Download "Coming of Age": A Case of Dysuria

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you need to say something about PCOS
have you timed your reading of this manuscript? 31 pages is quite long. You
can keep the audience’s attention for a maximum of 40 minutes after which you
will start to lose them.
One alternative to shorten the presentation would be to describe what you did, and
then to critique it based on whatever guidelines you have come across. That way
you don't have to go into the “textbook details” but the running commentary on
your management vis-à-vis the guidelines will still be informative to the audience.
Alex where did you encounter the patient? Adol clinic or Derma? I think you need to start
with the description of your initial encounter with the patient. Upon reading your
manuscript the patient has PCOS which caused all the metabolic and cardiovascular
manifestation. So with this perpective your discussion should focus on PCOS in
adolescent rather than hypertension and obesity. It is just like discussing metabolic
syndrome in adults. You can keep your objectives but your discussion should be focused
on PCOS. I am attaching a CPG on PCOS that you may want to read so you would know
how to do the flow of the discussion. This is what I would approach if I am the one
presenting:
- Presenting the case with multiple medical problems – adolescent with High BP,
obese
- Look at the differentials of such – primary cardiovascular? Metabolic? Renal kasi
had GN in the history
- Zero in to PCOS
- Discuss prevalence in adolescent population – worldwide? Philippines
- How to diagnose – what was done to your patient and compare it to what CPG is
recommending, then what was missed? Or what should have not been
- How to manage – what was the management of your patient and compare it to
what CPG is recommending. Include both medical and biopsychosocial
- What is the continuity of care for this type of cases – health maintenance, issues
that would challenge adolescent life (identity, sexuality and education), what were
your initial work along this line (short term) and what will you be pursuing for the
next visit (long-term)
- End it with your insights on handling the case – ‘aha” moments
“The Power of Change: A Case of Hypertension and Obesity in an Adolescent”
(A Clinical Case Presentation)
INTRODUCTION
The Power to Change…(still under construction)
Good Morning Everyone. I am Alejandro E. Legarda, a first year resident of the
Department of Family and Community Medicine, and I am here to present my clinical
case presentation entitled, The Power of Change: A Case of Hypertension and Obesity in
an Adolescent
OBJECTIVES
My objectives in presenting this case are:
To present an adolescent with hypertension and obesity
To discuss the differential diagnosis for high BP in the young.
To discuss the approach to management of adolescent with hypertension and obesity
To present short-term and long-term wellness plan appropriate for the patient’s condition.
RATIONALE
Hypertension is usually found in the adult population and there have been so many
studies devoted to the mentioned age group however there has been an increasing
incidence in the adolescent population as well. Few studies and literature have been
written in the past thus it has been a challenge for primary care physicians but until
recently there has been an increasing studies on how to screen, diagnose and manage.
Aside from Hypertension, Overweight/ Obesity is also an increasing issue. Furthermore I
would like show how important behavior change and lifestyle modifications are for our
patient which always a great concern for us Family Physicians.
Let me introduce you to my patient.
PATIIENT PROFILE
E.J. is 13 year old, female, single Roman Catholic an upcoming 3rd high school student
who lives in Imus, Cavite.
CHIEF COMPLAINT
Elevated Blood Pressure
HISTORY OF PRESENT ILLNESS
5 years prior to consult, patient was 8 years old and apparently well until she had to
seek consult on her fever intermittent and her previous reccurring multiple erythematous
vesicle lesions.
She was said to have diagnosed to have Post Streptococcal
Glomerulonephritis and was admitted for 1 week. She was said to have a high
BP(unrecalled). Nifedipine was given to control her hypertension. Upon discharged, no
consult was done nor further follow-up.
Interim: Patient was apparently well, No consults were done
Until 3 years prior to consult, Patient began to gain weight. Eating became a family
past time as she began to enjoy eating with her Father and her brothers hence Her food
intake severely increased. She also began to eat lots of fatty and salty foods not only at
home but outside as well especially in the fast food restaurants. At that time, patient’s
blood pressure was yearly taken during the annual PE (where) and was said to be elevated.
She and her parents would ignore and didn’t seek consult for the elevated blood pressure.
Interim: Patients gained more weight progressively and spends lots of time at home
just watching TV and
Then 2 weeks prior to consult, patient sought consult at the UP-PGH Derma
department for her vesicular lesions. She also had an incidental finding of a 160/90 blood
pressure.
The Assessment:a)Acne Vulgaris, etiology probably to PCOS
b)Hypertension secondary to
1. Obesity related/PCOS
2. R/o Adrenal/Cushing Syndrome
c) Insect bite hypersensitivity reaction
Patient was given Amlodipine 5mg/tab OD, Benzoyl Preoxide gel OD, Tretinoin
cream on face, Cloxacilin 500mg/tab for 7 days, Mupirocin Betamethasone ointment ITD,
Sunscreen and mild soap. Patient was referred to Pedia Adolescent hence consult.
REVIEW OF SYSTEMS
(+) polyuria, (+) polydipsia, (-) rashes, (-) epistaxis, (-) gum bleeding, (-) neck pain, (-)
dysphagia, (-) chest pain, (-) orthopnea, (-) dyspnea on exertion, (-) orthopnea, (-)edema,
(-) neck pain, (-) abdominal pain, (-) constipation, (-) diarrhea, (-) urgency, (-) frequency,
(-) dysuria, (-) nocturia, (-) hematuria, (-) heat intolerance, (-) jaundice
PAST MEDICAL HISTORY
(-) Asthma (-) Allergy (-) Pulmonary Tuberculosis , (-) bronchial asthma
No Accident and injury
Hospitalization for (+) PSGN (2007) and Dengue Fever (2009)
There was no previous surgery, Medication: Co-amoxiclav for her recurrent skin
infections
OB/GYNE HISTORY
Menarche: January 2011
Irregular flow occurring only 3x since her menarche
No dysmenorrhea
No sexual contact
BIRTH AND MATERNAL HISTORY
Patient was born full-term via spontaneous vaginal delivery at a local hospital delivered
by an obstetrician with no known feto-maternal complications.
NUTRITIONAL HISTORY
Patient was breastfed for 3 months then shifted to bottle feeding of Bona milk every 3 to
4 hours starting at 4 months old up to 12 months old. Complementary feeding was
started at 6 months old.
Patient would skip breakfast but have 2 snacks before a heavy lunch. She would have 2
heavy merienda like 2 hamburgers/hotdogs or cups of icecream .Most of the food she eat
are either fried or salty with plenty of desserts.
IMMUNIZATION HISTORY
The patient has complete immunization obtained from a local health center with BCG x 1,
hepatitis B vaccine x 3, DPT x 3, OPV x 3, and measles x 1.
FAMILY HISTORY
The patient is the fourth child with a father who works as a employee at a company and
her mother who is a housewife. Her paternal grandmother has a hypertension and diabetes
mellitus as do her paternal aunts and uncles. Her father and 2 brothers and 1 sister are
all overweight. No pulmonary tuberculosis, bronchial asthma, or other heredofamilial
diseases.
PERSONAL SOCIAL HISTORY: HEADSSS
HOME: Patient lives at home with her parents, 2 brothers and 2 sisters at their own in
Imus Patient has a good relationship with her parents. Parents spend a good time with
them as they always eat and she has a good relationship with her siblings. They usually
eat together and watch TV. No problem or any conflict in the family.
EDUCATION: Patiently is an incoming 3rd year high school student with above average
grades, She has a barkada consist of 6 close friends. No problem with her teachers but
sometimes gets teased by her classmates due to her weight. She claimed that she wa never
had been bullied nor had enemies. She enjoy going to school to be with her friends and
eat. Her favorite subject is science and math.
ACTIVITIES: Eating is her favourite past time.she would eat merienda before lunch and
2 snacks before dinner. She would eat hotdogs and burgers regularly. She seldom go out
of her home and spends most her time in the computer and TV especially in facebook.
She has no outdoor activites except for a very occasional badminton session.
DRUGS: Denies cigarette and alcohol use. The patient denies that she or his friends
used any illicit drugs nor does she smoke.
SEXUAL: Patient claims to be not conscious at her body and haven’t tried to change
her appearance. Patient had no relationship with the opposite sex but she does however
have crushes at school.
SUICIDALITY:
ideation.
The patient does not have any episodes of depression or suicidal
SAFETY: Patient lives in a peaceful community with minimum crimes incidents . There
are no weapons at home. Patient uses the public transportation to travel. She is not a
member of any gang or sorority
PHYSICAL EXAMINATION
General Survey: Awake, alert, coherent, in pain, not in cardiorespiratory distress (-)
muscle wasting, (-) moon facies, (-) proximal muscle weakness (-) buffalo hump
Vital Signs:Blood Pressure: 150/90>99th percentile Heart Rate: 75 beats/minute,
Respiratory Rate: 18 breaths/minute, Temperature: 36.8 C
Anthropometrics: Height: 157 cm, Weight: 96.5 kg, Body Mass Index: 40.7 kg/m2 (Z
score: 2.58)
Head and Neck: Anicteric sclerae, pink conjunctivae, pupils 2-3mm OU reactive to light,
(+) Short leg length (+) Acanthosisnigricans, (-) masses, (-) cervical lymphadenopathy,(-)
anterior neck mass(-) tonsillopharyngealcongestion, (-) neck veinengorgement, (-)ear
discharge
Chest and Lungs: Equal chest expansion, no deformities, no lesions, clear breath
sounds,
(-) crackles/rales/wheezes
Heart: Adynamic precordium, distinct heart sounds, apex beat at 5th intercostal space left
midclavicular line, regular rate and rhythm, no murmurs
Abdomen: Flabby, (+) Striae no deformities, no lesions, soft, normoactive bowel sounds,
(-)masses or tenderness, liver span 8 cm right midclavicular line, intact Traube’s space, no
costovertebral angle tenderness
(+) Triceps skin test >95th percentile Pink nailbeds, full and equal pulses, no
cyanosis/clubbing/ edema, No crepitations, no limitation of passive and active motion on
both upper extremities
(-) shooting pain on straight leg raise of both lower extremities, (-) limitation of motion
due to pain
No crepitations on hips, knees or ankles, No joint swelling or deformities, (-) Pain on
active leg raise of both lower extremities
CN I –intact gross olfaction
CN II –pupils 2-3 mm OU briskly reactive to light
CN III,IV,VI –full range of extraocular muscle movement
CN V –brisk corneals, good masseter tone,
CN VII –no facial asymmetry, no altered taste
CN VIII –intact gross hearing, no lateralization on Weber Test
CN IX –no altered taste, can swallow
CN X –can swallow
CN XI –good symmetrical shrug
CN XII –can protrude tongue, no deviation
Sensory
Pain: Intact on all dermatomes, Light Touch: Intact on all dermatomes, Vibratory: Intact
on all dermatomes
Motor
Normal Gait, Good muscle tone, no atrophy, no limb size discrepancy
Full motor strength on both upper extremities
Tanner Stage 3
External genitalia with Dark, coarse, curly hair spreads over mons pubis Elevation of
Breast contour; areolae enlarge
SALIENT FEATURES OF THE CASE
>A 13-year-old female
>Chief complaint of elevated blood pressure
> History of hypertension ,DM and Obesity
> Previous history of renal disease (+) poluyuria, (+) polyphaga.
>Anthropometrics: Height: 157 cm, Weight: 96.5 kg, Body Mass Index: 40.7 kg/m2
(Z score: 2.58),
>(+) Short neck length (+) Acanthosis nigricans nape are, Flabby abdomen with (+)
Striae, (+) Triceps skin test >95th percentile.
INITIAL MPRESSION
Hypertension stage 2 etiology to be determined
Acne Vulgaris, probably secondary to PCOS
DM suspect
Obese 2
Amenorrhea secondary to PCOS
Management:
Diagnostics:
Complete blood count
Plasma sodium, potassium and calcium,
BUN, Crea
Fasting plasma glucose
Lipid profile
Urinalysis
Whole AB ultrasound
Chest Xray, ECG
TSH, FT4
Therapeutics:
Continue medication….
Cloxacillin 500 for 7 days
Tretnoin Cream in face
Mupirocine Betamethasone ointment TID
Sun screen and mild soap daily
Start Amlodipine 5mg once a day
Refer back to Derma
Refer to Ob/Gyne
APPROACH TO HYPERTENSION
According to Management of high blood pressure in children and adolescents:
recommendations of the European Society of Hypertension the previous guideline did not
contain any section of devoted to hypertension in childhood and adolescence in 2003 but
due to the growing evidence it has gained ground in cardiovascular medicine, It has been
possible to look at the presence of subclinical organ damage through measures and
markers much more sensitive than those available years ago and it has lastly been
possible to relate adult hypertension and organ damage to several abnormalities of the
younger age, for example overweight and tachycardia, thus adding to the rationale of
extending prevention strategies to the pre-adult individuals which we will . The guideline
have roots of hypertension in adulthood extend back to childhood. The study mentioned
childhood BP has been shown to track into adulthood thus their children with elevated BP
are more likely to become hypertensive adults hence it is important to approach and
manage our patient. Unlike adults, the diagnostic criteria for elevated BP in children are
based on the concept that BP in children increases with age and body size, making it
impossible to utilize a single BP level to define hypertension.
In taking the blood pressure in children and adolescent the guideline has specific
recommendations…. The recommended method is auscultatory, Use K1 for systolic BP
and K5 for diastolic B. (xxx better remind us about what k1 and k5 are) If the
oscillometric method is used, the monitor needs to be validated and if hypertension is
detected by the oscillometric method, (xxx describe briefly the oscillometric method) it
needs to be confirmed using the auscultatory method. The Use the appropriate cuff size
according to arm width (40% of the arm circumference) and length (4_8 cm, 6_12 cm,
9_18 cm, 10_24 cm, to cover 80–100% of the individual’s arm circumference). The same
taskforce has specific blood pressure values for the specific age
Table: Blood pressure for girls by age and height percentiles (xxx is this for
filipinos?)
Table 4 Systolic and diastolic ambulatory blood pressure (systolic/diastolic) values for
clinical use (xxx is this for Filipinos? Will it matter?)
According to Task Force for Blood Pressure in Children , the Fourth Report on the
Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and
Adolescents, The normal BP in children is defined as SBP and DBP less than 90th
percentile for age, sex and height, whereas hypertension is defined as SBP and/or DBP
persistently 95th percentile or more, measured on at least three separate occasions with
the auscultatory method. In diagnosing BP in the adolescent it is important to consider
what they call White-coat (or isolated office) and masked (or isolated ambulatory)
hypertensions which was reported prevalence of white-coat hypertension in various
studies on children and adolescents has ranged from 1 to 44% hence the importance of
taking the BP multiple times and use of home blood pressure Children with average
SBP or DBP 90th percentile or more but less than 95th percentile are classified as having
high-normal BP. Adolescents with BP 120/80mmHg or more even if less than 90th
percentile are also considered as having high-normal BP.
Stage 1 hypertension is defined as BPs from the 95th percentile to the 99th percentile
plus 5mmHg.While Stage 2 hypertension denotes any BP above the 99th percentile plus
5mmHg
Our patient had a regular blood pressure of 150/90 which is above of the 99th
percentile for her age. She is classified to have hypertension stage 2. Upon diagnosing our
patient to have hypertension, the next phase in our algorhytm we must look at the
etiology and organ damage.
The guidelines mentioned several pertinent data to consider and look for based on.
FAMILY HISTORY
Hypertension
Cardiovascular and cerebrovascular disease
Diabetes mellitus
Dyslipidemia
Obesity
Hereditary renal disease (Policystic kidney disease)
Hereditary endocrine disease (pheochromocytoma,
glucocorticoid-remediable aldosteronism, multiple
endocrine neoplasia type 2, von Hippel–Lindau)
Syndromes associated with hypertension (neurofibromatosis)
CLINICAL HISTORY
Perinatal history
Birth weight, gestational age, oligohydramnios,
anoxia, umbilical artery catheterization
Previous history
Hypertension
Urinary tract infection, renal or urological disease
Cardiac, endocrine (including diabetes) or neurological
disease
Growth retardation
Symptoms suggestive of secondary hypertension
Dysuria, thirst/polyuria, nocturia, hematuria
Edema, weight loss, failure to thrive
Palpitations, sweating, fever, pallor, flushing
Cold extremities, intermittent claudication
Virilization, primary amenorrhea and male pseudohermaphroditism
Symptoms suggestive of target organ damage
Headache, epistaxis, vertigo, visual impairment
Facial palsy, fits, strokes
Dyspnea
Sleep history
Snoring, apnea, daytime somnolence
Risk factor history
Physical exercise, dietary habits
Smoking, alcohol
Drug intake
Anti-hypertensives
Steroids, cyclosporine, tacrolimus or other
Tricyclic anti-depressants, atypical antipsycotics,
decongestants
Oral contraceptives, illegal drugs
Pregnancy
In our patient, she had family history of hypertension ,DM and Obesity.
Unremarkable perinatal history, previous history of renal disease, (+) poluyuria, (+)
polyphaga. No pertinent suggestive target organ damage, Unremarkable sleep history,
Risk factors such as physical exercise, poor dietary habits, smoking and alcohol. No drug
intake
The guideline also mention the pertinent PE exam to look for..
Another guideline by Vikas Kohli of Hypertension in Children and Adolescents:
Diagnosis, Evaluation, and Treatment had a prepared a table.
Indicators on Physical Exam of Etiology of Hypertension in a Child
Thyromegaly
Hyperthyroidism
Acne, hirsutism, striae
Cafe´-au-lait spots
Adenoma sebaceum
Malar rash
Acanthrosis nigricans
Chest widely spaced nipples
Heart murmur
Friction rub
Abdomen Mass
Epigastric/flank bruit
Palpable kidneys
Genitalia Ambiguous/virilization
Extremities Joint swelling
Muscle weakness
Cushing syndrome, anabolic steroid abuse
Neurofibromatosis
Tuberous sclerosis
Systemic lupus erythematosus
Type 2 diabetes
Turner syndrome
Coarctation of the aorta
Systemic
lupus
erythematosus
(pericarditis),
Wilms
tumor,
neuroblastoma,
pheochromocytoma
Renal artery stenosis
Polycystic kidney disease, hydronephrosis,
multicysticdysplastic kidney
Adrenal hyperplasia
Systemic lupus erythematosus, collagen
vascular ds
Hyperaldosteronism, Liddle syndrome
Our patient presented a significant Anthropometrics: Height: 157 cm, Weight: 96.5 kg,
Body Mass Index: 40.7 kg/m2 (Z score: 2.58), (+) Short neck length (+) Acanthosis
nigricans nape are, Flabby abdomen with (+) Striae, (+) Triceps skin test >95th percentile.
Others were none pertinent
Aside from evaluation for etiology, it is important to determine if the patient has
organ damage. The guidelines mentions target organ damage of the heart, blood vessels,
kidney, brain and fundoscopy for evaluation. For the organ damage of the heart it is said
that Left Ventricular Hyperthrophy (LVH) remains to date the most thoroughly
documented form of end-organ damage caused by hypertension in children and
adolescents. LVH is known to be an independent risk factor for cardiovascular events in
adults, although no such evidence is available from prospective studies in children, it
appears prudent to identify LVH in children at any early time, as this may facilitate
primary prevention of cardiovascular disease. For our patient ECG was done to evaluate
the heart end organ damage.
In the blood vessels, the first morphological changes of the arterial wall, thickening
of the intima-media complex, can be identified by high-resolution ultrasound.
Investigators have used intima-media thickening (IMT) to study children at high risk for
development of atherosclerosis later in life. Children with familial hypercholesterolemia
have higher IMT than age-matched healthy children. Overweight and obesity are
associated with increased IMT in children with or without essential hypertension. Our
patient’s Lipid profile was done to find if there is a risk for atherosclerosis
In the Kidney, the diagnosis of hypertension-related renal damage is based on a reduced
renal function or an elevated UAE. Renal insufficiency is classified according to the
glomerular filtration rate (GFR) calculated by the Schwartz formula, which is based on
age, body height and serum creatinine, in which GFR. In adults, an increase in UAE is a
marker of hypertensioninduced renal damage. Proteinuria is a marker of glomerular
damage in primary and secondary glomerulopathies. It so it is an indication for
BP-lowering interventions. Even small amounts of UAE are correlated with progression
of nephropathy and to a higher cardiovascular risk. An increased rate of urinary albumin
or protein excretion indicates a deranged glomerular filtration barrier. Microalbuminuria
(20–300mg/g creatinine, 2–30 mg/mmol creatinine, 30–300 mg/day, 20–200mg/min) has
been shown to predict the development of diabetic nephropathy, whereas the presence of
overt proteinuria (>300 mg/day) indicates the existence of established renal parenchymal
damage. Urinalysis, BUN, Creatinine and Renal ultrasound were done.
Cerebral seizures, stroke, visual impairment and retinal vascular changes are
complications associated with severe hypertension. In our patient, the Neuro exam and
clinical history was unremarkable. Fundoscopy was also done in because in a study of 97
children and adolescents with essential hypertension, found that 51% displayed retinal
abnormalities, as detected from direct ophthalmoscopy. Recently another study howed
that even in young children aged 6–8 years. Fundoscopy was unremarkable for our
patient
Obesity and Hypertension
Aside from being hypertensive, our patient is also obese. In my upcoming discussions,
there is a big correlation between Hypertension and Obesity thus it is important to discuss
both of them. Obesity is a broad topic and limit the correlation of the 2.
Using the 2000 CDC growth charts, at risk of overweight for ages 2 to 20
years overweight is defined as a Body Mass Index (BMI)-for-age between the 85th
and the 95th percentiles. Overweight in children is defined as a BMI-for-age at or
above the 95th percentile on the charts. BMI is weight in kilograms divided by height
in meters squared (kg/m2). While BMI is commonly used to evaluate overweight and
obesity in adults, only recently has it been recommended to screen children and
adolescents. An advantage of using BMI-for-age is that it can be used continuously from
age 2 years through adulthood. BMI is used differently to define overweight in children
and adolescents than it is in adults. In children and adolescents, BMI changes with age
and gender. As children age, BMI increases (Hammer et al., 1991; Pietrobelli et al., 1998).
Therefore, BMI is plotted on a chart of the appropriate gender, relative to the child.s age.
BMI is evaluated using percentile cutoff points to compare values for a given child with
other children of the same age and gender from a national reference sample. At the 95th
percentile
In terms health consequences related to overweight can begin in childhood or adolescence;
overweight children and adolescents are at increased risk for various chronic diseases in
later life. In a study conducted by Freedman and colleagues (1999), nearly 60 percent of
overweight children had at least one cardiovascular risk factor compared to 10 percent of
those with a BMI-for-age < 85th percentile; 25 percent of overweight children had two or
more risk factors. The psychosocial consequences of overweight are significant.
Overweight in children has been linked to social discrimination, a negative self-image in
adolescence that often persists into adulthood (Stunkard et al., 1967), parental neglect
(Lissau and Sorenson, 1994), and behavioral and learning problems (Mellbin and Vuille,
1989).
The CDC mentions the Common Medical Consequences of Overweight (Dietz, 1998)
Hyperlipidemia, glucose intolerance, hepatic steatosis, cholelithiasis, Sleep apnea,
Obesity hypoventilation syndrome and of course hypertension, A variety of orthopedic
complications
As most cases of high-normal BP and hypertension in childhood are now known not to be
cases of secondary hypertension to be detected and specifically treated, efforts should be
made to understand conditions associated in order to return BP within the normal range or
toavoid high-normal BP in youth developing into full hypertension in adulthood.
Overweight is probably the most important of the conditions associated with elevated BP
in childhood and accounts for more than half the risk for developing hypertension. Fatter
children are known to be more likely to remain fat, and adiposity is the most powerful
risk factor for higher BP. In addition to body mass index, waist circumference (abdominal
obesity) has been shown to play a role. Birth size and postnatal growth have also been
recently implicated in the development of high BP and adult cardiovascular disease .
Finally, dietary habits early in life, and particularly high salt intake, have been implicated
as factors favoring higher BP values
Aside from Obesity, there are many reasons and etiology for Hypertension In the
screening and evaluating for the etiology, here are the Laboratory investigations
recommended.
Laboratory investigations
Routine tests that have to be performed in all
hypertensive children
Full blood count
Plasma sodium, potassium and calcium, urea, creatinine
Fasting plasma glucose
Serum lipids (cholesterol, LDL cholesterol, HDL cholesterol)
Fasting serum triglycerides
Urinalysis plus quantitative measurement of microalbuminuria
and proteinuria
Renal ultrasound
Chest Xray, ECG and
Some hypertensives can have sustained hypertension in which it can be classified as
secondary when a specific cause can be found, then it can be corrected with specific
intervention. There should be work-up should be done if hypertension
Box 9. Diagnosis of secondary causes of hypertension
The study also mentioned that Genetic analysis merits a specific comment even if it has
not yet been demonstrated to have a clear role to play in the routine assessment of
children with hypertension. All presently known monogenic causes of hypertension are
characterized by abnormal sodium transport in the kidney, volume Liddle’s syndrome,
glucocorticoid-remediable aldosteronism, apparent mineralocorticoid excess, Gordon’s
syndrome, mineralocorticoid receptor hypersensitivity syndrome and hypertensive forms
of congenital adrenal hyperplasia
MANAGEMENT
Diagnostic
My plan for patient, the diagnostic work-up were based on the recommended laboratory
work-up and based from my clinical history and physical exam
(xxx what were the
results of the lab tests?)
Laboratory Plan…
Complete blood count
Plasma sodium, potassium and calcium,
BUN, Crea
Fasting plasma glucose
Lipid Profile
Urinalysis
Whole AB ultrasound
Chest Xray, ECG
TSH, FT4
Non pharmacologic Strategies:
Table: Life-style recommendations to reduce high
BP values
GOALS
BMI<85th percentile: Maintain BMI to prevent
overweight
BMI 85–95th percentile: Weight maintenance
(younger children) or gradual weight loss in adolescents
to reduce BMI to <85th percentile
BMI>95th percentile: Gradual weight loss (1–2 kg/
month) to achieve value <85th percentile
GENERAL RECOMMENDATIONS
Moderate to vigorous physical aerobic activity
40 min, 3–5 days/week and avoid more than 2 h daily
of sedentary activities
Avoid intake of excess sugar, excess soft drinks,
saturated fat and salt and recommend fruits, vegetables
and grain products
Implement the behavioural changes (physical
activity and diet) tailored to individual and family
characteristics
Involve the parents/family as partners in the behavioural
change process
Provide educational support and materials
Establish realistic goals
Develop a health-promoting reward system
Competitive sports participation should be limited
only in the presence of uncontrolled stage 2 hypertension
A. Counseling and Implement Behavior Change (xxx I think the more appropriate
model here is motivational interviewing rather than CEA.)
Patient was not so much concerned on her weight. She doesn’t know the risk and the
health issues regarding hypertension. She was not aware why she was at PGH for
consult and really wanted to go home. Catarrhsis, Education and Action(CEA) was done
to the patient and I tried to elicit insight and counsel her. Patient was on pre
-contemplation stage at that time and I was hoping to make her aware and give her insight
to bring her to the stage where she can contemplate. When I asked about her hypertension,
she said she knew had it for years but no one told her about the dangers. She was not
aware her that being overweight have some health risk as well.
The parents are also unaware of the risk of hypertension and the eating habits and
lifestyle that increase her obesity. They couldn’t believe that this would happen at her age.
I applied CEA to the parents on the risk of hypertension on the family as the lifestyle
should be changed not only from the patient but also the family. I mentioned the whole
family is at risk since everyone except the wife are obese. At 1st it was hard for the father
to get to change thei habits but upon education, he realized that it is important for his
family to be all healthy. I talked to them about the food at home should have more
vegetable and less fried and salty food plus less snacks. One issue of mine is how the
patient’s siblings react to the change of eating habits. The parents told me that they will
talk to the other children about their eating habits.
B. I advise the patient to have Regular BP monitoring at home
C. Physical Activity: I mentioned to the patient to start to lessen sedentary activities and
start to walk more around the subdivision and play with pets. A Exercise program was not
done yet as I want for the patient to reach the preparation/action
D. Eating Habits: Change of eating was advised. The Patient love to skip breakfast and
eat lots of snacks. I told the patient to less
E. A Diet Program: I was planning to put the patient into a low Energy Diet of 2000kcal
C350 P75 F 35 from a 3022kcal diet on the next follow up
Pharmacologic/Therapeutic strategies
Aside from the non pharamacologic strategies, I had a dilemma on how will I use
therapeutic strategies for my patient
In the European Society of Hypertension, it said that until recently, no antihypertensive
drug was licensed for use in children and adolescents. The US effort (Best
Pharmaceuticals for Children Act, Pediatric Research Equity Act) has stimulated
European authorities to realize that children also have the right to be treated with drugs
that have been studied in and authorized for children
EVIDENCE FOR THERAPEUTIC
MANAGEMENT
Reduce mortality and sequelea in life-threatening
conditions
Reduce left ventricular hypertrophy
Reduce urinary albumin excretion
Reduce rate of progression to end-stage renal disease
The said guideline mentions when to use the therapeutic management of hypertension. In
our patient. I started to treat the patient based on the >99 percentile BMI
Therapeutic management of hypertension
Indications for Antihypertensive Drug Therapy in Children
Symptomatic hypertension
Secondary hypertension
Hypertensive target-organ damage
Diabetes (types 1 and 2)
Persistent hypertension despite nonpharmacologic measures
>99 percentile BMI
Treating Hypertension with drugs are most indicated in end organ damage of the Heart
and Kidney/Renal
In the Heart, Regression of LVH was reported in three children with essential
hypertension receiving enalapril, in 19 children with primary and secondary hypertension
treated with ramipril for 6 months, and in 65 children with chronic kidney disease (CKD)
stage 2–4 receiving ramipril for up to 2 years. In renal, there were evidence has
prompted a large pediatric intervention study; the Effect of Strict Blood Pressure Control
and ACE Inhibition on Progression of Chronic Renal Failure in Pediatric Patients
(ESCAPE) trial, which has shown efficient BP and proteinuria reduction for the ACE
inhibitor ramipril in 352 children with CKD . Still, a gradual rebound of proteinuria
despite persistently good BP control was observed on extended treatment, questioning the
long-term nephroprotective advantage of ACE inhibition in children
Monotherapy
It is reasonable that in children, treatment should be started with a single drug
administered at a low dose in order to avoid rapid fall in BP. Like in adults, choice of
antihypertensive agents can include ACEIs, angiotensin receptor antagonists (ARBs),
calcium antagonists, beta-blockers and diuretics. A few placebo-controlled studies are
available, but almost no head-to-head study directly comparing the efficacy and safety of
different antihypertensive drugs in children or adolescents. A recent review mentioned
that of 27 pediatric studies reports comparable BP reductions with ACEIs
(10.7/8.1mmHg), ARBs (10.5/6.9 mmHg) and calcium antagonists (9.3/7.2mmHg).
For other antihypertensive agents, no pediatric studies have been conducted for diuretics,
except for a very small old study on chlorthalidone ,direct vasodilators, centrally acting
agents, or alpha-1 receptor antagonists, despite their having a long history of clinical use
in the pharmacological management of hypertension in children. Pediatric experience has
been reported with hydrochlorothiazide and chlorthalidone. Very high doses of thiazides
affect BP only marginally, but may be associated with increased incidence and severity of
side effects Recommended initial doses for selected antihypertensive agents for the
management of hypertension in children and adolescents.
Combination therapy
In children with renal disease, monotherapy is often not sufficient to achieve adequate BP
control. Therefore, early combination therapy is required. Early dose combination of
antihypertensive agents is more efficient and has a lower rate of adverse drug reaction
compared with that of high-dose monotherapy. Antihypertensive drugs of different classes
have complementary effects, resulting in a higher degree of BP reduction and a lower rate
of adverse drug reaction. The best choices of antihypertensive drug combinations are
those recommended in the ESH/ESC 2007 Guidelines . Fixed-dose combinations of two
drugs are rarely used in children, as individual based contributions are preferred, but
fixed combinations may have a place in treating adolescents to improve compliance
Clinical conditions for which specific antihypertensive drug classes are recommended or
contraindicated
For our patient, she was given a monotherapy of Amlodipine 5mg/tab once a day.
1st Follow-up April 2012
The Patient’s BP maintained from 150/90…no decrease of BP despite of Amlodipine 5mg
tablet. Patient started to jog for minutes around the house and roam around the area with
her dog. Patients lessen her calorie intake thanks to the parents change of food at home.
Parents started to prepare healthier food with less salt Parents have been very supportive.
Siblings stop to eat with the patient for snacks and joined the patient to jog. One of her
sibling who still was a bad influence to her was transferred to their grandmother’s house.
Results
Hgb 139, Hct 0.432, Plt 356 WBC 8.7
Urinalysis
Dark yellow, 1.030, RBC 0-2, WBC 3-4 EC 3+ Sugar (-) Albumin (-)
CXR: Normal Chest Findings
ThyriodFT4- 20.6, Free T3-5.5, TSH IRM 6.1
Glucose 6.4, BUN 3.30, Crea 45.5, Chole 5.0, Trigly 5.01 HDL 0.98, LDL 1.74, AST 38,
ALT 46, Albumin 42 Calcium 2.44, Na- 138, K 4.8
ECG- Sinus Rhythm, Within Normal Limits
Whole Ab Ultrasound: normal
With the current labs results, I was able to rule out many etiology of hypertension and
was able to determine that there was no organ damage.
Assessment
Hypertension stage II probably secondary to Obesity
Hyperlipidemia
Obese II
Diagnostic: NONE
PHARMACOLOGIC
Changed Amlodipine 5mg to Losartan 50mg/tab as there was no change for one
month. Decided to change to prevent target organ damage and decrease fluid retention
COUNSELING
I once again ask the patient how was she. How did she feel about the diet change If she
was fully aware and really understand her condition. She told to me “ok lang” “Ginagawa
ko rin dahil sa ng mama ko.” I asked her if she still remembers what I told her about the
health risk involved in hypertension and obesity. She said “Opo doc naala ko naman.” I
asked her about if her overweight made her conscious on her appearance, she said no on
the 1st consult but she did admit that it was especially when some of her classmates tease
her. She also wanted to be noticed by her crush.
Then I started to use a behavior change tool….I asked her what are her goals in life? She
said she wanted to work in as an engineer and have a family for own. She wanted to
travel and have lots of friends. I asked her what does eating to much and having a
sedentary lifestyle has to do with her dream. She said that being hypertensive and
overweight .. “magkakasakit ako palagi at baka palagi nasa hospital”. She then realized
that she would have to change.
(xxx good application of a motivational interviewing
tool. You may want to explain the model a bit so that people realize that you were doing
something structured and previously studied rather than just counseling “off the cuff”.
Look up the “decisional-balance technique” of prochaska and diclementi)
The patient is now willing to change hence I made a treatment plan to target obesity
hence decrease hypertension….
APPROACH ON TREATMENT TO OBESITY
According the AAP’s Recommendations for Treatment of Child and Adolescent
Overweight and Obesity
To date, no clinical trials have determined whether specific dietary modifications alone
(ie, without behavioral interventions and increased physical activity) are effective in
reducing childhood overweight and obesity rates. Comprehensive interventions that
include behavioral therapy along with changes in nutrition and physical activity are the
most closely studied and seem to be the most successful approaches to improving
long-term weight and health status. The said report reviews evidence about the treatment
of obesity that may have application in the primary care setting. It examines current
information about eating behaviors, physical activity behaviors, and sedentary behaviors
that may affect weight gain. Many of the studies are correlational, rather than
interventional. Also examined are studies of multidisciplinary, behavior-based, obesity
treatment programs and information about more-aggressive forms of treatment, such as
bariatric surgery. Reviews are followed by evidence-based treatment recommendations
In the study…showed a guideline on how to treat and manage adolescent obesity
Based on
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Nutritional Treatment
Macronutrient Therapy
Food Behaviors
Dietary Interventions
Physical Activity and Reducing Sedentary Activities
Behavioral Approaches
Other Interventions
Recommendations of Stages of Treatment
Nutritional Treatment
In the guideline, it reviewed nutritional treatment for our patient to decrease obesity
which included Fruits and Vegetables, Fruit Juice, Sweetened Beverage, Dairy Food
and Calcium and Dietary fiber Fruits and Vegetables
Eight studies evaluating the relationship between fruit and/or vegetable intake and body
weight were reviewed; All had mixed results but two studies found an inverse association
with adiposity
Macronutrient Therapy
In terms of macronutrient alternations the study says that Carbohydrates and Fat have
shown that significant weight loss can be achieved over 3 to 6 months with energy
restricted or ad libitum dietary prescriptions varying widely in macronutrient
composition.52–59 However, follow-up rates have been disappointing. Weight loss at
follow-up times of 12 to 18 months rarely exceeds 5% of baseline weight. Very-low-fat
diets have been shown to promote weight loss in several studies with adults. glycemic
index (GI) has been proposed to affect body weight regulation and risk for
obesity-associated complications.80 The GI is defined as the area under the glucose
dose-response curve after consumption of 50 g of available carbohydrate from a test food,
divided by the area under the curve after consumption of 50 g of available carbohydrate
from a control food (either white bread or glucose). Short-term feeding studies indicated
that hunger and cumulative food intake were greater 3 to 5 hours after a high-GI versus
low-GI meal, controlled for macronutrient and energy contents.81 However, not all
observational studies found a direct association between GI and weight gain.f a
very-low-energy diet The evidence for children and adolescents does not support any
specific macronutrient or dietary strategy at this time.
Protein The use of Protien diet or PSMF(Protein Sparing Modified Fast) is not a diet to be
used for long-term treatment of overweight. Rather, the purpose of using a PSMF diet is
to bring about rapid weight loss during the initial phase of treatment while minimizing the
negative effects.
FOOD BEHAVIORS
In terms of the FOOD BEHAVIORS of our patient Breakfast Skipping showed
Evidence supports observations that obese children are more likely to skip breakfast or to
eat smaller breakfasts than leaner children. The evidence seems to suggest that breakfast
skipping may be a risk factor for increased adiposity, particularly among older children or
adolescents.. Overweight children have also been reported to eat smaller breakfasts and
larger dinners, in comparison with non overweight children. It has been suggested that
eating. Hence patient was advised not to skip meals. One problem of our patient is
Snacking In a review of the literature, the American Dietetic Association13 found that
snacking frequency or snack food intake might not be associated with adiposity in
children furthermore, snacks tend to have higher energy density and fat content than
meals, and frequent snacking has been associated with high intakes of fat, sugar, and
energy. In Eating Out, evidence shows that consuming food away from home,
particularly at fast food establishments, may be associated with adiposity, especially
among adolescents. In addition, the frequency of eating fried foods away from home was
associated with greater intakes of total energy, sugar-sweetened beverages, and trans fats,
as well as less consumption of low-fat dairy foods and fruits and vegetable.
DIETARY INTERVENTIONS
Use of Balanced-Macronutrient/Low-Energy Dietsa reduced-energy diet (less energy than
required to maintain weight but not less than 1200 kcal [5040 kJ]/day) may be an
effective part of a multicomponent weight management program in children 6 to 12 years
of age.108–113 Use of a reduced-energy diet (not less than 1200 kcal [5040 kJ]/day) in
the acute treatment phase for adolescent overweight is generally effective for short-term
improvement in weight status; without continuing interventions,however, weight is
regained. Another intervention is the traffic light diet its goal was to provide the
most nutrition with the lowest energy intake. The Food Guide Pyramid was designed as a
general guide for diet and exercise and not as a weight loss tool. Although it may be used
as a component of a comprehensive childhood weight management program, the evidence
does not indicate that, by itself, the Food Guide Pyramid is an effective weight loss tool.
PHYSICAL ACTIVITY
It used these measurements to calculate physical activity levels, as follows: physical
activity level_ total energy expenditure/basal metabolic rate. Body fat and BMI were used
to estimate body composition. Body fat and BMI were found to be significantly inversely
correlated with physical activity levels. 131 Studies that use weight loss as the only
criterion with which to assess the value of increased physical activity may miss other
important benefits this confers. In a meta-analysis, P. McGovern, PhD (unpublished data,
2006) found that physical activity decreased fat mass but not BMI. Other studies
indicated that exercise also improved cardiovascular risk factors.
There is some debate in the literature regarding whether structured or unstructured
activities should be promoted as a means to increase physical activity. The position of the
American Academy of Pediatrics on physical fitness and activity in schools advocates
increases in both forms of activity.140 It states that the development of a physically
active lifestyle should be a goal for all children.
Amount of Physical Activity
the US Department of Agriculture has recommended that children and adolescents
participate in 60 minutes of moderate-intensity physical activity most days of the week,
preferably daily.
The American Academy of Pediatrics
Recommends that 30 minutes of this activity occur during the school day. Very obese
children may need to start with shorter periods of activity and gradually increase the time
spent being active. The CDC suggests that parents can help children meet this activity
goal by serving as role models, incorporating enjoyable physical activity into family life,
monitoring the time their children spend watching television, playing video games, and
using the computer, and intervening if too much time is spent in sedentary pursuits
Reducing Sedentary Activities
A complementary strategy for promoting physical activity among children and
adolescents is to decrease their inactivity by decreasing the time spent in sedentary
activities such as television viewing, leisure time use of the computer, and video game
playing. Staying active while watching television by stretching, performing calisthenics,
or using exercise equipment can also reduce the time spent in sedentary pursuits.
Television viewing may have a negative effect on both sides of the energy balance
equation.
Television Viewing and Obesity
Investigators have examined many aspects of diet and physical activity, but some of the
strongest evidence of a behavioral risk for overweight in children points to the impact of
television viewing. Epidemiologic and experimental evidence from the past decade
supports de-Television viewing is likely to influence overweight by replacing more
vigorous activities, as well as affecting diet.
Weight Recommendations According to Age and BMI
Percentile
The AAP guideline provided a systematic approach which to manage obesity patietns
The staged care process is divided into 4 stages, that is, (1) Prevention Plus (healthy
lifestyle changes), (2) structured weight management, (3) comprehensive
multidisciplinary intervention, and (4) tertiary care intervention.
Use of
NONPHARMACOLOGIC PLAN
A. Use Prevention Plus Stage 1 Intervention
Using the algorhythm, our patient is at the >99 percentile hence a Prevention
Plus Stage 1 interventions should be based on the family’s readiness to change
and include the following
1. Consumption of 5 servings of fruits and vegetables per day
2. Minimization or elimination of sugar-sweetened beverages
3. Limits of 2 hours of screen time per day, no television in the room where the
child sleeps, and no television viewing
4. 1 hour of physical activity per day
Physical activity can be increased gradually for sedentary children. Children may
be unable to achieve 1 hour of activity per day initially but can gradually
increase activity to reach 1 hour/day.
B. Stricter implementation on the Diet
Low Energy Diet of 2000kcal C350 P75 F 35 from a 3022kcal diet and a strict
decrease of salt content
C. Establishing an exercise plan
Jogging at their area for 40 min starting from moderate to vigorous
aerobic-based physical activity 3–5 days/week
2nd follow-up May 2012
S> Weight loss of 8 pounds for 2 months…
Lessen of BP from 150/90 to 130/80…
Management
Maintain medicines and continued diet and excerise plan.
No OB consult yet..patient was advised to Patient still has no menstration.
I also advised that their family, the parents and her brothers and sisters to seek consult
for the obesity
3rd Follow-up August 2012
Patient had weight loss of 2 pounds but having trouble to maintain diet and exercise
during the school year due to the availability of food and temptations. BP lowered to
120/80. Patient started to play badminton with family and still continue to jog if she has
free time.
Plan:
Advise to have a more structured diet and exercise to adapt to school by having a list of
food to eart in day. Patient was advised to have cooked food from home
PSYCHOSOCIAL ISSUES - ADOLESCENT ISSUES
1. Self-Image
2. Addiction to TV and Facebook
3. Role of parents in adolescence
WELLNESS PLAN FOR THE PATIENT
1. Lifestyle
Continue the Prevention Plus Plan for our patient with a advice increase
Physical and outdoor activities.
2. Screening
Patient was advised an annual screening to detect organ damage and risk of
other disease like Type II Diabetes
3.
Immunizations- Influenza vaccine yearly, Varicella vaccine.
GOING BACK TO THE PATIENT
The good news is that the patient’s BP is at 120-130/80-90. Patient hasn’t made
progressively weight loss though since the 3 months ago however her lifestyle changed
dramatically from the years where in she have been eating excessively. She started to
have self confidence and The family as well, changed their eating habits and have
increase
INSIGHTS ON THE CASE
THANK YOU VERY MUCH