Category Archives: OPD

Medically unexplained symptoms

“Persistent physical symptoms” preferred term? Chronic pain overlaps.

“Functional disorder” is used for various gastro and neurological problems, preferred by some adults, but needs explained!

Chronic fatigue syndrome and PANDAS are health disorders that appear to have a physical/scientific cause but disputed.

Health anxiety, malingering, or factitious illness, different from a psychological point of view.

Bleed the symptoms dry! [John Stone, Glasgow].

In a 1965 paper by Eliot Slater, more than half of patients diagnosed as having “hysteria” later turned out to have “organic” disease – but John Stone’s study of adult neurology referrals found very few who turned out to have an occult disease.

Louise Stone in Australia has done a lot of work in primary care. She identifies negative feelings and a lack of diagnostic language and frameworks as barriers to managing these patients effectively. The negative feelings (such as frustration, shame and helplessness), are shared between doctors and patients…

Managing your own feelings and frustrations, and finding ways of understanding and managing the therapeutic relationship important.

Let family feel validated for all concerns – at least in the first instance. Helps develop a therapeutic alliance.

Commit to the patient, which includes advocacy and support.

Family response to symptoms?

Explore beliefs, specific worries (eg cancer). May then allow broadening out to more general worries. 

Manage uncertainty – including managing the need for a disease name! Not having a predictable outcome is hard.

Harm minimisation. Shift from diagnosis to coping with ongoing symptoms.

Good to offer a tentative preamble to difficult conversations! “This is something we as doctors have to deal with every day – signs and symptoms that are very real, with a real impact on a child/family, but where physical examination and investigations do not offer any clues to what the underlying problem might be…”

Paed psychology if issues mostly seem related to child and this is a new problem; CAMHS if new problem adding to existing child/parent issues.  

Can be rewarding in the long term!

[Louise Stone, Aust Fam Physician 2013 Jul;42(7):501-2]

Long COVID

Doesn’t seem to be associated with severity of initial illness.

Long COVID is less common if you are vaccinated already. In a community based study of adults aged 18 to 69 years infected with SARS-CoV-2 before vaccination against covid-19, the odds of experiencing long covid symptoms decreased by an average of 13% after a first covid-19 vaccine dose, with a further 9% decrease in the odds of long covid after a second dose. [https://doi.org/10.1136/bmj-2021-069676

If you already have long COVID, further COVID immunisations seem to be beneficial, rather than harmful:

  • In a non-controlled study of 900 social media users with long COVID, more than half experienced an improvement in symptoms after vaccination compared with 7% who reported a deterioration.19
  • A study of 44 vaccinated patients and 22 unvaccinated controls previously admitted to hospital with covid-19 in the UK, which inevitably had limited power to detect clinically relevant effects, found no evidence for vaccination being associated with worsening of long covid symptoms or quality of life.20
  • A French study of 455 self-selected participants found reduced long COVID symptom burden and double the rate of remission at 120 days in vaccinated participants compared with unvaccinated controls.

All about symptoms, excluding treatable conditions, then self management. For adults:

Threadworms

=enterobius. Common in young children, probably due to hygiene issues. Also called pinworms. Small (1-2cm), like white threads. Can be intensely itchy, usually in night when worms emerge to lay eggs.

Mebendazole effective at killing live worms in gut, not effective if eggs in vagina. Licensed from age 2 but can be used off license below that. Does not kill eggs however, and main issue is reinfection so consider treating whole family, with repeat doses after 2 weeks when any eggs will have hatched, and follow NHS Inform advice on hygiene.

Sometimes you just have to keep repeating treatment over months/years! Mebendazole is harmless, although symptoms may be caused by clearance of large worm burdens.

Chronic pain

Gate theory useful – it’s not just about the stimulus coming to your nerve endings. That signal has to pass through a gate, to register in your brain, and different things affect whether the gate is more or less open or closed.

A feature of many chronic health conditions, eg juvenile idiopathic arthritis, migraine. Often a feature of chronic fatigue syndrome. Can be part of a functional disorder such as functional abdominal pain. In a limb, can lead to reflex sympathetic dystrophy. But often unexplained.

Think about PTSD – it’s all “in your head” but that doesn’t mean it’s nothing. Or phantom limb pain – there isn’t even a true signal coming from the limb, but you still feel pain.

Pain is performative – no one gets credit for trying to cope and hide it. But you can be accuse of “laying it on thick”.

Having a diagnosis helps socially. 

Pain can make you a different person from who you were. Impatience and irritability can be understood, besides an inability to do some activities that might be important to identity (and to relieving stress). Social isolation is common.

Chronic pain also steals any sense of your future because it is too intolerable to imagine more pain. 

Fear needs to be detached from pain. 

Acceptance therapy – not to accept eternity of pain but to focus on progress and function. 

[Haider Warraich podcast with Kate Bowler]

Contraception and sexual health

All methods with exception of condoms more than 99% effective  – if you use it as directed, of course! Combined – Rigevidon has v safe progesterone.  Evra is a patch (replace each week for 3 weeks then week free).  Nuvaring is monthly ring, less effected by GI problems but more expensive.

Contraindications for any combined product – migraine with aura, first 6 weeks breast feeding.  DVT risk related to which progesterone is in combination – risk triples with levonorgestrel (Rigevidon), norethisterone, norgestimate (Cilest) but quadruples for others.  But cf risk in pregnancy, more than 10x higher. UKMEC has risk table for family history etc.

Move towards only 4 pill free days – to avoid risk of ovulation if you miss day 1.  Ultimately going to 63-84 days continuously (3-4 packs) but potentially confusing as need to stop and start on different days of the week.

Progesterone only pills were just barrier methods, due to effect on mucus. Cerazette (desogestrel) different, inhibits ovulation without other oestrogen effects. Bleeding is quite common in early days.  Good for controlling cycle related problems eg menorrhagia, catamenial migraine. Good for young people because continuous. Depot good as lead in for implant (else weight gain as side effect).

Nexplanon is implant, under local, lasts 3 years.  But side effects include irregular bleeding. 

Enzyme inducers – cbz, phenytoin, topimarate! And st john’s wort! Rifampicin.  Lamotrigine is not an inducer, but interacts with COCP/POP so avoid unless no other option, in which case needs dose adjustment and must be continuous method.

Consent to sexual activity often confused! Under 13 cannot consent (so different from medical treatment consent).  Consent must be “free agreement” so sleep, coercion, under influence not allowed.  Disclosure of child protection concerns is tricky due to fear of disengagement with service.

Transition

Jargon for the process of transferring care of child to adult services, or to independent self management.

Paediatricians famously bad at discussing issues such as sex, drugs, alcohol, careers! And famously bad at seeing young people one to one, without parents present!

Raise contraception as soon as puberty comes up in clinic!? But remember that complications of pregnancy probably a bigger issue to discuss!

Ready, steady, go! is RCPCH document on the general principles, whereby you assess readiness for transition, and aim to provide information in an appropriate format (typically in small chunks) and at the right time (young person led). Then ideally one or more joint clinics with adult service, if appropriate.

Screen time

Sedentary time spent in front of screens programs metabolism and brain neurochem.  Similar to addiction.

But it’s complicated! Partly because there are so many different kinds of activity that can now be done with mobile phones and tablets, and because it’s difficult to control or randomize.

How people interact with screens is changing too. In the mid-2000s in the US, children over 8 spent an average of 6.43 hours a day on electronic media, but this was mainly watching TV.  Evidence of stress response (reduced cortisol increase) on waking after using screens for average 3 hours a day.

But now mobile devices are the centre piece of young people’s social lives.  Boys tend to spend more time gaming, girls more time on social networking.

Effect of high levels of screen time does not seem to be attenuated by equivalent exercise.

High levels of screen time (over 4 hours daily) is associated with poorer school performance. Social skills are poorer. These children tend to form cliques with shared interest, that create further social isolation.

Violent games and media are associated with aggression in children as young as pre-school. Aggression in children can be manifest physically, or verbally, or relationally (ignoring, excluding, spreading rumours). There is also significantly more hostile attribution bias, where you interpret behaviour (such as not being invited to a party) as hostile, even when it is not, or at least ambiguous.

Parental involvement matters – how frequently parents watch TV with their children, discuss content with them, and set limits on time spent playing video games.

Exposure to media violence must also be seen within a risks/resilience approach. [Gentile and Coyne, Aggressive Behaviour 2010] ]

Some evidence that some “social” games themed around cooperation and construction eg Animal crossing have benefits. Similarly, links between media and relational violence pretty weak, but that could be because relational violence content isn’t really examined! Actual content probably more important than time spent playing. Note that in that study of Animal Crossing, background mental health problems seemed to reduce benefit.

Hypertension

In children under 10, high BP is usually secondary to an underlying disease or condition. Primary hypertension increasingly recognised in older, obese children.

Do repeated measurements, ideally automated home BP monitoring, before diagnosing hypertension. Check manually as well as with automated device. Beware “white coat effect”, even if not clearly anxious.

Use appropriate cuff size – cuff should cover at least 75% of the upper arm from the acromion to the olecranon (should be sufficient space at the antecubital fossa to apply stethoscope!) .  An inappropriately small cuff will overestimate BP.

Long list of causes, so follow the clues.

Family history important, of course.

Examination

So needs thorough history and examination, including:

  • Fundi
  • Bruits, radiofemoral delay
  • Neck for goitre

Complications

Consider then end organ effects –

  • Proteinuria, high creatinine
  • Retinopathy
  • Left ventricular hypertrophy, cardiac failure
  • Abnormal tone and reflexes, cranial nerve deficits if severe

Management

Depends on how high, whether other risk factors (diabetes, chronic kidney disease), symptoms and evidence of end organ damage.

Initially low salt diet, weight loss (if obese).  Remember other morbidities related to obesity.

Acute hypertension might need frusomide and/or nifedipine.

Long term treatment is only going to be started if no improvement with lifestyle measures. Target BP depends on risk factors, as above.

[2016 European Society for Hypertension guidelines]

Infantile Self-gratification

Sometimes called infantile masturbation – but often doesn’t involve touching the genitals at all, which can lead to confusion – can be mistaken for silent reflux, seizures or painful spasms. 

More commonly girls.  Often starts before the age of 1yr, diagnosis often late (median 11 months delay)!  Can happen in car seats, on floor, high chairs, push chairs, falling to sleep etc. 

Characteristic rocking or crossing of legs, often rhythmic. Grunting, sweating, “zoning out” pretty typical.  Can appear tired afterwards (or tiredness is a trigger) and may fall asleep, which might suggest post ictal period!  Some seem to get upset with it!

Key features are distractability, and in particular, irritation when distracted! [Linda Ross etc, ADC 2004]

Fisting often seen in young infants, in older children grasping of clothes or objects, so not just legs! [Hansen, 2009]

Parent friendly article

Nothing to worry about – but no one likes to talk about it and parents can feel mortified. Very little information on internet about it! Distraction is all that is needed. As they get older it is likely to go away by itself – but otherwise teach that it is a private thing! Avoid shame…

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