Graber and Wilbur's Family Medicine

Examination and Board Review, Fifth

Edition Brigit Ray
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 Graber and Wilbur's
Family Medicine
Examination and Board Review
5TH EDITION

• Covers every topic on the Family

Medicine Boards

• Great for USMLE® Step 3 review

• Features hundreds of clinical cases

covering all specialty areas

• Includes Quick Quizzes, Clinical Pearls,

and Learning Objectives

MARK A. GRABER
BRIGIT E. RAY
JASON K. WILBUR
 Graber and Wilbur’s
FAMILY MEDICINE
EXAMINATION
& BOARD REVIEW

FM.indd 1 29-11-2019 18:41:49

 Graber and Wilbur’s
FAMILY MEDICINE
EXAMINATION
& BOARD REVIEW
FIFTH EDITION
Editors

Mark A. Graber, MD, MSHCE, FACEP

Clinical Professor
Departments of Family Medicine and Emergency Medicine
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa

Brigit E. Ray, MD, MME

Clinical Assistant Professor
Department of Family Medicine
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa

Jason K. Wilbur, MD, FAAFP

Clinical Professor
Department of Family Medicine
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa

New York/Chicago/San Francisco/Athens/London/Madrid/Mexico City/

New Delhi/Milan/Singapore/Sydney/Toronto

FM.indd 3 29-11-2019 18:41:52

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 To the people who make Family Medicine happen. Jogjakarta:
Dr. Mora Claramita, Dr. Adi Heru Husodo, Dr. Wahyudi Istiono,
and Dr. Fitriana Murriya. Moscow: Professor Dr. Gregorii Efimovich
Roitberg, Dr. Olga Sharkun, Dr. Irina Slastnikova, Dr. Janna Dorosh,
and Professor Timothy O’Connor. Haiphong: Dr. Hùng Nguyễn Văn,
Dr. Linh Nguyễn, and Dr. Nguyễn Thuý Hiếu.
—MAG

To my parents, Bill and Bonnie Ray, for always loving, supporting, and
encouraging me to follow my dreams to become a family physician.
To all of my Family Medicine and education mentors including: Drs.
George Bergus, Rick Dobyns, Jason Wilbur, Bob Tallitsch, Jeff Pettit,
and Marcy Rosenbaum. Your guidance and support along this journey
have shaped me into the family physician educator I have become!
—BER

To my many mentors in Family Medicine, including Drs. John Ely,

Mark Graber, Paul James, Gerald Jogerst, and Barcey Levy; and to Dr.
Kate Thoma and all the Family Medicine program directors and faculty
members who work tirelessly (and mostly thanklessly) to develop the
next generation of excellent family doctors. Keep teaching; keep leading!
—JKW

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 Contents
Contributors..............................................................................................ix
Preface..................................................................................................... xiii
A Few Words on Studying and Taking the Board Examination...... xv
1 Emergency Medicine................................................................... 1
2 Cardiology......................................................................................43
3 Pulmonology.............................................................................. 105
4 Allergy and Immunology....................................................... 141
5 Nephrology................................................................................. 150
6 Hematology and Oncology................................................... 183
7 Gastroenterology...................................................................... 211
8 Infectious Diseases................................................................... 253
9 HIV/AIDS...................................................................................... 281
10 Endocrinology........................................................................... 296
11 Rheumatology........................................................................... 330
12 Orthopedics and Sports Medicine..................................... 364
13 Pediatrics..................................................................................... 395
14 Adolescent Medicine............................................................... 437
15 Obstetrics and Women’s Health.......................................... 451
FM.indd 7
16 Men’s Health............................................................................... 501
17 Dermatology.............................................................................. 525
18 Neurology.................................................................................... 551
19 Ophthalmology......................................................................... 585
20 Otolaryngology......................................................................... 607
21 Care of the Older Patient........................................................ 631
22 Care of the Surgical Patient................................................... 662
23 Psychiatry.................................................................................... 693
24 Nutrition and Herbal Medicine............................................ 729
25 Substance Use Disorders....................................................... 742
26 Ethics............................................................................................. 763
27 End-of-Life Care......................................................................... 774
28 Evidence-Based Medicine..................................................... 788
29 Patient-Centered Care............................................................. 800
30 Final Examination..................................................................... 813
Index........................................................................................................841
vii
29-11-2019 18:41:52
 Contributors
Emad Abou-Arab, MD, CME Guru V. Bhoojhawon, MBBS, MD, FAAP
Clinical Assistant Professor Clinical Associate Professor
Department of Family Medicine Department of Pediatrics
Roy J. and Lucille A. Carver College of Medicine Roy J. and Lucille A. Carver College of Medicine
University of Iowa University of Iowa
Iowa City, Iowa Iowa City, Iowa
10. Endocrinology 13. Pediatrics

Daniel M. Anderson, DO
Nicholas R. Butler, MD, MBA
Senior Associate Consultant
Clinical Associate Professor
Department of Neurology
Department of Family Medicine
Mayo Clinic Health System Franciscan Healthcare
Roy J. and Lucille A. Carver College of Medicine
La Crosse, Wisconsin
University of Iowa
18. Neurology
Iowa City, Iowa
A. Ben Appenheimer, MD 21. Care of the Older Patient
Clinical Assistant Professor
Department of Internal Medicine Rachel R. Butler, MD
Division of Infectious Diseases Clinical Assistant Professor
Roy J. and Lucille A. Carver College of Medicine Department of Internal Medicine
University of Iowa Division of Pulmonary, Critical Care, and Occupational
Iowa City, Iowa Medicine
8. Infectious Diseases Roy J. and Lucille A. Carver College of Medicine
9. HIV/AIDS University of Iowa
Iowa City, IA
Stacey Appenheimer, MD 3. Pulmonology
Clinical Assistant Professor
Department of Family Medicine
Meghan Connett, MD
Roy J. and Lucille A. Carver College of Medicine
Clinical Assistant Professor
University of Iowa
Department of Family Medicine
Iowa City, Iowa
Roy J. and Lucille A. Carver College of Medicine
14. Adolescent Medicine
University of Iowa
Iowa City, Iowa
Olivia E. Bailey, MD
15. Obstetrics and Women’s Health
Clinical Associate Professor
Department of Emergency Medicine
Roy J. and Lucille A. Carver College of Medicine Dustin Z. DeYoung, MD
University of Iowa Psychiatrist
Iowa City, Iowa Behavioral Health Associates
1. Emergency Medicine University of California, Los Angeles
Los Angeles, California
Maresi Berry-Stoelzle, MD
Department of Family Medicine Austin R. Fox, MD
Roy J. and Lucille A. Carver College of Medicine Department of Ophthalmology and Visual Sciences
University of Iowa University of Iowa
Iowa City, Iowa Iowa City, Iowa
6. Hematology and Oncology 19. Ophthalmology
ix

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 x CONTRIBUTORS

Mark A. Graber, MD, MSHCE, FACEP Aaron R. Kunz, DO, MA, MME
Clinical Professor Clinical Assistant Professor
Departments of Family Medicine and Emergency Medicine Department of Family Medicine
Roy J. and Lucille A. Carver College of Medicine Roy J. and Lucille A. Carver College of Medicine
University of Iowa University of Iowa
Iowa City, Iowa Iowa City, Iowa
1. Emergency Medicine 16. Men’s Health
2. Cardiology
7. Gastroenterology Victoria Linares, MD
12. Orthopedics and Sports Medicine CAQ Geriatric Medicine
26. Ethics Clinical Assistant Professor
28. Evidence-Based Medicine Department of Primary Care
30. Final Examination Loyola University Medical Center
Maywood, IL
Erin Hayward, MD 21. Care of the Older Patient
Clinical Assistant Professor
Department of Family Medicine Britt L. Marcussen, MD
University of Iowa CAQ Sports Medicine
Iowa City, Iowa Clinical Associate Professor
22. Care of the Surgical Patient Department of Family Medicine
Roy J. and Lucille A. Carver College of Medicine
Priyanka Iyer, MD, MPH University of Iowa
Clinical Associate Professor Iowa City, Iowa
Department of Internal Medicine 12. Orthopedics and Sports Medicine
Division of Immunology
University of Iowa Clinics and Hospitals
Denise A. Martinez, MD
Iowa City, Iowa
Clinical Associate Professor
11. Rheumatology
Associate Dean for Diversity, Equity, and Inclusion
Department of Family Medicine
Monika Jindal, MD
Roy J. and Lucille A. Carver College of Medicine
Instructor, University of Colorado School of Medicine
University of Iowa
Department of Psychiatry
Iowa City, Iowa
Department of Family Medicine
29. Patient-Centered Care
Denver Health Medical Center
Denver, Colorado
23. Psychiatry Patrick J. McCarthy, MD, MME
Assistant Professor
Nicholas H. Kluesner, MD, FACEP Section of Hospital Medicine, Department of Pediatrics
Associate Medical Director Medical College of Wisconsin/Children’s Hospital of
Department of Emergency Medicine Wisconsin
UnityPoint Health – Des Moines Milwaukee, Wisconsin
Des Moines, Iowa 13. Pediatrics
26. Ethics
Sarah L. Miller, MD, FACEP, FAAP
Jason Kruse, DO Clinical Associate Professor
Department of Internal Medicine Department of Emergency Medicine
Broadlawns Medical Center Roy J. and Lucille A. Carver College of Medicine
Des Moines, Iowa University of Iowa
7. Gastroenterology Iowa City, Iowa
1. Emergency Medicine
Bharat Kumar, MD, MME, FACP, RhMSUS
Department of Internal Medicine and Division of Megan H. Noe, MD, MPH, MSCE
Immunology Instructor
Department of Internal Medicine Department of Dermatology
Roy J. and Lucille A. Carver College of Medicine Brigham & Women’s Hospital
University of Iowa Harvard Medical School
Iowa City, Iowa Boston, Massachusetts
11. Rheumatology 17. Dermatology

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 Contributors xi

Scott R. Owen, MD Melissa L. Swee, MD, MME

Assistant Professor Clinical Assistant Professor
Director of Facial Plastic and Reconstructive Surgery Department of Internal Medicine
Department of Otolaryngology, Head and Neck Surgery Division of Nephrology
University of Iowa Roy J. and Lucille A. Carver College of Medicine
Iowa City, Iowa University of Iowa
20. Otolaryngology Iowa City, Iowa
5. Nephrology
Juan R. Pagan-Ferrer, MD, DABIM, Ger, HPM
Clinical Assistant Professor Teri Thomsen, MD
Department of Internal Medicine Clinical Associate Professor
Roy J. and Lucille A. Carver College of Medicine Department of Neurology
University of Iowa Roy J. and Lucille A. Carver College of Medicine
Iowa City, Iowa University of Iowa
27. End-of-Life Care Iowa City, Iowa
Sanjeev Patil 18. Neurology
Assistant Professor
Department of Rheumatology and Immunology Alka Walter, MBBS, MS
University of Vermont Medical Center Clinical Assistant Professor
Burlington, VT Department of Family Medicine
Roy J. and Lucille A. Carver College of Medicine
Brigit E. Ray, MD, MME University of Iowa
Clinical Assistant Professor Iowa City, Iowa
Department of Family Medicine 22. Care of the Surgical Patient
Roy J. and Lucille A. Carver College of Medicine
University of Iowa Karolyn A. Wanat, MD, FAAD
Iowa City, Iowa Associate Professor
15. Obstetrics and Women’s Health Department of Dermatology
22. Care of the Surgical Patient Medical College of Wisconsin
30. Final Examination Milwaukee, Wisconsin
17. Dermatology
Wendy W. Shen, MD, PhD
Clinical Associate Professor
Department of Family Medicine Jason K. Wilbur, MD, FAAFP
Roy J. and Lucille A. Carver College of Medicine Clinical Professor
University of Iowa Department of Family Medicine
Iowa City, Iowa Roy J. and Lucille A. Carver College of Medicine
4. Allergy and Immunology University of Iowa
Iowa City, Iowa
Tameem A. Shoukih, MD 2. Cardiology
Clinical Assistant Professor 6. Hematology and Oncology
Departments of Emergency Medicine and Pediatrics 16. Men’s Health
Roy J. and Lucille A. Carver College of Medicine 24. Nutrition and Herbal Medicine
University of Iowa 30. Final Examination
Iowa City, Iowa
12. Orthopedics and Sports Medicine Qiang Zhang, MD
Movement Disorder Fellow
Kelly Skelly, MD Department of Neurology and Iowa Neuroscience Institute
Clinical Associate Professor Physician Scientist Training Program
Department of Family Medicine Clinical NeuroScientist Training Program
Roy J. and Lucille A. Carver College of Medicine Roy J. and Lucille A. Carver College of Medicine
University of Iowa University of Iowa
Iowa City, Iowa Iowa City, Iowa
14. Adolescent Medicine 18. Neurology
C. Blake Sullivan, MD
Resident Physician
Otolaryngology – Head and Neck Surgery
University of Iowa
Iowa City, Iowa
20. Otolaryngology

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 Preface
Welcome to the fifth edition of Graber & Wilbur’s Family
Medicine Examination & Board Review book. We hope that you
are as excited to be here as we are. The whole book has been
meticulously updated to not only serve you well as a study guide,
but also to provide you with cutting edge, up-to-date, informa-
tion pertinent to your practice. For those of you who love your
e-readers and tablets, there is a portable, electronic version of
the book. You can also now find us on “AccessMedicine.”
What is new? We have added a succinct guide to the rec-
ommended health maintenances for children and adults, per-
fect for a quick review. We estimate that 30% of the material
has been changed since our last edition: think of hepatitis C
diagnosis and treatment, new cholesterol and blood pressure
guidelines, new heart failure guidelines (and drugs), the ever-
changing anticoagulation guidelines, etc.
What has not changed? Our essential style remains the same.
The book is divided into 29 chapters based on body system and
elements of patient care, followed by the “Final Examination”
(Chapter 30). The thousands of questions in the book are woven
into cases, which we hope you will find interesting, practical,
and relevant. To test your acquisition of knowledge, each case
ends with the learning objectives. To break the monotony of
slogging through a study guide, you will find “Quick Quizzes”
and “Helpful Tips” peppered throughout each chapter.
A dozen years ago when we wrote the first edition, we made
the decision to use the second-person voice in order to engage
the reader better and to give the book a conversational appeal.
We have tried to keep the book from being boring. Yes, we are
aware that this is a study aid. But why must studying be an exer-
cise in tedium and endurance? It should be enjoyable, appli-
cable to real life and provide a surprise every now and again.
You will find (sometimes feeble) attempts at humor throughout
the book. We have noticed that an occasional reader does not
appreciate our sense of humor. As Abraham Lincoln famously
never said, “You can please some of the people all of the time,
and then again, some people just won’t think you’re funny.”
We have been impressed with the level of engagement of
our readers. Over the years, we have received scores of e-mails
from readers who have thanked us, corrected us, and some-
times chided us. No matter the intent of the message, the tone
is almost universally positive—readers are invested in the book
and want to offer helpful suggestions. Likewise, the comments
posted online (not usually the place one goes for affirmation)
have been mostly approving, constructive, and enthusiastic.
FM.indd 13
The first edition was published amid a less-than-friendly
environment, with declining interest in print media and several
well-known board review books already on the market. Because
our book carried a different tone, readers slowly gravitated to
it, and its market share grew by word-of-mouth. Engaged and
supportive readers play a huge role!
In preparation for work on the fifth edition, we saved all of
your e-mails and scoured the Internet for reader comments and
reviews. We read and considered all that we could find—which
amounted to several hundred readers’ ideas. So, you, the reader,
have helped shape this book. Keep those e-mails coming!
With all of the board review books out there, why should you
choose our text? There are two crucial differences between this
book and other board review books on the market. First, we
have written this book not only to help you pass the boards but
also to broaden your knowledge of family medicine. The major-
ity of questions contain a detailed explanation not only of why
an answer is right but also why the other answers are wrong.
In the rapidly changing world of medical knowledge, we have
endeavored to provide you with the most relevant and up-to-
date evidence. When the current evidence is controversial and
we are not certain what the American Board of Family Medicine
(ABFM) will do with it, we acknowledge the uncertainty and try
to help you navigate the current evidence.
We have tried to make this book as broad and as comprehen-
sive as possible. In addition to its use as a board review book
for family medicine, it can be employed as a general review for
primary care physicians, physician assistants, and nurse practi-
tioners. Students and residents studying for Step 3 of the licens-
ing examination should find the book helpful as well. However,
no board review book can possibly cover the entire scope of
family medicine. Use these questions as a guide: what areas are
your strengths and what do you need to study further? Each
answer of the “Final Examination” is referenced in the book
so you can go back and review any topic that you might have
missed.
In this book, the use of eponymous medical terms such as
Crohn disease and Wilson disease reflects the current American
Medical Association recommendations for these and simi-
lar terms where the possessive form is dropped. In addition,
there is a general trend toward using fewer eponyms, such as
Wegener, which has been dropped completely. We have made
note of both new and old terms when we have deemed the old
term more recognizable.
xiii
29-11-2019 18:41:52
 xiv PREFACE
We enjoyed writing this book and we hope that you enjoy
using it. If you have suggestions or complaints (okay, maybe
all of our jokes aren’t politically correct or even funny), do not
hesitate to write us at mark-graber@uiowa.edu, jason-wilbur@
uiowa.edu, or brigit-ray@uiowa.edu. We take your comments
seriously as we endeavor to make studying for the board exami-
nation more effective and more fun.
We acknowledge and thank all our chapter authors who have
brought their expertise to bear on this project. We also want
to thank the good people at McGraw-Hill who have edited the
book to keep errors to a minimum and created a handsome and
readable layout.
Mark would like to thank you, the reader, for buying this
book. Thanks also to his family: Hetty, Rachel, and Abe (as
always). But not to the dogs, Nietzsche and “Vash the Stampede.”
They need to learn to stay either in or out of the house. No
more of this back and forth. Music that has kept Mark awake:
“Hellborg, Lane, and Sipe” (check out “Time is the Enemy” and
“Personae” [yes, it is spelled with an “e”]), Stephane Wrembel
(Barbes-Brooklyn is Mark’s favorite but you can’t go wrong),
and the Kinks. Finally, thanks to his bicycle for keeping Mark
sane … although some would argue this point.
Jason thanks his loving and supportive family. After some
initial threats, Deb has granted her patience and understanding
FM.indd 14
to the project, and Jason simply owes her dinner every night …
for a year. Jason thanks his boys, Ken and Ted, who offer a great
distraction from work (like learning to drive—yikes!) and find
it entertaining that their dad is some form of an author. Finally,
as with every edition, Jason must acknowledge that the book
would never get finished without large amounts of coffee; so,
he thanks everyone involved in the worldwide production of
coffee, from the pickers on the Central American fincas to the
local baristas. He’s really hoping that we all do something about
climate change to at least save the coffee-growing regions of the
world.
Brigit thanks her husband, Austin, for being so patient when
she has been cranky and sleep deprived. She is so proud of her
husband’s hard work and dedication in the completion of his
research, residency, and fellowship. He has been an inspiration
and her greatest sidekick, friend, and love, and she can’t wait
to start this new chapter in their life together; by FINALLY liv-
ing in the same location! She would like to acknowledge the
“Academy” (no really, she’s not joking) as she has spent many
hours on her couch with the movies and the AAFP editing this
book and completing her CME questions. Lastly, she would like
to thank the open roads, blue skies, and sunshine for always
providing her with much needed “run therapy” and happiness.
29-11-2019 18:41:52
 A Few Words on Studying and
Taking the Board Examination
Throughout the book, you will find that we give advice on what
we think is likely to be on the examination. That’s what you’re
paying for, right? However, the fourth edition marked the first
time that we offered advice on studying for and taking the
examination. We thought it worthwhile to keep this section for
the fifth edition. We recommend you read this section prior to
diving into the rest of the book.
While we acknowledge that some people are simply better
test takers than others, there is good evidence to show that any-
one can improve his or her scores. In fact, examination scores
are directly proportional to time spent studying for the exami-
nation (although this association grows weaker for those who
have high scores already). The point is, you don’t have to be a
genius who got a 36 on the ACT in order to rock the ABFM
Certification/Recertification Examination. But you may need to
put in the work.
Your first step in studying for the examination—after pur-
chasing this book, of course—should be to develop a study
plan. Plotting out time and dedicating that time to uninter-
rupted study is important. How much time do you have before
the examination? How many hours per week can you devote to
studying? When are you most productive in your studying—
morning or night? What are the chances of a worldwide failure
of coffee crops? Will a new Star Wars movie open before the
examination? Thinking through these questions, get a calen-
dar, mark the examination date, and plot out days and times
that you will devote to studying. If you have taken the exami-
nation before and it didn’t turn out so well, you may need to
change your daily work schedule for 2 to 3 months before the
examination to accommodate studying 10 to 15 hours per
week. We endorse neither “cramming” for the examination nor
“adding on” studying to an already full schedule. To get the
most out of studying, you need to approach it like a daily
devotion.
In order to maximize your return on your studying and to
focus on deficiencies, try taking a pre-test. The best pre-test is
the ABFM In-Training Examination (ITE) — keep reading for
more on this. You can use your results on the pre-test to see
what areas are your weakest. Studying weak areas is less fun
but will net higher yield results than studying areas of relative
strength. If your practice is narrow in scope (e.g., a hospitalist),
FM.indd 15
you probably already have a sense of areas of strength and weak-
ness. Make sure you address your weak areas with relatively
more time on them.
Next, know what is on the examination. The percentage of
examination content devoted to various systems is posted on
the ABFM website, and we recommend you review it. The top
systems tested are usually cardiovascular, respiratory, and mus-
culoskeletal systems. If you are weak in any of these areas, be
certain to focus your studying on them.
Now, what material should you use when studying? Some of
our readers have been overly kind, suggesting in their reviews
that this book is the only study tool needed for the board exami-
nation. While we would like to believe it, we cannot endorse this
point of view.
To get a flavor for the questions on the examination, the
best strategy is to go to the source. The ABFM posts its ITE
for the last 3 years on its website (www.theabfm.org). A login
is required, which board-certified family physicians should all
have. The ITEs are perhaps the best source for assessing your
knowledge—we strongly recommend you use them. Although
we do not recommend relying on the ITEs as your only study aid
(obviously; we’re trying to sell books here!), you can use these
as a way to measure your progress as you study. The critiques
are available as well, so you can learn what the ABFM thinks
you should know. The ABFM also has extensive information on
what you should expect when you sit for the certifying/recerti-
fying examination, including a tutorial that simulates the exam-
ination. If you are an anxious test-taker, be certain to check out
the tutorial. While the ABFM has several useful tools, be aware
that the Self-Assessment Modules are not representative of the
types of questions you will find on the certifying/recertifying
examination; however, the more recent Continuous Knowledge
Self-Assessment activity, where the diplomate answers 25 ques-
tions per quarter, is a closer representation.
Another great source for questions is the American Academy
of Family Physicians (AAFP) website. If you are a member of
AAFP, you can access questions for free. They are categorized by
body system and can be done in chunks of ten at a time worth
0.25 CME credits. This question bank offers another opportu-
nity to test your knowledge and determine where you need to
focus your studying.
xv
29-11-2019 18:41:52
 xvi A Few Words on Studying and Taking the Board Examination
Also, the AAFP markets a comprehensive board review self-
study course, which will set you back over $1,000 if you are a
member and more if you are not. Indeed, it covers everything
you need to know for the examination. But so does this book!
So, the choice is yours, but we doubt that you will need both our
book and the AAFP board examination self-study package.
What about texts and primary sources? Well, while we would
admire your perseverance in slogging through whole texts pre-
paring for the examination, we do not recommend attempt-
ing to read cover-to-cover texts like Robert Rakel’s Textbook of
Family Medicine or reference material like UpToDate. Don’t get
us wrong. We like these sources and recommend them to you as
references as you are studying, but you should not rely on them
as your sole study material. Likewise, using primary sources,
like medical journals, is impractical as a study foundation but
useful to expand your knowledge when you don’t understand
something.
As far as board review courses: to each his or her own. If you
are considering attending a course, the AAFP offers compre-
hensive courses multiple times per year in locations all across
the country. For-profit entities provide additional options. If
you learn best in a live lecture setting, these courses may be a
good option for you, but you need not attend a course to get all
that information (c’mon—you’ve got this book!).
There are some important basic things you need to know
about the examination. As of the writing of this book, the exam-
ination is composed of 4 sections, each consisting of 80 multiple
choice questions and 100 minutes in length. Sections 1, 3 and
4 have questions from a wide variety of family medicine topics.
Section 2 consists of 40 questions from a chosen module and
40 questions pertaining to the general breadth of family med-
icine. It is best to choose modules with which you are more
familiar. For example, if you practice primarily in an emergency
department, you may want to choose Emergent/Urgent Care or
Hospital Medicine rather than Maternity Care (unless you’re
looking for the additional challenge). We highly recommend
to check out the ABFM website (https://www.theabfm.org/con-
tinue-certification/cognitive-expertise/one-day-fmc-exam) for
exam information as this may change.
The examination consists entirely of four-item multiple-
choice questions. You are not penalized for guessing. An unan-
swered question will always be wrong; whereas, a guessed
question has a 25% chance of being right. If you have no idea,
go ahead and guess. As a corollary to that rule, never exit the
examination without first completing all the items. You cannot
return to answer unmarked items.
FM.indd 16
Read every stem and option carefully. Although we doubt
that the ABFM writes “trick questions,” they do use catch
words/phrases, such as “except,” “most likely,” “first step,” and
“least likely.” If you are not attending to the catch phrase, you are
likely to answer the question wrong.
In the past, the ABFM recommended relying on evidence in
place up to 2 years before the examination rather than the most
recent medical evidence. Now, the ABFM recommends exam-
inees rely on the most up-to-date evidence available. So, when
you are looking at a question and thinking, “Well, the answer
last year might have been ‘A’ but now the evidence points to ‘B’.”
Choose “B.”
Successful test-takers do not use grand strategies to outsmart
the question writers; instead they tend to employ a few simple
rules when answering multiple-choice questions. These simple
rules that follow amount to guidelines that cannot be blindly
applied to the entire test, but are often true. No secret to many
of you, perhaps, but here they are:
• Go with your first thoughtful choice unless you have a solid
reason to change it (e.g., you misread the question).
• Look for catch words in the answers, such as “always” and
“never.” These will often be incorrect.
• Avoid answers with unfamiliar terms (e.g., obscure disease
names or rarely performed procedures). These are often
incorrect.
• The most detailed answer is often the correct answer.
• If two answers are similar, they are probably both wrong.
• Stick with family medicine principles (e.g., answers with
“more history” or “shared decision making” are more likely
to be correct).
• If you don’t know, guess and move on. Do not waste time
deliberating on a single question.
Finally, we part offering advice that we know busy doc-
tors seldom follow: get plenty of rest. Seriously! Be prepared
for the examination day by getting a good night’s sleep. Don’t
stop taking care of your health prior to the examination, and
that includes rest. Eat a good breakfast, bring a snack for your
breaks, and plan to take yourself out for a nice lunch (but skip
the martini—you’ve got an examination to finish). Just like a
mountain climber, wear layers. Some of those test-taking cen-
ters are freezing; some are boiling. Stay positive, take a deep
breath and keep moving through it. You will pass this thing!
Good luck.
29-11-2019 18:41:52
 Emergency Medicine
Olivia E. Bailey, Sarah L. Miller, and Mark A. Graber
▶▶ CASE 1.1
You get a call from a panicked mother because her 4-year-old
drank a bottle of children’s Tylenol. She found the empty bot-
tle in her child’s bed after a nap, and her child had been in bed
for 90 minutes. She thinks there were about 3 ounces of liquid
left in the bottle. She is about 35 minutes from the hospital.
She states her child weighs 15 kg.
Question 1.1.1 Your advice to her is:
A) Induce vomiting to reduce acetaminophen absorption
B) Have the child eat to slow absorption and proceed directly to
the hospital
C) Proceed to the hospital
D) Breathe deeply and calm down; the amount of acetamino-
phen this child could have ingested is harmless
Answer 1.1.1 The correct answer is “C.” Proceed to the hospi-
tal. “A” is incorrect for a couple of reasons. After 90 minutes, it is
not likely that there is significant medication left in the stomach
and induced vomiting can lead to aspiration (this is true of liq-
uids and pills). “B” is incorrect because you do not want to delay
definitive treatment. “D” is incorrect as this patient may have
ingested up to 3 oz (90 mL) of 160 mg/5 mL solution (total dose
of 2880 mg or 192 mg/kg).
HELPFUL TIP:
Acetaminophen is the most common agent involved
in pediatric ED visits for over-the-counter medica-
tion exposures. Reasons for these high exposure rates
include the medication’s reputation as “safe,” its ubiq-
uity in medicine cabinets, errors in dosing, as well as
co-administration of medications that also contain
acetaminophen.
The patient arrives in your emergency department (ED).
She is alert with stable vital signs. The mother states she now
Ch01.indd 1
1
believes the ingestion occurred about 50 minutes ago as her
child told her she found the bottle in the bathroom when she
woke up from her nap. You contemplate gastrointestinal (GI)
decontamination.
Question 1.1.2 Which of the following statements is true
about gastric lavage?
A) Except in extraordinary circumstances it should only be
done in the first hour after an overdose
B) Patients who have had gastric lavage have higher incidence
of pulmonary aspiration than patients who have not
C) Patients who undergo gastric lavage have a higher incidence
of esophageal perforation
D) It can push pill fragments beyond the pylorus
E) All of the above are true
Answer 1.1.2 The correct answer is “E.” All of the options are
true. Generally, the efficacy of gastric lavage is limited. Outcome
data do not support the use of gastric lavage after the first hour.
In a particularly severe overdose or in an overdose that is likely
to delay gastric emptying (e.g., tricyclic antidepressants), you
might want to consider lavage, but such circumstances are
unusual. Gastric lavage increases the risk of aspiration, esoph-
ageal perforation, and can push pill fragments beyond the
pylorus.
Question 1.1.3 After careful consideration, you decided
not to lavage. She is now 90 minutes after the ingestion.
Her physical exam is normal other than some dried sticky
liquid on her face, shirt, and hands that smells like cherry
flavoring. The next best step to take in this patient is to:
A) Check blood acetaminophen levels and refer for hemodialy-
sis if markedly elevated
B) Administer 5 g/kg of charcoal with sorbitol
C) Start treatment with N-acetylcysteine (NAC)
D) Prophylactically treat this patient for seizures using
phenytoin
E) Observe and measure acetaminophen level at 4 hours after
ingestion
1
29-11-2019 12:14:48
 2 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Answer 1.1.3 The correct answer is “E.” Giving charcoal is
likely helpful only within the first hour after ingestion, and
even this remains controversial. “A” is incorrect because hemo-
dialysis is not indicated for acetaminophen (APAP) overdose
and measuring levels at 90 minutes will not allow appropri-
ate risk stratification for this child. “C” and “D” are incorrect
because seizure prophylaxis is not indicated in this patient, and
although NAC could be initiated for a known dose of >150
mg/kg, this child clearly had spilled medication on her skin and
clothing. In order to determine the risk of APAP-induced hepa-
totoxicity and treatment via the Rumack–Matthew nomogram,
a 4-hour APAP level is necessary.
HELPFUL TIP:
Although frequently given, single dose activated char-
coal has limited or no effect on outcomes of poisonings. It
reduces absorption by about 30% if given within 1 hour
of ingestion and likely has no benefit after 1 hour. It can
also cause vomiting with aspiration. For this reason, it
has fallen out of favor (we don’t remember the last time
we used it in our ED). We are not sure what the correct
answer on the test will be.
HELPFUL TIP:
Do NOT give activated charcoal to patients with an
altered mental status or who are otherwise unable to
protect their airway. To prevent aspiration, do not give
charcoal to a patient likely to have a seizure (such as
with tricyclic overdose).
Question 1.1.4 Assuming you are using charcoal, for which
of these overdoses is charcoal NOT indicated?
A) Acetaminophen
B) Aspirin
C) Iron
D) Digoxin
E) Opiates
Answer 1.1.4 The correct answer is “C.” Charcoal will not
bind iron. Charcoal will also not bind Caustics/corrosives,
Heavy metals, Alcohols, Rapid-onset cyanide, Chlorine (or
iodine), Other insoluble tablets, Aliphatics (hydrocarbons),
or Laxatives (mnemonic: CHARCOAL). Some of you may
have answered “A.” Theoretically, charcoal could interfere
with the action of N-acetylcysteine, the antidote for acet-
aminophen 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 rec-
ommended are quite high, and you can give a higher dose if
you will be using it with charcoal. Finally, intravenous (IV)
N-acetylcysteine is available and is obviously not affected by
Ch01.indd 2
charcoal. “B,” “D,” and “E” are all incorrect. While we do have
antidotes for digoxin and opiates (Digibind, naloxone), char-
coal may still be indicated to reduce absorption within the
first hour.
▶▶ Objectives: Did you learn to …
• Manage a patient with an acute ingestion?
• Describe the appropriate use of gastric lavage and charcoal
administration?
• Identify situations where charcoal may not be indicated?
QUICK QUIZ: BIOTERRORISM AND THE ATTACK
OF GODZILLA
Oh, no. Godzilla is attacking Tokyo. And this time it is with
weapons of mass destruction. Which of the following
properly describes the isolation requirements of a patient
with pulmonary anthrax?
A) No isolation necessary. The patient may be in the same room
with an uninfected patient
B) Respiratory isolation only
C) Respiratory and contact isolation
D) Negative pressure room (such as with tuberculosis) + ­contact
isolation
The correct answer is “A.” Pulmonary anthrax is NOT trans-
mitted person to person. Contact isolation is indicated in those
with cutaneous anthrax and GI anthrax (where diarrhea may be
infectious).
Godzilla is not done yet… Which of the following drugs
should be used as prophylaxis against inhaled anthrax,
should exposure to aerosolized spores be documented?
A) A first-generation cephalosporin
B) Trimethoprim/sulfamethoxazole
C) Ciprofloxacin
D) A third-generation cephalosporin
The correct answer is “C.” Fluoroquinolones are the drugs of
choice when treating those exposed to anthrax. Doxycycline
may also be used. Cephalosporins and TMP/SMX are not active
against anthrax.
Godzilla, frustrated by his failed anthrax attack, is now
spreading smallpox. Which of the following is NOT true
about smallpox?
A) Isolation is best done at home if possible
B) The patient is infectious until he or she becomes afebrile
C) All lesions are generally in the same stage of evolution,
unlike what is seen in varicella
D) Smallpox immunization causes an encephalitis in 1:300,000
of which 25% of cases are fatal
The correct answer is “B.” The patient is infectious until all
lesions crust over. Infectivity has nothing to do with the pres-
ence or absence of fever. “A” is true. Isolation is best done at
29-11-2019 12:14:48

home since this will limit spread (as those in the household have
likely already been exposed). “C” is also true; all lesions are in a
similar state of evolution. Finally, “D” is true and is the reason
we do not currently immunize against smallpox—well, that and
the fact we eradicated it in the wild (Way to go, humans!).
▶▶ CASE 1.2
A 22-year-old female presents to the ED with an overdose.
She has a history of depression, and there were empty bottles
found at her bedside. The bottles had contained clonazepam
and nortriptyline. The patient is unconscious with dimin-
ished breathing and is unable to protect her airway.
Question 1.2.1 The BEST next step is to:
A) Intubate the patient
B) Begin gastric lavage and administer charcoal
C) Administer flumazenil, a benzodiazepine antagonist, to
awaken her and improve her respirations
D) Administer bicarbonate
E) Administer lipid emulsion
Answer 1.2.1 The correct answer is “A.” This patient should
be intubated. Remember in any emergency situation that the
ABCs (airway, breathing, and circulation) are the priority. “B” is
incorrect because, as noted earlier, patients who undergo gastric
lavage have a higher incidence of pulmonary aspiration—an even
greater concern in the obtunded patient. In fact, airway protection
is MANDATORY before undertaking lavage. “C” is incorrect.
Flumazenil will reverse the benzodiazepine. However, we know
from experience that seizures in patients who have had flumaze-
nil are particularly difficult to control. This would be particularly
problematic in a patient with a mixed overdose, such as with a
tricyclic, where seizures are common. Thus, it is recommended
that flumazenil be used only as a reversal agent after procedural
sedation in patients who are not on chronic benzodiazepines. “E”
is incorrect. Lipid emulsion refers to the liquid fatty acids given
as part of total parenteral nutrition and theoretically can be used
to bind fat-soluble drugs in the blood. Case series support con-
sideration of lipid emulsion for calcium channel blocker, beta-
blocker, and tricyclic antidepressant overdoses, as well as other
fat-soluble drugs but only in cases of refractory cardiac arrest or
cardiovascular collapse—and certainly not before the airway has
been secured. Keep reading for a discussion of answer “D.”
You notice that the patient begins to have an abnormal trac-
ing on the cardiac monitor, so you order an ECG.
Question 1.2.2 Which of the following findings would you
expect to find in a tricyclic overdose?
A) Normal QRS complex
B) Second- and third-degree heart block
C) Widened QRS complex
D) Sinus tachycardia
E) Any of the above
Ch01.indd 3
CHAPTER 1 • Emergency Medicine 3
Answer 1.2.2 The correct answer is “E.” All of the above find-
ings can be seen with a tricyclic overdose. In fact, the most
common presenting rhythm is a narrow-complex sinus tachy-
cardia. As toxicity progresses, you can see a prolonged PR
interval, a widened QRS complex, and a prolonged QT inter-
val. A QRS >100 ms is predictive of seizures and QRS >160
ms is highly predictive of ventricular arrhythmia in patients
with a tricyclic antidepressant overdose. Heart blocks (second-
and third-degree) herald a poor outcome and may be seen late
in the course. Asystole is not a primary rhythm in tricyclic
overdose and tends to reflect the end stage of another
arrhythmia.
YIKES!! The patient becomes unresponsive and you look at
the monitor. You obtain an ECG which shows the following
(Fig. 1-1).
Question 1.2.3 What is the patient’s rhythm?
A) Monomorphic ventricular tachycardia
B) Sinus tachycardia with a bundle branch block
C) Paroxysmal supraventricular tachycardia
D) Torsades de pointes
E) Third degree heart block
Answer 1.2.3 The correct answer is “D.” This is torsades de
pointes which is a subtype of polymorphic ventricular tachycar-
dia. In French, it literally means “twisting of the points,” but in
every language it means “bad news.” Torsades de pointes can be
recognized by the varying amplitude of the complex in a some-
what regular pattern. “A” is incorrect because the complexes are
not monomorphic. “B” is incorrect for two reasons. First, there
are no P waves visible. Second, sinus tachycardia should not
have varied amplitude. “C” is incorrect because, again, there are
no P waves and the complexes are polymorphic. “E” is incorrect
because there are no P waves.
Question 1.2.4 This patient needs treatment post haste.
After taking care of the ABCs, what is the ONE BEST drug for
the treatment of this arrhythmia in a patient with a tricyclic
overdose?
A) Esmolol
B) Lidocaine
C) Sodium bicarbonate
D) Procainamide
E) Amiodarone
Answer 1.2.4 The correct answer is “C.” The treatment of
choice for arrhythmias in patients with a tricyclic overdose is
sodium bicarbonate. Raising the pH and administering sodium
seem to “prime” the sodium channels in the heart, reversing
the toxicity of the tricyclic. Procainamide (“D”) and quinidine
should not be used because they act in similar fashion to tricy-
clics and may worsen the problem. Lidocaine (“B”) can be used
as can amiodarone (“E”), but they are not the best choices. Beta-
blockers such as esmolol (“A”) can worsen hypotension and
should be avoided.
29-11-2019 12:14:48
 4 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
FIGURE 1-1. ECG for patient in question 1.2.3.
This is not your patient’s lucky day. She begins to seize after
the administration of the bicarbonate.
Question 1.2.5 The treatment of choice for this seizing
patient is:
A) Lorazepam (Ativan)
B) Repeat the bolus of sodium bicarbonate and start a bicar-
bonate drip
C) Phenytoin (Dilantin)
D) Fosphenytoin (Cerebryx)
E) None of the above
Answer 1.2.5 The correct answer is “A.” Benzodiazepines
are the treatments of choice in tricyclic-induced seizures.
While most seizures are self-limited, it is important to control
seizures because the resultant acidosis can worsen tricyclic
toxicity (beyond the fact that prolonged seizures can cause
CNS injury). “B” is incorrect. This patient is already alkalinized,
and although sodium bicarbonate is the preferred therapy for
tricyclic-induced cardiovascular toxicity, sodium bicarbonate
is not particularly effective in tricyclic-induced seizures. “C,”
phenytoin, can be used, but benzodiazepines and phenobarbital
should be administered first if possible. In addition to not work-
ing well as an antiepileptic drug in tricyclic overdose, phenytoin
is also a class Ib antiarrhythmic, which may further prolong
the QRS and worsen the cardiac toxicity of the tricyclic. “D” is
incorrect for two reasons. First, since fosphenytoin is metabo-
lized to phenytoin, the concern about efficacy applies. Second,
fosphenytoin is a prodrug and requires adequate circulation and
renal and hepatic function to be converted into active drug. If
our patient becomes hypotensive with poor liver and renal per-
fusion, adequate drug levels might not be achieved. Finally, both
Ch01.indd 4
phenytoin and fosphenytoin can cause hypotension—not what
you need in this unstable patient.
You correct the arrhythmia and stop the seizures, and she is
admitted to the intensive care unit.
HELPFUL TIP:
A patient who is entirely asymptomatic 6 hours after a
tricyclic overdose is unlikely to have any serious con-
sequences from the ingestion. They can be “medically
cleared” at that point for admission to a psychiatric
unit. Note that “symptomatic” may just be tachycardia
or mild confusion. We mean the entirely asymptomatic
patient.
▶▶ Objectives: Did you learn to …
• Understand the importance of the ABCs in an unstable
patient?
• Describe the role of flumazenil in toxicologic emergencies?
• Manage a tricyclic overdose?
• Recognize ECG findings in a tricyclic overdose?
• Recognize torsades de pointes and its treatment in the
context of a tricyclic overdose?
QUICK QUIZ: DESIGNER AND CLUB DRUGS
An 18-year-old male presents after a party. He is having alter-
nating episodes of combative behavior interspersed with epi-
sodes of coma. He becomes almost apneic during the episodes
of coma. He has alternating bradycardia (while in coma) and
29-11-2019 12:14:48

TABLE 1-1   TOXIDROMES
Drug Class Examples
Anticholinergic Tricyclics, diphenhydramine, scopolamine, loco
weed (jimson weed), some mushrooms, etc.
Opiates Morphine, heroin, codeine, oxycodone, etc.
Cholinergic Organophosphate or carbamate pesticides,
some mushrooms
Sympathomimetic Cocaine, ecstasy, methamphetamine
Gamma-hydroxybutyrate (GHB) GHB, liquid ecstasy, etc.
tachycardia when awake. The patient is also having myoclonic
seizures. His serum alcohol level is zero, and his pupils are
miotic.
The most likely drug causing this is:
A) Ecstasy (MDMA)
B) GHB (gamma-hydroxybutyrate aka “liquid ecstasy”)
C) Methamphetamine
D) LSD (lysergic acid diethylamine aka “acid”)
E) Oxycodone
The correct answer is “B.” The episodic coma and bradycar-
dia interspersed with episodes of extreme agitation are almost
pathognomonic of GHB overdose. GHB intoxication also causes
pinpoint pupils. “A” is incorrect because MDMA causes an
amphetamine-like reaction with agitation, hypertension, hyper-
thermia, tachycardia, etc. “C” is incorrect for the same reason.
“D” is incorrect because LSD rarely (if ever) causes coma. “E” is
incorrect because patients with opioid overdoses are generally
somnolent or comatose without interspersed episodes of agita-
tion, although opioids may also cause miosis (be aware that not
all narcotic overdoses are associated with pinpoint pupils). GHB
is odorless and has slight salty taste. Besides being a street drug,
GHB is available by prescription as “sodium oxybate” for nar-
colepsy (Xyrem). It has become a drug of choice for “date rape”
since it cannot be detected in the urine. The toxicity tends to be
self-limited and can be treated with intubation if needed along
with tincture of time. The half-life is only 27 minutes.
QUICK QUIZ: TOXIDROMES
A patient presents to the hospital with a diphenhydramine
overdose.
Which of the following signs and symptoms are you likely
to find in this patient?
A) Bradycardia, dilated pupils, flushing, and increased bowel
sounds
Ch01.indd 5
CHAPTER 1 • Emergency Medicine 5
Signs and Symptoms
Tachycardia, flushing, dilated pupils, low-grade temperature,
and confusion. Mnemonic: Dry as a bone, red as a beet, mad
as a hatter, blind as a bat
Pinpoint pupils, hypotension, hypopnea, coma, hypothermia
Lacrimation, salivation, muscle weakness, diarrhea, vomiting,
miosis. Mnemonic: SLUDGE BBB (salivation, lacrimation,
urination, diarrhea, GI upset, emesis … Bradycardia,
bronchorrhea, bronchospasm)
Tachycardia, hypertension, elevated temperature, dilated
pupils (mydriasis)
Alternating coma with agitation, hypopnea while comatose,
bradycardia while comatose, and myoclonus
B) Bradycardia, pinpoint pupils, flushing, and decreased bowel
sounds
C) Tachycardia, dilated pupils, diaphoresis, and increased
bowel sounds
D) Tachycardia, dilated pupils, flushing, and decreased bowel
sounds
E) Tachycardia, pinpoint pupils, flushing, and increased bowel
sounds
The correct answer is “D.” This patient has an anticholinergic
toxidrome. Toxidromes are symptom complexes associated with
a particular overdose that should be immediately recognized by
the clinician. Common toxidromes are listed in Table 1-1.
▶▶ CASE 1.3
A patient presents to your office with neck pain after a motor
vehicle accident. He was restrained and the airbag deployed.
He notes that he had some lateral neck pain at the scene. He
continues to have lateral neck pain.
Question 1.3.1 Which of the following IS NOT a criterion for
clearing the cervical spine clinically?
A) Absence of all neck pain
B) Normal mental status including no drugs or alcohol
C) Absence of a distracting injury (such as an ankle fracture)
D) Absence of paralysis or another “hard” sign that could be
caused by a neck injury
E) Absence of retrograde amnesia
Answer 1.3.1 The correct answer is “A.” Patients can have lat-
eral 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 (e.g., trapezius) neck pain.
Patients with central neck pain (e.g., over the spinous processes)
DO need imaging (radiographs ± CT) to clear their cervical
spine. All of the other criteria are required in order to clinically
clear the cervical spine (Table 1-2). These criteria have been
validated in both adult and adolescent patients.
29-11-2019 12:14:49
 6 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
TABLE 1-2   CLEARING THE CERVICAL SPINE CLINICALLY
No central neck pain on questioning or palpation
No distracting, painful injury (e.g., bone fracture)
No symptoms or signs referable to the neck (paralysis, stinger-type injury, etc.)
Normal mental status including no drugs or alcohol. This includes any retrograde amnesia, etc.
HELPFUL TIP:
CT has pretty much replaced plain x-rays in the evalu-
ation of the bones of the neck. If you are doing plain
films, the most common cause of missed fractures is an
inadequate series of radiographs. An adequate series of
radiographs for the cervical spine includes an AP film,
a lateral film including the top of T-1, and an odontoid
film. Flexion–extension views add little and should be
avoided.
The patient’s daughter, aged 4 years, was in the same motor
vehicle accident and also had her cervical spine cleared by
radiograph. However, you get a call from the ED 48 hours
after the initial accident that she is paralyzed from just above
the nipple line down (never a good thing—you quickly make
a mental note to make sure your malpractice insurance pre-
miums are paid up). You review the initial radiographs with
the radiologist, which are negative as is a CT of the cervical
spine bones done after the onset of the paralysis.
Question 1.3.2 The most likely cause of this patient’s
paralysis is:
A) Missed transection of the thoracic cord
B) Conversion reaction from the psychological trauma of the
accident
C) Subarachnoid hemorrhage
D) SCIWORA syndrome
E) Guillain–Barre syndrome
Answer 1.3.2 The correct answer is “D.” This likely represents
SCIWORA syndrome (spinal cord injury without radiologic
abnormality). SCIWORA has become a bit of a misnomer
in the age of MRI, as up to two-thirds of children with this
diagnosis will have abnormal MRI findings. This entity occurs
from stretching of the cord secondary to flexion/extension-
type movement 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 presenta-
tion up to 72 hours after the injury. “A” is incorrect because a
cord transection would present with paralysis immediately at
the time of injury. “B” is incorrect because this child is 4 years
old, and conversion reaction is unlikely in children. In addi-
tion, conversion reaction is always a diagnosis of exclusion.
“C” and “E” are incorrect because this is neither the presen-
tation of a subarachnoid hemorrhage (headache, stiff neck,
perhaps focal neurologic symptoms) nor of Guillain–Barre
Ch01.indd 6
syndrome (progressive numbness and weakness from autoim-
mune myelitis).
Question 1.3.3 The next step in the management of this
patient is:
A) Avoid hypotension and hypoxia to prevent secondary insult
to the cord
B) Fluid restriction and diuretics to reduce cord edema
C) Mannitol to reduce cord edema
D) Neurosurgical intervention to decompress the cord
E) Lollipop and a gift card for “service recovery”
Answer 1.3.3 The correct answer is “A.” Patients with a cord
injury should be monitored closely to avoid hypotension and
hypoxia, both of which will further damage the already com-
promised spinal cord. Neither diuretics (“B”) nor mannitol
(“C”) will be useful in this situation. “D” is incorrect because
the process of SCIWORA involves stretching of the cord (and
subsequent dysfunction) rather than cord compression such as
would be seen with a bony injury. “E” might be the right choice
if you are taking this test as a “patient experience expert” instead
of a doctor; but doctors should choose “A.”
HELPFUL TIP:
Don’t use steroids for spinal cord injuries. It doesn’t
work. There are also secondary complications from
the steroids, including hyperglycemia, myopathy, and
infections (e.g., pneumonia).
Question 1.3.4 The father is, understandably, irate that his
child is now paralyzed. You can tell him that the natural
history of SCIWORA syndrome in THIS CHILD is likely to be
the following:
A) Continued paralysis with the necessity of long-term, perma-
nent adaptation to the injury
B) Progression of the injury over the next week to include fur-
ther paralysis in an ascending fashion
C) Resolution of paralysis and sensory symptoms over the next
several months
D) Resolution of all symptoms except sensory symptoms over
the next several months
E) Large lawsuit payout on the way. Do not pass go; do not col-
lect $200; go directly to a malpractice attorney
Answer 1.3.4 The correct answer is “C.” Generally, patients
with SCIWORA syndrome regain their strength and sensory
29-11-2019 12:14:49
 CHAPTER 1 • Emergency Medicine 7

abilities over time. However, this depends on when they pres-
ent 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). Patients with
significant spinal cord findings on MRI are more likely to have
persistent deficits.
▶▶ Objectives: Did you learn to …
•
Clinically “clear” the cervical spine and decide when to order
cervical spine radiographs?
• Understand the physiology, natural history, and
management of SCIWORA syndrome?
▶▶ CASE 1.4
A patient with an extensive history of alcohol use presents to
the ED after drinking a bottle of automobile winter gas treat-
ment (Rothschild Vintage, 1954). He is intoxicated, has a
headache, and describes a “misty” vision, “like a snowstorm”
(if you live in southern Florida or Hawaii, call one of us in
Iowa for a description). He is tachycardic and tachypneic.
You start an IV and administer saline. You obtain a blood
gas, which shows a mild metabolic acidosis.
Question 1.4.2 This patient’s anion gap is:
A) 13
B) 15
C) 23
D) Unable to calculate the anion gap with the information
provided
Answer 1.4.2 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 = 135 - (108 + 12) = 15.
The normal anion gap is typically considered to be 12 or
less. However, since albumin is the major unmeasured anion
in the serum, the anion gap should be adjusted for hypoal-
buminemia. Every 1 g decrease in albumin will decrease the
anion gap by about 3. Therefore, you should subtract (3 ×
[normal albumin − actual albumin]) to get the “real” anion
gap. The normal albumin is considered to be 4. So, let us say
we calculate an anion gap of 16 but the albumin is 2. In this
case, the corrected anion gap will be (16 − [3 × (4 − 2)] =
16 − 6), or 10.

Question 1.4.1 A metabolic acidosis is consistent with all

of the following ingestions EXCEPT: HELPFUL TIP:
A) Ethylene glycol In methanol ingestions, the severity of acid–base distur-
B) Methanol bance is generally a better predictor of outcome than
C) Ethanol (e.g., vodka, gin) serum methanol levels.
D) Petroleum distillates (e.g., non-alcohol-containing gasoline
products)
Question 1.4.3 All of the following are causes of an anion
Answer 1.4.1 The correct answer is “D.” Ethylene glycol, gap acidosis EXCEPT:
methanol, and ethanol can all cause a metabolic acidosis. A) Lactic acidosis
Hydrocarbons (e.g., gasoline products) do not cause a meta- B) Diabetic ketoacidosis
bolic acidosis. The main manifestation of hydrocarbon toxicity C) Renal tubular acidosis
is secondary to the inhalation and aspiration of the hydrocar- D) Uremia
bon and the resulting pneumonitis. E) Ingestions such as methanol

This patient’s electrolytes are as follows: sodium 135 mEq/L, Answer 1.4.3 The correct answer is “C.” See Table 1-3 for more
bicarbonate 12 mEq/L, chloride 108 mEq/L, BUN 12 mg/dL, on causes of anion gap acidosis.
Cr. 1 mg/dL.

TABLE 1-3   CAUSES OF ACIDOSIS

Causes of an elevated anion gap acidosis Lactic acidosis
Diabetic ketoacidosis
Ingestions such as ethanol, methanol, etc.
Uremia
Alcoholic ketoacidosis

Causes of a normal anion gap acidosis GI bicarbonate loss (e.g., chronic diarrhea)
Renal tubular acidosis (types I, II, and IV)
Interstitial renal disease
Ureterosigmoid loop
Acetazolamide and other ingestions
Small bowel drainage

Ch01.indd 7 29-11-2019 12:14:50

 8 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Question 1.4.4 Which of the following findings IS NOT
frequently 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
Answer 1.4.4 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 frequent
finding in methanol overdose. This makes sense. The patient
is trying to compensate for a metabolic acidosis by blowing off
CO2. Optic disk abnormalities, abdominal pain and vomiting,
basal ganglia hemorrhage, and meningeal signs are all seen as
part of methanol toxicity. It is thought that many of these signs
and symptoms are secondary to central nervous system (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 ingestion in order
to obtain alcohol (a treatment for methanol ingestion—break
out the single malt scotch!).
Question 1.4.5 What test is most likely to help you
determine if the patient has methanol ingestion?
A) Complete blood cell count (CBC)
B) BUN/creatinine
C) Liver enzymes
D) Measured serum osmolality
E) Amylase and lipase
Answer 1.4.5 The correct answer is “D.” With a mea-
sured serum osmolality, you can calculate the osmolar gap.
To do so, 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 circulating,
unmeasured osmole. A normal osmolar gap is usually about
6 mOsm/L or less. Any osmolar gap over 10 mOsm/L sug-
gests a concurrent ingestion with the alcohol (such as in our
case, methanol).
In this case, for example:
Measuredserumosmolality = 368
Bloodalcohol = 200 mg/dLor 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 that could,
in the clinical context of the case, represent methanol. Thus, we
Ch01.indd 8
know that the patient did not simply overindulge on ethanol
(methanol, such as “gas dry,” will make one intensely drunk …
but has obvious downsides).
You decide that there is sufficient evidence that this patient
has ingested methanol to institute treatment.
Question 1.4.6 Appropriate treatment(s) for this patient
include:
A) Fomepizole (4-MP)
B) Acetylsalicylic acid
C) Ethanol
D) A and C
E) All of the above
Answer 1.4.6 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 toxicity
of methanol is caused by formic acid, which is a by-product
of methanol metabolism. Ethanol is metabolized by alcohol
dehydrogenase, the same enzyme that breaks down methanol.
Thus, methanol metabolism is competitively inhibited by etha-
nol. 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. “B” is
incorrect. Acetylsalicylic acid (ASA), or aspirin, has no role in
methanol ingestion, and would likely worsen any gastritis or
hemorrhaging.
HELPFUL TIP:
Hemodialysis should be available for any patient who
has ingested methanol. Indications for hemodialysis
include methanol level >50 mg/dL, severe and resistant
acidosis, and renal failure.
▶▶ 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 down the differential
diagnosis of metabolic acidosis?
QUICK QUIZ: BETA-BLOCKER OVERDOSE
Which of the following has been shown to be useful in
beta-blocker overdose when conventional, adrenergic
vasopressors are ineffective?
A) Calcium chloride
B) Glucagon
C) Milrinone
D) High-dose insulin
E) All of the above
29-11-2019 12:14:53

The correct answer is “E.” In beta-blocker overdoses, the
following findings may be observed: bradycardia, AV block,
hypotension, bronchospasm, nausea, emesis, and hypoglyce-
mia. This is very similar to the presentation of a calcium chan-
nel blocker overdose, but calcium channel blocker overdose
often lacks bronchospasm and patients are hyperglycemic as
insulin release from the islet cells is calcium dependent. When
a beta-blocker overdose has been identified, the usual treat-
ments are employed (e.g., IV fluids, vasopressors, airway pro-
tection). If conventional vasopressors have failed, glucagon
in a dose of 3 to 5 mg IV bolus and a drip at 1 to 5 mg/hr
may be effective in treating beta-blocker overdose. It is gener-
ally preferred over atropine in this situation. Milrinone and
other phosphodiesterase inhibitors may also be used but are
considered third-line agent. Likewise, calcium is considered
a third-line agent in beta-blocker overdose. Calcium chloride
may potentiate the action of glucagon. There is also a grow-
ing body of literature supporting use of high-dose insulin
(while maintaining euglycemia) for beta-blocker, calcium
channel blocker, or combination overdoses. The insulin is
started at 0.5 U/kg/hr and titrated to as high as 10 U/kg/hr,
titrated by hemodynamic improvement (Clin Toxicol (Phila).
2011;49(4):277–283). Dextrose infusion may be required to
maintain euglycemia. Does it seem counterintuitive to give
glucagon and insulin? Both appear to mitigate the deleteri-
ous effects of beta-blockers on cardiac myocyte metabolism,
although the mechanism is not completely understood. Both
can be given (usually in sequence with the glucagon first) to
the same patient for beta-blocker overdose. Remember to
maintain euglycemia if using insulin for beta-blocker or
calcium channel blocker overdose.
QUICK QUIZ: TOXICOLOGY 1
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
The correct answer is “E.” Drunk patients, no matter how
much they annoy you, will just have to sleep it off. The rate of
alcohol metabolism is fixed with zero-order kinetics at lower
doses (fixed metabolic rate) and first-order kinetics at higher
doses (rate proportional to levels). In general, this rate is in the
range of 9 to 36 mg/dL/hr, with 20 mg/dL/hr being the accepted
norm. At this point, there are no available agents to increase the
metabolism of ethanol. “B” is incorrect because ethanol is too
rapidly absorbed for charcoal to be of any benefit. “C,” forced
diuresis, will just result in an incontinent, sleeping patient and
does not hasten metabolism.
Ch01.indd 9
CHAPTER 1 • Emergency Medicine 9
QUICK QUIZ: TOXICOLOGY 2
The best therapy for seizures secondary to an isoniazid
overdose is:
A) Lorazepam
B) Phenytoin
C) Pyridoxine
D) Thiamine
E) Phenobarbital
The correct answer is “C.” Isoniazid is a vitamin B6 antagonist.
Thus, pyridoxine (in massive doses!) 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 active or latent tuberculosis; often
these patients are immigrants and were exposed to TB in their
country of origin.
▶▶ CASE 1.5
A family of four comes into your ED after being exposed to car-
bon monoxide (CO). They were in an idling car in the garage
and were running the engine and heater to stay warm. You
want to get a carboxyhemoglobin level on the whole family,
but cannot get an arterial blood gas from the youngest child.
Question 1.5.1 What is your response?
A) Check pulse oximetry, and if the oxygen saturation is nor-
mal, be reassured
B) Check end-tidal carbon dioxide
C) Check a venous carboxyhemoglobin level
D) Check a venous carboxyhemoglobin and correct for the dif-
ference between venous and arterial samples
Answer 1.5.1 The correct answer is “C.” A venous carboxyhe-
moglobin is just as accurate as an arterial c­ arboxyhemoglobin—
in fact, no correction is needed, which is why “D” is wrong—and,
a venous gas much less painful to draw. “A” is incorrect because
the pulse oximeter does not reflect hypoxia in carbon monoxide
poisoning. Thus, standard pulse oximetry is useless in deter-
mining the carboxyhemoglobin level. “B” is incorrect because
end-tidal carbon dioxide is measuring CO2 and not CO.
Question 1.5.2 When determining which patients need
hyperbaric oxygen on the basis of a carboxyhemoglobin
level, the level to rely upon is:
A) The carboxyhemoglobin level on arrival to the ED
B) The carboxyhemoglobin level at 4 hours after exposure
C) The carboxyhemoglobin level projected to “time zero” (e.g.,
at the time of exposure)
D) None of the above
Answer 1.5.2 The correct answer is “C.” A major consider-
ation regarding the initiation of hyperbaric oxygen therapy is
29-11-2019 12:14:53
 10 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
the patient’s clinical situation. More severely ill patients with
CO poisoning (e.g., severe acidosis, unconscious, unresponsive)
should be considered candidates for hyperbaric oxygen, and
some hyperbaric oxygen centers will treat regardless of mea-
sured carboxyhemoglobin level in these patients. If the treat-
ment decision is made based on the carboxyhemoglobin level,
the level projected to time zero gives the most accurate informa-
tion about the degree of exposure. The rest of the answers are
incorrect.
The father has a headache and a time zero carboxyhemoglo-
bin level of 12%. The mother, who is pregnant, is asymptom-
atic and has a time zero carboxyhemoglobin level of 18%.
Both of the children are asymptomatic. The 6-year-old has a
time zero carboxyhemoglobin level of 18% while the 8-year-
old has a level of 23%.
Question 1.5.3 The first step in the treatment of these
patients is:
A) Start an IV and administer saline
B) Start N-acetylcysteine, which is a free radical scavenger
C) Start continuous positive airway pressure (CPAP) to maxi-
mize airflow by keeping the airways from collapsing
D) Administer 100% oxygen
E) Intubate the most severe patient, 100% oxygen for the others
Answer 1.5.3 The correct answer is “D.” Because CO competi-
tively binds to hemoglobin in place of oxygen and in fact has
greater affinity for hemoglobin than oxygen, high-flow 100%
oxygen is the cornerstone of treating CO poisoning. The half-
life of CO in a patient breathing room air is approximately 300
minutes; this is reduced to 90 minutes when breathing high
flow oxygen and reduced to 30 minutes when breathing 100%
hyperbaric oxygen. Thus, the first step in CO poisoning is to
administer 100% oxygen. The rest of the answers are incorrect.
If the patient is not ventilating well and requires intubation,
this would be appropriate, and the FiO2 should be set to 100%,
regardless of the patient’s pulse oximetry or arterial oxygen
readings. However, in our patients who are breathing without
difficulty, there will be no advantage (and much higher risk) to
intubation.
Question 1.5.4 Which of the following can be seen with
carbon monoxide poisoning?
A) Rhabdomyolysis
B) Cardiac ischemia
C) Long-term neurologic sequelae, including dementia
D) Pulmonary edema
E) All of the above
Answer 1.5.4 The correct answer is “E.” All of the above can
be seen with carbon monoxide poisoning. Additional findings
include lactic acidosis, seizures, syncope, and headache. “C”
deserves a bit more discussion. Long-term neurologic sequelae
can develop from days to months after the exposure and include
cognitive deficits, focal neurologic deficits, movement disor-
ders, and personality changes. It appears that using hyperbaric
Ch01.indd 10
oxygen in the appropriate patient can reduce long-term neuro-
logic sequelae.
Your closest diving chamber is about 90 minutes away and
will hold only one patient at a time. You need to make a deci-
sion about who to send for hyperbaric oxygen.
Question 1.5.5 Which patient will benefit most from
hyperbaric oxygen therapy?
A) Asymptomatic pregnant mother, time zero carboxyhemo-
globin of 18%
B) Asymptomatic 6-year-old, time zero carboxyhemoglobin of
18%
C) Asymptomatic 8-year-old, time zero carboxyhemoglobin of
23%
D) Adult male with mild headache only, time zero carboxyhe-
moglobin level of 12%
Answer 1.5.5 The correct answer is “A.” Generally accepted crite-
ria for hyperbaric oxygen include: mental status changes, asymp-
tomatic carboxyhemoglobin levels >25%, acidosis, cardiovascular
disease, and age >60. Obviously, these are relative criteria. An
otherwise normal 61-year-old with a mild exposure need not have
hyperbaric oxygen. Pregnancy is an indication for hyperbaric oxy-
gen therapy because fetal hemoglobin has a high affinity for carbon
monoxide, with the fetus acting as a “sink” for CO. The high aerobic
metabolic activity of fetal development is impacted greatly by expo-
sure to the anaerobic environment created by carbon monoxide.
Question 1.5.6 All of the following are well-established
consequences of hyperbaric oxygen EXCEPT:
A) Seizures
B) Psychosis
C) Myopia
D) Ear and pulmonary barotraumas
E) Direct pulmonary oxygen toxicity
Answer 1.5.6 The correct answer is “B.” All of the rest are
found as a result of hyperbaric oxygen. “C,” myopia, is found in
up to 20% of patients being treated with hyperbaric oxygen. It is
due to direct toxicity of oxygen on the lens and usually recovers
within weeks to months.
▶▶ Objectives: Did you learn to …
• Diagnose and manage patients with carbon monoxide
poisoning?
• Describe complications of carbon monoxide poisoning?
• Identify patients who may benefit from hyperbaric oxygen
therapy?
• Describe the complications of hyperbaric oxygen therapy?
▶▶ CASE 1.6
A 50-year-old man comes to your ED after being bitten by a
stray dog outside your hospital. Apparently, there is a prob-
lem with roving packs of feral dogs in your part of town. The
29-11-2019 12:14:53

bite was unprovoked and is on the abdomen. The patient has
no other health history of note and has not taken antibiotics
for over a year. There is a 3-cm laceration on the abdomen.
Question 1.6.1 All of the following are true about dog bites
EXCEPT:
A) They tend to be primarily crush-type injuries
B) In general, the infection rate is similar to a laceration from
any other mechanism (e.g., knife cut), except on the hands
and feet
C) A common organism in infected dog bites is Staphylococcus
aureus
D) Primary closure of dog bite wounds is an acceptable option
(except perhaps on the hands and feet)
E) They always require antibiotics
Answer 1.6.1 The correct answer is “E.” All of the rest are true
statements. Dog bites (except, perhaps, for those from teacup
poodles named Fifi) tend to be crush injuries (as contrasted
with cat bites and Fifi, which are primarily puncture wounds).
The infection rate is about the same as other lacerations. Bites
on the hands and feet tend to have a higher rate of infection.
Most dog bite infections are polymicrobial with mixed aerobic
and anaerobic bacteria. S. aureus is often present, along with
other organisms including Pasteurella and Capnocytophaga (say
that one ten times fast). Other organisms include Streptococcal
species and Gram-negative species. Dog bites do not generally
require antibiotic prophylaxis, except under certain circum-
stances (e.g., presentation >9 hours after bite, immunocompro-
mised, large, or complicated wound, perhaps hands and feet).
Question 1.6.2 You are concerned about rabies prophylaxis.
Which of the following is the best next step?
A) Isolate the suspect animal for 3 days
B) Sacrifice the suspect animal and examine the liver
C) Administer rabies immune globulin IM
D) Administer rabies immune globulin IV followed by rabies
vaccination series
E) Administer rabies immune globulin by infiltrating it around
the wound followed by rabies vaccination series
Answer 1.6.2 The correct answer is “E.” You should infiltrate
rabies immune globulin around the wound and then begin the
rabies vaccination series. Infiltrate as much of the immune glob-
ulin as possible around the wound and administer the remainder
IM at a different site. Do not give more than the recommended
dose of immunoglobulin. This can reduce the immunogenic-
ity of the vaccine. “A” is incorrect because the animal needs to
TABLE 1-4   GUIDELINES FOR RABIES PROPHYLAXIS
General Rule
Always assume rabid unless available for testing
Judge on an individual basis
Never require rabies prophylaxis
Ch01.indd 11
CHAPTER 1 • Emergency Medicine 11
be isolated for 10 days, not 3. “B” is incorrect. If captured, the
animal can be sacrificed, but the brain should be examined—
not the liver. “C” and “D” are both incorrect methods of admin-
istering the vaccine and immune globulin. Note that the average
incubation period of rabies is 85 days. So, immunizing up to
3 months (90 days) after the bite-event is indicated.
Question 1.6.3 Which of the following requires rabies
prophylaxis in all cases?
A) Stray rabbit bites
B) Stray rat bites
C) Stray bat bites
D) Stray squirrel bites
E) Stray snake bites
Answer 1.6.3 The correct answer is “C.” All bats should be con-
sidered rabid unless available for observation and testing. See
Table 1-4 for detailed recommendations. Also, see the CDC or
your state public health website for information about rates of
infection in wild animals in your area. Of note, there have been
rabid squirrels in Iowa City, our illustrious home: Google it.
HELPFUL TIP:
Patients should receive a tetanus booster every 10
years. For a contaminated wound, the tetanus booster
should be within the last 5 years. Patients should
receive at least one dose of Tdap (tetanus, diphtheria,
and acellular pertussis) between ages 11 and 18 and a
single dose between ages 18 and 64. In addition, health-
care workers and those > 65 years of age who will be
around infants should receive a single dose of Tdap (for
pertussis prophylaxis). Pregnant women should have a
Tdap with every pregnancy to protect the infant (week
27–30 seems optimal; Healy CM et al. JAMA 2018 Oct 9).
HELPFUL TIP:
If a patient at risk for tetanus has not had a primary
series of tetanus immunizations, administer tetanus
immune globulin, and start the primary tetanus series.
Children who have had at least 3 doses of their primary
series (routinely given at age 2, 4, and 6 months) are
considered “immune” and can be given a booster as
needed as listed above. DTaP is appropriate for children
aged 6 weeks to 7 years.
You decide to irrigate this patient’s wound.
Animals
Foxes, bats, raccoons, skunks, dogs, cats, ferrets, other carnivores
Rodents (rats, mice, etc.), lagomorphs (rabbits, etc.), squirrels
Non-mammals (snakes, lizards, etc.)
29-11-2019 12:14:53
 12 FAMILY MEDICINE EXAMINATION & BOARD REVIEW
Question 1.6.4 Which of the following statements is true
about irrigating a wound and subsequent risk of wound
infections?
A) Povidone-iodine as a 50% irrigation solution (e.g., Betadine)
in the wound will decrease the infection rate
B) Irrigation with normal saline is the only recommended
method of cleaning a wound
C) Irrigation with normal saline and irrigation with tap water
are equally effective in reducing wound infection rates
D) Use of lidocaine with epinephrine in a wound increases the
rate of infection
E) Irrigation of a wound with either alcohol or hydrogen per-
oxide will reduce the rate of wound infection
Answer 1.6.4 The correct answer is “C.” Infection rates (in the
United States) are the same whether the wound is irrigated with
normal saline or tap water. “A” is incorrect. Povidone-iodine is
toxic to tissue and polymorphonuclear leukocytes and actually
may increase infection rates unless a solution of 1% or less is
used. Full strength povidone-iodine can be used on intact skin
as a cleanser but should not be used in a wound. “B” is incor-
rect because other solutions (poloxamer 188, balanced salt solu-
tions, etc.) can be used but are more expensive and do not offer
any benefit in reduction in infection rates. “D” and “E” are both
incorrect. Use of lidocaine with epinephrine (“D”) may be war-
ranted for local anesthesia for further wound exploration and/or
closure. It has not shown to increase rates of infection. As with
povidone-iodine, alcohol (“E”) may be used for cleaning skin,
but should be kept out of the wound. It is toxic to tissue and acts
as a fixative. Hydrogen peroxide (“E”) is also toxic to tissue and
should not be used in open wounds—no matter what grandma
says! Chlorhexidine can also be used on intact skin (not in the
wound) and is more bactericidal than Povidone-Iodine.
Question 1.6.5 How long after a laceration occurs can the
wound be closed primarily?
A) 6 hours
B) 12 hours
C) 18 hours
D) 24 hours
E) Any of the above can be correct depending on the wound
Answer 1.6.5 The correct answer is “E.” There is no arbitrary
time limit to when a wound can be closed. Facial wounds may
be closed up to 24 hours after injury for cosmetic reasons, while
you may not want to close other, contaminated wounds more
than 12 hours after injury. Some wounds you may not want
to close at all (e.g., bites to the hand, wounds contaminated
with grease, wounds contaminated with manure, human bite
wounds), rather allowing them to close by secondary intention.
▶▶ Objectives: Did you learn to …
• Describe the indications for rabies prophylaxis?
• Recognize the issues that arise with animal bites and
indications for closure and/or prophylactic antibiotics?
• List recommendations for tetanus prophylaxis and
boostering?
Ch01.indd 12
• Use various wound irrigation solutions for cleansing
wounds?
• Decide upon the time frame for wound closure?
▶▶ CASE 1.7
A 52-year-old male presents to your ED via ambulance
complaining of a headache after a fall. He was working
and fell approximately 10 ft. He notes no injury except for
head and neck pain. A quick survey reveals that he has a
BP of 128/86 mm Hg, pulse 100 bpm, and respirations of
12. There was no loss of consciousness at the scene. He “saw
stars” and was clumsy, dazed, and cognitively slowed at the
scene without any focal neurologic deficit. He is now back
to his baseline.
Question 1.7.1 A concussion is defined as:
A) Any neurologic symptoms (e.g., clumsy, dazed, or slow, nau-
sea, dizziness) after head injury
B) Loss of consciousness followed by return to baseline
C) Loss of consciousness with continued neurologic
symptoms
D) Confusion after head trauma regardless of whether the
patient lost consciousness or not
E) Any traumatic injury to the head
Answer 1.7.1 The correct answer is “A.” A concussion is
defined as any neurologic symptom after head trauma. Note
that a concussion does not require a loss of consciousness. For
this reason, “B” and “C” are incorrect. “D” is incorrect because
manifestations of concussion are not limited to confusion, but
also include protracted vomiting, transient amnesia, slowed
mentation, “dizziness,” and other neurologic symptoms. “E” is
incorrect because by definition, a concussion requires neuro-
logic symptoms.
Your patient opens his eyes spontaneously, follows com-
mands, answers all orientation questions correctly, but
appears unsteady when ambulating.
Question 1.7.2 His Glasgow Coma Scale (GCS) is:
A) 5
B) 10
C) 14
D) 15
E) 20
Answer 1.7.2 The correct answer is “D.” The Glasgow Coma
Scale (GCS) is a scale used to indicate the severity of neuro-
logic dysfunction and is often applied to victims of head trauma.
Remember, however, that it does not predict mortality or mor-
bidity, but is only used as a descriptive scale of the patient’s
current state. Only the maximum score of 15 is considered a
normal GCS. There are three components to the GCS, listed in
Table 1-5.
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TABLE 1-5   GLASGOW COMA SCALE
Eye opening
Mnemonic: “4 eyes”
Verbal response
Mnemonic: “Jackson 5”
Motor response
Mnemonic: “Six Cylinders”
HELPFUL TIP:
Your chair and refrigerator each have a GCS of 3.
Remember that nothing can have a GCS less than 3.
Question 1.7.3 In patients with head injury, and
independent of other factors, a GCS score of 15 indicates
that:
A) The patient does not require a head CT scan
B) There is essentially no possibility that this patient has an
intracranial injury requiring surgical intervention
C) There is little or no possibility that this patient has any focal
intracranial bleed
D) There is up to a 4% chance this patient will need neurosurgi-
cal intervention
E) None of the above
Answer 1.7.3 The correct answer is “D.” In appropriately
selected patients (e.g., those with a significant mechanism of
injury), about 18% with a GCS of 15 will have some intracranial
lesion, and up to 4% will eventually require neurosurgical inter-
vention. These are generally patients who have a depressed skull
fracture but a normal GCS. “A” is incorrect since a normal GCS
in and of itself does not allow one to forgo head CT in patients
with a significant mechanism of injury. “B” and “C” are also
incorrect for the reasons noted earlier. Remember that the GCS
is not linear; a GCS of 14 is bad. Patients with a GCS of 14 must
have a CT scan—unless another factor in the clinical decision-
making dictates otherwise (e.g., the finding is preexisting from
dementia or otherwise).
Question 1.7.4 In an adult patient with a significant head
injury, which of the following is NOT an indication for a
head CT scan?
A) Intoxication with drugs or alcohol
B) Persistent vomiting
C) Amnesia or memory deficit
D) Age greater than 40
E) Seizure
Ch01.indd 13
CHAPTER 1 • Emergency Medicine 13
Spontaneous = 4
To speech = 3
To pain = 2
No response = 1
Alert and oriented = 5
Disoriented conversation = 4
Nonsensical speech = 3
Moaning = 2
No response = 1
Follows commands = 6
Localizes pain = 5
Withdraws from pain = 4
Decorticate flexion = 3
Decerebrate extension = 2
No response = 1
Answer 1.7.4 The correct answer is “D.” Older patients are at
greater risk of developing serious intracranial injuries, and the
age of 60 is usually considered an independent indication for a
head CT with significant injury. While there is no “upper limit
of normal” for vomiting after head trauma, the best data avail-
able suggest that any vomiting after head trauma in an adult
indicates the need for a head CT. The currently recommended
criteria for a CT of the head in various age groups are listed in
Table 1-6.
You obtain the head CT and find a subdural hematoma. You
arrange to transfer this patient for neurosurgical interven-
tion in order to drain the subdural hematoma. It is about a
4-hour drive by ambulance to the nearest facility that has a
neurosurgeon.
Question 1.7.5 Which of the following is indicated as
prophylaxis against increased intracranial pressure in this
patient?
A) Hyperventilation after intubation
B) IV mannitol
C) Trendelenburg position
D) IV dexamethasone
E) None of the above
Answer 1.7.5 The correct answer is “E.” None of the above is
indicated as prophylaxis for increased intracranial pressure. “A”
is incorrect for two reasons. First, this patient does not need to
be intubated. Second, routine hyperventilation as prophylaxis
for increased intracranial pressure is of no benefit. This has been
well studied. What happens is that hyperventilation does cause
vasoconstriction reducing intracranial blood flow and therefore
intracranial pressure. However, hyperventilation also causes
ischemia around the area of the injury secondary to the vaso-
constriction and may worsen outcomes. “B” is incorrect because
prophylactic mannitol, like prophylactic hyperventilation, con-
fers no benefit. “C” is incorrect. Trendelenburg positioning, or
elevating the legs above the heart, would result in increased
intracranial pressure. There is very limited data to support or
29-11-2019 12:14:53
 14 FAMILY MEDICINE EXAMINATION & BOARD REVIEW

TABLE 1-6   INDICATIONS FOR HEAD CT BY AGE

Indications for Head CT after Trauma with a Significant
Patient Age Mechanism
Adult Intoxication
Age >60
Any memory deficit
Vomiting (number of times undefined)
Seizure
Headache

PECARN Rules for Pediatric Head Trauma and Need for CT Scan (The Lancet. 2009;374(9696):1160–1170)

CT needed if:

Children >2 year GCS <15

Signs of a basilar skull fracture
Agitation, somnolence, slow responses, or perseveration
Vomiting
Loss of consciousness
Severe headache
Severe mechanism (Fall >5 ft, MVC with ejection, roll over, fatality)
Bike/pedestrian vs. car without helmet
High impact object
If there are changes during observation (MS change, worsening
headache, new or persistent vomiting), consider CT based on clinical
judgment

Children <2 years GCS <15

Palpable skull fracture
Agitation, somnolence, slow responses, perseveration
Scalp hematoma (except for frontal)
LOC >5 seconds
Severe mechanism (fall >3 ft, MVC with ejection, roll over, fatality)
Bike/pedestrian vs. car without helmet
High impact object
If there are changes during observation (MS change, worsening
headache, new or persistent vomiting), consider CT based on clinical
judgment. If child <3 months of age, consider parenteral preference and
consider scanning

refute prophylactic elevation of the head of the bed to prevent • Manage patients presenting with potential intracranial
increased intracranial pressure; while this will reduce intracra- injuries?
nial pressure, cerebral perfusion pressure will also be mildly
reduced. For treatment of increased intracranial pressure, there
is slightly more evidence for benefit of elevating the head of the ▶▶ CASE 1.8
bed (i.e., reverse Trendelenberg). “D” is incorrect since steroids
are not useful acutely in head trauma. However, steroids are A 23-year-old male is in a bar fight. He only had “two beers”
useful in cerebral edema secondary to tumor. and was just standing there “minding my own business” when
he was jumped by those infamous “two dudes” (how can
those two dudes be in so many places at once?). He presents
HELPFUL TIP:
to you about 1 hour after the event with facial trauma. His
About two-thirds of patients with a mild head injury (not
vitals are normal and he is mentating well (with the exception
deemed severe enough to obtain a CT scan) will have
of some impaired judgment secondary to the alcohol). His
some measurable decrement in function at 1 month
blood alcohol level is 150 mg/dL, showing that he is legally
secondary to post-concussion syndrome. Symptoms
intoxicated. On examination, you notice that the patient has
include headache, dizziness, difficulty concentrating,
some epistaxis and a quite swollen nose. In addition, there is
personality changes, etc. (J Emerg Med. 2011;40:262).
one avulsed tooth and one tooth that is displaced.

▶▶ Objectives: Did you learn to … Question 1.8.1 The best way to transport an avulsed
• Use the GCS? tooth is:
• Recognize which patients with head trauma are appropriate A) In sterile water
to obtain a head CT? B) In the buccal mucosa after thorough washing with soap

Ch01.indd 14 29-11-2019 12:14:54


C) In a glass of milk
D) Wrapped in saline-soaked gauze
E) Under a pillow
Answer 1.8.1 The correct answer is “C.” The best way to trans-
port an avulsed tooth is (1) in a glass of milk, (2) in Hanks’ bal-
anced salt solution (good luck finding this when you need it!),
or (3) in the buccal mucosa or under the tongue in a patient in
whom the risk of aspiration is not a concern. “A” is incorrect
because sterile water is hypotonic and may damage the tooth
root decreasing the success rate of reimplantation. “B” is incor-
rect because washing the tooth with soap is not appropriate.
Again, you want to maintain the viability of the root if possible.
“D” is incorrect as well. If this is the only option available to
you, it is better than nothing, but a glass of milk or under the
buccal mucosa is preferred. “E” is acceptable only if you are a
tooth fairy.
You call the dentist who is (of course) out of town. A dentist
will not be available for at least 12 hours.
Question 1.8.2 Your best course of action at this point is:
A) Continue to keep the tooth viable in a glass of milk
B) Continue to keep the tooth viable in the buccal mucosa
C) Clean the tooth and keep it sterile and dry for reimplan-
tation in 12 hours realizing that a bridge will probably be
needed to hold the tooth in position
D) Reinsert the tooth into the socket yourself
Answer 1.8.2 The correct answer is “D.” If there is going to
be any delay in reimplantation by a dentist, the best course of
action is to reinsert the tooth into the socket yourself. “A,” “B,”
and “C” are all incorrect because they will reduce the rate of suc-
cessful reimplantation.
HELPFUL TIP:
Primary (“baby”) teeth should NOT be re-inserted
into the socket! They ankylose to the bone preventing
the eruption of the permanent tooth and cause a cos-
metic deformity.
HELPFUL TIP:
Any patient who is in the ED, says he only had three
beers, and was “minding his own business” is probably
not telling the truth on either account.
You now turn your attention to this patient’s bloody nose and
are trying to decide whether or not to get an x-ray.
Question 1.8.3 The BEST timing for a radiograph of the
nose is:
A) As soon as possible after the trauma, once other injuries are
stabilized and more important problems are addressed
Ch01.indd 15
CHAPTER 1 • Emergency Medicine 15
B) As soon as possible to assure that there are no bone frag-
ments threatening the brain
C) There is no need for a radiograph acutely. You can wait for 3
or 4 days
D) There is never any indication for nasal radiographs
Answer 1.8.3 The correct answer is “C.” There is no need for
radiographs acutely except in extraordinary circumstances.
The reasons for a radiograph are to document a fracture and
to assist in reduction. Because of swelling, it is difficult to get a
good cosmetic result reducing a nasal fracture acutely. Thus, a
radiograph is indicated in 3 to 4 days only if there is evidence
of nasal deformity once swelling has resolved. If there is good
cosmesis and the patient can breathe through his (they are
almost always male) nose, a radiograph is unnecessary just to
document a fracture. “A” and “B” are incorrect because, as noted
earlier, there is no reason to do a radiograph at all unless there
is evidence of deformity once the swelling is resolved. “D” is
incorrect for the reasons noted earlier.
Question 1.8.4 You get the epistaxis stopped and examine
the nasal mucosa. Which one of these is considered an
emergency?
A) Closed nasal fracture
B) Septal hematoma
C) Trauma to Kiesselbach plexus
D) A deviated septum
Answer 1.8.4 The correct answer is “B.” A septal hematoma
is considered an emergency. The problem is that the perichon-
drium, which supplies nutrition to the septum, is no longer in
contact with the septum because of the intervening hematoma.
Thus, the septal cartilage can necrose leading to a perforated
septum. Septal hematomas should be drained acutely and the
nose packed to keep the perichondrium in contact with the
septal cartilage. “A” is incorrect (see previous question). “C”
is incorrect. Kiesselbach plexus is in the anterior nose and is
a venous plexus. Bleeding is easily controlled and generally is
self-limited. “D,” a deviated septum, may indicate an underlying
fracture but in and of itself is not an emergency.
You continue to evaluate this patient and note that he has the
loss of upward gaze in the right eye, the side on which he was
hit. All of the other extraocular motions are intact.
Question 1.8.5 The most likely diagnosis in this patient is:
A) Blowout fracture with entrapment of the inferior rectus
B) Blowout fracture with dysfunction of the superior rectus
C) Injury to cranial nerve III, which controls the superior AND
inferior rectus muscles
D) Volitional refusal to perform upward gaze on the right side
in this intoxicated patient
Answer 1.8.5 The correct answer is “A.” The most likely diag-
nosis is blowout fracture with entrapment of the inferior rectus.
The force of a blow to the globe is transmitted to the inferior
orbital wall, which is the weakest point in the orbit. This can
29-11-2019 12:14:54
Another random document with
no related content on Scribd:
The Project Gutenberg eBook of Don
Sebastian
This ebook is for the use of anyone anywhere in the United States
and most other parts of the world at no cost and with almost no
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under the terms of the Project Gutenberg License included with this
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you are located before using this eBook.

Title: Don Sebastian

or, The house of the Braganza: An historical romance. vol. 4

Author: Anna Maria Porter

Release date: December 6, 2023 [eBook #72343]

Language: English

Original publication: London: Longman, Hurst, Rees, and Orme,

1809

Credits: Chuck Greif and the Online Distributed Proofreading Team

at https://www.pgdp.net (This book was produced from
images made available by the HathiTrust Digital Library.)

*** START OF THE PROJECT GUTENBERG EBOOK DON

SEBASTIAN ***
 DON SEBASTIAN;

OR,

THE HOUSE OF BRAGANZA.

J. M‘CREERY,Printer,
Black-Horse-Court, Fleet-Street, London.

DON SEBASTIAN;

OR,

THE HOUSE OF BRAGANZA.

AN HISTORICAL ROMANCE.

IN FOUR VOLUMES.

BY MISS ANNA MARIA PORTER.

 AUTHOR OF THE HUNGARIAN BROTHERS.

Take Physic, Pomp!

Expose thyself to feel what wretches feel,
So shalt thou shake the superflux to them,
And shew the Heavens more just.
King Lear.

VOL. IV.

LONDON:

PRINTED FOR LONGMAN, HURST, REES, AND ORME,

PATERNOSTER ROW.
———
1809.

CHAP. I., CHAP. II., CHAP. III., CHAP. IV., CHAP. V.,
CHAP. VI., CHAP. VII., THE CONCLUSION.

DON SEBASTIAN;

OR,

THE HOUSE OF BRAGANZA.

 CHAP. I.
After serious reflection Sebastian came to the determination of
sacrificing his domestic comforts to the ultimate good of his people and his
child: the conflict was over with himself, but how was he to conquer the
heart of Kara Aziek? of that tender mother, who “chid the winds of
Heaven,” if they blew too roughly on the face of her darling?—that tender
mother and faithful wife, who saw so much of virtue and happiness around
her dwelling at Cachoeira, that she knew not where the world could shew a
station more productive of either.
Dreading the excess of her grief, yet arming himself to encounter it,
Sebastian quitted his solitude, and went forth to seek her.
He found her with Blanche, just returning from their village church,
where they had been witnessing the marriage of an Indian girl with one of
the most enlightened and amiable of her tribe. The happy scene from which
they were come, had lighted up the countenances of each: Blanche was yet
too young for complete sympathy with the blushing Izamba, but her heart
sympathized with happiness of any sort; and the tear of benevolent pleasure
which stood on the cheek of her mother, called a shower over hers.
Gently walking under a long line of cedars shading the Cachoeira,
Sebastian descried them afar off.—The full and perfectly-formed figure of
Kara Aziek, her slow soft step, the gentle dignity which distinguished her,
were contrasted by the slight and budding graces of Blanche’s more airy
form. Her step was quick, bounding, and uncertain as the young Gazelle’s;
her looks were timid, not majestic; and like spring preceding summer, she
sportively advanced, admiring every object she had seen and admired a
thousand times before.
Sebastian scarcely descried her ere she was at his side: by an irresistible
impulse he took her in his arms, and holding her to his heart, suffered the
tears he could no longer restrain, to fall over her face.
It was the first time that Blanche had ever felt her father’s tears; she
looked up, and the bright roses of health and delight faded from her cheek.
 “Be not alarmed, my child!” he whispered in a faltering voice, as he let
her go again, “I will rejoin your mother soon—speak not to her of this
weakness—I must explain it myself.”
Having spoken, he turned away, and hurrying towards a sugar-mill,
which he entered, as if intent on business, left Blanche to wait for her
mother, who seeing nothing extraordinary in this conduct of her husband,
entered her own habitation.
It was long ere Sebastian sufficiently recovered himself to join Kara
Aziek; the smile with which he dressed his pale countenance could not
conceal from her the unusual agitation of his heart: she fearfully inquired its
cause, and was answered by a cautious explanation of De Castro’s situation
and engagements.
Kara Aziek listened to him in profound silence, which she did not break
till some moments after he had concluded; she then turned on him her
expressive eyes; no tears were there, but they were full of that maternal
anguish she felt called upon to control.
She looked tenderly at him, as if she believed him unable to avert the
calamity with which she was threatened, and as if she considered him
equally with herself, an object of compassion. “I submit:” she said at length,
turning her eyes from her husband and fixing them on Heaven; “There are
periods in which I dare not yield to my feelings. That God who has blessed
us with our Blanche, calls her now to become an instrument for her father’s
restoration: I may not detain her.”—
At the last words, Kara Aziek closed her eyes as if she would have shut
from her husband’s sight the anguish of her soul: a general trembling seized
her, and unable to relieve herself by tears, she made an effort to smile, and
pressing his hand, leaned her face upon his shoulder.
Sebastian gently supported her. This unresisting acquiescence, this
uncomplaining grief, affected him far more than the most violent despair: in
proportion as his Aziek appeared more worthy of happiness, her different
destiny seemed more cruel.
“Dearest and best of women!” he exclaimed, “is it to day that I am to
receive the strongest proof of that love which has been the angel of my life?
—You know my heart, and you spare me the misery of contending with
tenderness for you, and duty to Portugal: you weep not, you complain not!
—O my Aziek, am I then indeed, dearer to thee than the child to whom thou
gavest birth?—I expected lamentation, remonstrance, shall I confess it?—
sorrowful reproaches—I find gentleness and heroism; I find that I am still
the first in that precious heart.”—
Transported out of himself by such a conviction, Sebastian folded his
arms around his wife, whose countenance suddenly glowing with vivid
emotion, was now bathed in tears. Instantaneously melted by this burst of
affection, she wept profusely, but her tears had no bitterness in them; she
forgot at that moment the impending evil she had been contemplating.
By degrees this rapture subsided, and the separation from her daughter
returned in all its force. “I will try to merit these kind praises:” she said
faintly, “but my heart may not always have such strength: pardon me
therefore Sebastian, if some moments of weakness should make me the
selfish creature you feared to find me. Remember that in this discourse I
have spoken my real sentiments, and do not attend to the temporary ravings
of a mother, who cannot always hear the voices of Reason and Religion;
who cannot always obey their commands. In my soul I am convinced we
ought to make this sacrifice; as such, it shall be completed.”
Again the tears of Kara Aziek ceased to flow, and her features resumed
their former paleness. Sebastian still looked at her with a mixture of anguish
and delight. His affection was eloquent, and repeated tributes to the
fortitude he admired, contributed to support and to console Kara Aziek.
One important matter yet remained to be discussed; should they or
should they not suffer Blanche to depart without knowing the story of her
birth?
Many arguments in favor of each line of conduct presented themselves
during this interesting discussion; but those had the most weight, which
dictated explanation.
Blanche was of an age and a character to feel the value of such a
confidence: the knowledge of her parents misfortunes would surely endear
them to her heart; and when widely separated, that anxiety which must
result from her acquaintance with their critical situation, would form still a
link of union. Their thoughts, their wishes, their solicitudes, would yet
remain the same, though their persons might be divided; it would be
impossible for Blanche not to remember and to love her parents, when her
dearest interests were inseparably interwoven with their images.
 In addition to this consideration, Sebastian urged one equally important:
Blanche would sooner attain the qualities requisite for her future guidance
through life, by this early call upon them. Discretion, courage, attentive
observation of persons and events, careful calculation of actions, and their
consequences, would be the natural fruit of thus giving her a necessity for
all these properties.
With the prospect of one day filling a station of responsibility, seeing in
the example of her father the awful vicissitudes to which even monarchy is
exposed, and feeling, in her own person, the dependance of man on man,
she would avoid the risk of becoming intoxicated with a distinction which
presented itself under a shape so forbidding.
Her imagination, chastized by experience, and her heart disciplined by
early care, would mature, fix, and ennoble her character: if Providence
should call her to a throne, that education would enable her to fill it with
honour; if destined to pass her life in obscurity, the memory of her parents
lot, would teach her the emptiness of the world, and the rarer treasures of
that benevolence which makes joy to itself in every station.
If blind to the advantages of candour, Sebastian should permit Blanche
to depart in ignorance of her real condition, he reflected, that she must go
with either a sentiment of curiosity about the concealed motives of her
parents, or with a sentiment of disappointment at their seemingly-lukewarm
affection: continual deception must be practised on her; and bearing away
with her no quickening principle of anxiety, her filial love would soon
languish.
The remembrance of her happy home, would, from its very happiness,
only serve to excuse her to herself for ceasing to feel an animated interest in
its inhabitants; and delivering up her young mind to the charms and
novelties of a gay life, she would perhaps lose much of her goodness and all
her simplicity.
These reflections decided Sebastian, for Kara Aziek had decided at first,
from the mere impulse of feeling.
Having left his Aziek seeking additional strength at that sacred source
whence human virtue is derived, he sought Gaspar, and imparted to him the
resolution to which he had brought himself: Gaspar’s emotion was purely
joyful; he neither dreaded dangers nor difficulties, oceans, nor dungeons,
when the prospect of being useful to his King lay before him.
 His sanguine nature made him certain that he should not be long
separated from Sebastian: the destruction of Spanish tyranny, and the
restoration of Portugal, were events that he concluded must follow the
interference of England; he was but leading his sweet young mistress to a
triumph, not to a struggle; he was but going to make the path broad and
open which led back to the throne of her ancestors.
“We part, Sire! it is true;” he said, “yet what is our parting?—we shall
meet again, and meet in happiness. I feel that Providence has now set a
period to your trials: this is the epoch destined for the recovery of your
former possessions.—We shall reach England—England will raise her
powerful arm, and as if by magic, the whole mass of foreign tyranny will
crumble to dust. My honoured young mistress will then be given to the
Portuguese as a pledge that their beloved sovereign yet lives, and will
condescend to reign over them: you will arrive, Sire, to find in your own
kingdom, power, adoration, and happiness!”
“Not adoration Gaspar,” said Sebastian, smiling kindly, “not adoration,
that is an impious tribute to kings, which, thank God, I never required, nay,
which I abhorred, even in my proudest day.—If I may regain the love of my
people, by convincing them that a parental tenderness for them glows in this
time-tried heart, I shall indeed rejoice that the meridian hours of my life are
not to pass away at Cachoeira. Marvellous destiny! (he added after a
thoughtful pause) shall I ever again find myself the ruler of a mighty nation
—the arbiter of their fates—the earthly God to punish and to reward?—
When I look back to the period in which I was this powerful creature, it
seems to me a long-past dream; suffering and seclusion, the only realities!”
“Not so, Sire!” gravely observed Gaspar, “you are a sovereign and a God
at Cachoeira; you are the happiest of husbands and of fathers,—and do you
say that there are no realities but suffering and seclusion?”
Sebastian fixed his eyes on him, with a look of generous approval,
“Ever, my friend!” he exclaimed; “ever watchful over my character as much
as my interest! I spoke, Gaspar, in a way too familiar with me: I spoke from
the impression of one recollection only; I remembered therefore my losses,
and forgot my possessions. Be satisfied, my soul is fully sensible of the rare
blessings I enjoy. Had I not lost my liberty and crown, I should never have
been the happy father and husband, never have opened my eyes on the light
of pure Christianity: this thought makes me consider my misfortunes as
benefits.”
Gaspar expressed his satisfaction at so ingenuous a confession of error,
and proceeded to name the time and preparations that would be required,
ere he could commence his voyage.
He knew that merchant-ships were then in the bay of St. Salvador, bound
for St. Lucar: in one of these, it was agreed he should procure a passage for
himself and his young charge, with whom he might easily proceed from St.
Lucar to Messina.
Nothing was more common than for the children of Brazilian settlers to
be sent to Europe for their education or health, and one of these motives
would certainly be attributed to Blanche’s separation from her parents,
should any persons think such an event of sufficient consequence to employ
their thoughts.
Charged with securing the cabin of the merchant-ship, and with
providing all things requisite for a tedious voyage, Gaspar hastened to St.
Salvador, leaving sadness in that house, which until now, never knew more
than the shadow of passing clouds.
The interview with his daughter was a trying hour to Sebastian: Kara
Aziek declined being present: her heart dreaded itself; and the nearer drew
the moment in which she was to make the sacrifice demanded, the more her
fears and her agitation increased.
“If I should fail at last!” she constantly repeated to herself, while striving
to strengthen her resolution by the recollection of Sebastian’s
commendations; “if I should disappoint his trust in my promise of
submission! ah God! pity me, succour me, support my feeble spirit, and
give me that added confidence in thy mercy, that added tenderness for his
feelings, which may successfully wrestle against the despair of a mother.”
Impressed with a sense of her own weakness, Kara Aziek fled from
every scene which could enervate her still further, courageous from that
very tenderness of character, with which her courage had to struggle, she
refused to herself the luxury of indulging her grief, and of participating in
that affecting interview which must increase it.
While she surrounded herself by various occupations, forcibly wresting
her mind towards the interest of others, Sebastian was unfolding to their
daughter the wonderful story of his youth.
 Her amazement and sympathy may be imagined; they were in proportion
to the sensibility of her character: but Sebastian looked beyond these, and as
he slowly related the events of his life, and pointed out the lessons to be
learned from them, he watched their effect on her who might hereafter need
such beacons to guide her in the same course.
A serious joy warmed his heart, when he beheld the impression made by
the knowledge of her birth: looks of trouble and apprehension were
instantly diffused over her features: she was not ambitious therefore: to
inspire her with zeal for her own rights, it would be requisite to teach her
the benevolent purposes to which they might be directed.
No parts of her father’s narrative so absorbed the attention of Blanche, as
those which related to her mother. While Sebastian detailed the variety of
Kara Aziek’s destiny, and the transitions from pain to pleasure which they
had had mutually endured, the eyes of Blanche alternately shone with the
brightness of joy, or fell to the ground blinded with tears. It was evident,
that from the moment Kara Aziek appeared upon the scene, her affectionate
child saw in her love the best blessing of life, and ceasing to think of her
father’s loftier anxieties, was solely interested in reaching the moment
which gave her parents to each other.
Once, and only once, did her agitated heart burst through the restraint
which delicate timidity, and filial respect had imposed: it was at the
description of Sebastian’s return to Portugal, at the reception of Donna
Gonsalva, and the conversation of the two noblemen at the house of Lopez
Vernara.
Powerfully moved by these incidents, she suddenly threw herself on the
bosom of her father, exclaiming, in a voice broken by sobs, “Ah send me
not to such a dreadful world! let me not live with people who have thus
outraged my dearest father!”
Much affected by a sensibility as just as it was exquisite, Sebastian
strained her to his breast, and lifting up the scattered ringlets from her
cheek, he kissed it fondly. That roseate cheek, those eyes now closed with
grief, but lovely still from the long lashes which fringed them, the soft arms
that twined around his neck, and the beautiful tresses which fell dishevelled
over them, all these were so like his Aziek’s, that he repeated his caresses,
and abandoned to a moment of weakness, whispered, “Should I not risk all
things to go with my child?”
 At this unexpected dawn of hope, Blanche raised her face, the sunshine
of happy youth was on it. “O my father;” she cried, “let us go together!—
my mother, my dear mother too—we cannot live without her.”
Sebastian had now recovered himself, and sorrowing to destroy the
illusion his own words had raised, he proceeded in a calmer tone, to explain
to her the weighty reasons which rendered it necessary for him to trust the
judgment of De Castro, and to act by his suggestion: he alone could decide
on the prudence of measures, which must be influenced by the conduct of
those potentates amongst whom he was acting.
Blanche had been early taught to yield to the voice of reason: the
moment she was convinced that what she wished was hostile to her better
interests, or blameable in itself, she ceased to form a wish on the subject.
She submitted to the commands of duty, as to the irreversible decrees of
Heaven.
This valuable habit of moral obedience, now enabled her to acquiesce in
the dreary prospect of separating from her parents, and committing herself
to a world, of which the history had made her afraid. She wept bitterly; but
she frequently repeated, that she saw her father could not in justice to
himself and his country, and in gratitude to those friends who were now
risking their lives for his sake by secret correspondence with the enemies of
Philip, do otherwise than grant them some rallying point like herself.
Sebastian contemplated her as she sat struggling against her grief,
kissing his hands and looking at him with humid smiles: Sebastian
contemplated her with many an admiring thought. He contrasted her
character and conduct with what his own had been at a much more forward
period of youth: at that period the whole globe was scarce large enough for
his tempestuous passions to rage in. Shame and compunction were on his
brow. “Blanche,” he exclaimed, “if the certainty that you possess the fullest
love, the most perfect approbation of your father, can give comfort to your
heart, be assured that you do possess them—never my child, never were
you half so dear or so estimable to me, as at this moment.”
Blanche started from her seat, and threw herself before him; Sebastian
bent towards her, and holding her against his breast in the lovely attitude in
which she had placed herself, he resumed his discourse. “Cultivate this self-
government which ennobles you thus in a parent’s eyes!—O my daughter,
self-government is dignity, is happiness, is dominion!—’tis the secret of
disarming adversity of its sting—’tis the virtue which comprehends all
others—’tis that which will entitle you to a crown in Heaven!—Had I been
like thee, my child, at this instant I should have nothing to reproach myself
with; I should have been dwelling in the house of my fathers, and I should
not have had to send my innocent Blanche into a faithless world in search
of that possession which my folly threw away.”
He stopt, and several deep sighs followed his words. Blanche kissed his
hand with repressed ardour; her timid voice trembled as she spoke. “You
have profited by your chastisements, dearest father, or how should I have
become the character you praise?—ah me! shall I always remain so? your
virtues have sprung up out of your trials; and mine perhaps may die under
them.”
Struck with the justice of this observation, and charmed with the salutary
humility which it proved, her gratified father pursued the theme she had
begun, and discoursing on principles and passions, on trials and
temptations, forgot the lapse of time.
Kara Aziek’s voice near the windows of the apartment in which they sat,
roused him to recollection, and taking Blanche by the hand, he went forth to
join her mother.
By the same impulse, Kara Aziek and her daughter pressed each other in
their arms without speaking; Sebastian approached, and drew them towards
him! he too was silent: after some moments of extreme emotion, they
recovered themselves, and rose from this sad embrace. The faces of Kara
Aziek and Blanche were bathed in tears, that of Sebastian was pale, but
more composed.
As if by tacit agreement, no one ventured to speak of the only subject
that engrossed their thoughts: their conversation was serious, and
interrupted by long pauses, but it was evidently connected with their most
interesting reflections.
Not till she was alone with her daughter, a few days previous to her
departure, had Kara Aziek courage to name the trial they were about to
encounter: at this instant fortitude forsook her, and the weeping Blanche
beheld for the first time, her gentle and hitherto patient mother, given up to
an agony of despair.
Periods like these, are not those in which human comfortings avail: the
soul must seek and find its comforter in itself. It must be habituated to
believe that all the decrees of Heaven are wise and good; then will sorrow
gradually subside, and a consolation past utterance will succeed to
distraction.
Experience had taught this most precious lesson to Kara Aziek; for often
had she had occasion to feel in her own person, and through that of her
husband, that

“We, ignorant of ourselves,

Beg often our own harms, which the wise powers
Deny us for our good: so find we profit
By losing of our prayers.”

The silent caresses and touching tears of her daughter, contributed to

console, rather than to afflict her: so sweet, so amiable, so excellent a
creature, was she not destined to ornament and to bless mankind?—The
heart of a fond mother answered in the affirmative; and like the sick person
who courageously bears the crisis of a disorder when the paroxysm is
expected to work his cure, she roused herself to support a parting which she
hoped would lead to permanent re-union.
Though flattering herself that many months would not elapse ere the
path should be open for Sebastian’s return to Portugal, she exhorted
Blanche, as if their separation were to endure for years: her admonitions
were few and impressive; she had nothing new to teach her daughter, but
what she had been hitherto teaching her every day by example rather than
precept, she now summed up, in easily-remembered maxims.
This discourse with her mother was never forgotten by Blanche.
Gaspar had provided the accommodations requisite for his young
mistress; all their arrangements were completed, and the day was fixed for
the sailing of the vessel which was to convey them to Europe. Sebastian
confided to his friend a packet for Don Emanuel De Castro, signifying the
extent to which he would engage himself with any foreign power willing to
assist him: this packet contained also a letter to Queen Elizabeth, which
Blanche was to deliver at their first meeting.
Sebastian had written with the dignity of a King, and the tenderness of a
father: by the warmth of his paternal expressions, he sought to make her
sensible that she could not hope to injure or distress his child with impunity.
He expressed himself strongly, yet with such courtly address, that although
Elizabeth must feel his meaning, and see his doubts, she could not openly
reply to them.
The hour of separation drew near; the ship was to sail on the morrow.
Having resolved to let no other objects share her heart with her parents,
at that moment in which she alone would occupy theirs, Blanche took leave
of the Indians on the preceding evening: their uncontrolled lamentations
affected her powerfully; and it was not till the night was far advanced, that
she recovered from the mournful impression.
Day-break awoke her: when she first opened her eyes at the rustling of
the breeze among the tall tops of a grove of Magnolias, when she saw their
beautiful foliage, and heard the birds singing from their branches, she felt a
sudden shock; for this was the last time in which she should see these trees,
or feel this air!
She was going far away! she was going from her parents! at this
conviction a death-like sickness oppressed her very heart; she sunk back on
her pillow, and believing the effort impossible, resigned herself to an excess
of despair. The tears which she shed in floods, gradually relieved her
feelings, and left them more obedient to her will: she repeated to herself the
injunctions and arguments of her parents, she strove to fix a short period for
the continuance of their separation, and having recourse to devotion, was
enabled to quit her chamber with a tolerably serene countenance.
It was yet early day; no one else was stirring, and Blanche rose thus
soon, that she might take a parting look at the recent grave of Barémel.
This playmate and guardian of her infant days, had died of old age, and
was buried by Sebastian himself under a cluster of Palmito’s in his garden.
No stone, with indecent resemblance to the monument of departed man,
marked the place where he laid; but a circle of plaited reeds enclosed the
little mound, and Blanche often stole there, to cover the bed of her favorite
with flowers.
She now moved lightly and timidly towards it, half-ashamed of a
sensibility it was amiable to feel. O lovely season of youth! how sweet art
thou to behold, with thy attendant graces of modesty, susceptibility, and
self-distrust!
The colours of the blooming flowers through which she passed painted
the soft complexion of Blanche; hers was the complexion that announced a
tender and intelligent heart, for it varied with every thought and every
feeling; it was now flushed with strong emotion.
She approached Barémel’s grave, and was going to throw herself upon it
with a violence of sorrow pardonable at her early age, when she was
checked by the apprehension of its being criminal.—“Yet he was so loving,
and faithful!” she exclaimed, tears trembling in her eyes, “I think it cannot
be wrong to remember him with affection.” Her innocent heart decided in
the affirmative, and sitting down near the grassy heap, she strewed it with
blossoms, and gave loose to her tears.
Her mind was quickly thronged with long-past images: different epochs
of holidays and festivals in which Barémel had constantly performed some
amusing part; passed in review before her. She remembered his joyful bark,
his supplicating whine, his watchful and loving looks, his unwearied
attendance of her from infancy to youth, over all the romantic region that
surrounded Cachoeira. “Poor Barémel! I can never see thee again!” she
said, sighing: that apostrophe conveyed to her heart a salutary exhortation
to take comfort on a far dearer subject.
She was indeed going to quit her parents, but not for ever; they were yet
in the flower of their lives, and Providence therefore permitted her to
anticipate their future re-union. Blanche was of a grateful disposition; she
loved to be happy, and far from partaking in the nature of those wretchedly
tempered spirits who seem to feast on discontent, and refuse to be
comforted; she opened her soul to admit the smallest particle of
consolation.
Her reflections now assumed a more serious cast, (for they were
employed in enumerating the mercies she yet possessed, and those she
might anticipate without presumption,) but they were no longer afflicting:
anxious to seize this moment of resignation for appearing before her
parents, she got up, and giving a long look of regret to the resting-place of
her early companion, turned homeward.
Sebastian was advancing in search of her: “I have only been to look at
poor Barémel’s grave,” she said blushing, “since you have told me all that I
owe to him, his memory has become almost sacred to me, he saved my dear
father’s life.”
Blanche added the last sentence with trepidation which shewed she was
eager to give an honorable excuse for what might have been deemed a
weakness. Sebastian pressed her hand as he led her forward: “like thy
mother in all things!” he observed, “ever diffident of thy best and most
engaging actions!”
They proceeded in silence to the apartment of Kara Aziek: she had yet
many things to say, or to repeat, and she was now gathering fortitude to
pronounce them calmly. Blanche sat down between her parents: each held
one of her hands, and frequently pressed it; but as yet, none of them spoke:
their eyes were fixed on the ground.
Why is it that the dearest connexions, when about to lose sight of each
other, avoid looking on the countenance they love, and which they will so
soon long to behold again? is it that the soul instinctively prepares for its
calamity, and tries to soften the pang by gradual abandonment of its
enjoyments? or is it that grief would be uncontrollable if those delightful
feelings were indulged which we are conscious must end with the removal
of the person beloved?
Whatever be the motive, its effect was seen in the family at Cachoeira:
they remained silent and immovable, drawing by stealth long and
interrupted sighs. They were summoning resolution to speak of parting.
At this moment Gaspar hastily entered; every eye was raised towards
him: “The ship sails an hour earlier than we expected, a messenger has just
come from St. Salvador to say so, we have not an instant to lose.”
Kara Aziek uttered a loud shriek, and clasped her daughter in her arms;
they had started up at Gaspar’s first words, and now remained clinging to
each other. Tears, sobs, broken exclamations, embraces repeated again and
again, were the witnesses of their sorrow.
Gaspar called on them to remember the fatal consequence of delay:
almost subdued himself, he yet had courage to appear barbarous, that he
might shorten the pangs of others.
Blanche heard him not: she flung herself alternately from the arms of
one parent to those of the other, and as she deluged their bosoms with her
tears, she called on them to assure her that their separation should not be
eternal.
Cold damps stood on the brow of Sebastian, for the pains of death were
in his heart, but his eyes were tearless. Kara Aziek was like one frantic; her
softness had given place to a wild and resisting despair: she clung to her
child, and no remonstrances had power to loosen her grasp!
 Sebastian trembled for her reason, and that fear gave him strength to
accomplish what he knew to be indispensible. He advanced towards his
wife, forcibly, yet tenderly, unlocked her hands as they met round the waist
of Blanche, and hastily pushing his daughter towards Gaspar, exclaimed,
“Go, go my child! if you would not kill your mother. I have, I have blessed
you—I bless you again.”
Gaspar had seized the arm of Blanche, while his agitated master was
trying to detain Kara Aziek; he now led the former towards the door, and
lifting her up, ran with her from the house to the caloche which was to carry
them to St. Salvador.
On reaching the carriage, he found that she had fainted; less alarmed at
this natural effect of sorrow, than he would have been grieved by her
lamentations, he got into the vehicle, and supporting her against his
shoulder, proceeded to bathe her temples with a pungent essence he usually
wore about him.
His exertion succeeded, Blanche revived: she looked round, and seeing
herself on the road, she knew that all hope of present change was desperate:
her eyes closed again, but it was only to weep with less obviousness, and to
preserve their last look of her parents.