Dr Donald Payne Department of Paediatric and Adolescent ...
Dr Donald Payne Department of Paediatric and Adolescent ...
Dr Donald Payne Department of Paediatric and Adolescent ...
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<strong>Dr</strong> <strong>Donald</strong> <strong>Payne</strong><br />
<strong>Department</strong> <strong>of</strong> <strong>Paediatric</strong> <strong>and</strong> <strong>Adolescent</strong> Medicine<br />
Princess Margaret Hospital, Perth, WA
to describe an approach to the<br />
management <strong>of</strong> unexplained symptoms in<br />
adolescence<br />
to some provide practical tips<br />
to highlight approaches guaranteed to<br />
produce a poor outcome<br />
to generate discussion
Management <strong>of</strong> difficult asthma<br />
history<br />
examination<br />
chest x-ray<br />
lung function<br />
skin prick tests
Assessment <strong>and</strong> management <strong>of</strong><br />
medically unexplained symptoms<br />
Hatcher S, Arroll B. BMJ 2008;336;1124-1128
headache<br />
fatigue<br />
abdominal pain<br />
dizziness<br />
muscle <strong>and</strong> joint pains<br />
sleep problems
Serious morning fatigue in 11-17 year olds in Europe
Somatic symptoms in 11 -17 year olds in Europe
nausea<br />
vomiting<br />
bleeding<br />
rash<br />
collapse, seizures
General Practitioner(s)<br />
General Physician
General Practitioner(s)<br />
General Physician<br />
Neurologist<br />
Gastroenterologist<br />
Rheumatologist
General Practitioner(s)<br />
General Physician<br />
Neurologist<br />
Gastroenterologist<br />
Rheumatologist<br />
Cardiologist<br />
Endocrinologist<br />
Dermatologist
lood tests – including ANA, coeliac screen<br />
ultrasound <strong>and</strong> CT scan<br />
MRI brain<br />
EEG<br />
ECG
gastroscopy <strong>and</strong> colonoscopy<br />
echocardiogram<br />
lumbar puncture<br />
24 hour ECG
tilt test<br />
skin biopsy<br />
colonic transit time
all normal (except for a positive ANA)
more tests<br />
refer on<br />
go sailing<br />
enjoy the challenge
‘I’m so pleased you’re pregnant. I thought it<br />
was adolescent obesity.’
15 year old girl<br />
headache, dizziness <strong>and</strong> fatigue for two<br />
months<br />
prolonged school absence<br />
previously well, active, attending school<br />
initial examination <strong>and</strong> blood tests all<br />
normal
in year 10<br />
enjoys dance <strong>and</strong> netball<br />
doing well academically<br />
lots <strong>of</strong> friends<br />
parents separated – divides time between<br />
both homes<br />
no significant psychosocial problems<br />
identified
admitted for further assessment <strong>and</strong><br />
investigation<br />
CT scan <strong>of</strong> the brain<br />
lumbar puncture<br />
symptoms persisted despite escalating<br />
analgesia
admitted for further assessment <strong>and</strong><br />
investigation<br />
CT scan <strong>of</strong> the brain<br />
lumbar puncture<br />
symptoms persisted despite escalating<br />
analgesia<br />
decision made to move from investigation<br />
to rehabilitation
investigate, then stop<br />
no more referrals<br />
agree on a management plan<br />
interdisciplinary approach<br />
one co-ordinating physician
manage the symptoms<br />
restore normal function<br />
restore normal adolescence<br />
- encourage school attendance<br />
- interaction with peers<br />
- (re)discover independence
Community<br />
Child<br />
Family
Community<br />
<strong>Adolescent</strong> Child<br />
Family
medical <strong>and</strong> nursing staff<br />
physiotherapy<br />
occupational therapy<br />
school teacher<br />
psychological medicine
make a positive diagnosis<br />
like your patients<br />
ignore physical / psychological split if<br />
possible<br />
focus on what’s fixable<br />
make time for parent / family meetings<br />
sound out your colleagues
make a positive diagnosis
make a positive diagnosis<br />
like your patients
make a positive diagnosis<br />
like your patients<br />
ignore physical / psychological split if<br />
possible
make a positive diagnosis<br />
like your patients<br />
ignore physical / psychological split if<br />
possible<br />
focus on what’s fixable
School<br />
absence<br />
Effect<br />
on<br />
family<br />
Pain<br />
Fatigue<br />
Sports /<br />
activities<br />
Loss <strong>of</strong><br />
friends
School<br />
absence<br />
Effect on<br />
family<br />
Pain<br />
Fatigue<br />
Sports /<br />
activities<br />
Loss <strong>of</strong> friends
make a positive diagnosis<br />
like your patients<br />
ignore physical / psychological split if<br />
possible<br />
focus on what’s fixable<br />
make time for parent / family meetings
make a positive diagnosis<br />
like your patients<br />
ignore physical / psychological split if<br />
possible<br />
focus on what’s fixable<br />
make time for parent / family meetings<br />
sound out your colleagues
it’s all in your head<br />
there’s nothing wrong with you<br />
there’s nothing more we can do for you<br />
you’ll just have to get on with it
ehabilitation works, if the family will<br />
engage<br />
poor outcomes associated with<br />
persistent search for an organic ‘cause’<br />
breakdown in relationship between family <strong>and</strong><br />
health pr<strong>of</strong>essionals
Viner R, Christie D. Fatigue <strong>and</strong> somatic symptoms.<br />
BMJ 2005;330:1012-15<br />
Eminson DM. Medically unexplained symptoms in<br />
children <strong>and</strong> adolescents.<br />
Clin Psychol Rev 2007;27:855-71<br />
Calvert P, Jureidini J. Restrained rehabilitation.<br />
Arch Dis Child 2003;88:399-402<br />
Kreipe RE. The biopsychosocial approach to adolescents<br />
with somat<strong>of</strong>orm disorders.<br />
Adolesc Med Clin 2006;17:1-24
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