stress and being stressed out 02.26

8/2/2019 Stress and Being Stressed Out 02.26

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Symptoms are intermittent

T

hrobbing pain ³everywhere´ ± Worse in the morning, better mid day, bad

again right before bed time

± Nothing helps

Tried ibuprofen, Tylenol, caffeine, excedrinmigraine, hot packs, cold packs

± Keeps her up at night

Feels fatigued during the day

Headache



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

GI Upset



Difficulty sleeping ± mostly trouble falling asleep ± ³I think too much right before bed´

Poor appetite ± ³The 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

R OS otherwise negative ± Denies symptoms of low mood, difficulties with

concentration, restlessness, generalized worry, etc..

Other symptoms



Past Medical History: None, otherwise healthy

Developmental History: Met all milestones on time

Substance Use: ³I¶ve never tried any of it´ Current Medications: ³Mom gave me melatonin for

sleep´

± ³It¶s not working´

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

History



Social History:

± Middle child of 2 brothers and 2 sisters, parents

are married. ± Currently in 10th grade. Does ³awesome´ in

school ± except for three weeks ago when she

entered a national essay competition in her

English Class ± now school ³sucks.´ ± Dad lost his job two weeks ago and mom is

³super stressed about the money stuff´

± Not sexually active but thinking about it

Social History



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: R egular rate and rhythm.

ABDOMEN: Soft, nontender, nondistended. Positive bowel sounds.

BACK: No CVA tenderness. GENITOUR INARY A ND R ECTAL: Declined, not indicated at this time.

EXTR EMITIES: +2 radialis pulse bilaterally, +2 posterior tibialis pulses bilaterally, no

tibial edema, no cyanosis noted.

NEUR OLOGIC: CrN II-XII intact, +2 deep tendon reflexes. A ble to perform heel to

shin, finger to nose intact. Sensation intact to light touch proximally and distally.

Strength symmetrical throughout. Negative R omberg noted normal with gait.

Physical Exam



DIFFER ENTIAL???

15 year old with two week

history of headaches andabdominal pain



Stress and

Being

Stressed Out

R achel State, MD/MPH

Triple Board

PGY

-3(IDCC 2/27/2012)



What isS

tress?



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 headachesGritting, grinding teeth

Stuttering or stammering

Tremors, trembling of lips, hands

Neck ache, back pain, muscle spasmsLight headedness, faintness, dizziness

Ringing, buzzing or "popping sounds

Frequent blushing, sweating

Cold or sweaty hands, feet

Dry mouth, problems swallowing

Frequent colds, infections, herpes

Rashes, itching, hives, "goose bumps"

Unexplained "allergy" attacks

Heartburn, stomach pain, nausea

Excess belching, flatulence

Constipation, diarrhea

Difficulty breathingSudden attacks of panic

Chest pain, palpitationsFrequent urination

Poor sexual desire or performance

Excess anxiety, worry, guilt, nervousness

Increased anger, frustration, hostility

Depression, frequent mood swings

Increased or decreased appetite

Racing thoughts

Insomnia, nightmares, disturbing dreams

Difficulty concentrating

Trouble learning new information

Forgetfulness, disorganization, confusionDifficulty in making decisions

Feeling overloaded or overwhelmed

Frequent crying spell or suicidal thoughts

Feelings of loneliness or worthlessnessLittle interest in appearance, punctuality

Nervous habits, fidgeting, feet tapping

Increased frustration, irritability, edginess

Overreaction to petty annoyances

Increased number of minor accidentsObsessive or compulsive behaviorReduced work efficiency or productivity

Lies or excuses to cover up poor work

Rapid or mumbled speech

Excessive defensiveness orsuspiciousness

Problems in communication, sharing

Social withdrawal and isolation

Constant tiredness, weakness, fatigueFrequent 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 autonomicnervous system

± Epinephrine ± Norepinephrine

± Aldosterone

± Cortisol

± Thyroid Hormone

± Vasopressin



Fight-or-

Flight

± Increase cardiac output

± Increase in respiratorydrive

± Increase in bloodglucose levels

± Increase in bloodvolume

± Decrease in clottingtime

± Increase blood pressure

± Inhibit inflammation

± Increase restingmetabolic rate

± Muscle contraction

± Decrease in saliva

± Increase in stomachacid

± Acceleration or

deceleration of GI peristalsis

± Inhibit immunefunction



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 ³a great deal or a lot´

86% of kids are significantly affected by

stressed out parents

C.S. Mott Children¶s Hospital National Poll on Children¶s Health R eport

http://

www.apa.org/news

/ press

/releases

/2010

/11

/stress-in-america.aspx



Who¶sS

tressedA bout What

?

Source of Stress Youth (8-17) Moms Dads

Money 76% 88% 68%

Work 70% 62% 73%

R elationships 55% 8% 50%

Economy 65% 70% 60%

Health Problems

affecting my

family

47% 47% 42%

Personal Health

Concerns

52% 51% 45%

Personal Safety 30% 24% 18%



Parent-ChildD

iscrepancies 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



R andom

Stats

1 in 4 workers have taken a mental health dayoff 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 healtheffects 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



HowD

o WeD

eal WithS

tress?



How Kids Cope Listen to music: 49%

Exercise or walk: 48%

S pend time with

family/friends: 46%

R ead: 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

± R eceptive

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

± R epeat and note changes

Progressive Muscle

R elaxation ± Intentionally contract and relax each muscle

group



EasyS

tuff 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



MyF

avorite 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

A

void falling asleep Come back slowly



Psychopharmacology SSR Is ± response rate 40%-70%

± Fluoxitine (Prozac)

Start 10mg, effective dose 20-40mg, max 80mg

± S

ertraline (Zoloft) Start 25mg, effective dose 50-200mg, max 200mg

± Citalopram (Celexa)


± Escitalopram (Lexapro)


± 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.



³We do not see things as they are; we seethings as we are´ ± Talmud

³Man is not disturbed by events, but by theview he takes on them´ ± Epictetus

³What lies behind us and what lies before usare tiny matters compared to what lies

within us´ ± Oliver Wendell Holmes, MD



Thanks!!

stress and being stressed out 02.26

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