History and Physical Examination During the Domestic Medical Screening for Newly Arrived Refugees

Key Points:

• Review overseas medical documents, including vaccinations and screening for communicable conditions of public health importance
• Work with a qualified medical interpreter who speaks the patient’s preferred language
• During the initial screening appointment, address immediate health concerns/priority needs and obtain a detailed history, including aspects unique to refugees (e.g., travel history).
• Measure blood pressure (≥3 years), and complete a formal vision (≥3 years) and hearing screening (≥4 years)
• Conduct a thorough, head-to-toe physical exam as permitted by the patient, as this may reveal undiagnosed underlying diseases and other medical issues.

Background

Depending on their country of origin, refugees may be at increased risk for infectious or non-infectious conditions less commonly seen among the US-born population. The domestic refugee medical screening examination, conducted soon after US arrival, offers a timely opportunity to identify acute and chronic health conditions. The initial history and physical examination are critically important to identify and manage acute and chronic health conditions. The domestic medical screening also helps refugees develop a sense of trust in the US medical system and healthcare providers. Lastly, the domestic medical screening is an opportunity to introduce (or reaffirm) the importance of preventative medicine and routine physical examinations, as well as how and when to access emergency medical care.

Overseas Medical Examination: History and Physical

The overseas medical examination includes a medical history and physical examination to determine the presence and severity of Class A or Class B conditions. Panel physicians obtain a medical history, including current symptoms, significant acute or chronic conditions, and past hospitalizations and/or institutionalizations for chronic conditions.

Panel physicians conduct a review of systems and document symptoms that may suggest cardiovascular, pulmonary, musculoskeletal, or neuropsychiatric disorders. The physical examination is comprised of:

1. Mental status examination (relevant for age) that includes an assessment of intelligence, thought, cognition (comprehension), judgment, affect (and mood), behavior, and appropriate development for young children;
2. Physical examination including, a minimum of: examination of the eyes, ears, nose and throat, extremities, heart, lungs, abdomen, lymph nodes, and skin;
3. Diagnostic tests required to identify communicable diseases of public health significance, as well as other tests identified as necessary to confirm a suspected diagnosis of any other Class A or Class B condition.

Details of the overseas history and physical examination may be found in the Technical Instructions for Panel Physicians.

Recommendations for New Arrival History and Physical Examination

The domestic medical screening is likely a refugee’s first routine medical encounter with the US-healthcare system and is an opportunity to begin establishing a trusting patient-provider relationship. It is critical to use qualified medical interpreters for any patient with limited English proficiency. Individuals should be assured that this confidential medical visit is for their health, does not have any regulatory purposes, and will not affect their resettlement or visa status. During the initial screening appointment, providers should review overseas medical documents, address a refugee’s immediate health concerns and priority needs as well as obtain a detailed history, including documentation of standard past medical history, medications, allergies, and social and family history. Additionally, a thorough history must include aspects unique to refugees, such as a history of toxic environmental exposures, dietary history, and travel/geographic history.

Past Medical History

A detailed past medical history may be difficult to obtain due to lack of recall, accurate prior diagnoses, lack of access to medical care overseas, or differing cultural beliefs around health and disease. Items more likely to be recalled and reported are prior hospitalizations, episodes of severe illness, known chronic conditions, previous injuries, surgeries (including dental procedures), circumcision, and blood transfusions. Additionally, refer to any medical documentation accompanying the refugee (e.g., Department of State [DS] forms) for documentation of medical conditions, including conditions that may have been identified during the overseas medical examination.

Vaccination History

Vaccinations must be reviewed. Historical vaccination records may include refugee camp vaccination cards and records or booklets from other programs or clinics. Some vaccinations, such as those administered through the Vaccination Program for US-Bound Refugees, will also be documented on the DS-3025 (Vaccination Worksheet). In some instances, vaccinations given immediately before travel may be documented on the Pre-departure Medical Screening (PDMS) forms. For additional information, refer to the Guidance for Evaluating and Updating Immunizations during the Domestic Medical Examination for Newly Arrived Refugees.

Medication History

Medication history should include prescription and nonprescription medications. If a refugee is taking prescription medications, they should be provided with a minimum 30-day supply prior to departure. Details of dosing should be documented on the DS forms. Medication history should also include the use of traditional or herbal remedies and therapies with special attention to any products that may have potential drug interactions, teratogenicity, or be contaminated with toxins such as lead (see Screening for Lead during the Domestic Medical Examination for Newly Arrived Refugees for additional information) [1–3].

Family Medical History

A family history should be obtained. A detailed family history may be limited due to lack of access to medical care in a refugee’s country of origin, uncertainty around which family members to include (family members included in this history should be outlined by the provider), or lack of recall. Information about major conditions should be solicited (e.g., diabetes, asthma, seizures, sickle cell anemia, and hypertension).

Social History

A detailed social history should also be obtained, including housing, food, and schooling before and after arrival in the US. The current living situation and family structure should be ascertained, including the current support network and safety at home. Occupational history may raise suspicion about the patient’s and family members’ past environmental and chemical exposures. Education and literacy levels (including ability to read numbers) should be determined. This information should be used to ensure that health information and other resources are provided at an appropriate level and format (e.g., written, recorded, and/or pictograms). Education and literacy levels may assist in placement in the appropriate school year for children and adolescents (see Incorrect Date of Birth [Chronological Age Discrepancy] in the Key Considerations and Best Practices for additional information).

Travel History

Country of birth, migration history, and where a patient resided before arrival in the US allow clinicians to determine potential travel-related/geographic infectious disease risks, environmental exposures, and potentially significant recent stressors.

Environmental Exposures

In-home exposure to tobacco smoke and smoke from cooking or heating sources should be determined, as well as exposure risks from work sites and residences. Lead exposure risks should be evaluated. This includes cosmetics, cookware, pottery, home remedies, and exposure to lead in gasoline and contaminated soil. Clinicians should refer to Screening for Lead during the Domestic Medical Examination for Newly Arrived Refugees for additional guidance.

Substance Use History

Clinicians should inquire about alcohol, tobacco, and illicit drug use. Additionally, secondhand smoke exposure risk should be obtained, as well as other substances that have significant known associated morbidity and may have potential legal ramifications (e.g., khat).

Mental Health History

A mental health screen and/or clinical evaluation should be performed with the assurance that those with identified mental health needs are linked to appropriate services. Refer to the Domestic Mental Health Screening Guidance for more specific screening recommendations for adults and children.

Sexual History

For women and adolescent girls, the following components of a sexual history should be obtained: reproductive history, menstrual history (including last menstrual period), history of contraceptive use, and risk for early pregnancy (i.e., date of last unprotected sex relative to last menstrual period). This will help guide decision-making around contraception, if desired, and the potential need for repeat pregnancy testing or emergency contraception.

For all men and women, including teenagers, it is important to determine the date of last unprotected sex to ascertain if there is a need for repeat testing for sexually transmitted infections (i.e., HIV, hepatitis B and C, syphilis, gonorrhea, and chlamydia).

Refer to the Sexual and Reproductive Health Domestic Screening Guidance for more detailed information.

Review of Systems

A detailed review of systems should be obtained, keeping in mind particular infections or illnesses that the patient may have based on travel history, country of origin, environmental exposures, and history of trauma. Signs and symptoms such as fever, weight loss, night sweats, pulmonary complaints, diarrhea, abdominal complaints, pruritis, and skin lesions or rashes are particularly important.

Performing the Physical Exam

The physical examination can identify important health issues that need to be addressed at the domestic medical screening and chronic conditions that require further evaluation and management. A thorough, head-to-toe physical exam is critical and may reveal underlying diseases and medical issues. For many refugees, this may be the first comprehensive exam they have experienced. Steps should be clearly explained, using a professional medical interpreter, with gender-concordant examiners provided, if requested and feasible.

Vital Signs

Vital signs, including temperature, heart rate, and respiratory rate, should be measured in all patients. Measure blood pressure in all patients ≥3 years old (routine blood pressure measurement is not done overseas in children under 15 years). Clinicians who see children at the domestic medical screening should refer to Pediatric Blood Pressure Norms [PDF – 4 pages] for additional information. Weight and height (supine measurement if <2 years) should be recorded in all patients. Head circumference should be recorded for all children ≤2 years.

Vision

Perform formal vision screening in all patients ≥3 years of age at the initial domestic medical screening. Use of alternate vision charts may be needed if the individual cannot identify letters of the English alphabet. For further information on pediatric vision screening standards, see the Visual System Assessment in Infants, Children, and Young Adults by Pediatricians from the American Academy of Pediatrics. If there is clinical concern for earlier testing, refer patient for formal evaluation with a pediatric ophthalmologist.

Epidemiology and Impact

In refugees, visual impairment may be due to conditions commonly seen in the United States (e.g., strabismus, refractive errors, cataracts), due to infection (e.g., trachoma), and/or vitamin A deficiency. Blindness and vision impairment are major health problems and may lead to substantial suffering, disability, loss of productivity, and diminished quality of life [4]. Vision impairment often affects a person’s ability to drive, read, learn, use electronic screen-based technologies, or complete household or personal tasks [5]. Blindness or impaired vision may result in difficulty obtaining or maintaining employment, inability to learn in school, challenges driving to and from medical appointments, engaging in activities such as English language classes, or participating in other programs. Furthermore, reduced vision among mature adults has been shown to result in social isolation, increased fall risk, and subsequent bone fractures, depression, family stress, disability, and premature death [4, 6–8].

Vision Health Coverage

Coverage for eye examinations and glasses under Medicaid and Refugee Medical Assistance varies from state to state. Some insurance plans may cover eye examinations or glasses, while others do not. State Medicaid offices or local resettlement agencies may help determine available coverage. In addition, some providers may be able to provide free or low-cost eye exams and services to patients with demonstrated need if insurance coverage is limited. Check with local vision providers to determine availability and develop a referral process. Individual states may also have some programs to support vision care (some providing free glasses to those in need), and providers should also become familiar with these programs.

Hearing

A hearing screening should be performed using office audiometry for all refugees ≥4 years of age. The following may indicate an increased risk for abnormalities affecting hearing:

• Speech issues
• A history of recurrent or acute ear symptoms/diagnoses (i.e., history of recurrent otorrhea, otitis media)
• A history of traumatic brain injury or exposure to loud noises due to bomb blasts, artillery fire, or torture utilizing loud noises
• Abnormal internal or external ear examinations
• A history of renal anomalies [9]
• A family history of hearing loss and/or deafness

If there are concerns of hearing issues in children <4 years of age, they should be referred for a formal audiologic evaluation. For further information on pediatric hearing screening standards, refer to the Clinical Report—Hearing Assessment in Infants and Children: Recommendations Beyond Neonatal Screening from the American Academy of Pediatrics.

Epidemiology and Impact

Hearing loss and impairment are common yet often underreported health issues affecting approximately 15% of adults worldwide and 21% of adults in the United States [10–12]. Hearing loss can impact employment, work and school performance, language acquisition in infants and young children, and quality of life [13, 14]. Chronic hearing loss is associated with speech delays. Early diagnosis, prevention, and management can reduce morbidity associated with hearing loss

Limited data are available on hearing loss and conditions that may lead to hearing loss in refugee populations. Data from the World Health Organization (WHO) and scientific literature suggest that the age-standardized prevalence of hearing loss in adults varies by country [11, 12]. Data are similarly limited among refugee children. Among Syrian refugee children residing in Turkey (n=3000, aged 69-84 months), refugee children had a significantly higher rate of sensorineural hearing loss and chronic otitis media than Turkish-born children [15].

The etiology of hearing loss in refugees may be multifactorial. Cholesteatoma and chronic suppurative otitis media may be contributors. Torture has also frequently been associated with diminished hearing when loud music or other loud sounds are utilized as a form of torture [16].

Health Coverage

Medicaid or Refugee Medical Assistance plans will likely cover a complete hearing evaluation. However, coverage for hearing assistive devices may not be covered. Organizations such as the Starkey Hear Now Foundation may provide reduced-cost devices.

Head, Eyes, Ears, Nose, and Throat (HEENT)

Examine eyes for strabismus, cataracts, leukocoria, and Bitot spots [17]. Examine for thyromegaly, cervical lymphadenopathy, angular cheilitis, and glossitis.

Skin Examination

A careful skin inspection may help diagnose localized and systemic diseases, including micronutrient deficiencies and infectious diseases. Skin examination may reveal traditional healing techniques, such as burn sticks, cupping, and coining, which may indicate current or past illness. Tattoos, scarification, and piercings may have been performed using non-sterilized equipment.

Genitourinary

An external genital examination is an important part of the complete physical examination for infants, children, and adults of both sexes and may uncover diagnoses including cryptorchidism, hypospadias, testicular masses, precocious puberty, phimosis, skin findings from STIs, and female genital mutilation/cutting. However, the initial visit may not be an appropriate time or setting to perform an external genital examination (unless there are immediate clinical concerns warranting evaluation). The patient or caregiver may choose to defer the genital examination to a future visit, with assurance by the provider that a timely follow-up visit will occur and counseling regarding the reasons for this exam. The deferred examination should be documented and made available to the provider caring for the patient in their medical home.

Oral Examination

A careful oral examination should be performed for all new arrivals. Many refugees have not had access to regular dental services, including preventive care, so preventive dental care should be established soon after arrival in the US. Some refugees may have practiced traditional oral hygiene methods, such as using a teeth-cleaning stick (e.g., miswak, muswaki, siwak) [18] or locally prepared toothpaste. Basic dental hygiene, including daily brushing and flossing, should be introduced or revisited.

Pediatric Oral Health Considerations

• All children should be referred for dental care starting at 1 year old [19, 20].
• Fluoride toothpaste should be used from the first tooth eruption [19]. Young children should only use a smear of toothpaste, and children 2 years and over should use a pea-sized amount.
• Fluoride varnish should be applied during the domestic screening or initial well-child visit. Two to four fluoride varnish applications per year decrease cavity rates by 30-60% [21]. Consult state guidelines regarding age-based eligibility for Medicaid reimbursement.
• Families should be counseled to use tap water for its fluoride content. In areas without water fluoridation, prescribe fluoride supplements. Refer to the Guidelines on Fluoride Therapy [PDF – 4 pages] from the American Academy of Pediatric Dentistry.
• Some children will present with fluorosis, having been chronically exposed to excess naturally occurring fluoride found in water sources during tooth development. Moderate to severe fluorosis should be evaluated by a dentist for further management [22].

Early Childhood Developmental Screening

Developmental delays are common worldwide. Of note, one in 6 children in the general US population has developmental delays, and less than 25% of these children are linked to early intervention services by the age of 3 years. There are limited data on developmental delays in refugee populations [23]. However, early identification has implications for school enrollment (e.g., timely evaluation for Special Education), initiation of therapeutic services (e.g., early intervention services), and further diagnostic evaluation.

Age-appropriate developmental screening may be initiated during the domestic medical screening or at a subsequent well-child visit, provided culturally, and linguistically appropriate care is not delayed. The American Academy of Pediatrics and CDC recommend that developmental surveillance be incorporated at every well-child preventive care visit and that all children be periodically screened using a standardized tool. A list of early childhood developmental screening tools (many of which have been translated into multiple languages) is available from the Administration for Children and Families, in addition to the “Learn the Signs, Act Early” checklist from CDC. Because most tools have not yet been evaluated for a wide range of language and cultural groups, clinician judgment is necessary when interpreting screening results.