BODY TEMPERATURE ABG ANTHROPOMETRIC MEASUREMENTS

  Subnormal <36.6°C pH: 7.35-7.45 HCO3: 22-26mEq/L IDEAL BODY WEIGHT
Normal 37.4°C
  Subfebrile 35.7 – 38.0°C
pCO2:
pO2:
35-45
80-100
B.E.:
O2 sat:
+/- 2mEq/L
97% Age Kilograms Pounds
Fever 38.0°C
  High fever >39.5°C
At Birth 3kg (Fil)
3.35kg (Cau)
7
Hyperpyrexia >42.0°C
  NORMAL LABORATORY VALUES 3-12
mo
Age (mo) + 9 / 2 Age (mo) + 10 (F)
Age (mo) + 11 (C)
AGE HR (bpm) BP (mmHg) RR (cpm)
  RBC
NB
4.8-7.1
Infant
3.8-5.5
Child
3.8-5.
Adole
M: 4.6-6.2
1-6 y Age (y) x 2 + 8 Age (y) x 5 + 17
Preterm 120-170 55-75/35-45 40-70 7-12 y Age (y) x 7 – 5 / 2 Age (y) x 7 + 5
  Term 120-160 65-85/45-55 30-60 WBC 9-30,000 6-17,500
F: 4.2-5.4
5-10,000 6-10,000
0-3 mo 100-150 65-85/45-55 35-55 Given Birth Weight:
  3-6 mo 90-120 70-90/50-65 30-45
PMNs
Lymph
61%
31%
61%
32%
60%
30%
60%
30%
Age Using Birth Weight in Grams
< 6 mo Age (mo) x 600 + birth weight (gm)
  6-12 mo
1-3 yrs
80-120
70-110
80-100/55-65
90-105/55-70
25-40
20-30
Hgb 14-24 11-20 11-16 M: 14-18
F: 12-16 6-12 mo Age (mo) x 500 + birth weight (gm)
  3-6 yrs
6-12 yrs
65-110
60-95
95-110/60-75
100-120/60-75
20-25
14-22
Hct 44-64% 35-49 31-46 M: 40-54
F: 37-47 Expected Body Weight (EBW):
  12-17 yrs 55-85 110-135/65-85 12-18 Platelets 140-300 200-423
Ret 2.6-6.5 0.5-3.1
150-450 150-450
0-2 0-2
Term
Pre-Term
Age in days – 10 x 20 + Birth Weight
Age in days – 14 x 15 + Birth Weight
  µ BP cuff should cover 2/3 of arm
-: SMALL cuff: falsely high BP
  -: LARGE cuff: falsely low BP COUNT (%) Age of Infant Ideal Weight
4-5 months 2 x Birth Weight
  BMI BT 1-5 min 1-6 1-6 1-6 1 year 3 x Birth Weight
CT 5-8 min 5-8 5-8 5-8 2 years 4 x Birth Weight
  Underweight
Asian
<18.5
Caucasian
<18.5
PTT 12-20sec 12-14 12-14 12-14 3 years 5 x Birth Weight
  Normal
Overweight
18.5 – 22.9
≥ 23.0
18.5 – 24.9
25 – 29.9
5 years
7 years
6 x Birth Weight
7 x Birth Weight
  at risk
Obese I
23 – 24.9
25 – 29.9 30 – 39.9
10 years 10 x Birth Weight

  Obese II ≥ 30 >40

 
  APGAR
  LENGTH / HEIGHT
(50 cm) Age Transverse-AP 0 1 2
Inches Blue / Pink body/ Blue Completely
  Age Centimeters Inches At Birth
Diameter ratio
1.0 Transverse = AP
A
Pale extremities pink

  At Birth
1y
50
75
20
30
1y
6y
1.25
1.35
Transverse > AP
Transverse >>> AP
P Absent Slow (<100) > 100
Coughs,
(-)
  2-12 mo Age x 6 + 77 Age x 2.5 + 30 G
Response
Grimaces Sneezes,
Cries
  st
FONTANELS A
(-)
Movement
Some flexion /
extension
Active
movement
Age Gain in 1 Year is ~ 25cm
  0-3 mo + 9 cm 3 cm per mo Appropriate size at birth: 2 x 2 cm (anterior) R Absent Slow / Irregular
Good,
strong cry
3-6 mo + 8 cm 2.67 per mo Closes at: Anterior = 18 months, or as early
  6-9 mo + 5 cm 1.6 cm per mo as 9-12 months
8 – 10: Normal
Posterior = 6 – 8 weeks or
  9-12 mo + 3 cm 1 cm per mo
2 – 4 months
4 – 7:
0 – 3:
Mild / Moderate Asphyxia
Severe asphyxia
  HEAD CIRCUMFERENCE GCS
THORACIC INDEX
  (33-38 cms)
Function Infants/Young Older
TI = transverse chest diameter Eye 4- Spontaneous Spontaneous
  Age Inches Centimeters AP diameter Opening 3- To speech To speech
At Birth 35 cm (13.8 in) 2- To pain To pain
  < 4 mo + 2 in + 5.08cm Birth : 1.0 1- None None
(1/2 inches / mo) (1.27cm / mo) 1 year : 1.25
  5-12 mo + 2 in + 5.08cm 6 years : 1.35
Verbal 5- Appropriate
4- Inconsolable
Oriented
Confused
(1/4 inches / mo) (0.635cm / mo)
  1-2 yrs + 1 inch 2.54 cm
3- Irritable
2- Moans
Inappropriate
Incomprehensible
  3-5 yrs + 1.5 in
(1/2 inches / year)
+ 3.81cm
(1.27cm / mo) Motor
1- None
6- Spontaneous
None
Spontaneous
  6-20 yrs + 1.5 in
(1/2 inches / year)
+ 3.81cm
(1.27cm / mo)
5- Localize pain
4- Withdraw
Localize pain
Withdraw
  3- Flexion
2- Extension
Flexion
Extension
  1- None None

 
  EXPANDED PROGRAM ON IMMUNIZATION ADVERSE REACTIONS FROM VACCINES

  VACCINE AGE DOSE # ROUTE SITE INTERVAL BCG 1. Wheal ► small ► abscess ► ulceration ► healing / scar formation in
BCG-1 Birth 0.05mL 1 ID R- 12 wks
  or 6 wks (NB) Deltoid 2. Deep abscess formation, indolent ulceration, glandular enlargement,
0.1mL suppurative lymphadenitis
  (older) DPT 1. Fever, local soreness
DPT 6 wks 0.5mL 3 IM Upper
  Outer
2. Convulsions, encephalitis / encephalopathy, permanent brain
damage
thigh
  OPV 6 wks 2 drops 3 PO Mouth 4 wks
OPV
HEPA B
Paralytic Polio
Local soreness
  HEPA B 6 wks 0.5mL 3 IM Antero-
lateral
4 wks MEASLES 1. Fever & mild rash
2. Convulsions, encephalitis / encephalopathy, SSPE, death
  MEASLES 9 mos 0.5mL 1 SC
thigh
Outer 4 wks ACTIVE PASSIVE
  upper
arm
BCG
DPT
Diphtheria
Tetanus
  BCG-2 School entry 0.1mL 1 ID L-
Deltoid
OPV
Hep B
Tetanus Ig
Measles Ig

  TetToxoid Childbearing 0.5mL 3 IM Deltoid 1 mo then Measles

Hib
Rabies (HRIg)
Hep A Ig
women 6-12 mos
  MMR
Tetanus Toxoid
Hep B ig
Rubella Ig

 
Varicella

 
 
 
 
 
 
 
 
 
 
 
 
  
  H.E.A.D.S.S.S. H.E.A.D.S.S.S. NUTRITION
  Sexual activities Home Environment AGE WT. CAL CHON
  ◦ Sexual orientation?
◦ GF/BF? Typical date?
◦ With whom does the adolescent live? 0-5 mo 3-6 115 3.5
◦ Any recent changes in the living situation? 8-11 mo 7-9 110 3.0
  ◦ Sexually active? When started? # of persons?
Contraceptives? Pregnancies? STDs?
◦ How are things among siblings? 1-2 y 10-12 110 2.5
◦ Are parents employed?
  Suicide/Depression
◦ Are there things in the family he/she wants to
3-6 y
7-9 y
14-18
22-24
90-100
80-90
2.0
1.5
change?
  ◦ Ever sad/tearful/unmotivated/hopeless?
◦ Thought of hurting self/others?
10-12 y
13-15 y
28-32
36-44
70-80
55-65
1.5
1.5
Employment and Education
  ◦ Suicide plans? ◦ Currently at school? Favorite subjects? 16-19 y 48-55 45-50 1.2
◦ Patient performing academically?
  Safety
◦ Use seatbelts/helmets?
◦ Have been truant / expelled from school? TCR β = Wt at p50 x calories
◦ Problems with classmates/teachers? TCR = CHON X ABW
  ◦ Enter into high risk situations? ◦ Currently employed?
◦ Member of frat/sorority/orgs? ◦ Future education/employment goals? Total Caloric Intake : calories X amount of
  ◦ Firearm at home? intake (oz)

  Activities
◦ What he/she does in spare time? Gastric Capacity : age in months + 2
F.R.I.C.H.M.O.N.D.
  ◦ Patient does for fun?
◦ Whom does patient spend spare time? Gastric Emptying Time : 2-3 hours
◦ Fluids
  ◦ Respiration
◦ Hobbies, interests, close friends?
1:1 1:2
◦ Infection
  ◦ Cardiac
Drugs
◦ Used tobacco/alcohol/steroids?
Alacta
Enfalac
Bonna
Nursoy
◦ Hematologic
  ◦ Metabolic
◦ Illicit drugs? Frequency? Amount?
Affected daily activities?
Lactogen
Lactum
Promil
S-26
◦ Output & Input [cc/kg/h] N: 1-2
  ◦ Neuro
◦ Still using? Friends using/selling? Nan Similac
◦ Diet Nestogen SMA
  Nutraminogen
Pelargon
  Prosobee

 
 
 
  THE SEVEN HABITS OF
HIGHLY EFFECTIVE PEOPLE
  by Stephen R. Covey

  Habit 1: Be Proactive
Habit 2: Begin with the end in mind
  Habit 3: Put First Things First
Habit 4: Think Win-Win
  Habit 5: Seek first to understand and
then to be understood
  Habit 6: Synergize
Habit 7: Sharpen the saw
 
 
 
 
  EXPECTED LA SALLIAN
GRADUATE ATTRIBUTES
  (ELGA)

  1. Competent & safe physicians

2. Ethical & socially responsible
  Doctors / practitioners
3. Reflective lifelong learners
  4. Effective communicators
5. Efficient & innovative managers
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
DIARRHEA ACUTE DIARRHEA (at least 3x BM in 24 hrs) ETIOLOGY of AGE
 
◦ Chronic : >14 days, non-infectious causes 4 Major Mechanisms Bacteria Viruses
  ◦ Persistent : >14 days, infectious cause
1. Poorly absorbed osmotically active substances in
Aeromonas Astroviruses
Bacillus cereus Caloviruses
  lumen
2. Intestinal ion secretion (increased) or decreased
Campylobacter jejuni Norovirus
◦ ORS vol. after each loose stool 1 day Clostridium perfringens Enteric Adenovirus
  <24 mo 5-100mL 500mL
absorption
3. Outpouring into the lumen of blood, mucus
Clostridium difficile Rotavirus
Escherichia coli Cytomegalovirus
  2-10 y.o. 100-200mL 1000mL 4. Derangement of intestinal motility Plesiomonas shigelbides Herpes simplex virus
>10 y.o. As much as wanted 2000mL Salmonella
  Shigella
Rotaviral AGE (vomiting first then diarrhea) Staphylococcus aureus
  For severe dehydration / WHO hydration Ingestion of rotavirus ► rotavirus in intestinal villi Vibrio cholerae 01 & 0139
(fluid: PLR 100cc/kg) Vibrio parahaemolyticus
  ►destruction of villi
Yersinia enterocolitica
Age 30mL/kg 75mL/kg
  <12 1H 5H (secretory diarrhea ▼absorption ▲ secretion) ► AGE
Parasites
>12 30 mins 2½H
  Assessment of dehydration (Skin Pinch Test)
Balantidium coli
Blastocyctis hominis
  Patient in SHOCK ◦ (+) if > 2 seconds
Cryptosporidium
Giardia lamblia
  ◦ 20-30cc/kg IV fast drip
◦ no dehydration if skin tenting goes back
immediately
◦ but in infants 10cc/kg IV (repeat if not stable) Amoeba   Metronidazole  
  ◦ If responsive & stable 75/kg x 4-6 hours Ascariasis   Al/mebendazole  
  Cholera  
Shigella  
Tetracyline  
TMP/SMX  (Cotri)  
  Salmonella   Chloramphenicol  

 
 
 
 
  TREATMENT PLAN A TREATMENT PLAN C
  4 Rules of Home Treatment Treat severe dehydration QUICKLY!
  1. Give extra fluid (as much as the child will take) 1. Start IV fluid immediately
  > Breastfeed frequently & longer at each feeding
2. If the child can drink, give ORS by mouth while the
IV drip is being set up
> if the child is exclusively breastfed, give one or
  more of the following in addition to breastmilk
3. Give 100mL/kg Lactated Ringer’s solution

  ◦ ORS solution
◦ food based fluid (e.g. soup, rice, water) Age
First give Then give
30mL/kg in: 70mL/kg in:
  clean water
Infants
1 hour* 5 hours
(<12mo)
  How much fluid to be given in addition to the usual
fluid intake? Children
30 min* 2 ½ hours
(12mo-5yrs)
  Up to 2 years: 50-100 mL after each
  loose stool
Repeat once if radial pulse is very weak or not
  2 years or more: 140-200 mL
:- give frequent small sips from a cup
detectable
◦ reassess the child every 15-30 min.
  :- if the child vomits, wait for 10 min then
resume
if dehydration is not improving,
give IV fluid more rapidly
  :- continue giving extra fluids until diarrhea
stops ◦ also give ORS (~5mL/kg/hr) as soon as the child
  2. Give Zinc supplements
can drink [usually after 3-4 hours in infants; 1-2
hours in children]
  ◦ reassess after 6 hrs (infant) & 3 hrs (child)
Up to 6 mo: 1 half tab per day for 10-14 days
  6 months or more: 1 tab or 20mg
OD x 10-14 days
 
3. Continue feeding
  4. Know when to return

 
 
  TREATMENT PLAN B

  Recommended amount of ORS over 4 hour period

  Age up to:
Wt:
4 mo – 4 mo
<6kg
12 mo – 12 mo
6-9.9kg
2 yrs – 2 yrs
10-11.9kg
5 yrs
2-19kg
  (mL) 200-400 400-700 700-900 900-1400

  ◦ Use child’s age only when weight is not known

◦ Approximate amount of ORS (mL)
 
CHILDS WT (kg) x 25
  ◦ if the child wants more ORS than shown, give more
  ◦
◦
give frequent small sips from a cup
if the child vomits, wait for 10 min then resume
  ◦ continue breastfeeding whenever the child wants

  AFTER 4 HOURS
◦ reassess the child & classify dehydration status
  ◦ select the appropriate plan to continue treatment
◦ begin feeding the child while at the clinic
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
  ORS

  • Glucolyte 60 • Pedialyte 45 0r 90

IV-FLUID COMPOSITIONS (Commonly Used for Infants and Child):

-: for acute DHN secondary to GE or other forms -: prevention of DHN & to maintain normal
  of diarrhea except CHOLERA. In burns, post- fluidelectrolyte balance in mild to moderate
surgery replacement or maintenance, mild-salt dehydration.
  loosing syndrome, heat cramps and heat
exhaustion in adults. Glucose 45mEq Glucose 90mEq
  Na: 20mEq Na: 20mEq
Glucose: Cl: Gluconate:
  100mmol/L 50mmol/L 5mmol/L
K: 35mEq
Citrate: 30mEq
K: 80mEq
Citrate: 30mEq

 
  Na:
60 mol/L
Mg:
5mmol/L
Dextrose: 20g Dextrose: 25g

  K:
20 mmol/L
Citrate:
10 mmol/L
  • Pedialyte mild 30
-: to supplement fluid & electrolyte loss due to
  • Hydrite
-: 2 tab in 200ml water or 10sachets in 1L water
active play, prolonged exposure, hot and humid
environment
  Glucose: Cl: Glucose: Glucose: 30mEq Mg: 4mEq
  111mmol/L 80mmol/L 11mml/L Na: 20mEq lactate: 20mEq
Na: HCO3: Na: K: 30mEq Ca: 4mEq
  90 mmol/L 5mmol/L 90 mmol/L Energy:
K: K: 20kcal/ 100ml
  20 mmol/L 20 mmol/L

 
 
 
 
 
 
  ETIOLOGY OF PNEUMONIA
  Bacterial
  - Streptococcus pneumoniae
- Group B streptococci (neonates)
 
ARI PROTOCOL (PROGRAM FOR THE CONTROL OF ARI)

- Group A streptococci
- Mycoplasma pnemoniae (adolescents)
  - Chlamydia trachomatis (infants)
- Mixed anearobes (aspiration pneumonia)
  - Gram negative enteric (nosocomial pneumonia)

  Viral
- Respiratory syncitial virus
  - Parainfluenza type 1-3 (Croup)
- Influenza types A, B
  - Adenovirus
- Metapneumovirus
 
Fungal
  - Histoplasma capsulatum (bird, bat contact)
  - Cryptococcus neoformans (bird contact)
Child Age 2months up to 5years

- Aspergillus sp. (immunosuppressed)

Young Infants < 2months old

  - Mucormycosis
- Coccidioides immitis
(immunosuppressed)

  - Blastomyces dermatitides
- Pneumocystis carinii (immunosuppressed,
  HIV, steroids)

 
 
 
 
 
  LUDAN’S METHOD (HYDRATION THERAPY) Stage Pubic Hair
SMR GIRLS
Breasts

  MILD MODERATE SEVERE

1 Preadolescent
Sparse, lightly pigmented, straight,
Preadolescent
Breast & papilla elevated, as small
DEHYDRATION DEHYRATION DEHYDRATION 2
  < 15 kg, < 2 y/o 50 cc/kg 100 cc/kg 150 cc/kg
3
medial border of labia
Darker, beginning to curl, ▲amount
mound, areola diameter increased
Breast & areola enlarged, no contour

  > 15 kg, 2 y/o 30 cc/kg

D5 0.3% in
st
60 cc/kg
1 hr: ¼ Plain LR
st
90 cc/kg
1 hr: ⅓ Plain LR 4
Course, curly, abundant but amount <
separation
Areola & papilla formed secondary

  6-8 hours Next 5-7 hrs:

¾ D5 0.3% in
Next 5-7 hrs:
⅔ D5 0.3% in 5
adult
Adult, feminine triangle, spread to
mound
Mature, nipple projects, areola part of
medial surface of thigh general breast contour
  5-7 hours 5-7 hours

  HOLIDAY-SEGAR METHOD (MAINTENANCE)

Stage Pubic Hair
SMR BOYS
Penis Testes

  WEIGHT
0 - 10 kg
TOTAL FLUID REQUIREMENT
100 mL / kg
1 None
Scanty, long slightly
Preadolescent Preadolescent
Enlarged scrotum, pink
2 Slightly enlargement
  11- 20 kg
> 20 kg
1000 + [ 50 for each kg in excess of 10 kg]
1500 + [ 20 for each kg in excess of 20 kg] 3
pigmented
Darker, starts to curl, small
Longer
texture altered
Larger
  amount
Resembles adult type but
Larger, glans &
NOTE: Computed Value is in mL/day
  Ex. 25kg child
4 less in quantity, course,
curly
breadth ▲ in size
Larger, scrotum dark

Answer: 1500 + [100] = 1600cc/day Adult distribution, spread

  5
to medial surface of thigh
Adult size Adult size

 
 
 
 
 
 
 
 
 
  
 
  ATYPICAL PNEUMONIA
  -: extrpulmonary manifestations
> 3-12 mo
- RSV
  -:
-:
low grade fever
patchy diffuse infiltrates
- Other respiratory viruses
- Streptococcus pneumoniae
  -:
-:
poor response to Penicillin
negative sputum gram stain
- Haemophilus influenzae (Type B)
- C. trachomatis
  - M. pneumoniae
- Group A Streptococcus
  Etiologic Agents Grouped by Age
> 2-5 yrs

DENGUE PATHOPHYSIOLOGY
  > Neonates (<1mo) - RSV
- GBS - Other respiratory viruses
  - E. coli - Streptococcus pneumoniae
- other gram (-) bacilli - Haemophilus influenzae (Type B)
  - Streptococcus pneumoniae - C. trachomatis
- Haemophilus influenza (Type B) - M. pneumoniae
  - Group A Streptococcus
> 1-3 months - Staph aureus
  * Febrile pneumonia
- RSV > 2-5 yrs
  - Other respiratory viruses - Streptococcus pneumoniae
- Streptococcus pneumoniae - Haemophilus influenzae (Type B)
  - Haemophilus influenza (Type B) - C. trachomatis
  * Afebrile pneumonia
- M. pneumoniae
- Group A Streptococcus
  - Chlamydia trachomatis
- Mycoplasma homilis
- Staph aureus

  - CMV

 
 
 
 
 
  DENGUE Dengue Fever Syndrome (DFS) Dengue Shock Syndrome

  > MOT: mosquito bite (man as reservior) Biphasic fever (2-7 days) with 2 or more of the ff: Manifestations of DHF plus signs of circulatory failure
1. rapid & weak pulse
  > Vector: Aedes aegypti 1. headache
2. myalgia or arthralgia
2. narrow pulse pressure (<20mmHg)
3. hypotension for age
  > Factors affecting transmission:
- breeding sites, high human population density,
3. retroorbital pain
4. hemorrhagic manifestations
4. cold, clammy skin & irritability / restlessness

  mobile viremic human beings [petechiae, purpura, (+) torniquet test]

5. leukopenia DANGER SIGNS OF DHF
  > Age incidence peaks at 4-6 yrs
1. abdominal pain (intense & sustained)
  > Incubation period: 4-6 days Dengue Hemorrhagic Fever (DHF) 2. persistent vomiting
3. abrupt change from fever to hypothermia
  > Serotypes: 1. fever, persistently high grade (2-7 days) with sweating
- Type 2 – most common 2. hemorrhagic manifestations 4. restlessness or somnolence
  - Types 1& 3 - (+) torniquet test
- Type 4– least common but most severe - petechiae, ecchymoses, purpura
  - bleeding from mucusa, GIT, puncture sites Grading of Dengue Hemorrhagic Fever
> Main pathophysiologic changes: - melena, hematemesis
  a. increase in vascular permeability 3. Thrombocytopenia (< 100,000/mm )
3

▼ 4. Hemoconcentration
  extravasation of plasma - hematocrit >40% or rise of >20% from baseline
- hemoconcentration - a drop in >20% Hct (from baseline) following
  rd
- 3 spacing of fluids volume replacement
- signs of plasma leakage
  b. abnormal hemostasis [pleural effusion, ascites, hypoproteinemia]
  - vasculopathy
- thrombocytopenia
  - coagulopathy

 
 
 
 
MANAGEMENT OF DENGUE MANAGEMENT OF HEMORRHAGE
 
A. Vital Signs and Laboratory Monitoring
  Monitor BP, Pulse Rate
We have to watch out for Shock (Hypotension)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
Torniquet Test: SBP + DBP = mean BP for 5 mins.
  2 URINARY TRACT INFECTION

  if ≥20 petechial rash per sq. inch on antecubital fossa

(+) test Suggestive UTI:
  - Pyuria: WBC ≥ 5/HPF or 10mm
3

Herman’s Rash: - Absence of pyuria doesn’t rule out UTI

  - usually appears after fever lysed - Pyuria can be present w/o UTI
- initially appears on the lower extremities
  - not a common finding among dengue patients Presumptive UTI:
- “an island of white in an ocean of red” - (-) urine culture
  - lower colony counts may be due to:
* overhydration
  Recommended Guidelines for Transfusion: * recent bladder emptying
* previous antibiotic intake
  Transfuse:
  - PC < 100,000 with signs of bleeding
- PC < 20,000 even if asymptomatic
Proven or Confirmed UTI:
- (+) urine culture ≥ 100,000 cfu/mL urine of a single
  - use FFP if without overt bleeding
- FWB in cases with overt bleeding or
organism
- multiple organisms in culture may indicate a
  signs of hypovolemia contaminated sample

  > if PT & PTT are abnormal: FFP

> if PTT only: cryprecipitate
  3-7cc/kg/hr depending on the Hct (1 no.) level
st

  (D5LR)
10-20cc/kg fast drip PLR - hypotension, narrow pulse
  pressure fair pulse

  Leukopenia in dengue: probable etiology is

Pseudomonas
  therefore: give Meropenem or Ceftazidime
 
 
 
  ACUTE GLOMERULONEPHRITIS RHEUMATIC FEVER TREATMENT OF RHEUMATIC FEVER
 
Complications of AGN JONES CRITERIA: A. Antibiotic Therapy
  - CHF 2° to fluid overload - 10 days of Oral Penicillin or Erythromycin
- HPN encephalopathy A. Major Manifestations - IM Injection of Benzethine Penicillin
  - ARF due to ê GFR - Carditis (50-60%)
- Polyarthritis (70%) *** NOTE: Sumapen = Oral Penicillin!
  - Chorea (15-20%)
STAGES of AGN - Erythema Marginatum (3%) B. Anti-Inflammatory Therapy
  - Oliguric phase [7-10days] – complications sets in - Subcutaneous Nodules (1%)
- Diuretic phase [7-10days] – recovery starts 1. Aspirin (if Arthritis, NOT Carditis)
  - Convalescent phase [7-10days] – patients are B. Minor Manifestations Acute: 100mg/kg/day in 4 doses x 3-5days
usually sent home - Arthralgia Then, 75mg/kg/day in 4 doses x 4 weeks
  - Fever
- Laboratory Findings of: 2. Prednisone
  Prognosis ▲ Acute Phase Reactants (ESR / CRP) 2mg/kg/day in 4 doses x 2-3weeks
- Gross hematuria 2-3 weeks Prolonged PR interval Then, 5mg/24hrs every 2-3 days
  - Proteinuria 3-6 weeks
  - ▼C3
- microscopic hematuria
8-12 weeks
6-12 mo or
C. PLUS Supporting Evidence of Antecedent
Group-A Strep Infection
  - HPN
1-2 years
4-6 weeks
- (+) Throat Culture or Rapid Strep-Ag Test
- ▲Rising Strep-AB Test
PREVENTON

  A. Primary Prevention

 
+
> Hyperkalemia may be seen due to Na retention - 10 days of Oral Penicillin or Erythromycin
++
> Ca decreases in PSAGN - IM Injection of Benzethine Penicillin
  > ▲ in ASO titer
- normal within 2 weeks
  - peaks after 2 weeks
- more pronounced in pharyngeal infection
  than in cutaneous

 
 
 
  B. Secondary Prevention

 
 
 
 
  C. Duration of Chemoprophylaxis

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
  KAWASAKI DISEASE
  CDC-CRITERIA FOR DIAGNOSIS:
TREATMENT SEIZURES

  ADOPTED FROM KAWASAKI

(ALL SHOULD BE PRESENT)
Currently Recommended Protocol:
> Seizures: sudden event caused by abrupt,
  A) HIGH Grade Fever (>38.5 Rectally) PRESENT
A. IV-Immunoglobulin uncontrolled, hypersynchronous
discharges of neurons
  for AT LEAST 5-days without other Explanation 2g/kg Regimen Infusion EQUALLY Effective in
“High Grade Fever of at least 5 days” Prevention of Aneurysms and Superior to 4-day > Epilepsy: tendency for recurrent seizures that are
  DOES NOT Respond to any kind of Antibiotic! Regimen with respect to Amelioration of Inflammation unprovoked by an immediate cause
as measured by days of
  B) Presence of 4 of the 5 Criteria Fever, ESR, CRP, Platelet Count, Hgb, and Albumin > Status epilepticus: >30min or back-to-back
1. Bilateral CONGESTION of the Ocular Conjunctiva w/o return to baseline
  (seen in 94%) NOTE: There is a TIME FRAME of 10 days
2. Changes of the Lips and Oral Cavity (At least ONE) > Etiology:
  3. Changes of the Extremities (At least ONE) - V ascular : AVM, stroke, hemorrhage
4. Polymorphous Exanthem (92%) B. Aspirin - I nfections : meningitis, encephalitis
  5. Cervical Adenopathy = Non-Suppurative Cervical - T raumatic :
Adenopathy (should be >1.5cm) in 42%) HIGH Dose ASA (80-100mg/kg/day divided q 6h) - A utoimmune : SLE, vasculitis, ADEM
  should be given Initially in Conjunction with IV-IG - M etabolic : electrolyte imbalance
HARADA Criteria THEN - I diopathic : “idiopathic epilepsy”
  - used to determine whether IVIg should be given Reduced to Low Dose Aspirin (3-5mg/kg/day) - N eoplastic : space occupying lesion
- assessed within 9 days from onset of illness AND - S tructural : cortical malformation,
  1. WBC > 12,000 Continued until Cardiac Evaluation COMPLETED prior stroke
  2. PC <350,000
3. CRP > 3+
(approximately 1-2 months AFTER Onset of Disease) - S yndrome : genetic disorder

  4. Hct <35%
5. Albumin <3.5 g/dL
  6. Age 12 months
7. Gender: male
  • IVIg is given if ≥ 4 of 7 are fulfilled
  • If < 4 with continuing acute symptoms,
risk score must be reassessed daily
 
 
 
  TYPES OF SEIZURES CLASSIFICATION BY CAUSE SIMPLE FEBRILE SEIZURE
  A. Partial Seizures (Focal / Local) A. Acute Symptomatic A. Criteria for an SFS
  – Simple Partial
– Complex Partial (Partial Seizure +
(shortly after an acute insult)
– Infection
– < 15 minutes
– Generalized-tonic-clonic
  Impaired Consciousness)
– Partial Seizures evolving to Tonic-Clonic
– Hypoglycemia, low sodium, low calcium
– Head trauma
– Fever > 100.4 rectal to 101 F (38 to 38.4 C)
– No recurrence in 24 hours
  Convulsion – Toxic ingestion – No post-ictal neuro abnormalities (e.g. Todd’s
paresis)
  B. Generalized Seizures B. Remote Symptomatic – Most common 6 months to 5 years
– Absence (Petit mal) – Pre-existing brain abnormality or insult – Normal development
  – Myoclonic – Brain injury (head trauma, low oxygen) – No CNS infection or prior afebrile seizures
– Clonic – Meningitis
  – Tonic – Stroke B. Risk Factors
st nd
– Tonic-Clonic – Tumor – Febrile seizure in 1 / 2 degree relative
  – Atonic – Developmental brain abnormality – Neonatal nursery stay of >30 days
– Developmental delay
  C. Idiopathic – Height of temperature
SIMPLE FEBRILE SEIZURE – No history of preceding insult
  vs. – Likely “genetic” component C. Risk Factors for Epilepsy
COMPLEX FEBRILE SEIZURE (2 to 10% will go on to have epilepsy)
  – Developmental delay
Febrile Seizure: – Complex FS (possibly > 1 complex feature)
  “A seizure in association with a febrile illness in the – 5% > 30 mins => _ of all childhood status
absence of a CNS infection or acute electrolyte – Family History of Epilepsy
  imbalance in children older than 1 month of age – Duration of fever
  without prior afebrile seizures”

 
 
 
 
 
  BRONCHIAL ASTHMA (GINA GUIDELINES)

  Controlled Partly Controlled Uncontrolled

  Day
symptoms
none > 2x per wk

  Limitation of
activities
none any
3 or more symptoms
  Nocturnal Sx
(awakening)
none any of Partly Controlled
Asthma in any week
  Need for
< 2x per wk > 2x per wk
reliever
  Lung
normal < 80%
function
  Exacerbation none > 1x per yr 1x / week

 
 
 
 
 
 
 
 
 
 
 
 
 
  
  Clinical Features:
  RESPIRATORY DISTRESS SYNDROME
(Hyaline Membrane Disease) 1. Tachypnea, nasal flaring, subcostal and intercostal
TUBERCULOSIS
  retractions, cyanosis, grunting
A. Pulmonary TB o Male, preterm, low BW, maternal DM, & perinatal 2. Pallor – from anemia,
  – fully susceptible M. tuberculosis, asphyxia peripheral vasoconstriction
– no history of previous anti-TB drugs 3. Onset – within 6 hours of life
  – low local persistence of primary resistance to o Corticosteroids: Peak severity – 2-3 days
Isoniazid (H) • most successful method to induce fetal lung Recovery – 72 hours
  maturation
☤ 2HRZ OD then 4HR OD or 3x/wk DOT • Administered 24-48 hours before delivery Retractions:
  decrease incidence of RDS o Due to (-) intrapleural pressure produced by
• Most effective before 34 weeks AOG interaction b/w contraction of diaphragm & other
  – Microbial susceptibility unknown or initial drug
resistance suspected (e.g. cavitary) respiratory muscles and mechanical properties of
o Microscopically: diffuse atelectasis, eosinophilic the lungs & chest wall
  – previous anti-TB use
– close contact w/ resistant source case or living membrane
Nasal flaring:
  in high areas w/ high pulmonary resistance to
H. o Due to contraction of alae nasi muscles leading to
Pathophysiology: marked reduction in nasal resistance
  –
☤ 2HRZ + E/S OD, then 4 HR + E/S OD or
  3x/week DOT 1. Impaired/delayed surfactant synthesis & secretion
2. V/Q (ventilation/perfusion) imbalance due to
Grunting:
o Expiration through partially closed vocal cords
  B. Extrapulmonary TB
deficiency of surfactant and decreased lung
compliance
• Initial expiration: glottis closedà
lungs w/ gasà
  – Same in PTB 3. Hypoxemia and systemic hypoperfusion
4. Respiratory and metabolic acidosis
inc. transpulmo P w/o airflow
• Last part of expiration: gas expelled against
  – For severe life threatening disease
(e.g. miliary, meningitis, bone, etc)
5. Pulmonary vasoconstriction
6. Impaired endothelial &epithelial integrity
partially closed cords

  ☤ 2HRZ + E/S OD, then 10HR + E/S OD or

7. Proteinous exudates
8. RDS
Cyanosis:
o Central – tongue & mnucosa (imp. Indicator of
  3x/wk DOT impaired gas exchange); depends on
total amount of desaturated Hgb
 
 
  UMBILICAL CATHERIZATION
  Indications
Cathether length
• Standardize Graph
  • Vascular access (UV)
• Blood Pressure (UA) and blood gas monitoring in
– Perpedicular line from the tip of the shoulder to
the umbilicus
  NEWBORN RESUSCITATION critically ill infants • Measure length from Xiphoid to umbilicus and add
0.5 to 1cm.
  µ AIRWAY: open & clear Complications • Birth weight regression formula
• Positioning • Infection – Low line : UA catheter in cm = BW + 7
  • Suctioning • Bleeding – High line : UA catheter = [3xBW] + 9
• Hemorrhage – UV catheter length = [0.5xhigh line] + 1
  • Endotracheal intubation (if necessary)
• Perforation of vessel
• Thrombosis w/ distal embolization Procedure
  µ BREATHING is spontaneous or assisted
• Tactile stimulation (drying, rubbing)
• Ischemia or infarction of lower extremities, bowel • Determine the length of the catheter
or kidney • Restrain infant and prep the area using sterile
  • Positive-pressure ventilation • Arrhythmia technique
• Air embolus • Flush catheter with sterile saline solution
  µ CIRCULATION of oxygenated blood is adequate
• Chest compressions
• Place umbilical tape around the cord. Cut cord
Cautions about 1.5-2cm from the skin.
  • Medication and volume expansion • Never for: • Identify the blood vessels.
– Omphalitis (1thin=vein, 2thick=artery)
  – Peritonitis • Grasp the catheter 1cm from the tip. Insert into the
• Contraindicated in vein, aiming toward the feet.
  RESUSCITAION MEDICATIONS – NEC • Secure the catheter
  Atropine 0.02 ml/k IM, IV, ET
– Intestinal hypoperfusion • Observe for possible complications

Bicarbonate 1-2 meq/k

  Calcium 10 mg elem Ca/k slow IV
Line Placement
• Arterial line
  Calcium chloride
Calcium gluconate
0.33/k (27 mg Ca/cc)
1 cc/k (9 mg Ca/cc)
• Low line
– Tip lie above the bifurcation between L3 & L5
  Dextrose
1g/k = 2 cc/k D50
4 cc/k D25
• High line
– Tip is above the diaphram between T6 & T9
  Epinephrine 0.01 cc/k IV, ET

 
 
  BILIRUBIN

  PRETERM:
mg/dl mmol/L
  0-1 hr 1-6 17-100
1-2 d 6-8 100-140
  3-5 d 10-12 170-200

  TERM
mg/dl mmol/L
  0-1 hr 2-6 34-100
  1-2 d
3-5 d
6-7
4-12
100-120
70-200
  1 mo <1 <17

 
  KRAMERS CLASSIFICATION OF JAUNDICE

  ZONE JAUNDICE
SERUM
BILIRUBIN
  I Head & neck 6-8
Upper trunk
  II
to umbilicus
9-12

  III
Lower trunk
to thigh
12-16

  IV
Arms, legs,
below
15

  V Hands & feet 15

 
 
 
 
 
 
 
 
 
  
 
 
 
 
  MKD COMPUTATION
LUMBAR PUNCTURE • To diagnose other medical conditions such as:
– viral and bacterial meningitis Wt x mkd x preparation [mg/mL] = mL per dose
• the technique of using a needle to withdraw – syphilis, a sexually transmitted disease
cerebrospinal fluid (CSF) from the spinal canal. – bleeding around the brain and spinal cord e.g. 12kg x 10mg x 5ml = 5mL per dose
– multiple sclerosis, (affects the myelin coating of 120mg
SPINE the nerve fibers of the brain and spinal cord)
• spinal cord stops near L2 – Guillain-Barré syndrome, (inflammation of the * If per day, divide total (mL) by the # of divided doses
• lower lumbar spine (usually between L3-L4 or nerves)
L4–5) is preferable Dose x preparation x frequency = mkd
Complication weight
CSF • Local pain
• clear, watery liquid that protects the central • Infection
nervous system from injury • Bleeding µ Paracetamol Drops = Wt: move 1 decimal
• cushions the brain from the surrounding bone. • Spinal fluid leak point to the left
• It contains: • Hematoma (spinal subdural hematoma Age Wt
– glucose (sugar) • Spinal headache 1 10 kg
– protein • Acquired epidermal spinal cord tumor 2 12
– white blood cells 3 14
• Rate : 500ml/day or 0.35ml/min Caution & Contraindications 4 16
• Range : 0.3-04 ml/min • Increased ICP 5 18
• Volume : 50ml (infants) • Bleeding diasthesis 6 20
150ml (adults) • Traumatic Tap
• Overlying skin infection 1 drop = 1/20 mL
Indication • Unstable patient 1 teaspoonful = 5 mL
• to diagnose some malignancies (brain cancer and 1 tablespoonful = 15 mL
leukemia) 1 wineglassful = 60 mL = 2 ounces
• to assess patients with certain psychiatric 1 glassful = 250 mL = 8 ounces
symptoms and conditions. 1 grain = 60 mg
• for injecting chemotherapy directly into the CSF 1 pint = 500 mL
(intrathecal therapy) 1 quart = 1000 mL
1 ounce = 30 mL
1 Kg = 2.2 lbs
1 lb = 0.45359 Kg

Empirical dose
Ø 6 months ¼ tsp TID QID
Procedure Ø 6 mos – 2 yrs ½ tsp
• Apply local anesthetic cream (ideally) Ø 2-6 1 tsp
• Position the patient Ø 6-9 1 ½ tsp
• Prepare the skin using sterile techniques Ø 9-12 2 tsp
• Anesthetize the area with lidocane
• Puncture the skin in the midline just caudal to the
spinus process, angle cephalad toward the
umbilicus using a g23 needle
• Collect the CSF for analysis

CSF Analysis
1. Gram stain, culture and sensitivity
2. Cell count, differential count
3. Chemistries – sugar, protein
4. Special studies

After care
• Cover the puncture site with a sterile bandage,
apply pressure packing.
• Patients must remain lying down for 4-6 hours
• NPO for 4 hrs

CLINICAL FEATURES
CLASSIFICATION BASED ON SEVERITY
RESPIRATORY
MILD MODERATE SEVERE
ARREST
PERSISTENT - talking
INTERMITTENT
MILD MODERATE SEVERE - INF: softer, - at rest
Affects daily Affects daily Limits daily shorter, cry, - INF: stops
- walking
Exacerbation Brief activity & activity & activity & Breathless difficulty feeding Imminent
- can lie down
sleep sleep sleep feeding - hunched
Day-time Sxs <1x/wk >1x/wk daily continuous - prefers forward
Nightime Sxs <2x/mo >2x/mo >1x/wk frequent sitting
PEFR >80% >80% 60 - <80% <60% Talks in sentences phrases words
PEFR VAR <20% 20 - 30% >30% >30% may be usually usually drowsy /
Alertness
FEV1 >80% >80% 60 - <80% <60% agitated agitated agitated confused
often >30
RR ▲ ▲ bradypnea
mins
Accessory
(+) thoracoabd
muscles & none (+) (+)
movement
retractions