Adolescent Medicine. Management and Referral Guidelines

Transcription

1 Adolscnt Mdicin Providd by Adolscnt Mdicin Maria Mong, MD, FAAP Dian Rainosk, PPCNP-BC Pdiatric/Adolscnt Gyncology Roshi Mansouri Zinn, MD, FACOG 1

2 Eating Disordrs (F50.0-F50.8) and thir Mdical Complications Psychiatric Diagnoss: ICD-10 Anorxia Nrvosa: F 50.0 Unspcifid typ: F50.00 Rstricting typ: F50.01 Bing ating/purging typ: F50.01 Atypical Anorxia Nrvosa: F50.8 Avoidant/Rstrictiv Food Intak Disordr: F50.8 Bing Eating Disordr: F50.8 Bulimia Nrvosa: F50.2 Othr Spcifid Fding or Eating Disordr (x. sub-thrshold BN, AN): F50.8 Mdical complications of ating disordrs: ICD-10 Abnormal Wight Loss: R63.4 Imbalanc of Constitunts of Food Intak: E63.1 Protin Calori Malnutrition: E44.0, E44.1, E43.0 Targt Population Clinical Findings Eating disordrs ar most oftn diagnosd in adolscnts and young adults; howvr ating disordrs can affct patints of all ags, gndr, rac, socioconomic status, body wight and shap. Patints with ating disordrs may xhibit a varity of symptoms dpnding on thir condition. Patints with Anorxia Nrvosa (AN) and Atypical Anorxia Nrvosa (AAN) rstrict thir food intak rgardlss of th implications for thir physical and psychological halth. In AN, patints hav a low body wight and in AAN, patints hav all of th faturs of AN, but thir body wight rmains normal. Ths patints may prsnt with many diffrnt mdical complications including cardiovascular compromis, muscl wasting, cognitiv impairmnt, gastrointstinal complaints and findings, ostopnia, anmia, amnorrha and infrtility, among othrs. Patints with Bulimia Nrvosa xhibit bing ating followd by compnsatory wight losing bhavior such as forcd vomiting, ovr-xrcis, laxativ or diurtic ovrus. Thy may prsnt with lctrolyt abnormalitis, cardiovascular compromis, fluid disturbancs, poor dntition, 3

3 gastrosophagal rflux symptoms, or intstinal complaints from laxativs, among othrs. Th most common ating disordr in th Unitd Stats is Bing Eating Disordr which is charactrizd pisods of out of control ating whn not hungry or alrady full and is not followd by any compnsatory wight losing bhavior. Typically, ths patints ar markdly ovrwight and mdical complications aris from thir ovrwight/obs status. During th initial valuation, answrs to th following important qustions and physical findings should b dtrmind: Evaluation and Tratmnt Rcommndations History: How much wight has th patint lost and ovr what priod of tim? Is th patint currntly rfusing to at or drink? Is th patint complaining of syncop, pr-syncop or palpitations? Is th patint suicidal? Dos th patint hav an outpatint ating disordr tam in plac (thrapist, ditician, tc.)? Physical Exam: Currnt hight and wight % mdian BMI (patint s BMI/50 th cntil BMI for ag) Blood prssur and hart rat aftr lying for 5 minuts and thn standing aftr 2 minuts Tmpratur Labs/studis (rcommndd): CBC with diffrntial: CPT CMP: CPT TSH with rflx to T4: CPT ESR: CPT EKG if HR <50: CPT Rd Flags If at any tim patint dvlops signs/symptoms that mak mor urgnt valuation important, plas alrt our clinic ( ) to this chang in status. 4

4 T h s g u i d l i n s Tratmnt Rcommndations Additional Information Indications for immdiat rfrral to DCMC ER or considration of dirct admit to DCMC: Acut food and/or fluid rfusal for 24 hours <70% mdian BMI for ag Hypothrmia <96F HR < 45 (Bradycardia should NOT b considrd normal in an athlt) Symptomatic orthostasis Syncop Suicidailty Elctrolyt disturbancs (x. Hypokalmia, hyponatrmia) Indications for urgnt valuation (within 2 wks, unlss abov critria dvlop): <80% mdian BMI for ag HR Rcurrnt vomiting (>1 tim pr day) with normal lctrolyts Indications for timly valuation (within 4-6 wks, unlss abov critria dvlop): >80% BMI for ag HR >50 Rcommndd monitoring by PCP prior to Adolscnt Mdicin Evaluation: Patint should stop xrcising Prscrib additional snack or supplmnt (x. 1 can Boost/Ensur/Ensur Plus pr day) Wkly wight chck (in gown) Wkly vital sign (including supin rsting HR and orthostatics) and symptom chck Considr having family start finding outpatint tratmnt tam (thrapist, ditician) S Appndix I for common adolscnt mdicin ICD-10 Cods and dfinitions. If at any tim patint dvlops signs/symptoms that mak mor urgnt valuation important, plas alrt Adolscnt Mdicin clinic ( ) to this chang in status. 5

5 Ths guidlins ar dsignd to b usd by primary car physicians wishing to rfr childrn and adolscnt patints with suspctd ating disordrs for additional valuation and car. Thy ar rcommndations and ar basd on bst vidnc and xprt consnsus 1. 1 Position Papr of th Socity for Adolscnt Halth and Mdicin: Mdical Managmnt of Rstrictiv Eating Disordrs in Adolscnts and Young Adults. Journal of Adolscnt Halth, Volum 56, Issu 1,