COMAT Family Medicine

COMAT Family Medicine

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TABLE OF CONTENTS Preface........................................................................................................ 1 Introduction: About the COMAT Examinations ........................................... 4 Chapter One: General Presentation of the Patient ....................................... 6 Well Child Development and Developmental Delays ..................................................... 6 Developmental Delay ..................................................................................................... 10 Patients presenting for Routine Examinations ............................................................. 13 Patients presenting for Routine Screening.................................................................... 14 Vaccinations ................................................................................................................... 16 Key Takeaways ............................................................................................................... 19 Quiz ................................................................................................................................ 20 Chapter Two: Hematology / Oncology / Immune Disorders ...................... 23 Anemias .......................................................................................................................... 23 Bleeding Disorders ......................................................................................................... 25 Hypercoagulable States ................................................................................................. 27 Autoimmune Disorders ................................................................................................. 28 Immunodeficiency Disorders ........................................................................................ 32 HIV Disease.................................................................................................................... 34 Care of the Patient with Cancer ..................................................................................... 36 Key Takeaways ............................................................................................................... 38 Quiz ................................................................................................................................ 39 Chapter Three: Genitourinary/Renal and Reproductive Disorders ........... 42 Abnormal Vaginal Bleeding/Menstrual-related Disorders........................................... 42

Endometriosis ................................................................................................................ 43 Polycystic Ovarian Syndrome ........................................................................................ 46 Breast Disorders............................................................................................................. 47 Contraceptive Management ........................................................................................... 48 Pregnancy-related Disorders ......................................................................................... 49 Placental Abruption ....................................................................................................... 50 Placenta Previa ............................................................................................................... 51 Preeclampsia and Eclampsia ......................................................................................... 53 Erectile Dysfunction ...................................................................................................... 54 Incontinence .................................................................................................................. 55 Menopause/Hormone Replacement Therapy ............................................................... 57 Chronic Renal Disease ................................................................................................... 58 Sexually Transmitted Infections .................................................................................... 60 Urinary Tract Infections ................................................................................................ 61 Key Takeaways ............................................................................................................... 64 Quiz ................................................................................................................................ 65 Chapter Four: Gastrointestinal Disorders ................................................. 68 Gastroesophageal Reflux Disease .................................................................................. 68 Functional Dyspepsia..................................................................................................... 69 Peptic Ulcer Disease....................................................................................................... 70 Management of Chronic Hepatitis ................................................................................ 72 Nutritional & Vitamin Deficiencies ............................................................................... 73 Chronic Pancreatitis....................................................................................................... 74 Malabsorption ................................................................................................................ 75

Irritable Bowel Syndrome .............................................................................................. 77 Diverticulosis/Diverticulitis .......................................................................................... 78 Cirrhosis of the Liver ..................................................................................................... 81 Key Takeaways ............................................................................................................... 82 Quiz ................................................................................................................................ 83 Chapter Five: Endocrine Disorders ........................................................... 86 Pituitary Disorders ......................................................................................................... 86 Addison Disease ............................................................................................................. 87 Cushing Syndrome ......................................................................................................... 89 Diabetes-related Issues .................................................................................................. 90 Osteoporosis................................................................................................................... 92 Hypothyroidism ............................................................................................................. 95 Hyperthyroidism ............................................................................................................ 96 Disorders of Calcium Levels .......................................................................................... 97 Male Hypogonadism ...................................................................................................... 98 Key Takeaways ............................................................................................................. 100 Quiz ...............................................................................................................................101 Chapter Six: Musculoskeletal Disorders .................................................. 104 Approach to Sporting Injuries ..................................................................................... 104 Stress Fractures............................................................................................................ 105 Radiculopathy .............................................................................................................. 106 Soft Tissue Dysfunction ............................................................................................... 108 Overview of Sprains and Soft Tissue Injuries ............................................................. 109 Lateral Epicondylitis ..................................................................................................... 111

Medial Epicondylitis ..................................................................................................... 111 Carpal Tunnel Syndrome .............................................................................................. 112 Evaluation of Neck and Back Pain ................................................................................ 112 Evaluation of Arthritis .................................................................................................. 114 Fibromyalgia ................................................................................................................. 116 Somatic Dysfunction ..................................................................................................... 117 Myofascial Pain Syndrome ........................................................................................... 118 Key Takeaways ............................................................................................................. 120 Quiz ............................................................................................................................... 121 Chapter Seven: Dermatology Disorders .................................................. 124 Benign & Premalignant Growths ................................................................................. 124 Common Skin Cancers ................................................................................................. 126 Skin Burns ..................................................................................................................... 131 Psoriasis ....................................................................................................................... 132 Hyperhidrosis .............................................................................................................. 134 Alopecia ........................................................................................................................ 135 Atopic Dermatitis ......................................................................................................... 136 Impetigo ....................................................................................................................... 138 Cellulitis ....................................................................................................................... 140 Nummular Dermatitis .................................................................................................. 141 Vitiligo ........................................................................................................................... 141 Skin Manifestations of Systemic Disease .................................................................... 143 Key Takeaways ............................................................................................................. 144 Quiz .............................................................................................................................. 145

Chapter Eight: Psychiatry ....................................................................... 148 Child Abuse .................................................................................................................. 148 Substance Abuse .......................................................................................................... 150 Eating Disorders ........................................................................................................... 151 Sleep-related Disorders ............................................................................................... 153 Somatic Symptom Disorder ......................................................................................... 154 Schizophrenia................................................................................................................155 Depressive Disorders ....................................................................................................157 Bipolar Disorder........................................................................................................... 159 Generalized Anxiety Disorder ...................................................................................... 160 Key Takeaways ............................................................................................................. 162 Quiz .............................................................................................................................. 163 Chapter Nine: Neurological Disorders .................................................... 166 Delirium ....................................................................................................................... 166 Dementia ...................................................................................................................... 167 Migraine Headaches .................................................................................................... 169 Tension Headaches ...................................................................................................... 170 Peripheral Nerve Disorders ......................................................................................... 170 Epilepsy .........................................................................................................................172 Ischemic Stroke .............................................................................................................173 Multiple Sclerosis ......................................................................................................... 176 Infectious Brain Disorders ............................................................................................ 177 Key Takeaways .............................................................................................................. 181 Quiz .............................................................................................................................. 182

Chapter Ten: Cardiovascular Diseases .................................................... 185 Acute Myocardial Infarction ........................................................................................ 185 Heart Failure ................................................................................................................ 187 Management of Atrial Fibrillation ............................................................................... 189 Dyslipidemia ................................................................................................................. 191 Atherosclerosis ............................................................................................................. 193 Hypertension/Hypotension ......................................................................................... 194 Orthostatic Hypotension ............................................................................................. 196 Peripheral Vascular Disease ........................................................................................ 197 Key Takeaways ............................................................................................................. 199 Quiz ............................................................................................................................. 200 Chapter Eleven: HEENT and Respiratory Diseases .................................. 203 Acute Otitis Media ....................................................................................................... 203 Conjunctivitis ............................................................................................................... 205 Allergic Rhinitis ........................................................................................................... 207 Other Causes of Rhinitis ............................................................................................. 208 Sore Throat.................................................................................................................. 208 Asthma ......................................................................................................................... 210 Occupational Asthma .................................................................................................... 211 Other Environmental Lung Diseases .......................................................................... 212 Pulmonary Hypertension ............................................................................................ 212 Key Takeaways ............................................................................................................. 214 Quiz .............................................................................................................................. 215 Summary ................................................................................................ 218

Course Questions and Answers ............................................................... 221 Answers to Quiz ........................................................................................................... 276 Chapter One .............................................................................................................. 276 Chapter Two ............................................................................................................. 278 Chapter Three ........................................................................................................... 279 Chapter Four ............................................................................................................ 280 Chapter Five.............................................................................................................. 281 Chapter Six ............................................................................................................... 282 Chapter Seven ........................................................................................................... 283 Chapter Eight ............................................................................................................ 284 Chapter Nine............................................................................................................. 285 Chapter Ten .............................................................................................................. 286 Chapter Eleven ......................................................................................................... 287 Course Quiz...............................................................................................................288

PREFACE This course is designed to help you pass the COMAT Family Medicine clinical examination, which is one of eight examinations taken after the osteopathic student has completed the family medicine rotation in an accredited osteopathic college. While some osteopathic students aspire to specialize in a specific field of osteopathic medicine, many become primary care physicians and choose to care for families in mostly outpatient settings. Health promotion, screening for disease states, and the management of acute and chronic conditions are part of this practice. After you have completed this course, you should feel better prepared for the examination, in part because the course offers a compilation of the areas of family medicine you have been engaged in during the family medicine rotation.

The introduction of the course offers you an explanation of what you can expect from the examination itself. Each test you take will be different but will be standardized so it offers you a way of determining your knowledge base and skill level in the different areas of osteopathic medicine.

In chapter one in the course, we talk about general presentation, including the well child examination, the routine physical examination in the adult patient, screening for chronic diseases, and vaccinations, which are generally part of family medicine because they involve the well patient and the prevention of disease. The chapter will prepare you for the examination because it covers those things an osteopathic physician does on a day to day basis.

Chapter two talks about the management of blood disorders, immune diseases, and cancer. The family doctor will care for patients with each of these things, often with the help of a subspecialist. The disorders talked about in this chapter include anemias, immunodeficiency states, autoimmune diseases, coagulation disorders, and cancer.

These disorders are relatively common and should be things the family practitioner understands how to comanage.

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The focus of chapter three in the course is genitourinary, kidney, and reproductive diseases. As a primary care provider, you will manage independently patients who have acute and chronic illnesses related to the kidneys, the genitourinary system, and reproductive system. This will apply to the treatment of both men and women with issues related to these systems. You will manage abnormal vaginal bleeding, sexual disorders, kidney disorders, and urinary tract infections, among other things discussed in this chapter.

Chapter four includes topics related to disorders of the gastrointestinal system. There are many bowel and intestinal disorders that the family doctor needs to know how to identify and manage. These include esophageal reflux, gastric diseases, chronic liver disease, nutritional deficiencies, pancreatic disease, small bowel diseases, and irritable bowel syndrome—each of which is covered as part of this chapter.

The focus of chapter five in the course is endocrine disorders, of which there are several. Endocrine disorders are often treated by the primary care provider, both in the diagnosis of these diseases and their management. The endocrine system is responsible for releasing hormones that have numerous effects on the body systems. There are a number of endocrine diseases you might encounter, which are discussed as part of the chapter.

Chapter six includes discussions on musculoskeletal disorders. Musculoskeletal disorders are extremely common in primary care medicine, particularly in those who practice osteopathic medicine. You should be able to evaluate back pain, neck pain, sporting injuries, joint pain, and fibromyalgia because these will be the most common things you will encounter in a primary care setting. Each of these is discussed as part of this chapter.

In chapter seven of the course, we will look at the different skin problems you may encounter in everyday practice. Skin disorders are numerous and complex. As a primary care provider, you should be able to define what is a serious skin disease and what is not a serious skin problem. You will be asked to see many different skin diseases in your practice so you should be able to recognize these.

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The focus of chapter eight is psychiatry and psychiatric disorders. The primary care provider will deal with patients with psychiatric disorders all the time. Some of these are evaluated primarily by a psychiatrist, while others are managed by the primary care provider. The different disorders mentioned in this chapter include psychiatric and common psychological conditions commonly seen by primary care providers as part of their everyday practice.

Chapter nine in the course discusses the different neurological disorders seen in primary care medicine. Primary care providers will need to manage patients with a variety of neurological problems, many of which are chronic in nature. While many of these patients need to be followed by a neurologist, they also need be followed by their primary care provider. The different disorders discussed in this chapter include delirium, dementia, neuropathies, epilepsy, stroke, multiple sclerosis, and headaches.

Chapter ten is about the management of the different cardiovascular disorders.

Cardiovascular diseases are often comanaged by primary care physicians, particularly when it comes to chronic diseases. Cardiovascular diseases include acute myocardial infarction, atherosclerosis, atrial fibrillation, congestive heart failure, dyslipidemia, hypertension or hypotension, or peripheral vascular disease, which are covered in this chapter.

Chapter eleven in the course is about the diseases of the head and neck as well as the different respiratory diseases seen in the primary care setting. HEENT and respiratory diseases are things the primary care provider will often deal with. Many of these will be infectious in nature and will require short-term treatment. The management of otitis media, conjunctivitis, sore throat, and lung diseases are covered in this chapter.

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INTRODUCTION: ABOUT THE COMAT EXAMINATIONS The Clinical COMAT examinations actually comprise eight different areas of osteopathic medicine. Each examination covers a clinical area that you have as one of the rotations in osteopathic college. The tests are administered by one of many colleges of osteopathic medicine (COMs). The term COMAT stands for Comprehensive Osteopathic Medical Achievement Test. These are computer-based examinations and each test is 125 questions in length. You will be allowed exactly two hours and thirty minutes to take the examination.

If you take the COMAT examination more than one time, you will not be able to take the same test each time you take it; the individual COMs provide a different test each time but they will all be standardized and basically equivalent to one another. You cannot use any books, a cell phone, or another computerized device or tablet during the test. Each test question will be in a multiple-choice format with five possible choices per question.

Each clinical COMAT examination will be given after you have assimilated practical clinical knowledge about how to care for patients with various medical and osteopathic conditions. The examination you take is designed to see what you have learned in your clinical rotation.

According to the way the examinations are structured, the mean on the test will always be set to 100 points with a standard deviation of 10 points. The exam tests not only your clinical skills but the teaching abilities of your college. The college will use the information from the examination scores to help them improve their curriculum and testing standards. Each COM is allowed to give you a COMAT examination up to 10 times per year. Each test, a mentioned, will be different from the others but will be otherwise reliable and comparable to the other examinations.

The COMAT examination test questions are structured in two seamless dimensions. The first dimension relates specifically to patient presentation in the area of osteopathic medicine you study. The second dimension of the test places a focus on physician tasks, 4

CHAPTER ONE: GENERAL PRESENTATION OF THE PATIENT In this chapter, we talk about general presentation, including the well child examination, the routine physical examination in the adult patient, screening for chronic diseases, and vaccinations, which are generally part of family medicine because they involve the well patient and the prevention of disease. The chapter will prepare you for the examination because it covers those things an osteopathic physician does on a day to day basis.

WELL CHILD DEVELOPMENT AND DEVELOPMENTAL DELAYS Part of your care of the well child is to assess their development, which can include motor development, cognitive development, language development, and behavior.

There are rapid developmental changes that occur from infancy to the time when the child enters school. During this time, the healthcare provider and the parents are the main sources of information on how the child is developing. You should be evaluating the child’s development at every visit, beginning at the age of one month. These are the developmental milestones you should know about.

At age one month, the infant will make jerking arm and leg movements. The head will rotate from side to side while the child is lying prone. If unsupported, the head will be floppy. The fists will generally be tightly flexed and reflexes will be prominent. The vision is best focused at about a foot away from the child. Expect the eyes to cross at some point. Hearing is normal and sounds are recognized and sometimes turned toward. Smell is acute and the sense of touch is such that the child prefers soft fabrics.

Be particularly concerned if the child appears to be sucking poorly, doesn’t blink in bright light, and doesn’t focus her eyes. The legs should not be stiff, nor should they be floppy. If there is trembling of the jaw at rest, this is also a concern. Loud sounds should be responded to so there is concern if this doesn’t happen.

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At three months of age, the head and chest will raise when the child is prone and the upper body will be supported by the hands. Legs will be stretched out and kicking while prone and the hands will flex and extend. The legs will push on a firm surface when placed upright and the hands will come to the mouth. Actions to grab at a dangling object will be made but will generally not be successful, although toys can be grasped.

Faces will be attended to and moving objects will be followed by the eyes and head. The child will smile at the sound of a familiar voice and certain voices will be recognized by the baby. Babbling will begin, including the mimicking of sounds. Expect a social smile and expect some preference toward interaction with caregivers. Facial expressions can be imitated.

Be concerned if the child exhibits these delays. If sounds are not responded to or smiles have not occurred, this is concerning. It is concerning if they do not grasp objects and if they cannot support their head. Babbling should happen by four months and the child should be able to bring objects to her mouth. Be concerned if the eyes are still mostly crossed and if the child has a stiff tonic neck reflex. Also be concerned if the child doesn’t respond to faces.

By seven months of age, the child should be able to roll both ways and should sit with or without the support of the hands. Weight should be supported by the legs and reaching with one hand occurs. Objects should be transferred from hand to hand but the pincer grasp is not yet possible. Full color vision will be developed as will be distance vision.

The child will respond to her name and to the word “no”. She can distinguish emotions by the person’s tone of voice and will babble consonant sounds. Exploration occurs with the hand and mouth and objects out of reach will be reached for. Social play is preferred and the child will be interested in mirrors.

Be concerned if the muscles are stiff or floppy and if the head flops. If the child refuses to cuddle or shows no affection for their caregiver, this is concerning. The eyes should be completely focused and sounds should be responded to by the turning of the head. If sitting up doesn’t happen by six months or laughing doesn’t occur, this is a worry.

Expect active reaching and, if this doesn’t occur by six months, you should be concerned. Babbling should happen by eight months of age so, if this doesn’t happen,

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you should be concerned. Be concerned at his age if social play of some kind hasn’t occurred.

By one year, the child should be able to get to a sitting position and should be able to crawl using the arms and legs. She should pull herself to stand and walk along furniture. Standing briefly is normal as is walking a few steps independently. The pincer grasp is possible and objects should be banged together, taken out and put into a container. Objects should be let go of voluntarily and scribbling can be imitated. There will be gestures of no and both dada and mama should be used with intention, as should other simple words.

Objects should be readily explored and there should be object constancy. Simple everyday objects should be used correctly and gestures should be imitated. Shyness with strangers is common and fears will develop. The primary caregiver is preferred. Finger feeding is possible and the child will aid in dressing but will not be able to do this herself.

Be concerned if the child cannot point to objects, cannot use gestures, says no single words, cannot search for hidden objects, cannot stand when supported, or does not yet crawl by one year of age.

The child at two years of age will be able to walk independently and will pull toys behind her. Toys can be carried while walking and running should be beginning. She should be able to kick a ball, stand on tiptoe, and climb on furniture. Stairs can be managed with support and scribbling spontaneously is possible. A tower of up to four blocks can be stacked and a hand preference is noted.

Familiar people and objects should be recognized and multiple single words should happen by eighteen months. Simple phrases should happen by two years and simple instructions can be followed. Words will easily be repeated. Sorting into colors and shapes will happen and make-believe play begins. Behaviors are imitated and separateness is discovered. Interest in other children happens and defiant behavior is exhibited. Separation anxiety begins to pass.

Be concerned if walking doesn’t happen by eighteen months or if the child walks on tiptoes only. At least fifteen words should happen by eighteen months and two-word 8

phrases should happen by two years. Be concerned if the function of common objects isn’t known and if imitation and simple instruction following does not occur by two years of age. Expect the child to be able to push a wheeled toy by the age of two years.

The child at age four years should be able to hop on one foot for a few seconds and should climb and descend stairs without difficulty. A ball should be thrown overhead and kicked. A bounced ball should mostly be caught and the child should be relatively agile. Square shapes should be copied and a simple person should be drawn. Scissors should be able to be used and both circles and squares drawn independently. Some letters can be copied.

The child should know the difference between same and different, and grammar should be basically followed. Five-word sentences are spoken and most people should understand the child. The child should be able to tell stories and name some color. Some numbers should be known and the sense of time develops. Three-part commands should be followed and fantasy play well-established.

The child should be able to cooperate with other children and should be inventive in fantasy play activities. Dressing and undressing should happen and problems should be negotiable. The child will be concerned about monsters and will see herself independent of others. Fantasy and reality concepts cannot always be differentiated.

Be concerned if the child cannot stack four blocks and shows no interest in interactive games. The child who shows no interest in other children or who clings with their parents is concerning. Other worries include difficulty scribbling, inability to pedal a tricycle, lack of response to others, resistance to dressing or toileting, inability to copy a circle, and a lack of ability to use more than three words in a sentence.

By five years of age or when the child enters kindergarten, you should be concerned about extremely fearful behavior and aggression in the child. A lack of concentration for more than five minutes is suggestive of ADHD and lack of interest in others suggests autism. Sadness or unhappiness suggests abuse or depression. You should be concerned about the inability to tell fantasy from reality, extreme passivity, limited engagement, lack of ability to say one’s name, and lack of experiential talking behaviors.

Basic rules of hygiene should be followed by this age.

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DEVELOPMENTAL DELAY Developmental delay is seen at any age and involves a lack of ability to reach milestones.

It can be seen in behavior, cognition, motor skills, vision, speech, and hearing. Delays that are common in each category include the following: •

Cognition—this includes differing problems with mental retardation or specific learning disabilities in reading and mathematics.

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Motor—this includes cerebral palsy, spina bifida, and muscular dystrophy.

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Vision—this includes refraction disorders, night blindness, and juvenile cataracts.

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Hearing—this includes sensorineural or conductive hearing loss.

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Speech—this includes specific problems with articulation, expressive language disorder, and receptive language disorder.

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Behavior—this includes autism and ADHD.

Cognitive delays are evaluated with IQ testing. Mild mental retardation is most common and affects the child’s school performance and vocational skills. More severe cognitive impairment can affect all of the other areas of life, including behavior, motor skills, vision and hearing, and can lead to seizures in some children, who often need skilled care for basic needs.

Specific learning disabilities do not generally affect global cognitive functioning. They include deficits in speech, language, or the ability to read, spell, write, or do arithmetic.

Children with these deficits are generally discovered in primary school when the child’s skills are tested independently. Most of these children do well with certain educational accommodations.

Motor disabilities can involve the trunk, the ability to speak and swallow, and the movement of the extremities. Cerebral palsy is usually discovered in infancy, while muscular dystrophies, polio, and spinal muscle atrophies can be diagnosed later in life.

Cerebral palsy is not progressive but is permanent. It can affect any area of the body.

Most patients have spasticity, although cerebellar involvement can be seen as hypotonia.

Other disabilities are possible, including epilepsy, learning disabilities, mental retardation, and language delays. Other motor disorders, such as muscular dystrophy,

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are progressive but may also show cognitive delays. Polio and spinal cord deficits generally involve just motor skill problems.

Vision and hearing deficits are generally seen in adults but certainly could be a neurodevelopmental disorder. Refractive errors are the most common of these and are easily fixed with glasses. Speech and hearing are intricately involved so that the child who does not hear at the age of two often cannot later form speech well, even when their hearing is improved at a later time. Hearing screening is done in the newborn period so that modifications can be made as early as possible.

Behavior disorders are under-diagnosed unless the child is carefully monitored. Things like war, poverty, famine, and natural disasters can affect the child’s mental health.

Behavior problems are not necessarily linked to known disorders like ADHD or autism and can be environmentally-based. You should screen for behavior issues at every well child visit.

Developmental disabilities come often from damage or developmental anomalies of the immature nervous system. Many are inherited or genetic in nature. Other causes to consider are nutritional deficiencies, infections, or toxic exposures at critical developmental time periods. The timing of the insult is important because, for things like rubella, the infection is most serious in the first trimester.

Genetic aspects to development include the different hemoglobinopathies like thalassemia and sickle cell disease. Most children with sickle cell disease have some degree of mental retardation. Chromosomal abnormalities, such as Down syndrome, greatly affect learning and cognition. Marriages that are consanguineous have an increased risk of cognitive deficits in the child. There are also numerous inborn errors of metabolism and genetic diseases like Duchenne muscular dystrophy that contribute to developmental delays.

Nutritional deficiencies can affect the child’s morbidity and mortality; it occurs all over the world. Iodine-deficiency states lead to cretinism, which can be something the child is born with and can affect all developmental areas. Vitamin A deficiency usually leads to ocular disease, which can be permanent. It also contributes to an increased risk of infectious diseases.

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Iron-deficiency anemia is a widespread health problem, especially in low-income parts of the world. It lowers the infection resistance and affects vitamin A and fat absorption.

In infants, it leads to low birth weight. Low iron intake in childhood leads to cognitive delays, attention deficits, and learning disabilities.

Folate deficiency is problematic in early pregnancy. It contributes to an increase in neural tube defects like spina bifida, which affects motor function of the lower extremities. For this reason, it is recommended that a woman take folate prior to conception in order to reduce the risk of a neural tube defects.

Protein-calorie malnutrition can affect sensory integration, the development of language, behavior, and learning. There are specific neuropathies that can develop because of nutritional deficiencies. The effect on the developing brain is often permanent. It is unclear if the problem is with energy deficits in total or with specific nutritional deficiencies.

Infections can lead to developmental delays. The things you will most associate with these types of problems include congenital rubella, congenital syphilis, congenital cytomegalovirus, and congenital toxoplasmosis. Each of these will lead to specific symptoms along with mental retardation. Herpes simplex can be gotten in utero by the baby or at the time of birth and can lead to microcephaly, calcifications of the brain, and eye abnormalities. HIV disease is prevalent in low-income parts of the world and can lead to marked impairment of the CNS, movement disabilities, microcephaly, and cognitive delays.

After birth, infections can also cause developmental delays as well. Common infections that can lead to this include malaria, viral encephalitis, bacterial meningitis, polio, tetanus, trachoma, and measles. Malaria of the brain can cause seizures and coma. If the mother has it during pregnancy, there can be intrauterine growth restriction and maternal death from anemia.

Environmental toxins that can affect the fetus, infant, or child, include lead exposure, which can lead to lead encephalopathy. Heavy alcohol use in pregnancy leads to fetal alcohol syndrome, which involves cognitive impairment, microcephaly, facial abnormalities, and low birth weight. Salicylates and streptomycin can cause ototoxicity.

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Thalidomide is still used in some parts of the world for the treatment of HIV disease and leprosy.

Perinatal issues include birth asphyxia, intrauterine growth restriction, low birth weight, and preterm birth. Each of these affects a child’s development and is more prevalent in low-income populations because of a lack of good obstetrical care. Neonatal factors include untreated hyperbilirubinemia in the neonatal period and certain neonatal infections.

PATIENTS PRESENTING FOR ROUTINE EXAMINATIONS Routine examinations are part of the care of the well patient, the detection of disease in their early stages, and the prevention of disease processes. It is also called a wellness check, which is paid for by almost all insurance plans. Wellness checks have a cost benefit because they detect and prevent diseases that are costly once they have already become symptomatic. It is a time for asking question on the part of the patient regarding symptoms or issues they may have.

The main purpose of a routine examination is to determine the overall health status of the patient. It is often called an annual examination because it is done annually, particularly for those individuals over the age of 50 years. Diseases are detected in their early stages, imminent medical concerns are detected, immunizations updated, discussions are had about disease prevention, and a relationship is built between the well patient and their provider.

Besides the screening examination, several screening tests are done, which will be further discussed in the next section. Screening tests can be blood tests, such as cholesterol and blood sugar testing, screening vital signs, such as pulse and blood pressure, and other screening examinations, such as mammography and colonoscopy.

The idea behind screening is to identify early, asymptomatic disease processes.

Somewhat related to the annual examination are the preoperative examination and examinations done before certain medical treatments, such as chemotherapy for cancer treatment. With these examinations, the past medical history is focused on but there is less done regarding disease prevention and screening testing.

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Things that are covered include the past medical and surgical history, list of all medications, including OTC drugs and herbal supplements, current symptoms, if any, questions the patient has about health-related topics, vaccinations, and screening tests.

Information from specialists should be gathered so as to have a complete picture of the care the patient is receiving from all providers. Chronic diseases are discussed and managed during this examination.

In the history, the past medical history is covered, including past surgeries and allergies.

Lifestyle questions are asked about, such as smoking history, exercise, dietary habits, alcohol and drug use, and safety issues in the home. Medications taken are part of the history as well.

The examination is relatively thorough, with a dermatological evaluation, heart and lung exam, abdominal examination, genitourinary examination, and evaluation of muscle strength, gross neurological functioning, and gait. Vital signs are done to check for hypertension and rhythm abnormalities.

After the examination, immunizations are given. Immunizations are given to adults as well as children. Labs are done for screening purposes and to follow up for chronic illnesses. Things like mammography, PAP tests, and colonoscopies are done during the annual examination or ordered for a later date. If there are findings on any of the tests, these may need to be discussed with the patient at a later time, particularly if something needs to be done.

PATIENTS PRESENTING FOR ROUTINE SCREENING Routine screening is done at every stage of life. In the young patient above the age of 18 years and up to about 27 years, the patient should have several screening examinations.

There is no mammography or colorectal screening in the average-risk patient at this age but cervical cancer screening is done every three years, starting at age 21 and ending at age 65 years. Cytology with HPV testing is done every five years between 30 and 65 years of age. Skin cancer screening is done at the provider’s discretion.

Eye examinations are done annually on all diabetic patients but a hearing examination is not done if there are no symptoms. Zika virus screening is done for high-risk female 14

patients who are of reproductive age. All sexually active women under 25 years are screened for chlamydia and gonorrhea. Older persons are assessed for these STDs if they have high-risk sexual behaviors. Syphilis screening is done on all pregnant women.

HIV screening is done on pregnant women and annually on high-risk patients.

The immunization done every year is the influenza vaccination, which is done because the virus changes continually. The tetanus and diphtheria vaccines are given together every ten years. Pneumococcus is given in two doses and MMR is given for those born after 1957 or do not have documented vaccinations in the past. Two doses of the Varicella vaccine are given if there has been no immunity. Meningococcus is given once or twice, plus a booster every 5 years if there is a risk. The Herpes zoster shot is not given in young people. Young people under 27 are given up to 3 doses of the HPV examination and those that never had hepatitis B vaccinations as children should receive 3 doses. Hepatitis A is only done if the person is high risk. Haemophilus influenzae vaccination is given to those with sickle cell anemia, asplenia, or those who’ve had a stem cell transplant.

All patients should have their body mass index done annually. The lipid screen is done on adults older than 18 years but generally isn’t done every year. The blood pressure evaluation is done every visit and should be done in every patient every other year.

The middle-aged adult should also have a well visit every one to three years, regardless of their risk factors. There are some screening tests that need to be done. There is generally no cancer screening for colorectal cancer, skin cancer, or breast cancer unless the person reaches a certain age. For example, colorectal screening starts at age 45 years for African-Americans and mammograms are started after age 50 after discussing risks and benefits. Cervical cancer screening is the same as for younger people. Testicular and prostate cancer screening starts at age 40 with a PSA examination but stops at age 70 years.

Vision screening is done every 2 to 4 years in middle age, while people of African descent have glaucoma screening every 2 years after age 40. Hearing testing is not done if there are no symptoms. Immunizations are the same as for young people with annual influenza shots and tetanus-diphtheria every 10 years.

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The older adult should have an annual fecal immunochemical test or FIT test every year and a colonoscopy every 10 years, starting at age 50. Breast cancer screening is done after 50 every two years, although high-risk women should be screened annually. At age 75, the mammography is done after discussing risks and benefits. PSA screening for prostate cancer is reserved for men between 40 and 69 years.

An eye examination is done every 2 to 4 years between the ages of 40 and 54 years and every 1 to 3 years in adults between 55 and 64 years. As mentioned, glaucoma screening is done in people of African-American descent. Hearing screening is not done if there are no symptoms.

The only change for immunizations in the middle-aged adult is that 2 doses of the recombinant Herpes zoster vaccine are given to older adults above aged 50 years. The live-attenuated zoster immunization is given at aged 60 years or older.

Adults aged 65 years or older have some changes in their screening tests. Individuals aged 75 years to 85 years should talk to the doctor about screening for colon cancer but those older than 85 years should not be evaluated as a screening measure.

Mammography is not recommended after 75 years unless the benefits outweigh the risks. Skin cancer screening is done annually.

After ag 60, all adults should have glaucoma screening every 2 years. Hearing testing is not recommended in the older person unless there are symptoms. The Zoster immunization and influenza shots are recommended as has been discussed. Tetanus shots continue to be recommended in this age group.

VACCINATIONS Immunizations involve the provision of active immunity to the person by providing them with antigens that allow for antibodies to be made against part or all of a pathogen. As long as the antibodies and antibody-producing memory cells can be made, this type of immunity is possible. Passive immunity is different because it provides the antibodies to the patient for temporary immune function. Immune globulins and antitoxins are examples of providing passive immunity.

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Toxoids are immunizations that involve modified toxins that themselves are nontoxic.

Vaccines are whole inactivated pathogens or fractions of organisms given to provide immunity. Live, attenuated vaccines are often preferred but carry the risk of mutating back to a pathogenic organism and infecting the patient.

Vaccinations are very effective and have been responsible for eliminating or nearly eliminating diseases that were once prevalent. The smallpox vaccine has eradicated smallpox, while diphtheria and polio are now rare. There are no vaccines yet for most STDs, all tick-borne infections, most tropical diseases, and emerging diseases like Ebola and West Nile virus.

There are some vaccines that are available for people at risk for them. These include vaccines for yellow fever, typhoid, and rabies. Vaccines, as mentioned, are given for all age groups but it is rare to have 100 percent compliance with vaccinations. Minority groups have a particularly low rate of vaccination.

Many vaccines are not given in one shot but have several shots given in a row. People should get their shots at the recommended intervals, because the vaccine will lose its effectiveness if not given at the proper intervals Shots are given into the mid-lateral thick in children under five years of age and in the deltoid muscle in those older than that. Some are subcutaneous instead of intramuscular. If the interval has been too great, you will need to restart the series.

It is almost always possible to give different vaccinations together for convenience. The main exception is the provision of the pneumococcal vaccine and the pneumococcal vaccine to children with asplenia. There should be a month separating these shots.

People with egg allergies will need to be careful about getting their vaccines. Most influenza shots and childhood shots contain some egg antigens but serious allergic reactions are not likely. If anaphylactic reactions happen, the vaccinations should not be given. There are interventions for lesser reactions that can be used to counteract the reaction.

Patients with asplenia have a high risk of getting certain bacterial infections, mainly to encapsulated organisms, such as Neisseria meningitidis, Streptococcal pneumoniae, and

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Haemophilus influenzae type B. These patients should be vaccinated against these organisms.

Live vaccines shouldn’t be given with blood products or immune globulin because the simultaneous giving of these will interfere with antibody development. Minor infections shouldn’t be contraindications to vaccinations but high fevers or severe illnesses should delay the giving of these shots. Patients who have gotten Guillain-Barre syndrome after their tetanus or influenza shot should still get the shot if the benefits outweigh the risks.

Immunocompromised patients shouldn’t get live virus vaccines because of the risk of mutation and severe illness from the shot. HIV patients should get inactivated shots only unless they have normal CD4 counts. Pregnant patients shouldn’t get the MMR live vaccination or the live influenza shots. Patients who plan to have a solid organ transplant should get their shots before the transplant. There is no risk of autism with childhood vaccines. There are special vaccines given to travelers depending on where they are traveling to.

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KEY TAKEAWAYS •

The child well care visit should include a developmental examination, which involves motor, cognitive, language, behavioral, and social functioning.

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There are many causes of developmental delay, some of which are avoidable with proper care of the pregnant mother and child.

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The well visit or annual exam screens for early disease, monitors chronic health issues, and focuses on disease prevention and health promotion.

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The screening tests given to the adult depend on the adult’s age at the time of the well visit.

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Immunizations are given at all ages and are intended to prevent infectious diseases. There are some immunizations that are only given to certain populations.

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fallopian tubes and becoming affixed to the extra-uterine structures, although the tissue can travel in the bloodstream to distant sites.

The symptoms of endometriosis differ according to where the implants are located. The most common symptom is dysmenorrhea or painful periods because of the extra-uterine bleeding. Other symptoms include dyspareunia or pain with intercourse, infertility, pain with defecation, and dysuria. Figure 1 shows where endometriosis can be seen:

Figure 1.

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Figure 3

They can occur at any place in the large bowel but are most common in the sigmoid colon. There can be large diverticula but most are just 10 millimeters in size or less.

Most patients have several diverticula at the same time. It is so common that 75 percent of adults older than 80 years have this problem. The exact etiology is not known but it may be secondary to a low fiber or high meat diet.

If there are symptoms at all of diverticulosis, most will just have constipation. Others will have rectal bleeding with or without any pain. Mucus, bloating, or diarrhea are not common. The main complications are diverticulitis, segmental colitis, or diverticular bleeding. It is the most common cause of hematochezia in adults. Most of the time, the bleeding is painless with moderate to severe blood loss.

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and postmenopausal women with risk factors or who have had a fragility fracture. If a plain film suggests low bone density, a scan can then be done.

Plain x-rays can show decreased bone density but this isn’t a very sensitive test. Their main usefulness is to document fragility fractures and to check vertebral height. Ideally, those who have back pain and risk factors should have a lateral vertebral x-ray. Figure 4 shows a vertebral fracture:

Figure 4.

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