How to evaluate and manage a pediatric patient with greater BP and BMI than expected.
The first thing to jump out to me from this comment is that Elizabeth is going to run a myriad of tests. The only one left off the list was a thyroid screen. Thyroid screening by most providers consists of a TSH and that just makes me a little crazy :). Tell me what you consider to be “thyroid screening” for this patient and why it may be informative…or if you think it is not needed and why?
To help everyone with how hypertension and thyroid are related…
https://www.aafp.org/afp/2002/0901/p851a.html
There is so much to discuss just based on this one comment…so you all can run with it from this point. I look forward to reading your thoughts about this case study.
Thanks again
My initial discussion:
How to evaluate and manage a pediatric patient with greater BP and BMI than expected.
Patients with elevated BMI, especially children, should regularly undergo measurement through manual auscultation. National Health and Nutrition Examination Survey revealed that children with higher BP have large arm sizes and require adult cuffs. Utilization of cuff helps in proper measurement of BP. Patients with higher BP usually have conically shaped arms, and the upper arm can be large, almost 20cm, which is not expected in their age group (Brady, 2017). For children up to 20 years old, obesity is usually determined through body mass index (BMI).
During the evaluation, there are various aspects that should be put into consideration. First, it is important to understand the detailed history of the patient. This includes their sleeping history, where they should provide information about apneic events, daytime somnolence, and snoring. It is also important to evaluate their diet history, including their fiber intake, total calories consumed every day, frequency and timing of meals, and sugar or sweetened drinks intake (Styne et al., 2017). The other thing to evaluate is their physical activity levels which may include their musculoskeletal pain and intensity. The last thing is to determine their psychosocial history, for instance, anxiety and depression.
In addition, I would also like to have a detailed physical exam to obtain their BMI, and waist circumference. I would also examine their skin which includes striae, hirsutism, acanthosis nigricans, as well as their abdominal hepatomegaly. Laboratory assessment could also be useful in order to acquire hemoglobin A1c, fasting lipids, fasting insulin and glucose, and aspartate and alanine transaminase. Another form of evaluation that is important is to carry out a toxicology screen to determine anxiety and depression. Polysomnography is also crucial; in determining obstructive sleep apnea.
Physical exam findings and diagnostic results of concern.
One of the major concerns is the patient’s BMI which will help to classify the risk the patient is likely to face. Children to the age of 20 with a BMI ≥ of 95% are classified to be obese. If the patient has a BMI over or equal to 85% while that of BMI ≥ 120% is severely obese, which classifies the patient as class II obesity (Mayoclinic.org, 2020). If the patient is over 20 years old, their overweight or obesity cutpoint of BMI should be between 25 to 30kg/m2. Patients with hypertension have increased BMI, which can make them get to class III obesity, where the BMI is 40 kg/m2. In children, BMI usually influences BP since various studies have revealed that those with severe obesity or obesity have higher BP conditions and are at higher risk of developing hypertension than those of the same age but with lower BMI.
Final diagnosis and treatment recommendations.
The significant approach for the patient is to focus on a healthy weight and achieve a heart-healthy lifestyle. In case the patient is a child, the American Academy of Pediatrics (AAP) recommends a proper way to lose weight for children aged six and above, especially when the BMI has reached to obesity category. It also recommends the best way of maintaining weight for children whose BMI is in the category of overweight (Riley et al., 2018). It is important for the patient to consider changing their diets and adopt healthy eating plans like increased intake of fruits, low-fat dairy, and vegetables. Reduced carbohydrates, processed sugar intake, and fats. Such dietary intervention can help to decrease BP in children and adults. Another treatment is to involve regular physical activities. Exercising every day can also help the patient not only meet their physical fitness goals but also regulate their sugar levels in the body.
References
Brady, T. M. (2017). Obesity-related hypertension in children. Frontiers in Pediatrics, 5. https://doi.org/10.3389/fped.2017.00197
Mayoclinic.org. (2020). Obesity – Diagnosis and treatment – Mayo Clinic. Mayo Clinic – Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/obesity/diagnosis-treatment/drc-20375749
Riley, M., Hernandez, A., & Kuznia, A. (2018). High blood pressure in children and adolescents. AAFP American Academy of Family Physicians. https://www.aafp.org/afp/2018/1015/p486.html
Styne, D. M., Arslanian, S. A., Connor, E. L., Farooqi, I. S., Murad, M. H., Silverstein, J. H., & Yanovski, J. A. (2017). Pediatric obesity—Assessment, treatment, and prevention: An Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 102(3), 709-757. https://doi.org/10.1210/jc.2016-2573
