1. The Power of Change: A Case of a Adolescent with Multiple MedicalConditionA Clinical Case PresentationAlejandro E. Legarda III MD First Year ResidentDFCM

2. Objectives To present an adolescent with hypertension and obesity and its correlation to Metabolic syndrome and PCOS To discuss the differential diagnosis for high BP in the young To discuss the approach to management of adolescent with hypertension, obesity and the diagnose syndromes To present short-term and long-term wellness plan appropriate for the patients condition 3. Patient ProfileEJ13 years oldSingleRoman CatholicIncoming 3rd year high school studentChief ComplaintELEVATED BLOOD PRESSURE 4. Clinical History The patient was then eight years oldand sought a consult due to her re-occurring erythematous vesicularlesions. Upon consultation, she was diagnosed Five years with Post-streptococcalprior toglomerulonephritis. The patients wasadmitted in the hospital for a week due consultto this condition. Patient was documented to suffer from(2007)hypertension. Nifedipine was prescribedto control and manage herhypertension.After hospitalization, patient felt well again. No follow-up consult wasrecommended to the patient. 5. Clinical History The patient started gaining weight as food intake severely increased. Patients BP was taken annually Three years in school and showed elevated blood pressure. prior to The increased blood pressure consult readings was simply ignored by the patient and her parents,(2009) thus resulting in progressive, uncontrolled weight gain. 6. Clinical History Patient sought consultation at the UP-PGHDermatological Department for her vesicularlesions. Patient featured an incidental finding of 160-90blood pressure reading. Assessment reveals:Acne vulgaris with etiology related to PCOSTwo weeks prior toHypertension secondary to (1) PCOS (2)Cushings Syndrome (3) Insect bite hyper consultsensitivity reactionPatient was given: Amlodipine (5mg./tab) OD Benzoyl Peroxide gel OD Tretinoin cream for the face Cloxacilin (500mg./tab) for 7 days Mupirocin Bethamethasone ointment ITD Sunscreen mild soap Patient was referred to Pedia adolescent, hence the consult. 7. Clinical History At Consult (March 26, 2012) Patient was seen at the Pedia Adolescent Clinic 8. Review of Systems(+) polyuria(+) polydipsia(-) neck pain(-) rashes(-) abdominal pain(-) epistaxis (-) constipation(-) gum bleeding(-) diarrhea(-) neck pain (-) urgency(-) dysphagia (-) frequency(-) chest pain(-) dysuria(-) orthopnea (-) nocturia(-) dyspnea on exertion (-) hematuria(-) orthopnea (-) heat intolerance(-) edema (-) jaundice 9. Past Medical History(-) Asthma(-) Allergy(-) Pulmonary Tuberculosis(-) Bronchial asthmaNo Accident and injuryHospitalizations:Admitted for (+) PSGN (2007) and Dengue Fever (2009)Surgeries:There was no previous surgeryMedications:Co-amoxiclav for her recurrent skin infections 10. OB/GYNE HistoryMenarche: January 2011Irregular flow occurring only 3x since her menarcheLasting 4-5 days, Pads 2-4 a dayNo dysmenorrheaNo sexual contact 11. Birth and Maternal HistoryPatient was born full-term via spontaneousvaginal delivery at a local hospital delivered byan obstetrician with no known feto-maternalcomplications. 12. NUTRITIONAL HISTORYPatient was breastfed for 3 months and then shiftedto bottle feeding of Bona milk every 3 to 4 hoursstarting at 4 months old up to 12 months old.Complementary feeding was started at 6 monthsold.Patient would skip breakfast but would have 2snacks before a heavy lunch. She would have 2 heavymeriendas, e.g.,2 hamburgers/hotdogs or cups of icecream .Most of the food she eats are either fried orsalty and plenty of desserts. She loves to drink cola. 13. Immunization HistoryChildhood VaccinationsBacillus Calmette-Guerin (BCG), one doseHepatitis B vaccine, three dosesDiptheria Pertussis Tetatnus (DPT), three dosesOral Polio Vaccine, thress dosesMeasles, one dose 14. FAMILY GENOGRAMJorgo FamilyMarch 26, 2012I76806875II 3256 545046 Hypertension Accident 5248 OverweightDiabetesIII EJ191815 13ElaisaMJJJ 15. Personal and Social HistoryHome:- lives with parents and four siblings in Imus, Cavite-good relationship with parents and siblingsEducation:-Incoming third-year high school student-With above-average grades- has close set of friends in schoolActivities:-Favorite past time eating-Loves eating street foods and junk foods-Spends most of her free time in front of the TV orcomputer-Not involved in any outdoor activities such as sports 16. Personal and Social HistoryDrugs:-No history of cigarette or alcohol use-Denies use or history of use of illicit drugsSexual:-Does not showcase any consciousness with body weight andshape-Patient has not attempted to change her appearance-Currently no relationship with the opposite sexSuicidal Tendencies:-Patient exhibits no signs or episodes of depression or suicidalideationSafety:-Patient together with her family lives in a peaceful and orderlycommunity with minimum crime rate- uses public transportation to commute-Not a member of a gang or sorority 17. Physical ExaminationGeneral Survey:Awake, alert, coherent, in pain, not in cardio-respiratory distress(-) muscle wasting(-) moon face(-) proximal muscle weakness(-) buffalo humpVital Signs:Blood Pressure: 150/90(>99th percentile)Heart Rate: 75 beats/minuteRespiratory Rate: 18 breaths/minuteTemperature: 36.8 C 18. Physical ExaminationAnthropometrics:Height: 157 cmWeight: 96.5 kgBody Mass Index: 40.7 kg/m2(Z score: 2.58)Abdominal Circumference 102cm 19. Physical ExaminationHead and Neck:Anicteric sclerae, pink conjunctivae,pupils 2-3mm OU reactive to light,(+) Short leg length(+) Acanthosis nigricans,(-) masses, (-) cervical lymphadenopathy,(-) anterior neck mass(-) tonsillopharyngealcongestion,(-) neck vein engorgement, (-)ear discharge 20. Physical ExaminationChest and Lungs:Equal chest expansion, no deformities,no lesions, clear breath sounds,(-) crackles/rales/wheezesHeart:Adynamic precordium, distinct heart sounds,apex beat at 5th intercostal space left midclavicular line,regular rate and rhythm, no murmurs 21. Physical ExaminationAbdomen:flabby(+) Striae lower abodomenno deformitiesno lesionsSoft normoactive bowel sounds(-)masses or tendernessliver span 8 cm right midclavicular lineintact Traubes spaceno costo-vertebral angle tenderness 22. Physical ExaminationExtremitiespink nailbedsfull and equal pulsesno cyanosis/clubbing/ edemano crepitationsno limitation of passive and active motionon both upper extremities(-) shooting pain on straight leg raise ofboth lower extremities(-) limitation of motion due to painno crepitations on hips, knees or anklesno joint swelling or deformities(-) Pain on active leg raise of bothlower extremities 23. Physical ExaminationNeuro ExamCranial Nerve (CN) ExaminationCN I intact gross olfactionCN II pupils 2-3 mm OU briskly reactive to lightCN III,IV,VI full range of extraocular muscle movementCN V brisk corneals, good masseter tone,CN VII no facial asymmetry, no altered tasteCN VIII intact gross hearing, no lateralization on Weber TestCN IX no altered taste, can swallowCN X can swallowCN XI good symmetrical shrugCN XII can protrude tongue, no deviation 24. Physical ExaminationSensoryPain: Intact on all dermatomesLight Touch: Intact on all dermatomesVibratory: Intact on all dermatomesMotorNormal GaitGood muscle tone, no atrophy, no limb size discrepancyFull motor strength on both upper extremitiesTanner Stage 3External genitalia with dark, coarsecurly hair spreads over mons pubisElevation of Breast contour; areolae enlarged 25. Salient Features of the CaseSALIENT FEATURES OF THE CASEA 13-year old femaleChief complaint of elevated blood pressureHistory of hypertension ,DM and ObesityPrevious history of renal disease (+) poluyuria, (+)polyphaga.AmenorrheaObesityAnthropometrics: Height: 157 cm, Weight: 96.5 kg, BodyMass Index: 40.7 kg/m2 (Z score: 2.58),(+) Short neck length(+) Acanthosis nigricans nape area,Flabby abdomen with (+) Striae 26. Initial ImpressionHypertension, Stage II-- etiology to bedeterminedAcne Vulgaris probably secondary to PCOSDM suspectObese, Type 2Amenorrhea secondary to PCOS 27. ManagementDiagnostics:Complete Blood Count (CBC)Plasma sodium, potassium and calciumBUN, CreatinineFasting plasma glucoseLipid profileUrinalysisWhole AB ultrasoundChest X--rayECGTSH, FT4 28. TherapeuticsContinue the following medications:Cloxacillin 500 for 7 daysTretnoin Cream for the faceMupirocine Betamethasone ointment, TIDSun screen useMild soap useStart Amlodipine 5mg once a day 29. Approach to Hypertension 30. European Society of HypertensionThe study mentioned childhood BP has been shown totrack into adulthoodUnlike adults, the diagnostic criteria for elevated BP inchildren are based on the concept that BP in childrenincreases with age and body size, making it impossible toutilize a single BP level to define hypertension. 31. Specific recommendations for office BPmeasurement in children and adolescentsThe recommended method is auscultatory.Use K1 for systolic BP and K5 for diastolic B.If the oscillometric method is used, the monitor needs to be validatedand if hypertension is detected by the oscillometric method, it needs tobe confirmed using the auscultatory method.The Use the appropriate cuff size according to arm width (40% of thearm circumference) and length (4_8 cm, 6_12 cm, 9_18 cm, 10_24 cm,to cover 80100% of the individuals arm circumference). 32. Blood Pressure for Girls by Age and Height Percentiles 33. Systolic and diastolic ambulatory blood pressure (systolic/diastolic) values for clinical use 34. Task Force for Blood Pressure in Children, the Fourth Report onthe Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and AdolescentsThe normal BP in children is defined as SBP and DBP less than90th percentile for age, sex and height.Hypertension is defined as SBP and/or DBP persistently 95thpercentile or more, measured on at least three separate occasionswith the auscultatory method.Rule out White-coat (or isolated office) and masked (orisolated ambulatory) hypertensions 35. Definition and Classification of Hypertension in Children and Adolescents 36. Diagnostic Algorithm of Hypertension 37. Clinical Data To NoteFAMILY HISTORYHypertensionCardiovascular and cerebrovascular diseaseDiabetes mellitusDyslipidemiaObesityHereditary renal disease (Policystic kidney disease)Hereditary endocrine disease (pheochromocytomaglucocorticoid-remediable aldosteronism, multiple endocrine neoplasia type 2, von HippelLindau)Syndromes associated with hypertension (neurofibromatosis) 38. Clinical Data To NotePERINATAL HISTORYBirth weight, gestational age, oligohydramnios,anoxia, umbilical artery catheterizationPREVIOUS HISTORYHypertensionUrinary tract infection, renal or urological diseaseCardiac, endocrine (including diabetes) or neurologicaldiseaseGrowth retardationSymptoms suggestive of secondary hypertensionDysuria, thirst/polyuria, nocturia, hematuriaEdema, weight loss, failure to thrivePalpitations, sweating, fever, pallor, flushingCold extremities, intermittent claudicationVirilization, primary amenorrhea and male pseudohermaphroditismSymptoms suggestive of target organ damageHeadache, epistaxis, vertigo, visual impairmentFacial palsy, fits, strokesDyspnea 39. Clinical Data To NoteSleep history:Snoringapnea,daytime somnolenceRisk factor history:Physical exercise, dietary habitsSmoking, alcoholDrug intake:Anti-hypertensivesSteroids, cyclosporinetacrolimus or otherTri-cyclic anti-depressantsatypical antipsychoticsdecongestantsOral contraceptivesillegal drugsPregnancy 40. Physical Examination To Note Data to record:HeightWeightBody mass indexExternal features of syndromes/conditions associated withhypertensionNeurobromatosisKlippelTrenaunayWeberFeuersteinMimsVon HippelLindauMultiple endocrine neoplasiaPseudoxanthoma elasticumTurner,WilliamMarfanCushingHyperthyroidism,LupusVasculitisCongenital adrenal hyperplasia 41. Physical ExaminationData to RecordCardiovascular examinationPulse and BP measurement in both arms and legsBruits/murmurs heart, abdomen, anks, back,neck, headSigns of left ventricular hypertrophy or cardiac failureAbdomenMasses Wilms, neuroblastoma, pheochromocytoma, autosomaldominant and recessive polycystic kidney disease, multicystic kidneydisplasia, obstructive uropathyHepatosplenomegaly autosomal recessive polycystic kidney diseaseNeurological examinationFundoscopy for hypertensive changes and retinalamartoma (von HippelLindau)Evidence of VIII nerve palsyOther neurological defects including stroke 42. Indicators on Physical Exam of Etiology of Hypertension in a Child ThyromegalyHyperthyroidism Acne, hirsutism, striaeCushing syndrome, anabolic steroid abuse Cafe-au-lait spotsNeurofibromatosis Adenoma sebaceum Tuberous sclerosis Malar rash Systemic lupus erythematosus Acanthrosis nigricansType 2 diabetes Chest widely spaced nipplesTurner syndrome Heart murmur Coarctation of the aorta Friction rub Systemic lupus erythematosus (pericarditis), Abdomen Mass Wilms tumor, neuroblastoma,pheochromocytoma Epigastric/flank bruit Renal artery stenosis Palpable kidneys Polycystic kidney disease, hydronephrosis,multicysticdysplastic kidney Genitalia Ambiguous/virilization Adrenal hyperplasia Extremities Joint swelling Systemic lupus erythematosus, collagen vasculards Muscle weaknessHyperaldosteronism, Liddle syndrome 43. Patient PE PresentationSignificant Anthropometrics:Height: 157 cmWeight: 96.5 kg,Body Mass Index: 40.7 kg/m2 (Z score: 2.58)(+) Short neck length(+) Acanthosis nigricans nape areaFlabby abdomen with (+) Striae(+) AcneOther details were none pertinent 44. Target Organ Damage To NoteHeartBlood VesselsKidneyNeuroFundoscopy 45. HeartLeft Ventricular Hyperthrophy (LVH) remains to date the mostthoroughly documented form of end-organ damage caused byhypertension in children and adolescents. 46. Blood VesselsMorphological changes of the arterial wall, thickening of the intima-mediacomplex.Children with familial hypercholesterolemia have higher IMTOverweight and obesity are associated with increased IMT in children with orwithout essential hypertension. 47. KidneyHypertension-related renal damage is basedon a reduced renal function or an elevatedUAE. Proteinuria is a marker of glomerulardamage inprimary and secondaryglomerulopathies. An indication for BP-lowering interventions.Microalbuminuria (20300mg/g creatinine,230 mg/mmol creatinine, 30300 mg/day,20200mg/min) has been shown to predict thedevelopment of diabetic nephropathy .Overt proteinuria (>300 mg/day) indicatesthe existence of established renal parenchymaldamage. 48. Neuro and FundoscopyCerebral seizures, stroke, visualimpairment and retinal vascular changes arecomplications associated with severehypertension.Fundoscopy was also done in because ina study of 97 children and adolescents withessential hypertension, found that 51%displayed retinal abnormalities, as detectedfrom direct ophthalmoscopy. 49. Obesity and HypertensionUsing the 2000 CDC growth charts, at risk of overweightfor ages 2 to 20 years overweight is defined as a BodyMass Index (BMI)-for-age between the 85th and the 95thpercentiles.Overweight in children is defined as a BMI-for-age at orabove the 95th percentile on the charts.BMI is weight in kilograms divided by height in meterssquared (kg/m2).BMI is used differently to define overweight in childrenand adolescents than it is in adults. In children andadolescents, BMI changes with age and gender. 50. Obesity and HypertensionOverweight children and adolescents are atincreased risk for various chronic diseasesin later life.The psychosocial consequences ofoverweight are significant. Overweight inchildren has been linked to socialdiscrimination, a negative self-image inadolescence that often persists intoadulthood, parental neglect, and behavioraland learning problems. 51. Obesity and HypertensionBeing overweight is probably the mostimportant of the conditions associated withelevated BP in childhood and accounts formore than half the risk for developinghypertension.Adiposity is the most powerful risk factorfor higher BP.Waist circumference (abdominal obesity)has been shown to play a role.Dietary habits like high salt intake, havebeen implicated as factors favoring higher BPvalues. 52. Obesity and HypertensionThe CDC mentions the Common MedicalConsequences of Overweight (Dietz,1998)hyperlipidemiaglucose intolerancehepatic steatosischolelithiasissleep apneaObesityhypoventilation syndromehypertensiona variety of orthopedic complications 53. Laboratory Investigations Routine tests that have to be performed in allhypertensive childrenFull blood count and proteinuriaPlasma sodium, potassium and Renal ultrasoundcalcium, urea, creatinine Chest Xray, ECG and 2-DFasting plasma glucose echocardiographySerum lipids (cholesterol, LDLcholesterol, HDLcholesterol)Fasting serum triglyceridesUrinalysis plus quantitativemeasurement ofmicroalbuminuria 54. Recommended additionalscreening tests Plasma renin activity, plasma aldosterone concentration Urine and plasma catecholamines or metanephrines Tc99 dimercaptosuccnic acid scan Urinary free cortisol More sophisticated tests that should await results of above screening Color Doppler ultrasonography Captopril primed isotope studies Renal vein renin measurements Renal angiography I123 metaiodobenzylguanidine scanning Computed tomography/ Magnetic resonance imaging Urine steroid analyses and more complex endocrine investigations Molecular genetic studies (Apparent mineralocorticoid excess, Liddles syndrome, etc) 55. SECONDARY HYPERTENSIONSustained hypertension can beclassified as secondary when aspecific cause can be found, thenit can be corrected with specificintervention.There should be work-up shouldbe done if hypertension . 56. Diagnosis of Secondary Causes ofHypertension 57. MY MANAGEMENTDiagnostic ExaminationsLaboratory Plan:Complete blood countPlasma sodium, potassium and calcium,BUN, CreaFasting plasma glucoseLipid ProfileUrinalysisWhole AB ultrasoundChest Xray, ECGTSH, FT4 58. APPROACH TO MANAGEMENTNon pharmacologic Strategy Recommendations:GOALS:BMI