Other Flashcards
What are examples of somatisation
- Fatigue
- Headache
- Abdominal pain
- Back ache
- Dizziness
How common is somatisation?
- ¼ of children and young people
- 59% of adolescents have experienced at least one health complaint/week
What gender and age is somatisation most common in?
- Females
- Increases with age
What must we always look for when suspecting somatisation?
Exclude organic causes first
What are the consequences of somatisation?
- Impairment of daily functioning
- High levels of distress
- Poor school attendance
- Isolation from peers
- Significant use of healthcare
- Strongly held belief that there is an underlying physical disease
What are the physical symptoms in somatisation exacerbated by?
- Emotional upset: bullying, performance anxiety …
- Can start with an illness, surgery, injury, but continues beyond expected healing period due to propagating psychosocial factors e.g. school anxiety, lack of feeling cared …
- Some painful conditions e.g. migraines can be exacerbated by stress
What is important to ask in the history when suspecting somatisation?
- Identify symptoms of organic illness
- Use HEADS for psychosocial evaluation
- Compile a timeline
- Interview child on their own
- Report from school may be helpful
What is HEADS?
- Home life
- Education
- Activities
- Drugs + Diet
- Sexual health, Sleep. Suicide/Affect, Safety, Social Media
What can you gain from a physical examination when suspecting somatisation?
- Rule out organic caise
- Provides opportunity to gain further info on the nature of the symptoms- Apley’s rule: the further the pain is from the umbilicus, the more likely it is due to an organic cause.
Why shouldn’t we do investigations in somatisation?
- May cause secondary harm from unnecessary medical investigations and propagation of illness belief
What is the initial tx for somatisation?
Initial treatment – Primary care management with regularly scheduled visits
o Schedule regular outpatient visits
o Acknowledge somatic symptoms
o Communicate with specialists who are treating the patient –patients with somatic symptom disorder consult one doctor after another (“doctor shopping”).
o Evaluate for and treat diagnosable general medical diseases.
o Limit diagnostic testing and referrals to specialists.
o Reassure patients that grave medical diseases have been ruled out.
o Explain that the body can generate symptoms in the absence of disease, that psychological and social issues (e.g. stress) can affect the body.
o Assess for comorbid psychiatric disorders
o Stop unnecessary medications.
What is the tx for tx resistant somatisation?
• Treatment resistant patients – continue to meet regularly with the patient and also:
o Discuss the case with a psychiatrist
o Meet jointly with the patient and family members
o Administer relaxation training
o Provide formal psychoeducation
o Prescribe antidepressants for patients with prominent comorbid symptoms of anxiety disorders, depressive disorders, or obsessive-compulsive disorder
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What additional vaccines are given to at risk groups?
Also, for at risk groups, BCG at birth AND HBV for babies born to Hep B infected mothers, 1 month, 2 months and 12 months
What are contraindications for vaccines?
- Acute febrile illness
- Egg allergy – influenza, yellow fever and tick-borne encephalitis (NB: MMR is usually safe but can be given in hospital if egg allergic)
- Previous anaphylaxis to vaccine containing or constituent antigens/components
- Immunocompromised depends on cause.
o Short term–delay vaccines.
o Care with live vaccines
When shouldn’t a child be excluded from school?
o Conjunctivitis
o Slapped cheek syndrome(fifth disease)
o Roseola infantum
o Infectious mononucleosis
o Head lice
o Threadworms
When should a child be excluded for 24hrs after start of abx from school?
Scarlet fever
When should a child be excluded for 48hrs after start of abx from school?
o Whooping cough
o NOTE: if no antibiotics are given, exclude for 21 days from onset of symptoms
Exclusion for 4 days from onset of rash?
- Measles
- Rubella
Exclusion until all lesions crusted over?
- Chickenpox
- Impetigo
Exclusion for 5 days from onset of swollen glands
Mumps
Until symptoms have settled for 48 hours
D&V
Until treated?
Scabies
Until recovered?
Influenza
What are the MMR contraindications and side effects?
What are the types of neglect and abuse?
- Emotional abuse
- Physical neglect
- Sexual abuse
- NAI
What are the signs of emotional abuse?
- ‘Frozen watchful’ appearance
- Expressionless face, wary eyes
- Abnormally affectionate to strangers
What are the signs of sexual abuse?
Sexual abuse may take the form of inappropriate touching, forced expo- sure to sexual acts, vaginal, oral or rectal intercourse and sexual assault.
- Anogenital bruising and tears if acute
- Pregnancy, sexually transmitted diseases
• There may be no physical signs
It may come to light if disclosure is made, inappropriate sexual behaviour is exhibited or as a result of trauma or genital infections.
Signs of trauma may be found in the mouth, anus or genitalia, but absence of signs is common and fewer than half the victims have any substantiating physical evidence.
What are the signs of physical neglect?
• Unkempt dirty appearance
- Sores
- Uncared for nappy rash
- Failure to thrive - principal factor being inadequate nutrition
The mother is commonly deprived and unloved herself and often is clinically depressed.
The child looks malnourished and uncared for, and immu- nizations are often not up to date.
Delays in development are common, and signs of physical abuse may be seen.
When admitted to hospital these babies often show rapid weight gain.
What are the signs of NAI?
Bruises of suspicious shape or site
Burns and scalds
Bites
Hidden head injuries
Suspicious fractures
Drowsiness
Abused children are commonly fearful, aggressive and hyperactive, and many go on to become delin- quent, violent and the next generation of abusers.
Children with repeated injury to the CNS may develop brain damage with learning disabilities or epilepsy.
Injuries may range in severity from minor bruises to fatal subdural haematomas
What are red flags for NAIs?
- Injuries in very young children.
- Explanations which do not match the appearance of the injury, and change.
- Multiple types and age of injury.
- Injuries which are ‘classic’ in site or character.
- Delay in presentation.
- Things the child may communicate during the evaluation.
Who is usually the abuse in NAI?
In most cases the abuser is a related carer or male friend of the mother.
Most have neither psychotic nor criminal personalities, but tend to be unhappy, lonely, angry adults under stress, who may have experienced child abuse themselves.
Who do offender tend to be in sexual abuse?
Secrecy is often enforced by the offender who is usually male and a family member or acquaintance of the family
What are the investigations for neglect and abuse?
Investigations
o Skeletal survey
o CT head scan
o Bloods and bone profile
Rule out leukaemia, ITP etc.
o Fundoscopy(retinal haemorrhages)
What is the management of neglect and abuse?
Is the child in DANGER?
o Could the siblings or parents be in danger?
o MAKE SURE THE CHILD IS IN A SAFE PLACE
Who to get involved?
o Senior colleagues
o Named doctor for child protection
o Contact social services and make a formal referral
o Consider contacting the police (Child Abuse Investigation Team (CAIT))
o Consider contacting Multi-Agency Safeguarding Hub (MASH)
This includes a variety of people that help manage different aspects of a child’s life
How should you tell parents about involvement of social services in NAI?
We have to talk about what to do next from a medical and non-medical standpoint
Whenever we have a case where we don’t know why an injury has occurred, we have to involve some other people
This includes social services and the child safeguarding team (and maybe the police)
This is a routine requirement for all children in these situations, and our aim is to keep your child safe
Sometimes when children have similar injuries, they do not happen by accident and they are caused by someone else
