Family Medicine : Medical School Crash Course

Family Medicine Medical School Crash Course™

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INTRODUCTION: AudioLearn’s Medical School Crash Courses presents Family Medicine Written by experts and authorities in the field and professionally narrated for easy listening, this crash course is a valuable tool both during school and when preparing for the USMLE, or if you’re simply interested in the subject of Family Medicine.

The audio is focused and high-yield, covering the most important topics you might expect to learn in a typical Medical school Family Medicine course.

Included are both capsule and detailed explanations of critical issues and topics you must know to master Family Medicine.

The material is accurate, up to date and broken down into bite-sized sections.

There is a Q&A and a “key takeaways” section following each topic to review questions commonly tested and drive home key points.

Also included is a comprehensive test containing the top 100 most commonly tested questions in Family Medicine with the correct answers.

AudioLearn's Medical School Crash Courses support your studies, help with USMLE preparation and provide a comprehensive audio review of the topic matter for anyone interested in what medical students are taught in a typical medical school Family Medicine course.

TABLE OF CONTENTS Introduction: .......................................................................................................................... 4 Preface ................................................................................................................................. 13 Chapter 1: Preventative Healthcare ..................................................................................... 17 The Wellness Exam ................................................................................................................. 17 Preventative Healthcare for Ages 19-39 Years ....................................................................... 20 Preventative Healthcare for Ages 40-64 Years ....................................................................... 21 Preventative Healthcare for Ages 65 and Older ..................................................................... 22 Influenza Vaccine .................................................................................................................... 22 Other Immunizations .............................................................................................................. 24 Colorectal Cancer Screening ................................................................................................... 25 Breast Cancer Screening ......................................................................................................... 26 Key Takeaways ........................................................................................................................ 28 Quiz ......................................................................................................................................... 28 Chapter 2: History and Physical Exam of the Adult Patient .................................................... 33 Medical History ....................................................................................................................... 33 Physical Examination .............................................................................................................. 38 Cardiovascular Exam ............................................................................................................... 38 Respiratory Examination ......................................................................................................... 40 Abdominal Examination .......................................................................................................... 41 Musculoskeletal and Motor Examination ............................................................................... 43 Sensory Examination............................................................................................................... 46

Cranial Nerve Evaluation......................................................................................................... 46 Key Takeaways ........................................................................................................................ 47 Quiz ......................................................................................................................................... 47 Chapter 3: Complementary and Alternative Care .................................................................. 52 Alternative Medicine .............................................................................................................. 52 Tradition Chinese Medicine (TCM) ......................................................................................... 53 The Yin-Yang Theory ............................................................................................................... 54 Theories on Five Phases .......................................................................................................... 55 Qi Energy ................................................................................................................................. 55 TCM in Practice ....................................................................................................................... 57 Chinese Herbal Medicine ........................................................................................................ 59 Acupuncture............................................................................................................................ 62 Tui Na ...................................................................................................................................... 63 Qi Gong ................................................................................................................................... 64 Cupping ................................................................................................................................... 65 Gua Sha ................................................................................................................................... 65 Die-da ...................................................................................................................................... 66 Osteopathy.............................................................................................................................. 66 Homeopathy ........................................................................................................................... 68 Key Takeaways ........................................................................................................................ 69 Quiz ......................................................................................................................................... 70 Chapter 4: Psychosocial Influences on Health........................................................................ 74 The Biopsychosocial Approach ............................................................................................... 74 Psychosomatic Illnesses .......................................................................................................... 75 Hypochondriasis ...................................................................................................................... 76 Conversion Disorder ............................................................................................................... 77

Other Somatoform Disorders ................................................................................................. 78 Somatization Disorder ............................................................................................................ 79 Somatic Pain Disorder ............................................................................................................. 80 Body Dysmorphic Disorder ..................................................................................................... 80 Factitious Disorders and Malingering ..................................................................................... 81 Stress and Physical Illness ....................................................................................................... 85 Key Takeaways ........................................................................................................................ 89 Quiz ......................................................................................................................................... 90 Chapter 5: Obstetrical Care in Family Medicine ..................................................................... 95 Pre-pregnancy Care................................................................................................................. 95 Prenatal Care........................................................................................................................... 97 Prenatal Testing ...................................................................................................................... 99 First Trimester Prenatal Testing .............................................................................................. 99 Second Trimester Prenatal Testing ....................................................................................... 101 Third Trimester Prenatal Testing .......................................................................................... 103 Labor and Delivery ................................................................................................................ 104 Postpartum Care ................................................................................................................... 106 Breastfeeding ........................................................................................................................ 107 Postpartum Emotional Issues ............................................................................................... 108 Postpartum Sexuality ............................................................................................................ 109 Key Takeaways ...................................................................................................................... 110 Quiz ....................................................................................................................................... 110 Chapter 6: Newborn Care.................................................................................................... 115 Apgar Scoring ........................................................................................................................ 115 Neonatal Examination........................................................................................................... 116 Head Examination ................................................................................................................. 118

Eye Examination .................................................................................................................... 119 Ear Examination .................................................................................................................... 120 Nose Examination ................................................................................................................. 121 Mouth Examination .............................................................................................................. 121 Neck Examination ................................................................................................................. 122 Heart Examination ................................................................................................................ 122 Lung Examination .................................................................................................................. 123 Skin Examination ................................................................................................................... 123 Abdominal Examination ........................................................................................................ 123 Genitourinary Examination ................................................................................................... 124 Anus and Rectum Examination ............................................................................................. 125 Extremity Examination .......................................................................................................... 125 Neurologic Examination ........................................................................................................ 127 Newborn Screening............................................................................................................... 127 Circumcision .......................................................................................................................... 128 Neonatal Jaundice ................................................................................................................. 130 Key Takeaways ...................................................................................................................... 131 Quiz ....................................................................................................................................... 131 Chapter 7: Pediatric Medicine ............................................................................................. 136 Normal Child Development .................................................................................................. 136 Infancy ................................................................................................................................... 136 Toddlers ................................................................................................................................ 137 Preschoolers .......................................................................................................................... 139 School-Age Years ................................................................................................................... 140 Behavioral and Psychiatric Problems in Children ................................................................. 142 Children and Depression ....................................................................................................... 142 ADHD and Childhood ............................................................................................................ 143

Anxiety in Childhood ............................................................................................................. 144 Autism and Childhood........................................................................................................... 145 Conduct Disorder and Childhood.......................................................................................... 146 Learning Disorders in Children .............................................................................................. 148 Auditory Processing Disorder (APD) ..................................................................................... 149 Dyscalculia............................................................................................................................. 150 Dysgraphia ............................................................................................................................ 151 Dyslexia ................................................................................................................................. 151 Language Processing Disorder .............................................................................................. 152 Non-Verbal Learning Disabilities........................................................................................... 152 Cystic Fibrosis ........................................................................................................................ 153 Down Syndrome.................................................................................................................... 154 Muscular Dystrophy .............................................................................................................. 155 Turner Syndrome .................................................................................................................. 156 Neurofibromatosis 1 ............................................................................................................. 157 Respiratory Diseases in Children .......................................................................................... 158 Asthma in Children................................................................................................................ 158 Adenovirus Infections ........................................................................................................... 159 Respiratory Syncytial Virus or RSV ........................................................................................ 160 Bacterial Pneumonia ............................................................................................................. 161 GI Diseases in Children .......................................................................................................... 163 Gastroesophageal Reflux Disease or GERD .......................................................................... 163 GERD in Older Children ......................................................................................................... 165 Pyloric Stenosis ..................................................................................................................... 166 Lactose Intolerance ............................................................................................................... 166 Allergic and Immunologic Diseases in Children .................................................................... 168 Allergic Rhinitis...................................................................................................................... 168

Autoimmune Disorders ......................................................................................................... 170 Severe Combined Immunodeficiency Disorder .................................................................... 171 Congenital Heart Diseases .................................................................................................... 174 Pulmonic Stenosis ................................................................................................................. 174 Atrial Septal Defect ............................................................................................................... 174 Ventricular Septal Defect ...................................................................................................... 175 Transposition of the Great Arteries ...................................................................................... 176 Tetralogy of Fallot ................................................................................................................. 177 Hypertrophic Cardiomyopathy ............................................................................................. 177 Blood Disorders in Children .................................................................................................. 178 Sickle Cell Anemia ................................................................................................................. 178 Thalassemia........................................................................................................................... 180 Iron Deficiency Anemia in Children ...................................................................................... 181 Acute Lymphoblastic Leukemia ............................................................................................ 182 Acute Myeloid Leukemia ...................................................................................................... 183 Children’s Cancers................................................................................................................. 184 Brain Cancers in Children ...................................................................................................... 184 Neuroblastoma ..................................................................................................................... 187 Wilms Tumor ......................................................................................................................... 188 Retinoblastoma ..................................................................................................................... 189 Vesicoureteral Reflux ............................................................................................................ 191 Autosomal Dominant Polycystic Kidney Disease .................................................................. 193 Bladder Exstrophy ................................................................................................................. 194 Glomerulonephritis ............................................................................................................... 195 Endocrine Diseases in Children ............................................................................................. 196 Congenital Hypothyroidism .................................................................................................. 196 Type 1 Diabetes Mellitus ...................................................................................................... 198

Pediatric Hyperparathyroidism ............................................................................................. 200 Pediatric Hypoparathyroidism .............................................................................................. 201 Growth Hormone Deficiency ................................................................................................ 202 Key Takeaways ...................................................................................................................... 205 Quiz ....................................................................................................................................... 205 Chapter 8: Nutritional Issues in Family Medicine................................................................. 210 Infant Nutrition ..................................................................................................................... 210 Childhood Nutrition .............................................................................................................. 214 Eating Disorders .................................................................................................................... 216 Palliative Care and Hospice ................................................................................................... 286 Planning for Death ................................................................................................................ 287 After Death............................................................................................................................ 289 Key Takeaways ...................................................................................................................... 290 Quiz ....................................................................................................................................... 290 Summary ............................................................................................................................ 294 Course Questions and Answers ........................................................................................... 299

PREFACE Historically, family medicine was not always recognized as a separate specialty. In the last several decades, however, there has been a push to define family medicine as a specialty in its own right. This course covers the main issues that are uniquely dealt with by the family physician. Family practice medicine is about the care of chronic diseases, the care of acute illness in the outpatient setting, the care of families as a whole, and the involvement of psychosocial issues in the care of patients of all ages.

The purpose of chapter one in the course is to talk about the various aspects of preventative healthcare. This involves the care of the patient who clinically has no disease but is at risk for illnesses and diseases that can be prevented through preventative healthcare. The wellness examination, immunizations, and cancer screening are all part of providing this type of care to the adult patient and will be covered as part of this chapter.

The focus of chapter two in the course is the history and physical examination of the adult patient. Primarily, this involves performing the examination of the well patient for a routine physical examination, focusing on a head-to-toe examination of all body areas. There are not necessarily any routine blood tests recommended; however, in patients at risk for heart disease, a lipid profile can be done. Screening tests known to be beneficial as part of the examination of the adult include the Pap test, testicular examination, mammography, and

colonoscopy.

Complementary and alternative care are the topics of chapter three in the course.

These practices can be defined as any medical therapy that falls beyond the traditional scope of modern Western Medicine and involves those therapies that can be used alongside modern medical techniques in treating illnesses. Examples of complementary medical practices include Traditional Chinese Medicine (TCM), osteopathy, and homeopathy. These are discussed as part of the chapter.

The fourth chapter of the course focuses on the psychological and social influences on heath and illness. Family doctors often deal with patients that don’t have a purely physical problem but have underlying psychological factors that play into the development of diseases and patients that have purely psychological reasons for their complaints. Stress plays a large role in the severity of many physical illnesses and must be considered as a factor in treating the patient’s problem.

The topic of chapter five in the course is obstetrical care. A large proportion of family doctors will care for the obstetric patient from the pre-pregnancy state through the postpartum period. Obstetrical care can begin before the woman gets pregnant and follows the woman through the pregnancy. Family doctors will often do the vaginal delivery and will care for both the infant and the mother after delivery a part of total-family healthcare.

Chapter six in the course focuses on newborn care. The care of the newborn begins with the initial evaluation after the child is born by assessing the Apgar scores at 1 minute and 5 minutes after birth. After the mother has been

stabilized and the infant has been cleaned off and placed to the mother’s breast, a complete examination can take place. The infant is screened for certain genetic diseases and some male infants undergo a circumcision. Infants are generally discharged from the hospital one to two days after birth unless there are birth complications.

The study and practice of pediatrics is the topic of chapter seven in this course.

Family doctors care for the well child and follow well child development from birth through adolescence. They also manage many of the typical diseases common to children, including cardiovascular diseases, allergies, lung diseases, gastrointestinal diseases, and others. In this chapter, the various issues and disorders commonly seen in children are a part of the discussion as family doctors will deal with both well children and sick children.

The focus of chapter eight in the course is on the nutritional recommendations for healthy living in patients of all ages. Good nutrition starts in infancy and progresses through older adulthood. The recommendations a family practice physician needs to make vary according to age and the presence of special needs or other issues and these are part of this chapter. The problem of obesity is the biggest nutritional issue facing adults and children so this is included in the discussion in the chapter.

Family practice physicians care for a number of acute illnesses in their practice, which is the focus of chapter nine in the course. Typical acute illnesses a family doctor treats include the various respiratory diseases, influenza, back pain, and strep throat. These are things that can be seen in the absence of chronic diseases in people who normally healthy. This chapter will discuss the different acute

diseases the provider will come in contact with on a daily basis.

Primary care physicians are often a valuable resource for adult patients with chronic diseases, which will be the main topic of chapter ten in the course. In caring for these patients, the family doctor acts as internist, caring for patients with a wide variety of chronic diseases, including hypertension, cardiovascular disease, diabetes mellitus, COPD, and hyperlipidemia. These are lifelong conditions that need ongoing management by the primary doctor.

Caring for the elderly person and their chronic diseases is something the family practitioner does as part of caring for patients of all ages. This is the main focus of chapter eleven of the course. Older people have problems with Alzheimer’s disease, stroke, and depression, with a high suicide rate among people who are older and have depression. They also suffer from poor mobility secondary to osteoarthritis and some will have an increased fracture risk from falls in the face of osteoporosis.

Dying patients have special needs unique to the dying process, which are the focus of twelfth and final chapter. These patients no longer need heroic curative measures and need care related to comfort measures, such as pain control and special feeding needs. The family is often in close proximity to the dying patient and, in keeping with caring for the whole patient, these individuals need attention as well.

CHAPTER 1: PREVENTATIVE HEALTHCARE The purpose of this chapter is to talk about the various aspects of preventative healthcare. This involves the care of the patient who clinically has no disease but is at risk for illnesses and diseases that can be prevented through preventative healthcare. The wellness examination, immunizations, and cancer screening are all part of providing this type of care to the adult patient and will be covered as part of this chapter.

THE WELLNESS EXAM Many patients are relatively clear as to when they should see the doctor during an illness. When it comes to well patient care, however, the exact timing and frequency of visits is less clear. Patients have not been well instructed in when and for what reason they need preventative healthcare. Preventative healthcare examinations include annual medical physicals, prenatal visits, childhood checkups, and examinations of the well woman for gynecological and breast cancer screening. While some patients feel they need an annual well adult examination, the indications and benefits of an exam every twelve months is lacking and it is rare that the patient on no medications and with no chronic health problems needs this type of examination.

The American Medical Association has made recommendations as to how often the periodic health assessment should be performed in the well adult. For adults aged 18 to 40 years of age, the well checkup should be undertaken every five years. After the age of 40, the well checkup should take place every one to three

years. More frequent exams are recommended for patients who take some sort of prescription medication.

In young, healthy patients, there are generally symptoms of a physical illness that can be diagnosed via symptoms and a physical examination alone. Because of this, the person without risk factors does not need to have routine lab work unless there are risk factors for certain diseases, such as having a family history of hyperlipidemia. In the past, patients received routine blood testing with every examination. In the absence of indications, no blood work is recommended under aged 40 years.

So, what are the primary reasons for having a periodic well person examination?

The following are considered reasons for this type of examination: A. To identify by history any risk factors for chronic diseases B. To engage in primary prevention of disease C. For the secondary prevention of diseases that have no obvious symptoms (such as hypertension) D. To counsel patients on healthy behaviors necessary to prevent disease E. To promote an ongoing relationship with the well patient F. To update the patient record regarding symptoms and problems since the previous checkup The US Preventive Services Task Force has been the primary resource for recommendations about those things necessary for the prevention of disease.

The goal of this task force is to study the various chronic diseases and identify measures that can be taken to identify and reduce the incidence of chronic disease.

There are basically three levels of preventative healthcare. Disease prevention starts with primary prevention, which involves those interventions that completely avoid diseases in at-risk people. An example of primary prevention is giving immunizations to patients who might develop a disease but don’t have it yet. Secondary prevention actually involves the early detection of disease that might have no symptoms but have early, latent disease. Examples of this include things like doing Pap tests for early cervical cancer changes, blood pressure evaluations, and cholesterol screening in at-risk patients. Tertiary prevention involves already having a diagnosed illness that is managed and optimized before the disease becomes more serious.

There are many preventative interventions a primary care doctor might do as part of disease prevention. These include giving screening tests (laboratory, examrelated, and vital signs), providing immunizations to the healthy patient, recommending aspirin to patients who are known to be at risk for heart disease, and counseling patients on behavioral issues, such as smoking cessation techniques, nutritional issues, obesity prevention, and safe sex practices.

The first part of a wellness examination is to review preventative screening testing and their necessity, update the family and personal health history, review medications, talk about habits (like use of seatbelts, sexual practices, exercise habits, smoking, alcohol use/abuse, and illicit drug use), and obtain a review of systems. This provides a complete history of issues that may need to be addressed in the physical examination or lab testing.

The next part is the physical examination. This is a basic head-to-toe examination that is somewhat directed by things previously identified in the history and review

of systems. Vital signs are particularly important and should be included in every examination.

According to the US Preventative Services Task Force, certain screening tests are not done as part of the periodic screening examination. These include blood chemistries, hemoglobin, urinalysis, ECG, hearing and vision examination, prostate cancer screening, and ovarian cancer screening.

PREVENTATIVE HEALTHCARE FOR AGES 19-39 YEARS The current recommendation for men is to have this type of examination every five years, while the recommendation for females is every 3-5 years. Each visit should include a risk assessment for the various chronic diseases, a height and weight measurement, blood pressure evaluation, cholesterol levels (which does not have to be repeated every five years if normal), breast examination of females, and STD screening in patients who are engaging in high-risk sexual practices.

The examination should include counseling and health education. This can include nutritional education, folic acid supplementation recommendations for all women of childbearing age, tobacco cessation, alcohol and driving education, discussion on advance directives, contraceptive education, physical exercise recommendations, and the use of safety belts.

Immunizations need to be reviewed at every preventative examination.

Immunizations that should be considered include a tetanus-diphtheria booster shot (Td) every ten years, a Varicella vaccine (in any patient that never had

chickenpox), a Rubella immunization (in patients with a negative titer who did not receive the MMR as a child), the hepatitis B vaccine, and influenza (done annually during flu season). Patients at high risk for hepatitis A and pneumonia should be vaccinated.

PREVENTATIVE HEALTHCARE FOR AGES 40-64 YEARS Patients who are generally healthy should have visits every three to five years.

The exam should include routine risk assessment evaluation (by history), height and weight evaluation, annual breast examination, lipid profile, Pap test (every three years if previous three tests have been normal), mammogram (optional to age 50 and then annually after that), colon cancer screening (beginning at aged 50 years (with colonoscopy being the gold standard test), and screening for STDs and diabetes in high risk patients.

Education is similar to that given to younger adults, with nutritional advice, advice regarding tobacco use, drinking and driving behaviors, safety belt use, advance directives, exercise prescriptions, and (for women) a discussion of postmenopausal hormone replacement therapy when having menopausal symptoms. Postmenopausal HRT is not recommended for asymptomatic woman in menopause as there are risks that do not outweigh the benefits in asymptomatic females.

Immunizations that are beneficial in this age group include the Td booster and the influenza vaccine. High risk patients should be considered for hepatitis A, hepatitis B, Pneumococcus vaccine, rubella vaccine, and Lyme disease vaccine. In addition, patients with known risk factors for heart disease should be given

recommendations regarding aspirin use on a daily basis. The recommended aspirin dose is 81 mg per day.

PREVENTATIVE HEALTHCARE FOR AGES 65 AND OLDER These patients need a preventative healthcare visit every 1-2 years, even if healthy. The screening assessment should involve a risk assessment by history, medication review (include OTC medications and herbal supplements), height and weight assessment, blood pressure screening, breast examination (for women), lipid profile, colon cancer screening, annual mammogram up to age 75 years, vision and hearing testing (after the age of 74 years), and Pap test (only in women who decide to have the test as it is not mandatory).

Immunizations include an annual flu shot, Td vaccine every ten years, the Pneumococcal vaccine (which is generally given once), and (only in high-risk patients) a hepatis B and hepatitis A vaccine. Any patient at risk for heart disease or who already have heart disease should be counseled on daily aspirin use.

INFLUENZA VACCINE Influenza is a respiratory illness that leads to respiratory illnesses, hospitalization, and death. Millions of people get the disease each year, with hundreds of thousands of hospitalizations, and tens of thousands of deaths per year from complications. For these reasons, the recommendation is that everyone over the age of 6 months receive an annual flu shot. Influenza season in North America and the Northern Hemisphere is from October to May. The influenza vaccine begins to take effect after antibodies are made to the

immunization, which is about two weeks after being vaccinated. The contents of the flu shot depends on the most likely influenza strains expected each year based on available research on influenza trends. Most flu shots are trivalent, meaning they protect against the H1N1 (influenza A) virus, the H3N2 influenza A virus, and a type of influenza B virus. Quadrivalent immunizations are sometimes given, which have protection against four viruses (an added influenza B virus protection immunization is given).

There are inactivated flu shots and recombinant flue shots. Some years, a nasal spray immunization with live attenuated virus particles are used, while other years, it is not recommended. There is a standard dose shot given to people under age 65 and a high-dose shot given to people over the age of 65. An eggfree shot is used for people allergic to the albumin that comes in vaccines grown in an egg medium. Most shots are intramuscular but an intradermal quadrivalent shot can be given to adults under 65 years of age. There is not necessarily a “better” or “worse” flu shot.

The flu shot is recommended prior to influenza season so the body has time enough to develop antibodies against the influenza virus. In the Northern Hemisphere, this means getting vaccinated by the end of October. Getting vaccinated as late as January is still acceptable if the shot has not already been given. High-risk children should get two vaccinations four weeks apart. The immune response is not long-lasting so an immunization is recommended every year. In addition, different types of flu viruses are covered for in different years.

For these reasons, the shot must be annual.

Unfortunately, it is still a possibility that a person can get influenza after being

vaccinated but it is not from the vaccine itself. It is always possible that the vaccine won’t cover for the type of influenza a person gets at any given point in time and not everyone will develop an adequate antibody coverage against the flu shot.

The flu vaccine is especially important in patients with chronic health conditions and has been known to reduce the rate of hospitalization in diabetics by 79 percent and the rate of hospitalization in patients with chronic lung disease by 52 percent. Getting vaccinated in pregnancy can protect a baby after birth as the mother will have antibodies passed passively to the baby. This passive benefit lasts for several months. In patients who do get the flu despite the shot, the disease will likely be milder. Getting the flu shot provides “herd immunity”, which protects people from passing the disease to unimmunized individuals.

OTHER IMMUNIZATIONS In most cases, the adult patient should have the Td vaccine, which covers against tetanus and diphtheria. The vaccine should include coverage for pertussis (with the Tdap vaccine) at one time during the patient’s lifetime. Two doses of Varicella are recommended for individuals not known to have had chicken pox. One dose of the herpes zoster is recommended after the age of 60 years. The MMR should be given once or twice until the age of 55 years. Three doses of the HPV vaccine are given to females starting the age of 11 years and up to 27 years of age. Boys in adolescence should receive three doses of the HPV vaccine.

Pneumococcus vaccines come in two types: PCV13 and PPSV23. The PCV13 contains thirteen different strains of the bacterium, while the PPS23 contains

twenty-three strains of the bacterium. Only the PPS23 is definitely recommended in everyone, starting at 65 years of age for everyone and earlier in people who are high risk for pneumonia. One to two vaccines are given.

Vaccinations in adults that are generally reserved for high risk individuals include the hepatitis A, hepatitis B, meningitis, and Haemophilus influenza vaccines.

COLORECTAL CANCER SCREENING Colorectal cancer is extremely common, being the third most common cancer in incidence and the second most common cause of cancer deaths in developed countries. When optimally utilized, screening for colorectal cancer has the potential to save about 18,800 lives each year. Unfortunately, screening for this type of cancer is suboptimal, particularly in minority groups.

The gold standard for the testing of patients for colorectal cancer is the colonoscopy, although some people are screened with fecal occult blood testing, sigmoidoscopy, or fecal DNA testing. While colonoscopies are recommended every year after the age of 50 years, it is not a perfect test. It can still miss adenomatous polyps and colorectal cancer, depending on the experience of the examiner. Screening does not have to take place after the age of 75 years. The benefits of early detection go down after this age and the risks of colonoscopy are greater. Colonoscopy risk factors include perforation of the colon in about 4 of 10,000 procedures and multiple other complications, including diverticulitis, GI bleeding, cardiovascular events, and abdominal pain happen in about 25 of 10,000 procedures.

Of interest is the fact that CT colonography will pick up other abnormalities of the abdomen and pelvis in 16 percent of patients but it isn’t known if these will be false positive findings or whether further testing causes more harm than good.

Testing for these abnormalities can be costly and may not find anything really abnormal. The incidence of perforations stemming from this study is about 0-6 out of 10,000 procedures. This level of radiation exposure is estimated to cause one person out of a thousand to have cancer from the radiation itself.

As for sensitivity, the most sensitive test is the colonoscopy, followed by the flexible sigmoidoscopy, the Hemoccult SENSA test, the fecal immunochemical test, and lastly, the Hemoccult II test. When it comes to specificity, the colonoscopy and flexible sigmoidoscopy are equally specific, followed by the Hemoccult II, the fecal immunochemical test, and finally, the Hemoccult SENSA test.

For individuals between 50 years and 75 years, the following tests are recommended: 1) screening colonoscopy every ten years, 2) fecal occult blood testing every 3 years with sigmoidoscopy every 5 years, or 3) fecal occult blood testing every year.

BREAST CANCER SCREENING The most common screening test in medicine is the mammogram, which has solid evidence for being beneficial to women ages 40 and older. Breast cancer screening, according to the US Preventative Services Task Force, mammograms should be done annually for every woman above the age of 40 years; however, other organizations have indicated that the starting age should be 40 years. The

breast self-examination and even the clinical breast examination are less beneficial as they aren’t particularly sensitive tests. Other tests, like MRI, molecular breast imaging, ultrasound, and tomosynthesis are still being evaluated as possible adjuncts to the primary imaging test, the mammogram.

There is solid evidence to suggest that mammography is linked to a 15-20 percent reduction in breast cancer mortality among women ages 40-74 years. The main harm of doing mammography it is linked to over-diagnosis and treatment of benign insignificant tumors. Surgery to remove something benign can lead to deformity of the breast and there can be toxicity regarding the treatment of cancer that is not significant with things like radiotherapy and chemotherapy which can be harmful. It is estimated that about half of all breast cancers discovered by mammography stem from over-diagnosis.

About ten percent of women will be called back after a screening mammography but only 5 percent of these women will actually have cancer. About half of women screened over a ten-year period will have some type of false positivity, with 7-17 percent having unnecessary biopsies. Using other methods, such as the ultrasound and MRI, have reduced the biopsy rate. In addition, about 6-46 percent of invasive cancers will be missed on mammography, especially among women who are young and have dense breasts. Radiation from lifelong mammography testing will cause one breast cancer out of 1000 women.

No one knows the effectiveness of clinical breast exam alone as a screening test.

It is about 88-99 percent specific for breast cancer, with a false positive rate of about 1-12 percent. False negatives are more common, occurring in 17-43 percent of women ultimately diagnosed with cancer using other methods. Breast

self-exam on the other hand has no effect on breast cancer deaths. The biopsy rate is about 1.8 percent versus 1 percent of women who don’t do self-exams.

KEY TAKEAWAYS A. Preventative medicine includes primary prevention, secondary prevention, and tertiary prevention.

B. The well-adult health exam frequency varies according to the patient’s age.

C. The only two immunizations that people of all ages should have are the influenza vaccine and the Td vaccine.

D. Colon cancer screening begins at the age of 50 years.

E. Breast cancer screening begins at age 40 years or 50 years, depending on who is doing the recommendation.

QUIZ 1. What type of examination is not considered part of preventative healthcare? a. Prenatal examination b. Well-woman gynecological care c. Child checkups d. Medication follow-up examination Answer: d. Medication follow-up involves a person who already has a diagnosed disease. For this reason, this type of examination is not part of preventative healthcare.

2. How often should an adult aged 30 on no mediations receive a well examination for preventative healthcare?

a. Every year b. Every three years c. Every five years d. No well visits recommended Answer: c. A well adult should have an examination for preventative health maintenance every five years until the age of 40 years old .

3. How often should bloodwork be performed in the healthy person with no risk factors at 30 years of age? a. Every year b. Every three years c. Every five years d. No routine bloodwork recommended Answer: d. For the patient without risk factors under aged 40 years, no routine bloodwork is recommended.

4. Which patient should be counseled to take folic acid supplements? a. All female patients of childbearing age b. All female patients over the age of 40 years c. All male and female patients under 40 years of age d. All male and female patients over 40 years of age Answer: a. Folic acid supplements are recommended for all female patients of childbearing age as a way to prevent neural tube defects should the woman

become pregnant.

5. Which vaccination is given only to patients at high risk for the disease as opposed to everyone? a. Influenza b. Hepatitis B c. Hepatitis A d. Td Answer: c. The hepatis A vaccination should only be entertained in patients at high risk for the disease as opposed to every patient.

6. When is a screening colonoscopy first recommended? a. Age 45 years b. Age 50 years c. Age 55 years d. Age 60 years Answer: b. The first recommended colonoscopy should be given at the age of 50 years.

7. At what age should an asymptomatic patient begin having routine vision and hearing screening? a. Age 18 b. Age 50 c. Age 75

d. Never on an asymptomatic patient Answer: c. At every preventative examination in patients over the age of 75, the patient should have routine vision and hearing screening.

8. At what age should patients start receiving an annual flu shot? a. 6 months b. 18 years c. 40 years d. 65 years Answer: a. Patients above the age of 6 months should begin having an annual flu shot.

9. What is added to the trivalent vaccine to make the quadrivalent influenza vaccine? a. H1N1 coverage b. An extra influenza B vaccine c. An extra influenza A vaccine d. H3N2 coverage Answer: b. The added vaccine given in a quadrivalent influenza shot involves an influenza B vaccine.

10.How often should a colonoscopy be performed in the asymptomatic patient with no risk factors? a. Every 3 years