EBOOK First Aid For The Family Medicine Boards Third Edition 1St The Download Full Chapter PDF Docx Kindle
EBOOK First Aid For The Family Medicine Boards Third Edition 1St The Download Full Chapter PDF Docx Kindle
EBOOK First Aid For The Family Medicine Boards Third Edition 1St The Download Full Chapter PDF Docx Kindle
Concise summaries of
high-yield topics for
last-minute review
We invite you to share your thoughts and ideas to help us improve First Aid for the® Family Medicine Boards. See How to Con—
tribute, p. xiii.
'l'ao Le
Louisville
Michael Mendoza
Rochester
Diana Coffa
San Francisco
Lamercie Saint—Hilaire
San Francisco
Acknowledgments
This has been a collaborative project from the start. We gratefully acknowledge the thoughtful comments, corrections, and
advice of the residents, international medical graduates, and faculty who have supported the authors in the revision of the third
edition of First Aid for theé‘ Family Medicine Boards. Also, we would like to acknowledge Khaled Al Bishi.
For support and encouragement throughout the process, we are grateful to 'l'hao Pham.
Thanks to our publisher, McGraw—Hill, for the valuable assistance of their staff. For enthusiasm, support, and commitment to
this challenging project, thanks to Bob Boehringer. For outstanding editorial support, we thank Linda Ceisler, Emma Under—
down, Catherine Johnson, and Louise Petersen. We also want to thank Artemisa Gogollari, Susan Mazik, Virginia Abbott, Mar—
vin Bundo, and Hans Neuhart for superb illustration work. A special thanks to Rainbow Graphics, especially David Hommel,
for remarkable editorial and production work.
'l'ao Le
Louisville
Michael Mendoza
Rochester
Diana Coffa
San Francisco
Lamercie Saint—Hilaire
San Francisco
How to Contribute
To continue to produce a high—yield review source for the ABFM exam, you are invited to submit any suggestions or correc—
tions. We also offer paid internships in medical education and publishing, ranging from three months to one year (see below
for details). Please send us your suggestions for:
Study and test—taking strategies for the ABFM
New facts, mnemonics, diagrams, and illustrations
Low—yield topics to remove
For each entry incorporated into the next edition, you will receive up to a 310 gift certificate as well as personal acknowledg—
ment in the next edition. Diagrams, tables, partial entries, updates, corrections, and study hints are also appreciated, and signifi—
cant contributions will be compensated at the discretion of the authors. Also, let us know about material in this edition that you
feel is low yield and should be deleted. Please submit entries, suggestions, or corrections to the First Aid 'I‘eam’s blog at:
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NOTE TO CONTRIBUTORS
All entries become the property of the authors and are subject to editing and review. Please verify all data and spellings care—
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sible.
INTERNSHIP OPPORTUNITIES
The author team is pleased to offer part—time and full-time paid internships in medical education and publishing to motivated
physicians. Internships may range from three months (eg, a summer) up to a full year. Participants will have an opportunity
to author, edit, and earn academic credit on a wide variety of projects, including the popular First Aid series. Writing/editing
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CHAPTER
WWWNNNN
When Is the Exam Offered? Other High-Yield Areas
How Do | Register to Take the Exam?
What lfl Need to Cancel the Exam or Change Test Centers? Test—Taking Advice
Howls the ABFM Test Structured?
What Types of Questions Are Asked? Testing and Licensing Agencies
How Are the Scores Reported?
CHAPTER I GUIDE TO THE ABFIVI EXAMINATION
I Introduction
For residents, the American Board of Family Medicine (ABFM) certification exam
represents the culmination of 3 years of hard work, and for those taking the recertifi—
' KEY FACT
cation exam, 7 to 10 years after that. However, the process of certification and recerti—
The majority of patients WiII be aware of fication does not merely represent yet another in a series of expensive tests. To your
your certification status. patients and their families, it means that you have attained the level of clinical knowl—
edge and competency required to provide up—to—date and high quality clinical care.
In this chapter, we talk more about the ABFIVI exam and provide you with proven ap—
proaches to conquering the exam. For details about the exam, visit www.theabfm.org.
The ABFIVI also provides information about specific strategies for exam preparation,
available at www.theabfm.org/cert/exampreparation.aspx.
I ABFM—The Basics
The exam is offered during 2 months each year, typically in April and in November.
Applicants must register for one of the limited dates that are offered in each of those
months. Generally, more dates are available in the spring session than in the winter
session.
Those who are certifying for the first time must have a user name and password sup-
plied by their residency program. The registration deadline is typically January, with
increasing late fees for each subsequent month. The latest date to register is generally
in March. The registration fee in 2017 was $1300.
Prior to registering for the exam, applicants must be up to date on their required
Maintenance of Certification (MOC) training. Specifically, they must have com-
pleted 50 points of approved CME through the ABFIVI within the last 3 years. Of
these 50 points, at least 15 must be from a Knowledge Self Assessment module on
the ABFM Web site and another 15 must be from an ABFM approved Performance
Improvement module. This applies to people who are still in residency as well as to
those who have graduated. You can check the ABFM Web site to find modules that
' KEY FACT
qualify for MOC points and to confirm that you have accrued enough points to be
Completing a Performance Improvement
eligible to apply for the exam.
project can take a month. Be sure to start
your MOC requirements months before Check the ABFM Web site for the latest information on registration deadlines, fees,
you intend to appIy tor the exam. and policies. Note that the deadlines and schedules for the Certificates of Added
Qualifications vary.
30 days before the exam). You can also change your test center and test dates before
a specific deadline. Check the ABFM Web site for the latest on refund and cancella-
tion policies as well as current procedures.
All questions are single-best—answer type only. You will be presented with a scenario
and a question followed by five options. Most questions on the exam are vignette
' KEY FACT
based. A substantial amount of extraneous information may be given, or a clinical sce-
nario may be followed by a question that could be answered without actually requir— Most questions on the ABFM exam are case
ing that you read the case. As with other board exams, there is no penalty for guessing. based.
Questions can pertain to the diagnosis, treatment, or prevention of disease.
Both the scoring and the reporting of test results have varied, but may take up to 3
months. Your score report will give you a “pass/fail" decision, the overall number of
questions answered correctly with a corresponding percentile, and the number of
questions answered correctly with a corresponding percentile for more than 40 dif-
ferent subject areas. Results from all candidates who took the test on the same date
are presented alongside your results for each subject area. In 2016 for first-time and
repeat exam takers in the United States, the pass rate for the certification exam was
96%; for the recertification exam, the pass rate was 89%.
The recertification exam is one part of the Maintenance of Certification for Family
Physicians (MC—PP). The exam must be completed every 7 or 10 years, depending on
your situation. Additional components of the MC—FP include Self—Assessment Mod—
ules (SAMs), Performance Improvement (PI) activities, called Performance in Prac—
tice Modules (PPMs), and continuing medical education. Please check the ABFM
Web site for additional details.
CHAPTER I GUIDE TO THE ABFIVI EXAMINATION
Depending on the module you choose in the morning session, you may want to focus
on specific chapters and sections in the First Aid for the Family Medicine Boards:
Ambulatory Family Medicine: Community Medicine, Cardiology (hypertension,
dyslipidemia, heart failure), Endocrinology (diabetes), Gastroenterology, Pulmonary
Medicine, Dermatology, Reproductive Health (gynecology), and Behavioral Health.
Child and Adolescent Care: Pediatric and Adolescent Medicine, Reproductive
Health (gynecology), and Hematology and Oncology (anemia, leukemias).
Geriatrics: Geriatrics, Community Medicine, Cardiology, Neurology (cerebrovas-
cular disease), Dermatology (herpes zoster), and Psychiatry.
Women’s Health: Reproductive Health, Geriatrics (osteoporosis, incontinence),
Psychiatry, Pediatric and Adolescent Medicine (eating disorders, female athletic
triad), Surgery (breast cancer), and Community Medicine (domestic violence).
Maternity Care: Reproductive Health (obstetrics), Psychiatry, and Community
Medicine (domestic violence).
Emergent/Urgent Care: Emergency/Urgent Care, Psychiatry, Surgery, Pediatric
and Adolescent Medicine (common acute conditions), and Community Medicine
(bioterrorism).
Hospital Medicine: Cardiology, Pulmonary Medicine, Endocrinology (DKA,
HHNS), Gastroenterology (GI bleeding, end-stage liver disease, diverticulitis, pan-
creatitis), Hematology and Oncology (oncology), Infectious Disease, Pulmonary
(lower respiratory disease), Nephrology (acute renal failure), Neurology (cerebro-
vascular disease, seizure, syncope), Surgery, and Emergency/Urgent Care.
Sports Medicine: Sports Medicine.
Focus on topic areas that may not be emphasized during residency training but are
board favorites. These include the following:
Basic biostatistics (eg, sensitivity, specificity, positive predictive value, negative pre-
dictive value).
Adverse effects of drugs.
GUIDE TO THE ABFM EXAMINATION CHAPTER 1
NOTES
CHAPTER 2
I Preventive Medicine
ADULT IMMUNIZATIONS
Table 2.1 outlines common adult immunizations and their indications. For informa-
tion on immunization of pediatric populations, refer to the Child and Adolescent
Medicine chapter.
CANCER SCREENING
The following guidelines are based on recommendations from the United States Pre-
ventive Services Task Force (USPSTF) and the American Academy of Family Physi-
cians (AAFP). The USPSTF describes their strengths of recommendation as grades
(Table 2.2) that communicate both the importance of the recommendation and how
it should be incorporated into practice. Remember that these recommendations are
updated annually.
Skin Cancer
Insufficient evidence (grade I) for whole—body skin examination by a primary care
clinician or patient skin self—examination for the early detection of cutaneous mela—
noma, basal cell cancer, or squamous cell skin cancer in the adult general popula—
tion.
However, there is grade B evidence recommending counseling children adolescents
and young adults (ages 10—24) who have fair skin about minimizing their exposure
to ultraviolet radiation to reduce risk for skin cancer.
Cervical Cancer
Routinely screen for cervical cancer with a Papanicolaou smear all women 21 years
of age who have been sexually active and have a cervix (grade A strongly recom-
mended).
Repeat screening at least every 3 years, but this interval can be lengthened to every
5 years in women aged 30 to 65 years if they are being screened with a combination
of cytology and HPV testing.
COMMUNITY AND PREVENTIVE MEDICINE CHAPTER 2
VACCINE SCHEDULE
Td/Tdap Give the complete 1° series ifthe patient has not been previously vaccinated (first dose, Tdap; second dose,Td 4 weeks later;
third dose, Td 6 months later)
Tdap can substitute for only one of the three Td doses in the series
Booster doses od should be given every 10 years thereafter
Human papillomavirus Vaccinate girls and boys at 11 or 12 years (or as early as 9 years) with catch—up vaccination for young women and young men
between 13 and 26 years, and for men aged 22—26 years if immunocompromised (including HIV) and men who have sex with
men (MSM)
Varicella lfthe patient has a history ofchickenpox, consider immune; otherwise, vaccinate with two doses given 1—2 months apart
Herpes zoster Single dose recommended for adults 260 years regardless ofwhether they report a prior episode of herpes zoster
Measles, mumps, lfthe patient was born before 1957, consider immune
rubella lfthe patient was born after 1957, two doses should be given at least 1 month apart
For rubella specifically, ensure that women of childbearing potential have immunity
Influenza One dose annually recommended for all persons aged 26 months, including all adults
Pneumococcal Give to all adults 265 years: PCV13, then PPSV23 12 months later
(polysaccharide): Adults 19—64 years with comorbid conditions (chronic pulmonary disorders excluding asthma, CVD, DM, chronic liver or renal
PPSV23 (older) disease): PPSV23 vaccine only, give second dose 25 years later
PCV13 (newer) Adults with asplenia or immunosuppression: Both vaccines (PCV13 first, then PPSV23 8 weeks later)
Hepatitis A Vaccinate any person seeking protection or people of the following indications: MSM, chronic liver disease, persons traveling
or working in endemic areas
Two doses 6—1 2 months apart or three doses at 0, 1, and 6 months
Hepatitis B Vaccinate any person seeking protection or people of the following indications: persons at high risk for STIs, health care
personnel, end—stage liver disease patients, HIV—infected patients, chronic liver disease patients
Three doses (0, 1-2 months, 4-6 months)
Meningococcal: Give to adults with asplenia, first—year college students in dormitories, military personnel
4—valent conjugate 1—3 doses depending on type of vaccine and indication; consider a second dose at 5 years for those given polysaccharide
meningococcal B vaccine
Routine screening is not recommended for women >65 years of age with a history TA B L E 2.2. Definition of USPSTF
of adequate 9 screening and who are otherwise not at high risk. The evidence Grades
is insufficient to recommend for or against the routine use of new technologies or
A—Strongly recommends service
HPV testing alone to screen for cervical cancer.
B—Recommends service
high, the positive predictive value is low because of the low prevalence of ovarian can— D—Recommends against service
cer in the general population. Further, the invasive nature of testing that follows a l—lnsufficient evidence
C9 screening test led the USPSTF to conclude that the potential risks outweigh the
potential benefits (grade D, against recommendation).
Breast Cancer
Breast self-examination: General consensus among expert groups is not to recom-
mend breast self-examination.
CHAPTER 2 COMMUNITY AND PREVENTIVE MEDICINE
Mammography:
Women aged 50 to 74 years: Screen for breast cancer every 2 years with mam—
mography (grade B recommendation).
Women <50 years: Individualize your decision to start regular, biennial
screening mammography based on patient context, including the patient’s
values regarding specific benefits and harms. (Grade C recommendation to
screen women aged 40—49 years.)
Women 275 years: Do not routinely screen with mammography.
Germline predisposition (BRCAI or BRCAZ): Although a family history of breast
cancer is common in women who develop breast cancer, only 5% to 6% of all breast
cancers are associated with germline (inherited) genetic mutations. The majority
of these involve two genes, BRCA1 and BRCA2. Affected patients who meet the
National Comprehensive Cancer Network (NCCN) criteria for BRCA1 and BRCA2
screening include:
Female breast cancer diagnosed <50 years old.
'l’riple—negative breast cancer diagnosed <60 years old.
Invasive ovarian or fallopian tube cancer or 1° peritoneal cancer.
Male breast cancer.
Ashkenazi Jewish descent with breast, ovarian, or pancreatic cancer diagnosed
at any age.
Patients with breast cancer (any age) who have first—, second—, or third—degree
relatives with breast cancer diagnosed <50 years old in one or more relatives;
invasive ovarian, fallopian tube, or lO peritoneal cancer in one or more rela—
tives; breast, prostate, or pancreatic cancer diagnosed in two or more relatives.
Women who test (-9 for BRCAI or BRCAZ mutations are at I risk for both breast
and ovarian cancer. Such women should be referred for appropriate counseling to
consider options for reducing risk and intensified surveillance.
The NCCN guidelines recommend that BRCA carriers be offered prophylactic bilat—
eral mastectomy; however, that decision is made based on patient preference. Also,
bilateral salpingo—oophorectomy should be offered to women who have completed
childbearing. In women who opt not to have prophylactic bilateral mastectomy,
annual mammogram (starting at age 30 years) and annual breast MRI (starting at
age 25 years) is recommended. Additionally, selective estrogen receptor modula—
tors (tamoxifen or raloxifene) can be used to I the risk of invasive breast cancer in
high-risk women who opt against surgical options. In postmenopausal women, an
aromatase inhibitor (such as anastrozole) may also be used.
Prostate Cancer
The USPSTF recommends informed, individualized decision-making about screen-
ing for prostate cancer in men ages 55 to 69 years based on the man’s values and
preferences (grade C). PSA-based screening is not recommended for men 70 years
and older (grade D). With early detection of asymptomatic disease, very few, if any,
patients have improved survival and there will be more harm done by falsely elevated
PSA levels and the subsequent additional testing and treatment.
Colon Cancer
Screen adults 50 to 75 years of age for colon cancer with an annual fecal occult blood
test, sigmoidoscopy every 3 to 5 years, or colonoscopy every 10 years (grade A recom-
mendation). Screening adults aged 76 to 85 years is a grade C recommendation.
Screen earlier if there is I risk for colorectal cancer— eg, if the patient has a personal
or strong family history of colorectal cancer, adenomatous polyps, or a family history
ofa hereditary syndrome (familial adenomatous polyposis, hereditary nonpolyposis
colon cancer).
Do not screen for colorectal cancer in adults >85 years of age (grade D recommen—
dation).
COMMUNITY AND PREVENTIVE MEDICINE CHAPTER 2
Lung Cancer
There are currently differing opinions regarding lung cancer screening.
USPSTF recommends (grade B) annual screening for lung cancer with low-dose A 30—year—old woman who is otherwise
CT in adults ages 55 to 80 with a 30—pack year smoking history and currently smoke, healthy presents to you for the first time
or have quit in the last 15 years. Screening should be stopped when that patient has because she wants to be tested for the
ceased smoking for 15 years or develops a life-limiting condition or the willingness ”breast cancer gene.” She is concerned
to have curative lung surgery. because her 527yeareold mother was
diagnosed with metastatic breast cancer
AAFP finds that there is insufficient evidence to support this recommendation,
at 38 years of age. How would you answer
citing high number needed to screen, lack of reproducibility of these results in all
this patient?
settings, and high cost.
Tables 2.3 lists recommended clinical preventive services for different adult popula-
tions based on the grade A and B recommendations from the USPSTF and the AAFP.
Male- and female-specific screening recommendations are discussed below. Table 2.4
lists clinical preventive services for pregnant woman. See cancer screening and im-
munization recommendations above.
40-70 Type 2 DM Screen for abnormal blood glucose as part of cardiovascular risk assessment in those who are overweight or
obese; clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling
interventions to promote a healthful diet and physical activity
40—75 Lipid disorders Adults without a history of CVD (ie, symptomatic CAD or ischemic stroke) use a low— to moderate—dose statin for the
prevention of CVD events and mortality when the following criteria are met:
They are aged 40—75 years
They have one or more CVD risk factors (ie, dyslipidemia, diabetes, hypertension, or smoking)
They have a calculated 10—year risk of a cardiovascular event of 10% or greater
Identification of dyslipidemia and calculation of 10—year CVD event risk requires universal lipids screening in adults
aged 40—75 years
50-59 CVD and colorectal Low—dose aspirin is recommended for adults with 210%10—year CVD risk who are not at I risk for bleeding, have a
cancer life expectancy of at least 10 years, and are willing to take low—dose aspirin daily for at least 10 years
265 Falls Exercise or physical therapy and vitamin D supplementation in community—dwelling adults who are at T risk for falls
CHAPTER 2 COMMUNITY AND PREVENTIVE MEDICINE
Screening in Men
Abdominal Aortic Aneurysm: Offer one-time screening by ultrasonography for men
You advise her that she is likely a candidate 65 to 75 years of age who have ever smoked.
for BRCA I/BRCAZ mutation testing, given
that she has a firstrdegree relative with Screening in Women
premenopausal breast cancer, and refer her
for genetic testing Chlamydia and gonorrhea: Screen sexually active women age 24 years and younger
and older women who are at T risk for infection.
Intimate partner violence: Screen women of childbearing age for intimate partner
violence (grade B). There was insufficient data to recommend for or against screen-
ing other populations (grade I). See the Domestic Violence section below for more
information.
Osteoporosis: Screen in women aged 265 years and in younger women whose frac-
ture risk is 2 that of a 65-year-old white woman who has no additional risk factors.
The FRAX (Fracture Risk Assessment) tool can be used to estimate 10-year risks for
fractures for all racial and ethnic groups in the United States.
CONDITION RECOMMENDATION
Bacteriuria, Screen with urine culture at 12-16 weeks’gestation or at the first prenatal visit
asymptomatic
Breastfeeding Provide interventions during pregnancy and after birth to promote and
support breastfeeding
Depression Screen pregnant and postpartum women, implement screening with adequate
systems in place to ensure accurate diagnosis, effective treatment, and
appropriate follow—up
HIV infection Screen all pregnant women, including those who present in labor whose HIV
status is unknown
Neural tube All women planning or capable of pregnancy should take a daily supplement
defects containing 0.4—0.8 mg (400—800 pg) of folic acid
Rh(D) Order Rh(D) blood typing and antibody testing at the first prenatal visit; repeat
incompatibility antibody testing for all Rh(D)—negative women at 24—28 weeks’ gestation
Tobacco use Provide smoking cessation behavioral interventions for all pregnant smokers
COMMUNITY AND PREVENTIVE MEDICINE CHAPTER 2
MSM: The CDC recommends screening for HBsAg, syphilis (annually), gonorrhea,
chlamydia, and HIV. Hepatitis C screening should be done when other risk factors
are present. Anal Papanicolaou testing is available, but evidence and guidelines for
its use are inconsistent.
Additional screening for STI such as HIV and syphilis are recommended for all men
and women (regardless of sexual orientation) engaging in high-risk sexual behavior.
A thorough sexual history to assess patient sexual behavior is important. When
determining patients at risk for STIs, also consider demographics of the population
served (eg, if there is a high community prevalence of syphilis).
A total of 19% of children 2 to 5 years of age and 52% of children 5 to 9 years of age ex-
perience dental caries. Ethnic minority and economically disadvantaged children are
at T risk. Despite recommendations, few preschool-aged children ever visit a dentist.
ENDOCARDITIS PROPHYLAXIS
Offer antimicrobial prophylaxis for dental and other procedures to patients with car—
diac conditions with the highest risk of adverse outcome from infective endocarditis.
Endocarditis prophylaxis is recommended for the following cardiac conditions:
Cardiac valvulopathy in a cardiac transplant recipient.
Congenital heart defect completely repaired within the previous 6 months with
prosthetic material or device, whether placed by surgery or by catheter.
Repaired congenital heart disease with residual defects at the site or adjacent to
the site ofa prosthetic patch or device.
Unrepaired cyanotic congenital heart disease, including palliative shunts and con-
duits.
Previous history of infective endocarditis.
Prosthetic heart valves.
Do not offer antimicrobial prophylaxis to patients with any other form of congenital
or acquired heart disease such as bicuspid aortic valve, acquired aortic or mitral valve
disease (including mitral valve prolapse with regurgitation), or hypertrophic cardio—
myopathy. A 45—year—old male nonsmoker presents
fora routine annual physical exam, He is
Offer antimicrobial prophylaxis to patients with the cardiac lesions cited above when generally heaIthy and ofa normal weight
with no current medical complaints, He
they undergo procedures, such as the following, likely to result in bacteremia with a
exercises byjogging 30 minutes two times
microorganism that has the potential to cause endocarditis:
a week, on average. His family history
All dental procedures that involve manipulation of gingival tissue or the periapical includes high blood pressure (BP) and an
region of teeth or that perforate the oral mucosa. older brother with MI at age 48 years, He
Procedures of the respiratory tract that involve incision or biopsy of the respiratory is worried that this might happen to him,
mucosa. What preventive services can you offer this
Procedures in patients with ongoing GI or GU tract infection. patient?
Procedures on infected skin, skin structure, or musculoskeletal tissue.
CHAPTER 2 COMMUNITY AND PREVENTIVE MEDICINE
Three years after smoking cessation, Prevalence of cigarette smoking among adults in the United States was estimated by
the risk of recurrent Mi ~L to that of a the CDC to be 17% in 2014. Smoking causes as many as 480,000 deaths/year and is
nonsmoker. the most common preventable cause of death (Figure 2.1).
[~—
The ”5 A’s” approach to tobacco
that of a nonsmoker by 3 years after quitting.
Stroke: Associated with a J, risk over time.
Pulmonary disease: Slowed progression in the decline of FEV1 in patients with
COPD. Also associated with a l risk of pulmonary infections such as bacterial
cessation advocated by the pneumonia and TB.
National Cancer Institute: Malignancy: 1/ risk oflung, kidney, bladder, stomach, and cervical cancers, among
I Ask about smoking habits others.
l Advise all smokers to quit
PUD: 1/ risk of developing PUD; accelerated rate of healing.
I Assess patient’s readiness to quit
Osteoporosis: l risk of bone loss and fracture (begins 10 years after quitting).
I Assist with nonpharmacologic
measures such as counseling and
pharmacotherapy (as appropriate) Cessation Methods
I Arrange follow—up and support Evaluate the patient’s cigarette use, assess his or her interest in quitting, and find
out about previous attempts at quitting
Once the patient is ready, offer strategies such as setting a “quit day" and help define
alternative oral behaviors to substitute for the cigarette (eg, gum, throat lozenges).
Many behavioral methods have been advocated to encourage patients to work toward
quitting. Discuss and agree upon methods for cessation (Table 2.5) in advance of
the quit day.
9mm; .Qhr-zniskigsiée
3! mice
Blindness, cataracts. age-related maculnr degenemtinn
__—' Congenital defects—maternal smoking: orofacial :Icfls
(Irupharynx J l'eriodonlilis
larynx ‘ Aortic aneurysm. varly abdominal aortic
f atherosclerosis in young adults
Esophagus
‘ T 22,“ Coronary heart disease
' ‘7 \‘ r7 Pneumonia
“trachea. bronchus, and lung . — l :3“ l" Alhernsclcmlic peripheral vascular disease
,4 r. ' I
Acute nn‘clnitl leukemia I . “ Chronic obstruclivu pulmonary
. ..disease. lubcrculosls.
asthma. and nthur respiratory enacts
Stomach . d1‘ "-p ' .
Liver / I z), A ntlheten
I Obesity
In the United States, the prevalence of obesity is now about 34% in adults and 17% in
children. Screen all adult patients for obesity and offer intensive counseling and be-
havioral interventions to promote sustained weight loss in obese adults and children
and prevent morbidity and mortality associated with obesity, including:
T risk of both cardiovascular and overall mortality. In addition, there are clear ' KEY FACT
associations between obesity and T morbidity
T risk of cardiovascular disease, hypertension, stroke, type 2 DM and insulin resis- A BMI 230 is associated with T risk of both
tance, dyslipidemia, cancer (including cancers of the colon, kidney, and gallblad- death from CVD and overall mortality
der), sleep apnea, gallbladder disease, GERD, and knee osteoarthritis. Intentional weight loss of25 lb has been
I, quality oflife, including I mobility and social stigmatization. associated with a I in CVD, cancer, and
overall mortality.
Diagnosis
Overweight and obesity are diagnosed based on the calculation of BMI (kg/m2):
TA B L E 2 .6. BMI Categories for
BMI : weight (kg) /heightZ (m2) Overweight and Obesity
eating patterns and become physically active. This may lead to small/moderate
Super—obese 50—59
degrees of weight loss (1-6 kg) typically sustained for at least 1 year.
CHAPTER 2 COMMUNITY AND PREVENTIVE MEDICINE
Medication (Table 2.7): May be considered for patients with BMI >30 when diet
and exercise attempts have failed and/or when the patient has comorbidities. Weight
loss resulting from medication:
Calculate BMI, which for this patient is Is modest (average 3—5 kg), and discontinuation of medications may lead to
35 kg/mZ, and offer referral for intensive,
rapid weight gain.
multicomponent behavioral interventions,
Will only be significant when combined with lifestyle changes
as per USPSTF and AAFP recommenda
tions for patients with BMI 230 kg/mz. You
Is considered successful when a 5% to 10% reduction in initial weight. If that
explain that guar gum has not been shown amount of weight loss is not achieved with a particular agent, the medication
to be effective for weight loss and recom— should be discontinued to avoid adverse effects.
mend a diet and exercise regimen. Surgery:
Consider patients for gastric bypass and vertical banded gastroplasty if they
have a BMI >40 or BMI >35 with comorbidities, have failed to respond to pre—
vious nonsurgical weight loss attempts, and are well informed and motivated.
Discuss with them postoperative complications, which may include a mortal—
You check hematocrit, peripheral blood ity rate of 0.2%, wound infection, re—operation, vitamin deficiency, diarrhea,
smear, and 8,2 and folate levels Also and hemorrhage.
consider checking an l-lk, as his loss
Refer for bariatric surgery to high—volume centers with experienced surgeons.
of sensation could be caused by diabetic
Prepare patients and offer appropriate support, including psychological
neuropathy. His alcohol use should be
addressed as well including the risk of
screening and a diet and exercise program, for successful surgical weight loss.
thiamine deficiency. Patients who undergo Roux—en—Y gastric bypass will require lifelong vitamin
supplementation (multivitamin, B127 iron, zinc, magnesium) and yearly
screening labs for nutritional deficiencies.
Table 2.8 outlines the clinical manifestations and treatment of severe malnutrition.
Sympathomimetic drugs
Phentermine and diethylpropion Stimulates sympathetic nervous Can I BP, contraindicated in CAD, HTN
system Use up to 12 weeks only (schedule IV drugs with abuse potential)
Antidepressants
Fluoxetine Acts as an appetite suppressant Not FDA approved for weight loss; must use 260 mg/day
Bupropion Acts as a norepinephrine modulator Not FDA approved for weight loss
Antiepileptic drugs
Topiramate Also approved for treatment of Not FDA approved for weight loss as a single agent; available in
migraine combination treatment with phentermine
Zonisamide Has serotonergic and dopaminergic Not FDA approved for weight loss
activity
COMMUNITY AND PREVENTIVE MEDICINE CHAPTER 2
MARASMUS KWASHIORKOR
Treatment Correct fluid and electrolyte Treatment is the same as that for
abnormalities; treat infections; marasmus
' KEY FACT
give vitamins and minerals
Start with i g protein/kg and 30 If neurologic deficits are present, think
kcal/kg, preferably enterically vitamin B,2 deficiency. Immediate
treatment is necessary to prevent
Complications Immunosuppression, poor Same as those for marasmus irreversible peripheral neuropathy, balance
wound healing, impaired problems, dementia.
growth and development,
muscle atrophy leading to organ
dysfunction
VITAMIN DEFICIENCIES
A (retinol) Found in urban poor, elderly patients, and Night blindness, xerosis, Bitot spots (white High-dose vitamin A
those with fat malabsorption syndrome patches on the conjunctivae) leading
to keratomalacia, endophthalmitis, and
blindness
D Found in elderly patients, those with Children: Rickets (restlessness, High-dose oral vitamin D
insufficient sun exposure or malnutrition/ craniotabes, costochondral beading,
malabsorption, breastfeeding infants, and bowlegs, kyphoscoliosis)
anticonvulsant users Adults: Osteomalacia
K Poor diet, malabsorption, antibiotics Clotting factor deficiencies (II, VII, IX, X) Vitamin K SQ
CHAPTER 2 COMMUNITY AND PREVENTIVE MEDICINE
B1 (thiamine) The most common cause is alcoholism Anorexia, muscle cramps, paresthesias‘ Oral thiamine
Dry beriberi leading to neuropathy
and Wernicke—Korsakoff syndrome; wet
beriberi leading to high—output heart
failure
B2 (riboflavin) Usually occurs with other deficiencies Nonspecific symptoms (eg, mouth Oral vitamin B2
soreness, glossitis, cheilosis, weakness,
irritability) plus seborrheic dermatitis
and anemia
33 (niacin) Associated with alcoholism Nonspecific symptoms (see above); Oral nicotinamide
pellagra (Figure 2.2) (dermatitis,
diarrhea, dementia)
B6 (pyridoxine) Associated with medication interactions Nonspecific symptoms (see above); Oral or intramuscular vitamin 36
(INH, OCPs) or with alcoholism; fat peripheral neuropathy, anemia, and
malabsorption syndromes may seizures
contribute Levels can be measured (normal >50
ng/mL)
B12 Found in vegans, gastrectomy patients, Megaloblastic anemia, glossitis, Vitamin B,2 administered
(cyanocobalamin) gastric bypass patients, and those with anorexia, diarrhea intramuscularly
pernicious anemia Peripheral neuropathy, balance
problems, dementia (reversible if
treated within 6 months)
C (ascorbic acid) Found in urban poor, elderly, alcoholics, Scurvy: Poorwound healing, easy Oral vitamin C
cancer patients, smokers, and those in bruising, bleeding gums, subperiosteal
renal failure hemorrhage, and anemia leading
to edema, oliguria, neuropathy, and
intracerebral hemorrhage
Biotin Caused by eating large quantities of Myalgias, dysesthesias, anorexia, and Oral biotin
raw eggs nausea leading to dermatitis and
alopecia
Folic acid Caused by inadequate dietary intake Megaloblastic anemia, neural tube Oral folic acid
defects
Herbal Supplements
More than 40% of the US population uses some type of complementary or alterna-
tive medicine. Effects of herbal supplements are difficult to evaluate due to problems
in isolating the active component. Table 2.11 lists herbal supplements with demon-
strated safety. Certain herbal remedies have been associated with deleterious effects
and should be used with caution. Examples include:
Black licorice: Causes hypertension.
Chromium: \I/ blood sugar. F I G U R E 2.2. Pellagra. Characterized
Garlic, ginger, gingko, ginseng, feverfew, C0910: Prolong INR. by an erythematous rash in sun—exposed
skin. Findings range from obvious scaly
erythema to subtle changes that are often
mistaken for the photo—damage typically
I Domestic Violence seen in elderly patients. (Reproduced from
Oldham MA, et al. Pellagrous encephalopathy
presenting as alcohol withdrawal delirium: A case series
INTIMATE-PARTNER ABUSE and literature review. Addict Sci Clin Pract. 2012;7(1):12;
courtesy of Richard Johnson, MD, Department of
Defined as intentional controlling by or violent behavior from a person who was or Dermatology, Massachusetts General Hospital, Boston,
MA USA, 2012.)
is in an intimate relationship with the victim. This behavior may be physical abuse,
sexual assault, emotional abuse, economic control, and/or social isolation.
Women are more likely than men to be the victims of chronic physical abuse. ' KEY FACT
Violence in gay and lesbian relationships appears to be as common as in hetero-
sexual relationships. Be aware of herbal remedies that interact
Most states do not currently require mandatory reporting of domestic violence with warfarin, including garlic, ginger,
against competent adults. Table 2.12 outlines risk factors for intimate-partner abuse. gingko, ginseng, feverfew, and Cl O.
CHILD ABUSE
This important topic is addressed in the Child and Adolescent Medicine chapter.
Travel Medicine
Travel is associated with potential morbidity and even mortality from infectious
sources, modes of transportation, environmental exposures, and adverse medical out—
comes from illnesses independent of travel. In addition, always address safe sex strate-
gies when a patient will be traveling. Offer the following guidelines and recommen-
dations to those contemplating or planning travel to reduce the risk of adverse events.
Please see the CDC Web site for up—to-date information regarding specific locations.
PRETRAVEL ASSESSMENT
Determine the patients health status (eg, infants, elderly persons, pregnant women,
or those with chronic illnesses or underlying medical conditions).
Identify potential medical needs (eg, allergy to vaccine components, medication
use, immunosuppression).
Evaluate the patient’s travel itinerary (eg, planned destinations, climate and altitude,
rural vs urban environment, duration of stay, accommodations, purpose of travel).
Food: Advise patients that fruits are safe only when peeled and that vegetables need
to be fully cooked to prevent contamination from fecally passed organisms in the
soil. Unpasteurized dairy products and inadequately cooked fish or meat should be
When reviewing his immunization records, avoided.
look specifically for the date of his last Water: Counsel patients to avoid ice cubes and that water is safe only after it has
tetanus booster and Whether he has been been boiled. Chlorination will kill most viral and bacterial pathogens, but protozoal
immunized against HAV and HBV; otter pathogens such as Giardia lamblia can survive. Carbonated drinks, beer, wine, and
general travel advice regarding food, drinks made from boiled water are safe.
water, and insect repellant; and provide Insect repellents: Advise travelers to use at least 20% DEET on clothing and exposed
prescriptions for both malaria prophylaxis
skin to prevent mosquito-borne infections such as malaria, yellow fever, dengue
and traveler’s diarrhea, with strict and clear
fever, and Zika virus. Protection with DEET lasts for several hours but is mitigated
instructions on when and how they should
be taken.
by swimming, washing, sweating, wiping, and rain. Travelers may also choose to
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DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI
I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.