MORNING REPORTMatthew P Schmieder, MD. PGY-2.

SCENE

• Wards• Called about admission from ED• Referred from UC• CC: Pneumonia• Deets: 5 yo male, 3 days of cough, CXR shows

LLL opacity. Also, BP 149/108, initially. 140/97 on repeat.

HPI

• 6 yo Male, previously healthy• 3 days of cough and shortness of breath• Stayed home from school yesterday and today

because of cough• Began breathing faster AM of admission, started

working harder to breathe by late morning• Drinking well, no documented fever at home.• No sick contacts.• Went to UC for evaluation

HPI (CONTINUED)

• UC: Initial vitals: T 38.5 | HR 131 | RR 32 | BP 149/108, 140/97 | SpO2: 94%

• Rapid Strep: POS• Referred to PCH ED

HPI (CONTINUED)

• ED Course:• CXR: Small confluent opacity at the periphery for the left

lung base, could represent a consolidation superimposed on a background of viral respiratory illness.

• SpO2: 85% initially. Placed on 0.5L NC, improved.• RR and HR elevated. BP 141/119, 149/108 initially.• Given albuterol neb, no change in respiratory status• Given Ampicillin, admitted to the floor.• BPs “better” over the course of ED stay.

PAST MEDICAL HISTORY

• Previously healthy.• Born full term, product of normal gestation

and delivery.• No previous hospitalizations• No surgeries• No meds, regularly• No allergies to meds• Immunizations: UTD

PAST MEDICAL HISTORY

• Not seen regularly• UC visit from 10/2013 with BP of 140/92

recorded• Mom reports never being informed BP was

high in the past

FAMILY & SOCIAL

• Family: Negative for HTN, autoimmune disease, hyperthyroidism, adrenal tumors. Mom with anxiety.

• Social: Lives with his parents and two siblings. Parents are from Brazil. The primary language spoken in the home is Portuguese. He attends first grade. No tobacco smoke exposure, no substances of abuse in the home.

ROS

• NEGATIVES: Headache, change in vision, decrease in urine, change in urine color, nausea, vomiting, chest pain, diaphoresis, skin changes, heat/cold intolerance, night sweats, diarrhea, polydipsia.

• POSITIVES: Decreased PO intake, cough, shortness of breath.

OBJECTIVE

• WT: 20.59 46% | HT 119.38 75% | BMI 16.4 75%• Temp: 38.2• HR: 135• RR: 42• BP: 138/92, 149/108, 141/119• 95th Percentile: 115/75 | 99th Percentile: 123/83• SpO2: 94% on 0.5 LPM NC

PHYSICAL EXAMGEN: Alert, oriented. In no overt discomfort. Anxious appearing. Appropriately developed.HEAD: Normocephalic, atraumatic.EYES: Pupillary reflexes bilaterally, extraocular movements intact, conjugate gaze, fundoscopy with grossly normal

disc margins bilaterally. No conjunctival injectionEARS: Normal.NOSE: No discharge or obstruction.OROPHARYNX: Dry mucus membranes, tonsils 1+ without exudate, positive pharyngeal erythema.NECK: Supple, without adenopathy, normal ROM.CARDIOVASCULAR: Normal rhythm, tachycardic. Normal S1/S2, without murmur or gallop.Capillary refill time <3 seconds. Radial pulses and DP pulses symmetrically palpable.LUNGS: Diffuse expiratory wheezing bilaterally, crackles at the bases bilaterally, appropriate air-entry to the bases,

subcostal and supraclavicular retractions with positive accessory muscle use in respirations.ABDOMEN: Soft, non-tender, non-distended with active bowel sounds and no masses or hepatosplenomegaly.EXTREMITIES: All extremities warm and well perfused. No cyanosis, clubbing, or edema.BACK: Spine normal to palpation, no flank tenderness.GENITOURINARY: Normal tanner 1 male.NEUROLOGIC: Awake and alert, speaking in short full-sentence answers, CNs II-XII intact and symmetrical, patellar

tendon reflexes 2+ and symmetrical. Diffusely normal strength and tone.SKIN: No rashes, mottling, jaundice, or unusual birthmarks. No petechiae or purpura.

DIFFERENTIAL DIAGNOSIS

• 6 year old male with respiratory distress, hypoxia, and radiographic evidence of LLL pneumonia, with elevated blood pressure.

DIFFERENTIAL DIAGNOSISRenal diseasePyelonephritisRenal parenchymal disease/AKICongenital anomaliesReflux nephropathyAcute glomerulonephritisHenoch-Schönlein purpuraRenal traumaHydronephrosisHemolytic uremic syndromeRenal stonesNephrotic syndromeWilm's tumorHypoplastic kidneyPolycystic kidney disease

Endocrine diseaseHyperthyroidismCongenital adrenal hyperplasiaSteroidogenic Enzyme DefectsCushing syndromePrimary aldosteronismPrimary hyperparathyroidismDiabetes mellitusHypercalcemiaPheochromocytoma

Vascular diseaseRenal artery abnormalitiesRenal vein thrombosisCoarctation of the aortaMid-aortic SyndromePatent ductus arteriosusArteriovenous fistula

Psychologic causesMental stressAnxiety

Pharmacologic causesSympathomimeticsCorticosteroidsStimulantsOral contraceptivesAnabolic steroidsCocaineMDMA/EcstasyPhencyclidine (PCP)LicoriceNicotineCaffeine

Neurologic causesIncreased intracranial

pressureGuillain-Barré syndrome

Other causesEssential HypertensionNeuroblastomaHeavy metal poisoningAcute painCollagen vascular diseasesNeurofibromatosisTuberous sclerosisPregnancySerotonin SyndromeAnemiaWilliams SyndromeTurner SyndromeLower Extremity Traction

HYPERTENSION

View: Approach to hypertensive emergencies and urgencies in children. Jordan Symons, MD, et al. UpToDate.com. *

*Due to copyright UpToDate content cannot be included in presentation

EVALUATION

LABORATORY: Basic Metabolic Panel: Na = 138, K = 3.8, Cl =

107, CO2 = 22, BUN = 7, Cr = 0.41, Glucose = 94, Ca = 9.8

UA: Trace protein, otherwise WNL

EVALUATION (CONT)US RenalRight renal length: 7.6 cm.Left renal length: 7.9 cm.The normal renal length range for a patient of this age is 6.6 - 9.4 cm.Impression: Normal appearing kidneys bilaterally.

US Doppler RenalImpression:1. Abnormal Doppler arterial waveforms throughout the aorta and main renal

arteries, with lack of normal arterial upstroke and dicrotic notch. Bilateral brachial arterial Doppler waveforms are normal. This constellation of findings, in conjunction with hypertension, is concerning for aortic coarctation.

2. No evidence for renal arterial stenosis.

EVALUATION (CONT)TTE:1. Severe coarctation of aorta with long segment transverse arch

hypoplasia distal to the innominate artery. Hypoplastic transverse arch and proximal descending aorta with posterior shelf. Inferiorly displaced left subclavian artery.

2. Dilated aortic root.3. There is continuation of forward flow in diastole in the

abdominal aorta.4. There is dilatation of the left ventricle.5. LV hypertrophy, normal LV systolic function6. Normal right ventricular size and qualitatively normal systolic

function.

HYPERTENSION

In pediatrics, defined as either systolic and/or diastolic BP ≥ 95th Percentile for age, sex, and height, measured on three or more occasions.

Stage 1 HTN: Systolic and/or Diastolic between the 95th and 99th percentile plus 5 mmHg

Stage 2 HTN: Systolic and/or Diastolic greater than the 99th percentile plus 5 mmHg- Identifies those children who need prompt

evaluation and immediate treatment

HYPERTENSION

Hypertensive Emergency: Severe symptomatic BP elevation with evidence of target organ damage

Hypertensive Encephalopathy: Cerebrovascular endothelium breakdown secondary to failure of cerebral autoregulation– Most common target organ damage– Includes lethargy, coma, seizure, irritability

Hypertensive Urgency: Severe elevation in BP without symptoms

HYPERTENSIVE URGENCY

Initial evaluation should focus on signs/symptoms of end-organ dysfunction:

• Visual changes, headaches, seizures, AMS, focal deficits -- Encephalopathy

• SOB, orthopnea, PND, edema – HF• Visual change – Retinal hemorrhage or exudates• Flank pain, change in urine color/character – Renal

dysfunction/AKI• Epistaxis

HYPERTENSIVE URGENCY

Approach:• Confirm the elevated BP – Appropriate cuff,

etc.• Establish severity of BP elevation• Exclude other causes – Attn: increased ICP,

coarctation of aorta, ingestion of sympathomimetics (cocaine), where lowering BP could be contraindicated

Evaluation of Hypertensive Child and Adolescent

• MONSTER• Medication• Obesity• Neonatal history• Symptoms/Signs• Trends in the family• Endocrine• Renal

Feld LG and Corey H Pediatrics in Review 2007;28:283-298

HYPERTENSIVE URGENCYPhysical Exam:• Four extremity BPs• Pulses – UE/LE comparison• Mental status/Neuro• Signs of head trauma• Fundoscopy – Papilledema and retinal hemorrhage/exudates• Thyroid -- Goiter• CV -- Gallop• Renal -- Bruit• Abdomen: Masses• Extremities: Peripheral edema

HYPERTENSION EVALUATION

• RFP: quick eval for problems with potassium or glucose homeostasis, or renal dysfunction

• UA: screen for underlying renal disease, nephritis

• CBC: eval for anemia suggestive of chronic diseases, CKD or vasculitis

• EKG: looking for LVH• CXR: pulmonary edema, heart size

HYPERTENSION EVALUATIONAdditional Studies:• Renal imaging — determine the presence of both kidneys or presence

of any congenital anomaly, or disparate renal size.• Renovascular imaging -- MRA, CTA, or Duplex Doppler ultrasonography• Plasma and urine catecholamines – Pts with pheochromocytoma and

neuroblastoma will have elevated levels of both plasma and urine catecholamines and metabolites

• Plasma renin activity – Low in hyperaldostronism, high in renin-secreting tumor and renovascular disease

• TTE – LVH is the most prominent manifestation of target-organ damage from HTN. (LVH has been reported in 30 to 40 percent of children and adolescents with HTN)

References

• Hypertension in Childhood. Leonard G. Feld and Howard Corey. Pediatrics in Review August 2007; 28:283 298; doi:10.1542/pir.28-8-283

• Approach to hypertensive emergencies and urgencies in children. Jordan Symons, MD, et al. UpToDate.com.