected with Gilbert syndro e c n incre se
with sting or during ebrile illnesses, though r rely exceed-
ing 6 g/dL. Crigler–N jj r syndro e type I is r re disorder
le ding to severe unconjug ted neon t l j undice nd neuro-
logic i p ir ent due to kernicterus. Both choledocholithi sis
nd cet inophen hep totoxicity would be unlikely to c use
n isol ted incre se in unconjug ted bilirubin; the LF s should
be elev ted with these. T e nor l blood s e r, reticulocyte
count, nor l LDH, nd nor l h ptoglobin ke signi c nt
he olysis unlikely. T us, this present tion is ost consistent
with Gilbert syndro e.
Several months later, the patient’s older sister comes to see
you. She had gone to a local health air where screening liver
tests were ound to be abnormal. She recalled her brother
mentioning something about a amilial problem causing liver
test abnormalities and wonders i she has the same thing.
She is 39 years old with good general health, although she
wishes she could lose weight. She says she has been 30 to 40 lb
overweight or at least 10 years and is now at her heaviest weight
ever. She is a nonsmoker, who takes no medications and drinks
no alcohol. She denies any risk actors or viral hepatitis.
Physical examination reveals an obese woman. Blood
pressure is 138/88 mm Hg; BMI is 35 kg/m2. T ere is no
scleral icterus or other cutaneous stigmata o chronic liver
disease. T e abdomen is protuberant with the liver edge
palpable about 3 to 4 cm below the right costal margin and
is slightly tender to palpation. T ere is no splenomegaly
and no evident ascites.
Her liver panel rom the health air 3 months ago shows the
ollowing: AL 87 IU/L (normal range, 0–20), AS 53 IU/L
(0–31), alkaline phosphatase 110 IU/L (30–115), total protein
7.8 g/dL (6.0–8.0), albumin 4.2 g/dL (3.3–5.0), total biliru-
bin 0.9 mg/dL (0.2–1.0), and conjugated (direct) bilirubin
0.1 mg/dL (< 0.2).
Question 7.14.2 Appropriate steps at this time include all o
the ollowing EXCEPT:
A) Repe t the liver p nel.
B) Counsel the p tient th t her l bs suggest Gilbert syndro e.
C) Counsel the p tient reg rding weight loss.
D) Reco end serologic ev lu tion to ssess or chronic
vir l nd utoi une hep titis i the liver test bnor li-
ties persist.
E) Right upper qu dr nt ultr sound.
Answer 7.14.2 The correct answer is “B.” As discussed bove,
Gilbert syndro e is de ned by isol ted unconjug ted hyperbili-
rubine i . T is p tient’s p ttern o liver test bnor lities with
inotr ns er se elev tions cle rly indic tes di erent type o
proble . I these bnor lities persist, n ev lu tion or c uses
o chronic inotr ns er se elev tions is w rr nted (see di er-
enti l e rlier in this ch pter o elev ted liver enzy es). Chronic
vir l hep titis nd utoi une hep titis would be ong the
di gnostic consider tions. Given the pp rent hep to eg ly
nd tenderness on physic l ex in tion, n i ging study o
the liver is lso indic ted.
T e repeat liver panel is remarkable or AL 129 IU/L and
AS 76 IU/L. T e other tests are normal. HBsAg and HCV
antibody are negative. Antinuclear and antismooth muscle
antibodies are < 1:40 (normal). T e ultrasound examination
shows an enlarged liver with increased echogenicity, sugges-
tive o dif use atty in ltration.
Question 7.14.3 Regarding nonalcoholic atty liver disease
(NAFLD), or nonalcoholic steatohepatitis (NASH), all o the
ollowing are true EXCEPT:
A) It is requently ssoci ted with one or ore e tures o the
et bolic or insulin resist nce syndro e.
B) It is ore co on in en th n wo en.
C) T e histologic e tures c n closely i ic those o lcoholic
hep titis.
D) It y c use cirrhosis in inority o p tients.
Answer 7.14.3 The correct answer is “B.” NAFLD is ore
co on in wo en nd is ong the ost co on c uses o
elev ted liver enzy es. NAFLD re ers to spectru o histo-
logic ndings th t r nge ro si ple ste tosis to n ggressive
injury p ttern. NAFLD o en occurs in ssoci tion with obe-
sity, dyslipide i , nd/or glucose intoler nce, hypothyroidis ,
nd occurs ore co only in wo en th n en. While ost
p tients with NAFLD will not develop progressive liver dis-
e se, inority re t risk to develop cirrhosis. However, due
to its high prev lence in our popul tion (th nk you, st ood
n tion!), NAFLD/NASH is now the ost co on c use o cir-
rhosis. Fe le gender nd the presence o di betes incre se the
risk o progression to cirrhosis.
HELPFUL TIP:
Vitami E 800 IU BID ha bee h w t be help ul i
n As H (n E gl J Med. 2010;362:1675). H wever, great-
er tha 400 mg IU vitami E may i crea e verall
m rtality (RR 1.04 a d t that r m n As H, [JAMA.
2007;297:842]). Met rmi eem t be be e it,
but tati may be. Fatty liver di ea e i a d it el i
t a c trai dicati t tati .

Question 7.14.4 In this patient with NAFLD, all o the ol
lowing are appropriate actions EXCEPT:
A) Obt in sting lipid p nel.
B) Obt in sting seru glucose.
C) Reco end weight loss to get her BMI to the nor l r nge.
D) St rt “glit zone.”
Answer 7.14.4 The correct answer is “D.” Weight loss, includ-
ing ro g stric surgery, c n i prove NAFLD. However, too
r pid weight loss y be counterproductive in the setting o
NAFLD, s obiliz tion o peripher l t stores y worsen
hep tic ste tosis. Also, ddressing underlying et bolic ill-
nesses (e.g., di betes nd hypothyroidis ) would be i port nt
ele ents in the tre t ent. re ting hyperlipide i nd di betes
c n lso i prove NAFLD. Glit zones h ve been shown to be
ine ective in NAFLD s h s ursodeoxycholic cid.
HELPFUL TIP:
I Fra ce, they rce eed gee e t pr duce atty liver
(F ie Gra ). I the U ited s tate , we d it t ur elve . . .
Objectives: Did you learn to . . .
• Evaluate a patie t with ab rmal liver te t ?
• Rec g ize the cli ical a d lab rat ry pre e tati Gilbert
y dr me?
• De cribe di g alc h lic liver di ea e?
• Ma age a patie t with atty liver di ea e?
QUICK QUIZ: GI BLEED
Which o the ollowing h s shown bene t in reducing ort lity
ro v rice l GI bleeding?
A) V sopressin.
B) So tost tin/octreotide.
C) B nd lig tion o v rices.
D) IPS.
E) C nd D.
The correct answer is “E.” Un ortun tely, while edic l tre t-
ent y bene t the p tient by reducing bleeding, there is no
evidence th t v sopressin or so tost tin reduce ort lity. In
ct, v sopressin y increase ort lity bec use o ssoci ted
GI ische i . IPS nd lig tion o v rices vi n endoscope h ve
positive i p ct on ort lity. We re not trying to con use
you reg rding the previous question bout IPS—it does NOT
reduce overall mortality in end-st ge liver dise se, but it c n
reduce ort lity ro n cute GI bleed. So tost tin reduces
rebleeding when used with endoscopic ther py but does not
ect ort lity.
CASE 7.15
A 70-year-old emale presents to the emergency department
complaining o midepigastric pain associated with vomiting.
T is started approximately 12 hours ago and now she notes
CHAPTER 7 • GAs TRo En TERo Lo GY 227
vomiting, ever, and myalgias. Her vital signs are blood pres-
sure 110/70 mm Hg, pulse 115 bpm, and temperature 38.5°C.
On examination, the patient is quite tender in the midepigas-
tric region with guarding and some rebound. Her past his-
tory is signi cant only or lone atrial brillation (CHA2DS2-
VASc score o 1, see Chapter 2) and a seizure disorder or
which she is taking phenytoin.
Question 7.15.1 Your next steps in the diagnosis o this
patient should include all o the ollowing EXCEPT:
A) Chest r diogr ph.
B) CBC.
C) Liver enzy es.
D) Abdo in l C with contr st.
E) A yl se.
Answer 7.15.1 The correct answer is “D.” An bdo in l C
is not indic ted in this p tient s p rt o the initi l workup. “A,”
n upright chest r diogr ph, is the single best plain r diogr ph
or nding ree bdo in l ir nd is indic ted or this re son.
In ddition, the etiology o bdo in l p in y lso include
pneu oni (especi lly consider this in the elderly) nd other
thor cic p thology th t y be evident on chest r diogr ph.
Liver enzy es, yl se, nd CBC re indic ted since idepi-
g stric p in with ever c n be rel ted to p ncre titis, cute cho-
lecystitis, etc.
Her chest x-ray is normal and her laboratory results are as
ollows: elevated AS and AL (both mild), normal amy-
lase, mildly elevated white count (13.5 × 103 cells/mm3), and
elevated GG .
Question 7.15.2 The correct interpretation o these results
is:
A) T e p tient does not h ve p ncre titis.
B) T e elev ted GG is speci c or bili ry outlet obstruction.
C) T e elev ted AS nd AL y indic te bili ry outlet
obstruction.
D) None o the bove.
Answer 7.15.2 The correct answer is “C.” E rly in the course o
bili ry outlet obstruction (e.g., bili ry colic nd co on duct
stone), the AS nd AL y be ildly elev ted. “A” is incorrect
bec use the yl se is only 80% sensitive or p ncre titis. wenty
percent o p tients with p ncre titis h ve nor l yl se—
lse-neg tive test. “B” is incorrect bec use GG is nonspeci c.
GG is n inducible enzy e nd c n be elev ted in response to
lcohol nd v rious edic tions including phenytoin.
HELPFUL TIP:
I alc h l-related liver di ea e, the As T i ge erally
twice the level the ALT.
We still don’t know what is causing this patient’s pain. You
consider your dif erential. T e patient has a history o atrial
228 FAMILY MEDICIn E EXAMIn ATIo n & Bo ARD REVIEW
brillation and is not on anticoagulation (appropriately since
she has a CHA2-DS2-VASc score o 1). You are concerned
that there may be bowel ischemia rom an embolism.
Question 7.15.3 Which o the ollowing is true o mesen
teric thrombosis and bowel ischemia?
A) P tients gener lly h ve gu rding nd rebound e rly in the
course.
B) T e p in is out o proportion to the ex in tion nd p tients
y h ve nor l initi l ex in tion.
C) A seru l ct te level is help ul nd speci c or the di gnosis
o bowel ische i .
D) T e best study to di gnose this dise se entity is C with con-
tr st.
Answer 7.15.3 The correct answer is “B.” P tients with s ll
bowel ische i ro either e bolis or esenteric thro bo-
sis will gener lly present with severe bdo in l p in nd n
ex in tion th t is unre rk ble. L te in the course there will
be gu rding, rebound, nd other peritone l signs s the bowel
per or tes. However, e rly in the course o the illness, severe
p in with rel tively benign ex in tion is consistent with
the present tion o bowel ische i . “A” is incorrect or the re -
sons st rted bove. “C” is incorrect bec use the seru l ct te
c n be elev ted in nu ber o st tes, not just bowel ische i .
However, bdo in l p in plus l ctic cidosis should r ise the
suspicion th t there y be bowel ische i . “D” is incorrect
bec use r diogr phic ndings on C sc n re present in only
bout 65% o p tients with esenteric thro bosis/e bolis .
T e best study re ins ngiogr phy or C ngiogr phy, which
h s l rgely repl ced tr dition l ngiogr phy.
Since the patient’s examination includes guarding and
rebound, you put the diagnosis o bowel ischemia lower in
your list o possibilities. Based on the elevated white count,
AL and AS , you order an ultrasound o the right upper
quadrant, which shows evidence o a common duct stone.
T ere is thickening o the gallbladder wall but no pericolic
uid noted. You decide that there is a mild cholecystitis and
want to admit the patient to the hospital. Clearly, this patient
needs to be started on antibiotics.
Question 7.15.4 Which antibiotic is the most appropriate
choice or this patient?
A) IV clind ycin.
B) IV v nco ycin.
C) IV gent icin.
D) IV picillin/sulb ct .
Answer 7.15.4 The correct answer is “D.” T e ost ppropri-
te ntibiotic choice o those provided is picillin/sulb ct
(Un syn). T e in org nis s th t need to be covered re
Gr -neg tive org nis s nd n erobes (E. coli, Enterococ-
cus, Klebsiella, nd Enterobacter). A picillin/sulb ct will
cover ll o these org nis s. You ight lso choose piper-
cillin/t zob ct (Zosyn), which includes pseudo on l
cover ge, or ce ri xone + etronid zole or levo ox cin +
etronid zole. “A” is incorrect bec use clind ycin covers
Gr -positive org nis s nd n erobes, does not cover ost
Gr -neg tive org nis s. In ddition, ny enterococci re
resist nt to clind ycin. “B” is incorrect bec use v nco y-
cin only covers Gr -positive org nis s nd even then it is
rel tively we k ntibiotic or such (e.g., ort lity is higher
or MSSA th n with n cillin). “C” is incorrect bec use gen-
t icin does not cover n erobic org nis s. Other ntibiotic
options or tre ting this p tient include ce otet n nd ce oxi-
tin, ong others.
T e patient is admitted to the hospital. She is treated with
ampicillin/sulbactam, IV uids and pain medication.
Question 7.15.5 The next step or this patient is:
A) Percut neous “ ” tube pl ce ent to dr in the g llbl dder.
B) 2 weeks o IV ntibiotics ollowed by cholecystecto y.
C) Endoscopic retrogr de chol ngiop ncre togr phy (ERCP)
with sphincteroto y.
D) Lithotripsy.
Answer 7.15.5 The correct answer is “C.” T e p tient should
h ve n ERCP with sphincteroto y in n tte pt to retrieve
the stone in her co on bile duct. “A” is incorrect bec use
in this he lthy p tient, percut neous dr in ge would cert inly
be third-line procedure. “B” is incorrect bec use the p tient
essenti lly h s closed bscess (the g llbl dder blocked by
stone), which requires dr in ge. I the p tient h d cholecystitis
without obstruction, prolonged ntibiotics ollowed by cho-
lecystecto y would be n option. However, in patients with
cholecystitis without obstruction outcomes are overall better
with an early cholecystectomy. “D” is lso incorrect nd would
be less desir ble ppro ch th n is ERCP with sphincteroto y.
HELPFUL TIP:
s tudie have h w impr ved utc me i patie t with
evere gall t e pa creatiti a d/ r ch la giti that re-
ceive early (withi 72 h ur a ter admi i ) ERCP with
biliary phi cter t my.
T e ERCP is success ul but the patient develops worsening
pain in the midepigastric region.
Question 7.15.6 Which o the ollowing is the most com
mon adverse consequence o ERCP?
A) P ncre titis.
B) Contr st llergy.
C) Per or tion.
D) Bleeding.
E) Sepsis.
Answer 7.15.6 The correct answer is “A.” O the co plic tions
listed, p ncre titis is the ost co on, with n incidence o
bout 5% o p tients er ERCP. In ct, elev tions in p ncre-
tic enzy es ( ostly not signi c nt) occur in up to 75% o
 CHAPTER 7 • GAs TRo En TERo Lo GY 229

TABLE 7-7 DRUGS ASSOCIATED WITH PANCREATITIS D) When used in co bin tion with n SSRI, orphine is ore
likely to c use serotonin syndro e th n is eperidine.
Drugs with Def nitive Drugs with Probable
Association Association
Answer 7.15.8 The correct answer is “D.” Meperidine ( nd
Thiazide diuretic Acetami phe tr dol) y c use serotonin syndro e when co bined
s ul amide s alicylate with n SSRI. T is is not proble with orphine. T e rest re
Azathi pri e Metr idaz le
true st te ents. T ere is no evidence to support the tr dition
6-Mercapt puri e n itr ura t i
Fur emide Erythr myci th t eperidine is superior to orphine in bili ry or p ncre tic
E tr ge n s AID dise se. Meperidine is et bolized into nor eperidine, which
Tetracycli e ACE i hibit r c n c use git tion nd seizures. T us, “B” nd “C” re correct.
Valpr ic acid Methyld pa In gener l, orphine—or hydro orphone or ent nyl— re
Pe tamidi e s ter id
uch cle ner drugs to use or p in n ge ent.
Valpr ic acid
Dide xyi i e
You have the patient’s pain well managed with morphine,
despite grumbling rom your surgical colleague.

p tients post-ERCP. T e others re less co on nd in order
o descending incidence re bleeding, per or tion, sepsis, nd
contr st llergy (r re).
Although you suspect that this patient has pancreatitis sec-
ondary to the ERCP, you also consider other potential causes
o pancreatitis.
Question 7.15.7 All o the ollowing are causes o pancre
atitis EXCEPT:
A) Vir l in ection.
B) HMG-Co A reduct se inhibitors (st tins).
C) Alcohol.
D) Indin vir.
E) Bee stings.
Answer 7.15.7 The correct answer is “E.” T e ost co on
c uses o cute p ncre titis in the United St tes re eth nol
ingestion, bili ry tr ct dise se, nd endoscopic procedures
with bili ry tr ct dise se. “A” is true. Co on viruses th t
c n c use p ncre titis include HIV, hep titis viruses, EBV,
nd Coxs ckieviruses. “B” nd “D” re true. M ny other drugs
c n lso c use p ncre titis: o note re did nosine, so e
diuretics, so e NSAIDs, so e ntibiotics, etc. See ble 7-7
or ore on drugs th t c use p ncre titis. T e veno o
scorpion sting c n result in p ncre titis, s c n brown recluse
spider bites.
You re-check laboratory studies and the patient indeed has
worsening pancreatitis rom the ERCP. T e surgeon on the
case recommends against using morphine and would pre er
meperidine in this patient, mumbling something about that’s
the way they always did it in residency.
Question 7.15.8 All o the ollowing are true EXCEPT:
A) T ere is no evidence th t eperidine is superior to or-
phine even in g llbl dder nd p ncre tic dise se.
B) Meperidine is ore likely th n orphine to c use seizures
in this p tient.
C) Meperidine is ore likely th n orphine to c use con usion
nd git tion in elderly p tients.
Question 7.15.9 Which o the ollowing treatments is rou-
tinely indicated in the f rst day o pancreatitis?
A) NG tube with inter ittent suction.
B) H 2 blockers (e.g., ci etidine) or PPIs (e.g., l nsopr zole).
C) IV ntibiotics.
D) NPO order.
Answer 7.15.9 The correct answer is “D.” T e critic l words
here re “ rst d y”. Once p in nd in tion re decre sing
(gener lly within 24 to 48 hours o the onset o p in) PO nutri-
tion c n be rest rted ssu ing there is no ileus, vo iting, etc.
Early eeding in the hungry patient with pancreatitis hastens
disease resolution. Feedings can also be done via jejunal tube,
which bypasses the pancreas. Even a G-tube can be used or
eedings. However, i the patient is tolerating oral eeds let
them go or it! “A” is incorrect bec use there is no indic tion or
n NG tube in the p tient who is not vo iting. “B” is incorrect
bec use H 2 blockers or PPIs do not ch nge the outco e in p n-
cre titis. “C” is incorrect unless there is evidence o in ection
(e.g., ever) or necrotizing p ncre titis— nd even then there is
controversy.
Your patient is NPO because o an ileus and is receiving
appropriate IV uids and parenteral eedings with CVN
(remember nutrition, however you can give it, is important).
However, over the next couple o days, her condition worsens.
She begins to vomit and have increased pain as well as tachy-
cardia and ever. T e patient wants to know what her chances
o surviving this bout o pancreatitis are, so you break out a
chart and your smart phone.
Question 7.15.10 All o the ollowing are part o Ranson cri
teria EXCEPT:
A) P tient’s ge.
B) P tient’s white count on d ission.
C) HC t 72 hours.
D) Glucose on d ission.
Answer 7.15.10 The correct answer is “C.” T e HC t
48 hours is one o R nson criteri . T e other criteri re out-
lined in ble 7-8.
230 FAMILY MEDICIn E EXAMIn ATIo n & Bo ARD REVIEW

TABLE 7-8 RANSON CRITERIA Question 7.15.12 Which o the ollowing IS NOT true about
a pancreatic pseudocyst?
o admi i • Age > 55 year
A) Pseudocysts occur in 10% o p tients with p ncre titis.
• WBC > 16,000
• Gluc e > 200 B) Pseudocysts c n be dr ined by or ing stul with the
• LDH > 350 sto ch endoscopic lly.
• As T > 250 C) Pseudocysts c n le d to the or tion o rteri l pseudo n-
At 48 h ur • Hemat crit reducti by > 10% eurys s th t c n c use severe bleeding.
• BUn i crea e > 5 D) Open dr in ge is the pre erred ethod o tre t ent.
• Calcium < 8 E) Not ll pseudocysts require dr in ge.
• po 2< 60
• Ba e de cit > 4
• Fluid eque trati >6L
Answer 7.15.12 The correct answer is “D.” T e or tion o
stul with the sto ch using n endoscope is ctu lly the pre-
Note: Mild pa creatiti i de ed by the pre e ce 1 t 3 Ra criteria; erred ethod o dr in ge. T e one jor contr indic tion to
m rtality i crea e with the pre e ce 4 r m re. endoscopic tre t ent is pseudo neurys . Injury to n rtery
c n c use signi c nt bleeding th t is dif cult to control.

HELPFUL TIP:
HELPFUL TIP:
CT ca ca be u ed t l k r a p eud a eury m be-
The Ra criteria are either particularly e itive
re e d c pic drai age. A a eury m h uld al be
r peci ic r evere pa creatic di ea e a d ca t
u pected i the e circum ta ce : evide ce a upper
be c mpleted be re 48 h ur h pitalizati . The
GI bleed, a dr p i the HCT, r a udde expa i
Apache c re acc u t r bl d pre ure, xyge -
the p eud cy t.
ati , temperature, re pirat ry rate, creati i e, GCs,
etc., a d i a better predict r urvival. Fi ally, a HCT
44% r greater at admi i a d ailure t decrea e Objectives: Did you learn to . . .
at 24 h ur i al a excelle t predict r ecr tizi g • Rec g ize a d diag e me e teric thr mb i ?
pa creatiti a d multi rga ailure. The America Ga - • Ide ti y cau e acute pa creatiti ?
tr e ter l gical A ciati rec mme d the u e • Diag e a d ma age a patie t with acute pa creatiti ?
the Apache II c re (ye , we k w the APACHE c re i • Ma age the c mplicati pa creatiti ?
w up t IV. . . the Apache II eem t be the be t here,
• De cribe me ide e ect pare teral utriti i a h pi-
th ugh). talized patie t?
• De cribe the pri ciple arc tic ch ice i patie t with
pa creatiti ?
HELPFUL TIP:
E teral utriti i pre erred ver CVn r pa creatiti .
n G v n J eedi g i c tr ver ial. s me tudie h w a QUICK QUIZ: GALLs To n Es
be e it n J eedi g whe the eedi g tube i placed
bel w the ligame t Treitz. Thi reduce pa creatic A 40-ye r-old e le presents to you with g llstones ound on
timulati . “ ull body C sc n” per or ed t Live4Ever I ging echnolo-
gies, Inc. She is nxious th t she will beco e sick like her sister
who h d n e ergent cholecystecto y or her g llstone p ncre-
Question 7.15.11 Which o the ollowing IS NOT a complica titis. She sks you i she should h ve her g llbl dder re oved.
tion o CVN? She is sy pto tic nd her liver enzy es re nor l.
A) In ection.
B) Cholest sis. Which o the ollowing should you reco end?
C) Hypoglyce i . A) L p roscopic cholecystecto y bec use o ily history o
D) Ileus. severe g llstone p ncre titis.
B) Ultr sound to con r g llstones nd to check or co on
Answer 7.15.11 The correct answer is “D.” In ection, cholest - bile duct stones.
sis, nd hypoglyce i c n ll be result o CVN. Hypoglyce i C) No tre t ent or ollow-up is needed unless she develops
gener lly occurs when stopping CVN bec use o incre sed lev- sy pto s.
els o circul ting insulin. T is c n be itig ted by t pering CVN D) ERCP with sphincteroto y to llow stones to p ss without
or d inistering IV dextrose. obstructing co on bile duct or co pressing p ncre tic
duct.
Since the patient has continued to do poorly, you order a C E) Recheck liver enzy es nd i elev ted reco end cholecys-
scan o the abdomen that shows evidence o a pseudocyst. tecto y.

The correct answer is “C.” Asy pto tic g llstones do not
need speci l ttention since 70% to 80% re in sy pto tic.
Only 2% to 3% o p tients will present with cute cholecystitis
or other co plic tions nd there ore prophyl ctic cholecystec-
to y is not indic ted. A eric n Indi n popul tions h ve high
risk o stone ssoci ted g llbl dder c ncer nd re n exception
to this rule. Di betics or sickle cell dise se p tients h ve higher
risk o co plic tions ro g llstones but still should not h ve
their g llbl dder re oved i sy pto tic. F ily history o
co plic tion ro g llstones is not n indic tion or prophyl c-
tic cholecystecto y.
CASE 7.16
A 58-year-old woman with type 2 diabetes mellitus comes
to your clinic with nausea, vague epigastric abdominal pain,
bloating, early satiety, and intermittent vomiting or 3 weeks.
Her past medical history is signi cant or hypertension and
hyperlipidemia and her diabetes is complicated by retinopa-
thy and neuropathy. She is on met ormin, glyburide, lisino-
pril, aspirin, and atorvastatin.
She is a ebrile and not ill appearing on examination. She
has gained 5 kg in the last year. She has mild epigastric ten-
derness without rebound or guarding. Bowel sounds are nor-
mal and there is no abdominal distention. Laboratory results
show normal CBC and dif erential with HbA1c o 9.4%. You
suspect diabetic gastroparesis.
Question 7.16.1 Which statement is FALSE regarding diag
nosis o gastroparesis?
A) On scintigr phy (g stric e ptying study) > 60% o the st n-
d rd e l present in sto ch t 2 hours suggests g strop -
resis.
B) On scintigr phy > 10% o the st nd rd e l present in the
sto ch t 4 hours suggests g strop resis.
C) EGD looking or evidence o ood er n uncontrolled res-
t ur nt e l is good test or di gnosing g strop resis.
D) G strop resis c n be di gnosed by exh led r diol beled
CO2 e sure ent.
Answer 7.16.1 The correct answer (the alse statement) is
“C.” Si ply looking or ret ined g stric contents t n unspeci-
ed ti e er n unspeci ed ingestion is not the w y to di g-
nose g strop resis. T e ost widely used test or di gnosing
g strop resis is r dionucleotide sc n. T e p tient is given st n-
d rdized e l cont ining 99 technetiu sul ur colloid in
low- t eggs, nd nucle r ctivity is e sured t 2 nd 4 hours,
respectively. I r dio ctivity in the sto ch is > 60% t 2 hours
or > 10% t 4 hours, the p tient is considered to h ve del yed
g stric e ptying. You c n do liquid ph se g stric e ptying
study i you suspect du ping syndro e, but it is not necess ry
to ev lu te or g strop resis. “D,” r diol beled CO2 bre th test,
correl tes well with nucle r scintigr phy nd is e sier to per-
or in the co unity setting. However, r diol beled CO2
bre th test requires nor l s ll bowel, p ncre s, liver, nd
lung unction.
CHAPTER 7 • GAs TRo En TERo Lo GY 231
You order a radionucleotide gastric emptying study, and it
shows that 75% o the meal was present in the stomach at
2 hours and 20%at 4 hours. You diagnose gastroparesis.
Question 7.16.2 The best long term treatment option or
her is:
A) Cis pride.
B) Do peridone.
C) Erythro ycin.
D) Metoclopr ide.
E) I proved glucose control.
Answer 7.16.2 The correct answer is “E.” T e tre t ent o di -
betic g strop resis is o en dif cult nd rustr ting or p tients
nd clinici ns. Although not proven in prospective tri ls, ost
experts believe i proved glucose control with diet ry nd li e-
style odi c tion is the key to long-ter success in di betic
g strop resis. All o the bove edic tions (“A”–“D”) h ve
shown bene t in the short ter to reduce sy pto s ssoci ted
with di betic g strop resis. Cis pride w s re oved ro the r-
ket bec use o prolong tion o the Q interv l. Do peridone is
not v il ble in the U.S. nd c uses prolonged Q interv l, but is
used in other countries or g strop resis. Erythro ycin nd eto-
clopr ide re e ective nd v il ble. However, both c n c use
cr ps, nd erythro ycin c n c use n use , prolonged Q inter-
v l, nd o en r pidly beco es ine ective (t chyphyl xis) while
etoclopr ide y c use t rdive dyskinesi or dystoni . Other
crolides re not e ective. Liquid etro loper ide is suggested
or g stric p resis nd see s to work better th n t blets.
You add insulin to the diabetic regimen in an attempt to
tighten glucose control and prescribe metoclopramide 5 mg,
30 minutes be ore meals.
Question 7.16.3 In addition to this you recommend all o
the ollowing dietary and li estyle modif cations EXCEPT:
A) Incre se diet ry ber.
B) Ch nge ro our l rge to six s ll e ls d ily.
C) Moder te exercise.
D) Decre se diet ry t.
E) ADA 1800 kc l diet.
Answer 7.16.3 The correct answer is “A.” Fiber nd r w veg-
et bles c n or g stric bezo rs (phytobezo r) in g strop resis
nd this is o en seen on endoscopy. Bezo rs c use e rly s tiety
nd blo ting nd dd to the sy pto burden o g strop resis. I
bezo r is ound, it c n be dissolved using cellul se (K n l se®).
More requent, s ller e ls help with sy pto s; nd oder-
te exercise c n be help ul but excessive exercise y slow g s-
tric e ptying. Your p tient is g ining weight, so it is i port nt
to rein orce the ADA diet. F t slows g stric e ptying; there ore,
diet ry t should be reduced to less th n 40 g/d y.
Question 7.16.4 Which o the ollowing medications can
exacerbate preexisting gastroparesis?
A) Fluoxetine.
B) Oxycodone.
232 FAMILY MEDICIn E EXAMIn ATIo n & Bo ARD REVIEW
C) Angiotensin converting enzy e (ACE) inhibitors.
D) Met or in.
E) Insulin.
Answer 7.16.4 The correct answer is “B.” Oxycodone nd ll
n rcotics reduce GI otility nd re r rely toler ted by p tients
with g strop resis. T is c n be clinic lly ch llenging, nd tten-
tion to the c use o p in nd ltern tive n ge ent options
should be explored. Fluoxetine does not h ve signi c nt e ects
on g stric otility, but CAs nd other drugs with nti-cholin-
ergic ctivity do nd re not good options or p in syndro es
in g strop resis. ACE inhibitors do not ect GI otility.
Although et or in is ssoci ted with GI side e ects, it does
not ect GI otility. Insulin h s no dverse e ect on GI otil-
ity. Other edic tions th t reduce g stric e ptying re dop -
inergic gents, nti- drenergic nti-hypertensives, c lciu
ch nnel blockers, nd nti-cholinergic gents. All drugs known
to ect g stric otility should be stopped prior to obt ining
g stric e ptying study.
HELPFUL TIP:
There are multiple cau e ga tr pare i ther tha
diabete . s me the e i clude: p tviral ga tr e teri-
ti (may per i t r > 1 year), thyr id di ea e, eur l gic
di ea e , a d aut immu e di ea e . F rty perce t
ga tr pare i i idi pathic. s c ider thi i y ur di -
ere tial the patie t with a y the ll wi g: p t-
pra dial ull e , upper abd mi al pai , au ea, v mit-
i g, early atiety, a d regurgitati d h ur a ter
i take (yum!)
Objectives: Did you learn to . . .
• Diag e ga tr pare i ?
• Ide ti y medicati that ca exacerbate ga tr pare i ?
• Ma age ga tr pare i ?
QUICK QUIZ: GI BLEED
You d it 65-ye r-old wo n with end-st ge ren l dise se
on he odi lysis. She is being d itted bec use o recurrent
episodes o elen requiring tr ns usions. She is ne ic with
low erritin, iron, nd iron s tur tion. T e g stroenterologist
per or s n upper nd lower endoscopy without ny bleeding
source ound. Subsequently, c psule enteroscopy shows ul-
tiple s ll ngiodyspl si s throughout the s ll bowel, without
ny l rge, endoscopic lly tre t ble lesions.
Your p tient is disch rged er blood tr ns usion. Her
he oglobin is 11 g/dL. At ollow-up 1 onth l ter, her he o-
globin is 9 g/dL. T e p tient is on xi u doses o erythro-
poietin with di lysis nd is still h ving gu i c positive stools.
She re uses to t ke or l iron bec use o constip tion.
Which o the ollowing is the next best step in the n ge ent
o this c se?
A) Prescribe iron dextr n or sucrose IV with di lysis to in-
t in her iron stores.
B) ry to convince the g stroenterologist to repe t the endos-
copy nd tre t ny ngiodyspl si lesions th t c n be
re ched.
C) Prescribe octreotide.
D) Order Meckel sc n.
E) Prescribe estrogen–progesterone.
The correct answer is “A.” T is is n ppropri te situ tion or
the d inistr tion o IV iron. It is s er th n blood tr ns u-
sions nd c n be given on n outp tient b sis during he o-
di lysis. T ere re r re occurrences o n phyl xis with iron
dextr n, nd test dose should be given. So e reports suggest
iron sucrose is s er. “B,” repe t endoscopies with tre t ents o
ngiodyspl si s, y help but should be djunctive ther py to
inten nce o iron stores. T e scope only re ches the proxi l
jejunu nd the p tient h s lesions throughout the s ll bowel.
“C,” octreotide, h s been reported in c se series to h ve bene -
ci l e ect, but no r ndo ized tri ls h ve been per or ed nd it
c nnot be reco ended t this ti e. “D,” Meckel sc n (done
to look or Meckel diverticul ), would be redund nt s nother
c use h s been ound nd the p tient does not t the ost likely
ge group. “E,” hor one repl ce ent ther pies initi lly see ed
e ective t reducing bleeding ro ngiodyspl si but r ndo -
ized tri ls iled to show bene t.
HELPFUL TIP:
A gi dy pla ia are c mm ly mi ed a d are a -
ciated with i crea i g age, e d- tage re al di ea e,
a rtic te i , hereditary tela giecta ia (aut mal
d mi a t), a d are m re likely t bleed i patie t
l g-term a tic agulati a d a tiplatelet therapie .
o ther c mm ly mi ed le i i clude Camer le-
i ( mall ulcer cau ed by rubbi g hiatal her ia
ac agai t diaphragm) a d PUD.
HELPFUL TIP:
Cap ule e d c py the mall b wel u i g a mall
camera ca be help ul i a mall b wel ll w-thr ugh
d e t h w a urce bleedi g. o ther p ibilitie
i clude tagged red bl d cell (RBC) ca a d a gi g-
raphy that are ly really u e ul i vert bleedi g. The
tagged RBC ca eed 0.1 mL/mi bleedi g rate a d
a gi graphy require 0.5 mL/mi bleedi g rate t de-
tect bleedi g ite .
QUICK QUIZ: HEMATo CHEZIA
A 30-ye r-old e le co es to your clinic with the co pl int o
inter ittent blood on toilet p per or 3 ye rs. She s ys she lw ys
h s been constip ted nd t kes polyethylene glycol (Mir L x)
on regul r b sis. She h s no ily history o colorect l c ncer

nd is sy pto tic nd h s no weight loss. On ex in tion,
she does not ppe r ne ic nd bdo in l ex in tion is nor-
l. Rect l ex in tion is nor l nd nontender. Anoscopy is
nor l.
Wh t is the ost ppropri te ction?
A) Re ssur nce.
B) Anusol suppositories three ti es/week or 6 weeks; ollow
up s needed.
C) Flexible sig oidoscopy.
D) Colonoscopy.
E) Anorect l no etry.
The correct answer is “C.” T e ess ge is th t everybody re-
porting persistent blood in stools without lesions seen on nos-
copy w rr nts endoscopic ev lu tion. Colon c ncer is r re in
this ge group but c n h ppen. T e sy pto o red blood per
rectu suggests th t the c use could be ound dist l to descend-
ing colon nd likely in the rectu . I there is only single epi-
sode o bleeding, so e would rgue or ore conserv tive
ppro ch in p tients less th n 50 ye rs o ge without other
l r sy pto s (constitution l sy pto s or ch nge in bowel
h bits). In this young p tient, ull colonoscopy is not neces-
s ry unless there is strong ily history o colorect l c ncer
or other sy pto s suggestive o colitis such s urgency, weight
loss, or di rrhe . Anorect l no etry is not use ul in the ev l-
u tion o rect l bleeding. Anusol suppositories c n be help ul to
reduce p in ssoci ted with he orrhoids, but i bleeding is the
only sy pto , ber supple ents nd stool so eners re su -
cient. I the p tient is older th n 50 ye rs with rect l bleeding,
ull colonoscopy is indic ted.
CASE 7.17
A 73-year-old male comes to your o ce with a 3-day history
o le lower quadrant abdominal pain. He has elt cold and
clammy at times but has not checked his temperature. He
has had no nausea, vomiting, or diarrhea. T e pain does not
worsen a er meals, but his appetite has been poor since this
started. On review o systems, he reports increased urinary
requency and urgency or the same amount o time. He has
had no abdominal surgeries. He has diabetes mellitus type 2
and is on glipizide. He also takes aspirin 81 mg/day. He has
always declined screening colonoscopy, stating, “I it ain’t
broke, don’t x it”—apparently, his amily motto. On exami-
nation, he is in no distress with blood pressure 125/75 mm
Hg, pulse 90 bpm, respirations 15, and temperature 38.5°C.
His heart sounds are normal, and his chest is clear bilater-
ally. He has moderate le lower quadrant tenderness without
rebound tenderness or guarding. T ere is no abdominal dis-
tention or organomegaly. Bowel sounds are normal, and the
rectal examination is normal without stool in the rectal vault.
Urinalysis is normal.
Question 7.17.1 What is the most likely diagnosis?
A) Ische ic colitis.
B) Colon c ncer with l rge bowel obstruction.
CHAPTER 7 • GAs TRo En TERo Lo GY 233
C) IBS.
D) Pyelonephritis.
E) Diverticulitis.
Answer 7.17.1 The correct answer is “E.” Diverticulitis is the
ost likely c use o the p tient’s p in. Fever ssoci ted with
cute onset bdo in l p in loc ted in le lower qu dr nt
kes this p in ore likely to be due to diverticulitis. Diver-
ticulitis c n, however, occur in ny p rt o the colon. Ische ic
colitis (“A”) c n present with disproportion te bdo in l p in in
this loc tion but is usu lly ssoci ted with bloody di rrhe , so it is
less likely. IBS (“C”) l ost never presents in this ge group, is not
ssoci ted with evers unless there is stul or eg colon, nd
is chronic condition, not cute. Pyelonephritis (“D”) w s good
thought until the urine dipstick returned nor l. Urin ry sy p-
to s re co on in diverticulitis bec use o bl dder irrit tion.
Colon c ncer with l rge bowel obstruction (“B”) would present
with severe bdo in l p in nd distention. In obstruction, bowel
sounds re typic lly hyper ctive with inter ittent rushing.
Question 7.17.2 The most appropriate next step in the
workup o the patient is:
A) C sc n o bdo en nd pelvis.
B) Surgic l consult.
C) G stroenterology consult.
D) Abdo in l ultr sound.
E) Colonoscopy.
Answer 7.17.2 The correct answer is “A.” C sc n is very
sensitive nd speci c or diverticulitis nd c n si ult neously
ev lu te or other c uses o bdo in l p in. R diocontr st (or l
or IV) does not dd to the di gnostic ccur cy or diverticu-
litis or ppendicitis (Ann Emerg Med. 2010;55:51) but try tell-
ing th t to your r diologist. Co pro ise with the nd use
IV contr st lone i they insist. In gener l, C sc n is indic ted
i the p tient h s peritone l signs or ss suggesting diver-
ticul r bscess or tion. In p tient who h s h d previously
docu ented tt cks nd who h s none o the bove sy pto s,
e piric tre t ent is ppropri te. Surgic l nd/or GI consults
y be indic ted but re pre ture t this point. Abdo in l
ultr sound c n di gnose diverticulitis nd/or bscess, but it is
less sensitive th n C sc n. Colonoscopy is only indic ted in
the cute setting i obstruction is present or i colitis is thought
to be ore likely. In the setting o cute diverticulitis, the risk o
per or tion during colonoscopy is incre sed, nd colonoscopy
is pre er bly del yed until in tion h s subsided. Note th t
you speci c lly do not w nt to use rect l contr st i there is
question o per or tion (or th t you y c use per or tion).
You get the C scan the same day (with only IV contrast . . . you
partially win this round with the radiologist) and have the
patient return to your o ce to discuss the results. T e C
scan shows in ammation in the sigmoid colon with some out-
pouching structures suggesting diverticulosis. T ere is a 1.5 cm
uid collection posterior to the sigmoid colon suggesting
pericolonic abscess. No other ndings were noted, and the
colon above sigmoid appeared normal. No ree air was seen.
234 FAMILY MEDICIn E EXAMIn ATIo n & Bo ARD REVIEW
Question 7.17.3 Which o the ollowing is the most appro
priate next step in management?
A) C -guided dr in ge o the bscess.
B) Surgic l consult or i edi te diverting colosto y nd
bscess dr in ge.
C) Ad ission to the hospit l or IV ntibiotics nd seri l
bdo in l ex in tions.
D) Disch rge to ho e on levo ox cin nd etronid zole.
E) GI consult or endoscopic ultr sound guided tr nscolonic
dr in ge o bscess.
Answer 7.17.3 The correct answer is “C.” T is p tient should
be d itted or IV ntibiotics. Mild tt cks o diverticulitis c n
be n ged on n outp tient b sis. Our p tient h s s ll bscess
th t requires inp tient ther py. In ddition, he is i unosup-
pressed by his di betes, nd ll i unosuppressed p tients
with diverticulitis should be d itted or IV ntibiotics since
they re ore likely to develop co plic tions nd need surgery.
“A” is not the best choice. It is re son ble to sk the r diologist i
this bscess c n be dr ined, but the likely nswer is no, bec use
it is very s ll nd is posterior to colon. “B” is lso incorrect.
T e p tient does not h ve peritone l signs, nd the bscess
likely will respond to IV ntibiotics. T us, i edi te surgery is
not indic ted. As discussed bove, colonoscopy ( nd by exten-
sion endoscopic ultr sound) is rel tively contr indic ted in the
setting o cute diverticulitis. “E” is lso incorrect. No g stroen-
terologist h s been ound cr zy enough to try to dr in bscesses
by tr nscolonic ppro ch to our ( nd Pub ed’s) knowledge.
However, ybe the e erging N tur l Ori ce r nslu in l
Endoscopic Surgeons (NO ES) will tte pt this in the uture
but not on our p tient tod y. (Editor’s note: we didn’t ke this
one up either . . . T ey h ve been doing cholecystecto ies vi
tr nsv gin l ppro ch . . . don’t sk us why . . .)
HELPFUL TIP:
A tibi tic regime r diverticuliti mu t i clude b th
Gram- egative a d a aer bic c verage. s me c m-
m regime i clude cipr l xaci + metr idaz le,
ampicilli / ulbactam, am xicilli /clavula ate, ampi-
cilli + ge tamici + cli damyci , a d ce triax e +
metr idaz le.
Question 7.17.4 Which o the ollowing is true o diverticu
losis?
A) T e jority o p tients with this dise se will develop sy p-
to s t so e ti e.
B) T e condition is ssoci ted with high lign nt potenti l.
C) T e condition h s pe k incidence o occurrence in sixth,
seventh, nd eighth dec des o li e.
D) T e condition pri rily ects the scending colon.
Answer 7.17.4 The correct answer is “C.” Diverticulosis is n
cquired dise se th t pe ks in the sixth, seventh, nd eighth
dec des with bout 50% o octogen ri ns h ving the condition.
“A” is incorrect. Most re asymptomatic with only 10% to 20%
going on to develop sy pto tic diverticulitis. Acute divertic-
ulitis h s v riety o present tions. Peri-diverticul r in -
tion occurs when ec lith beco es entr pped in diverticul r
w ll resulting in loc lized, cont ined, icroper or tion. P in
is typic lly cute nd loc ted in the le lower qu dr nt. Ex i-
n tion y reve l only ildly tender bdo en without ny
sses. A peri-diverticul r bscess nd phleg on will typic lly
result in worsening le lower qu dr nt bdo in l p in, nd
o en ss is p lp ble.
HELPFUL TIP:
Epipl ic appe dagiti ( t appe diciti , ye it i pelled
c rrectly) ca mimic b th appe diciti a d diverticuli-
ti . It ge erally will pre e t imilarly t appe diciti but
the le t. It ccur m tly i pe ple i their 30 . It c-
cur whe there i t r i r i arcti a epipl ic
appe dage the perit eal a pect (“ ut ide”) the
c l . Diag i i by CT ca a d it ge erally re lve
it w with ut urgical i terve ti .
T e patient is admitted and he responds to IV antibiotics and
supportive measures. A repeat C scan 2 weeks later shows
resolution o the abscess. T e local gastroenterologist per-
orms colonoscopy 2 months a er the attack and con rms
le -sided diverticulosis with otherwise normal colonoscopy.
Question 7.17.5 Which o the ollowing statements is true
about this patient’s prognosis?
A) When the p tient h s his second tt ck o unco plic ted
diverticulitis, resection o the dise sed seg ent is lw ys
indic ted (sig oid colecto y).
B) 50% o p tients will h ve repe t tt ck within 5 ye rs.
C) He h s 20% to 30% ch nce o diverticul r per or tion in the
next 2 ye rs.
D) He h s 30% ch nce o diverticul r bleeding in the next
2 ye rs.
E) 33% o p tients will h ve second tt ck.
Answer 7.17.5 The correct answer is “E.” Only 33% o p tients
with n episode o diverticulitis will h ve second episode.
T ere is no set rule or the nu ber o tt cks needed be ore
p rti l colecto y is indic ted. T e co only used rule o three
tt cks is not b sed on prospective evidence. T e decision h s
to be individu lized, but the tendency is to oper te on he lthy
young people with requent tt cks while opting or observ tion
o elderly p tients with co orbidities (even i they h ve ore
th n three tt cks). Diverticul r per or tion is r re nd occurs
in only 5% to 10% o p tients within 2 ye rs o the initi l event.
Diverticul r bleeding h ppens in 3% to 5% o p tients with
diverticulosis nd the risk is not incre sed with diverticulitis; i
GI bleeding occurs during n episode o presu ed diverticuli-
tis, other di gnoses should be strongly considered.
On a weekend call 6 months later, your patient presents to
the emergency department a er experiencing sudden onset

o bright red blood per rectum mixed within stools. He has
passed ve stools in last 3 hours and the last one had blood
clots. He eels dizzy but has not passed out. He stopped taking
his aspirin a er his last illness, but otherwise his health and
medications are unchanged. His abdomen is nontender and
bowel sounds are normoactive. Rectal examination reveals
resh blood on the glove but no masses in rectum. Hemoglo-
bin is 10 g/dL, and you place two large bore IVs and admit
him to the hospital. He has no more bowel movements over-
night, his hemoglobin is 8.2 g/dL the next morning, and he is
eeling well. You assume that the bleeding was diverticular.
Question 7.17.6 Which o the ollowing statements is true?
A) Urgent colonoscopy is needed to loc lize nd tre t the lesion.
B) Colonoscopy is needed but c n be done on n outp tient
b sis.
C) gged RBC sc n ollowed by ngiogr phy is indic ted to
prevent rebleeding.
D) No urther workup is indic ted t this point.
E) Sig oid colon resection is indic ted bec use o the dyn ic
diverticul r duo (diverticul r bleed nd diverticulitis).
Answer 7.17.6 The correct answer is “D.” T e p tient h s cl s-
sic present tion o diverticul r bleeding with r pid onset nd
spont neous resolution o bleeding (75% stop spont neously).
T e p tient underwent colonoscopy recently nd the only nd-
ing w s diverticulosis. Since the p tient h s stopped bleeding,
colonoscopy is unlikely to help in the n ge ent o his condi-
tion. For the s e re son, colonoscopy does not need to be done
s n outp tient. I the p tient h d continued to bleed, there
would be two options or n ging this p tient nd both re
ccept ble. One ppro ch is to per or r pid colonic l v ge by
pl cing n NG tube nd giving 6 L (1.5 g llons) o polyethylene
glycol (GoLytely) over 4 hours nd per or colonoscopy to try
to nd the bleeding site nd tre t it. O en ultiple blood lled
diverticuli re seen, nd the source o the bleed c nnot be iden-
ti ed. T e second ppro ch is to per or t gged RBC sc n to
con r ctive bleeding, ollowed by selective ngiogr phy to
identi y the bleeding vessel nd e bolize it. T e ppro ch t ken
depends on the loc l expertise v il ble. Without tre t ent,
25% o p tients eventu lly rebleed nd o those who rebleed,
50% will h ve third bleed.
HELPFUL TIP:
The wh le thi g ab ut av idi g eed a d ut i th e
with diverticular di ea e i —pu i te ded— ut . I
act, patie t wh eat p pc r , ut , eed , etc., have a
lower i cide ce recurre t diverticular di ea e (JAMA.
2008;300:907). G d thi g, t , p pc r ha helped
uel ur b k editi g!
Objectives: Did you learn to . . .
• Ide ti y ig a d ympt m diverticuliti ?
• Appreciate the atural hi t ry diverticular di ea e?
• Ma age c mplicati diverticular di ea e?
CHAPTER 7 • GAs TRo En TERo Lo GY 235
QUICK QUIZ: CAn ’T s To P PUKIn G
M ry J ne is 27-ye r-old e le who presents to your clinic
co pl ining o recurrent bdo in l p in nd vo iting d ily
or the l st 6 onths. T e only w y th t she c n relieve the
sy pto s is to either sit in hot b th or t ke hot shower. She
does this co pulsively nd is the cle nest p tient you h ve ever
seen; she liter lly shines. In this c se, though, cle nliness y
not be next to godliness. Soci l history is re rk ble or d ily
use o riju n , tob cco use o ½ p ck per d y, nd bout 1 to
2 lcoholic drinks per d y. When her b ck hurts, she will t ke
her boy riend’s oxycodone— bout once per week.
T is beh vior is typic l or which o the ollowing disorders?
A) Cyclic vo iting syndro e.
B) C nn bis hypere esis syndro e.
C) Opioid bowel syndro e.
D) C t eni l cyclic vo iting syndro e.
E) Vo it-Shower-Vo it syndro e.
The correct answer is “B.” T is history is typic l o c nn bis hy-
pere esis syndro e. T is occurs in p tients who re requent
riju n users. C nn bis hypere esis syndro e is resist nt to
typic l ntie etics, but p tients will h ve n b te ent o their
sy pto s while they re in b th or shower (why is unknown).
T e syndro e resolves once they stop using riju n . “A”, cy-
clic vo iting syndro e, occurs in a stereotypical pattern; or
ex ple, p tient y h ve onset t 3:00 a m (2:00 to 7:00 a m
is the ost co on ti e) with preceding n use , p llor, b-
do in l p in nd norexi . Children usu lly h ve 12 cycles per
ye r s co p red to 4 in dults. E ch cycle y l st sever l d ys
or ore nd the p tient h s nor l he lth in between episodes.
T is y be igr ine v ri nt nd nti igr ine edic tions
re worth trying. “C”, opioid bowel syndro e, re ers to blo ting,
p in, distension nd vo iting ound in opi te users (not just
due to constip tion). It is prob bly hyper lgesi syndro e nd
resolves when opi tes re stopped (good luck with th t!). “D,”
c t eni l cyclic vo iting syndro e, is cyclic vo iting rel ted
to enses, which is not described in this c se since it is occur-
ring d ily. “E” sounds silly nd ction l—which it is.
Clinical Pearls
All patie t 50 year ld r lder with at lea t a 10-year li e
expecta cy h uld u derg r uti e c l ca cer cree i g;
vari u meth d are acceptable.
D t re er patie t r ch lecy tect my i they have
a ympt matic ch lelithia i .
D t re er patie t r upper e d c py (EGD) i they have
typical heartbur a d alarm ympt m (e.g., dy phagia,
weight l ).
Feed patie t with pa creatiti ce their au ea a d pai
begi t ub ide. Early eedi g i a ciated with better ut-
c me . There i eed r a jeju al tube i they t lerate ral
eedi g .
236 FAMILY MEDICIn E EXAMIn ATIo n & Bo ARD REVIEW
Ga tr pare i ca be cau ed by diabete a d al by viral
GI i ecti , thyr id di ea e, a d aut immu e di ea e.
P tviral ga tr pare i ca la t r up t a year.
I a cree i g c l c py i c mpletely egative, d
repeat c l ca cer screening a y ki d r 10 year .
M t pa creatiti i cau ed by gall t e r alc h l; ther
cau e (viral, drug i duced, elevated triglyceride , c rpi
ti g , etc.) are much le c mm .
s cree r hepatiti C at lea t ce i all U.s . adult b r
betwee 1945 a d 1965.
There i ab lute umber epi de diverticuliti that
ma date urgery. Tail r the treatme t t the patie t.
Titrate pr t pump i hibit r therapy t the l we t t lerable
d e— r di c ti ue, i p ible—a ter i itial therapy r
GERD. Remember that there i reb u d hyperacidity whe
t ppi g PPI r H2 bl cker .
BIBLIOGRAPHY
Biesiekierski JR, et l. No E ects o gluten in p tients with
sel -reported non-celi c gluten sensitivity er diet ry
reduction o er ent ble, poorly bsorbed, short-ch in
c rbohydr tes. Gastroenterology. 2013;145:320–328.
Eisenberg JM. M n ging chronic g stroesoph ge l re ux dis-
e se. AHRQ Co p r tive E ectiveness Reviews.
www.e ectivehe lthc re. hrq.gov/gerdupd te.c .
Accessed J nu ry 16, 2012.
Ford AC, et l. Ef c cy o prebiotics, probiotics, nd synbiot-
ics in irrit ble bowel syndro e nd chronic idiop thic
constip tion: syste tic review nd et - n lysis. Am J
Gastroenterol. 2014;109:1547–1561.
Heidelb ugh JJ, Bruderly M. Cirrhosis nd chronic liver
ilure: P rt I. Di gnosis nd ev lu tion. Am Fam
Physician. 2006;74(5):756–762.
Heidelb ugh JJ, Sherbondy M. Cirrhosis nd chronic liver
ilure: p rt II. Co plic tions nd tre t ent. Am Fam
Physician. 2006;74(5):767–776.
J cobs DO. Clinic l pr ctice. Diverticulitis. N Engl J Med.
t 2007;357:2057–2066.
Ji ng D. C re o chronic liver dise se. Prim Care. 2011;
38:483–498; viii-ix.
L nz FL, et l; Pr ctice P r eters Co ittee o the
A eric n College o G stroenterology. Guidelines or
prevention o NSAID-rel ted ulcer co plic tions. Am J
Gastroenterol. 2009;104:728–738.
Longstreth GF, et l. Function l bowel disorders. Gastroenter-
ology. 2006;130:1480–1491.
M l ertheiner P, et l. Peptic ulcer dise se. Lancet. 2009;
374(9699):1449–1461.
Mo yyedi P, et l. T e e ect o ber supple ent tion on
irrit ble bowel syndro e: syste tic review nd
et - n lysis. Am J Gastroenterol 2014;109:1367–1374.
Nery F, et l. C uses nd consequences o port l vein thro bo-
sis in 1,243 p tients with cirrhosis: results o longitudin l
study. Hepatology. 2015;61:660–667.
Rockey DC. Occult g strointestin l bleeding; pri ry c re.
N Engl J Med. 1999;341(1):38–46.
Sw roop VS, et l. Severe cute p ncre titis. JAMA. 2004;291:
2865–2868.
ck J, et l. Function l g stroduoden l disorders. Gastroenter-
ology. 2006;130:1466–1479.
United St tes Preventive Services sk Force. Screening or Colon
C ncer. 2008. http://www. hrq. gov/clinic/uspst /uspscolo.
ht . Accessed J nu ry 16, 2012.
Veter ns A irs. Guidelines or the re t ent o Hep titis C.
http://www.hep titis.v .gov/pd /tre t ent-
consider tions-2015–07.pd . Accessed October 15, 2015.
Whico b DC. Clinic l pr ctice. Acute p ncre titis. N Engl J
Med. 2006;354:2142–2150.
Infectious Diseases
Margo Schilling
CASE 8.1
Flu season is right around the corner and you are preparing
your clinic or the onslaught. First things rst . . . you need to
know how much vaccine to order and who will be receiving
it. T e Centers or Disease Control and Prevention (CDC)
annually publishes recommendations or administering
in uenza vaccine to the American public.
Question 8.1.1 The CDC recommends vaccination or all o
the ollowing groups, EXCEPT:
A) Healthcare workers
B) Nursing home residents
C) Egg-allergic, ebrile neonates
D) Diabetics
E) T e elderly
Answer 8.1.1 The correct answer is “C.” We start this chapter
with an easy one. Patients 6 months o age or younger should
not be vaccinated nor should children who are ebrile. T e
only other absolute contraindication to in uenza vaccination
is a known hypersensitivity to eggs or to other components o
the in uenza vaccine. Patients with an egg allergy can get the
recombinant u vaccine. T e egg based vaccine can still be used
in those who’s only reaction to eggs is hives i they are observed
or thirty minutes a er the injection (CDC 2016).
HELPFUL TIP:
Vaccinate all persons older than 6 months ann ally.
There are several types o vaccine available: trivalent
and q adrivalent inactivated in l enza vaccines (the old-
ashioned l shot), intradermal vaccine (e.g., Fl zone) or
patients 18 to 64 years o age, high-dose intram sc lar
vaccine or the elderly, and the intranasal live atten ated
in l enza vaccine (e.g., Fl Mist). Live atten ated in l -
enza vaccine is indicated or healthy, nonpregnant per-
sons aged 2 to 49 years, incl ding healthcare workers—
except for healthcare workers caring for very immu-
nosuppressed patients such as bone marrow trans-
plant patients. Contact with patients with HIV is not a
contraindication to the live atten ated vir s.
8
Oh, no! T e virus has struck. Like a zombie apocalypse,
it started with just a ew cases, but now it’s out o control.
Every other patient who calls complains o in uenza-like
illness.
Question 8.1.2 During this outbreak, what intervention(s)
is/are most appropriate or all your unvaccinated, rail nurs-
ing home patients who have no symptoms o ebrile respi-
ratory illness?
A) Antiviral prophylaxis with oseltamivir
B) Antiviral prophylaxis with amantadine
C) In uenza immunization
D) A and C given together
E) B and C given together
Answer 8.1.2 The correct answer is “D.” Persons at high risk
or complications o in uenza can still be vaccinated a er an
outbreak o in uenza has begun in the community, but develop-
ment o antibodies in adults can take up to 2 weeks. T us, che-
moprophylaxis should be considered or persons at high risk
during the time rom vaccination until immunity has devel-
oped. “A” alone might be appropriate or individuals who have a
contraindication to vaccination and wish to protect themselves
rom in uenza. “B” is not correct because in uenza A is increas-
ingly resistant to M2 drugs (e.g., amantadine, rimantadine), and
in uenza B has never been sensitive them. Vaccination alone
(“C”) can be used in individuals without known high-risk con-
ditions (chronic disorders including asthma, diabetes, renal
dys unction, immunode ciency or cardiovascular disease). But,
as noted above, vaccine alone is inadequate or those who are
institutionalized or have signi cant comorbidities. T ese higher
risk patients also need to be covered by oseltamivir until immu-
nity has developed (2 weeks).
HELPFUL TIP:
Sensitivity and speci icity o rapid diagnostic tests or
in l enza (70–75% and 90–95%, respectively) are lower
than viral c lt re b t tend to be more clinically se l
since early treatment is req ired to achieve maxim m
bene it rom antiviral dr gs.
237
238 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
HELPFUL TIP:
For a speci ic patient, tests o the vir s or s sceptibil-
ity to speci ic antivirals are not clinically se l d e to
the time req ired to get res lts. However, trends in the
comm nity g ide empiric therapy. Resistance varies by
year. Resistance o in l enza A H1N1 to oseltamivir was
99% in 2009. However, in 2013 to 2014 98.2% o in l -
enza A H1N1 isolates tested were susceptible to osel-
tamivir. The CDC monitors and reports ann al in l enza
antiviral sensitivity res lts on their website, www.cdc.
gov/ l .
Question 8.1.3 Which o these patients would quali y or
antiviral therapy during an in uenza outbreak?
A) A healthy 29-year-old male who presents 72 hours a er
onset o symptom onset and has a positive rapid test or
in uenza
B) A 70-year-old patient hospitalized with in uenza who pres-
ents 72 hours a er onset o symptoms
C) A pregnant women who presents within 48 hours o symp-
tom onset and has a positive rapid test or in uenza
D) B and C
E) All o the above
Answer 8.1.3 The correct answer is “D.” In outpatients, anti-
viral drugs are reserved or high-risk groups including preg-
nancy, age > 65 years, signi cant underlying medical illness
(DM, immunosuppression, morbid obesity, asthma, etc.), nurs-
ing home residents and children age < 2 years. Normal risk
outpatients should be prioritized lower on the treatment lad-
der. However, the CDC does recommend that antiviral drugs
be considered or otherwise healthy outpatients with con rmed
in uenza who can start medication within 48 hours o symptom
onset. All hospitalized patients should be treated even i it is
> 48 hours a er onset o symptoms.
T e director o nursing at your community nursing home
calls about an outbreak o ebrile respiratory in ections.
In the last 24 hours, three patients have become ill on the
dementia care unit. All residents o the home were vacci-
nated with the current year’s in uenza vaccine in Novem-
ber. Several o the aides have not been vaccinated and two
recently le work a er complaining o eeling tired, everish,
and achy.
Question 8.1.4 You suspect an in uenza outbreak and take
the ollowing actions EXCEPT:
A) Quarantine the nursing home and restrict access or visitors,
new admissions, and ill sta
B) Hospitalize all patients suspected o having in uenza
C) Limit the interaction o ill residents with non-ill residents
D) Administer antiviral prophylaxis to all well residents
E) Provide in uenza vaccine to any unvaccinated residents and
sta
Answer 8.1.4 The correct answer is “B.” Moving sick patients
only risks spreading the in ection to the hospital. In addition
to measures above, employees should be assigned to one work
area only to prevent spread via the sta . Activities, visits, and
gatherings in central common areas should be curtailed during
the outbreak.
HELPFUL TIP:
In l enza vaccine is only abo t 50% e ective in n rsing
home patients. Still, there is some herd imm nity and
vaccination is recommended as the primary way to pre-
vent an in l enza o tbreak. Considering all the options,
vaccinating sta may be the most e ective method to
prevent n rsing home o tbreaks.
Question 8.1.5 Time to update the pneumococcal vaccine
protocol at your nursing home! In accordance with 2015
CDC recommendations or older adults, you institute the
ollowing schedule or all patients at age 65 who have not
yet received a pneumococcal vaccination:
A) 23-valent pneumococcal polysaccharide vaccine (PPSV23)
once only
B) 13-valent pneumococcal conjugate vaccine (PCV13) once
only
C) PPSV23 ollowed by PCV13 one year later
D) PCV13 ollowed by PPSV23 one year later
E) Cowpox . . . lots and lots o cowpox
Answer 8.1.5 The correct answer is “D.” Indications or pneu-
mococcal vaccination include patients with chronic illness
at high risk or invasive pneumococcal disease (e.g., diabetes,
chronic pulmonary disease, and cardiovascular disease), institu-
tionalization, age 65 or older, immunocompromised state, and
tobacco use. Note that the tobacco use indication is relatively
recent and applies to all patients age 19 to 64 years old. T ere are
two pneumococcal vaccinations, (Pneumovax) and 13-valent
pneumococcal polysaccharide conjugate vaccine (PCV13 or
Prevnar-13). All adults aged 65 or older should receive both
vaccines. PCV13 should be administered be ore PPSV23
when practicable. PCV13 is also recommended or patients
with end-stage renal disease, asplenia, HIV, and many other
conditions. PVC13 vaccine is not indicated or those < age 65
only on the basis o smoking or the presence o lung disease (as
o 2015). However PPSV23 is indicated or both smokers and
those with COPD who are < 65 years o age.
HELPFUL TIP:
The most common ca se o bacterial pne monia com-
plicating in l enza is S. pneumoniae. However, Staphy-
lococcus aureus pne monia ( s ally ncommon in the
comm nity) is an important entity d ring in l enza
o tbreaks and generally presents with more severe
symptoms.

Objectives: Did you learn to . . .
• Describe who sho ld receive in enza and pne mococcal
vaccines?
• Identi y appropriate interventions to halt the transmission o
in enza in comm nity and care acility o tbreaks?
• Lead a s ccess l in enza prevention program in a health-
care setting?
• Prescribe in enza antivirals appropriately?
QUICK QUIZ: THE COMING PLAGu E
T e clinic triage nurse comes to you with a concern about a
patient who has just walked into clinic and is at the ront desk.
She is a 28-year-old Peace Corps worker who returned 10 days
ago rom a western A rican country in the midst o an Ebola
epidemic. She is otherwise healthy but started having a ever
suddenly last night. She describes atigue, night sweats, myal-
gia, and temperature o 38.5°C. T is morning she notes vom-
iting and diarrhea with blood in the stool. T e patient thinks
that she has a benign viral illness (“everyone was coughing on
the plane”) and does not recall any contacts with persons with
Ebola.
You tell the nurse:
A) “We will work her in. Just have her hang out in the waiting
room.”
B) “Give her any mask you can nd and send her to the ER.
Pronto.”
C) “Isolate the patient immediately in an examination room
(pre erably negative laminar ow i available) and call the
health department.”
D) “Shut down the whole clinic! We’re on lockdown!”
The correct answer is “C.” T is patient has been in an area o
Ebola epidemic, has the classic symptoms o Ebola ( ever, di-
arrhea, vomiting, bleeding [in this case in her stools]). Other
symptoms include meningoencephalitis, di use rash, a relative
bradycardia or the degree o ever (similar to that seen with
typhoid). reat her as though she has Ebola until proven other-
wise. Ebola is highly contagious and is spread by contaminated
body uids, including aerosolized droplets. You should endeav-
or to limit exposure o others to the ill patient, so “A” and “B”
are incorrect, as both options expose more persons. T e health
department in your area should be involved immediately, and
they would be in contact with the CDC. T e CDC recommends
symptomatic patients at risk or Ebola exposure be isolated
(a private examination room with doors closed is likely suf -
cient) and treated at the direction o public health authorities.
“D” is incorrect. Despite its contagious nature, causal exposure
to a patient with Ebola (e.g., sitting 10 away in the reception
area as she walks by) is unlikely to result in transmission. Re-
member that the persons at highest risk during the 2014 to 2015
Ebola outbreak in West A rica were healthcare workers and
caregivers o the Ebola patients. T e incubation period o Ebola
is 2 to 21 days. T e virus can persist in the sperm, eye, breast
milk and CNS or months a er symptoms have resolved.
CHAPTER 8 • INFECTIOu S DISEASES 239
CASE 8.2
An 80-year-old emale ell, broke her hip, and underwent
intraoperative repair with pinning o the racture. She devel-
oped a local in ection at the site o the repair and was treated
with a 10-day course o oral clindamycin. She was trans erred
to the nursing home or rehabilitation and has developed
loose, watery stools. oday when you visit her, she reports
eeling di use abdominal discom ort and has had 10 bowel
movements. She is very concerned because she cannot work
with the therapist and risks losing her Medicare bene t or
skilled nursing.
Question 8.2.1 You plan to do the ollowing:
A) Begin loperamide (Imodium) as needed to prevent diarrhea
during the therapy sessions.
B) Obtain stool specimens or Clostridium di cile toxin.
C) Obtain an abdominal C scan looking or evidence o
obstruction.
D) Ask your avorite gastrointestinal (GI) doctor to per orm
emergency endoscopy or evaluation o lower GI bleed.
E) Obtain stool specimens or ova and parasites.
Answer 8.2.1 The correct answer is “B.” C. di cile is the most
common bacterial cause o in ectious diarrhea in hospitalized
patients in the United States (Campylobacter jejuni is the most
common bacterial cause overall). Multistep diagnostic algo-
rithms using polymerase chain reaction (PCR) or the toxin
gene(s) have the best test per ormance characteristics (sensitiv-
ity 68–100% and speci city 92–100%). esting should be per-
ormed on only symptomatic patients. T ere is no bene t rom
testing more than one stool specimen. Although symptomatic
therapy is important, “A” is incorrect because antiperistaltic
agents should be avoided in patients with C. di cile. Although
other causes o diarrhea are possible, the most cost-e ective
approach in this patient would be laboratory testing or C. di -
cile according to local laboratory protocol prior to any other
more invasive procedure.
HELPFUL TIP:
The gold standard test or detecting C. di icile in the
stool is the cytotoxin assay, b t it is not commonly per-
ormed beca se it takes p to 2 days to per orm and is
more costly.
A stool specimen reveals the presence o C. dif cile toxin A
gene. T e patient is nontoxic with a normal complete blood
count (CBC) and creatinine.
Question 8.2.2 The pre erred, rst line, treatment o this
patient should include:
A) Di cid ( daxomicin)
B) Lactose restriction and acidophilus milk products
C) Metronidazole 500 mg PO ID or 10 days
D) Vancomycin 250 mg PO QID or 10 days
E) B and C
240 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Answer 8.2.2 The correct answer is “C.” reatment o C. di -
cile in ection (CDI) includes supportive care, discontinuation
o the o ending antimicrobial agent, and initiation o oral met-
ronidazole 250 mg our times daily or 500 mg three times or
10 days. Metronidazole has been pre erred over vancomy-
cin (“D”) or the treatment o mild CDI because o lower cost
and lower theoretical risk o promotion o vancomycin resis-
tant Enterococcus aecalis (VRE). Based on a recent study that
showed lower clinical success rate or metronidazole versus
vancomycin, it may be reasonable consider vancomycin rst
line or mild to moderate CDI and always i the patient has
severe CDI (white blood cell [WBC] >15000, creatinine >1.5×
baseline). Di cid ( daxomicin) was approved or treating CDI
in 2011. Randomized studies demonstrate similar cure rates
between daxomicin and oral vancomycin, with ewer recur-
rences with daxomicin. Fidaxomicin—at a much higher cost—
may be used or recurrent CDI or when there is a high risk o
recurrence. Fecal microbiota transplantation is associated with
resolution o recurrent CDI but its role in primary and severe
CDI has not been established. T ere is limited evidence that use
o probiotics is e ective in the treatment o C. di cile in ection
and prevention o recurrence. Please see help ul tip below.
Question 8.2.3 Risk actors or C. dif cile in ection in nurs-
ing home patients include:
A) Advanced age
B) Recent acute hospitalization
C) Proton pump inhibitor (PPI) use
D) Long-term residence in a chronic care acility
E) All o the above
Answer 8.2.3 The correct answer is “E.” Risk actors or acquisi-
tion o CDI in nursing home patients are similar to that o hos-
pitalized patients and include hospitalization, advanced age, GI
surgery/procedures, antibiotic exposure, and importantly PPI use.
HELPFUL TIP:
C. di icile diarrhea and colitis can be ca sed by any an-
tibiotic, incl ding metronidazole and vancomycin. The
probability o diarrhea seems highest with clindamycin.
Fl oroq inolones and broad spectr m cephalosporins
are increasingly associated with C. di icile in ection,
incl ding a highly toxigenic strain. Simply stopping the
antibiotic can lead to resol tion in 25% o the cases.
Failure to resolve C. dif cile-associated diarrhea a er a 10-day
course antibiotic therapy is common. Guess what? Your
patient’s diarrhea has persisted.
Question 8.2.4 The most reasonable treatment approach
is to:
A) Repeat a course o oral metronidazole
B) reat with a course o oral vancomycin
C) reat with a course o intravenous (IV) vancomycin
D) A or B
E) B or C
Answer 8.2.4 The correct answer is “D.” Relapse and/or recur-
rence is very common. ypically about 20% o patients have
a recurrence o symptoms within about 1 week o completing
therapy. T ese patients usually respond to re-treatment with
either metronidazole or oral vancomycin. IV vancomycin is
ine ective treatment o C. di cile since vancomycin does not
enter into the GI tract rom the vascular space.
HELPFUL TIP:
C. di icile toxin degrades at room temperat re. A stool
that has been at room temperat re or 2 ho rs will like-
ly be negative or C. di icile toxin even i the toxin was
initially present. A potential ca se o C. di icile nega-
tive pse domembrano s colitis is Klebsiella oxytoca.
Consider this i stool st dies are negative or C. di icile.
Finally, a positive stool culture is not diagnostic o in-
ection. C. di icile is a normal g t lora. The presence o
toxin sho ld be demonstrated to diagnose C. di icile
in ection or pse domembrano s colitis.
HELPFUL TIP:
Altho gh req ently sed in the prevention and treat-
ment o CDI, the e ectiveness o probiotics is ncertain.
G t lora is amazing (abo t 1014 bacteria rom 1,200 di -
erent species live in symbiosis with yo ), and adding a
little acidophil s might not c t it. In partic larly recalci-
trant cases, ecal microbiota (stool, basically) transplan-
tation can be per ormed. Patients are given “healthy”
stool via NG t be or colonoscopy to reestablish normal
GI lora. Y m. Altho gh a little y cky, it appears q ite
sa e.
Objectives: Did you learn to . . .
• Recognize the presentation o C. di cile in ection?
• Identi y risk actors or the development o C. di cile
diarrhea and colitis?
• Treat patients with initial and rec rrent C. di cile in ections?
CASE 8.3
You are called to the emergency department (ED) to exam-
ine a 40-year-old man with ever (temperature o 39°C) and
headache. His past history is remarkable only or a splenec-
tomy secondary to trauma at age 10. He is not allergic to any
antibiotics. Upon examination you note that he has menin-
geal signs. Nondilated undal examination shows sharp disc
margins, and he is neurologically intact with a non ocal
examination.
Question 8.3.1 The most appropriate action is:
A) Obtain a head C so that you can sa ely proceed with lumbar
puncture (LP).
B) Order IV penicillin as you prepare to per orm LP.
C) Per orm a LP immediately and begin antibiotic therapy
empirically.

D) Order IV erythromycin as you prepare to per orm LP.
E) Order IV vancomycin and IV ce riaxone as you wait or the
CBC. I the CBC is abnormal, you will do the LP.
Answer 8.3.1 The correct answer is “C.” Once you suspect
bacterial meningitis, rapid diagnostic evaluation and emergent
treatment are imperative, including LP and blood cultures. I LP
is going to be delayed, then appropriate empiric antimicrobial
and adjunctive therapy should be given without delay. Head
C is necessary only in those who are immunocompromised
(HIV/AIDS, those receiving immunosuppressive drugs, trans-
plant recipients), have a history o CNS disease (brain tumor
and stroke), develop new onset seizures, display papilledema on
examination, or who have an abnormal/ ocal neurologic de cit
or abnormal level o consciousness. Antibiotics or a 40-year-old
male should cover Neisseria meningitidis and S. pneumoniae, and
would include vancomycin and ce riaxone (“E”). However, “E”
is not the best choice. Never wait or a CBC to determine i an
adult needs an LP. T e decision to do an LP is a clinical one.
HELPFUL TIP:
I the preponderance o initial clinical and laboratory
data indicate that bacterial meningitis is likely and the
LP cannot be done immediately, draw blood c lt res
and administer dexamethasone and appropriate antibi-
otics. Yo won’t change the CSF c lt re res lts (in most
cases) i yo give a single dose o antibiotics be ore the
LP. However, it is considered pr dent to do the LP with-
in 2 ho rs o administering IV antibiotics. The standard
of care for suspected meningitis is to administer an-
tibiotics within 30 minutes of the patient presenting
to the ED.
Results o the cerebrospinal uid (CSF) obtained a er LP are
as ollows: cloudy, WBC count 5,000 cells/mm3, 95%neutro-
phils, glucose 20 mg/dL, and Gram-positive cocci in pairs.
Question 8.3.2 The most likely pathogen is:
A) S. pneumoniae
B) Listeria monocytogenes
C) S. aureus
D) N. meningitidis
E) Pseudomonas species
Answer 8.3.2 The correct answer is “A.” Gram stain exami-
nation o CSF may permit rapid identi cation o the causative
organism in bacterial meningitis with a sensitivity o 60% to
90%. Prior antibiotic therapy (e.g., a partially treated menin-
gitis . . . not a single dose o antibiotics in the ED) may reduce
the sensitivity by 20%. T e likelihood o a positive Gram stain
is highest in cases o S. pneumoniae (a Gram-positive diplo-
coccus). Only about one-third o L. monocytogenes menin-
gitis cases demonstrate a positive Gram stain. “D” requires
special mention. N. meningitidis is a diplococcus but is Gram
negative.
CHAPTER 8 • INFECTIOu S DISEASES 241
Question 8.3.3 An adjunctive therapy that has been shown
to improve neurologic outcomes in pneumococcal menin-
gitis is:
A) Dexamethasone
B) Activated protein C
C) Vasopressors
D) CSF shunt implantation
E) Monoclonal antibody directed against the capsule antigen o
the bacterium.
Answer 8.3.3 The correct answer is “A.” T e In ectious Disease
Society o America (IDSA) guideline recommends adjunctive
dexamethasone to be administered to all adult patients with
pneumococcal meningitis. No other adjunctive therapy has
proven bene t. Since the organism is not usually known at the
time o initiation o therapy, dexamethasone should be given
empirically until the causative organism is identi ed. I the
meningitis is not due to S. pneumoniae, dexamethasone should
be discontinued.
Patients should receive standard supportive therapies in an
intensive care setting. Complications, when they occur, usually
develop within the rst 2 to 3 days o therapy. Complications
include sepsis, mental status changes, and electrolyte abnor-
malities.
Question 8.3.4 Highly resistant S. pneumoniae in ections o
the CNS should be treated with:
A) T ird-generation cephalosporin
B) Vancomycin and a third-generation cephalosporin
C) High-dose penicillin G
D) Ampicillin
E) Vancomycin, gentamycin, and ri ampin
Answer 8.3.4 The correct answer is “B.” Vancomycin should
be combined with a third-generation cephalosporin (e.g., ce -
triaxone and ce otaxime) or highly resistant pneumococ-
cus. Do not use vancomycin alone; it does not cover Gram-
negative organisms. T e newer generation uoroquinolones
have enhanced in vitro activity against S. pneumoniae and may
be used as alternative agents. However, uoroquinolones are
not recommended unless the patient cannot tolerate or is
allergic to standard drugs.
HELPFUL TIP:
Resistance to penicillins (and others) is noted by the
minim m inhibitory concentration (MIC). For penicillin,
highly resistant pne mococc s has an MIC o >2 µg / mL,
intermediate resistance is 0.12 to 1 µg / mL while sensi-
tive is <0.06 µg / mL.
HELPFUL TIP:
The combination o Kernig and Br dzinski signs carries
a sensitivity and speci icity o 5% and 95%, respectively.
Th s, the great majority o patients do not mani est
these signs when they have meningitis, and they are
242 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
seless to r le o t meningitis. The sensitivity and speci-
icity o n chal rigidity (sti neck) is 30% and 68%, re-
spectively. In ad lts, the classic triad o ever, n chal
rigidity, and altered mental stat s was o nd in only
46%, with 85% having ever, 70% having neck sti ness,
and 67% having mental stat s changes.
Objectives: Did you learn to . . .
• Diagnose meningitis?
• Identi y the most likely ca sative organism based on epide-
miology and patient characteristics?
• Describe proper se o empiric antibiotics and steroid
therapy or bacterial meningitis?
QUICK QUIZ: BIG MENINGITIS ON CAMPu S
What is the most common bacterial cause o meningitis in
college-aged patients who live in dormitories?
A) N. meningitidis
B) S. pneumococcus
C) L. monocytogenes
D) Haemophilus in uenzae
E) Escherichia coli
The correct answer is “A.” Although S. pneumococcus is the
most common cause o bacterial meningitis in the adult pop-
ulation in the United States, N. meningitidis remains the lead-
ing cause in adolescents despite vaccination and is particularly
prevalent in the setting o dormitory living (e.g., college or mili-
tary). In addition, the presence o petechial (or purpuric) rash
in the lower extremities and pressure points is typical o N. men-
ingitidis. T e advent o vaccination has made H. in uenzae a
less common cause. L. monocytogenes is more prevalent in those
over age 50, in ants, and the immunocompromised. E. coli is
a common cause or meningitis in neonates and in ants but is
very uncommon in adolescents and adults.
QUICK QUIZ: SPLEENLESS IN SEATTLE
Patients undergoing elective splenectomy should receive all o
the ollowing EXCEP :
A) PCV13 ollowed by PPSV23 at least 8 weeks later
B) H. in uenzae type B conjugate vaccine
C) In uenza vaccine
D) Meningococcal vaccine
E) Oral polio vaccine
The correct answer is “E.” Oral polio vaccine is no longer rec-
ommended in the United States or anyone. T e risk o devel-
oping polio rom the live vaccine outweighs the bene t o
oral administration. All patients undergoing elective splenec-
tomy should receive preoperative vaccination against encap-
sulated organisms at least 14 days prior to splenectomy; this
includes vaccines against S. pneumoniae, meningococcus, and
H. in uenzae type B (all encapsulated bacteria). New recom-
mendations or all pneumococcal vaccine-naive immunosup-
pressed adults, including those with asplenia, advise vaccina-
tion with a dose o PCV13 rst, ollowed by a dose o PPSV23
at least 8 weeks later. Splenectomized individuals should be
re-immunized against pneumococcus in 5 years with a second
PPSV23. Patients who have undergone splenectomy need to
be educated about seeking prompt medical attention or ever.
CASE 8.4
A 74-year-old woman is in your of ce or a complete physical.
As part o her routine labs, you obtain a urinalysis (although
why is beyond us . . . there is no recommendation or a screen-
ing urinalysis or any nonpregnant patients). On urther
questioning, she has actually had stress urinary incontinence
or a number o years, which is unchanged. She reports no
evers, hematuria, dysuria, ank pain, or other symptoms.
T e urinalysis shows 10 to 20 WBC/hp and is nitrite positive
on dipstick. A culture o the urine shows 100,000 c u/mL o
E. coli.
Question 8.4.1 How should you treat this patient?
A) rimethoprim-sul amethoxazole DS 1 tab PO BID or
10 days
B) Erythromycin 500 mg PO q 6 hours or 14 days
C) Ampicillin 250 mg PO q 6 hours or 10 days
D) Ce riaxone 1 g IM every day or 3 days
E) With courtesy and respect, but not with antibiotics
Answer 8.4.1 The correct answer is “E.” A positive urine culture
in an asymptomatic patient (i.e., asymptomatic bacteriuria)
should not be treated with antibiotics except during pregnancy.
Asymptomatic bacteriuria is a very common nding, especially
in elderly emales, persons with indwelling catheters, and insti-
tutionalized persons. reatment does not reduce the incidence
o symptomatic in ection. reatment also does not reduce mor-
tality in rail elderly patients, and does not improve chronic
urinary incontinence symptoms. Persistent asymptomatic bac-
teriuria does not result in renal insuf ciency or the develop-
ment o hypertension.
Question 8.4.2 Which statement is true o asymptomatic
bacteriuria?
A) T e nding o pyuria in a urinalysis distinguishes urinary
tract in ection (U I) rom asymptomatic bacteriuria and
guides treatment decisions.
B) T e prevalence o asymptomatic bacteriuria in women is
unrelated to age, unction, or hormonal status.
C) Asymptomatic bacteriuria need not be treated in the preg-
nant patient.
D) None o the above.
Answer 8.4.2 The correct answer is “D.” None o the statements
are true. “A” is incorrect because the nding o pyuria with low
numbers o WBCs in a urinalysis specimen is nonspeci c, com-
mon, and requently unrelated to in ection. “B” is incorrect. T e

prevalence o asymptomatic bacteriuria in women increases
with age, declining unctional capabilities, and institutionaliza-
tion. More than 10% o community-dwelling women over the
age o 65 and up to 50% o elderly women in nursing homes will
have asymptomatic bacteriuria. “C” is incorrect. Pregnancy is
one state in which treating asymptomatic pyuria/bacteriuria is
indicated. T e risk o in ection rom asymptomatic bacteriuria
is high in pregnant patients.
HELPFUL TIP:
Treat asymptomatic bacteri ria in the ollowing pa-
tients: those with rinary tract obstr ction ( nctional
or anatomic), nephrolithiasis, pregnancy, or planned
rinary instr mentation. In the past, men with as-
ymptomatic bacteri ria were considered candidates
or treatment. This is no longer the case. Men with as-
ymptomatic bacteri ria sho ld not be treated; it does
not improve o tcomes and leads to resistant organ-
isms (see http://www.choosingwisely.org/societies/
in ectio s-diseases-society-o -america/).
HELPFUL TIP:
Not all py ria is rom u TI. Other pathologic ca ses o py-
ria incl de vaginitis (in ectio s and atrophic), rethritis
(Chlamydia trachomatis, Neisseria gonorrhoeae ), and
genital herpes in ections.
A ew years later, the same patient is now 80 years old (you’re
still paying o your med school loans and will probably
work until you’re 80), and she is admitted to a nursing home.
Her initial tuberculin skin test ( S ) with 5-tuberculin unit
injection o puri ed protein derivative was interpreted as
0 mm diameter o induration a er 48 hours.
Question 8.4.3 What is your next step?
A) Repeat a S now
B) Repeat a S in 2 weeks
C) Repeat a S in 1 year
D) Declare the patient ree o B
E) Obtain a chest x-ray
Answer 8.4.3 The correct answer is “B.” Because the preva-
lence o a positive S (Mantoux test) doubles between the
rst and second tests in initial nonresponders, the U.S. Public
Health ask Force recommends a two-step S by the Man-
toux method or screening high-risk populations (e.g., per-
sons living in nursing homes). I the rst S is negative, a
second test should be per ormed approximately 2 weeks later
in order to detect the “booster phenomenon.” Individuals
admitted to a nursing home with a positive S and no symp-
toms o active B may be presumed to have a distant history
o in ection.
CHAPTER 8 • INFECTIOu S DISEASES 243
HELPFUL TIP:
False-positive TSTs can be d e to Bacille Calmette–
G erin (BCG) vaccine and in ection with other myco-
bacteria. However, most patients who had the BCG vac-
cine will experience a decline in imm nity (a maxim m
o 20% will have a positive TST d e to BCG 10 years a ter
the vaccine was given). I there is concern abo t a po-
tential alse-positive test, an inter eron gamma release
assay sho ld be per ormed. There can also be alse-
negative TSTs, especially in the imm nos ppressed.
I yo s spect impaired imm nity, se an inter eron
gamma release assay.
T e S is repeated 2 weeks later and is interpreted again as
0 mm diameter o induration a er 48 hours. You reassure the
patient that her tuberculin test is negative.
Question 8.4.4 What would most accurately represent a
positive TST in THIS patient?
A) Erythema 5 mm in diameter
B) Induration 5 to 10 mm in diameter
C) Erythema o 10 mm in diameter
D) Induration 10 mm in diameter
E) Erythematous induration o any size
Answer 8.4.4 The correct answer is “D.” Here is the bottom
line. Routine screening is not recommended or low-risk patients
(e.g., community dwelling individuals rom a low-risk coun-
try). Screen only the ollowing: contacts o those with B, HIV
in ected patients, IV drug users, those with predisposing actors
to B in ection (diabetes, immunosuppressive drugs, lung can-
cer, etc.), oreign-born individuals arriving in the United States
within the last 5 years, healthcare workers, nursing home and
other institutionalized individuals and the homeless. Measure
the induration and not the erythema. T e de nition o a posi-
tive S changes with the population tested. See able 8-1.
TABLE 8-1 INTERPRETATION OF TUBERCULIN
SKIN TESTS
Diameter o
Induration Positive in These Situations
5–10 mm Chest x-ray consistent with past or c rrent
in ection; HIV positive; recent close contact o
person with active TB.
10–15 mm Instit tionalized persons; IV dr g sers;
imm nocompromised states other than HIV;
children less than 4; children exposed to high-risk
ad lts, healthcare workers.
≥15 mm Persons witho t risk actors. These are people
who probably sho ld not have been tested in the
rst place (e.g., the general p blic witho t any
expos re to TB).
244 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
HELPFUL TIP:
Whole blood inter eron-gamma release assays, or IGRAs
(e.g., Q antiFERON-TB Gold test, T-SPOT) are Food and
Dr g Administration (FDA)-approved or se in any sit -
ation in which the TST is c rrently employed. IGRAs are
more expensive and sho ld not be the rontline screen-
ing test b t may help in sit ations in which the TST re-
s lt is q estionable. IGRAs are not 100% sensitive and
should not be sed in patients who are symptomatic;
they are or asymptomatic screening only and cannot
di erentiate latent rom active in ection.
A year later, the nursing home calls about her annual S .
You examine the patient and nd the diameter o indura-
tion is 12 mm. T e patient denies cough, weight loss, ever,
or chills.
Question 8.4.5 The most appropriate next step in this case
is to:
A) Obtain a chest radiograph and, i normal, initiate isoniazid
300 mg and pyridoxine or 9 months.
B) Obtain a chest radiograph and, i normal, observe the
patient annually or signs o active B (weight loss, cough,
ever, etc.).
C) Obtain a chest radiograph and, i abnormal, initiate isonia-
zid 300 mg once daily and pyridoxine or 9 months.
D) Obtain sputum specimens or acid- ast bacilli (AFB) stains
and mycobacterial culture and sensitivity testing; and initi-
ate therapy with isoniazid, pyridoxine, pyrazinamide, and
ri ampin or 6 months.
E) Obtain an inter eron-gamma release assay, and i negative,
observe the patient annually or signs o active B (weight
loss, cough, ever, etc.).
Answer 8.4.5 The correct answer is “A.” T e patient lives in
a high-risk setting (nursing home). T e results o her S
1 year ago suggest that she was not in ected with Mycobacte-
rium tuberculosis at that time. She has newly converted—prob-
ably due to exposure to an active case o B in the acility.
T e risk o developing active disease ollowing B in ec-
tion is greatest in the rst 2 years ollowing in ection. T e
risk/bene t ratio avors prophylactic therapy with isonia-
zid (INH) or the patient who has converted within the last
2 years, as long as there is no sign o active disease and the
chest x-ray is negative. Pyridoxine should also be given to
prevent peripheral neuropathy. A negative chest x-ray does
not mean that you can orego prophylactic therapy, and thus
“B” is incorrect. “C” is incorrect because an abnormal chest
radiograph must be ollowed with collection o sputum speci-
mens or AFB staining and culture. “D” is incorrect because
a chest radiograph is necessary to evaluate all patients with a
positive Mantoux skin test. Sputum specimens should be col-
lected and multiple drug regimens initiated only in patients with
signs and symptoms o active disease based on clinical history,
examination, and radiographic ndings. “E” is incorrect. Since
this patient has converted rom 0 to 12 mm induration in 1
year, her pretest probability is high enough that per orming an
IGRA adds nothing.
HELPFUL TIP:
A directly observed 3-month co rse o INH pl s
ri apentine once weekly may be an eq al alternative
to a 9-month co rse o daily sel -s pervised INH in
otherwise healthy patients o at least 12 years o age.
However recommendations remain nchanged and the
INH pl s ri apentine regimen is not recommended or
n rsing home elders.
HELPFUL TIP:
I active disease is diagnosed, appropriate therapy
sho ld be initiated with a 4-dr g regimen or 6 to
8 weeks ollowed by a simpler regimen or 4 to 7 months
once sensitivities are known (average 6 months total).
A n mber o regimens are available, and all incl de
isoniazid and ri ampin. INH alone is never appropri-
ate or active TB beca se o resistance. First-line dr gs
sed or active TB incl de isoniazid, ri ampin, pyrazin-
amide, and ethamb tol. Ethamb tol may be dropped
i the organism is sensitive to isoniazid, ri ampin, and
pyrazinamide. Second-line dr gs incl de levo loxacin,
streptomycin, and others. Regimens vary by location
and local resistance patterns. Contact yo r local health
department.
T e patient’s son is somewhat distraught that his mother has
B. He asks i she should have received a vaccine be ore com-
ing into the nursing home.
Question 8.4.6 Regarding the BCG vaccine, which o the
ollowing statements is true?
A) Foreign-born persons who received the BCG vaccine should
never have a S administered.
B) T e BCG vaccine is most ef cacious or older adults, and
children bene t much less rom the vaccine.
C) A S in an individual with a remote history o BCG vac-
cine should be interpreted as i the BCG had not been given.
D) T e BCG vaccine is made rom killed M. tuberculosis.
Answer 8.4.6 The correct answer is “C.” T e S should be
interpreted exactly the same way whether or not the patient has
received the BCG. “B” is incorrect. BCG is most ef cacious in
children but protection rom the vaccine wanes over a ew years.
Even in children, it is a poor vaccine, protecting children rom
B only about 50% o the time. Persons vaccinated with BCG
should still be evaluated by S when appropriate and an indu-
ration o >10 mm (age <35 years) or >15 mm (age ≥ 35 years) is

considered positive. “D” is incorrect. T e BCG vaccine is made
rom attenuated Mycobacterium bovis.
Prior to starting INH, you measured the patient’s amino-
trans erase levels, which were normal. Now, 3 months into
treatment, her alanine aminotrans erase (AL ) is 42 IU/L
(about twice the upper limit o normal).
Question 8.4.7 Your next step is to:
A) Stop her INH since she has had a ew months o treatment.
B) Continue the INH as scheduled and ollow up with clinical
and laboratory monitoring.
C) Switch to ri ampin and pyrazinamide.
D) Re er her to a hepatologist or liver biopsy.
E) Start her on milk thistle.
Answer 8.4.7 The correct answer is “B.” While liver injury
is a signi cant problem with isoniazid, the drug need not be
stopped unless the liver enzymes rise to more than three times
the upper limit o normal. Others would suggest that even then
the drug can be continued and that only signs and symptoms o
hepatitis ( atigue, anorexia, nausea, and vomiting) along with
urther liver enzyme elevations should prompt discontinuation
o the drug. “A” is incorrect because she should have 9 months
o prophylactic therapy. “C” is incorrect because ri ampin and
pyrazinamide have potentially more hepatotoxicity than INH.
Finally, “D” and “E” are incorrect. Neither liver biopsy nor
milk thistle (touted or its bene t in liver disease) is likely to
be use ul.
HELPFUL TIP:
u n ort nately, TB has developed resistance to n mero s
irst-line agents. There is dr g-resistant TB, m ltidr g-
resistant TB (MDR-TB), and extensively dr g-resistant
TB (XDR-TB). The di erences:
• Dr g-resistant TB is resistant to one o the irst-line
dr gs (INH, ri ampin, ethamb tol, streptomycin, pyra-
zinamide).
• MDR-TB is resistant to at least INH and ri ampin and
possibly more dr gs.
• XDR-TB is resistant to at least INH, ri ampin, l oro-
q inolones, and aminoglycosides or capreomycin or
both.
Objectives: Did you learn to . . .
• Determine who needs to be treated or asymptomatic bacte-
ri ria?
• Interpret TST res lts?
• Describe the BCG vaccine and how patients who receive it
sho ld be approached?
• Recommend appropriate treatment o a positive TST?
• Recognize complications o isoniazid therapy?
• De ine and recognize the importance o dr g-resistant
TB?
CHAPTER 8 • INFECTIOu S DISEASES 245
CASE 8.5
A 37-year-old woman with a history o mitral valve prolapse
and mitral regurgitation presents or evaluation. She reports
no symptoms o shortness o breath or exercise intolerance.
She plans to undergo health-screening procedures, including
dental exams or routine cleaning and lling o several caries,
pelvic examination with removal o an intrauterine device
(IUD), and colonoscopy in the next year.
Question 8.5.1 According to the American Heart Associa-
tion (AHA) 2007 guidelines on prevention o in ective endo-
carditis, what should she receive prior to these procedures?
A) Amoxicillin 2 g orally
B) Azithromycin 500 mg orally
C) Clindamycin 600 mg orally
D) Nothing
Answer 8.5.1 The correct answer is “D.” Even now it seems the
news has not made it to every corner o the world. But in 2007
there were major changes to the AHA guidelines on in ective
endocarditis prevention. T e one change that would seem to
a ect the greatest number o patients in primary care practices
is the “downgrading” o mitral valve prolapse with regurgita-
tion, which is no longer considered a high-risk condition. I the
patient had a condition or which prophylaxis was warranted,
all o the other regimens (“A,” “B,” “C”) are options depending
on the patient’s allergies and other medications, conditions, etc.
Question 8.5.2 According to the AHA 2007 guidelines on
the prevention o in ective endocarditis, which o the ol-
lowing conditions is NOT a high-risk condition or the
adverse outcome o in ective endocarditis?
A) Bioprosthetic aortic valve
B) Mechanical aortic valve
C) Congenital heart disease completely repaired with pros-
thetic material
D) Bicuspid aortic valve
E) Previous history o in ective endocarditis
Answer 8.5.2 The correct answer is “D.” T e guidelines recom-
mend antibiotic prophylaxis or conditions considered to be high
risk or adverse outcomes o in ective endocarditis. High-risk
conditions include prosthetic valves (bioprosthetic homogra
and allogra valves and mechanical valves), previous in ective
endocarditis, and complex cyanotic congenital heart disease.
HELPFUL TIP:
Moderate-risk conditions, for which prophylaxis is not
indicated, incl de acq ired valv lar dys nction, s ch
as rhe matic heart disease, hypertrophic cardiomyopa-
thy, bic spid aortic valve, and mitral valve prolapse with
a sc ltatory evidence o valv lar reg rgitation and / or
thickened lea lets. Hip replacement is also not a reason
or ro tine dental prophylaxis.
246 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
HELPFUL TIP:
In ective endocarditis is m ch more likely to res lt rom
transient bacteremia that occ rs with ro tine dental
care at home, like br shing and lossing, than rom den-
tal, GI, and Gu proced res. Accordingly, good oral hy-
giene to lower the risk o bacteremia is more important
than prophylactic antibiotics.
Question 8.5.3 I your patient had a mechanical aortic
valve, appropriate endocarditis prophylaxis might include:
A) Ampicillin IV 2 hours prior to colonoscopy i biopsy o
lesions is anticipated
B) Ampicillin IV 2 hours prior to pelvic examination and IUD
removal
C) Amoxicillin PO 2 hours prior to routine dental cleaning
D) Amoxicillin PO 2 hours prior to any injection o local anes-
thesia and lling o caries
E) All o the above
Answer 8.5.3 The correct answer is “C.” For high-risk con-
ditions (e.g., mechanical aortic valve), antibiotic prophylaxis
is recommended by the AHA prior to cleaning o teeth and
removal o plaque. T e risk o endocarditis is highest or
dental procedures that might traumatize the oral mucosa,
such as tooth extractions, periodontal procedures, and clean-
ing o teeth with removal o adherent plaque. “A,” “B,” and
“D” are incorrect. Prophylaxis is not recommended prior to
these procedures. T e risk o endocarditis is low or proce-
dures such as lower GI endoscopy and pelvic examination
with IUD removal, because the microorganisms likely to
cause transient bacteremia ollowing these interventions are
not capable o adhering to cardiac valve tissues. Antibiotic
prophylaxis is not recommended or restorative dental proce-
dures (e.g., llings).
All o the evaluations, including the dental examination,
seem to go well. However, 1 month later, she returns to see
you or gradually (perhaps even subacutely?) worsening
ever, malaise, and night sweats. You are concerned that she
may have developed in ective endocarditis.
Question 8.5.4 The evaluation o a patient suspected o
having subacute bacterial endocarditis (SBE) should include
all o the ollowing EXCEPT:
A) T ree sets o blood cultures obtained at 1-hour intervals
within the rst 24 hours o assessment
B) Auscultation o chest or evidence o new or changing
murmur
C) ransthoracic or transesophageal echocardiogram
D) Spiral chest C
E) Electrocardiogram
Answer 8.5.4 The correct answer is “D.” Spiral chest C is
not indicated in the diagnosis o SBE. History is important:
onset o in ection can sometimes be related to a recent dental
extraction, IV drug abuse, or invasive medical procedure.
Symptoms generally begin insidiously and may include weak-
ness, atigue, ever, night sweats, arthralgias/myalgias, and
hematuria. “C,” echocardiography, is indicated. T e yield or
visualization o vegetations or transthoracic echocardiogra-
phy is 60% to 77% and increases to 96% with transesophageal
echocardiography. A prolongation o the PR interval on an
electrocardiogram may suggest involvement o the cardiac
conduction system.
You care ully examine the patient and nd that she is ebrile
and slightly tachycardic.
Question 8.5.5 You look or signs o in ective endocarditis,
paying particular attention to all o the ollowing EXCEPT:
A) Osler nodes
B) Painless erythematous macules on the palms and soles
C) Splinter hemorrhages
D) Painless nodules over bony prominences
E) Roth spots
Answer 8.5.5 The correct answer is “D.” Classical physical
examination ndings o SBE include intermittent ever; pete-
chiae; conjunctival hemorrhage; splinter hemorrhages under
the nails; erythematous pain ul nodules on the ngers, palms,
and soles (Osler nodes); undic hemorrhages (Roth spots);
painless erythematous macules on the palms and soles (Jane-
way lesions); and a new diastolic murmur. “D” is not a physical
examination nding in SBE. Painless nodules over bony promi-
nences are observed in rheumatic ever and are one o the Jones
criteria. Remember that in a modern medical practice, most
patients with SBE will not present with these ndings, and you
must maintain a high degree o suspicion or SBE in the appro-
priate clinical scenario.
HELPFUL TIP:
Laboratory eval ation in endocarditis may be remark-
able or anemia, le kocytosis, elevated erythrocyte sed-
imentation rate (ESR), and microscopic hemat ria.
Question 8.5.6 Which o the ollowing is/are included in
the major criteria o the modi ed Duke criteria or endo-
carditis?
A) Positive blood cultures
B) Janeway lesions (painless macules on palms and soles)
C) Echocardiographic evidence o valvular vegetation
D) A and B
E) A and C
Answer 8.5.6 The correct answer is “E.” T e modi ed Duke
criteria were developed to provide clinicians with standardized
criteria or the diagnosis o endocarditis. T ey have been vali-
dated by pathologic examination and are more sensitive than
other endocarditis criteria systems. See able 8-2.

TABLE 8-2 DUKE CRITERIA FOR BACTERIAL
ENDOCARDITIS
De nite endocarditis is established by the presence o 2 major criteria
and at least 1 minor criterion. Probable endocarditis is established by
the presence o 1 major and 1 minor criterion, or 3 minor criteria.
Major D ke criteria • New valv lar reg rgitation
• Echocardiographic evidence o vegetations
• Two positive blood c lt res o an organism
known to ca se endocarditis
• Single blood c lt re or antibody evidence
o Coxiella burnetii (Q ever)
Minor D ke criteria • Fever
(not an exha stive • Vasc lar phenomena (e.g., Janeway lesions,
list b t these are splinter or conj nctival hemorrhages, and
the most common septic emboli)
mani estations) • History o predisposing illness (e.g., IV dr g
ab se, heart lesion, and arti cial valve)
• Imm nologic phenomena (e.g., glomer lo-
nephritis and Osler nodes)
HELPFUL TIP:
Three words abo t blood c lt res—more is better. The
sensitivity o blood c lt res or endocarditis and bacte-
remia is directly related to the amo nt o blood taken
or c lt re and the n mber o c lt res drawn. Three
sets o blood c lt res are recommended or s spected
endocarditis, and at least 20 mL sho ld be drawn or
each c lt re. Timing o blood c lt res is less important,
b t sick patients sho ld have the c lt res drawn in
rapid s ccession (e.g., over an ho r or 2).
You draw a CBC, which shows leukocytosis with a “le shi ”
(e.g., a high percentage o bands and other immature neutro-
phils). Chest x-ray and urinalysis are unrevealing. You draw
blood cultures and admit her to the hospital and start anti-
biotics. T e next morning two blood cultures are reported
to grow Gram-positive cocci in clusters. You start IV vanco-
mycin and order a transesophageal echocardiogram. Indeed,
the echocardiogram shows a small vegetation on her mitral
valve. Blood cultures return showing methicillin-sensitive
S. aureus.
Question 8.5.7 What is the most appropriate treatment o
this patient now?
A) Na cillin 2 g IV q 4 hours or 4 to 6 weeks
B) Penicillin G 2 million units IV q 2 hours or 4 to 6 weeks
C) Vancomycin 1 g IV q 12 hours or 4 to 6 weeks
D) Ce riaxone 1 g IV q 24 hours or 2 weeks
E) Levo oxacin 500 mg IV q 24 hours or 4 to 6 weeks
Answer 8.5.7 The correct answer is “A.” Na cillin is the drug
o choice or the treatment o methicillin-sensitive S. aureus
endocarditis. Vancomycin should be reserved or patients with
penicillin allergy or patients with methicillin-resistant S. aureus
(MRSA). Neither ce riaxone nor levo oxacin would be consid-
ered appropriate therapy or staphylococcal endocarditis.
CHAPTER 8 • INFECTIOu S DISEASES 247
HELPFUL (AND IMPORTANT) TIP:
Patients who have a sensitive organism (MSSA) ac-
tually have better outcomes (fewer deaths, etc.)
with nafcillin than with vancomycin. So, save vanco-
mycin or MRSA or other resistant organisms. Other op-
tions or hospital-acq ired MRSA incl de linezolid and
tigecycline.
While hospitalized, the patient develops symptoms o heart
ailure and worsening mitral regurgitation by echocardio-
gram. T e heart ailure is managed medically, but the regur-
gitation is now categorized as “severe.” She has had 3 days o
antibiotics and is currently hemodynamically stable.
Question 8.5.8 Which o the ollowing is the most appro-
priate course o action?
A) Complete 6 weeks o antibiotics and manage her heart ail-
ure medically or the oreseeable uture.
B) Complete 6 weeks o antibiotics and manage her heart ail-
ure medically, i possible; plan or valve replacement a er
6 weeks o antibiotics.
C) Re er her or emergent valve replacement surgery, then
complete the course o antibiotics.
D) Re er her or immediate coronary catheterization, and con-
tinue antibiotics.
E) Re er her or heart transplant.
Answer 8.5.8 The correct answer is “C.” Progressive heart ail-
ure due to moderate-to-severe valvular dys unction is an indi-
cation or surgery. T ere is evidence that early surgery reduces
mortality and embolic complications especially in patients
who have le -sided endocarditis associated with large vegeta-
tions and severe valvular dys unction. T is is true even in the
absence o congestive heart ailure and in the presence o less
virulent pathogens. T us, “B” is incorrect. Also, “A” is incorrect,
as the patient should have surgery. “D” and “E” are incorrect,
as there is no indication or coronary catheterization or heart
transplant.
HELPFUL TIP:
Other indications or s rgery in cases o endocarditis in-
cl de m ltiple embolic events, in ections that are di i-
c lt or impossible to treat adeq ately with medications
(e.g., ngal in ections), cardiac cond ction abnormali-
ties d e to in ection, persistent bacteremia, partially
dehisced prosthetic valve, and perivalv lar in ection
(e.g., cardiac abscess and ist la).
Question 8.5.9 Which o the ollowing organisms is most
o ten responsible or causing in ective endocarditis?
A) E. coli
B) Streptococcus viridans
C) Proteus mirabilis
D) None o the above
248 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Answer 8.5.9 The correct answer is “B.” S. viridans is the most
likely organism to cause endocarditis. Gram-negative organisms,
such as E. coli and P. mirabilis, are in requent causes o in ective
endocarditis. Other organisms that cause endocarditis include
the HACEK organisms (Haemophilus species, Actinobacillus
actinomyces comitantes, Cardiobacterium hominis, Eikenella
species, and Kingella kingae). In summary, organisms typically
ound causing endocarditis are S. aureus, S. viridans, enterococci
(aerobic, Gram-positive organisms in chains that are GI or vagi-
nal ora), Streptococcus bovis, and HACEK organisms.
Objectives: Did you learn to . . .
• Determine who is an appropriate candidate or in ective
endocarditis prophylaxis?
• Recognize signs and symptoms o in ective endocarditis?
• Diagnose in ective endocarditis?
• Prescribe appropriate treatment or in ective endocarditis?
QUICK QUIZ: DRu G INTERACTIONS
Which o the ollowing medications is/are contraindicated in
patients taking linezolid?
A) MAOIs
B) SSRIs
C) Gentamicin
D) Vancomycin
E) A and B
The correct answer is “E.” Linezolid can cause serotonin syn-
drome when combined with SSRIs, lithium, MAOIs, and other
serotonergic drugs.
CASE 8.6
A 10-year-old boy presents with his mother, complaining o
intense itching, worse at night, since the rst week o school.
He has numerous excoriations in the interdigital web spaces,
wrists, and anterior axillary olds. His in ant sister (10 kg)
has recently developed intensely pruritic linear lesions on her
palms, soles, ace and scalp. T eir mother works in a nursing
home and has developed pruritus and reddish-brown nodular
lesions in her axillae and perineum that have persisted several
months a er she treated hersel with a lotion that was pro-
vided at her place o work. As you examination the patient,
your skin begins to itch—you need to solve this puzzle quickly.
Question 8.6.1 The most likely ectoparasite af ecting this
amily is:
A) Head lice (pediculosis)
B) Chiggers (mites)
C) icks
D) Fleas
E) Scabies
Answer 8.6.1 The correct answer is “E.” Scabies’ mites (Sarcop-
tes scabiei) burrow into the epidermis, lay eggs, and hatch larvae
in cycles o 3 to 4 days. T e most notable clinical symptom is
intense pruritus that is worse at night. T e typical lesion is small,
erythematous, and papular and may resemble eczema in qual-
ity and distribution. About 7% o individuals develop a nodular
variant (like the mother in this case). ransmission is typically
by direct contact and in estations may appear as epidemics in
institutions like nursing homes. T e organism may be spread by
omites as well, although to a lesser extent. Young children and
in ants o en have involvement o palms, soles, ace, and scalp.
A clinical diagnosis may be made in the setting o pruritic rash,
typical distribution and multiple amily members a ected.
Question 8.6.2 What is the next best step in this case
(remember that one child weighs 10 kg)?
A) Removal o the individual organisms.
B) etracycline 10 mg/kg divided ID or all a ected amily
members.
C) Single-dose oral ivermectin 200 µg/kg, repeated in 2 weeks
or all a ected amily members.
D) Symptomatic treatment with topical steroids and oral anti-
histamines.
E) Single-dose oral ivermectin 200 µg/kg repeated in 2 weeks or
the mother; one application o 5% permethrin cream or all
other amily members or 8 to 14 hours, ollowed by bathing.
Answer 8.6.2 The correct answer is “E.” Permethrin cream is
the topical medication o choice. Ivermectin, an antihelmintic
medication, is indicated or adults with nodular disease (like
the mother in this case), in epidemic settings and or treatment
o scabies crustosa. “B” is incorrect because tetracycline is not
help ul in this situation and should be avoided in children. “C”
is incorrect because oral ivermectin should be avoided in in ants
weighing <15 kg due to concerns about increased penetration o
the blood–brain barrier. Finally, “D” is incorrect because sca-
bies should be treated with speci c therapy rather than simply
symptomatic therapy. Oh, and “A” is just insane—how could you
do that? Is there even a CP code or that?
HELPFUL TIP:
All amily members sho ld be treated, regardless o
the presence or lack o symptoms. Microscopic exami-
nation o a skin scraping may identi y the mite b t has
poor sensitivity. Other viable treatment alternatives
incl de crotamiton 10% sol tion precipitated s l r in
petrole m and lindane (b t avoid lindane in children
<2 years old).
You success ully treated the whole amily. T ey are now com-
ortable, happy, and totally con dent in your abilities. T e
mother returns with her girl, who is now 3 years old, with
a new complaint. Apparently, the girl’s “bottom” is hurt-
ing, a symptom that her mother has interpreted to mean her
perineal pain. T e pain is worse at night, even waking her at
night with vaginal pain. T e mother thinks that she may have
a bladder in ection, but there are no urinary symptoms. In
the of ce, the patient complains only o “itchy butt” and her
examination is normal.

Question 8.6.3 What is the next best step in diagnosis o
this problem?
A) Reassurance that this is “just a stage”
B) Vaginal speculum examination with cultures
C) “Scotch tape” test
D) Stool collection or ova and parasites
E) Psychiatry consultation or the mother who obviously has
Munchausen by proxy syndrome
Answer 8.6.3 The correct answer is “C.” T e presentation is
consistent with pinworm (Enterobius vermicularis) in ection.
Clinical mani estations o pinworm in ection are related to the
li e cycle o the parasite, in which the adult worm resides in the
colon, exits the anus at night, lays eggs in the perianal skin, and
may also in est the emale GU tract. ypical symptoms include
pruritus ani, vulvitis, vaginal pain, poor sleep, and—rarely—
abdominal pain (pinworms can migrate and cause appendici-
tis, and other intra-abdominal illness). T e diagnostic test o
choice is the “Scotch tape” test. Clear cellophane tape is wrapped
around a tongue depressor, sticky side up, and used to sample
the perianal area rst thing in the morning be ore bathing. Mul-
tiple specimens should be obtained and stored in a re rigerator
(it’s a good thing OSHA has no jurisdiction in the home). T e
tape is then examined microscopically or the characteristic ova.
Your “Scotch tape” test is a success, proving your clinical sus-
picions.
Question 8.6.4 The best intervention is to:
A) reat the patient with mebendazole 100 mg orally once,
repeat in 2 weeks, and encourage good hand washing or the
whole amily
B) reat the patient and the entire amily with mebendazole
100 mg orally daily or 14 days
C) reat the patient and the entire amily with mebendazole
100 mg orally once, and repeat in 2 weeks
D) reat the patient with metronidazole 500 mg orally once,
and repeat in 2 weeks
Answer 8.6.4 The correct answer is “C.” As with scabies, the
entire amily should be treated. Mebendazole is the agent o
choice, although other antiparasitic agents (e.g., albendazole,
pyrantel pamoate) may also be used. Pyrantel pamoate is sec-
ond-line and only has a 90% response rate. “D,” metronidazole,
is not used or helminthic in ections but is e ective against
protozoal in ections, including amebiasis and trichomoniasis.
Make sure to wash all o the bed linens and clothing: eggs can
stay viable or 20 days (although 3 days is more typical).
Objectives: Did you learn to . . .
• Diagnose and treat scabies in estations?
• Diagnose and treat pinworm in ections?
QUICK QUIZ: SWEATING IN SAVANNAH
A 54-year-old construction worker with no signi cant travel
history presents with a ever. He developed the ever 4 weeks ago
CHAPTER 8 • INFECTIOu S DISEASES 249
and has been ebrile daily since. He saw another doctor recently.
He was evaluated but received no antibiotics or other treatment.
His evaluation, including history, physical examination, CBC
with di erential, urinalysis, serum chemistries, and chest x-ray,
has been unrevealing. oday his temperature is 38.5°C.
Which o the ollowing is the most appropriate next step in the
evaluation and management o this patient?
A) ESR and/or CRP
B) Chest C scan
C) Bone scan
D) PSA
E) Vancomycin 1 g IV daily and ce riaxone 1 g IV daily or
2 weeks
The correct answer is “A.” T is patient has a ever o unknown
origin (FUO). FUO in adults is de ned as ever greater than
38.3°C o at least 3 weeks duration with no obvious cause despite
extensive evaluation. In ections are the most common source o
FUO in children and young adults. T e most common in ec-
tions include tuberculosis and abscesses. In older adults (sorry
to say that this patient’s age o 54 counts!), collagen-vascular
diseases, such as giant cell arteritis and rheumatoid arthritis, are
more likely sources o FUO. T ere ore, tests or in ammatory
markers, like ESR and CRP, are indicated. Other tests to consid-
er at this point include ANA, rheumatoid actor, creatine kinase
(CK), and blood and urine cultures. Although malignancy is a
consideration, chest C (“B”) and PSA (“D”) should not be or-
dered without other symptoms associated with underlying lung
and prostate disease, respectively. A bone scan (“C”) would be
indicated to look or osteomyelitis, which is an unlikely occult
source o ever in this patient with no other reason to believe he
has a bone in ection. T ere is no indication or antibiotics (“E”)
at this point—wait until you have something to treat.
HELPFUL TIP:
The most common malignancies that present with an
Fu O are lymphoma, le kemia, renal cell carcinoma and
hepatoma. A CT scan o the abdomen sho ld pick all o
these p, except le kemia, o co rse. However, the diag-
nostic yield o a CT scan is lower than the yield o FDG-
PET/CT, which may detect active in lammation prior to
any speci ic anatomic change and may be considered
in place o stand-alone CT scanning in the eval ation o
Fu O. See Table 8-3 or a partial list o ca ses o Fu O.
CASE 8.7
A 45-year-old physician who has recently returned rom an
early summer shing vacation (in reality he mostly studied
or his upcoming board examination) in rural North Caro-
lina presents or a ebrile illness. He reports a 5-day history o
ever, malaise, headache, and vomiting. oday, he has devel-
oped a nonpruritic rash that began on his extremities and has
spread to his body. On examination he has a ever o 38.3°C
with a pulse o 120 bpm and otherwise normal vitals. T e
rash is maculopapular and generalized, involving his palms
250 FAMILY MEDICINE EXAMINATION & BOARD REVIEW

TABLE 8-3 PARTIAL LIST OF ETIOLOGIES OF FEVER that begins at the wrists and ankles and spreads centrally. Even-
OF UNKNOWN ORIGIN tually, the rash becomes petechial. Despite its name, RMSF is
endemic in the southeastern United States, the Atlantic states,
Infections
and the northern Rocky Mountains. Laboratory mani estations
• T berc losis
• Lyme disease o RMSF are generally nonspeci c: mild thrombocytopenia
• HIV (rarely becoming severe), hyponatremia, azotemia, elevated
• Endocarditis transaminases, and prolonged P and P .
• Dental abscess “B” is incorrect because the secondary stage o syphilis is char-
• Abdominal/pelvic abscess
acterized by a generalized maculopapular rash (including the
• CMV
• Epstein–Barr vir s palms and soles) and is not associated with systemic symptoms.
“E” is also incorrect. Human monocytic ehrlichiosis is caused
Malignancies
• Metastatic cancer by Ehrlichia chaf eensis and other related bacteria and presents
• Lymphoma with a ever and non-speci c “ u like” symptoms (headache,
• Le kemias ever, myalgias, chills, cough). Rarely a rash, maculopapular or
• Renal cell carcinoma petechial, is seen. T us, it may be easily con used with RMSF (and
Autoimmune Conditions in act some physicians re er to ehrlichiosis as “Rocky Mountain
• Polymyalgia rhe matic/giant cell arteritis Spotless Fever”). Patients are o en leukopenic and thrombocy-
• Rhe matoid arthritis
topenic. T e disease is tick-borne and endemic to midwestern,
• In ammatory bowel disease
• L p s south central, and southeastern states. So, i you think you have
• Vasc litides a case o RMSF but there is no rash, consider human monocytic
Drug-induced Fever ehrlichiosis. See able 8-4 or more details on tick-borne ill-
• Factitio s ever nesses. Yeah . . . we know . . . everything presents with ever, head-
• Veno s thrombosis ache and myalgias. T ey all sound the same to us too . . .
• Sarcoidosis
Question 8.7.3 What is the appropriate next step or this
patient?
and soles. Oral mucosa is dry but intact, and the examination
A) Obtain serologic studies and await results while treating
is otherwise nonspeci c.
symptomatically.
Question 8.7.1 What is the most appropriate next step? B) Obtain skin biopsy and await results while treating symp-
A) Reassurance and symptomatic treatment tomatically.
B) CBC, electrolytes, BUN, creatinine C) Obtain serologic studies and start doxycycline 100 mg orally
C) Dermatology re erral BID.
D) Punch biopsy o leading edge o rash D) Obtain skin biopsy and start levo oxacin 500 mg orally
E) Admission to the ICU daily.
E) Hospitalize and start ce riaxone 1 g IV daily until ever has
Answer 8.7.1 The correct answer is “B.” T is gentleman is sick resolved.
(pulse o 120 bpm, dry oral mucosa, headache, vomiting). We
would be amiss to simply reassure or re er this patient. A CBC Answer 8.7.3 The answer is “C.” Early treatment or RMSF
and electrolytes may give us an indication o the degree o dehy- is essential. Individuals treated a er 5 days o symptoms have
dration and help us narrow the di erential (bacterial, viral, etc.). worse outcomes than those treated earlier. Awaiting serologic
Blood cultures would also be indicated at this time. studies is inappropriate and treatment should not be delayed.
T e drug o choice in the treatment o RMSF is doxycycline
T e test results return quickly. CBC shows mild thrombocy- 100 mg PO BID or 14 days. T is is true or children as well!
topenia but is otherwise normal. BUN and creatinine are at Pregnant women should be treated with chloramphenicol.
the upper limits o normal, and the electrolytes are normal. Agents such as penicillin, uoroquinolones and cephalosporins
are inappropriate in this situation.
Question 8.7.2 The most likely diagnosis is:
Objectives: Did you learn to . . .
A) Chicken pox
• Identi y and diagnose RMSF?
B) Syphilis
• Initiate treatment o RMSF?
C) Parvovirus B19
• Recognize other tick-borne illnesses?
D) Rocky Mountain spotted ever (RMSF)
E) Human monocytic ehrlichiosis

Answer 8.7.2 The correct answer is “D.” RMSF is a tick-borne QUICK QUIZ: FLu CTu ANCE IN FLINT
(dog or wood tick) disease caused by Rickettsia rickettsii. It pres-
ents with a prodrome o ever and headache several days be ore A 27-year-old male carpenter presents with pain, redness, and
the onset o the characteristic rash—a maculopapular eruption swelling o the distal aspect o the right index nger. He reports
 CHAPTER 8 • INFECTIOu S DISEASES 251

TABLE 8-4 TICK-BORNE ILLNESSES

Geographic
Disease Etiologic Agent Distribution Clinical Findings

Babesiosis Babesia species New England, pper Fever, sweats, myalgias, arthralgias, red rine, hemolytic anemia (most
Midwest, Cali ornia severe cases occ r in splenectomized patients). Similar to malaria in that
there are periodic ever spikes. Diagnosis is by Giemsa stain

H man monocytic Ehrlichia chaf eensis So th, Midwest Fever, headache, myalgias (similar to RMSF b t rarely a rash). Diagnosis is
ehrlichiosis and ewingii by b f y coat examination, clinical presentation, PCR

H man gran locytic Anaplasma Atlantic states, Fever, headache, myalgias (similar to RMSF b t rarely a rash). Diagnosis is
anaplasmosis phagocytophilum pper Midwest by b f y coat examination, clinical presentation, PCR

Lyme disease Borrelia burgdor eri Northeast, pper Erythema migrans, myalgias, arthralgias, arthritis, ever, headache.
Midwest Diagnosis is by serology

Rocky Mo ntain Rickettsia rickettsii So theast, Atlantic Fever, headache, GI symptoms, mac lopap lar rash → petechiae,
Spotted Fever (RMSF) coast states myalgias. Diagnosis: clinical, serology (b t not + early)

T laremia Francisella So th, Midwest Fever, headache, co gh, myalgias, GI symptoms, tender lymphadenopathy
tularensis with rare skin lceration. Diagnoses by aggl tination or ELISA. Expos re
history (rabbits, ticks, ies)

getting a splinter in the site 2 days ago while working. T e pain
is now so severe that he cannot work. On examination, the
patient is a ebrile, the right index ngertip is extremely tender,
and there is an area o uctuance at the palmar aspect o the
nger. All o the redness and warmth are distal to the proximal
interphalangeal joint.
What is the most appropriate diagnosis?
A) Paronychia
B) Felon
C) Whitlow lesion
D) enosynovitis
E) Achy-breaky- nger
The correct answer is “B.” A elon is an abscess o the distal
ngertip, most commonly occurring in the index nger and
thumb. It can be distinguished rom paronychia (“A”) because
a elon is located in the at pad o the nger and not the tissue
around the nail. O en, an area o uctuance is palpable. A elon
can spread quickly and can involve the periosteum and bone.
Appropriate management includes x-ray o the nger (to rule
out osteomyelitis), antibiotics, and incision and drainage. “C” is
incorrect because a whitlow lesion results rom inoculation o
broken skin o the hand with type 1 or 2 herpes simplex virus.
T e whitlow lesion is o en typical o herpes (vesicles on ery-
thematous papules) but can also be con used with paronychia
or elon i at the distal nger. “D” is incorrect as well. enosy-
novitis should not involve the distal aspect o the digit without
a ecting the rest o the tendon sheath. “E” is just silly but could
be another big country hit!
CASE 8.8
T e Smith amily presents to your of ce in December seeking
travel vaccines or a trip to Nigeria. John (34) and Jane (35)
Smith have two children, Jack (7) and Jill (5). T ey will be in
Nigeria or a month and will be living in a suburb o Lagos,
Nigeria’s largest city (Boko Haram not withstanding). T ey
expect to take sightseeing trips into less developed areas.
John has no previous medical problems. Jane is currently tak-
ing venla axine (E exor) or depression and is known to have
a sul a allergy. Jack has had occasional bouts o reactive air-
way disease and also has a sul a allergy. Jill is healthy. Every-
one in the amily is up-to-date on all routine North American
vaccines.
Question 8.8.1 Regarding pathogens they might encounter
in A rica, which o the ollowing is caused by a virus?
A) Plasmodium ovale
B) Plasmodium alciparum
C) Dengue ever
D) Entamoeba histolytica
E) All o the above
Answer 8.8.1 The correct answer is “C.” Dengue ever (aka
“break bone” ever) is a viral in ection caused by Flavivirus
(more below). “A” and “B,” P. alciparum and P. ovale, are two
species o malaria parasites. P. alciparum tends to produce
more severe in ections that can be rapidly atal in malaria naıve
patients. “D,” E. histolytica, is the intestinal protozoan parasite
responsible or amebiasis.
Question 8.8.2 Mr. Smith asks or advice on the use o insect
repellent. What do you recommend?
A) Any repellent will do, they’re all the same. Just use the
cheapest
B) Pleasant-smelling repellents, such as Avon SkinSo-So M,
are just as e ective as any DEE -containing ormulation
C) Use repellent with DEE concentrations o at least 50% or
the children, since their protection is so vital
D) Apply permethrin insecticide to the skin to enhance any
other repellent’s ef cacy
252 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
E) Use DEE or picaridin-containing repellents, as they are the
most ef cacious insect repellents available, but avoid DEE
concentrations greater than 30% in children
Answer 8.8.2 The correct answer is “E.” Repeated experiments
clearly show DEE - and picaridin-containing repellents to be the
most e ective or deterring bites and these are the two recom-
mended by the CDC. Picaridin-containing insect repellents do
not cause neurotoxicity. T e American Academy o Pediatrics
recommends not exceeding 30% DEE concentration in repel-
lants or children, due to a slight risk o toxicity seen in requent
applications over a long period o time. Applying DEE to cloth-
ing rather than skin reduces the risk o toxicity. Adults can theo-
retically use any concentration, but 30% is usually suf cient or
most situations. O en, more cosmetically pleasing products, such
as Avon brand SkinSo-So , are less e ective and last a mere rac-
tion o the duration o DEE compounds. Permethrin insecti-
cide, when applied to clothes, tents, and bed nets, is synergistic with
insect repellent, but permethrin itsel is not ormulated or use as
an insect repellent on skin. O note, many countries have a com-
bination DEE -Permethrin product available or use on cloths.
Mrs. Smith reports that her riends get sick with diarrhea
every time they travel abroad. She would like to avoid this.
Question 8.8.3 Which o the ollowing is (are) true about
traveler’s diarrhea?
A) Enterotoxigenic E. coli (E EC) is the most common cause o
this condition
B) Even care ully avoiding the consumption o tap water or
unwashed vegetables may not be suf cient to prevent the disease
C) Fluoroquinolones can help to rapidly cure this condition but
are contraindicated in pregnancy and young children
D) T e use o loperamide is e ective in reducing the duration o
symptoms but is contraindicated in children <2 years o age
E) All o the above are true
Answer 8.8.3 The correct answer is “E.” In most parts o the
world, including A rica, E EC is the most common cause o
travelers’ diarrhea. Although it is advisable to avoid tap water,
unwashed oods, and raw oods, these measures are usually
insuf cient to completely eliminate the risk o contracting the
disease. A traveler may drink only bottled liquids, but might
orget that the ice in the glass is made rom tap water. Although
the disease is sel -limited, a single dose o cipro oxacin 750 mg
(see note below) may shorten the course o symptoms signi -
cantly. T e dose or moderate or severe disease is cipro oxacin
500 mg BID. A patient’s symptoms can be urther shortened
by adding loperamide, which is sa e in the absence o bloody
stools. Loperamide is potentially toxic to in ants and toddlers.
HELPFUL (AND VERY IMPORTANT) TIP:
The CDC no longer recommends fluoroquinolones
for travelers’ diarrhea acquired in Southeast Asia be-
cause of resistance. The c rrent recommendation is to
se azithromycin or travelers’ diarrhea in So theast Asia.
HELPFUL TIP:
The CDC maintains a ser- riendly and p-to-date travel
website at http:// wwwnc.cdc.gov/ travel. Always check
here irst to ass re yo are giving the right vaccines and
advice.
Finally, you discuss the medication options or malaria pro-
phylaxis.
Question 8.8.4 Which o the ollowing is TRUE?
A) Me oquine (Lariam) is relatively contraindicated or Jane
due to her history o psychiatric illness
B) Doxycycline would be a sa e and e ective option or the
whole amily
C) Although malaria is resistant to chloroquine in many parts
o the world, it can still be used or prophylaxis in West
A rica
D) Atovaquone/proguanil (Malarone) is contraindicated or
Jane and Jack due to their sul a allergy
E) A month is too long a time to use malaria prophylaxis sa ely;
recommend against it
Answer 8.8.4 The correct answer is “A.” Me oquine is an e ec-
tive, once-a-week prophylaxis or malaria. However, it carries a
signi cant risk o CNS side e ects including vivid or disturb-
ing dreams. T ere have been case reports o the medication
inducing psychosis, so the drug is relatively contraindicated
or patients with a history o psychiatric illness (such as Jane
Smith). “B,” doxycycline, may be a good option or the parents,
but is contraindicated in children because o their age and risk o
tooth discoloration. “C” is incorrect. Malaria throughout A rica,
India, Southeast Asia, and South America is now assumed to be
resistant to chloroquine. Finally, “D” atovaquone/proguanil is
relatively contraindicated in patients with G6PD de ciency due
to a risk o hemolysis, but it does not contain sul a. O particular
note is answer “E.” Medications used to provide malarial che-
moprophylaxis have been shown to be well-tolerated or at least
a year or more (http://www.cdc.gov/malaria/about/ aqs.html).
T ere ore, one month is not too long to use malaria prophy-
laxis sa ely and it should be recommended to the amily or their
travel.
Weeks pass, and you hear nothing more until you are called
to the acute care clinic, where Jack Smith has been brought
in by his parents or ever and lethargy. Jack had been treated
in Lagos, Nigeria, or malaria with an unknown medication,
and he subsequently recovered. Jack was apparently well until
10 days a er returning home, when he developed rapid onset
o a ever and shaking chills. He also complained to his par-
ents o generalized abdominal pain and watery, non-bloody
diarrhea. T e parents treated him at home or a day with
ibupro en and acetaminophen, but he seemed to worsen. He
became lethargic, stopped drinking and eating, and the ever
continued.

Jack appears drowsy and listless but is arousable. He does
not respond to questions about current symptoms, but coop-
erates with an examination. Findings are temperature 39.1°C,
pulse 136 bpm, blood pressure 100/50 mm Hg, and respira-
tory rate 24. His neck is supple with mild lymphadenopathy.
He is tachycardic with a mild ow murmur. His abdomen is
nontender with a palpable spleen. No rash or petechiae are
noted. T e rest o the examination is unremarkable. A recur-
rence o malaria is suspected.
Question 8.8.5 What is the best method or con rming this
diagnosis?
A) Blood culture
B) Malaria serology
C) Malaria antigen test
D) T in and thick blood smears
E) Stool ova and parasite
Answer 8.8.5 The correct answer is “D.” Malaria is usually
diagnosed by blood smear. T e thick blood smear is the more
sensitive screening test, and the thin blood smear is used to
identi y the species o parasite. T ere are rapid antigen tests
available they have higher alse positives and alse negatives
than a smear. In addition, they do not allow identi cation o
the species. T us, i one suspects malaria and the rapid test is
negative, thick and thin smears are still indicated. T e blood
smear remains the gold standard. Malaria serology and cul-
tures are used only in experiments and are not help ul or diag-
nosis o an individual patient. O note, PCR-based testing has
excellent sensitivity and speci city but is expensive and not
widely available. T e malaria parasite cannot be identi ed in
stool.
You begin IV uids and arrange hospital admission. T e rel-
evant laboratory tests are drawn and sent, including CBC,
blood cultures, tests or malaria, chemistry pro le, blood
type and screen, and urinalysis. LP is per ormed and the CSF
is normal. In the meantime, the laboratory calls with the
report that P. alciparum has been identi ed.
Question 8.8.6 What antimicrobial should be chosen as
initial therapy?
A) Oral hydroxychloroquine (Plaquenil), since many hospitals
do not stock chloroquine
B) Oral me oquine (Lariam)
C) Oral quinine
D) IV quinidine, since IV quinine is not generally available in
the United States
E) IV atovaquone/proguanil (Malarone)
Answer 8.8.6 The correct answer is “D.” Clearly, since this
patient is ill and not tolerating oral intake, an IV route or
malaria treatment is indicated. IV atovaquone/proguanil does
not exist, so the only available option is quinine. But IV quinine
is not available in the United States, so its isomer, quinidine (the
antiarrhythmic) is used instead. In patients rom chloroquine-
sensitive zones (currently Central America and the Middle
CHAPTER 8 • INFECTIOu S DISEASES 253
East), treatment with chloroquine is acceptable. Hydroxychlo-
roquine is an option i chloroquine is not available.
HELPFUL TIP:
Artes nate, another antimalarial, clears parasitemia
aster than q inidine b t is not approved by the FDA.
It is available rom the CDC on protocol. The CDC main-
tains a 24-ho r hotline or malaria advice that will
connect yo directly to a real, live clinician or assistance
in managing patients with malaria. Finally, a combina-
tion prod ct, artemether-l me antrine (Coartem) is
available in the u nited States. It works well b t can pro-
long the QT.
Despite a rightening hospital course that included general-
ized seizures, hypoglycemia, hematuria, renal insuf ciency,
and an exchange trans usion, Jack eventually recovers com-
pletely. T e Smith amily thanks you or your help and hopes
you’ll accompany them on their next trip to A rica.
Objectives: Did you learn to . . .
• Identi y important elements o a patient’s travel plans and
niq e risks when providing co nseling or overseas travel?
• Identi y preventative meas res or malaria, incl ding chemo-
prophylaxis and insect bite avoidance?
• Diagnose travelers’diarrhea and describe its prevention and
treatment?
• Recognize the signs and symptoms o malaria, describe
methods o diagnosis, and initiate therapy?
QUICK QUIZ: CRITTERS IN CLEVELAND
A amily comes to see you because the two children, ages 7 and
4, have developed itchy scalps. T e parents seem una ected. So
ar, they have not tried any treatments. On examination o both
children, you nd erythematous papules on the occiput and
small white eggs rmly attached to the hair sha about 1 cm
rom the scalp. Upon leaving the room, you head straight or the
shower and scrub your scalp or 5 minutes.
T e most appropriate treatment or the suspected diagnosis is:
A) Application o 1% permethrin cream to all amily members
or 10 minutes ollowed by rinsing, combing out all nits with
a special louse comb, and decontaminating a ected gar-
ments and bed linens. Repeat in 7 days
B) Elimination o animal or omite sources o in estation and
use o insect repellents
C) Removal o any adherent organisms and oral doxycycline
or 14 days
D) Application o 5% permethrin cream to all amily members
or 8 to 14 hours, ollowed by showering
E) Shave everyone’s head
The correct answer is “A.” T ese are head lice. Pediculosis in-
estations o the hair and scalp are usually asymptomatic but
254 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
can present with itching. T e diagnosis is made by demonstra-
tion o the louse or nits, which uoresce a pale blue under a
Wood’s light. reatment with topical agents such as permethrin
cream or two applications and wet combing to remove nits is
recommended by the CDC. Ivermectin may be e ective in cas-
es o resistant organisms. It is reasonable to recommend wash-
ing clothing and bedclothes o an in ested person, but head lice
do not survive o the scalp longer than 48 hours. “B” is ap-
propriate or chiggers (mites) or eas. “C” is appropriate or
ticks (i also at risk or a tick-borne illness). “D” is a treatment
o scabies (note the di erence in strength o permethrin). O
note, there is no bene t to keeping children with head lice out o
school. Avoid sharing hats, etc. Just try to get this one past the
school nurse.
CASE 8.9
A 19-year-old emale college student presents to student
health services with “the u.” She has noted a ever o 38.9°C
and myalgias. She is treated with symptomatic care and dis-
charged back to her dormitory. T ree hours later her room-
mate nds her lethargic and dif cult to arouse, so she calls
911. On examination, her blood pressure is 70/30 mmHg
with a pulse o 145 bpm. Her neck is supple, but she is lethar-
gic and complaining o severe muscle aches. She denies head-
ache. T ere is a ne macular rash over her abdomen.
Question 8.9.1 You need to obtain a little more history. The
most important historical actor in this case is:
A) History o splenectomy
B) History o acetaminophen overdose
C) History o tobacco use
D) Sexual history
Answer 8.9.1 The correct answer is “A.” “A” is important since
patients with a splenectomy can get sick rather rapidly rom
pneumococci and other encapsulated bacteria. T e rest are much
less important. Shock is not a prominent eature o acetamino-
phen overdose (“B”)—i it occurs at all. In addition, acetamino-
phen overdose is not associated with a rash. “C” and “D” are
incorrect. T ese elements o social history, while important to
her overall care, will not aid you in the diagnosis and immediate
management. Another very pertinent historical eature would
be tampon use, which is important because this patient may
have toxic shock syndrome.
T e patient is able to give you the additional history that
she does not use tampons and has not taken any medication
except or occasional acetaminophen and ibupro en in rec-
ommended doses. She has her spleen . . . in a jar in her dorm
room—no, wait, we mean in her le upper quadrant. It’s her
ex-boy riend’s spleen in the jar.
Question 8.9.2 On the basis o this in ormation you decide
that:
A) It is unlikely that this is toxic shock syndrome given that she
does not use tampons.
B) T e combination o acetaminophen and ibupro en in this
patient with the u has led to hypotension.
C) Given that she is immunocompetent and has her spleen
intact, this cannot be sepsis since it started so quickly.
D) oxic shock, which was a big problem in the 1980 s and early
1990 s, no longer occurs since the advent o less absorbent
tampons.
E) None o the above.
Answer 8.9.2 The correct answer is “E.” “A” is incorrect
because up to 50% o cases o toxic shock occur as the result o
staphylococcal in ections unrelated to tampons. T ese may be
ingrown toenails, in ected abrasions, etc. “B” is incorrect. Acet-
aminophen and ibupro en are requently combined without di -
culty. “C” is also incorrect. Splenectomized patients are more
prone to sepsis rom encapsulated organisms, but the act that
the patient has a spleen does not grant invincibility. Sepsis obvi-
ously occurs in the normal host as well. Finally, “D” is incorrect.
While absorbent tampons are a major culprit in toxic shock syn-
drome, as noted above, there are other causes. T us, toxic shock
syndrome is not going away anytime soon.
Question 8.9.3 The organism(s) responsible or toxic shock
syndrome is (are):
A) Staphylococcus
B) H. in uenzae
C) Streptococcus
D) A and B
E) A and C
Answer 8.9.3 The correct answer is “E.” T ere are two types
o toxic shock syndrome, one caused by Staphylococcus and
the other by Streptococcus. T ere are certain subtypes o these
bacteria that make the toxin responsible or toxic shock syn-
drome and only certain hosts are thought to be susceptible.
O note, most patients with streptococcal toxic shock are bac-
teremic, whereas those with staphylococcal toxic shock are
not.
Question 8.9.4 Which o the ollowing would you NOT
expect to nd on laboratory testing o this patient with
suspected toxic shock syndrome?
A) Creatinine o 2.0 mg/dL (normal 1 mg/dL)
B) Elevated AL /AS
C) Platelets o 450,000/mm 3
D) Elevated CPK
Answer 8.9.4 The correct answer is “C.” By the de nition o
toxic shock syndrome, the platelet count should be <100,00 mm 3
in Staphylococcal-related toxic shock. All o the other ndings
are representative o the multisystem dys unction that catego-
rizes toxic shock syndrome.
Your patient is a little more alert, most likely due to your
charming wit. A second set o vitals shows: blood pressure
72/44 mm Hg, pulse 140 bpm, respirations 24, temperature
39°C. Labs are pending.

Question 8.9.5 What is the single best next step in the care
o this patient?
A) Start IV na cillin
B) Place two large-bore IV lines and start aggressive uid
replacement
C) Start IV norepinephrine
D) Give a single dose o IV dexamethasone
E) rans use two units o packed red cells
Answer 8.9.5 The correct answer is “B.” reatment is mainly
supportive. She’s in shock. wo large-bore IV lines should be
placed with uids running wide open, and norepinephrine
(or other pressor) should be available i her pressure does not
improve rapidly. “A” is o special note. Patients with classic toxic
shock syndrome (staphylococcal) are not bacteremic. T ey are
su ering rom the e ects o a localized in ection that has pro-
duced a toxin that is the causative agent in their illness. T ere-
ore, while an anti-staphylococcal drug is important (as is locally
treating the site o in ection with incision and drainage, toenail
removal, etc.), the anti-staphylococcal drug is not to treat bac-
teremia. However, the patient should receive empiric antibiotics
(IV clindamycin and vancomycin) to treat a suspected localized
in ection, with narrowing o the spectrum when more data (e.g.,
cultures and susceptibilities) become available. “D” and “E” are
incorrect since neither steroids nor blood products are cur-
rently indicated.
HELPFUL TIP:
Norepinephrine is the pressor o choice in almost all sit -
ations. It has s perior s rvival when compared to dopa-
mine in sepsis and is clearly better in cardiogenic shock.
Objectives: Did you learn to . . .
• Identi y signs and symptoms o toxic shock syndrome?
• Describe the pathophysiology o toxic shock syndrome?
• Initiate management or a patient with sepsis and toxic
shock syndrome?
QUICK QUIZ: BOILS IN BOSTON
A 15-year-old male presents with his mother who had to drag
him in to your clinic. He won’t look up rom his iPhone as his
mother gives an exasperated history. He’s had “boils” several
times on his buttocks and legs that he pre ers to “pop” rather
than to have treated by a medical pro essional. oday he has a
large red lump on his anterior le thigh. On examination, you
nd a healthy-looking male with normal vital signs and a 3 cm
area o erythema with central pustule and uctuance. You incise
the lesion, obtain a sample or culture and drain it completely
(just in time or lunch).
I the culture returns with MRSA as you suspect it will, you
must treat with:
A) Good local wound care
B) Packing the wound daily
CHAPTER 8 • INFECTIOu S DISEASES 255
C) Chlorhexidine baths and mupirocin to nares daily
D) Doxycycline orally or 2 weeks
E) Oritavancin (trade name Orbactiv) 1,200 mg IV, single dose
The correct answer, and the only thing you must do or this
patient, is “A.” You have already treated the local in ection, the
abscess on his skin, with incision and drainage. Unless his has
an extending cellulitis or is systemically ill (e.g., ebrile), he does
not require systemic antibiotics, so “D” and “E” are incorrect.
Packing a small abscess a er incision and drainage (“B”) is a
time-honored method o in icting mild torture on patients.
T is practice is grounded in tradition and perceived bene ts o
packing large, deep so tissue wounds. However, wound packing
has not been shown to bene t small skin abscesses (e.g., less than
5 cm), but it has been shown to increase pain, prolong healing and
result in greater healthcare utilization. “C” sounds good or a pa-
tient who has a history o skin abscesses and is probably worth
a try in patients with recurrent MRSA skin in ections; but the
bene ts are minimal at best. Even a er clearing MRSA, the little
bugger has a tendency to recur; re-colonization rates are as high
as 75% several months a er decolonization. Finally, decoloniza-
tion with “bleach bathes” has also been tried, and these seem to
be marginally e ective i they are e ective at all (Clin In ect Dis.
2014;58:679).
I treating a MRSA cellulitis, many options are available,
including “D” and “E.” Antibiotic therapy should be dictated by
culture and susceptibility when available. Empiric oral antimicro-
bials that are generally regarded as e ective against MRSA include
trimethoprim-sul amethoxazole, tetracyclines (e.g. doxycycline),
and linezolid. For more serious MRSA in ections and those ail-
ing to respond to empiric oral antibioitics, vancomycin (30 mg/kg
per 24 hours) is still rst-line IV therapy. Other options include
daptomycin, ce aroline, lipoglycopeptides, and tigarcycline (3rd
or 4th line due to increased mortality risk). T e newer lipoglyco-
peptides (e.g., oritavancin, dalbavancin) are long-acting antimi-
crobials that have the advantage o in requent administration—in
act, oritavancin is given as a single dose. T e lipoglycopeptides
are expensive and have no medical advantage over less expensive
options. In addition, they are or skin in ections only and not
systemic in ections. T ere is too much resistance to clindamycin
to recommend it when treating MRSA.
CASE 8.10
One o your patients has recently been in Indonesia or a
prolonged period o time. Upon return to the United States,
he develops a ebrile illness 5 days a er landing in Iowa (yes,
we have airports). When he presents to the ED, he recalls
being bitten by a particularly large and persistent mosquito
just be ore boarding the airplane. On arrival to the ED, he
complains o severe, di use body pain, headache, and eye
pain and eye redness. Vitals show a temperature o 38.5°C,
pulse 145 bpm. Labs show a low white count and throm-
bocytopenia. He does NO note cyclic evers. His eosino-
phil count is normal. A Giemsa stain o the blood shows no
organisms.
256 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Question 8.10.1 The most likely cause o this illness is:
A) Pneumococcal sepsis
B) Dengue ever
C) Malaria
D) Filariasis
E) Kuru
Answer 8.10.1 The correct answer is “B.” T is patient has
Dengue ever. Dengue ever is most common in Asia but also
occurs in A rica, South and Central America, and the Carib-
bean (and may eventually occur in the southern United States i
global temperatures continue to rise). Patients typically present
with ever, conjunctivitis, headache, retro-orbital pain, leukope-
nia, and thrombocytopenia. T e sine-qua-non o Dengue ever
is severe myalgias and arthralgias, hence the moniker “break
bone ever.” More mild orms do occur, however. “A” is incor-
rect since patients with pneumococcal sepsis will generally not
have thrombocytopenia and a low WBC count (yes, we know
there are exceptions). “C” is incorrect because the patient does
not have cyclic evers and a blood smear is negative (plus, we’ve
already had our malaria case. Why would we repeat it?). Fila-
riasis, “D,” presents with eosinophilia and micro laria in the
bloodstream. Again, this should be evident on the blood smear.
“E,” kuru, is a prion-driven degenerative neurological disease
ound in Papua, New Guinea. T is patient does not have any
evidence o neurological disease, aside rom a headache, which
also makes this option less likely.
With supportive care, the patient recovers. However, not
having learned his lesson he returns to Indonesia. When he
comes home to Iowa again, he presents again to the ED, sus-
pecting that he has Dengue ever.
Question 8.10.2 Signs and symptoms o a second occur-
rence o Dengue ever include all o the ollowing EXCEPT:
A) Capillary leak with hypovolemia and hemoconcentration
B) Hemorrhagic complications including capillary ragility
C) Onset >14 days a er exposure
D) Severe thrombocytopenia
Answer 8.10.2 The correct answer is “C.” I a returning trav-
eler presents more than 14 days a er returning home, Dengue
ever can be e ectively ruled out. In this case, think o other
in ectious diseases including malaria. T e incubation period o
Dengue ever is 3 to 7 days. T e rest are correct. Patients with
their second or subsequent episode o Dengue ever can present
with capillary leak syndrome, marked thrombocytopenia, and
severe hemorrhage. It is usually the second or subsequent in ec-
tion that leads to mortality.
HELPFUL TIP:
The treatment o Deng e ever is s pportive care. In
many co ntries, treatment is beg n with alb min to
replace the circ lating vol me (given the capillary leak
syndrome). However, saline is j st as good and a lot less
expensive.
Objectives: Did you learn to . . .
• Describe the presentation o Deng e ever?
• Disting ish the dif erence between the rst and s bseq ent
episodes o Deng e ever?
Clinical Pearls
Do not delay antibiotics in a s spected case o meningitis. I
the l mbar p nct re is going to be delayed, administer
antibiotics irst.
Do not rely on Kernig and Br dzinski signs to r le o t
meningitis. The sensitivity is as low as 9%.
Do not treat asymptomatic bacteri ria in most patients; it is
not help l and only leads to resistance.
Do not treat Lyme disease with prolonged co rses o
antibiotics. Postin ectio s complications are not d e to
persistent in ection.
Do not treat pper respiratory in ections with antibiotics.
Do not se pre-proced ral prophylactic antibiotics or most
valv lar heart disease. Exceptions incl de prosthetic valves,
pervio s endocarditis and some congenital heart diseases.
Do not se vancomycin in patients who prove to have
methicillin-sensitive Staphylococcus aureus; o tcomes are
worse with vancomycin than with targeted coverage s ch as
na cillin.
Start l ids and antibiotics as soon as possible in cases o
pres med sepsis. It may take 3 L or more o crystalloid to
stabilize the septic patient.
There is no need to excl de patients with head lice rom
school. Avoid sharing hats and head to head contact,
however.
Treat patients with a positive PPD who have had the BCG
vaccine j st the same as any other patient with a positive
PPD. Age is not a limitation to treating with isoniazid.
BIBLIOGRAPHY
Angus DC, van der Poll . Severe sepsis and septic shock.
N Engl J Med. 2013; 369: 840–851.
Bagdasarian N, et al. Diagnosis and treatment o Clostridium
dif cile in adults a systematic review. JAMA. 2015;13(4):
398–408.
Bratton RL, Corey R. ick-borne disease. Am Fam Physician.
2005;71(12):2323–2330.
Centers or Disease Control and Prevention. Section on in u-
enza. http://www.cdc.gov/ u/ pro essionals/index.htm.
Accessed June 28, 2015.
Centers or Disease Control and Prevention. Section on
traveler’s health. http://wwwnc.cdc.gov/ travel/. Accessed
June 28, 2015.
Centers or Disease Control and Prevention. Section on
vaccines. http://www.cdc.gov/vaccines/hcp/acip-recs/
recs-comprehensive.html. Accessed June 28, 2015.

Kang DH, et al. Early surgery or le -sided endocarditis
accompanied by severe valve dys unction and large
vegetation, even in absence o heart ailure, saves lives
and prevents serious illness rom stroke. N Engl J Med.
2012;366:2466–2473.
Lawn SD, Zumla AI. uberculosis. Lancet. 2011;378:57–72.
Lew DP, Waldvogel FA. Osteomyelitis. N Engl J Med. 1997;
336:999–1007.
Mylonakis E, Calderwood SB. In ective endocarditis in adults.
N Engl J Med. 2001;345:1318.
Nichol KL, et al. E ectiveness o in uenza vaccine in
community-dwelling elderly. N Engl J Med. 2007;357:
1373–1381.
CHAPTER 8 • INFECTIOu S DISEASES 257
Sterling S, et al. T ree months o ri apentine and isoniazid or
latent tuberculosis in ection. N Engl J Med. 2011;365:
2155.
al S, et al. Fever o unknown origin in older adults. Clin Geriatr
Med. 2007;23:649–668, viii.
olan RW Jr. Fever o unknown origin: A diagnostic approach
to this vexing problem. Clin Pediatr. 2010;49:207–213.
Wendel K, Rompalo A. Scabies and pediculosis pubis: An
update o treatment regimens and general review. Clin
In ect Dis. 2002;35:S146–S151.
Wilson W, et al. Prevention o in ective endocarditis: Guideline
rom the American Heart Association. Circulation. 2007;
116(15):1736–175.
HIV/AIDS
A. Ben Appenhei er and Jack T. Stap et n
Note: T e antiretroviral treatment o HIV/AIDS (HAAR )
continues to evolve, and guidelines or use are regularly
updated (https://aidsin o.nih.gov/guidelines). T is chapter
ocuses on the primary care aspects o HIV/AIDS including
initial evaluation, drug side e ects, and in ectious disease
prophylaxis.
CASE 9.1
A 23-year-old emale presents to your clinic complaining o
sore throat, ever, and body aches. She reports that the ill-
ness began about a week ago and has persisted despite ther-
apy with NSAIDs, acetaminophen, and sore throat lozenges.
She denies cough, abdominal pain, nausea, or vomiting, but
reports a persistent headache. Her past medical and surgical
history is unremarkable. T e patient smokes about one pack
o cigarettes a week, drinks occasional alcohol, and denies
other drugs, including intravenous (IV) use. She is hetero-
sexual, and has had eight sexual contacts in the past year. She
takes oral contraceptives, and her partners usually do not use
condoms.
On examination, her vital signs are 38.9°C, P 112 bpm,
BP 115/68 mm Hg, R 20 bpm. She has pharyngitis and
enlarged tonsils with exudates. T ere is di use cervical
lymphadenopathy, but the neck is supple. T ere are enlarged
lymph nodes in her axillae and inguinal areas as well. T e
spleen is palpable and nontender. T e rest o the examination
is unremarkable. You obtain a throat culture, CBC with di -
erential, and heterophile antibody (Monospot) test. Given
her history o unprotected intercourse with eight new part-
ners within the last year, you also consider testing or HIV.
Q estion 9.1.1 The most appropriate laboratory test(s) to
r le o t the ac te retroviral syndrome wo ld be:
A) HIV-1 antibody by ELISA ollowed by a Western blot.
B) HIV-1 antibody by rapid detection method.
C) HIV DNA by PCR.
D) CD4 lymphocyte count.
E) Combined HIV-1 antibody and antigen ELISA test.
258
9
Answer 9.1.1 The correct answer is “E.” T is presentation is
consistent with an acute retroviral syndrome, which occurs very
early in the in ection and is characterized by a mononucleosis-
like illness that can last several weeks. Current HIV diagnostic
ELISA methods include the option or both antibody and antigen
detection. Since the antibody to HIV will not develop or at least
2 to 8 weeks a er in ection and the retroviral syndrome typically
occurs be ore seroconversion, HIV antibody tests, including
rapid detection methods (“B”), may well be negative. During the
acute HIV in ection, HIV viral loads are very high, and patients
are more in ectious compared to other times during their HIV
in ection. Consequently, the HIV antigen assay, which measures
HIV p24 protein, is typically positive during this period. Not all
laboratories have adopted the HIV antibody–antigen ELISA. I
this option is not available, the alternative approach would be to
measure the HIV RNA by PCR. However, the PCR test is more
expensive, thus the antibody–antigen ELISA is pre erred. T e
HIV DNA PCR assay (“C”) is not standardized and should not
be used in this setting. T e CD4 count (“D”) is not a reliable way
o diagnosing HIV in ection; it can become depressed with any
acute illness or may be normal in early HIV disease.
HELPFUL TIP:
I ur c inica suspici n is high and the antib d /anti-
gen c binati n test is negative, the ne t step ud
be an HIV RNA PCR. This can be detected appr i ate-
10 da s a ter in ecti n and is t pica p sitive 4 t
10 da s pri r t the HIV p24 antigen.
T e ELISA returns positive or HIV antigen and negative
or antibody. A er appropriate treatment and counseling
about her test results, blood is also sent or CD4 count, HIV
RNA viral load testing, and drug-resistance (genotype) test-
ing. Follow-up is arranged or the patient, and she returns in
4 weeks with no complaints or symptoms. A complete his-
tory and physical examination are per ormed. T e patient
has mild cervical lymphadenopathy and no other ndings.
Laboratory studies are ordered and show:

WBC 3,200 cells/mm3
HC 42%
Platelets 185,000 cells/mm3
Chemistry panel (normal)
Liver enzymes (normal)
CD-4 lymphocytes 645 cells/mm3
HIV viral load 5,000 copies/mL
HIV genotype has K103 N mutation
Q estion 9.1.2 At her next visit, what baseline st dies
sho ld be ordered?
A) PPD or Quanti eron Gold testing.
B) Rapid plasma reagin (RPR) or Syphilis IgG.
C) Repeat HIV ELISA.
D) Hepatitis B and C antibody.
E) All o the above.
Answer 9.1.2 The correct answer is “E.” During the initial
assessment o an HIV-in ected person, all o these studies are
important. A positive PPD (> 5 mm induration in a person
in ected with HIV) warrants treatment or latent tuberculosis
( B) i the patient is ound to not have active disease. Since
patients with any sexually transmitted in ection (S I) are at risk
or another S I, screening or syphilis with an RPR or syphilis
IgG is recommended. T e same rationale applies or hepatitis
B and C, which can be acquired via the same routes as HIV.
T e patient has documented HIV by virtue o the positive HIV
antigen–antibody ELISA and positive HIV RNA; however, doc-
umentation o seroconversion is important, and a repeat HIV
antibody ELISA should be sent at 12 weeks with positives con-
rmed by HIV Western blot.
HELPFUL TIP:
Gen t pe testing r resistance against certain edi-
cati ns sh u d be per r ed at base ine diagn sis re-
gard ess hether antiretr vira (ARV) therap i be
initiated r de erred.
T e patient is counseled appropriately about all her results.
Q estion 9.1.3 What is the most important actor in deter
minin when to start hi hly active antiretroviral therapy
(HAART)?
A) A rising viral load.
B) A decrease in CD4 count.
C) T e development o an opportunistic in ection.
D) T e patient’s willingness and ability to maintain strict adher-
ence to an antiviral regimen.
E) An undetectable viral load (< 50 copies/mL).
Answer 9.1.3 The correct answer is “D.” T e decision to
start HAAR must be done on an individual basis. T e most
important consideration by ar, however, is the willingness o
the patient to strictly adhere to complicated medical regimens.
Poor compliance virtually guarantees the development o
resistance, hampers treatment o the patient in later stages,
Ch Apt Er 9 • HIV/AIDS 259
and risks the spread o resistant strains to other patients. T e
current recommendations are to start all HIV in ected indi-
viduals on HAAR therapy regardless o CD4 count, although
the strength o these recommendations varies depending on the
CD4 count. Early HAAR therapy helps prevent disease pro-
gression or HIV-in ected individuals and is also an important
step in helping prevent transmission o HIV. Evidence does not
support using the viral load (“E”) as an independent determi-
nant o initiating therapy.
HELPFUL TIP:
HAART regi ens have bec e increasing c p e
ith the additi n an ne drugs, c asses, and
c binati n pi s. H ever, the basics can be br ken
d n and si p i ied. The backb ne usua c nsists
t nuc e side reverse transcriptase inhibit rs (NRTIs).
There are a e p pu ar c binati n pi s used r this
backb ne but the t ten used are Truvada (ten -
vir/e tricitabine) and Epzic (abacavir/ a ivudine).
These are p pu ar because the are b th nce dai and
are c bined ith an additi na edicati n r re a-
tive si p e regi ens. T c p ete a regi en, an addi-
ti na edicati n is added r a di erent c ass usua
either a n nnuc e side reverse transcriptase inhibit r
(e.g., e avirenz), pr tease inhibit r (e.g., darunavir/rit -
navir), r integrase inhibit r (e.g., d utegravir, ra te-
gravir, r e vitegravir). The t current ne-pi nce
dai initia rec ended regi ens c bine an NRTI
backb ne ith and integrase inhibit r. These are Tri-
u eq (Epzic + d utegravir) r Stribi d (Truvada +
e vitegravir/c bicistat).
Common Adve se Effec s of Ar V medica ions include:
Ten vir (c p nent Truvada)—rena ai ure
Abacavir (c p nent Epzic )—h persensitivit
reacti n
E avirenz—CNS e ects inc uding increased suicida it
Atazanavir—as pt atic h perbi irubine ia
HELPFUL TIP:
Current guide ines rec end treat ent immedia e-
ly fo egnan women a any s age of h IV infec ion,
inc uding during the acute retr vira s ndr e. Treat-
ent thers during the acute retr vira s ndr e is
c nsidered pti na , and there is n pr ven ng-ter
bene it. HIV edicati ns suitab e r use during preg-
nanc ust be used.
Q estion 9.1.4 Aside rom considerin HAART and stress
in the importance o partner noti cation, what other
intervention sho ld be o ered at this sta e?
A) 13-valent conjugated pneumococcal and hepatitis B vac-
cines.
B) rimethoprim/sul amethoxazole ( MP/SMX) DS one tablet
per day or the prevention o P. jiroveci pneumonia (PCP).
260 FAmIl y mEDICINE ExAmINATIo N & Bo ARD REVIEw

TABLE 9-1 r ECOMMENDED pr Oph YLAXIS IN HELPFUL TIP:

h IV pAt IENt S Partner n ti icati n is ver i p rtant. State a s var
CD4± c nsiderab regarding partner n ti icati n, and state
Co nt Or anism Recommended Prophylaxis hea th depart ents are usua ver he p u in aci itat-
<200 Pneumocystis TmP/Smx r daps ne (sh u d ake
ing this. S e states have cri ina trans issi n statutes
sure patient is n t G6PD de cient) r having se ith ut te ing the partner ne’s HIV
status. Pr secuti n a n t require actua trans issi n.
<100 T p as sis TmP/Smx r c binati n
daps ne + p ri etha ine +
euc v rin

<50 m c bacteriu Azithr cin, c arithr cin, r
aviu c p e ri abutin
(mAC)
Adapted r Pane n o pp rtunistic In ecti ns in HIV-In ected Adu ts and
Ad escents. Guide ines r the preventi n and treat ent pp rtunistic
in ecti ns in HIV-in ected adu ts and ad escents: rec endati ns r
the Centers r Disease C ntr and Preventi n, the Nati na Institutes
Hea th, and the HIV medicine Ass ciati n the In ecti us Diseases S ciet
A erica. http://aidsin .nih.g v/c ntent es/ vguide ines/adu t_ i.pd .
Accessed August 31, 2015. Tab e 1.
C) Azithromycin 1200 mg per week or the prevention o
Mycobacterium avium complex (MAC).
D) Fluconazole 100 mg per day or the prevention o cryptococ-
cal meningitis.
Answer 9.1.4 The correct answer is “A.” Adequate immuni-
zations at a clinical stage when the patient is likely to bene t
rom the vaccines (i.e., CD4 > 500 cells/mm 3) are important.
Live vaccines, such as the MMR, should be avoided in immu-
nocompromised persons, generally considered those HIV-
in ected persons with a CD4 count < 200 cells/mm3. Pneumo-
coccal vaccines are indicated or HIV positive patients. While
the polysaccharide 23-valent vaccine (Pneumovax) covers more
serotypes, the 13-valent conjugate vaccine (Prevnar) has a more
robust immune response. I previously unvaccinated, the rec-
ommendation is to start with the 13-valent conjugate vaccine
ollowed by the 23-valent polysaccharide pneumococcal vac-
cine a er at least 8 weeks. A er 5 years, boost with the 23-valent
pneumococcal vaccine.
MP/SMX (“B”) or PCP prevention is indicated when
the CD4 drops below 200 cells/mm 3, and azithromycin (“C”)
is indicated or MAC prophylaxis when the CD4 count drops
below 50 cells/mm 3. Fluconazole (“D”) is used or chronic sup-
pression a er the treatment o cryptococcal meningitis or or
the treatment o esophageal candidiasis; but it is NO currently
used as prophylaxis. T ere is no survival bene t to prophylaxis
or cryptococcal meningitis. See able 9-1 or recommended
prophylaxis in patients with HIV.
A er consultation with an HIV specialist, the patient elects
not to start therapy at this time and is scheduled or ollow-up
with regular checks o her viral load and CD4 count. A er 1
year, the patient’s lab values have changed: CD-4 lymphocytes
280 cells/mm3 and HIV viral load 75,000 copies/mL. In the
past year, she has been treated three times or lobar pneumo-
nia and once or oral candidiasis (without esophageal disease).
Q estion 9.1.5 Does this patient meet the CDC case de ni
tion or the acq ired imm ne de ciency syndrome (AIDS)?
A) No, because she has not had an AIDS-de ning illness.
B) No, because her CD4 count is > 200 cells/mm 3.
C) No, because she has only been diagnosed with HIV in ection
or 1 year.
D) Yes, because she has had recurrent (two or more episodes) o
lobar pneumonia.
E) Yes, because her viral load is > 10,000 copies/mL.
Answer 9.1.5 The correct answer is “D.” T e CDC HIV clas-
si cation system requires a case o HIV in ection be reported as
AIDS i the CD4 count is less than 200 cells/mm 3 or the patient
develops an AIDS-de ning illness. T ese AIDS-de ning ill-
nesses include esophageal (not oral) candidiasis, cryptococcal
in ection, disseminated histoplasmosis, invasive cervical can-
cer, tuberculosis, HIV wasting disease, and recurrent pneumo-
nia (more than one episode per year). Other in ections, Kaposi
sarcoma, and certain lymphomas may also de ne AIDS in an
HIV-in ected person. Duration o in ection and viral load are
not currently criteria.
T e patient is started on teno ovir/emtricitabine ( ruvada)
and ritonavir-boosted atazanavir once daily. E avirenz
(Sustiva) was not used due to the original resistance testing.
In addition, the patient is o childbearing age and e avirenz
is contraindicated during pregnancy i the patient were to get
pregnant. She does well with the treatment, and tolerates the
medications. On a later routine ollow-up, she reports mild
atigue, but is otherwise well. Her laboratory results over sev-
eral visits are listed in able 9-2.

HELPFUL (BUT CONFUSING) TIP:

PCP is n nger P. carinii. It is n Pneu c stis jir veci. TABLE 9-2 CASE 1, LABOr At Or Y r ESULt S
w e didn’t d it, h nest. It as s e icr bi gist- Jan ary March May
ta n ist h anted t c n use us a . Just t add 3 3 3
CD4 c unt 204 ce s/ 178 ce s/ 244 ce s/
t the c n usi n, P. jir veci pneu nia is sti ten
abbreviated “PCP” as in Pneu C stis jir veci pneu nia. Vira ad 5,500 c pies/ l <50 c pies/ l <50 c pies/ l

Current laboratory results also include WBC 4,500 cells/
mm3, Hgb 12.1 g/dL, platelets 128,000 cells/mm3, and total
bilirubin 2.1.
Q estion 9.1.6 At this point, what chan es, i any, sho ld
be made to the patient’s re imen?
A) T e patient has ailed HAAR treatment, and the drug regi-
men should be changed.
B) T e patient has su ered a severe adverse e ect (hyperbiliru-
binemia) rom the drug regimen and all three drugs should
be changed.
C) T e patient has ailed to reconstitute her immune system
(CD4 count still less than 200 cells/mm 3), so one o her
drugs should be changed.
D) T e patient is doing well and her regimen should be contin-
ued. T e hyperbilirubinemia is a side e ect associated with
atazanavir.
Answer 9.1.6 The correct answer is “D.” T e patient’s viral
load is suppressed, which is the primary goal o HAAR . T e
patient has not su ered any major adverse reactions. Indirect
hyperbilirubinemia is commonly seen with atazanavir, and other
hepatic enzymes should be ollowed regularly to ensure that the
change in laboratory studies is only due to the atazanavir. It can
be mild, but can become severe on occasion. Criteria or chang-
ing drug regimens include < 1 log10 reduction in viral RNA by
8 weeks (e.g., 100,000 to 10,000 is a 1 log10 reduction), ailure to
depress viral RNA to undetectable levels by 6 months, repetitive
detection o viral RNA a er initially achieving undetectable lev-
els, persistent decline in CD4 counts (on at least two measure-
ments), or signi cant clinical deterioration. T e expected rise in
CD4 counts is much slower than the all in HIV RNA, and little
or no change may be seen in the rst 6 months o therapy.
HELPFUL TIP:
w hen changing drug regi ens r vir gic ai ure, it
is i p rtant t repeat gen t pe testing hi e n their
current regi en t deter ine hether the patient’s
virus has n deve ped resistance t their current
regi en.
T e patient’s HAAR regimen is maintained. However, she
misses her next two appointments, and returns to clinic
6 months later. She reports taking all o her medications but
complains o a 10-lb unintended weight loss. She also notes
increased requency o night sweats but no evers. A physical
examination is unremarkable except or a gaunt appearance
and temporal muscle wasting.
Her laboratory results show:
CD4 count: 78 cells/mm3
Viral load: 6,400 copies/mL
CBC: WBC 2,400 cells/mm3
Hgb: 11.3 g/dL
Platelets: 145,000 cells/mm3
otal bilirubin: 1.8
Ch Apt Er 9 • HIV/AIDS 261
Repeat CD4 count and viral load 2 weeks later shows:
CD4 count: 32 cells/mm3
Viral load: 7,100 copies/mL
Q estion 9.1.7 At this point, what chan es, i any, sho ld
be made to the patient’s re imen?
A) T e patient has ailed HAAR treatment and her ARV regi-
men should be adjusted.
B) Since her hyperbilirubinemia has persisted, the patient is
assumed to have su ered a severe adverse e ect rom her
atazanavir, so it alone should be changed.
C) T e viral load is not over 50,000 copies/mL, so the current
regimen should be continued.
D) T e patient is doing well and her regimen should be contin-
ued. T e hyperbilirubinemia is a side e ect associated with
atazanavir.
Answer 9.1.7 The correct answer is “A.” T e patient has ailed
HAAR based on several criteria, including the reemergence o
detectable viral RNA a er it had been completely suppressed
and a alling CD4 count (see explanation o previous question,
above). Her ARV therapy should be changed once the results o
the repeat genotype testing are known.
A new ARV therapy regimen is recommended based on the
genotype results along with PCP and MAC prophylaxis,
with MP/SMX and azithromycin, respectively. wo weeks
later, the patient’s CD4 count rises to 210 cells/mm3 and she
has more energy. However, she returns to clinic 3 weeks later
(5 weeks a er starting her new HIV regimen) and is com-
plaining o severe shortness o breath. She says that she had
been taking her HIV medications and the azithromycin, but
that she lost her PCP prophylaxis prescription ( MP/SMX),
and had orgotten to get a new one. Her current illness
began 6 days ago as a ever and mild cough. She devel-
oped signi cant dyspnea with minimal exertion, and now
is even short o breath at rest. Her chest hurts bilaterally,
worse with inspiration. She has drenching night sweats. She
denies hemoptysis, sputum production, nausea, vomiting,
or abdominal pain.
Physical examination reveals the ollowing vital signs:
39°C, BP 90/60 mm Hg, P 135 bpm, RR 38 bpm, and SpO2
78%on room air. T e patient is in severe respiratory distress
and in the tripod position. T e lung examination shows di -
use rales and tachypnea. You call the ambulance because she
looks like she needs help! You place oxygen to help improve
her oxygen saturation and her respiratory rate. She does not
respond to oxygen and becomes unresponsive.
Q estion 9.1.8 Aside rom respiratory isolation, what sho ld
be done next?
A) Sputum culture to evaluate or any lung organisms that may
be causing her respiratory distress.
B) Bronchoalveolar lavage (BAL) or PCP via direct immuno-
uorescence (DFA).
262 FAmIl y mEDICINE ExAmINATIo N & Bo ARD REVIEw

C) Bag mask the patient and have your nurse place an IV in

order to prepare or rapid sequence intubation and IV uids.
D) Oxygen, urosemide, and nitroglycerin. She clearly is vol-
ume overloaded.
E) Chest x-ray (CXR), blood count, CD4 count, and viral load
to assess or underlying in ection.

Answer 9.1.8 The correct answer is “C.” T e patient presented

in severe respiratory distress and now has impending respira-
tory ailure. She is also hypotensive and tachycardic and must be
stabilized be ore any urther workup is done. Remember those
ABC’s (Airway, Breathing, Circulation) rom all those certi -
cation classes you had to take? “D,” Oxygen, urosemide, and
nitrates are use ul treatments o congestive heart ailure, but this
is unlikely in this young woman. P. jiroveci pneumonia (PCP) is
the most likely diagnosis that explains o her ndings. Further FIg u RE 9-1. Chest radi graph.
workup including sputum culture, PCP direct immuno uores-
cence, CXR, and blood count are all indicated but only a er the
patient is stabilized. Given the timing o the onset o symptoms
in the setting o a rapid CD4 response to ARV therapy, this is Q estion 9.1.9 What sho ld be the initial antibiotic therapy?
likely related to immune reconstitution in ammatory syndrome A) Four drug anti-tuberculosis regimen.
(IRIS). B) Azithromycin and Ce riaxone IV.
C) MP-SMX IV.
D) IV corticosteroids ollowed by MP-SMX IV.
HELPFUL TIP:
E) No antibiotics initially—just wait or the culture results.
I une rec nstituti n in a at r s ndr e (IRIS–
as pp sed t ISIS the terr rist rganizati n) is e
Answer 9.1.9 The correct answer is “D.” T e patient is
na ed. It is identi ied b a parad ica sym oma ic
acutely ill, and likely has PCP. Steroids decrease the mortality
rsening a pre-e isting in ecti us pr cess as the
in patients with severe PCP (PaO2 < 70 on room air or arte-
i une s ste rec nstitutes ith ARV therap . Basi-
rial–alveolar O2 gradient > 35 mm Hg). T e best antibiotic or
ca , the b d ’s i une resp nse recks hav c at the
PCP is MP-SMX. Pentamidine IV may be used in cases o
sites in ecti n (e.g., CmV retinitis, tubercu sis, cr p-
sul a allergy, but it has been associated with hypotension and
t c cca eningitis and bvi us , PCP). The in ecti n
hypoglycemia. Although the classic CXR appearance or PCP
a be under treat ent r subc inica and bec es
is bilateral interstitial in ltrates, it can present di erently (as
s pt atica rse hen IRIS deve ps. C n
in this case). A normal CXR examination is not uncommon,
indings are ever, increased atigue and a aise, un-
and approximately 10% o people diagnosed with PCP have a
e p ained eight ss, rsening respirat r and neu-
normal CXR on presentation. Since the in ecting organism is
r gica status. IRIS usua ccurs ithin the irst 4 t
not known with certainty, it would prudent to secondarily add
8 eeks a ter initiati n therap but it can be de a ed
empiric therapy or bacterial pneumonia with ce riaxone and
severa nths in s e cases.
azithromycin or respiratory uoroquinolone pending bron-
choscopy results. However, this is not the initial best treatment
or the patient’s clinical condition. O note, PCP does not grow
A er appropriate resuscitation and transportation to a in standard cultures; but it can be visualized by silver staining
higher level o care at the local emergency room, laboratories or direct immuno uorescence assays (DFA) on BAL specimens.
and a CXR are obtained. T e x-ray is shown in Figure 9-1. Detection o PCP is not reduced during the rst 48 hours a er
Laboratory results are: starting therapy, and cysts may be seen or much longer in peo-
ple responding to therapy, despite e ective treatment.
WBC 3,400 cells/mm3
Hgb 11 g/dL T e patient is admitted to the ICU and given antibiotics.
Platelets 180,000 cells/mm3 Her condition stabilizes until 4 hours into her ICU stay. At
Creatinine 2.4 mg/Dl (high) that time, her respiratory rate on assisted-control ventilation
LDH 1,280 IU/L (high) dramatically increases rom 18 to 42. Peak airway pressures
P 12.4 seconds, P 27 seconds according to the ventilator are greater than 60 cm o water,
Liver enzymes normal when they were less than 30 cm water previously. Breath
ABG: pH 7.56, PaCO2 23 mm Hg, PaO2 68 mm Hg (on sounds are absent on the right side o her chest, and her tra-
100%FiO2) chea is deviated to the le . Heart sounds are audible, but
Sputum and blood cultures are pending. tachycardic. Neck veins are distended bilaterally.

Q estion 9.1.10 What is the next appropriate step, BEFORE
a repeat CXR is taken?
A) Give Versed 2 mg IV or sedation, the patient must be very
anxious.
B) Pull the E tube back 1–2 cm, as it is likely in the right main
stem bronchus.
C) Per orm a blind pericardiocentesis, as the patient is develop-
ing tamponade.
D) Insert a large Angiocath into the le second intercostal space
to relieve the tension pneumothorax on the le .
E) Insert a large Angiocath into the right second intercostal
space to relieve the tension pneumothorax on the right.
Answer 9.1.10 The correct answer is “E.” T e patient has
developed a dreaded complication o PCP, a pneumothorax.
T e organism, Pneumocystis, has a propensity to cause blebs
(cysts) in the lung tissue. Since the patient was receiving positive
pressure ventilation, a tension pneumothorax developed that
requires immediate needle decompression. T is should be done
without waiting or a portable CXR. When the pneumothorax is
later con rmed, a tube thoracostomy may be per ormed under
controlled conditions.
Following a protracted ICU admission, the patient improves,
and is re-started on the HIV medication regimen that was
selected based on her drug resistance testing. She is dis-
charged, and in response to this li e-threatening complica-
tion, she is highly motivated and becomes very adherent with
her medications. wo years later her CD4 is 385 cells/mm3,
her HIV RNA concentration is < 20 copies/mL (nondetect-
able), and she recently started a job that she enjoys.
Objectives: Did yo learn to . . .
• Identi the signs and s pt s the acute retr vira s n-
dr e?
• Use appr priate tests r the diagn sis HIV in ecti n?
• Eva uate a patient ith HIV and nit r that patient’s pr g-
ress?
• Revie the preventative hea th easures and vaccinati ns
i p rtant in patients ith HIV in ecti n?
• Understand the guide ines r initiating and changing
HAART?
• Rec gnize s e the re c n edicati ns used t
treat HIV and their side ef ects?
• Rec gnize s e the re c n pp rtunistic in ec-
ti ns in patients ith HIV and h t prevent the ?
• Describe IRIS?
CASE 9.2
A 32-year-old emale presents to the of ce seeking prenatal
care. Her last menstrual period was 2 months prior to her
visit. She believes that she is pregnant and has tested posi-
tive with a home pregnancy test. She has been pregnant twice
be ore, with one living child and one spontaneous abortion
(G3P1). In an interesting twist on modern romance, she is
married to the ather o her children. She has no health
Ch Apt Er 9 • HIV/AIDS 263
problems but does smoke pack o cigarettes per day.
She also admits to occasional alcohol use (one drink every
2 weeks). She denies illicit drug use, including IV drug use.
Q estion 9.2.1 Besides prenatal vitamins with iron and
olate, yo recommend:
A) Smoking cessation.
B) Con rming the home pregnancy test with a serum HCG in
your laboratory.
C) HIV testing and counseling.
D) A and C.
E) All o the above.
Answer 9.2.1 The correct answer is “D.” Smoking during preg-
nancy is associated with lower birth weight and preeclampsia,
and smoking in the house with a young child is associated with
respiratory diseases, especially asthma. Although con rming
pregnancy by examination (uterine size or etal heart tones)
and/or urine HCG is appropriate, serum HCG is unnecessary
and expensive. In addition, when used correctly, home preg-
nancy tests are highly sensitive and speci c. But really, this is
the HIV chapter, and we want you to know that HIV screen-
ing should be included in the routine panel o prenatal tests
or all women seeking prenatal care. Routine testing or HIV
in expectant emales has dramatically reduced the HIV preva-
lence in children in developed countries. Vertical transmission
o HIV is still a tremendous problem in A rica and other devel-
oping regions o the world.
HELPFUL TIP:
Specia c nsent is no necessar pri r t testing r
HIV and a patient’s genera c nsent r edica care is
en ugh. o c urse, this a depend n the a s the
state in hich u practice. The CDC rec ends that
testing a pregnant en be r utine and ered
as an “ pt ut” test ( eaning n specia c nsent r HIV
testing).
You explain that HIV testing is routine, but that the patient can
“opt out,” and the patient agrees to HIV testing. Her pregnancy
is con rmed. Her HIV Ab/Ag combination test is positive.
Q estion 9.2.2 What is the next step in con rmin the dia
nosis o HIV?
A) HIV viral load
B) HIV-1/HIV-2 multispot test
C) HIV western blot
D) HIV genotype
E) CD4 count
Answer 9.2.2 The correct answer is “B.” T e recommended
testing algorithm has recently changed. Previously an HIV Ab
ELISA “screening” test was done initially, ollowed by a “con r-
matory” Western Blot. However, the current recommendation
(based on CDC guidelines) starts with the HIV antigen/antibody
264 FAmIl y mEDICINE ExAmINATIo N & Bo ARD REVIEw
combination immunoassay. T is combines the p24 antigen test
(which is positive be ore seroconversion) with an antibody test
or IgM and IgG. T is will diagnose any HIV in ection 2 to
3 weeks a er in ection (including HIV-2). I the antigen-
antibody test is positive, it is ollowed by an HIV-1/HIV-2 Ab
di erentiation immunoassay. I positive, HIV diagnosis is con-
rmed. I negative, an HIV RNA viral load should be sent to
determine whether the patient truly has HIV.
Your patient is understandably shaken by the news o this
test result. Being an empathetic physician, you say something
like, “I can see that you are shaken by the news o this test
result.” She is most concerned about her unborn child.
Q estion 9.2.3 What sho ld yo tell her?
A) Her child is almost certainly also in ected.
B) A therapeutic abortion at this point is the only humane
thing to do.
C) With e ective therapy, the risk o transmission to the child
can be lowered to less than 2%.
D) With e ective therapy, the risk o transmission to the child
can be lowered to 15%.
E) Despite e ective therapy, the risk o transmission remains at
25%.
Answer 9.2.3 The correct answer is “C.” Although it is possible
or HIV to in ect the unborn etus, the large majority o mother
to child HIV transmission occurs due to exposure during deliv-
ery to maternal genital-tract virus. T e most important variable
or transmission is the HIV viral load (HIV RNA concentration
in plasma) in the mother. ARV drugs reduce perinatal transmis-
sion by several mechanisms, including lowering maternal ante-
partum viral load and providing in ant pre- and postexposure
prophylaxis (PEP). T ere ore, combined antepartum, intrapar-
tum, and in ant ARV prophylaxis is recommended to prevent
perinatal transmission o HIV.
Your patient is somewhat relieved that her baby can be pro-
tected, and wants to know what can be done to treat her. She
eels ne, is now in the second trimester, and would rather
not take medications unless she had to.
Some additional laboratory tests are ordered:
CD4 count: 756/mm3
HIV viral load: 80,000 copies/mL
Hgb: 11.2 g/dL
BUN/Cr: 11 mg/dL/0.7 mg/dL.
Q estion 9.2.4 What sho ld yo tell her abo t HAART in
pre nancy?
A) o minimize the risk o transmission to her child, she should
start triple ARV therapy as soon as possible.
B) ARV medications are teratogenic and should be avoided at
all costs during pregnancy, except just be ore delivery.
C) Since her CD4 count is normal and she eels well with no
sign o opportunistic in ections, starting HAAR is not
indicated.
D) Her renal unction makes HAAR relatively contraindicated.
E) Her hemoglobin level makes HAAR relatively contraindi-
cated.
Answer 9.2.4 The correct answer is “A.” ARV therapy is rec-
ommended or all pregnant women regardless o their viral load
to prevent transmission to the child. Factors that increase risk
o transmission o HIV include high maternal viral load, low
maternal CD4 count, advanced clinical stage o her HIV, and
lack o maternal use o ARV therapy. Vaginal delivery is also a
risk actor—but only i the mother did not receive antepartum
ARV therapy. Although the patient’s hemoglobin is low, it does
not preclude her rom taking therapy. Her renal unction is nor-
mal, so it should not be an issue.
Ideally, the mother should have her HIV suppressed (unde-
tectable viral load) on combination antiretroviral therapy
(HAAR ) prior to delivery. Waiting to start therapy until the
second trimester is recommended by some; however, more
recent recommendations suggest consideration o initiation o
ARV as soon as HIV is diagnosed in avor o earlier viral sup-
pression and decreased risk o transmission. I the HIV viral
load (HIV RNA concentration in plasma) is nondetectable at
36 weeks, the transmission risk is < 2%.
I the mother’s viral load is unknown or > 1,000 copies/mL,
current guidelines recommend also adding continuous in u-
sion o zidovudine (ZDV) to the mother during labor as well as
scheduled cesarean delivery. Postpartum prophylactic medica-
tions or the newborn should be given or 6 weeks regardless o
maternal viral load. Women who present in labor without HIV
testing during pregnancy, or with undocumented HIV in ec-
tion, should be tested by rapid HIV ELISA. I this is positive,
continuous in usion ZDV should be started. Current guidelines
do not recommend additional intrapartum drugs in this setting,
including nevirapine, which has been shown to cause rapid
resistance when used in this setting.
T e patient is started on HAAR (Combivir plus Kaletra)
and tolerates her regimen well. Repeat laboratory results at a
return visit 4 weeks later are as ollows:
CD4 count: 692/mm3
HIV viral load: 5,500 copies/mL
Hgb: 10.9 g/dL
Her HAAR seems to be e ective. Her viral load has
decreased by > 10- old (one log10). You remember rom your
last patient how sick patients can get with P. jiroveci pneumonia.
Q estion 9.2.5 What do yo recommend to this patient
re ardin PCP prophylaxis?
A) She should start prophylaxis with MP-SMX immediately,
because PCP in pregnancy can be particularly severe.
B) She should start PCP prophylaxis with inhaled pentamidine,
because MP-SMX is contraindicated in pregnancy.
C) PCP prophylaxis is not indicated, since her CD4 count is
> 200/mm 3.
D) PCP prophylaxis is not a major concern or pregnant pa-
tients.

Answer 9.2.5 The correct answer is “C.” PCP is particularly
severe in pregnant patients, but prophylaxis is not generally
indicated or CD4 counts > 200 cells/mm 3. MP-SMX is asso-
ciated with hyperbilirubinemia in newborns, but is still indi-
cated or PCP prophylaxis. Oral dapsone is another option, as is
inhaled pentamidine.
She continues her ARV therapy, but at 36 weeks, her viral load
is still detectable (2,500 copies/mL). You recommend chang-
ing the ARV, but at the next appointment (37.5 weeks), the
patient tells you that she did not ll the new prescriptions,
and admits that she has not been adherent with her medica-
tions. As this visit, you renew discussions about adherence,
and about delivery plans with the patient.
Q estion 9.2.6 Which o the ollowin is/are tr e re ardin
the delivery?
A) A cesarean section (C-section) is likely to reduce the risk o
transmission to her in ant.
B) A C-section section is indicated, because this patient’s viral
load remains greater than 1,000 copies/mL despite HAAR .
C) A C-section should be per ormed at 38 weeks gestation,
prior to the onset o labor.
D) Peripartum ZDV should be given to the mother and in ant.
E) All o the above.
Answer 9.2.6 The correct answer is “E.” I a patient achieves
e ective suppression with ARV therapy (undetectable viral
load), the risk o transmission is minimal, and the mode o
delivery should depend on the pre erences o the mother and
the other usual obstetric actors. Vaginal delivery is not contra-
indicated i the mother’s viral load is suppressed. I , as in this
patient’s case, the viral load is > 1,000 copies/mL, current guide-
lines recommend delivery by C-section at 38 weeks. When per-
ormed at 38 weeks, prior to the onset o labor, the relative risk
o transmission is reduced by 50%. Perinatal ZDV, as discussed
above, may also help reduce the risk o transmission. Also, the
premature rupture o membranes should be addressed promptly
in HIV-in ected mothers. Children born to mothers more than
4 hours a er rupture are twice as likely to acquire HIV.
T e patient delivers a healthy, 3-kg male in ant via C-section.
T e postpartum course is unevent ul. Blood taken rom the
in ant at day 1 and at 2 weeks both test positive or HIV anti-
bodies.
Q estion 9.2.7 What does this mean?
A) T e in ant is in ected with HIV.
B) Although technically HIV positive, the in ant’s in ection sta-
tus is unclear rom the in ormation given.
C) Maternal HIV antibodies are expected to be circulating in
the in ant, but it can be assumed that no transmission o
in ection took place.
D) A positive test at day 1 is expected due to maternal antibod-
ies, but a repeat positive at 2 weeks indicates in ant antibody
production and is evidence o in ection.
E) None o the above.
Ch Apt Er 9 • HIV/AIDS 265
Answer 9.2.7 The correct answer is “B.” Children born to HIV-
positive mothers will test positive or HIV antibodies as mater-
nal antibodies are acquired across the placenta or at least the
rst 6 months. Maternal HIV antibodies may persist and inter-
ere with interpretation o a positive HIV antibody test; there-
ore, HIV antibody testing is not recommended to diagnose an
HIV in ection in in ants.
Q estion 9.2.8 How sho ld the HIV stat s o the in ant be
determined?
A) Serial HIV antibody tests: a our old drop in titer can be
considered negative.
B) p24 antigen testing in the rst 48 hours o li e.
C) Viral load by PCR in the rst 48 hours o li e.
D) Viral load by PCR at 14 to 21 days, 1 to 2 months, and 4 to
6 months.
E) p24 antigen and PCR viral load on cord blood samples.
Answer 9.2.8 The correct answer is “D.” T e best test to assist
with diagnosis o HIV in ection is viral load by PCR, and a
positive test (by DNA PCR or RNA assays) indicates likely HIV
in ection. Con rmation o HIV in ection is provided by two
positive virologic tests obtained rom separate blood samples.
Overall, the sensitivity o virologic testing increases rapidly by
2 weeks. One can consider obtaining virologic testing within the
rst 48 hours in newborns who are at high risk or HIV in ection,
such as in ants born to HIV-in ected mothers who did not receive
prenatal ARV therapy or who had HIV viral loads > 1,000 copies/
mL close to the time o delivery. I this returns positive, this
would indicative o an intrauterine in ection rather than intra-
partum in ection, which is normally acquired during delivery.
“A” is incorrect. HIV antibody testing is useless in in ants, and
quanti ed titers are not typically generated. “B” is incorrect
because the p24 antigen is less sensitive and speci c than the
viral load in this setting. “E” is incorrect. ests done on the cord
blood may be contaminated with maternal blood and do not
give an accurate assessment o the in ant’s status.
Q estion 9.2.9 What sho ld yo advise yo r patient abo t
breast eedin her son?
A) HIV is not transmitted by breast milk.
B) HIV is transmitted by breast milk, but the bene ts o breast-
eeding outweigh the risk o transmission in this setting.
C) HIV is transmitted by breast milk, but her son will be pro-
tected rom serious in ection due to maternal antibodies in
the breast milk.
D) HIV is transmitted by breast milk, and breast- eeding should
be avoided i possible.
Answer 9.2.9 The correct answer is “D.” Postpartum trans-
mission o HIV rom mother to child occurs in 10% to 14% o
breast- eeding mothers. T is is not a major problem in devel-
oped nations, where there is reliable access to ormula. HIV-
positive mothers should be discouraged rom breast eeding
in the developed world, including the U.S. T e recommenda-
tions may be di erent in developing areas o the world, where
the mother’s milk may be the only clean source o nutrition
266 FAmIl y mEDICINE ExAmINATIo N & Bo ARD REVIEw
available to the in ant. In act, in many developing nations, the
bene t o breast eeding outweighs the risk o HIV transmission;
ormula eeding can increase mortality due to inadequate access
to good nutrition, lack o clean water source, and risk o diar-
rheal illnesses. T e World Health Organization (WHO) suggests
that “when replacement eeding is acceptable, easible, a ord-
able, sustainable and sa e,” bottle- eeding is the best option.
Despite the best e orts o your patient and all the physicians
and nurses participating in her care, her child tests positive
by PCR or HIV at 4 weeks and 4 months. Now, you need to
think about how to treat this child with HIV.
Q estion 9.2.10 Which o the ollowin is tr e abo t the
se o HAART in children?
A) reatment should be initiated immediately or all children as
soon as HIV in ection is diagnosed.
B) Since they are just little adults with relatively big heads com-
pared to their torsos, treatment indications or children and
adults are the same.
C) HAAR is highly toxic in children and treatment should be
reserved until the child’s li e is in immediate danger rom
HIV-related complications.
D) No one really knows the best approach, but the treatment is
recommended in most children and should be given to all
in ants < 12 months.
E) reatment indications or children are similar to those or
adults, but monotherapy is pre erred over combination
therapy.
Answer 9.2.10 The correct answer is “D.” Recommendations
or when to start therapy di er by the age o the child. CD4
counts and HIV RNA viral loads vary by age in children and both
markers are poor predictors o disease progression and mortality
in children < 12 months o age. T e risk o rapid progression o
the disease and mortality is high in in ants, and current guide-
lines recommend initiating therapy or all in ants < 12 months
regardless o their clinical status, CD4 counts, or viral load. For
children older than 12 months o age, treatment is recommended
or AIDS or signi cant symptoms re erable to HIV, regardless o
CD4 count. For asymptomatic children > 1 and < 6 years old,
HIV therapy should be started i the HIV viral RNA is > 100,000
or the CD4 count is < 1,000. HAAR regimens are more dif -
cult to choose and adjust in children because o a limited num-
ber o pediatric (non-pill) ormulations and a lack o data about
long-term ef cacy and sa ety. However, combination therapy can
e ectively and sa ely suppress viral load and stimulate immuno-
logic reconstitution. Monotherapy is NO recommended.
Q estion 9.2.11 Which o the ollowin statements re ard
in the nat ral history o HIV complications in children is
tr e?
A) Hepatobiliary complications, such as AIDS cholangiopathy,
are more common in children.
B) Kaposi sarcoma requently occurs in young children.
C) Focal brain lesions in children are almost always due to
toxoplasmosis.
D) Many children show cognitive and motor de cits, but rank
AIDS dementia is uncommon.
E) Lymphocytic interstitial pneumonitis (LIP) is more com-
mon in adults than in children.
Answer 9.2.11 The correct answer is “D.” wenty- ve percent
o children with HIV in ection demonstrate some cognitive and
motor de cits. T ey ace problems with verbal expression, atten-
tion de cits, hyperactivity, and hyperre exia. LIP is characterized
by di use reticulonodular in ltrates and hilar lymphadenopathy
and occurs in up to 40% o children with perinatally acquired
HIV. LIP is very rare in adults. Kaposi sarcoma is associated with
a herpes virus in ection and is very rare in children. oxoplasmo-
sis, usually presenting as ocal mass brain lesions, is a reactivation
o previous in ection, and is there ore also very rare in children.
Hepatobiliary complications are more common in adults than in
children, but the reason or this is unclear.
Q estion 9.2.12 What sho ld yo recommend or this in ant
re ardin PCP prophylaxis?
A) Prophylaxis is unnecessary because children do not get PCP.
B) Prophylaxis is unnecessary i the child’s CD4 count is > 200
cells/mm 3.
C) Prophylaxis is unnecessary until the child reaches 1 year o
age.
D) Prophylaxis with MP-SMX is contraindicated in in ants
less than 6 months o age due to the risk o hyperbilirubine-
mia.
E) Prophylaxis with MP-SMX as the rst-line agent should be
initiated at 4 weeks o age because the highest risk or PCP
in children is at 3–6 months o age.
Answer 9.2.12 The correct answer is “E.” T e highest incidence
o PCP occurs in the rst year o li e with peak onset at 3 to
6 months o age. MP/SMX is still considered rst-line therapy
or prophylaxis and should be started at 4–6 weeks o age. CD4
counts are naturally higher in children and decrease to adult
levels by the age o 6 years. PCP prophylaxis is recommended
or all HIV-in ected in ants < 12 months regardless o CD4
count or percentage. It should be continued until the in ant is
determined to be HIV unin ected or presumptively unin ected.
I this drug is not tolerated, dapsone or aerosolized pentamidine
are acceptable alternatives.
T e child tolerates the HAAR very well and demonstrates
a consistently suppressed viral load. He has urther ollow-
up by a pediatric in ectious disease specialist. T e mother
returns to you or urther care. She had been taking the
previously prescribed HAAR , but quit all her medications
3 months ago because she had orgotten to take a couple o
doses and did not want to “screw things up.”
Her latest laboratory results show the ollowing:
CD4 count: 254 cells/mm3
HIV viral load: 50,000 copies/mL
(Previously CD4 count: 692/mm3; HIV viral load: 5,000
copies/mL)

Q estion 9.2.13 In addition to enco ra in her to con
tact yo r of ce immediately when she stops or chan es
medication, which o the ollowin is the most appropriate
advice to provide her now?
A) She should have continued to take the medications because
now the HIV has a “ oothold” and it will be much harder to
treat.
B) It would not have mattered i she took the medications or
not. Her disease is progressing as expected.
C) With the degree o drop seen in her CD4 count, the virus
must be resistant, and urther HAAR is utile.
D) She should have continued the medications, even i she was
missing doses. A little o ARV activity is better than nothing.
E) She did the right thing by stopping the medications. I a pa-
tient is not able to comply ully, it is better to not take any
HAAR at all.
Answer 9.2.13 The correct answer is “E.” Starting HAAR is
a very dif cult and serious decision and should be made a er
care ul and complete counseling. I taken intermittently, her
virus is highly likely to develop resistance to the medications
she is taking, and these can easily become ine ective. Patients
missing doses o HAAR requently are more likely to have
their HIV disease progress. Once multidrug resistance devel-
ops, it can be dif cult to nd an e ective regimen to slow dis-
ease progression.
A er the drug resistance genotype testing did not identi y
any mutations associated with drug resistance, she agrees to
try Atripla (e avirenz, emtricitabine, teno ovir) one tablet
PO QHS. She does not want any more children and is using
e ective contraception, as the e avirenz component in Atri-
pla is teratogenic.
At her ollow-up visit, she is slightly drowsy rom the Atri-
pla. Laboratory results are repeated and show an improve-
ment in her viral load:
CD4 count: 261 cells/mm3
HIV viral load: 7,000 copies/mL.
You explain that i her viral load continues to all and
becomes undetectable, she can expect an improvement in her
CD4 count over the next 1 to 2 years, and that the drowsiness
rom the Atripla should improve over the next ew weeks.
You take this of ce visit as an opportunity to catch up on pre-
ventative medicine. On one prior occasion 6 years ago, she
had an abnormal Pap smear result that returned to normal
a er a repeat examination and colposcopy. Prior to her diag-
nosis o HIV, she had never been diagnosed with an S I. A
pelvic examination today reveals a normal appearing cervix.
A sample or Pap smear is collected and sent to pathology.
Q estion 9.2.14 How o ten sho ld this patient et screened
or cervical cancer with Pap smear?
A) Cervical cancer is inevitable, so you should recommend
prophylactic radical resection.
B) She must be tested every 6 months, regardless o results o
this Pap smear.
Ch Apt Er 9 • HIV/AIDS 267
C) I she has two negative Pap smears 6 months apart and a
normal CD4 count, she may be screened annually with cer-
vical cytology.
D) She may be screened per the usual guidelines or HIV-
negative women.
E) She has almost no chance o developing cervical cancer and
screening may be discontinued.
Answer 9.2.14 The correct answer is “C.” Human papilloma
virus (HPV), implicated as a cause o cervical cancer, has a
higher prevalence and demonstrates a more aggressive course in
women with HIV in ection. I the patient has a relatively normal
CD4 count and has had two normal smears at 6-month intervals
in the rst year o her HIV diagnosis, Pap smears can be done at
1-year intervals (Note: this is di erent rom the guidelines or
non–HIV-in ected women). However, i the patient has a CD4
count less than 200 cells/mm 3, screening every 6 months is rec-
ommended. Any detection o cervical intraepithelial neoplasia
is treated the same as with HIV-negative women. HPV testing
alone is not recommended or ollow-up o an abnormal pap
smear in HIV in ected women as there is a high prevalence o
oncogenic HPV and results may be sub-optimal. Remember
that it is not unusual or multiple S Is to be transmitted together,
so consider testing or other S Is when obtaining a Pap smear.
HELPFUL TIP:
An STI causing genita u cers (e.g., herpes) increases
the risk trans issi n HIV.
Q estion 9.2.15 Aside rom an increased risk o a ressive
HPV and a hi h rate o menstr al disorders, how does the
nat ral history o HIV in ection in women di er rom that
in men?
A) Women have a lower rate o progressive multi- ocal leuko-
encephalopathy (PML) and bacterial pneumonia.
B) Women are more likely to present with oral thrush and
recurrent genital candidiasis.
C) Women with the same level o medical care as men have sig-
ni cantly shortened survival.
D) HAAR is more e ective and better tolerated in women.
E) Most women in the United States acquire HIV rom same-
sex partners.
Answer 9.2.15 The correct answer is “B.” T e natural history
o HIV in ection in women and men is very similar. Women
with the same level o access to medical care have similar sur-
vival rates to men, and HAAR is equally e ective (and haz-
ardous) in both sexes. Women are more likely to present with
recurrent, re ractory vaginal candidiasis, oral thrush, PML, and
bacterial pneumonias. T e majority o women in the United
States with HIV have acquired it rom heterosexual contact. T e
second largest route o exposure or U.S. women is IV drug use.
Females who have sex with other women are at low risk o con-
tracting HIV; the opposite is true or men who have sex with
other men. Worldwide, heterosexual contact is by ar the most
common means o transmission.
268 FAmIl y mEDICINE ExAmINATIo N & Bo ARD REVIEw
Objectives: Did yo learn to . . .
• Interpret HIV antib d and vira ad tests?
• Eva uate the risk vertica trans issi n HIV?
• Reduce the risk vertica trans issi n HIV?
• Interpret HIV tests in the ne nata peri d?
• Use HAART in chi dren?
• Identi s e dif erence in the c inica ani estati ns HIV
in en and chi dren?
CASE 9.3
A 39-year-old emale working as a nursing assistant in your
hospital comes into the emergency department looking quite
upset. About 30 minutes earlier, she was helping to move a
patient with known HIV when his IV was pulled out and he
bled. Several drops o blood got on her hands, but she washed
them immediately and thoroughly. On examination, she has
intact skin on the hands, no signs o trauma, and no residual
blood on her.
Q estion 9.3.1 The most appropriate action to take is:
A) Reassure her that her risk o contracting HIV or this event
is almost zero.
B) Obtain HIV antibody testing.
C) Start her on HAAR or prophylaxis.
D) Have her return in 6 weeks or HIV antibody testing.
E) B and D.
Answer 9.3.1 The correct answer is “A.” Fortunately, HIV is
not the most ef cient virus when it comes to spreading itsel .
Healthcare workers are at risk o contracting HIV when work-
ing with HIV-in ected patients, but exposure to in ected bodily
uid must occur through a percutaneous route or contact with
a mucous membrane or nonintact skin. Even percutaneous
exposure (e.g., open bore needle) with HIV-in ected blood car-
ries a transmission rate o only about 0.3%, and the mucous
membrane exposure to HIV-in ected blood carries a 0.09% risk.
T ere ore, contacting an in ected patient’s blood with intact
skin is very low risk.
T e patient is reassured that her risk o contracting HIV is
negligible. She looks a little sheepish when she tells you, “In
all the commotion I knocked over the urinal and spilled the
patient’s urine on my leg.” She changed clothes and washed
her leg. You inspect her and nd some eczema in the area
where the urine was spilled.
Q estion 9.3.2 Now, yo recommend that she:
A) Not worry, as the risk o transmission rom this event is
negligible also.
B) Start ZDV or 4 weeks or prophylaxis.
C) Be tested or HIV by viral load.
D) Start HAAR .
Answer 9.3.2 The correct answer is “A.” Your patient now has
an area o nonintact skin, which is a concern. However, urine
is not considered in ectious unless it is grossly bloody. Other
bodily uids not considered in ectious: eces, vomitus, sputum,
tears, sweat, nasal secretions, and saliva. Any visibly bloody
uids, blood, semen, and vaginal secretions are all considered
in ectious. Other bodily uids not already mentioned (e.g., CSF
and amniotic uid) should be considered potentially in ectious.
HELPFUL TIP:
HIV PEP sh u d be c nsidered r c ntact n nintact
skin r ra r genita uc sa ith p tentia in ected
b d uid (see ab ve) r a s urce that is HIV p sitive
r has an unkn n HIV status. PEP sh u d be started
ith a three-drug regi en as s n as p ssib e and c n-
tinued r 4 eeks. There are an pti ns r pr ph -
a is ith vari us advantages and disadvantages. The
Pub ic Hea th Service current rec ends ten vir
and e tricitabine (Truvada) in additi n t ra tegravir.
You see the patient back in your clinic 6 months later or rou-
tine ollow-up.
Q estion 9.3.3 g iven that yo did not screen her initially,
sho ld she be screened or HIV at this time?
A) No, both o these events were low risk or transmission and
there are no recommendations or routine screening.
B) No, both o these events were low risk or transmission and
she does not meet the criteria or risk actor-based testing.
C) Yes, she meets the recommendations or risk actor-based
testing.
D) Yes, everyone should be routinely screened or HIV.
Answer 9.3.3 The correct answer is “D.” In 2013, the United
States Preventive Services ask Force (USPS F) updated its
screening recommendation or HIV, recommending universal
HIV testing or all individuals between the age o 15 and 65 who
present to any health care setting. T e screening interval is not
currently well de ned. Repeated screening should be consid-
ered in patients known to be at risk or HIV in ection, those
engaged in risky behaviors, and those who live or receive medi-
cal care in high-prevalence settings (i.e., HIV seroprevalence o
at least 1%). Depending on their risk, this could be either yearly
or every 3 to 5 years. According to the CDC, universal screening
may be discontinued i the prevalence o HIV in a population
has been documented to be less than 0.1% (1/1,000).
Objective: Did yo learn to . . .
• Identi hen a hea th-care rker is at risk r c ntracting
HIV?
• App the USPSTF rec endati ns r r utine HIV screen-
ing?
CASE 9.4
A 32-year-old male patient comes in to establish care. He
does not have any signi cant past medical history and is not
currently taking any medications. However, his male partner
is known to be HIV positive and is currently on ARV therapy.

He is not sure what his partner’s viral load is but thinks he is
well-controlled. T ey use protection “most o the time.” He
is wondering what he can do to decrease his risk o acquiring
HIV.
Q estion 9.4.1 What sho ld yo tell him?
A) Recommend condom use.
B) Discuss prophylaxis with ARV medications.
C) Discuss sexual risk-reduction counseling.
D) A and C.
E) All o the above.
Answer 9.4.1 The answer in this case is “E”. Since he is in a
relationship with a known HIV-positive man, it would be rea-
sonable to consider pre-exposure prophylaxis (PrEP). Indica-
tions or PrEP go beyond men who have sex with men (MSM)
and also encompass high-risk heterosexual adults and IV drug
users. o be eligible or PrEP, the patient must be an adult,
not have acute or established HIV in ection, and not be in a
monogamous relationship with a known HIV-negative person.
For MSM, it is indicated or anyone with any male sex partner
in the past 6 months AND one o the ollowing: any anal sex
without condoms in the past 6 months, any sexually transmit-
ted in ections in the past 6 months, or in an ongoing sexual
relationship with an HIV-positive male partner (current recom-
mendations do not take into account the viral suppression o
the HIV-positive partner although studies in IV drug users and
heterosexual adults show a 96% reduction o transmission i the
partner’s viral load is suppressed). For heterosexual adults, PrEP
is recommended i condoms are in requently used with a part-
ner who is known to be at substantial risk or HIV in ection or
i the patient is in an ongoing relationship with an HIV-positive
partner. For IV drug users, PrEP should be considered i the
patient has shared injection or drug preparation equipment in
the past 6 months.
You decide to start the patient on PrEP based on his risk o
acquiring HIV through his in ected partner.
Q estion 9.4.2 What medications sho ld be sed?
A) eno ovir.
B) eno ovir/Emtricitabine ( ruvada).
C) E avirenz (Sustiva).
D) eno ovir/Emtricitabine/E avirenz (Atripla).
E) None o the above.
Answer 9.4.2 The correct answer is “B.” T e combination pill
o teno ovir and emtricitabine ( ruvada) is the only current
FDA-approved regimen or PrEP. In trials in IV drug users or
heterosexually active adults, teno ovir alone has shown ef cacy
but is not FDA-approved and has not been adequately studied
in MSM. Any PrEP regimen should be taken daily with strict
adherence. Coitally timed or other noncontinuous use is not
recommended. Pharmacologic PrEP should be done in combi-
nation with repeated condom provision, counseling on sexual
risk reduction, and evaluation and treatment or other sexually
transmitted in ections. While the combination pill o Atripla
Ch Apt Er 9 • HIV/AIDS 269
(“D”) would be e ective, it would unnecessarily subject the
patient to an additional medication (e avirenz) and its associ-
ated adverse e ects.
When initiating PrEP, discussions regarding an appropriate
ollow-up plan are imperative.
Q estion 9.4.3 Which o the ollowin is NOT necessary or
monitorin a patient prior to startin and while contin in
PrEP?
A) HIV testing at baseline and again every 3 months.
B) Baseline assessment o creatinine and repeat levels every
6 months.
C) Hepatitis B serologies at baseline.
D) Liver unction tests at baseline and at 3 months.
E) All o the above are necessary.
Answer 9.4.3 The correct answer is “D.” LF s need not be mon-
itored every 3 months. Prior to initiating PrEP, it is important to
rule out HIV in ection as the 2-drug therapy o ruvada would
be inadequate in treating HIV and could lead to resistance. In
addition, HIV testing should be repeated every 3 months prior
to re lling the prescription. I signs or symptoms o acute HIV
occur, an HIV viral load should be considered. eno ovir, one
o the components o ruvada, has been associated with acute
renal ailure and Fanconi’s syndrome. In the trials, only patients
whose CrCl was > 60 mL/min were included, and there ore the
current recommendation is to not prescribe PrEP with ruvada
or any patient with a CrCl o < 60 mL/min. Once PrEP is initi-
ated, creatinine clearance should be rechecked every 6 months.
In addition, hepatitis B serologies should be checked prior to
initiating PrEP with ruvada. Both components o ruvada have
activity against hepatitis B and, i stopped in a patient with active
hepatitis B, can lead to reactivation and severe hepatic damage.
Objective: Did yo learn to . . .
• Rec gnize the ef ectiveness PrEP?
• Deter ine hen PrEP is indicated?
Clinical Pearls
A p sitive PPD in patients ith HIV is c nsidered 5
indurati n.
A pregnant en sh u d be tested r HIV.
Dai ten vir/e tricitabine (Truvada) can be used as pre-
e p sure HIV pr ph a is in high-risk patients such as IV drug
abusers and th se h engage in risk se ua behavi r.
D n t treat patients ith high active anti-retr vira ther-
ap (HAART) i the are unab e t c p ith the treat ent
regi en. missing d ses HAART can ead t resistant strains
the virus and re di icu t treating the patient ater in
the disease c urse.
HIV d es n t see t cause birth de ects, and HAART sh u d
be c ntinued during pregnanc t reduce vertica trans is-
si n risk.
270 FAmIl y mEDICINE ExAmINATIo N & Bo ARD REVIEw
HIV gen t pe testing r drug resistance sh u d be d ne
hen starting r changing a HAART regi en.
Ne nates suspected e p sure t HIV sh u d be screened
ith a PCR r vira ad.
Screening r HIV (n t in the ne nate) sh u d be d ne using
a P24 antigen and ith an eva uati n Igm and IgG anti-
b dies. This i detect HIV as s n as 2 eeks a ter initia
in ecti n.
Start HAART ear . In genera , the ear ier the better.
The USPSTF suggests that all patients age 15 t 65 be
screened r HIV.
Use ster ids in patients ith pneu c stis pneu nia i the
Pao 2 is <70 r the A-A gradient is >35.
BIBLIOg RAPHY
Branson BM, et al. Revised recommendations or HIV testing
o adults, adolescents, and pregnant women in health-
care settings. MMWR Recomm Rep. 2006;55(RR-14):
1–17.
Khalsa AM. Preventive counseling, screening, and therapy in
the patient with newly diagnosed HIV in ection. Am Fam
Physician. 2006;73(2):271–280.
Mo enson LM, et al. Guidelines or the prevention and treat-
ment o opportunistic in ections among HIV-exposed and
HIV-in ected children: recommendations rom CDC, the
National Institutes o Health, the HIV Medicine Associa-
tion o the In ectious Diseases Society o America, the
Pediatric In ectious Diseases Society, and the American
Academy o Pediatrics. MMWR Recomm Rep. 2009;
58(RR-11):1–166.
Panel on Antiretroviral T erapy and Medical Management o
HIV-In ected Children. Guidelines or the use o antiret-
roviral agents in pediatric HIV in ection. 2015; pp. 1–268.
https://aidsin o.nih.gov/content les/lvguidelines/pedi-
atricguidelines.pd . Accessed August 30, 2015.
Panel on reatment o HIV-In ected Pregnant Women and
Prevention o Perinatal ransmission. Recommendations
or use o antiretroviral drugs in pregnant HIV-1-in ected
women or maternal health and interventions to re-
duce perinatal HIV transmission in the United States.
2015;14:1–207. https://aidsin o.nih.gov/content les/
lvguidelines/PerinatalGL.pd . Accessed August 31, 2015.
Panlilio AL, et al. Updated U.S. Public Health Service guide-
lines or the management o occupational exposures to
HIV and recommendations or postexposure prophylaxis.
MMWR Recomm Rep. 2005;54(RR-9):1–17.
U.S. Preventative Services ask Force. Final Recommendation
HIV In ection: Screening. Ann Intern Med. 2013;159(1):
51–60.
Endocrinology
Brian X. Shian
CASE 10.1
A 27-ye r-old e le resents to the o ce with the chie co -
l int o chronic tigue or 4 onths. She h s g ined 17 lb in
3 onths, des ite decre sed etite. She lso co l ins o
de ression, incre sed slee , l ck o energy, h ir loss, nd cold
intoler nce. Her st edic l history is unre rk ble, nd
she t kes no edic tions. She h s never h d ny surgeries.
Question 10.1.1 Which o the ollowing physical examina-
tion ndings would be expected?
A) chyc rdi
B) Exo hth l os
C) Fine tre or
D) Peri her l sensory loss
E) Del yed rel x tion in ref exes
Answer 10.1.1 The correct answer is “E.” T e history given is
consistent with hy othyroid st te. Sy to s o hy othyroid-
is include thinning h ir, dry skin, ho rse nd dee voice,
br dyc rdi , nd rolonged rel x tion in the ref exes. chyc r-
di nd ne tre or re ore ty ic l o hy erthyroidis , nd
exo hth l os is ch r cteristic o Gr ves’ dise se (one s eci c
c use o hy erthyroidis ). Proxi l uscle we kness y occur
in hy othyroidis , but sensory loss is not ty ic l ( lthough hy o-
thyroidis , di betes, gout, rheu toid rthritis, obesity, nd con-
nective tissue disorders c n contribute to c r l tunnel syndro e
which y be the initi l resenting sy to o these dise ses).
Question 10.1.2 How can the diagnosis o hypothyroidism
best be con rmed?
A) Elev ted thyroid-sti ul ting hor one ( SH) level
B) Low SH level
C) T yroid bio sy
D) R dionuclide sc n
E) Seru thyroglobulin
Answer 10.1.2 The correct answer is “A.” T e SH is the ost
sensitive test or both hy o- nd hy erthyroidis , nd ch nges
in the SH c n recede bnor lities in seru thyroxine (best
10
e sured s ree 4) level. An elev ted SH occurs when the
ituit ry detects insu cient thyroid hor one roduction (low
ree thyroxine), nd SH roduction is shut o when the itu-
it ry detects n excess o thyroid hor one circul ting (elev ted
ree thyroxine). With ituit ry dys unction, there is insu cient
SH roduction resulting in low SH nd decre sed ree thy-
roxine ( 4) roduction without eedb ck o n elev ted SH—
the ituit ry just doesn’t do its job (such sl cker!). In order
to discern between thyroid gl nd dys unction ( ore co on)
nd ituit ry dys unction ( ost o en second ry to ituit ry
deno ), it is necess ry to obt in ree 4 in conjunction with
the SH level. Since ituit ry disorders re r re, nd o en sug-
gested by other clues in the history nd hysic l, SH lone is
usu lly su cient or initi l screening or thyroid dise se. “C,”
bio sy, is used to ev lu te thyroid sses nd nodules. A
r dionuclide sc n (“D”) is lso used in the ev lu tion o thyroid
sses nd c n ( ostly) di erenti te unctioning deno s
ro c rcino s nd benign cysts. “E,” the seru thyroglobulin
e sure ent, is used to onitor thyroid c rcino ( nd is not
the initi l screening).
Her l bor tory results re nor l exce t or glucose 115 g/
dL, SH 22.3 µ IU/ L (re erence r nge is ty ic lly 0.27–4.20
but y v ry er l b), ree 4 0.56 ng/dL (re erence r nge
ty ic lly 0.93–1.70).
Question 10.1.3 Based on prevalence, labs, and presenta-
tion, what is the MOST likely cause o this patient’s disease?
A) Autoi une hy othyroidis
B) I trogenic hy othyroidis
C) uberculosis in ltr tion o the thyroid gl nd
D) Non unctioning ituit ry deno
E) Congenit l hy othyroidis
Answer 10.1.3 The correct answer is “A.” Autoi une hy o-
thyroidis (H shi oto thyroiditis) is the ost co on c use
o hy othyroidis in re s where there is dequ te iodine. I
this tient h d ituit ry deno c using hy othyroid-
is , the SH ( s well s the ree 4) would be low, since the
ituit ry is the source o SH. Congenit l hy othyroidis
271
272 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
c uses severe develo ent l del y nd constell tion o other
signs nd is tested or t birth s rt o routine neon t l screen-
ing. uberculosis is r re c use o hy othyroidis , but is the
ost co on c use o dren l ilure worldwide.
HELPFUL TIP:
Outside the United States, iodine de iciency is the most
common cause o hypothyroidism, with an estimated
2 billion persons bein iodine de icient althou h not all
bein hypothyroid.
Question 10.1.4 How should this patient be managed?
A) I131 d inistr tion
B) Surgic l excision o thyroid gl nd
C) St rt synthetic thyroxine hor one t 25 icrogr s (µg)
PO d ily, nd re-check sy to s nd SH in 2 onths
D) St rt synthetic thyroxine hor one t 200 µg PO d ily, nd
re-check sy to s nd SH in 2 onths
E) St rt synthetic thyroxine hor one t 25 µg PO d ily, nd
double every week until the tient ex eriences weight loss,
tre or, nd oor slee ( nd the desire to nd new doctor)
Answer 10.1.4 The correct answer is “C.” T e tient is de -
cient in thyroid hor one nd needs su le ent tion. wo str t-
egies y be used: (1) st rt with 25 µg d ily nd titr te u every
1 to 2 onths until the SH is in the nor l r nge or (2) st rt
with ull-dose ther y b sed on weight (1.6 µg/kg d ily) nd
djust b sed on SH in 1 to 2 onths. Either o tion is ro ri-
te in young, otherwise he lthy dults. However, older tients
(> 65 ye rs old) or those with ulti le co orbidities should
be st rted t low dose (25 µg d ily) due to incre sed c r-
di c risks ssoci ted with being overly re l ced (see hel ul
ti below). I the tient is titr ted u to 200 µg o levothyroxine
nd does not see to be res onding, the di gnosis needs to be
reconsidered or the tient’s co li nce needs to be c re ully
ssessed. Iron nd ood will decre se the bsor tion o levo-
thyroxine by s uch s 40%. T yroid edic tion should be
t ken under si il r circu st nces e ch d y: I it is t ken st-
ing, ne. I it is t ken with e l, this is lso OK but then
it should lw ys be t ken with e l to revent v ri ble
bsor tion d y-to-d y. V ri ble bsor tion c n ke titr t-
ing the dose di cult. It usu lly t kes 6 to 8 weeks or the body’s
endocrine res onse nd SH to re ch ste dy st te. T e go l o
ther y is euthyroid st te with the tient ex eriencing neither
hy er- nor hy othyroid sy to s. “A” nd “B” re tre t ents
o hy erthyroidis . Surgic l excision nd r dio bl tion with
I131 re ro ches to the tre t ent o Gr ves’ dise se. Both c n
result in i trogenic hy othyroidis th t requires li elong thyroid
hor one ther y.
HELPFUL TIP:
We enerally recommend startin levothyroxine at a
low dose or a couple o reasons. First, titratin the dose
up will assure that you do not overshoot. Second, i pa-
tients are started at 100 µ (a common inal dose), or
example, it can cause metabolic stress, especially in the
elderly, resultin in an ina, atrial ibrillation, etc.
You st rt the tient on 25 µ g levothyroxine (Synthroid) nd
schedule return oint ent in 2 onths. At ollow-u ,
she re orts gener l i rove ent in sy to s but is not
“b ck to nor l.” She re orts continued consti tion, l ck
o energy, nd eeling de ressed. She h s not lost ny ur-
ther weight nd re orts thickening o her h ir. L bor tory
results re s ollows: SH 11.8 µ IU/ L (0.27–4.20) nd ree
4 0.75 ng/dL (0.93–1.70).
Question 10.1.5 What adjustments, i any, should be made
to her regimen?
A) None, she will continue to i rove t the current dose
B) Incre se the dose to 50 µg/d y, nd re-check in 2 onths
C) Incre se the dose to 200 µg/d y, nd re-check in 2 onths
D) She is beco ing hy erthyroid, so cut the dose to 12.5 µg/
d y, nd re-check in 2 onths
E) Levothyroxine is ine ective in this tient. Ch nge her to
desicc ted thyroid tissue (e.g., Ar our T yroid) or triiodo-
thyronine ( 3)
Answer 10.1.5 The correct answer is “B.” T is tient h s
i roved ro her initi l resent tion, but she is clinic lly nd
che ic lly (elev ted SH) still hy othyroid. T e h l -li e o thy-
roxine is bout 1 week, so she h s h d lenty o ti e to re ch
ste dy st te. It is doubt ul th t her thyroid levels will ch nge uch
er 2 onths on this dose, so it is now ti e to incre se her dose.
Since you st rted with low dose, doubling o the dose is re -
son ble incre se th t is unlikely to ke her hy erthyroid. T e
go ls o ther y re elior tion o sy to s nd nor liz tion
o SH secretion by int ining the SH within the nor l re -
erence r nge exce t in the elderly or during regn ncy. T ere is
evidence o better outco es i the SH is ke t t the high normal
end in the elderly nd the low normal end during regn ncy. “E”
deserves s eci l ention. Desicc ted thyroid is gener lly voided
due to v ri bility in concentr tion o thyroid hor one content.
In ddition, 3 gener lly h s nothing to o er over levothyrox-
ine ( 4) des ite wh t the Internet “ex erts” ( nd your tients’
gr nd others) s y.
HELPFUL TIP:
Poor compliance is the most common reason or ailure
o medical therapy. Other causes include malabsorp-
tion, dru interactions (e. ., ri ampin and amiodarone),
dru – ood interactions, or dru s that reduce absorp-
tion (e. ., iron and sucral ate).
Your tient worries bout t king too uch thyroid hor one.
Question 10.1.6 Which o the ollowing can result rom
oversuppression o the TSH (iatrogenic hyperthyroidism)?
A) Ren l ilure
B) Pul on ry brosis
C) Hirsutis
D) Osteo orosis
E) Loss o second ry sex ch r cteristics

Answer 10.1.6 The correct answer is “D.” Hy erthyroidis ,
either i trogenic or endogenous, c uses osteo orosis. For this
re son, it is i ort nt to onitor the SH nd ssure th t the
tient is not overre l ced.
T e tient h s been doing gre t or cou le o ye rs when
she returns to see you or routine ollow-u . Her SH is
4.3 µ IU/ L nd the ree thyroxine ( 4) is within the nor-
l r nge. She then in or s you th t she h d no eriod or
5 weeks. You check urine regn ncy test in the clinic nd it
is ositive. T e tient is excited bout the regn ncy.
Question 10.1.7 What is the most appropriate manage -
ment or the patent’s hypothyroidism?
A) Continue the current levothyroxine dos ge without ny
ch nge
B) Incre se the levothyroxine dose by 10% now
C) Incre se the levothyroxine dose by 30% now
D) No ch nge o the levothyroxine dose, but h ve the thyroid
unction re-checked in 6 weeks
E) Re er her to n endocrinologist (w it ti e is currently
4 weeks)
Answer 10.1.7 The correct answer is “C.” Wo en with re-
existing hy othyroidis who re l nning to beco e regn nt
should o ti ize their thyroid hor one dose reconce tion i
ossible. T e jority o wo en with re-existing hy othyroid-
is require higher dose o levothyroxine during regn ncy
to int in go l SH levels. T e incre se in levothyroxine
require ents occurs s e rly s the 5th week o gest tion nd
l te us by 16 to 20 weeks. It is gener lly reco ended th t
the levothyroxine dose be incre sed by 30% to 50% t the ti e
o the ositive regn ncy test through the rst tri ester nd
djusted to chieve tri ester-s eci c SH go ls. Note th t
there re tri ester s eci c go ls which di er ro the go l in
the usu l tient. T e go l SH level ro or the rst tri ester
is 0.1 to 2.5 µIU/ L; second tri ester go l is 0.2 to 3.0 µIU/ L;
nd third tri ester go l is 0.3 to 3.0 µIU/ L (note the unit des-
ign tions nd check with your l b i these di er s so e l bs
use IU/L). T yroid unction should be ssessed every 4 weeks
to rotect the he lth o the other nd etus nd to void reg-
n ncy co lic tions. I the SH v lues re bove go l, the dose
o levothyroxine is incre sed nd thyroid unction is checked
every 2 to 4 weeks. “A”, “B,” nd “D” re incorrect bec use o the
re sons entioned bove. Also, “E” is incorrect. I you do not
eel co ort ble n ging the tient’s hy othyroidis during
her regn ncy, you y still need to incre se her levothyroxine
rst, then re er her to n endocrinologist. Good c re tr nsition
is critic l: ssure th t the tient’s hy othyroidis is n ged
until she is under the c re o the consult nt.
HELPFUL TIP:
Hashimoto thyroiditis is associated with primary thy-
roid lymphoma, which typically presents with an en-
lar ed neck mass and may be associated with local
CHAPTER 10 • ENDOCRINOLOg Y 273
compression symptoms and systemic symptoms like
ever, wei ht loss, and ni ht sweats. I lymphoma is
suspected, a core needle or excisional biopsy is o ten
needed to establish the dia nosis.
Objectives: Did you learn to . . .
• Reco nize the presentation o hypothyroidism and its most
common causes?
• Identi y common physical examination ndin s consistent
with hypothyroidism?
• Describe the basic medical and laboratory mana ement o
patients with hypothyroidism?
• Mana e hypothyroidism durin pre nancy?
CASE 10.2
A 32-ye r-old le resents co l ining o severe nxiety.
For the l st 4 onths, he h s h d di culty slee ing, rogres-
sively worsening nervousness, 25-lb weight loss, nd con-
st ntly eels “too w r .” He eels “sh ky” nd h s di culty
concentr ting. He denies di rrhe , but re orts h ving nor-
lly sh ed stools our to ve ti es er d y— ore th n
usu l or hi . T e tient denies neck or eye disco ort, nd
h s not noticed ny neck swelling. He h s no other signi c nt
edic l history. His other, who died 3 ye rs go ro coro-
n ry rtery dise se (CAD), h d “thyroid roble ,” but he
doesn’t know ny det ils.
Physic l ex in tion reve ls n nxious young dult
le. He h s notice ble resting tre or. You note ild
exo hth l os, conjunctiv l injection, nd lid l g. His thy-
roid is di usely, ildly enl rged nd bruit is udible over
the gl nd. T e c rdi c ex in tion reve ls t chyc rdi with
ow ur ur. T e rest o the ex in tion is unre rk ble.
Question 10.2.1 What is the most likely diagnosis?
A) Vir l thyroiditis
B) Gr ves’ dise se
C) An l stic thyroid c rcino
D) Hy er ctive thyroid deno
E) Surre titious thyroid hor one ingestion
Answer 10.2.1 The correct answer is “B.” T is is cl ssic re-
sent tion o Gr ves’ dise se. T e ily history, the sy to s
nd signs o hy erthyroidis (es eci lly the di usely enl rged
goiter with bruit), nd the exo hth l os re ty ic l; conjunc-
tiv l injection is lso requently noted. “A” is unlikely. Vir l thy-
roiditis c n c use hy erthyroidis nd goiter, but the thyroid
gl nd is usu lly tender. Also, vir l thyroiditis will likely not l st
4 onths, but is usu lly sel -li ited to < 6 weeks. An l stic
c rcino (“C”) is dev st ting dise se with dis l rog-
nosis: the thyroid gets very l rge very quickly, but the dise se
does not resent with hy erthyroidis . A hy er ctive deno
(“D”) nd surre titious ingestion o thyroid hor one (“E”)
would not c use goiter or exo hth l os.
274 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
HELPFUL TIP:
75% o patients with viral thyroiditis will pro ress
rom 2 weeks o sel -limited hyperthyroidism to 3 to
6 months o hypothyroidism that is also sel -limited.
The hyperthyroid phase is best treated with NSAIDs,
beta-blockers, and prednisone i needed.
Question 10.2.2 Which o the ollowing tests is most
SPECIFIC or Graves’ disease?
A) Anti-thyrotro in rece tor ( k nti- SH rece tor) ntibody
B) Anti-thyroglobulin ntibody
C) Anti-thyroid eroxid se ntibody
D) M rkedly su ressed SH
Answer 10.2.2 The correct answer is “A.” Gr ves’ dise se is
n utoi une rocess, nd ly hocytes in the thyroid gl nd
itsel re res onsible or l rge ount o the thyroid uto n-
tibodies roduced. Although sever l ty es o ntibodies c n be
ss yed, nti-thyrotro in rece tor ntibody is the ost s eci c.
Here is bre kdown o the v rious ntibodies nd where you
y see the elev ted:
• Anti-thyrotro in rece tor ntibody ( nti- SH rece tor
ntibody) (“A”) is ound in 80% to 95% o tients with
Gr ves’ dise se but lso in 10% to 20% o those with other
or s o utoi une thyroiditis.
• Anti-thyroglobulin ntibodies (“B”) re ound in Gr ves’
dise se, utoi une thyroiditis, so e tients with ty e 1
di betes nd in u to 20% o the gener l o ul tion.
• Antithyroid eroxid se ntibody (“C”) is elev ted in
Gr ves’ dise se, utoi une thyroiditis, ty e 1 di betes, nd
so e regn nt tients, etc.
You obt in l bs nd nd th t the CBC is nor l nd SH is
undetect ble.
Question 10.2.3 How should the patient be treated acutely?
A) Pro r nolol nd ethi zole st rted i edi tely.
B) Control the tient’s sy to s with ro r nolol now, then
st rt ro ylthiour cil (P U) when the tient eels better.
C) Iodine (Lugol solution).
D) R dio bl tion with I131.
E) T yroidecto y.
Answer 10.2.3 The correct answer is “A.” T ere is no need to
w it be ore st rting ethi zole ( zole), which blocks ro-
duction o thyroid hor one. P U c n lso be used but ethi -
zole is re erred bec use (1) it ords better control nd
(2) P U is ssoci ted with ore liver toxicity nd bone rrow
su ression ( lthough these dverse e ects c n occur with both
drugs). P U is re erred during the rst tri ester o reg-
n ncy due to the risk o birth de ects ( l si cutis nd cho n l
nd eso h ge l tresi ) ssoci ted with ethi zole. Current
guidelines reco end switching ro P U to ethi zole or
the second nd third tri esters bec use the risk o liver toxicity
or the other (with P U) is gre ter th n the risk o congenit l
de ects in the etus (with ethi zole); however, so e ex erts
still re er P U throughout regn ncy.
Pro r nolol is hel ul or controlling the sy to s o hy er-
thyroidis (t chyc rdi , tre or, etc.) nd revents the conver-
sion o 4 to ctive 3. “C” is incorrect, s iodine will rovide
urther substr te or the body in the roduction o thyroid hor-
one nd should not be given unless thyroid-blocking gent
h s been st rted. Iodine is use ul during thyroid stor to re-
vent the rele se o stored thyroid hor one, but it is given 1 hour
er P U or ethi zole. R dio bl tion is used or tients
who rove re r ctory to edicine or h ve oor co li nce.
T yroidecto y is r rely used or Gr ves’ dise se in current
edic l r ctice bec use o the e se nd e c cy o r dio ctive
iodine d inistr tion (exce t in the c se o regn ncy nd ew
other unusu l c ses).
Question 10.2.4 Which o the ollowing is/are possible side
e ects o PTU and methimazole therapy?
A) Gr nulocyto eni
B) A l stic ne i
C) Elev ted liver tr ns in ses
D) Inhibition o et l thyroid gl nd
E) All o the bove
Answer 10.2.4 The correct answer is “E.” All o the bove re
known side e ects o ntithyroid drugs (thio ides). Gr nulo-
cyto eni occurs in bout 0.5% o tients nd is sudden, idio-
syncr tic re ction. Cl ssic lly, tients resent with severe
sore thro t. I you h ve tient on P U or ethi zole
with sore thro t or ever, check CBC. A l stic ne i y
occur but is r re. For these re sons, tients st rting these ed-
ic tions should h ve b seline CBC. Mild, tr nsient elev tion
o the liver tr ns in ses is co on, nd the drug should be
discontinued only i the tr ns in ses incre se to gre ter th n
three ti es the u er li it o the re erence r nge. Both P U
nd ethi zole cross the l cent nd will inhibit the et l
thyroid, incre sing the risk or congenit l hy othyroidis . T e
risk to etus osed by the drugs is less th n the d nger osed
by other with cceler ting hy erthyroidis , so the edic -
tions should be used even during regn ncy i indic ted. T e
s llest doses ossible should be used. I regn nt tient is
not controlled edic lly, consider thyroidecto y.
HELPFUL TIP:
When treatin hyperthyroidism in pre nancy, aim or a
serum ree T4 level in the upper one-third o the re er-
ence ran e. Avoid radioactive iodine treatment durin
pre nancy since it will a ect the etus as well.
T e tient is interested in tre ting the o hth l o thy.
Question 10.2.5 What method has been used success ully
to treat Graves’ disease -related exophthalmos?
A) Orbit l r di tion
B) Glucocorticoids

C) Rituxi b
D) T yroidecto y
E) R dio ctive iodine ther y
Answer 10.2.5 The correct answer is “B.” A roxi tely 5%
to 10% o tients with Gr ves’ dise se develo clinic lly sig-
ni c nt o hth l o thy. T e ri ry go l o n ging Gr ves’
o hth l o thy is to est blish euthyroid st te. T e edic l
tre t ent or o hth l o thy includes loc l e sures ollowed
by tri l o corticosteroids. Glucocorticoids h ve been shown
to be e ective in tre ting Gr ves’ o hth l o thy. Intr venous
(IV) steroids re ore e ective th n or l but either c n be used.
Orbit l r di tion h s been used but with little success. T e
onoclon l ntibody tre t ent with rituxi b (“C”) or other
gents h ve h d ixed results nd re still ex eri ent l. R dio-
ctive iodine tre t ent (“E”) h s been ssoci ted with worsen-
ing o Gr ves’ o hth l o thy. In tient with Gr ves’ dise se,
thyroidecto y (“D”) is usu lly reserved or those tients with
tre t ent ilure to ntithyroid drugs, l rge or obstructive goi-
ters, nd coexisting hy er r thyroidis who re surgic l c n-
did te or r thyroidecto y.
Your tient co lies with the reco ended regi en nd
i roves. He is not sy to tic t return visit in 2 onths,
nd his eye thology h s not rogressed. Af er 6 onths o
good control, the tient elects to h ve cos etic eye surgery
or his exo hth l os, which h s not res onded well to gluco-
corticoids. A re-o er tive hysic l is unre rk ble. L bor -
tory studies rior to surgery re nor l exce t SH 0.21 µ IU/
L (0.27–4.20) nd ree 4 3.01 ng/dL (0.93–1.70).
Af er n unevent ul surgery, you re c lled to the ost n-
esthesi roo by the oculo l stic surgeon. She re orts th t
the tient h s beco e very nxious nd t chyc rdic. A quick
review o the ch rt reve ls no known llergies, no erson l or
ily history o re ctions to nesthesi , nd the only edi-
c tion is ethi zole ( ro r nolol h d been discontinued
2 onths e rlier due to l ck o sy to s).
Physic l ex in tion shows 39.8°C, BP 98/25 Hg,
RR 34, nd P 166 b . T e tient is git ted but lert nd in
cute distress. He is t chy neic nd tre ulous nd is un ble
to c rry on convers tion. He see s con used nd distr cted.
T e skin is di horetic nd ushed. His ucous e br nes
re dry, nd his sur ce veins re t. T ere is no JVD nd the
ven c v looks nor lly lled on ultr sound. Pul on ry
ex in tion reve ls di use r les. Re exes re brisk nd his
ent l st tus is s noted bove. T e re inder o the neuro-
logic l ex in tion is unre rk ble.
Question 10.2.6 What is the cause o this patient’s symp -
toms and signs?
A) T e tient bec e f uid overlo ded during the surgery due
to excessive hydr tion
B) T e tient h s neurole tic lign nt syndro e (NMS)
C) T e tient h s thyroid stor induced by the stress o
surgery
D) T e tient h s endoc rditis nd su ered v lve ru ture
E) T e tient h s euthyroid sick syndro e
CHAPTER 10 • ENDOCRINOLOg Y 275
Answer 10.2.6 The correct answer is “C.” T e syndro e o
thyroid stor is ch r cterized by ever, t chy rrhyth i s, ltered
ent l st tus, nd high out ut c rdi c ilure. It is induced by
jor stress (in ection, surgery, yoc rdi l in rction, etc.)
in tient with underlying hy erthyroidis (usu lly undi g-
nosed). T is tient, lthough clinic lly well-controlled, h d
low SH nd high ree 4 rior to surgery, suggesting he y
h ve su ered recurrence o dise se or h d sto ed t king his
edic tions. T e tient is not f uid overlo ded, s evidenced by
his clinic lly dry st tus (dry ucus e br nes, f t neck veins,
nor l ven c v l lling); thus “A” is incorrect. His ul on ry
ede (r les) is due to high out ut ilure r ther th n f uid over-
lo d. NMS resents with ltered ent l st tus nd hy erther i
(due to incre sed et bolic ctivity). But the tient is not cur-
rently t king neurole tics. A ru tured v lve due to endoc rditis
would t the tient’s clinic l icture, but he h d no ever reced-
ing the surgery. For endoc rditis to rogress to v lve ru ture, it
ust be long-st nding, nd there is nothing in the re-o er tive
ev lu tion or history to suggest this. Euthyroid sick syndro e
(“E”) is used to de ne st te in critic lly ill tients with l bor -
tory ndings o low ree 3, low ree 4, nd/or low SH. So e
ex erts think this is n d tive res onse, which lowers tissue
energy require ents in the ce o syste ic illness. It is reco -
ended th t the ter euthyroid sick syndro e be re l ced
with nonthyroid l illness syndro e. Further ore, this tient’s
history o Gr ves’ dise se kes euthyroid sick syndro e n
unlikely di gnosis. He could h ve lign nt hy erther i sec-
ond ry to nesthesi but this isn’t choice.
HELPFUL TIP:
Thyroid storm is a clinical dia nosis consistin o hyper-
thermia, tachycardia, CNS dys unction, and si ns and
symptoms o peripheral hyperthyroidism. While most
patients will have an elevated T3 and ree T4, there is no
laboratory level o these hormones that de ines thyroid
storm. Thyroid storm may cause ri ht upper quadrant
pain due to liver con estion secondary to hi h output
con estive heart ailure.
HELPFUL TIP:
A pheochromocytoma can be con used with hyper-
thyroidism. Both include tachycardia and possible hy-
pertension. Interestin ly, serum catecholamines are
normal (o ten hi h normal—but normal) in thyroid
storm. Catecholamines will be elevated in patients with
a pheochromocytoma.
Question 10.2.7 How should this patient now be treated?
A) Ad inister ggressive f uid hydr tion, cooling e sures,
benzodi ze ines, nd d ntrolene
B) Ad inister f uid hydr tion, cooling e sures, IV ro r no-
lol, ethi zole, corticosteroids, then iodine 1 hour l ter
C) Ad inister f uid hydr tion, do ine dri or his hy oten-
sion, nd ntibiotics; consult c rdiov scul r surgery i e-
di tely
276 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
D) Hold f uids; d inister nitroglycerin dri nd urose ide
or his he rt ilure; consider n intr - ortic b lloon u
E) Ad inister f uid hydr tion (even 3 L or ore) nd ntibiot-
ics; consider nore ine hrine dri i tient beco es ore
hy otensive
Answer 10.2.7 The correct answer is “B.” T is is the ro-
ri te n ge ent or thyroid stor in the correct sequence
o ther ies. T is tient is in distress (hy otensive nd t chy-
c rdic) nd needs f uid hydr tion, des ite his ul on ry ede .
Cooling e sures ddress his hy erther i , nd bet -block de
( ro r nolol) will i rove his high out ut ilure ( nd reduce
the ul on ry ede ). Corticosteroids hel block rele se o
thyroid hor one nd decre ses eri her l conversion o 4 to
3. In ddition, corticosteroids will tre t ny underlying dre-
n l insu ciency. Methi zole revents thyroxine synthesis.
T is ust be given be ore iodine. T e iodine blocks ny urther
rele se o thyroid hor one. So e ex erts reco end using
P U inste d o ethi zole or tient with li e-thre tening
thyroid stor d itted to n ICU bec use P U blocks 4 to 3
conversion nd results in lower seru 3 level. “A” is the ro-
ri te n ge ent o NMS. “C” is n ro ri te ro ch or
v lve ru ture ro endoc rditis. “D” describes the n ge ent
o severe he rt ilure. “E” describes essenti l ste s in the tre t-
ent o se sis.
HELPFUL TIP:
In patients with hyperthyroidism, diarrhea is a si n that
can presa e thyroid storm.
Your tient is tre ted ro ri tely nd eventu lly recovers.
He continues on ethi zole nd ro r nolol nd re ins
in good control. You c n try t ering the edic tions in
6 onths to see how he does. T e current evidence su orts
continued tre t ent or 1 to 2 ye rs; re-ex ine the tre t ent
o tions nd go ls t the end o this eriod.
Objectives: Did you learn to . . .
• Identi y the more common causes o hyperthyroidism?
• Reco nize the presentation o g raves’disease?
• Mana e hyperthyroidism and describe the indications and
risks o each treatment option?
• Reco nize and treat thyroid storm?
CASE 10.3
You re seeing 45-ye r-old e le who is nursing ssis-
t nt t loc l nursing ho e in your town. As rt o rou-
tine blood nel, the tient’s SH is noted to be elev ted t
7.2 µ IU/ L (0.27–4.20 µ IU/ L). She h s nor l ree 4
nd is sy to tic.
Question 10.3.1 The best option is to:
A) St rt levothyroxine t low dose to nor lize the SH
B) Begin 3 t low dose
C) Re ssure the tient nd h ve her ollow-u or re e t thy-
roid studies
D) Begin work-u or centr l hy othyroidis
E) Begin ethi zole
Answer 10.3.1 The correct answer is “C.” T is tient h s
subclinic l hy othyroidis ( sy to tic, SH between 5
nd 10, nd nor l ree 4). T ere is convincing evidence th t
sy to tic tients with ildly elev ted SH (gener lly
< 10 µIU/ L) nd nor l ree 4 do not bene t ro tre t-
ent in ter s o qu lity o li e, etc. In ct, tre ted tients tend
to h ve ore sy to tic nxiety. Follow-u thyroid studies
re indic ted, lthough the interv l y di er de ending on the
clinici n’s judg ent. O note, ny tients will h ve tr nsient
ch nges in their thyroid hor one levels due to co orbid ill-
ness, vir l thyroiditis, etc. Gener lly, the best thing to do is re-
check r ther th n st rt tre t ent exce t in those tients with
high risk or rogression to overt hy othyroidis ( SH level
> 10 µIU/ L, ositive ily history, goiter, resence o nti-
thyroid eroxid se ntibodies or desire to beco e regn nt; see
Clin Endocrinol (Ox ). 2015 M y 23. doi: 10.1111/cen.12824. or
hy othyroidis clinic l guidelines.)
HELPFUL TIP:
Amon patients with hyperlipidemia, overt and subclin-
ical hypothyroidism are common. Thus, patients with
hypercholesterolemia and hypertri lyceridemia should
be screened or hypothyroidism.
HELPFUL TIP:
T3 tends to have rapid astrointestinal (g I) absorption
and relatively short hal -li e leadin to erratic T3 serum
levels. It is best to avoid T3 in the vast majority o pa-
tients with hypothyroidism.
Objectives: Did you learn to . . .
• Describe subclinical hypothyroidism?
• Di erentiate primary versus central thyroid dys unctions?
QUICK QUIZ: SOMETHINg SUBACUTE
A 32-ye r-old white e le without signi c nt st edi-
c l history exce t n u er res ir tory tr ct in ection 4 weeks
go resents to the clinic or 1 week history o nterior neck
dull in, l it tions, nxiety, oor slee , nd chills. Physic l
ex in tion is unre rk ble exce t t chyc rdi with nterior
neck tenderness, but no ss reci ted. L bor tory results:
C-re ctive rotein 5 g/dL (high), SH < 0.01 µIU/ L (low),
nd ree 4 is 5 ng/dL (high). A bedside ultr sound shows n
enl rged thyroid gl nd.
Wh t is the ost ro ri te next ste in n ge ent?
A) Fine needle s ir tion or bio sy
B) Antithyroid edic tions like ethi zole or P U

C) 24-Hour r dio ctive iodine u t ke test
D) Neck so tissue co uter-to ogr hy (C )
The correct answer is “C.” Considering her recent vir l in ec-
tion, tender thyroid gl nd, elev ted inf tory rker nd
the low SH nd high 4 this is ost likely sub cute thyroiditis.
T e 24-hour r dio ctive iodine u t ke (RAIU) test e sures
thyroid gl nd iodine u t ke over 24 hours. We need to deter-
ine the etiology o this tient’s thyroiditis. In tients with
destructive thyroiditis like sub cute thyroiditis, the RAIU will
be low, usu lly less th n 5% over 24 hours. In contr st, Gr ves’
dise se will h ve n elev ted or nor l RAIU. Fine needle s-
ir tion (“A”) is used or ev lu tion o thyroid nodule but the
tient does not h ve one. Antithyroid gents (“B”) h ve no role
in the tre t ent o sub cute thyroiditis since it is usu lly sel -
li iting dise se er tr nsient (2–8 weeks) hy erthyroidis .
T e ri ry tre t ent ocus is sy to s relie nd includes
NSAIDs, nonselective bet -blockers, nd/or corticosteroids
( rednisone) i tient h s severe in or no i rove ent is
seen er 2 to 3 d ys. Ultr sound is n excellent i ging o-
d lity to ev lu te the thyroid gl nd; where s, C sc n (“D”) o -
ers little v lue in this c se.
QUICK QUIZ: THYROID TESTS
A 52-ye r-old le is being seen in your clinic or weight loss,
t chyc rdi , nd nxiety. You sus ect hy erthyroidis nd
decide to check blood work. T e tient h s low SH sugges-
tive o hy erthyroidis but h s nor l ree 4.
T e ost likely ex l n tion o this tient’s sy to s nd l bo-
r tory ndings is:
A) He h s ituit ry dys unction with ending centr l hy o-
thyroidis
B) He h s n isol ted 3 hy erthyroidis
C) He h s Addison dise se
D) He is t king s irin th t inter eres with the ss y or ree 4
E) He is t king s irin th t inter eres with the ss y or SH
The correct answer is “B.” Five ercent o tients with hy er-
thyroidis h ve n isol ted 3-toxicosis. T us, i you sus ect
hy erthyroidis nd the tient h s low SH but nor l
ree 4, check 3. O note, “D” nd “E” re incorrect. How-
ever, ny drugs c n inter ere with thyroid-binding globulin
nd c use ch nges in the e sur ble ounts o tot l 4 (not
ree) nd 3 in the seru . In ost c ses, the ree 4 nd ree 3
(unbound thyroid hor ones) re not ected by the ch nges in
thyroid-binding globulin levels.
QUICK QUIZ: HYPERTHYROIDISM
Which o the ollowing c use(s) hyperthyroidis ?
A) Lithiu
B) A iod rone
C) Peginter eron l -2
CHAPTER 10 • ENDOCRINOLOg Y 277
D) Phenytoin
E) B nd C
The correct answer is “E.” A iod rone (see Hel ul i )
nd eginter eron l -2 c n c use both hy othyroidis
nd hy erthyroidis . A iod rone c uses hy othyroidis
in roxi tely 10% o tients who t ke it chronic lly nd
hy erthyroidis in roxi tely 1%. “A” nd “D,” lithiu
nd henytoin, res ectively, c use hy othyroidis . Phenytoin
reduces SH secretion so tients y h ve low SH nd
low 4.
HELPFUL TIP:
Some physicians re ard amiodarone as a “dirty” dru as
it can cause photosensitivity, pi mentation o the skin,
peripheral neuropathy, pulmonary toxicity, and thyroid
disease. It has multiple e ects on the thyroid land
and on metabolism o T4 and T3, which can result in
hypothyroidism. It carries a hu e iodine load, which can
result in hyperthyroidism.
CASE 10.4
A 45-ye r-old e le resents to the o ce co l ining o
“b ll in y neck.” She noticed lu in her nterior neck
roxi tely 1 onth go. She is not sure i it h s incre sed
in size. She h s not noticed ny other lu s or sses. She
denies dys h gi , odyno h gi , neck in, cough, weight
loss, ever, chills, swe ts, or ch nge in bowel h bits. She
lso denies ny hy erthyroid or hy othyroid sy to s.
In 1993, she i igr ted to the United St tes ro Kiev,
(still in the Ukr ine t the ti e o this writing . . . . . t le st
until Putin t kes it), where she h d grown-u nd lived—
including ll o the 80s (you re e ber—M donn , leg
w r ers, Chernobyl). She h s no ily history o thyroid or
other endocrine disorders, but sever l rel tives in Kiev h ve
been di gnosed with v rious c ncers.
Question 10.4.1 Which o the ollowing actors rom history
INCREASES the likelihood that the nodule is malignant?
A) Nodule not incre sing in size
B) No region l deno thy
C) Age > 40 ye rs
D) M le gender
E) History o r di tion ex osure
Answer 10.4.1 The correct answer is “E.” T is tient lived in
Kiev, ne r the Chernobyl nucle r ower l nt during nd er
the re ctor ccident in 1986. She w s ex osed to r di tion nd,
like her ily e bers, is t signi c ntly incre sed risk or
c ncer, es eci lly thyroid lign ncies. Other clinic l ctors
th t suggest lign nt etiology include (in gener l, not neces-
s rily in this tient) nodule > 2 c or incre sing in size, dys-
h gi , ho rseness, region l ly h deno thy, x tion to the
surrounding tissues, e le gender, ge < 40, nd ily history.
278 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
HELPFUL TIP:
There are a lot o cancer survivors walkin around who
received radiation to the neck (e. ., mantle radiation or
Hod kin lymphoma). These patients are at increased
risk o developin thyroid cancers.
Physic l ex in tion reve ls n obese e le in no cute dis-
tress. Her he d, eye, nose, nd or l ex in tions re nor l.
She h s 2 c r nodule on the right ole o the thyroid.
T e nodule oves long with the other subcut neous struc-
tures u on sw llowing. She h s no ly h deno thy. T e
rest o the ex in tion is nor l.
Question 10.4.2 Which o the ollowing next steps would be
most likely to yield a def nitive diagnosis?
A) T yroid ultr sound
B) Fine needle s ir tion (FNA)
C) T yroid sc n ( c99)
D) Seru thyroglobulin level
E) Seru c lcitonin level nd CEA level
Answer 10.4.2 The correct answer is “B.” FNA c n conclu-
sively rove or dis rove the resence o neo l s nd should be
considered or ll thyroid nodules nd cysts. T t is the botto
line; the rest re interesting, but do the FNA.
Ultr sound c n be used i there is low lign nt otenti l
in order to look or worriso e sonogr hic e tures, but it c n-
not de nitively di erenti te benign nodule ro lign nt
one. Besides, any thyroid nodule with diameter greater than 1 cm
should be evaluated with FNA. T us, no ultr sound is needed in
this c se exce t to guide the FNA.
A thyroid sc n will identi y i nodule is ctively rocessing
thyroid hor one (“ unction l” or “hot”) or is not et bolic lly
ctive (“non unction l” or “cold”). A “hot” nodule y c use
hy erthyroidis , is usu lly benign (“hot is not” lign ncy)
nd c n be tre ted with I131. A cold nodule is either n deno
or lign ncy nd bio sy is nd ted.
A seru thyroglobulin is the tu or rker or thyroid
c rcino nd should be dr wn be ore thyroidecto y. It has
no value as a diagnostic test in the initial evaluation be ore
malignancy is diagnosed, but can be ollowed as a marker.
Antithyroglobulin ntibodies y inter ere with the ss y,
however.
Seru c lcitonin nd CEA levels re elev ted in the c se o
edull ry c rcino , but would h ve low yield in the initi l
ev lu tion. Ple se re er to the thyroid nodule work-u lgo-
rith in the Revised American T yroid Association Manage-
ment Guidelines or Patients with T yroid Nodules and Di er-
entiated T yroid Cancer t htt ://online.liebert ub.co /doi/
d /10.1089/thy.2009.0110.
Fine needle s ir tion is consistent with ill ry c rcino .
A seru thyroglobulin level, SH, b sic che istries, blood
count, nd blood ty e re ordered.
Question 10.4.3 What should be done next?
A) Observe the nodule or 1 onth
B) Co uterized to ogr hy (C ) o the he d nd neck with
contr st
C) R di tion ther y with I131
D) R di tion ther y with extern l be r di tion
E) Su ression o SH levels with levothyroxine
Answer 10.4.3 The correct answer is “B.” Surgery or re ov l
o the tu or is the ost ro ri te next ste , but C sc n is
indic ted to deline te the extent o the neo l s . R diother y
with I131 is used er surgery or et st tic dise se, but extern l
be r di tion is not used or thyroid c ncers exce t or lli -
tive ther y o n l stic c rcino . Bec use these tu ors re
SH res onsive, su ression o SH level ollowing surgery
or ill ry c rcino is chieved with levothyroxine (usu lly
2.2–2.5 µg/kg— irly high dose to co letely su ress SH
roduction).
HELPFUL TIP:
The most common thyroid cancer is papillary carci-
noma. Medullary carcinoma may be associated with an
elevated calcitonin and other endocrine mali nancies
(e. ., multiple endocrine neoplasia II [MEN II]).
HELPFUL TIP:
There’s a caveat to the emphatic endorsement o FNA
(which has a deservedly ood reputation or dia nosis).
Here it is: thyroid ollicular lesions. When an FNA returns
material rom a thyroid ollicular neoplasm, 15% to 25%
o these may be harborin cancer. Follicular thyroid
cancer cannot be ruled out on the basis o an FNA due
to inability to di erentiate a mali nancy rom a beni n
adenoma. Usually, a thyroid lobectomy or total thyroid-
ectomy is recommended to urther evaluate a ollicu-
lar neoplasm so that a patholo ic examination can be
completed.
Objectives: Did you learn to . . .
• Reco nize the major risk actors in uencin the development
and pro nosis o thyroid carcinomas?
• Evaluate a thyroid nodule?
• Describe the mana ement o papillary carcinoma, the most
common o the thyroid cancers?
CASE 10.5
A 78-ye r-old e le is brought to the e ergency de rt-
ent (ED) or str nge beh vior. According to her ily, she
h s been ore slee y nd we k throughout the l st week.
She is cting ore withdr wn nd de ressed nd see s to
res ond to nonexistent extern l sti uli. When sked bout
her de ression, she re orts she is s d bec use n in
clown suit who tr ins oodles kee s telling her she is going to
die (or ybe she just h s b d shb cks to the circus when
she w s younger). She co l ins o bdo in l cr s nd

bl es it on “being lugged u ,” nd her ily re orts no
bowel ove ent or 2 d ys. She lso notes chronic bone in
in her hi s nd b ck. T t’s bout ll you c n get be ore the
b d news clown returns . . .
A hysic l ex in tion is not ble only or 3 c irregul r
ss in her right bre st (we’re very i ressed th t you did
bre st ex in tion in the ED). T e ily thinks th t the
ss is new. Her neurologic l ex in tion is nor l, exce t
or her rent con usion.
Question 10.5.1 What nding would you expect rom an
ECG?
A) Pe ked -w ves
B) Long Q interv l
C) Short Q interv l
D) ors des de ointes
Answer 10.5.1 The correct answer is “C.” T is tient is likely to
h ve hy erc lce i , rob bly ro n undi gnosed et st tic
bre st c ncer. T e ECG in tient with signi c nt hy erc l-
ce i will show short Q interv l; r rely there is di use S
elev tion (which is ore co only seen in eric rditis). Hy o-
c lce i is ssoci ted with long Q interv l, which c n occ -
sion lly le d to rrhyth i s due to n R on heno enon ( n
R-w ve o PVC uses with the revious -w ve redis osing
to tors des de ointes). Hy erc lce i roduces sy to s in
the CNS (con usion, sychosis, de ression), GI syste ( bdo i-
n l in, cr s, consti tion), kidneys (ne hrolithi sis, oly-
uri , ren l insu ciency), nd usculoskelet l syste (we kness,
yo thy, osteo orosis). o hel you re e ber the sy to s
o hy erc lce i , use the hr se “stones, bones, o ns, gro ns,
nd sychi tric overtones.” “A,” e ked -w ves, re ssoci ted
with hy erk le i .
Your tient’s tot l seru c lciu level is re orted s
15.3 g/dL (u er li it 10.4 g/dL).
Question 10.5.2 What is the NEXT step in her treatment?
A) Moder tely ggressive nor l s line hydr tion
B) IV chlorth lidone d inistr tion
C) IV c lcitonin d inistr tion.
D) IV bis hos hon te in usion
E) IV glucocorticoids
Answer 10.5.2 The correct answer is “A.” Although “C” nd
“D” y be indic ted, dequ te hydr tion nd est blishing urine
out ut is critic l to the tre t ent o hy erc lce i nd should
be the next ste . A nor l s line in usion will incre se urin ry
c lciu excretion by inhibiting roxi l tubul r sodiu nd
c lciu re bsor tion. Note th t IV urose ide ( nd diuretics
in gener l) re lling out o vor nd should not be used.
Hydr tion is the ost i ort nt go l. An IV bis hos hon te
in usion (zoledronic cid) should be st rted t the s e ti e
nd will lower the c lciu level over 2 to 4 d ys. C lcitonin h s
li ited dur tion o ction nd c n be used in e ergencies where
s line is ine ective. Glucocorticoids re gener lly use ul in
hy erc lce i second ry to gr nulo tous dise ses nd so e
CHAPTER 10 • ENDOCRINOLOg Y 279
ly ho s neither o which our tient h s. “B” is o s eci l
note. Chlorth lidone nd other thi zide diuretics incre se c l-
ciu levels nd re contr indic ted.
In ddition to the bove, di lysis c n be used in hy erc lce-
ic e ergency (gener lly in tients with unres onsive severe
hy erc lce i (e.g., those with ren l ilure).
T e tient is tre ted ro ri tely or her hy erc lce i
nd her ent l st tus i roves. A bio sy o her bre st ss
is done nd reve ls n in ltr ting duct l c rcino . A bone
sc n reve ls di use et st tic dise se.
Question 10.5.3 Which o the ollowing statements about
the mechanism or malignancy-associated hypercalcemia
is/are TRUE?
A) Decre sed bone re bsor tion incre ses the seru c lciu
B) Secretion o osteocl st-inhibiting ctors incre ses the
seru c lciu
C) Secretion o r thyroid hor one (P H)-like subst nces
incre ses the seru c lciu
D) Direct erosion o bone by tu or cells does not c use hy er-
c lce i
E) All o the bove
Answer 10.5.3 The correct answer is “C.”T is is c se o hu or l
hy erc lce i o lign ncy (HHM) nd it incre ses the seru
c lciu level by secreting osteocl st- ctiv ting (not inhibiting s
in nswer “B”) ctors le ding to incre sed bone resor tion (thus
“A” nd “B” re lse). Secretion o P H-like subst nces c uses
retention o c lciu by the kidneys, which elev tes the seru
c lciu . Direct erosion o bone by tu or cells lso contributes
to the rele se o c lciu ro the bones ( nd redis oses the
tient to r ctures). T e neo l s s ost co only ssoci ted
with hy erc lce i re c ncers o the bre st, lung, rost te, nd
kidney s well s ulti le yelo nd ew other he tologic
c ncers.
Question 10.5.4 Your patient’s cancer cannot be cured. How
can her chronically elevated calcium level be managed?
A) Or l glucocorticoids
B) Or l hos h tes
C) Or l bis hos hon tes
D) All o the bove
Answer 10.5.4 The correct answer is “D.” Glucocorticoids
(e.g., rednisone 20–40 g/d y) decrease intestinal calcium
absorption, but in nd o the selves c n le d to bone density
loss nd n incre sed risk or r ctures. Or l hos h tes c n
decre se intestin l c lciu bsor tion nd bone re bsor tion
o c lciu . Bis hos hon tes, s reviously discussed, decre se
the seru c lciu nd incre se bone density.
HELPFUL TIP:
g ranulomatous diseases like tuberculosis, sarcoidosis,
Crohn disease and leprosy are associated with hypercal-
cemia because o increased levels o active Vitamin-D.
280 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Objectives: Did you learn to . . .
• Reco nize neoplastic causes o hypercalcemia?
• Identi y presentin symptoms o hypercalcemia?
• Understand the mechanisms underlyin hypercalcemia in
mali nancy?
• Initiate emer ency treatment or symptomatic hypercalce-
mia?
CASE 10.6
A 42-ye r-old le resents to the o ce or routine ollow-
u o his hy ertension. He denies ny co l ints. He h s ri-
ry hy ertension, or which he t kes ben ze ril 20 g PO
d ily nd hydrochlorothi zide 25 g PO d ily. T e tient
t kes no other edic tions. His vit l signs re s ollows:
BP 135/70 Hg, P 72 b , R 18, nd 98.6°F. T e hysic l
ex in tion is co letely nor l. His c lciu is elev ted
t 12.8 g/dL (u er li it nor l 10.4 g/dL). T e rest o
his electrolytes, BUN, nd cre tinine re nor l s is CBC
nd ECG. “H . . .” you think. “T is c lciu level could be
lsely elev ted.”
Question 10.6.1 Which o the ollowing is/are responsible
or spuriously elevated serum calcium?
A) Pseudo ot ssiu tr ns ort
B) Fever nd ctive et bolic st te
C) Use o lendron te or risedron te
D) Prolonged lic tion o the tourniquet while dr wing
blood
E) All o the bove
Answer 10.6.1 The correct answer is “D.” Prolonged lic -
tion o the tourniquet or high c lciu e l be ore blood
dr w c n both c use s uriously elev ted seru c lciu . In
ct, u to 50% o tients with hy erc lce i h ve nor l
c lciu when it is checked second ti e. So, the next ste
er nding elev ted c lciu is to re e t the test. “C” will
c use low c lciu level. “A” doesn’t exist th t we know o . . .
sorry.
Question 10.6.2 Assuming you repeat the laboratory value
and the calcium remains elevated, your next step is:
A) A bone sc n or occult c ncer
B) I edi te di lysis
C) Nothing, since the tient is sy to tic
D) Discontinue the hydrochlorothi zide nd re-check c lciu
in 2 weeks
E) Discontinue the ben ze ril nd re-check ot ssiu in 2 weeks
Answer 10.6.2 The correct answer is “D.” T is tient h s
hy erc lce i . Asy to tic hy erc lce i is not unco -
on on routine screening ex in tions. It should be ddressed
bec use it is lw ys bnor l nd c n be tre ted e rly be ore
ny sy to s develo . In this tient, the ost likely c use is
hydrochlorothi zide. T i zide drugs incre se the ren l re b-
sor tion o c lciu (re e ber the c se bove?). Angiotensin-
converting enzy e (ACE) inhibitors y c use hy erk le i
but re usu lly not ssoci ted with hy erc lce i . An investi-
g tion or occult c ncer y be in this tient’s uture, but it
is re son ble to ddress the otenti l dverse drug e ect rst.
Di lysis is not indic ted.
Being the s rt r ctitioner th t you re, you think th t
the hy erc lce i could be rel ted to his hydrochlorothi -
zide use, so you sk hi to sto it. He returns or l bor -
tory dr w 2 weeks l ter. T e c lciu level is now 12.9 g/dL.
“R ts,” you s y. “Where’s y thinking c —I e n iP d?”
Question 10.6.3 What should you do next?
A) W it nother onth nd re-check be ore t king ny other
ction
B) Order 24-hour bis hos hon te in usion
C) Per or rost te nd testicul r ex in tion or sses,
chest x-r y, nd int ct P H (iP H)
D) Per or rost te nd testicul r ex in tion or sses,
chest/ bdo en/ elvis C , nd bone sc n
E) Per or rost te nd testicul r ex in tion or sses,
chest x-r y, then re ssure tient i nor l
Answer 10.6.3 The correct answer is “C.” In this tient, it is
re son ble to rule out ri ry hy er r thyroidis while lso
checking or other otenti l c uses. A chest x-r y will rule out
signi c nt lung sses nd s rcoidosis. A testicul r nd ros-
t te ex in tion or sses is i ort nt so th t l rge tu ors
in these org ns do not go unnoticed (re e bering th t
digit l rect l ex in tion is neither sensitive nor s eci c s
screening/di gnostic test or rost te c ncer). An elev ted or
high nor l iP H in the resence o hy erc lce i con r s
the di gnosis o hy er r thyroidis er ruling out ili l
hy oc lciuric hy erc lce i . T e test or iP H will not sig-
nif cantly cross-react with the P H-like hormone produced by
neoplasms. Unless the history or hysic l is sus icious or ly -
ho , or so e other occult neo l s , n-body sc n is
w ste o oney nd ex oses the tient to unnecess ry r di -
tion. At this oint, it is not necess ry to cutely lower the c l-
ciu level bec use the c use h s not been identi ed nd the
tient is sy to tic. See ble 10-1 or ore c uses o
hy erc lce i .
he tient’s co lete ex in tion is nor l s is the
chest x-r y. he iP H level is twice the u er li it o nor-
l nd his urin ry c lciu scores, which should be done
s rt o the work-u o hy erc lce i (24-hour urin ry
c lciu excretion nd his c lciu -to-cre tinine cle r nce
r te) re not suggestive o ili l hy oc lciuric hy erc l-
ce i ( discussion o which is outside the sco e o this
book.)
Question 10.6.4 How should this patient be treated?
A) I edi te C o the chest, bdo en, nd elvis
B) IV bis hos hon te in usion
C) D ily di lysis until the c lciu level is nor l
D) Re err l or r thyroidecto y
E) Re err l or thyroidecto y
 CHAPTER 10 • ENDOCRINOLOg Y 281

TABLE 10-1 CAUSES OF HYPERCALCEMIA ex in tion is nor l. His neck wound is he ling well, with
ini l erythe nd no tenderness. T e rest o the hysic l
Pseudohypercalcemia
ex in tion is unre rk ble.
Excessive calcium intake
Hypervitaminosis D
Hyperparathyroidism (primary and secondary) Question 10.6.5 What is causing this patient’s symptoms?
Hyperthyroidism A) He su ers ro vit in D de ciency
Mali nancy B) T is tient h s MEN II nd lso h s heochro ocyto
Hypervitaminosis A
C) oo uch r thyroid tissue w s re oved during the sur-
Adrenal insuf ciency
Pheochromocytoma gery
Rhabdomyolysis D) T e stress o the surgery reci it ted thyrotoxicosis
Familial hypocalciuria E) T e stress o the surgery reci it ted the onset o ulti le
Immobilization sclerosis
Medications
• Lithium
• Me estrol Answer 10.6.5 The correct answer is “C.” T is tient likely
• Methyltestosterone h s hy oc lce i due to excessive re ov l o r thyroid
• Mycophenolate gl nd tissue— r re nd un ortun te co lic tion o r thy-
• Tacrolimus roidecto y. It is usu lly detected in the i edi te osto er -
• Tamoxi en
tive course. T e tient’s hysic l ex in tion de onstr tes
• Theophylline (toxicity)
• Thiazides Chvostek sign (t ing over the ci l nerve elicits twitch)
nd rousse u signs (c r o ed l s s er l ce ent o
blood ressure cu ). Vit in D de ciency, lthough c use
Answer 10.6.4 The correct answer is “D.” T is tient h s o hy oc lce i , is unlikely to develo so quickly. T e usu l
ri ry hy er r thyroidis . P tients with sy to tic ri- c uses o vit in D de ciency re l bsor tion or in dequ te
ry hy er r thyroidis (e.g., ne hrolithi sis, sy to - int ke, but there is nothing in the tient’s history to suggest
tic hy erc lce i ) should h ve r thyroid surgery, which is this. T ere is nothing to suggest MEN II (hy er r thyroidis ,
the only de nitive ther y. In sy to tic tients, surgic l edull ry thyroid c rcino , nd heochro ocyto ). T ere
indic tions lso include seru c lciu level gre ter th n is lso nothing here to suggest heochro ocyto (e isodic
1.0 g/dL over the u er li it o the re erence r nge, cre ti- di horesis, l bile blood ressure, recurrent l it tions, nd
nine cle r nce less th n 60 L/ in, bone density -scores less ne r-synco e). T ere is no clinic l evidence o thyrotoxicosis
th n − 2.5 in ny re , revious r gility r cture, nd ge less (t chyc rdi , tre or, etc.).
th n 50 ye rs. In elderly tients with ild hy er r thyroid-
is nd sy to tic hy erc lce i , edic l n ge ent is HELPFUL TIP:
n o tion. I the iP H is low, then e suring the r thyroid Another consideration or a patient who had a recent
hor one-rel ted e tide (P Hr - de by lign ncies) nd parathyroidectomy or primary hyperparathyroidism:
vit in D et bolites is needed to urther work-u the c use. “hun ry bone syndrome” ( reat name, what?), in which
I P Hr is elev ted, bone sc n or body C y be w rr nted. the unmineralized bone matrix produced durin the
Although bis hos hon tes will lower the seru c lciu nd period o hyperparathyroidism be ins to mineralize
y be used in n e ergency, r thyroidecto y is cur tive. a ter the PTH normalized. This results in hypocalcemia
Di lysis is not indic ted in this tient. and hypophosphatemia.

Your tient undergoes r thyroidecto y nd is dis-

ch rged ro the hos it l. T e thology re ort on the HELPFUL TIP:
re oved tissue con r s the resence o r thyroid It is always di icult to remember the MEN types. Here
deno nd no lign ncy. He returns or his rst osto - is a tip or you by Dr. Mark Yo e (who wanted to see his
er tive oint ent 1 week l ter, nd he is co l ining o name in print . . . a shout-out to his mom!).
we kness. He s ys th t the d y f er the surgery he elt ne, MEN 1: the number “1” in MEN1 should remind you o
but h s rogressively gotten we ker “ ll over” since th t ti e. primary or prime number. MEN1 involves thin s that
L st night, he w s ke t w ke by recurrent uscle s s s in start with the letter P:
his legs nd r s. He denies ever, chills, n use , or vo iting. • Pituitary adenoma
He s ys he is e ting, drinking, nd ssing urine nor lly. He • Parathyroid hyperplasia
h s h d no he turi or dysuri . His vit l signs re nor l. • Pancreatic islet cell tumors ( astrinoma, insulinoma,
On hysic l ex in tion, he e rs nxious. Just f er luca onoma)
t king the tient’s vit l signs, his lef r develo s uscle MEN 2A: happens to involve the letter C (This is MEN 2A,
s s nd n involunt ry exion o the wrist th t l sts or so there are two C’s in each item!):
bout 20 to 30 seconds. ing the cheek just nterior to • Calcitonin (medullary carcinoma o the thyroid with
the tr gus c uses the i sil ter l ce to twitch (to your gre t elevated calcitonin level)
delight . . . it is just like in the books!). T e rest o cr ni l nerve
282 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
• Calcium (parathyroid hyperplasia, which causes el-
evated calcium levels)
• Catecholamines which are made in the chromocytes
(as in pheochromocytoma)
MEN 2B: B is or bi (mar anoid habitus) and or belly
problems (mucosal neuromas)
A c lciu nd lbu in level is sent, s well s CBC nd
routine che istry nel including gnesiu . Everything is
nor l exce t: c lciu 5.1 g/dL(8.8–10.4 g/dL) nd lbu-
in 3.0 g/dL (3.4–5.0 g/dL). His hos h te level is 4.2 g/
dL (2.5–4.5 g/dL).
Question 10.6.6 Does this patient have hypocalcemia?
A) No, the seru c lciu level is nor l.
B) No, the seru c lciu level when corrected or the lbu in
is nor l.
C) Yes, bec use the seru (c lciu × hos h te) roduct is
> 20.
D) Yes, bec use the seru c lciu level is still low when cor-
rected or lbu in.
E) Not enough in or tion given to deter ine.
Answer 10.6.6 The correct answer is “D.” T e tient’s c lciu
level is low, even er correcting the hy o lbu ine i . o cor-
rect or lbu in, dd 0.8 g/dL to the seru c lciu level or
e ch 1 g/dL the lbu in is < 4 g/dL. In other words, corrected
seru c lciu = [(4 – lbu in) × 0.8] + e sured seru c l-
ciu , or in this c se the equ tion is [(4 – 3) × 0.8] + 5.1 = 5.9 g/
dL. When ev lu ting hy oc lce i , it is rudent to check BUN
nd cre tinine to rule out ren l ilure s c use ( ro ren l
osteodystro hy . . . see Ch ter 5 or ore in or tion).
HELPFUL TIP:
I you want to take the easy route and avoid the math,
check an ionized calcium. The ionized calcium need not
be corrected or albumin. An ionized calcium will also
be use ul in patients with monoclonal ammopathy or
multiple myeloma. Occasionally, these proteins can also
bind calcium.
Question 10.6.7 How should this patient now be treated?
A) C lciu glucon te 1 g by r id IV ush.
B) Correct his hy o gnese i with IV MgSO4.
C) Ad inister IV nor l s line 1 L bolus.
D) Initi te c lciu c rbon te 1 to 4 g with vit in D or lly
divided in 2 to 3 doses d ily.
E) No ther y, s the c lciu level will correct itsel .
Answer 10.6.7 The correct answer is “D.” T e tient now
requires or l c lciu su le ent tion, usu lly with vit in D
to sti ul te bsor tion. He will likely require it li elong. T is
tient h s neither hy o gnese i nor hy er hos h te i ,
nor ny other electrolyte bnor lities. I he h d, correcting
either would lso r ise the seru c lciu . “A” deserves s eci l
ention. IV c lciu glucon te or c lciu chloride c n be used
in severe hy oc lce i . But they should not be given by r id
IV ush but r ther by slow ush over cou le o inutes.
Objectives: Did you learn to . . .
• Describe the evaluation and treatment o primary hyper-
parathyroidism?
• Reco nize the si ns and symptoms o hypocalcemia and
hypercalcemia?
• Reco nize the causes o hypercalcemia and hypocalcemia?
• Evaluate and treat hypocalcemia?
CASE 10.7
A 36-ye r-old e le resents to the o ce co l ining o
di culty losing weight or 2 ye rs. She seeks rescri tion
drug to id in these e orts. She h s tried every d diet she
co es cross, but nothing see s to hel . She tries to exercise
regul rly, but n ges only w lking cou le o iles e ch
week. A nutrition l history reve ls th t she is e ting sensi-
ble low- t diet (how of en do you see th t!). Her st edic l
history includes hy ertension tre ted with edic tions or
the l st 3 ye rs nd ty e 2 di betes ellitus (DM2) tre ted or
one ye r. She lso h s been seeing sychi trist over the l st
6 onths or e otion l l bility, which she bl es on nxiety
over her in bility to get regn nt. T e tient t kes glyburide
5 g PO d ily nd chlorth lidone 25 g PO d ily. A review
o syste s reve ls thinning h ir, irregul r enses, del yed
wound he ling, nd in ertility (she’s been trying to get reg-
n nt or over one ye r).
Question 10.7.1 What advice do you o er this patient now?
A) She is e ting right; she just needs to exercise ore.
B) Low- t diets re ine ective; she needs to reduce her c rbo-
hydr te int ke.
C) She h s iled li estyle odi c tions, nd etite su res-
s nt edic tions re indic ted.
D) She is likely de ressed, nd needs to continue sychi tric
ther y nd rob bly should st rt tre t ent with selective
serotonin-reu t ke inhibitor (SSRI).
E) Reserve ny diet ry dvice t this ti e, s she rst needs
edic l work-u .
Answer 10.7.1 The correct answer is “E.” T e tient’s sy -
to s o weight g in nd ssoci ted ndings on review o sys-
te s (e otion lly l bile, thinning h ir, in ertility, irregul r
enses, nd del yed wound he ling) suggest second ry c use,
ost likely n endocrine bnor lity. (Wh t else would you
ex ect? T is is the endocrine ch ter er ll . . .)
Her vit ls in the o ce: P 88 b , BP 155/94 Hg, R 20,
nd 37.7°C. On hysic l ex in tion, you note n obese
e le with trunc l obesity nd thin extre ities. She h s
thinning h ir, round cies, hirsutis , nd bu lo hu t
her u er b ck. Her skin is hy er ig ented with bdo in l
stri e. T e rest o the ex in tion is unre rk ble.

Question 10.7.2 Based on this patient’s history and physical
examination, what diagnosis is most likely?
A) Hy othyroidis .
B) Hy erthyroidis .
C) Cortisol excess second ry to chronic steroid ther y.
D) Cortisol excess second ry to n endogenous rocess.
E) Cortisol de ciency second ry to utoi une dren l in-
su ciency.
Answer 10.7.2 The correct answer is “D.” T is tient h s the
cl ssic sy to s nd signs o Cushing syndrome, or cortisol
excess. T is y be due to corticosteroid ther y (the ost
co on c use), ecto ic AC H roduction ro neo l s s
(lung, ncre s, kidney, etc.), dren l neo l s s roduc-
ing cortisol, or AC H- roduction ro ituit ry neo l s
(ter ed Cushing disease). Her condition is unlikely due to ste-
roid ther y, s this should h ve been reve led in her edic l
history. At this oint in the ev lu tion, it is not cle r wh t the
source o AC H is, just th t there is excess AC H being ro-
duced. Note the hy er ig ent tion o this tient’s skin. T is
is the s e ech nis s in dren l destruction ( n elev ted
AC H); the ituit ry is u ing out AC H, which sti ul tes
el nocytes.
L bs re sent, ost o which re nor l exce t or n ele-
v ted glucose o 210 g/dL nd n elev ted 24-hour urin ry
ree cortisol o 115 µ g (nor l < 100 µ g). B sed on these
ndings, dex eth sone su ression test is ordered. T e
tient is given huge (g rg ntu n, w y big), su r ther eu-
tic dex eth sone doses or 2 d ys, nd then seru AC H
is dr wn, nd nother 24-hour urine collection is done. T e
re e t seru AC H is still slightly elev ted nd 24-hour uri-
n ry ree cortisol is 78 µ g (nor l).
Question 10.7.3 What is the source o this patient’s cortisol
excess?
A) An AC H- roducing tu or.
B) A cortisol- roducing dren l tu or.
C) Surre titious use o or l steroids.
D) Not enough in or tion to deter ine.
Answer 10.7.3 The correct answer is “A.” When the tient
w s given exogenous steroids during the test, there w s r-
ti l su ression o cortisol roduction ( decre se in 24-hour
urin ry ree cortisol). But ore i ort ntly, the seru AC H
level re ined bove nor l des ite the high steroid lo d. T e
AC H level should h ve been low in the resence o dex -
eth sone, or ny exogenous steroid, which would ct to shut
o AC H roduction in the nor l tient. I AC H is still
being roduced des ite high steroid lo d, then there ust be
n AC H- roducing neo l s so ewhere in the body (either
ecto ic roduction ro lung, ren l, or ncre tic c ncer, or
n AC H- roducing ituit ry tu or th t h s esc ed nor l
regul tory eedb ck ech nis s).
On hysic l ex in tion, the tient h s visu l eld cut.
CHAPTER 10 • ENDOCRINOLOg Y 283
Question 10.7.4 What is the best next step in this patient’s
evaluation?
A) Ultr sound o kidneys to ssess or sses nd dren l f ow.
B) C sc n o the br in to rule out et st tic lesions nd ssess
ituit ry size.
C) C sc n o the dren ls to ev lu te or dren l neo l s s.
D) MRI o the ncre s to ev lu te or neo l s s.
E) MRI o the ituit ry gl nd to ev lu te or neo l s .
Answer 10.7.4 The correct answer is “E.” T e revious studies
strongly suggest Cushing syndro e nd the visu l led cut sug-
gests ituit ry source o excess AC H (e.g., AC H- roducing
tu or o the ituit ry gl nd). An MRI o the ituit ry is the best
e ns to con r this. C sc n y suggest enl rge ent o the
sell turcic (where the ituit ry gl nd sits), but it is insensitive or
detecting bnor lities in the ituit ry, es eci lly icro deno s.
HELPFUL TIP:
I the MRI is ne ative, then the more rare case o ectopic
ACTH production rom occult cancer must be consid-
ered, and a body CT scan is indicated.
Objectives: Did you learn to . . .
• Reco nize the common presentin si ns and symptoms o
Cushin syndrome?
• Di erentiate Cushin syndrome rom Cushin disease?
• Identi y the causes o cortisol excess and how they are best
evaluated?
CASE 10.8
JFK is 38-ye r-old le resenting to the o ce with the
chie co l int o we kness. He re orts th t he l cks the
energy to co lete his reviously busy work schedule (such
s inv ding Cub ) nd h s cut his hours b ck the l st 2 to
3 weeks, which h s recently beco e n nci l h rdshi . He
lso re orts oor etite nd 20-lb weight loss over the
l st onth. He h s h d ltern ting eriods o di rrhe nd
consti tion. He is of en eeling int nd h s co e ne r to
ssing out f er st nding u quickly ew ti es; this is di -
erent or hi ro b seline. He h s no revious edic l
or surgic l history. He denies edic tions or llergies. He
re orts th t sever l o his rel tives on his other’s side h ve
h d thyroid roble s. “I c n’t go on like this,” he co l ins
in n ccent th t betr ys his Boston roots.
On hysic l ex in tion, his vit ls reve l BP 85/38 Hg,
P 85 b , R 20, nd 37°C. T e ex in tion shows hy er-
ig ent tion o bucc l ucos nd we kness in the roxi l
uscul ture (5–/5 strength in both u er nd lower extre i-
ties). His skin is hy er ig ented t the elbows, knuckles,
knees, nd the l r cre ses. T ere is no ede .
Question 10.8.1 What is the most likely cause o this
patient’s symptoms?
A) Hy erthyroidis
B) Hy othyroidis
284 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
C) Adren l gl nd hy er ctivity
D) Adren l insu ciency
E) De ression
Answer 10.8.1 The correct answer is “D.” Sever l clues oint
you in this direction, side ro the tient’s n e. First, the
hy er ig ent tion ound t stress/cre se oints on the skin
suggests the di gnosis o dren l insu ciency. T e low blood
ressure nd orthost sis is lso ore likely to be seen in dren l
insu ciency.
T is tient h s nu ber o sy to s consistent with both
de ression nd hy othyroidis (“B” nd “E”), but his hysic l
ex in tion suggests nother di gnosis. A tient with de res-
sion nd no underlying edic l c use would h ve nor l
hysic l ex in tion. A tient with hy othyroidis y h ve
slightly low blood ressure, but not rkedly low s in this
tient. T e he rt r te in sy to tic hy othyroidis is usu lly
low. Hy othyroidis y lso c use ch nges in the h ir, skin,
nd thyroid gl nd th t re not seen here. Fin lly, the tient’s
ref exes re nor l, r ther th n del yed. T ere is nothing in this
c se to suggest hy erthyroidis or cortisol excess (“A” or “C”).
L bor tory results show low sodiu (129 g/dL), low glu-
cose (69 g/dL), nd high ot ssiu (5.4 g/dL) long with
nor l SH nd ildly low he oglobin.
Question 10.8.2 Based on the in ormation provided thus
ar, what is the best test to diagnose this patient’s condi-
tion?
A) Cosyntro in sti ul tion test.
B) R ndo seru cortisol.
C) Bone rrow bio sy.
D) Pl s renin.
E) Ultr sound o kidneys to e sure their size.
Answer 10.8.2 The correct answer is “A.” T e l bor tory che -
istry results (hy erk le i , hy on tre i , nd hy oglyce i ),
co bined with the history nd hysic l ex in tion, strongly
suggest iner locorticoid de ciency. A cosyntro in sti ul -
tion test uses synthetic AC H to try to induce burst o cortisol
secretion. No dequ te incre se in the seru cortisol in res onse
to the cosyntro in suggests th t the dren l gl nds re un ble
to res ond to the body’s iner locorticoid nd glucocorticoid
needs. A ositive cosyntro in test kes the di gnosis o dre-
n l insu ciency. A r ndo seru cortisol is de nitely second
best, s cortisol levels nor lly f uctu te widely throughout the
diurn l cycle. Pl s renin is used in the ev lu tion o iner-
locorticoid excess (hy er ldosteronis ) nd should be low in
dren l insu ciency second ry to dren l dys unction ( ldo-
sterone c uses sodiu re bsor tion nd ot ssiu excretion,
the ex ct o osite seen in this tient who’s dren ls don’t ke
ldosterone). “E” is not likely to be hel ul. Even in the c se o
dren l insu ciency, the kidneys re unlikely to ch nge in size.
Although n ultr sound y show s ll, shrunken dren ls
th t h ve been destroyed by tuberculosis, C sc n is better
tool or ssessing the dren ls. “C” is w y o b se. T is tient
h s no indic tion or bone rrow bio sy.
HELPFUL TIP:
An early mornin serum cortisol level is o ten low in
patients with adrenal insu iciency. However, this test
alone is insu icient or screenin , as it has a hi h alse
ne ative rate. But a low (<5 µ / dL) early mornin serum
cortisol is likely to be due to adrenal insu iciency.
HELPFUL TIP:
Interpretin the cosyntropin stimulation test is not
always strai ht orward. The current criteria used to
indicate normal adrenal unction are a minimum se-
rum cortisol concentration ≥ 18 to 20 mc /dL (500–
550 nmol/L) BEFORE OR AFTER corticotropin injection.
An al orithm is available at http://www.arupconsult.
com/Al orithms/AdrenalInsu iciency.pd
Further l bor tory results re s ollows:
R ndo seru cortisol: 4 µg/dL (nor l 20 µg/dL).
Seru cortisol 1 hour er 0.25 g cosyntro in IV:
4.5 µg/dL (low).
Question 10.8.3 Based on the prevalence in the United
States, what is the most likely underlying cause o this
patient’s condition?
A) Autoi une dise se.
B) Inv sive c rcino .
C) Meningococc l se tice i .
D) S rcoidosis.
E) uberculosis.
Answer 10.8.3 The correct answer is “A.” All the conditions
listed re known c uses o primary dren l insu ciency, nd
ll c use this disorder by destruction o the dren l gl nds.
However, in the United St tes the ost co on c use is uto-
i une destruction o the dren l gl nds; s noted bove,
tuberculosis is the ost co on c use worldwide. Adren l
destruction will result in l ck o dren l hor one secretion
nd blunted res onse o the dren ls to AC H—hence, the
ini l rise o cortisol des ite d inistr tion o synthetic
AC H (cosyntro in). Cortisol level er cosyntro in sti u-
l tion test should be higher th n 18 to 20 cg/dL (500 to
550 n ol/L) in tients with nor l dren l unction.
Without e suring the seru AC H or 24-hour urine
AC H level, it is still ossible to tell the di erence between
ri ry (l ck o dren l res onse to AC H) nd second ry
( ituit ry l ck o AC H) dren l insu ciency.
Question 10.8.4 Which o the ollowing suggests primary
adrenal insu ciency (e.g., adrenal destruction) rather than
secondary?
A) B seline seru cortisol level > 7 µg/dL
B) Presence o hy er ig ent tion on hysic l ex in tion

C) Presence o neuro thy on hysic l ex in tion
D) Predo in nt sy to s o de ression
Answer 10.8.4 The correct answer is “B.” Hy er ig ent tion
t skin cre ses occurs in ri ry dren l insu ciency (but not
second ry dren l insu ciency). T is is bec use in ri ry
dren l insu ciency, the ituit ry is int ct. As result, the
AC H level is high, s is the level o el nocyte-sti ul ting
hor one. It is this el nocyte-sti ul ting hor one th t c uses
hy er- ig ent tion. An e rly orning b seline seru cortisol
level o 5 cg/dL or bove (“A”) would suggest ri ry dren l
insu ciency unlikely (the dren ls re still king cortisol).
Hy oglyce i nd de ression (“D”) re sy to s co on to
ll c uses o dren l insu ciency so don’t di erenti te between
ri ry dren l ilure nd second ry c uses o dren l insu -
ciency. Neuro thy (“C”) is not co on nding in dren l
insu ciency.
HELPFUL TIP:
Patients with primary adrenal insu iciency may pres-
ent with low serum sodium and hi h serum potassium
(althou h many will have normal electrolytes). This is
primarily because o loss o the aldosterone system.
Patients with secondary adrenal insu iciency (e. ., pi-
tuitary cause) have intact adrenal lands and there ore
intact aldosterone production. Thus, they will enerally
have normal electrolytes and less dehydration, hypo-
tension, etc.
Question 10.8.5 How should this patient now be treated?
A) Prednisone 60 g PO or 5 d ys, then slowly t ered over
2 weeks.
B) Cosyntro in 0.5 g SC d ily inde nitely.
C) Corticosteroids ( rednisone 5 g or hydrocortisone 15 g)
d ily inde nitely.
D) Corticosteroids ( rednisone 5 g or hydrocortisone 15 g)
d ily lus iner locorticoid (f udrocortisone 0.1 g) d ily
inde nitely.
E) Adren l tr ns l nt.
Answer 10.8.5 The correct answer is “D.” T is tient requires
chronic corticosteroid su le ent tion, nd bec use he h s ri-
ry dren l insu ciency, he lso requires iner locorticoid
su le ent tion. Usu lly, iner locorticoid d inistr tion is
not necess ry in the cute setting like dren l crisis but the v st
jority o tients with ri ry dren l insu ciency eventu-
lly require iner locorticoid re l ce ent with f udrocorti-
sone. Cosyntro in tre t ent (“B”) would h ve no e ect since
the dren ls re not unctioning. A short burst o rednisone
(“A”) is i ort nt i this tient ex eriences sudden stressor,
such s n in ection, but it is not the ri ry ther y. Medic l
ther y is irly e ective, so dren l (or ren l) tr ns l nt (“E”)
is not usu l tre t ent o tion.
JFK is tre ted ro ri tely nd, f er 4 weeks, is eeling
uch better, h s reg ined ost o his lost weight nd in
CHAPTER 10 • ENDOCRINOLOg Y 285
ct eels well enough to t ke on both C stro and Khrush-
chev (loc l co etitors to his dry-cle ning business). He no
longer su ers s ells o lighthe dedness or de ression. o
celebr te his new good he lth, he nd blond st rlet go out
or l vish se ood dinner, including resh oysters. Within
8 hours o the e l, JFK develo s severe cr ing bdo in l
in nd ro use w tery di rrhe (so uch or the d te . . .).
He tries to tre t hi sel t ho e with Pe to–Bis ol nd or l
uids, but gets rogressively we ker. Af er 12 hours o intes-
tin l sy to s, he c lls or n bul nce bec use he is too
we k to st nd.
U on resent tion in the ED, his vit l signs re: P 130 b ,
BP 70/20 Hg, R 30, nd 38°C. He is di horetic, ill-
e ring, nd in severe distress.
Question 10.8.6 A ter establishing adequate IV access,
what should be done next?
A) Order chest x-r y.
B) St rt “ren l-dose” do ine through eri her l line.
C) Give 2 L nor l s line by bolus.
D) St rt nor l s line t 125 cc/hr.
E) Give levof ox cin 500 g IV.
Answer 10.8.6 The correct answer is “C.” T is tient is
severely volu e de leted nd needs cryst lloid i edi tely.
All other tre t ent concerns, lthough they y eventu lly be
done, re second ry.
Des ite uid boluses, he re ins hy otensive. You scr tch
your he d nd onder wh t you y h ve orgotten.
Question 10.8.7 What should have been done simultane -
ously or this patient when the f uids were started?
A) Intub tion by r id sequence nd ech nic l ventil tion.
B) Ad inistr tion o henyle hrine dri .
C) Ad inistr tion o 4 g dex eth sone IV.
D) Ad inistr tion o 100 g hydrocortisone IV.
E) C or D.
Answer 10.8.7 The correct answer is “E.” T is tient h s
dren l insu ciency nd requires ddition l “stress doses” o
steroids in ti es o severe hysic l stress (e.g., in ection, tr u ,
nd yoc rdi l ische i ). T e steroids he regul rly t kes or his
dise se y not be su cient during these eriods, reci it ting
ddisoni n crisis. Without this ddition l tre t ent, the tient
y ex erience intr ct ble hy otension nd ossibly de th. In
less cute situ tion in which the tient h s inor illness, two
to three ti es the usu l inten nce glucocorticoid dose or
3 d ys (known s the “3 × 3 rule”) y bene t the tient.
HELPFUL TIP:
I you suspect adrenal insu iciency crisis (addisonian
crisis), start steroids immediately even i you do not
have laboratory con irmation. Dexamethasone is an
option or treatment, and it will not inter ere with the
cortisol assay when doin a cosyntropin stimulation
286 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
test. But note that dexamethasone does not have
mineralocorticoid activity and should be replaced
by hydrocortisone succinate just as soon as the
cosyntropin stimulation test is done.
T e next d y when you re doing your in tient rounding,
you eet your tient’s cousin Kenneth, who is 59-ye r-
old white le with st edic l history o hy ertension,
COPD, lcohol buse, nd osteo rthritis in his shoulders nd
knees. A rticul rly enthusi stic colle gue injected 80 g
o tri cinolone in both o the tient’s knees nd shoulders
sever l onths go (tot l dose o 320 g). He h d just gone
to joint injection worksho nd gured wh t the heck, lets
r ctice! T e tient notes we kness, lighthe dedness, n u-
se , nd decre sed etite recently. His ho e edic tions
re unre rk ble. Vit ls re BP 70/44 Hg, HR 60 b ,
35.6°C, oxygen s tur tion 98%. Physic l ex in tion shows
ildly distressed tient with ild ex ir tory wheezing on
uscult tion nd unste dy g it when he tries to st nd u .
L bs re unre rk ble exce t or sodiu o 123 Eq/L
(low), nor l ot ssiu , high BUN t 30 g/dL, cre tinine
o 2.1 g/dL ( tient’s b seline is 0.6 g/dL), Cl 84 Eq/L,
nd CO2 26 Eq/L. CBC, LF s, tot l rotein, nd lbu in
re nor l. A tro onin, SH, urine drug screen, lcohol
level, nd urin lysis re lso nor l.
He receives cou le o liters o nor l s line, nd his blood
ressure nor lizes. A re e t l b shows sodiu 130 Eq/dL
nd cre tinine 1.1 g/dL. One o your resident hysici ns
decides to urther worku the hy on tre i nd checks the
cortisol level, which returns 1.5 µ g/dL (low) with AC H t
18 g/ L (nor l 7–63 g/ L). A cosyntro in sti ul tion
test is done nd the seru cortisol level goes u to 14.9 µ g/dL.
Question 10.8.8 What is the most likely cause o the
patient’s hyponatremia?
A) Second ry dren l insu ciency due to nhy o ituit ris
B) Second ry dren l insu ciency due to exogenous steroid
use
C) COPD ex cerb tion
D) Hy othyroidis
Answer 10.8.8 The correct answer is “B.” T e tient received
ridiculous doses o intr rticul r tri cinolone sever l onths
go c using dren l su ression. “A” is incorrect bec use the
initi l AC H is nor l, which is not the ty ic l nding or cen-
tr l c uses o dren l insu ciency. “C,” COPD ex cerb tion, is
not consistent with the dren l unction tests. “D,” hy othyroid-
is , c n c use tigue nd hy on tre i , but the tient’s SH
is within the nor l li its.
Objectives: Did you learn to . . .
• Reco nize the presentation o adrenal insuf ciency?
• Evaluate a patient with adrenal insuf ciency?
• Treat a patient chronically or adrenal insuf ciency and when
in adrenal crisis?
• Understand secondary adrenal insuf ciency due to exo -
enous steroid use?
QUICK QUIZ: DIABETES DIAg NOSIS
Which o the ollowing c n be used to di gnose DM?
A) F sting blood glucose on one occ sion.
B) Glycosyl ted he oglobin (HbA1c) on one occ sion.
C) A r ndo blood sug r o > 160 g/dL.
D) None o the bove.
The correct answer is “D.” Here is why the di gnosis o DM
requires two elev ted sting blood sug rs o ≥ 126 g/dL or
two HbA1c levels o ≥ 6.5%. It c n lso be di gnosed i the
tient h s single r ndo blood sug r o > 200 g/dL with
signs nd sy to s o DM ( olyuri , olydi si , weight loss,
nd blurred vision). o be co lete, 2-hour ost r ndi l glu-
cose toler nce test result o > 200 er 1.75 g/kg o glucose ( x
dose 75 g) is di gnostic o DM. However, this is r rely used in
the United St tes.
QUICK QUIZ: A1c IN SPECIAL CONDITIONS
Which o the ollowing conditions rti ci lly raises the v lue o
he oglobin A1c?
A) Iron de ciency ne i .
B) Sickle cell dise se.
C) Chronic liver dise se.
D) Acute blood loss ne i .
E) All o the bove.
The correct answer is “A.” Iron de ciency y lsely elev te
the HbA1c. Sever l other conditions c n c use lsely low
HbA1c including sickle cell dise se, l ri , cute blood loss,
nd he olysis (see ttern develo ing here?). T is kes
sense: in ll these conditions the bone rrow is u ing out
new cells th t h ve not been ex osed to the elev ted glucose
levels. Conversely, iron de ciency nd vit in 12 nd ol te
de ciencies y be ssoci ted with lsely high HbA1c levels;
the ro ortion o old cells in the blood is high co red to the
nor l individu l. Chronic kidney dise se y c use either
lsely elev ted or lsely low HbA1c.
CASE 10.9
You re c lled to the ED to see 17-ye r-old n brought
in by his rents who ound hi in his roo t ho e. He
is leth rgic, but not unconscious or co tose. He is un ble
to give coherent history. His rents st te th t they h ve
been concerned bec use the tient h s been losing weight
in the l st 2 onths nd cting ore tired th n usu l. T ey
re worried th t he ight be busing drugs, but h ve not
ound ny drugs or drug r hern li in the ho e. T ey
h ve observed no other signs o illness. T e ily history is
ositive or hy ertension in ulti le ily e bers, nd
the tient’s other h s hy erli ide i . T ere is no ily

history o kidney or liver dise se, he rt tt cks, strokes,
di betes, or c ncer. His vit ls re: 36.9°C, P 125 b , BP
98/54 Hg, res ir tions re dee with r te o 28, S O2
95%on roo ir. He is leth rgic nd non-verb l but rouses
to in. His ucous e br nes re dry with ssured
tongue. You s ell ruity ro on his bre th th t re inds
you o th t bowl o ruity cere l you lef t ho e. His bre th-
ing is st nd he is t chyc rdic. His bdo in l ex in tion
reve ls sof bdo en with ild, gener lized tenderness. No
rebound or gu rding.
EKG shows sinus t chyc rdi . CBC shows Hgb 17.9 g/dL,
3 o ruity cereal the provider le t at home? All o the
WBC 16,200 cells/ with neutro hil redo in nce
3 colors o Fruit Loops taste exactly the same. Another
nd l telets 650,000 cells/ . Electrolytes show sodiu
131 Eq/L (slightly low), ot ssiu 5.7 Eq/L (high), chlo-
ride 97 Eq/L, bic rbon te 10 Eq/L (low), BUN 63 g/dL
(high), cre tinine 1.8 g/dL(b seline 0.7 g/dL), nd glucose
635 g/dL (high). Seru ketones re ositive. You re con-
cerned bout his res ir tory st tus so you obt in n ABG t
roo ir with H 7.20, P CO2 27 Hg, P O2 101 Hg,
nd bic rbon te 10 Eq/L.
You di gnose di betic keto cidosis (DKA) with dehydr -
tion > 10% nd d it the tient to the intensive c re unit.
As the rst st ge o ther y you wish to re l ce the lost uid
volu e.
Question 10.9.1 Which o the ollowing regimens is the
most appropriate initial intervention?
A) 5% dextrose in 0.45% (h l -nor l) s line to run t
150 cc/hr.
B) 0.45% (h l -nor l) s line with 20 Eq ot ssiu /L, to
run t 150 cc/hr.
C) 0.9% (nor l) s line 1 L to in use s quickly s ossible.
D) 0.9% (nor l) s line with 20 Eq ot ssiu /L to run t
1,000 cc/hr.
E) 5% dextrose in 0.225% (qu rter-nor l) s line with 20 Eq
ot ssiu /L to run t 1,000 cc/hr.
Answer 10.9.1 The correct answer is “C.” Initi l volu e
re l ce ent should be with isotonic s line in used t r id
r te (in the bsence o c rdi c dise se) until the volu e de cit
is corrected. “D” is o s eci l note. In gener l, ot ssiu should
be dded to the f uid l ter (o en the second b g) unless the
tient is lre dy hy ok le ic on the rst blood work (getting
ot ssiu , glucose, nd sodiu on the rst blood g s is good
olicy). Pot ssiu re l ce ent is y be essenti l even in the
hy erk le ic tient, s correction o the keto cidosis le ds to
r id shi o ot ssiu into the intr cellul r co rt ent.
Re e ber th t n cidosis rti ci lly incre ses the seru
ot ssiu by shi ing ot ssiu extr cellul rly. T e ot ssiu
incre ses by roxi tely 1 Eq/L or every H oint o 0.1
below 7.4 (so, H o 7.3 will incre se the ot ssiu ro 4 to
5 Eq/L). See Ch ter 5 or ore on cidosis, lk losis, nd the
e ects on ot ssiu . “D” is incorrect bec use you would like
the rst liter to in use s quickly s ossible in DKA nd not
over n hour. Besides, 20 Eq o ot ssiu IV in 1 hour should
not be routine nd only given i the tient h s continuous c r-
di c onitoring.
CHAPTER 10 • ENDOCRINOLOg Y 287
HELPFUL TIP:
Patients with severe hyper lycemia (like this uy) will
have hyponatremia secondary to the osmotic e ect
o lucose pullin water into the intravascular space,
increasin the plasma water content. What is the cor-
rected sodium or this patient? It is approximately
140 mEq/dLbased on the ormula: corrected sodium =
measured sodium + [1.6 (glucose − 100)/100]. This is
very approximate. I the lucose is > 400 m /dL, use “2”
rather than 1.6 or the correction. As an aside, the bowl
bubble broken . . . . . .
HELPFUL TIP:
Urine ketones are >99% sensitive or DKA in the ri ht
circumstance. Thus, checkin serum ketones is super-
luous in most cases.
Question 10.9.2 What is the most appropriate initial insulin
regimen or this patient?
A) Subcut neous NPH insulin, 1 unit/kg; re e t s necess ry.
B) IV regul r insulin, 5 unit IV bolus, ollowed by const nt
in usion t 0.05 to 0.1 unit/kg/hr; djusted s needed.
C) Subcut neous regul r insulin, 0.5 to 1 unit/kg; djust dose
by ngerstick blood glucose results.
D) Intr uscul r regul r insulin, 5 to 10 units hourly; djust
dose by ngerstick blood glucose results.
E) Insulin gl rgine 10 units d ily djusted b sed on sting glu-
cose levels.
Answer 10.9.2 The correct answer is “B.” A bolus o IV regu-
l r insulin, ollowed by const nt in usion, djusted to reduce
the blood glucose level by 50 to 75 g/dL/hr, is the ro ri te
ther y. T is y requently require > 0.1 unit/kg/hr, but 0.05
to 0.1 unit/kg/hr is good l ceto st rt. Intr uscul r insulin
d inistr tion is n ltern tive, but bsor tion is unreli ble,
es eci lly in hy otensive tients. Long- cting insulins nd
subcut neous insulin d inistr tion h ve no l ce in the initi l
n ge ent o DKA.
HELPFUL TIP:
Althou h tradition, the bolus o re ular insulin is unnec-
essary and does not chan e outcomes. Startin a drip o
re ular insulin is the critical step here.
Question 10.9.3 Which o the ollowing types o insulin can
be administered IV?
A) NPH insulin.
B) L ntus insulin.
C) Lente insulin.
D) Ultr lente insulin.
E) None o the bove.
288 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Answer 10.9.3 The correct answer is “E.” T e only insulin th t
c n be d inistered IV is regul r insulin. As n side, so e
insulins re inco tible when ixed together in the s e
syringe. For ex le, insulin gl rgine should not be ixed
with ny other or s o insulin due to the low H o its diluent.
Further, hos h te-bu ered insulins (e.g., NPH) should not be
ixed with Lente insulins.
T e tient’s st tus i roves, nd you re-check his blood
sug r. His glucose is now 200 g/dL nd his insulin dri is
still t 5 units er hour. His H is 7.30 with bic rbon te
level o 14 Eq/L.
Question 10.9.4 Given that his glucose has almost normal-
ized, your reaction at this point is to:
A) Ad inister bic rbon te in order to nish correcting the H.
B) Decre se the r te o the insulin in usion to 2 units er hour.
C) Add 5% to 10% dextrose to his IV f uids.
D) Consider the ddition o n or l hy oglyce ic gent.
E) Discontinue IV f uids nd switch to or l rehydr tion.
Answer 10.9.4 The correct answer is “C.” T is tient is still
cidotic nd will need continued insulin to reverse his c t -
bolic st te. T us, the ro ri te tre t ent is to incre se the
ount o sug r he is getting— dd so e dextrose to his IV
f uids. Re e ber, DKA is not ri rily result o too uch
sug r but r ther o too little insulin. “A” is incorrect. Bic rbon-
te l ys no role in the tre t ent o DKA no tter wh t the
H. In ct, the d inistr tion o bic rbon te ctu lly rolongs
cidosis nd ketosis nd roduces r doxic l CNS cidosis.
In ddition, it shi s the oxygen dis ssoci tion curve to reduce
oxygen delivery to the tissue. Fin lly, the only redictor o
cerebr l ede in children tre ted or DKA is the d inis-
tr tion o bic rbon te. So, there is no need to restrict f uids in
children being tre ted or DKA ( lthough this does NO e n
you should over hydr te the ).
HELPFUL TIP:
The common causes o DKA: “ the 5 I’s”
Insulin or medication noncompliance; In ection; myo-
cardial In arction; Incision (sur ery); Incidental (new
dia nosis o DM presents with DKA) (Not by Dr. Mark
Yo ee . . . a shout out to his mom).
Question 10.9.5 Which o the ollowing statements is
FALSE?
A) T e So ogyi heno enon occurs when tient’s blood
sug r beco es elev ted nd there is re ctive hy oglyce-
i .
B) P tients who re being tre ted ro ri tely or DKA y
h ve n incre se in seru ketones during tre t ent.
C) An elev ted WBC count is not strong redictor o in ec-
tion in tients with DKA.
D) Gluc gon is n in ro ri te tre t ent o tients with
lcoholic hy oglyce i .
Answer 10.9.5 The correct answer (and alse statement)
is “A.” Consensus is th t the So ogyi heno enon does
not exist reg rdless o wh t we were t ught (N Engl J Med.
1987;317(25):1552). But just or the record, it w s thought to
occur when tient beco es hy oglyce ic (o en in the id-
dle o the night) nd ex eriences re ctive hy erglyce i ro
drenergic out ouring. Actu lly, quite di erent heno enon
e rs to occur: nocturn l hy erglyce i is strongly ssoci-
ted with elev ted orning glucose levels. All o the rest re
true st te ents. “B” is correct bec use bet -hydroxybutyr te is
et bolized to ceto cetic cid th t will incre se seru ketone
e sure ents. “C” is true since DKA is ro-inf tory
st te nd the WBC count is o en elev ted due to DKA nd not
in ection. “D” is true st te ent. P tients with lcoholic hy o-
glyce i h ve exh usted their glycogen stores nd re lso gen-
er lly NAD de cient nd thus h ve i ired gluconeogenesis.
T us, gluc gon will not work. Another grou on which gluc -
gon will not work is the in nt or child who beco es hy ogly-
ce ic overnight nd h s seizure in the orning. T ey h ve
lre dy de leted their stores o glycogen.
HELPFUL TIP:
Consider the possibility o a silent myocardial in arction
in a diabetic patient who is enerally well-controlled
but suddenly has elevated blood su ars.
HELPFUL TIP:
Twenty percent o patients with DKA have “normo-
lycemic” DKA and present with a blood su ar under
300 m / dL.
It is ti e to tr nsition this tient to ho e-going insulin
regi en.
Question 10.9.6 Which o the ollowing statements is FALSE
regarding the use o insulin in this patient?
A) Insulin dete ir nd insulin gl rgine re both long- cting,
essenti lly equiv lent, nd c n ( l ost lw ys) be used once
d y s b s l insulin.
B) I you use NPH, st rt with 0.1 to 0.2 units/kg/d y nd give
2/3 in the AM nd 1/3 HS.
C) Regul r insulin should be given with e ls to cover blood
sug rs nd gener lly requires 0.1 to 0.2 units/kg/d y s
st rt.
D) Met or in c n rkedly reduce the need or insulin in this
tient.
E) T is tient’s insulin need y rkedly di inish over the
next 2 weeks.
Answer 10.9.6 The correct answer (which is alse) is “D.”
Met or in is used only in DM2. By virtue o the ct th t he’s
resenting with DKA, our tient l ost ssuredly h s ty e
1 di betes ellitus (DM1). T e rest re true st te ents. Insu-
lin dete ir nd gl rgine c n both be used once d y in ost

tients ( lthough not lw ys). T e st rting dose o both regul r
nd NPH insulin is bout 0.1 to 0.2 units/kg/d y or tot l ini-
ti l insulin dose o 0.2 to 0.4 units/kg/d y to st rt. “E” re ers to
the “honey oon eriod.” P tients usu lly resent with DM in
rel tion to so e et bolic stress. Once this stress resolves, the
need or insulin y decre se rkedly. T us, close onitoring
is required. (Editors note: Yes, et or in h s been studied in
DM 1 but see s not le d to ch nges in the HbA1c [ lthough it
c n reduce the insulin dose needed]).
HELPFUL TIP:
There is little is any outcome advanta e to brand name
insulins versus eneric insulins. Cost and convenience
should be the main considerations in choosin one ver-
sus the other. Lantus, Novolo , and Humalo cost up
to $250.00/bottle with eneric NPH costin as little as
$25.00/bottle.
T is tient resents to your clinic 10 ye rs l ter ( nd re-
su bly ulti le ti es in between). He h s noted ost r n-
di l ullness, re ux, nd occ sion l vo iting. You do g s-
tric e tying study th t shows del yed g stric e tying.
Question 10.9.7 Which o the ollowing are appropriate
drugs or treating this patient’s delayed gastric emptying?
A) O e r zole.
B) Metoclo r ide.
C) R nitidine.
D) Erythro ycin.
E) B nd D.
Answer 10.9.7 The correct answer is “E.” Both etoclo-
r ide nd erythro ycin will s eed g stric e tying. A third
drug, cis ride, is v il ble on co ssion te use rotocol. It
w s re oved ro the gener l rket second ry to risks o
rolonged Q nd subsequent tors des de ointes. It is cle r
th t di betic g stro thy is t le st so ewh t reversible with
good glucose control. T e higher the sug r, the worse the sto -
ch e ties.
HELPFUL TIP:
Remember that erythromycin causes a prolon ed QT.
And, there is o ten tachyphylaxis to the e ect o erythro-
mycin on astric emptyin . Also remember that chronic
metoclopramide is associated with extrapyramidal side
e ects that may be permanent (e. ., tardive dyskinesia).
Objectives: Did you learn to . . .
• Dia nose a patient with DKA?
• Initiate therapy in DKA?
• Identi y causes o DKA?
• Realize that the Somo yi phenomenon is scary but not real
(like g odzilla)?
• Prescribe treatment or diabetic astroparesis?
CHAPTER 10 • ENDOCRINOLOg Y 289
QUICK QUIZ: DIABETES PREVENTION
Which intervention h s been shown to h ve the greatest e ect
in reventing or del ying the onset o DM2 in tients with
i ired sting glucose or i ired glucose toler nce?
A) Diet ry odi c tions nd incre sed ctivity.
B) E rly gli izide tre t ent.
C) E rly et or in tre t ent.
D) Intensive tness tr ining.
E) Weight loss > 25% o b seline.
The correct answer is “A.” Met or in h s been shown to h ve
so e bene t in del ying rogression to di betes but is less e ec-
tive th n diet nd ctivity odi c tions. T e studies showing
bene t ro li estyle odi c tions used uch less ggressive
t rgets or weight loss nd ctivity level th n the 25% listed
in nswer “E.” T us, “E” is incorrect. Other edic tions th t
h ve been used (success ully) to reduce rogression to di be-
tes include the thi zolidinediones (“glit zones”) nd c rbose.
However, exercise nd diet re su erior to drugs. T e ben-
e t o drugs is rgin l. In ddition, the thi zolidinediones
h ve signi c nt downsides including ede nd ossibly
incre sed c rdi c events.
HELPFUL TIP:
Nonpharmacolo ic therapies that can reduce insulin
resistance include en a in in 30 minutes o modest
aerobic exercise 5 days per week (tell patients to aim or
150 minutes o exercise per week—how it’s divided is
not important), havin hi h iber in the diet, decreasin
caloric intake, and losin wei ht. Ma ic pill? We’re still
waitin . . .
QUICK QUIZ: DIABETIC RETINOPATHY
Which o the ollowing interventions h s NO been shown to
revent loss o vision in tients with retino thy due to ty e 2
di betes?
A) L ser hotoco gul tion ther y.
B) As irin.
C) ight glyce ic control.
D) ight blood ressure control.
The correct answer is “B.” As irin h s not been shown to be o
ny bene t in the E rly re t ent Di betic Retino thy Study.
All the other o tions h ve been shown to be use ul in del ying
the develo ent o di betic retino thy or reventing its ro-
gression to visu l loss.
CASE 10.10
You re seeing new tient in your o ce. He is 47-ye r-
old n with resenting co l int o tigue or sever l
onths. He denies ever, rigors, cough, n use , or di rrhe .
290 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
He h s lost bout 10 lb. U on questioning hi you discover
th t he is lso h ving nocturi ost nights nd is thirsty
ll the ti e. He h s sth , or which he uses n lbuterol
etered dose inh ler occ sion lly; he h s no other chronic
edic l roble s nd t kes no other edic tions on regu-
l r b sis. He h s ily history o di betes, hy ertension,
nd he rt dise se. He s okes bout one ck er d y, nd he
works s te cher t the loc l high school. He is w re o no
occu tion l ex osure to toxins.
Physic l ex in tion reve ls the ollowing: 37°C, BP
135/83 Hg, P 72 b , BMI 38 kg/ 2. Aside ro obesity,
the re inder o the ex in tion is nor l.
L bor tory test results reve l the ollowing: nor l
CBC, BUN/cre tinine, nd electrolytes. You sk hi to
return to the o ce the next d y or sting l bor tory tests,
which reve l sting glucose o 123 g/dL nd n HbA1c
o 7.5%.
Question 10.10.1 Does this patient have diabetes?
A) Yes; he h s n elev ted sting glucose.
B) Prob bly; he needs second sting glucose to con r the
di gnosis.
C) Prob bly; he needs second HbA1c to con r the di gno-
sis.
D) Yes; he h s the cl ssic sy to s o di betes: tigue, weight
loss, nd thirst, ssoci ted with n elev ted glucose.
E) Prob bly not; his HbA1c is not > 8%.
Answer 10.10.1 The correct answer is “C.” I results o two
di erent di gnostic tests or DM re discord nt, the test th t is
di gnostic o di betes should be re e ted. “A” nd “B” re incor-
rect bec use the sting glucose is < 126 g/dL (the threshold
or di betes). “D” is incorrect bec use we do not h ve his r n-
do glucose v lue th t is ≥ 200 g/dL. “E” is incorrect bec use
the A1c cuto or di betes di gnosis is ≥ 6.5%.
HELPFUL TIP:
There are new uidelines about whom to screen or
diabetes (USPSTF, 2015). Screen asymptomatic adults
a e 40 to 70 years o a e who are overwei ht or obese.
Repeat this screenin every 3 years. The 2008 USPSTF
uideline recommended screenin hypertensive adults
or diabetes, which has one the way o the dinosaur
or the 2015 uidelines. The 2015 ADA uideline recom-
mends screenin all asymptomatic adults every 3 years
startin at a e 45; earlier screenin is recommended
or adults at hi h risk o type 2 diabetes (BMI ≥ 25 k /
m 2; habitual physical inactivity; belon in to a hi h-risk
ethnic or racial roup; previously identi ied impaired
lucose tolerance; hypertension; dyslipidemia; history
o estational diabetes or delivery o a baby wei hin
> 9 lb; and polycystic ovary syndrome).
Question 10.10.2 Assuming another A1c is above 6.5%,
what urther study must be done to complete the diagnosis
o diabetes and determine whether the patient has type 1
or type 2 diabetes?
A) C- e tide level.
B) Anti-islet cell ntibodies.
C) Anti-insulin ntibodies
D) None o the bove.
Answer 10.10.2 The correct answer is “D.” T is tient’s ge,
history, ex in tion (BMI 38), nd l bor tory ndings re
consistent with the di gnosis o DM2. None o the other stud-
ies listed needs to be er or ed. However, i questions re in
reg rding the ty e o di betes (which will then ect ther y,
rognosis, ollow-u , etc.), you y choose to er or urther
studies. In DM1, the C- e tide level ( rker o endogenous
insulin roduction) is low. I it is equivoc l, give glucose lo d
(e.g., l rge e l) nd see i it goes u . I it goes u , the di gnosis
is likely DM2. Anti-islet cell ntibodies re resent in 80% o
ty e 1 di betics nd, i ound, re essenti lly di gnostic o ty e 1
di betes. “D” is incorrect bec use nti-insulin ntibodies h ve
low sensitivity or DM 1 nd y be elev ted second ry to the
use o exogenous insulin.
HELPFUL TIP:
To be complete, anti- lutamic acid decarboxylase (anti-
g AD) antibodies are present in 70% o patients with
DM1 at the time o dia nosis.
Question 10.10.3 The pathologic actors involved in type 2
diabetes in adults include:
A) P ncre tic bet -cell destruction through yet undeter ined
in ectious rocess.
B) T e roduction o nti-insulin ntibodies th t c use reci i-
t tion o insulin/ ntibody co lexes.
C) Resist nce to the e ects o insulin t eri her l tissues nd
relative insulin de ciency th t is rogressive over ti e.
D) An utoso l-do in nt rocess, with the di betes gene
loc ted on the long r o chro oso e 18.
E) oo uch exercise nd co lete l ck o “beer gut.”
Answer 10.10.3 The correct answer is “C.” DM2 is the result o
the develo ent o insulin resist nce t the eri her l tissues
(e.g., t nd uscle cells) nd rel tive l ck o insulin co red
to the incre sing ount th t the body requires. “A” is incorrect.
However, utoi une destruction o bet -cells in the ncre s
is res onsible or c using DM1. “B” is wrong lthough there re
nti-insulin ntibodies ound in DM1. “D” is incorrect s well, but
there is strong genetic co onent to DM2. T e ex ct genetic
ctors th t c use DM2 in dults h ve not been co letely elu-
cid ted, but there is no single gene res onsible tr ns itted in
n utoso l do in nt shion. “E” is incorrect bec use l ck
o exercise, weight g in, diet ry ctors, nd trunc l obesity (the
“beer gut”) redis ose ersons to the develo ent o DM2.
You eet with the tient nd his husb nd to go over the test
results nd ex l in the di gnosis o di betes. Given his ge,
body h bitus, nd l ck o exercise, you eel cert in th t this
tient h s ty e 2 di betes. You rovide so e b sic educ tion

on the n ture o di betes, its n tur l history, nd wh t c n be
done to n ge it.
Question 10.10.4 What is the most important next step or
this patient?
A) Initi tion o insulin ther y.
B) Initi tion o n ACE inhibitor
C) Re err l to n endocrinologist.
D) Di betic educ tion cl sses.
E) Initi tion o glyburide or other sul onylure .
Answer 10.10.4 The correct answer is “D.” A gener l educ -
tion rogr th t includes in or tion on diet, dise se
ge ent, nd the ily’s role in success ul di betes c re is the
ost i ort nt intervention listed. While s eci list consult -
tion y be use ul in co lex di betic tients or in those who
re not res onding to tre t ent, gener list hysici ns rovide
c re to the jority o tients with di betes. Insulin ther y
is not indic ted t this oint, nd n ACE inhibitor y or
not be hel ul de ending on the tient’s blood ressure nd
urine rotein. “E” is lso incorrect (kee re ding to le rn why).
U on his return, you nd th t the tient’s blood ressure is
elev ted. On three se r te occ sions, he h s systolic res-
sure ≥ 140 nd di stolic ressure ≥ 90 Hg.
Question 10.10.5 Which class o medications is the best
choice or initial therapy o hypertension in diabetics?
A) ACE inhibitors.
B) C lciu -ch nnel blockers.
C) Loo diuretics.
D) V sodil tors.
E) Bet -blockers.
Answer 10.10.5 The correct answer is “A.” ACE inhibitors h ve
been shown to rovide ren l rotection in tients with di be-
tes (ty es 1 nd 2). P tients with lbu inuri nd hy ertension
will cert inly bene t ro n ACE inhibitor. Loo diuretics
(e.g., urose ide) re not indic ted or the ri ry tre t ent
o hy ertension in di betics (or, re lly, nyone else). Angioten-
sin rece tor blockers (ARBs) re re son ble ltern tive in the
hy ertensive tient with lbu inuri i n ACE inhibitor is not
toler ted. V sodil tors nd c lciu -ch nnel blockers re not
o ti l choices in this tient lthough nondihydro yridine
c lciu ch nnel blockers (ver il, dilti ze ) re n o tion
or ren l rotection in tients with worsening lbu inuri
es eci lly in those who c nnot toler te n ACE inhibitor or
ARB. “E,” bet -blockers, should not be used rst line or tre t-
ing hy ertension in tients without c rdi c dise se.
Question 10.10.6 Which o the ollowing is NOT a side e ect
o ACE inhibitors?
A) Acute ren l ilure
B) Hy erk le i
C) Dry cough
D) Angioede
E) Cooties
CHAPTER 10 • ENDOCRINOLOg Y 291
Answer 10.10.6 The correct answer is “E.” All o those listed—
exce t cooties— re side e ects o ACE inhibitors. Cooties re
irborne r sites or which obnoxious 4th gr de boys serve
the in host. Ho e you got your “cooties shot” when you were
younger. I so, you should be ne.
Adverse e ects o ACE inhibitors re due to either reduced
ngiotensin II or tion or to incre sed kinin or tion. T ose
rel ted to reduced ngiotensin II or tion include hy oten-
sion, cute ren l ilure, hy erk le i , nd roble s during
regn ncy. Side e ects thought to be rel ted, t le st in rt,
to incre sed kinins include cough, ngioede , nd n hy-
l ctoid re ctions. er in tion o the ACE inhibitor should be
n- considered i hy erk le i c nnot be controlled or the seru
cre tinine concentr tion incre ses ore th n 30% bove the
b seline v lue within the rst 6 to 8 weeks when blood ressure
is reduced. Also, both ACE inhibitors nd ARBs re contr indi-
c ted in regn ncy.
y
HELPFUL TIP:
g uidelines published by JNC8 (2014) and the ADA
(2015) endorse hi her blood pressure oals or hyper-
tensive diabetics than was the case in prior uidelines.
The blood pressure tar et or most diabetic patients is
now < 140/90 mm H . A lower tar et (e. ., < 130/80)
may be appropriate or certain individual, such as
youn er patients, i it can be achieved without undue
treatment burden.
Af er 3 onths o diet ry ther y nd li estyle odi c tions,
the tient returns to see you with his husb nd. While he h s
been dherent to the reco end tions given by you nd the
di betes educ tion st , his HbA1c re ins elev ted t 7.9%.
You decide to begin h r cologic ther y.
Question 10.10.7 Which medication is the most appropriate
f rst-line therapy or an obese patient with type 2 diabetes?
A) A thi zolidinedione (“glit zone” [e.g., Actos]).
B) A sul onylure (e.g., gli izide).
C) Insulin.
D) Met or in.
E) A di e tidyl e tid se-4 inhibitor [DPP-4 or “gli tin” (e.g.,
J nuvi )].
Answer 10.10.7 The correct answer is “D.” Met or in does
not c use weight g in (unlike ost other tre t ents or di be-
tes), h s evidence or reducing di betes co lic tions, nd is
inex ensive; thus, it is the drug o choice in ost DM2 tients.
In ddition, it is well toler ted by ost tients nd h s very
little risk o hy oglyce i . Studies co ring e ects on end-
org n dise se show better outco es with et or in th n with
sul onylure s. T i zolidinediones known s “glit zones” (“A”)
re not rst-line or sever l re sons, chie ong these being
the ossibility o incre sed c rdiov scul r events (rosiglit zone
nd ioglit zone c n ex cerb te CHF). T e tr ck record o rosi-
glit zone is so ewh t s otty: it w s re oved ro the rket
292 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
due to n incre se in c rdiov scul r events nd then w s rein-
troduced even though there w s no ddition l s ety d t ; void
it i you c n. Sul onylure s (“B”) re lso e ective nd well-tol-
er ted but h ve signi c nt risk or hy oglyce i nd re sso-
ci ted with weight g in. All other or l drugs re best considered
second-line gents. “E” is o s eci l note. DPP-4 inhibitors, lso
known s “gli tins,” block the degr d tion o the body’s endog-
enous incretin, which hel s to lower blood sug r. DPP-4 cts
s “gluc gon-like e tid-1” (GLP-1). DPP-4 inhibitors (Sit -
gli tin–J nuvi , s x gli tin—Onglyz , logli tin–Nesin . . . see
below or c ution) c n be used s n “ dd-on” ther y i tr di-
tion l hy oglyce ic gents re not e ective nd h ve the bene t
o so e weight loss. In tient with very oor control (e.g.,
A1c > 9%) t di gnosis, insulin (“C”) would be otenti l rst-
line gent, but not in this tient whose is rti lly controlled.
HELPFUL TIP:
New data su ests an association (or maybe causal-
ity) o con estive heart ailure with saxa liptin (On -
lyza) and alo liptin (Nesina). This does not seem to be
a problem with sita liptin (Januvia). These dru s only
reduce HbA1c by about 0.5% and have no data dem-
onstratin cardiovascular bene it. Other reported side
e ects include headache, nasopharyn itis, and upper
respiratory tract in ections. Also, acute pancreatitis has
been reported in association with DPP-4 inhibitors, but
currently there is insu icient evidence to determine a
causal relationship.
HELPFUL TIP:
Another class o “ luca on-like peptide-1” (g LP-1)
dru s act as receptor a onists (e. ., exenatide—Byetta,
lira lutide—Victoza, albi lutide—Tanzeum, etc.) which
bind to the g LP-1 receptor. They are resistant to break-
down by the body and thus provide sustained lucose
control. These are iven by subcutaneous injection and
are airy costly but have the advanta e o bein more
potent than the liptins and may even cause wei ht
loss in type 2 diabetics.
Question 10.10.8 Which o the ollowing is NOT a side e ect
o GLP-1 receptor agonists (exenatide, liraglutide, albiglu-
tide)?
A) Weight g in.
B) P ncre titis.
C) Hy oglyce i
D) GI u set.
E) T yroid tu or.
Answer 10.10.8 The correct answer is “A.” Actu lly, GLP-1
gonists y c use weight loss o 1.5 to 2.5 kg over 30 weeks.
T ese drugs re ssoci ted with ncre titis lthough r rely nd
the ssoci tion is tenuous. Due to n ssoci tion with thyroid
c ncer, their use is contr indic ted in tients with erson l
or ily history o edull ry thyroid c rcino or MEN 2A
or 2B. T e risk o hy oglyce i is s ll—but not zero—with
GLP-1 gonists. So ewhere between 10% nd 50% o tients
y develo GI sy to s.
Question 10.10.9 Met ormin should NOT be used in which
class o patients?
A) P tients with COPD.
B) P tients with i ired ren l unction.
C) P tients with leuke i s or ly ho s.
D) Post yoc rdi l in rction tients with nor l systolic
unction.
E) P tients with insu cient t stores.
Answer 10.10.9 The correct answer is “B.” P tients with ren l
dise se re t higher risk o l ctic cidosis, the ost severe
co lic tion o et or in ther y, lthough it is exceedingly
r re (3 c ses er 100,000 vs. 2 c ses er 100,000 with other
hy oglyce ic gents). Current nu cturer reco end tions
st te th t et or in should be voided i the seru cre tinine
≥ 1.5 g/dL in les nd ≥ 1.4 g/dL in e les. However,
met ormin is likely sa e to start as long as the GFR is > 30 mL/min
(max dose 1,000 mg/day or those with a GFR between 30 and
60 mL/min). P tients with ul on ry or neo l stic dise ses y
t ke et or in unless they lso h ve severe he tic or ren l
ilure. CHF is rel tive contr indic tion to the use o et or-
in; it is being used with incre sed requency in st ble, tients
not t risk or hy oxe i . Use clinic l judg ent. Met or in
should be held or 48 hours f er contr st studies. Ple se re er
to the gener l reco end tions reg rding nti-hy erglyce ic
ther y in ty e 2 di betes by the ADA ( ble 10-2).
Question 10.10.10 Which one o the ollowing is NOT a risk
actor or prognostic marker or lower-extremity amputa-
tion in patients with diabetes?
A) Di betic retino thy.
B) Bony de or ity o the eet or nkles.
C) C-re ctive rotein (CRP) level.
D) Abnor l ono l ent testing or sensory unction.
E) Severe n il thology.
Answer 10.10.10 The correct answer is “C.” T e risk o ulcers
or ut tions is incre sed in tients who h ve h d di betes
or 10 ye rs or ore, re le, h ve history o oor glucose
control, or h ve evidence o icrov scul r co lic tions o
di betes (e.g., retino thy). Bony de or ities, loss o rotec-
tive sens tion, nd severely dystro hic toen ils re lso risk
ctors or ut tion. T e Se es–Weinstein 10 g ono-
l ent sensory ex in tion is the ost sensitive neurologic
test or redicting the uture occurrence o di betic oot ulcer.
An elev ted CRP in nd o itsel is not known risk ctor or
ut tion, but CRP y be elev ted i there is lower extre ity
in ection resent.
At the next visit, you review the tient’s edic l record nd
try to ssure th t he is u to d te on his reventive he lth
c re.

TABLE 10-2 RECOMMENDATIONS FOR MEDICALTREATMENT DIABETES MELLITUS TYPE 2
DPP-4-i, DPP-4 inhibitor; xs, ractures; g I, astrointestinal; g LP-1-RA, g LP-1 receptor a onist; g U, enitourinary; HF, heart ailure; Hypo, hypo lycemia;
Sg LT2-i, Sg LT2 inhibitor; SU, sul onylurea; TZD, thiazolidinedione.
From American Diabetes Association. Standards o Medical Care in Diabetes-2015. Diabetes Care. 2015;38:S1–S93.
Question 10.10.11 Which o the ollowing is NOT true
regarding preventive services in diabetics?
A) P tients di gnosed with ty e 2 di betes should h ve dil ted
eye ex in tion t the ti e o di gnosis.
B) P tients with ty e 1 di betes should h ve dil ted eye
ex in tion t the ti e o di gnosis i they re over
ge 12.
C) Check SH nnu lly in ty e 1 di betes, in tients with dys-
li ide i or di betic wo en over ge 50 ye rs.
D) A urine icro lbu in should be checked t le st ye rly in
ll ty e 2 di betics.
E) A oot ex in tion using 10 g nylon icro l ent should
be done nnu lly or ll di betics.
Answer 10.10.11 The correct answer is “B.” P tients with di -
betes ty e 1 should h ve n eye ex in tion 3 to 5 ye rs er
CHAPTER 10 • ENDOCRINOLOg Y 293
the di gnosis nd then ye rly. Age t the ti e o di gnosis is
not ctor in deter ining when n eye ex in tion should be
done. See ble 10-3 or co onents o reco ended di betes
ollow-u .
Question 10.10.12 Speaking o prevention, your patient,
now 48 years old with his diabetes controlled, asks i he
should be taking an aspirin daily to protect his heart. You
respond:
A) “ ke s irin 325 g d ily bec use it will lower your risk o
yoc rdi l in rction.”
B) “Di betes does not uto tic lly qu li y you or s irin
ther y. Let’s check your therosclerotic c rdiov scul r dis-
e se (ASCVD) score.”
C) “T e risks nd bene ts o s irin in your c se re unknown.”
D) “ ke it by the trucklo d. I’ve got lot o stock in B yer.”
294 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
TABLE 10-3 SUMMARY OF SCREENING
RECOMMENDATIONS
DM type 1:
• Urine microalbumin startin at a e 12 and then every 6 to
12 months.
• Dilated eye examination 5 years a ter dia nosis and then annually.
• HbA1c every 6 months or stable patients achievin lycemic oals,
every 3 months or patients chan in therapy or not meetin
lycemic oals.
• Blood pressure screenin at every visit.
• Foot examination and screenin or polyneuropathy at dia nosis
and annually.
• I not per ormed/available within past year
• Fastin lipid pro le, includin total, LDL, and HDL cholesterol and
tri lycerides, as needed
• Serum creatinine and calculated lomerular ltration rate
• TSH in type 1 diabetes, dyslipidemia, or women over a e 50 years.
DM type 2: Same as DM1 above, except:
• Eye examination at time o dia nosis and then yearly.
• Urine microalbumin at the time o dia nosis and then every
6–12 months.
Data rom American Diabetes Association. Standards o medical care in
diabetes—2011. Diabetes Care. 2011;34:S11–S61.
Answer 10.10.12 The correct answer is “B.” T e ADA rec-
o ends considering s irin ther y (75–162 g/d y) s
ri ry revention str tegy in those with ty e 1 or ty e 2
di betes t incre sed c rdiov scul r risk (10-ye r risk ≥ 10%).
Who would be in this c tegory o risk? Most di betic en ged
> 50 ye rs or di betic wo en ged > 60 ye rs who h ve t
le st one ddition l jor risk ctor ( ily history o c r-
diov scul r dise se, hy ertension, s oking, dysli ide i ,
or icro lbu inuri ). ADA reco ends AGAINS s irin
use or CVD revention or dults with di betes t low CVD
risk (10-ye r CVD risk < 5%, such s in en ged < 50 ye rs
nd wo en ged < 60 ye rs with no jor ddition l CVD
risk ctors) since the otenti l dverse e ects ro bleeding
likely o set the otenti l bene ts. I you decide to rescribe
s irin or ri ry CVD revention in di betic, use 81 g
d ily.
Un ortun tely, this tient ollows the “rule” o ty e 2 di be-
tes nd ends u on ulti le edic tions. When he returns to
your clinic ew onths l ter, he is co l ining o shortness
o bre th nd lower extre ity ede . You decide to ollow
the “rule” o bl ing drugs rst . . .
Question 10.10.13 Which o the ollowing drugs (by itsel —
not in combination with other drugs) is the most likely
cause o this patient’s edema, shortness o breath, and pos-
sible heart ailure?
A) Met or in.
B) Glyburide.
C) Pioglit zone.
D) Lisino ril.
E) Insulin.
Answer 10.10.13 The correct answer is “C.” T e thi zolidin-
ediones (“glit zones”) tend to c use ede s one o their jor
side e ects. T us, they re contr indic ted in tients with his-
tory o he rt ilure. So e drug co bin tions c n c use ede ,
including the co bin tion o gli e iride nd et or in.
Bec use o the roble with ede , you decide to ch nge
this tient to sul onylure , nd you choose to st rt gly-
buride. T e tient does well on this or sever l weeks but
is then ound unconscious in his ho e with blood sug r o
20 g/dL. Strike two, doc! He is r idly revived by the r -
edics with n o D50. You re c lled to see the tient
in the ED. He is currently w ke, convers nt, nd e ting (“
gre t excuse or cou le o cookies!”). He would like to go
ho e since he is b ck to his b seline.
Question 10.10.14 Which o the ollowing is the best next
step in the management o this patient’s hypoglycemic
episode?
A) Disch rge the tient ro the ED nd h ve hi continue
his regi en, including glyburide.
B) Disch rge the tient ro the ED nd h ve hi sto his
glyburide nd st rt insulin.
C) Ad it the tient nd st rt hi on IV dextrose 5% in usion.
D) Ad it the tient nd observe hi or 24 hours.
E) Give hi gi c rd to loc l c sino bu et, nd tell hi ,
“Pretend it’s your birthd y!”
Answer 10.10.14 The correct answer is “D.” P tients on n
or l hy oglyce ic gent—es eci lly longer- cting gents like
glyburide—should be d itted or observ tion. It would be re -
son ble to let hi e t, check his glucose eriodic lly, nd hold
his di betic edic tions. He is currently st ble nd does not
e r to need IV dextrose (“C”), but the tient should h ve
IV ccess, nd h l - or ull- ule o D50 c n be given i nec-
ess ry. T e bsor tion o or l hy oglyce ic gents is so ewh t
err tic, nd their e ect c n be rolonged. T e tient y h ve
n ddition l e isode o hy oglyce i or u to 36 to 48 hours
er the initi l e isode. T is is not true o tients on insulins
(NPH or short- cting insulin [e.g., regul r, lis ro]), who y be
disch rged ro the ED er ew hours. But or this tient,
disch rge ro the ED (“A,” “B,” nd “E”) would be unwise.
HELPFUL TIP:
15 to 20 o astin -actin carbohydrate like lucose
tablets, honey, corn syrup, non at or 1% milk, jellybeans,
umdrops, el tube, raisins, hard candy, re ular soda,
sweetened ruit juice can be used to treat symptomatic hy-
po lycemia. For severe hypo lycemia, luca on injection
may be needed. g luca on, 1 m IM or IV, is another option.
HELPFUL TIP:
The ollowin medications enerally do not cause hy-
po lycemia: met ormin, acarbose, dipeptidyl peptidase
(DPP-4) inhibitors and luca on-like peptide-1 (g LP-1)
receptor a onists.

It turns out th t one o your rtners h s st rted this tient
on bet -blocker or its c rdio rotective nd ntihy erten-
sive e ects while you were on v c tion. T e tient w nts to
know i this y h ve revented hi ro noticing the signs
nd sy to s o hy oglyce i .
Question 10.10.15 Your response is:
A) “Bet -blockers reduce your bility to recognize hy oglyce-
i nd the drug should be sto ed.”
B) “Bet -blockers reduce your bility to recognize hy oglyce-
i but the bene ts re worth it.”
C) “Bet -blockers do not decre se your bility to recognize
hy oglyce i to ny gre t degree. Don’t worry bout it.”
D) “ACE inhibitors re better drugs bec use they do not con-
tribute to hy oglyce i in di betics.”
Answer 10.10.15 The correct answer is “C.” Bet -blockers
do not signi c ntly inter ere with tients’ bility to recognize
hy oglyce i . T e in thing th t contributes to un w reness
o hy oglyce i in di betics is the r te o glucose dro ( slow
dro is less likely to be noticed) nd utono ic insu ciency
( tients c nnot res ond with t chyc rdi , swe ting, etc., to the
out ouring o drenergics). “D” is incorrect. ACE inhibitors,
like bet -blockers, re ctu lly ssoci ted with hy oglyce i in
di betics.
HELPFUL TIP:
The ADA recommends the tar et A1c in nonpre nant
adults with diabetes be < 7%. However, it also advises
more or less strin ent lycemic oals may be appro-
priate or individual patients and oals should be in-
dividualized on the basis o duration o diabetes, a e/
li e expectancy, comorbid conditions, known CVD or
advanced microvascular complications, hypo lycemia
unawareness, and individual patient considerations.
For patients with multiple comorbidities and hi her
risks or hypo lycemia and other dru adverse e ects, a
hi her A1c, even up to 8.5%, may be acceptable (but try
tellin that to the insurance companies).
You d it the tient nd dvise hi to c rry source o
glucose with hi t ll ti es nd everybody h s h y out-
co e until . . .
T e tient h s develo ed ersistent hy erglyce i
des ite being on xi l doses o et or in nd glyburide.
He is willing to begin insulin ther y, but w nts to give hi -
sel s ew injections s ossible.
Question 10.10.16 Which o the ollowing regimens would
be best or him?
A) A single injection o insulin gl rgine (L ntus M) or NPH
insulin t bedti e.
B) A single injection o 70/30 NPH/regul r insulin t bedti e.
C) A b seline bedti e injection o insulin gl rgine nd u to
three injections o short- cting insulin with e ls.
CHAPTER 10 • ENDOCRINOLOg Y 295
D) Regul r insulin with e ls to control ost- r ndi l blood
sug rs.
Answer 10.10.16 The correct answer is “A.” Bec use o its slow
rele se, insulin gl rgine rovides ste dy-st te insulin level
throughout 24 hours nd is less likely to c use nocturn l hy o-
glyce i . Other o tions include insulin dete ir nd ultr lente
insulin (o the rket in the United St tes), or bedti e NPH,
ll o which h ve rolonged ction. Regul r insulin ( s ound
in 70/30) is gener lly not the l ce to st rt with ty e 2 di bet-
ics (“B”). Multi le d ily insulin injections y be necess ry
or ty e 1 di betics, but r rely re so or ty e 2 tients. For
DM2, long- cting insulin is usu lly st rted rst nd bolus e l-
ti e insulin dded l ter, so “C” would not be the rst choice.
As noted s bove, regul r insulin (“D”) isn’t the l ce to st rt
in DM 2. I you re trying to st rt with the si lest ossible
regi en, choose so ething like “A.”
HELPFUL TIP:
Sul onylureas and insulin work in the same manner:
they both increase circulatin insulin levels. For this rea-
son, some choose not to use these two dru s to ether
and will taper the sul onylurea a ter the patient is on a
stable dose o insulin.
Your tient is hos it lized or cute diverticulitis nd
requires urgent rti l colecto y.
Question 10.10.17 Which o the ollowing statements
regarding the management o diabetes in hospitalized
patients is TRUE?
A) Hy erglyce i in the hos it l h s ini l i ny e ect on
outco es o yoc rdi l in rction.
B) A st nd rdized sliding-sc le insulin regi en is dequ te to
control hy erglyce i in ll hos it lized di betic tients.
C) Insulin require ents will be lower or cutely ill, hos it l-
ized di betic tients.
D) Met or in should be discontinued in seriously ill, hos it l-
ized tients.
Answer 10.10.17 The correct answer is “D.” In gener l, one
should consider discontinu tion o et or in in severely
ill, hos it lized tients due to the ossible need or contr st
studies, ch nges in f uid b l nce, ch nges in glo erul r ltr -
tion r te, etc. “A” is incorrect. Hy erglyce i is ssoci ted with
worse outco es in hos it lized tient with c rdi c dise se nd
those who re in n intensive c re unit or ost re sons. But
this y be bec use elev ted blood sug rs suggest they re
under gre ter et bolic stress nd sicker to begin with. “B”
is lso incorrect. Sliding-sc le regi ens, i used t ll, should
be individu lized to e ch tient, r ther th n rescribed s
st nd rdized regi en. It h s beco e cle r th t sliding sc le is
not the best w y to control blood sug rs in hos it lized tients.
Continuing so e ty e o “nor l” insulin regi en is best,
using su le ent l insulin s needed. In hos it lized tients,
296 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
it is gener lly reco ended to discontinue or l ntidi betic
gents nd control the glucose using insulin only, rovided in
co bin tion or including b s l long cting insulin lus
re- e l short cting insulin i on diet nd correction l insulin
( k b s l/bolus insulin). T e stress o cute illness nd surgery
will likely incre se insulin require ents in ost di betics, not
decre se the .
HELPFUL TIP:
Chasin the lucose in an attempt to maintain ti ht
control in the hospital is counterproductive and does
not improve outcomes! Even thou h patients with hy-
per lycemia may do worse, it is clear that the elevated
lucose is a marker or metabolic stress which is why
outcomes mi ht be worse . . . they are sicker to be in
with. Thus or sicker patients, aim or a blood su ar o
between 120 and 180 m / dL. This has been ound to be
superior to more intensive lycemic control.
He does well nd is re dy or disch rge. He sks bout sel -
onitoring o blood glucose.
Question 10.10.18 How o ten should a type 2 diabetic
on oral hypoglycemic agents measure his or her blood
glucose?
A) Once or twice week, t v rying ti es during the d y.
B) Four ti es d ily—be ore e ls nd t bedti e.
C) wice d ily— sting nd 2 hours er e l.
D) Once or twice d ily— sting nd be ore e l.
E) Routine blood sug rs re not indic ted on d ily b sis or
ty e 2 di betics.
Answer 10.10.18 The correct answer is “E.” D ily e sure-
ents o nger stick sug rs in tients on or l hy oglyce ic
gents do nothing to i rove glyce ic control (BMJ. 2012
Feb 27;344:e486). In these tients, we re not re cting to d ily
f uctu tions in glucose control but r ther king ch nges
in res onse to the HbA1c. Occ sion l r ndo sug rs re not
unre son ble to get gener l ide bout glyce ic control. y e
2 di betics on insulin ( nd ll ty e 1 di betics) should e -
sure their blood glucose t le st d ily, nd ide lly two or three
ti es er d y, reg rdless o the resence or bsence o sy -
to s. T e tient h s co e b ck to your clinic sever l ti es
or ollow-u , nd his current edic tions including et-
or in nd glyburide re djusted to their xi u doses.
T e tient is not interested in inject ble edic tion—he
ch nged his tune ro e rlier f er re ding online how he
ight get ddicted to insulin. You discuss dding third or l
gent, nd uster n ex ression th t belies enthusi s .
HELPFUL TIP:
THE NEW KID ON THE BLOCK: Another class o dia-
betic medication is the sodium- lucose co-transporter
2 (Sg LT2) inhibitors, which include cana li lozin
(Invokana), dapa li lozin (Farxi a), and empa li lozin
(Jardiance). They promote the renal excretion o lu-
cose (literally peein out the su ar) and thereby mod-
estly lower elevated blood lucose levels in patients
with type 2 diabetes. Sg LT2 inhibitors lower A1c levels
by 0.5% to 0.7%, limited by the iltered load o lucose
and the osmotic diuresis that is caused by this therapy.
The lucose-lowerin e ect is independent o insulin
(beta cell unction and insulin sensitivity). The overall
bene its o Sg LT2 inhibitors include a decrease in blood
pressure and wei ht and a low incidence o hypo lyce-
mia. The side e ects are exactly what you would think
iven the mechanism o action is to pee out su ar: vul-
vova inal candidiasis, urinary requency, and urinary
tract in ection. LDL oes up 4% to 8%. Also, the FDA has
issued a warnin re ardin ketoacidosis. There is also
some concern about an association with bladder cancer
that requires urther post-market monitorin . I there is
a “line” or these dru s, it’s third-line.
T e tient’s di betes is not o ti lly controlled nd he
develo s di betic neuro thy ye rs l ter.
Question 10.10.19 Which o the ollowing agents is LEAST
e ective in treatment o diabetic neuropathic pain?
A) ricyclic ntide ress nts.
B) SSRIs.
C) Duloxetine (Cy b lt ).
D) Preg b lin (Lyric ) or g b entin.
E) Venl xine (E exor XR).
Answer 10.10.19 The correct answer is “B.” Sever l drugs h ve
been roved s eci c lly or relie o di betic eri her l neu-
ro thic in in the United St tes ( reg b lin, duloxetine, nd
t ent dol), but none ords co lete relie , even when used in
co bin tion. Venl xine, itri tyline, g b entin, v l ro te,
nd other o ioids ( or hine sul te, tr dol, controlled rele se
oxycodone) y be e ective nd y be considered or tre t ent
o in ul di betic eri her l neuro thy. Low-dose tricyclic
ntide ress nts re the ost e ective o this grou (e.g., nor-
tri tyline or itri tyline 25 g qhs) but lso h ve nticho-
linergic side e ects (Lancet Neurol. 2015 Feb; 14:162). ricyclics
nd g b entin re dditive, so consider using the together i
needed). Re e ber th t g b entin c uses weight g in, so e-
thing these tients don’t need. For the tre t ent o neuro thic
in, CA>strong o i tes>tr dol>SNRIs> reg b lin>g b
entin. SSRIs re gener lly ine ective or neuro thic in.
HELPFUL TIP:
Well LA-DI-DA (well, LADA, anyway). LADA stands or la-
tent autoimmune diabetes in adults. This is a patient who
clinically starts as a patient with DM2 but also has circu-
latin anti-islet cell and/or anti-g AD antibodies. As some
point in their disease, these adult patients lose enou h

pancreas to convert to a type 1 diabetic. These are patients
who initially respond to noninsulin hypo lycemic a ents
(met ormin, sul onylureas, etc.) but eventually no lon er
respond to these dru s and become insulin dependent.
This may represent up to 10% o the DM 2 population.
Objectives: Did you learn to . . .
• Reco nize dia nostic criteria or diabetes?
• Di erentiate diabetes type 1 rom type 2?
• Evaluate a patient with new onset type 2 diabetes?
• Identi y risk actors or complications o diabetes?
• Initiate and mana e oral therapy in type 2 diabetes?
• Start a type 2 diabetic patient on insulin?
• Mana e diabetes in the hospital settin ?
• Treat o pain ul diabetic peripheral neuropathy?
CASE 10.11
A 32-ye r-old e le resents to your o ce co l ining o
“hy oglyce i .” She notices th t bout 2 to 3 hours f er
e l she gets n use ted, sh ky, nd irrit ble. When she w kes
u in the orning, she gener lly eels well even though she
e ts dinner t bout 5:00 pm nd does not e t ny sn cks f er-
w rd nd gener lly does not h ve bre k st until 8:00 a m.
Question 10.11.1 You can tell her that:
A) She likely h s n insulino .
B) She likely will h ve nor l blood sug rs when she eels sh ky.
C) Hy oglyce i does not exist s n entity in this or nd
she likely h s nxiety.
D) She likely h s “ sting” hy oglyce i .
E) Hy oglyce i is n unco on roble in nondi betics
but it could ex l in her sy to s.
Answer 10.11.1 The correct answer is “E.” “A” is incorrect
bec use tient with n insulino should be hy oglyce ic
er 15-hour st (when she’s not e ting between 5:00 pm nd
8:00 a m). “B” is incorrect. T is tient y h ve ost r ndi l
hy oglyce i th t occurs 2 to 4 hours er e ting. T e rocess
le ding to ost r ndi l hy oglyce i is s ollows: the tient
h s l rge e l with si le c rbohydr tes, the seru insu-
lin level incre ses in res onse but overshoots, nd the tient
beco es tr nsiently hy oglyce ic or 15 to 20 inutes usu lly
2 to 4 hours er e ting. T is is ssoci ted with drenergic out-
ouring in n tte t to correct the roble . It is the drener-
gic out ouring th t c uses the sy to s o tre or, n use , etc.
“C” is incorrect bec use hy oglyce i does exist. “D” is incor-
rect. T e tient does not h ve sy to s o sting hy ogly-
ce i , which occur 4 to 6 hours (or longer) er the l st e l.
Question 10.11.2 All o the ollowing are associated with
postprandial hypoglycemia EXCEPT:
A) Diuretics.
B) Alcohol int ke.
C) Postg strecto y syndro e.
D) Bet -blockers.
CHAPTER 10 • ENDOCRINOLOg Y 297
Answer 10.11.2 The correct answer is “A.” Diuretics tend to
incre se the blood sug r bit. As irin, indo eth cin, ACE inhib-
itors, ent idine, nd ren l ilure y be ssoci ted with ost-
r ndi l hy oglyce i . Other edic tions th t re ssoci ted
with hy erglyce i include quinolones, ty ic l nti sychot-
ics, corticosteroids, c lcineurin inhibitors, rote se inhibitors,
nd so e li id-lowering gents like ni cin nd torv st tin. It is
worth noting th t c rvedilol nd nebivolol re not ssoci ted with
the develo ent o hy erglyce i , nd g tif ox cin is ssoci ted
with both hy er- nd hy oglyce i . urns out th t the kidneys
re res onsible or bout 50% o gluconeogenesis. I the kidneys
ren’t working, the bility to res ond to hy oglyce i is blunted.
HELPFUL TIP:
Hypo lycemia should be suspected in any patient with
diabetes who has ocal neurolo ic si ns (such as mi ht
be seen in a CVA).
Question 10.11.3 You advise this patient to do all o the
ollowing EXCEPT:
A) Incre se the ount o si le c rbohydr tes with her e ls.
B) Incre se the ount o co lex c rbohydr tes with her
e ls.
C) Incre se the ount o rotein with her e ls.
D) Incre se the ount o t with her e ls.
E) E t s ller, ore requent e ls.
Answer 10.11.3 The correct answer (and what you would
not want to do) is “A.” Her roble is c used t le st in rt
by high int ke o si le c rbohydr tes, le ding to r id nd
high e k in her blood sug r ollowed by n excessive rele se o
insulin. T us, one would w nt to decre se the ount o si -
le c rbohydr tes in the diet nd dd rotein, t, nd co lex
c rbohydr tes. T ere is little d t suggesting th t ny o these
is rticul rly e ective, however. Del ying g stric e tying
(using n gent like ro ntheline, n nticholinergic/ ntis s
odic) doesn’t see to ke di erence (but ight ke the
tient slee y enough th t she doesn’t notice the sy to s!).
Reducing the s ike in c rbohydr te bsor tion using l h -
glucosid se inhibitors (e.g., c rbose) kes sense but lso does
not h ve ny good su orting d t or this indic tion.
INTERESTING (BUT MAYBE NOT SO HELPFUL) TIP:
g in and tonic and ackee ruit ( rom Caribbean islands)
are known causes o hypo lycemia. In “ in and tonic hy-
po lycemia” (the actual name o the syndrome), alcohol
prevents e ective counter-re ulatory measures to the
hypo lycemia produced by the quinine. As an aside
ackee ruit, common in the Jamaican diet, contains “hy-
po lycin” that prevents luconeo enesis.
HELPFUL TIP:
For insulinoma, watch the patient durin a controlled
ast durin which the patient is observed and can
be treated or hypo lycemia i necessary. I you are
298 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
considerin sel -induced hypo lycemia with insulin
(e. ., actitious hypo lycemia), measure the c-peptide.
This will be low i the patient is bein administered ex-
o enous insulin because pancreatic insulin production
will be shut o in response to hypo lycemia (remem-
ber, however, that it will also be low in type 1 diabetes).
Objectives: Did you learn to . . .
• Evaluate a patient with possible hypo lycemia?
• Treat a patient with postprandial hypo lycemia?
• Identi y causes o hypo lycemia?
QUICK QUIZ: CARBOHYDRATES AND CALORIES
Which o the ollowing st te ents is FALSE?
A) T e use o the glyce ic index (GI) nd lo d y hel di -
betic tients i rove their c rbohydr te-cont ining ood
selection.
B) Di betics should void sucrose-cont ining oods bec use
they worsen glyce ic control ore th n co r ble
ount o st rch.
C) For weight loss, either low-c rbohydr te or low- t c lorie-
restricted diets y be e ective in the short ter (u to 1 ye r).
D) Moder te lcohol int ke y reduce the risk o develo ing
di betes.
E) C rbohydr tes h ve ewer c lories er gr th n lcohol.
The correct (and alse) answer is “B.” Sever l studies de on-
str te th t diet ry sucrose does not incre se glyce i ore th n
isoc loric ounts o st rch. For ex le, the glyce ic index
o sucrose is 84 while th t o b n n is 88 (where higher is
worse). T e GI is nu ber ssoci ted with rticul r ty e o
ood th t indic tes the ood’s e ect on erson’s blood glucose
level, ty ic lly r nges between 50 nd 100, where 100 re resents
the st nd rd, n equiv lent ount o ure glucose. A rel ted
e sure, the glyce ic lo d (GL) o ood is nu ber th t esti-
tes how uch the ood will r ise erson’s blood glucose
level er e ting it. One unit o GL roxi tes the e ect o
consu ing one gr o glucose. Both GI nd GL re hel ul
in edic l nutrition l ther y or di betes. For “C,” lthough
low- t diets h ve tr dition lly been ro oted or weight loss,
studies ound th t subjects on low-c rbohydr te diets lost ore
weight. Nonetheless, either low-c rbohydr te or low- t c lorie-
restricted diets re e ective or weight loss. Reg rding “D,”
observ tion l studies re ort th t oder te lcohol int ke
reduce the risk or di betes, but the d t do not su ort reco -
ending lcohol consu tion to individu ls t risk o di betes.
Did you know th t 1 g o lcohol h s 7 c lories while one g o
c rbohydr tes only h s 4? Now you do!
CASE 10.12
A 24-ye r-old e le resents to the o ce co l ining o
enorrhe . Six onths go, her enses bec e irregul r
nd light. For the l st 4 onths, she h s not h d eriod t
ll. T is is c using her gre t distress, s she const ntly worries
bout being regn nt. She does desire to h ve children “so e
d y,” but not now. She h s run ulti le ho e regn ncy tests,
ll o which h ve been neg tive. L st week, she develo ed cle r
le k ge ro her ni les, nd the tient is now convinced
she is regn nt nd th t the ho e regn ncy tests ust be
ulty. She requests th t you er or “ re l regn ncy test.”
Question 10.12.1 Which o the ollowing may cause her
amenorrhea?
A) E otion l stress.
B) Pregn ncy, des ite ulti le neg tive tests.
C) T yroid dys unction.
D) Pituit ry tu or.
E) All o the bove.
Answer 10.12.1 The correct answer is “E.” T e di erenti l
di gnosis or enorrhe is r ther bro d, but includes ll o
the bove di gnoses. T e ost co on c use in wo n o
childbe ring ge is, o course, regn ncy. Although urine-b sed
regn ncy tests h ve beco e very sensitive ( ble to detect s
little s 20 IU/ L o β -hCG), the tient y h ve been using
the tests incorrectly nd thus w s getting lse neg tive results.
Other c uses o enorrhe include hy othyroidis , strenuous
exercise or norexi , e otion l stress, ituit ry tu or, cert in
edic tions (e.g., henothi zines, do inergic gents, che-
other y, nd estrogens), nd ov ri n ilure or genesis. See
Ch ter 15 or ore thorough discussion o enorrhe .
Further history ro the tient reve ls en rche t ge 12,
no regn ncies, nd no revious history o enstru l irregu-
l rities. She rtici tes in low-i ct exercise regul rly nd
does not eng ge in long-dist nce running or other de nd-
ing endur nce s orts. Review o syste s reve ls requent
ild he d ches, but no visu l disturb nces or sy to s o
hy othyroidis .
Physic l ex in tion de onstr tes well-develo ed,
well-nourished (neither obese nor excessively thin) dult
e le. She h s ro ri te second ry sex ch r cteristics, no
hirsutis , nd nor l thyroid gl nd to l tion. G l c-
torrhe is noted on bre st ex in tion. T e elvic ex in -
tion is nor l, with ro ri tely develo ed extern l genit -
li , v gin , nd cervix. T e uterus is l ble nd s ll, nd
the ov ries re neither l ble nor tender.
Question 10.12.2 In addition to a serum β -hCG and a TSH,
what other test(s) should be ordered?
y
A) K ryoty e, to ev lu te or testicul r e iniz tion nd urner
syndro e.
B) Adren l MRI, to ev lu te or dren l hy er l si .
C) Prol ctin level.
D) All o the bove.
E) None o the bove.
Answer 10.12.2 The correct answer is “C.” A rol ctin level
is n essenti l co onent o this ev lu tion. A rol ctino is
the ost co on or o ituit ry deno , nd it c n c use

second ry enorrhe , g l ctorrhe , nd in ertility (or i o-
tence in en). Ex nsion o the ss in the sell turcic y the tient should be re erred or surgery.
c use he d ches or visu l eld de ects (bite or l he i no -
si ), but the tu ors re ore o en too s ll to h ve ny loc l
e ects. Adren l hy er l si is unlikely in the tient bec use o
l ck o virilizing ch r cteristics ro ndrogen excess (such s
hirsutis ). Also, dren l i ging is not usu lly the rst ste in
the di gnosis o this disorder (24 urine collection or cortisol nd
17-OHS is indic ted i dren l hy er unction is sus ected). A
k ryoty e is not indic ted in this tient bec use she h s second-
ry enorrhe , or enorrhe th t h s develo ed er eriod
o ti e o nor l enses. P tients who co l in o never h ving
enstru l cycle re considered to h ve ri ry enorrhe ,
which y be evidence o either urner syndro e (XO geno-
ty e) or co lete ndrogen insensitivity ( k testicul r e ini-
z tion, which h s n XY genoty e with end-org n resist nce to
testosterone, resulting in e le henoty e). Both c ses result
in ov ri n genesis nd, there ore, no enstru l cycles.
You obt in l bor tory tests, nd the results re s ollows:
SH 3.1 IU/ L (0.27–4.20), β-hCG undetect ble, rol ctin
150 ng/ L (3.4–24.1).
Question 10.12.3 What is the best next step in this patient’s
evaluation?
A) Re ssure tient th t stress is c using her l ck o eriods nd
she will i rove when she le rns to de l with her li e.
B) No ddition l tests t this ti e, but return in 2 weeks or
re e t rol ctin level.
C) Ad it the tient to the hos it l nd st rt bro ocri tine
ther y S A .
D) MRI br in to ev lu te or ituit ry ss.
E) Re er tient or neurosurgic l intervention.
Answer 10.12.3 The correct answer is “D.” T is tient h s
high rol ctin level nd sy to s o rol ctin excess. In the
bsence o edic tions c using n elev ted rol ctin ( heno-
thi zines, n rcotics, estrogens, etc.) nd nor l SH, this ro-
l ctin result is virtu lly di gnostic or rol ctino . I ging
is indic ted reg rdless o visu l sy to s. A visu l eld ex i-
n tion by con ront tion is insensitive or inor visu l eld
loss. I she h d ild elev tion in rol ctin (u to two ti es
the u er li it o nor l), nd no other sy to s/signs, then
re e ting the level over sever l visits y be ro ri te. I the
level re ins elev ted, i ging nd edic l ther y should
then be considered. Neurosurgic l intervention is not i edi-
tely indic ted, since tri l o edic l ther y is usu lly the rst
ste in tre t ent.
T is tient undergoes br in MRI, which shows 1.3 c
ituit ry ss.
Question 10.12.4 How should this nding be interpreted
and managed?
A) T is is icro deno , nd the result c n be ignored.
B) T is is icro deno , nd edic l ther y with do -
ine gonist is indic ted.
CHAPTER 10 • ENDOCRINOLOg Y 299
C) T is is cro deno , so edic l ther y is utile, nd
D) T is is cro deno , but edic l ther y with do -
ine gonist should still be tte ted.
E) T is is cro deno , which tends to be sel -li ited, so
ther y c n be held or 6 onths when re e t sc n will be
done.
Answer 10.12.4 The correct answer is “D.” A ituit ry tu or
< 1 c in size is considered icro deno , nd tu ors 1 c
or gre ter in size re considered cro deno s. T e tre t-
ent i lic tions re slightly di erent. In both c ses, edic l
ther y with do ine gonist (e.g., bro ocri tine, c bergo-
line) is indic ted. Success ul shrink ge o even cro deno s
is ossible with this ther y. Re e ber th t the secretion o
rol ctin is under neg tive eedb ck loo . As CNS do ine
levels go u , rol ctin levels go down. When do ine levels go
down, rol ctin levels go u .
HELPFUL TIP:
Many psychoactive medications inhibit dopamine and
can result in hyperprolactinemia. Resist the knee-jerk
reaction o stoppin a psychoactive medication in a pa-
tient ound to have hyperprolactinemia. Hi h prolactin
levels do not kill patients, but untreated mental illness
does. Risks, bene its, and likelihood that the dru is to
blame must all be considered.
T e tient is st rted on bro ocri tine nd is scheduled or
ollow-u in 3 weeks. She returns e rlier th n scheduled due
to severe n use nd lighthe dedness. No other new sy -
to s h ve occurred. T e tient’s vit l signs re nor l, but
the systolic blood ressure decre ses by 20 Hg nd the
ulse incre ses by 20 be ts/ inute u on st nding.
Question 10.12.5 Aside rom a bolus o IVf uids, how should
you address this problem?
A) T is is co on side e ect ro bro ocri tine. Decre se
or sto the bro ocri tine, nd consider nother ty e o
do ine gonist, such s c bergoline.
B) Ad it her to the hos it l nd rr nge or S A he d C
sc n to rule out bleeding ro the ituit ry deno .
C) Re e t the regn ncy test.
D) She is h ving n n hyl ctic llergic re ction. Ad inister
e ine hrine nd di henhydr ine i edi tely.
E) She h s iled edic l ther y nd ust be re erred or neu-
rosurgic l intervention.
Answer 10.12.5 The correct answer is “A.” T e ost co on
side e ects o do ine gonists re n use , ostur l hy oten-
sion, nd di culty concentr ting. T ese sy to s tend to be
lessened when lower doses re used nd the dose is incre sed
very slowly. C bergoline tends to be better toler ted th n bro-
ocri tine.
300 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
T e tient is ble to toler te c bergoline, nd continues the
edic tion or 6 onths. During this ti e, the rol ctin
level decre ses slowly. She h s h d resu tion o her enses.
A re e t MRI is done f er 6 onths nd shows rked
decre se in size o the deno . T e tient h s re ched th t
gic l in ection oint in li e where she recognizes th t her
own ort lity is inevit ble, nd she desires to get regn nt
“ s soon s ossible.” She w nts to know i she should h ve
surgery to re ove the deno .
Question 10.12.6 What is/are the indication(s) or transs-
phenoidal pituitary surgery?
A) F ilure to res ond to do ine gonists.
B) F ilure to toler te do ine gonists.
C) re t ent o gi nt deno (> 3 c ) in tient who
desires regn ncy, des ite e c cy o edic l ther y.
D) A nd B.
E) All o the bove.
Answer 10.12.6 The correct answer is “E.” Surgery should
be reserved or those tients who il to res ond to or c n-
not toler te edic l ther y. Note th t visu l eld de ects re
not s eci c indic tion or surgery, since edic l ther y c n
be e ective in decre sing the size nd rel ted loc l e ects o
the tu or. I tient desires regn ncy nd h s l rge ss
(> 3 c ), surgery y be considered s n djunct to edic l
ther y. During regn ncy, there is hysiologic l incre se in
the size o the ituit ry gl nd. I such tient beco es reg-
n nt (without rior reduction in tu or size) nd discontin-
ues the do ine gonist or the dur tion o regn ncy, the
deno y incre se to clinic lly i ort nt size be ore
delivery.
HELPFUL TIP:
Bromocriptine and caber oline are classi ied as cate-
ory B or pre nancy risk (in other words, they are
enerally considered sa e). These medications can be
continued durin pre nancy, but a care ul risk–bene it
analysis and discussion between patient and physician
must occur be ore makin treatment decisions.
T e tient w nts to know how long she should be on c ber-
goline or bro ocri tine nd when tri l o o the edic -
tion is indic ted.
Question 10.12.7 You tell her which o the ollowing?
A) P tients with ituit ry deno h ve to be on edic tion
“ orever” to su ress the tu or.
B) A tri l o o do ine gonist should be done t 6 onths.
C) Prol ctin levels c n be llowed to rise er eno use with-
out roble unless visu l sy to s or other loc l sy -
to s develo . So, she should continue the edic tion until
eno use.
D) None o the bove.
Answer 10.12.7 The correct answer is “C.” Do ine gonists
c n be sto ed t eno use. Follow-u c n be done using
blood levels o rol ctin. I rol ctin levels rise, n MRI c n be
done to see i the deno is beco ing l rger. I not, there is no
re son to tre t the deno in ost eno us l tients. “A” is
incorrect bec use “C” is correct. And, this is si le test t king
skill. I you see “ orever” on test it is rob bly wrong. “B” is
incorrect. If there is no deno noted on MRI t b seline,
tri l o o do ine gonists c n be tried t 1 ye r. er the
drug nd ollow the rol ctin. In those with n deno on
MRI t b seline, tri l o o edic tions t 2 ye rs is re son ble
provided the prolactin level has allen to normal and there no evi-
dence o adenoma by MRI in the past two years. I rol ctin levels
re in under control, there is no need to continue edic tion.
Objectives: Did you learn to . . .
• g enerate a list o potential causes o secondary amenorrhea?
• Evaluate a patient with secondary amenorrhea?
• Dia nose and treat hyperprolactinemia secondary to a pitu-
itary prolactinoma?
CASE 10.13
A 39-ye r-old e le resents to the o ce co l ining o
enorrhe . She h s h d nor l enses until 8 onths go,
when they bec e in requent nd then sto ed. She insists
she c nnot be regn nt, bec use she h s not been sexu l
ctivity “in ye rs.” She believes she is going through “the
ch nge” but w nts to know why she is re ching eno use t
uch e rlier ge th n other wo en she knows. On review
o syste s, she co l ins o he d ches “ or ye rs” nd recent
onset o we kness nd tigue. She lso co l ins o rthri-
tis in the hi nd knees, so ething she ttributes to “getting
old.” She re orts th t her h nds re swollen, nd her rings do
not t ny ore. She denies other co l ints.
On hysic l ex in tion, vit ls re nor l. T e tient
is n dult e le o ver ge height, with notice bly l rge
j w nd h nds. Her h ir is thick nd co rse, nd hirsutis is
resent. Her thyroid gl nd is slightly enl rged, but regul r in
sh e. No bruit or tenderness is resent. T e oint o xi l
i ulse is dis l ced l ter lly, but the he rt rhyth is regul r
nd without ur ur. T e rest o the ex in tion is nor l.
Question 10.13.1 What is the most appropriate next step?
A) Re ssure the tient th t eno use is nor l rocess
nd o er estrogen re l ce ent ther y or sy to tic
relie (but w rn the tient bout risks o long-ter use)
B) ell the tient you sus ect de ression nd o er regi en
o counseling co bined with SSRI ther y
C) ell the tient she y su er ro growth hor one (GH)
excess, nd reco end sending seru insulin-like growth
ctor-I (IGF-I) level
D) ell the tient to quit being hy ochondri c nd to quit
re ding stu on the Internet
Answer 10.13.1 The correct answer is “C.” T is tient re -
resents cl ssic resent tion o cro eg ly due to GH excess,

nd the best single test or this is the IGF-I level. Although GH
levels will o en be elev ted, the IGF-I does not v ry ro hour
to hour nd is not de endent on ood int ke, s is the c se with
GH. An elev ted GH er glucose lo d is lso very sugges-
tive o GH excess. Acro eg ly o dult onset ( er usion o
the long bones) does NO result in incre sed height, but does
c use co rsening o ci l e tures, rogn this , nd thicken-
ing o the eet nd h nds. T ese ch nges c n be very subtle, nd
there is gener lly l g o 12 ye rs be ore di gnosis. Co r-
ing older hotogr hs o the tient to their current e r nce
y be clue ( driver’s license hotogr h y be convenient
source . . . lthough nobody looks good in their driver’s license
hoto). P tients with cro eg ly lso develo hy ertro hy o
cert in org ns (such s the thyroid nd he rt) nd y resent
with he rt ilure due to c rdio yo thy. Eighty- ve ercent o
e les with cro eg ly h ve t le st so e enstru l dys unc-
tion nd 60% re enorrheic. Finally, arthropathy is common
in acromegaly and may be the overriding symptom that prompts
a patient to be evaluated.
HELPFUL TIP:
Premature ovarian ailure is de ined as menopause at
a e 40 or youn er (two standard deviations below the
mean).
T e tient’s IGF-I is elev ted, nd her SH is nor l. An
MRI is er or ed th t reve ls ituit ry ss slightly
< 1 c in di eter.
Question 10.13.2 What is the most e ective therapy or this
condition?
A) Weekly nti-IGF-I ntibody in usions.
B) Bro ocri tine ther y
C) r nss henoid l ituit ry resection
D) So tost tin n logs (such s octreotide)
E) Pegviso nt (GH rece tor nt gonist)
Answer 10.13.2 The correct answer is “C.” Acro eg ly is
c used by GH-secreting ituit ry tu or. Surgery is the tre t-
ent o choice or tients with icro deno (1 c or less
in di eter) or or tients with cro deno th t e rs
to be ully resect ble. So tost tin n logs nd egviso nt
(So vert®) y be use ul djuncts to surgery, nd re n o tion
or tients who re not surgic l c ndid tes. Bro ocri tine is
not very e ective, nd only bout 10% o cro eg ly tients
will chieve nor l IGF-I levels with bro ocri tine; however,
c bergoline see s to work in bout h l o tients. C bergo-
line h s n dv nt ge over so tost tin n logs in th t it c n be
t ken or lly. R di tion is lso n o tion or ther y, es eci lly
or those tients who re not surgic l c ndid tes nd do not
toler te or do not res ond to edic l ther y. “A,” nti-IGF-I
ntibody (i it existed s edic tion), would not h ve n e ect
on GH-secreting tu or. But it does not exist. It’s de-u
nswer, so it’s wrong. By the w y, there’s no de-u stu on the
re l ex in tion . . . we think.
CHAPTER 10 • ENDOCRINOLOg Y 301
Objectives: Did you learn to . . .
• Reco nize si ns and symptoms o g H excess?
• Evaluate and mana e a patient with g H excess?
QUICK QUIZ: g ROWTH HORMONE
A 6-ye r-old boy is brought into the o ce by his concerned
other due to “growing too slowly.” She h s noticed th t he is
signi c ntly shorter th n his cl ss tes t school, nd she w nts
so ething done bout it. She he rd re ort on the nightly news
bout new edic tion th t kes children grow t ller nd
insists on getting it or her son. Both rents re deluded nd
ex ect their son to l y in the NBA or NFL nd believe he will
not ke it unless he “gets lot t ller re lly soon.” She in or s
you in no uncert in ter s th t i you don’t rescribe this “grow-
ing ill,” she will just nd so eone th t will.
You believe this other is in need o so e educ tion bout
GH de ciency.
Wh t re the approved indic tions in children nd dolescents
or GH re l ce ent ther y?
A) Growth hor one de ciency
B) Growth ilure due to chronic ren l insu ciency, intr uter-
ine growth ret rd tion with l ck o “c tch u ” growth by ge
2, urner syndro e, nd Pr der–Willi syndro e
C) An dolescent le who wishes to l y college or ro b s-
ketb ll but is only 5 eet 9 inches on good d y
D) A nd B
E) All o the bove
The correct answer is “D.” GH re l ce ent is s eci c lly -
roved or GH de ciency nd growth ilure due to chronic re-
n l insu ciency, intr uterine growth ret rd tion nd no “c tch
u ” growth by ge 2, urner syndro e, nd Pr der–Willi syn-
dro e. It h s been roved or use in “idio thic short st ture”
( ore th n two st nd rd devi tions below the e n height or
ge). Not ll tients with GH de ciency require GH re l ce-
ent, bec use not ll will su er the neg tive end-org n e ects,
such s rked short st ture, growth ilure, hy oglyce i in
in ncy, nd centr l distribution o body t.
HELPFUL TIP:
As with acrome aly, Ig F-I should be checked when con-
siderin short stature secondary to pituitary ailure. It
is also important to check Ig F-bindin protein-3 levels.
Low levels o Ig F-bindin protein-3 may cause prob-
lems with bindin o Ig F to the proper receptors.
HELPFUL TIP:
Even when used appropriately, g H only leads to a cou-
ple o inches increase in adult hei ht. Poo . . . . there o
the NBA dreams.
302 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Clinical Pearls
Do not order a thyroid ultrasound to routinely evaluate
abnormal thyroid unction tests.
Do not prescribe/recommend multiple daily blood lucose
monitorin in patients on oral hypo lycemic re imens.
Do not use bicarbonate to help correct the acidosis o DKA.
The main intent is to provide IV luid hydration and insulin to
help brin down the su ars and correct the acidosis.
Do not use diuretics to treat acute hypercalcemia. The
important point is to a ressively hydrate the patient.
Do not use T3 or hypothyroidism as its rapid astrointestinal
(g I) absorption and relatively short hal -li e lead to erratic T3
serum levels.
Initiate thyroid replacement at a low dose (e. ., 25 mc
levothyroxine) in the elderly (>65 years old) or those with
cardiac disease and slowly titrate upward every 4
to 8 weeks.
Rely primarily on the TSH to screen or thyroid disease in
symptomatic individuals and as part o monitorin thyroid
unction in thyroid disease.
Screen all obese adults rom a es 40 to 70 or diabetes.
Start steroids immediately i you suspect an adrenal
insu iciency (addisonian) crisis.
Start with an ACE inhibitor (or an ARB i ACEI is contraindi-
cated or has side e ects) in the treatment o proteinuria and
hypertension in patients with diabetes.
BIBLIOGRAPHY
A eric n Di betes Associ tion. Nutrition reco end tions
nd interventions or di betes. Diabetes Care. 2008;31(S1):
S61–S78.
A eric n Di betes Associ tion. St nd rds o edic l c re in
di betes—2015. Diabetes Care. 2015;38:S1–S93.
Betterle C, Morlin L. Autoi une Addison’s dise se. Endocr
Dev. 2011;20:161–172.
Bonor E, uo ilehto J. T e ros nd cons o di gnosing di -
betes with A1 C. Diabetes Care. 2011;34Su l 2:S184–90.
C rroll MF. A r ctic l ro ch to hy erc lce i . Am Fam
Physician. 2003;67:1959.
Findling JW. Di gnosis nd di erenti l di gnosis o Cushing’s
syndro e. Endocrinol Metab Clin North Am. 2001;30:729.
Finklestein BS. E ect o growth hor one ther y on height
in children with idio thic short st ture: A et - n lysis.
Arch Pediatr Adolesc Med. 2002;156:230.
Fr ser WD. Hy erthyroidis . Lancet. 2009;374:145–158.
Grozinsky-Gl sberg S, et l. T yroxine-triiodothyronine
co bin tion ther y versus thyroxine onother y or
clinic l hy othyroidis : Met - n lysis o r ndo ized
controlled tri ls. J Clin Endocrinol Metab. 2006;91:2592.
H bib G, et l. Intr - rticul r ethyl rednisolone cet te
injection t the knee joint nd the hy oth l ic-
ituit ry- dren l xis: A r ndo ized controlled study.
Clin Rheumatol. 2014;1:99–103.
Herrick B. Subclinic l hy othyroidis . Am Fam Physician.
2008;77:953.
Ke rns AE. Medic l nd surgic l n ge ent o hy er r -
thyroidis . Mayo Clin Proc. 2002;77:87.
Ki N. Ev lu tion o thyroid nodule. Otolaryngol Clin North
Am. 2003;36:17.
Moghissi ES, et l. A eric n Associ tion o Clinic l Endocri-
nologists nd A eric n Di betes Associ tion consensus
st te ent on in tient glyce ic control. Diabetes Care.
2009;32:1119–1136.
Montori VM, Fern ndèz-B lsells M. Glyce ic control in ty e
2 di betes: ti e or n evidence-b sed bout- ce? Ann
Intern Med. 2009;150:803–808.
N th n DM, et l. Di betes: A consensus lgorith or the
initi tion nd djust ent o ther y. Clinical Diabetes.
2009;27:4–16.
Norris SL, et l. E ectiveness o sel - n ge ent tr ining
in ty e 2 di betes: A syste tic review o r ndo ized
controlled tri ls. Diabetes Care. 2001;24:561–587.
R o G. Insulin resist nce syndro e. Am Fam Physician.
2001;63(6):1159–1163, 1165–1166.
Sherlock M, et l. Medic l ther y in cro eg ly. Nat Rev
Endocrinol. 2011;7:291–300.
ritos NA, et l. Medsc e. M n ge ent o Cushing dise se.
Nat Rev Endocrinol. 2011;7:279–289.
U.S. Preventive Services sk Force. Screening or gest tion l
di betes ellitus: U.S. Preventive Services sk Force
reco end tion st te ent. Ann Intern Med. 2008;148:
759–765.
Unger J. L tent utoi une di betes in dults. Am Fam
Physician. 2010;81:843.
Y ss L, M rqusee E, F wcett R, Alex nder EK. T yroid
hor one e rly djust ent in regn ncy (the HERAPY)
tri l. J Clin Endocrinol Metab. 2010;7:3234–3241.
Rheumatology
Bharat K mar, Vijay Al ri, and Rebecca T etken
A ew words on “rheumatology panels.” Doing a “rheumatol-
ogy panel” will never be the right answer. T e diagnosis o rheu-
matologic disease is clinical with speci c clinical criteria or each
illness. While antinuclear antibody (ANA), rheumatoid actor
(RF), erythrocyte sedimentation rate (ESR), C-reactive protein
(CRP), and other tests may be use ul in supporting a clinical
diagnosis and assessing disease activity, these tests have poor
speci city and may be positive in a variety o disease states. A
positive ANA without a clinical diagnosis is meaningless. Like-
wise, RF helps to gauge prognosis (seropositive vs. seronega-
tive) in rheumatoid arthritis (RA), but has very limited value
as a diagnostic test. RF may also be positive in sarcoidosis,
viral in ections (especially hepatitis C), and autoimmune dis-
eases such as granulomatosis with polyangiitis ( ormerly known
as Wegener granulomatosis), as well as a variety o primary
lung and liver diseases. ESR and CRP may support the clinical
impression o in ammatory disease, but are again nonspeci c.
CASE 11.1
A 43-year-old emale presents with body aches and sti ness,
which are worse in the morning. She urther describes a low-
grade ever and pain in her hands, eet, and le knee. She
eels that her grip strength is diminished. T ese symptoms
started rather abruptly 2 weeks ago and have not responded
to acetaminophen.
She requently camps with her amily. She remembers that
1 week they could not go because her 8-year-old daughter had
a ever, mild diarrhea, abdominal pain, and a skin rash (“legs,
arms, and especially ace were red and warm, and she seemed
‘ ushed’ all the time”). Her daughter’s symptoms resolved in
a ew days, she did not see a doctor, and no one else was sick.
She has no other illnesses, and review o systems is otherwise
negative.
On physical examination, her vitals are normal. She is
unable to close her hands completely. Although the physical
examination is somewhat limited by pain, there appears to
be swelling o all metacarpophalangeal (MCP) and proximal
11
interphalangeal (PIP) joints, as well as mild erythema over
the MCP joints bilaterally. In addition, upon examination o
the le knee, the bulge sign (indicating e usion) is detected.
Question 11.1.1 I ound on physical examination, which
o the ollowing would be LEAST use ul in helping you in
narrow your diagnosis?
A) Bilateral metatarsophalangeal (M P) joint swelling and
tenderness.
B) Painless oral ulcerations, with clean edges.
C) Firm, slightly tender subcutaneous nodules at the olecranon
bursae.
D) A “bull’s eye” rash in the right axilla.
E) Icterus and tender hepatomegaly.
Answer 11.1.1 The correct answer is “A.” T is patient pres-
ents with polyarticular in ammatory arthritis o unclear etiol-
ogy. While important to note, M P joint swelling would not
add much to the picture o subacute, symmetrical, small joint
polyarthritis that you have already ound on examination. T e
di erential diagnosis includes acute viral arthritis, speci cally
parvovirus B19 (due to the daughter’s history o acute illness
resembling erythema in ectiosum), coxsackievirus, hepatitis
B (hinted at in “E”), and HIV. Also on the di erential will be
Lyme disease (“D”) (although small joint symmetrical arthritis
would be atypical), RA (“C,” the presence o rheumatoid nod-
ules would be help ul although these would be unlikely in early
disease), and other in ammatory disorders. “B,” painless ulcer-
ations, are classically associated with SLE (systemic lupus ery-
thematosus), but it ought to be noted that lupus aphthae (ulcers)
may be pain ul as well.
A er you sneak o to do a little reading, you examine her
again. She has no rash. You detect bilateral pain and swelling
o the third and ourth M P joints. T ere are no oral ulcer-
ations and no lymphadenopathy. She is not icteric, and her
abdomen is di usely, mildly tender. T ere is no hepatomeg-
aly. You decide to order some blood tests.
303
304 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
TABLE 11-1 WHO LIKELY HAS RHEUMATOID
ARTHRITIS?
Patients who:
1. Have at least 1 joint with de nite clinical synovitis (swellin )
2. With the synovitis not better explained by another disease
A. Joint involvement
1 lar e joint
2–10 lar e joints
1–3 small joints (with or witho t involvement o lar e joints)
4–10 small joints (with or witho t involvement o lar e
joints)
> 10 joints (at least 1 small joint)
B. Serolo y (at least 1 test res lt is needed or classi cation)
Ne ative RF and ne ative ACPA
Low-positive RF or low-positive ACPA
Hi h-positive RF or hi h-positive ACPA
C. Ac te-phase reactants (at least 1 test res lt is needed or
classi cation)
Normal CRP and normal ESR
Abnormal CRP or abnormal ESR
D. D ration o symptoms
< 6 weeks
> 6 weeks
Diagnose rheumatoid arthritis if: Score o cate ories A–D is at least 6/10.
Data rom Aletaha D. 2010 Rhe matoid arthritis classi cation criteria: An
American Colle e o Rhe matolo y/E ropean Lea e A ainst Rhe matism
collaborative initiative. Arthritis Rheum. 2010;62:2569–2581.
Question 11.1.2 I positive, which o the ollowing tests
would be MOST help ul in ruling in a specif c rheumatologic
diagnosis?
A) Positive ANA.
B) Elevated white count.
C) Positive parvovirus B19 IgM.
D) Positive urinalysis or white blood cells (WBCs).
E) Elevated ESR and CRP.
Answer 11.1.2 The correct answer is “C.” T e presence o
IgM antibodies to parvovirus B19—or rising titers o IgG
antibodies—indicates acute viral in ection, which may present
with symptoms and signs seen in this patient. “A,” positive ANA,
will not help you rule in a diagnosis at this point. While the ANA
is a highly sensitive test, it is not speci c and has a low positive
predictive value. “B,” “D,” and “E” are all important ndings, but
would not lead you toward a speci c diagnosis. “D,” WBC in
the urine could be rom interstitial nephritis, a U I, a nephritic
urine rom other causes, etc. able 11-1 presents a ramework
or who should be tested or and diagnosed with RA.
HELPFUL TIP:
Note that the dia nosis o RA no lon er req ires
6 weeks o symptoms, altho h a lon er d ration o
polyarthritis makes RA more likely. Similarly, it wo ld
be n s al or parvovir s B19 to ca se symptoms or
6 weeks. However, the vir s can ca se prolon ed joint
pain in 10% o a ected ad lts.
Her laboratory results return as ollows:
• Hepatitis B: Sur ace antibody positive, sur ace antigen
negative.
• CMV: IgG positive, IgM negative.
• Parvovirus: IgG positive, IgM negative.
0 • RF: 200 (normal: < 14 units)
1 • Anti-citrullinated protein antibody (ACPA)*:
2
3
64 units (strong positive > 60 units)
• ANA: Negative.
5 • ESR: 58 mm/hr.
0
Note that based on results so ar and according to
2 able 11-1, she has seven points (4–10 joints involved, high
3 titers o RF and CCP antibody, and elevated ESR).
Question 11.1.3 Which o the ollowing is the most appro
0 priate next step?
1
A) Bilateral hand x-rays.
0
B) C o the chest.
1 C) Smith antibody, double-stranded DNA (dsDNA), comple-
ment levels.
D) Start methotrexate 15 mg weekly by mouth and daily olic
acid, with or without low-dose prednisone and ollow up in
4 to 5 weeks.
E) Start prednisone 60 mg daily by mouth and ollow up in 4 to
5 weeks.
Answer 11.1.3 The correct answer is “D.” T is patient most
likely has seropositive RA (see criteria in able 11-1). T e patient
should be started on a disease-modi ying anti-rheumatic drug
(DMARD), such as weekly methotrexate at a moderate dose,
along with olic acid 1 mg daily and prednisone 10 to 20 mg
daily. Evidence suggests that there is a “window o opportunity”
when treating early RA and that an early remission may lead to
sustained remission.
Note that investigating or any evidence o other systemic
involvement should be included as part o the initial evalua-
tion. It is appropriate to obtain CBC, liver unction tests, elec-
trolytes, BUN, creatinine, and urinalysis (to rule out glomeru-
lonephritis). “A” is incorrect. She is presenting airly early a er
the onset o symptoms, so it is unlikely that hand x-rays will
provide any signi cant ndings. “B” is also incorrect. Without
urther symptoms or signs o lung involvement (e.g., pulmo-
nary osteoarthropathy and respiratory symptoms), a C scan
would be inappropriate. As to “C,” she has no other symp-
toms o lupus and also had a negative ANA, so urther testing
or lupus (Smith antibody, dsDNA [also known as anti-native
DNA antibodies], complement levels) is not appropriate. “E” is
incorrect. Although steroids are indicated, low doses are ne;
higher doses are rarely necessary and are associated with greater
*Anti-citrullinated protein antibody (ACPA) is also known as anti-
CCP (anti-cyclic citrullinated peptides). Anti-CCP antibodies are very
speci c or RA; however, their sensitivity is 67% and there ore may be
negative in RA.

side e ects. T ere ore, early institution o a DMARD would be
pre erable.
HELPFUL (IF LONG) TIP:
In all cases o RA, and especially in those with a poorer
pro nosis, DMARDs sho ld be instit ted promptly, and
escalated airly rapidly, with oal bein disease remis-
sion. Methotrexate is the most commonly sed DMARD
in the u nited States, b t combination therapy (metho-
trexate pl s hydroxychloroq ine or s l asalazine) or
triple therapy (methotrexate, hydroxychloroq ine, and
s l asalazine) improves o tcomes over methotrexate
alone. Low-dose prednisone is indicated or immediate
symptomatic relie . Recent data s ests that low-dose
prednisone in the irst 6 months p to 2 years a ter dia -
nosis is associated with better pro nosis and more s s-
tained remission. Occ pational therapy re erral is help-
l in identi yin and treatin nctional impairment d e
to RA. Vitamin D 800 Iu /day and calci m 600 to 800 m
BID sho ld be initiated with prednisone therapy to help
prevent corticosteroid-ind ced osteoporosis. Eval a-
tion o bone density (DEXA scan) and a bisphosphonate
(e. ., alendronate) sho ld be considered i > 5 m o
prednisone is to be sed or > 3 months.
HELPFUL TIP:
RA typically has an insidio s onset with a l ct atin
co rse; however, a si ni icant minority o patients (per-
haps one-third) will experience rapid onset, over days
to weeks.
She returns in 4 weeks and is now about 7 weeks into her ill-
ness. She reports a moderate response to your intervention
(you started methotrexate 15 mg weekly with 1 mg olic acid
daily, and prednisone 20 mg daily), but now she has 1 to
2 hours o morning sti ness. She continues to complain o
pain in her hands and eet, with poor grip. In act, she had
to take time o rom work during the last week. On exami-
nation, she has persistent swelling o MCPs 2 to 5 bilaterally
and M Ps 3 and 4 bilaterally. You also note swelling in the
le wrist and both knees, but tenderness is reduced and there
is no erythema.
You take a step back and want to reassess the situation.
Question 11.1.4 What examination nding is so general
that it would NOT help you support/reconsider your diag
nosis?
A) Pleural rub auscultated on lung examination.
B) Firm, slightly tender subcutaneous nodules at the olecranon
bursae.
C) Faint pink rash over chest, which is not visible 15 minutes
later.
D) Reduced passive exion in le knee.
E) Le oot drop.
CHAPTER 11 • RHEu MATOLOg Y 305
Answer 11.1.4 The correct answer is “D.” While important to
note, limitation o passive movements o the knees is indica-
tive only o knee e usion (or pain), which you have already
observed, and is not speci c or any particular etiology. She
responded modestly to methotrexate and prednisone but clearly
still has active arthritis. What can you use to expand or limit
your di erential diagnosis? Pleural riction rub (“A”) is indica-
tive o possible lupus. Diagnostic criteria or lupus include sero-
sitis, which may be detectable as a pleural rub on auscultation
o the lungs (also, look or malar rash, discoid lesions, alope-
cia, and oral ulcerations). Although not part o the diagnostic
criteria or the disease, RA may also present with pleuritis or
pericarditis. Rheumatoid nodules (“B”) are ound in RA. A
salmon-colored, evanescent macular rash (“C”) would lead you
to consider adult-onset Still disease. Still disease, also known
as juvenile idiopathic arthritis (JIA, discussed in Chapter 13),
presents with an evanescent rash, intermittent ever, and arthri-
tis. “Adult onset” Still disease is Still disease with onset a er age
16. In addition, RF and CCP antibodies are typically negative
in adult-onset Still disease. A nding o isolated oot drop (“E”)
may be the result o mononeuritis multiplex, a eature o vascu-
litides, and paraneoplastic syndromes. In act, oot drop is the
most common weakness with mononeuritis multiplex ollowed
by wrist drop. Mononeuritis multiplex is de ned as injury o
two or more named nerves secondary to a vasculitis.
Question 11.1.5 Since your patient is taking methotrexate,
you caution her to avoid which o the ollowing?
A) Aspirin.
B) Sul onamide antibiotics.
C) Ibupro en.
D) Folate.
E) Penicillin antibiotics.
Answer 11.1.5 The correct answer is “B.” Methotrexate is
a olate antagonist. Anti- olate medications, such as sul on-
amide antibiotics, must be avoided in patients taking metho-
trexate because the combination may result in pancytopenia.
Supplemental olate, 1 mg daily, reduces the adverse e ects o
methotrexate. Patients with RA are o en treated with aspirin
or NSAIDs in combination with methotrexate. Penicillin anti-
biotics can be administered sa ely with methotrexate, although
methotrexate levels may increase by 8% or so.
HELPFUL TIP:
Dr interaction pro rams o ten warn abo t concomi-
tant se o NSAIDs and methotrexate, as well as aspirin
and methotrexate. These warnin s are most relevant to
hi h-dose methotrexate sed to treat cancer, not the
lower doses sed or in lammatory arthritis.
At her rst return visit, she had only mild improvement
so you (rightly) added hydroxychloroquine (good job!).
Initial hand x-rays demonstrate mild periarticular osteo-
penia. Liver unction tests, urinalysis, CBC, BUN, and cre-
atinine are normal. She returns 6 weeks a er starting the
306 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
hydroxychloroquine and is much improved, having returned
to work ull-time. She tells you that she still has problems
with opening jars and about 45 minutes o morning sti ness,
“but nothing like it was.”
Question 11.1.6 What is the BEST course o action to ollow
now?
A) Continue her current therapy and ollow up in 6 to
12 months with transaminases, RF, and hand x-rays.
B) Continue her current therapy and ollow up in 3 to 4 months
with transaminases, RF, and hand x-rays.
C) Continue current therapy and ollow up in 3 to 4 months;
arrange or monthly BUN, creatinine and CBC; and sched-
ule or an annual ophthalmology examination.
D) Begin prednisone taper, continue other medications, and
arrange or monthly transaminases and CBC; schedule or
baseline ophthalmology exam; and schedule ollow-up in
another 2 to 3 months.
E) Instruct her to discontinue methotrexate, taper the pred-
nisone dose, and continue hydroxychloroquine; arrange
ollow-up in 1 year.
Answer 11.1.6 The correct answer is “D.” She seems to be
responding to therapy, and a 3-month trial on her current medi-
cations (during which the methotrexate dose may be increased)
is indicated. A slow prednisone taper should be initiated to min-
imize the cumulative dose o corticosteroids. Close ollow-up is
critical; she should contact you should symptoms return dur-
ing the steroid taper. Guidelines or monitoring her DMARD
regimen recommend measurement o transaminases and CBC
every 8 to 12 weeks or methotrexate and routine eye examina-
tion to assess or hydroxychloroquine-related retinal toxicity. A
baseline eye examination is necessary when starting hydroxy-
chloroquine; annual screening should begin a er 5 years, unless
the patient is at high-risk or complications. Hand x-rays are
recommended at 2-year intervals. “E” is incorrect: DMARD
therapy reduces her risk o joint destruction and disease pro-
gression, and should not be discontinued.
At her next visit 3 months later, she eels better. Although she still
has dif culty opening jars, she now has < 30 minutes o morn-
ing sti ness and almost no pain. On examination, she has no
rash, nodules, or evidence o serositis. She now has swelling over
MCPs 2 to 4 on the right and 2 to 3 on the le . Her grip is still
somewhat weak but improved. Laboratory data shows an ESR
o 28 mm/hr, CRP 0.7 mg/dL, and normal transaminases and
CBC. Her symptoms increased when she tapered prednisone to
less than 10 mg/day, so she is taking 20 mg/day once again.
Question 11.1.7 Which o the ollowing is the most appro
priate next step?
A) Increase methotrexate to 25 mg weekly, continue hydroxy-
chloroquine, and re er to rheumatology.
B) Stop methotrexate and switch to le unomide 20 mg/day.
C) Increase prednisone to 60 mg daily.
D) Discontinue all medications except methotrexate.
E) Discontinue methotrexate, taper prednisone, and continue
hydroxychloroquine.
Answer 11.1.7 The correct answer is “A.” Despite her initial
response, she has evidence o ongoing in ammatory activity by
history and examination. Discontinuing or reducing medica-
tion is inappropriate. According to published guidelines, con-
sultation with a rheumatologist is now indicated—i it had not
been sought sooner. She has had a air initial response to meth-
otrexate, prednisone, and hydroxychloroquine. Further bene t
may be gained with increasing the methotrexate dose. Addition
o sul asalazine would also be appropriate. I “triple” therapy
with methotrexate, hydroxychloroquine, and sul asalazine
ails, she will need a biological agent. “B” is incorrect: since she
had an initial response to methotrexate, and may show urther
ef cacy at a higher dose, it would be wise to urther increase
the methotrexate dose, rather than substituting another agent
(le unomide . . . le unomide is a nonbiologic immunosuppres-
sant which can cause liver injury). “C” is incorrect: doses o
prednisone this high are not indicated or RA.
Question 11.1.8 This patient wants to become pregnant.
You can tell her that:
A) Symptoms remit in 70% o women during pregnancy.
B) She should avoid pregnancy while taking methotrexate.
C) RA is a contraindication to pregnancy.
D) Prednisone cannot be taken during pregnancy.
E) A and B.
Answer 11.1.8 The correct answer is “E,” both “A” and “B” are
correct. RA is an autoimmune disease, and it tends to remit
during pregnancy when a woman is relatively immunosup-
pressed. Methotrexate is class X or pregnancy and is actually
used in ectopic pregnancy to arrest etal growth. Women taking
methotrexate should use an e ective orm o contraception, and
continue contraception or 3 months a er stopping methotrex-
ate. “D” is incorrect since prednisone is o en used to control RA
during pregnancy, when methotrexate is contraindicated. Pred-
nisone does not cross the placenta, but use during pregnancy is
associated with higher risk or gestational diabetes.
T e patient is an avid runner and, prior to her diagnosis, par-
ticipated in numerous outdoor activities. She is concerned
about whether she will eventually become disabled.
Question 11.1.9 You can let her know that:
A) RA tends to progress without any remissions to involve
almost all joints in all patients.
B) Prednisone- ree disease remission has become the goal o
treatment.
C) Patients with RA have the same li e expectancy as the gen-
eral public.
D) Renal involvement is common with RA and is a major
source o morbidity and mortality.
E) She won’t need to worry about having a li e a er she gets
pregnant and has a child. All her energy will be absorbed by
that little parasite . . . er, child.
Answer 11.1.9 The correct answer is “B.” With the advent
o new potent disease-modi ying agents, it is now possible to

achieve remission, that is, the absence or near absence o joint
pain and swelling, in patients who have RA. “A” is incorrect.
Untreated RA may progress to involve urther joints, but not
all joints are a ected by RA. Classically, the distal interphalan-
geal joints are spared and, i there is DIP involvement, should
prompt reassessment o the diagnosis. Moreover, treatment
with DMARDs can, and requently does, induce remission. “C”
is incorrect. RA reduces the li e expectancy by up to 10 years.
“D” is incorrect. Renal disease is a rare complication o RA;
however, it can be a result o some o the medications used to
treat RA. Finally, “E”. I she needs a li e, she can buy them in
bulk or cheap at Costco (Walmart also has them or cheap but
they wear out too ast).
QUICK QUIZ: BIOLOg ICAL Ag ENTS
Which o the ollowing must be tested or be ore beginning a
biological agent to treat rheumatoid arthritis?
A) CMV
B) B
C) Heart ailure
D) Mucosal candidiasis
E) B and C
The correct answer is “E”. T ere are a number o biologicals
or treating rheumatoid arthritis that are NF inhibitors. Etan-
ercept (Enbrel) is a soluble NF receptor antagonist. In iximab
(Remicade) and adalimumab (Humira) are monoclonal anti-
bodies that bind NF both at the cell and when it is in its soluble
orm. T ese drugs can also reduce the resistance to in ection
and promote malignancies. All o the NF inhibitors essentially
have the same ef cacy. Any one o these agents can be added
to M X. T ings to watch or with NF inhibitors include seri-
ous in ections including B, ungal in ections, and malignan-
cies. Rule out B and hepatitis B be ore starting NF inhibitors.
T ere is also a concern or worsening congestive heart ailure in
those with pre-existing disease. T us, “E” is the correct answer.
Mucocutaneous candidiasis is not a contraindication to FN
inhibitors and routine testing or CMV is not recommended.
HELPFUL TIP:
Does joint replacement work in RA? Yes. Remember,
however, that the maxim m li e span o an arti icial
joint is abo t 15 years with c rrent technolo y. Th s, re-
placement sho ld not be ndertaken li htly in a yo n
(or any) patient.
Objectives: Did you learn to . . .
• Describe an appropriate dia nostic strate y or polyarthritis?
• Reco nize the dia nostic criteria or RA?
• Develop a mana ement strate y or RA?
• Reco nize the importance o early DMARD therapy or RA?
• Identi y the ses and adverse e ects o medications sed to
treat RA?
CHAPTER 11 • RHEu MATOLOg Y 307
QUICK QUIZ: AN ILL CHILD
A concerned mother brings in her 2-year-old son with a 1-week
history o ever. She is worried because she had expected the
ever to resolve by now. According to his mother, the patient
also has a rash, poor appetite, and lethargy. On examination,
he looks ill and his temperature is 39.0°C. T ere is a di use,
erythematous, macular rash, and peeling skin on the nger-
tips. T e oropharynx is injected and the tongue is bright red
with white papillae. Cervical lymph nodes are enlarged and
tender.
Based on the available in ormation, what is your leading diag-
nosis?
A) Rheumatic ever.
B) Parvovirus B19 in ection.
C) Kawasaki syndrome.
D) JIA.
E) Varicella in ection.
The correct answer is “C.” Kawasaki syndrome is an acute vas-
culitis o unknown etiology, which is most o en seen in chil-
dren. Kawasaki syndrome presents with at least 5 days o ever
(you cannot make the diagnosis o Kawasaki disease without
at least 5 days o ever), polymorphous rash, conjunctival in-
jection, mucous membrane involvement (e.g., “strawberry”
tongue), cervical lymphadenopathy, and extremity ndings o
erythema and desquamation. T e usual treatment is aspirin and
IVIG. Corticosteroid therapy is controversial and does not seem
to improve outcomes. T ere may be cardiac involvement with
the ormation o coronary artery aneurysms.
“A,” rheumatic ever, which is rare in developed countries, is
recognized by the Jones criteria. T e major Jones criteria con-
sist o polyarthritis, carditis, Sydenham chorea, erythema mar-
ginatum, and subcutaneous nodules. (Here’s a un mnemonic:
“JONES” with a heart shape in place o the “O,” so that J = joints,
O = carditis, N = nodules, E = erythema marginatum, and S =
Sydenham chorea). “B” is incorrect. Generally, children do not
appear this ill with parvovirus B19 in ection ( h disease). “D,”
JIA, would be unusual at such a young age, and is discussed in
Chapter 13. “E” is incorrect, as this is obviously not varicella.
CASE 11.2
A 62-year-old male whom you have ollowed or hyperten-
sion or several years presents with complaints o worsening
atigue and aching in his back, shoulders, and neck. He notes
3 months o symptoms unresponsive to acetaminophen.
Further history reveals that your patient has experienced
sti ness o the neck and shoulders each morning or over
30 minutes. He occasionally has dif culty getting out o bed
due to pain. Vital signs are within normal limits. T ere is no
evidence o synovitis o the hands, wrists, or elbows. Active
range o motion in the neck and shoulders is slow but ull.
T ere is tenderness to palpation o the shoulders, upper back,
and neck, but no apparent muscle atrophy.
308 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
TABLE 11-2 GENERALLY ACCEPTED CRITERIA
FOR DIAGNOSIS OF PMR
• A e ≥ 50 years
• Pain/achin or at least 1 month involvin 2 o the ollowin areas:
neck, sho lders/proximal arms, and pelvic irdle
• Hip pain or limited ran e o motion
• Mornin sti ness lon er than 45 min tes
• Elevated ac te phase reactant (ESR/CRP)
• Excl sion o other potential ca ses o the symptoms incl din iant
cell arteritis, RA (i.e., ne ative RF or ACPA)
Adapted rom Das pta B, et al. 2012 provisional classi cation criteria or
polymyal ia rhe matica. Arthritis Rheum. 2012;64(4):943–954.
Question 11.2.1 Which o the ollowing is the most appro
priate next step in the diagnosis o this illness?
A) Obtain an ESR and CRP.
B) Obtain a urinalysis.
C) Prescribe a diagnostic trial o corticosteroids.
D) Order a rheumatology panel, including ANA, uric acid, ESR,
CRP, and RF.
E) Per orm shoulder radiograph.
Answer 11.2.1 The correct answer is “A.” T is patient’s pre-
sentation is consistent with the diagnosis o polymyalgia
rheumatica (PMR). Elevations o ESR and/or CRP contribute
urther evidence to such a diagnosis and are use ul in ollowing
the treatment o PMR. While a urinalysis (“B”) may be impor-
tant in some rheumatologic illnesses (e.g., lupus, Behçet syn-
drome), PMR is not likely to be associated with renal disease.
A trial o corticosteroid therapy (“C”), may be appropriate,
but an ESR should be obtained rst to more conclusively estab-
lish the diagnosis. At this point all we know is that he has bilat-
eral shoulder and neck pain, which could be mechanical rom
the cervical spine, etc. As you already know rom earlier dis-
cussion, “D” is incorrect; a “rheumatology panel” will typically
include tests that are not indicated, and positive results can be
misleading. In the absence o small joint symptoms or examina-
tion ndings, an RF is not indicated in this case. Likewise there is
no history to suggest an ANA-related disorder. “E” is incorrect.
T is patient does not need shoulder radiographs. In a patient
with bilateral shoulder pain and neck pain, a neck radiograph
may be more use ul than shoulder imaging. Neck radiographs
help to evaluate or cervical canal narrowing and degenerative
disc disease, which may result in pain and neurologic ndings
in the upper extremities. An MRI o the neck might be use ul i
cervical spine disc disease or a syrinx were suspected. Diagnos-
tic criteria or PMR are given in able 11-2. Small joint syno-
vitis, or pu y swelling o hands and eet, will occur in 20% o
patients with PMR; and in these cases it is appropriate to check
RF and anti-CCP during your initial evaluation.
HELPFUL TIP:
Physical examination indin s o PMR are s btle. Active
ROM in the a ected areas is o ten limited by pain, b t
passive ROM sho ld be ll. Stren th is intact. In eneral,
PMR a ects sho lders to a reater de ree than hips,
and the hips more than the neck. The essential pathol-
o y is in lammation o the synovia, and m scles are not
directly involved.
HELPFUL TIP:
Patients with PMR o ten have a low- rade ever and a
normocytic anemia.
Question 11.2.2 The sensitivity o an elevated ESR in the
diagnosis o PMR and giant cell arteritis (GCA, AKA, tempo
ral arteritis) is:
A) 100%.
B) 85%.
D) 50%.
E) 25%.
Answer 11.2.2 The correct answer is “B.” Up to 15% o patients
with PMR or GCA (a closely related disorder—keep reading)
have a alse-negative ESR. Using ESR and CRP together is 97%
to 99% sensitive or GCA. Double alse negatives o ESR and
CRP are uncommon, but do occur. T us, in the patient in whom
GCA is suspected but in whom there is a normal ESR and/or
CRP, biopsy is still recommended. In those suspected o PMR, a
trial o corticosteroids is still recommended.
HELPFUL TIP:
PMR is ncommon in non-white pop lations. The mean
a e o onset is approximately 70 years. Women are
a ected twice as o ten as men.
You order radiographs o the neck, which demonstrate mild
degenerative disease. A CBC is unremarkable, except or a
mild thrombocytosis. T e ESR is 80 mm/hr. You relate these
ndings to the patient and tell him that your presumptive
diagnosis is PMR.
Question 11.2.3 Which o the ollowing is the most appro
priate initial treatment in this case?
A) Naproxen 500 mg twice daily.
B) Prednisone 15 mg daily.
C) Aspirin 650 mg twice daily.
D) Prednisone 50 mg daily.
E) Re erral to physical therapy.
Answer 11.2.3 The correct answer is “B.” Prednisone is the
treatment o choice in PMR. Doses o prednisone ranging rom
10 to 20 mg daily are usually suf cient to control the disease.
Higher doses (up to 30 mg/day) should be tried i there is no
response in 1 to 2 weeks. I the patient ails to respond to 30 mg
or less o prednisone, the diagnosis o PMR should be recon-
sidered. “A” is incorrect. NSAIDs may provide some symptom-
atic relie but are not the treatment or PMR. “C” is incorrect.
It remains controversial whether low dose aspirin, 81 mg/day

may decrease the risk o vision loss in giant cell arteritis.
However, high-dose aspirin therapy without corticosteroids
is not recommended. “E” is incorrect. Since patients usually
respond quickly to corticosteroids, physical therapy is not nec-
essary—although you could hardly be aulted or employing
physical therapy as part o your overall treatment approach.
HELPFUL TIP:
Lookin at the lon -term o tcomes, initial low-dose
therapy or PMR works better than hi h-dose therapy.
Patients have ewer relapses and are spared some o the
adverse e ects o hi h-dose corticosteroids.
You prescribe prednisone 15 mg daily, aspirin 81 mg daily,
and calcium and vitamin D supplementation. Your patient
presents or ollow-up 4 weeks later, reporting marked
improvement. On examination, there is no joint in amma-
tion, or muscle tenderness with range o motion exercises.
His ESR is 20 mm/hr. You believe that the patient’s disease is
now in remission.
Question 11.2.4 Which o the ollowing is the most appro
priate next step in his management?
A) Discontinue prednisone and initiate naproxen.
B) Continue the current dose o prednisone or the next
12 months.
C) Continue the current dose o prednisone or the next
6 months.
D) aper prednisone by 1 to 2 mg every 2 weeks to reach the
minimum e ective dose.
E) aper prednisone by 5 mg over 2 weeks and then discon-
tinue the drug.
Answer 11.2.4 The correct answer is “D.” Relapse o PMR
occurs more requently when corticosteroids are abruptly dis-
continued or tapered too quickly. However, due to complica-
tions associated with corticosteroid therapy, the dose should be
reduced as soon as possible; there ore, maintaining prednisone
15 mg daily or 6 to 12 months is inappropriate. T e usual rec-
ommendation is to reduce the dose o prednisone by 10% every
1 to 2 weeks until the minimum e ective dose is reached. While
tapering prednisone, the patient should be monitored with
an ESR and/or CRP every 2 to 4 weeks. I symptoms worsen,
prednisone should be increased slightly to achieve symptomatic
control. I the ESR increases to 40 mm/hr or greater and the
patient is asymptomatic, consider continuing the same dose o
prednisone until the ESR normalizes, then continue the taper.
However, an isolated elevation in ESR without symptoms is not a
reason to increase prednisone.
Question 11.2.5 Which o the ollowing is true regarding
the prognosis o PMR?
A) PMR is associated with an increased risk o mortality.
B) Most patients with PMR will require corticosteroid therapy
or li e.
CHAPTER 11 • RHEu MATOLOg Y 309
C) Up to 50% o patients who initially have a success ul remis-
sion will experience a relapse while tapering prednisone.
D) A relapse o PMR requires high-dose corticosteroids (pred-
nisone 50 mg daily) or success ul treatment.
Answer 11.2.5 The correct answer is “C.” Relapses occur in
30% to 50% o patients a er induction o remission and should
be treated by resuming or increasing prednisone. Usually, suc-
cess ul treatment o a relapse requires increasing the predni-
sone dose by a ew milligrams. “A” is incorrect. Although the
pathogenesis o PMR is incompletely understood, it has ea-
tures in common with vasculitides, including potential vascular
complications o GCA. However, PMR is not associated with
an increase in mortality. “B” is incorrect because PMR is a sel -
limited disease, and most patients recover within a ew months
to a ew years. T us, patients require prednisone or 6 months to
2 years, but prednisone therapy is typically not li elong. Remote
relapses o PMR a er prednisone has been success ully stopped
are seen in about 20% o cases, and can occur up to years later.
Your patient does well and is able to taper o prednisone
over a year. welve months a er stopping corticosteroids,
he presents to the ED one night. His shoulder and neck pain
and sti ness have returned, as well as severe atigue and
subjective evers. He has lost 5 pounds over 2 weeks. He is
now experiencing requent le -sided headaches. Finally, he
is most concerned about a new visual disturbance starting
today. He notes that he has a “hole” in his vision. On physical
examination, there is a prominent, tender vessel palpable at
the le temporal area. Funduscopic examination o the le
eye shows a pale disc with blurred margins. T e remainder o
the neurologic examination is normal. T e ESR is 70 mm/hr.
Question 11.2.6 Which o the ollowing is the most likely
diagnosis or the visual symptoms?
A) Polymyalgia Rheumatica (PMR).
B) Stroke (CVA).
C) Giant cell arteritis (GCA).
D) Multiple sclerosis (MS).
E) Acute angle-closure glaucoma.
Answer 11.2.6 The correct answer is “C.” Many o the patient’s
symptoms can be explained by PMR (“A”), but visual symptoms
do not occur with this disease. GCA is a related diagnosis that
is commonly seen in conjunction with PMR. Most experts now
agree that PMR and GCA are di erent presentations o the same
disease process. With the new symptoms o localized headache
and tenderness o the temporal artery and the previously known
ndings consistent with PMR, this patient now meets diag-
nostic criteria or GCA (see able 11-3). T e visual symptoms
described are typical o GCA and can occur acutely or chroni-
cally. As to the other answers, vision loss in multiple sclerosis is
attributable to optic neuritis, which is associated with pain and
presents initially in a younger population. Acute angle-closure
glaucoma is associated with eye pain and redness. T e lack o
other symptoms makes stroke less likely.
310 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
TABLE 11-3 DIAGNOSTIC CRITERIA FOR GIANT
CELL ARTERITIS
Consider dia nosis i ANYo the ollowin are present:
• A e ≥ 50 years at onset o symptoms
• New localized headache, jaw cla dication, vis al symptoms
• Temporal artery tenderness or decreased p lsation
• ESR ≥ 50 mm/hr
• Temporal artery biopsy ndin s consistent with vasc litis
HELPFUL TIP:
The initial vis al loss in g CA is peripheral, while the vi-
sion loss in mac lar de eneration is initially central.
I yo think abo t it, this makes sense. g CA basically
ca ses an anterior ischemic optic ne ropathy (AION)
secondary to involvement o the retinal artery by vas-
c litis. The rther yo are rom the artery, the poorer
the per sion.
Question 11.2.7 Which o the ollowing is the most appro
priate initial management o this patient?
A) Withhold treatment or now and arrange or temporal artery
biopsy within 48 hours.
B) Re er to a neurologist as soon as possible.
C) Re er to an ophthalmologist as soon as possible.
D) Initiate prednisone 20 mg daily, and re er or temporal artery
biopsy.
E) Admit and administer methylprednisolone 1 g intravenously
(IV), and arrange or temporal artery biopsy.
Answer 11.2.7 The correct answer is “E.” When symptoms o
vision loss occur, IV methylprednisolone 15 mg/kg/day (up to 1 g)
daily or 3 days, ollowed by prednisone 40 to 60 mg daily is
the standard o care. Compared to PMR, higher doses o corti-
costeroids are necessary to treat GCA. In the absence o vision
loss, prednisone doses o 40 to 60 mg QD are usually required
to relieve symptoms. Consultation with ophthalmology is also
necessary in providing proper care to the patient. “A” is incor-
rect. You do not want to withhold treatment rom this patient
whose vision is at risk (see “help ul tip” below). “B” and “C” are
incorrect or the same reason. “D” is incorrect because a dose o
20 mg o prednisone is too low to be e ective in GCA.
HELPFUL TIP:
Temporal artery biopsy is vital to the acc rate dia nosis
o g CA. Characteristic iant cell in lammation pathol-
o y can be seen or p to 4 weeks a ter initiatin hi h-
dose corticosteroids. However, corticosteroid therapy
should never be delayed for fear of reducing the in-
flammatory findings on the temporal artery biopsy.
Six years a er his diagnosis o GCA, your patient has experi-
enced several remissions and relapses. Although he has been
able to discontinue prednisone on occasion, he is now taking
5 mg daily with good symptomatic control.
One dark and stormy night, 3 AM in the ED—the weather
is cold and the co ee is colder—your patient presents with
tearing substernal chest pain radiating to his back. He is alert
but anxious and diaphoretic. His le radial pulse is dimin-
ished compared to the right. His heart rate is 120 bpm, and
his blood pressure is 92/56 mm Hg.
Question 11.2.8 Which o the ollowing studies will con rm
the most likely diagnosis?
A) Chest radiograph.
B) Chest C .
C) ECG.
D) Venous blood gas.
E) roponin- .
Answer 11.2.8 The correct answer is “B.” Your patient’s symp-
toms are classic or a dissecting thoracic aortic aneurysm, which
is o en mistaken or a myocardial in arction. T oracic aortic
aneurysm is a late complication o GCA; aortic aneurysms gen-
erally occur an average o 6 to 7 years a er the initial diagnosis
o GCA. T oracic aortic aneurysms occur 17 times more o en
in patients with GCA when compared to the general popula-
tion. T e diagnosis o thoracic aortic aneurysm is con rmed by
C scan o the chest, echocardiogram, or angiogram. While the
other studies listed should be done, none o them are going to
make the diagnosis o a dissecting aneurysm or you.
HELPFUL TIP:
With the initiation o corticosteroids in PMR or g CA,
start calci m 1,200 to 1,500 m daily and vitamin D 400
to 800 Iu daily or osteoporosis prevention. Once the
dia nosis is con irmed, bone mineral density sho ld be
meas red with a DEXA scan and bisphosphonates insti-
t ted on the basis o FRAX calc lated risk o ract re or
DEXA res lts (do yo see a pattern here o prophylaxis
or osteoporosis when startin corticosteroids?).
Objectives: Did you learn to . . .
• Describe the appropriate eval ation, incl din physical
examination and laboratory tests, o di se pain in the older
patient?
• Reco nize the dia nostic criteria or PMR and g CA?
• Describe the appropriate mana ement, incl din medical
therapy, o PMR and g CA?
• Identi y complications o PMR and g CA?
CASE 11.3
A 22-year-old graduate student presents to the ED on a Mon-
day night with an acutely swollen le knee. He admits to “wild
partying” over the weekend but only had “a couple o beers”
(that is the “college couple” . . . . 6 or 7). His knee was OK then.
However, when he woke up this morning, he noticed the knee
was swollen and pain ul (so was his head, but that’s another
matter). By early a ernoon, he had dif culty bearing weight.
He denies ever, but eels tired.

He reports a history o JIA (juvenile idiopathic arthritis,
previously termed juvenile rheumatoid arthritis), and has had
ankle and knee swelling previously, but not to this degree. He
took prednisone intermittently, as well as hydroxychloroquine
and methotrexate, or his JIA until age 18. He then continued
on hydroxychloroquine until 8 months ago, when he stopped
it because he elt ne. He denies any other medical problems.
He smokes only when drinking—which happens way too o en.
Question 11.3.1 What other in ormation rom the history
would be most help ul in establishing the diagnosis?
A) Sexual history, including sexual orientation, practices, and
last contact.
B) Personal or amily history o gout or kidney stones.
C) History o IV drug use.
D) Family history o pseudogout.
E) A, B, and C.
Answer 11.3.1 The correct answer is “E.” While all o these
points are important in the history, this patient is too young to
have pseudogout. While gout is unusual in young adults, there
are uncommon syndromes o amilial hyperuricemia and early
gout. Although there are several possible etiologies or this
patient’s presentation, septic arthritis should be considered rst
and oremost due to its high morbidity and mortality. As such,
the history and examination should ocus on those clues that
point toward an in ectious etiology and its source. T e clinician
must also consider nonin ectious in ammatory arthropathies.
IV drug abuse can lead to a septic joint as can gonorrhea. T us
“A” and “B” are important parts o the history.
Your patient is heterosexual and thinks he had intercourse
Saturday night but admits that his memory is somewhat
blurry (maybe he had more than the “couple” o beers he
claims). He denies a history o gout and IV drug use. He
complains o poor sleep and eeling sti in the mornings and
evenings lately.
Question 11.3.2 What ndings on physical examination
would be LEAST help ul in determining the diagnosis?
A) A ew vesiculopustular lesions on the back, arms, and legs.
B) Swollen, tender, nonerythematous MCP joints.
C) Nontender hepatomegaly.
D) Diastolic murmur at the right sternal border.
E) Whitish discharge rom the tip o penis.
Answer 11.3.2 The correct answer is “C.” Although non-
tender hepatomegaly may indicate presence o liver disease, it
is unlikely to help identi y the etiology o this patient’s arthri-
tis. Hepatitis B arthritis usually presents as a symmetric poly-
arthritis, although it can be migratory or additive (sequential
joints becoming involved without resolution in the initial
joints). Our patient has a single swollen, hot joint, which is
unlikely to occur as a result o hepatitis. “A” is help ul: a vesicu-
lopustular rash occurs in disseminated gonococcal in ections.
“B” is also help ul: the presence o other swollen joints should
prompt consideration o nonin ectious in ammatory arthritis,
CHAPTER 11 • RHEu MATOLOg Y 311
and the swelling o the MCPs in particular may be a clue or
active RA. T e detection o a diastolic murmur (“D”) is very
signi cant, since diastolic murmurs are almost always patho-
logic in adults, and may represent in ective endocarditis.
Finally, “E,” penile discharge, can result rom acute gonorrheal
in ections.
On examination, vital signs are signi cant only or tachycar-
dia and ever (HR: 112 bpm, emp: 38.2°C). He has no other
swollen joints, rashes, heart murmurs, or penile discharge.
You palpate a smooth, non-tender liver edge 2 cm below the
costal margin; it percusses to 15 cm. You note mild cervical
lymphadenopathy and whitish pharyngeal exudates.
Question 11.3.3 Which o the ollowing is the most appro
priate next step in the management o this patient?
A) Order hepatitis serologies.
B) Order blood cultures, urine PCR or chlamydia and gonor-
rhea, and abdominal ultrasound.
C) Administer ce riaxone 1 g IV and inject the knee with
triamcinolone.
D) Per orm knee aspiration.
E) Prescribe prednisone 20 mg PO QD and arrange consulta-
tion with a rheumatologist.
Answer 11.3.3 The correct answer is “D.” Did you get dis-
tracted by a big liver? I so, redirect your attention to the knee.
T e single most important step in evaluating acute monoarthri-
tis is joint aspiration, which will allow di erentiation between
in ammatory and nonin ammatory disease. Although blood
cultures and urine PCR or chlamydia and gonorrhea should
also be sent in this case, obtaining these studies must not delay
joint aspiration. Without determining whether the arthritis is
in ectious, it would be inappropriate—and potentially hazard-
ous to the patient—to start treatment with corticosteroids. Joint
aspiration will provide a specimen or crystal examination.
“C” and “E” are incorrect because you would not want to give
corticosteroids—especially intra-articular corticosteroids—to
a patient with an in ected joint. Analysis o the synovial uid
will aid in determining the appropriateness o treating with
antibiotics or anti-in ammatory medications. While you would
probably use empiric antibiotics (treat as septic until proven
otherwise), you will need to rst obtain cultures ( rom the knee
aspiration and blood).
HELPFUL TIP:
CBC, ESR, and CRP are not se l in dia nosin a sep-
tic joint. While they may be somewhat sensitive, they
are hopelessly non-speci ic. Yo have to tap the joint
re ardless!
You have obtained blood cultures and urine PCR or chla-
mydia and gonorrhea. A metabolic pro le, CBC, and hepa-
titis B and C serologies are pending. Knee aspiration yields
45 cc o turbid, blood-tinged uid.
312 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Question 11.3.4 You send the synovial uid or all so the
ollowing studies EXCEPT:
A) Cell count and di erential.
B) Crystal analysis.
C) Culture.
D) Glucose and protein.
E) Gram stain.
Answer 11.3.4 The correct answer is “D.” In contrast to analy-
sis o some other bodily uids (e.g., cerebrospinal uid [CSF],
pleural uid, and ascitic uid), chemistry analysis on synovial
uid is o little diagnostic value. Low glucose levels in synovial
uid are associated with the degree o in ammation but do not
help to determine its cause. Likewise, synovial protein levels do
not help di erentiate between types o arthritis. Cell count with
di erential, gram stain, and cultures should be routine when
suspecting in ection; crystal analysis is also part o the stan-
dard examination, but positive crystal analysis does not rule out
concomitant in ection.
T e synovial uid analysis reveals the ollowing ndings:
50,000 WBC/mm3, 95% polymorphonuclear cells, and no
crystals. Gram stain shows Gram-negative diplococci. Cul-
tures are pending. Gonorrhea and chlamydia PCR tests are
also pending.
Question 11.3.5 What is the sensitivity o a synovial uid
white count o 100,000/mm 3?
A) 30%
B) 40%
C) 50%
D) 60%
E) 75%
Answer 11.3.5 The correct answer is “A.” Un ortunately a
synovial white count o 100,000/mm 3 is only 30% sensitive or a
septic joint but is 99% speci c. 50,000 WBC/mm 3 is 62% sensi-
tive and 92% speci c while a WBC count o 25,000/mm 3 is 75%
sensitive and 73% speci c. T e point is that what we were taught
in school about the synovial WBC count being > 100,000/mm 3
in a septic joint is wrong.
Question 11.3.6 Which o the ollowing studies will be most
important to the OVERALL care o this patient?
A) HIV testing and RPR.
B) Chest x-ray.
C) ANA and RF.
D) Uric acid.
E) ESR and CRP.
Answer 11.3.6 The correct answer is “A.” His presentation is
very suggestive o disseminated gonococcal in ection with acute
arthritis, and the presence o diplococci is virtually diagnostic.
T ere ore, the clinician must also consider the presence o other
sexually transmitted diseases and screen the patient appropri-
ately. Assays or hepatitis B and C and chlamydia have been sent,
and tests or HIV and syphilis should now be per ormed. Also,
the patient must be counseled regarding sa e sexual practices
(e.g., condom use, reduced alcohol use, become a monk . . . .).
In this setting, the other studies are less relevant to his overall
health.
HELPFUL TIP:
g onococc s is c lt red rom the joint l id only abo t
50% o the time in patients with onococcal arthritis.
Th s, rine and joint l id PCR sho ld be done even i
the g ram stain is ne ative.
Question 11.3.7 Which o the ollowing is the most appro
priate treatment plan or this patient?
A) Ce riaxone 1 g IV once, ollowed by ce xime 400 mg twice
daily by mouth or 14 days. Follow-up in 7 days.
B) Admit to hospital, administer ce riaxone 1 g IV daily, and
per orm repeat knee aspirations.
C) Admit to the hospital and administer IV and intra-articular
ce riaxone 1 g daily.
D) Cipro oxacin 500 mg by mouth twice daily or 14 days.
Follow-up in 7 days.
E) Penicillin G 4 million units IV once, ollowed by amoxicillin
500 mg PO three times daily or 14 days. Follow-up with a
rheumatologist.
Answer 11.3.7 The correct answer is “B.” In order to ensure
the best outcome, this patient should be admitted or monitor-
ing and repeated joint aspiration. Purulent uid tends to col-
lect rapidly in the joint spaces in patients with septic arthri-
tis, necessitating requent drainage until antibiotics work and
in ammation begins to subside. Most cases o gonococcal
arthritis respond to needle aspiration, but arthroscopic or open
debridement is occasionally necessary. Because IV antibiotics
have good penetration into synovial uid, intra-articular antibi-
otics are not recommended. When culture, PCR, and sensitivity
results become available, antibiotic therapy should be tailored to
the particular in ectious agent and its susceptibilities.
HELPFUL TIP:
The initial antibiotic o choice in onococcal arthritis
is ce triaxone, administered IV. Spectinomycin IV is an
acceptable alternative when ce triaxone is contraindi-
cated. Remember that there is now l oroq inolone-
resistant onococc s. Beca se o this, l oroq inolones
are no lon er recommended as treatment o onorrhea.
Within 48 hours, your patient shows signs o improvement.
His knee appears much better, there is no recurrent e usion,
and he is a ebrile. He wants to leave the hospital. By the way,
his chlamydia PCR turned up positive.
Question 11.3.8 Which o the ollowing management strate
gies do you recommend?
A) Continue the hospital admission and ce riaxone 1 g IV
daily.

B) Discharge with cipro oxacin 500 mg by mouth twice daily.
C) Discharge with penicillin V 500 mg by mouth three times
daily.
D) Discharge with ce xime 400 mg by mouth twice daily, and
doxycycline 100 mg by mouth twice daily.
Answer 11.3.8 The correct answer is “D.” Since the patient is
improving, continued hospitalization and IV antibiotics are not
needed. T us, “A” is incorrect. Without knowing the antibiotic
sensitivities o the gonococcus, you should assume that it is
penicillin-resistant, making “C” a poor choice. Once local and
systemic signs are resolving, you can sa ely discharge the patient
with oral antibiotic therapy, using ce xime 400 mg twice daily
(or an acceptable alternative based on culture and susceptibili-
ties) to complete a 7 to 14 day course. In cases o gonococcal
in ection, you should always presumptively treat or concurrent
chlamydia in ection.
HELPFUL TIP:
Septic arthritis occ rs most o ten in lar e joints, s ch
as the knee and hip. Factors that predispose a patient
to septic arthritis incl de advancin a e (especially
> 80 years), RA, joint prostheses, recent joint s r ery,
diabetes, and skin in ection.
Question 11.3.9 What is the mortality rate o septic arthritis?
A) 0.5%
B) 5%
C) 10%
D) > 15%
Answer 11.3.9 The correct answer is “C.” T e mortality rate o
septic arthritis is 10%, with up to one-third o survivors having
persistent joint problems, such as limited range o motion, pain,
and swelling. Note that the mortality is probably not due to the
in ection alone but rather to a combination o the underlying
illness (e.g., immunosuppression) plus the in ection.
Objectives: Did you learn to . . .
• Describe the appropriate eval ation o monoarthritis?
• Appropriately mana e a patient with septic arthritis?
• Identi y risk actors or septic arthritis?
• Reco nize the pro nosis o septic arthritis?
CASE 11.4
A 55-year-old male presents to your of ce complaining o
severe le knee pain o 2 days duration. Although he was also
out partying over the weekend (is there a pattern here to the
patients in our practice?), he went home early. He denies any
previous history o knee pain or arthritis. He has elt everish
over the last 2 days. He recalls a similar episode o pain in his
right great toe 2 years be ore, but the pain resolved in a ew
days and he did not seek medical attention. He has hyperten-
sion treated with chlorthalidone but is otherwise healthy. He
CHAPTER 11 • RHEu MATOLOg Y 313
drinks about a case o beer per week—unless he’s been party-
ing, in which case he doubles his e ort. His amily history is
remarkable or osteoarthritis.
Physical examination reveals an uncom ortable-appearing
obese male in no acute distress. His temperature is 37.9°C,
blood pressure 168/98 mm Hg, and pulse 84 bpm. T e le
knee is red, warm, and di usely tender with a palpable e u-
sion. T ere are no visible or palpable subcutaneous nodules
on the ngers, toes, or at the elbows.
Question 11.4.1 Which o the ollowing is the most appro
priate next step to accurately diagnose this condition?
A) Radiograph o the a ected knee.
B) CBC.
C) Serum uric acid level.
D) Knee aspiration and synovial uid analysis.
E) Diagnostic corticosteroid injection.
Answer 11.4.1 The correct answer is “D.” We don’t mean to
sound like a broken record, but the diagnostic study o choice in
a monoarthritis is synovial uid analysis. Synovial uid analysis
allows the clinician to determine whether there is an in amma-
tory, in ectious, or crystalline cause o the arthritis. “A” is incor-
rect. Radiographs are typically not help ul acutely in in am-
matory arthritis (but would be indicated i there was trauma or
suspicion o tumor). “B” and “C,” a CBC is nonspeci c and uric
acid may be normal during an acute attack o gout. Neither o
these laboratory results will be diagnostic. Finally, corticoste-
roid injection must be avoided in monoarthritis until the pos-
sibility o in ection is eliminated.
You success ully aspirate 5 cc o slightly cloudy yellow syno-
vial uid rom the le knee. While the patient is waiting, the
laboratory reports the ollowing ndings: 5,000 WBC/mm3,
Gram stain negative or bacteria, many needle-shaped nega-
tively bire ringent crystals are noted.
Question 11.4.2 These synovial uid ndings are most
consistent with which o the ollowing diagnoses?
A) Osteoarthritis.
B) Septic arthritis.
C) CPPD (“pseudogout”).
D) Gout.
Answer 11.4.2 The correct answer is “D.” Monosodium urate
crystals o gout are needle-shaped as seen in this patient’s syno-
vial uid (a good way to remember this is that being stuck with
a needle hurts and so does gout). Calcium pyrophosphate dihy-
drate crystals are rod-, square-, or rhomboid-shaped and posi-
tively bire ringent in polarized light. T us, the synovial uid
ndings given above are most consistent with gout. “A” and “B”
are incorrect. Normally, synovial uid contains < 180 WBC/
mm 3, but it is generally considered nonin ammatory i the
WBC count is still < 2,000/mm 3. Low WBC counts are seen in
the synovial uid o osteoarthritic joints. Synovial uid contain-
ing ≥ 2,000 WBC/mm 3 is consistent with an in ammatory pro-
cess. When there are > 100,000 WBC/mm 3, the monoarthritis is
314 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
TABLE 11-4 DIAGNOSTIC CRITERIA FOR ACUTE GOUT
The presence o characteristic rate crystals in the joint f id or toph s
proved to contain rate crystals by chemical means or polarized li ht
microscopy or the presence o 6 o the ollowin 12 phenomena:
1. More than 1 attack o ac te arthritis
2. Maximal inf ammation developed within 1 day
3. Attack o monoartic lar arthritis
4. Joint redness observed
5. First MTP joint pain l or swollen
6. u nilateral attack involvin rst MTP joint
7. u nilateral attack involvin tarsal joint
8. S spected toph s
9. Hyper ricemia
10. Asymmetric swellin within a joint (radio raph)
11. S bcortical cysts witho t erosion (radio raph)
12. Ne ative joint f id c lt re or microor anisms d rin attack o
joint inf ammation
Data rom Wallace SL, Robinson H, Masi AT, Decker JL, McCarty DJ, Y TF.
Preliminary criteria or the classi cation o the ac te arthritis o primary
o t. Arthritis Rheum. 1977;20(3):895–900.
considered septic until proven otherwise (although as noted
above this is only 30% sensitive or septic arthritis). See able 11-4
or the diagnostic criteria or gout. Note that up to 20% o
patients with a crystalline arthritis will have a coexisting septic
arthritis (J Rheumatol. 2012; 39:157).
HELPFUL TIP:
Ser m ric acid is o ten normal d rin an ac te attack
o o t (probably beca se it precipitates in the a ected
joints); th s, yo cannot rely on ser m ric acid levels
alone to dia nose o t or re te this dia nosis.
Question 11.4.3 In general, all o the ollowing are risk
actors or gout EXCEPT:
A) obacco use.
B) Alcohol use.
C) Obesity.
D) Diuretic use.
E) Family history.
Answer 11.4.3 The correct answer is “A.” Your patient exhibits
many o the risk actors or gout, which include male sex, obe-
sity, high-protein diet, use o diuretics (either loop or thiazide),
alcohol, and amily history. However, tobacco use is not associ-
ated with gout.
HELPFUL TIP:
Many patients with hyper ricemia do not develop o t
or nephrolithiasis; it is nclear whether asymptomatic
hyper ricemia sho ld be treated with ric acid-low-
erin a ents, and research is on oin to answer this
q estion.
Question 11.4.4 Which o the ollowing is the next step in
the management o this patient?
A) Prescribe allopurinol.
B) Prescribe acetaminophen.
C) Discontinue chlorthalidone.
D) Prescribe naproxen at a ull anti-in ammatory dose.
E) Per orm a therapeutic joint aspiration.
Answer 11.4.4 The correct answer is “D.” An acute attack o gout
should rst be treated with NSAIDs, such as naproxen or indo-
methacin. T e doses prescribed should be at the upper limit or
the particular NSAID (e.g., naproxen 500 mg three times daily).
Earlier treatment is associated with greater relie o symptoms
and shorter duration o the acute event. Other potential rst-line
agents are colchicine and corticosteroids. T e e ectiveness o col-
chicine is best i started within 36 hours o onset o symptoms.
Colchicine is typically prescribed as one dose o 1.2 mg, ollowed
by 0.6 mg twice daily or 1 to 2 weeks, and then 0.6 mg daily or
2 to 6 months. Note that this is a much lower dose than we have
prescribed in the past! Due to signi cant toxicity at high doses,
it is no longer recommended to “titrate to diarrhea.” Oral or
intra-articular corticosteroid administrations are also options or
patients who have contraindications to NSAIDs, who have ailed
NSAID therapy, or who have more severe attacks. Corticosteroids
are just as ef cacious as NSAIDs and may be more appropriate or
patients with heart ailure, ulcers, or kidney disease. Prednisone,
30 mg per day or ve days is a reasonable dose. Narcotic pain
medication may be needed as an adjunct to your anti-in amma-
tory, but will do nothing to shorten the duration o an attack.
“A” is incorrect. Allopurinol is indicated to treat hyperuricemia
and prevent the next gout attack in patients who have had more
than one attack in the last year (though some would treat those with
a particularly bad attack even i < 1/year.), when tophi are present,
or, when single gout attack occurs with chronic kidney disease
grade 2 or more. “B” is incorrect because acetaminophen lacks
the anti-in ammatory properties o NSAIDs and is less e ec-
tive. Discontinuing chlorthalidone, “C” (a thiazide diuretic), and
switching to a non-diuretic anti-hypertensive is probably appro-
priate, but will not treat this gout attack. Joint aspiration is not
therapeutic in gout, but may be help ul in pseudogout.
HELPFUL TIP:
Other dr s that increase the risk o o t incl de ACEs
and ARBs and beta-blockers. Calci m channel blockers do
not increase the risk o o t (BMJ. 2012 Jan 12;344:d8190).
You start an NSAID. He returns in a ew days to discuss his
labs and x-rays. A radiograph o the le knee demonstrates
an e usion but is otherwise unremarkable. His knee pain
is much improved, and knee e usion is nearly resolved. His
uric acid level is 10.1 mg/dL (the upper limit o normal or
your lab is 7.2 mg/dL). CBC, creatinine, sodium, and potas-
sium are normal. You instruct the patient to reduce his alco-
hol intake (especially beer) and try to lose weight to decrease
his risk o gout attacks and or overall health. You schedule a
ollow-up visit, but he is a no-show and you don’t see him

again or more than a year (was it something you said?).
When the patient returns 18 months later, he reports re-
quent use o naproxen, and at least ve more acute attacks
o gout. He continues to consume alcohol. His examination
reveals no swollen or tender joints today, but there is a small
whitish subcutaneous nodule overlying a toe PIP joint. Cre-
atinine is 1.1 mg/dL, serum uric acid 10.5 (normal < 7.2 mg/
dL); liver enzymes and CBC are normal.
Question 11.4.5 Which is the most appropriate regimen to
start now in this patient to reduce the requency o gout
attacks?
A) wice-daily colchicine.
B) Daily allopurinol 300 to 600 mg
C) Daily probenecid.
D) Daily allopurinol 100 mg, with once- or twice-daily colchicine.
E) Daily probenecid and allopurinol.
Answer 11.4.5 The correct answer is “D.” T e presence o a
tophus, and the history o more than one attack in the last year
are both indications or starting long-term urate-lowering
therapy. Colchicine administered once or twice daily has been
shown to reduce the requency o gout attacks 75% to 85%, and
is especially use ul as prophylaxis (prevention o the next gout
attack) during the rst 6 to 12 months o urate-lowering thera-
py. Starting allopurinol at a low dose o 100 mg daily and then
increasing the dose every ew weeks is less likely to provoke new
gout attacks than starting at a larger dose. “B” is incorrect be-
cause it is a higher dose o allopurinol, given without prophy-
laxis, and could induce new gout attacks (which will make this
patient think that your treatment is not very good, and that you
are not a very good doctor).
Probenecid is a uricosuric agent that also reduces the re-
quency and severity o acute gout attacks but has multiple drug
interactions (including allopurinol) and contraindications (e.g.,
decreased renal unction, kidney stones, or presence o tophi).
“C” is incorrect in this case because the patient now has topha-
ceous gout.
You prescribe allopurinol 100 mg daily and once daily colchi-
cine, and schedule the patient to return every 2 to 4 weeks to
re-check his uric acid level and make urther allopurinol dose
adjustments.
Question 11.4.6 The target or uric acid lowering in this
patient is:
A) Less than 7.2 mg/dL, because this is the upper-limit o nor-
mal or a man his age.
B) Less than 6.0 mg/dL
C) Less than 5.0 mg/dL
D) Less than 3.14159 mg/dL, because precision counts
E) As low as possible.
Answer 11.4.6 The correct answer is “C.” T is patient has a
tophus; in order to resolve tophi, and minimize the risk or ur-
ther attacks, allopurinol should be increased in 100 mg steps
until his uric acid level is consistently less than 5.0 mg/dL. Uric
CHAPTER 11 • RHEu MATOLOg Y 315
acid crystals start to orm at serum levels > 6.7 mg/dL, which
is within the 95% con dence range in the adult population, so
within the “normal”—but not necessarily “harmless”—range.
“A” is not correct, as levels higher than 6.7 mg/dL would con-
tinue to cause gout attacks and will not resolve tophaceous de-
posits. “B” is the correct target or patients without evidence o
tophi, but < 6.0 mg/dL is not suf cient in this patient. “D” is the
rst ew digits o the mathematical constant pi. We know you
didn’t all or “D.”
Uric acid is a normal product o purine metabolism. T ere
have been some studies that show it may have some role in neu-
roprotection as well as ghting in ection. oo much is bad, but
too little (“E”) could be a problem as well so we do not target
uric acid to zero.
HELPFUL TIP:
Feb xostat (u loric) is an alternative to allop rinol. How-
ever, it is rather expensive (10 × the cost o allop rinol)
and there is post-marketin data s estin that there
is a hi her incidence o cardiovasc lar events in those
on eb xostat when compared to allop rinol. Howev-
er, this is a very e ective rate-lowerin a ent that is
appropriate or patients with history o intolerance or
hypersensitivity to allop rinol. Feb xostat can be start-
ed at hal a 40 m tablet daily and increased to 40, 80, or
even 120 m to reach the tar et ric acid level.
HELPFUL TIP:
Altho h colchicine is recommended as prophylaxis
when allop rinol is initiated, it sho ld be discontin ed
within 6 months (i possible) d e to the potential side
e ects o g I irritation, diarrhea, and myopathy.
Question 11.4.7 All o the ollowing are side e ects o allo
purinol EXCEPT:
A) Aseptic meningitis.
B) Rash.
C) Leukopenia.
D) Fever.
E) GI disturbance.
Answer 11.4.7 The correct answer is “A.” Additional side e -
ects include elevated liver enzymes, glomerulonephritis, aplas-
tic anemia, and vasculitis. Hypersensitivity reactions are espe-
cially common in Chinese, Indians, and others rom Asia in
whom it is up to 15%. Consider checking or HLA-B*5801 in
these groups be ore starting allopurinol. Not a pretty drug, but
look on the bright side . . . it’s not associated with meningitis!
HELPFUL TIP:
Probenecid sho ld be avoided in patients with a cre-
atinine o clearance < 50 mL/min, as it is ine ective and
there may be an increased risk o toxicity.
316 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
It is 9 years later. Congress has passed a law banning the
Kardashians rom being on V. Your avorite gout patient
is back. He’s had 9 years o acute intermittent gout attacks
(“O course I took my medication, Doc, but it didn’t work so
I stopped taking it”). He presents complaining o pain in his
knees and eet that has been present or several months. He
has also developed swelling and pain in his hands. T e pain
is less intense than his attacks o gout, but occurs in the same
areas and never completely resolves between attacks. He has
no morning sti ness, no muscle complaints, and no other
systemic complaints. You nd di use edema o both hands
and palpable hard nodules on the knees, ngers, toes, and in
the olecranon bursa.
Question 11.4.8 Which o the ollowing is the most likely
cause o his current symptoms?
A) RA.
B) Osteoarthritis.
C) ophaceous gout.
D) PMR.
Answer 11.4.8 The correct answer is “C.” T is patient has
a long history o acute intermittent gout. A er years o acute
attacks, patients with gout may develop a orm o the disease
called chronic tophaceous gout (the nodules are deposits o uric
acid called tophi; tophus or a single nodule), in which the inter-
critical periods are no longer ree o pain. T ere are no clinical
associations between gout and the other rheumatic conditions
mentioned and, there ore, no reason to suspect that another
rheumatic disorder is causing the chronic pain.
HELPFUL TIP:
Hyperlipidemia occ rs in 80% o patients with o t—
check lipids. Recall also that there can be renal inj ry
with lon standin o t as well as an increased risk o
rate stones.
HELPFUL TIP:
In addition to bein a n word, poda ra is a se l di-
a nostic tool. The irst MTP joint is a ected in 90% o
patients with o t, and the initial attack involves the
irst MTP joint in 50%.
Objectives: Did you learn to . . .
• Eval ate rec rrent monoarthritis?
• Describe the dia nostic synovial f id ndin s in o t?
• De ne dia nostic criteria or o t?
• Mana e a patient with o t and describe adverse e ects o
the medications sed to treat o t?
• Identi y the appropriate tar et ric acid level or rate-
lowerin therapy?
CASE 11.5
Citing your characteristic compassion and attention to detail,
your “gout guy” (as he now calls himsel ) re ers a riend he
met at meeting o his avorite club, Gouty Retirees in Love
with Li e (GRILL). T is riend o his is a 65-year-old emale
who reports a history o joint swelling, pain, and redness,
usually involving her knees, wrists, and hands; she has never
had rst M P joint involvement. Although she has never had
a joint aspiration per ormed, she has been treated or gout
or 5 years. She aith ully takes her medication but has ound
allopurinol unhelp ul. She is currently asymptomatic, but
uses ibupro en or acute attacks. T e joint examination is
notable only or some knee crepitus and reduced wrist range
o motion—but, again, she is currently asymptomatic.
Question 11.5.1 Which o the ollowing studies is most
appropriate or this patient?
A) Diagnostic knee injection with corticosteroids.
B) CBC.
C) RF.
D) Radiographs o the knees and wrists.
Answer 11.5.1 The correct answer is “D.” T e initial evaluation
should include radiographs o the a ected joints, which may
lend clues to the diagnosis. Radiographs may reveal osteophyte
ormation typical o osteoarthritis, subchondral cysts, chondro-
calcinosis typical o CPPD (calcium pyrophosphate dehydrate
crystal deposition disease), or erosions with an overhanging
edge typical o gout. Chondrocalcinosis is most o en seen in
the knees and triangular brocartilage o the wrists. “A,” an
injection o corticosteroids, might help relieve symptoms, but it
will not be diagnostic. “B,” CBC, is nonspeci c and will not be
help ul. “C,” RF, is also unlikely to be help ul given this patient’s
symptoms, which are not suggestive o RA. Also, RF may be
elevated in in ammatory arthritides other than RA, and so will
not be help ul.
HELPFUL TIP:
The crystals o o t ( ric acid) and pse do o t (calci m
pyrophosphate) can be seen in synovial l id d rin in-
tercritical periods. I there is an e sion even in the ab-
sence o ac te symptoms and yo are thinkin o t or
pse do o t, tap that joint!
HELPFUL TIP:
The dia nosis o pse do o t (CPPD) is not as strai ht-
orward as o t. To con se the clinician all the more,
CPPD tends to travel with other types o arthritis (e. .,
osteoarthritis, o t). Patients with CPPD are more likely
older than 65 and have knee arthritis, b t clinical criteria
alone are ins icient or the dia nosis, which req ires
demonstration o crystals in the joint l id.

FIGURE 11-1. Chondrocalcinosis o the knee joint. (Note arrows hi hli htin
calci cation.)
Your patient’s knee radiographs demonstrate chondrocalci-
nosis (see Fig. 11-1). Examination o synovial uid rom the
knee shows positively bire ringent, rhomboid crystals consis-
tent with CPPD (pseudogout) (maybe this is why her gout
medicine wasn’t working).
Question 11.5.2 Which o the ollowing do you recommend
to decrease her risk o recurrent acute attacks o pseudog
out?
A) Serial joint aspiration.
B) Daily allopurinol.
C) wice-daily colchicine.
D) Serial intra-articular corticosteroid injections.
E) Chondroitin sul ate.
Answer 11.5.2 The correct answer is “C.” Pseudogout is diag-
nosed by the presence o CPPD crystals (described above) in
synovial uid and/or typical x-ray ndings (basically, chondro-
calcinosis). Although prophylaxis is more predictably success ul
in gout, colchicine 0.6 mg BID has been shown to reduce the
requency o pseudogout attacks in CPPD. NSAIDs or colchicine
may be used in acute attacks. “A” and “D” are incorrect. While
joint aspiration and corticosteroid injection may be help ul dur-
ing acute attacks, they have no role in prophylaxis. “B” is also
incorrect. Since CPPD is not caused by abnormalities in uric acid
metabolism, allopurinol has no role in the management o pseu-
dogout. Finally, chondroitin sul ate is not use ul in pseudogout.
HELPFUL TIP:
g o t is more likely to occ r d rin middle a e and is
more common in men. Pse do o t has a peak inci-
dence later in li e and is abo t eq ally prevalent in both
males and emales.
Question 11.5.3 CPPD (pseudogout) is associated with
which o the ollowing?
A) Hypothyroidism.
B) Hyperparathyroidism.
CHAPTER 11 • RHEu MATOLOg Y 317
C) Amyloidosis.
D) Hemochromatosis.
E) All o the above.
Answer 11.5.3 The correct answer is “E.” All o the above are
associated with pseudogout. Additional associated conditions
include hypophosphatemia and hypomagnesemia. For this rea-
son, order the ollowing studies in patients newly diagnosed
with CPPD: thyroid-stimulating hormone ( SH), calcium,
phosphate, magnesium, trans errin saturation, and alkaline
phosphatase.
HELPFUL TIP:
Precipitants o ac te attack o o t and pse do o t
(CPPD) incl de tra ma, s r ery, severe medical illness,
and alcohol overind l ence.
Objectives: Did you learn to . . .
• Identi y clinical and dia nostic characteristics o CPPD?
• Implement appropriate therapy or CPPD?
QUICK QUIZ: CRYOg LOBu LINEMIA
Cryoglobulinemia, a vasculitic disease caused by antibodies
that precipitate in cold temperatures, is most o en caused by
which o the ollowing viral in ections?
A) HIV.
B) Hepatitis B.
C) Hepatitis C.
D) Parvovirus B19.
The correct answer is “C.” Hepatitis C is ound in 80% o vas-
culitis cases associated with mixed cryoglobulinemia. Although
up to 50% o patients with hepatitis C will eventually express
cryoglobulins, only a minority o patients have clinical vascu-
litis. As to the other options, hepatitis B and parvovirus B19
in ection may cause a symmetric polyarthritis. HIV is less
commonly a cause o cryoglobulinemia and is associated with
reactive arthritis. T e symptoms o mixed cryoglobulinemia
associated with HCV in ection typically include arthralgias,
ever, renal disease, palpable purpura, and neuropathy.
CASE 11.6
A 13-year-old male presents to your of ce with his ather. T e
patient complains o pain in his wrists, elbows, and knees
bilaterally. He has elt atigued and has been unable to work
his usual summer job as a busboy at his ather’s restaurant.
He complains o intermittent evers and an evanescent rash
that appears during ebrile episodes but which is short lived.
All o these symptoms have emerged in the last 6 weeks, a er
a week-long backpacking trip in the tick-in ested woods o
Minnesota. He has no signi cant past medical history. His
only medication is acetaminophen daily or joint pain. He
denies tobacco use, alcohol use, and sexual activity.
318 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Question 11.6.1 The di erential diagnosis should include
all o the ollowing EXCEPT:
A) Lyme disease.
B) JIA.
C) PMR.
D) Viral illness.
Answer 11.6.1 The correct answer is “C,” o course. From earlier
in the chapter, you will recall that the diagnosis o PMR is highly
unusual in adults under the age o 50. JIA is a chronic arthritis o
childhood that can present in a variety o ways, but must include
arthritis o one or more joints, lasting 6 weeks or more, with symp-
tom onset be ore age 16 years. Likewise, Lyme disease has several
presentations, presenting with arthritis early or late in the course.
Many viral illnesses can result in arthralgia and/or arthritis. Any
o the diseases listed may have associated symptoms o atigue,
malaise, headache, and myalgia. One actor that makes Lyme dis-
ease a more likely diagnosis is the history o being outdoors in an
endemic area (90% o Lyme disease in the United States occurs in
New York, New Jersey, Connecticut, Rhode Island, Massachusetts,
Pennsylvania, Wisconsin, and Minnesota).
Question 11.6.2 Which o the ollowing ndings on physical
examination would be more consistent with Lyme disease
than JIA?
A) Bell palsy.
B) emperature ≥ 38°C.
C) Rash.
D) Lymphadenopathy.
E) A and C.
Answer 11.6.2 The correct answer is “A.” All o the other nd-
ings are seen in both Lyme disease and JIA. Neurologic symp-
toms, including Bell palsy (“A”) and even meningitis, may occur
with Lyme disease but not JIA. Rash (“C”) is present in both
diseases but di ers substantially. T e characteristic rash o
Lyme disease is erythema migrans. T e rash o systemic-onset
JIA (also known as Still Disease) is macular, salmon-pink, and
brought on by heat. Erythema migrans occurs in about 80% o
patients with acute Lyme disease. T e lesion is o en described
as “targetoid,” meant to convey a red circular rash with central
clearing. However, most patients do not have the classic lesion.
Instead, most patients present with a mildly to brightly ery-
thematous patch in the axilla or belt line, where the tick bite
occurs. T e tick itsel is rarely seen. Erythema migrans is usually
not pain ul or pruritic. Both Lyme disease and JIA may have
associated systemic ndings, including ever and lymphade-
nopathy, so neither “B” nor “D” is a good discriminator.
HELPFUL TIP:
There is a “new” orm o Lyme disease in the Midwest
ca sed Borrelia mayonii (why does this have to happen to
Iowa?). Rather than the typical b ll’s eye rash, it can pres-
ent with a di se rash, perhaps ne rolo ic symptoms, and
a spirochetemia o ten visible on dark- ield examination.
So ar it is ncommon and limited to the pper Midwest.
Physical examination reveals a thin male in no acute distress.
His temperature is 37.3°C, pulse 100 bpm, and blood pres-
sure 120/70 mm Hg. Small, non-tender, mobile lymph nodes
are palpable in the neck and axillae. T ere is a large, warm,
erythematous patch with central clearing at the patient’s le
axilla. T ere is limited range o motion in his right wrist and
le elbow. An e usion is palpable at the le knee, which is
di usely tender.
Question 11.6.3 I you were to aspirate the patient’s knee —
so o ten the right answer in this chapter—which o the ol
lowing would you expect to nd in the synovial uid?
A) Greater than 100,000 WBC/mm 3.
B) Predominance o eosinophils.
C) Monosodium urate crystals.
D) Spirochetes.
E) Predominance o polymorphonuclear cells.
Answer 11.6.3 The correct answer is “E.” T is patient is pre-
senting now with classic eatures o Lyme disease. I synovial
uid is obtained in a patient with Lyme arthritis, analysis o the
uid reveals leukocytes, most commonly polymorphonuclear
cells. “A” is incorrect. I the synovial uid has > 100,000 WBC/
mm 3, you should consider septic arthritis (arthritis in Lyme dis-
ease is mostly an immunological phenomenon rather than true
septic arthritis). “B” is incorrect because eosinophils are not
the predominant cell in synovial uid o Lyme arthritis. “C” is
wrong since monosodium urate crystals are observed in gout—
an unlikely cause o this patient’s joint complaints. Finally, “D”
is wrong. In general, Borrelia burgdor eri spirochetes, the caus-
ative organism in Lyme disease, are not observed in the synovial
uid.
You strongly suspect Lyme disease. Because it is so swollen,
you aspirate the joint and nd slightly cloudy yellow uid,
with cell count 10,000/mm3, and 95% polymorphonuclear
cells. Gram stain is negative and culture was subsequently
ound to be negative.
Question 11.6.4 Which o the ollowing is true regarding
laboratory tests or Lyme disease?
A) Serologic tests are reliable within 1 week o the tick bite.
B) Serologic tests are use ul in screening or Lyme disease.
C) Blood cultures remain positive or B. burgdor eri or months
a er the tick bite.
D) Serologic tests remain positive or up to 10 years a er antibi-
otic treatment.
E) T e diagnosis o Lyme disease is based on serologic tests.
Answer 11.6.4 The correct answer is “D.” Serologic tests or
Lyme disease can remain positive or up to 10, and in some
cases 20, years a er exposure. T us, serologic tests alone are not
diagnostic o active Lyme disease. “E” is incorrect: the diagnosis
o Lyme disease is clinical with laboratory tests used to con rm
the diagnosis. A positive ELISA test is not adequate to make
the diagnosis o Lyme disease. Positive or equivocal ELISA tests

should be con rmed with Western blot analysis. “A” is incor-
rect: serologic assays may be alsely negative early in in ection.
“B” is incorrect. Lyme serology is set to be a very sensitive test:
there are ew alse negatives assuming enough time has elapsed
since Borrelia exposure, but it is not highly speci c and there
are many alse positives. Because o the high alse-positive rate,
serologic assays should not be used as a screening tool in the
general population but are a good step when Lyme disease is
suspected. Most laboratories will automatically do a Lyme
Western Blot study to con rm positive Lyme serology. “C” is
incorrect: positive blood cultures or B. burgdor eri are rarely
obtained. When cultures do grow B. burgdor eri, it is only early
in the disease. Cultures o skin biopsied rom the erythema
migrans lesion are more likely to be positive.
Question 11.6.5 For this 13 year old patient, whose weight
is 50 kg and who has no known allergies, which course o
therapy is sa est and most ef cacious?
A) Amoxicillin 500 mg by mouth three times daily or 1 week.
B) Ce riaxone 2 g IM, single dose.
C) Doxycycline 100 mg by mouth twice daily or 4 weeks.
D) Levo oxacin 250 mg by mouth daily or 2 weeks.
E) Erythromycin 250 mg by mouth our times daily or 4 weeks.
Answer 11.6.5 The correct answer is “C.” Recommended ther-
apy or Lyme arthritis (without neurologic disease) is 4 weeks o
either amoxicillin 500 mg three times daily, doxycycline 100 mg
twice daily, or ce uroxime axetil 500 mg twice daily. T is patient
is old enough to take doxycycline, which is generally avoided in
children < 8 years old due to tooth discoloration. T e duration
o amoxicillin prescribed here is too short, so “A” is wrong. I
this patient was younger and doxycycline was contraindicated,
a 4-week course o amoxicillin or ce uroxime would be the pre-
erred therapy. Ce riaxone is prescribed when neurologic abnor-
malities are present (such as Bell palsy or meningitis), and it must
be dosed daily or 2 to 4 weeks. Levo oxacin is not indicated or
Lyme disease. reatment with erythromycin or 4 weeks, while
an acceptable alternative, appears to be less ef cacious.
HELPFUL TIP:
There is no known resistance o B. burgdorferi to stan-
dard antibiotic re imens.
Several hours a er starting antibiotics, the patient’s ather
calls to reports worsening symptoms o ever, shaking, and
dizziness.
Question 11.6.6 You recognize this condition as which o
the ollowing?
A) An allergic reaction to the antibiotic.
B) B. burgdor eri sepsis.
C) Secondary bacterial in ection.
D) A cytokine-mediated reaction to the antibiotic-mediated
killing o spirochetes (Jarisch–Herxheimer reaction).
E) T e expected, natural course o Lyme disease.
CHAPTER 11 • RHEu MATOLOg Y 319
TABLE 11-5 STAGES OF LYME DISEASE
Early localized disease (Stage I): Occ rs days to a month a ter the tick
bite and incl des erythema mi rans, ati e, ever, malaise,
myal ias, arthral ia, arthritis, headache, and lymphadenopathy.
Except or erythema mi rans, it can be con sed with a viral illness.
Early disseminated disease (Stage II): Occ rs weeks to months a ter
the tick bite; 5–10% have cardiac mani estations (atrioventric lar
block o any de ree, myocarditis/pericarditis, and heart ail re) and
10–15% have ne rolo ic mani estations (see below).
Late disease (Stage III): Occ rs months to years a ter the tick bite and
incl des myal ias, arthral ias, ati e, polyarthritis, and ne rolo ic
symptoms (encephalopathy, co nitive dys nction, and peripheral
ne ropathy).
Adapted rom Bhate C, Schwartz RA. Lyme disease: Part I. advances and
perspectives. J Am Acad Dermatol. 2011;64(4):619–636.
Answer 11.6.6 The correct answer is “D.” A Jarisch–Herx-
heimer reaction occurs in 5% to 15% o patients treated with
antibiotics or Lyme disease. (Remember syphilis? Lyme is also
a spirochete disease.) T e reaction is mediated by the release
o cytokines and occurs within hours o initial administration
o antibiotics. In Lyme disease, the reaction is sel -limited and
usually resolves within a day. Only supportive treatment is nec-
essary, and antibiotics should be continued (But hey, you know
you got the diagnosis right!). “A” is incorrect because this reac-
tion is not typical o a drug allergy. “B” is incorrect because
B. burgdor eri does not cause sepsis. “C” is incorrect because it
is unlikely that a secondary bacterial in ection has occurred so
quickly. Finally, this does not represent the natural history o
Lyme disease (“E”). See able 11-5 or more on the natural his-
tory o Lyme disease.
HELPFUL TIP:
Lyme disease symptoms typically improve a ew days
a ter startin antibiotics.
Since he spends much o his ree time hunting deer in Minne-
sota (trying to shoot Bambi), your patient’s ather is worried
about contracting Lyme disease himsel .
Question 11.6.7 What do you recommend or primary pre
vention o Lyme disease?
A) Weekly tick checks.
B) N,N-diethyl-m-toluamide (DEE ) application prior to
hunting.
C) Daily doxycycline when in endemic areas.
D) Lyme vaccine.
E) Kill as many deer as possible in order to reduce the risk o
Lyme disease transmission to humans.
Answer 11.6.7 The correct answer is “B.” Primary prevention
is best accomplished with the use o insect repellents when in
endemic areas. Also, when in endemic areas, tick checks should
be per ormed daily (not weekly as in answer “A”). A tick that has
320 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
been attached or < 24 hours is not likely to transmit B. burg-
dor eri. Un ortunately, the species that transmits Lyme disease
(ticks o the Ixodes ricinus complex) are very small and dif cult
to see. “C” is incorrect. T ere is no role or routine prophylactic
antibiotics. However, i a tick bite rom the appropriate species
is noticed, a single dose o doxycycline 200 mg administered
orally reduces the risk o erythema migrans. T e dose should
be administered within 72 hours o a known I. ricinus tick bite.
“D” is not an option or this patient. In 2002, the vaccine was
removed rom the U.S. market due to low demand. When it was
available, antibody titers tended to wane quickly and protection
was not complete. A er the administration o three vaccinations,
the ef cacy o the vaccine to prevent Lyme disease was 76% at
best. “E” is just plain wrong . . . what with Bambi and all . . . And
urthermore, the white- ooted eld mouse, not the white-tailed
deer, is the major reservoir o B. burgdor eri bacteria.
HELPFUL TIP:
Repeat a ter s: there is no s ch thin as “chronic Lyme
disease” req irin months-to-years o antibiotics.
The CDC does reco nize an entity called “post-Lyme
disease syndrome,” that may incl de ati e, myal ia,
co nitive slowin and n mbness. However, post-Lyme
disease syndrome does NOT improve with prolon ed
antibiotics. Foc s on lookin or other ca ses (e. ., de-
pression, ibromyal ia) in these patients and alleviatin
symptoms, b t avoid the temptation to prescribe anti-
biotics that do not work.
HELPFUL TIP:
I Lyme menin itis is s spected, con irm by analysis o
CSF. Lyme menin itis m st be treated with IV ce triax-
one or penicillin g .
Objectives: Did you learn to . . .
• Describe the appropriate eval ation o polyarthritis?
• Dia nose Lyme disease?
• Describe the sta es o Lyme disease?
• Implement appropriate therapy or Lyme disease?
• Disc ss preventive strate ies or Lyme disease and describe
some o the complications o the disease?
CASE 11.7
A 42-year-old emale who was re erred by an orthopedic sur-
geon presents to your of ce with multiple joint complaints.
T e orthopedist has seen her or le knee pain, intermittent
swelling, occasional “clicking and locking,” present or about
10 years. A er knee radiograph and examination, the ortho-
pedist diagnosed a chronically damaged meniscus, but he
wants the patient evaluated by you or her other joint com-
plaints.
Laboratory data ordered by her orthopedist (apparently,
just to con use you) show an ANA 1:320 (speckled pattern)
and an ESR 20 mm/hr. T e patient moved to the United States
rom Guam 4 years ago. She reports poor sleep and eeling
quite depressed. She eels that she has no riends, and she has
had trouble adjusting to the colder weather. You notice she
has a bottle o water with her and upon your speci c ques-
tioning she states, “I have to sip some water throughout the
day. I’ve done this or the last 15 years because my mouth gets
so dry.” Over the past twenty years, she has had numerous ll-
ings or dental cavities. She denies problems with skin rash,
swallowing, and eye pain. She does not use arti cial tears.
Question 11.7.1 Which o the ollowing ndings in this
patient is most likely to be a sign o in ammatory arthritis?
A) Spider angiomas (telangiectasia) on the back and abdomen.
B) A small cool le knee e usion (“bulge sign”) with crepitus.
C) Presence o 16/18 bromyalgia tender points, with non-
tender control points.
D) Incomplete le grip.
E) Presence o a holosystolic murmur at the le sternal border,
without radiation.
Answer 11.7.1 The correct answer is “D.” Although her symp-
toms are suggestive o bromyalgia and depression, it is critical
to di erentiate between an in ammatory and a non-in amma-
tory condition, especially since many in ammatory disorders
(e.g., SLE, RA, Sjögren syndrome) may masquerade as bro-
myalgia. An incomplete grip in an otherwise healthy young
woman is suggestive o synovitis, which can be urther assessed
by care ul small joint examination. When synovitis is present,
it is always abnormal and suggests an in ammatory arthritis,
requiring urther evaluation. “A” is incorrect because telangiec-
tasias on the abdomen and trunk are typically related to liver
disease, while those ound on hands and nail beds are associ-
ated with systemic sclerosis and other rheumatic diseases. “B,” a
positive knee “bulge sign” (swelling o the knee joint that bulges
in eriorly when compressed superiorly), indicates uid in the
le knee joint. But rom the patient’s history and your ortho-
pedic colleague’s determination, this nding is chronic and
mechanical in nature. “C,” the presence o 16/18 tender points,
would argue or bromyalgia but would not help to di erentiate
between in ammatory and non-in ammatory disorders. Addi-
tionally, identi ying greater than 11 out o 18 tender points is
no longer part o the diagnostic criteria or bromyalgia (keep
reading or details). Finally, a holosystolic murmur (“E”), local-
ized to the le sternal border and present in a healthy young
woman, is nonspeci c and most likely unctional. I there were
other signs and symptoms o cardiac disease, the murmur might
indicate a more serious disorder.
On physical examination, you nd a “bulge sign” on the
le knee, but no other joint swelling. She has 16/18 tender
points and normal range o motion and strength. T e neu-
rological examination is grossly normal, except or poorly
de ned numbness and pain to touch on the le side o her
ace. You also notice a mildly tender, hard, nodular swelling
behind the angle o the mandible on the le in the area o the
parotid gland. Her oral mucosa appears dry. Her conjunctiva
is mildly, symmetrically injected.

Question 11.7.2 All o the ollowing studies and interven
tions are appropriate EXCEPT:
A) CBC, transaminases, ESR, CRP.
B) Anti-SS-A (Ro), anti-SS-B (La), anti-dsDNA, RF, serum
protein electrophoresis.
C) Prescribe trazodone 50 mg PO at bedtime and recommend
aerobic exercises.
D) Prescribe prednisone 20 mg PO daily, with calcium and vita-
min D supplement.
E) Maxillo acial MRI.
Answer 11.7.2 The correct answer (and the thing to avoid
right now) is “D.” Although prednisone may be used to treat
symptoms o autoimmune diseases, at this time the diagno-
sis is not secure, and initiating corticosteroid therapy exposes
the patient to potentially unnecessary risk. She has ndings o
Sjögren syndrome—red (possibly dry) eyes, dry mouth, and
enlarged parotid glands. However, the di erential o mass in
the parotid gland must include malignancy (e.g., lymphoma),
sarcoidosis, and other autoimmune diseases. T e laboratory
tests o ered in answers “A” and “B” may help assess other organ
involvement o Sjögren syndrome and also aid in con rming the
diagnosis. Other potential mani estations o Sjögren syndrome
include generalized vasculitis, interstitial lung disease, cirrhosis,
peripheral and cranial neuropathies, possibly thyroid disease,
and renal disease leading to proteinuria and renal tubule dys-
unction. Although not listed as an option, chest radiograph may
also be help ul, assessing or ndings associated with the diseases
on your di erential: Sjögren syndrome (interstitial lung disease),
sarcoidosis (adenopathy and interstitial disease), and lymphoma
(adenopathy). “E” is also important because although parotid
enlargement may be seen in Sjögren syndrome, it is usually sym-
metrical and non-tender. An imaging study is appropriate to rule
out a neoplastic process. Finally, “C” is correct. Her symptoms o
bromyalgia may respond to trazodone and exercise, and these
low-risk interventions are appropriate at this juncture.
She starts trazodone and exercise and eels better. T e tests
you order return as ollows: negative SSA, SSB, and dsDNA;
elevated RF; no monoclonal protein on SPEP but di usely
elevated globulins. A chest x-ray is normal. Her ESR is
35 mm/hr and CRP 0.5. A maxillo acial MRI shows an
enlarged le parotid, with an ill-de ned 2 × 3 × 1.5 cm dense
signal in the center without neurovascular compromise.
Question 11.7.3 What is the most appropriate next step in
the management o this patient?
A) Continue your current management and adopt a “watch ul
waiting” approach.
B) Re er or biopsy o the le parotid.
C) Initiate prednisone 20 mg PO daily, with calcium and vita-
min D.
D) Re er or minor salivary gland biopsy (lip biopsy).
E) MRI o the head and neck.
Answer 11.7.3 The correct answer is “B.” Even though her
presentation is suggestive o Sjögren syndrome, the presence
CHAPTER 11 • RHEu MATOLOg Y 321
o a mass-like ormation on MRI is concerning or lymphoma,
and urther evaluation (e.g., biopsy) is required. Additionally,
the negative SSA and SSB, while not excluding Sjögren syn-
drome, will make a biopsy necessary or diagnosis. Although
a minor salivary gland biopsy (“D”) is the most speci c way to
con rm a diagnosis o Sjögren syndrome, the rst priority is
to evaluate the parotid gland mass. T e elevated RF and poly-
clonal gammopathy are consistent with Sjögren syndrome,
and the ESR may be elevated due to increased globulins.
MRI o the head and neck (“E”) may provide some structural
in ormation but it is not in the diagnostic criteria or Sjögren
Syndrome.
Results o the parotid gland biopsy report read, “Lympho-
cytic in ltrate, no malignant cells noted.” You then order ow
cytometry, and it has no markers or lymphoma. Her biopsy
scar has healed nicely, and she has no pain or numbness. You
believe that she probably has Sjögren syndrome.
Question 11.7.4 What would you do next?
A) C chest/abdomen/pelvis.
B) Start prednisone 20 mg by mouth daily, with calcium and
vitamin D.
C) Recommend sugarless lemon drops and arti cial tears as
needed and continued trazodone and exercise.
D) Wide excision o the parotid gland.
Answer 11.7.4 The correct answer is “C.” Lemon drops (or
anything sour or that matter) will stimulate saliva produc-
tion, helping with her dry mouth. Arti icial tears may also be
indicated or dry eyes. At this time your working diagnosis
is Sjögren syndrome, and de initive diagnosis by minor sali-
vary gland biopsy ( rom the buccal mucosa o the lower lip)
is not likely to alter your therapy; and “D” is way too aggres-
sive anyway. Since she has responded to trazodone and exer-
cise and there is no evidence o systemic involvement, no
urther anti-in lammatory therapy (“B”) is warranted. I she
were to develop arthritis or other signs o systemic involve-
ment (e.g., cognitive dys unction or peripheral neuropathy),
prednisone would be an option. Further work-up or lym-
phoma, such as C scanning (“A”), does not appear war-
ranted. However, she will require active surveillance, since
patients with Sjögren syndrome carry an increased risk o
developing lymphoma.
HELPFUL TIP:
Sicca symptoms (dry eyes and mo th) are extremely
common, especially in the elderly, and sho ld be con-
irmed by objective physical indin s. The dia nosis o
Sjö ren syndrome is s ested by presence o anti-SS-
A, or positive ANA titer (1:320 or reater) with elevated
RF, b t de initive dia nosis o Sjö ren syndrome relies
on histopatholo ic land indin s on minor salivary
land (lip) biopsy.
322 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Objectives: Did you learn to . . .
• Describe the appropriate eval ation o polyarthral ia and
sicca symptoms?
• Eval ate a patient with probable Sjö ren syndrome?
• Implement appropriate therapy or Sjö ren syndrome?
CASE 11.8
Once again, your abled diagnostic and therapeutic abili-
ties have earned you a well-deserved re erral. Your previous
patient is so pleased with the way things are going that she
re ers her sister-in-law to you. T e sister-in-law is 46 years old
and reports having been diagnosed with bromyalgia several
months ago. She reports having all-over pain, all the time,
which has been worsening or the last 5 years. You thank the
patient or the re erral . . . NO . She takes only acetamino-
phen and codeine as needed or pain (she typically needs it
our times per day). She does not exercise because it hurts
too much. She drinks 2 liters o Mountain Dew a day, rom
sun-up to sundown. Her sleep is reported as poor and non-
restorative.
Question 11.8.1 Which o the ollowing statements is true
regarding management o bromyalgia:
A) Fibromyalgia pain is increased during exercise, so exercise
should be avoided.
B) Regular low impact exercise, and non-pharmacologic mea-
sures to improve sleep are more e ective than medications
or improving bromyalgia-type pain.
C) SNRI agents such as duloxetine and milnacipran lead
to rapid and long-term remission o ibromyalgia-type
pain.
D) Both NSAIDs and prednisone are help ul or reducing bro-
myalgia pain.
E) Opioids act on the central nervous system, which is why
they are the most e ective agents or treatment o bromyal-
gia pain.
Answer 11.8.1 The correct answer is “B:” improved sleep
through good sleep hygiene, and regular low-impact exer-
cise are o en more e ective than medications or reducing
bromyalgia-type pain. Indeed, improving sleep and exercise
(and identi ying any underlying sleep disorder) are central to
long-term management. “A” is incorrect: even when exercise is
poorly tolerated due to pain, a program o stretching and gradu-
ally increasing exercise is very help ul to reduce pain over time.
SNRI agents are help ul or reducing central pain sensitization,
and are important adjunctive treatment to sleep and exercise,
but they are not curative and do not provide rapid pain relie .
“D” is incorrect: NSAIDs and prednisone are not e ective or
bromyalgia-type pain. Opioids do act on the central nervous
system, and can lead to short term reduction o bromyal-
gia-type pain, but at the same time they increase central pain
sensitization which can actually lead to worsening o pain
(opioid-induced hyperalgesia).
Question 11.8.2 Which o the ollowing is NOT an appropri
ate medication or treating bromyalgia type pain?
A) Hydrocodone/acetaminophen
B) Gabapentin or pregabalin
C) Amitriptyline
D) Duloxetine
E) Combination duloxetine and pregabalin
Answer 11.8.2 The correct answer is “A.” Is there a theme
emerging here? Narcotics will provide a short-term reduction
in pain, but tend to worsen central sensitization and actually
increase bromyalgia pain over time; they should be avoided in
managing this type o pain. All o the other agents have shown
ef cacy in improving pain associated with bromyalgia. ricy-
clic antidepressants have the best ef cacy. SNRI agents such as
duloxetine may be combined with a gabapentin or pregabalin
as can tricyclics.
HELPFUL TIP:
Fibromyal ia is a common syndrome characterized by
di se chronic pain accompanied by other somatic
symptoms s ch as poor sleep, ati e, and sti ness,
in the absence o another identi iable disease. In order
to dia nose ibromyal ia, symptoms m st be present
or at least 3 months and other chronic pain conditions
m st be excl ded. However, an exha stive search or
occ lt disease is not recommended. Most dia noses
can be made with history, physical examination and
minimal labs (e. ., CBC, CRP, ESR to r le o t in lamma-
tory disease). The 1990 American Colle e o Rhe ma-
tolo y criteria incl ded identi ication o pain on palpa-
tion at 11 or more o 18 tender points (Fi . 11-2), b t
as o 2010, this minim m n mber is no lon er req ired
to establish a dia nosis. There is still val e in examin-
in these tender points, and a hi her n mber o tender
points are associated with hi her likelihood o ibro-
myal ia. However, yo need not have 11 o 18. Also,
sel -administered scales, s ch as the Widespread Pain
Index, may be se l in dia nosin ibromyal ia. There
is a emale predominance in ibromyal ia, with p to
75% o patients bein women.
Question 11.8.3 All o the ollowing are associated with
bromyalgia EXCEPT:
A) Irritable bowel syndrome.
B) Subjective ullness/swelling o hands and eet.
C) Paresthesias.
D) Fatigue.
E) Night sweats.
Answer 11.8.3 The correct answer is “E.” All o the others are
associated with bromyalgia. Additional symptoms include
headaches, depression, sleep disturbance (which may actually
be the etiology), other GI symptoms, and urethral spasm with
dysuria and urgency.
 CHAPTER 11 • RHEu MATOLOg Y 323

Occiput:
S uboccipita l
mus cle Low cervical:
ins e rtions Ante rior a s pe cts
Trapezius: of the inte rtra ns ve rs e
Midpoint of the s pa ce s a t C5–C7
uppe r borde r
Second rib:
Supraspinatus: S e cond
Above the me dia l cos tochondra l
borde r of the junctions
s ca pula r s pine
Lateral
Gluteal:
epicondyle:
Uppe r oute r
2 cm dis ta l to
qua dra nts
the e picondyle s
of buttocks

Greater
trochanter:
P os te rior to
the trocha nte ric
promine nce

Knee:
Me dia l fa t pa d
proxima l to the
joint line

FIGURE 11-2. Tender points in bromyal ia.

not cause osteoarthritis. Any disease that leads to a neuropathy,

HELPFUL TIP:
Altho h some SNRIs (D loxetine, Savella, Venla ax-
ine) are FDA-approved or ibromyal ia, they are not as
e ective as the TCAs.
Objectives: Did you learn to . . .
• Identi y typical symptoms o bromyal ia?
• De ne dia nostic criteria or bromyal ia?
• Implement appropriate therapy or bromyal ia?
QUICK QUIZ: SECONDARY OSTEOARTHRITIS
All o the ollowing diseases and conditions are secondary
causes o osteoarthritis EXCEP :
A) Fibromyalgia.
B) Hemochromatosis.
C) Hyperparathyroidism.
D) Amyloidosis.
E) Previous joint trauma.
The correct answer is “A.” One o the most common second-
ary causes o osteoarthritis is previous joint trauma. Systemic
diseases that can lead to osteoarthritis include hemochromato-
sis, hyperparathyroidism, and amyloidosis. Fibromyalgia does
such as diabetes, can predispose to osteoarthritis (e.g., Charcot
arthropathy).
CASE 11.9
A 25-year-old emale presents to your of ce complaining o
bi rontal headaches, occurring intermittently over the last
year. Also, she complains o atigue that seems to be slowly
worsening. Over the last 2 to 3 months, she has developed
generalized joint pain and sti ness. T e remainder o the his-
tory, including a detailed review o systems, is unremarkable.
On physical examination, you nd a thin emale in
no acute distress. She is a ebrile with a blood pressure o
110/62 mmHg and a pulse o 72 bpm. T e joint examination
shows ull range o motion and no swelling. T ere is mild
anterior cervical lymphadenopathy. Close inspection o her
skin reveals erythema o the malar eminences and the nose
laterally, with involvement of the nasolabial folds. You note
aking and scaling in the eyebrows.
Question 11.9.1 The RASH is most characteristic o which
o the ollowing diagnoses?
A) Dermatomyositis.
B) SLE.
C) Seborrheic dermatitis.
D) Psoriasis.
324 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Answer 11.9.1 The correct answer is “C.” T e classic rash o
SLE is the malar, or “butter y,” rash with erythema over the
malar eminences, bridging over the base o the nose. However,
the nasolabial olds are spared with the lupus malar rash.
Involvement o the nasolabial old characteristically occurs in
seborrheic dermatitis. In dermatomyositis, acial lesions involve
the upper lids and have a light reddish-purple hue (the so called
“heliotrope rash”). Flat-topped, violaceous papules over the
knuckles (Gottron papules) are classic eatures o dermatomyo-
sitis. T e typical lesions o psoriasis include erythematous pap-
ules and plaques with silvery scales, noted more commonly on
extensor sur aces.
Question 11.9.2 Which o the ollowing diagnoses or descrip
tions most accurately describes your patient ’s disease
process at this point in time?
A) Fibromyalgia.
B) Somato orm disorder.
C) Polyarthritis.
D) Polyarthralgia.
E) RA.
Answer 11.9.2 The correct answer is “D.” Your patient
complains o pain in multiple joints but has no indings o
in lammation o the joints; there ore, the designation o
“polyarthralgia” its best at this time. I multiple joints were
in lamed, you would use the term polyarthritis. At this time,
you do not have enough in ormation to make any o the other
diagnoses.
You screen or depression and anxiety and nd neither.
You recommend acetaminophen or joint pain and head-
aches and encourage her to exercise regularly. She returns
2 months later eeling worse. She has severe atigue and joint
pain, most commonly involving her hands and knees. She has
taken a leave o absence rom her job as a high school English
teacher. New symptoms include sores in her mouth as well
as chest pain, which is worse with inspiration. On examina-
tion, you note the presence o a cardiac riction rub. T ere
is di use tenderness to palpation o both knees and a small
e usion apparent in the le knee. Her le hand demonstrates
slow, incomplete grip. T e acial rash is barely noticeable.
T ere are two nontender ulcerations o the oral mucosa. T e
remainder o the examination is unchanged rom her previ-
ous visit.
Question 11.9.3 Her disease process and current ndings
are most suggestive o which o the ollowing diagnoses?
A) Lymphoma.
B) SLE.
C) Fibromyalgia.
D) Reactive arthritis.
E) Limited scleroderma (CRES syndrome).
Answer 11.9.3 The correct answer is “B.” While she does
not meet all the criteria or a diagnosis o SLE, this presenta-
tion is more consistent with SLE than any o the other options.
Several ndings point toward SLE: arthritis, cardiac riction rub
(presumably due to pericarditis), and painless oral ulcers. Keep
reading or more on the diagnostic criteria or SLE.
Based on your history, you recognize that your patient may
be at higher than normal risk or developing SLE.
Question 11.9.4 All o the ollowing groups have a higher
incidence o SLE than the general population EXCEPT:
A) Family members o patients with SLE.
B) Females.
C) Asian Americans.
D) Age in the third to h decades.
E) Caucasians.
Answer 11.9.4 The correct answer is “E.” Compared to other
groups, Caucasians have a lower risk o SLE. T e peak incidence
o SLE occurs in the third to h decades o li e. Women are
5 to 10 times more likely than men to be diagnosed with SLE.
First-degree relatives o patients with SLE are at higher risk as
well. win studies have shown a 25% to 50% concordance rate
among monozygotic twins.
You consider that this might represent drug-related lupus,
but your patient denies using any medications except or
acetaminophen.
Question 11.9.5 In drug related lupus, you expect to see all
o the ollowing EXCEPT:
A) Negative ANA.
B) Rapid resolution o symptoms a er discontinuing the drug.
C) Polyarthralgia.
D) Negative anti-dsDNA.
E) Low-grade ever.
Answer 11.9.5 The correct answer is “A.” Patients with drug-
induced lupus will generally have a positive ANA. However, it
can be di erentiated rom SLE by a negative anti-dsDNA. Drug-
related lupus presents with a lupus-like syndrome, with the most
common eatures being arthralgias, myalgias, atigue, malaise,
and low-grade ever. Pericarditis and pleuritis are occasionally
present. Skin, renal, and neurologic involvement are rare. Some
common drugs that cause drug-induced lupus include hydrala-
zine, diltiazem, hydrochlorothiazide, phenytoin, glyburide, in -
liximab and etanercept.
Your patient returns with a pain ul, swollen le knee, and
she wants to do something about it. You also discuss the ol-
lowing laboratory test results: WBC 5,100 cells/mm3, Hgb
11.0 g/dL, platelets 309,000 cells/mm3; BUN 10 mg/dL, creat-
inine 1.0 mg/dL; ESR 77 mm/hr; ANA 1:1,280 with a nucleo-
lar pattern; urinalysis + 1 protein, otherwise negative; urine
microscopic examination shows no RBCs or casts; chest
x-ray shows no cardiomegaly and normal lung elds; ECG
shows normal sinus rhythm. You believe that your patient
has SLE.

TABLE 11-6 DIAGNOSTIC CRITERIA FOR SYSTEMIC
LUPUS ERYTHEMATOSUS
SLE req ires the presence o 4 o the 11 ndin s below, not necessarily
occ rrin at the same time.
1. Malar rash
2. Discoid rash
3. Photosensitivity
4. Oral lcers ( s ally painless)
5. Nonerosive arthritis (involvin 2 or more peripheral joints with
tenderness, swellin , or e sion)
6. Serositis (pericarditis or ple ritis)
7. Renal disorder (persistent protein ria > 0.5 /day or cell lar casts)
8. Ne rolo ic disorder (seiz res or psychosis)
9. Hematolo ic disorder (hemolytic anemia, le copenia
< 4,000/mm 3 on 2 occasions, lymphopenia < 1,500/mm 3 on 2
occasions, or thrombocytopenia < 100,000/mm 3 in the absence o
o endin dr s)
10. Imm nolo ic disorder (anti-DNA, anti-Smith, or antiphospholipid
antibodies, or a alse-positive serolo ic test or syphilis)
11. Positive ANA
Adapted rom Tan EM, Cohen AS, Fries JF, et al. The 1982 revised criteria
or the classi cation o systemic l p s erythematos s. Arthritis Rheum.
1982;25:1271–1277 and Hochber MC. u pdatin the American Colle e
o Rhe matolo y revised criteria or the classi cation o systemic l p s
erythematos s [letter]. Arthritis Rheum. 1997;40:1725.
Question 11.9.6 Which o the ollowing management plans
do you suggest to the patient?
A) Start ibupro en 600 mg by mouth three times daily and
re er to a rheumatologist (3–6 month wait—sheesh, they are
busy).
B) Start prednisone 20 mg by mouth daily and hydroxychlo-
roquine 400 mg by mouth daily, schedule or ollow-up in
1 month, and re er to a rheumatologist (3–6 month wait).
C) Start methotrexate 10 mg by mouth weekly, prednisone
60 mg by mouth daily, and hydroxychloroquine 400 mg by
mouth daily, and schedule ollow-up in 1 month.
D) Start prednisone 60 mg by mouth daily and re er to a rheu-
matologist (3–6 months wait).
E) Start ibupro en 600 mg by mouth daily and adopt a “watch-
ul waiting” approach with ollow-up in 6 months.
Answer 11.9.6 The correct answer is “B.” Your patient now
meets diagnostic criteria or SLE, according to the American
College o Rheumatology. See able 11-6 or the diagnostic crite-
ria or SLE. Note that a positive ANA is only one o the criteria
and is not required or the diagnosis o lupus; however, the
vast majority o patients with SLE will have an elevated ANA,
and negative results should make you re-think the diagnosis.
Prompt treatment o her symptoms is important. NSAIDs, such
as ibupro en, are use ul in treating arthralgias, mild arthritis, and
mild pleurisy and pericarditis. In this case, oral (or perhaps intra-
articular) corticosteroids are indicated or immediate symp-
tomatic relie o her arthritis, and a low-to-moderate oral dose
should be used (10–20 mg rather than 60 mg). Vitamin D and
calcium supplements should be prescribed with the corticoste-
roids. Methotrexate can be used in recurrent, persistent arthritis.
In the event o more serious renal, hematologic, or neurologic
CHAPTER 11 • RHEu MATOLOg Y 325
disease, high-dose corticosteroids are employed. Hydroxychlo-
roquine may provide relie o musculoskeletal and constitutional
symptoms and may also have a corticosteroid-sparing e ect, but
most important is the observation that SLE patients who take
hydroxychloroquine have ewer organ-threatening lupus mani-
estations and ewer disease ares over time. Lupus patients who
take hydroxychloroquine live longer than those who do not.
Ideally, this patient should also be re erred to a rheumatologist,
but appropriate treatment should be started in a timely ashion.
Close ollow-up is necessary due to the potential adverse e ects
o these medications (e.g., diabetes with prednisone).
Over the next year, your patient does very well. She estab-
lishes care with a rheumatologist and is in remission when
she sees you next. She is interested in becoming pregnant
and wishes to seek your advice prior to trying to conceive.
(“Start a college und early,” you say. “Oh, that’s not what you
meant?”) Fortunately, she has been able to discontinue pred-
nisone and continues to tolerate hydroxychloroquine.
Question 11.9.7 With regard to pregnancy and SLE, your
patient is at higher risk or all o the ollowing EXCEPT:
A) Premature birth.
B) In ertility.
C) Intrauterine etal demise.
D) Spontaneous abortion.
Answer 11.9.7 The correct answer is “B.” Women with SLE
have a greater risk o premature birth, spontaneous abortion,
and intrauterine etal demise compared with otherwise healthy
women. However, these patients appear to have comparable
rates o ertility. Pregnancy outcomes are best when the patient
is in remission 6 to 12 months be ore conception. Pregnancy
appears to have a variable e ect on SLE, with some patients
experiencing exacerbations o the disease.
Your patient does well with her pregnancy but develops recur-
rent DV s in the subsequent ew years. You wish to evaluate
her or antiphospholipid antibody syndrome.
Question 11.9.8 Which o the ollowing results would you
expect to nd in a patient with antiphospholipid antibody
syndrome?
A) Elevated P /INR.
B) Low P /INR.
C) Prolonged dilute Russell viper venom time (DRVV ) that
corrects with addition o platelets.
D) Elevated aP that corrects with addition o normal serum.
E) High- brin degradation products.
Answer 11.9.8 The correct answer is “C.” T e DRVV assay is
highly sensitive to the presence to proteins that block phospho-
lipids, because the viper venom depletes phospholipid action.
T e DRVV may be prolonged when the less sensitive aP is
normal. When the DRVV is prolonged, addition o platelets
(as source o phospholipid) will correct the DRVV when pro-
longation is due to a lupus anticoagulant.
326 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Even though they are prone to clotting, patients with
antiphospholipid antibody syndrome o en have a paradoxically
elevated aP . I this abnormality does NO correct in vitro
with addition o normal serum, it is supportive o the presence
o a “lupus anticoagulant,” which is presumptive evidence o
antiphospholipid antibody syndrome. “D” is incorrect, as cor-
rection o a prolonged aP with normal serum implies actor
de ciency, not a lupus-anticoagulant. Besides venous thrombus
ormation, women with antiphospholipid antibody syndrome
are more likely to have late etal demise and multiple spontane-
ous abortions. “A” is incorrect, as a lupus anticoagulant will not
a ect the prothrombin time.
HELPFUL TIP:
Antiphospholipid antibody syndrome is a clinical syn-
drome ca sed by a toantibodies to phospholipids that
mod late the coa lation cascade. The term “l p s
anticoa lant” re ers to a s bset o these a toantibod-
ies that inter ere with clottin tests s ch as aPTT; these
can be detected by the dil te R ssell viper venom test
(DRVVT). Alternatively, the presence o antiphospho-
lipid antibodies can be determined by ELISA or anticar-
diolipin or beta-2- lycoprotein antibodies. However,
there is only an 85% concordance between the pres-
ence o antiphospholipid antibody syndrome and labo-
ratory detection o the ca sative antibodies. Antibodies
m st be detected on two occasions at least 12 weeks
apart, and there needs to be a clinical mani estation,
s ch as pre nancy morbidity or vasc lar thrombosis
(arterial, veno s, or small vessel). Pre nancy morbidi-
ties incl de: (1) more than one etal death o a morpho-
lo ically normal et s beyond 10 weeks o estation,
(2) more than one premat re birth be ore the 34th
week o pre nancy d e to pre-eclampsia, eclampsia, or
placental ins iciency, or (3) more than three consec -
tive (pre) embryonic losses prior to 10 weeks o esta-
tion.
HELPFUL TIP:
Only abo t 10% o patients with l p s have antiphos-
pholipid antibodies.
Question 11.9.9 Which o the ollowing statements is (are)
true?
A) Patients with anticardiolipin antibodies should be treated
prophylactically even i they have never had an abnor-
mal clotting event, in order to prevent venous thrombosis,
stroke, or other abnormal clotting events.
B) Percent actor II activity is an appropriate way to monitor
the response to heparin in patients with antiphospholipid
antibody syndrome.
C) Anti actor Xa should be used to monitor the activity o
enoxaparin i monitoring is required.
D) A and C
E) B and C.
Answer 11.9.9 The correct answer is “E.” Both “B” and “C”
are true statements. Since patients with antiphospholipid anti-
body syndrome have an elevated aP , this value cannot be
used to monitor anticoagulation with standard heparin. Per-
cent actor II activity is the most appropriate way to moni-
tor these patients i they are on standard heparin. Anti actor
Xa is used to monitor anticoagulation with enoxaparin. “A”
is incorrect because there is no evidence that prophylactic
treatment reduces complications (although there is signi -
cant controversy in this area). Clearly, a er a patient has had
a thrombotic event, or has another indication, she needs anti-
coagulation.
HELPFUL TIP:
u n ractionated heparin, low-molec lar-wei ht hep-
arin, and aspirin are all sed in the treatment o an-
tiphospholipid antibody syndrome in pre nancy.
War arin is terato enic and is contraindicated in pre -
nancy (remember, it is rat poison!). The newer anticoa -
lants s ch as dabi atran, rivaroxaban, and apixaban
sho ld not be sed in pre nancy: There is not eno h
experience with their e ectiveness and possible
terato enesis.
Question 11.9.10 Which o the ollowing drugs used to
treat lupus is associated with macular damage, corneal
opacities, and ciliary muscle dys unction?
A) Azathioprine.
B) Prednisone.
C) Hydroxychloroquine.
D) Cyclophosphamide.
E) Methotrexate.
Answer 11.9.10 The correct answer is “C.” Hydroxychloro-
quine is associated with macular damage, corneal opacities, and
ciliary muscle dys unction, and its use requires a baseline eye
examination, and then yearly exams a er 5 years o continuous
use. T e risk or signi cant ocular toxicity is reduced i the daily
hydroxychloroquine dose is kept below 6.5 mg/kg/day (based
on ideal body weight), which is approximately 400 mg/day or
most women, and 300 mg/day or smaller women. Other SLE
drugs and side e ects are noted in able 11-7.
TABLE 11-7 TOXICITIES ASSOCIATED WITH
MEDICATIONS USED TO TREAT SLE
• NSAIDs: astrointestinal bleedin , renal dys nction, hypertension
• Steroids: diabetes, hypertension, hyperlipidemia, osteoporosis,
cataract ormation, wei ht ain, in ections
• Hydroxychloroq ine: mac lar dama e, ciliary m scle dys nction,
corneal opacities, myopathy
• Azathioprine: in ections, myelos ppression, hepatotoxicity
• Cyclophosphamide: in ections, myelos ppression, hemorrha ic
cystitis
• Methotrexate: in ections, myelos ppression, hepatic brosis

Objectives: Did you learn to . . .
• Identi y clinical mani estations o SLE?
• De ne dia nostic criteria or SLE?
• Reco nize the waxin and wanin co rse o SLE?
• Implement appropriate treatment o the patient with SLE?
• Reco nize adverse e ects o medications sed in the treat-
ment o SLE?
• Describe some characteristics o antiphospholipid antibody
syndrome?
CASE 11.10
A 22-year-old white emale presents to your of ce with the
chie complaint o “blue ngers.” She reports a history o
intermittent bluish discoloration o the ngertips on both
hands when they are exposed to cold temperatures. Although
she believes the symptoms are worse now, she cannot recall
how long they have been present. She has never had ulcers on
her ngers or toes.
Question 11.10.1 With no urther in ormation, what is the
most likely explanation or these digital color changes?
A) Atherosclerotic disease o the extremities.
B) Acrocyanosis.
C) Scleroderma.
D) Physiologic response to cold.
Answer 11.10.1 The correct answer is “D.” At this point all
we know is that this patient’s ngers turn blue upon exposure
to cold. T is is a normal physiologic response—vasoconstric-
tion in response to cold. “A” is incorrect. Peripheral vascular
disease is the result o atherosclerotic disease o the extremities
and typically occurs in older individuals; mani estations include
claudication and skin ulceration. “B” is incorrect. Raynaud phe-
nomenon must be distinguished rom acrocyanosis, (a rare
vasospastic disorder o persistent coldness and bluish discolor-
ation o the hands and eet, not just ngers and toes, sometimes
ollowing a viral in ection). “C” is also incorrect. Scleroderma
by itsel does not cause blue ngers.
HELPFUL TIP:
Over 80% o cases o Rayna d phenomenon that pres-
ent to a primary care physician’s o ice are d e to an
exa erated physiolo ic response to cold or emotional
distress, which we call primary Rayna d phenomenon.
In most primary cases, patients report the onset o
symptoms in their teens or twenties. Altho h Rayna d
phenomenon occ rs in most patients with scleroderma
(90–95%), scleroderma is a rare disease and is m ch
less common than primary Rayna d phenomenon, so
the converse is not tr e. Th s, the presence o Rayna d
phenomenon is not synonymo s with the presence
o scleroderma. A very important cl e to s est that
Rayna d is d e to an nderlyin systemic rhe matic dis-
ease is onset a ter the a e o 40—these patients sho ld
CHAPTER 11 • RHEu MATOLOg Y 327
always have a thoro h eval ation or nderlyin sys-
temic ca ses. Other cl es s estin secondary Rayn-
a d phenomenon incl de a history o severe disease (i.e.
di ic lt to reverse attacks, di ital lcerations) or conc r-
rent onset o new c taneo s, m sc loskeletal, astroin-
testinal, or cardiop lmonary problems. In these patients,
an ANA titer may be help l in rther eval ation.
HELPFUL TIP:
B er er disease (thromboan iitis obliterans) is stron ly
associated with tobacco ab se and presents with distal
small vessel ischemia and symptoms that are similar to
Rayna d phenomenon. It event ally pro resses to in-
arction o tiss e, req ently req irin di it amp tation.
Further history reveals that the patient uses no medications.
She has been healthy all o her li e. Her mother and aunt have
had blue ngers in cold temperature, too. She denies tobacco
use. T e review o systems is unremarkable.
Question 11.10.2 All o the ollowing are expected ndings
in patients with primary Raynaud phenomenon EXCEPT:
A) Symmetric involvement o the hands.
B) Well-demarcated cyanosis.
C) Digital ulcerations.
D) Normal ESR.
Answer 11.10.2 The correct answer is “C.” Primary Raynaud
phenomenon is diagnosed when other causes o Raynaud phe-
nomenon have been eliminated. Primary Raynaud phenomenon
is not typically destructive, and digital ulcerations generally occur
when the phenomenon is secondary to some other disease process
(e.g., scleroderma and SLE). Primary Raynaud phenomenon is
almost always symmetric. Raynaud phenomenon can be di eren-
tiated rom a normal response to cold temperatures by the demar-
cation between pale or cyanotic ngertips and normal-appearing
skin. A normal response to cold may include mottling, with indis-
tinct borders between pale and purple-colored skin, and paresthe-
sias o the involved area. In patients with Raynaud phenomenon,
the distal most portion o the involved digit is pale or cyanotic,
and the transition to normal skin color is abrupt. Since primary
Raynaud phenomenon is not due to an in ammatory condition,
markers o in ammation such as the ESR are usually normal.
HELPFUL TIP:
Nail old capillary microscopy (NCM) can be sed to ex-
amine the nail old capillaries o patients with Rayna d
phenomenon. NCM involves placin a drop o oil (a drop
o s r ical l bricant also works well) on the c ticle o
one or more di its and vis alization o the nail old cap-
illaries thro h an ophthalmoscope set at + 40 diopters
(40 reen). u s ally the rin and middle in ers (or symp-
tomatic in ers) are examined. Normal capillaries are sym-
metric, non-dilated loops. Distorted, dilated, or absent
capillaries s est secondary Rayna d phenomenon.
328 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
You per orm a physical examination, including NCM which
is essentially normal. T ere is currently no discoloration o
the ngers.
Question 11.10.3 What is the next most appropriate step in
the evaluation and management o this patient?
A) Cold provocation.
B) Doppler ultrasound o the extremities.
C) Blood viscosity testing.
D) ANA.
E) A trial o therapy, nonpharmacologic and/or pharmacologic.
Answer 11.10.3 The correct answer is “E.” Given that she is
symptomatic, a trial o drug therapy is warranted. Cold prov-
ocation (“A”) is not recommended, as results are inconsistent.
Rather, the diagnosis is based on a convincing history o epi-
sodic cyanosis. Doppler ultrasound (“B”), might be use ul i
you were considering large vessel disease rom atherosclero-
sis, etc. However, it is not likely to be help ul in this patient.
Blood viscosity testing (“C”), is not something that is done
routinely. Measurement o ANA (“D”), can be help ul in ruling
out underlying autoimmune disease since patients with Rayn-
aud phenomenon and a positive ANA may have a higher risk o
developing a systemic autoimmune disease. However, based on
her age, symmetric involvement, lack o ulcerations, and lack o
other symptoms, this patient most likely has primary Raynaud
phenomenon unrelated to an underlying disease. A second-
ary cause (e.g., scleroderma) is more likely with any o the ol-
lowing: patients who are age 30 years old or older; attacks are
asymmetric or associated with skin ulcers; there are symptoms
suggestive o systemic involvement (e.g., arthralgias, dyspnea,
re ux, or weight loss). In addition to abnormal nail old capillar-
ies, other subtle ndings to suggest secondary Raynaud include
pu y hand swelling and telangiectasias on the ngers or around
the mouth. I you are concerned about secondary Raynaud phe-
nomenon, an ANA would be indicated.
HELPFUL (FINGER) TIP:
Most patients with secondary Rayna d phenomenon
will develop symptoms o their nderlyin a toim-
m ne disease within a ew years o onset o Rayna d
phenomenon. B t Rayna d phenomenon may occ r
years be ore other symptoms are prominent or bother-
some eno h or the patient to report them to a doctor.
A er reviewing the diagnosis with your patient, you make
several recommendations to help reduce the requency o
attacks: avoid cold temperatures, reduce emotional stress,
and avoid tobacco and medications that cause vasoconstric-
tion (e.g., sympathomimetic drugs).
Your patient returns 10 months later with new complaints.
Both hands are swollen, sti , and pain ul. She complains o
multiple joint aches and atigue despite sleeping well. Her
appetite is normal, and she has no GI complaints. Although she
has no rash, she complains o itchy hands (surely a sign o can-
cer, she thinks). On examination, you note that there is di use,
nonpitting edema o her ngers and hands. She has dif culty
making a st. She has no skin ndings. Her CBC is normal.
Her ANA is strongly positive with a nucleolar pattern.
Question 11.10.4 Which o the ollowing is the most likely
explanation o these ndings?
A) Raynaud phenomenon.
B) RA.
C) Scleroderma.
D) CRES syndrome.
Answer 11.10.4 The correct answer is “C.” T is patient is now
presenting with symptoms o scleroderma, also called systemic
sclerosis. Scleroderma encompasses a heterogeneous group o
conditions, which are variable in severity but share a common
pathophysiologic mechanism— brosis o the skin and other
organs. T e pathology o scleroderma also involves small ves-
sel vasculopathy, a process that leads to Raynaud phenomenon
and ischemia o other tissues. Scleroderma may a ect the joints,
skin, lungs, kidneys, heart, and GI system. Fi y percent o
patients with scleroderma have depression.
A positive ANA can be help ul when you suspect sclero-
derma based on clinical ndings. ANA by indirect immuno u-
orescence will report the type o nuclear staining pattern. Cen-
tromere or nucleolar patterns are most highly associated with
systemic sclerosis, but other patterns (such as speckled) are also
seen. Patients with systemic sclerosis may have a negative ANA.
T ese ndings are now much more than you would expect to
see with Raynaud phenomenon; thus, “A” is incorrect. Di use
swelling and sti ness is present rather than speci c synovitis,
so “B” (RA) is less likely. CRES syndrome (“D”) is an acronym
standing or calcinosis cutis, Raynaud phenomenon, esophageal
dysmotility, sclerodactyly, and telangiectasia, which are all man-
i estations that can occur in patients with systemic sclerosis.
CRES should be used as a mnemonic to help remember the
mani estation o systemic sclerosis, and not as diagnostic crite-
ria. O note, calcinosis is a relatively uncommon and late mani-
estation o systemic sclerosis.
HELPFUL TIP:
F rther dia nosis and cate orization o scleroderma
can be accomplished with the aid o more speci ic se-
rolo ic tests s ch as anti-RNA polymerase III antibod-
ies (which predict hi h risk or renal crisis) and anti-
topoisomerase antibodies (Scl-70) which predict hi her
risk or interstitial l n disease. Treatment or sclero-
derma is evolvin , with some imm nos ppressive
therapies showin promise in the lon -term mana e-
ment. Finally, the reatest treatment breakthro h or
scleroderma patients is the indin that ACE inhibitors
can treat scleroderma renal crisis, leadin to sharp re-
d ction in mortality and preservation o renal nction.
Because o the digital ulcers you observed and the increasing
pain o her Raynaud phenomenon attacks, you decide to pre-
scribe medication or Raynaud phenomenon.

Question 11.10.5 Which o the ollowing is the best therapy
or reducing the requency o attacks o Raynaud phenom
enon?
A) Amlodipine 5 mg daily.
B) Ni edipine 10 mg as needed.
C) Nitroglycerin 2% ointment daily.
D) Diltiazem 30 mg as needed.
E) Prazosin 1 mg twice daily.
Answer 11.10.5 The correct answer is “A.” All o the medica-
tions listed are potentially help ul treatments when Raynaud phe-
nomenon does not respond to conservative measures. However,
the most appropriate choice is daily amlodipine. Dihydropyridine
calcium-channel blockers, like amlodipine, have been shown to
reduce the requency o attacks by about 50% compared with pla-
cebo. T ey must be scheduled, rather than used as needed. In the
case o ni edipine, it is best to use an extended release version, as
the short-acting preparation is more likely to cause hypotension;
it also should not be used PRN (thus, “B” is incorrect). Diltia-
zem is not as e ective as the dihydropyridine calcium-channel
blockers. In systemic sclerosis, the bene t o calcium-channel
blockers is o en o set by their exacerbation o GERD. In these
patients, ACE inhibitors or angiotensin receptor blockers (ARBs)
are also bene cial or Raynaud phenomenon. opical vasodila-
tors like nitroglycerin have a role i calcium-channel blockers are
not e ective or the patient cannot tolerate them. T ere is less evi-
dence that prazosin is e ective, but alpha-antagonists have a role
i other therapies are unsuccess ul. Sildena l, a phosphodiester-
ase inhibitor, may promote healing o digital ulcers.
Question 11.10.6 Which o the ollowing is NOT indicated
or acute ischemic crisis related to Raynaud phenomenon?
A) Aspirin.
B) Beta-blocker.
C) Ni edipine.
D) Digital or wrist nerve block.
E) opical nitroglycerin.
Answer 11.10.6 The correct answer is “B.” Beta-blockers are
not indicated in the treatment o an ischemic crisis related to
Raynaud phenomenon. Beta-blockers actually cause periph-
eral vasoconstriction and may worsen the problem. Peripher-
ally, beta-agonists cause vasodilatation. When a beta-blocker is
used, the patient ends up with an unopposed alpha-adrenergic
response, which worsens vasoconstriction. All o the other
therapies are use ul in acute ischemic crisis. O particular note
is “D.” A nerve or wrist block with lidocaine e ectively causes
a sympathectomy, leading to decreased vascular tone. As men-
tioned above, sildena l appears to be bene cial in healing isch-
emic ulcers and or acute ischemic crisis.
Objectives: Did you learn to . . .
• Identi y complications o Rayna d phenomenon and dis-
eases associated with it?
• Develop a strate y or the prevention and treatment o
symptoms o Rayna d phenomenon?
• Reco nize clinical eat res o scleroderma?
CHAPTER 11 • RHEu MATOLOg Y 329
CASE 11.11
A 17-year-old male presents to your of ce with a history
o low–back pain worsening over the past ew months. He
recalls having intermittent back pain or at least a year. T e
pain does not radiate. He runs cross-country and track with-
out exacerbating his back pain. He denies evers, weight loss,
weakness, incontinence, and history o trauma. He is unaware
o any amily history o back pain. He is otherwise healthy.
Question 11.11.1 What urther in ormation will help you
di erentiate between potential causes o his back pain?
A) Relie with acetaminophen.
B) Morning sti ness.
C) Relie with rest.
D) A and C.
E) B or C.
Answer 11.11.1 The correct answer is “E.” Determining the
pattern o the pain is critical. In ammatory causes o back pain
are characterized by morning sti ness and improvement with
activity. In contrast, degenerative back disease causes pain that
is exacerbated by activity and relieved with rest. In ammatory
back pain typically presents in younger patients; degenerative
back pain typically does not present be ore age 30 or 40. Acet-
aminophen and other analgesics may relieve pain rom either
category o disease and so will not help you narrow the diag-
nosis.
HELPFUL TIP:
In a yo n patient with back pain, also consider rac-
t res (e. ., spondylolysis, a bilateral pars de ect), in ec-
tion, disc disease, and osseo s mali nancies.
On urther questioning, your patient reports morning sti -
ness and pain that improves with stretching. Activity does
not seem to aggravate his back but inactivity does. He has had
no penile discharge, rash, or conjunctivitis and denies diar-
rhea or other GI symptoms. On physical examination, your
patient is surprised to nd that he cannot reach his toes as
he had been able to do just a ew months ago in track prac-
tice. Range o motion in the neck, arms, and legs is normal. A
ocused neurologic examination is normal. T ere is mild, di -
use tenderness over the lumbosacral spine and with percus-
sion over the sacroiliac joints. When supine on the examina-
tion table, a FABER maneuver ( exion, abduction, external
rotation) reproduces sacral pain.
Question 11.11.2 The history and physical examination are
most consistent with a diagnosis o :
A) Reactive arthritis ( ormerly termed Reiter syndrome).
B) Osteoarthritis o the lumbar spine.
C) Degenerative disc disease.
D) Ankylosing spondylitis.
E) Vertebral body tumor.
330 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
TABLE 11-8 PHYSICAL FINDINGS IN THE
SPONDYLOARTHROPATHIES
• Limited ran e o motion in the axial spine
• Peripheral arthritis
• Tenderness at the sacroiliac joints
• Enthesopathy (pain at tendon site insertion- partic larly the Achilles
tendon and plantar ascia synovitis)
• Extra-artic lar symptoms (anterior veitis in 30–40%, psoriasis,
inf ammatory bowel disease)
Answer 11.11.2 The correct answer is “D.” T e history and
physical examination are most consistent with ankylosing
spondylitis, a seronegative (RF negative) spondyloarthropathy.
Ankylosing spondylitis is the most common orm o spondylo-
arthropathy and is thought to have a prevalence o 1% in Cauca-
sian populations. Historically, there is a 5:1 male-to- emale ratio
(but this may also be because ankylosing spondylitis is less rec-
ognized in women). Studies based on radiographic appearance
and human leukocyte antigen (HLA) B27 typing show a much
lower male: emale ratio. In addition to the historical eatures
mentioned in the answer to the previous question, there is o en
a amily history o ankylosing spondylitis in patients ultimately
diagnosed with the disease.
“A” is incorrect. Reactive arthritis occurs in reaction to an
in ection (Chlamydia urethritis, GI in ection, etc.) and presents
with mono- or oligoarthritis, usually o the joints in the leg. T is
patient’s age makes osteoarthritis and degenerative disc disease
less likely, so “B” and “C” are wrong. Also, he has no neurologic
ndings that you might expect with disc prolapse. Malignancy
is associated with constitutional symptoms ( ever and weight
loss), neurologic involvement, and steadily worsening pain that
is not relieved by activity—none o which are present in this
case. Physical examination ndings o spondyloarthropathies
are listed in able 11-8.
HELPFUL TIP:
The FABER (Flexion, Abd ction, External Rotation) test,
also known as the “ i re 4” test, is per ormed by hav-
in the patient lie s pine, passively lexin the knee to
90 de rees, restin the patient’s oot on the contralat-
eral thi h j st above the knee, and applyin press re
laterally and downward on the ipsilateral knee. When
viewed rom above, the patient’s le s take on the
“ i re 4” appearance. The pelvis sho ld be stabilized
by the examiner. A positive test occ rs i ipsilateral hip
or sacroiliac (SI) joint pain is reprod ced. It is non-spe-
ci ic and can be positive in many diseases o the SI joint
and hip.
Question 11.11.3 Time or some tests! Which o the ollow
ing is the best initial test that can be used to con rm the
diagnosis o ankylosing spondylitis?
A) ANA.
B) Lumbar spine radiographs.
C) HLA-B27.
D) ESR.
E) Sacroiliac joint radiographs.
Answer 11.11.3 The correct answer is “E.” T e hallmark o
ankylosing spondylitis is sacroiliitis on pelvic radiographs.
Although there are no universally accepted criteria or diagnos-
ing spondyloarthropathies, x-ray evidence o sacroiliitis in the
setting o a consistent clinical picture is suf cient to diagnose
ankylosing spondylitis. Un ortunately, in early ankylosing spon-
dylitis, x-rays are o en inconclusive. MRI is more sensitive or
detecting early sacroiliitis, but the cost is higher and may not
be necessary when plain x-ray images are strongly supportive
o sacroiliitis. T e rest o the answers are incorrect. Ankylosing
spondylitis is not associated with a positive ANA. Lumbar spine
x-rays may be use ul in ruling out other conditions and do show
some changes in ankylosing spondylitis but may miss early dis-
ease. HLA-B27, a class I HLA gene, is present in about 90% o
white patients and 50% to 80% o nonwhite patients with anky-
losing spondylitis and is generally associated with spondyloar-
thropathies. However, HLA-B27 is not speci c. It is present in
many normal individuals as well and is o very little diagnostic
value (although it does have a good negative predictive value).
ESR is slightly elevated in most cases o spondyloarthropathy,
but again it is not speci c.
Lumbar spine x-rays show squaring o the vertebral bodies.
Pelvic x-rays identi y mild symmetric sacroiliitis. You are
now con dent o the diagnosis o ankylosing spondylitis.
Question 11.11.4 Which o the ollowing management
plans is best or this patient?
A) Aspirin 650 mg by mouth our times daily (or Zorprin or
other extended release aspirin twice daily) and physical
therapy re erral.
B) Naproxen 500 mg twice daily and physical therapy re erral.
C) Orthopedic re erral or early surgical consideration.
D) Prednisone 40 mg daily and tting or a back brace.
E) Naproxen 500 mg twice daily and tting or a back brace.
Answer 11.11.4 The correct answer is “B.” NSAIDs are the
mainstay o medical therapy or active phases o spondyloar-
thropathy. Patients generally experience signi cant relie rom
NSAIDs, and any additional bene t rom systemic corticoste-
roids is questionable. Sul asalazine is a second-line drug. Inter-
estingly, aspirin tends to be less e ective in these patients. T us,
“A” is incorrect. T e management o ankylosing spondylitis
should also include an exercise regimen designed speci cally
or the patient, and physical therapy may play a key role. T e use
o braces is not help ul and may actually exacerbate the patient’s
symptoms. Orthopedic surgery only becomes necessary in cases
o advanced ankylosing spondylitis when kyphosis or periph-
eral joint symptoms become severe.
A er 3 months o physical therapy and NSAIDs, your patient
returns. He has noticed minimal bene t, and now you nd
limitation o his neck range o motion.

Question 11.11.5 What is the most appropriate next step
in the evaluation and management o this patient?
A) Discontinue naproxen and switch to indomethacin 50 mg
three times daily.
B) Begin methotrexate 15 mg per week and olic acid 1 mg
daily.
C) Begin prednisone 60 mg daily.
D) MRI o the cervical spine.
E) Continue naproxen and re er to rheumatology.
Answer 11.11.5 The correct answer is “E.” T e patient is losing
range o motion despite NSAID therapy. Re erral to a rheuma-
tologist to consider anti- NF therapy (e.g., in iximab, adalim-
umab, or etanercept) is the best next step. Anti- NF agents can
halt disease progression and o en improve range o motion in
early disease. “A” is incorrect. Switching NSAIDs may provide
some minor additional bene t but is unlikely to arrest disease
progression. “B” is incorrect: methotrexate may be bene cial or
the peripheral arthritis o spondyloarthropathies, but not or the
axial skeleton disease. “C” is incorrect since systemic cortico-
steroids have no value in treating spondyloarthropathies. Local
corticosteroid injections are o en bene cial or enthesopathy
and peripheral arthritis. “D” is incorrect. MRI o the cervical
spine will show in ammatory changes o the spine, but will not
change your management.
T e patient ails to keep his rheumatology appointment
and returns to you one year later. He is taking over-the-
counter naproxen. His neck is very sti , with even less range
o motion. He relates that he has been having crampy abdom-
inal pain, and loose stools with bloody mucous. He is having
dyspnea with mild exertion. On examination, his neck range
o motion is worse, and back exion is limited with straight-
ening o his lumbar lordosis.
Question 11.11.6 What is the next most appropriate step
in the evaluation and management o this patient?
A) Discontinue naproxen.
B) Check CBC with di erential and iron panel.
C) Consult gastroenterology or EGD and colonoscopy.
D) Consult rheumatology and tell patient he must keep his
appointment.
E) All o the above.
Answer 11.11.6 The correct answer is “E.” T e patient could
have enteropathic arthritis in association with in ammatory
bowel disease. NSAIDs can exacerbate in ammatory bowel
disease, and cause ulcers with chronic use, so discontinue
the naproxen (“A”). A CBC and iron panel may reveal iron
de ciency anemia, which would explain the patient’s dys-
pnea on exertion. Subspecialty evaluations by a gastroenter-
ologist and rheumatologist are indicated both to con rm the
diagnosis and to help with long-term disease management.
Anti- NF agents—like in iximab and adalimumab—but not
etanercept—are bene cial or both the spondyloarthropathy
and associated in ammatory bowel disease in enteropathic
arthritis.
CHAPTER 11 • RHEu MATOLOg Y 331
HELPFUL TIP:
The most common spondyloarthropathies are ankylos-
in spondylitis, psoriatic arthritis, enteropathic arthritis,
and reactive arthritis. These are patho enically similar
diseases that may be di ic lt to di erentiate in early
sta es, b t lack o di erentiation does not enerally
a ect therapy.
HELPFUL TIP:
Enteropathic arthritis occ rs req ently in patients
with in lammatory bowel disease, and has eat res in
common with ankylosin spondylitis, incl din in lam-
matory back pain and sacroiliitis. However, a reactive
spondyloarthropathy may also occ r a ter a g I in ection
s ch as Salmonella, Yersinia, Shigella, or Campylobacter
and other in ections s ch as chlamydia. Finally, other ill-
nesses s ch as celiac disease may ca se a reactive spon-
dyloarthropathy.
Objectives: Did you learn to . . .
• Reco nize clinical mani estations o spondyloarthropathies,
partic larly ankylosin spondylitis?
• Di erentiate between types o spondyloarthropathies?
• Develop an appropriate eval ation or the patient present-
in with inf ammatory back pain?
• Appropriately mana e a patient with ankylosin spondylitis?
QUICK QUIZ: SPONDYLOARTHROPATHIES
Which o the ollowing is NO a characteristic o reactive
arthritis?
A) Conjunctivitis.
B) Keratoderma blenorrhagicum.
C) HLA-B8.
D) Urethritis.
E) Arthritis.
The correct answer is “C.” Reactive arthritis ( ormerly Reiter
syndrome) is associated with HLA-B27 and not HLA-B8 (which
is ound in sclerosing cholangitis). All o the other choices are
seen with reactive arthritis, including keratoderma blenorrhagi-
cum, which is a rash ound especially on the soles o patients
with reactive arthritis. T e urethritis is generally due to Chla-
mydia trachomatis.
HELPFUL TIP:
The onset o reactive arthritis is less insidio s than that
o ankylosin spondylitis, with some patients presentin
with an ac te illness that incl des ever, ac te joint swell-
in , and rash (keratoderma blenorrha ic m). g enerally,
reactive arthritis resolves within 12 months. Antibiot-
ics are not e ective as a treatment o reactive arthritis
(altho h may be indicated or the nderlyin in ection).
332 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
CASE 11.12
A 52-year-old emale presents to your of ce or an initial
visit and complains o mild pain and weakness in her hips
and thighs. T e symptoms have been present or months.
About 2 years ago another doctor diagnosed her with psoria-
sis because o a rash on her hands and elbows, which has since
resolved. Otherwise, she reports being relatively healthy and
taking no medications. She is a smoker. She has had no recent
health screening. On physical examination, her vitals are nor-
mal. She has considerable dif culty getting out o her chair.
Her strength is symmetrically diminished in the quadriceps
and hip exors. T e rest o the examination is unremarkable.
Question 11.12.1 Which o the ollowing diagnostic tests
do you order rst?
A) Muscle biopsy.
B) Electromyography (EMG).
C) SH.
D) ANA.
E) roponin- .
Answer 11.12.1 The correct answer is “C.” Hypothyroid-
ism (along with many other diseases . . . . see below) can cause
a proximal muscle weakness. A muscle biopsy or EMG study
is premature without rst evaluating or myopathy with serum
enzyme levels (CK, aldolase). “D,” an ANA, is not likely to be
help ul. Autoimmune diseases such as polymyositis and derma-
tomyositis cause myopathy, but ANA is not speci c or diagnos-
ing these diseases. Finally, although CK-MB may be elevated
in patients with myopathy, troponin- (“E”) is an enzyme rela-
tively speci c to cardiac muscle and should be normal.
You order SH and CBC, which are both within normal lim-
its. ESR, CK, and AS are elevated. You proceed to order that
EMG which demonstrates abnormalities o the paraspinal
muscles. Your patient returns to discuss her test results and
complains that her psoriasis is back. T ere are violaceous
plaques on her knuckles and elbows and around her eyes.
Question 11.12.2 You recommend the ollowing manage
ment plan or the disease:
A) Ultraviolet light therapy.
B) opical corticosteroids.
C) Oral corticosteroids.
D) opical emollients.
E) Acetaminophen.
Answer 11.12.2 The correct answer is “C.” T is patient now
has ndings that support a diagnosis o dermatomyositis. o
diagnose idiopathic in ammatory myopathy, such as dermato-
myositis or polymyositis, certain criteria must be present (see
able 11-9). T is patient has three o these criteria plus skin
changes consistent with dermatomyositis. Violaceous plaques
on the knuckles are commonly called Gottron papules. Similar
lesions are o en observed over pressure points (e.g., elbows).
Because dermatomyositis is a systemic condition, treatment
TABLE 11-9 DIAGNOSTIC CRITERIA FOR
POLYMYOSITIS AND DERMATOMYOSITIS
Three o o r are req ired:
• Elevated m scle enzymes (CPKand aldolase)
• Symmetrical proximal m scle weakness
• Abnormal EMg
• Consistent ndin s on m scle biopsy
Note: Skin ndin s m st be present in order to dia nose dermatomyositis.
should likewise be systemic. Local topical therapies do not
treat the disease, and oral corticosteroids are typically the
rst-line agents. Hydroxychloroquine is help ul when the rash
does not respond to corticosteroids. Addition o immunosup-
pressive drugs, such as methotrexate or azathioprine, may be
indicated.
Question 11.12.3 You diagnose dermatomyositis. Which o
the ollowing tests and exams should now be ordered?
A) Pap and pelvic examination, CA-125, and pelvic ultrasound.
B) Screening mammogram.
C) Chest radiograph.
D) Fecal occult blood screening.
E) All o the above.
Answer 11.12.3 The correct answer is “E.” Patients with adult-
onset dermatomyositis have a six- old increased risk o develop-
ing cancer. T ere ore, upon diagnosing dermatomyositis, a thor-
ough history and physical examination must be per ormed. All
patients should undergo age-appropriate cancer screening tests
(e.g., Pap smear, ecal occult blood testing, and mammography).
Also, other tests generally recommended include CBC, meta-
bolic pro le, liver unction tests, urinalysis, and chest x-ray—
especially important in smokers. Since the patient is over age 50,
colonoscopy is indicated. T e cancers most commonly associ-
ated with dermatomyositis include ovarian and gastric cancers
and lymphoma. T ere ore, it is reasonable to consider CA-125
and pelvic ultrasound.
HELPFUL TIP:
The association o dermatomyositis with g I mali nancy
is partic larly stron . Yo may consider endoscopies
and an alpha- etoprotein ( or astric cancer). Some a -
thorities also s est CT o the abdomen and pelvis to
r le o t mali nancy.
HELPFUL TIP:
Other ca ses o proximal m scle weakness incl de al-
cohol se, m sc lar dystrophy, medications (e. ., peni-
cillamine and HMg -CoA red ctase inhibitors), C shin
syndrome, viral in ections, hypothyroidism and diabetes
mellit s. The list oes on, incl din myasthenia ravis
and Eaton–Lambert syndrome.

Objectives: Did you learn to . . .
• Reco nize symptoms and si ns o dermatomyositis and
polymyositis?
• Describe how inf ammatory myopathies are eval ated and
dia nosed?
• Appreciate the relationship between mali nancy and inf am-
matory myopathy?
QUICK QUIZ: ARTHRITIS AND JOINT
INVOLVEMENT
Compared with RA, osteoarthritis has a greater predilection or
which o the ollowing joints?
A) MCPs.
B) DIPs.
C) Knees.
D) Wrists.
The correct answer is “B.” Osteoarthritis tends to a ect the DIP
and PIP joints in the hand, sparing the MCP joints, whereas RA
a ects the MCPs and spares the DIPs. Both disease processes
may involve the knees and wrists.
Clinical Pearls
Aspirate a monoarthritis and send synovial l id or cell co nt
with di erential, ram stain, c lt re and crystal analysis or
eval ation and r le o t o a septic joint.
Be in s pplementation with calci m and vitamin D or
osteoporosis prevention with initiation o corticosteroids in
the treatment o rhe matolo ic disease.
Do not delay initiation o hi h dose corticosteroids or
treatment o iant cell arteritis while awaitin a temporal
artery biopsy.
Do not rely pon ser m ric acid levels to dia nose or re te
a o t attack.
Do not ro tinely order “rhe matolo y panels.” Order
appropriate rhe matolo ic tests based on clinical eval ation
and speci ic disease nder consideration.
Do not ro tinely screen or Lyme disease or chronic
m sc loskeletal pain. Repeat a ter s: “There is no s ch thin
as chronic Lyme disease.”
Do not se opioid pain medications in treatin chronic pain
related to ibromyal ia as they tend to worsen central
sensitization and increase ibromyal ia pain over time.
Ens re that women o child-bearin a e on methotrexate
have reliable contraception.
Prescribe a trial o DMARDs (disease modi yin anti-
rhe matic dr s) as irst-line therapy in rhe matoid arthritis.
u se the lowest and minim m e ective prednisone dose or
ac te symptomatic relie o in lammatory arthritis.
CHAPTER 11 • RHEu MATOLOg Y 333
BIBLIOGRAPHY
Aletaha D, et al. Rheumatoid arthritis classi cation criteria:
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Against Rheumatism collaborative initiative. Arthritis
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Álvarez-Lario B, MacArrón-Vicente J. Is there anything good
in uric acid? Q J Med. 2011; 104(12):1015–1024.
Bhate C, Schwartz RA. Lyme disease: Part I. advances and
perspectives. J Am Acad Dermatol. 2011;64(4):619–636.
Bhate C, Schwartz RA. Lyme disease: Part II. Management and
prevention. J Am Acad Dermatol. 2011;64(4):639–653.
Botzoris V, Drosos AA. Management o Raynaud’s phenom-
enon and digital ulcers in systemic sclerosis. Joint Bone
Spine. 2011;78(4):341–346.
Clauw DJ. Fibromyalgia: a clinical review. JAMA. 2014;311(15):
1547–55.
Dasgupta B, et al. Provisional classi cation criteria or polymy-
algia rheumatica. Arthritis Rheum. 2012;64(4):943–954.
Dougados M, Baeten D. Spondyloarthritis. Lancet.
2011;377:2127–2137.
Firestein GS, et al., eds. Kelley’s extbook o Rheumatology.
9th ed. Philadelphia: Elsevier Saunders; 2012.
Haile Z, Khatua S. Beyond osteoarthritis: recognizing and
treating in ectious and other in ammatory arthropathies
in your practice. Prim Care Clin Of ce Pract. 2010;37(4):
713–727, vi.
Khanna D, et al. American College o Rheumatology guide-
lines or management o gout part II: therapy and anti-
in ammatory prophylaxis o acute gouty arthritis.
Arthritis Care Res. 2012;64(10):1447–1461.
Klippel JH, et al., eds. Primer on the Rheumatic Diseases.
13th ed. New York: Springer; 2007.
Margaretten ME, et al. Does this adult patient have septic
arthritis? JAMA. 2007;297(13):1478–1488.
Marmor MF, et al. Revised recommendations on screening or
chloroquine and hydroxychloroquine retinopathy.
Ophthalmology. 2011;118(2):415–22.
Nam JL, et al. Ef cacy o biological disease-modi ying anti-
rheumatic drugs: a systematic literature review in orming
the 2013 update o the EULAR recommendations or the
management o rheumatoid arthritis. Ann Rheum Dis.
2014;73:516–528.
Pincus , Gibson KA, Shmerling RH. An evidence-based
approach to laboratory tests in usual care o patients
with rheumatoid arthritis. Clin Exp Rheumatol. 2014;
32(Suppl 85):S23–8.
Singh JA, et al. 2012 updated to the 2008 American College o
Rheumatology recommendations or the use o disease-
modi ying antirheumatic drugs and biologic agents in
the treatment o rheumatoid arthritis. Arthritis Care Res.
2012;64(5):625–639.
Van Hecke O. Polymyalgia rheumatic-diagnosis and manage-
ment. Aust Fam Physician. 2011;40(5):303–306.
Villa-Forte A. Giant cell arteritis: suspect it, treat it promptly.
Cleve Clin J Med. 2011;78(4):265–270.
Orthopedics and Sports Medicine
Ross E. M h sen, N chol s E w r s, Br L. M rcussen, n Jon N. V n Heukelom
General note: I you have a choice between acetaminophen and
an NSAID or an acute injury, acetaminophen will always be
the right choice. Most acute injuries are not in ammatory and
acetaminophen is a lot sa er without gastropathy or platelet in-
hibition. I you do use an NSAID, naproxen is the sa est rom a
cardiovascular standpoint but carries the same gastrointestinal
risks as other NSAIDs.
CASE 12.1
A 5-year-old boy presents with acute onset o le t anterior
thigh and hip pain that began 2 days ago with no known
prior trauma. He reports that it initially “loosened-
up” a ter he had been out o bed or a ew hours but has
become worse again by a ternoon. His pain is exacerbated
by weight bearing and active or passive range o motion
(ROM). His mother notes that he had a cold 7 to 10 days
ago, but has been asymptomatic until he complained o
thigh pain two nights ago. She also notes that he has had a
low-grade ever. He has no other signi icant constitutional
symptoms and appears to be in some pain, but otherwise
he appears well.
Question 12.1.1 Based on the in ormation obtained thus
ar, which o the ollowing is the most likely diagnosis?
A) Osteomyelitis.
B) Rheumatic ever.
C) Slipped capital emoral epiphysis (SCFE).
D) Legg–Calve–Perthes disease (LCPD).
E) ransient (toxic) synovitis.
Answer 12.1.1 The correct answer is “E.” T is presentation
is classic or transient (toxic) synovitis. T is is the most com-
mon cause o hip pain in children aged 3 to 0 years, with peak
occurrence in ages 5 to 6 years. It is more commonly seen in
boys (male: emale ratio o 2–3: ) and is o en preceded by a
viral respiratory in ection, although numerous studies have
ailed to demonstrate a speci c viral or bacterial agent. Physical
examination reveals a limp or re usal to walk and complaint o
pain over the groin and/or proximal thigh. T ere is pain with
334
12
ROM testing, especially during abduction. Most children will
be a ebrile with a temperature o ≤ 38°C.
Question 12.1.2 Appropriate diagnostic work up might
include which o the ollowing?
A) Joint aspiration.
B) Plain lm radiographs.
C) In ammatory markers including erythrocyte sedimentation
rate (ESR) and C-reactive protein (CRP).
D) CBC with di erential.
E) All o the above.
Answer 12.1.2 The correct answer is “E.” All o the above may
be appropriate as transient synovitis is a diagnosis o exclusion.
Patients with mild symptoms may be observed without ur-
ther investigation. However, i the pain is signi cant, ROM is
signi cantly impaired, or the temperature is > 37.5°C, urther
diagnostic work-up is indicated. Laboratory ndings consistent
with transient synovitis include: clear joint uid aspirate, nor-
mal CBC, and a mildly increased ESR. Blood cultures, antistrep-
tolysin O (ASO) titer, bone scan, and MRI may also be o bene t
to rule out other possibilities (e.g., septic arthritis, rheumatic
ever, and SCFE). It is o extreme importance to di erentiate
transient synovitis rom septic arthritis. Un ortunately, there
is no combination o physical ndings and laboratory tests
short o joint uid that will de nitively rule out septic arthri-
tis. T ere are published clinical decision tools, but these are
generally based on observational data and o en have con ict-
ing results. It requires clinical judgment; decide which patients
you are worried enough about that you want to commit them to
hip joint aspiration.
HELPFUL TIP:
Sep c r hr s s n or hope c emergency n com-
monly presen s w h n elev e emper ure, gen-
er l m l se, pronounce p n—o en w h sp sm n
gu r ng. Gener lly, you w ll lso see n elev e wh e
bloo cell (WBC), CRP, n ESR, although neither these
or fever is a good enough indicator to rule out a

TABLE 12-1 TERMINOLOGY FOR DESCRIBING
A FRACTURE
Avulsion fracture: Fr gmen o bone pulle rom s norm l pos on
by muscul r con r c on or res s nce o l g men .
Closed fracture: a r c ure h oes no commun c e w h he
ex ern l env ronmen ( .e., no hrough he sk n).
Comminuted fracture: Cons s ng o hree or more r gmen s.
Greenstick fracture: incomple e, ngul e r c ure o long bone,
p r cul rly n ch l ren.
Open fracture: Fr c ure h commun c es w h he ex ern l
env ronmen .
Torus (Buckle) fracture: d escr be s buckle r c ure or compress on
o he bone w hou cor c l srup on. Seen espec lly n he s l
ore rms o ch l ren.
septic joint by their normality or absence. Jo n lu
w ll h ve numerous WBCs (cl ss c e ch ng s > 50,000
WBC/mm 3, however, coun s lower h n h s o no rule
ou sep c r hr s (50,000 WBC/mm 3 s only 62% sen-
s ve w h 25,000 WBC/mm 3 s ll only 77% sens ve).
Bloo cul ures re pos ve n 30% o p en s.
Question 12.1.3 What is the most appropriate treatment
or this patient with transient synovitis?
A) Open xation.
B) Immobilization.
C) Antibiotics.
D) Surgical decompression.
E) Ibupro en and rest.
Answer 12.1.3 The correct answer is “E.” Conservative treat-
ment is warranted: the appropriate initial treatment is rest,
weight bearing as tolerated, and observation. ransient syno-
vitis generally responds well to oral NSAIDs. Home care is
acceptable; however, admission is indicated i the diagnosis is
equivocal or i signi cant pain management is required. For
septic arthritis, prompt administration o an intravenous (IV)
antibiotic—directed at the most likely in ecting pathogen and
altered as necessary based on culture results—is indicated. Sur-
gical irrigation o the joint is o en necessary and early orthope-
dic consultation is needed.
Objectives: Did you learn to . . .
• Recogn ze he cl n c l presen on o r ns en synov s?
• d eren e r ns en synov s rom sep c r hr s?
• t re p en w h r ns en synov s?
CASE 12.2
A 6-year-old white male is brought into clinic by his par-
ents because he is complaining o pain in his hip and ante-
rior thigh. He is walking much less than usual since the pain
began about 4 weeks ago. You order a plain radiograph,
which shows mild sclerosis with some increased density o
the emoral head. An MRI is ordered, which the radiologist
interprets as “demonstrating osteonecrosis o the emoral
head.”
CHAPTER 12 • ORt HOPEd iCS a Nd SPORt S MEd iCiNE 335
Question 12.2.1 What is the most likely diagnosis in this
patient?
A) Osteomyelitis.
B) Septic arthritis.
C) SCFE (Slipped Capital Femoral Epiphysis).
D) LCPD (Legg-Calve-Perthes Disease).
E) Sickle cell anemia.
Answer 12.2.1 The correct answer is “D.” LCPD is idiopathic
osteonecrosis o the emoral head. It is unilateral in 90% o
cases, and the typical age range is 4 to 8 years, but patients may
be as young as 2 years and as old as 2 years. “A” is a possibility,
although there should be evidence o osteomyelitis on MRI. “B”
is discussed in the previous case. “C,” SCFE, classically occurs in
obese children (male predominance) who are 0 to 6 years old.
“E,” sickle cell anemia, can cause osteonecrosis o the emoral
head also, but the disease is rare in white populations. LCPD is
less common in black populations.
Question 12.2.2 Which o the ollowing actors best pre
dicts a poor outcome or patients with LCPD?
A) Later age at onset o illness.
B) Findings o subchondral ractures or ragmentation.
C) Early appropriate treatment.
D) Severity o pain and ability to bear weight.
E) Bilateral involvement.
Answer 12.2.2 The correct answer is “A.” Compared to older
children, younger children generally have a longer time or
remodeling to occur via molding o the emoral head within the
acetabulum; and there ore, younger children have less attening
o the emoral head.
Question 12.2.3 Which o the ollowing is the best initial
treatment or this patient with LCPD?
A) Joint replacement.
B) Osteotomy.
C) Rest and physical therapy.
D) Opioids.
E) Corticosteroid injection o the hip joint.
Answer 12.2.3 The correct answer is “C.” T e initial treatment
or a patient with LCPD typically includes rest, activity restric-
tion, and physical therapy. T e objectives are to increase ROM
in the hip and to reduce the risk o signi cant de ormity. In gen-
eral, patients should be seen by an orthopedic specialist. T e
likelihood o a good outcome with nonoperative treatment is
signi cantly higher in younger patients, less than 8 years o age.
“A” is incorrect because joint replacement is not an option. “B” is
incorrect. While osteotomy may be used, it is typically reserved
or older children and patients who are not progressing well with
conservative therapy. “D” and “E” are not appropriate interven-
tions in this patient with mild pain and no joint in ammation.
LCPD is dif cult to treat largely because o the long duration o
treatment and activity restrictions required. Periods o rest with
activity restriction, physical therapy, and surgical intervention
336 Fa MiLY MEd iCiNE EXa MiNa t iON & BOa Rd REViEW
may be indicated over 1 to 2 years o treatment and observa-
tion. Even with the best o care, prognosis is air with need or
total hip replacement reaching approximately 50% by middle
age due to severe degenerative arthritis.
Objectives: Did you learn to . . .
• Recogn ze he cl n c l presen on o LCPd ?
• M n ge p en w h LCPd ?
CASE 12.3
A 15-year-old emale cross-country runner presents to your
clinic with the chie complaint o bilateral knee pain. She
describes a gradual increase in her symptoms during the rst
3 weeks o the season. She wants to run varsity this year and
has done extra running and hill training a er practice each
day. She describes anterior knee pain in the patellar region
with little or no swelling, but complains o crepitus and pain
exacerbated by running, squatting, stair climbing, and pro-
longed sitting with the knee bent.
Question 12.3.1 The most likely diagnosis or the condition
described is:
A) Osgood–Schlatter disease.
B) Chondromalacia patellae.
C) Patello emoral pain syndrome (PFPS).
D) Femoral stress racture.
E) Jogger’s joints.
Answer 12.3.1 The correct answer is “C.” PFPS is a common
overuse syndrome seen more requently in runners and emale
athletes (thus the moniker “runner’s knee”). T is condition is due
to orces across the knee that lead to biomechanical overload o
the patello emoral joint and other anterior knee structures. Mal-
tracking and malalignment o the patello emoral joint can con-
tribute to this overload, as can training errors, core weakness, and
muscle imbalance. “B,” Osgood–Schlatter disease, is also related
to overuse but is 2 to 3 times more common in males, particularly
in athletes engaging in repetitive jumping. T e pain o Osgood–
Schlatter is generally well localized to the tibial tubercle. Radio-
graphic evidence o ragmentation o the epiphysis or hetero-
tropic ossi cation anterior to the tubercle may be seen but is not
necessary or diagnosis. “C,” chondromalacia patella, is so ening
o the articular cartilage o the patella as seen on arthroscopy and
may be a result o long-term patello emoral dys unction. T is is
a surgical diagnosis and the term should be avoided clinically.
Femoral stress racture (“D”) would be unlikely to present bilat-
erally. “E” is not a real thing but has nice alliteration.
Question 12.3.2 What is the pre erred treatment or this
emale runner?
A) Arthroscopic debridement.
B) Decreased activity level along with and quadriceps and hip
strengthening exercises.
C) Evaluation or “Female Athlete riad.”
D) Casting or immobilization.
E) Corticosteroid injection.
Answer 12.3.2 The correct answer is “B.” T e most e ective
treatment modality is a combined physical therapy regimen
consisting o strength training o the hip abductors and quadri-
ceps, as well as quadriceps stretching. Quadriceps strengthening
is usually initiated by resisted straight leg raises (SLRs) to mini-
mize patello emoral compressive orces. NSAIDs, cross-training,
and core strengthening may also be o bene t. Adjunctive tri-
als o therapeutic modalities such as orthotics may be consid-
ered, but should not be used in isolation. Recalcitrant cases
and patients with recurrent dislocation/subluxation should be
re erred to your riendly neighborhood orthopedic surgeon or
consideration o surgical intervention.
T ree months later, the same patient presents complaining o
unilateral right knee pain over the medial knee joint. Again,
this pain is exacerbated by knee exion and she notes pop-
ping and snapping when she stands rom sitting. She notes
that the pain is worse a er prolonged sitting or going up or
downstairs. Your examination shows tenderness about 1 cm
medial to the patella with palpable ullness in the area.
Question 12.3.3 The most likely diagnosis is:
A) Osteosarcoma
B) Medial collateral ligament (MCL) strain
C) Plica syndrome
D) Recalcitrant PFPS
E) Meniscal tear
Answer 12.3.3 The correct answer is “C.” T is is the typical
presentation o plica syndrome. Plicae are synovial remnants
that did not resorb properly during development. T ey can be
irritated, usually chronically or subacutely, especially in sports
that require repeated exion o the knee (e.g., rowing, cycling,
running etc.). ypical symptoms include popping or snapping
sensation with knee exion; there may also be knee locking and
catching as well as having the knee “give.” reatment includes
rest, ice, quadriceps strengthening, and NSAIDs. I conservative
management ails, steroid injection or arthroscopy may alleviate
the symptoms.
HELPFUL TIP:
t he pl c shoul be p lp ble. a me l/ n er or pl c s
he mos common (be ween he p ell n he me l
jo n l ne). i c n lso occur l er lly n e her bove or
below he m -pole o he p ell .
Objectives: Did you learn to . . .
• i en y n m n ge PFPS?
• Recogn ze pl c syn rome?
CASE 12.4
A mother brings her 18-month-old son in or well child
check. Her only new concern today is that he seems to walk
“bow-legged.” He has been somewhat pigeon-toed since he
could pull himsel up and cruise along walls and urniture at

home. On examination, you nd the child’s eet to be point-
ing inward. T e oot is exible and looks normal. T e patellae
are in a neutral position acing directly orward.
Question 12.4.1 What is the most likely diagnosis in this
patient?
A) Cerebral palsy.
B) Excessive emoral retroversion.
C) Fore oot varus.
D) Internal tibial torsion.
E) Bilateral developmental dysplasia o the hip (DDH).
Answer 12.4.1 The correct answer is “D.” T is represents
a case o intoeing (pigeon-toeing), which is o en caused by
internal tibial torsion. Internal tibial torsion is characterized by
a exible, normal oot, with the patellae in a neutral position.
T e condition can be diagnosed by examining the child on his
knees. Normally, there should be approximately 30 degrees o
external rotation o the eet in this position. With internal tibial
torsion, the toes will be pointing inward. In addition, when the
child is sitting with legs dangling over a table, the lateral malleo-
lus will be anterior to the medial malleolus, which is the oppo-
site o what is normally observed. Finally, the hips must be nor-
mal in order to con rm this diagnosis. “A” is incorrect because
you would expect other ndings in a patient with cerebral palsy.
“B” is incorrect. In act, emoral retroversion is synonymous
with “outtoeing,” which is the opposite o intoeing (o course!).
Excessive emoral anteversion can be a cause o intoeing. “C”
is incorrect because the oot examination does not show varus
de ormity. Finally, “E” is incorrect, although bilateral DDH can
be quite dif cult to diagnose i not caught early in the newborn
period. With DDH one would expect external rotation o the
leg rather than intoeing.
Question 12.4.2 What is the treatment o choice or this
child?
A) Re erral or bilateral osteotomy.
B) Shoe modi cation and bracing.
C) Physical therapy re erral.
D) Serial casting.
E) Reassurance and watch ul waiting.
Answer 12.4.2 The correct answer is “E.” Spontaneous resolu-
tion is the norm or most intoeing and outtoeing de ormities.
Most will spontaneously correct by age 6. Children continu-
ing to have dif culty with persistent trips and alls or grossly
unsightly gait beyond this time may bene t rom a rotational
osteotomy. Children with neuromotor disorders and cerebral
palsy are more likely to require surgical intervention.
HELPFUL TIP:
a no her c use o n oe ng s emor l ors on. Femor l
ors on s gnose by pl c ng he p en prone w h
he h ps n neu r l n knees lexe o 90 egrees. Fee
re ro e w y rom m l ne o me sure n ern l
CHAPTER 12 • ORt HOPEd iCS a Nd SPORt S MEd iCiNE 337
ro on ( n evers on). For ex ern l ro on (re rover-
s on), pl ce one h n on he bu ocks n move one leg
hrough m l ne un l he pelv s beg ns o l . t yp c lly,
norm l ex ern l ro on s 45 egrees, n norm l n-
ern l ro on s 35 egrees. Ro on gre er h n h s
s cons ere excess ve s ccomp n e by l m e
ROM n he oppos e rec on. In a ddition, when a pa -
tient with femora l torsion is sea ted with legs da ngling,
the pa tella e will not fa ce forwa rd (they fa ce inwa rd for
intoeing a nd outwa rd for outtoeing).
Objective: Did you learn to . . .
• Ev lu e n m n ge n oe ng n ou oe ng n ch l ren?
CASE 12.5
A 13-year-old male presents to the clinic with his mother or
dif culty walking. He is unsure o when the problem rst
began, but has noticed it getting worse over the last week. It
has orced him to stop playing sports. He reports a dull pain
in the le hip but denies trauma. On examination, you nd
an obese male in no distress. T ere is loss o internal rotation,
abduction, and exion at the le hip joint. When his hip is
exed to 90 degrees, this loss o ROM is more pronounced.
Question 12.5.1 What is the most likely diagnosis in this
case?
A) Osteoarthritis.
B) Septic arthritis.
C) SCFE.
D) LCPD.
E) Juvenile rheumatoid arthritis.
Answer 12.5.1 The correct answer is “C.” SCFE occurs most
commonly in active, overweight, adolescent males. Shear orces
across the relatively weak physis causes displacement. Slip-
page is generally gradual, but may occur acutely. Mean age
at presentation is 2 or emales (range 0– 4) and 3 or males
(range – 6). Endocrinopathies, such as hypothyroidism and
osteodystrophy, should be considered in those presenting atypi-
cally or outside the typical age range. Watch or development o
a similar process in the contralateral hip over time, which has
been reported anywhere rom 20% to 80% o the time.
Question 12.5.2 Which o the ollowing is the rst study you
order to con rm the diagnosis?
A) AP and rog-leg lateral radiographs o the hip.
B) C scan o the hip/pelvis.
C) MRI o the hip/pelvis.
D) ESR.
E) None; physical examination is suf cient.
Answer 12.5.2 The correct answer is “A.” Radiographs o the
hip should demonstrate displacement o the emoral head,
which can then be classi ed as mild, moderate, or severe.
338 Fa MiLY MEd iCiNE EXa MiNa t iON & BOa Rd REViEW
“B” and “C” are incorrect because the radiograph is diagnostic
in most cases. “D” is incorrect since SCFE is not an in amma-
tory condition. “E” is incorrect. Imaging should be obtained in
order to con rm the diagnosis and rate the severity. MRI may be
able to diagnose an early SCFE when radiographs are negative.
Question 12.5.3 The treatment o choice or this patient is:
A) Antibiotics.
B) Immobilization.
C) Physical therapy.
D) Surgical decompression.
E) Surgical xation.
Answer 12.5.3 The correct answer is “E.” T e goals o treat-
ment o SCFE are to prevent urther slippage, promote closure
o the physis, and to minimize the risk o osteonecrosis or chon-
drolysis. T ese aims are best accomplished through re erral to
an orthopedic surgeon and, ultimately, surgical xation. “B”
and “C” are incorrect because they delay de nitive therapy and
will not produce the desired result. “A” and “D” are incorrect
because SCFE is not an in ectious process.
Objectives: Did you learn to . . .
• Recogn ze he cl n c l presen on o ch l w h SCFE?
• t re p en w h SCFE?
CASE 12.6
A worried mother presents with her 4-year-old son or evalu-
ation o lower extremity pain. She reports the boy has com-
plained o some vague bilateral leg pains over the past several
weeks a er vigorous physical activities. She became alarmed
a er he had awakened the past two nights crying in pain.
T e boy reports the pain is hardly noticeable during the day.
Recently, the pain has been in the bilateral distal thighs; how-
ever, his mother notes times o unilateral pain. T e boy and
his mother both deny constitutional symptoms now or over
the past several weeks. Examination reveals an a ebrile, well-
developed male in no distress. T e musculoskeletal examina-
tion is normal.
Question 12.6.1 The most likely diagnosis or the condition
described above is?
A) Ewing sarcoma.
B) Growing pain.
C) Kohler disease.
D) Leukemia.
E) Osteochondritis dissecans.
Answer 12.6.1 The correct answer is “B.” Growing pain is a
diagnosis o exclusion, although history and physical examina-
tion usually suf ce or excluding more serious diagnoses. It is
a condition o unknown etiology, but is thought by some to be a
result o overuse/over activity on an immature musculoskeletal
system. It is most requently seen in otherwise healthy, active
children aged 2 to 5, with some older children a ected as well.
Pain is commonly bilateral or/and localized to the cal , but may
be elt at the ankle, knee, or thigh. Pain may be elt during the
day a er vigorous activities but is more common in the evening
or causing awakening at night. Presentation with constitutional
symptoms should lead to radiographic and/or metabolic evalu-
ation.
Question 12.6.2 Which o the ollowing should you enter
tain when a patient presents with typical growing pain?
A) Osteomyelitis.
B) Malignancy.
C) Juvenile rheumatoid arthritis.
D) All o the above.
E) None o the above.
Answer 12.6.2 The correct answer is “D.” It is important to
consider other potential causes o what would otherwise appear
to be growing pain. Although you may not nd it necessary to
per orm any laboratory or radiologic studies, you should at least
keep these and other diagnoses in mind when taking your his-
tory and per orming your examination. Remember, growing
pain is a diagnosis o exclusion.
HELPFUL TIP:
Severe or pers s en p n ur ng he y is not “grow ng
p n.” By e n on, “grow ng p n” occurs pr m r ly
n gh n s be er ur ng he y.
Question 12.6.3 Treatment or growing pain includes:
A) Reassurance, rest, and short-term use o NSAIDs.
B) Amputation.
C) Chemotherapy and radiation.
D) Casting and bracing ollowed by physical therapy.
E) Staging o the disease is required prior to initiation o
therapy.
Answer 12.6.3 The correct answer is “A.” OK, so this was just
a un one. Do not do anything drastic or a benign condition!
T ose o you who chose “B,” amputation, will nd themselves
in one o Dante’s circles (or in court—which is worse?) . . . and
clearly need a co ee break.
T e same boy returns with his mother years later. He is now
12 years old and requires a physical examination or junior
high school sports. You plan to evaluate him or scoliosis.
Question 12.6.4 Which o the ollowing screening methods
is the most sensitive or detecting scoliosis?
A) Observe the patient rom the ront with a loose- tting shirt
on. Measure the di erence in shoulder height.
B) Observe the patient rom behind, with shirt o , while he
bends orward at the waist. Look or elevation o the ribs or
paravertebral muscle mass on one side.
C) Observe the patient rom the ront, with shirt o , while he
bends orward at the waist. Look or elevation o the ribs or
paravertebral muscle mass on one side.

D) Observe the patient rom the side, with shirt o , while he
bends orward at the waist. Look or elevation o the ribs or
paravertebral muscle mass on one side.
Answer 12.6.4 The correct answer is “B,” which is known as
the “ orward bending test.” T is test is more sensitive than the
other methods described. T e orward bending test is accom-
plished by having the patient bend at the waist with eet together
and hands hanging ree. Observe the patient rom behind and
note any elevation o the ribs or paravertebral muscle mass on
one side. T e elevation should be measured in degrees (incli-
nometers are available), and an inclination o 5 degrees or more
should be evaluated urther. Options “A,” “C,” and “D” are not
accepted methods o screening or scoliosis.
HELPFUL TIP:
Routine screening for scoliosis is a recommenda-
tion “D” by the US Preventative Services Task Force.
Rou ne scol os s screen ng is not recommen e . i m y
be ppropr e n p en s who h ve no ce p n or
some o her bnorm l y. d on’ o !
HELPFUL TIP:
Scol os s s l er l curv ure o he sp ne, usu lly c-
comp n e by ro on n gener lly occurr ng n he
hor c c or lumb r re s. i c n occur w h excess ve
kyphos s (pos er orly convex curv ure) or lor os s ( n-
er orly convex curv ure).
On orward bending test, you nd slight elevation o the
le paravertebral muscles mass, which you estimate to be
7 degrees. T e remainder o the examination is normal. You
decide to obtain radiographs that show 12 degrees o angula-
tion (Cobb angle).
Question 12.6.5 This patient’s scoliosis is most likely:
A) Congenital.
B) Idiopathic.
C) Related to a tumor.
D) Secondary to in ection.
Answer 12.6.5 The correct answer is “B.” Most scoliosis that
develops during adolescence is idiopathic. When there is no
pain, ever, weight loss, or other warning signs (e.g., neuro-
logic symptoms), the curvature is unlikely to be due to tumor
or in ection. “A,” congenital scoliosis, typically presents earlier
in li e.
Question 12.6.6 The most appropriate initial management
plan or this patient includes:
A) Bracing.
B) Observation.
C) Physical therapy.
D) Surgery.
CHAPTER 12 • ORt HOPEd iCS a Nd SPORt S MEd iCiNE 339
Answer 12.6.6 The correct answer is “B.” In an otherwise
healthy patient with a curvature measured at < 25 degrees,
observation is appropriate. “C” is incorrect because physical
therapy and exercise regimens do not seem to limit the progres-
sion o scoliosis. “A” and “D” are incorrect because bracing and
surgery are typically not warranted or this degree o scoliosis.
Repeat examination and possibly repeat radiographs are war-
ranted, but i the scoliosis remains stable and mild, the patient
is not likely to experience any signi cant progression o disease
with aging.
HELPFUL TIP:
Br c ng or scol os s shoul be l m e o hose w h -
op h c scol os s n 25 o 45 egrees o ngul on.
Br c ng s only e ec ve he ch l s s ll grow ng n
<1 ye r p s men rche em le.
T e mother returns now with her 2-year-old daughter who is
re using to move her right arm. Earlier today she threw a tan-
trum at the store when her ather re used to buy her the new
“princess toy” (advertising hits them young). Dad was hold-
ing on to her arm when she opped to the oor. She immedi-
ately began crying and re using to move her right arm. In the
of ce, she is well but holds her right arm adducted, exed,
and pronated. (T e princess toy is in the other hand. Guilt is
a power ul weapon.) Despite every trick you know, you can’t
get her to move that arm. You inspect and palpate the entire
extremity and clavicle and nd no crepitus, swelling, or ten-
derness.
Question 12.6.7 What is your next diagnostic step?
A) Obtain an x-ray o the elbow.
B) Actively supinate the orearm and ex the elbow while
applying pressure over the radial head.
C) Actively twist the orearm at the elbow 360 degrees.
D) Consult orthopedics.
E) Per orm a skeletal survey, mostly to bide time.
Answer 12.6.7 The correct answer is “B.” T is child has a
“nursemaid’s elbow” that is due to subluxation o the annular lig-
ament rather than subluxation or dislocation o the radial head.
It occurs in toddlers due to traction via pulling on a pronated
and extended arm. Symptoms are immediate and care is sought
due to child’s re usal to move the arm. T e diagnosis is clinical.
Manual reduction may be done via supination/ exion or hyper-
pronation. Sedation is not needed. A palpable click may be elt.
T e child usually regains immediate movement o the arm and
relie o discom ort. Immobilization is not needed but parents
should be told that recurrent subluxations may occur and there-
ore pulling on the arm should be avoided. “A” would be correct
i there was concern or a racture based on ndings o swell-
ing, history o trauma, or ocal tenderness. “C” is impossible:
Can you really rotate a joint 360 degrees? “D” is incorrect as any
primary-care provider may manage this. “E” is unnecessary as a
nursemaid elbow is not a marker o abuse, although traumatic
injuries in children should always make one consider abuse.
340 Fa MiLY MEd iCiNE EXa MiNa t iON & BOa Rd REViEW
HELPFUL TIP:
Re uc ng nursem ’s elbow s gr y ng. t he p en
w h nursem ’s elbow shoul be us ng he rm nor-
m lly w h n m nu es. i he ch l s ll re uses o use he
ex rem y er equ e observ on, recons er your
gnos s n whe her he re uc on w s success ul.
No e h m ny w ll spon neously re uce wh le r o-
gr phs re be ng one ( her peu c x-r y?). Bo h lex on
n sup n on n ex ens on n pron on h ve been
use o re uce nursem s elbow.
HELPFUL TIP:
When e l ng w h pe r c or hope cs, lw ys
member h ch l buse s n he eren l
nos s. Be sure h he repor e mech n sm o
njury s cons s en w h he n ngs on ex m n on
r ogr ph.
A er success ul reduction, you see the same 2-year-old child
a month later presenting to your clinic with the parents who
state that the child has been crying and has re used to walk
since tripping over a toy a couple o hours ago. You look at
the child and nd no signs o abuse. T e injured area is rep-
resented by the lower leg image in Figure 12-1.
Question 12.6.8 Your approach at this point is to:
A) Consult Child Wel are since this is almost always abuse
B) Consult orthopedics or casting and urther treatment.
C) No treatment necessary or this particular racture in a
2-year-old.
D) Obtain an MRI.
FIGURE 12-1.
Answer 12.6.8 The correct answer is “B.” T is is a typical
“toddler’s racture” that consists o a spiral racture o the tibia
usually rom insigni cant rotational trauma (e.g., running and
alling with a twisting motion). T ere should not be an associ-
ated bular racture. “A” is incorrect because this type o rac-
ture is not usually rom abuse. A mid-sha racture would more
likely be rom abuse. “C” is incorrect because this racture needs
to be treated.
Objectives: Did you learn to . . .
• Cons er bro er eren l gnos s n p en
presen ng w h yp c l “grow ng p n?”
• in e conserv ve re men or p en w h grow ng p n?
• Screen p en or scol os s?
re-
• d evelop n ppro ch o he olescen w h scol os s?
g-
• Recogn ze he cl n c l presen on n re men o
he
“nursem ’s elbow” (r l he sublux on)?
n
• Recogn ze o ler’s r c ure?” ( b l sp r l r c ure).
CASE 12.7
A mother presents to your clinic with her 10-month-old
son. She is concerned that he has been very irritable since
she arrived home rom work, particularly when his legs are
touched. She states that he has been crying “nonstop” since
she arrived home. He was well when she le or work this
morning, leaving the patient under the care o her boy riend,
ony “the Hustler” Jones. T e patient’s mother denies any
evers, vomiting, diarrhea, or cough. On examination, he is
generally ussy, worsening with palpation o his le leg, par-
ticularly around his knee. You also note ve bruises on his
anterior and posterior chest. T e remainder o the examina-
tion is unremarkable. You obtain the ollowing radiograph o
his le knee (Fig. 12-2).
Question 12.7.1 Which o the ollowing mechanisms is most
likely responsible or the racture seen on x ray (marked
with the help ul arrow sign)?
A) A low-energy all ( all o a low couch).
B) A high-energy all ( all out o a second story window).
FIGURE 12-2.

C) A low-energy rotational orce (tripping causing the oot to
twist inward).
D) A high-energy tension or shearing orce (a violent twisting
o the leg).
E) Any o the above could result in the injury.
Answer 12.7.1 The correct answer is “D,” a high energy
tension or shearing orce. T e above radiograph depicts a
metaphyseal corner racture that is highly speci c or nonac-
cidental trauma (that’s the nice way to say “child abuse”). T ese
ractures are typically caused by shaking o the child with ail-
ing o the extremities or with orce ul yanking or twisting or the
arm or leg. T e incidence o these ractures decreases substan-
tially as children grow beyond year o age.
Question 12.7.2 In which o the ollowing patients is a skel
etal survey indicated or concern o nonaccidental trauma?
A) A 2-month-old male with multiple bruises but no other
localizing injuries.
B) A 2-year-old emale with an intracranial injury on brain C .
C) A 6-month-old male with a known metaphyseal corner
racture.
D) An 8-month-old emale with burns consistent with non-
accidental trauma.
E) A skeletal survey is indicted or all the above patients.
Answer 12.7.2 The answer is “E,” all o the above. T e Ameri-
can Academy o Pediatrics consensus guidelines on the radio-
graphic evaluation o child abuse state that a skeletal survey
should be obtained or all children younger than 2 years o
age who may have experienced maltreatment. Skeletal surveys
should also be considered or children between the ages o 2 and
5 depending on the clinical scenario. T e ollowing images are
generally included in a skeletal survey: humeri, orearms, lower
legs, hands, eet, skull, cervical spine, thorax (including oblique
views), lumbar spine, and pelvis.
Question 12.7.3 Which o the ollowing ractures is consid
ered highly speci c or nonaccidental trauma?
A) Posterior rib ractures.
B) Clavicle ractures.
C) Distal radius ractures.
D) Spiral ractures o the tibia.
E) Supracondylar ractures.
Answer 12.7.3 The correct answer is “A,”posterior rib ractures.
In addition, the ollowing ractures have moderate to high speci c-
ity or nonaccidental trauma: metaphyseal ractures, multiple rac-
tures (especially i bilateral), ractures o di erent ages, epiphyseal
separations, vertebral body ractures, digital ractures, scapular
ractures, sternal ractures, and complex skull ractures.
Objectives: Did you learn to . . .
• Recogn ze me physe l corner r c ure n wh mpl c -
ons h s r c ure h s?
• Know he n c ons o per orm skele l survey when sus-
pec ng non cc en l r um n wh m ges re nclu e ?
CHAPTER 12 • ORt HOPEd iCS a Nd SPORt S MEd iCiNE 341
• Un ers n wh ch r c ures re spec c or non cc en l
r um ?
QUICK QUIZ: t HE BURNiN’HiP O’FiRE
A 35-year-old obese emale with a large pannus presents with
a burning pain in anterior–lateral thigh. It started when she
bought a new wide belt (ornate with skulls and Harley–Davidson
logos) and started wearing hip hugger pants in order to display
her taste ul sacral tattoo (yikes!). T e pain seems worse on days
when she wears the belt and seems better on days when she
hangs out au naturel at home.
T e most likely diagnosis is:
A) Meralgia paresthetica.
B) Supratrochanteric bursitis.
C) ropical pyomyositis.
D) Ruptured plantaris muscle.
E) rucker’s thigh.
The correct answer is “A.” Meralgia paresthetica is described as a
burning pain in the anterior–lateral thigh and is caused by com-
pression o the lateral emoral cutaneous nerve. It is most com-
mon in those who wear tight jeans and wide belts and who are
obese. reatment is to relieve the inciting cause. ricyclic antide-
pressants or other medication or neuropathy may also be help-
ul. “B,” supratrochanteric bursitis, occurs when there is in am-
mation o the bursa over the greater trochanter o the emur.
Patients complain o pain in the lateral hip and outer thigh. T ere
is point tenderness over the greater trochanter. reatment is phys-
ical therapy or core strengthening and a steroid injection o the
bursa. “C,” tropical pyomyositis, is a deep in ection o the muscle
that is o en caused by Staphylococcus aureus. It is increasingly
recognized in the United States. “D,” a ruptured plantaris muscle,
occurs in the cal and is not related to the thigh. It is o en caused
by planting o the oot orce ully (such as in tennis or basketball)
and patients may report a “pop” ollowed by cal /gastrocnemius
pain. “E” is not a real thing, we are sorry to say.
CASE 12.8
A concerned ather presents to your clinic with a 1-month-
old daughter. He is worried that his daughter appears to be
pigeon-toed, and his mother-in-law is sure (as most mothers-
in-law are) that the child will need immediate surgery or cor-
rection. Your examination reveals a pleasant, well-developed
1-month-old emale with moderate medial deviation o the
ore oot bilaterally. A line bisecting the heel passes through
the ourth toe on each oot. T e lateral borders o the eet are
convex; the heels are in a normal neutral position. T e eet
are exible and the de ormity can be passively corrected to
the midline.
Question 12.8.1 The above description is best character
ized as?
A) Club oot.
B) Internal tibial torsion.
342 Fa MiLY MEd iCiNE EXa MiNa t iON & BOa Rd REViEW
C) Flexible at oot.
D) Excessive emoral anteversion.
E) Metatarsus adductus.
Answer 12.8.1 The correct answer is “E.” T e above is a clas-
sic description o the oot shape o metatarsus adductus. In the
normal oot, a line bisecting the heel would pass through the
second and the third toe webspace. In those with metatarsus
adductus, it passes more laterally depending on the severity.
In those with the most severe de ormity, a line bisecting the
heel would pass through the ourth and the h toe webspace.
In addition to the heels remaining in a neutral position—
indicating that the problem is isolated to the shape o the
oot and not to an internal rotation o the tibia—the ore oot
is lexible and easily straightened into normal position. his
is as opposed to metatarsus varus in which the ore oot is
rigid.
Question 12.8.2 The most appropriate treatment or the
above case would be?
A) Surgical re-construction.
B) Serial casting.
C) Physical therapy re erral or stretching and exercise.
D) Watch ul waiting and reassurance.
E) Orthopedic out are shoes.
Answer 12.8.2 The correct answer is “D.” Spontaneous correc-
tion occurs in most children. Parents can begin a regimen o
gentle oot stretching. It gives them something to do but does
not change the outcome. Care should be taken to avoid keeping
the child in the prone position with the eet in an inward posi-
tion. I the de ormity is severe and in exible, serial casting
and/or surgical intervention may be indicated. A rigid meta-
tarsus adductus in a child > 3 months or a residual problem in a
child with a exible metatarsus adductus > 6 months is an indi-
cation or pediatric orthopedic re erral.
HELPFUL TIP:
Club oo ( l pes equ nov rus) s observe b r h. P -
en s re more o en m les (2:1 m le: em le r o) n
presen w h he ollow ng n ngs: c lc neus seems
o be r wn nw r n upw r , mo er e ore oo
uc on, n he oo c n be pl ce n neu r l po-
s on by p ss ve m n pul on. t hese p en s c n be
re e success ully w h e rly re err l or ser l c s ng
n m n pul on ( .e., he Ponse me ho , wh ch we
re obl g e o promo e s nce d r. ign c o Ponse e-
velope he Un vers y o iow . a c u lly, re lly
s n ex remely mpor n v nce n club oo re -
men , n s now he s n r o c re use roun he
worl ).
Objectives: Did you learn to . . .
• i en y p en w h me rsus uc us?
• d scuss re men ppro ches o me rsus uc us?
CASE 12.9
A 5-year-old girl who has recently recovered rom chicken
pox (“T ank you, anti-vaccine parents!”) presents with her
mother or evaluation o le leg pain and re usal to walk. T e
mother reports that she has complained o worsening pain
over the last 4 to 5 days. She started to limp noticeably yes-
terday and re used to walk this morning. Also, the mother
reports general malaise and subjective ever. T e patient
complains o pain over the distal thigh and knee. T e mother
has not seen any swelling o the knee, and the patient denies
trauma.
Examination reveals a pleasant 5-year-old emale who
appears uncom ortable, but nontoxic and in no acute dis-
tress. Her temperature is 38.5°C. T e le distal thigh (not the
joint) is pain ul to palpation, and slightly warm. T e knee
joint has no e usion and the ROM is ull with only mild dis-
com ort on knee motion. T ere is no hip joint involvement.
Question 12.9.1 What is the most common bacterial patho
gen associated with this patient’s condition?
A) Group A Streptococcus.
B) Group B Streptococcus.
C) Haemophilus in uenzae.
D) S. aureus.
E) None o the above. T is is not an in ection.
Answer 12.9.1 The correct answer is “D.” T e acute nature o
the symptoms, presence o ever, and minimal involvement o the
joint makes osteomyelitis the most likely diagnosis. In addition,
osteomyelitis is associated with chicken pox in children. T ere is
clearly an increase in the prevalence o MRSA as a pathogen in
osteomyelitis (two-thirds o cases in a recent review). T us, it is
wise to choose an antibiotic with MRSA coverage.
HELPFUL TIP:
Pseudomonas aeruginosa s commonly ssoc e w h
os eomyel s n he se ng o pl n r punc ure woun
hrough enn s shoe.
Allow us to digress.
Question 12.9.2 The most common organism causing
osteomyelitis in patients with sickle cell disease is:
A) Neisseria gonorrhoeae (Gonococcus).
B) Polymicrobial.
C) Salmonella species.
D) S. aureus.
E) Streptococcus species.
Answer 12.9.2 The correct answer is “C.” Staphylococcus is
responsible or the majority o bone in ections in the general
population. Salmonella species are responsible or up to 85% o
bone and joint in ections in patients with a history o sickle cell
disease with E. coli another important player

HELPFUL TIP:
Mos c ses o ch l hoo os eomyel s re he resul o
hem ogenous spre r her h n by rec con m n -
on o he bone.
Question 12.9.3 Identi cation o the pathogen in a case o
osteomyelitis is typically made by:
A) ASO titer.
B) Blood culture.
C) Joint aspiration, culture, and Gram stain.
D) Pathology report ollowing open biopsy.
E) Witchcra .
Answer 12.9.3 The correct answer is “B.” A blood culture will
reveal the o ending organism in 40% to 50% o cases. Joint
aspiration is not typically indicated unless there is strong evi-
dence o joint involvement. It can take weeks or changes to be
seen on plain lm radiographs. T ere ore, MRI is the imaging
modality o choice. C or bone scan can also be used i MRI is
not available or contraindicated. I changes are identi ed and a
neoplastic process is ruled out, aspiration at the site o periosteal
elevation and bony destruction should be considered i a patho-
gen has not yet been identi ed by blood culture. “A,” an ASO
titer, would not be help ul here since this test or Streptococcus
pyogenes in ection. An ASO titer would be help ul i looking or
rheumatic ever. “D,” surgical biopsy, may be required i blood
cultures do not reveal a pathogen and the patient is not respond-
ing appropriately to empiric antibiotics.
HELPFUL TIP:
t re men o os eomyel s requ res 4 o 6 weeks o n -
b o cs. Surg c l ebr emen s usu lly ( no lw ys)
requ re s well.
Objectives: Did you learn to . . .
• d gnose os eomyel s n ch l ?
• i en y common p hogens nvolve n os eomyel s?
CASE 12.10
A 45-year-old emale with a history o rheumatoid arthritis,
on chronic low-dose prednisone, presents to your clinic with
2 days o right knee pain. T e patient reports that her knee
has been swollen and pain ul to touch, and she now is having
dif culty bearing weight due to the pain. She has had previ-
ous knee pain, but nothing this severe. She denies any trauma,
evers, chills, knee surgery, illegal drug use, or risky sexual
behavior. On examination, she is well appearing, a ebrile, and
has a moderate right knee e usion with limited ROM. T ere
is no overlying erythema, but the knee eels warm to touch.
Question 12.10.1 Which o the ollowing diagnostics is the
most valuable to rule in or rule out the diagnosis with the
highest potential morbidity?
A) Plain lms o the a ected knee.
B) WBC count.
CHAPTER 12 • ORt HOPEd iCS a Nd SPORt S MEd iCiNE 343
C) ESR.
D) Arthrocentesis.
E) MRI.
Answer 12.10.1 The correct answer is “D.” T e most con-
cerning diagnosis with the highest potential morbidity in this
patient is septic arthritis. Her history o rheumatoid arthritis as
well as long-term steroid use put her at high risk. In a patient in
whom you are concerned about septic arthritis, the most impor-
tant piece o diagnostic data that you can obtain comes rom
synovial uid analysis. While plain radiographs, a WBC count,
an ESR, and CRP may be obtained (your riendly neighborhood
orthopedic surgeon will surely want to know them), they are
neither sensitive nor speci c enough to rule in or rule out septic
arthritis in a high-risk patient.
Question 12.10.2 Which o the ollowing signs or symp
toms has su cient sensitivity to rule out septic arthritis i
absent?
A) Joint edema or e usion.
B) Fever.
C) Sweats.
D) Signi cantly restricted ROM.
E) None o the listed signs or symptoms has suf cient sensitiv-
ity to rule out septic arthritis, i absent.
Answer 12.10.2 The correct answer is “E.” Un ortunately,
there are no clinical signs or symptoms that have suf cient sen-
sitivity to rule out septic arthritis. Signs and symptoms should
raise clinical suspicion, however the only de nitive diagnostic
modality is arthrocentesis.
You e ortlessly obtain 10 mL o cloudy synovial uid that is
sent to the lab or Gram stain, culture, cell count with di -
erential, glucose, and crystal analysis. T e Gram stain is
negative with cultures pending. T e synovial WBC count is
51,000/µL with >90% polymorphonuclear cells. T e crystal
analysis shows calcium pyrophosphate crystals. You obtain
a peripheral WBC count that is 11,000/µL and an ESR is
55 mm/hr.
Question 12.10.3 What is the most appropriate next course
o action based on these ndings?
A) Prescribe high-dose prednisone or a air o her rheumatoid
arthritis.
B) Start IV antibiotics and obtain emergent orthopedic consul-
tation.
C) reat her or pseudogout.
D) Recommend rest, ice, compression, and a prescription or
oxycodone.
Answer 12.10.3 The correct answer is “B.” Various cuto s
or synovial WBC counts have been proposed, ranging rom
> 25,000/µL to > 00,000/µL in native joints, with sensitivi-
ties ranging rom 30% to 77% ( able 2-2). Cuto s are much
lower in patients with prosthetic joints. A prosthetic joint with
WBC count o > ,700/µL may be up to 94% sensitive or septic
344 Fa MiLY MEd iCiNE EXa MiNa t iON & BOa Rd REViEW
TABLE 12-2 SENSITIVITY AND SPECIFICITY OF
SYNOVIAL FLUID ANALYSIS IN SEPTIC ARTHRITIS
Synovial Fluid
WBC Count Sensitivity (%) Speci city (%)
> 100,000/mm 3 30 > 99
3
> 50,000/mm 62 92
> 25,000/mm 3 77 73
arthritis. A synovial WBC count o 5 ,000/µL does not rule out
septic arthritis in this patient. When the percentage o polymor-
phonuclear cells is > 90%, this signi cantly increases the like-
lihood o septic arthritis. Don’t let the calcium pyrophosphate
crystals dissuade you rom suspecting septic arthritis as both
gout and pseudogout coexist with septic arthritis up to 25% o the
time (J Rheumatol. 20 2;39: 57).
Objectives: Did you learn to . . .
• Recogn ze he cl n c l presen on o sep c r hr s?
• Un ers n he l m ons o us ng s gns n symp oms o
rule ou sep c r hr s?
• d escr be he ppropr e work-up or p en w h sus-
pec e sep c r hr s?
QUICK QUIZ: MY BiG Fat GREEK KNEE Pa iN
A 55-year-old obese emale comes to your of ce complaining
o knee pain when she walks. She had an MRI at an urgent care
center, which showed some meniscal damage. She is tender
in eriorly and medial to the patella on the proximal tibia (but
not on the joint line).
Which o the ollowing is true?
A) Washing out her knee by arthroscopy will help to relieve her
symptoms.
B) T e nding o a meniscal injury on MRI correlates well with
symptoms o pain.
C) Based on its location, pes anserinus bursitis is the likely
cause o her pain.
D) Baklava is Dr. Wilbur’s avorite ood.
The correct answer is “C.” T e pes anserine (“goose’s oot”)
bursa is located on the medial, proximal aspect o the tibia and
is where the tendons o the sartorius, gracilis, and semitendi-
nosus attach. It o en becomes in amed causing signi cant and
chronic knee pain. Conservative therapy with rest, ice, NSAIDs,
and stretching may be tried initially. However, these o en ail;
most patients experience signi cant improvement with cortico-
steroid injections. “A” is incorrect. Several studies have ound
that washing out the knee and trimming the cartilage is o no
bene t. “B” is also incorrect. MRI o the knee is not particu-
larly use ul or determining i a meniscal injury is the source o
pain. Similar to herniated disks, many asymptomatic patients
have meniscal injuries on MRI limiting our ability to assign
symptoms to an MRI nding. T is is especially true in the
elderly with arthritis where > 90% will have meniscal damage.
As to “D,” it obviously does not relate to the case. We call that
“test taking skill.” I you chose “D,” woe is with you.
QUICK QUIZ: ORt HOPEd iC iNFECt iONS
T e most common organism causing septic arthritis in the teen-
age years is:
A) N. gonorrhoeae (Gonococcus).
B) Polymicrobial.
C) Salmonella species.
D) S. aureus.
E) Streptococcus species.
The correct answer is “A.” Gonococcus is the most common
organism isolated rom the joints o sexually active, teenage
individuals.
CASE 12.11
A 28-year-old male presents to your clinic or evaluation o
lower-back pain (LBP). Yesterday morning he rst noticed
the discom ort, mani esting as sti ness and soreness in the
lower back. T e day be ore had been spent running a oor
polisher. He describes his pain as sharp in nature and 8/10 in
intensity. He denies radiation o the pain, sensory changes,
and constitutional symptoms. He is concerned this may be an
injury to a disk and that he may be permanently disabled due
to his extreme pain.
Question 12.11.1 Which o the ollowing signs or symptoms
would be “red ags” indicating the need or early imaging
and/or re erral?
A) Pain radiating down one or both legs into the posterior
thigh.
B) Severe pain, prompting the patient to request narcotics.
C) Pain greater with active lumbar extension than with orward
exion.
D) New onset erectile dys unction with back pain.
E) None o the above.
Answer 12.11.1 The correct answer is “D.” T e onset o erec-
tile dys unction is suggestive o neurologic involvement and
warrants urther investigation. None o the other options are
suggestive o signi cant disease requiring immediate interven-
tion (“A” certainly could represent disk disease; however, this
does not require immediate intervention). O note, spontane-
ous erections without sexual stimulation can also be a sign o
neurologic involvement.
Question 12.11.2 Early imaging should be obtained in all
o the ollowing presentations o LBP EXCEPT:
A) Neurologic symptoms such as bowel or bladder dys unction
and impotence.
B) History o ever, night sweats, and weight loss.

C) History o cancer.
D) rauma.
E) Age > 30 years.
Answer 12.11.2 The correct answer is “E.” Patients over the
age o 50 should have early imaging. See able 2-3 or other
criteria that should prompt early imaging.
HELPFUL TIP:
Sever l o he n c ors l s e n t ble 12-3 re ssoc -
e w h c u equ n syn rome. C u equ n syn-
rome s he pro uc o n cu e re uc on n he vol-
ume o he sp n l c n l wh ch c n le o compress on
n p r lys s o mul ple nerve roo s n resul n ur -
n ry re en on, s le nes hes , n lower ex rem y
we kness. i s o en c use by cen r l sk hern ons,
ep ur l bscesses n hem om s, r c ures, n o her
r um . Cauda equina syndrome is an orthopedic
emergency. An MRI and surgical consultation should
be sought without delay.
HELPFUL TIP:
P en s who do not h ve lms one n lly c u lly
h ve be er ou comes h n hose who o. When we or-
er m g ng s u es, we “me c l ze” he llness, c us ng
he p en o expec longer recovery n he nee
or n erven on n or er o ge be er. d on’ o unless
hey mee he bove cr er .
Upon physical examination, you note the vital signs are nor-
mal. Straight leg raise (SLR) testing on the right leg at 55
degrees reproduces the patient’s pain in the lower back and
a pain ul “tightness” in the posterior thigh. He complains o
the same discom ort on the le at 30 degrees.
Question 12.11.3 Based on these ndings, which o the ol
lowing statements is true?
A) T is is a positive SLR test bilaterally and is speci c or disk
herniation.
TABLE 12-3 CRITERIA SUGGESTING THE NEED
FOR EARLY IMAGING FOR BACK PAIN
Bowel or bl er ys unc on
New onse o mpo ence
Fevers or n gh swe s
Unpl nne we gh loss
N gh p n
Person l h s ory o c ncer
S le nes hes
H s ory o recen r um (e.g., ll or rec blow, NOt w s ng or l ng)
a ge >50 or <18 ye rs
P en w h curren or recen use o s ero s
a ny susp c on o n n ec ous or neopl s c c use or low-b ck p n
P n or >6 weeks
CHAPTER 12 • ORt HOPEd iCS a Nd SPORt S MEd iCiNE 345
B) T is is a positive SLR test on the le and is speci c or disk
herniation.
C) T is is a positive SLR test on the right and is speci c or disk
herniation.
D) T is is a negative SLR test bilaterally.
Answer 12.11.3 The correct answer is “D.” T e SLR test can be
per ormed in several ways, which are listed here.
• Seated active: with the patient seated on the examination
table, the patient dorsi exes the oot and extends the knee.
• Seated passive: with the patient seated on the examination
table, the examiner passively extends the knee, and radicular
symptoms will be exacerbated with passive ankle dorsi ex-
ion.
• Lying passive: with the patient in a supine position, the ex-
aminer holds the knee in ull extension and passively exes
the hip, and radicular symptoms will be exacerbated with
passive ankle dorsi exion.
In all cases, the test is positive when radicular symptoms occur
(e.g., pain and paresthesias down the leg below the level o the
knee—not back or thigh pain rom muscle stretching) between
25 and 75 degrees o hip exion while lying or with knee exten-
sion while seated. T e symptoms will be exacerbated with active
or passive ankle dorsi exion. However, the SLR is neither sensi-
tive nor speci c or disk disease. “Crossover” pain with radicu-
lar symptoms in the leg not li ed is very speci c or disk disease
but is not very sensitive.
Even though SLR is negative, you continue your neurologic
examination. You note symmetric patellar re exes, dimin-
ished Achilles re ex on the right, and symmetric strength in
the legs except or decreased strength with right oot plan-
tar exion. You also note decrease in gross sensation to light
touch over the right lateral oot.
Question 12.11.4 Which o the ollowing nerve roots is
most likely compromised?
A) L3.
B) L4.
C) L5.
D) S .
E) S2–4.
Answer 12.11.4 The correct answer is “D.” A summary o
nerve root innervation is given in able 2-4.
Question 12.11.5 Appropriate initial treatment or this
patient’s acute back pain should include which o the
ollowing?
A) Strict bed rest.
B) Pain control.
C) Corset or lumbar belt.
D) Re erral or epidural steroid injection or endoscopic disk
resection.
E) A and B.
346 Fa MiLY MEd iCiNE EXa MiNa t iON & BOa Rd REViEW

TABLE 12-4 EXAMINATION FINDINGS OF LUMBAR AND SACRAL SPINAL NERVE ROOTS
Nerve Root Re ex Motor Sensory Test
L2–3 None Qu r ceps a n er or h gh Knee ex ens on

L4 P ell t b l s n er or ( oo ors ex on, Me l lower leg n oo W lk on heels

nvers on)

L5 Me l h ms r ng Ex ensor h lluc s longus ( ors ex on o d ors l oo Hol up gre oe

( f cul o ssess) b g oe)

S1 a ch lles Peroneus longus n brev s ( nkle L er l oo W lk on oes

evers on) n pl n r ex on o oo

S2–4 a n l w nk in r ns c oo muscles, n l sph nc er one Per n l

Answer 12.11.5 The correct answer is “B.” In acute mechani- have equivocal data with most studies being negative. “Back
cal back pain (no longer than 6 weeks), regardless o the School” also does not seem to help.
method o treatment, 40% are better within week, 60% to 85%
in 3 weeks, and 90% in 2 months. Negative prognostic actors
HELPFUL TIP:
include more than three episodes o back pain, gradual onset
Phys c l her py mo l es such s ppl c on o he ,
o symptoms, and prolonged absence rom work. Bed rest
col , ul r soun , n muscle s mul on m y h ve
does not contribute to a return o unction and may worsen
shor - erm bene . Reh b l on exerc ses ocus ng
outcomes. Early mobilization o the patient is best or allow-
on runk ex ensors, b om n l muscles, n erob c
ing him to continue activities as tolerated. Acetaminophen is
con on ng promo e e rly mob l z on, wh ch s cr -
a great drug or pain control and has ewer side e ects than
c l n re ng cu e b ck p n. The specific exercise
do the NSAIDs. Chiropractic care may be use ul. Data on acu-
does not matter as much as the mobilization. Sh m
puncture are mixed.
her py works s well s spec c exerc ses s long s he
p en s mob le.
HELPFUL TIP:
For LBP, e rly mob l z on n w lk ng s mpor n .
Objectives: Did you learn to . . .
Ep ur l s ero njec ons, wh le n u vely ppe l ng
• Gener e eren l gnos s n un ers n he e ol-
or sk se se, h ve been shown o be o no long- ogy o lumb r sp ne p n?
erm ( n l le shor erm) bene (J Bone Joint Surg.
• Ev lu e n re cu e LBP?
2012;94:1353–1358; BMJ. 2015;350:h1748).
• Recogn ze w rn ng s gns o LBP?
For spinal stenosis, surgery h s no been shown o be
p r cul rly be er h n conserv ve, nonsurg c l, re -
men (Ann Intern Med. 2015;162:465). S ero s h ve lso QUICK QUIZ: Ba CK Pa iN
no been shown o be o ny bene n sp n l s enos s.
Spondylolysis commonly occurs in which part o the spine?
A) Cervical spine lateral processes.
You prescribe your pain medication o choice and recom- B) T oracic spine pars interarticularis.
mend rehabilitation exercises. C) T oracic spine lateral processes.
D) Lumbar spine pars interarticularis.
Question 12.11.6 Which o the ollowing has been shown
to be ef ective at reducing the recurrence o back injury in The correct answer is “D.” Spondylolysis is characterized by
the workplace? pars interarticularis stress ractures and most commonly occurs
A) Back support belts. in the lumbar region.
B) “Back School” that teaches proper li ing techniques, stretches,
etc.
C) Increasing physical tness and muscle tone. QUICK QUIZ: MORE Ba CK Pa iN
D) A and C.
E) B and C. Anterior slippage o one vertebra on another is called:
A) Spondylolysis.
Answer 12.11.6 The correct answer is “C.” T e only thing that B) Spondylolisthesis.
has been unequivocally shown to reduce urther back injuries is C) Spondylitis.
improving the overall tness o the patient and his muscle tone. D) Spondyloarthropathy.
O special note, back support belts, long worn in industry, E) Scheuermann disease.
 CHAPTER 12 • ORt HOPEd iCS a Nd SPORt S MEd iCiNE 347

The correct answer is “B.” Slippage o one vertebra on another usually ound in children age in ancy to 3 years but may occur
is called spondylolisthesis. “A,” spondylolysis, is discussed at any age. T e etiology is usually Staphylococcus (low-grade
above. Spondylolysis can lead to spondylolisthesis. Spondyloar- in ection) but there may be sterile in ammation. Fever is
thropathy is a nonspeci c term re erring to in ammation o the usually absent in discitis (seen in only 25%), and blood cul-
spine and encompasses such diseases as ankylosing spondylitis, tures are sterile. T e white count is usually normal, although
Reiter disease, enteropathic arthritis, etc. Spondylitis is a more ESR is elevated in 90%. reatment is not standardized, but
speci c term or the same thing (e.g., ankylosing spondylitis). most experts would include anti-staphylococcal antibiotics.
“E,” Scheuermann disease, is a process causing kyphosis by “B,” occult racture, is unlikely in a child this age. “C,” grow-
compression o the vertebrae (at least 5 degrees o wedging in ing pains, does not present with back pain (see the discussion
three consecutive vertebrae). T e cause is unknown but it tends o growing pains earlier in this chapter). Juvenile rheumatoid
to present in adolescence. arthritis presents with small joint involvement as opposed to
back pain.
Spondylolisthesis is graded based on the degree o slipping
o one vertebra on the other. Which o the ollowing patients CASE 12.12
would need surgical consultation?
A 24-year-old male presents to the clinic 2 days a er a col-
A) Grade one (< 25% slip) with no symptoms in an early teen
lision during a so ball game in which he ell on his out-
( 2– 4).
stretched right hand (“But I made the play!” he exclaims). He
B) Grade 2 (25–50% slip) with no symptoms in an early teen
reports he could not continue playing and that his pain has
( 2– 4).
not improved. He has some general edema around the right
C) Grade 3 (50– 00% slip) with mild pain in a 20 year-old col-
wrist, poor grip strength secondary to pain, point tenderness
lege gymnast.
over the radial aspect o the wrist (“snu box tenderness”),
D) When slippage is 0% to 5% with no symptoms in a patient
and decreased ROM. T ere is no obvious de ormity, and he is
> 60 years old.
neurovascularly intact.
E) When slippage is 25% with no symptoms in a patient
> 60 years old.
Question 12.12.1 O the ollowing, what would be the most
likely diagnosis or this patient?
The correct answer is “C.” Spondylolisthesis is generally a
A) Colles racture.
problem in the late teens and 20s. Patients o en become symp-
B) Scaphoid racture.
tomatic when there is 25% slippage or greater. Mild degrees o
C) Smith racture.
slip can be treated conservatively, although surgical treatment
D) Extensor carpi radialis strain.
threshold varies considerably among orthopedic surgeons.
E) Scapholunate sprain.
Predisposing actors include recurrent lumbar hyperextension
(gymnasts, ootball players, etc.), although many patients do not
Answer 12.12.1 The correct answer is “B.” Although all o
have an identi able cause. Any adolescent athlete who presents
these could be in the di erential diagnosis, “B” is the most likely
with back pain that is made worse by hyperextension should
based on mechanism o injury and clinical ndings. T e scaph-
raise your suspicion. Older patients who are asymptomatic do
oid spans both the proximal and distal carpal row. In this posi-
not need to be considered or surgical treatment unless the slip
tion, it is quite vulnerable to high-impact injuries, such as a all
is grade 4 ( 00% or greater).
on an out-stretched hand, and is the most commonly ractured
carpal bone. T e absence o de ormity makes a Colles or Smith
QUICK QUIZ: Ba CK Pa iN iN CHiLd REN racture less likely (options “A” and “C”). Further, a sprain or a
strain (options “D” and “E”) are less likely given the bony point
A 4-year-old boy presents to your of ce accompanied by his tenderness, decreased range o motion, and overall nonim-
mother who says he has a limp and LBP. T is has been getting provement with conservative measures.
progressively worse over the past 2 weeks. When the patient sits,
he sits in a “tripod” position supporting his weight on his hands.
HELPFUL TIP:
Vitals are normal without a ever and a CBC is normal.
P lp ng or snu box en erness w h he wr s n
sl gh uln r ev on ncre ses he sens v y o he
T is history is most consistent with:
phys c l ex m n on. a n on l phys c l ex m n -
A) Discitis.
on n ng cons s en w h sc pho njury s p n
B) Occult racture.
he sc pho w h x l lo ng o he humb.
C) Growing pains.
D) Juvenile rheumatoid arthritis.
E) Mechanical low back strain.
Plain lm radiographs, including AP and lateral o the
The correct answer is “A.” T is history is most consistent hand and wrist as well as scaphoid views, are negative or
with discitis. Discitis is an in ammatory process o the disk racture.
348 Fa MiLY MEd iCiNE EXa MiNa t iON & BOa Rd REViEW

Question 12.12.2 What is the most appropriate next step

or this patient?
A) Short-arm thumb spica cast with ollow-up in 0 to 4 days.
B) NSAIDs, ice, compression, and elevation ollowed by physi-
cal therapy.
C) MRI or C to rule out an occult racture.
D) Orthopedic re erral.
E) Return to play within the week.
Answer 12.12.2 The correct answer is “A.” Scaphoid ractures
are o en occult acutely and usually will be evident on plain
lms a er 0 to 4 days due to bony resorption along the rac-
ture line. I repeat lms are negative but suspicion remains high,
an MRI or C should be considered.
HELPFUL TIP:
a l hough no he s n r o c re, e rly MRi or Ct
(ne her s e n vely super or o he o her) o ev lu-
e or occul sc pho r c ures m y llow p en s o
re urn o ull c v y sooner h n woul be poss ble
hey were spl n e or 10 o 14 ys. t h s m y be cos -
e ec ve or cer n p en s ( .e., concer v ol n s s or
he iow H wkeyes’ s r ng qu r erb ck). Bo h MRi
n Ct re be er exclu ng r c ures h n hey re
con rm ng hem ( hey c n be rule ou , bu no neces-
s r ly rule n).
Repeat wrist radiographs including scaphoid views 2 weeks
post injury indicate a nondisplaced racture o the proximal
pole o the scaphoid.
Question 12.12.3 You recommend which o the ollowing
treatment plans?
A) Wrist and thumb spica splint and physical therapy because
good blood supply at the proximal pole allows ast heal-
ing.
B) T umb spica cast or 6 weeks then repeat x-rays.
C) Short-arm cast excluding the thumb or 4 to 6 weeks.
D) Orthopedics re erral or open reduction/internal xation.
E) B or D.
Answer 12.12.3 The correct answer is “E.” It is clear that a spica
cast with the thumb included is important; whether a short- or
long-arm cast is optimal is still a matter o debate. Open xa-
tion is another option. Generally, an orthopedic surgeon should
oversee treatment o scaphoid ractures since the complication
rate is high. A proximal pole racture has high risk or nonunion
and avascular necrosis (90%). T e blood supply to the scaph-
oid is through the distal pole, putting the proximal pole at
high risk or complications. Evidence o healing may not be
well visualized on plain lms, and a C or MRI may be needed
to con rm the degree o healing. T e closer the racture line
is to the proximal pole, the lower the threshold or orthopedic
re erral.
HELPFUL TIP:
He l ng me or s l pole sc pho r c ure s 6
o 8 weeks, m le h r or w s r c ures re 8 o
12 weeks, n prox m l pole r c ures c n ke 12 o
24 weeks.
Objectives: Did you learn to . . .
• Recogn ze p en r sk or sc pho r c ure?
• M n ge p en w h sc pho r c ure?
QUICK QUIZ: Ha Nd iNJURiES
A patient presents a er “jamming” his index nger while play-
ing basketball. He has mild swelling at the DIP joint. At rest, his
DIP is exed. He has ull ROM o all joints except he cannot
extend at the DIP.
What is the appropriate treatment and ollow-up?
A) RICE therapy, PRN ollow-up.
B) A ull extension splint o the DIP joint worn at all times with
orthopedic ollow-up in to 2 weeks.
C) A removable aluminum splint to be worn or com ort, ollow-
up in clinic in month.
D) Ibupro en and return to ull activities, PRN ollow-up.
The correct answer is “B.” T e patient has su ered an injury
to his extensor tendon mechanism, known as a “mallet nger.”
X-rays are indicated to evaluate or a bony racture/avulsion.
T e initial treatment is an extension splint at the DIP joint, and
ollow-up with an orthopedic surgeon as surgical correction is
sometimes required. T e splint must be worn at all times. See
Figure 2-3 or the anatomy o a mallet nger.
QUICK QUIZ: FRa Ct URES
A Colles racture consists o :
A) Fractures o the midsha o the radius and ulna.
B) Fractures o the head o radius and ulna that is displaced
dorsally and is angulated.
Rupture d te ndon
Dis ta l
pha laynx
Fra cture
MALLET FINGER
FIGURE 12-3.

C) Fractures o the head o the radius and ulna that are dis-
placed ventrally and is angulated.
D) None o the above.
The correct answer is “D,” none o the above. OK, some o
you may have chosen “B.” However, the head o the radius is
at the elbow and not at the wrist. T us, none o the answers is
correct. A Colles racture is a racture o the distal radius at the
metaphysis, which is displaced dorsally and o en angulated. It
is the most common wrist racture in adults. T e ulnar styloid
is o en involved, and there may be intra-articular involvement
as well.
QUICK QUIZ: d E QUERVa iN t ENOSYNOVit iS
Which o the ollowing physical examination ndings would be
associated with the diagnosis o De Quervain tenosynovitis?
A) Positive Finkelstein test.
B) Positive Phalen test.
C) Positive inel sign.
D) Sensory loss over the C7 dermatome.
E) Weakness o the intrinsic muscles o the hand.
The correct answer is “A.” De Quervain tenosynovitis is a ten-
donitis o the abductor pollicis longus, the extensor pollicis bre-
vis, and occasionally the extensor pollicis longus. Full exion o
the thumb into the palm and ulnar deviation o the wrist pro-
duces exquisite tenderness over the radial aspect o the wrist
(positive Finklestein test). Other ndings may include so -
tissue swelling and pain over the abductor pollicis longus and
extensor pollicis brevis tendons near the radial styloid. Crepitus
may also be palpable or audible with ROM.
QUICK QUIZ: d E QUERVa iN t ENOSYNOVit iS
T e appropriate treatment o De Quervain tendonitis includes
which o the ollowing?
A) T umb spica splint.
B) NSAIDs.
C) Steroid injection.
D) Surgical decompression o the tendon.
E) All o the above.
The correct answer is “E.” All o the above treatments have been
used success ully or the treatment o De Quervain tendonitis.
It is o note that some pre er steroid injection as the rst-line
therapy rather than NSAIDs. Surgery is obviously a last choice.
QUICK QUIZ: a NGER Ma Na GEMENt iSSUES
A 9-year-old male was mad at his computer and decided to
punch the wall. “He ought the wall and the wall won.” Radio-
graphs demonstrate a h metacarpal racture with some angu-
lation.
CHAPTER 12 • ORt HOPEd iCS a Nd SPORt S MEd iCiNE 349
What is the maximal acceptable angulation and rotation or a
boxer racture, ourth or h metacarpal, to maintain ull hand
unction?
A) 0 degrees o dorsal angulation and 0 degrees o rotation.
B) 30 degrees o dorsal angulation and 5 degrees o rotation.
C) 40 degrees o dorsal angulation and 0 degrees o rotation
D) 90 degrees o dorsal angulation and 0 degrees o rotation.
The correct answer is “C.” Any degree o rotation, or > 40
degrees o dorsal angulation, may result in signi cant unc-
tional de cits. Reduction should be attempted i angulation is
> 0 degrees. Patients should be advised that with angulations
> 0 to 5 degrees, there will likely be a loss o metacarpopha-
langeal (MCP) prominence, although there should be no loss
o unction. I this is unacceptable to the patient, re erral is
recommended.
HELPFUL TIP:
a ny “sc ssor ng” or cross ng o he p en ’s ngers
wh le hey clench he r s shoul r se your susp c on
or ro on l e orm y.
HELPFUL TIP:
i you c n’ be your compu er chess, on’ ge rus-
r e ; ry ch ng ng spor s. We re sure you c n be
your compu er m xe m r l r s.
CASE 12.13
T e next patient in the ED is an 18-year-old high school oot-
ball player. He was playing in a ootball game this evening
when he was tackled rom the side and landed directly on
the lateral aspect o his right shoulder. He states that he can
actively move his arm, but is limited by pain on the top o
his shoulder. He has also noticed a small pain ul bump on
top o the right shoulder and is concerned that he “broke his
collarbone.”
Question 12.13.1 Based on the mechanism o injury and
patient history, the most likely injury would be?
A) Acromioclavicular (AC) sprain.
B) Biceps tendon rupture.
C) Glenohumeral dislocation.
D) Rotator cu tear.
E) Scapula racture.
Answer 12.13.1 The correct answer is “A.” Although any o
these injuries may be present, an AC sprain is the most likely
based on the history and the way the patient ell. A thorough
examination should be able to urther distinguish between
these injuries. “B” is not likely, given the mechanism o injury.
T e de ormity associated with biceps tendon rupture (a de ect
in tendon with pain and de ormity in the muscle belly repre-
senting the contracted, detached muscle) would be on the upper
arm or at the elbow, not on the “top” o the shoulder. “C” is
350 Fa MiLY MEd iCiNE EXa MiNa t iON & BOa Rd REViEW
incorrect. T e de ormity and loss o ROM o a glenohumeral
dislocation (shoulder dislocation) is usually obvious. T e mech-
anism o injury is typically a orced abduction and external rota-
tion. “D” is less likely. A rotator cu tear will present with pain
more laterally over the subacromial space and should not have
an associated de ormity. T e ROM is generally markedly lim-
ited by pain. “E” is unlikely. Scapula ractures are uncommon
and are usually the result o high velocity blunt trauma such as
a blow rom a baseball bat or motorcycle accident. Plain lm
radiographs should be obtained to rule out a clavicle racture,
especially when any de ormity is present.
Question 12.13.2 Your patient is worried that he broke
his “collarbone.” I he did sustain a nondisplaced clavicle
racture, which o the ollowing would be appropriate
treatment?
A) Rest, ice, and NSAIDs or pain control.
B) A sling or com ort only.
C) A gure-o -eight splint.
D) A and B
E) External xation with molded plaster to maintain align-
ment.
Answer 12.13.2 The correct answer is “D.” While the tradi-
tional teaching has been that a gure-o -eight splint is required,
it adds nothing to the treatment o a clavicle racture. Pain con-
trol and using a sling works just as well. Additionally, gure-
o -eight splints o en increase a patient’s pain and can cause
a brachial plexus injury. T us, a sling is pre erable. Complete
immobilization is not necessary or nondisplaced clavicle rac-
tures, thus making “E” incorrect.
Question 12.13.3 The proper treatment or a clavicle rac
ture that is minimally displaced is:
A) Closed reduction and then a sling.
B) Open reduction and immobilization.
C) Open reduction and early mobilization.
D) A sling.
E) None o the above.
Answer 12.13.3 The correct answer is “D.” T e ends o a dis-
placed clavicle racture need not be 00% approximated or
healing to occur and or unction to return. T us, reduction is
generally not necessary.
HELPFUL TIP:
t he p r gm o he re men o cl v cle r c ures s
sh ng. More p en s re ge ng surg c l n erven on
( n n ern l x on), espec lly hle es when qu ck
re urn o spor s es re . t h s ec s on epen s on
he egree o spl cemen n he occup on o he
p en (Surgeons? Yes. C r S lesmen? No so much).
Gre er egrees o r c ure spl cemen n b yone -
ng h ve h gher r es o r c ure nonun on. t hus, s-
cuss on w h n or hope s s ppropr e or p en s
w h spl ce cl v cle r c ures.
You send the patient or x-rays. AP radiographs show slight
widening o the AC joint on the injured side. T e examina-
tion and radiograph con rm your suspicion o an AC injury.
Question 12.13.4 For this patient with an AC sprain, you
of er:
A) Sling or com ort, ice, and NSAIDs or analgesics or pain
control.
B) Re erral or open xation.
C) Figure-o -eight strap or 4 to 6 weeks.
D) Corticosteroid injection ollowed by physical therapy.
E) Manual reduction, then sling-and-swath immobilization or
6 to 8 weeks.
Answer 12.13.4 The correct answer is “A.” Conservative man-
agement is appropriate or low-grade AC joint sprains. AC
sprains are graded I to VI. Grades I to III are generally treated
conservatively, while grades IV–VI may need to be treated surgi-
cally. Signs o high-grade (IV–VI) AC sprains include posterior
or in erior displacement o the clavicle and widening o 00% or
more o the coracoclavicular space. Just like with clavicle rac-
tures, gure-o -eight straps have largely allen out o avor or
treatment AC joint injuries. Corticosteroid injections are not the
treatment o choice or acute AC joint injuries. An injection may
be considered as an adjunct treatment or degenerative arthritis
o the AC joint at some distant point in the uture. Sling-and-
swath immobilization is not indicated.
Objectives: Did you learn to . . .
• d eren e be ween c uses o shoul er njur es?
• t re cl v cul r r c ure?
• M n ge a C njur es?
CASE 12.14
A 65-year-old male presents with le shoulder pain and
weakness, which started 2 weeks ago a er he put a new roo
on his house. He does not recall a speci c injury. T e pain
is worse with reaching or and li ing objects as well as with
overhead activities. Nighttime pain is present. He describes
himsel active and healthy, and he only takes acetaminophen
when needed or shoulder pain. You suspect that he may have
rotator cu tendinopathy.
Question 12.14.1 I this is the case, what do you expect to
nd on examination?
A) enderness to palpation o the greater tuberosity o the
humerus.
B) Limited active ROM.
C) Normal passive ROM.
D) Shoulder shrug with attempted abduction (such as with a
rozen shoulder).
E) Any o the above.
Answer 12.14.1 The correct answer is “E.” Ok, so this might t
under the category o “trick question,” but the shoulder exam-
ination can be normal in a patient with a rotator cu tear or

tendinopathy, or it can include any o the elements listed in “A”
through “D.” Notably, normal PASSIVE ROM (“C”) does not
rule out rotator cu pathology.
Question 12.14.2 Which o the ollowing muscles is NOT a
part o the rotator cuf ?
A) Supraspinatus.
B) In raspinatus.
C) Subscapularis.
D) eres major.
E) eres minor.
Answer 12.14.2 The correct answer is “D.” T e rotator cu
consists o the other our muscles listed and unctions to rotate
the arm and stabilize the humeral head.
Question 12.14.3 Which o the ollowing muscles is the
most commonly torn in the rotator cuf ?
A) Supraspinatus.
B) In raspinatus.
C) Subscapularis.
D) eres minor.
Answer 12.14.3 The correct answer is “A.” T e supraspinatus
is generally the point o origin or most tears.
HELPFUL TIP:
Full h ckness e rs o he ro or cu re uncommon n
n v u ls below he ge o 40, unless ssoc e w h
r um . a symp om c ro or cu e rs re very com-
mon n hose over he ge o 60 n re no lw ys he
p n gener or— n o her wor s—or er MRis ju c ous-
ly n h s popul on!
Based on your history and physical examination, you diag-
nose a rotator cu tendinosis.
Question 12.14.4 Appropriate initial management o this
65 year old male should be:
A) Acetaminophen and physical therapy.
B) Oral corticosteroids and physical therapy.
C) Subacromial injection with corticosteroid and physical ther-
apy.
D) Surgical repair and physical therapy.
E) None o the above.
Answer 12.14.4 The correct answer is “A.” For initial manage-
ment in an individual > 60 years o age, acetaminophen and
physical therapy or 6 weeks is the best answer. I the patient
has no improvement or inadequate response, a corticosteroid
injection may be used judiciously. Injection likely will result in
at least short-term pain relie , but there is no good evidence that
it helps long term. In addition, it is thought to weaken the ten-
don and may accelerate extension o a tear, i present. Patients
with signi cant symptoms or ailed therapy should be consid-
ered or MRI, orthopedic re erral, and surgical management.
CHAPTER 12 • ORt HOPEd iCS a Nd SPORt S MEd iCiNE 351
Patients under the age o 60 with acute traumatic tears should
be considered or surgery, with best results within 6 weeks
o injury.
HELPFUL TIP:
t he ol ge bou cor cos ero s c us ng we ken ng
o he en on h s recen ly been ques one . i s now
hough h he s ero njec on prov es enough
rel e o he p n h he p en w ll s r us ng he
ex rem y n w ys he or she h no one be ore. t h s
le s o en on rup ure rom he on l lo . How-
ever, he po n rem ns h s ero njec ons m y be
ssoc e w h, bu no c us ve o , en on rup ure.
Your patient is success ul in rehabilitating his le shoulder,
but then he returns 2 years later with right shoulder prob-
lems. T e right shoulder has become progressively sti and
pain ul, and his ROM is now signi cantly limited in all direc-
tions. Your examination is consistent with “ rozen shoulder”
or adhesive capsulitis.
Question 12.14.5 Adhesive capsulitis is most commonly
associated with which o the ollowing?
A) Diabetes.
B) Hyperthyroidism.
C) Spondyloarthritis.
D) Nondominant arm.
E) Male gender.
Answer 12.14.5 The correct answer is “A.” Adhesive capsulitis
has no clear predilection as to gender, race, arm dominance, or
occupation. It is characterized by loss o ROM o the shoulder
in all directions, with loss o both passive and active motion. It
has a high incidence in patients with diabetes and tends to be
more recalcitrant in those patients, o whom up to 50% will have
bilateral involvement—although not necessarily concomitantly.
Adhesive capsulitis is not typically related to trauma, but it can
be associated with disuse due to pain, osteoarthritis, sling use,
etc. Other conditions that are associated with adhesive capsuli-
tis include hypothyroidism and Parkinson disease.
HELPFUL TIP:
a hes ve c psul s s cons ere o be op h c n
sep r e rom pos r um c or pos oper ve jo n s -
ness or hes ons.
Question 12.14.6 What initial treatment do you recom
mend or this patient with adhesive capsulitis?
A) Arthroscopic debridement.
B) Oral corticosteroids.
C) NSAIDs and a sling or com ort.
D) Extended progressive physical therapy.
E) Mobilization under anesthesia.
352 Fa MiLY MEd iCiNE EXa MiNa t iON & BOa Rd REViEW
Answer 12.14.6 The correct answer is “D.” A progressive
stretching program with heat and NSAIDs or acetaminophen
to improve com ort is the most appropriate early treatment. A
corticosteroid injection (under ultrasound guidance or uo-
roscopy) may be bene cial, but should be used cautiously in
diabetic patients. Oral steroids have no greater bene t than
NSAIDs. “C” is incorrect because a sling will contribute to ur-
ther immobilization and worsening o the problem. Mobiliza-
tion or capsular release under anesthesia may be a last resort in
adhesive capsulitis.
HELPFUL TIP:
t he yp c l cl n c l course or hes ve c psul s evolves
over 1 o 2 ye rs w h n n l “ reez ng” ph se ch r c-
er ze by progress ng p n n s ness ollowe by
slow “ h w ng” ph se w h ecre s ng p n n ncre s-
ng ROM.
Objectives: Did you learn to . . .
• d e ne he muscles o he ro or cu ?
• i en y, ev lu e, n re ro or cu njury?
• Recogn ze he presen on, ssoc ons, n re men o
hes ve c psul s?
CASE 12.15
A 58-year-old male presents a er sudden onset o right upper
arm pain. He was working in the yard, cutting and pulling
out some bushes, when he heard a “snap” and elt the pain.
He has a history o rotator cu tendinosis and osteoarthritis.
Question 12.15.1 You should look or all o the ollowing on
physical examination EXCEPT:
A) A positive elevated arm stress test (“Roos” test).
B) A palpable biceps muscle de ect.
C) Normal grip strength.
D) An asymmetric bulge in the a ected arm.
Answer 12.15.1 The correct answer is “A.” T e elevated arm
stress test is used to evaluate a patient or thoracic outlet syn-
drome. Have the patient li both arms with the elbow at shoul-
der height while pushing the shoulders backward and repeatedly
gripping and relaxing the hands. T e test is positive i neuro-
logical or vascular symptoms are reproduced when the arm
is elevated or a prolonged period. T is patient’s presentation
is not consistent with thoracic outlet syndrome. However, the
history is consistent with biceps tendon rupture. “B” through
“D” would be expected in a patient with biceps tendon rup-
ture. Yes, there is usually normal grip strength. T e injury is, o
course, in the upper arm.
HELPFUL TIP:
Provoc ve m neuvers or hor c c ou le syn rome
(Roos es , e c.) h ve poor sens v y n spec c y
(<60%). t hey re mos help ul pos ve n he p -
en ’s symp oms re repro uce .
Question 12.15.2 Which portion o the biceps is most com
monly involved in ruptures?
A) Distal tendon.
B) Proximal short head tendon.
C) Proximal long head tendon.
D) Mid-muscle belly.
E) Proximal short head belly.
Answer 12.15.2 The correct answer is “C.” T e long head is
most commonly a ected due to its position and risk or weaken-
ing secondary to rotator cu tendinosis and shoulder impinge-
ment.
You decide this patient has a rupture o the long head o the
biceps tendon.
Question 12.15.3 How is this injury treated initially?
A) Immediate surgical repair.
B) Delayed surgical repair.
C) Immobilization or 4 to 6 weeks with sling.
D) NSAIDs and physical therapy.
E) Biceps muscle transplant, pre erably rom a retired NFL
player.
Answer 12.15.3 The correct answer is “D.” For most isolated
proximal long or short head tears (with the exception o some
young athletes and heavy laborers who would not tolerate the
slight decrease in strength), treatment is conservative. Analge-
sics and physical therapy typically suf ce. Surgical repair may
be indicated i conservative therapy ails. O note, you should
discuss with patients the cosmetic de ormity that will be perma-
nent when these injuries are unrepaired versus scarring associ-
ated with surgery. Generally, there is approximately a 0% loss
o elbow exion and supination strength with an isolated proxi-
mal tear.
HELPFUL TIP:
a l hough prox m l b ceps en on rup ures re re e
conserv vely, s l rup ures shoul be re erre or
e rly surg c l rep r, s he con nu y o he en re mus-
cle s los n unc on he elbow jo n s s gn c n ly
mp re w h 30% o 40% loss o s reng h cross he
elbow jo n .
Objectives: Did you learn to . . .
• i en y he cl n c l presen on o b ceps en on rup ure?
• M n ge p en w h b ceps en on rup ure?
CASE 12.16
A 25-year-old male presents to you with a history o a soccer
injury. Someone evidently ell on his right oot while trying
to steal the ball. T e patient rapidly and orce ully twisted
around the xed oot. Since then he has had signi cant pain
and swelling o the oot. His x-ray is shown in Figure 12-4.

FIGURE 12-4.
Question 12.16.1 Which o the ollowing is true regarding
this radiograph?
A) It shows a step-o between the base o the second metatarsal
and the middle cunei orm.
B) It shows mid oot boney instability.
C) It may require weight-bearing lms to identi y this injury.
D) T e abnormality is named a er a French gynecologist.
E) All o the above are true.
Answer 12.16.1 The correct answer is “E,” all o the above.
T is is a Lis ranc racture, which occurs between the metatar-
sals and the tarsal bones (the space between the metatarsals
and the tarsal bones is known as the Lis ranc joint). Look or a
widened space between the rst and second and/or second and
third metatarsals. T ere may also be a stepo between the sec-
ond metatarsal and middle cunei orm. T ese ractures may be
dif cult to identi y, but obtaining weight-bearing lms or stress
views may help. Signi cant oot pain should be a tip o . See
Figure 2-5 or urther explanation. And, yes indeed, Dr. Lis-
ranc was a surgeon and gynecologist in Napoleon’s army! Why
did Napoleon need a gynecologist on campaign with him? T at
is a matter o debate.
Question 12.16.2 Appropriate treatment or this type o
injury should include:
A) Weight bearing as tolerated in a post-op or hard-soled shoe.
B) Rest, ice, compression, elevation, NSAIDs, and activity as
tolerated. Will heal well and can be treated like a mid- oot
sprain.
C) Orthopedic re erral or open reduction/internal xation
(ORIF).
D) Walking boot that can be removed or several weight-bearing
hours a day.
E) Early 9th century French legionnaire’s boot.
CHAPTER 12 • ORt HOPEd iCS a Nd SPORt S MEd iCiNE 353
Answer 12.16.2 The correct answer is “C.” T is injury/dislo-
cation will lead to signi cant long-term pain and mid oot insta-
bility i not recognized and treated appropriately. Any signi cant
displacement (> 2 mm) should be re erred or surgical consid-
eration. T ese are generally complex injuries prone to poor out-
comes and should be managed by an orthopedic consultant.
Objectives: Did you learn to . . .
• i en y L s r nc njury?
• M n ge p en w h L s r nc njury?
CASE 12.17
An 18-year-old emale gymnast lands her dismount rom
the balance beam awkwardly. She reports the knee buckling,
hearing a pop, and experiencing immediate right knee pain.
She presents to your of ce 45 minutes a er the injury. She is
able to bear some weight on the leg but reports it is already
swollen and eels “loose.” On examination, there is a knee
e usion present.
Question 12.17.1 Based on the in ormation above, the
most likely isolated injury experienced by this athlete is:
A) Medial meniscus tear.
B) MCL sprain.
C) Distal quadriceps/patellar tendon rupture.
D) Anterior cruciate ligament (ACL) rupture.
E) Distal emur racture.
Answer 12.17.1 The correct answer is “D.” Did the patient
or someone else hear a pop? I yes, suspect ACL tear (80%),
meniscal injury ( 5%), and rarely a racture. When did you
notice swelling? I 0 to 2 hours a er the injury, suspect ACL
tear, racture, or patellar dislocation/subluxation; i 2 to
24 hours, suspect meniscal injury. I there is hemarthrosis on
354 Fa MiLY MEd iCiNE EXa MiNa t iON & BOa Rd REViEW
S te p off s e cond me ta ta rs a l
a nd middle cune iform
We dge s ha pe fra cture
ofte n s e e n with Lis fra nc
Wide s pa ce be twe e n
1s t a nd 2nd me ta ta rs a ls
FIGURE 12-5.
aspiration, suspect ACL injury (> 75%), patellar subluxation, or
intra-articular racture. A history o , “My knee gives way; buck-
les; eels loose; or comes apart,” may be secondary to patellar
subluxation/dislocation, ACL de ciency, or arthritis. Medial
and lateral collateral ligament injuries, do not typically present
with signi cant e usion and typically eel stable with orward
ambulation but are pain ul with side-to-side movements. Mus-
cle or tendon rupture may cause buckling, but will not typically
cause e usion and will generally have an obvious de ormity and
inability to bear weight.
Question 12.17.2 The best test to con rm the diagnosis o
the above injury would be?
A) Plain lm radiographs.
B) McMurray test.
C) Lachman test.
D) Anterior drawer test.
Answer 12.17.2 The correct answer is “C.” In the hands o an
experienced clinician, the Lachman test is the most sensitive
test or ACL insuf ciency (80–95%). T e anterior drawer sign
is negative in about 50% o acute ACL tears, and o en is nega-
tive subacutely. McMurray test is used to evaluate or a meniscal
tear. Plain lms should be obtained or all patients with acute
knee injury with e usion or suspected ACL tear. A Segond
racture (small avulsion o the lateral tibial plateau) is an x-ray
nding associated with ACL tears. Although an MRI may be
considered a gold standard test, its sensitivity has been reported
as 97% when compared against arthroscopy ndings, and is pos-
itive in only 82% in cases o complete rupture. An orthopedic
consult is generally indicated i ACL injury is suspected, and
obtaining one is less expensive than MRI.
HELPFUL TIP:
t he L chm n es s per orme w h he knee lexe
20 o 30 egrees w h he p en n sup ne pos on.
t he ex m ner hen emp s o n er orly spl ce he
b on he emur wh le s b l z ng he emur. a lw ys
remember o check he con r l er l s e. Some p -
en s h ve n ur lly l x l g men s.
You eel that this patient is very appropriate or radiographic
evaluation, and you obtain x-rays o the knee.
Question 12.17.3 Which o the ollowing is NOT one o the
criteria o the Ottawa knee rules predicting the need or
knee radiographs?
A) Age < 8.
B) Pain isolated to the patella.
C) enderness at the head o the bula.
D) Inability to ex the knee 90 degrees.
E) Inability to bear weight or our steps.
Answer 12.17.3 The correct answer is “A.” T e age criterion
or the Ottawa knee rules is age > 55 years. All o the other
options are correct. I any o these criteria are present (including
a patient > 55 years o age), a radiograph should be obtained.
T ese rules have been validated and are 97% sensitive or rac-
ture. T e Pittsburgh rules, which are reportedly 99% sensitive,

have only two criteria: ( ) age < 2 years or age > 50 and (2)
inability to bear weight in the clinic or ED. O the two, the
Ottawa rules are the more commonly accepted.
T e x-ray shows no racture. You prescribe a knee immobi-
lizer, rest, ice, NSAIDs, and re er the patient to an orthope-
dic surgeon. T e patient returns 2 days later with marked
e usion and pain. o help relieve the pain, you per orm an
arthrocentesis and 90 mL o bloody aspirate is obtained. As
per your clinic’s standard protocol, the joint uid is sent or
analysis. T e analysis returns with the only abnormalities
being blood and at droplets.
Question 12.17.4 Based on the ef usion, you suspect what
diagnosis?
A) Complete ACL rupture.
B) Meniscal tear.
C) ACL and PCL tear.
D) Intra-articular racture.
E) Patellar subluxation.
Answer 12.17.4 The correct answer is “D.” Fat rom bone
marrow may be seen even with a small intra-articular racture.
Consider C or MRI i racture is not noted on plain lm. I a
racture is still not demonstrated, consider re erral or orthope-
dic consultation.
HELPFUL TIP:
t here s no nee o re er or n a CL njury cu ely
( hough hey s ll shoul be re erre ). in c , ou comes
re he s me reg r less o whe her he a CL s rep re
or no (BMJ. 2013;346:f232). So w ng couple o ys
or week or n or hope c ppo n men s OK; m ke
hem nonwe gh be r ng n cons er mmob l z on,
hough.
Objectives: Did you learn to . . .
• Gener e eren l gnos s or knee p n n n hle e?
• d gnose a CL njury?
• d e erm ne when knee r ogr phs re ppropr e?
QUICK QUIZ: KNEE Pa iN
T e best clinical test(s) or determining the presence o a menis-
cal injury is (are):
A) Posterior sag test.
B) Apley test.
C) McMurray test.
D) Pivot shi test.
E) B and C.
The correct answer is “C.” T e McMurray test is the best test
or determining meniscal injury. T is is done by exing the
knee and then extending the knee while per orming internal
and external rotation o the tibia/ bula. Keep one hand on the
CHAPTER 12 • ORt HOPEd iCS a Nd SPORt S MEd iCiNE 355
knee. T e test is positive when the examiner eels a pop during
the maneuver or when there is signi cant pain during internal
or external rotation. T e Apley test is done with the patient in
a prone position. Move the knee to 90 degrees o exion. Put
downward pressure on the tibia/ bula while internally and
externally rotating the lower leg. Pain suggests a meniscal tear.
Pain should be relieved by distracting the joint. T e posterior
sag test is used to detect PCL injury, while the pivot shi test is
used to detect ACL injury.
CASE 12.18
A 24-year-old emale presents to the clinic 24 hours a er
slipping on a patch o ice outside her home. She reports eel-
ing a “pop” and immediate pain on the lateral aspect o the
ankle. She reports signi cant swelling in the rst ew hours
with pain and inability to bear weight initially, but now she
is able to walk with a signi cant limp. She reports no signi -
cant past injuries to the oot or ankle. On examination, you
note edema/e usion over the lateral ankle, some ecchymosis,
tenderness, but no laxity on anterior drawer and inversion
stress. T ere is no bony tenderness on palpation o the oot
and ankle, but there is tenderness anterolaterally in the so
tissue.
Question 12.18.1 The most likely injury this patient has
suf ered is?
A) Fracture o the distal tibia.
B) Fracture o the distal bula.
C) Sprain o the lateral ligament complex.
D) Sprain o the medial ligament complex.
E) Syndesmosis sprain.
Answer 12.18.1 The correct answer is “C.” A sprain is most
likely because there is no bony tenderness. And, since she is ten-
der laterally, the lateral ligament complex is most likely sprained.
Question 12.18.2 In this case, the most likely structure
injured would be the:
A) Anterior talo bular ligament.
B) Distal bula.
C) Distal tibia.
D) Deltoid ligament.
E) Achilles tendon.
Answer 12.18.2 The correct answer is “A.” T is is a sprain
o the anterior talo bular ligament. T is is the rst ligament
injured with an inversion ankle sprain. It is ollowed by the
calcaneo bular ligament i enough orce is involved. “E,” Achil-
les tendon injury (speci cally rupture), is o special note. First,
this injury presents as pain in the Achilles tendon area. With
a complete Achilles tendon tear, the patient will have marked
weakness o plantar exion. A diagnostic test (T ompson test)
is to squeeze the posterior cal with the patient lying supine on
the bed and the eet dangling o . In response, the oot should
plantar ex. I this does not occur, consider Achilles rupture.
Operative and nonoperative treatments can be used.
356 Fa MiLY MEd iCiNE EXa MiNa t iON & BOa Rd REViEW

A. Pos te rior Ma lle ola r zone

e dge or tip B. Pos te rior
of la te ra l e dge or tip
ma lle olus of me dia l
6 cm
Midfoot zone 6 cm ma lle olus

C. Ba s e of
fifth
me ta ta rs a l D. Navicula r

Lateral view Medial view

An a nkle ra diogra phic s e rie s is re quire d only if the re is a ny pa in in the ma lle ola r zone
a nd a ny of the s e findings is pre s e nt:
(1) bone te nde rne s s a t A
(2) bone te nde rne s s a t B
(3) ina bility to be a r we ight both imme dia te ly a nd in the ED

A foot ra diogra phic s e rie s is re quire d only if the re is a ny pa in in the midfoot zone a nd
a ny of the s e findings is pre s e nt:
(1) bone te nde rne s s a t C
(2) bone te nde rne s s a t D
(3) ina bility to be a r we ight both imme dia te ly a nd in the ED

FIGURE 12-6.

HELPFUL TIP: HELPFUL TIP:

t he O w cr er rel bly pre c who nee s n nkle E rly mob l z on n we gh be r ng re uces he me
r ogr ph n who oes no . t h s h s been v l e o s b l y or nkle spr ns. Res n nonwe gh be r-
n ges 5 o 55. t he O w oo n nkle cr er re ng shoul be m n m ze . a llow he p en o v nce
l s e n F gure 12-6. c v es s oler e .

Objectives: Did you learn to . . .

Question 12.18.3 Which o the ollowing is the most appro
priate management o this patient’s sprained ankle?
A) Cast or 4 weeks ollowed by physical therapy.
B) Crutches, nonweight-bearing or 2 weeks, and then progres-
sive physical therapy.
C) Rest, ice, elevation, and early mobilization using external
support, crutches or cane i needed. Progress to activity as
tolerated.
D) Re er or orthopedic consultation.
E) Immobilization with short-leg walking cast, heat or com-
ort, analgesics or NSAIDs, and progress to activities as
tolerated.
Answer 12.18.3 The correct answer is “C.” reatment or most
sprains includes an external supportive brace, ice application,
and elevation; early mobilization is critical and will hasten
recovery. NSAIDs or acetaminophen should be used or pain
control. T e patient should be allowed partial weight bearing
as tolerated with crutches or a cane. Patients with recurrent
problems o instability should be re erred to an orthopedist or
evaluation.
• i en y p en w h n nkle spr n?
• d eren e nkle spr n rom r c ure b se on h s ory n
ex m n on?
• Use he O w nkle rules o e erm ne when o ob n n
nkle r ogr ph?
• M n ge p en w h n nkle spr n?
CASE 12.19
A 27-year-old male presents to your clinic ollowing an
inversion-type injury to the oot and ankle. He cannot bear
weight on the oot on presentation. He complains o pain and
swelling laterally on the oot and ankle. T ere is some so -tissue
swelling but no obvious de ormity. T ere is tenderness over the
lateral ankle ligaments as well as over the base o the h meta-
tarsal. AP and lateral lms o the oot and ankle are obtained and
reveal a nondisplaced racture at the base o the h metatarsal.
T e radiograph is available or your review in Figure 12-7.
Question 12.19.1 What is the name o this racture ?
A) Jones racture.
B) Maisonneuve racture.
 CHAPTER 12 • ORt HOPEd iCS a Nd SPORt S MEd iCiNE 357

C) Operative internal xation.

D) Walking boot with crutches or 6 to 8 weeks.
E) None o the above.

Answer 12.19.2 The correct answer is “A.” Nondisplaced

tuberosity ractures generally heal well with conservative mea-
sures. T ese may be managed with a postoperative shoe with
weight bearing as tolerated. A walking boot may be needed
initially i there is signi cant pain present preventing ambu-
lation in a hard soled shoe, however, ankle immobilization is
generally not needed or these avulsion ractures to heal. For a
racture with a displaced ragment > 3 mm, orthopedic re erral
should be considered. Fractures to the metaphyseal–diaphyseal
junction (Jones ractures) result rom a vertical load placed on
the lateral oot, such as an inversion injury or a stress injury.
Jones ractures may potentially be managed with 6 to 8 weeks
in a nonweight-bearing short-leg cast i nondisplaced, however,
many require surgical intervention. Jones ractures should be
re erred due to the high incidence o nonunion.

HELPFUL TIP:
S ress r c ures o he ore oo re common n compe -
ve n recre on l hle es, espec lly er su en
ncre se n c v y, n ens y, ur on, requency, or
FIGURE 12-7. ch nge n sur ce ype. t hey m y be occul on pl n
lms cu ely, bu some sub le per os e l ch nge m y

C) Colles racture.
D) Avulsion racture o tuberosity, base h metatarsal

Answer 12.19.1 The correct answer is “D.” T is is an avulsion

racture o the base o the h metatarsal that may result rom
an inversion ankle injury. Classically, this has been thought to
occur due to an attempt at dynamic stabilization by the pero-
neus brevis, causing an avulsion o the proximal portion o the
metatarsal base. A Jones racture is a transverse racture o the Avuls ion
proximal h metatarsal at the metaphyseal–diaphyseal junc-
tion and typically extends into the inter-metatarsal acet (see
Fig. 2-8). Jones ractures have a high incidence o nonunion
because they occur in a watershed area o blood supply. A mai-
sonneuve racture is a racture o the proximal 1 o the bula
associated with an external rotation injury o the ankle. A colles
racture is a racture o the distal radius (not involving the joint)
with dorsal angulation o the distal racture ragment.
J one s
HELPFUL TIP:
a n un use pophys s n ch l ren n olescen s m y
be con use w h h me rs l vuls on njury. t u-
beros y vuls on r c ures re r nsverse, wh le he
un use pophys s s or en e ver c lly long he long
x s o he me rs l.

Question 12.19.2 Appropriate treatment or the racture

described above would be: Apophys is
A) A hard soled postoperative shoe bearing weight as tolerated.
B) Nonweight-bearing short-leg cast or 6 to 8 weeks. FIGURE 12-8.
358 Fa MiLY MEd iCiNE EXa MiNa t iON & BOa Rd REViEW
be ev en on close ex m n on n he re o m x m l
en erness. i pl n lms re neg ve bu susp c on re-
m ns h gh, re s r c ure s presen . You m y con-
s er n MRi or repe pl n lms n re-ex m n on n
10 o 14 ys. t he s me re men cons er ons pply
o me rs l s ress r c ures s o ny o her non s-
pl ce ore oo r c ure.
HELPFUL TIP:
Be ler or m oo en erness over he n v cul r. a ll
n v cul r r c ures, nclu ng s ress r c ures, shoul be
re erre o n or hope s ue o po en l or v scul r
necros s.
Objectives: Did you learn to . . .
• Ev lu e oo njur es?
• d escr be h me rs l r c ures?
• M n ge s r gh orw r me rs l r c ures n en y
wh ch r c ures shoul be re erre ?
CASE 12.20
A 40-year-old emale actory worker presents with progres-
sively worsening heel pain. She has pain when she rst gets
out o bed in the morning. T e pain tends to subside a er
20 to 45 minutes but is worsened by standing on the con-
crete oor o the actory where she works. She has a history
o diabetes and hyperlipidemia. On examination, you nd an
obese emale with a normal stance and gait. She has exquisite
tenderness to palpation just distal to the heel on the under-
side o the oot. Pain is exacerbated by extension o the toes.
Question 12.20.1 Which o the ollowing is the most likely
diagnosis?
A) arsal tunnel syndrome.
B) Achilles tendon rupture.
C) Charcot oot.
D) Plantar asciitis.
E) Plantar ascia rupture.
Answer 12.20.1 The correct answer is “D.” Plantar asciitis,
the most common cause o heel pain in adults, is a degenerative
condition o the origin o the plantar ascia. “A” is incorrect. ar-
sal tunnel syndrome is due to posterior tibial nerve entrapment
and presents with di use pain at the medial ankle and arch o
the oot. Paresthesias and dysesthesias o en occur as well. “B,”
Achilles tendon rupture, is incorrect because the pain should be
sudden, stabbing, and located in the cal (not the plantar aspect
o the heel). “C” is also incorrect. Charcot oot does occur in dia-
betics, but it is actually the result o neuropathy and so generally
does not present with pain. Instead, Charcot oot presents as an
in ammatory condition (e.g., warmth, erythema, and edema)
and progresses to joint instability and severe oot de ormities.
Finally, “E” is incorrect because plantar ascia rupture should
have a sudden onset and is o en related to trauma.
Question 12.20.2 Which o the ollowing is true o plantar
asciitis?
A) It more commonly occurs in individuals with pes cavus.
B) It is more common in women.
C) It is commonly an acute injury.
D) Radiographic identi cation o a “heel spur” or osteophyte is
pathognomonic.
Answer 12.20.2 The correct answer is “B.” Plantar asciitis is
not associated with any particular oot type. It is nearly twice
as common in women as men. It is also more common in over-
weight individuals. A rupture o the plantar ascia may occur
acutely. Spurring may be seen in up to 50% o patients with
plantar asciitis, but is present in 20% o age matched asymp-
tomatic adults. T us, the nding o a spur is not diagnostic.
Question 12.20.3 Appropriate initial treatment or this
patient’s plantar asciitis should include:
A) A heel cup or silicon pad.
B) Achilles stretching.
C) Ice or heat.
D) NSAIDs.
E) All o the above.
Answer 12.20.3 The correct answer is “E,” all o the above.
Other initial treatments to consider include night splints to
maintain ankle dorsi exion and stretch the Achilles tendon and
plantar ascia. Physical therapy modalities such as ultrasound
may be help ul as well. Advanced treatments, such as corticoste-
roid injections, may be considered a er ailure o initial conser-
vative therapy. However, injections are not without risk, includ-
ing plantar ascia rupture, loss o the at pads o the eet causing
signi cant pain and disability, and in ection.
HELPFUL TIP:
No ll heel p n s pl n r sc s. Remember hese
o hers: rs l unnel syn rome ( escr be bove), p n-
ul heel p syn rome (p n loc e over he heel sec-
on ry o bre k own o brous sep e rom overuse
n wh ch m y ke up o 6 mon hs o he l), n p ezo-
gen c p pules (p n over me l/ n er or spec o heel,
en er p pules no e when p en s n ng).
Objectives: Did you learn to . . .
• d gnose pl n r sc s n cons er o her c uses o heel
n oo p n?
• d escr be he n ur l h s ory o n re men s or pl n r
sc s?
QUICK QUIZ: Ha Nd iNJURiES
A “gamekeeper’s thumb” would likely be seen as the result o
which o the ollowing injuries?
A) Fall on an outstretched hand.
B) Crush injury, or example, between two pieces o machinery.
C) Fall by a skier using a ski pole.
 CHAPTER 12 • ORt HOPEd iCS a Nd SPORt S MEd iCiNE 359

D) Excessive electronic gaming (e.g., Nintendo and Xbox).

E) Fall rom a mountain bike.

The correct answer is “C.” A gamekeeper’s thumb is de ned as

an injury (partial or complete tear) o the ulnar collateral liga-
ment o the rst MCP joint. T is injury can occur with a val-
gus orce on the thumb, which may occur when alling with a
ski pole. Plain lms should be obtained to evaluate or racture.
reatment is immobilization o the thumb, such as with a thumb
spica splint. Displaced ractures and/or the presence o a Stener
lesion (when a piece o the torn ulnar collateral ligament dis-
places super cially to the adductor pollicis aponeurosis, prevent-
ing healing o the ligament) will require surgical re erral. “Gam-
er’s thumb,” “D,” is a repetitive use syndrome caused by playing
(appropriately enough) video games. It is an overuse syndrome
o en presenting with swelling at the base o the thumb.

QUICK QUIZ: ELBOW FRa Ct URE

T e most speci c nding on radiograph or a radial head rac-

ture is:
A) Anterior at pad sign.
B) Posterior at pad sign.
C) rousseau sign.
D) Medial at pad sign.

The correct answer is “B.” T e posterior at pad sign, which FIGURE 12-9.
indicates an e usion in the joint, is the most speci c o the
ndings or a radial head racture. An anterior at pad sign is
the most sensitive. Figure 2-9, demonstrates both the anterior
and posterior at pad signs. T ere is no medial at pad sign, and
C) Medial condyle racture.
rousseau sign is related to hypocalcemia and is carpal spasm
D) Lateral condyle racture.
with arterial occlusion (as with a blood pressure cu ).
E) Olecranon racture.

QUICK QUIZ: Ra d ia L HEa d FRa Ct URE
T e proper treatment o a nondisplaced, ractured radial head
is:
A) Internal xation.
B) Sling with early mobilization.
C) Short-arm cast.
D) Long-arm cast.
The correct answer is “B.” For a nondisplaced radial head rac-
ture, the treatment is simply a sling or com ort and early mobi-
lization. Mobilization is especially important to avoid a sti
elbow. Orthopedic re erral should be considered i there is any
limitation o motion.
QUICK QUIZ: PEd iat RiC FRa Ct URES
The answer is “B” supracondylar racture. Although in adults
the most common occult elbow racture is o the radial head,
in the pediatric population it is a supracondylar racture. T ese
may be signi cantly displaced, but i nondisplaced they can be
very subtle and the only sign o a racture may be a displaced
posterior (or anterior) at pad.
QUICK QUIZ: HiP Pa iN
A 76-year-old emale nursing home resident is brought to clinic
a er rolling out o bed last night. She is normally able to ambu-
late independently, but today cannot bear weight due to pain in
her hip. She has signi cant hip tenderness and pain with any
movement o her leg. She is unable to per orm a SLR secondary
to pain. Plain x-rays o her pelvis and hip are read as osteopenia
with no obvious racture.

T e most common elbow racture in the pediatric population What is the most appropriate next step?
with a positive “ at pad sign” but no obvious racture on x-ray is: A) Conservative treatment with acetaminophen and bed rest
A) Radial head racture. until able to ambulate.
B) Supracondylar racture. B) Admission or observation.
360 Fa MiLY MEd iCiNE EXa MiNa t iON & BOa Rd REViEW
C) Hip MRI.
D) Physical therapy.
E) Fentanyl patch.
The correct answer is “C.” T e patient may have an occult hip
racture. Rates o occult hip ractures range rom 2% to 0% o
all hip ractures. o miss the diagnosis o a hip racture may lead
to displacement o the racture and a worse outcome. Both C
and MRI can be used to evaluate or occult racture, but most
studies indicate that MRI has a greater sensitivity.
CASE 12.21
A 45-year-old emale hospital clerk presents with bilateral
aching pain in the orearms and thenar eminences. T e pain
is made worse with driving and typing. She also has intermit-
tent numbness over the same areas. She tried to ignore the
symptoms, but today she dropped her co ee mug on her com-
puter keyboard and became alarmed at her loss o strength.
She has hypothyroidism and is obese, but she reports that her
health is otherwise good.
Question 12.21.1 Based on the history alone, which o the
ollowing is the most likely diagnosis?
A) Carpal tunnel syndrome.
B) Osteoarthritis.
C) Ulnar neuropathy.
D) Diabetic neuropathy.
E) Stroke.
Answer 12.21.1 The correct answer is “A.” Carpal tunnel syn-
drome is due to median nerve entrapment in the carpal tunnel
o the wrist. ypical symptoms include numbness, paresthesias,
and pain at the palmar/radial aspect o the hand, quintessen-
tially the thenar eminence. In more severe or long-lasting cases,
you may see atrophy o the thenar eminence. Patients may also
develop weakness o thumb opposition. Osteoarthritis o the
wrists does not usually cause nerve symptoms but can cause
spondylosis and nerve root impingement on occasion. Ulnar
neuropathy involves the ulnar aspect o the hand, especially the
ourth and h ngers, rather than the radial aspect, which is
involved with carpal tunnel syndrome. Diabetic neuropathy
typically presents in the eet since they are innervated by the
longest nerves in the body. Note: T is could represent cervical
disk disease as well, especially given that it is bilateral.
Phalen sign is positive (placing the wrists in a exed position
causes aching and numbness in the median nerve distribu-
tion).
Question 12.21.2 What is the best next step in the continu
ing evaluation and management o this patient?
A) Nerve conduction studies.
B) Radiograph o the wrist.
C) MRI o the cervical spine.
D) Orthopedic re erral.
E) Initiation o treatment.
Answer 12.21.2 The correct answer is “E.” In a clear-cut
case o carpal tunnel syndrome, there is no need or urther
studies. I the diagnosis is in doubt, electromyogram and
nerve conduction studies (EMG-NCS) may be o bene t. I
the ROM in the wrist is limited, x-rays may be help ul. At this
point in time, MRI and orthopedic re erral are not likely to
add much.
Question 12.21.3 Which o the ollowing IS NOT associated
with carpal tunnel syndrome?
A) Hypothyroidism.
B) Diabetes mellitus.
C) Amyloidosis.
D) Polycythemia vera.
E) Rheumatoid arthritis.
Answer 12.21.3 The correct answer is “D.” All o the above are
associated with carpal tunnel syndrome except or polycythe-
mia vera. Polycythemia vera can cause erythromelalgia which is
a burning pain o the hands and eet associated with erythema,
pallor, or cyanosis. It responds to aspirin. Other conditions
associated with carpal tunnel syndrome include pregnancy,
menopause, obesity, acromegaly, and end-stage renal disease.
T e point here is that patients with carpal tunnel syndrome
should have a systemic cause ruled out, either clinically or with
labs.
Question 12.21.4 What is the most appropriate initial
treatment?
A) T umb spica splint.
B) Steroid injection.
C) NSAIDs and neutral position wrist splints.
D) Short-arm casts.
E) Bilateral gure-o -eight splints.
Answer 12.21.4 The correct answer is “C.” Conservative ther-
apy should be initiated rst, unless there is some compelling
reason or more aggressive therapy (e.g., severe weakness o
the hands and loss o unction). Most patients respond well to
NSAIDs and the use o neutral position splints. T e traditional
cock-up splints are not as e ective as neutral position splints.
T e splints should be worn at night. T e patient may wear the
splints during the day, too, but should take them o or several
hours per day to avoid disuse muscle atrophy. “A” is incorrect
since a thumb spica is not needed. “B,” steroid injection, might
be tried i initial conservative measures ail. However, the ben-
e t is generally limited to month. “D” is just wrong—don’t cast
patients with carpal tunnel syndrome! “E” is a terrible idea as
well since a bilateral gure-o -eight splint is basically a straight
jacket.
HELPFUL TIP:
Or l s ero s h ve been use or c rp l unnel w h l m-
e success. Un or un ely mos mo l es (NSa id s,
spl n s, s ero s, e c.) re no be er h n pl cebo n
r n om ze r ls.

HELPFUL TIP:
Ph len n t nel s gns re cru e ools bes . t nel s gn,
wh ch s p n ul sens on o he ngers n uce by
percuss on o he me n nerve he level o he c rp l
unnel, m y be pos ve, bu s only 50% sens ve ( l p
co n) n 54% spec c. Ph len s gn, keep ng bo h wr s s
n p lm r- lexe pos on, m y repro uce symp oms.
Sens v y v r es rom 10% o 88% epen ng on s u y;
s spec c y s 80%.
Objectives: Did you learn to . . .
• d gnose c rp l unnel syn rome n cons er o her c uses
o wr s p n?
• M n ge p en w h c rp l unnel syn rome?
QUICK QUIZ: Ca St iNG
A ew days ago, your partner placed a cast on the arm o a
20-year-old male or a distal radial racture. He calls your of ce
today, when your partner has gone shing (darn her, anyway).
T e patient is complaining o increasing pain and numbness o
his ngers in the casted arm.
Which course o action is most appropriate?
A) Have the patient ollow up tomorrow, when your partner is
back in the of ce.
B) Send the patient to the emergency room or compressive
Doppler examination o the arm to rule out venous throm-
bosis.
C) Ask the patient to come to clinic to have the cast replaced.
D) ell the patient that these are expected symptoms and advise
him to take some aspirin.
E) Recommend that he have his cast signed by as many riends
as possible to take his mind o these clearly psychosomatic
symptoms.
The correct answer is “C.” T is patient has symptoms that are
most likely due to an improperly tted cast. T e problem here
could be vascular compromise, nerve compression, or a com-
partment syndrome. He should be seen without delay to evaluate
or these, and the cast should be adjusted or replaced. T e cast
can be bivalved or have a window cut into it, then be observed
or improvement in symptoms i the cast does not need com-
pletely removed to rule out the pathology noted above.
Clinical Pearls
d o no le he presence c lc um pyrophosph e crys ls
or ur c c ssu e you rom suspec ng sep c r hr s
as both gout and pseudogout commonly coexist with septic
arthritis.
d o no rou nely or er pl n lms or low b ck p n unless
r um , bnorm l phys c l ex m n on n ngs, or “re l g”
symp oms re presen .
CHAPTER 12 • ORt HOPEd iCS a Nd SPORt S MEd iCiNE 361
d o no rou nely screen or scol os s n symp om c oles-
cen s.
M n n h gh susp c on or sc pho r c ure here s
r um w h snu box en erness presen .
S r w h ce m nophen or re men o musculoskele l
njur es.
t o ch eve s er recovery, recommen e rly mob l z on or
low-b ck p n n nkle spr ns.
Use he O w a nkle Cr er o e erm ne pl n lms re
nee e or ev lu on o nkle njur es.
BIBLIOGRAPHY
Alshryda S, et al. Acute ractures o the scaphoid bone:
Systematic review and meta-analysis. T e Surgeon.
20 2: 0(4):2 8–229.
Anderson BC. Of ce Orthopedics or Primary Care: reatment.
3rd ed. Philadelphia, PA: Saundesrs; 2005.
Dartness J, et al. Haematolgenous acute and subacute paediatric
osteomyelitis. J Bone Joint Surg. Br. 20 2;94-B:584–595.
DeVries JG, et al. T e h metatarsal base: anatomic evaluation
regarding racture mechanism and treatment algorithms.
J Foot Ankle Surg. 20 5;54:94–98.
Dixit S, et al. Management o patello emoral pain syndrome.
Am Fam Physician. 2007;75(2): 94.
Grif n LY, et al., eds. Essentials o Musculoskeletal Care. 3rd ed.
Rosemont, IL: American Academy o Orthopaedic
Surgeons; 2005.
Kindale S. Evaluation and treatment o acute low back pain.
Am Fam Physician. 2007;75(8): 8 – 88.
Margaretten ME, et al. Does this adult patient have septic
arthritis?. JAMA. 2007;297( 3): 478– 488.
McGillicuddy DC, et al. How sensitive is the synovial uid
white blood cell count in diagnosing septic arthritis?
Am J Emerg Med. 2007;25(7):749–752.
Osmon DR, et al. Diagnosis and management o prosthetic
joint in ection: clinical practice guidelines by the In ec-
tious Disease Society o America. Clin In ect Dis. 20 3;
56( ):e –e25.
Reid D, et al. Acromioclavicular Joint Separations Grades I-III:
A review o the literature and development o best practice
guidelines. Sports Med. 20 2;42(8):68 –696.
Rixe JA, et al. A Review o the management o patello emoral
pain syndrome. Phys Sportsmed. 20 3;4 (3): 9–28.
Sawyer JR, Kapoor M. T e limping child: A systematic
approach to diagnosis. Am Fam Physician. 2009;79(3):2 5.
Simons R, Sherman S, eds. Emergency Orthopedics. 6th ed.
New York, NY: McGraw-Hill Pro essional; 20 0.
Simpson MR. endinopathies o the oot and ankle. Am Fam
Physician. 2009;80( 0): 07.
Steill IG, et al. Prospective validation o a decision rule or
the use o radiography in acute knee injuries. JAMA.
996;275:6 .
Wilson JJ, Best M. Common overuse tendon problems: A
review and recommendations or treatment. Am Fam
Physician. 2005;72(5):8 –8 8.
Pediatrics
Erin R. Howe
CASE 13.1
A 6-year-old male presents to your o ce with his mom. He
has been soiling his underwear requently and it is causing
stress at home and school. His parents are rustrated and
think he is old enough to know better. At school, he is being
teased and being called “stinky pants” and he reports eeling
embarrassed. Mom asks you i there is something medically
wrong with him.
Question 13.1.1 What percentage o chronic encopresis
is unctional (meaning no underlying medical or organic
cause)?
A) 10%.
B) 25%.
C) 50%.
D) 75%.
E) 90%.
Answer 13.1.1 The correct answer is “E.” Ninety percent o
chronic encopresis is unctional. Functional encopresis is the
repeated involuntary passage o stool into underwear in a child
who is 4 years o age or older and at a developmental level appro-
priate or toilet training in the absence o an underlying medical
cause. T e most common reason is retentive constipation with
over ow incontinence. Frequently, the child has an associated
psychological problem. Boys are a ected more o en than girls.
Children with this disorder withhold eces voluntarily thereby
avoiding de ecating. As stool stays in the colon, more water is
absorbed creating harder stool that is more di cult to pass. T is
leads to a sel -perpetuating cycle. T e excess stool stretches the
rectum with eventual loss o sensation to de ecate. Liquid stool
may leak around the impacted mass, which parents o en mis-
take as diarrhea. In some, a triggering event such as passage o
a pain ul stool leading to ear o stooling, orced toilet training
be ore the child is ready, or dislike o using public toilets (starting
school) may have occurred. A common theme is parental misun-
derstanding o the problem thinking it is due to an undiagnosed
medical problem, attention-seeking behavior, or child laziness.
362
13
HELPFUL TIP:
Some e ini ions . . . Non-retentive encopresis is he
voluntary s ooling o one’s p n s. On e me i l use
h s been rule ou , his is purely beh vior l or psy hi-
ri problem. Primary encopresis is when s ool on i-
nen e h s never been hieve . Secondary encopresis
o urs when i en s beg n er perio o su ess-
ul oile r ining.
Question 13.1.2 Which o the ollowing conditions is associ
ated with encopresis?
A) Urinary tract in ections.
B) Enuresis.
C) Social isolation.
D) ADHD.
E) All o the above.
Answer 13.1.2 The correct answer is “E.” Encopresis is an
independent risk actor or urinary tract in ections. Feces in
the underwear allows or close contact with the urethra and
introduction o bacteria. Chronic contracting o pelvic oor
muscles to withhold stool may lead to dys unctional voiding
and urinary stasis. Enuresis occurs in up to 40% o patients
with chronic constipation. A mass o stool in the rectum can
compress the bladder leading to uncontrolled voiding. T e
chronic odor o eces makes socialization rough and teasing
requent (recall that this kid has started to be called “stinky
pants”). ADHD requently is associated with unctional con-
stipation and encopresis due to being too distracted to use the
bathroom.
HELPFUL TIP:
En opresis or y ime enuresis shoul promp you o
rule ou spin l or lesion wi h e ile ex min -
ion n ur her im ging su h s n MRI i in i e by
ex min ion.

Question 13.1.3 Which o the ollowing are medical (organic)
causes o constipation?
A) Hypothyroidism.
B) Hypercalcemia.
C) Cystic brosis.
D) Lead poisoning.
E) All o the above.
Answer 13.1.3 The correct answer is “E.” All o the above can
cause constipation and thus ecal incontinence. Organic causes
account or only 5% to 10% o encopresis cases and can be ana-
tomical (anterior displaced anus), neurological (Hirschsprung
disease), metabolic (Celiac disease), or iatrogenic (medications
such as narcotics or anticholinergics). T e rst step in evaluat-
ing a child with encopresis is to rule out an underlying medical
condition starting with a good history and physical examina-
tion. Do not orget to ask about timing o meconium passage in
the past medical history as delayed meconium passage may sug-
gest cystic brosis or Hirschsprung disease. Rectal examination
is essential. Look at the back or signs o an occult spina bi da
such as sacral dimple or hair tu . Lack o anal wink, cremas-
teric re ex, or deep tendon re exes is suggestive o a neurologic
cause. O en a pain ul ssure may initiate a vicious cycle o pain
with stooling leading to the withholding o stool leading to even
more pain ul de ecation, etc.
HELPFUL TIP:
Fe l imp ion is lini l i gnosis m e by eeling
h r s ool m ss on re l ex min ion. I is no m e by
b omin l x-r y. t his me ns re l ex min ion mus
be one. Yes . . . re l ex min ion on hil . No one’s
h ppy bou i ; jus o i .
HELPFUL TIP:
a buse m y be riggering even or ons ip ion n
en opresis. I buse is suspe e , on hil pro e -
ive servi es.
Question 13.1.4 All o the ollowing are use ul in the treat
ment o unctional encopresis EXCEPT:
A) Polyethylene glycol (MiraLAX®).
B) Oral sodium phosphate solution (OsmoPrep).
C) Mineral oil.
D) Lactulose.
E) Milk o magnesia.
Answer 13.1.4 The correct answer is “B.” In 2008, the FDA
placed a black box warning on oral sodium phosphate solutions
due to risk o acute kidney injury rom deposition o calcium–
phosphate crystals. As a result, nonphosphate-containing medi-
cations are used. reatment begins with disimpaction that can
be per ormed manually, with enemas, or with an oral medi-
cation such as polyethylene glycol (MiraLAX) or mineral oil.
Many treatment guidelines pre er disimpaction using oral poly-
ethylene gylcol solutions over manual disimpaction. It seems like
CHAPTER 13 • PEd Ia t RIc S 363
a strange concept but it works just as well as manual disimpac-
tion and is more humane (Pediatrics. 2009;124(6):e1108–15).
reatment should be individualized. A er disimpaction,
patients require maintenance therapy (combination o medical,
behavioral, dietary, and counseling). Medications such as milk
o magnesia (magnesium hydroxide), mineral oil, or polyethyl-
ene glycol (MiraLAX) should be used daily and incrementally
increased until the patient is having regular, so bowel move-
ments. Increased ber and uid intake should be encouraged
to help keep stools so . Behaviorally, the child should sit on the
toilet with active pushing a er each meal to make use o the
gastrocolic re ex. Even i the child does not stool, he is learning
to use the toilet and training his bowels. Use o a ootstool may
improve Valsalva maneuvers. A sticker chart can give visual
encouragement. Families need to understand that there is no
quick x and relapse is common (about 50%). It takes months
or the rectum to return to normal size and sensation. Patients
who ail to improve a er 6 months o compliant treatment
should be re erred to a pediatric gastroenterologist.
HELPFUL TIP:
Remember never o use miner l oil in ny hil who is
risk o spir ion. I n use hemi l pneumoni is.
Objectives: Did you learn to . . .
• d es ribe en opresis, in lu ing i s presen ion, i gnosis,
n uses?
• d i eren i e be ween org ni n nonorg ni uses o
en opresis?
• Me i lly m n ge en opresis?
QUICK QUIZ: NEONat a L POLYc Yt HEMIa
Causes o neonatal polycythemia (central venous hematocrit o
65% or greater) in the immediate postpartum period include all
o the ollowing EXCEP :
A) Delayed umbilical cord clamping.
B) win–twin trans usion.
C) Congenital adrenal hyperplasia.
D) Diabetic mother.
E) Sepsis.
The correct answer is “E.” Neonatal polycythemia can be
caused by all o the above except or sepsis. Other causes include
chronic intrauterine hypoxia (e.g., mother is a heavy smoker),
intrauterine growth restriction, maternal hypertension, con-
genital hypothyroidism, and chromosomal abnormalities (e.g.,
trisomy 21, 18, and 13).
QUICK QUIZ: MORE ON NEONat a L
POLYc Yt HEMIa
Patients with neonatal polycythemia are at risk or hyperviscos-
ity syndrome including respiratory distress, hypoxia, cyanosis,
364 Fa MILY MEd Ic INE EXa MINa t ION & BOa Rd REVIEW
hyperbilirubinemia, and hypoglycemia. Heart ailure, stroke,
renal vein thrombosis, and necrotizing enterocolitis may also
occur.
T e best treatment or these patients is:
A) Phlebotomy.
B) Exchange trans usion with normal RBCs.
C) Exchange trans usion using D5W.
D) Exchange trans usion using normal saline.
E) Aspirin.
The correct answer is “D.” Partial exchange trans usion using
normal saline is the treatment o choice. “A” is incorrect since
phlebotomy alone will reduce overall circulating volume and
may actually exacerbate the problem. “B” is incorrect. I you
chose this, back home or you! What is the point o taking out
cells and then putting more in, we ask you? “C” is incorrect
because large amounts o D5W can cause uid shi s, electrolyte
abnormalities, and hemolysis. O note, patients with a hemato-
crit o 65% to 70% can be observed i they are asymptomatic.
T ere is no one-to-one predictable relationship between hema-
tocrit and blood viscosity. Also o note, there is no evidence that
long-term outcomes are improved in asymptomatic patients
with partial exchange trans usion versus observation.
CASE 13.2
Amy, a 4-day-old emale, comes to clinic because “she is yel-
low.” She was born at term to a 25-year-old woman (well o
course . . . it wouldn’t be a male). Maternal lab results are as
ollows: blood type A+ , syphilis negative, rubella immune,
group B streptococcus (GBS) negative. Amy has been breast-
eeding every 3 to 5 hours. She has had one stool and three
urine diapers a day. Her weight is 15% less than her birth
weight. On your examination, you notice jaundice rom the
head to the thighs. Her total bilirubin level is 25.2 mg/dL. T e
conjugated (direct) raction is 0.4 mg/dL. T e unconjugated
(indirect) bilirubin is 21.2 mg/dL.
Question 13.2.1 Which o the ollowing statements is
correct?
A) She has breast eeding ailure jaundice.
B) She has physiologic jaundice.
C) She has biliary atresia; you must consult pediatric gastroen-
terology.
D) T ere is an ABO incompatibility between the mother and
child.
Answer 13.2.1 The correct answer is “A.” Amy most likely has
breast eeding ailure jaundice. T is occurs within the rst sev-
eral days o birth be ore the mother’s milk supply is adequate.
T is must be distinguished rom breast milk jaundice, which
usually occurs later without evidence o dehydration. One sign
that Amy is not receiving adequate breast milk eedings—and
that this is breast eeding failure jaundice instead o breast milk
jaundice—is the act that she is 15% below birth weight, hav-
ing ewer than 6 wet diapers per day and ewer than two to ve
stools a day. Remember that a well-hydrated in ant o Amy’s age
should lose no more than 10% o birth weight. You should try to
evaluate the mother’s milk supply by asking about the mother’s
eeling o engorgement, eeling o breast emptying with eeding,
seeing milk on the in ant’s lips and tongue immediately a er
eeding, and hearing the in ants swallow with eedings. “B” is
incorrect. Even though physiologic jaundice peaks at this age,
the level o 25.2 mg/dL is higher than would be expected with
physiologic jaundice (which should not be higher than 17 mg/dL
in a term in ant). “C” is incorrect because biliary atresia presents
with conjugated hyperbilirubinemia (the liver can appropri-
ately conjugate bilirubin, but there is obstruction to the out ow
o the conjugated bilirubin—essentially an obstructive process).
“D” is incorrect because ABO incompatibility is unlikely in a
mother whose blood type is something other than O (who have
both anti-A and anti-B antibodies). In addition, Rh incompat-
ibility is impossible due to the mother being Rh+ . However,
minor antigen incompatibility remains a possibility.
HELPFUL TIP:
Causes of an elevated direct (conjugated) bilirubin:
in e ion (in lu ing ongeni l), me boli bnorm li-
ies ( ys i ibrosis, Ro or n d ubin Johnson, e .), n -
omi bnorm li ies (bili ry resi , e .), n holes sis
(espe i lly rom c VN). No e h conjuga ted bilirubin
does not ca use kernicterus.
Causes of an elevated indirect (unconjugated)
bilirubin: in re se bre k own o RBc s (a BO/Rh in-
omp ibili y, eph lohem om , h l ssemi s, e .),
prem uri y, hypo hyroi ism.
Question 13.2.2 Which o the ollowing is NOT a risk actor
or severe neonatal hyperbilirubinemia?
A) Exclusive breast eeding.
B) Gestational age ≥41 weeks.
C) Signi cant birth trauma.
D) Visible jaundice in rst 24 hours o li e.
E) East Asian race.
Answer 13.2.2 The correct answer is “B.” Postdates gestational
age is not associated with jaundice. Rather, premature in ants are
at a greater risk o jaundice. “A” is true, and exclusively ormula-
ed in ants are less likely to have severe hyperbilirubinemia (but
this is not a reason to recommend bottle eeding). Cephalohe-
matoma and large bruises result in increased bilirubin produc-
tion rom heme breakdown, so “C” is true. T e earlier jaundice
occurs, the higher the peak is likely to be, so “D” is also true.
Other major risk actors or severe hyperbilirubinemia include
a sibling who required phototherapy, East Asian race, and blood
group incompatibility.
HELPFUL TIP:
In n s wi h o l serum bilirubin levels > 5 mg/ L ypi-
lly h ve visible j un i e. t he j un i e usu lly s r s
he he n progresses is lly o he ee . I resolves
in he opposi e p ern wi h he is l ex remi ies
resolving irs .

HELPFUL TIP:
J un i e presen in he irs 24 hours o li e is p ho-
logi n usu lly ue o hemoly i ise se su h s a BO
in omp ibili y.
Amy’s CBC is unremarkable and blood type is A+ .
Question 13.2.3 Which o the ollowing is the most appro
priate initial treatment or this patient (remember the con-
jugated [direct] raction is 0.4 mg/dL. The unconjugated
[indirect] bilirubin is 21.2 mg/dL)?
A) Admission or exchange trans usion.
B) Admission or IV uids alone to improve hydration.
C) Admission or phototherapy.
D) Discharge to home with recommendations or ormula eed-
ing, light exposure, and ollow-up bilirubin tomorrow.
Answer 13.2.3 The correct answer is “C.” Amy should be
treated with intensive phototherapy given her level o hyper-
bilirubinemia. “A” is incorrect because phototherapy should
be employed rst and an exchange trans usion would ollow i
phototherapy ailed to lower the bilirubin level or signs o acute
bilirubin encephalopathy developed. “B” is incorrect since pho-
totherapy is the de nitive treatment. Adjunctive therapy with
intravenous uids is considered i weight loss exceeds 12% o
birth weight, which in this case it does. “D” is incorrect because
a serum bilirubin level o 25 mg/dL or higher is a medical emer-
gency and requires immediate hospital admission or photo-
therapy.
HELPFUL TIP:
t he a meri n a emy o Pe i ri s (a a P) h s es b-
lishe hreshol v lues or hyperbilirubinemi re -
men wi h pho o her py n ex h nge r ns usion.
d e isions reg r ing re men v ry epen ing on he
in n ’s risk, ge (in hours er elivery), ges ion l
ge, n o l bilirubin level. t here re gr phs, bles,
n nomogr ms (su h s he Bhu ni urve) o ssis
wi h e ision-m king. d e ision-m king l ul or is
v il ble : h p://bili ool.org/
You admit Amy or urther management. You con rm Amy’s
current weight, which is indeed down 15% rom birth weight.
Children o en lose about 10%o their weight a er birth.
Question 13.2.4 Beyond what point in time is it considered
problematic i the patient has not returned to his or her
birth weight?
A) 5 days.
B) 7 days.
C) 10 days.
D) 14 days.
E) None o the above. Don’t worry, be happy.
CHAPTER 13 • PEd Ia t RIc S 365
Answer 13.2.4 The correct answer is “D.” Children should
regain their birth weight by age 2 weeks. Anything beyond this
is reason or concern.
Amy does well under your care (and the bili lights) and
returns at age 2 months. Mom questions the need or immu-
nizations during the well examination “since we never see
these archaic diseases anymore—I mean, come on, I can’t even
nd a chicken pox party.” Plus, she’s read in ormation on the
Internet and has concerns about immunization sa ety. And
wasn’t there a study about kids who su ered autism because
o thimerosal in a vaccine? And another study that vaccines
trans ormed children into space aliens? Un ortunately, Amy’s
mother’s concerns are not unusual. Parents—and politi-
cians—o en harbor misconceptions about vaccinations.
Question 13.2.5 What is a common side e ect that Amy
might have a ter her immunizations at her 2 month visit?
A) Fever to 104°F.
B) Autism.
C) Diabetes.
D) Erythema at the site o immunization.
E) Symptomatic shedding o virus in her stool.
Answer 13.2.5 The correct answer is “D.” Vaccine side e ects,
such as low-grade evers (not to 104°F as in “A”), induration and
redness at the site, and ussiness are common. However, they
are sel -limited. “B” and “C” are incorrect. Autism and diabetes
have NO been linked to vaccines in many large, well-designed
studies. “E” is incorrect because the D aP, HIB, and IPV vac-
cines are inactivated. T us, the virus or bacteria is killed and
puri ed or a speci c component. T e hepatitis B vaccine is con-
structed with genetic engineering in a yeast cell. T us, one would
not shed virus in the stool. T e MMR, oral polio, oral rotavirus,
and varicella vaccines are live attenuated vaccines. With these
immunizations, the virus has been weakened but can still rep-
licate and be shed in stool. In an immunocompetent host, this
usually is not o clinical signi cance. T us, “E” is incorrect. Also,
oral polio vaccine is no longer used in the United States because
the risk o disease rom the vaccine is greater than the risk o
disease rom wild-type polio; IM polio vaccine only, please.
HELPFUL TIP:
t he r i le linking MMR v ine o u ism w s wi h-
r wn by he u hors ( n Lancet) ye rs go, n he
le u hor h s los his li ense o pr i e be use o
r u ulen . He urne ou o be sp e lien ben
on in e ing he e r h. d espi e his here re on inue
mis ons rue hough s bou v ines.
HELPFUL (BUT CONFUSING) TIP:
Prior o minis ering v ines, pre re ing he hil
wi h e minophen n in re se p ien om or .
However, he e minophen seems o blun he im-
mune response le ing o lower n ibo y i ers. Whe h-
er his is lini lly signi i n is unknown.
366 Fa MILY MEd Ic INE EXa MINa t ION & BOa Rd REVIEW
Amy’s mother accepts your advice but still has concerns.
Question 13.2.6 What other actually correct in ormation
can you share with her about vaccines?
A) Giving a child multiple vaccines at the same time weakens
her immune system.
B) T e ever and rash side e ects o the MMR are rom the
measles component and usually occur 1 week a er the
vaccine is given.
C) I Amy receives her MMR at a 9-month visit (be ore she
travels to visit Aunt illey who lives in an area where mea-
sles has re-sur aced due to lack o vaccination), her MMR
immunization would be considered complete a er this dose
and another one at 5 years old.
D) I Amy had an acute otitis media and evers o 100.4°F, we
should delay her immunizations until she is a ebrile.
E) Immunizations are not important, since these diseases are
rare in the United States.
Answer 13.2.6 The correct answer is “B.” T e measles com-
ponent can cause a ever and rash 5 to 10 days a er the immu-
nization. T is occurs in 5% to 15% o in ants. Up to 25% o
adult women may have arthralgias a er receiving the vaccine.
T e MMR dosing schedule includes two doses o MMR. How-
ever, the rst must be a er 1 year o age. It may be given sooner
i the child is at risk (such as with travel or with a measles
outbreak) but must be repeated a er the rst birthday. T us,
“C” is incorrect. Minor illnesses should not prevent vacci-
nation. rue contraindications include anaphylactic reac-
tions to a vaccine or vaccine constituent, moderate-to-severe
ebrile illness, and encephalopathy within 7 days o D aP. Live
virus vaccines are contraindicated in immunocompromised
patients.
HELPFUL TIP:
a s gener l rule, i p ien misses v ine, jus s r
up where you le o . t here is no nee o in re se he
number o v ines given. I you h ve ques ions, you
m y onsul he c d c websi e on h-up immuniz -
ion re ommen ions ( n n even re e person l-
ize h-up s he ule!).
Amy continues her scheduled well child examinations. At
one o those visits, she was babbling and crawling around the
o ce. She poked her ngers at the outlets (which thank ully
were covered) and used a pincer grasp to pick up a raisin o
the f oor (ew, gross!).
Question 13.2.7 These behaviors are appropriate or the
development o a child at approximately age:
A) 6 months.
B) 9 months.
C) 15 months.
D) 24 months.
Answer 13.2.7 The correct answer is “B.” ake a moment to
review the developmental milestones in able 13-1.
Amy continues her scheduled well child examinations. How-
ever, at 14 months old, mom brings Amy or a sick visit
because she turned blue. A er taking a complete history and
doing a complete physical examination, you appropriately
diagnose breath-holding spells.
Question 13.2.8 Which o the ollowing statements about
breath holding spells is true?
A) T e incidence o breath-holding spells or children between
6 months old and 6 years old is 50%.
B) I a color change occurs, it occurs a er loss o consciousness.
C) Seizure-like activity may occur with breath-holding spells.
D) A child typically takes 60 to 90 minutes to return to her
baseline a er a breath-holding spell.
E) T e evaluation should include an echocardiogram (ECG)
and electroencephalogram (EEG).
Answer 13.2.8 The correct answer is “C.” A typical breath-
holding spell begins with an inciting event (like Santa did not
bring the right toy or mom re used to buy a Happy Meal).
Breath-holding spells occur in up to 4% o children and 80%
start be ore 18 months. T e child begins to cry, holds his or her
breath, turns blue, and (may) lose consciousness. A er loss o
consciousness, some rhythmic jerking o the extremities may
occur. T e loss o consciousness is brie and the child returns
quickly to normal activity (no post-ictal state). T e di erential
diagnosis includes cardiac arrhythmias, seizures, and apnea. I
the history is classic or breath-holding spells, no urther evalu-
ation is necessary. T e treatment is parental reassurance. Par-
ents should be encouraged to ignore the episodes and not to
give in to child’s requests in attempt to avoid the spells. Iron
supplementation may decrease the requency o spells i anemia
or iron de ciency is present.
HELPFUL TIP:
t his ype o spell in a child under 1 year of age m y
be re erre o in he li er ure s n “a Lt E” ( pp ren
li e- hre ening even ). t he new erm or a Lt E is BRUE
(brie resolve unexpl ine even ). t he erm BRUE is
nonspe i i n is e ine by wh he p ren s observe:
pne , y nosis, e re se responsiveness, e . t here
is no rel ionship be ween n BRUE n su en in n
e h syn rome (SId S). t he mos ommon uses o n
BRUE in lu e lower respir ory r in e ions, GERd ,
n seizure. a i ion l uses in lu e bre h-hol ing
spells, ele roly e bnorm li ies, r i ysrhy hmi s,
me boli ise ses, n c NS problems. a lw ys onsi er
hil buse in your i eren i l. Fi y per en o he ime
no use is i en i ie . a goo his ory n physi l ex-
min ion re he mos impor n ev lu ion ools. d i-
gnos i es ing shoul be gui e by his ory n physi-
l ex min ion in ings. See t ie er JS, e l. Pediatrics,
2016 M y, or new BRUE gui elines.
 CHAPTER 13 • PEd Ia t RIc S 367

TABLE 13-1 DEVELOPMENTAL MILESTONES

Age Gross Motor Visual Motor Language Social
1 mo R ises he sligh ly rom H s igh gr sp, ollows o a ler o soun (e.g., by blinking, Reg r s e
prone, m kes r wling mi line moving, s r ling)
movemen s, li s hin up

2 mo Hol s he in mi line, li s No longer len hes s Smiles er being s roke or lke o Re ognizes p ren
hes o ble igh ly, ollows obje
p s mi line

3 mo Suppor s on ore rms Hol s h n s open res , c oos (pro u es long vowel soun s in Re hes or mili r
in prone, hol s he up ollows in ir ul r shion musi l shion) people or obje s,
s e ily n i ip es ee ing

4–5 mo Rolls ron o b k n Moves rms in unison Orien s o voi e; 5 mo: orien s o Enjoys looking roun
b k o ron , si s well o gr sp, ou hes ube bell (lo lize l er lly), s ys “ hgoo,” environmen
when proppe , suppor s pl e on ble r zzes
on wris s, n shi s weigh

6 mo Si s well unsuppor e , pu s Re hes wi h ei her h n , B bbles;7 mo: orien s o bell (lo lizes Re ognizes s r ngers
ee in mou h in supine r ns ers, uses r king in ire ly); 8 mo: “ /m m ”
posi ion gr sp in is rimin ely

9 mo c reeps, r wls, ruises, Uses pin er gr sp, probes Un ers n s “no,” w ves bye-bye;10 S r s o explore
pulls o s n , pivo s when wi h ore nger, hol s mo: “ /m m ” is rimin n ly; environmen , pl ys
si ing bo le, nger- ee s 11 mo: one wor o her h n “ / p - - ke
m m ”

12 mo W lks lone t hrows obje s, le ’s go o Follows one-s ep omm n wi h Imi es ions, omes
oys, h n rele se, uses ges ure, uses 2 wor s o her h n when lle , ooper es
m ure pin er gr sp “ /m m ”; 14 mo: uses 3 wor s wi h ressing

15 mo c reeps ups irs, w lks Buil s ower o 2 blo ks Follows one-s ep omm n In i es some simple
b kw r in imi ion o ex miner, wi hou ges ure, uses 4–6 wor s nee s by poin ing, hugs
s ribbles in imi ion n imm ure j rgon (runs sever l p ren s
unin elligible wor s oge her)

18 mo Runs, hrows oy rom t urns 2 or 3 p ges Knows 7–20 wor s, knows 1 bo y c opies p ren in sks
s n ing wi hou lling ime, lls spoon n ee s p r , uses m ure j rgon (in lu es (e.g., sweeping, us ing),
sel in elligible wor s in j rgon) pl ys in omp ny o o her
hil ren

21 mo Squ s in pl y, goes up Buil s ower o 5 blo ks, Poin s o 3 bo y p r s, uses a sks o h ve oo n o

s eps rinks well rom up 2-wor ombin ions, h s 20 wor go o oile
vo bul ry

24 mo W lks up n own s eps t urns p ges one ime, Uses 50 wor s, 2-wor sen en es, P r llel pl y
wi hou help removes shoes, p n s, uses pronouns (I, you, me)
e ., imi es beh vior o in ppropri ely, poin s o 5 bo y
o hers p r s, un ers n s 2-s ep omm n

30 mo Jumps wi h bo h ee o Unbu ons, hol s Uses pronouns (I, you, me) t ells rs n l s n mes
f oor, hrows b ll overh n pen il in ul shion, ppropri ely, un ers n s on ep when ske , ge s rink
i eren i es horizon l o “one,” repe s 2 igi s orw r wi hou help
n ver i l line

3 yr Pe ls ri y le, n d resses n un resses Uses 3-wor sen en es, plur ls, n Group pl y, sh res oys,
l ern e ee when going p r i lly, ries h n s i p s ense. Knows ll pronouns. kes urns, pl ys well
up s eps remin e , r ws ir le Minimum o 250 wor s, un ers n s wi h o hers, knows ull
on ep o “ wo” n me, ge, sex

4 yr Hops, skips, l ern es ee Bu ons lo hing ully, Knows olors, s ys song or poem t ells “ ll les,” pl ys
going owns irs hes b ll rom memory, sks ques ions ooper ively wi h
group o hil ren

5yr Skips, l ern ing ee , t ies shoes, spre s wi h Prin s rs n me, sks wh wor Pl ys ompe i ive g mes,
jumps over low obs les kni e me ns bi es by rules, likes o
help in househol sks
368 Fa MILY MEd Ic INE EXa MINa t ION & BOa Rd REVIEW

19–23
Vaccine Birth 1 mo 2 mos 4 mos 6 mos 9 mos 12 mos 15 mos 18 mos 2-3 yrs 4-6 yrs 7-10 yrs 11-12 yrs 13–15 yrs 16–18 yrs
mos

Hepatitis B (HepB) 1 dose 2 dose 3 dose

Rotavirus (RV) RV1 (2-dose See

1 dose 2 dose
series); RV5 (3-dose series) footnote 2

Diphtheria, tetanus, &acellular 1 dose 2 dose 3 dose 4 dose 5 dose

pertussis (DTaP: <7 yrs)
Tetanus, diphtheria, &acellular (Tdap)
pertussis (Tdap: >7 yrs)
Haemophilus in uenzae type b See 3 or 4 dose,
1 dose 2 dose
(Hib) footnote 5 See footnote 5

Pneumococcal conjugate6 1 dose 2 dose 3 dose 4 dose

(PCV13)
Pneumococcal polysaccharide
(PPSV23)
Inactivated poliovirus 1 dose 2 dose 3 dose 4 dose
(IPV: <18 yrs)
In uenza (IIV; LAIV) 2 doses for Annual vaccination (LAIV or Annual vaccination (LAIV or IIV)
Annual vaccination (IIV only) 1 or 2 doses IIV) 1 or 2 doses
some: See footnote 8 1 dose only

Measles, mumps, rubella (MMR) See footnote 9 1 dose 2 dose

Varicella (VAR) 1 dose 2 dose

Hepatitis A (HepA) 2-dose series, See footnote 11

Human papillomavirus (HPV2:

(3-dose
females only; HPV4: males and series)
females)
Meningococcal (Hib-MenCY
> 6 weeks; MenACWY-D >9 mos; See footnote 13 1 dose
MenACWY-CRM ≥ 2 mos)

Range of recommended Range of recommended ages Range of recommended ages for Range of recommended ages during Not routinely
ages for all children for catch-up immunization certain high-risk groups which catch-up is encouraged and for recommended
certain high-risk groups

FIGURE 13-1. Re ommen e immuniz ion s he ule or persons ge 0 hrough 18 ye rs.

Question 13.2.9 Between 12 and 15 months o age, Amy
should receive all o the ollowing vaccines, as per Centers
or Disease Control and Prevention (CDC) recommenda
tions, EXCEPT:
A) MMR.
B) Varicella.
C) Hepatitis A.
D) Rotavirus.
E) In uenza.
Answer 13.2.9 The correct answer is “D.” Vaccination sched-
ules and recommendations seem to represent quickly moving
targets, so a regular review is required to keep up to date. At 12 to
15 months, the CDC recommends initial MMR, varicella, and
hepatitis A vaccinations or all U.S. children. In uenza recom-
mendations are updated annually and have become progressively
more inclusive over time. T e CDC recommends that all children
ages 6 months through 18 years receive the in uenza vaccine
annually during the appropriate season. I the child is receiving
her rst year o in uenza vaccination and is between 6 months
and 8 year o age, she should receive 2 doses about 1 month apart
to help boost immunity. Following this, the child may receive one
dose o in uenza vaccination annually. O note, rotavirus vaccine
should not be administered to children older than 32 weeks, and
the rst dose should not be given a er 15 weeks.
O course, the vaccine schedule is updated periodically but
does not usually change drastically rom year to year. We have
included the current vaccine schedule in Figure 13-1. For the most
up to date version, go to the CDC website at http://www.cdc.gov/
vaccines/schedules/hcp/child-adolescent.html. T ere is also an
excellent CDC app or immunization or both the iPhone and
Android plat orms. It is easier to comprehend than the website.
Amy’s breath-holding spells resolve by the time she is 3 years
old, and she continues to grow and develop normally. Amy’s
next issue comes when she is 5 years old and in your o ce or
her pre-kindergarten physical.
Question 13.2.10 You notice a new murmur. O the ollow
ing, which suggests that this is a benign murmur?
A) Murmur is grade II/VI.
B) Murmur has a thrill.
C) Murmur radiates to the apex.
D) Murmur is diastolic.
E) Murmur is holosystolic.
Answer 13.2.10 The correct answer is “A.” Not all murmurs
need to be re erred to a cardiologist. T ere are eatures that can
help di erentiate pathologic rom benign murmurs. A murmur
that is diastolic, grades III to VI, pansystolic, or associated with
cardiac symptoms is likely pathologic and requires urther inves-
tigation. A benign murmur typically is systolic, so (grades I–II,
occasionally III), nonradiating, and short. A “benign” murmur
is not a diagnosis o exclusion. You should try to make a deci-
sion about which innocent murmur it is. See able 13-2.
On Amy’s examination, you hear a grade III/VI systolic mur-
mur in the pulmonic area with xed splitting o the second
heart sound. She is otherwise healthy without any cardiac
symptoms.

TABLE 13-2 “BENIGN” CARDIAC MURMURS
OF CHILDHOOD
Still murmur: a gr e I–III murmur he r bes in le mi le s ern l
bor er or be ween le lower s ern l bor er n pex. I is
“musi l,” vibr ory or buzzing sys oli eje ion murmur, whi h is
lou er when he p ien is supine, omp re wi h when uprigh ,
n e re ses in volume wi h V ls lv m neuver. a S ill murmur
m y ge lou er s bloo f ow in re ses wi h ever, exer ise, or
ex i emen .
Venous hum: a gr e on inuous I–III murmur he r bes in
he supr l vi ul r re . I shoul resolve when he p ien is
re umben or wi h pressure over he jugul r vein.
Pulmonic murmur: He r s gr e I–III sys oli eje ion murmur
in he rs h l o sys ole. I is gener lly bes he r in he le upper
s ern l bor er.
Murmurs h h nge wi h respir ion re gener lly, bu no lw ys,
benign.
Question 13.2.11 What is the appropriate next step in man
agement o this issue?
A) Family reassurance.
B) Endocarditis prophylaxis at the dental visit next week.
C) ECG and chest radiograph.
D) Limit physical activity.
E) Re er or immediate operative repair.
Answer 13.2.11 The correct answer is “C.” Most likely, Amy
has an ASD or atrial septal de ect. T e murmur is a systolic
ejection murmur heard best at the upper le sternal border.
T e sound you hear is caused by increased ow across the pul-
monic valve creating a relative stenosis (more volume needs to
get through a relatively xed outlet) and NO rom ow across
the ASD. T e increased ow across the pulmonic valve causes
a wide, xed split S2. T ere may be a mid-diastolic rumbling
murmur at the lower le sternal border rom increased ow
across the tricuspid valve i the ASD is very large. T e chest
x-ray may demonstrate cardiomegaly with increased pulmo-
nary vascular markings. T e ECG can be normal or may show
mild right ventricular hypertrophy, right axis deviation, and/or
right bundle branch block with the characteristic rsR´ pattern
in the right precordial leads. Children with an ASD do NO
need endocarditis prophylaxis (except or the rst 6 months
a er their surgical repair) and rarely need to limit their physi-
cal activity. Most small ASDs will close spontaneously by age
4 years. Closure by one o a variety o methods is recommended
or symptomatic and signi cant le -to-right shunts with right
ventricular enlargement.
Objectives: Did you learn to . . .
• d es ribe he uses o neon l hyperbilirubinemi ?
• M n ge n in n wi h bre s ee ing ilure j un i e?
• I en i y risk ors or severe hyperbilirubinemi ?
• Re ommen v ines or hil ren in or n e wi h c d c
gui elines?
• I en i y v ine mis on ep ions, lis MMR si e e e s, n
i en i y on r in i ions o immuniz ion?
• Re ognize s ges o in n evelopmen ?
CHAPTER 13 • PEd Ia t RIc S 369
• d es ribe n m n ge bre h-hol ing spells?
• d i eren i e benign rom p hologi r i murmurs in
hil hoo ?
QUICK QUIZ: Ja UNd Ic E
T e current recommendation or the treatment o breast milk
jaundice (NO breast eeding ailure jaundice as per the above
case) is:
A) Continue to breast eed.
B) Stop breast eeding and change to a cow’s milk ormula.
C) Stop breast eeding and change to soy milk ormula.
D) Stop breast eeding and treat with rehydration solution (e.g.,
Pedialyte).
The correct answer is “A.” Patients with hyperbilirubinemia
due to breast milk jaundice should continue to breast eed.
Breast milk jaundice begins on days 5 to 7 o li e, peaks by
2 weeks o age, and usually resolves by 10 weeks o age; monitor
to make sure that the jaundice remains unconjugated and there
is no need to look or a second source. Bilirubin levels will grad-
ually decline while breast eeding is continued. I breast eeding
is discontinued, serum bilirubin levels decline rapidly. Kernic-
terus is rare. T e etiology is unclear but glucuronidase in breast
milk resulting in de-conjugation and increased enterohepatic
recirculation o bilirubin has been proposed.
CASE 13.3
A amily has moved into the area and brings their 12-month-
old girl in or a well-child check. T ey bring her medical
records with them. Her parents have no concerns, and she has
been healthy. Her growth chart concerns you, however. Her
length tracks along the 25th percentile. But her weight has
gone gradually rom around the 25 to 50th percentile at 0 to
6 months old to the 10th percentile at 9 months old, and now
is at the 5th percentile at 1 year.
Question 13.3.1 Which o the ollowing most likely explains
her pattern o growth?
A) Normal.
B) Familial short stature.
C) Prenatal insult such as exposure to drugs or in ection.
D) Hypothyroidism.
E) Inadequate nutrition.
Answer 13.3.1 The correct answer is “E.” T is patient’s pat-
tern o growth is consistent with ailure to thrive (now termed
“undernutrition”). T e criteria or diagnosis include weight
less than the 3rd to 5th percentile (depending on the source)
or a all o weight o > 2 major percentile lines in 6 months or
weight less than 80% o ideal weight or age and/or weight or
height less than 5th percentile. T e patient meets more than
one o these criteria, so “A” is incorrect. In “B,” both height and
weight would be a ected. In this child, only the weight (and
not the height) is a ected. “C” is incorrect because a child with
370 Fa MILY MEd Ic INE EXa MINa t ION & BOa Rd REVIEW
a prenatal insult tends to be smaller globally in both height
and weight, and the weight percentile would not be expected
to drop so dramatically rom birth. “D” is unlikely because in
general, the endocrinologic causes result in “stunting” where a
child stops gaining height but continues to gain weight. T us,
“E” is the most likely cause o this patient’s ailure to thrive.
aking more history, you discover that the patient eats mostly
rice and ruit. She does not like meat (happily supported
by one o your editors who is vegetarian!). She is picky. She
drinks about 12 oz o whole milk and 12 oz o apple juice
each day. She is active and developmentally appropriate. Her
review o systems is negative as is her past medical history.
Question 13.3.2 What is the LEAST appropriate way to pro
ceed with evaluation and management o this patient?
A) Allow the child to eed hersel whenever she is hungry or
thirsty. Parents should o er ood and drink requently
throughout the day.
B) Obtain CBC, iron studies, and urinalysis.
C) Limit juice intake.
D) Consult a nutritionist.
E) Prescribe a multivitamin.
Answer 13.3.2 The correct answer (and least appropriate
approach) is “A.” T e goal o management o ailure to thrive is
to increase caloric intake, identi y treatable causes o ailure to
thrive, and look or e ects o her malnutrition. T us, a CBC, iron
studies, electrolytes, bicarbonate, glucose, and urinalysis may be
help ul to investigate possible iron de ciency, anemia, or renal
tubular acidosis. Juice should be limited (due to its low nutritional
value), meals scheduled, and caloric intake boosted. Although
children should eed themselves, they take in more calories when
given a set schedule or meals and snacks instead o being allowed
to graze on ood or drink throughout the day as in “A.” A nutri-
tionist can help educate the amily on appropriate ood choices
or a toddler and ways to boost calories. A child with a restrictive
eating pattern, especially poor in iron-containing oods (such as
meats), may bene t rom a multivitamin with iron.
HELPFUL TIP:
For in n s wi h ilure o hrive, en our ge he p ren s
o in re se he lori ensi y o oo s n rinks. a sk
hem o use whole milk r her h n re u e milk,
o in re se he on en r ion o ormul ( ing less
w er), bu er o oo , e .
Your patient presents to the emergency department (ED) at 14
months old. Mom states that she has had several episodes o
emesis over the last 48 hours and today began to have watery,
oul-smelling diarrhea (as opposed to the yummy-smelling
diarrhea to which we are so accustomed). Mom has lost track
o number o episodes o emesis and diarrhea. She cannot
tell i the child has had urine output because o the watery
diarrhea. On your examination, the temperature is 102.5°F,
heart rate 180 bpm, respiratory rate 50, blood pressure
80/50 mm Hg. Her weight is 8 kg. She has dry, cracked lips
and dry skin. She lies in her mom’s arms and is not very
interested in your examination. Her capillary re ll is about
4 seconds with some mottling o the extremities.
Question 13.3.3 What is the MOST appropriate next step in
the management o this patient’s condition?
A) Evaluate or underlying bacterial in ection with blood,
urine, and stool cultures.
B) Admit to an inpatient unit and begin maintenance IV uids.
C) In use 20 mL/kg normal saline IV over 20 minutes.
D) Begin oral rehydration with Pedialyte.
E) In use 10 mL/kg D5/hal -normal saline over 2 hours.
Answer 13.3.3 The correct answer is “C.” T is patient is
severely dehydrated (estimated 15%) with signs o compro-
mised tissue per usion; there ore, she should have parenteral
uid resuscitation quickly with a 20 mL/kg isotonic uid bolus.
Although she might need admission, she should be stabilized in
the ED be ore trans er to the inpatient unit; in addition, starting
with maintenance uids is inappropriate. Oral rehydration is
cost-e ective in less severe dehydration without compromised
tissue per usion. T ere are several tables published listing the
clinical examination associated with various degrees o dehy-
dration. See able 13-3 or clues in determining the degree o
dehydration.
HELPFUL TIP:
d ehy r ion is lini l i gnosis bu l bor ory in -
ings n be help ul. t he serum so ium l ssi ies he
ehy r ion s hypo oni , iso oni , or hyper oni . Me -
boli i osis is o en presen n l ul ion o he
nion g p helps e ermine he use. Bloo ure ni ro-
gen n serum re ine on en r ions n be help ul
bu m y be e e by o her on i ions.
A er completing the initial management, the patient is more
interested in her surroundings. Her vital signs are pulse
160 bpm, respiratory rate 36, and blood pressure 80/50 mm
Hg. Her lips are still dry and she is irritable. T e capillary
re ll is 2 to 3 seconds. She is more interactive with her mother.
TABLE 13-3 SIGNS AND SYMPTOMS OF
DEHYDRATIONa
Mild (5% in an infant, 3% in a child): Norm l skin urgor, mois lips,
e rs presen , norm l vi l signs, onsol ble
Moderate (10% in an infant, 6% in a child): d ry skin n lips, skin
en ing, sligh ly in re se pulse, e re se urine ou pu , norm l
pill ry re ll
Severe (15% in an infant, 9% in a child): P r he lips, sunken eyes,
e re se or no urine ou pu , ool skin, elev e pulse, prolonge
pill ry re ll, le h rgi or ob un e
a
Be use o he poor sso i ion o physi l n ings wi h p r i ul r
per en ehy r ion use he erms “mil , “mo er e” or “severe” is pre erre
over rying o ssign per en ehy r ion.

Question 13.3.4 What urther treatment is indicated or her
dehydration?
A) 80 mL/hr × 2 hours o D5-quarter-NS.
B) 33 mL/hr × 24 hours o D5-hal -NS with 20-mEq KCl.
C) 50 mL/hr × 24 hours o D5-quarter-NS.
D) 20 mL/kg NS over 20 minutes.
E) 10 mL/kg D5-hal -NS over 2 hours.
Answer 13.3.4 The correct answer is “D.” A er an initial
bolus, the patient should be reassessed. T is patient is still mod-
erately dehydrated. Although she has responded to her initial
bolus o normal saline, she still has abnormal vital signs as well
as signs o dehydration on examination. T ere ore, the normal
saline bolus should be repeated. Hypotonic solutions (e.g.,
NS) or those containing glucose and/or potassium should never
be used as a bolus. Also, potassium (i needed at all) should
be withheld until the patient urinates and has better hydration
status.
HELPFUL TIP:
M in en n e lui s n be l ul e using he Holi y-
Seg r me ho : ily w er nee s or he irs 10 kg o
bo y weigh is 100 mL/kg/ y; w er nee s or he nex
11 o 20 kg is 50 mL/kg/ y; e h i ion l kg over 20
kg is 20 mL/kg/ y. d o no orge o oun or ehy-
r ion, whi h will require i ion l lui s o repl e
he lui e i i . a lso, repl e ongoing losses rom i r-
rhe , emesis, e . You n lso l ul e he hourly lui
requiremen by he “4, 2, 1” me ho . c hil ren shoul
ge 4 ml/kg/hr or he irs 10 kg bo y weigh , 2 mL/kg/
hr or he nex 10 kg n 1 mL/kg/hr or every kg over
20 kg.
Flui e i i (L) = usu l weigh (kg) − urren weigh (kg)
HELPFUL (AND IMPORTANT) TIP:
t r i ion lly, “pe s” solu ion (1/4 NS) h s been use
or m in en n e lui s in hil ren. t his le s o hypo-
n remi n seizures. Norm l s line shoul be use
s m in en n e lui jus s in ul s (Lancet. 2015;
385(9974):1190–1197; 28).
T e patient recovers well rom her GI illness, but she returns a
ew months later to your clinic with a new illness. She has had
temperatures o 103°F at home or 2 to 3 days. She has had no
upper respiratory symptoms. Her oral intake has decreased,
but she is maintaining good urine output. She has had no
vomiting or diarrhea. Your examination reveals a ebrile child
who is slightly irritable. She is nontoxic and not dehydrated.
Her oral cavity shows increased tonsil size with ulcers on her
tongue and lips but not on the tonsillar pillars. Her anterior
cervical lymph nodes are enlarged. T e rest o her examina-
tion is noncontributory.
CHAPTER 13 • PEd Ia t RIc S 371
Question 13.3.5 What is the most likely diagnosis?
A) Streptococcal pharyngitis.
B) Hand, oot, and mouth disease (coxsackie virus).
C) Herpetic gingivostomatitis.
D) Varicella.
E) In ectious mononucleosis.
Answer 13.3.5 The correct answer is “C.” Primary oral her-
pes (herpetic gingivostomatitis) is associated with a relatively
high ever and anteriorly placed ulcerations and vesicles (gums,
tongue, and lips). Symptoms tend to start relatively abruptly
with pain, salivation, re usal to eat, and ever. Herpes gingivo-
stomatitis may recur during li e in the orm o “cold sores.” “B”
is incorrect because the patient does not have hand and oot
lesions. “D,” varicella, can occur in the oral pharynx but would
have lesions elsewhere in various stages and respiratory symp-
toms as well. In ectious mononucleosis is not associated with
vesicular lesions or mucosal ulcerations.
HELPFUL TIP:
t he poorly n me “herpangina,” use by en erovi-
ruses (usu lly oxs kie a ), is no her onsi er ion in
he hil wi h ever n mou h sores. Herp ngin is s-
so i e wi h ewer vesi les n ulcers located in the
posterior oropharynx along the posterior soft pal-
ate and tonsillar pillars and fossa. He he, vomi -
ing, n b omin l p in m y be presen s well. No e
h his is i eren lini l en i y rom h n , oo , n
mou h ise se espi e he en erovir l use.
Next, you see the patient’s sister who is age 10 and presenting
or a school physical. Her mother is concerned because this
patient has pubic hair, which her mother thinks is prema-
ture (and scary . . . her baby is not growing up yet!). On your
examination, she has enlarged areola and a small amount o
breast tissue. She also has sparse, dark, but mostly straight
pubic hair.
Question 13.3.6 This patient is sexual maturity rating or
Tanner stage:
A) 1.
B) 2.
C) 3.
D) 4.
E) 5.
Answer 13.3.6 The correct answer is “B.” Breast buds and
sparse, downy pubic hair put the patient in anner stage 2. an-
ner stage 1 is prepubertal. Any sign o puberty moves a child rom
anner 1 to anner 2. anner stage 5 is adult or ully matured
secondary sexual characteristics. See able 13-4 or details.
T e mom has a lot o questions about puberty. She is ner-
vous about beginning to discuss sexual development with her
daughter.
372 Fa MILY MEd Ic INE EXa MINa t ION & BOa Rd REVIEW
TABLE 13-4 TANNER STAGES
S ge 1: Prepuber l
S ge 2: Sp rse grow h o owny h ir b se o penis or long l bi
• Girls: Bre s bu evelopmen .
• Boys: Enl rgemen o s ro um n es es wi h re ening n
hi kening o s ro l skin
S ge 3: d rkening, o rse h ir sp rsely in pubi re
• Girls: Enl rgemen o bre s s (prim ry moun ); Boys: elong ion o
penis n in re se size o es es.
S ge 4: a ul pubi h ir is ribu ion ( ri ngle) bu sm ller re
overe wi h no ex ension o me i l highs
• Girls: a reol n p pill begin o moun bove he level o he
bre s (se on ry moun )
• Boys: In re se in bre h n evelopmen o penis, rkening o
s ro l skin, enl rgemen o es s
S ge 5: a ul bre s s, geni ls, n h ir is ribu ion.
Question 13.3.7 What is a developmental act that you can
provide the mom or discussion with her daughter?
A) ypically, in emales, the rst sign o puberty is pubic hair.
B) At 10 years old, the patient is experiencing premature
puberty.
C) T e height spurt occurs early during puberty and is almost
complete at menarche.
D) Menarche occurs approximately 1 year a er breast budding.
E) Schools discuss puberty and relieve mom or dad o that duty
(whew!).
Answer 13.3.7 The correct answer is “C.” In girls, the growth
spurt occurs early and is almost complete at menarche. Females
begin puberty about 1 to 2 years be ore males. “A” is incorrect
as thelarche, or breast budding, marks emale onset o puberty.
“B” is incorrect. T e average age o breast budding is 10.9 years.
T us, Sara is appropriate in her pubertal timing. “D” is incor-
rect. Menarche typically begins 2 years a er breast budding. “E”
is incorrect. Although schools may discuss puberty, these dis-
cussions are o en limited in the time and content. It is impor-
tant or the child to hear her mother’s opinions on puberty and
sex.
HELPFUL TIP:
Pre o ious or e rly puber y is e ine s he onse o
se on ry sexu l h r eris i s be ore ge 8 or girls
n ge 9 or boys. d el ye puber y is he l k o su h
h nges by ge 14.
Objectives: Did you learn to . . .
• d e ne ilure o hrive in hil ?
• Ev lu e hil wi h ilure o hrive?
• Ev lu e ehy r e hil n e ermine severi y o ehy-
r ion?
• M n ge ehy r ion in he Ed ?
• c l ul e rehy r ion f ui s or ehy r e hil ?
• Gener e i eren i l i gnosis or ph ryngi is wi h blis-
ers?
• d es ribe h nges o puber y n t nner s ging in em le?
QUICK QUIZ: FEEd ING INFa Nt S
Which is not an indication or use o soy ormula in an in ant?
A) Galactosemia.
B) Congenital lactase de ciency.
C) Cow milk protein intolerance.
D) Parental desire or a vegan diet.
The correct answer is “C.” Few indications exist or use o
soy-based ormula over cow milk-based ormula. Soy ormula
is lactose ree and there ore should be used in conditions “A,”
“B,” and “D.” Galactosemia is a metabolic disorder character-
ized by the inability to breakdown galactose. Dietary galac-
tose comes rom lactose ound in human and cow milk. An
extensively hydrolyzed or amino acid ormula should be used
or cow milk protein intolerance. In ants who are sensitive to
cow milk protein have an approximately 10% to 15% chance
o also being sensitive to soy proteins. Re ux deserves special
note. T ere is no data supporting the use o soy ormula or
re ux.
CASE 13.4
A 2-year-old male presents to your o ce with his ather
complaining that the patient has had intermittent crying
ollowed by episodes o pro ound lethargy during which he
is di cult to arouse. T e ather relates that the patient will
sometimes clutch at his abdomen and roll into the etal posi-
tion during episodes. T ese episodes have been going on or
about 4 hours. He has had no ever, no vomiting, and no diar-
rhea. Nobody else at home has been sick. He is developmen-
tally normal and has no signi cant past medical history. His
examination reveals that he is a ebrile and lethargic but can
be aroused. His abdominal examination is benign. T e rest o
the examination is unremarkable.
Question 13.4.1 Given his presentation, your clinical suspi
cion is or:
A) Meningitis.
B) Renal colic.
C) Intussusception.
D) Gastric outlet obstruction.
E) Appendicitis.
Answer 13.4.1 The correct answer is “C.” T e patient may
have intussusception. T e combination o abdominal colic
plus mental status changes should suggest intussusception. T e
etiology o the mental status changes is not clear, but mental
status changes are one o the classical ndings o intussuscep-
tion. “A,” meningitis, should still be a consideration in a patient
with mental status changes, but abdominal pain is not usually
part o the presentation. In addition, the patient is a ebrile and
his symptoms are intermittent, making meningitis less likely.
“B” is not associated with mental status changes. “D” and “E”
usually present with some abnormal ndings on abdominal
examination.

HELPFUL TIP:
Fewer h n 15% o p ien s wi h in ussus ep ion pres-
en wi h he l ssi ri o oli ky b omin l p in,
p lp ble s us ge-sh pe b omin l m ss, n urr n
jelly s ool.
Question 13.4.2 Which laboratory nding will help you to
con rm the diagnosis o intussusception?
A) CBC.
B) Urinalysis.
C) Glucose.
D) Serum lactate.
E) None o the above.
Answer 13.4.2 The correct answer is “E.” None o the above
will help to make the diagnosis o intussusception. Early in
the course, the CBC may be normal and only 75% will have
heme positive stools.
HELPFUL TIP:
“c urr n jelly s ools” re l e in ing in in ussus ep-
ion n re re le ion o mu os l is hemi . You re lly
w n o m ke he i gnosis be ore you see “ urr n jel-
ly” per re um. (Hey, h ve you ever u lly seen urr n
jelly? I is brigh re n gloopy, kin o like gr n m ’s
r nberry s u e.)
Question 13.4.3 You decide that this patient probably has
intussusception based on your history and physical exami
nation. The next step in diagnosing this patient is:
A) Upper GI with barium.
B) A plain lm o the abdomen.
C) An air enema.
D) An abdominal ultrasound.
E) Administration o IV antibiotics.
Answer 13.4.3 The correct answer is “D.” In general, an ultra-
sound is the diagnostic modality o choice. An ultrasound may
show a typical “bull’s eye” lesion helping to make the diagnosis.
“C,” an air enema, is a diagnostic and therapeutic intervention.
An air enema can be used to reduce the intussusception obviat-
ing the need or surgery. In general, however, a diagnosis is rst
made by ultrasound. An upper GI will be o no use since intus-
susception is a distal process. A plain lm o the abdomen will
most likely be nondiagnostic as is the case in most abdominal
processes (except perhaps bowel obstruction or ree air).
HELPFUL TIP:
For in ussus ep ion, n ir or w er-soluble on r s en-
em is pre erre over r i ion l b rium enem . Bowel
per or ion is he m in risk o nonoper ive re u ion.
a ir n w er-soluble on r s re mu h less h rm ul
h n b rium i le ke in o he peri oneum.
CHAPTER 13 • PEd Ia t RIc S 373
Well, the ultrasound tech is in the Cayman Islands, so you
opt or an air enema, which simultaneously diagnoses and
reduces the intussusception. T e patient appears well with no
signs o per oration. He is eating gold sh crackers by the st-
ul in the ED and generally making a mess o the examination
room. Recommendations vary as to the patient’s disposition.
Some authors recommend admission since recurrence rate is
10%in the rst 24 hours while others would let the child go
home. We suspect admission will be the right answer or the
test.
HELPFUL TIP:
Mos ses o in ussus ep ion re i iop hi . Less h n
10% o p ien s h ve p hologi le poin su h s
Me kel iver i ulum, in es in l polyp, or lymphom . In-
re se ge o hil in re ses he risk o le poin .
HELPFUL TIP:
d i eren ypes o in es in l obs ru ions o ur i er-
en ges. Obs ru ion bir h is ypi lly n n omi
resi , me onium ileus, or Hirs hsprung ise se. Vol-
vulus ue o m lro ion n o ur ny ge, bu mos
ommonly ppe rs in in n y (even wi hin he irs
mon h o li e . . . w h or bilious vomi ing, sign o vol-
vulus). Be ween bir h n 5 weeks o ge, hyper rophi
pylori s enosis ppe rs. In ussus ep ion is he mos
ommon use o GI obs ru ion be ween 3 mon hs
n 6 ye rs o ge.
Objectives: Did you learn to . . .
• Re ognize he lini l presen ion o in ussus ep ion?
• Ev lu e n re hil wi h in ussus ep ion?
CASE 13.5
Benjamin, a 4-month-old male, comes to your o ce or a
well-baby check. His parents have no concerns. Development
and eeding are progressing as expected. Looking at him, you
think to yoursel , “My gosh. In ants have such big heads rela-
tive to their bodies.” On your examination, his head is >95th
percentile, but his weight and height are still at the 50th per-
centile. His previous head circum erences have all been at the
50th percentile. He is a social in ant but is having di culty
supporting his large head.
Question 13.5.1 What is the imaging study LEAST likely to
assist in the diagnosis o the macrocephaly?
A) X-ray.
B) C scan.
C) MRI scan.
D) Ultrasound.
Answer 13.5.1 The correct answer is “A.” Because the relative
head size is so dramatic, an imaging study is needed, but skull
374 Fa MILY MEd Ic INE EXa MINa t ION & BOa Rd REVIEW
radiographs are not likely to assist you in arriving at a diagnosis.
T e other modalities are used in this setting, and each has its ben-
e ts and detractions. Ultrasound is o en used in in ants when the
anterior ontanelle is still patent and o ers the advantage o no
radiation exposure. Ultrasound is primarily used to assess uid-
lled spaces (ventricles in hydrocephalus, subdural hematoma,
etc.). C scan is a rapid and readily available test that can detect
hemorrhages, intracranial calci cations, skull ractures, Chiari
mal ormations, and more but given the concern or radiation
exposure and the risk o uture malignancy, it is not the rst line
imaging technique. C is also limited in its ability to delineate
so -tissue problems, which is where MRI becomes important.
HELPFUL TIP:
t he i eren i l i gnosis o m ro eph ly is long n
in lu es hy ro eph lus, br in umor, benign mili l
m ro eph ly, benign enl rgemen o he sub r h-
noi sp e (BESS), neuro u neous isor er (e.g., neu-
ro ibrom osis, uberous s lerosis), hemorrh ge, n
me boli isor ers (e.g., t y–S hs ise se, mu opoly-
s h ri oses).
Question 13.5.2 The ultrasound tech is still on vacation
(why can’t we have his job?) and your MRI is undergoing
scheduled maintenance, so you order a CT scan, which
shows subdural hematomas. What is your next step in
managing this patient?
A) Admit to the hospital.
B) Examination o eyes in an ophthalmologist’s o ce.
C) “Babygram” to view entire skeleton o in ant or ractures.
D) Alert the department o human services within the next week.
E) Send the patient to a neurosurgeon’s o ce or the next avail-
able appointment.
Answer 13.5.2 The correct answer is “A.” Subdural hematomas
in an in ant are highly suspicious o abusive head trauma. Your
rst priority is to protect the child by admission to the hos-
pital. A retinal examination and skeletal survey are important
in the evaluation but are secondary to protection o the child.
A “babygram” should never be done to evaluate or skeletal
trauma. T ere is a speci c procedure or per orming a skeletal
survey or abuse. Your state agency responsible or investigating
child abuse must be noti ed within 24 hours (although clini-
cians are encouraged to know their legal responsibilities in the
state in which they practice). Protection o the child is most
important; i the amily ees, calling the police or the appro-
priate state agency would be the rst step. Suspicion o abuse,
especially abusive head trauma, is an emergency, and it should
not wait or a neurosurgeon’s next available appointment.
HELPFUL TIP:
Re in l hemorrh ges, re highly suspi ious or buse.
Non busive uses o re in l hemorrh ges re very r re.
V in ions, mil he r um (su h s lling o o
so ), c PR, seizures, n rou ine pl y o not use re i-
n l hemorrh ges.
As you have done in this case, radiological studies should
always be obtained in the evaluation o suspected child abuse.
However, the cause o ractures has a broader di erential
than abuse.
Question 13.5.3 Which patient’s injuries and/or radiologi
cal studies would be pathognomonic o abuse?
A) A 9-month-old male with widened distal radius and ulna
with raying and cupping evident on radiograph.
B) A 21-month-old emale with multiple ractures at di er-
ent ages on radiograph. She has delayed tooth eruption and
sparse hair.
C) A colicky 1-month-old male in ant with callus on the le
clavicle radiograph.
D) A 2-year-old emale with a spiral racture o the distal right
tibia.
E) None o the above.
Answer 13.5.3 The correct answer is “E.”None o these injuries is
diagnostic o abuse. Although each o these children would make
you think o possible abuse, none o them have been abused. “A”
is a child with rickets. “B” is a child with osteogenesis imper ecta.
“C” is a child who sustained a clavicle racture at birth. “D” is a
child with a “toddler’s racture.” A toddler’s racture is a spiral tib-
ial racture ound in children age 9 to 36 months (see Chapter 12).
T ese ractures are ound in the distal one-third o the tibia.
Benjamin’s evaluation shows bilateral subdural hemorrhages
and retinal hemorrhages. His skeletal survey is negative. T e
state agency removes him rom the home and places him
in oster care. Benjamin then returns or his 6-month well
child examination. He has been in oster care since you last
saw him. His vision is being ollowed by an ophthalmologist.
He smiles and squeals. His oster mother says, “Looks like
he’s right-handed. Does that mean that he’s advanced or his
age?” He rolls both ways. He has started on rice cereal and
bananas. He sleeps well. On your examination, he continues
to have macrocephaly but a so ontanelle. His le hand is
sted. T e rest o the examination is unremarkable.
Question 13.5.4 What is your assessment and plan or
Benjamin?
A) Normal 6 months old: Routine anticipatory guidance and
immunizations.
B) In ant with history o head trauma: Delay pertussis vaccina-
tion because o the autism risk.
C) In ant with history o head trauma: Per orm Denver Devel-
opmental Screening est and document ndings; repeat in
3 months.
D) Hypertonic le upper extremity: Monitor progress at next
well child check.
E) Hypertonic le upper extremity: Re er or urther evalua-
tion and treatment o his delay.
Answer 13.5.4 The correct answer is “E.” Benjamin has a risk
o developmental delays due to his abusive head injury. He

should be monitored closely or delays. One way to monitor
or delays is by per orming a screening test, such as the Den-
ver Developmental Screening est. However, Benjamin has
concerns that go beyond screening. His tightly sted le hand
with corresponding avoring o his right hand suggests spastic
hemiplegia. Early hand pre erence is a worrisome sign. ypi-
cally hand pre erence is not de nite be ore 18 to 24 months.
Hand pre erence should prompt the physician to examine the
other extremity. In this case, there is hypertonicity resulting
rom his trauma. Any child with concern o developmental
delay should be re erred or urther evaluation. Some local
and state agencies o er a ree service to amilies to evaluate
development and o er therapy. Do NO watch and wait with a
suspected delay. T e earlier intervention begins, the better the
outcome.
Objectives: Did you learn to . . .
• Re ognize n ev lu e m ro eph ly in n in n ?
• Gener e i eren i l i gnosis o m ro eph ly in n
in n ?
• d e ermine when hil buse shoul be in lu e in he
i eren i l i gnosis?
• d es ribe some spe s o evelopmen l el y n i s
m n gemen ?
QUICK QUIZ: d EVELOPMENt a L d ELaY
A mother brings her 18-month-old son in or a routine visit but
is concerned that he is not as verbal as he was 3 months ago.
She reports that he eats well. He just started walking. You wish
to screen him or a pervasive developmental disorder (which
includes autism, Rett syndrome, Asperger syndrome, childhood
disintegrative disorder, and others).
What is the most appropriate o ce tool to use with this patient
given his age and presenting symptoms?
A) Ages and Stages Questionnaire (ASQ).
B) Conner’s Rating Scale—Revised Short Form.
C) Denver Developmental Screening est.
D) Modi ed Checklist or Autism in oddlers (M-CHA ).
E) Parents Evaluation o Developmental Status (PEDS).
The correct answer is “D.” T e Modi ed Checklist or Autism
in oddlers (M-CHA or short) is a validated o ce-screening
tool or autism spectrum disorders. It would be the most appro-
priate tool o the options given. O note, the AAP recommends
screening all children or autism spectrum disorders using a
standard screening tool such as the M-CHA at ages 18 and
24 months. “A” is incorrect as the Ages and Stages Questionnaire
is a broad-based developmental screening tool, as is “D”, the
Denver Developmental Screening est. “B” is incorrect because
this test is used to detect ADHD. Note that the USPS F does
not recommend or or against autism screening between 18 and
30 months noting that there is insu cient evidence to take a
position on such screening. However, most practitioners ollow
the AAP recommendations.
CHAPTER 13 • PEd Ia t RIc S 375
CASE 13.6
A 7-year-old male presents to your clinic with his mother
with a complaint o enuresis. Evidently, this child has never
been completely continent at night, wetting his bed several
times per week. T is has become somewhat o a problem
or him now that his riends are having sleepover birthday
parties. Plus, his mother con des that she’s tired o paying
or pull-ups and cleaning sheets. His incontinence is mono-
symptomatic (meaning no overactive bladder symptoms or
daytime wetting).
Question 13.6.1 What percent o 7 year old continue to
have enuresis?
A) 1%.
B) 10%.
C) 20%.
D) 40%.
E) 75%.
Answer 13.6.1 The correct answer is “B.” About 10% continue
to have enuresis at age 7 years which tapers to 1% to 2% at age
15 years or greater. Even though this would suggest that it is a
variant o normal, there is extreme social pressure on children
age 7 to remain dry at night. Parental expectations may depend
on their experience with other children. For example, i an older
sibling was dry at night at age 3 or i a younger sibling is dry
while an older child has enuresis, parents may not accept the
bed wetting as normal. Age 7 is considered the cuto or “nor-
mal” enuresis; there ore, beyond age 7 years, it is considered a
problem.
HELPFUL TIP:
No e h he hil in his se is m le. Enuresis e s
wi e s m ny m les s em les.
Because he has had no period o nocturnal dryness, this
patient has primary enuresis.
Question 13.6.2 Which o the ollowing is likely to be part o
this child’s history?
A) A amily history o enuresis.
B) A stress ul event in the amily such as the birth o a new
child or parental divorce.
C) Increased uid intake over the past 2 months.
D) History o urinary tract in ections.
Answer 13.6.2 The correct answer is “A.” Enuresis is divided
into primary and secondary enuresis. Primary enuresis occurs
in cases where there is never a consistent period o dryness
at night. Secondary enuresis occurs when there is a period o
dryness (by convention, 6 months) be ore the patient develops
enuresis. “B,” “C,” and “D” would more likely be seen in children
with secondary enuresis. Primary enuresis tends to be a amilial
trait.
376 Fa MILY MEd Ic INE EXa MINa t ION & BOa Rd REVIEW
HELPFUL TIP:
a bou 15% o p ien s wi h enuresis be ome ry e h
ye r. t he longer enuresis persis s, he less likely i is o
resolve.
T is patient’s examination is essentially normal including
neurologic evaluation.
Question 13.6.3 Further evaluation o this patient should
include all o the ollowing EXCEPT:
A) Asking about a history o bowel problems.
B) Assessment o growth and development.
C) Investigation into amily history o nocturnal enuresis.
D) Spine MRI to rule out pathologic lesion.
E) Urinalysis.
Answer 13.6.3 The correct answer is “D.” Patients with enure-
sis who have an otherwise normal neurologic examination need
not have an MRI done. I on examination this child had neuro-
logic ndings, an MRI would be indicated. All o the remaining
options are part o a thorough evaluation o nocturnal enuresis.
O particular note is the assessment o growth and development
(is this child neurologically delayed leading to enuresis?). Atten-
tion to bowel problems is also important. Fecal impaction can
lead to incontinence. Asking about snoring can help to identi y
obstructive sleep apnea, which can be associated with enuresis.
You nd no indication o an underlying cause, and you
decide that this is primary enuresis. T e parents are desper-
ate or some sort o intervention to x the problem, since it is
becoming a major source o anxiety in the home and o teas-
ing at school (o course anything can be a source o teasing at
school).
Question 13.6.4 Which o the ollowing should constitute
the INITIAL treatment o this patient’s primary enuresis?
A) Patient education and motivational training (e.g., rewards
or staying dry).
B) Over-learning.
C) Enuresis alarm.
D) Nasal desmopressin (DDAVP).
E) Oral desipramine.
Answer 13.6.4 The correct answer is “A.” All o the above have
been ound to be use ul in the treatment o enuresis; however,
the best initial approach includes education. Patients and par-
ents should be in ormed o how common this condition is, how
to reduce uid intake in the evening without getting dehydrated,
and how to schedule voiding. Motivational training plays a role
as well. T e other interventions are secondary. “B,” over-learn-
ing, is thought to help prevent relapses in patients who have been
success ul with an enuresis alarm. Once continence is achieved
with the alarm, the child drinks a set amount o uid be ore
bedtime. T e amount is successively increased once dryness
is achieved until a maximum is reached. T e idea is that the
patient is conditioned to respond to his increasing bladder
capacity.
“C,” an enuresis alarm, is an e ective treatment but relatively
expensive and requires signi cant motivation on the part o
the amily. T e enuresis alarm increases success o the other
options, and when used in combination with other modalities, it
has shown the best long-term results. “D” and “E” are incorrect
in this scenario although they are used to treat enuresis. Relapse
is more common when pharmacologic therapy is discontinued
than with the other modalities. However, medications are e ec-
tive as a short-term treatment option but are elt to be second
tier and used when the urine alarm ails or is impractical (think
sleepover or summer camp). O note, “D” is wrong or another
reason: nasal DDAVP is no longer approved or nocturnal
enuresis due to problems with hyponatremia. Oral DDAVP still
carries the enuresis indication, but it can cause hyponatremia as
well—it just occurs less o en.
HELPFUL TIP:
Re en ion on rol r ining is no longer re ommen e
s i w s no oun o signi i n ly e re se we ing.
Re en ion- on rol r ining w s b se on he ( ul y)
premise h enure i hil ren h sm ller bl er -
p i ies. t he hil woul hol in urine in n emp
o s re h he bl er n in re se p i y. Re en-
ion on rol r ining n in re se bl er p i y bu
oes no improve enuresis. Bu m ybe i you re ru k
river or surgeon . . .
Objectives: Did you learn to . . .
• d e ne prim ry n se on ry enuresis?
• d es ribe some o he epi emiologi h r eris i s o enure-
sis?
• Ev lu e p ien wi h enuresis?
• d evelop m n gemen s r egy or enuresis?
QUICK QUIZ: MEc ONIUM
Delayed meconium passage occurs in which o the ollowing
conditions?
A) Encopresis.
B) Hirschsprung disease.
C) Cystic brosis.
D) Hyperthyroidism.
E) B and C.
The correct answer is “E.” Seventy percent o newborns will
pass meconium within the rst 12 hours o li e. More than
90% o newborns pass meconium within the rst 24 hours. In
those with delayed passage o meconium (generally de ned as
> 24 hours o li e), consider Hirschsprung disease, cystic bro-
sis, hypothyroidism, sepsis, intrauterine narcotic exposure, or
imper orate anus.

QUICK QUIZ: Ra SH
Your next patient is a 3-year-old emale with a rash. A er play-
ing outside (could playing out-side be a red herring? T e editors
think so . . .), her ather ound spots on her legs, and she did not
want to walk because her knees hurt. On examination, she is
a ebrile with normal vitals and slightly irritable but otherwise
interactive. She has slight nasal drainage, which her ather says
is a residual rom a cold last week. Her legs and buttocks have
palpable purpura. Her knees are mildly swollen and are pain ul
with range o motion. Her CBC (including platelets) and coagu-
lation studies are normal, and her urinalysis is signi cant or
2+ hematuria.
T e most likely diagnosis in this patient is:
A) Acute exposure to lawn chemicals.
B) Henoch–Schönlein purpura (HSP) AKA “Immunoglobulin
A vasculitis”.
C) Juvenile idiopathic arthritis (JIA).
D) Meningococcemia.
E) Rocky Mountain spotted ever.
The correct answer is “B.” T is is classic HSP, an IgA-
mediated, generally sel -limited, leukocytoclastic vasculitis.
T e symptoms and signs o HSP are a rash (typically non-
thrombocytopenic purpura), abdominal pain ( rom submu-
cosal hemorrhage and edema), arthritis/arthralgia, and renal
disease. ypically, the vasculitis ollows an upper respiratory
in ection or streptococcal pharyngitis, as in this case. reat-
ment or HSP is supportive.
“A,” lawn chemical exposure, usually results in nothing acute
but may cause acute cholinergic symptoms i organophosphates
are used. “C,” JIA, is not likely because the rash o systemic onset
JIA is evanescent salmon-pink rash on the trunk and axilla that
classically occurs when the patient spikes a ever. “D,” meningo-
coccemia, is incorrect because the patient is a ebrile, alert, and
nontoxic appearing without laboratory evidence o dissemi-
nated intravascular coagulopathy. “E” is unlikely because Rocky
Mountain spotted ever presents with headache, high ever,
petechial rash involving the palms and soles, and the patients
will appear toxic. In addition, patients with Rocky Mountain
spotted ever have thrombocytopenia when their petechiae
appear.
HELPFUL TIP:
t he r sh o HSP is requen ly ini i lly ur i ri wi h sur-
roun ing e em . t he r sh en s o be symme ri n
o ur in epen en re s eveloping irs on he legs or
on pressure poin s (bu o ks). a is ussion o re men
is beyon he s ope o his book. However, ommon in-
volvemen s in lu e ren l ilure, GI blee ing, n more
r rely c NS involvemen su h s seizures, c NS hemor-
rh ge, e .
CHAPTER 13 • PEd Ia t RIc S 377
CASE 13.7
A 7-month-old ully immunized emale presents to the o ce
with ever. Mom reports she has “not been hersel ” and elt
“a bit warm on the orehead.” Vitals reveal a temperature o
39.2°C. Physical examination reveals a mildly toxic in ant.
You per orm a complete history and physical but are unable
to identi y a source o the ever.
Question 13.7.1 What is the rst step in your approach to
this child?
A) Obtain a urinalysis and urine culture.
B) Admit or observation and per orm blood, urine, and CSF
or culture.
C) Give an intramuscular dose o ce riaxone.
D) Order acetaminophen 30 mg/kg and discharge the patient i
the temperature comes down.
E) Admit or IV uids overnight.
Answer 13.7.1 The correct answer is “A.” At this age, occult
serious bacterial in ection is less likely than during the neonatal
period especially when vaccinated against Haemophilus in uen-
zae type b and Streptococcus pneumoniae. In a well-appearing
child older than 90 days with a ever without a ocal source,
most experts recommend a screening urinalysis and urine cul-
ture as the initial diagnostic test. “B” is overly aggressive, and
“C” is not indicated and can make cultures more di cult to
interpret should this child become sicker. “D” might be appro-
priate although the dose o acetaminophen is wrong (it should
be 15 mg/kg/dose by mouth every 4–6 hours). Since you are not
seeing signs o dehydration, “E” is inappropriate.
HELPFUL TIP:
S u ies h ve shown h he in i en e o o ul b -
eremi is less h n 1% in well- ppe ring fully immu-
nized in n s 3 o 36 mon hs o ge presen ing wi h
ever wi hou lo lizing signs. O en, posi ive bloo
ul ure is ue o on min ion, whi h resul s in un-
ne ess ry i ion l es ing, re men , n os . Some
o you m y be hinking, “Wh bou c Bc ?” In his
ype o p ien , he WBc oun n be equ lly misle -
ing. t he mos impor n ors in e ision-m king
re he p ien ’s ge, immuniz ion s us, n lini l
ppe r n e.
Question 13.7.2 What is the most appropriate manner in
which to obtain a urine specimen in this child?
A) Midstream “clean-catch.”
B) Bag specimen rom sterile plastic bag taped to the perineal
region.
C) Bladder catheterization.
D) Suprapubic aspiration.
E) C or D.
Answer 13.7.2 The correct answer is “C.” T e gold standard
test or the diagnosis o urinary tract in ection is a quantitative
378 Fa MILY MEd Ic INE EXa MINa t ION & BOa Rd REVIEW
urine culture. While the urinalysis and microscopy may suggest
U I, no component, or combination o components, is as sensi-
tive or speci c as culture. T ere ore, i a child is likely to require
antimicrobial therapy, one should attempt to obtain urine or
culture in a manner not likely to cause contamination. T e mid-
stream “clean-catch” may be obtained in older children who
are toilet trained; making certain that the perineum is cleansed
rst. Bag specimens are prone to contamination and should be
avoided in toxic patients who are likely going to need antibiot-
ics. Suprapubic aspiration is generally not necessary though it is
the gold standard.
HELPFUL TIP:
a neg ive b g- olle e urine in non oxi in n m y
be help ul. Gui elines sugges h one op ion in non-
toxic in n is o ge b gge urine. I his is posi ive,
i mus be ollowe up wi h urine ob ine by h-
e eriz ion or supr pubi spir e. t his shoul hen be
sen or ul ure. a ny hil who will nee n ibio i s on
rel ively emergen b sis or Ut I shoul h ve urine
ob ine by he eriz ion or supr pubi spir ion
sen or ul ure.
Question 13.7.3 The patient has 20 WBC/hp on UA. With
out knowing the culture and susceptibility results, which
antibiotic would be the LEAST appropriate choice or the
treatment o a UTI in this child?
A) rimethoprim/sul amethoxazole ( MP/SMX).
B) Amoxicillin.
C) Ce dinir.
D) Ce xime.
Answer 13.7.3 The correct answer is “B.” T e majority o uri-
nary tract in ections are due to Gram-negative organisms such
as Escherichia coli in children and the resistance rate to amoxi-
cillin is high (up to 40%). T us, amoxicillin is not a good choice
or treating a U I in children—or anybody, or that matter. T e
usual choice or empiric oral antibiotic treatment o U I in chil-
dren includes sul onamides or third-generation cephalosporins.
Caution should be used with empiric use o MP/SMX due to
increasing resistance o E. coli to this agent. Fluoroquinolones
may be considered in adolescents or children older than 1 year
with a complicated U I; uoroquinolones do seem to be sa e in
children but should be saved or situations where other drugs are
sub-optimal. T e duration o treatment should be 7 to 10 days
or uncomplicated U I. I the child appears clinically ill sug-
gesting pyelonephritis, initial parenteral treatment with ce ri-
axone would be an appropriate rst-line agent.
Her urine culture reveals Escherichia coli susceptible to trim-
ethoprim/sul amethoxazole, and you treat her appropriately.
Question 13.7.4 Following her initial treatment, what diag
nostic study should be per ormed next?
A) Abdominal supine and upright radiographs.
B) Renal ultrasound and voiding cystourethrogram (VCUG).
TABLE 13-5 INTERNATIONAL REFLUX STUDY
COMMITTEE GRADING OF VESICOURETERAL REFLUX
Gr e I: Involves he ure er only.
Gr e II: Involves he ure er, pelvis, n ly es wi hou il ion.
Gr e III: Involves he ure er, pelvis, n ly es wi h mil ure er n
pelvis il ion.
Gr e IV: Involves he ure er, pelvis, n ly es wi h signi n
il ion n blun ing o he ly e l orni es.
Gr e V: d emons r es il ion n or uosi y o he ure er s well
s loss o he ly e l orni es.
C) Spiral C o abdomen and pelvis.
D) Urology consultation or urodynamic studies.
E) None o the above.
Answer 13.7.4 The correct answer is “E.” In ebrile in ants
with U I, it is important to look or anatomic abnormalities
o the urinary tract. Ultrasound imaging (not VCUG) is rec-
ommended ollowing a rst ebrile U I to identi y those at risk
or recurrence and subsequent damage to renal parenchyma
(male or emale). So, “B” would be correct i not or the inclu-
sion o VCUG. Urinary tract ultrasonography should be per-
ormed at the earliest convenient time. Ultrasound is use ul
in the evaluation or kidney size and hydronephrosis, but it
is limited in the evaluation o vesicoureteral re ux (VUR), a
common abnormality associated with recurrent U I. VUR is
evaluated with a VCUG or radionuclide cystogram (RNC).
VCUG should be done a er a rst ebrile U I only when
there is evidence o renal abnormality on the ultrasound
including scaring, hydronephrosis, abnormal anatomy, etc.
Routine VCUG is NO recommended. T us, choice “B” is
incorrect.
For some unknown reason, a VCUG is done (you said “Is it
time or tea?” and it got transcribed as “do a VCUG”) and
your patient is ound to have grade II ref ux (see able 13-5).
Question 13.7.5 Which o the ollowing would be the most
appropriate initial management o her grade II ref ux?
A) Prescribe prophylactic antibiotics.
B) Re er or surgical intervention.
C) Per orm GFR to assess renal scarring.
D) Observe or now with repeat VCUG in 6 months.
E) None o the above.
Answer 13.7.5 The correct answer is “E.” Since the last edi-
tion o this book things have just gotten more muddled. It
seems (most) everyone agrees that children with grade I–II
re ux with bladder and bowel dys unction bene t rom pro-
phylactic therapy. In those with grade I-II re ux and no blad-
der or bowel dys unction the bene t is less clear. It gets a bit
trickier with grade III–IV. Overall, children with III-IV re ux
seem to have about hal the number o in ections with prophy-
lactic therapy (typically with MP/SMX); the bene t is most

pronounced in those with a ebrile rst episode and bowel or
bladder dys unction. However, there is no di erence in renal
scarring and 63% develop resistant organisms (vs. 19% in the
placebo group) (N Eng J Med. 2014;370;2367–2376 and N Eng J
Med. 2014;370:2440–2441). Have a discussion with the parents.
And promptly treat any U Is to prevent renal scarring (par-
ticularly a risk in those with a temperature o > 39°C or a non
E. coli organism). Mild re ux tends to resolve with maturity.
Renal scarring is best detected by radioisotope scanning with
99 m-technetium dimer captosuccinate. Doing a GFR looks at
kidney unction and does not assess or renal scarring. T ere-
ore, “C” is incorrect. “D” is incorrect because a VCUG was not
indicated in the rst place!
HELPFUL (OR CONFUSING) TIP:
We on’ know wh he bo r ex min ion will w n
s n nswer. t r i ion lly, ul r soun a nd Vc UG h ve
been one er irs Ut I in m le in n n se on
Ut I in em le in n . Even hough he a a P gui elines
o no suppor oing Vc UG, he Se ion on Urology
o he a meri n a emy o Pe i ri s publishe
s emen in a pril 2012 is greeing wi h he re om-
men ion o no ob in Vc UG in hil ren ge
2 mon hs o 2 ye rs er he irs ebrile Ut I. Surgi l
in erven ion is gener lly reserve or hose wi h severe
re lux (gr es IV–V) or re urren Ut I espi e prophyl -
i n ibio i s. See Pediatrics. 2011;128(3):595–610 or
more in orm ion.
Objectives: Did you learn to . . .
• Ev lu e n ol er (> 3 mon hs ol ) in n wi h ever?
• d i gnose n re hil wi h n ini i l urin ry r in e -
ion?
• Re ognize h urin ry r in e ion is o en m rker or
urin ry r bnorm li ies in hil ren?
• M n ge p ien wi h VUR?
CASE 13.8
Anthony is a 2,300-g male in ant born at 35 weeks’ gestation
to a 23-year-old G2P2 mother. T e mother did not seek pre-
natal care and routine screening labs were not available. She
presented to the ED in active labor shortly ollowing spon-
taneous rupture o membranes at home. Upon trans er to
the obstetric ward, she was noted to be ebrile (38.8°C) and
received intravenous antibiotics. Five hours later, the in ant
was delivered via spontaneous vaginal delivery.
Question 13.8.1 Management o this newborn in ant whose
mother probably has chorioamnionitis (not simply GBS
screen positive) should include which o the ollowing?
A) Empiric therapy with ampicillin and gentamicin.
B) Empiric therapy with ampicillin.
C) Empiric therapy with vancomycin.
D) Empiric therapy with ce riaxone
E) Empiric therapy with ampicillin and erythromycin.
CHAPTER 13 • PEd Ia t RIc S 379
Answer 13.8.1 The correct answer is “A.” Maternal chorioam-
nionitis is an important risk actor or early onset sepsis in the
newborn. T e 2010 CDC guideline on the prevention o peri-
natal group B streptococcal disease recommends that all in ants
born to mothers with chorioamnionitis have screening labs and
blood cultures at birth ollowed by minimum o 48 hours o
antibiotic therapy. Antibiotic therapy may be extended and/or
modi ed depending on the clinical course and culture results.
A lumbar puncture or CSF culture and analysis should be per-
ormed i the child is septic appearing. Ampicillin and gentami-
cin as empiric therapy cover the most likely organisms includ-
ing GBS and Gram-negative pathogens, respectively.
Anthony is started on appropriate antibiotics. Examination
o this neonate reveals hepatosplenomegaly, lymphadenop-
athy, petechiae, and white mucocutaneous patches in the
in ant’s mouth. His CBC reveals hemoglobin o 12 g/dL and
a platelet count o 85,000/mm3 with evidence o hemolysis on
the peripheral smear.
Question 13.8.2 The most likely pathogen in ecting this
in ant is:
A) Rubella.
B) Cytomegalovirus.
C) oxoplasma gondii.
D) reponema pallidum.
E) Candida albicans.
Answer 13.8.2 The correct answer is “D.” Neonatal mani esta-
tions o congenital syphilis include hepatosplenomegaly, lymph-
adenopathy, jaundice, rash, hemolytic anemia, and thrombocy-
topenia. Un ortunately, these ndings overlap considerably with
many o the other congenital ORCH (toxoplasmosis, rubella,
CMV, herpes) in ections. Abnormalities more speci c to congeni-
tal syphilis include white, patchy mucocutaneous lesions (think
“condylomata lata”), edema, rhinitis (snuf es), osteochondritis,
and pseudoparalysis. Congenital syphilis is caused by trans-
placental transmission o the spirochete . pallidum (“D”).
Intrauterine in ection can result in stillbirth, hydrops etalis, or
prematurity.
HELPFUL TIP:
L e sequel e o ongeni l syphilis involve he bones
n join s, ee h, eyes, n c NS n in lu e bowe shins
(S ber shins), ron l bossing, s le nose, pegge en-
r l in isors, in ers i i l ker i is, n sensorineur l e -
ness. t he Hu hinson ri in lu es in ers i i l ker i is,
e ness, n no he , peg-sh pe ee h.
In addition to the laboratory data obtained above, you order
an ultrasound o the patient’s head, which appears normal.
Question 13.8.3 Intracerebral calci cations are CLASSI
CALLY associated with which congenital in ection(s)?
A) Cytomegalovirus.
B) oxoplasmosis.
380 Fa MILY MEd Ic INE EXa MINa t ION & BOa Rd REVIEW
C) . pallidum.
D) Rubella.
E) A and B.
Answer 13.8.3 The correct answer is “E.” T e clinical mani-
estations o congenital cytomegalovirus and toxoplasmosis are
o en similar. In ants are typically asymptomatic at birth, but
a signi cant number ultimately develop visual impairment,
learning disabilities, and developmental and intellectual delays
months to years later. T ose in ants who are symptomatic at
birth may demonstrate intrauterine growth retardation, hepato-
splenomegaly, jaundice, hemolytic anemia, and thrombocyto-
penia. Intracerebral calci cations also occur in both CMV and
toxoplasmosis. T e calci cations tend to be periventricular in
CMV (remember this by the act that the calci cations look like
a “C” in CMV) and more dispersed throughout the cortex in
toxoplasmosis (remember by noting the “X” in both cortex and
toxoplasmosis). Additional central nervous system abnormali-
ties include microcephaly, chorioretinitis, and sensorineural
hearing loss.
Objectives: Did you learn to . . .
• a ppropri ely m n ge he neon e born o mo her who
h s evi en e o horio mnioni is?
• Re ognize h m ny ongeni l t ORc H in e ions m y h ve
overl pping signs n symp oms?
• Re ognize h m ny in n s wi h ongeni l t ORc H in e -
ions re symp om i bir h?
QUICK QUIZ: c ONGENIt a L INFEc t IONS
A small or gestational age newborn in ant is ound to have
hepatosplenomegaly, jaundice, and thrombocytopenia. Cardiac
examination reveals a grade II/VI continuous murmur heard
best at the le upper sternal border. An ophthalmologic exami-
nation demonstrates microphthalmia and cataracts.
T e result o which maternal prenatal screening lab is likely to
have been concerning in the above case?
A) VDRL.
B) Rubella immunity status.
C) HIV status.
D) Varicella zoster immunity status.
E) GBS cultures.
The correct answer is “B.” Cardiac, ophthalmologic, auditory,
and neurologic ndings predominate in the symptomatic in ant
with congenital rubella. Up to 85% o in ants in ected during
the rst 12 weeks o gestation will have some orm o congenital
de ect. T is decreases to 5% when the primary in ection occurs
a er the third to ourth month o gestation. Ophthalmologic
ndings include microphthalmia, cataracts, glaucoma, and salt
and pepper retinopathy. In ants are o en microcephalic and
develop sensorineural hearing de cits, meningoencephalitis,
and developmental delay. Dea ness, cataracts and cardiac
anomalies are the classic ndings with congenital rubella.
Additional ndings o hepatosplenomegaly, thrombocytopenia,
and osteitis may be present. A characteristic “blueberry mu n”
appearance may be present due to the combination o jaundice
and extramedullary (skin) hematopoiesis. Syphilis and GBS
in ections are described above and they do not typically cause
the ophthalmologic ndings described in this case. “C” is incor-
rect because congenital HIV in ection is commonly asymptom-
atic. Evidence o immune de ciency may present later in the
child’s li e with ailure to thrive, generalized lymphadenopathy,
hepatosplenomegaly, and recurrent in ections. “D” is incor-
rect because congenital herpes in ections do not cause cardiac
abnormalities.
HELPFUL TIP:
USPSt F re ommen s univers l he ring s reening or
newborns.
QUICK QUIZ: c ONGENIt a L RUBELLa
Which o the ollowing cardiac lesions is likely to be ound in an
in ant with congenital rubella?
A) Patent ductus arteriosus (PDA).
B) etralogy o Fallot.
C) ransposition o great vessels.
D) Coarctation o aorta.
E) Bicuspid aortic valve.
The correct answer is “A.” T e most common cardiac lesions
associated with congenital rubella are a PDA and peripheral pul-
monary artery stenosis. PDA is characterized by a continuous
“machine-like” murmur heard best over the le upper sternal
border. etralogy o Fallot and transposition o great vessels are clas-
sically cyanotic heart de ects that have no known association with
congenital in ections. Coarctation o the aorta and bicuspid aortic
valve both cause harsh systolic murmurs. T e murmur o coarc-
tation radiates to the back. Both coarctation and bicuspid aortic
valve are commonly ound in emales with urner syndrome.
CASE 13.9
A term newborn in ant is noted to have a solitary, tense bulla
located on the dorsum o his wrist. T e underlying skin is
nonerythematous. Pregnancy was uncomplicated; however,
the in ant was delivered via cesarean section or ailure to
progress. T e in ant appears to be a vigorous eeder and is
noted to requently suck on his hands and wrists while in the
nursery. He is otherwise asymptomatic.
Question 13.9.1 Which o the ollowing is MOST appropri
ate at this time?
A) Start acyclovir.
B) Per orm lumbar puncture and send a sample o the CSF or
HSV PCR.
C) Per orm a zanck smear o the bulla uid.
D) Obtain CBC and blood cultures.
E) Observation with no intervention at this time.

Answer 13.9.1 The correct answer is “E.” Nothing needs to
be done at this time. T e appearance and location o the bulla
is consistent with a sucking blister. A solitary bulla or blister on
normal-appearing skin located on the upper limbs may be pres-
ent at birth rom in utero sucking. O en when presented with
the a ected extremity, the in ant will demonstrate the sucking
behavior in that location. Such blisters are o en mistaken or her-
pes simplex, but the solitary nature and location help to establish
the correct diagnosis—although there may be multiple blisters
at times. Additional history o cesarean section makes HSV less
likely in this scenario. Nonetheless, a sucking blister is a diagnosis
o exclusion, and other more serious diagnoses should be ruled
out by history and examination and urther testing as indicated.
Question 13.9.2 The FALSE statement regarding neonatal
herpes simplex virus in ection is:
A) T e majority o in ants with neonatal HSV are born to
mothers with symptomatic herpetic lesions.
B) T e incidence o neonatal transmission is higher when
the pregnant woman experiences primary in ection versus
secondary reactivation.
C) Most neonatal HSV in ections are caused by HSV 2.
D) Intrauterine exposure accounts or the minority o perinatal
HSV in ection.
E) Herpetic skin lesions are o en present in in ants with CNS
or disseminated HSV.
Answer 13.9.2 The correct answer is “A.” Less than one-third
o in ants with neonatal HSV are born to mothers with active
genital lesions. In act, most cases o neonatal HSV are ound
in in ants o asymptomatic mothers who are shedding the virus.
Neonatal herpes simplex virus o en results in serious morbidity
and mortality. In ants with HSV present with one o the ollow-
ing three disease patterns with overlapping eatures: localized
disease involving the skin, eyes, and mouth; CNS disease; or
disseminated in ection. Encephalitis may occur with or without
skin involvement; there ore, HSV in ection should be suspected
in any in ant rom birth to approximately 4 weeks o age that
presents with ever, seizure, or mental status abnormalities such
as lethargy, irritability, or poor eeding.
T e other options are correct. A woman who contracts a
primary in ection during the pregnancy has a greater than 30%
chance o transmitting the virus to her in ant (“B”). T ere is
less than 2% transmission i she experiences a secondary reac-
tivation intrapartum. T e majority o neonatal HSV is due to
in ection with HSV 2 (“C”). Only 5% o congenital in ections
occur in utero (“D”), as the majority occurs via exposure to
in ected cervical secretions during birth. Skin lesions (“E”) are
present in 60% o CNS cases and about 75% o disseminated
cases.
HELPFUL TIP:
Mos neon es wi h HSV in e ion o no presen wi h
skin in ings bir h. I is more ypi l or neon es o
evelop HSV skin lesions 5 o 14 ys er elivery.
CHAPTER 13 • PEd Ia t RIc S 381
HELPFUL TIP:
In n s born v gin lly or vi es re n elivery o moms
wi h ive geni l HSV lesions nee HSV ul ures o he
mou h, n soph rynx, onjun iv , n re um ob ine
12 o 24 hours o ge. In in n s born o moms wi h
primary ou bre k ime o elivery, some exper s
re ommen empiri y lovir her py er ob ining
he ppropri e ul ures. In n s o mo hers wi h re-
urren ou bre k o no require empiri y lovir re -
men bu s ill shoul be moni ore losely or signs o
in e ion.
Objectives: Did you learn to . . .
• d i eren i e be ween herpes lesion n su king blis er?
• Re ognize r es n mo es o r nsmission o herpes in
neon es?
• I en i y some o he lini l m ni es ions o neon l
herpes?
CASE 13.10
A bunch o parents in your neighborhood decide to have
a “chickenpox” party (prompting you to consider mov-
ing to a place where people believe in modern medicine).
hey want to synchronize their kids’ chickenpox outbreaks
with their busy schedules (heaven orbid we should get
immunized—a ter all, it isn’t natural!). One o the moth-
ers, who has never had chickenpox hersel , inds out that
she is pregnant the day a ter being exposed to chickenpox.
She is not yet symptomatic ( rom the pregnancy or the
chickenpox).
Question 13.10.1 The best advice or this potential mother
about her pregnancy is:
A) Consider termination since it is likely that the child will have
congenital varicella.
B) Get treated within 96 hours o exposure with varicella
immune globulin.
C) Get treated within 96 hours o exposure with varicella
immune globulin plus varicella vaccine.
D) Get treated within 96 hours o exposure with IVIG plus vari-
cella vaccine.
Answer 13.10.1 The correct answer is “B.” Women who are
varicella-susceptible (nonimmune), pregnant, and exposed to
chickenpox should be treated with varicellaimmune globulin
(VariZIG) within 96 hours o exposure. I VariZIG is unavailable,
IVIG may be given instead. T e vaccine should be avoided
during pregnancy (thus “C” and “D” are incorrect). It is a
live, attenuated, virus and still carries some risk to the etus
(although the degree o risk is unknown). It is sa e to give the
vaccine to mom in the postpartum period and is indicated i
the mother is screened to be varicella nonimmune during her
pregnancy. T e risk o congenital varicella syndrome i the etus
is exposed in the rst trimester is about 2%. T e risk o neonatal
382 Fa MILY MEd Ic INE EXa MINa t ION & BOa Rd REVIEW
in ection is much higher i the mother is in ected within 5 days
o birth, and 30% o these cases result in severe neonatal vari-
cella in ection.
Question 13.10.2 You can let the mother know that:
A) Varicella immune globulin has been shown to reduce the
risk o congenital varicella.
B) Varicella immune globulin is aimed mostly at attenuating
the case in the mother should she be in ected.
C) Varicella immune globulin has not been shown to prevent
congenital varicella.
D) A and B.
E) B and C.
Answer 13.10.2 The correct answer is “B.” Varicella immune
globulin is aimed at reducing the symptoms in the mother and
attenuating her case o varicella. Both “A” and “C” are alse.
T ere are no good data either way about how varicella immune
globulin will a ect the child’s outcome vis-à-vis congenital
varicella.
Question 13.10.3 Mani estations o intrauterine in ection
with varicella zoster include all o the ollowing de ects
EXCEPT:
A) Optic atrophy.
B) Congenital cataracts.
C) Cardiac abnormalities.
D) CNS abnormalities.
E) Limb hypoplasia.
Answer 13.10.3 The correct answer is “C.” Cardiac abnor-
malities are not seen with varicella zoster exposure in utero. In
addition to the ndings above, patients with congenital varicella
zoster will have cutaneous scarring called cicatrix.
Glory!! She ound a chickenpox party! Now that all o
these children have been in ected with varicella zoster, the
question arises about how long they should be kept out o
school.
Question 13.10.4 These children are considered in ectious
until:
A) 5 days a er the rst lesion appears.
B) 10 to 14 days a er the rst lesion appears.
C) New lesions are no longer orming.
D) All lesions are crusted over.
E) T ey are no longer ebrile.
Answer 13.10.4 The correct answer is “D.” Patients are consid-
ered in ectious until all lesions are crusted over. Lesions need
not have healed entirely, only crusted over.
Objectives: Did you learn to . . .
• O er re men or v ri ell exposure o pregn n nonim-
mune em le?
• Re ognize he uses o v ri ell immune globulin?
• I en i y symp oms o ongeni l v ri ell in e ion?
CASE 13.11
A 3-year-old child presents to your o ce with a history o
bright red cheeks. Over the past several days, she has had
mild ever with mild muscle aches. Except or the rash, the
child is now asymptomatic.
Question 13.11.1 The most likely cause o this patient’s
illness is:
A) Parvovirus B-19.
B) Herpes virus 6.
C) Rubeola.
D) Rubella.
E) In uenza virus.
Answer 13.11.1 The correct answer is “A.” A mild systemic
illness ollowed by red, “slapped cheeks” is typical o erythema
in ectiosum or “ h disease,” caused by parvovirus B-19. T e
red, slapped cheeks are generally ollowed by a lacy, reticu-
lar rash on the extremities and trunk. T is is generally a sel -
limited illness in children.
Question 13.11.2 Which o the ollowing is NOT a compli
cation o parvovirus B 19 in ection—either congenital or
acquired?
A) Aplastic anemia.
B) Birth de ects, including CNS and limb disease.
C) Hydrops etalis.
D) In ammatory arthritis.
E) Intrauterine etal death.
Answer 13.11.2 The correct answer is “B.” Parvovirus B-19
causes all o the above except or birth de ects. Fetal death,
anemia, or nonimmune-mediated hydrops etalis are poten-
tial outcomes o intrauterine exposure (one-third o in ected
women will pass the virus to their etus). Most in ants in ected
in utero are born normally at term, including those with evi-
dence o hydrops earlier in the pregnancy. A small subset will
acquire chronic or prolonged postnatal in ection o unknown
signi cance. “A,” transient aplastic crisis, can occur in those
with chronic hemolytic conditions such as sickle cell anemia.
“D,” in ammatory arthritis, is common in adults and adoles-
cents with emales more commonly a ected.
T e question o whether or not to exclude this child rom
preschool is raised. T e patient still has the rash. T ere are a
couple o pregnant teachers at the preschool.
Question 13.11.3 You can tell the child’s mother that:
A) T is child is in ectious and should be excluded rom pre-
school until the rash resolves.
B) Since almost all adult women are already immune, there is
no need to worry about transmission to the teachers.
C) Since this virus is an enterovirus, care ul hygiene in the
school will prevent spread.
D) T is child can be allowed back into preschool and is no
longer in ectious.

Answer 13.11.3 The correct answer is “D.” Once the rash is
present, this child is no longer in ectious and can be allowed
back into school. “B” is incorrect because only about 50% o
adult women are immune. “C” is incorrect. First, this is not
an enterovirus. Even though URI symptoms are o en absent,
transmission is mostly respiratory with vertical transmission
o mom to etus, and hematogenous spread (via transmissions)
being much less common.
HELPFUL TIP:
Jus ry ge ing his hil wi h r sh b k in s hool
n p s he s hool nurse (we re you); i is impos-
sible . . . On he o her h n , s hools re sure h here
is “m gi l e e ” o opi l n ibio i s in preven ing
he spre o vir l onjun ivi is.
Objectives: Did you learn to . . .
• Re ognize he lini l m ni es ions o p rvovirus B-19
in e ion (“ h ise se”)
• I en i y ompli ions o p rvovirus B-19 in e ion?
QUICK QUIZ: c HILd HOOd INFEc t IONS
Which o the ollowing is characterized by a high ever, pos-
sibly over 40°C, a bulging ontanelle, a maculopapular rash that
begins af er the ever abates, conjunctivitis, and upper respira-
tory symptoms?
A) Roseola in antum (erythema subitum).
B) Rubeola (measles).
C) Rubella (German measles).
D) Varicella (chicken pox).
E) Meningococcal meningitis.
The correct answer is “A.” Such a clinical presentation is typical
o roseola in antum. Roseola in antum, which is caused by the
human herpes 6 (and rarely herpes 7) virus, is characterized by
a high ever or 3 to 5 days (o en over 40°C), generalized mal-
aise, a bulging ontanelle in up to 26% o in ants, conjunctivitis,
perhaps oral mucosal ulcers, and a rash that appears as the ever
begins to de ervesce. Children usually look amazingly well or
the height o the ever.
QUICK QUIZ: Ga St ROINt ESt INa L SYMPt OMS
A young couple brings in their 18-month-old emale or a
12-hour history o vomiting and diarrhea. T e patient has elt
warm, and her oral intake has been depressed. However, she
continues to make tears with crying and has wet diapers. Her
medical history is unremarkable. On examination, you nd a
tired-looking emale who perks up slightly when you open
a bag o toys (who are you anyway . . . Santa?). Her tempera-
ture is 38.5°C, and her capillary re ll is less than 3 seconds.
T e remainder o the examination is non ocal. You think that
CHAPTER 13 • PEd Ia t RIc S 383
she has a viral gastroenteritis, and give the parents some advice
regarding rehydration.
Which o the ollowing is the most appropriate advice or this
patient?
A) Avoid all solid ood or the next 24 to 48 hours.
B) Use milk as the primary rehydration solution.
C) Use only watered-down tea or rehydration.
D) Use a commercially prepared oral rehydration solution and
reintroduce oods as tolerated.
E) Use cola beverages (e.g., Coca-Cola or Pepsi) because they
contain more sodium than commercially available oral rehy-
dration solutions.
The correct answer is “D.” E ective oral rehydration can be
accomplished with any one o the rehydration solutions on the
market (e.g., Pedialyte). “A” is incorrect. T ere is no need to limit
the ood intake o patients with vomiting or in ectious diarrhea.
T ey can have whatever they can tolerate without vomiting. T e
concept o “gut rest” is obsolete and leads to increased bowel
permeability and prolonged diarrhea. So, early eeding is opti-
mal and recommended. T ere is no need to avoid lactose-
containing products. ransient lactase de ciency a er gastro-
enteritis is usually sel -limited (and generally limited to those
< 2 months o age) and does not require treatment unless symp-
toms are prolonged or severe a er dietary re-introduction. “C”
and “E” are incorrect. T ere is no role or weak tea, at soda,
“Jello water,” sports drinks, juice, etc., in the management o
gastroenteritis. T e most common cause o hyponatremic sei-
zures in the child is improper rehydration during gastroenteri-
tis. Many commercial drinks, such as cola beverages and sports
drinks, are not speci cally designed or oral rehydration, and
the sodium concentration is typically much lower than that in
rehydration solutions, risking hyponatremia (in other words,
the reverse o “E” is true). In addition, many o these have a high
sugar content, which can worsen diarrhea due to osmotic e ects.
HELPFUL TIP:
In he ex lusively bre s e in n wi h vomi ing n /or
i rrhe , bre s ee ing shoul be en our ge n no
repl e wi h or l rehy r ion solu ions.
HELPFUL TIP:
d uring GI illness, vise p ren s o voi non bsorb-
ble sug rs, like hose oun in pple or gr pe jui e.
t hese n promo e n osmo i i rrhe .
CASE 13.12
A new mother and ather bring their 2-month-old in ant
to your o ce with a complaint o inconsolable crying. T is
started at about 3 weeks o age and occurs about the same
time every day. T e crying will last or hours and is becom-
ing quite disruptive. T e child will draw up his knees and
seem to be in quite a bit o pain. T ey have tried pretty much
everything that they can think up including car rides, swings,
384 Fa MILY MEd Ic INE EXa MINa t ION & BOa Rd REVIEW

swaddling, various types o soothing music (such as death

HELPFUL TIP:
metal), etc., but to no avail. Shivers run up and down your
t he use o oli is unknown n likely mul i ori l.
spine as you recall your own early parenting experiences . . . or
R rely me i l expl n ion is oun . It is important to
as you remember why you don’t have kids (please apply the
identify alternative caregivers, since infant colic can
appropriate phrase or your personal experience).
be a major stress on parents and can possibly lead to
abuse (particularly shaken baby syndrome). P ren
Question 13.12.1 The most likely diagnosis is:
e u ion is ri i l.
A) Colic.
B) Intussusception.
C) Hair around the penis or toes or corneal abrasion.
HELPFUL TIP:
D) Constipation.
t here is evi en e o suppor ri l o n ex ensively
E) Cluster headache.
hy rolyze in n ormul (e.g., Nu r migen). d isn’
he s ronges , hough. Use o p r i lly hy rolyze or
Answer 13.12.1 The correct answer is “A.” Colic generally
l ose- ree ormul s is o no bene i . c h nging o soy
begins at 3 weeks o age, peaks at about 6 weeks o age, and
ormul oes no work.
abates by 3 months o age. It is de ned by a rule o 3s: intense
crying or 3 hours per day, or 3 days per week, or 3 weeks.
However, most parents, grandparents, nosy aunts, and pediatri-
HELPFUL TIP:
cians will describe any particularly ussy baby as “colicky.” T e
d sugges h probio i s re NOT e e ive in in n
cause is unknown. “B” is incorrect. While intussusception can
oli (BMJ. 2014;348:g2107). However, hey re s e
certainly present with colicky abdominal pain, it is not likely
n give he p ren s some hing o o. In bre s ee -
to be recurrent or several days or weeks without a more sig-
ing women, elimin ion o ommon llergens (milk,
ni cant problem (e.g., bloody stools) developing. “C,” a hair or
eggs, nu s, whe ) n be rie . a g in, he isn’ he
thread around a child’s toes or penis or corneal abrasion, should
gre es . Evi en e or spin l m nipul ion in re ing
be considered in any child with inconsolable crying. Again, this
oli is in on lusive. a s wi h mos hiropr i s u -
is not likely to result in crying that is daily and episodic. “D” is
ies, he is poor. In rossover s u y, 24% su rose
incorrect as this history is not consistent with constipation. And
h s been shown o be bene i i l (t oo swee n o her
“E,” a cluster headache, does not occur in this age group.
br n s . . . or m ke i yoursel ).

HELPFUL TIP:
While in onsol ble rying h s o en been ribu e o Objectives: Did you learn to . . .
orne l br sion, re en lls his in o ques ion. • Ev lu e p ien wi h oli n o er m n gemen s r e-
Jus s m ny hil ren who were NOt rying h orne l gies o he p ren s?
br sions.

QUICK QUIZ: EPIGLOt t It IS 1

Question 13.12.2 You can advise the parents that:
A) Phenobarbital is sa e and e ective or controlling in ant colic
(when given to the parents to help them “chill out” . . . and
knock o the death metal).
B) Elimination o cruci erous vegetables rom the diet o breast-
eeding mothers has been shown to reduce in ant colic.
C) Simethicone has been shown to be e ective in in ant colic.
D) Anticholinergic drugs are e ective in treating in ant colic,
but the risks are unacceptable.
E) Children who breast eed are less likely to develop colic.
Answer 13.12.2 The correct answer is “D.” Anticholinergic
drugs have been shown to be e ective in the treatment o colic.
However, the risks associated with the use o these drugs are
generally considered unacceptable. T e rest o the answers are
incorrect. It does not seem as though breast ed in ants are any
less likely to develop colic than are bottle- ed in ants. T e evi-
dence or elimination o cruci erous vegetables is inconclusive.
Simethicone is NO e ective in treating in antile colic, but it
gives the parents something to do.
You have a child in the ED who is toxic appearing with the sud-
den onset o high ever, drooling, and stridor. You suspect epi-
glottitis.
What is the FIRS step in the treatment o this patient?
A) Draw blood work including a CBC.
B) Place an IV or access and uids.
C) Give a dose o IM steroids (e.g., dexamethasone 0.6 mg/kg)
to help shrink the epiglottis.
D) Put a ace mask on the child and administer albuterol.
E) Leave the child on the mothers lap and don’t upset the child
(you don’t want a temper tantrum in the ED . . .).
The correct answer is “E.” Anything that upsets the child can
lead to increased airway obstruction. Leave the child in the par-
ent’s lap and do not upset him. “A” and “B” are incorrect because
they may upset the child, leading to increased work o breathing
and increased obstruction. “C,” dexamethasone, is indicated or
croup and not or epiglottitis. “D” is also incorrect. However, it

would not be wrong to give blow-by oxygen or blow-by nebu-
lized epinephrine i it did not agitate the child.
QUICK QUIZ: EPIGLOt t It IS 2
Which o the ollowing IS NO needed in the optimal diagnosis
and treatment o epiglottitis?
A) “T umb sign” on radiograph.
B) Antibiotics to cover H. in uenzae.
C) Antibiotics to cover S. pneumoniae.
D) An operating room.
E) Personnel able to emergently manage the airway.
The correct answer is “A.” T e use o radiographs in suspected
epiglottitis is raught with problems and delays potentially li e-
saving therapy. DON’ DO I . Epiglottitis is a clinical diagno-
sis that requires visualization o the epiglottis. T is is pre erably
done in the operating room with a setup or both intubation
and tracheostomy should that become necessary. I the child
is mildly ill, looking at the epiglottis in the ED is permissible.
However, be prepared to manage the airway. “B” and “C” are
both correct. Since the advent o H. in uenzae vaccine, there
is no longer a single organism causing most cases o epiglot-
titis. Bacteria that can cause epiglottitis include H. in uenzae, S.
pneumoniae, S. aureus, and groups A, B, and C beta-hemolytic
streptococci. Epiglottitis may also be o viral origin.
QUICK QUIZ: NEONat a L INFEc t IONS
What is the most likely etiologic agent in this child: 2-week-old
male with conjunctivitis, cough, rales, nasal congestion, in l-
trate on radiograph, but no ever or wheezes?
A) In uenza.
B) Chlamydia.
C) RSV.
D) Parain uenza.
E) Gonorrhea.
The correct answer is “B.” T is is a classic description o
Chlamydia in ection in the newborn. Patients usually present
between 5 and 14 days with exudative conjunctivitis and pneu-
monia. T e gold standard or diagnosis o neonatal Chlamydia
in ection remains a culture obtained rom conjunctival swabs o
the everted eyelids; however, nucleic acid ampli cation tests o
conjunctival scrapings have been ound to have high sensitiv-
ity and speci city when compared with culture. Conjunctival
cells must be present or an adequate specimen because Chla-
mydia is an intracellular pathogen. reatment is with systemic
antibiotics even i conjunctivitis is the only symptom present.
Erythromycin is the drug o choice at a dose o 50 mg/kg/day
divided our times daily or 14 days. Azithromycin is an alter-
native. opical treatment may be used as an adjunct but alone
is not su cient or treatment o this patient. Remember, the
antibiotic eye ointment applied to the neonate at birth protects
against ocular gonococcal infection but not Chlamydia.
CHAPTER 13 • PEd Ia t RIc S 385
CASE 13.13
A 12-month-old presents to your o ce in January with a
2-day history o runny nose and cough. T e child now has
wheezing with nasal f aring and retractions, and his oxygen
saturation is 89%. T ere has been no ever, and several o the
other children and adults in the amily have had “a cold” over
the past several weeks. On examination, you hear scattered
wheezes and rales. You diagnose bronchiolitis.
Question 13.13.1 The MOST LIKELY organism involved in
this child’s illness is:
A) Rhinovirus.
B) Adenovirus.
C) Respiratory syncytial virus (RSV).
D) Parain uenza.
E) Human metapneumovirus.
Answer 13.13.1 The correct answer is “C.” T e most common
cause o bronchiolitis in children is RSV. All o the others can
also cause bronchiolitis, as can in uenza virus, but less com-
monly than RSV.
Question 13.13.2 Which o the ollowing treatments has
been unequivocally shown to be e ective in bronchiolitis?
A) Nebulized albuterol.
B) Nebulized epinephrine.
C) Corticosteroids such as prednisone or dexamethasone.
D) All o the above.
E) None o the above.
Answer 13.13.2 The correct answer is “E.” None o the above
has been shown to be e ective in bronchiolitis. T e mainstay
o treatment is supportive care. Albuterol may cause worsening
hypoxia due to induction o V/Q mismatch.
HELPFUL TIP:
Nebulize hyper oni s line (3%) h s been shown o be
mildly bene i i l in hospitalized p ien s wi h bron hiol-
i is by e re sing lini l bron hioli is s ore n shor -
ening leng h o s y. t his m kes sense. t he hyper oni
s line will r w lui rom he bron hi n shrink issues
hereby re u ing obs ru ion.
Question 13.13.3 RSV is usually diagnosed by:
A) Nasal wash using immuno uorescence or antigen detection.
B) Baseline and convalescent antibody titers.
C) Blood culture or RSV.
D) Sputum gram stain.
E) Induced sputum culture.
Answer 13.13.3 The correct answer is “A.” A nasal wash or
RSV immuno uorescence or antigen detection is used to diag-
nose RSV. I a nasal wash cannot be obtained, a nasal pharyngeal
swab or throat swab o ers the next best alternatives. Reverse
386 Fa MILY MEd Ic INE EXa MINa t ION & BOa Rd REVIEW
transcription-polymerase chain reaction (R -PCR) assays may
also be used. T e other options are incorrect.
HELPFUL TIP:
Bron hioli is is lini l i gnosis h oes no require
ny i gnos i es ing.
HELPFUL TIP:
Never give rib virin or he re men o RSV. I oesn’
work.
Question 13.13.4 Which o the ollowing is indicated or the
prevention o RSV in high risk in ants?
A) Vaccination against RSV.
B) Oral ribavirin.
C) Rimantadine or oseltamivir.
D) Palivizumab (Synagis®)
E) RSV–IVIG (RespiGam)
Answer 13.13.4 The correct answer is “D.” Palivizumab is a
licensed prophylactic monoclonal antibody against RSV that is
given via monthly intramuscular injection to high-risk patient
populations during the RSV season. Potential quali ying in ants
include those with associated prematurity, signi cant congeni-
tal heart disease, neuromuscular disorders, or chronic lung dis-
ease. Administration o palivizumab usually begins be ore RSV
season begins and then is given monthly or a maximum o
5 doses. RSV–IGIV, or RespiGam, is no longer used. T ere is
no current RSV vaccine. None o the antiviral medications (“B”
and “C”) works or prevention or treatment o RSV.
Objectives: Did you learn to . . .
• Re ognize he lini l presen ion o p ien wi h RSV
bron hioli is?
• d i gnose n re RSV bron hioli is?
• d es ribe wh p ien s m y possibly bene rom rib virin
(none!) n RSV prophyl xis?
CASE 13.14
A 4-week-old in ant presents to your o ce with his parents.
T e parents note that he vomits every time he eats. His vomi-
tus is mostly ormula and nonbilious. He seems to be hungry
and is demanding to be ed o en. Except or the vomiting, he
seems to be well without diarrhea. Examination reveals an
a ebrile in ant in no distress with normal cardiac and pul-
monary examinations and a relatively benign abdomen. His
weight today is unchanged rom a weight taken in your o ce
2 weeks ago. T ere is no “olive” palpable (it must be in the
martini you’re drinking as you’re reading through this book).
Question 13.14.1 Your working diagnosis is:
A) Midgut volvulus.
B) Gastroenteritis.
C) Pyloric stenosis.
D) CNS injury with increased intracranial pressure.
Answer 13.14.1 The correct answer is “C.” T is most likely
represents idiopathic hypertrophic pyloric stenosis. T e classic
presentation o pyloric stenosis is nonbilious vomiting immedi-
ately a er eeding, ollowed by a demand to eed again soon a er
(much the same as a teenager . . . the demand o eeding, not the
vomiting). T e symptoms are progressive. Initially, the vomit-
ing may or may not be projectile and may occur a er every eed
or intermittently. Classically, pyloric stenosis occurs in in ants
2 weeks to 2 months o age. “A,” midgut volvulus, is unlikely
because these patients have bilious vomiting. Our patient has
nonbilious vomiting. “B,” gastroenteritis, is not likely because
there is no diarrhea, ever, or appetite loss. “D” is unlikely. While
CNS injury with increased intracranial pressure and vomiting
is a possibility, you would expect to see other evidence o CNS
injury such as lethargy, possibly signs o head injury, etc. Note
that this patient’s weight is unchanged rom 2 weeks ago . . . . . it
should be higher than 2 weeks ago.
Question 13.14.2 Which o the ollowing patients is most
likely to present with pyloric stenosis?
A) A rst born male.
B) A rst born emale.
C) A second born male.
D) A second born emale.
E) T e rate o pyloric stenosis is equal in all o these groups.
Answer 13.14.2 The correct answer is “A.” T ere is a
4:1 male: emale preponderance, and about 30% o all cases
occur in a rst born child. T us, rst born males are at a par-
ticular risk or pyloric stenosis. Also, amily history is important
as in ants born to a mother or ather who had pyloric stenosis
are at increased risk.
You give the patient a bolus o IV normal saline and decide to
con rm the diagnosis with a Gastrogra n test.
Question 13.14.3 What are you most likely to see on radio
graph i this patient has pyloric stenosis?
A) “Bullseye” or “target” lesion.
B) Corkscrew pattern o small bowel.
C) Ulcerations o the gastric mucosa.
D) “String” sign.
E) Rapid lling o the bowel distal to the pylorus.
Answer 13.14.3 The correct answer is “D.” T e string sign is
ormed when contrast material trickles through the elongated
pyloric channel (and thus looks like a thin string on x-ray). “A,”
“bullseye” or “target” lesion, is seen on ultrasound with intus-
susception. “B,” a corkscrew pattern, is seen with midgut volvu-
lus. Ulcerations o the gastric mucosa are seen, o course, with
gastric ulcers. “E” is obviously not true. T e whole problem with
pyloric stenosis is that little or anything can get rom the stom-
ach to the small bowel. Ultrasound can also be used to make the
diagnosis o pyloric stenosis. Ultrasound is o en the rst test
ollowed by a contrast study i needed. Physical examination is
o en unreliable (when have you actually elt that “olive”?). Do
an imaging study i you have any concern or pyloric stenosis.

HELPFUL TIP:
t he e ini ive re men or pylori s enosis is surgi l.
However, i is n urgen , bu no emergen , surgi l in-
i ion. M ke sure o ke he ime o orre lui n
ele roly e bnorm li ies prior o surgery.
You have a surgical consultant see the patient, pyloromyot-
omy is done, and everybody is happy.
Objectives: Did you learn to . . .
• I en i y lini l m ni es ions o pylori s enosis?
• d i gnose n m n ge pylori s enosis?
QUICK QUIZ: PEd Iat RIc BELLY Pa IN
T e treatment or midgut volvulus is:
A) Watch ul waiting.
B) Maneuver o Leopold.
C) Emergent surgery.
D) Air enema.
E) Nasogastric suction and bowel rest.
The correct answer is “C.” Midgut volvulus is a surgical emer-
gency. Midgut volvulus is an anatomical twisting o the bowel
and needs to be surgically corrected. It presents with recurrent
bilious vomiting; bilious vomiting in an in ant should prompt
you to rule out mid-gut volvulus. None o the others are cor-
rect. Watch ul waiting is dangerous and risks ischemic bowel
with per oration, so “A” and “E” are wrong. Leopold maneuvers
are used to move a breech pregnancy to vertex and have noth-
ing to do with the bowel. “D,” air enema, can be used to reduce
an intussusception but has no role in the treatment o midgut
volvulus. “E” nasogastric suction and bowel rest are the treat-
ment or a small bowel obstruction (though NG is not really
help ul except to ameliorate vomiting). Any bowel obstruction
in a child demands investigation.
CASE 13.15
A 5-year-old male who was recently diagnosed with inf u-
enza presents to your ED with complaints (via the parents)
o intractable vomiting and mental status changes. On exam-
ination, the child is ebrile and is vomiting but has neither
meningeal signs nor ocal neurologic ndings. His liver is
palpable.
Question 13.15.1 Inf uenza is associated with which o the
ollowing complications?
A) Pneumonia.
B) Rhabdomyolysis.
C) Myocarditis.
D) Encephalitis
E) All o the above.
CHAPTER 13 • PEd Ia t RIc S 387
Answer 13.15.1 The correct answer is “E.” All o the above can
be a result o in uenza. Pneumonia may be viral or due to a
secondary bacterial superin ection. Patients may present with
in uenza-related severe leg pain secondary to rhabdomyoly-
sis; the CK will be elevated. Myocarditis can present with CHF,
arrhythmias, and sudden death; myocarditis can also be sub-
clinical. Obviously, encephalitis will present with mental status
changes.
You get labs on this patient. He is noted to be hypoglycemic
and to have markedly elevated liver enzymes. His bilirubin is
normal. T e patient’s white blood cell count and di erential
suggest a viral illness.
Question 13.15.2 The MOST LIKELY diagnosis based on this
patient’s history, physical, and laboratory ndings is:
A) Reye syndrome.
B) Bacterial meningitis.
C) ransverse myelitis.
D) Hepatic encephalopathy secondary to hepatitis.
E) Diabetes mellitus in the “honeymoon” period with Somogyi
phenomenon.
Answer 13.15.2 The correct answer is “A.” T is patient most
likely has Reye syndrome (encephalopathy with atty liver de-
generation). Reye syndrome presents with intractable vomit-
ing, elevated transaminases with a normal bilirubin level, hypo-
glycemia, and mental status changes (excitability, delirium,
coma). Reye syndrome generally occurs in a genetically sus-
ceptible person associated with a viral illness such as in uenza
or chickenpox who has been given aspirin. T is patient is not
likely to have meningitis given the absence o an elevated white
count and lack o meningeal signs. Also, he clearly does not
have transverse myelitis, an autoimmune condition producing
rapidly progressive weakness and sensory disturbance. “E” is
incorrect since the Somogyi phenomenon re ers to stress hor-
mone-induced morning hyperglycemia in a patient on insu-
lin who is having unrecognized hypoglycemia at night (and,
much like the Loch Ness Monster, does not actually exist . . . see
Chapter 10).
Question 13.15.3 The medication MOST associated with
Reye syndrome is:
A) Ibupro en.
B) Celecoxib (Celebrex).
C) Aspirin.
D) Acetaminophen.
E) Naproxen.
Answer 13.15.3 The correct answer is “C.” T e use o aspirin
in a child with a viral illness, classically in uenza or chicken-
pox, has been associated with the development o Reye syn-
drome. O note, the incidence o Reye syndrome has been
steadily declining now that parents are aware that they should
avoid aspirin use in children. Reye syndrome is now a very rare
disease.
388 Fa MILY MEd Ic INE EXa MINa t ION & BOa Rd REVIEW
TABLE 13-6 CAUSES OF HEME POSITIVE STOOLS
IN CHILDREN
Less than 1 year: Sw llowe m ern l bloo (espe i lly i he hil
is v mpire), n l ssure, in ussus ep ion, uo en l or g s ri
ul ers, g ngrenous bowel, Me kel iver i ulum, ow milk pro ein
in oler n e
More than 1 year: c olon polyps, ul ers, n l ssure, esoph ge l
v ri es, in ussus ep ion, hemorrhoi s, sw llowe epis xis,
M llory–Weiss e rs, b eri l en eri is.
HELPFUL TIP:
t he re men o Reye syn rome is suppor ive n in-
lu es on rolling hypogly emi n re ing erebr l
e em . t here is no spe i i re men o his illness. t he
mor li y r e rem ins high. Surviving p ien s shoul
be s reene or n un erlying y i oxi ion
ee .
For some reason, you ound heme positive stool in this
patient. You must have been thinking that every patient
deserves at least one rectal examination.
Question 13.15.4 All o the ollowing are relatively common
causes o heme positive stools in children 1 to 5 years o
age EXCEPT:
A) Colon polyps.
B) Ulcers.
C) Swallowed epistaxis.
D) Gangrenous bowel.
E) Intussusception.
Answer 13.15.4 The correct answer is “D.” Gangrenous bowel
tends to be ound in neonates and younger in ants < 1 year old
as a result o necrotizing enterocolitis, midgut volvulus, etc.
All o the others are correct. See able 13-6 or more causes o
occult GI blood loss in children.
Objectives: Did you learn to . . .
• Re ognize sequel e o inf uenz in e ion?
• d es ribe Reye syn rome?
• M n ge p ien wi h Reye syn rome?
• I en i y some uses o heme posi ive s ools in hil ren?
CASE 13.16
A mother comes to you with concerns about SIDS in her
in ant. Evidently, her sister had a child who died o SIDS, and
she is concerned that her child is now at elevated risk.
Question 13.16.1 You can tell her which o the ollowing?
A) win concordance studies suggest SIDS is a genetic disorder.
B) Since her child is now 5 months old, there is no risk o SIDS
since SIDS generally occurs be ore 3 months o age.
C) Siblings o an in ant with SIDS have a ve old increase in the
risk o SIDS.
D) SIDS is more likely to occur in emale in ants.
E) Young maternal age (< 20 years old) is associated with
reduced risk o SIDS.
Answer 13.16.1 The correct answer is “C.” A sibling o child
who died with SIDS has a ve old increased risk o dying o SIDS
(although the absolute risk is still less than 1%). “A” is incorrect.
T e cause o SIDS is unknown. Abnormal arousal rom sleep
may play a role. SIDS does not seem to be an isolated genetic
disorder. “B” is incorrect. SIDS generally occurs between 2 and
4 months (median age 11 weeks). However, 90% o cases occur
be ore 6 months o age, so a 5-month-old child is still at risk.
“D” is incorrect as it is more common in males with a ratio o
3:2. Finally, the opposite o “E” is true: maternal age < 20 years
old is a risk actor as is maternal smoking and the in ant’s sleep-
ing position.
Question 13.16.2 All o the ollowing have been associated
with an increased incidence o SIDS EXCEPT:
A) Side-sleep positioning.
B) Prone-sleep positioning.
C) Early introduction o solid oods.
D) Premature birth.
E) Intrauterine exposure to drugs.
Answer 13.16.2 The correct answer is “C.” T e introduction
o solid oods has nothing to do with the development o SIDS.
All o the other actors increase the rate o SIDS. O note, any
nonsupine sleeping position is associated with an increased
incidence o SIDS.
Question 13.16.3 The most important advice you can give
to prevent SIDS is:
A) Avoid eeding close to bedtime to reduce aspiration risk.
B) Place the child in the prone position (stomach and ace
down) when sleeping.
C) Use a child alarm in the room to alert the parent(s) i some-
thing is wrong.
D) Place the child in the supine position (stomach and ace up)
when sleeping.
E) Use sheepskin or polystyrene bedding to prevent su oca-
tion.
Answer 13.16.3 The correct answer is “D.” Having the in ant
sleep in a supine position (“back to sleep”) reduces the risk o
SIDS by up to 50%. “B” (prone sleeping position) and “E” (poly-
styrene or sheepskin bedding) increase the risk o SIDS. Smok-
ing cessation is important as smoking during pregnancy or a er
increases the risk o SIDS. Co-sleeping should be discouraged as
it increases the risk o SIDS.
HELPFUL TIP:
t he use o p i iers in be u lly e re ses he risk
o SId S s well. Give i o he hil when he or she is
pu own or sleep. d o no reinser i on e he hil is
sleep i he/she spi s i ou .

HELPFUL (AND SCARY) TIP:
No hing is ree (espe i lly he bo r ex min ion . . . how
mu h re you p ying or h su ker?). Supine sleeping
h s in re se he r e o posi ion l pl gio eph ly ( l -
ening o he he , in his se in he o ipi l region).
t his risk n be minimize by pl ing he hil in
prone posi ion while awake and supervised ( om-
monly re erre o s “ ummy ime”). Helme s o re orm
he sh pe o he skull h ve been shown no o work
(BMJ. 2014;348:g2741).
Objectives: Did you learn to . . .
• I en i y risks o SId S?
• Give vi e on how o re u e he risk o SId S?
CASE 13.17
T e parents o a 1-month-old emale bring the in ant or her
routine check-up. T ey are rst time parents and are con-
cerned about eeding. Evidently, one o the grandmothers
is “ rom the old country”. Back in her day in the “old coun-
try,” they would start children on solid oods at 2 months o
age—usually starting with strained liver (lots o vitamins
and stu plus it is disgusting and the adults wouldn’t eat it).
T is grandmother also cannot gure out why the couple is
wasting their money on ormula when cow’s milk (better yet,
goat’s milk when available) “worked just ne or me.” T ey
would like your advice about eeding.
Question 13.17.1 You let them know that:
A) Solid oods should be introduced at 3 months or all chil-
dren. wo months o age is too soon. And grandma’s right.
Start with liver.
B) Cow’s milk is considered adequate only a er 6 months
o age.
C) Early introduction o cow’s milk has been irre utably linked
to type 1 diabetes mellitus.
D) T e rst oods introduced should be strained meats.
E) Children should have good head control be ore solid oods
are introduced.
Answer 13.17.1 The correct answer is “E.” Doesn’t “E” just
sound best? We mean, even i you hadn’t a clue, you would still
pick “E,” right? Children should have good head control be ore
starting solid oods. “A” is incorrect or several reasons. First,
solid oods are generally not recommended until 4–6 months
o age. Second, note that the answer says “all children.” T ird,
the answer involves liver. Liver is disgusting no matter what
age . . . don’t oist it on a trusting, unsuspecting, in ant. “B” is
incorrect. Cow’s milk should be avoided or the rst year o li e.
Breast eeding is optimal and in ant ormula is another good
option i mom decides not to breast eed; ormula contains addi-
tional nutrients not ound in cow’s milk. In addition, the early
use o cow’s milk has been linked to an increase in gastrointes-
tinal blood loss and iron de ciency anemia. “C” is incorrect.
CHAPTER 13 • PEd Ia t RIc S 389
T ere has been some observational evidence to suggest a con-
nection between diabetes type 1 and cow’s milk, but the data are
quite suspect. “D” is incorrect. Foods should be introduced one
at a time, but there is no requirement as to what the rst ood
should be. Usually, iron orti ed cereals are introduced rst.
HELPFUL TIP:
In ro u ing Foo s n Foo a llergy: c on r ry o wh
m ny o us h ve been ugh , he e rly in ro u ion
o llergens su h pe nu s seem o reduce he risk o
subsequen llergy (N Engl J Med. 2015;372:803–813).
Whe her his ex en s o o her oo s is no known. Bu
i is le s re son ble o in ro u e possibly llergeni
oo s (pe nu s, whe ) e rly.
HELPFUL TIP:
a a P gui elines re ommen 400 IU/ y o vi min d
rom bir h hrough he een ge ye rs, no ex ep ions.
t his n ome ei her rom supplemen s or oo s. Bre s
milk oes no on in enough vi min d , n ex lusive-
ly bre s - e in n s shoul be supplemen e in he irs
ew ys o li e.
T e parents manage to end o this grandmother (quite an
accomplishment, eh?). T e child continues on ormula eed-
ings. However, the child gets somewhat ussy on occasion and
has bouts o diarrhea. T e amily wants to know what to do.
Question 13.17.2 Your advice is to:
A) Change ormulas because this represents an allergy to the
cow’s milk ormula.
B) Do not change ormulas.
C) Change ormulas because this likely represents lactase de -
ciency.
D) Switch to a ormula based on short chain atty acids since
this likely represents an inability to absorb and metabolize
ats.
Answer 13.17.2 The correct answer is “B.” Children will occa-
sionally be ussy and have occasional diarrhea. T is does not
indicate a ormula allergy or intolerance. Re ux and spitting
up are also common in in ants. Again, this does not indicate
a ormula allergy. T e parents should be reassured that as long
as the child is growing and is not having signi cant di culties,
continuing the current ormula is acceptable.
HELPFUL TIP:
Remember, s no e bove, re lux or spi ing up oes
no me n ormul in oler n e. Do not make multiple
formula changes! t his me i lizes norm l p ern
in hil ren. t he m jori y o spi ing up n re lux will
resolve by 1 ye r o ge. I he hil looks well n is
growing, here is no nee o h nge he ormul .
390 Fa MILY MEd Ic INE EXa MINa t ION & BOa Rd REVIEW
T e parents decide that you are correct and continue to eed
the child the cow’s milk ormula. Much as you predicted, the
child does well on this ormula. However, the child is now
becoming “constipated” and the grandmother would like to
give this child a laxative (pre erably some concoction rom
the “old country” that no one else can pronounce or ormu-
late). She (the in ant, not the grandmother) is having only
one bowel movement per day rather than the 3 to 4 per day
that occurred during the rst several months o li e.
Question 13.17.3 You let the parents know that:
A) One stool a day is likely normal or this in ant.
B) An in ant having less than 2 to 3 bowel movements per day
is likely constipated since bowel transit time is only 8.5 hours
or so.
C) In ants ed soy-based ormula tend to have so er stools than
those ed cow’s milk ormula.
D) Breast ed in ants may normally have up to 10 stools per day.
E) A and D.
Answer 13.17.3 The correct answer is “E.” T e number o
bowel movements in a normal in ant can vary widely rom 10
per day in a breast ed in ant to 1 per day or every other day in
a ormula- ed in ant. What is more important is whether the
child has to strain to pass stool, how hard the stool is, etc. T e
number o stools per day is less important.
On urther questioning, it becomes clear that the grand-
mother may be correct. T is child is having a hard time pass-
ing stool and passes only small amounts o hard stool with
great e ort (red-purple ace, lots o crying, etc.). T e parents
would like some advice.
Question 13.17.4 Which o the ollowing is a reasonable
suggestion to treat this in ant’s constipation?
A) Change to a ormula with a preponderance o whey protein
such as Carnation Good Start.
B) reat with corn syrup (whatever brand is cheapest).
C) Add ruit juices i the child is older than 2 months.
D) reat with lactulose.
Answer 13.17.4 The correct answer is “D.” Let’s look at this in
detail (since parents will tell you all o the details o their child’s
stools and o en bring in a “sel e” o the stool . . . . don’t tell us it
hasn’t happened!). “A”, whey protein”, was thought in the past
to ease constipation. T is has turned out not to be the case. “B”
is problematic or a di erent reason. Many corn syrups in the
past contained glycoproteins that were metabolized into non-
absorbable sugars. T is is no longer true or many corn syrups;
the ormulation has changed. Fruit juices contain sorbitol and
are e ective. However, they should not be used under the age
o 4 months. Beyond that age, sorbitol-containing juices such
as pear, prune, or apple may be used to treat constipation. As
an aside, glycerin suppositories can be used sparingly or very
hard stool in the rectum. Routine use o glycerin suppositories
may lead to tolerance (a dependence on manual stimulation to
stool) as well as irritation o the rectal and anal mucosa. Finally,
polyethylene glycol solution is reasonable in those greater than
4 months o age as are sorbitol containing purees such as prunes
(assuming the child is taking solids).
T e child does well a er the parents implement your lactu-
lose plan, but she continues to have some ref ux symptoms.
T is is getting worrisome to the parents although the child is
growing well.
Question 13.17.5 Which o the ollowing IS recommended
as standard therapy in treating this child’s ref ux?
A) Prone positioning o the child when sleeping.
B) rial o hypoallergenic diet.
C) Use o a proton pump inhibitor.
D) Elevating the head.
E) T ickening the ormula with rice cereal.
Answer 13.17.5 The correct answer is “E.” T ickening the or-
mula may be help ul. Placing the child in prone position while
sleeping increases the risk o SIDS. Neither a hypoallergenic
diet, an H 2 blocker, a proton pump inhibitor, nor elevating the
head has been shown to reduce re ux. In act, elevating the head
(as in a car seat) may increase re ux.
HELPFUL TIP:
In in n s wi h g s roesoph ge l re lux disease (weigh
loss, e ., no jus physiologi re lux), ri l o milk n
soy pro ein- ree ie or 1 o 2 weeks is re son ble. H2
blo kers n PPIs h ve lso been use bu wi h very lim-
i e su ess. Prokine i gen s su h s me o lopr mi e
n ery hromy in help improve g s ri emp ying, bu
s u ies h ve ile o show mu h e i y or GERd . In
2009, he Fd a issue bl k box w rning linking hron-
i me o lopr mi e use wi h r ive yskinesi .
Objectives: Did you learn to . . .
• Give ppropri e vi e or nu ri ion n ee ing uring
in n y?
• d i gnose n m n ge ons ip ion in in n y?
• t re n in n wi h signi n g s roesoph ge l ref ux?
CASE 13.18
A 23-year-old G2P1 emale at 31 weeks o gestation pres-
ents to the ED and delivers precipitously. Her pregnancy was
uncomplicated. T e neonate is a 1.25-kg male. T e helicop-
ter is on its way to transport this premature in ant to your
regional pediatric hospital. However, it is going to be at least
3 hours because o weather concerns.
Question 13.18.1 In the meantime, the BEST treatment or
this newborn is:
A) Antibiotics.
B) Corticosteroids.
C) High-pressure 100% oxygen.

D) Routine care (warmth, stimulation, etc.) and nothing else.
E) Sur actant.
Answer 13.18.1 The correct answer is “E.” Without any urther
in ormation, you must assume that this patient is at signi cant
risk or neonatal respiratory distress syndrome (RDS). T e appro-
priate treatment is sur actant. T e dose o sur actant depends
on the preparation, and the timing o administration varies by
source (some authors avor immediate administration “pro-
phylaxis,” while others recommend “early rescue” treatment—
usually within 2 hours o delivery). Sur actant therapy has good
evidence or decreasing morbidity and mortality and should be
used in all premature in ants who are at risk or RDS (see next
question) or acutely symptomatic. On the basis o synergistic
interactions, experts recommend combination therapy with
antenatal corticosteroids or the mother (i possible . . . see Chap-
ter 15) and sur actant or the premature in ant. “A” is incorrect
as it is not the most important initial therapy although empiric
antibiotic therapy is o en indicated in premature in ants due
to di culty in distinguishing between RDS and sepsis. “B” is
incorrect because steroids or the newborn in ant are associated
adverse neurodevelopmental outcomes. As or “C,” excessive
oxygen can be toxic to premature in ants, and initial resuscita-
tion should begin with blended oxygen or room air. “D” might
be the second best option i sur actant were unavailable but note
that it says “and nothing else.” It is highly unlikely this premature
in ant would be in need o “nothing else” (college tuition may be
nice). Sur actant is undoubtedly indicated here.
HELPFUL TIP:
Sur n h s been shown o e re se ir le ks n
mor li y rom Rd S bu oes no e re se he in i en e
o hroni lung ise se or bron hopulmon ry yspl si .
Question 13.18.2 All o the ollowing are risk actors or
neonatal RDS EXCEPT:
A) Cesarean section.
B) Gestational diabetes.
C) Male sex o in ant.
D) Prolonged rupture o membranes.
Answer 13.18.2 The correct answer is “D.” Prolonged rupture
o membranes is associated with a decreased risk o neonatal
RDS. All o the others are associated with an increased risk. O
course, increasing prematurity is associated with increasing risk
o RDS as is multi etal pregnancy, especially in the second etus
delivered in a twin pregnancy.
HELPFUL TIP:
t he le i hin/sphingomyelin (L/S) r io is he r i ion l
me ho or ssessing e l lung m uri y. I he L/S r io
is > 2, he risk o Rd S is low. O her op ions in lu e phos-
ph i ylgly erol level n ire sur n me sures. I
is impor n o re lize h hese es s h ve irly low-
posi ive pre i ive v lues.
CHAPTER 13 • PEd Ia t RIc S 391
HELPFUL TIP:
a s prem ure in n s grow in o ul s, keep n eye on
heir bloo pressures n glu ose levels. In n s who
were born prem urely n very low bir h weigh
(< 1.5 kg) h ve more problems wi h hyper ension n
glu ose in oler n e s ul s.
Because o your congenial bedside manner and amazing
command o medical knowledge, this amily returns to see
you many times over the ensuing years. A er looking at your-
sel in the mirror and ref ecting on how awesome you are,
you turn your attention to the newest addition to the am-
ily, a 4-day-old male in ant you delivered—this time in the
labor and delivery unit and at term. Gestation and delivery
were uncomplicated. He is breast ed and was doing well until
this morning. Un ortunately, his mother noticed today that
he is breathing harder, eating poorly, and looking more yel-
low. You note a respiratory rate o 72 and crackles on lung
examination, so you order a chest x-ray.
Question 13.18.3 Which o the ollowing diagnoses is most
likely?
A) Neonatal RDS.
B) Persistent pulmonary hypertension.
C) Pneumonia.
D) Pneumothorax.
E) ransient tachypnea o the newborn.
Answer 13.18.3 The correct answer is “C.” Pneumonia is more
likely than the other options because o the timing o the symp-
toms. Neonatal pneumonia may be early (within the rst week
o li e) or late onset. T e pathogenic organisms involved are di -
erent or early and late disease. Patients presenting with early
onset pneumonia are more likely to have acquired the in ection
in utero or during delivery; GBS is the most common patho-
gen in these cases. Patients presenting with late pneumonia
may have acquired the disease during delivery, during hospi-
talization, or while in the community; GBS, E. coli, S. aureus,
Listeria, HSV, and Chlamydia may all cause pneumonia in these
patients. “A” is incorrect since RDS should not occur in a ull-
term in ant nor present this late. “B” is incorrect because persis-
tent pulmonary hypertension should present shortly a er birth
with hypoxemia and cyanosis. “D,” pneumothorax, is a com-
mon result o birth trauma; up to 2% o in ants may sustain a
pneumothorax during delivery. However, very ew in ants with
a pneumothorax are symptomatic, and you would expect the
symptoms to occur shortly a er delivery. In addition, breath
sounds would be absent or diminished, and there would not be
rales. “E” is incorrect because transient tachypnea is a result o
delayed reabsorption o alveolar uid, occurs with 1 to 2 hours
o birth and resolves on its own.
You ound your rectal thermometer, and it turns out that
your patient is ebrile. T e chest x-ray shows a le lower lobe
in ltrate.
392 Fa MILY MEd Ic INE EXa MINa t ION & BOa Rd REVIEW
Question 13.18.4 Which o the ollowing antibiotics is
LEAST appropriate in this setting?
A) Ampicillin.
B) Ce riaxone.
C) Gentamicin.
D) Vancomycin.
Answer 13.18.4 The correct answer is “B.” Ce riaxone is con-
traindicated in neonates. Ce riaxone displaces bilirubin rom
albumin-binding sites resulting in more severe hyperbilirubine-
mia and the risk o bilirubin encephalopathy (this in ant is jaun-
diced). Ce riaxone may cause atal precipitates in the lung and
kidney when co-administered with calcium (perhaps not an
immediate concern or this patient). Ce otaxime may be used,
but this is not given as a choice. It would be prudent to provide
empiric antibiotic coverage or all likely bacterial pathogens.
T e combination o ampicillin and gentamicin is pre erred or
coverage o GBS, Gram-negative enteric bacteria, and Listeria.
Due to the potential or MRSA to cause pneumonia in the neo-
natal period, vancomycin is reasonable but should not be used
alone.
HELPFUL TIP:
Remember he possibili y o sus ine p roxysm l su-
pr ven ri ul r hy r i wi h c HF in he in n who
is hypnei . t hese hil ren o en presen wi h poor
ee ing, we kness, hypne , n r les. t re men
in lu es v g l m neuvers (su h s pl ing b g o i e
over he e or 15 o 30 se on s . . . . n w hing he
horror on he p ren s’ es s hey hink you re su -
o ing he ki ). O her op ions in lu e r ioversion
n enosine.
Objectives: Did you learn to . . .
• Provi e ppropri e re men o n in n risk or neon -
l Rd S?
• I en i y risk ors or neon l Rd S?
• d es ribe uses o respir ory is ress in he neon l
perio ?
• Ini i e re men or neon l pneumoni ?
CASE 13.19
A 20-day-old ormer term male in ant is brought to the clinic
or evaluation o ever. He was born via uncomplicated vagi-
nal delivery. Mom was GBS negative. In clinic, the in ant has
a temperature o 38.5°C but is otherwise vigorous with nor-
mal vital signs.
Question 13.19.1 What should be done next?
A) Discharge home with ollow-up the next day.
B) reat with empiric antibiotics. Cultures are not necessary or
this age group.
C) Obtain a chest x-ray.
D) Admit to the hospital.
E) reat with ibupro en.
TABLE 13-7 EVALUATION OF THE FEBRILE NEONATE
Age < 7 days: a LL shoul re eive ull workup in lu ing urine, bloo
ul ures, LP wi h ul ures, c Bc , c XR, mpi illin + gen mi in. a mi .
Age 7–28 days: a LL shoul re eive ull workup in lu ing urine,
bloo ul ures, LP wi h ul ures, c Bc , c XR in hose wi h respir ory
symp oms. a mpi illin + e o xime or mpi illin + gen mi in.
a mi .
Age 28–60 (or 90) days:
Well appearing: Urine wi h ul ure; c Bc (WBc o 5,000–15,000 and
< 500 b n s sugges s lower risk o in e ion); LP no nee e i hil
is well looking wi h reli ble ollow-up; c XR i respir ory r e
> 50, r les, rhon hi, o her respir ory symp oms → I workup is low
risk onsi er e ri xone 50 mg/kg × 1 ose n re urn visi he
nex y or re he k. I high risk b se on c Bc , e . mi (see bx
hoi e below).
Ill appearing: c Bc , LP, Ua in lu ing urine, bloo n c SF ul ure, c XR
i ny respir ory symp oms (see bove), c e ri xone + a mpi illin.
a v n omy in i c SF is bnorm l. a mi o hospi l.
Answer 13.19.1 The correct answer is “D.” Fever in a neo-
nate (younger than 28 days) or young in ant (age 29–90 days)
is de ned as a temperature 38°C or 100.4°F (rectal) or higher.
Up to 15% o ebrile neonates and young in ants will have a
serious bacterial in ection such as bacteremia, urinary tract
in ection, meningitis, pneumonia, osteomyelitis, septic arthri-
tis, omphalitis, mastitis, or scalp abscess. U I is the most
common. T e in ant may appear well with ever being the
only mani estation o a serious in ection. Risk strati cation
is based on age, co-morbidities, laboratory studies, and the
presence o viral in ection such as bronchiolitis. T ere is
no clear consensus on the best approach to evaluating and
managing ebrile in ants younger than 90 days. Currently,
all ebrile neonates, ill appearing in ants, or those not meet-
ing low-risk criteria should be admitted or a ull evaluation
(including UA, LP, CBC, blood cultures) and empiric antibi-
otic therapy. “B” is incorrect as cultures should be obtained
prior to antibiotic therapy. You may obtain a chest x-ray as
part o your evaluation, but the best answer is admission.
Ibupro en is not approved or use in in ants younger than
6 months. See able 13-7 or evaluation o a ever in a child 7
to 90 days o age.
T e patient is admitted. Blood work including a complete
blood count and blood culture is obtained. Urinalysis and
urine culture are obtained via sterile catheterization. A
lumbar puncture is per ormed a er obtaining consent (o
course) and cerebrospinal f uid is sent or culture and analy-
sis. (Use lidocaine or the LP even in these young in ants . . . . it
hurts!)
Question 13.19.2 While waiting or your laboratory testing
results what empiric antibiotics will you start?
A) Ampicillin and clindamycin.
B) Gentamicin.
C) Vancomycin and metronidazole.
D) Ce riaxone
E) Ampicillin and ce otaxime.

Answer 13.19.2 The correct answer is “E.” T e choice o
empiric antibiotics is based on most likely in ecting bacterial
organisms in a patient o this age. Bacterial in ections in neo-
nates likely were acquired during delivery. T e most common
organisms are GBS, E. coli, and Listeria monocytogenes. Empiric
treatment should be with ampicillin and ce otaxime or ampi-
cillin and gentamicin. Ampicillin provides coverage or Liste-
ria and enterococci. Broadened coverage should be considered
depending on ocus o in ection and i Gram-positive cocci are
seen on CSF Gram stain, vancomycin should be used instead o
ampicillin. Empiric acyclovir treatment should be considered i
signs and symptoms o HSV in ection are present.
While examining the patient, you notice he is not moving his
right arm. When you ask the mom, she believes that is new
but is unsure when he stopped using it. Examination reveals
tenderness over the right proximal humerus with overlying
redness, swelling, and pain with moving the shoulder joint, a
symmetric Moro ref ex, and intact grasp ref ex.
Question 13.19.3 What is the likely cause?
A) Erb palsy.
B) Klumpke palsy.
C) Humerus racture.
D) Osteomyelitis.
E) Cerebral vascular incident.
Answer 13.19.3 The correct answer is “D.” Fever, pseudopa-
ralysis (reluctance to move a ected limb) and swelling with ery-
thema o the a ected area is concerning or osteomyelitis with
associated septic arthritis. Osteomyelitis, an in ection o the
bone, usually results rom hematogenous seeding. In ants have
blood vessels that cross the growth plate allowing or bone in ec-
tions to spread to the adjacent joint resulting in septic arthritis.
S. aureus is the most common cause o osteomyelitis in all pedi-
atric age groups. H. in uenzae is less common since immuniza-
tions were begun; however, until culture results are available,
it should be covered empirically in children aged 6 months to
4 years who have not yet completed their immunization series.
GBS and Gram-negative rods such as E. coli are seen in neonates
and should be covered empirically. “A” and “B” are types o bra-
chial plexus injuries rom birth trauma that result in paralysis
and an asymmetric Moro re ex due to peripheral nerve injury.
“C,” a humerus racture, though rare can occur as a result o
birth trauma but is unlikely based on delayed presentation. “E”
is incorrect as most neonatal strokes present with seizures and
or altered mental status. O note, the normal Moro and grasp
re exes in this child point us away rom true paralysis.
HELPFUL TIP:
Neon es wi h os eomyeli is re ommonly ebrile
n presen wi h nonspe i i symp oms su h s irri -
bili y, e re se movemen o limb (pseu op r lysis),
or p in wi h moving he e e ex remi y ( hink p in
uring i per h nge). O en he i gnosis is el ye
n mis i gnose irs s r um i injury.
CHAPTER 13 • PEd Ia t RIc S 393
HELPFUL TIP:
Neon l os eomyeli is o en involves mul iple bones.
You discuss your concerns with the mother.
Question 13.19.4 She asks you how you will you diagnose a
bone in ection? Your response is:
A) Clinically.
B) With cultures.
C) With x-ray.
D) With MRI.
E) All o the above.
Answer 13.19.4 The correct answer is “E.” Osteomyelitis is a
clinical diagnosis requiring you to think about it in your di er-
ential. Cultures and imaging con rm the diagnosis. T ere is no
speci c laboratory test. Frequently, a leukocytosis with le shi
and reactive thrombocytosis are present. In ammatory mark-
ers, including C-reactive protein and erythrocyte sedimenta-
tion rate, are usually elevated; CRP can be ollowed to docu-
ment response to therapy; ESR takes too long to change to be o
much use in monitoring treatment. Cultures o the blood, joint
uid, and/or bone are positive in 50% to 80%. Plain x-rays can
rule out other causes such as a racture but are o en not use ul
in early osteomyelitis as it can take up to 10 days to see changes
such as a lytic lesion. MRI is the best imaging study allowing
or abscess detection and di erentiation between bone and so -
tissue in ection. MRI o en requires sedation and is expensive. A
radionuclide bone scan is help ul or poorly localized pain and
or concerns about multiple bone involvement. Ultrasound can
be help ul in septic arthritis.
You consult your pediatric orthopedic colleagues who take
the in ant to the operating room to wash out the joint and
obtain cultures. An x-ray shows a lytic lesion in the proximal
humerus.
Question 13.19.5 Cultures o the joint and bone grow GBS.
What is the length o antibiotic treatment?
A) 7 days.
B) 10 days.
C) 4 weeks.
D) 3 months.
E) 1 year.
Answer 13.19.5 The correct answer is “C.” Acute osteomyelitis
is treated with antibiotics or a minimum o 3 weeks with most
courses lasting 4 to 6 weeks. T e majority o patients may be
treated initially with intravenous antibiotics ollowed by transi-
tion to oral antibiotics a er clinical improvement and lack o
contraindication to oral therapy. In neonates, the entire course
is requently completed intravenously due to lack o clinical
trials. Even with appropriate treatment, neonatal osteomyelitis
394 Fa MILY MEd Ic INE EXa MINa t ION & BOa Rd REVIEW
may result in permanent de ormities to the bone or joint with
resulting decreased range o motion, asymmetric limb length,
and abnormal gait; there ore, long-term ollow-up is manda-
tory. Note: Now that she has had one child with invasive GBS
disease, mom will need GBS prophylaxis during all uture labors
i she were to get pregnant again.
HELPFUL TIP:
a n ibio i prophyl xis uring l bor e re ses he in i-
en e o e rly onse GBS ise se (wi hin he irs 7 ys
o li e) bu oes no e l e onse GBS ise se (7 ys
o 3 mon hs o ge). See c h p er 15 or in i ions or
n ibio i prophyl xis or GBS uring l bor.
Objectives: Did you learn to . . .
• Ini i e i gnos i inves ig ion n m n gemen s r egy
or ebrile in n younger h n 90 ys?
• d i gnose n m n ge os eomyeli is?
QUICK QUIZ: FEBRILE SEIZURE
You are evaluating a 10-month-old ully immunized child a er
a simple ebrile seizure. T e child has been previously healthy
and has not taken antibiotics recently. Physical examination is
unremarkable with no meningeal signs and a normal neuro-
logic examination.
What diagnostic testing should be per ormed?
A) Lumbar puncture.
B) EEG.
C) Neuroimaging such as head C or MRI.
D) Serum electrolytes.
E) None o the above.
The correct answer is “E.” Per the 2011 AAP guidelines, evalu-
ation o a simple ebrile seizure should ocus on identi ying the
cause o the ever. Meningitis should always be considered and
a lumbar puncture should be per ormed i meningeal signs or
symptoms are present. Previous recommendation was to per-
orm a lumbar puncture on all in ants younger than 12 months
who presented with a simple ebrile seizure. T is recommen-
dation was made be ore the widespread immunization against
H. in uenzae type b (Hib) and S. pneumoniae. Lumbar puncture
is an option in in ants 6 to 12 months o age who are not ully
immunized or i the immunization status is unknown. Consider
an LP in patients who have been on antibiotics because signs
o meningitis may be masked. Routine evaluation with EEG,
neuroimaging, serum electrolytes, or complete blood cell count
should not be done i the only reason is to identi y the cause o
the ebrile seizure.
Clinical Pearls
d o no gi e hil i you suspe epiglo i is s his m y
worsen irw y obs ru ion.
d o no per orm rou ine he im ging in hil wi h simple
ebrile seizure. d ire your inves ig ion ow r ev lu ion
n re men o he un erlying ever.
d o no pres ribe n ibio i s or vir l in e ions, in lu ing vir l
onjun ivi is n ol s.
d o no rou inely per orm Vc UG or he ev lu ion o irs
ebrile Ut I.
d o no use e ri xone in neon es s i ispl es bilirubin rom
lbumin bin ing si es n n use severe hyperbilirubinemi .
Ob in s reening l bs n bloo ul ures bir h ollowe by
minimum o 48 hours o n ibio i s in in n s born o mo h-
ers wi h horio mnioni is.
Per orm re l ex min ion in ev lu ing hil or ons i-
p ion n en opresis.
Per orm univers l he ring n me boli s reening in new-
borns.
Re ommen pl ing b bies “B k o Sleep” o re u e he risk
o SId S. t he i ion o in n home pne moni ors oes
no provi e i ion l bene i .
BIBLIOGRAPHY
Advisory Council on Immunization Practices. Birth-18 years
and “catch up” immunization schedules. Available at
http://www.cdc.gov/vaccines/schedules/hcp/child-
adolescent.html. Accessed September 24, 2015.
Bekkali NL, et al. Rectal ecal impaction treatment in child-
hood constipation: enemas versus high doses o oral PEG.
Pediatrics. 2009;124(6):e1108–1115.
Berg MD, et al. Part 13: pediatric basic li e support: 2010
American Heart Association guidelines or cardiopulmo-
nary resuscitation and emergency cardiovascular care.
Circulation. 2010;122(18, Suppl 3):S862–S875.
Brown ML, et al. reatment o primary nocturnal enuresis in chil-
dren: a review. Child Care Health Dev. 2011; 37(2):153–160.
Cohen-Silver J, Ratnapalan S. Management o in antile colic: a
review. Clin Pediatr (Phila). 2009;48(1):14–17.
Committee on In ectious Diseases, American Academy o
Pediatrics. Kimberlin DW, Brady M , Jackson MA,
Long SS, eds. Red Book: 2015 Report o the Committee
o In ectious Diseases. 30th ed. Elk Grove, IL: American
Academy o Pediatrics; 2015.
Du oit G, et al. Randomized trial o peanut consumption in
in ants at risk or peanut allergy. N Engl J Med. 2015;
372:803–813.
Fu LY, Moon RY. Apparent li e-threatening events (AL Es) and
the role o home monitors. Pediatr Rev. 2007;28(6):
203–208.
Gerber JS, O t PA. Vaccines and autism: a tale o shi ing
hypotheses. Clin In ect Dis. 2009;48(4):456–461.
Hoberman A, et al. Antimicrobial prophylaxis or children
with vesicoureteral re ux. N Eng J Med. 2014;370;
2367–2376.
Ingel nger JR, Stapleton FB. Antibiotic prophylaxis or
vesicoureteral re ux-answers, yet questions. N Eng J Med.
2014;370:2440–2441.

Kattwinkel J, et al. Part 15: neonatal resuscitation: 2010 Ameri-
can Heart Association guidelines or cardiopulmonary
resuscitation and emergency cardiovascular care.
Circulation. 2010;122(18, Suppl 3):S909–S919.
Kliegman RM, et al. Nelson extbook o Pediatrics. 19th ed.
Philadelphia, PA: Elsevier Saunders; 2011.
Lauer BJ, Spector ND. Hyperbilirubinemia in the newborn.
Pediatr Rev. 2011;32(8):341–349.
Mishori R, et al. Chlamydia trachomatis in ections: screen-
ing, diagnosis, and management. Am Fam Physician.
2012;86(12):1127–1132.
Moon RY, Fu LY. Sudden in ant death syndrome. Pediatr Rev.
2007;28(6):209–214.
Rappaport DI, et al. Should blood cultures be obtained in all
in ants 3 to 36 months presenting with signi cant ever?
Hosp Pediatr. 2011;1(1):46–50.
Russell KF, et al. Glucocorticoids or croup. Cochrane Database
Syst Rev. 2011;(1):CD001955.
Subcommittee on Urinary ract In ection, Steering Committee
on Quality Improvement and Management, Roberts KB.
Urinary tract in ection: clinical practice guideline or the
CHAPTER 13 • PEd Ia t RIc S 395
diagnosis and management o an initial U I in ebrile
in ants and children 2 to 24 months. Pediatrics. 2011;128(3):
595–610.
Sung V, et al. reating in ant colic with the probiotic Lactoba-
cillus reuteri: a double blind, placebo controlled random-
ized trial. BMJ. 2014;348:g2107.
abbers MM, et al. Evaluation and treatment o unctional
constipation in in ants and children: evidence-based
recommendations rom ESPGHAN and NASPGHAN.
J Pediatr Gastroenterol Nutr. 2014;58(2):258–272.
ieder JS, et al. Brie resolved unexplained events ( ormerly
apparent li e-threatening events) and evaluation o lower-
risk in ants. Pediatrics. 2016;137:e20160590.
van Wijk RM, et al. Helmet therapy in in ants with positional
skull de ormation: randomised controlled trial. BMJ.
2014;348:g2741.
Wan J, et al. Section on urology response to new guidelines or
the diagnosis and management o U I. Pediatrics. 2012;
129(4):e1051–1053.
Zaoutis L, Chiang V. Comprehensive Pediatric Hospital Medicine.
Philadelphia, PA: Mosby, Inc. 2007.
Adolescent Medicine
M gha C
CASE 14.1
A 14-year-old male presents to your clinic with his mother
or a routine well-child examination. T e patient’s mother
has some questions about puberty. Her son enjoys playing
sports and she is concerned that he may be too small to play
ootball. T e past medical history is unremarkable.
Question 14.1.1 Which o the ollowing can you tell the
mother will likely be the rst sign o puberty in this boy?
A) Increase in penile length.
B) Enlargement o the testes.
C) Deepening o the voice.
D) Rapid increase in linear growth.
E) Coarsening o pubic hair.
Answer 14.1.1 The correct answer is “B.” Increase in the vol-
ume o the testes is the rst sign o pubertal development in
boys. T e age o onset o puberty in the past was 12 years (range
10–14), but recent studies have shown that the mean age o onset
is now 1.5 to 2 years earlier than these historical norms. In a
study including more than 4,000 healthy boys, the mean age or
entering puberty was 10.14 years or Caucasian boys, 10.04 years
or Hispanic boys, and 9.14 years or A rican-American boys.
“E” is o special note. While pubic hair appears shortly a er
the onset o puberty, it is initially long and straight and not in
a mature distribution. Coarsening o the pubic hair is a more
advanced pubertal stage, occurring approximately 1.5 years a er
the onset o puberty; an increase in penile length occurs simulta-
neously. T e maximal growth spurt occurs approximately 2 years
a er the onset o puberty. Changing o the voice is a secondary
hormonal e ect that is quite variable in nature.
From the mother, you learn that the patient’s ather began
going through puberty during high school, and he did not
reach his adult height until he was in college at about age 20.
T e patient’s ather is 5′ 10′′ tall ( 178 cm). T e mother is 5′ 3′′
tall ( 160 cm). Physical examination reveals that your patient
is anner stage I or genitalia and pubic hair. His height and
396
14
weight continue to track along their previously established
curves on the growth chart, both at approximately the h
percentile. T e remainder o the examination is unremarkable.
Question 14.1.2 What is your next step in evaluation o this
patient’s short stature?
A) Obtain hand radiographs to assess bone age.
B) Draw blood to test or growth hormone and testosterone
levels.
C) Obtain an endocrinology consult.
D) Order computed tomography (C ) imaging o the brain to
rule out hypothalamic tumors.
E) Order magnetic resonance imaging (MRI) o the brain to
rule out hypothalamic tumors.
Answer 14.1.2 The correct answer is “A.” In the ace o a
normal physical examination and appropriate linear growth
velocity, the likelihood o an intracranial process is very low. An
assessment o bone age can be obtained easily, relatively inex-
pensively, and would be use ul prior to per orming other tests.
You decide to obtain a bone age, and the radiologist reports
bone age as 12 years and 3 months (remember that our
patient is 14 years old).
Question 14.1.3 What is the most likely diagnosis or your
patient?
A) Growth hormone de ciency.
B) Sella turcica tumor.
C) Constitutional delay o growth and puberty.
D) Idiopathic testicular atrophy.
E) estosterone receptor abnormality.
Answer 14.1.3 The correct answer is “C.” T e bone age o
12 years and 3 months is reassuring. Since there is no usion o
the growth plates, his bones are immature and still have the abil-
ity to grow. Had the bone age been 14, it is likely that his adult
height would be short; the bones would no longer have the inher-
ent ability to grow. Bone age assessment is an accurate tool or

determination o expected growth. Constitutional delay is the
most common diagnosis or short stature and it is o en associ-
ated with a delayed onset o puberty. Constitutional delay is a
diagnosis o exclusion; a complete history and physical o en rules
out other diagnoses. Family history o en reveals a parent who
was a “late bloomer” but eventually had normal pubertal develop-
ment. T is adolescent’s history o normal linear growth velocity
(albeit along the h percentile) is reassuring or the absence o
growth hormone de ciency or intracranial abnormalities. T is
adolescent’s combination o appropriate linear growth velocity,
appropriate adjustment or bone age, and paternal history o late
pubertal development is classic or a constitutional delay.
When your patient’s height is plotted on a growth curve and
adjusted or bone age rather than chronological age, the
height now plots just below the 50th percentile. Your patient
now has a question o his own. His biggest concern is that
some o his classmates are starting to get taller, and he is
a raid he will be too short to continue competing in sports.
Once again, his mother is 5′ 3″ tall ( 160 cm) and his ather
is 5′ 10″ tall ( 178 cm).
Question 14.1.4 Based on what you know today, what is
your best estimate o this patient’s adult height?
A) 5′ 3″ ± 2 (160 ± 5 cm).
B) 5′ 5″ ± 2 (165 ± 5 cm).
C) 5′ 7″ ± 2 (170 ± 5 cm).
D) 5′ 9″ ± 2 (175 ± 5 cm).
E) 5′ 11″ ± 2 (180 ± 5 cm).
Answer 14.1.4 The correct answer is “D.” You can provide a
rough estimate o the patient’s adult height using the calculation
or mid-parental height (MPH). Remember that the parent o
the opposite gender—the mother in this case—must have the
height adjusted or this calculation. For boys, add 5 inches to
the mother’s height (12.5 cm) and then average this corrected
maternal height with the paternal height to determine the MPH.
For girls, subtract 5 inches rom the paternal height (12.5 cm . . .
that is what you subtract, and NO the paternal height) and
then average this corrected paternal height with the maternal
height to calculate the MPH. In our patient’s case, his mother’s
corrected height is 68 inches which averaged with his ather’s
height o 70 inches, equates to a MPH o 69 inches. A margin
o error o ± 2 inches (5 cm) is o en given with MPH estimates.
Objectives: Did you learn to . . .
• eva ua a pa w h gr w h c c r ?
• i y h c ca pr a c u a ay?
• Ca cu a MPH?
CASE 14.2
Your next patient is a 16-year-old emale cross-country run-
ner who you are seeing in ollow-up or right shin pain. She
was diagnosed in the local emergency department 1 week ago
with “shin splints” and told to limit her activities. In your
o ce, she tells you that the pain has been worsening over the
CHAPTER 14 • Ad o l es Cen t Med iCin e 397
last 3 months, and she has progressively decreased the dis-
tance and time o her runs (but, o course she’s a runner, so
she hasn’t quit). She denies ever, swollen joints, or other sys-
temic symptoms. She normally has regular menses but notes
that she has irregular menses during cross-country season.
T e patient’s past medical history is signi cant or a stress
racture in her le oot 18 months ago. Your examination
reveals tenderness at the middle one-third o the right tibia.
In addition, she has pain on a single-leg hop. You are able to
review her x-rays rom the emergency department, which do
not reveal any ractures or other abnormalities.
Question 14.2.1 What is the most appropriate next step to
diagnose your patient’s leg pain?
A) Ultrasound o the lower extremity.
B) MRI o the lower extremity.
C) Dual-energy x-ray absorptiometry (DEXA) scan.
D) T yroid-stimulating hormone ( SH) level.
E) Urine pregnancy test.
Answer 14.2.1 The correct answer is “B.” MRI is sensitive and
speci c or stress ractures and has become the pre erred study.
T e patient’s history and examination are concerning or the
presence o a tibial stress racture. Stress ractures o en pres-
ent insidiously and cause gradual progression in symptoms over
time until a critical point is reached in terms o sports partici-
pation. Hal o stress ractures are not visible on plain radio-
graphs. Ultrasound can help in evaluating so tissue masses, but
it does not play a role in evaluating stress ractures. DEXA scan
can provide whole-body and site-speci c measurement o bone
mineral density, which may be related to the pathophysiology
o stress ractures, but does not help diagnose a site o injury.
Radionuclide bone scans are o en less expensive than C or
MRI, and they demonstrate sites o injury based on increased
uptake o the radionuclide material. However, bone scans are
not speci c or stress ractures and are o en alsely positive. O
note, plain radiographs may take months to become positive
a er a stress racture and, while radiographs may be done, they
will not be o use i the result is negative. Given the patient’s
other complaints, SH and urine pregnancy test may be warranted
but will not assist in the diagnosis o her leg pain.
An MRI is obtained and con rms the presence o a stress
racture in the middle one-third o the right tibia. Because
o your patient’s history, especially that o multiple stress
ractures, you are concerned she may be su ering rom the
emale athlete triad.
Question 14.2.2 What are the components o the emale
athlete triad?
A) Disordered eating, menstrual dys unction, altered bone
mineral density.
B) Depression, weight loss, sports-related injury.
C) Poor sports per ormance, low sel -esteem, injury.
D) Weight gain, bony injury, mood changes.
E) Fanatical attachment to sports, testosterone abuse, anger
management issues.
398 FAMil Y Med iCin e eXAMin At io n & Bo ARd ReVieW
Answer 14.2.2 The correct answer is “A.” T e emale athlete
triad was rst identi ed in the early 1990s and originally char-
acterized as anorexia, amenorrhea, and osteoporosis. As more
has been learned about the triad, the realization has been made
that the triad likely represents a broader spectrum disorder
within each category. Many young women with the triad will
exhibit disordered eating behaviors, such as caloric restriction
or use o diuretics and diet pills, but would not meet the crite-
ria or anorexia or bulimia nervosa. Menstrual dys unction may
include oligomenorrhea or irregular, intermittent menses, as
well as amenorrhea. T ese young women may also have abnor-
mal bone mineral density, with predisposition to bony injury,
without having reached the strict criteria o osteoporosis.
T e patient comes back to the o ce to receive her test results,
and you take the opportunity to obtain more history. T e
patient admits that she is very concerned about her diet
during her cross-country season, and she is very care ul to
choose oods that have very little at but are o en high in pro-
tein. She will occasionally “go overboard” and eat a lot, or
which she compensates by taking part in extra workouts. She
has also used laxatives in the past “to not gain weight when
I eat too much.”
Question 14.2.3 Which o the ollowing ndings is NOT
classically ound in bulimia nervosa?
A) Loss o dental enamel.
B) Enlarged parotid glands.
C) Metabolic acidosis.
D) Skin changes over the dorsum o the hands.
E) Maintenance o a signi cantly low body weight.
Answer 14.2.3 The correct answer is “E.” Loss o dental enamel,
skin changes over the dorsum o the hands, and enlarged
parotid glands may be seen as a result o repetitive sel -induced
vomiting. While sel -induced vomiting would cause a metabolic
alkalosis through loss o stomach acid, repetitive use o laxatives
can cause gastrointestinal losses o bicarbonate, resulting in a
metabolic acidosis. Individuals with bulimia nervosa o en
maintain a normal weight, while anorexia nervosa has strict
diagnostic criteria requiring maintenance o signi cantly low
body weight, o en less than 85% o the ideal body weight.
Your patient also relates that she began having her peri-
ods around age 12. While they were initially irregular, they
seemed to become more regular prior to starting high school.
However, as she became more involved in high school sports,
her periods became more irregular. During her o -season,
her menses are “more regular,” though she cannot predict
when they will occur. She recalls that her last period was
about 7 weeks ago.
Question 14.2.4 In evaluating your patient’s menstrual
dys unction, what would be your next course o action?
A) Obtain serum LH, ollicle-stimulating hormone (FSH), and
estradiol levels.
B) Order an abdominal and pelvic ultrasound.
C) Per orm a speculum-assisted pelvic examination with Pap
smear.
D) Obtain a urine beta-hCG.
E) Prescribe an oral progestin-only pill (progestin challenge).
Answer 14.2.4 The correct answer is “D.” T e most common
cause o secondary amenorrhea in women o childbearing age
remains pregnancy. I pregnancy has been excluded, and the
history and physical are reassuring, a progestin challenge can
be help ul to determine i adequate estrogen is present; the pro-
gestin challenge should induce menses i adequate estrogen exists
(see Chapter 15 or details on the evaluation o amenorrhea).
Imaging studies and hormonal levels may help in excluding other
diagnoses or may be warranted based on physical examination.
A pelvic examination may be warranted based on history, but is
o en not necessary in the initial evaluation o menstrual dys unc-
tion. Pap smears are no longer recommended or women under
the age o 21, regardless o sexual activity status.
Your patient’s pregnancy test is negative and a progestin
challenge induced menses, indicating adequate circulating
estrogen. A comprehensive plan is developed that includes
psychological counseling, dietary modi cation, physical
therapy, consultation with a nutritionist, and requent ollow-
up. Over the next several months, the patient recovers rom
her injury, and returns to running on a modi ed schedule.
However, she now complains o heavy, pain ul menses and
wants to go on the “shot” to stop them.
Question 14.2.5 In your counseling about birth control
options, which o the statements below is FALSE?
A) T e birth control pill can be used to treat irregular menses o
the emale athlete triad and will also increase bone deposition.
B) T e e ect o Depo-Provera (medroxyprogesterone) is to
suppress the hypothalamic—pituitary—ovarian axis, creating
a low estrogen state akin to peri-menopause.
C) T e FDA issued a “Black Box” warning on Depo-Provera
that states “prolonged use . . . may result in loss o bone
density that may not be completely reversible a er discon-
tinuation o the drug.”
D) T e risk o uture racture using Depo-Provera is unknown,
as bone density is an incomplete measure o bone strength,
and remodeling and recovery are signi cant.
E) Use o a Long Acting Reversible Contraceptive (LARC)
should be o ered as rst line contraceptive choice.
Answer 14.2.5 The correct (and “ alse”) answer is “A.” T e
other statements are all true. Starting a combined estrogen/pro-
gesterone contraceptive pill will restart a menstrual cycle but
may not increase bone density. As to “E,” an American Acad-
emy o Pediatrics (AAP) policy statement rom September 2014
recommends that a LARC be considered as a rst line contra-
ceptive option in adolescents, including intrauterine device
(IUD) or subdermal implant. T ese can provide 3 to 10 years
o contraception and are e ective and sa e orms o birth con-
trol. Concerns about an increase in pelvic in ammatory disease
(PID) with the IUD have been ound to be unwarranted.

In your routine anticipatory guidance, you discover that she
avoids most dairy products due to a combination o prior
concerns about at content and lactose intolerance.
Question 14.2.6 What do you recommend or her daily
intake o elementary calcium?
A) 900 mg.
B) 1,100 mg.
C) 1,300 mg.
D) 1,700 mg.
E) 2,100 mg.
Answer 14.2.6 The correct answer is “C.” While the absolute
best intake o calcium or individuals is unknown, studies have
shown positive calcium balance or adolescents with an intake
o 1,200 to 1,500 mg daily. In its 2010 report, the Institute o
Medicine (IOM) set 1,300 mg/day as the “adequate” dietary
intake or boys and girls 9 to 18 years o age. T is guideline was
set to meet the needs o 95% o healthy children, with the upper
limit o calcium intake set at 2,500 mg/day.
For most persons, 1,300 mg/day o calcium intake can be
accomplished with our servings o dairy products (8 oz o milk =
8 oz o yogurt or cottage cheese = 1 inch cube o cheese) plus
a varied diet that includes other calcium-rich oods (e.g., broc-
coli, collard greens, and turnip greens). It is generally pre erable
to achieve intake o calcium via diet, including orti ed oods,
because oods provide multiple nutrients that are important
or bone health, such as phosphorus and magnesium. Despite
widespread non- and low- at dairy options and numerous
supplements, concern over at intake has resulted in an average
adolescent intake o only 700 to 800 mg/day or girls and about
1,000 mg/day or boys—and yet, we have an obesity epidemic.
Ironic but not unny.
Question 14.2.7 On average, what percentage o total body
mineral content has a young woman deposited by the time
she reaches 12 years o age?
A) 20% to 30%.
B) 40% to 50%.
C) 70% to 75%.
D) 80% to 85%.
E) 95% to 100%.
Answer 14.2.7 The correct answer is “D.” Research suggests
that by age 12, a young woman has reached approximately 83%
o her peak bone mineral content, with 50% deposition hap-
pening rom the time o “peak height velocity,” which is pre-
menarchal through 1 year post-menarche. T e ability to absorb
calcium rom the diet is also enhanced during this period.
Rates o deposition begin to decline approximately 2 years post-
menarche and no signi cant gains are seen a er the age o 17.
T ese statistics emphasize that osteoporosis, while mani esting in
older adults, is truly an issue o adolescent preventive medicine.
Your patient returns rom a high-powered sports medicine
clinic in Palm Springs (or Laguna Beach . . . or anywhere more
CHAPTER 14 • Ad o l es Cen t Med iCin e 399
likely to make V than Iowa). She brings you her DEXA scan
results that are consistent with osteopenia. She looks up rom
her Instagram eed and asks, “So, what are we gonna do about
that, Doc?”
Question 14.2.8 You scour the literature and recommend:
A) Alendronate.
B) Calcium and vitamin D.
C) Vigorous weight-bearing exercise.
D) Dehydroepiandrosterone (DHEA).
E) All o the above.
Answer 14.2.8 The correct answer is “B.” Alendronate has no
proven bene t in adolescent osteopenic emales. Recommend-
ing exercise is the usual course or older patients with osteo-
penia, but you need to be care ul in the adolescent with weight
concerns who may exercise excessively at baseline. DHEA is
investigational and has not been shown to increase bone mineral
density. Stick with the standard o care: calcium in the daily doses
as recommended above and vitamin D 600 IU daily (note that
this recommendation is a change in the 2010 IOM guideline).
Objectives: Did you learn to . . .
• eva ua g pa a ru r?
• i y h “ ma a h r a ?”
• R c g z h mp r a c ca c um a v am d ak
a p r pr v a c c ?
QUICK QUIZ: Ad o l es Cen t At Hl et es
For adolescent athletes, what is the number one cause o sudden
cardiac death (SCD)?
A) Mar an syndrome.
B) Coronary artery disease.
C) Congenital mal ormation o coronary arteries.
D) Hypertrophic cardiomyopathy.
E) Long Q syndrome.
The correct answer is “D.” Hypertrophic cardiomyopathy is an
autosomal-dominant trait with highly variable penetrance that
results in asymmetric septal wall hypertrophy. T is may cause
unctional aortic out ow tract obstruction, as well as predis-
pose the athlete to arrhythmias. Un ortunately, this condition
is o en asymptomatic prior to the terminal event and screening
tests such as electrocardiographs and echocardiograms have not
been proven e ective at early detection o this condition. Aber-
rant coronary arteries are the second leading cause o SCD in
young athletes. Mar an syndrome and long Q syndrome are
less common.
CASE 14.3
As part o your group’s community outreach, you are partici-
pating in a sports physical screening (somehow your partner
got to throw out the rst pitch at a baseball game, and you
got this . . . we’re guessing you must be new). One o the stu-
dents is noted to be hypertensive with a blood pressure o
400 FAMil Y Med iCin e eXAMin At io n & Bo ARd ReVieW
143/95 mm Hg. T ere is no amily history o sudden death
or early heart attack. He has never experienced any symp-
toms with exercise. His parents indicated on the orm that
they did not recall any history o previous heart murmur or
high blood pressure. T e remainder o the examination is
unremarkable except or a I/VI systolic murmur. You ask the
athlete to per orm a Valsalva maneuver by holding his breath
and bearing down while cardiac auscultation is repeated.
Question 14.3.1 Which o the ollowing correctly describes
the relationship between murmur intensity and the likely
type o murmur?
A) Valsalva maneuver increases ow murmur, decreases out ow
tract obstruction murmur.
B) Valsalva maneuver increases both ow murmur and out ow
tract obstruction murmur.
C) Valsalva maneuver decreases both ow murmur and out ow
tract obstruction murmur.
D) Valsalva maneuver decreases ow murmur, increases out ow
tract obstruction murmur.
Answer 14.3.1 The correct answer is “D.” T e Valsalva maneu-
ver decreases venous return to the heart, resulting in decreased
diastolic lling. You would expect this to cause decreased ow
through the out ow tract and thus a so er ow murmur. How-
ever, the decreased ow exacerbates the unctional out ow
tract obstruction o hypertrophic cardiomyopathy (there is less
volume to push the septum out o the way resulting in a tighter
unctional stenosis), resulting in a louder murmur. In summary,
benign f ow murmurs will decrease in intensity with Valsalva
maneuver, while the murmur o hypertrophic cardiomyopathy
will increase with a Valsalva maneuver.
HELPFUL TIP:
th y c cr c – cr c murmur hyp r-
r ph c car my pa hy cr a y wh h
pa m v r m a up a upr gh p . s4
may b h ar a w . Car ac au cu a h u b
p r rm b h up a upr gh r a p r par c -
pa phy ca .
Reassured by a murmur that disappears with Valsalva
maneuver and an otherwise unremarkable examination, you
are now aced with an adolescent athlete with an elevated
blood pressure con rmed by manual re-testing.
Question 14.3.2 What is the best recommendation or this
athlete regarding sports participation and ollow-up o his
elevated blood pressure?
A) Quali ed participation pending serial blood pressure checks
over the next 3 weeks.
B) Complete disquali cation or 2 months, ollowed by return
i ECG and echocardiogram are normal.
C) Disquali cation rom competition only or 1 month, but
allowed to practice once seen by a nephrologist.
D) Full participation with no required ollow-up based on
reassuring history and examination.
E) Full participation with blood pressure re-check prior to the
next competitive sport season.
Answer 14.3.2 The correct answer is “A.” It is important to
remember that the diagnosis o hypertension cannot be made at
a single screening visit. T e screening may be a ected by patient
anxiety (“white coat hypertension” or standing hal naked in ront
o all o his peers), recent ca eine ingestion, drugs, or a number
o other actors (including a common occurrence o schedul-
ing examinations right a er practice). Most recommendations
include three separate recordings o blood pressure on di erent
occasions a er several minutes at rest, sitting com ortably.
Because exercise is bene cial or blood pressure control,
continued aerobic activity should be encouraged while the
serial blood pressure readings are obtained. Debate exists as to
recommendations regarding static exercises, such as weightli -
ing. While li ing o heavy weights can exacerbate high blood
pressure, there is some evidence to suggest that use o light-to-
moderate weights with repetition is bene cial. Certainly, the
presence o any additional symptoms with exercise, such as
headache or lightheadedness, would require more signi cant
limitations in activity.
Objectives: Did you learn to . . .
• i y mp r a u a r a h pr -par c pa
phy ca xam a ?
• eva ua a a c ah w h va b
pr ur ?
• eva ua a car ac murmur r v a pr -par c pa
phy ca xam a ?
CASE 14.4
A 15-year-old emale presents to your o ce or a well-
adolescent examination. She is a healthy teenager with no
complaints—well, she has the usual teenager complaints (her
parents are stupid, the teachers don’t know anything, etc.).
You have incorporated into your routine a screening tool, the
Guideline or Adolescent Preventive Services (GAPS) ques-
tionnaire, one o many such tools available. T e questions
cover all areas o adolescent development and are designed
so that areas o concern are easily identi ed.
Question 14.4.1 What are the three leading causes o mor-
tality or adolescents?
A) Leukemia, suicide, accidental drowning.
B) Childhood cancers, perinatally acquired HIV, suicide.
C) Congenital mal ormations, childhood cancers, suicide.
D) Accidental injury, homicide, suicide.
E) Childhood cancers, SCD, suicide.
Answer 14.4.1 The correct answer is “D.” Accidental injury,
homicide, and suicide are the three leading causes o death or
adolescents and should be addressed during preventive health
visits. As a category o accidents, motor vehicle atality is the
leading cause o death to teenagers, representing over one-third
 CHAPTER 14 • Ad o l es Cen t Med iCin e 401

o all deaths. A high number o teens report unsa e driving Question 14.4.3 What would your next step be?
behavior: 41.4% o teens have reported texting or emailing while A) Call the police and report the illegal use o substances by a
driving; and while most states have made this illegal, it is still minor.
important to discuss with your adolescent patients. Accidental B) Reassure the patient about her con dentiality rights, counsel
injuries o en involve the use o alcohol or other substances in her to quit using drugs, and see her back annually.
combination with motor vehicle operation or other risk-taking C) Begin the patient on an SSRI and see her back in a month.
behaviors. Ask about personal use o alcohol and i they are D) Negotiate next steps to guarantee the patient’s sa ety and
ever passengers o another teenager (or adult) who drives while consider counseling re erral.
impaired or intoxicated. T e greater the number o teens in E) Obtain a nonconsented urine drug screen to document
the car o a teen driver, the greater the likelihood o an acci- recent use o substances.
dent. T is argues or the law in some states that restrict the
number o passengers in a teen driver’s car. Answer 14.4.3 The correct answer is “D.” Most states’ laws, as
well as HIPAA, guarantee teenagers con dentiality, to be broken
You also noticed that your patient checked “yes” or a history only when there is an issue o imminent danger to sel or others
o use o alcohol and marijuana. or physical/sexual abuse. It is recommended that the patient be
involved and consent to who and how the in ormation is shared.
Question 14.4.2 What is the approximate requency o Rarely is there a need to involve police, unless there is an issue
li etime use o these substances among 9th to 12th grade o abuse requiring a report or concern over sa ety i the patient
students according to the Centers or Disease Control and is returned to the home environment.
Prevention (CDC’s) 2013 Youth Risk Behavioral Survey? “C” is incorrect. I an SSRI is started, close supervision is
A) Alcohol 10% to 20%; marijuana 5% to 10% required or adolescents. Studies suggest increased suicidal-
B) Alcohol 30% to 40%; marijuana 10% to 20% ity in teenagers treated with SSRIs. T ere are also increased
C) Alcohol 50% to 60%; marijuana 20% to 30% attempts at suicide but not an increase in success ul suicide. T e
D) Alcohol 60% to 70%; marijuana 30% to 40% American Academy o Child and Adolescent Psychiatry website
E) Alcohol 70% to 80%; marijuana 40% to 50% has resources outlining patient and parent in ormation about
the risks and bene ts o pharmacologic treatments. Cognitive
Answer 14.4.2 The correct answer is “D.” T e survey ound behavioral therapy (CB ), along with talk therapy, has been
66.2% o adolescents reporting use o alcohol at some point in shown to be the best rst-line treatment or adolescents with
their lives, and 40.7% reporting use o marijuana. In addition, mood disorders. In any case, close ollow-up o a depressed
41.1% have tried cigarettes. Alcohol use has been ound to be adolescent (weekly visits or phone calls) is recommended.
slightly higher in emales at 67.9% compared to 64.4% in males.
HELPFUL TIP:
HELPFUL TIP: A F bruary 2016, h Us Pr v a v s rv c
scr g ra c ub a c u cu t a k F rc w r c mm cr g rm -
h “CRAFFt ” qu , v p by h “C r r r r ag r ag 12 18 as long as there are
A c s ub a c Abu R arch” (C As AR), Ch - adequate resources available to aide in diagnosis, treat-
r ’ H p a B . s m ar h “CAGe” r ment, and follow-up. t h y pr v h a gra B prac-
a u ac h a m , h r a r: c r c mm a . th r u c v c
• C—Hav y u v r r a CAR r v by m a h p r cr g ch r ag 11 y ar
( c u g y ur ) wh wa “h gh” r ha b u g ag r y u g r.
ac h r rug ?
• R—d y u v r u a c h r rug Rel AX,
b r ab u y ur , r ? HELPFUL TIP:
• A—d y u v r u a c h / rug wh y u ar by ss Ri ar ha c v r p a r c/a c
y ur , Al o n e? pr .t h nnt b pa 10. F u x-
• F—d y u v r Fo RGet h g y u wh u g ha h m av rab b /r k pr a -
ac h r rug ? c a r c mm a r - h rapy by
• F—d y ur am y r FRien d s v r y u ha y u m pub h gu .
h u cu w y ur r k g r rug u ?
• T—Hav y u g t Ro UBl e wh y u w r
u gac h r rug ?
HELPFUL TIP:
t h Am r ca Aca my P a r c ha a p
a m aga h u c ur rug
A er eliciting a positive response to questions about drug cr a a “ cr g” u h ack accuracy
use, you ask the patient about depression, and she states that a h v a pa ru .
she has been eeling “down” or several months now.
402 FAMil Y Med iCin e eXAMin At io n & Bo ARd ReVieW

D) reat with oral steroids to suppress the response and promote

(ONE MORE) HELPFUL TIP:
quicker return to wrestling.
A u y pub h Lancet u ha a c -
E) reat with topical anti ungal medication and allow return to
harm (cu g, bur g, c.) ccur ab u 10%
wrestling.
a c . H w v r, y u ca r a ur par ha
h c 3% a a y u g a u (M ra P, a.
Answer 14.5.2 The correct answer is “C.” Cutaneous herpes,
Lancet. 2012).
also re erred to in wrestling as herpes gladiatorum, is a highly
contagious illness. “B” is incorrect because topical acyclovir is
Objectives: Did you learn to . . . not e ective in treating herpes simplex. Most state high school
• i ya mp y u u cr g rr u a - athletic associations have speci c rules regarding the treatment
c xam a ? o cutaneous disorders in wrestling, including herpes, tinea cor-
• R c g z h mp r a c cr ga r a g pr - poris, and impetigo. With regard to herpes simplex, all lesions
a c ? must be ully crusted over and the athlete must have had at
• d cr b c mm cau ah a c ? least 3 days o oral antiviral therapy prior to returning to com-
• U r a h c mm m xp r c u ac h , petition. “D” is incorrect because oral steroids would suppress
bacc , a mar jua a? the athlete’s immune response, which would allow or urther
• d cr b cr ga r am p rm r r spread o the lesions.
a ub a c abu ?
Your next patient is a 12-year-old male who is here or a
sports physical. You review your patient’s chart and scan his
CASE 14.5 immunizations. T e patient’s mother remembers her son
Your a ernoon has a number o patients with sports-related receiving his “kindergarten shots;” he has had no immuniza-
complaints. A 14-year-old wrestler has arrived in the o ce tions since. His records reveal the ollowing vaccines: 5 doses
complaining o a rash on his le shoulder. T e rash appears o diphtheria–tetanus–acellular pertussis (D aP), 4 doses o
to consist o several small lesions with a vesicular appearance injectable polio vaccine (IPV), 4 doses o Haemophilus Inf u-
but no purulence and minimal erythema. T ere is neither ten- enzae ype B (Hib), 3 doses o hepatitis B; 4 doses o PCV 13,
derness to palpation nor tactile warmth in the a ected area. 2 doses o measles–mumps–rubella (MMR), and 2 doses o
varicella vaccine.
Question 14.5.1 What would be your best test to con rm
your diagnosis o these lesions? Question 14.5.3 Which, i any, immunizations would you
A) Microscopic evaluation with potassium hydroxide (KOH) of er today?
preparation o the contents o one o the lesions. A) None. T e patient is up-to-date or all immunizations.
B) Gram stain o the contents o one o the lesions. B) Conjugate pneumococcal vaccine.
C) Culture o the contents o one o the lesions. C) Hepatitis A/B vaccine, conjugate meningococcal vaccine,
D) zanck smear o the contents o one o the lesions. IPV.
D) Hepatitis A vaccine; etanus, diphtheria and pertussis ( dap);
Answer 14.5.1 The correct answer is “D.” A zanck prep will conjugate meningococcal vaccine and start o the HPV series.
give you immediate in ormation about whether this represents E) Human papillomavirus (HPV) vaccine, dap, varicella
herpes simplex. T is is important in ormation when deciding vaccine.
whether or not this patient can return to wrestling. HSV PCR
assays are a more sensitive method to con rm HSV in ection in Answer 14.5.3 The correct answer is “D.” Universal vaccina-
clinical specimens obtained rom genital ulcers and mucocuta- tion or hepatitis B is included in the primary immunization
neous sites and should also be obtained. However, these typically series or in ants, so most adolescents have been vaccinated.
take several days to return results. However, it is still important to make sure this is up-to-date.
Since adolescence is a time when experimentation with drugs
T e lesions have appeared within the past day, and your labo- and sexual activity becomes more prevalent, vaccination or
ratory testing con rms that the diagnosis is herpes simplex. hepatitis B becomes even more relevant. Hepatitis A vaccine is
Your patient does not recall any previous lesions like these. now being required in many states be ore entry to school and
He denies any systemic symptoms. is universally recommended or all children ages 12 months to
2 years. A catch-up vaccination schedule is now recommended
Question 14.5.2 What would be the best course o treat- or ages 2 to 18 years. For those not up-to-date with their hepa-
ment or this patient? titis B vaccination, a combined hepatitis A/B vaccine exists.
A) Cover the involved area to allow return to wrestling. Most children receive their last D aP prior to entering pre-
B) reat with topical acyclovir and return to wrestling when school or kindergarten (age 4–5 years). Beginning in 2005, the
lesions have crusted over. CDC recommended giving the tetanus booster with pertussis
C) reat with oral acyclovir and return to wrestling when ( daP) at entry to middle school/junior high (ages 11–12) in
lesions have crusted over. place o the tetanus booster ( d).

For protection against some serotypes o Neisseria meningiti-
dis, the CDC recommends universal vaccination with the conju-
gate meningococcal vaccine (e.g., Menactra) or teens, including
a booster dose between ages 16–18 years.
T e CDC recommended HPV vaccination or boys in 2011.
E ective March o 2015, the CDC recommends 9-valent HPV,
4-valent HPV, or 2-valent HPV or routine vaccination o
emales 11 or 12 years o age and emales through 26 years o
age who have not been vaccinated previously or who have not
completed the 3-dose series. Further, the CDC recommends
the 9vHPV or 4vHPV or routine vaccination o males 11 or
12 years o age through 21 years o age who have not been vac-
cinated previously or who have not completed the 3-dose series.
T is age cut-o may be extended out to 26 years old or men
who are immunocompromised or have sex with men and have
not been previously vaccinated. “E” is incorrect because he has
already had chicken pox.
Question 14.5.4 Which statement does NOT accurately
describe how the conjugate meningitis vaccine (Menactra)
dif ers rom the older polysaccharide meningitis vaccine
(Menomune)?
A) Menactra elicits a -cell immune response that gives long-
term immunity and allows or herd immunity.
B) Menactra protects against all the types o N. meningitidis: A,
B, C, Y, W-135.
C) Menomune does not elicit a booster e ect, may only be
given once, and is recommended only at the onset o high-
risk activity, such as living in dorms or being a military
recruit.
D) Menactra should be o ered at entry to middle school/junior
high school (11–12 years) with a booster dose recommended
between age 16 and 23 years.
Answer 14.5.4 The correct answer is “B.” Un ortunately nei-
ther Menomune nor Menactra protect against serogroup ype B.
T e other choices are correct. N. meningitidis ype B is endemic
in North America and up until 2014, no such vaccine was avail-
able. In 2014 and 2015, the FDA approved two meningococcal
ype B vaccinations (3 dose MenB-FHbp ( rumenba®) and 2
dose MenB-4c (Bexsero®). T e ACIP in October 2015 provided
a grade B recommendation that MenB vaccination may be given
in addition to Menactra and other indicated age-based vaccina-
tions (pre erably at a di erent anatomic site) between ages 16
and 23 with pre erable dosing at 16 to 18 years to provide peak
desired immunologic e ect in the group that is at most risk.
HELPFUL TIP:
R v w h vacc r c mm a c h y ar
up a r qu y by h Cd C; vacc r c mm a-
ca b u a h p://www.c c.g v/vacc /
ch u /.
Objectives: Did you learn to . . .
• i y h rp g a a rum a cr b r am ? A) Encouraging breast- eeding.
• R c mm vacc appr pr a ra c ?
CHAPTER 14 • Ad o l es Cen t Med iCin e 403
CASE 14.6
A 15-year-old emale returns or her annual well-child check
and sports physical. She is well known to your clinic, and over
the years she has steadily gained weight. Her parents and a
younger sibling are overweight, and now she has become
obese by measure o the pediatric BMI percentages. In recent
years, you have become more diligent with watching the BMI
on her growth curve. She is aware o her weight problem, yet
has not voiced any plan or attempting weight loss.
Question 14.6.1 What de nes “obesity” in adolescence?
A) A BMI in the 85th to 94th percentile or age-speci ic
measures.
B) A BMI ≥ 95th percentile or age-speci c measures.
C) T e child has the appearance o being heavy.
D) T e child complains o being at or overweight.
E) BMI > 35 kg/m 2.
Answer 14.6.1 The correct answer is “B.” A BMI at or above
the 95th percentile is considered “obese.” A BMI in the range o
85th to 94th percentiles is considered “overweight.” T e use o
BMI allows or an objective measure, and although not per ect,
can give a picture on the growth curve to patients and parents
where they stand relative to age-related norms. Strict BMI num-
bers (as in “E”) are not applicable to children and adolescents.
A subjective concern about weight (“D”) is important, but does
not necessarily always warrant urther evaluation.
Question 14.6.2 Her BMI is now at the 97th percentile,
having jumped rom the 86th percentile last year. What
additional work-up is needed?
A) Fasting plasma glucose level.
B) Fasting lipids.
C) Renal unction testing with BUN and creatinine.
D) Liver unction testing with AS and AL .
E) All o the above.
Answer 14.6.2 The correct answer is “E.” Once a child reaches
a BMI at the 85th to 94th percentiles, a lipid panel is recom-
mended to evaluate or hyperlipidemia and screening should
be done or early onset type 2 diabetes. When the BMI reaches
the 95th percentile, renal unction and blood pressure should
be monitored and liver unction should be checked (looking
or signs o atty liver). Fatty liver disease is possible at an early
age and is reversible i weight loss can be achieved. Close atten-
tion to amily history is essential. I amily members are obese
or have obesity-related comorbidities, early intervention and
evaluation are even more crucial. For emales who have started
menses, it is important to assess or any changes in menstrual
patterns.
Question 14.6.3 Which o the ollowing is NOT a recom-
mended early childhood intervention to prevent and/or
treat obesity?
B) Decreasing screen time o electronic devices.
404 FAMil Y Med iCin e eXAMin At io n & Bo ARd ReVieW

C) Planning ewer amily meals. Question 14.6.5 Which o these medications would you
D) Restricting calories rom sweets and ast oods. recommend now as a rst-line therapy or weight loss?
E) Improving e orts or exercise and outdoor activity. A) opiramate ( opamax).
B) Bupropion (Wellbutrin).
Answer 14.6.3 The correct answer is “C.” Helping with ood C) Orlistat (Xenical).
preparation, and sitting down as a amily or meals, can lead D) Sibutramine (Meridia).
to consumption o more nutritious and lower calorie dense E) None o the above.
oods. Breast- eeding can lead to protection against obesity
even into the teenage years. Formal recommendations suggest Answer 14.6.5 The correct answer is “E.” No medication is
limiting V, tablet, phone, computer use, and video games approved or children or adolescents as a rst-line therapy. Anti-
to less than 2 hours per day. Fast ood, sweets, and desserts depressants are not help ul i used primarily or weight loss. I
need to be limited to small servings or ew servings per week. there is comorbid depression, which is more common in obese
Finally, 60 minutes o exercise should be encouraged every children, a “weight loss” or “weight neutral” antidepressant may
day—doing a variety o activities will keep children more be appropriate. Antiepileptic medications have not proven help ul.
engaged and interested. Sibutramine was pulled o the market in 2010 due to troubling
cardiac side e ects, but was not approved or use in children any-
way. Orlistat is approved or children age 12 and older. Yet, the
HELPFUL TIP:
bene ts are limited to an additional 2 to 3 kg o weight loss. Side
i ch r b c m v rw gh r b , r c
e ects are o en intolerable and include loose, oily stools and stool
w gh h u b mp m .F r k w h a
urgency (just mention the phrase “ ecal incontinence” to a teen-
BMi a h 85 h 94 h p rc , h g a w gh
ager and see how ar you get). Experts agree that orlistat is only
ma a c u h y r ach a BMi a h 84 h p rc -
appropriate or adolescents with comorbidities caused by obesity.
r . W gh a a ra 1 b p r w k r c-
mm r k wh hav BMi a h 95 h 99 h
p rc .F r h ch r a r ab v a BMi h HELPFUL TIP:
99 h p rc , h r c mm w gh 2 b t h r k b c m g v rw gh ca cr a by 4%
p r w k. r ach m h br a - g up ag 9 m h .

HELPFUL TIP:
During the examination o the patient, you notice more acne
W gh a c c w k y a cr a
than the past, some coarse acial hair, and dark skin pigmen-
car va cu ar a a a a u (Ju a a M, a.
tation around the base o her neck.
N Engl J Med. 2011).
Question 14.6.4 What is another nding you may expect to
see with urther questions and tests?
A) Normal menses. HELPFUL TIP:
B) Low ree testosterone level. M ab c y r m ch h k w r iQ
C) Low DHEA sul ate (DHEA-S). c r a mpa r c g . Wh h r m ab c y -
D) Hypoglycemia. r m cau a a wh h r h r v r b y
E) Abnormal hypothalamic–pituitary axis hormones. k w (Yau Pl , a . Pediatrics. 2012).

Answer 14.6.4 The correct answer is “E.” She is showing signs Objectives: Did you learn to . . .
o possible polycystic ovarian syndrome (PCOS). T is can be • d “ v rw gh ” a “ b y” a a c ?
associated with elevated prolactin, low SH, and a marked ele- • i y r k ac r a c a w h b y a a c ?
vation o FSH relative to luteinizing hormone (LH). PCOS can • Ma ag a a c w h a w gh pr b m?
be associated with early menarche, dysmenorrhea, and amenor-
rhea. A pregnancy test should be done in any case o amenor-
rhea. PCOS is also associated with elevations o testosterone,
CASE 14.7
DHEA-S, and androstenedione. I there are other signi cant You have watched your patient trans orm over the years rom
physical examination ndings such as elevated blood pressure, a rather normal-appearing boy into a very large, muscular,
purple striae, and a “bu alo hump,” consider screening or and intense young man. He is now 17 years old, and he has
Cushing syndrome. gained almost 45 lb in the last year alone as he prepares or
his senior year o ootball and attempts to attract the atten-
Her obesity is discussed openly during the o ce visit. As tion o college recruiters. Without a doubt he has worked
expected, she is ashamed and embarrassed about her weight very hard on the eld and in the weight room, but you also
gain. She admits to not knowing what to do and she asks i must raise the question o whether or not he has used some
anything can be done to quickly lose weight. kind o supplement to help him change so drastically.

Question 14.7.1 Which o these substances is NOT prohib-
ited by high school athletic associations or the NCAA?
A) Erythropoietin.
B) Creatine.
C) Androstenedione.
D) Ephedrine.
E) DHEA.
Answer 14.7.1 The correct answer is “B.” Creatine is allowed
or use as a dietary supplement or athletes. However, the
American College o Sports Medicine (ACSM) does not recom-
mend the use o creatine in any athlete less than 18 years old.
An estimated 8% o children 14 to 18 years old take creatine
routinely. T e NCAA does not allow colleges to provide ath-
letes with creatine, but athletes can take it i they choose. All the
other listed supplements are prohibited or use as per ormance-
enhancing supplements. Other prohibited substances include
anabolic steroids, pseudoephedrine, and blood trans usions.
Your patient does admit to using regular protein shakes and
taking creatine. He denies the use o any illegal or prohibited
substances and says he would never do anything dangerous.
During his examination, his blood pressure is 146/92 mm Hg
and his lab results show normal electrolytes, normal SH,
normal urinalysis, BUN 22 mg/dL, and creatinine 1.6 mg/dL
(marked elevation or age 17).
Question 14.7.2 What is a possible side ef ect rom the use
o creatine?
A) Gastrointestinal discom ort.
B) Edema.
C) Muscle cramps.
D) Acute renal insuf ciency.
E) All o the above.
Answer 14.7.2 The correct answer is “E.” All are potential
adverse e ects rom creatine use. Most importantly, i used care-
lessly, creatine can lead to acute renal insuf ciency. Creatine is
excreted via the kidneys, and i overconsumed in the setting o
dehydrating exercise, it can cause renal injury. Seventy- ve per-
cent o adolescent athletes who take creatine are either unaware
o the proper dose or knowingly take too much. I used, plenty
o water is required to help avoid troubling side e ects.
Question 14.7.3 All o the ollowing substances can provide
potential athletic per ormance bene ts, except:
A) Human growth hormone (HGH).
B) Ca eine.
C) Creatine.
D) Electrolyte replacements.
E) Sodium bicarbonate.
Answer 14.7.3 The correct answer is “A.” HGH has no proven
bene ts or enhancing sports per ormance. Other substances
with no proven bene ts include amino acids, beta-hydroxy-beta-
methylbutyrate, androstenedione, DHEA, chromium, and iron
(when not iron de cient). T e other substances can provide
CHAPTER 14 • Ad o l es Cen t Med iCin e 405
short-term or long-term bene ts. Ca eine has only a transient
e ect to help sharpen ocus and intensity or brie periods o
activity. Creatine can improve strength or those sports that
require very short bursts o intense e ort. Electrolyte replace-
ment drinks (or tablets) and sodium bicarbonate can help or
more prolonged endurance activities where dehydration and
resulting electrolyte imbalances are common.
Your patient denies using “steroids,” but does know o older
guys in the gym where he trains who have routinely used
anabolic steroids.
Question 14.7.4 Besides the obvious added muscle girth,
what are some other potential bene ts o anabolic steroids
or athletes?
A) Improved lipid pro le.
B) aller stature.
C) Anxiety relie .
D) Lower blood pressure.
E) None o the above.
Answer 14.7.4 The correct answer is “E.” T ere are no other
clear bene ts o anabolic steroids i used or athletics only. Poten-
tial negative e ects include lower HDL, elevated blood pressure,
le ventricular hypertrophy, gynecomastia, aggressive or even
suicidal behavior, azoospermia, virilization o emales, prema-
ture physeal closure in adolescents that could lead to shorter
stature, and acute myocardial in arction. Approximately 33%
o anabolic steroid users are not even athletes and use the sub-
stance to help improve physical appearance. Estimates in high
school athletes show steroid use to be about 4% in males and
about 2% in emales. T e temptation to use the illegal substance
is driven by pressures to be better than peers, to ul ll one’s “ ull
potential,” to live up to sports idols, and to help acquire college
scholarships and/or sports contracts at a young age.
Objectives: Did you learn to . . .
• d cr b h f c m c mm p r rma c - ha c g
rug ?
CASE 14.8
A 14-year-old emale comes into the o ce with a chie com-
plaint o headache. She says the headache began a er her soccer
game yesterday. She recalls striking her head against an oppo-
nent when trying to head the soccer ball. During the remain-
der o the game, she began to eel a headache, and the harder
she ran, the more “woozy” she elt. She denied any loss o con-
sciousness, vomiting, visual symptoms, or neck pain. oday,
she also has poor concentration and eels excessive atigue.
Question 14.8.1 Which o the ollowing is NOT a eature o
an acute concussion?
A) Caused by an impulsive orce transmitted to the brain.
B) Symptoms usually resolve spontaneously.
C) T ere is a unctional disturbance to the body.
D) Neuroimaging always shows abnormalities.
E) Clinical symptoms are highly variable and inconsistent.
406 FAMil Y Med iCin e eXAMin At io n & Bo ARd ReVieW

Answer 14.8.1 The correct answer is “D.” T ere may be no Question 14.8.3 In which case o head injury would neuro-
evident structural brain injury with an acute concussion. Evi- imaging be appropriate?
dence suggests that multiple concussions, or even lessor repeti- A) Ongoing mild headache or several days.
tive head injuries (such as with soccer “heading”) can eventually B) Poor memory o the recent game and the events o the injury.
lead to structural tissue damage. T e symptoms o concussions C) Any new seizure activity.
have a rapid onset and can vary rom short-lived impairment D) Loss o consciousness or less than 30 seconds.
to prolonged post-concussive symptoms. Studies are showing E) Mild irritability, depressed mood, and insomnia.
that younger athletes tend to have more severe symptoms and
recover more slowly than older, college-aged athletes. T is is Answer 14.8.3 The correct answer is “C.” Seizure activity a er
likely due to the more dynamic brain growth in younger children head trauma or concussion requires imaging. Other symp-
and adolescents. toms that should prompt a head C include severe headache,
ocal neurological symptoms, repeated emesis, dif culty arous-
ing, slurred speech, prolonged poor orientation, concurrent
HELPFUL TIP: neck pain, signi cant irritability, loss o consciousness or over
C cu a a urba c bra u c 30 seconds, and any new neurologic or escalating symptoms. T e
cau by rauma h h a .i r qu r initial study is normally a head C , but i presenting a er 48 hours
c c u r am a. l gh h a , r - rom injury, a brain MRI is more suitable. Remember that the
a ,a au a, c. a r h a jury ar a p b vast majority o concussion cases will not require imaging.
g c cu . s ymp m p c cu y -
r m may c u h a ach , cu y c c ra g, Question 14.8.4 Which o the ollowing elements o past
“ zz ,” gh h a , au a, a gu , rr ab - medical history may be relevant or this adolescent patient
y, a x y a pr . s ymp m g ra y r v ollowing her concussion?
bu may b g v , p ca y h v r ag 50, A) Depression.
wh may v r r ur ba . B) Generalized anxiety disorder.
C) Attention-de cit hyperactivity disorder (ADHD).
D) Migraine headaches.
HELPFUL TIP: E) All o the above.
i a ah u a ah a jury r a har h , h a h-
h u b r m v r m h gam a a Answer 14.8.4 The correct answer is “E.” All o these condi-
a m h u b p r rm a ra yp - tions could be negatively a ected by a concussion. Concussions
b c cu . A mp a ar z u can cause a temporary mood disorder and certainly aggravate
h acu a m c cu a ub qu depression and anxiety. Commonly, concussions will cause
va ua h s p r C cu A m t decreased concentration and inattentiveness. eens who already
(sCAt -3) qu a r (Br J Sports Med. 2013;47: 259). have ADHD will likely have worsened symptoms and may
If a concussion is suspected, the athlete should NOT need modi cation o their treatment. T e headache o post-
be allowed to return to the game. concussive syndrome may overlap or intensi y an underlying
headache diagnosis. Concussion may act as a trigger causing an
increase in pre-existing migraines.
Question 14.8.2 Which o the ollowing treatments is key
or your patient with a concussion? Your patient is an accomplished soccer player and eels a
A) Early return to aerobic exercise—today i possible. lot o pressure to return to action. She wants to play in the
B) Ibupro en 800 mg every 8 hours as needed. next game, and her coach and teammates are asking i she’ll
C) Avoiding excessive sleep. be back to practice this a ernoon—which explains why your
D) Aspirin 325 mg daily as needed. waiting room is so ull o teenage girls wearing shin guards.
E) Full cognitive rest (put down that smartphone, tablet, and
social media!), even missing school i needed. Question 14.8.5 What is your best advice about her return
to practice and play?
Answer 14.8.2 The correct answer is “E.” T e initial and key A) “Go back to practice today, but take it slow and avoid ull
step in caring or patients with a concussion is ull physical speed play.”
and cognitive rest. Very o en, a return to the classroom can B) “ ry to participate in simple drills and just cheer on your
aggravate or prolong concussive symptoms. Once symptoms teammates.”
are clearly improving at rest, the student-athlete can get back C) “Go home and engage in cognitive rest (is “engage in” and
to class and slowly be re-acclimated to physical activity. Sleep “rest” an oxymoron?). May return to activity with graded
can provide a means o allowing the brain to rest and heal. No return to play regimen once symptoms resolve.”
medications have proven help ul in alleviating the e ects o a D) “Return to ull, unrestricted team play as your soccer team
concussion. NSAIDs, aspirin, or acetaminophen may help with needs you!”
headache or pain. E) “Do whatever you want.”.
 CHAPTER 14 • Ad o l es Cen t Med iCin e 407

Answer 14.8.5 The correct answer is “C.” Her return to par-

ticipation needs to be a graded return to activity. Each step o Clinical Pearls
the recovery may be 24 hours. I she advances her activity to the C r g-ac gr v r b c rac p v (l ARC ), par-
next level and has recurrence o symptoms, then she needs to cu ar y n xp a ,a r - h rapy r c rac p
go back to the prior recovery step. T e rst stage o recovery is a c .
no activity—complete physical and cognitive rest. T e next step d a wa a c r ur p ay a r curr g a
is return to ull academic activities. Step three is light aerobic c cu .K p h a h u a pr cr b c g v r .
activity, ollowed by sport-speci c drills. Next, the player can o c ymp m hav mpr v , w y a w h a c
return to non-contact practice. I still symptom ree, then she r ur p ay a gra ua a pr cr b a h .
can return to ull speed, contact practice. Finally, she can return d cr r ub a c abu w h -c ur
to game action. I exertion causes any return o symptoms, then rug cr .
she is not ready and should return to the stage in which she was
R u y cr a c r ub a c abu a m
symptom ree. Even with normal neuropsychiatric tests, symp-
r r a qua upp r r urc ar ava ab .
tomatic athletes should not play.
T e above steps should be ollowed with the assistance o a Ru y vacc a a c w h t aP, c juga m g
health-care provider or a quali ed athletic trainer. T e athlete vacc , a HPV r .
cannot be put in the position o making the decision about how
ast to return to regular play. A er a rst concussion, the player
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Obstetrics andWomen’s Health
Elizabeth S. Cramer, Sandra R. Rosen eld-O’Tool, and Brigit E. Ray
15
CASE 15.1 Question 15.1.2 A ter reassuring her regarding the con
cerns o weight gain, you tell her about the additional
A 24-year-old nulligravida e ale resents or her annual potential bene t(s) o OCPs, which include:
exa ination. Her gynecologic history is re arkable or A) Improvement in acne
irregular enses, enstruating every 4 to 8 weeks. She would B) Decreased dysmenorrhea
like a ore reliable or o contrace tion (currently using C) Decreased menstrual ow
condo s) and would like to have redictable enses, but is D) Decreased risk o ovarian cancer
very concerned regarding weight gain with various contra- E) All o the above
ce tive ethods.
Answer 15.1.2 The correct answer is “E.” Besides these, addi-
Question 15.1.1 How would you counsel her regarding
tional potential bene ts o OCP use include regulation and pre-
weight changes and contraception?
dictability o menses, decreased anemia, decreased hirsutism,
A) Studies show there is no signi cant di erence in weight gain
and decreased risk o endometrial and colon cancers. (Note: the
o women initiating oral contraceptive pills (OCPs) versus
cancer risk reduction is based on epidemiologic studies, not
placebo
randomized controlled trials.)
B) Weight gain o 10 lb is expected during the rst year o use
with any type o OCPs
C) Weight gain o 10 lb is expected during the rst year o use
HELPFUL TIP:
with monophasic pills but not with triphasic ormulations
A ter starting OCPs, patients should ollow up within a
D) Weight loss o 10 lb is expected during the rst year o use
ew months or blood pressure checks, assuring compli-
with Depo-Provera (medroxyprogesterone acetate)
ance, etc.
Answer 15.1.1 The correct answer is “A.” Studies have shown
no signi cant weight gain with OCP use when compared with
placebo. rials have been conducted evaluating estrogen com-
A er urther discussion, she re orts that she has head-
ponents o 20 to 50 µg, both monophasic and triphasic. T ere
aches every 1 to 2 onths. She has never been evaluated or
is no evidence to su ort the re ise that tri hasic or u-
igraines, but re orts that her headaches are bilateral, oste-
lations o er i rove ent in weight changes. Depo-Provera
rior, throbbing, and relieved with slee and over-the-counter
has variable e ects on weight gain. Several studies have shown
edication. She denies associated aura, nausea, or ocal neu-
a weight gain o 3 to 6 kg in the rst year o use; however, other
rologic changes.
studies have shown no di erence in weight gain between Depo-
Provera and placebo.
Question 15.1.3 How would you counsel her regarding
OCPs and headaches?
HELPFUL TIP:
A) Headaches are an uncommon reason or discontinuation o
Recall that in 2004 the FDA placed a “black box warn-
OCPs
ing” on Depo-Provera or bone loss that “may not be
B) She should not use OCPs because they are contraindicated
reversible.” However, subsequent studies showed bone
in anyone with headaches
gain a ter stopping Dep-Provera. The prudent thing
C) She should use progestin-only pills
would be to avoid Depo-Provera in women at high risk
D) She can use OCPs, as it is hard to predict whether her head-
o osteoporosis.
aches will be a ected
409
410 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Answer 15.1.3 The correct answer is “D.” Although headache
is a requently cited reason or women to discontinue OCPs,
there is no strong correlation between headache requency and
intensity or most women. T ere is no evidence that the type
o progestin or amount o estrogen will alter the headaches,
except in women with menstrual migraines. Among women
with migraines, headaches improve, worsen, or are unchanged
a er initiation o OCPs (help ul, right?). T ere is an increased
risk o stroke in wo en with a history o seudotu or
cerebri or igraines with aura or ocal neurologic changes.
T ere ore, OCPs are CON RAINDICA ED in these s eci c
subgrou s o wo en.
HELPFUL TIP:
Additional contraindications to combination OCP use
include any previous thromboembolic event or stroke, a
history o estrogen-dependent tumor (e.g., some breast
cancers), active liver disease, pregnancy (although ac-
cidental use o OCPs early in pregnancy has not been
de initively linked to adverse outcomes), undiagnosed
abnormal uterine bleeding, women older than 35
years who smoke (due to increased risk o cardiovas-
cular disease), and first 3 weeks postpartum (2011
CDC recommendation based on increased venous
thromboembolism risk in the immediate postpartum
period).
T e atient wants to know how long she should use a backu
ethod o contrace tion a er starting the co bination
estrogen/ rogesterone OCP.
Question 15.1.4 You tell her the ollowing regarding using
a backup method:
A) I she starts taking the pill during the rst 5 days o her men-
strual period, no backup method is needed
B) I she starts taking the pill greater than 7 days a er the onset
o her period, she needs a backup method or 7 days
C) She should use a backup method or 2 months a er starting
the pill regardless o when she started it
D) T e OCP provides e ective contraception immediately and
no backup method is needed
Answer 15.1.4 The correct answer is “A.” T e old canard o
requiring a month o backup contraception a er starting OCPs,
implants, etc. has allen by the wayside. For combination estro-
gen/progesterone OCPs, or example, no secondary method o
contraception is needed as long as the OCP is started within
7 days o the onset o the last menses. I the OCP is started
greater than 7 days a er the onset o the last menses, only
7 days o a secondary contrace tion ethod (e.g., condo s,
dia hrag ) is needed; combination OCPs work within 7 days
o the start date. Please see able 15-1 regarding CDC recom-
mendations or backup contraception.
TABLE 15-1 BACKUP CONTRACEPTION WHEN
INITIATING METHODS
Contraceptive Method Backup Method: Initiation a
Copper-containing IUD None needed
(Paraguard)
Levonorgestrel-containing 7 days; only needed i > 7 days a ter
IUD starting menses
Implant 7 days; only needed i > 5 days a ter
starting menses
Injectable 7 days; only needed i > 7 days a ter
starting menses
Combined hormonal 7 days; only needed i > 5 days a ter
contraceptives starting menses
Progestin-only pill 2 days; only needed i > 5 days a ter
starting menses
Note: Barrier methods or abstinence rom intercourse may be used during
the recommended backup interval.
a
Any method may be initiated at any time i there is reasonable certainty
the woman is not pregnant, based on the criteria o the Centers or Disease
Control and Prevention.
Table adapted rom Klein DA, Arnold JJ, Reese ES. Provision o contraception:
key recommendations rom the CDC. Am Fam Physician. 2015;91(9):625–633
and Division o Reproductive Health, National Center or Chronic
Disease Prevention and Health Promotion, Centers or Disease Control
and Prevention (CDC). U.S. Selected Practice Recommendations or
Contraceptive Use, 2013: adapted rom the World Health Organization
selected practice recommendations or contraceptive use, 2nd edition.
MMWR Recomm Rep. 2013;62(RR-05):1–60.
HELPFUL TIP:
Ri ampin, ri aximin and ri abutin are the only antibiotic
that reduces the e ectiveness o OCPs. There ore, there
is no need or a backup method when giving penicillin
or strep throat, or example.
HELPFUL TIP:
The thinking about methods o contraception has
changed in the last several years. The IUD is becoming
increasingly popular or nulliparous teenagers. IUDs
clearly decrease pregnancy in this group when com-
pared to OCPs and do not seem to increase the risk o
STDs (N Engl J Med. 2014;371:1316). Nor do they result in
increased risky sexual activity.
The American Academy o Pediatrics (2014) rec-
ommends that a long-acting reversible contraceptive
(LARC) be considered as a irst-line contraceptive option
in adolescents; options include implants and intrauter-
ine devices (IUDs). LARCs can provide 3 to 10 years o
contraception and are e ective and sa e orms o birth
control. The use o condoms goes down with LARCs,
however (JAMAPediatr. 2016 Mar 14).

Eight onths later, the atient calls to s eak with your nurse
regarding nausea and vo iting. A arently, she decided to
sto taking her OCP. Her last enstrual eriod was 10 weeks
earlier, and she had a ositive ho e regnancy test 5 weeks
ago. Over the last week, she has been vo iting once every
day, at various ti es, but is nauseated throughout ost o the
day. She wants to know i there is anything else that is “sa e”
that she can do to decrease the nausea.
Question 15.1.5 What is your most appropriate response?
A) “T is level o nausea and vomiting is abnormal and needs an
immediate workup to rule out other pathology”
B) “T is level o nausea and vomiting is very common, and
there are several modi cations and over-the-counter medi-
cations that are sa e”
C) “T is level o nausea and vomiting is very common; how-
ever, there are no medications that can be initiated in the
rst trimester”
D) “T is level o nausea and vomiting is very common. Meto-
clopramide, promethazine, and ondansetron are our rst-
line therapies”
E) “Deal with it. You got yoursel into this mess”
Answer 15.1.5 The correct answer is “B.” Mild-to-moderate
nausea and vomiting are very common in the rst trimester o
pregnancy, o en improving by 16 weeks o gestation. Several
modi cations can improve symptoms, including small, requent
meals, avoiding atty oods, and avoiding environmental trig-
gers (per umes, smoking, position changes, or certain move-
ments). Over-the-counter remedies include ginger root or ale,
the combination o vitamin B6 (10–25 mg three to our times
daily) and doxylamine (10–12.5 mg three to our times daily).
Vitamin B6 and doxylamine may be used separately. For those
who do not respond, antiemetics including metoclopramide or
promethazine should be considered (thus, “D” represents a next
step, not a rst step). Ondansetron would be third line due to
slightly greater potential risk to the etus. Up to 2% o the time,
nausea and vomiting represent hyperemesis gravidarum, which
involves weight loss o more than 5% o prepregnancy weight or
dehydration and ketonuria.
HELPFUL TIP:
Diclegis (doxylamine succinate and pyridoxine hydro-
chloride) is now a FDA approved medication or nausea
and vomiting o pregnancy. Patients should take 2 tab-
lets at bedtime as a starting dose and may increase to 1
in the morning, 1 in the mid-a ternoon, and 2 at night-
time, i needed. However, it is way expensive and has
no advantage over the combination o OTC doxylamine
and pyridoxine.
Question 15.1.6 I the patient had instead presented with
6 to 8 episodes o emesis daily, an 8 lb weight loss since
her last menses, and a urine speci c gravity o > 1.030 and
ketonuria, your workup should have included:
CHAPTER 15 • OBSTETRICS AND WOMEN’S HEALTH 411
A) Quantitative β -human chorionic gonadotropin (β -hCG)
B) Serum electrolytes, BUN, and creatinine
C) T yroid-stimulating hormone ( SH)
D) Pelvic ultrasound
E) All o the above
Answer 15.1.6 The correct answer is “E.” As with any other
severely nauseated and vomiting patient, it is reasonable to check
or electrolyte imbalances. Severity o nausea and vomiting cor-
relates with higher levels o hCG, as would be seen with a molar
or twin pregnancy. Gestational trophoblastic disease, although
rare, should be evaluated or with an hCG level. T e ultrasound
would con rm a twin pregnancy and could provide evidence o
a molar pregnancy. SH can exclude hyperthyroidism.
Fortunately, your atient’s sy to s i roved with dietary
changes, vita in B6, and doxyla ine. She resents or her
initial renatal visit at 12 weeks o gestation.
Question 15.1.7 You o er her the routine prenatal tests at
this visit, which include all o the ollowing EXCEPT:
A) Syphilis testing
B) HIV testing
C) 1-hour glucose tolerance test
D) Blood type and antibody screen
E) Fetal nuchal translucency with maternal hCG and plasma-
associated pregnancy protein A (PAPP-A)
Answer 15.1.7 The correct answer is “C.” Diabetes screening
with a 1-hour glucose tolerance test (50-g carbohydrate load
with blood glucose obtained at 1 hour) is typically per ormed
between 24 and 28 weeks o gestation. Patients with risk ac-
tors or gestational diabetes, which our patient doesn’t have, are
candidates or earlier screening, even at the rst prenatal visit.
Risk actors include history o previous pregnancy with gesta-
tional diabetes, polycystic ovarian syndrome (PCOS), history o
macrosomia, high prepregnancy BMI, rst-degree relative with
diabetes mellitus type 2 and certain ethnic groups such as East
Asian, Hispanic, and Paci c Islander. Syphilis and HIV testing
are completed to decrease the risk o perinatal transmission. T e
blood type and antibody screen are used to identi y mothers
with blood antibodies that could cause hemolytic disease o the
etus. Mothers who are Rh negative will subsequently receive
RhoGAM as well. wo maternal serum markers, hCG and preg-
nancy-associated plasma protein (PAPP-A . . . an early screen
or Down syndrome), and one etal marker (nuchal thickness)
should be used between 11 and 14 weeks to evaluate or Down
syndrome. T is method o ers a Down syndrome detection rate
o approximately 85% with a 5% alse-positive rate.
HELPFUL TIP:
Nuchal translucency looks at luid collections in the
posterior etal neck. Increased translucency suggests
increased luid collection and is associated with abnor-
malities such as Down syndrome, Turner syndrome, and
hemodynamic problems (cardiac abnormalities).
412 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
HELPFUL (AND IMPORTANT) TIP:
Since it does not screen for neural tube defects, first-
trimester screening does not negate the need for a second
trimester maternal serum triple or quad screen. The triple
screen, which screens or chromosomal abnormalities
(e.g., Down) and neural tube de ects, includes levels
or AFP (α - etoprotein), HCG, and uE3 (unconjugated
estriol). The quadruple screen adds an inhibin A. The
triple or quadruple screen is done between 15 weeks 0
days and 19 weeks 6 days o gestation. The triple screen
has a 70% sensitivity or neural tube de ects and Down
syndrome with a 5% alse-positive rate. The quadruple
screen has an 81% sensitivity and a 5% alse-positive
rate.
T e atient has assed all o her screening tests with ying
colors, and she returns at 36 weeks o gestation.
Question 15.1.8 What additional screening test(s) is/are
obtained near 36 weeks o gestation?
A) Amniocentesis
B) 3-hour glucose tolerance test
C) Fetal bronectin (FFN)
D) Group B streptococcus (GBS) culture or PCR
E) All o the above
Answer 15.1.8 The correct answer is “D.” T e CDC recom-
mends maternal screening or GBS between 35 and 37 weeks
o gestation. T e only patients who should be excluded rom
screening are women who had bacteriuria with GBS during
the current pregnancy or those who had an in ant previously
in ected with GBS. T ese mothers are treated empirically with
antibiotics in labor and do not need screening. Mothers whose
culture or PCR status is unknown should receive antibiotic pro-
phylaxis in labor only i one o the ollowing exists: (1) intrapar-
tum ever (> 38°C), (2) preterm labor (< 37 weeks o gestation),
or (3) prolonged rupture o membranes (> 18 hours).
Objectives: Did you learn to . . .
• Describe contraception options?
• Provide appropriate routine prenatal care?
• Recognize nausea and vomiting o pregnancy and describe
its appropriate management?
CASE 15.2
You are taking obstetric calls or your grou over Labor
Day (Get it? Bad joke?) weekend. Labor and delivery calls
you about a 27-year-old G1P0 at 38 weeks o gestation who
awoke this orning co laining o wetness. However, when
she went to the bathroo she discovered signi cant vaginal
bleeding that had soaked her bed. She denies any cra ing
or abdo inal ain. She is on her way to the hos ital—and so
are you.
Question 15.2.1 You tell the nurses to call you with her
vital signs and to initiate all o the ollowing interventions
immediately upon the patient’s arrival EXCEPT:
A) Obtain IV access
B) Draw blood or type and screen
C) Per orm a digital vaginal examination
D) Initiate etal monitoring
E) Draw blood or complete blood count
Answer 15.2.1 The correct answer is “C.” A small-to-moderate
amount o bleeding is not unexpected during labor; however,
the pro use bleeding described by the patient is an obstet-
ric emergency. T e rst priorities are to obtain IV access and
ensure that the mother is hemodynamically stable. Baseline lab-
oratory evaluation will give some indication o the amount o
blood loss and establish that blood is available or trans usion i
necessary. Monitoring o the etal heart rate (FHR) will evaluate
etal status. Also, an ultrasound should be done to evaluate or
placenta previa. A digital vaginal exa ination should NO
be er or ed until the diagnosis o lacenta revia has been
excluded. A consultation with someone skilled in cesarean sec-
tion should be obtained i the initial evaluation suggests that
immediate etal delivery is necessary.
HELPFUL TIP:
Classically, placenta previa presents as painless third-
trimester bleeding, whereas placental abruption classi-
cally presents as pain ul third-trimester bleeding. Note
that these are the “classic” presentations, not pathog-
nomonic.
When the atient arrives at the hos ital, she alters her recol-
lection o events (never ha ens in our ractice) to say that
the uid soaking the bed sheets was blood-tinged and ink
in color and rst occurred 2 hours ago. She continues to have
vaginal leakage but denies any bright red bleeding or con-
tractions. Ultrasound reveals a undal lacenta (not a la-
centa revia) without any evidence o abru tion. Fetal heart
tones are in the 140s and reactive. Sterile s eculu exa i-
nation reveals uid, which is nitrazine and erning ositive
(both evidence o ru tured e branes). Her GBS culture
er or ed 3 weeks ago is negative. She is still not feeling con-
tractions, and there are no contractions on the monitor.
Question 15.2.2 What is the most appropriate next step in
the management o this patient?
A) Begin an induction o labor
B) Send her home a er 4 hours o reassuring etal monitoring
C) reat her with IV penicillin or GBS prophylaxis
D) Repeat her GBS test to con rm GBS status
Answer 15.2.2 The correct answer is “A.” A patient should
not be sent home a er rupture o membranes. She is at risk
or intrauterine in ection, and induction is indicated to reduce
the risk o in ection at term. Induction o labor, even with an

un avorable cervix, is not associated with an increase in cesar-
ean or operative vaginal delivery, but it is associated with ewer
maternal in ections and ewer neonatal intensive care unit
admissions. “C” and “D” are incorrect. Her GBS status was neg-
ative 3 weeks ago. Although GBS colonization can be transient,
since the test was collected a er 35 weeks it should be reliable.
Even i her membranes were ruptured or more than 18 hours,
she would not require treatment with antibiotics unless she
developed a ever (remember she is GBS negative . . . review the
criteria in answer 15.1.8). I a ever develo s, think chorioa -
nionitis when choosing antibiotic thera y.
Sterile vaginal exa ination reveals a cervix that is 3 c
dilated, 2 c long (e ace ent), so , anterior, and vertex at
a − 1 station. T e atient agrees to an induction o labor.
Question 15.2.3 The best induction method or this patient
is to:
A) Insert intracervical laminaria
B) Begin IV oxytocin at 2 milliunits per minute
C) Insert intravaginal dinoprostone
D) Have her partner sit on her abdomen
E) Have her run a ew laps around L&D (or walk around the
hospital)
Answer 15.2.3 The correct answer is “B.” T e use o intra-
vaginal and intracervical methods or cervical ripening could
be cautiously considered in patients with premature rupture o
membranes with an un avorable cervix; but “C” is not the best
choice—she is already 3cm dilated with a Bishop score o 6!
Drugs or cervical ripening may include prostaglandins which
act in the cervix to acilitate smooth muscle relaxation resulting
in so ening and dilatation o the cervix. T ey also may induce
myometrial contraction. Currently the only prostaglandin
labeled by the Food and Drug Administration (FDA) or such
purpose are the prostaglandin E2 agents such as dinoprostone
(Prepidil, Cervidil). Prostaglandin E1 agents such as misopro-
stol (Cytotec) inserted intravaginally are also commonly used
or cervical ripening but do not carry a label by the FDA or this
indication. Intracervical use o laminaria (an expanding pledget
placed in the cervix) (“A”) is generally reserved or pregnancy
termination. “D” would not be com ortable and may cause
undue harm to mom and the etus, and is kind o weird. “E” is
not the best choice. While walking may stimulate contractions,
she already has ruptured membranes and a more aggressive
approach is warranted.
Oxytocin should be care ully titrated via IV route or labor
induction or augmentation. T e general starting doses are 0.5
to 2 milliunits per minute, increased by 1 to 2 milliunits every
20 to 40 minutes, to a maximum dose rarely exceeding 30 to
40 milliunits per minute.
T e atient is currently in labor (success!), and now her cer-
vical exa ination is 6 c dilation, 1 c e aced, and − 1 sta-
tion. T e a niotic uid is still clear, having ru tured a rox-
i ately 22 hours ago. She has had an e idural laced or
analgesia. T e FHR baseline has increased to 165 beats er
CHAPTER 15 • OBSTETRICS AND WOMEN’S HEALTH 413
inute with ini al variability. Contractions occur every
3 inutes. Maternal te erature is now 38.6°C, and her
ulse is 110 b . T e atient denies any co laints.
Question 15.2.4 Given the history o prolonged rupture o
membranes and ever, which o the ollowing is the most
likely diagnosis?
A) Normal labor
B) Epidural ever
C) Nosocomial in ection
D) Chorioamnionitis
Answer 15.2.4 The correct answer is “D.” Chorioamnionitis
is the most likely diagnosis and the diagnosis o most concern
given the prolonged rupture o membranes (we gave you this
answer above i you were reading . . .). reatment should be initi-
ated immediately. “A” is incorrect as ever is not a normal part o
labor. “B” is possible, but not as likely and a dangerous assump-
tion. T ere is an association between the use o epidural anal-
gesia and a rise in maternal temperature. Etiologies proposed
or this temperature increase include lack o pain-induced
hyperventilation and decreased perspiration due to sympathetic
blockade. “C” is extremely unlikely given her brie time in the
hospital.
Question 15.2.5 What is the next step in the care o this
patient?
A) Increase the oxytocin to hasten delivery
B) Remove the epidural
C) Initiate broad-spectrum antibiotics
D) Call your backup or cesarean section (or do it yoursel )
E) Give acetaminophen 1,000 mg orally
Answer 15.2.5 The correct answer is “C.” Initiation o anti-
biotics is associated with a decrease in both maternal and neo-
natal morbidity. Multiple organisms are isolated in more than
66% o cases; there ore, antibiotics should be broad. Approved
regimens include ampicillin and gentamicin, ticarcillin/clavu-
lanate, or piperacillin. T ere is no need to increase the oxyto-
cin (“A”); she has already made good labor progress. T ere is
also no need to proceed with a cesarean delivery (“D”) unless
there is another indication, such as nonreassuring FHR pat-
tern. Although epidural anesthesia is associated with increased
maternal temperature, it should only be removed i it is elt to be
contributing to maternal pathology (e.g., meningitis, epidural
abscess, or epidural bleed). Acetaminophen is ne, but it should
not be used in lieu o antibiotics.
T e atient’s labor is rogressing. Her cervix is 9 c dilated,
co letely e aced, and station is + 3. Her te erature is
39.0°C. T e FHR attern is shown in Figure 15-1.
Question 15.2.6 What is the FHR interpretation?
A) Baseline 165 beats per minute, reactive
B) Baseline 165 beats per minute, with periods o bradycardia
C) Baseline 165 beats per minute, with late decelerations
D) Baseline 165 beats per minute, with variable decelerations
414
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F I
G U R E 1 5 - 1 .

TABLE 15-2 FETAL HEART TRACING
CATEGORY DEFINITIONS
CATEGORY I Tracing (normal): FHR include ALL o the ollowing:
• Baseline FHR within normal range at 110–160 bpm
• Moderate baseline FHR variability
• Absent late or variable decelerations
• Accelerations may be present or absent
CATEGORY II Tracing: Includes all FHR tracings that are not
categorized as Category I or Category III. May represent an appreciable
part o those encountered in clinical practice (atypical . . . May
represent etal hypoxia).
Any o the ollowing:
• Bradycardia with FHR < 110 bpm WITH variability
• Fetal tachycardia with FHR > 160 bpm
• Minimal baseline variability or absent baseline variability WITHOUT
recurrent decelerations, or marked baseline variability
• Absence o induced accelerations a ter etal stimulation
• Recurrent variable decelerations accompanied by minimal to
moderate baseline variability
• Prolonged deceleration > 2 minutes but < 10 minutes
• Recurrent late decelerations with moderate baseline variability
• Variable decelerations with other characteristics such as slow return
to baseline, “overshoots,” or “shoulders”
CATEGORY III Tracing (abnormal):
EITHER
• Absent baseline FHR variability AND any o the ollowing:
• Recurrent late decelerations
• Recurrent variable decelerations
• Fetal bradycardia
OR
• A sinusoidal pattern
Table adapted rom American College o Obstetricians and Gynecologists.
ACOG Practice Bulletin no. 106: Intrapartum etal heart rate monitoring,
nomenclature, interpretation and general management principles. Obstet
Gynecol. 2009;114(1):192–202.
Answer 15.2.6 The correct answer is “C.” T e FHR pictured
is described as Category II (see able 15-2) with a baseline o
about 165 beats per minute. T ere is moderate variability pres-
ent. Following each contraction, there are late decelerations to
the 110s. “A” is incorrect since “reactive” re ers to a nonstress
test, not etal monitoring during labor (see Help ul ip or
more). “B” is incorrect as etal bradycardia is de ned as an FHR
o less than 110 beats per minute or at least 10 minutes. “D”
is incorrect. Variable decelerations vary with respect to timing,
duration, and depth.
HELPFUL TIP:
Nonstress tests are per ormed outside o the intrapar-
tum period. A reactive nonstress test is de ined as two
accelerations o at least 15 beats above baseline and
lasting at least 15 seconds within a 20-minute interval
in gestations greater than 32 completed weeks. In
gestations less than 32 weeks, reactive is de ined as two
accelerations at least 10 beats above baseline and last-
ing at least 10 seconds.
CHAPTER 15 • OBSTETRICS AND WOMEN’S HEALTH 415
Question 15.2.7 What is the likely etiology o the etal heart
rate (FHR) tracing in Figure 15 1?
A) Head compression
B) Placental insuf ciency
C) Cord compression
D) Any o the above is equally likely to cause the tracing
Answer 15.2.7 The correct answer is “B.” Late decelera-
tions are believed to be secondary to transient etal hypoxia in
response to decreased placental per usion. Prompt evaluation
and intervention is warranted. Early decelerations are gener-
ally reassuring and attributed to etal head compression. Vari-
able decelerations are the most common decelerations seen in
labor and indicate cord compression. Variable decelerations can
sometimes be relieved by maternal repositioning or amnioin u-
sion (in using saline or Ringers Lactate to “reexpand” the uterus
and relieve the pressure on the cord).
Question 15.2.8 What is the LEAST appropriate course o
action now?
A) Administer maternal oxygen
B) Stop oxytocin
C) Forceps or vacuum-assisted vaginal delivery
D) Consider cesarean delivery
E) Reposition mother (roll to one side or knee–chest)
Answer 15.2.8 The correct answer is “C.” Increasing mater-
nal oxygenation may improve etal oxygenation. Oxytocin can
decrease placental blood ow via uterine stimulation, and hence
should be decreased or stopped i non-reassuring FHR changes
are present. I there is evidence o maternal hypotension, mater-
nal hydration may be indicated. Another option is position
changes (le lateral) to improve placental per usion. Maternal
position can a ect uterine blood ow and placental per usion.
T e gravid uterus may compress the vena cava while supine.
Because the patient is 9 cm dilated, orceps or vacuum-assisted
vaginal delivery (also known as “operative vaginal delivery”) is
NO indicated; dilation needs to be complete (10 cm) in order
to use orceps or vacuum
T e FHR changes resolve with your a ro riate interventions.
T e atient rogresses to co lete dilation and delivers vagi-
nally 1 hour later. Maternal antibiotics are discontinued ol-
lowing delivery, and the aternal te erature 2 hours a er
delivery is 37.0°C. On ost artu day 1, your atient co -
lains o sore breasts ro breast eeding but no articular
swelling o the breast (beyond what is ex ected ost artu ),
and her abdo en is sore “all over.” She is having a oderate
a ount o lochia, and her te erature is 38.4°C.
Question 15.2.9 The most likely cause o the ever at this
time is:
A) Endometritis
B) Mastitis
C) Deep vein thrombosis
D) Septic pelvic thrombophlebitis
416 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Answer 15.2.9 The correct answer is “A.” Whenever ever
occurs in the immediate postpartum period, endometritis
should be suspected. T e presence o intra-amniotic in ection
(chorioamnionitis) increases the risk o postpartum endometri-
tis to 13% (or 1 in 8 women, i you pre er ractions). Antibiotics
are not routinely continued or chorioamnionitis a er a vagi-
nal delivery because the “source” o the in ection (the placenta)
has been removed. Mastitis (“B”) is characterized by a swollen,
rm, tender breast with systemic symptoms including evers,
chills, and u-like symptoms. However, it was stipulated that
the breasts were normal or our postpartum patient, and having
bilateral mastitis is unlikely. Staphylococcus aureus is the typi-
cal pathogen in mastitis. Pregnancy and the postpartum period
increase a woman’s risk o thrombogenesis. However, DV (“C”)
is not a likely source o the ever. Septic pelvic thrombophlebitis
(“D”) is a diagnosis o exclusion and is usually entertained when
ever spikes continue despite treatment or endometritis.
You start a ro riate antibiotics and the atient does well.
T e a ily, in gratitude, na es the child a er you (adding
the suf x “-to s” to the child’s na e, like “ ricerato s”)
and akes you the god arent necessitating gi s or the next
18 years on the child’s birthday.
HELPFUL TIP:
In ants born to women with chorioamnionitis have a
our old increase in neonatal mortality and a three old
increase in the incidence o respiratory distress, neona-
tal sepsis, and intraventricular hemorrhage.
Objectives: Did you learn to . . .
• Triage and manage third-trimester bleeding?
• Recognize and treat a patient with premature rupture o
membranes?
• Evaluate and manage intrapartum ever?
• Interpret FHR patterns and begin initial management o
abnormal patterns?
• Appreciate the risk actors, evaluation, and management o
postpartum in ection?
CASE 15.3
You are seeing a 31-year-old G2P1 at 41 weeks o gestation
by de nite last enstrual eriod and 16-week ultrasound.
She continues to note etal ove ent and her exa ination is
nor al: BP 120/68 Hg, urine di stick negative or ro-
tein and glucose, undal height 42 c , etus is vertex, FHR
156 b . Her cervix is so , anterior, 2 to 3 c dilated, 50%
e aced, and + 1 station. She was induced with her rst reg-
nancy, and this ti e she wants to have a “natural labor.” You
decide to calculate a Bisho score.
Question 15.3.1 The Bishop score helps to determine:
A) T e health o the etus
B) T e need or cervical ripening agents or induction and
helps to predict labor induction success
C) T e maturity o the etal lungs
D) T e results o a Catholic intramural baseball game
Answer 15.3.1 The correct answer is “B.” T e Bishop score,
which takes into account cervical dilation, e acement, consis-
tency, and position, as well as etal station, is a use ul tool to
determine i cervical ripening agents are needed or induction
and to predict induction success. Calculators are readily avail-
able online.
T e Bisho score is avorable at 9–10.
Question 15.3.2 Which o the ollowing are the most appro
priate recommendations at this point?
A) She should be induced at once; there is a high chance o etal
mortality a er 41 weeks o gestation.
B) Since her antepartum course has been uncomplicated
to date, it is sa e or her to await spontaneous labor until
43 weeks o gestation.
C) She should undergo a nonstress test and ultrasound or
amniotic uid index.
D) She should plan or a cesarean section.
Answer 15.3.2 The correct answer is “C.” By de nition, a term
gestation is one completed in 38 to 42 weeks. T ere is no signi -
cant increase in etal mortality in an uncomplicated pregnancy
at term. Virtually all reports suggest an increase in perinatal
morbidity and mortality when pregnancy goes beyond 42 weeks
o gestation. Antenatal surveillance o post-term pregnancies
should be initiated at 41 weeks o gestation.
HELPFUL TIP:
Accurate determination o conception is important in
reducing the alse diagnosis o post-term pregnancy.
The estimated date o delivery is most reliably and ac-
curately determined early in pregnancy. Ultrasound
may assist in determining dates, but has a standard
o error that is dependent on the gestational age (see
Table 15-3).
Question 15.3.3 At 41 weeks she is really (really, really) tired
o being pregnant and wants “a natural way” to induce
contractions. Which o the ollowing nonpharmacologic
methods o inducing or augmenting labor is LEAST likely
to be e ective?
A) Stripping the amniotic membranes
B) Prolonged walking
C) Amniotomy
D) Nipple stimulation
Answer 15.3.3 The correct answer is “B.” Stripping mem-
branes appears to be e ective in initiating spontaneous labor
within 72 hours. Amniotomy may be used or labor induction,
especially i the Bishop score is avorable. However, a Cochrane
review rom 2013 did not nd strong evidence supporting the
use o amniotomy alone or in combination with oxytocin or
 CHAPTER 15 • OBSTETRICS AND WOMEN’S HEALTH 417

TABLE 15-3 GUIDELINES FOR DATING BASED ON ULTRASONOGRAPHY

Discrepancy Between Ultrasound Dating
Gestational Age Range Based on LMP Method o Measurement and LMP Dating that Supports Re dating
≤13 6/7 weeks CRL
• ≤8 6/7 weeks • More than 5 days
• 9 0/7 weeks to 13 6/7 weeks • More than 7 days

14 0/7 weeks to 15 6/7 weeks BPD, HC, AC, FL More than 7 days

16 0/7 weeks to 21 6/7 weeks BPD, HC, AC, FL More than 10 days

22 0/7 weeks to 27 6/7 weeks BPD, HC, AC, FL More than 14 days

28 0/7 weeks and beyond a BPD, HC, AC, FL More than 21 days

AC, abdominal circum erence; BPD, biparietal diameter; CRL, crown rump length; FL, emur length; HC, head circum erence; LMP, last menstrual period.
a
Because the risk o re-dating a small etus that may be growth-restricted, third-trimester re-dating should be guided by care ul consideration o the entire
clinical picture and close surveillance.
Adapted rom American College o Obstetricians and Gynecologists. Method or estimating due date. Committee Opinion No. 611. Obstet Gynecol. 2014;124:
863–866.

induction. Nipple stimulation causes release o oxytocin and

may be utilized or labor induction, but its marginal bene t is
only seen in patients with a avorable Bishop score. Walking
does not result in labor induction or augmentation, but it’s not
harm ul either.
HELPFUL TIP:
Sexual intercourse is sometimes recommended to in-
duce labor. Studies are o low quality and use various
endpoints . . . also, it is di icult to standardize the inter-
vention (we could make a joke here but won’t). One o
the better quality studies (Tan et al., 2006) did ind that
coitus was associated with reduced need or labor in-
duction at 41 weeks.
Question 15.3.4 I induction becomes necessary, which o
the ollowing pharmacologic interventions would be the
best approach to your patient who has a cervix that is so t,
anterior, 2 to 3 cm dilated, 50% e aced, and+ 1 station?
A) IV oxytocin
B) Intracervical PGE2 (dinoprostone)
C) Intravaginal PGE2 (dinoprostone)
D) Intravaginal PGE1 (misoprostol)
E) None o the above. All pharmacologic interventions are
contraindicated
Answer 15.3.4 The correct answer is “A.” T is patient does not
need urther cervical ripening but is a candidate or induction o
labor. I cervical ripening were needed, there are several available
agents. Option “D,” PGE1 (misoprostol, brand name Cytotec)
can be administered intravaginally or orally (but note that the
Food and Drug Administration [FDA] has not approved it or
use in pregnancy). “B” and “C”, PGE2 (dinoprostone, brand
name Cervidil) is administered intravaginally. PGE2 gel (dino-
prostone, brand name Prepidil) can be administered either
intravaginally or intracervically. Because the cervix is avorable
in this case, proceeding with oxytocin is the best option.
Your atient’s husband is called u or active duty in Iraq
(or A ghanistan . . . or Libya or . . . sadly, we are on the 4th
edition o this book and have not needed to change this
scenario) and is due to re ort in the next ew days. She is
now 41 2/7 weeks o gestation and desires induction so he
can be with her or the delivery. You ad it her to labor and
delivery the ollowing orning. T e initial FHR onitoring
be ore induction (also known as a nonstress test) is shown
in Figure 15-2.
Question 15.3.5 What is the correct interpretation?
A) Baseline 150 beats per minute; not reactive
B) Baseline 150 beats per minute; reactive
C) Baseline 180 beats per minute; decelerations to 150s; not
reactive
D) Baseline 180 beats per minute; moderate variability; reactive
Answer 15.3.5 The correct answer is “B.” T e baseline is about
150 beats per minute. T ere are two accelerations greater than
15 beats and lasting longer than 15 seconds, which meets the
criteria or a reactive nonstress test. T ere is one contraction
and evidence o uterine irritability noted as well.
HELPFUL TIP:
When interpreting FHR tracings, variability is an impor-
tant element that demonstrates etal cardiac response to
parasympathetic input. The small wave orm luctuations
within the baseline heart rate tracing represent the FHR
variability. A ter 28 weeks o gestation, variability should
be present. It is categorized as absent (no amplitude,
lat tracing), minimal (0–5 beat amplitude), moderate
(6–25 beat amplitude), or marked (> 25 beat amplitude).
The absence o variability is associated with etal decom-
pensation or distress.
418
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F I G U R E 1 5 - 2 .
 CHAPTER 15 • OBSTETRICS AND WOMEN’S HEALTH 419

Question 15.3.7 What is the correct interpretation o this

You er or a nioto y with return o articulate eco-
niu -stained uid. Her cervix is now 5 c dilated, 80%
e aced, with vertex at + 1 station. You elect to continue on-
itoring rogress.
Question 15.3.6 Which o the ollowing choices o labor
analgesia is MOST appropriate at this point?
A) Epidural analgesia
B) Local perineal anesthetic in ltration
C) Bilateral pudendal nerve block
D) All o the above are equally appropriate
Answer 15.3.6 The correct answer is “A.” Epidural analgesia
o ers the most e ective orm o pain relie and generally may be
utilized once the patient is determined to be in active labor. Var-
ious local anesthetic agents are available or local in ltration o
the perineum and vagina to provide analgesia or e isioto y or
laceration re air ollowing delivery but not or labor. Bilat-
eral pudendal nerve blocks are use ul during the second stage
o labor, as a supplement to epidural analgesia or anesthesia o
the sacral nerves, or as an option or operative vaginal delivery
anesthesia (e.g., orceps, vacuum). Opioid agonists and agonist–
antagonists are also available and commonly employed. How-
ever, some reports suggest that the analgesic e ect o opioids in
labor is limited when using the lower doses that are generally
regarded as sa er or the etus.
T e nurse notices so e changes on the etal heart onitor.
T e current FHR is shown in Figure 15-3.
FHR tracing?
A) Baseline 160 beats per minute; reactive
B) Baseline 160 beats per minutes; variable deceleration to the 90s
C) Baseline 160 beats per minute; late decelerations to the 90s
D) Baseline 160 beats per minute; early decelerations to the 90s
Answer 15.3.7 The correct answer is “B.” A variable decelera-
tion to the 90s occurs with the rst contraction on this strip.
Variable decelerations vary with respect to timing, duration, and
depth—thus, the name “variable.” T ey are not uni orm. Vari-
able decelerations represent changes in the FHR in response to
cord compression. Please re er to the able 15-2 with de nitions
and FHR tracing categories.
HELPFUL TIP:
A systematic review in 2013 showed no bene it in out-
comes or continuous FHR monitoring compared to
intermittent FHR monitoring. Un ortunately, there are
more cesarean sections and operative vaginal deliver-
ies when continuous FHR monitoring is used. However,
much o FHR monitoring use is dictated by local practice
patterns, expert consensus, and medicolegal concerns.
Question 15.3.8 Given the ndings in Figure 15 3, which o
the ollowing should be per ormed next?
A) Check the patient’s cervix
B) Place a etal scalp electrode
C) Begin IV oxytocin in usion
D) Place an intrauterine pressure catheter and begin an amnio-
in usion

240 240

210 210

180 180

150 150

120 120

90 90

60 60

30 30

#11:20
100 100
MEDS MEDS MEDS
DL DL DL
80 80
EFF EFF EFF
S TA S TA S TA
60 60
RDM RDM RDM
pH pH pH
40 40
O2 O2 O2
P ULS E P ULS E P ULS E
20 20
TEMP TEMP TEMP

FIGURE 15-3.
420 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Answer 15.3.8 The correct answer is “A.” Variable decelera-
tions are common in labor, and brie variable decelerations are
benign. When variable decelerations become recurrent, progres-
sively deeper, and longer lasting with delayed return to baseline,
they are non-reassuring and may re ect etal hypoxia. A pelvic
examination should be per ormed to determine i the umbilical
cord is prolapsed or i there has been rapid descent o the etal
head or rapid progression o labor. Oxytocin, “C,” should not be
considered in this patient since she is having adequate contrac-
tions. Replacement o the amniotic uid (“D,’’ amnioin usion)
with normal saline in used through a transcervical catheter has
been reported to decrease both the requency and severity o
repetitive variable decelerations and can decrease rate o cesar-
ean section. However, it would rst be help ul to assess the cer-
vical status. O note, amnioin usion is no longer recommended
as a prophylactic intervention or moderate or severe meconium.
Labor rogresses without incident. Your atient is now co -
letely dilated and e aced, with etal head at + 3 station. She
is co ortable with her e idural and able to ush with good
e ort. T e FHR tracing is reassuring. Contractions are every
3 inutes.
Question 15.3.9 Appropriate management at this point is:
A) Continue pushing
B) Vacuum-assisted delivery
C) Forceps-assisted delivery
D) Midline episiotomy
E) Augment with oxytocin
Answer 15.3.9 The correct answer is “A.” At this point, labor
is progressing and maternal– etal status is reassuring. You
should continue expectant management. No intervention is
indicated.
HELPFUL TIP:
Episiotomies should not be per ormed routinely. Indica-
tions or episiotomy are typically related to non-reassuring
etal status and dystocia. There is no evidence that epi-
siotomies reduce perineal trauma, postpartum dyspa-
reunia, etc.
She ushes or 3 hours. She is now exhausted. T e etal
head now se arates the labia with contractions, and then
recedes slightly. You consider o ering assistance with
delivery.
Question 15.3.10 In counseling your patient and her hus
band about the maternal risks o operative vaginal deliv
ery, which o the ollowing should you discuss?
A) Vaginal trauma
B) Shoulder dystocia
C) Fetal injury
D) Perineal and rectal trauma
E) All o the above
Answer 15.3.10 The correct answer is “E.” Maternal risks o
operative vaginal delivery include injury to the lower genital
tract and rectal sphincter involvement in the case o a third- or
ourth-degree laceration. In addition, etal complications need
to be discussed as well. Shoulder dystocia is more common with
operative delivery than with a spontaneous vaginal delivery (see
below or more in ormation).
Question 15.3.11 Each o the ollowing is a etal risk o
operative vaginal delivery EXCEPT:
A) Cephalohematoma
B) Skull racture
C) Brachial plexus injury
D) Respiratory distress syndrome
E) Facial nerve palsy
Answer 15.3.11 The correct answer is “D.” Respiratory dis-
tress syndrome is not increased by assisted delivery. Neonatal
cephalohematoma, retinal hemorrhage, and jaundice (second-
ary to breakdown and reabsorption o the cephalohematoma)
are more common with vacuum-assisted delivery than with
orceps-assisted delivery. Skull racture and acial nerve injury is
more common with orceps-assisted delivery than with vacuum-
assisted delivery. Shoulder dystocia with resultant brachial
plexus injury is more common with vacuum-assisted deliv-
ery, prolonged time required or delivery, and increasing birth
weight. Note that injury can occur be ore operative delivery as a
result o abnormal labor orces (we don’t think anyone has told
the malpractice attorneys . . .).
Delivery o an 8-lb baby is acco lished without o erative
vaginal assistance. T e ere resence o the vacuu on the
table was enough to entice the uterus to er or one last
assive contraction—assisted by the in ant clawing its way
out when it saw the vacuu co ing. Following s ontaneous
delivery o the intact lacenta 15 inutes later, you note a
large gush o blood.
Question 15.3.12 Which o the ollowing is the most likely
source o the bleeding?
A) Uterine atony
B) Vaginal laceration
C) Cervical laceration
D) Retained placenta
Answer 15.3.12 The correct answer is “A.” Postpartum hem-
orrhage is most commonly associated with uterine atony. Risk
actors include prolonged labor, over-distended uterus (such
as rom 2 or 8 gestations [remember Octomom?]), very rapid
labor, high parity, chorioamnionitis, retained placental tis-
sue, poorly per used myometrium, halogenated hydrocarbon
anesthesia, and previous uterine atony. Maternal trauma to the
genital tract (“B” and “C”) may result in postpartum hemor-
rhage and should be routinely investigated, particularly ol-
lowing operative delivery. A retained placenta cotyledon is
another common source or postpartum hemorrhage. T e
placenta should be inspected, and i there is any question o

retained products o conception, the uterus should be manu-
ally explored.
Question 15.3.13 Which o the ollowing should be under
taken next?
A) Obtain IV access and initiate hydration
B) Begin bimanual uterine compression
C) Inspect vagina and cervix or lacerations
D) Obtain blood or type and screen or possible blood trans u-
sion
E) All o the above
Answer 15.3.13 The correct answer is “E.” Postpartum hemor-
rhage is an obstetrical emergency and must be addressed imme-
diately. T e gravid uterus receives 500 mL o blood per minute,
which can lead to massive hemorrhage i not addressed quickly.
Additional personnel should be noti ed to help with obtaining
IV access and blood draws, while you quickly try to identi y the
source o bleeding.
A er thorough ex loration o the vagina and uterus, you sus-
ect uterine atony is the cause o bleeding. While continuing
uterine assage, you think about your o tions.
Question 15.3.14 Which o the ollowing is/are options in
treating this patient’s bleeding?
A) Dilute oxytocin IV
B) Methylergonovine (Methergine) IM
C) Carboprost tromethamine (Hemabate) IM
D) Misoprostol PR
E) All o the above
Answer 15.3.14 The correct answer is “E.” All o the drugs
listed cause smooth muscle contraction o the uterus. Oxytocin
can be given as a dilute IV solution or IM. It should never be
administered as an undiluted IV bolus, due to the risk o hypo-
tension and cardiac arrhythmia. Methergine (methylergono-
vine) is an ergot alkaloid and may be administered orally or
intramuscularly (not intravenously). Caution should be used
in women with hypertension, as Methergine can cause hyper-
tension. Hemabate (carboprost tromethamine) is an F-2 pros-
taglandin analog that is administered IM or directly into the
uterine myometrium. Caution should be used in women with
asthma, as Hemabate can cause bronchoconstriction. Misopro-
stol is a prostaglandin E1 analog, that works well and can sa ely
be administered to women with asthma or hypertension. Rectal
or oral administration can be used, but rectal administration is
pre erred in a patient with potential hemodynamic instability.
T is can be a li esaver especially in third world countries where
other options may not exist.
She requires IV crystalloid and 4 units o acked red cells or
sy to atic ane ia ollowing delivery. Both other and
in ant do well and the atient and baby are discharged on
ost artu day 2. You schedule a ollow-u a oint ent in
2 days. You are concerned about Sheehan syndro e given the
severe ost artu he orrhage.
CHAPTER 15 • OBSTETRICS AND WOMEN’S HEALTH 421
Question 15.3.15 All o the ollowing are characteristic o
Sheehan syndrome EXCEPT:
A) Failure in lactation
B) Amenorrhea
C) Desire to be a punk rocker
D) Decreased LH/ ollicle-stimulating hormone (FSH)
E) Adrenal cortical insuf ciency
Answer 15.3.15 The correct answer is “C.” Severe intrapartum
or postpartum hemorrhage may result in pituitary necrosis due
to hypovolemia and hypoper usion. T is leads to a global hypo-
pituitarism known as Sheehan syndrome. Sheehan syndrome
is characterized clinically by endocrine de ciency syndromes
as a result o loss o anterior pituitary unction. Initial symp-
toms may be vague (lethargy, anorexia, weight loss, dif culty
with lactation), and the syndrome can go unrecognized. Later
mani estations include ailure o lactation, amenorrhea, breast
atrophy, loss o pubic and axillary hair, adrenal cortical insu -
ciency, and hypothyroidism. Desire to be a punk rocker is
“Sheena syndrome.” I you don’t get it, you missed the Ramones.
Objectives: Did you learn to . . .
• Recognize the risks o prolonged pregnancy and identi y
appropriate timing o intervention?
• Describe the indications and risks associated with induction
o labor?
• Interpret intrapartum FHR patterns and choose appropriate
management options?
• Evaluate analgesia options, contraindications, and risks
during labor and delivery?
• Recognize the indications or and management o operative
vaginal and abdominal delivery?
• Evaluate and manage postpartum hemorrhage?
QUICK QUIZ: WHAT’S SCARIER THAN TWINS?
While on call or your small community hospital, a nurse on the
labor and delivery ward calls you about a patient with preterm
contractions. You come in to see the patient and nd a 33-year-
old G1P0 at 26 weeks o gestation by in vitro ertilization. She
is usually ollowed at an academic hospital 400 miles away. She
looks worried and says, “I’m going to have twins. But not now!”
She recalls her prenatal lab results were unremarkable. She
recalls her ultrasound showed “two heart beats.”
All o the ollowing risks are increased with a multi etal gesta-
tion EXCEP :
A) Preterm labor
B) D-isoimmunization (Rh isoimmunization)
C) Preterm rupture o membranes
D) Intrauterine growth restriction
E) win–twin trans usion syndrome
The correct answer is “B.” T e most signi cant complication o
multiple gestations is preterm labor resulting in preterm deliv-
ery. Preterm rupture o membranes and intrauterine growth
restriction also occur more requently in multiple gestations
422 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
than singleton pregnancies. T e risk o all these complications is
directly proportional to the number o etuses. win–twin trans-
usion syndrome rarely occurs and is associated with mono-
chorionic gestations. Multi etal gestations do not increase the
risk o D-isoimmunization.
CASE 15.4
A er a busy day in clinic, you get the traditional 5 pm call
ro labor and delivery. T e nurse tells you that your art-
ner’s atient is resenting with concerns or reter labor.
She is a 24-year-old G1 at 26 weeks by LMP and rst-tri ester
ultrasound. She is having contractions but no vaginal dis-
charge. T e contractions started about an hour ago and are 5
to 6 inutes a art. T e nurse asks i you want to check etal
bronectin (FFN).
Question 15.4.1 A NEGATIVE etal bronectin is associated
with:
A) Fetal lung immaturity
B) Ruptured etal membranes
C) A decreased risk o preterm birth
D) An increased risk o preterm birth
Answer 15.4.1 The correct answer is “C.” FFN is a basement
membrane protein produced by the etal membranes. A nega-
tive test is use ul in assessing the risk o preterm delivery during
the ollowing 2-week period. With a properly per ormed test in
a symptomatic patient, up to 99.5% o patients with a negative
FFN will not deliver in the subsequent 7 days. A positive test is
not use ul as the test has low positive predictive value. In per-
orming FFN testing, the ollowing criteria must be met: intact
amniotic membranes, minimal cervical dilation (< 3 cm), and
sampling between 24 0/7 and 34 6/7 weeks. Recent sexual inter-
course and the presence o vaginal discharge or bleeding may
cause a alse positive test. Collect the swab in the posterior vagi-
nal ornix be ore cervical checks and transvaginal ultrasound
as these can also cause the test to be alsely positive. FFN does
not assess etal lung maturity (“A”). Ruptured membranes (“B”)
would cause a positive FFN.
You are wondering i this atient is a good candidate or cor-
ticosteroid thera y.
Question 15.4.2 Regarding the risks and bene ts o corti
costeroid therapy or etal lung maturation, which o the
ollowing is FALSE?
A) Corticosteroid therapy is recommended or all pregnant
women between 24 and 34 weeks o gestation who are at risk
o preterm delivery within 7 days
B) Corticosteroid therapy has been associated with an increased
risk o neonatal in ection
C) Antenatal corticosteroid therapy reduces the incidence o
respiratory distress syndrome, intraventricular hemorrhage,
and necrotizing enterocolitis
D) Corticosteroids accelerate the production o pulmonary sur-
actant in the etal lungs
Answer 15.4.2 The correct answer is “B.” T ere is no evidence
that antenatal corticosteroid therapy increases the risk o neonatal
in ection. However, maternal in ection is a relative contraindica-
tion to corticosteroid therapy. Corticosteroids are recommended
or all pregnant women between 24 and 34 weeks o gestation
who are at risk o preterm delivery within 7 days. Corticosteroids
may be given a er 34 weeks i there is documented etal lung
immaturity and delivery will likely occur be ore lung maturation.
Question 15.4.3 Which o the ollowing FDA approved
tocolytics is regarded as rst line therapy to abort preterm
labor?
A) Ni edipine
B) Magnesium sul ate
C) Prostaglandin inhibitors
D) Ritodrine
E) None o the above
Answer 15.4.3 The correct answer is “E.” T e only FDA-
approved agent or use as a tocolytic was ritodrine, a β-adrenergic
receptor agonist, which was pulled rom the market in the United
States in 1993. T ere are no currently available FDA-approved
tocolytics. T us, other agents have been investigated. erbuta-
line, magnesium sul ate, prostaglandin inhibitors, and calcium
channel blockers have all been studied and may be utilized in
select cases or tocolysis—but realize that these drugs are not
approved by the FDA or this indication and that they carry sub-
stantial risks. Indomethacin has also been used success ully or
tocolysis. Again, it is not approved or this indication.
HELPFUL TIP:
Tocolysis only prolongs labor by 48 hours at best, so
the real goal should be to prolong the pregnancy until
steroids have time to be e ective. Contraindications to
tocolysis include evidence o etal distress, etal anoma-
lies, abruptio placentae, placenta previa with heavy
bleeding, and severe maternal disease.
You exa ine the atient a er collecting a FFN. Her cervix is
1 c dilated at the external os and closed at the internal os,
long, and osterior. Ultrasound shows that the in ant is ver-
tex. T e onitor shows FHR baselines o 140 and 145 b .
Contractions are irregular, occurring every 4 to 9 inutes.
Urine di stick shows a s eci c gravity o 1.030.
Question 15.4.4 The LEAST appropriate intervention in this
26 week gestation is:
A) Continuation o monitoring
B) Oral hydration
C) Obstetrical consult or cerclage placement
D) est or group B streptococci, gonorrhea, and chlamydia
E) Administration o corticosteroids
Answer 15.4.4 The correct answer is “C.” Cerclage (stitch to
hold the cervix closed) is indicated or incompetent cervix, not
preterm labor. A cerclage is typically placed in the rst part o

the second trimester a er etal viability has been established. It
would not be used at 26 weeks. T e patient should be evaluated
care ully and the requency o uterine contractions should be
assessed during the initial management. Because dehydration
may result in uterine irritability, rehydration may stabilize the
uterus. T ere is no proven bene t o hydration in the patient
who is euvolemic. Get cultures to prevent perinatal transmis-
sion even though treatment o positive cultures has not been
established to aid in the prevention o preterm birth. Cortico-
steroids are discussed earlier.
HELPFUL (AND USELESS IF NOT AT LEAST
INTERESTING) TIP:
Delivery rates in Israel go up around Jewish holiday ast
days likely because o the relative dehydration.
Objectives: Did you learn to . . .
• Recognize preterm labor and manage it appropriately?
• Understand the indications, contraindications, risks, and
bene ts o tocolytics and corticosteroids?
CASE 15.5
A 33-year-old G1 at 35 2/7 weeks resents to labor and deliv-
ery. Her regnancy has been co licated by reter labor.
Her GBS status is unknown. On ad ission, she is unco ort-
able with regular contractions every 3 to 4 inutes. T e FHR
baseline is 135 with oderate variability. Her cervix is 6 c
dilated, co letely e aced, with a bulging a niotic sac and
etus in vertex resentation.
Question 15.5.1 Which o the ollowing is your best course
o management?
A) Administer corticosteroids
B) Administer tocolytics
C) Initiate GBS prophylaxis
D) Discharge her to home until she is in active labor
E) A, B, and C
Answer 15.5.1 The correct answer is “C.” GBS prophylaxis is
indicated or preterm delivery i GBS status is unknown. Appro-
priate antibiotics include penicillin or ampicillin or an alterna-
tive intravenous agent i the patient has a penicillin allergy.
T is patient is outside the window (24–34 weeks) or cortico-
steroid administration. Given the gestational age (> 34 weeks),
advanced cervical dilation, and high likelihood o imminent
delivery, tocolysis should be avoided.
HELPFUL TIP:
Indications or GBS prophylaxis: (1) GBS screen positive
during current pregnancy; (2) GBS bacteriuria anytime dur-
ing current pregnancy; (3) prior history o giving birth to
a neonate with GBS disease; (4) unknown GBS status plus
ever or preterm labor, or prolonged rupture o mem-
branes. No GBS prophylaxis is indicated in women who are
culture negative with ever (but think about chorioamnio-
nitis!), preterm labor, or prolonged rupture o membranes.
CHAPTER 15 • OBSTETRICS AND WOMEN’S HEALTH 423
HELPFUL TIP:
The risk or recurrent premature delivery in subsequent
pregnancies is about 15%. 17α -Hydroxyprogesterone
caproate (brand name Makena) may reduce the inci-
dence o preterm birth when started at 16 to 20 weeks
and can be o ered to a woman with a singleton ges-
tation and a history o a prior spontaneous preterm
singleton birth. Recent data suggests it may be less
e ective than once thought (Lancet. 2016; Feb 23). I
prior preterm birth was secondary to an incompe-
tent or shortened cervix, then a cerclage should also
be considered (ACOG. Obstet Gynecol. 2012;120(4):
964–973).
Objective: Did you learn to . . .
• Describe indications or GBS prophylaxis?
QUICK QUIZ: PRETERM BIRTH
Risk actors or preterm birth include each o the ollowing
EXCEP :
A) Multiple gestation pregnancy
B) Maternal bacteriuria
C) Maternal history o preterm contractions with term birth
D) Maternal smoking
E) Maternal hypertension
The correct answer is “C.” While preterm contractions are con-
cerning, a maternal history o preterm contractions with term
birth does not increase the risk o preterm delivery in a subse-
quent pregnancy. Multiple gestations, history o preterm birth,
smoking, cocaine use, asymptomatic bacteriuria, and hyperten-
sion are all risk actors or preterm birth.
CASE 15.6
A 37-year-old G3 P0111 ( ull ter , reter , abortions/ is-
carriage or any reason, living children) resents or routine
obstetric care at 10 weeks o gestation. Her second regnancy
was co licated by reecla sia with severe eatures at
35 weeks requiring induction o labor and agnesiu sul-
ate thera y. Her ast edical history is unco licated. Her
blood ressure is 132/86 Hg, urine rotein is negative,
and hysical exa ination is unre arkable. Uterine size is
consistent with dates and etal heart tones are auscultated.
T e atient wonders i she will need to deliver early and need
agnesiu again.
Question 15.6.1 You counsel her that her risk o recurrent
preeclampsia with severe eatures is in the range o :
A) < 5%
B) 20% to 30%
C) 50% to 60%
D) > 90%
424 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Answer 15.6.1 The correct answer is “B.” T e risk o recur-
rence o preeclampsia is a ected by both gestational age at diag-
nosis and the severity o preeclampsia. Preeclampsia at an early
gestational age or preeclampsia with severe eatures increases
the risk o recurrence. T e overall recurrence risks are estimated
at less than 10% or mild preeclampsia and greater than 20% or
preeclampsia with severe eatures. Risk actors or preeclampsia
include young maternal age, advanced maternal age, diabetes,
and chronic hypertension, among many others.
T e atient would like to do anything reasonable to revent
reecla sia again.
Question 15.6.2 In addition to obtaining baseline labora
tory evaluation (CBC, AST, ALT, creatinine, 24 hour urine
or protein) to aid in early diagnosis, you recommend the
ollowing therapy:
A) Low-sodium diet
B) Diuretic or hypertension and edema
C) Aspirin 81 mg daily
D) Subcutaneous heparin therapy at prophylactic doses
E) None o the above
Answer 15.6.2 The correct answer is “C.” ACOG’s ask Force
on Hypertension in Pregnancy rom November 2013 recom-
mends the use o 81 mg aspirin daily in patients who have a
history o early-onset preeclampsia with preterm delivery or in
patients with a history o preeclampsia in more than one prior
pregnancy. USPS F recommends the use o low-dose aspirin as
a preventive medication a er 12 weeks o gestation in women
who are at high risk or preeclampsia.
Because o her age (37 years), the atient also inquires about
her risk or delivering a baby with Down syndro e.
Question 15.6.3 What is her estimated risk o a Down syn
drome baby with this pregnancy?
A) 1/9,000
B) 1/1,200
C) 1/150
D) 1/12
Answer 15.6.3 The correct answer is “C.” T e risk o Down
syndrome begins to rise rapidly at age 35, with an estimated risk
o 1/250 at age 35, 1/150 at age 37, and 1/70 at age 40.
A er hearing her age-related risk or Down syndro e, the
atient asks about what tests she should have to screen or
Down syndro e.
Question 15.6.4 You counsel her regarding various tests
and o er:
A) First-trimester triple screening (PAPP-A, hCG, and nuchal
lucency)/integrated screening
B) Chorionic villus sampling (CVS)
C) Amniocentesis
D) Second-trimester quadruple screening (hCG, maternal
serum alpha etal protein [MSAFP], estriol, inhibin A)
E) Cell- ree etal DNA testing rom maternal peripheral blood
F) All o the above
Answer 15.6.4 The correct answer is “F.” All patients should be
o ered rst-trimester screening, and i declined, they should be
o ered second-trimester quadruple screening. Because o her
advanced age (> 35 years at the time o delivery), the patient
should be o ered CVS and amniocentesis as well. Patients
should understand that the rst- and second-trimester screen-
ing tests are just that—screening ethods. However, both CVS
and amniocentesis can diagnose Down syndrome, in addition
to other chromosomal abnormalities. CVS is typically com-
pleted between 10 and 13 weeks o gestation, whereas amnio-
centesis is per ormed a er 15 weeks. Both are invasive proce-
dures, which carry risks, including pregnancy loss, rupture
o membranes, and etal injury. Cell- ree etal DNA testing is
a newer and noninvasive screening test that can be done a er
10 weeks o gestation in patients at high risk or aneuploidy. I
abnormal, it should be ollowed up with a diagnostic test, such
as an amniocentesis.
T e atient has a negative rst-tri ester screening, which
decreases her Down syndro e risk to 1/800. She declines an
a niocentesis. You draw her MSAFP only at 17 weeks, because,
as you learned above, the rst-tri ester screening does not
evaluate or neural tube de ects. T e AFP is nor al. She subse-
quently undergoes diabetes screening with a 1-hour ost-50-g
glucose test, which shows a glucose level o 170 g/dL.
Question 15.6.5 The next step is:
A) Order a 3-hour glucose tolerance test
B) Set up diabetes teaching and a consult with a nutritionist/
dietician
C) Start glyburide
D) Start insulin
E) All o the above
Answer 15.6.5 The correct answer is “A.” T e 1-hour 50-g glu-
cose load test is a screening test or gestational diabetes. Since
hers is abnormal (≥ 140 mg/dL), the next step is to per orm a
diagnostic test, which is the asting 3-hour glucose tolerance
test, utilizing a 100-g glucose load.
HELPFUL TIP:
The cuto or the 1-hour 50-g glucose load (Glucola) test
is either ≥ 130 or ≥ 140 mg/dL, and either is currently
acceptable. The International Association o Diabetes
in Pregnancy Study Group has proposed new screen-
ing guidelines or gestational diabetes. These would be
more aggressive, including universal screening (with
asting glucose or A1C) at the initial visit and a glucose
level 2 hours a ter a 75-g glucose load in the second tri-
mester that would be used or screening and diagnosis.

T e patient completes her glucose tolerance test with values o :
• Fasting: 92 mg/dL
• 1 hour: 194 mg/dL
• 2 hours: 169 mg/dL
• 3 hours: 148 mg/dL
Question 15.6.6 The next step in management is:
A) Continue routine prenatal care
B) Set up diabetes teaching and a consult with a nutritionist/
dietician
C) Start glyburide
D) Start insulin
Answer 15.6.6 The correct answer is “B.” T e recommended
upper limit o normal serum glucose levels or the 3-hour glu-
cose tolerance test are:
• Fasting: 95 mg/dL
• 1 hour: 180 mg/dL
• 2 hours: 155 mg/dL
• 3 hours: 140 mg/dL
I a patient has two or more glucose levels that are above
these, she is diagnosed with gestational diabetes (GDM).
Your patient ails on three o our o her results. T e recom-
mendation is to initiate dietary modi cations including car-
bohydrate restriction with requent blood sugar monitor-
ing. I the target glucoses cannot be met with dietary changes
alone, medical therapy should be started. Although insulin has
been the standard therapy, glyburide or met ormin are also
equally appropriate or rst-line therapy. Insulin is better than
met ormin, which is better than glyburide (BMJ. 2015; 350:
h102).
T e atient is seen or her 32-week visit and her undal height
is only 28 c (which sur rises you, given her diagnosis o
gestational diabetes . . . the babies o diabetic others tend to
be large!). She has been co liant with the dietary changes
and her blood sugars are usually 80s asting and 120s 2-hour
ost randial. She has gained 20 lb so ar in the regnancy.
You send her or an ultrasound, which reveals an in ant
easuring only 28 3/7 weeks o gestation, weighing 1,168 g
(< 10th ercentile). A niotic uid volu e and u bilical
artery Do lers are nor al.
Question 15.6.7 Appropriate ollow up includes:
A) Changing the estimated due date
B) Scheduling an induction
C) Repeating the ultrasound or growth in 1 week
D) Repeating the ultrasound or growth in 4 weeks
Answer 15.6.7 The correct answer is “D.” Current ultrasound
techniques are not sensitive enough to assess growth at weekly
intervals (“C”), and there ore waiting 4 weeks would give a bet-
ter assessment o growth rate. T is in ant demonstrates intra-
uterine growth restriction. T e patient had a rst-trimester
ultrasound with her rst-trimester screening, which establishes
CHAPTER 15 • OBSTETRICS AND WOMEN’S HEALTH 425
her due date. It is ina ro riate to change her due date based
on a 32-week ultrasound (“A”). Initiating an induction would
be inappropriate without urther investigation, given the early
gestational age (“B”). You could do an ultrasound at 1 to 2 weeks
to assess amniotic uid and umbilical Doppler but not etal size.
Antenatal surveillance is indicated at this time with bi-weekly
nonstress testing.
T e atient continues with bi-weekly nonstress tests and her
ultrasound at 35 weeks reveals a ro riate interval growth,
but re ains growth-restricted at a weight o 1,846 g (< 10th
ercentile). oday her blood ressure is 146/88 Hg and
urine rotein on di stick is + 1. Ugh . . . she can’t see to
catch a break.
Question 15.6.8 At this time, appropriate intervention
includes:
A) Administering corticosteroids
B) Obtaining a 24-hour urine or protein
C) Following up with a routine appointment in 1 week
D) Starting labetalol
E) Starting lisinopril
Answer 15.6.8 The correct answer is “B.” Given the patient’s
elevated blood pressure and 1+ protein on dipstick, you need
to be concerned about recurrent preeclampsia. Urinary excre-
tion o protein may be transient, and a 24-hour urine pro-
tein level is a more accurate re ection o proteinuria and the
pre erred method to diagnose preeclampsia. Alternatively, a
protein/creatinine ratio o at least 0.3 mg/dL can also be used
or preeclampsia diagnosis. “A” is incorrect. T e patient is at
35 weeks o gestation (although measuring smaller), which is
beyond the recommended gestation at which corticosteroids
are administered (24–34 weeks). T is patient must be ollowed
up in a couple o days so that you don’t miss the diagnosis o
preeclampsia. Although anti-hypertensives such as labetalol
can be utilized in pregnancy, they are not routinely initiated
or mild elevations in blood pressure at later gestations. We
hope you avoided “E,” as ACE inhibitors are contraindicated in
pregnancy.
Serial blood ressure easure ents in the clinic reveal no
blood ressures greater than 146/88. Her nonstress test is
reactive. T e atient is sent ho e to collect her 24-hour
urine and returns in 2 days. Her blood ressure is now
148/90 Hg and she has trace rotein on urine di stick.
T e 24-hour urine returns at 180 g (her baseline 24-hour
urine rotein at the beginning o the regnancy was 116
g). She denies any headache, visual changes, nausea, or
abdo inal ain.
Question 15.6.9 Your diagnosis is:
A) Gestational hypertension
B) Preeclampsia
C) Preeclampsia with severe eatures
D) Acute renal ailure
426 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
TABLE 15-4 DIAGNOSTIC CRITERIA FOR
PREECLAMPSIA
2013 Diagnostic Criteria for Preeclampsia
Blood pressure:
• ≥ 140 mm Hg systolic or > 90 mm Hg diastolic on TWO occasions at
least 4 hours apart AFTER 20 weeks o gestation in a woman with
history o previously normal blood pressure
• ≥ 160 mm Hg systolic or ≥ 110 mm Hg diastolic; hypertension can
be con rmed within a short interval (minutes) to acilitate timely
antihypertensive therapy
AND
• Proteinuria:
• ≥ 300 mg per 24-hour urine collection (or this amount
extrapolated orm a timed collection)
OR
• Urine protein:creatinine ratio greater than or equal to 0.3 with
each measured in mg/dL
OR
• Dipstick reading o 1+ (used only i other quantitative methods
aren’t available)
OR
In the absence o proteinuria, new-onset hypertension with the onset
o any o the ollowing (laboratory values urther de ned under
“Diagnosis o Preeclampsia with Severe Features below):
Thrombocytopenia
• Renal insu ciency
• Impaired liver unction
• Pulmonary edema
• Cerebral or visual symptoms
Diagnose “Preeclampsia with Severe Features” when there is the
presence of any of the following:
• Blood pressure > 160 mm Hg systolic or ≥ 110 mm Hg diastolic on
two occasions at least 4 hours apart while the patient is on bed rest
(unless antihypertensive therapy is initiated be ore this time)
• Platelet count o less than 100,000/µL (thrombocytopenia)
• Serum creatinine concentrations greater than 1.1 mg/dL or a
doubling o the serum creatinine concentration in the absence o
other renal disease (renal insu ciency)
• Elevated blood concentrations o liver transaminases to 2× normal
concentration, severe persistent right upper quadrant or epigastric
pain unresponsive to medication and not accounted or by
alternative diagnoses or both (impaired liver unction)
• Pulmonary edema
• New-onset cerebral or visual symptoms
Adapted rom American College o Obstetricians and Gynecologists.
Executive summary: hypertension in pregnancy. Obstet Gynecol. 2013;
122(5):1122–1131.
Answer 15.6.9 The correct answer is “A.” She now has two
blood pressure readings greater than 140/90 mmHg and more
than 6-hours apart, which satis y the criteria or hyperten-
sion. Given that this elevation in blood pressure started a er
20 weeks o gestation, it is likely pregnancy related. She does
not have protein > 300 mg in a 24-hour urine collection, so she
does not meet that diagnostic criterion or preeclampsia and
does not have symptoms that would quali y her or a diagnosis
o preeclampsia with severe eatures. Note that proteinuria is no
longer required to make the diagnosis o preeclampsia. Another
abnormality such as elevated LFTs, thrombocytopenia, renal
insuf ciency, CHF, or CNS symptoms can make the diagnosis o
preeclampsia even in the absence o proteinuria. T e diagnostic
criteria or preeclampsia are outlined in able 15-4.
She returns to the of ce or her a oint ent 5 days later at
36 weeks o gestation a er having elt well over the weekend.
However, today she develo ed a headache. Her blood res-
sure is 166/112 and her urine di stick reveals 3+ rotein.
Question 15.6.10 Your next step is to:
A) Start oral labetalol and see the patient back in 2 days or a
blood pressure check
B) Repeat the 24-hour urine or protein
C) Admit to labor and delivery or blood work and monitoring,
with plans to move toward delivery
D) Immediate Cesarean section
Answer 15.6.10 The correct answer is “C.” T e clinical pic-
ture is now developing into preeclampsia with severe eatures
(headache, systolic BP > 160, diastolic BP > 110, and 3+ pro-
teinuria . . . see able 15-4). T e patient needs to be admitted
or urther monitoring o blood pressure and symptoms. In
addition, blood work should be obtained including a CBC and
liver and renal studies. Starting oral labetalol would treat the
patient’s hypertension, but this step alone is not prudent or a
patient who appears to have preeclampsia with severe eatures.
T e 24-hour urine protein collection may be help ul in meeting
the technical criteria to diagnose preeclampsia and can be done
during admission; however, the results would not change the
immediate management o the patient. I a aster evaluation is
needed, the protein/creatinine ratio could be done in this case.
However, as noted above, preeclampsia with severe eatures
can also be diagnosed without the presence o proteinuria in
the presence o certain clinical and/or laboratory ndings (see
able 15-4).
HELPFUL TIP:
In a preeclamptic patient, blood pressure can be con-
trolled with labetalol, hydralazine, or oral ni edipine.
Avoid nitroprusside. The downside o BP control is that
it reduces placental low. Also, treating the BP has
no effect on the course of preeclampsia. Therefore,
treat BP only if > 160/100 mm Hg or the patient is having
end-organ symptoms. Further in ormation on acute and
emergent management o severe hypertension can be
ound in Am Obstet Gyencol. 2015;(623):1–5.
You ad it her to the hos ital. Re eat blood ressure is
164/98 Hg and urine di stick shows 3+ rotein. Her
cervix is so , 2 c dilated, 50% e aced, with etus vertex at
− 2 station.
Question 15.6.11 What is the most appropriate interven
tion at this point?
A) Begin induction o labor
B) Start magnesium sul ate
C) Prepare or a cesarean delivery in case it is needed
D) All o the above

Answer 15.6.11 The correct answer is “D.” All o these options
are important to consider at this time. Induction with oxytocin
and treatment o preeclampsia with magnesium are appropri-
ate at this point. Obstetrical backup should be involved earlier
rather than later unless you possess the skill to do the cesarean
section yoursel .
HELPFUL TIP:
Delivery o the baby (baby and placenta, really) is the
ultimate treatment or preeclampsia and should be ini-
tiated as soon as easible when the mother’s condition
demands it.
You begin agnesiu sul ate or the reecla sia and oxy-
tocin or induction. T e induction roceeds without inci-
dent, and she delivers a viable ale in ant.
Question 15.6.12 How long will you continue the magne
sium sul ate?
A) Until delivery o the placenta
B) For 12 hours a er delivery
C) For 24 hours a er delivery
D) Until the urine protein dipstick is negative
E) Until discharge
Answer 15.6.12 The correct answer is “C.” reatment should
be continued or 24 hours ollowing delivery.
HELPFUL TIP:
Monitor deep tendon re lexes, level o consciousness,
and urine output or all patients on magnesium. Turn
o the magnesium in usion i signs o toxicity emerge
(e.g., decreased mental status, hypore lexia) or i the
patient is at risk or impending toxicity (e.g., rom renal
ailure).
ANOTHER HELPFUL TIP:
Remember all those “mag checks” you did every 2
hours as a medical student? Well, for pa tients with pre-
ecla mpsia without severe fea tures, ACOG no longer
recommends ma gnesium sulfa te a s a routine inter-
vention (again, look at Table 15-4). Not a total waste
o time, right? “Mag checks” did improve your rapport
with your patients . . . maybe. Remember that the pur-
pose o magnesium sul ate in usion is to reduce the risk
o seizures (i.e., the progression to eclampsia). The NNT
or mild preeclampsia is 100.
YET ONE MORE HELPFUL TIP:
According to ACOG guidelines, bed rest should not be
prescribed or patients with gestational hypertension or
preeclampsia without severe eatures.
CHAPTER 15 • OBSTETRICS AND WOMEN’S HEALTH 427
Objectives: Did you learn to . . .
• Screen or, diagnose, and manage gestational diabetes?
• Evaluate, diagnose, and manage hypertension in preg-
nancy?
• De ne and manage preeclampsia?
• Identi y intrauterine growth restriction?
CASE 15.7
Now, you have to rush ro L&D back to clinic (this never
ha ens, right?) where you eet a 31-year-old wo an or
reconce tion counseling. She has a history o hy ertension
and a heart ur ur. She has dys nea when cli bing stairs
but er or s nor al activities o daily living with ini-
al dif culty. She takes lisino ril 10 g daily or her blood
ressure. On hysical exa ination, heart rate is 82 b and
blood ressure is 138/90 Hg. Height is 5′ 6″ and weight is
160 lb. She a ears well.
Question 15.7.1 Regarding the management o her chronic
hypertension during pregnancy, which is the most appro
priate next step?
A) Discontinue lisinopril and begin methyldopa, labetolol, or
ni edipine and recheck blood pressure in 2 weeks
B) Increase lisinopril to 20 mg daily and recheck blood pressure
in 2 weeks
C) Make no changes at this time
D) Discontinue lisinopril; recheck blood pressure in 2 weeks
E) Either A or D is correct
Answer 15.7.1 The correct answer is “E.” ACE inhibitors are
contraindicated in pregnancy; there ore, a woman contemplat-
ing pregnancy should discontinue the medication or replace it
with a sa er alternative. In act, or a woman capable o conceiv-
ing, ACE inhibitor use is discouraged unless no better alter-
native exists and the patient is using a reliable orm o birth
control. Women with mild chronic hypertension (systolic
blood pressure 140–160 mm Hg) have a low risk or cardio-
vascular complications during pregnancy and can be managed
with nonpharmacologic therapy as long as asymptomatic. In
2 weeks, when she has her return visit, i she is hypertensive
(> 140–160/> 100 mm Hg), select a medication regarded
as sa e during pregnancy; methyldopa, ni edipine, or labet-
alol would be pre erred. You could also start one o these at
the current visit while discontinuing the ACE inhibitor. Note
that the ACOG recommendation is to treat chronic hyperten-
sion in pregnancy only i the systolic BP is >160/105 mm Hg. I
the patient has hypertension secondary to preeclampsia, ACOG
would recommend treating only i the blood pressure is greater
than >160/110 mm Hg or i there are symptoms. T ese recom-
mendations are controversial and many would initiate blood
pressure control in both groups at a lower BP. reating hyper-
tension reduces the incidence o “severe” hypertension, but
does not change outcomes (N Engl J Med. 2015;372:407–417).
See also Obstet Gynecol. 2013;122:1122 i you are interested in
this topic.
428 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Question 15.7.2 Which o the ollowing statements about
cardiovascular physiology in pregnancy is INCORRECT?
A) Blood volume and cardiac output increase by approximately
50% during pregnancy
B) Heart rate increases by 10 to 20 beats per minute, peaking in
the third trimester
C) Systemic arterial pressure increases during the rst trimes-
ter, reaches a peak in mid-pregnancy, and remains at that
level until labor and delivery
D) Le ventricular ejection raction remains constant or
increases slightly throughout pregnancy
E) A temporary rise in venous return immediately ollowing
delivery may lead to a substantial rise in le ventricular ll-
ing pressure and cardiac decompensation in women with
certain types o heart disease
Answer 15.7.2 The correct answer (and what does not hap
pen in pregnancy) is “C.” Systemic arterial pressure decreases
during the rst trimester, reaches a nadir during the second tri-
mester, and returns to prepregnancy levels in the third trimes-
ter. T e other statements are true. “E” deserves special mention.
Immediately ollowing delivery, relie o caval compression may
cause a rise in venous return leading to clinical deterioration in
some women with heart disease.
Objectives: Did you learn to . . .
• Manage hypertension during preconception counseling?
• Recognize normal cardiac physiological changes associated
with pregnancy?
CASE 15.8
You are seeing a 28-year-old e ale who’s LMP was a roxi-
ately 7 days ago. She is co laining o vaginal bleeding and
states that she is going through one ad every 20 inutes.
Needless to say she is concerned. She is not using anything
or contrace tion. Her vital signs and examination are unre-
markable except for blood at the os.
Question 15.8.1 A ter ruling out pregnancy and assuring
that her hemoglobin is stable, what is your next step?
A) Fresh rozen plasma
B) Cyclic medroxyprogesterone 10 mg a day
C) DDAVP to maximize platelet unction
D) Observation: nonintervention is the best policy i the hemo-
globin is normal
Answer 15.8.1 The correct answer is “B.” T is patient has
abnormal uterine bleeding, which is a broad term that includes
di erent unctional and structural causes o uterine bleeding.
Dys unctional uterine bleeding (DUB) secondary to anovu-
lation is a very common cause o abnormal uterine bleeding.
One popular regimen or DUB is medroxyprogesterone 10 mg/
day or 10 days. T is should be ollowed by a withdrawal bleed.
T is regimen can be repeated or the rst 10 days o the next
3 months. Other options include starting a monophasic OCP
(three pills twice a day or 1 day, two pills twice a day or 1 day,
one pill twice a day or 1 day, and then nish out the pack).
Conjugated estrogens are a third option. ranexamic acid (an
anti brinolytic) 1.3 g orally ID or 5 days is an additional alter-
native or patients with contraindications to hormonal therapy.
Question 15.8.2 The most common side e ect o medroxy
progesterone at the above dose includes:
A) Bone marrow suppression
B) T romboembolic disease
C) Depression
D) Sore breasts
Answer 15.8.2 The correct answer is “C.” Many women will
become depressed when taking this dose o medroxyproges-
terone. T ey should be made aware o this ahead o time. T e
major side e ect o the OCP regimen or abnormal uterine
bleeding is nausea and vomiting. Consider giving the OCP regi-
men with an antiemetic. “B” is o note. Progesterones alone do
not increase clot risk. T ey do inhibit thrombolysis, however.
HELPFUL TIP:
Another long-term option or patients with chronic ab-
normal uterine bleeding, a ter workup has been com-
pleted, is Mirena IUD.
Question 15.8.3 Causes o this patient’s bleeding could
include all o the ollowing EXCEPT:
A) Hypothyroidism
B) Von Willebrand disease
C) Prolactinoma
D) Parathyroid disease
E) Uterine cancer
Answer 15.8.3 The correct answer is “D.” All o the remain-
ing can cause abnormal bleeding. Obviously, uterine cancer
would be unlikely in a 28-year-old. Other causes o bleeding to
consider are cervical polyps, endometrial polyps, adenomyo-
sis, broids, and endocrine problems such as PCOS and hypo/
hyperthyroidism, etc.
Objective: Did you learn to . . .
• Evaluate a patient with abnormal uterine bleeding?
• Treat a patient with abnormal uterine bleeding?
CASE 15.9
A 37-year-old G3 P1112 ( ull ter , reter , abortions/ is-
carriage ro any cause, living children) resents or an
annual gynecologic exa ination and has questions regard-
ing contrace tion. She is wondering i she is a candidate or
an IUD.
Question 15.9.1 All o the ollowing are contraindications
to IUD placement EXCEPT:
A) Pregnancy
B) Acute pelvic in ection

C) Undiagnosed vaginal bleeding
D) History o chlamydia in ection
Answer 15.9.1 The correct answer is “D.” Although active cer-
vicitis and acute pelvic in ammatory disease (PID) are contra-
indications to placement o an IUD, a prior chlamydia in ection
does not exclude a patient rom obtaining an IUD. Undiag-
nosed vaginal bleeding can be a sign o either endometritis
or structural abnormalities o the uterine cavity, which must
be addressed prior to considering an IUD. I you chose “A,”
some goons rom the Board are coming to relieve you o your
certi cation.
Your atient has none o these contraindications, and she
would like to roceed with the IUD. Her riends have told
her that all IUDs cause abortions, and she is unsettled by this
idea.
Question 15.9.2 The mechanism o action o IUDs (copper
or progesterone) is:
A) Aborti acient
B) Causes a sterile in ammatory reaction to a oreign body
C) Impairs sperm transport rom the cervix to the allopian
tube
D) B and C
E) All o the above
Answer 15.9.2 The correct answer is “D.” Studies detecting
levels o hCG reveal that this hormone is not present in IUD
users during the luteal phase. T us, the IUD is NO an abor-
ti acient. Studies suggest that the mechanism o action o IUDs
includes inter erence with sperm transport rom the cervix to
the allopian tube, inhibition o sperm survival, and endome-
trial in ammatory changes that inhibit implantation.
HELPFUL TIP:
The progesterone-releasing Mirena IUD is approved or
5 years o contraception versus 10 years or the copper
IUD. Skyla is approved or only 3 years.
A er all o that counseling (that you can’t bill or), her hus-
band undergoes a vasecto y. During a routine a oint ent
2 years later, she co lains o worsening enorrhagia. She
denies inter enstrual s otting. She has not noticed any
lightheadedness or dizziness, but does co lain o gener-
alized atigue. On hysical exa ination, you nd a nor al
sized thyroid and an enlarged, irregular uterus easuring
10 to 12 weeks in size. T ere are no distinct adnexal asses,
but this is so ewhat dif cult to discern due to the irregular
uterus.
Question 15.9.3 Your initial workup in this 39 year old
emale should include all o the ollowing EXCEPT:
A) CBC
B) SH
CHAPTER 15 • OBSTETRICS AND WOMEN’S HEALTH 429
C) CA-125
D) Pelvic ultrasound
E) Pregnancy test
Answer 15.9.3 The correct answer is “C.” A CBC will pro-
vide in ormation regarding the hematocrit (and there ore the
level o anemia) and platelet count—important in ormation or
someone with heavy menstrual bleeding. SH will screen or
hypothyroidism, which is a common cause o menorrhagia in a
39-year-old emale. A pelvic ultrasound will aid in the evalua-
tion o the mass palpated on examination and characterize the
location and size o any uterine broids that may contribute
to the bleeding; it will also evaluate or any adnexal masses. A
pregnancy test is always a good idea to rule out possible preg-
nancy, ectopic pregnancy, and miscarriage as an underlying eti-
ology. CA-125 is a nonspeci c tumor marker that has a high
alse-positive rate in premenopausal women. T us, CA-125
is not recommended as a screening test or ovarian cancer. It
can be used as an adjunct to pelvic ultrasound when a complex
adnexal mass is identi ed.
T e atient returns in 2 weeks ollowing her ultrasound.
Her he atocrit was 31% (indices are consistent with iron-
de ciency ane ia), latelets 195,000, and SH 2.8 U/L
(nor al). T e ultrasound reveals a uterus easuring 12 × 8 ×
6 c , with ulti le s all intra ural broids easuring less
than 2 c in dia eter. T ere is one subserosal, edunculated
broid easuring 3.5 c at the undus.
Question 15.9.4 What is the most appropriate initial man
agement?
A) Expectant management and reassurance
B) Nonsteroidal anti-in ammatory drugs (NSAIDs)
C) Gonadotropin releasing hormone (GnRH) agonists
D) Blood trans usion
E) Hysterectomy
Answer 15.9.4 The correct answer is “B.” Most broids are
asymptomatic, although the most common symptom associated
with leiomyomata ( broids) is abnormal bleeding. T is patient’s
broids are not impinging on the uterine cavity but may be
contributing to the patient’s menorrhagia. Initial treatment o
menorrhagia may include NSAIDs that inhibit prostaglandin
synthesis. NSAIDs have been shown to reduce menstrual blood
loss by 30% to 50% in women with menorrhagia. GnRH agonists
may be utilized to produce a medical menopause. However, they
are expensive, and long-term usage is associated with signi cant
side e ects (e.g., osteoporosis). Hysterectomy is the de nitive
treatment or leiomyomata in symptomatic women who have
completed childbearing. However, the mortality associated with
hysterectomy is approximately 0.5/1,000, at that age. It is gener-
ally reserved or women who have ailed medical management
or have symptoms or signs related to broid size. O particular
note, levonorgestrel-releasing IUD can be used as an alternative.
Studies have shown a reduction in uterine volume and bleeding
and an increase in hematocrit a er placement o IUD. I the
broids are intracavitary, an IUD should NO be used.
430 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
You start an NSAID. She res onds oderately well. You add
an OCP, which adequately controls her sy to s. I the
atient had not res onded to edical thera y, you ight
have considered re erral to a gynecologist or otential surgi-
cal thera y.
Question 15.9.5 What other characteristic(s) would have
prompted evaluation or surgery?
A) Prolapsing broid through the cervix
B) 5-cm submucosal myoma protruding 50% into the uterine
cavity
C) Rapidly enlarging uterus
D) 20-week sized uterus and pelvic pressure
E) All o the above
Answer 15.9.5 The correct answer is “E.” A broid prolapsing
through the cervix has a potential or necrosis and in ection and
may require surgical removal. A submucosal myoma, especially
one that distorts the uterine cavity, can contribute to menorrha-
gia. A rapidly enlarging uterus would be concerning or a uter-
ine malignancy and would require urther investigation. Larger
uterine broids are more likely to contribute to symptoms o
pelvic pressure and pain, which may only respond to surgical
correction.
T e atient returns in 1 year or her annual exa ination, and
her elvic exa ination is unchanged. However, she ex resses
concern that these broids could beco e cancerous.
Question 15.9.6 What is the risk o uterine malignancy
(leiomyosarcoma) in a patient with broids?
A) < 1%
B) 5% to 10%
C) 40% to 50%
D) 90% to 95%
Answer 15.9.6 The correct answer is “A.” T e estimated inci-
dence o leiomyosarcoma discovered at the time o surgery
or broids is less than 1%. A leiomyosarcoma is a malignant
tumor that does not arise rom preexisting benign leiomyoma.
Leiomyosarcomas typically arise in the h or sixth decade o
li e and are usually associated with abnormal bleeding or a rap-
idly enlarging uterus.
Objectives: Did you learn to . . .
• Recognized contraindications to IUD use?
• Treat menorrhagia?
• Describe management principles or uterine leiomyomas?
CASE 15.10
A 20-year-old nulligravid e ale resents or evaluation
o irregular enstrual cycles. Her ast edical history is
unco licated. Her gynecologic history is re arkable or
enarche at age 12 years, irregular enses occurring every
21 to 40 days, and lasting 5 days, with last enstrual eriod
6 onths ago. Her exa ination reveals no abnor al hair
growth, no acne, nor al anner stage V breast develo ent,
nor al external genitalia and cervix, with a slightly enlarged
uterus at 10 weeks size, and no adnexal asses.
Question 15.10.1 What is the rst test you should order?
A) Pelvic ultrasound
B) Serum prolactin level
C) Urine hCG
D) Serum FSH
E) Serum SH
Answer 15.10.1 The correct answer is “C.” Primary amen-
orrhea is de ned as either (1) the absence o menarche by 15
years with secondary sexual characteristics or (2) the absence o
menarche by 13 years o age in the absence o secondary sexual
characteristics. Secondary amenorrhea is de ned as the absence
o periods or 3 cycles in a woman who previously had menses.
Pregnancy is the most common cause o secondary amenorrhea
and thus must always be ruled out. A er pregnancy has been
excluded, the diagnostic ocus is on di erentiating between
anatomic cause, ovarian ailure, and endocrine abnormalities.
T e other tests may be done at some point, but a pregnancy test
is rst.
T e urine regnancy test is ositive. Because o her irregular
enses, you schedule her in 1 week or a vaginal ultrasound
to con r her gestational age. However, she calls your nurse
in 3 days with vaginal s otting and lower elvic cra ing.
Question 15.10.2 The most important diagnosis to con rm
or exclude is:
A) Spontaneous abortion
B) Incomplete abortion
C) Inevitable abortion
D) Ectopic pregnancy
E) win gestation
Answer 15.10.2 The correct answer is “D.” Ectopic pregnancy
is the leading cause o pregnancy-related death during the rst
trimester in the United States. Risk actors or ectopic pregnancy
include prior PID, prior ectopic pregnancy, and prior tubal
or other pelvic surgery. Spontaneous, incomplete, inevitable,
threatened, and missed abortions (or miscarriages) are terms to
describe pregnancy loss occurring be ore 20 weeks o gestation.
Each can result in signi cant maternal morbidity (including
hemorrhage and in ection) or death. However, these outcomes
are less requent than with an ectopic pregnancy.
Question 15.10.3 Which o the ollowing tests is/are impor
tant in the management o this patient?
A) Progesterone level
B) Serum quantitative β -hCG
C) Hematocrit, blood type, and screen
D) Pelvic ultrasound
E) All o the above
 CHAPTER 15 • OBSTETRICS AND WOMEN’S HEALTH 431

Answer 15.10.3 The correct answer is “E.” “A,” progesterone

T e atient returns a er her ultrasound, which reveals an
level, helps to assess the viability o the pregnancy. A proges-
intrauterine regnancy easuring 6 weeks, 5 days gestation
terone level < 5 ng/mL is non-reassuring (85% spontaneous
with cardiac activity at 110 beats er inute. T e laboratory
abortion, 14% ectopic pregnancy), and a level > 25 ng/mL is
sta called you to let you know that the antibody screen was
reassuring (< 2% ectopic pregnancies). wo serum quantitative
in error, and in act the atient is A negative, antibody screen
β -hCGs obtained 48 hours apart help assess viability. A rise in
negative. T ere ore, you ad inister RhoGAM.
level o > 66% will occur in 85% o normal pregnancies, but only
17% o ectopic pregnancies. ransvaginal ultrasounds should be
Question 15.10.5 You counsel the patient that her diagno
able to detect an intrauterine pregnancy at hCG levels o 1,500
sis at this time is:
to 2,000 IU. With hCG levels below 1,500 IU, an ultrasound is
A) T reatened abortion
o en still help ul or identi ying an adnexal mass and potential
B) Missed abortion
ectopic pregnancy. A blood type and screen and hematocrit are
C) Complete abortion
important to evaluate or Rh status and anemia and prepare or
D) Ectopic pregnancy
trans usion should the hemorrhage be signi cant.
E) All remain in the di erential
U on resentation, the atient has nor al vitals and a ears
Answer 15.10.5 The correct answer is “A.” T reatened abor-
clinically stable. T e blood work returns with a he atocrit
tion is de ned as any vaginal bleeding in the rst trimester or up
o 38% and blood type A negative, antibody screen positive
to 20 weeks o gestation, which accompanies a currently viable
for anti-D. T e hCG level is 5,500 IU and rogesterone is
intrauterine pregnancy with a closed cervix. A missed abortion
18 ng/ L. She has not received any treat ent or this bleed-
is retention o dead products o conception in utero. A complete
ing rior to co ing to your of ce.
abortion indicates the pregnancy and all products o conception
have passed rom the uterus.
Question 15.10.4 While waiting or her ultrasound, you
counsel her regarding her blood work, which indicates:
Over the next 2 days, her cra ing and bleeding increase and
A) She should receive RhoGAM immediately, given that she is
she asses tissue (co lete abortion). T e atient is so ewhat
Rh negative
anxious regarding her ertility and is concerned that she ay
B) She has previously been exposed to the D antigen and has
have so ething “wrong” with her that led to the iscarriage.
developed antibodies
C) T is etus is D antigen positive and she has developed anti-
Question 15.10.6 What is the most likely etiology o this
bodies to this etus
miscarriage?
D) She should receive RhoGAM only a er con rming that she
A) Uterine anomalies
has an intrauterine pregnancy
B) Maternal in ection
C) Undiagnosed maternal diabetes
Answer 15.10.4 The correct answer is “B.” Rh “negative” or
D) Embryonic chromosomal abnormality
“positive” re ers to the D antigen, the antigen that is responsible
or most cases o Rh sensitization. RhoGAM, or anti-D immune
Answer 15.10.6 The correct answer is “D.” Approximately
globulin, is used to prevent the development o Rh-D antibodies.
50% o rst trimester spontaneous miscarriages are due to chro-
I Rh-D antibodies are already present (i.e., the patient has
mosomal abnormalities. Some o these occur prior to clinical
already been sensitized), RhoGAM is not e ective. T is is why
recognition o the pregnancy and will go unrecognized by the
options “A” and “D” are incorrect. T is patient has evidence o
patient. All o the others can be responsible or a rst-trimester
antibodies and has previously been exposed to the Rh-D anti-
miscarriage as well but are less common.
gen. “C” is incorrect because not enough time has elapsed with
her current bleeding to have induced antibody production to
the D antigen. Without RhoGAM, 17% o mothers become sen- HELPFUL TIP:
sitized. RhoGAM is recommended with ectopic pregnancies, The rate o spontaneous abortion increases with
spontaneous abortions, induced abortions, threatened abor- advancing maternal age. For women younger than
tions, amniocentesis, antepartum hemorrhage, and routinely at 20 years with recognized pregnancies, the rate o spon-
28 weeks o gestation or Rh-D-negative women who are not taneous abortion is about 12%; the rate increases to
already sensitized. 26% in women older than 40 years.

HELPFUL TIP:
I the Rh-D-negative woman is positive or D antibody,
Question 15.10.7 The next step in the care o this patient is:
either she has previously been exposed to the D-antigen
A) Hysterosalpingogram
and mounted a response or she was given anti-D
B) Gonorrhea and chlamydia cultures
immune globulin during the previous 12 weeks (and it
C) Glucose screening
is still present).
D) Paternal chromosome testing
E) Counseling and reassurance
432 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Answer 15.10.7 The correct answer is “E.” Evaluation to
determine the cause o this patient’s pregnancy loss is not rec-
ommended. In general, evaluation is not recommended or a
single rst-trimester spontaneous loss i the woman is otherwise
healthy. Patients with 2 to 3 consecutive spontaneous pregnancy
losses are candidates or an evaluation to determine the etiology.
Objectives: Did you learn to . . .
• Maintain a high degree o suspicion or pregnancy in a pa-
tient presenting with secondary amenorrhea?
• Identi y causes o rst-trimester bleeding?
• De ne terminology used in spontaneous abortion (e.g.,
missed, completed, and threatened)?
• Manage early pregnancy loss?
• Describe Rh-D isoimmunization?
CASE 15.11
You are now assu ing care o a 28-year-old G3 P2002 at
38 3/7 weeks. Her regnancy has been unco licated. On
exa ination, you note her blood ressure is 102/66
Hg, urine di stick is negative or rotein and glucose, etal
heart tones are 154 beats er inute, and the undal height is
44 c . In reviewing her ante artu record, you note that her
revious babies weighed 8 lb 8 oz and 9 lb 6 oz at delivery. She
has no history o shoulder dystocia. During this regnancy,
her lab results have been nor al, and her 1-hour glucose
a er 75 g o glucose was 127 g/dL at 28 weeks.
Question 15.11.1 Noting that she has a size –date discrep
ancy, what is your next step in the evaluation and manage
ment o this patient?
A) 3-hour glucose tolerance test
B) Nonstress test
C) Fetal ultrasound or growth and amniotic uid index
D) Immediate induction o labor
E) Contraction stress test (CS )
Answer 15.11.1 The correct answer is “C.” Size–date discrep-
ancy can be caused by numerous maternal– etal actors. Given
the patient’s history, the likely etiologies are either etal macro-
somia or polyhydramnios. Additionally, her body habitus could
render the undal height measurement inaccurate (her weight is
not noted). o best determine the etiology, an ultrasound with
amniotic uid index is warranted. A 3-hour glucose tolerance test
(“A”) is not indicated since her screening glucose tolerance test
was normal. A nonstress test (“B”) may be warranted depend-
ing on the outcome o the etal ultrasound and amniotic uid
index. However, i growth and uid were normal, a nonstress test
would not be indicated. T e CS (“E”) is utilized to assess etal
well-being in utero. A CS is done by administering oxytocin to
induce contractions and observing the resulting FHR tracing. All
else being equal, a CS is not warranted at this time.
HELPFUL TIP:
Controversy surrounds the issue o induction or etal
macrosomia. Induction or macrosomia has not been
shown to improve maternal or etal outcomes.
Question 15.11.2 Risk actors or etal macrosomia include
all o the ollowing EXCEPT:
A) Gestational age
B) Maternal smoking
C) Excessive maternal weight gain
D) Multiparity (not a multiple gestation)
E) Macrosomia in a prior in ant
Answer 15.11.2 The correct answer is “B.” Maternal smoking
is associated with restricted etal growth. All o the others are
associated with macrosomia. Additionally, male etus and high
maternal birth weight, and bad karma in a previous li e are asso-
ciated with macrosomia.
Ultrasound ndings de onstrate a etus in the vertex resen-
tation with an esti ated etal weight o 4,200 g (9 lb 2 oz) and
an a niotic uid index o 12.6 c (nor al). You check her
cervix and note that she is 1 c dilated, 50% e aced, with
vertex at 0 station.
Question 15.11.3 The optimal management at this time is:
A) Induction o labor
B) Cesarean section
C) Expectant management
D) Repeat the ultrasound weekly
E) Initiate a weight loss program
Answer 15.11.3 The correct answer is “C.” Fetal macrosomia
is generally de ned as a birth weight greater than 4,500 g. Large
or gestational age implies a birth weight greater than the 90th
percentile or a given gestational age (or 4,000 g at delivery).
Expectant management with spontaneous labor onset gener-
ally has been shown to have the best outcomes; all interventions
entail an increase in etal and maternal morbidity.
HELPFUL TIP:
According to ACOG (2009), prophylactic cesarean
section should be o ered or estimated etal weight
> 5,000 g in nondiabetic pregnancies and > 4,500 g in
diabetic pregnancies.
HELPFUL TIP:
Maternal risk rom macrosomia is primarily related to
labor abnormalities and includes postpartum hemor-
rhage, signi icant vaginal lacerations, cesarean delivery,
and in ection.
Contractions start s ontaneously. Shortly a er arrival to
labor and delivery at 39 weeks, your atient has s ontane-
ous ru ture o e branes with clear uid and requests an
e idural or anage ent o labor ain. Her cervix is 5 c
dilated, 90%e aced, and 0 station. FHR baseline is 145 b
with oderate variability and no decelerations (a Category I
tracing). Four hours later, she is co ortable a er e idural is
laced. Her cervix is unchanged.

Question 15.11.4 Appropriate intervention at this time is:
A) Induction o labor
B) Augmentation o labor
C) Cesarean section
D) Expectant management
E) Ultrasound to con rm vertex presentation
Answer 15.11.4 The correct answer is “B.” Her labor has
su ered rom arrest o dilation and descent. At this time, the
appropriate management is augmentation o labor. Induction
o labor is the technical term or initiating uterine contrac-
tions be ore the onset o spontaneous labor, so “A” is incorrect.
While expectant management may be acceptable at this point
a er counseling the patient, there is a risk o prolonged rupture
o membranes and chorioamnionitis. Cesarean section at this
point would be premature and unnecessary.
With IV oxytocin, she roceeds to co lete and a er 2 hours o
ushing is ready to deliver. You antici ate a shoulder dystocia.
Question 15.11.5 Appropriate maneuvers to reduce a
shoulder dystocia include all o the ollowing EXCEPT:
A) McRoberts maneuver ( exing the patient’s knees up against
the abdomen)
B) Suprapubic pressure
C) Fundal pressure
D) Delivery o the posterior arm
E) Woods corkscrew
Answer 15.11.5 The correct answer is “C.” Fundal pressure
may urther worsen impaction o the shoulder and may result in
uterine rupture—both are generally considered bad outcomes.
All the others may be used to help relieve shoulder dystocia.
o manage dystocia, the Advanced Li e Support or Obstet-
rics (ALSO) course uses the “HELPERR” mnemonic: H—call
or help (wait . . . . aren’t you the help?), E—evaluate or episi-
otomy, L—legs exed at the hip and knee (McRoberts maneu-
ver), P—suprapubic pressure, E—enter to rotate etus (Rubin
II, Woods corkscrew maneuver, reverse corkscrew maneuver),
R—remove posterior arm, and R—roll the patient. T ere is no
evidence that any one maneuver is superior to another in releas-
ing an impacted shoulder or decreasing the chance o injury.
ypically, McRoberts maneuver is used rst. Last resort tech-
niques include intentional racture o the etal clavicle, cephalic
replacement (aka, the Zavanelli maneuver—pushing the head
back up into the pelvis and per orming a cesarean section), and
transcutaneous symphysiotomy. Why obstetricians continue to
use con using eponyms is beyond us. But i you want to belong
to the club you need to know the secret passwords . . . .
HELPFUL TIP:
Risk actors or shoulder dystocia include: previous shoul-
der dystocia, gestational diabetes, post-dates pregnancy,
maternal short stature, abnormal pelvic anatomy, sus-
pected etal macrosomia, protracted active phase o irst
stage o labor, protracted second stage o labor, and as-
sisted vaginal delivery.
CHAPTER 15 • OBSTETRICS AND WOMEN’S HEALTH 433
In the sa e way that carrying an u brella revents a thun-
derstor , erely being re ared or dystocia obviates the
need or s ecial aneuvers. Ha y day! i e to talk to her
about nursing.
Question 15.11.6 You tell her the bene ts o breast eeding,
which include all the ollowing EXCEPT:
A) Species-speci c and age-speci c nutrients or in ants
B) Adequate iron or premature newborns
C) High level o immune protection rom colostrum
D) Decreased risk o breast and ovarian cancer in mothers who
breast eed
E) Fewer illnesses while the in ant is breast ed
Answer 15.11.6 The correct answer is “B.” T e bene ts o
breast eeding or in ants, women, amilies, and society are well
documented. However, human milk may not provide adequate
iron or re ature newborns, term in ants whose mothers have
low iron stores, and in ants older than 6 months. All the other
choices are correct.
HELPFUL TIP:
Breast milk should only be kept at room temperature or
6 hours. However, it is sa est to re rigerate it or 4 days
maximum or reeze immediately. Do not heat re rig-
erated breast milk in the microwave, as it will destroy
valuable micronutrients. Warming in hot water is a bet-
ter way o reheating.
Your atient and her in ant do well and are discharged ho e
on ost artu day 2. She returns or her ost artu exa i-
nation in 6 weeks. She notes incontinence o urine several
ti es a day, es ecially with coughing, laughing, and sneez-
ing. She has not ex erienced nocturia, dysuria, or he aturia.
Question 15.11.7 These symptoms are indicative o which
type o incontinence:
A) Stress incontinence
B) Urge incontinence
C) Over ow incontinence
D) Functional incontinence
E) Psychogenic incontinence
Answer 15.11.7 The correct answer is “A.” Stress inconti-
nence is the involuntary loss o urine during physical activity
such as coughing, laughing, jumping, running, and sneezing.
Urge incontinence is the involuntary loss o urine associated
with an abrupt and strong desire to void (detrusor overactiv-
ity). Over ow incontinence is the involuntary loss o urine due
to under-activity o the detrusor muscle (e.g., neurogenic blad-
der) or obstruction (e.g., BPH in men) but this (urinary outlet
obstruction, not BPH) is becoming more common in women.
Functional incontinence is loss o urine associated with physical
limitations (e.g., mobility restriction, arthritis, and dementia) in
434 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
persons who have otherwise adequate bladder control. Psycho-
genic incontinence, incontinence secondary to severe depres-
sion or other psychological problem, is a rare disorder in this
population and should be considered a diagnosis o exclusion.
It is more requent in patients with dementia.
Question 15.11.8 Which o the ollowing is most important
prior to initiating incontinence therapy?
A) Evaluate or a vaginal stula using a dye instillation test
B) Obtain urinalysis ollowed by urine culture i abnormal
C) Re er or cystoscopy
D) Order urodynamic studies
Answer 15.11.8 The correct answer is “B.” T e rst step in
the diagnosis o incontinence is a detailed history and physical
examination. A urinalysis and urine culture should be obtained
to exclude urinary tract in ection. Bacteriuria should be treated
because the endotoxin produced by Escherichia coli may trig-
ger abnormal detrusor activity or act as an α -adrenergic blocker
(cool, huh?). Additional diagnostic tools may include a voiding
diary, stress test (have the patient cough or bear down and see
i there is leakage rom the urethra), checking a postvoid resid-
ual, cystometry, and cystourethroscopy. I there is concern or a
vaginal stula elicited by the history and physical examination,
dye instillation testing may be warranted (IV dye to evaluate or
a ureteral stula, bladder instillation to evaluate or a bladder
stula).
HELPFUL TIP:
Bariatric surgery (gastric banding, etc.) reduces the rate
o urinary incontinence in women who quali y: body
mass index (BMI) > 40 or BMI > 35 + comorbidities (DM,
sleep apnea, severe joint disease, weight-related cardio-
myopathy).
When you have co leted your evaluation, you deter ine
that she has stress urinary incontinence.
Question 15.11.9 The best initial treatment option is:
A) Pelvic muscle exercises
B) rial o oxybutynin hydrochloride
C) Fitting o a pessary
D) Surgical consult
E) Incontinence pads
Answer 15.11.9 The correct answer is “A.” Pelvic muscle exer-
cises (e.g., Kegel exercises) acilitate improved urinary control
in 40% to 75% o patients. T e correct method can be taught
during a routine pelvic examination. Pelvic physical therapy
can be used to provide eedback on the patient’s success with
these exercises. “B” is incorrect. Oxybutynin hydrochloride
is approved or detrusor instability (i.e., urge incontinence)
and does not appear to be e ective or stress incontinence. It
also has signi cant anticholinergic side e ects. “C” is incor-
rect. Several vaginal pessaries have been designed with the
intent o providing di erential support to the urethrovesical
junction or treatment o stress urinary incontinence. T is
is an option or many women, especially those who want to
avoid surgery, but a pessary would not be the initial treatment.
“D” is incorrect. Surgical correction is typically reserved until
6 to 12 months postpartum, as the symptoms may continue
to improve during that time. Note that surgical esh has a
very high rate o co lications when used or the treat ent
o incontinence ( id-urethral sling) and, according to the
FDA, has NO bene t over the traditional surgical treat ent
o stress incontinence. We would not subject our relatives to
this . . . . .
Objectives: Did you learn to . . .
• Evaluate and manage etal macrosomia?
• Manage a delivery complicated by shoulder dystocia?
• Discuss the bene ts o breast eeding?
• Classi y urinary incontinence and treat stress-type inconti-
nence?
CASE 15.12
A 31-year-old nulligravid single e ale resents or an
annual exa ination. She has no gynecologic concerns, and
her last enstrual eriod was 3 weeks ago. She uses oral con-
trace tion and has regular cycles. Her exa ination is unre-
arkable. T e Pa s ear returns with high-grade squa ous
intrae ithelial neo lasia (HSIL).
Question 15.12.1 You noti y her o the Pap smear ndings
and explain this indicates:
A) She has cervical cancer
B) She needs urther diagnostic testing including colposcopy
and possible biopsy
C) She needs treatment with cryotherapy or laser ablation
D) She should have the Pap smear repeated in 3 to 4 months
E) She should be enrolled in a hospice program
Answer 15.12.1 The correct answer is “B.” Cervical cytology is
the most e ective cancer-screening program ever implemented.
Both types o screening, liquid based and traditional Pap smears,
have the same accuracy, and both types are endorsed or screen-
ing. Abnormal Pap smear ndings require urther investiga-
tion with colposcopy and directed biopsy, i indicated. Given
the nding o high-grade intraepithelial neoplasia on the Pap
smear, repeating the Pap smear in 3 months is inappropriate. An
endocervical specimen (Pap smear or endocervical curettage)
will need to be per ormed regardless o the appearance o the
ectocervix to exclude endocervical pathology. reatment with a
nonexcisional procedure (“C”) is not acceptable and premature
without a biopsy to con rm the diagnosis rst.
You er or a col osco y, and the cervix a ears grossly
nor al. An endocervical Pa s ear is obtained. T ere are
acetowhite changes with areas o osaicis at the squa o-
colu nar junction ro the 4 o’clock to 11 o’clock osition.
T e col osco y is adequate.

Question 15.12.2 When you discuss the cervical ndings
you explain that:
A) She needs a biopsy o the abnormal area
B) Given the previous Pap smear, you recommend a “see and
treat” loop electrosurgical excision procedure (LEEP)
C) T e ndings are consistent with dysplasia; no urther ther-
apy is warranted
D) She needs a repeat Pap smear in 3 to 4 months
E) Either A or B would be acceptable choices
Answer 15.12.2 The correct answer is “E.” When acetic acid is
applied to the cervix, abnormal cells tend to turn white (“ace-
towhite”), and as the acetowhite ades, the degree o vascular-
ity can be appreciated. Mosaicism, or mosaic changes, re er to
areas with increased vascularity and are indicative o abnormal
changes, o en dysplasia. However, “visual” ndings at colpos-
copy are no more than suggestive, so “C” is incorrect. Biopsy
o the area is warranted to obtain a tissue diagnosis. T e see-
and-treat approach (“B”) is an option or our patient since she
is 31 years old; however the see-and-treat approach should not
be done in young women between the ages o 21 and 24 per
the current ASCCP guidelines. In this age range lesions o en
regress spontaneously. However, consider the “see and treat”
approach in any patient who is unlikely to ollow up.
T e endocervical Pa s ear is negative or dys lasia. You
also er or ed a bio sy o the acetowhite change area, which
revealed high-grade cervical intrae ithelial neo lasia (CIN III).
Question 15.12.3 Which o the ollowing do you recom
mend?
A) Hysterectomy
B) rachelectomy
C) Cytological ollow-up
D) LEEP or LASER ablation
E) 5- uorouracil intravaginally
Answer 15.12.3 The correct answer is “D.” While some
patients with severe dysplasia (CIN III) may be candidates or
a hysterectomy, it would be an overly aggressive approach in
this 31-year-old emale who has never been pregnant and may
wish to conceive in the uture. Additionally, women who had
high-grade CIN be ore hysterectomy can develop recurrent
vaginal dysplasia (VaIN) or cancer at the vaginal cu . Likewise,
trachelectomy (removal o the entire cervix) would be overly
aggressive with no added bene t over a LEEP procedure. Cyto-
logical ollow-up or “expectant management” is NO recom-
mended or high-grade dysplasia in this patient. T e likelihood
o regression is low in this patient’s age demographic, while
the likelihood o persistence or progression to cancer is unac-
ceptably high. Young women between 21 and 24 do have the
option proceeding with treatment (which is pre erred with CIN
III or inadequate colposcopy) OR observation with cytology
and colposcopy at 6 month intervals or 12 months. A LEEP
or ablation therapy would be the best recommendation in this
patient. T e use o 5- uorouracil intravaginally is typically not
recommended or initial treatment o cervical dys lasia. It is
CHAPTER 15 • OBSTETRICS AND WOMEN’S HEALTH 435
used instead or vaginal dys lasia, when the extent o disease
precludes complete excision or destruction.
Your atient wants to know the likelihood o regression to
“nor al” without treat ent.
Question 15.12.4 What will you counsel?
A) About 90% o CIN III lesions will become invasive cancer
without aggressive treatment
B) About one-third o CIN III lesions spontaneously regress
C) About two-thirds o CIN III lesions spontaneously regress
D) About 90% o CIN III lesions will remain CIN III on ollow-
up a er 10 years
Answer 15.12.4 The correct answer is “B,” although the data
on prognosis varies due to variation in histologic diagnoses
o CIN. In some studies, about one-third o untreated CIN III
lesions will spontaneously regress, while about 50% will persist
and the remaining will progress to invasive carcinoma. Other
studies have shown progression to invasive carcinoma much
higher.
She is concerned about uture childbearing i she undergoes
a LEEP.
Question 15.12.5 All o the ollowing are possible complica
tions o LEEP EXCEPT:
A) Cervical incompetence
B) Cervical stenosis
C) Cervical ectopic pregnancy
D) Decreased ertility
E) Premature rupture o membranes
Answer 15.12.5 The correct answer is “C.” Cervical incompe-
tence, stenosis, decreased ertility, and premature rupture o the
membranes have been identi ed ollowing all types o cone pro-
cedures, including LEEP, and are estimated to occur ollowing
less than 1% o procedures. Each o these complications seems
to be related to the volume o tissue removed with the procedure
rather than the procedure itsel . Cervical ectopic pregnancy is
quite rare and has NO been associated with cone or LEEP pro-
cedures.
She undergoes LEEP treat ent as reco ended. T e atho-
logy reveals CIN III with argins uninvolved.
Question 15.12.6 What do you counsel her about ollow
up?
A) She should return or a Pap smear and pelvic examination in
1 year
B) She should return or a Pap smear plus HPV co-testing in 12
and 24 months
C) She should return or a Pap smear in 2 to 3 months
D) She should return or a colposcopy and Pap smear in 2 to
3 months
E) She should just “chill out”; no ollow-up is indicated
436 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Answer 15.12.6 The correct answer is “B.” T e current rec-
ommendations or ollow-up include a Pap smear plus HPV
co-testing at 12 and 24 months. I both are negative, HPV co-
testing should then be repeated 3 years later and i all remains
negative she then may return to routine age-based screening or
20 years. I any o the Pap smears reveal atypical squamous cells
(ASC) or higher grade dysplasia, or positive high-risk HPV, the
patient should undergo repeat colposcopy.
At the ollow-u evaluation at 12 onths, her cervix a ears
nor al, without lesions or discharge. T e Pa s ear returns
as nor al with negative high-risk HPV co-testing; however,
testing is li ited by absence o endocervical cells on the Pa
s ear.
Question 15.12.7 What is the best recommendation or
management o this patient now?
A) Repeat Pap smear and co-testing in another 12 months
B) Cervical dilation and endocervical curettage
C) Cervical dilation and endocervical Pap smear
D) Repeat LEEP
E) Repeat the Pap smear as soon as possible
Answer 15.12.7 The answer is “A.” Since the HPV test was neg-
ative there is no need or urther testing at this time and screen-
ing should proceed as previously outlined above or her CIN III.
However, urther evaluation now WOULD be necessary i the
HPV was positive or unknown.
All your artners are on vacation and you are covering all their
atients’ tests. Suddenly you receive a S A age ro the
athology lab (a athological e ergency?). T ey wanted to
noti y you that they ade a istake when inter reting one o
the Pa s ear results on a 33-year-old atient and, in act, the
correct re ort should have been ASC-US (aty ical squa ous
cells o undeter ined signi cance) instead o ASC-H (aty i-
cal squa ous cells, high grade). T e lab technician is new here
and is not quite sure i they can add on an “HPV test” to the
Pa sa le.
Question 15.12.8 As you prepare yoursel to call the patient,
what do you tell her is the next step?
A) Repeat Pap smear in 1 year
B) Ask the lab personnel to investigate i the HPV test can be
done on that sample
C) Contact your malpractice attorney
D) Both A and B
Answer 15.12.8 The correct answer is “D,” according to cur
rent ASCCP guidelines. I you are able to do HPV co-testing and
it returns negative she could have repeat co-testing in 3 years. I
you choose to repeat cytology only in 1 year and it returns nor-
mal, she may return to age-appropriate screening. I the cytol-
ogy returns with any other abnormalities greater than or equal
to ASC then a colposcopy is indicated. Colposcopy would also
be indicated i the HPV test returns positive. Make sure that the
Pap report does not actually read ASC-H (atypical squamous
cells: cannot exclude high-grade SIL). In this case, colposcopy
would be indicated no matter the HPV status in this patient’s
age demographic. I the patient was pregnant, or between the
ages o 21 and 24, management would be di erent. Making sure
your malpractice insurance is current and up to date is always a
good idea but probably is unnecessary in this case.
HELPFUL (MAYBE) TIP:
The guidelines or Pap smears are ridiculously complex
and include di erences based on patient age, preg-
nancy status, etc. We strongly recommend that you re-
view the ASCCP guidelines and algorithms available at
http://www.asccp.org/consensus.shtml.
Objectives: Did you learn to . . .
• Manage an abnormal Pap test?
• Recognize the indications or colposcopy?
• Evaluate and manage cervical dysplasia?
• Recognize the risks and potential complications o LEEP?
• Manage the absence o endocervical cells on a Pap test?
CASE 15.13
You are called to the e ergency de art ent to evaluate
a atient with a 2-day history o abdo inal ain. She is a
24-year-old G1 P1 e ale whose LMP was 1 week ago. On the
“1–10” scale, her ain is a “12.” She is on oral contrace tives
or birth control. She has “never issed a ill” and “could
not ossibly be regnant.” Her ain is across her lower abdo-
en and a little ore on the right side than the le . She has
elt everish. She has had so e nausea but no vo iting. She
denies bowel or bladder roble s. Her ain i roves with
aceta ino hen and worsens with activity.
On exa ination, she a ears unco ortable but not toxic.
Her te erature is 38°C, but the rest o her vitals are nor-
al. Her abdo inal exa ination reveals decreased bowel
sounds, with tenderness to al ation ri arily across the
lower quadrants. She has ini al guarding and no rebound
tenderness. Her elvic exa ination is re arkable or cervi-
cal otion tenderness. T e uterus is o nor al size and con-
sistency with no asses.
Question 15.13.1 Which o the ollowing diagnoses can be
absolutely excluded rom your di erential at this point?
A) Ectopic pregnancy
B) Appendicitis
C) Pelvic in ammatory disease (PID)
D) Pyelonephritis
E) None o the above diagnoses should be excluded based on
the in ormation available
Answer 15.13.1 The correct answer is “E.” T e di erential
or lower abdominal pain in a young emale includes all o the
above and more. Even though your patient seems unlikely to be
pregnant due to her consistent use o contraceptives and recent
menses, you should not exclude pregnancy without a negative

TABLE 15-5 CRITERIA FOR ADMISSION FOR THE
TREATMENT OF PID
• Uncertain diagnosis
• Surgical emergencies (e.g., appendicitis) cannot be excluded
• Suspected tubo-ovarian abscess
• Concurrent pregnancy (due to high risk o maternal mortality, etal
wastage, and preterm delivery)
• Severe illness, intractable nausea and vomiting, or high ever
• Patient cannot tolerate or ollow an outpatient regimen (e.g., severe
vomiting)
• Lack o clinical response to oral outpatient antimicrobial therapy
Adapted rom Gradison M. Pelvic in ammatory disease. Am Fam Physician.
2012;85(8):791–796.
urine hCG. Emergency department studies consistently show
that women who claim to never have been sexually active can
be pregnant. Either something metaphysical is going on here or
history cannot always be trusted.
You obtain cultures/PCR or chla ydia and gonorrhea. T e
urine regnancy test is negative (“I told you not to waste
health care dollars—es ecially in this econo y,” your atient
co lains). T e urinalysis is negative or nitrites and leuko-
cytes, and the WBC is 15,600/ 3
with an increase in bands.
She re orts that she’s had an a endecto y.
Question 15.13.2 What is the most appropriate next step?
A) Consult surgery and gynecology to con rm your ndings
B) Admit or IV antibiotics and IV hydration
C) reat as an outpatient with antibiotics and schedule ollow-
up or 36 to 48 hours
D) reat with IV antibiotics on an outpatient basis utilizing vis-
iting nurse care
E) Obtain cultures, discharge the patient, and treat based on
culture results
Answer 15.13.2 The correct answer is “C.” T e patient’s his-
tory, examination, and diagnostic tests are most consistent with
pelvic in ammatory disease (PID). PID is a clinical syndrome
caused by the ascent o microorganisms rom the lower geni-
tal tract (e.g., vagina) to the upper genital tract (e.g., endome-
trium). Most cases o PID can be managed in the outpatient
setting. Indications or hospitalization are listed in able 15-5.
HELPFUL TIP:
The diagnosis o PID is a clinical one and not labora-
tory based! Untreated PID has signi icant morbidity and
mortality; empiric treatment is recommended i the pa-
tient meets the ollowing minimal diagnostic criteria:
• Uterine/adnexal tenderness or
• Cervical motion tenderness and
• No other cause or illness identi ed
Other help ul (but not necessary) criteria include:
• Temperature ≥ 38.3°C
• Abnormal cervical or vaginal mucopurulent discharge
CHAPTER 15 • OBSTETRICS AND WOMEN’S HEALTH 437
• Presence o an abundant number o white cells on sa-
line microscopy o vaginal uid
• Adnexal mass
• Laboratory evidence o gonorrhea or chlamydia in-
ection
• Elevated C-reactive protein and/or ESR
Question 15.13.3 For empiric antibiotic therapy or PID in
this patient, you prescribe:
A) Amoxicillin 500 mg PO ID or 14 days
B) Ce riaxone 250 mg IM once PLUS azithromycin 1 g
C) Ce riaxone 250 mg IM once PLUS doxycycline 100 mg PO
BID or 14 days
D) A and B
E) B and C
Answer 15.13.3 The correct answer is “C.” Recommendations
or treatment o PID include ce riaxone (Rocephin) 250 mg IM
once PLUS doxycycline 100 mg PO BID or 14 (yes, 14) days.
Metronidazole may be added to this regimen to cover anaerobic
bacteria. Note that single-dose azithro ycin is not indicated
or the treat ent o PID, only or cervicitis. T us, 14 days o
doxycycline are indicated.
T e current (2015) CDC treatment guidelines or rectal,
oral, cervical, or penile gonorrhea include ce riaxone 250 mg
IM once PLUS azithromycin 1 g or 7 days o doxycycline. T is
is true even i the patient has ONLY gonorrhea. T is is to pre-
vent the development o resistant gonorrhea and also due to the
high co-in ection rate o gonorrhea with chlamydia. I ce ri-
axone is not available, ce xime 400 mg orally in a single dose
PLUS azithromycin 1 g orally in a single dose is an appropriate
alternative. O note, patients who have been treated or gonor-
rhea should be re-tested 3 months a er treatment regardless o
whether they believe their sex partners were treated as there is a
high incidence o rein ection (CDC, 2015).
Just when you were about to discharge her the atient starts
vo iting and is unable to kee down her oral edications
(doxycycline, aceta ino hen). You ad it her and she is dis-
charged when she is tolerating oral intake and has been a e-
brile or 48 hours. You instruct her to nish a 14-day course
o doxycycline. She resents or ollow-u a week later, at
which ti e her sy to s have co letely resolved.
Question 15.13.4 Which o the ollowing is a potential
consequence o PID?
A) In ertility
B) Chronic pelvic pain
C) Increased risk or ectopic pregnancy
D) Recurrent PID
E) All o the above
Answer 15.13.4 The correct answer is “E.” All the choices
above are potential sequelae o PID. Additionally, a tubo-ovar-
ian abscess may develop.
438 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
HELPFUL TIP:
The etiology o PID is polymicrobial, although sexu-
ally transmitted in ections, predominantly gonorrhea
and/or chlamydia, are implicated in up to two-thirds o
cases. Antibiotic regimens are chosen or broad cover-
age. The CDC no longer recommends the use o luo-
roquinolones or treatment o PID or gonorrhea due to
increasing resistance. O note, there is ce triaxone-
resistant gonorrhea in Japan with intermediate-resistant
gonorrhea in the United States.
You see her next or her annual exa ination. She quit tak-
ing her oral contrace tive 3 onths ago a er se arating ro
her husband (the jerk gave her chla ydia, a er all!). Subse-
quently, her eriods have been irregular. She is not obese, has
ini al acne, and no hirsutis or galactorrhea. Her hysi-
cal exa ination is essentially nor al. Urine hCG is negative
(you did i ediately think o an hCG, didn’t you?) and a
seru SH is nor al.
Question 15.13.5 What is the most likely etiology o the
irregular cycles?
A) Anovulation
B) Pituitary tumor
C) Polycystic ovarian syndrome
D) Premature ovarian ailure
E) Androgen secreting tumor
Answer 15.13.5 The correct answer is “A.” OCPs work by sup-
pressing ovulation. Resumption o ovulation a er pill cessation
can take several months (up to 6 months). In the absence o
abnormal history, physical examination, or laboratory ndings,
the other choices are unlikely to be the etiology o the irregular
cycles in this patient.
Question 15.13.6 Each o the ollowing is appropriate initial
management o this patient’s irregular menses, EXCEPT:
A) Expectant management
B) Reestablishment o cycle regulation with OCPs
C) Progestin induced withdrawal cycles
D) Colposcopy with cervical and endometrial biopsies
Answer 15.13.6 The correct answer is “D.” Anovulation is
expected ollowing OCP cessation; thus, expectant manage-
ment is a reasonable option, as most people will resume regular
cycling within 6 months. She could also opt to resume OCPs
or cycle regulation i that is her goal. Withdrawal bleeds could
be induced by cyclical progestin challenges. Colposcopy is not
indicated in this patient as she has no cytologic abnormalities
noted that would require ollow-up with colposcopy and biopsy.
T e atient is reluctant to resu e “the ill.” You next evalu-
ate her 8 onths later. Her last eriod was 7 weeks be ore.
A urine regnancy test is ositive. Given her history o PID,
you request a quantitative seru β-hCG and are considering
a elvic ultrasound to con r intrauterine regnancy.
Question 15.13.7 What is the minimum expected increase
in quantitative hCG in early gestation in a normal preg
nancy?
A) 20% increase in 24 hours
B) 66% increase in 48 hours
C) 100% increase in 24 hours
D) 10% increase in 48 hours
E) 75% increase in 72 hours
Answer 15.13.7 The correct answer is “B.” hCG typically
doubles (increases by 100%) every 48 hours in normal gesta-
tion. T e minimum increase considered to be compatible with a
viable pregnancy is 66% in 48 hours.
Question 15.13.8 I the quantitative serum β hCG is
5,500 ng/mL and the pelvic ultrasound reveals no intrauter
ine pregnancy but a probable right tubal pregnancy, what
would be the most appropriate management option?
A) Medical management with methotrexate
B) Laparoscopic surgery with evacuation o the products o
conception
C) Consultation with someone able to do a salpingectomy i
necessary
D) Dilation and curettage
E) Hysterectomy
Answer 15.13.8 The correct answer is “C.” An ectopic preg-
nancy may rupture and become a li e-threatening event at any
point be ore complete resolution. I the patient becomes hemo-
dynamically unstable, she will need emergent surgery. T us, an
early re erral or management is warranted. Medical treatment
with methotrexate may be indicated but should be done under
close supervision with surgical consultation available.
Question 15.13.9 I the quantitative serum β hCG had
come back at 1,000 ng/mL and no ultrasound were avail
able, how would you have counseled the patient?
A) Given the history o PID, this is most likely an ectopic preg-
nancy. She should abort the pregnancy at once
B) Given the history o PID, she should remain on bed rest
until a de nitive diagnosis is made
C) She should be educated about ectopic pregnancy and mis-
carriage
D) She should have an urgent surgical consultation today or
exploratory laparotomy
E) She should read the patient education material entitled “So,
You Might Be Having an Ectopic Pregnancy”
Answer 15.13.9 The correct answer is “C.” T is β -hCG level
is consistent with an early gestation given her history o irregu-
lar cycles. However, with her history o PID, she is at risk or
ectopic pregnancy. T us, she should receive ectopic pregnancy
and miscarriage precautions. While a history o PID increases
the risk o ectopic pregnancy by 7- to 10- old, only 8% o such
patients will ever have an ectopic. So, it is still highly probable
that the patient has a normal intrauterine pregnancy. I you
chose “E,” you may also want to hand her the pamphlet entitled
“So, Your Doctor Has a Horrible Bedside Manner.”

In reality, her quantitative seru β-hCG is 6,000 ng/ L. A
elvic ultrasound con r s a viable intrauterine regnancy
at 8 4/7 weeks o gestation. She wins the ecto ic lottery.
HELPFUL TIP:
Assisted reproductive technology substantially increases
the risk o a heterotopic pregnancy (two pregnancies
with only one inside the uterus) to about 1%, and in
these patients, the rate o ectopic pregnancy is 4% to
8%, which is about our old higher than the general
population. Having one ectopic pregnancy predisposes
to having a subsequent one.
Objectives: Did you learn to . . .
• Evaluate a patient with pelvic pain?
• Diagnose and treat PID?
• Evaluate and treat irregular menses?
• Diagnose and manage ectopic pregnancies?
CASE 15.14
A 52-year-old e ale atient o yours resents or an annual
exa ination and Pa s ear. Her last enstrual eriod was
3 onths ago. She has inter ittent hot ashes and night
sweats. Her exa ination is re arkable or ild vaginal atro-
hy. She wonders about “estrogen testing” to see i she needs
hor one re lace ent thera y.
Question 15.14.1 How will you counsel her about the role
o estrogen testing?
A) Recommend against estrogen testing
B) Recommend buccal swab testing as it is the most accurate
C) Recommend asting morning serum estradiol testing
D) Recommend estrogen testing with FSH to ensure meno-
pause status
E) Recommend annual estrogen testing a er the age o 55 years
Answer 15.14.1 The correct answer is “A.” In a woman o the
right age with symptoms consistent with menopause, no testing
is recommended. esting is only recommended i the diagnosis is
unclear (e.g., a patient younger than 35). It can also be use ul when
a patient on OCPs presents with symptoms suggestive o meno-
pause. In this case, an FSH could be done a er the patient has dis-
continued hormonal contraception or 1 week (or on the last day
o her placebo pills). I the FSH is high (> 25 mIU/L), this indicates
that the patient has likely entered the menopausal transition.
She jokes that you’re robably getting kickbacks ro the
insurance co any or ordering ewer tests, and then she
asks, “How will you know i I’ going through eno ause
without an estrogen level?”
Question 15.14.2 How will you counsel her about meno
pause and its diagnosis?
A) FSH is the de nitive test
B) T ere is no de nitive test o menopause
CHAPTER 15 • OBSTETRICS AND WOMEN’S HEALTH 439
C) 6 months amenorrhea, elevated FSH, and decreased estra-
diol con rm the diagnosis
D) 12 months amenorrhea, elevated FSH, and decreased estra-
diol are the de nitive test
E) 2 years o mood swings and hot ashes will clinch the diag-
nosis
Answer 15.14.2 The correct answer is “B.” Menopause is a
clinical syndrome characterized by the cessation o spontaneous
menstrual periods along with associated symptoms o estrogen
de ciency such as hot ashes, vaginal atrophy, and psychologi-
cal symptoms. As such, there is no de nitive test.
She is concerned about eno ause and wonders i she needs
hor one re lace ent thera y.
Question 15.14.3 All the ollowing are bene ts o estrogen
containing hormone replacement therapy (HRT) EXCEPT:
A) Osteoporosis prevention
B) Decrease in colon cancer risk
C) Decrease in hot ashes and vasomotor symptoms
D) Decrease in stroke risk
Answer 15.14.3 The correct answer is “D.” We have learned a
lot about HR in postmenopausal women with data rom the
Women’s Health Initiative. Here’s a quick summary. Proven
bene ts o HR are limited to the ollowing:
• Reduced risk o osteoporosis and related ractures.
• Decreased colon cancer risk (not seen in estrogen only arm).
Data now suggest that even though the number o colon can-
cers is reduced, they are diagnosed at a more advanced stage.
HR is not recommended or chemoprevention o colon
cancer in women.
• Improvement o vasomotor symptoms such as hot ashes.
HR may increase the risk o the ollowing (variable ndings):
• Breast cancer (estrogen only arm showed a paradoxical re-
duction in risk o breast cancer)
• Myocardial in arction (estrogen only arm showed no in-
crease risk)
• Venous thromboembolic events
• Stroke
Only women with vasomotor symptoms appear to have
improved overall quality-o -li e scores with HR . Given the sig-
ni cant excess risks with HR usage, many practitioners now
recommend short-term HR use only or vasomotor symptoms
and not or osteoporosis or other purported bene ts.
Question 15.14.4 An absolute contraindication to use o
HRT is:
A) Heart disease
B) Breast cancer
C) Endometrial cancer
D) Previous thromboembolic event
E) All o the above
440 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Answer 15.14.4 The correct answer is “D.” Previous thrombo-
embolic disease is the only absolute contraindication to HR .
T e others are relative contraindications. While HR is not
routinely recommended or women who have heart disease or
a history o breast or endometrial cancer, it may be use ul in
women who have signi cant impairment in their quality o li e
rom vasomotor symptoms re ractory to other management
methods.
You discuss eno ause and the otential risks and bene ts o
HR with your atient. She decides against HR or now, but
returns in 6 onths with continued a enorrhea, hot ashes,
and vaginal dryness—which see s to bother her the ost.
Question 15.14.5 Options to treat the vaginal dryness
include which o the ollowing?
A) Systemic HR
B) Vaginal estrogen
C) Lubrication
D) All o the above
Answer 15.14.5 The correct answer is “D.” Systemic and local
estrogen administration are both e ective or treating vaginal
dryness. Lubrication with vegetable oil and speci cally manu-
actured lubricants can be e ective.
Question 15.14.6 How is vaginal atrophy most rapidly and
accurately diagnosed?
A) Biopsy o vaginal mucosa
B) Culture o vaginal swab
C) Patient’s history and physical examination
D) Serum hormone levels
E) KOH prep o vaginal swab
Answer 15.14.6 The correct answer is “C.” T e diagnosis o
urogenital atrophy is clinical, based on history and physical
examination ndings. ests such as microscopic examination o
the vaginal smear, will reveal an abundance o basal and para-
basal cells and a paucity o mature squamous epithelium. A
biopsy is a bit extreme. “B” and “E” are incorrect since atrophy
is not an in ectious issue.
Des ite your te id endorse ent o HR , she wants to try it to
reduce hot ashes. You also counsel her on other o tions to
treat hot ashes.
Question 15.14.7 Further options to treat symptomatic hot
f ashes include which o the ollowing?
A) Progesterone alone
B) Clonidine
C) Exercise
D) rial o an SSRI
E) All o the above
Answer 15.14.7 The correct answer is “E.” HR is the most
ef cacious treatment or vasomotor symptoms with almost 90%
o women responding. Other options include progestins such as
medroxyprogesterone (Provera) or megestrol (Megace), SSRIs,
clonazepam, gabapentin (Neurontin), venla axine (E exor),
clonidine, exercise, and environmental modi cations (e.g.,
thermostat settings, ans). Note that we do not list estrogen alone.
Unopposed estrogen can increase the risk o endometrial cancer
and should be avoided unless the woman has had a hysterectomy.
T ere is con icting evidence or the ef cacy o vitamin E and
black cohosh; there is no good data to suggest that propranolol
or phytoestrogens, such as soy, are e ective in treating vasomo-
tor symptoms.
Objectives: Did you learn to . . .
• Evaluate menopausal symptoms?
• Describe hormone replacement therapy, including risks, ben-
e ts, and contraindications or its use?
• Diagnose and manage atrophic vaginitis?
• Treat menopausal symptoms?
CASE 15.15
A 57-year-old ost eno ausal atient resents or her
annual exa ination. She is ex eriencing hot ashes and
night sweats, as well as a recurrence o vaginal bleeding. Her
edical history is otherwise unre arkable. She wants your
o inion about resu ing hor one re lace ent. Her el-
vic exa ination is re arkable or atro hic vaginal ucosal
changes, a stenotic cervix without lesions, nor al size uterus,
no adnexal asses, and no asses al able on rectovaginal
exa ination.
Question 15.15.1 All o the ollowing are possible causes o
her vaginal bleeding EXCEPT:
A) Cervical cancer
B) Uterine polyp
C) Polycystic ovary disease
D) Atrophic vaginitis
E) Endometrial cancer
Answer 15.15.1 The correct answer is “C.” Polycystic ovar-
ian disease does not cause vaginal bleeding in postmenopausal
women. All the other choices are diagnostic considerations in a
postmenopausal emale with vaginal bleeding or spotting.
Question 15.15.2 Which o the ollowing studies should
you consider obtaining?
A) Urinalysis
B) Pap smear
C) Endometrial biopsyv
D) Stool guaiac
E) All o the above
Answer 15.15.2 The correct answer is “E.” T e patient could
easily mistake the source o the bleeding; thus, it is prudent to
rule out a rectal or urinary source. Cervical and endometrial
evaluations are necessary to rule out gynecological pathology,
such as endometrial polyp, hyperplasia, or cancer.
 CHAPTER 15 • OBSTETRICS AND WOMEN’S HEALTH 441

TABLE 15-6 RISK FACTORS FOR Question 15.15.4 O the ollowing, the most appropriate
ENDOMETRIAL CANCER intervention is:
A) Repeating the endometrial biopsy
Advancing age
B) Per orming a transvaginal ultrasound to assess endometrial
Obesitya
Nulliparity thickness
Early menarche C) Starting high-dose progestin therapy
Late menopause D) Starting high-dose selective estrogen receptor modulator
Chronic anovulation (e.g., PCOS) therapy (e.g., tamoxi en)
Unopposed exogenous estrogen use
E) Arranging or de nitive management (e.g., hysterectomy)
Tamoxi en
Hypertension
Diabetes Answer 15.15.4 The correct answer is “E.” Her biopsy ndings
Estrogen producing tumor are highly abnormal and may indicate already existing carci-
Lynch Syndrome noma that was not contained in the sample examined. Re erral
a
to a gynecologist or de nitive management is warranted at this
Obesity leads to increased estrogen levels rom peripheral conversion o
androstenedione. The presence o DM and HTN as risk actors may simply
time.
re ect the high incidence o obesity in patients with these disorders.

Question 15.15.3 All o the ollowing increase the risk o
endometrial cancer EXCEPT:
A) Smoking
B) Obesity
C) Unopposed estrogen
D) Diabetes
E) Hypertension
Answer 15.15.3 The correct answer is “A.” Endometrial can-
cer is believed to be caused by unopposed estrogen stimu-
lation o the endometrium. Smoking decreases luteal phase
estrogen and is epidemiologically linked to a decrease in the
risk or endometrial carcinoma (o course, this risk is o set
by the other adverse health e ects o smoking—go gure!).
Risk actors and protective actors are listed in the ables 15-6
and 15-7.
HELPFUL TIP:
In postmenopausal women, an endometrial stripe o
greater than 5 mm on ultrasound is suggestive o en-
dometrial cancer. With an endometrial stripe o < 4 mm,
malignancy is rare. In evaluation o postmenopausal
women with vaginal bleeding, transvaginal ultrasound
is an alternative to endometrial biopsy when an endo-
metrial biopsy cannot be done. Further bene it o ob-
taining a transvaginal ultrasound, regardless o endo-
metrial biopsy, is that it can detect structural lesions or
masses.
Objectives: Did you learn to . . .
• Evaluate postmenopausal bleeding?
• Manage a patient with postmenopausal bleeding?
• Assess patient or risk o endometrial cancer?

You review your atient’s test results: nor al Pa s ear and

urinalysis, stool guaiac negative or blood, and endo etrial
bio sy with rag ents o benign oly .
Over the next 3 years, she continues to have rare occur-
rences o vaginal s otting. She has declined urther evalu-
ation given the in requency o the e isodes. However, over
the last several onths, she has ex erienced an increase in
the a ount and requency o the bleeding. Other than an
interval weight gain o 27 lb, there has been no change in her
exa ination. Re eat endo etrial bio sy reveals co lex
hy er lasia with aty ia, and the athologist cannot rule out
endo etrial cancer.
TABLE 15-7 PROTECTIVE FACTORS FOR
ENDOMETRIAL CANCERa
Progesterone
Oral contraceptives
Cigarette smoking
Multiparity
Child bearing at an older age
a
All reduce exposure to unopposed estrogens.
CASE 15.16
A 15-year-old nulligravid e ale resents with her other
or evaluation o ain ul eriods. Menarche was at age 14.
Her eriods are ty ically every 4 to 8 weeks and are asso-
ciated with severe cra ing. She has issed 1 to 2 days o
school with each enses because o ain. She denies inter-
course. She has never had a elvic exa ination. Her review
o syste s is otherwise negative.
Question 15.16.1 What is the MOST LIKELY etiology o her
irregular cycles?
A) Pregnancy
B) Endometriosis
C) Anovulation
D) Hyperthyroidism
E) Imper orate hymen
Answer 15.16.1 The correct answer is “C.” Abnormal uterine
bleeding is common among adolescent girls who have reached
menarche. T e rst ew years o menstruation are o en charac-
terized by irregular cycles as a result o anovulation. Pregnancy
442 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
and imper orate hymen lead to absence o menses, not irregular
menses. While hyperthyroidism may lead to irregular cycles, it
does not typically cause dysmenorrhea and is usually associated
with other systemic complaints. Additionally hyperthyroidism
would be unusual, but not out o the question, in a patient o this
age. Endometriosis may cause dysmenorrhea, but is unlikely to
occur in a patient this young; most cases o endometriosis pres-
ent in patients aged 20s to 30s.
Question 15.16.2 What is the etiology o her dysmenor
rhea?
A) Prostaglandin release
B) Streptococcal endotoxin release
C) Estrogen release
D) Excessive testosterone production
Answer 15.16.2 The correct answer is “A.” Dysmenorrhea is
the term that describes excessive pain in association with men-
struation. It is the most common gynecologic complaint, a ects
about hal o all adolescent emales, and is the leading cause o
periodic school absenteeism. T e pathogenesis o dysmenor-
rhea involves excess prostaglandin release, which causes pro-
longed, pain ul uterine contractions. It can be divided in two
main subtypes: primary and secondary. Primary dysmenorrhea
usually starts be ore the age o 20 and has a tendency to occur
with menarche. It is caused by prostaglandin stimulation o the
myometrium. Secondary dysmenorrhea typically arises a er
the age o 20 and is associated with pelvic pathology or other
organic disease.
You er or a hysical exa ination, revealing nor al vital
signs, nor al weight, a benign abdo en, anner stage V, and
no signs o androgen excess.
Question 15.16.3 Which o the ollowing is the best next
step in caring or this patient?
A) O er reassurance and observation
B) Initiate combined hormonal contraception
C) Initiate a GnRH agonist
D) Prescribe a narcotic analgesic
E) Re er or diagnostic laparoscopy
Answer 15.16.3 The correct answer is “B.” OCPs o er cycle
regulation and a reduction in dysmenorrhea. “A,” expect-
ant management, is inappropriate given the severity o symp-
toms and availability o sa e and e ective treatment. A urther
workup is not needed at this stage, as her history is straight-
orward and her physical examination is reassuring. She cer-
tainly does not need surgery now (“E”). “C” is incorrect. GnRH
agonists will induce amenorrhea, hot ashes, accelerated bone
loss, are expensive, and require add-back estrogen when utilized
longer than 6 months. Narcotic analgesics (“D”) do not help
reduce prostaglandin levels and are not appropriate or pain
control in this case. NOTE: Although not listed in the answers,
NSAIDs are also quite e ective at treating dysmenorrhea and
should be considered as a rst-line drug. Anecdotal evidence
suggests that me enamic acid (Ponstel) may be more e ective
or dysmenorrhea than other NSAIDs. Acetaminophen is not as
e ective as NSAIDs.
HELPFUL TIP:
The average age o menarche is 12.8 years in the United
States, with the range rom 10 to 15 years.
Your atient and her other o t to try hor onal regulation
with birth control ills. She returns or ollow-u in 4 onths
and is doing well. She ad its to being sexually active.
Question 15.16.4 In addition to reviewing the use o birth
control pills, she should be questioned or counseled about
which o the ollowing?
A) Knowledge o sexually transmitted diseases and use o con-
doms
B) Age o her boy riend
C) Consensual nature o her relationship
D) HPV vaccination
E) All o the above
Answer 15.16.4 The correct answer is “E.” Visits or contra-
ception are great opportunities or you to discuss sa e sexual
practices with the patient. Such an interview should include
evaluation or sexual assault, coercion, or abuse. Although she
is a little late or starting HPV vaccination, “D” is still correct
(better late than never—truly!). T e Advisory Committee on
Immunization Practices (ACIP) recommends the routine use o
quadrivalant (Gardasil), 9-valent, or bivalent HPV vaccine in
emales rom age 9 to 26 years. T e quadrivalent HPV vaccine
protects against HPV types 6, 11, 16, and 18. HPV types 6 and
11 are commonly associated with genital warts, while 16 and 18
are commonly responsible or cervical cancer. T e 9-valent vac-
cine protects against HPV types 6, 11, 16, 18, 31, 33, 45, 52, and
58. Both the quadrivalent and the 9-valent vaccines are given
in 3 doses (0, 2, and 6 months rom rst dose). T ere is also
a bivalent vaccine (brand name Cervarix) that protects against
HPV types 16 and 18 only and is approved or use in emales
aged 11 to 25 years. It is given as a three-injection series at 0, 1,
and 6 months. In general, the 9-valent vaccine should be used
i it is an option.
HELPFUL TIP:
HPV is the most common viral sexually transmitted in-
ection in the United States with point prevalence in
emales ranging rom 26% to 64%. Many patients have
serial in ections with di erent HPVtypes. A two-shot se-
ries may be as e ective as a three-shot series but has
not yet been endorsed as o icial policy. I the vaccina-
tion series is interrupted or any length o time, it can be
resumed without restarting the series.

HELPFUL TIP:
The best time to check a pregnancy test is a ter the
irst missed menses. Otherwise, you risk having a alse-
negative test. Even on day 1 o a missed menses, the
sensitivity is only 90% (thus, patients can present with
an ectopic pregnancy with a negative urine pregnancy
test).
You lose touch with the atient, and she discontinues her OCP.
Years later when she returns or a hysical exa ination—
and you’re still aying o your student loans—she co lains
o increasing irritability along with inter ittent bloating
and swelling during the week be ore her eriod each onth.
Although she is annoyed by these sy to s, they are not
so severe as to inter ere with her usual activities. Her en-
ses now occur onthly without inter enstrual s otting or
issed eriods.
Question 15.16.5 What is her most likely diagnosis?
A) Major depression
B) Premenstrual dysphoric disorder (PMDD)
C) Premenstrual syndrome (PMS)
D) Polycystic ovary syndrome (PCOS)
E) Hypothyroidism
Answer 15.16.5 The correct answer is “C.” PMS is a constel-
lation o physical, emotional, and behavioral symptoms. It is
cyclical in nature, occurs during the second hal o the men-
strual cycle (luteal phase, 7–10 days be ore menses), and
resolves soon a er menses. A symptom- ree interval occurs
during the rst hal o the cycle ( ollicular phase). PMDD is
more severe but occurs during the same time rame as PMS.
Symptoms o PMDD include labile mood, depressed mood,
irritability, eelings o hopelessness, hypersomnia or insomnia,
and decreased interest in usual activities. PMDD is diagnosed
by DSM-V criteria and some unctional impairment must be
present.
HELPFUL TIP:
Premenstrual symptoms exist on a continuum with
up to 90% o women a ected by minimal PMS symp-
toms while 10% are severely a ected. This group with
more severe symptoms can be categorized as having
PMDD.
Question 15.16.6 Each o the ollowing is a key element o
the diagnosis o PMS EXCEPT:
A) Physical symptoms o bloating, swelling, and/or atigue
B) Elevated luteinizing hormone to ollicle stimulation hor-
mone (LH:FSH) ratio
C) Restriction o symptoms to the luteal phase o the menstrual
cycle
D) Exclusion o other diagnoses that may better explain the
symptoms
CHAPTER 15 • OBSTETRICS AND WOMEN’S HEALTH 443
TABLE 15-8 TREATMENT OPTIONS FOR
PREMENSTRUAL SYNDROME
Nonpharmacologic
Aerobic exercise
Increased intake o complex carbohydrates and ber
Reduction in sodium, caf eine, and alcohol intake
Supportive psychotherapy
Pharmacologic
Anxiolytics such as buspirone and benzodiazepines
Calcium and vitamin D supplementation
Danazol
Hormonal treatment (combination OCPs, GnRH agonists,
progesterones)
NSAIDs
Serotonergic antidepressants such as SSRIs and venla axine
Spironolactone (NOT thiazide diuretics)
Vitamin B6 (pyridoxine)
Chasteberry
Adapted rom Biggs W, Demuth RH. Premenstrual syndrome and
premenstrual dysphoric disorder. Am Fam Physician. 2011;84(8):918–924.
Answer 15.16.6 The correct answer is “B.” PMS is a clinical
entity and no laboratory data exist to aid in diagnosis. All other
options described above are correct. An elevated LH:FSH ratio
o 3:1 in the ace o appropriate symptoms is suggestive o PCOS.
Question 15.16.7 Each o the ollowing is a possible treat
ment option or PMS and PMDD EXCEPT:
A) Supportive therapy/counseling
B) Aerobic exercise
C) Selective serotonin reuptake inhibitors
D) T iazide diuretics
E) Calcium
Answer 15.16.7 The correct answer is “D.” T iazide diuretics
are not help ul in PMS or PMDD, but all o the other options
are potentially use ul. reatment options that have been shown
to help with PMS are listed in able 15-8.
Objectives: Did you learn to . . .
• Evaluate concerns about menarche and describe normal
early menstrual patterns?
• Evaluate and manage dysmenorrhea?
• Diagnose and treat PMS?
CASE 15.17
A rantic 25-year-old atient calls you. She and her boy riend
were having intercourse and the condo broke at the ti e o
ejaculation about 16 hours ago. She does not use any other
or o contrace tion. Her last enstrual eriod was about
2 weeks ago. You tell her that 8%o wo en beco e regnant
a er a single act o coitus. She is orti ed, exclai ing, “I’ve
always been in the to 8%o everything!”
Question 15.17.1 Appropriate methods o “emergency con
traception” or this patient include:
A) Levonorgestrel (Plan B)
B) Ethinyl estradiol plus levonorgestrel (Yuzpe regimen)
444 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
C) High-dose ethinyl estradiol (Ivanapyuk method)
D) A and B only
E) A, B, and C
Answer 15.17.1 The correct answer is “D.” Many OCPs are
also e ective i used at the right doses and within 72 hours (the
Yuzpe method). However, as o 2015, only Plan B and ulipris-
tal (an antiprogestin, brand name Ella) are FDA-approved or
postcoital contraception. Plan B uses a high dose o levonorg-
estrel and is more e ective than the combined OCPs or post-
coital contraception. Plan B is available over the counter (in the
United States in 2015). Ulipristal appears to be more e ective
than Plan B and may be taken up to 120 hours a er unprotected
intercourse but is only available by prescription. Copper IUD is
another option and may be used up to 8 days a er unprotected
intercourse. “C” is incorrect as estrogen alone is not known to
be e ective as emergency contraception, and “Ivanapyuk” is a
made-up name (but a good description o what happens to a
patient who takes a massive dose o estrogen).
HELPFUL TIP:
Prescribe an antiemetic with postcoital OCPs as nausea
and vomiting are common side e ects. Plan B has ewer
GI side e ects. About the only contraindication to post-
coital treatment is active pregnancy. Use a progestin-
only regimen in women with a history o thromboem-
bolism.
HELPFUL TIP:
Mi epristone (Mi eprex) is not approved in the United
States for postcoital pregnancy prophylaxis but is
very e ective (99–100%) and has a more avorable side-
e ect pro ile when compared with other regimens.
Mi epristone is approved by the FDA to use in conjunc-
tion with misoprostol (Cytotec) or termination o early
pregnancy (within 49 days o last menstrual period).
O note, there have been serious adverse events as-
sociated with this combination, including sepsis rom
Clostridium in ections and even death. However, these
events are very rare.
You reco end Plan B. Since she now trusts you, she sched-
ules an a oint ent with you or evaluation o inter ittent
abdo inal and elvic ain. Her ain has gradually worsened
over the last 2 years and is al ost o ni resent. Now she
co lains o severe abdo inal cra ing and stabbing in the
right lower quadrant. T e ain radiates to the le lower quad-
rant at ti es and is worse during enstruation. Her eriods
have beco e heavier and occasionally irregular. She has no
bowel or bladder sy to s. She has been issing work 1 or
2 days each onth and is now concerned about her job.
Your exa ination reveals a well-develo ed wo an who
looks de ressed and unco ortable. Her abdo en is so ,
nondistended, and di usely tender to al ation in the lower
quadrants. T ere is no evidence o guarding, rebound ten-
derness, or al able asses. She has no back tenderness. T e
external genital and vaginal exa inations show no lesions or
erythe a. T ere is a crea y discharge noted at the cervix.
Bi anual reveals a retroverted uterus with uterosacral nod-
ularity al able. Both adnexal areas are tender to exa ina-
tion, but without asses.
You get a regnancy test, cultures, and urinalysis, all o
which are negative.
Question 15.17.2 Based on her symptoms and your physi
cal examination, what is the most likely etiology o the
patient’s chronic pelvic pain?
A) Irritable bowel syndrome
B) Myo ascial pain disorder
C) Endometriosis
D) Cervical dysplasia
E) Pain ul bladder syndrome (the disease ormerly known as
interstitial cystitis)
Answer 15.17.2 The correct answer is “C.” T ere were no
bowel symptoms elicited on the history to suggest irritable
bowel syndrome. T ere were no signs elicited on the examina-
tion to suggest a myo ascial pain disorder. T e patient’s history
and physical examination, including uterosacral nodularity, is
consistent with a diagnosis o endometriosis. Dysplasia is typi-
cally asymptomatic. T ere were no bladder symptoms elicited
on the history to suggest pain ul bladder syndrome. Be truth ul;
have you ever actually elt ligament nodularity?
HELPFUL TIP:
I a ter a care ul assessment the diagnosis o endome-
triosis is highly likely, empiric therapy is considered a vi-
able alternative to laparoscopy and pre erred by many
experts. However, de initive diagnosis relies upon direct
visualization o endometrial implants con irmed by his-
tologic examination.
She does not want la arosco y. You o er alternatives, and
she elects to undergo cycle su ression with a 3- onth trial
o leu rolide (Lu ron) and to co lete a ain calendar. You
see her in ollow-u in 3 onths, and she is eeling uch bet-
ter. T e ain has been al ost co letely su ressed, and she
has issed only 1 day o work since you last saw her—but that
was or a Star rek convention. A er all, the uture birth lace
o Ca tain Kirk is located in Iowa (Riverside, Iowa). She has
hot ashes, but they are inor.
Question 15.17.3 What is the most appropriate manage
ment at this point?
A) Continue the Lupron or up to another 3 months (6 months
total)
B) Stop the Lupron and monitor
C) Switch to a trial o cycle suppression using Depo-Provera
(medroxyprogesterone acetate) or continuous low-dose
OCPs

D) Switch to a trial o Premarin (conjugated estrogens)
E) A or C
Answer 15.17.3 The correct answer is “E.” For pain relie ,
treatment with a GnRH agonist or 3 to 6 months is e ective
in most patients. Oral contraceptives, as well as oral or depo
progestins (Provera), are more e ective than placebo. Given the
marked treatment success with the depo-Lupron, discontinu-
ing treatment would likely result in recurrence o the patient’s
pain symptoms. Since endometriosis is estrogen dependent, use
o estrogen (Premarin) theoretically could worsen symptoms.
Another option is treatment with danazol. However, danazol is
less well tolerated than GnRH agonists, Provera, or OCPs.
HELPFUL TIP:
NSAIDs are use ul monotherapy in patients with mild
endometriosis and are use ul in combination with
hormonal therapy (e.g., OCPs) or patients with more
severe symptoms.
T e atient is concerned about how endo etriosis ay a ect
her uture ertility. You recall that she is 25 years old and has
never atte ted regnancy (at least not intentionally). She
has regular enstrual cycles.
Question 15.17.4 What will you tell her?
A) “You are surely in ertile. Look into adoption”
B) “You just cannot know or sure until you have tried to con-
ceive”
C) “What are you worried about? T ere is no association
between endometriosis and in ertility”
D) “Look at my ace. See how tired I am? Do you really want
kids?”
Answer 15.17.4 The correct answer is “B.” It is impossible to
predict ertility and in ertility based on the available in orma-
tion. Early-stage endometriosis is not likely to be associated
with alterations in ecundity. I the patient is willing, a diagnos-
tic laparoscopy may aid in visualization o anatomic pathology
and allow one to render a guess as to possible tubal disease.
HELPFUL TIP:
Chronic pelvic pain is a symptom, not a speci ic disease.
By de inition, chronic pelvic pain re ers to pain that has
been present or more than 6 months and or which
a thorough investigation has been negative. Here is a
help ul starting guide or elucidating the underlying
causes o chronic pelvic pain:
• Is the pain cyclic? It may be related to endometriosis,
dysmenorrhea, adenomyosis, or other diseases that
respond to hormones such as irritable bowel syn-
drome and interstitial cystitis.
• Is the pain noncyclic? It may be urinary, constipa-
tion, a myo ascial trigger point in the abdominal wall,
etc.
CHAPTER 15 • OBSTETRICS AND WOMEN’S HEALTH 445
• Always ask about sexual and physical abuse: There
is a high correlation between chronic pelvic pain and
a history o sexual abuse.
• To go by the textbook, the “diagnosis” o chronic pel-
vic pain requires a negative diagnostic laparoscopy.
However, laparoscopy may not be per ormed in all
cases.
Objectives: Did you learn to . . .
• Manage patients who desire emergency oral contraception?
• De ne and evaluate chronic pelvic pain?
• Describe the rami cations, evaluation, diagnosis, and man-
agement o endometriosis?
QUICK QUIZ: A“TRICHY” 1
A 19-year-old sexually active emale presents to your urgent
care center with a oul smelling vaginal discharge. She has noted
the discharge or about 3 days. On examination, she is in no
acute distress, and her vital signs are normal. Her pelvic exami-
nation is remarkable or mild vaginal erythema and a rothy
gray discharge. You note a malodorous discharge and suspect
Trichomonas (bacterial vaginosis can also be malodorous, o
course, with a shy smell). A wet prep con rms your diagnosis.
At this point in time, you recommend that she also be tested or:
A) Chlamydia and gonorrhea
B) Herpes simplex
C) Hepatitis A
D) All o the above
The correct answer is “A.” Routine screening or chlamydia
and gonorrhea in ection is recommended or all sexually active
adolescents. Given the presence o one S I, it is appropriate to
o er testing or other S Is at this visit. Currently, herpes simplex
virus (HSV) is not routinely tested or in asymptomatic persons,
and the USPS F recommends against serologic screening or
HSV. Hepatitis A is not a sexually transmitted disease. It may be
appropriate to o er testing or hepatitis B, HIV, syphilis, etc., as
individual cases dictate.
QUICK QUIZ: PROLAPSE
An 80-year-old woman presents or evaluation o a “bulge” she
noted a er gardening over the weekend . . . or maybe it’s been
there or years—she’s not sure. She has no discom ort and no
dif culty with bowel or bladder elimination. On examination,
you note her cervix extends 1 cm beyond the vaginal introitus
with Valsalva. T ere are no lesions or excoriations noted.
O the ollowing, what is the best initial treatment option?
A) Hysterectomy
B) rachelectomy
446 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
C) Pessary trial
D) Bed rest
E) Hormone therapy
The correct answer is “C.” Seventy percent o women who
are tted with a pessary are satis ed at 5-year ollow-up. Hys-
terectomy and trachelectomy (removal o the cervix) are both
unnecessarily invasive treatments without trying a conservative
strategy.
QUICK QUIZ: OVARIAN MASS 1
What is the best way to manage an asymptomatic 4-cm ovarian
cystic mass ound initially on pelvic examination and con rmed
by pelvic ultrasound as a simple cyst in a 22-year-old emale
who is otherwise healthy?
A) Re erral to a gynecologist
B) Start hormonal therapy to reduce ovulation
C) Expectant management with repeat ultrasound in 2 months
D) Serum CA-125 level
The correct answer is “C.” A 4-cm ovarian mass likely repre-
sents a unctional cyst in a woman who is cycling (reproductive
age). In general, premenopausal women with simple cysts 10 cm
or smaller may be managed conservatively with serial ultraso-
nography in 4 to 12 weeks. Since the mass is asymptomatic and
without concerning ultrasound ndings (complex mass, sep-
tations, solid components), expectant management is the best
option. No urther evaluation is warranted at this time. CA-125
is a tumor marker or epithelial ovarian cancer, but it is not use-
ul as a screening test.
QUICK QUIZ: OVARIAN MASS 2
What is the best rst step in managing an asymptomatic palpable
4 cm adnexal mass in a 76-year-old postmenopausal woman?
A) Re erral to a gynecologist
B) Start hormonal therapy to suppress FSH and LH
C) Expectant management with repeat examination in
2 months
D) Serum CA-125 level
E) Pelvic ultrasound
The correct answer is “E.” Unlike a relatively small palpable
ovarian mass in a reproductive-age woman, a palpable ovarian
mass in a postmenopausal woman represents ovarian malig-
nancy until proven otherwise. T e best initial imaging study
or evaluation o a pelvic mass is ultrasound. Ultrasound will
not only identi y the location o the mass but will also iden-
ti y its internal consistency. Characteristics suggestive o cancer
include bilaterality, solid and cystic components, thick septa-
tions, and the presence o ascites. CA-125 is a marker or epi-
thelial ovarian cancer and may assist in evaluation, but it cannot
be relied upon to rule in or to rule out cancer as a diagnosis.
(Best case scenario, in appropriately selected patients, CA-125
has a sensitivity around 95% and a speci city around 90% or
the diagnosis o ovarian cancer.) CA-125 is use ul in ollow-up
o patients with a history o ovarian cancer.
QUICK QUIZ: GYNECOLOGIC CANCERS
What is the leading cause o death rom a gynecologic malig-
nancy in American women?
A) Ovarian cancer
B) Uterine cancer
C) Cervical cancer
D) Fallopian tube cancer
E) Vaginal cancer
The correct answer is “A.” Ovarian cancer is the leading cause o
death rom gynecologic malignancy, is the second most common
gynecologic malignancy, and is the ourth leading cause o cancer
death in women. Endometrial cancer is the most common gyne-
cologic malignancy but also one o the most treatable. Cervical
cancer is the third most common gynecologic malignancy. Both
allopian tube and vaginal malignancy are relatively rare.
QUICK QUIZ: OVARIAN CANCER
How does ovarian cancer typically present?
A) Early satiety
B) Abdominal ullness and pain
C) Urinary obstruction
D) Asymptomatic mass noted on routine examination
E) A and B
The correct answer is “E.” T ere are no speci c early symptoms
o ovarian cancer. T us, most patients present with symptoms
associated with increasing tumor mass: early satiety, abdominal
ullness or bloating, and abdominal pain. Un ortunately, ovar-
ian cancer is rarely identi ed at an early stage on routine annual
examination.
HELPFUL TIP:
An ovarian mass is more likely to be malignant i the
patient is premenarcheal or postmenopausal, is greater
than 10 cm in diameter, and has solid or complex cystic
eatures on ultrasound.
CASE 15.18
While covering the e ergency de art ent on the graveyard
shi a 21-year-old college student resents sobbing with a
riend. Her riend says, “She’s been ra ed.”
Question 15.18.1 Relevant history includes all o the ol
lowing EXCEPT:
A) Whether orce was used and what type
B) Physical characteristics o the assailant

C) Details regarding penetration (vaginal, anal, oral)
D) Number o sexual partners the victim has had in her li etime
E) Condom use
Answer 15.18.1 The correct answer is “D.” T e patient’s past
sexual history is not relevant in the evaluation o sexual assault.
T e other issues are pertinent to the case. Although it may be
dif cult or the patient to relive the experience, you should try
to obtain a detailed history o the assault. In order to assess her
risk or pregnancy and in ection, you need to ask about the area
penetrated (e.g., vaginal, oral, or anal penetration), whether
the assailant ejaculated, and i a condom was used. In a sexual
assault case, your job is also to collect evidence, including per-
tinent historical elements (e.g., number o assailants, names,
physical appearance, whether orce was used, and what type—
threat, restraints, weapons, etc.).
HELPFUL TIP:
Sexual assault includes genital, anal, or oral penetration
by a part o the assailant’s body or by an object. By de i-
nition, it occurs without the victim’s consent and need
not involve direct orce or violence.
Question 15.18.2 Which o the ollowing are important
physical elements to collect or the orensic evaluation in
this case?
A) Combed specimens rom the scalp and pubic hair
B) Swabs o the oral, vaginal, and rectal mucosa
C) T e patient’s clothing
D) Fingernail scrapings
E) All o the above
Answer 15.18.2 The correct answer is “E.” All o the items
listed will be important to the investigation. Evidence collection
kits or sexual assault cases (“rape kits”) should be available in
your emergency department.
Although a arently inebriated, the atient is able to give a
coherent history. When you broach the subject o hysical
exa ination, her riend says, “Look, she was ra ed an hour
ago. Can’t you let her just recover a bit be ore you violate her
all over again?”
Question 15.18.3 Which o the ollowing is the most appro
priate response?
A) “O course. Come back tomorrow a er you have sobered up
and taken a shower”
B) “An examination is important or your health and in the
event that this becomes a criminal case. T e yield o the
examination declines with time. Even i you don’t eel like
prosecuting now, you may decide to do so in the uture, and
the best evidence is gathered early”
C) “T e examination has a airly high yield even a week a er
the assault, so take your time on this”
D) “Under ederal law I am required to per orm this examina-
tion”
CHAPTER 15 • OBSTETRICS AND WOMEN’S HEALTH 447
Answer 15.18.3 The correct answer is “B.” T e yield o a oren-
sic examination declines with time. Even i a patient states that
she does not want to prosecute the assailant, she should be
encouraged to have the examination done in case she changes
her mind. Also, you are concerned about her health, and she
may be at risk or sexually transmitted diseases, pregnancy, and
traumatic injury. Despite the act that yield does decline with
time, reliable evidence may still be gathered up to 5 days a er
the assault.
HELPFUL TIP:
“Rape trauma syndrome” generally occurs in three stag-
es. The irst includes anger, anxiety, guilt, shame, sleep
disturbance, etc. The second stage includes somatic
complaints (pelvic pain, other pain) and psychiatric
complaints (depression, phobias, etc.). Some patients
will resolve these issues while others will develop post-
traumatic stress syndrome. The third stage is renormal-
ization.
Question 15.18.4 Which o the ollowing is the LEAST appro
priate to o er this patient at this point in time?
A) HIV antigen/antibody testing
B) HSV antibody testing
C) Prophylactic treatment or gonorrhea and chlamydia
D) Mental health services re erral
E) Emergency contraception
Answer 15.18.4 The correct answer is “B.” Herpes virus anti-
body testing will only tell you i she has been exposed to HSV
in the past. Further recommendations include syphilis testing,
hepatitis B antibody testing, per orming a wet prep o a vaginal
sample, and checking a urine pregnancy test.
Objectives: Did you learn to . . .
• Evaluate a patient or sexual assault?
• Manage a patient who has been the victim o sexual assault?
CASE 15.19
A 21-year-old wo an resents to your of ce co laining o
elvic ain with intercourse, worse over the last 2 weeks. She
also co lains o not getting regnant, even though she’s had
several artners over her last 3 years o sexual activity and
has been trying to get regnant with the sa e artner or the
ast 6 onths. She states she never has used birth control
o any ty e—not even once. You co end her on co it-
ent to her rinci les. She started her eriods around age 14
but has only had a cou le o eriods since then. A arently,
this attern o enstruation is nor al or her a ily, as her
other was the sa e way.
On hysical exa ination, you notice the atient is a cen-
trally obese young wo an, a ebrile, with (culturally de ned)
excess hair noted down the side o her ace and under her
chin. She also has so e erythe atous ustules on her cheeks.
448 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Question 15.19.1 Which o the ollowing lab results would
be most consistent with the history and examination nd
ings?
A) Positive urine pregnancy test
B) Low SH level
C) Elevated CA-125 level
D) Mildly elevated androgens
E) Prolactin level more than three times normal
Answer 15.19.1 The correct answer is “D.” T is patient gives a
history and has an appearance consistent with polycystic ovar-
ian syndrome (PCOS). T e clinical eatures o PCOS include
oligomenorrhea (90%), hirsutism (80%), obesity (50%), amen-
orrhea (40%), and in ertility (40%). Early symptoms in an ado-
lescent may consist only o irregular periods, acne, and central
obesity. Clinical or laboratory evidence o androgen excess
may be present, such as mildly elevated testosterone. Note that
depending on the diagnostic criteria you are using or PCOS, an
ultrasound may not be necessary. An LH:FSH ratio greater than
3:1 adds urther support to the diagnosis. You should certainly
do a pregnancy test, a SH, and a prolactin level. However, this
patient most likely has PCOS.
HELPFUL TIP:
The most recent evidence points to insulin resistance
as the underlying cause o PCOS, and these patients
may have acanthosis nigricans. Insulin resistance can
be quanti ied by calculating the ratio o asting glucose
to insulin. A ratio o less than 4.5 indicates insulin resis-
tance. Insulin resistance stimulates ovarian androgen
production, which leads to anovulation.
You roceed with the elvic ortion o the exa ination, not-
ing the atient also has a dia ond-sha ed, rather than trian-
gular-sha ed, ubic hair attern. You nd no lesions on the
vulva or in the vagina. However, the cervix a ears reddened,
with an al ost strawberry texture. And, even though there is
a generous a ount o yellowish, alodorous leukorrhea in
the vaginal vault, there is no notable us at the cervical os.
Bi anual exa ination is li ited due to the atient’s obesity.
TABLE 15-9 VAGINITIS DIAGNOSIS AND TREATMENT
Organism Discharge Odor
Bacterial Thin, gray, Fishy with
vaginosis homogeneous positive “whif
test”
Candida Adherent, white, Neutral
“cottage cheese” like
Trichomonas Copious yellow, gray, Malodorous
green, oamy. Friable
“strawberry” cervix
Adapted rom Hainer BL, Gibson MV. Vaginitis: diagnosis and treatment. Am Fam Physician. 2011;83(7):807–815.
Question 15.19.2 O the ollowing, which is the most likely
cause o her cervicitis?
A) HSV in ection
B) Trichomonas vaginalis in ection
C) Candida albicans in ection
D) PID
E) Bacterial vaginosis
Answer 15.19.2 The correct answer is “B.” Trichomonas is a
protozoan that is sexually transmitted and can cause urethritis
in both sexes. However, in women, it most commonly causes
ulceration o the cervical mucosa with punctate hemorrhages
known as a “strawberry cervix.” Signs and symptoms also
include a malodorous discharge and occasional vulvar and
vaginal irritation. T e cervix can be somewhat tender to touch,
either during examination or intercourse, and patients o en
complain o a nonspeci c pelvic pain. Males are o en asymp-
tomatic.
T e wet ount de onstrates Trichomonas; there is no evi-
dence o yeast or clue cells. You send sa les or chla ydia
and gonorrhea tests as well as a Pa s ear. You reco end
testing or HIV, sy hilis, and he atitis B, and she agrees.
Question 15.19.3 For her Trichomonas vaginal in ection,
you prescribe:
A) Flagyl (metronidazole) 2 g orally in a single dose
B) MetroGel-Vaginal (topical vaginal metronidazole) 5 g applied
nightly or 5 days
C) Di ucan ( uconazole) 150 mg orally in a single dose
D) Zithromax (azithromycin) 1 g orally in a single dose
E) Levaquin (levo oxacin) 250 mg orally in a single dose
Answer 15.19.3 The correct answer is “A.” T e best choice
is oral metronidazole. opical antibiotic gels, creams, or
ovules—either metronidazole or clindamycin (Cleocin)—only
treat bacterial vaginosis, as the concentration is insuf cient
to reach the protozoa in the glands and urethral areas. T e
remaining options are all incorrect or treating Trichomonas.
See able 15-9 or more on diagnosis and treatment o in ec-
tious vaginitis.
Microscopy pH Treatment
Clue cells > 4.5 Metronidazole 500 mg BID × 7 days or
clindamycin 300 mg BID × 7 days or topical
metronidazole 1 applicator ul intravaginally
daily × 5 days (lower success rate)
Pseudohyphae but only < 4.5 Fluconazole oral, topical clotrimazole,
65–85% sensitive miconazole, etc.
Trichomonads > 4.5 Metronidazole 2 g PO once (recommended),
or 500 mg
BID × 7 days (alternative)

HELPFUL TIP:
As with other STIs, a patient with Trichomonas should
have her partner tested and treated (or just treated de-
pending whether or not this is allowable under your
state law).
HELPFUL TIP:
While it makes sense that single-dose azithromycin
would work better in treating Chlamydial cervicitis be-
cause o compliance issues, the cure rate is the same
whether azithromycin or the doxycycline is used. There
is about a 3% ailure rate with azithromycin which isn’t
seen with doxycycline.
You now return your attention to her PCOS (re e ber, way
back then, the reason she ca e in?). Her lab results de -
onstrated a LH:FSH ratio > 3; nor al SH and rolactin;
slightly elevated testosterone, but still well below the nor al
ale range; asting glucose:insulin ratio < 4.5; and slightly
elevated total cholesterol and triglycerides. Her LH:FSH ratio
was consistent with the diagnosis o PCOS. She has not en-
struated or 4 onths. A urine hCG is negative, and a re eat
asting glucose is 120 g/dL.
Question 15.19.4 Which o the ollowing recommendations
should you make now?
A) Initiate met ormin
B) Attempt weight loss through a nutritious diet and increased
exercise
C) Initiate oral contraceptives to regulate menses
D) A and C
E) All o the above
Answer 15.19.4 The correct answer is “E.” T is patient has
glucose intolerance (elevated asting glucose and ratio o glu-
cose: insulin < 4.5), and it is reasonable to initiate dietary and
medical therapy at this point in time. Another option is to start
with li estyle modi cations and check asting glucose again
3 to 6 months later. Due to increased risk o endometrial car-
cinoma in patients who have rare menses, it is important to
regulate her cycles. OCPs (“C”) can accomplish menstrual
regulation.
HELPFUL TIP:
For hirsutism associated with PCOS, spironolactone is
usually irst-line therapy unless the patient has a con-
traindication; traditional hair removal techniques will
still be required or the existing hair growth. Since spi-
ronolactone can result in eminization o a male etus,
patients taking spironolactone must be using reliable
birth control.
CHAPTER 15 • OBSTETRICS AND WOMEN’S HEALTH 449
HELPFUL TIP:
Not all women with PCOS are obese and hirsute. Many
patients may be thin with sparse body hair and present
with menstrual irregularities and ertility concerns.
Objectives: Did you learn to . . .
• Identi y the clinical presentation o PCOS?
• Diagnose and treat Trichomonas in ection?
• Diagnose and manage PCOS?
QUICK QUIZ: SCREENING IN TEENS
A 16-year-old emale presents with her mother. T ey don’t look
happy. Her mother says, “She needs a Pap smear because she’s
been having sex with a couple o boys—in my house, I will have
you know— or a year!” T e patient rolls her eyes.
Consistent with published guidelines, you recommend:
A) Pap smear
B) Gonorrhea and chlamydia testing
C) Pap smear and gonorrhea and chlamydia testing
D) Return or a Pap a er sexually active or 3 years (age 18 or
this patient)
E) A chastity belt
The correct answer is “B.” It is now recommended to delay cer-
vical cancer screening until age 21, even i the woman has been
sexually active. T e reasoning: although adolescent emales are
requently in ected with HPV, they also easily clear these in ec-
tions, with 95% o lesions spontaneously regressing. Exceptions
to this rule include patients who are immunocompromised
(e.g., organ transplant, HIV in ection). For this patient, ensur-
ing that she has completed her HPV serious and counseling on
sa e sexual behavior is also warranted.
QUICK QUIZ: AN ITCHYVULVA
A 65-year-old emale presents or a health maintenance exami-
nation. She complains o a vulvar itching due to what she calls
“recurrent yeast in ections,” and her symptoms have worsened
over the last ew months. She is sexually active with her hus-
band and has experienced dyspareunia with penetration lately.
She always uses a water-based lubricant with intercourse. On
examination, you nd complete loss o the borders o the labia
minora, constriction o the vaginal outlet, and several thin white
plaques (like parchment paper) on the vulva. T ere is no other
skin or mucosal involvement.
What is the most likely diagnosis?
A) Lichen planus
B) Lichen simplex
C) Lichen sclerosus
D) Vulvovaginal candidiasis
E) Squamous carcinoma
450 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
The correct answer is “C.” T e clinical description above is
characteristic o lichen sclerosus, which occurs more commonly
in older women but also has a peak in young girls. Almost all
lichen sclerosus is intensely pruritic. As lichen sclerosus pro-
gresses, there may be loss o labial architecture, stenosis o the
introitus, and obliteration o the clitoris. T e lesions are usually
multiple and appear as thin, shiny, white, wrinkled patches or
plaques. T e rest are incorrect. However, “E,” squamous car-
cinoma, occasionally can be con used or lichen sclerosus but
is more likely to present with ulceration and induration and is
less common (though i you are suspicious o cancer, a biopsy is
indicated). Patients with lichen sclerosus have a squamous cell
cancer risk o 3% to 7% and should have an examination every
6 to 12 months with biopsies as indicated or persistent and
nonhealing lesions.
HELPFUL TIP:
Initial treatment or lichen sclerosus involves local ste-
roid ointment application. High-potency steroids are
initiated and then tapered to the lowest e ective po-
tency and requency that maintain symptom control.
Testosterone creams have allen out o avor due to
lesser e icacy and secondary virilization. Vaginal dila-
tors can be used i there is constriction o the vaginal
opening causing dyspareunia.
QUICK QUIZ: VULVOVAGINAL CANDIDIASIS
A 48-year-old perimenopausal emale presents with a 3-day his-
tory o vulvar pruritus. Her history is signi cant or mitral valve
replacement and she is on war arin with INR 2–3. A limited
vulvar and vaginal examination reveals signi cant erythema
with satellite lesions on the labia majora. Wet prep microscopy
reveals abundant pseudohyphae and in ammatory cells. You
somehow assemble all these clues into a diagnosis o candidal
vulvovaginitis (and you can tell the patient is impressed when
she says, “T at’s right, genius. I’ve got a yeast in ection”). She
enquires about use o oral therapy, as vaginal creams are “messy.”
How will you counsel this patient regarding use o oral ucon-
azole (Di ucan)?
A) “You have no contraindications to oral uconazole”
B) “Given your use o war arin, you should not use oral ucon-
azole”
C) “You will need to stop war arin while taking oral ucon-
azole”
D) “You should take extra war arin i you take oral uconazole”
The correct answer is “B.” T ere are numerous drug interac-
tions with oral uconazole, including war arin (both inhibit
CYP3A4). T e INR will increase a er even one dose o uco-
nazole therapy. Similarly, the ubiquitous statins are a ected
by oral uconazole with several case reports o rhabdomyoly-
sis in the literature. In this case, stick with topical anti ungals,
although your patient satis action scores may plummet. (Inci-
dentally, patient satis action has been inversely correlated with
healthcare quality—although there appears to be a direct link
between increased satis action and increased health care expen-
diture.)
CASE 15.20
A 27-year-old e ale resents with her husband seeking
advice regarding regnancy loss. She recently had a iscar-
riage. Your atient states that this was her third iscarriage
in the last 2 years. All three occurred at about 9 weeks o ges-
tation.
Question 15.20.1 Possible explanations or recurrent preg
nancy loss in this patient include each o the ollowing
EXCEPT:
A) Parental structural chromosome abnormalities
B) Uterine anatomic abnormalities
C) Anticardiolipin antibody syndrome
D) Idiopathic (unexplained etiology)
E) Conception while on oral contraceptives
Answer 15.20.1 The correct answer is “E.” Conception while
on oral contraceptives will not increase the risk o recurrent
spontaneous miscarriages. Parental structural chromosome
abnormalities (balanced structural chromosome rearrangement
in one partner) are responsible or pregnancy loss in 2% to 4%
o couples. Uterine anatomic abnormalities (“B”) have been
associated with 10% to 15% o pregnancy loss. “D” is true. T e
majority o couples with recurrent pregnancy loss will have an
uncertain etiology despite extensive evaluation (> 50%).
HELPFUL TIP:
Recurrent pregnancy loss is classically de ined as loss o
three or more consecutive pregnancies.
T e cou le desires testing or ossible causes o the reg-
nancy losses.
Question 15.20.2 O the ollowing, which test(s) should be
included in the evaluation?
A) Cultures or bacteria
B) est or glucose intolerance
C) Maternal antipaternal antibodies
D) Lupus anticoagulant and anticardiolipin antibody
E) All o the above
Answer 15.20.2 The correct answer is “D.” Antiphospholipid
syndrome is associated with pregnancy loss in 3% to 15% o
women with recurrent pregnancy loss. T e others are not use-
ul. However, chromosomal testing o the parents (not given as
an option in this question) may be use ul. Other tests that can
be considered include screening or thyroid abnormalities with
anti-thyroid peroxidase ( PO) and SH with ree 4.

Evaluation o the recurrent regnancy loss ails to identi y a
cause. T us, like ost cou les with recurrent regnancy loss,
the etiology re ains unex lained.
Question 15.20.3 What is the likelihood that this couple
will have a success ul pregnancy outcome in the next preg
nancy?
A) Highly unlikely, they should consider adoption
B) Less than one in our chances o success ul pregnancy
C) 60% to 70% chance o success ul next pregnancy
D) You cannot hazard a guess. Amazingly, this has not been
studied
Answer 15.20.3 The correct answer is “C.” Studies suggest that
60% to 70% o couples with unexplained recurrent pregnancy
loss will have a success ul next pregnancy.
Objectives: Did you learn to . . .
• De ne recurrent pregnancy loss and discuss some o its
epidemiologic aspects?
• Enumerate potential causes o recurrent pregnancy loss?
• Identi y etiologies and the workup o recurrent pregnancy
loss?
QUICK QUIZ: WEIGHT GAIN IN PREGNANCY
A 28-year-old primigravida emale presents or an initial obstet-
ric visit. Pelvic examination is consistent with a 6- to 8-week
gestation uterus, and the remainder o the examination is unre-
markable. As this is her rst pregnancy, she has a number o
questions. She wants to know how much weight gain is expected
and whether she should “watch her weight.”
You calculate her BMI as 24 kg/m 2 and recommend the ollow-
ing:
A) “Eat anything you want. You’re eating or two!”
B) “Your BMI is normal. Your goal is to gain no more than 20 lb”
C) “Your BMI is low. Your goal is to gain 40 lb”
D) “Your BMI is high. Your goal is to gain no more than 15 lb”
E) “Your BMI is normal. Your goal is to gain 30 lb”
The correct answer is “E.” T e Institute o Medicine recom-
mends weight gain in pregnancy based on pregravid BMI (see
able 15-10). In this patient, her BMI is in the normal range, so
her goal or weight gain in pregnancy is 25 to 35 lb. Women with
a normal prepregnancy BMI should gain about 1 lb per week
during their second and third trimesters.
QUICK QUIZ: AMENORRHEA
A 32-year-old emale is coming to see you or amenorrhea.
She had regular menses until the last year when they became
irregular. She has not had any menses or the past 6 months.
She is somewhat distraught because she wants to have a amily.
CHAPTER 15 • OBSTETRICS AND WOMEN’S HEALTH 451
TABLE 15-10 PREGNANCY WEIGHT GAIN GUIDELINES
BMI (kg/m 2) Goal Weight Gain (kg) Goal Weight Gain (lb)
< 18.5 12.5–18.0 28–40
18.5–24.9 11.5–16.0 25–35
25.0–29.9 7.0–11.5 15–25
> 30 5–9 11–20
Adapted rom Institute o Medicine, Resource Sheet, May 2009: Weight
Gain During Pregnancy: Reexamining the Guidelines: http://www.iom.
edu/Reports/2009/Weight-Gain-During-Pregnancy-Reexamining-the-
Guidelines.aspx.
Being the smart doctor that you are, you know that a pregnancy
test is the rst thing to do: it is negative. Being the smart doc-
tor that you are, you also think about the emale athlete triad:
amenorrhea, an eating disorder, and osteoporosis. She does not
meet this pro le. You take more o a history and nd out the
ollowing:
• T ere is no additional stress in her li e (such as starting col-
lege or a new job), weight loss, or illness, etc., which might
lead to hypothalamic amenorrhea.
• She has no galactorrhea (prolactinoma).
• She has no hot ashes, vaginal dryness, etc. (premature
menopause).
• She denies headaches, visual changes, atigue, polydipsia, or
polyuria (pituitary problems).
• She has no acne, hirsutism, etc., suggestive o PCOS.
Hey, did you notice how we are cleverly giving you the
workup o secondary amenorrhea in the question?
As recommended, you check a SH and prolactin; they are
normal.
T e next step in the evaluation o this patient’s amenorrhea is:
A) A progestin challenge
B) Hysterosalpingogram to prove cervical patency
C) A trial o oral contraceptives to prove cervical patency
D) An LH to rule out menopause
E) All o the above
The correct answer is “A.” A progestin challenge should cause
a withdrawal bleed i there is still adequate estrogen (thus rul-
ing out premature ovarian ailure). T e step ollowing this
would be to start a combination oral contraceptive. Failure to
induce menses with a combination OCP suggests a mechanical
blockage such as Asherman syndrome (scarring o the endo-
metrial lining with intrauterine adhesions). Failure to induce
menses with a combination OCP can be ollowed by a hys-
terosalpingogram or hysteroscopy to identi y any mechanical
problems.
You did it! You success ully worked u secondary a enor-
rhea.
452 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
HELPFUL TIP:
But wait, there is more! Check an FSH as well. I this is
high, it might indicate ovarian ailure. If the FSH is normal
or low in the absence of circulating estrogen (a nega-
tive progestin challenge), consider a pituitary cause o
amenorrhea including possible hypothalamic–pituitary
axis dys unction rom weight loss, stress, pituitary tumor,
empty sella syndrome, etc. No pituitary? No FSH.
Clinical Pearls
Do not per orm elective deliveries (C-sections or inductions)
that are not medically indicated prior to 39 weeks o gesta-
tion.
Do not per orm routine screening or ovarian cancer in
asymptomatic, low-to-average risk women.
Do not require a Pap and a pelvic examination to prescribe
contraception. The only necessary requirement is to per orm
a detailed history to ascertain risk actors o using hormonal
contraception, blood pressure check, and the per ormance o
a urine pregnancy test to ensure the woman is not pregnant.
Do not routinely per orm episiotomies; there is no evidence
that episiotomies reduce perineal trauma, postpartum
dyspareunia, etc.
Do not start Pap smear screening be ore the age o 21
regardless o sexual activity status.
Due to the increased risk o endometrial cancer, do not use
unopposed estrogen in a woman unless she has undergone
a hysterectomy.
In a pregnant woman with third-trimester vaginal bleeding,
do not per orm a digital or speculum vaginal examination
until you can rule out the diagnosis o placenta previa.
Per orm routine GBS screening on pregnant women between
35 and 37 weeks o gestation UNLESS the woman has a
documented history o GBS bacteriuria during current
pregnancy or prior history o in ant born with invasive GBS
in ection, in which cases they would be treated anyway.
Recommend olic acid in all women o childbearing age to
prevent any risk o neural tube de ects i she should become
pregnant.
Use the ASCCP guidelines to determine requency o Pap
smears and management o abnormal smears.
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Men’s Health
Vic oria J. A. Sharp a d Jaso K. Wi bur
CASE 16.1
A 58-year-old black male presents to your clinic complaining
o urinary hesitancy, requency, and three to our episodes o
nocturia per night, which have been worsening over the past
ew years. His urinary stream is weaker than it was a ew years
ago and he eels he does not empty his bladder completely. He
denies any history o urinary tract in ections (U Is) or pain ul
urination. He is otherwise well with no signi cant past medi-
cal or surgical history. Currently, he takes no medications and
has no allergies. On reviewing his amily history, he notes
his ather and older brother died o prostate cancer in their
50s. His general physical examination is normal and a geni-
tal examination is unremarkable. Digital rectal examination
reveals a smooth prostate with no nodules or tenderness.
Question 16.1.1 Based on this patient’s history and physical
examination, all o the ollowing would be appropriate at
this stage EXCEPT:
A) Serum assay or prostate-speci c antigen (PSA)
B) American Urological Association (AUA) symptom score
C) Post-void residual urine volume
D) ransrectal ultrasound with prostate biopsies
E) Urinalysis and microscopic examination o the urine
Answer 16.1.1 The correct answer is “D.” Although your
patient has an increased risk o prostate cancer, transrectal
ultrasound with prostate biopsies is not indicated at this stage.
T is diagnostic test should be reserved or a higher suspicion o
prostate cancer. Based on this patient’s amily history and the
act that he is black (black males have a 50% higher incidence
o and mortality rom prostate cancer compared with whites),
PSA testing (“A”) is appropriate in this setting, as opposed to
general population screening, which is discussed later in the
chapter. T e AUA symptom score (“B”) is a seven-item ques-
tionnaire about symptoms o urinary outlet obstruction, which
can be used to assess severity and assist in management o pros-
tate disease. It is not very use ul or diagnosis, but on the bright
side, it is reely available online. T ere is also the International
454
16
Prostate Symptom Score, which is remarkably similar but has an
additional question regarding how symptoms a ect the patient’s
quality o li e. Since your patient may not empty his bladder
well, a post-void residual urine volume and urinalysis will help
determine i he is experiencing urinary retention (“C”) or an
in ection (“E”).
Question 16.1.2 When considering benign prostatic hyper-
plasia (BPH), you re ect on the common symptoms o this
syndrome, which include all o the ollowing EXCEPT:
A) Urinary retention
B) Post-void dribbling
C) Frequency
D) Nocturia
E) Hematuria
Answer 16.1.2 The correct answer is “E.” Hematuria is not
usually associated with BPH. However, it can occur i a man’s
prostatic urethra is very enlarged and riable. Enlargement o
the prostate o en results in obstructive ow symptoms (e.g.,
hesitancy and slow, weak stream), which in turn can lead to
irritative symptoms (e.g., requency, urgency, and nocturia).
Obstruction rom an enlarged prostate alone can cause hyper-
trophy o the detrusor, or it can lead to an in ection that results
in detrusor instability—the cause o irritative symptoms. I irri-
tative symptoms are present without obstructive symptoms,
other diagnoses should be considered, including bladder
cancer, urolithiasis, in ection, and neurogenic bladder.
Your patient’s urinalysis and PSA are normal. A er emptying
250 mL o urine, the postvoid residual urine volume is 50 mL.
Question 16.1.3 With this in ormation, you recommend
which o the ollowing strategies?
A) Urodynamic studies
B) Medical therapy
C) Surgical therapy
D) Scheduled bladder catheterization
E) Bio eedback

Answer 16.1.3 The correct answer is “B.” You have enough
in ormation to diagnose symptomatic BPH, and urther stud-
ies are not necessary. Depending on the patient’s pre erences,
the next step is to begin treatment, and in most cases, medical
therapy is initiated rst. I medical therapy ails or i a patient
has severe BPH with ongoing obstruction, retention o large
volumes o urine, bladder stones, or recurrent U Is, surgical
therapy should be considered. T e most commonly per ormed
surgery is transurethral resection o the prostate ( URP), but
other techniques can be employed as well, including transure-
thral incision o the prostate, minimally invasive procedures,
and open surgery or very enlarged prostate glands. “D” is
incorrect. Scheduled bladder catheterization is unlikely to ben-
e t your patient since his post-void residual is not very large.
A post-void residual greater than 200 mL is associated with
an increased risk o U Is, and such patients may bene t rom
scheduled catheterizations i medical or surgical interventions
do not correct the problem or are contraindicated. Kegel exer-
cises and bio eedback (“E”) may be used to treat incontinence
but are not used in BPH. Also, bio eedback is help ul or voiding
dys unction due to incomplete urinary sphincter relaxation.
Your powers o deduction lead you to the conclusion that the
patient’s urinary symptoms are due to BPH. Embarrassed
that he is taking more bathroom stops than his wi e on their
road trips, your patient desires treatment.
Question 16.1.4 To give him the most immediate relie , you
prescribe which o the ollowing?
A) Finasteride
B) Oxybutynin
C) amsulosin
D) Imipramine
E) Furosemide
Answer 16.1.4 The correct answer is “C.” iming and type o
intervention should depend on how much the patient is both-
ered by his symptoms and whether complications o BPH are
present. I the symptoms do not signi cantly inter ere with your
patient’s li e, he may choose to wait and take no treatment once
he is reassured that he does not have a li e-threatening illness. In
general, medical management begins with a selective alpha-1a
receptor blocker, such as tamsulosin, which relaxes the prostate
at the bladder neck. In the past, non-uroselective alpha-1 block-
ers (e.g., terazosin, doxazosin) were considered rst-line; but
this is no longer the case. Let’s ace it: i your patient is on an
alpha-1 receptor blocker or any reason—including hyperten-
sion—he has tried a ew other things rst. T e risk–bene t ratio
does not avor them when compared with other drugs or BPH
or hypertension (see next question).
I the patient does not receive su cient relie rom maxi-
mum doses o an alpha-1a blocker, consider adding a 5-alpha-
reductase inhibitor (e.g., nasteride, dutasteride). T ese drugs
work by reducing the size o the prostate gland by inter ering
with the e ects o androgens on prostate tissue. However, it may
take up to 6 months or a 5-alpha-reductase inhibitor to result
in a noticeable di erence in symptoms (thus, “A” should not be
CHAPTER 16 • Men ’S HeAl t H 455
the rst treatment); whereas the ull bene t o an alpha-blocker
will be apparent within 4 to 6 weeks. “B” and “D” are incorrect
because these anticholinergic drugs are used or incontinence
due to detrusor instability and may make urinary retention
worse in patients with outlet obstruction. Furosemide, “E,” is a
potent diuretic and would be a cruel joke to play on this patient.
HELPFUL TIP:
Si c 5-a pha-r duc as i hibi ors shri k pros a is-
su , h y r duc h produc io o pros a -sp ci ic
a ig (PSA). B awar ha PSA v s d cr as by
approxima y 50% wi hi 6 mo hs o i i ia i g o
o h s drugs. t h r or , i or som r aso you ch ck
a PSA i a ma o i as rid or du as rid , h va u
shou d b doub d wh compari g o orma ra g s.
Question 16.1.5 Be ore you tear up the prescription or ter-
azosin you accidentally wrote, you review its side e ects.
Potential side e ects o alpha-blockers include all the
ollowing EXCEPT:
A) Retrograde ejaculation
B) Hypertension
C) Intraoperative oppy iris syndrome
D) Priapism
Answer 16.1.5 The correct answer is “B.” Hypotension (not
hypertension) is the most commonly encountered problem
with terazosin and other alpha-blockers, including the uroselec-
tive alpha-blockers, although to a lesser degree. In elderly males,
the hypotension can be particularly problematic as the propen-
sity or alling may increase. Additionally, alpha-blockers in
combination with phosphodiesterase inhibitors (e.g., sildena l)
can cause dangerously low blood pressures. Retrograde ejacula-
tion (“A”) and priapism (“D”) are not common but have been
reported. And, as i we needed it, here is more evidence or a
direct link between the male ocular and genital systems: intra-
operative oppy iris syndrome has been observed in men taking
alpha-blockers and undergoing cataract surgery; causality has
not been proven. Yes, you may have thought we made this up
but we didn’t.
You start tamsulosin. Un ortunately, the patient is not able
to tolerate it due to dizziness. His symptoms are bothersome
enough that he wishes to try something else. You consider
nasteride.
Question 16.1.6 Which o the ollowing is true o f nasteride?
A) It permanently reduces prostate volume, even a er the drug
is stopped
B) It is approved by the Food and Drug Administration (FDA)
or abnormal hair growth in women
C) It may reduce the overall risk o developing prostate cancer
but increase the risk o developing high-grade prostate
cancers
D) It improves symptoms within 1 week o starting the drug
E) None o the above
456 FAMIl Y MeDICIn e eXAMIn At IOn & BOARD ReVIeW
Answer 16.1.6 The correct answer is “C.” T is is important:
5-alpha-reductase inhibitors lower the overall risk o can-
cer but increase the risk o those cancers diagnosed being
high grade. Finasteride (and dutasteride) works by inhibiting
5-alpha-reductase, which is the enzyme that converts testos-
terone to dihydrotestosterone. Dihydrotestosterone stimulates
hyperplasia o the prostate gland, and removing this stimulus
results in decreased prostate volume. However, removal o n-
asteride allows hyperplasia to continue, and thus answer “A” is
incorrect. “B” is also incorrect because nasteride or hirsutism
in women is not approved by the FDA. Additionally, nasteride
is category X in pregnancy, with potential teratogenic e ects
on the etus. “D” is incorrect because nasteride takes time to
work—a lot o time. As previously mentioned, its peak e ective-
ness is not seen or 3 to 6 months a er starting the medication.
HELPFUL TIP:
I compariso ria s wi h a pha-b ock rs, 5-a pha-r -
duc as i hibi ors hav show variab r su s. t h
addi io o a 5-a pha-r duc as i hibi or o a a pha-
b ock r do s o s m o hav addi io a b i ov r
a pha-b ock r h rapy a o i h near term, bu com-
bi a io h rapy has show r duc d i cid c o
c i ica progr ssio o BPH i longer trials.
You decide to add nasteride. You see him again 2 months
later when he presents with a ebrile illness. He thinks that he
might have the u, but his BPH symptoms worsened at the
same time. For the last 2 days, he has elt everish with back
pain, perineal pain, and generalized malaise. He complains
o dysuria and worsening urinary requency and urgency.
Question 16.1.7 During your examination, you make sure
NOT to:
A) Per orm a rectal examination
B) Massage the prostate
C) Swab the urethra or chlamydia
D) Per orm urinalysis and microscopic examination o the
urinary sediment
Answer 16.1.7 The correct answer is “B.” T ere is a risk o
seeding bacteria into the bloodstream when an in ected pros-
tate is massaged. T is patient has symptoms o prostatitis; thus,
you should avoid prostatic massage. Nonetheless, you should
per orm a prostate examination. T e ollowing physical ndings
are associated with prostatitis: tenderness, warmth, enlargement,
and bogginess.
You suspect prostatitis and obtain urine or analysis.
Question 16.1.8 All o the ollowing laboratory abnormali-
ties are consistent with the diagnosis o acute prostatitis
EXCEPT:
A) Leukocytosis
B) Hematuria
C) Bacteriuria
D) Elevated creatinine
E) Elevated PSA
Answer 16.1.8 The correct answer is “D.” ests o renal unc-
tion should not be abnormal in simple, acute prostatitis. Chronic
partial or complete urinary outlet obstruction may cause abnor-
mal renal unction but not acute prostatitis. Abnormal serum BUN
and/or creatinine in the setting o prostatitis should prompt ur-
ther investigation. T e urine o en shows bacteriuria, pyuria, and
hematuria. However, the urine may also be negative. Urine should
be sent or culture and sensitivity to de nitively determine the
pathogen and direct urther treatment. “E” is true: the PSA is o en
elevated in prostatitis. However, it is not necessary nor is it recom-
mended to obtain a PSA to diagnose prostatitis. When the PSA is
elevated due to acute prostatitis, it may not return to normal levels
or 1 month or more a er the resolution o in ammation.
HELPFUL TIP:
Ob ai i g uri is impor a i h diag osis o pros a-
i is, bu you shou d avoid b add r ca h riza io du
o h po ia o spr ad i c io . B sid s, you wa
uri ha has b i co ac wi h h pros a .
On examination, you nd an uncom ortable appearing male
in no distress. His temperature is 38.4°C, and the rest o his
vital signs are normal. T e prostate on digital rectal exami-
nation is tender, enlarged, warm, and boggy. T e remainder
o the examination is unremarkable. Urinalysis is consistent
with an in ection. He has a sul a allergy.
Question 16.1.9 Which o the ollowing is the most appro-
priate treatment plan or this patient?
A) Prescribe amoxicillin 500 mg orally ID or 10 days
B) Prescribe cipro oxacin 500 mg orally BID or 28 days
C) Admit or IV levo oxacin 500 mg daily or 14 days
D) Admit or IV levo oxacin 500 mg daily, ollowed by com-
pletion o therapy with oral levo oxacin 500 mg daily or
14 days when the patient is stable
E) Per orm transrectal ultrasound to rule out prostatic abscess
Answer 16.1.9 The correct answer is “B.” T e most appropriate
treatment or this patient is a uoroquinolone, such as cipro oxa-
cin, or at least 28 days. Some authorities recommend longer treat-
ment (up to 6 weeks) to reduce the risk o chronic prostatitis. In
patients who are not allergic, a sul a antibiotic could be considered
as an alternative to a uoroquinolone. In this case, “C” and “D”
are overkill. Admission is appropriate or patients who appear sep-
tic, have not responded to oral antibiotics, or who have signi cant
comorbidities. However, uoroquinolones have 100% bioavailabil-
ity PO. T us, there is no indication or giving these drugs IV unless
the oral route is unavailable (e.g., vomiting). Additionally, the treat-
ment course or “C” and “D” is too short. “E” is incorrect because
abscesses are rare and imaging or an abscess is only undertaken i
the patient does not respond to appropriate antibiotics.

HELPFUL TIP:
t h mos commo caus o acu pros a i is is Escherichia
coli (58–88% o m ).
When you see this patient again, his symptoms o prostatitis
have cleared, but he does not think that nasteride is really
helping. His AUA symptoms score is 21 (severe). He is won-
dering i a transurethral re-section o the prostate ( URP)
might help him, and he wants to discuss the downsides o the
operation.
Question 16.1.10 Compared with watch ul waiting, all o
the ollowing are observed at greater rates in men who
undergo TURP EXCEPT:
A) Erectile dys unction
B) Urinary incontinence
C) Urethral stenosis
D) Increased urine ow
E) Decreased post-void residual urine volume
Answer 16.1.10 The correct answer is “A.” URP is a com-
monly per ormed procedure or BPH. Indications or URP
include ailure o medical therapy, recurrent in ections, bladder
calculi, renal insu ciency, and patient pre erence. Patients who
undergo URP typically experience decreased AUA symptom
scores, increased urine ow rates, and decreased post-void
residual volumes. T ere are downsides to URP, including
urinary incontinence, urethral stenosis, and the need to repeat
the surgery. Strange as it may seem, several studies have shown
that erectile dys unction does NO occur at increased rates in
patients undergoing URP compared with watch ul waiting.
However, men can have retrograde ejaculation status post-
URP.
HELPFUL TIP:
Dai y ow-dos Cia is ( a ada i ) has b approv d or
r a i g BPH. Bu , h b i ov r p ac bo is o y 2.3
poi s o a 35-poi sca . . . do ’ xp c mirac s.
Your patient is so happy with his care that he shared his story
over beers, and his riend comes to see you. T is patient is a
50-year-old male, in no apparent distress, who presents with
a 6-month history o recurrent irritative voiding symptoms
( requency, urgency, etc.), low back and distal penile pain, and
recurrent U Is with the same organism. oday he is a ebrile
with a mildly tender prostate on digital rectal examination.
Question 16.1.11 Based on this patient’s history and physi-
cal examination, all would be the most appropriate at this
stage, EXCEPT:
A) Have the patient complete the NIH Chronic Prostatitis
Symptom Index questionnaire
B) Per orm a 2 glass pre- and post-prostatic massage test
CHAPTER 16 • Men ’S HeAl t H 457
C) Obtain urine culture and i positive, treat based on sensitivi-
ties or at least 4 weeks
D) Obtain a pelvic MRI
Answer 16.1.11 The correct answer is “D.” T ere is no indica-
tion or a pelvic MRI at this time. T e 2 glass pre- and post-
prostatic massage test is a very use ul method o diagnosing
chronic prostatitis. A mid-stream voided urine specimen is
collected and sent or culture. I the urinalysis has greater
than 10 WBCs per high-power eld, next prostatic massage is
per ormed, and then the rst 10 mL o voided urine a er the
massage that should include expressed prostatic secretions
should be sent or culture. reatment is based on the culture
and sensitivity results. A 4- to 6-week course o treatment is
recommended with an appropriate antibiotic with good tissue
penetration. T e most common organisms isolated in chronic
bacterial prostatitis are E. coli, Klebsiella, Proteus, Pseudomonas,
and Gram-positive Enterococcus. T e NIH Chronic Prostatitis
Symptom Index questionnaire is a reliable, valid method to
assess symptoms and quality o li e impact in men with chronic
prostatitis (http://www.prostatitis.org/symptomindex.html).
Objectives: Did you learn to . . .
• R cog iz h pa r o voidi g dys u c io s i BPH?
• Ma ag a pa i wi h BPH a d u d rs a d h po ia
adv rs c s o m dica io s us d o r a BPH?
• Diag os a d r a acu pros a i is?
• D scrib i dica io s or a d comp ica io s o t URP?
• eva ua chro ic pros a i is?
QUICKQUIZ: SeXUAl l Yt RAn SMIt t eD In FeCt IOn S
A 21-year-old college student, sel -described as a “ladies’ man,”
(interpret: jerk) presents because o a concerning spot that
developed on his penis. He complains o pain at the spot but
denies itching. He reports no ever. When asked urther about
his sexual practices, he reports no condom use because his
partners are all “on the pill.” He had chlamydia in high school
but is otherwise healthy. His review o systems is negative. On
examination o the penis, you nd a 1-cm tender, erythematous
papule with a deep central ulceration at the glans penis. T ere is
some mild, tender lymphadenopathy in the inguinal area. T e
rest o the examination is unremarkable.
T is lesion is most likely caused by:
A) Haemophilus ducreyi
B) Neisseria gonorrhoeae
C) Staphylococcus aureus
D) Treponema pallidum
The correct answer is “A.” T is is the lesion o H. ducreyi, oth-
erwise known as chancroid. It can be con used with the chan-
cre o primary syphilis, caused by T. pallidum, but the syphilis
chancre is painless. Gram stain (Gram-negative rods in chains),
culture, or biopsy (which this guy deserves) may con rm the
diagnosis. A ew more notes: chancroid is rarely diagnosed in
458 FAMIl Y MeDICIn e eXAMIn At IOn & BOARD ReVIeW
the United States and is probably under diagnosed; it requently
co-in ects with syphilis and tends to occur in clusters. A num-
ber o treatments are available including ce riaxone (250 mg
IM once), azithromycin (1 g PO once), cipro oxacin (500 mg
PO BID or 3 days), and erythromycin base (500 mg PO ID ×
7 days).
CASE 16.2
A 22-year-old male presents complaining o a painless lump
on his le testicle. He denies penile discharge, dysuria, or
other urinary complaints. He underwent a le orchidopexy
or an undescended testicle at age 6. Otherwise, his past med-
ical history is unremarkable. On examination, the penis is
circumcised with no lesion or discharge. T ere is adenopathy
in the le inguinal area. His testicles are descended bilater-
ally with a 1-cm palpable, irregular mass on the mid-lateral
portion o the le testicle. His examination is otherwise unre-
markable. Your patient is worried about testicular cancer and
wants to know i he is at risk.
Question 16.2.1 All o the ollowing are associated with an
increased risk o testicular cancer EXCEPT:
A) Vasectomy
B) HIV in ection
C) Cryptorchidism
D) Kline elter syndrome
E) Family history
Answer 16.2.1 The correct answer is “A.” Epidemiologic data
do not support an association between testicular cancer and
vasectomy. As is true o some other malignancies, males with
HIV in ection have an increased risk o testicular cancer. Also,
males with cryptorchidism ( ailure o one or both testicles to
descend into the scrotum) and Kline elter syndrome are at
increased risk o testicular cancer. About 25% o testicular can-
cers occurring in patients with cryptorchidism arise in the con-
tralateral (normally descended) testicle. While testicular cancer
does not have as strong o a hereditary component, a positive
amily history is a risk actor or testicular cancer. O note, black
males have a much lower incidence o testicular cancer than do
white males.
Question 16.2.2 I your patient had not had an orchidopexy
to repair the undescended testicle, he would be at risk or
developing all o the ollowing problems EXCEPT:
A) In ertility
B) Inguinal hernia
C) esticular torsion
D) esticular malignancy
E) Impotence
Answer 16.2.2 The correct answer is “E.” Organic impotence is
not a consequence o cryptorchidism. All o the other problems
listed occur at an increased requency in males with an unde-
scended testicle. T e best time to begin treatment or an unde-
scended testicle to minimize uture sequelae is between 6 and
18 months o age and pre erably by the end o the rst year. T e
consequence o not treating an undescended testicle is a 20% to
40% increased risk o developing a testicular malignancy, which
o en presents as a painless mass (although it is not clear that
xing the undescended testicle lowers the cancer risk). T ere-
ore, the reasons to treat cryptorchidism are (1) to better palpate
the testicle to assess or potential malignant trans ormation;
(2) to decrease the risk o malignant trans ormation (maybe);
(3) to improve chances o ertility; (4) to decrease risk o testicu-
lar torsion; (5) to decrease psychological e ects rom having an
empty scrotum; and (6) to repair an inguinal hernia at the same
time, i it is present.
HELPFUL TIP:
I pa i s wi h hypospadias a d u i a ra or bi a ra
mp y scro um, h r is a high r ra o chromosoma
a oma i s.
Question 16.2.3 A ter an appropriate history and physical
examination, which o the ollowing tests is the initial diag-
nostic study o choice in your patient with a scrotal mass?
A) C scan
B) Ultrasound
C) Complete blood count (CBC)
D) Alpha etoprotein (AFP)
E) Pelvic x-ray
Answer 16.2.3 The correct answer is “B.” T e best initial diag-
nostic test would be a scrotal ultrasound to determine i this
mass is cystic or solid. I it is determined to be a solid mass
suspicious or malignancy, then other diagnostic studies would
be warranted, such as β -hCG and AFP. In conjunction with a
radical inguinal orchiectomy or testicular cancer, a C scan
would be indicated to evaluate or metastatic disease, but it is
not the test o choice or initial diagnosis, so “A” is incorrect.
CBC (“C”) would have a role in suspected in ection. X-ray
(“E”) has no role in the evaluation o this patient since this is a
so tissue mass.
HELPFUL TIP:
I h u rasou d o a scro a mass is quivoca , MRI or
uro ogica r rra shou d b co sid r d x .
Question 16.2.4 In taking this patient’s history, i he had
described a painful lump in his scrotum, the LEAST likely
cause would be:
A) Chlamydia
B) Inguinal hernia
C) Hydrocele
D) esticular torsion
Answer 16.2.4 The correct answer is “C.” Spermatoceles and
hydroceles are usually not pain ul. When a young, sexually
active male presents with a pain ul scrotal mass or swelling,

epididymitis rom chlamydia or gonorrhea should be considered.
esticular torsion o en has a very abrupt onset o pain and is
a surgical emergency. Inguinal hernias can be intermittently
pain ul i moving reely in the inguinal canal. However, i one
becomes incarcerated, intense pain occurs. O note, varicoceles
are usually an incidental nding; however, large varicoceles may
occasionally be pain ul. Likewise, testicular cancers are usually
not pain ul but can become so i the tumor growth is rapid.
Your patient’s ultrasound is concerning or testicular cancer,
and you re er him to a urologist.
T e next day the patient’s 15-year-old brother presents
with scrotal pain. You wonder i you are on the cusp o dis-
covering an in ectious cause o testicular cancer, but alas, it
appears to be coincidence.
T is patient’s pain is on the right and he can localize it well
to the ront o the testicle. It has been present or 3 days and
seemed to occur gradually over a ew hours. T ere is no radi-
ation o the pain. Running makes it worse, and cool packs
seem to help. Yesterday he noticed a slight swelling o the
scrotum on the same side. He denies trauma to the area, any
history o sexual activity, other genitourinary complaints,
ever, nausea, or vomiting. On examination, you nd nor-
mal vitals. He has a well-localized tender spot at the anterior
superior right scrotum with a bluish discoloration under the
skin . . . as i it were some sort o sign . . . a blue dot sign.
Question 16.2.5 Which o the ollowing is the most likely
diagnosis?
A) orsion o the appendix testis
B) orsion o the testicle
C) Varicocele
D) Abscess
E) Spermatocele
Answer 16.2.5 The correct answer is “A.” T is is the classic
presentation o a torsed appendix testis. T e appendix testis is
a pedunculated, vestigial structure at the anterior superior tes-
ticle. orsion o the appendix testis is one o the most common
causes o scrotal pain in children. T e pain is usually well local-
ized. T ere may be a reactive hydrocele. Diagnosis is con rmed
by ultrasound. Unlike a torsed testicle, a torsed appendix testis
is not an emergency. It may be treated by conservative therapy
(rest, NSAIDs, ice) or surgical excision.
Objectives: Did you learn to . . .
• R cog iz po ia caus s o a pai ss scro a mass?
• eva ua a s icu ar mass?
• R cog iz h sig i ca c o cryp orchidism?
• Id i y orsio o h app dix s is?
QUICK QUIZ: HeMAt OSPeRMIA
A 28-year-old male presents to your o ce looking quite con-
cerned. Several days ago a er sexual intercourse with his girl-
riend, he noticed bloody ejaculate in the condom. Since then
CHAPTER 16 • Men ’S HeAl t H 459
he has masturbated twice (“just to check”) and has not seen any
more blood. He denies pain, hematuria, dysuria, evers, night
sweats, and weight loss. He reports that he is otherwise healthy.
His examination, including genitourinary and rectal examination,
is normal. A urinalysis is negative.
What is your next step in the evaluation and management o
this patient?
A) Reassurance and ollow-up
B) Scrotal ultrasound
C) Pelvic C scan
D) ransrectal ultrasound
E) PSA
The correct answer is “A.” Hematospermia, the name given
to bloody penile ejaculate, is airly uncommon. It can occur
in men o any age and is perhaps most common a er pros-
tate biopsy or prostate surgery. In otherwise healthy young
men, the cause is most o en idiopathic and is almost always
benign. History should ocus on traumatic causes (e.g., long
bicycle ride), symptoms o prostate disease, and symptoms o
in ection. A genital and prostate examination should be per-
ormed. Urinalysis is help ul to exclude in ection. Consider
gonorrhea and chlamydia cultures in the appropriate patients,
or example, those with symptoms o urethritis. In this patient,
reassurance is adequate. Persistent hematospermia, with
symptoms present or over a month, may require urther eval-
uation with PSA, imaging, and urologic consultation. Some
experts recommend a more aggressive work-up, especially in
older males, but there is no evidence to support more exten-
sive evaluations. Also ask about recent travel: schistosomiasis
is a requent cause o hematospermia and hematuria in other
parts o the world. In most cases o hematospermia, semen
analysis is not warranted, but it can be diagnostic in patients
with schistosomiasis.
CASE 16.3
A couple you have known or a ew years comes to your o ce
to announce that they are expecting and that they want you
to be the baby’s doctor (strange that they didn’t ask you to
be the mother’s doctor, but you let it slide). According to an
ultrasound, the etus is male. T e couple is ambivalent about
neonatal circumcision and wants your advice.
Question 16.3.1 You start the conversation by saying:
A) “Circumcision is a relic o history and should be illegal.”
B) “All major medical organizations (e.g., AAFP, AAP, AMA)
recommend routine neonatal circumcision.”
C) “T e decision to per orm circumcision is a personal one,
in uenced by a number o actors—but primarily by cultural,
religious, and amilial issues.”
D) “Do whatever you want. I don’t really care what you do with
a tiny piece o skin”
Answer 16.3.1 The correct answer is “C.” One o the strongest
predictors o whether a newborn in the United States will be
460 FAMIl Y MeDICIn e eXAMIn At IOn & BOARD ReVIeW
circumcised is the circumcision status o the ather. T ere are
other reasons cited by parents as well (discussed later in the
case). “A” is incorrect simply because the statement is e used
with emotion and lacks logic. “B” is incorrect. T e AAFP has no
policy statement on circumcision. In 2012 the American Academy
o Pediatrics changed its statement on circumcision (since 1999
the AAP did not nd the data su cient to recommend routine
neonatal circumcision) to the ollowing: the health benef ts out-
weigh the risks, and circumcision should be made available to all
amilies who choose it. However, ‘routine’ universal circumcision
is still not recommended. I you chose “D,” you need to work on
your bedside manner!
Question 16.3.2 Consequences o circumcision include
which o the ollowing?
A) Overall reduction in mortality o circumcised in ants com-
pared with uncircumcised in ants
B) Reduction in U Is in the rst year o li e
C) Reduction in the number o sexual partners
D) All o the above
Answer 16.3.2 The correct answer is “B.” T e rate o U Is in
uncircumcised males in the rst year o li e is about 10 times
greater than the rate or circumcised males. In order to pre-
vent one U I in the rst year o li e, about 100 circumcisions
need to be per ormed. T e e ect o circumcision on rates o
U I later in li e is not well studied. T e rate o U I may be
higher shortly a er circumcision (within the rst 2 weeks). “A”
is incorrect because there is no data showing any di erence in
mortality between circumcised and uncircumcised in ants. “C”
is incorrect; some surveys have shown increased requency and
variety o sexual practices in circumcised males compared with
uncircumcised (note that this is an association, not a causal
relationship).
HELPFUL TIP:
Circumcisio r duc s h ra o c rvica ca c r i
h ma par rs o ma s who w r circumcis d
a d pr vious y had six or mor s xua par rs. t his is
hough du o d cr as d ra o HPV ra smissio . O
cours , i is ow r comm d d o provid vacci a io
o a you g m a d wom wi h h HPV vacci a io
s ri s. S h Chap rs 13 a d 14 or mor i orma io .
Question 16.3.3 Neonatal circumcision is associated with
all o the ollowing EXCEPT:
A) Risk o hemorrhage with the procedure
B) Psychological trauma and decreased sexual satis action later
in li e
C) Reduced risk o in ection with S Is, such as HIV
D) Reduced risk o penile cancer
Answer 16.3.3 The correct answer is “B.” Despite what some
anti-circumcision websites maintain, circumcision does not
appear to result in any signi cant psychological trauma or
decreased sexual satis action or most men later in li e. “A”
is true. T ere is a small but real risk o hemorrhage with the
procedure, and this occurs mostly in patients who have an
unknown or unrealized coagulopathy. In act, abnormal bleed-
ing a er circumcision is a common way in which sporadic
cases o hemophilia are discovered (including one case discov-
ered this way by one o the editors—and he still eels bad!).
“C” is true. Several studies have demonstrated that circumcised
men are less likely to have HPV in ection. T e data or the risk
o other sexually transmitted in ections (S Is) are somewhat
contradictory, but generally avor a reduced risk o S Is in cir-
cumcised males. “D” is true. T ere is evidence that circumci-
sion may decrease the transmission o HPV and penile cancer.
Retrospective studies have shown that the rate o squamous cell
carcinoma o the penis is about three old higher in uncircum-
cised men, at least in the United States. However, penile cancer
is exceedingly rare (about 0.6 cases/100,000) and the number
o circumcisions needed to prevent 1 case o penile cancer is
about 300,000. However, the American Cancer Society does
not recommend routine neonatal circumcision or the preven-
tion o penile cancer but does recommend that all risk actors
be addressed.
HELPFUL TIP:
I is abu da y c ar ha circumcisio r duc s h
ra smissio o HIV. t his has d o a ca or rou i
circumcisio i high-risk popu a io s ( .g., som par s
o sub-Sahara A rica, c.).
HELPFUL TIP:
I addi io o u circumcis d s a us, risk ac ors associ-
a d wi h p i ca c r i c ud smoki g, risky s xua
b havior, poor hygi , a d g i a war s.
You have a nice, long conversation with the couple, discuss-
ing the potential bene ts and risks, and they decide to have
their son circumcised. A er the birth, you are per orming
a thorough examination when you nd something slightly
abnormal with the penis.
Question 16.3.4 Neonatal circumcision is indicated or:
A) Congenital phimosis
B) Micropenis
C) Hypospadias
D) Ambiguous genitalia
Answer 16.3.4 The correct answer is “A.” Signi cant congeni-
tal phimosis rarely occurs and is an indication or circumcision.
Phimosis is de ned as the inability to retract the oreskin (pre-
puce) over the glans. T is is a normal nding in uncircumcised
in ants. However, signi cant congenital phimosis may com-
pletely cover the urethra and not allow the normal passage o
urine. “B,” “C,” and “D” are reasons to avoid routine circumcision
and to call on the aid o a urologist.

HELPFUL TIP:
Wh p r ormi g circumcisio , oca a s h ic is r c-
omm d d, a d i h r dorsa p i rv b ock or
subcu a ous ri g b ock is pr rr d. O h r pai co ro
moda i i s may b us d as w , i c udi g pr -proc dur
ac ami oph , sucros coa d paci i r, ca mi g music,
swadd i g, c.
Objectives: Did you learn to . . .
• Discuss h b s a d risks o circumcisio wi h par s?
• Id i y i dica io s a d co rai dica io s or o a a
circumcisio ?
• emp oy appropria pai co ro m asur s or h proc dur
o circumcisio ?
CASE 16.4
A 32-year-old male presents to discuss permanent sterilization.
He clearly states that he wants a vasectomy, and sooner is better
than later. He is married and has three children at home. His
wi e just gave birth to twins. He is healthy and takes no medica-
tions. He looks tired and anxious. You examine him and nd
no abnormalities. T e vas de erens is easily isolated bilaterally.
Question 16.4.1 What is your next step?
A) Re er him or psychological counseling as he is clearly under
a great deal o stress
B) Provide him with detailed counseling on vasectomy, give him
written material on the procedure, and ask him to discuss it
with his wi e
C) Do the vasectomy right now; the next patient can wait
D) ell him that he is not an appropriate candidate or vasectomy
Answer 16.4.1 The correct answer is “B.” Patient education,
counseling, and selection are very important aspects o vasec-
tomy. When you counsel him on vasectomy, you should explore
his reasons or wanting the procedure. You should not schedule
a vasectomy without providing counseling and assuring that
he understands the procedure in detail. T is patient appears to
be atigued—an issue that should be explored urther . . . and he
has newborn twins at home. Who the heck wouldn’t be tired!
So, immediate re erral or psychological counseling without
investigating the underlying cause is not appropriate.
Question 16.4.2 While counseling this patient, you discuss
which o the ollowing issues?
A) Partner’s desire or permanent sterility
B) E ect o the procedure on sexual unction
C) Reversibility o the procedure
D) Complications
E) All o the above
Answer 16.4.2 The correct answer is “E.” All these issues are
important to discuss prior to scheduling the procedure. It is
important that the couple agree on this procedure because it
is the couple—not just your patient—who will be sterile. Aside
CHAPTER 16 • Men ’S HeAl t H 461
rom psychological e ects o vasectomy, the procedure should
not directly a ect sexual unction, orgasm, or ejaculation.
Patients should be aware that vasectomy results in permanent
sterility and that reversal procedures are only success ul about
hal o the time. Potential complications include ailure and
unwanted pregnancy, in ection, pain, bleeding, hematoma, etc.
Your patient decides to “get snipped” as he puts it. You per-
orm the vasectomy using a no-scalpel technique. T e pro-
cedure was airly easy, and the patient tolerated it well. One
month a er the procedure, the patient calls to complain
about a pain ul swelling that has developed superior and
slightly posterior to the le testis. He has no other symptoms.
Question 16.4.3 Which o the ollowing is the most likely
diagnosis?
A) Hematoma
B) Varicocele
C) Congestive epididymitis
D) Abscess
Answer 16.4.3 The correct answer is “C.” Without any urther
in ormation, congestive epididymitis is the most likely cause o
this patient’s current complaint. Congestive epididymitis occurs
in about 3% o patients post-vasectomy, and the onset is usually
within weeks to months a er the procedure. “A,” hematoma, can
be avoided in most cases i hemostasis is achieved during the pro-
cedure and the patient does not overexert himsel immediately
post-operation. A hematoma is more likely to develop early rather
than a month later. Likewise, an in ection (“D”) would be unlikely
so ar out rom the procedure. “B” is incorrect because varicoceles
do not develop a er vasectomy (unless you are operating ar away
rom where you are supposed to be). Overall, the most common
scrotal pathology a er vasectomy is sperm granuloma, which
occurs in up to 40% o patients but is generally asymptomatic.
HELPFUL TIP:
th r a m o co g s iv pididymi is ca b rus-
ra i g. Mos m who hav a vas c omy wi hav som
m o co g s iv pididymi is, bu mos wi hav
mi or sw i g wi hou pai . For pa i s wi h pai u
co g s iv pididymi is, a ria o n SAIDs a d si z ba hs
or s v ra mo hs is i dica d. Fai i g co s rva iv
h rapy, s roid i j c io or surg ry may b i dica d.
wo months a er the vasectomy, your patient returns with a
semen sample, showing no sperm. His surgery was success ul,
but ailures do occasionally occur.
Question 16.4.4 Vasectomy ailure is usually due to:
A) Failure to identi y and transect the vas at the time o surgery
B) Recanalization
C) Le -handed doctors
D) In ection
E) Immaculate conception
462 FAMIl Y MeDICIn e eXAMIn At IOn & BOARD ReVIeW
Answer 16.4.4 The correct answer is “B.” Although “redundant
systems” (removing a segment o the vas de erens, clipping or
suturing the ree ends, cauterizing the transected vas, suturing
ascia around one ree end while leaving the other outside the
ascia) are employed to avoid this complication, recanalization
can occur. A new pathway can orm between the ree ends o
the transected vas de erens, allowing sperm into the ejaculated
semen. T ere ore, all patients should return post-vasectomy or
semen analysis. “A” and “D” are potential, but in requent, causes
o ailure. “C” is incorrect. What have you got against le ies? As
to “E,” only God knows.
Your patient is ultimately pleased with his vasectomy results.
He returns to see you several years later because o concerns
that he is balding. On examination, you nd non-scarring
hair loss at the vertex. T e scalp appears normal otherwise.
Question 16.4.5 You should entertain all o the ollowing
diagnoses EXCEPT:
A) Androgenetic alopecia (yes, it is “androgenetic” and not
“androgenic”)
B) elogen ef uvium
C) Alopecia areata
D) Hypothyroidism
E) inea capitis
Answer 16.4.5 The correct answer is “E.” Hair loss is common
in males, a ecting up to two-thirds o all men. Alopecia is o en
divided into scarring and non-scarring orms. Most in ectious
causes o hair loss (e.g., tinea capitis and olliculitis) are scar-
ring i not treated, whereas the other causes listed (“A” through
“D”) are non-scarring. Without any signs o in ammation or
hyperkeratosis, tinea capitis is unlikely. “A,” androgenetic alope-
cia, is quite common in adult males (male balding). “B,” telogen
ef uvium, presents with di use hair loss usually secondary to
metabolic (including dieting) or emotional stress. T is occurs as
an abnormal percentage o hair enters the telogen phase during
which they are shed. Grab some hair: i more than ve hairs in
telogen phase come out, you have your diagnosis. “C,” alopecia
areata, results in patchy hair loss in round or oval shapes. Meta-
bolic conditions should also be in the di erential diagnosis o
hair loss, and these might include hypothyroidism (“D”), hyper-
thyroidism, and iron de ciency.
HELPFUL TIP:
S co dary syphi is caus s a o -i amma ory, o -
scarri g hair oss ha may b pa chy or di us . Co sid r
s i g or syphi is i appropria pa i s.
T e patient reports a strong amily history o baldness. On
your examination, the patient has thin hair at the vertex and
recession o the hairline in an “M” shape at the rontotem-
poral area. On the basis o the history and examination, you
diagnose androgenetic alopecia. He would like to do some-
thing about his hair loss.
Question 16.4.6 Regarding androgenetic alopecia, which
o the ollowing statements is true?
A) Minoxidil must be used or at least 2 years to achieve perma-
nent hair regrowth.
B) Lower doses o 5-α -reductase inhibitors (e.g., nasteride) are
used in treating androgenetic alopecia compared with BPH.
C) Hair transplant should be avoided unless all other therapeutic
attempts have ailed.
D) opical steroids are an e ective therapy or androgenetic
alopecia.
E) A toupee looks great on anyone.
Answer 16.4.6 The correct answer is “B.” Finasteride (Prope-
cia) is FDA approved or androgenetic alopecia, and the dose is
1 mg/day rather than the 5 mg/day dose used to treat BPH symp-
toms. Minoxidil applied to the scalp is also an e ective therapy
or androgenetic alopecia. Both minoxidil and nasteride must
be continued inde nitely to be e ective. Hair transplant is a via-
ble option or men and women with androgenetic alopecia, and
it is sometimes used as a rst-line therapy. T us, “C” is incorrect.
opical steroids are not e ective or this type o hair loss. “E” is
clearly wrong; there are a lot o bad toupees out there.
Objectives: Did you learn to . . .
• Provid pr -vas c omy cou s i g?
• R cog iz comp ica io s o vas c omy?
• Id i y caus s o hair oss i m ?
• D scrib curr r am op io s or a drog ic a op cia?
QUICK QUIZ: DeAt H RAt eS In Men
For all the ollowing causes o death, the age-adjusted death rate
is higher or males than or emales EXCEP :
A) Liver disease
B) Alzheimer disease
C) Coronary artery disease
D) Suicide
E) Cancer
The correct answer is “B.” When it comes to Alzheimer disease,
men get a break; the death rate is higher or emales. All o the
other causes o death listed have greater death rates in males. For
example, compared with women with liver disease, same age men
with liver disease are twice as likely to die o their liver disease.
QUICK QUIZ: MORe ABOUt DeAt H In Men
T e relative risk o death or males is greater throughout the li e
span. Compared with same age emales, at what age range is the
relative risk o death greatest or males?
A) < 1 year
B) 5 to 14 years
C) 15 to 24 years
D) 25 to 34 years
E) > 85 years

The correct answer is “C.” Un ortunately, males aged 15 to
24 years have a relative risk o death o greater than 2.5 com-
pared with same age emales (usually preceded by a cry o “Hey,
look what I can do!”). Mother Nature has a way o making up
or boys and young men dying: more male etuses are conceived
than emale. However, the miscarriage rate is also greater or
male etuses. Nonetheless, about 105 males are born in the
United States or every 100 emales. By age 35, enough males
have died o that the number o males and emales at that age is
about equal, and therea er the number o emales exceeds the
number o males (in other words, the singles scene improves
markedly or the remaining males).
CASE 16.5
A 14-year-old male presents with his mother, who is worried
that he has growing breasts. Over the last 2 or 3 months, the
patient has developed swellings beneath both nipples. He
denies discharge or pain, but the nipples are tender at times.
Question 16.5.1 You can tell this patient that physiologic
gynecomastia (subareolar breast tissue) is a condition that
a ects:
A) Newborns
B) Adolescents
C) Elderly males
D) All o the above
Answer 16.5.1 The correct answer is “D.” T e incidence o
physiologic gynecomastia is trimodal, with peaks in the neona-
tal period, adolescence, and old age. Data can be contradictory
at times, but clinically palpable breast tissue (either at or true
breast tissue) may be present in more than 50% o males in each
o these three age groups.
Question 16.5.2 Which o the ollowing hormones is respon-
sible or the proli eration o breast tissue?
A) estosterone
B) Estrogen
C) Androstenedione
D) Growth hormone
E) Progesterone
Answer 16.5.2 The correct answer is “B.” Estrogens induce
ductal hyperplasia and growth o glandular tissue. estoster-
one and androstenedione inhibit the actions o estrogens on the
breast tissue. Some men with gynecomastia have increased sen-
sitivity o breast tissue to circulating estrogens. Others may have
an increased proportion o estrogens compared with androgens.
Yet, others may have a mixture o both processes or another
process altogether.
Question 16.5.3 Potential causes o gynecomastia include
all o the ollowing EXCEPT:
A) Renal ailure
B) Marijuana use
C) esticular cancer
CHAPTER 16 • Men ’S HeAl t H 463
D) Hypothyroidism
E) Phenothiazines
Answer 16.5.3 The correct answer is “D.” Hyperthyroid-
ism, not hypothyroidism, can cause gynecomastia through
increased aromatization o testosterone to estradiol and andro-
stenedione to estrone. A number o drugs are associated with
gynecomastia, including marijuana, alcohol, 5-alpha-reductase
inhibitors, phenothiazines, tricyclic antidepressants, andro-
gens, estrogens, growth hormone, calcium channel blockers,
and spironolactone. Other causes o gynecomastia include:
hypogonadism, hyperprolactinemia, testicular tumors (some
secrete estrogens), renal ailure, and liver diseases (cirrhosis).
Obesity is associated with gynecomastia, but obese patients
may also appear to have gynecomastia while simply having
excess at deposition in the area o the breast (sometimes called
“pseudogynecomastia”).
A thorough drug history is negative. On physical examina-
tion, you nd palpable, nontender tissue beneath the nipples,
with slightly more prominent tissue mass on the right. T e
tissue is about 2 to 3 cm in diameter, and no discrete masses
are palpable. T ere is no nipple discharge. An adult male’s
hair growth pattern is evident in the axillary and inguinal
areas. T e testicles are normal size without masses.
Question 16.5.4 At this point in time, you recommend
which o the ollowing?
A) Observation
B) Re erral to a surgeon
C) Limited laboratory studies, including thyroid-stimulating
hormone ( SH), testosterone, and liver enzymes
D) Biopsy o the tissue
E) Mammogram and/or ultrasound
Answer 16.5.4 The correct answer is “A.” As previously men-
tioned, physiologic gynecomastia is quite common in adoles-
cent males. T e ndings on examination are reassuring. T is
patient does not display any other signs o testosterone de -
ciency, and urther workup is not indicated at this time. I there
are no discrete masses on examination, a mammogram, ultra-
sound, or biopsy is not likely to be help ul. Re erral to a surgeon
is premature, as 90% o these patients experience spontaneous
involution o the breast tissue over 3 years.
HELPFUL TIP:
I ado sc ma s wi h gy comas ia, ur h r va ua-
io wi h abora ory s udi s a d imagi g is i dica d i
h br as issu is rapid y argi g or is gr a r ha
5 cm i diam r, a mass ( o orma br as issu ) is
pa pab , or o h r sig s o u d r a drog iza io ar
pr s .
You provide the patient and his mother with reassurance and
have them return in a year. At ollow-up, there is no palpable
464 FAMIl Y MeDICIn e eXAMIn At IOn & BOARD ReVIeW
tissue. When you see the patient again, he is 17 years old. He
told his mother that he was having abdominal pain, but really
he is worried that he may have contracted an S I. He has
become airly promiscuous and does not use condoms (a er
the gynecomastia disappeared, his mojo returned). In the last
week, he has developed dysuria and a yellowish urethral dis-
charge. He has no other symptoms.
Question 16.5.5 Which o the ollowing is the most likely
diagnosis?
A) HPV
B) Syphilis
C) Gonorrhea
D) richomonas
E) Herpes simplex
Answer 16.5.5 The correct answer is “C.” T is patient’s symp-
toms are typical o gonococcal urethritis. However, N. gonor-
rhoeae may be present in the urethra without any symptoms
and Chlamydia trachomatis can present with a purulent
discharge that is classically thought o as gonorrhea; gonor-
rhea and chlamydia cannot be reliably distinguished on clini-
cal grounds. “A” is incorrect as HPV causes genital warts, not
urethritis. “B,” syphilis, may present as a painless ulcer (pri-
mary syphilis). “D” is incorrect because most men in ected with
Trichomonas vaginalis are asymptomatic, although some will
have mild urethritis. Finally, “E,” herpes simplex, presents with
pain ul vesicles at the area o inoculation.
You obtain urine or PCR or gonorrhea and chlamydia. You
discuss other S Is and decide to per orm some other tests
(e.g., HIV, hepatitis B, RPR/VDRL).
Question 16.5.6 At this point in time, you are compelled to
do all o the ollowing EXCEPT:
A) Recommend sa e sexual practices
B) In orm the public health services i he tests positive
C) reat him with antibiotics now
D) Encourage him to contact his partners and tell them to get
tested
E) In orm his mother o your ndings
Answer 16.5.6 The correct answer is “E.” In general, adoles-
cents can seek care or S Is and be treated without parental con-
sent. However, clinicians should re er to the laws o the state in
which they practice or ultimate legal authority in this matter.
O course, the time o diagnosis and treatment should be used
as an opportunity to educate the patient regarding sa e sexual
practices. “B” is true. Gonorrhea and chlamydia are reportable
diseases in every state. Again, clinicians should re er to the laws
o their state and the reporting protocols o the clinic in which
they practice. Empiric treatment is the rule here, so “C” is cor-
rect. “D” is also correct since all o this patient’s partners should
be contacted, tested, and treated. T ere are several ways to con-
tact the partners, and allowing the patient to do so is only one
way. T e clinician or the public health authorities could contact
the partners as well.
HELPFUL TIP:
exp di d par r r a m i which h pa i b -
i g r a d or a St I is a so giv m dica io or his/
h r par r(s) is r comm d d by h C rs or Dis-
as Co ro a d Pr v io (CDC) a d o h rs. S
h p://www.cdc.gov/s d/ p / or mor i orma io a d
h ga i y o h prac ic i your s a .
Question 16.5.7 Which o the ollowing methods maintains
a high degree o sensitivity and is also the quickest and
least expensive way to diagnose gonococcal urethritis in a
symptomatic male?
A) Culture
B) Gram stain
C) Serologic antibody assay
D) PCR
E) DNA probe
Answer 16.5.7 The correct answer is “B.” In symptomatic
males, Gram stain o a urethral sample can identi y Gram-
negative diplococci (N. gonorrhoeae) with a sensitivity o about
90% to 95%. T e sensitivity drops to about 70% in asymptom-
atic males. I the materials and expertise are readily available, a
Gram stain is quick and inexpensive. Culture o a urethral spec-
imen on T ayer–Martin agar takes longer and alse-negative
tests can occur with high requency (due to the need to have a
CO2-rich environment and to keep the culture in a narrow tem-
perature range). PCR and other nucleic acid testing are more
sensitive than cultures but still not 100%. PCR is particularly
attractive as a screening test, as it can be per ormed on urine
specimens instead o urethral swab specimens. Serologic assays
or gonorrhea would not be help ul in diagnosing urethritis.
Question 16.5.8 Your clinical suspicion o gonorrhea is high.
What is your next step?
A) Single doses o ce riaxone 125 mg IM
B) A single dose o penicillin G 1.2 million units IM and eryth-
romycin 500 mg orally QID or 7 days
C) etracycline 500 mg orally QID or 10 days
D) Single doses o cipro oxacin 500 mg orally and ce xime
400 mg orally
E) Single dose o ce riaxone 250 mg IM and azithromycin 1 g orally
Answer 16.5.8 The correct answer is “E.” I there is any concern
or compliance, it is best to treat the patient in the o ce i you have
access to the appropriate antibiotics. As o 2015, the CDC recom-
mends ce riaxone 250 mg IM as a single dose (rather than 125
mg, due to increasing resistance) PLUS azithromycin 1 g PO or
uncomplicated gonococcal urethritis. T e azithromycin is given
or two reasons: increasing resistance among gonococcal isolates
and to cover or possible chlamydia co-in ection. I ce riaxone
is not available, ce xime 400 mg PO is an acceptable alternative.
Fluoroquinolones are not recommended or gonorrhea due
to high rates o resistance in some communities. “A” is incor-
rect because ce riaxone alone will not provide empiric coverage
or chlamydia, and the dose is too low anyway. “B” is incorrect

because penicillin should never be used to treat gonorrhea (due to
the prevalence o penicillinase-producing strains o the bacteria).
“C” is incorrect. etracycline antibiotics provide adequate cover-
age or chlamydia and some strains o N. gonorrhoeae, but other
strains o N. gonorrhoeae are resistant to tetracyclines, so these
drugs are not used as rst-line agents in treating gonorrhea. “D”
is incorrect because uoroquinolones are not recommended or
gonorrhea and it contains nothing or the treatment o chlamydia.
HELPFUL TIP:
A o h r qua y c iv r gim or ch amydia is
doxycyc i 100 mg BID or 7 days. t his is qua i
icacy o azi hromyci r gard ss o h ac ha som
dos s may b miss d. O o , doxycyc i has b i o his penis. He is monogamous with his wi e, and he denies
shor supp y p riodica y.
You treat this patient with ce riaxone and azithromycin and
tell him to contact his partners so that they can get treated.
When your patient returns to discuss his lab tests, he is eel-
ing much better. You tell him that he was in ected with both
gonorrhea and chlamydia but that the rest o his tests were
negative. He is relieved that he does not have HIV, but he
wonders what problems chlamydia can cause.
Question 16.5.9 C. trachomatis has been implicated in
which o the ollowing?
A) Reiter syndrome
B) Lymphogranuloma venereum
C) Proctitis
D) Epididymitis
E) All o the above
Answer 16.5.9 The correct answer is “E.” A small percentage
o men with chlamydia urethritis develop reactive arthritis, and
a subset o these will go on to have the triad o Reiter syndrome
(urethritis, arthritis, and uveitis). Lymphogranuloma venereum
is also due to a particularly virulent strain o C. trachomatis, but
it produces genital ulcers and lymphadenitis and is generally
seen in tropical areas. Lymphogranuloma venereum is treated
with extended courses o doxycycline (100 mg PO BID or
21 days) or azithromycin (1 g PO weekly or 3 weeks). Chla-
mydia proctitis occurs almost exclusively in homosexual men
and presents with rectal pain, bleeding, and discharge. Diagno-
sis is con rmed by rectal swab, and the treatment is the same
as or chlamydia urethritis. “D,” epididymitis is most o en the
result o in ection with C. trachomatis or N. gonorrhoeae. Ure-
thral strictures are also commonly related to prior S Is.
HELPFUL TIP:
t h majori y o ma s (a d ma s) who ar i c d
wi h ch amydia a d/or go orrh a do not have symp-
toms. t h r or , h r is a good argum o b mad
or scr i g asymp oma ic ma s i high-risk popu a-
io s ( .g., ado sc s, you g adu s, a d hos wi h
mu ip s xua par rs). For ma s, s Chap r 15.
CHAPTER 16 • Men ’S HeAl t H 465
Objectives: Did you learn to . . .
• D gy comas ia a d u d rs a d i s caus s?
• Id i y wh o i i ia ur h r va ua io i a pa i wi h
gy comas ia?
• R cog iz symp oms o go orrh a a d ch amydia?
• I i ia r a m i a ma wi h ur hri is?
• R cog iz ma i s a io s o ch amydia i c io i m ?
QUICK QUIZ: An In Fl AMeD Gl An S
A 36-year-old male diabetic patient presents with a 3-day
history o irritation, itching, dysuria, and redness at the tip
any history o high-risk sexual behavior or S Is. On exami-
nation, you ind an a ebrile patient in no acute distress. he
penis is circumcised, and the glans penis is red, tender, and
edematous. here are numerous small, white papules on the
glans.
Which o the ollowing is the most appropriate treatment?
A) Sitz baths and improved hygiene
B) Oral doxycycline
C) opical bacitracin
D) opical miconazole
E) opical steroids
The correct answer is “D.” T is patient has balanitis, which is
de ned as an in ammatory condition o the glans penis (bal-
anoposthitis is the name applied to in ammation o the glans
and oreskin). Some authors believe that balanitis is a nonin-
ectious, in ammatory condition. Others implicate in ectious
causes. O in ectious causes, the most common is Candida
albicans, especially in diabetic patients. his patient has clas-
sic indings o candidal balanitis and is diabetic. here ore,
the most appropriate therapy is a topical anti ungal agent,
such as miconazole. Fluconazole is an option. opical and
oral antibiotics will not help, and topical steroids should
be avoided. Sitz baths and improved hygiene should be
encouraged, but they should not be employed without an
anti ungal agent.
CASE 16.6
While covering the emergency department (ED), a 40-year-
old male presents with a pain ul erection that began 4 hours
ago “out o the blue” (perhaps a er he took a little “blue
pill”).
Question 16.6.1 Which o the ollowing is true regarding
priapism and normal erections?
A) Normal erections can last up to 12 hours, so this is not
priapism
B) Abnormally prolonged sexual desire can “convert” a normal
erection into priapism
C) T e corpus spongiosum and glans penis are not involved in
priapism
466 FAMIl Y MeDICIn e eXAMIn At IOn & BOARD ReVIeW
D) Acute urinary retention may lead to priapism and vice versa
E) All o the above are true statements
Answer 16.6.1 The correct answer is “C.” Priapism is de ned
as the prolonged engorgement o the penis (or—rarely—the cli-
toris in emales), unrelated to sexual desire or stimulation. T e
word priapism comes rom the Greek god Priapus, apparently
well known or his lasciviousness and generous genital endow-
ment. In most cases o priapism, the corpus spongiosum and
glans penis are not involved. Only the corpora cavernosa are
engorged and rigid. Priapism typically lasts longer than 6 hours,
whereas normal erections last minutes to hours. With normal
erections, detumescence occurs a er ejaculation or a er the
stimulus is removed. T is is not the case with priapism, and sex-
ual desire does not play a role in the development o priapism;
thus, “B” is incorrect. “D” is also incorrect. Urinary retention is
not thought to cause priapism, and priapism does not lead to
urinary retention.
Question 16.6.2 Priapism may be secondary to all o the
ollowing EXCEPT:
A) Sickle cell disease
B) Penile trauma
C) Leukemia
D) Iron de ciency anemia
E) razodone use
Answer 16.6.2 The correct answer is “D.” A number o di -
erent disease states and drugs have been implicated in the eti-
ology o priapism. In one way or another, these diseases and
drugs a ect the balance o blood ow into the penis, leading
to increased arterial blood ow and/or decreased venous out-
ow. Local malignancies, such as bladder and prostate cancers,
can cause obstruction. Likewise, any condition that increases
blood viscosity (e.g., sickle cell disease, polycythemia, leuke-
mia) or results in thromboembolic phenomena (e.g., vasculitis)
can cause priapism. Penile trauma that results in laceration o
penile arteries can cause priapism. Numerous drugs have also
been implicated (see able 16-1), but in most cases, the cause is
not identi ed.
TABLE 16-1 DRUGS ASSOCIATED WITH PRIAPISM
Psychotropics
• t razodo
• Ch orpromazi
Agents used to treat erectile dysfunction
• I racav r osa i j c io s ( .g., papav ri )
• Phosphodi s ras i hibi ors ( .g., si d a )
Antihypertensives
• Hydra azi
• Prazosi
Anticoagulants
• H pari
Drugs of abuse
• A coho
• Cocai
• Marijua a
Question 16.6.3 What is your next step in management o
this patient?
A) Reassurance
B) Call or emergent urologic consultation
C) Give oral alpha-blockers
D) Engage patient in guided imagery to lead his thoughts away
rom sex
Answer 16.6.3 The correct answer is “B.” Priapism is a uro-
logic emergency and needs to be treated ASAP. All the other
answers could result in your undesired new title o “de endant.”
Until the urologist arrives, conservative measures are probably
best, and you should try to make the patient com ortable using
analgesics, oxygen, and hydration. Check a CBC since leukemia
can rarely present with priapism. Some patients will respond to
analgesics and ice packs. Oral or subcutaneous terbutaline may
be help ul. Some authors recommend sedatives, such as benzo-
diazepines.
HELPFUL TIP:
I a uro ogis is o avai ab a d/or you ar com or -
ab p r ormi g h proc dur (a d you hav a good
awy r), you ca a mp d um sc c . A d is
i s r d i o h corpora cav r osa a d b ood is wi h-
draw . t h a vasoac iv ag ( .g., ph y phri )
is i j c d. t his proc dur is r p a d v ry 5 mi u s
u i d um sc c occurs. I shou d go wi hou sayi g
ha h pa i ’s vi a sig s mus b c os y mo i or d
duri g his i rv io b caus h y wi ik y d
s da io .
HELPFUL TIP:
A r r cov ry, abou 50% o m wi h priapism su r
r c i dys u c io . P i imp a s ar a op io .
Objectives: Did you learn to . . .
• R cog iz priapism a d i s caus s?
• Ma ag a pa i wi h priapism?
QUICK QUIZ: DePReSSIOn An D SUICIDe
Which o the ollowing groups has the highest rate o death by
suicide?
A) Black males
B) White males
C) Black emales
D) White emales
E) Hispanic males
The correct answer is “B.” In the United States, white males
make up about 70% o all deaths due to suicide. Although
emales account or more suicide attempts, males are at greater
risk o death rom suicide. Men tend to use deadlier means, such
 CHAPTER 16 • Men ’S HeAl t H 467

as guns, hanging, and car collisions. In other words, men are

HELPFUL TIP:
very e cient at suicide. White men older than 85 years have one
I a ma pa i wi h os oporosis has s os ro
o the highest rates o death due to suicide: 59/100,000 (with the
d ici cy, s os ro supp m a io may b a
rate in the general public being 10.6/100,000). As a group, black
r aso ab r a m op io , bu h icacy o s os-
males have the second highest rate o suicide. O those groups
ro i his sc ario is not w s ab ish d. A hough
listed above, black emales have the lowest risk o death rom
s os ro co ribu s o p ak bo mass i you g
suicide.
m a d ow s os ro is associa d wi h a i -
cr as d rac ur risk i o d r m , s os ro or h
CASE 16.7 r am o os oporosis has b disappointing.
A 78-year-old male presents or ollow-up a er an emergency
department visit last week. He sustained a all that resulted
in a 11 compression racture. You obtained a DEXA scan to Question 16.7.2 Which o the ollowing is true regarding
con rm that he has osteoporosis and ound that his -score testosterone supplementation in older men with testoster-
is indeed osteoporotic-range. Just to be on the sa e side, you one def ciency?
order a bunch o laboratory tests, all o which are normal A) estosterone supplementation has markedly bene cial e ects
except or serum testosterone. Lo and behold, his testoster- on depression
one level is very low. He’s also been tired, elt weak, and lost B) T e e ects o testosterone supplementation in young hypo-
his libido. Because he knows we need to cover testosterone gonadal males and older testosterone-de cient males are the
supplementation in this book, he asks you, “Should I be on same
one o those ancy testosterone supplements?” C) In testosterone-de cient older males with erectile dys unc-
tion, testosterone supplementation dramatically improves
Question 16.7.1 Which o the ollowing testosterone sup- erections
plementation products would you AVOID? D) In testosterone-de cient older males with poor libido, tes-
A) ransdermal testosterone patches tosterone supplementation improves libido
B) Buccal testosterone tablets E) estosterone supplementation has no e ect on lean muscle
C) Oral testosterone tablets mass or grip strength
D) Intramuscular testosterone injections
E) ransdermal testosterone gel Answer 16.7.2 The correct answer is “D.” In testosterone-
de cient older males, testosterone supplementation does
Answer 16.7.1 The correct answer is “C.” Oral testosterone improve libido. Un ortunately, “C” is incorrect: its e ects on
should be avoided due to signi cant rst-pass metabolism erectile dys unction are not impressive. Even in testosterone-
and potential liver toxicity. T e other choices listed are viable de cient men with erectile dys unction, a phosphodiesterase
options or testosterone replacement (see able 16-2). T e IM inhibitor (e.g., sildena l) is more likely to be success ul. In terms
option is not the best or a steady state. Patients o en like it due o the neuropsychiatric e ects o testosterone, many questions
to the peaks. are as yet unanswered. However, testosterone supplementation

TABLE 16-2 TESTOSTERONE SUPPLEMENTATION PRODUCTS

Agents Dosages Comments
Bucca ab (S ria ) Dos d 30 mg BID a d mus b t h produc do s o disso v comp y
k p b sid bucca mucosa

t ra sd rma g s (A drog , For s a, Dos d dai y Cov r h app ica io ar a o r duc risk o spr adi g by co ac
t s im) wi h o h rs

t ra sd rma pa ch (A drod rm) App i d dai y Ro a si s o r duc ski irri a io

Scro a pa ch s (t s od rm) n ow rar y us d du o scro a irri a io a d mor acc p ab

a r a iv s

I ramuscu ar i j c io s (D po- s os ro , Dos d v ry 2–4 w ks S rum s os ro v s f uc ua sig i ca yb w dos s

D a s ry )

Subcu a ous p s (t s op ) t h s ar imp a d ( ik n orp a ) a d ar rar y us d or

supp m a io

Ora ag s (m hy s os ro ) n o avai ab i h U i d S a s; sig i ca rs -pass m abo ism,

f uc ua i g s rum v s, a d risk o iv r oxici y
468 FAMIl Y MeDICIn e eXAMIn At IOn & BOARD ReVIeW
does not appear to signi cantly a ect depression, so “A” is incor-
rect. “B” is not true. Young hypogonadal males who are treated
with testosterone have increased peak bone mass and viriliza-
tion. But the e ects on older males are di erent: older males
have improved strength, libido, and sense o well-being with-
out some o the e ects seen in the young hypogonadal males.
“E” is incorrect because testosterone has been shown to consis-
tently improve lean muscle mass and grip strength. estoster-
one replacement does not replace the need or antidepressants
i depression is the cause o symptoms.
HELPFUL TIP:
Hypogo ada ma s shou d not ak s os ro r -
p ac m whi ryi g o impr g a h ir par rs
b caus i wi ur h r d cr as h ir sp rm cou s (du
o h c o xog ous s os ro di g back o
h hypo ha amic–pi ui ary–go ada axis). t o improv
r i i y i h s pa i s, u prov mpiric h rapy is
o us d, i c udi g c omiph , huma chorio ic
go ado ropi , a d go ado ropi -r asi g hormo .
HELPFUL TIP:
t opica s os ro ca hav a a drog izi g cs
o wom a d chi dr i h y com i co ac wi h h
g o a ma ’s ski .
You have a conversation with your patient about starting
testosterone therapy. He would like to try it. T ose direct-to-
consumer marketing campaigns really work!
Question 16.7.3 You tell him about adverse e ects and
monitoring and tell him it is important to periodically
check:
A) Hematocrit
B) Potassium
C) Alanine aminotrans erase
D) A and B
E) A and C
Answer 16.7.3 The correct answer is “E.” T ere are good
reasons behind the recommendation or periodic monitoring
with certain serum tests. estosterone increases erythropoietin
production and can cause erythrocytosis. In act, testosterone
should not be started in a patient with a hematocrit greater than
50% (or severe heart ailure or untreated sleep apnea). estos-
terone can cause elevated liver enzymes, increased cholesterol,
and growth o prostate and breast tissue, including prostate
and breast cancers. Prostate examination and PSA are recom-
mended prior to starting therapy and periodically while on
testosterone. O course, it makes sense to periodically monitor
serum testosterone levels to assure that the patient is in the nor-
mal range and not sub- or supratherapeutic. Potassium (“B”) is
not directly a ected and no monitoring is recommended.
HELPFUL TIP:
I 2015, h FDA r quir d upda d ab i g o s os-
ro produc s o add i orma io abou h possib
i cr as d risk o cardiovascu ar v s. t h risk–b i
ra io o s os ro produc s app ars o n Ot w igh i
h ir avor.
Objectives: Did you learn to . . .
• Id i y s os ro r p ac m produc s a d discuss how
o d r ma s migh b (or o ) rom h m?
• R cog iz som o h risks associa d wi h s os ro
supp m a io ?
CASE 16.8
A 50-year-old male presents or a “get acquainted” visit. He has
a history o hyperlipidemia treated with lovastatin. He takes
no other medications and states that he is otherwise healthy.
A er watching a television eature called “What’s Killing Us
Now: Prostate Cancer,” he thought he should be screened.
Question 16.8.1 In order to assess his risk or prostate can-
cer, you should take into account all o the ollowing actors
EXCEPT:
A) Age
B) Race
C) Family history
D) Cigarette smoking
E) Ultraviolet light exposure
Answer 16.8.1 The correct answer is “E.” Ultraviolet light expo-
sure increases the risk o skin cancer but not prostate cancer (it is
where “the sun don’t shine”). Advancing age is strongly and directly
associated with the development o prostate cancer. Between ages
50 and 70 years, the incidence o prostate cancer more than qua-
druples, and it continues to increase therea er. Black ancestry and
positive amily history carry the strongest associations with pros-
tate cancer. Cigarette smoking has been linked to an increased risk
o prostate cancer, but not with the strength o association o age or
amily history. Interestingly, dietary actors may have a role in the
development o prostate cancer, although the associations are not
strong and studies con ict. A diet rich in sh and vegetables and
low in red meat may reduce the risk o prostate cancer.
Your patient is Caucasian and denies any amily history o
prostate cancer. He has no urinary symptoms and denies
sexual dys unction.
Question 16.8.2 I he did have urinary symptoms, which
o the ollowing could be used to reliably distinguish BPH
rom prostate cancer?
A) Urgency
B) Nocturia
C) Frequency
D) Hesitancy
E) None o the above . . . or a unctional crystal ball

Answer 16.8.2 The correct answer is “E.” A male who presents
with urinary symptoms o urgency, nocturia, requency, and/
or hesitancy is more likely to have BPH and not prostate can-
cer. T ese urinary symptoms are incredibly common in older
persons in general and most o en are benign in nature. In act,
“BPH symptoms” (better termed lower urinary tract symptoms
or “LU S”) are common in older women as well. However, uri-
nary tract cancers (including prostate and bladder cancers) can
present with these symptoms and must be considered. T e point
is that we cannot always attribute urinary symptoms in an older
male to BPH.
You discuss prostate cancer screening with him, presenting
the controversial and con icting guidelines, discussing posi-
tive and negative values o lab tests and what they signi y,
using a dry erase board and giving a mini-lecture. wenty
minutes later, he says, “It’s just a blood test right? I think I
want one ounce o prevention, you understand, Doc.” He gets
“the works”: digital rectal examination and PSA. T e exami-
nation is remarkable or a slightly enlarged, smooth, non-
tender prostate without nodules. T e PSA level is 16 ng/mL
(re erence range or your lab 0–4 ng/mL).
Question 16.8.3 The most appropriate next step is to:
A) Repeat the PSA in 3 to 6 months
B) Order a transrectal ultrasound o the prostate
C) Re er to urology or urther evaluation and prostate biopsy
D) Repeat the rectal examination and try to nd the nodule that
you missed
E) Order a ree PSA
Answer 16.8.3 The correct answer is “C.” o use the Monop-
oly line: go directly to the urologist; do not pass GO. I he had
symptoms o prostatitis, you might try treating with an appro-
priate antibiotic or 4 weeks and repeat the PSA to con rm ele-
vation be ore re erral. But this patient is completely asymptom-
atic. He is at relatively high risk o having prostate cancer based
on his PSA level (16—that’s high, in case you were uncertain)
and age at presentation. Sending him to a urologist or pros-
tate biopsy is the most prudent step. Follow-up PSA alone (“A”)
would be more de ensible i the PSA level were < 10 ng/mL
and/or the patient were much older. “B,” a transrectal ultra-
sound, is likely to miss more than it would nd in this case.
With this patient’s PSA and current li e expectancy, ultrasound
should only be used as part o a larger urologic evaluation,
including biopsy. “D,” repeating the rectal exam, is just nuts.
T ere is no need or this. Did you miss a nodule? Maybe. Would
it hurt your ego? Who cares! You will eventually get over it.
More likely, there was no palpable nodule. T is patient could
have stage 1 prostate cancer in which, by de nition, no nod-
ules are palpable. He could have a nodule located anteriorly in
the prostate—a location you cannot palpate. He also may have
a PSA elevation or reasons other than prostate cancer. Finally,
“E” is incorrect. T e ree PSA is most help ul when the total
PSA is in the intermediate risk zone (4.01–10 ng/mL). When
the PSA is higher (> 10 ng/mL), the risk o cancer is too great
to make the ree PSA use ul. T e raction o PSA that is “ ree”
CHAPTER 16 • Men ’S HeAl t H 469
(not bound to plasma proteins) is inversely proportional to risk
o prostate cancer: the lower the ree PSA compared with total
PSA, the greater the risk o prostate cancer (cuto percentages
vary rom 10% to 25%).
HELPFUL (OR NOT SO HELPFUL) TIP:
t h d rmi a io o wh o s d a pa i or pros-
a biopsy is mad o c i ica grou ds a d mus ak
i o accou h pa i ’s risk, comorbidi i s, xami a-
io i di gs, PSA v , possibi i y o a s -posi iv or
ga iv s s, pa i ’s pr r c , c. t his d cisio
ca o b mad bas d o a arbi rary PSA va u .
Question 16.8.4 Which o the ollowing is true o the PSA
test when used or screening purposes?
A) T e positive predictive value approaches 100%
B) Since PSA testing has become widespread, prostate cancer
incidence and mortality have increased
C) T e alse-negative rate is 20% to 25%
D) Age-speci c cuto values or PSA have proven to increase
positive predictive value and speci city
E) Race-speci c cuto values or PSA have proven to increase
positive predictive value and speci city
Answer 16.8.4 The correct answer is “C.” T ere is a substan-
tial alse-negative rate— rom 20% to 25%—limiting the use o
PSA or screening purposes. “A” is incorrect by a long shot. T e
positive predictive value (likelihood o a positive test indicating
true prostate cancer) ranges rom about 20% to 60%, depending
on the PSA level. T e positive predictive value increases with
increasing PSA level. “B” is incorrect. Since the PSA test has
come into widespread use, the incidence o prostate cancer has
increased, but mortality due to the disease has decreased. T e
reason or these trends has not been completely explained, and
the role o the PSA test in these trends is not known. “D” and
“E” are incorrect. Since older males seem to have higher PSA
values in the absence o prostate cancer and black males tend to
have prostate cancer ound at lower PSA levels, age-speci c and
race-speci c cuto values have been proposed and investigated.
However, the use o age-speci c and race-speci c PSA cuto
values is o questionable value.
HELPFUL TIP:
t h 5-y ar surviva ra o pros a ca c r is abou
99%. Whi h i im pr va c o pros a ca c r is
abou 14%, h i im risk o dyi g o pros a ca c r
is ss ha 3%. For o d r m , w o h ar, “You ar
mor ik y o di with pros a ca c r ha of pros a
ca c r.” t his sayi g app ars roo d i r a i y.
Again your winning personality and reputation or thorough
care has won you a re erral. Your patient re ers a riend to
you. T is patient is a 60-year-old male who presents to your
clinic or advice regarding treatment a er recently being
470 FAMIl Y MeDICIn e eXAMIn At IOn & BOARD ReVIeW
diagnosed with prostate cancer. A urologist recommended
surgery but he wants to know what you think. (Don’t let it go
to your head.)
Question 16.8.5 Possible treatment options or prostate
cancer include all the ollowing, EXCEPT:
A) External beam radiation
B) Saw palmetto
C) Active surveillance
D) Robotic prostatectomy
Answer 16.8.5 The correct answer is “B.” While over-the-
counter saw palmetto is sometimes taken by patients or BPH
even though it has not been proven to be e ective, it is not used
or prostate cancer treatment. External beam radiation, brachy-
therapy, surgery (open, laparoscopic, or robotic prostatectomy),
and androgen deprivation therapy are options considered or
higher-risk prostate cancers. Watch ul waiting and active sur-
veillance are options considered or lower-risk prostate cancers.
Active surveillance consists o scheduled PSA testing and digi-
tal rectal examinations every 3 to 6 months and repeat prostate
biopsies at 1- to 3-year intervals.
HELPFUL TIP:
I is impor a o r a iz ha h r is gr a co rov rsy
ov r h ro o digi a r c a xami a io a d PSA i
scr i g or pros a ca c r. t h y ar o co sid r d
“good” scr i g s s (high ra o a s posi iv s
a d as ga iv s), bu h r is o hi g s o o r
a his im . I 2013 h Am rica Uro ogica Associa-
io cha g d h ir guid i s o scr i g ag s 55 o
69 v ry o h r y ar. Si c 2012, h US Pr v iv S r-
vic s t ask Forc has r comm d d AGAIn St pros a
ca c r scr i g. t h wo arg s s udi s o pros a
ca c r scr i g wi h PSA ( h Pros a , l u g, Co o ,
a d Ovaria Ca c r Scr i g t ria [Pl CO] a d h
europ a Ra domiz d S udy o Scr i g or Pros-
a Ca c r [eRSPC]), do o a sw r h qu s io o
how PSA scr i g a c s mor a i y, arriv d a oppo-
si co c usio s (Pl CO show d o mor a i y c wi h
scr i g, whi h eRSPC show d a pros a ca c r-
sp ci ic mor a i y r duc io wi h PSA scr i g). How-
v r you approach his issu , you’r o a o , a d h
compa y you k p is jus as co us d. ev ryo agr s
ha scr i g or m o d r ha 75 y ars or wi h ss
ha 10 y ars o iv is o us u .
HELPFUL TIP:
t h r su s o a ra domiz d ria sugg s ha vi ami e
supp m a io may i cr as h ra o pros a
ca c r. Do ’ do i (JAMA. 2011;306(14):1549–1556).
Objectives: Did you learn to . . .
• Id i y risk ac ors or pros a ca c r?
• Discuss pros a ca c r scr i g wi h a pa i ? a er puberty, prior chemotherapy or radiation, intake o calcium
• I rpr a va d PSA?
• R cog iz h imi a io s o pros a ca c r scr i g?
• R cog iz various r a m op io s or pros a ca c r?
CASE 16.9
A 32-year-old male accompanied by his wi e presents or eval-
uation o in ertility. T ey have been married or 5 years and
have been attempting conception or 3 years without success.
T e patient’s wi e has a 7-year-old daughter rom a previous
marriage. T e patient has no signi cant past medical or sur-
gical history. He does not smoke but drinks a six-pack o beer
and one cup o cof ee daily—not necessarily in that order. He
relaxes a er work and on weekends by sitting in their hot tub
or hours at a time. His BMI is 32 kg/m2. He has normal acial
and body hair and his testicles are descended bilaterally and
o normal size. You note a moderate sized varicocele on the
le .
Question 16.9.1 Which o the ollowing is not a modif able
risk actor or male sub ertility?
A) Alcohol intake
B) Hot tub usage
C) Varicocele
D) obacco use
E) Obesity
Answer 16.9.1 The correct answer is “D.” We should note
that the study o in ertility risk actors and treatments is
complicated by inconsistent outcome measures (e.g., sperm
count, sperm motility, conception, pregnancy resulting in
live birth). However, there are no conclusive studies correlat-
ing tobacco use with male sub ertility. T e other answers are
modi able risk actors and have been directly linked to sub-
ertility, either in decreased sperm count or decreased sperm
motility. It is important to ask about alcohol use (“A”). Other
drug use, such as marijuana, should be investigated as well
since it can a ect sperm quality and motility. “B” is true. Hot
tub usage, ebrile illnesses, and the presence o a varicocele
raise the temperature o the testicles, thereby decreasing the
optimal environment or the maturation o sperm. But how
about the boxers versus brie s controversy? ype o under-
wear does not seem to a ect scrotal temperature signi cantly,
and more to the point, tight underwear is not associated
with decreased ertility. T e presence o a varicocele (“C”)
is an interesting issue. It is certainly modi able in that the
patient could undergo a varicocelectomy, which might help
i the varicocele is moderate to large in size. However, the
degree to which a varicocele contributes to in ertility is not
well-known. Varicoceles are noted to occur more commonly
in in ertile men, but they also occur in 10% to 15% o the
normal, ertile male population. Obesity (“E”) contributes to
the increased peripheral aromatization o testosterone into
estradiol in atty tissue.
Other actors that contribute to sub ertility/in ertility
include a history o cryptorchidism, hypospadias, viral orchitis

channel blockers, and retrograde ejaculation associated with
diabetes and multiple sclerosis.
HELPFUL TIP:
I r i i y i a coup is d i d as i abi i y o co c iv
d spi 1 y ar o r qu (how r qu is o d i d),
u pro c d s xua i rcours . I h U i d S a s,
h pr va c o i r i i y is 7% o 15% d p di g o
how h s a is ic is m asur d.
Question 16.9.2 You order a seminal uid analysis, and the
sperm density is 12 million/mL with a motility o 35%. This
f nding is:
A) Normal or both sperm count and motility
B) Normal or sperm count but abnormal or motility
C) Abnormal or sperm count but normal or motility
D) Abnormal or both sperm count and motility
E) Scary; that seems like a lot o sperm
Answer 16.9.2 The correct answer is “D.” As a general rule,
normal sperm concentration or ertility is considered to be
15 million/mL or greater. However, as they say, it only takes one
sperm to make a baby, so men with lower sperm counts can
be ertile. At least 40% or more should be motile. Another
nding o importance on SFA is the sperm morphology. Using
strict criteria, normal morphology should be 4% or more (yes,
un ortunately or men, only 4%).
You repeat the SFA 2 weeks later, and again it is abnormal.
His testosterone level is low or his age, and his FSH and LH
are high.
Question 16.9.3 Which o the ollowing is most likely to be
the cause o his decreased ertility?
A) Congenital absence o the prostate gland
B) Primary hypogonadism
C) Bilateral complete vas de erens obstruction
D) Androgen resistance
Answer 16.9.3 The correct answer is “B.” A low testosterone
level accompanied by elevated LH and FSH could indicate tes-
ticular ailure, or primary hypogonadism. “A” is not a known
cause o in ertility, and in act it is not a known disorder as ar
as the editors can determine. T e prostate gland’s only impor-
tant unction is to provide a subject or an endless debate over
screening so that epidemiologists have something to do. Just
kidding. . . . T e prostate gland actually has a role in produc-
ing important substances that are part o the seminal uid and
assist sperm in their migration through the emale genital tract.
However, prostate problems do not seem to cause in ertility.
“C,” an obstruction o the vas de erens, would most likely result
in azoospermia with normal or high testosterone levels. “D” is
incorrect. You would expect to see elevated testosterone levels
in patients with androgen resistance. See able 16-3 or a list o
causes o in ertility in males.
CHAPTER 16 • Men ’S HeAl t H 471
TABLE 16-3 A PARTIAL LIST OF CAUSES
OF MALE INFERTILITY
Mechanism Specif c Examples
Hypo ha amic– Co g i a disord rs (Ka ma sy drom ),
pi ui ary disord rs pi ui ary umors, pi ui ary i arc io ,
hormo a or psycho ropic drug us
Primary Ki r sy drom , cryp orchidism,
hypogo adism a coho us , ch mo h rap u ic ag s,
s icu ar orsio , hyp r h rmia
Disord rs o sp rm Co g i a abs c o h vas d r s,
ra spor pididyma dys u c io , spi a cord i jury
Idiopa hic i r ii y U xp ai d sa is ac ori y by his ory,
xami a io , a d abora ory va ua io
Question 16.9.4 How can you now best help this patient
achieve ertility, assuming that there are no problems with
his partner?
A) Empiric treatment or gonorrhea and chlamydia
B) Empiric treatment with testosterone injections
C) Empiric treatment with gonadotropin-releasing hormone
D) Re erral to an in ertility treatment center
Answer 16.9.4 The correct answer is “D.” At this point o time,
you have per ormed a reasonably complete evaluation and even
arrived at a potential cause o in ertility. However, treatments
or male in ertility are the subject o much debate, and the
patient is probably best served by re erral to an in ertility treat-
ment specialist. “A” is incorrect. Genital in ections are not
thought to play a major role in male sub ertility/in ertility, so
without clear evidence o gonorrhea and/or chlamydia, treating
or these diseases is not recommended. “C” is incorrect because
this patient does not appear to have a hypothalamic source or
his in ertility. “B,” testosterone injection, can actually make the
problem worse. T e most e ective therapy or patients with
in ertility and primary hypogonadism (i.e., this patient) may be
sperm retrieval or intracytoplasmic sperm injection (not typi-
cally thought o as an o ce procedure or the amily physician).
You re er this gentleman to an in ertility treatment center
in your neck o the woods. He is so pleased with your atten-
tion to detail and well-reasoned approach that he re ers his
best riend to you or the same problem—in ertility. T is new
patient reports never conceiving, although his wi e has had
one child rom a previous marriage. On physical examina-
tion, you note a thin rame, mild symmetric gynecomastia,
and small, rm testicles. He has complete azoospermia on
two semen analyses.
Question 16.9.5 His most likely diagnosis is:
A) Cystic brosis
B) Psychosomatic azoospermia
C) Kline elter syndrome
D) esticular cancer
E) urner syndrome
472 FAMIl Y MeDICIn e eXAMIn At IOn & BOARD ReVIeW
Answer 16.9.5 The correct answer is “C.” T e triad o small
rm testicles, gynecomastia, and azoospermia are classic nd-
ings in patients with Kline elter syndrome. Kline elter syn-
drome occurs in 1 in 1,000 live male births and is responsible or
14% o cases o azoospermia. T e most common (90%) chro-
mosomal abnormality in Kline elter syndrome is 47,XXY. “A”
is incorrect. Although males with cystic brosis can have con-
genital absence o the vas de erens, these patients usually have
normal-sized testicles and no gynecomastia. “B” is, o course,
not a real thing. “D” is incorrect. Patients with testicular cancer
usually have an enlarged testicle with a mass on the sur ace or
inside the testicle. Although the treatments or testicular cancer
may result in in ertility, patients with testicular cancer do not
typically present with in ertility. “E” is incorrect. urner syn-
drome (45,X) is associated with unambiguously emale genitalia
with no breast development.
Objectives: Did you learn to . . .
• D modi ab risk ac ors or ma sub r i i y/ i r i i y?
• R cog iz h sig i ca c (or ack o sig i ca c ) o a vari-
coc ?
• Id i y h appropria i dica io s or ob ai i g abora ory
s udi s i ma pa i s wi h i r i i y co c r s?
• R cog iz som impor a caus s o i r i i y?
CASE 16.10
A 63-year-old male with a history o insulin-dependent dia-
betes complains o decreased libido and di culty maintain-
ing an erection, worsening over the past ew years. He does
have occasional erections su cient or penetration and
awakens with an erection at times. His medical history is also
signi cant or hypertension and an appendectomy. His medi-
cations include insulin, lisinopril, and hydrochlorothiazide.
He has been married or 30 years and has two grown children,
ages 24 and 26.
Question 16.10.1 Which o the ollowing historical ele -
ments is NOT likely to contribute to this patient’s erectile
dys unction?
A) Diabetes
B) Depression
C) Hypertension
D) History o appendectomy
E) Antihypertensive medications
Answer 16.10.1 The correct answer is “D.” We’re checking to
see i you’re still awake. All the other options could cause some
degree o erectile dys unction. Any disease process that a ects
the nervous, vascular, endocrine, or smooth-muscle systems
can result in erectile dys unction. A partial list o other risk
actors or erectile dys unction includes advancing age, pros-
tate disease or surgery (i the nerves are cut . . . not an issue
with URP), pelvic racture, alcohol or other substance abuse,
medications (addressed later), spinal radiculopathy or spinal
cord injury, multiple sclerosis, endocrine disorders (e.g., hypo-
thyroidism, hyperthyroidism), smoking, cardiovascular disease,
chronic renal ailure, and Peyronie disease (a localized plaque-
like brosis leading to possible erectile dys unction, penis cur-
vature, shortening o the penis).
HELPFUL TIP:
t h r ar wo ca gori s o r c i dys u c io —
psychog ic a d orga ic. I m you g r ha 35 y ars,
psychog ic r c i dys u c io is much mor com-
mo . I co ras , m o d r ha 50 y ars ar mor ik y
o hav a orga ic caus or h ir r c i dys u c io .
Question 16.10.2 What urther historical element(s) is/are
use ul in the evaluation o erectile dys unction?
A) Rapidity o onset o sexual dys unction
B) Presence o nocturnal erections
C) Status o relationship with the sexual partner
D) Partner’s interest in sex
E) All o the above
Answer 16.10.2 The correct answer is “E.” Further history
should involve all the elements listed. Patients with a sudden
onset o erectile dys unction o en have a primary psychogenic
erectile dys unction. T e presence o nocturnal erections estab-
lishes that the patient’s neurologic and vascular mechanisms
work to produce an erection. An organic disorder may still be
playing a role, but the circuit is working. T e status o the rela-
tionship with the patient’s partner, his attraction to that part-
ner, and the partner’s interest in sex are important. I the patient
and his partner are having relationship problems outside o the
sexual arena, counseling may be the best rst step in trying to
address the erectile dys unction.
Question 16.10.3 All o the ollowing drugs or classes o
drugs can adversely a ect male sexual unction EXCEPT:
A) Cimetidine
B) Chlorthalidone
C) Prednisone
D) Clonidine
Answer 16.10.3 The correct answer is “C.” T ere are many
drugs, prescription and recreational, that a ect sexual unction,
and some o these include antihypertensives, antidepressants,
antipsychotics, anxiolytics, hormonal agents (e.g., antiandro-
gens, estrogens, progestational agents, and anabolic steroids),
and the H 2 blocker cimetidine (but apparently not ranitidine or
amotidine). T e e ects range rom decreased libido to impo-
tence and/or ejaculatory dys unction. Various recreational drugs
such as alcohol, marijuana, heroin, and cocaine may initially
cause a state o disinhibition and enhanced libido. However,
excessive or chronic use leads to erectile dys unction. Predni-
sone is not known to cause signi cant erectile dys unction.
On physical examination, you nd normal genitalia, normal
emoral and dorsalis pedis pulses, appropriate virilization,
and slightly diminished sensation at the plantar aspects o
the eet with an otherwise intact neurological examination.
 CHAPTER 16 • Men ’S HeAl t H 473

Question 16.10.4 Which o the ollowing will be most use -

HELPFUL TIP:
ul in evaluating a cause or his erectile dys unction and
t h r is o much di r c b w h various phos-
directing urther therapy?
phodi s ras i hibi ors o h mark . t h icacy is
A) BUN and creatinine
abou h sam . Sid - c pro i s ar simi ar. O s
B) SH
o ac io is abou h sam . t ada a i has h o g s
C) PSA
ha - i . n o ar g ric ( or h i dica io o r c i
D) Nocturnal penile tumescence study
dys u c io —as o 2015). A ar v ry xp siv , abou
E) Arterial and venous Doppler studies
$40 per tablet (a h wri i g o his book).
Answer 16.10.4 The correct answer is “B.” With the advent
o sa e and e cacious therapy or erectile dys unction, many
clinicians proceed directly to a medication trial without labo- You start the patient on sildena l. He discovers love again,
ratory studies. In many patients, this approach is acceptable. but his wi e nds out. Now you’re in trouble!
Other patients may bene t rom a limited laboratory evalu-
Objectives: Did you learn to . . .
ation—especially those men with other symptoms and/or
• eva ua a pa i wi h r c i dys u c io ?
comorbidities. Initial labs might include SH, testosterone,
and prolactin. I not done already, screening or diabetes and • D scrib various io ogi s o r c i dys u c io ?
vascular risk (e.g., lipids) is appropriate. T e role o nocturnal • Id i y m dica io s ha a c r c i u c io ?
penile tumescence is debated, but it is not necessary prior to • R cog iz i dica io s, co rai dica io s, a d sid c so
a therapeutic trial and this patient reported having nocturnal h rap u ic moda i i s or r c i dys u c io ?
erections anyway. BUN, creatinine, and PSA are not likely to
be help ul. Doppler ow studies o emoral vessels are unlikely
to change therapy as long as the physical examination dem- Clinical Pearls
onstrates normal distal blood ow. In this patient, you know Do o d ay a urg uro ogica co su or h r am
that he has vascular disease (diabetes, hypertension, and now o priapism as his is a uro ogica m rg cy.
erectile dys unction), so his treatment should already involve
Do o p r orm pros a ic massag i h r is a suspicio
lowering his vascular risk actors. or pros a i is du o h risk o s di g bac ria i o h
b oods r am.
Question 16.10.5 Concurrent use o which o the ollowing
Do o us ora s os ro r p ac m h rapy as h r
drugs is an absolute contraindication to taking a phospho-
is a sig i ica irs -pass m abo ism a d po ia or iv r
diesterase type 5 inhibitor (e.g., tadalaf l, vardenaf l, silde - oxici y.
naf l)?
A) Hydrochlorothiazide e gag i a shar d discussio abou h us o PSA i scr -
i g or pros a ca c r, po ia b i s, a d po ia ga-
B) Isosorbide dinitrate
iv co s qu c s prior o d cidi g o p r orm scr i g. t h
C) estosterone USPSt F r comm ds agai s rou i scr i g or pros a
D) Finasteride ca c r bu h guid i s/r comm da io s vary!
E) Saw palmetto
Rou i y scr you g ma pa i s or high-risk b haviors
as rauma is h adi g caus o d a h i you g m .
Answer 16.10.5 The correct answer is “B.” In patients who take
nitrates or coronary heart disease, phosphodiesterase inhibitors Scr or po ia s co dary caus s o r c i dys u c io
are contraindicated. T e combination has been shown to cause prior o pr scribi g m dica io .
hypotension, in rare cases severe enough to result in stroke. Scr you g boys or cryp orchidism by doi g a g ia a d
While concurrent use o nasteride is sa e, the alpha-blockers s icu ar xami a io a w -chi d visi s.
used to treat BPH are another story (see below). Drugs that
inhibit cytochrome P450 isoenzyme, such as cimetidine, eryth-
romycin, clarithromycin, itraconazole, ketoconazole, and HIV BIBLIOGRAPHY
protease inhibitors, may warrant phosphodiesterase inhibitor American Urological Association Education and Research, Inc.
dosage reductions. Caution with phosphodiesterase inhibitors (AUA). Early detection o prostate cancer: AUA guideline.
is advised in patients with uncontrolled hypertension, recent Linthicum (MD): American Urological Association
stroke or myocardial in arction, li e-threatening arrhythmias, Education and Research, Inc.; 2013.
unstable angina, or heart ailure. Other potential medical thera- Bremner WJ. estosterone de ciency in older men. N Engl J
pies or erectile dys unction include testosterone supplementa- Med. 2010;363:189.
tion and yohimbine. T ere are even more treatment modalities: Centers or Disease Control and Prevention. Sexually transmit-
sex therapy, vacuum erection devices, intracavernosal injection ted diseases treatment guidelines, 2015. MMWR. 2015;
therapy, intraurethral pharmacotherapy, arterial revasculariza- 64(3)59(RR-12):1–137.10.
tion (not routinely per ormed strictly or ED), penile prosthesis Craw ord P. Evaluation o scrotal masses. Am Fam Physician.
implantation, and combined therapy. 2014;89(9):723–727.
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Dickson G. Gynecomastia. Am Fam Physician. 2012;85(7);
716–722.
Edwards JL. Diagnosis and management o benign
prostatic hyperplasia. Am Fam Physician. 2008;77(10):
1403.
Heidelbaugh JJ. Management o erectile dys unction. Am Fam
Physician. 2010;81(3):305.
Lindsay J. Evaluation and treatment o in ertility. Am Fam
Physician. 2015;91(5):308–314.
Mohan R. reatment options or localized prostate cancer.
Am Fam Physician. 2011;84(4s):413–420.
Pearson R. Common questions about the diagnosis and
management o benign prostatic hyperplasia. Am Fam
Physician. 2014;90(11):769–774.
Sharp V. Prostatitis: diagnosis and treatment. Am Fam
Physician. 2010;82(4);397–406.
ask Force on Circumcision. Male circumcision. Pediatrics.
2012;130(3):e758–e785.
eichman JMH. Urology: 20 Common Problems. New York, NY:
McGraw-Hill; 2001.
U.S.Preventive Services ask Force. Screening or prostate
cancer: Recommendation Statement, and rationale. Ann
Intern Med. 2002;137(11):915.
U.S. Preventative Services ask Force. Screening or prostate
cancer: recommendation statement. Am Fam Physician.
2013 Feb 15;87(4):1–7.
Wieder JA. Pocket Guide to Urology. 5th ed. Oakland, CA:
J. Wieder Medical; 2014.
Dermatology
Megan H. Noe and Karolyn A. Wanat
Since dermatology is a visual science, take a look at pictures
at www.dermnet.org.nz/sitemap.html, or www.dermnet.com.
See able 17-1 or commonly used dermatology terms.
CASE 17.1
A 37-year-old white emale presents to clinic or her annual
well adult physical examination. A er a complete skin exam-
ination, you nd a suspicious lesion on her back (Fig. 17-1).
It measures 16 mm × 8 mm. She has approximately 20 nevi
that appear normal. T e patient reports never per orming
sel -skin examinations and does not know i the lesion in
TABLE 17-1 DERMATOLOGY TERMS
17
question is new. She denies any symptomatic lesions. Her am-
ily history is remarkable or “skin cancer” on her ather’s side.
Many amily members have “tons o moles.” She requented
a tanning parlor in college (too much ree time . . . probably
majored in communications) and occasionally still does so
be ore social events (didn’t learn much about skin health in
college).
Question 17.1.1 How do you evaluate the lesion?
A) ake a photograph and see her back in 2 months
B) ake a shallow shave biopsy o the lesion
C) Excise the entire lesion with 1- to 2-mm margins
D) Excise the entire lesion with 3-cm margins
E) All o the above are equally valid approaches

Abrasion: Partial-thickness loss o the epidermis Answer 17.1.1 The correct answer is “C.” T is lesion is wor-
Abscess: Localized collection o purulent exudate risome or malignant melanoma because o the di erent pig-
Annular: Grouped in a circular arrangement mentation colors and irregular borders. Any time you suspect
Bulla: Fluid- lled cavity greater than 1 cm melanoma, you are obligated to completely remove the entire
Crust: Dried exudate on the skin sur ace; can be serous (yellow or lesion and send it or pathology either with a punch biopsy or
honey-colored) or hemorrhagic (red-brown); when related to an excisional biopsy. “A” is not an option; i you suspect melanoma,
in ection the term impetiginization can be used the earlier you make the diagnosis the better. A shave biopsy
Desquamation: Skin cells coming o in scales or akes (“B”) is also not recommended because the shave biopsy is o en
Erythema: A red color change that is blanchable with pressure too shallow and the deep margins are not visible, which is the
Herpetiform: Grouped in a dermatomal distribution
Macule/Patch: Circumscribed area o color-change without elevation
or depression; a “macule” is < 1 cm in diameter and a “patch” is > 1 cm
in diameter
Nodule: A solid subcutaneous mass
Nummular: coin-shaped or circular
Papule/Plaque: A palpable, (elevated) skin lesion; a “papule” is < 1 cm
in diameter and “plaque” is > 1 cm in diameter
Purpura: Bleeding into the skin; does not blanch with pressure
Pustule: A papule with purulent exudate
Ulcer: Full-thickness loss o the epidermis
Vesicle: A uid- lled cavity in the skin less than 1 cm
Wheal: A round or irregular-shaped edematous plaque that tends to
be transient (hive)
FIGURE 17-1.

475
476 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
most important actor in staging melanoma. Partial removal o
a lesion may lead to a sampling error, which is why excisional
biopsy with narrow (e.g., 1–2 mm) margins is pre erred. “D” is
pre erable to “A” and “B”; however, it would be unnecessary to
remove the lesion with such large margins when the histopa-
thology is not yet known.
You excise the entire lesion with a small border. T e pathol-
ogy report reveals a malignant melanoma.
Question 17.1.2 Which o the ollowing lesion characteris
tics will determine your patient’s prognosis?
A) T e depth and ulceration
B) T e diameter o the lesion
C) T e number o colors in the lesion
D) Whether or not it arose in a pre-existing mole
E) T e number o lymphocytes in the biopsy
Answer 17.1.2 The correct answer is “A.” As alluded to pre-
viously, the depth o the melanoma is the most important
prognostic indicator. Breslow tumor thickness is most com-
monly used to arrive at a prognosis. Breslow tumor thickness
measures the depth o the melanoma rom the granular layer
in the epidermis to the base o the melanoma in millimeters.
A thinner melanoma correlates with a better prognosis and
melanomas with a Breslow depth 0.75 mm generally have the
best prognosis. Ulceration is associated with more aggressive
cancers and a poorer prognosis. Clark level (invasion based
upon the anatomic structure o the skin) is still reported but is
not as important in regards to prognosis as Breslow depth. T e
diameter o the lesion (“B,” or the size observed on the skin) has
not been associated with prognosis (e.g., super cial spreading
melanoma may be large but generally carries a good progno-
sis). A very large, clinically atypical pigmented lesion can o en
be benign. Melanomas can also be o one color, many colors,
or nonpigmented; color does not correlate with prognosis. Up
to two-thirds o melanomas arise in normal skin. T ey can be
just as aggressive as those arising rom moles. T e number o
mitoses in a lesion can help predict the outcome; the more the
mitoses, the worse the prognosis. T e number o lymphocytes
observed within a lesion can provide some in ormation regard-
ing the in ammatory response but does not possess the same
prognostic value as the Breslow depth.
HELPFUL TIP:
I there is regional or distant spread o disease, the over-
all survival drops to less than 50% or regional metasta-
ses and less than 10% or distant metastases.
Question 17.1.3 In the United States in 2011, the li etime
risk o developing melanoma in a Caucasian emale is
approximately:
A) 1/10
B) 1/55
C) 1/105
D) 1/1500
Answer 17.1.3 The correct answer is “B.” T e li etime prob-
ability o melanoma in the year 2011 or Caucasian emales was
approximately 1 in 55. Caucasian males in the United States are
worse, with a li etime probability o 1/37.
Your biopsy reveals a malignant melanoma in situ. You excise
the entire lesion with 0.5-cm margins. T ere is no penetra-
tion o the epidermis.
Question 17.1.4 What additional evaluation is necessary?
A) Chest x-ray
B) C scan o the chest
C) Serum lactic acid dehydrogenase (LDH)
D) All o the above
E) None o the above
Answer 17.1.4 The correct answer is “E.” I the melanoma has
not penetrated the epidermis, it is re erred to as a melanoma
in situ. I excised with 0.5- to 1-cm margins, the long-term sur-
vival at 5 and 10 years approaches 100%. T ere ore, any addi-
tional workup is not necessary according to the 2010 report
rom the American Joint Commission on Cancer. When the
melanoma depth is greater than 1 mm, urther workup is o en
per ormed. In general, chest radiography and a serum LDH
level are recommended or malignant melanomas greater than
1 mm in depth, mostly to obtain a “baseline.” Regarding a sen-
tinel lymph node biopsy, although there is no proven therapeu-
tic bene t, it can provide additional prognostic in ormation or
melanomas with a depth > 1 mm. Serum LDH levels are usually
positive in very advanced cases that have metastasized to bone
or liver. A C scan o the chest and pelvis and MRI o the brain
can be ordered i metastatic disease is suspected, but these stud-
ies are not routinely recommended. Metastatic disease has not
been reported with malignant melanoma in situ.
Question 17.1.5 Which o the ollowing has NOT been asso
ciated with an increased risk o the development o mela
noma?
A) Blistering sunburns in childhood
B) Sister with melanoma
C) Fair hair color
D) More than 50 moles on a person’s body
E) Smoking
Answer 17.1.5 The correct answer is “E.” A history o blister-
ing sunburns, melanoma in rst-degree relatives, air hair, and
more than 50 moles are all associated with an increased risk
o developing melanoma. Also, high socioeconomic class and
immunosuppression appear to be risk actors. Smoking has not
yet been linked to malignant melanoma—unlike many other
malignancies.
Question 17.1.6 The most common subtype o melanoma
in people o A rican descent is:
A) Super cial spreading melanoma
B) Lentigo maligna melanoma

C) Nodular melanoma
D) Acral lentiginous melanoma
E) Amelanotic melanoma
Answer 17.1.6 The correct answer is “D.” T ere are our clas-
sical subtypes o malignant melanoma. T e subtype does not
predict prognosis. Super cial spreading melanoma is the
most common type in air skin populations. It can occur at any
site and clinically presents as a brown macule with irregular,
notched borders. It grows radially (outward) initially. Nodular
melanoma is the second most common type in air skin indi-
viduals and, as the name suggests, is an exophytic nodule and
o en associated with deeper level o invasion and a vertical
(downward) growth phase. Amelanotic melanoma is a subtype
o nodular melanoma that presents with little to no pigment
and may be red or pink in color. Lentigo maligna melanoma
most o en occurs in the elderly on sun-exposed areas, such as
the ace and hands and presents as a brown macule or patch
with hue variations that spreads outward slowly. When there is
dermal invasion, lentigo maligna is re erred to as lentigo maligna
melanoma. Acral lentiginous melanoma is the least common
type in Caucasian populations but is the most common type in
races with pigmented skin, such as people o A rican descent.
Acral lentiginous melanoma occurs on the palms, soles, or near
the nails. T is is what killed Bob Marley.
Objectives: Did you learn to . . .
• Evaluate a patient with suspected melanoma?
• Describe how the prognosis o melanoma is determined?
• Recognize the li etime risk o malignant melanoma in the
United States?
• Identi y risk actors or the development o melanoma?
• Recognize the our classic subtypes o melanoma and which
are the most common in A rican and Caucasian populations?
QUICK QUIZ: ITCHYELBOWS
A 22-year-old emale presents with a pruritic rash on her elbows
and extensor orearms. She’s studying or nals, so she’s been
indoors or days eating Wheat T ins and drinking Mountain
Dew. She has a history o celiac disease, but is otherwise healthy
and takes no medications. On examination, she is a ebrile and
has 2- to 4-mm diameter vesicular lesions with numerous exco-
riations in a bilaterally symmetrical pattern on her extensor
orearms, knees, and buttocks.
T e most likely diagnosis is:
A) Dermatitis herpeti ormis
B) Poison ivy (contact dermatitis)
C) Herpes simplex
D) Neurotic excoriations
E) Nerd elbow
The correct answer is “A.” Dermatitis herpeti ormis is the most
common skin condition to occur in association with celiac dis-
ease (gluten enteropathy). T is patient seems to have lapsed in
CHAPTER 17 • DERMATOLOGY 477
her gluten- ree diet, and her skin eruption has worsened as a
result. Dermatitis herpeti ormis presents with excoriated vesi-
cles that are extremely pruritic. It can be con used with scabies.
O en, only excoriations (and no blisters) are seen on exami-
nation. Dermatitis herpeti ormis is also commonly symmetri-
cal (as opposed to HSV) and may involve several body areas,
most commonly extensor sur aces o the extremities. T e cor-
nerstone o treatment is a gluten- ree diet. Dapsone can also
help speed up resolution o the rash, but a strict gluten- ree diet
will also lead to disease resolution. In this case, “B” is unlikely
due to symmetric and di use eruption without linear lesions
and no reported exposure to poison ivy (we didn’t tell you this,
but her college is located in Antarctica, making poison ivy very
unlikely). “C” is incorrect since the eruption is di use and there
is no pain. Neurotic excoriations (“D”) do not present with
vesicles. I “E” were a real entity, the editors believe it would
be an orthopedic disorder—some underuse atrophy o the joint
maybe.
CASE 17.2
A 7-month-old male is brought to clinic or a “rash all over.”
Six weeks ago, his parents noticed him rubbing his legs
against his crib and scratching his head requently. T ey
are concerned because they nd blood on his sheets in the
morning, and he has become increasingly irritable. He is
eating and drinking normally. His past medical history is
unremarkable. His ather has sensitive skin and hay ever,
but no one else in the amily currently has a rash. He does not
attend a daycare. On skin examination, you nd licheni ed
and erythematous patches o skin with ssures and bleeding
on the ventral heels, dorsal eet, hands, and a ew areas on the
scalp. His cheeks are bright red with scale. His diaper area is
uninvolved and there are no lesions in the web spaces o the
hands and eet.
Question 17.2.1 Based on the description, which o the
ollowing is the most likely diagnosis?
A) Seborrheic dermatitis
B) Atopic dermatitis
C) Scabies
D) inea corporis
E) inea versicolor
Answer 17.2.1 The correct answer is “B.” T e most likely diag-
nosis is atopic dermatitis, also known by the moniker eczema.
Atopic dermatitis is characterized by an intensely pruritic erup-
tion o the skin with associated dryness. A red rash subsequently
develops. Atopic dermatitis is o en re erred to as the “itch that
rashes.” It occurs in characteristic locations. In younger in ants,
the cheeks and neck are involved. As they begin to crawl, their
extensor sur aces are involved. T e diaper area, because it is
moist, is not usually involved. In older children, the exural
areas, such as the antecubital and popliteal ossae, are involved.
Seborrheic dermatitis (“A”) is common in in ants (cradle cap)
and is usually seen on the scalp and ace, although it can involve
the whole body. Seborrheic dermatitis is usually associated with
478 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
a yellow, greasy scale and is less erythematous than atopic der-
matitis. Scabies (“C”) typically a ects certain locations (web
spaces, wrists, waist, etc.) and uncommonly involves the scalp,
except in in ants or immunocompromised patients. Also, in this
question, he does not appear to have any exposure to scabies.
inea corporis (“D”) presents with a ring o advancing ery-
thema and a central clearing (“ringworm”). Finally, tinea ver-
sicolor (“E”) typically involves the trunk and extremities with
hypo- or hyperpigmented patches with super cial scale. It does
not involve the scalp, and is not very pruritic.
You diagnose the patient with atopic dermatitis.
Question 17.2.2 Which o the ollowing is true about atopic
dermatitis?
A) T e prevalence o atopic dermatitis appears to be decreasing
worldwide
B) Atopic dermatitis tends to worsen with use o emollients
C) In some patients, skin in ections can exacerbate atopic der-
matitis
D) Positive skin prick tests and RAS testing correlate highly
with ood challenges (e.g., those with positive tests will have
worsening o their rash when given a ood challenge)
E) In most in ants, atopic dermatitis will not signi cantly
improve or resolve by school age
Answer 17.2.2 The correct answer is “C.” Skin in ections
(Staph or Strep in ections) can be associated with worsening
atopic dermatitis, and when children are, impetiginization
(superin ection) should be considered. In these situations, a
course o antibiotics may improve the overall clinical course
(cephalexin is o en a good choice). Sixty percent o atopic der-
matitis appears in the rst year o li e, usually a er 2 months o
age; and it will usually get somewhat better by school age. T e
cause o atopic dermatitis is not yet known. T e role o speci c
allergens is controversial. In some patients, a ood allergy can
worsen the disease but is not thought to be the cause. However,
in severe, unresponsive atopic dermatitis, ood allergens should
be evaluated. Most patients who have positive allergy testing
to oods do not have improvement in their skin with removal
o the allergen. Atopic dermatitis does tend to improve as the
a ected child ages (“E”), and the use o emollients (“B”) is a
cornerstone o therapy.
HELPFUL TIP (OR NOT):
The link between allergies o any kind, including ood
and environmental, and atopic dermatitis has been
called into question. It does seem that a subset o pa-
tients have atopic dermatitis that lares in response to
exposure to certain ood and environmental triggers,
but these patients are the minority. Random elimina-
tion diets are to be discouraged. Only patients with
proven ood allergy and an immediate worsening o
symptoms when exposed to that ood should eliminate
that particular ood rom their diet.
Question 17.2.3 The clinical eatures o impetiginized
atopic dermatitis include:
A) Licheni cation o the skin
B) Pruritus and relapsing nature
C) Associated asthma or allergic rhinitis
D) Elevated IgE serum levels
E) Redness o the skin with honey-crusting
Answer 17.2.3 The correct answer is “E.” Although all o the
above can be associated with atopic dermatitis, honey crust-
ing implies a secondary bacterial in ection (impetigo), which
is common in atopic dermatitis and needs to be recognized
and treated to get atopic dermatitis under control. Oral anti-
biotics and chlorinated baths can be used to help control the
superin ection. Waxing and waning pruritus is what de nes
this common skin condition. Chronic scratching o en leads to
thickened skin with accentuation o skin lines (licheni cation).
Early lesions will not have licheni cation, however. Asthma and
allergic rhinitis can be associated with atopic dermatitis. T is
common hypersensitivity triad is re erred to as atopy (although
atopic dermatitis is not allergic in nature). “D,” elevated IgE,
does occur in patients with atopic dermatitis, and higher levels
o serum IgE are associated with more extensive disease o
greater chronicity. However, an elevated IgE level is merely an
association and is not pathognomonic o atopic dermatitis. Ery-
thema o the skin is a nonspeci c sign o in ammation and is
seen in many skin disorders.
Question 17.2.4 Your initial recommendation should
include which o the ollowing in the management o
atopic dermatitis:
A) Daily use o thick emollients such as white petrolatum
B) Bathing with lukewarm water and mild cleansers
C) opical corticosteroids or topical immunomodulators
D) Oral antibiotics i there is evidence o superin ection
E) All o the above
Answer 17.2.4 The correct answer is “E.” T e protective barrier
o the skin is broken down in patients with atopic dermatitis. By
requently applying a protective barrier, such as petrolatum, the
skin becomes less pruritic resulting in less itching-induced skin
trauma and rash, thus decreasing the “itch-scratch cycle.” T is
is the most important aspect o long-term management. opical
steroids and immunomodulators work well to decrease the
in ammation in the skin and are rst-line anti-in ammatory
treatment; however, the goal is to protect the skin with thick
emollients so that the skin does not dry out and itch, leading
to scratching and subsequent in ammation. Daily bathing
with mild cleansers and cool water ollowed by the application
o emollients is recommended. Patients with atopic dermatitis
have a higher bacterial count o Staphylococcus aureus on their
skin. By bathing or short periods daily, the bacterial count is
decreased, thus decreasing the risk o secondary in ection. Oral
antihistamines cause some level o sedation, which is o en help-
ul at night when the child is awake and itching. Interestingly,
there is almost no evidence to support the use o antihistamines
in the treatment o atopic dermatitis, except small studies that

have shown nonsedating antihistamines to be no better than
placebo. I you choose to recommend an antihistamine, use an
older drug (e.g., diphenhydramine) but use extreme caution
in children under 2 years o age—there is no proven bene t
or any indication in this age range and in ants are more sensi-
tive than adults and older children to the CNS depressant e ects
o diphenhydramine. “E” is incorrect. However, oral antibiotics
may be necessary i there is extensive impetigo. Finally, bacteria
can lead to a are o atopic dermatitis. Occasionally, treatment
with antibiotics may be o bene t (more below).
HELPFUL TIP:
Mid-potency steroid (e.g., triamcinolone) ointments are
the mainstay o pharmacotherapy or atopic dermatitis
lares. For the ace, low-potency steroid (e.g., hydrocor-
tisone) ointments can be used or a maximum o 2 to
3 weeks at a time. For severe, acute lares, systemic
steroids can be employed or 10 to 14 days.
HELPFUL TIP:
Topical calcineurin inhibitors (e.g., tacrolimus, pimecro-
limus) are second-line therapies in the treatment o
atopic dermatitis. Although they are generally sa e and
well tolerated, they are expensive and carry a “black box
warning” related to possible cancer risk. There are a ew
reported cases o lymphoma and cutaneous cancers de-
veloping in humans using topical calcineurin inhibitors.
Animal studies support this association. They are con-
traindicated in patients younger than 2 years.
A recent ear in ection has caused your patient’s skin to
worsen. He returns to clinic and your physical examination
reveals the skin lesion seen in Figure 17-2. He has apprecia-
bly enlarged cervical lymph nodes. T e patient has no known
drug allergies.
FIGURE 17-2. (Courtesy o Drs. Karolyn Wanat and Megan Noe.)
CHAPTER 17 • DERMATOLOGY 479
Question 17.2.5 Which o the ollowing oral antimicrobials
would be the best initial choice or this patient?
A) Cephalexin
B) Cipro oxacin
C) Metronidazole
D) etracycline
E) No systemic treatment is necessary at this time
Answer 17.2.5 The correct answer is “A.” Patients with atopic
dermatitis are prone to certain skin in ections that may exac-
erbate their disease. Ninety percent o patients with atopic der-
matitis will grow S. aureus on swab cultures o their crusted
lesions. By decreasing the bacterial count, in amed lesions o en
heal aster. Depending on your community susceptibilities,
community-acquired methicillin-resistant S. aureus (CA-MRSA)
may be o concern. However, rst-generation cephalosporins
are a reasonable initial antibiotic choice or impetiginized atopic
dermatitis because o excellent skin penetration and activity
against Gram-positive cocci (both Staph and Strep). etracycline
is another option or impetiginization; however, this should be
avoided in young children, as should uoroquinolones (except in
rare cases such as cystic brosis). Systemic therapy is necessary
at this time due to clinical worsening and presence o lymphade-
nopathy.
HELPFUL TIP:
Patients with head and neck atopic dermatitis may ben-
e it rom systemic anti ungal therapy (e.g., itraconazole)
or a month. Malassezia yeast is a common skin lora
ound to cause an in lammatory reaction in patients
with head/neck atopic dermatitis, and its eradication
may improve atopic dermatitis symptoms in these pa-
tients. The evidence is pretty weak, so save it or third-
line treatment in patients with more severe symptoms.
Your patient’s culture results are consistent with methicillin-
sensitive S. aureus (MSSA). With the appropriate antibi-
otics, the patient improves markedly. ime to rest on your
laurels . . . Wait . . . there’s this little thing called continuity o
care, and 3 months later, your patient returns with a new
eruption. Clinical appearance is shown in Figure 17-3.
Question 17.2.6 Which o the ollowing is the most appro
priate treatment at this time?
A) Acyclovir
B) Cephalexin
C) Cipro oxacin
D) Metronidazole
E) A and B
Answer 17.2.6 The correct answer is “E.” Patients with eczema
may also develop eczema herpeticum, a particularly severe
orm o disseminated herpes simplex with punched out erosions
and rapid spread o HSV within the areas o eczema. Patients
can develop both eczema herpeticum and impetiginization,
480 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
FIGURE 17-3.
so treatment o both is important. T e characteristic look o
punched out erosions requires immediate therapy with acyclo-
vir, and o en requires intravenous medications. T ese patients
should be treated immediately with antivirals as the disease may
be atal. reatment with cephalexin in addition should be uti-
lized, especially because the patient improved previously.
As the patient grows, he improves signi cantly. However,
his skin continues to be sensitive to many products. As a
teenager, he presents with a recurring rash near his wrist
that is intensely pruritic. He has recently started wearing a
bracelet . . . and he won’t take it o despite the rash because
he’s too cool . . . even though it seems to be a girl’s bracelet (see
Fig. 17-4).
Question 17.2.7 The test most likely to con rm your pre
sumptive diagnosis is:
A) Potassium hydroxide (KOH) o a skin scraping
B) zanck preparation
FIGURE 17-4.
C) Patch testing
D) Serum thyroid-stimulating hormone level
E) Serum IgE levels
Answer 17.2.7 The correct answer is “C.” T e patient most
likely has an allergic contact dermatitis to the nickel in the metal
bracelet on his wrist. Patients with a history o atopic dermati-
tis are more likely to have contact hypersensitivities. Nickel is a
common contact allergen and can also be seen with contact to
earrings, optical glasses, and buttons on jeans. Patch testing is a
test or reactions to delayed-type hypersensitivity reactions that
can identi y many o the common contact allergens in the skin.
KOH application to a skin scraping is used to identi y ungal
elements. KOH dissolves keratin, the protein in skin, to better
identi y the ungal elements. zanck preparations stain blister
scrapings to evaluate lesions suspicious or herpes or varicella
viruses. T yroid disease can cause many skin conditions but is
not a known cause o allergic contact dermatitis. An abnormal-
ity in the SH level is least likely to yield a diagnosis in this case.
As to “E,” serum IgE levels may be elevated in atopic patients,
but this is not diagnostic as IgE can be elevated in many states.
Objectives: Did you learn to . . .
• Recognize atopic dermatitis by its classic presentations?
• Identi y the hallmarks o atopic dermatitis?
• Manage a patient with atopic dermatitis and its complica-
tions?
• Recognize that eczema herpeticum in those with atopic
dermatitis?
CASE 17.3
A 49-year-old obese white male with poorly controlled dia-
betes mellitus, hypertension, and hyperlipidemia presents to
clinic or a regularly scheduled visit. He complains that his
le and right legs are extremely red and pain ul. He denies
constitutional symptoms. His vital signs are within normal
limits. He has warm legs with circum erential erythema
extending rom the ankle to the mid-calves with 2+ pit-
ting edema bilaterally with hemosiderin staining (brownish
macular lesions) o the ankles. T ere is no lymphadenopa-
thy. T ere are no open sores or minor trauma noted (see
Fig. 17-5). His complete blood count with di erential is
within normal limits. You send him or Doppler studies that
ail to reveal venous thromboses. You prescribe 7 days o oral
antibiotics and send him home, con dent that your therapy
will not ail.
He returns 3 days later with modest improvement in the
redness. A er completing the antibiotic course, he presents
to clinic 3 weeks later complaining o return o the redness.
(Why don’t patients just get better with a pill like they are
supposed to?)
Question 17.3.1 The most appropriate next step in the care
o this patient is to:
A) Prescribe another course o oral antibiotics or 14 days
B) Admit the patient to the hospital or intravenous antibiotics
C) Send a punch biopsy o skin or bacterial culture

FIGURE 17-5.
D) Recommend daily leg elevation and use o compression hose
E) Prescribe a diuretic (e.g., urosemide)
Answer 17.3.1 The correct answer is “D.” T is patient has a
characteristic history o stasis dermatitis, a condition that is
o en misdiagnosed as recurrent or chronic cellulitis. Stasis
dermatitis is a dermatitis o the lower extremities that results
rom chronic edema. It can start relatively abruptly and be uni-
lateral or bilateral. T e pitting edema with hemosiderin stain-
ing is a clue that there is chronic uid extravasation rom the
vessels o the lower extremities. Ectatic veins may also be pres-
ent. T e goal o therapy is directed at resolution o the edema.
Patients must lose weight and employ a strict routine o com-
pression hose and leg elevation. In the short term, topical corti-
costeroids can improve the in ammation. In general, diuretics
should not be used simply to treat edema, as these drugs have
numerous systemic e ects. Paradoxically, diuretics can actually
make edema worse in the long term by causing low circulating
volume and renal retention o sodium and water to make up
or the diuretic-induced hypovolemia. Chronic lower extrem-
ity edema can lead to local tissue necrosis, resulting in ulcer-
ation. With long-standing venous insu ciency, more chronic
changes can also occur including lipodermatosclerosis (which
CHAPTER 17 • DERMATOLOGY 481
is “woody” brosis), bound down skin as well as overlying reten-
tion o the skin and verrucous eatures (elephantiasis nostra
verrucosum).
From years o diabetic nephropathy, the patient’s kidneys
eventually ail leading to transplantation (and use o immu-
nosuppressants). A er 5 years o stable renal unction and
improved control o his diabetes, he develops a new nonheal-
ing lesion on the le orearm.
Question 17.3.2 What cutaneous malignancy is he at the
highest risk o developing?
A) Basal cell carcinoma
B) Malignant melanoma
C) Squamous cell carcinoma
D) Metastases rom an undiagnosed internal malignancy
E) Kaposi sarcoma
Answer 17.3.2 The correct answer is “C.” All primary cutane-
ous malignancies are increased in immunosuppressed patients.
However, squamous cell carcinoma is the most common in
transplanted, immunosuppressed patients, surpassing basal cell
carcinoma, which is most common in the general population.
Depending on sun exposure and length o immunosuppression,
the incidence o squamous cell carcinoma in transplant popula-
tions is as high as 45%. Any nonhealing lesion should be urther
investigated with a biopsy. T ere are also signi cantly increased
rates o Kaposi sarcoma in immunocompromised patients.
You removed the lesion, which was indeed squamous cell car-
cinoma. Good job! T e patient develops a shallow ulcer supe-
rior to the medial malleolus. “Is that another one o them
cancers, Doc?” your patient asks.
Question 17.3.3 The most common cause o an ulceration
at this location is
A) Arterial insu ciency
B) Diabetic neuropathy
C) Chronic venous stasis
D) Pyoderma gangrenosum
E) Prolonged pressure (e.g., “decubitus” ulcer)
Answer 17.3.3 The correct answer is “C.” Your patient is at
risk or many o the above diagnoses; however, venous ulcer-
ations classically occur over the medial lower leg. In contrast
to this patient’s venous ulceration, arterial insu ciency ulcers
(“A”) classically have a punched-out appearance and occur over
bony prominences (e.g., malleoli) or distal aspects (e.g., tips o
toes) and are extremely pain ul (in the absence o neuropathy)
and usually dry. Poor peripheral pulses, cool extremities, and
hairlessness are clues to arterial insu ciency. Abnormal ankle–
brachial indices help to con rm peripheral artery disease. Neu-
ropathic ulcers (“B”), such as those associated with diabetic
neuropathy, also occur over pressure points including the plan-
tar sur ace o the oot. T e patient may complain o burning
or tingling o the oot, but the ulcer is asymptomatic (because
o lack o pain sensation rom diabetic neuropathy). Pyoderma
482 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
gangrenosum (“D”) is a rare cause o ulceration associated with
systemic diseases including in ammatory bowel disease, con-
nective tissue diseases, and hematologic malignancies. Pressure
ulceration (“E”) is common and results rom tissue ischemia
rom prolonged pressure, usually over bony prominences, such
as the sacrum, coccyx, and heels.
As you start to exit the examination room, the patient states
“Oh by the way, Doc, can you do anything or my toenails?”
Your examination reveals three, yellow heaped-up nails on
the le oot. You suspect a dermatophyte in ection.
Question 17.3.4 What do you do next?
A) Per orm a KOH examination o toenail scrapings
B) Empirically treat with an oral anti ungal
C) Empirically treat with a topical anti ungal
D) ell the patient that his nails are the least o his worries
Answer 17.3.4 The correct answer is “A.” T e cost o anti ungal
therapy has declined substantially over the last ew years with
generic options becoming available. Some experts now argue
that “B,” empiric therapy, is reasonable in otherwise healthy
patients without contraindications. However, a board examina-
tion is not real li e, and “A” would be the best choice. Here’s the
argument or testing prior to treating: all that looks ungal is not
necessarily ungal. Dystrophic nails can mimic onychomycosis
and may be the result o psoriasis, eczema, trauma, or other
in ammatory conditions. KOH is an inexpensive and easy test
to per orm in the clinic setting. I it is negative, then a toenail
clipping can be sent or ungal culture or pathologic study with
periodic acid–Schi staining i desired.
T e KOH is negative, so you send a toenail clipping or cul-
ture. It grows a Candida species.
Question 17.3.5 Which o the ollowing would be the LEAST
ef cacious medication?
A) Amphotericin
B) Fluconazole
C) Nystatin
D) erbina ne
E) Voriconazole
Answer 17.3.5 The correct answer is “D.” All the above medi-
cations have some Candida species coverage, but terbina ne
(Lamisil) has the least yeast coverage. O note, amphotericin
would be the most toxic (but still would work well) and should
be avoided. A plea from your editors: the topical “paint on” nail
anti ungals are relatively expensive, have a marginal bene t, and
the recurrence rate tends to be high. Besides, who is really going
to paint their nails everyday or a year?
HELPFUL TIP:
Terbina ine (Lamisil) is e ective against most derma-
tophyte in ections o the nails. Most cases o onycho-
mycosis are caused by various Tinea species, which are
sensitive to terbina ine. Complete cure rates or systemic
anti ungals range rom 50% to 75% (terbina ine has the
highest rate), while cure rates or topical anti ungals
are less than 10% even under ideal conditions. For all-
comers, recurrence a ter clearance is as high as 50%.
Another patient comes in with toenail ungus, but this time
he has white changes, most prominent on his proximal nail-
olds.
Question 17.3.6 You would like to test him or:
A) Diabetes mellitus
B) Kidney disease
C) Lupus erythematosus
D) HIV
E) Yum, let’s go eat mushrooms
Answer 17.3.6 The correct answer is “D.” T is pattern o der-
matophyte in ection, proximal white subungual onychomyco-
sis, is characteristic o immunosuppression and particularly
HIV disease. esting or underlying HIV is important with
this clinical presentation. Other nailbed changes can be seen
with diabetes, kidney disease, and lupus. As to “E,” mushrooms
might have this appearance but don’t grow on toes—we hope.
As an aside, there is a great restaurant in Jogjakarta, Indonesia,
where everything is made out o various types o mushrooms
(shel ungus, etc.). It is pretty yummy. I you are in the area
check out “Je Jamuran.”
Objectives: Did you learn to . . .
• Recognize the presentation o stasis dermatitis and describe
its etiology?
• Treat stasis dermatitis?
• Recognize the cutaneous malignancies seen in transplanted,
immunosuppressed patients?
• Di erentiate between common causes and sites o lower
extremity ulcerations?
• Diagnose and treat onychomycosis?
CASE 17.4
You are working in the student health clinic at the local uni-
versity when a previously healthy 19-year-old emale presents
with malaise or 3 weeks and a severe sore throat or 3 days.
Yesterday, she took some old amoxicillin that her roommate
gave her. oday, she developed a di use macular, red skin
eruption, starting on her chest and spreading to involve her
extremities. Her mucous membranes, palms, and soles are
ree o lesions, but she has enlarged tonsils with exudates and
large cervical lymph nodes, including prominent posterior
nodes. A rapid Strep test is negative.
Question 17.4.1 You suspect:
A) An allergic reaction to the amoxicillin
B) An Epstein–Barr virus in ection (mononucleosis)

C) An enterovirus in ection
D) A gonococcal in ection
E) Scarlet ever
Answer 17.4.1 The correct answer is “B.” All o the above
in ections except or enterovirus can present with an exuda-
tive pharyngitis; enterovirus presents with gastrointestinal or
meningeal symptoms. T e clinical scenario describes the usual
course o in ectious mononucleosis: a college-age student, a
ew week prodrome o malaise, and posterior cervical lymph-
adenopathy. Amoxicillin or ampicillin given to patients with
in ectious mononucleosis can result in a macular, di use rash.
T is is not an allergy but can be mistaken or one. Scarlet ever,
which this patient does not have, is a complication o group A
streptococcal in ection, which presents with an erythematous,
coarse (“sandpaper”) rash, strawberry tongue, and skin desqua-
mation.
Later that same day, a 16-year-old male presents with a mildly
pruritic rash on his trunk. He had a cold ew weeks earlier but
is otherwise healthy. He denies high-risk sexual activity or IV
drug abuse (o course, your de nition o “high-risk” and his
may not be the same!). Your examination reveals the ndings
in Figure 17-6.
Question 17.4.2 You tell the patient:
A) T is skin condition is usually chronic and relapsing
B) T at topical corticosteroids are needed to speed up the
healing
FIGURE 17-6. (Courtesy o Drs. Karolyn Wanat and Megan Noe.)
CHAPTER 17 • DERMATOLOGY 483
C) T at the rash usually resolves within 6 to 8 weeks without
treatment
D) T at the rash is likely to be atal
E) T at he is living a Ka aesque nightmare and slowly meta-
morphosing into an insect
Answer 17.4.2 The correct answer is “C.” T e rash is consis-
tent with pityriasis rosea (PR), which is an acute, o en asymp-
tomatic, eruption on the trunk and proximal extremities. T e
etiology is (still) unknown. Secondary syphilis, which is on the
rise in some areas o the United States, can mimic PR. A sexual
history is necessary, and appropriate laboratory studies should
be undertaken i a patient is sexually active, especially i high-
risk behaviors have occurred or i local syphilis rates are high.
PR, unlike syphilis, o en resolves within 8 weeks without treat-
ment and does not usually recur. opical steroids are not neces-
sary or healing but may be help ul in the minority o patients
who experience itching. “E” is incorrect. T is rash just isn’t that
serious.
HELPFUL TIP:
PR starts with a “herald patch,” a salmon-colored, 2- to
5-cm oval-shaped lesion on the back, neck, or chest. The
herald patch may clear a bit and scale and is then ol-
lowed by numerous smaller lesions that crop up mostly
on the trunk. These lesions tend to be oval in shape and
are oriented along skin lines, giving a “Christmas tree”
appearance.
Your next patient is a 20-year-old emale complaining o
“a rash down there.” You con rm that she is talking about a
vulvar rash and ask about her sexual history. She says that
she had not been sexually active with anyone or about 1 year
until a recent spring break ing in Florida. On examination,
you nd a rash over the pubic region and extending into the
inguinal areas and medial thighs. T ere is no pain or pruritus
(see Fig. 17-7).
Question 17.4.3 Which o the ollowing is FALSE?
A) T ese lesions are transmitted in adults only by sexual contact
B) I not treated, the lesions may resolve on their own
C) opical corticosteroids do not improve this skin condition
D) T e lesions are contagious and can spread readily and
rapidly
E) T e skin lesions are a result o a viral in ection
Answer 17.4.3 The correct answer is “A.” T ese lesions,
re erred to as molluscum contagiosum, result rom a pox
virus. Molluscum is commonly spread via sexual contact in
adults; however, any physical human contact can also spread
it. Molluscum is extremely common in children in daycare set-
tings. T e lesions generally resolve in time without treatment.
Because they can be auto-inoculated, the molluscum lesions
can rapidly increase in number, and it is or this reason that
484 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
FIGURE 17-7.
treatment is recommended. reatment consists o destructive
methods, such as cryotherapy or curetting. T e immune modu-
lator imiquimod has been used, but is not approved by the Food
and Drug Administration (FDA) or molluscum, and only small
trials have been undertaken. opical steroids are not indicated.
In immunocompromised patients, molluscum lesions can be
widespread and persist much longer.
HELPFUL TIP:
Other molluscum therapies appear e ective in small
trials but are not FDA approved, including podo ilox
0.5%, KOH 5% to 10%, and cantharidin.
Your next patient is a healthy 18-year-old male who presents
or treatment o plantar warts. He has tried topical salicylic
acid 17%at home. He used it or a ew weeks without signi -
cant improvement.
Question 17.4.4 Which o the ollowing can be used or
therapy or plantar warts (verruca plantaris)?
A) Cryotherapy (liquid nitrogen)
B) Duct tape occlusion
C) Imiquimod
D) Candida antigen injection
E) All o the above
Answer 17.4.4 The correct answer is “E.” No therapy or cuta-
neous warts (plantar or otherwise) has been proven superior,
and all o the options can be used with di erent pros and cons.
“A,” cryotherapy, is easily per ormed in the o ce and is quick
but may be too pain ul or children to tolerate. Also, cryotherapy
may result in hypopigmented scarring in dark-skinned patients.
As we all know, duct tape can be used or anything (e.g., hold-
ing your muf er together, preventing poison gas exposure) and
has been used to treat warts, but the evidence is con icting. “C,”
imiquimod, is initially painless, can lead to a brisk in ammatory
response, and unlikely to cause scarring, so it is a good choice
or acial warts or dark-skinned patients. However, it is the most
expensive option. “D,” candida antigen injection, is a therapy
that aims at stimulating an immune response to the warts.
Mumps antigen has been used as well. In the antigen injection
studies, only one wart was injected to achieve treatment or all
o a patient’s warts. T is can be e ective but is a pain ul injec-
tion. Destructive methods are all approximately 70% e ective
at eradicating warts. It is important to remind patients that no
single method is more likely to work than another, and warts
can resolve on their own. In immunocompetent patients, most
warts resolve in time without treatment. For young children,
this is an important issue, since they cannot understand the
pain associated with most treatment modalities.
HELPFUL TIP:
To use duct tape or warts, the patient should put a
piece o duct tape on the wart and leave it on or 6 days.
On day 7, remove the duct tape, soak, and abrade the
wart with a pumice stone. Reapply the duct tape the
next day.
A 30-year-old stressed out medical student presents to your
clinic with a worsening, pain ul rash on one side o her chest.
She denies any prior spots like this and has no other medi-
cal problems. She is up-to-date on her vaccinations because
o medical school and complains that this rash is inter ering
with studying or the upcoming nal block o examinations
(she wants to be a dermatologist, so she really has to ace her
examinations). Physical examination demonstrates a linear
group o vesicles with erythema on her le chest.
Question 17.4.5 Treatment should be initiated with which
o the ollowing therapies:
A) Cephalexin
B) Mupirocin
C) Paroxetine
D) Valacyclovir
E) No treatment is necessary as this is sel -limited
Answer 17.4.5 The correct answer is “D.” T is is most likely
herpes zoster, which is reactivation o the varicella zoster virus.
Valacyclovir is an e ective treatment. Even in immunocompe-
tent patients, herpes zoster can be reactivated rom the dorsal
root ganglion during periods o stress. Although it can be sel -
limited, treatment with antiviral (valacyclovir or acyclovir) is
recommended during rst 72 hours to decrease outbreak and
risk o postherpetic neuralgia. With the presentation o pain,
gabapentin or pregabalin is also o en prescribed.
Objectives: Did you learn to . . .
• Recognize that ampicillin/amoxicillin given to patients with
mononucleosis will o ten result in a macular rash?
• Diagnose pityriasis rosea (PR) and recognize secondary
syphilis as a mimic?
• Recognize and treat molluscum contagiosum?
• Describe the treatment modalities or verruca plantaris?
• Recognize and treat herpes zoster?
 CHAPTER 17 • DERMATOLOGY 485

QUICK QUIZ: HYPERSENSITIVITY REACTION

Which o the ollowing represents a type IV hypersensitivity

reaction?
A) Serum sickness reaction
B) Contact dermatitis to poison ivy
C) Urticaria
D) Vasculitis

The correct answer is “B.” Contact dermatitis has a geomet-

ric appearance and a characteristic immune-mediated reaction;
someone may not react when they rst encounter the agent and
then develop stronger in ammatory responses with subsequent
exposures. Contact dermatitis is an example o a delayed-type
hypersensitivity reaction. Serum sickness is a type III immune
complex reaction. Urticaria is a type I hypersensitivity response, FIGURE 17-8.
mediated by mast cell degranulation. Vasculitis can be either
immune complex, antibody, or complement mediated.
demonstrating multinucleated giant cells, viral culture, or direct
uorescent antibody or HSV 1 or 2. Commonly seen in warm
HELPFUL TIP: climates, miliaria (“C”) or “prickly heat” is due to blocked sweat
Auto-eczematization or “id” reactions represent a hy- ducts presenting as nonin amed pinpoint clear di use vesicles.
persensitivity response o the body to a signi icant in- Epidermolysis bullosa (“E”) is a chronic blistering disease pre-
ection or dermatitis in another part o the body. For senting as blisters at sites o mild trauma.
example, patients with severe tinea pedis can develop
eczematous lesions on other parts o the body and
treatment o the tinea pedis will resolve the eczematous HELPFUL TIP:
eruption (or “id” reaction). Neonatal acne presents as a pustular, acial eruption
with a mean onset at 2 to 3 weeks o li e. It is asymptom-
atic and diagnosed clinically. Fungal organisms have
been ound in some pustules. Treatment or acne is not
CASE 17.5 necessary as most lesions resolve in several weeks; i
severe, topical “azole” anti ungals can be used. Besides,
You are rounding in the newborn nursery. A healthy 2-day-
we doubt neonatal acne will a ect the child’s chance o
old term in ant has a new rash characterized by yellow pus-
landing a daycare prom date.
tules on an erythematous base (Fig. 17-8) involving the trunk
and extremities but sparing the palms and soles.

Question 17.5.1 What is the diagnosis?
A) ransient neonatal pustular melanosis
B) Herpes simplex
C) Miliaria
D) Erythema toxicum neonatorum
E) Epidermolysis bullosa
Answer 17.5.1 The correct answer is “D.” Erythema toxicum
neonatorum is a common, benign, sel -limited rash seen in
term in ants. Lesions usually appear a er 24 to 48 hours o age.
Lesions may begin as erythematous macules that progress to yel-
low pustules on an erythematous base, may be sparse or numer-
ous, and involve the trunk and extremities, sparing the palms
and soles. T e etiology is unknown and the diagnosis is clinical.
ransient neonatal pustular melanosis (“A”) usually a ects term
A rican-American in ants presenting at birth with pustules on a
hyperpigmented macule that may involve the palms and soles.
Neonatal herpes (“B”) presents with blisters or erosions and an
ill-appearing child. Diagnosis is made via a zanck preparation
While taking care o the neonate in the newborn nursery,
you notice a child in isolation. His skin catches your eye
(see Fig. 17-9).
Question 17.5.2 The most common cause o this rash in
newborns in the United States is:
A) Cytomegalovirus (CMV)
B) Rubella
C) Langerhans cell histiocytosis
D) Rh incompatibility
E) Parvovirus B19
Answer 17.5.2 The correct answer is “A.” All the above can
present as a “blueberry mu n baby”; however, CMV is the most
common cause in the United States. CMV is the most common
congenital viral in ection, a ecting about 1% to 2% o all births.
Rubella was the most common cause in the prevaccination era.
In most cases, the purple plaques represent extramedullary
hematopoiesis.
486 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
FIGURE 17-9.
Later that same morning, a previously healthy 2-month-
old neonate presents to your clinic with peeling o the skin
and a ever (Fig. 17-10). She had appeared well until 2 days
ago when she became more irritable. Her mother noted a
decrease in her urine output. T e child was born vaginally
without complications and has no known medical condi-
tions. On physical examination, you notice a well-nourished,
crying in ant with large sheets o desquamating skin on her
extremities. Her mucus membranes appear normal. You
order complete blood count and urine analysis.
FIGURE 17-10. (Courtesy o Drs. Karolyn Wanat and Megan Noe.)
Question 17.5.3 The most likely diagnosis is:
A) oxic epidermal necrolysis ( EN)
B) Burns
C) Staphylococcal scalded skin syndrome (SSSS)
D) Di use cutaneous mastocytosis
Answer 17.5.3 The correct answer is “C.” T is is Staphylococ-
cal scaled skin syndrome, which results rom a distant Staphy-
lococcal in ection (o en involving urinary tract, nasopharynx,
eyes, perianal areas). T e key eatures o SSSS in Figure 2-10 are
bright red erythema with impending desquamation in the neck
olds and periori cial areas with sparing o the oral mucosa. So
what di erentiates “C” rom “A?” EN presents with shedding o
sheets o skin and o en has mucosal involvement that separates
it clinically rom SSSS. Both can present with signi cant skin
pain. However, EN is a result o drug hypersensitivity or bacte-
rial sepsis (in the case o the neonate children); and neonates with
EN are quite ill compared with children with SSSS. In EN, a
biopsy would show ull-thickness necrosis o the epidermis versus
an intraepidermal split in SSSS. Burns (“B”) can mimic SSSS, but
burns would not be likely to cause a di use red eruption and will
o en have a speci c shape depending on what burned the skin.
“D,” di use cutaneous mastocytosis, can present with hemor-
rhagic blisters and erosions, but these are usually ocal areas, not
sheets o skin loss. Keep reading or more in ormation on SSSS.
Question 17.5.4 In this case o SSSS, peeling o the skin is
a result o :
A) Necrosis o the entire epidermis rom lymphocyte attack
B) A widespread bacterial skin in ection
C) Histamine released in the skin with edema and blistering
D) oxin-mediated skin blistering rom nonskin source o
in ection
Answer 17.5.4 The correct answer is “D.” T is clinical scenario
describes SSSS, which is an epidermolytic toxin-driven disease.
Extreme tenderness o the skin precedes super cial, widespread
desquamation. T e skin is usually bright red with areas o akiness.
Radial wrinkling o the mouth, giving an “old, sad man” appear-
ance, is common. T e source o in ection is not the skin but rather
an occult site such as nasopharynx, eye, perianal area or urinary
tract; there ore, investigation or a causative in ection should be
undertaken (e.g., blood, nares, ocular, perianal, and urine cultures).
Objectives: Did you learn to . . .
• Recognize neonatal benign cutaneous eruptions?
• Identi y a “blueberry muf n” neonate and know the common
causes?
• Recognize SSSS and consider its di erential diagnosis?
QUICK QUIZ: NAILS
Which o the ollowing nail ndings–systemic disease pairing
is INCORREC ?
A) Muehrcke nails–nephrotic syndrome
B) Nail pitting–psoriasis
C) Periungual broma–tuberous sclerosis
 CHAPTER 17 • DERMATOLOGY 487

D) Splinter hemorrhages–in ective endocarditis

E) Koilonychia–systemic lupus erythematosus

The correct answer is “E.” Koilonychia, otherwise known as

“spoon nail,” is a result o so ening and thinning o the nail
plate and is ound in patients with long-standing iron de -
ciency anemia, Plumer–Vinson syndrome, Raynaud disease,
hemochromatosis, and trauma. It can also be inherited as an
autosomal-dominant trait. Connective tissues diseases, such as
lupus, are more commonly characterized by nail old abnormal-
ities, such as nail old telangiectasias, rather than koilonychia.
Muehrcke nails (“A”) have paired narrow horizontal (meaning
perpendicular to the long axis o the nger) white bands, sepa-
rated by normal nail, which remain static as the nail grows. T ey
are most o en seen in patients with nephrotic syndrome, and FIGURE 17-11.
their presence re ects the degree o hypoalbuminemia. When
you see onycholysis (separation o the nail plate rom the nail and has lobulated appearance with a central pore. Squamous
bed that appears opaque), consider trauma, onychomycosis, cell carcinoma is usually a hyperkeratotic or ulcerated papule
psoriasis, and other systemic disease. Nail pitting can be asso- or plaque. Metastases rom solid organ malignancies are subcu-
ciated with several conditions including psoriasis, atopic der- taneous, rm nodules, although they may ulcerate. Merkel cell
matitis, and alopecia areata. A periungual broma (“C”) should carcinoma is a rare tumor on the head and neck that usually
prompt evaluation or tuberous sclerosis with brain imaging or appears as an ill-de ned, violaceous nodule.
tuberous lesions. Splinter hemorrhages (“D”) are usually a result
o trauma but can be a sign o in ectious endocarditis. CASE 17.6
While working in the emergency department, a 6-month-
HELPFUL TIP: old healthy emale in ant is brought in by her grandmother.
Paronychia, in lammation around the nail, may be acute She is bleeding rom her birthmark on her buttocks (see
or chronic. Acute paronychia is o ten due to bacterial Fig. 17-12). Her grandmother watches her during the day
in ection and is treated with oral antibiotics, drainage, while her mother is at work and has noticed the lesion getting
warm compresses, and soaks. Chronic paronychia is larger recently. A er holding pressure on the lesion or about
related to eczema and may have secondary Candida 20 minutes, the bleeding stops. You educate the grandmother
in ection. Treatment is with topical steroids, topical an- about the natural history o the “birthmark.”
ti ungals, and oral anti ungals.
Question 17.6.1 Which o the ollowing is NOT a true state
ment about this type o birthmark?
QUICK QUIZ: DERM PHOTO A) T is is the most common type o so -tissue tumor o in ancy
B) Most o these birthmarks undergo spontaneous involution
A 52-year-old white male presents to clinic with a nonhealing,
asymptomatic “pimple” on the cheek. It has been present or
6 months and has recently started to bleed when he shaves. On
examination, you note his air skin, blue eyes, and ruddy com-
plexion. You nd the lesion in Figure 17-11.

Your preliminary diagnosis is:

A) Sebaceous hyperplasia
B) Squamous cell carcinoma
C) Basal cell carcinoma
D) Metastases rom internal malignancy
E) Merkel cell carcinoma

The correct answer is “C.” T e photograph is a classic picture

o a basal cell carcinoma with its rolled, pearly pink borders,
and telangiectasias. It is ound commonly on sites that get a lot
o sun exposure, especially the head and neck. People with air
skin and light hair and eyes are at particular risk. Sebaceous
hyperplasia can look similar but is ivory or yellow in appearance FIGURE 17-12.
488 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
C) reatment is indicated in all lesions lest they become malig-
nant
D) β -Blockers are the most appropriate therapy or ulcerated
lesions
E) Many are not present at birth but develop shortly therea er
Answer 17.6.1 The correct answer is “C.” T e child has an
ulcerated hemangioma o in ancy. In antile hemangiomas are
benign proli erations o endothelial cell lineage that are usually
present at birth or soon therea er. T ey are characterized by
rapid growth in the rst several months o li e with a plateau
occurring around 1 year o age. T ey spontaneously involute
over years. reatment options should be individually tailored,
depending on the size and location o the lesion. Lesions located
on the central ace or in the diaper area should be treated, as
should ulcerated hemangiomas at any body site. opical or oral
β -blockers are the standard o care or in antile hemangiomas
that require treatment. Larger, segmental hemangiomas should
be urther evaluated with imaging studies to rule out syndromes
with other associated anomalies such as PHACES syndrome
(posterior ossa mal ormation, hemangioma, arterial anoma-
lies, cardiac de ects, coarctation o the aorta, eye abnormalities,
sternal de ects/supraumbilical raphe) and LUMBAR syndrome
(lower body hemangioma, urogenital anomalies, myelopathy,
bony de ormities, anorectal mal ormation/arterial anomalies,
and renal anomalies).
T e same patient returns, this time with mom, at age 5. T e
hemangioma has involuted. About 2 months ago, the mother
noticed a spot on the patient’s le index nger, and now she
is concerned that it is not resolving. T e patient is not both-
ered by the lesion, except that it occasionally bleeds when she
bumps it on something. On examination, you nd a 3-mm
dome-shaped, bright red nodule on the palmar aspect o the
le index nger. It is nontender and smooth (see Fig. 17-13).
Question 17.6.2 The most likely diagnosis is:
A) Basal cell carcinoma
B) Squamous cell carcinoma
FIGURE 17-13.
C) Acne
D) Pyogenic granuloma
E) Nodular melanoma
Answer 17.6.2 The correct answer is “D.” T is patient most
likely has a pyogenic granuloma, which is essentially a nodu-
lar hemangioma arising at sites o trauma, especially the ngers
and toes. Although pyogenic granuloma is not cancerous, it can
be con used with basal and squamous cell carcinomas as well as
melanoma. For this reason, it is prudent to per orm excision
and histologic examination. A er excision, the base o the
lesion should be ablated (electrocautery or laser), or the pyo-
genic granuloma may return. Pyogenic granulomas are more
common during pregnancy and have been associated with
drugs such as oral retinoids, indivair, EGFR inhibitors, metho-
trexate, sirolimus, and capecitabine. “C,” acne, should not be a
consideration, as sebaceous glands are not ound on the palms.
By the way, did you notice that this poor child has developed
coarse, dark hair growth on her knuckles? As it turns out, she’s
been playing with dad’s Rogaine.
Objectives: Did you learn to . . .
• Describe the natural history o in antile hemangiomas?
• Identi y options or treating ulcerated hemangiomas?
• Describe the eatures and management o pyogenic
granuloma?
CASE 17.7
A 78-year-old emale presents with a rash on her legs. It
started 1 week ago and was preceded by itching o the legs
without any visible changes. T en red blotches developed
that quickly became blisters. She denies pain or drainage. She
also has some sores in her mouth. She reports overall good
health and takes no medications. On examination, you nd
an a ebrile, com ortable looking emale. She has 1+ pitting
edema at her ankles. You notice round, tense bullae erupt-
ing on erythematous patches on the abdomen and extremi-
ties. T ere are also scattered erosions present at the sites o
previous bullae. T e bullae contain clear uid. T ere is no
purulent material or blood (see Fig. 17-14).
Question 17.7.1 Which o the ollowing is the most likely
diagnosis?
A) Pemphigus vulgaris
B) Bullous pemphigoid
C) Varicella zoster
D) Dermatitis herpeti ormis
E) Stevens–Johnson syndrome (SJS)
Answer 17.7.1 The correct answer is “B.” Bullous pemphi-
goid is an autoimmune disorder and is primarily a disease o
the elderly. O en patients will report pruritus or urticaria-like
lesions, prior to the eruption o typical bullous lesions. When
the bullae orm, they are requently asymptomatic but can be
intensely pruritic and/or mildly tender. In contrast to pemphi-
gus vulgaris (“A”) and SJS (“E”), systemic symptoms are not

FIGURE 17-14. (Courtesy o Drs. Karolyn Wanat and Megan Noe.)
part o bullous pemphigoid. Additionally, pemphigus vulgaris
lesions are pain ul, and classically the bullae are accid rather
than tense. SJS generally occurs in response to medications, and
this patient is taking none. Varicella zoster (“C”) should ollow a
dermatomal pattern rather than appear bilaterally; zoster is usu-
ally associated with pain and paresthesia. Dermatitis herpeti or-
mis (“D”) presents with crops o vesicles and excoriations rather
than bullae.
Although she eels well, the lesions are dramatic, and the
patient is very concerned that she might have cancer. o con-
rm your diagnosis, you decide to biopsy the skin.
Question 17.7.2 The most appropriate way to per orm a
biopsy in this situation is:
A) 4-mm punch biopsy o the margin o an intact bulla or light
microscopy
B) 4-mm punch biopsy o perilesional normal skin or light
microscopy
C) 4-mm punch biopsy o perilesional normal skin or immu-
no uorescence
D) A and B
E) A and C
Answer 17.7.2 The correct answer is “E.” Bullous pemphigoid
is diagnosed de nitively by demonstration o autoantibod-
ies deposited along the basement membrane o normal skin.
Immuno uorescence examination o normal-appearing skin
can demonstrate linear depositions o IgG and C3. A biopsy o
the edge o an intact bulla will show the characteristic pathol-
CHAPTER 17 • DERMATOLOGY 489
ogy o a subepidermal blister with eosinophils. For a de nitive
diagnosis, both “A” and “C” should be done.
You assure her that the lesions are not cancerous.
Question 17.7.3 What else can you tell her about the prog
nosis o bullous pemphigoid?
A) T e average course resolves spontaneously in 5 to 6 years
B) It is associated with an increased risk o systemic malig-
nancy
C) It is associated with a high mortality rate
D) It will likely spread to cover her entire body until she’s one
big blister, and her hair will all out, and her riends will
shun her, a la Job in the Old estament
Answer 17.7.3 The correct answer is “A.” Bullous pemphigoid
may undergo complete resolution and never recur. Alterna-
tively, the disease may have resolutions and exacerbations over
time. It is not associated with an increased risk o cancer or a
high mortality rate. Very extensive involvement may lead to skin
in ections and bacteremia, but di use disease is not common.
She seems miserable. You want to o er her the medication
with the astest onset o action.
Question 17.7.4 What is the most appropriate treatment
option with a ast onset o action?
A) Oral azathioprine
B) Oral cephalexin
C) Oral prednisone
D) opical antimicrobials
Answer 17.7.4 The correct answer is “C.” Bullous pemphigoid
is an autoimmune disease, so anti-in ammatory medications
and immunosuppressive agents are used to treat it. Oral steroids
are the rst-line treatment because o the quick onset o action;
however because o concerns or long-term side e ects patients
should be transitioned to “steroid-sparing” agents as neces-
sary. Once the disease is under control, oral steroids should be
tapered to the lowest e ect dose in combination with a tetracy-
cline antibiotic or other immunosuppressive agent such as aza-
thioprine, methotrexate, or mycophenolate. For patients with
limited disease, high-potency topical steroids can also be used.
opical antimicrobials are used when treating in ected, open
bullae but are not e ective or the treatment o the disease itsel .
Objectives: Did you learn to . . .
• Distinguish bullous diseases rom one another?
• Diagnose and treat bullous pemphigoid?
QUICK QUIZ: PAPULAR ERUPTION
A 30-year-old emale presents with a several month history
o bumps on her chin and around her mouth. Although she
has never had problems with acne, she thought that she was
developing acne and tried benzoyl peroxide. A month ago, she
490 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
FIGURE 17-15.
stopped the benzoyl peroxide because it did not seem to work,
and she switched to hydrocortisone cream, which has worsened
the outbreak. T e rash is neither itchy nor pain ul. She works in
an o ce and cannot recall any contact irritants. On examina-
tion, you nd erythematous papules with small pustules on the
chin and laterally around her mouth (see Fig. 17-15). T e neck
and the remainder o the ace are not involved.
Which o the ollowing treatments do you recommend?
A) Oral tetracycline
B) Oral isotretinoin
C) opical high-potency steroids
D) opical triple antibiotic ointment
E) opical retinoic acid
The correct answer is “A.” T is patient appears to have perioral
dermatitis. Appropriate treatments or perioral dermatitis include
topical metronidazole or topical erythromycin or oral tetracy-
cline antibiotics (tetracycline, minocycline, or doxycycline). T e
etiology o perioral dermatitis is unknown. “B” and “E” are incor-
rect, since these are treatments o acne vulgaris. “C” is incor-
rect, since high-potency topical steroids can make the condition
worse, with rebound erythema upon discontinuation. opical
triple antibiotic ointment (“D”) is not likely to be e ective.
CASE 17.8
A 15-year-old male presents to your of ce complaining o
“zits” on his ace and back. He has several scattered comedo-
nes on his ace and several deep nodules on his back. He also
has some papulopustular lesions on his chin. You diagnose
him with acne vulgaris.
Question 17.8.1 Which o the ollowing is NOT TRUE about
acne?
A) Noncomedonal acne is an in ammatory process
B) It commonly presents rst in adolescence
C) It may rst appear in adulthood
D) It is more severe in emales than in males
E) T e incidence is lower in Asians and A ricans than in
Caucasians
Answer 17.8.1 The correct answer is “D.” Acne is an in am-
matory process that involves the pilosebaceous units o the ace
and trunk. It can be comedonal, papulopustular, or nodulocys-
tic in presentation. It typically presents rst in adolescence with
girls developing it rom age 10 to 17 years and boys rom 14 to
19 years. However, it may not appear until early adulthood. It is
more severe in males than in emales (thus “D” is not true), and
it is less prevalent among Asians and A ricans.
HELPFUL TIP:
Open comedones (blackheads) and closed comedones
(whiteheads) are considered nonin lammatory lesions,
whereas papular and cystic lesions are considered in lam-
matory. And no matter how tempting, patients should
not pick at them! Picking may exacerbate scarring.
Your patient has heard many things about acne and wonders
i they are true.
Question 17.8.2 Regarding acne, all o the ollowing are
true EXCEPT:
A) Acne is not caused by medications
B) Acne can be caused by industrial exposures such as cutting
oils, aromatic hydrocarbons, and petroleum-based products
C) In requent acial cleansing does not cause acne
D) Emotional stress a ects the course o acne
E) Acne can present at any age
Answer 17.8.2 The correct answer is “A.” Acne can be caused
by many medications including oral steroids, EGFR inhibitors,
lithium, isoniazid (INH), and phenytoin. Medication-induced
acne presents as monomorphic papules on the ace, chest, and
back. Exposure to industrial chemicals that occlude the olli-
cle can also lead to an acnei orm eruption. Neither in requent
washing nor chocolate (or any other oods) cause acne—no
matter what your mother told you. However, stress (like that
homecoming dance in high-school) can o en are acne.
T ere are di erent types o acne that can a ect individuals at
various stages o li e. Neonatal acne presents shortly a er birth
and is transient. In antile acne presents at 6 to 12 months o
age and resolves within 1 to 2 years. T e most common time
to develop acne is around puberty; however, women in their
30s and 40s can also experience acne ares with hormonal uc-
tuations. As an aside, oral contraceptives (OCPs) go both ways
with regard to acne: several OCPs are marketed to treat acne,
but they have been reported to worsen acne in some patients.
T e result o OCPs may depend on the hormonal milieu o the
speci c patient (women with hyperandrogenism may bene t)
and the type o progestin in the OCP. Acne is o en improved
in the summer months and worse in the all and winter. Many
women also tend to are up right be ore menses.
 CHAPTER 17 • DERMATOLOGY 491

Question 17.8.3 For acne, which o the ollowing treatment one-third o patients who receive isotretinoin will require
principles is correct? additional courses during their li etime. Isotretinoin has been
A) reatment can o en lead to initial worsening o lesions reported to cause premature closure o growth plates rarely.
B) T erapeutic response o en takes several months
C) Mild acne can be treated with topical medications
HELPFUL TIP:
D) O en times, two or more therapeutic agents must be com-
Retinoids (isotretinoin and topicals) are related to vita-
bined or e ective treatment
min A, so vitamin A supplements should be avoided as
E) All o the above are correct
the combination may lead to vitamin A toxicity.

Answer 17.8.3 The correct answer is “E.” opical retinoids,

topical antibiotics, and benzoyl peroxide are the rst-line agents
HELPFUL TIP:
and can be titrated as needed. Retinoids should be applied at
Women should have a pregnancy test monthly while
bedtime. T e main oral antibiotic agents are tetracyclines and
on isotretinoin and should continue contraception or
should be used as add-on therapy to topical agents or mod-
1 month a ter discontinuing treatment.
erate-to-severe in ammatory acne. OCPs with low androgenic
progesterones can also be help ul. Since acne lesions may take
up to 2 months to resolve, one may not notice a therapeutic Objectives: Did you learn to . . .
response or several months (once the current crop o lesions • Diagnose and treat acne?
resolve). • Identi y side e ects o isotretinoin?

A er a ew months o topical benzoyl peroxide wash and

topical clindamycin cream, you add topical retinoic acid.
Your patient returns with persistent lesions, including mild
scarring and cystic lesions. You are considering re erral or
isotretinoin, which is indicated or severe, recalcitrant, nod-
ular acne.
CASE 17.9
A 26-year-old emale patient presents to your of ce with
pain ul, nonpruritic pink bumps that started last week on
her shins. You nd the rm lesions easier to palpate than to
visualize (see Fig. 17-16).

Question 17.9.1 What is the most likely diagnosis in this

HELPFUL TIP: patient?
Topical tretinoin (Retin-A) is most e ective or comedo- A) Erythema multi orme
nal acne. B) Urticaria

Question 17.8.4 Which o the ollowing is FALSE regarding

the use o isotretinoin?
A) wo methods o contraception are required in all reproduc-
tive age women along with requent pregnancy tests
B) It should not be used with tetracycline
C) Hypertriglyceridemia is a possible side e ect
D) Patient should be monitored closely or changes in mood
E) A patient can only receive one course o isotretinoin

Answer 17.8.4 The correct answer is “E.” Isotretinoin is an oral

retinoid and is pregnancy category X. Because o this, the FDA
has developed a mandatory patient registry called “iPLEDGE.”
All patients must enroll in his registry be ore receiving the
medication and prescribers also need to be registered. Female
patients o reproductive age are required to use two contracep-
tive methods and have monthly pregnancy tests. As both tetra-
cycline and isotretinoin can lead to pseudotumor cerebri, they
should not be used together. Hypertriglyceridemia, dry skin,
and decreased night vision are common side e ects. T ere have
been reports in the popular press and the scienti c literature
o suicide in patients on isotretinoin, though there is no good
controlled data to suggest that the drug is responsible. Patients
with a history o mental health issues should be ollowed care-
ully or any changes in their mood or behavior. Approximately FIGURE 17-16.
492 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
C) Erythema nodosum
D) Erythema migrans
E) Lumpy shin disease (aka, “ ootballer’s disease” in England)
Answer 17.9.1 The correct answer is “C.” T is is erythema
nodosum. ypically, these rm nodules occur rst on shins
and are o en more easily palpated than seen. T ey may then
spread to the thighs, trunk, and extensor sur aces o the arms.
Erythema multi orme (“A”) presents as erythematous, targetoid
lesions usually a ecting the distal extremities including palms
and soles. Urticaria (“B”) is not tender but would be intensely
pruritic. Erythema migrans (“D”) is the quintessential lesion o
Lyme disease: a nontender, nonpruritic red plaque with a cen-
tral clearing. While “E” is technically correct in its description,
we know o no such disease entity.
HELPFUL TIP:
Erythema migrans is o ten thought o as a single “bull’s
eye” lesion in the area o the tick attachment. However,
the “bull’s eye” is present in a minority o cases, and ery-
thema migrans can have multiple widespread lesions in
some patients with Lyme.
Question 17.9.2 Which o the ollowing can cause erythema
nodosum?
A) OCPs
B) Streptococcal pharyngitis
C) Sarcoid
D) Viral upper respiratory in ection
E) All o the above
Answer 17.9.2 The correct answer is “E.” All o these entities
may cause erythema nodosum, but viral URI and streptococcal
pharyngitis are most common. Multiple medications can also
be responsible.
T is patient does relate a history o URI symptoms about
1 week prior to the onset o her symptoms.
Question 17.9.3 What advice are you going to give this
patient?
A) T e rash tends to be sel -limiting and will resolve in 4 to
6 weeks
B) T e rash will heal with scarring
C) T e rash will likely spread to the ace and upper extremities
be ore it resolves
D) T is is a chronic disease and no treatment is available
Answer 17.9.3 The correct answer is “A.” In general, erythema
nodosum heals spontaneously in 3 to 6 weeks without scarring.
T ere are treatment options available i the patient is symp-
tomatic. I erythema nodosum is caused by an in ection, that
in ection should be treated appropriately. I it was caused by a
medication, such as an oral contraceptive pill, it should be dis-
continued. Nonsteroidal anti-in ammatory agents can be used
to help with the pain. For patients with severe pain ul disease,
systemic steroids can be considered.
Objectives: Did you learn to . . .
• Recognize erythema nodosum?
• Describe some o the causes and natural history o erythema
nodosum?
QUICK QUIZ: ERYTHEMA MULTIFORME
Which o the ollowing cause erythema multi orme?
A) Viral upper respiratory in ection
B) Cimetidine
C) Herpes simplex outbreak
D) Ni edipine
E) All o the above
The correct answer is “E.” All o the above are causes o ery-
thema multi orme as are many, many other medications, etc.
T e most common precipitator o erythema multi orme is
herpes simplex. Look or this association in your patients.
HELPFUL TIP:
Sunlight is a requent precipitator o an outbreak o her-
pes labialis.
CASE 17.10
A patient presents to your of ce with a 1-week history o a
pruritic rash that comes and goes. No lesion is present or
more than 24 hours. It involves his entire body except or his
ace. He cannot remember any new products with which he
has been in contact (soaps, detergents, etc.). He is quite con-
cerned. You correctly diagnose urticaria.
Question 17.10.1 Your next step is:
A) Skin testing or various commercial products
B) Viral titers or CMV, EBV, etc.
C) RAS test or common allergens
D) Recommend no urther evaluation.
E) Prescribe an epinephrine injection or emergency use at
home
Answer 17.10.1 The correct answer is “D.” No workup is
needed at this time. Urticaria should be classi ed as “acute”
(< 6 weeks) or “chronic” (> 6 weeks). Acute urticaria requires
no urther workup and should be treated symptomatically
with antihistamines. In patients with chronic urticaria, a more
detailed history should be taken looking or other symptoms
or signs o in ection, with laboratory testing as appropriate. In
act, beyond a good history, an extensive workup is pretty much
utile. It is almost impossible to identi y a cause o urticaria by
laboratory testing. “E,” an epinephrine injector, is not indicated
or the treatment o urticaria but would be appropriate i this
patient has experienced an anaphylactic reaction.
 CHAPTER 17 • DERMATOLOGY 493

TABLE 17-2 CAUSES OF URTICARIA: A PARTIAL LIST

Medications (Direct Mast
Physical Urticaria Allergic Systemic Cell Degranulators)
• Pressure • Foods (nuts, sh) • Malignancy • NSAIDs
• Water • Insect stings • SLE • Aspirin
• Vibration • Drugs (IgE • RA • Opiates
• Cold mediated) • Chronic Hep B and C • ACE Inhibitors
• Sunlight • EBV • Contrast dye

Question 17.10.2 Urticaria is categorized as which o the Answer 17.10.4 The correct answer is “E.” All o the above can
ollowing? cause urticaria. In act, these are not uncommon causes and
A) ype I hypersensitivity reaction can be identi ed by history. Patients may develop urticaria with
B) ype II hypersensitivity reaction exercise and sweating (cholinergic urticaria), cold (during the
C) ype III hypersensitivity reaction winter), and pressure (e.g., walking). O particular note is water
D) ype IV hypersensitivity reaction urticaria that occurs with water contact, including bathing and
E) None o the above showering. See able 17-2 or a more complete listing.

Answer 17.10.2 The correct answer is “A.” Urticaria is a clini-

cal eature o a type I reaction. Other clinical presentations HELPFUL TIP:
o type I reactions include anaphylaxis and angioedema. See Cold urticaria o ten starts with lesions appearing on ex-
Chapter 4 or a detailed answer on hypersensitivity reactions. posed skin, but may be worsened with rewarming.

Question 17.10.3 You decide to provide symptomatic care

or this patient. Appropriate medications include which o
the ollowing?
A) Ranitidine
B) Doxepin
C) Diphenhydramine
D) Cetirizine
E) All o the above
Answer 17.10.3 The correct answer is “E.” All o the above can
be use ul in the symptomatic treatment o urticaria. Patients
should be started on sedating and nonsedating anti-histamines
to control their symptoms. Doses greater than the recommended
daily dose are requently required. H 2-blockers are e ective in
the 10% to 15% o patients who do not respond to H 1-blockers.
O note, H 2-blockers also are used in anaphylaxis treatment but
the evidence is weak. Finally, doxepin is a particularly e ective
H 1- and H 2-blocker that can be used as a sedating antihistamine.
T e patient returns to see you 6 weeks later and is still hav-
ing symptoms. You are wondering a bit more about potential
causes o this un ortunate individual’s urticaria.
Question 17.10.4 Which o the ollowing are causes o
urticaria?
A) Sweating
B) Cold (OK, get over it. Move to Hawaii and quit whining!)
C) Water (So that is why you never shower and only drink
beer?)
D) Pressure (OK, get over it. Use an antigravity unit and quit
whining!)
E) All o the above
You decide that this patient probably has cold urticaria (the
act that it is summer does not dissuade you as it may be
related to all o that air conditioning!).
Question 17.10.5 The next drug you might want to try on
this patient is:
A) Cyproheptadine (Periactin)
B) Prednisone
C) Montelukast
D) Ni edipine
E) Aspirin
Answer 17.10.5 The correct answer is “A.” T e physical urti-
carias (cold and pressure especially) may respond better to
cyproheptadine than other modalities. I this patient had a
“typical” urticaria, you might want to try prednisone, one o
the leukotriene inhibitors or ni edipine (which inter eres with
mast cell degranulation). Remember that leukotriene inhibi-
tors, steroids, etc. are second line and should be used only
when rst-line drugs have ailed or are not tolerated (cypro-
heptadine or physical urticaria; doxepin, anti-histamines, etc.,
or “typical” urticaria). T ere are no good studies on the e ec-
tiveness o leukotriene inhibitors (anecdotal evidence only), but
they might be worth trying when all else ails.
HELPFUL TIP:
Any number o drugs can cause urticaria. Look at the
med list! Medications that act as mast cell degranula-
tors should be avoided in patients with chronic urticar-
ia, including aspirin, opiates, polymyxin B, NSAIDs, and
systemic lidocaine.
494 FAMILY MEDICINE EXAMINATION & BOARD REVIEW

Objectives: Did you learn to . . .

• Recognize urticaria?
• Identi y potential causes o urticaria?
• Develop a treatment strategy or patients with urticaria?

QUICK QUIZ: PRECANCEROUS LESIONS

Actinic keratoses (AKs) are precursors to what?

A) Nothing
B) Melanoma
C) Basal cell carcinoma
D) Squamous cell carcinoma
E) Granuloma annulare

The correct answer is “D.” AKs are precursors to squamous cell

carcinomas. As such, they should be treated. Options include FIGURE 17-17. (Courtesy o Drs. Karolyn Wanat and Megan Noe.)
cryotherapy, laser therapy, or 5- uorouracil topically.

HELPFUL TIP:
Less than 1% o AKs progress to squamous cell carci-
noma per year. Some spontaneously involute and some
remain as AKs. However, in an individual, the risk o an
AK developing into a squamous cell carcinoma increas-
es with the number o AKs present.
QUICK QUIZ: SKIN BARNACLES
What is the appropriate treatment or an asymptomatic sebor-
rheic keratosis?
A) No treatment necessary
B) Cryotherapy
C) Surgical excision
D) opical steroids
E) opical antibiotic ointment
The correct answer is “A.” Seborrheic keratoses are benign
lesions that do not develop into malignancies. T ey are the
greasy-looking, stuck-on growths that occur with age. T ey can
be treated, i symptomatic, with cryotherapy. T ey look ugly,
patients hate them, but they are harmless.
CASE 17.11
A 50-year-old emale with type 2 diabetes controlled with
insulin complains o a rash that has developed on her legs over
the past year. It started as a small patch on her le leg and then
“spread” to her right leg. It is neither pain ul nor pruritic. You
are impressed by the rash she shows you in Figure 17-17.
Question 17.11.1 The most appropriate next step in the
management o these lesions is which o the ollowing?
A) A topical mid-potency steroid under occlusion or intral-
esional steroids
B) Discontinue insulin
C) Increase her insulin dose
D) Liberal use o emollients (e.g., petrolatum)
E) Leg elevation and application o compressive stockings
Answer 17.11.1 The correct answer is “A.” T is patient has
developed necrobiosis lipoidica, a benign condition o the skin
a ecting a small percent o diabetics, usually those on insulin.
Look or brownish red patches or plaques with yellowish areas
through the center. T e center is o en shiny with telangiectasias.
T e legs are most o en involved and the lesions may be pain-
ul. T e name describes the pathology: necrobiosis re ers to the
in ammation around destroyed collagen, and lipoidica re ers to
the yellowish color associated with lipid deposits. It does not
seem to be caused by insulin or a ected by glucose control, so
“B” and “C” are not appropriate choices. T ese lesions can be
con used or eczema, and in act may respond to topical steroids
(“A”); however, emollients are not use ul. Finally, necrobiosis
lipoidica might be con used with the skin changes associated
with venous stasis and chronic edema, which would be treated
as in “E.” Patients should know that necrobiosis lipoidica is
o en chronic and di cult to treat but benign. T e diagnosis is
clinical but can be con rmed by biopsy, and treatment is not
always necessary.
Your patient also complains o thick, dark, velvety patches
under her arms (Fig. 17-18). She’s unsure o the duration,
but states, “T ey’ve been with me a while. I just wondered i
my medication might cause these.” She gives you an accusing
look, and you have to admit that she takes more than a ew
medicines related to her diabetes.
Question 17.11.2 Which medication provides a clue to the
diagnosis?
A) Aspirin
B) Lisinopril
C) Insulin
D) Simvastatin

FIGURE 17-18. Wol K, Johnson RA, Suurmond D. Fitzpatrick’s Color Atlas
& Synopsis of Clinical Dermatology. 5th ed. New York: McGraw-Hill; 2005,
Fig. 5–1. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.
Answer 17.11.2 The correct answer is “C.” T e lesions are typi-
cal o acanthosis nigricans, a hyperkeratotic, hyperpigmented
condition a ecting skin olds (neck, inguinal area, axilla, etc.).
T e common causes o acanthosis nigricans are obesity, insu-
lin resistance, and diabetes. From med school, we all remember
acanthosis nigricans as a cutaneous mani estation o internal
malignancy. But such a presentation is rare. Cancer is more
likely in patients with extensive and quickly progressing lesions,
and as you might expect, it’s not a good sign.
HELPFUL (ISH) TIP:
Another cutaneous mani estation o internal malignancy
is the sign o Leser–Trelat: a large crop o seborrheic
keratoses that erupt quickly. Note that seborrheic kera-
toses themselves are benign and that knowing about
Leser–Trelat is mostly good or looking smart.
Your patient returns a year later and the lesions on her legs
have essentially disappeared. Now she has a new concern. She
reports a sore on the bottom o her great toe. She’s uncertain
how it occurred and thinks it has only been present or a ew
days. You nd a 1-cm circular ulcer at the plantar aspect o
her great toe. Pulses are diminished.
Question 17.11.3 Which o the ollowing should be the next
step in treatment?
A) Culture the wound
B) Per orm an MRI o the oot
CHAPTER 17 • DERMATOLOGY 495
C) Per orm mono lament testing to check sensation in the oot
D) Debride the wound
E) Obtain ankle–brachial indices
Answer 17.11.3 The correct answer is “E.” T e described
wound is most likely a diabetic oot ulcer, but the location and
the patient’s history o diabetes do elicit concern or an ulcer
related to vascular disease. Additionally, good vascular sup-
ply to the oot is necessary or wound healing. T ere ore, you
need to know the status o blood ow to the oot. T is may be
accomplished by physical examination. For patients at high risk
or peripheral vascular disease or without strong pulses, ankle–
brachial indices would be the next step. Culture o an open oot
ulcer is pretty much worthless as it will likely return as polymi-
crobial. X-ray may be warranted as well as probing the lesion to
see i it reaches the bone in order to evaluate or osteomyelitis,
but MRI is jumping the gun. Knowledge o a patient’s baseline
sensation is important and good general oot care (shoes that
t, meticulous skin and nail acre) can help in the prevention o
uture ulcers. Wound debridement will help to remove necrotic
tissue and improve the speed o wound healing. T e bio lm
must be removed down to healthy tissue in order to maximize
healing.
Ankle–brachial indices in both legs are normal. T e rest o
her skin is in good condition. T rough her diligent care and
control o her diabetes, the ulcer heals. She returns 3 months
later with a new skin concern. On her anterior shin, she has
developed a clear uid- lled blister about 1 cm in diameter
and irregular in shape. T ere is no erythema, no pruritus,
and no pain. She denies trauma and new environmental
contacts.
Question 17.11.4 Which o the ollowing is the most likely
diagnosis?
A) Dyshidrotic eczema
B) Contact dermatitis
C) Staphylococcal scalded skin syndrome (SSSS)
D) Bullosis diabeticorum
E) Drug eruption
Answer 17.11.4 The correct answer is “D.” Bullosis diabetico-
rum, or bullous disease o diabetes, occurs in less than 1% o
diabetic patients. However, patients may be alarmed by it and
seek treatment. T e cause is unknown, but it typically ollows
a benign course and resolves spontaneously over a ew weeks
or months. Because it requires no intervention, it is use ul to
distinguish bullosis diabeticorum rom dyshidrotic eczema and
contact dermatitis, both o which may mimic the disease except
or pruritus and in ammation.
Objectives: Did you learn to . . .
• Identi y necrobiosis lipoidica, acanthosis nigricans, and
bullosis diabeticorum?
• Treat these conditions (i necessary)?
• Evaluate a diabetic oot ulcer?
496 FAMILY MEDICINE EXAMINATION & BOARD REVIEW

QUICK QUIZ: MR. SCRATCHER

A 76-year-old male comes to your clinic with a 1-year his-

tory o pruritic, eczematous rash on his chest and back. He
has no atopic history or eczema as a child. He has no other
active medical issues. He has tried moisturizers and over-the-
counter hydrocortisone cream, which have provided minimal
relie .

Which o the ollowing is the most appropriate next step in his

management?
A) acrolimus ointment
B) Skin scraping or KOH preparation
C) High-dose topical steroids
D) Punch biopsy
FIGURE 17-19. (Courtesy o Drs. Karolyn Wanat and Megan Noe.) E) Oral antihistamines

The correct answer is “D.” T e development o a new, eczema-

tous rash in an adult patient should raise the concern or a more
QUICK QUIZ: SKIN SO ITCHY serious condition. It is rare or an elderly person to develop
atopic dermatitis de novo. T is may be indicative o an under-
lying lymphoproli erative malignancy such as cutaneous -cell
A 60-year-old male who underwent pacemaker placement
lymphoma. Bowen disease (squamous cell carcinoma in situ)
3 days ago comes in with the pruritic rash seen in Figure 17-19.
is another possibility. T e most appropriate next step in this
patient’s management would be punch biopsy.
T is rash is most likely:
A) Grover disease
B) Lichen planus QUICK QUIZ: DARIER SIGN
C) Contact dermatitis
D) Atopic dermatitis
A 4-year-old girl comes to clinic accompanied by her mother
E) Pyoderma gangrenosum
or her yearly checkup. Her mother requests that you exam-
ine her daughter’s skin because o a rash. Upon examination,
The correct answer is “C.” T is is contact dermatitis, which
you identi y scattered reddish-brown macules on the back and
may be acute, subacute, or chronic. It is an erythematous,
chest. When stroked, the lesions urticate. T ere are no other
pruritic eruption that usually blisters and leaves a crust. More
complaints or abnormalities on physical examination.
chronic orms o contact dermatitis present with licheni cation
and scaling. T e rash in Figure 17-19 does not look like any o
What is the most likely diagnosis?
the other choices. Grover disease, also known as transient acan-
A) Atopic dermatitis
tholytic dermatosis, presents with small, sometimes pruritic,
B) Contact dermatitis
erythematous papules on the back and chest, which may blister.
C) Congenital nevi
Lichen planus presents with pruritic, red-to-purple, at-topped
D) Cutaneous lupus
papules. Atopic dermatitis is discussed earlier in the chapter.
E) Urticaria pigmentosa
Pyoderma gangrenosum presents with pain ul, red nodules and
pustules that ulcerate. Again, since we cannot display pictures
The correct answer is “E.” T is child’s rash is most likely sec-
o all diseases mentioned, please look at one o the websites
ondary to urticaria pigmentosa, which is a cutaneous orm o
included at the beginning o this chapter.
mastocytosis. Clinical ndings include reddish-brown macules
or slightly raised papules, which represent cutaneous accumula-
HELPFUL TIP:
tions o mast cells. T ese occur most commonly on extensor
Pyoderma gangrenosum is a diagnosis o exclusion
sur aces, thorax, and abdomen. When stroked, these lesions
but may be di erentiated rom other ulcer types by
can urticate (Darier sign). Urticaria pigmentosa is the most
the exquisite pain it causes and the pathergic phe-
common skin mani estation o mastocytosis in children and
nomenon it displays, where the wound will worsen
adults. Eighty percent o cases appear during the rst year o
in response to surgical manipulation (e.g., biopsy,
li e. Lesions resolve in > 50% o patients by adolescence. T e
debridement).
diagnosis is con rmed by skin biopsy. In children, urticaria pig-
mentosa is rarely associated with systemic disease.

Clinical Pearls
Be sure to look or abnormal looking skin lesions on the
palms, soles o the eet and near the nails as these lesions
may progress to more aggressive orms o melanoma be ore
they are discovered.
Con irm a toenail ungal in ection prior to initiating systemic
anti ungal therapy.
Do not per orm a shave biopsy on a skin lesion i you are
suspecting melanoma as depth o the lesion is used to stage
melanoma and determine prognosis.
Do not routinely recommend diuretics as general therapy
or venous stasis as they may make symptoms worse by
decreasing circulating volume and increase renal retention o
sodium. Instead, recommend weight loss, compression
stockings, and leg elevation.
Do not use systemic antibiotics or irst-line treatment o
acne. Instead, employ topical agents as irst-line therapy.
Do not use topical anti ungal agents to treat ungal nail
in ections due to these agents being relatively expensive,
having marginal bene it, and a high recurrence rate.
Recommend regular sun protection using sunscreen, light
protective long sleeved clothing, hat, and sunglasses.
Recommend timely removal/biopsy o any suspicious looking
nevi.
Re er in ants with larger, segmental hemangiomas to
dermatology and obtain imaging studies to rule out
syndromes with other associated anomalies.
CHAPTER 17 • DERMATOLOGY 497
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Bruckner AL, Frieden IJ. Hemangiomas o in ancy. J Am Acad
Derm. 2003;48:477–493.
Di Lorenzo G, et al. Leukotriene receptor antagonists in mono-
therapy or in combination with antihistamines in the
treatment o chronic urticaria: A systematic review.
J Asthma Allergy. 2008;2:9–16.
Gershenwald JE, et al. 2010 NM staging system or cutaneous
melanoma . . . and beyond. Ann Surg Oncol. 2010;17:1475–
1477.
Hurwitz S, eds. Eczemetous eruptions in childhood. In: Clinical
Pediatric Dermatology. 3rd ed. Philadelphia, PA: W.B.
Saunders Co.; 2005.
Khumalo N, et al. Interventions or bullous pemphigoid.
Cochrane Database Syst Rev. 2003;(3):CD002292.
O’Connor NR, McLaughlin MR. Neonatal skin: Parts I and II.
Am Fam Physician. 2008;77:47–60.
Rager EL. Cutaneous melanoma. Am Fam Physician. 2005;72:
269–276.
Ramsey HM, et al. Factors associated with nonmelanoma skin
cancer ollowing renal transplantation. J Am Acad
Dermatol. 2003;49(3):397–406.
Usatine RP, et al. T e Color Atlas of Family Medicine. Part 13:
Dermatology. New York: McGraw-Hill; 2009.
Wol K, Johnson RA. Fitzpatrick’s Color Atlas and Synopsis of
Clinical Dermatology. 6th ed. New York: McGraw-Hill;
2009.
Neurology
Sp iha Pa i
CASE 18.1
A 75-year-old right-handed man presents to the emergency
department (ED) with dizziness that started 5 hours ago. His
dizziness consists o a spinning sensation and he eels o bal-
ance as he walks. He reports coughing when trying to drink
water earlier, but otherwise notes no other symptoms. He
has an unremarkable past medical history and is taking no
medications. On examination, he is ound to have le -sided
ptosis and le acial numbness to pinprick. Gag re ex is
absent. Motor examination is otherwise unremarkable. Sen-
sory examination revealed decreased pinprick sensation o
the right arm and leg. He is unsteady while walking, tending
to lean le ward.
Question 18.1.1 What is the most likely diagnosis in this
patient?
A) Acute vestibulitis/labyrinthitis
B) Benign paroxysmal positional vertigo (BPPV)
C) Cerebellar stroke
D) Brain stem stroke
E) Ménière attack
Answer 18.1.1 The correct answer is “D.” Although dizzi-
ness can be associated with all o the above disorders, a brain
stem stroke is the most likely answer. T e associated symp-
toms o ptosis (suggestive o Horner syndrome), absent gag
re ex with patient report o possible dysphagia, and crossed
sensory ndings (le side ace, right side body) are most con-
sistent with brain stem localization. In peripheral etiologies
o vertigo (“A,” “B,” and “E”), one would not expect sensory
phenomena, ptosis, or swallowing di culties. In BPPV, one
would expect brie attacks, lasting seconds to minutes, and
not a prolonged attack. In Ménière’s, there is o en some his-
tory o tinnitus and/or hearing loss (low requency initially).
A pure cerebellar stroke would not be expected to have sensory
ndings.
498
18
HELPFUL TIP:
Wh n a pati nt c mp ains dizzin ss, ask what th pa-
ti nt m ans b “dizzin ss.” Th t m “dizzin ss” m ans
di nt thin s t di nt pati nts. “Dizzin ss” ma
p s nt ti , i hth ad dn ss, p -s nc p , dis-
q i ib i m wh n wa kin ( . ., a in t n sid ),
anxi t , tc. A s , kn w that th is c nt s am n
xp ts as t wh th this d in ati n dizzin ss is
m mis adin than it is h p .
In con erring with your colleague, she asks i you are going to
give tissue plasminogen activator (tPA).
Question 18.1.2 Which one o the ollowing is NOT a contra-
indication to intravenous (IV) tPA?
A) Age > 75
B) INR > 1.7
C) Platelets < 100,000
D) Stroke within last 3 months
E) Glucose < 50
F) Hemorrhage seen on head C
Answer 18.1.2 The correct answer is “A.” Acute stroke treat-
ment with thrombolytics may be o bene t i administered to
care ully selected patients within 3 hours o symptom onset
or 4.5 hours o symptom onset i certain criteria are met (see
able 18-1). When administered properly, the number needed
to treat or improvement at 3 months is 6. However, there is
no survival bene t. T e risk o hemorrhage is 6% (1 in 16). O
those with symptomatic hemorrhagic trans ormation, 60% are
atal. T ere is no upper age cutof or administration o tPA.
Strong contraindications include minor or rapidly improv-
ing symptoms as well as those listed in able 18-1. In selected
patients, there is a role or neurointerventional procedures
including intra-arterial tPA and thrombectomy. Unlike IV tPA,
 Ch Apt Er 18 • Neu r o l o g y 499

Ta b LE 18-1 ELIGIBILIt Y AND CONt r AINDICAt IONS C) Administer IV nitroglycerin with a blood pressure goal o
FOr pA FOr ACUt E ISCh EMIC St r OKE, SYMpt OM 150/90 mm Hg
ONSEt 0–4.5 h OUr S D) Administer sublingual ni edipine with a blood pressure goal
o 160/95 mm Hg
Eligibili y
E) Monitor the patient’s blood pressure and avoid anti-
• A >18 a s
• C inica dia n sis isch mic st k ca sin m as ab n ica hypertensives
d cit
Answer 18.1.3 The correct answer is “E.” Do not treat this
Con aindica ions
• Int ac ania h m ha n CT patient’s blood pressure unless the blood pressure is > 220 mm
• C inica p s ntati n s sts s ba achn id h m ha Hg systolic or > 120 mm Hg diastolic; and even then the goal
• S mpt ms min apid imp in would be to reduce blood pressure by 15% over 24 hours. reat-
• N ic s within th past 3 m nths ing blood pressure during the acute phase o ischemic stroke
• St k s i s h ad t a ma within 3 m nths
reduces central nervous system (CNS) per usion and puts isch-
• S stain d b d p ss SBP >185 DBP >110 mm H
• S iz with p sticta sid a n ica impai m nts emic brain at risk. Obviously, this does not apply i the patient
• Kn wn a t i n s ma mati n, n p asm an sm has a hypertensive urgency or hypertensive crisis (e.g., heart
• Acti int na b din ailure or other end-organ dys unction). Note that this is or
• Kn wn b din diath sis ischemic stroke and not hemorrhagic stroke. Lowering the
• P at t c nt <100,000
blood pressure to a systolic o around or below 160 mm Hg
• H pa in within ast 48 h s with at d PTT antic a ati n
with an INr >1.7 PT >15 is indicated in hemorrhagic stroke. In this scenario, i you
• C nt s di ct th mbin inhibit s di ct act Xa inhibit s use an anti-hypertensive, labetalol or nicardipine is pre erred.
Why labetalol or nicardipine and not nitrates? Nitrates cause
r ela ive Con aindica ions
• Maj s s i s t a ma, xc din h ad t a ma, in th past intracranial vasodilatation increasing CNS pressure.
14 da s
• gI ina t act h m ha within past 21 da s Question 18.1.4 A ter admission to a monitored bed, which
• r c nt a t ia p nct at a n nc mp ssib sit o the ollowing diagnostic evaluations is LEAST likely to be
• r c nt mba p nct o urther bene t in this patient?
• P st-m ca dia in a cti n p ica ditis
• P nanc
A) Fasting lipid pro le
B) Magnetic resonance angiography (MRA) o the head and
Addi ional r ela ive Con aindica ions fo pa ien s p esen ing in neck
e Window of 3–4.5 h ou s f om Sym om Onse
• A > 80 a s
C) Fasting glucose
• Hist p i st k and diab t s D) Hypercoagulable testing
• An acti antic a ant s , n with INr < 1.7 E) ransesophageal echocardiogram
• NIH st k sc > 25
• CT sh win m ti ba in a cti n (> 1/3 midd c b a a t Answer 18.1.4 The correct answer is “D.” Hypercoagulable
dist ib ti n)
states are an uncommon cause o stroke. I you are unable to
determine the origin o a clot in a thromboembolic stroke and
the patient is otherwise low-risk (let’s say a healthy 25-year-old
there are not clearly de ned criteria or inclusion/exclusion. In male who runs marathons), then you can consider a workup
general, patients should be within 6 hours o onset o symptoms or a hypercoagulable state. Such an evaluation is not use ul in
and have well-localized symptoms. most stroke patients—like your typical 80-year-old hyperten-
sive emale, even i her carotid Dopplers and echocardiogram
are negative. In addition to monitoring the patient or signs o
HELPFUL TIP: neurologic decline or complications, evaluation o potential
Mak s a c mp si ab t inc si n and x- risk actors or recurrent stroke is an integral part o stroke care.
c si n c it ia! Wh n in d bt, ca th n a st st k Hypertension, hyperlipidemia, cardiac arrhythmia or structural
acc dit d h spita t sp ak t th n-ca n ist. de ects, illicit drug use (IV drugs and stimulants), smoking, and
diabetes mellitus are risk actors or recurrent stroke and should
be evaluated. MRA allows noninvasive evaluation o intracra-
T e patient is outside o the 4.5-hour window or thromboly- nial and cervical blood vessels in both the anterior and posterior
sis and has a blood pressure o 200/100 mm Hg. circulation. Echocardiography is also an important part in the
evaluation o stroke, and transesophageal echocardiography
Question 18.1.3 The best next step in treatment at this is more sensitive or identi ying thrombotic sources or stroke
point is to: when compared with transthoracic echo.
A) Administer IV labetalol with a blood pressure goal o 140/
90 mm Hg T e patient is ound to have a lateral medullary stoke on MRI
B) Administer IV labetalol with a blood pressure goal o 130/ and has heavy atherosclerotic burden in his vertebral arteries.
85 mm Hg Echocardiogram and telemetry are normal.
500 FAMIl y MeDICINe eXAMINATIo N & Bo Ar D r evIeW

Question 18.1.5 What would be the optimal antithrom- Ta b LE 18-2 ABCD2 Cr It Er IA

botic medication in this patient or prevention o recurrent
A : 1 p int a ≥ 60 a s
stroke?
B d p ss : 1 p int s st ic > 140 diast ic > 90 mm H
A) Coumadin (war arin) C inica at s: F ca w akn ss (2 p ints) n sp ch di c t
B) Aspirin (1 p int)
C) Plavix (clopidogrel) D ati n s mpt ms: > 60 min t s (2 p ints), ≤ 59 min t s (1 p int)
D) Aggrenox (aspirin/dipyridamole) Diab t s: 1 p int
E) Pletal (cilostazol) ABCD2 Sco e r isk of S oke in Nex 48 h ou s (%)

Answer 18.1.5 The correct answer is “B.” In patients with a 0–3 p ints 1
noncardiogenic source or their stroke, there is no data to sup- 4–5 p ints 4.1
port the use o anticoagulation (war arin) or stroke prevention.
Similarly, there is no prospective data to support a role or 6–7 p ints 8.1
cilostazol or pentoxi ylline in the prevention o stroke.
With regard to antiplatelet agents, aspirin is the rst-line
duration o symptoms, blood pressure, and diabetes. T is can
choice. T ere is no bene t to dual therapy (i.e., clopidogrel
be used to predict the 48-hour risk o stroke.
[Plavix] and aspirin). T ere is also no bene t in increasing the
Rapid evaluation o the at-risk patient is warranted, although
dose o aspirin to more than 81 mg every day. I a patient ails
it is unclear i earlier interventions make a dif erence (beyond
aspirin (recurrent stroke o same mechanism), either change to
starting antiplatelet agents, etc.).
clopidogrel or Aggrenox (combination aspirin/dipyridamole);
both are equally ef ective in stroke prevention. Because o cost,
most authors recommend aspirin as a primary preventive agent HELPFUL (a ND UNFORTUNa TE) TIP:
in those who have had a transient ischemic attack ( IA). Th initia Mr I is a s n ati 13% th tim at
4.5 h s in n np st i ci c ati n i ns (Stroke.
2013;44(6):1647–1651). It is n w s in th p st i
HELPFUL TIP:
ci c ati n. Th initia Mr I pick d p n 50% st k s
y ma s aspi in and c pid s dt th in th
in th p st i ci c ati n that w < 1 cm in siz and
i st 21 da s a t a min isch mic st k TIA. This is n t
92% th s > 1 cm in siz (Neurology. 2014;83(2):169–
t standa d ca a th h th a s m data s p-
173). What d s this m an ?I think a pati nt
p tin this s in Chin s pati nts, in wh m th ti
has had a st k b t th Mr I is n ati , th pati nt
st k m c mm n inc d s int ac ania st n sis
ma sti ha had a st k .
and in wh m c pid is m tab iz d di nt than
in th p p ati ns (N Engl J Med. 2013; 369:11–19). This
b n it d s n t xt nd b nd 21 da s. Objectives: Did you learn to . . .
• Id nti si ns/s mpt ms s sti ac t isch mic st k
(c b a in a cti n)?
It seems that there is a 2- or-1 special on neurologic symp- • Initiat a dia n stic a ati n a pati nt with a p ssib
toms in your ED this evening (well, at least isn’t a three- er st k ?
with 3 kids in the same amily all o whom have colds. . . . • D sc ib th int a n s and/ int a-a t ia tPA in
and the parent is sure they have pneumonia). Your next th t atm nt ac t isch mic st k ?
patient is a 59-year-old male who appears to have had a • e a at pti ns s c nda p nti n st k ?
simple IA with le -sided ocal weakness. T e IA lasted • Ass ss st k isk a t TIA?
< 10 minutes and the patient has a normal blood pressure
and is nondiabetic.
QUICK QUIZ: WHeN To Cu T?
Question 18.1.6 His risk o having a stroke in the 48 hours
a ter a simple TIA is: Which o the ollowing re errals or carotid endarterectomy is
A) 1% most likely to result in a bene t to the patient?
B) 5% A) A symptomatic woman with 70% or greater stenosis to a
C) 10% surgeon who has a 5% complication rate
D) 20% B) An asymptomatic man with 60% stenosis to a surgeon who
E) 30% has a 7% complication rate
C) A symptomatic woman with a 50% to 69% stenosis and a li e
Answer 18.1.6 The correct answer is “A.” T e overall risk o expectancy o > 5 years to a surgeon who has a 5% complica-
stroke ranges rom 4% to 20% in the 90 days a er a IA. T is is tion rate
a pretty wide range. o narrow down the range a bit, the ABCD2 D) None o the above
( able 18-2) has been developed and takes into account age, E) All o the above

The correct answer is “A.” All sources agree that a symptomatic
patient who has 70% stenosis o the carotid will bene t rom
surgery provided that the surgeon’s complication rate is su -
ciently low. Men, but not women, seem to have a bene t with
symptomatic stenosis o 50% to 69% i the li e expectancy is
> 5 years and the surgeon’s complication rate is < 6% (NN 22).
In asymptomatic patients, those with > 60% stenosis will ben-
e t rom carotid endarterectomy, but NN is 33 and the bene t
is less than those with symptomatic disease. Stenting is another
option. It seems as though long-term outcomes with stenting
and endarterectomy are about the same although more data is
needed (N Engl J Med. 2016 Feb 1). Stenting seems to be worse
than endarterectomy in patients over 70, however (Lancet. 2016
Feb 12).
QUICK QUIZ: A PAIN IN THe NeCK
A 35-year-old emale presents or worsening right-sided pos-
terior neck pain that radiates to her right occiput. T e pain
has been dull and intermittent or about a week and associ-
ated with some right posterior scalp tenderness. She became
alarmed today because she elt dizzy a er her workout. She
describes several minutes o vertigo that resolved a ew hours
ago. Now, sitting in your examination room, she denies vision
changes, muscle weakness, numbness, paresthesia, swallow-
ing problems, and speech de cits. Since she’s training or a
“Viking’s Valor Race,” she has intensi ed her workouts in
the past ew weeks, li ing heavier weights. She is relatively
healthy but does take lisinopril or hypertension due to bro-
muscular dysplasia. Her vitals are normal. Her neurological
examination is normal.
T e most appropriate next step in the care o this patient is:
A) Reassurance, rest rom exercise, ibupro en
B) Re erral to a neurologist
C) Initiation o aspirin 81 mg daily
D) Urgent head C
E) Urgent MRI/MRA o the head and neck
The correct answer is “E.” T is patient is presenting with
symptoms concerning or vertebral artery dissection. Extra-
cranial arterial dissections o the head and neck are relatively
more common causes o stroke in young adults compared with
older adults. Fortunately, many patients experience symptoms
o dissection (typically head and/or neck pain, although a
Horner syndrome can develop in patients with carotid artery
dissection) prior to having a stroke and can be identi ed early
i the physician is attentive and orders the appropriate test. In
this case, “D” is not the right test. Head C would be unlikely
to show anything since she does not currently have neurologic
signs or symptoms. Even with a C angiogram o the brain, the
extracranial neck arteries (where the problem exists) would not
be visualized. T us, the imaging must include the head and neck
and must provide views o the arteries. I “E” is not available,
C A o the head and neck is a reasonable alternative. Classi-
cally, an angiogram was used to make the diagnosis, but it is
Ch Apt Er 18 • Neu r o l o g y 501
more common now to use MRA or C A. O note, patients with
bromuscular dysplasia are more likely to have vertebral and
carotid artery dissections, but the vast majority o patients with
vertebral or carotid dissection do not have any known connec-
tive tissue disorder. Case series o dissections o en describe
a minor trauma (e.g., weight li ing, amusement park rides,
various sports, “ ender bender” accidents, chiropractic neck
manipulation, etc.) prior to the onset o symptoms.
CASE 18.2
A 24-year-old right-handed woman presents to you in the
ED a er her second episode o loss o consciousness. T e
rst spell occurred 6 months ago and was associated with
a 60-second loss o consciousness and jerking movements
o her arms and legs. Following the spell, she was con used
or about 15 minutes. At that time, her initial ED evaluation
was unremarkable. She presents today ollowing a spell that
occurred about 45 minutes ago. Her riends observed her
to all to the ground and shake her arms and legs or about
2 minutes. T ey could not get her to respond during this
time. A erward, she was con used and they brought her to
the ED. Upon arrival in the ED, she is mildly drowsy but oth-
erwise oriented. She has no memory o the earlier events. Her
general medical examination and neurological examination
are unremarkable.
Question 18.2.1 Which o these tests would be LEAST
help ul in determining the etiology o this spell?
A) Urine toxicology screen
B) Electrolytes
C) Neuroimaging (head C or MRI)
D) Electrocardiogram (ECG)
E) Electroencephalogram (EEG)
Answer 18.2.1 The correct answer is “D.” In this case, ECG
would be the lowest yield, as this spell is most suggestive o
seizure. Syncopal episodes, which are o en o primary cardiac
etiology, are generally o shorter duration without postictal
con usion. Although a ew tonic–clonic movements can be seen
with syncope (convulsive syncope), it would be atypical or
those movements to continue throughout the entire period o
loss o consciousness.
All o the other tests would be use ul. Evaluation o a rst-
time seizure should include assessment or alcohol or other
drug withdrawal (especially benzodiazepines and barbiturates)
as well as drug intoxication (cocaine, methamphetamine, and
other sympathomimetics). In ection, including meningitis and
encephalitis, can provoke a seizure. Hyponatremia, hyperna-
tremia, hypocalcemia, hypoglycemia, hyperglycemia, hypo-
magnesemia, hypophosphatemia, and uremia are all associ-
ated with seizures. o rule out structural lesions (e.g., tumor
and AV mal ormation) and hemorrhage, neuroimaging should
be per ormed. Although MRI has greater sensitivity, it is o en
not available in a timely manner, and thus, C is the modality
o choice. EEG would be able to assess or any seizure activity
wave orms.
502 FAMIl y MeDICINe eXAMINATIo N & Bo Ar D r evIeW
HELPFUL TIP:
A pati nts with synco e, inc din chi d n, d s
at ast n eCg in d t tp n d QT in-
t a , B ada s nd m , tc. I th sp is n t c a a
s iz and c d b s nc p , t an eCg . Pa tients with
simple syncope, no hea d tra uma , a nd a norma l neu-
rologic exa mina tion do not need a CT sca n (see www.
choosingwisely.org).
HELPFUL TIP:
Th m st c mm n ca s stat s pi ptic s in a pa-
ti nt with s iz dis d is n nc mp ianc ! o n th
m st c mm n ca s s b akth h s iz s in th s
with a kn wn s iz dis d is s p d p i ati n.
Evaluation in the ED, including electrolytes, CBC, brain C
scan, and urine toxicology, is unremarkable. An electroen-
cephalogram (EEG) is obtained in the ED and read as nor-
mal. T e patient is eeling well and does not wish to remain in
the hospital. Her riends assure you that they will be with her
over the next 24 hours. She returns to your clinic in 2 days.
Question 18.2.2 A ter reviewing her test results with her,
what do you recommend or urther management?
A) Continued ollow-up with no urther workup or treatment
B) Video/EEG monitoring
C) Initiate treatment with antiepileptic drug(s)
D) ilt table testing
E) Whirligig testing
Answer 18.2.2 The correct answer is “C.” T is is this patient’s
second seizure. In adults with a rst seizure, only 30% to 60%
will go on to have a second seizure. In patients who have a second
seizure, the likelihood o going on to have a third is 80% to 90%;
there ore, a er a second unprovoked seizure, treatment is rec-
ommended. Video/EEG monitoring (“B”) is appropriate or clas-
si ying spells o unclear etiology. In order or video/EEG to be an
ef ective tool, the patient should have spells requently enough
to capture them during a reasonable inpatient stay (3 days aver-
age). ilt table testing (“D”) would not be o value, as syncope is
unlikely to be the cause o these spells, and whirligig testing (“E”)
is not a real thing (but it may be in a Dr. Seuss book!).
You discuss her case with the neurologist, Dr. Lotta Branes,
who recommends that she start an antiepileptic drug (AED)
since this is her second unprovoked seizure. “Huh? What?”
you say. “Start her on an antiepileptic drug? Didn’t she have
a negative EEG?”
Question 18.2.3 What is the sensitivity o a single interictal
EEG or seizure ocus?
A) 20%
B) 30%
C) 50%
D) 60%
E) 90%
Answer 18.2.3 The correct answer is “D.” A single interictal
EEG has only a 60% sensitivity or picking up a seizure ocus.
T e sensitivity goes up to 90% a er three interictal EEGs. How-
ever, this still means that an EEG will be negative in 10% o
those with seizures even a er three EEGs.
She has multiple questions about AEDs . . . and so do you!
Question 18.2.4 Which o the ollowing AEDs is NOT
typically associated with weight gain?
A) Depakote (valproic acid)
B) Lamictal (lamotrigine)
C) egretol (carbamazepine)
D) Neurontin (gabapentin)
Answer 18.2.4 The correct answer is “B.” Depakote, egre-
tol, and Neurontin are all associated with weight gain. Gabitril
(tiagabine) is also associated with weight gain. Lamictal is typically
weight neutral. Felbatol ( elbamate) and opamax (topiramate)
are associated with weight loss.
Question 18.2.5 Which o the ollowing adverse ef ects is
NOT typically associated with phenytoin (Dilantin)?
A) Cerebellar atrophy
B) Gingival hyperplasia
C) Stevens–Johnson syndrome
D) Hypertension
E) Bone demineralization
Answer 18.2.5 The correct answer is “D.” Phenytoin (Dilantin)
is associated with a number o idiosyncratic ef ects including
cerebellar atrophy, hirsutism, Stevens–Johnson syndrome, and
gingival hyperplasia. Diplopia and nystagmus can be prominent
side ef ects, particularly with supratherapeutic doses. Dizziness,
drowsiness, atigue, headache, nausea, vomiting, weight loss,
and urine discoloration (pink, red, or reddish-brown) are among
some o the side ef ects seen with phenytoin. Many AEDs cause
increased metabolism o vitamin D via the liver. Long-term use
o AEDs may lead to osteoporosis, so vitamin D supplementation
with calcium is routine. Phenytoin is associated with hypotension
and cardiac dysrhythmia (particularly with IV administration)
and can cause “purple glove syndrome” i the peripheral IV in l-
trates. T is is due to the solution/carrier or the drug. Fosphe-
nytoin (Cerebyx) does not have risk o “purple glove syndrome”
and has much lower incidences o hypotension and arrhythmias,
so is the ormulation o choice when giving phenytoin IV.
Question 18.2.6 Which o the ollowing AEDs is NOT Class D
or pregnancy?
A) Valproic acid (Depakote)
B) Phenytoin (Dilantin)
C) Lamictal (lamotrigine)
D) Phenobarbital
E) Primidone

Answer 18.2.6 The correct answer is “C.” T e newer AEDs
including Neurontin (gabapentin), Lamictal (lamotrigine),
Keppra (levetiracetam), rileptal (oxcarbazepine), Gabitril
(tiagabine), and Zonegran (zonisamide) are currently Class C
in pregnancy. Valproic acid, phenytoin, phenobarbital, primi-
done, and carbamazepine are all Class D drugs in pregnancy.
opiramate has been associated with birth de ects and should
be avoided. In particular, valproic acid has a known association
with neural tube de ects. As a result, it is recommended that all
women o childbearing age be on olate and a prenatal vitamin
while on AEDs. It is not recommended that women discon-
tinue AEDs when pregnant, but simpli ying to monotherapy is
recommended i possible.
HELPFUL TIP:
In th thi d t im st , itamin K10 m Po dai is c m-
m nd d b s m xp ts d t d p ssi n c ttin
act s with man anti pi ptics. This w in
c ttin act s has b n ass ciat d with n nata
b din .
Question 18.2.7 Which o the ollowing drugs does NOT
have potential interactions with oral contraceptives?
A) Depakote (valproic acid)
B) egretol (carbamazepine)
C) rileptal (oxcarbazepine)
D) Dilantin (phenytoin)
E) opamax (topiramate)
Answer 18.2.7 The correct answer is “A.” Interactions with
oral contraceptives, decreasing the e cacy o the OCP not the
anticonvulsant, have been reported with oxcarbazepine, pheno-
barbital, phenytoin, lamotrigine, and topiramate.
Zonisamide, (zongran), valproic acid (Depakote),
tiagabine (Gabitril), levetiracetam (Keppra), gabapentin
(Neurontin), and elbamate (Felbatol) do not inter ere with
oral contraceptives. A barrier method o contraception, in
addition to oral contraceptives, is recommended in women on
AEDs, particularly those with known interactions with oral
contraceptives.
Question 18.2.8 Which o the ollowing is NOT part o rou-
tine counseling with epilepsy and initiation o therapy with
an antiepileptic drug?
A) Work sa ety
B) Calcium and vitamin D supplementation
C) Driving
D) Alcohol consumption
E) Epilepsy surgery
Answer 18.2.8 The correct answer is “E.” Epilepsy sur-
gery is reserved or patients who are intractable to medical
management and have ailed at least two AEDs. Exceptions
would include patients with ocal pathology (e.g., malig-
nancy or vascular mal ormation). “B,” calcium and vitamin
Ch Apt Er 18 • Neu r o l o g y 503
D supplementation, should be initiated in patients on AEDs
due to increased risk o osteoporosis. “A” and “C,” work and
driving sa ety issues, should be discussed. Most states have spe-
ci c laws regarding driving and seizures and the time be ore
resumption o driving privileges varies greatly; check the laws
in your state(s) o practice. Epileptic patients should be warned
o potentially dangerous activities at work and home (e.g.,
working on ladders, with heavy equipment, bathing, and swim-
ming). “D,” alcohol use, should be discussed with patients.
Patients should also be warned o potential actors that could
lower their seizure threshold, including alcohol consumption,
herbal ephedra supplements, sleep deprivation, in ection, and
medication noncompliance.
Objectives: Did you learn to . . .
• e a at a pati nt with a p t ntia n w dia n sis
pi ps ?
• Id nti s m a as sp ci c c nc n a din w m n’s
iss s in pi ps ?
• r c niz c mm n nc nt d s i s sid cts
with anti pi ptic d s?
• C ns pati nts with pi ps dai acti iti s and
a din m dicati n mana m nt?
QUICK QUIZ: SeIZu r e DISo r Der S
All o the ollowing are indicated in the treatment o petit mal
seizures (aka absence seizures, aka generalized nonconvulsive
epilepsy) EXCEP :
A) Ethosuximide
B) Acetazolamide
C) Valproic acid
D) Clonazepam
E) Phenytoin
The correct answer is “E.” Phenytoin is not indicated in the
treatment o petit mal seizures. T e other options are indicated.
Other drugs known to be use ul in petit mal seizures include
lamotrigine, phenobarbital, and topiramate.
HELPFUL TIP:
F and ma s iz s, a p ic acid s ms t b th
d that is m st cti and th s th b st initia d
(b t n t in p nanc ). F pa tia s iz s ( . ., t m-
p a b pi ps ), am t i in s ms t b th b st
initia d .
CASE 18.3
A 60-year-old le -handed man comes in with a complaint
o numbness and tingling in his lower extremities or about
10 months. He notes no weakness. He has had type 2 diabe-
tes mellitus or 6 years and has a 30 pack-year smoking his-
tory. Examination reveals decreased sensation to light touch,
504 FAMIl y MeDICINe eXAMINATIo N & Bo Ar D r evIeW

pin-prick, and vibratory sensation in the eet extending to

HELPFUL TIP:
7 cm below the knees symmetrically. You also notice lack o
A hist ac h s is imp tant, as ch nic a c h
hair on his leg to the same level. Chest, abdomen, and upper
ab s is c mm n ass ciat d with p n path ,
extremities have normal sensation. His re exes are 1+ in the
n in th abs nc itamin B12 th n t iti na
upper extremities and quadriceps with absent Achilles bilat-
d ici nci s.
erally. T e remainder o his neurological and general medi-
cal examination is unremarkable. He says his diet is good but
always brings you a dozen doughnuts when he visits . . . with
one or two missing. Your patient is on a number o medications.

Question 18.3.1 This history is most consistent with: Question 18.3.3 Which o the ollowing medications is
A) Stroke known to cause a peripheral neuropathy?
B) Early mononeuritis multiplex A) Metronidazole
C) Guillain–Barré syndrome (GBS) B) HMG-CoA reductase inhibitors
D) Brown–Sequard syndrome C) Amiodarone
E) Peripheral neuropathy D) Disul ram
E) All o the above
Answer 18.3.1 The correct answer is “E.” T is is the quintes-
sential presentation o a patient with diabetic peripheral neu- Answer 18.3.3 The correct answer is “E.” All o the above can
ropathy. “A” is incorrect because o the distribution. Bilateral cause a peripheral neuropathy. Some o the other drugs that
distal lower extremity sensory changes are not likely rom a can cause neuropathy include phenytoin, isoniazid, several
stroke. “B,” mononeuritis multiplex, is—at least initially—not chemotherapeutic agents, nitro urantoin, ddC, and D4 . See
in a stocking-glove distribution. Patients with mononeuritis able 18-3 or more causes o peripheral neuropathy.
multiplex will notice a stepwise loss o sensation and motor
ability in discrete peripheral nerve distributions. Eventually,
Ta b LE 18-3 VEr Y pAr t IAL LISt OF CAUSES OF
these may become con uent and resemble a stocking-glove
pEr Iph Er AL SENSOr Y NEUr OpAt h Y
neuropathy. However, this is ound late in the disease. Addi-
tionally, there is usually motor involvement. “C” is unlikely Infec ious
because GBS has a relatively rapid onset and is associated with S phi is
l m dis as
motor ndings. “D,” Brown–Sequard syndrome, is the result o M c p asma
a lesion in one side o the spinal cord. Patients have dimin- W st Ni i s
ished proprioception, vibration sense and strength on the side l p s
o the lesion, decreased sharp sensation, and loss o tempera-
Nu i ional
ture sense on the other side. Since our patient’s ndings are vitamin B12 d ci nc
symmetrical in both distribution and mani estation, it is not Thiamin ( itamin B1) d ci nc
Brown–Sequard syndrome. F ic acid d ci nc
vitamin B6 t xicit
Question 18.3.2 Which o the ollowing laboratory tests C iac dis as
would NOT be use ul in helping to determine a particular D ugs
cause o this patient’s neuropathy? M t nidaz
A) Serum immuno uorescence electrophoresis Is niazid
B) SH/ ree 4 Ph n t in
Tha id mid
C) Hemoglobin A1C
D) Electrolytes (Na, K, Cl, CO2) Me abolic
E) Vitamin B12 Diab t s
H p th idism
Answer 18.3.2 The correct answer is “D.” Electrolytes are not t oxic
likely to give us a diagnosis in this patient. T e initial evalu- M c
ation o a patient with “stocking-glove” sensory loss should Tha i m
ocus on nding potentially treatable causes o neuropathy. o th h a m ta s
Ac h
T ese would include hypothyroidism (“B”) and vitamin B12
de ciency (“E”). In addition, serum immuno uorescence elec- Miscellaneous
trophoresis (“A”) can help to identi y monoclonal gammopathy, Am id
which is associated with neuropathy. Hemoglobin A1C (“C”) is Pa an p astic s nd m s
Mit ch nd ia dis as
a marker o glycemic control in diabetes and would be associ-
Ch nic inf ammat d m inatin p n path (m t > s ns )
ated with diabetic polyneuropathy. Serum heavy metal levels M n c na amm path
may also be o use.

Question 18.3.4 Electrophysiological testing (electromyog-
raphy and nerve conduction studies or EMG/NCV) can be
help ul or all o the ollowing EXCEPT:
A) Con rming the presence o sensory de cits
B) Identi ying subclinical motor de cits
C) Identi ying a speci c etiology o the neuropathy (e.g., diabetic
vs. B12 de ciency vs syphilis)
D) Determining axonal damage versus demyelination as the
primary pathologic process
E) Dif erentiating between primarily myopathic and neuro-
pathic processes
Answer 18.3.4 The correct answer is “C.” EMG and NCV are
not capable o yielding results speci c to the etiology o neu-
ropathy (e.g., identi ying diabetic neuropathy vs. B12 vs. syphi-
lis); however, they can yield a pattern suggestive o a particular
etiology. For example, increasing motor reaction to repeated
stimulation is classic Eaton–Lambert syndrome (a paraneoplas-
tic syndrome), while a decreasing motor response with repeated
stimulation is suggestive o myasthenia gravis. EMG and NCV
can be help ul in con rming the presence o a radiculopathy in
the proper clinical setting. T ey can also determine i the pro-
cess is primarily axonal (damage directly to the axons/reduction
in the number o axons) versus demyelinating (damage to the
myelin sheath). NCV can con rm the presence o sensory de -
cits (although NCV is looking at large bers and may not identi y
small ber, pain ul neuropathies) as well as identi ying subclinical
motor involvement. EMG and NCV can be used to dif erentiate
between myopathic and neuropathic processes.
HELPFUL TIP:
I ct ph si ica t stin sh ws a p ima d m -
inatin n path , a n ic c ns t is c m-
m nd d. Th s ma sp nd t int a n s imm n -
b in (IvIg ), st ids th imm n s pp ssi
a nts, and p asma xchan , am n th s.
A er being ollowed in clinic or several years, the patient
begins to complain o a pain ul, burning sensation developing
in his eet and ankles. T is pain developed gradually over the
last ew years in the areas that previously were numb. He has a
riend who was started on gabapentin (Neurontin) or a similar
problem and is wondering i this would be a good drug or him.
Question 18.3.5 Which o the ollowing is NOT an adverse
reaction or contraindication to gabapentin?
A) Dizziness
B) Peripheral edema
C) Fatigue and drowsiness
D) Hepatic disease
E) Paresthesias
Answer 18.3.5 The correct answer is “D.” Gabapentin (Neuron-
tin) is renally—rather than hepatically—cleared. Also, it is not
metabolized by the liver. In the setting o renal dys unction, reduced
Ch Apt Er 18 • Neu r o l o g y 505
dosing is necessary. Although gabapentin is generally well-toler-
ated, numerous side ef ects have been reported. Among the most
prominent complaints are those o dizziness, vertigo, and ataxia.
Fatigue and drowsiness are also relatively common adverse ef ects;
paresthesias, myalgias, and weakness have also been reported.
Peripheral edema (particularly lower extremities) and acial edema
are also seen as a result o therapy with gabapentin. itrating slowly
to the target dose over several weeks can improve tolerance.
Your patient is concerned about swelling in his legs, as he has
had problems with this in the past and does not want to try
gabapentin at this time.
Question 18.3.6 All o the ollowing medications would be
a reasonable FIRST choice or treatment o pain ul neurop-
athy EXCEPT:
A) Amitriptyline
B) opical lidocaine ointment
C) Oxycodone
D) opical capsaicin cream
E) Valproic acid
Answer 18.3.6 The correct answer is “C.” Narcotics are not the
treatment o choice or peripheral neuropathy and tend not to
be as ef ective in this setting as in other types o pain. ricyclic
antidepressants ( CAs) are commonly used in the setting o
neuropathic pain and remain the rst-line therapy. T e evi-
dence or CAs suggests they are superior to other classes o
drugs. I pain is con ned to a small area, a topical treatment
such as capsaicin cream or topical lidocaine may be ef ective.
Lidoderm patches prescribed outside the setting o post-herpetic
neuralgia represent an of -label use.
HELPFUL TIP:
o th t atm nts n pathic pain i TCAs ai inc d
antic n sant d s s ch as abap ntin, p aba in,
a p ic acid, and ca bamaz pin . Fina , m thad n is
m cti than th piat s n pathic pain.
You wan a numbe needed o ea , you say? Fo a
50% ain educ ion e NNt s a e as follows: t CAs:
3.6, s ong o ia es: 4.3, Duloxe ine/SNr Is: 6.4, Gaba-
en in: 7.2–8.3, p egabalin: 7.7 (La ncet Neurol. 2015
Feb; 14:162). What d s this m an pati nt?
Basica m st th s d s wi n t w k m st pa-
ti nts. D n’t xp ct s cc ss . . . as w kn w m
xp i nc . o ma b a ch nic n path pain
pati nts a a happ , smi and s nn !!
Question 18.3.7 What is the most common in ectious cause
o peripheral neuropathy in the world (not just in the
United States)?
A) HIV
B) Lyme
C) Leprosy
D) Hepatitis C
E) uberculosis
506 FAMIl y MeDICINe eXAMINATIo N & Bo Ar D r evIeW
Answer 18.3.7 The correct answer is “C.” T e most common
in ectious cause o peripheral neuropathy in the world is leprosy.
Leprosy (Hansen disease) is caused by Mycobacterium leprae, an
acid- ast bacillus. It usually presents with a hypopigmented anes-
thetic patch. T e sensory de cits start with loss o temperature
sensation ollowed by loss o pain and then tactile sensations.
Modalities carried by the posterior columns (proprioception
and vibration) are spared. Sensation in the palms, soles, mid-
chest, and mid-back is preserved until late in the disease.
HIV can cause peripheral neuropathy, most commonly
being a symmetric, distal polyneuropathy. Autonomic dys unc-
tion and mild weakness accompany distal paresthesias and
burning sensations with sensory loss. Keep in mind that many
o the medications used in HIV therapy are also associated with
peripheral neuropathies.
Early neurologic mani estations o Lyme disease include
lymphocytic meningitis, cranial neuropathy (a Bell palsy-
like picture), or pain ul radiculoneuritis. Guillain–Barré syn-
drome (GBS), and mononeuritis multiplex can be seen early
in the course o Lyme disease. Advanced (late) neurologic
complications o Lyme disease include peripheral neuropathy
and encephalomyelitis.
Hepatitis B and C can cause peripheral nerve mani estations.
Hepatitis B has been associated with GBS (demyelinating) and
mononeuritis multiplex. Hepatitis C is also associated with
multiple mononeuropathies.
uberculosis has rarely been associated with neuropathy, but
isoniazid is well-known to cause peripheral neuropathy (that’s
why we prescribe pyridoxine with it).
HELPFUL TIP:
In th u nit d Stat s, diab t s and a c h s dis d s
a th m st c mm n ca s s p iph a n path .
Objectives: Did you learn to . . .
• r c niz c mm n ti i s p iph a n path ?
• Id nti app p iat s s ct ph si ica t stin ?
• Id nti t p s n path that a p t ntia t atab ?
• P sc ib m dica th ap pain p iph a n path ?
QUICK QUIZ: Wr IST Dr o P
Which o the ollowing is most likely to cause an isolated wrist
drop?
A) C-3 disk lesion
B) Ulnar nerve compression
C) Radial nerve compression
D) C-4 disk lesion
E) Median nerve compression
The correct answer is “C.” Compression o the radial nerve
(such as sleeping with someone’s head on your arm) can cause
an isolated wrist drop, the so-called “Saturday Night Palsy.” Sus-
pect alcohol or other drug abuse in patients with this lesion. It is
pretty hard to get this type o compressive lesion i you are not
passed out or very sedated. “B,” ulnar nerve compression (cubi-
tal tunnel syndrome), presents with pain and numbness in the
elbow and ourth and h ngers and weakness o the intraos-
seous muscles (weakness with spreading ngers). “E,” median
nerve compression (including carpal tunnel syndrome), leads to
numbness on the palmar sur ace o the thumb and ngers two,
three, and the radial hal o our. T ere is weakness and perhaps
atrophy o the thenar muscles (unable to maintain opposition o
thumb to h nger against resistance).
CASE 18.4
A 25-year-old woman presents to your clinic complaining o
a bi rontal headache that started this morning. She describes
the pain as throbbing and 8/10 in severity. She is complaining
o photophobia and nausea. She has had similar headaches in
the past, lasting a ew hours to all day. She is unable to work
during these headaches and pre ers a dark, quiet room (as
do we all). T e physical examination, including neurological
examination, is unremarkable.
Question 18.4.1 Which o the ollowing statements is most
accurate?
A) She likely does not have migraine headaches because her
headache is bilateral
B) She likely does not have migraine headaches because they
most commonly present in the ourth to h decade o li e
C) She likely does not have migraine headaches because they
rarely occur in the morning
D) She likely has migraine headaches
Answer 18.4.1 The correct answer is “D.” She likely has
migraine headaches. Migraine headaches may vary consid-
erably in severity, time o day, and characteristics. T e Inter-
national Headache Society (IHS) has a use ul classi cation
system with criteria or the diagnosis o migraine headaches
( able 18-4). “B” is incorrect because migraine headaches typi-
cally present in the rst three decades o li e. Attacks typically
last less than 1 day although they may occasionally last longer.
Migraine headaches are typically moderate to severe in inten-
sity, may occur at any time during the day, and occur with or
without aura. Most migraine headaches are unilateral, preceded
Ta b LE 18-4 Cr It Er IA FOr t h E DIAGNOSIS OF
MIGr AINEWIt h OUt AUr A
At ast attacks in th win c it ia:
• H adach astin 4–72 h s ( nt at d ns cc ss t at d)
• H adach has at ast tw th win cha act istics:
1. u ni at a cati n
2. P satin q a it
3. M d at s int nsit (inhibits p hibits dai acti iti s)
4. A a ati n b wa kin stai s simi a tin ph sica acti it
• D in h adach at ast n th win :
1. Na s a and/ mitin
2. Ph t ph bia and ph n ph bia
• N id nc anic dis as
 Ch Apt Er 18 • Neu r o l o g y 507

Ta b LE 18-5 Cr It Er IA FOr t h E DIAGNOSIS OF migraines. Oral NSAIDs (“A”), including aspirin and combi-
MIGr AINEWIt h AUr A nation analgesics containing caf eine, are a rst-line choice or
mild-to-moderate migraine attacks or severe attacks that have
At ast tw mi ain s (s Tab 18-4) in at ast th th been NSAID responsive in the past. “B,” the “migraine-speci c”
win cha act istics:
treatments, commonly called the “triptans” (e.g., sumatriptan,
1. o n m sib a a a s mpt ms indicatin b ain zolmitriptan, naratriptan, rizatriptan, almotriptan, eletriptan,
d s ncti n and rovatriptan—wow, talk about “me too” drugs . . . ), are
2. At ast n a a s mpt m d ps ad a 5 min t s ( ef ective and relatively sa e or the acute treatment o migraine
n ) tw m s mpt ms cc in s cc ssi n
3. N sin a a s mpt m asts m than 60 min t s
headaches. riptans are an appropriate initial treatment choice
4. H adach b ins d in a a within 60 min t s th nd in patients with moderate-to-severe migraines who have no
th a a contraindications to their use (see below). Alternative vaso-
constrictive agents, including DHE nasal spray (dihydroergot-
Hist , ph sica , and app p iat dia n stic t sts xc d a s c nda
ca s
amine, “D”), can provide a sa e and ef ective treatment o acute
migraine attacks. DHE can be administered IV as well. Vaso-
a
An a a sh d ha s mpt ms m tw n ic d mains— is a constrictive side ef ects, including the risk o coronary artery
and/ s ns and/ sp ch. Th s mpt ms ma b p siti ( . ., spasm, should speci cally be discussed with patients prior to
f ick in i hts, pins/n d s s nsati n) n ati ( . ., sc t ma, initiation o therapy.
n mbn ss).

HELPFUL TIP:
by aura, and accompanied by nausea and vomiting. T ey are
Addin a m t c p amid t aspi in NSAIDs wi
more prevalent among women, with a 1-year prevalence rate o
imp th i at s cc ss. Pa t th na s a and
approximately 18% in women, 6% in men, and 4% in children.
mitin m mi ain s (and th as n that a m d-
Family history is important as 80% o patients with migraine
icati ns t n d n t w k) is m ast ic pa sis. M t -
headache have a rst-degree relative with migraines.
c p amid c m s this p b m and t ats na s a
Migraine headaches were ormerly classi ed as classic type
as w . o a it d t t at h adach s with is
(migraine with aura) and common type (migraine without
p ch p mazin , 10 m Iv 25 m Pr . This w ks
aura). ypical auras develop over several minutes and last or
b th mi ain and t nsi n-t p h adach s. S
less than 60 minutes. Auras may involve visual, language, sen-
Tab 18-6 a ist mi ain h adach t atm nts.
sory, or motor de cits. T e visual auras are by ar the most com-
mon and may appear as photopsias ( ashes o light), scotomas
(blind spots), or complex shapes that build or move across the
visual eld. T e IHS criteria or migraine with aura are listed in Ta b LE 18-6 U.S. h EADACh E CONSOr t IUM GUIDE-
able 18–5. LINES FOr t r EAt MENt OF h EADACh E
Group 1: P n, p n nc d • Sumatriptan SC/IN
statistica and c inica b n t (at ast • DHE (IV/IM/SC/IN)
HELPFUL TIP: tw d b -b ind, p ac b -c nt d • Prochlorperazine IV
Remember that the IHS criteria are research tools. Patients st di s and c inica imp ssi n • Butorphanol IN
may have a migraine and not meet all of the criteria noted ct)
by the IHS. Whi pati nts with a c tain t p mi ain
Group 2: M d at statistica and • Prochlorperazine IM/PR
h adach wi id a m t a c it ia, it is n t n c s- c inica b n t ( n d b -b ind, • Chlorpromazine IV/IM
sa t m t a c it ia t mak a c inica dia n sis p ac b -c nt d st di s and c inica • Metoclopramide IV
mi ain h adach . imp ssi n ct) • Ketorolac IM
• Lidocaine IN
• Meperidine IM/IV
• Butorphanol IM
You have decided to treat this woman’s migraine headache. • Methadone IM

Group 3: C nf ictin inc nsist nt • Metoclopramide IM/PR

Question 18.4.2 Which medication would be LEAST appro- id nc
priate or acute management o her headache?
A) Oral ibupro en Group 4: P n t b statistica • Chlorpromazine IM
c inica in cti ( ai d cac s. • Granisetron IV
B) Intranasal sumatriptan p ac b ) • Lidocaine IV
C) IV meperidine (Demerol)
D) Intranasal DHE Group 5: C inica and statistica • Dexamethasone IV
b n ts nkn wn (ins ci nt • Hydrocortisone IV
id nc a ai ab )
Answer 18.4.2 The correct answer is “C.” T e least appropri-
ate treatment rom the above list would be Demerol (meperi- Data m u .S. H adach C ns ti m: http://www.
dine). T e long-term use o opiates or rescue therapy has am icanh adach s ci t . /p ssi na s c s/ s_ h adach _
not been ound to improve the quality o li e in patients with c ns ti m_ id in s/.
508 FAMIl y MeDICINe eXAMINATIo N & Bo Ar D r evIeW
Question 18.4.3 Which o the ollowing statements is
correct?
A) I a patient does not respond to sumatriptan, there is no
point in trying another triptan because the patient will not
respond
B) DHE and sumatriptan may be sa ely used within the same
24-hour time period
C) Sumatriptan use is contraindicated in patients with known
coronary artery disease, regardless o age
D) Flushing, sweating, and paresthesias a er a dose o sumat-
riptan is an indication o a severe reaction and continued use
o this medication is contraindicated
Answer 18.4.3 The correct answer is “C.” T e triptans should
not be used in patients with known coronary disease. Patients
who do not respond to one triptan may respond to other
triptans, and a trial o other triptans is appropriate. Also, a
patient may respond initially to a triptan but not respond on
other occasions. Each triptan has a maximum recommended
dose, and a good rule o thumb is that the initial dose may be
repeated once in a 24-hour period o time. However, avoid
the use o DHE within 24 hours a er a triptan has been
given due to increased vasoconstriction and the possibility o
vasospasm.
Question 18.4.4 Contraindications to the use o “triptans”
include all o the ollowing EXCEPT:
A) Lung cancer
B) Uncontrolled hypertension
C) Use o an MAO inhibitor within the last 2 weeks
D) Use o an ergot preparation within the last 24 hours
Answer 18.4.4 The correct answer is “A.” Lung cancer is not a
contraindication to the use o triptans. In addition to “B” to “D,”
caution should be used in patients with history o stroke, known
cardiac risk actors, and impaired liver unction.
HELPFUL TIP:
C mm n acti ns t t iptans inc d jaw ti htn ss,
shin , anxi t , dizzin ss, and sw atin . Th s a
nc m tab b t n t dan s. S i s acti ns
t t iptans inc d c na as spasm, anaph axis,
h p t nsi c isis in pati nts with kn wn CAD,
h p s nsiti it t t iptans, nc nt d h p t n-
si n. S Tab 18-6 ac t t atm nt mi ain
h adach s.
HELPFUL TIP:
C nsid d xam thas n as an adj nct th ap in s -
h adach . A sin d s d xam thas n 10 m
Po , Iv, IM a t ab ti th ap in th eD ma p -
nt h adach c nc in pati nts wh ha had a
h adach m than 24 h s (NNT 9).
Your patient has decided to take ibupro en or her headaches.
T is medication seemed to be e ective at rst, but she notes
or the last several weeks that she is taking two to three doses
o ibupro en per day without signi cant headache relie . She
has had a dull bilateral headache that is moderate in severity
or the last 2 weeks. T e medication dulls the headache but
it comes right back. She has no personal or amily history o
coronary artery disease.
Question 18.4.5 Which o the ollowing statements is
correct?
A) She likely has a tension headache and should increase her
requency o ibupro en and continue to take it on a daily
basis
B) She likely has a medication-overuse headache in addition to
chronic migraine headache (status migrainous) and should
taper and then discontinue ibupro en
C) A medication such as sumatriptan used on a daily basis does
not increase the risk o rebound headache
D) She likely does not have medication-overuse headache
because opiates are the only medications that increase the
risk o these headaches
Answer 18.4.5 The correct answer is “B.” See below or a
detailed explanation.
Question 18.4.6 Which o the ollowing medications taken
on a requent basis is LEAST likely to cause medication-
overuse or rebound headache?
A) Sumatriptan
B) Morphine
C) Ibupro en
D) Amitriptyline
E) All o the above are equally likely to cause rebound headache
Answer 18.4.6 The correct answer is “D.” Frequent use o opi-
ates, acetaminophen, NSAIDs, ergotamine, triptans, and any
other analgesics may put a patient at risk or medication-overuse
or rebound headache. Although analgesic rebound headache
characteristics can vary signi cantly, the patient typically
reports a pattern o headache that decreases modestly in sever-
ity with the use o their analgesic o choice, and then in 2 to
4 hours (depending on the medication), the headache returns to
its previous severity or worsens urther. Failure to repeat analge-
sic use results in a withdrawal headache (similar to the caf eine
withdrawal headaches physicians o en experience when they
miss their morning cof ee). In the case o triptans, the headache
may not worsen or many hours or even until the next day, but a
cycle o regular use o the medication is still established. At this
time, no clear consensus on the duration o therapy necessary
to produce analgesic rebound is reported. As a general rule, it is
best to limit the use o analgesic medications to no more than
2- to 3-headache days per week. In addition, limit the patient’s
analgesic use to no more than 2 to 3 weeks per month. Patient
education is the most important part o therapy in treating anal-
gesic rebound or medication-overuse headaches.
 Ch Apt Er 18 • Neu r o l o g y 509

HELPFUL TIP: in th t atm nt mi ain th h adach s.

T atm nt b nd h adach s c nsists disc n- Addicti n, ab s , and di si n a p t ntia iss s
tin in th m dicati n. S a app ach s ha b n with th s d s.
ti dt d c h adach s a t th ana sic has b n
withd awn. Th s inc d Iv a st ids, n -
Question 18.4.8 Which one o the ollowing medications is
actin NSAIDs (nap x n), and cti admissi n, and
rated Class B or better in pregnancy?
th ap with Iv DHe (dih d tamin ) Th azin
A) Phenergan (promethazine)
(ch p mazin ). Th s sh d b c mbin d with a
B) Imitrex (sumatriptan)
p ph actic m dicati n s ch as amit ipt in ( th
C) Codeine
t ic c ic) s d n a dai basis. Pati nts can a s tak
D) Amitriptyline
h d x zin and p ch p azin wh n th ha a
E) None o the above
b akth h h adach at h m ; th s m dicati ns d
n t ca s b nd h adach s.
Answer 18.4.8 The correct answer is “E.” Headache treatment
in pregnancy remains a di cult problem. Although numerous
Question 18.4.7 Which o the ollowing medications would medications are available or headache treatment, their sa ety in
be the LEAST appropriate or the preventative treatment o pregnancy has not been established. Amitriptyline and valproic
your patient’s migraine headaches? acid are class D in pregnancy. Other commonly used tricyclics
A) Verapamil include imipramine (Class C) and nortriptyline (Class D); ven-
B) Propranolol la axine is Class C. Promethazine, prochlorperazine, codeine,
C) Amitriptyline hydrocodone, and meperidine are all Class C. Ergotamine
D) Clonazepam (DHE 45) is Class X. T e triptan class o medications, including
sumatriptan, remains Class C, though pregnancy registries, ret-
Answer 18.4.7 The correct answer is “D.” Clonazepam is not rospective, and observational studies suggest that sumatriptan
used as a preventive treatment or migraine headaches. Keep is sa e.
in mind the common side ef ects o these medications and the
appropriateness in your speci c patient. For example, valproate Question 18.4.9 In which o the ollowing patients is neuro-
would be a bad choice or many patients secondary to weight imaging LEAST likely to be use ul?
gain or teratogenicity. Propranolol may cause hypotension. A) A 30-year-old woman with a headache typical o a migraine
Amitriptyline may cause cardiac arrhythmia in certain patients, B) A 23-year-old woman with a history o migraine headaches
while constipation and urinary retention are relatively common that is very concerned because her current headache o
in elderly patients. opiramate ( opamax) may actually cause 1-week duration is more severe than her typical migraine
weight loss, and impaired cognition is common. headaches. She has been unable to sleep or concentrate at
work because o her “headache anxiety.”
HELPFUL TIP: C) A 60-year-old man with new headache, worse in the morning
A n mb m dicati ns a s in th prevention and o 6 weeks duration
mi ain h adach s. D) A 40-year-old man with a headache and right arm weakness
• Medications that have been found to have medium-
t -hi h cac , d st n th id nc , and mi d- Answer 18.4.9 The correct answer is “A.” According to the U.S.
t -m d at sid cts inc d amit ipt in , di a - Headache Consortium, neuroimaging is not typically recom-
p x s di m, and p p an /tim , t pi amat mended in migraine patients with a normal neurologic exami-
• Medications of lower e cacy include atenolol/metop nation. Imaging may be considered in patients who are disabled
/nad , nim dipin / apami , aspi in/nap x by their ear o serious pathology or i the provider is suspicious
n/k t p n, f x tin , ACe inhibit s, abap ntin, about underlying pathology. Factors that may lead one to con-
w, ma n si m, and itamin B2 sider neuroimaging include a nonacute, atypical headache or
• Antidepressants such as uvoxamine, paroxetine, unexplained abnormal neurologic examination.
n t ipt in , s t a in , t az d n , and n a axin
ha a s b n nd t b c inica caci s bas d HELPFUL TIP:
n c ns ns s and c inica xp i nc , b t n and m- N t a ni at a h adach s a mi ain s. Think c-
iz d c nt d t ia s ha b n d n t stab ish cipita n a ia, t mp a a t itis, j ts and jabs (ic pick)
th i cac h adach , t mp a is m sc s /TMJ s nd m ,
ch nic pa x sma h mic ania, sh t- astin ni at a
n a i m h adach attacks with c nj ncti a inj c-
HELPFUL TIP: ti n and t a in (Su NCT) s nd m , and c st h ad-
C mbinati n p d cts s ch as b ta bita /ca in /ac ta ach s, am n th s. W can’t c a th s in
min ph n/c d in ( . ., Fi ina with c d in ) ha n imit d spac . W a t in ha d st, captain.
510 FAMIl y MeDICINe eXAMINATIo N & Bo Ar D r evIeW
Objectives: Did you learn to . . .
• r c niz and dia n s mi ain h adach s?
• Initiat app p iat ac t th ap mi ain h adach s?
• Id nti c nt aindicati ns and ad s acti ns th
t iptan m dicati ns?
• r c niz and t at ana sic- at d h adach s?
• Id nti app p iat p nti th ap ch nic
h adach s?
CASE 18.5
A 30-year-old woman presents to your of ce with a 2-day
history o progressive, unilateral arm (proximal and dis-
tal) numbness without weakness. She has been diagnosed
with bromyalgia in the past. She is taking uoxetine or
depression and has a history o previous hospitalizations or
depression.
Question 18.5.1 Which o the ollowing is the most appro-
priate next step?
A) Monitor her symptoms and reassure that her numbness is
likely related to her bromyalgia
B) Order nerve conduction velocity (NCV) studies
C) Order a head C
D) Get additional history; ask about previous similar episodes
or other neurological concerns
E) Order a chest radiograph (CXR) and complete blood cell
count (CBC)
Answer 18.5.1 The correct answer is “D.” O course, the
answer is “more history.” With a progressive neurological de -
cit, the rst step in the workup is to urther explore the history.
Frequently, patients will not mention previous neurological
symptoms because they— the symptoms, not the patients—are
vague (although, to be air, some patients are vague).
When you ask about previous spells, she notes that she had
an episode o le leg numbness that lasted about 1-week sev-
eral years ago, but she thought nothing o it, as it was mild.
Six months ago, she had a 3-day visual disturbance in her
right eye, during which she ound it dif cult to read and
ocus on objects; no blind spot was noticed. However, she had
pain in the eye, especially when moving it.
Question 18.5.2 What is the most likely diagnosis based on
the history given?
A) Multiple sclerosis (MS)
B) Fibromyalgia
C) Conversion disorder
D) Atypical migraine
E) ransient ischemic attacks
Answer 18.5.2 The correct answer is “A.” MS would be the
most likely diagnosis based on the history related above. MS
most commonly presents in women 20 to 35 years old and in
men 35 to 45 years old. It is almost ve times more prevalent
among women than among men and is more common in the
Caucasian population. MS is a CNS demyelinating disease that
is thought to occur by an immune mediated process. T e demy-
elinating lesions o MS can occur anywhere in the CNS includ-
ing the brain stem and spinal cord. T e presenting symptoms o
MS vary, but common symptoms are visual complaints, weak-
ness, and sensory de cits. Although migraine can be associated
with neurologic symptoms, one would expect more stereotypic
events and a history o previous headaches. Fibromyalgia is
associated with numerous somatic complaints, but is not typi-
cally associated with sensory de cits or visual problems. Con-
version disorder can produce all o the symptoms described
earlier but is a diagnosis o exclusion. IAs would be unusual in
a patient o this age, though not impossible by any means, and
would typically present with stroke-like symptoms (dysarthria,
vertigo, hemiparesis, etc.).
HELPFUL TIP:
MS has a aphic p di cti n. Th incid nc
MS inc as s with inc asin distanc m th q a-
t (A askans a sc w d). va i s th i s ha s -
st d an ass ciati n with s n i ht xp s , itamin
D, i s xp s , thnicit .
Question 18.5.3 I your patient indeed does have MS, which
type is most likely?
A) Devic disease
B) Relapsing–remitting
C) Primary progressive
D) All o the above are equally likely
Answer 18.5.3 The correct answer is “B.” T e two common
orms o MS are primary progressive and relapsing–remitting.
T e diagnosis o relapsing–remitting MS is based on clini-
cal grounds and laboratory data. Clinically, symptoms o CNS
dys unction develop over hours to days, stabilize, and then
improve. It is important to identi y clinical events disseminated
in space and time. In this case, your patient had a prior his-
tory o optic neuritis and lower extremity numbness and now
has arm numbness. “A,” Devic disease (neuromyelitis optica),
is a CNS demyelinating illness that is characterized by bilateral
optic neuritis (simultaneous or occurring at dif erent times) and
spinal cord demyelination.
Question 18.5.4 Which o the ollowing tests would NOT be
help ul in urther diagnosing MS?
A) MRI brain
B) Lumbar puncture
C) Nerve conduction studies
D) Visual evoked potentials
E) MRI spine
Answer 18.5.4 The correct answer is “C.” MS is a central
demyelinating process and does not produce abnormalities
that would be seen on nerve conduction studies. “A” and “E,”
MRI o the brain and/or spine, would be help ul. Brain MRI is
85% to 97% sensitive in detecting MS plaques. Multiple areas
 Ch Apt Er 18 • Neu r o l o g y 511

o increased signal in the periventricular area are suggestive o ,
but not speci c or, MS. Gadolinium-enhancing lesions suggest
active disease. “B,” lumbar puncture, can also be use ul. Cere-
brospinal uid (CSF) abnormalities suggestive o MS include
oligoclonal bands and increased synthesis o IgG. A spinal uid
examination may be considered i the clinical diagnosis o MS is
suspected but is not de nite. However, the positive and negative
predictive value o CSF oligoclonal bands is inadequate to do
more than support the clinical diagnosis. Recent evidence or
serum antibody testing to other myelin components has yielded
promising initial results as a supportive diagnostic tool. Finally,
“D,” visual evoked potentials, may be help ul. Evoked potential
may be used to aid in the diagnosis o MS by indicating prior
demyelination o the optic tract (optic neuritis) i the clinical
history is vague (e.g., eye pain without vision loss or no recol-
lection o symptoms). T is will aid in proving the occurrence o
dif erent events separated by space and time.
Answer 18.5.6 The correct answer is “C.” T e inter eron agents
(Avonex, Rebi , and Betaseron) and amantadine are associated
with worsening o depression. Given this patient’s history o
severe depression requiring hospitalization, one would avor
Copaxone as an initial therapy, although treatment with inter-
eron is not absolutely contraindicated.
T e patient is wondering what she can do to prevent exacer-
bations.
Question 18.5.7 Which o the ollowing is associated with
exacerbation o MS symptoms?
A) Cold temperatures (you could recommend she move to
Florida)
B) Urinary tract in ection
C) In uenza vaccination
D) rauma

Question 18.5.5 Which o the ollowing is not a recognized
therapy or MS?
A) Corticosteroids
B) Inter eron-β
C) Glatiramer acetate
D) Sul asalazine
E) Amantadine
Answer 18.5.5 The correct answer is “D.” Sul asalazine is
not use ul in the treatment o MS. Immune-modulating ther-
apy reduces the number o exacerbations and active lesions
on MRI. T ese include inter eron-β -1a (Avonex and Rebi )
and inter eron-β -1b (Betaseron), as well as glatiramer acetate
(Copaxone). T ese medications are more e cacious i started
early in the course o the disease. Common adverse ef ects o
inter eron include atigue, depression, and myalgias. Amanta-
dine is given commonly as monotherapy and in combination
with immunomodulatory therapy to treat atigue associated
with MS. Corticosteroids have a role in treating severe acute
exacerbations (e.g., optic neuritis, severe neurological impair-
ments limiting activities o daily living) in the orm o a short
burst and taper (typically methylprednisolone, 1 g/day o en ol-
lowed by an oral prednisone taper). Steroid use does not appear
to of er long-term unctional bene t, excluding the possible
exception o IV pulsed steroid dosing. Currently, oral immu-
nosuppressive therapies (mycophenolate mo etil, azathioprine,
and cyclosporin) are being considered in treating re ractory
MS, but their long-term e cacy and sa ety are not known. Simi-
larly, the value o IVIG and plasma exchange has not been con-
clusively demonstrated and use o these treatment modalities is
reserved or re ractory patients.
Answer 18.5.7 The correct answer is “B.” Urinary tract in ec-
tions can exacerbate MS. Un ortunately, urinary tract in ections
are particularly common in those with MS because o the re-
quent occurrence o neurogenic bladder. Systemic in ection has
also been reported to provoke MS exacerbations. “A” is o spe-
cial note. Cold is not associated with exacerbations, but heat is
notorious, and this phenomenon actually has a name—Uhthof
phenomenon. Patients with MS should be instructed to avoid
hot tubs, saunas, steam rooms, etc. “C,” vaccinations, including
in uenza vaccine, had been posited as a cause o exacerbations.
However, a review o multiple clinical trials showed no increased
risk o exacerbations in patients with MS receiving the in u-
enza, hepatitis B, or tetanus vaccinations. Note that we do not
have experience with nasal in uenza vaccine and MS. Since
the nasal vaccine contains live virus, it should probably be
avoided in patients with MS. “D,” trauma, has been suggested
as a possible exacerbation trigger, but the American Academy o
Neurology clinical practice guidelines state that the majority o
class II evidence available on this issue supports no connection.
HELPFUL TIP:
A w d n th d s MS . . . Amp a (da amp idin )
is s pp s d t inc as wa kin distanc . Z n ia (d xt -
m th phan + q inidin ) is d si n d t d c ps -
d b ba s mpt ms ( m ti na abi it with sp ntan s
a hin , c in ). B th a ma ina b n it. Th a
man m th api s apsin - mittin MS ( . .,
dim th ma at , mit xant n , nata iz mab t i n -
mid , and m ), m st which q i n ic sp -
cia t ca and ca hi h isk ad s nts.

Question 18.5.6 Which o the ollowing treatments would Objectives: Did you learn to . . .
you most likely choose or this patient, given her history o • Id nti pid mi ic cha act istics MS?
depression? • Id nti app p iat w k p pati nts with p ssib MS?
A) Avonex (inter eron-β -1a) • Dia n s MS?
B) Amantadine • Disc ss p t ntia t atm nt pti ns a ai ab n -t m
C) Copaxone (glatiramer acetate) dis as m di cati n as w as ac t xac bati ns?
D) Betaseron (inter eron-β -1b) • r c niz act s that mi ht s t in xac bati ns MS?
512 FAMIl y MeDICINe eXAMINATIo N & Bo Ar D r evIeW
CASE 18.6
A 43-year-old woman with a history o myasthenia gravis
presents to the ED while on vacation. She reports she is eel-
ing tired and rundown and endorses u-like symptoms in
addition to some worsening o her proximal lower extrem-
ity weakness. On examination, she is a ebrile with a respi-
ratory rate o 18. She has mild diplopia with lateral gaze.
Her strength is 4/5 proximally and 4+ /5 distally bilaterally.
Her sensory examination is normal. Plantar responses are
down-going bilaterally.
Question 18.6.1 In determining this patient’s urther dispo-
sition, what is the most important test?
A) Arterial blood gas
B) CXR
C) Head C
D) Spirometry ( orced vital capacity [FVC] and negative inspi-
ratory orce [NIF])
E) CBC
Answer 18.6.1 The correct answer is “D.” T is patient is
experiencing an exacerbation o myasthenia gravis. T is
could be occurring or any number o reasons including con-
current illness or possibly noncompliance with her regimen.
T e greatest morbidity and mortality or this patient lies in
the potential or respiratory ailure and arrest. In primary
neuromuscular respiratory ailure (e.g., myasthenia gravis,
acute in ammatory demyelinating polyradiculoneuropa-
thy, GBS), the arterial blood gas may remain normal despite
impending respiratory collapse. T e best way to evaluate
respiratory status is with the FVC and NIF. I the FVC is less
than 15 mL/kg or NIF less than − 20 cm H 2O, elective intu-
bation is recommended, although some centers will choose
to monitor these patients closely in an intensive care setting.
Once a myasthenic patient has been intubated, you should
stop their pyridostigmine as it will increase respiratory secre-
tions and GI motility leading to diarrhea. Neither o these is
desirable in an intubated ICU patient (the nurses will love you
or this one) and the pyridostigmine will not liberate them
rom the ventilator. Monitoring the FVC/NIF should be done
regularly throughout the hospital course until the patient is
clinically improved and stable.
You decide to give this patient a dose o edrophonium try-
ing to reverse her symptoms. When you do this, she becomes
increasingly weak, requiring intubation.
Question 18.6.2 The BEST explanation o this is:
A) Since she has missed multiple doses o her pyridostigmine,
she has become desensitized and will have an overwhelming
response to small doses o IV edrophonium
B) In uenza has made her particularly susceptible to edropho-
nium
C) T e patient has taken too much pyridostigmine by accident
D) T e alcohol that she has had on vacation has changed her
pyridostigmine requirement
Answer 18.6.2 The correct answer is “C.” Myasthenic crisis
can be due to two causes. First, the patient may have not taken
enough medication or may have missed doses. In this case,
edrophonium will improve symptoms. T e second cause is too
much pyridostigmine. T is will also cause weakness. In this
case, the edrophonium will worsen the patient’s symptoms.
Here’s how it works. Pyridostigmine and edrophonium are both
cholinesterase inhibitors similar to organophosphates. T ey act
by binding to acetylcholinesterase and preventing the break-
down o acetylcholine. oo much o either drug (or a combina-
tion o the drugs) will cause weakness and an organophosphate
toxicity-like syndrome (salivation, lacrimation, de ecation, uri-
nation, weakness, etc.).
Question 18.6.3 Which o the ollowing IS NOT likely to
contribute to the diagnosis o myasthenia gravis?
A) ensilon (edrophonium) test
B) Nerve conduction studies
C) Antithymocyte antibodies
D) Antiacetylcholine receptor antibodies
Answer 18.6.3 The correct answer is “C.” Antithymocyte anti-
bodies are used to treat renal rejection and have also been used
in aplastic anemia, red cell aplasia, and other disorders. T ey
have no relationship at all to myasthenia gravis . . . sorry. All o
the others can be used in the diagnosis o myasthenia gravis.
T e edrophonium test is a unctional test. One must be ready
to intubate the patient when per orming an edrophonium test,
as weakness may get worse. Nerve conduction studies show a
reduction in the amplitude o the response to repeated stimu-
lation (thus, patients get weaker with repeated muscle use).
Antiacetylcholine receptor antibodies are ound in the majority
(80–90%) o patients with myasthenia gravis. In act, when an
ultrasensitive test is done, it is ound in 70% o “antibody nega-
tive” cases o myasthenia gravis.
HELPFUL TIP:
M asth nia a is can b s st mic imit d t th c -
a m sc s. It is t n ass ciat d with a th m ma (
th m s h p p asia), and pati nts with m asth nia a-
is sh d ha a ch st CT scan t t th m ma
th m s h p p asia. I p s nt, m a th th m ma
wi t n “c ” th pati nt’s dis as .
Question 18.6.4 Which o the ollowing is LEAST likely to be
con used with myasthenia gravis on the basis o its neuro-
logic symptoms?
A) Eaton–Lambert syndrome
B) Guillain–Barré syndrome (GBS)
C) Amyotrophic lateral sclerosis
D) Botulism toxicity
E) Penicillamine-induced myasthenia gravis
Answer 18.6.4 The correct answer is “B.” Remember that
myasthenia gravis has no sensory ndings. GBS includes sensory
ndings o pain, paresthesias, numbness, etc. that are generally

absent in the other syndromes. “A,” Eaton–Lambert syndrome,
is a paraneoplastic process, which consists o weakness that gets
better with repetitive movement. T is is the exact opposite o
what is seen with myasthenia gravis where repetitive tasks lead
to increased weakness. T us, Eaton–Lambert syndrome is o en
worse in the morning and better toward the a ernoon—the
reverse o what is seen with myasthenia gravis. Patients with
amyotrophic lateral sclerosis, botulism, and penicillamine-
induced myasthenia gravis do not have sensory symptoms.
T us, these can be con used with myasthenia gravis.
HELPFUL TIP:
Al S s ts in pp and w m t n n d ath. With
pp m t n n dis as , x s main intact and
a in act xa at d a in th dis as . As Al S p -
ss s and m n ns a in d, x sa st.
T e patient and her husband have some questions about
myasthenia gravis and are wondering i there are any medi-
cations that might exacerbate this patient’s weakness.
Question 18.6.5 Which o the ollowing can worsen myas-
thenia gravis?
A) Fluoroquinolones
B) Verapamil
C) β -blockers
D) Oral contraceptives
E) All o the above
Answer 18.6.5 The correct answer is “E.” All o the above can
worsen myasthenia gravis. Other drugs o note include amino-
glycosides, anesthetic and paralytic agents, diuretics, tetracy-
clines, and magnesium, among many others.
You decide to add to the treatment o this patient.
Question 18.6.6 Which o the ollowing is considered a
standard therapy or myasthenia gravis?
A) Plasmaphoresis or an acute myasthenic crisis
B) IVIG
C) Prednisone
D) Azathioprine
E) All o the above are used or myasthenia gravis
Answer 18.6.6 The correct answer is “E.” Do you see a pat-
tern here? All o the treatments are immunomodulators. Most
people will start with prednisone and azathioprine. Other
options are cyclosporin and mycophenolate. T e idea here is to
reduce antiendplate antibodies (although nobody is quite sure
how IVIG works). Prednisone is generally considered rst-line
therapy or an exacerbation. It may be that immunomodulators
will become rst line (many neurologists are already using them
as rst line and using pyridostigmine only as a bridge until the
immunomodulator kicks in). Plasma exchange can be used to
treat an acute exacerbation. Remember thymectomy as this may
be a cure i a thymoma is present.
Ch Apt Er 18 • Neu r o l o g y 513
Objectives: Did you learn to . . .
• Mana a pati nt with an xac bati n m asth nia a is?
• u nd stand th s dia n stic t sts in m asth nia a is?
• r c niz dia n s s that can b c n s d with m asth nia
a is?
CASE 18.7
A 29-year-old woman presents to the ED with sudden onset
o a severe headache involving bilateral occipital pain asso-
ciated with nausea. T e headache has not responded to her
sumatriptan (Imitrex) injection. She has a history o migraine
headaches consisting o right-sided throbbing pain that typi-
cally respond to sumatriptan but occasionally require IV
ketorolac and metoclopramide. She appears to be in moder-
ate pain but otherwise has a normal general and neurological
examination. T is is the worst headache o her li e.
Question 18.7.1 What is the next step in the management
o this patient?
A) Ketorolac ( oradol) and metoclopramide IV
B) Hot tea and so pillow
C) Dihydroergotamine (DHE) IV
D) Head C
E) Lumbar puncture
Answer 18.7.1 The correct answer is “D.” Although this patient
has a history o migraines, she is reporting a sudden onset head-
ache that is markedly changed rom her typical pattern o head-
ache. In this setting—especially with the “worst headache o her
li e”—the diagnosis o subarachnoid hemorrhage (SAH) must
be ruled out. None o the other answers are correct. While pain
management can be given be ore C (e.g., IV morphine or en-
tanyl), ketorolac, aspirin, and DHE are inappropriate i there is a
question o SAH. Ketorolac and aspirin have antiplatelet ef ects,
which can increase bleeding. DHE can cause vasospasm and
worsen brain ischemia. Finally, i you recall, this patient tried
her sumatriptan. One should not use DHE within 24 hours o a
triptan. Note that in a patient with a non ocal examination who
is immunologically intact LP may be done be ore C .
T e patient’s head C is negative.
Question 18.7.2 What next?
A) Lumbar puncture
B) IV hydroxyzine and meperidine and discharge when she is
com ortable
C) IV hydroxyzine and promethazine (Phenergan) and dis-
charge when she is com ortable
D) Discharge home with prescription or acetaminophen and
oxycodone (Percocet)
E) Discharge home with prescription or rizatriptan (Maxalt)
Answer 18.7.2 The correct answer is “A.” In the setting o a
“worst headache o li e” a C scan to rule out SAH is required.
T e sensitivity o C scan o the brain or hemorrhage in the set-
ting o SAH is 90–95% within 24 hours o the event (decreases
to 80% at 72 hours). C only picks up 50% o warning leaks. As
514 FAMIl y MeDICINe eXAMINATIo N & Bo Ar D r evIeW
a result, a negative head C does not adequately rule out SAH
and should be ollowed with a lumbar puncture. T e CSF rom
the lumbar puncture must be spun down immediately to examine
or xanthochromia; delay in examining the CSF may result in
alse-positive results. Xanthochromia is a yellow discoloration
o the normally clear CSF resulting rom degradation o hemo-
globin. In addition to xanthochromia, markedly elevated RBC
counts are indicative o SAH. I either the C or LP is positive
or SAH, an emergent our-vessel cerebral angiogram (or MR
angiogram or C angiogram) is indicated.
HELPFUL TIP:
Thi t -nin p c nt pati nts with an SAH ha n
n ic si ns s mpt ms. o n 10% pati nts
with SAH ha an initia ca xaminati n. Pati nts
with SAH ma ha a and k c t sis. Whi
kin at th pati nt’s ndi is imp tant, th abs nc
papi d ma d s n t t SAH. SAH can p s nt
as back pain. Sinc ach b d ca i s a 50% m ta it ,
this is n dia n sis d n t want t miss. u s l P
ib a in app p iat pati nts.
HELPFUL TIP:
y ma h a ab t a c p st di s that ha
sh wn that a CT scan d n within 6 h s h ad-
ach ns t is s nsiti n ht t SAH with t
th n d an l P. This has d init n t tb c m
th standa d ca .
You complete the LP, and it is normal. Apparently, this was
just the worst migraine o her li e. A er loading her up on
some good drugs, her pain subsides. Problem solved!
Objective: Did you learn to . . .
• Id nti a pati nt p s ntin with SAH s mpt ms and p -
m an app p iat w k p?
CASE 18.8
A 40-year-old man presents with a complaint o low-back pain
that is dull in nature, which started 2 days ago. T is morn-
ing he woke up with a eeling o numbness and tingling in his
eet, which gradually seemed to worsen. By noon, he noted
dif culty walking and decided to come to the ED. He denies
bowel or bladder incontinence. On examination, he is in no
acute distress and has a respiratory rate o 12. He has strength
o 5/5 in his upper extremities, and in his lower extremities,
strength is 4/5 proximally and 3/5 distally. Sensory examina-
tion reveals a mild decrease in pinprick and light touch in a
stocking distribution to the mid-cal . Re exes in the upper
extremities are 2+ /4 and in the lower extremities are trace
at the knees and absent at the Achilles. Plantar response is
down-going bilaterally.
Question 18.8.1 What is the most likely diagnosis?
A) Diabetic polyneuropathy
B) Guillain–Barré syndrome (GBS)
C) Diabetic amyotrophy
D) Stroke
E) Conversion reaction
Answer 18.8.1 The correct answer is “B.” O the choices given
above, the most likely diagnosis is acute in ammatory demy-
elinating polyradiculoneuropathy (GBS). With an acute onset
o bilateral lower extremity weakness and sensory de cits, the
diagnosis o an acute cord-compressing lesion (e.g., tumor and
epidural abscess) should also be considered and ruled out, espe-
cially when back pain is also present. T e time course described
above is not consistent with diabetic polyneuropathy nor would
one expect to see weakness as a prominent symptom. Diabetic
amyotrophy is characterized by pain ul proximal muscle weak-
ness with minor sensory loss. T e onset o diabetic amyotrophy
can be subacute or acute. T e time course described above o
gradually progressing de cits is not consistent with stroke. Addi-
tionally, the ndings o a stroke should not be bilateral.
Question 18.8.2 Which o the ollowing is/are associated
with GBS?
A) Campylobacter jejuni in ection
B) Lyme disease
C) Epstein–Barr virus
D) CMV virus
E) All o the above
Answer 18.8.2 The correct answer is “E.” All o these in ectious
agents are associated with GBS, especially Campylobacter Other
associations include viral URIs, HIV, immunizations (rare),
mycoplasma, epidural anesthesia, sarcoid, lupus, etc. Add to this
the Zika virus and the West Nile virus. T e point here is that one
should look or an underlying illness in patients with GBS.
HELPFUL (a ND INTERESTING) TIP:
Antib di s t Campylobacter ha b n sh wn t c ss-
act with n tiss , th s th ass ciati n Campy-
lobacter with g BS.
Question 18.8.3 Which o the ollowing actions would NOT
be appropriate or additional diagnosis and/or manage-
ment o this patient with progressive weakness?
A) Cardiac monitoring
B) Forced vital capacity (FVC)
C) Discharge to home on steroids with a ollow-up in the
morning
D) EMG/NCV
Answer 18.8.3 The correct answer is “C.” T is patient should
not be sent home. Did you even consider it? Discharge is a
particularly bad idea because his disease has worsened rapidly
over the last 12 hours. As with other potential causes o neuro-
muscular respiratory ailure, an FVC and NIF are necessary to

determine adequate respiratory reserve. T e FVC and NIF
should be monitored closely during the acute illness. GBS can
have a rapid and catastrophic worsening that necessitates moni-
toring during the acute phase o illness. ypically, patients reach
the peak o severity about 2 weeks into the illness. Autonomic
dys unction is associated with GBS, and close cardiovascular
monitoring is important. EMG/NCV can be o value in diag-
nosing GBS—although early on in the course o the disease,
these tests may be normal.
A diagnosis o GBS is made.
Question 18.8.4 Which o the ollowing is NOT an appropri-
ate treatment modality?
A) IVIG
B) Plasma exchange
C) Elective intubation i FVC is < 15 cc/kg
D) Corticosteroids
Answer 18.8.4 The correct answer is “D.” Corticosteroids are
not used in the treatment o GBS. Multiple studies have shown
no bene t to corticosteroids in this disease. reatment options
or GBS include care ul monitoring o disease and supportive
therapy with no intervention. Some experts recommend initiat-
ing IVIG or plasma exchange. I a patient requires ventilatory
support or has weakness that precludes ambulation, treatment
should be started immediately. Elective intubation is appropri-
ate i the FVC is less than 15 cc/kg or the NIF is –20 cm H 2O. As
discussed in regard to neuromuscular respiratory ailure with
myasthenia gravis, arterial blood gases are not reliable markers
o impending ailure, and the FVC must be closely monitored.
T e amily would like to know what the outcome in this
patient with GBS will be, so you pull out your crystal ball.
Question 18.8.5 Well, instead o sarcasm, you actually opt
or compassion and tell them that FULL RECOVERY can be
expected in __________ percent o patients.
A) 15%
B) 50%
C) 80%
D) Greater than 95%
Answer 18.8.5 The correct answer is “A.” Fi een percent o all
patients with GBS will have complete resolution o their symp-
toms. Sixty- ve percent will be le with minor de cits, and
about 10% will become disabled. Despite excellent care, some
patients still die.
HELPFUL TIP:
W st Ni i s in cti n can p s nt as ith a g BS
(s mm t ica n ica s mpt ms with ss x-
s) a p i m itis- ik s nd m ( n a as m-
m t ica w akn ss with w s w akn ss p xima ,
ss x s, ascic ati ns).
Ch Apt Er 18 • Neu r o l o g y 515
Objectives: Did you learn to . . .
• r c niz th c inica p s ntati n g BS?
• Id nti nd in i n ss s that a ass ciat d with g BS?
• Mana a pati nt with g BS?
CASE 18.9
A 38-year-old woman is brought to the ED by her husband
who expresses concerns over changes in her mental status
over the past 2 days. She has become con used, orgetting
the names o persons well-known to her, and orgetting
what she is doing. Her conversations have become increas-
ingly more dif cult to ollow, and over the past 12 hours,
she has gradually become sleepier. On examination, she has
a temperature o 38.0°C. She is drowsy but can be aroused.
She has no meningismus. She is oriented only to person. She
responds to questions slowly and incorrectly and ollows only
simple commands (“stick out your tongue”). T e remainder
o her neurological examination is essentially normal, given
her limited ability to cooperate. CBC, coagulation studies,
and electrolytes (including calcium, magnesium, and phos-
phorous) are normal.
Question 18.9.1 What is the best next step in evaluating
this patient?
A) Lumbar puncture
B) Head C
C) Electroencephalogram (EEG)
D) Chest x-ray (CXR)
Answer 18.9.1 The correct answer is “B.” Although per-
orming all o the above tests will be help ul in evaluating this
patient, the most important test to do at this time is a head C
to rule out any mass lesion or hemorrhage. You could argue
that “A,” an LP, could be done rst, and some experts would
agree with that decision. However, the standard in the United
States is to do the C scan rst i there is any possibility o a
mass lesion. T ere is a possibility that nonconvulsive status epi-
lepticus is causing these mental status changes. However, even
i the EEG showed nonconvulsive status epilepticus, a head C
and lumbar puncture would remain necessary. Although pneu-
monia could cause con usion, a CXR is unlikely to be o high
yield in this setting.
Her head C is normal. You per orm a lumbar puncture,
which reveals 18 WBCs (all lymphocytes), 12 RBCs, CSF
protein 67 mg/dL (elevated), and CSF glucose 70 mg/dL
(normal). An EEG is normal.
Question 18.9.2 What is the next step in managing this
patient?
A) Admit or viral encephalitis with close monitoring
B) Admit or viral encephalitis and start acyclovir and
antibiotics
C) Admit or bacterial meningitis and start antibiotics
D) Discharge to home with close ollow-up tomorrow at 8 am
516 FAMIl y MeDICINe eXAMINATIo N & Bo Ar D r evIeW
Answer 18.9.2 The correct answer is “B.” T e probable diag-
nosis in this setting is herpes simplex encephalitis. Her CSF
results are consistent with a viral process and are not consis-
tent with bacterial meningitis (due to the normal glucose and
only lymphocytes in the dif erential). Given the mortality o
herpes simplex encephalitis (30–70%), all patients in whom the
diagnosis is suspected should be started on acyclovir 10 mg/kg
every 8 hours IV empirically (with appropriate dosage adjust-
ments or renal ailure), while urther con rmatory testing is
pending (CSF PCR or the herpes simplex virus). reatment
should be or a minimum o 10 days and has been advocated
(with little evidence to support it) to be as long as 21 days. It
is important to recognize that the EEG and C may be normal
in herpes simplex encephalitis, particularly early in the dis-
ease. However, on C , one may see evidence o temporal lobe
hemorrhage and/or hypodensity in the temporal lobes. EEG
can show either periodic lateralized epilepti orm discharges or
ocal slowing in the temporal lobes. emporal lobe changes may
be even more prominently visualized on MRI, and this may
be o bene t in cases in which the diagnosis remains unclear.
Even with prompt, appropriate treatment, only 38% o patients
returned to normal or near-normal neurologic unctioning at
2 years. “B” includes antibiotics because most clinicians would
cover or bacterial meningitis until the CSF cultures come back
negative.
Objectives: Did you learn to . . .
• r c niz th c inica p s ntati n and th ab at
ndin s in i a nc pha itis?
• Initiat app p iat t atm nt in a pati nt with a p s mp-
ti dia n sis h p s nc pha itis?
CASE 18.10
A 70-year-old male presents to your of ce as a new patient.
He is with his wi e, who assists in providing the history. His
appetite is reduced, and he has lost 10 lb in the past 6 months.
His only medication is aspirin, and he has no signi cant past
medical history.
On examination, his vital signs are normal, and he is in
no acute distress. His gait is slow, and he takes eight steps to
turn. He has retropulsion (takes two steps backward when
you pull him rom behind). T ere is a resting tremor in both
hands but more prominently in the right. You nd cogwheel
rigidity in both arms as well, but again more prominently dis-
played on the right. His cognitive screening tests are normal.
Question 18.10.1 The most likely diagnosis is:
A) Essential tremor
B) Parkinson disease
C) Normal pressure hydrocephalus (NPH)
D) Progressive supranuclear palsy
E) Stroke
Answer 18.10.1 The correct answer is “B.” T is patient most
likely has Parkinson disease. “A” is incorrect because essential
tremor is typically worsened by activity and is not associated
with the other neurologic ndings seen in this patient. “C” is
incorrect. T e classic triad o NPH includes urinary inconti-
nence, gait ataxia, and dementia. “D” might be a consideration,
but there is no speci c nding o progressive supranuclear palsy
here (e.g., aggressive course, more severe axial rigidity, dysar-
thria, dysphagia, and downward gaze paresis). Stroke is quite
unlikely to present in this insidious ashion with generalized
ndings.
Question 18.10.2 Which o the ollowing is NOT a common
eature o idiopathic Parkinson disease?
A) Rigidity
B) Extraocular movement paresis
C) Bradykinesia
D) Loss o postural re exes or gait disturbance
E) Asymmetric tremor
Answer 18.10.2 The correct answer is “B.” T ere are our
cardinal eatures o Parkinson disease: tremor, bradykinesia,
rigidity, and postural instability. wo or more o these eatures
should be present to make the diagnosis. T e tremor o Parkin-
sonism is a resting tremor (as opposed to the postural, inten-
tion, or action tremor) and is most common in the hands, typi-
cally with one side af ected more than another. Rigidity (“A”) is
described as increased resistance to passive movement and may
be rein orced by having the patient open and close the st on
the opposite hand. Cogwheel rigidity is a ratchet-like sensation
noted when testing a limb with concurrent tremor. Bradykine-
sia (“C”) may be observed by monitoring the speed and ampli-
tude o movements. Gait disturbance (“D”) with reduced stride
length and stooped posture is a common nding but generally
occurs later in the course o the disease. Postural re exes and
ability to rise rom a chair are also impaired. Postural re exes
may be tested by retropulsion.
You are airly certain that your patient has Parkinson disease.
Question 18.10.3 What else might you nd with idiopathic
Parkinson disease?
A) Micrographia
B) Urinary incontinence
C) Apraxia
D) Autonomic dys unctions
E) Alien limb phenomenon
Answer 18.10.3 The correct answer is “A.” Micrographia,
writing in small letters, is associated with Parkinson disease.
T e others are not. T is is important because there are a num-
ber o neurologic syndromes that can mimic Parkinson dis-
ease, and knowing the additional eatures o Parkinson disease
will help you to dif erentiate it rom other diseases. Decreased
acial expression (hypomimia) with decreased rate o eye blink
and diminished vocal volume (hypophonia) are also com-
mon with Parkinson disease. Other conditions that occur in
patients with Parkinson disease include depression, cognitive
impairment, and REM sleep behavioral disorder (e.g., kicking
and screaming during REM sleep in response to vivid, disturbing
dreams).
 Ch Apt Er 18 • Neu r o l o g y 517

A) ACE inhibitors
HELPFUL TIP:
B) HMG-CoA reductase inhibitors
Th a “Pa kins n p s” s nd m s, s -ca d
C) Calcium channel blockers
b ca s th p s nt with pa kins nian at s with
D) Metoclopramide
an th cha act istic. l k th s s nd m s in
E) All o the above
th s that b i ma ha Pa kins n dis as :
(1) P ssi s p an c a pa s , which is ass ciat d
Answer 18.10.5 The correct answer is “D.” Metoclopramide
with s p an c a az pa s , d sa th ia, d spha ia,
is a requent cause o the misdiagnosis o Parkinson disease
p st a instabi it , and axia i idit .
in the elderly. Additional medications, such as SSRIs, antipsy-
(2) Sh –D a s nd m , which is n tab a t -
chotics, and others, can mimic Parkinson disease. Importantly,
n mic d s ncti n, inc din ma k d th static
drug-induced parkinsonism may last or up to 6 months a er
h p t nsi n.
discontinuation o the o ending agent.
(3) C tic basa an i nic d n ati n, which is ass -
ciat d with ap axia, c tica s ns d s ncti n, and
You think it is best to initiate treatment in this patient.
th “alien limb enomenon” (ICD-10 c d r 41.4 i
a int st d). A i n imb ph n m n n cc s
Question 18.10.6 Possible treatments o Parkinson disease
wh n th pati nt’s a m m s b its ( . ., wi ach
include all o the ollowing EXCEPT:
p t t ch th pati nt’s ac ). Th pati nts d n t b -
A) Levodopa
i that th imb b n s t th m. Sp ntan s imb
B) Pallidotomy
m m nts a s cc wh n th pati nt is sta t d
C) Pramipexole
th imb is t ch d (an n s D . St an ?).
D) Donepezil
E) Selegiline
Question 18.10.4 The diagnosis o Parkinson disease is
Answer 18.10.6 The correct answer is “D.” Donepezil is used
most appropriately made:
to treat Alzheimer disease. T e initial symptoms o Parkinson
A) With a brain MRI
disease typically respond well to levodopa and the dopamine
B) By CSF analysis
agonists. Selegiline is a monamine oxidase B inhibitor and
C) Clinically
yields modest symptomatic bene ts. Dopamine receptor ago-
D) By a neurologist
nists, such as pramipexole (Mirapex), ropinirole (Requip), and
E) At autopsy
bromocriptine, are important medications that may be used in
the initial treatment o Parkinson disease.
Answer 18.10.4 The correct answer is “C.” T e diagnosis is
based on a history and physical examination that are consistent
with Parkinson disease. Additionally, a response to dopami- HELPFUL TIP:
nergic agents is virtually diagnostic o Parkinson disease. I the S ica pti ns ad anc d Pa kins n dis as inc d
patient does not have some response to a dopaminergic agent, pa id t m and d p b ain stim ati n. In n a,
reconsider your diagnosis. “A” is incorrect because there are no stim ati n th tha am s is s d t t at t m b t
ndings on neuroimaging that are speci c or the diagnosis o has itt impact n th th s mpt ms Pa kins n
Parkinson disease. Likewise, “B” is wrong because CSF analy- dis as (b ad kin sia, tc.). S btha amic n c s stim-
sis cannot provide the diagnosis. “D” is clearly wrong—do you ati n is m b n icia am i atin th th
really need a neurologist or this? T e “gold standard” or diag- at s Pa kins n dis as , b t ma ha a ss p -
nosis is neuropathologic examination, but you would rather not nd impact n t m .
wait or the autopsy to diagnose Parkinson disease.
Question 18.10.7 Which o the ollowing is NOT a common
HELPFUL TIP:
side ef ect o levodopa?
u p t 10% pati nts with Pa kins n dis as wi ha
A) Nausea
s m d int nti n t m in additi n t th i
B) Paresthesias
stin t m .
C) Dyskinesia/dystonia
D) Hallucinations

Answer 18.10.7 The correct answer is “B.” Paresthesias are not

Your patient takes only aspirin, which you know does not
cause parkinsonism.
Question 18.10.5 Which o the ollowing medications is re-
quently associated with a Parkinson-like syndrome in the
elderly?
associated with the use o carbidopa/levodopa. T e use o carbi-
dopa with levodopa allows the dose o levodopa to be optimized.
Carbidopa helps to prevent levodopa-induced nausea (“A”). Dys-
tonia and dyskinesia (“C”) are common with therapy lasting more
than 2 years or at peak dose responses and may necessitate lowering
the doses. Psychiatric problems (“D”), including hallucinations and
518 FAMIl y MeDICINe eXAMINATIo N & Bo Ar D r evIeW
psychosis, can be seen with dopaminergic agonists and levodopa.
Other common side ef ects o levodopa include hypotension, con-
usion, and other psychiatric disturbances.
HELPFUL TIP:
l d pa is a d pamin p c s , and ca bid pa is a
p iph a d pad ca b x as inhibit that d s n t
c ss th b d–b ain ba i . Th s mpt ms t m ,
i idit , and b ad kin sia a initia i d b - C) Con usional state
d pa. H w , with tim , a d s sa q i d
t maintain c nt s mpt ms.
HELPFUL TIP:
on th d pamin a nists (p amip x , pini , withdrawal is also associated with an acute con usional state
and b m c iptin ) can b s d t h p minimiz th
d s d pa n d d, th s minimiz th sid cts
d pa.
You decide to start levodopa/carbidopa (Sinemet) and bro-
mocriptine. At the ollow-up visit, the patient is doing rela-
tively well on this combination. However, he notices that
in the mornings and evenings, he tends to be sti and has
dif culty ambulating.
Question 18.10.8 The most appropriate next step is to:
A) Initiate a “drug holiday” to restore the patient’s sensitivity to
the drug
B) Add another dopaminergic agent such as ropinirole (Requip)
C) Add a catechol-O-methyl-trans erase (COM ) inhibitor
such as entacapone (Comtan)
D) Add an anticholinergic agent such as benztropine (Cogentin)
Answer 18.10.8 The correct answer is “C.” T e patient is expe-
riencing the “wearing-of ” phenomenon. T ere are several ways
to address this. One option is to add a COM inhibitor (like
tolcapone [ asmar] or entacapone [Comtan]) in order to slow
down the metabolism o levodopa. COM inhibitors have no
ef ect on their own and should only be used with levodopa.
Another option is to switch the patient rom immediate-
release carbidopa/levodopa to a sustained-release product (e.g.,
Sinemet CR). T e ef ectiveness o this strategy is not conclu-
sively proven, and there is no bene t rom using controlled-
release carbidopa/levodopa as the initial agent in Parkinson
disease. Another common approach to the “wearing-of ” phe-
nomenon is altering the dosing o carbidopa/levodopa—either
increasing the dose or shortening the interval between doses.
HELPFUL TIP:
T cap n (Tasma ) is ass ciat d with ata h patic n -
c sis and q i s m nit in i ncti n t sts
(l FTs). Th s, ntacap n (C mtan) is th p dd . sion is commonly seen in Parkinson disease and is reported to
A cap n is ass ciat d with tax asi n and “hits.” This
Cap n sh d b a id d as w ( t it? A Cap n ??).
When you counsel your patient regarding medication use,
you urge him not to stop taking his medication all at once.
Question 18.10.9 Which o the ollowing is NOT a potential
adverse ef ect o abrupt discontinuation o dopaminergic
agonists and/or levodopa?
A) Neuroleptic malignant syndrome (NMS)
B) Severe rigidity
D) Severe dyskinesias
Answer 18.10.9 The correct answer is “D.” Levodopa and
dopamine agonists should be tapered. Abrupt discontinuation
o these medications may precipitate NMS. In addition, abrupt
separate rom the mental status changes seen in NMS. Severe
worsening o the patient’s parkinsonism is expected, which can
result in prominent rigidity. Dyskinesias are requently seen
with dopaminergic agonist/levodopa therapy, but are not exac-
erbated or triggered by withdrawal o these agents.
HELPFUL TIP:
Dia n stic c it ia d init NMS inc d h p th -
mia, m sc i idit , and i th win : m nta
stat s chan s, t m , tach ca dia, inc ntin nc , abi
b d p ss , m tab ic acid sis, tach pn a/h p xia,
ati n c atin kinas , diaph sis/sia h a,
and k c t sis. T atm nt inc d s s pp ti ca
as w as th s b m c iptin and p p an ,a -
th h th is imit d data t s pp t th s ith
a nt. Dan olene is ineffec ive.
A year later your patient returns and seems to be doing well.
You ask him about symptoms o Parkinson disease, i he is
having any adverse e ects o medications, and i he is experi-
encing any o the Parkinson-associated diseases.
Question 18.10.10 Which o the ollowing is NOT associated
with Parkinson disease?
A) Depression
B) Dementia
C) REM sleep disorder
D) Narcolepsy
E) Decreased visual contrast sensitivity
Answer 18.10.10 The correct answer is “D.” Narcolepsy has
not been associated with Parkinson disease. However, excess
daytime sleepiness has been associated. T is is likely due to a
combination o actors, such as sleep disturbance, depression,
dopaminergic drugs, and Parkinson disease itsel . Depres-
occur in up to 41% o patients. Dementia, typically with Lewy
bodies present on pathological analysis, is seen and can af ect
the decision to proceed with surgical treatment o Parkinson

disease, as patients with advanced dementia get less bene t
rom surgery. Also, REM sleep behavior disorders are seen in
Parkinson disease and can be a source o stress or amilies and
caretakers. REM sleep behavior disorder is characterized by
acting out o dreams that can consist o vocalizations as well
as active and even violent movements. ypically, REM sleep
behavior disorder responds to clonazepam. Finally, decreased
visual contrast sensitivity can occur with Parkinson disease
as well.
HELPFUL TIP:
Th d pamin a nists (p amip x , pini , tc.)
ha b n ass ciat d with c mp si b ha i (s x a
c mp si n, c mp si amb in , tc.). This ma x-
p ain wh d pati nts ik t t l as v as
and At antic Cit . . . .
Objectives: Did you learn to . . .
• Id nti c mm n at s Pa kins n dis as ?
• Dia n s Pa kins n dis as ?
• Mana a pati nt with Pa kins n dis as ?
• u nd stand pha mac th ap a ai ab Pa kins n
dis as and s m th p t ntia ad s cts d
th ap ?
CASE 18.11
A 45-year-old le -handed woman who is a busy executive
or a Fortune 500 company presents with excessive daytime
sleepiness. She is otherwise healthy and takes no medications.
Question 18.11.1 How do you approach this problem?
A) Reassure her that it is normal or people to be drowsy under
stress ul work conditions
B) Begin zolpidem at night or sleep
C) Schedule the patient or polysomnography
D) Discuss the patient’s sleep hygiene
E) Administer moda nil (Provigil) prior to important board
meetings
Answer 18.11.1 The correct answer is “D.” It is essential
that all patients with complaints o either insomnia or exces-
sive daytime sleepiness have a thorough sleep history taken.
Polysomnography may be necessary, but this test—like all
diagnostic tests—should be driven by a hypothesis. A history
is necessary to develop a hypothesis and determine a test’s
utility. Starting hypnotic agents (“B”) or stimulants (“E”)—or
both—without thoroughly investigating the underlying prob-
lem may cover up a signi cant, treatable problem and is con-
sidered bad orm.
Question 18.11.2 Which o the ollowing is NOT an impor-
tant aspect o a sleep history?
A) Sleeping and waking times
B) Use o stimulants and alcohol
C) Sleep interruptions (children, pagers, etc.)
Ch Apt Er 18 • Neu r o l o g y 519
D) Work schedule
E) Listening to “so rock” (“easy listening” or “adult contem-
porary”)
Answer 18.11.2 The correct answer is “E.” Okay, maybe this
one was too easy, but we hate “easy listening” music. T e Geneva
Convention prohibits its use on prisoners o war . . . we’ve been
told. All ranting aside, this tidbit o her history has no bearing
on her sleep. Important parts o the sleep history include the
sleeping environment (alone, with spouse or other individual,
in the daylight hours, etc.), nap history, amily history o sleep
problems, and symptoms o speci c sleep disorders (snoring,
hypnagogic hallucinations, etc.). A medication history is impor-
tant as well as a history o watching V in bed, eating in bed,
etc., which indicate poor sleep hygiene. As the sleep experts say,
your bed should be used or only two purposes: sleep and sex
(not necessarily in that order).
HELPFUL TIP:
on th a it pa as mnias th dit s is “ x-
p din h ad s nd m ” (this is act a a, n t a
j k ). Pati nts ha th in p ppin xp -
si ns cc in in th i h ad as th a as p.
Question 18.11.3 Which o the ollowing is NOT part o a
typical sleep study?
A) Monitoring o EEG
B) Monitoring respirations and oxygen desaturations
C) Evaluating the sleep latency in response to sleep aids, such
as zolpidem and trazodone, to maximize ef ective pharma-
cologic therapy
D) Monitoring EMG
E) Video monitoring o sleep
Answer 18.11.3 The correct answer is “C.” Sleep studies are
generally done in the naıve state without the use o medications.
All o the rest are true. “D” and “E” deserve more attention. “D,”
monitoring EMG, allows in orming the physician about muscle
activity during sleep (e.g., restless limbs). “E,” video monitoring
and taping, allows the physician to look or problems, such as
awakening, evidence o restless leg syndrome, and sleep apnea.
Question 18.11.4 In considering a diagnosis o narcolepsy,
which o the ollowing is NOT part o the diagnosis?
A) Cataplexy
B) Sleep paralysis
C) Hypnagogic hallucinations
D) Sleep myoclonus
E) Excessive daytime sleepiness
Answer 18.11.4 The correct answer is “D.” Sleep myoclonus
(hypnagogic jerks) is commonly seen in normal people as they
begin to all asleep (witness colleagues at grand rounds with sud-
den tossing o the head) and is not a part o narcolepsy. Narco-
lepsy is a disorder characterized by our cardinal traits, although
520 FAMIl y MeDICINe eXAMINATIo N & Bo Ar D r evIeW
not all need be present to make the diagnosis: cataplexy, exces-
sive daytime sleepiness, sleep paralysis, and hypnagogic halluci-
nations. “A,” cataplexy, is a sudden loss o voluntary muscle con-
trol during which the patient may appear to be asleep; however,
cataplexy does not have to be accompanied by sleep attacks,
and the patient may be aware throughout the attack. “B,” sleep
paralysis, can occur either at the onset o sleep or upon awaken-
ing and can be quite rightening to the patient. “C,” hypnagogic
hallucinations, are vivid and typically ear ul dreams that occur
at the onset o sleep but can also occur upon awakening (hyp-
nopompic hallucinations). “E,” excessive daytime sleepiness, is
a hallmark o narcolepsy and can include sleep attacks as well
as persistent drowsiness and “micro sleep” (brie intrusions o
sleep during a waking state). T e complete tetrad o symptoms
is seen in only 10% o patients with narcolepsy.
Question 18.11.5 Which o the ollowing is NOT a treatment
or narcolepsy?
A) Amitriptyline
B) Clonazepam
C) Fluoxetine
D) Moda nil (Provigil)
E) Sodium oxybate
Answer 18.11.5 The correct answer is “B.” Clonazepam is not
a treatment or narcolepsy. T e treatment o narcolepsy has two
primary goals. T e rst goal is to address daytime sleepiness,
which is primarily done with stimulants such as moda nil or
methylphenidate. T e second goal is to reduce the symptoms o
cataplexy. T is can be accomplished with agents such as tricy-
clic antidepressants, and to a lesser extent, SSRIs. Sodium oxy-
bate (also known as gamma hydroxybutyrate) can be used or
treatment o cataplexy as well as sleep hallucinations and sleep
paralysis. Some evidence suggests it may also help with exces-
sive daytime sleepiness. Given its street popularity and abuse
potential (including date rape), it should not be prescribed to
those with a history o drug abuse, etc.
A er a thorough history, you nd nothing to suggest narco-
lepsy besides daytime sleepiness. O course, you are consider-
ing other diagnoses simultaneously—unless you are experi-
encing a sleep attack yoursel .
Question 18.11.6 Which o the ollowing would NOT sug-
gest a possible diagnosis o obstructive sleep apnea?
A) Di culty alling asleep
B) Frequent nighttime arousals
C) Obesity
D) Paroxysmal nocturnal dyspnea
E) Snoring
Answer 18.11.6 The correct answer is “A.” Di culty alling
asleep is not one o the components o obstructive sleep apnea.
Snoring, obesity, excessive daytime sleepiness, and paroxys-
mal nocturnal dyspnea are all associated with obstructive sleep
apnea. Some patients will note requent arousals rom sleep
with or without accompanied shortness o breath.
HELPFUL TIP:
It is imp tant t n t that n t a pati nts with s p
apn a a w i ht, and this dia n sis m st b c n-
sid d in a pati nts with xc ssi da tim s pin ss
th s sti s mpt ms. Sma pha n a
ai wa ( sp cia in in w m n) and ast s pha-
a x a ass ciat d with s p apn a.
Question 18.11.7 What treatment options would NOT be
appropriate to consider in your patient i she has obstruc-
tive sleep apnea?
A) Bilevel positive airway pressure (BiPAP)
B) Continuous positive airway pressure (CPAP)
C) Positional therapy
D) Uvulopalatopharyngoplasty (UPPP)
E) Zolpidem
Answer 18.11.7 The correct answer is “E.” Sleep aids, including
benzodiazepines, do not have a role in the treatment o obstructive
sleep apnea and may actually worsen symptoms. CPAP and BiPAP
are both potential treatments. Polysomnography (sleep testing)
with titration o CPAP or BiPAP should determine which modal-
ity to use and the pressure settings. T ese should not be arbitrarily
set to the “normal settings” or a patient. Positional therapy, avoid-
ing sleeping on one’s back, may be ef ective in some patients. Some
techniques or achieving this goal include sewing an object on the
back o the pajama shirt that will irritate the patient when they
roll onto it (i.e., tennis balls in a sock). Weight loss, although not
mentioned above, can provide improvement in symptoms as well.
Surgical therapies including UPPP can also be considered based
on the patient’s symptoms and pre erences.
HELPFUL TIP:
J st as C ki M nst has a n d that c ki s a a
“s m tim s d,” h pn tic m dicati ns sh d n -
a b c nsid d a “s m tim s m dicin .” Pati nts d -
pt anc t a c mm n s d h pn tics with th
p ssib xc pti n m at nin. Additi na , s m h p-
n tics ca s amn sia and th s ( ik th xin inhibi-
t c ass [ . ., s xant (B s m a)]) ca s p n d
da tim s mn nc th n xt da . S xant can a s
ca s xt mit w akn ss and s m p p ca t
c mp x b ha i s (s ch as d i in ) whi nawa . H p-
n tics n add ab t 15 t 30 min t s t a pati nt’s t ta
s p tim . F man pati nts, th isk–b n it ati d s
n t a h pn tics. Sta t with s p h i n .
Further history leads you to suspect that she has restless legs
syndrome, and you con rm the diagnosis with a sleep study.
Question 18.11.8 Which would be a f rst-line agent or treat-
ment o restless legs syndrome?
A) Clonazepam
B) Codeine

C) Methadone
D) Pramipexole
E) ramadol
Answer 18.11.8 The correct answer is “D.” Restless legs syn-
drome is characterized by an urge to move the lower extremi-
ties due most o ten to an uncom ortable sensation. his sen-
sation usually occurs during rest and is typically relieved
by moving the legs. Dopaminergic agents, either levodopa
(e.g., Sinemet) or agonists, such as ropinirole (Requip) and
pramipexole (Mirapex), are the irst-line treatments or rest-
less legs syndrome. A variety o other medications are used
or restless leg syndrome but do not carry an FDA indication
or it. Benzodiazepines (“A”) and narcotic medications (“B”
and “C”) as well as tramadol and gabapentin have all been
reported to be success ul alternative therapies or restless leg
syndrome.
Question 18.11.9 What other workup would you suggest
or this patient once the diagnosis o restless legs syn-
drome is made?
A) No urther workup is indicated, initiate treatment as
above
B) Serum calcium
C) Serum iron studies, including erritin
D) Serum vitamin B12
E) Serum vitamin B6
Answer 18.11.9 The correct answer is “C.” Studies have
shown a link between low iron stores and restless legs syn-
drome. All patients with restless legs syndrome should have
an iron pro le per ormed, and low iron or erritin levels merit
iron supplementation (and workup or underlying cause, o
course). Other associations are diabetes, pregnancy, end-
stage renal disease, Parkinson disease, venous insu ciency,
olate de ciency, and caf eine intake (dump that ourth cup
o cof ee . . . )
Objectives: Did you learn to . . .
• Tak an app p iat s p hist ?
• g n at a di ntia dia n sis da tim s pin ss?
• g ain ami ia it with th dia n stic t stin s d in a s p
ab at ?
• Id nti th p s ntati ns and t atm nts c mm n
s p dis d s, inc din na c ps , bst cti s p
apn a, and st ss s s nd m ?
CASE 18.12
A 60-year-old right-handed gentleman presents with the
complaint o head pain.
Question 18.12.1 Which o the ollowing historical descrip-
tions is o the LEAST VALUE in identi ying a speci c diag-
nostic classi cation or head/ ace pain?
A) Right-sided, electric, stabbing pain involving primarily the
cheek, occurring or seconds to minutes repeatedly through-
out the day
Ch Apt Er 18 • Neu r o l o g y 521
B) Right-sided, electric, stabbing pain involving primarily the
throat, tongue, and right ear
C) Right-sided severe headache involving the orbit and associ-
ated with lacrimation and rhinorrhea typically occurring at
the same time each day or a given period o time.
D) “Sinus pressure” with a history o sinus headaches respon-
sive to antibiotics in the past
E) Pattern o severe right-sided “stabbing and boring” head-
aches around the age o 30 that went away with scheduled
indomethacin
Answer 18.12.1 The correct answer is “D.” Sinus headaches
are typically a diagnosis o exclusion. Acute sinusitis can
cause severe head and ace discom ort, but sinusitis remains
a relatively uncommon etiology or recurrent head and
ace pain. T e speci c headache syndromes described in “A,”
“B,” “C,” and “E” are described in more detail in the ollowing
questions.
Question 18.12.2 Let’s say this patient gives you the history
o right-sided severe headache involving the orbit associ-
ated with lacrimation and rhinorrhea typically occuring at
the same time each day or a couple o weeks.. Which o the
ollowing would you use or initial acute treatment o this
headache syndrome?
A) Naproxen
B) Oxygen
C) ylenol
D) Verapamil
Answer 18.12.2 The correct answer is “B.” T e type o head-
ache syndrome described is most consistent with cluster head-
aches. T ese are most commonly seen in men and are char-
acterized by exquisite pain, typically centered at the orbit.
Conjunctival injection, rhinorrhea, and lacrimation requently
accompany the headache. Pain is o en disabling. As the name
suggests, the patient tends to have headaches in groups (or clus-
ters). T ese headaches are more common at night, and REM
sleep is thought to be a triggering actor. For acute treatment,
conventional headache medications such as DHE and the trip-
tans can be ef ective. reatment with high- ow oxygen has
also shown signi cant e cacy as an abortive treatment: typi-
cal protocol would be 8 L oxygen on nonrebreather or 15 min-
utes, with reports o 70% o patients achieving headache relie .
Verapamil can be ef ective or prophylaxis but is not ef ective as
an abortive. Other, more typical migraine prophylactic agents
(propranolol, topiramate, indomethacin, valproic acid) have
been tried, but no systematic studies have been done to evaluate
their e cacy in cluster headaches.
Question 18.12.3 Let’s say your patient describes a history
o severe right-sided “stabbing and boring” headaches
around the age o 30 that went away with scheduled indo-
methacin. This description would be most consistent with
which o the ollowing headache syndromes?
A) ension headache
B) Paroxysmal hemicrania
522 FAMIl y MeDICINe eXAMINATIo N & Bo Ar D r evIeW

C) Migraine without aura

HELPFUL TIP:
D) Chronic daily headache
A ni at a ct ic, stabbin pain cc in in th
E) Analgesic rebound headache
t n , pha nx, and ccasi na xt ndin t th
ipsi at a a has b n d sc ib d; this is kn wn as glos-
Answer 18.12.3 The correct answer is “B.” Paroxysmal hemi-
so a yngeal neu algia. T atm nt ss pha n-
crania is classically described as a unilateral headache with a
a n a ia is simi a t th pha mac ic t atm nt
stabbing/boring character. Although age o onset can vary
t i mina n a ia d sc ib d ab . I th pati nt
greatly, it classically occurs in women in their 30s (although it
c mp ains stabbin t mp a h adach s ast-
can be seen in men as well). Patients will have between 2 and
in s c nds, c nsid th dia n sis “j ts and jabs”
40 episodes during a given day, although they do not cluster
h adach s (aka “ic pick” h adach ). Th cc 40 t
together as is typical in cluster headaches. Although autonomic
50 tim s a da m and a ik a mi ain a iant.
symptoms (rhinorrhea, lacrimation, conjunctival injection, and
ptosis) can be seen in a majority o patients, these headaches
can be dif erentiated rom clusters by the pattern o recurrence Objectives: Did you learn to . . .
(sporadic throughout the day versus a predictable time o day • D sc ib th at s a i s h adach s nd m s?
or a certain period o time); signi cant overlap between the two • Initiat t atm nt c st h adach s, pa x sma
headache syndromes does exist and dif erentiation can be di - h mic ania, and t i mina n a ia?
cult. Paroxysmal hemicrania is typically exquisitely sensitive
to indomethacin, and response to indomethacin is highly corre-
lated with this diagnosis. Migraine headaches (“C”) typically do
CASE 18.13
not occur multiple times in one day and are usually described A 55-year-old male with a history o diabetes and prostate
as a throbbing pain. Chronic daily headaches (“D”) as well as carcinoma presents to your of ce complaining o back pain,
analgesic rebound headaches (“E”) are generally continuous in groin numbness, and an inability to initiate voiding. T is has
nature with limited, i any, periods o time without some degree been worsening over the past 1 week.
o headache. Chronic daily headache in the setting o prolonged
analgesic use is highly suggestive o analgesic rebound head- Question 18.13.1 The most likely explanation or these
ache. T e duration o analgesic therapy necessary to trigger and symptoms is:
propagate these headaches remains uncertain. However, it can A) Cauda equina syndrome
be as little as three times per week. B) Urinary outlet obstruction secondary to prostate carcinoma
C) Hydroureter and hydronephrosis secondary to urolithiasis
With urther history, your patient describes right-sided, D) Neurogenic bladder rom long-standing diabetes
electric, stabbing pain involving primarily the cheek and E) All o the above are equally likely
occurring or seconds to minutes repeatedly throughout
the day. Answer 18.13.1 The correct answer is “A.” T is is a presen-
tation o cauda equina syndrome. Cauda equina syndrome is
Question 18.12.4 What would be the rst-line choice or caused by compression o the cauda equina at the level o L4 or
therapy o this entity? L5 by a protruding disk, tumor, etc. Symptoms include progres-
A) Carbamazepine sive ecal or urinary incontinence (secondary to inability to ini-
B) Amitriptyline tiate voiding), impotence, distal motor weakness, and sensory
C) Ibupro en loss in a saddle distribution. T is patient’s symptoms are not
D) Morphine likely to be due to urinary outlet obstruction (“B”). Urinary out-
E) Microvascular decompression (Janetta procedure) let obstruction should not be associated with sensory changes
in a saddle distribution. T e same is true o “C.” “D,” neurogenic
Answer 18.12.4 The correct answer is “A.” T is description bladder rom diabetes, could be a possibility. However, this
is typical o trigeminal neuralgia. Carbamazepine has been should not include back pain or perineal numbness.
shown to be ef ective in treating trigeminal neuralgia and was
used or treatment o this disorder prior to being used or sei- Question 18.13.2 On examination o this patient, you would
zures. ricyclic antidepressants, opioids, and nonsteroidal anti- expect to nd:
in ammatory agents are not rst-line agents or treatment. A) Increased rectal tone
ypically, NSAIDs are o limited, i any, bene t in this setting. B) Decreased rectal tone
Other agents that have been used or treatment with at least C) Normal rectal tone
anecdotal reports o bene t include gabapentin, oxcarbazepine, D) No rectum
clonazepam, baclo en, phenytoin, and topiramate. Microvascu-
lar decompression (the Janetta procedure) can be ef ective in Answer 18.13.2 The correct answer is “B.” Patients with cauda
alleviating pain rom trigeminal neuralgia. However, medical equina syndrome should have decreased rectal tone. I you chose
therapy remains the rst-line treatment. “D” . . . well, there are a lot o things we could say but won’t.
 Ch Apt Er 18 • Neu r o l o g y 523

Question 18.13.3 The initial treatment o this patient second such episode in 18 months. On arrival, the patient is
with cauda equina syndrome should include which o the ebrile, lethargic, and looks postictal.
ollowing?
A) Pain management with narcotics Question 18.14.1 Your next step is to:
B) Dexamethasone administered IV A) Reassure the parents that this is a simple ebrile seizure
C) Placement o a Foley catheter B) Obtain blood cultures and start ce riaxone
D) Urgent neurosurgical consultation C) Per orm an LP i the CBC shows leukocytosis and elevated
E) All o the above bands
D) Administer acetaminophen and wait or 2 hours to see i the
Answer 18.13.3 The correct answer is “E.” Pain management patient returns to baseline be ore deciding on urther treat-
is critical in any patient. Dexamethasone may reduce tumor- ment
related edema leading to a reduction in cord compression— E) Arrange or an outpatient EEG
although high-dose steroids are no more ef ective than usual
doses. A Foley catheter is indicated to treat the patient’s urinary Answer 18.14.1 The correct answer is “B.” T is patient must
retention. Since this is a neurosurgical emergency, urgent neu- be assumed to have meningitis until proven otherwise. reat-
rosurgical or orthopedic consultation should be obtained. Local ment should be started immediately. “A” is incorrect. T is is
radiation may also be used acutely depending on your surgeon, not a simple ebrile seizure by history. T e child is postictal and
oncologist, etc. looks ill. While it may end up being a simple ebrile seizure,
you cannot make that conclusion at this point. I the child did
not look lethargic and was up and running around, no urther
HELPFUL TIP: evaluation or treatment would be needed at this time. “C” is
Th dia n sis ca da q ina s nd m is t n d - incorrect. First, the CBC may be relatively normal even with
a d m nths sinc man pati nts initia ha meningitis. Second, you do not want to delay antibiotics until
inc mp t s nd m s, inc din n pain and mi d the CBC and LP are done. “D” is incorrect or the same reason.
n ic s mpt ms. This is n t nat sinc t- T e standard o care in meningitis is antibiotics within 30 min-
c m d p nds n th d n ic d s ncti n utes o hitting the door. Waiting to see the patient’s response to
at th tim dia n sis. acetaminophen or 2 hours will clearly put you out o this time
window.

Objectives: Did you learn to . . .
• r c niz th c inica p s ntati n ca da q ina s n-
d m ?
• Id nti ca s s ca da q ina s nd m ?
• Initiat t atm nt a pati nt with ca da q ina s nd m ?
You do the right thing and treat the patient with ce riax-
one. T e patient does look better in an hour or so and has
returned to baseline. She is alert, attentive, and playing with
toys. T e parents are concerned about whether or not this
patient has a seizure disorder. T ey would like a urther
evaluation.

QUICK QUIZ: SeIZu r e DISo r Der S
Absence seizures are characterized by all o the ollowing
EXCEP :
A) Loss o consciousness
B) Feeling o déjà vu
C) Rhythmic lip smacking or eye blinking
D) Staring spells
E) Occurrence up to hundreds o times per day
The correct answer is “B.” Feelings o déjà vu and other “psy-
chic” phenomenon such as hallucinations are associated with
temporal lobe (aka simple partial) seizures.
CASE 18.14
A 2-year-old emale presents to the ED a er having a sei-
zure. T e parents note that the patient was ne this morn-
ing, spiked a temperature to 39.9°C, and then had a 5-minute
tonic–clonic seizure that resolved spontaneously. T is is her
Question 18.14.2 Which o the ollowing is indicated at this
point, assuming you decide to evaluate the patient or a
seizure disorder?
A) EEG done on the same day
B) Admission to the hospital and EEG the next day
C) Serum electrolytes and glucose
D) rial o antiepileptic drug
E) None o the above
Answer 18.14.2 The correct answer is “C.” T e workup o
a seizure includes serum electrolytes, calcium, magnesium
phosphate, glucose, etc. Note that this need not be done or
someone with a known seizure disorder who has his or her
typical seizure and returns to baseline. In these cases, only
a drug level o their antiepileptic drug need be done unless
there is some change in the seizure type, mental status, etc. “A”
and “B” are incorrect. T e EEG will be positive because o the
recent seizure and may not re ect the underlying condition.
T us, waiting a couple o weeks a er the seizure will give a
better picture o what the brain’s innate electrical activity looks
524 FAMIl y MeDICINe eXAMINATIo N & Bo Ar D r evIeW

like. “D” is incorrect because we have not yet proven this child
HELPFUL TIP:
has a seizure disorder. Prescribing antiepileptic drugs would
Ab t 50% pati nts wh ha th i i st b i s i-
be premature.
z nd a 15 m nths wi ha a c nt b i
s iz . This d ps t 30% i th i st s iz is a t
HELPFUL TIP: 15 m nths a . Fami hist is a s in d; 45%
A “stat” eeg can b h p i a n ts i a pati nt th s wh ha a i st-d ati with b i
is ha in ( had) an acti s iz s s a n n pi p- s iz s wi ha a s c nd s iz .
tic sp ( m ca d a “ps d s iz ” n w ca d a
“ps ch nic n n pi ptic s iz ”). A “stat” eeg ma
a s b h p in a pati nt with m nta stat s chan s Objective: Did you learn to . . .
wh b i ma b ha in n nc n si stat s • Dia n s and mana b i s iz s in chi d n?
pi ptic s.

Clinical Pearls
T e parents are wondering what to do about treating this B s t w th inc si n and xc si n c it ia
patient to prevent urther ebrile seizures. administ in tPA ac t st k . I in d bt, ca
n a st st k -acc dit d h spita c mm ndati ns.
Question 18.14.3 Your recommendation to prevent urther D n ta ssi t at at d b d p ss s in an
seizures is: ac t isch mic st k as it d c as s c b a p si n and
A) Acetaminophen at the onset o ever p ts isch mic b ain at isk th inj .
B) Ibupro en at the onset o ever D n tp mn ima in in an indi id a with a hist
C) Phenytoin until the child reaches the age o 5 c nsist nt with t pica mi ain h adach s simp s nc p
D) Buccal midazolam at the onset o any ever with a n ma n ica xaminati n and n id nc
E) None o the above h ad t a ma.
D n t sc n as mpt matic pati nts ca tid a t
Answer 18.14.3 The correct answer is “E.” None o these dis as .
choices are optimal in the management o this patient. “A” and enq i ab t s p apn a si ns and s mpt ms in a
“B” seem like a good idea but do nothing to reduce the occur- ad ts p s ntin with da tim s mn nc and d
rence o ebrile seizures. Neither “C” nor “D” is ef ective. One a p s mn am a ati n i th is s spici n
study suggests that rectal diazepam at the onset o a ever will s p apn a.
reduce the occurrence o ebrile seizures. However, it is asso- P m a mba p nct t t s ba achn id h m -
ciated with some morbidity (e.g., sleepiness) and should be ha n in th c nt xt a n ati h ad CT as a h ad CT
reserved or those with requent ebrile seizures. n d t cts ab t 50% wa nin aks.
r tin na c tics a n t c mm nd d t atm nt
HELPFUL TIP: n pathic pain mi ain h adach s.
Ph n ba bita can p nt b i s iz s b t is ass ci- r tin c mm nd ds ph i n as i st- in th ap
at d with b ha i and a nin p b ms and is n - ins mnia and ati .
a n t c mm nd d. Sta t antibi tics a i ha a hi h s spici n bact ia
m nin itis. This inc d s b th mba p nct i
s spici n is hi h n h.
T e parents have another child at home who has had one us t iptans in pati nts with c na a t dis as is
ebrile seizure. He is now 12 months old. T e parents want to c nt aindicat d d t inc as d isk c na as spasm.
know what his likelihood o having a seizure disorder.

Question 18.14.4 You can let them know that he has approx-
imately:
A) 1% to 5% chance o developing a seizure disorder
B) 10% to 15% chance o developing a seizure disorder
C) 40% to 50% chance o developing a seizure disorder
D) 80% to 90% chance o developing a seizure disorder
Answer 18.14.4 The correct answer is “A.” Patients who have
a single ebrile seizure have approximately 1% to 5% chance o
developing a seizure disorder. T is is essentially the same risk as
the general population.
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Fenstermacher N, et al. Pharmacological prevention o
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Ophthalmology
Brian R. Kirsc in
GLOSSARY OF TERMS
Accommodation: Change in the shape o the lens to compensate
or changes in ocal length. T e term is also used more generally
to mean the adjustment o the eye in general to compensate or
ocusing on objects at di erent distances.
Amblyopia: Poor, uncorrectable monocular (and rarely binoc-
ular) vision that is cortical in nature and not attributable to a
structural abnormality o the eye or visual pathway. T is may
be a result o strabismus, high uncorrected re ractive error, or
visual deprivation during the critical period o cortical visual
development during childhood.
Esotropia: Deviation o the eyes inward when compared with
normal alignment.
Exotropia: Deviation o the eyes outward when compared with
normal alignment.
Relative a erent pupillary de ect (RAPD): T e “swinging ash-
light test” in a darkened room is used to test or a RAPD.
T e pupillary response should be equal in both eyes. A
RAPD is detected when there is a relative di erence in the
pupillary response to a direct and consensual light stimulus
between the two eyes. An eye with a RAPD will (abnormally)
dilate with direct light to the eye but constrict normally in
response to light shined in the ellow eye. A RAPD is seen
when there is optic nerve damage or signi cant retinal dis-
ease (e.g., large retinal detachment, retinal artery occlusion,
optic neuritis). One will not get a RAPD in re ractive errors,
vitreous bleeds, etc.
Strabismus: A general term that re ers to a misalignment o the
eyes. Esotropia, exotropia, and hypertropia (one eye deviated
upward) are all examples o strabismus. T e term strabismus
says nothing about etiology, which can be congenital, neuro-
logic, or muscular.
526
19
CASE 19.1
A mother presents with her healthy, 2-month-old male in ant.
She reports that or the past week his eyes have been notice-
ably crossed. He appears to xate with either the right or le
eye. She eels that aside rom being cross-eyed, he seems to
see well. On examination, his eyes are very crossed. When
either eye is covered, he xes and ollows with the ellow eye
and appears to have normal motility.
Question 19.1.1 The most likely diagnosis in this patient is:
A) Pseudoesotropia
B) Congenital esotropia
C) Accommodative esotropia
D) Sixth nerve palsy
Answer 19.1.1 The correct answer is “B.” Esotropia is more
common than exotropia. Congenital esotropia is generally ound
in children younger than 6 months. “C,” accommodative esotro-
pia, is the most common cause o esotropia in childhood and
develops between age 6 months and 7 years. It is rare or accom-
modative esotropia to develop be ore 4 months or a er 8 years o
age. Pseudoesotropia is common in in ants due to their at nasal
bridges and medial epicanthal olds, giving an appearance o eso-
tropia. A simple way to assess children or a true strabismus is to
shine a penlight in their eyes and evaluate the corneal re ection
o your light. T e light re ex will be in the same location bilater-
ally or pseudoesotropia but in di erent parts o the eye with true
esotropia or other orms o strabismus (see Fig. 19-1).
HELPFUL TIP:
It is i ortant to di erentiate an esotro ia or exotro ia
ro sixt nerve a s . A sixt nerve a s a ects t e
atera rectus usc e and t e atient wi ave i ited
abduction on t e a ected side. T is is usua t e irst
crania nerve a ected in atients wit increased intra-
crania ressure. In adu ts, t e ost co on etio o is
vascu o at ic. In c i dren, it is trau a.

FIGURE 19-1. Con enita esotro ia. Note t e ar e deviation wit abnor a
cornea i t re exes. T e cornea i t re ex o t e e t e e a ears ore
te ora t an t at o t e ri t e e. T ere ore, t e e e is deviated inward.
Question 19.1.2 Which o the ollowing statements is FALSE?
A) Congenital esotropia is nearly always present at birth
B) Alternating xation (e.g., the ability to x on an object with
either eye) is characteristic o congenital esotropia
C) Patients with congenital esotropia generally have normal
amounts o hyperopia ( arsightedness) or their age
D) Patients with a high degree o uncorrected hyperopia ( ar-
sightedness) can develop an accommodative esotropia
Answer 19.1.2 The correct answer (and the alse statement)
is “A.” Congenital esotropia presents by the age o 6 months but
is rarely present at birth. I true esotropia is observed at birth, it
may be due to another neurologic disorder and urther evalu-
ation is indicated. Any orm o strabismus may result in vision
loss, and or this reason, it is important to treat strabismus
early in li e. T e rest o the answers are true. Option “B”: since
patients have two eyes with equal vision, neither is pre erred,
so they will use both eyes to ocus on objects (although not at
the same time, o course!). Option “C”: patients with congenital
esotropia do have a normal degree o hyperopia or their age.
“D” is also a true statement (see Fig. 19-2).
Question 19.1.3 Which o the ollowing is NOT an appropri
ate treatment or strabismus?
A) Surgical correction i correction o re ractive errors with ull
hyperopic spectacle does not resolve the strabismus
B) Patching the strabismic (misaligned) eye
C) Atropine drops or patching the nonstrabismic eye without
surgery
D) Atropine drops or patching the non-strabismic eye plus surgery
Answer 19.1.3 The correct answer is “B.” T e goal o the
treatment o strabismus is to prevent amblyopia. Amblyopia
is commonly caused by strabismus (ocular misalignment),
CHAPTER 19 • Oph Th Al mOl Og y 527
FIGURE 19-2. Acco odative esotro ia i roves w en vision is correct-
ed. Ada tation or near vision consists o acco odation (c an e in ens
s a e), iosis (constriction o t e u i ), and conver ence. T is can even-
tua ead to an acco odative esotro ia, w ic can easi be corrected
wit asses. A ter asses, t e atient no on er uses t e near res onse o
acco odation and conver ence, since t e asses are now rovidin t e
correction so t e e es resu e nor a a i n ent.
signi cant uncorrected re ractive error, or disorders that dis-
tort images rom the eye to the brain (i.e., congenital cata-
racts). In amblyopia, the brain “turns o ” or suppresses the
vision in the a ected eye, thus allowing the una ected eye to
work unimpeded. In addition to surgical treatment (realign-
ment, removal o cataract, etc.), amblyopia therapy and pre-
vention is accomplished by blurring or impeding the vision in
the una ected (good) eye to strengthen the a ected (bad) eye.
T is can be done by physically patching the good eye (not the
strabismic eye as noted in “B”) or by pharmacologic “patch-
ing” o the good eye using atropine drops i compliance with a
patch is an issue (although eye patches remind kids o pirates
and pirates are cool—aargh, matey!). NO E: erms such as
“bad eye” and “good eye” are requently con using, so strabis-
mic or deviated eye o en replaces “bad eye” as no eye is truly
bad, but rather a product o its environment, and “good eye”
is usually reserved as a popular greeting in Australia (just say
it like Russell Crowe would!).
Question 19.1.4 In which o the ollowing situations would
neuroimaging be necessary?
A) A 6-month-old with longstanding esotropia and equal visual
acuity bilaterally
B) A 5-year-old with recent onset esotropia correctable by
glasses
C) A 12-year-old with normal re raction and acute onset eso-
tropia with diplopia
D) A newborn with a unilateral congenital cataract and an eso-
tropia
Answer 19.1.4 The correct answer is “C.” ANY unexplained
new onset strabismus mandates an evaluation. A 12-year-old
with acute esotropia and diplopia and no evidence o hypero-
pia requires neuroimaging to rule out any underlying neuro-
logical disorder. T e age o the patient is older than that seen
with congenital, acquired, or accommodative esotropia. T e
re raction is normal, so this does not t with accommodative
esotropia. Diplopia also suggests acute onset. Further workup
is there ore necessary. “A” is incorrect because this is a classic
528 FAmIl y mEDICINE EXAmINATION & BOARD REVIEW
history or congenital esotropia. “B” is incorrect because it is
consistent with accommodative esotropia. Fixing uncorrected
re ractive error would be the appropriate rst step here. Note
that arsightedness (hyperopia) is a much more common cause
o accommodative esotropia compared to nearsightedness
(myopia). “D” is incorrect because we have reason or the eso-
tropia—a congenital cataract is causing poor binocular usion
and coordination.
HELPFUL TIP:
Acquired strabis us always requires a ra id and co -
ete eva uation. It can be due to trau a, vascu o at ic
actors, tu or, intracrania e orr a e, botu is , ead
oisonin , etc. An c i d (or adu t, or t at atter) wit
new onset strabis us requires a u o t a o o ic
exa ination.
Objectives: Did you learn to . . .
• Describe t e no enc ature o strabis us?
• Deter ine t e under in causes o esotro ia?
• Reco nize so e unusua cases o strabis us t at require
urt er worku ?
• Describe t e risk and treat ent o a b o ia?
CASE 19.2
A 50-year-old Asian emale presents to the emergency depart-
ment (ED) with severe nausea, vomiting, right eye pain, and
blurry vision. She reports the symptoms began only a ew
hours earlier. She has no signi cant past medical history. On
gross examination, her visual acuity is OD 20/200, her right eye
is injected, and her right pupil is larger than her le . T ere does
NO appear to be a relative a erent pupillary de ect (RAPD).
Question 19.2.1 With regard to this patient’s presentation,
which o the ollowing would NOT be considered in the di
erential diagnosis?
A) rauma secondary to blunt injury rom a so ball
B) Central retinal artery occlusion
C) Contact lens associated bacterial keratitis
D) Acute angle closure glaucoma
E) Anterior uveitis
Answer 19.2.1 The correct answer is “B.” Among these
choices, only central retinal artery occlusion would be pain-
less and also associated with a RAPD ( rom di use retinal isch-
emia). All o the others will present with pain and WI HOU
a RAPD. “A,” blunt injuries, may result in decreased vision sec-
ondary to corneal abrasions or edema, intraocular in amma-
tion, hyphema, or retinal injuries. Injury can also cause injec-
tion and a traumatic mydriasis (dilation o the pupil). Direct
and consensual pupillary re exes would be normal (no RAPD)
unless there was an associated traumatic optic neuropathy or
signi cant retinal damage. “D,” acute angle closure glaucoma,
would cause di use injection with a mid-dilated pupil and no
RAPD. “E,” anterior uveitis, would also cause injection—but
o en only ciliary ush—and no RAPD. T ere is o en asymme-
try o the pupils in chronic anterior uveitis secondary to central
posterior synechiae (adhesions between the iris and lens).
Question 19.2.2 Which o the ollowing is required in order
to diagnose acute angle closure glaucoma?
A) Slit lamp
B) onometer
C) Fluorescein and appropriate UV light
D) Snellen eye chart
E) A and B
Answer 19.2.2 The correct answer is “B.” T e most impor-
tant examination technique used to diagnose acute glaucoma
is intraocular pressure measurement. T is could be achieved by
onopen, Goldmann applanation tonometry at the slit lamp,
Schiotz tonometer (anyone remember this antique?), assessed
via digital palpation, etc. “A” is incorrect. A slit lamp is use ul
or diagnosing structural problems, iritis, etc. “C,” uorescein,
is used to diagnose corneal injuries (de-epithelized cornea will
take up uorescein). “D,” a Snellen eye chart, is used to deter-
mine visual acuity but is not necessary or diagnosing glau-
coma. It is always a good idea to check vision in each eye in
every patient with eye complaints; think o checking visual acu-
ity as taking “vital signs” or the eye (see Fig. 19-3).
Question 19.2.3 Which o the ollowing is NOT a risk actor
or acute angle closure glaucoma?
A) Hyperopia ( arsightedness)
B) Asian descent
C) Male gender
D) Pharmacologic dilation
E) Increasing age
Answer 19.2.3 The correct answer is “C.” Associated risk ac-
tors or acute angle closure glaucoma are hyperopia, Asian
ancestry, female gender, and older age. Patients with hyperopia
FIGURE 19-3. Acute an e c osure auco a. Note t e injection, az cornea
re ex, and id-di ated u i .
 CHAPTER 19 • Oph Th Al mOl Og y 529

have smaller eyes and more shallow anterior chambers. Females TABLE 19-1 DRUGS USED FOR ACUTE GLAUCOMA
and people o Asian descent also tend to have smaller eyes. As AND HOW THEY WORK
people age, cataracts may develop, become thicker, and crowd
Drug Mechanism o Action
the anterior chamber, increasing the likelihood o developing
pupillary block leading to glaucoma. To ica β-b ockers (e. ., ti o o ) Decreases aqueous u or
roduction

To ica α-adrener ic a onists Decreases aqueous u or

HELPFUL TIP: (e. ., bri onidine) roduction
p ar aco o ic di ation a resu t in an attack o acute prosta andin ana o s (e. ., Increases aqueous u or
an e c osure auco a. But w ere better a ace or atano rost, bi ato rost, out ow t rou uveosc era
it to s ow u t an in our o ice or t e ED? Neovas- travo rost) c anne s
cu arization o t e e e (suc as ro diabetes or reti-
To ica carbonic an drase Decreases aqueous u or
na oxia) can ead to “neovascu ar auco a” ro in ibitors (e. ., dorzo a ide, roduction
neovascu arization o t e iris and an e. h e a can brinzo a ide)
cause auco a ro c ot obstructin t e out ow o
Ora carbonic an drase in ibitor Diuretic and, ore
aqueous u or.
(e. ., acetazo a ide) i ortant , decreases t e
roduction o aqueous u or

mannito (rare use now or acute Os otic diuretic draws

Question 19.2.4 Which o the ollowing is NOT a presenta auco a, ost OR cases on ) aqueous u or ro t e e e
tion o acute closed angle glaucoma?
A) Headache
B) Abdominal pain etc.) increase aqueous out ow, thereby also decreasing intraoc-
C) Vomiting ular pressure. It is generally third line a er iridotomy or acute
D) Limitation o extraocular motion closed-angle glaucoma.
E) Halos around light

Answer 19.2.4 The correct answer is “D.” Patients with acute
closed-angle glaucoma can present with all o the above ndings
except or the limitation o extraocular motion. Severe eye pain
and blurred vision are commonly noted due to corneal edema
and clouding secondary to the increased intraocular pressure.
You call your local ophthalmologist or optometrist to see this
patient with suspected acute angle glaucoma. She is going to
be delayed because o tra c—it’s Iowa, so she’s likely stuck
behind a big tractor . . . we don’t have “rush hour,” only “rush
minute.”
Question 19.2.5 Which o the ollowing drugs is NOT appro
priate to use as a temporizing measure?
A) opical carbonic anhydrase inhibitors
B) opical β -blockers
C) opical glycerin
D) opical atropine drops
E) opical prostaglandin analog drops
Answer 19.2.5 The correct answer is “D.” Atropine is contra-
indicated in acute glaucoma since it will dilate the eye, exacer-
bating the problem. opical β -blockers (“B”) and topical (“A”) or
oral carbonic anhydrase inhibitors (e.g., acetazolamide) reduce
aqueous production and thereby reduce intraocular pressure. In
addition to the medications noted above, a topical α -adrenergic
agonist (e.g., brimonidine, apraclonidine) also lowers eye pres-
sure by selectively a ecting the α -2 receptors and decreasing
aqueous production. opical glycerin (“C”) is used to clear the
corneal edema. Prostaglandin analogs (“E”, e.g., latanoprost,
HELPFUL TIP:
In enera , e e dro s t at di ate t e e e ave a red ca
on t e , so i ou are in a anic and ou’ve or otten a
t e ood advice ro t is aweso e book, a ood ru e
o t u b is to use a ny eye drop WITHOUT a red ca p.
See Tab e 19-1 or detai s on auco a edications.
HELPFUL TIP:
Did ou notice t at i ocar ine, t e c assic a ent or
treatin acute auco a, is absent ro t e ist? Turns
out it doesn’t work a t at we un ess t e intraocu ar
ressure is a read ess t an 40 h .
An ophthalmologist makes it to the hospital and recom-
mends surgery.
Question 19.2.6 What is the de nitive treatment of choice or
acute angle closure glaucoma?
A) Laser peripheral iridotomy
B) apping o the anterior chamber to lower intraocular pres-
sure
C) Aqueous suppressant therapy
D) Surgical iridectomy
E) Chiropractic manipulation o the iris
Answer 19.2.6 The correct answer is “A.” T e treatment goal
is to allow the ree ow o aqueous so that it does not accumu-
late behind the iris to push it orward to obstruct the trabecular
530 FAmIl y mEDICINE EXAmINATION & BOARD REVIEW
meshwork. A laser peripheral iridotomy creates a small hole in the
peripheral iris that allows aqueous ow to improve and thereby
decreases intraocular pressure. As long as this hole remains pat-
ent, the patient is no longer at risk or an attack o angle closure
glaucoma, and it is unusual or the hole to close unless there is
a history o intraocular in ammation. “B,” tapping the anterior
chamber, can be used be ore laser therapy in order to clear the
cornea so that visualization is better or the procedure. However,
it is adjunctive and not a treatment o choice. Also, topical glyc-
erin works well and can accomplish the same goal without being
invasive. “C,” aqueous suppressant therapy, is discussed in the
previous question. “D,” a surgical iridectomy, is per ormed or
patients who are unable to sit still or the laser procedure (i.e.,
children, intellectually disabled). As to “E” . . . nothing against
chiropractors, but this might not be the right time.
Question 19.2.7 Which is FALSE regarding closed and
open angle glaucoma?
A) T e main di erence is that the drainage angle (trabecular
meshwork) is closed in angle closure glaucoma and open in
open-angle glaucoma
B) Scopolamine and other agents with anticholinergic proper-
ties are contraindicated in open-angle glaucoma but not in
closed angle
C) Acute angle closure glaucoma usually occurs in hyperopic
individuals while myopia is associated with open-angle
glaucoma
D) T e majority o people diagnosed with glaucoma have pri-
mary open-angle glaucoma
Answer 19.2.7 The correct answer (and alse statement) is
“B.” Scopolamine and agents with anticholinergic properties,
which would cause dilation o the pupil, are actually contrain-
dicated in those with closed-angle glaucoma (and those with
narrow angles who may not yet have obstructed). Once periph-
eral iridotomy is per ormed, anticholinergics are no longer an
issue since the patient is no longer at risk. All o the rest o the
statements are correct.
Question 19.2.8 Which o the ollowing does NOT increase
a patient’s risk or primary open-angle glaucoma?
A) Family history
B) Caucasian race
C) Elevated intraocular pressure (> 21 mm Hg)
D) Age > 40
Answer 19.2.8 The correct answer is “B.” Patients o A rican
heritage are much more likely to develop open-angle glaucoma
than are Caucasians and are also more likely to su er vision loss
rom glaucoma. Family history, high intraocular pressures, and
thin corneas are all risk actors or the development o open-
angle glaucoma. High intraocular pressures lead to optic nerve
damage. Minor risk actors include diabetes and myopia (near-
sightedness). All patients should be screened or glaucoma as
part o their routine eye examination. T is is usually done by
assessing intraocular pressure, examining the optic nerve and
corneal thickness, and per orming any ancillary diagnostic tests
such as peripheral visual eld analysis.
Question 19.2.9 Which o the ollowing is typical o early
open angle glaucoma?
A) Central vision loss
B) Peripheral vision loss
C) Lack o symptoms
D) Decreased contrast
E) Blurring o vision
Answer 10.2.9 The correct answer is “C.” Most people with
early open-angle glaucoma are asymptomatic. T is is why screen-
ing is important. A signi cant number o the approximately one
million axons o the optic nerve may be damaged be ore this
mani ests itsel as visual eld loss. Examination o the optic nerve
or abnormalities is the best way to diagnose early glaucoma.
Later symptoms involve loss o peripheral or central vision.
Question 19.2.10 Which o the ollowing is necessary to
diagnose a patient with open angle glaucoma?
A) Optic nerve head cupping or irregularity with correspond-
ing visual eld loss
B) T in corneas
C) Elevated intraocular pressure
D) Narrow but open drainage angle
Answer 19.2.10 The correct answer is “A.” Cupping o the optic
nerve head is caused by thinning o the neural rim secondary to
damage rom high intraocular pressure. T ere should be a cor-
responding visual eld de ect consistent with the appearance o
optic nerve cupping to diagnose a patient with glaucoma. In open-
angle glaucoma, the mechanism o injury to the optic nerve is
thought to be direct mechanical compression. Note that elevated
intraocular pressure is not diagnostic o open-angle glaucoma.
Glaucoma describes the changes to the optic nerve that are
o en secondary to ocular hypertension. Elevated intraocular
pressure by itsel is considered a risk actor or glaucoma. When
not accompanied by cupping or visual eld loss, it is considered
ocular hypertension. Patients with ocular hypertension still need
to be monitored and treated to prevent the development o open-
angle glaucoma. Conversely, some patients with glaucoma never
develop high intraocular pressure indicating that glaucoma may,
in act, be due to optic nerve damage arising rom a variety o
etiologies, the most common being elevated intraocular pressure.
T inner corneas (“B”) increase the risk o glaucoma but are not
required or diagnosis. “D” is incorrect. T e drainage angle must
be widely open—thus the name “open-angle glaucoma.”
Question 19.2.11 Which o the ollowing statements
regarding glaucoma is true?
A) I treated early enough, normalizing the intraocular pressure
can reverse the process o glaucoma and restore sight
B) T e unduscopic examination in patients with glaucoma
will generally show small retinal hemorrhages in addition to
optic nerve cupping

FIGURE 19-4. Nor a o tic nerve.
C) Papilledema is seen with glaucoma as a result o increased
pressure on the optic nerve
D) T ere are no identi ed genetic markers that correlate to
development o glaucoma
E) None o the above
Answer 19.2.11 The correct answer is “E.” So, wrong, wrong,
wrong . . . and wrong. Once there is visual loss, it cannot be
restored (“A”). Optic nerve hemorrhages, and not retinal hem-
orrhages, are seen in glaucoma (“B”). Retinal hemorrhages are
typically seen with diabetic or hypertensive retinopathies. Pap-
illedema results rom increased intracranial—not intraocular—
pressure (“C”). T ere are multiple genes that have been identi-
ed that contribute to the development o glaucoma (“D”). See
Figure 19-4 or images o normal-appearing optic nerves, and
FIGURE 19-5. g auco atous o tic nerve. Observe t e cu in o t e o tic
nerve ead. T e cu (centra de ression, seen as t e bri t art o t e disc)
o t e o tic nerve, w ic re resents t e axons divin down into t e o tic
nerve, is ar er co ared wit nor a . A cu > 50% o t e disc widt is in-
dicative o auco a. Cu in re resents da a e to t e o tic nerve and
ewer axons are resent.
CHAPTER 19 • Oph Th Al mOl Og y 531
compare these with Figure 19-5, which shows optic nerve nd-
ings in patients with glaucoma.
Objectives: Did you learn to . . .
• Reco nize t e si ns and s to s o acute an e c osure
auco a?
• Identi risk actors associated wit acute an e c osure
auco a?
• Describe t e at o o and basis or treat ent or
auco a?
• Di erentiate between an e c osure and o en-an e
auco a?
• Describe o tic nerve f ndin s in auco a?
QUICK QUIZ: g l AUCOmA Ag ENTS
opical β -blockers lower intraocular pressure by decreasing
aqueous production.
Which o the ollowing is NO considered a systemic side e ect
o these medications?
A) Bronchospasm
B) Bradycardia
C) Worsening o congestive heart ailure
D) Increased low-density lipoprotein (LDL)
The correct answer is “D.” β -Blockers do not increase LDL.
T e take-home message here is that topical β-blockers can
have systemic e ects including congestive heart ailure and
bradycardia. Be aware o this, especially in the elderly. Con-
versely, systemic medications such as steroids or β -blockers can
also a ect intraocular pressure.
QUICK QUIZ: VISION l OSS
A 70-year-old white emale presents with sudden loss o the
upper hal o her vision in the le eye. She reports no pain. Her
past medical history is signi cant or hypertension and type 2
diabetes.
Which o the ollowing is the LEAS likely diagnosis given this
history?
A) Retinal detachment
B) Branch retinal artery/vein occlusion
C) Optic neuritis
D) Anterior ischemic optic neuropathy
The correct answer is “C.” Retinal detachment, branch retinal
artery/vein occlusion, and anterior ischemic optic neuropathy
all cause painless sectorial loss o vision in this age group. Optic
neuritis usually occurs in a younger age group and is associated
with pain and a central scotoma (blind spot).
532 FAmIl y mEDICINE EXAmINATION & BOARD REVIEW
HELPFUL TIP:
man atients co ain o ain w en t e ove t eir
e es. Dia noses to consider inc ude o tic neuritis, in-
traorbita in ection/in a ation, sinusitis, and orbita
ositis o u ti e etio o ies suc as orbita ce u itis,
acute g rave’s disease, orbita seudotu or, sarcoidosis,
o arteritis nodosu , s ste ic u us er t e atosus,
der ato ositis, r eu atoid art ritis, and We ener
ranu o atosis (now known as ranu o atosis wit
o an iitis).
QUICK QUIZ: ANTERIOR ISCh EmIC
OpTIC NEUROpATh y
Ischemic optic neuropathy is the most common cause o optic
nerve lesions with visual loss in patients older than 50 years.
It is re erred to as “anterior” when it a ects parts o the optic
nerve behind the optic disc. It generally results rom ischemia
o the optic disc (sort o makes sense since it is called “anterior
ischemic optic neuropathy”).
Which o the ollowing is CORREC regarding nonarteritic
(not related to temporal arteritis) anterior ischemic optic neu-
ropathy (NA-AION)?
A) It is not associated with diabetes
B) Women are a ected ve times as o en as men
C) As with giant cell arteritis, it responds quickly and dramati-
cally to systemic corticosteroids
D) Avoiding nocturnal hypotension is an important aspect o
treatment
The correct answer is “D.” It is important to avoid nocturnal
hypotension. Most eye specialists, there ore, recommend
avoiding anti-hypertensive administration at bedtime. Occa-
sionally, midodrine needs to be prescribed to support the blood
pressure at night. T e remaining statements are incorrect. T ink
o NA-AION as being equivalent to peripheral vascular disease:
it is associated with hypertension, smoking, diabetes, etc. Males
and emales are equally a ected. While the age o patients with
NA-AION overlaps with that o patients with giant cell arteritis,
the patients with NA-AION tend to be younger and NA-AION
is painless. Unlike giant cell arteritis, steroids are not the treat-
ment o choice.
HELPFUL TIP:
Sur ica intervention or NA-AION is not e u and
a ead to worsenin b indness. In act, t ere is no
known e ective t era . Treat ent o risk actors is
ara ount.
CASE 19.3
A 65-year-old white male complains o “seeing wavy lines” or
“window blinds” when looking at the doorway with his right
eye. He has no pain or other ocular symptoms. His past medi-
cal history is signi cant or hypertension. He has a 40-pack-
year smoking history. On examination, his visual acuity is
20/400 in the right eye. He has no RAPD and slit-lamp exam-
ination reveals that his anterior segment is normal. Exami-
nation o his right undus reveals a subretinal hemorrhage
involving his ovea.
Question 19.3.1 Which o the ollowing is the most likely
cause o this patient’s vision loss?
A) Age-related macular degeneration (AMD)
B) Acute angle closure glaucoma
C) Cataract
D) Diabetic retinopathy
E) Malingering
Answer 19.3.1 The correct answer is “A.” T is is a typical pre-
sentation or AMD (continue to the next question or more
in ormation). “B” is incorrect because acute angle closure glau-
coma presents with pain. “C” is incorrect since cataracts cause
slowly progressive vision loss. “D” is incorrect: this would be an
unusual presentation or diabetic retinopathy, and the patient
has no known history o diabetes. Save “E” or the psychiatry
chapter.
Question 19.3.2 Which o the ollowing statements is FALSE?
A) AMD is the leading cause o severe central vision loss in per-
sons older than 50 years in the United States
B) Smoking has been shown to be a risk actor in the develop-
ment o wet AMD
C) AMD is less common in Caucasians when compared with
other populations
D) T e Age-Related Eye Disease Study Part 2 (AREDS2) has
shown a bene cial e ect o vitamin E, vitamin C, lutein, zea-
xanthin, zinc, and copper in delaying the progression to wet
AMD
E) T e main presenting complaint o wet AMD is metamor-
phopsia, which is distortion or waviness centrally in the
visual eld
Answer 19.3.2 The correct answer is “C.” AMD occurs more
commonly in Caucasian populations. “A” is correct as AMD is
the leading cause o central vision loss in patients older than
50 years. “B” is correct. Smoking is a signi cant risk actor in the
progression to wet AMD; there ore smoking cessation is highly
recommended in any individual with early AMD ndings or
with a strong amily history o AMD. As to “D,” the listed micro-
nutrients are bene cial in delaying the progression rom dry to
wet AMD according to the AREDS2 results. “E” is also correct.
Patients with AMD complain o distortion and/or waviness in
the central visual eld.

HELPFUL TIP:
Dr AmD is t e non-neovascu ar or o AmD. It is c ar-
acterized b drusen ( e ow-w ite esions in t e outer
retina a ers o t e acu a) or atro wit in t e ac-
u a. Dr AmD a ead to wet (neovascu ar) AmD, w ic
is associated wit a c oroida neovascu ar e brane
(CNVm). T e CNVm is an abnor a rowt o subretina
b ood vesse s, w ic rows in t e acu a or ovea and
a ects vision due to uid eaka e.
HELPFUL (BUT UNFORTUNATE) TIP:
micronutrients or t e enera o u ation do not see
to revent t e deve o ent o AmD. h owever, t e do
see to work to revent ro ression once t e atient
as AmD.
HELPFUL TIP:
T ere are severa treat ents avai ab e or neovascu ar
AmD. T ese inc ude aser o t e CNVm, intravenous in-
jection o otosensitizin dru (verte or in) o owed
b nont er a red i t, intravitrea injection o vascu-
ar endot e ia rowt actor in ibitor (VEg F-in ibitor)
edications, and sur ica re ova o CNVm. T e treat-
ent o c oice is VEg F-in ibitors (bevacizu ab, ranibi-
zu ab, or a iberce t). Wit re ard to otosensitizin
dru s, t e NNT to improve vision is 12, t e NNh wit vi-
sion oss is 100. A treat ents are ai ed toward stabi iz-
in and reservin existin vision, not i rovin vision,
a t ou occasiona so e i rove ent is seen. In ad-
dition, atients s ou d be encoura ed to cease s okin .
Objectives: Did you learn to . . .
• Reco nize t e si ns and s to s o AmD?
• Di erentiate between dr and wet AmD?
• Reco nize treat ent oda ities or wet AmD?
CASE 19.4
A 55-year-old white male with a history o newly diagnosed
type 2 diabetes mellitus presents or routine evaluation. He has
no complaints, including vision. On non-dilated direct oph-
thalmoscopic examination, both undi appear to be normal.
Question 19.4.1 When should this patient be re erred or
ormal ophthalmologic examination?
A) Immediately upon diagnosis
B) Within 3 months
C) Within 6 months
D) Within 1 year
E) When he develops visual symptoms, maybe 2 days be ore he
goes blind
CHAPTER 19 • Oph Th Al mOl Og y 533
Answer 19.4.1 The correct answer is “A.” Patient with type 2
diabetes should be re erred or a dilated examination immedi-
ately upon diagnosis since they may have been undiagnosed or
a long time period and may already have a degree o retinop-
athy. For type 1 diabetic patients, the recommendation is to
re er within 5 years o diagnosis.
Question 19.4.2 What are the common ndings seen on
direct ophthalmoscopic examination in nonproli erative
diabetic retinopathy?
A) Exudates
B) Cotton wool spots
C) Dot-blot hemorrhages
D) Microaneurysms
E) All o the above
Answer 19.4.2 The correct answer is “E.” Direct ophthalmo-
scopic examination may reveal all these ndings in nonproli -
erative diabetic retinopathy. T ese are caused by the increased
ragility o capillaries and arterioles o the retina with diabetes.
While hemorrhages and microaneurysms are unmistakably red,
exudates and cotton-wool spots are white and u y in appear-
ance.
Question 19.4.3 What is the main cause o vision loss in
nonproliferative diabetic retinopathy?
A) Dot-blot hemorrhages
B) Macular edema
C) Cataract
D) Neovascularization
Answer 19.4.3 The correct answer is “B.” Nonproli erative
diabetic retinopathy by de nition has no neovascularization
(new, ragile blood vessel growth secondary to microvascular
disease). T e main source o decreased vision is macular edema.
reatment o ocal macular edema consists o ocal laser to leak-
ing microaneurysms. I the patient has di use macular edema, a
more extensive (“grid laser”) pattern is used. Increasingly, treat-
ment o nonproli erative diabetic macular edema may include
intravitreal injection o antivascular endothelial growth ac-
tor (anti-VEGF); intravitreal triamcinolone acetonide is used
rarely.
Question 19.4.4 What is the main cause o vision loss in pro-
liferative diabetic retinopathy?
A) Cataract
B) Macular edema
C) Vitreous hemorrhage
D) Neovascular glaucoma
Answer 19.4.4 The correct answer is “C.” Vision loss in pro-
li erative retinopathy occurs when riable neovascular ves-
sels break open and bleed (vitreous hemorrhage). Vision loss
can also occur i the neovascular vessels grow over the drain-
age angle o the eye, causing glaucoma, although this is ar less
534 FAmIl y mEDICINE EXAmINATION & BOARD REVIEW
FIGURE 19-6. pro i erative diabetic retino at . Neovascu arization o t e
o tic nerve.
common than vitreous hemorrhage. See Figure 19-6 or an
image o neovascularization.
T e treatment o proli erative diabetic retinopathy consists
o panretinal photocoagulation, which involves lasering the
peripheral retina, thereby decreasing the ischemic drive or
neovascularization. reatment o vitreous hemorrhage includes
observation with the head o bed elevated until the hemor-
rhage settles out and clears enough or laser treatment. Vitre-
ous hemorrhages may be caused by other things, such as retinal
detachments, so ultrasound is usually per ormed acutely, since
one will not be able to adequately examine the retina a er a sig-
ni cant hemorrhage.
HELPFUL TIP:
As irin is sa e in atients wit neovascu arization. T e
risk o b eedin does not increase si ni icant . T e car-
diovascu ar bene it outwei s t e risk to t e e e.
Objectives: Did you learn to . . .
• Identi w en to re er atients or or a o t a o o ic
exa ination in t e 1 and t e 2 diabetes?
• Reco nize t e si ns o diabetic retino at on direct o -
t a osco ic exa ination?
• Understand t e causes o vision oss in t ose wit non ro i -
erative and ro i erative diabetic retino at ?
• Describe t e basis or treat ent o bot non ro i erative and
ro i erative diabetic retino at ?
CASE 19.5
A 20-year-old male presents to the ED, complaining o a
“bloody eye.” He was in a ght earlier in the evening and
was hit in the eye (“. . . but you should see the other guy!” .
. . and with your luck, you probably will). You examine him
and discover the ndings in Figure 19-7. His visual acuity in
FIGURE 19-7.
the a ected eye is hand motions only. He also has moderate
edema o the lids but is able to open his eyes. On slit-lamp
examination, the pupil appears normal. His motility is ull
and there is no diplopia.
Question 19.5.1 What is the single most important rst step
in evaluation o this patient?
A) Detection o a RAPD
B) Patching until the heme clears
C) Evaluation or possible open globe
D) Immediate C scanning to evaluate or an orbital racture
E) Surgical anterior chamber washout o the heme
Answer 19.5.1 The correct answer is “C.” T is is a hyphema,
with blood lling about one-third o the anterior chamber in
Figure 19-7. More important is the history o trauma. T e rst,
and most important, step in ocular trauma is to look or evi-
dence o an open or ruptured globe. T ere should be no pres-
sure placed on the eye until an open globe is ruled out. Signs
o ruptured globe would be 360 degrees o conjunctival chemosis
(conjunctival swelling), a shallow anterior chamber, an irregular
or “peaked” pupil, or low intraocular pressure. However, a normal
globe pressure does not rule out a ruptured globe. T e leak may be
small or may be plugged with choroid. NO E: Intraocular pres-
sure measurements should not be taken until an open globe is
ruled out. I there is any doubt about whether there is an open
globe, consult an ophthalmologist or optometrist. “D” is incor-
rect and deserves special mention: C is not sensitive enough to
rule out an open globe, even with thin cuts through the globe.
HELPFUL TIP:
W en eva uatin or a ru tured obe, re e ber t at
t e ost co on areas o ru ture are t e i bus (t e
ar in o t e cornea w ere it eets t e sc era) and
sc era be ind t e insertion o rectus usc es. T is is
w ere t e sc era is t innest.

HELPFUL TIP:
A “Seide test” can be used to ook or an o en obe.
A oistened uorescein stri is ent aced at t e
site o injur . S it- a exa ination is done wit Coba t
b ue i t. I a ru ture is resent, t e uorescein d e wi
be di uted b t e aqueous, w ic wi a ear as a dark
strea t rou t e reen uorescein.
Question 19.5.2 Which is NOT a complication o hyphema
(bleeding into the anterior chamber)?
A) Corneal blood staining
B) Glaucoma
C) Rebleeding
D) Iris heterochromia
Answer 19.5.2 The correct answer is “D.” Complications o
hyphema include rebleeding, which is most common in the
rst 3 to 5 days a er injury. T e hyphema may also stain the
corneal endothelium, which may take months to clear. Glau-
coma may also occur because o clogging o the trabecular
meshwork by red blood cells, leading to a rise in intraocular
pressure. “D,” iris heterochromia, describes di erence in iris
coloring (e.g., one blue eye and one brown) and can be caused
by a retained oreign body (e.g., iron) but is more o en due to
an underlying condition (e.g., neuro bromatosis) or designer
contact lenses that can also be used at Halloween to look really
reaky.
You rule out ruptured globe and orbital racture. He’s
seen by the ophthalmologist on call who recommends
treatment.
Question 19.5.3 Which o the ollowing is the most appro
priate treatment or this patient?
A) reat at home with topical steroids
B) Hospital admission and IV steroids
C) Hospital admission and IV antibiotics
D) Hospital admission and topical antibiotics
E) reat at home with topical antibiotics
Answer 19.5.3 The correct answer is “A.” T is patient has a
hyphema, which is blood in the anterior chamber, usually due
to direct trauma. While the party line in the past was that all o
these patients require admission, sending a patient home with
instructions to avoid urther trauma and vigorous activities is
suf cient in reliable patients with limited disease. However,
an ophthalmologist or optometrist should be involved in
this decision. In addition to topical steroids, other potential
treatments include cycloplegic agents and perhaps anti bri-
nolytic agents such as aminocaproic acid.
OK. ime or a joke. What is the de nition o a double-blind
study? wo orthopedic surgeons reading an electrocardio-
gram.
CHAPTER 19 • Oph Th Al mOl Og y 535
Objectives: Did you learn to . . .
• Reco nize t e co ications o ocu ar trau a?
• Exa ine a atient at risk or o en obe?
• Identi t e co ications o e a?
• Initiate ana e ent o a atient wit e a?
CASE 19.6
A 27-year-old male presents with irritation and redness o his
right eye a er hammering on an old iron ence. He was not
wearing sa ety glasses at the time (they aren’t very cool looking
and he was hoping his attractive neighbor would be out garden-
ing). He’s now 3 days out rom his injury. On examination, his
visual acuity is 20/200. His right eye is injected, and his pupil is
irregularly peaked to one side upon gross inspection. Slit-lamp
examination reveals a laceration o his cornea extending to the
limbus with a wick o iris occluding the laceration site. You place
a Fox shield on the eye to prevent any pressure on the globe,
update the patient’s tetanus vaccine, and start antibiotics.
Question 19.6.1 What would be the next step in the evalua
tion and treatment o this patient?
A) Imaging or an intraocular oreign body by orbital C scanning
B) Evaluation or an intraocular oreign body by orbital ultra-
sound
C) ry to remove the oreign body rom the posterior chamber
with a magnet
D) Complete ocular examination, including intraocular pres-
sure and dilated unduscopic examination
Answer 19.6.1 The correct answer is “A.” Given his history, the
patient needs to be evaluated or a possible intraocular oreign
body. T e best imaging modality is with orbital C scanning.
Orbital ultrasound (“B”) would also be appropriate, but or surgi-
cal planning C scanning is pre erred. “C” is incorrect because it
is likely to cause more damage. T is type o oreign-body removal
is best le to a specialist in the OR. Finally, it would be best to
de er intraocular pressure measurements until the extent o the
laceration is evaluated since no pressure should ever be placed on
a potential open globe.
T e patient undergoes an orbital C . T ere appears to be a
piece o metal within his vitreous cavity.
Question 19.6.2 Which o the ollowing are inert intraocular
oreign bodies?
A) Iron
B) Copper
C) Glass
D) Aluminum
E) C and D
Answer 19.6.2 The correct answer is “C.” Iron, copper, and
aluminum are all reactive species and must be removed rom
the eye. Glass is inert and may be le in place, depending on the
situation and the risk o surgery.
536 FAmIl y mEDICINE EXAmINATION & BOARD REVIEW
Question 19.6.3 Which is NOT a sign o a retained iron intra
ocular oreign body?
A) Iris heterochromia
B) Mydriasis
C) Glaucoma
D) Retinal degeneration
E) High re ractive error
Answer 19.6.3 The correct answer is “E,” also known as severe
myopia or nearsightedness. Although, the patient in this case
may have been extremely nearsighted in his decision to not wear
sa ety glasses, we mean that metaphorically, and the retained
iron oreign body has nothing to do with nearsightedness. All o
the rest are signs o siderosis caused by a retained iron intraocu-
lar oreign body. Given the toxicity to the eye, the oreign body
must be removed surgically.
HELPFUL TIP:
Cornea orei n bodies a be re oved usin a
need e a ter t e ad inistration o to ica anest etic.
meta ic orei n bodies in t e cornea a eave a rust
rin around t e area o t e orei n bod , w ic can
be re oved usin an ocu ar burr or an a er brus .
T e rust rin a a so be e t in ace i it is out o
t e visua axis since it does not cause an on - astin
rob e s.
Objectives: Did you learn to . . .
• Reco nize t e si ns o a corneosc era aceration?
• mana e a corneosc era aceration in t e e er enc
settin ?
• A reciate t e e ects o intraocu ar orei n bodies?
• mana e an intraocu ar orei n bod in t e e er enc
settin ?
CASE 19.7
A 55-year-old armer presents to the ED complaining o
ocular pain and irritation. He reports accidentally splash-
ing ammonia in both eyes. (In Iowa, this is usually rom
cooking meth—but not by armers. Ammonia is used to
produce meth, so meth cookers drill into tanks o anhy-
drous ammonia and problems occasionally ensue when
they don’t ollow proper OSHA handling regulations. See
all the un things we are learning?) He attempted to rinse
his eyes with water prior to coming to the ED. His visual
acuity is OD 20/100 and OS 20/80. Both eyes are injected
with corneal edema.
Question 19.7.1 What is the immediate rst step in the
treatment o chemical injuries to the eye?
A) Complete ocular examination, including dilated undu-
scopic examination
B) Manual removal o particulate material ollowed immedi-
ately by irrigation with saline until the pH is 7.0
C) Application o topical glycerin to clear the corneal edema
D) opical anesthetic with debridement o sur ace epithelium
E) Build rapport by making small talk, asking about his tractor,
etc.
Answer 19.7.1 The correct answer is “B.” Step one: clean
out the chemical. Any particulate matter should be removed
prior to irrigation i it is a reactive substance (e.g., ammonium
hydroxide crystals) since uid may dissolve these causing more
injury. T e upper lid should be everted to check or any par-
ticulate matter. A moistened cotton swab may be used to sweep
the superior/in erior ornices to remove any residual debris.
T en, immediate irrigation with normal saline (or water—i
saline is unavailable) is the next step even be ore completing
the examination. A lid speculum should be placed and topical
anesthesia applied. Irrigation may be administered by a hand-
held bottle or through IV tubing with an irrigation lens. T e
pH should be checked with a pH strip and irrigation discontin-
ued when the pH reaches 7.0.
Question 19.7.2 Which o the ollowing is a complication o
chemical injuries to the eye?
A) Corneal ulceration
B) In ammation
C) De-epithelialization o the cornea
D) All o the above
E) None o the above
Answer 19.7.2 The correct answer is “D.” All o these are com-
plications o chemical injuries to the eye. I you chose “E,” you
should take a break now. You are tired.
HELPFUL TIP:
A ka i burns tend to be ore severe t an acid burns. A -
ka i burns cause ocu ar sur ace da a e b sa oni in
att acids in ce e branes. A ka ine a ents readi
enetrate t e cornea causin de radation. Acids cause
rotein denaturation, w ic creates a barrier to en-
etration. T ere ore, acids cause ess tissue destruction.
Nerve destruction a cause a decrease in sensitivit
to t e e e, so absence o burnin sensation is not ad-
equate to deter ine w et er urt er irri ation is need-
ed. Check the pH as noted above.
Objectives: Did you learn to . . .
• Describe t e di erence between acid and a ka i injuries to
t e e e?
• Treat a c e ica e e ex osure in t e e er enc settin ?
• Reco nize t e co ications o c e ica e e injuries?
 CHAPTER 19 • Oph Th Al mOl Og y 537

CASE 19.8
A 25-year-old college student complains o redness, sensitiv-
ity to light, and tearing o her right eye or the past day. She
lives in the dorm but reports no exposure to others with a
red eye. For the past ew days, she has had a sore throat and
slight cough. You suspect she may have the dreaded “pink
eye” (conjunctivitis).

Question 19.8.1 Regarding conjunctivitis, which o the ol

lowing is FALSE?
A) Gonococcal conjunctivitis presents with severe hyperacute
purulent discharge
B) Adenoviral conjunctivitis generally begins in one eye and
spreads to the other eye
FIGURE 19-8. Vira conjunctivitis. Note t e o ic es t at are round co ection
C) An enlarged preauricular node is a sign o allergic conjunc- o oc tes in t e in erior ornix.
tivitis
D) oxic conjunctivitis has been associated with the use o topi-
cal antibiotics, antivirals, and preservatives
used, a er other etiologies such as herpetic lesions have been
Answer 19.8.1 The correct answer (and FALSE one) is “C.” ruled out, or 1 week then tapered to prevent signi cant scarring.
T ere is no enlargement o preauricular nodes with aller- However, this is rare. See Figure 19-8 or an image o hemor-
gic conjunctivitis. An enlarged preauricular node is a rhagic viral conjunctivitis generally rom adenovirus, enterovi-
prominent eature o adenoviral conjunctivitis—which is rus and coxsackie virus. It is highly contagious.
extremely contagious (and no matter what the school says,
does not respond to antibiotic eye drops). Allergic conjunc-
tivitis tends to itch and a ect both eyes. All other statements
HELPFUL TIP:
are true.
Antibiotics ave a ica owers in vira conjunctivitis.
h ow e se can ou ex ain t e act t at a sin e dose o
Your patient has no purulent drainage. On examination, her
to ica antibiotics is enou to et a c i d back into
visual acuity is 20/40. Her right eye is di usely injected and
sc oo or da care? most sc oo s and da care o icies
tearing; the le eye appears normal to inspection. She has a
require t e c i d to be on so e sort o dro s (o an
slightly tender right preauricular lymph node about 1 cm in
sort) in order to return. In rea it , even wit bacteria
size.
conjunctivitis, t ere is itt e di erence between antibi-
otics and arti icia tears at 6 da s . . . and ost o t e
Question 19.8.2 What do you recommend as the initial
eo e we treat ave vira conjunctivitis an wa ak-
treatment o this patient’s conjunctivitis?
in t e NNT u e.
A) Symptomatic treatment with arti cial tears our to eight
times per day, cool compresses, and strict hygiene to prevent
spread to the other eye or to other individuals
B) reatment with topical vasoconstrictors/antihistamines Question 19.8.3 I your patient is a part time nursing assis
QID or 1 to 2 weeks tant at a care acility, how long should she stay away rom
C) opical antibiotic treatment or 1 week so she can go back to patient care?
class A) wo days
D) Administration o topical steroids, arti cial tears, and cool B) wo weeks
compresses C) Until her eyes are clear
D) Until she has taken antibiotics or 24 hours
Answer 19.8.2 The correct answer is “A.” T is patient appears
to have viral conjunctivitis, which is treated symptomatically. Answer 19.8.3 The correct answer is “C.” Viral conjunctivitis
T ere is no need to treat with topical vasoconstrictors and/or is highly contagious and is thought to be in ectious as long as
antihistamines unless there is a signi cant itching component. the eye is red and producing discharge. Promote good hand
It’s not bacterial, so no antibiotics are needed. Additionally, hygiene and avoidance o contact with others until the eye
prophylactic antibiotics are not necessary since there is rarely clears. In many instances, complete removal rom school and/or
a secondary bacterial in ection. Occasionally, corneal subepi- work is not easible, but patient education regarding the highly
thelial in ltrates will develop that reduce vision and cause a contagious nature o viral and bacterial conjunctivitis remains
oreign-body sensation. In these cases, topical steroids may be important.
538 FAmIl y mEDICINE EXAmINATION & BOARD REVIEW
FIGURE 19-9. Bacteria conjunctivitis. Note t e uco uru ent disc ar e.
Question 19.8.4 Which o the ollowing is appropriate in
the management o acute gonococcal conjunctivitis?
A) Conjunctival Gram stain and culture
B) Ce riaxone IM/IV
C) Saline irrigation
D) All o the above
E) None o the above
Answer 19.8.4 The correct answer is “D.” he hallmark o
acute gonococcal conjunctivitis is severe purulent discharge,
which occurs within 12 to 24 hours o in ection. Preauricu-
lar adenopathy may also be seen. Management consists o
Gram stain and culture o the purulent material to document
gonococcus, administration o ce triaxone (or spectinomy-
cin i cephalosporin allergic) IM/IV plus azithromycin ( or
possible concurrent chlamydia in ection), and eye irrigation.
Fluoroquinolones are no longer recommended a s initial
therapy. See Figure 19-9 or an image o bacterial conjuncti-
vitis and Figure 19-10 or an image O Gonococcal ophthal-
mia neonatorum.
FIGURE 19-10. O t a ia neonatoru . Note t e severe uco uru ent
disc ar e.
Question 19.8.5 Which o the ollowing is NOT indicated in
the treatment o allergic conjunctivitis?
A) Cool compresses
B) Arti cial tears
C) Chronic topical vasoconstrictors/antihistamines
D) Short-term topical steroids
E) Diphenhydramine
Answer 19.8.5 The correct answer is “C.” Given the pos-
sibility o rebound hyperemia with prolonged use, chronic
vasoconstrictors/antihistamines are never indicated. opical
steroids should be reserved or severe cases and tapered over 1
to 2 weeks. opical NSAIDs (ketorolac) and antihistamines or
mast cell stabilizers (levocabastine or olopatadine) may be used
to alleviate intense itching but are very expensive. Ketoti en
is an e ective and inexpensive O C mast cell stabilizer and
H1-antihistamine that, when used routinely, greatly decreases
allergic conjunctivitis symptoms.
Objectives: Did you learn to . . .
• Di erentiate a on vira , bacteria , and a er ic
conjunctivitis?
• Not rescribe o t a ic antibiotics or vira conjunctivitis—
ou ot t at, ri t?
• C oose a ro riate treat ents oda ities or t e various
causes o conjunctivitis?
CASE 19.9
A patient complains o possible oreign body in her eye. She
was scraping barnacles o the bottom o her multi-million
dollar yacht currently dry-docked right next to one o Don-
ald rump’s (Could she be a radiologist? Maybe a plastic sur-
geon?). She elt something f y into her eye and had immediate
pain.
Question 19.9.1 Which o the ollowing is FALSE regarding
the use o topical f uorescein, which is used to highlight
epithelial de ects o the cornea?
A) Fluorescein is a nontoxic, water-soluble dye
B) It uoresces under a cobalt blue lter
C) It exhibits positive staining o epithelial de ects
D) Fluorescein does not penetrate the cornea
Answer 19.9.1 The correct answer is “D.” Fluorescein does di -
use through the corneal stroma and causes a green are in the
anterior chamber. Rapid staining o the anterior chamber a er
the removal o a corneal oreign body suggests a large, deep cor-
neal injury.
HELPFUL TIP:
Always evert t e u er e e id to ook or additiona
orei n bodies. T ese can be re oved usin a cotton-
ti ed swab. Irri ation a a so be use u .

During your complete examination, you notice a small f eck
o what looks like paint on the cornea. A er success ully
removing the piece o paint, you plan to discharge the patient.
Question 19.9.2 Which o the ollowing is NOT an appropri
ate treatment or corneal abrasions?
A) Observation alone
B) opical antibiotics
C) Cycloplegics
D) opical steroids
E) Patching
Answer 19.9.2 The correct answer is “D.” In uncomplicated
corneal abrasions in non-contact lens wearers, observation alone
is o en adequate. Antibiotics should be used or all contact lens–
related abrasions (or in non-wearers i you are particularly wor-
ried about the wound). opical broad-spectrum antibiotics, such
as polymyxin B/trimethoprim, are good rst-line choices in those
without contact lenses. A topical uoroquinolone can be used
in contact lens wearers. T e patients should also be advised to
withhold contact lens use until the abrasion is healed and should
be evaluated by their contact lens prescribing provider. In many
cases a bandage contact lens may be utilized by the patient’s eye
care provider to improve com ort and aid in healing. Patching
may also be used or patient com ort but is unnecessary and may
actually increase pain and prolong healing time. opical steroids
may inhibit epithelial healing and promote in ection and should
be avoided. “C” deserves special mention. Use o a long-acting
cycloplegic is acceptable or discom ort related to severe pho-
tophobia and blepharospasm secondary to corneal abrasions.
However, there is no data supporting (or re uting) their use in
the treatment o corneal abrasions themselves.
HELPFUL TIP:
mu ti e vertica cornea abrasions su est a orei n
bod under t e u er id ( orei n-bod “trackin ”).
B inkin and c osin t e e e wi eave an abrasion on
t e cornea. Evert t e e e id and swee t e ornices wit
a oistened cotton swab to re ove an residua or-
ei n bod .
As you already know, most corneal abrasion should heal
within 24 to 48 hours. You ask the patient to ollow up the next
day to make sure that things are going well. On arrival (the
act that she ollowed up at all rules out the possibility that
she is a physician . . . maybe an investment banker?), she notes
increased pain in the eye with increased injection and photo-
sensitivity. You place anesthetic drops in her eye but the pain
does not resolve. T e corneal abrasion seems to be healed.
Question 19.9.3 What do you expect to see on slit lamp
examination in her anterior chamber?
A) Cells and are
B) Opacity o the lens
CHAPTER 19 • Oph Th Al mOl Og y 539
C) Foreign bodies o Schlemm
D) A tear o the anterior lens capsule
Answer 19.9.3 The correct answer is “A.” his patient is pre-
senting with typical posttraumatic iritis. Findings would be
“cell and lare” in the anterior chamber. “B” and “D” are obvi-
ously not going to be a result o a super icial corneal abra-
sion. “C” is something we made up, but “Canal o Schlemm”
is part o the eye and one o our avorite names in medicine—
it is just humorous (humorous, get it? . . .ah, poor Schlemm).
HELPFUL TIP:
Iritis, a so ca ed anterior uveitis, c aracteristica
resents wit ci iar us (a red rin around t e iris)
wit out tearin or disc ar e. On s it- a exa ina-
tion, t e “ce and are” are due to individua in a -
ator ce s and o -a earin rotein eaked ro
b ood vesse s.
Question 19.9.4 Appropriate treatment or this patient
with post traumatic iritis includes which o the ollowing?
A) opical antibiotics
B) Cycloplegic agents
C) opical steroids
D) A, B, and C
E) B and C only
Answer 19.9.4 The correct answer is “E.” Post-traumatic iritis
is generally treated with topical steroids and cycloplegic agents.
Again, we usually do this in consultation with an eye care pro-
vider. O special note is “C.” While we all worry about promoting
in ection with topical steroids, they can also increase intraocu-
lar pressure, and when used chronically, can cause glaucoma,
which is generally more o a concern. So, these patients require
close ollow-up.
Assume that this patient was presenting de novo with iritis
and it is not post-traumatic.
Question 19.9.5 Which o the ollowing do you NOT have to
worry about as an etiology o iritis?
A) Rheumatoid arthritis
B) Diabetes mellitus
C) Syphilis
D) Sarcoid
E) Lyme disease
Answer 19.9.5 The correct answer is “B.” Iritis is an in amma-
tory process that can be caused by multiple underlying illnesses
including ankylosing spondylitis, lupus (rarely), Behcet disease,
syphilis, sarcoid, B, Reiter syndrome, toxoplasmosis (com-
mon, even in non-immunosuppressed), juvenile idiopathic
arthritis, and many others.
540 FAmIl y mEDICINE EXAmINATION & BOARD REVIEW
Objectives: Did you learn to . . .
• Re ove a cornea orei n bod ?
• Use to ica uorescein in cornea abrasions?
• mana e unco icated cornea abrasions?
• Reco nize iritis and its causes?
CASE 19.10
A 65-year-old white male with a history o hypertension,
adult-onset diabetes, rheumatoid arthritis, and rosacea
presents with chronic complaints o redness, tearing, and
irritation OU. He sometimes also has “a lm over his vision”
that comes and goes. His ocular examination appears nor-
mal. He does, however, have an oily tear lm with rapid
breakup o his tears over his ocular sur ace. T ere is evi-
dence o capped meibomian glands (sebaceous glands along
his lid margins), but the eyelids are otherwise normal in
appearance.
Question 19.10.1 Which o the ollowing is the most likely
diagnosis?
A) Meibomian gland dys unction
B) Staphylococcal blepharitis
C) Hordeolum
D) Chalazion
E) Seborrheic blepharitis
Answer 19.10.1 The correct answer is “A.” Meibomian glands
are the sebaceous glands o the upper and lower eyelids, which
are located along the posterior lid margin behind the lashes.
T ese are punctate openings along the lid margin, which
become clogged with thick secretions. When coupled with
chronic in ammation o the lid margin, this eventually leads
to an unstable tear lm, creating symptoms o burning, red-
ness, oreign-body sensation, and lmy vision. It is considered
a orm o blepharitis (in ammation o the eyelids). “B” and “E”
are incorrect. Staphylococcal and seborrheic blepharitis have
similar symptoms but involve the anterior eyelid margin at the
base o the lashes (not the meibomian glands as noted in this
case). Both typically have predominant signs o crusting or
mattering. Seborrheic blepharitis o en has crusting o an oily
or greasy consistency. “C” and “D” are in ammatory processes,
commonly but incorrectly grouped together as “styes.” A hor-
deolum a ects the anterior lid margin glands, which become
acutely plugged and in amed. A chalazion a ects the poste-
rior lid margin glands, which become plugged and chronically
in amed. “Stye” is typically synonymous with hordeolum; how-
ever, both hordeolum and chalazion grossly appear similar on
examination.
Question 19.10.2 What part o his past medical history is
associated with meibomian gland dys unction?
A) Hypertension
B) Diabetes
C) Rheumatoid arthritis
D) Rosacea
Answer 19.10.2 The correct answer is “D.” Meibomian gland
dys unction is associated with rosacea. ypical ndings o rosa-
cea include acial papules, pustules, telangiectasia, erythema,
and rhinophyma.
Question 19.10.3 What treatment do you prescribe or this
patient?
A) Observation and reassurance
B) Daily warm compresses, lid scrubs with dilute baby sham-
poo, and oral doxycycline, minocycline, or metronidazole
C) Erythromycin ophthalmic ointment PRN
D) Daily warm compresses, topical steroids, and requent use o
arti cial tears
Answer 19.10.3 The correct answer is “B.” T e treatment
o meibomian gland dys unction consists o lid hygiene and
doxycycline or minocycline 50 to 100 mg daily to BID or 3
to 6 weeks (which will also help treat the rosacea). T e dosage
may then be tapered according to symptoms. Gastrointestinal
upset and photosensitivity are common side e ects o doxy-
cycline.
Seborrheic blepharitis is o en treated with aggressive lid
hygiene. opical steroids are only used or short duration i
there is signi cant in ammation present and should generally
be prescribed by an ophthalmologist or optometrist or this
condition. opical therapies such as cyclosporine emulsion
are aimed at lubrication and addressing chronic in ammation
and are now available by prescription but are expensive and
not that e ective. Over-the-counter lubricating arti cial tears
can improve com ort but generally don’t resolve the underly-
ing condition.
Question 19.10.4 Which o the ollowing is a common com
plication o meibomian gland dys unction?
A) Bacterial keratitis
B) Preseptal cellulitis
C) Chalazion
D) Scleritis
E) Chronic conjunctivitis
Answer 19.10.4 The correct answer is “C.” Meibomian gland
dys unction can cause a chronic granuloma to orm behind
the plugged meibomian gland, which is called a chalazion. T e
in ammation is sterile—unlike a hordeolum (“stye”), which is
a pain ul purulent abscess. reatment o a chalazion involves
requent warm compresses and massage. opical antibiotics are
o little value since it is sterile. I these measures ail, an intra-
lesional injection o steroids or incision and drainage is war-
ranted. Hordeola (styes) o en resolve spontaneously but warm
compresses and massage are o en help ul. I there is any evi-
dence o cellulitis, systemic oral antibiotics are indicated. Drain-
age using a needle may also be help ul. opical antibiotics are
o en not e ective.
Objectives: Did you learn to . . .
• Reco nize t e si ns and s to s o b e aritis and ei-
bo ian and d s unction?

• Describe t e etio o ies o b e aritis and eibo ian and
d s unction?
• Di erentiate a on eibo ian and d s unction and
sta ococca and seborr eic b e aritis?
• Deter ine a ro riate treat ent or b e aritis and eibo-
ian and d s unction and t e co ications o ordeo a
and c a azion?
CASE 19.11
A 7-year-old emale presents with pain ul swelling and red-
ness o upper and lower lids o her right eye. She reports hav-
ing a bug bite near her right eye a week ago, and it’s been
very itchy. Now, it has become more erythematous and pain-
ul (in ected, one might even say). On examination, her right
eyelids are extremely edematous with a well-demarcated
area o erythema. Her ocular examination is normal, includ-
ing normal vision. She has no RAPD, proptosis, or motility
de cit.
Question 19.11.1 This presentation is most consistent with:
A) Orbital cellulitis
B) Preseptal cellulitis
C) Anaphylactoid reaction to the insect bite
D) Blepharitis
E) None o the above
Answer 19.11.1 The correct answer is “B.” he presentation
o this patient is consistent with preseptal cellulitis, which
is de ined as in lammation/in ection anterior to the orbital
septum. his is less dangerous than orbital cellulitis, which
occurs posterior to the orbital septum and has the risk o
spread o in ection into adjacent structures. “A” is incor-
rect. In ection occurring posterior to the orbital septum is
called orbital cellulitis. his is characterized by ever, pro-
ptosis, restriction o globe motility, chemosis, and pain on
eye movements. Orbital cellulitis can be complicated by sub-
periosteal abscess, cavernous sinus thrombosis, meningitis,
or intracranial abscesses. “C” is incorrect since an anaphy-
lactoid reaction is systemic.
Question 19.11.2 Which o the ollowing is TRUE?
A) T e most common cause o preseptal cellulitis in children is
sinusitis
B) T e most common cause o preseptal cellulitis in teens and
adults is sinusitis
C) Orbital cellulitis is most commonly caused by bacteremia
rom a secondary source, as opposed to direct spread rom
an adjacent structure
D) T e most common secondary source or orbital cellulitis is
otitis media
Answer 19.11.2 The correct answer is “A.” T e most common
cause o preseptal cellulitis in children is sinusitis. In contrast,
teens and adults usually have preseptal cellulitis rom a super -
cial source, such as skin trauma with inoculation.
CHAPTER 19 • Oph Th Al mOl Og y 541
HELPFUL TIP:
Both orbita ce u itis and rese ta ce u itis are
co on secondar to sinusitis. Bot rese ta and
orbita ce u itis a a so occur ro direct inocu ation or
bactere ia ro a distant source.
Question 19.11.3 The most common pathogen causing
preseptal cellulitis rom a skin trauma with inoculation is
which o the ollowing?
A) Staphylococcus epidermidis
B) Haemophilus inf uenzae
C) Staphylococcus aureus
D) Streptococcus pneumoniae
Answer 19.11.3 The correct answer is “C.”S. aureus is the most
common pathogen o preseptal cellulitis rom skin trauma. Some
may have chosen “B.” Prior to the introduction o the HIB vac-
cine, children younger than 5 years o en had preseptal cellulitis
secondary to H. inf uenzae. However, this is no longer the most
common pathogen. Most cases o preseptal and orbital cellulitis
in children are caused by Gram-positive cocci. Orbital cellulitis
in children is usually caused by a single organism. In contrast,
adults with orbital cellulitis requently have polymicrobial in ec-
tions including Gram-positive cocci, H. inf uenzae, and anaer-
obes. Mucormycosis should be suspected in diabetic patients
and immunocompromised individuals.
HELPFUL TIP:
Orbital cellulitis is an o t a o o ic e er enc . In
addition to s read to ot er structures (e. ., cavernous
sinus t ro bosis), orbita ce u itis a cause a tense
ro tosis eadin to b indness. T ink about t is as a
“co art ent s ndro e o t e e e.” A co art ent
s ndro e (and b indness) can a so be seen wit trau-
a and secondar intraorbita ( ostse ta ) b eedin or
retrobu bar e ato a eadin to ro tosis. T e treat-
ent is e er ent atera cant oto .
Objectives: Did you learn to . . .
• Di erentiate between orbita and rese ta ce u itis?
• Reco nize conditions t at redis ose atients to t ese
rocesses?
CASE 19.12
A 67-year-old white man with a history o coronary artery
disease, hypertension, and peripheral vascular disease pres-
ents with the sudden onset o painless loss o vision OD sev-
eral hours ago. He states he was watching V when “things
went black” in his right eye. He notes that this happened a ew
times be ore, but his vision always returned to normal a er a
couple o minutes. On examination, he has light perception
542 FAmIl y mEDICINE EXAmINATION & BOARD REVIEW
FIGURE 19-11. A centra retina arter occ usion. Note t e c err -red s ot
in t e acu a, w ic is t e nor a c oroida circu ation a idst t e isc e ic
retina.
vision, the presence o a RAPD, and a normal anterior seg-
ment o the eye. Upon unduscopic examination, the undus
appears di usely white with a reddish hue within the macula
(see Fig. 19-11).
Question 19.12.1 The patient’s history and examination are
most consistent with which o the ollowing?
A) Central retinal vein occlusion
B) Anterior ischemic optic neuropathy
C) Central retinal artery occlusion
D) Choroidal ischemia
Answer 19.12.1 The correct answer is “C.” A central reti-
nal artery occlusion is characterized by acute painless loss o
vision. T e ischemia and edema o the retina cause di use whit-
ening. T ere is a cherry-red spot in the macula, which is the
normal choroidal circulation amidst the ischemic retina (see
Figure 19-11). T e extensive ischemia causes a RAPD and sig-
ni cant visual loss. His previous history o recurrent episodes o
loss o vision that returned to normal is consistent with amau-
rosis ugax.
Question 19.12.2 In a patient with this history, irreversible
retinal damage occurs a ter what time rame?
A) 10 minutes
B) 30 minutes
C) 90 minutes
D) 6 hours
Answer 19.12.2 The correct answer is “C.” I central retinal
artery occlusion is complete or more than 90 minutes, irre-
versible retinal damage and visual loss ensue. Patients should
seek medical care immediately. Amaurosis ugax, or transient
monocular blindness, is typically caused by carotid disease. It is
o en described as a curtain or shade coming over the vision. It
lasts rom a ew seconds to 15 minutes. Patients with a history
o amaurosis ugax should be evaluated or carotid and cardiac
disease.
Question 19.12.3 Treatment or central retinal artery occlu
sion includes all o the ollowing EXCEPT:
A) T rombolytics
B) Digital compression/decompression o the globe
C) Oxygen
D) Increasing blood carbon dioxide levels (e.g., rebreathing)
E) Acetazolamide
Answer 19.12.3 The correct answer is “A.”T erapy or central ret-
inal artery occlusion is entirely aimed at dislodging the embolism,
maintaining retinal viability, and reducing intraocular pressure (to
increase the pressure gradient between the artery and the eye). T is
can be accomplished by digitally compressing (press hard!) then
decompressing the eye with a nger (to dislodge the embolism),
oxygen (which will increase oxygen delivery), increasing serum
carbon dioxide levels by rebreathing (thus dilating intracranial
arteries), and acetazolamide (to reduce intraocular pressure). o
accomplish the goals o increasing oxygen and carbon dioxide, try
using a nonrebreather acemask with supplemental oxygen.
Question 19.12.4 Comparing central retinal artery occlu
sion to central retinal vein occlusion, which o the ollowing
is TRUE?
A) Central retinal artery occlusion is more likely to be associ-
ated with giant cell arteritis
B) T e main eature o both is retinal whitening with a cherry
red spot
C) Central retinal vein occlusion usually results rom atheroscle-
rotic thrombosis, while central retinal artery occlusion results
rom hyperviscosity syndromes and hypercoagulable states
D) A RAPD is characteristic o central retinal artery occlusion
but is not seen with central retinal vein occlusion
Answer 19.12.4 The correct answer is “A.” Giant cell arteritis
is seen in 1% to 2% o central retinal artery occlusion. However,
a more limited anterior ischemic retinopathy is generally seen
with giant cell arteritis. I a patient presents with symptoms o
central retinal artery occlusion, but no embolus is visualized, he/
she should be asked about symptoms o giant cell arteritis. “B” is
incorrect because only central retinal artery occlusion is associ-
ated with retinal whitening and a cherry red spot. T e appear-
ance o a central retinal vein occlusion is one o tortuous dilated
veins, optic nerve edema, and intraretinal hemorrhages/edema
(the so-called “blood and thunder” appearance o the undus—
although since thunder is a sound, having something look like
thunder makes no sense to us, but maybe we are just too literal.)
“C” is incorrect because central retinal artery occlusion is usu-
ally caused by atherosclerotic thrombosis or emboli, while cen-
tral retinal vein occlusion is associated more with hyperviscosity
syndromes (e.g., polycythemia) and hypercoagulable states (e.g.,
protein C de ciency). In older patients with central retinal vein
occlusion, the main risk actors include vasculopathic states such
as hypertension and diabetes. “D” is incorrect because a RAPD
can be seen with either syndrome. T ere is always an RAPD with
a central retinal artery occlusion due to the di use distribution
o ischemia. A RAPD may or may not be seen with a central reti-
nal vein occlusion depending on the level o ischemia.

FIGURE 19-12. Centra retina vein occ usion. Note t e di ated tortuous
veins, o tic disc ede a, and retina e orr a e/ede a.
HELPFUL TIP:
Ot er causes o centra retina arter occ usion inc ude
vascu itides and b ood d scrasias. Ot er causes o cen-
tra retina vein occ usions inc ude increased intraorbita
or intraocu ar ressure, auco a, b ood d scrasias, u-
us anticoa u ant, anti os o i id antibod , and ro-
tein C de icienc . See Fi ure 19-12 or an i a e o t e
retina in centra retina vein occ usion.
Question 19.12.5 Further evaluation and treatment o a
central retinal artery occlusion includes all o the ollowing
EXCEPT:
A) opical timolol
B) ESR/CRP
C) Carotid doppler
D) Orbital MRI/MRA
E) Echocardiogram
Answer 19.12.5 The correct answer is “D.” T ere is no need
or orbital imaging in the management o a central retinal artery
occlusion. All o the other choices are important management
steps. In addition, blood pressure, asting blood sugar or gly-
cosylated hemoglobin, CBC, and P /P should be done. I
there is a suspicion o giant cell arteritis, an ESR/CRP should be
checked. Other tests might include a rheumatoid actor, syphilis
serology, serum protein electrophoresis, and antiphospholipid
antibodies. A similar workup is warranted in central retinal
vein occlusion, except there is no need to search or an embolic
source with a carotid doppler and echocardiogram.
Objectives: Did you learn to . . .
• Reco nize t e s to s o vascu ar disorders o t e e e?
• Di erentiate between centra retina arter and vein occ u-
sions?
• Describe so e causes o ocu ar vascu ar occ usions?
• Deter ine t e a ro riate s ste ic worku or arter and
vein occ usions?
CHAPTER 19 • Oph Th Al mOl Og y 543
CASE 19.13
A 40-year-old white emale presents to your ED complain-
ing o seeing “little f oating black spots” in her vision in
the le eye. She also notes little sparks o light in the tem-
poral periphery o the le eye. She noted this while shop-
ping today at Wal-Mart. First, you think this may be the
revenge o the gods or shopping at Wal-Mart instead o
buying locally. But then, you gather your wits about you.
On examination, there is no RAPD (she has normal direct
and consensual pupillary ref exes). Con rontation visual
elds demonstrate peripheral vision loss in the le eye.
Dilated peripheral retinal examination reveals billowing
gray olds. T e macula appears normal, and her vision is
20/20 in that eye.
Question 19.13.1 Which o the ollowing is the most appro
priate step in the management o this patient?
A) Place a patch over the le eye
B) Re er to an ophthalmologist immediately
C) Lower blood pressure acutely with IV labetalol
D) Apply timolol solution to the a ected eye
E) O er reassurance
Answer 19.13.1 The correct answer is “B.” T is patient is
presenting with urgent ophthalmologic disease. She has clas-
sic symptoms o retinal detachment— ashing lights, visual
eld disruption, and oaters. Also, the majority o her vision
is still intact. In her current state, she has a high likelihood o
retaining good vision. None o the other treatments o ered
do anything or retinal detachment. Speci cally, “A” does
nothing, “C” is treatment or hypertensive retinopathy, “D” is
or glaucoma, and “E” is just plain nuts in this case.
Question 19.13.2 Risk actors or retinal detachment
include all o the ollowing EXCEPT:
A) Glaucoma
B) Aphakia (surgical removal o the lens, such as in cataract
surgery)
C) Myopia
D) rauma
E) Prior ocular surgery
Answer 19.13.2 The correct answer is “A.” Glaucoma is
not a risk actor or retinal detachment. Both myopia (near-
sightedness) and aphakia (surgical removal o lens) are risk
actors. rauma and previous surgery also predispose to
retinal detachments. Most persons with retinal detachment
are older than 50 years. As patients age, the vitreous liqui ies
and contracts, and this vitreoretinal traction or tugging can
cause a tear, detaching the retina rom the posterior wall o
the eye.
Objectives: Did you learn to . . .
• Sus ect retina detac ent in atients resentin wit
“ oaters” and “ as es?”
• Identi atients w o are at risk or retina detac ent?
544 FAmIl y mEDICINE EXAmINATION & BOARD REVIEW
CASE 19.14
A 55-year-old white male complains o a gradual decrease in
vision in both eyes. He notes glare with oncoming headlights
while night driving. Despite this, he eels that he is able to
read better without his bi ocals.
Question 19.14.1 Based on the history given, which o the
ollowing is the most likely cause o this patient’s com
plaints?
A) Retinal detachment
B) Cataracts
C) Glaucoma
D) Diabetic retinopathy
E) Presbyopia
Answer 19.14.1 The correct answer is “B.” Progressive visual
loss and glare rom oncoming headlights while driving at night
are common complaints caused by cataracts. T e eye examina-
tion can con rm the diagnosis, as most signi cant cataracts are
easily visualized. T e red re ex is diminished bilaterally, and
a haze o gray is observed over the lens. Symptoms o retinal
detachment (“A”) are more acute. Glaucoma (“C”) and diabetic
retinopathy (“D”) are less likely, but could also be present. Intra-
ocular pressures and a dilated eye examination should be com-
pleted to adequately assess and diagnose the patient’s condition.
Question 19.14.2 All o the ollowing conditions/medica
tions are risk actors or cataract ormation EXCEPT:
A) Corticosteroids
B) rauma
C) Radiation
D) Calcium channel blockers
E) Diabetes mellitus
Answer 19.14.2 The correct answer is “D.” All o the other
choices are associated with cataract ormation. Other risk ac-
tors include age, tobacco, alcohol, and sunlight (so, wear your
UV blocking shades!).
Question 19.14.3 O all o the patients with cataracts below,
which one has an indication or cataract surgery?
A) A patient with no visual complaints with a visual acuity o
20/50
B) A patient with complaints o glare and inability to drive at
night with a visual acuity o 20/40
C) An older patient with a history o monocular congenital cat-
aract and best-corrected visual acuity o 20/100 in that eye
D) A patient with right monocular diplopia that resolves with
new spectacle correction
Answer 19.14.3 The correct answer is “B.” T ere is no strict
visual acuity that determines the appropriate timing o cataract
surgery. It is really a unctional de nition. I there are signi -
cant li estyle limitations secondary to visual disability rom a
cataract, then cataract surgery is (potentially) indicated. “C” is
incorrect. An older person with a history o congenital cataracts
and poor best-corrected visual acuity most likely su ered rom
amblyopia; there ore, cataract surgery is unlikely to bene t such
a patient. “D” is incorrect. Monocular diplopia (double vision
rom one eye only) is an indication or cataract surgery, but i
new spectacle correction improves the diplopia, then cataract
surgery is not necessary.
Question 19.14.4 Complications o cataract surgery include
all o the ollowing EXCEPT:
A) Endophthalmitis
B) Retinal detachment
C) Glaucoma
D) Hemorrhage
E) Meibomian gland dys unction
Answer 19.14.4 The correct answer is “E.” Meibomian gland
dys unction is a chronic condition as discussed previously in
this chapter. Modern day cataract surgery is typically done by
phacoemulsi cation with an intraocular lens implant. Phaco-
emulsi cation is an ultrasound method o ragmenting and
aspirating the cataract. Although associated with ewer compli-
cations than older large incision cataract surgery techniques, the
potential complications mentioned above still exist. Additional
complications include: wound leaks, uveitis, macular edema,
retained lens material, and vitreous loss.
HELPFUL TIP (AND ONE THAT MAY BE ON THE
BOARDS):
One o our avorite disease na es (besides “ex odin
ead s ndro e” . . . rea , ook it u ) is “ o iris s n-
dro e.” T is occurs w en atients on a a-b ockers
(usua en or Bph ) o or cataract sur er . T e resu t
is an iris t at irreversib ro a ses durin cataract sur-
er . h ow on t is e ect o a a-b ockers ast a ter
ast usa e is not known so be care u w en su estin
sur er to t ese atients.
Objectives: Did you learn to . . .
• Identi atients at risk or cataract deve o ent?
• Describe indications or cataract sur er ?
• Reco nize t e s to s and visua disabi it in t ose wit
ro ressive cataracts?
QUICK QUIZ: SOmETh INg ON Th E EyE
A patient presents to your clinic without vision symptoms
but complains o a growth on the colored part o his eye
(Fig. 19-13). T e growth is painless and has been present or
several years but is now getting to the point that it is pretty
obvious. Strangers tend to stare. Children run the other way
when they see him coming. He cries himsel to sleep every
night because o this.

FIGURE 19-13.
T is growth is most likely due to:
A) Systemic in ammatory illness
B) Exposure to UV light and dust
C) Foreign-body granuloma
D) rauma to the sclera and cornea with scarring
E) Any o the above can lead to this nding
The correct answer is “B.” T is is a pterygium, an overgrowth
o conjunctival tissue, which is a result o recurrent exposure to
UV light and high winds with dust. It is o no clinical signi -
cance unless it encroaches on the visual eld or causes cosmetic
distress. It is characterized by involvement o the cornea nasally
or temporally as opposed to a pinguecula, which has a similar
appearance but does not in ringe upon the cornea. Care ul his-
tory taking o en uncovers a patient history o outdoor li estyle
( arming, construction, boating, etc.) or residing in a region
more equatorial and, thus, more pleasant in February than the
40 degrees north latitude and sub-zero temps we endure here in
the Hawkeye state.
QUICK QUIZ: pAINFUl EyE
A 40-year-old patient presents with a pain ul, red area on the
eye (Fig. 19-14). He notes the gradual onset o severe pain o a
boring nature with pain in the periocular area as well. He has a
history o rheumatoid arthritis.
What is the diagnosis?
A) Episcleritis
B) Pterygium
C) Scleritis
D) Pinguecula
E) Epidemic hemorrhagic conjunctivitis
The correct answer is “C.” T is is scleritis. Note the erythema
and in ammation, which di erentiates it rom a pterygium.
Scleritis may also be nodular in nature or di use. Scleritis can
be easily mistaken or episcleritis, which may appear similar.
CHAPTER 19 • Oph Th Al mOl Og y 545
FIGURE 19-14.
Episcleritis is in ammation o the tissues overlying the sclera.
One thing that di erentiates episcleritis rom scleritis is that
patients with episcleritis do not have the severity o pain noted
with scleritis. A pinguecula appears as yellowish, slightly raised
nodules that are ound on the conjunctiva nasal or temporal to
the cornea. A pinguecula generally appears in middle age, has
similar risk actors as pterygium, and removal is rarely indicated.
HELPFUL TIP:
E isc eritis wi enera reso ve s ontaneous or wit
a bit o to ica steroid. Scleritis can result in globe
rupture and s ou d be re erred ur ent .
QUICK QUIZ: SCl ERITIS
Which o the ollowing is NO a common cause o scleritis?
A) Wegener granulomatosis
B) Lupus
C) Gout
D) Nephrotic syndrome
E) Rheumatoid arthritis
The correct answer is “D.” Nephrotic syndrome does not gen-
erally represent ongoing in ammation. More than 50% o cases
o scleritis have an associated systemic in ammatory disease
such as gout, lupus, rheumatoid arthritis, ankylosing spondyli-
tis, or herpes zoster.
QUICK QUIZ: my Impl ANTED l ENS
ISN’T WORKINg
A 70-year-old emale presents or a routine medical evaluation.
She reports no problems, but on review o systems she states
that she has had a gradual decrease in vision in the right eye
over the past several months. She had success ul cataract sur-
gery o both eyes 3 years ago. A er the surgery, she had 20/20
546 FAmIl y mEDICINE EXAmINATION & BOARD REVIEW
vision OU. Now on examination, her vision is OD 20/50 and
OS 20/20. She has no RAPD. T e slit-lamp examination o her
anterior segment o both eyes reveals well-positioned bilateral
posterior chamber intraocular lens (PCIOL) implants. T ere
seems to be a hazy membrane behind her lens implant in the
right eye.
T e most likely diagnosis is which o the ollowing?
A) Posterior capsular opacity
B) Endophthalmitis
C) Retinal detachment
D) Posterior uveitis
E) Intraocular lens dislocation
The correct answer is “A.” Months to years a er success ul
cataract surgery, patients may experience a gradual decline in
their vision due to an opaci cation o the posterior capsule
behind their intraocular lens implant. During cataract surgery,
most o the normal capsule o the lens remains and holds the
intraocular lens implant. In success ul cataract surgery, only
the anterior portion o the capsule is removed. T e posterior
portion o this capsule may become hazy over time due to the
proli eration o residual lens epithelial cells. T e patient does
not have any symptoms o in ection or in ammation and re-
ports no ashes or oaters that would eliminate most o the
other choices. An intraocular lens dislocation is rare and is
usually seen in the setting o trauma. reatment or capsular
opaci cation is YAG laser capsulotomy and is per ormed in an
outpatient setting.
CASE 19.15
A 56-year-old white male with a history o hypertension and
diabetes complains o double vision and pain or the past 2
days. On examination, his vision is OD 20/50 and OS 20/25.
He has a larger pupil with a RAPD OD. T e lid o his right eye
is slightly lower than the le . His right eye is deviated slightly
temporally and in eriorly, and he has di culty adducting
and elevating the eye.
Question 19.15.1 The most likely diagnosis is which o the
ollowing?
A) Grave’s disease
B) Horner syndrome
C) T ird nerve palsy
D) Myasthenia gravis
Answer 19.15.1 The correct answer is “C.” T e case presented
is a typical scenario o a third nerve palsy. Patients with a third
nerve palsy present with diplopia ( rom ocular muscle paraly-
sis), ptosis, and a dilated pupil. Recall that the ocular muscles
are innervated by CN3 except or the lateral rectus (CN6) and
the superior oblique (CN4), so the eye will be “down and out”
when the lateral rectus and superior oblique act unopposed
in a third nerve palsy. O en the pupil is spared in diabetic
patients. Pupil involvement should prompt an investigation
or an intracranial aneurysm. “A,” Grave’s disease, may pres-
ent with motility de cits and compression o the optic nerve
resulting in a RAPD. However, Grave’s disease is less likely in
this patient because it should present with lid retraction and
proptosis, not ptosis. Grave’s disease also may cause restriction
o the medial and in erior rectus muscles, which causes dif -
culty abducting and elevating the eye. “B,” Horner syndrome,
may present with ptosis, but the a ected side would have miosis
(not mydriasis as in this patient), and it does not present with
motility de cits. “D,” myasthenia gravis, may present with ptosis
and motility de cit, but these ndings are usually elicited with
atigue and are variable.
Question 19.15.2 The workup o this patient should involve:
A) Cerebral angiography
B) C /C A
C) MRI/MRA
D) Orbital ultrasonography
Answer 19.15.2 The correct answer is “C.” Although cerebral
angiography has long been the gold standard in detecting cere-
bral aneurysms, the rst line and less invasive diagnostic test is
MRI/MRA.
Objectives: Did you learn to . . .
• Dia nose a t ird crania nerve a s and initiate
ana e ent?
Clinical Pearls
A wa s evert t e e e ids in an atient w o a ave a or-
ei n bod in t e e e.
Do not de a ur ent consu tation wit an o t a o o ist in
a atient sus ected o avin orbita ce u itis.
Do not er or routine reo erative tests on atients under-
oin e e sur er un ess t ere is a edica indication.
Do not rescribe antibiotics or vira conjunctivitis.
per or a co ete and t orou o t a o o ic exa ina-
tion and consider i a in or an atient resentin wit
new onset strabis us.
Re er atients wit t e 2 diabetes or di ated e e exa ina-
tion at initia dia nosis. patients wit T e 1 diabetes s ou d
ave a di ated undusco ic exa ination wit in 5 ears o
dia nosis.
Trau atic ro tosis s ou d ave an i ediate eva uation or
ossib e atera cant oto .
ACKNOWLEDGMENTS
Photographs were provided by the Department o Ophthal-
mology, University o Iowa. Special thanks to Dr. Greenlee,
Dr. James Folk, and Dr. Young Kwon or their photograph con-
tributions.
 CHAPTER 19 • Oph Th Al mOl Og y 547

BIBLIOGRAPHY Ozcura F, et al. E ects o central corneal thickness, central

corneal power, and axial length on intraocular pressure
American Academy o Ophthalmology. Basic and Clinical
measurement assessed with Goldmann applanation
Science Course. 2006–2007. San Francisco, CA: American
tonometry. Jpn J Ophthalmol. 2008;52:353–356.
Academy o Ophthalmology; 2006.
Pediatric Eye Disease Investigator Group. T e clinical spectrum
Dickersin K, et al. Surgery or nonarteritic anterior ischemic
o early-onset esotropia: Experience o the Congenital
optic neuropathy. Cochrane Database Syst Rev. 2006;1:
Esotropia Observational Study. Am J Ophthalmol. 2002;
CD001538.
133:102–108.
Evans JR. Antioxidant vitamin and mineral supplements
Sheikh A, Hurwitz B. Antibiotics versus placebo or acute
or slowing the progression o age-related macular
bacterial conjunctivitis. Cochrane Database Syst Rev.
degeneration. Cochrane Database Syst Rev. 2006;2:
2006;2:CD001211.
CD000254.
Shields MB. Textbook o Glaucoma. 5th ed. Philadelphia, PA:
Fingert JH. Primary open-angle glaucoma genes. Eye (Lond).
Lippincott Williams & Wilkins; 2005.
2011;25(5):587–595.
Sowka J, et al. Handbook o Ocular Disease Management.
Liu Y, Allingham RR. Molecular genetics in glaucoma. Exp Eye
Available at http://cms.revoptom.com/handbook/;
Res. 2011;93:331–339.
Accessed December 11, 2011.
Nicholson BP, Schachat AP. A review o clinical trials o anti-
Wormald R, et al. Photodynamic therapy or neovascular
VEGF agents or diabetic retinopathy. Grae es Arch Clin
age-related macular degeneration. Cochrane Database Syst
Exp Ophthalmol. 2010;248:915–930.
Rev. 2007;3:CD002030.
Otolaryngology
Ch is Bu esh
CASE 20.1
A 2-year-old is brought to your o ce by her mother who is
concerned that she has been pulling at her le ear since late
last night and has a ever o 101.3°F. She has had recurrent
bouts o these symptoms, the last o which was 9 months ago.
Each time, the symptoms resolved with one “shot.” She is
alert and interactive. She has some evidence o mucoid dis-
charge rom her nares bilaterally.
Question 20.1.1 Each o the ollowing ndings is diagnostic
o acute otitis media (AOM) EXCEPT:
A) Pro use, purulent ear discharge without other evidence o
otitis externa.
B) Air– uid level behind the tympanic membrane ( M) with
marked redness o the M and poor movement with pneu-
matic otoscopy.
C) Bulging, thickened yellow and red M that does not move
well with pneumatic otoscopy.
D) Bubbles in uid behind the M with impaired mobility o
the M on pneumatic otoscopy.
E) Yellow, opaque M, poor movement with pneumatic otos-
copy, and substantial ear pain.
Answer 20.1.1 The correct answer is “D.” Suspected ear in ec-
tions drive many parents to bring their children to a amily phy-
sician. T ere may be uid in the middle ear that is not in ected
(otitis media with e usion [OME]). In order to diagnose AOM,
you need evidence o uid in the middle ear and in ammation,
and the symptoms should be acute (starting in the last ew days).
Middle ear e usion is diagnosed by (1) bubbles and/or air–
uid level behind the M or (2) two or more o the ollowing:
decreased or absent M movement with pneumatic otoscopy,
opaci cation o the M, and discoloration o the M (yellow,
white, blue). T ese ndings get you to OME but not AOM. o
diagnose AOM, you will need to have OME with evidence o
acute in ammation, such as marked pain, thickened and/or
bulging M, and reddened M. For these reasons, “B,” “C,” and
548
20
“E” are examples o AOM. “A,” purulent otorrhea without evi-
dence o otitis externa, would be the one exception where you
can diagnose AOM without even seeing the M. “D” describes
OME without in ammation.
HELPFUL TIP:
Do ’t be ieve a ed ea d um. B itse , ed ess o the TM
has a 15% positive p edictive va ue o dia osi AOM.
Use pneumatic otoscopy, which is the sta da d o ca e
o dia osi AOM. Tympanometry is a a te ative
to p eumatic otoscop . O cou se, ou sti eed to ook
i the ea .
Your patient’s le M is opaque, red, and immobile upon
pneumatic otoscopy.
Question 20.1.2 Each o the ollowing actors increases her
risk or developing otitis media EXCEPT:
A) She attends day care
B) Her mother smokes inside the house
C) T e patient is a emale
D) Patient still uses a paci er
Answer 20.1.2 The correct answer is “C.” T e ollowing are
known risk actors or the development o AOM: day care atten-
dance, smoking inside the home, male gender, paci er use,
children in developing countries, age between 6 and 18 months,
lack o breast eeding, and going to bed with a bottle.
Question 20.1.3 Which o the ollowing ndings is reliably
ound in patients with AOM?
A) Fever
B) Ear pulling
C) Irritability
D) Rhinitis
E) None o the above

Answer 20.1.3 The correct answer is “E.” None o the above is
reliably ound in patients with AOM. Other unreliable actors
include vomiting, diarrhea, and cough. T e presence or absence
o any o these ndings is not help ul in making the diagnosis
o otitis media. Note that while ear pain is a symptom o in am-
mation, it is a relatively weak predictor o AOM and must be
accompanied by other ndings as listed above. However, pneu-
matic otoscopy or otoscopy plus tympanometry is the way to
make the diagnosis, but always make sure that you have a good
seal or you run the risk o a “ alse-positive” nding.
HELPFUL TIP:
A chi d e < 6 mo ths o a e with otitis media shou d
be t eated with a tibiotics. Patie ts om 6 mo ths to
2 ea s shou d eceive a tibiotics i the diagnosis is
suspected and the patient meets high-risk criteria
(mode ate-to-seve e ea pai , eve > 39°C, immu o-
supp essed). I patie ts 6 mo ths to 2 ea s, obse -
vatio is a optio i the meet ow- isk c ite ia ( eve
< 39°C, mi d ota ia, immu ocompete t, u i ate a
AOM, and o ow-up assu ed withi 48–72 hou s). Pa-
tie ts with p ove AOM who a e o de tha 2 ea s
ma be obse ved athe tha t eated with a tibiotics as
o as the meet ow- isk c ite ia. A a esics shou d be
ive to a patie ts. The e’s a so the optio o p ovid-
i a “backup” a tibiotic p esc iptio (e do sed b the
Ame ica Academ o Pediat ics) o the patie t to sta t
i the s mptoms a e pe sisti o e tha 2 to 3 da s.
T is patient has not had any problems with otitis media or at
least 9 months, has not been on antibiotics during that time,
is not in day care, and has no allergies. You opt to treat her
with an antibiotic.
Question 20.1.4 What is the most appropriate treatment
or this patient?
A) Amoxicillin 40 mg/kg/day divided ID
B) Amoxicillin 80 to 90 mg/kg/day divided BID
C) Ce riaxone 50 mg/kg IM once
D) Azithromycin 10 mg/kg or 1 day then 5 mg/kg or days 2 to 5
E) Amoxicillin/clavulanate 40 to 80 mg/kg/day divided BID
Answer 20.1.4 The correct answer is “B.” Amoxicillin is the
rst-line treatment o AOM. T e dose is 80 to 90 mg/kg/day
in all patients whether antibiotic-naive or not. More broad-
spectrum drugs such as ce riaxone and amoxicillin/clavulanate
should be reserved or patients who ail initial therapy with a
rst-line drug or have a penicillin allergy.
HELPFUL TIP:
r emembe that ou ca t eat chi d e o de tha
6 ea s with a 5-da cou se o amoxici i . Amoxici i /
c avu a ate shou d be ese ved o t eatme t ai u es.
Ce di i o ce u oxime is the backup p a i case o
pe ici i a e .
CHAPTER 20 • OTOl Ar yn g Ol Og y 549
HELPFUL TIP:
n o a tibiotic has bee p ove supe io to amoxici i
i the t eatme t o otitis media. Othe a tibiotics wi
wo k but a e mo e expe sive a d/o have eate side
e ects. This is ike seco da to the act that most OM
is vi a a d wi et bette e a d ess o what we do.
Question 20.1.5 Which o the ollowing statements best
characterizes the role o antibiotics in the treatment o
AOM?
A) Antibiotics have been shown to reduce suppurative compli-
cations o AOM, such as mastoiditis, in developed countries.
B) T e majority o patients with AOM bene t rom the use o
antibiotics.
C) T e use o antibiotics or AOM reduces hearing loss and
bene ts language development.
D) With or without antibiotics, about 75% o children have res-
olution o AOM symptoms a er 7 days.
E) All o the above are true.
Answer 20.1.5 The correct answer is “D.” T e bene t o antibi-
otics or most children with AOM is marginal and the number
needed to treat (NN ) is about 12; thus, the option exists to
observe and not even give antibiotics in children ≥ 2 years who
have mild symptoms, are immunocompetent, and have good
ollow-up. T e rest o the statements are incorrect. Antibiotics
do not reduce suppurative complications in developed coun-
tries, but they do seem to prevent suppurative complications
in developing countries where sanitation and healthcare access
are not optimal. “B” is incorrect. T e bene t is limited to a 5%
absolute reduction in those who have pain at days 2 to 3 (11.6%
without antibiotics vs. 15.9% with antibiotics). “C” is incorrect
as well, since treating with antibiotics does not impact these
outcomes in any way.
HELPFUL TIP:
AOM is usua caused b Streptococcus pneumoniae,
Haemophilus influenzae, Moraxella catarrhalis, a d va i-
ous vi uses. Most a e vi a , a d the majo it o cases—
bacte ia o vi a —wi eso ve spo ta eous .
You prescribe amoxicillin or 10 days and suggest acetamino-
phen or com ort. A ew days later, the patient’s mother calls
to say that she is no better. You ask her to come in to clinic or
evaluation.
Question 20.1.6 When treating AOM, which o these individ
uals should be considered a treatment ailure and switched
to another antibiotic?
A) A patient with a ever that continues at 24 hours a er start-
ing an oral antibiotic
B) A child who is still tugging at his ear 5 days into a course o
antibiotics
550 FAMIl y MEDICIn E EXAMIn ATIOn & BOAr D r EVIEW
C) A symptomatic child who still has a bulging, red, immobile
M 3 days a er starting antibiotics
D) A child who continues to have rhinorrhea 1 week a er start-
ing antibiotics
E) All o the above
Answer 20.1.6 The correct answer is “C.” You should consider
switching to a di erent antibiotic in patients who remain symp-
tomatic at 3 days and who continue to have positive ndings
on pneumatic otoscopy. Symptoms are not enough: they are
unreliable. Remember, since most o these are viral in ections,
you are not doing a whole lot o good with your antibiotics
anyway. “A” is incorrect because 24 hours is not suf cient to
determine i a particular antibiotic will be e ective. “B” is incor-
rect because children pull at their ears or a number o reasons
besides AOM (such as “Ha! I just discovered I have ears!”). “D”
is incorrect. I you chose this one, back to Microbiology 101 or
you! Rhinorrhea does not respond to antibiotics and is most
likely not bacterial in origin.
HELPFUL TIP:
Fo t eatme t ai u es, amoxici i /c avu a ate is ecom-
me ded b the AAFP a d AAP. Othe optio s i c ude
ce di i , ce podoxime, ce t iaxo e, a d ce u oxime.
Mac o ides a d TMP/SMX a e ess e ective as seco d-
i e the ap because o bacte ia esista ce (this i -
c udes the eve -popu a azith om ci , o ks). r emembe
the umbe eeded to ha m is about 8 with amoxici i /
c avu a ate; the dia hea a d esu ta t diape ash a e
o te mo e dist essi tha the otitis.
She returns with persistent pain and ever a er taking amoxi-
cillin or 3 days. On examination, you nd evidence o persis-
tent AOM. You switch the patient to your avorite second-line
antibiotic. You see her back in 2 weeks or an ear check and
nd complete resolution. T e mother asks what she could do
to avoid these troublesome in ections in the uture.
Question 20.1.7 All o the ollowing have been shown to
reduce the incidence o recurrent otitis media EXCEPT:
A) Antibiotic prophylaxis
B) Conjugate pneumococcal vaccine
C) ympanostomy tubes
D) onsillectomy
E) In uenza vaccine
Answer 20.1.7 The correct answer is “D.” Primary tonsillec-
tomy has not been shown to reduce the recurrence o otitis
media. However, adenoidectomy with or without tonsillec-
tomy will reduce the rate o recurrent otitis media in patients
who already have tympanostomy tubes. “A,” the use o anti-
biotic prophylaxis, will reduce recurrent otitis media. Anti-
biotic prophylaxis should be considered in the patient who
has had ≥ 3 episodes o otitis media in 6 months or ≥ 4 epi-
sodes in 12 months. Reasonable choices or antibiotics include
amoxicillin and trimethoprim/sul amethoxazole. Give hal o
the usual daily dose. T is is generally given at bedtime. O en,
antibiotics can be stopped during the summer since an upper
respiratory in ection (URI) is the precipitant o most cases o
otitis media. Pneumococcal vaccine (e.g., Prevnar) will reduce
the risk o recurrence in children with severe and recurrent
AOM. T e same is true o in uenza vaccine. Also recommended
to reduce the requency o AOM: avoid paci er use, avoid bottle
propping at night, avoid smoke exposure, and encourage breast
eeding or at least the rst 6 months o li e.
HELPFUL TIP:
A thou h it is t aditio a do e, the e is o easo to
o ow up AOM i patie ts > 15 mo ths o a e who a e
as mptomatic. C ea , i the a e sti s mptomatic,
o ow-up is wa a ted.
HELPFUL TIP:
Addi Co tispo i suspension (the so utio bu s) is
app op iate i the e is AOM with a uptu ed TM (ma i-
ested b pu u e t ea d ai a e). Othe a tibiotic d ops
(cip o oxaci ) ca be used as we but a e mo e expe -
sive. n o . . . Co tispo i wo ’t cause hea i oss.
T e patient returns 4 weeks later with the mother saying, “She
is still pulling at her le ear.” T ere are no other complaints.
On examination, you nd the le M is without redness or
opacity but there is still a uid level. T e right ear examina-
tion is unremarkable.
Question 20.1.8 What is your next diagnostic step?
A) Pneumatic otoscopy
B) Hearing test
C) ympanostomy
D) No urther diagnosis needed—treat with antibiotic
Answer 20.1.8 The correct answer is “A.” Even though we all
think we can do it well, the diagnosis o otitis media is raught
with problems. Pneumatic otoscopy should be done in essen-
tially all patients but especially in those in whom long-term
therapy is being considered. Remember that uid can persist
or a month or more a er an otitis media.
On your examination, the M does not move with insu a-
tion. T e patient’s mother asks you i the child should have
tubes placed.
Question 20.1.9 Which o the ollowing is NOT a criterion
or tympanostomy tubes?
A) Chronic bilateral e usions or more than 3 months with
unilateral hearing loss
B) Failure o antibiotic therapy to prevent recurrent otitis media
C) Language delay secondary to otitis media
D) Greater than 20 dB hearing loss bilaterally
 CHAPTER 20 • OTOl Ar yn g Ol Og y 551

Answer 20.1.9 The correct answer is “A.” Patients should meet TABLE 20-1 CAUSES OF EAR PAIN
the criteria listed above be ore being considered or tympa-
• Au icu a disease
nostomy tubes. Note that this requires that patients also meet
• Ca a disease
the criteria or prophylactic antibiotic therapy (≥ 3 episodes o • Otitis exte a
AOM in 6 months or ≥ 4 episodes in 12 months). A modi ca- • Fo ei bod
tion o “A” is also a criterion: chronic bilateral e usions or more • T auma
than 3 months with bilateral hearing loss. Although included • Eczema
• r amsa –Hu t s d ome
as a criterion, there is no evidence that tympanostomy tubes
• Midd e ea disease
improve language development in the short or long term. • Otitis media
• Mastoiditis
I uid persists in the middle ear a er AOM, it is termed • Mé iè e disease
OME. • r e e ed pai
• De ta disease (e. ., abscess)
• Tempo oma dibu a joi t s d ome
Question 20.1.10 Which o the ollowing interventions has • Ca otid ia
proven bene t in patients with OME? • Pha ea disease (e. ., pha itis)
A) Oral decongestants • C a ia e ve esio s (Cn V, VII, IX, X)
B) Oral antihistamines • Uppe ce vica e ve disease, a causes (e. ., disk disease)
C) Prolonged treatment (≥ 1 month) with oral antibiotics • Be pa s a d othe eu o o ic diseases (e. ., t i emi a eu a ia)
D) Oral corticosteroids
E) None o the above

Answer 20.1.10 The correct answer is “E.” For persistent OME,
there are no use ul medical interventions (although there is some
data that amoxicillin-clavulanate leads to normal tympanometry
2 weeks be ore it is achieved with placebo [JAMA Pediatr. 2014
May 5]). Autoin ation (“eustachian tube exercises” or orced
exhalation with closed nose and mouth) is o en recommended
but has not shown a bene t (and try explaining how to do this to
a 6-month-old). Patients may bene t rom surgical intervention
(see the question about tympanostomy tubes above).
Objectives: Did you learn to . . .
• Dia ose otitis media app op iate ?
• I itiate t eatme t i a patie t with otitis media?
• r eco ize ai ed a tibiotic the ap a d choose a ew a tibi-
otic o otitis media?
• Desc ibe p eve tio st ate ies o ecu e t otitis media?
• r eco ize i dicatio s o t mpa ostom tube p aceme t?
QUICK QUIZ: EAr PAIn
pain is increased by motion o the pinnae. T e external audi-
tory canal is erythematous, edematous, and exquisitely ten-
der when you try to use the otoscope to examine her M.
T ere is whitish debris in the external auditory canal.
Question 20.2.1 The most likely organism involved in this
patient’s disease is:
A) Streptococcus
B) Haemophilus
C) Moraxella
D) Pseudomonas
E) Parainf uenza
Answer 20.2.1 The correct answer is “D.” T is patient likely
has otitis externa. T e most common pathogenic organism iso-
lated in cases o otitis externa is Pseudomonas (guess those ag-
ellated bacteria sure can cause swimmer’s ear!) ollowed closely
by Staphylococcus aureus. However, up to one-third o cases o
otitis externa are polymicrobial.

Question 20.2.2 Which o the ollowing is/are considered

Which o the ollowing can cause ear pain?
A) emporomandibular joint ( MJ) syndrome
B) Cervical spine degenerative arthritis
C) Cranial nerve lesions (5, 7, 9, or 10)
D) Bell palsy
E) All o the above can cause ear pain
The correct answer is “E.” All o the above can cause ear pain.
A more complete list is given in able 20-1. T e main point here
is that not all ear pain is otitis media.
CASE 20.2
A 23-year-old emale college student presents to your clinic
complaining o ear pain. She is on the swimming team and
notes that this pain occurs during swimming season. T e
rst line treatment or otitis externa?
A) Oral cipro oxacin
B) Acetic acid ear drops
C) Polymyxin and neomycin combination ear drops
D) A and C
E) B and C
Answer 20.2.2 The correct answer is “E.” Otitis externa can
be treated with a wide array o topical agents. One option is to
acidi y the external ear canal. Neither Pseudomonas nor Staph-
ylococcus species can thrive at an acidic pH. T us, acetic acid
drops (e.g., VoSol®) can be used: they are cheap and e ective.
Another approach is to use a topical antibiotic. Polymyxin/
neomycin combinations (e.g., Polysporin) are sa e and e ective.
A number o other antibiotic preparations are available as well.
552 FAMIl y MEDICIn E EXAMIn ATIOn & BOAr D r EVIEW
Alcohol-based solutions are another alternative. “A” is incorrect
because oral treatment is not indicated or simple otitis externa.
However, topical cipro oxacin may be used.
HELPFUL TIP:
The e a e a umbe o much mo e expe sive t eat-
me ts o otitis exte a o the ma ket, i c udi cip o-
oxaci otic d ops a d o oxaci otic d ops. These have
o adva ta e a d a e ve expe sive. I act, there is
no treatment advantage to using antibiotics at all.
Topical drying agents, alcohols and acetic acid, have
just as good an outcome as do antibiotics.
Question 20.2.3 This patient is concerned about recur
rences o her otitis externa. What advice can you give her?
A) Avoid exposure by putting a petroleum jelly (e.g., Vaseline)
impregnated cotton plug in her ear be ore swimming
B) Use a blow dryer on her ear a er swimming
C) Instill a 50/50 mixture o alcohol and vinegar in her ears
a er swimming
D) Avoid swimming when she has active disease
E) All o the above
Answer 20.2.3 The correct answer is “E.” All o the above can
be used to minimize disease recurrence. T e bene t o “C” is
less certain.
HELPFUL TIP:
r emembe that necrotizing (malignant) otitis
externa is a di e e t c eatu e a to ethe that occu s
p ima i i diabetic patie ts but a so i those with HIV
a d othe immu osupp essi diseases/meds. It is a
i vasive pseudomo a (95%) ce u itis that causes e -
thema a d te de ess a ou d the ea . Comp icatio s
i c ude osteom e itis, me i itis, abscess o matio ,
a d c a ia e ve pa sies. It is a t ue eme e c equi -
i IV a tibiotics a d su ica co su tatio .
You treat the patient with neomycin/polymyxin drops, and
the symptoms persist and possibly worsen a little a er 5 days.
T e patient has no ever and no signs o cellulitis around the
ear.
Question 20.2.4 O the ollowing possibilities, which is the
LEAST likely to explain her persistent symptoms?
A) Resistant organisms
B) Noncompliance with medical recommendations
C) Misdiagnosis o otomycosis
D) Development o contact dermatitis
Answer 20.2.4 The correct answer is “A.” Several things could
explain her persistent symptoms. First, the patient should be
questioned regarding compliance. Is she still swimming despite
advice to the contrary? Is she using the drops at least ID and
letting them soak into her ear? Another issue is the develop-
ment o an allergic reaction, especially in response to neomycin
(up to 35% o patients treated chronically with topical neomycin
develop a dermatitis). Patients may also “ ail” treatment or oti-
tis externa due to misdiagnosis. Otomycosis, a ungal in ection
o the auditory canal, causes redness, discharge, itching, and
sometimes pain. With respect to “A,” treatment ailures due to
antibiotic resistance are uncommon, and as noted above, anti-
biotics are not even necessary in the treatment o most cases o
otitis externa.
On examination, you notice ne, white, cotton-like bers ll-
ing the ear canal along with the other debris. T e examina-
tion is otherwise unchanged.
Question 20.2.5 What is your next step?
A) Admit or intravenous (IV) antibiotic and anti ungal therapy
B) Clean the ear canal under direct otoscopy and add oral
amoxicillin/clavulanate to her medication regimen
C) Clean the ear canal under direct otoscopy and add topical
clotrimazole 1% to her medication regimen
D) Order C or MRI o the head and neck to rule out abscess
E) Re er to an otolaryngologist
Answer 20.2.5 The correct answer is “C.” On examination,
you have identi ed signs o otomycosis. It could be that the oto-
mycosis was present initially or developed in the interval with
antibiotic administration. Otomycosis is usually due to Asper-
gillosis; Candida only represents 10% to 20% o cases. T orough
cleaning o the ear canal is an important part o therapy. A topi-
cal anti ungal that is active against Aspergillosis is recommended
(e.g., clotrimazole, miconazole, and nystatin).
HELPFUL TIP:
Ea wicks a e exce e t too s o aidi i the de ive
o medicatio deep i to the ea ca a but should be
changed daily.
Objectives: Did you learn to . . .
• Ide ti bacte ia patho e s imp icated i otitis exte a?
• Dia ose a d t eat a patie t with otitis exte a?
• r ecomme d p eve tio st ate ies o otitis exte a?
• Dete mi e wh t eatme t o otitis exte a ma ai ?
CASE 20.3
A 59-year-old male presents with a 3-week history o hoarse-
ness. He denies sore throat or heartburn. He has had no
evers, night sweats, or weight loss. When he initially pre-
sented a week ago, your partner treated him empirically or
postnasal drainage. He smokes 2 packs o cigarettes per day
and drinks alcohol daily. On examination, his vital signs are
normal. His voice sounds husky. You nd no other abnor-
malities (besides the burn holes in his shirt and the pint o
whisky in his back pocket).

Question 20.3.1 The best next step in the management o
this patient is:
A) Empiric antibiotic treatment
B) Empiric proton pump inhibitor treatment
C) Direct laryngoscopy
D) Esophagogastroduodenoscopy (EGD)
E) Neck MRI
Answer 20.3.1 The correct answer is “C.” T e rst concern
is to rule out malignancy, so the larynx should be visualized.
Direct laryngoscopy is a straight orward of ce procedure and
takes only a ew minutes. I the equipment and expertise are not
available in your of ce, re erral to an otolaryngologist is appro-
priate. Although there are no rm guidelines, some authors
recommend direct laryngoscopy a er 2 weeks o hoarseness in
patients who are at risk (older patients and those who have a
history o tobacco and alcohol use). Since laryngoscopy is such
an available, low-cost, low-risk procedure, it is hard to justi y
postponing it or any patient at risk or malignancy. T ere ore,
“A” and “B” are incorrect, as urther empiric medication trials
will only delay laryngoscopy. Besides, antibiotics are not indi-
cated or the lone symptom o hoarseness. In other instances
(e.g., low-risk patient with heartburn and hoarseness), empiric
proton pump inhibitor therapy may be more practical, since
gastroesophageal re ux is a common cause o hoarseness. “D” is
incorrect. In this case, direct laryngoscopy is pre erred to EGD.
Finally, “E” is incorrect. Neck MRI is not indicated in the ini-
tial evaluation o hoarseness, but it might be used or ollow-up
a er laryngoscopy or to investigate a neck mass.
Question 20.3.2 All o the ollowing are potential causes o
hoarseness EXCEPT:
A) Vocal cord mass
B) In ectious laryngitis
C) Hypothyroidism
D) Lung malignancy
E) A vow o silence
Answer 20.3.2 The correct answer is “E.”Far rom being a cause
o hoarseness, voice rest is o en recommended or patients with
hoarseness due to overuse (e.g., singers). All o the other options
are known to cause hoarseness. O particular note is “C”: hypo-
thyroidism can result in an accumulation o connective tissue
elements, basically myxedema, in the vocal cords. Intrathoracic
processes such as lung cancer can present with hoarseness (see
“Help ul ip” below).
Characterizing the nature o the patient’s hoarseness can
be help ul in narrowing the di erential diagnosis. T e voice
changes may be urther characterized as breathy, low-pitched,
strained, tremulous, or hoarse. A “breathy” voice may be seen
with vocal cord paralysis, abductor spasm, or unctional dys-
phonia. A “low-pitched” hoarseness might be due to edema
(seen in smokers), vocal abuse, re ux laryngitis, vocal cord
paralysis, or muscle tension dysphonia. A “strained” voice may
occur with adductor spasm, muscle tension dysphonia, or re ux
laryngitis. A “tremulous” voice occurs in parkinsonism, essen-
tial tremor, spasmodic dysphonia, or muscle tension dysphonia.
CHAPTER 20 • OTOl Ar yn g Ol Og y 553
A “hoarse” voice may be due to vocal cord lesions, muscle ten-
sion dysphonia, and re ux laryngitis. Vocal atigue (loss o
volume over time) may also be noted (especially during presi-
dential campaigns) and is o en caused by muscle tension dys-
phonia, vocal cord paralysis, re ux laryngitis, or vocal abuse.
However, one cannot eliminate a cause o hoarseness based on
these characteristics.
HELPFUL TIP:
The a opha x is i e vated b the ecu e t
a ea e ve, a b a ch o the va us e ve (c a ia
e ve X). I additio to bei u a d i te esti medi-
ca t ivia, k owi the i e vatio is impo ta t because
chest ma i a c , a eu sms, comp icatio s o tho acic
su e , etc. ca pote tia p ese t with hoa se ess.
On direct laryngoscopy, you notice a mass lesion on the right
vocal cord. You re er the patient to an otolaryngologist. T e
patient asks i you think that the mass is cancer. Because you
are compassionate and also not entirely certain, you avoid
saying, “Oh, heck yeah. T at’s cancer all right.” You try to be
more optimistic.
Question 20.3.3 However, you want to remind him o risk
actors or laryngeal cancer, which include all o the ollow
ing EXCEPT:
A) obacco smoking
B) Alcohol use
C) Epstein–Barr virus (EBV)
D) Family history o head and neck cancers
E) Male sex
Answer 20.3.3 The correct answer is “C.” EBV in ection is
associated with the development o nasopharyngeal cancer, not
laryngeal cancer. Additionally, EBV in ection has been associ-
ated with Burkitt lymphoma (children in A rica), Hodgkin
disease, and non-Hodgkin lymphoma. obacco and alcohol
use are independent risk actors or the development o most
types o head and neck cancers (oral, laryngeal, etc.), and the
two substances may act synergistically in the promotion o these
cancers. A amily history o head and neck cancer has a weaker
association, but the association is still present. Males are two to
our times more likely to have head and neck cancers compared
with emales. T ese risk actors sound a lot like our patient.
Question 20.3.4 I this patient is ound to have cancer, what
pathologic variant is most likely?
A) Adenocarcinoma
B) Squamous cell carcinoma
C) Schneiderian papilloma
D) Neuroblastoma
Answer 20.3.4 The correct answer is “B.” Upon pathologic
examination, the great majority o head and neck cancers are
ound to be squamous cell carcinomas. Adenocarcinoma may
554 FAMIl y MEDICIn E EXAMIn ATIOn & BOAr D r EVIEW
FIGURE 20-1. F om Usati e r P et a ., eds. Color Atlas of Family Medicine.
2 d ed. n ew yo k: Mcg aw-Hi ; 2013. Cou tes o r icha d P. Usati e, MD.
arise rom the gastrointestinal tract and could be seen on laryn-
goscopy but would rarely occur on the vocal cords. Schneide-
rian papillomas (“C”) are polyps that arise rom the nasal and
sinus mucosae, are associated with HPV, and may trans orm
into carcinomas. Neuroblastomas (“D”), which arise rom the
sympathetic nervous system, rarely occur in the head and neck
region.
During your examination o the oropharynx, you also
encountered a small, white, indurated plaque on the under-
side o the tongue. When you scraped the plaque with a
tongue blade, nothing happened (see Fig. 20-1).
Question 20.3.5 This lesion is most appropriately described
as:
A) Squamous cell carcinoma
B) Candida albicans
C) Leukoplakia
D) Geographic tongue
E) Aphthous ulcer
Answer 20.3.5 The correct answer is “C.” Leukoplakia is a
premalignant lesion o the oropharynx (about 5% will progress
to cancer over 10 years). It occurs in response to trauma and/
or exposure to irritants and carcinogens, having an especially
strong association with smokeless tobacco (e.g., “snu ,” “chew”)
use. In act, the lesion could be squamous cell carcinoma (“A”),
and it should be biopsied. However, it would be premature
to diagnose the patient with squamous cell carcinoma, and
the lesion is more accurately described as leukoplakia. “B,” C.
albicans lesions, may look just like leukoplakia (white plaques
on oropharyngeal mucosa), but you should be able to scrape
some o the plaques o with a tongue blade (although thrush
can be remarkably adherent and may cause some bleeding). A
trial o anti ungal therapy may be appropriate i the lesion is
low-risk and you suspect thrush but cannot scrape it o —but
ollow the patient closely and re-examine him. “D,” geographic
tongue, is so named because o the meandering white-bordered
patches that occur on the dorsum o the tongue. It is most o en
asymptomatic, and the lesions vary in shape (or completely
resolve) over time. Finally, “E,” an aphthous ulcer, is just that—
an ulcer, not a plaque. You should not con use leukoplakia or
an aphthous ulcer.
HELPFUL TIP:
n o i te ve tio s have bee show to be use u i p o-
moti the e essio o eukop akia.
HELPFUL TIP:
I c easi , a histo HPVi ectio is bei eco ized
i o opha ea ca ce s. As much as 70% o these ca -
ce s, usua squamous ce ca ci omas, ma be caused
b HPV i ectio . HPV t pe 16 ca ies the st o est as-
sociatio with head a d eck ca ce s a d is cove ed
b mode vacci es. Cu e t e o ts at HPV vacci atio
a e expected to educe the i cide ce o head a d eck
ca ce s i utu e e e atio s—just o e mo e easo to
ca the HPV vacci e a “a tica ce ” vacci e a d ot a
“sa e sex” vacci e.
You receive a letter rom the otolaryngologist stating the
patient does indeed have squamous cell carcinoma o the lar-
ynx. T e patient will be seen in consultation with an oncolo-
gist and presented at tumor board. His treatment may consist
o surgery, chemotherapy, and/or radiation. Un ortunately,
he lost the roll o the cosmic dice.
Objectives: Did you learn to . . .
• g e e ate a di e e tia dia osis o hoa se ess o voice?
• Eva uate a patie t with a voice comp ai t?
• Ide ti o a esio s, pa ticu a eukop akia?
• r eco ize impo ta t issues i the p eve tio a d t eatme t
o head a d eck ca ce s?
CASE 20.4
A 61-year-old man presents to your o ce complaining that
over the last ew months he cannot seem to understand what
people are saying when they are standing to his le side. He
also has episodes o “dizziness,” especially when he changes
position rom sitting to lying and vice versa. He denies nau-
sea and vomiting. He worked or 30 years in a actory and
has had bilateral tinnitus or the last 10 years. He has had no
previous hearing problems or evaluation. His past medical
history is signi cant or CAD and hypertension. He takes
atenolol, chlorthalidone, and aspirin. T ere is no amily his-
tory o ear disease. On examination, both ears are normal
in appearance. Weber test is best heard by the patient on his
right side. Rinne test on both sides was negative (air conduc-
tion was greater than bone conduction).
 CHAPTER 20 • OTOl Ar yn g Ol Og y 555

Question 20.4.1 These ndings are consistent with which TABLE 20-2 CAUSES OF CONDUCTIVE AND
type o hearing loss on the left? SENSORINEURAL HEARING LOSS
A) Conductive
Conductive Hearing Loss Sensorineural Hearing Loss
B) Sensorineural
C) Mixed T auma: ossic e dis uptio , P esb cusis
D) Selective TM pe o atio
E) Unable to tell Ce ume i the ca a Mé iè e disease

Answer 20.4.1 The correct answer is “B.” Hearing can be Otosc e osis
assessed in the of ce using the Weber and Rinne tests. T e Ba ot auma St oke
Weber test is per ormed by putting the tuning ork on the ore-
head and seeing i the sound lateralizes to one side or the other. Otitis media Tumo (e. ., acoustic eu oma)
In conductive hearing loss (“A”), the sound will be louder (i.e., Midd e ea e usio I ectio (e. ., s phi is, CMV, etc.)
the test will lateralize) to the “bad” side (e.g., the side with wax
occluding the canal, otosclerosis). However, in sensorineural
hearing loss, the sound will lateralize to the “good” side (e.g., in Iowa). See able 20-2 or some causes o conductive and sen-
the side not a ected by a hearing problem). sorineural hearing loss.
T e Rinne test is per ormed by comparing bone conduc-
tion (on the mastoid) to air conduction. Patients will notice Question 20.4.3 What is the next step in the evaluation o
poor air conduction versus bone conduction i there is a con- this patient?
ductive hearing loss. Normal Rinne tests in both ears suggest A) Audiogram
that neither ear has conductive loss. Our patient, (or more B) Brainstem evoked responses
likely his amily) complains about decreased hearing on the C) MRI
le and the Weber test lateralizes to the right, and these nd- D) ympanogram
ings point to a problem with sensorineural hearing loss in the
le ear. Answer 20.4.3 The correct answer is “A.” An audiogram can
urther de ne the air versus bone conductance relationship,
Question 20.4.2 Which o the ollowing is LEAST likely to be
check speech discrimination, and de ne the requency o hear-
responsible or this patient’s hearing loss?
ing loss. Brainstem-evoked responses evaluate the neural path-
A) Ménière disease
ways o hearing and, along with MRI, could be use ul i tumor
B) Acoustic neuroma
were higher on the di erential. A tympanogram, which evalu-
C) Presbycusis
ates movement o the M, might be use ul i conductive hearing
D) Otosclerosis
loss were suspected.
E) Noise exposure

Answer 20.4.2 The correct answer is “D.” Otosclerosis is HELPFUL TIP:

a bony overgrowth that involves the stapes and leads to con-
ductive loss. Your patient has a sensorineural hearing loss.
Ménière disease (“A”) presents with the classic triad o hearing
loss, tinnitus, and vertigo. T ese mani estations may be tempo-
rally separated with hearing loss, tinnitus, and vertigo occur-
ring at di erent times. Patients with Ménière disease will note
ullness in their ear, which resolves with the onset o vertigo.
ypically, the vertigo will last or several hours. “B” is true.
Sensorineural hearing loss can also be caused by an acoustic
neuroma, a benign tumor that arises rom cranial nerve VIII
(acoustic nerve), and symptoms include unilateral hearing loss,
vertigo, tinnitus, and disequilibrium. “C,” presbycusis, is one o
the most common causes o sensorineural hearing loss and is
o en thought o as the “normal” hearing loss that is associated
with aging. Presbycusis mani ests as an inability to hear high
requencies. T is leads to problems with speech discrimination,
especially in noisy environments (e.g., parties). It is typically
symmetrical and may be associated with tinnitus. However, it
may be unilateral, especially in those who have one ear turned
toward noisy equipment in their job (e.g., armers driving trac-
tors and looking behind them—remember, this is being written
B ai stem-evoked pote tia s measu e how o it takes
a audito si a to each the b ai stem. I a acous-
tic eu oma is p ese t, the b ai stem-evoked pote tia
wi be p o o ed. Howeve , the a se- e ative ate is
up to 30%, a d b ai stem-evoked pote tia s have bee
a but ep aced b Mr I i the dia osis o acoustic
eu oma.
T e audiogram con rms sensorineural hearing loss in the
le ear. Because o the associated symptoms o vertigo, you
order an MRI o the posterior ossa to rule out acoustic neu-
roma, and the results are negative. T e patient continues
to have episodes o vertigo, and the hearing loss on his le
side persists. When probed urther, he does in act have an
increase in tinnitus during his vertiginous episodes.
Question 20.4.4 You should consider all o the ollowing
treatments or this condition EXCEPT:
A) Salt, ca eine, and tobacco restriction
B) Diuretics (e.g., hydrochlorothiazide)
556 FAMIl y MEDICIn E EXAMIn ATIOn & BOAr D r EVIEW
C) Intracochlear injection o gentamicin
D) Labyrinthectomy or endolymphatic sac shunt
E) H 2-blockers (e.g., cimetidine)
Answer 20.4.4 The correct answer is “E.” T e clinical picture
now looks most like Ménière disease—a disease or which there
is no cure. Luckily not all patients with Ménière disease will
experience worsening o their condition over time, and up to
90% are able to maintain normal daily activities with optimal
medical management. Few patients progress to debilitating dis-
ease. T e mainstays o therapy include diet/li estyle modi ca-
tion and diuretics. Outside the United States, betahistine, an
H1-blocker, is commonly used (to theoretically reduce endo-
lymphatic hydrops), but H 2-blockers have no role in therapy.
A more aggressive approach is indicated in patients with more
severe disease, and this might include surgery, intracochlear
gentamicin (to kill the nerve and reduce vertigo), labyrinthec-
tomy, or endolymphatic sac shunt.
HELPFUL TIP:
T eati Mé iè e disease ca be p ob ematic. Studies
o this co ditio a e eque t o poo qua it with a
si i ica t p acebo e ect (i c udi the studies o di-
u etics a d betahisti e). This, a o with spo ta eous
emissio s a d exace batio s, imits the use u ess o
data about t eatme t.
HELPFUL TIP:
Thi s to emembe about ti itus: It ca be caused
b a umbe o medicatio s i c udi n SAIDs, ca cium
cha e b ocke s, diu etics, etc. It ca a e be caused
b a vascu a esio (b uits, A-V shu ts, etc.). Othe
causes i c ude TMJ s d ome, eustachia tube d s-
u ctio , a d—most commo —se so i eu a hea -
i oss (especia p esb cusis).
Objectives: Did you learn to . . .
• Eva uate a patie t with hea i oss?
• Desc ibe di e e ces betwee co ductive a d se so i eu a
hea i oss?
• g e e ate a di e e tia dia osis o hea i oss?
• Dia ose a d t eat a patie t with Mé iè e disease?
QUICK QUIZ: PEr IPHAr yn g EAl In FECTIOn
A 7-year-old emale is brought to your of ce by her concerned
parents. Over the last 24 hours, the patient has developed pain
in her mouth, drooling, and ever. She re uses to eat. On exami-
nation, she is ebrile and slightly tachycardic. T e sublingual
space is swollen and tender bilaterally. T e tongue is elevated in
the mouth. T ere are no ulcerations. T ere is well-demarcated
erythema, brawny edema, tenderness, and warmth in the sub-
mandibular area. Her respirations are normal, and her lung
sounds are clear.
What is the next step in the evaluation and management o this
patient?
A) Reassurance, oral rehydration, and analgesics
B) Oral antibiotics
C) MRI o the head and neck
D) IV antibiotics
E) Intubation and mechanical ventilation
The correct answer is “D.” T is patient is presenting with classic
signs and symptoms o Ludwig angina (related neither to angina
nor to Ludwig von Beethoven). T ese include brawny edema,
tenderness and warmth in the submandibular region along with
elevation o the tongue. T e term Ludwig angina is reserved or
in ection o the submandibular and sublingual areas. T e status
o the patient’s airway must be addressed, o course. T is patient
is stable and her airway appears patent; there ore, “E” is incor-
rect. “A” and “B” are incorrect because patients with Ludwig
angina may experience rapid progression o symptoms and
should be treated with IV antibiotics and observed in the hos-
pital. Finally, “C” is incorrect because the diagnosis o Ludwig
angina is clinical. Also, MRI may delay antibiotic treatment and
is unlikely to be o any value, unless you suspect the presence o
an abscess. Even then C would be the examination o choice.
Surgical intervention may be necessary.
HELPFUL TIP:
T ismus is usua abse t i l udwi a i a as opposed
to pe ito si a abscess, etc.
CASE 20.5
A 30-year-old man comes to your o ce complaining o a
swollen neck. He noticed it 3 weeks ago when he was stung
by a bee on the right side o his anterior neck. T e area has
continued to enlarge. It is no longer tender. It was erythema-
tous a er the sting, but the redness has resolved. He notes
no other symptoms. On examination, you nd a 2-cm rm,
somewhat tender, enlarged lymph node in the right anterior
cervical chain. T e node is mobile, non uctuant, with no sur-
rounding erythema. T ere are also shotty anterior and poste-
rior cervical nodes in addition to the larger node described.
You nd neither splenomegaly nor lymphadenopathy o the
supraclavicular, axillary, and inguinal regions.
Question 20.5.1 What elements o the presentation make
malignancy LESS likely?
A) T e node is reely mobile
B) T e node is only 2 cm
C) T e node is associated with trauma (bee sting)
D) T e node is tender
E) All o these help to rule out malignancy
Answer 20.5.1 The correct answer is “A.” Nonmalignant nodes
are generally less than 1 cm in size, reely mobile, and rubbery
in constancy. Malignant nodes tend to be larger, rock-hard, and
xed. T ey become immobile secondary to tumor invasion into

TABLE 20-3 DIFFERENTIAL DIAGNOSIS OF
NECK MASS IN ADULTS
Congenital Anomalies
• l ate a eck: b a chia c sts a d stu ae, c stic h omas, de moids
• Ce t a eck: th o ossa duct c st, th oid masses, th mic ests,
de moids
In ection/Inf ammation
• Mo o uc eosis
• Tube cu osis
• Toxop asmosis
• Cat-sc atch disease (Bartonella henselae)
• Staph ococcus
• St eptococcus
• Othe vi a , bacte ia , a d u a i ectio s
• Sia ade itis
• Abscess
• I f ammato o eactive mphade opath
Neoplasm
• Be i masses: ipoma, hema ioma, eu oma, b oma
• Ma i a t masses: mucosa head a d eck ca ce s, mphoma,
th oid ca ce , sa iva a d ca ce , sa coma, dista t metastases
Trauma
• Hematoma (acute o b osed)
• Pseudoa eu sm
• AV stu a
Idiopathic and Others
• Metabo ic: out, CPPD (pseudo out)
• I f ammato pseudotumo
• Cast ema disease (a be i mphop o i e ative diso de )
• Kimu a disease (a ch o ic subcuta eous i f ammato co ditio ,
cause u k ow )
the surrounding tissues and/or in ammation. Remember that
pain in a node is not always indicative o an in ammatory or
benign process. Hemorrhage into, or necrosis o , a malignant
node can cause capsular distention leading to pain. “C” is o
particular note. T is patient’s bee sting was quite a while ago
and is unlikely to be a use ul part o the history unless there
is ongoing in ammation. Patients will o en attribute a physi-
cal malady to something in their lives whether or not it makes
sense rom a biological and medical perspective (one o us had
a patient who swore that his purulent sputum was because his
lungs were connected to his gallbladder). O course, lymphade-
nopathy is not the only source o neck masses. See able 20-3 or
the di erential diagnosis o neck masses in adults.
Question 20.5.2 What is the most appropriate next step in
the management o this patient?
A) Empiric antibiotics
B) Observation or 4 weeks
C) Open biopsy o the node
D) Fine needle aspiration o the node
E) Incision and drainage
Answer 20.5.2 The correct answer is “B.” Patients with lymph-
adenopathy can be observed or 3 to 4 weeks unless there is a
suggestion o malignancy (e.g., ever, night sweats, and weight
loss). Note that a 3- to 4-week delay makes no dif erence in
CHAPTER 20 • OTOl Ar yn g Ol Og y 557
patient outcome i the node does turn out to be malignant.
I adenopathy does not resolve, urther evaluation including
biopsy can be done. Open biopsy and ne needle aspiration
each have advantages and disadvantages, but either could be
used to obtain tissue. “A,” empiric therapy with antibiotics, is
possibly correct i you suspect a lymphadenitis or a bacterial
in ection causing secondary lymphadenopathy. However, in our
patient, there is no tenderness or other signs o in ection, argu-
ing against lymphadenitis.
Question 20.5.3 Which o the ollowing tests is NOT help
ul in arriving at a diagnosis in a patient with GENERALIZED
lymphadenopathy?
A) CBC
B) Chest radiograph
C) Glucose, BUN, creatinine
D) HIV
E) Heterophile antibody
Answer 20.5.3 The correct answer is “C.” Glucose, BUN, and
creatinine are not likely to help you with the diagnosis o gen-
eralized lymphadenopathy. Lymphadenopathy in primary care
is malignant approximately 1% o the time. A er a period o
observation, the workup should proceed in stages. First step:
CBC, chest radiograph. Second step: PPD, HIV, syphilis test
(RPR or other), ANA, heterophile antibody. Final step: biopsy.
Use your clinical judgment to determine the extent o testing
necessary in any individual case.
HELPFUL TIP:
l mph odes a e just ike i ea estate: ocatio , oca-
tio , ocatio . Sup ac avicu a odes a e ma i a t up
to 50% o the time i those o de tha 40 ea s.
HELPFUL TIP:
Be i mphade opath is commo i ou chi -
d e . I patie ts ou e tha 5 ea s p ese ti o a
hea th mai te a ce exami atio , up to 44% have pa -
pab e mph odes. Occipita a d poste io au icu a
odes a e commo i i a ts but ot i chi d e o de
tha 2 ea s.
Objectives: Did you learn to . . .
• Desc ibe eatu es o ma i a t a d o ma i a t mph
odes?
• Eva uate a patie t with mphade opath ?
CASE 20.6
A 42-year-old businesswoman presents to your o ce with the
chie complaint o 2 days o headache, sore throat, and nasal
congestion productive o green mucus. She denies any ever,
contact with ill persons, and gastrointestinal symptoms, but
she does have a history o seasonal allergies. On examina-
tion, she has completely normal vital signs. Her posterior
oropharynx has mild erythema and postnasal drainage but
558 FAMIl y MEDICIn E EXAMIn ATIOn & BOAr D r EVIEW
no exudates. T ere is nasal mucosal erythema and swelling
with clear rhinorrhea. Her neck is supple with no adenopa-
thy. Respirations are clear.
Question 20.6.1 The most likely agent causing her symp
toms and the most common cause o acute rhinosinusitis
is:
A) Rhinovirus
B) S. pneumoniae
C) H. inf uenzae
D) M. catarrhalis
E) Norwalk virus
Answer 20.6.1 The correct answer is “A.” Viruses are the most
common cause o URIs (or colds or rhinosinusitis). Up to 50% o
colds are caused by the 100 di erent serotypes o rhinoviruses.
Other viruses that commonly cause colds include coronaviruses,
RSV, parain uenza, and in uenza. Norwalk virus typically
causes an intestinal illness. T e bacteria listed (“B”–“D”) are also
associated with in ections o the upper respiratory tract, particu-
larly otitis, and sinusitis, but are much less common than viruses.
HELPFUL TIP:
r eside t bacte ia i the asopha x i c ude S. pneu-
moniae, H. influenzae, a d M. catarrhalis. Whi e most
causes o si usitis a e vi a , these bacte ia make up the
eat majo it o o a isms causi bacte ia si usitis.
Si usitis ma a so esu t om exte sio o de ta oot
i ectio i to the si us cavit , a d these i ectio s a e
caused b mic oae ophi ic a d a ae obic bacte ia.
Question 20.6.2 Initial treatment or this patient includes:
A) Oral decongestants
B) NSAIDs
C) Oral antibiotics
D) A and B
E) A and C
Answer 20.6.2 The correct answer is “D.” Most cases o rhi-
nosinusitis are viral and need only symptomatic treatment.
Analgesics and systemic and nasal decongestants are reasonable
options. Other treatment options include ipratropium nasal
spray (which will also help to decrease mucus production),
nasal steroids (at least one well-done randomized trial proved
mometasone is superior to placebo . . . but it takes a while), and
rst-generation antihistamines with anticholinergic activity
(e.g., diphenhydramine).
HELPFUL TIP:
yeah, eah . . . We k ow. The pa t i e is that i st-
e e atio a tihistami es a e ot use u o hi o -
hea om a Ur I. Howeve , this is tech ica i co -
ect. A Coch a e eview showed some be e it o
i st- e e atio a tihistami es a d some e ect o com-
bi atio p oducts. (A tihistami es o the commo co d.
Cochrane Database Systematic Rev. 2003;3; 2012;2.)
Question 20.6.3 Which o the ollowing does NOT increase
the likelihood that a patient has a bacterial sinusitis?
A) Persistence o symptoms or greater than 7 days
B) T ickened nasal mucosa or e usion on C scan
C) Maxillary tooth pain
D) Unilateral maxillary sinus pain
Answer 20.6.3 The correct answer is “B.” Radiography is par-
ticularly poor at di erentiating bacterial sinusitis rom a simple
URI. T ickened nasal mucosa is only 40% to 50% speci c or
sinusitis ( ip a coin, it’s cheaper). T e other problem with imag-
ing is that essentially all patients with a URI will have uid in
the sinuses. Clinical criteria are more help ul in predicting the
presence o bacterial sinusitis; thus, “A,” “C,” and “D” are cor-
rect. Additionally, a biphasic course, sometimes re erred to as
“double sickening,” is a help ul predictor o bacterial sinusitis:
i the patient initially improves and then gets worse, consider
a secondary in ection. T e color o snot is meaningless. T ick,
green, nasal drainage does not necessarily mean that bacteria
are present. Secretions will turn green with a viral illness, as
with anything else that concentrates protein in the mucous (e.g.,
anticholinergics).
HELPFUL TIP:
A vi a Ur I ca ast up to a mo th. I act, 25% o patie ts
with a Ur I a e sti s mptomatic at 14 da s, so du atio
o s mptoms alone is ot dia ostic o bacte ia si us-
itis. So, do ’t te ou patie t that she wi be bette i
4 to 5 da s. g ive ou patie ts ea istic expectatio s: 10
to 14 da s.
T e patient is initially convinced that only antibiotics will
make her better. T rough skill ul negotiation (and a he y
dose o haloperidol), you manage to avoid prescribing anti-
biotics or what you strongly suspect is a viral in ection. wo
weeks later, the patient returns. Initially, she improved, but
then she developed subjective ever, ace pressure, maxillary
tooth pain, and copious green nasal drainage. You now sus-
pect that a bacterial sinusitis has developed. T e look on her
ace says, “I told you so . . . and I am not taking any more o
that haloperidol stuf .” She has no drug allergies.
Question 20.6.4 Which o the ollowing treatments do you
of er as rst line therapy?
A) Azithromycin
B) rimethoprim/sul amethoxazole
C) Prednisone
D) Ce riaxone
E) Amoxicillin/clavulanate
Answer 20.6.4 The correct answer is “E.” According to 2012
In ectious Diseases Society o America guidelines addressing
the treatment o acute bacterial sinusitis, amoxicillin/clavulanate
should be used as rst-line treatment or adults and children—
although the evidence is weak. Previously trimethoprim/sul a-
methoxazole (“B”) would have been the best choice but there is

increasing resistance. Azithromycin (“A”) is not recommended
due to resistance patterns and poor penetration into the sinuses
(Got that . . . No Z-Pack). “C” is incorrect. T ere is no reason to
prescribe steroids here. “D,” ce riaxone, might be considered
in cases o treatment ailure, but oral antibiotics are generally
pre erred. Per 2012 guidelines, doxycycline is recommended as
second-line therapy, ollowed by respiratory uoroquinolones.
O course, you should continue to recommend that the patient
use decongestants and other symptom-oriented therapies.
HELPFUL TIP:
Eve with bacte ia si usitis, the n n T o a tibiotics to
be e it o e patie t is 9. Most patie ts a e etti o o these our types.
be e it om ou ca e u mi ist atio s—o k ee-je k
eactio to p esc ibe a tibiotics (whicheve app ies . . .).
HELPFUL TIP:
r emembe that whe t eati si usitis ou a e basica
t eati a abscess. D ai i it is the ke : use topica
ox metazo i e o imited pe iods, s stemic deco es-
ta ts, a d sa i e i i atio .
HELPFUL TIP:
A oses that u a e ot i ectious. r emembe a e ic
hi itis, vasomotor rhinitis (now termed idiopathic
rhinitis), etc. Idiopathic hi itis is a exa e ated e-
spo se to stimu i such as co d, ecumbe c , a d ai
po utio . It ca be di e e tiated om a e ic hi itis
b the abse ce o othe a e ic s mptoms (itchi , e e
i vo veme t, pe haps asthma, etc.) a d the abse ce o
eosi ophi s o Ha se stai o mucus (who ooks at s ot
u de a mic oscope a wa ?). Othe co side atio s
i c ude hi itis medicame tosum as a esu t o with-
d awa om topica vasoco st icto s (e. ., ox metazo-
i e, cocai e).
Objectives: Did you learn to . . .
• Desc ibe the most commo patho e s i vo ved i hi osi-
usitis?
• r eco ize c i ica si s a d s mptoms that a e mo e co sis-
te t with bacte ia si usitis tha vi a hi osi usitis?
• P esc ibe t eatme t o vi a a d bacte ia si usitis?
CASE 20.7
A 65-year-old male presents with dizziness that started a ew
days ago. He reports that he is otherwise healthy and takes no
medications.
Question 20.7.1 Which o the ollowing is the best question
to ask him in order to elicit a better characterization o his
dizziness complaint?
A) “Is the room spinning round and round?”
B) “Do you eel that you are going to aint?”
CHAPTER 20 • OTOl Ar yn g Ol Og y 559
C) “Can you describe the dizziness using any other words?”
D) “Do you eel as though you are drunk?”
E) “Are you really just drunk right now?”
Answer 20.7.1 The correct answer is “C.” When exploring a
complaint o dizziness, insist that the patient characterizes the
nature o the dizziness urther without putting words into his
mouth. T is is a good time or that old technique learned in
medical school but rarely used in practice: the open-ended
question. T ere are essentially our types o dizziness: vertigo,
presyncope, imbalance (disequilibrium), and undi erentiated
dizziness. Patients will usually come up with their own termi-
nology that will allow you to categorize their dizziness into one
T e patient describes a sensation o the room spinning, usu-
ally lasting less than a minute. Further, this sensation comes
on in dif erent positions and has led to a all, which resulted
in minor injuries. He denies any upper respiratory symptoms,
evers, hearing loss, or tinnitus. He sometimes eels nause-
ated with the dizziness but has not vomited. He rst noticed
the dizziness while in bed and rolling over, but it now occurs
more requently and in various positions. Sudden turning o
the head de nitely exacerbates his symptoms. It tends to be
worse in the morning and better in the evening. You are com-
ortable calling this type o dizziness vertigo.
Question 20.7.2 Which o the ollowing is LEAST likely to
cause vertigo (in a general sense . . . not in this particular
patient)?
A) Labyrinthitis
B) Ménière disease
C) Migraine aura
D) Otitis media
E) Perilymphatic stula
Answer 20.7.2 The correct answer is “D.” T ere are many
causes o vertigo, but otitis media should not generally be
thought o as one o them (or at least should be a diagnosis o
exclusion). Labyrinthitis is usually caused by viral in ection
and results in severe vertigo that lasts or days. Ménière dis-
ease results in episodic vertigo that lasts or minutes to hours.
Migraine aura can present with vertigo as well as many other
symptoms (e.g., scotoma, diplopia, blindness, and paresthesias).
Perilymphatic stula occurs when perilymph leaks through a
tear in the oval window (secondary to a all or barotrauma—
including sneezing). It typically resolves on its own. Although
a perilymphatic stula o en results in vertigo, it is a relatively
uncommon cause o vertigo.
Question 20.7.3 Which o the ollowing is the best next step
in the diagnosis o this patient?
A) Dix–Hallpike maneuvers
B) Obtain blood or CBC, electrolytes, BUN, and creatinine
C) MRI brain and brainstem
D) C brain
E) Audiometry
560 FAMIl y MEDICIn E EXAMIn ATIOn & BOAr D r EVIEW
Answer 20.7.3 The correct answer is “A.” A complete evalu-
ation o the patient with vertigo includes examination o the
neurological and cardiovascular systems as well as the ears,
eyes, nose, and throat. T e Dix–Hallpike maneuver is designed
to di erentiate central rom peripheral vertigo, can be a use ul
tool (more on this later . . .). In order to per orm the maneuver,
rapidly move the patient rom a seated to a supine position,
turning the head to the le or right, and observe or nystagmus.
T e patient is helped into a seated position, and the maneuver is
repeated, turning the head to the other side. I nystagmus occurs
within 30 seconds o per orming the maneuver, it is considered a
positive test. “B” is incorrect. Laboratory tests are rarely help ul.
“C” and “D” are not correct because neuroimaging should only
be per ormed i the history and/or examination indicate the
need or it. In this case, the examination is not even complete
yet! Likewise, audiometry (although help ul in the diagnosis o
Ménière disease) is premature.
Dix–Hallpike maneuver is positive with rotation o the head
to the le . T e rest o the physical examination is unremark-
able. T e patient gets vertiginous and then it resolves in less
than 1 minute.
Question 20.7.4 Given the history and examination, the
most likely diagnosis in this patient is:
A) Labyrinthitis
B) Benign paroxysmal positional vertigo (BPPV)
C) Vertebrobasilar stroke
D) Motion sickness
E) Cerebellar stroke
Answer 20.7.4 The correct answer is “B.” T e history o epi-
sodic, positional vertigo and the positive Dix–Hallpike maneu-
ver make BPPV the most likely diagnosis. Note that the Dix–
Hallpike maneuver is not speci c or BPPV. T e Dix–Hallpike
maneuver is designed to dif erentiate central rom peripheral
vertigo. In this case, the history is probably the most important
aspect in making the diagnosis. BPPV is more common in older
patients but can occur at any age. Women are more commonly
a ected than men. BPPV is caused by calcium stone deposition
in the posterior semicircular canal. BPPV tends to be worse
in the morning and better toward evening because, being o
peripheral origin, the vertigo response atigues as the day goes
on (see able 20-4). T e other diagnoses listed are less likely.
TABLE 20-4 DIX–HALLPIKE MANEUVER
Suggestive o Peripheral Vertigo
• De a ed o set o sta mus a d s mptoms
• n sta mus a wa s i same di ectio
• Ve ti o ef ex ati ab e a te mu tip e ma euve s.
• n sta mus supp essib e b patie t
Suggestive o Central Vertigo
• n sta mus i mu tip e di ectio s
• n o ate c to o set o sta mus
• r ef ex ot ati ab e
However, “C” and “E” deserve special mention. Stroke should
be considered in any patient presenting with sudden onset, per-
sistent vertigo, and risk actors (e.g., hypertension and atrial
brillation). In general, there should be other ndings such
as diplopia, dysmetria, and ataxia. However, not every elderly
patient with vertigo needs an MRI. I the history is consistent
with BPPV, then neuroimaging is not necessary.
HELPFUL TIP:
A pe i mph eak p ese ts i the opposite ma e o
BPPV. It is best i the mo i a d wo se i the eve-
i . g avit is ot the patie t’s ie d. As mo e a d
mo e pe i mph eaks out du i the da , the patie t
ets p o essive mo e ve ti i ous.
HELPFUL TIP:
“Past poi ti ” o i e -to- ose testi usua i di-
cates a pe iphe a esio . A d, patie ts e e a a
towa d the side o pe iphe a d s u ctio .
Question 20.7.5 For this patient with BPPV, the LEAST
appropriate treatment at this time is:
A) Prednisone
B) Lorazepam
C) Meclizine (Antivert)
D) Rehabilitation exercises
E) Dimenhydrinate (Dramamine)
Answer 20.7.5 The correct answer is “A.” Steroids are not likely
to improve symptoms in BPPV. Benzodiazepines, anticholiner-
gics, and antihistamines have all been employed in treating the
symptoms o BPPV, but should all be second-line therapies a er
rehabilitation and repositioning exercises. Cawthorne rehabili-
tation exercises, physical therapy, and physician-directed head
positioning (AKA Epley maneuvers to move stones out o the
posterior semicircular canal) may be success ul. Most patients
will improve with time, although many will have relapses.
HELPFUL TIP:
Simp t eati the patie t with medicatio s to sup-
p ess the ve ti o ca actua p o o the cou se o the
disease. The b ai eeds to ea to adapt to the si a
causi ve ti o. I ou b ai we e ta ki (a sca p os-
pect), it wou d sa , “OK, I am ot a i . I ca i o e that
i put.” Supp essi the ve ti o de a s this adaptatio .
Howeve , medicatio s ma be ecessa o s mptom
co t o i some patie ts.
Objectives: Did you learn to . . .
• Desc ibe t pes o dizzi ess?
• g e e ate a di e e tia dia osis o ve ti o?
• Dia ose a d t eat a patie t with BPPV?

CASE 20.8
A 15-year-old male wrestler presents to the ED with a nose-
bleed and a swollen ear. He clearly did not win this round.
Prior to coming to the ED, he held pressure to his nose or
30 minutes. He has had nosebleeds be ore, but none were
this bad. When asked how much blood he lost, his ather
shrugs and says it was “all over the mat.” On examina-
tion, you see blood oozing slowly rom the anterior nasal
septum.
Question 20.8.1 Which o the ollowing is a source o ante
rior epistaxis?
A) Ethmoid artery
B) Sphenopalatine artery
C) Kiesselbach arterial plexus
D) Palpatine artery
Answer 20.8.1 The correct answer is “C.” Kiesselbach plexus
is a collection system involving several terminal arteries (ante-
rior ethmoidal, greater palatine, and superior labial arteries)
in the anterior nose. It is the most common site o nasal bleed-
ing. As one o your editors learned to his embarrassment, the
Kiesselbach plexus lies very anterior and can be missed when
using a speculum to inspect the nares. Don gloves, retract the
patient’s nasal tip, shine a light, and you will see it. T e eth-
moid and sphenopalatine arteries supply the posterior area
o the nose, and bleeding rom these sites is more dif cult to
control. O special note is “D.” Emperor Palpatine, also known
as “Darth Sidious,” converted Anakin Skywalker to the Dark
Side using hatred, anger and lies—not epistaxis caused by an
eponymous artery. Also, don’t con use the Kiesslebach plexus
with the Kessel Run, which the Millennium Falcon allegedly
completed in under 12 parsecs.
Question 20.8.2 What is the best next step in managing this
patient’s nosebleed?
A) Continue to hold pressure against the septum
B) Pack the anterior naris with gauze
C) Spray the mucosal sur ace with phenylephrine
D) Chemical cautery with silver nitrate
E) Any o the above can be used
Answer 20.8.2 The correct answer is “E.” Any o the options
listed could be used alone or in combination to try to stop the
bleeding. I these methods are not success ul, consider electro-
cautery, laboratory evaluation or signs o bleeding disorders
(e.g., CBC, P /P ), and otolaryngology consultation. Labora-
tory studies will rarely be help ul, though.
HELPFUL TIP:
I ou pack a patie t’s ose, p a o eavi the packi
i p ace o 24 hou s o o e . A so, p esc ibe a tibiot-
ics to p eve t si usitis.
CHAPTER 20 • OTOl Ar yn g Ol Og y 561
With silver nitrate cautery and direct pressure, you were able
to stop the bleeding. You now turn your attention to his le
ear. You nd a purplish, tender, uctuant swelling at the le
pinna.
Question 20.8.3 The best treatment or this condition is:
A) Analgesics, protection, and observation
B) Compressive dressing, using a headband (pre erably that
sweatband in your gym bag)
C) Oral antibiotics
D) Incision and drainage, leaving the wound open to drain and
heal by secondary intention
E) Needle drainage ollowed by compressive dressing sutured
into the pinna
Answer 20.8.3 The correct answer is “E.” With traumatic
auricular hematoma/seroma, uid collects between the peri-
chondrium and underlying cartilage, predisposing the carti-
lage to loss o vascular supply and necrosis. In order to avoid
“cauli ower ear” de ormity, the hematoma or seroma must be
evacuated via incision or needle drainage. However, you cannot
stop there: a compressive dressing must then be sutured into
the pinna, or the uid is likely to re-accumulate. “B” is incor-
rect because compressive dressing alone is insuf cient. “D” is
incorrect only because it does not include compressive dress-
ing. “A” and “C” are incorrect because taking these actions will
delay de nitive treatment—and antibiotics are not needed any-
way. I the patient were to present late (10 days or more a er the
injury), he will not bene t rom incision or needle drainage, and
instead should be re erred or otoplasty.
HELPFUL TIP:
r epeat a te me, “The ose is ot the e ease va ve o the
ca diovascu a s stem.” Most asa b eedi is ve ous
a d ot at a e ated to e evated b ood p essu e.
Objectives: Did you learn to . . .
• Eva uate a d t eat a patie t with epistaxis?
• T eat a patie t with au icu a t auma?
QUICK QUIZ: MOUTH SOr ES
A 20-year-old emale presents with three pain ul ulcerations on
her inner lip and tongue. She has no other symptoms. Although
she has never had such sores be ore, everyone else in her amily
has had similar mouth sores. She only smokes when drinking
cheap wine coolers, which occurs about once per week. She is
a ebrile, and her examination is otherwise unremarkable.
T e most likely diagnosis is:
A) Aphthous ulcers
B) Behcet disease
C) Crohn disease
D) Gluten enteropathy
E) Squamous cell carcinoma
562 FAMIl y MEDICIn E EXAMIn ATIOn & BOAr D r EVIEW
The correct answer is “A.” T is otherwise healthy young wom-
an with a amily history o “similar sores” most likely has aph-
thous ulcers or “canker sores.” T e etiology o aphthous ulcers is
not well understood, and they are alternatively explained as vi-
ral, autoimmune, genetic, traumatic, or due to chemical irritants
or other processes (also, karmic retribution, divine punishment
or sin, etc.). “B,” Behcet disease, is uncommon in the United
States. It is thought to be an autoimmune disease, and it pres-
ents with recurrent oral and genital ulcerations and skin and
eye lesions among other ndings. “C” and “D” can both present
with isolated oral ulcers but are less common than idiopathic
aphthous ulcers: there should also be other GI symptoms. “E”
is incorrect because it is highly unlikely that this young, healthy
person has developed cancer . . . in three places . . . simultaneous-
ly. Finally, lupus pemphigoid, pemphigus, and multiple in ec-
tions (e.g., Hand-Foot-Mouth, HIV, herpes, and syphilis) may
present with oral ulcers.
CASE 20.9
A 34-year-old male dentist presents to your o ce with a
1-week history o right acial weakness and a bit o tongue
numbness. He states that he “just woke up this way one
morning.” He would have come in sooner, but he was busy
with his practice and he has elt ne. He has not noticed any
other neurological symptoms. He denies pain, ever, or upper
respiratory symptoms. He reports being healthy and taking
no medications. On examination, his vital signs are normal.
You note that his right eyebrow sags, as does the right cor-
ner o his mouth. He cannot close the right eye completely
or raise his right eyebrow, and the right nasolabial old is less
prominent than the le . T e remainder o the neurological
examination is normal.
Question 20.9.1 The neurological nding in this patient
that most suggests a cranial nerve process (as opposed to a
central brain lesion) is:
A) Normal strength in the upper extremities
B) Inability to smile on the right
C) Inability to wrinkle the orehead
D) Normal blood pressure
E) Normal speech rate and rhythm
Answer 20.9.1 The correct answer is “C.” Partial sparing o
the orehead muscles suggests a brain lesion because innerva-
tion o the orehead contains crossed bers rom both sides
o the brain; a bilateral brain lesion is possible but unlikely.
T us, a dense paralysis is more likely to be peripheral (CN7)
since all innervation is knocked out when this is involved. T is
patient’s entire right ace, including the orehead, is paralyzed,
which suggests a lower motor neuron (CN7) process. While
“A” and “E” are ound in a normal neurologic examination and
are reassuring, they are not as help ul in isolating the loca-
tion o the lesion to a lower motor neuron source. “B,” lower
acial muscle weakness or paralysis, can occur with upper or
lower motor neuron disease. “D,” normal blood pressure, is
not help ul.
HELPFUL TIP:
O ote, to ue i vo veme t is ot u usua i Be pa s .
The seve th e ve is i vo ved i taste se satio o the
a te io two-thi ds o the to ue. Patie ts ma ote a
headache i the et oau icu a a ea be o e the o set o
s mptoms.
You tell the patient that you suspect he has Bell palsy. He asks
what causes this problem.
Question 20.9.2 Which o the ollowing is the most likely
cause o this patient’s Bell palsy?
A) Herpes virus
B) ick-borne illness
C) Diabetes
D) Adenovirus
E) T e dark side o the orce
Answer 20.9.2 The correct answer is “A.” It seems that many
cases o Bell palsy are due to reactivation o herpes simplex
virus (HSV). Other viral etiologies have been implicated as well,
including EBV, CMV, coxsackievirus, and adenovirus (“D”),
but all are much less commonly isolated compared with HSV.
While “B,” tick-borne illnesses such as Lyme disease cause Bell
palsy, these represent a minority o cases. “C,” diabetes, may put
a patient at increased risk o contracting Bell palsy, but it does
not cause the disease.
HELPFUL TIP:
Be pa s is mo e ike to occu i p e a c , especia
the ast t imeste a d the i st week postpa tum.
Question 20.9.3 Which o the ollowing treatments is most
likely to bene t this patient?
A) Acyclovir
B) Prednisone
C) Arti cial tears and eye patching at night
D) A and B
E) None o the above
Answer 20.9.3 The correct answer is “C.” In a patient with Bell
palsy and weakness to eye closure, good eye care, and protec-
tion rom trauma must be employed to prevent corneal dam-
age (remember that this patient cannot close his right eye). T e
evidence or antiviral therapy is negative; acyclovir likely
doesn’t work, and it is no longer recommended. T ere may be
some slight bene t to corticosteroids. Steroids are most likely to
provide a bene t i started within the rst 3 days a er the onset
o symptoms. Our patient is now a ull week out, so steroids are
unlikely to produce a bene t.
You recommend eye care but not other medications. Know-
ing that patients with Bell palsy generally require a lot o
reassurance, you discuss the diagnosis in detail, including
prognosis.

Question 20.9.4 The patient can expect which o the ollow
ing?
A) Complete resolution ( 100% likelihood) with nearly zero
risk o recurrence
B) Likely resolution (> 50% likelihood) with nearly zero risk o
recurrence
C) Likely resolution (> 50% likelihood) with about 10% risk o
recurrence
D) High probability ( 95% likelihood) o persistent paralysis
Answer 20.9.4 The correct answer is “C.” Most patients will
recover (71% complete, 13% minor impairment with the rest
having signi cant sequelae), but it may take months. I a patient
with suspected Bell palsy has no improvement in symptoms
a er a ew months, reconsider the diagnosis. Patients with
complete paralysis are more likely to have persistent symp-
toms, whereas those with partial paralysis usually recover more
quickly and completely. Other treatments such as surgical nerve
decompression and nerve stimulation have little or no evidence
supporting them.
HELPFUL TIP:
r amsa –Hu t s d ome is the ame ive to zoste
oticus comp icated b hemi acia pa a sis. I ide ti ied
ea , a tivi a s ma he p the patie t with r amsa –Hu t
s d ome. you ma see b iste s i the ea ca a .
Objectives: Did you learn to . . .
• Di e e tiate Be pa s om a ce t a esio ?
• Desc ibe causes o Be pa s ?
• Ma a e a patie t with hemi acia pa esis?
QUICK QUIZ: OH, My ACHIn g JAW
A 30-year-old emale presents with several months o pain and
sti ness in her jaw. When asked to localize the pain, she points
to the temporomandibular joints ( MJ) bilaterally. She notes
that the pain is worse with stress ul situations, driving, and
chewing. Her husband complains that she grinds her teeth at
night. She is otherwise healthy. On physical examination, you
nd palpable popping in the MJs bilaterally, and the remain-
der o her examination is unremarkable.
You make all o the ollowing recommendations EXCEP :
A) Start chewing gum daily
B) Use ibupro en as needed
C) Use a bite block at night
D) Learn relaxation techniques
The correct answer is “A.” T is patient’s history is consistent
with MJ syndrome. In addition to those described in the case,
symptoms o MJ may include ear pain, headache, “sinus”
headache, limited jaw mobility, and crepitus and tenderness on
palpation o the joint. MJ syndrome may occur unilaterally
or bilaterally. No single therapy appears to have greater ef ca-
cy than any other, and many di erent interventions have been
CHAPTER 20 • OTOl Ar yn g Ol Og y 563
tried, although poorly studied. “A,” increased use o the joint by
chewing gum, is the exact opposite o what the patient should
be doing. Jaw rest is important. All o the other interventions are
reasonable. Also, you might recommend a so er diet, hot packs,
and MJ massage.
HELPFUL TIP:
The headache o TMJ ma be e t i the si us e io ,
et oo bita o as a ea ache. Check o TMJ whe pa-
tie ts p ese t with these t pes o s mptoms.
CASE 20.10
A 22-year-old emale presents to your o ce complaining o
severe acial pain or the past 3 days. She has poor dentition
and you nd that on examination, there is mandibular swell-
ing and tenderness.
Question 20.10.1 All o the ollowing are causes o mandib
ular area swelling EXCEPT:
A) Submandibular duct stone
B) Dental abscess
C) Retropharyngeal abscess
D) Ludwig angina
E) Branchial cle cyst
Answer 20.10.1 The correct answer is “C.” Retropharyngeal
abscesses are generally not visible but present with ever, throat
pain, and symptoms due to swelling o the retropharyngeal
space (dysphagia, drooling, odynophagia, and airway obstruc-
tion). All o the other options can cause swelling around the
mandible.
Question 20.10.2 One o the diagnoses you are consider
ing is parotitis. Which o the ollowing is true regarding
parotitis?
A) You will only see mumps in science-denying, anti-vaccine,
whack jobs
B) Mumps can be associated with pain and in ammation o the
meninges, pancreas, and gonads as well as the parotid glands
C) Bacterial parotitis is mostly caused by pan-sensitive strepto-
coccus and can be treated with penicillin
D) Mumps is usually treated with IVIG
Answer 20.10.2 The correct answer is “B.” Mumps can lead to
in ammation o other tissues including the meninges, pancreas,
and gonads (possibly leading to decreased ertility in males, not
in emales), and will occasionally require hospitalization. T ank-
ully, most people recover spontaneously with good supportive
care, including NSAIDs and warm compresses. IVIG would
be reserved or those with severe complications as mentioned
above. “A” is incorrect. While the MMR vaccine is about 88%
e ective a er 2 doses, this still leaves over 10% o the popula-
tion susceptible to outbreaks. T ere ore, you may see mumps in
immunosuppressed patients as well as anyone who is more than
10 years out rom their last vaccination. Bacterial parotitis (“C”)
564 FAMIl y MEDICIn E EXAMIn ATIOn & BOAr D r EVIEW
is usually caused by Staphylococcus aureus and anaerobes. In the
hospital setting, approximately 40% o the Staphylococcus aureus
is methicillin resistant, so rst-line therapy is usually IV van-
comycin pending culture results. Parotitis secondary to stones
is o en treated with cephalexin, dicloxacillin, or amoxicillin/
sulbactam. Use clinical judgment and assure good ollow-up.
Question 20.10.3 Which o the ollowing is NOT typical o
sialolithiasis (salivary duct stones)?
A) Intermittent swelling o the salivary gland
B) More than 80% o stones involve the parotid gland
C) T e majority resolve with conservative, nonoperative treat-
ment
D) Anti-staphylococcal antibiotics should be used in their
treatment
E) Sialogogues (e.g., lemon drops) should be used as part o the
treatment
Answer 20.10.3 The correct answer is “B.” In actuality, more
than 80% o cases o sialolithiasis involve the submandibu-
lar gland. “A” is true. Swelling tends to occur when patients eat
and tends to resolve between meals as saliva slowly makes its
way through the duct. “C” is true. Most salivary duct stones pass
spontaneously. “D” is true. T ink o this as an abscess. I there is
any sign o in ection, anti-staphylococcal antibiotics should be
used until the stone passes. Finally, sialogogues such as lemon
drops promote saliva ormation. T e e ectiveness is question-
able, but it is worth a try and it gives the patient something to do.
Question 20.10.4 Which o the ollowing is considered
good practice with regard to salivary duct stones?
A) Patients should be ollowed up within 72 hours i the stone
does not pass
B) Stones can be removed using sialolithotomy (using a probe
and/or scalpel to nick the outlet)
C) Patients should be re erred or lithotripsy i stones do not
pass within 4 days
D) Surgical excision o the duct should be done i the stone does
not pass
E) ricyclic antidepressant prophylaxis i stones occur re-
quently
Answer 20.10.4 The correct answer is “B.” A probe can be
used to “dilate” the duct. Occasionally, the outlet needs to be
nicked using a scalpel blade to allow the stone to egress. T e rest
are incorrect. With regard to “A,” patients should be ollowed
up in 24 hours i the stone does not pass. “C” is also incorrect.
Lithotripsy has actually been used with some good results but
is de nitely third line. Finally, “D” is incorrect. Excising the
duct seems a little dramatic. “E” is very wrong. Anticholinergics
reduce salivary ow and thus contribute to stone ormation.
You check the patient’s mouth and decide that there is likely
a dental abscess, not a salivary duct stone. She needs to have
her tooth extracted, but the dentist will not be able to see
the patient until the morning. She requires antibiotics but is
penicillin-allergic.
Question 20.10.5 The antibiotic o choice or this patient is:
A) Erythromycin
B) Clindamycin
C) Azithromycin
D) Levo oxacin
E) rimethoprim/sul amethoxazole
Answer 20.10.5 The correct answer is “B.” Clindamycin is the
drug o choice as an alternative to penicillin. T e drug used or
a dental abscess should cover anaerobes. T ere is resistance
to erythromycin and azithromycin. Neither levo oxacin nor
trimethoprim/sul amethoxazole covers anaerobes.
During your examination, you also noticed a rm nodule in
the submental area in the midline. (It is de nitely not this
patient’s day!) It moves up and down when she swallows.
She says that it has been there or years—as long as she can
remember.
Question 20.10.6 The most likely cause o this midline nod
ule is:
A) Submandibular gland in ection
B) T yroglossal duct cyst
C) In ected renulum
D) Branchial cle cyst
E) An accumulation o midi-chlorians
Answer 20.10.6 The correct answer is “B.” T is is likely a thy-
roglossal duct cyst. T e rest are not likely. Submandibular glands
(“A”) and branchial cle cysts (“D”) are lateral to the midline.
“C” is incorrect. T e renulum is under the tongue. As or “E,”
another Star Wars re erence. Maybe there will be a Wookie at
the end o the chapter. Keep reading.
You start the patient on clindamycin, but she returns in the
morning with severe submandibular swelling. T e tongue
is elevated in the mouth and there is brawny edema; she is
having trouble talking. You make the diagnosis o Ludwig
angina. (“Didn’t we just do this?” you ask. “Yes, we are going
to do it again,” we reply.)
Question 20.10.7 At this time, the most appropriate treat
ment or this patient is:
A) Continue PO clindamycin and add saltwater gargles
B) Continue PO clindamycin and add PO metronidazole
C) Incise and drain the swollen area under the tongue
D) Re er immediately or surgical evaluation or possible tra-
cheostomy
E) Administer IV uids and ce riaxone in the of ce and ollow
up tomorrow
Answer 20.10.7 The correct answer is “D.” T is patient’s situ-
ation has become airly desperate overnight even while on an
appropriate antibiotic. Securing an airway should be your rst
concern. Un ortunately, these patients do not respond to local
incision and drainage, as the swelling is usually di use, quickly
spreading, and does not result in discrete pus pocket ormation

until late in the course. She should be admitted or IV uids,
appropriate IV antibiotics (not levo oxacin), and possible
tracheostomy. Patients with advancing Ludwig angina do not
tolerate endotracheal intubation; thus, an alternative airway is
o en provided with tracheostomy.
Objectives: Did you learn to . . .
• Dia ose sa iva sto es?
• T eat sa iva sto es?
• r eco ize the p ese tatio o subma dibu a masses?
CASE 20.11
A 21-year-old male presents or a sore throat. His symp-
toms started 3 days ago. He has had subjective evers, sweats,
atigue, and mild nausea. He has no cough or rhinorrhea. His
temperature is 38.3°C. His vital signs are normal otherwise.
He has symmetrically enlarged tonsils with exudates present
and tender anterior cervical lymphadenopathy.
Question 20.11.1 At this point, you:
A) Reassure and recommend saltwater gargles
B) Obtain a routine aerobic culture o the oropharynx
C) Prescribe penicillin 500 mg BID or 10 days
D) Prescribe levo oxacin 500 mg daily or 7 days
Answer 20.11.1 The correct answer is “C.” T is patient has 4
o 4 signs/symptoms suggestive o streptococcal (group A strep
or Streptococcus pyogenes) pharyngitis. T ese are the “Centor
criteria”: (1) ever, (2) tender cervical adenopathy, (3) exudative
pharyngitis, and (4) lack o other URI symptoms. In this case,
the most appropriate step would be empiric antimicrobial treat-
ment. “B,” per orming a culture, will take a ew days and does
not add much, given the strength o the clinical argument or
strep throat. Furthermore, the oropharynx is colonized by many
kinds o ora that do not cause disease, and we only really care
about group A streptococcus, so a routine aerobic culture is o
no value. Alternatively, a rapid assay or a speci c “rule out” cul-
ture or group A strep could be done rather than treating based
on clinical grounds (the rapid strep has a 5% alse negative rate).
While saltwater gargles seem to help reduce the pain o pharyn-
gitis, “A” is incorrect because you would want to do more than
that or this patient who likely has strep throat. “D” is incorrect
because levo oxacin and other uoroquinolones are not indi-
cated or treatment o strep throat.
Here are three strategies or the patient you think might have
strep throat:
Strategy 1: No testing (or minimal testing)
In this strategy, one treats based on clinical symptoms. You
are looking or our things: ever, exudate, absence o other
URI symptoms, and tender anterior cervical adenopathy. reat
patients with 3 or 4 criteria, and do not treat others. Another
approach is to treat patients with 4 criteria, do a rapid strep test
on those with 3 (and maybe 2) criteria, and avoid treatment and
testing o others. T e CDC has recommended this or nonim-
munosuppressed patients in the absence o an outbreak o rheu-
matic ever in the community.
CHAPTER 20 • OTOl Ar yn g Ol Og y 565
Strategy 2: esting
est all patients and treat those with a positive strep screen. Do
not culture others.
Strategy 3: For Children
T e majority o group A strep pharyngitis occurs in children
between ages 5 and 15 years. In this age group, 15% to 30% o
acute pharyngitis is caused by group A strep. In children, doing
a rapid strep test is considered the standard (although many
argue convincingly that it is not even necessary here in the older
child). Cultures are again optional depending on the reliability
o your rapid antigen test. Many would culture all rapid strep
test negative patients and this is certainly an acceptable strategy
as well.
So, now you are quite con used. So is everyone else . . .
Question 20.11.2 Which o the ollowing is true about anti
biotic therapy o streptococcal pharyngitis?
A) Azithromycin is the drug o choice because o resistant
streptococci
B) T ere is no signi cant resistance seen in Group A β -hemolytic
streptococci, and penicillin is still the drug o choice
C) Cephalexin is the pre erred drug because it covers H. inf u-
enzae, which is a requent coin ector with streptococci
D) Amoxicillin is pre erred or strep throat because it does not
cause a rash i the patient happens to have mononucleosis
Answer 20.11.2 The correct answer is “B.” T ere is no sig-
ni cant resistance among group A β -hemolytic streptococci to
penicillin. T us, penicillin remains the drug o choice despite
drug detailing. T ere is no reason to use anything else, except
in the case o allergy where erythromycin or cephalexin can be
used. Remember that there is now resistance to erythromycin,
azithromycin, and clarithromycin. “D” is important. Amoxicil-
lin can cause an uncom ortable rash should your patient turn
out to have mononucleiosis rather than strep throat.
HELPFUL TIP:
Pe ici i VKca be used BID i st eptococca pha i-
tis, a d this admi ist atio eque c i c eases comp i-
a ce.
Question 20.11.3 Antibiotics should be started within what
time period to reduce the risk o rheumatic ever rom
streptococcal pharyngitis?
A) 2 days a er presentation
B) 2 to 4 days a er presentation
C) 4 to 6 days a er presentation
D) 6 to 8 days a er presentation
E) 8 to 10 days a er presentation
Answer 20.11.3 The correct answer is “E.” Antibiotics should
be started within 9 days a er presentation in order to prevent
rheumatic ever, which is really our goal when we treat strep-
tococcal pharyngitis. T us, there really is no reason to hurry
treatment.
566 FAMIl y MEDICIn E EXAMIn ATIOn & BOAr D r EVIEW
Your patient is a student teacher and wants to know how long
to stay out o the classroom.
Question 20.11.4 A patient with streptococcal pharyngitis
should be considered in ectious and kept out o school or
what period a ter beginning antibiotics?
A) 12 hours
B) 24 hours
C) 36 hours
D) 48 hours
Answer 20.11.4 The correct answer is “B.” Patients should be
considered in ectious or 24 hours a er the initiation o thera-
py or streptococcal pharyngitis. T e risk o transmission goes
down markedly a er this point. Un ortunately, the patient is
actually in ectious or the 3 to 5 days be ore they become symp-
tomatic, so removing the patient or 24 hours a er treatment is
closing the barn door a er the horses have le . O course, since
this is being written in Iowa, so we are closing the pen a er the
hogs have le . T ere is some preliminary data that it is OK to
return to work/school 12 hours a er starting treatment but this
is not yet the standard o care (Pediatr In ect Dis J. 2015 Aug 20).
You see the same patient 3 weeks later. He took all o his pen-
icillin even though he elt ne a ew days a er he le your
o ce. (Wow! A compliant patient!) However, he now has the
same symptoms, starting 2 days ago. His examination is the
same.
Question 20.11.5 Which o the ollowing is the most likely
cause or his current symptoms?
A) Gonococcal pharyngitis
B) In ection with a resistant streptococcal organism
C) Mononucleosis
D) Staphylococcal pharyngitis
E) None o the above
Answer 20.11.5 The correct answer is “E.” Since his symptoms
resolved, you either got the diagnosis and treatment right or
he had some other sel -limited in ection. T ere ore, it would
be unlikely that he had gonococcal pharyngitis or resistant
streptococcal organisms. Nonetheless, sexual history is impor-
tant—even when con ronted with pharyngitis; i a patient with
exudative pharyngitis is not improving, think about gonococ-
cal disease. Remember that gonococcal disease will be missed
or two reasons in this scenario: the history is never obtained
regarding oral sex and gonococcus requires T ayer-Martin agar
to grow, so it will not show up on routine culture, and there are
a lot o alse negative cultures; consider PCR i thinking about
gonococcal pharyngitis. “B,” penicillin-resistant Streptococcus
organisms causing pharyngitis, like the ooth Fairy, are non-
existent. “C” is unlikely in this case because his symptoms re-
solved, but mononucleosis can cause prolonged symptoms o
sore throat and atigue and can be con used with strep throat.
In this case, recurrent strep throat is most likely and he should
be advised appropriately: retreat with penicillin, not a more
broad-spectrum antibiotic; consider testing and/or treating co-
habitants; have the patient replace his toothbrush.
HELPFUL TIP:
Ma causes o th oat pai a e acute i ectio s (st ep
th oat, othe bacte ia i ectio s, vi a pha itis, mo o-
uc eosis), but co side othe o i ectious causes as
we —ca otid ia, vi a th oiditis, mouth-b eathi ,
pe ito si a abscess. n o - oup A st eptococci (es-
pecia St eptococcus a a actiae, a oup B st ep) a e
i c easi bei cu tu ed om the pha x. St ep-
tococcus a a actiae ca cause i vasive disease a d
wo th t eati i ou d. It wi espo d to cepha exi o
c i dam ci (amo othe s).
It’s a “two or uesday” at your clinic. T e next patient comes
in or a sore throat and tender anterior and posterior cer-
vical adenopathy. He is ebrile and relatively stoic. He has
been sick or 2 weeks with signi cant atigue and just isn’t
getting better. In addition to the adenopathy, you notice le -
sided abdominal tenderness with minimal guarding but no
rebound tenderness. You believe that you eel a spleen edge.
However, the patient’s heterophile antibody (monospot) is
negative. You decide to get anti-EBV (Epstein–Barr virus)
antibodies. T e results o the anti-EBV antibody test are as
ollows (VCA is against the capsid): IgM-VCA positive, IgG-
VCA negative, anti-EBV nuclear antigen antibody negative.
Question 20.11.6 How do you interpret these results?
A) T e patient has acute EBV in ection
B) T e patient has had EBV at least 6 weeks ago
C) T e absence o anti-EBV nuclear antigen antibody makes
acute in ection highly unlikely
D) T e patient has never been in ected with EBV
Answer 20.11.6 The correct answer is “A.” T e patient has an
EBV in ection, starting in the last ew weeks. Here is why. IgM-
VCA is produced acutely and is elevated in the acute in ection
or 2 to 4 weeks. Since this patient’s IgM-VCA is positive, he has
had an acute EBV in ection within the past month. IgG-VCA is
measurable 3 to 4 weeks a er acute in ection and persists or li e.
T us, it gives no in ormation about when in ection occurred.
T e absence o IgG-VCA means either (1) the patient has no
history o EBV in ection or (2) the patient has had a recent EBV
in ection. Antibodies against the EBV nuclear antigen show up
at 6 to 12 weeks a er in ection. I this antibody is present in the
blood, it suggests that there has not been an acute in ection; the
in ection had to have been at least 6 weeks ago.
Question 20.11.7 O the ollowing, which DOES NOT cause
a mononucleosis like syndrome?
A) Human immunode ciency virus (HIV)
B) Cytomegalovirus (CMV)
C) oxoplasmosis
D) West Nile virus (WNV)
E) Leptospirosis

Answer 20.11.7 The correct answer is “D.” WNV is charac-
terized by ever, headache, myalgias, back pain, and anorexia
lasting 3 to 6 days. Much less common mani estations are nau-
sea, vomiting, diarrhea, encephalitis, etc. T us, WNV does not
cause a mononucleosis-like syndrome because it does not last as
long and rarely includes pharyngitis. One thing to note is that
WNV may include lymphadenopathy. All the other answers can
cause a mononucleosis-like syndrome. Other causes o mono-
nucleosis-like syndromes include adenovirus, parvovirus B19
(erythema in ectiosum), herpes virus 6 (roseola in antum), and
ehrlichiosis (Asian orm only). Remember these diagnoses in
heterophile negative mono-like illness.
HELPFUL TIP:
Depe di o what popu atio is studied, 1% to 2% o
patie ts with a mo o uc eosis- ike s d ome who a e
heterophile negative a e HIV positive.
Question 20.11.8 There is some concern o splenic rupture
in patients with mono who have splenomegaly. I spleno
megaly were con rmed in this patient, what would be the
generally accepted recommendation with regard to ath
letic participation (e.g., cage ghting)?
A) No participation until negative acute titers or EBV
B) No participation or 2 week a er the diagnosis is made,
assuming complete resolution o symptoms and then ull
participation
C) No participation until 3 weeks a er the diagnosis is made,
assuming complete resolution o symptoms and then only
noncontact training or another week
D) Full practice and competition allowed immediately unless
abdominal pain occurs
E) Full practice and competition immediately with body armor
(e.g., Kevlar vest)
Answer 20.11.8 The correct answer is “C.” It is generally
thought that return to practice or noncontact training is sa e
3 weeks a er the diagnosis o mononucleosis, provided that
all other symptoms have also resolved. I there are no clinical
concerns or splenic enlargement at 4 weeks, then the athlete
may be cleared to return to ull competition. T is recommen-
dation is based on the observation that most cases o splenic
rupture in athletes have occurred when those athletes returned
to competition in less than 4 weeks rom the time o diagnosis.
T e patient returns 2 days later and is noting increased pha-
ryngeal swelling and di culty swallowing. You look into his
throat and note “kissing tonsils.” T ere is no stridor, but he
eels as though there is something in his throat.
Question 20.11.9 What is the best treatment or this patient
at this time?
A) Observation
B) Amoxicillin
C) Clindamycin
CHAPTER 20 • OTOl Ar yn g Ol Og y 567
D) Prednisone
E) onsillectomy
Answer 20.11.9 The correct answer is “A.” You may want to give
steroids (“D”), but you will nd little data to back you up. A Co-
chrane Collaboration Review updated in 2011 ound insuf cient
evidence or steroids or symptom control in patients with mono.
However, many physicians still prescribe steroids or patients with
signi cant symptoms. Antibiotics are not indicated or mononu-
cleosis. onsillectomy is also not indicated. T e patient likely has
paratracheal node swelling, as well. In this patient, hospital admis-
sion may be indicated i there is concern or airway obstruction.
Question 20.11.10 What is the approximate sensitivity o
the heterophile antibody test (“monospot”) or mononu
cleosis within the rst 2 weeks o symptoms?
A) 10%
B) 30%
C) 50%
D) 70%
E) > 90%
Answer 20.11.10 The correct answer is “D.” T e sensitivity o
the monospot ranges rom 60% to 80% 2 weeks into the illness.
T e point here is not the number per se but the act that there
are heterophile-negative mononucleosis syndromes and not ev-
eryone with EBV mononucleosis will have a positive monospot
when tested. However, they should have atypical lymphocytes
on WBC di erential.
HELPFUL TIP:
Co side pe ito si a abscess i a patie t with a so e
th oat. The e wi e e a be a mu ed, “hot potato,”
voice, deviatio o the uvu a awa om the side o the
abscess, a d p ot usio o a to si towa d mid i e. This
ma be a exte sio o a p io pha itis but ma a so
a ise de ovo. T eatme t is a tibiotics a d d ai a e
( eed i it is OK— o eed o su ica i vo veme t i
a cases). It is a so impo ta t to pa atte tio to the ai -
wa si ce the e is the possibi it o obst uctio .
HELPFUL TIP:
The mo ospot is ot as se sitive i chi d e . It wi be-
come positive i ess tha 40% o chi d e ou e tha
5 ea s whe the a e i ected with EBV. Howeve , a ti-
EBV a tibodies wi be positive.
HELPFUL TIP:
Arcanobacterium haemolyticum is a bacte ium that
causes pha itis especia i ou adu ts (tee s,
ea 20s). It c i ica ooks ike st ep th oat but o te
has a associated ash especia o the a ms (50%
o ). It does ot cause o -te m seque ae, so testi
o it is ot ecessa i i dicated (but it is coo to ide ti
whe the patie t comes i with the app op iate ash!).
568 FAMIl y MEDICIn E EXAMIn ATIOn & BOAr D r EVIEW
I ou choose to t eat (which some p actitio e s do), it
is e e a se sitive to pe ici i s, cepha ospo i s, a d
tet ac c i es.
Objectives: Did you learn to . . .
• Desc ibe di e e t st ate ies to app oachi the patie t with
s mptoms o streptococcal pha itis?
• T eat a patie t with streptococcal pha itis a d ecu e t
pha itis?
• Deve op a b oad di e e tia o so e th oat?
• Dia ose a d t eat mo o uc eosis?
QUICK QUIZ: In THE SAME VEIn . . .
Uh, oh. You have treated a 19-year-old college student or pre-
sumed streptococcal pharyngitis with azithromycin (didn’t we
say not to do this?!). In your de ense, he wanted to get better
ast because he landed the lead role in the new musical You
Had Me at Arrrgh: A Wookie Love Story. He returns 1 week later
with high ever and a cough, looking quite ill. Chest radiograph
shows small pulmonary abscesses and he is tender over a swol-
len carotid sheath. His throat looks aw ul . . . . .
T e most likely diagnosis is:
A) Lemierre syndrome
B) Complication o EBV mononucleosis
C) Cardiac valvular disease rom rheumatic ever
D) Aspiration pneumonitis rom his pharyngitis
E) Scarlet ever
The correct answer is “A.” T is is a classic case o Lemierre
syndrome, or septic thrombophlebitis o the jugular vein rom
(generally) Fusobacterium necrophorum. T is is an anaerobic
in ection o the posterior pharynx that may be misdiagnosed
as streptococcal disease. Generally, patients look ill with a
temperature o > 39°C, have tenderness in the neck, and have
septic emboli in the lungs. T e basic problem is a septic throm-
bophlebitis o the jugular vein. It is being increasingly recog-
nized especially in young adults (teens–early 20s). T is patient
must be admitted or IV antibiotics and may require anticoagu-
lation and/or surgical intervention. In the pharyngitis stage, it is
sensitive to penicillin. See, i you would have listened to us and
used penicillin in the rst place you wouldn’t be in this bind!
Clinical Pearls
Arcanobacterium a d Fusobacterium pha itis ca ook
just ike St ep th oat a thou h the apid St ep wi be
e ative. Arcanobacterium is o te associated with a ash.
Fusobacterium ca ead to a septic th omboph ebitis o the
ju u a vei (l emie e s d ome).
Co side mumps i a patie t with sa iva a d swe i
eve i patie ts who have had both MMr vacci atio s;
immu it wa es with time a d the e a e ea outb eaks i
the U ited States.
Do ot su est ea tubes o patie ts with u i ate a se ous
otitis. The mai u ctio o ea tubes i this situatio is to
assist with a ua e deve opme t. This is ot a issue with
u i ate a se ous otitis.
I ectio s o the ca ti a i ous ea pi ae om pie ci sa e
o te om Pseudomonas. This is a eme e c .
Most asa t auma eed ot be add essed at a i st visit:
ou ca et a bette cosmetic esu t o ce the swe i has
eso ved. Howeve , a septa hematoma is a eme e c
that equi es p ompt atte tio to p eve t septa ca ti a e
dest uctio .
Pe ici i is sti the d u o choice o St ep th oat. The e is o
esista ce a d i the patie t has mo o ou have ’t ated them
to 6 weeks o a ash, which mi ht occu with amoxici i .
Use a wick whe t eati otitis exte a with d ops. This wi
he p assu e that the medicatio ets to whe e it is eeded.
BIBLIOGRAPHY
American Academy o Pediatrics Subcommittee on Manage-
ment o Acute Otitis Media. Diagnosis and management
o acute otitis media. Pediatrics. 2013;131(3):E964–E969.
Aring AM, Chan MM. Acute rhinosinusitis in adults. Am Fam
Physician. 2011;83(9):1057–1063.
Buescher JJ. emporomandibular joint disorders. Am Fam
Physician. 2007;76(10):1477–1482.
Centor RM, Samlowski R. Avoiding sore throat morbidity and
mortality: When is it not “just a sore throat?”. Am Fam
Physician. 2011;83(1):26, 28.
Chow AW, et al. Executive Summary: IDSA Clinical Practice
Guideline or Acute Bacterial Rhinosinusitis in Children
and Adults. Clin In ect Dis. 2012;54(8):1041–1045.
Ely JE, et al. Diagnosis o ear pain. Am Fam Physician. 2008;
77(5):621.
Feierabend RH, Shahram MN. Hoarseness in adults. Am Fam
Physician. 2009;80(4):363–370.
Lockhart P, et al. Antiviral treatment or Bell’s palsy (idiopathic
acial paralysis). Cochrane Database Syst Rev. 2009;4:
CD001869.
Lodi G, et al. Interventions or treating oral leukoplakia. Co-
chrane Database Syst Rev. 2006;4:CD001829.
McAllister K, et al. Surgical interventions or the early man-
agement o Bell’s palsy. Cochrane Database Syst Rev.
2011;2:CD007468.
Paradise JL, et al. Developmental outcomes a er early or
delayed insertion o tympanostomy tubes. N Engl J Med.
2005;353:576–586.
Parnes LS, et al. Diagnosis and management o benign parox-
ysmal positional vertigo (BPPV). CMAJ. 2003;169(7):681.
Rosen eld RM, et al. Clinical practice guideline: Acute otitis
externa. Otolaryngol Head Neck Surg. 2006;134(4, Suppl):
S4–S23.
Salinas RA, et al. Corticosteroids or Bell’s palsy (idiopathic
acial paralysis). Cochrane Database Syst Rev. 2010;3:
CD001942.
Schwetschenau E, Kelley DJ. T e adult neck mass. Am Fam
Physician. 2002;66(5):831.
Care of the Older Patient
Nicholas R. Butler and Jason K. Wilbur
CASE 21.1
An 83-year-old emale patient whom you have ollowed
or many years has just been admitted to a nursing home
ollowing a short hospitalization. Because o a steady
decline in unction and lack o amily and social support,
you and the patient have come to the realization that she
can no longer sa ely live alone in her home, and her needs
were too great or assisted living. Her medical problems
include: congestive heart ailure, chronic atrial ibrilla-
tion, osteoarthritis, and depression. Her current medica-
tions are: war arin, urosemide, acetaminophen, calcium
carbonate, lisinopril, metoprolol, and luoxetine. Both
the patient and the nursing sta report poor sleep and
depressed mood or the last 2 weeks, and the nurses are
asking or a sleep aid.
Question 21.1.1 What is the best next step in the manage -
ment o her insomnia?
A) A iphenhy ramine 50 mg PO HS
B) A iazepam 5 mg PO HS
C) A amitriptyline 25 mg PO HS
D) Recommen increase activity uring the ay, avoi ance o
naps, warm milk be ore be , an waking at the same time
each morning
E) A 2 shots o bourbon PO HS
Answer 21.1.1 The correct answer is “D.” T ere are no
great me icines or promoting sleep in el erly nursing home
resi ents. Given the lack o e cacy ata o most hypnotics
couple with the known a verse e ects, a trial o goo sleep
hygiene shoul be un ertaken rst. “Goo sleep hygiene” gen-
erally consists o the ollowing: eliminate or re uce aytime
naps, a aily activities, maintain a set waking time, increase
aerobic exercise (but not within a ew hours o be time), an
maintain a quiet, com ortable sleeping environment. Night-
time rituals, such as me itation an warm milk, may help
insomnia an are unlikely to cause any harm, but avoi the
21
bourbon as alcohol inter eres with normal sleep architecture
(single malt scotch?? . . . maybe). I these initial e orts ail, a
low ose o a hypnotic (e.g., zolpi em an zaleplon) or trazo-
one is an appropriate choice. razo one has ewer anticho-
linergic an bloo pressure e ects than other options, such as
tricyclics an benzo iazepines, but shoul still be use with
caution while monitoring or a verse e ects. Diphenhy r-
amine (“A”) has power ul antihistaminic an anticholinergic
properties that may result in increase con usion an alls.
Diazepam (“B”) has an exceptionally long hal -li e in el erly
patients an may cause aytime somnolence. Amitriptyline
(“C”) is liste by the Centers or Me icare an Me icai Ser-
vices (CMS) as a me ication to be avoi e in nursing home
patients ue to high potential or severe a verse rug reac-
tions ( alls, constipation, etc.).
HELPFUL TIP:
Melatonin receptor agonists (e.g., ramelteon) are an-
other option or insomnia but are not great. Patients
sleep about 7 minutes more per night compared to pla-
cebo (let’s talk about statistically signi icant vs. clinically
signi icant now!). They are relatively sa e and do not
lead to a “hangover” as with many hypnotics. The use
o ramelteon has also been shown to be bene icial in
preventing the onset o delirium in acutely hospitalized
elderly patients. What about melatonin, you say? Poor
evidence but low chance o harm, so some physicians
will try it irst. And then there are orexin receptor an-
tagonists, such as suvorexant (Belsomra). But they look
pretty scary (suicidal ideation, “sleep driving,” need to
warn about next-day driving and other dangerous ac-
tivities); there have been cases o daytime cataplexy.
Suvorexant has a 12-hour half-life in the nonelderly lead-
ing to signi icant dys unction the day a ter taking the
drug. Never prescribe them or elderly patients. In act,
orget we mentioned them.
569
570 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
HELPFUL TIP:
There are many potential causes o sleep disturbance
in the nursing home. The ollowing are sources o sleep
problems that you may want to investigate or treat
empirically: pain, anxiety, depression, delirium, demen-
tia, primary sleep disorders (e.g., sleep apnea, restless
leg syndrome), environmental issues (e.g., alarms and
lights).
T e nurses grudgingly accept your recommendation to try
sleep hygiene (“Can’t we just give her a pill?”), and over the
next month your patient’s sleep improves, as does her mood.
T ere’s one in the win column or the doctor! Un ortunately,
she experiences two alls with minor injuries while ambulat-
ing in her room. Upon examination, you nd normal vital
signs, no orthostatic hypotension, and no ocal neurological
de cits.
Question 21.1.2 Which o the ollowing is the most appro-
priate next step?
A) Discontinue war arin
B) Employ be an chair alarms
C) Obtain a computerize tomography (C ) scan o the hea
D) Re uce or iscontinue uoxetine
E) Restrict activities an prescribe a wheelchair
Answer 21.1.2 The correct answer is “D.” As of en happens
in li e, there is no great answer here. Falls are usually multi ac-
torial in origin, so simple interventions o not generally solve
the problem. SSRIs have been shown (in imper ect stu ies) to
increase the risk o alls in the el erly, so re ucing or iscon-
tinuing uoxetine is pru ent, but you will have to watch or
moo an anxiety symptoms. “A,” iscontinuing war arin, may
be appropriate i she continues to all but this action is not likely
to re uce her all risk. “B,” the use o be an chair alarms, is
help ul when patients have cognitive impairment an can-
not remember to ask or help when getting up; however, these
evices can act as tethers to urther restrict a patient’s move-
ment. Likewise, urther restriction o activities an man a-
tory wheelchair use may lea to econ itioning, loss o mus-
cle strength, an an increase risk o alls. A C scan o the
hea may be warrante i the patient sustaine a hea injury or
ha an abnormal neurological examination, but it’s unlikely to
etermine the cause o her alls.
Over the next year, you observe a steady decline in your
patient’s unction, with a series o alls despite interventions.
Ultimately, your patient has a devastating thromboembolic
stroke, which results in right hemiparesis and dysphagia.
A er a short hospital stay, she returns to the nursing home
and undergoes therapy. You order a swallow study (which
you will do or all stroke patients). She continues to have di -
culty with her swallowing but is able to tolerate thickened
liquids without aspirating. She has a 5%weight loss over the
next 2 months, and her nurse reports poor oral intake. Her
medications are now war arin, urosemide, acetaminophen,
calcium carbonate, and lisinopril.
Question 21.1.3 In this malnourished, elderly nursing home
patient, which o the ollowing interventions or diagnostic
studies will most likely lead to improvement in her condi-
tion?
A) A mit to the hospital an initiate parenteral ee ing
B) Re er or esophagogastro uo enoscopy (EGD)
C) Screen or epression
D) A megestrol acetate
E) A marijuana
Answer 21.1.3 The correct answer is “C.” Depression is one o
the most common causes o weight loss in the nursing home,
an stroke survivors are at high risk or epression. Also, this
patient has a history o epression with no current treatment
(Remember? We stoppe the uoxetine earlier). Consi er using
a screening tool, such as the geriatric depression scale. A positive
screen requires urther investigation. Now that she is be ri -
en, alls are not as much o an issue, so an SSRI may be appro-
priate. “A” is incorrect. We are not sure o the patient’s wishes
regar ing intravenous (IV) nutrition, an more conservative
measures shoul be institute be ore consi ering parenteral
nutrition. “B” is incorrect. While an EGD may be important at
some point, procee ing to EGD imme iately is premature. “D,”
megestrol acetate, has been reporte to improve oo intake in
patients with cancer cachexia, but its value in the nursing home
is questionable, an it may be associate with an increase risk
o mortality. “E” is also incorrect. Even i you practice in one o
the tokin’ states, we cannot have her lighting up in the nursing
home.
HELPFUL TIP:
The initial evaluation o a nursing home patient with
weight loss should ocus on medication review, gastro-
intestinal (GI) symptoms, dental and mouth problems,
swallowing dys unction, ability to eed one-sel , and
psychiatric disorders (e.g., depression, dementia, or
psychosis). Hyperthyroidism, hyperparathyroidism, ma-
lignancy, and chronic in ection should be considered as
causes o weight loss (albeit less likely). Factors associ-
ated with aging, such as decreased ol action, taste, and
salivation (and nursing home ood), may decrease the
enjoyment o eating.
You diagnose depression and initiate treatment. You also
encourage the nursing sta to observe your patient while
eating and assist her i necessary. You add a daily multivita-
min. Her mood improves slightly and her weight stabilizes.
However, over the next 6 months, your patient becomes more
withdrawn and spends most o her time in bed. Because o
her stroke, she is not very mobile, and she requires assistance
with trans ers and movement in bed. Ultimately, she develops
 CHAPTER 21 • CARE OF THE OLDER PATIENT 571

TABLE 21-1 PRESSURE ULCER STAGES

Stage I Stage II Stage III Stage IV Unstageable
Nonblanchable Partial-thickness Full-thickness skin loss Full-thickness skin loss Ulcer covered in eschar
erythema skin loss and depth unknown

Intact skin Epidermis and/or Damage or necrosis o Extensive destruction, tissue

dermis subcutaneous tissues, necrosis, or damage to muscle,
extending to underlying ascia bone or supporting structures

Changes in skin Presents as Presents as deep crater

temperature, abrasion, blister, or
consistency, or shallow crater
sensation

a skin ulcer on her sacrum. Nursing sta reports a sacral
pressure ulcer measuring 3 × 2 cm. T ere appears to be some
interruption o the epidermis, like an abrasion.
Question 21.1.4 According to conventional staging criteria,
what stage is this pressure ulcer?
A) Stage I
B) Stage II
C) Stage III
D) Stage IV
Answer 21.1.4 The correct answer is “B.” Pressure ulcers (in
ol er parlance, ecubitus ulcers, pressure sores, or be sores)
are cause by unrelieve pressure resulting in amage to un er-
lying tissue. Stage II ulcers are partial thickness injuries that are
shallow an appear as open ulcers. Anatomic areas o concern in
be -boun patients inclu e sacrum, coccyx, heels, an occiput.
Chair-boun patients are more likely to evelop ulcers over
the ischial tuberosities. Risk actors or pressure ulcers inclu e
a vancing age, immobility, moisture (e.g., urinary or ecal
incontinence), malnutrition, an ecrease sensory perception.
Ulcers are stage by clinical appearance (see able 21-1).
Because o miscommunication within the nursing home
sta , the ulcer goes untended over the weekend. An alarmed
nurse calls you to report ull thickness skin loss. You arrange
to visit the patient in the evening . . . here comes another
“above and beyond” award.
Question 21.1.5 In the meantime, you prescribe what
treatment?
A) Foam pa with occlu ing ressing (e.g., Allevyn, Mepilex)
B) Wet-to- ry ressing
C) opical antibiotics
D) ransparent, occlusive ressing (e.g., ega erm)
E) Chemical enzyme ebri ement (e.g., Accuzyme)
Answer 21.1.5 The correct answer is “A.” In treating pressure
ulcers, there are several principles to ollow: relieve pressure,
protect the woun an surroun ing skin rom urther trauma,
maintain a clean woun be , provi e a moist woun environ-
ment, eliminate ea space, control exu ates, ensure a equate
nutrition, an iagnose an treat in ection. Your patient’s ulcer
has worsene an is now at least stage III. Without urther in or-
mation, oam ressing is a sa e choice or initial treatment o
a stage III ulcer. Foam pa s are use ul or eeper woun s with
mo erate exu ate an may also protect the woun rom urther
pressure. In most cases, the woun shoul be kept moist, so wet-
to- ry ressings are not appropriate (they also ebri e the woun
o both necrotic an healthy tissues—ouch). I moist gauze pack-
ing is use , it shoul be kept moist with intermittent reapplica-
tion o saline or change be ore rying. From the nurse’s report,
there is no evi ence o necrosis, excessive rainage or in ection,
so ebri ement an antibiotics may not be help ul at this time.
A transparent, occlusive ressing is use or stage II ulcers, but is
insu cient or stage III or IV. In a ition to ressing the woun ,
you shoul employ the ollowing measures: repositioning every
1 to 2 hours, pressure-relieving mattress an cushions, an opti-
mizing nutrition. Consultation with a woun care specialist or a
surgeon may be necessary i these measures ail.
HELPFUL TIP:
There is minimal evidence o bene it or the use o most
adjunctive therapies or pressure ulcers (electrical stim-
ulation, ultrasound, hyperbaric oxygen, ultraviolet light,
vasodilators, vacuum devices, etc.). In general, stick with
pressure relie , good wound care, and nutrition.
HELPFUL TIP:
To prevent pressure ulcers, schedule regular and re-
quent repositioning or bed and chair-bound individu-
als. Turn at least every 2 to 4 hours on a pressure-reduc-
ing mattress or every 2 hours on a nonpressure-reducing
mattress. Also, maintain the head o the bed ≤ 30 de-
grees i possible to reduce pressure on the sacral area.
Question 21.1.6 Which o the ollowing statements is NOT
true about the evaluation and treatment o pressure ulcers?
A) A pressure ulcer covere by eschar cannot be stage until
the eschar is remove .
B) I a pressure ulcer shows no signs o healing over 2 weeks,
one shoul reevaluate woun management strategies an
reexamine actors a ecting the woun .
C) One shoul consi er osteomyelitis or eep sof -tissue in ec-
tion in a woun that is not healing.
572 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
D) Woun cultures shoul be obtaine routinely to target anti-
biotics towar the organisms oun .
E) In an otherwise clean woun that is not healing as expecte ,
one shoul consi er empiric therapy with topical antibiotics.
Answer 21.1.6 The correct answer is “D.” T e routine cul-
turing o pressure ulcers is not recommen e . Antibiotics are
generally not use ul since the organisms oun are polymicro-
bial colonizers an not responsible or in ection. Obviously,
this oes not hol true or patients with a true in ection, an
empiric therapy with topical antibiotics is in icate i a woun
shows no improvement with goo woun care.
Objectives: Did you learn to . . .
• Manage insomnia in elderly nursing home residents?
• Develop an approach to the problem o alls in nursing home
residents?
• Identi y nursing home residents at risk or malnutrition?
• Develop a treatment plan or malnutrition in the institution-
alized elderly?
• Diagnose, evaluate, and manage pressure ulcers in the nurs-
ing home setting?
QUICK QUIZ: VACCINES
A 65-year-ol male presents or a routine visit an you recom-
men pneumococcal vaccination (23-valent polysacchari e
vaccine, Pneumovax). Your patient asks what the vaccine is sup-
pose to o.
Accor ing to the best available evi ence, you are able to say:
A) “T is vaccine will re uce your risk o pneumococcal bacte-
remia.”
B) “T is vaccine will re uce your risk o pneumococcal pneu-
monia.”
C) “T is vaccine will re uce your risk o all types o pneumo-
nia.”
D) “T is vaccine will re uce your risk o eath rom in uenza.”
E) “T is vaccine will o all o the above.”
The correct answer is “A.” T e 23-valent polysacchari e pneu-
mococcal vaccine has only been shown e ective in re ucing the
risk o pneumococcal bacteremia an meningitis. T e vaccine
oes not appear to re uce the risk o pneumonia in general or
even pneumococcal pneumonia in particular. In uenza vacci-
nation ecreases the risk o eath ue to in uenza, but pneumo-
coccal vaccination oes not.
But what you should have done is o er this patient the pneu-
mococcal conjugate vaccine (e.g., Prevnar) rst. In 2014, the
CDC recommen e the 13-valent pneumococcal conjugate
vaccine (PCV 13) or use in all patients over the age o 65 as a
one-time ose. It shoul be a ministere to vaccine-naive in i-
vi uals ollowe by the 23-valent polysacchari e pneumococcal
vaccine (Pneumovax) 6 to 12 months later. For in ivi uals who
have been immunize with the 23-valent polysacchari e pneu-
mococcal vaccine, it is recommen e that the PCV 13 be given
as a single ose at least 1 year af er the last ose o the 23-valent
polysacchari e pneumococcal vaccine.
QUICK QUIZ: HORMONES AND AGING
Noticing a vertisements or testosterone treatment to “make
you a vital man again,” one o your vivacious ol er emale
patients asks about testosterone or her husban won ering i it
can make him 50 years ol again.
Regar ing sex hormone changes associate with aging, which o
the ollowing is true?
A) Ley ig cells in the testes increase with aging
B) otal testosterone levels increase with aging
C) Sex hormone bin ing globulin levels increase with aging
D) Follicle-stimulating hormone levels are unchange with
aging
E) Luteinizing hormone levels ecrease with aging
The correct answer is “C.” Sex hormones in males over age
40 emonstrate eclining total testosterone at a rate o 1% to
2% per year. Simultaneously, sex hormone bin ing globulin
increases, resulting in a sharper ecline in bioavailable testos-
terone. In response to low testosterone, ollicle-stimulating an
luteinizing hormone levels increase. Ley ig cells (responsible
or pro ucing testosterone) ecrease in number. Ol er males
with subphysiologic testosterone levels are at increase risk o
sexual ys unction, osteoporosis, iminishe lean bo y mass,
epression, an inability to kill a mountain lion with their bare
han s. Although controversial, some experts recommen tes-
tosterone supplementation in symptomatic males with low
serum testosterone. estosterone supplementation may (notice
the wor “may”) improve strength, lean bo y mass, epresse
moo , bone mineral ensity, an sexual unction in aging males
with ocumente low testosterone levels. Si e e ects o testos-
terone supplementation in ol er males inclu e: car iac isease,
liver ys unction, yslipi emia, erythrocytosis, prostate tis-
sue growth, acne, gynecomastia, an e ema. I your patient is
bale ul and pushes the request or “ ,” point out that testosterone
adds nothing to the treatment o erectile dys unction beyond that
bene t which is o ered by tadala l (Cialis), sildena l (Viagra),
etc. You can reassure him that he will be just as virile at age 98
without testosterone an will avoi the risk o worsening heart
isease (Ann Intern Med. 2012;157:681).
HELPFUL TIP:
Any time you see the word “may,” think “may not.” They
are logical equivalents.
CASE 21.2
A 79-year-old emale patient, well known to you rom 5 years
o treating her hypertension, presents to your o ce or an
“annual examination” and “medication re ll”. Her only medi-
cations are lisinopril, amlodipine, and acetaminophen. She’s

noticed some hearing loss over the last year, and wonders
i she should blame her medications and not all those rock
concerts she attended as a young adult. Oh, by the way, her
gynecologist recently retired and she would now like you to
assume that care, which apparently included all o her pre-
ventative care.
Question 21.2.1 Which o the ollowing drugs is NOT associ-
ated with sensorineural hearing loss?
A) Ibupro en
B) Aminoglycosi es
C) Furosemi e
D) Magnesium salicylate
E) Acetaminophen
Answer 21.2.1 The correct answer is “E.” All o these rugs
except or acetaminophen can cause hearing loss. Cisplatin,
aminoglycosi e antibiotics, an loop iuretics have been asso-
ciate with hearing loss, as have salicylates (e.g., aspirin) an
some o the other NSAIDs (e.g., ibupro en an i unisal) an
chloroquine. T is list is obviously not exhaustive.
HELPFUL TIP:
Hearing loss, and sensory impairments in general, can
be con used with cognitive impairment or an a ective
disorder. Hearing aids are use ul or most cases o pres-
bycusis, but i speech discrimination is < 50%, results
with hearing aids may be poor.
Your patient then asks, “Do I have to keep getting mam-
mograms and Pap smears?” She relates a history o normal
annual mammograms and Pap smears or the past 20 years,
as her previous physician hadn’t changed her practice since
T e Backstreet Boys were popular. She had a hysterectomy
or uterine bromas and has been monogamous with her
husband or 55 years. Her sister died o breast cancer. Using
your magic crystal ball, you estimate her li e expectancy at
10 years.
Question 21.2.2 Consistent with current guidelines, you
recommend:
A) Continue Pap smears an pelvic examinations yearly
B) Discontinue mammography but per orm clinical breast
examinations every 2 years
C) Discontinue pelvic examinations but continue Pap smears
D) Discontinue Pap smears but o er mammography at 1- to
2-year intervals
Answer 21.2.2 The correct answer is “D.” ricky question.
Screening ecisions in the el erly shoul be in ivi ualize ,
an the patient’s overall health status must be consi ere . T is
patient has very little risk o cervical, en ometrial, or vaginal
cancer (status post hysterectomy or a benign con ition, low-
risk sexual behavior, an a history o normal examinations);
there ore, it is reasonable to iscontinue Pap smears. Annual
CHAPTER 21 • CARE OF THE OLDER PATIENT 573
pelvic examination is more controversial, with the American
Cancer Society (ACS) recommen ing it as a screening measure
or ovarian cancer an the US Preventive Services ask Force
(USPS F) recommen ing against it.
Screening or breast cancer continues to be recommen e
or women with a 5 to 10 years li e expectancy, but the optimal
interval in ol er women is unknown: T e American College o
Physicians (kin o presumptuous name . . . what about FM? Are
we not physicians?) an USPS F recommen screening o aged
50 to 74 years every other year; our patient is 79. Whether this
patient will bene t rom mammography is unknown. T ere is a
signi cant question o the “over iagnosis” o breast cancer; this
is cancer iagnose by mammogram that woul not ever have
cause a problem or the patient (think o it as the equivalent o
the iagnosis o prostate cancer in men . . . they may ie with the
cancer an not o the cancer) (e.g., JAMA Intern Med. Publishe
online July 06, 2015. oi:10.1001/jamainternme .2015.3043).
Be ore or ering a mammogram, we nee to have a iscussion
with our patients about what types o intervention they woul
want shoul a positive mammogram be note .
HELPFUL TIP:
The 2012 consensus guidelines on screening or cervi-
cal cancer recommend discontinuing screening at age
65 i the previous three Pap smears prior to age 65
were completely normal and there were no indings o
CIN2 or higher in the previous 20 years. Once stopped,
screening should not be resumed or any reason, in-
cluding a new sexual partner.
Your patient is an overweight white emale with no history o
bone racture. She has never had a bone mineral density test
and asks i she should have one. You are unaware o any risk
actors in her other than Caucasian race and postmenopause
status.
Question 21.2.3 What do you tell her?
A) “You are not at risk or osteoporosis an shoul not be
screene ”
B) “All women over age 65 shoul be screene or osteoporosis
regar less o risk”
C) “ ake 1,000 mg o calcium per ay to prevent osteoporosis.
You’ll be unbreakable—like Wolverine”
D) “Due to your risk actors, you shoul start a bisphosphonate,
vitamin D, an calcium supplementation”
E) “Alcohol—an lots o it—will help ecrease your risk o os-
teoporosis”
Answer 21.2.3 The correct answer is “B.” T e USPS F cur-
rently recommen s bone ensitometry screening or all women
o age 65 years an ol er. T e National Osteoporosis Foun-
ation recommen s bone ensitometry or postmenopausal
emales with one or more o the ollowing risk actors: amily
history o osteoporosis, personal history o low trauma racture,
current smoking, or low bo y weight (< 127 lb). A itional risk
574 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
actors or osteoporosis inclu e: emale sex, Caucasian or Asian
races, alcohol abuse (thus, “E” is wrong), se entary li estyle, an
poor intake or absorption o calcium an vitamin D. Smoking is
associate with osteoporosis. Diabetes, once thought to protect
against osteoporosis, may actually increase the risk o alls an
ractures in ol er a ults. T e pre erre metho or measuring
bone ensity is ual-energy x-ray absorptiometry (DEXA). All
postmenopausal women shoul consume 1,200 mg o elemen-
tal calcium per ay in ivi e oses. T e optimal amount o
vitamin D is 400 to 800 IU/ ay. Weight-bearing exercises also
strengthen bone. Bisphosphonates are in icate or treatment
o osteoporosis an shoul not be use without a iagnosis (so
“D” is incorrect).
HELPFUL TIP:
Supplementing vitamin D is probably more important
than supplementing calcium. Calcium supplementa-
tion has not consistently demonstrated racture risk re-
duction. However, many elderly Americans are vitamin
D de icient, and correction o the de iciency results in
reduced racture risk. Given the low risk o adverse e -
ects with daily vitamin D (up to 1,000 IU/day), empiric
supplementation is justi iable. Finally, 1,000 to 1,200 mg
(not 1,500 mg) o calcium is probably plenty. Additional
calcium has been linked to an elevated risk o coronary
artery disease and no change in racture risk. Calcium
and vitamin D are clearly bene icial in those with osteo-
porosis, however.
Next, your patient asks whether any o her medications put
her at risk or osteoporosis.
Question 21.2.4 Which o the ollowing is LEAST likely to
increase the risk o osteoporosis?
A) Glucocorticoi s
B) Anticonvulsants
C) Sul onylureas
D) Loop iuretics
E) Proton-pump inhibitors
Answer 21.2.4 The correct answer is “C.” Sul onylureas o not
have a irect e ect on bone mineralization. Glucocorticoi s an
anticonvulsants are known to increase bone turnover, resulting
in increase risk o osteoporosis. Loop iuretics cause renal
calcium wasting. T ere is an association between proton-pump
inhibitor use an osteoporosis, possibly through re uce cal-
cium absorption or irect e ects on bone metabolism. T ere
oes not appear to be this same association with H 2-blockers
such as amoti ine. A itionally, heparin, methotrexate, cyclo-
sporine, an gona otropin-releasing hormone agonists may
increase the risk o osteoporosis. Excessive amounts o levothy-
roxine can cause increase bone turnover. T iazi e iuretics are
protective.
Your patient asks what causes osteoporosis.
Question 21.2.5 Although most osteoporosis in women is
primary (idiopathic), which o the ollowing cause(s) sec-
ondary osteoporosis?
A) Hypoparathyroi ism
B) Multiple myeloma
C) Estrogen use
D) Hyperlipi emia
E) Overly ambitious, or perhaps calcium-a icte , ooth
Fairies
Answer 21.2.5 The correct answer is “B.” About 70% o
women have no i enti able cause or osteoporosis an there-
ore are iagnose with primary (i iopathic) osteoporosis.
Common causes o secon ary osteoporosis inclu e chronic
corticosteroi use, alcoholism, GI isor ers, hyperthyroi ism,
hyperparathyroi ism (so, “A” is wrong), multiple myeloma,
an primary renal iseases. Hyperlipi emia is not known to be
associate with osteoporosis. Estrogen increases bone mineral
ensity.
You encourage appropriate vitamin D and calcium intake as
well as weight-bearing exercises. You plan to obtain a DEXA
scan.
Question 21.2.6 Using DEXA scan results, osteoporosis is
de ned as:
A) A -score o 2.5 stan ar eviations or more below the
mean o a healthy young a ult (≤ − 2.5).
B) A -score rom 1.0 up to 2.5 stan ar eviations below the
mean o a healthy young a ult (− 1.0 up to − 2.5).
C) A Z-score o 2.5 stan ar eviations or more below the
mean o a healthy young a ult (≤ − 2.5).
D) A Z-score rom 1.0 up to 2.5 stan ar eviations below the
mean o a healthy young a ult (− 1.0 up to − 2.5).
Answer 21.2.6 The correct answer is “A.” T e -score com-
pares the patient’s bone mineral ensity to that o young,
healthy women ( or emale patients; male normative ata is
use or males). Osteoporosis is e ne as a -score o 2.5 stan-
ar eviations or more below the mean (≤ − 2.5). Osteopenia
is e ne as a -score rom 1.0 up to 2.5 stan ar eviations
below the mean (− 1.0 to − 2.5). “C” is incorrect. T e Z-score
compares bone mineral ensity to that o age-matche controls.
T ere ore, it oes not re ect the bone loss rom baseline in a
young healthy emale, an it is not use or iagnosis. “D” is
incorrect or the same reason.
Question 21.2.7 I you nd that your patient has osteopo-
rosis, you may consider using all o the ollowing drugs to
treat her osteoporosis EXCEPT:
A) Bisphosphonates (e.g., alen ronate an rise ronate)
B) Estrogens
C) Progesterone (e.g., Provera an Depo-Provera)
D) Vitamin D an calcium
E) Calcitonin

Answer 21.2.7 The correct answer is “C.” Progesterones are
not in icate or the treatment or prevention o osteoporo-
sis. In act, in young, healthy, premenopausal women, they
are associate with a ecrease in bone mineral ensity. T is is
because they suppress estrogen pro uction (such as with Depo-
Provera). All o the other options are acceptable choices in the
treatment o osteoporosis.
She returns to discuss her test results, and her bone density is
very low with her hip -score 3.2 standard deviations below
the mean (− 3.2). You diagnose her with osteoporosis. “Are
my bones like Swiss cheese?” she asks. No, you think. Swiss
cheese has more calcium.
Question 21.2.8 Given that she is otherwise relatively
healthy, what is the most appropriate initial therapy or her
osteoporosis?
A) Alen ronate (Fosamax) 70 mg PO weekly
B) Estrogen (e.g., Premarin) 0.625 mg PO aily
C) eriparati e (Forteo) 20 g SC aily or 5 years
D) Zole ronic aci (Reclast) 5 mg IV every 3 months
Answer 21.2.8 The correct answer is “A.” Bisphosphonates
are the treatment o choice or osteoporosis. Alen ronate, rise-
ronate, an zole ronic aci have all been shown to re uce
the risk o vertebral an hip ractures in persons with osteo-
porosis. Iban ronate only appears to lower vertebral racture
risk; there ore, it shoul not be your rst choice. Si e e ects
o bisphosphonates inclu e hypocalcemia (more likely with IV
a ministration, as with zole ronic aci , an in patients with
vitamin D e ciency), nausea, esophagitis, osteonecrosis o the
jaw (usually at higher oses, such as those use to treat cancer),
an atypical emur ractures. Although you might be tempte
to choose “D,” zole ronic aci , ue to this patient’s more severe
osteoporosis, there is no clear evi ence that zole ronic aci is
more e ective than oral bisphosphonates. T e IV route shoul
be reserve or when the patient has aile oral bisphosphonate
therapy or some reason—usually ue to upper GI isease or
si e e ects. Zole ronic aci can cause a “ u-like” illness, with
i use myalgias an arthralgias or ays af er the in usion. “B”
is incorrect as the sa ety ata or bisphosphonates is superior to
that or estrogen. “C” is incorrect or two reasons: teriparati e,
a recombinant parathyroi hormone, is a ministere aily an
carries a risk o osteosarcoma. For this reason its use is limite
to 2 years, not 5. eriparati e is e ective at increasing bone
ensity an re ucing racture risk, but the ata is not nearly as
robust as the ata or bisphosphonates. It is not a rst-line rug.
HELPFUL (MAYBE) TIP:
It seems as though more than 5 years o a bisphospho-
nate may increase atypical emur racture risk (thought
to be due to the suppression o osteoclast activity and
reduced ability o bone to remodel). There ore, a drug
holiday is likely warranted. Additionally, many patients
maintain bone density a ter stopping a bisphosphonate
CHAPTER 21 • CARE OF THE OLDER PATIENT 575
a ter 5 years o therapy—at least or a ew years. There
are not clear guidelines on this yet. Consider getting a
DEXA scan a couple o years a ter stopping the bisphos-
phonate. I it shows bone loss, consider restarting the
bisphosphonate.
HELPFUL TIP:
Denosumab (Prolia) is a RANKL inhibitor approved by
the FDA or treatment o postmenopausal osteoporosis.
It appears to be e ective in reducing racture risk (ver-
tebral and hip). It also appears well tolerated. However,
it also inhibits RANKL in the immune system (which acts
similar to TNF), and the long-term e ects on in ection
and carcinogenesis are unknown, so stay tuned.
Be ore she leaves the o ce, you present your patient with
literature on living wills and durable power o attorney or
healthcare (DPOA-HC).
Question 21.2.9 Which o the ollowing is CORRECT regard-
ing advance healthcare planning?
A) T e Joint Commission requires that patients be aske about
their a vance irectives on a mission to the hospital.
B) A DPOA-HC can overri e a patient’s ecision regar ing
treatment.
C) Once the patient has signe a living will, no urther changes
can be ma e regar ing treatment ecisions.
D) A DPOA-HC must be a amily member or bloo relative.
Answer 21.2.9 The correct answer is “A.” T e Joint Commis-
sion requires that patients be aske about their a vance irectives
on a mission to the hospital. A vance irectives can take many
orms but are usually mani est in one o two ways: through a liv-
ing will or a DPOA-HC. T e purpose o a living will is to instruct
healthcare ecision-making in uture events when the patient may
not be able to communicate his or her wishes. T ese ocuments
of en contain brie clinical scenarios with patient pre erences
or li e-sustaining measures. In contrast, a DPOA-HC is not as
limite an can a ress situations not oreseen in a living will. I
the patient becomes unable to participate in healthcare ecision-
making, then the DPOA-HC is instructe to exercise substitute
ju gment, using the patient’s previously state healthcare pre er-
ences, to help irect uture care. T e DPOA-HC is appointe by
the patient an can be a amily member or another a ult. T e
DPOA-HC cannot overri e a patient’s ecision in healthcare
matters, as such an action woul violate patient autonomy.
HELPFUL TIP:
Although advance directives should be addressed with
all patients, it is o particular importance to discuss them
in the setting o chronic illness, li e-threatening illness,
advancing age, and with any deterioration in health sta-
tus. A patient can change advance care plans whenever
he or she wishes, as these decisions may change over
time depending on goals o care.
576 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Objectives: Did you learn to . . .
• Identi y and implement appropriate preventive health ser-
vices or older emales?
• Discuss issues related to breast and gynecologic cancer
screening?
• De ne appropriate criteria or osteoporosis screening and
identi y risk actors?
• Recognize the important and complementary roles o DPOA
and advance directives?
QUICK QUIZ: GERIATRIC PREVENTIVE CARE
Which o the ollowing statements is INCORREC regar ing
preventive health in ol er a ults?
A) Although the optimal interval or vision screening is un e-
termine , many pro essional organizations recommen
vision an glaucoma screening every 1 to 2 years in persons
over age 65
B) In women at high risk or breast cancer, tamoxi en re uces
the risk o cancer by almost 50%
C) T e American Cancer Society (ACS) an American College
o Obstetrics an Gynecology (ACOG) recommen screening
ultrasoun or ovarian cancer in all women over the age o 60
D) Although Pap smears are not generally recommen e or
el erly women, the istribution o cervical cancer cases is
bimo al, with peaks at 35 to 39 years an 60 to 64 years
The correct answer is “C.” In act, ACOG, the USPS F, an
the American College o Physicians speci cally recommen
against ultrasoun screening or ovarian cancer in asymptom-
atic women. All other statements are correct.
CASE 21.3
An 82-year-old male patient presents to your o ce or con u-
sion. His wi e reports that he was in his usual state o health
until 3 days ago. At that time, he developed abdominal pain
and elt everish. He then began to have a dry, hacking cough.
On examination, his temperature is 100.3°F and blood pres-
sure is 118/56 mm Hg. He is pale and lethargic but in no acute
distress. He is oriented to person only. Other than mild upper
abdominal tenderness, there are no additional ndings on
examination. T is patient appears to have a new onset o con-
usion. You suspect delirium.
Question 21.3.1 Which o the ollowing is true with regard
to delirium and dementia?
A) In elirium it is rare to n an un erlying me ical cause
B) A primary eature o elirium is inattention
C) Dementia is characterize by an acutely uctuating course
D) Delirium only occurs in patients with ementia
E) T ey are the same. Af er all, memory is but an ephemeral
light in the long sha ow o time
Answer 21.3.1 The correct answer is “B.” T e Diagnostic
an Statistical Manual o Mental Disor ers (DSM-V) provi es
the iagnostic criteria or elirium. A iagnosis o elirium
requires the ollowing criteria: isturbance o consciousness
with re uce ability to ocus attention; isorientation, memory
e cit, or another change in cognition that cannot be accounte
or by a preexisting ementia; acute onset with uctuating
course (of en changing throughout the ay); an evi ence that
the isturbance is cause by an un erlying me ical con ition or
rug use. Not all signs an symptoms o elirium are present in
every patient with elirium, nor will they be present at the same
time. Delirium can be con use with ementia, epression, or
psychosis. Patients with elirium may present as agitate , psy-
chotic, somnolent, or with rawn (these are the tough ones to
recognize). Dementia is more chronic in nature with an insi i-
ous onset. Dementia progresses over time an usually cannot
be reverse . Of en elirium is treatable or reversible i the
un erlying me ical con ition is i enti e an treate . Patients
with ementia usually have intact attention, whereas patients
with elirium have marke ly impaire attention. Patients with
ementia have “poverty o thought,” which implies ecrease
content o their thoughts. Patients with elirium may have a
rich content to their thoughts, but the thoughts are isor ere .
HELPFUL TIP:
Delirium may be either hypoactive or hyperactive or
both, all in the same patient. Many patients with de-
lirium are not even identi ied due to their hypoactive
state (these aren’t the ones screaming obscenities and
yanking out in lated bladder catheters—ouch!). Elderly
patients are more susceptible to delirium, and delirium
is sometimes the only identi iable symptom in an elder
with an acute illness.
With urther history rom the patient’s wi e, you nd that he
has coronary artery disease, diabetes mellitus type 2, hyper-
tension, and benign prostatic hyperplasia.
Question 21.3.2 Which o the ollowing is the most use ul
question to elicit risk actors or delirium?
A) “Does the patient have any rug allergies?”
B) “Does the patient use tobacco?”
C) “Does the patient use alcohol?”
D) “Does the patient have e ema?”
E) “Does the patient use acetaminophen?”
Answer 21.3.2 The correct answer is “C.” Stu ies have consis-
tently i enti e the ollowing risk actors or elirium: a vanc-
ing age, preexisting ementia, un erlying structural brain is-
ease other than ementia, uncorrecte impairment in vision or
hearing, multiple chronic illnesses, polypharmacy, the use o
physical restraints, history o alcohol abuse, male gen er, an
unctional impairment.
While hypoxia ( ue to myocar ial in arction, pulmonary
embolus, or any other source) may lea to elirium, tobacco
use alone oes not pre ispose a patient to evelop elirium.
In isolation, knowle ge about e ema, acetaminophen use, or

TABLE 21-2 CAUSES OF DELIRIUM,
“WHHHHIMP” MNEMONIC
• Wernicke encephalopathy
• Hypoper usion
• Hypoglycemia and other metabolic abnormalities
• Hypertensive encephalopathy
• Hypoxia
• In ection or intracranial bleed
• Meningitis or encephalitis
• Poisons or medications
rug allergies is less help ul. Questioning about alcohol use will
help to i enti y patients who have a ten ency to overuse alco-
hol, putting themselves at risk or elirium. Also, elirium may
result rom alcohol with rawal.
HELPFUL TIP:
Preexisting dementia greatly increases the risk o de-
lirium, and simply moving a patient with dementia to a
new environment can precipitate delirium.
Question 21.3.3 The appropriate evaluation o the patient
with delirium includes which o the ollowing?
A) Evaluation o metabolic causes such as electrolytes an
glucose
B) Evaluation or in ection such as pneumonia
C) Evaluation o a patient’s me ications
D) Evaluation o oxygen saturation
E) All o the above
Answer 21.3.3 The correct answer is “E.” Causes o elirium
are protean, of en acting together in a multi actorial manner,
an are best consi ere by a systematic approach. Metabolic
causes inclu e electrolyte isturbances ( on’t orget calcium),
hypoglycemia, an hypoxia. Numerous in ections may lea to
elirium. Neurologic causes inclu e hea trauma, meningitis,
an vasculitis. Many me ications cause elirium inclu ing anti-
cholinergics, anti epressants, se ative–hypnotics, an steroi s.
Dehy ration an prerenal azotemia may lea to elirium. See
able 21-2.
You reach or the “shotgun” (metaphorically, we hope) and
order a bunch o tests. T e chest radiograph shows a le
lower lobe consolidation. T e abdominal lm shows a non-
speci c bowel gas pattern. T e white blood cell (WBC) count
is 12,700/mm3 , blood urea nitrogen 36 mg/dL, creatinine
1.5 mg/dL, and glucose 150 mg/dL. T e remainder o the
blood counts and chemistries are normal. With the excep-
tion o trace ketones, the urinalysis is within normal limits.
Cultures will not be available or at least 24 hours. T e ECG
shows normal sinus rhythm. With the available in ormation,
you decide to admit this patient or treatment o delirium
due to pneumonia and dehydration.
CHAPTER 21 • CARE OF THE OLDER PATIENT 577
You are called in the middle o the night or agitated
behavior and noncompliance with nursing care. T e patient
has pulled out his IV and struck a nurse.
Question 21.3.4 You appropriately prescribe which o the
ollowing interventions?
A) A minister haloperi ol 0.5 mg PO
B) A minister haloperi ol 1 mg IV
C) Apply physical restraints
D) A minister morphine 5 mg IV
E) Lorazepam 1 mg PO or the patient, 0.5 mg or the nurse
Answer 21.3.4 The correct answer is “A.” Most o the time,
elirium DOES NO require any pharmacologic treatment.
However, this patient is at risk o harming himsel an others
ue to his agitate elirium, so some action must be taken. Agi-
tate elirium causes physiologic an psychologic stress on the
patient, results in inter erence with me ical care, an porten s
a poorer prognosis. T e inci ence o elirium in hospitalize
patients o all ages is 30%, an the inci ence in postoperative
patients may approach 50%. Agitate elirium shoul be treate
quickly, an haloperi ol is the treatment o choice. In ol er
patients, rug clearance ecreases, so low oses o antipsychotic
me ication shoul be a ministere initially. As the geriatricians
say, “Start low an go slow.” Increasing oses o oral haloperi ol
can be given every 30 minutes i the patient continues to have
agitation. “B” is incorrect because IV haloperi ol is associate
with a greater egree o Q prolongation; PO or IM haloperi-
ol is pre erre . “C” is incorrect; physical restraints may lea
to patient injury an may worsen elirium. Restraints shoul
only be applie when absolutely necessary an or as short a
uration as possible. “D” is incorrect because we have no rea-
son to believe the patient is in pain, an a ministering nar-
cotics coul worsen his elirium. However, pain can certainly
result in agitation, so keep it in min . Finally, “E” is wrong
or at least two reasons: there is a substantial risk o para oxi-
cal agitation with benzo iazepine a ministration in emente
el ers, an you shoul not prescribe controlle substances
to sta nurses.
You ref ect on the act that primary prevention o delirium
is probably more e ective than treatment. For this patient,
delirium must now be treated, but you try to avoid this com-
plication in your hospitalized older patients.
Question 21.3.5 You know that research has shown a reduc-
tion in delirium in hospitalized older patients when which
o the ollowing strategies is employed?
A) Increase se ative me ication use or sleep eprive patients
B) Early mobilization or immobilize patients
C) Cholinesterase inhibitor (e.g., onepezil) therapy or cogni-
tively impaire patients
D) Physical restraints or combative patients
E) Music therapy or epresse patients
Answer 21.3.5 The correct answer is “B.” I enti ying risk
actors an targeting interventions to re uce or eliminate risk
578 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
actors can prevent elirium. Because one patient may have
numerous risk actors or elirium an because elirium is usu-
ally a multi actorial syn rome, a multicomponent intervention
strategy is warrante .
An of en-cite stu y by Inouye et al. (1999) emonstrate
the e ectiveness o this strategy. In the stu y, sleep- eprive
patients receive a warm rink, relaxing music, an back mas-
sage at be time. Unit-wi e noise re uction was implemente .
Early ambulation an active range-o -motion exercises were
employe or be -boun patients. All patients were encour-
age to ambulate. Cognitively impaire patients receive ori-
enting stimuli an cognitively stimulating activities. Patients
with hearing an visual impairments receive portable ampli-
ying evices an visual ai s, respectively. Investigators use
a protocol or early recognition an treatment o ehy ration.
T ere was no speci c therapy or epression or combative-
ness. As you can see, the preventative strategies or elirium
must also be broa as no one treatment has been singularly
e ective.
T e Con usion Assessment Metho (CAM) is an evi ence-
base tool that coul have helpe you i enti y elirium sooner
in your patient. It takes into account onset, inattention, isorga-
nize thinking, isorientation, an other important actors. See
https://www.healthcare.uiowa.e u/igec/tools/cognitive/CAM.
p or a worksheet to calculate CAM. Using CAM takes just
a ew minutes an is, o course, easier an much sa er than
waiting to n him walking his imaginary ragon through the
hospital war while carrying a hal - lle be pan.
Question 21.3.6 Which o the ollowing statements about
delirium is true?
A) Be rails an restraints are e ective in preventing injury in
the patient with elirium
B) Atypical antipsychotics (e.g., olanzapine an risperi one)
can be use to treat elirium
C) Diphenhy ramine is a goo choice or a sleep ai in patients
who are prone to eveloping elirium
D) A ee ing tube (e.g., Dobho tube) shoul be use in the
patient who is not eating in or er to prevent elirium.
E) Shouting, “You on’t have a ragon! T ey aren’t real!” helps
to prevent complications o elirium
Answer 21.3.6 The correct answer is “B.” Atypical antipsychot-
ics can be use in the treatment o elirium, but nonpharmaco-
logic metho s (e.g., be si e sitter an re irection) shoul be
use rst. “A” is incorrect because be rails an restraints actu-
ally increase the risk an severity o injury in the patient with
elirium. Restraints are use as a last resort. “C” is incorrect.
Diphenhy ramine is a particularly poor choice because o its
anticholinergic si e e ects, which can exacerbate or cause elir-
ium. razo one woul be better. Melatonin an the melatonin
agonist ramelteon have shown some ability to re uce the risk
o elirium but only when starte prior to the onset o symp-
toms an only in small trials. “D” is incorrect, as anyone who
has one inpatient work knows: the ee ing tube an the Foley
are of en the rst to get yanke ! “E” is also no goo . Never argue
with a patient about his elusion. You will not win.
HELPFUL TIP:
Ethical dilemmas abound in the treatment o delirium.
Atypical antipsychotic use in patients with dementia is
associated with increased mortality. Older antipsychot-
ics pose a greater risk or extrapyramidal symptoms
when compared with atypicals and have a higher mor-
tality risk. By de inition, agitated, patients with delirium
cannot provide in ormed consent, so “implied consent”
is usually substituted to use drug therapy or patients
with delirium at risk or sel -injury and to stabilize criti-
cally ill patients with delirium.
Objectives: Did you learn to . . .
• De ne delirium?
• Describe the signs and symptoms o delirium?
• Distinguish delirium rom dementia?
• Identi y causes and risk actors or delirium?
• Treat and prevent delirium?
CASE 21.4
In the early morning hours, a 78-year-old emale presents
to the emergency department complaining o right buttock
and hip pain. Several hours be ore her arrival, she ell in the
bathroom o her daughter’s home. She recalls standing on a
f oor mat, leaning her head back to drink a glass o water, and
then hitting the ground. She denies loss o consciousness.
Her daughter was at the scene quickly and ound the patient
awake, alert, and moving all extremities. Her vital signs are
normal. Other than right hip tenderness, her examination is
unremarkable.
Question 21.4.1 Which o the ollowing is most likely to
assist you in determining the cause o her all?
A) C scan o the hea
B) ECG
C) A itional history
D) Serum chemistry pro le
E) CBC
Answer 21.4.1 The correct answer is “C.” I there’s an option
or “more history,” it’s usually the right answer. History is one o
the most important actors in etermining the etiology o a all.
en percent o alls in ol er persons can result in serious injury,
such as a hip racture or sub ural hematoma. Falls in el erly
patients are typically multi actorial in nature. Ran omize
clinical trials emonstrate a re uction in the occurrence o alls
in community- welling el ers when healthcare personnel engage
in a multi actorial risk assessment with targete management.
Such an approach requires a thorough history.
Question 21.4.2 All o the ollowing are risk actors or alls
in elderly EXCEPT:
A) Use o our or more me ications
B) Orthostatic hypotension

C) Attempting tai chi, or which goo balance is require
D) Environmental hazar s (e.g., poor lighting or uneven walk-
ing sur aces)
Answer 21.4.2 The correct answer is “C.” In act, oing tai chi
has been shown to re uce the risk o alls in the el erly. All o
the others liste increase the risk o alling. A itional risk ac-
tors or alls inclu e history o a all in the last year, impaire
balance an gait, poor vision (acuity < 20/60), ecrease mus-
cle strength, an syncope or arrhythmia. Still more risk actors:
poor lighting, lack o grab bars an han rails, cluttere oor,
restraint use, an improper be height.
Question 21.4.3 During your examination, which o the ol-
lowing physical maneuvers is most likely to assist you in
evaluating the risk o uture alls?
A) Get-up-an -go test
B) est or pulsus para oxus
C) Osler maneuver
D) Lumbar spine exibility test
E) est or nystagmus
Answer 21.4.3 The correct answer is “A.” T e “time get-up-
an -go-test” is a commonly use metho o assessing isability
an all risk in geriatric assessment. From a seate position, the
patient is instructe to stan up, walk 3 m (approximately 10 f ),
turn aroun , an return to her chair. An a ult with no isability
shoul be able to complete this test in < 10 secon s. Increasingly
longer time to per orm the test is associate with increasing all
risk. While per orming the test, assess the patient’s sitting bal-
ance, transition rom sitting to stan ing, gait an stea iness,
an quickness with turning. While potentially use ul in the
evaluation, the other tests liste are not irectly associate with
all risk. T e Osler maneuver may be help ul in n ing cases o
pseu ohypertension an shoul be checke in patients who are
having alls associate with position changes espite normal or
even high bloo pressures as measure by sphygmomanometer.
T e Osler maneuver is per orme by blowing up the bloo pres-
sure cu until the ra ial pulse is absent. T en see i you can pal-
pate a sclerotic, noncompressible, ra ial artery. I so, the Osler
test is positive an the patient may have pseu ohypertension.
A er a thorough history, you per orm a complete workup,
including ECG, radiology studies, and appropriate labora-
tory tests. You nd that the all was caused by environmental
actors (poor lighting and a loose throw rug) rather than an
organic cause intrinsic to the patient. Fortunately, x-ray o
her hip is negative or racture. T e patient asks how exercise
might help her avoid uture alls.
Question 21.4.4 Which o the ollowing is the best answer?
A) Physical therapist supervision is essential to have an e ec-
tive all prevention program
B) In el erly patients, the e ect o exercise on alling is
unknown
C) Strength training has a greater e ect than balance training
on re ucing all risk
CHAPTER 21 • CARE OF THE OLDER PATIENT 579
D) Unsupervise balance an strength training is e ective in
re ucing all risk
E) Group exercise is more e ective than exercising alone to
prevent alls
Answer 21.4.4 The correct answer is “D.” T ere is no particu-
lar type o exercise that seems to prevent alls to a greater egree
than any other type o exercise. Strength, balance, an gait train-
ing all appear to be important. Exercise programs have been
shown to bene t el ers at risk or alls. Although initial instruc-
tion by a therapist may be help ul, a physical therapist nee not
supervise all exercises. Patients are able to per orm exercises
targete towar all prevention at home, an they o not nee to
be part o an exercise group. A meta-analysis o the Frailty an
Injuries: Cooperative Stu ies o Intervention echniques (FIC-
SI ) trials oun that combine balance an strength training
re uces the risk o alls in community- welling el ers.
HELPFUL TIP:
Peripheral sensory disturbance is a common inding in
the elderly and increases the risk o alling. A common
cause o peripheral neuropathy is vitamin B12 de iciency.
Check vitamin B12 levels. I they are low, great; treat
with oral B12, 1,000 to 2,000 mcg/day. Alternatively you
can treat with 1,000 mcg/month IM. I the B12 level is
borderline and you still have a high suspicion, check
serum methylmalonic acid and homocysteine levels.
These should both be high in B12 de iciency.
You recommend strength and balance exercises to the patient,
but she is worried and says, “My heart’s too old or exercise.”
Question 21.4.5 You assure her that light exercises are
sa e and then review normal age -related cardiovascular
changes, which include:
A) Re uce ventricular compliance
B) Re uce maximal heart rate
C) Re uce response to sympathetic nervous stimulation
D) Increase atrial lling
E) All o the above
Answer 21.4.5 The correct answer is “E.” Even in the healthy
el erly without signs o vascular isease, there are important
changes in the car iovascular system. Maximum car iac output
is re uce , mostly through re uce maximal heart rate; thus the
equation:
Estimate maximal heart rate = 220 – age.
A itionally, there is re uce response to sympathetic stimu-
lation, with less chronotropic an inotropic response to stress.
Re uce ventricular compliance results in increase atrial ll-
ing volume an pressure, increase lef atrial size, an increase
epen ence on atrial contraction or ventricular lling. How-
ever, en urance training may improve car iac output, an
active ol er a ults have a higher car iac output compare with
se entary persons o the same age.
580 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
HELPFUL TIP:
Hip ractures in the elderly are o ten caused by alls. In
general, the sooner that a ractured hip is repaired, the
better the outcome. Ideally, a hip should be repaired
within the irst 24 hours a ter the injury.
Because o her right hip pain, you consider giving the patient
an ambulatory device or temporary use. She has good upper
extremity strength, can bear some weight on the right, but
needs improved stability.
Question 21.4.6 Which o the ollowing devices would be
most appropriate in this setting?
A) Wheele walker
B) Forearm crutches
C) Walk cane (hemi-walker)
D) Imperial walker
E) Multiple-legge cane (qua cane)
Answer 21.4.6 The correct answer is “E.” Ambulatory evices
are employe with the ollowing goals: improve mobility,
ecrease the risk o alling, an relieve iscom ort associate
with acute or chronic musculoskeletal an neurologic con i-
tions. An inappropriately selecte evice can increase energy
expen iture an the risk or alls. Canes wi en a patient’s base,
resulting in increase stability. T ey are typically use or bal-
ance, not weight bearing. Multiple-legge canes—calle “qua
canes” because o the presence o our tips—provi e a more
stable base an some weight bearing, when compare with
stan ar , single-tippe canes. Walk canes are use ul or patients
who require ull weight bearing on one arm, as in a stroke sur-
vivor with loss o lower extremity unction. Crutches, either
orearm or axillary, are use or patients who cannot bear any
weight on one leg.
Walkers can support a patient’s weight, provi e lateral sta-
bility, an expan a patient’s support base. Stan ar walkers,
those with our rubber tips, provi e the greatest support an are
help ul in cases o ataxia. Front-wheele walkers are use ul or
patients with a ast gait, such as a estinating gait in parkinson-
ism. Also, a ront-wheele walker is easier to manipulate than
a stan ar walker. Four-wheele walkers shoul be use when
the patient requires some increase stability but oes not nee
as much weight-bearing as a stan ar walker woul provi e.
Patients with mil -to-mo erate Parkinson isease may bene t
rom our-wheele walkers. In this case, the patient requires only
improve stability an slight assistance with bearing weight.
O the available choices, the multiple-legge cane is the best
option. A single-tippe cane may have been a reasonable choice
as well. I you chose answer “D,” you—like one o the e itors—
are a Star Wars ner .
Un ortunately, you do not have access to a multiple-legged
cane or your patient. But you do have a supply o adjustable
single-tipped aluminum canes available.
Question 21.4.7 I you were to provide her with a cane,
what method would you use to t the cane?
A) Allow the patient to t the cane length to her com ort level.
B) Select a evice with a length equal to the istance rom the
oor to the greater trochanter o the emur.
C) Fit the cane length so that the han le comes to rest at the
patient’s waist.
D) Select a evice with a length equal to the istance rom the
oor to the ngertips with the arm relaxe .
E) Exten the cane to its maximum length, giving it the appear-
ance o a shepher ’s crook or wizar ’s sta .
Answer 21.4.7 The correct answer is “B.” You shoul t a cane
or a patient by selecting a evice that reaches rom the oor to
the greater trochanter o the emur. Another option is to t the
cane so that it reaches the exor crease o the wrist when the
arm is exten e to the si e. A properly tte ambulatory evice
shoul be com ortable, allowing the patient to stan erect with-
out excessive orwar exion o the spine. Excessive orwar
exion occurs when the evice is too short an can result in
increase risk o alling. Also, to obtain maximum e ciency
rom the upper extremities, the evice shoul not be too long.
T e usual recommen ation is to have a evice tte so that the
elbow is exe at 15% to 30% when the cane is in use. T is is
one by measuring as note above.
Objectives: Did you learn to . . .
• Recognize the morbidity associated with alls in older people?
• Evaluate causes and risks o alls in this population?
• Implement appropriate interventions or alling patients?
• Assess gait abnormalities that may lead to alls?
• Select ambulatory devices or appropriate patients?
QUICK QUIZ: ASSISTIVE DEVICES
I a patient is having i culty walking ue to lef -si e leg
weakness ue to osteoarthritis o the hip, in which han shoul
a cane be use ?
A) Lef han
B) Right han
C) Either han
D) Both han s simultaneously
E) No cane shoul be prescribe ; a wheelchair is pre erre
The correct answer is “B.” Whenever a cane is use to sup-
port lower leg unction limite by weakness or pain, the cane
shoul be use in the han contralateral to the a ecte si e (lef
si e weak, right han gets the cane). T is enables the patient to
maintain normal arm swing while a vancing the cane an the
a ecte leg at the same time to re uce the weight-bearing orces
on the a ecte limb uring the step.
CASE 21.5
A 69-year-old emale with no complaints presents to your
o ce with her two daughters. Further history rom her
daughters reveals that the patient was widowed 4 years ago,

now lives alone, and has experienced memory loss over the
last 2 years. One daughter has taken over the patient’s check-
book and is responsible or paying the bills. She has noticed
that her mother o en wears the same clothes and bathes
in requently—new and un ortunate habits or her. T e past
medical history includes hypothyroidism and hypertension.
Family history is signi cant or depression and memory
problems in the patient’s mother prior to her death rom “old
age.” T e patient takes chlorthalidone, levothyroxine, and
acetaminophen as needed.
Physical examination reveals a thin, elderly emale in no
distress. She is alert but does not correctly identi y the year.
She describes her mood as “happy” most o the time. T e
remainder o the examination is unremarkable. You suspect
dementia.
Question 21.5.1 Which o the ollowing is true regarding
the diagnosis o dementia?
A) T e iagnosis is rarely misse in the primary-care setting
B) o iagnose ementia, impairment in executive unction
must be present
C) o iagnose ementia, impairment in memory must be
present
D) Alzheimer isease (AD) is a iagnosis o exclusion
E) Neuroimaging is essential in the iagnosis o ementia
Answer 21.5.1 The correct answer is “C.” One o the neces-
sary components in or er to make a iagnosis o ementia is
memory impairment. “A” is incorrect. In contrast to elirium
an epression, the onset o ementia is insi ious. Symptoms
of en go unrecognize or months to years prior to iagnosis.
Although the patient may complain o con usion or memory
loss, amily members are more likely to provi e the chie
complaint an history. During the initial phases o a ement-
ing illness, patients an amily members may attribute cogni-
tive changes to normal aging. In early cognitive impairment,
memory symptoms may wax an wane. However, symptoms o
ementia can be i erentiate rom occasional normal lapses
base on their increasing severity. For example, it is normal to
orget an acquaintance’s name, but clearly abnormal to orget
a spouse’s name. “B” is incorrect. Many patients with emen-
tia have impaire executive unctioning (e.g., ju gment, rea-
soning, an planning), but the presence o impaire executive
unctioning is not a requirement. “D” is incorrect, as AD is
iagnose by a speci c set o clinical criteria. DSM-V pro-
vi es iagnostic criteria or ementia an AD, making AD a
iagnosis o inclusion rather than exclusion. “E” is incorrect.
Dementia is a clinical iagnosis an oes not require neuro-
imaging or con rmation. Experts an pro essional me ical
associations i er in their recommen ations regar ing the use
o neuroimaging in ementia. In general, neuroimaging is rec-
ommen e i ementia occurs in the ollowing scenarios: onset
be ore age 65, su en onset, presence o ocal neurologic signs,
an suspicion o normal pressure hy rocephalus (NPH), which
inclu es urinary incontinence, gait isturbance, an cognitive
impairment.
CHAPTER 21 • CARE OF THE OLDER PATIENT 581
You use several o ce assessment tools to urther character-
ize the memory loss. She scores 23/30 on the Folstein Mini-
Mental State Exam, missing orientation and recall items.
Clock drawing is grossly abnormal. Her geriatric depression
scale is 3 positive responses out o 15 (positive screen is 5/15
or greater). She per orms all basic activities o daily living
(ADLs) independently, but has voluntarily given up driving
and control o her nances.
Question 21.5.2 Regarding assessment tools used in the
evaluation o memory loss, which o the ollowing state -
ments is most accurate?
A) T e Mini-Mental State Exam (MMSE) evaluates executive
unction an visual-spatial skills
B) Formal neuropsychological testing o ers no bene t over the
MMSE or etecting ementia
C) T e use o a screening tool or epression is not help ul in
the evaluation o memory loss
D) Clock rawing evaluates executive unction an visual-
spatial skills
E) T e MoCA evaluates the ability to iscern a chocolate co ee
beverage rom regular co ee
Answer 21.5.2 The correct answer is “D.” Clock rawing can
be use to evaluate executive unction as well as visual-spatial
skills. Clock drawing is a simple test that takes 1 minute or
less to per orm. T e patient is aske to raw a clock ace an
set the han s to 2:50 or 11:10. T is test requires planning an
visual-spatial ability on the part o the patient—two areas that
are incompletely evaluate by the MMSE. A normal clock oes
not rule out ementia, but an abnormal clock is suggestive o
cognitive impairment. T ere are several scoring systems, an
the sensitivity an speci city or ementia are as high as 87%
an 82%, respectively.
“A” an “B” are incorrect. T e MMSE is a 30-point scale,
with the cuto or ementia between 24 an 26. T e MMSE
can be per orme in a ew minutes an tests memory, orien-
tation, language, construction, an concentration. T e MMSE
oes not test proso y (expressive an receptive in ection o
vocalization) or executive unction an , as a result, has poor
sensitivity or early cognitive impairment in some in ivi uals.
Per ormance on the MMSE is strongly correlate with e uca-
tion; there ore, there may be alse-positives in un ere ucate
patients an alse-negatives in highly e ucate in ivi uals.
Compare with the MMSE, ormal neuropsychological testing
assesses a broa er array o cognitive unctions, an it i enti es
behavioral abnormalities an assesses moo isor ers. It can
also help to i erentiate between types o ementia. In general,
neuropsychological testing is the most sensitive an speci c
cognitive assessment tool, but it is time-consuming an requires
a high level o expertise to a minister an interpret.
“C” is incorrect because epression may cause memory
problems, especially in the el erly, an epression screening
shoul be inclu e in the workup o memory concerns. Depres-
sion of en coexists with ementia, an treatment o epression
may improve memory problems. It is also important to keep in
582 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
min that epression commonly is the rst presenting sign or
memory problems. “E” is incorrect. See the relate Help ul ip
or more on the MoCA.
HELPFUL TIP:
The Montreal Cognitive Assessment (MoCA) is a cogni-
tive assessment tool reely available online, published
in multiple languages, and validated in the diagnosis
o dementia. Like the MMSE, it is a 30-point scale, but
the MoCA tests a wider range o cognitive domains with
less emphasis on orientation. Compared to the MMSE,
the MoCA has greater sensitivity or detecting dementia
but takes a ew minutes longer to administer.
So ar, you have collected the ollowing in ormation on this
patient: MMSE score 23/30, impairment in driving and man-
aging nances, disorientation to time, but intact abilities to
cook, clean, and care or hersel .
Question 21.5.3 Using conventional staging or AD, how
would you categorize this patient’s dementia?
A) Mil
B) Mo erate
C) Severe
D) erminal
E) Insu cient in ormation to etermine the stage
Answer 21.5.3 The correct answer is “A.”
• Mil AD symptoms inclu e impaire memory, mil person-
ality changes, an mil isorientation (MMSE 19–24)
• Mo erate AD symptoms inclu e aphasia, apraxia, insomnia,
an increasing con usion (MMSE 10–19)
• Severe AD symptoms inclu e severe memory loss, motor
impairment, an loss o some basic ADLs (e.g., urinary in-
continence an ee ing i culties) (MMSE < 10)
• Symptoms o terminal AD inclu e immobility, ysphagia,
an increasing susceptibility to in ections
Question 21.5.4 Which o the ollowing ndings would
most likely cause you to search or a diagnosis other than
AD in a patient presenting with memory impairment?
A) Paranoi behavior
B) Apraxia
C) Poor ju gment
D) Aphasia an personality changes
E) Bra ykinesia an rigi ity
Answer 21.5.4 The correct answer is “E.” Bra ykinesia an
rigi ity are eatures o parkinsonism, which, in the setting o
memory loss, shoul prompt consi eration o Lewy bo y
ementia or Parkinson isease. Paranoi behavior, elusions,
an hallucinations can all occur with more severe AD. Apha-
sia, apraxia, an personality changes typically occur later in AD
but can be initial complaints in atypical presentations o AD. In
or er to iagnose ementia, impairment in memory must be
present along with at least one o the ollowing:
• Aphasia (language isturbance)
• Apraxia (impaire motor abilities espite intact motor unc-
tion)
• Agnosia (impaire ability to i enti y objects espite intact
sensation)
• Disturbance in executive unction (e.g., planning, ju gment,
an insight)
T e iagnostic criteria or ementia require that these cognitive
isturbances result in unctional impairments that represent a
signi cant change rom a previous level o unctioning.
Although you strongly suspect AD in this patient, you con-
sider other types o dementia as well. Suppose this patient
presented with urinary incontinence and ataxia in addition
to her current ndings.
Question 21.5.5 Which o the ollowing diagnoses would be
most likely?
A) Creutz el t–Jakob isease
B) Lewy bo y ementia
C) Normal pressure hy rocephalus (NPH)
D) Pick isease
E) Walking corpse syn rome
Answer 21.5.5 The correct answer is “C.” NPH classically pres-
ents with ementia, gait ataxia, an urinary incontinence. When
etecte early, it respon s to ventriculoperitoneal shunting an
is thus a reversible cause o ementia. However, the ementia
is rarely ully reversible. Gait abnormalities typically occur rst
an are the most likely to improve with removal o cerebrospi-
nal ui (CSF). T e iagnosis o NPH is supporte by n ings
on brain MRI, an it is con rme by symptom improvement
af er CSF removal. Inci entally, NPH is a misnomer since inter-
mittent CSF pressure elevations have a pathophysiologic role in
the isease. “E” is a real thing, but not the right answer. Walk-
ing corpse syn rome is a rare psychiatric illness in which the
patient is un er the elusion that he is ea . Keep rea ing to
learn why the other oils are wrong.
You’ve got this patient stuck in your head (perhaps with
superglue?). On morning rounds in the hospital, your col-
league asks your opinion on a patient with rontotemporal
dementia (F D).
Question 21.5.6 You think it is unlikely that your patient has
FTD because she does not have:
A) Depression
B) Disinhibition
C) Hemiplegia
D) Rapi ly progressing ementia
E) remors an hallucinations

Answer 21.5.6 The correct answer is “B.” F Ds (inclu ing Pick
isease) constitute a heterogeneous group o neuro egenerative
isor ers that have the common pathologic n ing o cortical
egeneration in rontal areas o the brain. ypical eatures o
these ementias inclu e an insi ious onset an a slowly progres-
sive course. Patients have impairments in ju gment an insight.
T ey are isinhibite an socially inappropriate. Patients may
present with anxiety, epression, elusions, or emotional in i -
erence. “A” is incorrect. Depression requently coexists with
many types o ementia but oes not e ne one particular type.
“C” is incorrect; the presence o hemiplegia in a patient with
ementia shoul bring to min vascular causes. “D” is incorrect
because rapi ly progressing ementia is the hallmark o prion
isease, such as Creutz el t–Jakob isease. “E” is incorrect as
tremors, hallucinations, an memory loss are consistent with
Lewy bo y ementia (name or its characteristic pathological
n ing—the presence o Lewy bo ies in the brain stem an cor-
tex). Clinical eatures consist o cognitive impairment, etaile
visual hallucinations, uctuation in alertness, an motor symp-
toms o parkinsonism.
HELPFUL TIP:
AD is the most common orm o dementia, encompass-
ing about 60% o patients with dementia. Vascular and
Lewy body dementias account or about 15% to 30%. In
many cases, dementia has more than a single cause. AD
and vascular dementias requently coexist—an entity
commonly re erred to as “mixed dementia.”
T e elevator is stuck on your way back rom making your
rounds, giving you more time to consider dementia.
Question 21.5.7 Which o the ollowing is NOT consistent
with the diagnosis o vascular dementia?
A) Diabetes
B) obacco use
C) Di use slowing or normal electroencephalogram (EEG)
D) Normal brain MRI
E) History o caroti en arterectomy
Answer 21.5.7 The correct answer is “D.” A normal MRI
essentially rules out vascular ementia. Features suggestive o
vascular ementia inclu e a stepwise eterioration in cognitive
unction, onset o cognitive impairment with stroke, in arcts
an white matter changes on neuroimaging, an ocal neuro-
logic n ings on examination. T ere are no well- e ne cri-
teria or clinically iagnosing vascular ementia, an available
rating scales have poor pre ictive value when compare with
autopsy as the iagnostic stan ar . Known vascular isease
(like caroti artery isease) an vascular risk actors, such as
iabetes, hypertension, an smoking, support the iagnosis.
Finally back in your o ce with co ee in hand, you decide to
evaluate or reversible causes or this patient’s dementia, and
you consider ordering laboratory tests.
CHAPTER 21 • CARE OF THE OLDER PATIENT 583
TABLE 21-3 LABORATORY EVALUATION OF DEMENTIA
Required Minimum Testing
• Complete blood count
• Serum glucose and electrolytes
• Vitamin B12
• Renal unction tests
• Liver unction tests
• Thyroid unction tests
Testing Based on Clinical Suspicion
• Neuroimaging (recommended or all patients by some societies)
• Urinalysis
• Urine toxicology screen
• HIV antigen/antibody assay
• CSF analysis
• RPR or VDRL
Question 21.5.8 Which o the ollowing laboratory tests is
NOT indicated in the initial evaluation or reversible causes
o dementia?
A) Cyanocobalamin (vitamin B12)
B) Liver enzymes
C) CBC
D) CSF analysis
E) T yroi unction tests
Answer 21.5.8 The correct answer is “D.” When evaluat-
ing a newly iagnose case o ementia, one must consi er
in ectious, metabolic, toxic, an in ammatory etiologies.
T ere ore, the minimal require laboratory tests shoul
inclu e CBC, serum glucose an electrolytes, vitamin B12,
an renal, liver, an thyroi unction tests. Further laboratory
tests shoul be obtaine as clinical suspicion in icates. In the
appropriate patient, one might obtain urinalysis, urine toxicol-
ogy screen, HIV antibo y assay, an CSF analysis. Because o
the extremely low inci ence o neurosyphilis in mo ern times,
routine testing or syphilis is no longer require but shoul
be consi ere in the appropriate setting. Neuroimaging is not
a require part o every workup but may be help ul in some
patients. See able 21-3.
Blood chemistries, blood counts, thyroid hormone levels,
vitamin B12 level, and liver enzymes are in the normal range.
A noncontrast C scan o the brain shows nonspeci c “age-
related” changes (that was help ul!). T e patient and her am-
ily return to discuss the test results. You begin to educate
them about AD and dementia in general. T e two daughters
are concerned that other amily members may be at risk or
developing AD.
Question 21.5.9 Which o the ollowing is the strongest risk
actor or developing AD?
A) Age
B) Apolipoprotein E 4 (APOE 4) allele
C) Family history
D) Hea trauma
E) Low e ucational level
584 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Answer 21.5.9 The correct answer is “A.” As with many is-
eases, age is the greatest risk actor or eveloping AD. Among
persons 65 to 69 years ol , the inci ence o AD is 1%. In persons
85 years an ol er, the inci ence rises to 8%. All o the other
answer options are associate with an increase risk o AD but
not to the same egree as age.
Family history is another actor strongly associate with
eveloping AD. By age 90, almost hal o persons with rst-
egree relatives with AD evelop the isease. T ere are genetic
risk actors as well. Mutations on chromosomes 1, 14, an 21
are known risk actors or AD. risomy 21 is a risk actor or
eveloping AD at an earlier age (of en by age 50). APOE 4 allele
increases risk an ecreases age-o -onset o AD in a ose-
relate ashion, with the greatest risk present in persons homo-
zygous or APOE 4.
Other potential risk actors inclu e a history o hea trauma,
lower e ucational achievement, emale gen er, an epres-
sion. Postmenopausal estrogens may actually increase the risk
o ementia. Hypertension, iabetes, an hyperlipi emia are
associate with ementia, an controlling these iseases might
re uce the risk o eveloping ementia in the uture, but the
evi ence is not strong. Increase physical, mental, an social
activities may re uce cognitive ecline in later years.
Question 21.5.10 The patient and amily ask about medi-
cations to treat AD. Which o the ollowing statements is
TRUE?
A) All stu ies show that vitamin E supplementation improves
cognition an prevents urther neuron loss in AD.
B) Ginkgo biloba an cholinesterase inhibitors have a synergis-
tic e ect, improving cognition in AD.
C) Cholinesterase inhibitors o not prevent neuron loss in AD.
D) Cholinesterase inhibitors maintain cognition at baseline
levels or 2 years af er initiation o therapy; af er that time,
patients ecline slowly.
E) Memantine is consi ere rst-line therapy or mil cogni-
tive impairment an early ementia.
Answer 21.5.10 The correct answer is “C.” Cholinesterase
inhibitors o not prevent neuron loss. Results with vitamin E
have been inconsistent, an some stu ies have oun a slightly
higher risk o eath in those on high- ose vitamin E (400 IU/
ay), primarily in those with coronary artery isease. Given
the low cost an potential bene ts o vitamin E, it may still be
reasonable to use in combination with a cholinesterase inhibi-
tor in AD at a ose o < 400 IU/ ay i the patient or amily is
so incline . T ere is no evi ence to support the use o ginkgo
biloba in AD. As o 2015, there are just two classes o rugs FDA
approve or AD. Cholinesterase inhibitors (e.g., onepezil, riv-
astigmine, galantamine, an tacrine) represent the larger class
o available pharmacotherapy use to treat mil -to-mo erate
AD. Stu ies suggest that cognitive ecline may stabilize or 3
to 6 months af er which there is stea y loss o cognition. By 9
to 12 months, there is no i erence in ecline between those
on therapy an those on placebo. T e other class has only one
me ication, memantine, which is an N-methyl d-aspartate
(NMDA) antagonist use to treat mo erate-to-severe AD.
NMDA antagonists an cholinesterase inhibitors are of en pre-
scribe in combination; however, there seems to be no bene t
to combining these rugs. Memantine appears to o nothing
or mil ementia an has shown very minimal (some might
say clinically insigni cant) i erence in mo erate-to-severe
ementia.
HELPFUL TIP:
All o the cholinesterase inhibitors have similar e icacy.
Tacrine is known to cause hepatotoxicity and is rarely
used. The choice o cholinesterase inhibitor depends on
cost, patient acceptance, and physician experience.
Using your avorite clinical decision aid, the Ouija board, you
decide to start the patient on a cholinesterase inhibitor.
Question 21.5.11 In your discussion about the medication,
you tell the patient and her amily:
A) “T ese rugs are in icate or treating all types o ementia”
B) “T ese rugs o er no bene t in mo erate Alzheimer
ementia”
C) “T ese rugs are proven to reverse memory loss”
D) “T ese rugs are proven to re uce mortality”
E) “Gastrointestinal intolerance is one o the most common
si e e ects o these rugs”
Answer 21.5.11 The correct answer is “E.” T ere is no short-
age o controversy when it comes to me ications or emen-
tia. However, the si e e ects are in isputable. Gastrointestinal
intolerance—with nausea, anorexia, an iarrhea—is the most
common. Also, cholinesterase inhibitors have a “vagotonic”
action, which can cause bra ycar ia an syncope an worsen
car iac con uction abnormalities. o minimize a verse events,
the ose o cholinesterase inhibitor shoul be increase only
af er the patient has been on a stable ose or 4 to 6 weeks.
T ere are statistical i erences in the outcomes measure
or AD patients on cholinesterase inhibitors, but are these
changes clinically signi cant? T ere is no i erence in per-
ormance o ADLs, time to nursing home placement, etc. “A”
is incorrect. Mostly, these rugs are use in AD. T eir use in
Lewy bo y an vascular ementia is o -label but may be worth
a try; there is some ata to support cholinesterase inhibitors or
these patients. However, there is no evi ence to support their
use in F Ds (e.g., Pick isease). “B” is not true. Most stu ies o
cognitive e ects o cholinesterase inhibitors have occurre in
mil -to-mo erate AD (MMSE 10–24). “C” an “D” are incor-
rect. Compare with placebo, cholinesterase inhibitors elay
urther cognitive an unctional ecline but neither reverse
ementia nor a ect mortality. In cholinesterase inhibitor stu -
ies o mil -to-mo erate ementia, there is typically a 3-point
i erence on the MMSE between treatment an placebo
groups at 6 months. T is n ing is ue to a loss o thinking
abilities in the placebo group an a elay in that loss in the
treatment group.
 CHAPTER 21 • CARE OF THE OLDER PATIENT 585

TABLE 21-4 MEDICATION MANAGEMENT FOR BEHAVIORAL

SYMPTOMS OF DEMENTIA
Behavioral Subtype Acute Management Long-Term Management
Psychosis Conventional high potency Risperidone, CHAP
Antipsychotic (CHAP)a

Anxiety Benzodiazepines Buspirone

Insomnia Trazodone Trazodone

Sundowning Trazodone; consider CHAP, Trazodone; consider CHAP, risperidone,

risperidone, olanzapine olanzapine

Aggression, severe CHAP, risperidone Divalproex, risperidone, CHAP

Aggression, mild Trazodone Divalproex, SSRIs, trazodone, buspirone

a
CHAP includes haloperidol, perphenazine, and uphenazine. For elderly patients with dementia, typical
doses should be about one quarter o the usual dose (e.g., risperidone 0.25 mg, olanzapine 2.5 mg, or
quetiapine 25 mg, and haloperidol 0.25–0.5 mg)
Note: Recent data suggests tha quetiapine is the sa est option or an antipsychotic in this group with haloperidol
being associated with the greatest increase in stroke and mortality risk (JAMAPsych 2015, March 18).

activities may acilitate a better sleep–wake cycle. A ult ay care

HELPFUL TIP:
Not every con used elderly person should be put on a
cholinesterase inhibitor. Consider the diagnosis, sever-
ity o disease, and the goals or the patient and amily.
Determine why you are starting the drug and be clear
on the goals you hope to achieve. Then be willing to dis-
continue it i your patient is not reaching those goals.
The side e ects o cholinesterase inhibitors are symp-
toms o ten seen in nursing home patients (e.g., alls due
to bradycardia and weight loss rom anorexia). I your
patient is losing weight and/or alling, consider discon-
tinuing the cholinesterase inhibitor.
One year later, the patient returns with her daughter, with
whom she now lives. T e daughter reports disturbing symp-
toms that occur nightly. T e patient wakes up in the middle
o the night and wanders the house, becoming con used and
agitated. With a subtle nod toward her mother, the daughter
states, “I just can’t take much more o this.”
Question 21.5.12 A ter inquiring about pain and any changes
in health status and nding none, your initial recommenda-
tion is to:
A) Employ sof restraints only uring the night
B) Consi er environmental changes inclu ing more aytime
structure activities through an a ult ay care center
C) Initiate an antipsychotic be ore be time
D) Initiate a se ative–hypnotic be ore be time
Answer 21.5.12 The correct answer is “B.” reating behavioral
issues in patients with AD can be very challenging. Further his-
tory must explore the possibility o pain-relate agitation, ecline
in comorbi con itions or new health con itions, such as occult
in ection, an any me ication changes that may be playing a role.
I a treatable cause is not i enti e , then environmental change
is the best initial recommen ation. A ing structure aytime
programs exist that specialize in ay care or el erly people inclu -
ing patients with ementia. A ult ay care can provi e structure
activities uring the ay, along with respite or the aughter who
is obviously asking or extra support. Although me ications are
sometimes nee e , “C” an “D” are incorrect or initial treat-
ment in this case. Once environmental changes have aile or
there are other imme iate health risks involve , then me ica-
tions may be necessary. Antipsychotics currently o er the only
rug treatment or behavioral symptoms in ementia; however,
there are no great choices. Haloperi ol, risperi one, an olan-
zapine are use most of en. See able 21-4 or selecte me ica-
tions use to treat behavioral symptoms in ementia. Se atives,
such as benzo iazepines, of en result in para oxical agitation
in el erly patients with ementia. “A” is incorrect. Restraints
shoul be avoi e in most cases, even sof restraints. Although
they are sometimes require to prevent harm to the patient or
caretakers, restraints are known to result in worsene agitation
an an increase risk o all, injury, an rhab omyolysis.
HELPFUL TIP:
When patients with Lewy body dementia receive anti-
psychotic medication or hallucinations, parkinsonian
eatures become much more pronounced. I possible,
avoid antipsychotics in these patients.
Despite the addition o adult day programming, medication
became necessary. Haloperidol, or “vitamin H,” nightly has
resolved the agitation. Although you may have increased your
patient’s risk o dying (as seems to occur when antipsychot-
ics are used in dementia), her daughter is thrilled with the
result. T ree months later she returns with concerns about
depression. T e patient spontaneously cries several times per
day, her appetite is poor, and she has no desire to leave the
house or even get dressed most days.
586 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Question 21.5.13 Since a pill worked last time, her daugh-
ter wants to know what antidepressant is most e ective or
depression in patients with dementia?
A) Citalopram
B) Mirtazapine
C) Sertraline
D) None o the above
Answer 21.5.13 The correct answer is “D.” T ere are very ew
quality stu ies available to gui e treatment o epression in
patients with ementia. T e available evi ence shows no i -
erence between anti epressant therapy an placebo. T e iag-
nosis o epression in a patient with ementia is complicate ,
since ementia causes apathy, sleep isturbance, appetite loss,
an social with rawal. I epression is suspecte in a patient
with ementia, a pru ent approach woul be to employ non-
pharmacologic therapy an then provi e an empiric trial o an
anti epressant.
Over time, as the patient’s dementia progresses, you reevaluate
end-o -li e issues and advance directives. With the support o
her amily, the patient decides not to have cardiopulmonary
resuscitation.
Question 21.5.14 In end-stage AD, which o the ollowing
is correct?
A) Malnutrition is the most common cause o eath in patients
with severe ementia
B) Hospitalization or pneumonia in patients with severe
ementia improves morbi ity an mortality
C) In severe ementia, gastrostomy tube ee ing prevents aspi-
ration
D) o increase com ort, ehy rate patients with severe
ementia shoul receive IV hy ration
E) In a vance AD, treatment o in ections with oral an IV
antibiotics is equally e cacious
Answer 21.5.14 The correct answer is “E.” Hospitalization or
emente patients with pneumonia is a wash. T e number o
patients save by the use o IV antibiotics is o set by an increase
in eath an unctional eterioration as a result o the hospi-
talization. T us, on balance, oral an IV antibiotics are equally
e cacious in the treatment o in ections in these patients; there-
ore, severely homeboun patients with ementia or nursing
home resi ents shoul be treate in their usual environment
rather than hospitalize i the amily agrees. “A” is incorrect. T e
majority o patients with ementia ie o in ection, not malnu-
trition. “B” is incorrect as note above. “C” is incorrect. Even
in mo erate-to-severe AD, ee ing tubes can be use ul in the
acute setting. But the tube shoul be remove an natural ee -
ing resume as soon as the acute event passes. Permanent gas-
trostomy tube eeding is not recommended in patients with
severe or terminal dementia. ube eeding does not prolong
li e, prevent aspiration, or promote weight gain in advanced
dementia. Although many patients with a vance ementia are
malnourishe an ehy rate , these con itions o not appear
to cause iscom ort. Han ee ing is as e ective as any other
means or provi ing nutrition an can lea to rewar ing inter-
actions or both the patient an the caregiver.
HELPFUL TIP:
Remember the caregivers! Ask about their health and
mood. Twenty- ive percent o caregivers to the elderly
are depressed, while older people caring or their dis-
abled spouses have a 63% higher chance o dying than
noncaregivers o the same age.
Objectives: Did you learn to . . .
• Identi y symptoms, signs, and diagnostic criteria or demen-
tia?
• Describe dif erent types o dementia and how they are diag-
nosed?
• Evaluate the patient with dementia, considering the poten-
tial causes o dementia?
• Describe potential bene ts and limitations o current phar-
macologic therapy or AD?
• Describe the natural course o AD?
• Manage a patient with end-stage AD?
CASE 21.6
A 71-year-old male whom you have known since starting
your practice recently su ered a stroke, resulting in language
de cits and right hemiparesis. His medical history is signi -
cant or hypertension, hyperlipidemia, ulcer requiring par-
tial gastrectomy (remote), and coronary artery disease. He
quit tobacco and alcohol 5 years ago. He is retired and wid-
owed. A er a 3-day hospitalization, he appears stable enough
or discharge. His medications include aspirin, metoprolol,
lisinopril, and atorvastatin. Prior to entering a nursing home
to receive skilled nursing care and therapies, the patient
wants to know who will pay or the services. He has Medicare
parts A and B.
Question 21.6.1 You are able to assure him:
A) Me icare will cover all expenses in e nitely regar less o
personal nancial resources
B) Me icai will cover all o the expenses or the rst 100 ays
o skille care regar less o personal nancial resources
C) Me icare will cover part o the expenses or the rst 100
ays o skille care regar less o personal nancial resources
D) Me icare requires a hospital stay o 7 ays or longer prior to
entering a nursing home or skille care
E) Me icai an Me icare o not cover nursing home expens-
es un er any circumstances
Answer 21.6.1 The correct answer is “C.” Me icare Part A,
which provi es some healthcare or patients 65 years an ol er
i they quali y or Social Security bene ts, will pay all costs or
skille care or the rst 20 days an part o the costs therea -
ter up to a total o 100 ays per calen ar year. T is Me icare
bene t inclu es rehabilitation (e.g., physical therapy, occupa-
tional therapy, an speech therapy) an skille nursing care

(e.g., nursing home, skille care acility, an rehabilitation hos-
pital) af er a hospital stay o at least 3 ays. T is bene t is con-
tingent upon the patient having an appropriate iagnosis an
rehabilitation potential, an continuing to show improvement
uring the time the bene t is in place. Me icare oes not pro-
vi e exten e nursing home coverage. Me icai will provi e
exten e nursing home care i a person’s assets an income
are below a certain threshol , which varies rom state to state.
Note: Although Me icare Part B will pay or physician visits to
nursing home patients, Me icare oes not pay or nursing or
other care irectly relate to permanently living in a nursing
home.
Although he received airly intensive physical, occupational,
and speech therapies, your patient does not regain much
unction. He has only minimal movement in the right arm
and complains o pain in the right shoulder. A radiograph o
the right shoulder shows degenerative changes. T e nursing
sta administers acetaminophen 650 mg PO when the pain
is severe, yet he continues to complain o shoulder pain. You
involve physical therapists in his care to reduce the risk o
chronic dislocation o the shoulder.
Question 21.6.2 In order to control his pain, which o the
ollowing is the most appropriate to add as a scheduled,
and presumably chronic, medication?
A) Acetaminophen
B) Oxyco one
C) Gabapentin
D) Aspirin
E) Naproxen
Answer 21.6.2 The correct answer is “A.” T e point here is
that sche ule acetaminophen is better or chronic pain than
PRN osing. Acetaminophen is the sa est analgesic o those
liste . It may provi e su cient pain relie —i given sche ule
(e.g., 1,000 mg PO ID). I it oes not, then another me ica-
tion may be a e . “B” is incorrect as a rst step as narcotics
can cause con usion, se ation, urinary retention, an alls, an
they have been associate with an increase mortality risk in
the el erly. However, this patient has a history o an ulcer, an
a narcotic analgesic may be a reasonable me ication to a
af er acetaminophen. “C” is incorrect. Gabapentin is in icate
or postherpetic neuralgia an is more use ul or neuropathic
pain (although not very use ul there either; tricyclics are better).
“D” an “E” are incorrect. Aspirin an NSAIDs must be use
with caution in the el erly ue to increase risks o silent GI
blee ing, atal GI blee ing, an ki ney injury. NSAIDs are typi-
cally not rst-line agents or arthritis pain in this age group an
probably o er no greater pain relie than acetaminophen. Also,
consi er topical therapies or pain, inclu ing capsaicin. Non-
pharmacologic mo alities shoul be employe as well, inclu -
ing massage, exercises, an physical therapy.
A nurse calls to report that your patient has developed leth-
argy, decreased appetite, and a temperature o 37.8◦ C. Your
rst thought is, “So? T at’s not a ever.”
CHAPTER 21 • CARE OF THE OLDER PATIENT 587
Question 21.6.3 And then you realize that:
A) An elevate temperature in ol er persons is most of en ue
to changes in basal bo y temperature regulation
B) Oral antibiotics will not be su cient to treat this in ection
C) Antibiotics will not be necessary to treat this con ition
D) Absence o signi cant ever in the el erly oes not rule out
serious bacterial in ections
Answer 21.6.3 The correct answer is “D.” Ol er persons, espe-
cially rail el ers an nursing home patients, of en have lower
basal bo y temperatures compare with younger persons an
may not mount as great a ebrile reaction to in ection. A tem-
perature > 38.1°C in a rail el er is most likely associate with a
serious bacterial or viral in ection. Absence o signi cant ever
oes not rule out serious bacterial in ections. “C” is incorrect.
With the available in ormation, it is i cult to say with any cer-
tainty i the patient has an in ection treatable with antibiotics.
I he i , oral antibiotics are of en appropriate in the nursing
home setting, even when treating pneumonia.
With a decline in his unction and a mildly elevated tem-
perature, you plan to evaluate this patient or in ection.
According to the nursing sta , there are no other residents
with apparent in ections. Your patient has not developed
any ocal symptoms (e.g., cough, dysuria, diarrhea, or site-
speci c pain).
Question 21.6.4 Which o the ollowing tests will be LEAST
help ul?
A) CBC
B) Urinalysis with microscopic examination
C) Stool culture
D) Chest ra iograph
E) Bloo oxygen saturation (pulse oximetry)
Answer 21.6.4 The correct answer is “C.” He is not having
iarrhea so a stool culture is not likely to be o bene t. T is is
not a black-or-white area, but there are some principles an
expert opinions to ollow. Patient an amily wishes regar ing
care must be known prior to initiating an evaluation, therapy, or
hospital trans er. While the el erly may have a serious in ection
with only slight or even no leukocytosis, a normal WBC count
on CBC will re uce suspicion or serious bacterial in ection.
Even without speci c urinary symptoms, urinalysis is recom-
men e because o the high inci ence o U I in this population.
Remember, however, that asymptomatic bacteriuria can occur
in up to 50% o women an 40% o men living in long-term
care acilities an treating this con ers no bene t. Bloo oxygen
saturation below the normal range (< 90% on room air) may
in icate serious respiratory illness; in the setting o hypoxia, a
chest ra iograph is recommen e .
Question 21.6.5 Regarding in ectious diseases in nursing
home settings, which o the ollowing is correct?
A) I the in uenza vaccine is a ministere within 24 hours o
an outbreak, patients require no urther prophylaxis
588 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
B) All resi ents who are carriers o methicillin-resistant Staph-
ylococcus aureus (MRSA) must be treate with appropriate
antibiotics
C) Most cases o bacteremia are cause by in ecte skin ulcers
D) New resi ents shoul receive a two-step tuberculin skin test,
unless positive on the rst test
E) All resi ents who are carriers o Clostridium dif cile must be
treate with appropriate antibiotics
Answer 21.6.5 The correct answer is “D.” T e inci ence o
tuberculosis is relatively high in the ol er population, as is
mortality rom the isease. Institutionalize el ers shoul be
screene or tuberculosis with the two-step tuberculin skin
test. A two-step test involves repeating the tuberculin skin test
1 to 3 weeks af er an initial negative test (< 10 mm in uration).
Anergy testing is no longer recommen e . T e test is positive i
the in uration is 10 mm or more.
“A” is incorrect. In a nursing home, an in uenza outbreak
can have evastating results, with a mortality rate up to 30%.
In the event o an outbreak, even resi ents who receive the
vaccine shoul receive antiviral prophylaxis (see Chapter 8 or
more). Only about 30% to 50% o nursing home resi ents will
evelop an a equate antibo y response to the in uenza vaccine,
an that response takes up to 2 weeks af er a ministration to
evelop. “B” an “E” are incorrect. Resi ents who are carriers
o MRSA or C. dif cile will not bene t rom era ication i they
are not in ecte . In a ition, they may return to a carrier state
quickly af er antibiotic treatment; there ore, antibiotic treat-
ment o these carrier states is not recommen e . “C” is incor-
rect because U Is are the most common cause o bacteremia in
nursing home resi ents.
HELPFUL TIP:
In elderly nursing home residents, a positive response to
tuberculin skin testing is most o ten due to reactivation
o old disease. Risk actors associated with reactivation
o tuberculosis include chronic steroid use, diabetes,
malignancy, malnutrition, renal ailure, and chronic in-
stitutionalization.
HELPFUL TIP:
The high-dose in luenza vaccine (e.g., Fluzone-HD) has
our times the usual dose o antigen and was approved
or adults 65 years by the FDA in 2009. Seroconversion
rates are higher or patients receiving the higher dose
vaccine, and in luenza-like illness rates are modestly
lower in recipients. However, it has not shown a ben-
e it or more serious morbidity or mortality. The cost is
higher than that o the other options, side e ects are
similar, and its role is not well established.
Over the next year, the patient has increasing di culty with
cognition. He begins to experience urinary incontinence sev-
eral times per day, necessitating the use o a pad. A midstream
clean-catch urinalysis shows bacteria and WBCs (2–4 WBC/
hp ) but is negative or glucose and nitrites. His post-void
residual bladder volume is 80 cc.
Question 21.6.6 Which o the ollowing is true regarding
the potential cause o and therapeutic intervention or uri-
nary incontinence in this patient?
A) T e most likely cause is obstruction rom the benign pros-
tate hyperplasia, an an alpha-blocker will improve the
incontinence
B) T e most likely cause is immobility, an sche ule voi ing
is in icate
C) T e most likely cause is etrusor hyperactivity, an an
in welling catheter is in icate
D) T e most likely cause is stress incontinence, an pelvic oor
muscle strengthening (Kegel exercises) is in icate
E) T e most likely cause is bacteriuria, an antibiotics will im-
prove the incontinence
Answer 21.6.6 The correct answer is “B.” Urinary inconti-
nence is incre ibly requent in nursing home resi ents, with
a rate o up to 50%. As with many other geriatric syn romes,
incontinence is of en multi actorial or the result o ecrease
physical an /or cognitive unctions. A requent cause o uri-
nary incontinence in nursing home resi ents is immobility ue
to severe physical impairment, ementia, or both. In this set-
ting, the initial treatment o choice is prompte voi ing every
2 hours when the patient is awake. Also, ui an ca eine intake
shoul be monitore an a juste to re uce urine output with-
out causing ehy ration.
“A” is incorrect. Although there is no in ormation about
the patient’s prostate size, he has a relatively normal post-voi
resi ual volume, making over ow incontinence rom outlet
obstruction less likely. A post-voi resi ual volume greater than
300 mL woul be more concerning or urinary retention. “C”
is incorrect—or at least the iagnosis o etrusor hyperactiv-
ity cannot be ma e on the basis o current in ormation. T e
patient has not been ully evaluate with uro ynamic tests, so it
is i cult to etermine whether his incontinence is stress-type
or urge-type. I he has urge-type incontinence ue to etrusor
hyperactivity, an in welling bla er catheter is not appropriate.
Detrusor hyperactivity can of en be treate success ully with
pharmacotherapy (anticholinergic me ications). It is impor-
tant to be min ul o the anticholinergic si e e ects, which
inclu e alls, con usion, constipation, ry mouth, an urinary
retention an coul ultimately be more etrimental than the
incontinence.
“D” is also not likely. Stress incontinence is less common in
men than women, an urine loss is typically associate with
increase ab ominal pressure (e.g., coughing, sneezing, an
lif ing). Finally, “E” is incorrect. T e presence o bacteria in the
urine is a common n ing in nursing home patients. In gen-
eral, bacteriuria without symptoms (the main symptom we look
or being ever rather than incontinence) shoul not be treate .
Stu ies have emonstrate little or no improvement in inconti-
nence af er treating asymptomatic bacteriuria in el erly nursing
home patients.

HELPFUL TIP:
When urinary incontinence is due to obstruction or
detrusor hypore lexia, intermittent bladder catheter-
ization should be employed and chronic indwelling
catheters avoided. Appropriate indications or chronic
indwelling bladder catheters in the nursing home in-
clude com ort care o the terminally ill, presence o skin
wounds contaminated by incontinent urine, and urine
retention not practically managed with intermittent
catheterization.
Although his urinary incontinence improves, your patient
develops di culty with loose stools and occasional ecal
incontinence. T e stools are quite watery with no blood or
melena. Aside rom occasionally abdominal cramping, he
eels well. He has no new neurologic symptoms.
Question 21.6.7 Which o the ollowing is the most likely
cause o ecal incontinence in this situation?
A) In ectious iarrhea
B) Ulcerative colitis
C) Decrease anal sphincter tone
D) Fecal impaction
Answer 21.6.7 The correct answer is “D.” In nursing home
resi ents with limite physical mobility, over ow incontinence
ue to ecal impaction is most likely. Nursing home patients
are of en taking me ications that contribute to constipation as
well. Even with a stool sof ener an /or a laxative, constipation
may still result. A ecal impaction can be treate with an enema,
stool sof eners, laxatives, an ietary changes, but sometimes
requires manual isimpaction (where’s a me ical stu ent when
you nee him?). Decrease sphincter tone may occur as a result
o neurologic insult, but this patient was previously continent o
stool. Although in ection might be causing incontinence, there
are no other symptoms o in ection. T e onset o in ammatory
bowel isease is usually seen in younger populations, of en with
bloo in the stools, making ulcerative colitis less likely.
As a result o your patient reporting physical abuse o another
patient by the nursing sta , an investigation is under way in
the nursing home.
Question 21.6.8 Ref ecting on elder abuse and neglect, you
realize which o the ollowing is true?
A) Up to 75% o nursing ai es in nursing homes have seen or
hear o a resi ent being abuse or neglecte
B) A “ epen ent el er” is e ne as anyone living in a nursing
home
C) Approximately 70% o el er abuse an neglect occurs in
nursing homes
D) T ere is a universally accepte e nition o el er abuse an
neglect, which is co i e in e eral law
E) El er abuse is wi ely e ne as “purpose ul physical harm
o anyone over the age o 65 years”
CHAPTER 21 • CARE OF THE OLDER PATIENT 589
Answer 21.6.8 The correct answer is “A.” In some stu ies, high
rates o mistreatment have been oun in nursing homes, with
up to 75% o nursing ai es witnessing or hearing about acts o
abuse. However, it is not known whether nursing home resi-
ents are at greater risk than community- welling epen ent
el ers. “B” is incorrect. T e e nition o “ epen ent el er” is
not consistent, an may apply to el ers who are cognitively
impaire , physically ebilitate , or nancially epen ent. Nurs-
ing home resi ents are requently epen ent; however, living in
a nursing home itsel is not su cient to establish that a person
is a epen ent el er. “C” an “D” are incorrect. T e stu y o
el er abuse an neglect (also re erre to as el er mistreatment)
su ers rom lack o a universally accepte e nition, varia-
tions in laws between states, an inherent i culties in obtain-
ing accurate reports o abuse. T ere ore, attempts to etermine
the inci ence o el er abuse an neglect have resulte in wi e
variations. “E” is incorrect. El er abuse may inclu e physical
harm, sexual abuse, psychological abuse, neglect, or nancial
exploitation. Although all states now have laws a ressing el er
mistreatment, those laws vary between states, an healthcare
provi ers are encourage to know the laws in their area.
HELPFUL TIP:
Risk actors or elder mistreatment include older age,
cognitive impairment, substance abuse, low socioeco-
nomic standing, minority status, and caregiver stress
(probably the most important).
As your patient’s cognitive impairment progresses, he
becomes more withdrawn and uncooperative with nursing
care, such as bathing. A nurse calls to ask, “Shouldn’t he be
on risperidone or something to improve his behavior?”
Question 21.6.9 According to the Omnibus Budget Recon-
ciliation Act o 1987 (OBRA), antipsychotic medication is
indicated or demented patients with:
A) Repetitive, bothersome behavior (e.g., name calling)
B) Continuous crying out an screaming
C) Uncooperative behavior (e.g., re using to eat an bath)
D) All o the above
Answer 21.6.9 The correct answer is “B.” One goal o OBRA
was to ecrease the inappropriate use o antipsychotic me i-
cations in nursing home resi ents. In patients with ementia,
antipsychotic me ications may be appropriately a ministere
in the ollowing settings: agitate , belligerent acts that present
a anger to the patient or other resi ents; psychotic symptoms
( elusions, hallucinations, paranoia); an continuous crying out
an screaming (lasting 24 hours or longer). Attempts to re irect
the patient shoul always be employe rst. You shoul also
attempt to uncover occult causes o agitation, such as in ection
or pain. Once behavior control is attaine , assess whether the
antipsychotic can be re uce in ose or iscontinue . Accor -
ing to OBRA, inappropriate in ications or antipsychotic me -
ication inclu e restlessness, uncooperative behavior, poor sel -
care, or repetitive an bothersome actions.
590 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Objectives: Did you learn to . . .
• Describe some common Medicare/Medicaid reimbursement
issues or nursing home care?
• Manage chronic pain in the nursing home?
• Describe an appropriate evaluation or the nursing home
resident with ever?
• Recognize in ectious disease issues commonly presenting in
the nursing home?
• Develop an appropriate strategy or the evaluation and man-
agement o urinary and ecal incontinence in nursing home
residents?
• Recognize the impact o elder abuse and neglect? Imple-
ment appropriate measures or agitated behavior in the
nursing home?
QUICK QUIZ: GERIATRIC PHARMACOTHERAPY
Which o the ollowing is true about rug therapy in the el erly?
A) GI absorption is substantially ecrease in the el erly
B) Se ative–hypnotic rugs shoul be given an 8-week trial
without interruption or anxiety in the el erly
C) Mirtazapine (Remeron) causes anorexia an weight loss in
the el erly
D) Compare with young a ults, the volume o istribution o
at-soluble rugs is increase in the el erly
The correct answer is “D.” T e volume o istribution o at-
soluble rugs is relatively increase in the el erly ue to a loss
o muscle mass an proportionately more at mass. T ere ore,
at-soluble rugs, like iazepam, have a greater relative volume
o istribution, while water-soluble rugs, like alcohols, will
have a relatively smaller volume o istribution. “A” is incorrect
because rug absorption oes not change substantially with
aging. “B” is incorrect. Se ative–hypnotic rugs shoul be use
only or short-term therapy o 2 to 4 weeks because o the risk o
alls an other a verse e ects; this is true or both community-
welling el ers an those in nursing homes. “C” is incorrect
because mirtazapine can actually increase appetite an lea to
weight gain in the el erly. For this reason, it can be use ul in
patients who are epresse an not eating well.
HELPFUL TIP:
Although hepatic drug metabolism does not change
substantially with age, drugs tend to have decreased
elimination in the elderly as a result o decreased renal
unction. For these reasons, the hal -li e o many seda-
tive–hypnotic drugs is substantially increased in the
elderly.
CASE 21.7
Your next patient is an 83-year-old male amiliar to your
clinic, who presents or routine care. He has hyperten-
sion, hyperlipidemia, and osteoarthritis. He has been wid-
owed or 10 years and continues to live independently in an
apartment in the same town as his daughter. He stopped
smoking 30 years ago, but continues to drink alcohol. He
denies any problems related to his drinking, but you inquire
anyway and ask speci cally how much he drinks. His rou-
tine includes three shots o whiskey per day. He says he likes
drinking one shot be ore his daily walk and the other two
shots a er he returns. He nds the routine very motivating
and keeps him in shape.
Question 21.7.1 In regard to his drinking behavior, you are
aware that:
A) Ol er a ults accumulate signi cantly lower bloo alcohol
levels than younger a ults ue to ecrease absorption
B) Drinking three shots per ay shoul not be any concern as
long as his liver unction tests are normal
C) Alcohol consumption can re uce the availability o nutri-
ents such as zinc, vitamins A, B1, B2, B6, B12, an olate
D) T e li etime prevalence o alcoholism or men age ≥ 65 is
less than 5%, but shoul still be screene or routinely
E) T e stan ar screening CAGE questionnaire or rinking
problem behavior has not been vali ate in ol er a ults
Answer 21.7.1 The correct answer is “C.” Alcohol consump-
tion can re uce the availability o nutrients such as vitamins
A, B1, B2, B6, B12, zinc, an olate. Alcoholic patients of en
present with malnutrition, poor sel -care, an alcohol-relate
illnesses such as anemia, peptic ulcer isease, iabetes, hyper-
tension, liver isease, neuropathy, an cognitive impairment.
Checking or e ciencies may be warrante in this situation
epen ing on your patient’s other ietary intake. “A” is incor-
rect. Ol er a ults accumulate signi cantly higher bloo alcohol
levels than younger a ults. A young a ult’s bloo alcohol level
will be approximately 0.03% af er “one rink” (1.5 oz o istille
liquor, 5 oz o wine, or 12 oz o beer); whereas in a 75-year-ol ,
the level may rise as high as 0.08%, which is the legal limit or
intoxication in many states. “B” is incorrect. Drinking behavior
should be questioned regardless o liver unction tests.
T e National Institute on Alcohol Abuse an Alcoholism
has i enti e rinking more than one alcoholic beverage per
ay as potential problem rinking in ol er a ults. “D” is incor-
rect. T e li etime prevalence o alcoholism or men age ≥ 65
is higher, at approximately 14%; while women age ≥ 65 have a
prevalence o 1.5%. Denial o the problem is more requent in
ol er patients, an impairments in unctioning relate to alco-
hol use may not be recognize until serious complications arise.
“E” is incorrect. Diagnosis o alcohol abuse an epen ence in
ol er a ults is challenging. Brie screening tools such as the CAGE
questionnaire ( able 21-5) have been vali ate in the ol er popu-
lation an coul be use in this situation. A positive response to
any CAGE questions suggests rinking problem.
In this case, your patient denies any drinking problems and
his CAGE screen is negative. Still, you advise him to cut back
to one drink per day or less and plan to ollow up. As you
review the patient’s basic ADLs and instrumental activities o
daily living (IADLs), he is independent in all basic ADLs and
most IADLs. He walks daily, eats three small meals per day,

TABLE 21-5 CAGE SCREENING TOOL FOR
PROBLEM DRINKING
C: Have you ever elt you should Cut down?
A: Does others’criticism o your drinking Annoy you?
G: Have you ever elt Guilty about your drinking?
E: Have you ever had an “Eye opener” to steady your nerves or get rid
o a hangover?
Positive response to any suggests drinking problem; questionnaire has
been validated in older population.
and maintains a steady weight around 180 lb (BMI = 25 kg/m2).
He manages his own nances, prepares his own meals, but
usually has his daughter do the grocery shopping or his con-
venience. When you ask about transportation, he reports that
he mostly drives to get around town to the gol club, social
events, and the post o ce when needed. He denies any vision
or hearing problems.
Just as a review (this is a review book, a er all) . . .
Basic activities o daily living (ADLs) include: bathing, ress-
ing, toileting, maintaining continence, grooming, ee ing, an
trans erring.
Instrumental activities o daily living (IADL) include: shop-
ping or groceries, riving or using public transport, using the
telephone, per orming housework, oing home repairs (not
climbing on the roo . . . changing light bulbs an such), pre-
paring meals, oing laun ry, taking me ications, han ling
nances.
Question 21.7.2 In order to keep him healthy, sa e, and
unctional, you appropriately recommend:
A) In oor walking only
B) Weight loss
C) Perio ic screening or hearing impairment
D) Restricte riving
E) Intensive weight-lif ing an aerobic workouts
Answer 21.7.2 The correct answer is “C.” T e Institute o Me -
icine, recommen s au iometric testing once between ages 40 to
59, 60 to 74, an 75 an over. In this case, asking about hearing
i culty an testing with a whispere -voice out o the el o
vision perio ically is a reasonable approach or hearing screen-
ing. However, the USPS F updated its recommendations or
o ce screening in 2012 and concluded that current evidence
is insu cient or audiometric o ce-based testing or hear-
ing loss in asymptomatic older adults. “A” an “E” are incor-
rect. Daily exercise inclu ing walking in oors or out oors in
sa e environments (weather permitting) shoul be encourage
in all age groups, but intensive training oes not appear to a
extra bene t to unction or overall health. “B” is incorrect. His
current weight is a equate, an he is at risk or malnutrition i
he has rinking problem, so he oes not nee to lose weight.
“D” is incorrect. Sa ety is a concern ue to the increasing num-
CHAPTER 21 • CARE OF THE OLDER PATIENT 591
ber o ol er rivers, their higher crash rate per mile riven, an
their increase likelihoo o serious injury an eath. However,
most seniors pre er automobile transportation to keep active in
the community an shoul continue to rive. In this case, with-
out speci c concerns, there is no nee to recommen restricte
riving.
HELPFUL TIP:
I you are concerned about driving sa ety, ask direct
questions about any recent driving problems, such
as minor accidents, tra ic violations, or getting lost.
The legal requirements about physician reporting o
unsa e older drivers vary rom state to state, but the
AMA has published a use ul guide, available online and
updated in 2010, called “Physician’s Guide to Assess-
ing and Counseling Older Drivers” (http://www.nhtsa.
gov/people/injury/olddrive/OlderDriversBook/pages/
Contents.html)
One month later, your patient’s daughter calls to in orm you
that he ell and broke his le hip while vacationing with the
amily in Cali ornia. He had total hip arthroplasty ( HA)
and is still in the hospital recovering. Now they are trying to
make arrangements to bring him home. T e discharge plan-
ner has identi ed a local nursing home that can provide reha-
bilitation, but some o the amily would like or him to return
to his apartment.
Question 21.7.3 In regard to recovery a ter hip surgery, you
in orm the daughter that:
A) Rehabilitation af er hospital ischarge results in better out-
comes or patients with hip racture
B) Rehabilitation can only be provi e inpatient at a hospital or
nursing home, not at home
C) Surgical repair in el erly patients shoul be elaye i pos-
sible (> 72 hours af er injury) to re uce 1-year mortality an
other complications
D) Early mobilization af er hip surgery is recommen e in
younger patients, but in ol er patients weight bearing is
usually elaye at least 5 ays af er surgery to allow proper
healing
Answer 21.7.3 The correct answer is “A.” Stu ies show that
rehabilitation imme iately af er hospital ischarge appears to
result in superior outcomes or patients with hip racture or
stroke. “B” is incorrect. Rehabilitation can be provi e in either
inpatient (i.e., hospital or skille nursing acility) or outpa-
tient settings (clinic, ay hospital or home). For inpatient care,
patients must be able to participate in rehabilitation that inclu es
a minimum o 3 hours o therapy 5 ays per week. Care usually
involves an inter isciplinary team inclu ing nurses an various
therapists. Home-base services can provi e part-time or inter-
mittent therapy as prescribe by a physician. “C” is incorrect.
Early surgical repair (< 24 hours af er racture) is i eal an has
been shown to re uce 1-year mortality an complications such
592 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
as pressure ulcers an elirium. Delay or me ically unstable
patients may be necessary. “D” is incorrect. Early mobilization
is the stan ar o care or both hip an knee arthroplasty in
younger an ol er a ults. Weight bearing of en begins on the
secon postoperative ay.
Your patient and his daughter agree that rehabilitation
locally sounds like the best plan.
Question 21.7.4 The goals o rehabilitation include:
A) Restore unction
B) Help patients compensate or an a apt to unctional losses
C) Prevent secon ary complications
D) Maximize potential or participation in social, leisure, or
work roles
E) All o the above
Answer 21.7.4 The correct answer is “E.” T ese are all goals o
rehabilitation.
T e patient returns to the local nursing home or inpatient
rehabilitation. Despite wonder ul progress with physical
therapy, he is unable to ambulate without using a cane. He is
rustrated that he cannot walk on his own, and is concerned
that all this walking and exercise is going to damage the
recently surgically repaired hip joint.
Question 21.7.5 You can tell him that:
A) He oes not nee to restrict his activity because the hip
prosthesis is well esigne or ben ing, walking, an climb-
ing stairs
B) His rustration is likely a major epressive isor er an will
require me ication treatment
C) He shoul continue the exercises because the a vantages
outweigh the low risks o surgical ailure
D) He shoul not expect ull recovery even with exercise, be-
cause nearly every patient requires an assistive evice to
walk af er total hip replacement
Answer 21.7.5 The correct answer is “C.” Whether correc-
tion is with screws, partial repair, or complete joint replace-
ment, early weight bearing is usually tolerable with low rates
o surgical ailure an helps to counteract the poor outcomes
clearly associate with prolonge inactivity. As note in a pre-
vious question, early mobilization an continue exercise are
the keys to preventing urther ecline an loss o unction. “A”
is incorrect. Af er total hip replacement, patients shoul avoi
certain motions such as ben ing over to tie shoes an cross-
ing legs when seate . Of entimes a raise toilet seat is also
recommen e to re uce the loa place on the hip prosthe-
sis in extreme exion. Walking an general range o motion
exercises shoul be encourage as tolerate . “B” is incorrect.
Depression is not uncommon af er a isabling injury such as
hip racture. However, this patient’s rustration may or may
not re ect clinical epression an shoul be urther evalu-
ate be ore starting me ication. “D” is incorrect. Although hip
ractures carry approximately 5% in-hospital mortality an a
mortality o approximately 25% in the year ollowing racture,
about 75% o survivors recover to prior level o unction. Up to
50% o these patients require an assistive evice, but certainly
not everyone.
HELPFUL (AND REALLY IMPORTANT) TIP:
For hip ractures, repair using an anterior approach as
opposed to the traditional posterior/lateral approach
reduces recovery time and generally allows complete
mobility (including crossing legs, etc.) with a lower risk
o dislocation. They are o ten ambulating well the irst
postoperative day.
A er 2 more weeks, your patient is now unctioning well
enough to return home. He can trans er independently and
ambulates with a cane or support. Prior to discharge, the
rehabilitation team would like to assess his home environ-
ment.
Question 21.7.6 The occupational therapy practitioner on
the team:
A) Provi es a comprehensive assessment wherever the patient
is employe base on his/her occupation, which oes not
typically inclu e the home environment
B) May provi e training or speci c a aptive equipment or
patients to enhance per ormance in every ay activities an
promote in epen ence
C) Is a skille pro essional who has complete an occupational
therapy training program af er completion o high school
D) Is license to write prescriptions in most states, primarily or
pain control
Answer 21.7.6 The correct answer is “B.” Occupational thera-
pists (O s) provi e training or speci c a aptive equipment to
enhance per ormance in every ay activities an promote in e-
pen ence. T ey also provi e gui ance to amily members an
caregivers i nee e . “A” is incorrect. O s provi e home or job-
site assessment, regar less o employment status or occupation.
“C” is incorrect. O s are skille pro essionals whose e ucation
inclu es the stu y o human growth an evelopment with an
emphasis on the social, emotional, an physiological e ects o
illness an injury. One must have earne a bachelor egree or
beyon to enter the el o occupational therapy. T ere are also
occupational therapy assistants who generally earn an associate
egree an practice un er the supervision o a traine O . “D”
is incorrect since O s o not have license to prescribe me ica-
tions.
Objectives: Did you learn to . . .
• Identi y and screen or drinking problem in the older
patient?
• Promote early rehabilitation a ter hip racture repair?
• Describe some aspects o rehabilitative services?

CASE 21.8
A 68-year-old male arrives at your clinic to establish care.
He admits that he does not visit the doctor regularly, but he
eels his health has been pretty good since he changed his
“bad habits.” He did not bring any records, but he knows
he has heart disease and high blood pressure. His bad hab-
its included smoking about 1 pack per day or 40 years, but
he proudly states he quit “cold turkey” a er a heart attack at
age 63. As ar as healthcare maintenance, he did have a colo-
noscopy 5 years ago at his wi e’s request, and he remembers
his last PSA was normal, but he does not recall any type o
screening or abdominal aortic aneurysm (AAA).
Question 21.8.1 The USPSTF recommends one -time AAA
screening:
A) For all men age 65 to –74 years
B) For all men age 65 to 74 years who have smoke > 100 cig-
arettes in their li etime
C) For all men age 55 to 64 years who have smoke ≥ 1 pack
o cigarettes per ay or 10 years or more
D) For all men age ≥ 75 i li e expectancy > 10 years
E) All smokers ≥ 55, regar less o gen er
Answer 21.8.1 The correct answer is “B.” T e USPS F an a
consortium o lea ing pro essional organizations recommen
one-time AAA screening with ab ominal ultrasonography or
all men age 65 to 74 years who have ever smoke ( e ne as
> 100 li etime cigarettes). “A” an “C” are incorrect. T e USP F
currently oes NO recommen screening men who have never
smoke (< 100 cigarettes in a li etime). T e American Col-
lege o Car iology/American Heart Association (ACC/AHA)
gui elines a vise screening men ol er than 60 years who have
a strong amily history (parents or siblings) o AAA, but amily
history is not explicitly consi ere in the USPS F gui elines.
“D” an “E” are incorrect. T e evi ence in men ol er than age
75 years an in women oes not support AAA screening, an
neither o the above gui elines recommen s routine screening
in those groups. One o several imaging mo alities can be use
or screening, inclu ing ultrasoun an C scan.
You recommend a screening ultrasound or AAA, but then
he questions why screening or AAA is necessary (guess you
need to work on your rapport-building).
Question 21.8.2 You in orm him that:
A) AAA occurs in approximately 1 in 20 ol er men who have
ever smoke
B) Rupture o an AAA has a morality rate o 50%
C) AAA ruptures cause approximately 1,000 eaths per year in
the Unite States
D) reatment or AAA inclu es open surgical repair, en ovas-
cular repair, or surveillance once the aneurysm reaches 6 cm
but not be ore this
Answer 21.8.2 The correct answer is “A.” AAA is a common
con ition, occurring in approximately 1 in 20 ol er men who
CHAPTER 21 • CARE OF THE OLDER PATIENT 593
have ever smoke . “B” is incorrect. Rupture o an AAA is associ-
ate with an even higher mortality rate o 80%, hence the impor-
tance o screening. “C” is incorrect. Epi emiologic stu ies in i-
cate that AAA ruptures cause approximately 10,000 to 15,000
eaths per year in the Unite States. “D” is incorrect. reatment
o AAA is base on the aneurysm size, rate o expansion, an
symptoms. Asymptomatic patients with aneurysms ≥ 5.5 cm in
iameter shoul un ergo repair, not surveillance. Surveillance
or me ium size aneurysms (4–5.4 cm) is by ultrasoun or
C every 6 to 12 months an every 2 to 3 years or aneurysms
3 to 4 cm. Earlier repair in men with AAA ≥ 5 or women with
AAA ≥ 4.5 cm may be in icate i rate o increase is ≥ 0.5 cm in
6 months. AAA repair options inclu e open surgical repair or
en ovascular repair. En ovascular repair has lower 30- ay mor-
tality rate, but overall mortality is i entical af er 3 to 4 years. In
2011, the ACC/AHA up ate their gui elines regar ing AAA
repair, recommen ing either surgical or en ovascular repair or
most patients.
T e ultrasound shows minimal atherosclerotic disease o
the abdominal aorta and no aneurysm. wo years later, the
patient returns or ollow-up at the prompting o his daugh-
ter who has been noticing that he complains about his knees
hurting all the time. He has never been interested in surgery,
but he would like to try something di erent. When asked
about his pain on a scale o zero to ten (zero meaning no pain
and ten meaning the worst pain possible), he reports pain
around 2/10 most days, and up to 6/10 a er moderate activ-
ity. He uses acetaminophen sometimes but does not want to
get addicted to pain medicine.
Question 21.8.3 In addition to increasing his dose o acet-
aminophen, you suggest a topical analgesic such as:
A) T e 5% li ocaine patch because it can be applie conve-
niently anywhere on the bo y to provi e a itional knee
pain control
B) T e 5% li ocaine patch because it acts locally where applie
without achieving clinically signi cant serum rug levels
C) Capsaicin cream because it can be applie topically once per
ay or e ective pain control
D) Capsaicin cream because it only takes 1 to 2 ays to achieve
a clinical e ect
E) Diclo enac 1% gel because it can provi e anti-in amma-
tory e ect with lesser GI toxicity compare with systemic
NSAIDs
Answer 21.8.3 The correct answer is “E.” Ol er a ults are less
likely to be a equately treate or pain compare with younger
a ults. Acetaminophen remains the best choice or rst-line
therapy o mil -to-mo erate pain ue to its tolerability. opical
agents such as the li ocaine, capsaicin, or iclo enac can also
provi e localize pain control. opical agents can be very use ul
pain therapy because they penetrate the skin to act on periph-
eral nerves an sof tissue irectly un erlying the application
site. T ese topical agents have minimal systemic absorption
an thus limite potential or any clinically signi cant systemic
e ect or rug– rug interactions. Diclo enac 1% gel is a topical
594 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
NSAID well-suite or treatment o osteoarthritis. A verse GI
events are less common compare to oral NSAID therapy, an
overall a verse events rates are low. However, cost may be pro-
hibitive or iclo enac gel.
“A” is incorrect. T e li ocaine patch must be applie irectly
over the pain ul area or best results and isn’t e ective in arthri-
tis. opical li ocaine only really works or neuropathic pain
(e.g., post-zoster) or or local, super cial, skin irritation. “B” is
wrong or the same reason. “C” an “D” are incorrect. Capsaicin
cream is ose on a regular sche ule every 6 hours to achieve
maximal e ect, which generally takes 2 to 4 weeks.
He tries acetaminophen 1,000 mg ID and capsaicin 3 to
4 times per day, and reports improved pain control. You see
him 1 month later or a ollow-up visit. oday he picked up
a coupon at the local drug store or an arthritis pill that con-
tains chondroitin. He wants to know i this might help his
knee pain.
Question 21.8.4 You discuss the current evidence and
in orm him that:
A) Large-scale trials in icate signi cant symptomatic bene t in
osteoarthritis with the use o chon roitin supplements
B) For patients with severe osteoarthritis only, a clinically rel-
evant bene t is likely an the use o chon roitin shoul be
encourage
C) Chon roitin is a large macromolecule that is poorly igeste
an is potentially unsa e in ol er patients with any stomach
problems
D) T e combination o chon roitin an glucosamine is the
most popular supplement sol over-the-counter or joint
pain in the Unite States
Answer 21.8.4 The correct answer is “D.” T e combination o
chon roitin an glucosamine is the most popular supplement
sol over-the-counter or joint pain in the Unite States. How-
ever, scienti c evidence is lacking to support the use o chondroitin
to prevent or reduce joint pain associated with osteoarthritis. “A”
is incorrect. In a systematic review o 20 trials that compare the
e ects o chon roitin with placebo or no treatment in patients
with hip or knee osteoarthritis, chon roitin ha minimal or no
e ect on joint pain. “B” is incorrect. For patients with a vance
osteoarthritis, a clinically relevant bene t is unlikely. “C” is
incorrect. Chon roitin is a large macromolecule, an only
12% to 13% o ingeste chon roitin is absorbe into the bloo
stream. However, multiple stu ies have oun no evi ence to
suggest that chon roitin is unsa e (except to the sharks that
provi e the cartilage to make the supplement—they are rapi ly
becoming extinct).
Now that your patient has seen you or a ew years, he eels
more com ortable in discussing other health concerns . . . like
constipation (hey, you’ve built some rapport!). He usually has
a bowel movement (BM) every 2 to 3 days, but sometimes he
gets hard stools that require excessive straining. His wi e tells
him to eat more ber, but he wants to know what else he can
do to help “keep regular.”
TABLE 21-6 ROME CRITERIA FOR
FUNCTIONAL CONSTIPATION
Two or more o the ollowing should be present or at least 12 weeks
out o the preceding 12 months:
• Straining or greater than 25% o de ecations
• Lumpy or hard stools or greater than 25% o de ecations
• Sensation o incomplete evacuation or greater than 25% o de eca-
tions
• Less than three de ecations per week
• Manual evacuation or assistance to acilitate de ecation
Question 21.8.5 Which o the ollowing statements is true
about constipation?
A) T e prevalence o sel -reporte constipation ecreases with
aging
B) Patients shoul be encourage to e ecate be ore meals
when the colonic activity is the greatest
C) Fiber is a sa e, inexpensive approach to improve stool con-
sistency an accelerate colon transit time
D) Increase caloric intake correlates well with constipation in
the el erly
Answer 21.8.5 The correct answer is “C.” Fiber is a sa e, inex-
pensive approach to improve stool consistency an accelerate
colon transit time. Increasing ber is a goo rst-line approach
an shoul be encourage . T e aily recommen e ber
intake is 20 to 35 g. “A” is incorrect because the prevalence o
sel -reporte constipation increases with aging—up to 45% o
rail el erly in ivi uals report constipation as a health issue. It
is not uncommon or patients an physicians to have i erent
clinical e nitions o constipation, so urther history is help ul
to clari y what the patient means by “constipation.” T e Rome
Criteria o ers a consensus e nition o constipation use in
clinical trials as outline in able 21-6 an may be help ul to
urther characterize constipation. “B” is incorrect. Patients
shoul be encourage to e ecate rst thing in the morning
or 30 minutes a er meals when colonic activity is the greatest,
an to take a vantage o the gastrocolic re ex. “D” is incorrect.
Decrease (not increase ) caloric intake is more likely to be
associate with constipation in the el erly.
You rule out secondary causes o constipation and decide
that your patient likely has primary transit constipation. You
rst provide nonpharmacologic recommendations to pro-
mote regular bowel habits, including dietary changes and
increased exercise.
Question 21.8.6 Which o the ollowing options would be
the best pharmacologic approach to use on a daily basis in
order to help this patient with his constipation?
A) Fiber: psyllium (Metamucil), oat bran, or methylcellulose
(Citrucel)
B) Stool sof ener: ocusate calcium (Sur ak) or ocusate
so ium (Colace)
C) Stimulant laxative: senna (Senokot), castor oil, or bisaco yl
(Dulcolax)

D) Enema: tap water, so ium bisphosphonate, or soap enema
E) Prokinetic agent: tegasero (Zelnorm), a 5H 4 agonist
Answer 21.8.6 The correct answer is “A.” Primary causes o
constipation all into three categories: (1) normal transit con-
stipation, (2) slow transit constipation, an (3) anorectal ys-
unction. T ere is no evi ence-base gui eline or the pre erre
or er o using i erent types o laxatives. Supplemental ber
helps improve stool orm an requency an is a goo rst step.
Psyllium also has the bene t o re ucing lipi s an improving
glucose control in iabetics. A equate ui intake is necessary
when using psyllium since it may exacerbate constipation when
ui intake is insu cient. “B” is incorrect. While stool sof en-
ers are commonly prescribe an may be help ul, they are less
e ective than other options inclu ing psyllium. “C” is incor-
rect. Stimulant laxatives, when use in recommen e oses, are
unlikely to harm the colon i use or short uration. However,
stimulant laxatives may cause electrolyte imbalance or ab omi-
nal pain an are not the rst-line therapy. “D” is incorrect. Ene-
mas shoul only be use in acute situations an with caution
ue to the risk o colonic per oration. Large-volume enemas
can result in hyponatremia, while enemas containing phosphate
can lea to hyperphosphatemia an renal ailure, especially in
patients with renal insu ciency. “E” is incorrect. Prokinetic
agents stimulate propulsion along the GI tract. T e 5H 4 ago-
nist tegasero (Zelnorm) improves symptoms o constipation in
women with irritable bowel syn rome (its only FDA-approve
in ication) but is associate with a verse car iovascular events
an is available only un er restricte use.
HELPFUL TIP:
There are many causes o secondary constipation, in-
cluding numerous medications (e.g., anticholinergics,
calcium channel blockers, opiates) and coexistent medi-
cal conditions such as diabetes, hypothyroidism, sclero-
derma, and amyloidosis.
Objectives: Did you learn to . . .
• Screen or AAA?
• Provide the sa e and ef ective treatment or osteoarthritis
pain?
• Identi y and treat constipation in the older patient?
CASE 21.9
A 73-year-old male patient returns to see you or urther
management o diabetes mellitus type 2. He has had diabetes
or decades and he has been generally well controlled on oral
medications o met ormin and glipizide. He also has hyper-
tension and hypercholesterolemia or which he is treated. He
thinks he is in otherwise air health and is active in his com-
munity and lives independently with his wi e.
Question 21.9.1 What is his target hemoglobin A1C?
A) < 5.5%
B) < 6.5%
CHAPTER 21 • CARE OF THE OLDER PATIENT 595
C) < 7.5%
D) < 8.5%
Answer 21.9.1 The correct answer is “C.” T e American
Geriatrics Society recommen s a goal hemoglobin A1C o less
than 7.5% or ol er a ult patients who are otherwise healthy
an have goo unctional per ormance. T e bene ts versus the
risks o intensive iabetic control start to shif as the me ical
complexity an unctional impairments o the patient increase.
T ere ore, the goal hemoglobin A1C or an in ivi ual who is
requiring assistance with greater than 2 instrumental activi-
ties o aily living or has multiple complex me ical problems
is < 8.0%. T ose with poor health or en -stage chronic illness
(inclu ing mo erate to severe cognitive impairment) shoul
have a goal o < 8.5%. In these situations, attempting to achieve
hemoglobin A1C levels < 7.0% is associate with higher mortality
an more requent hypoglycemic events.
His HbA1C is 7.3%. He has been tolerating his diabetic medi-
cations well. He is also on a cholesterol-lowering agent, sim-
vastatin 80 mg daily. He has been on this medication or
several years and has been tolerating it well without any mus-
cle aches or documented liver derangements.
Question 21.9.2 What is his goal LDL level in the context o
his comorbid medical conditions?
A) LDL < 130 mg/ L
B) LDL < 100 mg/ L
C) LDL < 70 mg/ L
D) LDL re uction o at least 50% rom baseline
E) T ere is no LDL goal an statins shoul be avoi e in the
el erly
Answer 21.9.2 The correct answer is “D.” T e American Col-
lege o Car iology an the American Heart Association release
new gui elines regar ing the management o cholesterol in
2013. Fortunately, there are a number o online calculators to
ai you in assessing a patient’s risk pro le. For your patient
to ay, with his iabetes, age, an hypertension, the goal woul
be a 50% re uction o his LDL rom baseline. His 10-year car-
iovascular isease (CVD) risk is > 7.5%, an this re uction is
best achieve with a high-intensity statin such as atorvastatin 40
to 80 mg or rosuvastatin 20 to 40 mg. T e important point here
is that he should be on a high-dose statin. T is is the goal; we no
longer ollow LDL. Mo erate-intensity statins (e.g., atorvastatin
10–20 mg, simvastatin 20–40 mg, an lovastatin 40 mg) pro-
vi e a 30% to 50% re uction o LDL an are recommen e or
patients whose 10-year CVD risk is 5% to 7.5%. T e ACC/AHA
recommen ations also state that starting a statin or increasing
intensity o therapy in those age > 75 years does not appear
to improve survival. However, the recommen ations go on to
state that patients shoul be maintaine on their current statin
me ication an osage so long as they are tolerating it well. T e
ACC/AHA guidelines do not recommend the use o other
cholesterol-lowering agents such as ezetimibe.
It is also worth noting that the FDA recommen s against
starting patients on simvastatin 80 mg because o increase risk
596 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
or rhab omyolysis. T eir recommen ation goes on to say that
patients who have been tolerating simvastatin without signs o
muscle injury or 12 months may continue using it. It is prob-
ably best to move away rom using simvastatin 80 mg in general
at this point.
Objectives: Did you learn to . . .
• Appropriately determine diabetes goals in the elderly?
• Identi y the best cholesterol-lowering agent based on a
patient risk pro le?
Clinical Pearls
Avoid antipsychotics in the demented elderly with behavioral
and psychological disturbances. First, explore and treat
potential underlying causes, modi y the environment and
educate caregivers.
Conduct a complete drug review regularly, looking or
drug–drug interactions, drug–disease interactions, ine ective
drugs, and symptoms attributable to medications.
Do not per orm cervical cancer screening on women over
the age o 65 years i the previous 3 Pap smears prior to age
65 years were completely normal and there were no indings
o CIN2 or higher in the previous 20 years.
Do not treat asymptomatic bacteriuria in older adults.
Do not treat insomnia in older adults with sedative drugs,
including diphenhydramine. First, employ good sleep
hygiene and consider melatonin.
Do not use medical interventions, such as appetite stimulants
and gastric tube eedings, or demented older adults who are
losing weight. Provide appealing and calorically dense oods,
eeding assistance, and a social context or eating.
Estimate longevity and determine patient pre erences prior
to initiating screenings and preventative interventions.
Older patients who sustain a hip racture have better clinical
outcomes with early repair (within the irst 24 hours).
Periodically reassess cholinesterase inhibitors or dementia;
taper and discontinue the drug i there is no perceived ben-
e it or i adverse events occur (e.g., weight loss, bradycardia).
Pressure ulcers should be treated primarily with pressure
relie , good wound care, and good nutrition. Minimal bene it
is attributable to dressing type or advanced wound care
treatments (e.g., electrical stimulation, ultrasound).
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ize patients with activity limitation. JAMA. 1995;273(11):
856–870.
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A clinical practice gui eline rom the ACP/AAFP. Ann
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Drivers.” Available at http://www.nhtsa.gov/people/injury/
ol rive/Ol erDriversBook/pages/Contents.html.
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DC: American Psychiatric Association; 2013.
Barnes A. Legal issues in geriatric me icine an gerontology.
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an in ection in long-term care acilities. Clin In ect Dis.
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Fam Physician. 2011;84(4):405–411.
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ications, an ose limitations o Zocor (simvastatin) to
re uce the risk o muscle injury. Available at http://www.
a.gov/Drugs/DrugSa ety/ucm256581.htm. Accesse on
June 2015.
Hatta K, et al. Preventative E ects o Ramelteon on elirium
a ran omize placebo-controlle trial. JAMA Psychiatry.
2014;397–403.
Inouye SK, et al. Clari ying con usion; the con usion assess-
ment metho . Ann Intern Med. 1990;113:941–948.
Inouye SK, et al. A multicomponent intervention to prevent
elirium in hospitalize ol er patients. N Engl J Med.
1999;340:669–676.
Kirkman S, et al. Diabetes in ol er a ults: A consensus report.
J Am Geriatr Soc. 2012;60(12):2342–2356.
Loue S. El er abuse an neglect in me icine an law: T e nee
or re orm. J Leg Med. 2001;22:159–209.
Mehr DR, atum PE. Primary prevention o iseases in ol
age. Clin Geriatr Med. 2002;18(3):407–430.
Panel on Prevention o Falls in Ol er Persons, American
Geriatrics Society an British Geriatrics Society. Up ate
AGS/BGS clinical practice gui eline or prevention o
alls in ol er persons. J Am Geriatr Soc. 2011;59(1):
148–157.
Pergolizzi J, et al. Opioi s an the management o chronic
severe pain in the el erly. Pain Pract. 2008;8(4):287–313.
Pham CB, Dickman RL. Minimizing a verse rug events in
ol er patients. Am Fam Physician. 2007;76(12):1837–1844.
Po sia lo D, Richar son S. T e time “Up & Go”: A test o
basic unctional mobility or rail el erly persons. J Am
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ariot PN. Me ical management o a vance ementia. J Am
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Care of the Surgical Patient
D vdB m r ner, N s B. W e n, nd Br E. R y
CASE 22.1
A 40 year old ale atient with ty e 2 diabetes calls your
o ce because he is having di culty urinating and quite a bit
o ain in the erineal area. He has not elt well or several
days and was running a low-grade ever. He went to his chiro-
ractor 2 days ago when he only had ain and swelling in the
scrotu and the chiro ractor adjusted his . . . well, we won’t
go there . . . . He is now noting that his te erature is higher
(he doesn’t have a ther o eter and is reading his te era-
ture via his old ood ring ro the 90s). You suggest that he
resents to your o ce.
Exa ination reveals an obese ale who is waddling into
the o ce because o ain in his scrotal area. Vitals: blood
ressure 150/100 Hg, ulse 112 b , res irations 20
b , and te erature 39.0°C. Other signi cant ndings
include a swollen scrotu that is bright red, exquisitely ten-
der to touch, and without cre itus. You do not have extended
laboratory access in your o ce, but a urine di stick is nega-
tive or blood and leukocyte esterase. His blood sugar, which
is usually airly well controlled, is elevated at 320 g/dL.
Question 22.1.1 Your next step or this patient will be which
o the ollowing?
A) Start the patient on cephalexin (Ke ex) or methicillin-
sensitive Staphylococcus aureus and Streptococcus coverage
and ollow-up with the patient in the morning
B) Emergent surgical re erral
C) Begin trimethoprim/sul amethoxazole (Bactrim) or meth-
icillin-resistant S. aureus (MRSA) coverage and ollow-up
with the patient in the morning
D) Admit the patient and start him on IV vancomycin, piper-
acillin/tazobactam, and metronidazole or coverage o
MRSA, Streptococcus, Pseudomonas, anaerobes
Answer 22.1.1 The correct answer is “B.” T is likely repre-
sents Fournier gangrene. T e erythematous, swollen scrotum
with pain out o proportion to examination and associated signs
o ever, tachycardia, and elevated blood sugar make Fournier
598
22
gangrene the most likely diagnosis. While crepitus is common
with Fournier gangrene due to presence o gas- orming anaerobic
bacteria, its absence is not sensitive enough to rule out gangrene.
Without early surgical debridement and IV antibiotics, in ec-
tion can progress rapidly causing sepsis and multiorgan ailure.
T ere ore, “B,” emergent surgical re erral is the best option or
this patient. Antibiotics, particularly oral (options “A” and “B”),
are inappropriate as a sole therapy. “D” has the right intent with
broad-spectrum coverage but is incorrect because the patient
needs adjunct surgical debridement to remove the necrotic tissue.
Question 22.1.2 Fournier gangrene can best be described
as:
A) Necrotizing asciitis
B) Necrotizing cellulitis
C) Caused by aerobic bacteria
D) Secondary to streptococci
E) A mathematical unction that can be written as an in nite
sum o harmonics
Answer 22.1.2 The correct answer is “A.” Fournier gangrene
is a orm o necrotizing asciitis. T is is termed “ ype I” nec-
rotizing asciitis and is caused by mixed aerobic and anaerobic
bacteria. “B” is incorrect. Necrotizing cellulitis is isolated to the
super cial skin. Fournier gangrene involves deep tissues includ-
ing the ascia. “C” is incorrect because, as noted above, Fournier
gangrene is caused by mixed aerobic and anaerobic bacteria.
“D” is incorrect. T ere is necrotizing asciitis secondary to
stre tococci (see below); however, it has di erent causative
agents than Fournier gangrene. Fournier gangrene is typically
caused by coli orms, Clostridia, Bacteroides, Klebsiella, Staphy-
lococcus, and Streptococcus. I you used “the-longest-answer-is-
always-right” method and chose “E,” you are way o base and
also a math nerd; “E” describes Fourier’s trans orm.
Question 22.1.3 Which o the ollowing is NOT a risk actor
or Fournier gangrene?
A) Diabetes
B) Immunosuppression
 CHAPTER 22 • Ca RE o t h E Su Rg iCa l Pa t iENt 599

C) Varicella in ection
D) End-stage renal disease
E) Advanced age
Answer 22.1.3 The correct answer is “C.” All the other options
are risk actors or Fournier gangrene. Varicella in ection is a
risk actor or y e II necrotizing asciitis, which is a di erent
entity. ype II necrotizing asciitis is caused by group A Strep-
tococcus. Generally, patients with ype II necrotizing asciitis
are not diabetic or otherwise immunocompromised. Other risk
actors or ype II necrotizing asciitis include IV drug use, pen-
etrating trauma, and blunt trauma.
T e surgeon evaluates the atient and asks or your o inion
on the antibiotic regi en. You nearly all over in shock that
your advice was solicited.
Question 22.1.4 What do you recommend or this patient
with necrotizing asciitis?
A) Penicillin and clindamycin
B) Clindamycin and metronidazole
C) Meropenem, vancomycin and clindamycin
D) Piperacillin/tazobactam (Zosyn), vancomycin and metroni-
dazole
E) C or D
T e atient has a wide excision o necrotic tissue. A er sur-
gery, he beco es hy otensive and tachycardic (blood res-
sure 85/50, ulse 128), and his seru lactate is 8 g/dL (very
high).
Question 22.1.5 What is the most appropriate next step in
his management?
A) Start IV dopamine to stabilize his blood pressure
B) Start IV norepinephrine to stabilize his blood pressure
C) Start IV 0.9% normal saline boluses to stabilize his blood
pressure
D) Start IV albumin boluses to stabilize his blood pressure
E) Read him the hospital charges he has accumulated thus ar
Answer 22.1.5 The correct answer is “C.” T is patient is likely
hypovolemic secondary to third spacing and/or is in septic shock
and needs volume. T e lactate o 8 mg/dL suggests that he has
hypoper usion with poor tissue oxygenation (although it could
also be secondary to necrotic tissue). Just giving dopamine (or
other vasopressors) will not increase peripheral circulation and, in
act, may decrease tissue oxygenation by increasing vascular tone
and decreasing per usion. Albumin has not been shown to have
any advantage over crystalloids in almost any circumstance—post
large-volume paracentesis (> 5 L) being the exception. Mortality
o necrotizing asciitis approaches 30% even with the best care.

Answer 22.1.4 The correct answer is “E.” As noted above, HELPFUL TIP:
Fournier gangrene is a mix o aerobic and anaerobic bacte- t e nk n b seps s s c n ed n e s ew
ria. T e rst two choices (“A” and “B”) will cover anaerobes ye rs w e S rv v n Seps s C mp n (Crit Care Med.
and some Gram-positive organisms. However, Gram-nega- 2013;41(2):581–637) nd sever s bseq en s d es
tive coverage is lacking. More broad-spectrum antimicrobial spec s de ne. S ccess y re n seps s
coverage is needed in this situation. Most experts and guide- req res e r y rec n n, e r y ress ve d res s-
lines recommend a broad-spectrum antibiotic with anaerobic c n (b ses 30 ml /k ), nd br d-spec r m n-
and Gram-negative coverage (e.g., piperacillin/tazobactam, b cs w n 1 r rec n n severe seps s r
ampicillin/sulbactam, or a carbapenem) lus MRSA cov- sep c s ck. Following speci ic sepsis protocols (e.g., with
erage (usually vancomycin) lus anaerobic coverage (e.g., central venous pressure and hematocrit goals) does not
clindamycin, metronidazole). Although MRSA is not usually change outcomes (N Engl J Med. 2014;370:1683–1693). Ag-
the causative agent, these in ections are polymicrobial, and gressive use o central lines, vasopressors, trans usions, etc.
empiric MRSA coverage is required. Clindamycin deserves also does not alter mortality in septic patients (N Engl J Med.
a special mention. Clindamycin blunts the adverse e ects o 2014;371:1496–1506). E r y rec n n nd v nce
Staphylococcal and Streptococcal toxins so is especially help ul e e c re e m, m n r n e sep c p en
in Staphylococcal and Streptococcal toxic shock syndromes and c se y r c n es n s s (v v s ns, ex m n n
toxin-related shock. s ns per s n, r s nd ssessmen iVC pres-
s re, r ne p , e c.), re m re mp r n n nv -
s ve m n r n . Again, early recognition, along with
HELPFUL TIP: aggressive volume resuscitation with crystalloid,
iVig s been sed n necr z n sc s c sed by treatment o underlying in ection, and attention to
Clostridium spec es s we s n se w s rep - patient status, are the keys to surviving sepsis.
c cc sc s. W e ere s s es n bene ,
ed re nc mp e e nd m re s dy s w rr n ed.
Objectives: Did you learn to . . .
h yperb r c xy en s s been sed b s ers r m
• D n se nd re rn er n rene?
e s me ck d . t ese re men s re p en
dj nc re men s. t e de n ve re men s e r y, • D eren e be ween ypes necr z n sc s?
ress ve, s r c debr demen ! • Prescr be ppr pr e ds nd v s press rs re seps s
nd sep c s ck?
600 a Mil Y MEDiCiNE EXa MiNa t io N & Bo a RD REViEW

and elvis, but ro the waist u he is ne. Nonetheless, the

QUICK QUIZ: Pa iN Co Nt Ro l a bulance crew laces the atient in a collar and on a back-
board and trans orts hi to the ED.
Which o the ollowing drugs will give you the most rapid pain T e atient is in signi cant ain ro his lower extre i-
control when given intravenously ties and elvis (o course, since he is a stoic ar er, he denies
A) Fentanyl (Sublimaze) this and just wants to go back to lanting corn). His blood
B) Hydromorphone (Dilaudid) ressure is initially 100/65 Hg with a ulse o 118 b .
C) Meperidine (Demerol) Pri ary survey is unre arkable, although he is still boarded
D) Morphine and collared.

The correct answer is “A.” Fentanyl has a peak e ect at 3 to Question 22.2.1 Which o the ollowing most clearly re ects
5 minutes. T is is ollowed by meperidine at 5 to 7 minutes, the best approach to this patient’s pain?
morphine at 20 minutes, and hydromorphone at 15 to 30 min- A) Use IV meperidine (Demerol) or pain control
utes. T us, to get rapid control o pain, entanyl is the pre erred B) Use IV morphine or pain control
agent. Meperidine is the least pre erred agent because o drug C) Use IV entanyl (Sublimaze) or pain control
interactions (MAO inhibitors, SSRIs) and toxic metabolites D) Pain medications are contraindicated at this point given the
(normeperidine that can cause agitation and seizures). patient’s overall condition
E) Since he’s so tough, just o er him some useless platitudes
HELPFUL TIP: like “no pain, no gain”
V nc myc n s n re dr r re n Staphylo-
coccus. in c , np en m r y r es re er n Answer 22.2.1 The correct answer is “C.” Fentanyl generally
p en s w me c n-sens ve Staphylococcal n- has a negligible e ect on blood pressure (although one should
ec ns re ed w v nc myc n nw er n- never say “never”). Both morphine and meperidine tend to drop
b cs. S , y ve me c n-sens ve S. aureus, a patient’s blood pressure, so they are relatively contraindicated
c n e n b cs s me n er n v nc myc n, in this patient with a marginal blood pressure or hypotension.
s c s n c n, pen c n, r mp c n/s b c m— r T ose who chose “D” or “E” have been hanging around old-
w ever e s scep b es nd c e. time surgeons too long. It is unconscionable to withhold pain
medication.

Further exa ination, by gentle inward ressure on the ante-

QUICK QUIZ: a Nt iBio t iC Co VERa g E
rior su erior iliac s ines bilaterally, shows that the atient’s
elvis is unstable. As you recall, a ractured elvis can lead to
Which o the ollowing organisms is/are not generally covered signi cant blood loss into the retro eritoneal s ace.
by trimethoprim/sul amethoxazole ( MP/SMX)?
A) S. aureus
Question 22.2.2 In the short term, what is the best way to
B) Streptococcal species
temporize the underlying pathology?
C) Escherichia coli
A) Vasopressors (e.g., dopamine) plus uids
D) Enterococcus
B) Pelvic binder
E) B and D
C) Fluids (normal saline)
D) Activated actor VIIa (NovoSeven)
The correct answer is “E.” Neither Streptococcus nor enterococ-
E) Embolization by interventional radiology (45-minute delay)
cus species are sensitive to MP/SMX. T is has implications or
the treatment o MRSA. Cellulitis (one o the mani estations o
Answer 22.2.2 The correct answer is “B.” A pelvic binder will
MRSA) can be rom either staphylococcal or streptococcal spe-
signi cantly reduce bleeding in most unstable pelvis ractures.
cies. So, unless you are con dent that you have MRSA (abscess
“A” is incorrect because in trauma dopamine is not indicated
ormation, etc.), MP/SMX is not a great single agent or cel-
when the problem is hypovolemia. In act, vasopressors increase
lulitis. I there is an abscess, treat or MRSA (drainage, MP/
mortality in hypovolemic shock. “C” is incorrect. While nor-
SMX, doxycycline). I there is a super cial cellulitis, treat or
mal saline is a good choice or resuscitation uids, we want
Streptococcus (cephalexin, amoxicillin/clavulanate). I you are
to tamponade the bleeding and not just chase our tails with
not sure, one option would be clindamycin as a single agent,
uids. “D” is incorrect. Recombinant activated actor VIIa has
though resistance rates are on the rise.
not been shown to improve outcomes a er trauma ( J rauma.
2010;69:353–359). Additionally, it has a number o adverse
CASE 22.2 e ects including increased thromboembolic phenomenon
You are working in a rural ED when you get a call that a (pulmonary embolism [PE], deep venous thrombosis [DV ],
62-year-old ar er has been tra ed between a tractor and etc.). Finally, interventional radiology will likely be needed at
a silo while loading silage. It see s to have inned his legs some point. T ey are quite good at stopping bleeding vessels.
 CHAPTER 22 • Ca RE o t h E Su Rg iCa l Pa t iENt 601

However, the delay time during which you are watching the
HELPFUL TIP:
patient bleed is unacceptable.
i y ee nc m r b e d n rm cys s my,
cen r ne w b n p ced n e b dder c n be
HELPFUL TIP: sed s emp r z n s n.
t r nex m c c d, dr preven s br n ys s, s
been s wn (m r n y) red ce m r y r m
b eed n n r m p en s w ny d wns de. t e Objectives: Did you learn to . . .
d se s 1 iV ver 10 m n es wed by 1 ver e • t re c e r m c p n?
nex 8 rs. i s d be s r ed w n e rs r. • Rec n ze nd re pe v c r m nd n r pe v c
C ns der s s emp r zer y ve n c ve y em rr e?
b eed n p en . • Descr be c n r nd c ns b dder c e er p cemen ?

You a ro riately lace a elvic binder that ta onades the CASE 22.3
bleeding. T e atient’s blood ressure stabilizes. You now
A 55-year-old gentle an with history o s oking and dia-
turn to other issues. T is atient will clearly need a Foley
betes resents to your o ce or a ass in his right groin.
catheter.
He works as a night stocker in a local su er arket. He rst
noticed the ass a er li ing a 60 lb box ro the oor to the
Question 22.2.3 Relative contraindications to placement o
shel several nights ago. Since then, he notices that the ass
a Foley catheter include which o the ollowing?
is ain ul and “ ulses” when he coughs. He has not been able
A) Blood at the urethral meatus
to work since he rst noted the ass due to ain; in act,
B) Gross hematuria
he wonders i you should just ll out disability a ers or
C) High-riding prostate
hi now (never ha ens, right?). He endorses a history o
D) Gross blood rom the rectum
chronic consti ation or which he takes over-the-counter
E) A and C
edications. He denies weight loss, nausea, vo iting, and
urinary sy to s.
Answer 22.2.3 The correct answer is “E.” Both blood at the
On exa ination, the atient is a ebrile with a blood res-
meatus and a “high-riding prostate” (ever wonder what it is
sure o 135/86 Hg and a ulse o 84 b . Abdo inal
riding on?) signi y the possible disruption o the urethra. T us,
exa ination de onstrates a ildly obese gentle an with no
since one does not want to place the catheter in the wrong
scars o rior surgeries. Bowel sounds are nor al. He denies
place—like the peritoneal space—catheterization is relatively
tenderness with al ation o all our quadrants. T ere is no
contraindicated. “B,” gross hematuria, can be rom the kidney
guarding. With standing, exa ination o the groin de on-
and is not a contraindication to catheterization.
strates an enlarged scrotu on the right side. On coughing
the ass beco es ore ro inent and you can eel so e-
You nd blood at the urethral eatus. T e atient co lains
thing rotruding ro the inguinal canal.
that he really needs to void.

Question 22.2.4 Your options at this point include which o
the ollowing?
A) Urethrogram to document an intact urethra
B) Per ormance o suprapubic cystostomy using ultrasound
guidance
C) Use a Coudé catheter to catheterize the urethra
D) Placement o a bladder catheter via the urethra but using a
wire guide (such as with a central line)
E) A and B
Question 22.3.1 Based on the in ormation above what is
the next step in this patient’s overall care?
A) Get C scan o the abdomen to evaluate or etiology o the
mass
B) Re er the patient to a surgeon
C) Have the patient monitor the mass over the next couple o
months or changes
D) Have the patient cut back on his constipation medication
E) Place the patient in an inguinal binder

Answer 22.2.4 The correct answer is “E.” One could per orm
a urethrogram using a water-soluble dye (e.g., Gastrogra n)
to document that the urethra is intact and i so place a stan-
dard Foley. One could also do a suprapubic cystostomy using
ultrasound guidance. “C” and “D” are both incorrect. A Coudé
catheter is used to bypass a stricture (prostate or otherwise) and
would be no sa er than a regular catheter in this patient. Like-
wise, a wire could end up anywhere and should not be used in
this case.
Answer 22.3.1 The correct answer is “B.” T e patient has an
inguinal hernia. History and physical examination are typi-
cally su cient to make the diagnosis, so no urther imaging
is warranted (“A”). Because the hernia is relatively large and
a ecting his ability to work, surgical repair is recommended
rather than watch ul waiting (“C”). For small, asymptomatic,
or mildly symptomatic hernias, surgical repair can be de erred
with expectant management and counseling on signs and symp-
toms o strangulation that would warrant emergent evaluation.
602 a Mil Y MEDiCiNE EXa MiNa t io N & Bo a RD REViEW
Because constipation is a risk actor or hernias, advising him
to cut back on his constipation medication is probably not rec-
ommended (“D”). Finally, “E” sounds like a medieval torture
device rather than a therapeutic intervention.
HELPFUL TIP: STUFF THE GUTS BACK IN OR NOT?
as ded b ve, bserv n symp m c r
m n m y symp m c ern s s c mes re
j s s d s rep r (JAMA. 2006;295:285–292). in c ,
b ne- rd p en s w ve s r c rep r
ve c n n ed p n w 6% ve deb n p n.
n y, pen rep r seems be be er n p r -
sc p c rep r n erms rec rrence, nd, s rpr s n y,
per per ve m rb d y. h wever, p r sc p c rep r
res ed n ess r n n mbness nd p n n n erm
(Ann Surg. 2012;255:846).
You re er the atient to a general surgeon within the onth
and he undergoes a la arosco ic hernia re air with esh
lace ent. He is discharged to ho e the ollowing day. He is
relieved that he doesn’t need that disability a erwork lled
out a er all and already 2 days osto erative is wondering
when he can go back to work. He is unable to reach his surgeon
who is in the OR (or aybe on the gol course) and calls your
o ce asking when he can return to work . . . li ing 60-lb boxes.
Question 22.3.2 How do you counsel him about when he
can return to work?
A) He may return to work once he is no longer requiring any
pain medications and can drive
B) Return to work is typically permitted within 2 to 4 weeks or
laborers and within 10 days as tolerated or pro essionals
C) Return to work at his current job is not recommended, as it
requires too strenuous activity and heavy li ing. He should
seek another line o work
D) Return to work is typically permitted within 6 weeks or all
pro essions
Answer 22.3.2 The correct answer is “B.” Hernia repair is a
airly low-risk surgery and patients are typically able to return
to work within 2 to 4 weeks, primarily based on their surgeon’s
pre erence. For pro essionals with more sedentary jobs, return
to work may be as early as 10 days as long as no heavy li ing or
straining will take place; there ore “D” is not the best answer.
While patients should be o all their pain medications prior to
return to work or driving, “A” is not the best answer as the sur-
gical wound needs at least 2 to 4 weeks to heal to a reasonable
strength. “C” is not correct as he should be able to resume his
prior job activities once the surgical wound heals to maximum
strength. However, the patient should be counseled on sa e
li ing techniques and possibility or recurrence o his hernia.
T e atient is able to success ully return to work about
4 weeks osto eratively. He is eeling so well that he orgets
to return to his ollow-u a oint ents with you. wo years
later, the atient returns a er he has initiated a running regi-
en to lose weight. Un ortunately, he is now having groin
ain on the le a er he runs and is worried that he now has
an inguinal hernia on the le (his rior hernia was on the
right). He denies any nausea, vo iting, consti ation (you
cured hi with the Miralax!), urinary sy to s, or asses
in the groin area. Pain is an aching sensation and worsened
with changing ositions ro sitting to standing or going u
stairs. He denies any injury.
On exa ination, the atient is a ebrile with a blood res-
sure o 120/78 Hg and a ulse o 84 b . Abdo inal
exa ination de onstrates a nor al-weight gentle an
with well-healed la arosco ic incisions on the right. Bowel
sounds are nor al. He denies tenderness with al ation o
all our quadrants. T ere is no guarding or rebound. Pain is
re roducible with al ation o the inguinal liga ent on the
le . T ere is no inguinal ly hadeno athy. With standing,
exa ination o the groin de onstrates a nor al-sized and
sy etric scrotu bilaterally without any al able asses.
With al ation o the a ected area, there is no ass when the
atient coughs.
Question 22.3.3 What is the most common diagnosis or
this patient’s symptoms?
A) Osteoarthritis o the le hip
B) Femoral adenitis
C) Le direct inguinal hernia
D) Osteitis pubis
E) Ligamentous strain
Answer 22.3.3 The correct answer is “E.” While all o the
above should be considered in the di erential or groin pain,
the most likely diagnosis or this patient’s symptoms with
his new running regimen is a ligamentous strain. Without a
bulge detected on Valsalva maneuver (coughing) or a palpable
abdominal wall de ect, a hernia is unlikely (“C”). T ere are no
palpable inguinal lymph nodes and patient does not have clini-
cal signs o a ever, so “B” is unlikely. Hip osteoarthritis (“A”)
can be a cause o groin pain, particularly in people with good
old wear-and-tear. However, the type o pain with hip osteoar-
thritis tends to be a deep and aching sensation within the groin
area that is not reproducible on palpation. O particular note is
“D.” Osteitis pubis, an in ammatory process o the symphysis
pubis, is a very common overuse syndrome causing groin pain
in athletes; it mani ests as pain over the pubic symphysis, not
the inguinal ligament. Other causes include childbirth, uro-
logic or gynecologic surgery, and rheumatologic conditions.
reatment includes rest, NSAIDs, and, in rare cases, injection
o the symphysis pubis with a steroid mixture ( or athletes).
Other causes o groin pain that should be considered within
the di erential and should be based on your clinical history
and ndings include epididymitis, re erred pain, ectopic testes,
stress ractures, and tendinopathies. I the pain had been local-
ized to the right, adhesions and mesh complications rom prior
hernia repair must also be considered.

You treat your atient conservatively and he goes on to co -
lete his rst hal - arathon a year later.
Objectives: Did you learn to . . .
• D n se ern b sed n c n c s ry nd p ys c
ex m n n?
• a ppr pr e y m n e re men r ern s?
• C nse p en s n rec mmended re rn c v es p s -
per ve y?
• iden y er p en c ses r n p n?
CASE 22.4
A 60-year-old e ale resents to your o ce or severe
abdo inal ain . . . at 4:45 pm . . . on a Friday. She re orts
that she develo ed vague le lower quadrant abdo inal ain
yesterday. T is orning she awakened ro her slee with
severe, di use abdo inal ain, anorexia, and vo iting.
On exa ination, she is lying very still. e erature is
38.4°C, ulse 106 b , res irations 16 b , blood ressure
100/62 Hg. She has dry ucous e branes. Her abdo-
en has di inished bowel sounds and is rigid with invol-
untary guarding and rebound tenderness greatest in the le
lower quadrant. On elvic exa ination, she is exquisitely
tender on the le abdo en. T ere is no cervical otion ten-
derness or adnexal ullness. T ere are no asses on rectal
exa ination, and her stool is negative or occult blood.
Laboratory tests include a negative urine regnancy (she’s
60 a er all—but can you be too care ul?!), WBC 25,500/
3 3
, HC 32%, latelets 450,000/ , Na 142 Eq/L, K
3.2 Eq/L, BUN 24 g/dL, and Cr 1.0 g/dL. Abdo inal
x-ray de onstrates ree air under the dia hrag . Based on
the in or ation you decide that she has diverticulitis.
T e atient undergoes surgery with a artial bowel resec-
tion and ri ary re-anasto osis. wo onths ollowing your
atient’s surgery, she resents co laining o abdo inal
ain. T e ain is cra y and inter ittent. Further history
reveals a 24-hour history o vo iting, abdo inal bloating,
and low-grade ever. She re orts her last bowel ove ent
was 2 days ago and denies any atus over the last 24 hours.
On exa ination, her te erature is 37.1°C, ulse 105 b ,
res irations 12 b , and blood ressure 158/60 Hg. Her
abdo en is slightly distended, di usely tender to al ation
without rebound or guarding, and has hy eractive bowel
sounds. On at late and u right views o the abdo en, there
are dilated loo s o s all bowel and ulti le air uid levels.
Question 22.4.1 Which o the ollowing is true regarding
this patient’s current disease process?
A) She most likely has a closed-loop small bowel obstruction
(SBO)
B) She most likely has an extramural source o obstruction
C) Dilated loops o small bowel are de ned as being > 5 cm in
diameter on plain lm
D) Both partial and complete bowel obstructions reveal no
colonic gas on plain lm
CHAPTER 22 • Ca RE o t h E Su Rg iCa l Pa t iENt 603
Answer 22.4.1 The correct answer is “B.” T is patient most
likely has an external source o obstruction. Bowel obstructions
are divided into two classes: mechanical and unctional (also
known as pseudo-obstruction, ileus, or neurogenic obstruc-
tion). Mechanical obstructions are urther classi ed by both
their location and etiology. Possible etiologies include intralu-
minal bodies (e.g., gallstone ileus or oreign body), intramural
lesions (e.g., tumor or intussusception), and extramural lesions
(e.g., adhesions). Obstructions can urther be divided into open
and closed loop. Open-loop obstructions have an outlet or
gas and secretion relie (e.g., vomiting) whereas closed-loop
obstructions block both in ow and out ow to an area. Closed-
loop obstructions, like bowel torsion or volvulus, cause acute,
severe abdominal pain, and generally require urgent surgical
intervention.
Bowel obstruction presents with crampy, intermittent
abdominal pain, vomiting, distention, and obstipation. History
o en includes previous abdominal surgery. Depending on the
degree o obstruction and its duration, there may be hyperac-
tive bowel sounds, high-pitched bowel sounds, or decreased/
absent bowel sounds. An upright abdominal plain lm or lateral
recumbent abdominal lm con rms diagnosis with ndings o
dilated loops o small bowel (bowel > 3 cm in diameter) on the
at plate and air uid levels on the upright or decubitus lm.
However, the sensitivity, speci city, and accuracy o plain radio-
graphs are 79% to 83%, 67 to 83%, and 64% to 82%, respec-
tively. C scan is ore sensitive and s eci c (93%and 100%)
or obstruction than are lain l s and will o en reveal the
source o the obstruction. However, C should be reserved or
patients in whom the diagnosis is unclear. Patients with a com-
plete SBO will lack air in the colon on plain lm; but remem-
ber that air can be introduced into the rectum during a rectal
examination.
Question 22.4.2 Which o the ollowing cause ileus?
A) Burns
B) Spinal cord injury
C) Hypokalemia
D) Pneumonia
E) All o the above can cause an ileus
Answer 22.4.2 The correct answer is “E.” All o the above can
cause an ileus. Additional causes include peritonitis, pancreatitis,
uremia, surgery, and narcotics.
You diagnose a SBO, which you believe is ost likely related
to adhesion or ation a er he icolecto y.
Question 22.4.3 Which o the ollowing is INCORRECT
regarding the management o bowel obstruction?
A) Initial treatment orders should include maintaining the
patient NPO, IV uid resuscitation, and electrolyte replace-
ment as needed
B) T is patient should undergo emergent surgical intervention
C) I she has ever or leukocytosis, she should undergo surgical
intervention
604 a Mil Y MEDiCiNE EXa MiNa t io N & Bo a RD REViEW
D) I she requires surgery, broad-spectrum antibiotics to cover
anaerobes and Gram-negative aerobes should be adminis-
tered perioperatively
Answer 22.4.3 The correct answer is “B.” Peritoneal adhesions
account or more than hal o all SBOs. Up to 80% o episodes o
SBO caused by adhesions resolve without surgical intervention.
Initial treatment includes restricting oral intake, IV uid resus-
citation with normal saline, and electrolyte correction. T e goal
is to prevent small bowel strangulation. Patients can be sa ely
observed i there is no evidence o strangulation. Indications
o strangulation include rapidly progressing abdominal pain
or distention, development o peritoneal ndings, ever, dimin-
ished urine output, leukocytosis, hyperamylasemia, metabolic
acidosis, and persistent obstruction. Co lete bowel obstruc-
tion, and closed-loop obstructions, should always be treated sur-
gically. Also, patients with de novo obstruction (e.g., no history
o laparotomy) usually require surgical intervention. I surgery is
necessary, broad-spectrum antibiotics that cover anaerobes and
Gram-negative aerobes should be administered perioperatively
to reduce wound in ection and abdominal sepsis rates.
HELPFUL TIP:
a n Ng be s r d n y sed n SBo , e
se s p n . a n Ng be s nd c ed e p ev -
e v m n , d s en n, e c., b d es n s en e
res n e SBo .
HELPFUL TIP:
Remember p en -c n r ed n es (PCa ) s
e m s e ec ve m d y r re n p n n e
p s per ve p en nd n m ny er c nd ns
(e. ., p ncre s, c e c es syndr me). S de e ec s
n rc cs m y nc de r n ry re en n n dd n
c ns p n r resp r ry depress n.
Objectives: Did you learn to . . .
• a ssess bd m n p n nd rec n ze n c e bd men?
• Pr v de ppr pr e per per ve m n emen r s r n-
es n (g i) s r ery?
• iden y nd re sm b we bs r c n er bd m n
s r ery?
CASE 22.5
Mr. and Ms. Biggs have always been “big boned.” T ey have
decided that weight reduction surgery is the thing or the .
However, they are concerned that, or the rst ti e in their
lives, they ay not be big enough.
Question 22.5.1 Which o the ollowing is NOT a necessary
condition or weight loss surgery?
A) BMI ≥ 40 kg/m 2 regardless o the presence o weight-related
disease
B) BMI ≥ 35 kg/m2 without the presence o weight-related disease
C) BMI ≥ 35 kg/m 2 plus other weight-related disease such as
sleep apnea, diabetes, severe joint disease, or weight-related
cardiomyopathy
D) Failure to control weight with diet and other medical inter-
ventions
Answer 22.5.1 The correct answer is “B.” A BMI o ≥ 40 kg/m 2
(not ≥ 35 kg/m 2) alone is considered an appropriate weight or
surgical intervention in the absence o other co orbidities. As
noted above, a BMI o ≥ 35 kg/m 2 with weight-related comor-
bidities is considered an indication or bariatric surgery. “D” is
worthy o comment. Most weight control drugs are airly useless.
However, ailure o medical therapy is considered a necessary
condition or bariatric surgery, as is an acceptable operative risk.
Much to their chagrin, they do eet the criteria or weight
loss surgery. T ere are several surgeons in town who er or
di erent techniques, including a Roux-en-Y and la aro-
sco ic banding.
Question 22.5.2 Which o the ollowing is NOT true?
A) Roux-en-Y is associated with greater weight loss at 1 year
B) Laparoscopic banding is associated with a greater need or
recurrent surgery compared with Roux-en-Y
C) Mortality is higher with Roux-en-Y and there are more hos-
pital admissions or complications
D) Vertical banded gastroplasty leads to sustained weight loss
and ew complications
Answer 22.5.2 The correct answer is “D.” Vertical banded gas-
troplasty does not lead to sustained weight loss and has many
complications including disruption o the staple line, GERD,
vomiting, and erosion o the band into the stomach. For this
reason, it has (or should have) allen out o avor. T e rest are
true. Roux-en-Y results in the best weight loss and requires
ewer recurrent surgeries when compared with laparoscopic
banding. However, the mortality rate is higher (0.06% vs. 0.17%)
or Roux-en-Y and there are more perioperative complications.
It also requires longer hospital stays.
Mr. and Ms. Biggs are wondering i this is worth the trouble
at all.
Question 22.5.3 You can tell them that:
A) Although they may lose weight, weight loss surgery does
nothing or their underlying diabetes, hypercholesterolemia,
and coronary artery disease (CAD)
B) T ere is no psychological or quality-o -li e bene t to weight
loss surgery: they will have the same existential crisis be ore
and a er the surgery
C) NSAIDs are relatively contraindicated a er weight loss
surgery
D) Dumping syndrome is more common a er laparoscopic
banding than with Roux-en-Y
E) T ere is rarely a need or supplemental vitamins a er bariatric
surgery

Answer 22.5.3 The correct answer is “C.” T e rate o gastric
ulcers rom NSAIDs is higher a er bariatric surgery. T e rest are
not true. Weight loss does improve cholesterol, CAD, DM, etc.,
so “A” is incorrect. Additionally, there is both a psychological and
quality-o -li e bene t (“B”). Finally, dumping syndrome is com-
monly seen a er a Roux-en-Y but not with laparoscopic band-
ing (“D”) and most patients will need supplemental vitamins
(“E”). Vitamin de ciencies a er bariatric surgery are common,
especially olic acid, and de ciencies are more o a concern with
Roux-en-Y procedures. However, supplementation is recom-
mended or all post bariatric surgery patients.
HELPFUL TIP:
C e s s s s c mm n er b r r c s r ery,
espec y R x-en-Y, nd cc rs s res r pd
we ss.
A er their o erations, they return to see you. Mr. Biggs (who
o ted or the Roux-en-Y rocedure and who is changing
his na e to Mr. Little) co lains o recurrent ost randial
colicky abdo inal ain, dia horesis, nausea, diarrhea, and
tachycardia. His wi e, who went or the la arosco ic banding,
has no such sy to s. You ake the diagnosis o “du ing
syndro e.”
Question 22.5.4 Your advice is to:
A) Start an anticholinergic to reduce stomach emptying
B) Increase the content o simple sugars to quickly raise the
blood sugar with meals
C) Increase the size o eedings a bit in order to increase the
amount o ood available or digestion
D) Separate solid rom liquid intake or at least 30 minutes (no
beer with that pizza!)
E) None o the above
Answer 22.5.4 The correct answer is “D.” Separating liquid
rom solid intake by 30 minutes may help to reduce dumping
syndrome. T e others are incorrect. While theoretically plau-
sible, anticholinergics have not been shown to be o bene t in
dumping syndrome (nor has octreotide). Additionally, small
and requent meals devoid o si le sugars are the way to go.
T e symptoms seem to be related to the rapid transit o simple
sugars into the bowel. Smaller volume meals without simple
sugars mitigate the problem.
HELPFUL TIP:
N r n de c enc es w n b r r c s r ery c n
res r m w d n ke, d n er nces, r exces-
s ve v m n . a s s c , e w n b r ry es s re
rec mmended be per rmed 3, 6, nd 12 m n s
nd en nn y: CBC, b s c me b c p ne w c -
c m, r n s d es, v m n B1 ( m ne), v m n B12,
e, ver enzymes, b m n, p d pr e, z nc, nd
c pper.
CHAPTER 22 • Ca RE o t h E Su Rg iCa l Pa t iENt 605
HELPFUL TIP: An Orch est ra Cond uctor?
“M es r ” (yes, s e n me) s s r c y mp n -
ed v ss m r n err p s e s n ev -
s e br n s red c n n er. i s e s me
nd c ns s er s r c ec n q es nd e ds 8%
m re we ss n se n e s m r p.
Objectives: Did you learn to . . .
• Rec n ze e nd c ns r b r r c s r ery?
• Descr be s me d eren ec n q es r b r r c s r ery nd
e r pr s nd c ns?
• Pr v de n - erm m n emen e b r r c s r ery
p en nd d mp n syndr me?
CASE 22.6
A 24-year-old ale resents to your clinic with a 5-day his-
tory o rectal bleeding. For several years, he has had hard
stools but has develo ed rectal bleeding in the last ew days.
In addition, he has severe, inter ittent, and cra y abdo i-
nal ain that he thinks is due to consti ation. He re orts a
ild ever.
On exa ination, te erature is 37.9°C, ulse 95 b ,
res irations 12 b , and blood ressure 108/78 Hg. His
abdo en is nontender and without guarding or rebound
tenderness. Anosco y reveals gross blood and two internal
he orrhoids.
Question 22.6.1 Regarding hemorrhoids in general, which
o the ollowing is true?
A) Patients with hemorrhoids most commonly present or peri-
anal burning, itching, swelling, and pain
B) A grade III hemorrhoid can be reduced manually
C) I a patient under the age o 50 with rectal bleeding is ound
to have hemorrhoid on examination, urther studies are not
indicated
D) Because they are above the dentate line, strangulated inter-
nal hemorrhoids are not pain ul
Answer 22.6.1 The correct answer is “B.” Grade III hemor-
rhoids can be reduced manually. Hemorrhoids are normal
vascular structures in the anal canal; however, the venules can
become engorged and symptoms such as pain, bleeding, and
itching may result. wo types o hemorrhoids exist: external
hemorrhoids derived rom the in erior hemorrhoidal plexus
below the dentate line and internal hemorrhoids derived rom
the anal cushions above the dentate line. Internal hemorrhoids
occur on the le lateral, right anterior, and right posterior anal
walls and are classi ed into grades I to IV. Grade I hemor-
rhoids slide below the dentate with straining but not through
the anus. Grade II hemorrhoids protrude the anus but spon-
taneously reduce, whereas Grade III hemorrhoids must be
manually reduced. Grade IV internal hemorrhoids cannot be
reduced. “A” is incorrect because most patients with symptom-
atic hemorrhoids present with painless rectal bleeding. “C” is
606 a Mil Y MEDiCiNE EXa MiNa t io N & Bo a RD REViEW
incorrect. You should consider urther evaluation (e.g., ex-
ible sigmoidoscopy and colonoscopy) in patients under the age
o 50 presenting with rectal bleeding, even i hemorrhoids are
present and are the likely source o bleeding. In patients older
than 50 with rectal bleeding, a ull colonoscopy is routinely rec-
ommended to rule out any cancerous process. “D” is incorrect.
Although most internal hemorrhoids do not cause pain, stran-
gulated internal hemorrhoids are very pain ul and can become
necrotic and gangrenous, requiring emergent surgery. Note that
strangulated is di erent rom thro bosed.
Question 22.6.2 Which o the ollowing would you NOT
consider as a treatment o this patient’s hemorrhoids?
A) Psyllium
B) Dicyclomine
C) Warm sitz baths
D) Short course o topical hydrocortisone
E) Increased water intake
Answer 22.6.2 The correct answer is “B.” Dicyclomine (Bentyl,
Antispas) is not indicated. Dicyclomine is an anticholinergic
and will contribute to constipation—exactly what you want to
avoid in hemorrhoids. “A” and “E” are the primary modes o
treatment. Psyllium, as well as a diet high in ber and water, will
reduce straining and thus reduces intra-abdominal pressure.
“C,” warm baths or showers (40°C), have been shown to reduce
anal canal pressures. “D,” a short course o topical hydrocorti-
sone (e.g., Anusol HC), may be o bene t. Long-term topical
steroids are contraindicated. Finally, good hygiene and analge-
sia should be prescribed as needed.
HELPFUL TIP:
M s symp m c em rr ds resp nd c nserv -
ve me s res nd s r ery s d n be per rmed n-
ess c nserv ve me s res r er nd c ns ex s
(e. ., s r n n).
Question 22.6.3 Which o the ollowing is true about treat-
ing hemorrhoids surgically?
A) Irritable bowel syndrome is a relative contraindication to
hemorrhoid surgery
B) It is best to ligate all hemorrhoids in a single o ce visit
C) Band ligation results in sloughing o hemorrhoid in about 1
to 2 weeks
D) Following excision, thrombosed external hemorrhoids
should be closed to prevent bleeding
Answer 22.6.3 The correct answer is “C.” Rubber-band liga-
tion generally results in the sloughing o the hemorrhoid in 1 to
2 weeks. “A” is incorrect. In ammatory bowel disease (IBD)—
not irritable bowel syndrome (IBS)—is a relative contraindi-
cation to the surgical treatment o hemorrhoids. Other con-
traindications to o ce-based hemorrhoidectomy procedures
include bleeding diathesis, pregnancy and the period immedi-
ately postpartum, anorectal ssures, active anorectal in ections,
AIDS or other immunode cient states, portal hypertension,
rectal wall prolapse, and anorectal tumors. Complications o
hemorrhoidectomy include pain, signi cant bleeding with
sloughing, thrombosis o external hemorrhoids, and very
rarely sepsis with pelvic cellulitis. “B” is incorrect. Although
evidence is scarce, standard o care dictates that only one hem-
orrhoid be ligated in a single o ce visit (due to concerns about
excessive tissue necrosis). “D” is incorrect. Patients who pres-
ent with external hemorrhoids that are pain ul, tender, swol-
len, with bluish discoloration have thrombosis. I the patient
presents within 48 hours o thrombosis, the thrombus should
be expressed. It is important not to close the hemorrhoid once
the clot is expressed. In act, a small ellipse o the hemorrhoid
should be removed to acilitate continued drainage and prevent
re-accumulation o clot.
You rescribe conservative treat ent or your atient’s he -
orrhoids, and since he does not return or his next sched-
uled a oint ent, you assu e he is doing well. You see hi
again 6 onths later. He re orts that he had indeed healed.
Although he still takes sylliu , he began having ain ul
bowel ove ents with blood-streaked stool 2 days ago.
U on exa ination o the anus, you nd a ssure.
Question 22.6.4 All o the ollowing ndings would lead
you to consider Crohn disease EXCEPT:
A) Posterior midline ssure
B) Painless ssure
C) Multiple ssures
D) Nonhealing ssure
Answer 22.6.4 The correct answer is “A.” T e posterior (dorsal)
midline is where solitary ssures, unrelated to IBD, are typically
located. Fissures in any other location should raise suspicion or
Crohn disease. “B,” “C,” and “D” are also suggestive o Crohn
disease.
Question 22.6.5 In a patient with an uncomplicated, initial
anal ssure, what do you recommend or f rst-line therapy?
A) Lord dilation
B) Botulinum toxin injections
C) opical nitroglycerin
D) Oral psyllium
E) Oral ni edipine
Answer 22.6.5 The correct answer is “D.” All o the options
are employed or treating anal ssures. However, in patients
with an uncomplicated, initial anal ssure, it seems prudent
to initiate conservative therapy (e.g., psyllium, dietary ber,
water, and warm soaks) prior to proceeding to more invasive
measures. Most ssures will respond to conservative mea-
sures. Generally, healing takes 2 to 4 weeks. In addition to the
treatments listed, topical diltiazem and topical ni edipine are
also use ul as are various surgical approaches. Lord dilation
deserves special mention as a relatively arcane procedure or
stretching the anal sphincter muscle (under anesthesia, we
hope!).

You note that this atient’s ssure is dee , ulcerating, and
located at the le lateral as ect o the anus. Given this exa i-
nation, you are concerned about Crohn disease. You brie y
consider what you know about IBD.
Question 22.6.6 Which o the ollowing is true o IBD?
A) Ulcerative colitis is primarily a diagnosis o young males
B) Crohn disease can be isolated to the colon
C) Ulcerative colitis is generally associated with deep colonic
ulcerations and transmural in ammation while those o
Crohn disease are more super cial
D) Crohn disease is more common in A rican Americans, while
ulcerative colitis is more common in Caucasians
Answer 22.6.6 The correct answer is “B.” Although o en
thought o as a disease o the entire GI tract, Crohn disease can
be isolated to the colon. “A” is incorrect because ulcerative colitis
is evenly distributed between men and women with a similar
incidence in each. “C” is incorrect. Crohn disease is associated
with deeper ulcerations and transmural in ammation leading
to stulae and strictures, etc. “D” is incorrect. In general, IBD
is more common in Caucasians than other races. See Chapter 7
or more questions about Crohn disease.
Objectives: Did you learn to . . .
• C r c er ze em rr ds b sed n c n?
• g r de n ern em rr ds b sed n sever y?
• M n e em rr ds w c nserv ve nd s r c re -
men s?
• t re n nc mp c ed n f ss re?
• Rec n ze n f ss res s p en s ns Cr n d se se?
CASE 22.7
A 58-year-old e ale resents to your clinic or a lu
ound on routine breast sel -exa ination. Her older sister
died ro breast cancer, and she is very concerned about
the ossibility o breast cancer in hersel . She never isses
her onthly breast exa ination and notes she has never
elt this lu be ore. She rst noticed the lu 2 weeks
ago, and it has not changed in size or consistency since
that ti e. Consistent with her ersonal health care goals
but totally inconsistent with any current guidelines, she
has had yearly a ogra s since age 40 that have always
been nor al. She denies any weight loss or atigue and
re orts being ost eno ausal or the last 5 years. She re-
viously took co bination hor one re lace ent thera y,
which she discontinued last year.
On exa ination, her breasts a ear sy etrical with
no skin abnor alities. T e ni les are sy etric in size,
sha e, and color without retraction or discharge. You al-
ate a s all, ea-sized thickening in u er outer quad-
rant o the right breast. T is is the lu that she noticed
2 weeks ago. It is xed to the dee as ect o the chest wall,
so you have a hard ti e delineating whether the borders
are s ooth.
CHAPTER 22 • Ca RE o t h E Su Rg iCa l Pa t iENt 607
Question 22.7.1 Regarding breast lumps, which one o the
ollowing is FALSE?
A) Abnormal screening mammography is the most common
presentation o breast carcinoma
B) Cysts are more common in premenopausal women than
postmenopausal women
C) A history o broadenoma is associated with an increased
risk o breast cancer
D) A radiographic oil cyst is pathognomonic or at necrosis
Answer 22.7.1 The correct answer is “A.” T e most common
presentation o breast carcinoma is a breast lump elt by the
patient. Breast masses can be cysts, broadenomas, thickened
areas with brocystic change, at necrosis, and carcinoma.
“B” is true. Cysts primarily present when women are pre-
menopausal and are uncommon in the postmenopausal state,
unless the woman is taking hormone replacement. Cysts are
well-demarcated, mobile, and rm. T e diagnosis is con-
rmed with aspiration o nonbloody uid ollowed by com-
plete resolution o the mass. Fibroadenomas occur between
the ages o 20 and 50 and are described as rm, rubbery, and
mobile. T ey can be con rmed by characteristic ndings on
ultrasound and ne needle aspiration (FNA) i necessary. “C”
is also true. While historically believed to be entirely benign,
broadenomas are associated with a small but signi cant
increased risk or breast cancer. “D” is true. A radiographic
oil cyst (a circumscribed mass o mixed so -tissue density
and at with a rim that is o en calci ed) is due to at necrosis,
which occurs in areas o the breast that have been subject to
trauma, surgery, in ection, or radiation therapy. About hal
o the time, at necrosis has no precipitant. Oil cysts are most
common in the super cial aspects o pendulous breasts o
obese women. When an oil cyst is seen radiographically, no
urther evaluation is needed.
Your atient is concerned about her a ily history o breast
cancer. She asks about genetic testing.
Question 22.7.2 You are able to tell her that the BRCA 1
gene is associated with which o the ollowing?
A) Breast cancer
B) Uterine cancer
C) Ovarian cancer
D) A and B
E) A and C.
Answer 22.7.2 The correct answer is “E.” T e BRCA (BReast
CAncer) 1 and 2 genes are related to amilial breast cancer, and
BRCA 1 is also associated with an increased risk o ovarian can-
cer. T ey are not associated with uterine cancer. T e use ulness
o testing or these genes in primary care is questionable, and
they cannot be relied upon or general screening or diagnostic
purposes.
You are sus icious that this atient’s ass ay be cancer, and
you order a ogra hy and ultrasound. However, these
studies show no ass. When your atient returns to discuss
608 a Mil Y MEDiCiNE EXa MiNa t io N & Bo a RD REViEW
her test results, you exa ine her again. T e ass is still al-
able and essentially unchanged.
Question 22.7.3 The next best step in management o this
patient is:
A) Breast examination and mammogram every 6 months
B) Breast examination and mammogram every 3 months
C) Re erral to a surgeon to consider excisional biopsy
D) Ultrasound-guided needle biopsy
E) Return to normal screening
Answer 22.7.3 The correct answer is “C.” A palpable mass that
is suspicious or cancer cannot be ignored even in the presence
o negative radiologic studies. No other option is acceptable,
nor would any other option be de ensible i this patient were
to develop overt breast cancer. “D” would be a viable option i a
mass were identi ed on ultrasound, but none was.
When aking diagnostic decisions regarding breast asses,
age atters.
Question 22.7.4 Which o the ollowing is NOT TRUE about
how a diagnostic evaluation should proceed?
A) In women < 40 years o age, lesions that appear benign on
ultrasound may be ollowed simply by a repeat examination
in 3 months
B) In women > 40 years o age, lesions that appear benign on
ultrasound and cytological analysis need no ollow-up
C) In women > 40 years o age where a lesion is palpated but
not seen on mammogram or ultrasound, excision should
ollow i clinical suspicion dictates
D) In women > 40 years o age who have a palpable lesion and
desire de nitive removal, no urther testing is necessary pri-
or to excisional biopsy
Answer 22.7.4 The correct answer is “B.” Women over the age
40 should be ollowed up in 3 months even with negative cytol-
ogy. Clinical diagnosis o carcinoma has accuracy o 60% to
85%. Extent o evaluation, however, is driven by clinical suspi-
cion. Radiologic studies should be ordered as indicated. A nee-
dle biopsy either by FNA or core needle biopsy is the next step
in evaluation o solid tumor masses. Needle diagnosis o ers the
advantages o being simple, quick, inexpensive, relatively non-
invasive, highly available, and an accurate way o diagnosing
atypical cells.
Because o the risk or carcinoma, algorithms or evaluation
o solid tumors di er between women < 40 years versus those
40 years and older. Women < 40 years who desire observation
should be evaluated by ultrasound and/or FNA. I either is sus-
picious, surgical excision should be per ormed. I there is a neg-
ative FNA, the patient can be ollowed up in 3 months.
In women 40 years o age or older, palpable masses should
urther be evaluated by ultrasound and mammography. I
the lesion cannot be identi ed radiographically, it should be
removed by excision i clinical suspicion dictates. I the lesion
appears benign by radiography, it can be ollowed by FNA.
T ose with atypia on FNA should be re erred or excision. I
the lesion appears benign both radiographically and cytologi-
cally, it still warrants urther ollow-up in 3 months by clinical
examination. “D” is correct. All women with a palpable breast
mass who desire an excisional biopsy can proceed directly to
de nitive removal, regardless o age.
You er or an FNA, which the cyto athologist reads
as “ robable alignancy.” You recall ro revious vis-
its that the atient’s older sister had breast cancer. Addi-
tionally, your atient went through eno ause at age 53,
and used hor one re lace ent thera y or 5 years. You
obtain urther history, including a history o enarche at
14 years o age and the act that the atient has never been
regnant.
Question 22.7.5 Which o these actors DOES NOT contrib-
ute to an increased risk o breast cancer in THIS patient?
A) Her nulliparity
B) Her age at menarche
C) Her amily history
D) Her age at menopause
E) Her history o hormone replacement
Answer 22.7.5 The correct answer is “B.” T e risk o breast
cancer is roughly associated with the li etime exposure to
estrogen. T is patient’s age at menarche is in the mid-to-
late age range and is thus not a risk actor or breast cancer.
Younger age at menarche (e.g., 10 years old) is associated with
an increased risk o breast cancer. Nulliparity and greater age
at rst pregnancy are associated with an increased risk, as is
greater age at menopause. A history o a rst-degree relative
with breast cancer is a strong risk actor. Finally, as demon-
strated in the Women’s Health Initiative, estrogen/progesterone
replacement therapy (HR ) is associated with an increased risk
o breast cancer (an excess o about 8 breast cancers per 10,000
women treated with HR ).
While you wait or de nitive athology results, you consider
the di erent ty es o breast cancer that this atient ight
have.
Question 22.7.6 Regarding various types o breast cancer,
all o the ollowing are true EXCEPT:
A) Cystosarcoma phyllodes tumors are not always malignant
B) In ltrating lobular carcinoma is the most common histo-
logical type o invasive breast carcinoma
C) Paget disease o the breast clinically appears eczematous
D) Sarcomas, lymphomas, melanomas, and angiosarcomas are
all possible causes o cancer in the breast
Answer 22.7.6 The correct answer is “B.” In ltrating ductal
(not lobular) carcinoma is the most common histological type
o invasive breast cancer. Invasive breast carcinoma includes
a wide variety o histological diseases. In ltrating ductal car-
cinoma accounts or 65% to 80% o breast cancers, whereas
in ltrating lobular carcinoma is the second most requent,
accounting or 10% o breast cancers. “A” is true. Cystosarcoma
 CHAPTER 22 • Ca RE o t h E Su Rg iCa l Pa t iENt 609

phyllodes tumors, which have a clinical presentation similar Objectives: Did you learn to . . .
to broadenomas but are more rapidly growing, may be either • g ener e d eren d n ses r bre s m sses?
malignant or benign. Yet the malignant nature o cystosarcoma • Ev e p en w bre s m ss?
phyllodes is sometimes di cult to determine on cytology, and • iden y r sk c rs r bre s c ncer?
the lesions may require a wide excision. “C,” Paget disease o the • Descr be sever ypes bre s c ncers?
breast, is a rare orm o breast cancer with eczematous changes • Descr be c rs re sed es b s pr n s s n
o the nipple, including itching, erythema, and nipple discharge. bre s c ncer?
“D” is true as well. Many other malignancies may occur in
the breast, including sarcomas, lymphomas, melanomas, and
angiosarcomas. QUICK QUIZ: BREa St Ca NCER RiSK

T e athology results are nal and show in ltrating ductal A 50-year-old emale presents or a routine physical. She wants
carcino a. Your atient will see a breast surgeon next week. to know her risk o developing breast cancer. You want to give
As you await the results o surgery, you consider her rog- her a more accurate picture, and you decide to use the Gail
nosis. model.

Question 22.7.7 All o the ollowing are avorable prognos- When taking her history, you must ask about all o the ollowing
tic indicators in breast cancer EXCEPT: EXCEP :
A) Hormone receptor negative A) Number o rst-degree relatives with breast cancer
B) Absence o axillary nodal involvement B) Age at rst menstrual period
C) Low-grade tumor C) Number o breast biopsies
D) Pure tubular, mucinous, or medullary histological types D) Age at rst live birth
E) umor size < 1 cm E) Number o live births

Answer 22.7.7 The correct answer is “A.” Patients whose The correct answer is “E.” T e Gail model is a computer pro-
tumors are hormone receptor negative have worse outcomes gram that estimates a woman’s chance o developing breast
than do patients whose tumors are hormone receptor positive. cancer. Factors that a ect the score include the number o
“B,” absence o axillary nodal involvement, is obviously a bet- rst-degree relatives with breast cancer, current age, age o
ter prognostic actor than the presence o nodal involvement. rst menstrual period, number o breast biopsies, BRCA gene
In act, axillary lymph node status is the single most important status, age at rst live birth, race, and history o atypia in a
predictor o overall survival in breast cancer. “C,” low tumor biopsy. T is tool may be use ul in patients who are candidates
grade, is also a good prognostic actor. “D,” patients with a single or tamoxi en or breast cancer prophylaxis. However, the Gail
cell type have a better prognosis as well. “E” is true. A very use- score is uch better at redicting the likelihood o breast
ul predictor o tumor behavior is tumor size, and tumor size cancer in o ulations than in any individual. So, realize that
< 1 cm is a positive prognostic sign. it has li itations. T e National Cancer Institute maintains a
website or the Gail model calculation, located at http://bcra.
nci.nih.gov/brc/q1.htm.
HELPFUL TIP:
t m rs c n be e er es r en r pr es er ne recep- CASE 22.8
r p s ve r ne ve nd h er2/ne ( yr s ne-pr e n
An ortho edic colleague asks you to consult on a 64-year-old
k n se recep r) p s ve r ne ve. t m rs re
ale rior to an elective total hi re lace ent. T e surgery
p s ve r es r en nd/ r pr es er ne recep rs re
is scheduled or 3 onths ro now. T e atient is a s oker
e m s ke y resp nd rm n er py (e. .,
with diabetes ellitus ty e 2 and has recently had a cardiac
m x en). t m rs re p s ve r h er2/ne re
catheterization that showed signi cant, but nonby assable,
m s ke y resp nd yr s ne k n se n b rs (e. .,
coronary disease. He is asy to atic and is able to walk
h ercep n).
stairs without dys nea or chest ain. T e surgeon would like
so e erio erative reco endations.

HELPFUL (BUT DISTURBING) TIP:

Question 22.8.1 You would recommend all o the ollowing
i rns ppr x m e y 20% w men w
EXCEPT:
nder bre s -c nserv n s r ery r bre s c ncer
A) T e patient should stop smoking 4 weeks be ore surgery
need repe s r ery. a dd n y, 15% se w
B) T e patient should have preoperative and postoperative
p s ve m r ns d d n r re-exc s n. D s rb n
β -blockers i the pulmonary status allows it
w m j r mp c ns r n rmed c nsen (JAMA.
C) T e patient should have a ECG done
2012;307:467).
D) T e patient should have his hemoglobin/hematocrit drawn
E) T e patient should have his creatinine measured
610 a Mil Y MEDiCiNE EXa MiNa t io N & Bo a RD REViEW

TABLE 22-1 PREOPERATIVE STUDIES AND THEIR INDICATIONS

Tests Indications
B n/cre n ne o ver 60; s ry ren , c rd c, r v sc r d se se

CBC/h &h P ss b e em c r n ec s pr cess; s n f c n b d ss pred c ed

C n s d es S m ver d se se, s ry c p y, p ss b e DiC, n c n, c b se

ECg /CXR a s nd c ed by s ry nd p ys c (e. ., ex cerb n p m n ry d se se w c )

E ec r y es D re c se, s ry ren r c rd c d se se, p ss b e de ydr n by s ry r p ys c

g c se D be cs, bese p en s, nder n v sc r pr ced res, er re s n r ncre sed c se (e. ., s er ds)

l ver enzymes h s ry ver d se se r s m ver d se se

u r ne β - Cg i nd c ed by s ry

u r n ys s Pre n ncy, d be es, r c s r ery, symp m cp en s

a d p ed r m ee y Ma , C ns CS, e . Pre per ve es n be re n nc rd c s r ery: de nes nd rec mmend ns. Am Fam Physician. 2013;87(6):
414–418.

Answer 22.8.1 The correct answer is “A.” Paradoxically, unless
patients stop smoking 8 weeks or more be ore surgery, the risk
o adverse pulmonary outcomes is increased. T e cause o this
phenomenon remains unclear but may occur because the cilia
are able to mobilize material in the lungs. “B” is true. T e use
o pre-, intra-, and postoperative β -blockers is well supported
or patients with CAD. One o the most serious intraoperative
events is a myocardial in arction. β -Blockers have been shown
in multiple studies to reduce this risk and to improve outcomes
i the patient has an elevated risk or a myocardial in arction.
Note, however, that a β-blocker should be started well in
advance o the surgery and not just on the day o surgery.
It is critical to assure that the patient is on a stable dose o a
β -blocker at the time o surgery. Starting the β -blocker too close
to surgery may increase the risk o stroke, likely secondary to
intraoperative hypotension. While “C,” “D,” and “E” are true, a
lot o other routine preoperative assessments are not supported
in the literature. See able 22-1 and able 22-2 or the appropri-
ate evaluation o the preoperative patient.
Question 22.8.2 Which o the ollowing is ef ective or the
prevention o postoperative DVT?
A) Early mobilization
B) Enoxaparin 30 mg subcutaneously every 12 hours
C) Enoxaparin 40 mg subcutaneously every 24 hours
D) Heparin 5,000 Units subcutaneously every 12 hours
E) All o the above
TABLE 22-2 MAYO CLINIC PREOPERATIVE GUIDELINES
Age in Years Studies Indicated
a e < 40 N r ne pre per ve ev
req red
a e 40–59 ECg , cre n ne, nd c se
a e 60 r der ECg , c es r d r p , CBC, cre
c se
Answer 22.8.2 The correct answer is “E.” All o the modali-
ties listed above can prevent the development o DV . Aspirin
and low-dose war arin (target INR 1.5) are also e ective but less
so than heparin or enoxaparin. Sequential compression devices
(SCDs) may also be used. Subcutaneous heparin may require
ID dosing in larger patients.
HELPFUL TIP:
Recen d s es s r ded c mpress n s ck-
n s re m r n y bene c bes r DVt preven n
nd m y e d ncre sed sk n bre kd wn, e c. r s
re s n, n erm en pne m c c mpress n w SCDs
s pre erred (Ann Surg. 2010;251(3):393–396 nd Lancet.
2009;373:1958–1965).
T e atient undergoes his hi re lace ent, and his osto era-
tive ECG is nor al. Four hours a er surgery, he develo s ild
res iratory distress, a ever, and cough. On chest x-ray, there is a
right lower lobe in ltrate. T ere is no evidence o uid overload.
Question 22.8.3 Which o the ollowing is the most likely
cause o this patient’s ever and in ltrate?
A) Pneumococcus
B) Gram-negative organisms
C) Atelectasis
D) Aspiration pneumonitis
E) Aspiration pneumonia
Answer 22.8.3 The correct answer is “D.” In the hours a er sur-
gery, an aspiration pneumonitis would be the most likely cause
n o this patient’s current ndings. Aspiration pneumonitis occurs
when there is aspiration o gastric contents with a pH o less than
2.5. In order or aspiration pneumonitis to develop, the volume
o aspirate needs to be at least 1 to 4 mL/kg o stomach contents.
n ne, Aspiration pneumonitis develops over a matter o hours. In con-
trast, pneumococcal and Gram-negative pneumonias generally
 CHAPTER 22 • Ca RE o t h E Su Rg iCa l Pa t iENt 611

develop several days a er surgery (unless a subclinical pneumo-
nia was present at the time o surgery). Aspiration pneumonia is
caused by anaerobes and mixed ora and develops slowly over
days to a week. Atelectasis warrants special mention. Atelectasis
does not cause ever. Both atelectasis and ever occur requently
in the postoperative period, but their occurrence together is
most likely due to chance. T e old adage about atelectasis and
ever has been shown to be untrue. T us, in the postsurgical
patient with ever, look or another cause besides atelectasis.
C) It should be treated with antibiotics that cover or anaerobes
D) It tends to resolve in about 7 days
Answer 22.8.5 The correct answer is “C.” Aspiration pneumo-
nitis is a chemical process that is unrelated to in ection. T us,
aspiration pneumonitis does not need to be treated with antibi-
otics at all (although it usually is as a practical matter—since we
are chicken). T e rest o the options are true.

Question 22.8.4 O the ollowing, which generally IS NOT a HELPFUL TIP:

cause o postoperative ever in the rst 48 hours? t e erm “ sp r n pne m n ” s sed d eren y n
A) Malignant hyperthermia e d eren p r s e er re. t s e ds s me
B) Surgical “trauma” (e.g., cutting through muscle) c n s n. S me se e erm nc de pne m -
C) Wound in ection n s c sed by sp r n. M ny e c ses nc ded
D) Hyperthyroidism n s de n n re c sed by m ny e s me r-
E) Drug ever n sms c se c mm n y- cq red pne m n ,
nc d n pneumococcus nd Haemophilus in luenzae.
Answer 22.8.4 The correct answer is “C.” Wound in ections t ese p en s end ve ever nd n r e, e c.,
generally are not ound in the rst 48 hours a er surgery. All o w c deve p w n 2 d ys e sp r n. r
the rest can be ound either immediately a er surgery (malig- ese p en s, e ppr pr e n b cs s d n-
nant hyperthermia, hyperthyroidism, drug ever, etc.) or soon c de en s c ver sp - cq red r n sms,
therea er ( ever rom surgical trauma secondary to the release espec y g r m-ne ve r n sms, nc d n Pseu-
o cytokines). able 22-3 summarizes the time course and causes domonas.
o postoperative ever. o er r ps m y de ne sp r n pne m n s
n er b c n ec ns res r m sp r n. t ese
T e atient’s chest radiogra h is consistent with as iration p en s ve m re nd en c rse, w nse
neu onitis (in ltrate in the right lower lobe . . . yes, lower symp ms ver d ys weeks. g ener y, ese p en s
lobe is ore co on). ve p r en sp m, w wer be nv vemen
m s c mm n. t e pper bes m y be nv ved e
Question 22.8.5 Which o the ollowing is NOT TRUE with p en sp r es w e rec mben . t ese p en s m y
regard to aspiration pneumonitis? ve p ym cr b n ec n nc d n Peptostrep-
A) It can progress to ARDS tococcus, Fusobacterium, Bacteroides, nd Prevotella.
B) Patients with aspiration pneumonitis present with ever, t ese p en s s d be re ed w n b cs s c
dyspnea, bronchospasm, and hypoxia s c nd myc n, mp c n/s b c m (u n syn), r
m x c n/c v n e (a men n); v d me r n d -
z e s s n e en d e re r e.
TABLE 22-3 CAUSES OF POSTOPERATIVE FEVER
S , w en y re d e er re b sp r n
Immediate (within hours o surgery): pne m n , be s re y kn w w c de n n e -
• Dr s r b d pr d c s: g ener y yp ens n, r s , e c. rs re s n , bec se e descr p n e d se se
• t r m r m s r ery r be re s r ery: Ev den r m s ry
nd e re men s v ry.
• M n n yper erm : W n 30 m n es nes es nd c n
b m y be rs

Acute (f rst week a ter surgery):

HELPFUL TIP:
• N s c m n ec ns r ex ens n pre per ve n ec n
• C. dif cile n ec n Dr s r se e s r c ph (h 2-b ckers, pr n
• in b n p mp n b rs) ncre se e r sk p s per ve
• a sp r n pne m n ( nd Clostridium di icile). N rm y, e c d
• u t i: Espec y c r n c ndwe n r r cm n p n ph e s m c preven s c n z n w p -
• S r c s e n ec n ener y >1 week c se ever b m y
en c b c er . t s de ense s c mpr m sed w en e
cc r n 1s week. B r p a Strep nd Clostridium m y cc r
w n rs s r ery. s m c ph r ses. t s, n ec n w sp r n s m re
• a s : P ncre s, c w dr w , PE, Mi, r mb p eb s, ke y.

Subacute (1–4 weeks a ter surgery):

• iV nd cen r c e er s e n ec ns
• a n b c ss c ed d rr e , nc d n C. dif cile n ec n You treat the atient with uids and tracheal suction. How-
• Dr ever: β - c ms, s , ep r n, e c. ever, he re ains ebrile and tachycardic at about 128 b .
• DVt , PE, emb r m n b nes, p s c n, c e c es syn- T ere is no evidence o dehydration at this oint and he
dr me (SSa )
see s euvole ic.
612 a Mil Y MEDiCiNE EXa MiNa t io N & Bo a RD REViEW
Question 22.8.6 Which o the ollowing would be the most
appropriate rst step in the treatment o tachycardia in this
postsurgical patient?
A) Oral or rectal aspirin
B) Oral or rectal acetaminophen
C) IV β -blockers
D) IV uids
Answer 22.8.6 The correct answer is “B.” T e initial treatment
o this patient is acetaminophen. Reducing the ever and meta-
bolic stress will result in a reduction in the heart rate. “A” is not
the best choice since this patient is postsurgical. Giving aspi-
rin, an antiplatelet agent, may result in increased postoperative
bleeding. “C,” IV β -blockers, can be used and would be appro-
priate i the patient was having ischemic symptoms and needed
an immediate reduction in pulse. “D,” IV uid, is incorrect in
this patient who is already well hydrated (as stipulated in the
question). Note that IV uids are appropriate in postoperative
tachycardia i the patient is dehydrated.
T e atient’s ul onary status has i roved. T e surgeon
notices that the atient has hy erkale ia and thro bocyto-
enia. T e atient is on a nu ber o drugs osto eratively.
She is wondering which o these drugs is causing the roble .
Question 22.8.7 You let her know that the most likely cause
is:
A) β -Blockers
B) Albuterol
C) Aspirin
D) Morphine
E) Heparin
Answer 22.8.7 The correct answer is “E.” Heparin can cause
both hyperkalemia and thrombocytopenia (HI S, or heparin-
induced thrombocytopenia and thrombosis syndrome).
Hyperkalemia is caused by heparin’s ability to block the aldo-
sterone system and usually requires prolonged heparin use
(although in diabetics and those with renal ailure it may
occur more rapidly because o poor reserve). T rombocyto-
penia is caused by the development o antiplatelet antibod-
ies and occurs 5 to 10 days a er the start o heparin therapy
and is associated with thromboembolic phenomenon. Plate-
lets can get as low as 30,000 platelets/µL. Stop the heparin
and anticoagulate with a nonheparin agent (e.g., bilivarudin).
A non–immune-mediated thrombocytopenia also occurs
in up to 20% o individuals who receive heparin. T is mild
thrombocytopenia occurs within the rst 4 days o heparin
administration, resulting in a nadir o 100,000 platelets/µL
and no clinical consequences. “A,” β -blockers, may result in
hyperkalemia at high doses (via a β 1-receptor e ect inhibiting
renin release) but do not cause thrombocytopenia. “B,” alb-
uterol, can cause hypokalemia (as can other catecholamines)
by driving potassium intracellularly. However, albuterol does
not cause hyperkalemia or thrombocytopenia. Likewise, “D” is
incorrect because morphine is not associated with hyperkale-
mia or thrombocytopenia.
HELPFUL TIP:
h ep r n c n s c se p s per ve ever.
A er you sto the atient’s he arin, the thro bocyto enia
and hy erkale ia begin to resolve.
You start the atient on inter ittent leg co ression with
SCDs.
Question 22.8.8 Which o the ollowing is TRUE about the
use o heparin in patients with a history o heparin induced
thrombocytopenia?
A) A low-molecular-weight heparin (LMWH) should be used
in patients with a history o HI S
B) Heparin can be re-introduced once the HI S has been
treated with steroids
C) T e use o lepirudin and argatroban are contraindicated in
the treatment o HI S
D) Un ractionated heparin can be used during cardiopulmo-
nary bypass despite a previous history o a thrombocytope-
nic reaction to heparin i the patient is HI antibody nega-
tive
E) None o the above
Answer 22.8.8 The correct answer is “D.” Heparin can be
used during cardiopulmonary bypass despite a previous his-
tory o HI S. T e theory is that the development o enough
antibodies to reproduce thrombocytopenia takes several days
and patients will generally be on cardiopulmonary bypass
or only a matter o hours. T us, heparin can be used dur-
ing cardiopulmonary bypass even i there is a history o prior
heparin-induced thrombocytopenia. “A” is incorrect. LMWH
should be avoided in patients with strongly suspected (or
con rmed) HI S. It is recommended to consider an alter-
native, nonheparin anticoagulant (e.g., danaparoid, lepiru-
din, argatroban, ondaparinux, bivalirudin) over the urther
use o un ractionated heparin or LMWH. “C” is incorrect. In
act, the treatment o patients who need anticoagulation a er
HI S includes lepirudin and argatroban. T ese two agents
are direct thrombin inhibitors that do not cross-react with
heparin. Note that there are now a number o oral alternatives
to heparin including dabigatran, apixaban, and rivaroxaban.
Any o these would also be appropriate although dabigatran
requires 7 days o overlap with heparin so would not be the best
choice here….
Objectives: Did you learn to . . .
• Per rm pre per ve med c ev n?
• g ener e d eren d n s s r p s per ve ever?
• D n se nd re sp r n pne m n s?
• Rec n ze s me c mp c ns ep r n se?
• Emp y ppr pr e DVt pr p y x s me s res?
• M n e p en w ep r n- nd ced r mb cy pen ?

QUICKQUIZ: g ENERa l a NESt h ESia o RSu Rg ERY
Regarding anesthesia evaluation both preoperatively and intra-
operatively, which one o the ollowing is FALSE?
A) T erapeutic β -blockade should be administered preopera-
tively in vascular surgery patients who have underlying car-
diac disease in order to reduce perioperative and long-term
risks o cardiac events.
B) Minimum potassium be ore proceeding with elective coronary
artery bypass gra (CABG) surgery should be 3.5 mEq/L.
C) American Society o Anesthesiologists (ASA) Class IV des-
ignation includes patients who have well-controlled major
systemic disease.
D) Risks o anesthesia include allergic drug reactions, ailure to
intubate and provide adequate oxygenation and ventilation,
nerve damage, and malignant hyperthermia.
The correct answer is “C.” ASA Class IV includes patients who
have a systemic disease that is li e threatening and NO well
controlled. All the other options are true. “A” is true, but the
β -blocker should be started well in advance o the surgery and
the patient should be on a stable dose at the time o the sur-
gery. Starting the β -blocker at the time o the surgery worsens
outcomes as noted above. “B” is a correct statement. T ere are
increased perioperative arrhythmias and need or cardiac resus-
citation in patients with serum potassium levels < 3.5 mEq/L.
“D” is also a correct statement. Anesthesia risks include allergic
drug reactions, ailure to intubate and provide adequate oxygen-
ation and ventilation, nerve damage, and malignant hyperther-
mia, among others. Mortality rate rom anesthesia is surmised
to be about 1 to 2 per 10,000 patients. T e ASA classi cation
system is outlined in the able 22-4.
QUICK QUIZ: t h E Rh Yt h M iS g o NNa g Et Ch a
A 60-year-old male patient o yours is planning to undergo
CABG. A er you per orm a physical examination and labora-
tory tests, you discuss his case with the surgeon. She asks i you
will help to manage him postoperatively, and you agree. She
then asks i you are aware o his risk o arrhythmia during the
postoperative period.
TABLE 22-4 ASA PHYSICAL STATUS CLASSIFICATION
Class Description
C ss i he y pers n
C ss ii P en w m d sys em c d se se
C ss iii P en w severe sys em c d se se
C ss iV P en w severe sys em c d se se
nd re e
C ss V P en w s n ke y s rv ve r 24
w s r ery
CHAPTER 22 • Ca RE o t h E Su Rg iCa l Pa t iENt 613
You correctly reply:
A) “His risk or atrial brillation is less than it would be i he were
undergoing valve replacement simultaneously with CABG.”
B) “O the potential arrhythmias, he is most likely to encounter
bradycardia, which is the most common postoperatively.”
C) “Nonsustained ventricular tachycardia is highly unlikely in
this setting.”
D) “Keep his potassium low, around 3.0 mEq/L, and he will be
less likely to experience tachyarrhythmias.”
The correct answer is “A.” With CABG, the risk o postopera-
tive atrial utter or brillation is around 30%. T at risk almost
doubles when valve replacement is accomplished simultane-
ously with CABG. “B” is incorrect because bradyarrhythmias
occur less requently than tachyarrhythmias. “C” is incorrect.
Nonsustained ventricular tachycardia is extremely common
in the immediate postoperative period. “D” is also incorrect.
Plasma potassium levels < 3.5 mEq/L are associated with an
increased risk o tachyarrhythmias.
CASE 22.9
A 15-year-old ale resents to your o ce with a 3-day his-
tory o diarrhea and right lower quadrant abdo inal ain.
He has tenderness in the right lower quadrant with guard-
ing and rebound. He re ains a ebrile and has been hungry,
scar ng down ve bacon-wra ed waf es or break ast (but
less than his usual 6…). T e atient has no other signi cant
history. You decide that this atient ight have a endicitis,
so you draw so e labs. T e white blood cell count is nor al
(7,500/ 3
), as is the urinalysis.
Question 22.9.1 Which o the ollowing is true about appen-
dicitis?
A) A normal white count e ectively rules out the diagnosis o
appendicitis.
B) T e majority o patients with appendicitis present with ever.
C) T e absence o anorexia e ectively rules out appendicitis.
D) A ecalith is ound on radiograph in the majority o patients
with appendicitis.
E) None o the above.
Answer 22.9.1 The correct answer is “E.” None o the above is
true. aking these in order, 10% o patients with appendicitis
Risk o Operative
Mortality (%)
< 0.1
0.5
sc n r ed 4.4
s nc n r ed 23.5
rs, w r 50.8
614 a Mil Y MEDiCiNE EXa MiNa t io N & Bo a RD REViEW
have a normal white count, a minority o patients with appen-
dicitis present with ever (15% in one study), only 75% o
patients with appendicitis complain o anorexia, and a radio-
graphic ecalith is ound in only a small minority o patients.
Question 22.9.2 Which o the ollowing is specif c or appen-
dicitis?
A) Obturator sign
B) Psoas sign
C) Rovsing sign
D) enderness at McBurney’s point
E) None o the above is speci c or appendicitis
Answer 22.9.2 The correct answer is “E.” None o the above is
speci c or appendicitis. An obturator sign is present i there is
pain on internal and external rotation o the hip. T e obtura-
tor sign can be seen with any pelvic abscess that is in contact
with the hip area, but is more commonly seen with a retroce-
cal abscess. T e psoas sign is pain on use o the psoas muscle
(e.g., li ing the leg at the hip), and it can be seen with any
in ammatory process that is in contact with the psoas muscle,
including a psoas abscess. Rovsing sign is when pain increases
in an area o peritonitis when the abdomen is palpated else-
where. For example, in a patient with appendicitis, right lower
quadrant pain will be increased with palpation o the le lower
quadrant. T is is indicative o peritonitis in the area that has
increased pain, but it is not speci c or appendicitis. ender-
ness at McBurney’s point can be seen in a number o processes
including appendicitis, ileitis, any process in the cecum, and
urinary tract in ection.
Question 22.9.3 Which o the ollowing is true about the
treatment o pain in the acute abdomen?
A) Early treatment with morphine will obscure the proper
diagnosis
B) reatment with pain medication invalidates in ormed
consent
C) Early treatment o pain with morphine is sa e except in chil-
dren
D) Ketorolac is pre erred or patients who may undergo a surgi-
cal procedure
E) None o the above is true
Answer 22.9.3 The correct answer is “E.” None o the above
is correct. Early treatment o pain in the acute abdomen actu-
ally i roves diagnostic accuracy in both children and adults.
Ketorolac is not a good choice because o its antiplatelet e ects,
which increase the risk o bleeding intraoperatively. Pain medi-
cation does not inherently invalidate in ormed consent (but
obviously can i the patient is hardly arousable).
Although you have thought a lot about his otential rob-
le , you have not actually done anything ore to evaluate
this 15-year-old with abdo inal ain!
Question 22.9.4 The BEST test to help you arrive at a
diagnosis in this p atient is:
A) Erythrocyte sedimentation rate (ESR)
B) C-reactive protein (CRP)
C) Abdominal ultrasound
D) Abdominal C scan
E) Colonoscopy
Answer 22.9.4 The correct answer is “D.” T e test most likely
to arrive at a diagnosis in this patient is a C scan o the abdo-
men looking at the appendix. “A” and “B” are incorrect. Both the
CRP and the ESR are nonspeci c markers o in ammation and
are not help ul in the diagnosis o appendicitis. “C,” an ultra-
sound, can be used and is o en recommended as the f rst test in
pediatric patients to avoid the ionizing radiation associated with
C . T e speci city or ultrasound is high (95–99%). However, it
is not as sensitive as a C scan (as varied as 60–85% depending
on the study). Although “D” is the textbook answer, it would be
reasonable to start with an ultrasound, and i equivocal, one can
then move on to C or surgical consultation or serial abdomi-
nal examinations depending on institutional pre erence. Finally,
ultrasound can also be use ul in the emale patient in whom
other diagnoses need to be ruled out, such as ovarian pathology.
“E,” colonoscopy, is not particularly use ul in the diagnosis o
appendicitis but could be used or other purposes such as looking
or IBD once appendicitis is ruled out by C .
HELPFUL TIP:
N p en s w p en ppend c s need Ct
sc n! Those with obvious appendicitis should go di-
rectly to the OR. Ct s d n y be sed n p en s n
w m e c n c d n s s s eq v c . t ere s s me
n - erm r sk r m r d n exp s re, s Ct s d
n be d ne w d nd c n. h wever, y
m s s be w re e s nd rd pr c ce n y r
c n s m ny s r e ns n w ns s p n Ct sc n
pr r n e o R.
Question 22.9.5 I this patient’s CT scan is positive or
appendicitis, the likelihood that he will have a normal
appendix removed at appendectomy is:
A) 0%
B) 10%
C) 20%
D) 30%
E) 50%
Answer 22.9.5 The correct answer is “B.” With the advent o
C scanning, the alse positive rate (o taking normal patients
to the OR) has improved, but perhaps not as much as you would
think. T e negative laparotomy rate is still about 10%. T e nega-
tive laparotomy rate has gone down in men and the young but
has increased in the elderly and in women. T ere is evidence that
C scanning changes the treatment plan in more than hal o
cases o suspected appendicitis. T e sensitivity o C or appen-
dicitis is 91% to 98%, but the speci city is as low as 75% depend-
ing on the radiologist and the population tested (range 75–93%).
 CHAPTER 22 • Ca RE o t h E Su Rg iCa l Pa t iENt 615

history is signi cant or a 5-year history o diabetes. He takes

HELPFUL TIP:
glyburide, atorvastatin, and as irin (he clearly isn’t your
t ere s newer ev dence s es s uncom-
atient . . . he is not on et or in, the drug o choice in ty e
plicated ppend c s m y be re ed w n b -
2 diabetes). He has no revious surgical history. You order an
cs ns e d s r ery nd s n ss c ed w ny
ultrasound. T e ultrasound reveals a nor al aorta, but the
ncre sed c mp c ns. t e s nd rd c re n e
technician notes several stones in the gallbladder. You are con-
u n ed S es e me s p b s n rem ns p-
cerned that this atient ay have sy to atic cholelithiasis.
pendec my (JAMA. 2015;313(3):2340–2348 nd Ann
Surg. 2015;261(1):67–71).
Question 22.10.1 Which o the ollowing is true o his risk
or gallstones?
A) T is patient has an increased risk o cholesterol stones
Question 22.9.6 In general, which o the ollowing is true because he is diabetic
about appendicitis? B) T is patient’s risk o gallstones would have peaked in his
A) Pain is in the right upper quadrant in the majority o preg- ourth decade o li e
nant women with appendicitis C) T is patient’s risk o gallstones is increased because o his
B) Atypical presentations are more common in the elderly atorvastatin use
patient than in other groups D) T is patient’s risk or cholesterol stones is lower because o
C) Patients with a retrocecal appendix generally present with his advanced age
well-localized tenderness and signs o peritoneal irritation E) T is patient’s risk o gallstones is increased because he’s male
D) An appendicitis is great way to postpone your board exami-
nation—get one soon! Answer 22.10.1 The correct answer is “A.” Patients with diabe-
tes have an increased risk o gallstones when compared with the
Answer 22.9.6 The correct answer is “B.” Symptoms tend to be general population. Other associations include emale gender
atypical in the elderly. In act, elderly patients may have appen- (not male, so “E” is wrong), amily history, obesity, and certain
dicitis with a normal white count, poorly localized pain, and medical illnesses including hyperlipidemia, cystic brosis, short
absence o ever. So, maintain a high index o suspicion. “A” is bowel syndrome, parenteral nutrition, hemolytic anemia (e.g.,
incorrect. Despite classic teaching, patients who are pregnant sickle cell), and history o terminal ileum resection. “B” and “D”
tend to have “typical” symptoms with right lower quadrant pain. are incorrect because the risk o gallstones increases linearly
T is is especially true in the rst hal o pregnancy. Certainly with age. “C” is incorrect. Atorvastatin and other “statins” are
the appendix can be displaced cephalad, but the majority will not associated with an increased risk o gallstone ormation, but
still have right lower quadrant pain. “C” is incorrect. Patients clo brate and other brates are. “D” is also incorrect.
with retrocecal appendicitis will commonly complain o a dull
ache. However, signs o peritoneal irritation may be minimal or Question 22.10.2 Which o the ollowing statements is
absent. FALSE regarding the evaluation o the gallbladder?
A) Ultrasound will nd pericolic uid in only 50% o patients
with cholecystitis
HELPFUL TIP: B) An HIDA scan can be abnormal/positive (e.g., no tracer in
S me p en s ve rec rren ppend c s. t ese p - the duodenum) in patients with common bile duct obstruc-
en s w presen w m p e ep s des “ yp c ” tion and/or cholecystitis
ppend c s, w c res ve d r n bserv n. W en C) Endoscopic retrograde cholangiopancreatography (ERCP)
e ppend x s n y rem ved, s req en y sc rred has an attendant risk o pancreatitis
d wn. D) T e absence o disease on ultrasound e ectively rules out
gallbladder disease
Objectives: Did you learn to . . . Answer 22.10.2 The correct answer is “D.” While ultrasound
• Descr be e f nd n s n c e ppend c s?
is highly sensitive or stones (95% or greater), it will miss some.
• D n se ppend c s nd de erm ne w nc ry es s re “A” is a correct statement as are “B” and “C.” An HIDA (hepatic
bes sed n e p en presen n w s ns nd symp ms
iminodiacetic acid) scan can be abnormal (e.g., no tracer in the
ppend c s?
duodenum) in cholecystitis but also in any other condition in
• M n e p en w ppend c s?
which the common duct is blocked including a common duct
stone or tumor. Additionally, i there is liver disease (which may
prevent the uptake o HIDA into the gallbladder), a ull gall-
CASE 22.10 bladder, gallbladder dys unction, or spasm o the sphincter o
A 72-year-old ale resents to your o ce or a 3- onth his- Oddi, one can have a alse positive scan (e.g., no tracer in the
tory o e isodic abdo inal ain. It is ri arily located in the duodenum). MRCP (magnetic resonance cholangiopancreatog-
e igastric region and radiates to the back. It occurs both dur- raphy) or ERCP can be used to identi y stones in the common
ing the night and day and lasts about 1 hour. His ast edical duct prior to surgery.
616 a Mil Y MEDiCiNE EXa MiNa t io N & Bo a RD REViEW
HELPFUL TIP:
Ct s n very sens ve s dy r s nes. u r -
s nd s e s dy c ce r d n s n s nes
(sens v y s 25% r Ct vs. 95% r r s nd).
Question 22.10.3 Regarding dif erent types o gallstones,
all o the ollowing are true EXCEPT:
A) Cholesterol stones are associated with obesity and hyperlip-
idemia
B) Black pigment stones are associated with cirrhosis
C) Brown pigment stones are associated with liver uke in ec-
tion
D) Blue pigment stones are associated with being an avid an o
the St. Louis Blues hockey team and/or the Blue Man Group
Answer 22.10.3 The correct answer is “D.” While we have
noticed that beer-swilling hockey ans might be prone to devel-
oping gallstones, there are no studies that show this. Besides,
blue pigment stones do not exist. All the other options are true.
Stone types include cholesterol, black pigment, and brown pig-
ment stones. Cholesterol stones are associated with advancing
age (due to decreased synthesis o bile salts rom cholesterol),
hyperlipidemia, diabetes, obesity, and living in the Western
Hemisphere (thank you, ast ood industry!). Black pigment
stones contain calcium bilirubinate, calcium carbonate, and
calcium phosphonate. T ey are associated with hemolytic dis-
eases, Crohn disease, ileal resection, cirrhosis, and total parental
nutrition ( PN). Brown stones are observed more o en in East
Asia and are associated with liver uke in ection.
You re er the atient to your avorite surgical consultant, Dr.
Hugh Jeego (or his artner, I. M. Agodd), or evaluation o cho-
lecystecto y. However, be ore his surgery a oint ent, you see
hi again in the ED. He resents with ever, nausea, vo iting,
and anorexia or the last 48 hours. His exa ination is signi -
cant or te erature 38.9°C, ild tachycardia and tachy nea,
and a nor al blood ressure. He is tender in the right u er
quadrant and has a ositive Mur hy sign. He has no jaundice or
al able right u er quadrant ass. Laboratory values include
3
WBC 14,800/ , AL 58 IU/L, AS 64 IU/L, alkaline hos-
hatase 45 IU/L, total bilirubin 1.5 g/dL ( ildly elevated liver
enzy es and bilirubin), a ylase 95 IU/L, and li ase 52 IU/L
(nor al a ylase and li ase).
Question 22.10.4 At this point in time, your working diag-
nosis is:
A) Acalculous cholecystitis
B) Acute calculous cholecystitis
C) Pancreatitis
D) Ascending cholangitis
E) Myocardial in arction
Answer 22.10.4 The correct answer is “B.” T e clinical pre-
sentation, examination, and laboratory data point toward acute
cholecystitis. “A” is incorrect because acalculous cholecystitis
occurs more o en in critically ill hospitalized patients, and you
already know that this patient has stones, so his cholecystitis is
by de nition calculous in nature. T ere must be no gallstones
detected on ultrasound to diagnose acalculous cholecysti-
tis (thus the name). “C” is incorrect. His pancreatic enzymes
are normal; and although one can certainly have pancreatitis
with a normal amylase and lipase, you have a better explana-
tion with cholecystitis. “D” is incorrect. Patients with ascending
cholangitis usually have markedly elevated transaminases and
an obstructive laboratory pattern (e.g., elevated bilirubin, alka-
line phosphatase, and pancreatic enzymes). “E” is very unlikely
in this patient who has ndings more consistent with intra-
abdominal pathology, but you should always consider cardiac
(and other thoracic organ) etiologies in older patients present-
ing with abdominal complaints.
Question 22.10.5 Regarding the dif erential diagnosis o
complicated cholelithiasis, which o the ollowing is true?
A) Empyema o the gallbladder is primarily a disease o the
elderly and carries a high mortality rate due to associated
Gram-positive sepsis
B) Emphysematous cholecystitis occurs primarily in elderly
diabetics as a late complication o miliary tuberculosis ( B)
C) T e most common consequence o gallbladder per oration
is generalized peritonitis
D) Charcot’s triad (jaundice, ever, and right upper quadrant
pain) is associated with cholangitis
Answer 22.10.5 The correct answer is “D.” T e classic Char-
cot’s triad (jaundice, ever, and right upper quadrant pain) is
associated with cholangitis, but it is not seen in the majority o
cases, probably due to early detection o cholangitis. Nonethe-
less, it can be help ul i present. “A” is incorrect because patients
generally develop a Gram-negative sepsis. “B” is incorrect
because emphysematous cholecystitis is not a complication o
miliary B, but it can occur with anaerobic cholecystitis. Mili-
ary B rarely a ects the gallbladder. “C” is incorrect. T e most
common consequence o gallbladder per oration is a localized,
walled o abscess. Additionally, a cholecystoenteric stula may
orm between the gallbladder and the duodenum or jejunum.
Stones can then pass into the bowel. Stones larger than 2 cm
in diameter are likely to lodge in the terminal ileum, a process
termed gallstone ileus.
Generally, patients with cholecystitis have a prior history o
biliary colic. Pain with acute cholecystitis is similar to that o
cholelithiasis except is more o en severe, longer lasting (> 24
hours), and associated with anorexia, nausea, vomiting, ever,
elevated white count (12,000–15,000/mm 3), right upper quad-
rant guarding, and a positive Murphy sign (arresting inspira-
tion when palpating the gallbladder). However, Mur hy sign
is only 65% sensitive (less in the elderly). Additionally, 38%
with con r ed cholecystitis have neither leukocytosis nor
ever. About 15% o the time there is associated jaundice and
20% o the time there is a palpable mass in the right upper
quadrant. Biliary pancreatitis can occur when there is blockage
o the ampulla o Vater, and cholangitis occurs when there is
ductal stone obstruction and biliary in ection. Emphysematous

cholecystitis occurs primarily in elderly male diabetics: gas pro-
ducing bacteria, most commonly C. per ringens, result in gas in
the gallbladder and can cause a severe sepsis.
Given the hysical ndings, leukocytosis, and ild elevation
o transa inases, you conclude that this atient has chole-
cystitis.
Question 22.10.6 Which o the ollowing should NOT be
considered in the management o this disease?
A) Initial treatment includes hospitalization with IV uid
resuscitation
B) Select an antibiotic regimen to include a third-generation
cephalosporin ± metronidazole, piperacillin/tazobactam
(Zosyn), or uoroquinolone + metronidazole
C) Choose a narrow-spectrum antibiotic to treat enterococcus
(e.g., vancomycin)
D) I early cholecystectomy is not chosen as treatment, it should
be per ormed late (at least 6 weeks a er diagnosis)
Answer 22.10.6 The correct answer is “C.” T is answer is
incorrect or two reasons. First, just over 50% o episodes o
cholecystitis are sterile; as a matter o course they are treated
with antibiotics because o our inability to determine which are
in ected. Second, while enterococcus is requently encountered,
it is rarely a solitary pathogen and does not require speci c tar-
geted antimicrobial therapy. T e initial treatment o cholecysti-
tis includes hospitalization, broad-spectrum IV antibiotics, and
IV uid resuscitation. De nitive therapy or cholecystitis is cho-
lecystectomy. Controversy surrounds whether cholecystectomy
should be per ormed acutely or be delayed. Generally, shorter
hospitalizations and better outcomes are ound with early cho-
lecystectomy.
Objectives: Did you learn to . . .
• iden y r sk c rs r s nes?
• Rec n ze c mp c ns b dder d se se?
• M n e p en w symp m c s nes nd c e-
cys s?
CASE 22.11
A 28-year-old ale who was the restrained ront assen-
ger o a vehicle traveling in excess o 60 h is brought to
the ED via a bulance. T e driver o the vehicle was ound
dead at the scene. A bulance ersonnel re ort it took 5 to
10 inutes to extricate the atient. On arrival, he is u -
bling incoherently. He is initially able to give his na e, but
he is slurring his words. He denies any edical roble s,
edications, or allergies. Vitals signs include te erature
35.5°C, ulse 148 b , res irations 35 b , blood ressure
65/30 Hg, and oxygen saturation 81% on 100% oxygen
by ace ask. On exa ination, he is in severe res iratory
distress. Lung sounds are absent on the right and di in-
ished on the le . Heart sounds are uf ed. You deter ine
that this atient needs i ediate treat ent o a neu o-
thorax.
CHAPTER 22 • Ca RE o t h E Su Rg iCa l Pa t iENt 617
Question 22.11.1 Which o the ollowing is most appropri-
ate at this time?
A) Per orm needle decompression on the le
B) Per orm needle decompression on the right
C) Place a chest tube on the le
D) Place a chest tube on the right
E) Per orm a chest radiograph and act on the basis o the results
Answer 22.11.1 The correct answer is “B.” T e combination o
hypotension, hypoxia, and absent breath sounds suggests a ten-
sion pneumothorax. I ediate deco ression o the a ected
he ithorax should be er or ed by lacing a large-bore (14-
or 16-gauge) needle through the chest wall to relieve intra-
thoracic ressure. Per Advanced rauma Li e Support guide-
lines, the correct placement is in the second intercostal space at
the mid-clavicular line. However, due to risk o mediastinal vas-
cular injuries, some experts recommend placing the needle in
the traditional location or chest tube—that is the h or sixth
intercostal spaces at the mid-axillary line. Either site is accept-
able i the pleural space can be reached (it may be more di cult
in the midaxillary line given increased subcutaneous tissue). O
particular note is “E.” I tension pneumothorax is suspected, you
should never wait or con rmation o the diagnosis by a chest
radiograph. It is a true emergency that requires treatment on the
basis o clinical examination.
HELPFUL (AND UNFORTUNATE) TIP:
g ven e ep dem c bes y n e u n ed S es,
s mp e need e m y n be n en re c e
p e r (yes, re y, s been s d ed). h ve b ck p
p n, s c s n er, p c e er.
His vital signs and oxygen saturation i rove with needle
deco ression. You lace a chest tube and give boluses o
nor al saline through two eri heral IVs. T en, the atient is
laced in external xation device or his e ur racture. O er-
ating roo xation is de erred secondary to unstable edi-
cal status. He is ulti ately intubated or continued increased
work o breathing. He is ad itted to the intensive care unit
(ICU) on a ventilator with a cervical collar ollowing negative
FAS exa ination ( ocused assess ent with sonogra hy or
trau a—a sonogra hic evaluation to rule out uid in erihe-
atic, eris lenic, elvic, and ericardial s aces).
Re eat chest x-ray in the ICU shows the endotracheal (E )
tube and chest tube in a ro riate ositions. Several rib rac-
tures are noted. T ere are “ u y in ltrates” in the le chest
that were not resent on initial trau a chest series.
Question 22.11.2 Which o the ollowing is true o pulmo-
nary contusions?
A) T ey occur in less than 25% o patients with signi cant blunt
trauma to the chest
B) reatment includes aggressive IV steroid and uid adminis-
tration
C) T e condition starts to resolve in 48 to 72 hours
D) reatment includes appropriate antibiotics
618 a Mil Y MEDiCiNE EXa MiNa t io N & Bo a RD REViEW

Answer 22.11.2 The correct answer is “C.” Pulmonary contu-

sions begin to resolve in 48 to 72 hours. However, 2 to 3 weeks
may be required or complete resolution. “A” is incorrect. Pulmo-
nary contusions occur in up to 70% o trauma patients with sig-
ni cant blunt chest trauma. It is usually, but not always, associ-
ated with ractured ribs. T ere may also be a ail segment noted.
Chest x-ray changes are usually evident within 1 hour post-
trauma but may not appear or up to 6 to 7 hours. Pulmonary
contusions result in a ventilation–per usion mismatch, hypox-
emia, and an increased A-a gradient. I a patient is able to main-
tain oxygenation and ventilation, intubation is not required. “B”
and “D” are incorrect. reatment currently only involves intuba-
tion as necessary, observation, and tincture o time.
You elect to roceed with ul onary artery catheter lace-
ent due to the severity o this atient’s condition. Over-
night, he begins to deco ensate. T e nurse ages you with
his vital signs and Swan–Ganz readings: te erature 37.0°C,
ulse 100 b , res irations 20 b (ventilator set at 14 b ),
blood ressure 82/30 Hg, PCWP 24 Hg (nor al
5–15), cardiac index 2.0 L/ in/ 2 (nor al 2.5–3.5), syste ic
vascular resistance 2,000 dyne-sec/c 2 (nor al 1,000–1,500),
and oxygen delivery o 700 L/ in (nor al 900–1,200).
Question 22.11.3 What is the cause o shock at this time?
A) Hypovolemic shock
B) Neurogenic shock
C) Cardiogenic shock
D) Septic shock
Part o the injuries sustained by this atient includes burns to
the abdo en and back.
Question 22.11.4 Which o the ollowing is FALSE regarding
burn wound management in general?
A) T e Parkland ormula or uid resuscitation calls or 2 to
4 mL/kg/% body sur ace area burned with hal o the volume
in the rst 8 hours and the other hal over the next 16 hours
B) Escharotomy should be per ormed on all partial-thickness
burns
C) Patients with chemical burns should be treated rst with tap
water irrigation
D) Prevention o wound in ection via topical antimicrobial
agents, such as silver sul adiazine cream, or via silver-coated
dressings is the standard o care
Answer 22.11.4 The correct answer is “B.” Any time you see
“all,” it is probably the wrong answer. Escharotomy is not neces-
sary unless there is a ull-thickness wound that is circum eren-
tial and compromising vascular supply. T e thinking about this
is changing and some suggest escharotomy o all ull-thickness
burns. “A” is a correct statement about the Parkland ormula.
“C” is also correct with the addendu that any articulate
atter should be brushed o rior to irrigation. Water ay
activate so e substances such as sodiu hydroxide. “D” is
also a correct statement although thinking is changing. Silver
delays wound healing and bacitracin is being used with increas-
ing requency.

Answer 22.11.3 The correct answer is “C.” T is patient appears

to be in cardiogenic shock (elevated pulmonary capillary wedge HELPFUL TIP:
pressure, decreased cardiac index). Cardiogenic shock may be ds re req red r d s w > 15% b dy
caused by myocardial ailure, valve ailure, dysrhythmias, and s r ce re (t BSa ) b rns (sec nd r rd de ree) nd
tamponade. reatment is directed at the underlying disorder. > 10% r c dren ed 10 ye rs nd y n er. r
See able 22-5 or more on the categories o shock. adults e “R e 9’s” s sed de erm ne t BSa ec -
ed. B dy s r ce re s es m ed s ws: e e d,
e c rm, r n e c e , nd b ck e c e c n
HELPFUL TIP . . . OR NOTE OF CAUTION: r 9% t BSa e c ; e r n nd b ck e r nk e c
t ere s n d ev dence s pp r e se Sw n– c n r 18%; e rem n n 1% t BSa s cc n ed
g nz c e ers n ser s y p en s. in c , e ev - r by e en . t BSa ec ed n c dren nd d -
dence s es s worse c mes w Sw n–g nz m n - escen s s d be b sed n e-spec c c r s. B
rn nw ( r m seps s, r mb s s, e c.). Be very ec ed nd n ec ed BSa s d be c c ed
c rc mspec be re e ec n se Sw n–g nz c e ers. ss re cc r e es m n.

TABLE 22-5 CATEGORIZATION OF SHOCK BY PHYSIOLOGIC PARAMETERS

Systemic Vascular Pulmonary Capillary Oxygen Consumption Cardiac
Type o Shock Resistance Wedge Pressure (Based on Venous Gas) Output
h yp v em c incre sed Decre sed Decre sed Decre sed

C rd en c incre sed incre sed Decre sed Decre sed

Ds rb ve (seps s, ne r en c) Decre sed Decre sed r n rm incre sed incre sed

o bs r c ve (PE, ven c v bs r c n, incre sed l w e , r Decre sed Decre sed

ens n pne m r x)

HELPFUL TIP:
t e P rk nd rm w s des ned ss re deq e
ydr n n b rn p en s s re ec ed by r ne p
( n e p en w nc n n k dneys, c rse).
a dj s ds ppr pr e y m n n deq e ydr -
nw nd c n e r re.
Question 22.11.5 Which o the ollowing is TRUE regarding
uid administration in burn and dehydrated patients?
A) A peripheral line will deliver uid more rapidly than a cen-
tral line o an equivalent gauge
B) Albumin is the uid o choice in the treatment o burns and
should be considered or all patients with signi cant uid
de cits
C) D5W-½ NS (D5W-0.45%NS) is the pre erred uid or resus-
citation in all nonburn patients
D) All o the above are true
Answer 22.11.5 The correct answer is “A.” A peripheral line
will deliver uid more rapidly than a central line o an equiva-
lent gauge, according to Poiseuille’s law ( ow is directly propor-
tional to tube radius and inversely proportional to tube length).
T e shorter the catheter, the more quickly uid is delivered
(think o a short tra c jam as opposed to a longer one on the
same sized road). T e largest port on a traditional triple lumen
catheter will give the same ow rates as a 20 gauge peripheral IV.
Consider a “cordis” catheter i placing a central line in a patient
who may also require rapid uid resuscitation. T is is a larger
diameter, shorter central line. “B” is incorrect. Albumin is not
help ul and may increase adverse outcomes in trauma. “C” is
also incorrect. Normal saline (0.9% NS), or Lactated Ringer’s
i you are a surgeon, are the uids o choice or resuscitation.
Remember that Lactated Ringer’s is actually slightly hypotonic
and thus may worsen cerebral edema. T ere is no evidence
avoring Lactated Ringer’s over normal saline.
Objectives: Did you learn to . . .
• a ppr c r m p en w n nders nd n
dv nced r m e s pp r pr nc p es?
• iden y nd m n e p en w ens n pne m -
r x?
• Descr be v r s ypes s ck nd w ey re d eren -
ed?
• t re p en n s ck?
• M n e p en w s n f c n b rns?
QUICK QUIZ: iNh a l at io N iNJu RY
Carbonized particles in the nasal cavity and/or posterior phar-
ynx in a burn patient should suggest:
A) T e need or excision o the perichondrium in the nose to
prevent underlying cartilage injury rom avascular necrosis
B) Inhalational injury to the lungs
C) Ingestion o a large amount o particulate matter
CHAPTER 22 • Ca RE o t h E Su Rg iCa l Pa t iENt 619
D) T e need to check carboxyhemoglobin levels
E) B and D
The correct answer is “E.” Carbonaceous material in the nares
or oropharynx should suggest the possibility o an inhalation
injury. T ought should be given to intubate these patients early,
especially i there will be a prolonged trans er time. Further,
given that this is related to the inhalation o combusted mate-
rial, a carboxyhemoglobin level should be considered.
CASE 22.12
A 48-year-old e ale arrives at the ED via a bulance a er
witnesses saw her vo iting large volu es o blood in a local
convenience store be ore colla sing to the oor—obviously,
not her best day. She is barely co unicating and cannot ro-
vide any history. A bulance ersonnel have laced two large-
bore IVs and started nor al saline boluses. Just as you start
your initial evaluation, she has a large volu e he ate esis.
You are concerned about her de ressed ental status and the
severity o her illness and decide to intubate her. A er intuba-
tion, the chest wall rises sy etrically and the lungs sound
clear. Her heart sounds are distant, and she is tachycardic
( ulse 120 b ). Her blood ressure is 80/40 Hg. Her
oxygen saturation is 78%.
Question 22.12.1 The standard o care in detecting esopha-
geal intubation is:
A) Auscultation
B) Radiograph
C) End-tidal CO2
D) Oxygen saturation
E) Direct laryngoscopy
Answer 22.12.1 The correct answer is “C.” T e standard o
care is the end-tidal CO2. All o the others are notoriously unre-
liable. However, they all should be done. I you think you hear
breath sounds but the oxygen saturation is not rising and end-
tidal CO2 is low, the E tube is probably in the esophagus.
Question 22.12.2 The end-tidal CO2 can be alsely negative
(detecting no CO2) in which o the ollowing situations?
A) Ingestion o carbonated so drinks (or “pop” as we call it in
the Midwest)
B) Intubation in the posterior pharynx above the cords
C) Nasotracheal intubation
D) During cardiac arrest
Answer 22.12.2 The correct answer is “D.” T e end-tidal CO2
requires that there is gas exchange in the lungs. I there is no
gas exchange, the CO2 will be low. T is may be the case during
cardiac arrest. “A” can actually cause a alse ositive. Carbon
dioxide in the stomach will give a positive end-tidal CO2 with
an esophageal intubation. T e same is true o “B.” I the patient
is breathing spontaneously, the CO2 will be elevated even when
the E tube is above the cords. “C,” nasotracheal intubation,
should have no e ect on end-tidal CO2.
620 a Mil Y MEDiCiNE EXa MiNa t io N & Bo a RD REViEW
You order laboratory studies that include a CBC, basic eta-
bolic ro le, liver che istries, a ylase, li ase, and coagula-
tion studies. In addition, you ty e and cross or six units o
acked red blood cells. T e nurses have already contacted the
gastroenterologist on call, and she is on her way. You decide
to er or nasogastric (NG) lavage.
Question 22.12.3 Which o the ollowing is FALSE regarding
NG lavage?
A) NG lavage may be negative even in the presence o an upper
GI bleed
B) NG lavage should not be attempted in obtunded patients
until they are intubated
C) Iced uid should not be used to lavage patients with an
upper GI bleed
D) T e placement o a NG tube is contraindicated in patients
who may have variceal bleeding
Answer 22.12.3 The correct answer is “D.” Varices are not a
contraindication to the use o a NG tube. Studies suggest that
a NG tube does not increase bleeding. Both “A” and “B” are
true statements. Lavage should not be done in patients who
are obtunded or otherwise unable to protect their own airway
unless they are intubated. In act, i the atient has obvious
blood in the vo itus, NG lavage is not necessary unless it
is to clear sto ach contents in order to er or endosco y
or to revent vo iting. It adds nothing to the anage ent
o the atient with an u er GI bleed exce t con r ing the
diagnosis. Remember that alse-negative NG aspirates occur
with intermittent bleeding and bleeding beyond the ligament
o reitz. “C” is also a true statement. Iced lavage uid should
not be used in patients with a GI bleed. T e cooler temperature
that results rom the ice inhibits hemostasis and can increase
bleeding.
HELPFUL TIP:
C n r nd c ns s r c v e nc de kn wn n-
es n ydr c rb ns nd c s c en s, s c s
k s nd c ds.
While your nurse is er or ing the war water lavage
(although why lavage is being done is a se arate question
since as noted above it does not add anything to this atient’s
care), you er or a secondary hysical exa ination on the
atient. Her ost obvious nding is a arkedly jaundiced
state. Other ertinent ndings include a 6-c scal lacera-
tion, which continues to actively bleed, oderate ascites, and
lower extre ity ede a. A er lavage with nearly 5 L o iso-
tonic uid, the atient’s as irate continues to be bloody. At
this oint, her vitals are re aining steady but have shown no
sign o i rove ent. Initial e ergent labs have returned: Na
142 Eq/L, K 3.2 Eq/L, Cl 106 Eq/L, CO2 18 Eq/L, BUN
40 g/dL, Cr 0.8 g/dL, glucose 110 g/dL, WBC 7,000/
3 3
, Hgb 9.8 g/dL, Hct 29%, Plt 62,000/ , INR 3.0, P
48, albu in 2.4 g/dL, AS 76 IU/L, AL 39 IU/L, Bili 3.5 g/
dL, a ylase 210 IU/L, and li ase 24 IU/dL. T e gastroenter-
ologist is still 5 to 10 inutes away.
Question 22.12.4 In considering what to do next, which o
the ollowing would be most appropriate?
A) Address the presence o platelet dys unction by trans using
with a 10-pack o platelets
B) In order to accurately assess degree o volume depletion,
place a central venous pressure (CVP) catheter or Swan–
Ganz catheter, and bladder catheter
C) Regardless o the gastroenterologist, central line placement
should be priority at this time because uid resuscitation is
the primary concern
D) Emergent gastric tamponade should be attempted with a
Foley catheter
E) None o the above is a great idea right about now
Answer 22.12.4 The correct answer is “E.” None o the
above is a particularly good idea at this juncture. Looking at
them one by one, “A” is not necessary since a platelet count o
62,000 is adequate or hemostasis (although you would not
be aulted or giving platelets). A platelet count o < 50,000
is considered an indication or platelet trans usion in an
actively bleeding patient. “B” and “C” are not good ideas
because coagulopathy (INR 3.0) is a relative contraindica-
tion to central line placement. It can still be done, but the
line is not needed at this point. Recall that peripheral cath-
eters will deliver more luid more rapidly when compared
with central catheters. hus, two large-bore, peripheral IVs
are the access o choice. “D” is incorrect because gastric tam-
ponade with a Foley is like trying to stop a leak in the Hoover
dam with putty: it won’t work. he most e ective treatment
at this time may be to give vitamin K and resh rozen plasma
to reverse her coagulopathy.
Question 22.12.5 Ef ective methods or controlling upper
GI variceal bleeding that improve outcomes include all o
the ollowing EXCEPT:
A) Variceal ligation
B) Sclerotherapy
C) ransjugular intrahepatic portosystemic shunt ( IPS) pro-
cedure
D) Vasopressin
Answer 22.12.5 The correct answer is “D.” Vasopressin, while
achieving initial control o bleeding in up to 60% o patients, has
essentially no e ect on rebleeding and no e ect on ortality.
T is may be because ischemia o the splanchnic bed and other
areas caused by vasopressin outweighs any bene t. In more
bad news, octreotide also does not have any e ect on mortal-
ity unless combined with variceal ligation. Variceal ligation and
sclerotherapy both reduce mortality. Additionally, a IPS pro-
cedure has been shown to e ectively stop bleeding by reducing
portal pressures. It also reduces acute mortality. Data is con-
icting on long-term outcomes, but encephalopathy is more
common a er IPS.

HELPFUL TIP:
a n e ev ed Bu N c n be nd rec ev dence g i b eed
n p en s w ver d se se. t e d es n b d
e ds e e ev ed Bu N.
Des ite Dr. Graber’s warning to the contrary, you consider
lacing a central line.
Question 22.12.6 Which o the ollowing locations o cen-
tral line placement is associated with the highest rate o
in ection?
A) Internal jugular
B) Femoral vein
C) Subclavian vein
D) T ey all have similar in ection rates
Answer 22.12.6 The correct answer is “D.” T e classic teaching
is that emoral lines are more likely to get in ected. However, the
data doesn’t back this up; in ection rates seem to be the same or
all above locations (Crit Care Med. 2012;40:2479). Subclavian
veins have a higher risk o complication such as arterial injury,
hemothorax, pneumothorax, and lung injury. T oracic duct
injury is most common with le internal jugular cannulation.
Note that ultrasound guidance o central line insertion is the
standard o care.
T e gastroenterologist arrives and you ex lain the situation.
Vitals at this ti e include a te erature o 36.8°C, ulse
105 b , res irations 14 (ventilator de endent) b , blood
ressure 85/40 Hg, and oxygen saturation o 92%. T e
gastroenterologist lans to atte t endosco y with sclero-
thera y, but would like to have the general surgeons available
or backu in case e ergent o erative intervention beco es
necessary. As you re are to contact the surgeon, you recall
risk strati cation or cirrhotic atients is via the Child–Pugh
classi cation syste .
Question 22.12.7 Which o the ollowing is FALSE regarding
the Child–Pugh scoring system?
A) T e Child–Pugh scoring system can be used to predict the
risk o variceal bleeding
B) T e ve criteria used in the Child–Pugh classi cation are
ascites, encephalopathy, albumin, bilirubin, and INR
C) T e Child–Pugh scoring system can be used to determine i
the patient with a deep hepatic encephalopathy will “wake
up”
D) A patient with a serum bilirubin o 3.5 mg/dL may have the
exact same Child–Pugh score as a patient with a serum bili-
rubin o 25 mg/dL
Answer 22.12.7 The correct answer is “C.” T e Child–Pugh
scoring system does not predict the course o hepatic encepha-
lopathy. T e other statements are true. T e Child–Pugh clas-
si cation includes evaluation o ascites, encephalopathy status,
albumin, bilirubin, and INR. “A” is true because the Child–Pugh
CHAPTER 22 • Ca RE o t h E Su Rg iCa l Pa t iENt 621
TABLE 22-6 CHILD–PUGH CLASSIFICATION
P n s ss ned 1 2 3
Encep p y N ne l w r de h r de
a sc es N ne S M der e- r e
B r bn 1–2 m /dl 2–3 m /dl > 3 m /dl
a b mn > 3.5 /dl 2.8–3.5 /dl < 2.8 /dl
iNR < 1.7 1.8–2.3 > 2.3
score can be used to predict the risk o variceal bleeding as well
as the surgical risk and the overall mortality in patients with
liver disease. “D” is true since there is a maximum to the Child–
Pugh scoring system or each parameter, and the same score is
given or all bilirubin levels above 3 mg/dL.
Further discussion: T e Child–Pugh classi cation as a
global battery o tests can help to more accurately assess degree
o cirrhosis, need or transplant (minimum score o 7), mor-
tality rate rom variceal bleed, and outcomes a er surgery and
IPS, and outcomes with a hepatoma ( able 22-6).
Class A is de ned as having 5 to 6 points, Class B is 7 to 9
points, and Class C is 10 to 15 points. T e 1- and 2-year survival
in patients with Class C disease is 45% alive at 1 year and 35%
alive at 2 years.
Class A patients have an operative mortality o 1%, while
Class B and C have operative mortalities o 3% to 10% and 30%
to 50%, respectively. In patients with hepatomas, no Class B or
C patients survived 3 to 5 years ollowing resection, although
about 40% o Class A patients survive or 5 years.
You quickly recall that there is another rognostic scoring
syste available or risk strati cation and ortality, which
is used by United Network or Organ Sharing (UNOS) and
called the Model or End-stage Liver Disease (MELD) scor-
ing syste .
Question 22.12.8 Which o the ollowing is TRUE regarding
the MELD scoring system?
A) T e MELD scoring system can be used to predict 3-month
survival ollowing IPS
B) T e three criteria used in the MELD classi cation are biliru-
bin, INR, and creatinine
C) T e primary use o the MELD classi cation is or assessing
mortality risk and prioritizing patients on the waitlist or
liver transplant
D) T e minimum score is 6
E) All o the above
Answer 22.13.8 The correct answer is “E.” T e MELD score
was originally used to predict the 3-month mortality a er IPS
(“A”). However, now the MELD score has been validated as a
tool to estimate overall mortality related to liver disease and to
prioritize patients on the transplant wait list (“C”). T e MELD
score is computed by a logarithmic ormula using creatinine,
622 a Mil Y MEDiCiNE EXa MiNa t io N & Bo a RD REViEW
INR, and bilirubin levels. T e ormula is quite complex, so
thank ully there are handy online calculators readily available
(http://www.mayoclinic.org/medical-pro essionals/model-end-
stage-liver-disease/meld-model-unos-modi cation). For any
measured bilirubin, INR, and creatinine less than 1, the or-
mula automatically sets the values to 1 so the minimum score
is 6 (“D”). T e MELD score is interpreted as ollows: score
≥ 40, 71.3% mortality in 3 months; 30–39, 52.6% mortality in
3 months; 20–29, 19.6% mortality in 3 months; 10–19, 6.0%
mortality in 3 months; < 9, 1.9% mortality in 3 months.
Objectives: Did you learn to . . .
• M n e p en w m ss ve pper g i b eed?
• De erm ne n Et be s been p ced c rrec y?
• Rec n ze e ses nd m ns s r c v e?
• Rec n ze e ses nd m ns cen r ne p cemen
nd Sw n–g nz c e er p cemen ?
• Ev e p en w ver d se se, s n e C d–P
nd MEl D c ss f c n sys ems?
QUICK QUIZ: iNt u Bat io N
Which o the ollowing IS NO a contraindication to a blind
nasotracheal intubation?
A) Patient is not breathing
B) Patient is anticoagulated or has had PA
C) Mid ace trauma
D) History o a septoplasty
The correct answer is “D.” All o the rest are contraindications
to a blind nasotracheal intubation. Speci cally, it is not possible
to do a blind nasotracheal intubation in a nonbreathing patient.
Patients who are anticoagulated may bleed pro usely a er a
nasotracheal intubation, and mid ace trauma suggests the pos-
sibility that the tube could end up in the brain. Although the
standard o care, two studies have ailed to show a di erence
between CNS complications with orotracheal and nasotracheal
intubation. Nonetheless, avoid nasotracheal intubation in mid-
ace trauma, except as a last resort, or you will get dinged i there
is a complication.
CASE 22.13
You are seeing a 33-year-old resident at a large university
hos ital setting where edical care is rovided reely to hi .
He is about to co lete his Internal Medicine residency and
wants to “get his oney’s worth” o ree rocedures be ore
he leaves. He has scheduled a ull a ernoon o rocedures
with you, including toenail re oval, excision o a ole on his
neck, and a stylish new cartilage ear iercing or his new job
as a cruise shi doctor.
He has had trouble with recurrent ain and in a a-
tion on his le great toe at the edial side. On exa ination
you identi y onychocry tosis (ingrown nail). He has tried
soaks, growing ast the skin, and regular aring—all with-
out success.
Question 22.13.1 Regarding nail removal in this patient,
which one o the ollowing is FALSE?
A) T e great toe is the most commonly a ected toe or ony-
chocryptosis
B) I the patient chooses partial nail removal, about 25% o the
nail should be removed on the a ected side
C) Phenol should be placed or no longer than 10 seconds to
the germinal tissue to prevent necrosis
D) When removing the nail, an upward twist o the hand to the
medial side should be per ormed
Answer 22.13.1 The correct answer is “C.” Phenol can be le in
place or 3 minutes. Ingrown toenails almost exclusively a ect
the great toe on either the medial or lateral side. Partial or ull
nail removal should be implemented when conservative mea-
sures have ailed. Besides ingrown nails (onychocryptosis), ony-
chomycosis ( ungal in ection o the nail), recurrent paronychia
(nail old in ammation), and onychogryphosis (de ormed,
curved nail) are all indications or partial or ull nail removal. I
recurrent ingrown nails have occurred, germinal tissue can be
ablated with phenol on a cotton swab held in place or 3 min-
utes, and a erward the phenol should be neutralized with alco-
hol. Other approaches to matrixectomy include electrosurgical
and laser techniques and application o sodium hydroxide.
Next, he co lains about a s all regular ole on his neck
that he re eatedly cuts while shaving. He would like to have it
re oved in whatever way you dee best. T e lesion is raised
above the skin. Although it is ildly irregular in a earance
ro the re eated trau a o shaving, there is no evidence o
aty ia.
Question 22.13.2 Which o the ollowing is NOT a correct
statement regarding removal o this lesion?
A) Curettage or shave biopsy would be ideal or this sort o
lesion
B) I sutures are required, 6-O nylon would be ideal in this
location
C) I a punch biopsy is per ormed, skin should be held taught
perpendicular to the angle o the mandible (the natural skin
lines o the neck)
D) In this location, both shave and punch techniques require
closure by suture approximation
Answer 22.13.2 The correct answer is “D.” Various types o
skin lesion removal exist: punch biopsy, shave biopsy, curettage,
and elliptical excisional biopsy. Punch biopsy involves taking a
ull-thickness sample in skin areas (except or the eyelids, lips,
or penis). Skin should be held taught perpendicular to the natu-
ral skin tension lines, and punch instrument is rotated through
the skin. T e site is closed with either a single interrupted or
vertical mattress suture. Shave biopsy is indicated or removal
o elevated skin lesions where complete thickness removal is
unnecessary. Shave should be made rom both lateral edges
into center to avoid cutting too deep. No suturing is necessary.
Curettage entails a method o removing lesions that also does
not require ull-thickness sampling. A Fox dermal curettage

is used to scrape away unwanted tissue ollowed by electrical
or chemical cautery or hemostasis. Finally, elliptical excision
is used when ull dermal thickness excision is necessary. Con-
traindications to skin biopsy include in ection at the site and
coagulopathy.
Finally, your atient is a little e barrassed to be seen at the
all getting his ear ierced, and asks i you could ierce it
or hi . He is considering a standard lobe ierce versus an
auricular cartilage iercing.
Question 22.13.3 Which o the ollowing is true in regard to
counseling and technique?
A) Eczema at the site is a contraindication to piercing
B) Auricular cartilage piercing should only be per ormed by a
trained physician
C) Ears should be pierced rom the posterior to anterior site
D) Ear piercing involves boring a 20-gauge needle into the
marked site
E) Ear piercing is contraindicated in nerds
Answer 22.13.3 The correct answer is “A.” Eczema in the
area is a contraindication to piercing. Other contraindica-
tions include in ection, previous keloid ormation, immuno-
de ciency, and coagulopathy. Auricular cartilage piercing is
prone to in ection and destruction o the cartilage. Pseudo-
monas is a common pathogen and oral uoroquinolones are
indicated as treatment. All o the other options are incorrect.
“E” deserves special mention, as “nerds” can be converted to
“hipsters” simply by piercing their ears. However, there is a
corollary to this axiom: any aging male with a gray ponytail
should avoid piercings.
Objectives: Did you learn to . . .
• Descr be ec n q es nd nd c ns r en rem v ?
• Descr be v r s sk n b psy ec n q es?
• iden y c n r nd c ns e r p erc n ?
QUICK QUIZ: Do C, iS t h at a h o SE iN MYCh ESt ?
What statement represents correct chest tube management?
A) A tube that shows no water uctuations when placed on
“water seal” should have wall suction increased in attempt
to re-open
B) Initial postoperative setting o a chest tube is most o en
–100 cm H 2O
C) Unless there is major injury to the lung, continuous bub-
bling o the water seal chamber most likely represents an
apparatus leakage
D) I a purse string was placed during initial placement o the
chest tube, tightly tying the purse string when pulling the
chest tube is enough to prevent pneumothorax
The correct answer is “C.” Continued bubbling in the water seal
chamber suggests that there is a leak in the system. T eoretically,
CHAPTER 22 • Ca RE o t h E Su Rg iCa l Pa t iENt 623
once the pleura are drained o air, there should be no urther
bubbling. Air leakage is seen as air bubbles that increase with
increased intrathoracic pressure (e.g., cough, Valsalva maneu-
ver, and positive pressure ventilation). Continuous air leakage
may be due to a large tear in the lung parenchyma, broncho-
pleural stula, or an apparatus leak. “A” is incorrect. A tube that
is non unctional should be removed. Increasing the suction will
not reopen it. “B” is incorrect as well. Initial suction should be
20 cm H 2O. “D” is incorrect because an occlusive dressing, such
as petrolatum gauze, should be placed over the ormer chest
tube site once the tube is removed.
A chest tube can be removed when the ollowing criteria
are met: uid drainage is less than 150 cc/day, the lung is ully
expanded on chest x-ray, and no air leak is present. ypically,
chest tubes are rst placed to “water seal” or 6 to 24 hours to see
i the patient will tolerate having the tube removed.
CASE 22.14
John is a 63-year-old ale who resents to your o ce or a
hysical exa ination. As art o the exa ination, you do a
rectal exa ination and stool guaiac. T e guaiac is he occult
ositive. On colonosco y, he is noted to have bio sy- roven
colon cancer.
Question 22.14.1 Regarding colon cancer, what is the most
likely type o cancer you will nd?
A) Squamous cell carcinoma
B) Adenocarcinoma
C) Clear cell carcinoma
D) Lymphoma
Answer 22.14.1 The correct answer is “B.” Adenocarcinoma
represents the overwhelming majority o colon cancers. Other
histologic types o colon cancer include adenosquamous, poorly
di erentiated cancers with neuroendocrine aspects, small cell
carcinomas (o neuroendocrine origin), and others.
John has the erennial question that theologians are usually
better quali ed to answer: “Why e?” In this case, however,
we can hel to rovide so e insight.
Question 22.14.2 Which o the ollowing is NOT considered
a risk actor or colon cancer?
A) Familial polyposis
B) Alcohol use
C) Obesity
D) In ammatory bowel disease
E) Chronic constipation
Answer 22.14.2 The correct answer is “E.” Chronic consti-
pation is not a risk actor or colon cancer. Aside rom those
listed above, risk actors include acromegaly, diabetes melli-
tus, and A rican American race, among others. In act, A rican
Americans have the highest risk or colon cancer o any ethnic
group with a 20% increase in mortality when compared with
whites.
624 a Mil Y MEDiCiNE EXa MiNa t io N & Bo a RD REViEW

John is justi ably worried about the ossibility o colon cancer HELPFUL TIP:
in his o s ring. Un ortunately, none o his o s ring exercise W e 5-h ia a s nds ke n cr nym r s me new
(which reduces colon cancer risk) and they are avowed carni- vernmen n ve, s m rker c rc n d m r
vores eschewing ruit, vegetables, and anything with ber ( ber c v y.
ay reduce colon cancer risk, although the data is con icting).

Question 22.14.3 Which o the ollowing has been shown to John undergoes surgery and ends u with a total colecto y
reduce cancer risk and takes so little ef ort that even John’s and ileosto y.
sloth ul of spring may partake?
A) Met ormin Question 22.14.6 Which o the ollowing is NOT true o ile -
B) Aspirin ostomy care?
C) Antioxidants A) Fluid output tends to be relatively high with an ileostomy
D) Vitamin B6 but no other antioxidants requiring increased uid intake to prevent dehydration
E) B and C B) Since the diameter o the ileostomy is limited, avoiding large
amounts o nondigestible ber helps to prevent bezoar or-
Answer 22.14.3 The correct answer is “B.” Aspirin and other mation
NSAIDs have been shown to reduce the risk o colon cancer. C) ime-release drugs are usually well absorbed because most o
Un ortunately, the rest o the answers are incorrect and none the digestion and absorption occur be ore the colon anyway
have been ound to reduce the risk o colon cancer D) Proteolytic enzymes are present in the ef uent and may lead
to skin breakdown
It is ti e to stage John’s cancer. T e Duke’s classi cation sys-
te is no longer used or colon cancer and has been re laced Answer 22.14.6 The correct answer is “C.” ime-release medi-
with the ore standardized MN syste . cations should be avoided, since absorption o en takes place in
the colon. All o the rest are correct.
Question 22.14.4 Which o the ollowing is the most com-
mon rst site o metastasis o colon cancer?
HELPFUL TIP:
A) Lungs
l per m de c n be sed red ce p n s r b w-
B) Liver
e syndr me ( nc d n n se w n s my) s n
C) Bone
s b c er ver r w s n n ss e.
D) Brain

Answer 22.14.4 The correct answer is “B.” T e liver is the

most common rst site o colon cancer metastases, which arrive John does well and has a ha y and long li e, although his chil-
via the portal system. Colon cancer can also metastasize to the dren re ain slugs and he su orts the well into their 40s.
lungs, bone, lymph nodes, and brain (uncommon). Intraperito- Objectives: Did you learn to . . .
neal spread may also occur. • Descr be s me m r m rkers r v r s c ncers?
• Def ne v r s s c ypes c n c ncers nd e
Question 22.14.5 While tumor markers or colon cancer are p ern me s s z n ?
not used in staging disease, the presence o which o these • Rec n ze r sk c rs r c n c ncer nd w ys red ce
markers suggests a poor prognosis i it remains elevated e r sk c n c ncer?
a ter surgical resection o the tumor? • M n e s m es?
A) Carcinoembryonic antigen (CEA)
B) β -hCG
C) CA-195 Clinical Pearls
D) Vasoactive intestinal peptide (VIP) a n e ev ed c e c n nd c e ss e sc em r m yp -
E) α - etoprotein (AFP) per s n (s ck, v sc r c mpr m se— e s -c ed “ ype a ”
c c c d s s). Be w re er c ses c c cd ss
Answer 22.14.5 The correct answer is “A.” T e presence o nc de n es ns s c s me n r e n , ver d se se,
CEA a er resection o a colon cancer is a poor prognostic ac- d be es, me rm n, d be es, e c. (“ ype B” c c c d s s).
tor. T is should be obvious: there is still tumor present. β -hCG a n Ng be s n necess ry n e re men sm
is elevated in testicular cancer. CA-195 is a marker or ovarian b we bs r c n. h wever, c n be e p n preven n
cancer (although it is also expressed by colon cancer cells). VIP v m n . t e r de- s n Ng be s nc m r b e.
is either the patient who everyone swarms over and nobody C mpress n s ck n s d n n preven p s per ve
can please or vasoactive intestinal peptide, which is ound with DVt s nd m y c se sk n bre kd wn: d n’ se em. u se
some pancreatic adenocarcinomas and carcinoid tumors. AFP s bc ne s ep r ns r n erm en pne m c c mpres-
is elevated in germ-cell tumors, such as testicular and ovarian s n n w e rym b z n.
cancer, and liver cancer.
 CHAPTER 22 • Ca RE o t h E Su Rg iCa l Pa t iENt 625

Maglinte DD, et al. Reliability and role o plain lm radiogra-

D n e “b se ne” bs s c s CBC, Pt /Pt t /iNR, r e ec-
phy and C in the diagnosis o small-bowel obstruction.
r y es pre per ve y w n nd c n n p en s w
Am J Roentgenol. 1996;167:1451–1455.
d n ve s n c n sys em c d se se. t ey re n e p-
. t r e y r pre per ve w rk p b sed n e p en ’s Marino PL. Marino’s T e ICU Book. 4th ed. Philadelphia, PA:
c m rb d es. Wolters Kluwer Health/Lippincott Williams & Wilkins; 2014.
Mechanick JI, et al. Clinical practice guidelines or the periop-
D n se c ds r d res sc n n ess ere s
erative nutritional, metabolic, and nonsurgical support o
spec c nd c n (e. ., b m n er r e v me p r cen-
the bariatric surgery patient—2013 update: Cosponsored
es s). t e c mes re ener y w rse n w crys d
by American association o clinical endocrinologists, the
nd e c ds re m re expens ve.
obesity society, and American society or metabolic &
o n y 65% p en s w c ecys s w ve p s - bariatric surgery. Obesity. 2013;21(S1):S1–S27.
ve M rp y’s s n nd 40% w ve ne er ever n r n McCahill LE, et al. Variability in re-excision ollowing breast
e ev ed w e c n . conservation surgery. JAMA. 2012;307:467.
P en s w ve d b r r c s r ery c n be v m n- Mittal MK, et al. Per ormance o ultrasound in the diagnosis o
de c en nc d n v m ns D, m ne, B12 nd e. a pediatric appendicitis in a multicenter cohort. Acad Emerg
m v mns d be s es ed n ese p en s. Med. 2013;20(7):697–702.
Pr p y c c n b cs s d be ven be ore s r ery nd Morris RJ, Woodcock JP. Intermittent pneumatic compression
not c n n ed er s r ery. or graduated compression stockings or deep vein throm-
t en percen p en s w ppend c s w ve n rm bosis prophylaxis? A systematic review o direct clinical
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Mulholland MW. Greenf eld’s Surgery: Scientif c Principles and
W en c e r z n ver d se se, e MEl D sc re s ess s b- Practice. 4th ed. Philadelphia, PA: Lippincott Williams &
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P enninger JL, Fowler GC. P enninger and Fowler’s Proce-
dures or Primary Care. 3rd ed. Philadelphia, PA: Elsevier
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Psychiatry
Monika Jindal
CASE 23.1
You are seeing a 48-year-old emale who presents with a
3-month history o low mood, low energy, poor concentra-
tion, and irritability. She has lost interest in most things she
had enjoyed and has also noticed a 20-lb weight gain. She has
been having requent headaches, has been short tempered,
and has noticed that it is hard to wake up in the morning.
She reports no thoughts o suicide but has wondered i death
would be a relie . She says she has elt restless or a while
and eels that she is a bad person. Her mother su ered rom
depression. She does not consume alcohol or any other sub-
stances. She is divorced and has no children.
You think that this patient may meet criteria or a depres-
sive disorder.
Question 23.1.1 Which o the ollowing is NOT a criterion
or the diagnosis o major depressive disorder (MDD)?
A) Low ood
B) Presence o suicidal ideation
C) Decreased a etite
D) Anhedonia or loss o interest
E) Mood uctuations
Answer 23.1.1 The correct answer is “E.” T e resence o
ood uctuation is not used to ake the diagnosis. Low ood
should be resent nearly every day to ake the diagnosis. All
o the other o tions listed are art o the criteria set orth in
the Diagnostic and Statistical Manual o Mental Disorders, 5th ed.
(DSM-5). S ecial e hasis is laced on the resence o
de ressed ood and decreased interest, one o which ust be
resent in order to diagnose MDD. Instead o de ressed ood,
atients ay re ort so atic co laints or irritability.
Criteria or Major Depression: wo weeks or ore o
de ressed ood or loss o interest or anhedonia AND our
o the ollowing: (1) signi cant change in weight or a etite;
(2) inso nia or hy erso nia; (3) sycho otor agitation or
retardation; (4) atigue or loss o energy; (5) eeling worthless
626
23
or excessive guilt; (6) oor concentration; and (7) recurrent
thoughts o death, suicidal ideation, atte t, or lan.
HELPFUL TIP:
Seve al mnemonics ave been developed o elp clini-
cians emembe e DSM-5 c i e ia and wo o ese a e
“SIG-ECAPS” and “SPACE DIGS.” Sleep, In e es , Guil ,
Ene g , Concen a ion, Appe i e, Ps c omo o c anges,
Suicidali .
Question 23.1.2 Which one o this patient’s symptoms is
considered an atypical symptom o “a typica l depression”
or MDD?
A) Hy erso nia
B) Low ood
C) Anhedonia
D) Psycho otor retardation
E) Irritability
Answer 23.1.2 The correct answer is “A.” T e ty ical vegeta-
tive sy to s o de ression include oor slee or inso nia,
reduced a etite, and decreased libido. Patients with atypi-
cal depression have hyperphagia, hypersomnolence, leaden
paralysis, and mood reactivity.
You begin to explain the nature o depression to this patient.
Question 23.1.3 Which o the ollowing epidemiological
statements is NOT true?
A) T e average A erican has about a 16% chance o develo ing
de ression over his or her li eti e
B) About 7% o A ericans su er de ression each year
C) Wo en are ve ti es as likely to su er de ression as are
en
D) T e incidence o de ression is increasing in younger cohorts
E) Divorced eo le are ore likely to be de ressed
 CHAPTER 23 • PSyCh IAt r y 627

Answer 23.1.3 The correct answer is “C.” T e li eti e reva-

HELPFUL TIP:
lence o MDD is 16% with 6.9% o adults su ering ro MDD
t e e a e seve al b ie sel - a ing dep ession scales a
in any given year. De ression ay be recurrent throughout
can be used o sc eening (e.g., Beck Dep ession Inven-
one’s li eti e. Wo en are twice (not ve ti es) as likely to have
o , P ima Ca e Evalua ion o Men al Diso de s, Pa-
de ression than are en. T e rate beco es equal in the elderly
ien h eal Ques ionnai e, and Zung Dep ession Scale).
with elderly en being at a higher risk o suicide than elderly
A wo-ques ion sc een ma be as e ec ive o sc eening
wo en. Being divorced is a risk actor or de ression.
as ese mo e ex ensive scales. Simpl ask:

HELPFUL TIP: • Ove e pas 2 weeks, ave ou o en el down, blue

Anxie , no mee ing e level o an anxie diso de , o in e dumps?
equen l accompanies dep ession (70%). h oweve , • Ove e pas 2 weeks, ave ou los in e es in mos
60% o people wi a li e ime diagnosis o MDD ave ac ivi ies o ings a used o b ing ou pleasu e?
ad a diagnosable anxiety disorder. A posi ive answe o ei e o ose wo ques ions
s ould p omp a mo e o oug evalua ion o dep es-
sion. A nega ive answe o bo e ec ivel ules ou de-
T is patient’s situation is not unusual or your practice. p ession in mos pa ien s.

Question 23.1.4 What is the prevalence o MDD in primary

care patients?
You realize that it is also important to ocus on the social his-
A) 1% to 2%
tory in patients with depression.
B) 5% to 10%
C) 25% to 30%
Question 23.1.6 Which o the ollowing is associated with a
D) 45% to 50%
DECREASED risk o depression?
E) 100% (see s like everyone . . . even the clinic sta )
A) Une loy ent
B) Poverty
Answer 23.1.4 The correct answer is “B.” About 5% to 10% o
C) Being un arried
ri ary care atients eet criteria or MDD and about twice o
D) Fa ily history
that (10–20%) any have “ inor” de ression. I you answered
E) Asian race
“E,” you work in a sad, sad lace. Hire a clown to work the ront
desk.
Answer 23.1.6 The correct answer is “E.” Factors associated
with an increased risk o de ression include being un arried
HELPFUL TIP: (single or divorced), having a a ily history o de ression, a
One eason o lack o diagnosis o dep ession in p ima recent childbirth or regnancy, edical co orbidities, lack o
ca e is a dep ession o en p esen s wi soma ic social su ort, emale gender, une loy ent, overty, and
complain s. Ano e is a e spec um o disease substance use. T ere is a lower revalence o de ression a ong
in p ima ca e o ices is less seve e, leading o ewe eo le o Asian and Black ancestry when co ared to the Cau-
diagnoses. casian o ulations. Protective actors include arriage, having
children, and being retired (so, retire ent is when we are su -
osed to have un?).
Question 23.1.5 Which o these epidemiological state -
ments about depression in primary care is true? You believe that your patient is su ering rom an episode o
A) Most de ressed atients (about 80%) seek ental health major depression, and you decide to initiate treatment with
care ro ri ary care hysicians an antidepressant.
B) Only about 50% o the atients with de ression are recog-
nized by their ri ary care hysician Question 23.1.7 Following the rst episode o depression,
C) Only about hal o the atients diagnosed with MDD receive what is her risk o relapse?
adequate treat ent A) < 1%
D) T e 2015 United States Preventive Services ask Force B) 25%
(USPS F) reco ends screening and having adequate sys- C) 50%
te s or treat ent, ollow-u and/or re erral. D) 75%
E) All o the above. E) > 99%

Answer 23.1.5 The correct answer is “E.” All are correct. “D” Answer 23.1.7 The correct answer is “C.” T e incidence o
requires s ecial ention. T e revious (2009) reco endation rela se ollowing the rst e isode o de ression is roughly 50%.
suggested screening contingent u on having adequate services wo-thirds o these rela ses can be revented by continuing
or atients diagnosed with de ression. antide ressant edications chronically. Following the second
628 FAMILy MEDICINE EXAMINAt ION & BOAr D r EVIEW
e isode, the risk o rela se is roughly 75%, cli bing u to 90%
a er the third e isode. In order to reduce the risk o rela se,
ost authorities reco end antide ressant thera y or 6 to
12 onths a er re ission in atients with their rst e isode o
de ression. Patients who ight bene t ro inde nite edical
thera y include those with a severe rst e isode (e.g., signi cant
suicide atte t), atients with a sychotic de ression, atients
with three or ore e isodes, elderly atients with their rst e i-
sode o de ression, and ossibly those with a strong a ily his-
tory o de ression.
You choose a serotonin reuptake inhibitor (SSRI) and tell
your patient to contact you i she su ers rom adverse e ects.
Question 23.1.8 Which o the ollowing is NOT a typical
adverse ef ect o SSRIs?
A) Nausea
B) Headaches
C) Restlessness
D) Inso nia
E) Urinary retention
Answer 23.1.8 The correct answer is “E.” Urinary retention is
not seen with SSRIs, but the other our o tions are ty ical o
SSRIs. T e anticholinergic e ect o urinary retention is ty ical
o the tricyclic antide ressants ( CAs). Sexual dys unction and
GI roble s are co only seen with SSRIs. Akathisia and dys-
tonic reactions can (rarely) be seen with SSRIs as well.
Your patient returns to see you 2 weeks a er starting her
SSRI and reports that she has not noticed any bene t rom
the medication.
Question 23.1.9 Which o the ollowing statements is most
accurate?
A) T e antide ressant is not going to work, so she should switch
edicines to one o the sa e class
B) T e antide ressant is not going to work, so she should switch
edicines to another antide ressant ro a di erent class
C) It is too early to judge the ef cacy o the antide ressant at
this oint
D) She’s robably su ering a aradoxical reaction o increased
de ression with her edication
E) Going u on the dose is not an o tion at this ti e
Answer 23.1.9 The correct answer is “C.” T e e ects o antide-
ressant drugs on de ression usually take 3–4 weeks (although
side e ects such as sedation, etc. will occur right away). T us, it
is re ature to abandon this edication. Most authorities rec-
o end trying an antide ressant or 6 weeks at an adequate
dose be ore considering that edication a treat ent ailure.
Increasing the dose or giving it at least 4 to 6 weeks total at the
current dose would be valid o tions.
You increase the medication dose, and the patient returns to
see you in another 2 weeks. T is time, she is eeling better and
more energetic. People at work are beginning to notice her
improved attitude, and her sleep has become more re resh-
ing. She wants to know how long she should stay on the medi-
cation.
Question 23.1.10 The correct answer is:
A) At least 1 onth
B) At least 2 onths
C) At least 4 to 6 onths
D) At least 2 years
E) Forever
Answer 23.1.10 The correct answer is “C.” Di erent organiza-
tions reco end di erent durations o treat ent but the short-
est reco ended course is 4 to 6 onths, with ost authorities
treating or 6 to 12 onths a er recovery.
Objectives: Did you learn to . . .
• Diagnose MDD?
• App ecia e e epidemiolog and na u al is o o
dep ession?
• r ecognize ea u es o a pical dep ession?
• Ini ia e ea men o dep ession?
• Iden i adve se e ec s o SSr Is?
CASE 23.2
You are assessing a 45-year-old pro essional male who has
a history o MDD in his early 20s but has ully recovered
since then. He recently su ered an uncomplicated anterior
wall myocardial in arction (MI). His wi e mentions that she
thinks he is depressed. He is tired all the time, has poor sleep,
a poor appetite, and he has been irritable. He has also been
tear ul and blames himsel or his MI (too many “pounder”
burgers . . . with cheese . . . and bacon). He is willing to con-
sider the diagnosis o depression because he remembers hav-
ing su ered rom it be ore. He also knows a history o MDD
puts him at risk or medical illnesses.
Question 23.2.1 Which o the ollowing illnesses is more
prevalent in patients with MDD?
A) Coronary heart disease
B) Cerebrovascular disease
C) Diabetes ellitus
D) Osteo orosis
E) All o the above are ore revalent in de ressed atients
Answer 23.2.1 The correct answer is “E.” It is unclear i
patients with depression are more likely to have these illnesses
as a result o the depression or the reverse: patients with these
illnesses are more likely to be depressed. De ressed atients
have an average o 3.4 ore chronic edical conditions than
nonde ressed atients. At least two studies have now linked a
li eti e history o MDD to an increased risk (1.2–3 ti es) o
early eno ause (o course, that would be a bit strange in our
atient, a ale).
You know that some o this patient’s symptoms could be
secondary to his medical illness.

Question 23.2.2 Which one o the ollowing symptoms, i
present, is the most specif c or depression?
A) Slee roble s
B) A etite dif culties
C) Psycho otor agitation
D) Low energy
E) Excessive reoccu ation with death
Answer 23.2.2 The correct answer is “E.” In the ne onic
“SPACE DIGS,” the last our letters stand or sy to s that are
ore s eci c or de ression and ore inde endent o so atic
illnesses. T ese sy to s are De ressed ood, loss o Inter-
ests, ina ro riate Guilt, and thoughts o Suicide (“DIGS”). T e
resence o any o these sy to s should lead you to sus ect
de ression.
HELPFUL TIP:
W ile dep ession can o en be p ecipi a ed b a s es-
so , i can also a ise wi no p ecipi a ing ac o , and
e esponse o ea men is independen o w e e
i is “ eac ive” (iden i iable s esso p esen ) o “endog-
enous” (no iden i iable s esso ).
Question 23.2.3 Which o the ollowing statements is NOT
true about depression post-MI?
A) Major de ression is an inde endent risk actor or ost-MI
ortality
B) Minor de ression is an inde endent risk actor or ost-MI
ortality
C) Minor de ression is ore revalent than ajor de ression
ost-MI
D) reating de ression i roves cardiac outco es in ost-MI
atients
E) A roxi ately hal o the eo le who sustain an MI have
sy to s o de ression a erward
Answer 23.2.3 The correct answer is “D.” In the ost-MI
eriod, ajor de ression revalence is al ost 20%, and inor
de ression is about 27%. Concurrent ajor de ression elevates
ortality risk a er MI by a actor o 3.5, which is the sa e
degree o risk as heart ailure. Patients with a ood distur-
bance (e.g., inor de ression) also have a higher ortality
rate. While treat ent o de ression has been shown to i rove
so e edical outco es (e.g., HbA1C levels in diabetics), this is
not the case in cardiovascular disease. reat ent o de ression
does not change ortality or orbidity a er an MI (but ay
i rove quality o li e).
HELPFUL TIP:
Pa ien s su e ing s okes also ave an eleva ed isk o
dep ession wi app oxima el one- i d o pos -s oke
pa ien s mee ing c i e ia o MDD; e e is a simila co -
ela ion o dep essive s mp oms o s oke mo ali .
CHAPTER 23 • PSyCh IAt r y 629
You decide to recommend treatment to this patient.
Question 23.2.4 Which o the ollowing therapies is the
LEAST desirable choice or treating his depression?
A) Bu ro ion (Wellbutrin)
B) Cognitive behavioral thera y
C) Nortri tyline
D) Fluoxetine (Prozac)
E) Sertraline (Zolo )
Answer 23.2.4 The correct answer is “C.” CAs should be
avoided in atients with cardiovascular disease because o their
arrhyth ogenic otential (e.g., torsades de ointes). Re e -
ber that SNRIs and citalo ra (Celexa) can also rolong the
Q interval. Bu ro ion (“A”) and cognitive behavioral thera y
(CB ) (“B”) are also reasonable choices. Generally, SSRI ther-
a y (“D” and “E”) would be the re erred drug or the ajority
o atients who are candidates or har acothera y.
HELPFUL TIP:
Conside a baseline ECG in all pa ien s o w om ou a e
conside ing t CAs and ci alop am o evalua e e Qt in-
e val. I e Qt is p olonged a baseline, i p edisposes
pa ien s o a mias.
Objectives: Did you learn to . . .
• Diagnose dep ession occu ing wi an acu e medical ill-
ness?
• r ecognize e impac o dep ession on o e medical condi-
ions?
• t ea a pos -MI pa ien wi dep ession?
QUICK QUIZ: SAD ALL t h E t IME
A 44-year-old atient o yours has co e to see you ulti le
ti es or low ood. She does not have trouble with energy or
slee , but with ro ting re orts occasional roble s with
concentration and a etite. Basically, she tells you, “I’ve been
de ressed or as long as I can re e ber.” You have tried treat-
ing her with two di erent SSRIs, but she had trouble with side
e ects and did not notice uch i rove ent in her ood.
Which o the ollowing is the best diagnosis or this atient?
A) Adjust ent disorder
B) Bi olar a ective disorder
C) Persistent de ressive disorder (dysthy ia)
D) MDD
E) Pre enstrual dys horic disorder
The correct answer is “C.” Persistent de ressive disorder ( or-
erly dysthy ia in DSM-4) is best thought o as long-ter ,
low-level de ressive sy to s that do not eet criteria or
MDD. Sy to s include de ressed ood ost days or at
least 2 years and two or ore o the ollowing: concentration
630 FAMILy MEDICINE EXAMINAt ION & BOAr D r EVIEW
dif culties, ho elessness a etite change, slee disturbance,
low energy or atigue, and low sel -estee . In order to diag-
nose ersistent de ressive disorder, the erson cannot be ree o
the sy to s or ore than 2 onths during the rst 2 years.
T e treat ent is the sa e as or de ression; ersistent de ressive
disorder res onds to SSRIs and sychothera y. Many eo le
with ersistent de ressive disorder ay also ex erience one or
ore e isodes o MDD in their li eti e.
CASE 23.3
A 34-year-old emale presents to your clinic or treatment o
depression. She reports a li elong history o low-level depres-
sive symptoms that have worsened over the past 6 months
since she lost her job (don’t worry—this is a di erent case
than the previous one). She also su ers rom inadequately
controlled diabetes mellitus (HbA1C 9.0%) and has been
diagnosed with a personality disorder in the past. She drinks
3 to 4 beers everyday (hmm . . . multiply by 2 just to be sa e)
and has been arrested or driving while intoxicated twice. On
questioning, you realize she has a moderately severe level o
depression. She is not suicidal so you decide to initiate treat-
ment as an outpatient with close ollow-up.
Question 23.3.1 Which o these actors does NOT contrib -
ute to a poor outcome when treating depression?
A) Chronic de ressive sy to s
B) Fe ale gender
C) Personality disorder
D) Co orbid edical conditions
E) Alcoholis
Answer 23.3.1 The correct answer is “B.” Even though e ales
are twice as likely to get de ressed as ales, gender does not
see to in uence treat ent res onse. T e resence o any o the
other actors listed reduces the chance o a success ul res onse
to treat ent.
In choosing an antidepressant or this patient, you would
like to use one with a high success rate (as opposed to other
patients who you might treat with one that doesn’t work or a
placebo—what?). However, you know that the success rates
or most antidepressants are airly similar.
Question 23.3.2 What are the chances o this patient ailing
to respond to the rst antidepressant chosen?
A) < 1%
B) 10% to 20%
C) 30% to 40%
D) 60% to 70%
E) 90% to 95%
Answer 23.3.2 The correct answer is “C.” Studies have con-
sistently shown an antide ressant res onse rate o so ewhere
between 60% and 70% with 30% to 40% ailing to res ond,
regardless o what antide ressant is tried. When un ublished
studies are included, the ailure rate or SSRIs a roaches 50%.
HELPFUL TIP:
Fi pe cen o pa ien s w o do no espond o an ini-
ial SSr I will espond o ano e d ug in e same class.
So, c anging o ano e SSr I is easonable in a pa ien
w o as ailed one SSr I. Is is obse ved e ec due o
di e ences be ween d ugs, p a macod namics, p a -
macogene ics, o longe ea men ? No one knows.
When you spin your Random Depression T erapy Wheel
that your occultist riend gave you during the last blue moon,
it lands on venla axine (E exor). So, you start your patient
on that drug. en days later, she calls you just to say that the
new medicine seems no better and her sleep is even worse.
She started taking the medication in the morning because
she thought it might be inter ering with her sleep. She tends
to lie in bed or 2 hours be ore alling asleep.
Question 23.3.3 In addition to recommending good sleep
hygiene and increased exercise, you prescribe:
A) razodone
B) Zol ide
C) Loraze a
D) Phenobarbital
E) wo shots o whiskey QHS, re erably a classic like Basil
Hayden
Answer 23.3.3 The correct answer is “A.” razodone is o en
added to hel with inso nia and boost serotonergic activity.
For de ression, it is re erred to benzodiaze ines unless anxi-
ety is a signi cant issue. Additionally, given this atient’s daily
alcohol use, neither benzodiaze ines (nor ore alcohol!) are
advised. Phenobarbital should be avoided. Zol ide ight be a
consideration (Hey, I don’t re e ber driving the car in y
underwear and baking two ans o lasagna last night, but oh
well), but trazodone is re erred in atients with de ression.
Obviously avoid alcohol or slee in this and other atients.
HELPFUL TIP:
Indica ions o ps c ia ic e e al o dep ession in-
clude:
• Failu e o medical ea men
• Imminen suicidali
• Seve e dep ession o w ic ospi aliza ion is oug
o be necessa
• Diagnos ic cla i ca ion o ea men ecommenda-
ion
• Como bidi ies a make ea men esponse less
likel
• Pa ien eques s e e al
You add trazodone 50 mg HS PRN and titrate up to the
maximum dose o venla axine, and your patient’s symptoms
are now coming under control. When you see her next, she

describes a 20-minute episode o chest tightness, dyspnea,
diaphoresis, and extreme anxiety. You believe that she su -
ered a panic attack. You wonder i you should alter your
diagnosis.
Question 23.3.4 In which o the ollowing disorders do
panic attacks NOT occur?
A) Panic disorder
B) MDD
C) Generalized anxiety disorder
D) Social hobia
E) None o the above
Answer 23.3.4 The correct answer is “E.” Panic attacks are a
cluster o sy to s signi ying anxiety and are not a disorder by
the selves. As such, they can be art o any a ective syndro e
and are requently seen in a variety o syndro es including
those entioned above. T e resence o a single anic attack in
a erson with a de ressive disorder should not necessarily lead
to a new diagnosis.
Objectives: Did you learn to . . .
• Iden i isk ac o s o a poo ou come w en ea ing
dep ession?
• Assess e likeli ood o a success ul ou come in a pa ien
wi dep ession?
• Gene a e al e na ive me ods o ea ing esis an
dep ession?
CASE 23.4
A 41-year-old emale comes to your o ce complaining o di -
culty trusting people, irritability, low mood, and recurrent
nightmares. Her symptoms started ollowing the death o her
parents in a house re when she was a teenager. She has never
been able to orgive hersel or surviving while her parents
died. She has not been able to orm close relationships, and
she is seeking help because o renewed nightmares. T ey were
common in the rst 2 years ollowing the incident but had
aded away until recently. Continuing news reports o ter-
rorist activities and bombings (FYI . . . we are on the 4th edi-
tion here, and this is still relevant . . . sigh) have brought all o
this back to the ore ront again. She sometimes wakes up in a
right a er dreaming that her own house is on re. She avoids
going near any bright lights or reworks displays. When she
is orced to be in the presence o res, she requently notices
palpitations, dyspnea, and a sense o doom.
Question 23.4.1 What is the patient’s primary diagnosis?
A) MDD
B) Generalized anxiety disorder
C) Panic disorder
D) Post-trau atic stress disorder (P SD)
E) Acute stress disorder
Answer 23.4.1 The correct answer is “D.” T e atient’s sy -
to s are characteristic o P SD, which arises a er one has been
ex osed to a situation in which one’s li e or “ hysical integrity”
CHAPTER 23 • PSyCh IAt r y 631
(or that o another erson) is in danger. Kee reading or ur-
ther ex lanation o why this is the best choice.
Question 23.4.2 Which o the ollowing is NOT necessary or
a diagnosis o PTSD?
A) T e atient needs to ex erience, witness, or be con ronted
by a otentially li e-threatening event, or an event threaten-
ing the hysical integrity o the atient or others
B) T e atient ust res ond with intense ear, horror, or hel -
lessness
C) Sy to s have to be resent or ore than a onth
D) T e atient ust be involved in co bat
E) T e atient ust eet a s eci ed nu ber o sy to s
Answer 23.4.2 The correct answer is “D.” Although P SD is
co on a ong ilitary veterans (and was reviously known by
ter s like “shell shock” and “battle atigue”), there is no require-
ent that the atient has been in co bat. o eet criteria or
P SD, the atient ust have been ex osed to an event that is
threatening to the integrity or li e o the atient or another. Such
events are as varied as co bat, ra e, assault, cancer, or an inten-
sive care unit stay (or, one could hy othesize, taking the boards,
erha s?). T e atient then has recurrent intense ear, hel less-
ness, or horror that lasts or > 1 month. Sy to s occurring
within 4 weeks o the event and lasting or at least 2 days but less
than a onth can quali y or the diagnosis o acute stress disorder.
Question 23.4.3 Which o the ollowing is NOT a part o
PTSD?
A) Night ares
B) Flashbacks
C) Hy ervigilance
D) Fear o death
E) Dif culty aintaining relationshi s
Answer 23.4.3 The correct answer is “D.” Fear o death is not a
criterion. Sy to s o P SD are divided into our clusters. o
eet the sy to criteria or P SD, the atient needs at least
one sy to ro the rst cluster, one ro the second, two or
ore ro the third, and two or ore ro the ourth.
T e rst cluster (one required) involves intrusive sy -
to s regarding the trau atic ex erience (e.g., ashbacks,
night ares, intrusive e ories and sychological distress in
res onse to triggers that evoke the ex erience).
T e second cluster (one required) involves avoidance o
sti uli associated with the trau a ( eo le, laces, events) and
avoidance o distressing e ories, thoughts, or eelings related
to the trau a.
T e third cluster (two or more required) relates to nega-
tive ood and negative changes in cognition a er the trau atic
event. Patients ay re ort a nu bing o general res onsiveness
( arkedly di inished interest or artici ation in signi cant
activities, eeling o detach ent or estrange ent ro others,
inability to ex erience ositive e otions, being in a negative
e otional state). T ey ay have negative thoughts distortions
toward the selves (negative belie s about the selves or the
causes o the trau atic event).
632 FAMILy MEDICINE EXAMINAt ION & BOAr D r EVIEW
T e ourth cluster (two or more required) involves ersis-
tent sy to s o increased arousal, such as dif culty alling or
staying aslee , irritability or outbursts o anger, dif culty con-
centrating, hy ervigilance, or an exaggerated startle res onse.
Question 23.4.4 Which o the ollowing is true o treatment
or PTSD?
A) T ere is no e ective treat ent
B) T ere are no FDA-a roved edications
C) Most atients ex erience s ontaneous re ission
D) Although treat ent is o en e ective, ost atients do not
achieve cure
E) Aty ical anti sychotics have no role in treat ent
Answer 23.4.4 The correct answer is “D.” Sy to i rove-
ent, but not cure, is the nor . Cognitive behavioral thera y
is the rst-line thera y ollowed by SSRIs then SNRIs. Interest-
ingly, “critical incident debrie ng” (essentially talking through
the incident or reliving the event to try to ini ize sy to s,
such as with e otive journaling) actually see s to ake things
worse. CB and “objective, none otive” journaling see to
hel (see Soc Sci Med. 2011;7:316–326 and Ann Behav Med.
2002;24:244–250, or exa le). T ere is no good ef cacy data
or CAs, aty ical anti sychotics, onoa ine oxidase inhibi-
tors (MAOIs), or other drugs. Prazosin ay hel with slee
and night ares but the studies are s all; still, it is worth a trial
added to other har acothera y i the atient is not res ond-
ing in an adequate anner. Psychothera y can be hel ul and
benzodiaze ine use should be li ited because o the high risk o
de endency in this o ulation and the lack o ef cacy as ono-
thera y.
Objectives: Did you learn to . . .
• r ecognize isk ac o s o Pt SD?
• Diagnose Pt SD?
• t ea Pt SD?
CASE 23.5
A 29-year-old emale presents to you or a second opinion,
bringing a large stack o medical records with her. In act, she
says that this is more like a “ ourth or h opinion” (lucky
you). She heard rom a riend o a riend that you are the
smartest doctor around and could determine what is wrong
with her. In act, she notes, “None o those other doctors
understand my symptoms at all. But you will. T ey say you’re
the best.”
Although you nd many negative diagnostic studies in her
record, she is sure that her many symptoms must have some
physical cause. Over the last ew years, she has had chronic
headaches, multiple joint pains, and intermittent abdomi-
nal and chest pains. Her symptoms have prevented her rom
working. She has diarrhea and bloating on occasions, but
upper endoscopy, colonoscopy, C scans, and other studies
have not revealed an etiology. She reports severe anxiety that
has worsened with the onset o “seizures” in the last year (and
you note that brain MRI, EEG, and neurological examination
at the time did not support a seizure disorder). Additionally,
she complains o some vague weakness and numbness and
thinks that she might have had a stroke. Nothing she does
improves any o these symptoms. Further review o her
records shows a variety o diagnoses rom di erent physi-
cians: “chronic pain syndrome,” “chronic atigue,” “ bromy-
algia,” “irritable bowel syndrome,” “premenstrual syndrome,”
and others.
Question 23.5.1 Which o the ollowing is the most likely
primary diagnosis?
A) Illness anxiety disorder ( or erly hy ochondriasis)
B) So atic sy to disorder ( or erly so atization disor-
der)
C) Generalized anxiety disorder
D) Factitious disorder
E) Conversion disorder
Answer 23.5.1 The correct answer is “B.” y ically, atients
with unex lained sy to s see any doctors, have nu erous
tests, and o en undergo a variety o rocedures. At the outset,
it is i ortant to consider a ri ary sychiatric disorder, but
a thorough and a ro riate evaluation into ossible organic
causes should be co leted be ore a sychiatric diagnosis is
reached. Many ti es, atients with unex lained sy to s
will ulti ately be diagnosed with a so atic sy to disorder
as well as a related disorder (o which “A,” “D,” and “E” are all
ty es).
T is atient resents with so atic sy to disorder, which
by de nition ust have:
• One or ore so atic sy to that is distressing or disru -
tive o daily li e;
• Excessive thoughts, behaviors, or eelings associated with the
so atic sy to s which are exhibited by dis ro ortionate
thoughts about the seriousness o sy to s, high anxiety
about sy to s, or large a ounts o ti e and energy s ent
on the health concerns;
• Sy to s are ersistent, generally at least 6 onths.
“A” is incorrect. Illness anxiety disorder is characterized by
a preoccupation that one has some sort o serious disease,
and somatic symptoms are either not present or are less
intense. “C” is incorrect because anxiety is resent but totally
overshadowed by the so atic co laints. “D,” actitious dis-
order, is diagnosed in atients who intentionally roduce
sy to s (e.g., overdosing on insulin or injecting eces into
the bloodstrea ) to assu e the “sick role.” “E” is incorrect.
With conversion disorder, atients resent with sudden
onset o anato ically i lausible neurological sy to s
(e.g., whole-body nu bness and bilateral dea ness). Conver-
sion disorder is, by de nition, not under conscious control. I
it is under conscious control, the diagnosis is “ alingering”
(really . . . that is a diagnosis). Re e ber that conversion dis-
order is, to so e degree, a diagnosis o exclusion. You need
to ake sure there is not an organic basis or the atient’s
sy to s.

You believe that this patient has somatic symptom disorder.
Question 23.5.2 You begin by saying:
A) “Relax. T is is all in your head.”
B) “Your ain isn’t real. But your sychiatric illness is. It’s called
so atic sy to disorder.”
C) “You have a nu ber o sy to s that are very real but can-
not be ex lained by our investigations. T e evidence sug-
gests that you do not have any li e-threatening illnesses. You
have a well-de ned disorder, and other atients have si ilar
roble s.”
D) “You have a lot o very serious sy to s. But y hysical
exa is inconsistent with your co laints. Basically, I don’t
believe a word your saying. T e sooner that you ad it to al-
si ying these sy to s, the sooner I can start hel ing you.”
E) “I have a s ecialist to re er you to in Outer Mongolia . . . take
your ti e getting back.”
Answer 23.5.2 The correct answer is “C.” In atients with
so atic sy to disorder, it is best to use an honest but gentle
a roach. Most atients eel better i they have a na e or an ill-
ness, but using the ter “so atic sy to disorder” ay actually
be detri ental. It is i ortant to af r the atient’s sy to s
(these are real roble s causing real distress) and to try to nd
so e co on language to use to describe what he or she is eel-
ing. Patients ay not be rece tive to your inter retation initially,
but re eating the discussion at subsequent visits and ocusing on
nor al diagnostic tests ay hel the acce t the diagnosis.
Next, you discuss a plan o action with this patient.
Question 23.5.3 You recommend:
A) A ultidisci linary a roach, utilizing any di erent s e-
cialty services
B) Starting an SSRI
C) Starting electroconvulsive thera y (EC )
D) Monthly visits with you and li ited diagnostic testing and
s ecialty consultation
E) Re erral or ex loratory la aroto y
Answer 23.5.3 The correct answer is “D.” It is best to have
atients with so atic sy to disorder establish regular clinic
visits, ideally with one rovider. Unscheduled visits to the e er-
gency de art ent should be discouraged unless rst discussed
with the ri ary rovider. Patients should be allowed to dis-
cuss all o their co laints, and a hysical exa ination should
be er or ed at every of ce visit. T ese easures will let the
atients know that their concerns are being taken seriously.
Laboratory tests, radiogra hs, and consultations should be li -
ited, with the clinician using his or her best judg ent as to when
such diagnostic tests are indicated. “B” and “C” are incorrect as
SSRIs and EC are not acce ted thera y or so atic sy to
disorder. But, you could robably rescribe an aty ical anti-
sychotic or benzodiaze ine (neither o which work) but will
sedate the atient enough that she won’t bother you any ore
(OK, don’t do that . . . it’s just a joke).
CHAPTER 23 • PSyCh IAt r y 633
HELPFUL TIP:
In pa ien s wi soma ic s mp oms diso de w o a e
willing o be e e ed o men al eal p ovide s, indi-
vidual ps c o e ap , CBt , and g oup e ap ma be
bene icial.
Objectives: Did you learn to . . .
• r ecognize and desc ibe soma ic s mp om diso de ?
• Gene a e an app op ia e plan o a pa ien wi soma ic
s mp om diso de ?
CASE 23.6
A 21-year-old college student presents to your o ce or evalu-
ation. She is complaining o eeling stressed out. She is taking
classes ull-time and is also in one o the military reserve units
at the college. One weekend a month, she must attend drill that
involves handling weapons. Although she did not have prob-
lems handling the weapons initially, she now gets very emo-
tional and upset when she thinks about having to use them at
the next drill weekend. She is nervous and is a raid that she
might accidentally re a weapon. She knows that her ears are
silly and she has been telling hersel to “just get over it.” Last
weekend, while at drill, she suddenly elt that she was going to
have a heart attack. She developed tightness in her chest, her
heart was racing, and she elt unable to breathe. Although the
symptoms eventually abated, the episode made her even more
alarmed, and now she is worried that it will happen again and
she will have a heart attack. She comes to see i you can help.
Question 23.6.1 Which o the ollowing is UNNECESSARY
or the initial workup?
A) ake ore edical, sychiatric, and a ily history
B) Order an echocardiogra
C) Per or a hysical exa ination
D) Order thyroid unction tests
E) Per or a ental status exa ination
Answer 23.6.1 The correct answer is “B.” Given the in or a-
tion you have so ar, an echocardiogra is not indicated and
is rarely used as art o a ri ary worku . When it co es to
test questions, never say no to ore history (unless you are su -
osed to be anaging a atient’s airway). A co lete history
and hysical exa ination are essential in the evaluation o this
new atient. T yroid abnor alities can be a cause o so e o
these sy to s, including al itations and chest tightness.
She has no prior psychiatric history, but her mother is taking
medication or depression. While taking her social history,
you ask questions regarding substance abuse.
Question 23.6.2 Use o which o the ollowing substances
might explain her symptoms?
A) Nicotine
B) Alcohol
C) Ca eine
634 FAMILy MEDICINE EXAMINAt ION & BOAr D r EVIEW
D) Herbal weight loss edication
E) Any o the above
Answer 23.6.2 The correct answer is “E.” Many substances can
cause sy to s like this atient has. T ese include sti ulants,
such as ca eine and nicotine, and so e herbal weight loss rod-
ucts containing e hedra (Ma Huang). Withdrawal ro hy -
notics like alcohol can also lead to si ilar sy to s.
She does not smoke, doesn’t drink alcohol (you can tell
she’s not a Hawkeye . . . no tailgating?!), and drinks co ee on
weekday mornings be ore class. Her physical examination is
normal. Her mental status examination is remarkable or a
neutral mood, a restricted and anxious a ect, but no suicidal
thoughts, and no psychotic symptoms. T e laboratory tests
you order are normal. You are leaning toward a psychiatric
diagnosis at this point, speci cally an anxiety disorder.
Question 23.6.3 Which o the ollowing is NOT an anxiety
disorder?
A) Panic disorder
B) Social anxiety disorder
C) Agora hobia
D) Generalized anxiety disorder
E) Deliriu
Answer 23.6.3 The correct answer is “E.” Deliriu , while it
ay resent with eatures si ilar to an anxiety disorder, is a
cognitive disorder. Anxiety disorders are the ost co on
or o ental illness in the United States, with a li eti e rev-
alence o 28.8%. T ey include o tions “A” through “D” as well
as se aration anxiety disorder, s eci c hobias, selective ut-
is , uns eci ed anxiety disorder, and anxiety disorders that are
judged to be secondary to a edical condition or a substance.
O the listed anxiety disorders, you think she has developed
panic disorder and that she has been having panic attacks.
Question 23.6.4 Which o the ollowing is NOT a typical
symptom o a panic attack?
A) Pal itations
B) Dia horesis
C) Synco e
D) Dys nea
E) Dizziness
Answer 23.6.4 The correct answer is “C.” T e sy to s o a
anic attack are those associated with an activation o the “ ght-or-
ee res onse,” or the overactivation o the sy athetic nervous
syste . y ical sy to s include chest ain, nausea, dizziness,
nu bness, al itations, sweating, tre bling, dys nea, a sense o
s othering, ear o dying, tingling, and derealization or de er-
sonalization. (At this oint, we’d like to ask Mother Nature how
chest ain hel s us when acing a saber-toothed tiger.) It would
be rare or a atient to actually lose consciousness ro a anic
attack (though they ay eel they ight), and actual synco e
should orce one to look or an alternate diagnosis.
HELPFUL TIP:
h pe ven ila ion can cause ce eb al vasocons ic ion
and seconda ce eb al poxia esul ing in s ncope.
t is can occu wi panic diso de . h oweve , is is
p e unusual.
o make your diagnosis o panic disorder, the patient needs
to meet certain criteria.
Question 23.6.5 Which o these is NOT a criterion or panic
disorder?
A) Recurrent and unex ected anic attacks
B) At least 1 onth o worry about having ore attacks
C) Worry about the i lication o the attack or its conse-
quences (dying, “going crazy,” etc.)
D) Change in behavior related to the attacks
E) Predictable anic attacks that occur in res onse to cues
Answer 23.6.5 The correct answer is “E.” T e criteria or anic
disorder do not include redictable anic attacks in res onse to
cues. A er atients have had re eated anic attacks, they o en
develo hobic avoidance o laces, objects, or events associ-
ated with their sy to s (e.g., agora hobia). Agora hobia is a
se arate diagnosis in DSM-5. Patients o en scout out routes o
esca e be ore going to laces that ight rovoke an attack—o
the anic variety as o osed to the terrorist variety.
HELPFUL TIP:
t e vas majo i o pa ien s wi panic diso de p esen
wi soma ic complain s a e an cogni ive o mood
s mp oms. Pa ien s a e o en misdiagnosed ini iall .
Conside panic a acks in pa ien s p esen ing wi e
app op ia e soma ic s mp oms. And neve ule ou a
p sical diagnosis (e.g., PSVt ) wi ou an app op ia e
wo kup.
Your patient is worried that these attacks will keep occurring.
Question 23.6.6 How would you best describe the progno-
sis or panic disorder?
A) It is easily curable in ost atients
B) T ere is no e ective drug treat ent beyond benzodiaz-
e ines, es ecially al razola (Xanax)
C) Most atients do not i rove over ti e
D) It is a recurrent or chronic illness
E) None o the above
Answer 23.6.6 The correct answer is “D.” Panic disorder is a
recurrent or chronic disease in ost atients. “A” and “C” are
incorrect. Although anic disorder is not easily curable, al ost
all atients will i rove over ti e, but very ew attain co lete
re ission even with edical treat ent. Rela se is co on.
T e patient is, o course, very concerned about uture panic
attacks. She asks what to do when another occurs.

Question 23.6.7 You advise her to do all o the ollowing
EXCEPT:
A) Move to a quiet area
B) Slow down her breathing
C) Reassure hersel that she is not dying
D) Breathe into a brown a er bag
E) Avoid sti ulants like ca eine or nicotine
Answer 23.6.7 The correct answer is “D.” All o the other
o tions are reasonable reco endations or a atient su ering
ro anic attacks. Although co only observed in o ular
lore, breathing into a a er bag is not reco ended. Breath-
ing into a brown a er bag can have the o osite e ect o that
intended—the atient ay continue hy erventilating with CO2
building u , which ay contribute to ore anic sy to s.
Hy erventilating (blowing o CO2) does not roduce a anic
attack nor relieve it. It’s just a sy to o one. However, edu-
cating the atient on consciously slowing her breathing—using
slow, dee breaths— ay hel abort the anic attack. Quiet
roo s and reassurance can also hel .
You begin to discuss treatment options with this patient.
Question 23.6.8 Which o the ollowing is NOT an ef ective
treatment o panic disorder?
A) Benzodiaze ines such as clonaze a (Klono in)
B) Bu ro ion (Wellbutrin)
C) Psychothera y such as CB
D) SSRIs such as uoxetine (Prozac)
E) CAs such as i i ra ine
Answer 23.6.8 The correct answer is “B.” Bu ro ion does
not work or anxiety disorders. A ong e ective edications
(SSRIs, SNRIs, CAs), no class has roven su erior, and edi-
cation choice is based on sa ety, adverse e ect ro le, toler-
ability, co orbid illnesses, history o substance use, cost, etc.
SSRIs are requently considered rst line. Psychothera y has
been ound to be as e ective as edications or the treat ent o
ild-to- oderate anic disorder and can be used in co bina-
tion with edications or ore severe cases.
As you decide on the medication and dosage, you remember
an article you just read in a journal on common mistakes
made by physicians treating panic disorder in the community.
Question 23.6.9 Which o these is NOT one o the common
mistakes made in the treatment o panic disorder?
A) Starting the SSRI too high
B) Not achieving a high enough target dose
C) Underutilization o benzodiaze ines
D) oo ra id a titration
E) O en using edications not roven to work with anic
disorder
Answer 23.6.9 The correct answer is “C.” Far ro being
underutilized, benzodiazepines are o en overprescribed.
While e ective or anic disorder, roble s with tolerance,
CHAPTER 23 • PSyCh IAt r y 635
de endence, and abuse li it benzodiaze ines as long-ter
agents or anic disorder. Patients with anic disorder are
extre ely sensitive to edication side e ects and are likely to
su er ro jitteriness and restlessness i started at a high dose
o an SSRI. In order to reduce the chances o reci itating jit-
teriness and restlessness, a lower dose o SSRI (about hal the
starting dose used to treat de ression) is usually reco ended.
T e sa e roble s can occur with ra idly increasing doses
o SSRIs, so “start low and go slow,” increasing the dose every
2 to 4 weeks to reach the axi u allowable dose. Benzodi-
aze ines are at least third line (a er CB and SSRIs). A plea:
don’t rescribe al razola . It is addictive, short-acting, and has
a rebound e ect ( aking de endence even ore likely). I you are
going to choose a benzodiaze ine, choose one that is longer
acting such as clonaze a or diaze a . a er benzodiaze ines as
soon as ossible. Avoid the in atients with severe ersonality
disorders and substance abuse.
Your patient says, “I know another emale in the reserve who
has something similar, but I’ve never noticed the guys to have
a problem. Is this just something that happens to women?”
You tell her a bit about gender di erences in anxiety disor-
ders.
Question 23.6.10 Which o these is NOT true about the gen-
der ratio o the ollowing disorders?
A) Generalized anxiety disorder a ects ore wo en than en
in a 2:1 ratio
B) Panic disorder a ects ore wo en than en in a 2:1 ratio
C) P SD a ects ore en than wo en in a 2:1 ratio
D) Social anxiety disorder a ects slightly ore wo en than
en
Answer 23.6.10 The correct answer is “C.” Many a ective ill-
nesses ( ood and anxiety disorders) including de ression and
so e anxiety disorders are biologically sexist: wo en are ore
likely to be a ected than en. All o the o tions listed are cor-
rect exce t “C,” which inverts the true ratio.
Objectives: Did you learn to . . .
• Evalua e pa ien s wi anxie s mp oms?
• r ecognize panic a acks and diagnose panic diso de ?
• Ini ia e ea men o panic diso de ?
• Desc ibe some epidemiologic issues wi anxie diso de s?
CASE 23.7
You have a 34-year-old male patient who has started sustained-
release bupropion (Wellbutrin SR) 150 mg BID or depression.
He reports partial but not total resolution in his symptoms.
He also thinks that the medication is causing some side
e ects.
Question 23.7.1 Which o the ollowing is the most likely
adverse ef ect attributable to this medication?
A) Inso nia
B) Sexual dys unction
636 FAMILy MEDICINE EXAMINAt ION & BOAr D r EVIEW

C) Weight gain
D) Q rolongation
E) Increased s oking
Answer 23.7.1 The correct answer is “A.” Bu ro ion is associ-
ated with vivid drea s and inso nia. aking the second dose
no later than 4 pm can hel reduce the likelihood o this side
e ect. Unlike ost other antide ressants, bu ro ion is not
associated with sexual dys unction or weight gain. In act, it has
been associated with weight loss in the short ter , and atients
who quit s oking are less likely to gain weight i they are tak-
ing it. Bu ro ion can cause dry outh and nausea, which are
usually sel -li ited. It does not cause Q rolongation, unlike
CAs, so e SNRIs, and citalo ra . Bu ro ion a ears to curb
the cravings or nicotine. It lowers the seizure threshold and
should be avoided in atients with e ile sy.
T is patient is relatively healthy and takes no other medica-
tions, giving you a wide number o options or treatment. In
other words, you did not have to think too hard be ore start-
ing bupropion. However, sometimes you have to use your
brain, so let’s think about when not to use bupropion.
Question 23.7.2 In which o the ollowing disease states
would bupropion be contraindicated?
A) Hy ertension
B) Severe de ression
C) Buli ia nervosa (BN)
D) Bi olar de ression
E) Borderline ersonality disorder
Answer 23.7.2 The correct answer is “C.” Bu ro ion is con-
traindicated in atients with anorexia nervosa (AN) or BN (an
increased risk o seizures is ound in both diseases) or a cur-
rent or ast seizure disorder. Additionally, bu ro ion ust be
avoided in atients taking MAOIs. It is as e ective as the other
antide ressants, and it can be used in bi olar disorder and
severe de ression.
You decide to switch his medication rom bupropion to cita-
lopram (Celexa).
Question 23.7.3 Which is the best way to accomplish this
switch?
A) Sto the bu ro ion i ediately and then wait or 2 weeks
be ore starting citalo ra
B) a er the bu ro ion over 2 weeks to avoid a discontinuation
syndro e, and then start the citalo ra
C) Start citalo ra i ediately, and then ta er the bu ro ion
over several days
D) Start citalo ra now; then ta er o the bu ro ion a cou le
o weeks later i he is doing well
Answer 23.7.3 The correct answer is “C.” Unlike SSRIs, which
can cause a serotonin withdrawal syndro e, bu ro ion can be
discontinued with a ini al (i any) ta er. A brie ta er ay
avoid a sudden rebound o de ressive sy to s, while the new
agent is started. “A” is incorrect. Bu ro ion can be taken with
an SSRI. However, “D” is less desirable, as it is re erable to
sto the bu ro ion rather than continuing it inde nitely while
taking another edication. A single e ective agent is generally
re erred i ossible.
Objectives: Did you learn to . . .
• Use bup opion app op ia el ?
• Iden i adve se e ec s o bup opion?
• r ecommend s a egies o ansi ion om bup opion o
ano e an idep essan ?
QUICK QUIZ: h OMESICK
A 22-year-old college student who oved to your town ro
Lagos, Nigeria, last onth is re erred to you by his acade ic
advisor or concerns that he ay be de ressed. Although he
s eaks English well, he does not know anyone in town. His
a ily is still in Lagos, and he does not antici ate returning
to see the anyti e soon. He has not ade any riends yet.
He enjoys watching soccer in his s are ti e (which, o course,
nobody in the United States a reciates, but that is another at-
ter), but he is not slee ing well, and he eels quite ho esick.
Which o the ollowing is the ost a ro riate diagnosis at this
ti e?
A) MDD
B) Adjust ent disorder
C) Bi olar a ective disorder
D) Dysthy ia
E) Footballer’s withdrawal syndro e
The correct answer is “B.” Adjust ent disorder is the devel-
o ent o e otional or behavioral sy to s in res onse to
identi able stressor(s) occurring within 3 onths o the onset
o the stressor(s). T e sy to s or behaviors ust be clinically
signi cant, such that either the atient’s distress is in excess o
what would be ex ected ro ex osure to the stressor, or there
should be i air ent in social or occu ational/acade ic unc-
tioning. T e atient’s sy to s cannot be due to bereave ent
(a se arate diagnosis). Once the stressor (or its consequences)
is ter inated, the sy to s should resolve within 6 onths.
reat ent de ends on the level o distress and can range ro
su ortive care to active intervention with edications, thera-
y, or hos italization.
CASE 23.8
An 85-year-old woman is brought to the emergency depart-
ment by her daughters because she has been acting strangely
lately. Her house is a mess, even though or most o her li e
she has been quite astidious. She has been calling her daugh-
ters at odd hours o the night, upset and insisting that her
youngest daughter is stealing her money. During the day, she
goes outside o her house in her nightgown and housecoat,
again quite unlike her usual customs. Four months ago, her
husband o 58 years was diagnosed with a brain tumor. His

condition has deteriorated quite rapidly, and he is now in a
nursing home and does not recognize his wi e or daughters.
T e daughters have attributed the patient’s odd behavior to
the stress she is under. But as her symptoms have continued
to worsen, they are now quite concerned and decide they
must bring her in or evaluation.
In the emergency department, the patient is dressed in
her housecoat and slippers and appears disheveled. She is
lying on a cart, but she keeps trying to get up and leave. She
is angry at her two daughters who are with her, and she is
uncooperative with the physical examination. When you ask
her about what has been happening, she appears distrusting,
and her answers do not make sense.
Question 23.8.1 Which o the ollowing diagnoses is LEAST
likely at this point in time?
A) Deliriu
B) De entia
C) Bereave ent
D) Psychotic de ression
E) Alcohol abuse
Answer 23.8.1 The correct answer is “C.” Although your
atient’s husband is gravely ill and she is grieving, her sy -
to s are ore severe than what is ex ected or bereave ent.
Bereave ent is a nor al rocess, but it does not include severe
i air ent in social or occu ational unctioning, nor does it
include aranoid delusions or other sychotic sy to s. All o
the other diagnoses listed could result in the severity o sy -
to s described in this case.
Question 23.8.2 Which o the ollowing tests is indicated in
the evaluation o this patient’s behavior changes?
A) Chest x-ray
B) Urinalysis
C) CBC
D) B-12 levels
E) All o the above
Answer 23.8.2 The correct answer is “E.” A thorough edical
worku is warranted in the atient with “ ental status changes”
(e.g., deliriu and new onset sychotic sy to s). Several
edical roble s—in ection, hy oxia, MI, to na e a ew—can
cause the sy to s the atient is ex eriencing and ust be
ruled out.
Her workup does not reveal an organic cause or her altered
mental state. You are now suspecting that she has psychotic
depression.
Question 23.8.3 All o the ollowing are appropriate man-
agement options at this time EXCEPT:
A) Discharge with re erral or out atient sychothera y
B) Ad ission to a sychiatric unit
C) EC (electroconvulsive thera y)
D) Psychiatric consultation
CHAPTER 23 • PSyCh IAt r y 637
Answer 23.8.3 The correct answer is “A.” Psychothera y is
not an a ro riate single thera y or sychotic de ression—
es ecially in this atient, whose sy to s are so severe. “B” is
a ro riate, as the atient ay bene t ro hos italization. “C” is
a ro riate as well. EC is e ective in treating sychotic de res-
sion and is o en indicated i sa ety is o i ediate concern or an
early res onse is needed. “D” is a ro riate. In general, atients
with sychotic de ression should be re erred to a sychiatrist.
You determine that your patient’s symptoms are severe
enough or hospitalization. Her daughters agree, but the
patient is adamantly opposed and insists on returning to her
home. She’s sick o you “NSA-types pushing her around,” and
“i you don’t let her go, she’s going call her riend, Donald
rump.”
Question 23.8.4 How would you proceed?
A) Call hos ital security and ake lans to hos italize her;
a er all, she a ears quite ill and cannot care or hersel ;
when she is well, she will understand that it was the right
lan
B) Discharge her ho e, asking her daughters to take turns
staying with her until she is better
C) Follow state-dictated rotocol to atte t to obtain a legal
order or hos italization against her will
D) Follow national rotocol (New World Order Directive
55.12.A) to atte t to obtain a legal order or hos italiza-
tion against her will
E) Make a edical deter ination that she is not co etent,
allowing you to hos italize her des ite her objection
Answer 23.8.4 The correct answer is “C.” Each state has its own
laws that govern how an involuntary hos italization rocess is
conducted. I the atient oses an i inent threat to hersel or
others, the law generally allows involuntary hos italization or
a brie eriod o ti e until a court hearing is held. Involuntary
hos italization is also allowed i the atient is unable to care or
hersel and she is su ering ro a ental illness that renders
her inca able o aking healthcare decisions. “D” is incorrect.
T ere are no national laws governing involuntary hos italiza-
tion (and the New World Order is a aranoid delusion o so e
extre ists . . . or aybe we just want you to believe that). “B” is
incorrect. Because o the severity o this atient’s sy to s, it
would be ina ro riate to si ly discharge her to the care o
her daughters.
You have admitted the patient under a 72-hour hold, and you
are discussing treatment options with the psychiatrist, who
thinks that EC might be appropriate. You are concerned
about cognitive problems in this patient.
Question 23.8.5 All o the ollowing are associated with an
increased risk o memory loss with ECT EXCEPT:
A) Conco itant lithiu use
B) Bilateral electrode lace ent
C) High sti ulus doses
D) History o seizure disorder
638 FAMILy MEDICINE EXAMINAt ION & BOAr D r EVIEW
Answer 23.8.5 The correct answer is “D.” Seizure disorder is
not associated with an increased risk o e ory loss with EC .
EC is known to cause transient roble s with e ory loss.
T is usually ani ests with the atient having trouble re e -
bering events that occur around the ti e o the EC (such as
the invasion o exas by the UN . . . oh, aybe we are aranoid
and deluded now . . . or not). Most o the e ory co laints
co letely resolve within a ew onths o co leting EC .
However, so e situations ay increase the risk o e ory loss,
including conco itant lithiu use, bilateral electrode lace-
ent (unilateral is sa er), and a higher sti ulus dose.
In urther discussions with the patient and her amily, you
try to explain EC and dispel some myths.
Question 23.8.6 All o the ollowing are potential complica-
tions or adverse ef ects o ECT EXCEPT:
A) Deliriu
B) Nonsustained ventricular tachycardia
C) Headache
D) De entia
E) Fatigue
Answer 23.8.6 The correct answer is “D.” Although transient
e ory loss and even deliriu can occur a er EC , it does not
cause de entia. A nu ber o cardiac rhyth disturbances can
occur and are ore likely in atients with cardiac disease. How-
ever, these are sel -li ited and generally inor (e.g., re ature
ventricular contractions, atrial re ature co lexes, and non-
sustained ventricular tachycardia). Headache and atigue are
co on a er EC .
Objectives: Did you learn to . . .
• r ecognize abno mal be avio and gene a e an app op ia e
di e en ial diagnosis?
• Evalua e a pa ien wi new cogni ive and be avio al p ob-
lems?
• De e mine w en involun a ospi aliza ion is app op ia e
and ow i mig be unde aken?
• Discuss po en ial adve se e ec s o ECt ?
• Become mo e suspicious o e New Wo ld O de ?
QUICK QUIZ: A r EALLy BAD WEEK
A 47-year-old e ale resents to your clinic in tears, request-
ing your hel . She cannot sto crying, her slee is oor, and
she eels terribly lonely. However, she is able to carry out all li e
unctions with little decre ent in ability. She tells you that last
week her other had a stroke. She survived, but is now in a
nursing ho e and su ering ro Broca’s a hasia. Your atient
describes her other as her “best riend.” She has not had trou-
ble with de ression or other ental illness in the ast.
Which o the ollowing is the ost likely diagnosis?
A) Bereave ent
B) Adjust ent disorder
C) MDD
D) Bi olar e ective disorder
E) Dysthy ia
The correct answer is “A.” Bereave ent is a natural reaction
to a signi cant loss. So e o the sy to s ay i ic those
o de ression or adjust ent disorder, which can cause throw
you o the track o aking the ro er diagnosis. Unlike be-
reave ent, both de ression and adjust ent disorder ust, by
de nition, cause signi cant i air ent. Our atient has only
a inor decre ent in her level o unctioning. T e duration
and ex ression o bereave ent di ers a ong di erent cultur-
al grou s and subgrou s, urther co licating the diagnostic
rocess. Generally, a diagnosis o MDD is not given unless the
sy to s o de ression are resent 2 onths a er the loss.
CASE 23.9
You get a call rom a patient complaining o “not eeling well
and getting worse” over the past 3 days. She has had electrical
shock sensations in her upper extremities and head and also
complains o dizziness and malaise. She takes no medications
since she stopped her paroxetine (Paxil) a ew days ago.
Question 23.9.1 Which o the ollowing is the most likely
diagnosis?
A) In uenza
B) Bu ro ion discontinuation syndro e
C) SSRI discontinuation syndro e
D) Serotonin syndro e
E) Hy ertensive crisis
Answer 23.9.1 The correct answer is “C.” OK, so this was a
so itch. We already told you above that bu ro ion does not
have a discontinuation syndro e. A discontinuation syndro e
(also known as withdrawal syndro e) has been associated with
SSRIs when they are suddenly sto ed or doses are issed or
reduced. T is is es ecially co on with aroxetine because o
its short hal -li e. T e sy to s described above are ty ical o
the discontinuation syndro e, articularly the aresthesias that
atients o en describe as an “electric shock” ( able 23-1).
Question 23.9.2 Which o the options below is INCORRECT
in ormation to give the patient over the telephone?
A) Sy to s usually begin within a ew days o sto ing the
SSRI
B) T e sy to s rarely last longer or 2 weeks and are sel -
li ited
C) Restarting the edication takes about 2 weeks to relieve
sy to s
D) T e longer the atient has been on the edication, the ore
likely the risk o a discontinuation syndro e
Answer 23.9.2 The correct answer is “C” (which is not
true). Sy to s can be noticeable in so e atients with just
one issed dose (es ecially with aroxetine [Paxil]) but ty i-
cally develo within 2 days o edication discontinuation. T e

TABLE 23-1 SYMPTOMS OF SSRI
DISCONTINUATION SYNDROME
Somatic Symptoms
• Disequilib ium (e.g., dizziness, ve igo, a axia, and emo )
• Gas oin es inal s mp oms (e.g., nausea, vomi ing, and ano exia)
• Flu-like s mp oms (e.g., a igue, le a g , m algias, c ills, and
eadac e)
• Senso dis u bances (e.g., pa es esias and sensa ions o elec ic
s ock)
• Sleep dis u bances (e.g., insomnia and vivid d eams)
Psychological Problems
• Anxie /agi a ion
• C ing spells
• I i abili
• Ove ac ivi
• Depe sonaliza ion
• Dec eased concen a ion/slowed inking
• Con usion and memo p oblems
syndro e is unco ortable but usually sel -li ited, lasting
< 2 weeks. Restarting the edication will lead to cessation o
sy to s within 24 hours in virtually all cases. T e risk o dis-
continuation increases with length o thera y, articularly when
the atient has been on an SSRI longer than 7 weeks.
Question 23.9.3 Which SSRI is LEAST likely to cause a dis-
continuation syndrome?
A) Fluoxetine
B) Sertraline
C) Paroxetine
D) Citalo ra
E) Fluvoxa ine
Answer 23.9.3 The correct answer is “A.” T e risk o withdrawal
increases with shorter hal -lives. T e hal -li e o uoxetine is
about 4 to 6 days, while its active etabolite nor uoxetine has a
hal -li e u to 16 days, aking it highly unlikely that uoxetine
would cause a discontinuation syndro e in ost atients, as it
e ectively acts as its own ta er. Fluvoxa ine (with a hal -li e o
15 hours) and aroxetine (21 hours) have the shortest hal -lives
and are ost likely to cause the discontinuation syndro e. o
ini ize the risk o withdrawal syndro e, ta er o SSRIs when
sto ing the .
HELPFUL TIP:
Discon inua ion s nd ome is likel a pose o one gic
s a e; e e o e, all se o one gic agen s can cause a se-
o onin wi d awal. t ese agen s include SSr Is, MAOIs,
t CAs, se o onin–no epinep ine eup ake in ibi o s
(SNr Is), and mi azapine (r eme on) . . . bu no bup opi-
on (is a o se dead o s ould we bea i some mo e?).
Your patient restarts her SSRI and eels better. She has ques-
tions about antidepressants in general, wondering i she is
taking the right one. As you start to discuss bene ts and risks
CHAPTER 23 • PSyCh IAt r y 639
o di erent medications, you remind yoursel about some
important issues. For example, all SSRIs are not the same.
Question 23.9.4 Which SSRI has the most anticholinergic
activity?
A) Fluoxetine
B) Paroxetine
C) Sertraline
D) Citalo ra
E) Escitalo ra
Answer 23.9.4 The correct answer is “B.” With the exce tion
o aroxetine, SSRIs do not ossess a reciable anticholinergic
activity. Do you get the idea we don’t like aroxetine?
Question 23.9.5 Which o the ollowing SSRIs is LEAST likely
to have drug–drug interactions via P450 enzymes?
A) Fluoxetine
B) Paroxetine
C) Citalo ra
D) Sertraline
E) Fluvoxa ine
Answer 23.9.5 The correct answer is “C.” Citalo ra and its
stereoiso er, escitalo ra , have relatively clean ro les with no
ajor interactions with any o the cytochro e P450 enzy es.
Sertraline is also an attractive o tion i drug–drug interactions
are a concern. T e other three have signi cant drug–drug inter-
actions that have clinical i ortance. O course, this bene t o
citalo ra is te ered by its known roble s with Q rolon-
gation which can be exacerbated by other Q rolonging drugs.
Question 23.9.6 Mirtazapine (Remeron) is commonly asso-
ciated with the ollowing side ef ects EXCEPT:
A) Sedation
B) Weight gain
C) Dizziness
D) Lycanthro y
E) Increased triglycerides
Answer 23.9.6 The correct answer is “D.” Lycanthro y is, o
course, the ability to trans or into a werewol . Although close
in behavior to antisocial ersonality disorder, lycanthro y is
not caused by irtaza ine but rather by the bite o another
lycanthro e. Mirtaza ine is a otent antihista ine, and an
α 1-adrenergic agonist, otentially leading to orthostatic hy o-
tension. Sedation is resent in over 50% o atients taking the
drug, while weight gain is re orted in as any as 12%. It can
also lead to increased triglycerides. Paradoxically, the side e ect
o sedation lessens with increasing doses. It is a great antide-
ressant or atients who have lost their a etite, lost weight, or
have inso nia. y ical doses range ro 15 to 60 g/day.
Question 23.9.7 Which o the ollowing antidepressants
has a black box warning about hepatic ailure?
A) Ne azodone (Serzone)
B) Bu ro ion
640 FAMILy MEDICINE EXAMINAt ION & BOAr D r EVIEW
C) Paroxetine (Paxil)
D) Nortri tyline
E) Phenelzine (Nardil)
Answer 23.9.7 The correct answer is “A.” Ne azodone is a
5H -2 A rece tor antagonist and is an e ective antide ressant
with sedative ro erties. It has signi cant inhibitory e ects
on CYP3A4 and has several signi cant drug interactions as a
result. In the recent ast, several cases o he atic ailure have
been re orted with this drug, leading to a black box warning on
the ackage insert and li iting its clinical use. None o the other
antide ressants listed have had such roble s.
Question 23.9.8 Venla axine has been noted to typically
cause all o the ollowing side ef ects EXCEPT:
A) Increased blood ressure
B) Dizziness
C) Dry outh
D) Weight gain
E) Sexual disturbance
Answer 23.9.8 The correct answer is “D.” Venla axine and
duloxetine (Cy balta) are both nore ine hrine and serotonin
reu take inhibitors and have ini al activity on the cholin-
ergic, hista inergic, and α -rece tors. T ere is a dose-related
increase in blood ressure, with a ean elevation o 10 to 15
Hg in diastolic ressure at doses o 300 g or greater in u to
10% o atients. T ere is a slight increase in ulse, as well. “D” is
not true. In act, weight loss is a co on co laint. Otherwise,
venla axine and duloxetine generally have the sa e side-e ect
ro le as the SSRIs, otentially causing sexual dys unction, diz-
ziness, and dry outh. Patients can have a signi cant withdrawal
ro venla axine and should be ta ered o o it slowly.
HELPFUL TIP: ANTIDEPRESSANTS AND
BIRTH DEFECTS
Fluoxe ine and pa oxe ine a e associated wi bi
de ec s. t is doesn’ p ove causali and e c ance is
slig (e.g., anencep al isk goes om 2 in 10,000 o
7 in 10,000). h oweve , i is wo discussing wi e
p ospec ive pa en s. t e o e SSr Is do no seem o
ave e same associa ion (BMJ. 2015;351: 3190). We
s ill don’ like pa oxe ine.
HELPFUL (AND SCARY) TIP:
Venla axine (E exo ) and duloxe ine (C mbal a) a e
oxic in ove dose. t e cause Qt and Qr S p olonga ion
in ove dose. t ea men is e same as e ea men o
t CA ove dose (bica bona e, e c.), al oug da a is lim-
i ed. r emembe a ci alop am can cause a p olonged
Qt in e val wi bo egula doses and in ove dose.
You decide to switch the patient to f uoxetine and she does
well.
Objectives: Did you learn to . . .
• Iden i SSr I discon inua ion s nd ome?
• r ecognize impo an an idep essan in e ac ions?
• Desc ibe adve se e ec s o va ious an idep essan s?
QUICK QUIZ: MAOIs
You are seeing a new atient with a history o recurrent ajor
de ression. Many years ago a di erent hysician ut hi on
henelzine (Nardil), which you recognize as having otentially
serious ood and drug interactions. You are considering switch-
ing hi to an SSRI.
How long a er an MAOI is discontinued can an SSRI be started?
A) 1 day
B) 3 days
C) 7 days
D) 14 days
E) SSRIs and MAOIs can be given together
The correct answer is “D.” Because o signi cant drug–drug in-
teractions (see next question), SSRIs should not be started until
2 weeks a er discontinuation o an MAOI.
QUICK QUIZ: MAOI + SSr I = BADNESS
What is the drug–drug interaction o concern with SSRIs and
MAOIs?
A) Stevens–Johnson syndro e
B) Serotonin syndro e
C) Anticholinergic crisis
D) Hy ertensive crisis
E) Existential crisis
The correct answer is “B.” Serotonin syndro e is caused by an
excess o serotonin and can be caused by drug–drug interac-
tions involving serotonergic agents including SSRIs, bus irone,
e eridine, dextro ethor han, lithium, tra adol, and tri -
tans, a ong others. MAOIs inhibit ona ine oxidase, which is
an enzy e involved in the etabolis o any neurotrans it-
ters, including serotonin. T ere ore, MAOIs increase serotonin
as well. Serotonin syndro e is characterized by uscle rigidity,
hy erre exia, hy erther ia, con usion, and agitation a ong
other sy to s. It can be atal. As a result, the concurrent use
o an SSRI and MAOI is absolutely CON RAINDICA ED.
Stevens–Johnson syndro e (“A”) is an autoi une der ato-
logical disorder that leads to desqua ation o ucosal sur aces
and is not associated with antide ressant use (although it can
be seen with other drugs). Anticholinergic crisis (“C”) is not
a ter used in co on edical arlance but does evoke the
idea o anticholinergic syndro e, caused by excess anticholin-
ergic drugs, such as CAs, etc. Hy ertensive crisis (“D”) occurs
when oods containing tyra ine (e.g., aged cheese and cured
eats) interact with MAOIs to release catechola ines, causing

hy ertension, headaches, nausea, and dia horesis. In severe
cases, it can lead to strokes or death.
HELPFUL TIP(S):
Linezolid is absolu el con aindica ed wi MAOIs. I
is a se o one gic d ug. Among e oods a cause a
pe ensive c isis wi an MAOI a e banana peels (bu
no e banana . . . we a e no su e w o igu ed is one
ou . . .), aged mea s (bes avoided an wa i ou ink
abou i ), d aug bee (boo) bu no bo led bee ( es!),
and kimc i/saue k au .
CASE 23.10
A 43-year-old man who you started on citalopram or depres-
sion 4 weeks ago returns or a ollow-up visit. He eels better
but complains o delayed ejaculation. You consider changing
him to an antidepressant that is less likely to cause sexual
dys unction.
Question 23.10.1 Which o the ollowing would you AVOID?
A) Ne azodone
B) Bu ro ion
C) Mirtaza ine
D) razodone
E) Nortri tyline
Answer 23.10.1 The correct answer is “E.” Sexual dys unction
is a co on side e ect o ost sychotro ics. T ere are ew
controlled data to guide us as to how to a roach this issue,
but sildena l (Viagra) and si ilar drugs are e ective in anti-
de ressant-induced erectile dys unction. O the o tions given,
nortri tyline—and other CAs—is ore requently associated
with sexual dys unction.
HELPFUL TIP:
S . Jo n’s wo ma be e ec ive in mild- o-mode a e de-
p ession. h oweve i is a known induce o e CyP450
enz me, educing e e icac o o al con acep ives.
I as also been associa ed wi dec eased e icac o
an i e ovi als, c clospo ine, digoxin, eop lline, and
wa a in.
T is patient is also having sleep di culties and asks what
herbal therapy he might be able to use.
Question 23.10.2 Which o the ollowing is an herbal alter-
native to benzodiazepines or anxiety and insomnia?
A) Valerian root
B) St. John’s wort
C) Saw al etto
D) Ginseng
E) Ginkgo
CHAPTER 23 • PSyCh IAt r y 641
Answer 23.10.2 The correct answer is “A.” Valerian root
(Valeriana o cinalis) has been touted to have anxiolytic ro er-
ties, si ilar to benzodiaze ines, and its echanis o action is
thought to be si ilar (e.g., inhibition o GABA). It a ears to be
sa e and has the sa e drug interactions and contraindications
as benzodiaze ines. T e other o tions are not known to a ect
slee to a signi cant degree.
HELPFUL TIP:
Kava-kava is adve ised as an anxiol ic bu s ould gen-
e all be avoided. Kava-kava (Piper methysticum) as
been epo ed o cause live damage, in some cases
leading o live ansplan o even ual dea .
Objectives: Did you learn to . . .
• Iden i w ic an idep essan s a e less likel o cause sexual
d s unc ion?
• r ecognize e bal e apies a mig be emplo ed in
ea ing s mp oms o dep ession?
CASE 23.11
You are seeing a 28-year-old emale whose rst child you
delivered a month ago. She comes to your clinic with her
son or his 1-month well-child check. You observe that
she seems tired and is less animated than usual. She is
gentle with her in ant, but her ace doesn’t seem to light
up with the glow that you o en see with new mothers. You
know . . . the glow o terror, sleeplessness, and anxiety?
T at’s the one.
Question 23.11.1 Which o the ollowing best explains your
observations?
A) Slee de rivation
B) Marital discord at ho e
C) Post artu de ression
D) T yroid dys unction
E) Any o the above
Answer 23.11.1 The correct answer is “E.” Your atient’s sy -
to s could be due to any o these roble s and ore, includ-
ing dif culty with role adjust ent, alcohol or drug abuse, and
ane ia.
You want to gather more in ormation to see i there is a path-
ological process underlying her behavior.
Question 23.11.2 You would do all o the ollowing EXCEPT:
A) Ask her to ll out an Edinburgh Postnatal De ression Scale
(EPDS)
B) Order thyroid unction tests
C) Order a slee study
D) Ask ore questions about how things are at ho e and how
she is co ing
E) Ask about a revious history o de ression
642 FAMILy MEDICINE EXAMINAt ION & BOAr D r EVIEW
Answer 23.11.2 The correct answer is “C.” In this case, there
are any other ore likely roble s than a ri ary slee dis-
order, and a slee study is unlikely to be hel ul ( lus as those
o us who have had in ants know, your slee is naturally disor-
dered). T e EPDS is a validated sel -rated scale that is use ul or
detecting ost artu de ression. Hy othyroidis can always
i ic de ression and ight need to be ruled out. A thorough
history is always essential.
Question 23.11.3 The incidence o postpartum depression
is about:
A) 1%
B) 10%
C) 30%
D) 50%
Answer 23.11.3 The correct answer is “B.” About 7 in 10
wo en su er ro “baby blues,” ost artu sy to s that
can ani est as ood swings, anxiety, atigue, and sadness
occurring within a ew days o delivery and lasting only a
week or so. However, ost artu de ression a ects a roxi-
ately 10% o wo en, and sy to s can a ear anywhere
ro weeks to onths a er birth. T e diagnosis is o en
issed because any others are asha ed to ad it eeling
unha y at a ti e when they think (and society tells the )
that they should be ha y. Physicians ay ocus on the
in ant’s hysical health and iss assessing the other–baby
interaction.
In obtaining more history, you realize that this patient
was having some troubles with depression even during her
pregnancy.
Question 23.11.4 When is the most common time or
pregnancy-related depression to occur?
A) At conce tion
B) First tri ester
C) Second tri ester
D) T ird tri ester
E) Post artu
Answer 23.11.4 The correct answer is “D.” A large e ide i-
ological study ro the United Kingdo ollowed regnant
wo en ros ectively throughout the course o their regnan-
cies and ound that the incidence o depression was actually
higher in the third trimester than it was in the postpartum
period. T is suggests the need or the hysician to begin to
enquire about sy to s earlier.
HELPFUL TIP:
r epea a e me, “P egnanc does no ea dep ession.”
Fo some eason, i ad been assumed in e pas a
a woman’s dep ession would aba e du ing p egnanc .
S udies in e las couple o ea s ave disp oved is
m making ongoing ea men o dep ession c ucial.
I you had been aware o her depression earlier and wanted to
prescribe an antidepressant during her pregnancy, you would
have been cautious, hoping to prescribe a Pregnancy Sa ety
Category B drug.
Question 23.11.5 Which o the ollowing antidepressants is
Category B in pregnancy?
A) Fluoxetine
B) Bu ro ion
C) Nortri tyline
D) Mirtaza ine
E) None o the above
Answer 23.11.5 The correct answer is “E.” T ere is no antide-
ressant that is category B or regnancy. All the drugs listed
are category C. T is is not to say that antide ressants ust
be avoided in regnancy, but the bene ts and risks should be
weighed care ully.
Question 23.11.6 Risks associated with SSRI use during
pregnancy include all o the ollowing EXCEPT:
A) Irritability o the neonate
B) Preter delivery
C) Low birth weight
D) Persistent ul onary hy ertension
E) etralogy o Fallot
Answer 23.11.6 The correct answer is “E.” SSRIs have not
been linked to develo ent o etralogy o Fallot. However, a
nu ber o adverse e ects have been associated with SSRI use in
regnancy, including neonatal irritability, low birth weight, and
reter labor. In ants ex osed to SSRIs during the second hal
o regnancy (i.e., a er 20 weeks gestation) had an increased risk
(a roxi ately 1% absolute risk) o develo ing persistent pul-
monary hypertension, not a birth de ect but still a otentially
li e-threatening condition, a er birth (BMJ. 2012;344:d8012).
Question 23.11.7 I you had decided to prescribe an antide -
pressant medication or her during pregnancy, which one
o the ollowing would have been LEAST desirable?
A) Paroxetine
B) Sertraline
C) Nortri tyline
D) Citalo ra
Answer 23.11.7 The correct answer is “A.” Although no anti-
de ressant edication has been shown to be risk- ree when
used during regnancy, aroxetine is the only antide ressant
edication listed that is Category D in regnancy, due to the
increased incidence o cardiac ano alies ( ainly atrial and
ventricular se tal de ects) in in ants who were ex osed in utero.
As you undoubtedly re e ber ro above, uoxetine is also
generally to be avoided because o the risk o birth de ects. Do
you still think we don’t like aroxetine?
You start her on f uoxetine and o er to watch her baby or a
ew days, and everyone is happy!

Objectives: Did you learn to . . .
• r ecognize e ig incidence o dep ession and dep essive
s mp oms in e pos pa um pe iod?
• Diagnose pos pa um dep ession?
• t ea dep ession in e p egnan and pos pa um pa ien ?
CASE 23.12
A couple, you have known or some time, brings in their
7-year-old son, Jimbo, to your clinic because his behavior has
changed over the past month. His school per ormance has
worsened, and he has started to get into ghts at school. He
is not eating as well and is having requent nightmares. He
now has requent headaches and stomachaches and clings to
his mother when it is time to go to school. T e parents can-
not understand what is going on and report no antecedent
trauma.
Question 23.12.1 Which o the ollowing is the most likely
diagnosis?
A) MDD
B) Disru tive ood dysregulation disorder
C) Adjust ent disorder
D) Bereave ent
E) Nor al childhood dif culties ex ected with being na ed
Ji bo
Answer 23.12.1 The correct answer is “A.” U to 3% o chil-
dren and 9% o adolescents su er ro de ression. DSM-5
criteria are the sa e as in the adult, exce t irritability can be
substituted or the depressed mood requirement in children.
Disru tive ood dysregulation disorder (“B”) is a new addi-
tion to DSM-5. It is characterized by severe, ersistent irritabil-
ity. T ere ust be requent te er outbursts that occur over
the course o at least a year and ust be in 2 di erent settings.
Adjust ent disorder (“C”) is not likely since there have been no
ajor changes in the child’s regi en, and bereave ent (“D”) is
not likely since there have been no losses in the child’s li e. T is
atient’s sy to s are clearly not art o nor al childhood,
even i his na e is Ji bo.
HELPFUL TIP:
O cou se bull ing a sc ool and o e social p oblems
need o be inves iga ed w en an c ild p esen s wi
s mp oms o dep ession.
Question 23.12.2 Which o the ollowing is NOT true about
depression in children?
A) Abuse or neglect increases the risk o de ression
B) Having a de ressed arent increases the risk o being a
de ressed child
C) T e clinical course is roughly the sa e as in adults
D) “Masked” sy to s, such as abdo inal ain, are ore
co on in children than the ty ical sy to s o de res-
sion, such as slee disturbance
E) Male and e ale children are equally a ected by de ression
CHAPTER 23 • PSyCh IAt r y 643
TABLE 23-2 COMMON MANIFESTATIONS OF
DEPRESSION IN CHILDREN
• Inc eased i i abili , ange , o os ili
• Being bo ed
• r eckless be avio
• Ou bu s s o s ou ing, complaining, unexplained i i abili , o
•
c ing
Poo sc ool pe o mance
• Fea o dea
• Alco ol o subs ance abuse
• F equen nonspeci c p sical complain s suc as eadac es,
muscle ac es, s omac ac es, o a igue
Dep ession in C ild en and Adolescen s, Na ional Ins i u es o
h eal Publica ion No. 00-4744. p://www.nim .ni .gov/publica /
depc ild es ac .c m.
Answer 23.12.2 The correct answer is “D.” Although clini-
cians should be aware o age-a ro riate ani estations (see
able 23-2), sy to s o de ression are si ilar in children and
adults. In act, ty ical sy to s o de ression are ore co -
on in children than are “ asked” sy to s such as sto ach-
aches and ear o leaving ho e.
You tell the amily about Jimbo’s prognosis.
Question 23.12.3 Which o the ollowing statements regard-
ing prognosis is FALSE?
A) Childhood MDD con ers a two- to our old increase in risk
or adult MDD
B) About 25% o adolescents with MDD develo substance
abuse disorders
C) Al ost hal o children with MDD will atte t suicide
so eti e in their li e
D) Roughly 20% o adolescents have su ered at least one e i-
sode o MDD by 18, while 65% re ort transient sy to s
o de ression
E) A er the initial e isode, only 10% will su er a rela se
Answer 23.12.3 The correct answer is “E.” Between hal and
two-thirds (not 10%) will have a recurrence within 5 years a er
resolution o their rst e isode. T e other o tions are all true. In
children and adolescents, the ean de ression e isode length
is 7 to 9 onths with re ission ty ically occurring over 1.5 to
2 years.
HELPFUL TIP:
t e isk o suicide is ve ig among dep essed ou s.
I is e i d leading cause o dea in e 15- o 24- ea
age g oup, and c ild en wi MDD ave a ou - o ive-
old ig e li e ime incidence o suicide a emp s an
nondep essed c ild en. t wen pe cen o adolescen s
ave suicide idea ion eac ea , and 5% o 8% will a -
emp suicide eac ea . P e dep essing s a is ics, e ?
You recommend treatment or Jimbo.
644 FAMILy MEDICINE EXAMINAt ION & BOAr D r EVIEW
Question 23.12.4 Which o the ollowing therapies has NOT
shown e icacy in childhood dep ression in randomized
controlled trials?
A) Fluoxetine
B) Sertraline
C) CB
D) Venla axine
E) Inter ersonal thera y
Answer 23.12.4 The correct answer is “D.” In act, the akers
o venla axine sent out a “Dear Doctor” letter suggesting that
venla axine not be used in children under 18 because it lacks
ef cacy data, and it has an increased incidence o e otional
lability. T e botto line is that uoxetine is robably the SSRI
o choice in children, ollowed by sertraline. However, the NN
or SSRIs is 10 to bene t one child. Avoid aroxetine since it
ay be associated with a higher suicide risk (there is a attern
develo ing here…). CAs should be avoided because o lack o
ef cacy and otential suicide risk. CB and inter ersonal ther-
a y have been shown to be e ective in children and adolescents.
HELPFUL TIP:
As ou would expec , CBt /counseling/ e ap plus an
an idep essan a e mo e e ec ive an ei e modal-
i alone. Adve se e ec s o medica ion in c ild en a e
simila o ose in adul s and include insomnia, a igue,
eadac es, and ne vousness. Keep a close e e on ado-
lescen s w o ou s a on an idep essan s, and wa n
pa ien s and ei pa en s a dep ession can wo sen
in e ea l p ase o ea men . h ave em e u n o en
in e i s ew mon s o ea men .
Objectives: Did you learn to . . .
• Inc ease ou awa eness o c ild ood dep ession?
• Diagnose dep ession in c ild en?
• Desc ibe e na u al is o o dep ession in c ild en?
• Gene a e an app op ia e ea men plan o c ild en wi
dep ession?
CASE 23.13
ommy is a 9-year-old male who has been having di culty
with his behavior since he started rst grade. He is o en dg-
ety and squirming in his chair and has di culty remaining in
his seat. He talks out o turn, is o en “on the go,” and is not
liked by the other kids because he intrudes into games and
has a hard time waiting his turn. His mom also notes simi-
lar problems at home. He is the product o an uncomplicated
pregnancy and has no signi cant past medical history.
Question 23.13.1 What is the most likely diagnosis?
A) Attention-de cit/hy eractivity disorder (ADHD)
B) Adjust ent disorder
C) O ositional de ant disorder (ODD)
D) Conduct disorder (CD)
E) S eci c learning disorder
Answer 23.13.1 The correct answer is “A.” T e sy to s o
ADHD are listed below. “B,” adjust ent disorder, is unlikely
since there is no history o a signi cant li e event. ODD and
CD are characterized by aggressive behavior and a disregard
or rules and adults. T ese are not given as art o o y’s
history. S eci c learning disorder resents with school er or-
ance roble s and ay be associated with ADHD but would
not be directly res onsible or this atient’s hy eractivity.
For the diagnosis o ADHD, atients ust eet one o the
ollowing criteria:
1. At least six sy to s o inattention or at least 6 onths that
is alada tive and inconsistent with level o develo ent:
• Careless istakes, oor attention to details
• Cannot sustain attention
• Does not see to listen
• Poor ollow through on tasks
• Dif culties with organization
• Avoids or dislikes tasks that require sustained attention
• O en loses things required or a task (notebooks, ens, etc.)
• Easily distracted ro a task
• Forget ul in daily activities
2. Six or ore o the ollowing hy eractive–i ulsive sy to s
or 6 onths, which is alada tive and inconsistent with level
o develo ent:
Hy eractivity sy to s
• Fidgets or squir s in seat
• Leaves seat at ina ro riate ti es
• Hy eractivity in ina ro riate settings
• Cannot lay or relax quietly
• Always in otion
• alks too uch
I ulsivity sy to s
• Blurts out answer be ore questions co leted
• rouble waiting or turn in ga es, school, etc.
• Interru ts others (verbally, in ga es, etc.)
In addition to ul lling criteria 1 and 2 above, the ollowing
are required:
• Sy to s ust be resent be ore age o 12 years!
• I air ent in two settings (ho e, work, school, worshi , etc.)
• Clinically signi cant i air ent in social, acade ic, or
occu ational s heres
• Sy to s are not due to another roble (develo ental
delay, ersonality disorder, ood disorder, etc.)
Question 23.13.2 Which o the ollowing is FALSE about
ADHD?
A) It a ects 3% to 7% o children
B) T ere are genetic and environ ental in uences on the risk
o develo ing ADHD
C) Males are ore likely to have ADHD than e ales
D) T e incidence o ADHD has increased over the years
E) Co orbid disorders are not co on
Answer 23.13.2 The correct answer is “E.” ADHD a ects 3%
to 7% o children. Heritability is 70%, si ilar to that or schizo-
hrenia and bi olar disorder. Alcohol and tobacco ex osure

in utero have both been linked to at least a two old increase in
risk. Males are twice as likely to be diagnosed with ADHD as
e ales. Co orbid disorders are very co on in ADHD with
CD, ODD, de ression, anxiety, learning disabilities, and devel-
o ental delay being the ost requent.
Question 23.13.3 Which o the ollowing is NOT TRUE o the
prognosis and treatment o Tommy’s ADHD?
A) T e natural history o ADHD is that one-third o children
will outgrow the sy to s, one-third will have the sa e
requency and intensity o sy to s, and one-third will
have residual sy to s, which are subclinical
B) o y has a 70% to 80% chance o res onding to sti ulants
C) I o y is treated with sti ulants, his risk o drug abuse is
halved
D) o y is at increased risk o getting into accidents
E) Behavior thera y is e ective or reducing ADHD sy to s
Answer 23.13.3 The correct answer is “E.” Un ortunately,
intensive behavior thera y has been shown to be ine ective. T e
breakdown o the rognosis or children with ADHD sy to s
is that roughly one-third will ex erience co lete sy to reso-
lution, one-third will get so e i rove ent, and one-third will
re ain ill with the disorder. Sti ulants, which are rst-line ther-
a y, will work in 70% to 80% o the atients. I a atient does not
res ond to the rst sti ulant, she still has a 70% to 80% chance o
res onding to a second sti ulant. Children treated with sti u-
lants are hal as likely to abuse substances as those who are not
treated. Children with ADHD are at risk or i ulsive behavior
and risk-taking, which leads to substance abuse, accidents, etc.
You decide to start ommy on methylphenidate.
Question 23.13.4 Which o the ollowing is NOT true about
treatment with methylphenidate?
A) It i roves handwriting
B) O ti al dosing is 0.6 to 1 g/kg/day
C) It can cause reduced growth
D) Short-ter e ory is not a ected
E) o y ight get along better with his class ates
Answer 23.13.4 The correct answer is “D.” In act, sti ulants
i rove short-ter e ory in atients with ADHD. T e rest
are true. As to “A,” do you think this is why doctors have notori-
ously bad handwriting? Maybe we all need sti ulants …. Sti -
ulants have a wides read e ect on ulti le do ains, so e o
which are listed in able 23-3.
ommy’s ather is happy with his son’s response to methyl-
phenidate and wonders i he too would bene t rom a simi-
lar medication. He recalls being in trouble ever since grade
school or talking “out o turn” and always being put in deten-
tion. He was always restless and dgety but this has improved
as he ages. He has a hard time at work sitting through meet-
ings, as he tends to daydream, and he has numerous ghts
with his wi e because she accuses him o not listening to her.
He has been unable to get promoted because he cannot pass
CHAPTER 23 • PSyCh IAt r y 645
TABLE 23-3 STIMULANT EFFECTS ON
PATIENTS WITH ADHD
Ef ects o Stimulants on Motor Response
• r educe ac ivi o no mal
• Dec ease excessive alking, noise, and dis up ion in e class oom
• Imp ove andw i ing
• Imp ove ne mo o con ol
Ef ects o Stimulants on Social Skills
• r educe o - ask be avio in class oom
• Imp ove abili o pla and wo k independen l
• Dec ease in ensi o be avio
• r educe bossiness wi pee s
• r educe ve bal and p sical agg ession
• Imp ove (bu no no malize) pee social s a us
• r educe noncompliance, de ance, and opposi ional be avio wi
adul s
• Pa en s and eac e s become less con olling and mo e posi ive
Ef ects o Stimulants on Cognitive Ability
• Imp ove abili o sus ain a en ion, especiall in bo ing asks (like
s ud ing o e FM Boa d Exam)
• r educe dis ac ibili
• Imp ove s o - e m memo
• r educe impulsivi
• Inc ease amoun o academic wo k comple ed
• Inc ease accu ac o academic wo k
Side Ef ects
• Lack o appe i e
• Dec eased g ow , especiall ini iall
• Insomnia
• h eadac es and s omac ac es
• I i abili
• t ac ca dia o blood p essu e inc ease ( a e)
• Muscle ics o swi c es ( a e)
• Ps c osis o deli ium ( a e)
the examinations he has to take, but he thinks that he is smart
enough. He says that he just cannot concentrate.
Question 23.13.5 Which o the statements below is NOT
true or an adult presenting with ADHD?
A) Adults resent with the sa e core sy to s as children but
in a di erent ashion
B) Adults are less likely to have overt hy eractivity sy to s
co ared with children
C) Adults o en resent when their children are diagnosed
D) Adults are less likely to s oke than sa e-age ersons with-
out ADHD
E) Adults o en seek ro essions that allow the to use their
sy to s to their advantage
Answer 23.13.5 The correct answer is “D.” Adults with atten-
tion de cit disorder are ore likely to s oke than their sa e-
aged eers ( erha s it’s because nicotine is a sti ulant?). Adults
resent di erently than children, but have the sa e core sy -
to s o hy eractivity, inattention, and i ulsivity. Many adults
are diagnosed with ADHD only when their children have been
diagnosed or when increasing dif culty at work or at ho e leads
the to seek hel . O en, co orbidities drive the to seek hel ,
and the ri ary diagnosis o ADHD is ade only incidentally.
646 FAMILy MEDICINE EXAMINAt ION & BOAr D r EVIEW

TABLE 23-4 PRESENTATIONS OF ADHD SYMPTOMS IN CHILDREN AND ADULTS

Children
h pe ac ive c ild: squi ms, canno s a in
is sea , and cons an l on e go
Impulsive c ild: blu s ou answe s,
in e up s o e s, and alks incessan l
Ina en ive c ild: does no ollow oug , is
o ge ul, does no lis en
Fewe en e college and g adua e, compa ed
wi c ild en ei age wi ou ADh D
Adults
h pe ac ive adul : as subjec ive inne es lessness and ouble elaxing
Impulsive adul : speeding icke s, ca c as es, impa ien , smokes mo e, ig e divo ce a e, ig e
subs ance use a e, and ove ea ing
Ina en ive adul : o en la e o appoin men s, o ge s annive sa ies, as dif cul wi wo k mee ings;
p oblems wi ocusing, planning, o ganizing, and comple ing asks a ome and a wo k; advances
mo e slowl a wo k an pee s; misplaces ke s, glasses, and o e i ems; ma o ge o pa bills, pick
up e kids on ime, e c.

Adults ty ically resent seeking hel or their inattention and

HELPFUL TIP:
concentration dif culties, as overt hy eractivity lessens with
S imulan s do no cause ca diac p oblems and seem
age. So e adults co ensate by ursuing in careers that reward
o be sa e in bo c ild en and adul s (JAMA. 2011;306:
their intellectual curiosity, endless energy, and desire or change
2673; JAMA. 2011;306:2723; N Engl J Med. 2011;365:
(e.g., like a ily edicine and e ergency edicine?). able 23-4
1896).
co ares adult and child resentations o ADHD.

HELPFUL TIP:
r emembe a adul s ma ave esidual s mp oms, HELPFUL TIP:
w ic do no mee ull c i e ia o ADh D a e ime o A omoxe ine (S a e a) is a nons imulan d ug ap-
evalua ion. A clear history o symptoms starting in p oved o ADh D (i is a selec ive no epinep ine eup-
childhood be ore age 12 must be present to diag- ake in ibi o ) and e onl d ug app oved o adul
nose an adult with ADHD. There is no such thing as ADh D. I is no a con olled p esc ip ion, aving no ap-
“Adult-Onset ADHD” (but there is adult stimulant pa en abuse po en ial. I s place in e ap is no e
abuse). Con i ma ion o e is o can be ob ained well de ined bu mig be used in ose wi a d ug
om colla e al sou ces, including old sc ool epo s abuse is o , e c. Maximum e icac o a omoxe ine is
and amil membe s. t ink abou o e diagnoses suc ac ieved in a ew weeks, and i as a simila side-e ec
as anxie diso de and dep ession in pa ien s w o p o ile o e s imulan s.
ink e ave “adul -onse ADh D.”

Objectives: Did you learn to . . .

You decide to treat ommy’s ather with a medication. He
would pre er not to have a stimulant, and he asks i there are
other options or treatment.
Question 23.13.6 Which o the ollowing medications
would you recommend?
A) Fluoxetine
B) Bu ro ion
C) Mirtaza ine
D) Phenelzine
E) Ris eridone
Answer 23.13.6 The correct answer is “B.” In addition to sti -
ulants, which are also rst-line agents in adults, there are a vari-
ety o edications that can be used to treat ADHD, although
ost studies are undertaken in children and ost o these ed-
ications are not FDA-a roved or treating ADHD. Second-line
agents include the antide ressants bu ro ion, desi ra ine,
i i ra ine, and nortri tyline. T e α -blockers guan acine and
clonidine are also used, ostly as an adjunct in children with
conco itant conduct disorder or slee roble s. Re e ber
that a history o substance abuse or sychotic disorder is al ost
always a contraindication to sti ulant use.
• r ecognize c ild ood and adul p esen a ion o ADh D?
• P esc ibe ef cacious ea men s o ADh D?
• r ecognize side e ec s and advan ages o va ious medica-
ions o ADh D?
CASE 23.14
A gentleman calls your o ce because he is concerned that
his wi e o 2 years is acting strangely. She has not slept or
most o the past week, staying up at night cleaning the house
and sending multiple texts to riends and amily. She even
went out and spent $3000 on a dress that le nothing to
the imagination and was seen kissing another man (Santa
Claus, you hope). You ask him to bring his wi e in as soon
as possible.
T at a ernoon you nd a provocatively dressed 30-year-
old emale sitting in your o ce and laughing giddily as her
husband gives most o the intelligible history. She keeps
reaching over to touch you on the leg as you interview
her. You nd her hard to understand because she talks so
ast. You manage to catch something about “running or
President.”

Question 23.14.1 What is the most likely diagnosis?
A) Mania
B) Psychosis
C) Agitated de ression
D) Anxiety disorder
E) ADHD
Answer 23.14.1 The correct answer is “A.” Mania is the cor-
rect diagnosis. None o the other conditions can ully ex lain
the abnor al elevation in ood and the subsequent behav-
ior changes. Patients with bipolar I disorder ust have had
at least one e isode o ania: a distinct eriod o abnor ally
and ersistently elevated, ex ansive, or irritable ood, lasting
at least 1 week (or any duration i hos italization is necessary).
In addition, there ust be at least three o the ollowing sy -
to s concurrently: (1) in ated sel -estee or grandiosity, (2)
decreased need or slee , (3) ore talkative than usual, (4) ight
o ideas or racing thoughts, (5) distractibility, (6) increased
goal-directed activity or sycho otor agitation, and (7) exces-
sive involve ent in leasurable activities that have a high risk
or negative consequences/i ulsivity (ga bling, s ending
s ree, risky sexual indiscretions, etc.). T e e isode ust cause
i air ent in occu ational or social unctioning and cannot
be substance induced.
Patients with bipolar II disorder have had at least one e i-
sode o hy o ania: a distinct eriod o ersistently elevated,
ex ansive, or irritable ood, lasting or at least 4 days, which
is clearly distinct ro the usual, nonde ressed ood. During
the hy o anic e isode, at least three o the anic sy to s
listed above ust be resent, although the e isode is not severe
enough to cause arked i air ent in occu ational or social
unctioning, require hos italization, or include sychotic sy -
to s.
HELPFUL TIP:
Al oug pa ien s wi bipola diso de s o en ave
dep essive episodes as well as manic o pomanic
episodes, dep ession is no equi ed o e diagnosis o
bipola diso de . (“So w is i called bipola ,” ou ask?
Well, w o a e ou o ques ion adi ion?)
Question 23.14.2 Regarding the epidemiology o bipolar
illness, which o the ollowing is FALSE?
A) T e revalence o bi olar 1 is about 0.6% to 1.5%
B) Many atients are isdiagnosed initially with de ression
C) Untreated, the suicide rate is al ost 20%
D) Wo en are twice as likely to be a ected as en
E) Suicide risk is highest in the de ressed or ixed state
Answer 23.14.2 The correct answer is “D.” Unlike de ression,
bi olar illness a ects ales and e ales equally. Bi olar I a ects
about 0.6% to 1.5% o the o ulation, while bi olar II a ects
about 0.8% to 3%. Untreated, nearly 20% will co it suicide—
a rate about 20 ti es that o the general o ulation. Risk is
highest in de ressed states or the ixed states (both ania and
de ression resent at the sa e ti e). Bi olar disorder ty ically
CHAPTER 23 • PSyCh IAt r y 647
has its onset in early adulthood, although it can begin in child-
hood or adolescence. De ression is resent 20% to 30% o the
ti e, even with ongoing aintenance treat ent. Over hal o
bi olar atients are initially isdiagnosed with de ression, and
the average atient is only accurately diagnosed a er 5 years o
sy to s.
HELPFUL TIP:
Up o 50% o people wi bipola diso de ave con-
comi an alco ol abuse o dependence.
You want to start a medication or this patient . . . or commit
her . . . or both.
Question 23.14.3 Which o the ollowing would NOT be an
appropriate treatment choice or her mania?
A) Lithiu
B) Olanza ine
C) Dival roex
D) Carba aze ine
E) Bus irone
Answer 23.14.3 The correct answer, and the medication to
avoid, is “E.” Bus irone is not e ective in the treat ent o bi o-
lar disorder. Lithiu (“A”) was the rst edication a roved
or treat ent o bi olar ania and de ression. It reduces the
incidence o recurrence o ania, hy o ania, and de ression
by about two-thirds. Lithiu has a signi cant antisuicide e ect
with an esti ated eight- to nine old reduction in risk. It is dosed
at nightti e or twice daily. Lithiu has a narrow thera eutic
window, and there are nu erous drug–drug interactions.
Both olanza ine (“B”) and dival roex (“C”) have FDA
a roval or treat ent o acute ania and a ear to be so e-
what e ective in the revention o recurrent e isodes. However,
only lithiu and la otrigine (La ictal) are FDA-a roved or
bi olar treat ent and aintenance. Carba aze ine (“D”) is
a second-line agent that is also e ective, but side e ects li it
its use.
You decide to start lithium.
Question 23.14.4 Which o the ollowing is a well-recog-
nized side ef ect o lithium?
A) Diabetes ellitus
B) Hy othyroidis
C) I unosu ression
D) Abnor al hair growth
E) T e ability to hold an electric charge
Answer 23.14.4 The correct answer is “B.” Patients who take
lithiu should have their thyroid unction onitored. Also,
lithiu can a ect renal unction and electrolyte levels, so check
seru electrolytes eriodically. As lithiu has a narrow thera-
eutic window, seru lithiu levels should be easured as
well, with a goal o 0.6 to 1.0 Eq/L.
648 FAMILy MEDICINE EXAMINAt ION & BOAr D r EVIEW
Question 23.14.5 Which o the ollowing drugs or drug
classes do NOT alter lithium levels?
A) NSAIDs
B) Diuretics
C) ACE inhibitors
D) ARBs
E) Narcotics
Answer 23.14.5 The correct answer is “E.” Lithiu is cleared
by the kidney. Anything that can cause a change in renal unc-
tion can a ect lithiu levels. NSAIDs, diuretics, ACE inhibi-
tors, and ARBs can all a ect renal unction.
Objectives: Did you learn to . . .
• r ecognize and diagnose bipola diso de ?
• Ini ia e ea men o bipola diso de ?
• Desc ibe some po en ial adve se e ec s o ea men o
bipola diso de ?
CASE 23.15
A 20-year-old emale gymnast presents to you because she
has missed her period or 6 months. She eels cold all the time
and has noticed that when she crosses her legs, she gets pins-
and-needles sensations down her leg. She had a stress rac-
ture o her right tibia 5 years ago but denies any other medi-
cal history. She denies being sexually active and the review o
systems is positive or requent heartburn, constipation, and
atigue.
Question 23.15.1 Which o the ollowing diagnoses would
be in your dif erential?
A) Pregnancy
B) Hy erthyroidis
C) Malignancy
D) Anorexia nervosa (AN)
E) All o the above
Answer 23.15.1 The correct answer is “E.” All the answers
should be art o a reasonably broad di erential diagnosis in
this young wo an. In atients resenting with weight loss
and a ossible eating disorder, you should eli inate edi-
cal causes o weight loss, using history, hysical exa ination,
and a ro riate labs. Des ite her denial o sexual activity,
a regnancy test is a necessary art o the evaluation, since
regnancy is the ost co on cause o a enorrhea in this
o ulation. Hy erthyroidis and alignancy can resent
with vague co laints si ilar to this atient’s. Likewise,
AN can give rise to this atient’s constellation o sy to s,
though amenorrhea is no longer a diagnostic criteria or AN in
DSM-5.
As you take more history, you realize that this patient is a
very nicky eater. She is a strict vegan (So? What is wrong
with that?) and restricts her calories to < 1000/day in order
to stay in shape. She is 5 3 in tall and weighs only 100 lb, but
she thinks she is overweight.
Question 23.15.2 Which o these additional ndings would
you expect on physical examination?
A) Bradycardia
B) Hy ertension
C) Adnexal ass
D) Clonus
E) Pro tosis
Answer 23.15.2 The correct answer is “A.” Co on hysical
ndings in weight loss, and s eci cally AN, include e aciation,
sunken cheeks, hy otension, bradycardia, lanugo, ottled teeth,
and dry or yellow skin. Peri heral ede a ay develo during
weight gain or when laxative or diuretic abuse is sto ed. Mur-
urs can occasionally be auscultated.
Question 23.15.3 Patients with AN may present with:
A) Paresthesias
B) Cold intolerance
C) Consti ation
D) Fatigue
E) All o the above
Answer 23.15.3 The correct answer is “E.” All o the above are
sy to s o AN. T ese are co on sy to s seen in starva-
tion. “A” is not intuitive but is true. Loss o at allows or greater
ex osure o su er cial nerves, so the act o crossing the legs or
sitting down on a hard chair can cause aresthesias.
HELPFUL TIP:
Pa ien s wi AN a el ave insig in o e illness and
o en den a weig loss is a p oblem. t ese pa ien s
a e o en pe ec ionis s and ove ac ieve s w o a e
sensi ive o c i icism and come om amilies wi con-
lic . Weig loss is a me od o con ol and is seen as a
signi ican ac ievemen .
HELPFUL TIP:
t e wo d “ano exia” in AN is a misnome , as loss o ap-
pe i e is exceedingl a e in is illness. Pa ien s a e un-
g bu volun a il es ic ei calo ic in ake. t e ini ial
weig loss ma be p ecipi a ed b appe i e loss caused
b dep ession, medical illness, die ing, o s ess ul li e
even .
Question 23.15.4 Which would be an expected laboratory
nding in this patient?
A) Leukocytosis
B) Hy erkale ia
C) Increased a ylase
D) Decreased cholesterol
E) Erythrocytosis
Answer 23.15.4 The correct answer is “C.” A ylase ay be
increased as a result o urging behavior (and thus salivary
sti ulation). “A” and “E” are incorrect. Leuko enia, not leu-
kocytosis, with a ild, nor ochro ic, nor ocytic ane ia
 CHAPTER 23 • PSyCh IAt r y 649

TABLE 23-5 SELECTED MEDICAL COMPLICATIONS weights at the sa e ti e they are ex ected to reach eak bone
OF ANOREXIA NERVOSA ass. I a atient beco es osteo enic or osteo orotic when she
is young, she will re ain so as she ages (sans treat ent). Return
Neu ologic Seizu es
to good nutrition will not add bone ass that has been lost. All
Pe ip e al neu opa
Co ical a op o the other hysical changes listed should return to nor al
Cogni ive impai men with return to a nor al weight.
Ca diovascula B ad ca dia
Question 23.15.6 Which o the ollowing is the most appro-
O os a ic po ension
h ea ailu e priate next step in the management o this patient?
ECG c anges: low vol age, nonspeci c St A) ell her to sto gy nastics, withdraw ro classes, and go to
segmen c anges, Qt p olonga ion live with her other
B) Start an antide ressant
Endoc ine Ameno ea
Low t 3, t 4, and t Sh ( ansien cen al C) Ad it her to the hos ital
po oidism, p eviousl called “eu oid D) Consult sychiatry and nutrition s ecialists
sick s nd ome”) E) All o the above are equally valid o tions at this ti e
Os eopenia/os eopo osis
G ow e a da ion Answer 23.15.6 The correct answer is “D.” T is atient is ost
Fluids and De d a ion likely to bene t ro a coordinated lan involving a ultidisci-
elec ol es Me abolic alkalosis linary tea , including ri ary care, sychiatry, and nutrition.
h pokalemia “A” is incorrect, as it is a dra atic reaction that does not address
h pomagnesemia the atient’s ri ary roble , and the atient is unlikely to
h pocalcemia
co ly with it. “B” is incorrect. An antide ressant ay be hel -
Gas oin es inal Eleva ed live enz mes ul in atients with a clearly de ned de ressive or anxiety dis-
Cons ipa ion order. However, the use o antide ressant thera y or AN has
Esop agi is not been success ul, and certain antide ressants are associated
Mallo –Weiss ea s
Pa o id gland pe op
with weight loss. “C,” hos italization, is not likely to be bene -
cial at this oint. T e utility o hos italization has been dif cult
De ma ologic Lanugo to deter ine in AN. Co only acce ted reasons or hos ital
B i le nails and ai ad ission include the ollowing: severe low weight (70–75% o
Ac oc anosis
D , scal skin
ideal body weight), severe bradycardia (< 40 b ) or cardiac
arrhyth ia, arked sy to atic hy otension or synco e,
h ema ologic Bone ma ow supp ession acute sychiatric e ergency (threatened suicide), signi cant
dehydration or electrolyte disturbances, acute ood re usal, and
ailed intensive out atient thera y.
is a co on he atologic nding, although the CBC ay be
nor al. “B” is incorrect. T ere is usually whole-body de letion While you plan to involve psychiatric and nutritional ser-
o otassiu , zinc, agnesiu , and hos hate ( ro vo iting vices, you continue your discussion o eating disorders with
and/or inadequate intake). “D” is also incorrect, as cholesterol this patient.
is o en elevated (as are BUN and liver enzy es). T is choles-
terol elevation is neither intuitive nor well understood but is Question 23.15.7 Which o the ollowing is NOT TRUE about
observed to occur in atients with AN. See able 23-5 or ore the epidemiology o eating disorders?
edical co lications o AN. A) At least 90% o eating disorder atients are e ale
B) Rates are higher in industrialized, Western nations
In order to increase your patient’s motivation to comply with C) A a ily history o de ression increases the risk o e ales
medical recommendations, you describe some o the adverse develo ing eating disorders
e ects o excessively low weight. D) Male wrestlers have a higher risk o eating disorders than the
average ale
Question 23.15.5 All o the ollowing abnormal ndings E) Mortality rates in AN are si ilar to the general o ulation
will resolve when an adequate body weight is regained
EXCEPT: Answer 23.15.7 The correct answer is “E.” AN is characterized
A) Bradycardia by a high ortality, one o the highest o sychiatric illnesses. It
B) Muscle wasting ust be taken very seriously. U to 10% o hos italized atients
C) Osteo orosis die ro direct e ects o starvation, re eeding syndro e, sui-
D) In ertility cide, or electrolyte i balance leading to cardiac arrhyth ias.
At least 90% o eating disorder atients are e ale with reva-
Answer 23.15.5 The correct answer is “C.” Patients with AN lence rates higher in certain grou s, such as odels, actresses,
are usually young and there ore ex erience so e o their lowest athletes, and dancers. Western, industrialized societies endorse
650 FAMILy MEDICINE EXAMINAt ION & BOAr D r EVIEW
thinness and dieting as an ideal or wo en, resulting in higher
rates o eating disorders. Des ite having a nor al body weight,
over 40% o 9- and 10-year-old American girls believe they
are overweight and consider dieting as an o tion! Eating dis-
orders are unco on in oorer countries where starvation is
wides read, and there is no cultural endorse ent o thinness.
“C” is true. A a ily history o de ression or obesity increases
risk o an eating disorder by two- to ve old, with a a ily his-
tory o de ression alone increasing the risk about ve old. “D”
is also true. In ales, wrestlers have a higher revalence o eat-
ing disorders because o weight require ents in their s ort. In
ales, body sha e and not necessarily absolute body weight is
the ty ical ocus o concern.
HELPFUL TIP:
t e e a e wo sub pes o AN: es ic ive and binge/
pu ge. t e e o e, a pa ien w o binges and pu ges
( oug o ced emesis, laxa ives, e c.) does no neces-
sa il ave bulimia.
HELPFUL TIP:
Como bidi ies a e p evalen in ea ing diso de pa ien s
and include MDD (50–75%), anxie diso de s, obsessive–
compulsive diso de , and subs ance abuse. Pe sonal-
i diso de s a e also p evalen wi e anxious, sen-
si ive, igid, and pe ec ionis ic pes p edomina ing
(Clus e C).
In your discussion o eating disorders, your patient asks
about bulimia and how you distinguish between AN and
bulimia nervosa (BN).
Question 23.15.8 Which o the ollowing is NOT TRUE when
comparing patients with AN and BN?
A) BN is ore revalent than AN
B) BN atients are ore likely to be nor al weight than AN
atients
C) T e rognosis or AN is better than that or BN
D) BN atients are ore likely to have eso hageal tears
E) Medications are e ective in BN but not in AN
Answer 23.15.8 The correct answer is “C.” BN has a bet-
ter rognosis than AN, with only 20% o atients still eet-
ing diagnostic criteria 5 to 10 years a er initial resentation.
BN is ore co on than AN, with the revalence increasing
just like it has with AN. “B” is true. Patients with BN are usu-
ally close to nor al weight. However, they show several stig-
ata: loss o dental ena el and chi ed teeth with cavities;
enlarged arotid salivary glands with elevated seru a ylase
ro re eated vo iting e isodes; enstrual irregularities;
bradycardia, hy otension, and decreased etabolic rate. Rare
co lications include eso hageal tears ro requent vo iting
or gastric ru ture due to gastric dilatation secondary to bing-
ing. “E” is true. reat ent o BN involves the sa e rinci les
as AN. Fluoxetine is the rst-line drug with a target dose o 60
g being shown to be e ective in trials. Other SSRIs are sec-
ond line. T ird-line agents include CAs, MAOIs, and trazo-
done. T ese agents reduce binge eating and buli ic sy to s
whether atients are de ressed or not.
HELPFUL TIP:
t e mean age o onse o ea ing diso de s is 17 ea s,
wi ve a e onse a e e age o 40 (al oug ecu -
ence can occu in is popula ion).
Objectives: Did you learn to . . .
• Evalua e a oung pe son wi a suspec ed ea ing diso de ?
• Diagnose AN?
• r ecognize medical complica ions o ea ing diso de s?
• Dis inguis be ween AN and bulimia?
• Ini ia e app op ia e ea men and e e al o a pa ien wi
an ea ing diso de ?
QUICK QUIZ: BINGE AND PUr GE
In order to be diagnosed with BN according to DSM-5, a atient
ust eet all o the ollowing criteria EXCEP :
A) Recurrent urging via sel -induced vo iting
B) Recurrent binge eating
C) Sy to s are resent on average at least once er week or
at least 3 onths
D) Sel -evaluation is unduly in uenced by body sha e and
weight
The correct answer is “A.” For the diagnosis o BN, sel -induced
vo iting need not be resent. Rather, so e sort o co ensa-
tory behavior ust be resent during buli ic e isodes. T is
behavior ight include vo iting, but is not li ited to vo it-
ing, and ay also include laxative or diuretic use, asting, or
excessive exercise. “B,” “C,” and “D” are required or the diag-
nosis o BN. BN a ects about 1% to 3% e ales (usually white)
and 0.1% to 0.3% ales. Co orbidities o de ression, anxiety,
substance abuse, and ersonality disorders are also co on.
Dra atic, unstable ersonality traits (cluster B) redo inate
in this illness unlike the sensitive, rigid (Cluster C) ersonality
traits in AN.
QUICK QUIZ: EAt ING DISOr DEr S (Or , h OLD t h E
PIE FOr NOW, PLEASE)
A reviously healthy 17-year-old e ale is hos italized or AN.
She has her weight ra idly restored with intravenous uids and
a 3000 kcal/day diet. She gains 10 lb in her rst 2 days (so gain-
ing 10 lb in 2 days sounds like a good thing?) and see s to be
doing well. However, when you round the next orning, she is
nonres onsive. Physical exa ination reveals evidence o JVD,
ul onary rales, and lower extre ity ede a.

What is the ost likely cause o this atient’s a arent heart
ailure?
A) Previously undiagnosed heart disease
B) Re eeding syndro e
C) Suicide atte t by SSRI overdose
D) Myocardial in arction
E) akotsubo cardio yo athy
The correct answer is “B.” T e scenario described ts with the
clinical icture caused by re eeding syndro e. Re eeding syn-
dro e occurs when ra id ex ansion o the circulating volu e
overwhel s the cardiovascular syste ’s ability to ada t, lead-
ing to heart ailure. It also involves changes in electrolytes and
glucose. It ty ically occurs in alnourished atients. Preven-
tion involves care ul onitoring o electrolytes including ag-
nesiu , hos horus, otassiu , and calciu , while advancing
caloric intake in a s all, linear ashion and kee ing track o vol-
u e status. “A,” “D,” and “E” are incorrect as the atient is un-
likely to have signi cant heart disease given her age and gender.
HELPFUL TIP:
t e e is no case o is able bu edi o s a e i w en
e e is no “call ou ” o a able. So, see t able 23-6 o
wa ning signs a an agi a ed pa ien ma become
violen . See t able 23-7 o wa s o calm e agi a ed pa-
ien (al oug in e edi o s’ expe ience no ing bea s
IM alope idol and IM lo azepam).
QUICK QUIZ: Ph ySICIAN h EAL t h ySELF?
Which o the ollowing is true about hysicians’ risk o suicide
co ared to the general o ulation?
A) Fe ale hysicians have a risk o success ul suicide equal to
ale hysicians
B) Physicians are ore likely to be de ressed than the general
o ulation
TABLE 23-6 WARNING SIGNS THAT AN AGITATED
PATIENT MAY BECOMEVIOLENT
h pe ac ivi : pacing o o e inc ease in ps c omo o ac ivi
Loud, ang , o p o ane speec
Inc eased muscle ension, mani es ed b clenc ed jaw, s , igid
pos u e, g ipping c ai , si ing on c ai edge, e c.
In oxica ion
Suspicious, ang , o i i able a ec
B ea lessness, ac ca dia, diap o esis, pupilla dila ion, visibl
palpi a ing empo al a e ies
Uncoope a iveness wi eques s
Doo slamming, c ai oppling, o o e o m o p ope des uc ion
G abbing objec s a could be po en ial weapons
Ve bal o p sical ea s
t e clinician’s esponse o e pa ien : i ou eel anxious, ake i
se iousl and be ale o possible dange
CHAPTER 23 • PSyCh IAt r y 651
C) Fe ale hysicians are ore likely to atte t suicide than
the general e ale o ulation
D) Medical students and residents are less likely to be de ressed
than the general o ulation
The correct answer is “A.” In the general o ulation, wo en
have 2 to 4 ti es ore suicide atte ts than en, while en
are 4 ti es ore likely than wo en to be success ul. However,
a ong hysicians, the rate o success ul suicide in en and
wo en is equivalent (we didn’t study all o that har acology or
nothing!). T is occurs des ite the act that e ale hysicians have
ewer atte ts than the general e ale o ulation (we didn’t get
through ed school by just atte ting studying!). Physicians
have roughly the sa e rate o de ression as the general o u-
lation, while edical students and residents have higher rates
than the general o ulation (15–30% vs. 16% in the general
o ulation . . . i you were ever a edical student or resident we
are sure you got this one right). Other actors a ecting suicide
risk (in addition to being a hysician) are noted in able 23-8.
QUICK QUIZ: SUICIDE r ISK
You have a colleague who is de ressed and has transient
thoughts o suicide.
Which o the ollowing would suggest that he should be hos i-
talized today?
A) He thinks about suicide only in requently
B) He has not or ulated a lan to co it suicide
TABLE 23-7 TECHNIQUES TO CALM THE
AGITATED PATIENT
r emove e pa ien o a quie and nons imula ing envi onmen
Keep a dis ance om e pa ien and avoid p sical con ac
Iden i exi s and ala ms
Main ain non ea ening demeano and s ance
Keep ou ands a ou side w e e e a e easil visible
W ile main aining s ead e e con ac , speak in a s ead bu
au o i a ive voice, using e pa ien ’s name wi eac sen ence
Avoid sudden je k movemen s and emain calm
h ave amilia aces nea b i possible
S ow e pa ien conce n bu ell im a violence is no accep able
and ou a e willing o wo k wi im i e calms down
t e e is s eng in numbe s; ave o e pe sonnel nea b o elp i
necessa
Call o elp om police o secu i i needed; a back-up s s em, w ic
as been es ed, s ould be in place
Conside an ips c o ics, suc as alope idol (available in o al and
pa en e al o ms) and ispe idone (available in liquid); a benzodiazepine
ma be used as an adjunc , bu s ould not be used alone
Mec anical es ain s ma be emplo ed i absolu el necessa
r emembe o gu e ou why e pa ien is agi a ed (e.g., ake is o ,
pe o m men al s a us examina ion, and o de app op ia e es s)
652 FAMILy MEDICINE EXAMINAt ION & BOAr D r EVIEW

TABLE 23-8 FACTORS AFFECTING SUICIDE RISK CASE 23.16

Risk Factors
• Living alone (pa icula l s ea alone) You are on call and have been paged to see a 21-year-old
• Loss o spouse o sepa a ion emale who has just overdosed on a hand ul o acetamino-
• Alco ol use phen because her boy riend le her a er their most recent
• h aving access o a gun o le al means ght. She has had similar overdoses three times in the past
• Loss o ac ivi , job, p ope , o capabili ies
(they ght a lot). According to a riend, she has a history o
• Mild/minimal cogni ive impai men
• Pa anoia tumultuous relationships. In the emergency department, she
• h opelessness is combative and yelling, “I’m so angry that I’m still alive!”
• Anxie She has a blood alcohol level o 106 mg/dL. T ere are scars on
• Olde w i e male her arms rom cutting.
• Pe sonal o amil is o o suicide a emp o comple ion
• U ban dwelle
Question 23.16.1 What is the most likely primary diagnosis?
Protective Factors A) Antisocial ersonality disorder
• E ec ive ea men o men al and p sical diso de s B) Bi olar e ective disorder
• Social and amil suppo
C) MDD
• Coping skills
• r esilience D) Borderline ersonality disorder
• r eligious ai E) Inter ittent ex losive disorder
• Lack o access o le al means
Answer 23.16.1 The correct answer is “D.” T is atient’s his-
tory is consistent with a diagnosis o borderline ersonality dis-
order. Persons with borderline ersonality disorder o en have
C) He has u dated his will within the ast ew days stor y relationshi s, characterized by extre es o e otional
D) He is willing to ollow u in clinic to orrow intensity (e.g., “love–hate” relationshi s). You ight also con-
sider de ression as a diagnosis here, but the history does not
The correct answer is “C.” I a erson ad its to suicidal ide- su ort MDD. However, conco itant de ression is co on in
ation, ask the ollowing questions to assess his level o risk and atients with borderline ersonality disorder. “A,” “B,” and “E”
to deter ine whether or not he should be hos italized: are not su orted by the clinical resentation. Borderline er-
• How o en does he think about suicide? sonality disorder is ostly a diagnosis o e ales (over 90%).
• Does he have a concrete lan? And i so, is it lausible? Characteristics are listed in able 23-9.
( ying onesel to a rocket does not count . . . or ost eo le.)
• Is he giving away treasured belongings, u dating his will,
aking nal lans, etc.? HELPFUL TIP:
• Is he in danger o acting on his thoughts? A pe sonali diso de is an endu ing pa e n o ela ing
• Why has he not atte ted suicide yet? What kee s hi ro o e wo ld in wa s a a e in lexible, ine ec ive, and
doing it? ma kedl di e en om cul u al no ms. Pe sonali dis-
• Does he have access to har ul eans (e.g., guns and drugs)? o de s cause dis ess o unc ional impai men and s a
b adolescence in mos people. t e p evalence a e o
pe sonali diso de s va ies widel ac oss s udies, wi
QUICK QUIZ: PSyCh Ot r OPIC Dr UGS bo de line pe sonali diso de being e mos p eva-
len o all.
Which o these antide ressants can be ad inistered once
weekly?
A) Paroxetine (Paxil) TABLE 23-9 CHARACTERISTICS OF BORDERLINE
B) Bus irone (Wellbutrin) PERSONALITY DISORDER
C) Fluoxetine (Prozac)
D) Escitalo ra (Lexa ro) • Fea s o abandonmen
• Uns able and in ense ela ions ips
E) Venla axine (E exor-SR) • Uns able sense o sel
• Impulsivi
The correct answer is “C.” Fluoxetine has a long-enough hal - • Suicidal be avio , ea s o ges u es o sel -mu ila ion (cu ing is
li e that it can be ad inistered once a week. You don’t need to o en a ea u e o bo de line pe sonali diso de )
rescribe the “long-acting” uoxetine. Any uoxetine can be • Signi can mood eac ivi
• C onic eelings o emp iness (Camus o Nie zsc e?)
dosed once weekly. It is traditionally dosed daily, but i atients • In ense ange ou bu s s
are ex eriencing side e ects, dosing can be adjusted to every • t ansien s ess- ela ed pa anoid idea ion o dissocia ion
other day or weekly.

TABLE 23-10 CHARACTERISTICS OF ANTISOCIAL
PERSONALITY DISORDER
• r ecu en c iminali
• Decei ulness s own b epea ed l ing, use o aliases, o conning
o es
• Impulsivi
• I i abili and agg ession
• r eckless dis ega d o sa e
• Consis en i esponsibili , ailing o ul ll nancial obliga ions o
wo k
• Lack o emo se
• h is o o c ild ood conduc diso de in a pa ien now a leas 18
Your patient’s boy riend storms into the emergency depart-
ment and demands to see her. He has “love” and “hate”
tattooed on his knuckles and another less savory symbol
tattooed on his arm—although he swears it’s just a ibetan
good luck charm. T e nurse recognizes him immediately as
a requent visitor. Apparently, he has been in the emergency
department on multiple occasions or injuries sustained
rom ghts. Your patient pulls you aside to tell you that she
is a raid o him, saying, “I just worry when he gets mad.
He went to jail or beating and raping his last girl riend.”
T e nurse also in orms you that he is suspected o stealing
narcotics rom a pharmacy in town. You call security.
Question 23.16.2 Which o the ollowing personality disor-
ders is most likely in this man?
A) Paranoid ersonality disorder
B) Histrionic ersonality disorder
C) Schizoty al ersonality disorder
D) Antisocial ersonality disorder
E) I ajerk ersonality disorder
Answer 23.16.2 The correct answer is “D.” Antisocial er-
sonality disorder is ri arily seen in ales, and o the o tions
given, it is the only ersonality disorder that really ts. Antiso-
cial ersonality disorder is quite revalent in rison o ulations.
“A” and “C” are incorrect because these are Cluster A disorders,
which are characterized by strange rather than violent behavior.
“B” is incorrect. Histrionic ersonality disorder shows attention-
seeking and seductive behavior. Although atients with antiso-
cial ersonality disorder can be char ing, they also use violence
and threats to achieve their ur oses. “E” is incorrect because
it does not exist as a disorder—it’s a joke (I’ -a-jerk, get it?)—
although i it did exist, this atient would be a ri e exa le.
Characteristics o antisocial ersonality disorder are listed in
able 23-10.
Question 23.16.3 Besides borderline personality disorder,
which other personality disorder increases the risk o com-
pleted suicide the most?
A) Paranoid ersonality disorder
B) Histrionic ersonality disorder
C) Schizoty al ersonality disorder
CHAPTER 23 • PSyCh IAt r y 653
D) Avoidant ersonality disorder
E) Antisocial ersonality disorder
Answer 23.16.3 The correct answer is “E.” Along with border-
line ersonality disorder, antisocial ersonality disorder is the
other ersonality disorder ost likely to be seen in co leted
suicides.
Question 23.16.4 Borderline personality disorder and anti-
social personality disorder all within what cluster or cat-
egory o personality disorders?
A) Cluster A
B) Cluster B
C) Cluster C
D) Cluster D
Answer 23.16.4 The correct answer is “B.” T ere are three
clusters o ersonality disorders that are categorized based on
their characteristics.
• Cluster A: “the weird cluster”— atients are aloo , act strange,
and re er to be alone. Paranoid, schizoid, and schizoty al
ersonality disorders are included here.
• Cluster B: “the wild cluster”— atients have signi cant rob-
le s with ood lability, i ulsivity, or are reoccu ied with
being ad ired or their sexuality or intelligence. Borderline,
antisocial, histrionic, and narcissistic ersonality disorders
are included here.
• Cluster C: “the whiny or worried cluster”— atients are
clingy, sensitive, and rigid. Avoidant, de endent, and obses-
sive–co ulsive ersonality disorders are included here.
HELPFUL TIP:
you will be app o know (as a e we) a , as o DMS 5,
e old “axis” designa ion s s em (axis 1, axis 2, e c.) o
ps c ia ic disease as gone e wa o e dodo bi d
(o pick ou avo i e ex inc species).
HELPFUL TIP:
Impulsivi is a isk o comple ed suicide. Even oug
pa ien s ma no wan o die, an impulsivel aken ove -
dose o o e suicide a emp ma inadve en l lead o
dea . t is is w pa ien s wi bo de line pe sonali
diso de and an isocial pe sonali diso de ave a ig
isk o comple ed suicide.
You have a rank discussion with your emale patient about
suicide.
Question 23.16.5 Which o the ollowing is NOT TRUE about
suicide in the general population?
A) Medical diagnoses can increase the risk o suicide
B) Over 90% o eo le who co it suicide have a ental or
substance abuse disorder
654 FAMILy MEDICINE EXAMINAt ION & BOAr D r EVIEW

TABLE 23-11 MNEMONICS FOR SUICIDE Question 23.17.1 Which o the ollowing would you NOT
RISK ASSESSMENT expect to nd on mental status examination?
A) Delusions
NO HOPE SAD PERSONS
B) Hallucinations
No amewo k o meaning (r eading Sex—male C) Lack o insight
Nie zsc e and being an exis en ialis ?) Age—olde D) Decreased sycho otor activity
Ove c ange in clinical condi ion Dep ession E) Poverty o s eech
Hos ile in e pe sonal envi onmen P evious a emp
Ou o ospi al ecen l E anol abuse Answer 23.17.1 The correct answer is “D.” T e atient
P edisposing pe sonali ac o s Ra ional oug loss
described is acutely sychotic. You would ex ect hi to have
Excuses o d ing o elp o e s increased sycho otor activity. All o the other o tions would
Social suppo lacking
also be antici ated ndings in this atient. Co on sy to s
O ganized plan
o sychosis include delusions, hallucinations, sycho otor
No spouse
agitation, ight o ideas, nonsensical s eech and behavior, lack
Sickness o insight into one’s behavior, and lack o judg ent. Note that
“poverty o speech” re ers to brie , empty replies to questions and
C) Older A ericans are at higher risk o suicide than the gen- not to content which may be quite anci ul.
eral o ulation
D) T e rate o success ul suicides has increased over the years Question 23.17.2 All o the ollowing are potential causes
E) Suicide is one o the to 10 causes o death in the United o this patient’s psychosis EXCEPT:
States A) Substance abuse
B) Alcohol withdrawal
Answer 23.16.5 The correct answer is “D.” T e rate o success- C) Bi olar disorder
ul suicide has actually stayed stable over ti e. “A” is a correct D) Bereave ent
state ent. Medical diagnoses can be risk actors or suicide. Par- E) Schizo hrenia
ticularly roble atic are chronic illness, ter inal illness, chronic
ain, or recent surgery. Older A ericans co it suicide at a rate Answer 23.17.2 The correct answer is “D.” Bereave ent ay
our ti es than that o the general o ulation with a eak inci- result in ild delusions and so eti es hallucinations regarding
dence at age 75 or en and 60 or wo en. “E” is also correct. the bereaved subject (Hey? Is that o back ro the dead?),
Suicide is the seventh leading cause o death in the United States but it should not cause overt sychosis. Moreover, there is noth-
and the third leading cause o death in those aged 15 to 24 years. ing in the history here to su ort a diagnosis o bereave ent.
T ere are two ne onics that are use ul or assessing suicide T e re aining o tions are otential cause o sychosis, and
risk: “NO HOPE” and “SAD PERSONS” (see able 23-11). they are listed along with other otential causes in able 23-12.

TABLE 23-12 CAUSES OF PSYCHOSIS AND

HELPFUL TIP: DELIRIUM: A PARTIAL LIST
Seven - ive pe cen o olde Ame icans w o commi
suicide ave seen ei p ima ca e p sician wi in Potentially Imminently Li e -Threatening Causes
• Meningi is o encep ali is
e p eceding 4 weeks and 39% wi in e same week. • h poxemia
Up o al o success ul suicides ave made a p io • h pe ensive encep alopa
a emp . • We nicke encep alopa
• In ac anial bleed
• D ug wi d awal, in oxica ion, o eac ion o p esc ibed d ugs
Objectives: Did you learn to . . .
• Iden i bo de line and an isocial pe sonali diso de s? Other Medical Causes
• Me abolic diso de s (e.g., pe gl cemia and pona emia)
• Classi pe sonali diso de s? • Neu ologic diso de s
• Assess suicide isk? • Nu i ional de ciencies (e.g., pellag a, be ibe i, and pe nicious
anemia)
CASE 23.17 • Indus ial exposu e o oxins

Psychiatric Causes
A 21-year-old man presents to your clinic because his girl- • Sc izop enia o sc izop eni o m diso de s
riend dragged him in. He just started his rst year in college • B ie ps c o ic diso de
but quit 2 days ago because he eels that “they are all out to • Mood diso de s including bipola diso de and ps c o ic
get me.” (“I he’s talking about the IRS, or New World Order, dep ession
he’s probably right,” you think to yoursel .) He has not been • Sc izoa ec ive diso de
• Demen ia
sleeping because he thinks he might be murdered in his sleep. • Deli ium
He tells you that the FBI has bugged your o ce and, there- • Delusional diso de
ore, he does not want to answer your questions.

HELPFUL TIP:
Ps c osis is a s mp om and no a diagnosis and s ould
p omp a sea c o an e iolog . Some o e causes a e
po en iall li e ea ening.
T e patient relaxes and becomes cooperative, and you are
able to obtain a history and per orm a physical examination.
He denies drug use or medical illnesses. Your patient worries
that he is going “crazy” and admits that he has been having
these symptoms “ or a while” but did not want to tell any-
body, or ear o being institutionalized. Your physical exami-
nation and labs are unremarkable.
Question 23.17.3 Which o the ollowing diagnoses is the
most likely cause o this patient’s psychosis?
A) Schizo hrenia
B) Psychotic de ression
C) Deliriu
D) Drug intoxication
E) De entia
Answer 23.17.3 The correct answer is “A.” Schizo hrenia is a
heterogeneous grou o disorders characterized by the ollow-
ing: ositive sy to s (delusions, hallucinations, disorganized
behavior, disorganized s eech); negative sy to s ( overty
o s eech, anhedonia, a ective attening, avolition, asocial-
ity); ood sy to s (dys horia, suicidal thoughts, ho eless-
ness); and cognitive sy to s (attention and e ory de cits
and dif culty with abstract thinking). It is the ost co on o
the sychotic disorders. A negative laboratory evaluation and
hysical exa ination ake drug intoxication unlikely, while
this atient’s ability to converse with you and give a history
akes deliriu and de entia unlikely. Psychotic de ression is
unusual in young eo le, but rather is ore co only seen in
older atients with severe de ression.
Question 23.17.4 Which o the ollowing is NOT TRUE about
schizophrenia?
A) Nearly 50% atte t suicide with a 10% success rate
B) Li eti e revalence is 1% worldwide, consistent across cul-
tures
C) Schizo hrenia is a disease o late adolescence or early adult-
hood
D) Men are ore likely to be a ected than wo en
E) Risk o rela se is at least 50% a er success ul treat ent in
atients who do not re ain on anti sychotic aintenance
thera y
Answer 23.17.4 The correct answer is “D.” Schizo hrenia has
a worldwide revalence o about 1%, which is true or all cul-
tures, countries, and both genders. It generally begins in late
adolescence or early adulthood, and onset a er age 50 is rare
and should ro t the search or other etiologies to ex lain
the sychosis. Men have a slightly earlier age o onset (early
20s) than wo en (late 20s), but en and wo en are a ected
CHAPTER 23 • PSyCh IAt r y 655
equally by the illness. T e course is variable with so e atients
having exacerbations and re issions (although ull re issions
are rare), while others re ain chronically ill. About hal o the
atients who develo schizo hrenia have a a ily history o
schizo hrenia. Suicide atte ts are co on, usually the result
o de ression or a res onse to co and hallucinations, ara-
noid delusions, or agitation. Nearly 50% will atte t suicide,
while about 10% will be success ul. A er success ul treat ent o
the rst e isode, about 50% will rela se i not on aintenance
edication.
Question 23.17.5 Which o the ollowing medication options
is the proper treatment choice?
A) Olanza ine (Zy rexa)
B) Ris eridone (Ris erdal)
C) Halo eridol (Haldol)
D) Ari i razole (Abili y)
E) Any o the above
Answer 23.17.5 The correct answer is “E.” All o the anti sy-
chotics listed are rst-line treat ent choices or schizo hrenia.
Most sychiatrists have re laced older “ty ical” (now known
as “ rst-generation” agents like halo eridol, chlor ro azine,
u henazine, thioridazine) with newer “aty ical” (now known
as “second-generation” agents, such as ris eridone, cloza ine,
zi rasidone, ali eridone, and olanza ine) because o better tol-
erability and ossibly increased bene t or negative sy to s.
Although, the newer agents are signi cantly ore ex ensive
than the older agents, ore generics are beco ing available.
Also, any “aty icals” cause signi cant weight gain, and so e
have been linked to new onset diabetes. O the newer agents,
ari i razole (Abili y) and zi rasidone (Geodon) are less associ-
ated with weight gain and diabetes.
Question 23.17.6 Which o the ollowing IS TRUE o the
course o schizophrenia?
A) Positive sy to s usually occur rst
B) Negative sy to s are easier to treat than ositive sy -
to s
C) Negative sy to s o en look like de ression
D) Schizo hrenia is not ty ically associated with brain changes
E) Fa ily thera y is not hel ul in this illness
Answer 23.17.6 The correct answer is “C.” Negative sy -
to s o en recede the develo ent o the ositive sy to s
by any years, are o en nons eci c, and can be istaken or
de ression. A ty ical history is that o a nor al young an
or wo an who begins to ail classes and avoid his old riends
as he gets to the end o high school. T is is o en istaken
or teenage rebellion, de ression, or drug use until the onset
o ositive sychotic sy to s o hallucinations or delu-
sions several years later. “B” is incorrect. Negative sy to s
are chronic and are resistant to treat ent with all currently
available anti sychotics. Anti sychotic drugs odulate do a-
ine and/or serotonin and are uch better at treating osi-
tive sy to s. “D” is not true, as brain i aging ay reveal
656 FAMILy MEDICINE EXAMINAt ION & BOAr D r EVIEW
enlarge ent o cerebral ventricles and decreased brain volu e.
However, these ndings are neither sensitive nor s eci c
enough to have uch value in diagnosis. “E” is incorrect. A
large body o literature su orts the act that a ily thera y,
es ecially directed at su ort and sychoeducation, reduces
the risk o rela se. Recent evidence indicates that individual
CB can also be e ective.
HELPFUL TIP: DUAL ANTIPSYCHOTICS:
t e e is almos neve an indica ion o mo e an one
an ips c o ic. Don’ do i .
Objectives: Did you learn to . . .
• r ecognize ps c osis and i s causa ive diagnoses?
• t ea ps c osis?
• r ecognize sc izop enia and unde s and i s epidemiolog
and p ognosis?
CASE 23.18
A 33-year-old actory worker comes to your clinic complain-
ing o sleep di culty since he moved to the “graveyard shi .”
He complains o alling asleep at work and having di culty
sleeping during the day.
Question 23.18.1 Which o the ollowing is the most likely
diagnosis?
A) Narcole sy
B) Circadian rhyth slee –wake disorder
C) Obstructive slee a nea
D) Pri ary inso nia
E) Fatal a ilial inso nia
Answer 23.18.1 The correct answer is “B.” T is atient su ers
(as do ost residents and a signi cant nu ber o hysicians)
ro a circadian rhyth slee –wake disorder, which is de ned
as a slee disru tion leading to excessive slee iness when the
atient wishes to be awake or inso nia when the atient wishes
to be aslee . It occurs as a result o a is atch between the
biological circadian rhyth and the erson’s environ ent. He
does not give a history consistent with narcole sy or obstructive
slee a nea, and ri ary inso nia is a diagnosis o exclusion.
Fatal a ilial inso nia is a rare genetically deter ined rion
disease resulting in co lete inability to slee , de entia, and
death within a ew years.
He asks your advice on how to treat his sleeplessness.
Question 23.18.2 What would be the best advice to of er at
this time?
A) Have hi slee at work (we do!)
B) Have hi take na s throughout the day
C) ell hi to quit his job
D) Reco end bright light at night be ore going to work
E) Prescribe sti ulants or when he is at work
Answer 23.18.2 The correct answer is “D.” T is atient’s
circadian rhyth disturbance ight also be called a “ hase-
advance” ty e slee disorder (early slee onset with inso nia at
the desired slee eriod). Such roble s res ond best to bright
light in the evening to kee one awake during the ti e the indi-
vidual would usually be aslee . Light boxes are available co -
ercially and should rovide white light at 2,500 lux or ore.
T e light should be airly close to the atient’s eyes, and a bit o
to the side. T e other o tions are not likely to be hel ul i this
atient wants to kee his job.
Question 23.18.3 I this patient wished to use a nutritional
or herbal supplement, which o the ollowing would you
recommend?
A) Melatonin
B) Kava-kava
C) Ginkgo
D) Ginseng
E) St. John’s wort
Answer 23.18.3 The correct answer is “A.” T ere is so e evi-
dence to suggest that elatonin can hel with circadian rhyth
disorders (and not inso nia in general where data is s otty).
Melatonin should be taken at the ti e o day the atient wants
to slee . In this case, you should advise hi to take it in the
orning. T e doses used or circadian rhyth disturbances are
uch less than the dose used or ri ary inso nia, ty ically
0.5 g or less, co ared with 3 g. T e other herbal su le-
ents have no evidence or use in slee disturbances exce t or
kava-kava, which is too dangerous to reco end.
Question 23.18.4 Which o the ollowing is NOT a delayed
sleep phase type o circadian rhythm sleep disorder?
A) Re-ada tation to day work ro night work
B) West-to-east jet lag
C) East-to-west jet lag
D) All o the above are delayed slee hase disorders
Answer 23.18.4 The correct answer is “C.” Delayed slee hase
involves a ersistent attern o late slee onset and late orning
awakening. T is is exe li ed by the average teenager during
su er vacation (just try to get hi to ow the lawn be ore
noon!). West-to-east jet lag and re-ada ting to day shi a er
working night shi also cause si ilar roble s. “C” does not
cause a delayed slee hase disturbance. East-to-west jet lag
causes the o osite roble , advancing slee hase so that
ersons are slee y early in the evening but then awake early in
the orning. A otentially e ective treat ent o delayed slee
hase would include rescribing a bright light in the orning
and elatonin in the a ernoon.
Objectives: Did you learn to . . .
• r ecognize ci cadian m diso de s?
• r ecommend ea men o ci cadian m diso de s?

QUICK QUIZ: LESt yOU FOr GEt
A 70-year-old an resents with e ory loss that has been
rogressive over the years. He o en has uctuating attention
and is rigid with bradykinesia. He requently ex eriences visual
hallucinations.
Which o the ollowing is the ost likely diagnosis?
A) Alzhei er disease
B) De entia with Lewy bodies (DLB)
C) Parkinson disease
D) Vascular de entia
E) Frontote oral de entia
The correct answer is “B.” DLB shares any eatures in co -
on with Parkinson disease. T ese eatures include arkin-
sonian otor sy to s, such as bradykinesia, rigidity, and
tre or. Both Parkinson disease and DLB are characterized
histologically by the resence o Lewy bodies. However, in
DLB, Lewy bodies are di usely s read in the cortical regions
and brainste , whereas in Parkinson disease, Lewy bodies are
ri arily resent in the subcortical nuclei. Fluctuating cog-
nition that rese bles deliriu , visual hallucinations, and an
exquisite sensitivity to the adverse e ects o neurole tics all
characterize DLB. T ere is a lack o res onse o do a inergic
agents with DLB but cholinesterase inhibitors o er a odest
bene t.
QUICK QUIZ: DEMENt IA
A 65-year-old an with a history o hy ertension, diabetes, and
eri heral vascular disease has been noted to have abru t dete-
rioration in his cognitive ability ollowing an e isode o disori-
entation and word- nding dif culty 1 onth ago.
Which o the ollowing is the ost likely diagnosis?
A) Alzhei er disease
B) DLB
C) Parkinson disease
D) Vascular de entia
E) Frontote oral de entia
The correct answer is “D.” Vascular de entia ( reviously
known as ulti-in arct de entia) is caused by vascular dis-
ease (sur rise! An illness with a na e that akes sense!) and,
next to Alzhei er disease and Lewy body de entias, is one o
the ost co on causes o de entia. It classically resents
with an abru t onset ollowed by ste -wise deterioration o
cognitive unction. Medical co orbidities are co on, in-
cluding diabetes, hy ertension, and obesity. Evidence o vas-
cular disease is usually resent on clinical exa ination with
ocal neurological signs, such as are seen a er a stroke involv-
ing otor areas. I aging ty ically shows in arctions o eri-
ventricular and dee subcortical white atter, resenting as
CHAPTER 23 • PSyCh IAt r y 657
white atter hy erintensities on 2-weighted MRI. reat ent
includes odi ying vascular risk actors.
CASE 23.19
A 37-year-old emale patient returns to see you or ollow-up
o depression. You last saw her 4 weeks ago, and at that time
she was experiencing her third relapse o recurrent major
depression. She had been in remission or 3 years be ore, and
until 2 years ago she had been taking sertraline 150 mg daily,
a regimen that she had ound e ective during an 18-month
course o treatment. At her visit last month, you assessed her
symptoms with the Patient Health Questionnaire-9 (PHQ-9),
and her score at that time was 21. You reinstituted sertraline
at 50 mg daily or 2 weeks and then 100 mg daily. At her
visit today, now on sertraline 100 mg daily or 2 weeks, her
PHQ-9 score is 17. She denies having thoughts o death or
suicide.
Question 23.19.1 Which o the ollowing statements is NOT
true regarding the PHQ-9?
A) T e PHQ-9 is a clinician-ad inistered questionnaire to
evaluate or sy to s o ajor de ression
B) It takes 3–5 inutes to co lete the PHQ-9
C) A score o 10 or ore on the PHQ-9 is a ositive screen
D) T e PHQ-9 can be used to screen or de ression as well as to
onitor sy to severity over ti e
E) T e PHQ-9 does NO assess or suicide risk
Answer 23.19.1 The correct answer is “A.” T e PHQ-9 is a
atient-ad inistered, nine-ite questionnaire that takes 3 to
5 inutes to co lete. It can be used to screen or ajor de res-
sion as well as to onitor sy to severity over ti e. A score
> 10 is considered a ositive screen, while a score < 5 is consid-
ered to be negative or in re ission. T e axi u score is 30.
While the PHQ-9 does ask about the resence o “thoughts o
death or dying,” it does not assess whether so eone is at low or
high risk or suicide atte t.
Question 23.19.2 Which o the ollowing options is LEAST
appropriate to recommend to your patient at this time?
A) Continue sertraline 100 g daily and return or ollow-u in
1 onth
B) Continue sertraline 100 g daily, add weekly CB , and
return or ollow-u in 1 onth
C) Increase sertraline to 150 g daily and return or ollow-u
in 1 onth
D) Sto the sertraline and start citalo ra 20 g daily and
return or ollow-u in 1 onth
E) Continue sertraline 100 g daily and add bu ro ion SR
150 g BID, return or ollow-u in 1 onth
Answer 23.19.2 The correct answer is “D.” At the current
visit, the atient has been taking sertraline or 1 onth and
has been at the resent dose or 2 weeks. It can take u to
658 FAMILy MEDICINE EXAMINAt ION & BOAr D r EVIEW
6 to 8 weeks or an antide ressant edication to reach its ull
e ect, so it is reasonable to aintain the edication at its
resent dose and reassess in 1 onth. However, o tions “B,”
“C,” and “E” are reasonable as well. Co bination treat ent
with CB and an antide ressant edication has been shown
to be ore e ective or treating de ression than either treat-
ent strategy alone. You can also consider the addition o an
aug entation agent (bu ro ion, 3, or a second-generation
anti sychotic). Since she has had a artial res onse to the
current regi en, adding an aug entation agent is a reason-
able o tion. Switching to a new antide ressant at this ti e is
not indicated.
Despite increasing the dose o sertraline, your patient’s
depression does not improve. She’s been watching a lot o
V (no wonder she’s depressed) and seen ads or a medi-
cation called Happi y, which is used to augment tradi-
tional antidepressant therapy. She says, “I think I need
one o those new wonder drugs, Doc” (the so-called “won-
der drugs” because it is a wonder that they ever got FDA
approval).
Question 23.19.3 Which o the ollowing have gained FDA
approval as add-on therapy or depression?
A) Ari i razole
B) Halo eridol
C) Olanza ine
D) Quetia ine
E) A, C, and D
Answer 23.19.3 The correct answer is “E.” Ari i razole, que-
tia ine, and olanza ine are FDA a roved as add-on edica-
tions to aug ent antide ressants in ono olar de ression.
T e bene ts are arginal. For exa le, ari i razole added to a
traditional antide ressant i roved de ression by 3- oint di -
erence on a 60- oint scale and then only in en. Ari i razole
is ex ensive and a sizeable inority o atients develo akathi-
sia or restlessness. And re e ber that statistically signi cant
does not necessary ean clinically signif cant. For ari i razole,
the nu ber needed to treat to achieve this s all reduction in
de ressive sy to s is 10. On the bright side, ari i razole is
less associated with weight gain co ared with other aty ical
anti sychotics. And, the drug co anies are chortling on their
way to the bank.
Objectives: Did you learn to . . .
• Develop s a egies o ea esis an dep ession?
• Desc ibe a widel used dep ession assessmen ool, e Manual o Mental Disorders. 5th ed., ext Revision. Wash-
Ph Q-9?
T e world o sychiatric drugs is constantly oving (akathi-
sia?). See htt ://www.ncbi.nl .nih.gov/books/NBK84656/ or a
list o anti sychotics and age a ro riate FDA a roved indica-
tions. A si ilar table or antide ressants is ound at htt ://www.
de ressionhealth.net/antide ressants/.
HELPFUL TIP:
r andom ings o emembe o e examina ion: clo-
zapine (Cloza il) manda es a CBC mon l because o
bone ma ow supp ession; second-gene a ion an ips -
c o ics can cause diabe es and a e no ee o neu ologic
side e ec s (e.g., ex ap amidal eac ions); an ic olin-
e gics (e.g., benz opine) s ould be used wi is-
gene a ion an ips c o ics o p even Pa kinsonian
side e ec s.
Clinical Pe arls
Avoid i s -line use o an ips c o ic medica ion o indica-
ions o e an ps c o ic diso de s (e.g., dep ession in an
pa ien , insomnia in an pa ien , be avio al diso de s in
c ild en, o demen ed elde s).
Do no p esc ibe benzodiazepines as i s -line e ap o e
ea men o anxie diso de s.
Do no diagnose “adul -onse ” ADh D. Explo e e is o and
i e pa ien as ad ADh D s mp oms since c ild ood, e/
s e ma ave a missed o dela ed diagnosis o ADh D.
Do no p esc ibe wo an ips c o ic medica ions simul ane-
ousl .
Ensu e a s s ems a e in place o ea and e e pa ien s
diagnosed wi dep ession, and sc een o dep ession in e
gene al adolescen and adul pa ien popula ion.
O e p a maco e ap and p o essional counseling se vices
o all pa ien s diagnosed wi dep essive diso de s as e
combina ion esul s in be e ou comes an ei e in e ven-
ion alone.
Sc een o me abolic s nd ome pe iodicall in pa ien s
aking second-gene a ion an ips c o ics (e.g., olanzapine,
ispe idone, que iapine).
BIBLIOGRAPHY
Ables AZ, Nagubilli R. Prevention, recognition, and an-
age ent o serotonin syndro e. Am Fam Physician.
2010;8:1139–1142.
A erican Psychiatric Association. Practice Guideline or the
Treatment o Patients with Major Depressive Disorder. 3rd
ed. 2010. Available at htt :// sychiatryonline.org/content.
as x?bookid=28&sectionid=1667485.
A erican Psychiatric Association. Diagnostic and Statistical
ington, DC: A erican Psychiatric Association; 2013.
Glick ID, et al. Mid-ter and long-ter ef cacy and e ective-
ness o anti sychotic edications or schizo hrenia: A
data-driven, ersonalized clinical a roach. J Clin
Psychiatry. 2011;72:1616–1627.
Hendin H, et al. Con ronting de ression and suicide in
hysicians: A consensus state ent. JAMA. 2003;289:
3161–3166.

Khan A, et al. Suicide rates in clinical trials o SSRIs, other
antide ressants, and lacebo: Analysis o FDA re orts.
Am J Psychiatry. 2003;160:790–792.
National Institute on Mental Health. Major De ression A ong
Adults. Available at htt ://www.ni h.nih.gov/health/
statistics/ revalence/ ajor-de ression-a ong-adults.sht l.
Rader R, et al. Current strategies in the diagnosis and treat ent
o childhood attention-de cit/hy er-activity disorder.
Am Fam Physician. 2009;79:657–665.
Rush AJ, et al. Acute and longer-ter outco es in de ressed
out atients requiring one or several treat ent ste s: A
S AR D re ort. Am J Psychiatry. 2006;163:1905.
CHAPTER 23 • PSyCh IAt r y 659
Schatzberg AF, et al. Antide ressant discontinuation syn-
dro e: Consensus anel reco endations or clinical
anage ent and additional research. J Clin Psychiatry.
2006;67(Su l 4):27–30.
Wagner KD, et al. Ef cacy o sertraline in the treat ent o
children and adolescents with ajor de ressive disorder:
wo rando ized controlled trials. JAMA. 2003;290:
1033–1041.
Wheeler BW, et al. T e o ulation i act on incidence o suicide
and non- atal sel -har o regulatory action against the use
o selective serotonin reu take inhibitors in under 18 s in the
United Kingdo : Ecological study. BMJ. 2008;336:542.
Nutrition and Herbal Medicine
J B hk n
CASE 24.1
A 59-year-old male presents or ollow-up. He is well known
to you, receiving chronic anticoagulation with war arin or
a mechanical aortic valve. His P and INR have been in the
therapeutic range or years. When asked, he denies taking
any other medications. He has had no new medical problems
and is eeling well. oday his INR is 6.2 (therapeutic range
2.5–3.5). You inquire about dietary changes, ocusing on
oods rich in vitamin K.
Question 24.1.1 Which o the ollowing is true regarding
vitamin K?
A) Vitamin K is a water-soluble vitamin
B) Broccoli and olive oil are good sources o vitamin K
C) Vitamin K de ciency results in a hypercoagulable state
D) War arin reduces the absorption o vitamin K
E) Vegetarians are at risk or developing vitamin K de i-
ciency
Answer 24.1.1 The correct answer is “B.” Vitamin K is a
at-soluble vitamin present in lea y green vegetables such as
spinach and cabbage and in other oods such as milk, butter,
bacon, and vegetable oils. Olive oil and broccoli are particu-
larly rich in vitamin K. T ere ore, vegetarians who consume
these regularly are not at high risk or developing vitamin K
de ciency. Vitamin K de ciency causes a hypocoagulable state
resulting in a reduction in clotting actors and elevated pro-
thrombin time and INR, leading to poor clotting ability and
hemorrhage. War arin does act on vitamin K, but by reducing
conversion o vitamin K to its active orm rather than reducing
absorption.
Question 24.1.2 You would be more likely to suspect vita-
min K de ciency in this patient i he also suf ered rom
which o the ollowing conditions?
A) Crohn disease
B) Irritable bowel syndrome
660
24
C) Well compensated hepatitis C with mild brosis
D) Coronary artery disease (CAD)
E) All o the above
Answer 24.1.2 The correct answer is “A.” Vitamin K de ciency
can occur with chronic small bowel disease, a er small bowel
resection, and with use o broad-spectrum antibiotics. Micro-
organisms in the bowel synthesize vitamin K, and use o broad-
spectrum antibiotics reduces the numbers o these organisms.
T e majority o vitamin K is absorbed in the distal small bowel,
and any disease a ecting this area—including Crohn disease
and celiac disease—can reduce the absorption o the vitamin.
Irritable bowel syndrome is a unctional disease not associated
with impaired absorption. “C” is o special note. Patients with
cirrhosis and decompensated liver disease are o en vitamin K
de cient. However, the mere presence o hepatitis C does not
cause vitamin K de ciency.
Upon more direct questioning, the patient denies any
changes in his diet but admits to recently starting a vitamin
therapy program. He has no clue what he is actually taking
and calls his wi e to nd out what the products contain (it
was Miracle Mega Mansomething . . .). Meanwhile, you sus-
pect that he is taking excessive doses o vitamins that may
a ect his INR.
Question 24.1.3 Large doses o which o the ollowing vita-
mins are most likely to result in an increased INR in patients
taking war arin?
A) Vitamin A
B) Vitamin C
C) Vitamin D
D) Vitamin E
E) Zinc
Answer 24.1.3 The correct answer is “D.” Large doses o vita-
min E (> 400 IU/day) can inter ere with vitamin K metabolism
and platelet unction, resulting in increased prothrombin time
 CHAPTER 24 • Nu t r it io N a Nd Her Ba l Med ic iNe 661

TABLE 24-1 COMMON VITAMINS AND HERBALS about taking a multivitamin, complaining, “Gotta do some-
THAT INTERACT WITH WARFARIN (PARTIAL LIST) thing to get my mojo back, Doc.”
War arin Interaction Vitamin/Herbal
Question 24.1.4 From available evidence, and regarding his
↑ iNr n sk b ng d nsh n mojo (whatever that is), you are able to tell him:
d ng q A) “Most multivitamins do not contain enough vitamin E to
F sh cause a problem”
G B) “Multivitamins should be standard preventive medicine and
G nkg have a well-described role in improving health”
P s n C) “Iron supplements are recommended or middle-aged
V mne males”
D) “Folic acid and B vitamins should be taken by everyone with
↓ iNr n sk b ng c nzym Q10
aortic stenosis to reduce homocysteine”
S . J hn w
V mnK
Answer 24.1.4 The correct answer is “A.” Most multivitamins
contain less than 400 IU o vitamin E and usually will not cause
a problem. A airly well-balanced diet based on whole, unpro-
and there ore increased INR in some patients. In patients taking cessed oods provides the necessary nutrients to avoid vitamin
war arin, starting a high-dose vitamin E supplement should be de ciency syndromes. Supplementation with multivitamins is
done cautiously. Extra monitoring o INR and/or war arin dose not necessary unless there are dietary intake de ciencies related
adjustments may be needed. See able 24-1 or more on supple- to an unbalanced diet.
ments that can a ect the INR. aking a multivitamin generally has not been linked to
T e other options are unlikely to a ect the INR. Vitamin A improved health status (Arch Intern Med. 2009;169(3):294–
consumed in quantities exceeding 10 times the recommended 304; J Am Geriatr Soc. 2007;55:35–42). Average adult males
daily allowance (RDA) or several months may cause alope- generally have adequate iron stores and should not receive
cia, ataxia, glossitis, and hepatotoxicity. Vitamin C is usu- supplemental iron due to the potential or exacerbating undi-
ally well tolerated but large doses can cause nausea, diarrhea, agnosed iron storage disease. While olate, vitamin B6, and
and abdominal pain. Excessive intake o vitamin D may cause vitamin B12 lower serum homocysteine levels, there is no
hypercalcemia, hypercalciuria, nausea, vomiting, myalgia, and evidence that this intervention is help ul in reducing disease
bone demineralization. Symptoms o zinc toxicity include nau- burden or improving health in those with known coronary
sea, anemia, loss o sense o smell and taste (when administered artery disease or aortic stenosis (JAMA. 2008;300(7):795–
nasally), and depressed immune unction. 804; JAMA. 2010;303(24):2486–2494). However, when ele-
vated serum homocysteine is present (especially in those who
are homozygous or the M HFR C677 gene mutation, which
HELPFUL TIP: leads to an enzyme de ect that increases homocysteine lev-
c mp w hw -s b v m ns (B n c ), -s - els), treatment with B vitamins is a reasonable intervention to
b v m ns (a , d , e, n K) m k y m - reduce homocysteine.
, s ng n x y. in n ws, a m ns
s h v h m s xp ns v n n h w
Question 24.1.5 Regarding vitamin and mineral supple -
h n m sw -s b v m n s pp m n s w
mentation, which o the statements is FALSE?
k . . . s mp y p ss h m h gh k n ys.
A) Folate supplementation during pregnancy is recommended
to decrease the risk o neural tube de ects
B) Calcium and vitamin D supplementation in postmenopausal
(VERY) HELPFUL TIP: emales is recommended to reduce the risk o osteoporosis
V mnK nb s np n sw h h n- and ractures
iNr . S v m n K s pp m n 100 200 C) Vitamin D supplementation is recommended or breast ed
µg/ y. t h s w h p mn - p n n iNr in ants, starting be ore 2 months o age
ns. D) Vitamin D supplementation in elderly patients does not
reduce the risk o alling
E) Vitamin E supplementation in elderly patients may reduce
T e patient learns that the vitamin therapy he currently takes the risk o cardiovascular disease
has large amounts o vitamin E, but no vitamin K. You coun-
sel him to discontinue this supplement, hold a dose o war a- Answer 24.1.5 The correct answer (and alse statement) is
rin, and then continue on the same dose. You ask him to come “E.” Vitamin E supplementation has not been shown to reduce
back next week or another P /INR. Be ore leaving, he asks the risk o cardiovascular disease and may be associated with
662 Fa Mil Y Med ic iNe eXa MiNa t io N & Bo a r d r eVieW
an increased risk o all-cause mortality at doses > 400 IU/day.
Additionally, high-dose vitamin E is associated with an increase
in prostate cancer in men (JAMA. 2011;306(14):1549–1556).
“A” has plenty o evidence to back it up. Folate supplementa-
tion is universally recommended during the prenatal period
and should be started even be ore pregnancy actually occurs.
“B” is widely recommended, although the evidence or calcium-
reducing racture risk is weak. As or “C,” the CDC recommends
that breast ed in ants take 200 IU o vitamin D daily, starting
be ore 2 months o age. “D”, Vitamin D, a mighty orce in medi-
cine just a ew years ago, has allen ar. In act, it is no longer
recognized as an intervention or all prevention in the elderly.
Several negative studies have been published, and the Cochrane
Collaboration concluded, “Overall, vitamin D supplementation
does not appear to prevent alls.”
HELPFUL TIP:
in g n , y m v m ns n n n
n gh s s v m ns s n x y.
Objectives: Did you learn to . . .
• d s b s gns n s s v mnK n y?
• i n y mm n v m ns n h b s h n w h
w n?
• r gn z symp ms -s b v m n x s?
• i n y b n s, sks, n m ns v m n s pp m n-
n?
QUICK QUIZ: Su PPl eMeNt S t o Br ea St Mil K
A 6-month-old male in ant presents or routine health exami-
nation and immunizations. His mother is a strict vegan and has
been nursing him exclusively. She has not introduced any oods
and she wants to keep breast eeding him primarily or at least
the next 6 months . . . or until his riends start to tease him, she
jokes (you hope). She takes no medicines and no supplements
o any kind.
T is breast ed patient should have supplementation o all o the
ollowing EXCEP :
A) Vitamin B12
B) Vitamin C
C) Vitamin D
D) Iron
The correct answer is “B.” Children breast ed by strict vegan
mothers should have vitamin B12 supplementation. As above,
vitamin D is recommended or all breast ed in ants. Iron is rec-
ommended in all breast ed in ants starting at 4 months o age
until iron-containing oods become a routine part o their diet
(supplemental dose is 1 mg/kg/day). Vitamin C supplementa-
tion is not required. T ere are a variety o liquid multiple vita-
mins to choose rom (e.g., Poly-Vi-Sol® ).
CASE 24.2
A 34-year-old emale presents to your o ce with concerns
about weight gain. She has gained over 100 lb since she grad-
uated rom high school. She tear ully reveals that the weight
gain has come despite “not eating much.” She walks or exer-
cise, but is unable to quanti y her walking.
She denies chronic illnesses. Her only surgery was a tubal
ligation a er her last child. She smokes 10 cigarettes per day
and is unwilling to quit due to ears o urther weight gain.
She drinks alcohol once or twice per week, never consuming
more than three beers. T e review o systems is positive or a
dry cough, bilateral knee pain, and atigue.
On physical examination, you nd an a ebrile emale
with an elevated blood pressure (142/94 mm Hg). She is 5
3 in tall and weighs 231 lb. Her body mass index (BMI) is
41 kg/m2. You nd trace pitting edema at the ankles bilater-
ally. T ere is increased pigmentation in the olds o the neck
g and the knuckles. T e remainder o the examination is unre-
markable.
T e patient realizes that she is overweight and asks, “How
bad am I?”
Question 24.2.1 Regarding de nition and classi cation o
obesity, which o the ollowing is true?
A) Obesity is de ned as BMI ≥ 25 kg/m 2
B) Severe obesity is de ned as BMI > 30 kg/m 2
C) Underweight is de ned as BMI < 20 kg/m 2
D) Obesity is de ned as BMI ≥ 30 kg/m 2
E) Malnourished supermodel status is de ned as BMI
< 30 kg/m 2
Answer 24.2.1 The correct answer is “D.” Obesity is de ned by
BMI ≥ 30 kg/m 2; there ore, only “D” is correct. See able 24-2
or de nitions o weight status by BMI. T e calculation or BMI
is as ollows:
BMI (kg/m 2) = weight (kg)/[height (m)]2.
Example: weight = 110 lb (50 kg), height = 59 in (1.5 m), there-
ore
BMI = 50/(1.5)2 = 22.2 kg/m 2.
TABLE 24-2 DEFINITION OF WEIGHT STATUS BY BMI
Weight Status BMI (kg/m 2)
un w gh < 18.5
N m 18.5–24.9
o v w gh 25.0–29.9
ob s c ss i 30.0–34.9
c ss ii 35.0–39.9
ex m y b s c ss iii ≥ 40.0
 CHAPTER 24 • Nu t r it io N a Nd Her Ba l Med ic iNe 663

Question 24.2.3 Which o the ollowing is the most appro-

HELPFUL TIP:
priate next step in the evaluation o this patient’s weight
in a m n s, h mb n p v n b s y
gain?
n v w gh (BMi ≥ 25 kg/m 2) s 60% m n n
A) Re er or a sleep study
51% w m n. a b 35% u .S. s b s .
B) Check urinary ree cortisol level
N w h ’s wh w n p m !
C) Draw blood or thyroid-stimulating hormone level
D) Evaluation or adrenal adenoma causing Cushing disease
HELPFUL TIP:
th h s b n n v sy g ng wh h h - Answer 24.2.3 The correct answer is “C.” Because o her
n BMi - s pp b ss n hn obesity, this patient is also at risk or sleep apnea, diabetes,
p p ns s h h s b n v n h b y p - hypertension, and hyperlipidemia. T ese concerns will need
n g , s b n b y (w s -h p ) n BMi to be addressed. However, her chie complaint is weight gain.
m y w hn n hn g ps (Obstet Gynecol. Although in most overweight patients a cause or weight gain
2010;115(5):982–988). F h , h s b n n n is not ound, the physician is obligated to search or potentially
h w s m n n w s –h p m y b treatable causes o weight gain, including hypothyroidism. T e
s p BMi n p ng v s s s sk, symptoms o hypothyroidism are o en nonspeci c and include
sn n s vs p s ss s ss w h weight gain and atigue.
ns n s s n n m b syn m , wh h sk
s yp 2 b s n v s s s . HELPFUL TIP:
c mp ns b s y n h s s , yp 2
b s, hyp ns n, s k , hyp p m , g -
You ask her about medications, ocusing on those related to b s s , y, n s sk -
obesity. n n s (p s , n, b s , n m ), n
m n s ss.
Question 24.2.2 All o the ollowing drugs are associated
with weight gain and an increased risk o obesity EXCEPT:
Question 24.2.4 The ind ing o acanthosis nigricans in
A) Olanzapine
this p atient raises concern or which o the ollowing
B) Met ormin
d iseases?
C) Amitriptyline
A) Skin cancer
D) Valproic acid
B) Diabetes
E) Glipizide
C) Hemochromatosis
D) Colon cancer
Answer 24.2.2 The correct answer is “B.” Met ormin may help
E) Hypertriglyceridemia
patients with diabetes lose or maintain weight and, there ore, is
not associated with worsening obesity. See able 24-3 or a list
Answer 24.2.4 The correct answer is “B.” Acanthosis nigri-
o medications associated with weight gain.
cans, classically described as velvety hyperpigmentation in
skin creases (axilla, back, neck, exor aspects o arms), is
TABLE 24-3 DRUGS ASSOCIATED WITH WEIGHT associated with a number o diseases. Acanthosis nigricans
GAIN (NOT AN EXHAUSTIVE LIST) occurs in insulin-resistance syndromes, commonly in patients
Class Speci c Agents with type 2 diabetes. It is also associated with other endocrine
abnormalities, including Cushing disease and hypothyroid-
a ph B k s P z s n, x z s n, z sn ism. Acanthosis nigricans can be an external sign o internal
an nv s n s V p , b m z p n ,g b p n n malignancy, most commonly gastrointestinal (GI) cancers.
However, this patient is at lower risk o colon cancer than dia-
an p ss n s t y s ( .g., m p y n ) n m n m n betes given her age, weight gain, and lack o other signs and
x s nh b s (Ma o -is), s v s nn
p k nh b s (SSr is) n s m p ns
symptoms o cancer. Hemochromatosis, hypertriglyceridemia,
and skin cancer are not directly associated with acanthosis
an h s m n s c yp h p n , ph nhy mn nigricans.
a n psy h s o nz p n , h zn ,h p ,
sp n She wonders which popular diet she should use to lose weight.

B b k s P p n ,m p , n Question 24.2.5 You let her know that the most ef ective
d b s gs ins n, s ny s, h z n n s popular diet is:
A) Low carbohydrate (“Atkins”)
S c s s, n p v s, s g n, B) Low at (“Ornish”)
h m n s p g s n , s s n
C) Low glycemic load diet (“Zone diet”)
664 Fa Mil Y Med ic iNe eXa MiNa t io N & Bo a r d r eVieW

D) Portion restriction such as Weight Watchers
E) No one particular diet is more e ective than others or weight
loss. T e key to success is choosing a diet that you can stick to
Answer 24.2.5 The correct answer is “E.” Any diet you can
stick to seems to work. T ere does not seem to be any advantage
to one diet over another or weight loss (except or making the
proprietors wealthy; JAMA. 2005;293(1):43–53). For example,
Weight Watchers may have a bit better success because o peer
pressure, weekly meetings, motivational techniques, etc. (BMJ.
2011;343:d6500). But any diet that you can stick to long-term
will work. O note, the common belie that maintaining a 3,500
calorie de cit will result in 1 lb (0.45 kg) o weight loss per week
is a myth. But reducing calorie intake by 100 calories per day
may lead to a gradual weight loss o approximately 10 lb over 1
to 3 years (Am Fam Physician. 2015;91(9):634–638).
Question 24.2.7 Which o the ollowing is the most appro-
priate next step?
A) Prescribe L-thyroxine
B) Prescribe methylphenidate (Ritalin)
C) Prescribe orlistat (Xenical, Alli)
D) Prescribe paroxetine (Paxil)
Answer 24.2.7 The correct answer is “C.” Drug therapy is
considered appropriate as an add-on to li estyle management or
people with a BMI o 30 kg/m 2 or greater, or a BMI o 27 kg/m 2
or more who already have a comorbid condition such as dia-
betes, hypertension, or hyperlipidemia. O the choices listed,
orlistat is the most appropriate (more below). “A” and “B” are
incorrect, as obesity alone is not an indication or L-thyroxine
or methylphenidate. “D” is incorrect because paroxetine may
be associated with weight gain and is not indicated or obesity.

She is wondering about her level o physical activity and is Question 24.2.8 Which o the ollowing weight loss drugs
a raid that her obesity will decrease her ability to become results in GI side ef ects in up to 40% o patients using it?
unctionally t with exercise. A) Orlistat (Alli, Xenical)
B) opiramate ( opomax)
Question 24.2.6 Your response to this is that: C) Phentermine (Adipex-P, Ionamin)
A) Gluttony and sloth go together, so give up the exercise D) Leptin
B) One cannot improve one’s physical per ormance without
weight loss Answer 24.2.8 The correct answer is “A.” Orlistat is a lipase
C) Dante did not know what he was talking about. It is V and inhibitor that unctions in the intestines and prevents the
sloth that go together absorption o about 30% o dietary ats. Because o its mecha-
D) Exercise is bene cial or tness regardless o whether or not nism o action, orlistat is associated with GI side e ects in 40%
one loses weight o patients taking the drug. T e most bothersome potential
adverse events include ecal incontinence and abdominal pain.
Answer 24.2.6 The correct answer is “D.” Losing weight is noto- Orlistat should be taken with meals. T e prescription dose is
riously hard to do. T ank ully, exercise, in and o itsel , increases 120 mg three times per day. Weight loss is modest: 3 to 4 kg
unctional capacity regardless o weight loss (N Engl J Med. over 1 year compared with placebo. opiramate alone is not
2011;364(13):1218–1229). Obviously, patients do better i they approved by the FDA or use as a weight loss drug, but the com-
both exercise and lose weight. But sticking to an exercise regimen is bination phentermine/topiramate (Qsymia) is. Phentermine is a
still help ul. With regard to the others, there was no evidence-based sympathomimetic and causes hypertension, tachycardia, etc. It
medicine or V during the time o Dante, so we will never know. should only be used or 12 weeks. Leptin has been used success-
ully but is not FDA approved or weight loss.
HELPFUL TIP:
a w-g y m n x (v g b s, h k n, sh,
wh g ns, b ns, n s, .) n w Hba 1c n yp
HELPFUL TIP:
2 b s wh n mp w h h gh wh -g n
th otc s s (a ) s h h s h p -
b hy (b wn , wh wh s, .).
s p n s ng h. H w v , s q y v hs
Psy m (M m n h s) n s h p
w s .
Hba 1c . a P h b s n m , sh, s, v g-
b s, v g b s, ggs, n n s s s n
w m nv s Hba 1c , s b p ss ,
w gh , BMi, n w s m n v 3-m n h
p wh n mp n am n d b s a ss - You initiate a medication to help her lose weight and re er
n (Cardiovasc Diabetol. 2009;8:35). her to a weight loss program that ocuses on overall li estyle
modi cation. When she returns in 3 months, her weight is
235 lb, and she is very rustrated.
You nd that the patient’s thyroid unction is normal. A er
consultation with a nutritionist and a prescription or exer- Question 24.2.9 You appropriately recommend which o
cise, she returns 3 months later. Her weight is 222 lb. ear- the ollowing?
ully, she tells you that she barely eats and needs something A) Adding a second drug or weight loss
more to help her lose weight. B) Re erral to psychiatry
 CHAPTER 24 • Nu t r it io N a Nd Her Ba l Med ic iNe 665

C) Re erral to bariatric surgery include Wernicke encephalopathy (ataxia, occular motor ab-
D) Re erral to plastic surgery normalities [e.g., gaze paralysis], mental status changes, dietary
de ciency) and Wernicke–Korsako syndrome (Wernicke syn-
Answer 24.2.9 The correct answer is “C.” T is patient now drome plus additional memory loss and con abulations). Note
meets accepted indications or bariatric surgery. See Chapter 22 that most patients do not have all o the ndings. Most have a
or more in ormation about weight loss surgery. partial syndrome. reatment is to administer thiamine IV and
then to continue oral supplementation.
HELPFUL TIP:
d g h py n s g y n s bs b s HELPFUL TIP:
sy m ns, n ng pp p y th s g h mn mns m n n
m ns n g b x s .th s - p v n n W n k n ph p hy s. F
sy pp h s sh b n n ng g p v n n W n k n ph p hy, g v h m n
m n n bs y ss n s g y. 100 mg y. F m n W n k n ph p -
hy, g v h m n 500 mg iV Bid – t id 2 ys -
w by 500 mg iV y 5m ys ( h gh -
Objectives: Did you learn to . . .
mm n ns v y n n n mz s s pp
• d n n m w gh , v w gh , n b s y?
n gm n v n h ).
• a pp p y v h b s p n?
• r gn z g s n m h s ng b s y?
• r gn z mp ns h s s b s y? HELPFUL TIP:
o h m n n n s h n h
p ns n n n n y s ng n p g
QUICK QUIZ: Vit a MiN d eFic ieNc ieS ( m s, h , n m n ); n y
s ng n m y n m ; v m n B12 n y
A 63-year-old male presents to the of ce a er his daughter (g n y p b ms w h Gi bs p n h
came home or the holidays and ound him con used. At rst h n s h sm) s ng n n m ,
she thought he was drunk, but a er a ew days, the con usion n p hy, n m n .a m v mn s ny
persisted. He has never had problems with complicated alcohol s n b n h sp n p p n.
withdrawal be ore. According to the daughter, the patient drinks
about hal o a bottle o vodka per day and has done so or years
(Hawkeye Vodka is the Iowa avorite . . . about $12.00/1.75 L).
Although the patient is not able to give much o a coherent his-
CASE 24.3
tory, you are able to determine that he has developed shortness A 58-year-old postmenopausal emale presents to your o ce
o breath and leg edema. His appetite has been poor or “a long with concerns about osteoporosis. A review o her medical
time” and he may have lost some weight although he is not sure. history shows a bone density -score o –1.8 rom 2 years ago,
Physical examination reveals a malnourished, disoriented suggesting moderate osteopenia. As you review her medi-
male who appears older than his stated age and is disheveled. cal record, you note that last year she had lipids measured
He is mildly tachycardic, but his other vital signs are normal. He which were: total cholesterol o 210 mg/dL, LDL 140 mg/dL
has bibasilar crackles on lung examination, 2+ pedal edema, and HDL 45 mg/dL, and triglycerides 125 mg/dL. She had a
hepatomegaly, and spider telangiectasias. partial thyroidectomy 15 years ago and currently takes levo-
thyroxine 88 µ g/day.
What is your rst action to take with this patient?
A) Administer D50 intravenous (IV) Question 24.3.1 Based on the evidence, which o the ollow-
B) Administer thiamine IV ing supplements is most appropriate or this patient?
C) Administer vitamin B12 IM A) Calcium alone
D) Administer niacin orally B) Calcium and vitamin D
E) Administer olate orally C) Vitamin D alone
D) Ipri avone
The correct answer is “B.” T is patient almost certainly has
thiamine (vitamin B1) de ciency and appears to be symptom- Answer 24.3.1 The correct answer is “B.” Postmenopausal
atic. In the United States, thiamine de ciency is most o en seen women should take 1,200 mg/day o elemental calcium with total
in malnourished alcoholics. Early symptoms o thiamine de - o diet plus supplements not exceeding 2,000 mg o elemental cal-
ciency are vague (similar to how the author/editors wrote the cium per day. T e recommendations or supplemental calcium
case) and include anorexia, atigue, and irritability. T iamine are muddied a bit by the observation that higher calcium supple-
de cient patients may progress to beriberi (wet or dry), possess- ment intake is associated with greater risk o CAD. Vitamin D is
ing symptoms o heart ailure and/or neuropathy (motor and also appropriate and many women do not get enough. As supple-
sensory). Other possible mani estations o thiamine de ciency ments go, vitamin D may be more important than calcium.
666 Fa Mil Y Med ic iNe eXa MiNa t io N & Bo a r d r eVieW

In terms o vitamin D, recommended doses are 400 IU/day
or in ants, 600 IU/day or ages 1 to 70, and 800 IU/day in those
over age 70 (Institute o Medicine, 2011). T e guideline also
concludes that there is not any good evidence or vitamin D
beyond its use or bone health.
Ipri avone is a semisynthetic iso avone produced rom soy
iso avones. T ere is evidence that it can prevent bone mineral
density loss when used with calcium in postmenopausal women,
but it has not been shown to reduce racture rates. T ere are also
concerns that it might cause lymphocytopenia in some patients.
shown to reduce lipid levels. Soy protein is not nearly as e ec-
tive as are statin drugs (e.g., atorvastatin and simvastatin). Soy
protein or soy iso avone supplements are not an appropriate
alternative to calcium and vitamin D.
Your patient is hoping you can settle a bet. She asks about her
younger sister who is going through “the change” (quarters,
nickels, pennies . . .) and started taking black cohosh. Her sis-
ter swears the black cohosh helps her hot f ashes, but your
patient thinks it’s “all in her head.”

Question 24.3.4 Regarding the use o black cohosh or the

HELPFUL TIP: treatment o perimenopausal vasomotor symptoms, you
i y n n b p v n n s p s s, tell her:
s y, y y. c ns s n m s A) Black cohosh is equivalent to hormone replacement therapy
g s 1,300 mg m n m n 600 iu B) Black cohosh is equivalent to placebo
v mnd y. C) Black cohosh is not good or vasomotor symptoms but does
promote liver health
D) Black cohosh is only e ective when taken as part o a multi-
You counsel her to take 1,200 mg o elemental calcium per day. botanical supplement

Question 24.3.2 In order to improve GI absorption o cal- Answer 24.3.4 The correct answer is “B.” Most studies o black
cium, you recommend: cohosh are not well done. A Cochrane Collaboration review in
A) aking 1,200 mg at one time with a meal 2012 ound insuf cient evidence or black cohosh or meno-
B) aking 1,200 mg at one time an hour be ore eating pausal symptoms. T e arguments against its use are the rare
C) aking 1,200 mg in three divided doses with meals cases o hepatotoxicity, so “C” is wrong.
D) aking 1,200 mg in three divided doses on an empty stomach
E) aking 1,200 mg with her levothyroxine
HELPFUL TIP:
Answer 24.3.2 The correct answer is “C.” Calcium is best S yp n n g n h sg n y g-
absorbed when taken with ood. T eoretically, GI absorption o nz ss n s p b w m n wh w n
calcium is limited, and or that reason divided dosing in 500 to y .B sh n p p v n h p s. S y s
600 mg aliquots is recommended. Patients should take levothy- mm n g n, n sh b v by h s
roxine separately rom their calcium. I taken together, calcium w h gy s ns v y s y. S t b 24-4 n
reduces levothyroxine absorption. T is is also true o iron and v v w s y b n s.
levothyroxine.

She then asks you about her cholesterol levels and whether HELPFUL TIP:
taking soy would be help ul. A riend told her that older Wh h h b p s k phy s g ns, w
women should take soy to prevent heart disease, breast can- y m, p m s , n v mne m y n -
cer, osteoporosis—basically, they told her soy will help her to ng m n p s symp ms, g s y s gn n
cheat death. sp m h v n n m h -
y.
Question 24.3.3 Which o the ollowing is appropriate to
tell this patient?
A) Soy iso avone supplements are pre erred or reducing lipid Question 24.3.5 Which o the ollowing natural products
levels could be recommended or lowering LDL cholesterol?
B) Dietary soy protein is not associated with a reduced risk o A) Fish oil
developing heart disease in Western women B) Psyllium
C) Soy protein is as e ective as a statin or lowering cholesterol C) Garlic
D) Soy iso avones are an acceptable alternative to calcium and D) Policosanol
vitamin D or preventing osteoporosis E) All o the above

Answer 24.3.3 The correct answer is “B.” Soy protein can mod- Answer 24.3.5 The correct answer is “B.” aking a psyllium
estly reduce lipid levels in some patients but has been shown supplement (e.g., Metamucil) 10 to 12 g daily can reduce total
not to a ect important outcomes such as heart attack or death cholesterol by up to 14% and LDL by up to 10%. Fish oil is
in Western women. Soy iso avone supplements have not been e ective or lowering triglycerides, but not total cholesterol
 CHAPTER 24 • Nu t r it io N a Nd Her Ba l Med ic iNe 667

TABLE 24-4 OVERVIEW OF THE EFFECTIVENESS OF SOY

Condition Ef ectiveness Data Comment/Recommendation
B s n H gh n k s y n h s ss w h s sk u nkn wn b n s n W s n p p ns. d
b s n .B m s s h m as n p p ns. M y n n s ng n gh mm n ys y
pp y W s n p p ns. N n s. hs s .

Hyp p m / c ns m ng s y p n np h p ns s m gh m s y S bs ng ys y h p ns s
v s p v s. d s n pp y s y s v n s pp m n s. N p b ,b n ym s b n xp ;n
s s v n h ng s y mp v s m ss h s h h n n v m y v s v n-
k. P p n s h sh ws n s sk h s m s ng h p s s h s s ns.
n W s n w m n.

os p ss c ns m ng ys yp n m gh mp v b n m n ns y n th s p ss b b n ng s y p n
p s m n p s w m n n p ss b y sk; h w v , n h ,b b n s k y b m s b s.
v n s ns s n . S y sn s bs m n v m n d.

or LDL cholesterol. Clinical outcomes do not seem to change Answer 24.3.7 The correct answer is “E.” Many patients use
with the use o sh oil and it has allen by the wayside. Garlic alternative therapies including herbal supplements or vari-
was long considered e ective or modest reduction in choles- ous reasons, some o which are listed above. Other reasons
terol, but the evidence shows that garlic does not signi cantly cited include perceived physician apathy, di iculty with
reduce cholesterol in most people. Similarly, policosanol was physician access, ear o medication side e ects, belie that
once considered e ective or reducing cholesterol, but evi- medications lack e icacy, and the act that they are not “nat-
dence is inconsistent. T e most reliable evidence shows that ural.” Many patients do not in orm their physicians about
it is ine ective. their use o these products, mistakenly believing that “nat-
ural” means sa e. As or “E,” un ortunately there is a large
Question 24.3.6 What percentage o Americans use alter- demand or shark cartilage including its use as chondroitin
native therapies? sul ate. Shark populations have been severely stressed as a
A) 10% result. Up to 100 million sharks per year are killed or their
B) 20% ins and cartilage.
C) 30%
D) 40%
Question 24.3.8 What is the current status o the regulation
E) 50%
o “natural” therapies?
A) T e FDA does not have a regulatory role with regard to nat-
Answer 24.3.6 The correct answer is “D.” T irty-eight per-
ural therapies
cent o adults and 12% o children use complementary or
B) Natural products have to be proven sa e and e ective in
alternative therapy (Natl Health Stat Report. 2015;79:1–15).
order to be marketed in the United States
Only 40% o patients in ormed their physicians o their use
C) Natural therapies are regulated by the Department o Health
o these therapies. Examples o unconventional therapies used
and Human Services
include:
D) As long as they contain the ingredients claimed, natural
Relaxation Sel -help groups Homeopathy Spiritual healing therapies can be marketed in the United States
Chiropractic Bio eedback Li estyle diets Acupuncture E) Natural therapies are regulated by Pan, the Greek god o na-
Massage Energy healing Herbal medicine Exercise ture
Imagery Hypnosis Megavitamins Prayer

At least 15 million patients take prescription medications
along with their alternative medications, sometimes with
adverse outcomes.
Question 24.3.7 Which o these is NOT a reason that patients
might use alternative therapies?
A) T ey believe they are sa er than medications
B) Conventional medicine is too technical or impersonal
C) Prescription medicines are too expensive
D) Cultural practices
E) T ey didn’t like the shark in Jaws and there ore use shark
cartilage in an attempt to rid the oceans o sharks
Answer 24.3.8 The correct answer is “A.” T e FDA has no reg-
ulatory role with regard to natural therapies. T ey are classi ed
as dietary supplements and not medications. All o the rest are
incorrect. “B” is incorrect because natural therapies need not
be proven sa e and e ective in order to be marketed. “D” is
incorrect. T ere is no quality control on “natural” therapies in
the United States. Products may contain varying amounts o
the advertised therapy or, in some cases, none at all. In act,
there are data suggesting that some products or sale do not
contain what they advertise and in other cases, contain pre-
scription drugs such as war arin, steroids, alprazolam, and
diethylstilbestrol.
668 Fa Mil Y Med ic iNe eXa MiNa t io N & Bo a r d r eVieW

C) Glucosamine
HELPFUL TIP:
D) None o the above
t h Fd a n m v n h py p s n
sh w h h y h z s. t h s s s w n b -
Answer 24.3.10 The correct answer is “A.” Ginkgo biloba is one
sp ss s v n by h w ng k m v
o the most popular herbal products and is promoted or mild
ph m h u .S. m k .
memory loss, dementia, and peripheral circulatory disorders. As
ap s ns n v m ss s ws:
noted above, its e ectiveness has not been proven or either
• H p x :ch p ,g m n , use. Ginkgo can have antiplatelet e ects so should be used with
• c n g n :B g , m s, s , m y, caution or not at all in patients taking aspirin. Side e ects include
, n s ss s GI disturbances, headaches, and dizziness. “B,” SAM-e, is used
• Ms n s x y: M H ng ( ph ), p k or arthritis and depression and has been shown to be “likely
e ective.” “C,” glucosamine, has NO been shown to be e ective
or osteoarthritis. Most o the data is o poor quality.
HELPFUL TIP:
Question 24.3.11 Which herbal product has aldosterone -
P n s s ng h b s sh b w n h h p -
like properties and can cause a pseudohyperaldosteron-
sm yn n n wh h y m n h h y
ism?
sh k h p s h wn sk.
A) Ma Huang
B) Ginseng
HELPFUL TIP: C) Licorice
th m g 3 y s n v s s s D) Melatonin
(c Vd ) s n v s . t h b s s s sh w n b n
n h s w h p - x s ng c Vd . t h n p m yp - Answer 24.3.11 The correct answer is “C.” Licorice (Glycyr-
v n n s ss w s b sh (BMJ. 2010;341: 6273). rhiza spp.) has aldosterone-like e ects and can lead to uid
G nkg h s s m n p n s retention, hypertension, and hypokalemia. T us, it should
h p ng w h v s s s n m n , h gh not be combined with other potassium-wasting drugs such as
p s k ng (JAMA. 2009 d 23;302(24):2663–2670). non-potassium sparing diuretics. It is also contraindicated in
patients with severe liver disease and in pregnant patients (may
induce premature labor).
HELPFUL TIP:
V n h s b nz z pn - k s n w ks Question 24.3.12 For which o the ollowing diseases is
s p n y. SAM-e “likely ef ective?”
A) Depression
B) Fibromyalgia
Question 24.3.9 Grape ruit juice interacts with multiple C) Cirrhosis
medications. Which o the ollowing IS NOT af ected by D) Osteoarthritis
grape ruit juice? E) Both A and D
A) acrolimus
B) Itraconazole/Ketoconazole Answer 24.3.12 The correct answer is “E.” SAM-e is “likely
C) Benzodiazepines e ective” in treating depression and osteoarthritis. It is “possi-
D) Clopidogrel bly e ective” in treating bromyalgia, and there is insuf cient
E) Aspirin evidence to rate its use in cirrhosis. SAM-e is contraindicated
in bipolar patients as it can induce mania. SAM-e can possibly
Answer 24.3.9 The correct answer is “E.” All o the other interact with antidepressants, including MAOIs, leading to sero-
drugs interact with grape ruit juice. Grape ruit juice is a potent tonin syndrome. GI disturbance is the only notable side e ect.
CYP3A4 inhibitor and can interact with numerous medications
including those listed above, some calcium channel blockers, Question 24.3.13 Which o these is use ul in the treatment
carbamazepine, benzodiazepines, amiodarone, atorvastatin, o migraine headaches?
lovastatin, simvastatin, and others. T is underscores the impor- A) St. John wort
tance o knowing what “alternative” medications your patient B) Valerian root
might be using. C) Ginger
D) Fever ew
Question 24.3.10 Which o the ollowing supplements has E) Saw palmetto
been touted as being ef ective or memory problems and
peripheral circulatory problems? Answer 24.3.13 The correct answer is “D.” Fever ew is “pos-
A) Ginkgo biloba sibly e ective” in treating migraine headaches (Neurology.
B) S-Adenosylmethionine (SAM-e) 2012;78(17):1346–1353). “A,” St. John wort, is use ul or
 CHAPTER 24 • Nu t r it io N a Nd Her Ba l Med ic iNe 669

depression. However, there are major interactions between
St. John wort and other multiple drugs including: cyclospo-
rine, nevirapine, and digoxin among others. “B,” valerian root,
is use ul or insomnia. Ginger is used or nausea and seems to be
e ective. Saw Palmetto is used or benign prostatic hypertrophy
but is ine ective.
The correct answer is “D.” T e three choices listed above have
the reputation o helping alleviate the symptoms o the com-
mon cold. T e ef cacy o all o these is questionable, however.
Intranasal zinc has been removed rom the market in the Unit-
ed States due to reports o permanent loss o sense o taste and
smell a er its use.

Question 24.3.14 Which o these is NOT potentially use ul CASE 24.4

or women with pregnancy-related nausea and vomiting?
A) Ginger A 17-year-old male patient o yours comes to your o ce or
B) Acupressure a sports pre-participation physical. He is a little smaller than
C) Vitamin B6 most o his classmates and has heard that creatine supple-
D) Doxylamine mentation can help him increase muscle mass and improve
E) Black cohosh his per ormance.

Answer 24.3.14 The correct answer is “E.” Ginger is “pos- Question 24.4.1 Which o the ollowing is NOT true about
sibly e ective” in treating nausea and vomiting in pregnancy, creatine?
postoperative vomiting, and vertigo. Vitamin B6 (pyridoxine) A) Creatine exists primarily in skeletal muscle
and doxylamine, an antihistamine, have been shown singly and B) It causes weight gain by increasing muscle mass
together to be sa e and e ective in pregnancy-related nausea C) It is ine ective in boosting per ormance in aerobic exercise
and vomiting. Acupressure has no known adverse e ects, and D) It can lead to increased creatinine levels in patients with nor-
there is some suggestion o ef cacy. Black cohosh can stimulate mal renal unction
uterine contractions, and has no known ef cacy or nausea and
vomiting in pregnancy, and so is contraindicated in pregnancy. Answer 24.4.1 The correct answer is “B.” Creatine monohy-
drate is a naturally occurring protein in the body that exists pri-
Objectives: Did you learn to . . . marily in skeletal muscle. High levels o creatine are thought to
• d s b h p v n n v h py s ?
enhance the ability to renew A P or short bursts o energy. It
• a pp h v s n ns v sh b p - appears to be e ective or enhancing muscle per ormance dur-
s n h v n b s h m?
ing repeated bouts o brie , high-intensity exercise, but ine ec-
• r gn z h bs ns s n h s ns tive or other types o exercise. It does not improve per ormance
ns ?
in aerobic exercise nor does it bene t older adults seeking to
• r gn z p b m g n ns w h v y build muscle mass. It also does not appear e ective or increas-
n v h p s?
ing endurance or or improving per ormance in highly trained
athletes, but its use is widespread among athletes, both amateur
and pro essional. It causes weight gain by increasing water reten-
HELPFUL TIP: tion and not by a ecting muscle mass. Creatine can cause elevated
d y kn w h m m n, PPis, n H2 b k s n creatinine levels in patients with normal renal unction as cre-
s B12 n y? N w y . atine is metabolized to creatinine. Complicating this is the act
that creatine has been linked to renal dys unction in some cases.

Question 24.4.2 Which o these is NOT a disease that cre -

QUICK QUIZ: a l t er Nat iVe c u r e Fo r atine is purported to treat?
t He c o MMo N c o l d ? A) Heart ailure
B) Neuromuscular disease
One o your patients who o en uses complementary and alter- C) Mitochondrial cytopathies
native medicine comes into your of ce with several days o rhi- D) Muscular dystrophies
norrhea, sore throat, and ear pain. Your examination reveals a E) Diabetes
viral upper respiratory in ection. He asks you to recommend an
alternative cure. Answer 24.4.2 The correct answer is “E.” Creatine is also pro-
moted or heart ailure, neuromuscular diseases, mitochondrial
Which o these are touted as alternative remedies or the com- cytopathies, and various muscular dystrophies. Oral creatine
mon cold? may improve exercise tolerance in patients with heart ailure but
A) Echinacea has no e ect on ejection raction. IV creatine seems to improve
B) Zinc ejection raction temporarily. When used orally, it seems to
C) Vitamin C marginally improve muscle strength and daily-li e activity in
D) All o the above adults and children with various muscular dystrophies in the
E) None o the above short term. T ere is no evidence o its ef cacy in the treatment
670 Fa Mil Y Med ic iNe eXa MiNa t io N & Bo a r d r eVieW

o diabetes. It appears to be sa e when used orally and in appro-

priate doses, though high doses raise the concern o adverse
hepatic, renal, or cardiac unction. Side e ects include GI pain,
nausea, and diarrhea, while college athletes taking it requently
complain o muscle cramping.
Objectives: Did you learn to . . .
• d s b h s n v s f s n ?
QUICK QUIZ: iNFo Mer c ia l “c u r e”
Fo r KNee Pa iN
A 51-year-old emale patient o yours with knee osteoarthritis
comes to your of ce because she has seen commercials on V
advertising a product containing glucosamine and chondroi-
tin sul ate, which was touted as being e ective or osteoarthri-
tis. She has been using naproxen with symptom relie but has
had heartburn and is worried about the potential or bleeding.
Moreover, she likes the idea o using something “natural.” She
asks or your advice.
QUICK QUIZ: a Bl o o d YHer B
A 51-year-old patient o yours is about to have a scheduled cho-
lecystectomy. He is in otherwise good health and is taking the
ollowing herbs and supplements.
Which would you recommend him to stop be ore surgery
because o association with prolonged bleeding time?
A) Valerian root
B) Ginseng
C) Vitamin B complex
D) Echinacea
E) Ginkgo
The correct answer is “E.” Ginkgo is the only one above that
has been associated with a prolonged bleeding time. T us, it
should be stopped prior to planned surgery. Other supplements
that have antiplatelet e ects include garlic, ever ew, vitamin E
(at doses o greater than 800 IU/day), and sh oil.

Which o the ollowing is true about the use o glucosamine sul-

Clinical Pearls
ate and/or chondroitin sul ate or osteoarthritis?
A) T e combination is more e ective than either product alone a b s- n n s sh v s pp m n v m n
B) Glucosamine is e ective in improving symptoms o osteoar- d w hn h s w ys n s pp m n n
thritis 4 m n hs n ng n- n n ng s.
C) Glucosamine may lower blood sugars a w m n ns ng b m ng p gn n sh k
D) Chondroitin can help patients with coagulation disorders p n v mn s pp m n .
E) Chondroitin is “possibly e ective” or osteoarthritis d n mm n m h n 400 iu p y v m n e.
d n n y mm n m v m ns p ns
The correct answer is “E.” Glucosamine sul ate is a glycoprotein g n h h.
that occurs naturally in the body but is available commercially
r gn z h 40% p ns s mp m n y n
as a synthetic product or rom marine exoskeletons. It is not e -
n v h p s, n n n n m -
ective in osteoarthritis. Side e ects are generally mild and GI in
m n s, n h h Fd a sn g n
nature including nausea, heartburn, diarrhea, and constipation. h p s.
Patients at risk or diabetes, hyperlipidemia, and hyperten-
r gn z h h sm yh v m p n n -
sion should use this product cautiously as glucosamine can
n s, n ng , h m n , Bv m ns, n v m n K
increase both blood glucose and insulin levels. It can increase
n n p n n y.
blood sugars by impeding glucose-induced insulin secretion
and impairing the insulin-induced glucose uptake by skeletal
muscle.
Chondroitin sul ate is a glycosaminoglycan made rom ani- BIBLIOGRAPHY
mal and sh cartilage. It is “possibly e ective” in osteoarthritis,
although there are both positive and negative studies. When Barnes PM, Bloom B. Complementary and alternative medi-
cine use among adults and children: United States, 2007.
only the best quality studies are included, there seems to be no
Natl Health Stat Report. 2008;12:1–23.
benef t to chondroitin sul ate. It is a minor component o the
Barry MJ, et al. E ect o increasing doses o saw palmetto ex-
low–molecular-weight heparin, danaparoid, so there is the con-
tract on lower urinary tract symptoms: a randomized trial.
cern o possible anticoagulant activity. T is has not been shown JAMA. 2011;306(12):1344–1351.
in studies but because o this concern, it should be used with
Bischo -Ferrari HA, Dawson-Hughes B, Staehlin HB, et al. Fall
caution (or not at all) in patients on antiplatelet or anticoagulant prevention with supplemental and active orms o vitamin D:
agents or those with bleeding disorders. It is generally well toler- a meta-analysis o randomised controlled trials. BMJ.
ated but can cause epigastric pain and nausea in some patients. 2009;339:b3692.
Chondroitin dosing is typically 200 to 400 mg two to three times Bolland MJ, et al. Calcium supplements with or without vita-
daily. Although chondroitin sul ate and glucosamine sul ate are min D and risk o cardiovascular events: reanalysis o the
requently sold together in combination products, no evidence Women’s Health Initiative limited access dataset and meta-
supports the notion that both are better than either alone. analysis. BMJ. 2011;342:d2040.

Chaiyakunapruk N, et al. T e ef cacy o ginger or the
prevention o postoperative nausea and vomiting: a
meta-analysis. Am J Obstet Gynecol. 2006;194(1):
95–99.
Clarke C, et al. rends in the use o complementary health
approaches among adults: United States, 2002–2012.
Natl Health Stat Report. 2015;79:1–15.
Ford SK, Moll S. Vitamin k supplementation to decrease
variability o international normalized ratios in patients
on vitamin k antagonists: a literature review. Curr Opin
Hematol. 2008;15(5):504–508.
Holick MF, et al. Evaluation, treatment, and prevention
o vitamin D de ciency: an Endocrine Society
clinical practice guideline. J Clin Endocrinol Metab.
2011;96(7):1911–1930.
Institute o Medicine Committee to Review Dietary Re er-
ence Intakes or Vitamin D and Calcium, Ross AC, aylor
CL, Yaktine AL, et al., eds. Dietary Re erence Intakes or
Calcium and Vitamin D. Washington, DC: T e National
Academies Press; 2011.
Jellin JM, Gregory PJ, eds. Natural Medicines Comprehensive
Database. Stockton, CA: T erapeutic Research Faculty;
2015. Available at http://naturaldatabase.therapeuticre-
search.com. Accessed September 25, 2015.
Jenkins DJ, et al. E ect o a low-glycemic index or a high-cereal
ber diet on type 2 diabetes: a randomized trial. JAMA.
2008;300(23):2742–2753.
Jonsson , et al. Bene cial e ects o a Paleolithic diet
on cardiovascular risk actors in type 2 diabetes: a
randomized cross-over pilot study. Cardiovasc Diabetol.
2009;8:35.
Lesser LI, et al. Nutrition myths and healthy dietary advice
in clinical practice. Am Fam Physician. 2015;91(9):
634–638.
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Neuhouser ML, et al. Multivitamin use and risk o cancer
and cardiovascular disease in women’s health initiative
cohorts. Arch Intern Med. 2009;169(3):294–304.
Newton KM, et al. reatment o vasomotor symptoms o
menopause with black cohosh, multibotanicals, soy,
hormone therapy, or placebo: a randomized trial. Ann
Intern Med. 2006;145(12):869–879.
Rahman M, Berenson AB. Accuracy o current body
mass index obesity classi cation or white, black, and
Hispanic reproductive-age women. Obstet Gynecol.
2010;115(5):982–988.
Reed SD, et al. Vaginal, endometrial, and reproductive hor-
mone ndings: randomized, placebo-controlled trial o
black cohosh, multibotanical herbs, and dietary soy or
vasomotor symptoms: the Herbal Alternatives or Meno-
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Snitz BE, et al. Ginkgo biloba or preventing cognitive
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ering with olic acid plus vitamin B12 vs placebo on mortal-
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Substance Use Disorders
Dav d A. B d ll
CASE 25.1
A 45-year-old male presents to your clinic to establish care or
his chronic back and leg pain. He denies any other medical
conditions. He reports being injured at work approximately
5 years ago, at which time he was started on oxycodone. He
reports being on a stable dose or the last ew years. He appears
slightly drowsy during the appointment, has small pupils, and
is having moderate di culty describing his injury and pre-
vious treatments. He reports his mood as okay, but becomes
irritable when you begin to ask speci cs about his injury. He
has not been able to keep a job or the last year because “every-
one res me.” He states that he needs the oxycodone to unc-
tion and that he ran out o his medication 1 week ago. He does
report occasional alcohol use, although he states the he knows
not to mix alcohol with his oxycodone.
Question 25.1.1 What is the most likely explanation o the
patient’s current presentation?
A) Opioid withdrawal.
B) Opioid intoxication.
C) Uncontrolled pain.
D) Alcohol intoxication.
E) Alcohol withdrawal.
Answer 25.1.1 The correct answer is “B.” T e patient presents
with pupillary constriction, drowsiness, impairment in attention
and memory, psychological changes (dysphoria/irritability),
and impairment in unctioning (not able to keep a job). All o
these ndings are included in the diagnostic criteria or opi-
oid intoxication. T e DSM-5 criteria or opioid intoxication
include: (1) Recent use o an opioid; (2) clinically signi cant
problematic behavioral or psychological changes (euphoria ol-
lowed by apathy, dysphoria, psychomotor agitation or retarda-
tion, impaired judgment, or impaired social or occupational
unctioning) that develop during, or shortly a er, opioid use;
(3) pupillary constriction (or pupillary dilation due to anoxia
rom severe overdose) and one or more o the ollowing signs:
drowsiness or coma, slurred speech, and impairment in attention
672
25
or memory; (4) and the symptoms are not due to a general
medical condition or another mental disorder.
“A” is incorrect and will be discussed later in this case. “C” is
incorrect because a patient would not display the above symptoms
with signi cant pain. “D” could be correct because acute alcohol
intoxication is characterized by slurred speech and impairments in
memory and judgment; however, the patient does not have other
ndings consistent with alcohol intoxication such as an unsteady
gait or nystagmus. “E” is incorrect as the patient was not hyper-
tensive, ebrile, diaphoretic, and did not have tremors or vomiting.
You are hesitant to prescribe the oxycodone partly because you
recall that there were over 16,000 deaths related to prescription
opioids in 2013. Although heroin-related deaths have increased
much more rapidly than prescription opioids in the last
15 years, they are still only about hal as common. You o er
him alternatives or pain control, including a re erral to physi-
cal therapy, NSAIDs, and a ENS unit. He says he has tried
them all and none o them work. He gets upset and walks out o
your o ce. wo days later, while you are covering an emergency
department (ED) shif , the same male presents to the ED or
severe, uncontrolled pain. He is vomiting, complains o muscle
aches and diarrhea, his pupils are dilated, and he is ebrile.
Question 25.1.2 What is the most likely explanation or the
patient’s current presentation?
A) Opioid withdrawal.
B) Opioid intoxication.
C) Uncontrolled pain.
D) Alcohol intoxication.
E) Alcohol withdrawal.
Answer 25.1.2 The correct answer is “A.” T e criterion or
opioid withdrawal is cessation (or reduction in) opioid use
that has been heavy or prolonged (several weeks or longer) or
administration o an opioid antagonist a er opioid use with
three or more o the ollowing developing within minutes to
several days a er the above: dysphoric mood, nausea or vomit-
ing, muscle aches, lacrimation or rhinorrhea, pupillary dilation,
 CHAPTER 25 • Su BSt An c e u Se DiSo r Der S 673

piloerection, sweating, diarrhea, yawning, ever, or insomnia. Objectives: Did you learn to . . .
T ese signs and symptoms cause clinically signi cant distress • D p d x a a d w hd awal?
or impairment in social, occupational or other important areas • D s b h s b p ph ma ag p d
o unctioning and are not due to another medical condition or d p d ?
better accounted or by another mental disorder.
CASE 25.2
T e patient is trans erred to a substance abuse treatment
center voluntarily. Based on the available resources in your A 70-year-old emale is brought into the clinic by her daugh-
community, you decide on buprenorphine induction and ter due to concerns about her mother’s sleeplessness, isola-
maintenance treatment. tion, weight loss, alls, and anxiety over the past year. In
addition, since the patient has been staying at her daugh-
Question 25.1.3 All o the ollowing are true o buprenor ter’s home the past 3 days, she began vomiting, hallucinat-
phine EXCEPT: ing, perspiring pro usely, and wanting to return to her own
A) Buprenorphine should be administered prior to withdrawal home. T e patient has no history o medical problems. She is
symptoms. disheveled, con used, diaphoretic, and tremulous. Her blood
B) ypical rst dose o buprenorphine is 4 mg, with a maximum pressure is 162/110 mm Hg, pulse is 120 bpm, and temper-
rst day dose o 8 mg. ature is 38.5°C. She blames her symptoms on being unable
C) Buprenorphine monotherapy, without naloxone, should be to have a cigarette. She also blames her daughter’s nagging.
used or patients addicted to long-acting opioids (such as When asked about alcohol use, the patient says she has had a
methadone or sustained-release morphine). cocktail every evening since she retired rom her job last year,
D) Continue to increase buprenorphine on subsequent days by and that this helps her to sleep.
the total dose o the previous day plus an additional 4 mg
dose, until withdrawal symptoms are relieved. Question 25.2.1 Which o the ollowing best describes the
E) Nearly all patients will stabilize on 8 to 16 mg daily. patient’s current clinical condition?
A) Alcohol withdrawal.
Answer 25.1.3 The correct answer, and alse statement, B) Alcohol intoxication.
is “A.” Buprenorphine is started when patients are exhibiting C) Alcohol tolerance.
early signs o withdrawal. For short acting opioids (heroin, D) Alcohol abuse.
oxycodone) this may be 12 hours a er the last use; or longer- E) Alcohol dependence.
acting opioids such as methadone, this may be up to 48 hours
a er last use. T e rst day dose should be 4 mg, and patients Answer 25.2.1 The correct answer is “A.” T e patient pres-
should be monitored or withdrawal symptoms or 2 to 4 hours, ents tachycardic, hypertensive, and ebrile, with diaphoresis,
with the opportunity to administer an additional dose. Mono- tremors, vomiting, and hallucinations. All o these ndings
therapy (i.e., without naloxone) is appropriate or patients on are included in the diagnostic criteria or alcohol withdrawal.
long-acting opioids or the rst 1to 2 days to avoid any possibil- “B” is incorrect. Acute intoxication is characterized by slurred
ity that naloxone will cause withdrawal e ects, but then these speech, unsteady gait, nystagmus, and impaired memory and
patients should be trans erred to combination therapy. Nearly judgment. “C,” “D,” and “E” are incorrect and are discussed
all patients will stabilize on 8 to 16 mg daily; however, some may later in this case.
require doses up to 32 mg daily, which is the maximum dosage. T e criteria or alcohol withdrawal include: (1) T e patient
has stopped or reduced a previously heavy alcohol intake and
(2) at least two o the ollowing within hours or days: auto-
HELPFUL TIP:
nomic hyperactivity (hypertension, sweating, tachycardia, etc.),
Adva ag s b p ph v m had a
hand tremor, insomnia, nausea or vomiting, hallucinations,
ha a b d sp s d a a phys a ’s with
agitation, anxiety, or grand mal seizures. In addition, one must
an appropriate DEA waiver wh h q s h ab l y
have signi cant distress or impairment in unctioning with the
p vd h pa s l g, l k
withdrawal and no other illness causing the symptoms.
m had , wh h a ly b d sp s d a d s g a -
d am s; a d b a s s pa al ag s
Question 25.2.2 Which class o drugs would you choose to
a ,b p ph has a “ l g ” w h ga d
treat the symptoms o alcohol withdrawal?
v d s . M had p d s as g sp a y
A) Benzodiazepines.
s pp ss w h as g d s s.
B) Antipsychotics.
C) Antibiotics.
HELPFUL TIP: D) Alcohol.
S b x s a mb a b p ph a d E) Phenytoin.
al x .i d p s b , a phys a ds a
sp al “X” DeA mb . Answer 25.2.2 The correct answer is “A.” T e treatment o
choice is metabolic support and the use o benzodiazepines
674 FAMiLY MeDic in e eXAMin At io n & Bo Ar D r eVieW

to decrease physical distress and to prevent major withdrawal

s mpa abl a ab 79%. S s v y h c AGe
(delirium tremens, D ) rom occurring. “B” is incorrect. Anti-
a g s m ab 75% 95%, b h c AGe may
spychotics may control behavior but they do not prevent with-
m ss d p d al h l s d s d s ( .g., b g
drawal seizures and vasomotor instability. “D” is incorrect.
d k g). Y a h p ss bl s al h l
Although alcohol will work to prevent withdrawal, it has a airly
s d s d s, a d mm ly d p ma y
short hal -li e, and you generally do not want to endorse the
a l s, s h Al h l u s D s d s id a
use o alcohol in a patient with an alcohol use problem. “E” is
t s (Au Dit ). t h s s a 10 q s s v y ha has a
singularly incorrect. Phenytoin does nothing to prevent alcohol
s s v y 92% a d a sp y a 94%.
withdrawal seizures.

HELPFUL TIP: HELPFUL TIP:

th ad al “ba a a bag” w h m l v am s s - u a ly, y a always s h am ly’s h s-
ssa y. o al v am s ppl m s a j s as - y h . t h y may b abl g h al h l add
v a d l ss xp s v .th ly x p s h am , awa . Als , lab a y w k ps ( .g., l v
wh h y may wa g v iV iM h pa has a zym s) a b l d p mak h d ag -
h am d y. ss al h l ab s /d p d —al h gh l va d
GGt a d ASt /ALt a 2 a s pp v b bly
sp .
Question 25.2.3 What would be the best approach to eval
uating this patient or alcoholism?
A) Ask her the average amount she drinks.
B) Ask her how o en she drinks. Upon urther questioning, you begin to uncover a long his-
C) Ask her how requently she gets drunk. tory o heavy drinking—seems that there was more than just
D) Ask what her amily and riends say about her drinking. a nightcap.
E) Pour a bourbon in ront o her and see what happens.
Question 25.2.4 Which o the ollowing statements about
Answer 25.2.3 The correct answer is “D.” T e de ense mecha- this patient’s situation is TRUE?
nism o denial is so strongly evident in alcoholism that the best A) Cerebellar degeneration is uncommon.
approach is to explore how alcohol a ects her li e, rather than B) She is at risk or developing peripheral neuropathy.
direct questions about drinking behavior. In ormation rom C) Alcoholic “ atty liver” is irreversible.
amily and riends may provide a more accurate account o the D) She is at decreased or normal risk or heart disease.
problem. T e CAGE questionnaire is a very brie and use ul E) Immune unction should remain relatively intact.
screening tool, employed e ectively in the primary care setting.
A positive answer to two or more questions is very sensitive Answer 25.2.4 The correct answer is “B.” Peripheral neuropa-
and speci c or an alcohol use disorder. It consists o asking the thy can be seen in 10% o heavy drinkers as a result o vitamin
patient the ollowing our questions: de ciencies and the direct impact alcohol has on nerve unction.
Have you ever “A” is incorrect because cerebellar degeneration—suggested by
• C: elt that you should Cut Down on your drinking? ataxia and nystagmus—does occur as a result o alcohol over-
• A: been Annoyed that people criticized your drinking? use. “C” is incorrect because alcoholic “ atty liver” will reverse
• G: elt bad or Guilty about your drinking? with abstinence rom alcohol. “D” is incorrect. Heavy drinking
raises blood pressure and levels o triglycerides, increasing risk
• E: taken a drink rst thing in the morning (Eye Opener) to
o myocardial in arction. Finally, “E” is incorrect. Heavy drink-
get rid o a hangover or steady your nerves?
ing lowers the white blood cell count and inter eres with spe-
ci c aspects o the immune system; or example, it compromises
HELPFUL TIP: -cell unction.
Ask g h q s “H w ma y m s h pas y a
hav y had v m d ks a day ( m ) T is patient reports to you that she has needed to drink
m d ks ( w m ) a day?” s a s - increasing amounts o alcohol to help her all asleep.
ls q y h avy d k g. A p s v
s s m d s h avy d k g. i Question 25.2.5 The need or increasing amounts o alcohol
y hav a p s v s , ask ab s al q y is an example o :
a dq a y al h l s m d h lp d m A) Intoxication.
h p s abs al h l ab s d p - B) Dependence.
d .th s q s al has ab a 82% s s v- C) olerance.
y d g a al h l s d s d . Sp y D) Relapse.
E) Abuse.
 CHAPTER 25 • Su BSt An c e u Se DiSo r Der S 675

Answer 25.2.5 The correct answer is “C.” olerance is de ned Question 25.2.7 Which o the ollowing medications
as the need or increasing amounts o a drug to achieve the same would be indicated to prevent DT in a patient with hepatic
response as initial use o the drug. “A” is incorrect. Intoxication impairment?
is a characteristic syndrome o maladaptive behavior or psycho- A) Alprazolam (Xanax).
logical changes that occurs with substance use, is drug-speci c, B) Chlordiazepoxide (Librium).
and reverses when the drug use is discontinued. “D” is incorrect. C) Diazepam (Valium).
Relapse involves re-starting use o the drug a er being abstinent D) Lorazepam (Ativan).
or a while. E) Clonazepam (Klonopin).

Answer 25.2.7 The correct answer is “D.” Benzodiazepines

HELPFUL (CLARIFYING) TIP: that are metabolized by the cytochrome P450 system will build
DSM-iV d v d d s bs a ab s a d s bs a d p - up in the presence o liver disease, so using those with inter-
d . DSM-5 v ws h s w a g s as d mediate hal -lives and no active metabolites is essential. Only
p s a sp m s bs a s d s d . th lorazepam, oxazepam, and temazepam meet these criteria. “B”
a s bs a s d s d a a l as 2 h is incorrect. Although chlordiazepoxide is o en used to prevent
ll w g 11 a( l s d 4 g ps): symptoms o alcohol withdrawal, it is hepatically metabolized
A. impa d l: 1 ak g m l g ha and has an exceptionally long hal -li e and, there ore, should be
d d, 2 s ss l s s p d w avoided in patients with liver problems. Alprazolam is too short
s , 3sp d g a g a d al m ba g, s g, acting to use in this situation.
v g m s , 4 av g s bs a .
B. S al mpa m : 5 a l l ll maj bl ga s Question 25.2.8 Which o the ollowing medications would
d s ,6 d s d sp p bl ms a s d be a good alternative to benzodiazepines to treat alcohol
xa ba d by s 7
mp a a v s g v withdrawal in an otherwise healthy, younger individual in
p d db a s s . mild to moderate withdrawal?
c . r sky s : 8 s haza d s s a sa d A) Atenolol.
9
d s d sp phys al psy h l g al B) Diltiazem.
p bl ms a s d xa ba d by s . C) Acetazolamide.
D. Pha ma l g d p d : 10d v l p g l a D) Carbamazepine.
11
w hd awal E) Prazosin.

Answer 25.2.8 The correct answer is “D.” Carbamazepine

Question 25.2.6 Which o the ollowing lab test results are
you most likely to nd in this patient?
A) Microcytic anemia.
B) Low erritin.
C) Decreased serum triglycerides.
D) Hyperglycemia.
E) Increased gamma-glutamyltrans erase (GG ).
Answer 25.2.6 The correct answer is “E.” Elevated GG is con-
sidered to be the most sensitive indicator o alcohol intake and
is o en present along with elevation o the alanine and aspar-
tate transaminases (AL and AS ). Remember that GG is not
speci c, as it is an inducible enzyme and can be induced by a
number o medications. T e classic AS :AL ratio in active
alcohol abusers is 2:1. Remember, however, that these labora-
tory ndings are not speci c or alcohol use and can be caused
by medications and other illnesses. T e other answers are incor-
rect. Patients with alcoholism typically have macrocytic ane-
mia, elevated serum triglycerides, and hypoglycemia. Ferritin
is o en increased in active alcohol users in the absence o iron
overload. In addition, the trans errin saturation may be elevated
because alcohol inhibits trans errin synthesis.
You have ordered liver unction tests, but the results will not
be available until the next day. T e laboratory technician is
out getting Botox.
has been used extensively in Europe (just like public trans-
portation and universal health coverage . . . so what do they
know?). Carbamazepine prevents seizures and was ound
superior to oxazepam in reducing global psychological dis-
tress, aggression, and anxiety. It has no abuse potential. It
is superior to benzodiazepines in preventing rebound with-
drawal symptoms. Relative risk o drinking again a ter with-
drawal is three times higher or benzodiazepines compared
to carbamazepine. he downside is it interacts with medi-
cines that undergo oxidative metabolism in the liver. Alpha-
adrenergic agonists (“E”), beta-blockers (“A”), and calcium
channel blockers (“B”) have been used to control the symp-
toms o alcohol withdrawal; however, they are not e ective in
preventing D or seizures. “C” does not address the problem
o alcohol withdrawal although there is some animal evi-
dence that diuretics including acetazolamide may decrease
brain damage rom binge drinking.
You remember rom a lecture that patients without seri-
ous comorbidities, either medical or psychiatric, that have
mild to moderate withdrawal symptoms can sa ely be with-
drawn in an outpatient setting. T e tool that has been best
validated is the revised “Clinical Institute Withdrawal
Assessment or Alcohol” (CIWA-Ar) which involves assess-
ment o the severity o 10 signs and symptoms associated
with alcohol withdrawal.
676 FAMiLY MeDic in e eXAMin At io n & Bo Ar D r eVieW

Question 25.2.9 Assessment o the severity o which o the IM. However, or reasons previously stated, lorazepam is the
ollowing symptoms is NOT included in that tool? pre erred drug o those listed.
A) Headache or eelings o ullness in head.
B) Palpitations. HELPFUL TIP:
C) Paroxysmal sweats. t h iV m l az pam a als b adm s d s b-
D) actile disturbances. l g ally sp d abs p y wa s a al
E) remor. m d a . o bv sly iV s v as y .

Answer 25.2.9 The correct answer is “B.” Palpitations are not

included in the CIWA-Ar scale. In addition to “A,” “C,” “D,” and Question 25.2.12 DT carries a atality rate o :
“E,” the other signs and symptoms are nausea/vomiting, anxiety, A) < 1%.
agitation, auditory disturbance, visual disturbance, and orienta- B) 5%.
tion/clouding o sensorium. Each sign or symptom is given 0 to C) 10%.
7 points according to its severity except or orientation/clouding D) 25%.
o sensorium which is only 0 to 4 points. Withdrawal is considered E) 50%.
mild i the score is < 15, moderate is 16 to 20, and severe is > 20.
Answer 25.2.12 The correct answer is “B.” Prior to modern
You are considering whether or not this patient has D . treatment, the mortality reached up to almost 40% per episode.
T e rest are incorrect.
Question 25.2.10 Which o the ollowing is true o DT?
A) T e majority o patients with alcohol withdrawal develop Question 25.2.13 Which o the ollowing does NOT predis
D i not treated. pose to developing DT?
B) Auditory hallucinations are more common than visual A) Prior episodes o D .
hallucinations in D . B) Pneumonia.
C) Symptoms o D could easily be con used or dementia. C) Gastrointestinal (GI) bleed.
D) Her last drink would need to be about 1 week ago or her to D) Female gender.
have D . E) Hepatic ailure.
E) Autonomic instability is present in D .
Answer 25.2.13 The correct answer is “D.” Female gender does
Answer 25.2.10 The correct answer is “E.” Autonomic instability not predispose an individual to D but the other options do.
with elevated pulse, blood pressure, and ever are common in D .
“A” is incorrect. Minor withdrawal symptoms are quite common, Question 25.2.14 Which o the ollowing is NOT a complica
but D develops in only 3% to 5% o patients undergoing alcohol tion o alcoholism?
withdrawal. “B” is incorrect. Visual hallucinations are common A) Dementia.
in D ; auditory hallucinations are less likely. “C” is incorrect. B) Pancreatitis.
Withdrawal delirium typically presents acutely over a matter o C) Hypermagnesemia.
hours or days; whereas, in dementia, the cognitive decline is over D) Megaloblastic anemia.
a course o months to years. In addition, autonomic instability is E) Marchia ava–Bignami disease.
not a eature o early dementia (OK, maybe in Shy–Drager syn-
drome although cognition is usually well preserved—just like our Answer 25.2.14 The correct answer is “C.” All o the above,
patient’s liver). Finally, “D” is incorrect because the risk or D with the exception o hypermagnesemia, are associated with alco-
usually peaks 72 hours a er the last drink. hol abuse. A ew merit special comment. Alcoholic dementia may
be related to direct e ects o alcohol on the brain or to nutritional
Question 25.2.11 Which medication would be the best de ciencies. Hypomagnesemia is a complication o alcoholism.
choice or DT in a patient who is vomiting pro usely and Hypomagnesemia may decrease the response to thiamine admin-
who has no IV access? istration. Marchia ava–Bignami disease is demyelination and/or
A) Diazepam (Valium). necrosis o the corpus callosum and the adjacent white matter.
B) Alprazolam (Xanax). It presents with dementia, dysarthria, spasticity, and inability to
C) Chlordiazepoxide (Librium). ambulate. It can occasionally be seen in nondrinkers as well.
D) Lorazepam (Ativan).
E) Clonazepam (Klonopin). HELPFUL TIP:
eld ly pa s w h al h l p bl ms g -
Answer 25.2.11 The correct answer is “D.” Lorazepam is g z d. Hav a h gh d x s sp pa sw h
absorbed well intramuscularly. T is makes it a good choice or s g s a d symp ms s h as lab l hyp s , s m-
the vomiting patient. Diazepam is erratically absorbed IM and a, l gal ma al p bl ms, q alls a d j s,
should be administered either orally or IV. One could argue that h ada h s bla k s, a d vag Gi mpla s.
diazepam given rectally is a reasonable alternative to lorazepam
 CHAPTER 25 • Su BSt An c e u Se DiSo r Der S 677

Question 25.2.15 Which o the ollowing is FALSE about Objectives: Did you learn to . . .
alcohol use disorders? • r g z s g s a d symp ms al h l w hd awal?
A) Most patients who develop alcohol disorders do so by their • D s b d ag s a al h l w hd awal?
mid-20s. • id y adv s s h avy al h l s ?
B) T e li etime prevalence o alcoholism is between 14% and 24%. • D a b w s bs a ab s a d d p d ?
C) Alcoholism is requently comorbid with other psychiatric • t a al h l w hd awal?
illnesses. • App a h w d al h ll ss plays a l h ass ss-
D) Alcohol abuse is ve times more requent in males than in m s bs a ab s ?
emales. • id y lab a y ab mal s bs v d al h l ab s
E) About 30% o patients with alcohol abuse meet criteria or a d d s a d h lm a s lab a y s d s?
major depressive disorder.

Answer 25.2.15 The correct answer is “A.” Most people who

QUICK QUIZ: n iGHt MAr e in MAr GAr it AViLLe
develop alcohol use disorders do so by their late 30s, not their
late 20s. T e rest are correct statements. Especially noteworthy is
“C.” Hal o all people with alcohol abuse have a comorbid psy- A 50-year-old divorced male presents to your clinic in an agi-
chiatric diagnosis. For example, about 50% to 60% o people with tated state, complaining o nausea, vomiting, and double vision.
bipolar illness have problems with alcohol abuse or dependence. He smells o alcohol, has gross bilateral hand tremors, and is
“E” is a correct statement as well. Although over 80%o patients disheveled. He is picking at his shirtsleeves and is oriented
with alcohol use disorders complain o depressive symptoms, to name only. On physical examination, he has lateral nys-
only 30%meet criteria or major depressive disorder. A use ul tagmus and an ataxic gait. Vital signs include: blood pressure
way to approach patients who complain o depression along with 160/92 mm Hg, pulse 100 bpm, and respirations 20 bpm. Labs
their alcohol abuse is to obtain a longitudinal history to see which are drawn, and his GG is moderately elevated.
came rst. I it is impossible to tease out, as is o en the case,
observe or 1 to 3 weeks o alcohol. I depression is still present Which o the ollowing is the most likely cause o his symptoms?
without alcohol use, it is prudent to treat with an antidepressant. A) Wernicke encephalopathy.
Be care ul when treating alcohol abusers with antidepressants: B) Normal pressure hydrocephalus.
active substance use severely reduces the e cacy o these drugs. C) Dementia.
D) Stroke.
E) Alcohol withdrawal.
HELPFUL TIP:
S bs a s a s a h gh s b w ag s 18 a d
The correct answer is “A.” Wernicke encephalopathy is the
25. A l h s s xp m a ha w ll d as h
result o thiamine de ciency and can occur in alcoholics and
d v d al ma s. S m , s , w ll g h
other patients with poor nutrition. See the next question or a
ab s .
description o the clinical ndings. Note that several symptoms
o Wernicke encephalopathy can mimic withdrawal (agitation,
etc.). However, as noted in the question, this patient is still
HELPFUL (AND IMPORTANT) TIP:
intoxicated.
S d s hav sh w ha symp m- gg d s ad
x d-d s p ls b z d az p am
al h l w hd awal as a pa may b h b s
QUICK QUIZ: Wer n ic Ke en c ePHALo PAt HY
way a a al h l w hd awal. A 2002 s dy
h Archives of Internal Medicine d m s a d ha h
symp m- gg d app a h am s l d l ss he triad o Wernicke encephalopathy includes all o the
s b z d az p s a sh h sp al s ay (20 h ollowing EXCEP :
vs. 62.7 h s, Arch Intern Med. 2002;162:1117–1121). A) Ataxia.
Symp m- gg d app a h s s h c iWA-A s - B) Oculomotor dys unction.
g sys m v y 4 8 h s w h b z d az p s p - C) Incontinence.
vd d s s >8 p v y h . B z d az p D) Encephalopathy.
gm s lz d l d : l az pam, d az pam, a d
hl d az p x d . r l h mb s s h small s The correct answer is “C.” Wernicke encephalopathy may pres-
v d s al b z d az p d d mp v ent with the classic triad o ataxia, encephalopathy (con usion),
symp ms. iV m la s d az pam a d l az pam and oculomotor dys unction (nystagmus, lateral rectus palsy,
may b lz d h a s g d d. o , etc.). However, the majority o patients presents with an incom-
Dt may q abs dly la g d s s b z d - plete syndrome and may be missing ophthalmoplegia, ataxia, or
az p s ( p s al b s s 70 mg iV d az pam encephalopathy. I you choose “B,” maybe you were thinking o
1 h ). normal pressure hydrocephalus, which presents with dementia,
incontinence, and ataxia.
678 FAMiLY MeDic in e eXAMin At io n & Bo Ar D r eVieW

A B C
FIGURE 25-1. F al al h l sy d m . A. A 2 1/2 y a s. B, C. A 12 y a s. n p ss sh palp b al ss s, p a hal lds, f a m d a ,
hyp plas ph l m, a d h pp v m l b d . t h s d v d al als has h sh , l a p p b al s a ha a s y g mal s w h
al al h l sy d m . (r p d d m S ssg h AP, c la SK, J s KL. n a al h s y h al al h l sy d m : A 10-y a ll w- p
l v pa s. Lancet. 1985;326:85–91, w h p m ss m els v .)

attention de cits, or mental impairment. T e other options are

CASE 25.3 incorrect. See Figure 25-1.
A 28-year-old married, pregnant patient and her mother are
presenting or a ollow-up appointment. At the appointment HELPFUL TIP:
today, the patient’s mother shares that her daughter has been th a FAS s 10% 50% am g h h ld
drinking alcohol during her pregnancy. T e daughter is very w m wh ab s d al h l d g p g a y. FAS is
annoyed when con ronted with her use o alcohol and will the leading cause o intellectual and developmental
not give speci c in ormation about it, but she does admit to disability in the Western Hemisphere. c h ld w h
drinking. She does not agree to quit during her pregnancy h s d s d hav a av ag iQ 68 70.
or to be re erred or substance abuse evaluation. You discuss
some o the e ects alcohol might have on the developing
etus, including etal alcohol syndrome (FAS). Question 25.3.2 Symptoms and signs o FAS may be
detected at what point a ter birth?
Question 25.3.1 The diagnosis o FAS requires speci c man A) Within 12 hours.
i estations in three areas, including: B) A er the rst week.
A) At least two acial anomalies, retardation o growth below C) At 1 month.
the 20th percentile, and little motor activity. D) At 3 months
B) At least two acial anomalies, retardation o growth below the E) A er 1 year.
10th percentile, and central nervous system (CNS) problems
that may include tremulousness, hyperactivity, attention Answer 25.3.2 The correct answer is “A.” Soon a er birth, the
de cits, or mental impairment. neonate may display symptoms o withdrawal, including tremu-
C) At least three acial anomalies, retardation o growth below lousness, inconsolability, vomiting, and poor eeding. T e char-
the 20th percentile, and poor sucking ref exes. acteristic cluster o acial/physical mal ormations (listed above)
D) Small size, hyperactivity, and one generalized acial anomaly. is evident within 12 hours o birth. Other principal eatures are
CNS dys unction, growth de ciency at birth, joint and limb
Answer 25.3.1 The correct answer is “B.” T e diagnosis o abnormalities, and heart de ects.
FAS requires in utero exposure to alcohol and at least two acial
anomalies, retardation o growth below the 10th percentile, and In addition to FAS, you discuss some o the potential prob-
CNS problems that may include tremulousness, hyperactivity, lems seen with more limited in utero exposure to alcohol.
 CHAPTER 25 • Su BSt An c e u Se DiSo r Der S 679

Question 25.3.3 What are the criteria or etal alcohol
ef ects (FAE)?
A) Small size, prematurity, hyperactivity, learning disabilities.
B) Inability to complete tasks, very active, very excitable.
C) Facial mal ormations, heart de ects, hyperactivity.
D) Growth de ciency at 10th percentile, learning disabilities.
E) Congenital cardiac anomalies, growth de ciency at 10th
percentile, acial mal ormations.
smoking up to two packs o cigarettes per day. She asks you
what is available to help her stop. You tell her that nicotine
replacement therapy (NR ), bupropion (Zyban), and vareni-
cline (Chantix) are currently approved to aid patients who
want to stop smoking.
You want to o er her an NR that is easy to use, has ew
side e ects, and provides steady blood levels o nicotine over
the whole day.

Answer 25.3.3 The correct answer is “A.” Knowledge continues Question 25.4.1 Which do you choose?
to grow regarding the more subtle e ects o maternal drinking, A) Nicotine patch.
such as that seen with “social” alcohol use. FAE can occur with B) Nicotine gum.
even moderate drinking during pregnancy. T e abnormalities C) Nicotine nasal spray.
commonly observed with FAE include small size, prematurity, D) Nicotine inhaler.
hyperactivity, and learning disabilities. E) E-cigarettes.

Question 25.3.4 In which stage o pregnancy does the tera Answer 25.4.1 The correct answer is “A.” T ere are bene ts
togenic action o alcohol cause acial mal ormations? and drawbacks to each o the smoking cessation aids. Like
A) During the embryonic phase, at the eighth week a er con- other NR , the nicotine patch is available without prescrip-
ception. tion. It is applied to the skin daily and provides a steady release
B) During the third week o pregnancy. o nicotine through the skin. For a patient with a heavy, long
C) During the late rst trimester. smoking history, begin with the 21 mg patch and taper to the
D) During the second trimester. 7 mg patch over a 3-month time rame. Some o the drawbacks
E) During the third trimester. o the patch include slower release o nicotine, the potential
or skin irritation, insomnia, and vivid dreams. Some o these
Answer 25.3.4 The correct answer is “B.” Facial mal ormations side e ects can be reduced by having the patient rotate applica-
occur with the use o alcohol during the third week. Organs and tion sites daily (to avoid skin irritation) and removing the patch
limbs appear most susceptible to the e ects o alcohol during be ore bedtime. Nicotine gum is an ion-exchange resin that
the embryonic phase, which is completed by the eighth week releases nicotine or absorption through the buccal mucosa
o conception, a time when most women are rst con rming with only 30% bioavailability in the rest o the GI tract. Side
pregnancy. Alcohol exposure during any stage o development e ects include mouth and throat soreness, jaw atigue, hiccups,
may a ect brain development or unction. and undesirable taste. T ere are advantages o nicotine gum:
it involves an active coping mechanism (chewing, placing the
You are able to convince this patient to reduce and eventually gum in one’s mouth, etc.) and is more likely than the patch to
eliminate her use o alcohol; she delivers a healthy-appearing delay weight gain. T e nasal spray delivers 0.5 mg nicotine per
newborn who she names “Harley” af er the motorcycle. dose and is sprayed one to two times per hour or a maximum
o 5 sprays per hour and 40 sprays per day. Most o the nico-
tine nasal spray side e ects are attributable to its route o use—
HELPFUL TIP:
nasal and throat irritation, rhinorrhea, sneezing, etc. T e oral
n v am y h ld a a m y l (Ha l y), a
inhaler provides an active delivery o nicotine similar to the
p sm al ( .g., Sapph , D am d), a W s
nasal inhaler, and its side e ects are also a consequence o its
la d ma ( .g., S a, c h y , c dy) a g
route o delivery—throat irritation and coughing. E-Cigarettes
(W ss r m g ). i s a s b ha y d h y
create a vapor (not smoke) that simulates smoking. Like other
w ll hav l g p bl ms (a l as ha s xp -
nicotine replacement products, the amount o nicotine may be
). n w, y am y kda a b a d wh sk y
decreased over time. T ere are more than 250 di erent brands
(l k h s g P k d d), ll g h w a h ’ll g !
o e-cigarettes. Very little is known about their sa ety; or while
they don’t contain the smoke they do contain nicotine and
Objectives: Did you learn to . . . other chemicals. E-cigarettes have a checkered track record
• id y p bl m d k g a p g a pa ? when it comes to being an aid to smoking cessation (vs. a gate-
• App a h a pa w h al h l ab s p g a y? way to nicotine addiction or younger users). T ere are studies
• D s b h d gs FAe a d FAS? to support their use but just as many that suggest that they do
not aid with smoking cessation.
CASE 25.4 Question 25.4.2 Which o the ollowing is the most signi
A 60-year-old emale presents to your o ce and is deter- cant side ef ect o varenicline (Chantix)?
mined to stop smoking. She has a history o schizophrenia A) Desire to commit violence or commit suicide.
treated with clozapine (Clozaril) and a 43-year history o B) Desire to watch endless reruns o Godzilla movies
680 FAMiLY MeDic in e eXAMin At io n & Bo Ar D r eVieW

C) Leukocytosis.
HELPFUL TIP:
D) Urinary retention.
A 2014 c h a v w d ha p yl has
ss ally h sam s ss a as b p p . n p-
Answer 25.4.2 The correct answer is “A.” T ere is an FDA
yl s s a d a 25 mg da ly 3 days, h 50 mg ll
warning about the possibility o suicidal or homicidal ideation.
h 7 h day wh h d s s as d 75 mg da ly.
T is is not good, especially in someone who already has a psy-
chiatric disorder. Other common side e ects include f atulence
(really), nausea, headache, and insomnia.
T e mood in the examination room turns a shade bluer as
Although this patient does not mind spending $6 to $7 per day your patient wonders whether, at age 60 and with an 86-pack-
on cigarettes, she does not want to pay a lot or something to year history, there is even any reason to quit. “It’s too late or
help her quit (Why is this, you ask? So do we . . . ). me,” she laments.

Question 25.4.5 How long does it take to reduce the risk o

Question 25.4.3 Which smoking cessation aid is the most
having a heart attack by 50% a ter one stops smoking?
expensive?
A) 24 hours.
A) Nicotine patch.
B) 6 months.
B) Nicotine gum.
C) 1 year.
C) Nicotine nasal spray.
D) 10 years.
D) Nicotine inhaler.
E) In nity.
E) Varenicline.
Answer 25.4.5 The correct answer is “C.” wenty minutes a er
Answer 25.4.3 The correct answer is “E.” Varenicline costs quitting smoking, blood pressure drops and the temperature o
approximately $280 to $350 per month. T e nicotine products hands and eet increases to normal. A er 24 hours, the risk o heart
are less expensive in the range o $60 to $120 per month. O attack begins to decrease. At 1 year, the chance o having a heart
course, some health insurance programs will support smoking attack is cut in hal . A er 5 years, stroke risk is reduced to that
cessation aids. o a nonsmoker. A er 10 years, the risk o dying rom lung cancer is
about hal that o a person who continues to smoke. A er 15 years,
“I tried those things, Doc, and nicotine didn’t work and var- the risk o coronary heart disease approaches that o a nonsmoker.
enicline made me shoot my boy riend in the leg—but he had
it coming. Isn’t there something else?” T e mood in the examination room is heading into a deeper
blue as your patient expresses concern that she will ail in this
Question 25.4.4 Which o the ollowing medications might attempt to quit smoking, as she has in the past. “I’ll never do it,”
you also prescribe to aid this patient in smoking cessation? she complains.
A) Naloxone.
B) Metoprolol. Question 25.4.6 On average, how many attempts to quit
C) Haloperidol. smoking are made be ore a person succeeds?
D) Bupropion. A) 2.
B) 6.
Answer 25.4.4 The correct answer is “D.” Bupropion is mar- C) 10.
keted as the antidepressant Wellbutrin and the smoking cessa- D) 16.
tion aid Zyban. It reduces the symptoms o nicotine withdrawal
by blocking dopamine in the brain’s reward center, and this Answer 25.4.6 The correct answer is “B.” It takes an average o
mechanism is thought to result in reduced nicotine craving. six attempts at quitting be ore success. So, i at rst your patient
Studies have shown that people who use bupropion doubled doesn’t succeed, try again and again and . . . so on.
their chances o quitting smoking. Its e ect appears to be addi-
tive to that o NR . Its e ect on smoking cessation is indepen- HELPFUL (AND UNFORTUNATE) TIP:
dent o its antidepressant e ect, as shown by its equal e cacy n h s ssa a ds hav a g a a k d
in depressed and nondepressed patients. One o the advantages s ss. Y a d mb s all v h b a d. W h
o bupropion is its ability to prevent the weight gain that occurs a ds, s m h g l k 15% pa s w ll b -
in most people when they stop smoking. Bupropion should ba a 1 y a . A s dy 2011 sh w d no di er-
be started at a dose o 150 mg daily or 3 days then increasing ence l g- m abs a sb w s s -
to 150 mg twice daily, i the patient is tolerating the drug. T e a ds a d h s wh q h w (Tob Control.
patient should be advised to stop smoking during the second 2013;22:32–37). W h b p p , h mb s l s
week o treatment. T ere is no evidence that SSRI are e ective 23%. Va l als has ab a 23% 1-y a abs
in smoking cessation. Pooled data rom 4 head to head trials a .c s l g may as h s ss a , a d all
comparing bupropion and varenicline indicate that varenicline sm k s sh ld b g d q a v y app m .
is more e ective.
 CHAPTER 25 • Su BSt An c e u Se DiSo r Der S 681

• e m a h phys l g al adva ag s sm k g
T is patient has been on clozapine (Clozaril) or control o ssa a a y ag ?
her psychosis. • r g z s g s a d symp ms w hd awal?

Question 25.4.7 The combination o clozapine and bupro

pion should be used with caution because: QUICK QUIZ: ALL in t He FAMiLY
A) Both may lower the seizure threshold.
B) Both may cause hypertension. Which o the ollowing characteristics is NO true o the
C) Bupropion may inter ere with the metabolism o clozapine. children o alcoholics?
D) Severe GI symptoms could occur. A) T ey experience earlier onset o problem drinking.
E) A psychotic episode could be precipitated. B) T ey experience earlier pregnancies (well, not the males . . . ).
C) T ey have less stable amily involvement.
Answer 25.4.7 The correct answer is “A.” Both drugs may lower D) T ey experience poor academic and social per ormance in
the seizure threshold. Hypertension should not be a concern. school.
Bupropion does not inter ere with the metabolism o clozapine, E) T ey have more antisocial behavior.
cause severe GI symptoms, or precipitate psychotic episodes.
The correct answer is “B.” T ere is no data to suggest early preg-
Af er all o your discussion, the patient wants to quit “cold nancy as a characteristic. win, adoption, and hal -sibling stud-
turkey.” You gently explain that going rom 40 cigarettes per ies and studies o amilial versus non amilial alcoholism indicate
day to zero might be hard on her although quitting cold tur- that children o alcoholics have our times the risk or develop-
key improves the chance o success (Ann Intern Med. Mar 15, ing alcoholism. T ey also have worse school per ormance, more
2016;164(6):377–448). antisocial behavior, and less stable amily situations.
Question 25.4.8 All o the ollowing are symp toms o
nicotine withdrawal EXCEPT:
CASE 25.5
A) Increased appetite. A 35-year-old intoxicated emale presents to your o ce
B) Dysphoria. requesting to be started on disul ram (Antabuse). She is oth-
C) achycardia. erwise healthy and recently has begun to drink in response to
D) Insomnia. the death o her sister. Be ore this, she was a teetotaler.
E) Irritability.
Question 25.5.1 Disul ram should not be administered
Answer 25.4.8 The correct answer is “C.” Nicotine withdrawal until the patient has been abstinent rom alcohol or how
is actually associated with decreased heart rate. In addition to the long?
above, trouble concentrating and restlessness are also common A) 4 hours.
symptoms. B) 12 hours.
C) 24 hours.
HELPFUL TIP: D) 48 hours.
cy s ( b s d w h ys ys ) s E) 72 hours.
a h bal d va v ha s v sm k g ssa-
(pla b 2.4% vs. ys 8%). i s l ss xp s v Answer 25.5.1 The correct answer is “B.” A minimum o
ha va l a d va l s a ally a d va v 12 hours should have elapsed be ore giving disul ram to avoid the
y s (N Engl J Med. 2011;365:1193–1200). disul ram–alcohol reaction. O course, this depends on how much
they were drinking. Remember, we are in a college town here . . .

HELPFUL TIP: HELPFUL TIP:

o h m as s ha a v h lp g a pa q D s l am s abs b d sl wly m h Gi a a d s
a a ma d ll ph m ssag s (Lancet. 2011;378: l m a d sl wly; h , a patient should wait at
49–55), sv a ( s ph alls, b d-s d least 1 week a ter stopping disul iram be ore return-
a h ga a Mi, ., CMAJ. 2009;180(13):1283–1284), ing to drinking.
a d pay g pa s q (N Engl J Med. 2009;360(7):
699–709). i add , p bl p l s s h as ax s
Question 25.5.2 I the patient consumes alcohol while taking
ga s a d ba g sm k g d s hav d m -
disul ram, which o the ollowing is most likely to occur?
s a d v ss a as g q g a s.
A) Respiratory depression.
B) Hypertension.
Objectives: Did you learn to . . . C) Nausea and vomiting.
• empl y pha ma h apy h am ba D) Cardiovascular collapse.
add ? E) Convulsions.
682 FAMiLY MeDic in e eXAMin At io n & Bo Ar D r eVieW

Answer 25.5.2 The correct answer is “C.” T e disul ram– Question 25.5.5 Which o the ollowing is true about
ethanol interaction generally includes f ushing o the skin, acamprosate?
nausea, vomiting, palpitations, hypotension, sweating, blurred A) It is contraindicated in those with renal impairment/renal
vision, and dizziness. Rarely, in more severe reactions, respira- ailure.
tory depression, cardiovascular collapse, convulsions, and death B) At 1 year, acamprosate is no better than placebo in preventing
may occur. T e severity o the reaction is typically dose related relapse o alcoholism.
and depends on the amount o alcohol ingested. C) T e combination o acamprosate and naltrexone is no more
e ective than either alone.
Question 25.5.3 Common side ef ects o disul ram include D) Drug reps will tell you that all o these medications are great
which o the ollowing? and that you should prescribe them.
A) Hypotension. E) All o the above.
B) Peripheral neuropathy.
C) Insomnia. Answer 25.5.5 The correct answer is “E.” All o the above are
D) Nausea. true. Un ortunately, at 1 year none o these drugs are signi -
E) Depression. cantly better than placebo. How do they get past the FDA, you
ask? So do we. Don’t even get us started on the topical onycho-
Answer 25.5.3 The correct answer is “B.” Drowsiness, hepa- mycosis treatments.
totoxicity, rashes, hypertension, peripheral neuropathy, metallic
Question 25.5.6 Which o the ollowing is true about acam
a er-taste, and optic neuritis may occur with disul ram use.
prosate?
T ese e ects are independent o alcohol ingestion.
A) Patients receiving opioid maintenance therapy or opioids or
pain will need higher levels o opioid medication.
HELPFUL TIP: B) It is contraindicated in those with liver impairment/liver
M l pl as s h pa s hav b p d w h ailure.
sag d s l am, a d bas l lv zym s C) Patients who require detoxi cation can be continued sa ely
sh ld b b a d p sa g d s l am a d on acamprosate.
h app x ma ly 2 w ks a a a - D) It is contraindicated in patients who are taking SSRIs.
m . o as ally, a ash may a ly . th
ash a b a d w h a h s am s a d h d g Answer 25.5.6 The correct answer is “C.” Acamprosate does
a b d. not interact with benzodiazepines or other medications used
in medical detoxi cation and thus can be continued sa ely i a
patient starts drinking and then requires detoxi cation. Acam-
prosate is not metabolized by the liver and can be used sa ely
Af er a discussion, the patient thinks that disul ram is the even in patients with severe liver disease, whereas naltrexone
“one thing that might work.” She tries it, but at ollow-up, and disul ram are contraindicated. T ose receiving opioids or
she is not having much success. She continues to drink acute or chronic pain or receiving opioid maintenance treatment
heavily and (thank ully) has been noncompliant with tak- can use acamprosate because it does not a ect these medica-
ing disul ram regularly. She reports strong craving or tions; and it is sa e to take with SSRIs.
alcohol.
HELPFUL TIP:
Question 25.5.4 At this point, as an FDA approved alterna
o h m d a s ha hav b s d a al -
tive to disul ram, you decide to prescribe:
h l sm l d p ama , ba l , da s ,a d
A) Naltrexone (Revia).
SSr is. t p ama has h b s da a a d da s
B) Naloxone (Narcan).
s ly v a ly s al h l sm h s wh
C) Nortriptyline.
hav a sp g 5-Ht a sp .
D) Nitroprusside.

Answer 25.5.4 The correct answer is “A.” Naltrexone is FDA-

HELPFUL TIP:
approved or the treatment o alcoholism. As an opioid antag-
n h s d gs a pa la ly v . Ds l -
onist, it blocks the euphoric e ects o alcohol. opiramate
am s b ha pla b , al x a d a am-
( opamax) and baclo en can also be used to decrease the crav-
p sa hav a n n t 12-20. n al x d s days
ing or alcohol. However, they are not FDA-approved or this
h avy d k g b a amp sa (JAMA. May 14,
indication. None o the other drugs listed are used to treat
2014;311(18):1889–1900).
alcohol abuse and dependence.

T is patient seems to recall something about using camel Objectives: Did you learn to . . .
paws to treat alcoholism. You very perceptively realize she • D s b h m ha sm a d s l am?
means Campral (acamprosate). • r g z sd s d s l am?

• D s b h al h l–d s l am a ? C) Contact the patient’s methadone maintenance clinic or dose
• P s b va s m d al h ap s al h l s d s d s?
CASE 25.6
A 25-year-old comatose emale presents to the ED with
pinpoint pupils and respiratory depression.
Question 25.6.1 Which o the ollowing is the most likely
cause o coma?
A) Blood alcohol level o 200 mg/dL.
B) Cocaine overdose.
C) Methadone overdose.
D) Benzodiazepine withdrawal.
E) Phencyclidine (PCP) intoxication.
Answer 25.6.1 The correct answer is “C.” T e classic “triad” o
opioid overdose consists o coma, respiratory depression, and
pinpoint pupils (miosis). Certain patients may have atypical
presentations, and the triad may not always be present in opioid
overdose. Miosis is particularly variable, o en not being seen
in those with meperidine and propoxyphene overdoses; and
coingestions, such as sympathomimetics and anticholinergics,
can also prevent miosis. “A” is incorrect. A patient with a blood
alcohol level o 200 mg/dL would likely be ataxic; but alcoholic
coma typically occurs at blood levels >400 mg/dL and depends
on the level o tolerance. Stimulant overdose would not likely
present with somnolence. Alcohol and PCP intoxication would
more likely present with nystagmus and not constricted pupils.
You treat her with naloxone and she wakes up (spitting mad,
agitated, and in withdrawal).
Question 25.6.2 What is the minimum amount o time
that you should observe a patient who has overdosed on
methadone?
A) 1 hours.
B) 4 hours.
C) 12 hours.
D) 36 hours.
E) 72 hours.
Answer 25.6.2 The correct answer is “D.” Methadone has
a long hal -li e (variable, but up to 60 hours), and there ore a
patient who has overdosed on methadone should be monitored
or at least 36 to 48 hours. Since the ½ li e o naloxone is 30 to
90 minutes, it may take multiple doses o naloxone to treat a
methadone overdose (a naloxone drip is o en used).
You discover that the patient has been on a methadone main-
tenance program, but then she relapsed and overdosed on
a combination o methadone and heroin. Her urine drug
screen returns positive or opioids.
Question 25.6.3 What would be the next most appropriate
course o action?
A) Detoxi y the patient o methadone as an outpatient.
B) Contact the authorities to have the patient arrested.
CHAPTER 25 • Su BSt An c e u Se DiSo r Der S 683
increase.
D) Noti y the patient o her positive urine drug screen and let
her know you are not surprised by the result, as methadone
is metabolized to morphine.
E) Have the patient committed to a substance abuse treatment
acility.
Answer 25.6.3 The correct answer is “C.” he act that
this patient has relapsed into heroin use may mean that her
methadone dose is too low or maintenance. his can lead to
additional heroin use. he rest are incorrect. “A” would be
dangerous. “B” is not necessary. “E” would be ine ective or
a patient not interested in quitting (but is o ten used anyway
as desperate measure). “D” is o particular note. Methadone
does not have any active metabolizes (so “D” is incorrect),
but it can be ound in the urine. Heroin and codeine are
metabolized to morphine.
HELPFUL TIP:
H gh-d s m had a l ad Qt p l ga a d
sad s d p s.
Question 25.6.4 Methadone is typically prescribed or opioid
maintenance therapy:
A) Once daily.
B) wice daily.
C) T ree times daily.
D) T ree times weekly.
E) Once monthly.
Answer 25.6.4 The correct answer is “A.” Methadone has an
elimination hal -li e o up to 60 hours (range 15–60 hours).
T us, once daily dosing is appropriate or the treatment o nar-
cotic addiction. T e advantage here is that the medication can
be given under direct observation. Remember that it is given
more requently (Q8 hours) or pain control.
Af er regaining consciousness, the patient in orms you that
she is 20 weeks pregnant.
Question 25.6.5 Regarding pregnancy and usage o opioids,
which o the ollowing would most likely have the best
outcome?
A) Continuing the patient on methadone.
B) Withdrawing the patient rom all opioids in the rst trimester
(too late or this one).
C) Withdrawing the patient rom all opioids in the second
trimester.
D) Withdrawing the patient rom all opioids in the third
trimester.
Answer 25.6.5 The correct answer is “A.” Opioid with-
drawal in a pregnant woman can cause etal distress and low
birth weight. Methadone is currently the standard o care in
684 FAMiLY MeDic in e eXAMin At io n & Bo Ar D r eVieW

the United States or the treatment o opioid addiction in

HELPFUL TIP:
pregnant women. Methadone maintenance has multiple
S m la s a a s a ya y l s a d
advantages, including longer durations o maternal drug
s v hyp s . My a d al a w hs m -
abstinence, better obstetrical care, reductions in etal illicit
la s sh ld b a d l k a y h Mi. Hyp -
drug exposure, and enhanced neonatal outcomes (e.g.,
s sh ld b a d w h alpha a d b a-bl k s.
increased etal growth, reduced etal mortality, and decreased
risk o preeclampsia).
Objectives: Did you learn to . . . HELPFUL TIP:
• r g z symp ms a d s g s v d s w h p ds a d ch m hamph am s s ass a d w h w d -
h ll d gs? sp ad d al a s a d g g val d s as ha a s l
• u s m had p d add ? l ss ma y, v all, h. “M h m h,” as h s
• t a a p g a pa w h p d add ? s mm ly all d, s p bably d p l g dp -
ds p d al hyg , x s m a, h gh al
d a d d k, a d h g d g.
CASE 25.7
A 40-year-old emale is admitted through the ED, arriving
Question 25.7.3 Which o the ollowing does NOT address
via ambulance rom a smaller hospital. T e local physician
the needs o this patient during withdrawal?
called to report that her riends said that she had “shot up a
A) Provide a secure environment.
lot o meth.” She is known to use her son’s Ritalin prescription
B) Provide regular meals and snacks.
on a regular basis. She appears rightened and anxious. She
C) Make sure the patient is awakened i she spends excess time
is uncommunicative, rocking back and orth on the examina-
sleeping.
tion table, and picking at her skin trying to remove bugs that
D) Consider giving a benzodiazepine i the patient remains
only she can see. She becomes angry easily and lashes out at
anxious.
sta in the ED.
E) Provide education as an intervention towards change.
Question 25.7.1 A reasonable dif erential diagnosis or this Answer 25.7.3 The correct answer is “C.” Amphetamine with-
patient would include all o the ollowing EXCEPT: drawal requires sleep, nutritious ood, and a sa e place until the
A) Schizophrenia. unstable state o being has diminished. T e patient should be
B) Drug-induced psychosis. allowed to sleep. Stimulant abusers o en stay up or a week or
C) PCP, hallucinogen, or cocaine intoxication. more at a time and then “crash” or sleep or days during with-
D) Diabetes. drawal. Antipsychotic medications and benzodiazepines may
E) D . be administered i needed.

Answer 25.7.1 The correct answer is “D.” Just checking to see Objectives: Did you learn to . . .
i you’re awake. T ough hypoglycemic patients can certainly • r g z h s g s a d symp ms amph am
x a ?
become con used, diabetes is least likely to be causing these
symptoms. Although there is a history o amphetamine use, the • App p a ly a a pa w h amph am x a
a d w hd awal?
other options should not be eliminated out o hand. T ere may
be more than one substance involved (o course, we never see
that sort o thing in Iowa . . . no, never). CASE 25.8
A 15-year-old male is brought into the ED by his neighbor
T e urine drug screen is positive or amphetamines alone. who ound the boy passed out in his backyard with a bag ull
o glue nearby. He had di culty rousing the boy. Currently,
Question 25.7.2 The ollowing are all symptoms o amphet the patient is lethargic with slurred speech and di culty
amine use EXCEPT: walking. When his parents arrive, they are shocked, as their
A) achycardia son has been a “good kid.” T ey had no idea he was using any
B) Hypertension. drugs. O course, he bought lots o tubes o “model glue” but
C) Perspiration or chills. they never did see any completed models.
D) Weight gain.
E) Psychomotor agitation. Question 25.8.1 The signs and symptoms o inhalant use
include all o the ollowing EXCEPT:
Answer 25.7.2 The correct answer is “D.” Weight loss, not A) Dizziness.
weight gain, can be anticipated in the amphetamine user. All o B) Slurred speech.
the other symptoms can be seen as a result o amphetamine use. C) Unsteady gait.
Symptoms can progress to con usion, arrhythmias, seizures, D) Smell o solvents or glue.
dystonias, or coma. E) Dilated pupils
 CHAPTER 25 • Su BSt An c e u Se DiSo r Der S 685

Answer 25.8.1 The correct answer is “E.” Inhalant intoxication Answer 25.8.5 The correct answer is “A.” Males, not emales,
is identi ed by impaired judgment, impaired social interaction, are more likely to abuse inhalants. Inhalant users tend to be o
and aggressive behavior o en leading to altercations. Higher lower socioeconomic status, younger (age 13–15), and have di -
doses can lead to lethargy, psychomotor retardation, stupor, or culty in school. T ere is an increased incidence o inhalant
coma. Dilated pupils are seen in anticholinergic toxicity and abuse among Native Americans.
other drugs (e.g., sympathomimetics) but not with inhalants.
HELPFUL TIP:
Question 25.8.2 All o the ollowing are considered inhal
“S g” s wh m s a hal d d ly m a
ants used by abusers EXCEPT:
s a h s bs a s pla d a bag
A) Kerosene.
a d hal d m h bag. “H g” s wh h s b-
B) Cleaning solvent.
sa s pla d a ag a d h hal d w h h ag
C) Gasoline.
pla d v h s a d m h. G a k w h l g .
D) Spray paint.
E) Glue.
Objectives: Did you learn to . . .
Answer 25.8.2 The correct answer is “A.” Kerosene is not • id y s m yp s hala s ab s d?
volatile enough to be abusable. T e rest can be abused by • r g z h symp ms hala ab s ?
inhalation. • D s b h d m g aph s hala ab s ?

HELPFUL TIP: CASE 25.9

th a x a v la l s g ally las s
A 40-year-old male who has been smoking marijuana daily
ab 30 m s. Gas l sa x p ; h as
or the past 20 years would like to quit his marijuana habit . . .
gas l , h x a a las p 6 h s.
but he just cannot nd the motivation. He wants to apply or
a new job, and a drug screen is part o the application pro-
Question 25.8.3 Withdrawal rom inhalants has been cess. He makes an appointment with you to discuss what he
described and includes all o the ollowing eatures EXCEPT: can expect when he quits and how long will it be until his
A) Onset o symptoms 24 to 48 hours a er use has stopped. drug screen is negative.
B) ransient illusions.
C) Diaphoresis. Question 25.9.1 All o the ollowing are symptoms o
D) Con usion. marijuana intoxication EXCEPT:
E) Intense hunger. A) Euphoria.
B) Sensation o slowed time.
Answer 25.8.3 The correct answer is “E.” Intense hunger is not C) Increased mental alertness.
a sign o withdrawal. In act, the patient may be nauseated. All D) Increased appetite.
o the other options are correct. E) Dry mouth.

Question 25.8.4 All o the ollowing can result rom chronic Answer 25.9.1 The correct answer is “C.” Statistically speak-
solvent or hydrocarbon inhalation EXCEPT: ing, 40% o you will know this one rom personal experience
A) Chronic brain injury. (you know who you are!). Marijuana intoxication decreases
B) Muscle weakness. mental alertness, although it can reportedly enhance the senses.
C) CNS microhemorrhages and secondary seizures. When inhaled, intoxication peaks a er 10 to 30 minutes and
D) Erythrocytosis. lasts about 3 hours.
E) Liver and renal damage.
HELPFUL TIP:
Answer 25.8.4 The correct answer is “D.” Solvents and hydro-
Ab 40% u .S. ad l s hav d ma j a a a s m
carbons can cause all o the e ects noted above except or eryth-
p h l v s, wh h has ha g d s g a ly
rocytosis. In act, one can see bone marrow suppression as a
h las 30 y a s.
result o chronic inhalant use.

Question 25.8.5 Risk actors or inhalant abuse include all Question 25.9.2 How long can marijuana (THC) be detected
o the ollowing demographic actors EXCEPT: in the urine?
A) Female. A) 30 days i used regularly; 2 to 7 days i used occasionally.
B) Age 13 to 15. B) 2 weeks.
C) Low socioeconomic state. C) 1 week or emales; 2 weeks or males.
D) Native American. D) 24 to 48 hours.
E) Poor school per ormance. E) It cannot be detected in urine samples.
686 FAMiLY MeDic in e eXAMin At io n & Bo Ar D r eVieW

Answer 25.9.2 The correct answer is “A.” T is patient will have

Ecstasy, als k w as MDMA ( 3,4-m hyl d xy-
to stop smoking marijuana or a minimum o 30 days be ore
m hamph am ), p d s s sa s ph a,
applying or the job, i he wants to assure his urine drug screen
ma y, a d d s h b . us s s pa s
will be negative. T e drug can be present in hair samples or an
b a s s asy a a s b x sm (D d ’ y w d
extended period o time—anywhere rom 1 to 6 months.
why all h s sa s k g a dy pa s?
J s l k l?). MDMA a a s s z s, l v d s-
Question 25.9.3 Which o these is NOT one o the touted
as , a d hyp h m a am g h s d s.
bene ts o marijuana?
A) Pain reliever. K2 (als k w as “sp ” a d “ h ll x”) s asy h
B) Anxiolytic. a ab d ha s m h m p ha ma j a a.
C) Antiemetic. i s s ld as s . th s s h hal h
D) Appetite stimulator. sm k . S d s l d a hy a d a, hyp s ,
E) Antidepressant. d aph s s, a x y, m d dys g la , m m y
laps s, pa a a, hall a s, d la d p p ls (myd a-
Answer 25.9.3 The correct answer is “E.” In act, the use o s s), a s a/v m g, f sh g, m a d s v
marijuana has been shown to actually worsen depression. Mari- as s s z s. t a m s yp ally s pp v m a-
juana has been used to treat pain, nausea, anorexia, glaucoma, s s w h alm g v m a d b z d az p s
etc. Despite the act that nearly hal o the states have passes laws as d d,
allowing some sort o medical marijuana use, evidence or many Bath salts (also known as “khat,” “vanilla sky” and
o the touted medical bene ts o marijuana is scant or contra- “white lightning” and “meph” ( or mephedrone,
dictory. T e best evidence o bene t has been seen with chronic which we think is people trying to pronounce
neuropathic pain. “meth” without any teeth) a sy h ah s.
Symp ms x ya yp ally sympa h m m ,
Objectives: Did you learn to . . .
s m la m hamph am w h v s m la , ag-
• r g z h symp ms ma j a a x a ?
g ss , ag a ,m m yd s, hall a a d
• A pa s ma j a a s ?
pa a a mm . o , h y may a s adv s -
s s h as h pa al ,a k d y j y, hab-
QUICK QUIZ: Du De, WHAt WAS in t HAt r o c K? d my lys s, a d m ab l d a g m s. t a m s
yp ally s pp v m as s w h iV f ds, b z d az-
p s h lp alm h pa , alm g v m
A 20-year-old male is brought by the police into the ED because
a d/ mp a y s l w-d s a psy h s
o severe agitation a er smoking what he thought was crack
psy h s s.
cocaine. He exhibits slurred speech, ataxia, circumoral numb-
ness, and horizontal nystagmus. GHB (AKA “g v s b d ly ha m,” “G g a h m b y,”
a d h s). A sh -a g d g, p d s b h s da-
Which o the ollowing substances is most likely causing his a d s m la (wh h may y l ap dly). Pa s
symptoms? may b b ady a d a d a ap b wh s m -
A) Cannabis ( HC). la d may b m ag a d a d v l .
B) Heroin. Salvia s a a ally gh b m h m am-
C) Methamphetamine. ly M x (salvia divinorum). t h h b s yp ally
D) PCP. sm k d b a b h w d a d abs b d m h
E) Nicotine. b al m sa. A v g d s salv A, wh h
b ds as κ p d p ag s . D s d sa
The correct answer is “D.” PCP (also called “angel dust”) s m la k am , LSD, a d a ab s. Adv s s
intoxication is characterized by agitation, impulsiveness, nys- l d : a x y, d p s al za , dysph a, -
tagmus, hypertension, tachycardia, numbness, ataxia, and s , h ada h s, d ws ss, a hy a d a a d hyp -
perceptual distortions. Intoxication begins 5 minutes a er use s .n ha s salv Ad s b d µ
and peaks in 30 minutes. PCP-induced psychosis is the most p d p s ha sp a y d p ss s yp -
common PCP-induced disorder and may mimic a schizo- ally s as w h p ds. t a m salv a x y
phrenic psychotic episode. PCP may be added to other drugs s yp ally s pp v w h alm g v m sa d
unbeknownst to the user. b z d az p s as d d.
Remember the abuse o caf eine (legally available in
HELPFUL TIP: crystalline orm over the internet) and the toxicity
A w w ds d sg d gs, wh h a b m g o nicotine ( rom ingestion o products meant or a
as gly p p la as h y a d l d vaporizer) when presented with a patient abusing
s a da d d gs s. drugs.
 CHAPTER 25 • Su BSt An c e u Se DiSo r Der S 687

American Psychiatric Association. Substance-related and

QUICK QUIZ: Qu ic K c o u n SeLin G addictive disorders. In: Diagnostic and Statistical Manual of
Mental Health Disorders: DSM-5 (5th ed). 2013. Arlington,
Brie intervention or alcohol problems is one o the most clini- VA: American Psychiatric Publishing.
cally e ective and cost-e ective preventive services rom among Alpert HR, et al. A prospective cohort study challenging the
those recommended by the USPS F. e ectiveness o population-based medical intervention or
smoking cessation. ob Control. 2013;22:32–37.
All o the ollowing are components or conducting brie Aoun EG, et al. Emerging drugs o abuse: clinical and legal
interventions EXCEP : considerations. Rhode Island Med J. 2014 Jun;97(6):41–45.
A) Ask and give eedback on screening results. Ballantyne JC. Opioid therapy in chronic pain. Phys Med
B) State recommendations about sa e drinking levels and o er Rehabil Clin N Am. 2015;26(2):201–218.
advice about change. Barry KL, et al. Reducing alcohol-exposed pregnancies: a
C) Assess the patient’s readiness to change. report o the National ask Force on Fetal Alcohol
Syndrome and Fetal Alcohol E ect. Atlanta, GA: Centers
D) Negotiate goals and strategies or change.
or Disease Control and Prevention; March 2009.
E) Follow-up annually.
Bayard M, et al. Alcohol withdrawal syndrome. Am Fam
Physician. 2004;69(6):1443–1450.
Answer OK, we will give you this one because we wanted to
Brensilver M, et al. Pharmacotherapy o amphetamine-type
introduce the concept o brie interventions. T e correct answer
stimulant dependence: an update. Drug Alcohol Rev.
(and the thing to avoid) is “E.” Follow-up should be arranged 2013;32:449–460.
much sooner than 1 year. T e “5 A’s” method or brie interven-
Daeppen JB, et al. Symptom-triggered vs. xed schedule doses
tions has substantial research support or its utility in alcohol o benzodiazepine or alcohol withdrawal. Arch Intern
use disorders across a variety o settings and can be incorpo- Med. 2002;162:1117–1121.
rated with motivational strategies in a step-by-step process. T e Free C, et al. Smoking cessation support delivered via mobile
“5 A’s” approach is a brie , goal directed way to more e ectively phone messaging (txt2stop): a single-blind, randomized
address substance use with patients. Altogether, the “5 A’s” may trial. Lancet. 2011;378:49–55.
take 1 to 5 minutes, depending on a provider’s clinical setting Howard MO, et al. Inhalant use and inhalant use disorders in
and roles. T ese components include Asking about use, Advis- the United States. Addict Sci Clin Pract. 2011;6(1):18–31.
ing to cut down/quit, Assessing willingness to quit, Assisting Moore HM, et al. Cannabis use and risk o psychotic or
with strategies or abstinence, and Arranging ollow-up. a ective mental health outcomes: a systematic review.
Lancet. 2007 Jul 28;370:319–328.
Clinical Pearls Nelson ME, et al. Emerging Drugs o Abuse. Emerg Med Clin N
Am. 2014;3(1):1–28.
Ask all ad l s ab ba s , adv s h m s p s g Rigotti NA. Helping smokers with cardiac disease to abstain
ba , a d p v d b hav al v sa d rom tobacco a er a stay in hospital. CMAJ. 2009;180(13):
pha ma h apy ( a d a d) ba 1283–1284.
ssa .
Shapiro B, et al. A primary care approach to substance misuse.
D adm s av s m l v am s pa sw h Am Fam Physician. 2013;88(2):113–121.
al h l d p d a d/ w hd awal. o al m l v am s Spitho S, Kahan M. Primary care management o alcohol
a s h maj y pa s. iV h am may use disorder and at-risk drinking part 1: screening and
b d a d h s s sp d hav g W k assessment. Can Fam Physician. 2015;61:509–514.
phal pa hy.
Spitho S, Kahan M. Primary care management o alcohol use
P vd d a a d s l g s h l-ag h ld a d disorder and at-risk drinking part 2: counsel, prescribe,
ad l s s ga d g ba , al h l a d ll d g s . connect. Can Fam Physician. 2015;61:515–521.
S all ad l s al h l m s s a d p v d p s s T ompson A, et al. Pharmacotherapy or alcohol dependence:
gag d sky haza d s d k g w h b b hav al astrati ed approach. Pharmacology & T erapeutics. 2015;
s l g v s d al h l m s s . 153:10–24.
S all p g a w m al h l m s s . P v d Volpp KG, et al. A randomized, controlled trial o nancial
s l ga d s s d m s s . F al al h l incentives or smoking cessation. N Engl J Med. 2009;
sy d m s h l ad g a s ll al d sab l y h 360(7):699–709.
u d S a s. Walley AY. HIV prevention and treatment strategies can help
address the overdose crisis. Prev Med. April 2015. Available
at http://dx.doi.org/10.1016/j.ypmed.2015.04.004.
BIBLIOGRAPHY Waterman EH, et al. Reducing etal alcohol exposure in the
American Academy o Family Physicians. Policies: substance United States. Obstet Gynecol Surv. 2013;68(5):367–378.
abuse and addiction. 2014. Available at http://www.aa p. West R, et al. Placebo-controlled trial o cytisine or smoking
org/about/policies/all/substance-abuse.html. cessation. N Engl J Med. 2011;365:1193–1200.
Ethics
Mark A. Graber
CASE 26.1
A 54-year-old married emale, Charlene, has insulin-dependent
diabetes and has seen you or her care or the last 7 years.
In the last year, she has developed diabetic retinopathy and
neuropathy. o your great rustration, Charlene continues to
resist the recommended li estyle changes required to control
her diabetes.
She is a casual, riendly woman known as the “candy
lady” in her neighborhood where she lives with her hus-
band o 30 years. She loves children and volunteers at the
local elementary school, where she is well known or a quick
smile, a reassuring hug, and a piece o candy in her large,
ull pockets. In act, she is noted during most o her appoint-
ments to be munching on M&M’s—her avorite candy. She
has had dietary consults and many education-oriented doc-
tor appointments but says, “I know I shouldn’t eat the way
I do, but I just don’t have the heart to change who I am, even
i it does help my eyes and legs. Who I am is about what I eat
and do.”
You wonder about Charlene’s capacity or decision-making,
given her rank noncompliance with care, even in the setting o
serious complications rom her diabetes.
Question 26.1.1 All o the ollowing variables are necessary
in decision-making capacity (DMC) EXCEPT:
A) Ability to communicate a choice.
B) Voluntary choice.
C) Understanding o the variables involved in the decision.
D) Ability to appreciate the personal impact o choices.
E) Family agreement that the patient is competent.
Answer 26.1.1 The correct answer is “E.” All o the other options
are considered important or determining DMC. Certainly amily
concerns need to be addressed but amily agreement has nothing
to do with determining a patient’s competence. One additional
necessary element or DMC is the ability to reason about the
options in the setting o personal values.
688
26
Question 26.1.2 What is the most relevant piece o in orma-
tion in Charlene’s account that suggests that her capacity
is intact?
A) T erapeutic alliance with you despite noncompliance with
treatment recommendations.
B) Integration into community relationships, including a stable
marriage and responsibilities in the elementary school.
C) Expression o placing perceived sel -identity as a higher
priority than control o diabetes and its complications.
D) Awareness that her dietary choices are associated with
symptoms o eye disease and neuropathy.
E) Flagrant disregard or medical recommendations by eating
candy while at her appointment.
Answer 26.1.2 The correct answer is “C.” While several o
these variables are relevant in assessing DMC, the capacity or
DMC is typically thought o in a stepwise ashion, starting with
(1) ability to communicate a choice, then (2) basic understand-
ing o the variables, then (3) ability to appreciate the personal
impact o choices, and nally (4) the ability to reason about the
options while considering personal values. T is last step is not
only the most complicated but also the most strongly indicative
that DMC is intact.
Question 26.1.3 Which o the ollowing is TRUE about DMC?
A) Patients who have been ound legally incompetent do not
have DMC.
B) A patient’s DMC may vary according to the circumstances o
the situation.
C) A minor’s DMC is not clinically relevant since there is a
surrogate who bears the responsibility or decision-making.
D) DMC should not be evaluated in cases in which the patient
makes an unconventional choice.
E) Patients with psychiatric disease, who are committed to a
treatment acility, do not have DMC.
Answer 26.1.3 The correct answer is “B.” DMC is not an all-or-
none distinction but can vary widely rom case to case or setting

to setting. Even patients who have been declared legally incom-
petent or who have been legally and involuntarily committed
may still have a measure o DMC. Moral theory typically urges
clinicians to consider the wishes and reasoning o their patients
as morally and clinically relevant, regardless o the placement o
a legal guardian or the state as a surrogate decision maker. DMC
may ultimately be overridden in certain kinds o legal circum-
stances, but it should not be done lightly as it suggests a unda-
mental denial o patient autonomy. As a result, many patients
with psychiatric illness still have the right to make choices, even
with diagnoses such as schizophrenia. Making unconventional
choices can sometimes be a marker that DMC is not intact but
does not automatically lead one to this conclusion (e.g., Jehovah
Witness and blood trans usions; re using blood is unconven-
tional but DMC may be intact). Finally, though minors techni-
cally cannot make many healthcare choices, their wishes should
be taken into consideration as they are o en able to articulate a
pre erence. In minors, this is termed “assent,” rather than con-
sent. Children may not be able to understand enough to consent
on their own but they can “assent” (or protest) a particular plan
o treatment.
Charlene continues to have a slow decline over time but
remains in good spirits despite the complications o her
uncontrolled diabetes. One day her husband brings her to
the emergency department. He had ound her in the bath-
room, unconscious, and called an ambulance. She has had a
stroke and remains unresponsive, on ventilation in the ICU.
Her prognosis is poor.
Question 26.1.4 What are appropriate considerations or
making a treatment decision about end-o -li e care or
Charlene?
A) Oral statements to her husband about her end-o -li e care.
B) Her husband’s wishes or her care as designated proxy
healthcare decision maker.
C) Written advance directives.
D) Oral statements to her physician about her end-o -li e care.
E) All o the above.
Answer 26.1.4 The correct answer is “E.” Written advance
directives are considered the most binding, although all o these
considerations are relevant in making end-o -li e decisions.
Question 26.1.5 Which o the ollowing statements can be
used to describe medical utility?
A) No worthwhile goals o care can be achieved.
B) T e likelihood o success is very small.
C) T e patient’s quality o li e is unacceptable.
D) All o the above.
Answer 26.1.5 The correct answer is “D.” All o the above
meanings have been explicitly or implicitly drawn into discus-
sions about medical utility. For this reason, many theorists have
objected to the use o the term “ utility” as a justi cation or
decisions and urge clinicians to be precise about the concerns
that arise in a given patient’s clinical situation. Another de nition
CHAPTER 26 • Et h ic s 689
o “ utility” is trying to make it through this book without vast
quantities o ca eine.
A er discussion with her husband, you decide to discontinue
ventilation. Charlene dies.
Question 26.1.6 This intervention is appropriately consid-
ered:
A) Active, nonvoluntary euthanasia.
B) Physician-assisted suicide.
C) Withholding medical intervention.
D) T e principle o double e ect.
E) Withdrawing medical intervention.
Answer 26.1.6 The correct answer is “E.” While the answer
might seem intuitive to you, many persons (including physi-
cians) do not recognize the di erences between these various
interventions. Active euthanasia (“A”) is when the physician
both supplies the means o death and is the nal human agent
in the events leading to the patient’s death (e.g., the physician
administers the lethal drug). Whether or not active euthanasia
is voluntary, involuntary or nonvoluntary depends on the DMC
o the patient. Assisted suicide (“B”) occurs when the physician
provides the means o death but the patient carries out the act,
such as taking an overdose o phenobarbital. Withholding med-
ical intervention (“C”) means not initiating care or a disease
state such that the disease itsel results in death (e.g., not placing
a gastric tube or arti cial eeding in a patient with end-stage
dementia). Withdrawing medical intervention (“E”) means
discontinuing an intervention that has already been used,
although the disease state itsel results in death with the inter-
vention’s discontinuation. T e principle o double e ect (“D”)
is an ethical theory that suggests that i there is an unintended
bad outcome (e.g., death) while pursuing an intended purpose
(e.g., pain relie ), there is diminished moral responsibility or
the unintended outcome. T is principle is sometimes used to
justi y the use o high-dose opiates or sedatives in patients with
intractable pain, even when the unintended e ect is respiratory
depression and death.
Question 26.1.7 Which o the ollowing is TRUE about the
role o law in li e -sustaining interventions?
A) Courts must be involved in decisions a er a patient has been
declared to not have capacity.
B) Li e-sustaining treatment may be withheld only i patients
are terminally ill or permanently unconscious.
C) Physicians may ace criminal charges or providing appro-
priate palliative care and not treating the underlying disease.
D) T e most prudent legal advice is to continue treatment in
medically utile cases.
E) T e law presents ew barriers to physicians withholding
li e-sustaining interventions.
Answer 26.1.7 The correct answer is “E.” Sometimes physi-
cians inappropriately provide treatment to patients who have
made their end-o -li e choices clear and have stated that they
do not want prolongation o li e. Respecting the patient’s prior
690 FAMiLY MEDic iNE EXAMiNAt iON & BOARD REViEW
wishes will not result in legal liability or the physician, but
the converse is not true; one can be legally liable or treating a
patient who does not want treatment (e.g., trans using a Jeho-
vah Witness patient who re used trans usion). “A” is incorrect.
A er a patient is declared to not have capacity the courts no
longer need to be involved, as a legal surrogate is appointed by
the court to make decisions or the patient. “B” is also incorrect
as treatment may be withheld at any time at the request o a
competent patient.
Objectives: Did you learn to . . .
• Evalua e a pa en ’ DMc ?
• Re ogn ze ow DMc may vary ba ed on e pa en and e
l n al e ng?
• iden y ome e al ue n end-o -l e are?
• De r be med al u l y and under and mpor an e n
mak ng e al de on ?
HELPFUL TIP:
Do “non ompl an ” pa en make you ru ra ed and
angry? Ju n ernal ze e pr n ple o pa en au ono-
my. We an make ugge on , bu up o e pa en
o de de ow o a on our adv e. in a , er
right o do o. Under and and you w ll ave a lo
le ear burn.
QUICK QUIZ: AN Et h ic AL DiLEMMA
You are seeing George, a 30-year-old, HIV-positive male, or
routine care and to assess his HIV status. During your conver-
sation, he mentions that he is in a new relationship—a relation-
ship that he hopes will become long term. T ey use condoms
“some o the time” but have unprotected sex on a regular basis
when there is no condom available. When you ask him whether
or not he has disclosed his HIV status to his partner, he states
that he has not done so and will not do so because o the ear
his partner will leave him. He also orbids you to contact his
partner to noti y her o his HIV status.
Your response in this situation is to:
A) Attempt to convince George to noti y his partner o his HIV
status.
B) Depending on your state, contact the health department and
have them ollow up on the patient’s sexual contacts.
C) Contact the partner directly and let him/her know o
George’s HIV status.
D) Maintain strict con dentiality and do not warn George’s
partner nor report his HIV status regardless o the situation.
E) A, B, and C.
The correct answer is “E.” “A” is clearly correct. Anything we
can do to convince George that it is critical he noti y his part-
ner o his HIV status (short o coercion) should be done. “B”
is correct but may vary by state. As o this writing, all 50 states
and most territories have con dential, name-based reporting or
HIV. However, patients can still be tested anonymously which
precludes reporting and can circumvent reporting laws. For this
same reason, “D” is incorrect. T ere are mandatory reporter laws
on the books. “C” is also correct. Although this is somewhat con-
troversial and there are con icting duties (the patient’s autonomy
and con dentiality vs. the duty to warn the partner), we have a
duty to protect the patient’s partner. In cases o a direct threat
to a known individual, we have a duty to warn the individual. A
more clear-cut case would be i George were threatening to shoot
his partner and storms out o the of ce with a gun. While this is
a more immediate example, the same principle holds. Clearly,
we must not take the breaking o patient con dentiality lightly.
And, we must in orm the patient o our course o action. You
may want to set a time rame or George to noti y his partner
with the understanding that i he does not do so, you must.
Alternatively, i all we know is that George is HIV positive
and have no knowledge o his partner(s), we cannot publicize
George’s HIV status in the local press in order to “protect the
public.” But i we have a speci c name o an ongoing sexual
partner, we have a duty to warn that individual which competes
with our duty to maintain con dentiality with George.
CASE 26.2
Robert, a 27-year-old married nurse rom your hospital, is
re erred to your emergency department or an urgent evalua-
tion by his supervisor. In the past 2 weeks, he has been noted
to be increasingly distressed while at work, with occasional
tear ulness, distractibility, and irritability.
During the initial assessment, Robert reveals that there is
a speci c reason that he has been so preoccupied. He indi-
cates that 2 weeks ago he was jailed or operating a vehicle
while intoxicated and that he eels ashamed. He is a raid that
his coworkers have read about it in the newspaper, although
no one on his oor has indicated that this is the case. T is
is his rst legal in raction o any kind and he describes it as
humiliating.
On urther questioning, Robert indicates that he uses
alcohol regularly. While it has not overtly a ected his work
as ar as he can tell, it has caused signi cant marital stri e. He
reports that his pattern is to stop by the bar on the way home
rom work to “relax and let go o the hospital stu that I worry
about.” He typically drinks three beers and then drives home,
where he continues to drink beer throughout the evening. He
notes that his wi e and kids complain that he is emotionally
absent and even irritable with them, but he says that his am-
ily simply doesn’t understand the stress o the workplace and
his need to “ orget about it or a ew hours.” He and his wi e
have started arguing lately about his alcohol use, especially
since the driving charge. He takes special exception to her
stating that he is an “alcoholic.”
As you take the history, Robert begins to be more guarded
in his responses and more restricted in his a ect. Suddenly,
he blurts out, “I don’t think I’m an alcoholic, but I don’t want
you to put anything in my record about any o this stu ! And
I want you to tell my supervisor that there are some personal
problems going on at home and that I’ll be ne in a ew days.”

Question 26.2.1 Which o the ollowing statements is TRUE
about your obligation with regard to documentation in the
chart?
A) You are obligated to document the visit as it occurred so ar
as the medical acts are concerned, including the concern
about alcohol abuse.
B) You can enter incorrect in ormation into the chart in order
to protect the patient.
C) You are under no obligation to document anything said and
can withhold in ormation rom the chart at the patient’s
request.
D) Hospital administration or legal counsel should be involved
i in ormation is going to be purpose ully le out o the
chart.
E) You can lie in the medical record . . . we’re pretty sure perjury,
liable, and slander don’t apply to doctors.
Answer 26.2.1 The correct answer is “A.” T e ethical princi-
ples o bene cence, nonmale cence, and justice drive the deci-
sion here. A patient may legitimately ask or nonactive medical
problems (e.g., distant history o sexual abuse) to be withheld
rom current documentation o an active problem (e.g., allergic
rhinitis—by the way, kudos on your detailed history-taking).
However, a patient cannot legitimately ask to have in ormation
withheld rom the record i that in ormation is pertinent to an
ongoing condition currently being evaluated and treated. In this
case, Robert is receiving care simply by virtue o being seen in the
emergency department and disclosing the chie complaint and
its associated variables. It is important or you to be orthcoming
in explaining why the in ormation may not be withheld rom
the medical record and also in reassuring him that nonrelevant
medical in ormation will be omitted rom the record i he eels
that this is necessary. For example, the speci cs o the argument
with a wi e need not be detailed beyond the comment that there
is nonviolent marital con ict over the patient’s alcohol use—
important because it supports an alcohol abuse disorder. Fur-
thermore, many institutions have speci c policies on manag-
ing sensitive medical in ormation and there may be a ormal
mechanism or increasing the security o the patient’s medical
record.
Question 26.2.2 Why is protection o conf dentiality impor-
tant in medical practice?
A) It shows respect or patient autonomy.
B) It helps prevent stigmatization and discrimination against
patients based on private medical issues.
C) It helps solidi y trust within the physician–patient relation-
ship.
D) It helps establish a boundary between the physician–patient
relationship and the rest o the medical system.
E) All o the above.
Answer 26.2.2 The correct answer is “E.” T e physician–
patient relationship is a long-honored tradition in medicine
that is increasingly ragile in a medical system with numerous
competing obligations. Nevertheless, it is prudent to remem-
ber the aspect o the Hippocratic Oath, which states, “What
CHAPTER 26 • Et h ic s 691
I may see or hear in the course o the treatment . . . which on
no account one must spread abroad, I will keep to mysel , hold-
ing such things shame ul to be spoken about.” T is is not only
important to the tradition o medicine itsel but also to the
physician–patient relationship. T ere is no doubt that loss o
con dentiality may cause harm to the patient when others are
in possession o con dential medical in ormation. Such harms
may be as overt as denying medical coverage or certain genetic
conditions or as subtle as devaluing a person seen waiting to
see the psychiatrist.
Question 26.2.3 Which o the ollowing are legally pro-
tected exceptions to the rule o maintaining patient con-
f dentiality?
A) Reporting tuberculosis to public of cials without patient
consent.
B) Warning a third party at risk o imminent and serious bodily
harm rom the patient without patient consent.
C) Reporting a patient’s alcohol abuse to a work supervisor
without the patient’s consent.
D) A and B.
E) All o the above.
Answer 26.2.3 The correct answer is “D.” Under current
national and state laws, physicians are mandatory reporters
o some in ectious diseases and o intent to harm another. In
most other cases, provision o medical in ormation without the
patient’s written consent is not legally protected, although there
may be cases in which it is elt to be morally justi able. Physicians
need to weigh violations o patient con dentiality very care ully,
even when legally sanctioned. Ethicists typically agree that i a
physician is going to compromise a patient’s con dentiality or
an overwhelming moral obligation that, in respect or patient
autonomy, the patient needs to be noti ed. In many situations in
which a physician hopes to communicate con dential in orma-
tion to a third party even when the patient is unwilling, a pro-
cess o education and negotiation with the patient occurs such
that respect or autonomy is acknowledged while simultaneously
making the patient aware o competing moral obligations.
HELPFUL TIP:
h av ng a axed, e-ma led, or ma led repor on a n ng a
pa en ’ on den al med al n orma on m d re ed
o an un n ended re p en not legally pro e ed. Be
au ou abou ran m on o pa en n orma on.
Question 26.2.4 Which o the ollowing inter eres with pro-
tecting patient conf dentiality in the medical structure?
A) Involvement o managed care organizations in patient care
and medical payments.
B) Electronic records and transmissions.
C) Group practices and/or teaching hospitals with multiple
care providers.
D) A and B.
E) All o the above.
692 FAMiLY MEDic iNE EXAMiNAt iON & BOARD REViEW
Answer 26.2.4 The correct answer is “E.” While individual
physicians and patients continue to prize the tradition o
respect or con dentiality, the multiple players in health care
make it nearly impossible to restrict all in ormation to the
dyad o physician and patient. Insurance companies will not
provide payment without, at least, in ormation about the diag-
nosis, and notably, insurance companies are not legally bound
by the same codes o conduct that apply to physicians regard-
ing patient privacy. Electronic records and transmissions by
e-mail, cellular phones, axes, and other means are much more
easily accessed by the curious or unintended recipients who
have no reason to have con dential in ormation. Open wait-
ing rooms and multiple providers o care mean that larger and
larger numbers o the community are aware that a patient is
being seen in certain clinics or certain purposes. While patient
records are not o en considered a con dentiality issue, the
reality is that once in ormation is in written orm, it is more
dif cult to control who might, either now or in the uture, have
access to the details o the report. For this reason, some physi-
cians try to err on documenting only that which is considered
absolutely necessary to patient care, although the distinction
between the “absolutely necessary” and unnecessary can be a
dif cult line to draw in the sand, especially without the abil-
ity to appreciate how multiple variables may play out in the
patient’s uture medical care.
Back to the patient at hand . . . Robert is asking you to be
deliberately deceptive with the supervisor. You disagree
with this.
Question 26.2.5 Which o the ollowing is FALSE?
A) rust in the physician–patient relationship depends on
allowing the patient to make such a directive about com-
munication with outside persons.
B) A physician who establishes a precedent or deception may
be expected to practice deception in a uture situation in
which the harms greatly outweigh the bene ts.
C) A physician who deceives may undermine general trust in
the pro ession.
D) All o the above.
Answer 26.2.5 The correct answer is “A.” Another way
o phrasing the question is, “What drives a physician to
be honest even when what the patient really wants is not
honesty?” Will the patient trust you more i you are decep-
tive or him? Will this help him (aside rom allowing him to
keep his job)?
T e physician–patient relationship is generally not consid-
ered an adequate reason to lie to a third party about the nature
o a patient’s illness and treatment. T ere has been concern
that a physician who deceives a third party, even in the imme-
diate interest o the patient’s con dentiality or other concerns,
establishes himsel or hersel as a physician who may not be
trustworthy in other matters. A patient may not consider this
at the time a deception is requested. T ese kinds o ripple
e ects rom the decisions o an individual physician can a ect
the pro ession in general, ultimately producing ears that phy-
sicians will take the sel -serving path rather than the higher
moral ground.
You tell Robert that he has alcohol dependence and then pro-
vide education about the diagnosis and treatment options.
You recommend outpatient treatment in Alcoholics Anony-
mous (AA) and a chemical dependency program. Robert
agrees, more or the sake o his amily stability rather than
because o any true insight into the severity o his problem.
You then arrange or ollow-up with one o your partners
(you’ve been selected as a contestant on the next Survivor and
get to escape to a tropical island).
At the next appointment, Robert meets his new physi-
cian, Dr. Pincus. At this appointment, Robert indicates that
he did attend two AA meetings but was very uncom ort-
able with the aspect o the 12-step program that requires
acknowledging a “higher power.” Robert indicates that he is
an atheist and secular humanist, believing that the locus o
sel -control comes rom within the individual human spirit.
He has re used to continue in AA due to his rejection o its
theistic oundation. He has had no urther legal problems
and reports that work is still going ne, with diminished
irritability once he resolved in his mind that his coworkers
were unaware o his previous driving violation. However, he
continues to drink six to nine alcoholic beverages per night
and admits that he occasionally needs a shot o whisky in the
morning to “make sure I don’t lose it with all the work stress”
(this is where his sel -control theory really comes together).
He also works a night shi about once per week and does use
approximately the same amount o alcohol be ore beginning
the night shi , although he denies being intoxicated while
on the job on these nights (“six beers just get me started”).
He doesn’t think this is a problem because “things are quiet
at night and everyone just helps each other keep the patients
com ortable.” He reports that his amily is satis ed with the
decrease in consumption and that he considers the matter o
alcohol abuse resolved.
Dr. Pincus has had her own problems with alcohol in
the past. She has had a rocky course over the past many
years but ound AA to be very help ul. She has become very
active in her Jewish synagogue and community, where she
receives support and is accountable to her riends. Her
own alcohol history has been marked by dif culty with
alcohol bingeing, such that when she starts to drink, she
drinks to intoxication. Only with aggressive honesty at a
pro essional-group AA, as well as a substance abuse proto-
col through the state board o medical examiners, does she
eel that she’s been able to remain completely abstinent or
the last 4 years.
Dr. Pincus is considering revealing to Robert some o her
own struggles as a health-care pro essional with a substance
abuse disorder. She believes that this will help him reevalu-
ate the role o AA in sobriety and the importance o very
tight control o alcohol consumption to prevent relapsing
illness.

Question 26.2.6 Sel -disclosure is best described as involv-
ing the ethical issues o :
A) Deception and nondisclosure.
B) Privacy and boundaries.
C) In ormed consent.
D) Impaired colleagues.
E) Autonomy.
Answer 26.2.6 The correct answer is “B.” T ere are explicit
and implicit boundaries that exist between a physician’s pri-
vate experiences and the physician–patient relationship. One
o these boundaries has to do with preventing physician needs
and private matters rom encroaching into the visit in a way
that is not therapeutic to the patient and does not respect the
physician’s boundaries. While it would appear that Dr. Pincus
has therapeutic reasons— or Robert, not or hersel — or cross-
ing the boundary o sel -disclosure, both physician motivation
or sel -disclosure and the immediate and potential e ects o the
sel -disclosure need to be weighed very seriously be ore private
matters are revealed. I there is even a potential o harm, cross-
ing the boundary in this way should be considered a violation o
pro essional norms.
Question 26.2.7 How could Dr. Pincus appropriately respond
to Robert’s re usal to participate in AA on the basis o his
religious impulse?
A) “AA is still shown the best intervention or preventing relaps-
ing alcohol use. I hope you can go and get something out
o it without acknowledging your acceptance o the ‘higher
power’ explicitly.”
B) “AA has important group support rom others who under-
stand how dif cult it is to stop using alcohol. It is not meant
to be religious, but rather a community o care.”
C) “I have ound both AA and a theistic world-view to be very
help ul in understanding my own powerlessness to control
some o my behaviors. Would it be help ul to you to hear
more about this?”
D) “I understand how the religious aspect o AA is inconsistent
with your own philosophy. Would you be willing to investi-
gate non-religious group meetings or alcohol abusers?”
Answer 26.2.7 The correct answer is “D.” AA is an example
o a prescribed treatment that involves an active theological
component. AA’s rst step involves acknowledgment o a higher
power, traditionally invoking a speci c monotheistic concep-
tion o the divine as a necessity to surrendering the illusion
o control. In the interest o respecting a patient’s religious
rights in a diverse community, and o optimizing treatment
options, it would be disrespect ul and ine ective to have the
patient participate in AA, while ignoring the rst step o
the program and the oundational philosophy o AA. While
there are ewer studies about the ef cacy o nonreligious alco-
hol treatment groups, it is appropriate to respect Robert’s belie s
by investigating nonreligious alternatives. As to option “A,” the
Cochrane database concludes, “No experimental studies
unequivocally demonstrated the e ectiveness o AA.”
CHAPTER 26 • Et h ic s 693
Whether or not sel -disclosure o one’s own religious belie s
is appropriate is an important question. As mentioned in the
discussion in the question above, it is very important or the
physician to measure the intent o the disclosure. Also, physi-
cians need to be exquisitely sensitive to the power di erential
that exists between a physician and a patient such that strong
individual viewpoints might become threatening or coercive
in the physician–patient relationship. In certain religious tra-
ditions, sharing one’s aith is an important step, demonstrat-
ing courage and integrity; nevertheless, physicians should be
strongly cautioned to pay heed to the virtue o practical wisdom
and the unique circumstances o the medical relationship that
makes proselytizing most o en inappropriate. A better strategy,
i a physician eels that a patient might be seeking additional
spiritual or philosophical direction, is to ask open-ended ques-
tions and then make an appropriate re erral to pastoral care or a
spiritual counselor who will be sensitive to the issues the patient
has raised as relevant.
Question 26.2.8 Which o the ollowing is true about inter-
vening with an “impaired colleague,” like Robert?
A) Impairment should be reported only to a state licensing
board i the colleague’s patients are placed at known and
documentable risk.
B) Because alcohol abuse is a con dential matter, it is inappro-
priate or a treating physician to report a colleague’s impair-
ment to a licensing board.
C) Removing a colleague rom direct patient care and increas-
ing supervision during patient care are reasonable rst-
step interventions or a colleague who is actively engaged
in substance treatment (e.g., a report has already been
made).
D) It is pre erable to contact a state licensing board directly
as opposed to discussing the matter with the patient
or institutional administration. his protects both the
reporter and the colleague rom unnecessary negative
repercussions.
Answer 26.2.8 The correct answer is “C.” Legal statutes on
reporting impaired colleagues vary rom state to state, with
some state laws making physicians mandatory reporters o
impaired physician colleagues, while others simply recom-
mend reporting. Furthermore, state laws are even less pre-
scriptive with regard to non-physician health pro essionals
with impairments. Any impairment should be treated seri-
ously, pre erably with support rom the institution’s adminis-
tration. It is imperative to protect patients rom harm. While
reporting the impaired colleague may result in anger and dis-
appointment rom the colleague or even supervisors who are
reluctant to tackle such a dif cult question, physicians should
consider the needs o vulnerable patients and the patients’
rights to adequate care.
Con dentiality adds an additional ethical dimension when
an impaired colleague reveals his or her impairment to his
treating physician. In an e ort to respect patient autonomy,
physicians will o en urge impaired colleagues to report
694 FAMiLY MEDic iNE EXAMiNAt iON & BOARD REViEW
themselves as well as voluntarily engage in treatment proto-
cols. Many states have less-restrictive policies or treatment
and monitoring or impaired colleagues who sel -report. I
a physician intends to report her patient’s impairment with-
out the consent o the patient, the physician is obligated to be
truth ul with the colleague about her intentions and rationale
or reporting.
Question 26.2.9 A colleague may be impaired in her prac-
tice by all o the ollowing EXCEPT:
A) Substance use.
B) Major depression.
C) Dementia.
D) De cits knowledge.
E) Barely passing her board examination.
Answer 26.2.9 The correct answer is “E.” Well, she “barely
passed,” and that’s what she needs to achieve to be certi ed. All
o the others, whether acute or chronic, may impair a health
pro essional’s ability to practice, but none o these automati-
cally imply global impairment in medical practice. Each has
its own implications or a colleague’s medical practice. Special
attention should be given to the colleague’s actual and possible
consequences in practice, given her speci c job requirements
and compensatory skills/supports, while assessing the presence
and degree o impairment. One might say that dementia is OK
in physicians working or insurance companies (or at least it
seems so!).
Objectives: Did you learn to . . .
• iden y w a em are requ red or n lu on n e med al
re ord?
• Re ogn ze e mpor an e o pa en on den al y and
under and w en on den al y m g be broken n order o
ul ll o er e al obl ga on ?
• Re ogn ze ob a le o pro e ng pa en on den al y?
• De r be e mpor an e o nd v dual and o e al ru
n nd v dual p y an and e med al pro e on a a
w ole?
• De r be e e al pr n ple nvolved n el -d lo ure?
• iden y an mpa red olleague and de erm ne ow o be
n ervene?
CASE 26.3
Anne is a 19-year-old single emale presenting or her rst
prenatal visit. She is G1P0, and roughly 10 weeks gesta-
tion by last menstrual period. She is new to your practice.
Anne has had no medical care at this acility and no physi-
cian appointments since childhood. In recollecting the past
medical history, Anne reveals that she has had several rst-
degree emale relatives who have been diagnosed with breast
and/or ovarian cancer: her mother, two maternal aunts, and
a maternal grandmother. A great aunt also died young o
unknown causes. Anne is unsure o the workup that they had,
but there was signi cant morbidity and mortality as a result
o the illnesses. It was as i God were playing with a cosmic
grenade launcher when it accidently went o and blasted
her amily apart. “Oh, well. Genetic roulette,” she says. Anne
only recently became aware o this amily history when her
mother and aunts were diagnosed. When you ask i she has
discussed genetic risks or breast cancer, Anne looks at you
blankly and replies, “No.”
Anne has been in a stable relationship with her boy riend,
Jordan, or 2 years. T ey cohabitate and are engaged, but have
not set a wedding date. Anne has completed high school and
works in telemarketing while applying to art schools. T e
pregnancy was not planned, but she and Jordan are thrilled,
even i a little nervous, about having a baby.
Being an extraordinarily astute clinician, you are con-
cerned about BRCA1 and 2 genes. In amilies with a high
incidence o breast and ovarian cancer, mutations in BRCA1
are associated with an 85%li etime risk o developing breast
cancer and a 50%risk o ovarian cancer.
You wonder i this is the best time to bring up genetic con-
cerns with Anne, given Anne’s concurrent transition with an
unplanned pregnancy.
Question 26.3.1 Which o the ollowing is/are true about
disclosure?
A) Nondisclosure is not justi able due to ears that a patient
will be distressed by the in ormation, unless disclosure
might cause death (e.g., suicide at hearing a diagnosis o
cancer).
B) Regardless o the consequences, nondisclosure could be
considered deception and would be morally wrong on the
basis o this intrinsic eature.
C) Disclosure is important because it respects patient auton-
omy and optimizes a patient’s ability to make an in ormed
choice.
D) Nondisclosure may be a sign o paternalism rather than
bene cence.
E) All o the above.
Answer 26.3.1 The correct answer is “E.” T ere are a variety
o moral theories which comment on whether or not deception
or nondisclosure is morally appropriate. Most theorists rely on
the principle o respect or patient autonomy, such that a per-
son who has incomplete in ormation is not able to act reely in
making a choice or hersel . “Consequentialism” is also a com-
monly used moral theory, suggesting that it is not the intrinsic
nature o the act itsel but the consequences that ollow deter-
mine whether the act is good or evil (as in “the end justi es the
means”). In virtue ethics, by comparison, the nature and moti-
vation o the act are very important as a re ection o the physi-
cian’s character and habits. In virtue ethics, deception is morally
blameworthy because it is comparable to lying. In virtue ethics,
motivation is also an important issue to judge the goodness o
the action. Answers “B” and “C” both make re erence, at least in
part, to virtue theory.

Question 26.3.2 Which o the ollowing is FALSE about test-
ing or genetic conditions?
A) In ormed consent or genetic testing should be taken more
seriously and ormally than other kinds o blood testing,
such as obtaining a hemogram.
B) Physicians should ask patients what they would do with the
di erent possible outcomes o the genetic test be ore the test
is per ormed.
C) Physicians should make a recommendation regarding
genetic testing guided by evidence-based medicine and the
patient’s speci c narrative and values.
D) Physicians should urge patients to disclose positive results to
relatives or spouses i the in ormation is pertinent medically
or emotionally to these third parties.
E) Physicians should never disclose genetic in ormation to a
third party without the consent o the patient.
Answer 26.3.2 The correct answer is “E.” Genetic testing
di ers rom other blood tests because o multiple actual and
potential risks, including personal e ects on the patient and her
amily, as well as discrimination by employers or insurers. T ere
is a shortage o ormally trained genetic counselors, and patients
rely on their physicians to not only help guide their decision
making about whether or not to per orm the test, but what to
do with the in ormation obtained. Because such testing has pro-
ound medical and/or psychosocial e ects on the patient and
amily, a discussion about disclosure should happen both be ore
and a er the test is obtained.
Con dentiality is important or many reasons, not only in
establishing and maintaining a good physician–patient relation-
ship and respecting patient autonomy but also because o the
potential discrimination and misuses o genetic in ormation
in today’s culture. However, when the risk o harm to another
related person is high and the patient re uses to disclose impor-
tant genetic in ormation, there may be adequate cause to break
con dentiality in order to prevent serious harm to the third
party; there ore, “E” is a alse statement.
HELPFUL TIP:
Many d agno and reen ng e (e.g., h iVan body,
Ps A, and b op e ) ould be approa ed l ke gene
e , a ur ng a e pa en a a lear under and-
ng o e mpl a on o e e , n lud ng ur er
d agno e ng, erap e , and progno . “W o a
e me?” you a k. We omm era e, bu ll . . .
You decide to disclose the possibility o genetic risk actors
to Anne at the rst prenatal visit and also discuss the risk
o passing genes to the etus. Anne seems overwhelmed and
asks to bring Jordan to the next visit to discuss this urther.
When Anne returns with her ancé, you discuss your con-
cerns about the BRCA1 and 2 genes and why Anne’s am-
ily history is suspicious. Jordan says, “I think you should
be tested right away, Anne. T is would totally change our
CHAPTER 26 • Et h ic s 695
uture.” Anne replies: “What are you saying? Will you leave
me i I have the gene? I can’t raise this baby by mysel !”
Question 26.3.3 Which o the ollowing statements are
appropriate to consider in promoting the patient’s best
interests?
A) Patients are vulnerable.
B) Physicians have expertise that patient’s lack.
C) Patients rely on their physicians.
D) Physicians and patients o en agree on what constitutes a
patient’s best interests, although they may di er in the way
they plan to meet those interests.
E) All o the above.
Answer 26.3.3 The correct answer is “E.” T e nature o a rela-
tionship between a physician and a patient may have as many
permutations as there are individuals. However, it is impor-
tant to appreciate the position o the patient and the need that
has pushed her to seek care. Patients are vulnerable in many
ways, and the vulnerability is enhanced by limited access to
technological and scienti c in ormation. When external vari-
ables, such as Jordan’s comment and Anne’s response, come
into play, physicians should pay attention to this narrative
and take some responsibility or establishing and maintaining
a supportive network even outside o the of ce. T is is par-
ticularly important as physicians give patients in ormation
about dif cult choices. While physicians and patients may
o en be able to negotiate a mutually acceptable alternative, an
active dialogue is important. Supports and advocates who are
amiliar with the patient’s values and wishes can be an impor-
tant adjunct to medical decision making, as long as there is
no material or psychological con ict o interests. Physicians
should not adopt a completely hands-o policy in decision-
making; rather, physicians should pay attention to supporting
the patient with real options and evidence-based variables in a
noncoercive, empowering relationship.
Anne decides not to have the test, but to have an elective
abortion “just in case I passed on a gene to the baby.” For the
sake o argument, you are philosophically opposed to elective
abortions in this scenario, but you would consider abortion
an appropriate intervention i the etus tests positive or the
gene by chorionic villus sampling.
Question 26.3.4 What is the best ethical option or you at
this point?
A) Explain that you are personally uncom ortable with abor-
tion, but in de erence to Anne’s legal rights, you will make
a re erral to another physician who is willing to provide the
elective abortion.
B) Re use to per orm or make a re erral or the abortion.
C) Re er to a “pro-li e” counseling agency.
D) ell Anne, or reasons that you do not eel com ortable
disclosing, you will no longer be able to care or her.
E) Per orm the elective abortion, despite personal convictions,
out o respect or the law and patient autonomy.
696 FAMiLY MEDic iNE EXAMiNAt iON & BOARD REViEW
Answer 26.3.4 The correct answer is “A.” Abortion is a ercely
contentious topic in the United States. Under the 1973 Roe v.
Wade decision and in subsequent rulings such as Planned Par-
enthood v. Casey, the Supreme Court has af rmed a woman’s
legal right to abort a etus. Physicians have responsibilities that
should transcend views about a physician’s own moral values,
such as ensuring that in ormed consent is practiced and that the
patient has medical care available. In ormed consent requires a
physician to provide the necessary in ormation about the vari-
ous medical choices available and to assess the patient’s emo-
tional needs. Coercion and ailure to disclose clinically relevant
in ormation is inappropriate; or example, a re erral to a pro-li e
group without in orming the patient o the counseling center’s
perspective (when known) is a orm o manipulation and ail-
ure to disclose. Abandoning the patient (“D”) without a simple
explanation is disrespect ul, although the physician should be
care ul not to coerce her in other ways while revealing personal
values/belie s.
Physicians should note that in some states there have been
rulings requiring physicians to participate in elective abortions i
working in a public aid clinic or in an area with limited physician
resources where trans er o care is not an option. Some physi-
cians or institutions (such as Catholic hospitals with clear policies
in uenced by theological statements) have practiced conscien-
tious objection and been subject to discipline o various orms,
including legal sanction. Physicians should be mind ul o com-
peting moral values, seeking support and pro essional guidance
in dif cult moral and legal cases such that they can act with integ-
rity and purpose in their roles as physicians and moral agents.
T ree years later, Anne is seen in a new clinic. She had the
abortion. Anne is now an art student and is married to Jor-
dan. Since her last clinic visit, Anne has had a prophylactic
mastectomy ollowing a positive test or the BRCA1 gene. She
has also had an elective tubal ligation. Anne wants to consider
in vitro ertilization (IVF) and has a riend, Jessica, who is
willing to donate ova. T ey put 18 embryos into cold storage,
using Jessica’s ova and Jordan’s sperm. Anne has 6 embryos
implanted, with the result o two etuses that are carried to
term. Anne decides that she does not want any more children
and contacts the lab to discard the remaining embryos, elimi-
nating storage costs. T e lab agrees and sells the embryos to a
private lab, where stem cell research is under way.
Question 26.3.5 What is NOT true about stored tissue
samples?
A) T e embryos are considered Anne’s property only as long as
she claims them.
B) Samples used or research purposes are potentially identi -
able by third parties as belonging to Jessica and Jordan.
C) issue samples may be used only or their initial intended
purpose, a er which time they must be destroyed.
D) T ird parties, such as research labs, upon discovering genetic
anomalies in tissue samples, have no legal obligation to nd
and in orm Anne, Jordan, and/or Jessica.
E) Embryos sold to a private lab may be used to establish germ
lines via destruction o the embryo.
Answer 26.3.5 The correct answer is “C.” At the time o pub-
lication, there is ongoing discussion about how to regulate use
o tissue samples. While it might seem that this is an ethical
question ar removed rom the purview o the amily physician,
patients in amily practice clinics are very requently targeted
or various research protocols due to their regular ollow-up and
easy accessibility.
Patients donating tissue samples o en give little thought to
what happens to those tissues a er they are obtained. In many
cases, tissues are banked inde nitely a er the initial research is
conducted, with various identi ers linked to the tissue poten-
tially including the donor’s gender, geographic location, educa-
tional level, amily history, or other private in ormation (e.g.,
T e Immortal Life of Henrietta Lacks). While e orts are made to
respect the privacy o the donor, there are ways to track down
the donor using even the limited identi cation in ormation
associated with the stored sample. Such means are especially
acilitated by the wide availability o personal in ormation via
the Internet.
issue samples may be collected or one purpose, but later
used or another. issue samples are very important in research
and are o en the limiting actor or studies, but should in ormed
consent include asking donors or permission or each and
every lab test run on the tissue sample? At what point, i any,
does the tissue sample become the sole property o the lab? In
the example o embryos, discarded embryos are sometimes sold
to private labs; parents using IVF technology are o en unaware
that such embryos may be used to establish a stem cell line
rom which genetically identical embryos can be created using
nuclear trans ers. Such stem cell lines are highly lucrative or
research purposes, and there has been discussion, or example,
o whether parents should be compensated in some manner
when a lab sells their discarded embryos or a research acility
develops a product using the embryonic stem cells.
HELPFUL TIP:
Fam ly p y an ould on nue o erve a advo-
a e or e r pa en . You an do o by nve ga ng
e pol e and pro edure o re ear group pr or o
allow ng a e o pa en and by ak ng ome re pon-
b l y or e n ormed on en pro e w en pa en
are volun eer ng o par pa e n re ear .
Question 26.3.6 All o the ollowing are legitimate ques-
tions and concerns about the consequences o human
somatic cell nuclear trans er, commonly called human
cloning, EXCEPT:
A) Will cloning result in increased miscarriages and de ormed
etuses, due to limitations o current technology to per orm
nuclear trans er?
B) Will cloning result in a culture preoccupied with “designer
babies?”
C) Will cloning result in a culture that devalues persons with
disabilities?

D) Will cloning increase reproductive options or same-sex
couples, diminishing value o traditional settings or repro-
duction?
E) Will cloning result in the mass production o stormtroopers
or Chancellor Palpatine’s army, thus solidi ying his control
over the galaxy, allowing him to create the First Galactic
Empire?
Answer 26.3.6 The correct answer is “E.” T e ethics o Star
Wars, should not be applied to real, live patients. All the other
choices have been raised as concerns, although there are many
more arguments on both sides o the discussion about the rela-
tive risks and bene ts.
Objectives: Did you learn to . . .
• De r be e e al ue regard ng d lo ure?
• Appre a e e many ompe ng n ere nvolved n gene
e ng?
• iden y pa en and p y an a or a af e e pa en –
p y an rela on p?
• F nd an e al and a ep able way o d agree w a pa en
and on nue o a ure a pa en ’ eal are?
Clinical Pearls
An mpa red med al pro e onal mu no be gnored.
P y an are bound by e and a e law o pro e
pa en and o e y by den y ng, a ng, and repor ng
mpa red med al pro e onal .
A k pa en abou advan ed d re ve per od ally a ou pa-
en v and w every o p al adm on. D u l v ng
w ll, durable power o a orney or eal are, re u a on
w e , and pe n erven on (e.g., eed ng ube u e) n
e appropr a e e ng.
CHAPTER 26 • Et h ic s 697
Ea pa en and ea l n al que on mu be a e ed nd -
v dually o de erm ne a pa en a de on-mak ng apa y
n a par ular r um an e. t e ame pa en may be able
o de de no o ollow a med ally nd a ed d e bu be
n apable o de d ng own d po on a er o p al za on.
Engage pa en n ared de on-mak ng regard ng
reen ng and d agno e a well a med al pro edure
and rea men .
P y an mu a n an e al manner n order o ma n a n
nd v dual ru n e p y an a well a o e al ru n e
pro e on.
Re ogn ze a pa en ave a r g o non ompl an e. W le
e p y an’ re pon b l y o prov de e be are re om-
menda on or a pa en , e pa en may re u e o ollow e
adv e o er pr or e (e.g., money, om or , avo dan e o drug
de e e ) ou rank eal n e pa en ’ de erm na on.
t ake grea are n e ran m on o pa en n orma on.
h av ng a axed, e-ma led, or ma led repor on a n ng a
pa en ’ on den al med al n orma on m d re ed o an
un n ended re p en not legally pro e ed.
BIBLIOGRAPHY
American Medical Association. Code o Medical Ethics.
Accessed on September 12, 2015, Available at
http://www.ama-assn.org/ama/pub/physician-resources/
medical-ethics/code-medical-ethics.page?
Beauchamp L, Childress JF. Principles of Biomedical Ethics.
4th ed. New York, NY: Ox ord University Press; 1994.
Campbell A, et al. Medical Ethics. 3rd ed. South Melbourne,
Australia: Ox ord University Press; 2001.
Lo B. Resolving Ethical Dilemmas: A Guide for Clinicians. 2nd ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2000.
Smith HL, Churchill LR. Professional Ethics and Primary Care
Medicine. Durham, NC: Duke University Press; 1986.
End-of-Life Care
Michelle T. Weckma a d Ma ti O. Bazelak
CASE 27.1
A 75-year-old man is admitted to the hospital or a heart
ailure exacerbation. T is is his second admission or heart
ailure within the last 6 months. His nurse asks i he is an
appropriate candidate or hospice care.
Question 27.1.1 Which o the ollowing would quali y your
patient or the Medicare hospice bene t?
A) His cardiac ejection raction is 20%, and he is dyspneic with
moderate exertion (NYHA class II heart ailure).
B) He agrees to a do not resuscitate (DNR) status in the event o
cardiorespiratory ailure.
C) He needs assistance with ambulation.
D) His implanted cardiac de brillator (ICD) has red once in
the past year.
E) He has had escalating cardiac hospitalizations despite opti-
mal medical management.
Answer 27.1.1 The correct answer is “E.” I your patient has a
terminal disease with declining unction, worsening symptoms,
worsening laboratory tests, or escalating hospitalizations, he or
she probably quali es or hospice. “A,” a low cardiac ejection
raction (typically < 20%), is a recommended criterion or heart
disease but must be accompanied by dyspnea at rest (class IV
heart ailure). “B” is incorrect. Despite popular belie , a hospice
patient need not agree to a DNR status; however, hospice agen-
cies are permitted to have di erent admission criteria and some
require a DNR status or admission. Check with your local hos-
pice agencies. Regardless, you should have a rank discussion
with the patient about the role o aggressive resuscitation and
the goals o hospice care. “C” is also incorrect. While a decline
in unctional status is a strong indication o worsening progno-
sis, it is not automatically a criterion. Most patients with heart
ailure need assistance with at least our activities o daily living
(ADLs) be ore having a prognosis o death within 6 months.
“D” is incorrect. Patients with ICDs are eligible or hospice,
and whether or not it has red does not impact enrollment
698
27
decisions. It is important to talk about the ICD, ideally be ore
a patient approaches the nal weeks/days o li e. Many patients
choose to have it disabled once they enroll in hospice. I an ICD
is not disabled, it is important that the hospice sta be aware
o it and know what to do as it will re when the patient dies,
which can be distressing or both the patient and the amily.
HELPFUL TIP:
As opposed to a ICD, a pacemake does ot cause dis
t ess (shocks) du i g the dyi g p ocess; howeve , i the
patie t’s ca diac hythm is completely depe de t o
the pacemake , the the pacemake is co side ed to be
li e p olo gi g.
HELPFUL TIP:
Although p og osis may be the most di icult task a
physicia aces, a attempt at p og osis i patie ts
with a te mi al ill ess may help them. The simple ques
tio “would you be su p ised i this patie t died i
the ext yea ?” is a good sc ee i g tool a d has bee
show to be a easo ably accu ate way to p edict who
might be e it om a hospice e e al.
Your heart ailure patient is currently on maximal medi-
cal management with an ACE inhibitor, beta-blocker, loop
diuretic, aldosterone antagonist, long acting nitrate, hydrala-
zine, and a dual chamber ICD. He wants to discuss the man-
agement o his cardiac therapies in relation to hospice.
Question 27.1.2 Which statement is true about cardiac
therapies or patients with heart ailure in hospice?
A) Hospice will not enroll patients on intravenous inotropic
support (such as dobutamine or milrinone in usions).
B) Oral cardiac medications like beta-blockers and diuretics
should be stopped because they are unlikely to provide any
bene t to quality o li e.

C) A uid restriction is no longer relevant once a patient enrolls
in hospice.
D) Hospice will not enroll patients who have not deactivated
their ICD.
E) None o the above
Answer 27.1.2 The correct answer is “E” none o the above.
Many o the therapies or patients with advanced heart ailure
provide symptomatic relie and improve quality o li e. Just
as you would do with any other advanced illness, a thorough
evaluation o each medication and intervention should occur
with the goal o determining i that intervention will contribute
to your patent’s overall goals. Physicians need to negotiate the
balance between bene t and burden o each individual ther-
apy. Although o en a surprise to physicians, “A” is incorrect.
A patient can have continuous inotropic in usion and still be
enrolled in hospice. Some heart ailure patients are dependent
on inotropes and require them to maintain a certain level o
quality o li e, and they are willing to accept the trade-o s o
having a continuous in usion to maintain that quality o li e. Be
aware that inotrope in usions do not prolong survival (in act
they shorten survival compared to no inotropes). T e burden
o inotrope in usions include: cost, risk o line in ections, and
increased risk or arrhythmia.
Hospice agencies are required to provide treatment to man-
age symptoms related to the terminal condition and many hos-
pice agencies utilize ormularies in order to control cost. Some
hospice agencies have ormularies that will allow the use o ino-
tropes or management o dyspnea, atigue, etc., while others
will speci y that the symptoms be controlled with other agents
such as opiates.
“B” is incorrect. T ere is so much more to palliative care
than giving morphine or shortness o breath in heart ailure!
Continuing cardiac therapies may allow a patient to maintain
their cardiac unctional status and prevent pulmonary conges-
tion and should never be discontinued just because a patient
enrolls in hospice. With that being said, there are times when
the patient’s goals support the discontinuation o these medi-
cations. “C” is incorrect because as noted above, every deci-
sion comes with both a bene t and a burden, which need to be
weighed. Some level o uid restriction may help with breathing
and pulmonary congestion and should be balanced against the
discom ort o restricting intake. “D” is incorrect because it is
not a requirement or an ICD to be deactivated. However, the
incidence o arrhythmia can be high in this population and
ICD shocks near the time o death can be very distressing to the
patient and the amily and should be discussed.
HELPFUL TIP:
I you’ve see o e hospice age cy, you’ve see o e hos
pice age cy. Hospices o te have di e e t o mula ies,
di e e t available a cilla y se vices (e.g., music the apy,
pet the apy, massage), a d di e e t policies i what
they cove o symptom ma ageme t (e.g., chemothe
apy, adiatio , blood t a s usio s). It ca be help ul to
k ow what se vices you local hospice cove s.
CHAPTER 27 • En D-O -LI E CAr E 699
You think that your patient may be appropriate or hospice
and decide that a palliative medicine consult might be use ul
to address his goals o care, review symptom management,
and discuss hospice.
Question 27.1.3 Which statement accurately re ects how
palliative medicine is dif erent rom hospice?
A) Only palliative medicine af rms li e and attempts to help
patients live as ully as possible.
B) Palliative medicine o ers treatments including aggressive
medical treatments such as radiation therapy, intravenous
(IV) uids, or interventional radiologic procedures, while
hospice does not.
C) Palliative medicine is per ormed by a physician only, while
hospice care involves an entire team o providers.
D) Palliative care can be o ered at any time during a li e-limit-
ing illness, even i a patient is still actively seeking a cure.
E) Palliative medicine consults are billed under Medicare Part
B while hospice care is reimbursed through the Medicare
Part H.
Answer 27.1.3 The correct answer is “D.” Palliative care is spe-
cialized medical care or people with serious illnesses that is
ocused on providing patients with relie rom the symptoms,
pain, and stress o the serious illness—whatever the diagnosis.
T e goal is to improve quality o li e or both the patient and the
amily. Palliative care is provided by a team o doctors, nurses,
and other specialists who work with a patient’s primary team to
provide an extra layer o support. Palliative care is appropriate at
any time in a serious illness and can be provided together with
curative treatment. Hospice care is a type o palliative care, which
occurs during the nal months o someone’s li e when cure is no
longer possible or no longer consistent with the patient’s goals.
“A” is incorrect because both hospice and palliative care strive to
make li e meaning ul and com ortable or patients. “B” is incor-
rect. Since the goal o both hospice and palliative care is to pre-
vent and relieve su ering, any o these modalities may be used
i appropriate. In act, any intervention can be considered pal-
liative i the intention is to relieve distressing symptoms associ-
ated with the atal disease (such as a hip-pinning or pain control
a er a pathologic racture). T ere are no restrictions prohibit-
ing a hospice agency rom providing “aggressive” interventions
designed to relieve pain and su ering. “C” is incorrect because
both hospice and palliative medicine are built on the concept o a
team providing care to the patient and amily. Hospice care usu-
ally (but not always) is directed by the primary physician. “E” is
incorrect because palliative medicine services are typically billed
as inpatient consult services and are reimbursed by Medicare
Part A, and there is no such thing as Medicare Part H—yet!
Question 27.1.4 Which o the ollowing is TRUE regarding
the Medicare hospice bene t?
A) T e Medicare hospice bene t requires all care related to
the primary admitting illness to be covered by the hospice
agency, including physician ees, as long as the hospice pro-
gram does not employ the physician.
700 AMILY MEDICIn E EXAMIn ATIOn & BOAr D r EVIEW
B) T e hospice bene t, similar to the Medicare home care ben-
e t, requires that the patient be homebound.
C) Respite care within an acute hospital setting is provided or
up to 5 days every 6 months.
D) Hospice entry requires that the patient cannot live alone
(must have an on-site primary caregiver).
E) A at per diem rate is paid to the licensed hospice program
regardless o the level o services provided.
Answer 27.1.4 The correct answer is “A.” T e Medicare hos-
pice bene t requires all care related to the primary admitting
illness to be covered by the hospice agency. T ink o it as capi-
tated care. However, Medicare a ords individual hospice agen-
cies wide latitude in determining what modalities they use to
treat the symptoms o a particular illness. For example, one
agency might allow blood trans usions or the relie o dyspnea,
while another agency only covers the use o medications such
as morphine or lorazepam or dyspnea. I necessary or acute
symptom management, Medicare also covers acute hospitaliza-
tions related to the primary illness. “B” is incorrect. A hospice
patient does not need to be homebound. Respite care can be
o ered as requently as needed, which makes “C” incorrect. T e
Medicare hospice bene t provides respite care. T is can last up
to ve nights at a time. T e respite care needs to be provided in a
setting where there is a registered nurse available continuously,
and the patient must come rom a home setting (including
assisted living). T is can be used i the caregiver is unable to care
or the patient or a variety o reasons. “D” is incorrect because
Medicare does not require that the patient have a primary care-
giver in the home to receive the hospice bene t; however, an
individual hospice agency may require a primary caregiver be
identi ed be ore enrolling a patient. “E” is incorrect because
Medicare pays the hospice organization a strati ed per diem
rate depending on the level o care the patient requires.
A er meeting with the palliative care team, your patient’s
amily inquires more about hospice care. T ey ask what other
services are covered.
Question 27.1.5 The Medicare hospice bene t includes
coverage or all o the ollowing expenses EXCEPT:
A) Medications related to symptom management.
B) Social work visits.
C) Home health aide services.
D) Room and board or a patient living in a nursing home.
E) Bereavement services.
Answer 27.1.5 The correct answer is “D.” All o the other
options listed are services covered under the Medicare hospice
bene t. A patient living in a nursing home is eligible or hospice
care, but the cost o room and board or the nursing home is
not paid by the hospice bene t. In some special circumstances,
nursing home care will be paid or a short duration (e.g., when
a hospice patient uses the ve-night respite care bene t or i
the patient is admitted to a nursing home or management o
a distressing symptom that cannot be controlled in the home
setting).
A ew months go by and your patient has again been hospi-
talized. You now believe that he has ewer than 6 months to
live. T e local hospice medical director reviews the case and
agrees. T e patient is dyspneic at rest, requires 24-hour oxy-
gen by nasal cannula, and his cardiac ejection raction has
decreased to 15%. He wishes to avoid urther hospitalization
and has elected to have a DNR status. His amily wants to
know what you can do when he becomes severely dyspneic.
Question 27.1.6 Which o the ollowing is appropriate pal-
liative treatment o severe dyspnea in this patient?
A) Intubation and ventilation.
B) Morphine.
C) Scopolamine.
D) Buspirone.
E) Hyperventilating into a paper bag.
Answer 27.1.6 The correct answer is “B.” Morphine and other
opioids analgesics are indicated or palliation o dyspnea in car-
diac ailure. Despite concerns about opiates worsening respira-
tory unction in end-stage heart ailure, studies have concluded
that oral morphine improves dyspnea in this patient population
and does not cause respiratory ailure or hasten death. T is is
supported by recommendations rom the American College o
Cardiology and the American Heart Association. I morphine
or other therapies or shortness o breath were to shorten li e,
the ethical principle o “double e ect” would be applicable. T e
double e ect principle states that as long as the intention o a
therapy is to reach a good outcome (such as improve pain and
alleviate su ering), then even i the unintended consequences
result in a negative outcome (e.g., shortening li e) the inter-
vention is permissible. T e key here is intention. I you choose
“A,” your patient’s ghost will be back to haunt you. T is patient
has chosen a ar less aggressive stance toward li e-prolonging
measures, and his wishes should be honored. “C” is incor-
rect. Scopolamine is used to reduce oropharyngeal secretions
(resulting in sonorous respirations) but is not likely to relieve
dyspnea in this patient. In addition, scopolamine is highly
anticholinergic and crosses the blood–brain barrier, which can
result in delirium and should be used with caution in an awake
and alert patient. Glycopyrrolate is a better choice to control
secretions in a patient who is alert and awake. “D” is incorrect.
While anxiety and dyspnea o en occur together and exacer-
bate each other, buspirone (BuSpar) is a weak anxiolytic and
has no direct e ect on dyspnea. Low-dose lorazepam would be
a reasonable alternative i you elt his dyspnea was complicated
by anxiety. And “E” is just plain wrong—although still not as
bad a choice as “A.”
Consider diuretics to relieve dyspnea in heart ailure patients
in hospice. O en times we are guilty o orgetting to treat the
underlying illness when someone is in hospice, reaching or
morphine rst. Are there signs o volume overload (e.g., ele-
vated JVD, di use crackles, pro ound edema)? Diuretic therapy
may reduce pulmonary congestion and relieve dyspnea, and the
bene ts and burdens should be weighed. T e burdens that need
to be considered include: patient’s bed bound status, risk or

incontinence decreasing quality o li e, patient’s agreement with
using a bladder catheter, renal unction, etc.
HELPFUL TIP:
Be zodiazepi es may be used i combi atio with opi
ates o added elie o dysp ea a d a xiety. The patie t
should be mo ito ed o excessive sedatio a d espi a
to y dep essio .
Objectives: Did you learn to . . .
• Ide ti y app op iate patie ts o e d o li e ca e, pa ticula ly
o the Medica e hospice be e t?
• Desc ibe the eatu es o the Medica e hospice be e t?
• T eat patie ts with dysp ea elated to e d stage ca diac
disease?
QUICK QUIZ: MOr E THAn A LITTLE HEADACHE
A 30-year-old male patient you have known or several years
was diagnosed with metastatic melanoma several months ago.
He presents now with intermittent, severe headaches associated
with nausea. A head C scan per ormed last week showed three
metastatic oci with surrounding edema. He currently takes
maximum doses o acetaminophen and large doses o mor-
phine.
What is the best initial treatment option to help relieve his head-
ache and nausea?
A) Neurosurgical intervention.
B) Dexamethasone.
C) Sumatriptan.
D) Ibupro en.
E) Increased morphine doses.
The correct answer is “B.” Corticosteroids are the pre erred
therapy or headaches due to increased intracranial pressure
rom edema, as is presumably the case here. Whole brain or ste-
reotactic radiation therapy, alone or in combination with cor-
ticosteroids, may also be used as palliative therapy or multiple
brain metastases. “A” is incorrect because neurosurgical con-
sultation or craniotomy should be reserved or patients who
ail other interventions or who present with rapidly worsening
symptoms. “C” and “D” are incorrect. Sumatriptan and ibupro-
en should not be used to treat increased intracranial pressure.
“E,” increased morphine doses, may be required, but corticoste-
roids are typically used rst.
QUICK QUIZ: EAr LYPALLIATIVE CAr E
A 74-year-old woman presents to your clinic with a new diag-
nosis o nonsmall cell lung cancer ound during an evaluation
or hip pain that revealed di use bony metastases on x-ray. She
inquires about ways to improve her quality o li e in addition to
CHAPTER 27 • En D-O -LI E CAr E 701
the care recommended by her oncologist. You recall reading the
landmark study (a study that every primary care and palliative
care physician should know—and i you don’t know you should
read it cover to cover several times) by emel et al., regarding
the introduction o early palliative care in patients with meta-
static nonsmall-cell lung cancer.
Which o the ollowing is NO true about the outcomes
or the patients that received the novel intervention o early
palliative care compared to those that received standard
oncologic care?
A) Introduction o early palliative care improved patients’
quality o li e.
B) Introduction o early palliative care improved patients’
mood.
C) Introduction o early palliative care shortened the median
survival.
D) Introduction o early palliative care resulted in ewer aggres-
sive therapies at the end-o -li e.
The correct answer is “C.” Introduction o early palliative care
was shown to increase median survival rom 8.9 months to
11.6 months, and this occurred despite the intervention group
patients receiving ewer aggressive interventions at the end-
o -li e. Both “A” and “B” are incorrect answers (but true state-
ments) because this study showed that both quality o li e and
mood were improved when early palliative care was introduced
to the standard oncologic care in this patient population. “D” is
incorrect (but again a true statement) because 33% o patients
who received early palliative care received “aggressive care”
(chemotherapy within 2 weeks o death, no hospice care, and/
or admission to hospice 3 days or less be ore death) as com-
pared to 54% o patients in the standard care group. T e emel
study applies to a very speci c patient population—patients
with metastatic nonsmall-cell lung cancer; however, there are
ongoing studies in other advanced illnesses to see i these out-
comes can be reproduced and applied to larger populations
o patients. In act, there is current research being done at the
University o Iowa introducing early palliative care to patients
with end-stage-liver disease and measuring the outcomes o
mood, quality o li e and mortality. Keep an eye out in the lit-
erature because the novel therapy o early palliative care may
prove to be applicable to more patient populations over the
next several years.
CASE 27.2
A 74-year-old emale was diagnosed with adenocarcinoma
o the colon 3 years prior to beginning hospice care. She has
known metastases to her liver and pelvis. She complains o
a cramping pain in her abdomen and a “deep pain” in her
groin. She is currently receiving morphine 10 mg orally (PO)
every 4 hours (except when asleep) and acetaminophen 650
mg PO ID. She says that her pain is 4 out o 10 on a numeric
pain scale. Her past medical history includes hemorrhage
secondary to a gastric ulcer 4 years ago (Helicobacter pylori
negative on biopsy).
702 AMILY MEDICIn E EXAMIn ATIOn & BOAr D r EVIEW
Question 27.2.1 Which o the ollowing strategies is the
best next step or improving this patient’s pain control?
A) Start gabapentin to treat the neuropathic aspect o her pain.
B) Add a strong nonsteroidal anti-in ammatory drug (NSAID)
such as ketorolac ( oradol) to her current regimen.
C) Add scheduled tramadol to try to decrease her morphine
use.
D) Start a long-acting morphine (e.g., MS Contin) at a dose
20% higher than her current morphine use.
E) Maximize the dose o acetaminophen to 1,000 mg every
4 hours.
Answer 27.2.1 The correct answer is “D.” T e patient is taking
short-acting opiates around the clock, which can lead to “chasing
the pain” (not to be con used with “chasing the dragon,” which
is inhaling heroin smoke, which leads to a leukoencephalopa-
thy . . . you never know . . . it could be on the test!). Patients o en
receive much better pain control when they are maintained on
a long-acting opiate. It is common practice to increase the dose
o opiates by 15% to 25% when a patient’s pain is only partially
controlled. It is then recommended to have the breakthrough
dose equivalent to 10% o her 24-hour use. “A” is incorrect as her
pain is better described as visceral or somatic rather than neuro-
pathic. Gabapentin is an acceptable choice or neuropathic pain
but is not likely to be e ective or this patient. “B” is incorrect.
Ketorolac is the NSAID with the highest rate o renal disease
and gastrointestinal (GI) bleeds and is contraindicated in a
patient who has had a GI bleed. I you were to add an NSAID,
ibupro en would be a better choice, and GI protection with a
proton pump inhibitor would be advisable or this patient. “C”
is incorrect. ramadol is a weak mu-receptor agonist, possess-
ing some norepinephrine and serotonin reuptake inhibition and
is much less ef cacious than morphine. ramadol is not likely to
bene t a patient with severe pain rom cancer and metastases.
ramadol also has a number o troubling side e ects such as an
increased risk o seizures and serotonin syndrome. “E” is incor-
rect because the current recommended daily maximum dose
o acetaminophen or elderly patients is 3,000 mg (don’t blame
us . . . blame the FDA), and the requency suggested in “E” would
ar exceed this amount.
When determining what medications are appropriate or
treating pain, it helps to know what type o pain the patient
has.
Question 27.2.2 Cancer is known to cause which type(s) o
pain?
A) Neuropathic pain.
B) Visceral pain.
C) So tissue/bony pain.
D) Pain rom increased intracranial pressure.
E) All o the above are types o pain.
Answer 27.2.2 The correct answer is “E.” Physiologic pain is
separated into our categories: so tissue or bony pain (also
called somatic pain), neuropathic pain, visceral pain, and the
pain o increased intracranial pressure. An example o somatic
pain is the musculoskeletal pain (e.g., sports injuries and rac-
tures) that everyone experiences at some point. Neuropathic
pain is generally described as burning and results rom nerve
damage, in ammation, or compression. Visceral pain comes
rom distention o an organ capsule (e.g., liver enlargement
rom metastases, and colicky pain rom the colon). Depending
on where a metastasis or primary tumor is located, it may cause
somatic pain (e.g., bone tumors), neuropathic pain (e.g., Pan-
coast tumor), visceral pain (e.g., peritoneal carcinomatosis), or
a headache rom increased intracranial pressure.
HELPFUL TIP:
Avoid usi g mepe idi e (Deme ol). It has toxic metabo
lites that may cause agitatio a d seizu es. Mepe idi e
ca also i te act with a umbe o d ugs to cause se o
to i sy d ome.
You decide to increase her morphine dose.
Question 27.2.3 Which o the ollowing statements is TRUE?
A) Intravenous morphine is 10 times more potent than oral
morphine.
B) Naloxone should be given i a hospice patient near death
demonstrates con usion, decreased responsiveness, a slowed
respiratory rate or cool extremities.
C) Patients exhibiting a local rash or intense pruritus at the site
o intravenous morphine administration must be consid-
ered allergic and given an alternate opiate.
D) olerance to morphine does not occur in patients with can-
cer, so any increased analgesic need is due solely to uncon-
trolled pain.
E) Renal and hepatic insuf ciency both contribute to the ac-
cumulation o morphine and its metabolites.
Answer 27.2.3 The correct answer is “E.” “A” is incorrect.
Intravenous (IV) morphine is about three times as potent as
oral morphine. “B” is incorrect. Patients who are within several
days or hours o death o en exhibit pallor, peripheral vasocon-
striction, apneic episodes, and obtundation as part o the physi-
ologic process o dying. Counseling the amily and patient is
pre erable to administering naloxone, which can cause abrupt
opiate withdrawal and signi cant distress and discom ort to
the patient (again, don’t make her ghost haunt you). “C” is
also incorrect. Local histamine release is a known e ect o IV
morphine administration. Histamine-mediated skin changes
proximal to the IV in usion site o morphine do not represent a
contraindication to uture morphine use. In act, antihistamines
(e.g., diphenhydramine) can be used to counter morphine-
related histamine e ects, such as rash, itching, and hypotension.
But again, i you choose to use an antihistamine you need to
monitor or delirium. “D” is incorrect. All patients can develop
tolerance to the e ects o morphine. O course, in patients
with terminal cancer, increasing opiate requirements are o en
entirely due to increasing pain. And even i your dying patient
develops morphine tolerance, you still need to treat the pain.

Finally, “E” is correct. Patients with renal and hepatic insuf -
ciency can accumulate metabolites o morphine, some o which
are help ul in pain control and others o which may have an
anti-analgesic e ect. T ese patients o en need lower doses o
opiates. I a patient is actively dying and has evidence o renal
ailure, opioid doses can o en be decreased signi cantly with-
out a worsening o pain control. Fentanyl and methadone are
considered the sa est opiates in renal ailure although metha-
done use is complicated by the long hal -li e.
HELPFUL TIP:
Sta t patie ts o a egime to p eve t co stipatio
whe i itiati g opioids. Thi k about the bowel egime
each time you i c ease the opiate dose. It will save you
a d you patie t a lot o g ie i the lo g u .
HELPFUL TIP:
o patie ts whose pai ca ot be co t olled with typi
cal t eatme ts, lidocai e i usio s have bee show to
be be e icial.
Question 27.2.4 Which o the ollowing statements is NOT
accurate regarding the appropriate use o opiates in end-
o -li e situations?
A) At times, delirium can be improved with opiate dosage
reduction and/or the addition o opioid-sparing analgesics
(e.g., acetaminophen).
B) I oral morphine cannot be swallowed, then either an enteral
eeding tube or a parenteral route (IM/IV/subcutaneous)
must be used.
C) Dosage conversion rom one opiate to another is a ected by
the type o opiate used and the route o administration.
D) ransdermal opiate delivery products are expensive, have a
slow onset o action, and have erratic absorption.
E) T ere is no pre-established ceiling dosage or opiates, and you
may increase the opiate dose until adverse side e ects occur.
Answer 27.2.4 The correct answer (and the alse statement)
is “B.” Concentrated oral morphine solutions (20 mg/mL) can be
given in small amounts to patients who are unable to swallow.
While it was previously thought that morphine elixir worked
by absorption through the buccal mucosa, it is now believed
to trickle down the throat to be absorbed through the gastric
mucosa. Fentanyl is the only opiate absorbed via the buccal
mucosa (thus, the entanyl lollipops). A secret that drug compa-
nies do not want you to know is that you can avoid the expense
o entanyl lollipops by using entanyl IV solution orally or con-
trol o breakthrough pain. Since concentrated morphine elixir
is e ective in patients who cannot swallow, eeding tubes or
parenteral routes o administration are unnecessary. “A” is true.
Delirium is a common and disturbing nding toward the end
o li e, and it is sometimes precipitated or exaggerated by opi-
ates. On the ip side, untreated pain can cause delirium, and the
delirium may improve when opioid doses are escalated. In these
CHAPTER 27 • En D-O -LI E CAr E 703
situations, it can be help ul to rotate opiates because the lack o
cross-tolerance means that the dose can o en be decreased while
maintaining the same level o pain control. Acetaminophen is
the sa est opiate-sparing analgesic, and its adjuvant action may
allow or opioid dosage reduction without a loss o overall anal-
gesia. In the appropriate patient, NSAIDs may also be used.
“C” is true. When a patient chronically taking one opiate
switches to another, a dose adjustment calculation must be made.
You cannot switch milligram or milligram. Also, some authori-
ties recommend that a er the calculation, you slightly reduce the
dose o the new opiate due to incomplete cross-tolerance (re er
to opioid dose conversion charts available in numerous pharma-
ceutical texts and handbooks). “D” is true. T e transdermal en-
tanyl patches, though convenient, have uctuating bioavailabil-
ity over the three days that each patch is worn, and breakthrough
doses o an alternative opiate should be available. Fentanyl is also
at-soluble and absorption/bioavailability is decreased in thin
and/or cachectic patients. T e entanyl patches are expensive
and initially have a slow onset until a steady state is achieved. For
this reason, a entanyl patch should never be used alone as an
initial treatment o acute pain. In act, i you want to avoid a law-
suit, a entanyl patch should never be used as the rst method to
treat pain in an “opiate-naïve” patient. “E” is true. Because o the
extraordinarily wide dosage range o opiates, the ceiling dosage
cannot be calculated or assumed. Rather, analgesic requirements
allow or continual increase unless adverse side e ects clearly
undermine the use o the drug.
HELPFUL TIP:
The e is o co siste t elatio ship betwee blood lev
els o mo phi e a d a algesic e ects. This is because
o tole a ce, i dividual va iability i d ug e ect, etc.
Thus, the e is o si gle “ ight” dose. You should tit ate
mo phi e to the desi ed e ect while watchi g o side
e ects.
You increase the morphine dose considerably over a 2-week
period and your patient begins having escalating pain and
muscle twitching.
Question 27.2.5 Which statement is true about opioid-
induced hyperalgesia (OIH)?
A) Patients with OIH always become delirious.
B) When a patient has OIH, the pain does not improve when
the opioid dose is increased.
C) T e pain in OIH is described as a worsening o the original
pain being treated.
D) OIH needs to be di erentiated rom worsening underlying
disease.
Answer 27.2.5 The correct answer is “D.” Be ore we presume
that a patient has OIH, we need to ensure that the increase in
pain is not due to urther disease progression. We also need
to consider increased pain resulting rom increased activ-
ity or other exacerbation (such as trips to x-ray or radiation
704 AMILY MEDICIn E EXAMIn ATIOn & BOAr D r EVIEW
therapy). Additional eatures that can help distinguish OIH
rom increased pain include: the development o muscle twitch-
ing, presence o allodynia (pain elicited rom ordinarily non-
pain ul stimuli, such as stroking skin with cotton—although
this can occur with neuropathic pain syndromes as well), and
development o seizures or delirium. However, not all patients
with OIH become delirious, making “A” incorrect. T e key ea-
ture o OIH is that the pain increases as the dose o the opiate is
increased and will decrease when the dose is decreased. We are
not certain why OIH occurs but several mechanisms have been
proposed. One proposed mechanism is upregulation o NMDA
receptors rom chronic use o high-dose opiates, which is why
switching to an opiate with NMDA antagonism could prove
help ul (such as methadone or ketamine). However, OIH can
still occur in patients new to opiates and on low doses, so there
is still more research needed on this subject. “C” is incorrect as
well. OIH typically produces di use pain, less de ned in quality
and extending beyond the pre-existing pain distribution.
You are concerned about OIH and you decide to rotate to
methadone.
Question 27.2.6 Which o the ollowing statements is FALSE
regarding the use o methadone?
A) Methadone can be legally prescribed or pain and addiction
by a physician with a current schedule II DEA license.
B) Methadone is more easily absorbed by those with bowel
problems than is sustained-release morphine.
C) T e hal -li e o methadone is 22 hours.
D) Methadone may be use ul or neuropathic pain because it
inhibits receptors in the dorsal horn o the spine.
E) Methadone is primarily excreted in the stool and thus drug
dosages do not need to be modi ed in those with mild to
moderate renal disease.
Answer 27.2.6 The correct answer (and alse statement) is
“A.” Methadone can be prescribed or pain control by physi-
cians with a schedule II DEA license but cannot be prescribed
or addiction or opiate withdrawal without a special license. “B”
and “C” are true. Methadone has a long hal -li e, and sustained-
release preparations are not needed. Sustained-release morphine
may pass unabsorbed in patients with short gut or dys unctional
gut, whereas methadone would be absorbed. “D” is true; metha-
done may be especially use ul in treating neuropathic pain. “E”
is also true. Methadone is primarily excreted into the GI tract.
Patients with liver disease should have doses adjusted. However,
those with renal disease may tolerate “normal” doses since renal
excretion is a minor part o methadone elimination.
HELPFUL TIP:
Whe it comes to switchi g o dosi g opiates the e a e
seve al use ul tips that we like to use: (1) do ’t o get
to accou t o i complete c oss tole a ce whe switch
i g classes o opiates— educe the dose o the ew opi
ate by 30% to 50%; (2) whe opiates a e ot helpi g,
i c ease the dose by 50%; esse tially, t eat opiates like
you would t eat a loop diu etic—i 60 mg o IV u o
semide does ot wo k, you would ’t t y 61 mg (o at
least we hope ot!), but athe go to 90 o 120 mg; (3)
o a opiate aive patie t who is sta ti g a patie t
co t olled a algesia (PCA) pump, go with mo phi e
2 mg IV Q10 mi utes as eeded without a co ti uous
(“basal”) i usio .
HELPFUL TIP:
Si ce methado e i te acts at the n MDA ecepto s, it is
the opiate o choice o eu opathic pai , which is o te
poo ly espo sive to othe opiates. I additio , meth
ado e is the o ly long acting opiate that comes i a
liquid o m a d ca be give buccally o i a e te al
tube. Methado e ca be dosed eve y 8 to 12 hou s with
ma y pai patie ts equi i g Q8 hou dosi g. r emem
be that methado e p olo gs the QT i high doses a d
ca cause to sades de poi tes.
Your nurse calls you about your patient and reports that her
pain level has been rising, and despite signi cant increases
in both basal and breakthrough opiate therapy, the patient’s
pain is uncontrolled. T e nurse asks you i there is something
else that can be added to the opiates as an adjunctive treat-
ment or pain. For no explicable reason, you cannot get gaba-
pentin out o your head—even though you know it’s probably
useless or this patient.
Question 27.2.7 Which o the ollowing is TRUE regarding
the use o the gabapentin?
A) Gabapentin is hepatically cleared and dose adjustment is
needed in patients with liver disease.
B) T e primary utility o gabapentin is in neuropathic pain.
C) Gabapentin primarily works via the µ-opiate receptors.
D) T e most common side e ects o gabapentin are supraven-
tricular arrhythmias (thus limiting its utility in heart ailure
patients).
E) I a patient does not respond to gabapentin, she will also not
respond to pregabalin.
Answer 27.2.7 The correct answer is “B.” Gabapentin has
proven to be a marginally e ective (NN = 7) therapy or a
number o diseases that mani est with neuropathic pain, includ-
ing postherpetic neuralgia, diabetic neuropathy, and cancer-
related neuropathic pain. “A” is incorrect because gabapentin is
excreted unchanged through the kidneys—a plus or patients
with working kidneys on multiple drugs. Why do we like drugs
that are not hepatically cleared? T ey do not interact in any o
the cytochrome P450 pathways and there ore have ew drug–
drug interactions. “C” is incorrect. T e mechanism o gaba-
pentin is complex and not ully understood, but we are airly
certain that it does not work through the µ-opiate receptors.
T e literature suggests there is an intricate interplay with mul-
tiple receptors, including voltage-dependent calcium channels

and increasing synthesis o GABA (more than you wanted to
know, right?). “D” is incorrect. T e most common side e ect o
gabapentin is its e ect on cognition, causing dizziness and som-
nolence. Gabapentin can also cause edema, which can be prob-
lematic or patients with heart ailure. “E” is incorrect. Although
gabapentin and pregabalin are thought to have the same mecha-
nism o action, it appears that patients that some patients will
respond to one but not the other. Another important distinction
between gabapentin and pregabalin is the time needed to titrate
to an e ective dose. With gabapentin we typically start at 100
to 300 mg and escalate the dose over the course o weeks up
to 3,600 mg divided three times a day; alternatively, pregabalin
starts at 75 mg daily and reaches a max dose o 300 mg BID
within a week o initiation.
HELPFUL TIP:
A opiate aive patie t should eve be sta ted o a
e ta yl patch. A patie t eeds to be taki g a o al mo
phi e equivale t o at least 25 mg i 24 hou s be o e the
lowest dose (12.5 mcg) e ta yl patch ca be applied.
As time goes on, the patient has other concerns, including
constipation, weight loss o 20 pounds over 2 months, sleep-
lessness, nausea, and anxiety. In addition, she expresses how
her loss o unctional abilities is a hardship or her and her
adult daughter who serves as her primary caregiver. Her guilt
or losing her health is a continual source o rustration and
anger.
Question 27.2.8 What is true regarding her social and emo-
tional pain?
A) It will not a ect the patient’s analgesic requirements.
B) It will likely complicate treatment adherence.
C) Active treatment o emotional sources o pain should only
occur a er the physical source has been addressed and
treated.
D) Prophylactic antidepressants in patients within 6 months o
death decrease the probability o developing depression.
Answer 27.2.8 The correct answer is “B.” Adherence, always
an issue, is especially compromised in those dying patients
whose social, spiritual, and emotional problems are not e ec-
tively addressed. Similarly, analgesic control o somatic pain is
complicated when social, emotional, and spiritual sources o
pain exacerbate the patient’s response and perception to somatic
pain. Concurrent treatment o all sources o pain is necessary.
Antidepressant therapy in dying patients who do not have clini-
cal depression o ers no prophylaxis against the development o
depression.
You estimate your patient’s li e expectancy to be 2 months or
less. Her railty has progressed to the point where she is bed-
bound and utterly dependent or all o her ADLs. You have
made some adjustments, and she is now on stable doses o the
ollowing medications:
CHAPTER 27 • En D-O -LI E CAr E 705
• Hydromorphone (Dilaudid) 20 mg PO Q 4 hours
• Acetaminophen 1,000 mg PO ID
• Sorbitol 30 mL PO ID
• Metoclopramide 20 mg PO ID
You want to optimize her medications.
Question 27.2.9 Which o the ollowing is the most appro-
priate medication adjustment to make at this time?
A) Hydromorphone → scheduled controlled release mor-
phine.
B) Hydromorphone → scheduled immediate release mor-
phine.
C) Hydromorphone → scheduled controlled release morphine
and immediate release morphine as needed.
D) Acetaminophen → immediate release morphine.
E) Acetaminophen → nortriptyline.
Answer 27.2.9 The correct answer is “C.” A patient who has
reached a stable dose o short-acting opiate, such as hydromor-
phone, should subsequently be switched to a long-acting opi-
oid agent. An immediate release medication should be available
or acute “breakthrough” pain. T ere is no reason to change
the acetaminophen. Nortriptyline is sometimes use ul as an
adjuvant medication and is particularly help ul when treating
neuropathic pain.
T e hospice nurse calls you. Your patient is at home and has
become restless with slow respirations (6/min) along with
paroxysmal coughing and gagging with a large amount o
secretions.
Question 27.2.10 The ollowing are all appropriate orders
or this patient EXCEPT:
A) Obtain subcutaneous access through placement o a subcu-
taneous button or butter y needle.
B) Lorazepam 1 to 2 mg PO or SL every hour PRN.
C) Glycopyrrolate 2 mg PO or SL every 4 hours PRN.
D) Midazolam 0.4 to 4 mg SC every hour PRN.
E) Naloxone 2 mg SC every 2 hours PRN.
Answer 27.2.10 The correct answer is “E.” Naloxone is a potent
opioid receptor antagonist. Although the sudden change in the
patient’s status could be partly due to opiate accumulation, the
risks o naloxone antagonism are great and include severe pain,
cardiac arrhythmias, and seizures (remember, you don’t want that
ghost haunting you). Withholding or reducing the next dose o
opiates is a sa er approach. A subcutaneous in usion pump (“A”)
may allow e ective administration o medications and uids
in patients who cannot tolerate oral administration. T e use o
hydration at the end o li e is controversial. Withholding uids
and nutrition has strong merit, but the evidence is not compelling
enough to declare that uid in usion is utile and possibly harm-
ul in this setting. In addition, dehydration is a common cause o
delirium at the end o li e, and her con usion may improve with
gentle hydration. It is more important to review the patient’s goals
706 AMILY MEDICIn E EXAMIn ATIOn & BOAr D r EVIEW
and only administer uids i consistent with her goals. Glycopyr-
rolate (“C”) has been shown to decrease oral/pulmonary secre-
tions that lead to the “death rattle” in the nal days and hours o
li e. Such treatment bene ts the patient and her grieving amily
and riends. “B” and “D” may also be use ul. Benzodiazepines
have the potential to reduce anxiety, agitation, and insomnia;
however, any benzodiazepine can worsen con usion and cause
delirium. Benzodiazepines with an extended hal -li e (e.g., diaz-
epam and chlordiazepoxide) should generally be avoided because
o the potential or toxic accumulation.
Objectives: Did you learn to . . .
• De e majo physiologic pai catego ies?
• Desc ibe the pha macology o pai co t ol?
• P esc ibe opiate pai medicatio s a d adjuva t the apies o
pai ?
• Ide ti y emotio al, social, a d spi itual symptoms a d ecog
ize how they ca a ect pai ma ageme t?
QUICK QUIZ: THE SUBCUTAn EOUS r OUTE
Regarding the subcutaneous administration o uids and medi-
cations, which o the ollowing is true?
A) Not more than 500 cc o saline per day can be given by hypo-
dermoclysis (subcutaneous administration).
B) Only medication with low lipid solubility can be delivered
via subcutaneous administration.
C) Most drugs used in end-o -li e care can be given subcutane-
ously.
D) In general, subcutaneous administration dosage conversion
is closer to oral dosage than to IV dosage.
The correct answer is “C.” T e subcutaneous route can be
quite e ective. Adverse events such as local irritation, pulmo-
nary edema, and local edema are less requent with subcutane-
ous administration when compared with IV administration. In
general, most drugs used in end-o -li e care can be given sub-
cutaneously. “A” is incorrect. Evidence demonstrates that up to
3,000 cc o crystalloid solution can be given subcutaneously in
a 24-hour period with limited adverse e ects. Experience sug-
gests that even greater volumes can be given. “B” is incorrect.
Lipid solubility is not a clinically relevant aspect o bioavailabil-
ity during subcutaneous administration. “D” is also not true.
Subcutaneous doses are generally very close to, but lower than,
the IV dose o a drug. As with IV administration, the onset o
action is more rapid than with enteral dosing.
CASE 27.3
You assume care or the 84-year-old ather o one o your
patients. He has severe dementia, which has caused him to
require nursing home care or the last 5 years. He has stable
heart ailure due to ischemic cardiomyopathy. He requires
ull assistance to eat, which the sta members spend an hour
doing at each meal. He has lost 20 lb in the last 6 months
(BMI now is 21 kg/m2). A acility nurse calls you worried
about his weight.
Question 27.3.1 What would be the best intervention or
weight gain in this patient?
A) Megestrol.
B) Nutritional supplements.
C) Dronabinol.
D) Mirtazapine.
E) Feeding tube.
Answer 27.3.1 The correct answer is “B.” T e most e ective
means to maintain weight in elderly patients with dementia
is hand eeding and providing avorite oods (yes, ice cream
with every meal is OK!) and requent o erings. Hand eeding
is expensive and o en problematic in nursing homes with lim-
ited sta . When hand eeding is not possible, nutritional sup-
plements are the least invasive alternative with minimal side
e ects and have been shown to be modestly e ective in pro-
moting weight gain in elderly patients with dementia. Other
important considerations related to nutrition in dementia
patients is being aware o e ective ways to decrease aspiration
risk, including sitting upright, eating small portions, use o
thickened liquids, and hand eeding. “A,” megestrol (Megace),
is minimally e ective in improving appetite and increas-
ing weight in patients with cancer cachexia and weight loss
related to AIDS, but there is sparse evidence or use in geri-
atric patients. rials are o short duration (1–2 months) using
widely varying amounts o megestrol (240–1,600 mg/day), and
the weight gained is typically uid and not muscle mass. With
such poor evidence or bene t but well-known side e ects,
there is no role or megestrol in this setting. In act, there is no
role or hormones or steroids in the treatment o weight loss in
the elderly patient with dementia. “B,” dronabinol, is synthetic
derivative o cannabis (known to cause “the munchies” . . . we’ve
heard). It increases appetite and improves nausea, but again
the studies are small and exploratory in nature and ocused
mainly on patients with AIDS and cancer. “D” is incorrect. I
the patient were depressed and losing weight as a result, mir-
tazapine might be a reasonable choice since it may stimulate
appetite. However, mirtazapine has not been shown to boost
appetite in nondepressed subjects (and like the SSRIs, does not
improve depression in the demented elderly anyway; Lancet.
2011;378:403–411). Some antidepressants, such as SSRIs and
bupropion, are associated with weight loss. Finally, a eeding
tube is invasive with numerous side e ects (cellulitis, leakage,
and increased ecal incontinence which can contribute to bed
sores). While enteric tube eeds may improve caloric intake,
they do not extend li e, increase weight, improve unctional
status, or reduce the incidence o pressure sores or aspiration in
dementia patients (exceptions to this are ALS and gastrointes-
tinal cancers with proximal obstruction with a good unctional
status). T us, “E” is incorrect.
HELPFUL TIP:
r emi d a d ei o ce to amilies that deme tia is a te
mi al ill ess a d that ou cu e t u de sta di g is that
tube eedi g is u likely to alte that ill ess.

Your nutrition shakes are not doing the trick. T e patient
continues to lose weight. o urther stage his dementia, you
attempt a Folstein Mini Mental Status Exam, but he cannot
participate. T e nurse reports that he needs assistance with
all ADLs, he is incontinent, and he is unable to speak more
than six intelligible words (and although you remember a
couple o post-call days when you were in the same condition,
you say nothing). T e nursing sta asks you i the patient is
appropriate or hospice care.
Question 27.3.2 Which o the ollowing is TRUE?
A) T e li e trajectory o terminally demented patients is unclear.
Wait until his cardiac disease worsens.
B) He does not yet meet Medicare hospice bene t criteria or
dementia.
C) A history rom the nursing sta or amily regarding the rate
o his unctional loss is the best predictor o death.
D) T e nursing home sta can provide all o the end-o -li e ser-
vices provided by hospice, so hospice is not needed.
E) Presence o a stage 2 pressure ulcer and aspiration risk is su -
cient or re erral to hospice.
Answer 27.3.2 The correct answer is “C.” Predicting death in
patients with dementing illness is dif cult which is why it is one
o most underutilized diagnoses or re erral to hospice care. In
act, dementia has the greatest variability among hospice diagno-
ses when it comes to predicting survival. However, waiting until
a more predictable organ system ailure occurs is not a reason
or delaying a hospice re erral, which makes “A” incorrect. “B” is
incorrect because he does meet criteria or hospice enrollment.
T e National Hospice and Palliative Care Organization (NHPCO)
hospice guidelines or eligibility in dementia include three com-
ponents: (1) demonstrating severity o dementia (e.g., an inability
to walk or dress or bathe without assistance, urinary/ ecal incon-
tinence, or inability to speak 6 di erent intelligible words per
day); (2) evidence o a severe comorbid condition within the past
TABLE 27-1 CAUSES AND TREATMENT OF NAUSEA AND EMESIS
Type o Nausea Receptors Causing Nausea
V Vestibula Choli e gic
Histami ic
O Obst uctio (caused by co stipatio ) Choli e gic
Histami ic
5 HT3
M DysMotility Choli e gic
Histami ic
5 HT3
I I ectio , I ammatio Choli e gic
Histami ic
5 HT3
T Toxi s (stimulati g the CTZ i the Dopami e 2
b ai , i.e., opioids) 5 HT3
5 HT3, 5 hyd oxyt yptami e (se oto i ); CTZ, chemo ecepto t igge zo e.
CHAPTER 27 • En D-O -LI E CAr E 707
6 months (e.g., aspiration pneumonia, pyelonephritis, sepsis, stage
≥ 3 decubitus ulcer, or ever despite antibiotics); (3) inability to
maintain uid/caloric intake (by demonstrating weight loss > 10%
in 6 months or albumin < 2.5 g/dL). “E” is incorrect. Aspiration
risk and stage 2 pressure ulcers alone are not suf cient or re erral
to hospice. I the patient had stage 3 or 4 pressure ulcers, he would
likely meet NHPCO hospice criteria or severe dementia. It is the
extrapolation o the patient’s loss o basic unctions over time that
best predicts death, as in “C.” “D” is incorrect because while most
nursing homes routinely care or dying patients without the assis-
tance o hospice, they are typically not able to o er the ull range o
services or the end-o -li e expertise that hospice o ers.
Your patient develops nausea and vomiting and on examination
you eel a large abdominal mass. He is still having bowel move-
ments, which are guaiac positive. You in orm the amily that
you suspect he has colon cancer, and they elect or no urther
evaluation but want his symptoms aggressively managed.
Question 27.3.3 Which o the ollowing drugs is the best
initial choice or treatment o this patient’s nausea and
vomiting?
A) Octreotide.
B) Metoclopramide.
C) Diphenhydramine.
D) Ondansetron (Zo ran).
E) Aprepitant (Emend).
Answer 27.3.3 The correct answer is “D.” “B” is not correct.
Using a pro-peristaltic agent in a patient who may have an
obstruction is not a good idea in general. Also, metoclopramide
has central anti-dopaminergic properties and can cause con-
usion and extrapyramidal side e ects. By understanding the
pathophysiology o nausea and targeting antiemetics to spe-
ci c receptors, therapy can be optimized and side e ects mini-
mized. An easy way to remember the causes o vomiting is to
use the “VOMI ” mnemonic. In able 27-1, pathophysiologic
Use ul Drug Classes Examples o Drugs o Choice
A ticholi e gic Scopolami e
A tihistami ic P omethazi e
Stimulate mye te ic plexus Se a p oducts
P u es
P oki etics to stimulate Metoclop amide
5 HT4 ecepto s
A ticholi e gic P omethazi e
A tihistami ic
A tidopami e gic P ochlo pe azi e
5 HT3 a tago ist Halope idol
O da set o
708 AMILY MEDICIn E EXAMIn ATIOn & BOAr D r EVIEW
mechanisms causing nausea are described using the letters o the
mnemonic. Blockade o these receptors allows rational, ocused
therapy.
Using able 27-1, another reasonable alternative would be
promethazine, although promethazine is not a great antiemetic.
“A” is incorrect. Octreotide works by slowing the GI track, and
its main use is ound in patients with nausea and vomiting due
to malignancy-related intestinal obstruction. However, it does
not rapidly treat nausea and is not easily administered (usually
continuous IV in usion but it can be given subcutaneously or
intramuscularly). “C” is incorrect because diphenhydramine
alone is a weak antiemetic, mostly used or motion sickness, and
it can cause con usion, particularly in the elderly. Aprepitant
(Emend) is a neurokinin receptor antagonist that is most e ec-
tive when used with serotonin receptor antagonists; its primary
use is in the management o chemotherapy induced nausea, and
it is very expensive.
HELPFUL TIP:
Whe t eati g chemothe apy i duced ausea, add
somethi g to thei cu e t egime . Do ot just d op
o e medicatio a d add a othe . This is cou te i tu
itive but is co side ed the app oach o choice.
T e patient’s nausea is ultimately controlled with scheduled
low-dose promethazine and ondansetron (See? wo drugs
instead o a large dose o one!). He is continuing to lose
weight and has been coughing a er eating. He spikes a ever
and you suspect he has developed aspiration pneumonia.
Question 27.3.4 Which is true regarding the use o antibiot-
ics or pneumonia in patients with terminal dementia?
A) Antibiotic use is considered the standard o care and should
be initiated without discussing with the amily.
B) Antibiotics might prolong patients’ lives but treatment
comes with signi cant risks that need to be weighed.
C) Antibiotics given in a controlled setting such as a nursing
home, where compliance can be ensured, lead to less antibi-
otic resistance.
D) Parenteral antibiotics are more success ul at treating aspira-
tion pneumonia in patients with dementia (compared with
oral antibiotics).
Answer 27.3.4 The correct answer is “B.” T e previous prevail-
ing belie o carte blanche use is being challenged. Currently,
antibiotic use is very common in nursing homes, and a major-
ity o nursing home residents will receive antibiotics in the
2 weeks be ore their death. Most o those antibiotics will be given
intravenously, which increases patient discom ort. But more
importantly, patients are o en admitted to a hospital, placing
demented patients at risk or delirium, restraints, and exposure
to hospital acquired organisms. T e reason we emphasize “might
prolong” patients’ lives is that the literature shows that in the
extremes o advanced dementia plus advanced illness (such as
bacteremia) antibiotics may not provide improved survival. In
act, in patients with advanced dementia, in ections o en char-
acterize the nal stage o their illness. “A” is incorrect because
antibiotic use in patients with dementia (speci cally in patients
with dementia who are hospice appropriate) should always be
discussed with the surrogate decision maker, and antibiotic
use should be based on an in ormed choice and the patient’s
wishes/goals. While antibiotics have been shown to prolong li e
in patients with dementia, they do so with the cost o increas-
ing discom ort, making “B” the correct answer. Families need
this in ormation when deciding i antibiotics should be used. “C”
is incorrect because nursing homes have been shown to harbor
drug-resistant bacteria, likely due in part to the requent use o
antibiotics in these patients. Oral antibiotics have been shown
to be as e ective as other more invasive administration routes in
patients with dementia, making “D” incorrect.
T e patient is enrolled in hospice and 3 weeks later you are
called by a nurse reporting an acute condition change. You
go to see the patient and he is unresponsive, breathing is
labored, and his eet are mottled.
Question 27.3.5 All o the ollowing can be signs o impend-
ing death EXCEPT:
A) Cheyne–Stokes breathing.
B) Fever.
C) Cyanosis and mottling.
D) Aldosterone escape phenomenon with increased urinary
output.
E) alking to someone who is already dead (and not via me-
dium at Coney Island).
Answer 27.3.5 The correct answer is “D.” Most dying patients
have a decrease in urinary output prior to death. T e other
options describe changes that are commonly seen in patients
who are actively dying. Respiratory changes in the active
dying phase include Cheyne–Stokes breathing, terminal secre-
tions (the “death rattle”), and periods o apnea. Dying is o en
accompanied by decreased circulation, which can result in cool
extremities and mottling (the skin turning blue and patchy par-
ticularly in the ngers and toes). It is not uncommon or a dying
patient to have a ever in the last 24 to 48 hours o li e, typically
thought to be secondary to aspiration pneumonia or another
serious in ection. It is not uncommon or someone who is dying
to talk about going on a journey or talk about seeing someone
who is dead. T is is typically believed to be part o the normal
dying process and in the absence o other symptoms should not
be con used with delirium or psychosis.
HELPFUL (OR AT LEAST INTERESTING) TIP:
A visit om Osca the (the apy) cat i a r hode Isla d
u si g home has p oved to be a ve y accu ate p edic
to o immi e t death ( eally—see the a ticle i N Engl J
Med. 2007;357(4):328). P esumably, Osca is eacti g to
the lack o patie t moveme t o the smell o keto es,
etc. The agai , Osca could be the A gel o Death i a
wol ’s (well, cat’s) clothi g.

HELPFUL TIP:
Deli ium is ve y commo (up to 85%) i the last ew
days o li e. I the symptoms a e dist essi g to the pa
tie t o amily, it is best t eated with a a tipsychotic
such as halope idol.
You need to call the son to tell him o his ather’s decline.
Question 27.3.6 Which o the ollowing should you say
when giving the son an update?
A) “T ere have been some changes in your ather’s condition.
I think you should go to see him. Call me i you have any
questions a er you have seen your dad.”
B) “Good news, your dad will soon be out o his misery and
released rom this mortal world.”
C) “I’m a raid I have some bad news or you regarding your
dad. Would you like to talk over the phone or meet at my
of ce later today to discuss it?”
D) “Your dad is dying. I you want to see him alive again you
had better go today.”
E) Don’t call at all. Ask the nurse to in orm the son o his
ather’s condition while you duck out quietly.
Answer 27.3.6 The correct answer is “C.” It gives a warning
shot and allows the person receiving the bad news some con-
trol by allowing him to determine how and where he wants to
receive the bad news. “A” avoids giving the bad news at all. “B”
is inappropriately ippant and uses euphemisms. “D” is inap-
propriately blunt and sounds aw ul (believe it or not, we are very
caring doctors; it is just that we have amused ourselves with this
book). “E” avoids having the discussion at all and is only appro-
priate i you will be unable to reach the son in a timely ash-
ion. Besides, you will be orever a er known to the nurses as
“Dr. Wuss.” A common ormat or giving bad news is to use the
SPIKES six-step protocol in able 27-2.
HELPFUL TIP:
Whe givi g bad ews, do ot use ph ases such as, “I’m
a aid the e is othi g mo e we ca do o you.” This
leaves patie ts a d amily eeli g aba do ed. It is bet
te to be mo e speci ic to say, “I am a aid that I do ’t
have a y t eatme ts that will cu e you ca ce , but
the e is still a lot I ca o e to help to keep you com o t
able i the time you have le t.” This assu es the patie t
a d the amily that the e is still somethi g to be do e
a d that you will ot aba do them.
Breaking bad news is dif cult in person and can be more di -
cult over the phone.
Question 27.3.7 Which suggestion below is NOT recom-
mended when breaking bad news over the phone?
CHAPTER 27 • En D-O -LI E CAr E 709
TABLE 27-2 A MNEMONIC FOR GIVING BAD NEWS
S Setti g. A i app op iate setti g ca make it dif cult to give bad
ews e ectively. Make su e the physical setti g is as co ducive as
possible by t yi g to e su e p ivacy, i volvi g sig i ca t othe s,
sitti g dow , co ecti g with the patie t (eye co tact, ha d holdi g),
e su i g e ough time, a d mi imizi g i te uptio s.
P Patie t’s pe ceptio . Ask what the patie t’s (o amily’s) k owledge
a d u de sta di g o the cu e t medical ill ess is.
I I vitatio . Ask what i o matio the patie t wa ts to eceive. Some
patie ts do ot wa t to hea bad ews themselves, a d i this case it
ca be help ul to ask i the e is someo e else with whom you should
speak.
K K owledge. Give the medical acts i a st aight o wa d ma e
usi g vocabula y a d la guage app op iate to the patie t’s level.
Avoid medical ja go a d do ot be excessively blu t (i.e., avoid
sayi g thi gs such as “you have ve y bad ca ce a d u less you do
somethi g, you will die”). Give the i o matio i small chu ks a d
eque tly assess what the patie t has u de stood. Whe possible
sta t o with a wa i g shot (i.e., “U o tu ately, I have some bad
ews o you”).
E Explo i g/empathy/emotio . A patie t’s emotio al eactio ca
va y a d is o te ha d o a physicia to expe ie ce. A empathetic
espo se ca be help ul. This ca be oste ed by allowi g sile ce a te
b eaki g the bad ews a d watchi g a d liste i g o the emotio .
Whe you have ide ti ed the emotio , it ca be help ul to ame it
a d dete mi e what caused it. The make a empathetic stateme t
such as “I’m so y. I k ow this is ’t what you wa ted to hea .”
S St ategy/summa y. A te the emotio s have bee add essed, it is
help ul to eview what has bee said a d ag ee o a pla . Co side
aski g the patie t i he wa ts to discuss t eatme t optio s at this
time o wait u til a utu e meeti g. r eceivi g bad ews ca be
ove whelmi g, a d patie ts o te o get the details o what is said. It
is impo ta t to have clea , well de ed, timely ollow up such as “Go
home a d talk with you amily, I will see you (a d you amily) back
tomo ow at 9 AM, a d we ca discuss speci c t eatme t optio s a d
a swe questio s at that time.”
Data om Baile W , Buckma r , Le zi r , et al. SPIKES A six step p otocol o
delive i g bad ews: applicatio to the patie t with ca ce . The Oncologist.
2000;5:302–311.
A) ake time to prepare what you are going to say and nd a
quiet place to make the call.
B) I no one answers the phone, it is acceptable to leave a mes-
sage or voicemail detailing the bad news.
C) Identi y yoursel and avoid answering any direct questions
until you are sure o the identity o the person to whom you
are talking.
D) Ask i the person is alone.
E) Speak clearly and slowly, allow time or questions; be empa-
thetic.
Answer 27.3.7 The correct answer is “B.” When breaking bad
news over the phone, steps similar to breaking bad news in per-
son should be used. You should obtain the ull name, address,
and phone number(s) o the person(s) you are calling. I you are
not calling the patient, try to establish rom the chart and nurs-
ing sta the relationship o the contact to the patient. In addition,
it can be help ul to write down the key in ormation you need
710 AMILY MEDICIn E EXAMIn ATIOn & BOAr D r EVIEW
and review what you will say and nd a quiet area with a phone.
Don’t delay in making the call. When you do call, clearly identi y
yoursel and ensure you are able to speak with the person closest
to the patient (ideally, the healthcare proxy or the contact person
indicated in the chart). Avoid responding to any direct question
until you have veri ed the identity o the person to whom you are
speaking. Not only is it morally risky but it also violates HIPPA.
Ask i the contact person is alone. Do not give death noti ca-
tion to minor children. I you do not have a prior relationship
with the person you are speaking to, ask what they know about
the patient’s condition. Provide a warning shot. Never deliver the
news o death to an answering machine or voice mail. Instead,
leave speci c contact in ormation. Allow time or questions; be
empathetic and ask i you can contact anyone or them. Assess
their emotional reaction and ollow up as indicated.
HELPFUL TIP:
Whe you eed to i o m a amily that a patie t has died,
wo ds like “dead” o “died” should be used; avoid euphe
misms such as “expi ed,” “passed away,” o “did ’t make
it” (also, “kicked the bucket,” “bit the bullet,” “bought the
a m,” a d so o ), which ca be misi te p eted.
Objectives: Did you learn to . . .
• Ge e ate a ma ageme t pla o a patie t with weight loss
due to a te mi al disease?
• Desc ibe c ite ia o hospice admissio i patie ts with
seve e deme tia?
• Ide ti y a d t eat causes o ausea a d vomiti g at the e d
o li e?
• Ide ti y sig s o the active dyi g p ocess?
• r ecog ize the p ope steps o b eaki g bad ews?
HELPFUL TIP:
Bewa e o Osca the cat.
Clinical Pearls
Avoid mepe idi e. Othe opioid a algesics a e p e e ed.
Do ot delay palliative ca e assessme t i a patie t with a
se ious, li e limiti g ill ess, eve i that patie t is pla i g
to seek cu ative the apy. Patie ts with a ea ly palliative
app oach live lo ge a d have a highe quality o li e.
Do ot leave a impla ted ca diac de ib illato (ICD) active
without assessi g the patie t a d amily’s goals o ca e. I
a patie t with a te mi al ill ess who is Dn r , it is logically
co siste t to deactivate the ICD, a d this optio should be
discussed with the patie t/ amily.
Do ot sta t a opioid aïve patie t o a e ta yl patch.
Opioid a algesics, mo phi e i pa ticula , elieve espi ato y
dist ess i dyi g patie ts.
Sta t a bowel egime whe eve sta ti g opioid a algesics.
The additio o a be zodiazepi e to a opiate educes
a xiety a d b eathless ess, but espi ato y ate a d me tal
status must be ca e ully mo ito ed.
Tit ate opioid a algesics to a e ect athe tha a pa ticula
dose o blood level.
Use equia algesic e e e ce cha ts a d accou t o i complete
c oss tole a ce whe switchi g om o e opioid to a othe .
BIBLIOGRAPHY
Adler ED, et al. Palliative care in the treatment o advanced
heart ailure. Circulation. 2009;120:2597–2606.
Baile WF, et al. SPIKES-A six-step protocol or delivering bad
news: Application to the patient with cancer. Oncologist.
2000;5:302–311.
Banerjee S, et al. Sertraline or mirtazapine or depression
in dementia (H A-SADD): a randomized, multicentre,
double-blind, placebo-controlled trial. Lancet. 2011;378:
403–411.
Bennett MI. Gabapentin in the treatment o neuropathic pain.
Palliative Med. 2004;18:5–11.
Bharadwaj P, Ward K . Ethical considerations o patients with
pacemakers. Am Fam Physician. 2008;78(3):398–399.
Bushnaq M, et al. T e easibility o using intravenous entanyl
as sublingual drops in the treatment o incidental pain in
patients with cancer. J Palliat Med. 2009;12(6):511–514.
Challapalli V, et al. Systemic administration o local anesthetic
agents to relieve neuropathic pain. Cochrane Database Syst
Rev. 2005;(4): Art No. CD003345.
Clemens KE, Klaschik E. Dyspnoea associated with anxiety–
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Coyne PJ, et al. Nebulized entanyl citrate improves patients’
perception o breathing, respiratory rate, and oxygen satu-
ration in dyspnea. J Pain Symptom Manage. 2002;23(2):
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Donner B, et al. Direct conversion rom oral morphine to
transdermal entanyl: a multicenter study in patients with
cancer pain. Pain. 1996;(643):527–534.
Dosa DM. A day in the li e o Oscar the cat. N Engl J Med.
2007;357(4):328–329.
Fox CB, et al. Megestrol acetate and mirtazapine or the
treatment o unplanned weight loss in the elderly.
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pneumonia in advanced dementia. Arch Intern Med.
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Johnson MJ, Oxberry SG. T e management o dyspnoea in
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Lampert R, et al. HRS expert consensus statement on the man-
agement o Cardiovascular Implantable Electronic Devices
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Mitchell S, et al. In ection management and multidrug-resis-
tant organisms in nursing home residents with advanced
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renal disease patients managed without dialysis: recom-
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Evidence-Based Medicine
Mark A. Graber
Yeah, we don’t like numbers either. But they are at the end o the
chapter or those o you who want to learn 2 × 2 tables, etc. We
do like evidence-based medicine (EBM) though, and it will be
on the examination. So here goes….
able 28-1 is here or re erence. You may want to re er to it as
you work your way through the chapter.
CASE 28.1
Research published in World’s Best Medical Journal studied
screening or lung cancer using a new method. T e research-
ers reported that patients who had lung cancer detected via
screening lived longer a er diagnosis than people who were
diagnosed with lung cancer but not screened.
Question 28.1.1 Which is true?
A) T is shows that screening is e ective at prolonging survival.
B) T is may be an example o lead-time bias.
C) T is may be an example o veri cation bias.
D) Well-respected medical journals (and board review books)
are always right.
Answer 28.1.1 The correct answer is “B.” T is may be an exam-
ple o lead-time bias. Screening is intended to diagnose disease
earlier, hope ully allowing or interventions that prevent or slow
the progression o the disease. Without screening, the disease
may be discovered only a er symptoms develop when it may
TABLE 28-1 USEFUL EQUATIONS
Sens t v ty: True Pos t ves/(true pos t ves + alse negat ves)
Spe ty: True Negat ves/(true negat ves + alse pos t ves)
False Pos t ve Rate: 1 − spe ty
False Negat ve Rate: 1 − sens t v ty
Pos t ve Pre t ve Value: True Pos t ve/(true pos t ve + alse pos t ve)
Negat ve Pre t ve Value: True Negat ve/(true negat ve + alse negat ve)
712
28
be too late to intervene. Screening, however, can also give the
appearance o longer survival even though no additional li e
has been gained. T is is called lead-time bias. Here’s another
example. Mr. X has the test, is diagnosed with disease, receives
treatment, and dies 5 years later. Mr. Y is in the control group,
develops symptoms at year 4 o the study and dies one year
a er that. T ey have both lived or 5 years a er being random-
ized to screening or no screening. Mr. X and Mr. Y both die at
age 65 o the same disease. Did Mr. X have more survival time or
just more “disease time?” T is lead-time bias may be avoided by
using age-speci c mortality rates rather than survival time rom
diagnosis. “C,” veri cation bias, occurs when you are looking
at a new diagnostic modality, and patients with a negative test
result ( or the new test) are not evaluated with the gold standard
test. For example, veri cation bias could occur in a study where
people with a negative cardiac stress test do not proceed to a car-
diac catheterization. T is underestimates the prevalence o dis-
ease in the population studied (we don’t really know about those
who didn’t have a catheterization) and overestimates the value o
the stress test (seemingly, all patients with cardiac disease were
picked up by the stress test… but only because we didn’t look ar
enough). See able 28-2 or more types o bias ound in studies.
As part o a quality control study, the hemoglobin A1c val-
ues o patients with diabetes at two clinics are compared. In
a study o 4,000 patients, it is ound that the mean hemoglo-
bin A1c value in group 1 is 7.4%and the mean hemoglobin A1c
value in group 2 is 7.6%. T e authors did the correct statisti-
cal test and ound a p-value o 0.04 or this comparison.
Question 28.1.2 Based on this in ormation, you conclude:
A) Group 1 is signi cantly di erent rom group 2. Reject the
null hypothesis.
B) Group 1 is not signi cantly di erent rom group 2. Don’t
reject the null hypothesis.
C) Group 1 is not signi cantly di erent rom group 2. Reject
the null hypothesis.
D) Group 1 is signi cantly di erent rom group 2. Don’t reject
the null hypothesis.
 CHAPTER 28 • EVid ENc E-BASEd MEd ic iNE 713

TABLE 28-2 SOME COMMON TYPES OF BIASES/PROBLEMS SEEN IN STUDIES

Type o Bias E ect
c on rmat on B as Th s o urs when you only look or ata that supports your ontent on an gnore any n ormat on to the ontrary ( .e.,
i bel eve that the internet s ull o so opaths, i oul on rm that by rea ng omments un er v eos poste on relate
webs tes an gnor ng everyth ng else that woul suggest otherw se).

c on oun ers Th s o urs when two or more a tors are asso ate w th the out ome an only the one be ng stu e s a ounte or ( .e.,
(c on oun ng resear h shows that 9 out o 10 c ubs ans have annoy ng behav or, but 9 out o 10 c ubs ans are also runk when the annoy ng
var ables) behav or o urs; we o not a ount or the on oun ng var able ( runkenness), we may n orre tly assume that be ng a c ubs
an causes annoy ng behav or . . . wh h an’t poss bly be true . . . an t?).

Length t me b as Th s o urs be ause s reen ng tests are more l kely to n slow grow ng tumors rather than those that are rap ly grow ng. Th s
(not lea t me) an b as results n avor o s reen ng be ause more slow grow ng an ers w th a goo prognos s w ll be oun w th a s reen ng
test.

Sele t on b as Th s o urs when subje ts sele te or the stu y o not represent the ent re populat on you m ght see l n ally. For example,
they may be s ker or less s k than the pat ents n your pra t e or they may be ex lu e rom the stu y or another reason. For
example, let’s say we are o ng a stu y on renal a lure. i all pat ents w th abetes are ex lu e , we w ll not be able to apply the
results to our pat ents many o whom have renal a lure an oex st ng abetes. Th s s avo e by hav ng large, representat ve
samples w th ew ex lus on r ter a.

Spe trum b as Th s o urs a stu y s skewe towar a part ular group o pat ents, or example, those w th an NSTEMi. i you stu y NSTEMi
pat ents, you annot apply your results to pat ents w th other relate on t ons, su h as a STEMi or unstable ang na. Spe trum
b as s ommon n stu es; o ten the pat ents stu e at a tert ary are nst tut on f er n the sever ty o llness than those n
pr mary are pra t es (who n general ten to have less severe sease).

Per orman e b as Someth ng bes es what you bel eve s g v ng you your pos t ve (or negat ve) results s a tually a t ve. An example o th s s
estrogen or heart sease. c ase– ontrol stu es suggeste estrogen was ar o prote t ve, but t n’t pan out n ran om ze ,
ontrolle tr als. Thus, the pos t ve ef e t was ue to someth ng else; maybe the women on estrogen exer se more, maybe
they ha better ets, maybe they smoke less an were more ntereste n the r health overall. Ran om ze , bl n e tr als
prote t aga nst th s b as.

Answer 28.1.2 The correct answer is “A.” o answer this ques-

HELPFUL TIP:
tion, you have to know what the usual cuto or signi cance is
A type II error o urs when a stu y a ls to show a
or a p-value, and you also have to know what a null hypothesis
eren e where one ex sts. Th s may o ur be ause there
is. A null hypothesis is the hypothesis that there is no signi cant
are not enough subje ts n a stu y or when there s
di erence between two groups being compared to one another.
measurement error. For example, n a (real) stu y o
By setting up null hypotheses in this way, we can then search
lorazepam versus azepam or se zures, tw e as many
or proo that the null hypothesis is incorrect. ests o signi -
pat ents ha the r se zures stop w th lorazepam. How
cance are a method o looking or evidence that a null hypoth-
ever, the on lus on o the stu y was that there was no
esis is incorrect. T e p-value gives you the probability that the
eren e between the two rugs. Th s s only be ause
results o the study occurred by chance alone. A p-value o 0.04
there were not enough subje ts or th s to rea h stat s
means that i the study results were untrue, we would expect to
t al s gn an e. in lu ng another 100 subje ts may
see these results only 4% o the time by chance alone and not
have ma e th s rea h stat st al s gn an e. Remember
related to the study intervention. By convention, a p-value o
th s by “Type II error s too ew pat ents.”
0.05 or smaller is considered statistically signi cant. T us, when
you have a p-value o less than 0.05, you have evidence that the
null hypothesis is alse and can there ore be rejected.
Objectives: Did you learn to . . .
• Re ogn ze orms o b as n resear h stu es?
HELPFUL TIP: • d e ne p value an null hypothes s?
A type I error o urs when a eren e s oun when • d es r be the s gn an e o p value an type i error?
none s present. The p value prov es you w th the prob
• Re ogn ze a type ii error?
ab l ty o a type i error. For example, a p value o 0.05 s
ons ere stat st ally erent. What th s means, how
ever, s that 5% o the t me, the same on lus on woul CASE 28.2
be pro u e by han e alone. By ontrast, a p value o
0.005 means that there s only a 0.5% han e that the Being the compulsive physician that you are, you are spend-
on lus on s m staken an o urre by han e. The ing your Saturday morning relaxing by reading your journals
lower the p value, the lower the han e o a type i error. (we know who you are; you can’t ool us . . . or else why would
you be working through the EBM chapter?). You notice a
714 FAMiLY MEd ic iNE EXAMiNATiON & BOARd REViEW
study o particular interest on type 2 diabetes, using a novel
drug called Shugabegone (not a real drug), and note that the
data were analyzed in two ways. T e rst method used was
an “intention to treat” analysis. T e second method was by a
“per-protocol” analysis. Hmm, you think. T e per-protocol
data sure makes you want to start prescribing Shugabegone
or your patients with diabetes.
Question 28.2.1 Which o the ollowing applies to a per
protocol analysis?
A) It provides an objective description o how a new therapy
will work in our patient population.
B) It is more statistically stringent when compared to an
intention-to-treat analysis.
C) It allows the study authors to manipulate the outcome to
make it look better than it is.
D) You are wrong, Dr. Graber. I am not reading this chapter.
Answer 28.2.1 The correct answer is “C.” Per-protocol anal-
ysis allows the authors to make the outcome look better than it
is. o understand why, we must know the di erence between
an “intention to treat” analysis and a “per-protocol analysis.”
A per-protocol analysis allows the authors to manipulate the
results, usually in avor o the study drug. Here is an example:
“O all o the patients who were enrolled in this study, those
who took the drug at least 75% o the time were included
in the inal analysis.” here is a problem here. Many o our
patients will not take all o their medicine. Maybe they orgot
to take it. Maybe it had side e ects that were intolerable. I
we only analyze the patients who took all o their medication,
the drug will look better in the per-protocol analysis than it
will in our clinical practice where adherence to a regimen is
less than complete. You will see this in many papers. In some
papers, there is a “wash-in period” where everyone is given
the medication and only those who tolerate it or 2 weeks
( or example) continue to the main trial. he results here will
not be representative o our patients, many o whom may not
tolerate a medication. In summary, per-protocol analysis =
bad.
An intention to treat analysis analyzes all study patients in
the group to which they were originally assigned. In this case
(to continue the hypothetical study above), the authors do
not care i the patients took the drug 75% o the time. Even i
they never took the drug but were assigned to the treatment
group, they are analyzed in the treatment group. Many o these
patients likely would be treatment ailures making the overall
results look worse. However, the results will be more applicable
to our patient population, many o whom will not take their
medications properly. In summary, intention to treat analysis =
good.
“OK,” you think. “I’ll pay attention to the intention to treat
analysis.” So, you next look at the inclusion and exclusion
criteria. In this diabetes drug study, the exclusion criteria
include renal disease, a history o heart ailure, coronary
artery disease, and peripheral vascular disease.
Question 28.2.2 From this we can conclude:
A) T e patients in this study are so nely selected that the
results cannot be applied to our general clinic population.
B) T e results should be generalizable to our general clinic pop-
ulation given the act that the medication worked so well in
this study.
C) T is is an example o “selection bias.”
D) A and C.
E) B and C.
Answer 28.2.2 The correct answer is “D.” We cannot apply
these results to our general clinic patients. T ink about it: how
many o your diabetic patients have no renal disease, no history
o CHF and no history o CAD/PVD? Not too many. Many o
our patients with diabetes have at least some renal disease (pro-
teinuria). You always need to look at the inclusion and exclusion
criteria o a trial be ore you can determine i the trial is appli-
cable to your patients. T is is called “selection bias”; only select
patients are entered into the study.
T ere is also a phenomenon called “spectrum bias.” In the
case o spectrum bias, the patients in the study are di erent
than our patients; they may be sicker or not as sick. Case in
point: glycoprotein IIB/IIIA inhibitors or acute coronary syn-
drome (ACS). T e initial studies looked at patients going or
cardiac catheterization; it appeared there was a small bene t
here. But the drug companies then generalized rom these sick
patients to say that all patients with ACS should have glycopro-
tein IIB/IIIA inhibitors. You can’t do this. Most o our “ACS”
admissions turn out not to have ACS, and they will get bet-
ter regardless o what we do. T ey certainly don’t need glyco-
protein IIB/IIIA inhibitors. And, thank ully, these drugs have
allen out o avor.
HELPFUL TIP:
Subgroup analyses (you know, the “our rug worke n
women over 60” p t h) an only be use to generate a
hypothes s. Th s s alle the “derivation set.” Be ore
a ept ng t nto pra t e, a se on stu y o that sub
group, alle the “validation set” must be one. Th s s
always true. d on’t let them tell you otherw se.
Objectives: Did you learn to . . .
• d es r be an ntent on to treat analys s an ts value or apply
ng stu y results?
• Re ogn ze the ef e t o n lus on an ex lus on r ter a on
the appl at on o stu y results?
QUICK QUIZ: FEELiNG SENSiTiVE ABOUT
SOMETHiNG SPEc iFic ?
Which o the ollowing statements is true?
A) Speci city is the most important test characteristic when
trying to nd a very dangerous disease.
B) As sensitivity increases, speci city decreases.
 CHAPTER 28 • EVid ENc E-BASEd MEd ic iNE 715

C) Speci city need not be considered as long as a test is sensi- 0.1 99

tive enough. 0.2 98
D) As sensitivity increases, speci city increases.
0.5 96
The correct answer is “B.” As sensitivity increases, speci c- 2000
ity decreases. T is makes intuitive sense. T e more cases you 1 1000 90
500
detect, the more alse positives you will have. We can have a 2 200 80
sensitivity o 100% i , or example, we say that everyone with 100
WBCs in their blood and a cough has pneumonia. We will pick 50 70
5
20 60
up everyone with the disease (very sensitive) but also a lot o
10 10 50
patients without the disease (poor speci city…everyone has at 5 40
least one, lonely, white cell running around). Ideally, we would 20 2 30
like to have a diagnostic screening test with both high sensi- 1
20
30 0.5
tivity and high speci city. In reality, there is an inherent trade- 40 0.2
o between sensitivity and speci city—as sensitivity increases, 50 0.1 10
speci city decreases and vice versa. “A” is incorrect. Generally, 60 0.05
5
when it is very dangerous not to detect a disease, it is important 70 0.02
to have a highly sensitive test (one that will f nd “all” cases) with 0.01
80 0.005 2
an acceptable speci city. “C” is incorrect. T is is why both an 0.002
ELISA and a Western blot may be done when trying to detect 90 1
0.001
HIV. T e ELISA is very sensitive (will pick up the great major- 0.0005
95 0.5
ity o HIV cases) but is not very speci c (will categorize a lot o
patients who do not have the disease as positive). T e Western 98 0.2
blot is more speci c and will lter the true positives rom the
alse positives ound on the screening test (the ELISA). 99 0.1
Pre-Test Likelihood Post-Test
Probability (%) Ratio Probability (%)
QUICK QUIZ: ALL THAT GLiTTERS . . .
FIGURE 28-1. Repro u e rom the c entre or Ev en e Base Me ne.
Ava lable at http://www. ebm.net.
You are having a meaning ul discussion with an industry repre-
sentative (yeah, right). OK, let’s recalibrate. You are being sold a
package o goods by an industry representative. She says that i intensive therapy or their diabetic neuropathy. In the rst
their test or Dreaded Disease is positive, the likelihood ratio o group, those assigned to routine therapy, 10% o patients
the disease being present is 3. developed neuropathy. In the second group, those assigned
to intensive therapy, 2%o patients developed neuropathy.
Your response to this is:
A) “Great! T e disease is three times more likely to be present i Question 28.3.1 Using the data above, how many patients
the test is positive.” with diabetes need to be treated with intensive therapy to
B) “Not so great! A likelihood ratio o 3 is pretty much worth- prevent the development o one case o neuropathy?
less in di erentiating between those who are ill and those A) 10.
who are not.” B) 11.
C) “What is this likelihood ratio stu anyway?” C) 8.
D) “What happened to my ree lunch?” D) 12.5.
E) 25.5.
The correct answer is “B.” In a situation in which the pretest
probability o a disease is between 30% and 70%, a likelihood Answer 28.3.1 The correct answer is “D.” T e question is really
ratio can meaning ully reduce the possibility o disease presence asking, “What is the number needed to treat (NN )?” In this
only i it is < 0.1. In a situation in which the pretest probability o question, the absolute risk reduction is 8% (10% in control
a disease is between 30% and 70%, a likelihood ratio can mean- group vs. 2% in the treated group). T e NN is the number o
ing ully increase the possibility o disease presence only i it is patients who need to be treated to prevent one adverse outcome.
over 10. So, a likelihood ratio o 3 is more or less useless. Draw o calculate this, we need to know a ew other terms:
some lines on this and you will see what we mean (Fig. 28-1).
ARR = Absolute Risk Reduction = control group event rate
(CER) − experimental group event rate (EER).
CASE 28.3
NN = 1/ARR (in percent, so 8% = 0.08 and 20% = 0.20)
One common and debilitating complication o diabetes is
neuropathy. In a ( ctional) study by ooth E. Fairie et al., one Using the values given above, ARR = 10 − 2% = 8% and NN =
group had routine therapy and an experimental group had 1/0.08 = 12.5.
716 FAMiLY MEd ic iNE EXAMiNATiON & BOARd REViEW
T e anti-clotting properties o aspirin are well described. In
a ( ctional) trial studying the long-term outcome o stroke
patients by Don Sox et al., 1%o patients on long-term aspirin
therapy developed new onset o strokes and 50% o patients
without aspirin therapy developed new strokes.
Question 28.3.2 Using the data above, how many stroke
patients need to be treated with aspirin therapy to prevent
one new stroke (what is the NNT)?
A) 2.
B) 8.
C) 10.
D) 12.
E) 25.
Answer 28.3.2 The correct answer is “A.” Again, the NN is
the number o patients who need to be treated to prevent one
adverse outcome. NN = 1/ARR, where ARR = CER – EER.
Using the values given above, 50 − 1% = 49% = ARR and NN =
1/0.49 = 2 (well, really close to 2).
In a ( ctional) pharmaceutical study by Amanda Hugginkes
et al., Group A is the placebo group and Group B is the group
that received the actual new drug. Data were gathered on
Groups A and B and con dence intervals (CI) were calcu-
lated. Side e ect rates were calculated as a percentage o each
group.
Question 28.3.3 Using the 95% CI, which o the ollowing
group comparisons are statistically signif cantly di erent?
A) Group A CI 30% to 46% and Group B CI 44% to 88%.
B) Group A CI 10% to 30% and Group B CI 44% to 88%.
C) Group A CI 0.1% to 0.3% and Group B CI 0.2% to 0.4%.
D) Group A CI 88% to 90% and Group B CI 88% to 90%.
E) None o the above is statistically signi cant.
Answer 28.3.3 The correct answer is “B.” T e CI is a range o
possible high to low values o data. T e true mean is likely to
be in the speci ed range. In general, the larger the study group,
the more narrow the CI. When you have a large study, you are
more likely to get closer to the true value.
“B” is correct because when comparing the CI between
two groups, there is no overlap. When there is an overlap
o CI, as in the other options, the groups are not statistically
signi icantly di erent. For example, in answer “A” the true
mean value o Group A could lie anywhere between 30% and
46% (it could be 45%), and the true mean value o Group B
could lie anywhere between 44% and 88% (it could also be
45%); there ore, the groups have no statistically signi icant
di erence.
HELPFUL TIP:
c on en e intervals are usually g ven as “c i 95%,”
mean ng that there s a 95% probab l ty that the true
mean value w ll be w th n the c i. When look ng at c i
or relat ve r sk (RR), relat ve bene t, o s rat o, et ., re
member that the c i 95% rosses “1,” there s no er
en e between the groups. Thus, an RR o 4.2, c i 95% o
0.8 to 10 s ons stent w th a 0.8 t mes r sk or a 10 t mes
r sk (or bene t). However, s n e the c i 95% rosses “1,”
there s no real eren e between the groups.
HELPFUL TIP:
c on en e ntervals are use ul when eterm n ng the
magn tu e o a treatment e e t. For example, a RR
has c i 95% o 1.2 to 1.4, th s means there s a small
eren e (0.2–0.4 t mes) between the two groups, even
though t s stat st ally s gn ant. Remember, some-
thing that is statistically significant may not be clini-
cally significant. On the other han , the RR has a c i
95% o 10 to 20, th s s a major eren e between the
groups. Th s means that one group has a 10 to 20 t mes
greater r sk (or bene t epen ng on what s be ng
stu e ) than oes the other group.
In a ( ictional) clinical trial testing a new provider order
entry (POE) technology at Big Important University Hos-
pital, relative and absolute risk reduction is discussed.
A group o amily medicine residents at the hospital was
allowed to give verbal orders during their intern year and
averaged seven medication errors per year. In the residents’
second year, POE was instituted (in which physicians were
required to enter orders and alerts to medication errors were
given be ore nalization o orders), and the group’s medica-
tion errors dropped to an average of four per year.
Question 28.3.4 Which o the ollowing is true?
A) T e RR reduction is 43% and the absolute risk reduction is
three in medication errors.
B) T e RR reduction is 57% and the absolute risk reduction is
three in medication errors.
C) T e RR reduction is 43% and the absolute risk reduction is
our in medication errors.
D) T e RR reduction is 57% and the absolute risk reduction is
our in medication errors.
E) POE has ruined medicine. I quit! boo-hoo!
Answer 28.3.4 The correct answer is “A.” POE compared with
no POE (the control group) resulted in a 43% relative decrease
in the risk o a medication error— rom seven to our errors
per year (3/7 = 43%). T e di erence in the number o medica-
tion errors be ore and a er POE is three errors (7 − 4 = 3),
which is the absolute reduction in the risk o a medication error.
Now, think about this rom a pharmaceutical or medical device
representative’s point o view. Would you say (a) “We reduced
errors by 3 per year,” or would you say (b) “We reduced errors by
43%per year!”? T at’s how you sell a study.

Objectives: Did you learn to . . .
• c al ulate number nee e to treat?
• d f erent ate between absolute an relat ve r sk re u t on?
• Use on en e ntervals to eterm ne stat st al s gn
an e?
CASE 28.4
Mr. Handsome Q. Drugrep has come to tell you all about
Happy Lucky Golden Drug (HLGD) that is newly indicated
or the treatment o the Dread ul Yucks. As a primary care
doctor, you are concerned about better treatment o this dis-
ease. Current standard treatment involves ChemoRAdical
Pharmacotherapy (CRAP). Cure rates with CRAP are only
about 10%. Mr. Drugrep has a study that shows HLGD has
a 12%cure rate versus placebo. He’s very excited and expects
HLGD to be the new standard o care.
Question 28.4.1 To his argument, you appropriately
respond:
A) “Wow. HLGD is clearly superior to CRAP.”
B) “Hmm. HLGD is statistically no di erent rom CRAP.”
C) “Wow. HLGD is clearly superior to placebo.”
D) “Do you have ree samples o HLGD? Where’s lunch?”
E) “I need more in ormation be ore I can make an in ormed
decision.”
Answer 28.4.1 The correct answer is “E.” You need more in or-
mation. Be ore coming to market, a drug manu acturer must
demonstrate sa ety and e cacy o a drug. T e new drug may
or may not be compared with another currently available treat-
ment. Without a study comparing HLGD to CRAP, you cannot
say anything about how these drugs compare, even i HLGD
looks better versus placebo. In addition, “C” is incorrect because
the placebo results have not been given.
You ask Mr. Drugrep or more in ormation. He proudly tells
you the drug study involved 10,000 subjects with the Dread-
ul Yucks, randomly assigned to placebo (5,000) or HLGD
(5,000). All o the subjects completed the trial. At the end o
1 year, 400 subjects on placebo (8%) were cured and 600 sub-
jects on HLGD (12%) were cured.
Question 28.4.2 He correctly tells you that:
A) T e NN is 10,000.
B) T e number needed to harm (NNH) is 10,000.
C) T e relative bene t o HLGD versus placebo is 50% greater
cure rate.
D) T e absolute bene t o HLGD versus placebo is 50% greater
cure rate.
Answer 28.4.2 The correct answer is “C.” When looking at
drug studies, bene t is o en stated as “relative bene t” or rela-
tive risk reduction. In this question, 600/5,000 patients bene t
rom HLGD and 400/5,000 bene t rom placebo; thus, 200 more
patients are cured with HLGD, 200/400 = 0.5 = 50% relative
CHAPTER 28 • EVid ENc E-BASEd MEd ic iNE 717
bene t o the drug vs. placebo. T e absolute bene t is only
4% (12% cure with HLGD vs. 8% cure with placebo). For the
NN in this example, think about the previously given equa-
tion: NN = 1/ARR, where ARR = CER − EER. T e con-
trol group, the placebo, had a risk reduction o 8% (92% still
had disease); and the experiment group had a risk reduction
o 12% (88% still had disease). So, the ARR = 12% − 8% =
4%, and NN = 1/0.04 = 25. NNH cannot be calculated with
the in ormation available since the adverse event rate is not
known.
In real li e, there are o en more dramatic examples o how
relative and absolute risks di er. It may be stated that there is a
50% reduction in complications o diabetes using Drug A ver-
sus placebo. However, when translated into patients, this could
be 1/1,000 complications o diabetes in the drug group versus
2/1,000 complications o diabetes in the placebo group. T is is
a 50% relative decrease in adverse outcomes but in act may be
clinically meaningless. T e absolute risk reduction is 1/1,000 or
0.1%! T is ploy is o en used to make drug studies look good.
T us, anytime you are looking at a new drug, ask or the abso-
lute risk reduction and the NN and the NNH. Forget the rela-
tive risk reduction and the p-values.
Mr. Drugrep tells you that the adverse event rate or HLGD
is only 1%. Aren’t you impressed? But he rowns a little when
you want to know the NNH.
Question 28.4.3 To calculate NNH, you ask him or:
A) T e types o adverse events that occurred in the treatment
group.
B) T e percentage o adverse events that occurred in the con-
trol group.
C) T e percentage o adverse events with standard treatment.
D) T e cure rate in the treatment group.
Answer 28.4.3 The correct answer is “B.” Adverse e ects o a
drug will o en be reported as an absolute number, and here it
is 1%. So, the conclusion you are given by the pharmaceutical
industry may be 50%reduction in disease and only a 1%risk
o side e ects o the drug. Both o these statements are true, but
it’s an “apples and oranges” comparison. We pre er comparing
apples-to-apples (or corn-to-corn in Iowa). In order to directly
compare bene ts and harms, we need to know the NN and
the NNH.
Let’s say that when you ask Mr. Drugrep, he tells you that the
adverse event rate in the placebo group was 0.5%. Here’s the cal-
culation: NNH = 1/ARI, where ARI (absolute risk increase) =
risk in experiment group − risk in control group.
Using the numbers in this question: ARI = 1 − 0.5 = 0.5;
NNH = 1/0.5 = 2.
So, or HLGD, the NN is 25 and the NNH is 2. By the way,
the adverse event in question is dis guring, pain ul ear hair
growth. You will have to treat 25 patients with HLGD to cure
one case o the Dread ul Yucks; but with every two patients you
treat, one will have an adverse event. Demand NN and NNH:
how many patients who take the drug will bene t and how
many will be harmed?
718 FAMiLY MEd ic iNE EXAMiNATiON & BOARd REViEW
Objectives: Did you learn to . . .
• Employ c i n the analys s o ata?
• Analyze ata us ng r sk re u t on an relat ve bene t?
• Un erstan the mportan e o absolute r sk re u t on, NNH,
an NNT when l n ally apply ng ata rom a stu y?
CASE 28.5
Mounting paperwork and electronic medical record hassles
have played a role in your decision to make a career change.
You have ound a nice academic job with a research ocus—
minimal patient care, 10 weeks o vacation, no paperwork.
Your work centers on reducing the risk o stroke in patients
who have survived one stroke.
Question 28.5.1 This is an example o which category o
prevention?
A) Primary prevention.
B) Secondary prevention.
C) ertiary prevention.
D) Quaternary prevention.
Answer 28.5.1 The correct answer is “C.” T e idea behind
primary prevention, a big interest in primary care, is to pre-
vent a disease rom occurring at all by removing its cause (i.e.,
inf uenza vaccine to prevent illness rom inf uenza). Primary
prevention may occur in the healthcare setting but is o en in
the domain o public health. Secondary prevention detects
disease at an early stage so that intervention can prevent pro-
gression (i.e., Pap smears detecting dysplasia prior to cancer
declaring itsel or treating elevated cholesterol prior to vascu-
lar events). Your new job will be to study tertiary prevention:
the reduction in complications and mortality due to disease
a er it is recognized. T e line between secondary and tertiary
prevention can be blurry: some would consider preventing
another stroke “secondary” prevention and preventing stroke
complications (e.g., muscle atrophy and pressure ulcer) “ter-
tiary” prevention. T ere is no such thing as quaternary pre-
vention.
In between day-trading and co ee breaks, you plan to
study two groups o patients (A and B) to see i variable
XYZ makes any di erence in death or recurrent stroke.
here is no randomization and there are no interven-
tions. You are just reviewing records to see how each
group did. Subjects in Group A had a stroke and then had
another stroke or died a year later. Subjects in Group B
had a stroke but were alive with no recurrent stroke at the
time o the study. You assess the presence o XYZ in each
group.
Question 28.5.2 This type o study is called a:
A) Prospective study.
B) Case–control study.
C) Cohort study.
D) Randomized, controlled study.
Answer 28.5.2 The correct answer is “B.” A case–control
study, like this one, will look at select subjects who are catego-
rized based on outcome and try to nd associations with cer-
tain variables. Case–control studies do not ollow subjects over
time and there ore are not prospective. Cohort studies look at
groups starting at time zero and ollowing them or a speci ed
amount o time to nd an association between a variable and an
outcome. T e variable in question is not under the researcher’s
control. An example o a cohort study might be one looking at
the association between two di erent diets (e.g., high-protein
vs. high-carbohydrate) and the development o type 2 diabetes.
T e highest quality evidence is produced by a randomized,
double blind, controlled trial, in which the researcher has con-
trol over exposure to a variable and studies its e ect on an out-
come. In general, the strength o trial design goes: experimental
study > cohort study > case–control study > cross-sectional
study. Un ortunately, it is not possible to design randomized
controlled studies or all conditions. So, a well-done cohort
study may be the best we can do.
You are concerned about numerous con ounding variables in
your study population. Never ear!
Question 28.5.3 Your trusty statistician recommends the
ollowing in order to minimize con ounding:
A) Multivariate analysis.
B) Care ul calculation o p-values.
C) Matched controls and cases.
D) A and B.
E) A and C.
Answer 28.5.3 The correct answer is “E.” Con ounders can be
a serious threat to any study. Con ounders result rom extrin-
sic actors—things that may a ect the outcome and are also
associated with the variable but are not accounted or in the
study. As an example, a study may nd an association between
long-haul truck driving and lung cancer. I tobacco use was not
accounted or in this study, the results o the study would be
meaningless. obacco is a con ounder. It is always advisable to
look at a study with an eye or what con ounder might be miss-
ing. Con ounding can be limited by a study design that antici-
pates con ounders and matches controls and cases (“C”). It is
important to note that i you match your control and cases on
a variable, you can no longer study that variable as a potential
cause o the outcome. For example, i you match cases and con-
trols on county o residence among the truck drivers, you can
no longer explore county o residence as a risk actor or lung
cancer. Also, multivariate analysis (“A”) is a statistical method
that allows or adjustment o known con ounders. “B” is incor-
rect because p-value has nothing to do with con ounding but
will tell you whether the results should be considered signi -
cant or not.
When you review the literature, you nd that there are a
number o small studies looking at the e ect o variable XYZ
on stroke victims. You even nd a meta-analysis.

TABLE 28-3 FACTORS IN DETERMINING THE
JADAD SCORE FOR META-ANALYSES
Ran om zat on W th rawals an ropout Bl n ng
numbers
Question 28.5.4 I this is a well done meta analysis, you
should f nd all o the ollowing EXCEPT:
A) Statistically con rmed heterogeneity between the included
studies.
B) A thorough search or all valid studies.
C) An evaluation o whether estimates change with varying
assumptions.
D) T e exclusion o poor-quality studies.
E) T e studies included measure the same underlying e ect.
Answer 28.5.4 The correct answer is “A.” Hope ully, a meta-
analysis would con rm homogeneity between studies. For
example, i one study measured NIH stroke scale and another
measured patient quality o li e (the outcomes are hetero-
geneous), it would be impossible to combine the studies.
Although there is controversy regarding the appropriate use o
meta-analyses, they are o en used to study various outcomes
by combining smaller studies. A meta-analysis is a systematic
review that combines the results o previous studies to evaluate
the magnitude or direction o an e ect or to evaluate the e ect
on a subgroup. All valid studies looking at similar outcomes
should be included; poor-quality studies should be excluded.
T e Jadad score is one common way that studies are judged as
to their appropriateness or a meta-analysis ( able 28-3). Meta-
analyses should also include a “sensitivity analysis.” T is may
consist o excluding large studies and only analyzing smaller
studies. It may consist o changing the economic assumptions
in a cost-bene t meta-analysis. I the outcome is the same
either way, the result is said to be “robust.” I excluding some
studies or changing the underlying economic assumption
changes the result, one has to wonder about the quality o the
studies etc.
Objectives: Did you learn to . . .
• d e ne f erent types o prevent on?
• d e ne f erent stu y types?
• i ent y an a ount or on oun ng var ables?
• d es r be some hara ter st s o a meta analys s?
HELPFUL TIP:
You w ll see an n reas ng number o “non n er or ty”
stu es be ng one. What oes “non n er or” mean?
Bas ally, t means that two rugs have some overlap n
the r e a y. See F gure 28 2. d rugs Y s non n er or to
d rug X even though t may not ure as many pat ents.
“Non n er or” oes not mean “as goo as.” “B o reep”
(wh h s one o our avor te terms an rem n s us o
zomb es) o urs when rug Z s now ompare to rug
CHAPTER 28 • EVid ENc E-BASEd MEd ic iNE 719
Drug X Cure s %
“Biocre e p”: the ne w a ge nt Z
is compa re d to the ne w Cure s % Drug Y
a ge nt Y. Z is cle a rly infe rior
to X but is non-Infe rior to Y.
Ne xt a ge nt
Cure s %
Drug Z
He re , drug Y is non-infe rior to drug X e ve n though
it ma y not a ctua lly be
a s good a s the s ta nda rd tre a tme nt.
FIGURE 28-2.
Y. d rug Z s non n er or to d rug Y although t learly
ures ewer people than d rug X. Thus, the stan ar
aga nst wh h new rugs are ompare be omes pro
gress vely less e a ous (F g. 28 2). in another on ern,
resear hers an e ne the r own “marg n” o non n er
or ty. For example the marg n s “2” (as n some o the
new ant oagulant stu es), the new rug oul allow
up to tw e as many events (e.g., pulmonary embol ) as
the ol rug an st ll be ons ere “non n er or.”
CASE 28.6
Uh, oh . . . Here comes the math. T is section is important,
especially the concepts o positive and negative predictive
values (PPV and NPV) and the concepts o sensitivity and
speci city. You need not do the math i you do not want to
(although it is simple). Here is a summary:
Sensitivity: How o en the test will pick up the disease i
it is there. Sensitivity = true positives/(true positives + alse
negatives). Note that the sum o true positives + alse negatives
represents all o the people with disease.
Speci city: Speci city is de ned as the proportion o
patients who do not have the disease and who will test nega-
tive or it. Speci city = true negatives/(true negatives + alse
positives). Note that the sum o true negatives + alse positives
represents all o the people who do not have disease.
Positive predictive value: T e probability that someone with
a positive test actually has the disease. T is takes the prevalence
o a disease into account. For example, an individual with a pos-
itive HIV test who is an IV drug user is more likely to really have
the disease than a clean-living nun with a positive HIV test. In
the nun, the test is more likely to be a alse positive.
Number o true positives
PPV =
Number o true positives + Number o alse positives
720 FAMiLY MEd ic iNE EXAMiNATiON & BOARd REViEW

Negative predictive value: T e probability that someone with a TABLE 28-5 TABLE FOR QUESTION 28.6
negative test actually does not have the disease. Again, this takes
Actual Reception
the prevalence o the disease into account. So, or example, a
negative HIV test in an IV drug user rom Sub-Saharan A rica + −
with a CD4 count o 150/mm 3 and PCP is likely to be a alse
Test + 90 (true pos t ve) 5 ( alse pos t ve)
negative. Conversely, a negative HIV test in a nun, or example,
is likely to be a true negative. Re ept on − 10 ( alse negat ve) 95 (true negat ve)

Total 100 100

Number o true negatives
NPV =
Number o true negatives + Number o alse negatives
A new test, the “reception-o-meter,” has been developed that
can tell whether a cell phone will have reception in a given
area (allegedly better than a guy walking around asking,
“Can you hear me now?”). When compared with the gold
standard o turning on your cell phone and checking whether
you have reception or not, the new test has a sensitivity o
90%(will pick up a signal 90%o the time when there is one)
and a speci city o 95% (there are only 5% alse positives;
thus, 95%o the time when the reception-o-meter says there
is a signal, there will actually be one).
So how can you tell i the phone company is pulling a ast
one or i this is a good test? You need to know the PPV o the
test. In order to calculate the PPV, you need three pieces o
data: the sensitivity o the test (how o en the test will pick
up the “disease” i it is there), the speci city o the test (how
o en you will get a alse positive), and the prevalence o the
condition, which in this case is the prevalence o having cell
phone reception (in other words, the true amount o cell
phone reception in a given area).
You are currently in Los Angeles, attending a CME course
where the reception or carrier X is 99%. You check your
“reception-o-meter” and it says you have coverage. But does
this mean you have coverage?
In order to answer this question, you can use Bayes theorem
or set up 2 × 2 tables. Here’s the 2 × 2 table method. Begin
by drawing a 2 × 2 table and lling in what you know. See
able 28-4 and able 28-5.
So this makes it easy.
Sensitivity = a/(a + c),
Speci city = d/(b + d),
PPV = a/(a + b),
NPV = d/(c + d)
I we have 100 phones, the data will look like that above.
So let’s add actual numbers to the table (above). Let’s use a
population o 10,000. We multiply by the prevalence o recep-
tion to get the subpopulation totals. Ninety-nine percent o the
population has reception (99% prevalence). So, 99% preva-
lence × 10,000 = 9,900 with reception; 1% × 10,000 = 100
without reception. Once we have these numbers, we simply
multiply by the sensitivity and the speci city to get the exact
cell numbers to plug into the table above: 9,900 × 90% sensi-
tivity = 8,910 or cell A (“true positives”); 9,900 − 8,910 = 990
or cell C (“ alse negatives”); 100 × 95% speci city = 95 or cell
D (“true negatives”); 100 − 95 = 5 or cell B (“ alse positives”).
See able 28-6.
Once the table is lled in, these numbers can then be used to
calculate the PPV, using the equation above. In this case, a/(a +
b) = 8,910/8,915 = 99.9%.
For those who pre er the Bayes theorem method, here’s
how this approach is done. Bayes theorem shows the relation-
ships between sensitivity, speci city, prevalence, PPV, and
NPV. T e equation or PPV, derived rom Bayes theorem, is
shown as is the calculation based on the numbers rom the
question:
Number o true positives
PPV =
Number o true positives + Number o alse positives
Sensitivity × prevalence
PPV =
(Sensitivity × prevalence) + [(1 - speci city) × (1 - prevalence)]
0.9 × 0.99
= = 99.9%
(0.9 × 0.99) + [0.05 × 0.01]
TABLE 28-6 TABLE FOR QUESTION 28.6 AFTER ADDING
IN POPULATION DATA FOR 99% PREVALENCE
A ter Adding Actual 99% Prevalence

TABLE 28-4 SAMPLE TABLE Actual Reception

Test Disease + −

+ − Test + 8,910 5

+ a (true pos t ve) b ( alse pos t ve) Re ept on − 990 95

– ( alse negat ve) (true negat ve) Total 9,900 100

Total a+ b+ (99% prevalen e)

 CHAPTER 28 • EVid ENc E-BASEd MEd ic iNE 721

Question 28.6.1 What would the likelihood o not having 1,000 × 10% will get the same result or cell “c”); 9,000 × 95%
coverage be i the “reception o meter” had said you did not speci city = 8,550 or cell “d”; 9,000 − 8,550 = 450 or cell “b”).
have coverage (what is the NPV)? T ese numbers can then be used to calculate the PPV, using
A) 95%. the equation above. In this case, a/(a + b) = 900/(900 + 450) =
B) 90%. 66.7% (rounds to 67%). Using Bayes theorem, the equation is
C) 50%. as ollows.
D) 9%. Sensitivity × prevalence
E) None o the above. PPV =
(Sensitivity × prevalence) + [(1 - speci city) × (1 - prevalence)]

Answer 28.6.1 The correct answer is “D.” T e question asks 0.9 × 0.1
or the NPV—the likelihood o not having coverage i the recep- = = 66.7%
(0.9 × 0.1) + [0.05 × 0.9]
tion-o-meter is negative. T is also can be derived rom Bayes
theorem or calculated using a 2 × 2 table. For those o you who
pre er the Bayes theorem method, the equation or NPV, derived HELPFUL TIP:
rom Bayes theorem, is shown as is the calculation based on the A test that has a negat ve pre t ve value o 99% may
numbers rom the question. soun goo . But only 1% o the populat on has the s
ease, o ng no test w ll have a 99% negat ve pre t ve
Number o true negatives
NPV = value.
Number o true positives + Number o alse negatives

You are now in rural Russia where you were invited to help Question 28.6.3 Still in that remote tuberculosis in ested
with community e orts to ght multidrug resistant tubercu- region o Russia, we ask: What would the likelihood o hav
losis. Here cell phone reception is 10% or Carrier Y. You check ing coverage be i the “reception o meter” said you did not
your “reception-o-meter” and it says you have reception. have coverage?
A) 50%.
Question 28.6.2 What is the likelihood that your cell phone B) 40%.
actually will have reception i you try to make a call? C) 30%.
A) 91%. D) 1%.
B) 83%. E) None o the above.
C) 67%.
D) 16%. Answer 28.6.3 The correct answer is “D.” Again, you can use
E) None o the above. the 2 × 2 method or Bayes theorem. T e 2 × 2 table or this
question is the same as it was or the previous question (see
Answer 28.6.2 The correct answer is “C.” You can use the 2 × 2 able 28-7). However, unlike previously, you are asked or the
method or the Bayes theorem methods. likelihood o reception i the “reception-o-meter” said there was
Here’s what our 2 × 2 table looks like. See able 28-7. no reception. In other words, you have been asked to calculate
o convert to 10% prevalence, we start with a large baseline the alse negative rate (FNR) or this scenario. T e equation or
population and multiply by the prevalence to get the subpopu- the FNR is below.
lation totals (10% prevalence × 10,000 = 1,000 with reception; False negatives
90% × 10,000 = 9,000 without reception). Once we have the FNR = or
False negatives + true negatives
subpopulation totals, we multiply by the sensitivity and the
speci city to get the exact cell numbers (1,000 × 90% sensitivity c 100
= = 1%
= 900 or cell “a”; 1,000 − 900 = 100 or cell “c” (or alternately c+ d 100 + 8,550

TABLE 28-7 EXAMPLE OF A COMPLETED 2 × 2 TABLE FOR QUESTION 28.6.2

Be ore Adding Actual Prevalence A ter Adding Actual Prevalence
Actual Reception Actual Reception

+ − + −

Test + 90 5 Test + 900 450

Re ept on − 10 95 Re ept on − 100 8,550

Total 100 100 Total 1,000 9,000

(50% prevalen e) (10% prevalen e)

722 FAMiLY MEd ic iNE EXAMiNATiON & BOARd REViEW

You were not asked to calculate it, but there is also a alse posi- FNR: Patient has the disease but the test is negative.
tive rate (FPR), which is shown below. FNR = (FN/( P + FN)) = 25/100 = 25% FNR. Also calcu-
lated as 1 − sensitivity.
False positives
FPR = or FPR: T e patient has a positive test but does not have the dis-
False positives + true positives ease.
b 450 FPR = (FP/(FP + N)) = 200/900 = 0.22 or 22% alse posi-
= = 33%
a+ b 450 + 900 tive. Also calculated as 1 − speci city.

We are going to make another assumption here about the

Cervical cancer is a disease in which early detection can make
a great di erence in halting disease progression. One screen-
ing procedure or this disease is the Papanicolaou (“Pap”)
smear. In a ( ctional) study to assess the competency o tech-
nicians who read the Pap smear slides, a local lab checked
their technician’s work against patient records.
A total o 1,000 Pap smears were read. O these,
100 patients had cervical abnormalities based on biopsy
(gold standard). O this group, 75 had abnormal (positive)
Pap smears and 25 had negative Pap smears. T ere were
900 women without disease. O these 900 women, 200 had
positive Pap smears and 700 had negative Pap smears. Note
that these are example numbers only, have no basis in reality,
and do not ref ect the actual sensitivities and speci cities o
Pap smears.
prevalence o disease. T e prevalence is the proportion o
individuals who have the disease at any point in time. One
way to describe it is as ollows: prevalence = (( P + FN)/ otal
population) = 100/1,000 = 10% or prevalence o 100 per
1,000 people.
Question 28.6.5 Given the above results o the Pap smear
screening tests and i the prevalence o cervical abnormali
ties among women is 10%, then applying Bayes theorem,
we f nd:
A) T e PPV is 27%.
B) T e NPV is 96%.
C) T e PPV is 0.999.
D) Unable to solve the problem with data provided.
E) A and B.

Question 28.6.4 Using the data above, which o the ollow
ing is true about this survey o Pap smear technicians?
A) FNR is 20%.
B) FPR is 15%.
C) T e sensitivity o the Pap test is 75%.
D) T e speci city o the Pap test is 98%.
E) T e prevalence o cervical cancer in this sample is 7.5%.
Answer 28.6.4 The correct answer is “C.” T e sensitivity o the
test is 75%. Setting up the data in a 2 × 2 table, we are able to
answer the question. See able 28-8.
Sensitivity: Probability that a patient with the disease will
have a positive result.
Sensitivity = ( P/( P + FN)) = 75/100 = 0.75 or 75% sensitive.
Speci city: Probability that a patient without the disease will
have a negative test.
Speci city = ( N/(FP + N)) = 700/900 = 0.777 or about
78% speci c.
Answer 28.6.5 The correct answer is “E.” T e prevalence o a
disease is the proportion o individuals who have the disease at
a given point in time (( P + FN)/( otal population) = 0.1 or
10%).
T e PPV o a test is the probability that a disease exists
given a positive test result= P/( P + FP) or 75/275 = 27%.
So, a patient with a positive test result only has a 27% chance
o actually having the disease because there are so many alse
positives.
T e NPV o a test is the probability o no disease given a
negative test result ( N/(FN + N)) = 700/725 = 96%. So, a
patient with a negative test has a 96% chance o not having the
disease. T is is because there are ew alse negatives compared
with the size o the overall population. I , or example, there
were 200 alse negatives in the same population, the negative
predictive value would be only 700/900 = 78%.
Recall that 100 out o 1,000 women had positive biopsies and
thus had the disease regardless o what the Pap test said.

Question 28.6.6 How does the pretest probability o cervi

TABLE 28-8 EXAMPLE OF A COMPLETED cal abnormalities among women compare with the post
2 × 2 TABLE FOR QUESTION 28.6.4 test probability?
Pap Test A) Posttest probability is about three times greater than the pre-
Result Cervical Disease No Cervical Disease test probability.
Pos t ve True pos t ve (TP) = 75 False pos t ve (FP) = 200 B) Pretest probability is about three times greater than the post-
test probability.
Negat ve False negat ve (FN) = 25 True negat ve (TN) = 700 C) Posttest probability is 10 times greater.
Total TP + FN = 100 FP + TN = 900 D) Pretest probability is 10 times greater.
E) T e pretest and posttest probabilities are equal.

Answer 28.6.6 The correct answer is “A.” T e pretest prob-
ability is given above as 100/1,000 or 10%. We know that 10%
o the population has the disease. T e posttest probability is
de ned as the PPV. Remember rom above, the PPV o a test is
the probability that a disease exists given a positive test result =
P/( P + FP) or 75/275 = 27%. Comparing the two results,
pretest probability o 10% and posttest probability o 27%, we
nd that the posttest probability is about three times greater
than the pretest probability. I answer “E” were correct and the
pretest and posttest probabilities were equal, there would be no
point in doing the test.
Objectives: Did you learn to . . .
• d e ne an al ulate sens t v ty an then apply t to ata
nterpretat on?
• d e ne an al ulate spe ty an then apply t to ata
nterpretat on?
• c al ulate pos t ve an negat ve pre t ve values?
• Apply Bayes theorem to eterm ne the ut l ty o a test?
Clinical Pearls
A h ghly sens t ve test helps to rule OUT sease; a h ghly
spe test helps to rule iN sease.
A treatment that s statistically significantly super or to
pla ebo may not o er a clinically significant bene t. Use
l n al ju gment when nterpret ng stu y results.
c ompare number nee e to treat (NNT) w th number
nee e to harm (NNH) when ons er ng therap es, rather
CHAPTER 28 • EVid ENc E-BASEd MEd ic iNE 723
than rely ng on relat ve r sk re u t on. The same al ulat on
an be one or s reen ng tests (e.g., number o women
nee e to s reen to avo one breast an er eath).
d o not raw on lus ons rom subgroup analyses. The only
on lus on that an be rawn s, “Th s must be stu e .”
Re ogn ze that the ut l ty o a test s ont ngent upon the
sens t v ty an spe ty o the test an the prevalen e o
sease n the populat on be ng teste . There ore, a sens t ve
an spe test may have a low pre t ve value n a popula
t on w th very low sease prevalen e.
When evaluat ng a non n er or ty stu y, look or the “marg n”
use by the nvest gators. Th s s the max mum extent o
l n al eren e that w ll be ons ere non n er or (e.g.,
a marg n o 2 means tw e as many events an o ur n the
exper ment group an st ll be ons ere non n er or).
BIBLIOGRAPHY
Centre or Evidence-Based Medicine. Available at http://www.
cebm.net. Accessed on June 1, 2015.
Fletcher RH, et al. Clinical Epidemiology: T e Essentials. 5th ed.
Baltimore, MD: Williams & Wilkins; 2012.
Friedland DJ, et al. Evidence-Based Medicine. New York, NY:
McGraw-Hill; 1998.
Greenhalgh . How to Read a Paper: T e Basics o Evidence-
Based Medicine. 5th ed. West Sussex, UK: John Wiley and
Sons, Ltd, BMJ Books; 2014.
Pagano M, Gauvreau K. Principles o Biostatistics. 2nd ed.
Australia: Duxbury T omson Learning; 2000.
Patient-Centered Care
De se A. Ma t ez
Note: T is chapter deals with culturally responsive care and
patient sa ety. Because not all Black patients identi y as A rican
Americans, the authors have elected to use the term Black in
this chapter as inclusive o A rican Americans as well as those
individuals who are o A rican descent but may be rom another
country. T e authors have also elected to use the term Latino/a
when re erring to individuals o “Hispanic” descent realizing
that many individuals identi y strongly with their country o
origin. We understand the sensitivity o this terminology and
ask your understanding.
CASE 29.1
You are doing a locum tenens job in Arizona on the Navajo
reservation. You are seeing a lot o patients with diabetes,
which reminds you that Native Americans, Latinos, and
Blacks all have a greater incidence o diabetes compared to
the general U.S. population.
Question 29.1.1 Which o the ollowing is TRUE about the
age -adjusted incidence o diabetes in adults?
A) All Alaska Native and Native American tribes have a higher
incidence o diabetes than non-Hispanic Whites (NHW).
B) Cuban Americans and South Americans have a higher inci-
dence o diabetes than NHW.
C) Mexican Americans and Puerto Ricans have close to 90%
higher incidence o diabetes than NHW.
D) Pima Indians in Mexico have the same high incidence o
diabetes as the Pima Indians in Arizona.
E) Non-Hispanic Blacks have a lower incidence o diabetes
than Latinos in the United States.
Answer 29.1.1 The correct answer is “C.” Mexican Americans
and Puerto Ricans have a higher incidence o diabetes com-
pared with NHW (“non-Hispanic White” being the term used
by the U.S. Census Bureau). T e other statements are alse, and
here’s how they break down. Although their diabetes incidence
is increasing rapidly, Alaska Natives historically had a 5.5% age-
adjusted incidence o diabetes compared with 7.1% or NHW.
724
29
Cubans and South Americans actually have the same incidence
as NHW. T e Pima Indians in Mexico whose li estyle is not
sedentary and who eat a more traditional diet actually have a
diabetes incidence o about 7%, while those in Arizona have
an incidence o 38%. Non-Hispanic Blacks have an incidence
higher than those o Latinos and NHW but not quite as high as
the Mexican Americans and Puerto Ricans.
HELPFUL TIP:
Eth c a d cultu al g oups a e ot u o m om a ep
dem olog cal o cultu al bel e sta dpo t. He ce, the e
a e o te la ge d e e ces betwee d v duals a d
subg oups. Th s s compl cated u the by the act that
we all belo g to, a d a e lue ced by, mult ple d
e e t cultu al g oups. Although the e a e cultu al pat
te s w th healthca e, t y ot to adopt those patte s
as ste eotypes o the d v duals a d g oups.
You are seeing a 57-year-old Navajo male with poorly controlled
type 2 diabetes. You are trying to understand why his hemoglo-
bin A1C is so high since he has access to healthcare, medicines,
supplies, and an amazing doctor (i you do say so yoursel ). You
remember a lecture on culturally responsive patient-centered
medicine where they talked about investigating a person’s
health problem using both disease and illness models.
Question 29.1.2 The di erence between disease and illness
is:
A) Disease is the biomedical explanation o the health condi-
tion; illness is the patient’s experience and understanding o
their health condition.
B) Disease is chronic; illness is acute.
C) Diseases have known causes; illnesses do not.
D) Disease is more serious and requently needs treatment; ill-
ness will resolve without medical intervention.
E) Disease versus illness . . . really? Aren’t we just into some
phony semantics here?

Answer 29.1.2 The correct answer is “A.” Simply put, “dis-
ease” is the way that physicians understand a health problem
and “illness” is the way the patient experiences it. T e cultur-
ally responsive patient-centered model looks not only at the
pathophysiology o disease, which is the ocus o most o our
early medical training, but also at what the patient is experienc-
ing, how it impacts him or her, and what is the larger cultural-
social-personal context o that health condition. T e patient-
centered physician weaves back and orth between the disease
and illness model, diagnosing and treating both the disease and
the illness.
You want to ocus on your patient’s illness in the larger con-
text o his li e and avoid just discussing glucose metabolism,
diet, exercise, lab results, and medication adherence. (Your
usual approach o explaining diabetes and its complications
has not improved his control.) You ask him, “What has your
experience with diabetes been like?” And he looks at you
strangely and answers that it has been tough.
Question 29.1.3 One way to help get an understanding o
his belie s about diabetes would be to:
A) Ask i amily members or tribal medical personnel are will-
ing to share in ormation about the intersection o cultural
belie s and care, speci cally diabetes; i they share in orma-
tion on their cultural belie s, listen with understanding and
gratitude.
B) Do a literature search on Navajo health belie s with respect
to diabetes to help ormulate questions to ask him about his
potential cultural belie s.
C) Ask about his experiences and belie s about diabetes so you
can have a greater understanding about his belie s to com-
municate with him about care in a way to meet his needs.
D) All o the above.
Answer 29.1.3 The correct answer is “D.” Any o these options
may help you understand this patient’s health belie s. Commu-
nity members can be a good source o cultural patterns. Having
a general idea o a cultural belie system makes it easier to ask
question about whether those belie s apply in this case and how.
Asking the right questions will help to get more use ul in orma-
tion. T ere are some canned questions that can be o assistance,
including those listed here rom series o questions developed
by a psychiatrist-anthropologist named Arthur Kleinman:
• D) Explain the in ormation to a tribal leader and let the tribal
What do you call your problem?
• What do you think caused your problem?
• What do you think is going on with your body?
• How have you treated this?
• What do you think helps?
• Why do you think it started when it did?
• situation since this patient’s belie system is in contradiction
What does your sickness do to you?
• How severe is it?
• What do you ear most about your problem?
• What are the biggest concerns that your sickness has caused
or you?
CHAPTER 29 • PATiEn T-CEn TEr ED CAr E 725
• What kind o treatment do you think would be help ul?
• What are the most important results you hope to receive
rom the treatment?
HELPFUL TIP:
Do ’t eel l ke you eed to memo ze all these spec c
quest o s. r athe , ocus o ask g quest o s that el c t
o mat o about the pat e t’s ow health bel e s
a o judgme tal way. A othe use ul m emo c that
ca appl ed ma y d e e t co texts s “iCE,” wh ch
sta ds o ideas, co ce s a d expectat o s. Fo “ deas”
you m ght ask what the pat e t th ks s caus g h s/he
p oblem. Fo “co ce s” you m ght ask what he/she s
wo ed s caus g the p oblem. Fo “expectat o s” you
m ght ask what they th k w ll happe w th the p ob
lem a d what they a e expect g om the v s t o health
ca e system.
T is same patient develops severe osteomyelitis o his right
leg and is admitted to your inpatient service. He has not
responded to several weeks o appropriate IV antibiotics and
debridement. T e in ection is gradually spreading proxi-
mally, and a decision has been made with the patient that you
will proceed with a below-the-knee amputation. Although
you are con dent that this is the right clinical decision, you
worry about the act that Native Americans (Navajos report-
edly highest in the world), Latinos, Blacks, and people rom
lower socioeconomic backgrounds all have disproportion-
ally higher rates o limb amputation, even when adjusting or
incidence o diabetes. T e surgeon you are working with asks
you to obtain in ormed consent rom the patient (and you
thought you le scut work behind when you le residency).
You have heard that Navajos believe that talking about some-
thing bad happening (i.e., in orming them o the procedural
risks) makes those adverse events more likely to occur.
Question 29.1.4 How do you want to get in ormed consent
rom your patient?
A) Proceed with the in ormed consent with the ull explanation
o the bene ts and risks o the procedure.
B) ell him the bene ts but do not talk about the risks.
C) Share with him the percentage chance o a good outcome
and do not talk about the possible risks and complications.
leader decide what to communicate with the patient.
E) Explain the process o in ormed consent to the patient and
allow him to opt out o any part o the process he desires to
avoid.
Answer 29.1.4 The best answer is “E.” T is is a challenging
with modern Western medical practices. In order to create a
culturally responsive plan o care or the patient, we should try
to align our guiding medical principles with the patient’s cul-
tural belie s. Using the our guiding principles o medical ethics
(autonomy, bene cence, nonmale cence, and justice) is one
726 FAMiLY MEDiCin E EXAMin ATiOn & BOAr D r EViEW
way to work through this dilemma. Some would argue or “A”
because the patient cannot make an in ormed decision without
knowing the potential risks and bene ts (autonomy), and, “it’s
the law.” However, i the patient has traditional Navajo belie s,
proceeding with the ull in ormed consent may deter the patient
rom undergoing a bene cial or even li e-saving procedure,
which presents con ict with the principles o bene cence and
nonmale cence. “B” and “C” rely on stereotypes without mak-
ing sure o the patient’s belie s. Asking a tribal leader and/or
someone rom the tribe who works in medicine is an excellent
way o obtaining a cross-cultural perspective. However, ulti-
mately we need to respect the patient’s autonomy.
Your patient consents or the surgery with a request that
makes you uneasy—he wants to take the amputated limb
home with him a er the surgery. He shares with you his cul-
tural belie that his body needs to be buried whole in order to
cross over to the next world a er he dies.
Question 29.1.5 How should you NOT explain to him the
potential health hazards o taking an in ected limb home?
A) Explore how other people in the community who have had
amputations have managed this.
B) Explain to him that you understand his concerns; however,
the health risk o him taking the limb home ar outweighs
any other consideration so the limb will have to be disposed
o by standard hospital practice.
C) Allow amily members and community leaders to partici-
pate in the discussion i the patient wishes.
D) Negotiate a way where as much as possible his wishes could
be met, personal and public health and sa ety preserved, and
community and hospital regulations ollowed.
Answer 29.1.5 The correct answer is “B.” T e underlying
concern is that the patient’s wishes are in direct con ict with tra-
ditional medical practices. Although hospital policy may limit
your options, there is usually enough exibility to allow you to
accommodate the patient’s wishes at least to some degree. You
can use the LEARN mnemonic (Listen, Explain, Acknowledge,
Recommend, Negotiate) to help approach this cultural con ict.
First, you Listen to the patient’s perspective. O en you have to
probe with nonjudgmental questions to elucidate this. “C” can
provide some cultural context or both the Listening and Nego-
tiating phases. “A” would be part o Explaining your perspec-
tive. Next you Acknowledge both the di erences and similari-
ties between the two perspectives. T en you Recommend a plan
hope ully where you and the patient both get what you want.
Finally as in “D,” you may need to Negotiate.
Objectives: Did you learn to . . .
• Desc be some d e e ces d abetes p evale ce amo g
d e e t eth c g oups?
• Def e the te ms “d sease” a d “ ll ess?”
• Explo e a pat e t’s pe so al a d cultu al easo s o o
adhe e ce to t ad t o al med cal adv ce?
• Develop some tools o p ov d g ca e to pat e ts who have
health bel e s that d ve ge om those o t ad t o al Weste
med c e?
CASE 29.2
A young couple that just immigrated to your town rom Bos-
nia comes to your clinic because they are expecting their rst
baby. T e wi e is a healthy 23-year-old woman and in her rst
trimester o pregnancy.
Your scheduler knows that many Bosnians are o the Mus-
lim aith and has heard that emale Muslims are supposed to
re rain rom care by male physicians.
Question 29.2.1 When making the appointment or this
patient, the scheduler should:
A) Schedule her with the rst available OB provider, regardless
i it is male or emale.
B) Schedule her with the rst available emale OB provider.
C) Schedule her with your only Bosnian-speaking OB provider
who is male (this will cut down on the time needed or an
interpreter).
D) Ask i she has a pre erence rom whom she would like to
receive care and schedule her within her pre erred provider.
E) Schedule her with the OB provider who has the most experi-
ence and interest in working with patients rom diverse cul-
tures (maybe Dr. Smith since he eats out at a di erent ethnic
restaurant every night).
Answer 29.2.1 The correct answer is “D.” Although many
Muslim women would nd it inappropriate to have a male pro-
vider, this is not universally true. Besides, we are not even sure
this patient is o Muslim aith (only about 40% o Bosnians are
Muslim)! Cultural characteristics and belie systems are gener-
alizations that o en accurately describe a population. However,
i you extrapolate these generalized belie s to the individual, you
are engaging in stereotyping and may o en come to the wrong
conclusion.
HELPFUL TIP:
Use you k owledge o a pat e t’s cultu e as a sta t g
po t. Ask about a y assumpt o s o susp c o s a
o judgme tal way. Make su e you k ow how the be
l e appl es the cu e t co text.
When she arrives in your clinic, you realize she speaks no
English and her husband speaks only a little. Using his limited
English and some hand gestures, you eel that you could con-
duct an interview with them. Because you completed a course
entitled “Advanced Li e Support or Culturally Responsive
Care,” you are able to deal with such a situation! Your mind
dri s back to that course . . . ah, CME on the beach!
Question 29.2.2 You recall that “culturally responsive care”
is de ned as:
A) Learning about multiple cultures.
B) Being able to speak multiple languages.
C) aking diversity classes.

D) Adopting a set o cultural behaviors and attitudes that enable
you to deliver e ective medical care to people o di erent
cultures.
E) Hiring sta rom a variety o di erent cultures—pre erably
all good cooks who will provide some excellent ethnic cui-
sine.
Answer 29.2.2 The correct answer is “D.” While the other
answers are laudable goals, they do not de ne culturally respon-
sive care. Culturally responsive care is a set o behaviors and
attitudes that aims to help healthcare providers deliver better
care to patients rom many di erent cultures.
You rack your brain trying to remember why culturally
responsive care is important to you. You now regret skip-
ping some o the lectures to go snorkeling in those beauti ul
Hawaiian waters.
Question 29.2.3 Which o the ollowing is NOT a bene t o
providing culturally responsive care?
A) It allows ef cient use o time and resources.
B) It increases the chance o providing services that are consis-
tent with patient needs.
C) It might improve health outcomes or minority patients.
D) It might improve patient retention.
E) It is less expensive in the long run.
Answer 29.2.3 The correct answer is “E.” Culturally respon-
sive care allows you to use your time and resources ef ciently
to increase the likelihood that you will provide the services
your patient actually wants, and needs! T is can lead to
improved health outcomes or your patients, increased patient
satis action and retention o your minority patients (and per-
haps increase your patient satis action scores!). Un ortunately,
no studies so ar have shown that it can reduce your practice
costs.
HELPFUL TIP:
The n at o al Ce te o Cultu al Compete ce at Geo ge
tow U ve s ty has de t ed s x compell g easo s
that healthca e p ov de s should co po ate cultu ally
espo s ve ca e to the p act ce. They a e as ollows:
1. To espo d to cu e t a d p ojected demog aph c
cha ges the U ted States
2. To el m ate lo g sta d g d spa t es the health
status o people o d ve se ac al, eth c, a d cultu al
backg ou ds
3. To mp ove the qual ty o se v ces a d health out
comes
4. To meet leg slat ve, egulato y, a d acc ed tat o
ma dates
5. To ga a compet t ve edge the ma ketplace
6. To dec ease the l kel hood o l ab l ty/malp act ce
cla ms
CHAPTER 29 • PATiEn T-CEn TEr ED CAr E 727
Pondering this, you decide to try and provide culturally
responsive care to this Bosnian woman.
Question 29.2.4 Which one o the ollowing is NOT a step in
providing culturally responsive care?
A) Understanding your own culture.
B) Understanding others’ cultures.
C) Being rustrated with having to work with people di erent
than you.
D) Understanding how your patients’ cultural belie s a ect
their attitude toward healthcare.
E) Adapting your way o practicing to provide optimal care.
Answer 29.2.4 The correct answer is “C.” T e goal o culturally
responsive care is to provide better healthcare or patients rom
di erent cultures. Some o the speci c things this goal calls or
include:
• Being respect ul o potential cultural di erences
• Learning about other cultures
• Being aware o the health impact o cultural belie s and prac-
tices
• Being sensitive to patients’ needs
• Using interpreters when necessary
• Adapting practices to provide optimal care
An easy way to achieve these goals is by using the Berlin and
Fowkes’ LEARN model described earlier in the chapter.
HELPFUL TIP:
Wh le lea g a d espect g pat e ts’ d e e t cul
tu al bel e s s v tal, p ov d g good ca e does ot call
o accept g p act ces that a e det me tal to you pa
t e t’s health. But bewa e . . . the e a e ma y pote t al
eth cal d lemmas that ca occu whe t ad t o al West
e med c e te sects w th a cultu e that has ad cally
d e e t health bel e s. Ma y c oss cultu al med cal
dec s o s a e ot as black a d wh te as we would l ke
to th k. Weste med c e may have to be d a l ttle to
accommodate bel e systems.
Now that you are ready to proceed with caring or your
patient, the question o language comes up. Should you
use the husband to interpret (he seems to know a bit more
English)?
Question 29.2.5 To help guide you, you call your hospital
compliance of cer who tells you that:
A) It is Federal Law that you must provide an interpreter or
patients who need it, at your own cost i necessary.
B) It is Federal Law that patients must provide their own inter-
preters at their own expense.
C) Most insurance companies reimburse or interpreter services.
728 FAMiLY MEDiCin E EXAMin ATiOn & BOAr D r EViEW
D) Using amily and sta to translate rarely re ects current
practice standard.
E) T ere are no privacy concerns when using nonpro essional
interpreters.
Answer 29.2.5 The correct answer is “A.” T e 2010 census
ound that more than 60.6 million adults (around 21% o the U.S.
population) speak a non-English language at home, while
almost 13% o the U.S. population is oreign born. When the
healthcare pro essional does not speak the primary language
o the patient, there is potential or loss o important in orma-
tion, misunderstanding o physician instructions, and poor
shared decision-making. itle VI o the 1964 Civil Rights Act
requires healthcare pro essionals to provide interpreter services
or patients who need them, at the physician’s cost i necessary.
Failure to do so would quali y as discrimination and could be
prosecuted in a court o law. Un ortunately, most insurance
companies do not reimburse or these services. Interpreters can
be scarce and costly. As a result, many physicians use any help
they can get or translation, including sta members and amily
members who are bilingual; this leaves room or error (so, “D”
is a alse statement). Using a amily member as an interpreter
makes it hard or the patient to disclose private in ormation
they do not want known by the amily. Pro essional interpreters
have been trained and certi ed, while ad hoc interpreters o en
have no ormal training and can make translation mistakes.
Question 29.2.6 Regarding provision o healthcare, lan-
guage barriers may result in:
A) Increased risk o intubation or children with asthma.
B) Greater nonadherence to medication regimens.
C) Higher resource use in diagnostic testing.
D) Increased risk o drug complications.
E) All o the above.
Answer 29.2.6 The correct answer is “E.” Language barriers
have been associated with worse health outcomes to include
lower likelihood o having a usual source o medical care; lower
likelihood ollow-up a er an emergency room visit; greater
nonadherence to medication regimens; increased risk o drug
complications; impaired understanding o diagnoses, medica-
tions, and need or ollow-up; lower patient satis action; longer
medical visits; higher resource utilization; increase risk o intu-
bation or children with asthma; greater risk o being labeled
with psychopathology; and increased risk o leaving the hospital
against medical advice.
Question 29.2.7 What is the proper method to use an inter-
preter?
A) Address all questions to the interpreter while acing the
interpreter.
B) Address questions to the patient while looking at the inter-
preter.
C) Address questions to the patient while acing the patient.
D) Address questions to the interpreter while acing the patient.
E) Have the interpreter get you co ee while you muddle
through using gestures.
Answer 29.2.7 The correct answer is “C.” T e physician
should speak to and look at the patient; in other words, don’t
speak about the patient in the third person. Remember that
nonverbal communication is important even when common
languages are not shared. Be aware that seemingly universal
gestures such as the “OK” sign and a thumbs up may have di -
erent meanings in other cultures. T e physician should speak
clearly and give the interpreter time to translate questions and
answers. T e physician should periodically pause and ensure
that the patient understands the questions that are being asked.
Failure to look at the patient while asking questions impairs the
establishment o the physician–patient relationship and should
be avoided.
You remember rom medical school that there was disagree-
ment as to the degree that a medical interpreter should unc-
tion as a cultural advocate.
Question 29.2.8 Which o the ollowing would be the most
e ective pre -encounter instructions or your interpreter to
acilitate the best possible communication between you
and your patient?
A) “ ranslate word- or-word all that the patient and I say. You
may repeat phrases, but do not rephrase anything.”
B) “When clari ying, explaining or culturally translating con-
cepts, make sure that you are transparent (i.e., let the both
parties know what you are saying and why).”
C) “Be sure to culturally translate whenever you think it is
appropriate.”
D) “I the patient doesn’t seem to understand, go ahead and ex-
plain whatever you think that I mean.”
Answer 29.2.8 The correct answer is “B.” Ideally, an inter-
preter would do an exact translation. However, many con-
cepts do not translate literally or have very di erent meanings
depending on the context that surrounds them. Good inter-
preters are o en aware when the healthcare provider and the
patient do not have the same understanding o an event, con-
cept, or plan. In this case, the translator should be sure to let
each party know exactly what has been communicated. T is
eedback to each party is important so that the interpreter’s
moral values don’t get projected onto the patient and unduly
in uence decisions made by the patient. ransparency is thus
critical.
You remember that low literacy is associated with poor out-
comes.
Question 29.2.9 Which o the ollowing is NOT true?
A) Patients with low literacy have a 50% increased risk o hos-
pitalization.
B) Only hal o all patients take medications as directed.
C) Low literacy is a stronger predictor o a person’s health than
race.
D) Low literacy is only an issue among minorities and immi-
grants.

Answer 29.2.9 The correct answer is “D.” Poor health literacy
skills are a stronger predictor o health status than a person’s
race, age, income, socioeconomic status, or employment. T is
relationship holds across di erent racial and cultural groups.
Un ortunately, up to 90 million people in the United States have
low literacy skills and many are ashamed to share this with their
physicians. T is can lead to “noncompliance” because patients
cannot read prescriptions and other instructions. It is not sur-
prising, then, that low-literacy patients have an increased risk
o hospitalization. o help combat this problem, the National
Patient Sa ety Foundation (NPSF) launched the “Ask Me 3”
program (http://www.nps .org/?page= askme3). “Ask Me 3”
urges doctors to make sure their patients ask and understand
the answers to three simple questions: What is my main prob-
lem? What do I need to do? Why is it important or me to do
this? Other suggestions to improve communication include
(1) asking the patient to repeat instructions back to the physi-
cian (known as the “teach back”); (2) using basic, nonmedical
language when talking to patients; and (3) allowing patients to
talk uninterrupted at the beginning o the visit.
HELPFUL TIP:
Betwee 10% a d 40% o low come ch ld e have o
books at home. A qua te o college educated pa e ts
do ot ead to the you g ch ld e da ly. r each Out a d
r ead s a p og am des g ed to c ease ead g at home.
You ca employ th s p og am to help w th l te acy by
us g the SAFEr m emo c: Show the book ea ly the
v s t, Sha e the book w th the ch ld you sel (model g
the ead g o the pa e ts), Ask the pa e ts about ead
g; Assess the ch ld’s developme t a d the pa e t–ch ld
elat o sh p; g ve Feedback about what you’ve obse ved
the ch ld do a d about pa e ts’att tudes a d te act o s
w th the ch ld, E cou age the pa e ts to ead da ly to the
ch ld; Expla about l te acy developme t. Re e to the
l b a y a d l te acy p og ams, a d Reco d the cha t
what you d d. Othe tha g v g a book a d b e ly ead
g to the ch ld, you eed ot do all the act v t es at each
v s t. i you cl c s ot volved the p og am, you ca
get sta ted at www. eachouta d ead.o g.
Objectives: Did you learn to . . .
• Desc be ways wh ch you qu e about a pat e t’s
cultu ally elated health bel e s?
• Def e cultu ally espo s ve ca e a d u de sta d ts
mpo ta ce?
• L st some compl cat o s that ca occu as a esult o
la guage ba e s?
• Use te p ete se v ces e ect vely a d app op ately?
• Desc be the state o health l te acy the U ted States a d
ts mpact o populat o health?
CASE 29.3
You are seeing a 67-year-old Black male or the rst time in
your clinic. He claims to be healthy but has not seen a physi-
cian or over three decades. He says, “Doctors . . . I try to avoid
CHAPTER 29 • PATiEn T-CEn TEr ED CAr E 729
them. My wi e made me come today.” You tell him you are
going to take a history and then per orm a physical exami-
nation on him. A er you are done, you tell him you recom-
mend age-appropriate screening examinations or colon and
prostate cancers. T e patient politely declines both. You try
to explain the importance o screening to him.
Question 29.3.1 Which o the ollowing statements about
screening is INCORRECT?
A) Prostate cancer is a leading cause o death among Black
men.
B) Colon cancer is a leading cause o death among Black men.
C) T ere is clear evidence that screening or colon cancer
reduces mortality in Black men.
D) T ere is clear evidence that screening or prostate cancer
among Black men saves lives.
E) Prostate cancer disproportionately a ects Black men.
Answer 29.3.1 The correct answer is “D.” T ere is con ict-
ing evidence or screening or prostate cancer and its e ect on
mortality (see Chapter 16). Prostate cancer is the h leading
cause o cancer death overall in the United States, and the bur-
den o prostate cancer varies among di erent racial and ethnic
groups. Black men have about a 60% higher incidence and a
2.4- old higher mortality rate rom prostate cancer compared
with White men. Compared with White men, mortality rom
prostate cancer is 17% lower in Latinos and 55% lower in Asian
Americans and Paci c Islanders.
Your patient now agrees to colon cancer screening but still
declines prostate cancer screening (which is ne because that’s
what the USPS F recommends anyway!). Your examination
also revealed an elevated blood pressure (BP) o 160/90 mm Hg
with no abnormal cardiac, lung, or other organ system ndings.
Question 29.3.2 Assuming you con rm this elevated BP
reading at subsequent visits, which o the ollowing antihy-
pertensives would you recommend?
A) Hydrochlorothiazide.
B) Ramipril.
C) Minoxidil.
D) Atenolol.
E) Losartan.
Answer 29.3.2 The correct answer is “A.” While thiazide
diuretics are a good choice or most patients with hypertension,
they are an especially good choice in Blacks, who tend to have
extremely salt-sensitive hypertension. Blacks are more likely
than other patients with hypertension to have low renin lev-
els, which make them less likely to respond to ACE inhibitors.
β -Blockers also tend to be less e ective in Black patients. A rea-
sonable second-line therapy in this patient would be a calcium
channel blocker such as amlodipine.
Your patient agrees to your medication choice, but he wants
to know i the research on which you based your choice
included Black people. You can con dently say yes, knowing
730 FAMiLY MEDiCin E EXAMin ATiOn & BOAr D r EViEW
that the ALLHA trial speci cally addressed the issue o gen-
eralizability by making sure that about a third o the 33,357
subjects were Black. However, you know this has not always
been true in scienti c research. In act, you know that minor-
ities are very underrepresented in research data on which we
base our treatment choices.
Question 29.3.3 Which o the ollowing is NOT a reason why
there are ew minorities in research studies?
A) Past history o abuse leading to mistrust o the healthcare
system.
B) Lack o representation o minorities in the medical pro es-
sion.
C) Discrimination.
D) Overrepresentation o minorities in lower socioeconomic
status.
E) Minorities are more likely to volunteer or studies but are
generally excluded.
Answer 29.3.3 The correct answer is “E.” Minorities’ contact
with the medical system has been raught with abuse in the
past. Possibly the most egregious example o this is the uskegee
Syphilis Study where Black men with syphilis were recruited or
a naturalistic study o the disease in the 1930s. Over 400 Black
men with syphilis were recruited with 200 men without syphilis
as controls. T ere was no in ormed consent, and they were told
the lie that spinal taps (done or research) were a orm o treat-
ment. It was soon apparent that the death rate among those with
syphilis was about twice as high as it was among the controls.
When penicillin was ound to be e ective as a cure or syphilis
in the 1940s, the participants were neither in ormed nor o ered
treatment, so the naturalistic study could continue.
T ese and other examples o past mistreatment by the medi-
cal community may constitute a signi cant source o distrust by
minority patients, who are less likely to participate in research.
T ere have also been overt and subtle discriminatory barriers
against minority participation in clinical trials. Minorities are
more likely to come rom lower socioeconomic groups and
have less education, while research subjects are generally more
educated and o higher socioeconomic status. Finally, there is
a signi cant underrepresentation o minorities in the medical
pro ession. For example, even though Blacks comprise 13% o
the population, they are only 3.5% o the physician population.
All these problems lead to dif culties recruiting minority par-
ticipants or research trials.
Question 29.3.4 As o 2010, what percentage o Americans
belong to a minority group?
A) 15%
B) 20%
C) 25%
D) 36%
E) 62%
Answer 29.3.4 The correct answer is “D.” According to the
2010 US Census estimates, 36% o Americans are ethnic minor-
ities, up rom 31% in 2000 and 24% in 1990. Yet, only 10% o
physicians are rom underrepresented minority groups. T is is
problematic. T e lack o minority physicians leads to a discrep-
ancy in healthcare access. Data shows that minority physicians
are more likely to serve minority patients and are more likely
to serve in urban, underserved areas (where there tends to be
greater concentration o underprivileged patients).
HELPFUL TIP:
Pat e ts o all eth c backg ou ds co s ste tly ate
the elat o sh ps w th the phys c a bette whe
the phys c a s o the same eth c backg ou d.
Question 29.3.5 Which o the ollowing is NOT true?
A) Patients living in a low socioeconomic neighborhood have
an increased incidence o coronary artery disease.
B) Patients living in low socioeconomic neighborhoods have
an increased incidence o asthma.
C) Patients o the same minority group with a low socioeco-
nomic status have the same incidence o disease as those
with a high socioeconomic status.
D) Very low income Black children have a higher incidence o
asthma than White children o the same socioeconomic sta-
tus.
E) Patients rom disadvantaged neighborhoods have a higher
risk o developing most cancers and are less likely to receive
aggressive treatment once diagnosed.
Answer 29.3.5 The correct answer is “C.” Patients living in low
socioeconomic neighborhoods have increased incidences o cor-
onary artery disease, most cancers (lung, colon, cervical), dia-
betes, arthritis, accidents, adverse birth outcomes, and asthma.
T ey are also likely to obtain overall less care, less aggressive care
(except or limb amputations in diabetics), and are less likely to
have evidence-based care. Minority patients with higher socio-
economic statuses tend to have better health when compared
to their race-matched peers rom lower socioeconomic statuses.
Question 29.3.6 In taking care o Black patients, all o these
cultural patterns (not stereotypes) are help ul to keep in
mind EXCEPT:
A) Family relationships are extremely important.
B) Religion o en has a role in the patient’s li e.
C) It is expected that physicians will call patients by their rst
name.
D) Food has important cultural signi cance.
E) Nonverbal communication is o en as important as what is
verbally communicated.
Answer 29.3.6 The correct answer is “C.” People in the Black
community o en maintain extended amily ties and view
healthcare as a amily responsibility. T ere ore, physicians
should consider enlisting the amily’s help in taking care o an
ill amily member.
Religion is o en an important aspect in Black culture and
members o the clergy are highly respected in the community.
Churches are o en very help ul or community outreach e orts.

Evidence exists that the use o churches to conduct preventive
care services, such as immunizations and screening programs
or illnesses, leads to better patient compliance with preventive
guidelines. Some patients may view illness as a test o one’s aith,
and it is prudent or the physician to acknowledge and respect
the patient’s belie s and perception o illness to the extent that
it in uences their seeking or receiving healthcare. People rom
lower socioeconomic backgrounds have little choice but to eat
what is available at a low cost. T is means our advice to patients
to eat a well-balanced diet with resh ruit, lean meat, and resh
vegetables may be met with some challenges due to access to
these resources. Advising simple changes in diet including sub-
stituting sh or chicken or red meat in dishes, eating inexpen-
sive raw vegetables, modi ying cooking techniques, and chang-
ing to a vegetable-based rather than a meat-based diet may be
more likely to be success ul.
Communication is important, with individuals in the Black
community being particularly attentive to nonverbal aspects
o communication such as body language and voice in ection.
Respect is also emphasized in the culture, and patients o en like
to be addressed by their ormal titles and not their rst names.
Asking patients’ permission to call them by their rst names can
be appreciated.
In ormation using real-li e examples can be a use ul commu-
nication tool, instead o cold, dry data, or written messages (this
actually holds true or most patients o a variety o cultures!). A
use ul summary o general principles to keep in mind when car-
ing or Black patients is ound in an article on Preventive Care
or A rican Americans by Witt et al. (2002). T ey are as ollows:
• Gaining trust and understanding the historical distrust o
the healthcare system.
• Understanding and employing the kinship web in decisions
regarding screening and treatment.
• Involving the church in developing and delivering preven-
tion and care messages.
• Asking patients about the meaning o words or phrases.
• Asking patients about the use o alternative medicines and
herbs.
• ailoring messages about prevention to depictions o real-li e
situations.
• Paying attention to body language and other nonverbal com-
munication.
You have learned in medical school about the importance o
behavior change in the management o chronic diseases like
hypertension, heart disease, and diabetes, yet are rustrated that
you have less success in patients who come rom low socioeco-
nomic backgrounds or rom minority racial or ethnic groups.
Question 29.3.7 Which o the ollowing behaviors or attri-
butes is most strongly associated with your patient’s health
status:
A) Physical activity level.
B) Health insurance coverage.
C) Dietary choices.
CHAPTER 29 • PATiEn T-CEn TEr ED CAr E 731
D) Socioeconomic status.
E) obacco use.
Answer 29.3.7 The correct answer is “D.” All o the other
choices do have an impact on overall health. However, socio-
economic status has the highest correlation with a patient’s
overall health. It’s like U2 says in their song God Part II, “T e
rich stay healthy; the sick stay poor.” Socioeconomic status is a
key driver o health status.
HELPFUL TIP:
F esh p oduce s o te ot ava lable o qu te expe s ve
low soc oeco om c e ghbo hoods (a d good luck
d g susta ably caught Coppe r ve salmo ). P e
dom a tly Wh te e ghbo hoods have ou t mes as
ma y supe ma kets as p edom a tly Black a d Lat o
e ghbo hoods. Th s makes d eta y mod cat o espe
c ally d cult.
Objectives: Did you learn to . . .
• ide t y the mpact o ace o p eve t o a d ma ageme t
o ch o c d seases such as colo ca ce sc ee g a d
hype te s o ?
• Desc be ba e s to m o ty pa t c pat o esea ch stud
es?
• Expla the mpact o soc oeco om c status o a pat e t’s
healthca e?
• r elate cultu al patte s to the p ov s o o healthca e educa
t o a d se v ces?
CASE 29.4
Your next two patients are a couple o Cuban riends who
present to your o ce seeking a amily physician to take care
o their general health needs. T ey are both o Cuban descent
but one looks White and the other looks Black.
Question 29.4.1 Which o the ollowing assumptions is
correct?
A) Latino people are o one race.
B) Latino people can all speak English.
C) Latino people come rom many di erent countries and can
look di erent rom one another.
D) Latino people are not American.
E) Latino people all like to be called Hispanic.
Answer 29.4.1 The correct answer is “C.” T e term “Latino”
denotes an ethnic group who shares some cultural practices but
not necessarily other characteristics. Latinos comprise a sig-
ni cantly diverse group who may or may not speak Spanish or
English, may be o any race, hail rom di erent countries o ori-
gin, have di ering histories, socioeconomic status, and cultural
identities. Further, some eel the term “Hispanic” is derogatory,
re ecting their European ancestry, and may pre er the term
Latino. T irteen percent o the overall U.S. population now
identi es as “Hispanic or Latino,” which makes this population
the largest ethnic group in the United States. Latinos come rom
a broad spectrum o socioeconomic backgrounds and a variety
732 FAMiLY MEDiCin E EXAMin ATiOn & BOAr D r EViEW
o living conditions in the United States, which has an enor-
mous impact on immigrant and public health.
Despite the diversity represented within the Latino culture,
there exist shared values such as strong amily ties, with amilies
o en tending to be large and extended. Families requently serve
as the main source o support and share in decision-making.
Physicians with a warm bedside manner who demonstrate
appropriate respect (especially to the elderly) are appreciated.
HELPFUL TIP:
Desp te ala m st pa a o a om some pa ts o ou po
l t cal spect um, seco d ge e at o Lat o mm g a ts
a e as l kely to speak E gl sh as we e p o waves o m
m g a ts om Eu opea cou t es. Do ’t eve get us
sta ted o the absu d dea o bu ld g a wall.
Question 29.4.2 Which o the ollowing is FALSE regarding
health issues a ecting the Latino community?
A) In ectious diseases are common.
B) Fear o deportation prevents some rom seeking healthcare.
C) Latinos are less likely to obtain preventative healthcare in
comparison to Whites or Blacks.
D) Moving to the United States can paradoxically raise the risk
or habits that lead to illness such as obesity and diabetes.
E) Elderly Latinos have a higher mortality than their White
counterparts.
Answer 29.4.2 The correct, and alse, answer is “E.” Recent
immigrants are o en prone to in ectious diseases due to inad-
equate housing, sanitation, and/or immunizations. Many rea-
sons exist why patients may not get vaccinated. T ese include
disbelie in the need or the vaccine, being unaware o the vac-
cine, lack o patient education by a healthcare provider, lack o
transportation, and nancial restrictions.
Immigrating to the U.S. can result in worse nutrition, obe-
sity, a sedentary li estyle, and an increase in smoking and risky
sexual behavior in Latinas (women). T is translates, in part,
into a two old increased incidence o diabetes in Latinas. For
Latino males, there is an increased risk o drug abuse, alcohol
abuse, tobacco use, and driving under the in uence. T ese risks
increase the longer the patient lives in the U.S.
Latinos o en ail to get preventive healthcare. For example,
they have a lower rate o screening or diabetes and hyper-
tension than Blacks or Whites. Some avoid presenting or
healthcare because they ear being discovered by immigration
authorities. Complementary and alternative practices are also
common. Even though they are less likely to access healthcare,
older Latinos seem to have a similar or greater li e expectancy
than same-age Whites in the U.S. and enjoy lower mortality rates
rom cardiovascular diseases, cancer, and chronic illnesses. T e
risk o diabetes, however, is higher. T is phenomenon has been
described as “selective immigration” and implies a predilection
or healthier individuals to immigrate to this country.
You get into a discussion on race with your new Cuban
patients, and they point out several things to you that you
had not thought o be ore.
Question 29.4.3 Which o the ollowing is true about race?
A) It is a valid biological construct.
B) It is interchangeable with ethnicity.
C) All members o a certain culture are the same race.
D) It is a purely social construct.
Answer 29.4.3 The correct answer is “D.” Race is a much
politicized and emotionally charged topic in the history o
the U.S. Since the late 18th and early 19th centuries, attempts
have been made to validate race as being biologically based to
justi y discriminatory practices. However, the Human
Genome Project demonstrated conclusively that there is NO
biological basis or race. Humans share over 99.9% o their
DNA, and one cannot tell a member o one race rom another
on the basis o genetics. “B” is incorrect. While race and eth-
nicity are o en used interchangeably, they are not necessarily
equivalent. Race is an arbitrary social construct that is given
to people based on visual appearance, while culture re ers to
people with a common country o origin, a shared ancestry,
or a common history. Culture re ers to a speci c set o values,
belie s, and customs shared by members o a community. “C”
is obviously incorrect. People rom the same culture can be o
di erent races so one can have White and Black Latinos rom
Cuba, or example.
Question 29.4.4 Which o the ollowing health outcome dis-
parities is FALSE?
A) White Latinos have a higher incidence o breast and colorec-
tal cancer than Blacks and Non-Hispanic Whites.
B) Clinicians may order ewer diagnostic tests i they do not
understand a patient’s description o symptoms.
C) Clinicians may overcompensate by ordering more tests
when they do not understand what their patients are saying.
D) Minority children are more likely to be evaluated and
reported or suspected abuse even a er controlling or like-
lihood o abusive injury.
E) Blacks have the highest colorectal cancer mortality rates o
any group in the United States.
Answer 29.4.4 The correct answer is “A.” T e incidence o
colorectal and breast cancer is actually lower in White Latinos
than in other Non-Hispanic Whites and Blacks. However, this
does not always translate into less signi cant disease. T ere are
signi cant disparities in healthcare quality and outcomes or
minorities compared with nonminorities, even when control-
ling or possible con ounding actors, such as income, edu-
cation, and insurance. So even though Latinos have a lower
incidence o the above-named cancers, they have a similar mor-
tality when compared with non-Latinos. All o the rest o the
statements are correct. O particular note, Blacks have the high-
est colorectal cancer mortality rates. Also, o note is the act that
when toddlers o di erent races present with similar ractures,
minority toddlers are signi cantly more likely to be reported
or suspected abuse, even a er controlling or age, insurance
status, and likelihood o abuse. T is is a re ection o biases and
stereotyping.

HELPFUL TIP:
M o ty pat e ts a e s g ca tly less l kely to ece ve
app op ate pa med cat o , eve a te su ge y a d
lo g bo e actu es. Add t o ally, the e a e o te ew,
a y, pha mac es poo , e c ty a eas that have
a cot cs ava lable o pat e ts w th a p esc pt o . Th s
adve sely a ects the pa ma ageme t o m o ty pa
t e ts eve u the .
In general, mortality rates among racial and ethnic minori-
ties are higher or cancer, heart disease, diabetes, stroke, kid-
ney ailure, and HIV/AIDS. Minority groups are also dispro-
portionately a ected by asthma, lead poisoning, accidents,
homicides, and other environmental health concerns. Some
minorities experience higher in ant mortality rates and are
less likely to receive timely prenatal care. T ere are numerous
other examples o healthcare disparities that exist between
majority and minority groups. T ese include but are not lim-
ited to:
• In ant death rates or Blacks are twice that o Whites.
• Heart disease mortality rates are 40% higher in Blacks as
compared with Whites.
• Latinos are almost twice as likely as Whites to die rom dia-
betes and are more likely to be obese and have high blood
pressure than are Non-Hispanic Whites.
• Blacks are 13% less likely to undergo coronary angioplasty
and one-third less likely to undergo bypass surgery than are
Whites.
• Only 7% o Black and 2% o Latino preschool children hos-
pitalized or asthma are prescribed routine medications
to prevent uture hospitalizations compared with 21% o
White children (not in itsel a good re ection on our pro-
ession).
• T e length o time between an abnormal screening mammo-
gram and ollow-up diagnostic testing is more than twice as
long or Asian American, Latinos, and Blacks compared with
Whites.
• Minorities are less likely to get immunizations, mammo-
grams, and other preventive care, even when paid or by
Medicare.
• T ere are higher rates o un-insured and lack o physicians in
minority communities, leading to reduced access to primary
care.
• Minorities are less likely to get heart catheterizations, by-
pass gra ing, dialysis, lung cancer surgery, and organ trans-
plants.
• Blacks have 55% higher mortality rate and 6-year shorter li e
expectancy than Whites.
• Several studies show the deleterious e ect o discrimination
on health outcomes, including increasing the risk o diabetes,
hypertension, depression, and preterm birth independent o
other risk actors.
CHAPTER 29 • PATiEn T-CEn TEr ED CAr E 733
HELPFUL TIP:
Although pe haps ot ove tly ac st, the e s data that
suggests that u co sc ous b ases ca a ect ou ca e o
pat e ts. A well k ow study the n EJM 1999 ou d
that, all th gs be g equal, phys c a s we e 60% less
likely to e e Black wome o ca d ac cathete zat o
tha me a d Wh tes. Hope ully, by be g made awa e
o th s u co sc ous b as, ts e ect ca be m t gated a d
bette ca e p ov ded to all pat e ts.
Objectives: Did you learn to . . .
• Desc be some health d spa t es based o ace, cultu e, a d
eth c ty?
• Del eate the d e e ces betwee the te ms ace, cultu e,
a d eth c ty?
CASE 29.5
A 35-year-old comes to your o ce today to establish care with
you. You see the rst name o “Jenni er” is on the medical
record. T e patient is wearing a suit and tie, and has a male
style haircut. T e gender listed on the medical record or this
patient is emale. Clearly the gender identity o this patient
does not match the patient’s gender designated at birth.
Question 29.5.1 How do you establish rapport with this
patient and use correct terminology?
A) Ask the patient rst thing, “Are you a man or a woman?”
B) Use the name Jenni er as well as emale pronouns she/her/
hers
C) Introduce yoursel and your pre erred pronouns, and ask the
patient or their name and pre erred pronouns
D) Say that you are glad they are here and that you have never
had a patient “like them” be ore
E) Ask i he is rom Iowa as you have heard Iowa is actually a
pretty progressive state
Answer 29.5.1 The correct answer is “C.” Biological gender,
gender identity, and gender expression are all di erent. Bio-
logical gender is de ned by one’s chromosomes, hormones,
and reproductive organs. T e assignment o gender is gener-
ally done at birth based on the appearance o external genita-
lia. Some newborns might be born with ambiguous genitalia
though will ultimately be assigned a sex at birth o either male
or emale. Gender identity is a person’s innate, deeply elt psy-
chological identi cation which may or may not correspond to
the sex assigned to them at birth. Gender expressions are the
external characteristics and behaviors that are socially de ned
such as dress, grooming, mannerisms, and speech patterns.
T ese can widely vary and are accepted as masculine, eminine,
or neutral. ransgender is an umbrella term or people whose
gender identity is incongruent rom the gender assigned to
them at birth. It is important to maintain respect or patients
who identi y as transgender in order to establish rapport and
better care or the patient. Using pre erred names and pronouns
734 FAMiLY MEDiCin E EXAMin ATiOn & BOAr D r EViEW
is extremely important in helping to establish respect. A good
way to introduce yoursel to a patient would be: “My name is
Dr. X, my pre erred pronouns are she/her/hers or he/him/his,
what is your name and pre erred pronouns?”
HELPFUL TIP:
T a s t o g s the p ocess that some t a sge de
people go th ough to beg l v g the a med ge de
de t ty. Th s may o may ot clude cha g g phys cal
appea a ce a d d ess, t at g ho mo e the apy, a d
u de go g ge de co mat o p ocedu es a d/o
su ge y. T eatme t o t a sge de pe so s, clud g
ho mo e the apy a d su ge y, has bee deemed med
cally ecessa y to t eat ge de dyspho a. As w th eve y
commu ty, the e s a g eat deal o d ve s ty w th the
t a sge de commu ty a d each t a sge de pe so ’s
t a s t o s u que a d may o may ot clude eve y
th g l sted.
Jenni er indicates she actually pre ers to go by emale pro-
nouns as she is o the emale biological sex. However, she also
likes to identi y and express hersel as a male gender at times.
She returns to your o ce or an annual physical examina-
tion. She discloses on her intake orm that she is in a long-
term, monogamous relationship, but the sex o the partner is
not asked on your intake orm (which needs updating!) and
thus isn’t speci ed or you. She has regular periods and is not
currently on birth control.
Question 29.5.2 Which o the ollowing questions should
you ask the patient:
A) “Are you using condoms with sexual activity?”
B) “What does your boy riend/husband do or a living?”
C) “Would you like a pregnancy test today?”
D) “Are you sexually active with men, women, or both?”
E) You don’t address the subject as you assume she is sexually
active and already using protection to prevent pregnancy as
she is in a stable relationship
Answer 29.5.2 The correct answer is “D.” It can be very unin-
viting to patients when assumptions are made about having
an opposite sex partner or made at all! Knowing the patient’s
sexual identity (gay/lesbian, bisexual, heterosexual) as well as
their past, current, and anticipated uture sexual partner(s) and
behavior are essential to providing comprehensive preventative
screening and guidance. It is important to not assume (we can
all recall the old adage about what assuming does or an individ-
ual…) the sexual identity or behavior o the patient but rather
ask a complete sexual health history prior to o ering treatment
or care to the patient.
Objectives: Did you learn to . . .
• Desc be the d e e ces betwee b olog cal sex, ge de
de t ty, a d ge de exp ess o ?
• Establ sh appo t by el c t g p e e ed p o ou s?
• Obta a app op ate sexual h sto y w thout mak g
assumpt o s ega d g the pat e t’s ge de a d sexual
de t t es?
CASE 29.6
You are on the board o your hospital’s quality and sa ety
committee and you have been asked to address the issue o
a medication error. Ms. Jones, a 72-year-old patient with
diabetes who was hospitalized or an acute myocardial
in arction, died rom what seems to be a sudden cardiac
event. T is was unexpected as she was recovering rather
well. One o the nurses on the f oor had told her supervisor
that your partner, had written an order or 6.0 U o insulin;
but the new nurse, resh out o nursing school, had misread
this as 60 U o insulin and had proceeded to give the poor
lady that amount, precipitating the hypoglycemic event that
led to her death. T e nurse is distressed as she thought she
was only ollowing orders. Around your o ce, Your partner’s
handwriting is a thing o legend: many pharmacists have
had to call to double-check his prescriptions on more than
one occasion.
Question 29.6.1 Which o the ollowing would have been
an e ective way to prevent the type o error that occurred?
A) T e nurse should have called to con rm the dose o insulin
be ore giving it.
B) Writing out “units” rather than “U” and “6” instead o “6.0.”
C) Use o computerized physician order entry.
D) Having a clinical pharmacist as part o the team.
E) All o the above.
Answer 29.6.1 The correct answer is “E.” It is estimated that
between 44,000 and 98,000 deaths annually are attributable
to medical errors, most o which are preventable. Although
the numbers have been challenged, it is indisputable that
medical errors continue to contribute to adverse outcomes
in our patients. One o the large contributors to this is error
in dosing and administering medication. One o the leading
causes o medication errors is the use o potentially dangerous
abbreviations and dose designations. T e use o “U” as above
has been reported in the literature to be very problematic as
it can easily be misread as a zero or a our, leading to up to
10- old overdoses that can o en have terrible consequences
in patients using insulin. A decimal point may not be seen,
leading to a actor 10 error (60 units o insulin being given
rather than 6).
Question 29.6.2 Which o these would NOT be recom-
mended as a way to prevent prescription errors (we will
give you this one)?
A) Computerized order entry systems.
B) A brie notation o the purpose or the prescription.
C) Metric system or all therapies except those like insulin and
vitamins that use standard units.
D) Inclusion o age, and when appropriate, weight o the patient.
E) A trailing zero a er a decimal.

Answer 29.6.2 The correct answer is “E.” Nurses and pharma-
cists may not see the decimal point and thus give an order o
magnitude higher dose o medication. All o the other options
are recommended to help decrease medication errors and, thus,
adverse patient events.
Objectives: Did you learn to . . .
• r ecog ze some causes o med cal e o s a d ways to p e
ve t them?
QUICK QUIZ: HiPAA, HiPAA, HOOr AY!
Which o these is prohibited by Health Insurance Portability
and Accountability Act (HIPAA)?
A) Calling out patients’ names in the waiting room.
B) Leaving a message on a patient’s answering machine or
voicemail.
C) Releasing health in ormation to a specialist without patient
authorization i that in ormation is to be used or purposes
o treatment, payment, or health operations.
D) Faxing patient in ormation.
E) None o the above.
The correct answer is “E.” Since the HIPAA went into e ect,
many physicians have been con used as to what they can and
cannot do under the HIPAA law. Providers can still call out
patients’ names in the waiting room as long as you do not go
into particulars o their presenting complaint in ront o other
people (e.g., don’t say to the whole waiting room, “Ms. Smith,
I’m ready to check on your herpes in ection”). You may leave
a message on a patient’s voicemail i the patient has autho-
rized you to do so. You may ax in ormation once you veri y
the ax number is correct—but you can only ax to persons the
patient designates or consents to. I you ax health in ormation
to a wrong number, you are responsible and could be violating
HIPAA. Finally, HIPAA gives physicians broad leeway in shar-
ing in ormation with other physicians, provided the in orma-
tion is used or treatment, payment, and healthcare operations.
You must give a notice o your privacy practices to the patients
and ask them to sign a orm acknowledging receiving the notice
or make a good- aith e ort to get them to sign it.
Clinical Pearls
Always o e te p ete se v ces to a pat e t who does ot
speak E gl sh p ma ly. Whe us g a te p ete , ma ta
eye co tact w th a d add ess quest o s to the pat e t.
Do ot ove est mate the legal autho ty o the Health
i su a ce Po tab l ty a d Accou tab l ty Act (HiPAA).
CHAPTER 29 • PATiEn T-CEn TEr ED CAr E 735
T a sm ss o o p otected o mat o s allowable o o go
g pat e t ca e.
Do ot make assumpt o s about sexual ty o ge de . S mply
ask.
Eve yo e possesses u co sc ous b ases. U co sc ous
b ases a ect the ca e o pat e ts. S mply ecog z g these
b ases may m t gate the det me tal e ects o pat e t
ca e.
Ge de de t ty a d ge de exp ess o a e a ected by but
sepa ate om sex ass g ed at b th. E qu e o t a sge de
pat e ts the p e e ed p o ou s.
i add ess g o adhe e ce, co s de a pat e t’s cultu al
backg ou d a d e qu e to how the cultu al bel e s may
co l ct w th those o t ad t o al Weste med c e.
BIBLIOGRAPHY
American Medical Association. Cultural Competence Compen-
dium: Section IV: Specif c Populations Needs and Resources.
Chicago, IL: American Medical Association Press; 1999:
pp. 153–178. Available at http://ww4.mgh.org/Physicians/
Shared%20Documents/physicianCulturalCompendium.
pd . Accessed September 24, 2015.
Diaz VA Jr. Cultural actors in preventive care: Latinos. Prim
Care. 2002;29(3):503–517.
Human Rights Campaign. Sexual Orientation and Gender
Identity De nitions. Available at http://www.hrc.org/re-
sources/entry/sexual-orientation-and-gender-identity-
terminology-and-de nitions. Accessed September 24,
2015.
Institute o Medicine Committee on Understanding and
Eliminating Racial and Ethnic Disparities in Healthcare.
Smedley BD, Stith AY, Nelson AR, eds. Unequal Treat-
ment: Con ronting Racial and Ethnic Disparities in Health
Care. Washington, DC: National Academies Press; 2003.
Available at http://books.nap.edu/books/030908265X/
html/. Accessed September 24, 2015.
National Center or Cultural Competence. Available at http://
nccc.georgetown.edu. Accessed September 24, 2015.
National Coordinating Council on Medication Error Report-
ing and Prevention. Recommendations to enhance ac-
curacy o prescription/medication order writing. Revised
October 22, 2014. Available at http://www.nccmerp.org/
recommendations-enhance-accuracy-prescription-
writing. Accessed September 24, 2015.
Witt D, Brawer R, Plumb J. Cultural actors in preventive care:
A rican-Americans. Prim Care. 2002;29(3):487–493.
Yarnall KS, Pollak KI, Østbye , et al. Primary care: is
there enough time or prevention? Am J Public Health.
2003;93(4):635–641.
Final Examination
Jas K. W bur, Mark A. Graber, a d Br g E. Ray
30
T is is your nal examination. See how you do. . . . 5) You admit a patient to the hospital a er an episode o
chest pain. T e patient has a history o chronic kidney disease
1) Which o the ollowing IS NO an absolute contraindica- stage 4, type 2 diabetes mellitus, hypertension, hyperlipid-
tion to cardiac exercise testing? emia, and obesity. At time o admission, troponin is elevated
A) Unstable angina. at 0.06 (normal < 0.03). T e medical student rotating with
B) Recent pulmonary embolism. you on her amily medicine clerkship asks the signi cance
C) Active pericarditis. o the elevated troponin. You tell her which o the ollowing?
D) Le bundle branch block. A) An elevated troponin is always indicative o cardiac
ischemia/in arct.
See question 2.2.2. B) roponin rises be ore creatine phosphokinase (CPK) and
stays elevated or a longer period o time.
2) Which o the ollowing is the pre erred antiplatelet drug C) Pulmonary embolism and renal ailure are two causes o an
or treating chest pain in the emergency department? elevated troponin.
A) Aspirin 81 mg PO. D) CPK is overall the most sensitive (but not speci c) cardiac
B) Aspirin 325 mg PO. marker or cardiac ischemia.
C) Clopidogrel 75 mg PO.
D) Clopidogrel 300 mg PO. See question 2.1.2 and Helpful ip.
E) 2B/IIIA glycoprotein inhibitor.
6) Which o the ollowing is true in a patient with known
See question 2.1.4. coronary artery disease?
A) A coronary calcium score will help to risk strati y this patient.
3) T is ECG, shown in Figure 30-1, represents a(n): B) T e LDL goal is 70 mg/dL or less.
A) In erior wall MI. C) A high sensitivity CRP (hsCRP) will help to risk strati y this
B) Anterior wall MI. patient.
C) In erolateral MI. D) T ere is no LDL goal. Just start a maximal dose o a statin at
D) Normal ECG. time zero; there is no need to titrate the statin up.
E) Pericarditis.
See questions 2.22.4 and 2.22.7.
See question 2.17.3.

4) T e most appropriate initial treatment o this rhythm in a 7) Which o the ollowing IS NO a contraindication to the
stable patient, shown in Figure 30-2, is: use o tPA in MI?
A) Amiodarone. A) Blood pressure o > 180/110 mm Hg.
B) Adenosine. B) Noncompressible vascular puncture (e.g., subclavian line).
C) Diltiazem. C) Major surgery within 3 weeks.
D) Lidocaine. D) Menstrual bleeding.

See question 2.3.5. See question 2.1.10 and able 2-1B.

736
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1 .
737
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F
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2 .
 CHAPTER 30 • Fin Al ExAMin At io n 739

8) Which o the ollowing IS NO necessary or a class 1 indi- 13) Human papilloma virus (HPV) vaccine is indicated or
cation or tPA in a patient with an acute myocardial in arc- all o the ollowing EXCEP :
tion? A) All otherwise healthy 11- to 12-year-olds (boys and girls).
A) Greater than 1 mm S elevation in 2 or more contiguous B) A 39-year-old emale who has never been sexually active.
leads. C) An 18-year-old male with known HPV.
B) Pain or less than 2 hours. D) Immunosuppressed 15-year-old emale who is HIV positive.
C) Age < 75. E) A 22-year-old emale with cervical dysplasia.
D) New complete bundle branch block and typical history sug-
gestive o MI. See question 14.5.3.

See question 2.1.10 and able 2-1A. 14) opical tretinoin (Retin-A) is most e ective in what kind
o acne?
A) Cystic/nodular.
9) Your patient has an elevation o his liver unction tests
B) In ammatory papular.
(LF s) a er starting an HMG-CoA reductase inhibitor (i.e.,
C) Pustular.
statin). When would you consider stopping this patient’s
D) Comedonal.
HMG-CoA reductase inhibitor?
A) Doubling o LF s.
See question 17.8.3: Helpful ip.
B) ripling o LF s.
C) Quadrupling o LF s. 15) In a study o drug A, 50%o patients in the treatment arm
D) Only when there is biopsy evidence o bridging brosis. bene t versus 25%in the placebo group. What is the number
needed to treat?
See question 2.22.8. A) 2.
B) 4.
10) Which medication(s) is (are) indicated in a patient with C) 6.
atrial brillation and a CHA2DS2-VASC score o 2? D) 8.
A) Aspirin.
B) War arin, rivaroxaban, dabigatran, or apixaban. See question 28.3.1.
C) Aspirin-dipyridamole (Aggrenox).
D) Clopidogrel. 16) You are seeing a 27-year-old male in your clinic or evalu-
E) Heparin IV. ation o a rash which began about 2 days ago and is erythema-
tous and macular with a pale center. He notes the rash itches.
See question 2.4.1 and able 2-6B. He denies any new lotions or creams. He has had recent cold-
like symptoms including a sore throat. He has a past history
only notable or chicken pox as a child. He is sexually active
11) Which o the ollowing DOES NO improve cardiovas- with several emale partners. You diagnose him with erythema
cular mortality in systolic heart ailure (heart ailure with multi orme. He asks what could have trigged this. You counsel
reduced ejection raction or HFrEF)? him that the most common cause o erythema multi orme is:
A) Digoxin. A) Herpes zoster.
B) Spironolactone. B) Streptococcal pharyngitis.
C) ACE inhibitors. C) Genital herpes.
D) Beta-blockers. D) Rhus exposure (“poison ivy”).
See question 2.7.7. See Chapter 17 Quick Quiz: Erythema Multiforme.

12) Which statement is true regarding gastric lavage in a
patient with a toxic ingestion?
A) Gastric lavage is o bene t even i it has been more than
1.5 hours, but less than 4 hours, since the ingestion.
B) Gastric lavage should be done until the returned material is
clear (maximum o 10 L).
C) Gastric lavage is associated with esophageal injury and aspi-
ration.
D) Gastric lavage is indicated or petroleum distillates within
1 hour o ingestion.
See question 1.1.2.
17) “Sensitivity” is best de ned as:
A) rue positive rate/(true positive rate + alse-negative rate).
B) rue positive rate/(prevalence o disease).
C) rue positive rate/(true positive rate + true negative rate).
D) rue positive rate/(true positive rate + alse-positive rate).
See Case 28.6.
18) Which o the ollowing is true regarding isotretinoin
(Accutane)?
A) Women should be on one orm o birth control be ore using
this drug.
740 FAMil Y MEDiCin E ExAMin At io n & Bo ARD REViEW

B) Pregnancy should be avoided or 3 months a er discontinu- 24) What is the appropriate course o action a er treating a
ation o this drug. child with croup with inhaled epinephrine?
C) Monthly pregnancy tests should be done on all women o A) Admission or observation.
reproductive age. B) Admission i room air oxygen saturation is less than or equal
D) Isotretinoin may increase the HDL. to 95%.
C) Observation or 12 hours ollowed by discharge i stable.
See question 17.8.4. D) Observation or 2 hours ollowed by discharge i stable.

See question 1.24.5.

19) In general, what will happen with an innocent ow
murmur during a Valsalva maneuver? 25) Which o the ollowing is NO included in the “drug
A) It gets louder. cocktail” or the unconscious patient?
B) It gets so er. A) Glucose.
C) It is unchanged in volume. B) T iamine.
D) T e sound becomes more harsh. C) Naloxone (Narcan).
E) It disappears entirely. D) Flumazenil (Romazicon).

See question 14.3.1. See question 1.20.1.

20) What blood level o morphine is the most appropriate 26) Which o the ollowing is indicated in the child with
when treating pain rom a terminal cause? croup (laryngotracheobronchitis) presenting to the emer-
A) 1 µg/dL. gency department?
B) 5 µg/dL. A) Amoxicillin.
C) 10 µg/dL. B) Azithromycin.
D) Blood levels are irrelevant in determining the appropriate C) Dexamethasone.
dose o morphine. D) Oral theophylline.

See question 27.2.4: Helpful ip. See question 1.24.4.

21) Which o the ollowing is NO seen with an anticholin- 27) You are evaluating a 22-year-old woman in the ED who
ergic overdose? presents with le -sided pelvic pain. She is sexually active
A) Dry, ushed skin. with men and does a poor job o remembering her oral con-
B) Miosis. traceptive; condom use is only sporadic. Her last menses was
C) Con usion. 6 weeks prior. You are concerned about a possible ectopic
D) Low-grade ever. pregnancy. Which o the ollowing is true?
A) A negative pregnancy test e ectively rules out ectopic preg-
See Chapter 1 Quick Quiz: oxidromes and able 1-1. nancy.
B) Absence o an adnexal mass e ectively rules out ectopic
pregnancy.
22) Which o the ollowing IS NO a cause o an elevated C) Every woman o reproductive age with a uterus in the ED
anion gap acidosis? with abdominal pain is pregnant until proven otherwise.
A) Methanol and other ingestions (e.g., salicylate). D) T e hCG should double every 5 days early in a normal preg-
B) Diabetic ketoacidosis. nancy. Any less than this is indicative o an ectopic preg-
C) Uremia. nancy.
D) GI bicarbonate loss.
See questions 1.19.1 and 1.19.4.
See question 1.4.3 and able 1-3.
28) Which o the ollowing is the best drug indicated or dys-
23) Reper usion o extremities in hypothermia can cause all pnea in the terminally ill patient?
o the ollowing EXCEP : A) Buccal scopolamine.
A) Acidosis. B) Lorazepam or other benzodiazepine.
B) Hypokalemia. C) Morphine or other opiate.
C) Paradoxical central temperature drop. D) Nebulized lidocaine.
D) Arrhythmia. E) Albuterol via inhaler.

See question 1.12.3. See question 27.1.6.

 CHAPTER 30 • Fin Al ExAMin At io n 741

29) What is the one best drug to reduce headache and con u- 34) Which o the ollowing is true regarding Barrett esopha-
sion secondary to CNS tumor with surrounding edema? gus?
A) Acetaminophen. A) All patients with GERD should have an endoscopy to stage
B) Dexamethasone. their disease vis-à-vis Barrett esophagus.
C) Morphine. B) Barrett esophagus is a change rom the normal columnar
D) Sumatriptan. epithelium to squamous epithelium.
C) Barrett esophagus is present in > 50% o patients with GERD.
See Chapter 27 Quick Quiz: More than a little headache. D) Barrett esophagus can regress with adequate treatment o
GERD.
30) You are called by an anxious mother about her 3-year-
old daughter who accidentally ingested lemon-lime smell- See questions 7.1.2 and 7.1.5.
ing household cleaner at her grandparent’s house thinking it
was soda. Mom has been instructed by her parents, who were 35) Which o the ollowing lesions is considered premalig-
born in the late 1950s, that she should give ipecac to induce nant on colonoscopy?
vomiting o the substance. You counsel her that ipecac: A) Sessile polyp.
A) Should not be used. B) Hyperplastic polyp.
B) Can be used i the ingestion may cause mental status C) ubular adenoma.
changes. D) Pedunculated polyp.
C) Is e ective i used within 30 minutes o an ingestion.
D) Is available over the counter in American pharmacies. See question 7.5.2: Helpful ip.

See question 1.1.1 and Helpful ip. 36) Which o the ollowing histories in a patient with GERD
is most concerning or serious underlying disease?
31) How requently should methadone be dosed when used A) Food bolus impaction on two separate occasions.
or pain control in the terminally ill? B) Dysphagia to solids ollowed in several months with dys-
A) Once daily. phagia to liquids.
B) Every 8 to 12 hours. C) Re ux o undigested ood at night.
C) Every 4 to 6 hours. D) Halitosis.
D) Methadone should not be used or pain management in the
terminally ill. See question 7.1.1.

See question 27.2.6: Helpful ip. 37) Which o the ollowing is an appropriate test o cure or
H. pylori?
32) A 46-year-old male presents to clinic or evaluation o le A) Stool antigen test done 1 month a er nishing treatment.
shoulder pain. He has been taking over-the-counter ibupro- B) Serum antibody test done 3 months a er nishing treat-
en 600 mg every 8 hours or the last 4 weeks. He is wonder- ment.
ing i there are any possible long-term side e ects o taking C) CLO test done 1 week a er nishing treatment.
this medication. Most notably, he is concerned, as his wi e D) Breath urea test done 1 week a er nishing treatment.
has told him that ibupro en can “tear up the gut.” You tell
him that NSAIDs, such as ibupro en, can cause ulceration in: See question 7.4.5.
A) T e stomach.
B) T e duodenum. 38) Which o the ollowing is true about a gastric eeding
C) T e colon. tube in the demented elderly?
D) All o the above. A) It increases the patient’s quality o li e.
B) It reduces the risk o pneumonia.
See question 7.4.5: Helpful ip. C) It reduces mortality.
D) It does nothing to improve quality o li e but can cause com-
33) What is true about the treatment o gastroesophageal plications.
re ux disease (GERD)?
A) reatment o Helicobacter pylori is e ective in curing GERD. See question 21.5.14.
B) reatment should always start with a proton pump inhibitor.
C) Surgical options (e.g., undoplication) are o en suboptimal 39) Which o the ollowing is NO a component o CRES
with patients still requiring medication. syndrome?
D) Esomeprazole is vastly superior to omeprazole. A) Calcinosis.
B) Renal ailure.
See questions 7.1.3 and 7.1.4. C) Esophageal dysmotility.
742 FAMil Y MEDiCin E ExAMin At io n & Bo ARD REViEW

D) Sclerodactyly. C) Cipro oxacin.

E) elangiectasia. D) Azithromycin.
E) Mebendazole.
See question 11.10.4.
40) Which o these drugs is indicated or control o an acute See question 7.8.2: Helpful ip.
are o Crohn disease?
A) Any 5-ASA moiety. 46) You recently diagnosed a 30-year-old emale with celiac
B) Oral prednisone. disease. She is wondering what oods she should avoid. Which
C) Sul asalazine. o the ollowing oods DOES NO contain gluten?
D) T alidomide. A) Wheat.
E) Metronidazole. B) Rye.
C) Rice.
See question 7.6.4. D) Sticky rice.

41) Which o the ollowing is a contraindication to use o sul- See question 7.8.6.
asalazine in Crohn disease?
A) Aspirin allergy. 47) Which o the ollowing tests is the most sensitive or
B) Heme positive stools. the diagnosis o bacterial overgrowth syndrome (o the GI
C) Fever. tract)?
D) Platelet count < 100,000. A) Urea breath test.
B) D-Xylose breath test.
See question 7.6.6. C) Hydrogen breath test.
D) CLO test.
42) Which o the ollowing is the best screening test or hepa-
titis C virus (HCV)?
A) Quantitative HCV PCR. See question 7.8.3.
B) Hepatitis C antibody.
C) Recombinant Immunoblot Assay (RIBA). 48) Which o the ollowing is a relative contraindication to
D) Qualitative HCV PCR. treatment o hepatitis C with inter eron?
A) Fever.
See question 7.10.1. B) Severe depression.
C) Severe osteoarthritis.
43) Which o the ollowing is the most speci c test or gluten D) Severe eczema.
enteropathy (nontropical sprue)?
A) Antiendomysial IgA antibody. See question 7.10.6.
B) issue transglutaminase antibody.
C) Antigliadin antibody. 49) Routine prenatal screening in the rst trimester includes
D) Hydrogen breath test. all o the ollowing EXCEP :
A) Blood type and antibody screen.
See question 7.8.4. B) Hepatitis B sur ace antigen.
C) HIV antibody.
44) C. dif cile colitis has been linked to all o the ollowing
D) MSAFP (maternal serum alpha- etoprotein).
EXCEP :
E) Rubella antibody.
A) Hospitalization.
B) Use o uoroquinolones.
C) Use o PPIs. See question 15.1.7.
D) Use o H 2 blockers.
E) Use o metronidazole. 50) A 22-year-old G2 P2 emale is ready to leave the hospi-
tal on postpartum day 2 a er a normal spontaneous delivery,
See question 8.2.3 and Helpful ip. but she develops lower abdominal pain and ever. She denies
urinary symptoms. She reports constipation and moderate
45) You are seeing a 15-year-old emale who works at a day lochia. Her temperature is 38.8°C. She had prolonged rup-
care where there was a recent Giardia outbreak. She has been ture o membranes and prolonged labor, and the placenta
experiencing diarrhea, malaise, and nausea. You are con- was removed manually. T e most appropriate course o
cerned she may have contracted Giardia. Which o the ol- action now is:
lowing is recommended or treating Giardia? A) Discharge with acetaminophen or ever and ollow-up in
A) Metronidazole. 2 days.
B) Vancomycin. B) Discharge with amoxicillin and ollow-up in 2 days.

C) Keep the patient in the hospital and obtain cultures or gon-
orrhea and chlamydia.
D) Keep the patient in the hospital and start IV gentamicin and
clindamycin.
E) Manual exploration o the uterus or retained placenta.
See question 15.2.9.
51) A 21-year-old G0 emale presents or a physical examina-
tion and her rst Pap smear. She has recently become sex-
ual activity and has one li etime partner. T e results o the
Pap smear show low-grade squamous intraepithelial lesion
(LSIL). In accordance with guidelines, you recommend:
A) Immediate colposcopy.
B) Immediate re erral or excisional procedure.
C) Return in 12 months or Pap smear.
D) Return in 3 months or Pap smear.
E) Return in 6 months or colposcopy and Pap smear.
See question 15.12.8: Helpful ip.
52) A 48-year-old emale presents with menopausal symp-
toms. She has had a total hysterectomy but her ovaries are
intact. She would like to know the bene ts and risks o taking
estrogen-only hormone replacement therapy (HR ). You tell
her that estrogen-only HR is associated with:
A) Decreased risk o myocardial in arction.
B) Decreased risk o ovarian cancer.
C) Increased risk o colon cancer.
D) Increased risk o osteoporosis.
E) Increased risk o stroke.
See question 15.14.3.
53) A 25-year-old G5P4 emale at 26 weeks o gestation pres-
ents to labor and delivery with abdominal pain. T e pain
is sharp or tearing and located in her lower abdomen. She
has not had any contractions. She just began to have a little
vaginal spotting be ore she came in. Her pregnancy has been
complicated by tobacco use and hypertension. What is the
most likely diagnosis?
A) Cervical cancer.
B) Normal labor.
C) Placenta previa.
D) Placental abruption.
E) Uterine rupture.
See question 15.2.1: Helpful ip.
54) T e USPS F recommends screening or osteoporosis in:
A) All adults aged 65 and older.
B) All men aged 75 and older.
C) All women aged 65 and older.
D) All women at onset o menopause.
E) Women who smoke at age 50 and older.
See question 21.2.3.
CHAPTER 30 • Fin Al ExAMin At io n 743
55) A 79-year-old male presents with his wi e who com-
plains that he has been more orget ul over the past month.
T e patient agrees and complains o orgetting where he
put things, where the car is parked, and names o acquain-
tances. Also, he is more irritable and angers easily. He has
trouble sleeping, and he has lost 5 lb. He is healthy and takes
no medications. He has poor eye contact, a blunted a ect,
and poor concentration. His vitals and physical examination
are otherwise normal. He can recall three items and draw a
clock with no dif culty. T e most likely cause o his symp-
toms is:
A) Delirium due to metastatic carcinoma.
B) Delirium due to underlying systemic in ection.
C) Dementia due to Alzheimer disease.
D) Dementia due to stroke.
E) Depression.
See question 21.5.2.
56) You are considering treating a 65-year-old male with sup-
plemental testosterone due to low serum testosterone levels
associated with atigue, muscle weakness, and mild depres-
sion. A er initiating testosterone, it is most important to
check which o the ollowing?
A) Creatinine.
B) Hemoglobin.
C) Potassium.
D) Sodium.
See question 16.7.3.
57) Delirium in the hospitalized elderly patient can be pre-
vented by implementing all o the ollowing interventions
upon admission EXCEP :
A) Assuring patient has access to usual aides (hearing aids,
glasses, etc.).
B) Early mobilization.
C) Lorazepam 1 mg QHS.
D) Noise reduction at night.
E) Orientation stimuli.
See questions 21.3.4 and 21.3.5.
58) A 75-year-old male with mild dementia, atrial brilla-
tion (not on anticoagulation), osteoarthritis, and depres-
sion presents a er sustaining a all in his home 1 week ago.
His son states, “He is a little banged up but otherwise ne.”
Your routine evaluation should include all o the ollowing
EXCEP :
A) Asking about potential neglect and abuse.
B) C scan o the brain.
C) Medication review.
D) Neurological examination.
E) Observation o the patient ambulating.
See questions 21.4.1 and 21.4.2.
744 FAMil Y MEDiCin E ExAMin At io n & Bo ARD REViEW

59) A 75-year-old emale ell and injured her hip. She did not C) A neurologic symptom that does not resolve within the rst
racture it but has signi cant pain. She has a remote history o 24 hours o a traumatic injury.
peptic ulcer disease. She takes lisinopril or hypertension and D) Absolutely any trauma involving the head and/or neck.
phenytoin or a seizure disorder. Which analgesic medication
will be sa est to initiate in this patient or her moderate pain? See question 14.8.1: Helpful ip.
A) Aspirin.
B) Meperidine. 64) A 17-year-old emale runner with secondary amenor-
C) Hydrocodone. rhea should be urther evaluated with all o the ollowing
D) Piroxicam. EXCEP :
E) Fentanyl transdermal patch. A) Assessing calcium intake.
B) MRI o the pituitary.
See question 21.6.2. C) Screening or eating disorders.
D) Urine beta-hCG.
60) An 80-year-old emale nursing home resident with
dementia recently started re using medication and slapping See questions 14.2.2 and 14.2.4.
at the sta when they try to bathe her. T e nurse at the care
center calls to request “something or her agitation.” As the 65) Gynecomastia in an adolescent male occurs as a response
sa est and most e ective intervention, you recommend: to which o ollowing mechanisms?
A) A behavior log to track when the agitation occurs and what A) Excessive dehydroepiandrosterone.
might be causing it. B) Excessive estrogen compared with testosterone.
B) Haloperidol 1 mg IV prior to bathing and medication C) Excessive growth hormone.
administration. D) Excessive progesterone compared with testosterone.
C) Haloperidol 1 mg PO BID. E) Rapidly developing obesity.
D) Restraints with bathing.
E) Alprazolam 1 mg PO ID. See question 16.5.2.

See question 21.6.9. 66) reatment o a patient in diabetic ketoacidosis (DKA)

includes all o the ollowing EXCEP :
61) T e most appropriate next step or a 60-year-old male A) Aggressive volume replacement.
with a PSA level 12.5 ng/mL (normal range < 4.0) is: B) Frequent glucose monitoring.
A) One month o a uoroquinolone ollowed by repeat rectal C) Insulin.
examination and PSA. D) Potassium.
B) Re erral or prostate biopsy. E) Sodium bicarbonate.
C) Repeat PSA in 6 to 12 months.
D) ransrectal ultrasound o the prostate. See questions 10.9.1 and 10.9.4.
E) reatment o benign prostatic hyperplasia with terazosin.
67) A 30-year-old male presents with dif culty obtaining an
See question 16.8.3. erection suf cient or penetration. He has acid re ux and
takes cimetidine. He reports a good relationship with his wi e
62) A 33-year-old male with depression had been taking par- and denies depression. He does not smoke and rarely drinks
oxetine 60 mg daily or a year or depression. Due to sexual alcohol. T e most appropriate intervention at this time is:
problems, he decided to try another medication, and his doc- A) o order a testosterone level.
tor prescribed bupropion. He stopped the paroxetine one day B) o per orm cardiac stress testing.
and started bupropion the next. He comes in 5 days later eel- C) o re er him to a urologist.
ing dizzy, nauseated, and atigued. He complains o myalgias, D) o replace cimetidine with omeprazole.
eelings o “electric shocks,” and insomnia. T ese symptoms E) o send him to a psychologist.
are most likely due to:
A) Adverse e ects o bupropion. See question 16.10.3.
B) Hyperthyroidism.
C) Major depression. 68) O the ollowing, the most requent side e ect o met or-
D) Serotonin syndrome. min is:
E) Discontinuation o paroxetine. A) Constipation.
B) Hypoglycemia.
See question 23.9.1. C) Lactic acidosis.
D) Renal ailure.
63) Concussion is de ned as: E) Weight loss.
A) A disturbance in brain unction caused by trauma.
B) A traumatic event resulting in the loss o consciousness. See question 10.10.7.

69) A 40-year-old male presents with generalized weakness
or 1 month. He has lost some weight, perhaps 10 lb. He
brie y lost consciousness yesterday while getting out o bed.
He denies depression, drug or alcohol use, and any signi -
cant medical history. He is hypotensive but not tachycardic.
He has orthostatic hypotension as well. Lab tests reveal mild
anemia, low sodium, elevated potassium, and normal SH,
BUN, creatinine, and glucose. He is surprisingly tan or being
a Caucasian armer in the winter. (Did he just return rom
Cancun? No. He’s not traveled. Good question.) o con rm
your presumptive diagnosis, you order:
A) 24-hour urine catecholamines.
B) Free 4 and 3.
C) Plasma metanephrines.
D) Serum cortisol and adrenocorticotropic hormone (AC H).
E) Serum testosterone.
See question 10.8.2.
70) A 62-year-old emale presents to the emergency depart-
ment with a sudden “hole” in her right visual eld developing
today. She also has a right temporal headache present or the
last 2 weeks, shoulder and neck pain or a month, and weight
loss o 5 lb. She is slightly hypertensive and has a prominent
tender vessel at the right side o her head. Her CBC is nor-
mal but the ESR is 85 mm/hr. What is the most appropriate
course o action?
A) Administer IV methylprednisolone and admit or urther
evaluation.
B) Admit or cardiac monitoring and rule out myocardial
in arction.
C) Discharge to home with oral antibiotics.
D) Discharge to home with re erral to an ophthalmologist in
the next week.
E) Per orm a C scan o the brain and discharge to home i
normal.
See question 11.2.7.
71) You nd a new and suspicious skin lesion in a patient who
has had a liver transplant or hepatitis C and is on immuno-
suppressive therapy. You plan to per orm a biopsy. I the skin
lesion turns out to be malignant, it will most likely be:
A) Basal cell carcinoma.
B) Distant metastasis rom liver cancer.
C) Melanoma.
D) Squamous cell carcinoma.
E) Kaposi sarcoma.
See question 17.3.2.
72) T e ractional excretion o sodium (FENa) is use ul or
determining:
A) I the patient has true hyponatremia.
B) Whether the patient has oliguric or anuric renal ailure.
C) Whether the renal ailure is due to acute tubular necrosis or
another cause.
CHAPTER 30 • Fin Al ExAMin At io n 745
D) Whether the renal ailure is due to intrinsic renal disease or
a prerenal cause.
E) I the patient has pseudohyponatremia.
See question 5.6.3.
73) T e major Jones criteria or rheumatic ever include all o
the ollowing EXCEP :
A) Carditis.
B) Fever.
C) Polyarthritis.
D) Subcutaneous nodules.
E) Sydenham chorea.
See Chapter 11 Quick Quiz: An Ill Child.
74) A 29-year-old emale daycare teacher presents with a
severely pruritic rash that started at her wrists and has pro-
gressed to the web spaces o her ngers, under her arms,
around her waist, and around her nipples. On examination,
she has multiple excoriations and ew small, erythematous
papules. T e most appropriate next step is:
A) Biopsy o normal-appearing skin.
B) Biopsy o one o the papules.
C) Empiric treatment with topical clotrimazole.
D) Empiric treatment with topical lindane 1%.
E) Empiric treatment with topical permethrin 5%.
See questions 8.6.1 and 8.6.2.
75) A 60-year-old emale with diabetic nephropathy is hos-
pitalized with chest pain, and a cardiac catheterization is
planned. Which one o the ollowing is the best option to
reduce her risk o contrast-induced nephropathy?
A) Administer ketorolac and IV saline.
B) Administer mannitol and IV saline.
C) Administer IV saline alone.
D) Administer N-acetylcysteine.
See question 5.1.7.
76) A 58-year-old man with hypertension, diabetes, heart
ailure, and chronic kidney disease (stage 4, GFR 25 mL/
min/1.73 m2) presents or ollow-up. His current medications
are insulin, aspirin, metoprolol, and lisinopril. His blood
pressure is 142/86 mm Hg and he has signi cant dependent
edema. His labs reveal serum potassium o 5.3 mEq/L. o
achieve his blood pressure to goal (< 130/80) while avoiding
adverse events, the best initial step is:
A) Discontinue lisinopril.
B) Furosemide 20 mg PO daily.
C) Hydrochlorothiazide 12.5 mg PO daily.
D) Increase lisinopril.
E) Losartan 25 mg PO daily.
See question 5.1.10.
746 FAMil Y MEDiCin E ExAMin At io n & Bo ARD REViEW
77) Which o the ollowing is most likely to cause hypokale-
mia?
A) Excessive use o “lite” salt.
B) Hypoaldosteronism.
C) Hypomagnesemia.
D) Overdose o propranolol.
E) Renal tubular acidosis type 4.
See question 5.5.2.
78) A patient presents with thickened, yellowish, dystrophic
toenails. What is the most appropriate next step?
A) Recommend that the patient return or toenail removal.
B) Send nail scrapings or KOH stain and/or ungal culture.
C) Start treatment with a topical anti ungal.
D) Start treatment with an oral anti ungal.
E) Start treatment with an IV anti ungal.
See question 17.3.4.
79) All o the ollowing are consistent with a diagnosis o
syndrome o inappropriate antidiuretic hormone secretion
(SIADH) EXCEP :
A) High urine osmolality.
B) Low plasma osmolality.
C) Low urine sodium.
D) Normal adrenal unction.
E) Normal thyroid unction.
See questions 5.7.2 and 5.7.3.
80) A 21-year-old male is brought in the emergency depart-
ment by his girl riend a er he overdosed on aspirin. He took
“a bottle, maybe 100 pills or so,” but he denies other inges-
tions. He complains only o nausea. He becomes more som-
nolent during the evaluation. He is slightly tachycardic and
ebrile with a normal blood pressure. His blood gas shows: pH
7.38, PaCO2 20 mm Hg, PaO2 98 mm Hg, HCO3 15 mEq/L.
His creatinine, CBC, and electrolytes are normal, except or
low potassium. What is the best description o this patient’s
blood gas?
A) Metabolic acidosis and metabolic alkalosis.
B) Metabolic acidosis and respiratory alkalosis.
C) Metabolic alkalosis and respiratory acidosis.
D) Pure metabolic acidosis.
E) Normal blood gas (no acidosis or alkalosis).
See Chapter 5 Quick Quiz: Acid–Base Disorder.
81) A 19-year-old college student presents to the emergency
department with ever, headache, myalgias, and con usion.
She has had a splenectomy but is otherwise healthy. T e
examination is notable or somnolence, ever, and nuchal
rigidity. Due to her inability to ollow directions, the neuro-
logical examination is dif cult to complete, but it appears to
be non- ocal. T ere are several other seriously ill patients in
the ED to triage. Which o the ollowing interventions should
not wait an hour and must be done now?
A) Administer ce riaxone, vancomycin, and dexamethasone.
B) Consult a neurosurgeon.
C) Per orm lumbar puncture.
D) Obtain blood cultures.
E) Order C o the brain.
See questions 8.3.1 and 8.3.3.
82) You per orm joint aspiration on a patient with a pain ul,
swollen knee. Microscopic examination o the uid shows
rhomboid-shaped, positively bire ringent crystals. Which
one o the ollowing is the most likely to alleviate the patient’s
acute symptoms?
A) Acetaminophen daily.
B) Allopurinol daily.
C) Ce riaxone IM.
D) Corticosteroid injection into the knee.
E) opical anti-in ammatory cream.
See question 11.5.2.
83) A 23-year-old male with HIV stopped taking all o his
medications 3 months ago due to cost. He was eeling ne
until 3 weeks ago when he developed a cough. He now has
daily evers around 101°F, a non-productive cough, dyspnea
on exertion, atigue, chills, and tightness in his chest with
inspiration. His examination is notable or ever, diaphore-
sis, bilateral crackles with inspiration, and mild tachypnea.
Chest x-ray shows di use bilateral interstitial in ltrates.
Which o the ollowing is the most likely causative agent or
this pulmonary in ection?
A) Adenovirus.
B) Cryptococcus neoformans.
C) Mycobacterium tuberculosis.
D) Pneumocystis jiroveci (PCP).
E) oxoplasma gondii.
See question 9.1.8.
84) Which o the ollowing is not use ul in the treatment o
hepatic encephalopathy?
A) Oral lactulose.
B) Polyethylene glycol (Golytely).
C) Oral ri amixin.
D) Lactulose enemas or acute encephalopathy.
See question 7.13.2.
85) An otherwise-healthy 70-year-old emale is admitted and
started on ce riaxone and azithromycin or pneumonia. On
hospital day 3, her serum creatinine is ound to have tripled
rom admission. She is mildly nauseated and has an ery-
thematous, macular rash on her trunk and arms. Her CBC
shows that her white cell count has declined rom admission,
but she now has a prominent eosinophilia. Urinalysis shows
 CHAPTER 30 • Fin Al ExAMin At io n 747

1 + protein, and urine sediment shows white cell casts and
eosinophils. T e most appropriate next step is:
A) Add metronidazole to her antibiotic regimen.
B) Bolus with IV 0.9% saline.
C) Consult a nephrologist or possible renal biopsy.
D) Discontinue ce riaxone and consider an alternative antibi-
otic.
E) Start urosemide to improve urine output.
See question 5.13.3: Helpful ip.
86) Each o the ollowing patients is ound to have asymp-
tomatic bacteriuria. Who should be treated with a course o
antibiotics?
A) An 88-year-old emale nursing home resident.
B) A 20-year-old pregnant patient.
C) A 75-year-old male with an indwelling Foley catheter or
obstructive BPH.
D) All o the above.
See questions 8.4.1 and 8.4.2, and Helpful ip.
87) In a patient with ascites, which o the ollowing will cause
a low serum-ascites albumin gradient (SAAG)?
A) Carcinomatous peritonitis.
B) Portal hypertension.
C) Budd–Chiari syndrome.
D) Cirrhosis.
90) Which o the ollowing is generally true in alcohol-related
liver disease?
A) AS is two times greater than AL .
B) AL is two times greater than AS .
C) Both AL and AS are elevated to the same degree.
D) T e GG is speci c or liver disease and higher than either
the AL or AS .
See question 7.15.2: Helpful ip.
91) Appropriate antibiotic treatment o diverticulitis includes
all o the ollowing EXCEP :
A) Cipro oxacin + metronidazole.
B) Amoxicillin clavulanate.
C) rimethoprim/sul amethoxazole + metronidazole.
D) Clindamycin + metronidazole.
See question 7.17.3: Helpful ip.
92) Which o the ollowing is true about the treatment o
pancreatitis?
A) Antibiotics should be used in most cases o pancreatitis.
B) Oral eedings is the pre erred method o nutrition i toler-
ated.
C) Pseudocysts must be drained or pancreatitis to resolve.
D) T e Ransom criteria can be used at the time o admission to
accurately predict mortality.

See question 7.12.4: Helpful ip. See questions 7.15.9 and 7.15.10: Helpful ip.

88) A patient comes to the emergency department a er sus- 93) Which o the ollowing does NO promote gastric emp-
taining a needle stick. She is a nurse who had just nished tying in gastroparesis?
drawing blood or culture on a patient with AIDS, and some- A) Erythromycin.
how she stuck hersel through her glove. She bled a little. She B) Metoclopramide.
washed the area copiously. What is the most appropriate next C) Amoxicillin.
step? D) Cisapride.
A) Prescribe antiretrovirals or 4 weeks.
B) Prescribe single-dose antiretroviral prophylaxis. See question 7.16.2.
C) Reassure the patient as her risk o contracting HIV is negli-
gible. 94) O the ollowing, the most common cause o acute pan-
D) est her or HIV and treat based on the results. creatitis in the United States is:
A) Alcohol.
See question 9.3.2: Helpful ip. B) Hypertriglyceridemia.
89) About hal o patients with portal hypertension have C) T iazide diuretics.
esophageal varices, and one-third o these will experience a D) Viruses.
gastrointestinal bleed. Patients with varices may bene t rom
preventative therapy aimed at reducing bleeding risk. Which See question 7.15.7.
o the ollowing IS NO use ul in the prevention o variceal
bleeding in patients with portal hypertension due to alco- 95) All o the ollowing are causes o non-alcoholic atty liver
holic cirrhosis? disease EXCEP :
A) Pentoxi ylline ( rental). A) Statin use.
B) Nadolol. B) Hypothyroidism.
C) Vitamin K. C) Diabetes.
D) Cilostazol (Pletal). D) Obesity.

See question 7.13.4. See question 7.14.3.

748 FAMil Y MEDiCin E ExAMin At io n & Bo ARD REViEW

96) T e most common cause o the development o drug D) A patient with a PPD reaction o 10 mm 1 year a er treat-
resistance in HIV is: ment or latent B.
A) Failure to include zidovudine in the treatment regimen.
B) Failure to initiate treatment until the patient has a known See questions 8.4.4 and 8.4.5.
AIDS de ning illness.
C) Poor compliance with medications. 101) T e recommended empirical antibiotic treatment o
D) Failure to include a protease inhibitor in the treatment meningitis in an immunocompetent adult age 40 is:
regimen. A) Ce riaxone.
B) Ce riaxone + vancomycin.
See question 9.1.3. C) Ce riaxone + cipro oxacin.
D) Ce riaxone + MP/SMX.
97) At what CD4+ level should one initiate prophylactic
treatment o Pneumocystis jiroveci (previously Pneumocystis See question 8.3.1.
carinii)?
A) CD4+ ≤ 50 cells/mm 3 102) T e most common bacterial organism causing meningi-
B) CD4+ ≤ 75 cells/mm 3 tis in adults is:
C) CD4+ ≤ 100 cells/mm 3 A) Pneumococcus.
D) CD4+ ≤ 200 cells/mm 3 B) Meningococcus.
C) Haemophilus.
See question 9.1.4. D) Listeria.

See questions 8.3.1 and 8.3.2.

98) Which o the ollowing recommendations regarding Pap
smear screening in an HIV positive woman is true?
A) No modi cation is needed in the Pap smear regimen.
B) I the CD4+ count is normal and the patient has two normal
Pap smears at 1 year intervals, you can go back to routine
screening.
C) I the patient has a CD4+ count < 200 cells/mm 3, screening
should be done every 6 months regardless o whether or not
the patient has had negative Pap smears.
D) Pap smears can be suspended in HIV-positive patients since
they will likely die rom HIV be ore they die rom cervical
cancer.
See question 9.2.14.
99) Which o the ollowing statements best re ects the cur-
rent thinking about treating in uenza?
A) Rimantadine and amantadine are the most e ective drugs
or in uenza B.
B) reatment with oseltamivir ( ami u) is highly e ective,
thus negating the need or in uenza vaccine.
C) Oseltamivir must be started within 48 hours o symptom
onset to be o any bene t.
D) T ere is no resistance o in uenza A to oseltamivir.
See question 8.1.3.
100) Assuming each o these patients has a negative chest
x-ray, which o the ollowing patients needs isoniazid treat-
ment?
A) A patient with no risk actors who has a PPD reaction o
5 mm.
B) A patient with recent exposure to B and a PPD reaction o
5 mm.
C) A health-care worker with a PPD reaction o 5 mm.
103) All o the ollowing can be used or malaria prophylaxis
EXCEP :
A) Doxycycline.
B) Me oquine.
C) Azithromycin.
D) Atovaquone/proguanil (Malarone).
See question 8.8.4.
104) Which o the ollowing is true regarding the diagnosis
o urolithiasis?
A) Over 90% o patients will have blood in their urine at the
time o diagnosis.
B) Urolithiasis may be di cult to di erentiate rom aortic dis-
section at the initial time o presentation.
C) Hematuria will reliably di erentiate urolithiasis rom aortic
dissection.
D) A negative “FAS ” ultrasound scan is considered the stan-
dard and i negative rules out urolithiasis.
See question 5.3.5: Helpful ip.
105) Which o the ollowing pro les are you likely to see in a
patient with a pre-renal cause o elevated creatinine?
A) Urine sodium < 20 mEq/L, ractional excretion o sodium
< 1%.
B) Urine sodium < 20 mEq/L, ractional excretion o sodium
> 2%.
C) Urine sodium > 40 mEq/L, ractional excretion o sodium
< 1%.
D) Urine sodium > 40 mEq/L, ractional excretion o sodium
> 2%.
See questions 5.6.3 and 5.13.1.
 CHAPTER 30 • Fin Al ExAMin At io n 749

106) Aldosterone resistance (such as occurs with diabetic D) Clopidogrel alone.

nephropathy) or hypoaldosteronism will present with which E) War arin.
o the ollowing?
A) Hypokalemia. See question 18.1.5.
B) Hyperkalemia.
C) Hyperphosphatemia. 112) Which one o the ollowing entities presents with
D) Hypophosphatemia. re exes preserved?
A) Guillain–Barré.
See question 5.1.9. B) Amyotrophic lateral sclerosis.
C) Charcot–Marie– ooth disease.
107) Which o the ollowing regimens IS NO recommended D) Diabetic neuropathy.
or treatment o a simple cystitis in an otherwise healthy,
non-pregnant adult emale? See question 18.6.4: Helpful ip.
A) Amoxicillin 500 mg PO ID or 3 days.
B) Levo oxacin 250 mg PO daily or 3 days. 113) Which one o the ollowing agents is most e ective or
C) Nitro urantoin 100 mg PO ID or 5 days. controlling the pain o peripheral neuropathy?
D) MP/SMX 1 PO ID or 3 days. A) ricyclic antidepressant ( CA).
B) Gabapentin.
See Chapter 5 Quick Quiz: Dysuria. C) Oxycodone or other narcotic.
D) Carbamazepine or other traditional antiepileptic.
108) Which o the ollowing drugs is LEAS LIKELY to See question 18.3.6 and Helpful ip.
reduce the progression o proteinuria?
A) Enalapril. 114) Which o the ollowing drugs IS NO associated with
B) Losartan. rebound headaches?
C) Verapamil. A) Acetaminophen.
D) Ni edipine. B) Dihydroergotamine (DHE).
C) Nortriptyline.
See question 5.1.5 and 5.1.13. D) Sumatriptan.

109) T e de nition o nephrotic syndrome requires all o the
ollowing EXCEP :
A) Hypoalbuminemia.
B) Urine albumin excretion > 3 g per day.
C) Edema.
D) Renal biopsy showing appropriate changes.
See question 5.4.5.
110) Which o the ollowing patients should have a carotid
endarterectomy based on all current U.S. guidelines?
A) A 60-year-old emale with a unilateral symptomatic 70%
carotid plaque.
B) A 60-year-old male or emale with an asymptomatic 69%
carotid plaque.
C) Patient o either gender with bilateral 50% carotid plaque,
symptomatic or asymptomatic.
D) None o the above meet current quali cation criterion.
See Chapter 18 Quick Quiz: When to Cut?.
See question 18.4.6.
115) T e risk o developing a seizure disorder a er a single
ebrile seizure is:
A) 1% to 5%; the same as the rest o the population.
B) 6% to 10%; slightly higher than the general population.
C) 11% to 15%; signi cantly higher than the general popula-
tion.
D) Unknown.
See question 18.14.4.
116) You determine that a 77-year-old emale has Parkinson
disease that is inter ering with her daily li e. T e best drug
or drug combination to alleviate her symptoms and improve
her unction is:
A) A COM inhibitor (e.g., Entacapone).
B) A dopamine agonist (e.g., Requip).
C) Levodopa/carbidopa (e.g., Sinemet).
D) Apomorphine.

111) I cost were NO an issue, which o the ollowing See question 18.10.6.
drugs/drug combinations would be the ideal regimen or the
secondary prevention o stroke? 117) T e PRESENCE o an RAPD (relative a erent pupillary
A) Aspirin + clopidogrel. de ect) can be indicative o :
B) Aspirin + dipyridamole. A) Cataracts.
C) Aspirin alone. B) Large retinal detachment.
750 FAMil Y MEDiCin E ExAMin At io n & Bo ARD REViEW
C) Bleed into the anterior chamber.
D) Severe re ractive error.
See Chapter 19 glossary and question 19.2.1.
118) Which o the ollowing patients has an indication or
cataract surgery?
A) Vision 20/100 bilaterally in a patient who has no visual com-
plaints or unctional impairment.
B) Vision 20/20 OD and 20/200 OS in a patient who can see
well enough to do everything she desires.
C) Vision 20/30 OD and 20/30 OS in a patient who is bothered
by her inability to quilt.
D) Vision unknown in a patient who can carry out all ADLs to
her own satis action.
See question 19.14.3.
119) All o the ollowing intraocular muscles are innervated
by cranial nerve III EXCEP :
A) In erior oblique.
B) In erior rectus.
C) Lateral rectus.
D) Medial rectus.
E) Superior rectus.
See question 19.15.1.
120) Skinnier, “politically correct” Santas are in vogue this
year (bearing gi s o celery, no doubt). Your patient is in
tizzy: he has played Santa or years without the need or pil-
lows. He wants to keep up his tradition as St. Nick. What can
you tell him about weight reduction surgery?
A) “Sorry, even though you may lose weight, it will not help
your overall health.”
B) “You must have a BMI > 40 kg/m 2 be ore quali ying or bar-
iatric surgery regardless o other underlying weight-related
conditions.”
C) “You must have a BMI o > 35 kg/m 2 AND signi cant
reversible disease (e.g., hypertension, diabetes) to quali y or
bariatric surgery.”
D) “T e reindeer union says it won’t work i Santa’s weight is
under 300 lb—they need to keep 8 reindeer working the
sleigh at all times.”
See question 22.5.1.
121) A 70-year-old male patient complains o severe unilat-
eral visual loss. He has no other symptoms. Here is a picture
o his undus (Fig. 30-3) that you took with your smartphone
jerry-rigged to a direct ophthalmoscope. His diagnosis is:
A) Acute glaucoma.
B) Acute venous disruption.
C) Acute arterial occlusion.
D) Diabetic retinopathy.
See question 19.12.1.
FIGURE 30-3.
122) What is the general course o rheumatoid arthritis dur-
ing pregnancy?
A) Worsening during pregnancy.
B) Worsening during pregnancy but only i methotrexate is
used.
C) It may remit during pregnancy and methotrexate is contra-
indicated.
D) Morning sickness is worse in those with rheumatoid arthri-
tis.
E) Pregnancy has no e ect on rheumatoid arthritis and vice
versa.
See question 11.1.8.
123) A diagnosis o rheumatoid arthritis can be made a er
symptoms have been present or at least:
A) 15 minutes.
B) 2 weeks.
C) 6 weeks.
D) Duration o symptoms is no longer a criterion or diagnos-
ing rheumatoid arthritis.
See question 11.1.2: Helpful ip.
124) You make a diagnosis o rheumatoid arthritis based
on laboratory and clinical criteria. T e best time to begin
disease-modi ying antirheumatic drugs (DMARDs) is:
A) At the time o diagnosis.
B) A er ailure o 2 NSAIDs.
C) A er the ailure o prednisone.
D) When complications o rheumatoid arthritis occur.
E) A er waiting 6 months to see a rheumatologist.
See question 11.1.3 and Helpful ip.
125) You are seeing a 57-year-old male in your practice who
is complaining o bi-temporal headache. He checked the web
and decided that he has giant cell (temporal) arteritis. T e
only problem is that his ESR is only 30 mm/hr. T e CRP is
not much more edi ying. You appropriately respond to him:
A) “You may still have temporal arteritis since 15% or more will
have normal ESR and CRP.”
 CHAPTER 30 • Fin Al ExAMin At io n 751

B) “You seem to be displaying drug seeking behavior since you C) Likelihood o resistant organisms (based on recent antibi-
came in to the ED with the same complaint 1 month ago.” otic use, daycare exposure, etc.).
C) “You may still have temporal arteritis, but we need to per- D) Patient age.
orm a temporal bone biopsy.” E) Medication allergies.
D) “You may still have temporal arteritis, but we will need to
submit your head to the state lab or ormal testing . . . You See question 3.12.1: Helpful ip, 3.12.2, and 3.12.3.
don’t mind . . . do you?”
131) Regarding depot medroxyprogesterone (Depo-Provera),
See question 11.2.2. women at signi cant risk o ______________ should con-
sider an alternative orm o contraception.
126) When treating gout, which one o these drugs or gout A) Osteoporosis.
will be ine ective in those with renal insuf ciency? B) Breast cancer.
A) Allopurinol. C) Ovarian cancer.
B) Probenecid. D) Depression.
C) Prednisone.
D) Colchicine. See question 15.1.1: Helpful ip.
E) Indomethacin.
132) Bleeding in a non-pregnant, amenorrheic patient in
See question 11.4.5. response to a “progesterone challenge” (e.g., medroxyproges-
terone given or 10 days and then stopped) indicates that the
127) Regarding therapy or giant cell arteritis, which o the patient has suf cient endogenous:
ollowing statements best describes the appropriate relation- A) Follicle stimulating hormone (FSH).
ship o aspirin, prednisone, and giant cell arteritis? B) Luteinizing hormone (LH).
A) ASA (81 mg/day) can be used as adjunctive therapy or C) Progesterone.
those on prednisone. D) Estrogen.
B) ASA (325 mg/day) can be used as adjunctive therapy or
those on prednisone. See Chapter 15 Quick Quiz: Amenorrhea.
C) High-dose ASA (650 mg/day) can be used in those who do
not tolerate prednisone. 133) You get the ollowing results on a vaginal wet prep: pH
D) ASA has no role in the treatment o giant cell arteritis. 5.0 and a positive “whi ” test. Wouldn’t you know it, the rest
o the results got lost. With the in ormation available, the
See question 11.2.3. most likely diagnosis is:
A) Vulvovaginal candidiasis.
128) T e one best, rst-line drug treatment o osteoarthritis B) Bacterial vaginosis.
pain is: C) Vaginal trichomoniasis.
A) Acetaminophen. D) Physiologic vaginal discharge.
B) Celecoxib (Celebrex).
C) Ibupro en. See Chapter 15: able 15-9.
D) Naproxen.
E) Morphine. 134) When is screening or Group B Streptococcus (GBS) in
the pregnant emale recommended?
See Chapter 12: General Note, at the start of the chapter. A) Between 30 and 32 weeks o gestation.
B) Between 32 and 34 weeks o gestation.
129) O the ollowing options, the best initial pharmacologic C) Between 35 and 37 weeks o gestation.
therapy or bromyalgia pain is: D) Intrapartum only.
A) Duloxetine.
B) Ibupro en. See question 15.1.8.
C) Nortriptyline.
D) ramadol. 135) Which o the ollowing is the most appropriate treat-
ment o chronic menorrhagia in a 42-year-old emale hyper-
See question 11.8.2. tensive smoker?
A) Low androgenic progesterone oral contraceptive.
130) Which o the ollowing should NO go into the calcu- B) Progesterone IUD (e.g., Mirena or Skyla).
lus o what antibiotic to use or a patient with community C) Copper IUD (Paraguard).
acquired pneumonia? D) Low estrogen oral contraceptive.
A) Appearance o in ltrate on chest x-ray (lobar vs. “atypical”).
B) Comorbid medical conditions. See questions 15.8.2: Helpful ip and 15.9.4.
752 FAMil Y MEDiCin E ExAMin At io n & Bo ARD REViEW
136) You are called to see a partner’s patient who is G3P2 at
32 weeks gestation and is having regular contractions. A er
monitoring and an examination, you suspect that she is in
labor. T e SINGLE most important step, and the rst step to
take, at this point is:
A) Administration o corticosteroids to hasten etal lung matu-
ration.
B) Administration a tocolytic such as terbutaline.
C) Insertion o a cervical cerclage to delay delivery.
D) Antibiotic therapy (ampicillin) rom now until delivery.
See questions 15.4.2 and 15.4.4.
137) T is etal tracing, shown in Figure 30-4, is:
A) Reassuring.
B) Worrisome.
C) An indication or immediate C-section.
D) An indication or the addition o Pitocin.
See Chapter 15: able 15-2.
138) Which o the ollowing must be present to make the
diagnosis o pelvic in ammatory disease?
A) Adnexal pain.
B) Elevated WBC count.
C) Elevated CRP.
D) emperature o > 38°C.
See question 15.13.2: Helpful ip.
139) A NEGA IVE etal bronectin suggests that:
A) T e etal lungs are immature.
B) T ere is little likelihood that the patient will deliver within
the next 2 weeks.
C) T ere is an amniotic uid leak.
D) Is not help ul. A positive bronectin suggests imminent
delivery.
See question 15.4.1.
140) Which o the ollowing is true about tocolytics or pre-
mature labor?
A) T ey are e ective at stopping labor and can arrest labor or
an average o 1 week.
B) T ey have very ew side e ects and should be used routinely
in premature labor.
C) T eir use is mostly to buy time or antenatal steroids to work
or those pregnancies between 24 and 34 weeks.
D) erbutaline is the only FDA-approved tocolytic.
See question 15.4.3: Helpful ip.
141) As you start a patient on uoxetine or depression, you
counsel him about the adverse e ects o this class o medi-
cations. All o the ollowing are common adverse e ects o
SSRIs EXCEP :
A) Anxiety.
B) Diarrhea.
C) Headaches.
D) Hypersexuality.
E) Insomnia.
See question 23.1.8.
142) A 12-month-old emale presents to the emergency
department a er 24 hours o vomiting, diarrhea, and ever.
She is lethargic, tachycardic, and hypotensive with poor skin
turgor. What is the most appropriate initial method o pro-
viding her uids?
A) Hal -normal saline, 20 mL/kg bolus.
B) Hal -normal saline with 5% dextrose, 10 mL/kg bolus.
C) Normal saline, 100 mL/kg bolus.
D) Normal saline, 20 mL/kg bolus.
See question 13.3.3.
143) A 15-month-old male is brought to the clinic by his par-
ents. Like everyone else at his home, he has had some rhinor-
rhea and diarrhea in the last week. However, 4 hours ago the
patient developed episodes o inconsolable crying accompa-
nied by lying in “the etal position” or 15 to 20 minutes at a
time. At rst his parents were puzzled but not too worried, but
these episodes have occurred six to seven times now and he has
become more lethargic. Finally, he had a bloody bowel move-
ment, so they decided to bring him in to the of ce. On examina-
tion, he is a ebrile, lethargic but arousable, and well hydrated.
His abdomen appears benign. What is your leading diagnosis?
A) Cholecystitis.
B) Gastroenteritis.
C) Intussusception.
D) Volvulus.
See question 13.4.1.
144) Which o the ollowing screening tests is recommended
universally or all children in the United States?
A) Eye examination at 24 months.
B) Hearing testing at 1 or 2 days old.
C) Hemoglobin at 12 months.
D) Lead level at 12 months.
See Chapter 13 Quick Quiz: Congenital Infections, Helpful ip.
145) During a visit or a physical examination, you note that
this 33-year-old emale has checked “depression” on her health-
screening questionnaire. You ask her more about this and nd
that she has elt that her mood has been depressed or 15 years
or more. She generally eels atigued and has low sel -esteem,
but she denies suicidal ideation and eelings o guilt and worth-
lessness. What diagnosis best characterizes her symptoms?
A) Avoidant personality disorder.
B) Borderline personality disorder.
C) Persistent depressive disorder
D) Major depressive disorder.
See Chapter 23 Quick Quiz: Sad All the ime.
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754 FAMil Y MEDiCin E ExAMin At io n & Bo ARD REViEW

146) Which o the ollowing symptoms would be LEAS 151) Because __________ is the major unmeasured anion
likely to be due to a panic attack and there ore would in the serum, the anion gap needs to be adjusted or
prompt urther investigation in a patient with known panic the ___________ level in the serum.
disorder? A) Albumin.
A) Chest pain. B) Calcium.
B) Dyspnea. C) Phosphate.
C) Palpitations. D) otal protein.
D) Syncope. E) Chloride.

See question 23.6.4. See question 1.4.2.

147) A 23-year-old male presents with symptoms sugges-
tive o panic attacks, an underlying anxiety disorder, and
possibly panic disorder. You re er him or counseling ser-
vices and recommend starting a medication. Which o
the ollowing drugs is LEAS e ective or treating panic
disorder?
A) Bupropion.
B) Nortriptyline.
C) Sertraline.
D) Venla axine.
See question 23.6.8.
148) All o the ollowing are part o the CHA2DS2-VASC
score EXCEP :
A) Age.
B) Sex/Gender.
C) History o stroke, thromboembolic disease, etc.
D) Active cancer.
E) Heart ailure.
See Chapter 2: able 2-6A.
149) According to the USPS F and CDC, hepatitis C
screening is recommended or all o the ollowing groups
EXCEP :
A) All individuals born between 1955 and 1975.
B) Hemodialysis patients.
C) Patients with a history o incarceration.
D) Users o illicit injection drugs.
E) Migrants rom an endemic area (e.g., Southeast Asia).
See question 7.10.3: Helpful ip.
150) Which o the ollowing patients does NO need a head
C scan per the PECARN rules?
A) A child with a GCS o 14 and no other symptoms or signs o
intracranial injury.
B) A 3-month-old with an occipital bruise a er a all o 3 .
C) A 3-year-old with an occipital bruise and a all o 3 .
D) A 1-year-old child with a palpable skull racture who is oth-
erwise neurologically intact.
E) A 1-year-old child with a scalp hematoma.
See Chapter 1: able 1-6.
152) Your patient has just returned rom Mexico where she
sustained an ankle bite rom a suspect dog. Rabies vaccine
and immunoglobulin are not likely to be e ective a er:
A) 10 days.
B) 20 days.
C) 30 days.
D) 90 days.
See question 1.6.2.
153) Dislocation o which o the ollowing joints is associated
with the highest risk o arterial injury?
A) Wrist.
B) Elbow.
C) Shoulder.
D) Knee.
E) Ankle.
See Chapter 1: Quick Quiz: Orthopedic Emergencies.
154) T e Women’s Health Initiative revealed which o the ol-
lowing statistically signi cant correlations?
A) Combined estrogen/progesterone therapy reduced breast
cancer risk.
B) Combined estrogen/progesterone therapy increased breast
cancer risk.
C) Estrogen monotherapy did not a ect breast cancer risk.
D) Estrogen monotherapy increased breast cancer risk.
See question 15.14.3.
155) A 2-year-old child presents having missed his routine
vaccines at 12 and 15 months. T e patient should:
A) Restart all vaccines.
B) Spread out the interval or his remaining vaccines to reduce
the risk o side e ects.
C) Receive all o his missed doses o vaccines right now.
D) Receive the vaccines due at age 12 months and continue on
the “catch-up” schedule.
See question 13.2.6: Helpful ip.
156) A 12-month-old emale in ant presents or her routine
well-child examination. She has some nasal congestion and
her temperature is 38°C. You should:
A) Administer her routine 12-month vaccines.
B) Administer hal her routine 12-month vaccines now and
hal in 2 weeks.

C) Have her return or vaccines when she is a ebrile or
24 hours.
D) Never give her any more vaccines as she clearly has a ebrile
reaction just being close to them.
See question 13.2.6.
157) A 20-year-old emale with asthma presents to the ED
wheezing and dyspneic. Within 5 minutes o a treatment with
nebulized albuterol, her wheezing improves but she still eels
dyspneic. T e most appropriate next step is:
A) Prepare or imminent intubation.
B) Administer IV magnesium.
C) Administer IV ce riaxone.
D) Administer another dose o nebulized albuterol.
E) Discharge her with a prescription or cough syrup.
See question 1.14.4.
158) T e diagnosis o chronic obstructive pulmonary disease
is secured by:
A) Cough and sputum production in a smoker.
B) wo or three o the ollowing symptoms over the last
6 months: cough, dyspnea, sputum production.
C) FEV1/FVC ratio o < 0.70.
D) FEV1 < 70% predicted.
E) FVC > FEV1.
See question 3.3.3.
159) A 16-year-old male with asthma and seasonal allergies
presents or ollow-up. His only asthma medication is an
albuterol inhaler. In the past ew months, he has needed the
medication more and more, and is now using his albuterol
inhaler one to two times per day. T e most appropriate next
step is to:
A) Add a low-dose inhaled corticosteroid (e.g., triamcinolone)
twice daily.
B) Add a long-acting bronchodilator (e.g., salmeterol) twice
daily.
C) Schedule his albuterol inhaler 4 times per day.
D) Add a low-dose systemic steroid (e.g., prednisone) daily.
E) Add a leukotriene inhibitor (e.g., montelukast) daily.
See question 3.3.6.
160) According to the USPS F, the most appropriate modal-
ity and requency or lung cancer screening is:
A) Posteroanterior and lateral chest radiographs annually.
B) Low-dose C o the chest annually.
C) Low-dose C o the chest every 3 years.
D) Sputum cytology annually.
E) None is recommended as the evidence is insu cient.
See question 3.11.6.
CHAPTER 30 • Fin Al ExAMin At io n 755
161) A 30-year-old male is ound unconscious, slumped in a
chair outside the ED. You arouse him brie y with a sternal
rub. He has pinpoint pupils and a respiratory rate o 8 per
minute. T e drug most likely to causing his current symp-
toms is:
A) Methamphetamine.
B) Cocaine.
C) Heroin.
D) Ecstacy.
E) Alcohol.
See Chapter 1: able 1-1.
162) You admit a 45-year-old male with cirrhosis or alcohol
withdrawal. He meets criteria or complicated withdrawal.
Which o the ollowing medications will be sa est and most
e ective at treating his withdrawal symptoms?
A) Chlordiazepoxide.
B) Clonidine.
C) Lorazepam.
D) Metoprolol.
See question 25.2.7.
163) You are admitting an 88-year-old male to a care acility
with hospice due to declining overall health. In the last year,
he has started to require total unctional dependence in most
activities o daily living. He has moderate-to-severe dementia,
ischemic cardiomyopathy and heart ailure with a le ventric-
ular ejection raction o 20%. When he was healthier, he had
an implanted cardiac de brillator (ICD) placed, which has
red once a year ago and caused him signi cant pain and dis-
tress. His daughter is his durable power o attorney and agrees
with the patient that hospitalization, procedures and CPR
are not desired. He has made these same goals clear in past
conversations with other care providers, documented in the
medical record. When his daughter asks about his ICD, you
recommend which o the ollowing?
A) Deactivate the ICD.
B) Change the settings so the ICD only res or ventricular
tachycardia.
C) Surgically remove the ICD.
D) Leave the ICD as it is.
See question 27.1.1.
164) A 58-year-old male tobacco connoisseur presents or
increasing cough, dyspnea and sputum production. He is a e-
brile. Oxygen saturation on ambient air is 88%. Lung examina-
tion demonstrates poor air movement and di use expiratory
wheezing. His chest x-ray is consistent with COPD and shows
no in ltrates. You decide to admit him. Which o the ollow-
ing drug regimens would be the best choice or this patient?
A) Nebulized albuterol every 4 hours as needed and IV methyl-
prednisolone 125 mg daily.
B) iotropium inhaler 1 pu daily, levo oxacin 500 mg PO
daily, and nebulized albuterol every 4 hours as needed.
756 FAMil Y MEDiCin E ExAMin At io n & Bo ARD REViEW
C) Prednisone 50 mg PO daily, doxycycline 100 mg PO BID,
and nebulized albuterol every 4 hours as needed.
D) Morphine 5 to 10 mg IV every 2 hours to palliate his breath-
lessness.
See question 3.4.1: Helpful ip.
165) A 35-year-old male presents or ollow-up, a er an
admission or pneumonia. Blood cultures grew Streptococ-
cus pneumoniae. Over the past 10 years, he reports having
several bouts o pneumonia and numerous sinus in ections.
Also, he has developed an autoimmune hemolytic anemia.
What is the most use ul test in making the diagnosis o an
immune de ciency in this patient?
A) Complement levels.
B) Immunoglobulin levels.
C) CBC and di erential.
D) Bone marrow biopsy.
E) Lymph node biopsy.
See Chapter 4: able 4-2.
166) You are evaluating a 70-year-old male or abdominal
pain that you suspect may be due to mesenteric ischemia. You
believe the best test would be a C angiogram o his abdo-
men, but he has a contrast allergy. When you inquire about
the allergy, he reports rash and shortness o breath. T e most
appropriate next step in the care o this patient is to:
A) Per orm a non-contrast C scan o the abdomen and pelvis.
B) Per orm a contrast-enhanced C scan o the abdomen and
pelvis and pre-treat the patient with prednisone and diphen-
hydramine.
C) Per orm a contrast-enhanced C scan o the abdomen
and pelvis and pre-treat with IV normal saline boluses and
N-acetylcysteine.
D) Consult a vascular surgeon or an interventional radiologist
or an angiogram.
E) Consult a surgeon or an exploratory laparotomy.
See Chapter 4: Quick Quiz: Contrast Allergy.
167) A 12-year-old male presents with his mother or con-
cerns about diplopia, which began two days ago. On exami-
nation, he has normal visual acuity when each eye is tested
individually, normal pupillary re exes, and esotropia. What
is the best next step to take in the care o this patient?
A) Reassurance that this is a normal, age-related change that
will improve with time.
B) Re er to an optometrist or corrective lenses.
C) Re er to a neurologist.
D) Order an MRI o the brain.
E) Order an EEG.
See question 19.1.4.
168) A 3-year-old emale returns or continued problems
with hearing. Her parents are concerned about another ear
in ection. She has had three episodes o otitis media that you
have treated over the last 6 months. Her hearing is dimin-
ished, per parents, and she indeed tests positive or hearing
loss bilaterally. On examination, you note bulging tympanic
membranes with clear, bubbly uid in the middle ears, but no
signs o in ammation. T e intervention most likely to help
this patient improve her hearing and prevent another in ec-
tion is:
A) Eustachian tube exercises.
B) ympanostomy tubes.
C) Prolonged antibiotics.
D) Nasal steroids.
E) Systemic decongestants.
See question 20.1.9.
169) Which o the ollowing ndings is diagnostic o acute
otitis media?
A) Child pulling at ears and ussing in the examination room.
B) Child with ever and injected tympanic membrane on exam-
ination.
C) Child with ever and an injected tympanic membrane that
does not move when ear canal is insuf ated.
D) Child with history o acute otitis media whose tympanic
membrane is clear but does not move when ear canal is
insuf ated.
See questions 20.1.1 and 20.1.3.
170) A 72-year-old male presents with hearing loss. He has
no other symptoms. He spent much o his li e working in a
machine shop a er he was discharged rom the army where
he was assigned to an artillery unit. His real passion has been
music: he continues to serve as a back-up vocalist and bass
guitar player in a rock band. On examination, he has normal
ears to inspection but high requency hearing loss. Which o
the ollowing is the most likely diagnosis?
A) Presbycusis.
B) Otosclerosis.
C) Acoustic neuroma.
D) Ménière disease.
E) Otitis media with e usion.
See question 20.4.2.
171) A 40-year-old obese emale walks into the of ce request-
ing a re ll on her oral contraceptives and asks to be seen or
acute onset o shortness o breath. She reports that she just
got back rom a 3-week road trip when she developed dys-
pnea. She wonders i it could be related to her smoking. On
examination, she is tachypneic and mildly tachycardic with
an oxygen saturation o 92%. She has a tender, swollen lower
leg on the le . Her lungs are clear to auscultation. T e most
appropriate next step in the care o this patient is to:
A) Order a d-dimer.
B) Prescribe an albuterol inhaler.
C) Order a contrast-enhanced chest C scan.
 CHAPTER 30 • Fin Al ExAMin At io n 757

D) Prescribe a course o antibiotics. D) Contact dermatitis.

E) Order pulmonary unction testing. E) Necrobiosis lipoidica.

See question 3.5.6. See question 17.11.1.

172) A 65-year-old emale presents or ollow up a er hos- 176) All o the ollowing are components o the “ emale ath-
pital discharge 5 days ago. She underwent laparoscopic lete triad” EXCEP :
cholecystectomy that was complicated by intra-abdominal A) Disordered eating.
hemorrhage and repeated surgical exploration. She was B) Recurrent stress ractures.
in the hospital or 10 days. Now, she complains o cough- C) Menstrual dys unction.
ing ts that hurt her surgical wounds. She produces yellow D) Altered bone mineral density.
sputum. She is currently ebrile, tachypneic and tachycardic
on examination. Chest x-ray shows a right middle lobe in l- See question 14.2.2.
trate. You decide to admit her and order the ollowing anti-
biotic regimen: 177) For adolescent athletes, what is the number one cause o
A) Ce epime and vancomycin. sudden cardiac death?
B) Ce riaxone and azithromycin. A) Chest trauma (e.g., baseball hit to the chest).
C) Linezolid. B) Anomalous coronary artery.
D) Clindamycin and metronidazole. C) Hypertrophic cardiomyopathy.
E) Doxycycline. D) Patent oramen ovale.

See question 3.12.7. See Chapter 14 Quick Quiz: Adolescent Athletes.

173) A 60-year-old male presents to discuss lung cancer 178) A 29-year-old male presents with symptoms o atigue,
screening via low-dose C scan. He has smoked 1 pack- weight loss, palpitations and anxiety. On examination, you
per-day o cigarettes or 40 years. Consistent with USPS F note tachycardia, lid lag, ne tremor and di usely enlarged
recommendations, you advise him to undergo annual screen- thyroid gland. Suspecting a hyperthyroid state, you order a
ing with C until he has quit smoking or: SH and ree thyroxine ( 4). T e SH is below the normal
A) 1 year. range but the ree 4 is normal. What is the next step in the
B) 5 years. management o this patient?
C) 15 years. A) Re er to an endocrinologist who can see him in 3 to
D) T e rest o his li e. T ere is no end time identi ed or ormer 6 months.
smokers. B) Check a calcium level.
C) Check a thyrotropin releasing hormone level.
See question 3.11.6. D) Check a ree tri-iodothyronine ( 3) level.
E) Send or thyroid biopsy.
174) Which o the ollowing medications is/are associated
with urticaria? See Chapter 10 Quick Quiz: T yroid ests.
A) Aspirin.
B) Lisinopril. 179) T yroid storm is diagnosed by:
C) Morphine. A) History and physical examination ndings.
D) All o the above. B) Elevated ree 3 level.
E) None o the above. C) Free 4 level 10 times the upper limit o normal.
D) SH level immeasurably low.
See question 17.10.5: Helpful ip. E) An endocrinologist, pre erably a really old one with a long
white beard.
175) A 45-year-old emale with type 2 diabetes presents
or ollow-up. On examination, she has two brownish-red See question 10.2.6: Helpful ip.
patches with yellowish areas through the center on her lower
legs. T e center o the rash appears shiny and has telangiec- 180) You are seeing a 75-year-old emale with progressive
tasia. When asked, she states the rash has been present or at memory impairment. In order to diagnose her with dementia
least a year and is mildly tender i touched. It is not pruritic. according to DSM-IV, she must demonstrate both memory
O the ollowing, what is the most likely diagnosis? impairment AND any one o the ollowing EXCEP :
A) Acanthosis nigricans. A) Apraxia.
B) Atopic dermatitis. B) Anosmia.
C) Cellulitis. C) Aphasia.
758 FAMil Y MEDiCin E ExAMin At io n & Bo ARD REViEW
D) Agnosia.
E) Impairment in executive unctioning.
See questions 21.5.1 and 21.5.3.
181) Regarding the treatment o hepatitis C or genotype
1 patients, which o the ollowing therapies has the highest
cure rate?
A) Ledipasvir/so osbuvir (Harvoni).
B) Ribavirin.
C) Inter eron alpha.
D) Pegylated inter eron alpha.
E) Inter eron alpha + ribavirin.
See question 7.10.6.
182) According to the 2015 USPS F guideline, which o the
ollowing patients should be screened or diabetes mellitus?
A) A 25-year-old emale whose mother is diabetic.
B) A 40-year-old emale whose BMI is 29 kg/m 2.
C) A 40-year-old emale whose average blood pressure over the
last three visits is 138/88 mm Hg.
D) A 25-year-old emale who really, really likes so drinks.
See question 10.10.1: Helpful ip.
183) You have diagnosed a 10-year-old child with immune
thromobocytopenic purpura (I P), and his platelet count is
currently 10,000/µ L. You are considering therapy to improve
this patient’s platelet count. All o the ollowing are treat-
ments or I P EXCEP :
A) Platelet trans usion.
B) Corticosteroids.
C) IVIG.
D) Splenectomy.
E) Rho(D) immunoglobulin (i he is Rh positive).
See question 6.2.2.
184) You are seeing a 45-year-old male with elevated liver
transaminases. His serum bilirubin, alkaline phosphatase,
and GG are normal. He does not drink alcohol. In your eval-
uation o his liver disorder, you nd that a liver ultrasound is
unremarkable or anatomic abnormalities, serologic studies
or hepatitis A, B, and C are negative or in ection, and his
erritin level is 725 ng/mL (upper limit o normal 300 ng/mL).
What is the pre erred next step in diagnosing his disease?
A) Bone marrow biopsy.
B) Liver biopsy.
C) Hemochromatosis gene testing.
D) Echocardiogram.
E) Diagnostic and therapeutic trial o phlebotomy.
See question 6.18.3: Helpful ip.
185) Fournier gangrene is caused by in ection with:
A) Virulent, esh-eating viruses.
B) Methicillin-resistant Staphylococcus aureus.
C) Mixed aerobic and anaerobic bacteria.
D) Yersinia pestis.
See question 22.1.2.
186) Sepsis survival is improved by:
A) Early central line placement or hemodynamic monitoring.
B) Early recognition with aggressive uid resuscitation and
antibiotic administration.
C) Speci c protocols guided by central venous pressures.
D) Early intubation and ventilation.
E) Early palliative care consultation.
See question 22.1.5: Helpful ip.
187) You are seeing a 30-year-old male in the ED. He has
survived a motor vehicle collision in which the driver o the
other car was killed. He has multiple traumatic injuries but
is alert—in act, he’s screaming in pain. His blood pressure is
88/56 mm Hg. What is the best option or managing his pain?
A) A lollipop and reassurance that the trauma team is on the
way.
B) IV morphine.
C) Oral morphine liquid.
D) IV entanyl.
E) IV ketorolac.
See question 22.2.1.
188) A 65-year-old emale presents with 6 hours o abdomi-
nal pain. She also notes nausea but has not had emesis. She
has not moved her bowels today. She has a history o abdomi-
nal surgeries, including hysterectomy, appendectomy, and
cholecystectomy—all or benign reasons. Her vital signs are
normal. Her abdomen is protuberant, tympanic to percus-
sion, and mildly tender di usely. Her bowel sounds are hypo-
active. You suspect a partial small bowel obstruction due to
adhesions. Your admission orders include all o the ollowing
EXCEP :
A) IV uids.
B) Antiemetics.
C) NPO status.
D) NG tube to continuous suction.
E) Analgesic medication.
See question 22.4.3: Helpful ip.
189) A er weight loss surgery, patients are at risk o develop-
ing nutritional de ciencies. Which o the ollowing de cien-
cies are patients NO likely to experience?
A) Protein de ciency.
B) Vitamin B1 (thiamine) de ciency.
C) Vitamin B12 de ciency.
D) Copper de ciency.
E) Zinc de ciency.
See question 22.5.4: Helpful ip.

190) By de nition, external hemorrhoids are located:
A) Proximal to the dentate line.
B) Distal to the dentate line.
C) Distal to the anal verge.
D) In the gluteal cle .
E) Proximal to the hospital administration.
See question 22.6.1.
191) A 55-year-old emale presents with concern or a new
mass she palpated in her le breast. She rst noticed it a
month ago and it has not changed. Your examination reveals
a 2-cm rm mass in the upper outer quadrant o the le
breast. T e examination is otherwise normal. You nd that a
screening mammogram, done 6 months ago, was completely
negative (BIRADS 1). T e best next step in the management
o this patient is:
A) Reassurance, as her mammogram was normal.
B) Repeat a mammogram in 6 months.
C) Have her return in 6 months or a ollow-up breast examina-
tion.
D) Re er or biopsy o the mass.
E) All o the above are equally appropriate.
See question 22.7.3.
192) A surgical colleague consults you on an 80-year-old
emale who broke her emur a er alling. T e patient under-
went an uncomplicated open reduction and internal xation.
It is now postoperative day 4 and she has developed a ever o
39°C. Potential causes o postoperative ever in this patient
include all o the ollowing EXCEP :
A) Atelectasis.
B) Wound in ection.
C) Venous thrombosis.
D) Pneumonia.
E) Drug-induced ever.
See Chapter 22: able 22-3.
193) A patient with a history o heparin induced thrombocy-
topenia and thrombosis syndrome CAN have:
A) Low–molecular-weight heparin or any reason.
B) Heparin or cardiopulmonary bypass during cardiac sur-
gery.
C) Heparin or low–molecular-weight heparin or prevention o
venous thromboembolism.
D) No heparin products or the rest o his or her li e.
See question 22.8.8.
194) Which o the ollowing tests has the highest sensitivity
(i.e., misses the ewest) or appendicitis?
A) CBC.
B) CRP.
C) C scan o the abdomen and pelvis.
CHAPTER 30 • Fin Al ExAMin At io n 759
D) Ultrasound o the right lower quadrant.
E) All o the above have equivalent sensitivity or appendicitis.
See question 22.9.4.
195) A hysterical mother runs into the ED with her 2-year-old
daughter in her arms, screaming, “She got scalded!” A er a
moment she is able to recount the story. T e child was by the
stove playing when she pulled on a pot handle and dumped
hot water on hersel . You nd that the dorsum o her right
hand and most o her dorsal right arm are covered in second-
and third-degree burns. Using the Parkland ormula, you
estimate that she has burned:
A) 1% o her body sur ace area.
B) 5% o her body sur ace area.
C) 10% o her body sur ace area.
D) None o the above. T e Parkland ormula should not be used
in children.
See question 22.11.4: Helpful ip.
196) A new test has been developed to detect pheochromocy-
toma (not really . . . just pretend). T e test has a very high sen-
sitivity but a very low speci city or pheochromocytoma. T e
prevalence o pheochromocytoma in the population is low.
I this new test is applied to the general population, which o
the ollowing is likely to occur?
A) T e speci city will increase.
B) T e sensitivity will increase.
C) T e positive predictive value will be low.
D) T e negative predictive value will be low.
See question 28.6.2: Helpful ip.
197) You are seeing 23-year-old emale or a routine physi-
cal examination. She tells you that she has a new male part-
ner who has used injectable drugs in the past and has shared
needles. His HIV status is not known. T ey do not always use
condoms when sexually active. In addition to recommending
consistent condom use, you also recommend pre-exposure
prophylaxis with:
A) eno ovir.
B) eno ovir/Emtricitabine ( ruvada).
C) E avirenz (Sustiva).
D) eno ovir/Emtricitabine/E avirenz (Atripla).
E) None o the above.
See question 9.4.2.
198) A 5-year-old patient presents with “leg pain” that you
determine is originating rom the right hip joint. An x-ray
demonstrates a density at the right emoral head. With your
Spidey senses tingling, you order an MRI which shows osteo-
necrosis o the emoral head. T e best next step in the care o
this patient is:
A) Acetaminophen and physical therapy.
B) Re erral to orthopedic surgery or a hip replacement.
760 FAMil Y MEDiCin E ExAMin At io n & Bo ARD REViEW

C) Systemic steroids (e.g., prednisone). C) Midsha 5th metatarsal racture.

D) Steroid injection o the hip joint. D) 5th metatarsophalangeal joint dislocation.

See question 12.2.3. See question 12.19.1.

200) You are watching a really bad grade B movie. Who do

199) A 35-year-old male presents or oot pain one day a er you think will win?
an injury. He was playing soccer when he twisted his right A) Mothra.
oot and ankle and ell. He has trouble bearing weight on the B) King Ghidorah.
oot due to pain. You order an x-ray o his oot and ankle. T e C) Biollante.
radiologist calls to tell you he has a Jones racture. When you D) Godzilla.
look at the x-ray, you expect to nd a: E) Mechagodzilla.
A) Proximal 5th metatarsal racture.
B) Distal 5th metatarsal racture. Never bet against Godzilla.
Index
Note: Page number ollowed by and t indicates gure and table respectively.

A treatment o , 491 constitutional delay, 396–397

A–a gradient, 109 types o , 490 depression in, 401
ABCD2 criteria, 500t Acquired immune de ciency syndrome (AIDS), 260. eating disorders in, 398
ABCDE algorithm, or primary survey, 28 See also HIV/AIDS emale athlete triad in, 397–398
ABCs (airway, breathing, and circulation), 3 Acral lentiginous melanoma, 477 hypertension in, 400
Abdominal aortic aneurysm (AAA) Acrocyanosis, 327 leg pain in, 397
blood pressure control in, drugs or, 66 Acromegaly, 300–301 mortality or, causes o , 400–401
dissection o , 66 therapy or, 301 obesity in, 403–404
in older men, 593 Acromioclavicular (AC) sprain, 349, 350 substance use, 401
repair o , 65–66 Actinic keratoses (AKs), 494 sudden cardiac death in, 399
screening or, 66, 593 Active euthanasia, 689 vaccine recommendations or, 402–403
ultrasound in, 65 Activities o daily living (ADL), 591 vitamin D intake, 399
Abdominal pain, 227 Acupressure, 669 weight loss in, 404 (see also Obesity)
ovarian torsion and, 28 Acute angle closure glaucoma, 528, 528 Adrenal adenoma, and hyperaldosteronism, 76
pelvic in ammatory disease and, 436–437 diagnosis o , 528 Adrenal hyperplasia, 299
and pregnancy test, 25 drugs used or, 529, 529t Adrenal insu ciency, 283–284
ABI (ankle-brachial index), 70, 495 presentation o , 529 diagnosis o , 284
Abili y. See Aripiprazole risk actor or, 528–529 primary, 284–285
Abortion treatment o , 529–530 secondary, 285, 286
complete, 431 Acute calculous cholecystitis, 616 treatment o , 285
elective, 695–696 Acute chest syndrome (ACS), 18, 186 Advance directives, 689
ethical issues, 695–696 exchange trans usion in, 18 AED. See Antiepileptic drug (AED)
missed, 431 management o , 18 Aeroallergen skin testing, 131
spontaneous, 431–432 Acute interstitial nephritis, 170 Aerophagia, 202
threatened, 431 development o , 170t Age-related macular degeneration (AMD), 532, 533
ABPA. See Allergic bronchopulmonary aspergillosis drugs associated with, 170t Aging
(ABPA) symptoms and laboratory ndings in, 170t and Alzheimer disease, 584
Abrasion, 475t treatment o , 171 sex hormone changes associated with, 572
Abscess, 475t Acute kidney injury, 156 Agitated patient
dental, 564 Acute myocardial in arction (AMI). See Myocardial and violence, 651t
lung, 111 in arction (MI) ways to calm, 651t
peritonsillar, 566, 567 Acute otitis media (AOM), 548 Agoraphobia, 634
retropharyngeal, 38 antibiotics or, 549–550 AIDS. See Acquired immune de ciency syndrome (AIDS)
Absence seizures, 523 causes o , 549 Air leakage, 623
Absolute risk reduction (ARR), 715, 717 ndings, 548–549 AKs. See Actinic keratoses (AKs)
Abuse treatment o , 549 Albiglutide, 292
child, 374 Acute sequestration syndrome, 19 Albumin, 223, 599, 619
elder, 589 Acute tubular necrosis (A N), 155, 158 detection o , 151
inhalant, 684–685 acute kidney injury due to, 159 Albumin/creatinine ratio, 140
skeletal survey or, 374 cause o death in, 159 Albuminuria, moderately increased, 140
Acamprosate, 682 causes o , 158 Albuterol, 36, 612
Acanthosis nigricans, 494–495, 495 , 663 treatment o , 158 or asthma exacerbation, 22
causes o , 495 Acyclovir, 150 and tachycardia, 22
diseases associated with, 663 AD. See Alzheimer disease (AD) Alcoholic hepatitis, 190
Accelerated junctional rhythm, 52 Adalimumab, 307 Alcoholics Anonymous (AA), 692, 693
Accommodation, 526 or in ammatory bowel disease, 211 Alcoholics, children o , 681
ACE inhibitors. See Angiotensin-converting enzyme Addisonian crisis, 285 Alcohol, metabolism o , 8
(ACE) inhibitors Adenocarcinoma, 553–554 Alcohol-related liver disease, 227
Acetaminophen, 334, 365, 549, 573, 587, 705 Adenoidectomy, 550 Alcohol use, 553, 590. See also Alcohol withdrawal
dose or older adults, 593 Adenomatous polyps, 209 CAGE questionnaire, 674
and methemoglobinemia, 191 colonoscopy in, 209 complication o , 676
or pain control, 346, 587 Adenosine, 49, 54 disorders with, 677
or rotator cu tendinosis, 351 or PSV , 83 evaluation in, 674
Acetazolamide, 542 Adenoviral conjunctivitis, 537 increased gamma-glutamyltrans erase (GG ) in, 675
Acetic acid ear drops, 551 ADHD. See Attention-de cit/hyperactivity disorder and peripheral neuropathy, 504, 674
N-acetylcysteine, 2, 142 (ADHD) tolerance and, 674–675
Achalasia, 204 Adhesive capsulitis, 351 Alcohol withdrawal, 577, 673
Achilles tendon rupture, 355, 358 clinical course or, 352 carbamazepine in, 675
Acid–base disorder, 168 treatment o , 352 criteria or, 673
Acidosis Adjustment disorder, 636, 643 treatment o , 673–674
anion gap, 7, 7t Adolescents Aldosterone, 668
causes o , 7t athletes, 399 Alendronate, 399, 575
metabolic (see Metabolic acidosis) bacterial meningitis in, 242 Alien limb phenomenon, 517
Acne, 490 birth control options, 398–399 Alirocumab. See Praluent
medication-induced, 490 calcium intake, 399 Aliskiren, 62
neonatal, 485 causes o death in, 400–401 Alkali burns, 536
761
762 INDEX

Allergen immunotherapy, 132 Angiodysplasias, 232 Antidepressants, 509

Allergic bronchopulmonary aspergillosis (ABPA), 127 Angiotensin-converting enzyme (ACE) inhibitors adverse e ects o , 639–640
diagnosis o , 127, 127t and cough, 112 and birth de ects, 640
treatment or, 127–128 or diabetic nephropathy, 144 or dementia, 586
Allergic conjunctivitis. See also Conjunctivitis or heart ailure, 61 erectile dys unction by, 641
about, 537 or HF exacerbation, 62 in pregnancy, 642
treatment o , 538 or hypertension, 74, 291 weekly dosage, 652
Allergic rhinitis, 128, 131–132, 559 or moderately increased albuminuria, 141 and weight gain, 663t
Hansel stain o nasal mucous in, 128 in pregnancy, 427 Anti-EBV (Epstein–Barr virus) antibody, 566
treatment or, 128 or proteinuria, 151–152 Antiepileptic drug (AED), 502
Alli. See Orlistat or Raynaud phenomenon, 329 interactions with oral contraceptives, 503
Allopurinol or renal disease, 171 in pregnancy, 502–503
or gout, 314, 315 side e ects o , 77, 291 side e ects with, 502
side e ects o , 315 Angiotensin receptor blockers (ARBs), 61, 141 Anti brinolytic therapy, 174, 535
Alogliptin, 292 and cough, 75 Anti ungal therapy, 554
Alpha-blockers or hypertension, 74, 291 Antigliadin antibodies, 214
or benign prostatic hyperplasia, 456 in pregnancy, 291 Anti-glutamic acid decarboxylase (anti-GAD) antibodies,
or hypertension, 74 or Raynaud phenomenon, 329 290
side e ects o , 455 or renal protection, 141 Anti-hepatitis A antibodies (IgG and IgM), 219
sildena l and, 55 and risk o gout, 314 Antihistamines, 538, 558
and weight gain, 663t Anion gap, 7 or allergic rhinitis, 128
Alpha- etoprotein (AFP), 220 Anion gap acidosis, 7, 7t and weight gain, 663t
5-alpha-reductase inhibitors, 456 Ankle-brachial index (ABI), 70, 495 Anti-mitochondrial antibodies (AMA), 225
Alport syndrome, 164 Ankle sprains, treatment or, 356 Antiphospholipid antibody syndrome, 196, 197,
Alprazolam, 635, 675 Ankylosing spondylitis, 330 325–326
AL E (apparent li e threatening event), 366 anti- NF therapy or, 331 in pregnancy, 326
Alternative therapies, 667–668 diagnosis o , 330 treatment o , 326
Alzheimer disease (AD) management o , 330 Antipsychotics, 585, 589
end-stage, 586 Annexa, 198 in alcohol withdrawal, 674
risk actor or, 583–584 Annular arrangement, 475t atypical, 578
symptoms, 582 Anorectal manometry, 233 or schizophrenia, 655
treatment o , 584 Anorexia nervosa (AN), 648 second-generation, 658
Amantadine, 511 and bulimia nervosa, 650 and weight gain, 663t
Amaurosis ugax, 542 laboratory nding in, 648–649 Antisocial personality disorder, 653
Amblyopia, 526, 527 management o , 649 characteristics o , 653t
24-hour ambulatory blood pressure monitoring, 72–73 medical complications o , 649 and risk o suicide, 653
Ambulatory devices, 580 mortality rates in, 649–650 Antithymocyte antibodies, 512
Amelanotic melanoma, 477 subtypes o , 650 Anti-thyroglobulin antibodies, 274
Amenorrhea, 298, 451 symptoms o , 648 Antithyroid drugs, 274
causes o , 298 Anovulation, 438, 441–442 side e ects o , 274
evaluation o , 451 Anterior cruciate ligament (ACL) rupture, 353–354 Antithyroid peroxidase antibody, 274
primary, 430 diagnosis o , 354 Anti-thyrotropin receptor antibody, 274
secondary, 398, 430 Anterior epistaxis, source o , 561 Anti- NF agents, or spondyloarthropathy, 331
American Cancer Society (ACS), 573 Anterior at pad sign, 359, 359 Anti-tumor necrosis actor ( NF)-alpha antibody
American Geriatrics Society, 595 Anterior ischemic optic neuropathy, 532 therapy, 211
American Society o Anesthesiologists (ASA) physical Anterior talo bular ligament, sprain o , 355 Antiviral therapy, during in uenza outbreak, 238
status classi cation, 613t Antibiotics, 550, 600 Anuria, 156
American Urological Association (AUA) symptom score, or acne, 491 Anusol suppositories, 233
454 or acute prostatitis, 26 Anxiety disorders, 634
Aminoglycoside antibiotics, and hearing loss, 573 or bacterial overgrowth, 214 AOM. See Acute otitis media (AOM)
Amiodarone, 46, 58, 277 or bronchiectasis, 125–126 Aortic dissection, 31
in atrial brillation, 54 or community-acquired pneumonia, 121 Aortic stenosis, 71, 71t
Amitriptyline, 131, 509, 569, 663 or contact lens–related abrasions, 539 management o , 72
Amlodipine, 329 or dental in ections, 38 symptoms in, 71–72
Amniotomy, or labor induction, 416 or diverticulitis, 234 Apache score, 230
Amoxicillin, 549, 550, 565 or ebrile neonates, 393 Aphakia, 543
Amoxicillin/clavulanate, 558 or Fournier gangrene, 598 Aphthous ulcers, 561–562
Amphetamine use, 684 or gonococcal arthritis, 312 Apixaban, 109, 195, 196, 198
symptoms o , 684 or gonorrhea, 464–465 in non-valvular atrial brillation, 54
withdrawal rom, 684 or impetiginized atopic dermatitis, 479 Apley test, 355
Ampicillin, or in ection in newborn, 34 or in ection in newborn, 34 Appendectomy, 614
Ampicillin/sulbactam (Unasyn), 228 or in ective endocarditis, 246 Appendicitis, 613–614
Ampyra, 511 or Lyme arthritis, 319 symptoms, 615
AN. See Anorexia nervosa (AN) or maternal chorioamnionitis, 379 Appendix testis, torsion o , 459
Analgesic-related headaches, 508 and meibomian gland dys unction, 540 Aprepitant, 708
Analgesics or meningitis, 241 Aranesp. See Darbepoetin
or otitis media, 549 or mononucleosis, 567 ARBs. See Angiotensin receptor blockers (ARBs)
or rhinosinusitis, 558 or neonatal osteomyelitis, 393–394 Arcanobacterium haemolyticum, 38, 567, 568
Anaphylactoid reactions, to radiocontrast material, 134 or neonatal pneumonia, 392 Aripiprazole, 655, 658
Anaphylaxis, 177 or neutropenic ever, 178 , 178t Arterial blood gas, 154
Anaplastic thyroid carcinoma, 273 or otitis media, 549 Arterial insu ciency ulcers, 481
Andexanet al a. See Annexa or pelvic in ammatory disease, 437 Asacol, 211
Androgenetic alopecia, 462 or Pneumocystis jiroveci pneumonia, 262 5-ASA drugs, or in ammatory bowel disease, 211
Anemia or pneumonia in terminal dementia, 708 Ascites, due to portal hypertension, 221–222
o chronic disease, 146, 183 or spontaneous bacterial peritonitis, 223 ASCVD risk calculator, 92, 93
iron de ciency, 181–183, 286 or streptococcal pharyngitis, 565 “Ask Me 3” program, 729
microcytic, 183 or urinary tract in ection, 378 Aspergillosis, 552
pernicious, 187–188 or viral conjunctivitis, 537 Aspiration pneumonitis, 1, 610–611
Anesthesia Anticholinergic crisis, 640 Aspirin, 112, 152, 181, 534, 587, 610, 668
evaluation, 613 Anticholinergics, 564 or antiphospholipid antibody syndrome, 326
mortality rate rom, 613 in colic treatment, 384 and asthma, 102
Aneurysm Anticholinergic toxidrome, 5, 5t and colon cancer risk, 624
abdominal aortic, 65–66 Anti-citrullinated protein antibody (ACPA), 304 or diabetes, 293–294
thoracic aortic, 310 Anticonvulsants, 574 or myocardial in arction, 41
Angel dust, 686 and weight gain, 663t or preeclampsia, 424
 INDEX 763

and Reye syndrome, 387 in ammatory, 329 Blood pressure. See also Hypertension
or stroke prevention, 500 lower (see Lower-back pain (LBP)) diabetes and, 52
Assisted reproductive technology, 439 Backup contraception, 410, 410t ischemic stroke and, 499
Assisted suicide, 689 Baclo en, 682 Blood trans usion, 176
Asthma Bacterial conjunctivitis, 537, 538 . See also Conjunctivitis indications or, 176t
albuterol in, 101 Bacterial in ection, in newborn, 33 reactions, 177
aspirin sensitive, 102 Bacterial meningitis Blowout racture, with entrapment o the in erior rectus,
exacerbations, 101, 102 in adolescents, 242 14–15
intermittent, 99, 101 causative organism, 241 Blunt injuries, 528
mild, 99 diagnosis o , 240–241 BN. See Bulimia nervosa (BN)
patient education in, 102 treatment or, 241 BODE index, 106
prevalence o , 98 Bacterial overgrowth syndrome, 213 Body mass index (BMI), 604
salmeterol in, 102 tests or, 214 calculation or, 622
severity classi cation and therapy, 100t Bacterial parotitis, 563 Boerhaave syndrome, 208
stepwise treatment approach to, 101 Bacterial sinusitis, 558 Bone age assessment, 396–397
testing in, 99 Bad news Bone densitometry screening, 573
triamcinolone in, 101 giving o , 709, 709t Bone marrow biopsy, 181
Asthma exacerbation, 21–22 SPIKES six-steps or breaking o , 709, 709t Bone marrow transplant, 185
discharging patient rom ED, 23 Balanitis, 465 Bone mineral density, 310, 397, 574
steroid use in, 22 Balanoposthitis, 27 estrogen and, 574
test in evaluation o , 22 Band ligation, 606 in women, 398, 575
theophylline in, 22–23 Bare metal stents (BMS), 50 Bone mineralization, 574
treatment or, 22 Bariatric surgery, 434, 604, 665 Booster phenomenon, 243
AS /platelet ratio index (APRI), 217 Barrett esophagus, 201 Borderline personality disorder, 652, 652t
Asymptomatic bacteriuria, 242–243, 587 Basal cell carcinoma, 487, 487 Borrelia mayonii, 318
Asystole, ventricular tachycardia and, 67–68 Bath salts, 686 Botrytis cinerea, 98
Atazanavir, 261 Bayes theorem, 720 Bowel ischemia and mesenteric thrombosis, 228
Atelectasis, 611 Bee sting kit, 24 Bowel obstruction, 603
Atherosclerotic cardiovascular disease (ASCVD), 92 Bee sting reaction, 23–24 closed-loop, 603
A N. See Acute tubular necrosis (A N) treatments in, 23 unctional, 603
Atomoxetine, 646 Behavior control, 589 management o , 603
Atopic dermatitis, 477 Behcet disease, 562 mechanical, 603
clinical eatures o , 478 Bell palsy, 562 open-loop, 603
management o , 478–479 Bence Jones proteins, 151 BPH. See Benign prostatic hyperplasia (BPH)
skin in ections and, 478, 479 Benign lymphadenopathy, 557 Bradycardia, re-warming or, 19
Atorvastatin, 615 Benign murmurs, o childhood, 368, 369t Bradycardia–tachycardia syndrome. See Sick sinus
Atovaquone/proguanil (Malarone), 252 Benign paroxysmal positional vertigo (BPPV), 498, 560 syndrome
Atrial brillation, 52, 53 treatment o , 560 Bradykinesia, 582
alcohol use and, 52–53 Benign prostatic hyperplasia (BPH), 454 Brain lesion, 562
anticoagulation be ore cardioversion in, 54 medical therapy or, 454–455 Brain natriuretic peptide (BNP), 59, 60
cardioversion o , 54–55 prostate cancer and, 468–469 Brainstem-evoked potentials, 555
causes o , 53 saw palmetto or, 470 Brain stem stroke, 498
diltiazem in, 54 tamsulosin in, 455 Branchial clef cysts, 564
lone, 55 and urinary retention, 27 BRCA 1 gene, 607
non-valvular, 54 Benzodiazepines, 585, 706 Breast cancer, 607–608
rate control in, 53–54 or alcohol withdrawal, 673–674 management o , 608
stroke and, 53 or dyspnea and anxiety, 700–701 prognostic indicators in, 609
war arin in, 54 in tricyclic-induced seizures, 4 risks or, 609
Atrial utter, postoperative, 613 Bereavement, 637, 638, 643 screening or, 573
Atrial septal de ect (ASD), 369 Beta-blockers soy or, 667t
Atrial tachycardia with third-degree heart block, 77, 79 or BP control in aortic dissection, 31 Breast eeding, 383
pacemaker or, 77, 80 or glaucoma, 529t bene ts o , 433
Atropine, 45 or heart ailure, 61, 64 HIV/AIDS and, 265–266
Attention-de cit/hyperactivity disorder (ADHD), or hypertension, 74 by vegan mothers, vitamin supplementation in,
644–645 overdose, 8 662
adults with, 645–646 or premature atrial contractions, 58 Breast eeding ailure jaundice, 364
behavior therapy in, 645 or sick sinus syndrome, 69 Breast lumps, 607
children with, 645 topical, 529t, 531 Breast milk, 389, 433
stimulant e ects on, 645, 645t and weight gain, 663t supplements to, 662
symptoms in, 646t Betahistine, 556 Breast milk jaundice, 364, 369
Audiogram, 555 Bexsero, 403 Breath-holding spells, 366
Augmentation o labor, 433 Bias, in research studies, 712, 713t Breath sounds, absent, on lef , 29–30
Auricular cartilage piercing, 623 Biceps tendon rupture, 349, 352 Breath urea test, 207
Auryxia. See Ferric citrate Bilateral brain lesion, 562 Bridging therapy, 56
Autism spectrum disorders, screening tool or, 375 Bilateral developmental dysplasia o hip (DDH), 337 Brie interventions, components or, 687
Autoimmune hypothyroidism, 271 Bile acid sequestrant, 94 Brilinta. See icagrelor
Autoin ation, 551 Bilevel positive airway pressure (BiPAP), 520 Bromocriptine, 299, 300
Autosomal dominant polycystic kidney disease Biliary atresia, 364 or Parkinson disease, 517
(ADPKD), 155 Biliary outlet obstruction, 227 Bronchiectasis
Autosomal-recessive polycystic kidney disease, 167 Biliary pancreatitis, 616 antibiotics in, 125–126
Avulsion racture, 335t Bilirubin, elevated, causes o , 364 etiology o , 126
o tuberosity, base f h metatarsal, 356–357, 357 Biocreep, 719 Bronchiolitis, 35, 97
Azathioprine Biological gender, 733 causative organism, 385
or in ammatory bowel disease, 211 Bipolar I disorder, 647 nebulized hypertonic saline in, 385
or myasthenia gravis, 513 Bipolar II disorder, 647 treatment in, 385
Azelastine nasal spray, 131 Birch pollen allergy, 133 Bronchitis, and hemoptysis, 114t
Azithromycin, 449, 538, 549, 559 Birth control options, 398 Bronchodilator therapy, in asthma exacerbation, 22
or travelers’ diarrhea, 252 Bishop score, 416 Bronchoscopy with endobronchial ultrasound
Bisphosphonates, 279, 574, 575 (EBUS)-guided ne-needle biopsies, 105–106
B Black cohosh, 666 Bronze diabetes, 190
Babesiosis, 251t Black patients, caring or, 730–731 Brown–Sequard syndrome, 504
Baby blues, 642 Black pigment stones, 616 Brown stones, 616
Bacille Calmette–Guerin (BCG) vaccine, 243, 244–245 Blastomyces dermatitidis, 127 Brudzinski sign, 241
Back pain Bleach, industrial, ingestion o , 20–21 Buerger disease (thromboangiitis obliterans), 327
causes o , 329 Blood dyscrasias, 543 Bulge sign, 320
764 INDEX

Bulimia nervosa (BN), 398, 650 Cardiogenic shock, 618, 618t Children
Bulla, 475t Cardiopulmonary bypass, heparin or, 612 with ADHD, 645
on skin, 380–381 Cardiovascular disease (CVD) risk, 595 breath-holding spells in, 366
Bullosis diabeticorum, 495 Carotid endarterectomy, re errals or, 500–501 depression in, 643, 643t, 644
Bullous pemphigoid, 488–489, 489 Carpal tunnel syndrome, 360 gross hematuria in, 167t
diagnosis o , 489 conditions associated with, 360 HAAR or, 266
prognosis o , 489 conservative therapy or, 360 heme positive stools in, 388
treatment o , 489 evaluation and management o , 360 HIV/AIDS in, 266
BUN/Cr ratio, 142–143, 156 symptoms o , 360 neutrophil counts in, 189
Buprenorphine, or opioid dependence, 673 Case–control study, 718 urinary tract in ection in, 377–379
Bupropion, 635 Catamenial cyclic vomiting syndrome, 235 Chlamydia in ection, in newborn, 385
adverse e ect o , 635–636 Cataplexy, 520 Chlamydia proctitis, 465
or attention-de cit/hyperactivity disorder, 646 Cataract ormation, risk actors or, 544 Chlamydia trachomatis, epididymitis by, 25
clozapine and, 681 Cataract surgery Chlamydia urethritis, 464–465
contraindication to, 636 complications or, 544 Chlordiazepoxide, 675
or depression, 629 indication or, 544 Chlorthalidone, 314
in smoking cessation, 680 opaci cation o posterior capsule, 546 or hypertension, 74
transition rom, 636 Cauda equina syndrome, 345, 522 Cholecystectomy, 617
Burkitt lymphoma, 553 decreased rectal tone in, 522 Cholecystitis, 616
Burn wound management, 618 diagnosis o , 523 initial treatment o , 617
Buspirone (BuSpar), 585t, 700 treatment in, 523 management o , 617
Cauli ower ear de ormity, 561 Cholecystoenteric stula, 616
C Cavitary lesion, on chest x-ray, 110–111, 111 Choledocholithiasis, 226
CA-125, 153, 429, 446 Cawthorne rehabilitation exercises, 560 Cholelithiasis
Cabergoline, 299, 300 CB . See Cognitive behavioral therapy (CB ) about, 605
CABG. See Coronary artery bypass graf ing (CABG) Ce dinir, 549 di erential diagnosis o , 616
CAGE questionnaire, 674 Ce epime, 123 Cholesterol stones, 616
Calcitonin, 279 Cef riaxone, 34, 392, 523, 538, 549, 559 Cholinergic, 5t
Calcium or pelvic in ammatory disease, 437 Cholinesterase inhibitors, 584
absorption, 666 Ce uroxime, 549 Chondrocalcinosis, 316
or osteoporosis prevention in adolescence, 399 Celecoxib, 42 o knee joint, 317
supplementation, 574 Celexa. See Citalopram Chondroitin, 594, 670
and vitamin D supplementation, 665 Celiac disease. See Gluten-sensitive enteropathy Chondromalacia patellae, 336
Calcium carbonate, 165 Cellulitis, 600 Chorioamnionitis, 413
Calcium channel blocker (CCB), 544 Centers or Disease Control and Prevention (CDC), 368, and antibiotics, 413
or hypertension, 74, 75 402–403 Choroidal neovascular membrane (CNVM), 533
overdose, 8 Centers or Medicare and Medicaid Services (CMS), 569 Christmas Disease, 173
Calcium chloride, 37, 282 Central line placement, 621 Chronic daily headache, 522
or beta-blocker overdose, 8 Central retinal artery occlusion, 542 Chronic granulomatous disease, 137t
Calcium disodium ED A, 185 about, 542 Chronic kidney disease (CKD), 145
Calcium gluconate, 143, 282 causes o , 543 and anemia o chronic disease, 146
in end-stage renal disease, 37 treatment o , 542, 543 stage 3, 145
Calcium oxalate stones, 149 Central retinal vein occlusion, 542, 543 stages o , 145t
Calcium pyrophosphate dehydrate crystal deposition Central venous nutrition (CVN), 230 U I in, cipro oxacin or, 146
disease (CPPD), 316 complication o , 230 Chronic lymphocytic leukemia (CLL), 192
pseudogout attacks in, 317 Central vertigo, 560t Chronic myelogenous leukemia (CML), 192–193
therapy or, 317 Cephalexin, 26, 565 Chronic obstructive pulmonary disease (COPD)
Cameron lesions, 208, 232 Cephalosporins, or impetiginized atopic dermatitis, 479 continuous low- ow oxygen in, use o , 106
Campylobacter jejuni, 514 Cerclage, 422–423 exacerbations, 104–105
Canagli ozin, 296 Cerebellar stroke, 498 hypoxemic patients with, 106
Cancer Cerebral angiography, 546 lung transplantation re erral in, 106
breast, 607–609 Cerebrospinal uid (CSF) analysis, 582, 583 noninvasive positive pressure ventilation in, 104
cervical, 267, 446 Cerebyx. See Fosphenytoin supplemental oxygen in, administration o , 104
colon, 190, 233, 623, 624 Certolizumab, or in ammatory bowel disease, 211 treatment or, 104–105, 105
endometrial, 441 Cervarix, 442 Churg–Strauss vasculitis, 127
laryngeal cancer, 553 Cervical cancer, 446 Chvostek sign, 165, 281
ovarian, 446, 573, 607 Cervical cytology, 434 Cialis, 55, 457
pain, 702 Cervical dysplasia, 435 Cilostazol, 70
prostate, 454, 468–470 Cervical intraepithelial neoplasia (CIN), 435–436 Cimetidine, or bee sting reaction, 23
testicular, 458 Cervical ripening, drugs or, 413 CIN. See Cervical intraepithelial neoplasia (CIN)
Candida albicans, 465 Cervical spine Cinacalcet, 165–166
Candida antigen injection, 484 clinical clearance, 5, 5t Cipro oxacin, or anthrax, 2
Cannabis hyperemesis syndrome, 235 radiographs or, 5 Circadian rhythm sleep–wake disorder, 656
Capsaicin cream, 594 C1-esterase inhibitor de ciency, 135 delayed sleep phase type o , 656
Capsular opaci cation, treatment or, 546 C1-esterase inhibitor replacement protein products, 135 Circumcision, 173, 459–460
Capsule endoscopy, o small bowel, 232 CHA2-DS2-VASC score, 55, 55t abnormal bleeding af er, 460
Carbamazepine, 647 and anticoagulation, 56 consequences o , 460
or alcohol withdrawal, 675 atrial brillation treatment based on, 56t indication or, 460
or trigeminal neuralgia, 522 Chalazion, 540 neonatal, 460
Carbohydrates diet, and calories, 298 Chancroid, 457–458 pain control measures or, 461
Carbonaceous material, 619 Chantix. See Varenicline Cirrhosis, portal vein thrombosis in, 224
Carbon dioxide in stomach, 619 Charcoal Cisapride, 231
Carbon monoxide poisoning, 9 contraindication to use o , 2 Cisplatin, 573
ndings with, 9 in iron overdose, 2 Citalopram, 636
hyperbaric oxygen therapy and, 9 in theophylline toxicity, 1–2 CKD. See Chronic kidney disease (CKD)
100% oxygen in, administration o , 9 Charcot oot, 358 Clarithromycin, or community-acquired pneumonia,
Carboprost tromethamine, 421 Charcot’s triad, 616 123
Carboxyhemoglobin level, in carbon monoxide Chemotherapy-induced nausea, 708 Clavicle ractures, 351
poisoning, 9 Chest pain, cardiac, 30–31, 47–48 Clavulanate, 549, 550
Carcinoembryonic antigen (CEA), 624 Chest tube management, 623 Clindamycin, 228, 564, 599, 600
Cardiac arrest, 619 Chest wound, sucking, 30 in lung abscesses, 111
Cardiac C angiogram (CC A), 52 Chest x-ray, in pneumonia, 122 Clinical Institute Withdrawal Assessment or Alcohol
Cardiac resynchronization, or heart ailure, 91 Chiari network, 64 (CIWA-Ar), 675–676
Cardiac tamponade, 51 Child abuse, 374 Clock drawing, 581
decompensated, 51 Child–Pugh classi cation, 621, 621t Clonazepam, 520
 INDEX 765

Clopidogrel, in myocardial in arction, 41–42 Congestive epididymitis, 461 Creatine use

Closed-angle glaucoma, 529 treatment or, 461 adverse e ects rom, 405
Close racture, 335t Conivaptan, 162 as dietary supplement or athletes, 405
Clostridium di cile, 204, 216 Conjunctivitis, 537 Creatinine, 557
diarrhea by, 239 adenoviral, 537 Creatinine clearance, estimation o , 143
recurrence o in ection by, 240 allergic, 537, 538 Cremasteric re ex, 24
risk actors or, in nursing home patients, 240 bacterial conjunctivitis, 537, 538 Crepitus, 598
treatment o , 239–240 gonococcal, 538 CRES syndrome, 203, 328
CLO test, 207 treatment o , 537 Crigler–Najjar syndrome type I, 226
Clotrimazole, 552 viral, 537, 537 Crohn disease, 210, 606
Clozapine, and bupropion, 681 Constipation and IBD, 607
Clozari, 658 causes o , 363 pathophysiology and natural history o , 210
Club oot, 342 colon cancer and, 623 ulcerative colitis and, 211
Cluster headaches, 521 ber or, 594–595 Cromolyn sodium, 101
high- ow oxygen treatment in, 521 unctional, Rome Criteria, 594t Cross-reactivity, 133
Cobalamin (B12) de ciency, 188 in in ancy, 390 Croup, 35
Coccidiodomycosis, 129 pharmacologic approach to, 594 steeple sign in, 35
Cochrane Collaboration review, 666 risk actor or hernias, 602 Crust, 475t
Cockcrof –Gault ormula, 143 secondary causes o , 594, 595 Cryoglobulinemia, 317
Cognitive behavioral therapy (CB ), 401 Constitutional delay o growth and puberty, 396–397 Cryoprecipitate, 165, 177
or depression, 629 Contact dermatitis, 485, 496, 496 Cryotherapy, 484
or post-traumatic stress disorder, 632 Contact isolation, 2 Cryptorchidism, 458
Cognitive impairment, 581 Contact lenses, 535 Cryptostroma corticale, 98
Cohort studies, 718 Continuous positive airway pressure (CPAP), 520 Crystalloid in usion, 285
Colchicine, 51 Contraception Culturally responsive care, 726–727
or gout, 314, 315 backup, 410, 410t Culture, 732
or pericarditis, 51 emergency, 443–444 CURB-65, 121
Cold, physiologic response to, 327 methods o , 410 (see also speci c methods) Curettage, 622
Cold sores, 33 postcoital, 444 Currant jelly stools, 373
Colesevelam, 94 weight changes and, 409 Cushing disease, 283
Colestipol, 94 Contraction stress test (CS ), 432 Cushing syndrome, 282–283
Colic, 383–384 Contrast dye allergy, premedication regimen or, AC H-producing tumor and, 283
anticholinergic drugs in, 384 133–134 cortisol excess in, 283
management strategies, 384 Contrast-induced nephropathy, 142 evaluation o , 283
Colleagues, impaired, 693–694 Conversion disorder, 510, 632 Cutaneous anthrax, 2
Colles racture, 347, 348–349, 357 Cooties, 291 Cutaneous herpes, 402
Colon cancer, 190 Copaxone, 511 CVID. See Common variable immune de ciency (CVID)
with large bowel obstruction, 233 COPD. See Chronic obstructive pulmonary disease CVN. See Central venous nutrition (CVN)
metastasis o , 624 (COPD) Cyclic vomiting syndrome, 235
risks or, 623 Corlanor. See Ivabradine Cyclopentolate eye drops, 15
Colonoscopy, 606 Corneal abrasions, 16 Cycloplegia, 15
Colposcopy, 436 treatment o , 539 Cycloplegic agents, 15–16, 535, 539
Coma cocktail, 28 Corneal oreign bodies, 536 Cyclosporine emulsion, 540
Comedones, 490 Corneal ulcer, 15 Cyclosporine, or in ammatory bowel disease, 211
Comminuted racture, 335t Corneal ulceration, 536 Cyproheptadine, 131, 493
Common cold, alternative cure or, 669 Corneas, thinner, 530 Cystitis, 25–26
Common variable immune de ciency (CVID), 136, 137t, Coronary angiography, 60 Cystosarcoma phyllodes tumors, 608
138 in myocardial in arction, 46 Cystostomy, 601
immunoglobulin levels in, 138 Coronary artery bypass graf ing (CABG), 50, 613 Cysts, 607
treatment options or, 138 indications or, 50 Cytisine, or smoking cessation, 681
Community-acquired methicillin-resistant S. aureus V/Q scan af er, abnormal, 50 Cytomegalovirus (CMV) in ection, 485, 486
(CA-MRSA), 479 Coronary artery disease, risk actors or, 91, 92t congenital, 379–380
Community-acquired pneumonia Coronary calcium score, 47 Cytotoxin assay, 239
azithromycin and cef riaxone or, 121 Cor pulmonale, 64
causative agent, 121 causes o , 64–65 D
chest x-ray in, 122 continuous, low- ow oxygen in, 65 Dabigatran, 109, 195, 196 198
outpatient treatment o , 123 ECG in, 65 in non-valvular atrial brillation, 54
parenteral antibiotics in, 121 Corticobasal ganglionic degeneration, 517 Dal ampridine. See Ampyra
Compartment syndrome, 16–17 Corticosteroids Danazol, 135
complications o , 17 or ABPA, 127, 127t Dapagli ozin, 296
treatment o , 18 or adrenal insu ciency, 285 Dapsone, 477
urinalysis in, 17 or giant cell arteritis, 310 Darbepoetin, 63
Compartment syndrome o eye, 541 or gout, 314 Darier sign, 496
Complete blood cell count (CBC), 587 or headaches, 701 Date o delivery, 416, 417t
Compression stockings, 110 or MS, 511 Date rape, 5
Comtan. See Entacapone or polymyalgia rheumatica, 308–309 DDAVP, 156, 165
COM inhibitors, 518 in pregnancy, 422 D-dimer test, 107
Concussion, 11–12, 405–406 Cortisporin suspension, 550 Death, impending, signs o , 708
a ects o , 406 Cosyntropin stimulation test, 284 Decision-making capacity (DMC), 688–689
cognitive rest af er, 407 Coudé catheter, 601 Deconditioning, 59
de nition o , 406 Cough Deep venous thrombosis (DV ), 195–196
imaging in, 406 ACE inhibitors and, 112 postoperative, prevention o , 610
prevention o , 407 causes o , 59 in pregnancy, 197
return to practice and play af er, 406–407 chronic, 112–113, 113t De erasirox, 185
second-impact syndrome, 407 gastroesophageal re ux and, 112 De eroxamine, 32
seizure activity af er, 406 proton pump inhibitor in, 112 De eroxamine challenge, 33
signs o , 406 Cow’s milk, 389 Dehydrated child, treatment o , 31
treatment or, 406 Coxiella burnetii, 127 Dehydration, 250, 370
Conductive hearing loss, 555t CRAFF questions, 401 degree o , 370t
Con dence intervals (CI), 716 Cranial nerve process, 562 uid requirement in, 167, 371
Con dentiality, in medical practice, 691–692, 695 C-reactive protein (CRP), 614 saline in usion in, 370
Con rmation bias, 713t role o , in cardiac disease, 92 signs and symptoms o , 370t
Con ounders, 713t, 718 Creatine monohydrate, 669 treatment, 370–371
Con usion Assessment Method (CAM), 578 Creatine phosphokinase (CPK), 17 Dehydroepiandrosterone (DHEA), 399
Congenital syphilis, 379 Creatine phosphokinase MB raction (CPK-MB), 41 Delayed puberty, 372
766 INDEX

Delirium, 576, 634, 676, 709 Diabetic ketoacidosis (DKA), 287 side e ects o , 299
causes o , 577t causes o , 288 Double sickening, 558
evaluation o patient, 577 home-going insulin regimen in, 288–289 Double vision, 546
interventions or, 577 insulin regimen in, 287–288 Down syndrome
prevention o , 577 Diabetic nephropathy risk o , 424
risk actors or, 576 ACE inhibitor in, 144 screening or, in pregnancy, 424
treatment o , 578 diagnosis o , 141 Doxycycline, 252, 449
Demeclocycline, 162 nondihydropyridine calcium channel blockers in, 144 or anthrax, 2
Dementia, 576, 582 Diabetic neuropathy, 296, 360, 481 or bronchiectasis, 126
antidepressant or, 586 Diabetic retinopathy, 289 or community-acquired pneumonia, 123
antipsychotic medication, 589 Dialysis, 159 or Lyme arthritis, 319
behavioral issues, 585, 585t indication or, 144–145 or pelvic in ammatory disease, 437
categorizing, 582 Diarrhea, 204 DPP-4 inhibitors, 292
diagnosis o , 581 by Clostridium di cile, 239 Drain cleaner, ingestion o , 20–21
hospice re erral in, 707 di erential diagnosis or, 215 Dressler syndrome, 50
laboratory evaluation o , 583 treatment or, 215 Dronabinol, 706
medication management or, 584, 585t Diastolic heart ailure (HFpEF), 60, 63–64 Drug-eluting stents (DES), 50
neuroimaging, 581 diuretics in, 64 Drug-related lupus, 324
Dementia with Lewy bodies (DLB), 657 drug therapy or, 64 Drug therapy in elderly, 590
Demerol, 507. See Meperidine in elderly, 64 Dry age-related macular degeneration, 532, 533
Dengue ever, 251, 256 hypertension and, 63 Dual-energy x-ray absorptiometry (DEXA) scan, 397, 574
second occurrence o , 256 Diazepam, 569, 676 Duct tape, or warts, 484
treatment o , 256 Diclegis, or nausea and vomiting o pregnancy, 411 Duloxetine, 640
Denosumab, 575 Diclo enac, 42, 593 Duodenal ulcers, 206
Dental abscess, 564 Dicyclomine, 606 Dutasteride, 455
Dental trauma, 13–14 N,N-diethyl-m-toluamide (DEE ), 252, 319 DV . See Deep venous thrombosis (DV )
Dentition, 563 Di using capacity, 126 Dysmenorrhea, 442
Denver Developmental Screening est, 375 Di cid, 240 primary, 442
Depakote, 502 DiGeorge syndrome, 138t secondary, 442
Dependent elder, de nition, 589 Digibind, 80 Dysphagia, 202
Depo-Provera, and weight gain, 409 Digital vaginal examination, 412 CRES syndrome and, 202
Depression. See also Major depressive disorder (MDD) Digoxin, 55 endoscopy in, 202
add-on therapy or, 658 in atrial brillation, 54 esophageal, 202, 203t
in children, 643, 643t, 644 in diastolic dys unction, 64 Dyspnea, 126
and dementia, 583 in HFrEF, 61 end-stage cardiac disease and, 700–701
postpartum, 642 Dihydropyridine calcium channel blocker, 144 Dysuria, 169–170
in pregnancy, 642 Dilantin. See Phenytoin
psychiatric re erral or, 630 Diltiazem E
risk actors or poor outcome on treatment, 630 in atrial brillation, 54 Ear pain, causes o , 551, 551t
SAM-e in treatment o , 668 side e ects o , 74 Ear piercing, 623
screening, 581 Dilute Russell viper venom test (DRVV ) assay, 325, 326 Eating disorders, 650
and weight loss, 570 Dimercaprol, 184 Eaton–Lambert syndrome, 513
Depression scales or screening, 627 Dinoprostone, 413 Ebola in ection, 239
De Quervain tenosynovitis, 349 Diphenhydramine, 558, 569, 578, 708 Echocardiography
treatment o , 349 or bee sting reaction, 23 or diagnosis o heart ailure, 59
Derivation set, 714 Diphenhydramine overdose, 5, 5t recommended intervals or valvular disease evaluation,
Dermatitis herpeti ormis, 477 Diphyllobothrium latum, 188 71t
Dermatomyositis, 324, 332 Diplopia, 527 E-cigarettes, 679
diagnostic criteria or, 332t Dipyridamole, 42, 49 Ecstasy, 4, 686
and GI malignancy, 332 Direct laryngoscopy, 553 EC . See Electroconvulsive therapy (EC )
proximal muscle weakness in, 332 Direct ophthalmoscopic examination, 533 Ectopic pregnancy, 27, 430
tests or, 332 Discitis, 347 emergent surgery in, 438
Desmopressin (DDAVP), 148, 174 Disclosure, 694 PID and, 438
Desquamation, 475t Discriminant unction (DF), 224 positive pregnancy test and, 27–28
Detrusor hyperactivity, 588 Disease and illness, di erence between, 724–725 risk actors or, 27, 430
Developmental delays, head injury and, 374–375 Disease-modi ying anti-rheumatic drug (DMARD), 304 serum HCG and, 28
Developmental milestones, 367t Disruptive mood dysregulation disorder, 643 tests in, 430–431
Devic disease (neuromyelitis optica), 510 Disseminated intravascular coagulation (DIC), 194 Eczema herpeticum, 479–480
Dexamethasone, 35–36 Distributive shock, 618t Edinburgh Postnatal Depression Scale (EPDS), 642
in addisonian crisis, 285–286 Disul ram, 681 Edoxaban, 54, 195–196
in severe headache, 508 interaction with ethanol, 681–682 Edrophonium, 512
DEXA scan. See Dual-energy x-ray absorptiometry side e ects o , 682 E ent. See Prasugrel
(DEXA) scan Diuretics, 144 Egg allergy, 134
DHE nasal spray (dihydroergotamine), or headaches, 507 hyponatremia by, 160 Ehrlichia cha eensis, 250
Diabetes, 663 and postprandial hypoglycemia, 297 Elbow dislocation, 16
age-adjusted incidence o , 724 Divalproex, 585t, 647 Elder abuse and neglect (elder mistreatment)
aspirin or primary CVD prevention in, 293–294 Diverticular bleeding, 235 about, 589
blood pressure goal in, 52 Diverticulitis, 233 risk actors or, 589
diagnosis o , 286 C scan o abdomen and pelvis in, 233 Elderly
education program or, 291 management o , 234 alcohol problems, 676
in hospitalized patients, 295–296 second episode, 234 cough in, 59
hypertension in, 291 Diverticulosis, 234 daily exercise or, 591
hypoglycemia in, 294–295 Dix–Hallpike maneuvers, 560, 560t drinking behavior in, 590
lisinopril or hypertension in, 74 Dizziness, 498, 559 hip ractures in, 580
lower-extremity amputation in, 292 DKA. See Diabetic ketoacidosis (DKA) hypertension in, 52
measurement o blood glucose in, 296 Dobutamine, 49 insomnia in, 569
pathologic actors, 290 Dog bites, 10 peripheral sensory disturbance in, 579
prevention o , 289 antibiotic prophylaxis or, 10 sicca symptoms in, 321
preventive services in, 293 in ections, 10 weight gain in, interventions or, 706
screening or, 290, 294t rabies prophylaxis af er, 10 Electrocardiography (ECG)
Diabetes mellitus type 2, 293t, 296, 533. See also Diabetes Domperidone, 231 in cor pulmonale, 65
progression to overt nephropathy in, 141 Donepezil, or Alzheimer disease, 517 in rst-degree AV block, RBBB, and LAFB, 85, 86 , 87
screening or kidney disease in, 140 Dopamine agonist in hyperkalemia, 87, 87
Diabetic amyotrophy, 514 or macroadenomas, 299 in hypokalemia, 87
Diabetic oot ulcer, 495 menopause and, 300 in in erior wall myocardial in arction, 77, 78
 INDEX 767

in LBBB, 85, 86 Epstein–Barr virus (EBV) in ection, 553, 566 Fasciotomy, or compartment syndrome, 18
in lef anterior ascicular block, 85 Epzicom (abacavir/lamivudine), 259 FAS examination, 30
in MA , 87, 88, 88 ERCP. See Endoscopic retrograde Fatal amilial insomnia, 656
in pericardial e usion, 80, 82 cholangiopancreatography (ERCP) Fat bodies, in urine, 152
in pericarditis, 50–51, 81, 83 Erectile dys unction, 472 Fat-soluble vitamin, 660, 661
in PSV , 81, 83, 83 evaluation o , 472 Fatty liver disease, 403
in second-degree heart block, Mobitz type II, 68–69, organic, 472 Febrile newborn, 34, 34t
68 , 80, 81 psychogenic, 472 Febrile seizures, 523–524
in second-degree heart block, type I, 77, 77 therapy or, 473 evaluation o , 394
in tricyclic overdose, 3 Erythema, 475t Febuxostat, 315
in ventricular tachycardia, 66, 67 Erythema migrans, 318, 492 Fecal impaction, 363, 589
in Wol –Parkinson–White (WPW) syndrome, 83, 84 Erythema multi orme, 492 Fecal incontinence, cause o , 589
Electroconvulsive therapy (EC ), 637–638 Erythema nodosum, 491–492, 491 Fecal occult blood, testing or, 208
adverse e ects o , 638 Erythema toxicum neonatorum, 485 Felbamate. See Felbatol
memory loss with, 637–638 Erythrocyte sedimentation rate (ESR), 614 Felbatol, 502
Electrophysiologic study, 57 Erythromycin, 231, 289, 565 Felon, 251
Elevated arm stress test, 352 Erythropoiesis-stimulating agents (ESAs), 63 Female athlete triad, 397–398
Eliquis. See Apixaban Erythropoietin, 146, 176 Femoral torsion, 337
Elliptical excision, 623 Escharotomy, 618t Femoral vein, 621
Eltrombopag, 175 Escherichia coli, 457 Feno brate, 94
Emend. See Aprepitant epididymitis by, 25 Fentanyl, 20, 600, 703
Emergency contraception, 443–444 Escherichia coli 0157, 215 Ferric citrate, 166
Emergent surgical re erral, 598 Esophageal dysphagia, 202, 203t Ferritin, 182
Empagli ozin, 296 Esophageal intubation, standard o care in, 619 Fetal alcohol e ects (FAE), criteria or, 678
Emphysema, 126 Esophageal manometry, 202 Fetal alcohol syndrome (FAS), 678, 678
Emphysematous, 616–617 Esophageal web, 204 diagnosis o , 678
Enalapril, in heart ailure, 61 Esophagitis, 207 rate o , 678
Enbrel. See Etanercept Esotropia, 526 symptoms and signs o , 678
Encopresis accommodative, 526, 527 Fetal bronectin (FFN) test, 422
conditions associated with, 362 acute, 527 criteria or, 422
unctional, 362 congenital, 526, 527, 527 negative, 422
non-retentive, 362 Essential thrombocythemia (E ), 181 Fetal heart rate (FHR) tracing, 413, 414
primary, 362 Essential tremor, 516 category de nitions, 415t
secondary, 362 Estrogen-containing hormone replacement therapy interpretation o , 415, 417, 418
treatment o , 363 (HR ), 439 management o abnormal patterns, 415
Endocarditis, 90 Estrogen/progesterone replacement therapy, 608 placental insu ciency and, 415
causative organisms, 91 Estrogen testing, 439 variable decelerations in, 419–420, 419
Duke criteria or, 90, 90t Etanercept, 307 Fetal macrosomia, 432. See also Macrosomia
valve a ected by, 90 Ethanol, or methanol ingestion, 8 Fever, 178
End-o -li e care, 689, 698–710 Euthyroid sick syndrome, 275 absence o , 587
Endolymphatic sac shunt, 556 Evolocumab. See Repatha intrapartum, 415–416
Endometrial biopsy, 441 Excessive daytime sleepiness, 520 postoperative, 610
Endometrial cancer, 441, 446 Exchange trans usions, 18, 19 causes o , 611, 611t
management o , 441t Exenatide, 292 Fever ew, or migraine, 668
protective actors or, 441t Exercise Fever, in neonate, 392
risk actors or, 441t programs, 579 antibiotics or, 393
Endometriosis, 444–445 or weight loss, 664 evaluation o , 392t
Endometritis, 415–416 Exercise stress testing, 48–49 osteomyelitis and, 393
Endoscopic retrograde cholangiopancreatography (ERCP) contraindications to, 48, 48t Fever o unknown origin (FUO), 249
adverse consequence o , 228–229 negative stress test, 48–49 causes o , 250t
with sphincterotomy, 228 sensitivity and speci city o , 49t evaluation in, 249
Endotracheal tube (E ), 29–30 Exjade. See De erasirox malignancies present with, 249
End-tidal CO2, 619 Exotropia, 526 FHR tracing. See Fetal heart rate (FHR) tracing
Enoxaparin, 110, 610 Exploding head syndrome, 519 Fibroadenomas, 607
or acute myocardial in arction, 45 External hemorrhoids, 605 Fibroids, uterine, 429–430
Entacapone, 518 Eye Fibromyalgia, 322, 510
Entamoeba histolytica, 251 chemical injuries to, 536 conditions associated with, 322
Enterobius vermicularis, 249 drops, 529 management o , 322
Enteropathic arthritis, 331 neovascularization o , 529 pain associated with, 322
Enterotoxigenic E. coli (E EC), 216, 252 Eye trauma, 16 tender points in, 323
Entresto, or systolic heart ailure (HFrEF), 91 Ezetimibe, 94 Fibrosis, 217
Enuresis, 375–376 side e ects o , 94–95 Fidaxomicin. See Di cid
evaluation o , 376 Fif h disease, 382
primary, 375 F Figure-o -eight splint, 351
and retention control training, 376 FABER (Flexion, Abduction, External Rotation) test, 330 Finasteride, 455–456
secondary, 375 Facial mal ormations, alcohol use during pregnancy or androgenetic alopecia, 462
treatment o , 376 and, 679 Fine needle aspiration (FNA), 557, 607
Enuresis alarm, 376 Facilitated PCI, 44 or thyroid nodules and cysts, 278
Eosinophilic esophagitis, 203 Factitious disorder, 632 Finklestein test, positive, 349
Epidermolysis bullosa, 485 Factor VIII in usion, in hemarthroses, 174 First-degree heart block, 69
Epididymitis Factor V Leiden mutation, 196 Fissures
in older men, 25 Failure to thrive (undernutrition), 369–370 rst-line therapy, 606
in young males, 25 management o , 370 types o , 606
Epidural analgesia, in labor, 419 Falls, in older people Fixed upper airway obstruction, ow/volume loop in,
Epiglottitis, 38, 384–385 ambulatory devices, use o , 580 103, 103
diagnosis o , 385 causes o , 578 Flagyl (metronidazole), or richomonas vaginal
Epilepsy surgery, 503 evaluation o uture risks, 579 in ection, 448
Epinephrine exercises and risk o , 579 Floating black spots, 543
in asystole, 68 and hip ractures, 580 Flow/volume loops, 103, 103
or bee sting reaction, 23 risk actors, 578–579 Flublok, 134
racemic, 36 False negative rate (FNR), 721 Flucelvax, 134
Epiploic appendagitis, 234 False positive rate (FPR), 722 Fluconazole, 465
Episcleritis, 545 Famotidine, 574 Fluid administration in burn, 619
Episiotomies, 420 Farmer’s lung. See Hypersensitivity pneumonitis Fluid overload, 221
Eplerenone, or heart ailure, 62 Farxiga. See Dapagli ozin Flumazenil, 3
768 INDEX

Fluorescein, 538 Gastroesophageal re ux disease (GERD), 200 Glycopyrrolate, 700, 706

Fluoroquinolone-resistant gonococcus, 312 complications o , 201 Glycosaminoglycan, 670
Fluoroquinolones, 2, 456, 538, 539 cough due to, 112 GnRH agonists, 442
Fluoxetine, 232, 401, 639, 642 diagnosis o , 200 Gonadotropin releasing hormone (GnRH) agonists, 429
and birth de ects, 640 Helicobacter pylori and, 200 Gonococcal arthritis, 312
dosage o , 652 in in ant, 390 Gonococcal conjunctivitis, 537, 538
reduction o , 570 surgery or, 201 Gonococcal pharyngitis, 566
Fluvoxamine, 639 treatment in, 200–201 Gonococcal urethritis, 464
Foam pad with occluding dressing, 571 Gastrointestinal illness, 383 antibiotics or, 464–465
FODMAPs, 213, 214 Gastrointestinal intolerance, 584 diagnosis o , 464
Folate de ciency, 187 Gastroparesis, 231 Good sleep hygiene, 569
and B12 de ciency, 187 causes o , 232 Gottron papules, 324, 332
Foley catheter, 601 exacerbation o , 231–232 Gout, 313
Fomepizole (4-MP), or methanol ingestion, 8 treatment o , 231 chronic tophaceous gout, 316
Food allergies, 134 GBS. See Guillain-Barré syndrome (GBS) diagnostic criteria or, 314t
Foreign body GCA. See Giant cell arteritis (GCA) drugs and, 314
in esophagus, 204 GDM. See Gestational diabetes (GDM) hyperlipidemia in, 316
in eye, 16 Gem brozil, 94 long-term urate-lowering therapy in, 315
ingestion, 36–37 Gender expressions, 733 management o , 314
Foreskin, retractable, 27 Gender identity, 733 risk actors or, 314
Formula eedings, 389–390 Genetic testing, 695 serum uric acid levels in, 314
Forward bending test, 339 Gentamicin synovial uid analysis in, 313–314
Fosamax. See Alendronate or in ection in newborn, 34 GPA. See Granulomatosis with polyangiitis (GPA)
Fos omycin, 26 ophthalmic ointment, 16 Grace Risk Model, 48
Fosphenytoin, 4, 502 Geodon. See Ziprasidone Gram-negative aerobes, 604
Fosrenol. See Lanthanum carbonate Geographic tongue, 554 Gram-negative pneumonias, 610
Fournier gangrene GERD. See Gastroesophageal re ux disease (GERD) Grand mal seizures, 503
as necrotizing asciitis, 598 Geriatric depression scale, 570 Granular casts, in urine, 152
treatment o , 598 Geriatric pharmacotherapy, 590 Granulomatosis with polyangiitis (GPA), 114. See also
Fox dermal curettage, 622 Gestational diabetes (GDM) Hemoptysis
Fractional excretion o sodium (FENa), 156 3-hour glucose tolerance test or, 424–425 ndings in, 114
Fracture risk actors or, 411 Grape ruit juice, 668
avulsion, 335t screening test or, 424 Graves’ disease, 273, 546
blowout, 14–15 Gestational hypertension, 425–426 in pregnancy, 274
blowout racture, 14–15 Gestational thrombocytopenia, 175 tests in, 274
clavicle, 351 Get-up-and-go test, 579 treatment o , 274
Colles, 347–349 GHB, 686 Graves’ ophthalmopathy, 274–275
comminuted racture, 335t Giant cell arteritis (GCA), 308, 309, 532, 542 Greenstick racture, 335t
greenstick, 335t diagnostic criteria or, 310t Grid laser, 533
Jones, 357 management o , 310 Groin pain, 602
Lis ranc, 352–353, 353 , 354 methylprednisolone or, 310 Gross hematuria, 147
Maisonneuve, 357 and thoracic aortic aneurysm, 310 in children, 167t
posterior rib, 341 GI anthrax, 2 Group A strep pharyngitis, 565
radial head, 359 Giardia in ection, 213 Group B streptococcus (GBS), 33
rib, 116 GI bleeding, upper, 205–206 GBS prophylaxis or preterm delivery, 423
scaphoid, 347–348 GI cocktail, 42 screening or, in pregnancy, 412
scapula, 350 Gilbert syndrome, 226 Grover disease, 496
tibial stress, 397–398 Gin and tonic hypoglycemia, 297 Growing pain, 338
toddler’s, 340 Ginger, 669 treatment or, 338
Framingham risk score, 47 Ginkgo biloba, 584, 668, 670 Growth hormone (GH)
Fresh rozen plasma (FFP) trans usion, 177 Glasgow Coma Scale (GCS), 12, 12t de ciency, 301
Frontotemporal dementia (F D), 582–583 need or intubation, 29 excess, 300–301
Front-wheeled walkers, 580 Glatiramer acetate, 511 replacement therapy, 301
Frostbite, 20 Glaucoma, 528–531 Guaiac tests, 208
Functional bowel obstructions, 603 acute angle closure, 528–529, 528 , 529 Guideline or Adolescent Preventive Services (GAPS)
Functional constipation, Rome Criteria, 594t drugs used or, 529t questionnaire, 400
Functional dysphagia, 202 open-angle, 530 Guillain–Barré syndrome (GBS), 504, 512–513, 514
Functional incontinence, 433–434 optic nerve ndings in, 531 diagnosis o , 514–515
Fundoplication, 201 and retinal detachment, 543 in ectious agents with, 514
FUO. See Fever o unknown origin (FUO) Gleevec. See Imatinib treatment o , 515
Furosemide, 17, 87, 143, 146, 152, 279, 455, 573 Glenohumeral dislocation, 350 GUS O V trial, 47
Fusobacterium necrophorum, 568 Glipizide, 663 Gynecomastia
Glitazones, 227, 291, 294 causes o , 463
G Globus sensation, 202 estrogens and, 463
Gabapentin, 502, 505, 587, 702, 704–705 Glossopharyngeal neuralgia, 522 physiologic, 463
contraindication to, 505 GLP-1 receptor agonists, side e ect o , 292
Gadolinium, use o , 142 Glucagon, or beta-blocker overdose, 8 H
Gail model, 609 Glucagon-like peptide-1 (GLP-1) drugs, 292 HAAR . See Highly active antiretroviral therapy
Galactosemia, 372 Glucocorticoids (HAAR )
Gallstones, 230–231 or elevated calcium level, 279 HACEK organisms, 248
evaluation o , 615 and risk o osteoporosis, 574 HAE. See Hereditary angioedema (HAE)
risk or, 615 Glucosamine and chondroitin, or osteoarthritis, 594, 670 Haemophilus ducreyi, 457
types o , 616 Glucose intolerance, 449 Haemophilus inf uenzae, 121
ultrasound or, 615, 616 Glucose-6-phosphate dehydrogenase (G6PD) de ciency, Hair loss, in males, 462
Gamekeeper’s thumb, 358–359 184, 191–192 Hair transplant, 462
Gamma-hydroxybutyrate (GHB) overdose, 4–5, 5t hemolytic crisis in, 192 Haloperidol, 577, 709
Gangrenous bowel, 388 interventions or, 192 Hampton hump, 107
Gardasil, 442 Gluten- ree grains/starches, 215 Hand eeding, 586, 706
Gastric bezoars, 231 Gluten-sensitive enteropathy, 213, 214 Hantavirus in ection, 128–129
Gastric emptying, delayed, 289 gluten- ree diet in, 214–215 Hashimoto thyroiditis, 271, 273
Gastric lavage, 1 tests or, 214 HC Z. See Hydrochlorothiazide; Hydrochlorothiazide
Gastric ulcers Glyburide, 294 (HC Z)
rom NSAID, 605 Glycemic index (GI), 298 HCV antibody test, 216
risk actors or malignancy in, 206t Glycemic load (GL) o ood, 298 Headaches, 509
Gastrinoma, 207 Glycoprotein IIb/IIIa inhibitors, 47 cluster, 521
 INDEX 769

migraine, 506–507, 522 transmission o , 218 or demented patients, 586

rebound, 508–509 treatment o , 218, 219t involuntary, 637
Head C Hepatocellular carcinoma (HCC), 220 Hot ashes, treatment o , 440
in headache, 513 Hepatorenal syndrome, 225 Household bleach ingestions, 20–21
indications or, 12, 13t Herbal supplements, 667 HPV. See Human papilloma virus (HPV)
Head lice, 253–254 Hereditary angioedema (HAE), 135 HPV vaccination, 442
Head trauma, 11–13, 13t and allergic angioedema, 136 H. pylori in ection, treatment or, 206–207
Health belie s, understanding o , 725 androgens or, 135 HR . See Hormone replacement therapy (HR )
Healthcare-associated pneumonia, 123 laboratory tests or, 135 HSV PCR assays, 402
Healthcare or older patients, 586 transmission o , 135–136 Human cloning, 696–697
Healthcare planning, 575–576 treatment o , 135 Human Genome Project, 732
Health Insurance Portability and Accountability Act Hereditary nephritis. See Alport syndrome Human granulocytic anaplasmosis, 251t
(HIPAA), 735 Hereditary nonpolyposis colorectal cancer (HNPCC), 209 Human monocytic ehrlichiosis, 250, 251t
Health literacy skills, 728–729 Hereditary spherocytosis, 191 Human papilloma virus (HPV), 267, 442
Hearing loss, 555–556 Hernia, 601 vaccine or boys, 403
and sensory impairments, 573 inguinal, 601–602 Humira. See Adalimumab
Heart block repair o , 602 Humoral hypercalcemia o malignancy (HHM), 279
rst-degree, 69 Herpangina, 371 Hungry bone syndrome, 281
myocardial in arction and, 45, 45t Herpes gladiatorum, 402 Hutchinson triad, 379
second-degree, type I (Wenckebach), 69 Herpes simplex encephalitis, 515–516 Hydralazine and isosorbide dinitrate, in heart ailure, 61
second-degree, type II (Mobitz II), 68–69, 68 Herpes simplex virus (HSV), 445, 562 Hydrocarbon toxicity, 7
third-degree, 69 Herpes virus in ection, in newborn, 33 Hydrochlorothiazide
Heart ailure (HF), 142–143 Herpes zoster, 484 or hypertension, 74, 729
cardiac resynchronization or, 91 Herpetic gingivostomatitis, 371 in urolithiasis, 150
diagnosis o , 59 Herpeti orm, 475t Hydrogen peroxide, 11
diastolic (see Diastolic heart ailure (HFpEF)) Heterophile antibody test, sensitivity o , 567 Hydrogen sul de poisoning, 97
echocardiography in, 59 Highly active antiretroviral therapy (HAAR ), 259, 267 Hydromorphone, 20, 600, 705
systolic (see Systolic heart ailure (HFrEF)) in children, 266 Hydroxychloroquine, 325
Heart Failure with a preserved Ejection Fraction in pregnancy, 264 side e ects o , 326
(HFpEF), 59. See also Diastolic heart ailure Hip ractures, 580, 592 Hydroxyurea, 18, 181
(HFpEF) Hip osteoarthritis, 602 Hyperactive thyroid adenoma, 273
Heart Failure with a reduced Ejection Fraction (HFrEV), Hip surgery, 591 Hyperaldosteronism
59. See also Systolic heart ailure (HFrEF) Histoplasma capsulatum, 127 causes o , 76
Heat exhaustion/heat stroke Histrionic personality disorder, 653 and hypertension, 76
risk actor or, 21 HIV/AIDS, 260, 506 hypokalemia and, 76
treatment o , 21 baseline studies in, 259 plasma aldosterone-to-renin ratio in, 76
Heliotrope rash, 324 and breast eeding, 265–266 treatment o , 76
HELPERR mnemonic, 433 cervical cancer with, 267 Hyperbaric oxygen, 599
Hemabate. See Carboprost tromethamine changing drug regimens in, 261 Hyperbaric oxygen therapy
Hematocrit, elevated, causes o , 181 children with, 266 carbon monoxide poisoning and, 9
Hematospermia, 459 con dential name-based reporting or, 690 consequences o , 10
Hematuria and delivery, 265 criteria or, 10
gross, 147 ailed HAAR treatment, 261 and myopia, 10
microscopic, 147 HAAR therapy in, 259, 261 in pregnancy, 10
Heme positive stools, in children, 388 HIV-1/HIV-2 multispot test or, 263–264 Hypercalcemia, 279
Hemochromatosis, 190 natural history o , in women, 267 causes o , 281t
iron studies in, 190 and partner noti cation, 260 ECG in, 279
treatment or, 190 PCP prophylaxis in, 262, 264–265 actors or elevated calcium level, 280
Hemodialysis, 37, 159 perinatal transmission o , prevention o , 264 granulomatous diseases and, 279
or methanol ingestion, 8 pneumococcal and hepatitis B vaccine in, 259–260 treatment o , 279
Hemoglobin A1c, 286 postpartum transmission o , 265–266 Hyperhomocysteinemia, 196
Hemoglobin A1C, 595 pre-exposure prophylaxis (PrEP), 269 Hyper IgE (Job syndrome), 137t
Hemolytic trans usion reaction, 177 and pregnancy, 263–265 Hyper IgM syndrome, 137t
Hemolytic uremic syndrome (HUS), 167, 215 recommended prophylaxis in, 260t Hyperkalemia, 143, 612
causes o , 168 respiratory distress and respiratory ailure, 261–262 causes o , 87
Shiga toxin, 168 screening recommendation or, 268 ECG ndings in, 87, 87 , 143
Hemophilia A, 173 spread o , 268 urosemide in, 143
Hemoptysis status o in ant, determination o , 265 Hyperlipidemia
causes o , 114t testing or, 258 in gout, 316
chest x-ray in, 113 testing or, in expectant emales, 263 obesity and, 403
endotracheal intubation in, 114–115 vertical transmission o , 263 soy or, 667t
massive, 114 HIV antibody–antigen ELISA, 258 Hypernatremia, 156
treatment o , 115 HLA-B27, 330 causes o , 156t
Hemorrhoidectomy, 606 Hodgkin lymphoma, 195 Hyperopia, 527, 528
Hemorrhoids B symptoms in, 195 Hyperprolactinemia, 299
surgery or, 606 late e ects o radiotherapy or, 179 Hypersensitivity pneumonitis, 97, 98, 127
treatment or, 606 lymph node biopsy in, 195 chronic, and ndings, 98
types o , 605 and preventive health issues, 179 oral steroids or, 98
Hemostasis, 620 Holiday heart, 53 respirator in, use o , 98
Henoch–Schönlein purpura (HSP), 166, 167, 377 Holiday- Segar method, or maintenance uids Hypersensitivity reaction, 133, 133t
Heparin, 45, 176, 610, 612 calculation, 371 type I, 493
Heparin-induced thrombocytopenia and thrombosis Homan sign, 196 type IV, 485
syndrome (HI S), 612 Hordeola (styes), 540 Hypertension, 52
Hepatic encephalopathy Hordeolum, 540 in adolescent athlete, 400
causes o , 223 Hormone receptor negative, 609 antihypertensives or, 73–74
treatment o , 223–224 Hormone replacement therapy (HR ) de nition o , 73
Hepatic iminodiacetic acid (HIDA), 615 bene ts o , 439 diagnosis o , 72, 400
Hepatic vein thrombosis, 176 contraindication to use o , 439–440 diltiazem or, 74
Hepatitis A vaccine, 402 in postmenopausal women, 439 doxazosin or, 74
Hepatitis B, 219–220, 220t, 506 or vasomotor symptoms, 440 initial evaluation o , 73
Hepatitis B arthritis, 311 Horner syndrome, 546 lisinopril or, 74
Hepatitis B sur ace antigen (HBsAg), 219 Hospice care, 698 during preconception counseling, 427
Hepatitis C, 506 cardiac therapies in, 698–699 in pregnancy, 425–427
and cryoglobulinemia, 317 and palliative care, 699 secondary causes o , 75, 75t
indications or treatment o , 218 Hospitalization, 617 white coat, 73
770 INDEX

Hypertensive crisis, 640–641 Indomethacin, 422 Intracranial aneurysm, 546

Hyperthyroidism, 273. See also Graves’ disease or pericarditis, 51 Intracranial pressure, increased, 12–13
causes o , 277 Induction o labor, 433. See also Labor induction Intranasal steroid spray, 131, 132
isolated 3-toxicosis in, 277 Inert intraocular oreign bodies, 535 Intraocular oreign body, 535
Hypertrophic cardiomyopathy, 53, 63, 399 In antile hemangiomas, 488 Intraocular lens dislocation, 546
systolic crescendo–decrescendo murmur o , 400 In ants Intraocular pressure
Hyphema, 529, 534, 535 constipation in, 390 elevated, 530
Hypnagogic hallucinations, 520 eeding and nutrition or, 389–390 measurement o , 528, 534
Hypnotics, 520 gastroesophageal re ux disease in, 390 Intrauterine devices (IUDs), 398, 410
Hypocalcemia, 164–165, 279, 281, 575 HIV/AIDS and, 265 contraindications to placement o , 428–429
evaluation o , 282 jaundice in, 364–365 mechanism o action o , 429
treatment in, 282 osteomyelitis in, 393–394 Intrauterine growth restriction, 425
Hypoglycemia, 294 respiratory syncytial virus and, 386 Intravenous (IV) nutrition, 570
causes o , 297 In ection, in newborn, 33–34 Intubation, 29, 622
in diabetics, 295 antibiotics or, 34 Intussusception, 372–373, 384
insulin glargine in, 295 causative organisms, 33 diagnosis o , 373
postprandial, 297 evaluation or, 33 and GI obstruction, 373
Hypokalemia In ectious diseases in nursing home settings, 587–588 treatment o , 373
causes o , 154 In ective endocarditis, 245–246 ultrasound in, 373
metabolic acidosis and, 154–155 antibiotic prophylaxis or, 246 Invasive breast carcinoma, 608
therapy or, 155 blood cultures or, 247 Invokana. See Canagli ozin
Hypomagnesemia, alcoholism and, 676 causative organisms, 247–248 Iodine de ciency, and hypothyroidism, 272
Hyponatremia, 159 high-risk condition or adverse outcome o , 245 Ipecac, 1
chronic, 161 laboratory evaluation in, 246 Ipratropium, 101, 132
di erential diagnosis o , 160 modi ed Duke criteria or, 246, 247t Ipratropium nasal spray, 558
diuretic-induced, 160 signs o , 246 Ipri avone, 666
hypovolemic, 159–160, 161 subacute bacterial endocarditis, 246 Iris heterochromia, 535
laboratory tests in, 161–162 surgery in, indications or, 247 Iritis, 539
therapy or, 160–161 treatment o , 247 Iron de ciency anemia, 181–182, 286
Hypotensive trauma patients, blood administration in, In erior wall myocardial in arction (IAMI), 42–43 causes o , 182t
30 ECG in, 77, 78 ailure o iron therapy or, 182–183
Hypothermia In ertility iron therapy or, 182
bradycardia in, 19 in couple, 471 IV iron preparations in, 183
risk actors or, 20 in males, 470–471, 471t Iron toxicity, 31–33
Hypothyroidism, 271, 332 In ammatory arthritis, 320 chelation with de eroxamine in, 32
causes o , 271–272 In ammatory bowel disease (IBD), 210, 606 mani estations o , 32, 32t
diagnosis o , 271 anemia in, 211 and serum iron levels, 31–32
ailure o medical therapy in, 272 extraintestinal mani estation o , 210 treatment in, 32
iatrogenic, 272–273 and risk o colon cancer, 212 Irreversible retinal damage, 542
and osteoporosis, 272–273 surgery in, 212 Irritable bowel syndrome (IBS), 212, 606, 660
and pregnancy, 273 treatment o , 211 e cacy o ber or, 212
treatment o , 272 In iximab, 307 Rome III criteria or, 212t
Hypovolemic shock, 618t or in ammatory bowel disease, 211 treatment o , 213
Hypoxia, 576 In uenza Ischemic colitis, 233
Hysterectomy, 435 antiviral therapy during, 238 Ischemic optic neuropathy, 532
or leiomyomata, 429 complications with, 387 Isoniazid (INH), 244, 245
in healthcare setting, prevention o , 238 overdose, 9
I outbreak, 588 Isoproterenol, 45
IAMI. See In erior wall myocardial in arction (IAMI) vaccines or (see In uenza vaccination) Isosorbide dinitrate, 144, 473
Ibandronate, 575 In uenza vaccination, 237–238, 588 Isotretinoin, 491
IBD. See In ammatory bowel disease (IBD) contraindication to, 237 side e ects o , 491
IBS. See Irritable bowel syndrome (IBS) egg- ree, 134 IUDs. See Intrauterine devices (IUDs)
Ibupro en, 573, 702 In ormed consent, 725–726 Ivabradine, 91
Ibutilide, in Wol –Parkinson–White syndrome, 85 Ingrown toenails, 622 Ivanapyuk, 444
ICE mnemonic, 725 Inguinal hernias, 459, 601 Ivermectin, 248, 254
Idiopathic rhinitis, 559 Inhalant abuse, 684–685
Idiopathic thrombocytopenic purpura. See Immune demographics o , 685 J
thrombocytopenic purpura (I P) types o , 685 Janeway lesions, 246
Id reactions, 485 withdrawal rom, 685 Januvia. See Sitagliptin
IgA de ciency, 137t, 138 Inhalation injury, 619 Jardiance. See Empagli ozin
IgA nephropathy, 147, 166 Insect repellent, use o , 252 Jarisch–Herxheimer reaction, 319
IGRAs, 244 Insomnia, 569, 585t Jaundice, in in ants, 364–365
Ileostomy care, 624 Instrumental activities o daily living (IADL), 591 JIA. See Juvenile idiopathic arthritis (JIA)
Ileus, causes o , 603 Insulin, 287–289 Joint aspiration, in monoarthritis, 311
Imatinib, 193 in diabetic ketoacidosis, 287–288 Jones ractures, 357
Imbalance (disequilibrium), 559 regular, 287–288 Juvenile idiopathic arthritis (JIA), 318, 377
Imiquimod, 484 Insulin-euglycemia, high dose, or beta-blocker
Immune reconstitution in ammatory syndrome (IRIS), overdose, 8 K
262 Insulin-like growth actor-I (IGF-I), 301 K2, 686
Immune thrombocytopenic purpura (I P), 174 Insulinoma, 297–298 Kava-kava, 641
causes o , 174 Intact P H (iP H), test or, 280 Kawasaki syndrome, 307
di erential diagnosis, 175 Intention to treat analysis, 714 Kayexalate, 143
treatment options or, 175 Inter eron agents, and depression, 511 Kegel exercises, 434
Immunizations. See Vaccination Inter eron and ribavirin, or hepatitis C, 218 Kernig sign, 241
Immunoblasts, 129 Inter eron-b, 511 Ketorolac, 538, 702
Immunode ciency syndromes, 136, 137–138t Intermittent claudication, peripheral arterial disease Ketoti en, 538
Immunologic reactions, 133, 133t and, 69 Kidney stones, 150
Implanted cardiac de brillator (ICD) Internal hemorrhoids, 605 and hematuria, 147, 148
hospice and, 698 Internal tibial torsion, 337 management in, 148–149
Inclusion and exclusion criteria o trial, 714 Interpreters, use o , 727–728 prevention o urther stone ormation, 149
Incontinence Intoeing (pigeon-toeing), 337 renal colic due to, 148
diagnosis o , 434 Intoxicated patient with minor trauma, care or, 15 Kiesselbach plexus, 14, 561
treatment o , 434 Intoxication, 675 Klebsiella oxytoca, 216, 240
type, 433–434 Intra-articular racture, 355 Kline elter syndrome, 471–472
Indinavir, 150 Intracochlear gentamicin, 556 Knee dislocation, and popliteal artery injury, 16
 INDEX 771

Knee pain, cure or, 670 Likelihood ratio, 715, 715 and anxiety disorder, 627
Koilonychia, 487 Linezolid, 248, 641 atypical depression, eatures o , 626
Korotko sounds, pulsus paradoxus and, 51 Lipid disorders criteria or diagnosis o , 626
Kuru, 256 lipid-lowering therapy, 93–94 actors with increased risk o depression, 627
screening recommendation or, 93 hypersomnia in, 626
L Lipid emulsion, 3 illnesses with, 628
Labetalol, 425 Lipid level reduction, 666 in post-MI period, 629
Labor analgesia, 419 Liraglutide, 292 prevalence o , 627
Labor induction Lis ranc racture, 352–353, 353 , 354 in primary care patients, 627
amniotomy or, 416 treatment or, 353 relapse ollowing rst episode o depression, 627–628
nonpharmacologic methods o , 416–417 Listeria monocytogenes, 33 in women, 627
oxytocin or, 417 Lithium, 162, 647 Makena, 423
af er rupture o membranes, 412–413 drug a ecting levels o , 648 Malaria, 252
antibiotics initiation af er chorioamnionitis side e ect o , 647 diagnosis o , 253
detection, 413 Lithotripsy, 564 therapy or, 253
drugs or, 413 Liver disease Malassezia yeast, 479
Labyrinthectomy, 556 assessment o degree o , 217 Male in ertility
Labyrinthitis, 559 in hepatitis C, 217 causes o , 471t
Lachman test, 354 Liver brosis, 217 risk actors or, 470–471
Lactated Ringer’s, 17, 619 Liver tests, elevated, 220–221 treatments or, 471
Lactic acidosis, 143 Lone atrial brillation, 55 Malignancy-associated hypercalcemia, 279
Lactose intolerance, 213 Long acting reversible contraceptive (LARC), 398, 410 Malignant melanoma, 475–476
Lamictal. See Lamotrigine Loop diuretics, 574 Breslow tumor thickness, 476
Lamisil. See erbina ne Loop electrosurgical excision procedure (LEEP), 435 evaluation in, 476
Lamotrigine, 502, 647 complications o , 435 risk actors, 476–477
or partial seizures, 503 Loperamide, 624 risk actors or, 476
Language barriers, 728 or in ammatory bowel disease, 211 Malignant nodes, 556
Lanthanum carbonate, 166 Lorazepam, 675 Mallet nger, 348
Laparoscopic banding, 604 or seizures, 4, 28 Mallory–Weiss tear, 208
Laparotomy, 614 or vomiting patient, 676 Mammogram, 573
Lariam. See Me oquine Lower-back pain (LBP), 344 Mania, 646–647
Laryngeal cancer, risk actors or, 553 early imaging in, need or, 345t Mannitol, 17, 529t
Laryngomalacia, 35 treatment or, 345–346 Mantoux test. See uberculin skin test ( S )
Laryngopharynx, 553 Low-glycemic index diet, 664 MAOIs. See Monoamine oxidase inhibitors (MAOIs)
Laryngoscopy, 553 Low–molecular-weight heparin (LMWH), 612 Marchia ava–Bignami disease, 676
Laryngotracheobronchitis. See Croup in antiphospholipid antibody syndrome, 326 Marijuana intoxication, 685–686
Laser peripheral iridotomy, 529–530 in pulmonary embolism, 109 Mastitis, 416
Latex allergy, cross-reactivity in, 133 LP. See Lumbar puncture (LP) MA . See Multi ocal atrial tachycardia (MA )
Latex- ruit cross-reactivity, 133 Ludwig angina, 38, 556 Maternal chorioamnionitis, 379
Latinos, 731–732 Lumbar and sacral spinal nerve roots, examination Mayo clinic preoperative guidelines, 610t
health issues a ecting, 732 ndings o , 346t McMurray test, 354
LBP. See Lower-back pain (LBP) Lumbar puncture (LP), 33, 513–514 or meniscal injury, 355
LCPD. See Legg-Calve-Perthes disease (LCPD) or bacterial meningitis, 240–241 MDD. See Major depressive disorder (MDD)
LDL cholesterol, natural product or lowering, 666 LUMBAR syndrome, 488 MDMA (3,4-methylenedioxymethamphetamine), 686
LDL level, 595 Lung abscesses, 111 MDS. See Myelodysplastic syndrome (MDS)
Lead poisoning, 184 intravenous clindamycin in, 111 Meatal stenosis, 27
symptoms o , 184 Lung cancer, screening or, 120 Mebendazole, or scabies, 249
Lead-time bias, 712 Lupus anticoagulant, 326 Mechanical bowel obstructions, 603
LEARN mnemonic, 726 Lycanthropy, 639 Meckel scan, 232
Lecithin/sphingomyelin (L/S) ratio, 391 Lyme disease, 251t, 318, 506 Meconium, delayed passage o , 376
LEEP. See Loop electrosurgical excision procedure (LEEP) ndings in, 318 Median nerve compression, 506
Lef anterior ascicular block (LAFB), 85, 85 laboratory tests or, 318–319 Medicaid, 587
Legg-Calve-Perthes disease (LCPD), 335 polymorphonuclear cells in synovial uid, 318 Medical errors, 734
initial treatment in, 335–336 primary prevention o , 319–320 prevention o , 735
poor outcome in, 335 stages o , 319 Medical utility, 689
Leg pain, in runner, 397 therapy or, 319 Medical record, in ormation in, 690–691
Leiomyosarcomas, 430 Lyme meningitis, 320 Medicare, 586–587
Lemierre syndrome, 568 Lymphadenopathy, 557 Medicare hospice bene t, 698, 699–700
Length time bias, 713t Lymph nodes, 557 services covered under, 700
Lentigo maligna melanoma, 477 Lymphogranuloma venereum, 465 Medication-overuse headache, 508
Leopold maneuvers, 387 Lynch syndrome. See Hereditary nonpolyposis colorectal Medroxyprogesterone, 428
Leprosy (Hansen disease), 505–506 cancer (HNPCC) Me enamic acid, 442
Leptin, 664 Me oquine, 252
Leser– relat sign, 495 M Megace. See Megestrol
Leukemia, acute, 193 Macroadenomas Megestrol, 706
Leukocyte adhesion de ciency, 137t dopamine agonist or, 299 Meibomian gland dys unction, 544
Leukoplakia, 554 surgery or, 300 complication o , 540
Leukotriene inhibitors, 102 Macrocephaly diagnosis o , 540
in asthma, 102 diagnosis o , 373–374 past medical history, 540
Levitra, 55 di erential diagnosis o , 374 treatment o , 540
Levodopa, 517 Macrolides, 550 Melatonin, 656
abrupt discontinuation o , 518 Macrosomia Melatonin receptor agonists, 569
side e ect o , 517–518 induction or, 432 MELD scoring system, 621
Levothyroxine, 272, 574 maternal risk rom, 432 Memantine, 584
Levothyroxine absorption, 666 risk actors or, 432 Membranoproli erative glomerulonephritis, 166
Lewy body dementia, 583 Macule/patch, 475t Memory impairment, 581
Leydig cells, 572 Magnesium salicylate, 573 Memory loss, clock drawing test or, 581
Lichen sclerosus, 449–450 Magnesium sul ate Menactra, 403
Licorice, 668 or preeclampsia, 426 Menarche, age o , 442
Lid margin, in ammation o , 540 or status asthmaticus, 22 Men, death rates in, 462–463
Lidocaine, 4, 46 Maintenance uids, 371 Ménière attack, 498
or pain control, 703 Maisonneuve racture, 357 Ménière disease
Lidocaine patch, 594 Major depressive disorder (MDD), 643. See also about, 555, 559
Li e-sustaining interventions, role o law in, 689–690 Depression treatment o , 556
Ligamentous strain, 602 antidepressants in, 628 Meningitis, 240–242. See also Bacterial meningitis
772 INDEX

Meningococcal ype B vaccinations, 403 Miliaria, 485 medications on discharge af er, 46

Meningococcemia, 377 Milk-alkali syndrome, 146 oxygen in, 41
Meniscal injury, test or, 355 Milrinone, or beta-blocker overdose, 8 pacemaker in, indications or, 45, 45t
Menomune, 403 Mineral oil, 363 and submaximal stress testing, 46
Menopause, 439 Minimal change disease, 166 thrombolytics in, 44
Menorrhagia, 429 Mini-Mental State Exam (MMSE), 581 Myoglobin, 17
MEN types, 281–282 Minimum inhibitory concentration (MIC), 241 Myopia, 536, 543
Men who have sex with men (MSM), 269 Minorities
Meperidine, 600, 702. See Demerol disparities in healthcare quality and outcomes or, N
Meralgia paresthetica, 341 732–733 Na cillin, or methicillin-sensitive S. aureus endocarditis,
6-mercaptopurine (6-MP), or in ammatory bowel in research studies, 730 247
disease, 211 Minute ventilation, 125 NAFLD. See Nonalcoholic atty liver disease (NAFLD)
Meridia. See Sibutramine Mirena IUD, 428, 429 Nail old capillary microscopy (NCM), 327
Meta-analysis, 718–719 Mirtazapine, 590, 706 Nail removal, 622
Jadad score or, 719t side e ects o , 639 Nails, dermatophyte in ections o , 482
Metabolic acidosis, 6–7 Miscarriages, spontaneous, chromosomal abnormalities Naloxone, 702, 705
and hypokalemia, 154–155 and, 431 Naltrexone, or alcoholism, 682
and respiratory alkalosis, 169 Misoprostol, 413, 421 Naproxen, 42, 334
Metabolic alkalosis, 144 Missed abortion, 431 or gout, 314
causes o , 163, 163t Mixed metabolic/respiratory acidosis, 124 Narcolepsy
chloride-responsive, 163 MMR vaccine, 365–366 diagnosis o , 519–520
interventions in, 163 Modi ed Checklist or Autism in oddlers (M-CHA ), 375 treatment or, 520
magnesium in, 163–164 Modi ed diet in renal disease (MDRD), 144 Narcotics, side e ects o , 604
with respiratory compensation, 162–163 Molluscum contagiosum, 483–484, 484 Nardil. See Phenelzine
urine studies in, 163 Moniker eczema. See Atopic dermatitis Nasal bleeding
Metal ume ever, 97 Monoamine oxidase inhibitors (MAOIs), 58, 640 about, 561
Metamucil, 95 Monoclonal gammopathy o undetermined signi cance management o , 561
Metaphyseal corner racture, 340–341 (MGUS), 189 treatment, 561
Metatarsus adductus, 341–342 Monocular diplopia, 544 Nasal congestion, 131, 132
treatment or, 342 Mononeuritis multiplex, 305, 504 Nasal steroids, 132
Met ormin, 232, 288 Mononucleosis, in ectious, 482–483 Nasal trauma, 14–15
or diabetes, 288, 289, 291, 292, 663 Mononucleosis-like syndrome, 566 Nasogastric (NG) lavage, 620
in diabetic patients with renal disease, 143 Monospot, 567 Nasotracheal intubation, blind, 622
Methadone, 673 Montelukast, 101, 102, 132 National Institute on Alcohol Abuse and Alcoholism,
overdose, 683 Montreal Cognitive Assessment (MoCA), 582 590
or pain control, 704 Morphine, 600 National Kidney Foundation, 144
Methanol overdose, 7 dosage o , 20 National Lung Screening rial, 120
omepizole and ethanol or, 8 in end-o -li e situations, 703 National Osteoporosis Foundation, 573
serum osmolality in, 7–8 intravenous, 702 National Patient Sa ety Foundation (NPSF), 729
tachypnea in, 7 or palliation o dyspnea in cardiac ailure, 700 Natrecor. See Nesiritide
Methemoglobinemia, 191 Mosaicism, 435 Natural therapy regulation, 667
treatment o , 191 Mouth sores, 561 Nausea and vomiting, 707–708
Methergine. See Methylergonovine MRI contrast, use o , 142 causes and treatment o , 707t
Methicillin-resistant Staphylococcus aureus (MRSA), MRSA cellulitis, 255 o pregnancy, 411, 669
588, 599 MS. See Multiple sclerosis (MS) Nearsightedness, 536
Methimazole, 274 Mucormycosis, 541 Neck mass in adults, di erential diagnosis o , 557t
Meth mouth, 684 Muehrcke nails, 487 Necrobiosis lipoidica, 494, 494
Methotrexate, 305–306 Multi ocal atrial tachycardia (MA ), 52 Necrotizing cellulitis, 598
and anti- olate medications, 305 ECG ndings in, 87, 88, 88 Necrotizing asciitis, 598
or in ammatory bowel disease, 211 treatment o , 88 IVIG in, 599
Methylene blue, 191 Multiple gestations, complications o , 421–422 recommendations or, 599
Methylergonovine, 421 Multiple-legged cane (quad cane), 580 ype II, 599
Methylphenidate, 645 Multiple myeloma, 188 Necrotizing (malignant) otitis externa, 552
Metoclopramide, 231, 289, 517, 707 work-up or diagnosis o , 188 Needle decompression, 617
in GERD, 201 Multiple sclerosis (MS), 510 Needle drainage and compressive dressing, 561
Metoprolol exacerbation o , 511 Needle thoracostomy, in tension pneumothorax, 30
or accelerated junctional rhythm, 80, 80 , 81 primary progressive, 510 Ne azodone, 639–640
or heart ailure, 61, 64 relapsing–remitting, 510, 511 Negative predictive value (NPV), 720, 721
or premature atrial contractions, 58 tests or diagnosis o , 510–511 Neisseria meningitides, 33
Metronidazole, in Clostridium di cile in ection, 239–240 treatment o , 511 Neonatal herpes simplex virus in ection, 381
Miconazole, 465 Multivariate analysis, 718 Neonatal hyperbilirubinemia
Microadenoma, 299 Multivitamins, 661 risk actor or, 364
Microcytic anemia, 183 Mumps, 563 treatment or, 365
Micrographia, Parkinson disease and, 516 Murmurs, benign, 368, 369t Neonatal polycythemia, 363–364
Micronutrient de ciencies, 665 Murphy sign, 616 causes o , 363
Micronutrients, 533 Myasthenia gravis, 546 treatment or, 364
Microscopic hematuria, 147 causes, 512 Neonatal respiratory distress syndrome (RDS), 390–391
evaluation o , 147t diagnosis o , 512 risk actors or, 391
and gross hematuria, 147 exacerbation o , 512 sur actant in, 391
screening or, 148 therapy or, 513 Neovascular glaucoma, 529
stones and, 147, 148 worsening o , 513 Neovascularization o optic nerve, 534
Microscopic polyangiitis, 115 Mycobacterium tuberculosis, 244 Nephrotic syndrome, 152, 545
Microvascular decompression (Janetta procedure), 522 Mycoplasma pneumoniae, 121 causes o , 152–153, 153t
Middle ear e usion, 548 Myelodysplastic syndrome (MDS), 189 criteria or, 152t
Midgut volvulus, 387 pancytopenia and, 189 evaluation in, 153
Midodrine, 532 Myeloperoxidase de ciency, 137t urine sediment in, 152
Mid-parental height (MPH), calculation o , 397 Myocardial in arction (MI), 40 Nerve conduction studies (NCV), 505
Mi eprex. See Mi epristone antiarrhythmics in, 46 Nesina. See Alogliptin
Mi epristone, 444 aspirin in, 41 Nesiritide, 63
Migraine headaches, 506–507, 522 chest pain and, 40–41 Neuroblastomas, 554
with aura, 507, 559 clopidogrel, 41–42 Neurogenic obstruction, 603
criteria or diagnosis o , 506, 506t, 507t enoxaparin in, 45 Neuroimaging, in migraine patients, 509
preventive treatment or, 509 heart block associated with, 45, 45t Neuroleptic malignant syndrome (NMS), 275, 518
treatment o , 507, 507t, 668 intervention in cath lab with P CA and/or stent Neurontin. See Gabapentin
without aura, 507 placement in, 43–44 Neuropathic pain, 505, 702
 INDEX 773

Neuropathic ulcers, 481 Occult hip ractures, 359–360 about, 573

Neutropenia, 178 Occupational therapists (O ), 592 causes o , 574
Neutropenic ever, 178 OCPs. See Oral contraceptive pills (OCPs) de nd, using DEXA scan results, 574
antibiotics or, 178 , 178t Octreotide, 232, 708 increasing risk o , 574
Neutrophil counts, in children, 189 Ocular pain and irritation, 536 initial therapy or, 575
Nicotine gum, 679 Odynophagia, 202 secondary, 574
Nicotine inhaler, 679 Oil cysts, 607 soy or, 667t
Nicotine nasal spray, 679 Olanzapine, 647, 658, 663 treatment o , 574–575
Nicotine patch, 679 Older patient, care o , 569–596. See also Elderly Otitis externa
Nicotine replacement therapy (NR ), 679 Oliguria, 156 rst-line treatment or, 551
Nicotine withdrawal, 681 Omeprazole, in GERD, 201 necrotizing (malignant), 552
Nighttime rituals, 569 Omnibus Budget Reconciliation Act o 1987 (OBRA), 589 Otitis media, 548. See also Acute otitis media (AOM)
NIH Chronic Prostatitis Symptom Index questionnaire, Ondansetron, 411 Otitis media with e usion (OME)
457 or reducing vomiting, 31 about, 548
Nitroglycerin Onglyza. See Saxagliptin bene ts or patients with, 551
in HF exacerbation, 62 Onychocryptosis, 622 Otomycosis, 552
hypotension with, 42–43 Onychomycosis, 482 Otosclerosis, 555
N-methyl d-aspartate (NMDA), 584 Open-angle glaucoma Ottawa oot and ankle criteria, 356
Nocturnal hypotension, 532 risk or, 530 Ottawa knee rules, 354–355
Nodular melanoma, 477 treatment or, 530 Outtoeing, 337
Nodule, 475t Open biopsy, 557 Ovarian cancer, 446, 573, 607
NO HOPE, mnemonics or suicide risk assessment, 654t Open racture, 335t Ovarian mass, 446
Nonalcoholic atty liver disease (NAFLD), 226–227 Open globe, 534 Ovarian torsion, lower abdominal pain and, 28
Nonalcoholic steatohepatitis (NASH), 226 Open-loop obstructions, 603 Over ow incontinence, 433
Nonarteritic anterior ischemic optic neuropathy Ophthalmia neonatorum, 538 Over-the-counter remedies, or nausea and vomiting o
(NA-AION), 532 Ophthalmologic examination, 533 pregnancy, 411
Noncontact training, 567 Opiates, 5t Overweight, 403
Nondihydropyridine calcium channel blockers, 144 in end-o -li e situations, 703 Oxazepam, 675
Nondisclosure, 694 or pain control, 702 Oxybutynin hydrochloride, 434
Non-Hodgkin lymphoma (NHL), 195 switching or dosing, 704 Oxycodone, 232, 505, 672
Noninvasive positive pressure ventilation, 104 Opioid addiction, in pregnancy, 683–684 Oxytocin, 413, 421
Nonmalignant nodes, 556 Opioid bowel syndrome, 235 or labor induction, 417
Nonproli erative diabetic retinopathy, 533 Opioid-induced hyperalgesia (OIH), 322, 703–704
Nonsteroidal anti-in ammatory drugs (NSAIDs) Opioid intoxication, 672 P
and asthma, 102 DSM-5 criteria or, 672 Pacemaker
or dysmenorrhea, 442 Opioid withdrawal, 672–673 in myocardial in arction, 45, 45t
or endometriosis, 445 Optic nerve in sick sinus syndrome, 69
gastric ulcers by, 207 glaucomatous, 531 PACs. See Premature atrial contractions (PACs)
and GI event risk, 206 hemorrhages, 531 PAD. See Peripheral arterial disease (PAD)
or gout, 314 neovascularization o , 534 Paget disease o breast, 609
or headaches, 507 normal, 531 Pain
or menorrhagia, 429 Optic nerve head cupping, 530 back, 329
or pericarditis, 51 Optic neuritis, 531 in cancer patients, 702
Nonstress tests, 415, 417, 432 Oral carbonic anhydrase inhibitor, 529t chest, 30–31
Nonsustained ventricular tachycardia, 613 Oral contraceptive pills (OCPs) leg, 397
Nonulcer dyspepsia, 204 backup method af er starting o , 410 neuropathic, 505, 702
detailed dietary history in, 204 bene ts o , 409 opiates in, 702
management o , 205 contraindications to, 410 pelvic, 444, 445
natural history o , 205 in dysmenorrhea, 442 social and emotional, 705
symptoms o , 204 and headaches, 409–410 visceral, 702
Nonverbal communication, 728 ri ampin and, 410 Pain control, 600
Norepinephrine, 255 and weight gain, 409 medication, 587
Normal pressure hydrocephalus (NPH), 516, 581, 582 Oral creatine, 669 Pain ul bladder syndrome, 168
Normal saline, in hypernatremia, 156 Oral psyllium, 606 diagnosis o , 168
Nortriptyline, 629, 641, 680, 705 Oral sodium phosphate solution, 363 treatment o , 168–169
Norwalk virus, 558 Orbital cellulitis, 541 Paleolithic diet, 664
Nose, radiographs o , 14 Orexin receptor antagonists, 569 Palivizumab, or RSV in ection, 386
NSAIDs. See Nonsteroidal anti-in ammatory drugs Organic dust toxicity syndrome (OD S), 97 Palliative care, 699
(NSAIDs) supportive care or, 97 dyspnea in, 700
Nuchal translucency, 411 Orlistat, 404, 664 early, 701
Null hypothesis, 713 Oropharyngeal cancers, HPV in ection and, 554 and hospice care, 699
Nulliparity, 608 Oropharyngeal dysphagia, 202 Palpable masses, 608
Number needed to harm (NNH), 717 Oropharynx, 554, 565 Palpitations, evaluation in, 57
Number needed to treat (NN ), 549, 715–717 Orthostatic proteinuria, 151 Pancreatic enzymes, 616
Nummular, 475t Oseltamivir, 237, 238 Pancreatic pseudocyst, 230
Nursemaid’s elbow, 339–340 Osgood–Schlatter disease, 336 Pancreatitis, 228
Nursing home patient with weight loss, 570 Osler nodes, 246 causes o , 229
Nutritional de ciencies, 605 Osmolar gap, 7–8 drugs associated with, 229t
Nutritional supplements, 706 OsmoPrep. See Oral sodium phosphate solution treatment in rst day o , 229
Osteitis pubis, 602 Panic attack, 631
O Osteoarthritis, 333 symptoms o , 634
Obesity. See also Weight loss glucosamine sul ate or, 670 Panic disorder
in adolescence, 403 o hip, 580 criteria or, 634
and brain natriuretic peptide level, 60 SAM-e in treating, 668 mistakes made in treatment o , 635
complications o , 663 secondary causes o , 323 prognosis or, 634
de ned, 662, 662t o wrist, 360 recommendations in, 635
drugs associated with, 663t Osteomyelitis, 342 treatment o , 635
and evaluation or hyperlipidemia, 403 antibiotics or, 393–394 Papanicolaou (Pap) smear, 434, 436, 722
prevention o , 403–404 blood culture in, 343 Papillary carcinoma, 278
Obstructive shock, 618t in child, 343 Papilledema, 531
Obstructive sleep apnea, 520 diagnosis o , 393 Pap smears, 573
Obturator sign, 614 in in ants, 393–394 Papule/plaque, 475t
Occlusive dressing in patients with sickle cell disease, 342 Paracentesis, large-volume, 224
or open sucking chest wound, 30 treatment o , 343 albumin replacement ollowing, 224–225
removal o , 30 Osteoporosis Paraphimosis, 27
774 INDEX

Parapneumonic e usion, 122 causes o , 504, 504t 23-valent pneumococcal polysaccharide vaccine
Parathyroidectomy, 281 electrophysiological testing in, 505 (PPSV23), 238
Parkinson disease, 516 evaluation in, 504 Pneumococcal vaccination, 238, 572
cardinal eatures o , 516 heavy drinking and, 674 Pneumocystis jiroveci pneumonia, 260, 262
dementia in, 518 in ectious cause o , 505–506 and pneumothorax, 263
depression in, 518 oxycodone in, 505 Pneumonia, 35. See also speci c type
diagnosis o , 517 Peripheral vascular disease, 327 neonatal, 391, 392
drug-induced, 517 Peripheral vertigo, 560, 560t Pneumonia severity index, 121
levodopa in, 517–518 Peritoneal adhesions, 604 Pneumonic plague, 129
REM sleep disorder in, 519 Peritonsillar abscess, 566, 567 Pneumothorax, 116, 263
treatments o , 517 Periungual broma, 487 Podagra, 316
visual contrast sensitivity with, 519 Permethrin cream, 248, 254 Poiseuille’s law, 619
wearing-o phenomenon, 518 Permethrin insecticide, 252 Poisoning/overdose
Parkinsonism, 582 Permissive hypercapnia, 124 beta-blocker, 8
Parkinson plus syndromes, 517 Pernicious anemia, 187–188 calcium channel blocker, 8
Parkland ormula, 618, 619 Per-protocol analysis, 714 iron, 31–33
Paronychia, 251, 487 Persistent depressive disorder, 629–630 methanol, 7–8
Parotitis, 563, 564 Personality disorders, clusters o , 653 theophylline, 1–2
Paroxetine, 639, 642 Pes anserinus bursitis, 344 tricyclic overdose, 2–4
and birth de ects, 640 Petit mal seizures, treatment o , 503 Policosanol, 667t
Paroxetine and weight gain, 664 PFA-100 (Platelet Function Analyzer) tests, 173–174 Poliomyelitis-like syndrome, 515
Paroxysmal hemicrania, 521–522 PFPS. See Patello emoral pain syndrome (PFPS) Polyarthritis, 324
Paroxysmal supraventricular tachycardia (PSV ), 54 PHACES syndrome, 488 Polyarticular in ammatory arthritis o unclear etiology,
Partial thromboplastin time (P ), 173, 176 Phagophobia, 202 303
Parvovirus B-19 in ection, 304, 307, 382–383 Phalen sign, 360, 361 Polycystic ovarian syndrome (PCOS), 404, 447–448
complications o , 382 Pharyngeal swelling, treatment o , 567 clinical eatures o , 448
and sickle cell disease, 19 Pharynx, posterior, swelling in, 38 management o , 449
slapped cheeks in, 382 Phase-advance type sleep disorder, 656 Polyethylene glycol, 235, 363
Patching, 539 Phenelzine, 640 Polymyalgia rheumatica (PMR), 308
Patch testing, 480 Phenobarbital, 524 criteria or diagnosis o , 308t
Patello emoral pain syndrome (PFPS), 336 Phenol, 622 elevated ESR in, 308
treatment or, 336 Phentermine, 664 physical examination ndings o , 308
Patent ductus arteriosus (PDA), congenital rubella and, Phenytoin, 4, 277 prednisone in, 308–309
380 side e ects with, 502 prognosis o , 309
Patient-controlled analgesia (PCA), 604 Pheochromocytoma, 275 relapse o , 309
Patient Health Questionnaire-9 (PHQ-9), 657 Philadelphia chromosome, 193 Polymyositis, 332, 332t
Patient’s culture, knowledge o , 726 Phimosis, 27, 460 Polymyxin, 539
Patiromer, 37 Phosphodiesterase inhibitors, or pulmonary Polymyxin/ neomycin combinations ear drops, 551
PCOS. See Polycystic ovarian syndrome (PCOS) hypertension, 90 Polysaccharide pneumococcal vaccine, 572
PCP intoxication, 686 Phototherapy, 365 Polysomnography, 519
PCSK9 (proprotein convertase subtilisin kexin type 9), 95 PHQ-9. See Patient Health Questionnaire-9 (PHQ-9) Ponstel. See Me enamic acid
PE. See Pulmonary embolism (PE) Physician-directed head positioning, 560 Portal hypertension, 221–222
Peds solution, 371 Physician–patient relationship, 691, 692 Portal vein thrombosis
Peginter eron al a-2 a, 277 Physiologic gynecomastia, 463 anticoagulation or, 224
Pegvisomant, 301 Picaridin-containing insect repellents, 252 in cirrhosis, 224
Pelvic binder, 600 PID. See Pelvic in ammatory disease (PID) Portola Phamaceuticals. See Annexa
Pelvic examination, annual, 573 Pill esophagitis, 207 Positional therapy, 520
Pelvic in ammatory disease (PID), 437 Pilocarpine, 529 Positive end-expiratory pressure (PEEP), 125
antibiotic therapy or, 437 Pilocarpine eye drops, 15 Positive predictive value (PPV), 719–721, 723
diagnosis o , 437 Pinguecula, 545 Positron emission tomography (PE ) testing, 59
etiology o , 438 Pinworm in ection, 249 Postconcussion syndrome, 406. See also Concussion
indications or hospitalization, 437t Piperacillin/tazobactam, 228 Posterior capsular opacity, 546
lower abdominal pain in, 436–437 Pittsburgh rules, 354–355 Posterior chamber intraocular lens (PCIOL) implants,
potential sequelae o , 437 Pituitary surgery, transsphenoidal, 300 546
Pelvic muscle exercises, 434 Pityriasis rosea (PR), 483, 483 Posterior at pad sign, 359, 359
Pelvic pain, chronic, 444, 445 Placenta previa, 412 Posterior rib ractures, 341
Pelvic ultrasound, or pelvic mass, 446 Planned Parenthood v. Casey, 696 Postin ectious glomerulonephritis, 167
Pemphigus vulgaris, 488–489 Plantar ascia rupture, 358 Post-Lyme disease syndrome, 320
Penicillin, 565, 566 Plantar asciitis, 358 Postpartum depression, 642
allergy, 133 treatment or, 358 Postpartum hemorrhage, 420–421
resistance to, 241 Plantar warts, 484 Postpericardotomy syndrome, 50
Pentasa, 211 Plasma exchange, 513 Postprandial hypoglycemia, 297
Pentosan polysul ate sodium (Elmiron), 168 Plasma potassium level, 613 Post-streptococcal glomerulonephritis, 166
Pentoxi ylline, 70, 224 Plasma renin, 284 Posttraumatic iritis, 16
Per Advanced rauma Li e Support guidelines, 617 Plasmodium alciparum, 251 about, 539
PERC rules, 107 Plasmodium ovale, 251 treatment o , 539
Per ormance bias, 713t Platelet dys unction, due to uremia, 166 Post-traumatic stress disorder (P SD), 631
Periactin. See Cyproheptadine Platelet trans usion, 620 criteria or, 631
Pericardiocentesis, 51 Pletal. See Cilostazol symptoms o , 631–632
Pericarditis Pleural e usion, 116 treatment or, 632
constrictive, 60, 64 bronchoscopy in, 117–118 Potassium hydroxide (KOH), o skin scraping, 480
ECG in, 50–51 categorization o , 117, 117t Povidone-iodine, 11
indomethacin or, 51 chest tube drainage o , 118 PPI. See Proton pump inhibitor (PPI)
Perilymphatic stula, 559 diagnosis o , 116 PR. See Pityriasis rosea (PR)
Perilymph leak, 560 exudates, 117, 117t Pradaxa. See Dabigatran
Perimenopausal vasomotor symptoms, treatment o , 666 Light’s criteria, 117 Praluent, 95
Perioperative care, anticoagulation approaches in, 198 loculated and septated, 118 Pramipexole
Perioral dermatitis, 489–490, 490 thoracentesis in, 116–117 or Parkinson disease, 517
Peripheral arterial disease (PAD), 69 transudates, 117, 117t or restless legs syndrome, 521
ankle-brachial indices af er exercise in, 70 Pleural riction rub, 305 Prasugrel, 42
diagnostic tests or, 70 Plica syndrome, 336 Prazosin, 632
invasive treatment o , 70–71 PMR. See Polymyalgia rheumatica (PMR) Precocious puberty, 372
pharmacologic therapy or, 70 Pneumatic otoscopy, 548, 549, 550 Prednisolone, 224
Peripheral neuropathy, 504 Pneumococcal conjugate vaccine (PCV 13), 238, 572 Prednisone, 560
alcohol use and, 504, 674 Pneumococcal meningitis, dexamethasone in, 241 or bullous pemphigoid, 489

and male sexual unction, 472
or myasthenia gravis, 513
or polymyalgia rheumatica, 308–309
Preeclampsia, 425–426
aspirin in, 424
BP control in, 426
and delivery, 426–427
diagnostic criteria or, 426t
24-hour urine or protein level in, 425
magnesium sul ate or, 427
in pregnancy, 423–424
recurrence o , risk o , 423–424
risk actors or, 424
with severe eatures, 426
treatment or, 426–427
Preexisting dementia, 577
Pre-exposure prophylaxis (PrEP), HIV, 269
Pregabalin, 705
Pregnancy
ACE inhibitors in, 427
antiepileptic drugs in, 502–503
cardiovascular physiology in, 428
corticosteroids in, 422
deep venous thrombosis in, 197
depression in, 642
diabetes in, 411
Graves’ disease in, 274
headache treatment in, 509
heterotopic, 439
HIV/AIDS and, 263–265
hypertension in, 425–427
opioid addiction in, 683–684
post-term, 416
preeclampsia in, 423–424
prenatal tests in, 411–412
quantitative hCG in, increase in, 438
weight gain in, 451, 451t
Pregnancy loss, recurrent, 450
causes o , 450
evaluation o , 450–451
Pregnancy-related depression, 642
Pregnancy test, abdominal pain and, 25
Premature atrial contractions (PACs), 58
metoprolol or, 58
mitral stenosis and, 58
Premature ovarian ailure, 301
Premenstrual dysphoric disorder (PMDD), 443
Premenstrual syndrome (PMS), 443
diagnosis o , 443
treatment options or, 443, 443t
Preoperative studies, 610t
Presbycusis, 555
Preseptal cellulitis, 541
Pressure ulcer, 482
caused by unrelieved pressure, 571
prevention o , 571
stages, 571, 571t
treatment o , 571
Presyncope, 559
Preterm birth, risk actors or, 423
Priapism, 465–466
drugs associated with, 466t
and erectile dys unction, 466
etiology o , 466
management o , 466
Primary amenorrhea, 430
Primary biliary cirrhosis, 225
Primary hyperparathyroidism, 280
parathyroid surgery in, 281
Primary prevention, 718
Primary survey, 28
Principle o double e ect, 689
Probenecid, 315
Problem drinking, CAGE screening or, 591t
Procainamide, 4, 67
Prochlorpemazine, or headaches, 507
Progesterones, 575
Progestin challenge, 398, 451
Progressive supranuclear palsy, 516, 517
Progressive visual loss and glare, 544
Prokinetic agents, 595
in GERD, 201
Prolactinoma, 298–299
Prolia. See Denosumab
Proli erative diabetic retinopathy
INDEX 775
neovascularization o optic nerve, 534 Purpura, 475t
treatment o , 534 Purulent discharge, 538
Promethazine, 31, 708 Pustule, 475t
Propecia. See Finasteride p-value, 713
Prophylactic antibiotics, 537, 551 Pyelonephritis, 233
Propranolol, 509 Pyelonephritis, and hospital admission, 26
or hyperthyroidism, 274 Pyloric stenosis, 386
Propylthiouracil (P U), 274 clinical mani estations o , 386
Prostacyclin, or pulmonary hypertension, 90 string sign, 386
Prostaglandin analogs, 529t treatment or, 387
Prostaglandin E1 agents, 413 Pyoderma gangrenosum, 481–482, 496
Prostaglandin E2 agents, 413 Pyogenic granuloma, 488, 488
Prostate biopsy, 469 Pyrantel pamoate, 249
Prostate cancer, 454 Pyridostigmine, 512
and BPH, 468–469 Pyridoxine, 244
screening or, 469 or isoniazid-induced seizures, 9
5-year survival rate o , 469 Pyrosis, 204
treatment options or, 470 Pyuria, 243
Prostate-speci c antigen (PSA) testing, 454, 469
2 glass pre- and post-prostatic massage test, 457 Q
Prostatitis, 456–457 Quad cane, 580
bacterial, 457 Quetiapine, 658
diagnosis o , 456 Quincke sign, 35
Prostatitis, acute, 26 Quinidine, 4
treatment or, 26 Quinolone, 26
Protean, 577
Protein C de ciency, 196 R
Protein S de ciency, 196 RA. See Rheumatoid arthritis (RA)
Proteinuria, 151 Rabies prophylaxis, 10–11, 11t
ACE inhibitors or, 151–152 Race, 732
orthostatic, 151 Radial head racture, 359
transient, 151 treatment o , 359
Prothrombin time (P ), 176 Radial nerve compression, 506
Proton pump inhibitor (PPI) Radioactive CO2 blood test, 207
in CRES syndrome, 203 24-hour radioactive iodine uptake (RAIU) test, 277
in GERD, 201 Radioallergosorbent testing (RAS ), 131
side e ects o , 205 Radiocontrast media, lower-osmolality, 134
Provider order entry (POE), 716 Radiography, 558
Pseudoesotropia, 526 Radiologic studies, 608
Pseudogout, 316 Ramsay–Hunt syndrome, 563
associated conditions with, 317 Randomized, controlled study, 718
Pseudohyponatremia, 159 Ranitidine, or bee sting reaction, 23
Pseudomonas, 551, 623 Ranson criteria, 229, 230, 230t
Pseudomonas aeruginosa, 33, 121, 342 Rape trauma syndrome, 447
Pseudo-obstruction, 603 Rapid shallow breathing index (RSBI), 125
Psoas sign, 614 Rasburicase, or prevention o tumor lysis syndrome, 180
Psoriasis, lesions o , 324 Raynaud phenomenon, 327
Psychogenic incontinence, 434 evaluation and management o , 328
Psychosis ndings in, 327
causes o , 654, 654t ischemic crisis related to, 329
symptoms o , 654 primary, 327
Psychotherapy secondary, 327, 328
or panic disorder, 635 therapy or reducing requency o attacks o , 329
Psychotic depression, 637 Reactive airway disease, 97
Psyllium, 606 Reactive arthritis, 330, 331
or lowering LDL cholesterol, 666 Rebound acid hypersecretion, 202
Pterygium, 545 Rebound headache, 508–509
P SD. See Post-traumatic stress disorder (P SD) Recommended daily allowance (RDA), 661
Puberty Rectal bleeding, 232–233, 605
age o onset o , 396 Rectal examination, 363
delayed, 372 Recurrent appendicitis, 615
early, 372 Recurrent pregnancy loss, 450
rst sign o , in boy, 396 Red cell casts, in urine, 152
Pubic ramus racture, 16 Redness o eye, 535
Pulmonary anthrax, 2 Re eeding syndrome, 651
Pulmonary contusions, 617–618 Regional wall motion abnormality (RWMA), 60
Pulmonary embolism (PE) Reglan. See Metoclopramide
anticoagulation in, 109 Rehabilitation
chest radiographs in, 107 about, 591
C angiography (C A) in, 108 goals o , 592
ECG nding associated with, 107 Reiter syndrome, 465
and pain, 42 Relative a erent pupillary de ect (RAPD), 526
PERC rules or, 107, 108 Relative risk reduction, 717
risk actors or, 107 Remeron. See Mirtazapine
tests or, 107–108 Remicade. See In iximab
Wells criteria or, 108, 108t Renal artery stenosis (RAS), screening test or, 75
Pulmonary hypertension, 88, 89 Renal biopsy, 147, 166
tests or causes o , 88–90 contraindications to, 153
treatment o , 90 indications or, 153, 153t
Pulmonary rehabilitation (PR), 105 Renal calcium wasting, 574
Pulmonic murmur, 369t Renal osteodystrophy, 165
Pulse oximetry, 9 Renal tubular acidosis (R A), 143
Pulsus paradoxus, 51 type 4, 143
Punch biopsy, 496, 622 Repatha, 95
Purple glove syndrome, 502 Reset osmostat, and hyponatremia, 160
776 INDEX

Respiratory distress, causes o , 35 Saline in usion Selection bias, 713t, 714

Respiratory uoroquinolones, 559 in dehydration, 370 Selective immigration, 732
Respiratory isolation room, 110–111 in hypernatremia, 156 Selegiline, or Parkinson disease, 517
Respiratory syncytial virus (RSV), 385 in jugular venous distention and peripheral edema, 51 Sel -disclosure, 693
bronchiolitis by, 385 in rhabdomyolysis, 17 Semmes–Weinstein 10 g mono lament sensory
diagnosis o , 385–386 Salivary duct stones, 564 examination, 292
prevention o , in high-risk in ants, 386 Salmeterol, 101, 102 Sensipar. See Cinacalcet
Restless legs syndrome, 520–521 Salsalate, 42 Sensitivity, 719
pramipexole or, 521 Salvia, 686 and speci city, 715
workup in, 521 SAM-e in depression treatment, 668 Sensorineural hearing loss
Restraints, 585 Samsca. See olvaptan about, 555, 555t
Retinal detachment Sarcoidosis, 115 drugs causing, 573
management o , 543 ACE levels in, 116 Septal hematoma, 14
risk actors or, 543 cardiac involvement with, 115 Septic arthritis, 311, 334–335, 343
Retinal hemorrhages, 374 ndings with, 115 causative organism, 344
Retinoids, or acne, 491 spontaneous resolution o , 116 management o , 312–313
Retropharyngeal abscess, 38, 563 Saturday Night Palsy, 506 mortality rate o , 313
Retropharyngeal space swelling, 35 Savaysa. See Edoxaban physical examination in, 311
Re-warming Saw Palmetto, 669 risk actors or, 313
or bradycardia, 19 Saxagliptin, 292 synovial uid analysis in, 312, 343, 344t
o extremities, 19–20 SBP. See Spontaneous bacterial peritonitis (SBP) treatment o , 312
rostbite, 20 Scabies, 248, 478 Septic pelvic thrombophlebitis, 416
methods o , 19 Scotch tape test, 249 Septic thrombophlebitis, 568
Reye syndrome, 387 treatment o , 249 Sequential compression devices (SCD), 610
aspirin use and, 387 Scaphoid racture, 347–348 Seroconversion, 588
treatment o , 388 treatment o , 348 Serologic testing, or H. pylori, 206
Rhabdomyolysis, 17 Scapula racture, 350 Serotonin–norepinephrine reuptake inhibitors (SNRIs),
adverse consequence o , 17 SCFE. See Slipped capital emoral epiphysis (SCFE) 629
renal ailure in, 155 Schatzki ring, 204 or anxiety disorders, 635
treatment or, 17–18 Scheuermann disease, 347 or bromyalgia, 323
Rh-D antibodies, 431 Schistocytes, 193, 194 or neuropathic pain, 505
Rheumatic ever, 307 Schizophrenia, 655 Q prolongation by, 629, 636
Jones criteria or, 307 antipsychotics or, 655 Serotonin reuptake inhibitors (SSRIs)
Rheumatoid arthritis (RA), 304, 304t course o , 655–656 or adolescent depression, 401
biologicals or, 307 prevalence o , 655 adverse e ect o , 628
DMARDs or, 304–306 Schneiderian papillomas, 554 in depression, 628, 630
remission in, 306–307 SCIWORA syndrome (spinal cord injury without discontinuation syndrome, 638–639, 639t
Rhinosinusitis, 557–558 radiologic abnormality), 6 and hyponatremia, 161
cause o , 558 management, 6 interactions with cytochrome P450 enzymes, 639
treatment o , 558 natural history, 6 and MAOIs, 640
Rhinovirus, 558 physiology, 6 in panic disorders, 635
Rho(D) immunoglobulin, 175 Scleritis, 545 in pregnancy, adverse e ects o , 642
RhoGAM, 431 Scleroderma, 327, 328 Serotonin syndrome, 640
Rib ractures, 116 Scleroderma-like syndrome, 142 Sertraline, 161, 657–658
Rickettsia rickettsii, 250 Sclerosing cholangitis, 225 Serum-ascites albumin gradient (SAAG), 222
Ri ampin, 410 Scoliosis, 339 high, 222
Ri apentine, 244 bracing or, 339 low, 222
Right bundle branch block (RBBB), 64, 86 , 87 detection o , 338–339 portal hypertension and, 222
Right ventricular in arct, 42–43 idiopathic, 339 Sevelamer, 165
Rinne test, 554, 555 management plan or, 339 Severe combined immunode ciency syndrome, 137t
Risedronate, 575 screening or, 339 Sex hormones, 572
Risperidone, 585t Scopolamine, 530, 700 Sexual assault, 446–447
Ritodrine, 422 Scotch tape test, 249 orensic evaluation in, 447
Rivaroxaban, 109, 195, 196, 198 Screening Sexual dys unction, psychotropics and, 641
in non-valvular atrial brillation, 54 or adolescent substance use, 401 Sexual health history, 734
Rocky Mountain spotted ever (RMSF), 250, 251t, 377 or chlamydia and gonorrhea in ection, 445, 449 Shave biopsy, 622
Rocuronium, 37 or colorectal cancer, 208, 209 Sheehan syndrome, 421
Ro umilast, or COPD, 105 or diabetes in pregnancy, 411 Shock
Rome criteria or constipation, 594 or diabetic kidney disease, 140 categories o , 618t
Romiplostim, 175 or hearing impairment, 591 causes o , 618
Roos test, 352 or hepatitis C, 217 Short stature, evaluation o , 396
Ropinirole, or Parkinson disease, 517 or mood disorders in teenagers, 401 Shoulder dislocation, 16
Rosacea, 540 or prostate cancer, 729 Shoulder dystocia, 433
Roseola in antum, 383 Screening or breast cancer, 573 risk actors or, 433
Rotational de ormity, 349 Scrotal mass, ultrasound o , 458 Shy–Drager syndrome, 517
Rotator cu , 351 Sea ood, allergy to, 134 SIADH. See Syndrome o inappropriate secretion o
tears, 350, 351 Seborrheic blepharitis, 540 anti-diuretic hormone (SIADH)
Rotator cu tendinosis, 351 Seborrheic dermatitis, 323–324, 477 Sialogogues, 564
Roth spots, 246 Seborrheic keratosis, 494 Sialolithiasis (salivary duct stones), 564
Roux-en-Y, 604 Secondary osteoporosis, 574 Sialolithotomy, 564
Rovsing sign, 614 Secondary prevention, 718 Sibutramine, 404
RSV. See Respiratory syncytial virus (RSV) Second-degree heart block, type I, 69, 77, 77 Sicca symptoms, in elderly, 321
Rubber-band ligation, 606 Sedative–hypnotic drugs, 590 Sickle-cell disease, 186
Rubella, congenital, 380 Sedatives, 585 and acute sequestration syndrome, 19
cardiac lesions associated with, 380 Seidel test, 535 aplastic crisis in, 19
Ruptured globe, 534, 535 Seizures, 501 eatures o , 186
Ruptured plantaris muscle, 341 absence, 523 homozygous SS, 186
antiepileptic drug or, 502 mani estation o , 19
S concussion and, 406 and pregnancy, 187
SAAG. See Serum-ascites albumin gradient (SAAG) evaluation o , 501–502 Sick sinus syndrome, 69
SAD PERSONS, mnemonics or suicide risk assessment, ebrile, 523–524 Sildena l, 467
654t grand mal, 503 alpha-blockers and, 55
SAFER mnemonic, 729 in theophylline toxicity, 2 and antihypertensive drugs, 55
Sa ety or older adults, 591 tricyclic-induced, 4 Simethicone, 384
Salicylates, 573 workup o , 523–524 Sinus headaches, 521
 INDEX 777

Sinusitis, 521, 541 physical ndings in, 330t Substance use disorder, criteria or, 675
Sitagliptin, 292 therapy or, 330 Subthalamic nucleus stimulation, 517
Sixth nerve palsy, 526 Spondylolisthesis, 346–347 Succinylcholine, 37
Size–date discrepancy, 432 Spondylolysis, 346, 347 Sucking blister, 380–381
Sjögren syndrome, 321 Spontaneous bacterial peritonitis (SBP), 222, 223 Sudden cardiac death (SCD), in young athletes, 399
biopsy in, 321 common organisms in, 223 Sudden in ant death syndrome (SIDS), 388–389
diagnosis o , 321 treatment o , 223 Suicide, 643
mani estations o , 321 Spoon nail. See Koilonychia assessment o risk level, 652
therapy or, 321 Sport Concussion Assessment ool (SCA -3) in general population, 653–654
SJS. See Stevens-Johnson syndrome (SJS) questionnair, 406 mnemonics or risk assessment, 654t
Skeletal surveys, 341 Sprain o anterior talo bular ligament, 355 risk actors or, 652t
Skin lesion removal, 622 Squamous cell carcinoma, in transplanted, risk o , in physicians, 651
Skyla, 429 immunosuppressed patients, 481 white males and death rom, 466–467
SLE. See Systemic lupus erythematosus (SLE) SSRIs. See Serotonin reuptake inhibitors (SSRIs) Sul asalazine, 511
Sleep apnea, and cor pulmonale, 65 SSSS. See Staphylococcal scalded skin syndrome (SSSS) contraindication to use o , 211
Sleep history, 519 Staphylococcal blepharitis, 540 Sul onylureas, 292, 574
Sleep hygiene, 569, 570 Staphylococcal scalded skin syndrome (SSSS), 486, Sumatriptan, 507, 508
Sleep myoclonus, 519 486 Super cial spreading melanoma, 477
Sleep paralysis, 520 Staphylococcus aureus, 238, 416, 541, 551, 564 Superior mesenteric artery (SMA) syndrome, 208
Sleep problems, sources o , 570 Stasis dermatitis, 480–481, 481 Supplemental ber, 595
Sleep studies, 519, 641–642 Statin-induced myopathy, 94 Supplementation with multivitamins, 661
Slipped capital emoral epiphysis (SCFE), 335, 337 Statins Supplements, per ormance-enhancing, 405
diagnosis o , 337–338 af er acute coronary syndrome, 46 Supraclavicular nodes, 557
treatment o , 338 candidate or, 92, 92t, 93 Supracondylar racture, 359
Slit-lamp examination, 528, 535, 539 af er myocardial in arction, 46 Suprapubic cystostomy, 601
Small bowel disease, 660 Steeple sign, 35 Supratrochanteric bursitis, 341
Small bowel obstruction (SBO), 603 S -elevation myocardial in arction, 44, 44t, 46 Sur actant therapy, 391
Smallpox, 2 Steroid hormones, 663t Surgical iridectomy, 530
Smith racture, 347 Steroids, 537, 539, 540, 562, 567 Suvorexant, 520, 569
Smoking, 532, 574, 610 anabolic, use o , 405 Swan–Ganz catheters, 618
Smoking cessation aid, 679–680 or asthma, 101 Sympathomimetic, 5t
Smoking cessation, heart attack risk, 680 or asthma exacerbations, 22 Syncopal episodes, 501
Snellen eye chart, 528 or atopic dermatitis, 479 Syndrome o inappropriate secretion o anti-diuretic
SNRIs. See Serotonin-norepinephrine reuptake inhibitors or community-acquired pneumonia, 123 hormone (SIADH), 160, 161
(SNRIs) or Crohn disease, 211 sodium chloride tablets in, 162
Social Security bene ts, 586 or hypersensitivity pneumonitis, 98 therapy or, 162
Socioeconomic status, and health status, 731 Stevens–Johnson syndrome (SJS), 488–489, 640 water restriction in, 162
Sodium bicarbonate, 142 Still disease, 305 Synovial uid analysis
in tricyclic overdose, 4 Still murmur, 369t in gout, 313–314
Sodium-glucose co-transporter 2 (SGL 2) inhibitors, 296 Stimulant laxatives, 595 in monoarthritis, 313
Sodium oxybate, 520 Stimulants, or attention-de cit/hyperactivity disorder, in septic arthritis, 312, 343, 344t
Sodium polystyrene, use o , 37 645, 645t, 646 Syphilis, 250
Solitary pulmonary nodules (SPNs), 118–119, 118 St. John’s wort, 641 congenital, 379
benign pattern o calci cation on C scan, 119 Stool antigen testing, 206 secondary, 462
recommendations or ollow-up o , 119t Stool leukocytes, 214 Systemic lupus erythematosus (SLE), 324
re erral to thoracic surgeon, 119–120 Stool sof eners, 595 diagnostic criteria or, 325t
risk o cancer in, 119 Strabismus drugs and side e ects, 326t
tobacco cessation, varenicline or, 120 about, 526 incidence o , 324
Somatic symptom disorder, 632 evaluation o , 527–528 management plans or, 325
plan or patient with, 633 treatment o , 527 pregnancy and, 325
Somatostatin, 207–208, 227 Straight leg raise (SLR) testing, 345 Systemic sclerosis, 328
Somatostatin analogs, 301 Strangulation, 604 Systolic heart ailure (HFrEF), 60
Somogyi phenomenon, 288, 387 Strattera. See Atomoxetine coronary angiography in, 60
Sore throat, 565 Strawberry cervix, 448 entresto in, 91
Sotalol, 58 Streptococcal pharyngitis exacerbation o , 62
Soy, e ectiveness o , 667t about, 565 metoprolol in, 61
Soy ormula, in in ant, 372 antibiotic therapy o , 565 nesiritide in, 63
Soy iso avone supplements, 666 period o in ection, 566 nonpharmacologic therapies or, 60–61
Soy protein, 666 symptoms, 566 pharmacologic therapy or, 61
SPACE DIGS mnemonic, 626, 629 Streptococcus viridans, 248 secondary to CAD, 60
Speci city, 719 Stress echocardiography, 49, 49t spironolactone in, 62
Spectrum bias, 713t, 714 Stress ractures, 397 trans usion in, 62–63
SPEC thallium test, 59 o ore oot, 357–358
Sperm granuloma, 461 MRI or, 397 T
Spider angiomata/telangiectasias, 221 Stress incontinence, 433, 434, 588 achyarrhythmias, risk o , 613
Spinal cord compression Stribild, 259 achy–brady syndrome. See Sick sinus syndrome
MRI o spine in, 178–179 Stroke, 516, 560 achycardia, treatment o , 612
treatment or, 179 aspirin in, 500 achypnea, in methanol overdose, 7
Spinal stenosis, 69, 346 evaluation o , 499 adala l, 473. See also Cialis
Spine sign, 35 risk af er IA, 500, 500t ai chi, 579
Spiral C , or coronary artery calci cation, 46 Struvite stones, 149 alipes equinovarus, 342
Spirometry, 99 Subacute bacterial endocarditis (SBE), 246 amsulosin, 455
ow/volume loop in, 103, 103 Subacute thyroiditis, 276–277 anner stages, 371, 372t
interpretation o results, 100t Subarachnoid hemorrhage (SAH), 513–514 apazole. See Methimazole
and obstructive lung disease, 99 Subclavian veins, 621 ap water, wound irrigation with, 11
Spironolactone, 222 Subclinical hypothyroidism, 276 arsal tunnel syndrome, 358
or heart ailure, 62 Subcutaneous administration, o uids and medications, asmar. See olcapone
or hypertension, 76 706 B. See uberculosis ( B)
Splenectomy, 175, 254 Subcutaneous heparin, 610 dap (tetanus, diphtheria, and acellular pertussis), 11
Splenic rupture, 567 Subdural hematomas, 374 egretol, 502
Splinter hemorrhages, 487 Sublingual (SL) desensitization, 132 ekturna. See Aliskiren
SPNs. See Solitary pulmonary nodules (SPNs) Submandibular swelling, treatment or, 564 emazepam, 675
Spondylitis, 347 Submaximal stress test, 46 emporal artery biopsy, or giant cell arteritis, 310
Spondyloarthropathies, 331. See also Ankylosing Suboxone, 673 emporomandibular joint ( MJ) syndrome, 551, 563
spondylitis Subphysiologic testosterone, 572 EN. See oxic epidermal necrolysis ( EN)
778 INDEX

eno ovir/Emtricitabine, 269 onometer, 528 -score, 574

enosynovitis, 251 onsillectomy, 550, 567 P. See T rombotic thrombocytopenic purpura ( P)
ension pneumothorax, 30, 263, 617 ooth, avulsed ube eeding, 586
erbina ne, 481 reinserting into socket, 13–14 uberculin skin test ( S ), 243–244
eriparatide, 575 transportation o , 13 interpretation o , 243t
ertiary prevention, 718 opamax. See opiramate uberculosis ( B), 115, 243–245, 506, 588
esticular cancer, 458 ophaceous gout, 316 BCG vaccine in, 244–245
esticular torsion, 24, 459 opical α -adrenergic agonists, or glaucoma, 529t drug-resistant, 245
cremasteric re ex and, 24 opical β -blockers, 531 extensively drug-resistant, 245
surgical exploration or diagnosis o , 24–25 or glaucoma, 529t multidrug-resistant, 245
testicular lay and, 24 opical calcineurin inhibitors, or atopic dermatitis, 479 uberosity avulsion ractures, 357
estosterone supplementation products, 467–468, 467t opical carbonic anhydrase inhibitors, or glaucoma, 529t ularemia, 251t
older males and, 467–468 opical steroids, 535, 539, 540 umor lysis syndrome, 180
risks associated with, 468 opiramate, 502, 509, 664, 682 hemodialysis in, 180
etracaine eye drops, 15 ORCH in ections, congenital, 379–380 prevention o , 180
etralogy o Fallot, 380 orsades de pointes, 3–4 uric acid nephropathy and renal ailure, 180
T alassemia, 185 orsion o appendix testis, 459 URP. See ransurethral resection o the prostate ( URP)
alpha, 185 orsion o testis, 24–25 2 × 2 table method, 720, 721
beta, 185 orus (Buckle) racture, 335t ympanic membrane ( M), 548, 550
Hgb electrophoresis or, 185 otal body sur ace area ( BSA) burns, 618 ympanometry, 548
management o , 185 otal hip arthroplasty ( HA), 591 ympanostomy tubes, 550
T alidomide, 211 oxic conjunctivitis, 537 ype I error, 713
T allium testing, 49 oxic epidermal necrolysis ( EN), 486 ype II error, 713
nonreversible (“ xed”) de ect on, 49 oxic megacolon, 210 zanck preparation, 402, 480
sensitivity and speci city o , 49t oxic shock syndrome, 254
T eophylline, poisoning/overdose, 1–2 laboratory testing in, 254 U
T ermoactinomyces candidus, 98 management o , 255 UFH. See Un ractionated heparin (UFH)
T ermoactinomyces sacchari, 98 types o , 254 Ulcerated hemangioma o in ancy, 487–488
T iamine, 674 oxidromes, 5, 5t Ulcerative colitis (UC), and Crohn disease, 211
de ciency, 665 oxoplasmosis, congenital, 379–380 Ulcers, 475t
T iazide diuretics, 146, 574 racheostomy, 564–565 arterial insu ciency, 481
or hypertension, 74 ramadol, 702 corneal, 15
T iazolidinediones, 291, 294 ranexamic acid, 30, 428, 600 diabetic oot, 495
T ird-degree heart block, 69 ranscatheter aortic valve replacement ( AVR), 72 duodenal, 206
T ird nerve palsy, 546 ransdermal entanyl patches, 703 pressure, 482, 571
T oracentesis, 116 rans er dysphagia. See Oropharyngeal dysphagia Ulipristal, 444
contraindications to, 117 rans errin receptor, serum, 184 Ulnar nerve compression, 506
T oracic aortic aneurysms, 310 rans usion related lung injury, 177 Ulnar neuropathy, 360
diagnosis o , 310 ransgender, 733–734 Uloric. See Febuxostat
T oracic aortic dissection, chest x-ray ndings in, 42 ransient acantholytic dermatosis. See Grover disease Ultrasound
T oracic duct injury, 621 ransient ischemic attack ( IA), 500, 510 in abdominal aortic aneurysm, 65
T oracic outlet syndrome, 352 ransient neonatal pustular melanosis, 485 or gallstones, 615
T reatened abortion, 431 ransient (toxic) synovitis, 334 in intussusception, 373
T roat pain, causes o , 566 diagnostic work-up in, 334 or pelvic mass, 446
T rombocytopenia, 612 and septic arthritis, 334 or scrotal mass, 458
T romboembolic stroke, 570 treatment or, 335 thyroid, 278
T rombolytics, 542 ransjugular intrahepatic portosystemic shunt ( IPS), in urinary tract in ection, 378
T rombolytics, in myocardial in arction, 44–45, 44t 225, 620 Ultrasound-guided thoracentesis, or pleural e usion,
reper usion af er, 45 ransposition o great vessels, 380 116–117
T rombophilia, 196 ransurethral resection o the prostate ( URP), 455, 457 Ultraviolet (UV) keratitis, 16
T rombotic thrombocytopenic purpura ( P), 167, 193 indications or, 457 Un ractionated heparin (UFH), 612
laboratory ndings in, 194 ransvaginal ultrasound, 441 or antiphospholipid antibody syndrome, 326
treatment in, 194 rapdoor racture, 15 or pulmonary embolism, 109
T umb sign, 35 rasylol, 58 Unresponsive patient, assessment and treatment o , 28
T yroglobulin level, serum, 278 raveler’s diarrhea, 216, 252 Upper gastrointestinal (GI) variceal bleeding, 620
T yroglossal duct cyst, 564 razodone, 569, 578, 585t, 630 Upper respiratory in ection (URI), 550, 558
T yroid malignancies, 277–278 rental. See Pentoxi ylline Uremia, bleeding dys unction in, 165
T yroid scan, 278 reponema pallidum, 379 Urethrogram, 601
T yroid-stimulating hormone ( SH), 271, 663 riamterene, 150 Urge incontinence, 433
T yroid storm, 275 richomonas vaginalis in ection, 448 Uric acid crystals, in urine, 152
management or, 276 ricyclic antidepressants ( CAs) Uric acid stones, 149
T yroid ultrasound, 278 or diabetic peripheral neuropathic pain, 296 Urinalysis with microscopic examination, 587
ibial stress racture, 397–398 in neuropathic pain, 505 Urinary incontinence
icagrelor, 42 ricyclic overdose, 2–4 cause o , 588
ick-borne illnesses, 250, 251t arrhythmias in, 4 indications or, 589
imed get-up-and go-test, 579 benzodiazepines or seizures in, 4 Urinary retention, in men, 26–27
ime-release drugs, 624 ECG ndings in, 3 Urinary tract in ection (U I), 26
IMI Risk Score, 48 torsades de pointes and, 3–4 antibiotics or, 378
imolol eye drops, 15 rigeminal neuralgia, 522 bag-collected urine, in nontoxic in ant, 378
inea corporis, 478 rimethoprim, 539 diagnosis o , 169–170, 377–378
inea versicolor, 478 rimethoprim/sul amethoxazole ( MP/SMX), 600 ultrasound in, 378
inel sign, 361 or bronchiectasis, 126 Urine beta-HCG, 25
IPS. See ransjugular intrahepatic portosystemic shunt riptans 24-hour urine collection, or protein and creatinine, 151
( IPS) contraindications to use o , 507, 508 Urine dipstick, 151
issue plasminogen activator (tPA), 498–499, 499t or headaches, 507 Urine sediment ndings, and associated conditions, 152t
issue samples, stored, 696 reactions to, 508 Urogenital atrophy, diagnosis o , 440
issue transglutaminase antibodies, 214 rismus, 38, 556 Urolithiasis, 148–149. See also Kidney stones
obacco use, 553 riumeq, 259 hospitalization in, 150
ocolysis, 422 ropheryma whippelii, 213 hydrochlorothiazide in, 150
agents or, 422 ropical pyomyositis, 341 recurrent, risk o , 149
contraindications to, 422 roponin, 41 Urticaria, 485, 492
oddler’s racture, 340, 374 rousseau sign, 165, 281, 359 acute, 492
olcapone, 518 rumenba, 403 causes o , 493, 493t
olerance, 674–675 ruvada. See eno ovir/Emtricitabine chronic, 492
olvaptan, 162 ruvada (teno ovir/emtricitabine), 259 cold, 493
 INDEX 779

treatment o , 493 Venous hum, 369t Wearing-o phenomenon, 518

water, 493 Venous thromboembolism (V E), 197 Weber’s test, 554, 555
Urticaria pigmentosa, 496 Venous ulceration, 481 Weight-bearing exercises, 574
US Preventive Services ask Force (USPS F), 573, 593 Ventilation Weight gain
Uterine atony, 420 initial settings, 124–125 drugs associated with, 663t
postpartum hemorrhage and, 420 weaning rom, 125 evaluation, 663
risk actors or, 420 Ventilator-associated pneumonia, 123 in pregnancy, 451, 451t
Uterine bleeding, abnormal, 428 Ventilator-induced lung injury (VILI), 124 Weight loss, 404
Uterine broids, 429–430 Ventricular tachycardia, 52, 57, 66–67, 67 adverse e ects o , 649
and risk o uterine malignancy, 430 and asystole, 67–68 antidepressants and, 706
surgery or, 430 cardioversion o , 67 depression in, 570
U I. See Urinary tract in ection (U I) compressions and ventilations in, 67–68 diet or, 664
Uvulopalatopharyngoplasty (UPPP), 520 electrophysiologic study or, 57 drugs or, 604, 664
nonsustained, asymptomatic, 57 due to terminal disease, 706
V Veri cation bias, 712 exercise or, 664
Vaccination, 365–366 Verruca plantaris, 484 medications or, 404
or adolescents, 402–403 Vertebral artery dissection, 501 physical ndings in, 648
be ore elective splenectomy, 242 Vertical banded gastroplasty, 604 surgery or, 604, 665
in uenza, 237–238 Vertical corneal abrasions, 539 Weight status by BMI, 662t
pneumococcal, 238 Vertigo, 559 Wenckebach block, 77, 77
schedules and recommendations, 368, 368 Vesicle, 475t Wernicke encephalopathy, 665, 677
side e ect o , 365 Vesicoureteral re ux (VUR), 378 triad o , 677
Vacuum-assisted vaginal delivery, 415 grade II re ux, management o , 378–379 Westermark sign, 107
Vaginal bleeding, postmenopausal, 440, 441 grading o , 378t West Nile virus (WNV), 515, 567
Vaginal delivery, operative VIPomas, 207 Wet age-related macular degeneration, 533
etal risk o , 420 Viral cardiomyopathy, 63 Wheal, 475t
maternal risks o , 420 Viral conjunctivitis, 537, 537 WHHHHIMP mnemonic, delirium, 577t
Vaginal dryness, 440 Viral encephalitis, 515–516 Whipple disease, 213
Vaginal pessaries, 434, 445–446 Viral gastroenteritis, 215 White coat hypertension, 73
Vaginitis, diagnosis and treatment o , 448t Viral thyroiditis, 273 Whitlow lesion, 251
Valacyclovir, 34, 484 Visceral pain, 702 Whole bowel irrigation with polyethylene glycol solution,
Valerian root, 641 Vision loss or iron toxicity, 32
Validation set, 714 medical history, 531 Wilson disease, 188
Valproic acid, 503, 663 in nonproli erative diabetic retinopathy, 533 Wiskott–Aldrich syndrome, 137t
Valsalva maneuver, 400, 602 painless, 541–542 Withdrawal, alcohol, 577, 673–675
Valve replacement surgery, indications or, 71 Visual acuity, 544 Withdrawal, o medical intervention, 689
Valvular disease, surgical indications, 58–59 Vitamin A, 661 Withholding, o medical intervention, 689
Valvulotomy, 72 Vitamin B6 (pyridoxine), 669 Wol –Parkinson–White (WPW) syndrome
Vancomycin, 228, 240, 247, 600 Vitamin B12 de ciency, 190, 579 ECG in, 83, 84
and cephalosporin, 241 Vitamin C, 183, 661 procainamide in, 83, 85
Vaprisol. See Conivaptan supplementation, 662 Wound
Vardena l. See Levitra Vitamin D care, 255
Varenicline bene ts, 661 closure, 11
side e ect o , 679–680 de ciency, 281 in ections, 611
or tobacco cessation, 120 or osteoporosis prevention in adolescence, 399 irrigation solutions, 11
Variceal bleeding, 227, 620 or postmenopausal women, 665 Wrist drop, 506
Varicella immune globulin (VariZIG), 381, 382 supplementation, 574
Varicella in ection, 599 Vitamin E X
Varicella syndrome, congenital, 381–382 or Alzheimer disease, 584 Xanthochromia, 514
Varicella zoster exposure in utero, 382 supplementation in elderly patients, 661 Xarelto. See Rivaroxaban
Varices, 620 Vitamin K, 56, 176, 177, 224, 660 Xenical. See Orlistat
Varicoceles, 459 de ciency, 660 X-linked agammaglobulinemia, 137t
Vascular dementia, 657 Vitreous hemorrhage, 533, 534 d-xylose breath test, 214
diagnosis o , 583 Vocal cord dys unction (VCD), 131
eatures o , 583 Vocal atigue, 553 Z
Vascular endothelial growth actor inhibitor Voiding cystourethrogram (VCUG), 378–379 Za rlukast, 102
(VEGF-inhibitor), 533 Von Willebrand disease, 173, 174 Zelnorm, 595
Vasculitides, 543 VQ (ventilation–per usion) scan, 108 Zenker diverticulum, 204
Vasectomy, 461 Vulvovaginal candidiasis, 450 Zenvia, 511
ailure o , 461–462 VUR. See Vesicoureteral re ux (VUR) Zetia. See Ezetimibe
Vasoactive intestinal peptide (VIP), 207, 624 Zidovudine (ZDV), 264
Vasomotor rhinitis, 559 W Zinc toxicity, 661
Vasopressin, 227, 620 Walk canes, 580 Ziprasidone, 655
Vasopressors, 600 Wandering atrial pacemaker, 52 Zoledronic acid, 279, 575
Vegan mothers, 662 War arin, 56, 176, 196, 197, 610 Zollinger–Ellison syndrome, 207
Vena caval lters, in PE, 110 in pulmonary embolism, 109 Zolpidem, 630
Venla axine reversal o , 56–57, 177 Zoster oticus, 563
in children, 644 and vitamin K, 660 Zosyn, 228
or diabetic peripheral neuropathic pain, 296 vitamins/herbals interacting with, 661t Z-score, 574
side e ects o , 640 Water-soluble vitamins, 661
 Fin a l exa m a n s w er s 783

Final Examination Answers

Question Question
Number Answer Answer Location in the Chapter Number Answer Answer Location in the Chapter
1 D See question 2.2.2 47 B See question 7.8.3
2 B See question 2.1.4 48 B See question 7.10.6
3 A See question 2.17.3 49 D See question 15.1.7
4 C See question 2.3.5 50 D See question 15.2.9
5 C See question 2.1.2 51 C See question 15.12.8: Helpful Tip
6 D See question 2.22.7 52 E See question 15.14.3
7 D See question 2.1.10 53 D See question 15.2.1: Helpful Tip
8 B See question 2.1.10 and Tables 2-1A and 2-1B 54 C See question 21.2.3
9 B See question 2.22.8 55 E See question 21.5.2
10 B See question 2.4.1 56 B See question 16.7.3
11 A See question 2.7.7 57 C See questions 21.3.4 and 21.3.5
12 C See question 1.1.2 58 B See questions 21.4.1 and 21.4.2
13 B See question 14.5.3 59 C See question 21.6.2
14 D See question 17.8.3 60 A See question 21.6.9
15 B See question 28.3.1 61 B See question 16.8.3
16 C See Chapter 17 Quick Quiz: Erythema Multiforme 62 E See question 23.9.1
17 A See Chapter 28: Case 6 63 A See question 14.8.1: Helpful Tip
18 C See question 17.8.4 64 B See questions 14.2.2 and 14.2.4
19 B See question 14.3.1 65 B See question 16.5.2
20 D See question 27.2.4: Helpful Tip 66 E See questions 10.9.1 and 10.9.4
21 B See Chapter 1 Quick Quiz: Toxidromes 67 D See question 16.10.3
22 D See question 1.4.3 68 E See question 10.10.7
23 B See question 1.12.3 69 D See question 10.8.1
24 D See question 1.24.5 70 A See question 11.2.7
25 D See question 1.20.1 71 D See question 17.3.2
26 C See question 1.24.4 72 D See question 5.6.3
27 C See question 1.19.1 73 B See Chapter 11 Quick Quiz: An Ill Child
28 C See question 27.1.6 74 E See questions 17.2.1, 8.6.1 and 8.6.2
29 B See Chapter 27 Quick Quiz: More than a 75 C See question 5.1.7
little headache 76 B See question 5.1.10
30 A See question 1.1.1 77 C See question 5.5.2
31 B See question 27.2.6: Helpful Tip 78 B See question 17.3.4
32 D See question 7.4.5: Helpful Tip 79 C See question 5.7.3
33 C See questions 7.1.3 and 7.1.4. 80 B See Chapter 5 Quick Quiz: Acid Base Disorder
34 D See questions 7.1.2 and 7.1.5 81 A See questions 8.3.1 and 8.3.3
35 C See question 7.5.2: Helpful Tip 82 D See question 11.5.2
36 B See question 7.1.1 83 D See question 9.1.8
37 A See question 7.4.5 84 B See question 7.13.2
38 D See question 21.5.14 85 D See question 5.13.3
39 B See question 11.10.4 86 B See questions 8.4.1 and 8.4.2
40 B See question 7.6.4 87 A See question 7.12.4
41 A See question 7.6.6 88 A See question 9.3.2
42 B See question 7.10.1 89 D See question 7.13.4
43 B See question 7.8.4 90 A See question 7.15.2
44 D See question 8.2.3 91 D See question 7.17.3
45 A See question 7.8.2: Helpful Tip 92 B See question 7.15.9
46 C See question 7.8.6 93 C See question 7.16.2
Fin a l exa min a t io n a n s w er s

Question Question
Number Answer Answer Location in the Chapter Number Answer Answer Location in the Chapter
94 B See question 7.15.7 148 D See Chapter 2: Case 4: Table 2-6A
95 A See question 7.14.3 149 A See question 7.10.3: Helpful Tip
96 C See question 9.1.3 150 C See question 1.7.4: Table 1-6
97 D See question 9.1.4 151 A See question 1.4.2
98 C See question 9.2.13 152 D See question 1.6.2
99 C See question 8.1.3 153 D See Chapter 1: Quick Quiz: Orthopaedic
100 B See question 8.4.5 Emergencies
101 B See question 8.3.1 154 B See question 15.14.3
102 A See questions 8.3.1 and 8.3.2 155 D See question 13.2.6: Helpful Tip
103 C See question 8.8.4 156 A See question 13.2.6
104 B See question 5.3.5 157 D See question 1.14.4
105 A See questions 5.6.3 and 5.13.1 158 C See question 3.3.3
106 B See question 5.1.9 159 A See question 3.3.6 and Table 3-2, Figure 3-1
107 A See Chapter 5 Quick Quiz: Dysuria 160 B See question 3.11.6
108 D See questions 5.1.5 and 5.1.13 161 C See Chapter 1: Table 1-1 Toxidromes and
109 D See question 5.4.5 question 25.1.1
110 A See Chapter 18 Quick Quiz: When to Cut? 162 C See question 25.2.7
111 B See question 18.1.5 163 A See question 27.1.1
112 B See question 18.6.4: Helpful Tip 164 C See question 3.4.1: Helpful Tip
113 A See question 18.3.6 165 B See Chapter 4: Table 4-2
114 C See question 18.4.6 166 B See Chapter 4: Quick Quiz: Contrast Allergy
115 A See question 18.14.4 167 D See question 19.1.4
116 C See question 18.10.6 168 B See question 20.1.9
117 B See Chapter 19 glossary and 19.2.1 169 C See questions 20.1.1 and 20.1.3
118 C See question 19.14.3 170 A See question 20.4.2
119 C See question 19.15.1 171 C See question 3.5.6
120 C See question 22.5.1 172 A See question 3.12.7
121 C See question 19.12.1 173 C See question 3.11.6
122 C See question 11.1.8 174 D See question 17.10.6: Helpful Tip
123 D See question 11.1.2: Helpful Tip 175 E See question 17.11.1
124 A See question 11.1.3 176 B See question 14.2.2; also Chapter 15 Quick
125 A See question 11.2.2 Quiz: Amenorrhea
126 B See question 11.4.5 177 C See Chapter 14: Quick Quiz: Adolescent Athletes
127 A See question 11.2.3 178 D See Chapter 10 Quick Quiz: Thyroid Tests
128 A See Chapter 12, General note, at the start 179 A See question 10.2.6
of the chapter 180 B See questions 21.5.1 and 21.5.3
129 C See question 11.8.2 181 A See question 7.10.6
130 A See question 3.12.1: Helpful Tip, 3.12.2, 3.12.3 182 B See question 10.10.1: Helpful Tip
131 A See question 15.1.1: Helpful Tip 183 A See question 6.2.2
132 D See Chapter 15 Quick Quiz: Amenorrhea 184 C See question 6.18.2: Helpful Tip
133 B See Chapter 15: Table 15-9 185 C See question 22.1.2
134 C See question 15.1.8 186 B See question 22.1.5: Helpful Tip
135 B See question 15.8.2: Helpful Tip and 15.9.4 187 D See question 22.2.1
136 A See question 15.4.2 and 15.4.4 188 D See question 22.4.6: Helpful Tip
137 B See Chapter 15, Table 15-2 189 A See question 22.5.4: Helpful Tip
138 A See question 15.13.2: Helpful Tip 190 B See question 22.6.1
139 B See question 15.4.1 191 D See question 22.7.3
140 C See question 15.4.3: Helpful Tip 192 A See question 22.8.4 and Table 22-3
141 D See question 23.1.8 193 B See question 22.8.8
142 D See question 13.3.3 194 C See question 22.9.4
143 C See question 13.4.1 195 D See question 22.11.4: Helpful Tip
144 B See Quick Quiz: Congenital Infections, 196 C See question 28.6.2
Helpful Tip 197 B See question 9.4.2
145 C See Quick Quiz: Sad All the Time 198 A See question 12.2.3
146 D See question 23.6.4 199 A See question 12.19.1
147 A See question 23.6.9 200 Godzilla Never bet against Godzilla