Professional Documents
Culture Documents
Report
JANUARY 28, 2019
NATASHIA BOTTOMS, PGY-2
So you’re at your outpatient longitudinal clinic
about to see your next patient…
Case 15 year old girl with T21 here for abdominal pain
HPI
Timing: Initially started 1 year ago, worse for past several weeks
Intensity: Has been sent home from school several times crying
Quantity: Episodes last 30 minutes to 3 hours and occur nearly every day
Mom has noted is that the pain sometimes occurs about an hour after pt drinks milk, though it can occur
without drinking milk.
Trisomy 21
VSD s/p closure
Primary pulmonary hypertension
Obstructive sleep apnea
Hypothyroidism
Hearing loss, scheduled to have surgery in 2 months
Reflux – three months ago had globus sensation/reflux, took omeprazole
for 1 month with improvement in sxs and then stopped
History of chronic constipation, now resolved with daily Miralax
Family and Social History
Physical
Throat: no erythema or exudate
Exam CV: RRR, no MRG, normal S1/S2, pulses 2+ and symmetric bilaterally
Abd: Soft, points to RUQ when asked about pain but does not flinch with exam, some voluntary guarding
throughout; normal BS, no masses or hepatosplenomegaly
Ext: warm and well-perfused; no cyanosis, edema, or clubbing
Neuro: CN 2-12 intact, grossly normal strength with moderate hypotonia, no focal deficits
Psych: limited verbal ability; anxious affect with restricted eye contact
Growth Chart
Differential Diagnosis – 15 y/o with T21 presenting with acute on
chronic abd pain
Gastrointestinal: Pulmonary:
Constipation Vascular: Lower lobe pneumonia
GERD Hemolytic Uremic Syndrome
Peptic ulcer disease Henoch-Schonlein-Purpura (HSP) Metabolic
Lactose intolerance Porphyria Hyper/hypoglycemia
Gastritis Adrenal insufficiency
Gastroparesis Gynecologic: Thyroid disease
Gastroenteritis Pregnancy (or Ectopic Pregnancy)
Bowel Obstruction Mittelschmerz Functional
Gallbladder disease (Biliary Colic, Dysmenorrhea IBS
Cholecystitis) Pelvic Inflammatory Disease Abdominal Migraine
H. Pylori Ovarian Torsion Dypepsia
IBD Imperforate Hymen Functional Abdominal Pain
Pancreatitis
Abdominal Trauma Urinary: Miscellaneous:
Inflammatory Bowel Disease UTI/Pyelonephritis Ingestion
Mesenteric Lymphadenitis Nephrolithiasis Child Abuse
Celiac disease Neoplasm
Labs
B-HCG negative
Lipase, amylase wnl
Free T4 1.06, TSH 1.87
TTA, Deaminated Gliadin Peptide 9 negative
IgA 246
UA normal
CBC: WBC 5.8 (27% bands, 34%N, 27%L, 11%M, 1%B); Hgb 15.5, Hct 44.3, MCV 89.3, Plt 143
CMP: Na 130, K 5.3, Cl 105, CO2 22, Agap 13, Glucose 91, BUN 16, Cr 0.68, Ca 10.7, Prot 8.6, Alb
4.7, TBili 1.0, Alk Phos 130, ALT 32, AST 39
RUQ Abdominal U/S
FINDINGS:
Liver is unremarkable in appearance. No liver mass. Liver span measures 12.1 cm.
IMPRESSION:
Dependent gallbladder sludge, without evidence of cholecystitis.
Somatization Disorders
Somatization Disorders
4 major categories: neurological, gastrointestinal, cardiac, and
pain
What it is:
MUPS – Medically Unexplained Physical Symptoms
Functional disorders
Conversion disorder (neurologic) – separate disorder in DSM
What it isn’t:
Illness anxiety disorder (hypochondriasis) – typically
symptoms not present
Factitious disorder – not intentionally producing symptoms
Munchausen or Munchausen by proxy
Somatoform Disorders (DSM V)
One or more physical symptoms that are distressing or cause disruption in daily life
DO DON’T
Create a differential Do unnecessary workup
Investigate red flag symptoms Dismiss the symptoms or say “nothing is
wrong”
Educate, educate, educate
Force the issue if patient denies any
Create a symptom management plan
mental health complaints
Reassure
Hospital Setting
Functional approach
Educate family on workup, diagnosis, and treatment
Create a daily schedule
Behavioral Health
PT/OT/speech as appropriate
Education consult to address school reintegration
Can consider brief rehab stay if significantly impaired
At discharge, need weekly PCP follow-up, outpatient
CBT, other therapies as indicated
Mind/Body
Connection
COGNITIVE/BEHAVIORAL
thoughts about illness—Illness
behaviors—prior learning
PSYCHOLOGICAL PHYSICAL
Emotional responses— biomedical
reinforcement—psychiatric processes—autonomic
history dysfunction—body
conditioning
ILLNESS
EXPERIENCE
Relaxation Techniques,
Pacing
Coping Mechanisms
Behavioral Cognitive
Activation Restructuring Exercise Plan
Practice Pearls
Our patient
Exercise program and outpatient therapy with excellent response
Bibliography
Al Awwad, Ahmed. “Recurrent Abdominal Pain in Pediatrics.” Urology Resident at King Fahad Military Medical
Complex, 23 Feb. 2013.
Chacko MD, Chiou MD. Functional abdominal pain in children and adolescents: Management in primary care. Post
TW, ed. UpToDate. Waltham, MA: UpToDateInc. http://www.uptodate.com (Accessed Dec 2017).
Henningsen, Peter. “Management of Somatic Symptom Disorder.” Dialogues in Clinical Neuroscience. 2018 March;
20(1): 23–31. Online https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6016049/ (Accessed Jan 2019).
Levensen, J., MD, Dimsdale, J., MD, & Solomon, D., MD. (2018, January). Somatic symptom disorder: Assessment and
diagnosis. Online https://www.uptodate.com/contents/somatic-symptom-disorder-assessment-and-diagnosis.
(Accessed Jan 2019)
Khan, Seema. “Functional Abdominal Pain in Children.” Functional Abdominal Pain in Children, American College of
Gastroenterology, Dec. 2012, patients.gi.org/topics/functional-abdominal-pain-in-children/.
Murphy, J.L., McKellar, J.D., Raffa, S.D., Clark, M.E., Kerns, R.D., & Karlin, B.E. Cognitive behavioral therapy for chronic
pain among veterans: Therapist manual. Washington, DC: U.S. Department of Veterans Affairs.
Robitz, Rachel. “What Is Somatic Symptom Disorder?” Warning Signs of Mental Illness, American Psychiatric
Association, Nov. 2018, www.psychiatry.org/patients-families/somatic-symptom-disorder/what-is-somatic-symptom-
disorder. (Accessed Jan 2019)
Somatic symptom disorder. (2018, May 08). Retrieved from https://www.mayoclinic.org/diseases-
conditions/somatic-symptom-disorder/diagnosis-treatment/drc-20377781. (Accessed Jan 2019).