Family Practice
Examination & Board
Review
NOTICE
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administer to be certain that the information contained in this work is accurate
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Family Practice
Examination & Board
Review
Second Edition
Editors
Mark A. Graber, MD
Professor
Departments of Family Medicine and Emergency Medicine

RACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION
THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY,
EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PAR-
TICULAR PURPOSE. McGraw-Hill and its licensors do not warrant or guarantee that the functions contained in the work will meet your requirements
or that its operation will be uninterrupted or error free. Neither McGraw-Hill nor its licensors shall be liable to you or anyone else for any inaccuracy,
error or omission, regardless of cause, in the work or for any damages resulting therefrom. McGraw-Hill has no responsibility for the content of any
information accessed through the work. Under no circumstances shall McGraw-Hill and/or its licensors be liable for any indirect, incidental, special,
punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the
possibility of such damages. This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort
or otherwise.
To Eric Nilles, MD, who is working in Darfur, and to Doctors Without Borders.
We can only hope.
— MAG
To my grandfathers, Homer Fritz, who wanted to become a doctor but could
not afford medical school, and Kenneth Wilbur, who taught me the
value of hard work and a generous spirit.
— JKW
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vii
Contents
CONTRIBUTORS IX
PREFACE XIII
1. EMERGENCY MEDICINE
Page 1
2. CARDIOLOGY
Page 48
3. PULMONARY
Page 128
4. ALLERGY AND IMMUNOLOGY
Page 170

20. OTOLARYNGOLOGY
Page 665
21. CARE OF THE OLDER PATIENT
Page 690
22. CARE OF THE SURGICAL PATIENT
Page 724
23. PSYCHIATRY
Page 762
24. NUTRITION AND HERBAL MEDICINE
Page 805
25. SUBSTANCE ABUSE
Page 820
26. ETHICS
Page 837
27. END-OF-LIFE CARE
Page 849
28. EVIDENCE-BASED MEDICINE
Page 862
29. PATIENT-CENTERED CARE
Page 876
30. FINAL EXAMINATION
Page 886
I
NDEX 909
COLOR PLATES APPEAR BETWEEN PAGES 594 AND 595.
viii FAMILY PRACTICE EXAMINATION & BOARD REVIEW
Contributors
ix
Alison C. Abreu, MD
Assistant Professor of Family Medicine and Psychiatry

Veterans Affairs Quality Scholar and Geriatric Fellow
Center for Research in the Implementation of Innovative
Strategies in Practice (CRIISP)
Iowa City Veterans Affairs Medical Center and
Division of General Internal Medicine
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa
Care of the Older Patient
Elizabeth C. Clark, MD, MPH
Assistant Professor
Department of Family Medicine
University of Medicine and Dentistry of New Jersey
Robert Wood Johnson Medical School
Somerset, New Jersey
Evidence-Based Medicine
Dana M. Collaguazo, MD
Assistant Professor of Emergency Medicine
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa
Emergency Medicine
Greg Davis, MD
Pulmonary and Critical Care Medicine Fellow Associate
Department of Internal Medicine
Division of Pulmonary, Critical Care and Occupational
Medicine
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa

Clinical Assistant Professor of Ophthalmology
Department of Ophthalmology
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa
Ophthalmology
Philip Gregory, PharmD
Center for Drug Information & Evidence-Based Practice
Creighton University
Omaha, Nebraska
Editor, Natural Medicines Comprehensive Database
Nutrition and Herbal Medicine
Rajesh Kabra, MD
Fellow, Division of Cardiology
Department of Internal Medicine
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa
Cardiology
Oladipo A. Kukoyi, MD, MS
Assistant Clinical Professor, UC Davis
Department of Psychiatry and Behavioral Sciences
Medical Director of Inpatient Psychiatry
VA Sacramento Medical Center
Hospital Way, Mather, California
Patient-Centered Care
Colleen M. Kennedy, MD, MS
Assistant Professor of Obstetrics and Gynecology
Roy J. and Lucille A. Carver College of Medicine
University of Iowa

Assistant Professor of Emergency Medicine
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa
Emergency Medicine
Janeta F. Tansey, MD
Clinical Associate Professor
Department of Psychiatry and
Program in Biomedical Ethics and Medical Humanities
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa
Ethics
Rebecca S. Tuetken, MD
Associate Professor of Rheumatology
Department of Internal Medicine
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa
Rheumatology
Philip N. Velderman, MD
Fellow, Division of Rheumatology
Department of Internal Medicine
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa
Rheumatology
Michelle Weckmann, MD
Assistant Professor of Psychiatry
Roy J. and Lucille A. Carver College of Medicine

Practice Examination
&
Board Review. Our primary goal
in writing this book is to help you pass your board
exam. However, there are two crucial differences
between this book and other board review books
on the market. First, we have written this book not
only to help you pass the boards but also to help you
broaden your knowledge of family medicine. Most
questions in the book contain a detailed explanation
not only of why an answer is right but also why the
other answers are wrong. If the current “state of the
art” differs substantially from the answers that will
be on the boards (which generally reflect informa-
tion that is 2 to 3 years out of date), we have made
a note of this and have given you the “state of the
art” information as well.
The second difference is that we are not boring.
You will find our (sometimes feeble) attempts at humor
throughout the book. There is no reason that studying
has to be an exercise in tedium and endurance. It
should be enjoyable and should provide a surprise
every now and again. We have noticed that an occa-
sional reader does not appreciate our sense of humor.
Oh well….
We have tried to make this book as broad and as
comprehensive as possible. In addition to its use as a
board review book for family medicine, it can be used
as a general review for primary care physicians, physi-
cian assistants, and nurse practitioners. Medical stu-

awake in the wee hours when text begins to swim across
the screen (doing the sidestroke, I think).
Jason thanks his wife, Deb, who has shown great
patience during the writing of this book (look…he
lives!), and his boys, Ken and Ted, who seem to have
changed more than medicine since the first edition.
And then there are the growers, producers, and roast-
ers of fine coffee, without whom there would be no fuel
for this endeavor. Who would I be without coffee?
I get a chill down my spine just thinking about it.
Thank you to David Bedell, who reviewed the chap-
ter on obstetrics and women’s health in addition to his
other contribution to this book.
This page intentionally left blank
CASE 1
You get a call from a panicked mother because her 4-year-
old took some of her theophylline. She thinks it may have
been as many as 10 pills but is not clear on the actual num-
ber. She is about 35 minutes from the hospital.
Your advice to her is:
A) Give ipecac to promote stomach emptying and
reduce theophylline absorption.
B) Do not give ipecac and proceed directly to the
hospital.
C) Call poison control and then proceed to the
hospital.
D) None of the above.
Discussion
The correct answer is B. Do not give ipecac but pro-
ceed to the hospital. Answer A is incorrect for two rea-

emptying (eg, anticholinergics such as diphenhy-
dramine or tricyclic antidepressants), you might want
to try lavage beyond the 1.5 hours, but such circum-
stances are unusual. Gastric lavage increases the risk of
aspiration, can push pill fragments beyond the pylorus,
and 5 liters is the maximum volume that should be
used.
Emergency Medicine
1
Christopher T. Buresh, Dana M. Collaguazo, Mark A. Graber, and Michael E. Takacs
1
HELPFUL TIP: The FDA has determined that
ipecac is ineffective and possibly harmful. It
causes myopathy and cardiac problems when
used chronically (such as in individuals with
anorexia nervosa).
2 FAMILY PRACTICE EXAMINATION & BOARD REVIEW
The next best step to take with this patient is to:
A) Check blood theophylline levels and refer for
hemodialysis if markedly elevated.
B) Administer 1 g/kg of charcoal with sorbitol.
C) Prophylactically treat this patient for seizures using
lorazepam.
D) Prophylactically treat this patient for seizures using
phenytoin.
Discussion
The correct answer is B. Giving charcoal is indicated
in almost all overdose situations. Answer A is incor-
rect because the patient’s situation could deteriorate
by the time blood levels return. Answers C and D are

Objectives: Did you learn to . . .
● Manage a patient with an acute ingestion?
● Describe the appropriate use of gastric lavage and
charcoal administration?
● Identify situations where charcoal may not be
indicated?
QUICK QUIZ: BIOTERRORISM
Oh no! Godzilla is attacking Tokyo with weapons
of mass destruction. Which of the following
properly describes the isolation requirements of
a patient with pulmonary anthrax?
A) No isolation necessary. The patient may be in the
same room with an uninfected patient.
B) Respiratory isolation only.
C) Respiratory and contact isolation.
D) Negative pressure room (such as with tuberculo-
sis) plus contact isolation.
Discussion
The correct answer is A. Pulmonary anthrax is not trans-
mitted person-to-person. Contact isolation is indicated
in patients with cutaneous anthrax and GI anthrax
(where diarrhea may be infectious).
Godzilla is not done yet. Which of the following
drugs should be used as prophylaxis against in-
haled anthrax should exposure to aerosolized
spores be documented?
A) A first-generation cephalosporin.
B) Trimethoprim/sulfamethoxazole.
C) Ciprofloxacin.
D) A third-generation cephalosporin.

CASE 2
A 22-year-old female presents to the ED with an over-
dose. She has a history of depression, and there were
empty bottles found at her bedside. The bottles had con-
tained clonazepam (a benzodiazepine) and nortriptyline
(a tricyclic). The patient is unconscious with diminished
breathing and is unable to protect her own airway.
The BEST next step is to:
A) Intubate the patient.
B) Begin gastric lavage and administer charcoal.
C) Administer flumazenil, a benzodiazepine antago-
nist, to awaken her and improve her respirations.
D) Administer bicarbonate.
E) None of the above.
Discussion
The correct answer is A. This patient should be intu-
bated. Remember that in any emergency situation that
the ABCs (airway, breathing, and circulation) are the
priority. Answer B is incorrect because, as noted above,
patients who are lavaged have a higher incidence of
pulmonary aspiration—an even greater concern in the
obtunded patient. In fact, airway protection is manda-
tory before undertaking lavage. Answer C is incorrect.
Flumazenil will reverse the benzodiazepine. However,
we know from experience that seizures in patients who
have had flumazenil are particularly difficult to control.
This would be particularly problematic in a patient
with a mixed overdose, such as with a tricyclic, where
seizures are common. Thus, it is recommended that
flumazenil be used only as a reversal agent after proce-

D) Torsade de pointes.
E) None of the above.
Discussion
The correct answer is D. This is torsade de pointes
(literally “twisting of the points”), which is a subtype
of polymorphic ventricular tachycardia. It can be rec-
ognized by the varying amplitude of the complex in a
somewhat regular pattern. Answer A is incorrect be-
cause the complexes are not monomorphic. Answer B
is incorrect for two reasons. First, there are no P waves
visible. Second, sinus tachycardia should not have
varied amplitude. Answer C is incorrect because, again,
there are no P waves and the complexes are polymorphic.
Figure 1–1
4
CHAPTER 1 EMERGENCY MEDICINE 5
This patient needs treatment posthaste. After
taking care of the ABCs, what is the one BEST
drug for the treatment of this arrhythmia in a
patient with a tricyclic overdose?
A) Beta-blockers.
B) Lidocaine.
C) Sodium bicarbonate.
D) Procainamide.
E) Amiodarone.
Discussion
The correct answer is C. The treatment of choice for
arrhythmias in patients with a tricyclic overdose is
sodium bicarbonate. Raising the pH and administer-
ing sodium seems to “prime” the sodium channels in

metabolized to phenytoin, the caveats above also apply
for it. Second, it requires adequate circulation and renal
and hepatic function for adequate metabolism and
blood levels. If your patient becomes hypotensive with
poor liver and renal perfusion, adequate drug levels
might not be achieved. Finally, both phenytoin and fos-
phenytoin can cause hypotension—not what you need
in this unstable patient.
**
The patient’s seizures stop and she is admitted to the
intensive care unit.
Objectives: Did you learn to . . .
● Describe the role of flumazenil in toxicologic
emergencies?
● Manage a tricyclic overdose?
● Recognize ECG findings in a tricyclic overdose?
● Recognize torsade de pointes and its treatment?
QUICK QUIZ: DESIGNER AND CLUB DRUGS
An 18-year-old male presents after a party. He is hav-
ing alternating episodes of combative behavior inter-
spersed with episodes of coma. He becomes almost
apneic during the episodes of coma. He has alternating
bradycardia (while in coma) and tachycardia (when
awake). The patient is also having myoclonic seizures.
His serum alcohol level is zero.
The most likely drug causing this is:
A) Ecstasy (MDMA).
B) GHB (gamma hydroxybutyrate, aka liquid ecstasy).
C) Methamphetamines.
D) LSD (lysergic acid diethylamine, aka “acid”).

half-life is only 27 minutes.
QUICK QUIZ:TOXIDROMES
A patient presents to the hospital with a diphenhy-
dramine overdose.
Which of the following signs and symptoms are
you likely to find in this patient?
A) Bradycardia, dilated pupils, flushing.
B) Bradycardia, pinpoint pupils, flushing.
C) Tachycardia, dilated pupils, diaphoresis.
D) Tachycardia, dilated pupils, flushing.
E) Tachycardia, pinpoint pupils, flushing.
Discussion
The correct answer is D. This patient has an anti-
cholinergic toxidrome. Toxidromes are symptom com-
plexes associated with a particular overdose that should
be recognized immediately by the clinician. Common
toxidromes are listed in Table 1–1.
CASE 3
A patient presents to your office with neck pain after a
motor vehicle accident. He was restrained and the
airbag deployed. He notes that he had some lateral
neck pain at the scene. He continues to have lateral
neck pain.
Which of the following IS NOT a criterion for
clearing the cervical spine clinically?
A) Absence of all neck pain.
B) Normal mental status including no drugs or
alcohol.
C) Absence of a distracting injury (such as an ankle
fracture).

required in order to clinically clear the cervical spine
(Table 1–2).
**
The patient’s daughter, aged 4 years, was in the same
motor vehicle accident and also had her cervical spines
cleared by radiograph. However, you get a call from
the ED 48 hours after the initial accident that the child
is paralyzed from just above the nipple line down
(never a good thing; the lawyers are probably close be-
hind). You review the initial radiographs with the radi-
ologist, they are negative as is a CT of the cervical
spine bones done after the onset of the paralysis.
The most likely cause of this patient’s paralysis is:
A) Missed transection of the thoracic cord.
B) Conversion reaction from the psychological
trauma of the accident.
C) Subarachnoid hemorrhage.
D) SCIWORA syndrome.
Discussion
The correct answer is D. This likely represents
SCIWORA syndrome (spinal cord injury without
radiologic abnormality). This occurs from stretching of
the cord secondary to flexion/extension-type of move-
ment in an accident. Patients with SCIWORA syn-
drome may be paralyzed at the time of initial
presentation (in the event of cord transection) or may
have a delayed presentation up to 72 hours after the in-
jury. Answer A is incorrect because a cord transection
would present with paralysis immediately at the time of
injury. Answer B is incorrect because this child is 4 years

No central neck pain on questioning or palpation
No distracting, painful injury (eg, bone fracture, etc)
No symptoms or signs referable to the neck (paralysis,
stinger-type injury, etc)
Normal mental status including no drugs or alcohol;
including any retrograde amnesia, etc
HELPFUL TIP: The most common cause of
missed fractures is an inadequate series of ra-
diographs. An adequate series of radiographs
for the cervical spine includes an AP film, a lat-
eral film including the top of T-1, and an odon-
toid film. CT should be done if radiographs are
negative and there is still clinical suspicion of a
fracture. Flexion-extension views add little and
should be avoided.
8 FAMILY PRACTICE EXAMINATION & BOARD REVIEW
A) Continued paralysis with the necessity of long-
term, permanent adaptation to the injury.
B) Progression of the injury over the next week to in-
clude further paralysis in an ascending fashion.
C) Resolution of paralysis and sensory symptoms over
the next several months.
D) Resolution of all symptoms except sensory symp-
toms of the next several months.
E) Large lawsuit payout on the way. Do not pass go,
do not collect $200 (adjusted for inflation).
Discussion
The correct answer is C. Generally, patients with
SCIWORA syndrome regain their strength and sen-
sory abilities over time. However, this depends on

and ethanol can all cause a metabolic acidosis. Hydro-
carbons (eg, gasoline products) do not cause a meta-
bolic acidosis. The main manifestation of hydrocarbon
toxicity is secondary to the inhalation of the hydrocar-
bon and the resulting pneumonitis.
**
This patient’s electrolytes are as follows: sodium
135 mEq/L, potassium 4.0 mEq/L, bicarbonate
12 mEq/L, chloride 108 mEq/L, BUN 12 mg/dL,
Cr. 1.0 mg/dL.
This patient’s anion gap is:
A) 13
B) 15
C) 23
D) Unable to calculate the anion gap with the infor-
mation provided.
Discussion
The correct answer is B. By convention, the anion gap
is calculated without using a major cation, potassium.
Thus, the anion gap is calculated as follows:
sodium – (chloride + bicarbonate).
In this patient the anion gap is
135 – (108 + 12) = 15
The normal gap is 12 or less.
All of the following are causes of an anion gap
acidosis EXCEPT:
A) Lactic acidosis.
B) Diabetic ketoacidosis.
C) Renal tubular acidosis.
D) Uremia.

You can test for ethanol at your hospital but do not have
a test for methanol on a stat basis and want to be sure
that this patient is not just saying he has a methanol in-
gestion in order to obtain alcohol (a treatment for
methanol ingestion––break out the single malt scotch!).
What test is most likely to help you determine if
the patient has methanol ingestion?
A) CBC.
B) BUN/creatinine.
C) Liver enzymes.
D) Serum osmolality.
E) Amylase and lipase.
Discussion
The correct answer is D. With a measured serum
osmolality, you can calculate the osmolar gap. Subtract
the total measured serum osmoles from the osmoles
known to be due to ethanol (each 100 mg/dL of
ethanol accounts for approximately 22 osmoles). If
there is an elevated osmolar gap, it is evidence of a cir-
culating, unmeasured osmole. In this case, it would be
methanol. So, for example:
Measured serum osmolality = 368
Blood alcohol = 200 mg/dl or about 44 osmoles
Calculated osmolality = 2(Na) + BUN/2.8
+ glucose/18 = 280 + 6 + 8 = 294
So, osmolar gap = 368 – (294 + 44) = 30
This means that there are 30 unmeasured osmoles
which could, in this case, represent methanol. Thus,
we know that the patient is not simply drunk.
**

Alcoholic ketoacidosis
Causes of a normal GI bicarbonate loss
anion gap acidosis (eg, chronic diarrhea)
Renal tubular acidosis
(types I, II, and IV)
Interstitial renal disease
Ureterosigmoid loop
Acetazolamide and other
ingestions
Small bowel drainage
10 FAMILY PRACTICE EXAMINATION & BOARD REVIEW
Objectives: Did you learn to . . .
● Recognize manifestations of alcohol ingestion?
● Identify causes of metabolic acidosis with elevated
and normal anion gaps?
● Use the osmolar gap to narrow the differential
diagnosis of metabolic acidosis?
QUICK QUIZ: BETA-BLOCKER OVERDOSE
Which of the following has been shown to be
useful in β-blocker overdose when conventional,
adrenergic pressors are ineffective?
A) Calcium chloride.
B) Glucagon.
C) Milrinone.
D) All of the above.
Discussion
The correct answer is D. In β-blocker overdoses,
the following findings may be observed: bradycardia,
AV block, hypotension, hypoglycemia, bronchospasm,
nausea, and emesis. When an overdose has been iden-

A) Aspirin.
B) Sustained-release verapamil.
C) Ethanol.
D) Acetaminophen.
E) Sertraline.
Discussion
The correct answer is B. Whole-bowel irrigation is
best used in patients who have taken sustained-release
tablets and in patients with a pill bezoar.
QUICK QUIZ:TOXICOLOGY
Which of the following can be used to increase
the metabolism of alcohol in an intoxicated
patient?
A) IV fluids.
B) Charcoal.
C) Forced diuresis.
D) GABA antagonists such as flumazenil.
E) None of the above.
Discussion
The correct answer is E. The rate of alcohol metabo-
lism is fixed with zero-order kinetics at lower doses
(fixed metabolic rate) and first-order kinetics at higher
doses (rate proportional to levels). Generally, this rate
HELPFUL TIP: Hemodialysis should be avail-
able for any patient who has ingested methanol.
Indications for hemodialysis include methanol
level >50 mg/dL, severe and resistant acidosis,
and renal failure.