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Family Practice
Examination & Board
Review
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Family Practice
Examination & Board
Review
Second Edition
Editors
Mark A. Graber, MD
Professor
Departments of Family Medicine and Emergency Medicine

Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa
Jason K. Wilbur, MD
Assistant Professor (Clinical)
Department of Family Medicine
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa
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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

5. NEPHROLOGY
Page 179
6. HEMATOLOGY AND ONCOLOGY
Page 217
7. GASTROENTEROLOGY
Page 250
8. INFECTIOUS DISEASES
Page 294
9. HIV/AIDS
Page 318
10. ENDOCRINOLOGY
Page 332
11. RHEUMATOLOGY
Page 367
12. ORTHOPEDICS AND SPORTS MEDICINE
Page 404
13. PEDIATRICS
Page 435
14. ADOLESCENT MEDICINE
Page 480
15. OBSTETRICS AND WOMEN’S HEALTH
Page 490
16. MEN’S HEALTH
Page 552
17. DERMATOLOGY
Page 579
18. NEUROLOGY
Page 605
19. OPHTHALMOLOGY
Page 638

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

Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa
Psychiatry
David A. Bedell, MD
Associate Professor of Family Medicine
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa
Obstetrics and Women’s Health
Ottar Bergmann, MD
Fellow, Division of Gastroenterology
Department of Internal Medicine
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa
Gastroenterology
Christopher J. Berry, MD
Chief Fellow
Division of Cardiovascular Medicine
University of Iowa Hospitals and Clinics
Iowa City, Iowa
Cardiology
Christopher T. Buresh, MD
Assistant Professor of Emergency Medicine
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa
Emergency Medicine
Katrina Cannon, MD

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

Pulmonary
Lori J. Day, MD
Fellow, Department of Obstetrics and Gynecology
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa
Obstetrics and Women’s Health
x FAMILY PRACTICE EXAMINATION & BOARD REVIEW
Richard C. Dobyns, MD
Professor of Family Medicine
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa
End-of-Life Care
Scott A. Frisbie, ATC, PA-C
Steindler Orthopedics
Iowa City, Iowa
Orthopedics and Sports Medicine
Mark A. Graber, MD
Professor
Departments of Family Medicine and Emergency
Medicine
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa
Emergency Medicine; Allergy and Immunology; HIV/AIDS;
Endocrinology; Orthopedics and Sports Medicine; Neurology;
Otolaryngology; Care of the Surgical Patient; Substance
Abuse; Patient-Centered Care Final Examination
Emily Greenlee, MD

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

Iowa City, Iowa
Obstetrics and Women’s Health
Chirag M. Sandesara, 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
Margo Schilling, MD
Associate Professor of Internal Medicine
Division of General Internal Medicine
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa
Infectious Diseases
Victoria Sharp, MD, MBA
Clinical Associate Professor
Departments of Urology and Family Medicine
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa
Men’s Health
Anne L. S. Sullivan, MD
Associate Professor of Family Medicine
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa
Adolescent Medicine
Michael E. Takacs, MD

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

University of Iowa
Iowa City, Iowa
End-of-Life Care
Deborah W. Wilbur, MD
Hematologist/Medical Oncologist
Private Practice
Oncology Associates
Cedar Rapids, Iowa
Hematology and Oncology
Jason K. Wilbur, MD
Assistant Professor (Clinical)
Department of Family Medicine
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa
Nephrology; HIV/AIDS; Pediatrics; Men’s Health;
Dermatology; Otolaryngology; Care of the Older Patient;
Patient-Centered Care; Final Examination
CONTRIBUTORS xi
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xiii
Preface
The first edition of this book published four years
ago and quickly became established as one of the
most relied-upon resources for preparing for fam-
ily practice board examinations. We are gratified
that so many residents, students, and clinicians
found the book helpful, and we have appreciated re-
ceiving your comments and suggestions over the last
few years. Welcome to the second edition of Family

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-

dents studying for Step 3 of the licensing exam should
find the book helpful as well. However, no board re-
view book can possibly cover the entire scope of fam-
ily medicine. Ask yourself this question as a guide for
using the book: what are the areas in which you are
strong and what are the areas in which you need further
study? We have provided a “final exam” of 150 ques-
tions, with which you can gauge what you have learned.
Each answer of the “final exam” is referenced in the
book so you can go back and review any topic that you
may have missed.
In this book, the use of eponymous medical terms
such as Crohn disease, Wegner disease, and Wilson
disease reflects the current American Medical Associ-
ation recommendations for these and similar terms.
We enjoyed writing this book and we hope that you
enjoy using it. If you have suggestions or complaints
(OK, maybe some of our jokes aren’t politically correct),
do not hesitate to write us at
or We take your comments
seriously as we endeavor to make studying for the board
exam more efficient and more fun.
Mark would like to thank all of the authors for their
contributions….sometimes “a bit” over deadline but
you know who you are. Thanks also to my family:
Hetty, Rachel, and Abe (as always). But not to the
dogs…they need to learn to stay either in or out of the
house. No more of this back and forth. Finally, thanks
to Buckethead, Shawn Lane, Jonas Hellborg, and the
soundtrack from “Noir” (the anime) for keeping me

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-

sons. First, ipecac is not a particularly effective method
of emptying gastric contents. More important, if the
patient should start to seize while vomiting as a result
of the ipecac, she could aspirate the vomitus causing an
aspiration pneumonitis. Answer C is incorrect because
you do not want to delay definitive treatment. You can
call poison control while the patient is on the way in.
**
The patient arrives in your ED. She is alert with a
tachycardia of 160 beats per minute but with a sta-
ble blood pressure. The ingestion occurred about
2.5 hours ago. You decide that the next step is GI
decontamination.
Which of the following statements is true about
gastric lavage?
A) Except in extraordinary circumstances it should be
done only in the first 1.5 hours after an overdose.
B) Patients who have had gastric lavage have higher
incidence of pulmonary aspiration than patients
who have not.
C) The maximum volume that should be used is
5 liters.
D) It can push pill fragments beyond the pylorus.
E) All of the above are true.
Discussion
The correct answer is E. All of the statements are true.
Generally, the efficacy of gastric lavage is limited. The
outcome data do not support the use of gastric lavage
after the first 1 to 1.5 hours. In a particularly severe over-
dose or in an overdose that is likely to delay gastric

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

incorrect because seizure prophylaxis is not indicated
in this patient. Although seizures are a major manifes-
tation of theophylline toxicity, they are more likely to
occur in patients who take theophylline chronically
and have toxic blood levels. Acute ingestions are less
worrisome.
For which of these overdoses is charcoal NOT
indicated?
A) Acetaminophen.
B) Aspirin.
C) Iron.
D) Digoxin.
E) Opiates.
Discussion
The correct answer is C. Charcoal will not bind iron.
Some of you may have chosen answer A, acetamino-
phen. Theoretically, charcoal could interfere with the
action of N-acetylcysteine, the antidote for acetamin-
ophen ingestion, by absorbing it. However, this is more
of a theoretical concern than an actual one. First, the
drugs should be used at different times. Charcoal
should be given immediately while N-acetylcysteine is
given only after 4-hour levels are available. Second, the
doses of N-acetylcysteine recommended are quite
high, and you can give a higher dose if you will be using
it with charcoal. Finally, IV N-acetylcysteine is avail-
able and is obviously not affected by charcoal. Answers
B, D, and E are all incorrect. While we do have anti-
dotes for digoxin and opiates (Digibind, naloxone),
charcoal is still indicated to reduce absorption.

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.

Discussion
The correct answer is C. Fluoroquinolones are the
drugs of choice when treating individuals exposed to
anthrax. Doxycycline may also be used. Cephalosporins
and TMP/SMX are not active against anthrax.
HELPFUL TIP: Although standard of care,
charcoal has limited or no effect on outcomes.
It reduces absorption by about 30% if given
within 1 hour of ingestion and likely has no
benefit after 1 hour (but it is still the correct an-
swer on the test!).
CHAPTER 1 EMERGENCY MEDICINE 3
Godzilla, frustrated by his failed anthrax attack, is
now spreading smallpox. Which of the following
is NOT true about smallpox?
A) Isolation is best done at home if possible
B) The patient is infectious until he or she becomes
afebrile.
C) All lesions are generally in the same stage of evo-
lution, unlike what is seen in varicella.
D) Smallpox immunization causes an encephalitis in
1:300,000, of which 25% of cases are fatal.
Discussion
The correct answer is B. The patient is infectious until
all lesions crust over; the infectious state is not affected
by the presence or absence of fever. Answer A is true.
Isolation is best done at home since this will limit
spread. Answer C is true. All lesions are in a similar
state of evolution. Answer D is true, which is why there
is not a mass immunization campaign against smallpox.

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-

dural sedation in patients who are not on chronic
benzodiazepines.
**
You notice that the patient begins to have an abnormal
ECG tracing.
Which of the following findings would you expect
to find in a tricyclic overdose?
A) Normal QRS complex.
B) 2nd- and 3rd-degree heart block.
C) Widened QRS complex.
D) Sinus tachycardia.
E) All of the above.
Discussion
The correct answer is E. All of the above findings can be
seen with a tricyclic overdose. In fact, the most common
presenting rhythm is a narrow-complex sinus tachycar-
dia. As toxicity progresses, you can get a prolonged PR
interval, a widened QRS complex and a prolonged QT
interval. Heart blocks (2nd- and 3rd-degree) herald a
poor outcome and may be seen late in the course. Asys-
tole is not a primary rhythm in tricyclic overdose and
tends to reflect the end-stage of another arrhythmia.
**
YIKES! The patient becomes unresponsive and you
look at the monitor. You obtain the ECG as shown in
Figure 1–1.
What is the patient’s rhythm?
A) Monomorphic ventricular tachycardia.
B) Sinus tachycardia with a bundle branch block.
C) Paroxysmal supraventricular tachycardia.

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

the heart reversing the toxicity of the tricyclic. Pro-
cainamide and quinidine should not be used because
they act in similar fashion to tricyclics and may
worsen the problem. Lidocaine can be used as can
amiodarone, but they are not the best choices. Beta-
blockers can worsen hypotension and should be
avoided.
**
This is not your patient’s lucky day. She begins to seize
after the administration of the bicarbonate.
The treatment of choice for this seizing patient is:
A) Lorazepam.
B) Repeating the bolus of sodium bicarbonate and
increasing the bicarbonate drip.
C) Phenytoin (Dilantin).
D) Fosphenytoin (Cerebryx).
E) None of the above.
Discussion
The correct answer is A. Benzodiazepines are the treat-
ments of choice in tricyclic-induced seizures. While
most seizures are self-limited, it is important to con-
trol seizures because the resultant acidosis can worsen
tricyclic toxicity. Answer B is incorrect. This patient is
already alkalinized, and sodium bicarbonate is not par-
ticularly effective in tricyclic induced seizures. Answer
C is incorrect because phenytoin can be used, but ben-
zodiazepines and phenobarbital should be administered
first if possible. Phenytoin is not a particularly good
antiepileptic drug in tricyclic overdose. Answer D is in-
correct for two reasons. First, since fosphenytoin is

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”).

E) Opiate overdose.
HELPFUL TIP: A patient who is asympto-
matic 6 hours after a tricyclic overdose is un-
likely to have any serious consequences from
the ingestion. The patient can be “medically
cleared” at that point for admission to the
psychiatric unit. Note that “symptomatic”
includes tachycardia or mild confusion. We
are talking about the entirely asymptomatic
patient here.
6 FAMILY PRACTICE EXAMINATION & BOARD REVIEW
Discussion
The correct answer is B. The episodic coma and
bradycardia interspersed with episodes of extreme ag-
itation are almost pathognomonic of GHB overdose.
Answer A is incorrect because MDMA causes an
amphetamine-like reaction with agitation, hyperten-
sion, hyperthermia, tachycardia, etc. Answer C is in-
correct for the same reason. Answer D is incorrect
because LSD rarely (if ever) causes coma. Answer E is
incorrect because patients with opiate overdoses are
generally somnolent or comatose without interspersed
episodes of agitation.
The main point of this case is to be aware of the in-
creased use of GHB (aka “Georgia home boy,” “griev-
ous bodily harm,” and other names) and of the toxicity
associated with it. It is odorless and has slight salty
taste. It has become a drug of choice for date rape. The
toxicity tends to be self-limited and can be treated with
intubation if needed along with tincture of time. The

half-life is only 27 minutes.
QUICK QUIZ:TOXIDROMES
A patient presents to the hospital with a 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).

Table 1–1 TOXIDROMES
Drug Class Examples Signs and Symptoms
Anticholinergic Tricyclics, diphenhydramine, Tachycardia, flushing, dilated pupils,
scopolamine, loco weed (jimson weed), low-grade temperature, and confusion.
some mushrooms, etc Mnemonic: Dry as a bone, red as a beet,
mad as a hatter, blind as a bat
Opiates Morphine, heroin, codeine, Pinpoint pupils, hypotension,
oxycodone, etc hypopnea, coma, hypothermia
Cholinergic Organophosphate or carbamate Lacrimation, salivation, muscle
pesticides, some mushrooms weakness, diarrhea, vomiting, miosis
Mnemonic: Moist as a slug, eyes like a
mole, weak as a kitten
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
while comatose, and myoclonus
CHAPTER 1 EMERGENCY MEDICINE 7
D) Absence of paralysis or another “hard” sign that
could be caused by a neck injury.
E) All of the above are needed to clear the cervical
spine clinically.
Discussion
The correct answer is A. Patients can have lateral neck
pain and still have their cervical spines cleared clini-
cally. However, no one will fault you for obtaining
radiographs in patients with lateral muscular (eg,
trapezius) neck pain. Patients with central neck pain
(eg, over the spinous processes) do need radiographs
to clear their cervical spine. All of the other criteria are

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

old, and conversion reaction is unlikely in children. Ad-
ditionally, conversion reaction is always a diagnosis of
exclusion. Answer C is incorrect because this is not the
presentation of a subarachnoid hemorrhage (headache,
stiff neck, perhaps focal neurologic symptoms).
The next step in the management of this patient is:
A) IV methylprednisolone to reduce cord edema.
B) Fluid restriction and diuretics to reduce cord edema.
C) Mannitol to reduce cord edema.
D) Neurosurgical intervention to decompress the
cord.
E) None of the above.
Discussion
The correct answer is A. Patients with a cord injury
should be treated with IV methylprednisolone
30mg/kg bolus (3 g in an adult) followed by a 5.4mg/kg
drip for 24 hours. The efficacy of this therapy in spinal
cord injury is limited, and its efficacy in SCIWORA is
unknown. However, it is currently considered the stan-
dard of care. Neither diuretics nor mannitol will be
useful in this situation. Answer D is incorrect because
the process of SCIWORA involves stretching of the
cord (and subsequent dysfunction) rather than cord
compression such as would be seen with a bony injury.
The father is, understandably, irate that his child
is now paralyzed. You can tell him that the natu-
ral history of SCIWORA syndrome in THIS
CHILD is likely to be which of the following?
Table 1–2 CLEARING THE CERVICAL SPINE
CLINICALLY

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

when they present with symptoms! Patients who
present with paralysis right after the accident may have
complete cord transection and thus will not regain
function. For this reason, it is important to obtain an
MRI on all patients with SCIWORA syndrome (and
any trauma-induced paralysis for that matter).
Objectives: Did you learn to . . .
● Clinically “clear” the cervical spine and decide when
to order cervical spine radiographs?
● Describe causes of missed cervical spine fractures?
● Understand the physiology, natural history, and
management of SCIWORA syndrome?
CASE 4
A hard-core alcoholic presents to the ED after drink-
ing a bottle of automobile winter gas treatment
(Rothschild Vintage, 1954). He is intoxicated, has a
headache, and describes a “misty” vision, such as
might be seen during a snowstorm. He is tachycardic
and tachypneic. You start an IV and administer IV
saline. You obtain a blood gas, which shows a mild
metabolic acidosis.
A metabolic acidosis is consistent with all of the
following ingestions EXCEPT:
A) Ethylene glycol.
B) Methanol.
C) Ethanol (eg, vodka, gin, etc).
D) Petroleum distillates (eg, non–alcohol-containing
gasoline products).
Discussion
The correct answer is D. Ethylene glycol, methanol,

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.

E) Ingestions such as methanol.
Discussion
The correct answer is C. See Table 1–3 for more on
causes of anion gap acidosis.
HELPFUL TIP: In methanol ingestions, the
severity of acid-base disturbance is generally a
better predictor of outcome than serum methanol
levels.
CHAPTER 1 EMERGENCY MEDICINE 9
Which of the following findings IS NOT fre-
quently seen in patients with methanol ingestion?
A) Hypopnea.
B) Optic disk abnormalities.
C) Abdominal pain and vomiting.
D) Basal ganglia hemorrhage.
E) Meningeal signs, such as nuchal rigidity.
Discussion
The correct answer is A. Hypopnea is not commonly
seen in methanol poisoning until the patient is close to
death. In fact, the reverse is true. Tachypnea is a fre-
quent finding in methanol overdose. This makes sense.
The patient is trying to compensate for a metabolic aci-
dosis by blowing off CO
2
. Optic disk abnormalities, ab-
dominal pain and vomiting, basal ganglia hemorrhage,
and meningeal signs are all seen as part of methanol tox-
icity. It is thought that many of these signs and symp-
toms are secondary to CNS hemorrhage.
**

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.
**

You decide that there is sufficient evidence that this
patient has ingested methanol in order to institute
treatment.
Appropriate treatment(s) for this patient include:
A) Fomepizole (4-MP).
B) Cimetidine.
C) Ethanol.
D) A and C.
E) All of the above.
Discussion
The correct answer is D. Both fomepizole (4-MP) and
ethanol are used for methanol ingestion. The idea is to
slow down the metabolism of the methanol. The toxi-
city of methanol is caused by formic acid, which is a
byproduct of methanol metabolism. Ethanol is metab-
olized by alcohol dehydrogenase, the same enzyme that
breaks down methanol. Thus, methanol metabolism is
competitively inhibited by ethanol. The same holds
true for fomepizole which is a competitive inhibitor of
alcohol dehydrogenase. Fomepizole and ethanol can
both be used for ethylene glycol ingestion as well.
Answer B is incorrect. While cimetidine does reduce
alcohol metabolism, the effect size is so small as to be
negligible.
Table 1–3 CAUSES OF ACIDOSIS
Causes of an elevated Lactic acidosis
anion gap acidosis Diabetic ketoacidosis
Ingestions such as ethanol,
methanol, etc
Uremia

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-

tified, the usual treatments are employed (eg, pressure
support, airway protection, charcoal, etc). If conven-
tional pressors have failed, glucagon in a dose of 3–5
mg IV bolus and a drip at 1–5 mg/hr may be effective
in treating β-blocker overdose. It is generally preferred
over atropine in this situation. Milrinone and other
phosphodiesterase inhibitors may also be used but are
considered third-line. Likewise, calcium is considered
a third-line agent in β-blocker overdose. Calcium chlo-
ride may potentiate the action of glucagon.
QUICK QUIZ:TOXICOLOGY
The best therapy for seizures secondary to isoniazid
ingestion is:
A) Lorazepam.
B) Phenytoin.
C) Pyridoxine.
D) Thiamine.
E) Phenobarbital.
Discussion
The correct answer is C. Isoniazid is a B
6
antagonist.
Thus, pyridoxine is the drug of choice in isoniazid-
induced seizures. These seizures are often resistant to
conventional therapy. Look for this type of overdose in
patients who are being treated for tuberculosis (either
active or latent disease).
QUICK QUIZ:TOXICOLOGY
Whole-bowel irrigation is most appropriate for
which of these overdoses?

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.