Fundamentals of Family Medicine: The Family Medicine Clerkship Textbook

624 Pages·2003·10.05 MB·English

by  Robert B. Taylor M.D., Alan K. David M.D., Scott A. Fields M.D., D. Melessa Phillips M.D., Joseph E. Scherger M.D., M.P.H. (eds.)

Fundamentals of
Family Medicine
Third Edition
Springer-Science+Business Media, LLC
Fundamentals of
Family Medicine
The Family Medicine
Clerkship Textbook
Third Edition
ROBERT B. TAYLOR, M.D. Editor
Professor of Family Medicine
Oregon Health & Science University
School of Medicine
Portland, Oregon
Associate Editors
ALAN K. DAVID, M.D. SCOTT A. FIELDS, M.D.
Professor and Chairman Professor and Vice Chairman
Department of Family and Department of Family Medicine
Community Medicine Oregon Health & Science University
Medical College of Wisconsin School of Medicine
Milwaukee, Wisconsin Portland, Oregon
D. MELESSA PHILLIPS, M.D. JOSEPH E. SCHERGER, M.D., M.P.H.
Professor and Chairman Dean, College of Medicine
Department of Family Medicine Florida State University College
University of Mississippi School of Medicine
of Medicine Tallahassee, Florida
Jackson, Mississippi
, Springer
Robert B. Taylor, M.D.
Professor of Family Medicine
Department of Family Medicine
Oregon Health & Science University
School of Medicine
Portland, OR 97201-3098, USA
Associate Editors
Alan K. David, M.D. Scoltt A. Fields, M.D.
Professor and Chairman Professor and Vice Chairman
Department of Family and Department of Family Medicine
Community Medicine Oregon Health & Science Uni versity
Medical College of Wisconsin School of Medicine
Milwaukee, WI 53226-0509, USA Portland, OR 97201-3098, USA
D. Melessa Phillips, M.D. Joseph E. Scherger, M.D., M.P.H.
Professor and Chairman Dean, College of Medicine
Department of Family Medicine Florida State University College
University of Mississippi School of Medicine
of Medicine Tallahassee, FL 32306-4300, USA
Jackson, MS 39216-4500, USA
With 30 ilIlustrations
Library of Congress CataIloging-in-Publication Data
Fundarmnentals of family medicine : the family medicine clerkship textbook 1I
Robert B. Taylor, editor.-3rd ed.
p. cm.
''Consists of an overview of the principles of generalist healthcare followed by 27 ailil
new chapters from the 6th edition of Family medicine"-Pref.
Includes bibliographical references and index.
IrSBN 0-387-95479-1 (softcover : a1k. paper)
1. Family medicine. Ir. TiUtle: Family medicine clerkship textbook. II. Taylor, Robert B.
m. Family medicine.
RA418.5.F3 F86 2002
616-dc21 2002020938
ISBN 978-0-387-95479-0 ISBN 978-0-387-21745-1 (eBook)
DOI 10.1007/978-0-387-21745-1
Printed on acid-free paper.
© 2003, 1999, 1996 Springer Science+Business Media New York
Originally published by Springer-Verlag New York, Inc in 2003
AIlIl rights reserved. This work may not be translated or copied in whole or in part without the writ-
ten permission of the publisher (<SSpprriinnger Science+Business Media, LLC) except for brief
excerpts in connection with reviews or scholarly analysis. Use in connection with any form of
information storage and retrieval, electronic adaptation, computer softwarree,, or by similar or dissimil-
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is not to be taken as an expression of opinion as to whether or not they are subject to proprietary
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While the advice and information in this book are believed to be true and accurate at the date of go-
ing to press, neither the authors nor the editors nor the publisher can accept any legal responsibility
for any errors or omissions that may be made. The publisher makes no warranty, express or implied,
with respect to the material contained herein.
9 8 7 6 5 432 SPIN 10955314
www.springer-ny.com
Preface
This third edition of Fundamentals of Family Medicine is designed to be the
course textbook for Family MedicinelPrimary Care Clerkships in medical schools
and a reference source to manage the everyday health problems seen in family
practice. The chapters that follow are intended to describe the process by which
family physicians provide high quality, comprehensive care for their patients,
and to serve as the basis for small group discussions by students and faculty.
The book consists of an overview of the Principles of Generalist Healthcare,
followed by 27 all new chapters from the 6th edition of Family Medicine: Prin-
ciples and Practice. l I selected the chapter topics based on the content of gen-
eral and family practice as recorded in the National Ambulatory Medical Care
Survey (see Chapter 1, Table 1.1) and on the patient care problems seen by the
physicians in our own Family Health Center.
This third edition contains two topics not discussed in prior editions of the
book. The first is Chapter 27, ''The Family Physician's Role in Responding to
Biological and Chemical Terrorism." Since the second edition, the possibility
that the family physician may face the threat or actual event of a terrorist attack
has become a grim reality. The other new chapter is "Information Mastery: Prac-
tical Evidence-Based Family Medicine," an approach that is reflected in all clin-
ical chapters in the book.
Preparing medical students to deal with uncertainty and diverse types of clin-
ical challenges is an important goal of medical schools.2 One key to develop-
ing this vital competency is understanding how the family physician can iden-
tify, prioritize, and manage the mUltiple problems of many patients in time lim-
ited visits. The how is the generalist approach, described in an updated Chapter
1. This approach, which emphasizes patient- and family-centered, evidence-based
concepts and focused clinical questions, is reinforced through the case presenta-
tions and discussion questions at the end of each clinical chapter. The patients
in the case scenarios are all members of one extended family, affording the reader
a sense of continuity of care and an awareness of the effects of illness on vari-
ous family members. The Nelson family, the case presentations, and discussion
questions are all explained in the section, "Notes for the Reader."
I am grateful for the contributions of the authors and the four associate edi-
tors: Alan K. David, M.D.; D. Melessa Phillips, M.D.; Scott A. Fields, M.D.;
v
VI PREfACE
and Joseph E. Scherger, M.D., M.P.H. I also thank Coelleda O'Neil and Lily Cha
for their assistance in manuscript preparation. In preparing this third edition, I
have spoken with numerous medical students and family medicine educators, and
many of their thoughts are found in the pages that follow.
Robert B. Taylor, M.D.
Portland, Oregon
References
1. Taylor RB, ed., Family Medicine: Principles and Practice, 6th Edition. New York:
Springer Verlag, 2oo3.
2. Fargason CA, Evans HH, Ashworth CS, Capper SA. The importance of preparing med-
ical students to manage different types of uncertainty. Acad Med 1997; 72: 668-92.
Contents
Preface ................................................. v
Notes for the Reader . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ix
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. xv
Principles of Generalist Health Care
Robert B. Taylor
2 Clinical Prevention 19
Anthony F. Jerant
3 Nonnal Pregnancy, Labor, and Delivery .................... 57
Margaret V. Elizondo and Joseph E. Scherger
4 Problems of the Newborn and Infant . . . . . . . . . . . . . . . . . . . . . .. 76
Richard B. Lewan, Christopher R. Wood, and Bruce Ambuel
5 Common Problems of the Elderly .. . . . . . . . . . . . . . . . . . . . . .. 110
James P. Richardson and Aubrey L. Knight
6 Domestic Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 133
Valerie J. Gilchrist
7 Headache......................................... 148
Anne D. Walling
8 Hypertension....................................... 169
Stephen A. Brunton
9 Sinusitis and Pharyngitis .............................. 191
Paul Evans and William F. Miser
10 Viral Infections of the Respiratory Tract 208
George L. Kirkpatrick
II Otitis Media and Externa .............................. 226
William F. Miser
VII
VIII CONTENTS
12 Ischemic Heart Disease ............................... 242
Jim Nuovo
13 Obstructive Airway Disease ............................ 270
Howard N. Weinberg
14 Gastritis, Esophagitis, and Peptic Ulcer Disease . . . . . . . . . . . . .. 288
Alan M. Adelman and Peter R. Lewis
15 Urinary Tract Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 304
Boyd L. Bailey, Jr.
16 Vulvovaginitis and Cervicitis 322
Mary Willard
17 Disorders of the Back and Neck 337
Walter L. Calmbach
18 Osteoarthritis....................................... 370
Alicia D. Monroe and John B. Murphy
19 Common Dermatoses 378
Daniel J. Van Durme
20 Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 402
Charles Kent Smith, John P. Sheehan, and Margaret M. Ulchaker
21 Human Immunodeficiency Virus Infection and Acquired
Immunodeficiency Syndrome ........................... 430
Steven P. Bromer and Ronald H. Goldschmidt
22 Anxiety Disorders ................................... 450
Deborah S. McPherson
23 Depression........................................ 470
Rupert R. Goetz, Scott A. Fields, and William L. Toffler
24 Care of Acute Lacerations ............................. 487
Bryan J. Campbell and Douglas J. Campbell
25 Athletic Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 514
Michael L. Tuggy and Cora Collette Breuner
26 Care of the Dying Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 538
Frank S. Celestino
27 The Family Physician's Role in Responding to Biological
and Chemical Terrorism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 553
Alan L. Melnick
28 Information Mastery: Practical Evidence-Based Family Medicine. .. 577
Cheryl A. Flynn, Allen F. Shaughnessy, and David C. Slawson
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 593
Notes for the Reader
To the Student
Your time on the Family MedicinelPrimary Care Clerkship may be the most im-
portant of all in medical school. 1 Here you will encounter concepts that will shape
your future patient care-whether or not you choose family practice as a spe-
cialty: concepts such as personal care, longitudinal care, the meaning of illness,
and the investment of self in the therapeutic relationship. The book presents these
and other principles of generalist health care plus factual data regarding a broad
range of common clinical problems, supplemented by case presentations that in-
volve members of a single family.
The discussion questions are not intended to be post-tests of the factual con-
tent of each chapter and the answers to some questions may not actually be in
the chapter, but rather in your ability to reason and solve problems - which, af-
ter all, are the most important skills you need as a physician. The questions are
designed to stimulate thought about the issues, encourage discussion, or even in-
spire a quest for more information.
To the Faculty
This book, intended to be a single source text for your clerkship, has been prepared
to meet the General Guidelines for a Third-Year Family Medicine Clerkship as de-
veloped by the Society of Teachers of Family Medicine (see Table 1). The 25 clin-
ical chapters (Chapters 2 through 26) present a broad spectrum of family practice
problems that are consistent with the topic categories taught in required family
medicine clerkships in U.S. medical schools.2 The case presentations and questions
that follow each chapter are intended to be the basis of small group discussions.
They include both traditional questions about medical history, physical examina-
tion, diagnosis, and management, as well as about psychosocial issues such as the
reason for the visit, the impact of illness on the family, the patient's adaptation to
illness, and the resources used in management. The case discussions have been
"field-tested" with third-year medical students, and they work. Try them.
IX
x NOTES FOR THE READER
About the Case Discussions in this Book:
The Nelson Family
Each chapter is followed by a case presentation with discussion questions, all in-
volving members of a single extended family: the Nelsons. The Nelson family
genogram is shown in Figure 1. During a period of 12 months, various members
of the Nelson family come to the office for care, some making two or three vis-
its during the year. The reader will find that the problems of various family mem-
bers are interconnected and that they evolve over time.
Figure 1 introduces the four-generation Nelson family, some of whom have
been your patients for more than a decade and who look to you as their personal
physician for comprehensive health care of all family members.
Harold and Mary Nelson
The senior family members are Harold and Mary Nelson, both in their seventies.
Harold Nelson retired from his job as a welder 13 years ago at age 61. He now
leads a quiet life and seldom leaves the house. He has had type 2 diabetes mel-
litus for 24 years and osteoarthritis of the hands for 20 years, both of which were
considerations in his early retirement.
Mary Nelson, age 71, is a retired nursery school teacher. She has been hy-
pertensive, taking medication, for 10 years. In addition, she has episodes of de-
pression that require treatment. She wishes that she and Harold were "doing
more" in their retirement, and worries about what will happen to their son,
Samuel, when they die.
Harold and Mary Nelson have four children: Ruth, Samuel, Ken, and Lois-
all in their 40s and 50s.
John and Ruth McCarthy
Ruth, the oldest Nelson child, is married to John McCarthy. Together they own
and operate a small delicatessen-style restaurant. Their restaurant business strug-
gles financially, and Ruth and John sometimes seek "loans" from her parents
during lean times. Both work long hours in the restaurant. Ruth enjoys good
health, but John has coronary artery disease with angina pectoris for which he
had been treated by an internist downtown. John McCarthy's previous physician
retired recently, and John has decided to transfer his care to you.
John and Ruth McCarthy have two children. Their oldest son is Mark, age 28,
who dropped out of college to organize a rock group which disbanded about two
years ago. Mark now works as a waiter in his parents' restaurant. John and Ruth
openly disapprove of Mark's lifestyle, which includes cigarette smoking, mari-
juana use, and numerous sexual contacts. Recently Mark was found to be posi-
tive for human immunodeficiency virus (HN).