Primary Care of Adolescent and School-Aged (After AAP Changes)

Question 1

Prevention Screening (6)

Answer 1

1. BP Screening
2. Nutrition and Diet Counseling
3. TB
4. Dyslipidemia
5. Adolescent Strength Based Counseling
6. Immunizations

• Older the child is = more related to HTN
• Younger = underlying reason for HTN, cardiac, endocrine disease, or another illness that causes HTN (renal vascular disease)

Question 2

Causes of Adolescent HTN (6)

Answer 2

1. Essential hypertension
2. Iatrogenic illness
3. Renal parenchymal disease
4. Renal vascular disease
5. Endocrine disease
6. Coarctation of Aorta

Question 3

HTN and Metabolic Syndrome (5)

Answer 3

1. Increase in Waist circumference
2. Elevated serum triglycerides levels
3. Low serum high density lipoprotein cholesterol
4. Impaired glucose tolerance
5. Hypertension
   * Note: no guidelines on pediatric metabolic syndrome; the above are adult guidelines

Question 4

Metabolic Syndrome Sum (8)

Answer 4

1. Central obesity
2. Glucose intolerance
3. High BP
4. High sugar
5. Kids are at increased risk for cardiovascular risks but there are no guidelines yet:
6. Male with waist greater than 30
7. Female greater than 35
8. Can define this as at risk over 18 years old but not under 18

Question 5

BP Basics (5)

Answer 5

1. Do not choose cuff based on patient’s upper arm.
2. YOU CHOOSE YOUR CUFF BASED ON ARM CIRCUMFERENCE
3. Using upper arm length in a rule of thumb of the cuff covering 2/3 or 3/4 the length of the upper arm to select your cuff SIGNIFICANTLY UNDERESTIMATES both systolic and diastolic blood pressure
4. 6. People don’t have good accuracy picking cuff size by eye, either, so if in doubt or if you actually want an accurate measurement, grab a tape measure and check the arm circumference.
5. The use of upper arm length is a FORMER recommendation, which had, by 1996, been changed

Question 6

Dimensions of BP cuff (3)

Answer 6

Two different dimensions in a blood pressure cuff:

1. Bladder width and bladder length.
2. Bladder width is supposed to be 40% or more of your arm circumference, with minimum error at 46% (Smith, 2005).
3. Bladder length is supposed to be 80% to 100% of your arm CIRCUMFERENCE

Question 7

Methods of taking BP (5)

Answer 7

1. Let the patient rest for 5 minutes
2. Seated position (with feet on the floor) with right arm supported at heart level.
   * Right arm at heart positions
   * 3 readings need to be done!!!!!!!!!
3. Auscultation in right arm
4. 3 separate reading on 3 separate visits to diagnose
5. Routinely done yearly in children 3 years or older

REMEMBER: DO AN AVG of 3 readings!

Question 8

HTN (3)

Answer 8

1. An average systolic blood pressure and/or diastolic blood pressure that is greater than or equal to 95th percentile for gender, age, and height on 3 or more occasions
2. BP is checked annually between 3-17 years old
3. BP is checked at every visit after 18 years old

Question 9

3-17 Years Old BP Guidelines if BP is <90th percentile (2)

Answer 9

1. Repeat in 1 year

2. Both need to be less than 90th percentile

Question 10

3-17 Years Old BP Guidelines if BP is greater than or equal to 90th percentile (2)

Answer 10

1. Repeat BP x2 by auscultation

2. Average replicate measurements and reevaluate BP category

Question 11

3-17 Years Old BP Guidelines if BP is confirmed between 90th-95th percentile (4)

Answer 11

1. PRE HTN
2. Heart Healthy diet
3. Recommend weight management if indicated
4. Repeat BP in 6 months

Question 12

3-17 Years Old If BP ≥95th percentile, <99th percentile + 5 mm Hg (3)

Answer 12

1. Repeat BP in 1–2 wk, average all BP measurements and reevaluate BP category
2. If BP confirmed >95th percentile, <99th percentile + 5 mm Hg = stage 1 HTN:
3. Basic work-up: Urine and Complete metabolic profile

Question 13

3-17 Years Old If BP ≥99th percentile + 5 mm Hg (4)

Answer 13

1. Repeat BP by auscultation × 3 at that visit, average all BP measurements and reevaluate BP category
2. If BP confirmed >99th percentile + 5 mm Hg = stage 2 HTN:
3. Refer to pediatric HTN expert within 1 wk OR
4. Begin BP treatment and initiate basic work-up

Question 14

18-21 years old HTN guidelines (4)

Answer 14

1. Measure BP at all health care visits
2. BP ≥120/80 to 139/89 = pre-HT
3. BP ≥140/90 to 159/99 = stage 1 HTN
4. BP ≥160/100 = stage 2 HTN

Question 15

Sports and HTN (3)

Answer 15

1. Restricted when symptomatic
2. Restricted with uncontrolled hypertension
3. DASH diet
   - Increase in fruit and vegetable
   - Increase in low fat dairy product
   - Restrict salt intake

Question 16

Long Term Goals of HTN Treatment

Answer 16

Prevention of end organ damage

1. Heart: left ventricular hypertrophy
2. Kidney
3. Eyes
4. Brain: encephalopathy, seizures, CVA evaluation

Question 17

First line Tx for Stage 1 (5)

Answer 17

1. Child 1 diet
2. Weight loss
3. Prevention of excess weight
4. Correlation between obesity and hypertension
   - Average SBP reduced from 5-20 mm/Hg/10kg
5. Weight loss combined with increased physical activity has greater antihypertensive effect

Question 18

6-12 Months Old Guidelines for Cardiovascular Health Diet (3)

Answer 18

1. Continue breastfeeding (should be exclusively until 6m/o) until at least 12 months of age while gradually adding solids; transition to iron-fortified formula until 12 months if reducing breastfeeding
2. Fat intake in infants <12 months of age should not be restricted w/o medical indication
3. Limit other drinks to 100%fruit juices = 4oz/day; no sweetened beverages; encourage water

Question 19

12-24 Months Old Guidelines for Cardiovascular Health Diet (6)

Answer 19

1. Transition to reduced fat (2% to fat free) unflavored cow’s milk
2. Limit/avoid sugar-sweetened beverage intake; encourage water
3. Transition to table food with total fat =30% of daily kcal, saturated fat should be 8-10% of daily kcal
4. Avoid trans fats as much as possible and limit sodium intake
5. Monosaturated and polyunsaturated fat up to 20% of daily kcal/EER
6. Cholesterol <300mg/d

Question 20

2-10 Years Old Guidelines for Cardiovascular Health Diet (8)

Answer 20

1. Primary beverage: fat-free, unflavored milk
2. Limit/avoid sugar-sweetened beverage intake and encourage water
3. Encourage high dietary fiber intake from food (goal= age + 5g/day)

Fat content:

4. Total fat 25-30% of daily kcal
5. Saturated fat 8-10% of daily kcal
6. Avoid trans fat as much as possible
7. Monosaturated and polyunsaturated fat up to 20% of daily kcal
8. Cholesterol <300mg/d

Question 21

11-21 Years Old Guidelines for Cardiovascular Health Diet (8)

Answer 21

1. Primary beverage: fat-free, unflavored milk
2. Limit/avoid sugar-sweetened beverage intake and encourage water
3. Encourage high dietary fiber intake from food (goal of 14g/1000 kcal)

Fat content:

4. Total fat less than or equal to 30% of daily kcal
5. Saturated fat 8-10% of daily kcal
6. Avoid trans fat as much as possible
7. Monosaturated and polyunsaturated fat up to 20% of daily kcal
8. Cholesterol <300mg/d

Question 22

PPD vs. IGRA (4)

Answer 22

1. BCG administration is ignored
   * Can use Interferon Gamma Release Assay or IGRA instead of PPD if over 5
   * PPD is cheaper
2. In general most schools require a PPD on entrance to junior high school
3. Travel to foreign countries need screening
4. No routine screening for low risk children

Question 23

Risk Factors for Dyslipidemia: Positive Family History (4)

Answer 23

1. Myocardial infarction
2. Angina
3. Coronary artery bypass graft/stent/angioplasty,
4. Sudden cardiac death in parent, grandparent, aunt, or uncle at <55 y for males, <65 y for females

Question 24

Moderate Risk Level Factors for Dyslipidemia (4)

Answer 24

1. Hypertension that does not require drug therapy
2. BMI at the ≥95th percentile, <97th percentile
3. HDL cholesterol < 40 mg/dL
4. Presence of moderate risk conditions

Question 25

High Risk Level Factors for Dyslipidemia (5)

Answer 25

1. Hypertension that requires drug therapy (BP ≥ 99th percentile + 5 mm Hg)
2. Current cigarette smoker
3. BMI at the ≥97th percentile
4. Presence of high-risk conditions
5. DM is also a high-level RF

Question 26

Special Risk Conditions for Dyslipidemia: High Risk

Answer 26

1. T1DM and T2DM
2. Chronic kidney disease/end-stage renal disease/post–
3. Renal transplant
4. Post–orthotopic heart transplant
5. Kawasaki disease with current aneurysms

Question 27

Special Risk Conditions for Dyslipidemia: Moderate Risk (4)

Answer 27

1. Kawasaki disease with regressed coronary aneurysms
2. Chronic inflammatory disease (systemic lupus erythematosus, juvenile rheumatoid arthritis)
3. HIV infection
4. Nephrotic syndrome

Question 28

Overview of Lipid Screening Recommendations: Below 2 years old

Answer 28

No screening below 2 years of age

Question 29

Overview of Lipid Screening Recommendations: 2-10 years old

Answer 29

Selective screening if:
1. Family history (+) for early CVD

2. Parent with known dyslipiedmia
3. Child with established risk factor
4. Child with special risk condition

Question 30

Overview of Lipid Screening Recommendations: 10 years old

Answer 30

Universal screening with non-fasting non-HDL-C (routinely check everyone at 10)

Question 31

Overview of Lipid Screening Recommendations: 11-18 years old

Answer 31

Selective screening if:
1. Family history (+) for early CVD

2. Parent with known dyslipiedmia
3. Child with established risk factor
4. Child with special risk condition

AND/OR

Universal screening between 16-18 years old

Question 32

Total Cholesterol levels: Acceptable, Borderline, Abnormal

Answer 32

Acceptable: <170

Borderline: 170-199

Abnormal: >/= 200

Question 33

LDL-C Levels: Acceptable, Borderline, Abnormal

Answer 33

Acceptable: <110

Borderline: 110-129

Abnormal: >/= 130

Question 34

Non-HDL-C Levels: Acceptable, Borderline, Abnormal

Answer 34

Acceptable: <120

Borderline: 120-144

Abnormal: >/= 145

Question 35

Triglyceride Levels: Acceptable, Borderline, Abnormal

Answer 35

Acceptable:
0-9 years old- <75
10-19 years old- <90

Borderline:
0-9 years old- 75-99
10-19 years old- 90-129

Abnormal:
0-9 years old- >/=100
10-19 years old- >/=130

Question 36

HDL Levels: Acceptable, Borderline, Abnormal

Answer 36

Acceptable: >45

Borderline: 40-45

Abnormal: <45

Question 37

Fasting Lipid Profiles (6)

Answer 37

1. MUST BE DONE TWICE!!!!; wait 1-2 weeks between panels
2. Only greater than or equal to 200 for total cholesterol is abnormal
3. Want high HDLs and low LDLs
4. Fasting = fasting for 12 hours
5. After doing it twice, check where it falls and then look for secondary causes if it’s very high (ex: nephritic syndrome)
6. If it’s very high, do a child 2 diet if they don’t respond to a child 1 diet

Question 38

High LDL Treatments (2)

Answer 38

1. If LDL-C is over/= to 130 and TG is <200, may consider bile acid sequestrant or ezetimibe
2. In high LDL-C patients, if non-HDL-C is >/=145mg/dL with LDL-C <130mg/dL –> target TG

Question 39

CHILD 2‐ LDL and CHILD 2‐ TG (3)

Answer 39

1. Saturated fat <7% of calories
   * Grade A, Highly recommend
2. Dietary cholesterol <200 mg/d
   * Grade A, Highly recommend
3. • With high TGs: Eliminate sugar sweetened beverages, reduce simple carbohydrates, increase dietary omega 3 content + weight management as needed.
     * Grade B, recommended

Question 40

Issues in Adolescence (21)

Answer 40

1. Suicide risk
2. Seat belt non Use
3. Riding with DUI or DUI
4. Sexual activity/contraception
5. Use of alcohol
6. Physical or sexual abuse
7. Safety, helmet use
8. Stress
9. Assertiveness/communication skills
10. Family issues
11. Violence exposure
12. Gun carrying
13. Drug use
14. Exercise/physical fitness
15. Diet and nutrition/physical fitness
    16 .School performance
16. Sibling abuse/rivalry
17. Sexually transmitted Disease
18. Alcohol avoidance
19. Use of cigarettes
20. Injury Prevention

Question 41

Primary Care Today- What’s Happening? (6)

Answer 41

1. Screening for high-risk behaviors and conditions at low rates
2. Adolescents want their primary care providers to address health issues through screening and counseling
3. Rand and colleagues found that preventive counseling seemed to be more commonly documented in administrative databases at acute than well visits.
4. Primary sources of adolescent morbidity and mortality
   - Not natural
   - Reflect their high risk behaviors
5. Preventive screening, counseling, and education are still potentially cost-effective and practical methods to address these problems
6. Counseling: strength based approach

Question 42

Strength Based Approach (2)

Answer 42

1. Tenets of shared decision making
   - I want to review with you some of the strength you have that I’ve learned about as we have been talking today
   - I am concerned about X, and I hope you will be willing to discuss that with me.
2. Use of Motivational Interviewing

Question 43

Impact of Trauma on Adolescent Development: Effects of toxic stress on brain development (5)

Answer 43

1. Impairs connection of brain circuits, may result in a smaller brain
2. Development of low threshold for stress, resulting in over-reactivity or chronic hyperarousal.
3. High stress suppress body’s immune response
4. Sustained high cortisol damages the hippocampus that is responsible for learning and memory—cognitive deficits continue to adulthood
5. Verbal abuse from parents and peers interferes with development of grey and white matter in the brain

Question 44

Outcomes of Traumatic Stress on Adolescent Development (8)

Answer 44

1. Hyperarousal
2. Memory problems and deficits information processing
3. Survivor guilt
4. Emotional dysregulation
5. Developmental interferences
6. Loss of social support
7. Avoidance or attitude change
8. Reenactment or maladaptive coping

Question 45

Effect of Stress on Physiology (6)

Answer 45

1. Adolescent who is easily upset, easily provoked, and highly reactive
2. Harder for the adolescent to form a relationship with an adult
3. Adolescent may have what some consider to be inappropriate emotions and behavior
4. Adolescent may be diagnosed as hyperactive or oppositional defiant
5. Adolescent may appear inattentive but he may be focusing on internal stimuli or to “danger signals”
6. Triggers in environment trigger flash backs.

Question 46

Allostatic Load (3)

Answer 46

1. Wear and tear on the body and brain from large forces like socioeconomic status
2. The number of children with incarcerated parents have increased dramatically in the last 20 years
   * Increases in allostatic load
3. Need to understand your own adolescence—Self reflection

Question 47

Strategy for Provision of Adolescent Preventive Services (4)

Answer 47

1. Gather information and identify problem
   - Look at GAPS guidelines
2. Further Assess
   - If there is an imminent and serious risk, referral for subspecialty evaluation
3. Identify and prioritize problems together
   - Assure confidentiality
   - Listen to adolescent perspective
   - Do not respond in punitive manner
4. Solution-Develop a plan
   - Negotiate the intervention
   - Promote confidence in plans that work
   - Discuss strategies with teen to overcome barrier to the management plan
   - Contract or verbal agreement
   - Follow-up with action

Question 48

Factors Relative to Health and Mental Health (9)

Answer 48

1. 15,000 children are in juvenile detention facilities
2. Mental Health problems affect 1 in every 5 children
3. Anorexia affects 1% of adolescent girls
4. Anxiety disorders affect 1 in 10
5. ADHD affects 5-10% of children
6. One third of 6-12 year old children are diagnosed with major depression will develop bipolar in a few years
7. 1 in 10 children have a conduct disorder
8. Depression may be as high as 1 in 8 adolescents
9. Suicide is the third leading cause of death in 15-24 year olds

Question 49

Scope of the Problem (4)

Answer 49

1. Adolescent one year prevalence rate of 4% to 8 %
2. Lifetime prevalence in adolescence is 15% to 20%
3. 65% report some depressive symptoms
4. 5% to 10 of youth
   with subsyndromal symptoms have considerable psychosocial impairment, high family load for depression, and risk for developing a major depressive disorder (MDD)

Question 50

Adolescent Depression Epidemiology (4)

Answer 50

1. Higher rates of depression in girls after puberty due to:
   - Increases in estradiol and testosterone
   - Higher rate of anxiety disorders and tendency to rumination
2. Increases in youth generated interpersonal conflict and sensitivity to conflict during adolescents
3. Mean length of episodes 7-9 months
4. 6-10% of depressive episodes will become protracted

Question 51

Adolescent Rates of Depression (7)

Answer 51

Higher If:

1. Early onset of puberty
2. Experimentation with drugs and alcohol
3. Decreased adult supervision
4. Greater physiologic need for sleep with tendency to sleep less
5. Higher rates of recurrent depression in adults
6. 20% will develop bipolar disorder
7. Associated with significant comorbidity, risk for suicide, risk for substance use/abuse

Question 52

Depression Comorbidities (4)

Answer 52

1. Anxiety
2. Attention deficit hyperactive disorder
3. Alcohol and tobacco abuse
4. Conduct disorder

Question 53

Depression Clinical Manifestations (3)

Answer 53

1. Core persistent and pervasive sadness, anhedonia, boredom, and irritability
2. Teens may have more sleep and appetite disturbances, more delusions and more suicidal ideation than younger children with MDD
3. Major differentiating factor is FUNCTIONAL IMPAIRMENT

Question 54

Depression Assessment Tools (4)

Answer 54

1. Gives a clinician a validated tool to use
2. Raises adolescent awareness of possible depression
3. Lets the adolescent know that mental health issues can be brought up
4. Demonstrates concerns
   - Use at yearly checks
   - If concerns during the visit

Question 55

Depression Management: SSRIs (3)

Answer 55

1. SSRI users had higher response rates than those who were taking placebo medication
2. Fluoxetine and citalopram yielded statistically significant higher response rates than did other SSRIs.
3. Fluoxetine is the only drug that is approved by the US Food and Drug Administration for treating MDD among youth.
   * Can be given in primary care

Question 56

Depression Management (5)

Answer 56

1. Psychotherapy
2. Establishment of a safety plan
3. Includes restricting lethal means, engaging a concerned third party
4. Developing an emergency communication mechanism should the patient deteriorate, become actively suicidal or dangerous to others
5. Experience an acute crisis associated with psychosocial stressors, especially during the period of initial treatment when safety concerns are highest

Question 57

Depression Treatment (2) or Referral (3)

Answer 57

Treat adolescent if

1. Initial episode and no suicidal ideations
2. Absence of comorbidconditions

Refer if

1. Chronic, recurrent depression
2. Lack of response to initial treatment
3. Coexisting substance abuse or other condition
   - Psychosis
   - Bipolar symptoms
   - High level of family conflict