Pediatric Primary Care (73 page)

•  Ablation of accessory pathways.

H.  Follow up.

1.  Follow up with pediatrician or specialist as indicated.

2.  Support for chronic pain.

3.  Assess for missed diagnosis if pain persists or worsens.

4.  No cause of chest pain may have been identified. Patient, family may require ongoing support, education, particularly if pain continues.

I.  Complications.

1.  Misdiagnosis.

2.  Sudden cardiac death rare.

J.  Education.

1.  Most often require assurance and education as to noncardiac nature of chest pain and resumption of normal activities.

2.  If cause of chest pain found, education regarding cause and treatment plan.

II. HYPERTENSION

A.  Etiology.

1.  May be early onset of essential hypertension.

2.  Etiology of adult-onset essential hypertension is unclear and thought to be multifactorial with genetic, familial, environmental factors contributing to development of essential hypertension. Becoming more clear that elevations of blood pressure in childhood are beginnings of adult essential hypertension.

3.  May be a sign of underlying pathology (secondary hypertension). a. Renal, cardiac, endocrine diseases.

4.  Related to systemic disease, chronic illness, or medication.

B.  Occurrence.

1.  By definition, 5% of children will have hypertension.

2.  Secondary hypertension is more common in children.

C.  Clinical manifestations.

1.  Definition is systolic and/or diastolic blood pressure consistently above 95th percentile for age, sex, height taken on 3 separate occasions.

a.  Stage 1 hypertension is 95th to 99th percentile +5 mmHg and should be repeated on 3 or more separate occasions to confirm.

b.  Stage 2 hypertension is greater than the 99th percentile +5 mmHg.

•  Prompt referral.

•  Immediate referral if patient is symptomatic.

c.  Prehypertension now defined as readings between the 90th and 95th percentile, and/or greater than or equal to 120/80 in adolescents.

d.  Check blood pressure in left arm and one lower extremity if hypertension present.

2.  Secondary hypertension.

a.  Hypertension secondary to another cause.

b.  Typically more severe elevation of blood pressure.

c.  Younger age.

d.  Severe elevation of blood pressure at any age should trigger an aggressive evaluation to look for an underlying cause.

3.  Essential hypertension.

a.  Typically milder elevation in blood pressure, but still > 95th percentile.

b.  Often associated with obesity.

c.  Typically, family history of essential hypertension.

d.  Elevated heart rate is common.

e.  Variable blood pressure measurements on repeated evaluation.

f.  Often no additional findings on history or physical.

g.  For mild elevation of blood pressure in asymptomatic adolescent, it is more likely to be essential hypertension, particularly if positive family history and/or presence of comorbid conditions.

D.  Physical findings.

1.  Essential hypertension: May be few abnormal physical findings but patient history is important adjunct to determine whether hypertension is essential or secondary.

a.  Family history of hypertension in first- or second-degree relative, myocardial infarction, stroke, renal vascular diseases, diabetes, obesity.

b.  Obesity in patient.

2.  Secondary hypertension: May be physical findings or important clues in patient's history as to possible cause of secondary hypertension.

a.  Neonatal history of invasive umbilical lines.

b.  History of urinary tract infections.

c.  Medication history: OTC, prescribed, and illicit drugs.

•  Tobacco, alcohol, diet pills, anabolic steroids, oral contraceptive pills, pseudoephedrine, phenylpropanolamine.

d.  Headaches.

e.  Weight loss (pheochromocytoma, hyperthyroidism).

f.  Overall slowing of growth parameters may indicate underlying chronic disease.

g.  Webbed neck (Turner syndrome associated with coarctation).

h.  Presence of skin lesions (tuberous sclerosis, systemic lupus erythematosus).

i.  Retinal exam: presence of vascular lesions due to chronic hypertension, papilledema with increased intracranial pressure.

j.  Dysmorphic features: Williams syndrome, Turner syndrome.

k.  Adrenal disorders.

l.  Anorexia, nausea.

m.  Tiredness, irritability.

n.  Epistaxis.

o.  Neurologic symptoms.

•  Headache, nausea, vomiting, anorexia, visual complaints, seizure, papilledema.

E.  Diagnostic tests.

1.  Errors in blood pressure measurement are common: use correct technique, appropriately sized equipment for repeated measurement.

a.  All children 3 years of age or older: blood pressure measured at every pediatric visit.

b.  Appropriate cuff size essential for accurate measurement.

c.  Bladder width of cuff should be 40% of child's arm circumference, bladder should cover 80% or more of circumference of arm.

d.  At least 3 separate measurements to diagnose hypertension.

e.  Measurement should occur after 5 minutes of quiet; child should be seated with back supported and feet on floor.

f.  Auscultation preferred method.

g.  Right arm preferred for measurement.

h.  Ambulatory blood pressure monitoring may be utilized by specialists to more accurately delineate blood pressure readings throughout the day and night.

2.  For all identified as hypertensive:

a.  Serum electrolytes, blood urea nitrogen, and creatinine.

b.  Urinalysis and urine culture.

c.  Complete blood count.

d.  Renal ultrasound.

3.  If overweight and prehypertensive and for all hypertensive:

a.  Fasting lipid panel and fasting glucose.

4.  Drug screen if concern for use of licit or illicit drugs.

5.  Polysomnography if history elucidates snoring.

6.  Evaluation for end-organ damage may be ordered by specialists.

a.  Echocardiogram.

b.  Retinal exam.

c.  Plasma renin.

d.  Renovascular imaging.

e.  Plasma and urine steroid and catecholamine levels.