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2020_PC
Swanson’s
9
TH
FAMILY EDITION
MEDICINE
REVIEW
A Problem-Oriented Approach
Editor-in-Chief
Alfred F. Tallia, MD, MPH

Professor and Chair
Family Medicine and Community Health
Robert Wood Johnson Medical School
Rutgers University
New Brunswick, New Jersey
Co-Editors
Joseph E. Scherger, MD, MPH

Core Faculty, Family Medicine
Primary Care
Eisenhower Health
La Quinta, California
Nancy W. Dickey, MD
Professor
Primary Care Population Health Department
Texas A&M University College of Medicine
Executive Director
A&M Rural and Community Health Institute
Texas A&M University
College Station, Texas
1600 John F. Kennedy Blvd.
Ste 1600
Philadelphia, PA 19103-2899
SWANSON’S FAMILY MEDICINE REVIEW: ISBN: 978-0-323-69811-5

A PROBLEM-ORIENTED APPROACH, NINTH EDITION
Copyright © 2022 by Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
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Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notice
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds or experiments described herein. Because of rapid
advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages
should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors
or contributors for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
Previous editions copyrighted 2017, 2013, 2009, and 2003.
Library of Congress Control Number: 2020947121
Senior Content Strategist: Charlotta Kryhl

Senior Content Development Specialist: Jennifer Ehlers
Publishing Services Manager: Catherine Jackson
Senior Project Manager: Claire Kramer
Design Direction: Patrick Ferguson
Printed in India
Last digit is the print number: 9 8 7 6 5 4 3 2 1

To the lasting memory of
Dr. Richard Swanson

An extraordinary physician and educator
CONTRIBUTORS
Rae Adams, MD Amanda E. Bray, MD

Clinical Associate Professor Clinical Assistant Professor
Department of Primary Care and Population Health Department of Primary Care and Population Health
College of Medicine College of Medicine
Texas A&M Health Science Center Texas A&M University Health Science Center
Program Director of the Texas A&M Family Medicine Residency Bryan, Texas
Bryan, Texas
Jeffrey W. Chen, DO
Fred Afari, MD Sports Medicine Fellow
Resident Physician Sports Medicine
Family Medicine Eisenhower Health
Eisenhower Health Palm Desert, California
Rancho Mirage, California
Aimmee Chin, MD
Geronima Alday, MD Family Medicine
Attending Physician Eisenhower Health
Veterans Affairs Maryland Healthcare Systems Rancho Mirage, California
Perry Point, Virginia
Hardeep Chohan, MD
Nancy Armanious, MD Resident Physician
Resident Family Medicine
Eisenhower Health Rancho Mirage, California
Jill Cotter, DO
Anna Askari, MD MedStar Franklin Square Medical Center
Resident Physician Family Medicine Residency
Family Medicine Baltimore, Maryland
Eisenhower Health
Rancho Mirage, California Kinder Fayssoux, MD
Faculty
Reham Attia, MD Center for Family Medicine
Addiction Medicine Department Eisenhower Health
Southern California Permanente Medical Group La Quinta, California
Glendale, California
Marcel Fraix, DO, MBA
Adity Bhattacharyya, MD, FAAFP Faculty
Associate Director Family Medicine
JFK Family Medicine Residency at Hackensack Rancho Mirage, California
Meridian Health Chair
Edison, New Jersey Physical Medicine and Rehabilitation
Western University of Health Sciences
Katherine Blalock, MD, FAAFP Pomona, California
Clinical Assistant Professor
Department of Primary Care Medicine Kory Gill, DO
Texas A&M University College of Medicine Program Director, Sports Medicine Fellowship
Bryan, Texas Assistant Professor of Primary Care and Population Health
Texas A&M Family Medicine Residency
Ramanpreet Brar, MD College of Medicine
Family Medicine Texas A&M Health Science Center
Eisenhower Health Bryan, Texas
iv
CONTRIBUTORS
Jenna Grindle, MD Gagandeep Mand, MD

Eisenhower Family Medicine Residency Psychiatry Resident
Family Medicine Residency CORE Faculty Arrowhead Regional Medical Center
Eisenhower Health Colton, California
Barbara Jo McGarry, MD
Grady C. Hogue, MD Program Director
Clinical Assistant Professor Family Medicine Residency
Primary Care and Population Health Department Robert Wood Johnson University Hospital
College of Medicine Family Medicine and Community Health
Texas A&M University Health Science Center Robert Wood Johnson Medical School
Bryan, Texas Rutgers University
David F. Howarth, MD, MPH
Associate Professor and Geriatrics Jason R. McKnight, MD, MS, FAAFP
Fellowship Director Clinical Assistant Professor
Family Medicine and Community Health Department of Primary Care and Population Health
Rutgers Robert Wood Johnson Medical School Texas A&M University College of Medicine
New Brunswick, New Jersey Bryan, Texas
Malcolm Lakdawala, MD Ali Moazzami, MD

Geriatric Medicine Fellow Family Medicine
Kaiser Permanente Eisenhower Health
Fontana, California Rancho Mirage, California
Geoffrey Lange, DO Scott Nass, MD, MPA

Physician Program Director
Family Medicine/Sports Medicine Family Medicine Residency
Eisenhower Health Eisenhower Health
Rancho Mirage, California Rancho Mirage, California
Martha Lansing, MD Gabriel Neal, MD

Associate Professor and Vice Chair Clinical Associate Professor
Department of Family Medicine and Community Health Primary Care and Population Health
Robert Wood Johnson Medical School Texas A&M University
Rutgers University Bryan, Texas
Andrew Nguyen, DO, MPH
Vinh (John) Le, MD Resident Physician
Resident Physician Family Medicine
Eisenhower Health Rancho Mirage, California
Dulce Maria S. Oandasan, MD, FAAFP
Anna Lichorad, MD Medical Director
Assistant Clinical Professor Center for Family Medicine
Department of Primary Care and Population Medicine Eisenhower Health
Texas A&M University Rancho Mirage, California
Bryan, Texas
Joshua J. Raymond, MD, MPH
Benjamin Mahdi, MD, MPH Program Director
Associate Program Director and Director of Inpatient Services Robert Wood Johnson Medical School Geriatric Fellowship
Family Medicine Program at CentraState Medical Center
Associate Medical Director Associate Professor
Primary Care Robert Wood Johnson Medical School
Eisenhower Health Department of Family Medicine and Community Health
Rancho Mirage, California Rutgers University
v
CONTRIBUTORS
Damoun Rezai, MD Mehyo Tabikh, MD

Director of Medical Education Physician
Family Medicine Clinicas de Salud del Pueblo
Borrego Health Coachella, California
Cathedral City, California
Susan Roberman, MD, FAAFP Professor and Chair
Assistant Clinical Professor Family Medicine and Community Health
Primary Care Medicine and Population Health Robert Wood Johnson Medical School
Texas A&M Health Science Center Rutgers University
Bryan, Texas New Brunswick, New Jersey
Samantha Rosekrans, MD Tharanga Weerasinghe, MD

Physician Family Medicine Physician
Reno, Nevada El Monte, California
Joseph E. Scherger, MD, MPH Jenny M. Wheeler, MD

Core Faculty, Family Medicine Primary Care Family Physician
Primary Care Riverside–San Bernardino County Indian Health
Eisenhower Health Thermal, California
Brandon Williamson, MD
Agarwal Shivali, MD Associate Program Director
Geriatric Medicine Fellow Texas A&M Family Medicine Residency
University of California Irvine Texas A&M Health Science Center
Irvine, California Bryan, Texas
Stephen R. Steele, DO Meredith Williamson, PhD

Director Clinical Assistant Professor
Argyros E365 Primary Care Department of Primary Care and Population Health
Program Director College of Medicine
Sports Medicine Fellowship Texas A&M Health Science Center
Eisenhower Health Bryan, Texas
Medical Director Tina Xu, DO
Skilled Nursing Facility Family Physician
Brookdale of Rancho Mirage Massachusetts General Hospital
Rancho Mirage, California Boston, Massachusetts
vi
PREFACE
This is the ninth edition of Swanson’s Family Medicine As with the previous edition, distinguished family
Review, a marvelous and enduring educational tool now physicians Nancy W. Dickey, MD, President Emerita
spanning multiple decades in service to generations of of the Texas A&M Health Science Center and professor
clinicians. This text is a testimony to the founding genius of family and community medicine in the Texas A&M
of Dr. Richard Swanson, the family physician who gave College of Medicine, and Joseph E. Scherger, MD, MPH,
birth to the Review. The text continues to be not only Vice President for Primary Care and Academic Affairs at
an effective tool for family physicians preparing for Eisenhower Medical Center and founding dean of the
certification, but also an excellent review for clinicians Florida State University College of Medicine, served as
simply desiring to hone their familiarity with the basic my co-editors on this edition. As a team, we reviewed
content pertinent to family medicine and primary care. the chapters and case problems for relevance and chose
areas of emphasis and ways to organize the content. We
The primary goals of the ninth edition are to update the selected the content to reflect the broad core of knowledge
content and retain the special essence that made previous required of every family physician. We also received
editions such valued and popular educational instruments. valuable input from other family medicine clinicians with
The book is divided into 11 sections. Ten sections special expertise in specific content areas.
represent a clinical area of Family Medicine, whereas the
eleventh section is a popular illustrated review. We recruited as chapter authors the finest practicing
family medicine experts from academic centers across the
Each section contains chapters covering specific subjects United States. They reaffirmed and updated chapter con-
relevant to that section. Each chapter presents clinical tent on the basis of thorough needs analyses, including
cases that simulate actual clinical situations, providing the opinions of readers, participants, and faculty in live con-
learner with a sense of reality designed to enhance retention tinuing medical education conferences, expert opinion,
of content. Each clinical case is followed by questions and other accepted methodologies. The editors and au-
concerning diagnosis and management. The question thors anticipate that the reader will both enjoy and profit
section is followed by an answer section, which provides a from the work that went into preparing this volume.
detailed discussion relevant to each question. Finally, each Happy studying and learning!
chapter contains a short summation of key learning points
and selected readings and references, including websites.
This time-tested learning methodology is designed to
increase retention and to expand and refine the reader’s
Rutgers University Biomedical and Health Sciences
knowledge of the diagnostic methods, therapeutics, and
Editor-in-Chief
patient management techniques presented by each case.
vii
ACKNOWLEDGMENTS
As editor-in-chief, I am indebted to many individuals for Thanks to Jennifer Ehlers, Lotta Kryhl, Claire Kramer,
their support and assistance in the preparation of the ninth and other staff at Elsevier for their inspiration and sup-
edition of Swanson’s Family Medicine Review. To begin, I port. Finally, much gratitude to our colleagues in the
wish to thank my two co-editors, Nancy W. Dickey, MD, academic and clinical communities that we call home for
and Joseph E. Scherger, MD, MPH, for their hard work their help and understanding of the demands that prepa-
and understanding. ration of this edition required.
Collectively, we would like to thank our spouses, Elizabeth

Tallia, Carol Scherger, and Frank Dickey, and our entire Alfred F. Tallia, MD, MPH
families, as well as those of the authors, for their sacri- Editor-in-Chief
fice of time and their understanding as we prepared this
edition.
viii
CONTENTS
Section One. Family, Community, and Population Health, 1 Chapter 19. Integrative Medicine, 81
Joseph E. Scherger and Anna Askari
Chapter 1. Family Influences on Health and Disease, 1
Martha Lansing Chapter 20. Cultural Competency, 86
Anna Askari and Fred Afari
Chapter 2. Clinical Decision Making, 5
Martha Lansing
Section Three. Adult Medicine, 89
Chapter 3. Consultation and Team Care, 12
Martha Lansing Chapter 21. Acute ST-Segment Elevation Myocardial
Infarction, 89
Chapter 4. Managing Multiple Morbidities, 15 Joseph E. Scherger and Benjamin Mahdi
Martha Lansing
Chapter 22. Acute Coronary Symptoms and Stable
Chapter 5. Quality Improvement, 18 Angina Pectoris, 96
Martha Lansing Joseph E. Scherger
Chapter 6. Clinical Prevention, 21 Chapter 23. Hyperlipidemia, 103

Chapter 7. Tobacco Dependency, 25 Chapter 24. Heart Failure, 107

Martha Lansing Joseph E. Scherger and Tina Xu
Chapter 8. Alcohol, 30 Chapter 25. Hypertension, 113

Martha Lansing Kinder Fayssoux and Aimmee Chin
Chapter 9. Diet, Exercise, and Obesity, 37 Chapter 26. Dysrhythmia, 119

Chapter 10. Trends in Cancer Epidemiology, 41 Chapter 27. Deep Venous Thrombosis and Pulmonary
Martha Lansing Thromboembolism, 122
Alfred F. Tallia
Chapter 11. Cardiovascular Epidemiology, 45
Martha Lansing Chapter 28. Chronic Obstructive Pulmonary Disease, 126
Joshua J. Raymond and Geronima Alday
Chapter 12. Bioterrorism, 49
Martha Lansing Chapter 29. Asthma, 133
Alfred F. Tallia
Chapter 13. Influenza and Other Emerging Diseases, 53
Martha Lansing Chapter 30. Diagnosis and Management of Community-
Acquired Pneumonia in the Adult, 142
Alfred F. Tallia
Section Two. Communication, 59
Chapter 31. Esophageal Disorders, 147
Chapter 14. Intimate Partner Violence, 59 Alfred F. Tallia
Scott Nass and Nancy Armanious
Chapter 32. Peptic Ulcer Disease, 152
Chapter 15. How to Break Bad News, 63 Alfred F. Tallia
Dulce Maria S. Oandasan and Vinh (John) Le
Chapter 33. Hepatitis and Cirrhosis, 156
Chapter 16. The Physician-Patient Relationship, 67 Alfred F. Tallia
Joseph E. Scherger
Chapter 34. Pancreatitis, 162
Chapter 17. Palliative and Hospice Care, 71 Alfred F. Tallia
Joseph E. Scherger
Chapter 35. Pancreatic Carcinoma, 165
Chapter 18. Ethical Decision-Making Issues, 75 Alfred F. Tallia
Joseph E. Scherger
ix
CONTENTS
Chapter 36. Biliary Tract Disease, 169 Chapter 55. Disorders of the Eye, 279
Alfred F. Tallia Alfred F. Tallia
Chapter 37. Inflammatory Bowel Disease, 173 Chapter 56. Headache, 284
Alfred F. Tallia Barbara Jo McGarry
Chapter 38. Irritable Bowel Syndrome, 178 Chapter 57. Seizures, 291
Alfred F. Tallia Joshua J. Raymond and Geronima Alday
Chapter 39. Acute Appendicitis, 181 Chapter 58. Sleep Disorders, 296
Alfred F. Tallia Joshua J. Raymond and Geronima Alday
Chapter 40. Colorectal Cancer and Other Colonic Chapter 59. Common Renal Diseases, 302
Disorders, 186 Jenny M. Wheeler
Alfred F. Tallia
Chapter 60. Renal Stones, 306
Joseph E. Scherger
Chapter 41. Diabetes Mellitus, 192
Alfred F. Tallia Chapter 61. Urinary Tract Infections, 309
Joseph E. Scherger
Chapter 42. Thyroid, 210
Alfred F. Tallia Chapter 62. Fluid and Electrolyte Abnormalities, 313
Scott Nass
Chapter 43. Common Endocrine Diseases, 217
Alfred F. Tallia Chapter 63. Anemia, 316
Joseph E. Scherger
Chapter 44. Immune-Mediated Inflammatory Disorders
and Autoimmune Disease, 223 Chapter 64. Certain Hematologic Conditions, 323
Jenny M. Wheeler Joseph E. Scherger
Chapter 45. Human Immunodeficiency Virus Infection, 227 Chapter 65. Breast, Lung, and Brain Cancer, 330
Scott Nass Joseph E. Scherger
Chapter 46. Multiple Sclerosis, 235 Chapter 66. Cancer Pain Management, 334
Hardeep Chohan Joseph E. Scherger
Chapter 47. Fibromyalgia, 239 Chapter 67. Developmental Disabilities, 340

Marcel Fraix Kinder Fayssoux and Aimmee Chin
Chapter 48. Chronic Fatigue Syndrome, 244 Chapter 68. Travel Medicine, 343
Stephen R. Steele and Geoffrey Lange Stephen R. Steele and Jeffrey W. Chen
Chapter 49. Rheumatoid Arthritis, 249

Marcel Fraix Section Four. Women’s Health, 349
Chapter 50. Osteoarthritis, 254 Chapter 69. Osteoporosis, 349

Marcel Fraix and Andrew Nguyen Adity Bhattacharyya
Chapter 51. Acute Gout and Pseudogout, 259 Chapter 70. Breast Disease, 355
Joseph E. Scherger Adity Bhattacharyya
Chapter 52. Acne, Rosacea, and Other Common Chapter 71. Vulvovaginitis and Bacterial Vaginosis, 361
Dermatologic Conditions, 263 Adity Bhattacharyya
Joseph E. Scherger
Chapter 72. Cervical Cancer Screening, 368
Chapter 53. Common Skin Cancers, 268 Adity Bhattacharyya
Joseph E. Scherger and Ramanpreet Brar
Chapter 73. Premenstrual Syndrome and Premenstrual
Chapter 54. Ear, Nose, and Throat Problems, 272 Dysphoric Disorder, 374
Alfred F. Tallia Adity Bhattacharyya
x
CONTENTS
Chapter 74. Postmenopausal Symptoms, 378 Chapter 92. Intrauterine Growth Restriction, 481
Adity Bhattacharyya Amanda E. Bray
Chapter 75. Dysmenorrhea, 383 Chapter 93. Postterm Pregnancy, 486

Adity Bhattacharyya Jill Cotter
Chapter 76. Abnormal Uterine Bleeding, 387 Chapter 94. Labor, 490
Adity Bhattacharyya Jill Cotter
Chapter 77. Ectopic Pregnancy, 394 Chapter 95. Delivery Emergencies, 493
Adity Bhattacharyya Amanda E. Bray
Chapter 78. Contraception, 398 Chapter 96. Postpartum Blues, Depression, and
Adity Bhattacharyya Psychoses, 498
Meredith Williamson
Chapter 79. Spontaneous and Elective Abortion, 408
Adity Bhattacharyya
Section Six. Children and Adolescents, 501
Chapter 80. Sexually Transmitted Diseases, 414
Adity Bhattacharyya Chapter 97. Common Problems of the Newborn, 501
Susan Roberman
Chapter 81. Infertility, 425
Adity Bhattacharyya Chapter 98. Infant Feeding, 503
Susan Roberman
Section Five. Maternity Care, 431 Chapter 99. Colic, 510

Rae Adams
Chapter 82. Family-Centered Maternity Care, 431
Amanda E. Bray Chapter 100. Immunizations, 513
Grady C. Hogue
Chapter 83. Preconception Care, 436
Anna Lichorad Chapter 101. Fever, 519
Gabriel Neal
Chapter 84. Routine Prenatal Care, 441
Anna Lichorad Chapter 102. Over-the-Counter Drugs, 522
Susan Roberman
Chapter 85. Immunization and Consumption of Over-the-
Counter Drugs During Pregnancy, 447 Chapter 103. Diaper Rash and Other Infant Dermatitis, 525
Anna Lichorad Anna Lichorad
Chapter 86. Exercise and Pregnancy, 451 Chapter 104. Failure to Thrive and Short Stature, 530
Gabriel Neal Susan Roberman
Chapter 87. Common Problems of Pregnancy, 454 Chapter 105. Child Abuse, 534
Gabriel Neal Katherine Blalock
Chapter 88. Spontaneous Abortion, 457 Chapter 106. Common Cold, 539
Jill Cotter Jenna Grindle
Chapter 89. Thyroid Disease in Pregnancy, 460 Chapter 107. Otitis Media, 544
Amanda E. Bray Jenna Grindle
Chapter 90. Gestational Diabetes and Shoulder Chapter 108. Croup and Epiglottitis, 549
Dystocia, 467 Joseph E. Scherger
Jill Cotter
Chapter 109. Bronchiolitis and Pneumonia in
Chapter 91. Hypertension in Pregnancy, 473 Children, 552
Amanda E. Bray Joseph E. Scherger
xi
CONTENTS
Chapter 110. Childhood Asthma, 558 Chapter 128. Urinary Incontinence in the Elderly
Gabriel Neal Patient, 635
David F. Howarth
Chapter 111. Allergic Rhinitis, 564
Jason R. McKnight Chapter 129. Prostate Disease, 640
David F. Howarth
Chapter 112. Viral Exanthems, 568
Grady C. Hogue Chapter 130. Pressure Ulcers, 646
David F. Howarth
Chapter 113. Cardiac Murmurs, 575
Gabriel Neal Chapter 131. Constipation in the Elderly Patient, 652
David F. Howarth
Chapter 114. Vomiting and Diarrhea, 579
Susan Roberman Chapter 132. Pneumonia and Other Common Infectious
Diseases of the Elderly Patient, 657
Chapter 115. Recurrent Abdominal Pain, 584 David F. Howarth
Jill Cotter
Chapter 133. Polymyalgia Rheumatica and Temporal
Chapter 116. Enuresis, 587 Arteritis, 663
Rae Adams David F. Howarth
Chapter 117. Lymphoma and Leukemia, 590 Chapter 134. Hypertension Management in the Elderly
Rae Adams Patient, 666
David F. Howarth
Chapter 118. Sickle Cell Disease, 593
Chapter 135. Cerebrovascular Accidents, 671
Jason R. McKnight
David F. Howarth
Chapter 119. Physical Activity and Nutrition, 597 Chapter 136. Depression in the Elderly, 677
Anna Lichorad David F. Howarth
Chapter 120. The Limping Child, 601 Chapter 137. Dementia and Delirium, 682
Rae Adams David F. Howarth
Chapter 121. Foot and Leg Deformities, 605 Chapter 138. Parkinson Disease, 689
Grady C. Hogue David F. Howarth
Chapter 122. Mononucleosis, 609 Chapter 139. Elder Abuse, 693
Grady C. Hogue David F. Howarth
Chapter 123. Adolescent Development, 614 Chapter 140. Emergency Treatment of Abdominal Pain in
Brandon Williamson the Elderly Patient, 697
David F. Howarth
Chapter 124. Adolescent Safety, 617
Grady C. Hogue
Section Eight. Behavioral Health, 701
Chapter 141. Depressive Disorders, 701
Section Seven. Geriatric Medicine, 623 Gagandeep Mand, Mehyo Tabikh, and
Damoun Rezai
Chapter 125. Functional Assessment of the Elderly
Patient, 623
Chapter 142. Bipolar Disorder, 708
David F. Howarth
Mehyo Tabikh and Damoun Rezai
Chapter 126. Polypharmacy and Drug Reactions in the
Chapter 143. Generalized Anxiety Disorder and Social
Elderly Patient, 626
Phobia, 713
David F. Howarth
Tharanga Weerasinghe and Damoun Rezai
Chapter 127. The Propensity and Consequences of Falls
Chapter 144. Posttraumatic Stress Disorder, 718
Among Elderly Patients, 631
Agarwal Shivali and Damoun Rezai
David F. Howarth
xii
CONTENTS
Chapter 145. Obsessive-Compulsive Disorder, 720 Chapter 159. Heat and Cold Illness, 778
Ali Moazzami and Damoun Rezai Jason R. McKnight
Chapter 146. Attention-Deficit/Hyperactivity Disorder, 723 Chapter 160. High Altitude and Barotrauma, 782
Scott Nass Brandon Williamson
Chapter 147. Conduct Disorder and Oppositional Defiant

Disorder, 728 Section Ten. Sports Medicine, 785
Agarwal Shivali and Damoun Rezai Chapter 161. Preparticipation Evaluation, 785
Kory Gill
Chapter 148. Diagnosis and Management of
Schizophrenia, 731 Chapter 162. Exercise Prescription, 788
Anna Askari and Damoun Rezai Kory Gill
Chapter 149. Substance Use Disorders, 736 Chapter 163. Concussions, 791
Reham Attia and Anna Askari Jason R. McKnight
Chapter 150. Eating Disorders, 741 Chapter 164. Acceleration and Deceleration Neck
Ali Moazzami and Damoun Rezai Injuries, 796
Kory Gill
Chapter 151. Somatoform and Related Disorders, 745
Andrew Nguyen and Damoun Rezai Chapter 165. Upper Extremity Injuries, 798
Kory Gill
Chapter 152. Sexual Dysfunction, 749
Malcolm Lakdawala and Damoun Rezai Chapter 166. Low Back Pain, 801
Grady C. Hogue
Chapter 153. Psychotherapy in Family Medicine, 755
Samantha Rosekrans and Damoun Rezai Chapter 167. Lower Extremity Strains and Sprains, 805
Kory Gill
Section Nine. Emergency Medicine, 761 Chapter 168. Joint and Soft Tissue Injections, 809
Kory Gill
Chapter 154. Cardiac Arrest, 761
Brandon Williamson Chapter 169. Fracture Management, 811
Kory Gill
Chapter 155. Advanced Trauma Life Support, 765
Brandon Williamson Chapter 170. Infectious Disease and Sports, 814
Kory Gill
Chapter 156. Diabetic Ketoacidosis, 769
Chapter 171. Female Athlete Triad, 817
Jason R. McKnight
Susan Roberman
Chapter 157. Acute and Chronic Poisoning, 771
Jason R. McKnight Section Eleven. Illustrated Review, 821
Chapter 158. Urticaria and Angioneurotic Edema, 775 Chapter 172. Illustrated Review, 821
Brandon Williamson Alfred F. Tallia
xiii
TIPS ON PASSING THE BOARD EXAMINATIONS
This section briefly discusses the philosophy and RULE 6: If there is a question in which one choice is sig-
techniques of passing board examinations or other types nificantly longer than the others and you do not know the
of medical examinations. Most examinations, such as answer, select the longest choice.
the certification and recertification examinations of the
American Board of Family Medicine, have moved to RULE 7: If you are faced with an “all of the above” option,
computer-based administration. If this applies to your realize that these are correct far more often than they are
examination, read and study the demonstrations provided incorrect. Choose “all of the above” if you do not know
on the internet or elsewhere. the answer.
First, realize that you are “playing a game.” It is, of course, RULE 8: Become suspicious if you have selected more than
a very important game, but a game nevertheless. When three choices of the same letter in a row. Two in a row
answering each question, ask yourself, “What informa- of the same letter is common, three is less common, and
tion does the examiner want? How do you ‘outfox the four is extremely uncommon. In this case, recheck your
fox’?” answers.
To find out, let us turn our attention to the most common RULE 9: Answer choices tend to be evenly distributed. In
type of question, the multiple choice. Following these other words, the number of correct “a” choices is close to
simple rules will maximize your chances. the number of correct “b” choices, and so on. However,
there may be somewhat more “e” choices than any other, es-
RULE 1: Allocate your time appropriately. At the begin- pecially if there is a fair number of “all of the above” choices.
ning of the examination, divide the number of questions If you have time, do a quick check to reassure yourself.
by the time allotted. Pace yourself accordingly and check
your progress every half hour. RULE 10: Never change an answer once you have recorded
it on the computer unless you have an extraordinary rea-
RULE 2: When using a computer-administered examina- son for doing so. Many people taking multiple-choice
tion, take time before the examination to become familiar examinations, especially if they have time on their hands
with the mechanics of maneuvering through the examina- after completing questions, start second-guessing them-
tion program. Learn whether you can return to questions selves and thinking of all kinds of unusual exceptions.
you were not sure about or whether this is not allowed. Resist this temptation.
RULE 3: Answer every question in order. On some com- RULE 11: Before you choose an answer, always read each
puter-administered examinations, you run the risk of and every choice. Do not get caught by seeing what you
not being able to return to an unanswered question. believe is the correct answer jump out at you.
Although American Board of Family Medicine exam-
inations allow you to return, not all examinations per- RULE 12: Scan the lead-in to the answers and the poten-
mit this. Some examinations use unfolding question tial answers first, then read the clinical case/vignette.
sequences that do not let you return to a previous ques- This way you will know what is being tested and will
tion. On paper-administered examinations, you run the better attend to the necessary facts. Read each question
risk of mis-sequencing your answers and thus submit- carefully. Be especially careful to read words such as not,
ting all answers out of order. except, and so on.
RULE 4: Do not spend more than your allotted time on Following these suggestions cannot guarantee success;
any one question. If you do not know the answer and you however, I do believe that these tips will help you achieve
are not penalized for wrong answers, simply guess. better results on your board examinations.
RULE 5: Even if you are penalized for wrong answers

(most examinations no longer do this) and you can elim-
inate even one choice, answer the question. Percentages Alfred F. Tallia, MD, MPH
dictate that you will come out ahead in the end. Editor-in-Chief
xiv
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xv
SECTION ONE
Family, Community,
and Population Health
3. Which is true about family and risk?

CHAPTER 1
a. family is one of the major influences on disease in-
Family Influences on Health cidence and prevalence
b. family risk outcomes are not modifiable
and Disease c. family risk need not be ascertained because there is
nothing you can do about it
C L I N I CA L CA S E PR O B L E M 1 d. family disease susceptibility is absolutely transmit-
table
A Calculated Risk
e. family risk is not ascertainable by current methods
A 32-year-old African American man comes to your of genetic screening
office for the first time requesting a health mainte-
nance visit. He is married and the father of two young C L I N I CA L CA S E PR O B L E M 2
children. He works as an accountant. His firm has
All in the Family
just offered a new health insurance plan, which pays
for a preventive health maintenance examination. He Two 75-year-old patients are hospitalized after both had
wants to stay healthy and to live longer than both his a stroke resulting in a left-sided hemiparesis. The size
parents. and location of the thrombotic events in these patients
are almost identical, as is the initial degree of impair-
ment. Treatment received is also the same. One patient
S E L E C T T H E B E S T A N S W E R TO T H E
lives alone and has a younger sibling living in a distant
FO L LOW I N G Q U E S T I O N S
state. The other patient is part of an extended family
1. Regarding his risk, you would ask him about which of with many social supports nearby, including grandchil-
the following? dren who visit her often while she is in the hospital.
a. diet history
b. exercise type and frequency 4. What outcomes would you predict for these patients
c. smoking history on the basis of their family social circumstances?
d. family history a. identical outcomes are likely given the identical le-
e. alcohol intake sions and initial impairments
f. all of the above b. it is impossible to predict outcomes
g. none of the above c. the patient with more family supports is likely to
have a better outcome
2. You discover that his father had his first heart attack d. the patient with fewer family supports is at less risk
at age 42 and died at age 49 following a second heart of acute mortality
attack. His mother had diabetes, hypertension, and e. outcomes achieved are independent of any family
congestive heart failure and died at age 73. Consider- social factors
ing this information, you would recommend which of
the following screening tests at this time? 5. In the case of the patient with strong family supports,
a. order a complete blood chemistry her family members decide to care for her in her
b. order a cardiac nonstress test home. What are the potential risks for these family
c. perform a resting electrocardiogram (ECG) now care providers?
d. screen for lipids now a. there are no risks; her family is happy to care for
e. none of the above because he is still younger than her
35 years b. financial loss of work hours and income
1
2 S ECTION O N E Family, Community, and Population Health
c. depression and anxiety 8. Possible positive aspects of the previous family situa-
d. serious illness tion include which of the following?
e. b, c, and d a. evidence of closeness and connectedness
b. a lack of criticism and blame
C L I N I CA L CA S E PR O B L E M 3 c. the absence of protectionism and rigidity
d. all of the above
Risks of Omission and Commission
e. none of the above
A 28-year-old woman presents to your office for the
first time for prenatal care. She is 14 weeks into her 9. You handle the situation with skill and care, and the
first pregnancy. She is human immunodeficiency virus grandmothers leave feeling reassured of your careful
(HIV) positive but stopped antiretroviral agents because attention to their first and only grandson, and they
she had heard that taking medication during pregnancy are impressed with his mother’s newly identified and
could harm the baby. She has a half-pack per day recognized competence. In future visits, anticipatory
smoking habit that she has been unable to stop despite guidance in this family should probably take into con-
many attempts at quitting. She drinks at least a glass sideration which of the following?
of wine with dinner each night. She works in sales at a a. family beliefs about child discipline
local food bar. She asks you what she can do to give her b. family influences on exercise and diet
child a better chance in life than she had. c. family beliefs about health and illness
d. none of the above
6. At this time, it is most appropriate to advise her of e. a, b, and c
which of the following?
a. perinatal transmission of the HIV virus poses the
child’s greatest risk
ANSWERS
b. smoking is by far the most hazardous factor in her
prenatal history 1. f. Family influences on health and disease are nu-
c. alcohol consumption during pregnancy is a major merous and multifactorial. These influences can be
risk factor for fetal alcohol syndrome expressed across individual and family life cycles. One
d. she must restart antiretroviral medications imme- of the most pronounced family effects is on genetic
diately or risk certain death and disease susceptibility. Although all the histori-
e. she should plan to breast feed her child cal elements listed are important, the family history,
often recorded in the medical record pictorially as a
C L I N I CA L CA S E PR O B L E M 4 genogram, will provide a constant guide for the as-
sessment of symptoms as they are manifested across
Unwanted Advice
the individual life cycle.
A 25-year-old woman presents for the first time with her
2-week-old infant, her first child. Also present are both 2. d. The US Preventive Services Task Force recom-
grandmothers. The infant’s mother is visibly concerned mends that men who are at increased risk for coro-
that the baby is “only” at the same weight as he was at nary heart disease be screened for lipid disorders be-
birth. One grandmother chimes in that she knew breast- tween the ages of 20 and 35. The preferred screening
feeding was a bad idea, and the other insists that it is test is fasting or nonfasting serum lipid levels (cho-
time to introduce cereal to the baby’s diet. They start ar- lesterol, high-density lipoprotein, and low-density
guing among themselves until you escort everyone but lipoprotein). Risk factors include family history of
the mother and the infant from the examination room. cardiovascular disease, along with diabetes, history
of previous coronary heart disease, or atherosclero-
7. In addition to giving the infant’s mother accurate ad- sis, tobacco use, hypertension, and obesity. There is
vice about breastfeeding and nutrition, which of the insufficient evidence to screen with a resting or an
following is an appropriate intervention at this time? exercise ECG. Based on his family history it would
a. refocus the attention of the grandmothers to some also be reasonable to screen for diabetes and hyper-
other facet of the family experience tension at this time.
b. establish and reinforce the competency of the
mother in her breastfeeding 3. a. Disease incidence and prevalence are directly re-
c. use your expert authority as the physician to set lated to the interplay of family genetics, behaviors,
family rules for decision making in the mother’s and the host environment. Physicians should attend
favor to known cues of family historical factors that can
d. acknowledge and reinforce the expert authority of often foreshadow overt disease in patients. Changes
the grandmothers in diet, exercise, and smoking habits can modify out-
e. a, b, and c are correct comes for those with family risk factors.
C H A P TER 1 Family Influences on Health and Disease 3
4. c. A large literature exists on the influence of family cians will recognize the situation. Dealing with
on survival and disease progression. Strong family family members beyond the presumed present pa-
supports are protective and promote healing in acute tient is a common occurrence in family medicine. In
disease circumstances. Studies of disease outcomes in fact, skillful use of family resources is a therapeutic
myocardial infarction and stroke reveal striking sup- advantage in the family physician’s armamentarium
portive effects of family supports even when other if it is done carefully. The supportive closeness of
variables are controlled for. this family must be counterbalanced by the rein-
forcement of the competence of the mother in this
5. e. Caring for family members has many benefits, but scenario. Although being careful not to alienate
it can be difficult to arrange schedules and provide the grandmothers is important, the mother’s com-
for the caregiver’s own needs. There may be financial petence and her decision-making authority must
losses of work hours, pay, and opportunities for ad- ultimately be reinforced. Because the physician
vancement and promotion. Care can be demanding possesses all forms of social power (expert, legal,
and lead to loss of sleep, anxiety, depression, and other coercive, referent, and reward), this can readily be
serious illness. Family physicians should assess the accomplished.
needs of the caregivers as well as of the patient and
can provide support and resources to help both the 8. a. Although answers b and c can be positive aspects
patient and the caregiver navigate this difficult period. of family, they are absent in this situation.
6. a. Family influence on prenatal and perinatal dis- 9. e. Understanding of family influences on health
ease transmission is another important influence of and disease is essential for effective practice as a
the family on health and disease. In 2013, there were family physician. Understanding allows not only
69 cases of HIV-infected infants compared with 216 appropriate interventions in acute disease but also
cases in 2002. Pregnant women with HIV can reduce anticipatory guidance in the prevention of morbid-
the risk of transmitting HIV to their babies to less ity and future illness, and the promotion of health
than 1% if they take antiretroviral drugs during preg- and well-being. Family factors that have protective
nancy. This mother can help her child’s future most influence on health and illness include closeness and
by resuming her antiretroviral therapy. Because the connectedness; well-developed problem-focused
virus is transmitted through breast milk, the Centers coping skills; clear organization and decision mak-
for Disease Control and Prevention (CDC) recom- ing; and direct communication. Family pathologies
mends that HIV-infected mothers should be advised that can adversely influence health and illness in-
not to breast feed their infants. clude intrafamily hostility, criticism, and blame;
perfectionism and rigidity; lack of extra-family
7. e. How many of us have been confronted by the support systems; and the presence of chronic psy
case illustrated? Most experienced family physi- chopathology.
S U M M A RY
The effects of family on health and disease are large and need to evaluate such testing and its uses wisely. A
multifactorial. They are expressed across the individual reliable resource for understanding genetic test-
and family life cycles. Family physicians and other health ing can be found at www.ncbi.nlm.nih.gov/sites/
care providers must be cognizant of these influences and GeneTests/?ob=GeneTests.
help individuals and families to navigate the positive and
less positive effects. The potential effects of family on 2. Prenatal and perinatal transmission of disease
health and illness include the following. Generations of families have experienced prena-
1. Genetics and disease susceptibility tal or perinatal transmission of diseases ranging
Family effects through genetics are particularly from syphilis to HIV infection. In many areas
strong. Although they can be moderated by envi- of the world, this family influence has charted
ronment and behavior, the effects are with us for the destiny of countless children. These risk fac-
a lifetime. Certain diseases, such as Huntington tors can be modified in many circumstances and
disease and Tay-Sachs disease, are directly related should be addressed when appropriate by the
to our parents; others, such as coronary heart dis- family physician.
ease, hypertension, and diabetes, are strongly me-
diated by family factors. Use of genetic testing and 3. Child rearing and nurturing
expanded family history tools will be increasingly Belief systems ranging from when to have children to
important in the 21st century, and physicians will how children should be raised, whether and how
Continued
S U M M A RY—c o n t ’d
much children should be held, and how to feed and nia to influenza. Many infectious illnesses are
put to sleep are all part of the family influences on passed from one family member to others in a
having and raising children. household, and families are important vectors
in times of epidemics.
4. Nutrition and lifestyle
Family traditions and socioeconomics play an import- 7. Outcomes in acute and chronic illness
ant role in access to adequate nutrition. Many life- Multiple studies have demonstrated different out-
style behaviors, such as smoking, diet, exercise, and comes in acute and chronic illness based on the
alcohol consumption, are influenced by our parents degree of social supports available in families.
and extended family and by their habits and beliefs. Similarly, family dysfunction can be a major con-
Exposures to environmental elements and the sub- tributor to illness and adverse health outcomes in
sequent effects particularly on children is part of a many individuals.
rapidly growing area of research that will further Family factors that have protective influence on
expand our understanding of how the environment health and illness include closeness and connect-
combined with the genetic makeup of the individual edness; well-developed problem-focused coping
affects health and development of disease. skills; clear organization and decision making;
and direct communication. Family pathologies
5. Access to and quality of care that can adversely influence health and illness in-
Family socioeconomics along with race, ethnicity, clude intrafamily hostility, criticism, and blame;
and culture, are all factors that influence the abil- perfectionism and rigidity; lack of extra-family
ity to access health care and successfully navigate support systems; and the presence of chronic
complex health care systems. psychopathology.
Family-level interventions used by family physicians
6. Spread of infectious disease to reduce risk factors and to increase protective
Family living situations and contacts are major functioning of families include various psycho-
influences on the spread of many infectious educational and psychotherapeutic techniques to
diseases ranging from Mycoplasma pneumo- address and enhance family relationships.
Suggested Reading
Givens M, Dotters-Katz SK, Stringer E, et al. Minimizing Valdez R, Yoon PW, Qureshi N, et al. Family history
the risk of perinatal human immune-deficiency virus in public health practice: a genomic tool for disease
transmission. Obstet Gynecol Surv. 2018;73(7):423–432. prevention and health promotion. Annu Rev Public
Nasir A, Nasir L. Counseling on early childhood concerns: Health. 2010;31:69–87.
sleep issues, thumb-sucking, picky eating, school readiness Wattendorf DJ, Hudley DW. Family history: the three
and oral health. Am Fam Physician. 2015;92:274–278. generation pedigree. Am Fam Physician. 2005;72:441–448.
Swartz K, Collins LG. Caregiver care. Am Fam Physician.
2019;99(11):699–706.
C H A P TER 2 Clinical Decision Making 5
CHAPTER 2 C L I N I CA L CA S E PR O B L E M 2
Clinical Decision Making A 25-Year-Old Medical Student Who Is

Having Anxiety Regarding His Upcoming
Epidemiology Examination
C L I N I CA L CA S E PR O B L E M 1
A 25-year-old medical student comes to your office in a
A Third-Year Medical Student Who Wants to state of extreme anxiety manifested by palpitations and
Know How to Think sweating throughout the previous week. He tells you he
A third-year medical student asks you to teach her the is scheduled to have a clinical epidemiology examina-
secrets of clinical decision making, or how you think tion in 24 hours.
when you approach and treat a patient. You agree to On physical examination, his blood pressure is 120/70
take her to see a patient in the emergency depart- mm Hg, pulse is 90 beats per minute and regular, and res-
ment. After you talk with the patient, you ask the stu- pirations are 24 per minute. His physical examination is
dent to describe everything she has seen and heard. normal. You order a thyroid-stimulating hormone test to
You carefully note that she has missed approximately exclude hyperthyroidism. You explain to him that given the
half of what happened in the conversation between low prevalence of thyroid disease in his age group and the
you and the patient and even more in the physical higher prevalence of anxiety in his medical school popula-
examination. tion of students, the negative predictive value (NPV) of the
test will be helpful. He looks confused and more anxious.
In an attempt to deal with his symptoms, you decide
to spend some time tutoring the student in basic epide-
S E L E C T T H E B E S T A N S W E R TO T H E
miologic concepts. You begin by explaining the basics
FO L LOW I N G Q U E S T I O N S
of a 2 × 2 table that relates positive and negative test
1. This case represents a problem with which step(s) of results to the presence or absence of disease in a spe-
the clinical decision-making process? cific population (Table 2.1).
a. cue acquisition Use the data from Table 2.1 for questions 4 to 9.
b. hypothesis formation
c. the search process 4. What is the sensitivity of test A for disease B?
d. all of the above a. 25.0%
e. none of the above b. 37.5%
c. 75.0%
2. The most common problem related to clinical deci- d. 62.5%
sion making by practicing physicians is: e. 11.0%
a. not formulating enough hypotheses
b. not formulating the correct hypotheses 5. What is the specificity of test A for disease B?
c. not attending to all the patient-relevant cues a. 25.0%
d. not knowing the prevalence of the condition b. 37.5%
e. not using time appropriately in treatment plans c. 75.0%
d. 61.5%
3. The student returns with you to the office and sees a e. 11.0%
patient on her own initially to gather historical and
physical examination data, which she then presents to 6. What is the positive predictive value (PPV) of test A
you. After seeing the patient, she is absolutely con- in the diagnosis of disease B?
vinced the patient has a particular diagnosis. You take a. 37.5%
her with you to see the patient, and you obtain more b. 25.0%
historical information and examine the patient. As c. 75.0%
you ask her questions about her reasoning, she pro- d. 61.5%
ceeds to ignore a whole variety of things that do not e. 11.0%
support her original diagnostic hypothesis. She has
made which of the following errors in clinical deci-
sion making? TA B L E 2.1 Relationship Between Test A and
a. failure to acquire a cue Disease B
b. failure to generate hypotheses Disease B Disease B
c. premature closure Present Absent
d. all of the above Test A result positive 30 50
e. none of the above
Test A result negative 10 80
TA B L E 2.2 Prevalence of Disease X in TA B L E 2.3 Sensitivity and Specificity of

Certain Populations Blood Glucose Levels in the
Prevalence Diagnosis of Diabetes Mellitus
Setting (Cases/100,000) Blood Glucose Levels 2
General population 50 Hours After Eating Sensitivity Specificity
Women, ≥50 years 500 >140 mg/100 (7.8 mmol/L) 57% 99.4%
Women, ≥65 years, with a suspicious 40,000
finding on clinical examination
a. 0.4%
b. 5.6%
7. What is the NPV of test A in the diagnosis of disease B? c. 34.7%
a. 37.0% d. 84.2%
b. 89.0% e. 93.0%
c. 25.0%
d. 75.0% 13. If the PPV of a test for a given disease in a given pop-
e. 61.5% ulation is 4%, how many true positive (TP) test re-
sults are there in a sample of 100 positive test results?
8. What is the likelihood ratio for test A in disease B? a. 4
a. 0.39 b. 10
b. 1.95 c. 40
c. 3.80 d. 96
d. 0.79 e. none of the above
e. 1.51 To answer question 14, consider the data in Table 2.3
regarding the sensitivity and specificity in the diagnosis
9. What is the prevalence of disease A in this popula- of diabetes mellitus in the population.
tion?
a. 15.5% 14. Given that the data are correct, if the sensitivity of the
b. 23.5% test for a given blood glucose level is 36%, which of the
c. 40.0% following would be the most likely value for specificity?
d. 10.5% a. 99.2%
e. 18.4% b. 98.7%
Consider the data in Table 2.2 illustrating the prevalence c. 92.4%
of disease X in various populations. On the basis of this d. 87.3%
information about disease prevalence and assuming the e. 100.0%
sensitivity of test A for disease X is 80% and the specificity
of test A for disease X is 90%, answer questions 10 to 13. 15. The validity of a test is best defined as which of the
following?
10. What is the PPV of test A in the diagnosis of disease a. the reliability of the test
X in the general population? b. the reproducibility of the test
a. 0.4% c. the variation in the test results
b. 1.3% d. the degree to which the results of a measurement
c. 5.4% correspond to the true state of the phenomenon
d. 15.7% e. the degree of biologic variation of the test
e. 39.6%
16. Which of the following terms is synonymous with the
11. What is the PPV of test A in disease X in women aged term reliability?
50 years of age or older? a. reproducibility
a. 0.4% b. validity
b. 3.9% c. accuracy
c. 10.7% d. mean
d. 23.6% e. variation
e. 52.7%
17. Which of the following is not a measure of central
12. What is the PPV of test A in disease X in women tendency?
older than 65 years of age with a suspicious finding on a. mean
clinical examination? b. median
TA B L E 2.4 Blood Pressure Readings Versus TA B L E 2.5 Ten-Year Mortality Data

Visit Number Average
Mean Diastolic Blood Diagnosed Survival
Visit Number Pressure (mm Hg) With Lung Time From
1 99.2 Group Description Cancer Diagnosis
2 91.2 Group 1 490 individuals 37 14 months
(experimental with annual chest
3 90.7
group) radiographs
Group 2 510 individuals 39 8 months
(control with no annual
c. mode group) chest radiograph
d. standard deviation (SD)
e. none; all of the above are measures of central ten-
dency Gaussian distribution
Consider the following experimental data: In a trial of 20. Length-time bias with respect to cancer diagnosis is
the effect of reducing multiple risk factors on the sub- defined as which of the following?
sequent incidence of coronary artery disease, high-risk a. bias resulting from the detection of slow-growing
patients were selected for study. Elevated blood pressure tumors
was one of the risk factors for people to be considered. b. bias resulting from the length of time a cancer was
People were screened for inclusion in the study on three growing before any symptoms occurred
consecutive visits. Blood pressures at those visits, before c. bias resulting from the length of time a cancer was
any therapeutic interventions were undertaken, were as growing before somebody started to ask some ques-
listed in Table 2.4. Use the data in Table 2.4 to answer tions and perform some laboratory investigations
question 18. d. bias resulting from the length of time between the
latent and more rapid growth phases of any cancer
18. Which of the following statements regarding these e. none of the above
data is true?
a. these results are very strange: consider publica- 21. Concerning population and disease measurement,
tion in any journal specializing in irreproducible prevalence is defined as which of the following?
results a. the fraction (proportion) of a population having a
b. this is an example of regression to the mean clinical condition at a given point in time
c. this is an example of natural variation b. the fraction (proportion) of a population initially
d. the most likely explanation is either interobserver free of a disease but that develops the disease
or intraobserver variation during a given period
e. we are probably dealing with faulty equipment c. equivalent to incidence
in this case; the most likely reason for this would d. mathematically as (a + b)/(a + b + c + d) in a 2 × 2
be failure to calibrate all of the blood pressure table relating sensitivity and specificity to PPV
cuffs e. none of the above
Consider the following experimental data: A population
of heavy smokers (men smoking more than 50 cigarettes 22. Concerning population and disease measurement, in-
per day) are divided into two groups and observed for a cidence is defined as which of the following?
period of 10 years. Use the data from Table 2.5 to answer a. the fraction (proportion) of a population having a
question 19. clinical condition at a given point in time
b. the fraction (proportion) of a population initially
19. Regarding these results, which of the following state- free of a disease but that develops the disease
ments is true? during a given period
a. these results prove that screening chest radio- c. equivalent to prevalence
graphs improve survival time in lung cancer d. of little use in epidemiology
b. these results prove that screening chest radio- e. none of the above
graphs should be considered for all smokers
c. these results are most likely a result of lead-time 23. Regarding clinical epidemiology in relation to the
bias discipline of family medicine, which of the following
d. these results are most likely an example of length- statements is true?
time bias a. clinical epidemiology is higher mathematics that
e. these results do not make any sense; the experi- bears little relation to the world in general, much
ment should be repeated less the specialty of family medicine
b. clinical epidemiology was invented to create anxi- cues in support or refute of a hypothesis. The search
ety and panic attacks that mimic hyperthyroidism process relies on knowledge of prevalence of condi-
in medical students and residents tions in different populations and knowledge of the
c. clinical epidemiology is unlikely to contain any value of the cue with respect to the hypothesis. The
useful information for the average practicing major error is making assumptions about the sensitiv-
family physician ity, specificity, or predictive value of data and coming
d. clinical epidemiology is a passing fad; fortunately to premature closure about a hypothesis under con-
for all concerned, we have moved on to evidence- sideration. The inexperienced or not very careful de-
based medicine cision maker often tries to squeeze as many cues into
e. none of the above statements about clinical epide- the incorrect hypothesis and often ignores nonsup-
miology is true porting cues.
The plan can be diagnostic or therapeutic or both.
The plan should be patient centered, and often it is ne-
ANSWERS
gotiated with the patient. Diagnostic and therapeutic
1. a. The clinical decision-making process in family plans may involve use of time, laboratory studies,
medicine involves four iterative steps: cue acquisi- pharmacotherapy or behavioral therapy, and consultation
tion, hypothesis formation, the search, and plan. Cues to gather new cues, to test hypotheses, or to provide de-
come in a variety of different forms, including tra- finitive care. Follow-up is essential and is a hallmark in
ditional patient-specific historical cues and physical the patient-physician relationship that facilitates decision
examination, and laboratory data cues. Clinicians also making in family medicine. The major error in plan for-
attend to sensory cues, such as what we see, smell, mation is not listening to the patient and not considering
hear, and feel about a patient and his or her story; the needs and desires of the patient. Patient nonadher-
contextual cues, such as physical location of the en- ence is often a direct result of this major failure to engage
counter; and temporal cues, such as frequency, rep- the patient in the plan.
etitions, intensity, and persistence of symptoms or Table 2.6 illustrates the answers to questions 4 to 9.
signs. All these different cues are part of our clinical
thinking. The major mistake we make as clinicians in 4. c. Sensitivity is defined as the proportion of people
cue acquisition is either missing or ignoring a cue or with the disease who have a positive test result. A sen-
cues. From research we know that experienced clini- sitive test rarely will miss patients who have the dis-
cians do not attend to all cues to arrive at a correct ease. In Table 2.6, sensitivity is defined as the number
diagnosis. Inexperienced clinicians such as medical of TPs divided by the number of TPs plus the num-
students often fail to identify key cues, and as a result ber of false negatives (FNs). That is:
they often fail to consider proper hypotheses about
Sensitivity = TP/ ( TP + FN )
what is going on to explain the chief complaint of the
patient. Sensitivity = a / ( a + c ) = 30/40 = 75
2. b. Hypotheses are explanatory models of what we A sensitive test (one that is usually positive in the presence
believe is going on in a patient. Traditionally, they of disease) should be selected when there is an important
lead to or are diagnoses. Hypotheses are generated penalty for missing the disease. This would be the case if
and rank ordered on the basis of the cues acquired. you had reason to suspect a serious but treatable condition
Knowledge of mortality and morbidity linked to (e.g., obtaining a chest radiograph in a patient with
cues helps clinicians to generate and rank order hy- suspected tuberculosis or Hodgkin disease). In addition,
potheses. Other factors that influence hypothesis sensitive tests are useful in the early stages of a diagnostic
formation include experience, curiosity, and novelty. work-up of disease, when several possibilities are being
A variety of hypotheses are possible and important considered, to reduce the number of possibilities. Thus
to consider, but hypotheses can be broadly placed in situations such as this, diagnostic tests are used to rule
into biomedical and psychosocial categories. The out diseases.
average skilled clinician will actively consider an
average of five active hypotheses at any one time.
The major error in clinical decision making over-
all is failure to generate or to consider the correct TA B L E 2.6 Disease X
hypothesis. Disease X Disease X
Present Absent
3. c. The search process gathers more cues to test the
Test A result positive 30 (a) TP 50 (b) FP
hypotheses being considered, and it is based on the
science of probability. Hypotheses are weighed on the Test A result negative 10 (c) FN 80 (d) TN
basis of sensitivity, specificity, and predictive value of FN, False negative; FP, false positive; TN, true negative; TP, true positive.
5. d. Specificity is defined as the proportion of people TA B L E 2.7 Calculations Involved in a

without the disease who have a negative test result. A
General 2 × 2
specific test rarely incorrectly classifies people with-
out the disease as having the disease. In Table 2.6, Target Disorder
specificity is defined as the number of true negatives Present Absent
(TNs) divided by the number of TNs plus false posi- Test result Cell a = (sensitivity) Cell b = (b + d ) − d
tives (FPs). That is: positive (a + c)
Specificity = TN/ ( TN + FP ) Test result Cell c = (a + c) − a Cell d = (specificity)
Specificity = d / ( d + b ) = 80/130 = 61.5
negative (b + d )
Column sums a+c Total = (b + d )
A specific test is useful to confirm, or rule in, a diagnosis Total = a + b +
that has been suggested by other tests or data. Thus a c+d
specific test is rarely positive in the absence of disease
(i.e., it gives few false-positive test results). Tests with
high specificity are needed when false-positive results can That is:
harm the patient physically, emotionally, or financially.
( a + c ) divided by ( a + b + c + d )
Thus a specific test is most helpful when the test result
= (30 + 10) / (30 + 10 + 50 + 80 ) = 23.5
is positive.
There is always a trade-off between sensitivity and As prevalence decreases, PPV must decrease along with it
specificity. In general, if a disease has a low prevalence, and NPV must increase.
choose a more specific test; if a disease has a high preva-
lence, choose a more sensitive test. 10. a. Answers 10 and 11 are explained in answer 12,
including Table 2.7.
6. a. PPV is defined as the probability of disease in a
patient with a positive (abnormal) test result. It is the 11. b. See answer 12.
proportion of people with a positive test result that
are TPs. In Table 2.6, the PPV is as follows: 12. d. The respective PPVs for test A in the diagnosis of
disease X in the general population, in women older
PPV = a / ( a + b ) = 30/80 = 37.5 than 50 years, and in women older than 65 years with
a suspicious finding on clinical examination are 0.4%,
7. b. NPV is defined as the probability of not having 3.9%, and 84.2%, respectively.
the disease when the test result is negative. It is the To perform the calculations necessary to obtain these
proportion of people with a negative test that are answers, the following steps are recommended:
TNs. In Table 2.6, the NPV is as follows: Step 1: Identify the sensitivity of the sign, symptom, or
diagnostic test that you plan to use. Many of these are
NPV = d / ( c + d ) = 80/90 = 89 published. If you are not certain, consider asking a
consultant with expertise in the area.
8. b. The likelihood ratio of a positive test result is the Step 2: Using a 2 × 2 table, set your total equal to an even
probability of that test result in the presence of dis- number (consider, for example, 1000 as a good choice).
ease divided by the probability of the test result in the Therefore
absence of disease. In Table 2.6, the likelihood ratio is
as follows: a + b + c + d = 1000
Likelihood ratio ( + ) test results a / ( a + c ) divided by b / ( b + d ) Step 3: Using whatever information you have about the
or 30/ (30 + 10) divided by 50/ (50 + 80) = 1.95 patient before you apply this diagnostic test, estimate
his or her pretest probability (prevalence) of the dis-
9. b. The prevalence of a disease in the population ease in question. Next, put appropriate column sum-
at risk is the fraction or proportion of a group with mation numbers at the bottom of the columns (a + c)
a clinical condition at a given point in time. Preva- and (b + d). The easiest way to do this is to express your
lence is measured by surveying a defined population pretest probability (or prevalence) as a decimal three
containing people with and without the condition of places to the right. This result is (a + c), and 1000 mi-
interest (at a given point in time). Prevalence can be nus this result is (b + d).
equated with pretest probability. In Table 2.6, preva- Step 4: Start to fill in the cells of the 2 × 2 table. Multiply
lence is defined as follows: sensitivity (expressed as a decimal) by (a + c), and put
the result in cell a. You can then calculate cell c by sim-
Prevalence = ( a + c ) / ( a + b + c + d ) ple subtraction.
Step 5: Similarly, multiply specificity (expressed as a dec- 15. d. Validity is the degree to which the result of a
imal) by (b + d), and put the result in cell d. Calculate measurement of a test actually corresponds to the
cell b by subtraction. true state of the phenomenon being measured.
Step 6: You now can calculate PPVs and NPVs for the
test with the prevalence (pretest probability) used. 16. a. Reliability is the extent to which repeated mea-
For example, to calculate the PPV for test A in the surements of a relatively stable phenomenon fall close
diagnosis of disease in women older than 65 years with to each other. Reproducibility and precision are other
a suspicious finding on clinical examination, use the words for this characteristic.
following equation:
17. d. Central tendency in a normal, or Gaussian, dis-
= =
Prevalence 40, 000 cases/100, 000 400/1000
tribution is characterized by the following measures:
Setting the total number equal to 1000, (1) Mean: the sum of the values for observations divided
by the number of observations;
( a + c ) / ( a + b + c + d ) = 400/1000 (2) Median: the value point where the number of obser-
Therefore vations above equals the number of observations be-
low; and
( a + c ) = 400 and ( b + d ) = 600
(3) Mode: the most frequently occurring value.
Thus Expressions of dispersion in the same normal, or
Cell a = sensitivity × 400 = 0.8 × 400 = 320 Gaussian, distribution are the following:
(1) Range: the difference between the lowest value and
Cell b = 400 − 320 = 80 the highest value in a distribution;
Similarly, (2) SD: the absolute value of the average difference of
individual values from the mean; and
Cell d = Specificity × 600 = 0.9 × 600 = 540
(3) Percentile: the proportion of all observations falling
Cell b = 600 − 540 = 60 between specified values.
The most valuable measure of dispersion in a normal, or
Calculate the PPV as follows: Gaussian, distribution is the SD. It is defined as follows:
PPV = a / ( a + b ) = 320/ (320 + 60) = 84.2 SD = ( ∑x − x 2

) / ( n − 1)
Similar calculations can be made for the general In a normal, or Gaussian, distribution, 68.26% of the
population (prevalence = 50/100,000) and for women values lie within ±1 SD from the mean, 95.44% of values
older than 50 years (prevalence = 500/100,000). lie within ±2 SD from the mean, and 99.72% of values lie
within ±3 SD from the mean.
13. a. If the PPV of a test for a given disease is 4%, then
only 4 of 100 positive test results will be TPs; the re- 18. b. As can be seen in this trial, there was a progres-
mainder will be FPs. Further testing (often invasive) sive and substantial decrease in mean blood pressure
and anxiety will be inflicted on the 96% of the popu- between the first and third visits. The explanation for
lation with a positive test result but without the dis- this is called regression to the mean. The following is
ease. the best explanation of regression to the mean.
Thus careful consideration should be given to the PPV Patients who are singled out from others because they
of any test for any disease in a given population before have a laboratory test result that is unusually high or low
ordering it. can be expected, on average, to be closer to the center
of the distribution (normal or Gaussian) if the test is
14. e. Remember the inverse relationship between sen- repeated. Moreover, subsequent values are likely to be
sitivity and specificity: if the sensitivity increases, then more accurate estimates of the true value (validity), which
the specificity decreases. The only value that is greater could be obtained if the measurement were repeated for a
than the previous specificity of 99.4% is 100%; there- particular patient many times.
fore it is the most likely correct value of the values listed
for the specificity of the test. The value in the table 19. c. This is an example of lead-time bias. Lead time is
is actually the case at a cutoff blood glucose level of the period between the detection of a medical condi-
180 mg/100 mL 2 hours after eating. If we use this val- tion by screening and when it ordinarily would have
ue for the cutoff, there will be even more false-negative been diagnosed as a result of symptoms.
results than at 140 mg/100 mL. That is, we will incor- For lung cancer, there is absolutely no evidence that chest
rectly label more individuals who actually have diabe- radiographs have any influence on mortality. However,
tes as being normal, although we will not label anyone if, as in this case, the experimental group had chest
who does not have diabetes as having diabetes. radiographs done, their lung cancers would have been
diagnosed at an earlier time and it would appear that they and as previously discussed in relation to sensitivity,
were longer survivors. The control group most likely specificity, and PPV in a 2 × 2 table, it is defined in
would have had their lung cancers diagnosed when they mathematical terms as (a + c)/(a + b + c + d).
developed symptoms. In fact, however, the survival time
would have been exactly the same; the only difference 22. b. Incidence in relation to a population is defined
would have been that men in the experimental group as the fraction (proportion) initially free of a disease
would have known that they had lung cancer for a longer or condition that go on to develop it during a given
period. period. Commonly, it is known as the number of new
cases per population in a given time.
20. a. Length-time bias occurs because the proportion
of slow-growing lesions diagnosed during a cancer 23. e. Clinical epidemiology is a specialty that will as-
screening program is greater than the proportions sume increasingly more importance in the specialty
of those diagnosed during usual medical care when of family medicine. It allows us to understand dis-
symptoms appear. The effect of including a greater ease, to understand laboratory testing, and to un-
number of slow-growing cancers makes it seem that derstand why we should do what we should do and
the screening and early treatment programs are more why we should not do what we should not do. More
effective than they really are. important, as family physicians are called on by
governments, patients, licensing bodies, and boards
21. a. Prevalence is defined as the fraction (proportion) to justify clinical decisions and treatments, clinical
of a population with a clinical condition at a given epidemiology will allow us to understand the dif-
point in time. Prevalence is measured by surveying a ference between “defensive” medicine and defensi-
defined population in which some patients have and ble medicine (the latter being what we are trying
some patients do not have the condition of interest at to achieve) in the interest of optimizing the health
a single point in time. It is not the same as incidence, care of patients.
S U M M A RY
1. The process of clinical decision making in family med- curiosity, and novelty. The typical skilled clinician
icine is essentially a four-step iterative process: cue ac- will actively consider an average of five active hy-
quisition, hypotheses formation, the search, and plan. potheses at any one time. The major error in clin-
ical decision making with respect to hypothesis
2. Cues come in a variety of different forms, including formation is failure to generate or to consider the
traditional patient-specific historical, physical exam- correct hypothesis.
ination, and laboratory data cues, as well as sensory
cues (e.g., what we see, smell, hear, and feel about pa- 4. The search process gathers more cues to test the
tients and their stories). There are contextual cues, hypotheses being considered and is based on the
such as physical location (e.g., the emergency depart- science of probability. Hypotheses are weighed on
ment, office, hospital, and home), and temporal cues the basis of sensitivity, specificity, and predictive
(e.g., frequency, repetitions, intensity, and persistence value of the cue with respect to the hypothesis. The
of signs and symptoms). The major mistake we make major error is making assumptions about the sen-
as clinicians in cue acquisition is either missing cues sitivity, specificity, or predictive value of data and
or ignoring cues. However, we know that experienced coming to premature closure about a hypothesis
clinicians do not attend to all cues to arrive at a cor- under consideration.
rect diagnosis.
5. The plan can be diagnostic or therapeutic or both.
3. Hypotheses are explanatory models of what we be- It should be patient centered and often is negotiated
lieve is going on in a patient. Traditionally, they with the patient. It can involve use of time, labora-
lead to or are diagnoses. A variety of hypotheses are tory studies, pharmacotherapy or behavioral thera-
possible and important to consider, but hypotheses py, and consultation to gather new cues, to test hy-
can be broadly classified into biomedical or psy- potheses, or to provide definitive care. Follow-up is
chosocial categories. Hypotheses are generated essential and is a hallmark in the patient-physician
and rank ordered on the basis of the cues acquired. relationship that facilitates decision making in fam-
Knowledge of mortality and morbidity linked to ily medicine. The major error in plan formation is
the cues acquired also helps clinicians to generate not listening to the patient and not considering the
and rank order hypotheses. Other factors that in- needs and desires of the patient. Patient nonadher-
fluence hypothesis formation include experience, ence is often a direct result.
Continued
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[1626] Gazette of the United States, May 16, 1799.
[1627] Aurora, June 25, August 5, 1799.
[1628] Ibid., September 24, 1799.
[1629] Adams, Works, X, 116-19.
[1630] Ibid.
[1631] Aurora, January 10, 1800.
[1632] Ibid., February 27, 1800.
[1633] Gibbs, II, 241; Morse to Wolcott.
[1634] May 14, 1799.
[1635] June 1, 1799.
[1636] May 16, 1799.
[1637] July 18, 1799.
[1638] Gibbs, II, 313-18.
[1639] Steiner, 382.
[1640] August 21, 1799.
[1641] Jefferson’s Works (to Madison), X, 49-53; (to Gerry), X, 74-86. All of which
is borne out by the signed statement of Logan, whose veracity was more reliable than
that of Harper.
[1642] New York Commercial Advertiser, November 15, 1798.
[1643] Ibid., November 22, 1798.
[1644] Adams, Works, VIII, 615.
[1645] Gibbs, II, 195.
[1647] Ibid., January 16, 1799.
[1648] Morison, Otis, I, 168-71.
[1649] Adams, Works, VIII, 617.
[1650] Jefferson’s Works, X, 86-89.
[1651] Gibbs, II, 313-18.
[1652] Adams, Adams, I, 523-24.
[1653] Lodge, Hamilton, 212.
[1654] Hamilton’s Works (to King), X, 314-15.
[1655] Ibid., 315-16.
[1656] Randall, Jefferson, II, 464.
[1657] Hamilton’s Works, X, 389.
[1658] See King’s Works, II, 649-66; III, 556, 565; Adams, Works, X, 145 and 147.
[1659] At the rate of four for Connecticut with a population of 250,000.
[1660] Adams, Adams, I, 536.
[1661] Adams, Adams, I, 538-39.
[1662] Jefferson’s Works (to Madison), X, 110-13.
[1663] Ibid. (to Madison), 119-21.
[1664] Pickering, III, 439. According to another version, Adams received the
committee politely until Sedgwick angered him with a slurring remark on Gerry.
[1665] Porcupine’s Gazette, February 20, 1799.
[1666] Ibid., February 21, 1799.
[1667] Ibid., February 28, 1799.
[1668] Adams, Adams, I, 544-45.
[1669] King’s Works, III, 68.
[1670] Steiner, 416.
[1671] King’s Works, IX, 249.
[1672] Lodge, Cabot, 224-26.
[1673] King’s Works, III, 7-10.
[1674] Lodge, Cabot, 221.
[1675] Gibbs (to Wolcott), II, 229-30.
[1676] Morison, Otis (to Otis), I, 171.
[1677] Ames (to Dwight), I, 252.
[1678] Morison, Otis, I, 174-75.
[1679] Anas, I, 351-52.
[1680] King’s Works (Cabot to King), III, 111; (to Pickering), 228; (to Wolcott),
229.
[1681] Aurora, April 27, 1799.
[1682] Centinel, June 8, June 17, 1799.
[1683] August 28, 1799.
[1685] Adams, Adams, I, 554.
[1686] Stoddert was reported to have told General Sam Smith that this was in his
mind; Anas, I, 349-50.
[1687] Lodge, Cabot, 240-42.
[1688] King’s Works (Cabot to King), III, 114.
[1689] Centinel, October 9, 1799.
[1690] Anas, I, 349.
[1691] Brown, Life of Ellsworth, 279.
[1692] Ibid.
[1693] Aurora, October 23, 1799.
[1694] Ibid., October 25, 1799.
[1695] Aurora, July 26, August 5, 1799.
[1696] Morison, Otis, I, 137; McRee, Iredell, II, 571.
[1698] Aurora, April 2, 1800.
[1699] Ibid., April 4, 1800.
[1700] Annals, March 28, 1800.
[1701] April 2, 1800.
[1702] Beveridge, II, 453.
[1703] King’s Works, III, 237-38.
[1704] The nature of the amendment is not disclosed in the Annals, April 16, 1800.
[1705] Aurora, April 28, 1800.
[1706] Ibid., April 30, 1800.
[1709] Ibid., 74.
[1710] Ibid., 89-92.
[1711] Adams, Works, X, 116-19.
[1712] Commercial Advertiser, February 13, 1800.
[1713] Randall, II, 470.
[1715] Ibid., 86-89.
[1716] Ibid., 95-97.
[1717] Ibid., 97-99.
[1718] Dodd, Macon, 157-59.
[1719] Thomas, Reminiscences, II, 54-56.
[1721] Ibid., 154-59.
[1722] Ibid.
[1723] Randall, II, 538.
[1725] Parton, Life and Times of Aaron Burr; Davis, Memoirs of Aaron Burr;
Familiar Letters, 237; Oliver, Hamilton; Bradford, Damaged Souls.
[1726] Adams, Gallatin (Matthew L. Davis to Gallatin), 232-34.
[1727] Parton, Burr, I, 247.
[1728] Myers, Tammany Hall, 12.
[1729] Commercial Advertiser, April 26, 1800.
[1730] Commercial Advertiser, July 26, 1800.
[1731] Ibid., April 29, 1800.
[1732] Ibid.
[1733] Commercial Advertiser, April 29, 1800.
[1734] Adams, Gallatin, 237-38.
[1735] Adams, Gallatin (to his wife), 240-41.
[1738] Ibid., 241.
[1739] Gibbs (McHenry to his brother), II, 246-48.
[1740] Gibbs, II, 246-48; Steiner, 454.
[1741] Pickering, III, 487.
[1742] Ibid., III, 488.
[1744] Steiner, 457.
[1745] Aurora, March 6, 1800.
[1746] Aurora, May 9, 1800.
[1747] Centinel, May 21, 1800.
[1748] Centinel, May 24, 1800.
[1750] Ibid., 250.
[1751] King’s Works (from Pickering), 262-63; (Ames to King), 275-76; (Goodhue
to Pickering), 243-44.
[1752] Ibid. (from Pickering), 248; (from Cabot), 249.
[1753] Hamilton’s Works (to Sedgwick), X, 375-76.
[1755] Ibid., 275-76.
[1756] Aurora, July 17, 1800.
[1757] Aurora, June 7, 1800.
[1758] Hamilton’s Works (to Bayard), X, 384-87.
[1759] Hamilton’s Works (to Bayard), X, 384-87.
[1760] Quoted by The Aurora, July 30, 1800.
[1761] August 5, 1800.
[1762] Familiar Letters, 373; Lodge, Cabot.
[1763] Memoir of Theophilus Parsons, 328-29; 336-42, 345, 418, 436.
[1764] Thomas, Reminiscences, I, 17; T. W. Higginson, Stephen Higginson, 137,
272, 280, 273-76.
[1765] Familiar Letters, 370-71, 381.
[1766] Centinel, June 21, 1800.
[1767] Centinel, June 21, 1800.
[1768] Ibid.
[1769] Aurora, June 21, 1800.
[1770] Aurora, June 30, 1800.
[1771] Centinel, June 28, 1800.
[1772] August 9, 1800.
[1773] Chronicle, July 31, 1800.
[1774] Ibid., August 18, 1800.
[1775] King’s Works (J. Hale to King), III, 270.
[1776] Hamilton’s Works, X, 379-80.
[1777] Gibbs (McHenry to Wolcott), II, 414-15.
[1778] Gibbs, II, 374-75.
[1779] Lodge, Cabot, 278-80.
[1780] Gibbs, II, 381.
[1781] Gibbs, II, 382.
[1782] Ibid., 379.
[1783] Ibid., 384.
[1784] Ibid., 400-05.
[1785] Aurora, September 11, 1800.
[1786] Lodge, Cabot (to Wolcott), 282.
[1787] Lodge, Cabot, 286-88.
[1788] Gibbs (Phelps to Wolcott), II, 380.
[1789] American Mercury, September 11. 1800.
[1790] Lodge, Cabot (Wolcott to Cabot), 278.
[1791] Aurora, July 26, 28, 1800.
[1792] Gibbs, II, 162.
[1793] Aurora, November 15, 1800; Langdon to Samuel Ringgold.
[1794] Gibbs, II, 418-19.
[1795] August 7, 1800.
[1796] This pamphlet is in New York Public Library.
[1797] Welling’s Lectures, 274-75.
[1798] Hartford Courant, June 23, 30, July 7, 14, 21, 26, August 4, 11, 18,
September 1, 15, 22, 1800.
[1799] American Mercury, July 10, 1800.
[1800] Robinson, Jeffersonian Democracy in New England, 27.
[1801] Robinson, Jeffersonian Democracy in New England, 27.
[1802] Centinel, March 1, 22, 1800.
[1803] Gibbs (Phelps to Wolcott), II, 418-19.
[1804] August 4, 1800.
[1805] New York Commercial Advertiser, May 13, 1800.
[1806] American Mercury, September 19, 1800.
[1807] Gibbs (from Phelps), II, 418.
[1808] Courant, September 15, 1800.
[1809] Ibid.
[1810] Connecticut in Transition, 315-16.
[1812] Original copies published in both Philadelphia and Newark are in New
York Public Library.
[1814] Courant, November 17, 1800.
[1815] Jefferson’s Works (to Uriah McGregory), X, 170-73.
[1818] Courant, August 25, 1800.
[1819] A Voice of Warning.
[1820] Serious Considerations.
[1821] Serious Facts.
[1822] Morse, Federalist Party in Massachusetts, 133-34.
[1823] Morse, Federalist Party in Massachusetts, 95, note.
[1824] The Claims of Thomas Jefferson to the Presidency Examined at the Bar of
Christianity, probably by Asbury Dickens in New York Public Library.
[1825] Address to the People of the United States, etc., by John James Beckley, in
New York public Library.
[1826] Independent Chronicle, June 30, 1800.
[1827] American Mercury, October 2, 1800.
[1828] Aurora, March 31, 1800.
[1829] Ibid., October 14, 1800.
[1830] Lodge, Cabot, 283-84.
[1832] Ibid., 388-89.
[1833] Lodge, Cabot (Cabot to Hamilton), 284-86.
[1836] Davis, Burr, II, 65.
[1837] Parton, I, 126-27; Davis, II, 65.
[1838] Copied in the Commercial Advertiser, November 27, 1800.
[1839] Hamilton’s Works, VII, 309-64.
[1840] Lodge, Cabot, 298-300.
[1841] Centinel, November 15, 1800.
[1842] Ibid., November 26, 1800.
[1843] October 27, 1800.
[1844] November 4, 1800.
[1845] October 30, 1800.
[1846] December 1, 1800.
[1847] October 29, 1800.
[1848] Reprinted in The Aurora, November 13, 1800.
[1849] Answer to Alexander Hamilton’s Letter Concerning the Public Conduct and
Character of John Adams.
[1851] Ames, I, 283-85.
[1852] Gibbs, II, 384-86.
[1853] American Mercury, June 19, 1800.
[1854] Steiner (Hamilton to McHenry), 466; (Dickinson to McHenry), 471.
[1855] A Series of Letters on the Subject of ‘The Legislative Choice’ of Electors in
Maryland, by ‘Bystander.’
[1856] August 4, 1800.
[1857] Gibbs (to Wolcott), II, 388-90.
[1858] Ibid., II, 399.
[1859] Ibid., II, 387-88.
[1860] Aurora, November 11, 1800.
[1861] Morris, Diary, II. 394-95.
[1862] Gibbs (Wolcott to wife), II, 456.
[1863] Adams, Letters of Mrs. Adams, II, 239-41.
[1864] Ibid., 243-44.
[1865] Morris. Diary, II, 396.
[1866] Mrs. Smith, 9-10.
[1867] Adams, Gallatin (Gallatin to his wife), 252-55.
[1868] Ibid., 255.
[1869] Ibid., 255.
[1870] Mrs. Smith, 13-15.
[1871] Ibid., 4.
[1872] Mrs. Smith, 3.
[1873] Ibid., 5.
[1874] Gallatin’s expression; Adams, Gallatin, 252-53.
[1877] Parton, Burr, I, 267.
[1879] Ibid., 393-97.
[1880] McLaughlin, Matthew Lyon, 386.
[1881] Parton, Burr, I, 270.
[1883] Ibid., 402-04.
[1884] Ibid., 404-05.
[1885] Ibid., 405-07.
[1886] Morris, Diary, II, 397.
[1888] Morison, Otis, I, 211-12.
[1890] Steiner, 485-88.
[1891] Ibid., 489-90.
[1892] King’s Works (Pickering to King), III, 366.
[1893] Parton, Burr, I, 272-73.
[1894] Ibid., 274.
[1895] Parton, Burr, I, 274-75.
[1896] Ibid., 277-78.
[1899] King’s Works (J. Hale to King), III, 372.
[1900] Ibid. (Sedgwick to King), 455.
[1902] King’s Works (Troup to King), III, 391.
[1903] Jefferson’s Works (to Hugh Williamson), X, 188; (to William Dunbar), 191.
[1904] Adams, Gallatin (Gallatin to his wife), 257.
[1905] Commercial Advertiser, January 17, 1801.
[1906] Reprinted in Connecticut Courant, January 26, 1801.
[1907] Centinel, January 28, 1801.
[1908] Centinel, January 7, 1801.
[1909] Ibid., February 11, 1801.
[1910] Ibid.
[1911] Adams. Gallatin, 248-51.
[1913] Ibid.
[1914] Centinel, February 18, 1801, before the result of the election was known.
[1915] Anas, I, 381.
[1918] Connecticut Courant, February 11, 1801.
[1919] Parton, Burr, I, 288.
[1920] Morison, Otis, I, 207-08.
[1921] Mrs. Smith, 24.
[1922] Commercial Advertiser, February 16, 1801.
[1923] Mrs. Smith, 24.
[1925] Morison, Otis, I, 207-08.
[1927] Ibid., 261-62.
[1928] Parton, Burr, I, 288.
[1929] Mrs. Smith, 23.
[1930] Parton, Burr; Letter to Hamilton.
[1931] Adams, Gallatin, 262.
[1932] Annals, February 21, 1801.
[1933] Annals, March 2, 1801.
[1934] Gibbs, II, 497.
[1935] Adams, Gallatin, 265.
[1936] Mrs. Smith, 12.
[1937] Ibid., 26.
[1938] Mrs. Smith.
[1940] Ibid., X, 444.
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