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
Medication non-adherence
- Maintain relationship and trust
- Explore concerns
- Make teenager feel heard
- Focus on the central issue that concerns the teenager - Gauge amount of non-compliance,
- How often? If minimal then may not be an issue
- Normalise occasional missing if not affecting condition
- Explore reasons for missing, what have they tried - Support contributing factors
- Mental health
- Burden of disease
- Self consciousness/image
-Other teenage priorities/stressors
Anxiety, low mood
- Identify triggers, exacerbating factors, impact on function
- Listen, HEADSSS screen
- Find what the child likes, enjoys, make this a focus
- Look at contributing factors - Risk stratification
- Suicide risk, safety plan - Non-pharmacological
- CBT
- Mindfulness
- School counsillor
- School supports - Phamacological
- Consider side effects i.e weight
- SSRI- fluoxetine
Behavioral escalation
- Explore triggers/extent
- Physical/verbal?
- Safety of family members
- School - Address underlying factors
- Sleep
- Discomfort, disease
- Medications
- Hearing/vision impairment
- Poor comprehension - Safety- plan for family members
- Verbal de-escalation
- Removal from situation
- Police
4.
Schooling choice in disabled child
Liase with kinder, get idea of current function
Parents priority/vision
Discuss pro’s/con’s
Mainstream
Pros:
- Inclusion (all children are entitled)
- Normalisation, social skill building
- More stimulation
- Family routine easier
Cons:
- Bullying, exclusion
- Inadequete resources/services
- May struggle to keep up
** School will get extra funding for aids, assistance, mods
Special school
Pros:
- Small class sizes
- Closely catered to patient’s needs- trained teachers & specialised equipment
** IQ 50-70 special school
***IQ <50 = spec dev school
Once decided
- Apply early
- Visit schools
- Educational needs questionnaire
Need formal neuropsych assessment to
- Cognitive assessment (WISC/WPPSI)
- Speech & language assessment (CELF)
Qualify for aide if
- ID
- Deficiency in adaptive behavior scale
- Specific language disorder
- Medical illnesss
- Social/emotional illness
Speech delay
Check hearing
Check if isolated or multiple domains
Early speech development
Application for NDIS funding- early intervention, if older diagnosis (GDD/language impairment)
- Speech pathology
Aggression
- Contributing factors
- Sleep
- Frustration- language impairment or ID (poor comprehension)
- Triggers, situations, relationships (where behavior is worse/better)
- Role modelling
?Evolving diagnosis
- ODD/ADHD - Strategies for containment
- List unacceptable actions
- Identify annoying behaviors (but tolerable)
Clear boundaries & consistency
- Time out
- Ignore negative behaviour
- Praise good behaviour, sticker charts, dedicated time
Constipation/encopresis
Stool chart
Exclude organic causes
- Non-pharm
- Diet & fluid intake
- Fibre/metamucil
- Timed sitting
- Sticker charts
- Foot stools - Pharm
- Osmotic vs stimulant
- Daily until soft stool
- Educate re: continuity of laxative
- Enemas
- Washout as later option
Restrictive/fussy eating
Growth
Nutritional deficiency
- Iron, B group vitamins important for cognitive development
Take pressure out of family meal time
Give opportunities for other choices in food, get involved in meal prep, food play
Poor sleep
Sleep routine
- Cool room
- Wind down, activities outside bed
- No stimulants/water
Other factors
- Stressors/anxiety
- Co-morbidities ADHD, OSA, tonsillar hypertrophy
OSA screen- weight, daytime somnolence, ?hyperactivity
Boundary setting
Pharm
Melotonin
Sedating antihistamines
Cognitive testing
Speech therapy & neuropsych
- Need to be able to say Y/N
- Receptive < expressive: ASD
IQ
- WPPSI: preschool
- WISC: school age, measures verbal comprehension, perceptual reasoning, processing speed & WM
- WAIS >16
Functional testing
- WIAT: cog/academic + functional impact
- Vineland adaptive behaviour test
- Sheridan Gardiner: visual acuity at reading age
- ADOS- gold standard for ASD
- PEDS- developmental delay
School mods in chronic disease
Share treatment plan
- EM management plan
- Effects of meds on school performance
Regular communication with school
- Web/email
- Tele-schooling
- Teacher visits
- Liase with support officer
Mods
- Special consideration
- Building modifications
- Modified curriculum
Student support groups
School refusal
Peak 5-7, then 11-14yrs
Outcomes
- Poor academic performance
- Worsening peer relationships, family tensions
- May lead to employment difficulties,risk of psychiatric illness
- Worse prognosis if >3yrs, adolescent, low IQ or MH
Detailed history
- Child alone, teacher, parental relationships, environments at home/community
- ?overprotection
- Temperament (shy/sensative)
- How easily the child makes friends
- Bullying, poor grades/self esteem, fatigue, anxiety, learning difficulties/ADHD/autism
- Parental responses to
Extent of problem
- Number of days over what time period
Management:
- Team approach
- Parents on board
- Immediate if refusal brief
- Graded exposure if longer periods
- routine for parents
- school: engage supports, active tasks, modified curriculum
- child: relaxation training/social skills training & reward system
Regular monitoring for:
- Relapse
- Emerging MH symptoms
- Compliance with plan/issues
Communication in disabled child
Formal hearing & vision assessment
- Ensure regular re-assessment
- Appropriate aids & enviromental modifications
Assess level of fine motor skill
Speech & OT involvement
Non aided:
- Gestures
- Signs for key words (Makaton vocab)
Aided:
- Books/boards, words, cards, pictures
- Objects
- Messaging systems
- Sound/picture boards
- Computer/ipad
Communcation resource centre and funding schemes
Nutrition and growth in CP
Growth trajectory
Consider:
- Decreased input
- Excessive utilisation: dystonia, other co-morbidities, puberty
- Malabsorption
Nutritional bloods
- CMP, electrolytes, iron, B12, folate, zinc, ADEK,
- Coeliac studies, stool sample
- TSH
Microaspiration
- Speech & swallow assessment
- ?Consider NG/PEG feeds
Caloric supplementation
Medication ADHERENCE
Important part of teenage health
- Review regimen, rationalise where possible
- Explore reasons for non-compliance
- Side effects
- Complex/too many/difficult to take
- Incompatible with lifestyle
- Embarassed/peer pressure
- Forgetful
- Depression
- Lack of understanding - Meet with adolescent to encourage autonomy over illness
- See teenager alone, focus on main goals, limitations
- re-education about importance of meds/correct misunderstandings - Simplify regime
- Less complex, less meds, combinations
- Manage side effects
- Medication free periods - Improve access to meds/planning
- Short term goals & f/u
- Ensure autonomy- HCC, support where needed
Adherence mnemonic
P = practical pointers (scripts, needles, carrying spacer etc.)
E = Encouragement (focus on positive things they have done) / Education R = routine
S = Short term goals
O = No one else except adolescent when history taking
N = negotiate role for parents to reduce nagging/take autonomy
S = simplify regime
Risk taking behaviors in teenager
Expected at this age but higher risk with chronic disease
Gain trust, establish safe safe
HEADSSS
- Safety, forensics
- Sex, drugs, peer pressure
- Contraception
Empower teenager to take autonomy over illness
- Motivational interviewing techniques
Transition of care, independant living, future
Meet with family, child
Meet with child - gauge understanding, goals for future, treatment, career/interests
Graded approach to establishing self management
- upskilled to give meds, attend appointments
- routine
- self esteem- public/body image/relationships
Cognitive testing, ?ID/GDD, functional needs assessment
- OT/neuropsych
- School - options for learning
Transition of care, independant living, future
Meet with family, child
Meet with child - gauge understanding, goals for future, treatment, career/interests
Graded approach to establishing self management
- upskilled to give meds, attend appointments
- routine
- self esteem- public/body image/relationships
Cognitive testing, ?ID/GDD, functional needs assessment
- OT/neuropsych
- School - options for learning
Nocturnal enuresis
History
- Frequency, volume
- Bedtime wetting? wetting during the day?
- Other symptoms (freq, urgency, polyuria)
- Previously achieved continence
- Other co-morbidities (UTI, DM, DI, constipation, renal abnormalities) BSL, dipstick, renal U/S
- Fluids/stimulants before bed
Management
- Minimise fluid intake
- Motivational therapy- sticker charts
- Bladder training- asking child to hold on
- Bell & alarm (most effective long term)- only if >7yrs, cognitively intact
- DDAVP (no further drinks)/imipramine (side effects), oxybutynin (if daytime symptoms- overactive), indomethacin (small trials)
- Wait and see 15% improve/yr
