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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 pCO2: 35-45 B.E.: +/- 2mEq/L
Subfebrile 35.7 – 38.0°C pO2: 80-100 O2 sat: 97% Age Kilograms Pounds
Fever 38.0°C
At 3kg (Fil)
High fever >39.5°C 7
Birth 3.35kg (Cau)
Hyperpyrexia >42.0°C NORMAL LABORATORY VALUES 3-12 Age (mo) + 9 / 2 Age (mo) + 10
mo (F)
AGE HR (bpm) BP (mmHg) RR (cpm) NB Infant Child Adole Age (mo) + 11
RBC 4.8-7.1 3.8-5.5 3.8-5. M: 4.6-6.2 (C)
Preterm 120-170 55-75/35-45 40-70 F: 4.2-5.4
Term 120-160 65-85/45-55 30-60 1-6 y Age (y) x 2 + 8 Age (y) x 5 + 17
WBC 9-30,000 6-17,500 5-10,000 6-10,000 7-12 y Age (y) x 7 – 5 / Age (y) x 7 + 5
0-3 mo 100-150 65-85/45-55 35-55 PMNs 61% 61% 60% 60%
3-6 mo 90-120 70-90/50-65 30-45 2
Lymph 31% 32% 30% 30%
6-12 mo 80-120 80-100/55-65 25-40 Hgb 14-24 11-20 11-16 M: 14-18
1-3 yrs 70-110 90-105/55-70 20-30 Given Birth Weight:
F: 12-16
3-6 yrs 65-110 95-110/60-75 20-25 Age Using Birth Weight in Grams
Hct 44-64% 35-49 31-46 M: 40-54
6-12 yrs 60-95 100-120/60-75 14-22 F: 37-47 < 6 mo Age (mo) x 600 + birth weight (gm)
12-17 yrs 55-85 110-135/65-85 12-18 Platelets 140-300 200-423 150-450 150-450 6-12 mo Age (mo) x 500 + birth weight (gm)
Ret 2.6-6.5 0.5-3.1 0-2 0-2
 BP cuff should cover 2/3 of arm Expected Body Weight (EBW):
-: SMALL cuff: falsely high BP Term Age in days – 10 x 20 + Birth
-: LARGE cuff: falsely low BP COUNT (%) Weight
Pre-Term Age in days – 14 x 15 + Birth
BMI BT 1-5 min 1-6 1-6 1-6 Weight
CT 5-8 min 5-8 5-8 5-8
Asian Caucasian PTT 12-20sec 12-14 12-14 12-14
Underweight <18.5 <18.5 Age of Infant Ideal Weight
Normal 18.5 – 22.9 18.5 – 24.9 4-5 months 2 x Birth Weight
Overweight ≥ 23.0 25 – 29.9
1 year 3 x Birth Weight
at risk 23 – 24.9
2 years 4 x Birth Weight
Obese I 25 – 29.9 30 – 39.9
Obese II ≥ 30 >40 3 years 5 x Birth Weight
5 years 6 x Birth Weight
7 years 7 x Birth Weight
10 years 10 x Birth Weight
APGAR
LENGTH / HEIGHT
(50 cm) Age Transverse- 0 1 2
AP Diameter Inches Pink body/
Blue / Completely
Age Centimeters Inches ratio A Blue
Pale pink
At Birth 50 20 At Birth 1.0 Transverse = AP extremities
1y 75 30 1y 1.25 Transverse > AP P Absent Slow (<100) > 100
2-12 Age x 6 + 77 Age x 2.5 + 30 6y 1.35 Transverse >>> Coughs,
(-)
mo AP G Grimaces Sneezes,
Response
Cries
(-) Some flexion Active
A
Age Gain in 1st Year is ~ 25cm FONTANELS Movement / extension movement
0-3 mo + 9 cm 3 cm per mo Slow / Good,
R Absent
Appropriate size at birth: 2 x 2 cm (anterior) Irregular strong cry
3-6 mo + 8 cm 2.67 per mo
6-9 mo + 5 cm 1.6 cm per mo Closes at: Anterior = 18 months, or as early
8 – 10: Normal
as 9-12 months
9-12 + 3 cm 1 cm per mo 4 – 7: Mild / Moderate Asphyxia
Posterior = 6 – 8 weeks or
mo 0 – 3: Severe asphyxia
2 – 4 months
GCS
HEAD CIRCUMFERENCE Function Infants/Young Older
THORACIC INDEX
(33-38 cms)
Eye 4- Spontaneous Spontaneous
TI = transverse chest diameter Opening 3- To speech To speech
Age Inches Centimeters AP diameter 2- To pain To pain
At Birth 35 cm (13.8 in) 1- None None
< 4 mo + 2 in + 5.08cm Birth : 1.0 Verbal 5- Appropriate Oriented
(1/2 inches / mo) (1.27cm / mo) 1 year : 1.25 4- Inconsolable Confused
5-12 mo + 2 in + 5.08cm 6 years : 1.35 3- Irritable Inappropriate
(1/4 inches / mo) (0.635cm / mo) 2- Moans Incomprehensible
1-2 yrs + 1 inch 2.54 cm 1- None None
3-5 yrs + 1.5 in + 3.81cm Motor 6- Spontaneous Spontaneous
(1/2 inches / (1.27cm / mo) 5- Localize pain Localize pain
year) 4- Withdraw Withdraw
6-20 yrs + 1.5 in + 3.81cm 3- Flexion Flexion
(1/2 inches / (1.27cm / mo) 2- Extension Extension
year) 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 2. Convulsions, encephalitis / encephalopathy, permanent brain
Outer damage
thigh OPV Paralytic Polio
OPV 6 wks 2 drops 3 PO Mouth 4 wks HEPA B Local soreness
HEPA B 6 wks 0.5mL 3 IM Antero- 4 wks MEASLES 1. Fever & mild rash
lateral 2. Convulsions, encephalitis / encephalopathy, SSPE, death
thigh
MEASLES 9 mos 0.5mL 1 SC Outer 4 wks ACTIVE PASSIVE
upper BCG Diphtheria
arm DPT Tetanus
BCG-2 School entry 0.1mL 1 ID L- OPV Tetanus Ig
Deltoid Hep B Measles Ig
TetToxoid Childbearing 0.5mL 3 IM Deltoid 1 mo then Measles Rabies (HRIg)
Hib Hep A Ig
women 6-12 mos
MMR Hep B ig
Tetanus Toxoid 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? ◦ With whom does the adolescent live? 0-5 mo 3-6 115 3.5
◦ GF/BF? Typical date? ◦ Any recent changes in the living situation?
◦ Sexually active? When started? # of persons? 8-11 mo 7-9 110 3.0
◦ How are things among siblings? 1-2 y 10-12 110 2.5
Contraceptives? Pregnancies? STDs? ◦ Are parents employed? 3-6 y 14-18 90-100 2.0
◦ Are there things in the family he/she wants to 7-9 y 22-24 80-90 1.5
Suicide/Depression change?
◦ Ever sad/tearful/unmotivated/hopeless? 10-12 y 28-32 70-80 1.5
◦ Thought of hurting self/others? Employment and Education 13-15 y 36-44 55-65 1.5
◦ Suicide plans? ◦ Currently at school? Favorite subjects? 16-19 y 48-55 45-50 1.2
◦ Patient performing academically?
Safety ◦ Have been truant / expelled from school? TCR β = Wt at p50 x calories
◦ Use seatbelts/helmets? ◦ 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 ◦ Hobbies, interests, close friends?
◦ Respiration 1:1 1:2
◦ Infection Drugs Alacta Bonna
◦ Cardiac ◦ Used tobacco/alcohol/steroids? Enfalac Nursoy
◦ Hematologic ◦ Illicit drugs? Frequency? Amount? Lactogen Promil
◦ Metabolic Affected daily activities? Lactum S-26
◦ Output & Input [cc/kg/h] N: 1-2 ◦ Still using? Friends using/selling? Nan Similac
◦ Neuro
◦ 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 Aeromonas Astroviruses
1. Poorly absorbed osmotically active substances in Bacillus cereus Caloviruses
lumen Campylobacter jejuni Norovirus
◦ ORS vol. after each loose stool 1 day 2. Intestinal ion secretion (increased) or decreased Clostridium perfringens Enteric Adenovirus
absorption Clostridium difficile Rotavirus
<24 mo 5-100mL 500mL 3. Outpouring into the lumen of blood, mucus 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) ►destruction of villi Vibrio parahaemolyticus
Yersinia enterocolitica
Age 30mL/kg 75mL/kg
<12 1H 5H (secretory diarrhea ▼absorption ▲ secretion) ► AGE
Parasites
>12 30 mins 2½H Balantidium coli
Assessment of dehydration (Skin Pinch Test) Blastocyctis hominis
Cryptosporidium
Patient in SHOCK ◦ (+) if > 2 seconds Giardia lamblia
◦ no dehydration if skin tenting goes back
◦ 20-30cc/kg IV fast drip 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 Tetracyline
Shigella 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
2. If the child can drink, give ORS by mouth while the
> Breastfeed frequently & longer at each feeding IV drip is being set up
> if the child is exclusively breastfed, give one or 3. Give 100mL/kg Lactated Ringer’s solution
more of the following in addition to breastmilk
◦ ORS solution
First give Then give
◦ food based fluid (e.g. soup, rice, water) Age
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 detectable
:- give frequent small sips from a cup ◦ reassess the child every 15-30 min.
:- if the child vomits, wait for 10 min then if dehydration is not improving,
resume give IV fluid more rapidly
:- continue giving extra fluids until diarrhea
stops ◦ also give ORS (~5mL/kg/hr) as soon as the child
can drink [usually after 3-4 hours in infants; 1-2
2. Give Zinc supplements hours in children]

Up to 6 mo: 1 half tab per day for 10-14 days ◦ reassess after 6 hrs (infant) & 3 hrs (child)
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: 4 mo – 4 mo 12 mo – 12 mo 2 yrs – 2 yrs 5 yrs
Wt: <6kg 6-9.9kg 10-11.9kg 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: K: 35mEq K: 80mEq
100mmol/L 50mmol/L 5mmol/L Citrate: 30mEq Citrate: 30mEq
Na: Mg: Dextrose: 20g Dextrose: 25g
60 mol/L 5mmol/L
K: Citrate:
20 mmol/L 10 mmol/L
• Pedialyte mild 30
-: to supplement fluid & electrolyte loss due to
• Hydrite active play, prolonged exposure, hot and humid
-: 2 tab in 200ml water or 10sachets in 1L water 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 (immunosuppressed)
- Coccidioides immitis
- Blastomyces dermatitides
- Pneumocystis carinii (immunosuppressed,
HIV, steroids)

SMR GIRLS
LUDAN’S METHOD (HYDRATION THERAPY) Stage Pubic Hair Breasts
1 Preadolescent Preadolescent
MILD MODERATE SEVERE Sparse, lightly pigmented, straight, Breast & papilla elevated, as small
DEHYDRATION DEHYRATION DEHYDRATION 2
medial border of labia mound, areola diameter increased
< 15 kg, < 2 y/o 50 cc/kg 100 cc/kg 150 cc/kg Breast & areola enlarged, no contour
3 Darker, beginning to curl, ▲amount
> 15 kg, 2 y/o 30 cc/kg 60 cc/kg 90 cc/kg separation
D5 0.3% in 1st hr: ¼ Plain LR 1st hr: ⅓ Plain LR 4
Course, curly, abundant but amount < Areola & papilla formed secondary
6-8 hours Next 5-7 hrs: Next 5-7 hrs: adult mound
¾ D5 0.3% in ⅔ D5 0.3% in Adult, feminine triangle, spread to Mature, nipple projects, areola part of
5
5-7 hours 5-7 hours medial surface of thigh general breast contour

HOLIDAY-SEGAR METHOD (MAINTENANCE) SMR BOYS


Stage Pubic Hair Penis Testes
WEIGHT TOTAL FLUID REQUIREMENT 1 None Preadolescent Preadolescent
0 - 10 kg 100 mL / kg Scanty, long slightly Enlarged scrotum, pink
2 Slightly enlargement
11- 20 kg 1000 + [ 50 for each kg in excess of 10 kg] pigmented texture altered
Darker, starts to curl,
> 20 kg 1500 + [ 20 for each kg in excess of 20 kg] 3 Longer Larger
small amount
Resembles adult type but
NOTE: Computed Value is in mL/day Larger, glans &
4 less in quantity, course, Larger, scrotum dark
Ex. 25kg child breadth ▲ in size
curly
Answer: 1500 + [100] = 1600cc/day Adult distribution, spread
5 Adult size Adult size
to medial surface of thigh
ATYPICAL PNEUMONIA
> 3-12 mo
-: extrpulmonary manifestations - RSV
-: low grade fever - Other respiratory viruses
-: patchy diffuse infiltrates - Streptococcus pneumoniae
-: poor response to Penicillin - Haemophilus influenzae (Type B)
-: negative sputum gram stain - 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
- M. pneumoniae
* Afebrile pneumonia - Group A Streptococcus
- Chlamydia trachomatis - Staph aureus
- Mycoplasma homilis
- 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. narrow pulse pressure (<20mmHg)
2. myalgia or arthralgia 3. hypotension for age
> Factors affecting transmission: 3. retroorbital pain 4. cold, clammy skin & irritability / restlessness
- breeding sites, high human population density, 4. hemorrhagic manifestations
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/mm3)
▼ 4. Hemoconcentration
extravasation of plasma - hematocrit >40% or rise of >20% from baseline
- hemoconcentration - a drop in >20% Hct (from baseline) following
- 3rd 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 10mm3
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 Proven or Confirmed UTI:
- PC < 20,000 even if asymptomatic - (+) urine culture ≥ 100,000 cfu/mL urine of a single
- use FFP if without overt bleeding organism
- FWB in cases with overt bleeding or - 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 (1st no.) level


(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 8-12 weeks C. PLUS Supporting Evidence of Antecedent
- microscopic hematuria 6-12 mo or Group-A Strep Infection
1-2 years - (+) Throat Culture or Rapid Strep-Ag Test PREVENTON
- HPN 4-6 weeks - ▲Rising Strep-AB Test
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
TREATMENT SEIZURES
CDC-CRITERIA FOR DIAGNOSIS:
ADOPTED FROM KAWASAKI Currently Recommended Protocol:
(ALL SHOULD BE PRESENT) > Seizures: sudden event caused by abrupt,
A. IV-Immunoglobulin uncontrolled, hypersynchronous
A) HIGH Grade Fever (>38.5 Rectally) PRESENT 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 (approximately 1-2 months AFTER Onset of Disease) - S yndrome : genetic disorder
3. CRP > 3+
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 (shortly after an acute insult) – < 15 minutes
– Complex Partial (Partial Seizure + – Infection – Generalized-tonic-clonic
Impaired Consciousness) – Hypoglycemia, low sodium, low calcium – Fever > 100.4 rectal to 101 F (38 to 38.4 C)
– Partial Seizures evolving to Tonic-Clonic – Head trauma – 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
– Tonic-Clonic – Tumor – Febrile seizure in 1st / 2nd 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 without – Duration of fever
prior afebrile seizures”

BRONCHIAL ASTHMA (GINA GUIDELINES)

Controlled Partly Controlled Uncontrolled


Day
none > 2x per wk
symptoms
Limitation of
none any
activities
3 or more symptoms
Nocturnal Sx
none any of Partly Controlled
(awakening)
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:
TUBERCULOSIS RESPIRATORY DISTRESS SYNDROME
(Hyaline Membrane Disease) 1. Tachypnea, nasal flaring, subcostal and intercostal
A. Pulmonary TB retractions, cyanosis, grunting
– fully susceptible M. tuberculosis, o Male, preterm, low BW, maternal DM, & perinatal 2. Pallor – from anemia,
– no history of previous anti-TB drugs asphyxia peripheral vasoconstriction
– low local persistence of primary resistance to 3. Onset – within 6 hours of life
Isoniazid (H) o Corticosteroids: Peak severity – 2-3 days
• most successful method to induce fetal lung Recovery – 72 hours
 2HRZ OD then 4HR OD or 3x/wk DOT maturation
• Administered 24-48 hours before delivery Retractions:
– Microbial susceptibility unknown or initial drug decrease incidence of RDS o Due to (-) intrapleural pressure produced by
resistance suspected (e.g. cavitary) • Most effective before 34 weeks AOG interaction b/w contraction of diaphragm & other
– previous anti-TB use respiratory muscles and mechanical properties of
– close contact w/ resistant source case or living o Microscopically: diffuse atelectasis, eosinophilic the lungs & chest wall
in high areas w/ high pulmonary resistance to membrane
H. Nasal flaring:
– o Due to contraction of alae nasi muscles leading to
 2HRZ + E/S OD, then 4 HR + E/S OD or Pathophysiology: marked reduction in nasal resistance
3x/week DOT
1. Impaired/delayed surfactant synthesis & secretion Grunting:
2. V/Q (ventilation/perfusion) imbalance due to o Expiration through partially closed vocal cords
B. Extrapulmonary TB deficiency of surfactant and decreased lung • Initial expiration: glottis closed→
– Same in PTB compliance lungs w/ gas→
3. Hypoxemia and systemic hypoperfusion inc. transpulmo P w/o airflow
– For severe life threatening disease 4. Respiratory and metabolic acidosis • Last part of expiration: gas expelled against
(e.g. miliary, meningitis, bone, etc) 5. Pulmonary vasoconstriction partially closed cords
6. Impaired endothelial &epithelial integrity
 2HRZ + E/S OD, then 10HR + E/S OD or 7. Proteinous exudates Cyanosis:
3x/wk DOT 8. RDS o Central – tongue & mnucosa (imp. Indicator of
impaired gas exchange); depends on
total amount of desaturated Hgb

UMBILICAL CATHERIZATION
NEWBORN RESUSCITATION Cathether length
Indications • Standardize Graph
 AIRWAY: open & clear • Vascular access (UV) – Perpedicular line from the tip of the shoulder to
• Positioning • Blood Pressure (UA) and blood gas monitoring in the umbilicus
• Suctioning critically ill infants • Measure length from Xiphoid to umbilicus and add
• Endotracheal intubation (if necessary) 0.5 to 1cm.
Complications • Birth weight regression formula
 BREATHING is spontaneous or assisted • Infection – Low line : UA catheter in cm = BW + 7
• Tactile stimulation (drying, rubbing) • Bleeding – High line : UA catheter = [3xBW] + 9
• Positive-pressure ventilation • Hemorrhage – UV catheter length = [0.5xhigh line] + 1
• Perforation of vessel
 CIRCULATION of oxygenated blood is adequate • Thrombosis w/ distal embolization Procedure
• Chest compressions • Ischemia or infarction of lower extremities, bowel or • Determine the length of the catheter
• Medication and volume expansion kidney • Restrain infant and prep the area using sterile
• Arrhythmia technique
• Air embolus • Flush catheter with sterile saline solution
• Place umbilical tape around the cord. Cut cord
RESUSCITAION MEDICATIONS Cautions about 1.5-2cm from the skin.
• Never for: • Identify the blood vessels.
– Omphalitis (1thin=vein, 2thick=artery)
Atropine 0.02 ml/k IM, IV, ET
– Peritonitis • Grasp the catheter 1cm from the tip. Insert into the
Bicarbonate 1-2 meq/k • Contraindicated in vein, aiming toward the feet.
10 mg elem Ca/k slow – NEC • Secure the catheter
Calcium
IV – Intestinal hypoperfusion • Observe for possible complications
Calcium chloride 0.33/k (27 mg Ca/cc)
Calcium gluconate 1 cc/k (9 mg Ca/cc) Line Placement
Dextrose
1g/k = 2 cc/k D50 • Arterial line
4 cc/k D25 • Low line
Epinephrine 0.01 cc/k IV, ET – Tip lie above the bifurcation between L3 & L5
• High line
– Tip is above the diaphram between T6 & T9

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 6-7 100-120
3-5 d 4-12 70-200
1 mo <1 <17

KRAMERS CLASSIFICATION OF JAUNDICE

SERUM
ZONE JAUNDICE
BILIRUBIN
I Head & neck 6-8
Upper trunk
II 9-12
to umbilicus
Lower trunk
III 12-16
to thigh
Arms, legs,
IV 15
below
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 nervous • Infection
system from injury • Bleeding  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
➢ 6 months ¼ tsp TID QID
Procedure ➢ 6 mos – 2 yrs ½ tsp
• Apply local anesthetic cream (ideally) ➢ 2-6 1 tsp
• Position the patient ➢ 6-9 1 ½ tsp
• Prepare the skin using sterile techniques ➢ 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 shorter, cry, - INF: stops
Affects daily Limits daily - walking
daily Breathless difficulty feeding Imminent
Exacerbation Brief activity & activity & - can lie down
activity & feeding - hunched
sleep sleep - prefers forward
sleep
Day-time Sxs <1x/wk >1x/wk daily continuous sitting
Nightime Sxs <2x/mo >2x/mo >1x/wk frequent Talks in sentences phrases words
PEFR >80% >80% 60 - <80% <60% may be usually usually drowsy /
Alertness
PEFR VAR <20% 20 - 30% >30% >30% agitated agitated agitated confused
FEV1 >80% >80% 60 - <80% <60% often >30
RR ▲ ▲ bradypnea
mins
Accessory
(+) thoracoabd
muscles & none (+) (+)
movement
retractions