Morning

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

 Location: Points to RUQ when asked

 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.

 Frequently complains of globus sensation (‘lump’ in the throat)/gags

 No recent vomiting, diarrhea, or constipation

PMHx

 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

 Lives with both parents and 2 healthy siblings

 Mother had gallbladder out at age 22
 Father has high cholesterol
 Maternal grandparents both have Diabetes Mellitus Type II
 While asking about school, you find out she recently
changed schools after an incident where she left
school and was found unsupervised at a mall later
that day.
 Concerns re: sexual assault and behavioral changes
 Occasionally been refusing to eat, and will shut the
curtains and claim that the clouds are scaring her.
Sometimes has difficulty with walks outside.
 SHF is involved; standard STI labs after were negative
 Mom does not feel like the symptoms necessarily warrant
intervention at this time, but is interested in scheduling an
appointment to discuss these concerns in the future.
 Vitals – T: 36.8, P: 65, RR: 18, BP: 95/59

Gen: well-appearing, non-toxic; no acute distress

Head: normocephalic, atraumatic, syndromic facies

Eyes: EOMI, PERRLA, conjunctiva clear with no scleral icterus

Ears: TMs clear and intact

Nose: no rhinorrhea or congestion

Physical
Throat: no erythema or exudate

Neck: supple, no LAD

Exam CV: RRR, no MRG, normal S1/S2, pulses 2+ and symmetric bilaterally

Pulm: CTAB, no increased work of breathing

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

Derm: no rashes or lesions

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.

Right kidney is normal in size, measuring 10.3 cm in length. No hydronephrosis.

Dependent sludge is seen within the gallbladder. No gallstones. No gallbladder wall

thickening. No pericholecystic fluid.

Common bile duct is normal in caliber, measuring 2 mm in diameter.

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

 Excessive thoughts, feelings or behaviors related to the physical symptoms or

health concerns with at least one of the following:
 Ongoing thoughts that are out of proportion with the seriousness of symptoms
 Ongoing high level of anxiety about health or symptoms
 Excessive time and energy spent on the symptoms or health concerns

 At least one symptom is constantly present, although there may be different

symptoms and symptoms may come and go

 Complaints present for at least 6 months

Risk Factors

 Genetic and biologic factors

 Environmental factors (family influence, low SES)
 Exposure to ACES
 Having a medical illness or recovering from one
 Underlying anxiety/depression*
 Decreased awareness of or problems processing emotions
So how do I treat this?
DO
 Create a differential
 Investigate red flag symptoms
 Educate, educate, educate
 Create a symptom management plan
 Reassure
DON’T
 Do unnecessary workup
 Dismiss the symptoms or say “nothing is
wrong”
 Force the issue if patient denies any
mental health complaints
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

SOCIAL & FUNCTIONAL

ENVIRONMENTAL disability in school—activities of
family life—spirituality—family daily living ADLs—Sleep —
Nutrition—Exercise
response—social life
  Breathing Techniques
 Guided Imagery
 Thought Replacement Techniques
Workbooks  Counter-stimulation
 Progressive Muscle Relaxation
Primary Care Setting
In Office Screeners
The Somatic Symptom Scale-8 (SSS-8)
In Office Screeners
Physical Symptoms (PHQ-15)
Cognitive Behavioral Therapy for Chronic Pain

Relaxation Techniques,
Pacing
Coping Mechanisms

Behavioral Cognitive
Activation Restructuring Exercise Plan
Practice Pearls

Diagnosis itself can Avoid “either-or” Communication is Healthy lifestyle Symptomatic

be therapeutic if mental vs physical key treatment when
done right thinking appropriate
  Okay to acknowledge there may be an
undetected organic cause
 Negotiate realistic treatment goals
So What if They (coping vs cure)

Don’t Accept  Listen attentively to physical complaints

Help the patient organize HPI into
The Diagnosis? 
coherent narrative
 Symptom-context diary
 Encourage them to extend view
Prognosis

 Pain resolves in 30% to 70% of patients by 2 to 8 weeks after

diagnosis.

 Factors associated with worse prognosis include male gender, age

younger than six years at diagnosis, more than six months duration of
symptoms before seeking treatment, presence of exacerbating
social factors, and high levels of depression/anxiety symptoms.

 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).