15 year old female with two week history of headache and GI discomfort

Headache
Symptoms are intermittent Throbbing pain everywhere
Worse in the morning, better mid day, bad again right before bed time Nothing helps
Tried ibuprofen, Tylenol, caffeine, excedrin migraine, hot packs, cold packs

Keeps her up at night

Feels fatigued during the day

GI Upset
Intermittent periods of stomach pain
Cramping, stabbing, throbbing in mid abdomen

Similar pattern to headaches

Worse in the morning and night

Not related to PO intake No change in bowel movements, no symptoms of constipation

Other symptoms
Difficulty sleeping mostly trouble falling asleep
I think too much right before bed

Poor appetite
The pain keeps me from eating

Hot and cold flashes

Happen mostly at school Wearing layers of clothes to cope

No fevers, no change in diet, no change in weight ROS otherwise negative

Denies symptoms of low mood, difficulties with concentration, restlessness, generalized worry, etc..

History
Past Medical History: None, otherwise healthy Developmental History: Met all milestones on time Substance Use: Ive never tried any of it Current Medications: Mom gave me melatonin for sleep
Its not working

Family History: No family history of thyroid disease, GI problems, or migraines. No history of anxiety, or depression.

Social History
Social History:
Middle child of 2 brothers and 2 sisters, parents are married. Currently in 10th grade. Does awesome in school except for three weeks ago when she entered a national essay competition in her English Class now school sucks. Dad lost his job two weeks ago and mom is super stressed about the money stuff Not sexually active but thinking about it

Physical Exam
VSS GENERAL: Thin adolescent female dressed is school uniform. No apparent physical distress. SKIN: No ecchymosis, rashes or abrasions. HEENT: Normocephalic and atraumatic. Moist mucous membranes. NECK: Supple, no lymphadenopathy, no thyromegaly. LUNGS: Clear to auscultation bilaterally. HEART: Regular rate and rhythm. ABDOMEN: Soft, nontender, nondistended. Positive bowel sounds. BACK: No CVA tenderness. GENITOURINARY AND RECTAL: Declined, not indicated at this time. EXTREMITIES: +2 radialis pulse bilaterally, +2 posterior tibialis pulses bilaterally, no tibial edema, no cyanosis noted. NEUROLOGIC: CrN II-XII intact, +2 deep tendon reflexes. Able to perform heel to shin, finger to nose intact. Sensation intact to light touch proximally and distally. Strength symmetrical throughout. Negative Romberg noted normal with gait.

15 year old with two week history of headaches and abdominal pain
DIFFERENTIAL???

Stress and Being Stressed Out

Rachel State, MD/MPH Triple Board PGY-3 (IDCC 2/27/2012)

What is Stress?

"Stress is a state we experience when the demands that are put upon us cannot be counter balanced by our ability to deal with them. -Richard Lazarus

The Good, The Bad, & The Ugly

Good
Motivation Better Performance

Bad
Tension Anxiety Out of Control Overwhelming

The Good, The Bad, & The Ugly

Ugly
Headaches Muscle pains Sleep disturbances GI discomfort Chest pain Food issues

Frequent headaches
Gritting, grinding teeth Stuttering or stammering Tremors, trembling of lips, hands

Insomnia, nightmares, disturbing dreams Difficulty concentrating

Trouble learning new information

Neck ache, back pain, muscle spasms

Light headedness, faintness, dizziness Ringing, buzzing or "popping sounds Frequent blushing, sweating Cold or sweaty hands, feet Dry mouth, problems swallowing

Forgetfulness, disorganization, confusion

Difficulty in making decisions Feeling overloaded or overwhelmed

Frequent crying spell or suicidal thoughts Feelings of loneliness or worthlessness

Little interest in appearance, punctuality Nervous habits, fidgeting, feet tapping Increased frustration, irritability, edginess Overreaction to petty annoyances Increased number of minor accidents

Frequent colds, infections, herpes

Rashes, itching, hives, "goose bumps" Unexplained "allergy" attacks

Heartburn, stomach pain, nausea

Excess belching, flatulence

Obsessive or compulsive behavior

Reduced work efficiency or productivity Lies or excuses to cover up poor work

Constipation, diarrhea Difficulty breathing

Sudden attacks of panic

Chest pain, palpitations

Frequent urination Poor sexual desire or performance

Rapid or mumbled speech Excessive defensiveness or suspiciousness

Problems in communication, sharing

Excess anxiety, worry, guilt, nervousness Increased anger, frustration, hostility Depression, frequent mood swings Increased or decreased appetite Racing thoughts

Social withdrawal and isolation Constant tiredness, weakness, fatigue

Frequent use of over-the-counter drugs Weight gain or loss without diet

Increased smoking, alcohol or drug use Excessive gambling or impulse buying

Why?

Fight-or-Flight
Sympathetic branch of the autonomic nervous system
Epinephrine Norepinephrine Aldosterone Cortisol Thyroid Hormone Vasopressin

Fight-or-Flight
Increase cardiac output Increase in respiratory drive Increase in blood glucose levels Increase in blood volume Decrease in clotting time Increase blood pressure Inhibit inflammation Increase resting metabolic rate Muscle contraction Decrease in saliva Increase in stomach acid Acceleration or deceleration of GI peristalsis Inhibit immune function

Not Just Us

Stats in our Youth

Top 10 overall health concerns for U.S. Children
Stress moved from 8th in 2009 to 5th in 2010

1 in 5 children surveyed reported they worry a great deal or a lot 86% of kids are significantly affected by stressed out parents
C.S. Mott Childrens Hospital National Poll on Childrens Health Report http://www.apa.org/news/press/releases/2010/11/stress-in-america.aspx

Whos Stressed About What?

Source of Stress Money Work Relationships Economy Health Problems affecting my family Personal Health Concerns Personal Safety Youth (8-17) 76% 70% 55% 65% 47% Moms 88% 62% 8% 70% 47% Dads 68% 73% 50% 60% 42%

52% 30%

51% 24%

45% 18%

Parent-Child Discrepancies
Answered they were under a great deal of stress: 20% vs. 3% Feel parental stress causes stress in kids: 89% vs. 31% Believe family finances are source of stress: 30% vs. 18% Marked experiencing headaches and trouble sleeping as significant symptoms of stress: 43% & 48% vs. 13%

Youth
Trouble falling asleep: 48% Headache 43% Stomach Upset: 41% Eating too much or too little: 38% Lack of motivation: 34% Anger/getting into fights: 22% Bad grades: 7% Drinking alcohol/smoking: 4%
http://www.apa.org/news/press/releases/stress2010/national-report.pdf

Adults
Irritability/Anger 45% Fatigue: 44% Lack of interest or motivation: 39% Headache: 38% Feeling nervous or anxious: 36% Stomach upset: 29% Muscular tension: 23% Teeth grinding: 17% Tightness in chest: 16%
http://www.apa.org/news/press/releases/stress2010/national-report.pdf

Random Stats
1 in 4 workers have taken a mental health day off from work to cope with stress 40 75% of all physician office visits are for stress related ailments and complaints 43% of all adults suffer from adverse health effects from stress Over 90% of disease is caused or complicated by stress Up to 60% of employee absences are due to psychological problems stress listed as #1

How Do We Deal With Stress?

How Kids Cope

Listen to music: 49% Exercise or walk: 48% Spend time with family/friends: 46% Read: 45% TV/movies: 38% Pray 37% Video Games/Surf the web: 35% Nap 34% Eat: 26% Church/religious activities: 22% Drink alcohol: 16% Smoke 13% Nothing: 6% Seek help from Dr: 4%

Some Healthy Options

Stress Management Techniques

Mediation
Mental focus Mindfulness

Visualization
Programmed Receptive

Autogenic Training
Self hypnosis Heavy, warm, quiet, calm, and relaxed

Stress Management Techniques

Body Scan
Start with toes Note sensations Work up noting every muscle group Repeat and note changes

Progressive Muscle Relaxation

Intentionally contract and relax each muscle group

Easy Stuff
Counting Down
Just relax in reverse order of importance to you Each muscle group with a number

Breathing Awareness
Chest vs. Belly Breathing

Alternate Nostril Breathing

In one out the other Exhale twice as long

My Favorite
The Lemon in The Fridge
Meditation Visualization Body Scan Breathing

Basics
Schedule a convenient time and place Be as comfortable as possible Try not to try Keep a relaxation log Avoid falling asleep Come back slowly

Psychopharmacology
SSRIs response rate 40%-70% Fluoxitine (Prozac) Start 10mg, effective dose 20-40mg, max 80mg Sertraline (Zoloft) Start 25mg, effective dose 50-200mg, max 200mg Citalopram (Celexa) Start 20mg, effective dose 30-40mg, max 60mg Escitalopram (Lexapro) Start 5mg, effective dose 10-20mg, max 20mg Paroxitine (Paxil) Start 10mg, effective dose 20-40mg, max 60mg Expect response in 4-6 weeks Medications should be continued for at least 6-12 months once patient becomes asymptomatic.

We do not see things as they are; we see things as we are Talmud Man is not disturbed by events, but by the view he takes on them Epictetus What lies behind us and what lies before us are tiny matters compared to what lies within us Oliver Wendell Holmes, MD

Thanks!!