Blueprints family medicine

 



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BLUEPRINTS

FAMILY
MEDICINE
Third Edition


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BLUEPRINTS

FAMILY
MEDICINE
Third Edition

Martin S. Lipsky, MD
Professor of Family Medicine and
Regional Dean
University of Illinois
College of Medicine, Rockford
Rockford, Illinois

Mitchell S. King, MD
Associate Professor
University of Illinois
College of Medicine, Rockford
Rockford, Illinois


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Acquisitions: Charles W. Mitchell
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Compositor: MPS Limited, A Macmillan Company
Third Edition
Copyright © 2011 Lippincott Williams & Wilkins, a Wolters Kluwer business.
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9 8 7 6 5 4 3 2 1
Library of Congress Cataloging-in-Publication Data
Lipsky, Martin S.

Blueprints family medicine/Martin S. Lipsky, Mitchell S. King.—3rd ed.
p.; cm.—(Blueprints)
Other title: Family medicine
Includes bibliographical references and index.
ISBN 978-1-60831-087-6
1. Family medicine—Outlines, syllabi, etc. 2. Primary care (Medicine)—Outlines, syllabi, etc.
I. King, Mitchell S. II. Title. III. Title: Family medicine. IV. Series: Blueprints.
[DNLM: 1. Family Practice—Examination Questions. 2. Primary Health Care—methods—
Examination Questions. WB 18.2 L767b 2010]
RC59.B58 2010
616—dc22
2010002515
DISCLAIMER
Care has been taken to confirm the accuracy of the information present and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty,
expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the
publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered
absolute and universal recommendations.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and
dosage set forth in this text are in accordance with the current recommendations and practice at the
time of publication. However, in view of ongoing research, changes in government regulations, and
the constant flow of information relating to drug therapy and drug reactions, the reader is urged to
check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication have Food and Drug Administration
(FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care
provider to ascertain the FDA status of each drug or device planned for use in their clinical practice.
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Contents
Contributors to the third edition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii
Contributors to the second edition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Contributors to the first edition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x
Reviewers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv
PART ONE: Principles of Family Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1 Elements of Family Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Patient Communication and Coordination of Care . . . . . . . . . . . . . . . . . . . . . 3
3 Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
4 Immunizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
5 Preventive Care: 19 to 64 Years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
6 Preoperative Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
7 Family Violence: Awareness and Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
PART TWO: Common Signs and Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
8 Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
9 Back Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
10 Chest Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
11 Constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
12 Cough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
13 Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
14 Dizziness/Vertigo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
15 Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
16 Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
17 Heartburn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

18 Hematuria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
19 Jaundice in Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
20 Knee Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
21 Lymphadenopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74


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vi • Contents

22 Nausea and Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
23 Painful Joints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
24 Palpitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
25 Pharyngitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
26 Proteinuria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
27 Red Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
28 Respiratory Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
29 Shortness of Breath . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
30 Shoulder Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
31 Somatization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
32 Swelling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
33 Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
PART THREE: Common Medical Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
34 Acne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
35 Alcohol and Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
36 Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
37 Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
38 Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
39 Atopic Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
40 Chronic Obstructive Pulmonary Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133

41 Congestive Heart Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
42 Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
43 Diabetes Mellitus Type 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
44 Diverticulitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
45 Human Immunodeficiency Virus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
46 Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
47 Hyperthyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
48 Hypothyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
49 Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
50 Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
51 Prostate Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
52 Sexually Transmitted Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
53 Skin Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
54 Tobacco Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
55 Urinary Tract Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
56 Urticaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190


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Contents • vii

PART FOUR: Women’s Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
57 Abnormal Pap Smear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
58 Abnormal Vaginal Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
59 Amenorrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
60 Breast Masses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
61 Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
62 Vaginitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
PART FIVE: Maternity Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214

63 Preconception Counseling and Prenatal Care . . . . . . . . . . . . . . . . . . . . . . . . 214
64 Common Medical Problems in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
65 Postpartum Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
PART SIX: Care for Infants, Children, and Adolescents . . . . . . . . . . . . . . . . . . . . . 222
66 Preventive Care: Newborn to 5 Years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
67 Preventive Care: 5 Years to 12 Years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
68 Adolescent Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
69 Common Medical Problems in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
70 Behavioral Issues in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
71 Fever in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
72 Otitis Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
73 Preparticipation Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
PART SEVEN: Care for Older Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
74 Preventive Care: 65 Years and Older . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
75 Geriatric Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
76 Common Medical Problems in Older Adults . . . . . . . . . . . . . . . . . . . . . . . . . 255
77 Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
78 Urinary Incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
79 Nursing Home and End-of-Life Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
Appendix: Evidence-Based Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309


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Contributors to the
third edition
Cassandra Lopez, MD

Chief Resident
University of Illinois
College of Medicine, Rockford
Family Medicine Residency Program
Rockford, Illinois

Daniel Cortez
Class of 2010
University of Illinois
College of Medicine, Rockford
Rockford, Illinois


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Contributors to the
second edition
Adam W. Bennett, MD
Attending Physician
Northwestern Memorial Hospital
Clinical Instructor, Family Medicine
Feinberg School of Medicine
Northwestern University
Chicago, Illinois
Sheila E. Bloomquist, MD
MCH Fellow/FP Physician
PCC Salud Family Health Center
Chicago, Illinois
Sandra V. Doyle, DO
Resident Physician, Family Medicine

McGaw Medical Center of Northwestern University
Glenview, Illinois
Priyah Gambhir, MD
Resident Physician, Family Medicine
Northwestern Memorial Hospital
Chicago, Illinois
Ati Hakimi, MD
Resident Physician, Family Medicine
McGaw Medical Center of Northwestern University
Glenview, Illinois
University of St. Eustatius
Netherlands-Antilles

Leslie Mendoza Temple, MD
Attending Physician
Evanston Northwestern Healthcare
Glenview, Illinois
Clinical Instructor, Family Medicine
Feinberg School of Medicine
Northwestern University
Chicago, Illinois
Purvi Patel, MD
Resident Physician, Family Medicine
McGaw Medical Center of Northwestern University
Glenview, Illinois
Ross University
Dominca, British West Indies
Joanna Turner Bisgrove, MD
Resident Physician, Family Medicine
Evanston Northwestern Healthcare

Glenview, Illinois
Darice Zabak-Lipsky, MD
Clinical Assistant Professor, Family Medicine
University of Illinois
College of Medicine, Rockford
Rockford, Illinois


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Contributors to the
first edition
Adam W. Bennett, MD
Attending Physician
Northwestern Memorial Hospital
Clinical Instructor, Family Medicine
Feinberg School of Medicine
Northwestern University
Chicago, Illinois
Jasmine Chao, DO
Resident, Family Medicine
McGaw Medical Center of Northwestern University
Glenview, Illinois
Arden Fusman, MD
Resident, Family Medicine
McGaw Medical Center of Northwestern University
Glenview, Illinois
Daria Majzoubi, MD
Resident, Family Medicine
McGaw Medical Center of Northwestern University

Glenview, Illinois

Leslie Mendoza Temple, MD
Attending Physician
Evanston Northwestern Healthcare
Glenview, Illinois
Clinical Instructor, Family Medicine
Feinberg School of Medicine
Northwestern University
Chicago, Illinois
Sanjaya P. Sooriarachchi, MD
Resident, Family Medicine
McGaw Medical Center of Northwestern University
Glenview, Illinois


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Reviewers
Melissa Beagle, MD
Resident, Denver Health Hospital
University of Colorado Family Medicine
Residency Program
Denver, Colorado

Kamran Shamsa, MD
Resident, Internal Medicine and Pediatrics
Combined Program
UCLA Medical Center
Los Angeles, California

Tara Creighton
Class of 2005
University of South Dakota School of Medicine
Vermillion, South Dakota

Scott Strom
Class of 2004
Michigan State University College of Osteopathic
Medicine
East Lansing, Michigan

Joseph W. Gravel, Jr., MD, FAAFP
Assistant Clinical Professor of Family Medicine
and Community Health
Program Director, Family Medicine Residency
Tufts University School of Medicine
Boston, Massachusetts
Marissa Harris
Resident
Beth Israel Medical Center Residency Program in
Urban Family Medicine
New York, New York
Celeste Chu Kuo, MD
Resident, Pediatrics
Saint Louis Children’s Hospital
St. Louis, Missouri
Amy Marie Little
Class of 2005
Georgetown University

Washington, DC

Christine Tsang, DO
Intern, Family Medicine
Crozer-Keystone
Chester, Pennsylvania
Amber M. Tyler, MD
Captain, United States Air Force
Resident, Family Medicine
University of Nebraska
Omaha, Nebraska
Brian J. West, MD
Resident, Family Practice
Shenandoah Valley Family Practice Residency
Program
Front Royal, Virginia


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Preface
I

n 1997, the first five books in the Blueprints series
were published as board review for medical students, interns, and residents who wanted high-yield,
accurate clinical content for USMLE Steps 2 & 3.
More than a decade later, the Blueprints brand has
expanded into high-quality trusted resources covering the broad range of clinical topics studied by medical students and residents during their primary,
specialty, and subspecialty rotations.
The Blueprints were conceived as a study aid created by students, for students. In keeping with this

concept, the editors of the current edition of the
Blueprints books have recruited resident contributors
to ensure that the series continues to offer the information and the approach that made the original
Blueprints a success.
Our readers report that Blueprints are useful for
every step of their medical career—from their clerkship rotations and subinternships to a board review for

USMLE Steps 2 & 3. Residents studying for USMLE
Step 3 often use the books for reviewing areas that
were not their specialty. Students from a wide variety
of health care specialties, including those in physician
assistant, nurse practitioner, and osteopathic programs, use Blueprints either as a course companion or
to review for their licensure examinations.
Now in its third edition, Blueprints Family
Medicine has been completely revised and updated to
bring you the most current treatment and management strategies. The feedback we have received from
our readers has been tremendously helpful in guiding
the editorial direction of the third edition. We are
grateful to the hundreds of medical students and residents who have responded with in-depth comments
and highly detailed observations.
Martin S. Lipsky
Mitchell S. King


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Acknowledgments
W

e would like to thank all of those who helped

us make the third edition of this book possible.
If our readers feel this book contributes to their understanding of family medicine it is largely due to the
many people who played a role in making this new
edition possible.
Given all the hair that Olympia Asimacopoulos,
Donna Brown, and Karen Morris tore out in working
on this project, we thank them for their assistance in
organizing the book and in organizing the authors!
Ellen Shellhouse, Jeannette Gawronski, and the library
staff at the University of Illinois College of Medicine,

Rockford deserve our thanks for tracking down references and assuring that the book accurately reflects the
latest guidelines and facts.
Finally and most importantly, both of us gratefully
acknowledge the support of our family and friends,
especially our wives, Darice Zabak-Lipsky and Jackie
King. Without Jackie and Darice, this and other projects would not be possible.
Martin S. Lipsky
Mitchell S. King


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Abbreviations
AC
ACE
ACL
ACOG
ACS
AD

AD/HD
ADA
ADLs
AFP
AGUS
AIDS
AIS
AK
ALS
ALT
ANA
ANCA
AOM
ARB
AROM
ASCUS
ASO
AST
AV
BAER
BCC
BMD
BMI
BNP
BP
BPH
BPV
BRAT
BUN
BV

BZD
CAD
CAP
CBC
CFS

acromioclavicular
angiotensin converting enzyme
anterior cruciate ligament
American College of Obstetricians and
Gynecologists
American Cancer Society
atopic dermatitis
attention deficit/hyperactivity disorder
American Diabetes Association
activities of daily living
alpha fetoprotein
atypical glandular cells of undetermined
significance
acquired immunodeficiency syndrome
adenocarcinoma in situ
actinic keratosis
amyotrophic lateral sclerosis
alanine aminotransferase
antinuclear antibody
antineutrophil cytoplasmic antibody
acute otitis media
angiotensin receptor blocker
active range of motion
atypical squamous cells of undetermined

significance
antistreptolysin O
aspartate aminotransferase
arteriovenous
brainstem auditory evoked response
basal cell carcinoma
bone mineral density
body mass index
brain natriuretic peptide
blood pressure
benign prostatic hypertrophy
benign positional vertigo
bananas, rice, applesauce, and toast
blood urea nitrogen
bacterial vaginosis
benzodiazepine
coronary artery disease
community-acquired pneumonia
complete blood count
chronic fatigue syndrome

CHF
CMV
CNS
COPD
COX-2
CPAP
CPK
CPR
CSF

CSOM
CT
CVA
DBP
DEXA
DHE
DHEA-S
DJD
dsDNA
DSM-IV

congestive heart failure
cytomegalovirus
central nervous system
chronic obstructive pulmonary disease
cyclooxygenase-2
continuous positive airway pressure
creatine phosphokinase
cardiopulmonary resuscitation
cerebrospinal fluid
chronic suppurative otitis media
computed tomography
cerebrovascular accident
diastolic blood pressure
dual-energy x-ray absorptiometry
dihydroergotamine
dehydroepiandrosterone sulfate
degenerative joint disease
double-stranded DNA
Diagnostic and Statistical Manual of Mental

Disorders, fourth edition
DTaP
diphtheria, tetanus, acellular pertussis
DTP
diphtheria, tetanus, pertussis
DTs
delirium tremens
DUB
dysfunctional uterine bleeding
DUI
driving under the influence
DVT
deep venous thrombosis
EBV
Epstein–Barr virus
ECG
electrocardiogram
EDD
estimated date of delivery
EEG
electroencephalogram
EGD
esophagastroduodenoscopy
ELISA
enzyme-linked immunosorbent assay
ENT
ear-nose-throat
ERCP
endoscopic retrograde
cholangiopancreatography

ESR
erythrocyte sedimentation rate
ET
essential tremor
FDA
Food and Drug Administration
FSH
follicle-stimulating hormone
FTA-Abs fluorescent treponemal antibody absorption
FTT
failure to thrive
G6PD
glucose-6-phosphate dehydrogenase
GDM
gestational diabetes mellitus
GERD
gastroesophageal reflux disease


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Abbreviations • xv

GFR
GGT
GI
GnRH
HC
hCG
Hct

HCTZ
HDL
HEPA
Hib
HIV
HNKDC
HPF
HPV
HRT
HSV
HTN
IADLs
IBD
IBS
ICU
IF
IgA
IgE
IM
INR
IPV
ISA
IUD
IV
IVP
JVD
KOH
LB
LDL-C
LEEP

LES
LFT
LH
LH-RH
LMP
LN
LRI
LTC
LVH
LVSD
MAOI
MASH
MCTD
MCV
MDI

glomerular filtration rate
gamma-glutamyl transferase
gastrointestinal
gonadotropin-releasing hormone
homocysteine
human chorionic gonadotropin
hematocrit
hydrochlorothiazide
high-density-lipoprotein cholesterol
high-efficiency particulate air
H. influenzae type b
human immunodeficiency virus
hyperosmolar nonketotic diabetic coma
high-power field

human papillomavirus
hormone replacement therapy
herpes simplex virus
hypertension
instrumental activities of daily living
inflammatory bowel disease
irritable bowel syndrome
intensive care unit
intrinsic factor
immunoglobulin A
immunoglobulin E
intramuscular
international normalized ratio
injectable polio vaccine
intrinsic sympathomimetic activity
intrauterine device
intravenous
intravenous pyelogram
jugular venous distention
potassium hydroxide (stain)
Lewy body
low-density-lipoprotein cholesterol
loop electroexcision procedure
lower esophageal sphincter
liver function test
luteinizing hormone
luteinizing hormone–releasing hormone
last menstrual period
lymph node
lower respiratory tract infection

long-term-care facility
left ventricular hypertrophy
left ventricular systolic dysfunction
monoamine oxidase inhibitor
medications, allergies, surgeries, and
hospitalizations
mixed connective tissue disease
mean corpuscular volume
metered-dose inhaler

MI
MMR
MMSE
MRA
MRCP
MRI
MS
MSAFP
MVA
NCAA
NGU
NH
NMDA
NNRTI
NRTI
NSAID
NTD
OCD
OCPs
OME

OPV
OTC
PAC
PCOS
PCR
PCV
PD
PE
PEF
PI
PID
PMI
PO
PPD
PPE
PPI
PPV
PR
PROM
PSA
PT
PTCA
PTT
PTU
PVC
PVD
PVL
PVR
RA
RAIU

RAST

myocardial infarction
measles, mumps, rubella (vaccine)
Mini Mental Status Examination
magnetic resonance angiography
magnetic resonance
cholangiopancreatography
magnetic resonance imaging
multiple sclerosis
maternal serum alpha fetoprotein
motor vehicle accident
National Collegiate Athletic Association
nongonococcal urethritis
nursing home
N-methyl-D-aspartate
nonnucleoside reverse transcriptase inhibitor
nucleoside reverse transcriptase inhibitor
nonsteroidal anti-inflammatory drug
neural tube defect
obsessive compulsive disorder
oral contraceptive pills
otitis media with effusion
oral polio vaccine
over the counter
premature atrial contraction
polycystic ovarian syndrome
polymerase chain reaction
pneumococcal conjugate vaccine
Parkinson disease

pulmonary embolus
peak expiratory flow
protease inhibitor
pelvic inflammatory disease
point of maximal impulse
by mouth
purified protein derivative
preparticipation health examination
proton pump inhibitor
pneumococcal polysaccharide vaccine
per rectum
passive range of motion
prostate-specific antigen
prothrombin time
percutaneous transluminal coronary
angioplasty
partial thromboplastin time
propylthiouracil
premature ventricular contraction
peripheral vascular disease
plasma viral load
postvoid residual
rheumatoid arthritis
radioactive iodine uptake
radioallergosorbent test


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xvi • Abbreviations

REM
ROM
RPR
RSV
SAH
SBE
SBP
SC
SD
SHEP
SIDS
SIL
SK
SLE
SLR
SSRI
STD
T3
T4
TB
TBG
TCA
Td
TIA

rapid-eye-movement (sleep)
recurrent otitis media
rapid plasma reagin (test)
respiratory syncytial virus

subarachnoid hemorrhage
subacute bacterial endocarditis
systolic blood pressure
subcutaneous
standard deviation
Systolic HTN in the Elderly Program
sudden infant death syndrome
squamous intraepithelial lesion
seborrheic keratosis
systemic lupus erythematosus
straight leg raising
selective serotonin reuptake inhibitor
sexually transmitted disease
triiodothyronine
thyroxine
tuberculosis
thyroxine-binding globulin
tricyclic antidepressant
tetanus-diphtheria vaccine
transient ischemic attack

TIBC
TIg
TM
TMJ
TMP/SMX
TNF
TRH
TSH
UA

UI
URI
US
USDHHS
USPHS
UTI
UV
V/Q
VCUG
VDRL
VZIG
WBC
WIC

total iron-binding capacity
tetanus immunoglobulin
tympanic membrane
temporomandibular joint
trimethoprim/sulfamethoxazole
tumor necrosis factor
thyrotropin-releasing hormone
thyroid-stimulating hormone
urinalysis
urinary incontinence
upper respiratory tract infection
ultrasound
U.S. Department of Health and Human
Services
U.S. Public Health Service
urinary tract infection

ultraviolet
ventilation/perfusion
voiding cystourethrogram
Venereal Disease Research Laboratory
varicella zoster immune globulin
white blood cell
Special Supplemental Nutrition Program
for Women, Infants, and Children


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Part I Principles of Family Medicine
Chapter

1

Elements of
Family Medicine

DEFINITIONS
Family medicine is a medical specialty that provides
continuing and comprehensive health care for individuals and families. It is a broad specialty that integrates
the biological, clinical, and behavioral sciences. The
scope of family medicine encompasses all ages, sexes,
organ systems, and disease entities. The specialty
evolved as an enhanced expression of general medical
practice and is uniquely defined in the family context.
A family physician is a practitioner in the field of
family medicine. At present, family physicians complete a 3-year residency in family practice. This prepares them to manage the broad scope of problems

involving patients, from newborns to the elderly. On
average, about 15% of a family physician’s practice is
devoted to the care of infants and children. Some
family physicians, about 25%, also deliver babies.
Family medicine is one of the primary care specialties. Currently, the most widely accepted definition of primary care is the one developed by the
National Academy of Sciences Institute of Medicine
in 1996. It defined primary care as the provision of
integrated, successful health care services by clinicians who are accountable for addressing a large
majority of personal health care needs, helping to sustain partnerships with patients, and practicing in the
context of family and community. In addition to family medicine, general pediatrics and general internal
medicine are considered primary care fields.

HISTORY OF FAMILY MEDICINE
After World War II, the United States saw a rapid
movement toward specialization among physicians.
In 1938, about 20% of U.S. physicians designated
themselves as specialists and 80% considered themselves generalists. In contrast, by 1970, about 75% of

physicians considered themselves specialists. By the
late 1960s, this trend toward specialization was noted
and the public perceived a need for generalist physicians who could coordinate care and serve as the entry
point or “first contact” into the health care system.
The findings of three commissions—the Folsom
Report, the Mills Report, and the Willard Report,
referred to by the names of their chairmen—were
published in 1966. These reports all affirmed the need
for general practitioners who could ensure the integration and continuity of all medical services for patients.
In 1969, family practice was approved as the 20th
medical specialty and the American Board of Family
Practice was established. From these early beginnings,

family medicine has grown to become the second
largest specialty in the United States, with over 400 residency programs and more than 90,000 physicians, students, and resident members of the American Academy
of Family Physicians. Practitioners in family medicine
care for more patients each day than do physicians in
any other specialty. In the year 2004, family and general
physicians managed about one-quarter of patient visits
or more than 200 million of the 910 million patient visits made in the United States. In comparison, general
internists accounted for 16% of patient visits and pediatricians 13%. Of patients making visits to family physicians, only 6.3% required referral to another discipline.

COMPONENTS OF FAMILY
MEDICINE
A successful family physician incorporates several
components of patient care, including accessibility,
medical diagnosis and treatment, comprehensiveness,
communication, coordination of care, continuity of
care, and patient advocacy. The family physician is
often the patient’s first contact and is available if the
patient has an urgent or chronic problem. Accessibility
1


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2 • Blueprints Family Medicine
includes being financially affordable and geographically accessible.
As the patient’s first contact, the family physician
must be knowledgeable about a broad array of diseases
and have the skill and judgment to determine the
scope, site, and pace of medical evaluation. The family
physician typically provides a broad range of services,

including acute and chronic disease management in
the office, hospital, or nursing home, or by telephone.
Family medicine incorporates the biological perspective as well as the social and psychological aspects of
care. The large number of visits to family physicians
for psychosocial and behavioral issues underscores the
relationship between emotion and illness.
Communication and coordination of care are also
essential elements. These topics are covered in greater
detail in Chapter 2.
Continuity is an important component of family
medicine. Family physicians typically develop longterm relationships with patients, maintain longitudinal
records of patients’ problems, and promote healthy
lifestyles. These require that the physician see each
patient for acute episodes of illness as well as periodically for health maintenance. Continuity nourishes a
trusting long-term relationship between patient and
physician. This relationship is a valuable tool for
improving patient adherence to treatment recommendations. Assessing disease risk, screening for illness, and
promoting health to prevent disease and disability are
inherent parts of a successful continuous relationship.
Early intervention—through health education, behavioral change, and the promotion of a healthy lifestyle—
can serve to prevent morbidity and mortality.
Finally, advocacy is a key responsibility for the
family physician. Once a patient has been accepted
into his or her practice, the family physician must
serve as the patient’s advocate. In addition, the physician is responsible for educating the patient about
treatment outcomes and prognoses, incorporating the
patient’s preferences into treatment plans, and
assuming responsibility for the patient’s total care
during times of health and illness. This includes helping the patient to make wise health care decisions and
to find the needed health care resources.

MEDICAL HOME
A new model of medical care that embraces the components of family medicine is the concept known as
the “Medical Home.” Also known as the Patient
Centered Medical Home (PCMH), the PCMH is
defined as comprehensive primary care that facilitates partnerships between patients and physicians
by connecting each individual to a personal physician who is trained to provide continuous and comprehensive care. The personal physician serves as
the patient’s first contact and assumes responsibility for coordinating and integrating an individual’s
care across the entire spectrum of health care
providers, agencies, and facilities with the goal to
enhance access while maintaining a focus on quality and safety.

KEY POINTS
• Family medicine is a medical specialty that
provides continuing and comprehensive
health care for individuals and families, including all ages, sexes, organ systems, and disease
entities.
• Practitioners in family medicine care for more
patients each day than do physicians in any
other medical specialty.
• A successful family physician incorporates
several components into caring for his or her
patients, including accessibility, medical diagnosis and treatment, comprehensiveness,
communication, coordination of care, continuity of care, and patient advocacy.
• Continuity nourishes a trusting long-term
relationship between patient and physician.
This relationship is a valuable tool for improving patient adherence to treatment recommendations.


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Chapter

2

Patient
Communication and
Coordination of Care

Despite advances in technology, effective communication remains the family physician’s most powerful diagnostic tool. An old adage is that up to 90% of the time,
the diagnosis is made from a complete and accurate history. The key to obtaining a good history is the ability to
communicate effectively and empathetically with
patients. Good doctor–patient communication also fosters effective treatment. The rule of thirds applies to
patient adherence: that is, approximately one-third of
the patients will follow recommendations, another onethird will partially follow recommendations, and the
remaining one-third will ignore most recommendations.
The ability to explain clearly, in lay terms, the results of
a test and the available treatment options increases the
likelihood that a patient will accept the diagnosis, adhere
to the treatment, and return for follow-up. Finally, good
communication reduces the risk of malpractice.
In addition to patient–physician communication,
the family physician plays a critical role in coordinating patient care. This requires effective communication, both oral and written, with peers, co-workers,
and ancillary personnel.

THE PATIENT INTERVIEW
The goal of the patient interview is to obtain information, establish good rapport, and provide an opportunity to educate patients about their health. An
important part of this process is projecting a nonjudgmental attitude and creating an environment that
allows the patient to feel comfortable and secure
about sharing personal information. Establishing good

eye contact and maintaining a relaxed manner are
important. Nodding occasionally and periodically
summarizing what you have been told allow the
patient to correct information that you may have misunderstood. Closing the doors of the examination
room, minimizing discussion about patients in open
areas, and providing written information in the waiting room that explains office procedures are steps that
can help to create an atmosphere of confidentiality.

second, it helps provide a global view of their medical
and psychological issues. It also allows patients to feel
more in control and comfortable with providing personal information. Despite this time-honored principle,
numerous studies show that physicians interrupt
patients less than 10 seconds into their opening remarks.

TARGETED QUESTIONS
Once a patient expresses his or her chief complaint
or the reason for the visit, it is important to start narrowing down the scope of the problem by asking
more specific questions. The mnemonic PQRST in
Box 2-1 can serve to guide targeted questions for pain
symptoms.
New patients must be asked about their medical,
surgical, family, and social history. Medications and
allergies should be reviewed and a review of systems
conducted. If time is limited, obtaining a MASH history (of medications, allergies, surgeries, and hospitalizations) is a way to acquire key information quickly.

PHYSICAL EXAMINATION
Communication can be further enhanced during the
physical examination. Ensuring that the patient’s
physical needs are met (by having a comfortable
room temperature and providing appropriate draping) is important for establishing rapport. Subtle

clues can also be gleaned from the patient’s reaction
during an examination. For example, a woman or
child with an unusual bruise or burn who gives an
evasive answer may very well be the victim of abuse.

PATIENT COUNSELING
Many patients have aspects of their lives that they
want to change. Counseling patients about healthy
᭿ BOX 2-1 The PQRST Mnemonicedical
What provokes and palliates the pain?
What is the quality of the pain?

OPEN-ENDED QUESTIONS

Does the pain radiate?

The patient interview should begin with an openended question. This has two effects: first, it allows
patients to express what they feel is important and,

What is the severity of the pain?
What is the temporal course of the discomfort?
3


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4 • Blueprints Family Medicine
᭿ TABLE 2-1 Patients’ Stages of Readiness and Smoking Cessation
Stage

Example of Intervention

Precontemplation

Not considering quitting smoking

Ask about smoking

May not believe they can quit

Ascertain knowledge about risks

Do not believe they are susceptible to severe illness
Contemplation

Considering quitting

Encourage patients to quit

Recognize dangers of smoking

Provide materials about quitting

May be upset about failed attempt
Preparation

Ready to make change by setting goal

Encourage patients to set a quit date
Offer nicotine replacement or other appropriate

therapy

Action

Are in the cessation process

Provide support and positive reinforcement
Discuss relapse strategies

Maintenance

Maintain former-smoker status

Continue support and reinforcement
Be available for help if relapse occurs

lifestyle behaviors requires a systematic approach
that evaluates the patient’s readiness for change and
offers information appropriate to his or her frame of
mind. A commonly used approach to behavioral
counseling is the “stages of readiness” model shown in
Table 2-1, which uses smoking cessation as an example. This model is also widely used to help patients
start exercising and changing their diets.

ELDERLY PATIENTS
Communicating with elderly patients poses special
challenges due to problems such as hearing loss and
cognitive impairment. If you suspect a hearing loss, it
is important to sit directly in front of the patient and
to speak loudly (do not shout) and clearly. Many

hearing-impaired patients unconsciously read lips.
Women who work with elderly patients can help by
making a special effort to wear lipstick, and men
should be careful to ensure that their facial hair is
neatly trimmed and does not obscure the mouth.
Patients with hearing aids should be instructed to
bring them to their office appointments. For cognitively impaired patients, having a family member or
other responsible individual present is critical to
obtaining an accurate history and planning treatment.
Another key issue to address with elderly patients
is advanced directives. These directives are a set of
instructions, usually written, intended to allow a
patient’s current preferences to shape medical decisions

during a future period of incompetence. All patients
admitted to a hospital or long-term-care facility
should be asked about their treatment preferences in
an open fashion should they become unable to speak
for themselves. If patients designate a durable power
of attorney for health care, it is important that they
be encouraged to discuss their treatment preferences
with the person who will have this responsibility. The
office setting provides the opportunity to initiate discussions about advanced directives when the patient
is not acutely ill or otherwise distressed.

INTERPRETERS
Family physicians may encounter patients who do
not speak English. Hospitals are required by federal
law to offer patients competent interpreters. Patients
may decline using an outside interpreter and prefer a

family member or friend. However, it is often preferable to use a competent and unbiased interpreter to
assure that information is being shared completely.
Family members may add their own biases to the
translation, which can negatively affect the ability to
obtain an accurate history. For example, a husband
interpreting for his wife may not be willing to tell the
interviewer about her history of a mental disorder, or
a family member who is not familiar with medical
terminology may translate information incorrectly.
Finally, an underage child should not interpret for a
parent or older family member.


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Chapter 2 / Patient Communication and Coordination of Care • 5
All physicians’ offices should have contact numbers for interpreter agencies or qualified individual
interpreters. In the case of deaf patients, a statelicensed sign language interpreter may have to be
called in. A useful way to know whether an interpreter will be needed is if the patient enlists a proxy
in calling for an appointment. Instruct the receptionist to be alert for such situations and to ask why the
patient is not making the call.

INFORMED CONSENT
Patients undergoing surgery or other invasive medical
treatments must grant informed consent. The elements of informed consent include describing the
nature of the patient’s condition and its consequences,
such as whether it is life threatening or potentially disabling. Recommended treatment and alternatives
should be reviewed, including benefits, risks, costs, discomfort, and side effects. Finally, possible outcomes of
nontreatment—including benefits, risks, discomfort,
costs, and side effects—should be discussed. Informed

consent is one of the cornerstones of preserving
patient autonomy and is an important aspect of
patient communication and treatment.

COORDINATION OF CARE
“Coordination of care” refers to the organization of
health care services in order to meet the needs of the
patient. A key element of this is the referral of the
patient to a specialist. Although approximately 95%
of patient problems seen in the outpatient family
practice setting can be handled by a family physician,
5% will need specialist attention.

In addition to written information, it is often helpful to call the specialist directly. This gives the family
physician the opportunity to discuss the patient with
the specialist and allows the specialist to ask specific
questions or to request information (e.g., old records)
that may be helpful in preparing for the consultation.

SPECIALIST RESPONSIBILITIES
It is the responsibility of the specialist to see any
referred patient in a timely fashion. Emergency consultations should be held that day, urgent consultations usually within 24 to 48 hours, and nonurgent
consultations within 1 to 2 weeks.
Specialists should attempt to answer any specific
questions and offer treatment options if this is
requested by the family physician. Specialists should
then send a follow-up letter and, when necessary, discuss on phone their findings and recommendations as
well as any treatments that might have been initiated.

CASE MANAGEMENT

The family physician often has the difficult but critically important task of coordinating information from
several different health care providers, all of whom are
participating in the care of one patient. In this situation, it becomes critical that the family physician provide oversight, so that medications and treatments do
not interact adversely with one another. In addition,
the family physician should review with the patient
the findings of other health care providers and specialists and make sure he or she understands and agrees
with the treatment options. Often, patients with complex care issues need the support of a trusted personal
physician to help guide them through the complexities
of modern-day health care.

RESPONSIBILITIES FOR A
REFERRING PHYSICIAN
The family physician is responsible for handling several
aspects of the referral process, including selection of
the desired specialist. The patient may request a certain specialist or may rely on the advice of the family
physician for this choice. The family physician must
provide required referral information and specify
whether he or she wants the specialist to evaluate and
treat or to limit the input to a consultation and recommendations about the patient’s condition. Referrals
should also specify the number of visits and treatments. In this regard, the physician should work with
the patient’s insurance guidelines as to preauthorization and address in-network versus out-of-network
referrals. In the referral, the family physician should
provide the consultant with information regarding the
nature of the complaint as well as important elements
of the history, physical examination, and previously
obtained test results. More importantly, the family
physician should pose any specific questions he or she
wants to have answered by the specialist.

KEY POINTS

• The rule of thirds applies to patient adherence, that is approximately one-third of
patients will follow recommendations,
another one-third will partially follow the recommendations, and remaining one-third will
ignore most recommendations.
• The goal of the patient interview is to obtain
information and to establish good rapport; it
should begin with an open-ended question.
• Communicating with elderly patients provides
special challenges that must be addressed.
• About 95% of patient problems seen in an
outpatient family practice setting can be handled by a family physician, 5% will need specialist attention.


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Chapter

3

Screening

Preventive health care and screening for various diseases are parts of routine medical care at all ages.
Disease prevention can be primary, secondary, or tertiary. Primary prevention seeks to prevent a disease or
condition from developing. An example of primary
prevention is vaccination, whereby many infectious
diseases are prevented through immunization.
Secondary prevention involves early detection of the
disease and is synonymous with screening to limit the
effects of the disease. Examples of screening tests are
mammography and testing for occult fecal blood (for

early detection of breast and colon cancers, respectively), in the hope that early intervention can lead to
a cure. Another example of screening is cholesterol
and blood pressure testing in order to lower risk for
future cardiovascular disease. Included within the
context of primary and secondary prevention are
screening and counseling for behaviors such as smoking or substance abuse that affect an individual’s
health.
“Tertiary prevention” refers to rehabilitation as
well as efforts to limit complications of a disease after
it has developed, such as an exercise program in a
patient who recently underwent coronary artery
bypass surgery.

CRITERIA FOR USE OF
SCREENING TESTS
In order for a screening test to be of value for routine
use in patient care, several criteria should be met.
First, the disease or condition screened for must be
common and have a sufficient impact on an individual’s health to justify the risks and costs associated
with the testing. Second, effective prevention or
treatment measures must be available for the condition, and earlier detection must improve clinical outcome. The screening and treatment benefits should
outweigh any risks associated with testing and therapy. Finally, there must be a screening test that is
readily available, safe, and accurate. The overall costeffectiveness of a screening program will be a factor
in terms of insurers’ and individuals’ willingness to pay
for the test or procedure. The availability and acceptability of the test affects whether or not patients will
actually undergo screening. For example, an individual
6

may refuse colonoscopy because he or she finds the
procedure distasteful.

TEST CHARACTERISTICS
Screening tests should be accurate at detecting the
intended disease or condition. Accuracy is a term that
considers several different testing measures—namely,
sensitivity, specificity, positive predictive value, and
negative predictive value (Table 3-1). Sensitivity is a
measure of the percentage of cases that a test is able

᭿ TABLE 3-1 Determining Sensitivity and

Specificity

Disease
Present

Disease
Absent

Positive test

a

b

Negative test

c

d

Sensitivity

a/a + c

Specificity

d/b + d

᭿ TABLE 3-2 Calculating Predictive

Values

Disease
Present

Disease
Absent

Positive
test

9500

4500

Negative
test

500

85,500

Sensitivity
9500/9500 +
500 = 95%

positive predictive
value
9500/9500 +
4500 = 68%

Specificity
85,500/4500 +
85,500 = 95%

negative predictive
value
85,500/500 +
85,500 = 99.4%

Total number of patients = 100,000.


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Chapter 3 / Screening • 7
to detect. Specificity measures the percentage of
patients testing negative who do not have the disease.
These test characteristics are factors in determining

the value of screening tests. Desirable characteristics
of screening tests include high levels of both sensitivity and specificity.
By combining disease prevalence with these test
characteristics, the clinician can determine the predictive values of a screening test. The positive predictive
value is the percentage likelihood that a patient with a
positive test actually has the disease; conversely, a negative predictive value indicates that a person with a negative test is disease-free. Disease prevalence critically
affects the predictive value, as shown by the following

example of screening for a disease with a prevalence of
10% in 100,000 patients, using a test that is 95% sensitive and 95% specific. In this instance, the positive
and negative predictive values for the test would be
68% and 99.4%, respectively (Table 3-2).
Thus, for every 9500 cases detected, an additional
4500 patients would have to undergo additional testing to determine that they were disease-free. However,
a negative test provides 99.4% assurance that the
patient is truly disease-free. For diseases with a potentially fatal outcome and where effective treatments are
available, this screening would be acceptable. However,
if the prevalence of the disease were 1% instead of
10%, the positive predictive value would fall to 16%

᭿ TABLE 3-3 Grade Definitions and Suggestions for Practice
Grade

Definition

Suggestions for Practice

A

The USPSTF recommends the service.

There is high certainty that the net
benefit is substantial

Offer or provide this service

B

The USPSTF recommends the service.
There is high certainty that the net
benefit is moderate or there is moderate
certainty that the net benefit is moderate
to substantial

Offer or provide this service

C

The USPSTF recommends against routinely
providing the service. There may be
considerations that support providing the
service in an individual patient. There is
at least moderate certainty that the net
benefit is small

Offer or provide this service only if other
considerations support the offering or
providing the service in an individual
patient

D

The USPSTF recommends against the
service. There is moderate or high
certainty that the service has no net
benefit or that the harms outweigh the
benefits

Discourage the use of this service

I

The USPSTF concludes that the current
evidence is insufficient to assess the
balance of benefits and harms of the
service. Evidence is lacking, of poor
quality, or conflicting, and the balance
of benefits and harms cannot be
determined

Read the clinical considerations section
of the USPSTF Recommendation
Statement. If the service is offered,
patients should understand the
uncertainty about the balance of benefits
and harms

The USPSTF updated its definitions of the grades it assigns to recommendations and now includes “suggestions for practice” associated
with each grade. The USPSTF has also defined levels of certainty regarding net benefit. These definitions apply to USPSTF
recommendations voted on after May 2007.
Quality of Evidence

The USPSTF grades the quality of the overall evidence for a service on a three-point scale (good, fair, poor):
Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess
effects on health outcomes.
Fair : Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or
consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.
Poor : Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in
their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.
From U.S. Preventive Services Task Force Grade Definitions. Rockville, MD: Agency for Healthcare Research and Quality; 2008. Available
at: />