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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 Birth 3kg (Fil)
High fever >39.5°C 7
3.35kg (Cau)
Hyperpyrexia >42.0°C NORMAL LABORATORY VALUES 3-12 Age (mo) + 9 / 2 Age (mo) + 10 (F)
mo Age (mo) + 11 (C)
AGE HR (bpm) BP (mmHg) RR (cpm) NB Infant Child Adole 1-6 y Age (y) x 2 + 8 Age (y) x 5 + 17
RBC 4.8-7.1 3.8-5.5 3.8-5. M: 4.6-6.2 7-12 y Age (y) x 7 – 5 / 2 Age (y) x 7 + 5
Preterm 120-170 55-75/35-45 40-70 F: 4.2-5.4
Term 120-160 65-85/45-55 30-60 WBC 9-30,000 6-17,500 5-10,000 6-10,000
0-3 mo 100-150 65-85/45-55 35-55 Given Birth Weight:
PMNs 61% 61% 60% 60% Age Using Birth Weight in Grams
3-6 mo 90-120 70-90/50-65 30-45 Lymph 31% 32% 30% 30%
6-12 mo 80-120 80-100/55-65 25-40 < 6 mo Age (mo) x 600 + birth weight (gm)
Hgb 14-24 11-20 11-16 M: 14-18
1-3 yrs 70-110 90-105/55-70 20-30 6-12 mo Age (mo) x 500 + birth weight (gm)
F: 12-16
3-6 yrs 65-110 95-110/60-75 20-25 Hct 44-64% 35-49 31-46 M: 40-54
6-12 yrs 60-95 100-120/60-75 14-22 F: 37-47 Expected Body Weight (EBW):
12-17 yrs 55-85 110-135/65-85 12-18 Platelets 140-300 200-423 150-450 150-450 Term Age in days – 10 x 20 + Birth Weight
Ret 2.6-6.5 0.5-3.1 0-2 0-2 Pre-Term Age in days – 14 x 15 + Birth Weight
 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
Asian Caucasian PTT 12-20sec 12-14 12-14 12-14 3 years 5 x Birth Weight
Underweight <18.5 <18.5
Normal 18.5 – 22.9 18.5 – 24.9 5 years 6 x Birth Weight
Overweight ≥ 23.0 25 – 29.9 7 years 7 x Birth Weight
at risk 23 – 24.9 10 years 10 x Birth Weight
Obese I 25 – 29.9 30 – 39.9
Obese II ≥ 30 >40

APGAR
LENGTH / HEIGHT
(50 cm) Age Transverse-AP 0 1 2
Inches Blue / Pink body/ Blue Completely
Diameter ratio A
Age Centimeters Inches At Birth 1.0 Transverse = AP Pale extremities pink
At Birth 50 20 1y 1.25 Transverse > AP P Absent Slow (<100) > 100
1y 75 30 6y 1.35 Transverse >>> AP Coughs,
(-)
2-12 mo Age x 6 + 77 Age x 2.5 + 30 G Grimaces Sneezes,
Response
Cries
FONTANELS (-) Some flexion / Active
A
Age Gain in 1st Year is ~ 25cm Movement extension movement
0-3 mo + 9 cm 3 cm per mo Appropriate size at birth: 2 x 2 cm (anterior) Good,
R Absent Slow / Irregular
3-6 mo + 8 cm 2.67 per mo Closes at: Anterior = 18 months, or as early strong cry
6-9 mo + 5 cm 1.6 cm per mo as 9-12 months
Posterior = 6 – 8 weeks or 8 – 10: Normal
9-12 mo + 3 cm 1 cm per mo 4 – 7: Mild / Moderate Asphyxia
2 – 4 months
0 – 3: Severe asphyxia

HEAD CIRCUMFERENCE GCS


(33-38 cms) THORACIC INDEX
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
Verbal 5- Appropriate Oriented
5-12 mo + 2 in + 5.08cm 6 years : 1.35
4- Inconsolable Confused
(1/4 inches / mo) (0.635cm / mo) 3- Irritable Inappropriate
1-2 yrs + 1 inch 2.54 cm 2- Moans Incomprehensible
3-5 yrs + 1.5 in + 3.81cm 1- None None
(1/2 inches / year) (1.27cm / mo) Motor 6- Spontaneous Spontaneous
6-20 yrs + 1.5 in + 3.81cm 5- Localize pain Localize pain
(1/2 inches / year) (1.27cm / mo) 4- Withdraw Withdraw
3- Flexion Flexion
2- Extension 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 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? 8-11 mo 7-9 110 3.0
◦ Sexually active? When started? # of persons? ◦ 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? 13-15 y 36-44 55-65 1.5
Employment and Education
◦ Suicide plans? 16-19 y 48-55 45-50 1.2
◦ Currently at school? Favorite subjects?
◦ 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 Nestogen SMA
◦ Diet
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 Vibrio cholerae 01 & 0139
Ingestion of rotavirus ► rotavirus in intestinal villi
(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 Balantidium coli
Blastocyctis hominis
Assessment of dehydration (Skin Pinch Test)
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
Children
fluid intake? 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 st
1 hr: ¼ Plain LR 1st hr: ⅓ Plain LR Course, curly, abundant but amount < Areola & papilla formed secondary
4
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, small
> 20 kg 1500 + [ 20 for each kg in excess of 20 kg] 3 Longer Larger
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

TREATMENT OF RHEUMATIC FEVER


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

- 10 days of Oral Penicillin or Erythromycin


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

B. Secondary Prevention
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
C. Duration of Chemoprophylaxis (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
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 – Duration of fever
without prior afebrile seizures”

Clinical Features:
TUBERCULOSIS RESPIRATORY DISTRESS SYNDROME
(Hyaline Membrane Disease) 1. Tachypnea, nasal flaring, subcostal and
A. Pulmonary TB
intercostal 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 • Determine the length of the catheter
 Medication and volume expansion or 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.
Calcium 10 mg elem Ca/k slow IV – NEC • Secure the catheter
Calcium chloride 0.33/k (27 mg Ca/cc) – Intestinal hypoperfusion • Observe for possible complications
Calcium gluconate 1 cc/k (9 mg Ca/cc)
1g/k = 2 cc/k D50 Line Placement
Dextrose
4 cc/k D25 • Arterial line
Epinephrine 0.01 cc/k IV, ET • Low line
– 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
Empirical dose Lower trunk
III 12-16
 6 months ¼ tsp TID QID to thigh
 6 mos – 2 yrs ½ tsp Arms, legs,
IV 15
 2-6 1 tsp below
 6-9 1 ½ tsp V Hands & feet 15
 9-12 2 tsp

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  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