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How would you evaluate and manage a pediatric patient who has BP and BMI greater than what is expected for his/her age group? Which additional conditions would you want to screen for and why?

To manage and evaluate a pediatric patient having obesity or hypertension concerns, one needs to obtain a weekly BP and weight chart. Furthermore, it is also appropriate to obtain a log of everything that patient has been eating and the information about how active they are daily. It is also appropriate to obtain information about the daily screen time of that patient and their daily sleeping habits. It is essential to obtain such information because they allow the clinicians or nurse practitioners to evaluate and determine the patient’s lifestyle changes that need to be solved or addressed as required (Cuda & Censani, 2019). Moreover, the information also allows the relevant stakeholders, such as the nurse practitioners determine whether these habits play a role in BP and weight concern, thus warranting additional testing. Evaluating pediatric patients with hypertension in the primary care setting begins with routine screening. Routine blood pressure screening should begin annually at age three. BP percentiles are determined by sex, age, and height on a standard growth cure. Elevated blood pressure is greater than the 90th percentile. Stage 1 hypertension (HTN) is greater than the 95th to 99th percentile plus 12mmHg. Stage 2 HTN is greater than the 99th percentile plus 12 mmHg (Maaks, Starr, & Gaylord, 2019). Managing HTN in the primary care setting is done first by diagnosing it. HTN can only be diagnosed if HTN is documented on three separate occasions. Initial evaluation for children with stage 1 HTN includes a complete blood count (CBC), serum nitrogen, creatinine, electrolytes, lipid panel, glucose, and urinalysis. A renal ultrasound should be done if urinalysis or renal function tests are abnormal. Initial management for HTN includes nonpharmacological measures including diet, exercise, and weight management. Medication management should be considered when HTN is symptomatic, HTN is stage 2 without a modifiable factor, and persistent HTN despite nonpharmacological measures. (Bunik, 2020). Additional conditions that should be screened for children with HTN include obesity, renal disease, type 1 or 2 diabetes mellitus, or known heart condition. These children should have BP screened earlier and at every visit as well as medication management may be indicated (Maaks, Starr, & Gaylord, 2019).  

Evaluating pediatric patients with obesity in the primary care setting also begins with routine screening. Obesity is screened in pediatric primary care by obtaining a history of diet and activity and plotting measurements on a growth chart. For children under two, the growth chart is based on a weight and height ratio The standard for measuring obesity in children older than age two is by calculating the body mass index (BMI). The BMI is plotted on a growth chart that is sex and age-appropriate. A BMI between the 85th and 95th percentile is considered overweight. A BMI over the 95th percentile is considered obese and is associated with secondary complications. A BMI greater than the 99th percentile indicates severe obesity and is associated with higher risks or complications (Bunik, 2020). Genetics, epigenetics, behavior, and environment contribute to childhood obesity. Obesity is managed in the primary care setting initially through prevention. This is done by routine monitoring and counseling. This includes identifying risk factors and developing interventions for the modifiable ones such as diet and exercise (Skelton, 2021). Additional conditions that should be screened for children with obesity include cardiovascular disease as well as endocrine, orthopedic, pulmonary, and mental health problems (Bunik, 2020).

Additional conditions that will be appropriate to screen are thyroid issues and diabetes. These conditions can sometimes cause weight gain and an increase in blood pressure. Therefore, nurse practitioners need to identify and understand the root cause of hypertension and obesity to be able to create a better treatment plan. Thyroid issues can sometimes lead to high blood pressure. Consequently, diabetes plays a huge role in high blood pressure and obesity.

What physical exam findings and diagnostic results would be concerning to you in this patient and why? What would be three differentials in this case?

The patient will not be given any particular diagnostic test at the appointment visit. A diagnostic test for 8-year-old Jimmy was given during his follow-up visit. The main diagnostic test for this patient is blood work. Some of these tests include fasting glucose or A1c test and the lipid panel test. It will be a concern if the patient's A1c goes above 6.5% when the test is being carried out. This would show that Jimmy is suffering from DM type II (Haimoto et al., 2021). The patient’s father is currently battling hyperlipidemia and diabetes type II, which increases the chances of Jimmy having the disease. It would be disheartening for Jimmy to suffer from such conditions due to her tender age. Diabetes type II can be very dangerous to children. The differential diagnosis for this case includes Diabetes type II, obesity, and HTN. The physical exam findings and diagnostic results that were a concern for eight-year-old Jimmy in the Aquifer case study were his poor controlled attention deficit hyperactivity disorder (ADHD), elevated blood pressure, and elevated BMI making those his three-differential diagnosis.

Attention-deficit hyperactivity disorder, unspecified type F90.9. Jimmy was diagnosed with ADHD-combined type six months ago and prescribed dextroamphetamine/amphetamine 5mg by mouth (PO) daily. His mother reports she has not been consistent with the medications because she is afraid of side effects. And did not follow up to evaluate the effectiveness of his medication. His behaviors have not improved at home or school since his last visit. His mother reports his behavior at home and school as impulsive, inattentive, and hyperactive. His behavior also contributes to him being sedentary as his mother states she does not let him play outside because she is afraid, he may dart out in the street or exhibit dangerous behavior. It also contributes to his poor diet as his mother states she sometimes gives him candy to get him to listen.

Secondary hypertension, unspecified I15.9. Jimmy’s normal blood pressure (BP) is based on his sex and height of 133cm. A normal systolic blood pressure (SBP) for him is less than 110 mmHg and normal diastolic blood pressure (DBP) is less than 71 mmHg. Jimmy’s initial blood pressure was elevated at 120/80 mmHg. A recheck that day showed a blood pressure of 116/76 mmHg which is still considered elevated. Six months earlier his blood pressure was 115/68 mmHg which is also elevated. If a third BP is done on another occasion and is elevated a diagnosis of HTN is indicated. These findings were concerning after reviewing his family history, diet, and activity. His family history revealed his father is obese, has type 2 diabetes mellitus, elevated cholesterol, and hypertension. His paternal grandfather has hypertension, and diabetes, and was on dialysis from end-stage kidney disease. His paternal grandmother also has hypertension. His diet reveals processed foods, candy, soda, and fast food several times a week. For exercise, he only rides his bike once a week and does not play outside. He spends most of his time playing video games and watching television.  

Obesity, unspecified E66.9. Jimmy’s BMI was 25.4 ranking him in the 97th percentile which classifies him as obese. At his previous visit, his BMI was in the 90th percentile. His family history, diet, and sedentary activity contribute to his obesity. Due to the presence of secondary complications such as elevated blood pressure and acanthosis nigricans on the back of his neck and in his axillae, he should lose one pound a month. Although acanthosis nigricans can be genetic, it also suggests an underlying health condition such as obesity, or an endocrine disorder such as insulin resistance. Initial screening for type 2 diabetes or insulin resistance is done for children older than 10 who are overweight or obese and have additional risk factors (Skelton, 2021).

What are your final assessments (diagnoses) for this patient? What is your treatment recommendation and education for the patient and family? Why?

The final diagnosis for this patient is ADHD. The patient had earlier suffered from this type of disease and was placed on a treatment plan. He was given 5mg of dextroamphetamine/amphetamine PO every day. My treatment plan for this patient is to continue using this medication. This medication is very important in situations where a patient has some learning and hyperactive concerns.

The mother of the child admitted that she does not strictly follow the drug prescription, and most of the time, Jimmy is not given the medication as prescribed. This is possibly a repeat condition. Sometimes when drugs are not taken as required or prescribed by the doctor, the condition might recur since it was not properly dealt with initially.

For this patient and the mother, I need to educate and inform them about the importance of taking the drugs as prescribed by the doctor. Moreover, I will also tell Jimmy's mother about the role the medication is given will play in their behavior and the success of Jimmy while in school. I will also inform the mother about lifestyle changes. For instance, I will advise the patient to eat fresh vegetables and fruits more and avoid high-calorie snacks. Although his ADHD is a concern and possibly has led to his obesity, this can be managed with medication compliance and follow-up previously established. His mildly elevated BP is also a concern, but initial management is diet, exercise, and weight loss. This makes Obesity, unspecified E66.9,  his final diagnosis. Obesity can be managed in the primary care setting in three progressive stages. Each stage has specific nutritional goals, activity goals, and behavioral interventions (Skelton, 2021).Stage 1 is for children older than two years old and a BMI greater than the 85th percentile. Jimmy falls into this stage. The nutritional goals include eating breakfast daily, minimizing sugary beverages, eating five servings of vegetables or fruit, and eating most meals at home as a family. Activity goals include less than two hours of screen time or television per day and more than one hour of physical activity. Behavioral interventions include follow-up visits every one to three months and allowing the child to self-regulate eating regimens. (Skelton, 2021). I would recommend a follow-up in one month to evaluate dextroamphetamine/amphetamine compliance and efficiency, BMI, and blood pressure.

References

Cuda, S. E., & Censani, M. (2019). Pediatric obesity algorithm: a practical approach to obesity diagnosis and management. Frontiers in pediatrics, 6, 431. https://www.frontiersin.org/articles/10.3389/fped.2018.00431/full

Edition). McGraw-Hill Learning Solutions. https://digitalbookshelf.southuniversity.edu/books/9781264258390

Haimoto, H., Murase, T., Watanabe, S., Maeda, K., & Wakai, K. (2021). Associations of dietary salt and its sources with hemoglobin a1c in patients with type 2 diabetes not taking anti-diabetic medications: Analysis based on 6-month intervention with a moderately low-carbohydrate diet. diabetes, metabolic syndrome and obesity: Targets and Therapy, 14, 4569. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8610379/

Maaks, D.L. G., Starr, N., & Gaylord, N. (2019). Burns' Pediatric Primary Care (7th Edition). Elsevier Health Sciences (US). https://digitalbookshelf.southuniversity.edu/books/9780323581967

Nik, W.H.L. A. (2020). CURRENT Diagnosis and Treatment Pediatrics (25th

Skelton, J. (2021). Prevention and management of childhood obesity in the primary care setting. UpToDate. Retrieved from: https://www.uptodate.com/contents/prevention-and-management-of-childhood-obesity-in-the-primary-care-setting?source=history#H5799548

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