Primary Care of Adolescent and School-Aged (After AAP Changes) Flashcards
1
Q
Prevention Screening (6)
A
- BP Screening
- Nutrition and Diet Counseling
- TB
- Dyslipidemia
- Adolescent Strength Based Counseling
- 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)
2
Q
Causes of Adolescent HTN (6)
A
- Essential hypertension
- Iatrogenic illness
- Renal parenchymal disease
- Renal vascular disease
- Endocrine disease
- Coarctation of Aorta
3
Q
HTN and Metabolic Syndrome (5)
A
- Increase in Waist circumference
- Elevated serum triglycerides levels
- Low serum high density lipoprotein cholesterol
- Impaired glucose tolerance
- Hypertension
* Note: no guidelines on pediatric metabolic syndrome; the above are adult guidelines
4
Q
Metabolic Syndrome Sum (8)
A
- Central obesity
- Glucose intolerance
- High BP
- High sugar
- Kids are at increased risk for cardiovascular risks but there are no guidelines yet:
- Male with waist greater than 30
- Female greater than 35
- Can define this as at risk over 18 years old but not under 18
5
Q
BP Basics (5)
A
- Do not choose cuff based on patient’s upper arm.
- YOU CHOOSE YOUR CUFF BASED ON ARM CIRCUMFERENCE
- 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
- 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.
- The use of upper arm length is a FORMER recommendation, which had, by 1996, been changed
6
Q
Dimensions of BP cuff (3)
A
Two different dimensions in a blood pressure cuff:
- Bladder width and bladder length.
- Bladder width is supposed to be 40% or more of your arm circumference, with minimum error at 46% (Smith, 2005).
- Bladder length is supposed to be 80% to 100% of your arm CIRCUMFERENCE
7
Q
Methods of taking BP (5)
A
- Let the patient rest for 5 minutes
- 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!!!!!!!!! - Auscultation in right arm
- 3 separate reading on 3 separate visits to diagnose
- Routinely done yearly in children 3 years or older
REMEMBER: DO AN AVG of 3 readings!
8
Q
HTN (3)
A
- 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
- BP is checked annually between 3-17 years old
- BP is checked at every visit after 18 years old
9
Q
3-17 Years Old BP Guidelines if BP is <90th percentile (2)
A
- Repeat in 1 year
2. Both need to be less than 90th percentile
10
Q
3-17 Years Old BP Guidelines if BP is greater than or equal to 90th percentile (2)
A
- Repeat BP x2 by auscultation
2. Average replicate measurements and reevaluate BP category
11
Q
3-17 Years Old BP Guidelines if BP is confirmed between 90th-95th percentile (4)
A
- PRE HTN
- Heart Healthy diet
- Recommend weight management if indicated
- Repeat BP in 6 months
12
Q
3-17 Years Old If BP ≥95th percentile, <99th percentile + 5 mm Hg (3)
A
- Repeat BP in 1–2 wk, average all BP measurements and reevaluate BP category
- If BP confirmed >95th percentile, <99th percentile + 5 mm Hg = stage 1 HTN:
- Basic work-up: Urine and Complete metabolic profile
13
Q
3-17 Years Old If BP ≥99th percentile + 5 mm Hg (4)
A
- Repeat BP by auscultation × 3 at that visit, average all BP measurements and reevaluate BP category
- If BP confirmed >99th percentile + 5 mm Hg = stage 2 HTN:
- Refer to pediatric HTN expert within 1 wk OR
- Begin BP treatment and initiate basic work-up
14
Q
18-21 years old HTN guidelines (4)
A
- Measure BP at all health care visits
- BP ≥120/80 to 139/89 = pre-HT
- BP ≥140/90 to 159/99 = stage 1 HTN
- BP ≥160/100 = stage 2 HTN
15
Q
Sports and HTN (3)
A
- Restricted when symptomatic
- Restricted with uncontrolled hypertension
- DASH diet
- Increase in fruit and vegetable
- Increase in low fat dairy product
- Restrict salt intake
16
Q
Long Term Goals of HTN Treatment
A
Prevention of end organ damage
- Heart: left ventricular hypertrophy
- Kidney
- Eyes
- Brain: encephalopathy, seizures, CVA evaluation
17
Q
First line Tx for Stage 1 (5)
A
- Child 1 diet
- Weight loss
- Prevention of excess weight
- Correlation between obesity and hypertension
- Average SBP reduced from 5-20 mm/Hg/10kg - Weight loss combined with increased physical activity has greater antihypertensive effect
18
Q
6-12 Months Old Guidelines for Cardiovascular Health Diet (3)
A
- 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
- Fat intake in infants <12 months of age should not be restricted w/o medical indication
- Limit other drinks to 100%fruit juices = 4oz/day; no sweetened beverages; encourage water
19
Q
12-24 Months Old Guidelines for Cardiovascular Health Diet (6)
A
- Transition to reduced fat (2% to fat free) unflavored cow’s milk
- Limit/avoid sugar-sweetened beverage intake; encourage water
- Transition to table food with total fat =30% of daily kcal, saturated fat should be 8-10% of daily kcal
- Avoid trans fats as much as possible and limit sodium intake
- Monosaturated and polyunsaturated fat up to 20% of daily kcal/EER
- Cholesterol <300mg/d
20
Q
2-10 Years Old Guidelines for Cardiovascular Health Diet (8)
A
- Primary beverage: fat-free, unflavored milk
- Limit/avoid sugar-sweetened beverage intake and encourage water
- Encourage high dietary fiber intake from food (goal= age + 5g/day)
Fat content:
- Total fat 25-30% of daily kcal
- Saturated fat 8-10% of daily kcal
- Avoid trans fat as much as possible
- Monosaturated and polyunsaturated fat up to 20% of daily kcal
- Cholesterol <300mg/d
21
Q
11-21 Years Old Guidelines for Cardiovascular Health Diet (8)
A
- Primary beverage: fat-free, unflavored milk
- Limit/avoid sugar-sweetened beverage intake and encourage water
- Encourage high dietary fiber intake from food (goal of 14g/1000 kcal)
Fat content:
- Total fat less than or equal to 30% of daily kcal
- Saturated fat 8-10% of daily kcal
- Avoid trans fat as much as possible
- Monosaturated and polyunsaturated fat up to 20% of daily kcal
- Cholesterol <300mg/d
22
Q
PPD vs. IGRA (4)
A
- BCG administration is ignored
* Can use Interferon Gamma Release Assay or IGRA instead of PPD if over 5
* PPD is cheaper - In general most schools require a PPD on entrance to junior high school
- Travel to foreign countries need screening
- No routine screening for low risk children
23
Q
Risk Factors for Dyslipidemia: Positive Family History (4)
A
- Myocardial infarction
- Angina
- Coronary artery bypass graft/stent/angioplasty,
- Sudden cardiac death in parent, grandparent, aunt, or uncle at <55 y for males, <65 y for females
24
Q
Moderate Risk Level Factors for Dyslipidemia (4)
A
- Hypertension that does not require drug therapy
- BMI at the ≥95th percentile, <97th percentile
- HDL cholesterol < 40 mg/dL
- Presence of moderate risk conditions
25
High Risk Level Factors for Dyslipidemia (5)
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
26
Special Risk Conditions for Dyslipidemia: High Risk
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
27
Special Risk Conditions for Dyslipidemia: Moderate Risk (4)
1. Kawasaki disease with regressed coronary aneurysms
2. Chronic inflammatory disease (systemic lupus erythematosus, juvenile rheumatoid arthritis)
3. HIV infection
4. Nephrotic syndrome
28
Overview of Lipid Screening Recommendations: Below 2 years old
No screening below 2 years of age
29
Overview of Lipid Screening Recommendations: 2-10 years old
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
30
Overview of Lipid Screening Recommendations: 10 years old
Universal screening with non-fasting non-HDL-C (routinely check everyone at 10)
31
Overview of Lipid Screening Recommendations: 11-18 years old
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
32
Total Cholesterol levels: Acceptable, Borderline, Abnormal
Acceptable: <170
Borderline: 170-199
Abnormal: >/= 200
33
LDL-C Levels: Acceptable, Borderline, Abnormal
Acceptable: <110
Borderline: 110-129
Abnormal: >/= 130
34
Non-HDL-C Levels: Acceptable, Borderline, Abnormal
Acceptable: <120
Borderline: 120-144
Abnormal: >/= 145
35
Triglyceride Levels: Acceptable, Borderline, Abnormal
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
36
HDL Levels: Acceptable, Borderline, Abnormal
Acceptable: >45
Borderline: 40-45
Abnormal: <45
37
Fasting Lipid Profiles (6)
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
38
High LDL Treatments (2)
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
39
CHILD 2‐ LDL and CHILD 2‐ TG (3)
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
40
Issues in Adolescence (21)
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
17. Sibling abuse/rivalry
18. Sexually transmitted Disease
19. Alcohol avoidance
20. Use of cigarettes
21. Injury Prevention
41
Primary Care Today- What’s Happening? (6)
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
42
Strength Based Approach (2)
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
43
Impact of Trauma on Adolescent Development: Effects of toxic stress on brain development (5)
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
44
Outcomes of Traumatic Stress on Adolescent Development (8)
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
45
Effect of Stress on Physiology (6)
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.
46
Allostatic Load (3)
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
47
Strategy for Provision of Adolescent Preventive Services (4)
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
48
Factors Relative to Health and Mental Health (9)
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
49
Scope of the Problem (4)
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)
50
Adolescent Depression Epidemiology (4)
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
51
Adolescent Rates of Depression (7)
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
52
Depression Comorbidities (4)
1. Anxiety
2. Attention deficit hyperactive disorder
3. Alcohol and tobacco abuse
4. Conduct disorder
53
Depression Clinical Manifestations (3)
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
54
Depression Assessment Tools (4)
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
55
Depression Management: SSRIs (3)
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
56
Depression Management (5)
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
57
Depression Treatment (2) or Referral (3)
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
