Long Case Mx Issues Flashcards
Outline management of nutrition?
- Encourage balanced diet: healthy eating food pyramid
- Appropriate RDI
(Neonates 100kCal/Kg/day
Child 100 + 100kCal per yr old)
* Young child – 50% CHO, 40% fat and 10% protein
o full cream is ok from 12 months
* Older child – 60% CHO, 30% fat and 10% protein - Monitoring: check growth parameters & skin fold thickness at regular intervals
- Micronutrient screening:
* Minerals: Iron, Ca2+, Zn+, Cu+, K+, Na+
* Vitamins: fat soluble (ADEK), non-fat soluble (B group, C group) - Consider specialty conditions
- CP: maintain subcut fat to prevent pressure sores, avoid obesity
- Diabetes: low GI- 70% complex carbs
- CF: 120% RDI
- ESRF <70%
Outline management of obesity?
- Assess: plot weight, trajectory, height
- BMI >85th centile = overweight
- BMI > 95th centile = obese
- Not valid if <2yrs
- Compare to condition/overall context - Risk/contributing factors
- FHx, parental obesity
- Sedentary time, eating habits, activity, ?to soothe behavior
- Medications (steroids, valproate, olanzipine)
- Depression, low mood
- Financials, food available - Investigations:
Hx/Exam: BP/cardiac, acanthosis nigricans, ?OSA sympotoms
Ix: LFTs/abdo US, HbA1c, lipid studies, TFTs, ?sleep study, ?nutritional screen
? Underlying cause- syndromic, thyroid, cushing’s, GH deficiency - Consider complications
- Blood pressure, BIH, CV risk
- Metabolic syndrome
- OSA
- Bone & joint
- T2DM
- Mood/body images - Aim to establish permanent habits, improve phys/psych cx of obesity
- Req parental participation
Diet
- Self motivated, gradual change
- Limit meals out, sugary food/drinks, energy dense foods
- Family meals, breakfast, F&V - parents decide the portiions
- Reduce proportions
- Consider low GI, healthy options, parental education
- Dietitian
Exercise
- Focus on enjoyment, engagement
- Limit screen time
- Exercise 60mins/day
- Group classes, sports groups, walking school bus
- Follow up
- Regular follow up, check in to see
- Weight management clinic referral
- Surgical management- banding
Outline management of oral aversion?
Consider in:
- Children on TPN early in life
- Long term NG
- Resp adjuncts
- Oral disease
- GERD
- Eliminate causative factor
- Involve speech path, dietitian and play therapist- multimodal assessment
- Educate parents
- Long term risk of oral aversion in later childhood
- Important to maintain growth & nutrition with chronic disease
- Ensures dental health - Introduce variety of foods at early age
- Observe behaviors during feeding, how food is offered etc
- Make food time fun
- Occurs around family dinner time - Monitor growth, nutritional parameters, dental health
Outline management of behavioral escalation?
- Strategies to minimise outbursts
- triggers
-de-escalate - music, specific words/person/activity
Remaining calm
- Rewarding appropriate de-escalation - Safety of environment – ie. Minimise what may be used to harm self or others in room
- Working with current allied health team – OT/psych etc. and school
- Consider pharmacological intervention
?Atypical antipsychotic – weigh up risk/benefit in setting of obesity
?Clonidine
Liaise with psychiatry
- Safety plan – phone 000 if anyone in immediate danger, ?PRN medications
Outline management of sleep?
- Screen for OSA/mental health/sleep disorders
- Encourage good sleep hygiene
- Avoid screens in the 30-60m prior to bedtime
- Avoid caffeine and sugary foods after dinner
- Encourage some physical activity earlier in the evening
- Regular bedtime
- Cool room etc - Consider melatonin/clonidine
Outline management of menstruation?
- Education
- Explain Sanitary pads, menstrual underwear
- Education for patient, parents, carers re: hygiene and use of sanitary items and what is a period
- Written resources are available for people at a range of developmental stages AND for parents
- Is a period tracking app on phone helpful - Consider hormonal management with contraceptive medications/LARC
- Screen for and manage dysmenorrhea and/or menorrhagia
- Dysmenorrhea: trial NSAIDs
- Menorrhagia: ?TXA, ?FBE+iron studies required - Also consider decisional capacity
- Mature minor vs paed patient
Outline management of parental burnout?
- Listen to concerns and normalise
- Mental health screen ?any acute risk
- GP MHCP
- psychologist
- social supports - Encourage accepting help from supports and respite
- Able to coordinate appts., do telehealth etc. to limit time burden due to hospital appointments - Protected time with other siblings and doing things he cares about
- Support groups
Outline management of osteopenia?
Assessment
1. Underlying cause
- Malabsorption (fat)
- Chronic disease/lack of weight bearing
- Delayed puberty
- Dietary- reduced intake
- Meds- valproate/phenytoin
- Investigations
- Bone age
- DEXA
- Bloods: CMP, vit D level, ALP - Falls risk assessment
- Vision
- Seizures
- Home environment
- Walking aids
Non Pharmacological
- Sun exposure
- Supplements (dietary, oral)
- Physiotherapy, weight bearing
Pharmacological
- Bisphosphonates
- Hormonal therapy
Outline management of saliva control?
Non-pharm
- Positioning
- Aids: waterproof bib, absorbent clothing/sweat band
- Chewing laterally, lip closure, subjective awareness
- Wheelchair posture
Pharm
1. Anticholinergic: Benzhexol hydrochloride (Artane):
- Cheaper therefore used first, BD dosing
2. Glycopyrolate
- Reportedly less SEs than benzhexol, more expensive & TDS dosing
3. Botox: 3-6mo
Other
1. Orthodontics
2. Submandibular/lingual gland excision >5yrs
Safety
- Swallow/aspiration risk
Outline management of recurrent chest infections?
Assessment
- Frequency/Triggers
- CXR- scoliosis, CT bronchiectasis, FEV1
- Safe swallow and aspiration risk in setting of sialorrhoea
- ?BAL to assess colonisation
- Investigation of immune function
Non pharm
- Positioning
- Chest physio
- Immunisations
Pharm
- Long term prophylaxis
Outline management of spasticity & contractures?
Assessment
- Level of pain, contracture
- Positioning
- Mobility
- Complications- pressure sores, deformity/scoliosis
Non-pharmacological
1. Stretching; physio
2. Orthoses- AFO
3. Heat packs/analgesia
Pharmacological
1. Baclofen- PO/IT- pump
2. Diazepam
3. Botox - 3-6mo
Surgical
1. Tendon releases
2. Rhizotomy/scoliosis surgery
3. Hip dysplasia (pelvic osteotomy) surgery- orthopaedics
Pain management
Pain multifactorial - consider multiple inputs as cause
- Pain
Non pharm
- Assessment of position, exacerbating factors: dystonia, contractures, pressure sores
- Timing/associations
- Heat packs, cool packs
- Physio- stretching exercises, activity
Pharm
1. Optimise paracetamol/ibuprofen
- Regular
- Side effects long term
2. Oxycodone for break through pain
- Advise about side effects, discourage regular use
3. Amitryptilline, gabapentin, pregabalin if neuropathic pain
4. Pain team/chronic pain clinic involvement if refractory
- Sleep
- Routine, ?pain affecting, OSA, environmental
- Optimise sleep hygiene
- Pharm: melatonin - Mood
- Awareness
- Psychology
- SSRI - Social structures
- Secondary gain
- Family structure
- School stressors, impact on attendance
Procedural anxiety
Non-pharm
1. Avoid patient’s room
2. Distraction techniques- play therapist/ipad/toys/VR
3. Procedural preparation
Pharm
1. EMLA
2. Sedation- nitrous/midazolam/ketamine
3. GA
Steroid dependance
- Explore side effects
- Psychosis/behavioral problems, BIH, proximal myopathy, osteoporosis, growth/stature, truncal obesity, skin changes, infection
- Investigate: growth/height, cataracts, DEXA scan, HbA1C, vitamin D/Ca, bisphosphonates, SSRI - Minimise dose
- minimal effective
- ?steroid sparing agent - If needs then ameliorate side effects
- Medical alert bracelet/wallet, additional vaccines, stress dose plan
- Lifestyle management plan (diet)
- Education/sick day plan
- Pregnancy risks
- Drug interactions- OCP
Transition of care
12 month process, start when there are not other stressors
