Pediatric Notes Draft 12 1

COMMON OPD DRUGS
FEVER CONSTIPATION
- Paracetamol 10 – 15 mkdose, Q4 prn (100/1, 120/5, 250/5) - Lactulose 1 – 3 mL/kg/day BID
<1y 5 mL Based on 3.3 g/5 QD
MULTIVITAMINS 1-6y 5 – 10 mL
< 3 months 0.3 mL 7 – 14 y 10 mL
3- 12 months 0.6 mL CI: GALACTOSEMIA
1 – 2 years 1.2 mL QD - Bisacodyl (Dulcolax) suppository
2 – 6 years 5 mL - Fleet enema >5y 1 bottle (adult)
7 – 12 years 10 mL 2 – 5 y ½ bottle of adult dose
* at 14th DOL, start 0.5 mL
ACUTE GASTRITIS/ GERD
ACUTE NASOPHARYNGITIS - Omeprazole 1 mkday QD – BID (max 20)
- 0.65% NaCl nasal drops/spray instill 2 – 3 drops per nostril then 5 – 10 mg 5 mg
suction secretions/ blow nose gently Q6 prn 10 – 20 kg 10 mg QD (10, 20 cap)
- Phenylpropanolamine ( >2 y/o) Disudrin > 20 kg 20 mg
1 – 2 y 1mL - Esomeprazole
2 – 6 y 2.5 mL Q6 x 5d 1 – 11 y 10 mg
7 – 12 y 5 mL (6.25/1, 12.5/5) > 12 years old 20 – 40 mg
* up to 8 weeks. DO NOT CRUSH/ CHEW! capsules enteric – coated
ACUTE TONSILLOPHARYNGITIS for bioavailability
- Amoxicillin 40 mkday Q8 x 10 d (100/1, 125/5, 250/5) * available: 10 mg granules/ sachet. Dissolve 1 sachet in 15 mL water
- Co-Amoxiclav 20 – 40 mkday Q8 or 25 – 45 mkday BID
(TID: 125/31.25/5 or 250/62.5/5) ACUTE URTICARIA/ PRURITUS
(BID: 200/28.5/5 or 400/57/5 or 600/42.9/5) - Hydroxyzine 2 mkday Q6 – 8 PRN
- Kamillosan spray 1 – 2 sprays per orem TID after meals (2/1, 10/5, 10, 25, 50)
- Hexetidine mouthwash. Gargle BID. - Cetirizine 0.25 mkdose QS – BID
- Dequalinium Lozenge <2y 2.5 mg
2 – 5 y 2.5 – 5 mg QD (2.5/1, 5/5. 10)
HERPANGINA >6y 5 – 10 mg
- Miconazole (Daktarin) oral gel. Apply over affected areas TID - Loratadine
- Dequalinium paint. 2 – 5 y 5 mg QD (1/1, 10)
- Solcoseryl oral paste > 6y 10 mg
- Diphenhydramine 1 – 2 mgdose Q6
IMPACTED CERUMEN (12.5 / 5, 25, 50; max 300 mg/day)
- Baby oil instill 3 to 4 drops on affected ear TID x 7 days
- Docusate Na ATOPIC DERMATITIS
- Clean ears - Antihistamine prn for pruritus
- Atopiclair / Physiogel/ Cetaphil. Apply TID
ACUTE OTITIS EXTERNA - Desonide cream. Apply over affected areas BID – TID after
- Fluocinolone acetonide + Polymixin B + Neomycin sulfate moisturizer
(Aplosyn) otic drops. Instill 3 – 4 drops on affected ear TID. - Do not prolong use to prevent rebound
ACUTE OTITIS MEDIA INTERTRIGO/ DIAPER DERMATITIS

- Amoxicillin or Co – Amoxiclav 80 – 90 mkday for 10 days (max 3 - Calamine + Zinc oxide (Calmoseptine) Apply over affected areas BID
g/day) – QID
- Clarithromycin 15 mkday (125/5, 250/5)
SCABIES
CHRONIC OTITIS MEDIA (ACTIVE) - Antihistamine for pruritus
- Ciprofloxacin otic drops. Instill 2 – 3 drops on affected ear and - Permethrin lotion. Apply from neck down. Leave on overnight (8 –
leave for 1 min BID x 7 days 12 hours) then rinse. May repeat after 1 week.
- Treat ALL household contacts and specific hygiene instructions
ACUTE GASTROENTERITIS
- ORS 75. Replace losses volume per volume PEDICULOSIS CAPITIS/ HEAD LICE / NITS
Hydrite 1 sachet in 200 mL H2O - Permethrin shampoo. Apply over wet hair. Leave on for 10 minutes
Glucolyte 1 sachet in 100 mL H2O then rinse. May repeat after 1 week (1%)
Homemade 1L H2O + ½ tsp salt + 6 tsp sugar - Use fine toothed comb. No sharing.
- Zinc sulfate (55/5 or 28.5/1) VARICELLA ZOSTER (CHICKEN POX) OR HERPES ZOSTER (SHINGLES)
< 6 months 10 mg QD x 14 days - NSS compress. Apply over affected areas for 15 minutes TID
> 6 months 20 mg - Acyclovir (case to case basis)
- Bacillus clausii (Erceflora). Mix 1 vial on any beverage BID x 5 – 7 VZV 80 mkday QID x 3 days
days HZV 4000 mg/day ÷ 5 x 5 – 7 days
INFECTIOUS DIARRHEA TINEA VERSICOLOR/ CORPORIS

- Cotrimoxazole 8 – 10 mkday (TMP) BID x 7d - Sertaconazole nitrate cream. Apply BID x 2 – 6 weeks
(200/40/5 or 400/80/5) - Ketoconazole cream. Apply QD x 2 – 6 weeks
- Ciprofloxacin 20 – 30 mkday BID x 3 – 5 days
IMPETIGO CONTANGIOSA/ FURUNCULOSIS ALLERGIC RHINITIS
- Cefalexin 25 – 100 mkday Q6 – 12 x 7 days Cetirizine 6 – 12 mo: 2.5 mg QD
(125/5, 250/5, 100/1) 1 – 2 y.o.: 2.5 mg QD – BID
- Cloxacillin 50 – 100 mkday Q6 x 7 fays 2 – 5 y.o.: 2.5 mg QD – BID
(125/5, 250/5) on empty stomach 5 – 10 y.o: 5 – 10 mg/day
- Clindamycin 10 – 30 mkday Q6 – Q8 x 7 days Levocetirizine: 6 – 11 y.o.: 2.5 mg QD
(75/5, 75. 150, 300; max 1.8/days) > 12 y.o: 5 mg QD
- Mupirocin ointment. Apply TUD Loratadine: 2 – 5 y.o.: 5 mg QD
> 6 y.o.: 10 mg QD
PNEUMONIA (PCAP A or B) Fluticasone > 4 y.o.: 1 – 2 sprays per nostril QD
- Amoxicillin 40 – 50 mkday Q8 x 7 days Mometasone 2 – 11 y.o.: 1 spray per nostril QD
- Cefuroxime 20 – 30 mkday Q12 x 7 days > 12 y.o.: 2 sprays per nostril QD
(125/5, 250/5,) Budesonide > 6 y.o.: 1 spray per nostril QD (max 4)
- Clarithromycin 15 mkday Q12 x 7 days
- CoAmoxiclav (same as Amoxicillin) URTICARIA
- Azithromycin 10 mkday on D1 then 5mkday on D2 – 5 (max 500 Antihistamines:
 250 mg/d) - Cetirizine: 2.5/5/10 mg QD
- Loratadine: 5/10 mg QD
TUBERCULOSIS - Desloratadine: 1/1.25/2.5/5 mg QD
- Primary PTB: 2 HRZE + 4 HR - Fexofenadine: 30/60/180 mg BID
- Extensive PTB: 2 HRZS + 4 HR - Cimetidine: 10 – 40 mkday Q6 -12
- Latent PTB: 9H - Ranitidine: 5 – 10 mkday Q12
- PTB Exposure: 3 - Famotidine: 1 – 2 mkday Q12
- Isoniazid 10 – 15 mkday (200/5) Leukotriene modifiers
- Rifampicin 10 – 20 mkday (200/5) - Montelukast: 4 /5 mg QD 10 mg QD
- Pyrazinamide 30 – 40 mkday (250/5, 500/5) - Zafirlukast: 10 mg BID
- Ethambutol 15 – 25 mkday (400 mg) Immunomodulator Drugs
- Streptomycin 20 – 40 mkday - Cyclosporine 4 – 6 mkday QD
(1g + 2mL H2O / IM) - Sulfasalazine: 30 mkday Q6
* Myrin P Forte (H75/R150/Z 400/ E 275) - IVIG: 400 mg/kg/day x 5 days
40 – 54 kg: 3 tab/day
55 – 70 kg: 4 tab/day QD ANAPHYLAXIS
> 71 kg: 5 tab/day “HERDS”
1. Epinephrine (adrenaline) at anterolateral thigh
ASTHMA / ALLERGIC COUGH 0.1 mL/kg/dose (1:10 000) or
- Salbutamol 0.1 mkdose Q8 (2/5) 0.01 mL/kg/dose (1:1000) /IM Q15
- Prednisone 1 – 2 mkday BID OFS Max 0.5 mL/0.3 mL (~ 0.1 mL = 0.1 mg)
(10/5 2. Ranitidine/ Cimetidine (H2 antagonist)
- Prednisolone 1 – 2 mkday BID OFS R: 1 mg/kg up to 50 mg/IV
(15/5 C: 4 mg/kg up to 200 mg/IV
- Inhalers / Puff 3. Diphenhydramine / Cetirizine (H1 antagonist)
Salbutamol 100 mcg/ actuation D: 1.25 mg/kg up to 50 mg/IM
Salmeterol + Fluticasone C: 0.25 mg/kg up to 10 mg
4. Hydrocortisone / Prednisone (Steroids)
ANEMIA / PROPHYLAXIS Solu- Medrol (IV): 1 – 2 mg/kg up to 12.5 mg/IV
FERROUS SULFATE Depo-Medrol (IM): 1 mg/kg up to 80 mg
-Prophylaxis Prednisone: 1 – 2 mg/kg up to 75 mg
Premature 2 mkday max 15 mg/day 5. Salbutamol Nebulization
Full Term 1 – 2 mkday max 15 mg/day 6. Fluid Therapy (for snack)
Adult 60 – 100 mg/day QD – BId
- Anemia ANAL FISSURE
Premature 2 - 4 mkday QD – BID FAKTU: Policresulen (condensation product of metacresolsulfonic acid
Child 3 – 6 mkday QD – TID and methanal), cinchocaine hydrochloride.
Adult 60 – 100 mg BID – QID Ointment: Apply BID-TID daily to the affected area. Rectal insertion of
ointment requires prior evacuation of bowel.
ACNE VULGARIS Suppository: 1 suppository BID-TID following evacuation.
- Adapalene + Benxzoyl peroxide > Lactulose if constipated.
Apply over affected sites ince a day
Policresulen. It arrests to bleeding by coagulating blood protein and
BACTERIAL CONJUCTIVITIS inducing the muscle fibers of small blood vessels to contract. The
- Tobramycin eye drops coagulating properties and the acid pH brings out the antimicrobial
Instill 1 –2 drops on affected eye every 4 hours action against E. coli, staphylococci and streptococci, Ps.
Avoid eye manipulation. Keep area clean and dry aeruginosa, Proteus vulgaris, candida and other bacteria. Thus, the
wound is protected against infection. The coagulation of necrotic and
UTI pathologically altered tissues cleans the wound and promotes healing.
- Cefuroxime 20 – 30 mkday BID x 7 days Cinchocaine has local anesthetic action which relieves pain and itching.
* Drugs that interfere with albumin = Jaundice

- Ceftriaxone, Oxacillin, Furosemide, ASA, Aminophylline,
Sulfonamides
CHRONIC CONSTIPATION (ROME III CRITERIA) K59.9 ACUTE GASTROENTERITIS
 Admit to __ under the service of Dr ____ _  Admit to __ under the service of Dr ____ _
 NPO  Diet for Age
 Monitor vital signs every 4 hours and record  Monitor vital signs every 4 hours and record
 Monitor input & output accurately every shift and record  Monitor input & output accurately every shift and record
 Monitor stool output, character and consistency. Refer to  For visual inspections of stools
PROD every after bowel movement.  Weight patient once at the ward ___ then once a day pre-
 Weight patient once at the ward ___ then once a day prebreakfast using the same weighing scale
breakfast using the same weighing scale  Watch out for signs of dehydration (sunken eyeballs, dry lips,
 IVF: D5LR 1L to run at ___ cc/hr (____%) tachycardia, weak pulses, CRT > 2 secs, decreased urine output)
Refer to PROD for reassessment after 6 hours  IVF: D5 0.3 NaCl 500 mL to run at ___ cc/hr (____%)
 Watch out for fever, persistent pain or vomiting, abdominal Refer to PROD for reassessment after 6 - 8 hours
distention and refer if with such.  Request for:
 Request for: CBC and platelet
CBC and platelet Fecalysis
SFA with Fleet enema  Therapeutics
 Therapeutics ORS 75 to replace losses volume per volume. If not tolerated
Sodium picosulfate (Dulcolax) 5 mg/5mL, 5 mL ODHS may replace with PLRS
Lactulose 3.3 g/5mL syrup, 5mL QD at daytime Zinc sulfate 20mg/5mL, give 5 mL QD x 14 days
Pediatric Fleet enema 60 mL per rectum now, replace watery Bacillus clausii (Erceflora) give 1 vial
stools with plain LR volume per volume Paracetamol at 10 – 15 mkdose, give ___ every 4 hours as
ORS 75 to replace losses volume per volume. If not tolerated needed for fever T 38.5OC and above
may replace with PLRS  Inform AMD of this admission
Omeprazole 40 mg via slow IV every 24 hours  Inform PROD and PIOD as well.
 Refer to Pedia-GHN for follow up care  Refer accordingly.
 Inform AMD of this admission
 Inform PROD and PIOD as well. *May request for urinalysis if indicated
 Refer accordingly. *May request for Na, K if with massive losses
ACUTE ABDOMEN INDICATION FOR FECALYSIS:

 Admit to __ under the service of Dr ____ _ 1. Mucoid/ Bloody stools
 NPO-TFO 2. Epidemic
 Monitor vital signs every 4 hours and record 3. Prolonged diarrhea > 2 weeks
 Monitor input & output accurately every shift and record 4. Immunocompromised
 Weight patient now ___ then once a day 5. Fever
 Watch out for fever, persistent pain or vomiting, bloody stool, 6. Toxic-looking
hematuria, abdominal distention and refer if with such.
 IVF: D5 0.3 NaCl 500 mL to run at ___ cc/hr (%) DISIMPACTION
Refer to PROD for reassessment after 8 hours 1. Bisacodyl (Dulcolax) 10 mg/suppository 1 suppository per
 Request for: rectum tomorrow (date, time)
SFA 2. 4 hours after Dulcolax suppository give flavored Castol oil
CBC with PC orange flavor 30 mL orals (time)
 Therapeutics 3. 6 hours after Castor oil, give Sodium picosulfate (Dulcolax Pico)
Antibiotics 5 mg/5mL 15 mL orally
Omeprazole 40 mg/slow IV push every 24 hours early Replace all stools with ORS 75 prepared as follows: Hydrite 1 sachet +
morning while on NPO water 200 mL in slow sips for every episode of loos stool
Paracetamol at 10 – 15 mkdose, give ___ every 4 hours as Use plain LR if ORS 75 is not tolerated
needed for fever T 38.5OC and above
 Refer to Gynecology for further evaluation and management
 Inform PROD and PIOD as well.
 Refer accordingly.
URINARY TRACT INFECTION
 Admit to __ under the service of Dr ____ _
 Diet for Age
 Monitor vital signs every 4 hours and record
 Monitor input & output accurately every shift and record
 Watch out for
 IVF: D5 0.3% NaCl 500 mL to run at __ mL/hr (100%)
 Request for:
CBC and platelet Urinalysis
Urine culture and sensitivity BUN, Creatinine
KUB Ultrasound
 Therapeutics
Cefuroxime at 75 – 150 mkday per slow IV infusion over 30
minutes every 8 hours
Paracetamol at 10 – 15 mkdose, give every 4 hours for fever
T 38.5OC and above
ORS 75 to replace losses volume per volume
BRONCHIAL ASTHMA SALBUTAMOL CHALLENGE TEST
 Admit to __ under the service of Dr ____ _  Nebulize with 1 nebule Salbutamol 2.5 mg/2.5 mL for 3 doses,
 Diet for Age. Hold food if RR> ___ (normal RR for age) given 20 minutes apart
 Monitor vital signs every 2 hours and record include pulse  Nebulize with Salbutamol nebulizing solution 1mg/mL, 2 for 3
oximetry Q4 and maintain O2 saturation > 95% doses, given 20 minutes apart
 Hook to O2 supplementation via nasal cannula at __ LPM BRONCHIAL ASTHMA IN SEVERE EXACERBATION
 Watch out for signs of respiratory distress (desaturation,  NPO – TFO. Hgt now __ then once a day while on NPO
tachypnea, alar flaring, cyanosis, dyspnea, retractions, stridor,  WOF: GI symptoms, tachycardia, arrhythmia
wheezing, diaphoresis)  Therapeutics:
 IVF: D5 IMB 500 mL to run at __ mL/hr 1. Salbutamol nebulization 2.5 mg/2.5 mL, 1 nebule Q1
 Request for: alternating with Salbutamol + Ipratropium bromide
CBC and platelet (Combivent) every 6 hours
CXR (PA/Lat) 2. Methylprednisolone 30 mg/IV q6 (1 mg/kg/dose)
 Therapeutics 3. Aminophylline 25 mg/mL loading dose 5.8 mL + 19.2 mL
1. Hydrocortisone LD 4-8 mkdose, MD: 8mkday /SIVP Q6 PNSS to make 25 mL to run for 30 minutes followed by
2. Salbutamol nebulization 2.5 mg/2.5 mL, 1 nebule Q2 maintenance dose 5.8 mL aminophylline + 94.2 mL PNSS to
3. 0.65% NaCL drops, instill 3 – 4 drops per nostril every 6 make 100 mL
hours then suction gently as needed
4. Paracetamol at 10 – 15 mkdose, give every 4 hours for
fever T 38.5OC and above
˃ Do gently physiotherapy after every nebulization
˃ Inform AMD of this admission
PNEUMONIA DENGUE FEVER
 Admit to __ under the service of Dr ____ _  Admit to ___ under the service of Dr. ____
 Diet for Age  Diet for Age. Avoid dark-colored foods. Include oral fluid intake
 Observe strict aspiration precaution. Hold food if RR> ___ up to ___/ day
 Keep head elevated from the waist up around 30O.  Monitor vital signs every 2 hours and record
 Monitor vital signs every 2 hours and record include pulse  Monitor input & output accurately every shift and record
oximetry Q4 c/o ___ and maintain O2 saturation > 95%  Watch out for signs of bleeding (gum bleeding, epistaxis, melena
 Monitor input & output accurately every shift and record and hematochezia), abdominal pain, vomiting and signs of
 Hook to O2 supplementation via nasal cannula at 2 LPM circulatory collapse (hypotension BP <___ mmHg, narrow pulse
 Watch out for signs of respiratory distress (desaturation, pressure <20 mmHg, weak pulses, cold clammy extremities,
tachypnea, alar flaring, cyanosis, dyspnea, retractions, stridor, tachycardia)
wheezing, diaphoresis)  IVF: PLRS 1L to run at a rate of ____ cc/hr (%)
 IVF: D5IMB 500 mL to run at __ mL/hr Refer back to PROD after 6 hours.
Refer to PROD after 6 hours for reassessment  Request for
 Request for: CBC and platelet
CBC and platelet Dengue NS1 or IgG/ IgM
CXR (PA/Lat) CXR
 Therapeutics  Therapeutics
1. Ampicillin __ mg/ SIVI over 30 minutes Q6 ( ) ANST. Paracetamol at 10 – 15 mkdose Q4 for fever T 38.5OC and above
Mild/ Moderate: 100 – 200 mkday ÷ Q6, ORS 75 to replace losses volume per volume. If not tolerated
Severe: 200 – 400 mkday ÷ Q 4 – 6 may replace with PLRS
or Ampicillin-sulbactam 1g/SIVI Q6 (__ mkd based on Omeprazole 40 mg/ slow IV push now then QD
Ampicillin content)  Inform AMD of this admission
2. Salbutamol nebulization 2.5 mg/2.5 mL, 1 nebule Q4 or  Inform PROD and PIOD as well.
Q2 alternating with Salbutamol + Ipratropium bromide  Refer accordingly.
(Combivent) every 6 hours
3. Paracetamol at 10 – 15 mkdose, give every 4 hours for DENGUE SHOCK
fever T 38.5OC and above  PLRS to run at 10 mL/kg/hr to be given over 1 hour
4. 0.65% NaCL drops, instill 3 – 4 drops per nostril every 6 (compensated shock) or over 15 minutes (hypotensive shock)
hours then suction gently as needed  Reassess
5. Fluimucil 200 mg/sachet, dissolve 1 sachet in 200 mL  If with improvement, gradually decrease IVF rate 10 > 7 > 5 > 3 >
water BID. maintenance
˃ Do gently physiotherapy after every nebulization  If no improvement: give 2nd bolus or consider blood transfusion
˃ Inform AMD of this admission with FWB at 20 mL/kg
 Refer accordingly. *Know P5, P50, P90, P95, P99
IDIOPATHIC THROMBOCYTOPENIC PURPURA BETA THALASSEMIA (DESFEROXAMINE TREATMENT)
 Diet for Age  Diet for Age
 Watch out for abdominal pain, epistaxis, gum bleeding and  Request for:
progression of hematoma CBC and platelet
 Insert heplock Serum Ferritin
 Request for:  Therapeutics
CBC and platelet (save smear) Desferoxamine 500 mg/vial, give 1 vial reconstituted with 5mL
PT, aPTT sterile water + 5 mL
 Therapeutics PNSS via subcutaneous infusion over 12 hours once a day for 5 –
Prednisone at 1 – 4 mkday 6 days
 Refer to Pedia-Hematology for further evaluation and Folic acid 5 mg/5mL give 1 mL once a day
management Multivitamins syrup give 5 mL once a day
 Inform AMD of this admission  Inform AMD of this admission
 Inform PROD and PIOD as well.  Inform PROD and PIOD as well.
 Refer accordingly.  Refer accordingly.
HEMOPHILIA A

 Diet for Age
 Watch out for abdominal pain, progression of swelling or
hematoma, or any other bleeding
 Insert heplock
 Request for:
Ultrasound (site of bleed)
 Therapeutics
Factor VIII ___ u/vial, give ___ vials per SIVP Q12
Apply cold compress over affected area TID
POST STREPTOCOCCAL GLOMERULONEPHRITIS NEPHROTIC SYNDROME

 Limit fluid intake to ___ cc/day  Limit fluid intake to ___ cc/day
 Limit sodium intake to ___ g/day  Limit sodium intake to ___ g/day
 Weight patient now __ then once a day  Weight patient now __ then once a day
 Measure abdominal circumference now ___, then once a day  Measure abdominal circumference now ___, then once a day
pre-breakfast pre-breakfast
 Watch out for hypotension, progression of edema, dyspnea  Watch out for hypotension, progression of edema, dyspnea
 Insert heplock  Insert heplock
 Request for:  Request for:
CBC and platelet ASO CBC and platelet TPAG
Na, K C3 Na, K Random urine protein
BUN, Creatinine Urinalysis BUN, Creatinine Random urine creatinine
 Therapeutics Urinalysis Total cholesterol
Furosemide Q12 with strict BP precautions.  Therapeutics
Hold if BP <90/60 mmHg Furosemide Q12 with strict BP precautions.
 Refer to Pedia Nephrology for further evaluation and Hold if BP <90/60 mmHg
management  Refer to Pedia Nephrology for further evaluation and
 Inform AMD of this admission management
 Inform PROD and PIOD as well.  Inform AMD of this admission
 Refer accordingly.  Inform PROD and PIOD as well.
*Know P5, P50, P90, P95, P99 *Know P5, P50, P90, P95, P99
FEBRILE SEIZURES
 May resume diet once fully awake
 IVF: ___________
 Request for:
CBC and platelet Chest X-ray (PA, lateral) as indicated
Urinalysis 21 channel EEG
 Therapeutics
Paracetamol at 15 mkdose Q4 RTC until 24 hours afebrile,
then as needed for fever T > 38OC
Antibiotics as warranted
 Seizure precaution at all times:
1. Diazepam at 0.3 mkdose (max 10 mg) / SIVP for active
seizures lasting for more than 3 minutes at bedside
(_mkd)
2. Hook to O2 via face mask at 10 LPM during active
seizures
3. Keep bed railings up at all times
4. Must be accompanied by 2 responsible adult at all times
5. Place patient on left lateral decubitus during active
seizures
ACUTE APPENDICITIS 
 NPO - TFO. Hgt once daily while on NPO.
 Monitor vital signs every 1 hour and record
 Watch out for persistence abdominal pain, vomiting, fever
and refer if with such
 IVF: D5NR 1L to run at __ gtts/min (___) M = D =
 Refer to PROD after 6 hours for reassessment
 Request for:
CBC with platelet
Urinalysis
 Therapeutics
Cefoxitin 1.5 g per slow IV infusion over 30 minutes every 8
hours ( ) ANST (____mkdose)
Refer to Surgery for further evaluation and management
CYCLOPHOSPHAMIDE INFUSION – NEPHROLOGY CYCLOPHOSPHAMIDE INFUSION

 Monitor VS every 4 hours and record. Refer if BP > 115/77 1. Pre-hydrate
 Monitor input & output accurately every shift and record D5 0.3% NaCl __ cc/hr for 2 hours (100 mL/ BSA/hr, max: 125
 Insert heplock mL/hr)
 Weigh patient once at the ward then daily prebreakfast and 2. Give MESNA 250 mg in 10 mL D5water over 10 – 15 minutes
record using the same weighing scale at all times (1/4 of cyclophosphamide)
 Measure abdominal circumference prebreakfast and record 3. Pre-medications
 Watch out for hypersensitivity reactions, hematuria Diphenhydramine 1 – 2 mkdose max: 50 mg/dose
 For cyclophosphamide infusion as follows: Metoclopramide 0.1 – 0.2 mkdose max: 0.8 mkday, 10 mg/dose
- Hydrate with ___ D5 0.3% NaCl to run at ___ for 8 hrs only 4. Give cyclophosphamide __ 10 mg in 100 mL D5 water for 1 hour
- Cyclophosphamide 575 mg + 100 mL D5W to run for 1 hour (0.5 – 1 g/BSA, max 1g)
on the 2nd hour of hydration 5. Give MESNA (same dose) immediately after cyclophosphamide
- Give metoclopramide 5 mg as SIVP 15 minutes before and 6. Post-hydrate with D5 0.3% NaCl __ cc/hr for 2 hours (100
30 minutes after cyclophosphamide infusion mL/BSA/hr, max: 125 mL/hr)
- Monitor VS q30 minutes while on cyclophosphamide 7. Give MESNA (same dose) 3 hours after last dose of MESNA
infusion 8. Post-medications:
Diphenhydramine (same dose)
Metoclopramide (same dose)
> Monitor vital signs every 1 hour while on cyclophosphamide

infusion
> Watch out for nausea, vomiting, gross hematuria, BP elevation or
other untoward reaction
> May give Diphenhydramine & Metoclopramide every 8 hours prn
nausea and vomiting
* Why give Diphenhydramine to patients taking Metoclopramide?

- Diphenhydramine is given as a prophylaxis against Metoclopramide-
induced asthma that often occur within 60 minutes after induction of
Metoclopramide
SLE NEPHRITIS (FOR MONTHLY CYCLOPHOSPHAMIDE) CNS LUPUS
 Admit to __ under the service of Dr ____ _  Low salt diet, low fat diet
 Low salt diet  Medications
 Monitor vital signs every 2 hours and record Prednisone 20 mg/tab 2 tablets QD prebreakfast
 Monitor input & output accurately every shift and record Hydroxychloroquine 200 mg/tablet 1 tab QD
 Watch out for Calcium carbonate 500 mg/tablet 1 tab BID
 Insert heplock Gabapentin 300 mg/cap 1 cap ODHS
 Request for:
CBC and platelet Urine random protein ALL, pre B
Na, K Urine random creatinine  Admit to __ under the service of Dr ____ _
Urinalysis  Neutropenic diet
 Therapeutics  Monitor vital signs every __ hours and record
Prednisone 2 mkday QD – TID (max: 80) after meals  Monitor input & output accurately every shift and record
Enalapril 0.08–5 mkday, Adolescent: 2.5–5 mg/day QD (PM)  Watch out for recurrence of fever, headache, vomiting,
Losartan 0.7mkdose (max: 50) QD (AM) respiratory distress, hypotension
Hydroxychloroquine 2.325-3.875 mkday (max: 310 mg/day or  Insert heplock
5.425 mg/kg/24 hour) QD-BID  IVF:
Calcium CO3 45–65 PO QID, adult: 1–2 mkday TID - QID  Request for :
 Inform AMD of this admission  Therapeutics:
 Inform PROD and PIOD as well. Ceftazidime
 Refer accordingly. Gentamicin
RETINOBLASTOMA GBM (admitted due to HTN)

 Neutropenic diet  Neutropenic diet
 Monitor vital signs every 2 hours and record  Monitor vital signs every 2 hours and record, Include BP
 Monitor input & output accurately every shift and record monitoring, GCS, pupillary light reflex in monitoring
 Watch out for rash, vomiting, hypotension, dyspnea  Monitor input & output accurately every shift and record
 Insert heplock  Watch out for headache, dizziness, elevated BP/ hypotension
 Request for: and poor pulses
CBC and platelet SGPT  IVF: PNSS
Urinalysis Bilirubin  Request for:
Creatinine Hearing test? CBC and platelet 15 L ECG
 Therapeutics Na, K, iCa Lipid profile
Pre-chemotherapy Medications: Urinalysis SGPT
Ondansetron 1 – 8 mg/SIVP 30 minutes prior to  Therapeutics
chemotherapy then PRN for nausea and vomiting Levetiracetam 100mg/mL , p832
Day 1 Chemotherapy: Cotrimoxazole prophylaxis 150 mg/m2/24 hour BID x 3
Vincristine 0.6 mg/SIVP consecutive days/wk, MAX: 320 mg/24 hour , p949
Carboplatin 220mg on D5W/50 mL to run over 2 hours  Inform AMD of this admission
Etoposide 60 mg in D5W 250 mL to run over 4 hours  Inform PROD and PIOD as well.
Day 2 Chemotherapy  Refer accordingly.
Etoposide 60 mg in D5W 250 mL to run over 4 hours
 Hold mainline IVF while on-going chemotherapy
LUMBAR PUNCTURE THORACENTESIS

 Please prepare the ff. materials:  Please prepare the ff. materials:
1. Sterile gloves (size __ ) # 2 1. Abhocath (gauge 18) # 2
2. Betadine solution #1 2. Macrodrip IV set # 1
3. Sterile cottonballs #1 3. Sterile specimen bottles 50 cc # 3
4. Sterile eyesheet #1 4. 1L IV bottle # 1
5. Spinal needle gauge 22 #1 5. Sterile cottonballs # 1
6. Manometer #1 6. Betadine solution # 1
7. Sterile test tubes #4 7. Alcohol # 1
8. Sterile gauze #1 8. Durapore # 1
9. 3 cc syringe #2 9. Sterile gloves (size ___ ) #2
10. Lidocaine #1 10. Sterile gauze # 1
11. Band – aid #1 11. Sterile eyesheet # 1
 Secure consent for lumbar puncture 12. Lidocaine # 1
13. 3 – way stopcock # 1
CSF ANALYSIS 14. 10 cc syringe # 2
 Please send specimen as follows  Secure consent for thoracentesis
TT #1 CSF cell count and differential count
COLONIC IRRIGATIONS
TT #2 CSF protein and glucose, AFB stain, gram stain
 Please prepare the ff. at bedside
TT #3 CSF culture and sensitivity, TB culture
1. Sterile gloves (size ___ ) #2
TT #4 Save specimen 2. F16 melaton catheter # 1
 Refer to Anesthesia for sedation or include in materials: 3. KY Jelly #1
1. Midazolam 5mg/vial #1 4. Kidney basin #1
2. Nalbuphine 10 mg/vial #1 5. Warm saline solution 1L #1
6. Garbage bag #1
*Note serum glucose level (HGT) during spinal tap 7. Aseptosyringe #1
* Bloody tap: ratio of WBC & RBC (1:700) PLEURAL FLUID ANALYSIS
* Correction of CSF protein in case of a bloody tap  Please send specimen as follows:
- subtract 1 mg for every 1000/ mm3 RBC Bottle no. 1 – cell count and differential count
Bottle no. 2- PF LDH, glucose and protein
Pressure WBC Protein Glucose Bottle no. 3 – Bacterial aerobic culture
(mm H2O) (mm3) (mg/dL) Bottle no. 4 – save specimen
Normal 50 – 80 < 5 >75 % L 20 – 45 > 50,75% s  Request for serum LDH and CHON
Bacterial ↑ 100–10 000 ↑ 100 – 500 ↓<40, 50% s
Viral N or ↑ rare < 1000 50 – 200 gen. normal TRANSUDATIVE
TB ↑ 10 - 500 100 – 3000 < 50 - CHF, Cirrhosis, Nephrotic syndrome, Hypoproteinemia, Acute
Fungal ↑ 5 – 500 25 – 500 < 50 atelectasis
Brain ↑ 5 - 200 75 - 500 N unless
Abscess (100 – 300) ruptures
EXUDATIVE
- Malignancy, Pneumonia, Tuberculosis, Pulmonary embolism,
Trauma, Pancreatitis
Osm ANALYSIS
TRANSUDATE EXUDATE
SIADH CSW DI pH > 7.2 < 7.2
BODY WATER ↑ ↓ ↓ Appearance Clear, yellow Serous, cloudy
Serum Na ↓ ↓ ↑ CHON < 3 mg/dL > 3 mg/dL
Urine Na ↑ ↑ ↓ CHON ratio <0.5 > 0.5
Serum Osm < 280 ↓ > 300 LDH < 200 IU > 200 IU
Urine Osm LDH ratio < 0.6 > 0.6
> 500 ↑ ↓
Cells < 2 000 > 2 000
Urine output ↓ ↑ ↑ Predominant Lymphocytes Neutrophils
Urine Osm >1 >1 < 1.5 *Ratio: pleural fluid/ serum
Serum Osm
CSF
BLOOD TRANSFUSION PLATELET TRANSFUSION
- Packed RBC: 10 – 15 mL/kg over 4 – 6 hours  Transfuse 1 unit platelet concentrate, type specific as fast drip
- FFP: 10 – 15 mL/kg over 4 hours  Pre-BT medications: Paracetamol
- Platelet concentrate: 1U/10 kg
- FWB: 15 – 20 mL/kg over 4 hours Estimated blood volume: 80 mL x wt
- CPP: 1U/g kg Estimated blood loss: 10% of EBV
Volume of pRBC = EBV (desired – actual) / Hct in pRBC
* 1 U pRBC will ↑ Hgb 1g/dL, Hct by 3% Amount ↑ in Hct = 0.4 x vol pRBC / EBV
* 1 U PC will ↑ platelet by 40 – 50
* 1 U FWB will ↑ Hgb by 1.5 – 2 g/dL BMA 1 SET BMA 2 SET BMA 3 SET
1 Betadine 1 Betadine 1 Betadine
EXCHANGE TRANSFUSION 1 Cotton Balls 1 Cotton Balls 1 Cotton Balls
 Please prepare the ff. materials: 1 Eye sheet 1 Eye sheet 1 Eye sheet
1. FWB MBT O+ 1 Formalin 10 Glass slides 1 NaCl 50 cc
8 Glass slides 1 Sterile Gauze 1 Spinal Needle g. 25/22
2. 2 pcs 3-way stopcock
1 Sterile Gauze 1 Sterile Gauze 6.5 1 Sterile Gauze
3. Sterile bottles 2 Sterile Gauze 7.5 1 Syringe 1 cc 1 Sterile Gauze 6.5
4. BT set 3 Syringe 10 cc 1 Syringe 3 cc 1 Syringe 3 cc
5. 10 cc syringe 1 Syringe 5 cc 3 Syringe 10 cc 4 Syringe 1 cc
6. Connecting tube 1 Transpore 2 Vacutainer – Green 2 Vacutainer – Red 10
7. Calcium gluconate 2 Vacutainer – Green 1 Xylocaine amp mL
8. Heparinized PNSS 1 Xylocaine amp 1 Xylocaine 2.0 amp
Blood volume: Preterm 100 cc/kg

Term 80 cc/kg
1. Double volume: 2 x BV x Wt
2. # of Aliquot (5% of BV)
3. Duration of exchange in 1 hour
BV ____= # of exchange
# aliquot
60 minutes _ =# minutes/ exchange
# of exchange
4. Give Calcium gluconate
- ET causes hypocalcemia due to citrate found in blood
product
BLOOD TRANSFUSION
> Reserve 1 ‘u’ pRBC properly typed and crossmatched
divided into 3 aliquots. Transfuse 1 aliquot over 4 hours
> Pre-BT medications (if not first time)
1. Diphenhydramine 12.5 mg/5mL (1-2 mkdose)
2. Paracetamol 250mg/5mL (10 – 15 mkdose)
> Watch out for fever, hypotension, flushing, chills,
wheezing, red – colored urine
> Monitor VS Q15 minutes for the first hour, Q30 minutes
for the 2nd hour then Q1 while ongoing transfusion
> Hold main IV line while ongoing transfusion
PONDERAL INDEX = (Wt in gm ÷ Lt in cm) x 100

IF > 2: Symmetrical SGA
< 2: Asymmetrical SGA
HARRIS – BENEDICT EQUATION for RESTING ENERGY EXPENDITURE (REE)

1. Basal Metabolic Rate
(Original in 1918)
BMR = 66.5 + ( 13.75 × weight in kg ) + ( 5.003 × height in cm ) – ( 6.755 × age in years )
BMR = 66 + ( 6.2 × weight in pounds ) + ( 12.7 × height in inches ) – ( 6.76 × age in years )
BMR = 655.1 + ( 9.563 × weight in kg ) + ( 1.850 × height in cm ) – ( 4.676 × age in years )
BMR = 655.1 + ( 4.35 × weight in pounds ) + ( 4.7 × height in inches ) - ( 4.7 × age in years )
(Revised Mifflin and St Jeor 1990)
= (10 × weight in kg) + (6.25 × height in cm) - (5 × age in years) + 5
= (10 × weight in kg) + (6.25 × height in cm) - (5 × age in years) - 161

2. Activity Factor
 Sedentary (little or no exercise) 1.2
 Light activity (sports 1 – 3 d/w) 1.4
 Moderate activity (3-5d/w) 1.6
 Very active (6-7d/w) 1.8
 Extra active 1.9
Ideal Body Weight for OVERWEIGHT/ OBESE PATIENTS)

= 50 kg + 0.9 (ht in cm – 152.4)
= 45.5kg + 0.9 (ht in cm – 152.4)
BASIC LIFE SUPPORT
1. Check if the scene is safe.
2. Check for response “Hey, hey are you okay?”
3. Check for breathing
- If with regular breathing – no need for CPR
- If gasping/ not breathing – continue BLS
4. Call for help. Activate the ERS “Help! Activate the emergency response system. You, grab me an AED.”
5. Check for pulse (Carotid/Brachial pulse
6. Start high quality CPR
- Push hard and fast, sufficient force to depress at least 1/3 APD or 1 ½ in (4 cm) in infants and 2 inches (5 cm) in children
- At least 100 compressions per minute
- Allow complete chest recoil after each compression
- Minimize interruptions of compression to < 10 sec
7. Open the airway and give ventilations
- Head Tilt – Chin Lift Maneuver (E-C)
- Check for chest rise
- Each breath should take about 1 second
8. Automated External Defibrillator (AED)
- In infants, a manual defibrillator is preferred at 2J/kg than 4J/kg
- If unavailable, an AED with a pediatric attenuator may also be used
* Coordinated compressions and ventilations CIRCULATION
30:2 Adult resuscitation - May attempt vascular access 2x
Single –rescuer resuscitation of infants and children - Intraosseous access (90O)
15:2 2 – rescuer resuscitation of infants and children Sites: proximal tibia, distal tibia, distal femur, ASIS
CI: osteogenesis imperfecta, previous attempt on
* Change of roles every 2 minutes same site, crush injuries, infection at site
- 5 cycles of 30:2 or
- 10 cycles of 15:2 ELECTRICAL THERAPY
- Manual Defibrillator is preferred
* Rescue Breaths - Cardiac monitor
- if with an advanced airway WHITE: Right, RED: Rib, BLACK: Left
Continuous compressions >100 bpm - Lead II to check rate and rhythm
Ventilations given every 6 – 8 seconds (at least 8 – - Tachycardia
10 breaths per minute) CHILD HR > 180 bpm INFANT HR > 220 bpm
- Shock (Paddle placement)
* In cases of respiratory arrest only - Sternum: Apex of the heart
- NO COMPRESSIONS - Unsynchronized vs Synchronized
- Adult: every 5 – 6 seconds (10 – 12/minute)
- Child: > 60 bpm every 3 – 5 sec (12 – 20 /min) SHOCKABLE RHYTHM (Unsynchronized)
< 60 bpm treat as arrest 1. VFib
2. Pulseless VTach (Wide QRS)
* Choking Management:
- in adults and older children, may do the subdiagphragmatic Class I: HQCPR
abdominal thrust (Heimlich maneuver) Class IIA: 2 J/kg  4 J/kg 
- in infants, perform cycles of 5 back slaps and 5 chest thrusts Class IIB: + Drug
until object is expelled or patient becomes unresponsive
ELEMENTS of GOOD COMMUNICATION. EFFECTIVE TEAM
PEDIATRIC ADVANCED LIFE SUPPORT DYNAMICS
AIRWAY/ BREATHING 1. Closed loop communication
- High flow oxygen (> 10 LPM) 100% FiO2 via Bag mask 2. Clear messages
ventilation with reservoir bag 3. Clear roles and responsibility
- Low flow oxygen (<10 LPM) 23–50% FiO2 via 4. Know limitations
Nasal cannula up to 4 LPM 5. Knowledge sharing
Face mask up to 10 LPM 6. Constructive intervention
7. Summarizing & Reevaluation
- Airway adjuncts 8. Mutual respect
1. Oropharyngeal airway (OPA)
- For unconscious/ patients without gag reflex THERAPEUTIC ENDPOINTS
- Corner of mouth to angle of mandible 1. Consciousness
2. Nasopharyngeal airway (NPA) 2. Color
- For conscious / patients with gag reflex 3. Blood Pressure
- Tip of the nose to the tragus 4. Heart rate
5. Temperature
-Intubation 6. Central Pulses
uncuffed size =age in years / 4 + 4 7. Peripheral Pulses
8. Capillary refill time
cuffed size = age in years / 4 + 3.5
9. Urine output
- 1O confirmation (5 point auscultation)
REASSES EVERY 2 MINUTES SAS!
Epigastric area
1. Stop compressions
2 Lung bases
2. Analyze rhythms
2 Lung apices
3. Switch roles (compression and electrical)
If with gurgling sound = REINTUBATE
If unequal BS = readjust 0.5 – 1 cm
REVERSIBLE CAUSES (Hs and Ts)
- 2O confirmation (capnography) HYPOXIA TENSION PNEUMOTHORAX
Qualitative- colorimetric capnography HYPOTHERMIA TRAUMA
- Original color: white/ green HYPOVOLEMIA THROMBOSIS
- Give 6 Tidal breaths HYPO/ HYPERKALEMIA - (CARDIAC/PULMONARY)
- Color change: Yellow/ Gold = GOOD! H ACIDOSIS TAMPONADE
Purple/ Blue = PROBLEM! HYPO/ HYPERGLYCEMIA TOXINS
Quantitative – capnography
- Ideal 35 – 40% RETURN OF SPONTANEOUS CIRCULATION (ROSC)
- Good rhythm with BP and pulse
- Rescue Breathing - Airway management
With pulse, no breathing: every 3 – 5 sec, 12- 20 / minute
No pulse, no breathing: every 6 – 8 sec, 8 – 10 / minute
- Reassessment of Airway
D Displacement
O Obstruction
P Pneumothorax
E Equipment failure
Supraventricular Tachycardia (SVT) Ventricular Fibrillation (VFib)
Ventricular Tachycardia (VTach) Asystole
VFib/ Pulseless Vtach Unstable SVT (↓BP) Stable SVT (normal BP)
↓ ↓ ↓
Defibrillate at 2J/kg Synchronized cardioversion (SC) at Vagal Maneuvers (10s)
Do HQPCR 0.5J/kg - Ice compress over forehead
↓ ↓ - Carotid massage
Defibrillate at 4J/kg SC at 1J/kg ↓
EPINEPHRINE Q3 – 5 min at 0.01mg/kg/dose ADENOSINE at 0.1 mg/kg/dose
(0.1ml/kg 1:10 000)
Bradycardia/ Asystole/ PEA
(Maximum dose: 6 mg)
Continue HQPCR ↓
↓
↓ EPINEPHRINE at 0.01mg/kg/dose
ADENOSINE at 0.2 mg/kg/dose
Defibrillate at 10J/kg (max) HQCPR
(Maximum dose: 12 mg)
Continue HQPCR
AMIODARONE at 5mg/kg/dose (EPI to be given Q3 – 5 min)
NO DEFIBRILLATION!
Bradycardia: HQCPR, Epi, Atropine

* EPINEPHRINE
IV/ IO: 0.01 mg/kg/dose (1:10 000 = 0.1 mg/kg)
ET: 0.1 mg/kg/dose (1:1 000 = 0.1 mg/kg)
ET SIZE (internal diameter in mm) ET DEPTH (LIP to TIP measurement in cm)

uncuffed size = (age in years / 4) + 4 = (age in years/2) + 12 or ET size x 3
cuffed size = (age in years / 4) + 3.5 = Wt in kg + 6 cm (NEONATES)
= If < 750 g = 6 cm length
For NEONATES (via ESTIMATION)
WEIGHT (G) AOG BLADE ET SIZE ET DEPTH
< 1000 < 28 0 2.5 6.5 – 7.0
1000 – 2000 28 – 34 0 3.0 7.0 – 8.0
2000 – 3000 34 – 38 0-1 3.5 8.0 – 9.0
> 3000 > 38 1 4.0 > 9.0
ET Level for TERM: T2 – T3
EMERGENCY PEDIATRICS:
PALS:
General Pediatric Assessment: (CBC)
Consciousness
Breathing
Color
Primary Assessment (ABCDE)
Airway
Breathing
Circulation
Disability
Exposure
Secondary Assessment (SAMPLE)
Signs/ Symptoms
Allergy
Medications
Past Medical History
Last Meal
Events leading to Head to toe PE
Tertiary Assessment: Diagnostics
FLUID MANAGEMENT FLUID CHALLENGE TEST
* Maintenance (Holliday – Segar Method) - If dehydrated with no urine output or questionable VS
< 10 kg 100 mL / kg/ day - PNSS at 20 cc/kg (10 cc/kg if dengue or with cardiac
11 – 20 kg 50 mL / kg/ day + 1000 problem)
> 20 kg 20 mL / kg/ day + 1500 - Expect patient to void within 2 hours
- May repeat twice
* Deficit (Based on Dehydration)
Mild Moderate Severe
<15 kg or < 2 y/o 50 100 150
> 15 kg or > 2 y/o 30 60 90
* Total Fluid Replacement (TFR) = Maintenance + Deficit

* TFR = mL/day ÷ 24 = cc/hr ÷ 4 = drops/min
FLUIDS COMPOSITION
Na+ Cl- K+ Ca2+ Dextrose D5 – 17 calories/ 100 mL
LRS 130 109 4 3 - If only on IVF – lose 0.5 = 1%/day
NSS 154 154 - - - Fever – 10-15% increase in maintenance water
D5 0.30% NaCl 51 51 - - 50 needs/ 1OC increase in T >38OC
D5 0.45% NaCl 77 77 - - 50
D5 0.90% NaCl 154 154 - - 50
D5 IMB 25 22 20 - 50
D5 NR 140 98 5 - 50
D5 NM 40 40 13 - 50
ORS COMPOSITION
Na+ Cl- K+ Glucose Citrate Osmolarity
ORS 75 75 65 20 75 10 245
ORS 45 45 70 40 125 7 300
Homemade: 1L or water + ½ tsp salt + 6 tsp sugar
COMPOSITION OF APPROPRIATE ORAL REHYDRATION SOLUTIONS

Solution Carbohydrate (g/dL) Sodium (mEq/L) Potassium (mEq/L) Base (mEq/L) Osmolality
Pedialyte 2.5 45 20 30 250
Infalyte 3 50 25 30 200
Rehydralyte 2.5 75 20 30 310
WHO/UNICEF* 2 90 20 30 310
* PRECAUTION - Only give K+ containing IVF to patients with established UO to prevent ACUTE TUBULAR NECROSIS.
ELECTROLYTE COMPOSITION OF BODY FLUIDS

FLUIDS Na+ (meq/L) K+ (meq/L) Cl-(meq/L) AGE RANGE
1. Gastric 20 – 80 5 – 20 100 – 150 Neonates < 34 weeks
2. Pancreatic 120 – 140 5 – 15 90 – 120 2–8d 11 – 15
3. Small Bowel 100 – 140 5 – 15 90 – 130 4 – 28 d 15 – 28
4. Bile 120 – 140 5 – 15 80 – 120 30 – 90 d 40 – 65
5. Ileostomy 45 – 135 3 – 15 20 – 115 Neonates > 34 weeks
6. Diarrhea 10 - 90 10- 80 10 – 110 2–8d 17 – 60
7. Burn 140 5 110 4 – 28 d 26 – 68
8. Sweat (N) 10 – 30 3 – 10 10 – 35 30 – 90 d 30 – 86
9. Sweat (CF) 50 - 130 5 - 25 50 - 110 1 – 6 mo 39 – 114
6 – 12 mo 49 – 157
ATOMIC WEIGHT and VALENCE 12 – 19 mo 62 – 191
Atomic Weight Valence >2y 89 - 165
Calcium 40 2 Estimated Creatinine Clearance

Sodium 23 1 * ECC = Gt in cm x k _
Potassium 39 1 Creatinine
Chlorine 35.5 1 Where K:
Magnesium 24.3 2 0.33 – preterm (<1 y/o)
Phosphorus 31 * 0.45 - infants (<1 y/o)
* Conversion: 0.55 – children, adolescent
mg to mEq = mg x valence mEq to mg = mEq x AW 0.70 – adolescent
AW valence
* DEHYDRATION = pre-illness wt – illness wt x 100 INSENSIBLE WATER LOSS (IWL) BODY SURFACE AREA (BSA)
pre-illness wt IWL = BSA x 400 – 600
> AFEBRILE 400
 GASTRIC CAPACITY (in ounce) = Age in months + 2 > FEBRILE = BSA x 500–600
 BLADDER CAPACITY < 2 y/o = Wt. in kg x 7 IWL in TERM: 20 mL/kg
> = age in years + 2 x 30
IWL in PREMATURE INFANTS in INCUBATORS (mL/kg/day)
PLASMA OSMOLALITY Age/BW 0.5-0.75 0.75-1.0 1-1.25 1.25-1.5 1.5-1.75 1.75-2
= 2 x Na + glucose (mg/dL)/18 + BUN (mg/dL)/2.8 0–7d 100 65 55 40 20 15
NV: 285 – 295 mosm/kg 7 – 14 80 60 50 40 30 20
EFFECTIVE OSMOLALITY FLUID LIMIT

= 2 x Na + glucose (mg/dL)/18 FL = IWL + (UO x 24) where UO ~ 0.5 – 1 cc/kg/hr
ANION GAP = Na+ - (Cl- + HCO3-) SODIUM LIMIT

Na limit = Wt in kg x 23 x maintenance Na+,
UO (ml/kg/hr_ = UO (mL)/ # of hours/ wt (kg) where 23 = MW of Na+
FLUID BALANCE = Input – Output Maintenance of Na+ = 2 – 4
OUTPUT = UO (mL) + IWL
MAINTENANCE FLUIDS:
Body Weight Fluids/day Hourly rate

0-10kg 100mL/kg 4mL/kg/hr
11-20kg 1000mL + 50mL/kg > 10kg 40mL/hr + 2mL/kg/hr x (wt-10kg)
>20kg 1500mL + 20mL/kg > 20kg 60mL/hr + 1mL/kg/hr x (wt-20kg)
Maximum fluids 2400mL/day 100mL/hr
REPLACEMENT FLUIDS:
Diarrhea composition: Na 55meq/L, K 25meq/L, HCO3 15meq/L, metabolic acidosis (Replace stool mL/mL of 1-6hrs)
- D5O.2NS + 20meq/L Na HCO3 + 20meq/L KCl
Gastric fluid: Na60meq/L, K 10meq/L, Cl 90meq/L, metabolic alkalosis (Replace output q1-6hrs mL/mL)
- NS + 10meq/L KCl
Altered renal output:
- Replacement of insensible fluid losses (25-40% maintenance)
- Replace with half normal saline
- If with polyuria – measure urine electrolytes and replace based on that
Third space loss
- replace with isotonic fluids
DEFICIT THERAPY:
Severity of Dehydration <15kg/ <2years old >15kg/ >2years old
Mild 50 mL/kg 30mL/kg
Moderate 100mL/kg 60mL/kg
Severe 150mL/kg 90mL/kg
Fluid deficit (L) = pre-illness weight (kg) – illness weight (kg)
% Dehydration = (pre-illness weight – illness weight) / pre-illness weight x 100%
FLUID MANAGEMENT OF DEHYDRATION:

- Restore intravascular volume: NS 20mL/kg x 20mins; may repeat as needed
- Rapid volume replacement: 20mL/kg NS/LRS (max of 1L) over 2 hours
- Calculate 24 hour fluid needs: maintenance + deficit
- Subtract isotonic fluid already administered from the 24 hour fluid needed
- Administer remaining volume over 24 hours using D5O.45% NaCl + 20meqs/L KCl
- Replace ongoing losses
CORRECTION OF ELECTROLYTES
To concoct FLUIDS: Amount of NaCl = (%) x vol

14.6
Hyponatremia:
Factitious etiologies:
- Hyperlipidemia: Na decreased by 0.002 x lipid (mg/dL)
- Hyperproteinemia: Na decreased by 0.25 x [protein (g/dL)-8]
- Hyperglycemia: Na decreased 1.6meq/L for each 100mg/dL rise in glucose
- Corrected Na = measured Na + 1.6 x (glucose – 100mg/dL) / 100
- Replacement: <12meq/L / 24hrs
For severe symptomatic hyponatremia:

- May give 3%NaCl: (0.5meqs/L)
o Dose 4.5mL/kg over 15-30mins
o NaCl(mL) = [3 x vol of prep needed (mL)] / 14.6
o ___mL NaCl + ___mL SW to make 1L
- OR calculate sodium deficit as follows and give over 4 hours:
o Na deficit = wt(kg) x 0.6 x (desired Na – actual Na)
o +Na maintenance = wt (kg) x 2
The estimated effect of 1 L of any infusate on s. Na can be calculated by
Androgue-Madias equation: change in s.Na = (infusate Na – s.Na) / (total body water + 1)
Total body water in children = 0.6 x BW
NaCl: 1gm contains 18 mmol Na

5.85% NaCl: 1 mL contains 1 mmol NaCl
Hypernatremia:
Total Uosm excretion = [U osmo (mOsm/kg) x 24 hours urine volume]
if > 1000 mOsm/day is excreted – consistent with osmotic dieresis
(glycosuria, diuretics, high protein diet)
If Euvolemic, calculate water replacement required for tonicity change:

Vol of water req to lower Na
= [(measured plasma Na x TBW) / desired plasma Na] – TBW
Hypernatremic Dehydration: (Nelson’s)

Restore intravascular volume: NS 20mL/kg over 20 mins
Determine TIME OF CORRECTION on bases of initial Na concentration:
145-157 meq/L: 24 hours
158-170 meq/L: 48 hours
171-183 meq/L: 72 hours
184-196 meq/L: 84 hours
Administer fluid at constant rate over time of correction: D5 half-normal saline (+20meq/L KCl);
typical rate: 1.25-1.5 x maintenance
Follow serum sodium – should be <12 meq/L/24 hours
(Harriet) Free Water Deficit (FWD) (L)

- 4 mL/kg needed to decrease sNa by 1 meq/L or 3mL/kg if Na>170 because less FW is required to decrease sNa at
higher concentrations
Therefore:
FWD = (4mL/kg or 3mL/kg) x wt (kg) x (conc. Na present/ ACTUAL – conc. Na desired)
(Chiu-Yap) FWD = [(measured Na x BW x 0.6 / desired Na] – (0.6 x BW)
TOTILAC (Hypertonic lactate)

- Na 504.15 meq/L Ca++ 1.36 mmol/L Lactate 504.15 meq/L
- K 4.02 meq/L Cl 6.74 meq/L
* LOADING DOSE: 3 – 5 mL/kg over 15 minutes
* CONTINUOUS INFUSION: 0.5 – 1 mL/kg/hr
WATCH OUT FOR: Hypernatremic, metabolic alkalosis, renal failure
Hypokalemia:
Potassium supplement should be given per orem whenever possible
- 1 kalium durule = 10 meqs K – will increase s. K by 0.1
- 1 medium latundan = 10 meqs K
- 1 gm KCl grain = 13.3 meqs K
For patient on IVF, add KCl 40 mmol to each L of IVF
Potassium Infusion Rate (KIR) = meqs/mL potassium x rate / wt(kg)
Hyperkalemia:
ECG, Limit exogenous K
Therapy with immediate onset of action:
- 10% Ca gluconate 0.5 mL/kg IV over 3-5 min with ECG monitoring (aims to stabilize cell
membrane and opposes the negative inotropic effect of hyperkalemia)
Therapy with rapid onset of action:
- Correct acidosis with NaHCO3 2mmoL/kg IV over 30 mins (aims to drive potassium into cells)
- Glucose and insulin drip: 5mL/kg D10 + 0.1 unit/kg over 30 – 60mins (aims to drive potassium
into cells)
- Salbutamol administration at 1-5 mcg/kg/min IV or nebulized at 10-20mg over 15 min (aims to
drive potassium into cells)
Therapy with longer onset of action:
- Kayexalate (Na polystyrene sulfonate resin) 0.5-1 gm/kg p.o or per rectum, 4-6 hours. A single
dose of 1g/kg can decrease s.K by 1 meq/L. (aims to decrease potassium absorption)
- Acute dialysis
HYPERKALEMIA
THERAPY DOSE ONSET DURATION
10% Ca Gluconate 1 mL/kg/dose over 3 – 5 min with ECG monitoring 1 – 3 min 30 – 60 min
(ANTAGONISM) May repeat in 10 min
NaHCO3 1 – 2 mEq/kg over 5 – 10 min 5 – 10 min 1 – 2 hours
(REDISTRIBUTION)
Insulin + 25% Glc Regular insulin 0.1 U/kg 30 min 4 – 6 hours
(REDISTRIBUTION) IV + 0.5g/kg over 30 min
Beta-agonist nebulization Over 15 minutes 15 min 15 – 90 min
(REDISTRIBUTION)
Kayexalate As retention enema over 4 – 6 hours 1 – 2 hours 4 – 6 hours
(ELIMINATION)
HD/ PD Depends per institution Immediate Until completed
(ELIMINATION)
PNEUMONIA
PCAP
A B C D
Risk Minimal Low Moderate High
Co-morbid (-) (+) (+) (+)
Compliance Yes Yes No No
Follow-up (+) (+) (-) (-)
Dehydration None Mild Moderate Severe
Able to feed Able Able Unable Unable
Age > 11 mo > 11 mo < 11 mo < 11 mo
RR <12 mo > 50 mo > 50 mo > 60 mo > 70 mo
1–5y > 40 mo > 40 mo > 50 mo > 50 mo
>5y > 30 mo > 30 mo > 35 mo > 35 mo
Retraction (-) (-) (+) (+)
Head Bobbing (-) (-) (+) (+)
Cyanosis (-) (-) (+) (+)
Grunting (-) (-) (-) (+)
Apnea (-) (-) (-) (+)
Sensorium Awake Awake Irritable Lethargy
Complications (-) (-) (+) (+)
PLAN OPD OPD A – RR A – Specialist
TCB 7 days TCB 3 days
DENGUE FEVER
- Caused by an ssRNA virus from the family Flaviviridae; 4 serotypes
- Vectors: Aedes so.
- Incubation period: 4 – 10 days
- Phases:
1. FEBRILE PHASE (2-7 days)
- High – grade fever reaching T > 40OC
- Accompanied by non-specific manifestations
- ↓ WBC and platelet count
- Monitor warning signs
2. CRITICAL PHASE (2-3 days)
- Fever defervescence
- Plasma leakage > Hemoconcentration
- ↑ Risk for bleeding, pleural effusion, and organ impairment
3. RECOVERY PHASE
- Gradual reabsorption of extravascular compartment fluid 48 – 72 hours
- WBC count starts to rise
- ↓ IVF rate to prevent congestion
TOURNIQUET TEST
- Inflate cuff midpoint of SBP and DBP for 5 mins
- (+) if > 20 petechiae per square inch
WARNING SIGNS
 Abdominal pain/ tenderness
 Persistent vomiting
 Clinical signs of fluid accumulation
 Mucosal bleeding
 Lethargy, restlessness
 Liver enlargement
 Decreased or no urine output for 6 hours
 ↑ Hct or ↓ platelet count
SEVERE DENGUE MANAGEMENT:

 Lives or travels in dengue endemic area 1. Out-patient: Serial CBC monitoring + ORS
 Fever for 2 – 7 days 3 – 10 kg: 100 mL/kg/day
 with or without signs + 10 – 20 kg: 75 mL/kg/day
1. Severe plasma leakage leading to: 20 - 30 kg: 50 – 60 mL/kg/day
 Shock (↓ BP, weak pulse, narrow 30 - 60 kg: 40 - 50 mL/kg/day
pulse pressure) 2. Admitted
 Fluid accumulation and WITHOUT SHOCK
respiratory distress - Isotonic fluids (0.9% NSS, LRS) based on
2. Severe bleeding Holliday-Segar method
3. Severe organ impairment
 Liver: ALT/ AST > 1000 > Renal * Frequent reassessment done to prevent over/ under-
 Heart: Myocarditis hydration
* COMMON LABORATORY FINDINGS:
- Leukopenia WBC < 5000 cells/mm3
- Thrombocytopenia plt <100 000
- Hemoconcentration
- Dengue NS1 (+)
- Dengue IgM (+)
PARAMETERS on REASSESMENT
1. Mental Status
2. Heart Rate
3. Blood Pressure
4. Respiratory Rate
5. Capillary refill Time
6. Peripheral pulses
7. Extremities
* Colloids may be given primarily to patients with hemodynamic instability or as rescue fluids to those who did not improve
after initial crystalloid resuscitation
* Maximum doses: Dextran 40 30 mL/kg/d
Voluven 50 mL/kg/d
Criteria for discharge:

 No fever for 48 hours
 Clinically improved
 Minimum of 2 – 3 days have elapsed after recovery from shock
 Increasing trend of WBC/ platelet count
 Stable hematocrit with IVT
COMPENSATED SHOCK FOR DENGUE
FOR DENGUE
IMMUNIZATIONS
1. BCG 2 Birth, 4 – 6 y.o.
2. Hep B 3 0, 1, 6 months
3. DTP 4 6, 10, 14 weeks, 15 – 18 months
4. Tdap 1 11 – 12 y/o
5. Hib 4 2, 4, 6 months, 4 – 6 y/o
6. OPV/ IPV 4 6, 10, 14 weeks, 15 – 18 months
7. Rotavirus 3 2, 4, 6 months
8. Measles 1 9 months
9. MMR 2 12 – 15 months, 4 – 6 y/o
10. PCV 4 2, 4, 6 months, 12 – 15 months
11. Varicella 2 12 – 18 months, 4 – 6 y/o
12. Hep A 2 11 – 23 months, 6 months after first
13. HPV 3 11 – 12 y/o, 2 months, 4 months
14. Influenza Annual (February – April)
15. Tetanus Booster every 10 years (5 if HR)
 Live attenuated vaccines, if not given on the same day, should be given at least 28 days apart to prevent viral interference
 DTP: 4th dose may be given as early as 6 months after the 3rd dose and the 5th dose given 10 years after the 4th dose
 Rotavirus vaccine must not be administered or initiated in infants >15 weeks old with maximum age of final dose at 8
months (intussusception)
 Passive immunization (Ig) lasts for 3 – 4 months

 Routes of administration
IM, 90O: Hep A, Hep B, Hib, HPV, IPV, Flu, DTP, Tetanus PCV
SC, 30 – 45 O: Measles, MMR, Varicella, LAIV
ID, parallel: BCG, PPD
CONTRAINDICATIONS & PRECAUTIONS: TETANUS TOXOID

General: - P: GBS < 6 weeks after receiving previous dose
- CI: Anaphylaxis/ Severe allergic reactions
- P: Moderate to severe illness + Fever MMR
- P: Thrombocytopenia
LIVE ATTENUATED VACCINES
- CI: Pregnancy, plan to conceive within 28 days, Known HAEMOPHILUS INFLUENZA B
severe immunodeficiency - CI: Age < 6 weeks old
- P: Recent recipient of Ab-containing blood products (<11
months) HEPATITIS B
- P: Infants < 2000 g =
DTP
- CI: Encephalopathy within 7 days of administration, HEPATITIS B VACCINE
Progressive neurologic disorder - administer vaccine prior to discharge
- P: Seizure < 3 days after receiving dose, Persistent cries > - if HBsAg (+): Hep B vaccine + HBIG within 12 hours
3 hours < 48 hours after dose, Fever > 40.5OC, shock - if unknown: Hep B vaccine within 12 hours, determine
HBsAg status within 7 days
PPV: HIGH RISK MEDICAL CONDITIONS

- Chronic heart disease – cyanotic congenital heart disease and cardiac failure
- Chronic lung disease - include asthma if treated with high – dose oral corticosteroid
- DM
- CSF leak
- Cochlear implant
- Sickle cell disease and other hemoglobinopathies
- Anatomic or functional asplenia
- HIV
- Chronic renal failure
- Nephritic syndrome
- Treatment with immunosuppressive drugs or radiation therapy including malignant neoplasms, leukemias, lymphomas,
Hodgkin’s disease
- Solid organ transplantation
- Congenital immunodeficiency
RABIES- IM/ ID
- Post-exposure prophylaxis: Days 0, 7, 21, 28
VERORAB: (inactivated purified rabies vaccine prepared on vero cell line)

Precaution: allergy to neomycin
Adverse Reaction: pain, erythema, edema, itching, allergic reaction
Pre-exposure 0.5 mL on Day 0, 7 , 28, booster after 1 year then every 5 years
Post-exposure
- in subjects unvaccinated against rabies 0.5 mL IM on Day 0, 3, 7, 14, 28
- in subjects with pre-exposure prophylaxis 0.5 mL on Day 0, 3
RABIPUR (purified chick embryo cell)
- Recommended single dose: 1 ml IM (adult/children), deltoid/thigh, NOT gluteal
- ID: 1 dose of 0.1 mL reconstituted vaccine
Non-vaccinated 2 injections of 0.1 mL each at 2 sites on upper arms over L and R deltoid on Day 0, 3, 7,
and 28 (or 30), 90
Fully Vaccinated Immediate booster of 0.1 mL on Day 0, 3
5 VACCINES: DTaP, Hib, Hep B
COMBINATION VACCINES: (source vaccine inserts)

VACCINE BRAND NAMES MIN DOSING SCHEDULE DOSE
AGE
DTaP-IPV/Hib (5 in 1) 2 Primary vaccination: 3 injections at an interval of 1 – 2 months 0.5 mL
*Pentaxim months from the age of 2 months, followed by one booster injection
*Infarix-IPV-Hib within the 2nd YOL
DTaP-IPV- (6-in-1) 2 Primary vaccination: 3 doses such as 2,3,4 months; 3,4,5 0.5 mL
HepB/Hib *Infanrix Hexa months months; 2,4,6 months; or 2 doses such as 3,5 months. There
should be an interval of at least 1 month between doses.
The EPI schedule (6,10,14 weeks) may only be used if a dose of Hep B vaccine has been given at birth.
Booster: after a vaccination with 2 doses of Infanrix hexa, a booster dose must be given at least 6 months after the last
priming dose, preferably between 11 and 13 months . After a vaccination with 3 doses a booster dose may be given at
least 6 months after the last priming dose and preferably before 18 months of age
Flu *Fluarix 6 Yearly, preferably before the start of the flu season, Feb to June 6–35 mo: 0.25 mL
*Vaxigrip months For children below, 9 yrs, 2 doses, 4 weeks apart, then yearly > 3yrs: 0.5 mL
*Influvac
Typhoid * Typhim 2 years Single injection ensures protection. Revaccination should be 0.5 mL
*Typherix performed every 3 years if the risk of exposure continues.
Hepatitis A *Avaxim 12 One primary vaccination dose, then booster injection 6-18 0.5 mL
*Havrix months months later
Hepatitis A – *Twinrix Jr.(1–15 Primary vaccination: 0, 1, 6 months > 16 yrs: 1mL
Hep B y.o) 1 – 15 yrs: 0.5 mL
*T. Adult (>15yo)
Rotavirus *RotaTeq (penta-) 6 weeks RotaTeq: 1st dose: 6 – 12 weeks, subsequent doses should be Comes in a ready-
*Rotarix (monov.) administered at a minimum interval of 4 weeks between each to-use squeezable
dose. Should not be given beyond 32 weeks. plastic tube
Pneumococcal *Prevaner 13 6 weeks For infants and children 6 weeks through 5 years 0.5 mL
13-valent Primary immunization: 3 doses at approx. 2 month-intervals,
conjugate followed by a fourth dose at 12 – 15 months.
(PCV 13) The customary dose for the 1st dose is 2 months, but it can be given as young as 6 weeks. The recommended dosing
interval 4 – 8 weeks. The 4th (booster) dose should be administered at approx. 12 – 15 months, at least 2 months after
the 3rd dose. For previously unvaccinated children: 7-11 months: total of 3 doses. 2 doses at least 4 weeks apartm then
3rd dose after the 1st bday, separated from the 2nd dose by at least 2 months.
12 – 23 months: total of 2 doses. 2 doses at least 2 months apart
> 24 months through 5 years (prior to 6th bday): 1 dose
Pneumococcal * Pneumo 23 2 yrs Primary vaccination: one dose 0.5 mL
polysaccharide *Pneumovax Revaccination every 5 years
vaccine
Quadrivalent *Gardasil 9 yrs For girls/women 9-45 y.o. 0.5 mL
HPV 1st dose: at elected date
(6,11,16,18) 2nd dose: 2 months after the 1st
3rd dose: 6 months after the 1st
For boy 9 – 26 yrs for the prevention of external genital lesions
and infection caused by HPV types 6, 11, 16, 18
Varicella *Vz-Vax 12 1st dose: 12 – 15 months; 2nd dose: 4 – 6 years but may be 0.5 mL
Vaccine *Varilrix months administered at an earlier age provided the interval between
*Okavax the 1st and 2nd dose is at least 3 months. All individuals aged 13
years and above and without previous evidence of immunity
should receive 2 doses at least 4 weeks apart.
OTHER VACCINES:
VACCINE BRAND NAMES MIN DOSING SCHEDULE DOSE
AGE
Tdap Adacel (Sanofi 4 – 64 0.5 mL IM single injection
Pasteur) yrs
DTap Boostrix (GSK) > 4 yrs 0.5 mL IM single inj
Hepa B Engerix (GSK) 0, 1, 6 for < 19 yrs OR 0, 1, 2, booster at 12th month > 20 yrs: 20 mcg/dose
<19 yrs:10 mcg/dose
Euvax (Sanofi P) (protective antibody titer: > 10 IU/L) >16 yrs: 1 mL 20 mcg
<15 yrs: 0.5 mL 10 mcg
Hepa A Havrix (GSK) > 19 yrs: 1 mL
1 – 18 yrs: 0.5 mL
PPV + non Synflorix (GSK) 6 weeks 6 wks-6 months  3 doses at least 1 month apart 0.5 mL IM
typable H booster at last 6 months after the last dose
influenza *7-11 months, previously unvaccinated  2 doses 1
protein D month apart, booster at 2 years, at least 2 months after
conjugate the last dose
vaccine *12 - 23 mos, previously unvaccinated  2 doses at
adsorbed least 2 months apart
* 24 months – 5 years  2 doses at least 2 months
apart
BRONCHIAL ASTHMA:
- In the past 4 weeks has the child had: CONTROLLED PARTLY CONTROLLED UNCONTROLLED
1. Daytime symptoms for more than few minutes, more than once a week
2. Any activity limitation due to asthma
3. Reliever needed more than once a week NONE 1–2 3–4
4. Night awakening/ coughing due to asthma
* Step-down of low dose ICS therapy: done if with good asthma control for at least 3 months
If controller is to be discontinued, follow – up the patient 3 - 6 weeks later
* Step-up of controller treatment if symptom control is poor despite 3 months of adequate controller therapy (assess inhaler
technique, adherence to medication, risk factors)
LEVELS of ASTHMA CONTROL

CONTROLLED PARTLY CONTROLLED UNCONTROLLED
Daytime Symptoms < 2x/week >2x/ week 3 or more features
Limit activities None Any Of partly controlled
Nocturnal symptoms None Any Present in any week
Need for reliever < 2x/week >2x/ week
Lung function Normal < 80% predicted
Exacerbation None > 1x/year > 1x/year
TYPES OF ASTHMA (SEVERITY)

Intermittent Mild Persistent Moderate Persistent Severe Persistent
Daytime Symptoms < 2x/ week > 2x/ week Daily Throughout the day
Limit activities < 2x/ month > 2x/ month > 1x/week Frequent
Nocturnal symptoms < 2x/ week > 2x/ week Daily Frequent
Need for reliever None Minor Some Extreme
Lung function > 80% predicted > 80% predicted 60 – 80% predicted < 60% predicted
Exacerbation < 20% 20 – 30% > 30% > 30%
PREDICTED PEFR (6 – 17year old)

- Male: (ht in cm – 100) x 5 + 175
- Female: (ht in cm – 100) x 5 + 170
Height PEFR Height PEFR Dr. Ong Style:

in cm L/min in cm L/min Ht 100 cm = PEFR 100
43. 109 147 56 142 320 Every ↑ 10 cm = ↑ PEFR by 50
44. 112 160 57 145 334
45. 114 173 58 147 347
46. 117 187 59 150 360
47. 119 200 60 152 373
48. 122 214 61 155 387
49. 124 227 62 157 400
50. 127 240 63 160 413
51. 130 254 64 163 427
52. 132 267 65 165 440
53. 135 280 66 168 454
54. 137 293 67 170 467
55. 140 307
PREFERRED INHALER DEVICE

- 0 – 3 y.o: Pressurized MDI + Dedicated spacer with face mask
- 4 – 5 y.o.: Pressurized MDI + Dedicated spacer with mouth piece
*Nebulizer with face mask / mouth piece only as an alternative
ASSESSMENT OF ASTHMA SEVERITY
MILD SEVERE
1. Altered consciousness No Agitated, confused
2. SpO2 > 95% < 92%
3. Speech Sentences Words
4. Pulse rate < 100 bpm > 200 bpm or > 180 bpm
5. Central cyanosis Absent Likely to be present
6. Wheeze intensely Variable Chest may be silent
SIX PART PROGRAM TO MANAGE AND CONTROL ASTHMA

1. Educate patients to develop a partnership in asthma care
2. Assess and monitor asthma severity
3. Avoid exposure to risk factors
4. Establish individual medication plans for long-term management in children and adults
5. Establish individual plans to manage asthma attacks
6. Provide regular follow up care
GOALS FOR SUCCESSFUL MANAGEMENT OF ASTHMA

- Minimal or no symptoms, including night time symptoms
- Minimal asthma episodes or attacks
- No emergency visits to physicians or hospitals
- Minimal need for reliever medications
- No limitations on physical activities or exercise
- Nearly normal lung function
- Minimal or no side effects from medication
ALLERGIC RHINITIS:
- Inflammatory disorder of the nasal mucosa (nasal congestion, itching, rhinorrhea) often accompanied by sneezing,&
conjunctival irritation
- Childhood AR have > 2-fold increased risk of asthma
- RF: family history of atopy, exposure to smoke, early food introduction
- S/s: allergic salute, nasal crease, allergic gape, allergic cluck, allergic shiners, boggy turbinates
- Complications: chronic sinusitis, nasal polyposis, asthma
Management of AR:
1. Avoidance of allergen/ irritant
2. Mild – intermittent: oral antihistamine
3. Mild- Persistent or Moderate – Severe – Intermittent
> Oral antihistamine Failure: Step – up management
> Intranasal corticosteroids Improved: continue for 1 month
4. Moderate- Severe Persistent
> Intranasal corticosteroids Improved: Step down and continue treatment
> Oral antihistamine or LTRA Failure: ↑ ICS dose
URTICARIA
- Caused by an allergic IgE – mediated reaction
- Self-limited process that occurs when an allergen activates mast cells in the skin
Acute Urticaria (<6 weeks)

 Food: Egg, milk, wheat, peanut, tree nuts, soy, shellfish, fish, strawberries
 Medications
 Insect stings: Bee, hornet, wasps, fire ants
 Infections
 Contact allergy: Latex, pollen, animal saliva
 Transfusion reactions: Blood, blood products
Chronic Urticaria: (> 2x/ week for > 6 weeks)

 Idiopathic
 Physical: Dermatographism, cold, cholinergic, delayed pressure, solar, vibratory, aquagenic
 Rheumatologic: SLE, JIA
 Endocrine: Hypo- / Hyperthyroidism
 Neoplastic: Lymphoma, mastocytosis, Leukemia
 Angioedema
PANCAKE SYNDROME
aka Oral Mite Anaphylaxis (OMA)
- Severe allergic manifestation in atopic patients shortly after intake of food with mite contaminated wheat flour
- S/s: breathlessness, wheezing, stridor, dyspnea, facial/ laryngeal edema, rhinorrhea, urticaria, cough, vomiting, pruritus,
cyanosis
- Thermoresistant
- Etiology: Wheat flour
- Mites: Dermatophagoides pteronyssinus, Dermatophagoides farina
- RF: atopic dermatitis, sensitization to mites, cutaneous hypersensitivity to NSAID, ingestion of food with contaminated wheat
> 1 mg mite allergen
NEW ASPIRIN TRIAD

1. Oral Mite Anaphylaxis
2. ASA/ NSAID hypersensitivity
3. Allergic rhinitis
* ASA: ↑ permeability of gastric mucosa to proteins and development of anaphylaxis
ANAPHYLAXIS
-Serious allergic reaction, rapid onset and may cause death (IgE mediated)
- Sudden release of potent biologically active mediators from mast cells and basophils leading to cutaneous respiratory CV and
GI symptoms
- Pathologic features:
 Pulmonary hyperinflation
 Pulmonary edema
 Visceral congestion
 Laryngeal edema
 Urticaria
 Angioedema
- VS ANAPHYLACTOID REACTIONS (non-IgE mediated)
 Direct release of mast cell mediators
 Disturbance of leukotriene metabolism
 Immune aggregates and complement activation
AT LEAST 1 of 3 CRITERIA FULFILLED:

1. Acute onset of an illness (minutes to several hours) with involvement of the skin and/or mucosal tissue (hives, pruritus,
flushing, swollen lips/ tongue/ uvula) PLUS 1
a. Respiratory compromise – dyspnea, wheeze, bronchospasm, stridor, ↓ PRFE, hypoxemia
b. Reduced BP or associated symptoms or end – organ dysfunction – hypotonia, syncope, incontinence
2. Reduced BP following exposure to a KNOWN allergen for that patient (minutes to hours)
a. Infants and children ↓ SBP or 30% drop SBP
b. Adults: SBP < 90 mmHg or 30% drop from baseline
3. Two or more of the ff that occur rapidly after exposure to a likely allergen for that patient (minutes to hours)
a. Skin or mucosal tissue
b. Respiratory compromise
c. Reduced BP or other symptoms
d. Persistent GI symptoms (pain, vomiting)
BIPHASIC ANAPHYLAXIS
- Recurrence after apparent resolution
- More common if therapy was initiated late or symptoms are more severe
- Occur within 72 hours after initial episode
Management of Anaphylaxis
1. Epinephrine
 alpha 1 adenergic vasoconstrictor effects in most body organ systems
 Ability to prevent and relieve airway obstruction caused by mucosal edema
 Prevent & relieve hypotension and shock
 Must be given as soon as anaphylaxis is strongly suspected at the mid-anterolateral thigh to achieve peak
plasma and tissue concentrations rapidly
 SFx: pallor tremor, anxiety, palpitations, dizziness and headache
 Serious adverse effects: Ventricular arrhythmia, hypertensive crisis, Pulmonary edema
2. Positioning of the patient
 MUST BE placed on the back and lower extremities elevated, or in cases of respiratory distress/ vomiting be
placed in a position of comfort and legs elevated
 Preserve fluid in the circulation
 Prevention of empty vena cava syndrome
3. H1 antagonists
 Relieve itching, flushing, urticaria, angioedema, nasal and eye symptoms
 DO NOT prevent/ relieve upper airway obstruction, hypotension or shock
4. B2 adrenergic Agonists
 Additional treatment for wheezing, coughing and shortness of breath not relieved by epinephrine
5. Glucocorticoids
 Switch off transcription of a multitude of activated genes that encode pro-inflammatory proteins.
6. H2 antagonists
 Often administered concurrently and H1 antagonists
ATOPIC DERMATITIS
- Chronic relapsing, often intensely pruritic inflammatory
disorder of the skin
- Typical distribution
Infancy: Cheeks, scalp, trunk, extremities
Early childhood: Flexural areas
Pathophysiology: Skin barrier dysfunction
FUNCTIONAL CONSTIPATION K59
* Delay/ difficulty in defecation for > 2 weeks causing

distress
* Risk Factors:
- Dietary changes (ex. human milk to cow milk 2O to
change in protein & CHO milk or an allergy to cow’s milk)
- Toddlers: coercive or inappropriate toilet training
- Older children : retentive constipation (ex. school)
* Clinical Manifestations
- FTT, weight loss, abdominal pain, vomiting, persistence
anal fissure or fistula
- DAYTIME ENCOPRESIS: voluntary or involuntary passage
of feces in inappropriate places at least once a month for 3
consecutive months once a chronologic or developmental
age of 4 yr has been reached.
* Management:
- diet and activity
- bowel training (sit on toilet 5-10 min after meals –
gastrolic reflex)
- Stool softeners via osmotic laxatives, etc.
- lactulose, mineral oil, polyethylene glycol
- Fecal dis-impaction
* Goal: BM > 3x/week, easy BM, Bristol 4-6

HIRSCHSPRUNG DISEASE Q43.1
 AKA congenital aganglionic megacolon
 Developmental disorder of the ENS d/t absence of ganglion cells in the submucosa and myenteric plexus
 Inadequate relaxation of the bowel wall (hypertonicity) – obstruction
 S/sx distended abdomen, failure to pass meconium, bilious emesis, feeding intolerance
 May cause enterocolitis d/t fecal stasis
 Dx: rectal suction biopsy (gold standard)
o (+) acetylcholinesterase
o anorectal manometry
 failure to relax despite rectal distention
o contrast enema
 (+) transition zone, small caliber of the rectum, rectosigmoid index < 1 contrast
retention > 50%, corrugated mucosal fold, narrow anorectal segment
 MX: Endorectal Pull Through (ERPT)
HISTORY FUNCTIONAL HIRSCHPRUNG

Onset of constipation > 2 y/o At Birth
Encopresis Common Very Rare
Failure to thrive Uncommon Possible
Enterocolitis None Possible
Forced bowel training Usual None
EXAMINATION
Abdominal distention Uncommon Common
Poor weight gain Rare Common
Rectum Full Empty
DRE Stool in rectum Explosive passage
Malnutrition None Possible
INVESTIGATION
Anorectal manometry IAS relaxation No IAS relaxation
Rectal biopsy Normal (-) ganglion cells
(+) Ach – esterase
Barium enema (-) transition zone (+) transition zone
(+) massive amount of stool Delayed evacuation (> 24h)
MALNUTRITION
 Target z-score at < -1.5 of WFL
 Start at 50% RENI and gradually increase by 10% every 3 days until 90% WFL is reached
 Computed calories may be given via:
o Food
o Milk Feeding
o Ready to use therapeutic food (RUTF)
 Food – Dietary Prescription (round off to 5)
o ___cal = _____g + ______g + _______g
TCR CHO CHON FAT
Divided into ______meals and _____snacks
 Milk Feeding
o AQIVA 1mL = 1 kCal
>5 scoops in 175mL water to make 200mL
o Pediasure 1mL = 1kCal
>5 scoops in 190mL water to make 225mL
o Significant residual >20% of feeding
 RUTF (as snack)
o 1 Tbsp. peanut butter
o 1 Tbsp. powdered milk
o 1 Tsp. sugar (20 cal)
o 1 Tsp. oil (45cal)
400cal
 Severe malnutrion (z < -3)

o Folic acid 5mg/5mL
 give 5mL orally on Day 1, then 1mL once a day on Days 2-10
o Zinc sulfate 55mg/5mL (20 mg elemental zinc)
 give 5mL orally once a day
o Multivitamins without iron
 give 5mL QD
o Vitamin A 50,000 IU/cap
 give 1/2/4 capsules as single dose (may be punctured)
 ENDORSEMENT – MALWARD
Bed # Patient Name Age/Sex
Day ___ of hospitalization Day ___ of rehabilitation
Diagnosis ______
WOA ______ Z-score ________
TW ______ PW _________ from ___________
F > AM/PM Feeding, Frequency
ACI _______ RENI ________ %RENI
RICHMOND
*Always check 24hr food recall
MALWARD COMPUTATIONS / REFERENCE:

 Breastfeeding 8x 500kCal
 AQIVA, Ensure, Pediasure 1kCal = 1mL
 BONA 20kCal = 30mL (-0.67)
 1 Tsp. oil 45kCal
 1 cup = 16 Tbsp. = 48 Tsp.
TEN STEPS TO RECOVERY Population Energy(kCal) CHON (g)

1. Treat/Prevent Hypoglycemia
<6mo 560 9
2. Treat/Prevent Hypothermia
3. Treat/Prevent Dehydration
6-12mo 720 14
4. Correct Electrolyte Imbalance 1-3y 1070 28
5. Treat the Infection 4-6y 1410 38
6. Correct micronutrient deficiencies 7-9y 1600 43
7. Start cautious feeding 10-12y 2140/1920 54/49
8. Rebuild wasted tissue (catch-up growth) 13-15y 2800/2250 71/63
9. Provide stimulation, play & loving care 16-18y 2840/2050 73/59
10. Prepare for follow-up after discharge PREGNANCY
1st T 66
STEP 1: TREAT HYPOGLYCEMIA
2nd T +300 66
 If patient is unconscious and able to drink, give 50 mL of
10% glucose or sugar water 3rd T +300 66
 If patient is unarousable or had convulsions, give 5 LACTATING
mL/kg of sterile 10% glucose per NGT 1st 6mo +500
 All malnourished children with suspected hypoglycemia 2nd 6mo +500
should be treated accordingly.
STEP 2: TREAT HYPOTHERMIA

 Rectal temperature T< 35.5OC or 95.9 F or
 Underarm temperature T < 35OC or 95 F
 Warm via the Kangaroo technique (skin to skin contact) and covering both of them
 Check rectal temperature Q2 until it rises to T > 36.5OC (Q30 min if heater is used)
STEP 3: TREAT DEHYDRATION
 Use ORS 45 instead of the standard ORS 75 since severely malnourished children are deficient in potassium and have
abnormally high levels of sodium,
ORS 75 ORS 45
Sodium 75 45
Potassium 20 40
Glucose 75 125
Chloride 65 70
Citrate 10 7
Osmolarity 245 300
 Start at 5mL/kg Q30 min for the first 2 hours orally/ NGT, then 5 – 10 mL/kg for the next 10 hours. Reassess the child
regularly.
STEP 4: CORRECT ELECTROLYTE IMBALANCE

 All malnourished patients have ↑Na and ↓K, Mg
 Give: Potassium 2 – 4 mmol/kg/day
Magnesium 0.3 – 0.6 mmol/kg/day
ReSoMal (modified ORS solution)
 Prepare food without salt
STEP 5: TREAT INFECTION

 Signs of infection often absent in severely malnourished patients, therefore give this routinely
o Broad – spectrum antibiotics
o Measles vaccine to unimmunized children
 May give Metronidazole x 7 days
STEP 6: CORRECT MICRONUTRIENT DEFICIENCIES

 Multivitamins supplement
 Folic acid 5mg/5mL, give 5 mL on Day 1 then 1 mL on Days 2-19
 Zinc sulfate 55mg/5mL, give 5 mL once a day
 Vitamin A 50 0000 IU/cap
o under 6 months 1 capsule
o 6 – 12 months 2 capsules
o 1 – 5 years 4 capsules
 Iron: NOT GIVEN until child starts gaining weight
STEP 7: START CAUTIOUS FEEDING
STEP 8: CATCH – UP GROWTH

 Catch up calories (based on RENI)
Age Kcal/day CHON/ day

0 – 6 months 560 9g
6 – 12 months 720 14 g
1 – 3 years 1070 28 g
4 – 6 years 1410 38 g
7 – 9 years 1600 43 g
10 – 12 years 1920/ 2140 54 g
13 – 15 years 2250/ 2800 63 – 71 g
16 – 18 years 2050/ 2840 59 – 63 g
 Stabilization Phase
o Starts at 50% RENI then increase by 10% daily
 Rehabilitation Phase
o 100% RENI given to increase 10 – 20% if no weight gain observed
o Place patient on head up position from the waist at 30O angle elevation
o Check positioning of NGT
STEP 9: STIMULATION, PLAY AND LOVING CARE

 To provide mental and behavioral development
STEP 10: FOLLOW –UP AFTER DISCHARGE

 Follow-up at 1 week, 2 weeks, 1 month, 3 months and 6 months, then 2x/year until 3 year old
* No apparent signs of infection
> Cotrimoxazole BID x 5 days
* With complications
> Ampicilllin 50 mg/kg Q6 x 2 days then shifted to amoxicillin 15 mg/kg Q8 x 5 days
> Gentamicin 7.5 mg/kg once daily x 7 days
* fails to improve within 48 hours

> Chloramphenicol 25mg/kg Q8 x 5 days
Criteria for discharge from non-residential care

Child  Weight-for-height has reached 1 – SD (90%) of NCHS/WHO media: reference values
 Eating an adequate amount of nutritious diet that the mother can prepare at home
 Gaining weight at a normal or increased rate
 All vitamin and mineral deficiencies have been treated
 All infections and other conditions have been or are being treated, including anemia, diarrhea,
intestinal parasitic infections, malaria, tuberculosis and otitis media
 Full immunization programme started
Mother or career  Able and willing to look after the child
 Knows how to prepare appropriate toys and to play with the child
 Knows how to give home treatment for diarrhea, fever and acute respiratory infections and how
to recognize the signs that means must seek medical assistances
Health worker Able to ensure follow-up of the child and support for the mother
COMPLEMENTARY FEEDING
 Starts at 6 months old
 “PAST”: Properly fed, Adequate. Safe. Timely
 Consistency of food
6 months Soft, pureed 2 – 3 x /day
8 months Finger food
10 months Lumpy/chopped 3 - 4x/day
> 12 months Table food
 Fruit Juice
1 – 6 y/o 4 – 6 oz/day
7 – 18 y/o 8 – 12 oz/day
 DO NOT add salt in diet < 1 year old
 Give NO MORE THAN 24 oz/day of cow milk
BREAST MILK STORAGE PERIOD

 Room Temperature (< 25 OC) 4 hours
 Room Temperature (>25 OC) 1 hour
 Refrigerator (4 OC) 8 days
 Freezer (1 – door) 2 weeks
 Freezer (2 – door) 3 meters
REFEEDING SYNDROME
 may follow overly aggressive enteral or parenteral alimentation
 Main features of Refeeding Syndrome
1. Abnormalities of Fluid Balance
2. Abnormalities of Glucose Metabolism
3. Vitamin Deficiency
4. Hypophasphatemia
5. Hypomagnesemia
6. Hypokalemia
 Starvation: ↑ Glucagon ↓ Insulin
Rapid conversion of glycogen stores  glucose  consumption
Ketone bodies and free fatty acides replace glucose as major energy stores
 Refeeding: Shift from fat to carbohydrate metabolism
Glucose load = insulin release = ↑ uptake of glucose, PO4. K+, Mg 2+, H2O, CHON
HEMATOLOGY
HEMOPHILIA
- X linked congenital bleeding disorder caused by deficiency in Factor VIII (Hemophilia A) and Factor IX (Hemophilia B)
- Female carriers
1. Daughter of a person with hemophilia
2. Mother of a son with hemophilia and who have at least one other family member with hemophilia/
known carrier
3. Mothers of 2 or more sons with hemophilia
PROPHYLACTIC FACTOR REPLACEMENT THERAPY
- Prophylactic replacement of clotting factor prevents bleeding and joint destruction and should be the goal of therapy to
preserve normal musculoskeletal function
1. MALMO PROTOCOL:
- 25-40 IU/kg per dose
- 3x a week for hemophilia A,
- 2x a week for hemophilia B.
2. UTRECHT PROTOCOL:
- 15-30 IU/kg per dose
- 3x a week for hemophilia A
- 2x a a week for hemophilia B
* Best given in the morning to cover period of activity
GUIDELINES FOR THE MANAGEMENT OF HEMOPHILIA 2nd edition, 2012
World Federation of Hemophilia
GUIDELINES FOR THE MANAGEMENT OF HEMOPHILIA 2nd edition, 2012
World Federation of Hemophilia
FVIII
 In the absence of inhibitor each unit of FVIII per kilogram of body weight infused IV will raise the plasma FVIII
level approximately 2 IU/dL
 Half-life of FVIII: 8 - 12 hours
 Dose of FVIII: Wt in kg x Level Desired in % x 0.5
 FVIII should be infused by slow IV injection at a rate not to exceed 3 ml per minute in adults and 100 units per
minute in young children, or as specified in the product information leaflet.
FIX
 In the absence of inhibitor each unit of FIX per kilogram of body weight infuse IV will raise the plasma FIX level
approximately 1 IU/dL
 Half-life of FIX: 18 – 24 hours
 Dose of FIX: Wt in kg x Level Desired in %
GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD) DEFICIENCY
- x-linked disorder characterized by a deficiency of an enzyme responsible for assuring a normal lifespan for RBCs
- cause Hemolytic anemia if certain food/drugs are ingested
DEFINITE RISK OF HEMOLYSIS

- Anti-helminthics: β-Naphthol, Niridazole, Stibophen
- Antibiotics: Nitrofurantoin, Nitrofurazone, Ciprofloxacin, Moxifloxacin, Nalidixic acid, Norfloxacin, Ofloxacin,
Chloramphenicol, Cotrimoxazole, Sulfonamides
- Antimalarials: Mepacrine, Pamaquine, Pentaquine, Primaquine
- Anti-methemoglobinemia: Methylene blue
- Anti-mycobacterials: Dapsone, Para-aminoxalicylic acid, Sulfones
- Anti-neoplastic agents: Doxorubicin, Rasburicase
- Others: Acetylphenylhydrazine, Phonylhydrazine
POSSIBLE RISK OF HEMOLYSIS

- Analgesics: ASA, Paracetamol, Aminopyrine, Tiaprofenic acid, Phenylbutazone, Phenazone
- Antibiotics: Furazolidone, Streptomycin, Sulfonamides
- Anticonvulsants: Phenytoin
- Anti-diabetics: Glibenclamide
- Antidotes: Dimercaprol
- Antihistamines: Antazolini, Diphenhydramine, Tripelennamine
- Anti-HTN: Hydralazine, Methyldopa
- Anti-mycobacterial: Isoniazid
- Others: Dopamine, Procainamide, Quinidine, Colcicine, Probenecid, Naphthalene, PABA, Fava beans
NEPHROTIC SYNDROME
- Nephrotic range proteinuria + triad of hypoalbuminemia, edema & hyperlipidemia
- NRP: > 40 mg/m2/hr or first morning UPC > 2- 3:1
- ↑ permeability of the glomerular capillary wall = massive proteinuria and hypoalbuminemia = ↓ plasma oncotic pressure &
transudation of fluid from IM compartment to interstitium = RAAS activation & ADH release = Na & H20 reabsorption
- Associated with hyperlipidemia due to
1. Hypoalbuminemia stimulates hepatic CHON synthesis including lipoproteins (↑ coagulation factors ~ ↑ risk of thrombosis)
2. ↑ urinary losses of lipoprotein lipase = ↓ lipid catabolism
IDIOPATHIC NEPHROTIC SYNDROME (90%)

- Primary glomerular disease without evidence of specific systemic cause
- M > F (2:1), often seen in 2 – 6 y.o.
- Initial episode usually follows minor infection
- Labs: 3+ or 4 + proteinuria in UIA
Spot UPCr of 2.0 or greater
Serum albumin < 2.5 g/dL
Serum Triglycerides ↑↑
Serum complement Normal
Treatment:
> Prednisone 60 mg/m2/day (max 80 mg) QD x 4 – 6 weeks, taper to 40 mg/m2/day every other day x 4 weeks, then slowly
tapered and discontinued over 1 – 2 months
> Low sodium diet
> Diuretics (reserved for severe cases_
> 25% Albumin at 0.5 – 1.0 g/kg via slow IV infusion
> Cyclophosphamide at 2mkday QD x 8 – 12 weeks
> Cyclosporine Tacrolimus, Mycophenolate
> Pneumococcal
SECONDARY vaccination
NEPHROTIC is recommended for nephrotic patients, ideally given when in remission or off-daily prednisone
SYNDROME
therapy (at
- Suspected in least 1 month)
> 8 y.o with HTN, hematuria, renal dysfunction, extrarenal symptoms and ↓ complement
CONGENITAL NEPHROTIC SYNDROME
- Manifest at birth – 3 months of life
- Typically with edema at birth, enlarged placenta
POST STREPTOCOCCAL GLOMERULONEPHRITIS

- Acute Nephritic Syndrome
- Characteristics:
1. Gross hematuria
2. Edema
3. Hypertension
4. Renal Insufficiency
- Follows skin/ throat infections caused by “nephritogenic” strains of GABHS
- Glomeruli appear enlarged and relatively bloodless with diffuse mesangial cell proliferation
- IF: Lumpy - bumpy deposits of immunoglobulin and complement on the GBM and mesangium
- EM: electron – dense deposits or humps on the epithelial side of the GBM
Clinical Manifestations:
- Most common in children 5 – 12 years old; uncommon before < 3 y/o
- Develop 1 – 2 weeks after streptococcal pharyngitis or 3 – 6 weeks after streptococcal pyoderma
- May develop hypertensive encephalopathy due to HTN or hypervolemia
Blurred vision, severe headache, altered mental status, seizure
- Peripheral edema is due to salt and water retention
- Nephrotic syndrome develops in minority of cases
- Resolves within 6 – 8 weeks
- Urinary protein excretion and HTN usually normalize by 4 – 6 weeks
- Persistent microscopic hematuria may persist up to 1 – 2 years after initial presentation.
Laboratory Findings:
- Urinalysis: RBC and RBC casts, proteinuria, polymorphonuclear leukocytes
- CBC: mild normochromic anemia may be due to hemodilution, low – grade hemolysis
- ↓ C3
- ASO titer is usually elevated after a recent streptococcal pharyngitis but rarely increases after streptococcal skin infections
(anti – deoxyribonuclease B for skin infection)
- MRI is indicated for patients where posterior reversible encephalopathy syndrome (PRES) is entertained
- If there is persistent hypocomplementemia consider chronic form of PSGN or MPGN
Treatment
FLUID LIMIT
- Supportive
= 1 WL + (UO x 24) where UO is 0.5 – 1 cc/kg/hr
- Sodium / Fluid restriction
- Diuresis (Furosemide)
SODIUM LIMIT
- ACEI / CCB for hypertension
= Wt in kg x 23 x 2 -4
Prognosis
- Complete recovery occurs in > 95%
- Recurrences are extremely rare
ACUTE RENAL FAILURE
NEUROLOGY
COMPONENTS OF NEURO EXAM
- Mental Status, Cranial Nerves, Motor function, Cerebellar, Sensory, Reflexes, Meningeal Signs
MANUAL MUSCLE TESTING

5/5 Complete joint ROM against full resistance
4/5 Complete joint ROM against moderate resistance
3/5 Full joint ROM against against gravity
2/5 Full joint ROM against gravity eliminated
1/5 Visible/Palpable muscle contraction
0/5 No muscle contraction
ACTIVITIES OF DAILY LIVING

D – Dressing/ Bathing
E - Eating
A - Ambulation
T - Toileting (urinating/ defacating)
H - Hygiene/ Grooming
INSTRUMENTAL ADL
S - Shopping for groceries/ clothing
H - Housekeeping
A - Accounting
F - Food preparation/ Medications
T - Telephone/ Transportation
INTERPRETATION:
<9 Severe brain injury/ coma
9 – 12 Moderate brain injury
> 12 Mild brain injury
STURGE WEBER SYNDROME
 aka Encephalotrigeminal angiomatosis
 Congenital neurological and skin disorder
 Sporatic vascular disorder
 Associated with the following:
o Port wine stain (facial capillary malformation)
o Seizures & Hemiparesis
o Developmental delay
o Glaucoma/ Buphthalmos
o Leptomeningeal angioma (cerebral malformation)
PORT WINE STAIN

 usually present at birth; usually unilateral
 due to overabundance of capillaries around the ophthalmic branch of the trigeminal nerve
SEIZURES and HEMIPARESIS; DEVELOPMENTAL DELAY

 Begin in infancy and may worsen with age
 Often occur at the OPPOSITE side of the PWS
 May manifest as stroke-like episodes that last for several days
 May be due to thrombosis of cortical veins
o Intellectual/ learning disability
GLAUCOMA and BUPHTHALMOS

 Optic neuropathy due to ↑ IOP
 Often at the IPSILATERAL side of the PWS
ROACH SCALE
Type 1: Facial and leptomeningeal angioma and possibility of glaucoma, 1 side of brain involved
Type 2: Facial angioma and no CNS involvement, may have glaucoma
Type 3: Leptomeningeal angioma only glaucoma rare.
IMAGING:
MRI with contrast
 Leptomeningeal angioma
 White matter abnormalities and may be die to chronic hypoxia
 Atrophy in ipsilateral side
MANAGEMENT (supportive)
1. Seizure control
2. Glaucoma monitoring
3. Prevent stroke like episodes
4. Pulse dye laser therapy for PWS
5. Hemispherectomy for intractable seizures
LENNOX GASTAUT SYNDROME

-Epilepsy with multiple different types seizures particularly tonic & atonic seizures
- Intellectual development is usually impaired
- Abnormal EEG patterns
GOODENOUGH DRAW – A – PERSON TEST
DIRECTIONS: “I want you to make a picture of a person. Make the very best picture that you can. Take your time and work
very carefully. Try very hard and see what a good picture you can make.”
TIME: No time limit. Usually 10 minutes will suffice with young children. This test is to be used primarily as a screening
device. The drawings of bright children more than 10 years old or those who have had drawing lessons will result in an invalid
evaluation of the child’s intellectual potential.
SCORING
CLASS A Preliminary Stage in which the drawing cannot be recognized as a human figure:
1. Aimless uncontrolled scribbling – score 0.
2. Lines somewhat controlled – approaches crude geometrical form – score 1.
CLASS B All drawings that can be recognized as attempts to represent the human figure. Each point is
scored plus or minus. One credit for each point scored plus and no half credits given.
GROSS DETAIL 1. Head present

2. Legs present.
3. Arms present
4. Trunk present
5. Length of trunk greater than breadth.
6. Shoulders are indicated (abrupt broadening of trunk below neck)
ATTACHMENTS 1. Both arms and legs attached to trunk.

2. Arms and legs attached to trunk at correct points.
3. Neck present.
4. Outline of neck continuous with that of head, trunk, or both.
HEAD DETAIL 1. Eyes present (one or two)

2. Nose present
3. Mouth present
4. Nose and mouth in two dimensions, two lips shown.
5. Nostril shown
6. Hair shown
7. Hair on more than circumference of head and non-transparent – better than a scribble.
CLOTHING 1. Clothing present (any clear representation of clothing)

2. Two articles of clothing non transparent (ex. Hat, trousers)
3. Entire drawing free from transparencies – sleeves and trousers must be shown.
4. Four articles of clothing definitely indicated. *should include 4 – hat, shoes, coat, shirt, necktie, belt,
trousers*
5. Costume complete with incongruities *business suit, soldier’s costume and hat, sleeves trousers and
shoes must be shown*
HAND DETAIL 1. Fingers present (any indication)

2. Correct number of fingers shown
3. Fingers in two dimensions – length greater than breadth, angle subtended not greater than 180
degrees
4. Opposition of thumb clearly defined
5. Hand shown distinct from fingers and arm
JOINTS 1. Arm joint shown – elbow, shoulder, or both

2. leg joint shown – knee, hip, or both
PROPORTION 1. Head not more than ½ or less than 1/10 of trunk

2. Arms equal to trunk but not reaching knee
3. Legs not less than trunk not more than twice trunk size
4. Feet in 2 dimensions – not more than 1/3 or less than 1/10 of leg
5. Both arms and legs in two dimensions
MOTOR COORDINATION 1. Lines firm without marked tendency to cross, gap, or overlap.
2. All lines firm with correct joining.
3. Outline of head without obvious irregularities. Develop beyond first crude circle. Conscious control apparent.
4. Trunk outline. Score same as #3.
5. Arms and legs without irregularities. 2 dimensions and no tendency to narrow at point of junction with trunk.
6. Features symmetrical (more likely to credit in profile drawings)
FINE HEAD DETAIL 1. Ears present (2 in full face, 1 in profile)

2. Ears present in correct position and proportion.
3. Eye details – brow or lashes shown.
4. Eye detail – pupil shown.
5. Eye detail – proportion. Length greater than width.
6. Eye detail – glance – only plus in profile.
7. Chin and forehead shown.
PROFILE 1. Projection of chin shown – usually + in profile.

2. heel clearly shown
3. Body profile – head, trunk, and feet without error.
4. Figure shown in true profile without error or transparency.
TABLE OF MENTAL AGE EQUIVALENTS OF SCORES
SCORE MA SCORE MA SCORE MA SCORE MA
1 3-3 14 6-6 27 9-9 40 13-0
2 3-6 15 6-9 28 10-0 41 13-3
3 3-9 16 7-0 29 10-3 42 13-6
4 4-0 17 7-3 30 10-6 43 13-9
5 4-3 18 7-6 31 10-9 44 14-0
6 4-6 19 7-9 32 11-0 45 14-3
7 4-9 20 8-0 33 11-3 46 14-6
8 5- 21 8-3 34 11-6 47 14-9
9 5-3 22 8-6 35 11-9 48 15-0
10 5-6 23 8-9 36 12-0 49 15-3
11 5-9 24 9-0 37 12-3 50 15-6
12 6-0 25 9-3 38 12-6 51 15-9
13 6-3 26 9-6 39 12-9
IN FINDING THE IQ OF RETARDED CHILDREN WHO ARE MORE THAN 13 YEARS OLF, THE CHRONOLOGICAL AGE SHOULD BE
TREATED AS 13 ONLY, AND THE IQ RECORDED AS “OR BELOW.”
IT IS NOT WISE TO ATTEMPT TO USE THIS TEST WITH BRIGHT CHILDREN OF MORE THAN 12 YEARS OF AGE.
PEDIATRIC SURGERY
* PHYSICAL STATUS CLASSIFICATION/ PRE-OPERATIVE RISK ASSESSMENT
PS 1 No underlying physical or metabolic disturbance
PS 2 Mild to moderate disturbance that do not interfere with daily routine
PS 3 Severe disturbance that interfere with daily ordinary activities
PS 4 Severe disturbances that are a constant threat tro life
PS 5 Moribund condition in patient likely to succumb within 24 hours
PS 6 Organ donor
ALLOWABLE BLOOD LOSS (ABL)

= Wt in kg x 80 ml/kg x 10% = volume in mL (neonates)
= Wt in kg x 80 ml/kg x 20% = volume in mL (older children)
ESTIMATED BLOOD LOSS

= Wt in kg x 24 x 0.80
IVF Resuscitation: NSS at 20 mL/kg [25% of estimated blood volume (80)]

BURN
DEPTH OF BURN
First Degree BURN Erythema, pain, absence of blisters Sunburn
Second Red or mottled, flash burns Contact with hot liquids
Third Dark and leathery, dry Fire, electricity, lightning, prolonged exposure to hot liquids/ objects
SERIOUS BURN REQUIRING HOSPITALIZATIONS

- Greater than 15% burns in an adult, 10% in a child
- Any burn in the very young, the elderly or the infirm
- Any full thickness burn
- Burn of special regions: face, hands, feet, perineum
- Inhalational injury
AGE
0 1 5 10
HEAD 10 % 9% 7% 6%
THIGH 3% 3% 4% 5%
LEG 2% 3% 3% 3%
ACUTE APPENDICITIS
- Due to luminal obstruction, inspissated fecal material, lymphoid hyperplasia, foreign body ingestion, tumor or parasites
 Obstruction = ↑ intraluminal pressure = lymphatic and venous congestion and impaired arterial perfusion = ischemia,
bacterial invasion and necrosis
 S/s: abdominal pain (periumbilical > RLQ), anorexia, nausea and vomiting, fever, diarrhea
 Ultrasound (>90% sensitivity and specificity)
o Wall thickness > 6 mm
o Luminal distention
o Lack of compressible
o Complex mass at RLQ
o Fecalith
 CT scan (>95%) – GOLD STANDARD
 DDx: AGE, UTI, Ovarian torsion Ectopic pregnancy, PID, Ruptured Ovarian Cyst
Scores
 ≤2 suggest a very low likelihood of appendicitis
 3 -7 warrant further evaluation or diagnostic studies
 ≥8 are highly associated with appendicitis
- Most common during 11 – 16 y.o.
- Failure of the physis & displacement of the femoral head relative to the neck
CLASSIFICATION
1. Based on onset
a. Acute: < 3 weeks, pain in the groin, thigh or knee with mild/ minor injury; osteonecrosis develop in 17 – 47%
b. Chronic: vague groin, thigh or knee pain, limp
2. Based on stability
a. Stable: able to walk with or without crutches
b. Unstable: 50%
- Goal: stabilize physis thru IN SITU PINNING
3. Based on Degree (Head – Shaft angle)
a. Mild < 30 O
b. Moderate 30 - 60 O
c. Severe > 60 O
- Combination of Mechanical & Endocrine factors
RF: Hypothyroid, Hypopituitarism, Obesity, Renal osteodystrophy, M>F, L>R
- X-ray:
 Widening & irregularity of physis
 ↓ epiphyseal height in the center of the acetabulum
 Crescent – shaped and of increased density in the proximal portion of the femoral neck
 “Blanch sign of steel” double density from anteriorly displaced femoral neck
SALTER HARRIS FRACTURES

- Fracture that involves the epiphyseal plate or growth plate of a bone
- Common injury found in children
- Types I: Slip Fracture through the growth plate
II: Above Fracture lies ABOVE the physis
III: Lower Fracture lies BELOW the physis
IV: Through Everything: Through the metaphysis, physis and epiphysis
V: Rammed : Physis has been crushed
KAWASAKI DISEASE
aka Mucocutaneous lymph node syndrome
- Vasculitis of medium – sized arteries with resulting aneurysm formation if untreated
- Criteria for KD:
Fever > 5 days (T > 40OC)
At least 4 of the following:
1. Bilateral non-purulent conjunctival injection
2. Polymorphic exanthema
3. Changes in lips/ oral cavity (strawberry tongue, red lips)
4. Changes in extremities (Beau’s lines, palmar erythema, periungual desquamation)
5. Cervical lymphadenopathy, unilateral > 1.5 cm
Most important manifestation:

> Myocarditis, coronary aneurysm, acute MI, pericardial effusion, valvular regurgitation
PHASES OF KD
1. Acute Febrile Phase (1-2 weeks)
2. Subacute Phase (2-4 weeks)
a. Desquamation
b. Thrombocytosis
c. Arthritis
d. Highest risk of sudden cardiac death (aneurysm)
3. Convalescent Phase (~6-8 weeks post-onset) ↓ APR
Treatment of KD:
1. IVIG infusion (2g/kg over 10-12h x 1)
2. High dose ASA (80-100 mkday x 14days) - anti-inflammatory property
3. Low dose ASA (3-5 mkday until week 8) - anti-thrombotic property
4. Methylprednisolone (30 mkday x 3 days) - for refractory KD or for those who cannot afford IVIG therapy
TREATMENT IF WITH CORONARY ABNORMALITIES

: Low dose ASA + Clopidogrel (1 mkday, max 75mg/d) + Warfarin (if high risk for thrombosis)
IVIG INFUSION (must be given w/in 10 days)

- Dose: 2g/kg
- Preparation: 2.5g / 50mL, 5g / 100mL or 2.5g / 25mL
˃ Start IVIG infusion as follows:
wt x 0.01 x 60 = _____cc/hr for 30min
*
wt x 0.02 x 60 = _____cc/hr for 30min
wt x 0.04 x 60 = _____cc/hr for 30min
wt x 0.08 x 60 = _____cc/hr for 30min
˃ Total Volume - * = _____mL to run for 10-12hr
˃ Hold main line while on IVIG infusion
˃ Monitor VS Q15min for the first hour, Q30min for the 2nd hour and Q1 thereafter
˃ Watch out for fever, hypotension, flushing, chills, headache
Dr. Bernal’s Style:

˃ Pre-medicate with Hydrocortisone 30minutes prior to IVIG infusion
˃ Give IVIG as follows:
IVIG _____g, infuse at 10mL/hour for 30min
Increase by increments of 10mL every 30min until 60mL/hour is reached, until infusion is completed
˃ Hold main line during infusion
˃ Monitor VS
˃ WOF
HENOCH SCHONLEIN PURPURA

- aka Non-thrombocytopenic purpura
- Most common vasculitis of childhood (M>F)
- Leukocytoclastic vasculitis and IgA deposition in the small vessels in the skin, joints, GIT, kidney
- Often follow a documented URTI
- Hallmark of HSP = Palpable Purpura*
- S/s : Arthritis / Arthralgia, abdominal pain, vomiting, diarrhea, melena
Paralytic ileus, intussusception, mesenteric ischemia
- Skin lesions are often symmetric and occur in gravity-dependent areas
- LABS: Leukocytosis, Thrombocytosis, Anemia, ↑ESR, ↑CRP, Intussusception
- Treatment: Supportive care
PREDNISONE at 1-2mkday for 1-2 weeks then taper (for GI symptoms)
ACR CRITERIA
 At least 2 of the ff MUST be present
- Palpable purpura
- Age of onset ≤ 20 y/o
- Bowel angina (post-prantdial abdominal pain, bloody diarrhea)
- Biopsy demonstrating intramural granulocytes in small arterioles/venules
OSGOOD-SCHLATTER DISEASE (aka Lannelonque disease)

- Common cause of knee pain in active adolescents (athletes)
- Self-limiting condition w/c often resolve with rest
- Inflammation of the patellar ligament at the tibial tubercle or traction apophysitis of tibial tubercle growth plate
- RF: overuse/growth spurt
- PE: point tenderness over the tibial tubercle and distal portion of the patellar tendon
- Typically without any acute traumatic inciting event
- Pain aggravated by sports activites but may persist with daily activities or even at rest
- Radiographic findings:
o Fragmentation of the Tibial Tubercle
o Soft Tissue Swelling
- Management:
o Rest! (Restriction of sports or dynamic activities until patient is pain-free)
o Physical Therapy in some cases
*Complication of OSD – Avulsion

- Type I : Small fragment displaced proximally
- Type II : Articular surface remains together & fracture occurs at the junction
- Type III : Total break ċ meniscal damage (surgery required)
JUVENILE DERMATOMYOSITIS (JDM)

- Most common inflammatory myositis in children
- Proximal muscle weakness and characteristic rash
- HLA-DQAI * 0501 and HLA-DRB * 0301
- Often associated with history of infection 3 months prior to onset of symptoms
- 3 per 1,000,000 children per year
- No racial predilection; F>M 2:1
- Peak age of onset: 4&10 y/o
- 2nd peak at late adulthood 45-64 y/o
- The facial rash of juvenile dermatomyositis. There is

erythema over the bridge of the nose and malar areas
with violaceous (heliotropic) discolorations of the upper
eyelids.
- The rash of juvenile dermatomyositis. The skin over

the metacarpal and proximal interphalangeal joints may
be hypertrophic and pale red (Gottron papules).
Rash and calcifications in dermatomyositis.

- Skin effects of calcification
- Radiographic evidence of calcification
DIAGNOSTIC CRITERIA FOR JUVENILE DERMATOMYOSITIS (JDM)

CLASSIC RASH Heliotrope rash of the eyelids
Gottron papules
Plus three of the following:
WEAKNESS Symmetric
Proximal
MUSCLE ENZYME ELEVATION (≥1) Creatine kinase
Aspartate aminotransferase
Lactate dehydrogenase
Aldolase
ELECTROMYOGRAPHIC CHANGES Myopathy
Denervation
MUSCLE BIOPSY Necrosis
Inflammation
CLINICAL MANIFESTATIONS
- Rash, Fever, Dysphagia, Dysphonia, Arthritis, Muscle Tenderness, Fatigue, Weakness, Photosensitivity
- SHAWL SIGN: macular erythema on the posterior neck and shoulders (V-SIGN if anterior)
- HELIOTROPE RASH: blue-violet discoloration of the eyelids often associated w/ facial erythema over the nasolabial fold
- GOTTRON PAPULES: scaly/erythematous dermatitis on the dorsum of the hand, MCP, PIP and DIP
- MECHANIC’S HANDS: roughened and fissuring of the skin on the palm and radial surfaces of fingers
- GOWER SIGN: use of hands on thighs to stand from a sitting position
EMG CHANGES:
- ↑insertional activity, fibrillations, sharp waves, ↓action potential, ↓amplitude and ↓duration
LIPODYSTROPHY AND CALCINOSIS
- sign of long-standing/untreated disease
- calcium phosphate, hydroxyapatite, fluoroapatite crystals > subcutaneous nodules with extrusion of crystals/calcific liquid
LABS
- ↑muscle enzymes, ESR often normal, anemia, ANA (+) in 80%, RF (-)
Treatment of JDM
1. Methotrexate (0.5-1 mg/kg or 15-20mg/BSA) - max 25mg
- ↓length of corticosteroid treatment
- risk: immunosuppression, blood dyscrasia, chemical hepatitis, pulmonary toxicity, nausea/vomiting
2. Corticosteroids - mainstay of treatment
- Methylprednisolone pulse at 30mkday x 3 days if with respiratory weakness – max 1g/day
3. IVIG - adjunct to severe disease
4. Hydroxychloroquine - 2° disease modifying agent to reduce rash and maintain remission (4-6 mg/kg/day)
5. Folinic acid - given 1mg QD to reduce MTX toxicity
PERIODIC FEVER APHTHOUS STOMATITIS PHARYNGITIS ADENITIS (PFAPA) SYNDROME
- Most common auto inflammatory fever disorder in childhood
- Recur at regular intervals
- Rash, headache, arthralgia may be present but not consistently noted
DIAGNOSTIC CRITERIA
- More than 3 documented episodes of fever, lasting no more than 5 days and occurring at regular intervals (3-6 weeks)
- Pharyngitis plus tender cervical lymphadenopathy or aphthous ulcers
- Normal growth parameters and good health between episodes
- Prompt resolution of symptoms with a single dose of prednisone
- TX: Benign and Self-Limited
May start Prednisone at 1-2 mkday or give Betamethasone 0.3 mkdose x 1
- Spontaneously resolves
RHEUMATIC FEVER
- Non-suppurative complication of Group A Streptococcal pharyngitis due to a delayed immune response
- Common in developing countries
JONES’ CRITERIA
- Evidence of streptococcal infection (↑ASO), PLUS 2 MAJOR or 1 MAJOR + 2 MINOR
MAJOR MINOR
- Migratory polyarthritis - Fever
- Carditis - Polyarthralgia
- Subcutaneous nodules - ↑ESR/CRP
- Erythema marginatum - Prolonged PR interval
- Sydenham chorea
 MIGRATORY POLYARTHRITIS
- Most frequent major manifestation of RF
- Sequential involvement of joints ċ each completing a cycle of inflammation and resolution
- Relatively short latent period : ~1 week
- Heals completely (no pathologic/functional residua)
 SYDENHAM CHOREA
- Emotional lability, uncoordinated movements and muscular weakness
- PRONATOR SIGN: hands pronate when raised ↑head
- MILKMAID GRIP: irregular, repetitive squeezing of examiner’s hand due to unsustained tetanic contraction;
DARTING TONGUE
- CHOREIFORM MOVEMENTS: often unilateral
- longer latency period: ~1-7 months
- may occur as the SOLE CRITERION for RF
 SUBCUTANEOUS NODULES
- Round, firm, freely movable, painless lesions varying in size 0.5-2.0cm
- Occur in crops over bony prominences or extensor tendons
- May persist from days to weeks, rarely more than 1 month
 ERYTHEMA MARGINATUM
- Appear as bright pink macule/papule that spreads outward in a circular or serpinginous pattern; multiple; never
on the face
- Non-pruritic, non-painful, blanch under pressure
- Not influenced by anti-inflammatory therapy
 INDOLENT CARDITIS
- inflammation of the heart muscle
- most sever clinical manifestation of RF
- tachycardia and cardiac murmur, with or w/o evidence of myocardial involvement
- may also occur as a SOLE MANIFESTATION of RF, however other entities must be ruled out
Treatment & Prevention of RF

ANTIBIOTIC THERAPY
 10 days of orally administered penicillin or erythromycin OR
 Single IM injection of Benzathine penicillin
 Secondary Prevention
o Penicillin and Benzathine
 600,000u for children ≤60lbs
 1.2Mu for children >60lbs
INFECTIVE ENDOCARDITIS: acute and subacute bacterial endocarditis
CLONING: reproductive embryo to mature, therapeutic – only the good

ORPHAN DISORDERS > Report, knowledge < 1000/IM or 1/20 000 PHIL
BACKPACKS:
 Should not be > 10 – 20% heavier,
 Padded, with compartments, chest and sternum straps
 4 INCH RULE: < 4 in from waist below Madocs,
 Impinge muscle blood flow ~ 3%: Surface pressures measured by the investigators were higher than the pressure
threshold to obstruct normal skin and muscle blood flow, measured at 30mmHg. According to previous studies children
commonly carry backpack loads of 22% of their body weight. The study found that pressures at 20% of body weight
measured 70 mmHg on the left shoulder and 110 mmHg on the right shoulder -- skin surface pressures that are more than
double and triple the threshold for reduced blood flow. (Researchers Report Results of Children’s Backpack Study 2005)
NOISE:
FETUS AND NEWBORN
HERLYN – WERNER – WUNDERLICH SYNDROME (HWW)

- Rare conginetal anomaly of the urogenital tract involving the Mullerian and Wolffian ducts
- Triad of Didelphys uterus, Obstructed hemivagina and Ipselateral renal agenesis
- Often discovered during puberty
- S/s: increasing pelvic pain, dysmenorrhea, palpable mass d/t hematocolpus /hematometra
- Menstruation is often regular
-
- Hepatitis B screening (HBsAg)
GROWTH AND DEVELOPMENT - Determine carrier state of mother (Vertical)
- If (+) give Hepatitis B Immunoglobulin for passive immunity
WEIGHT
- If (-) give Hepatitis B vaccine only
- Weight loss in the first few days (5 – 10% BW)
- If (?), may delay administration of Hep B Ig for a week and determine H
- Return to birth weight within 7 – 10 days, (2 weeks)
of the mother
AVERAGE WEIGHT AGE
- OGTT screening
2X BW 4 – 5 month - Often done at 24 – 28 weeks AOG or if high risk of having
3X BW 1 y/o
4X BW 2 y/o GDM - FBS < 92 mg/dL
5X BW 3 y/o 1O < 180 mg/dL
6X BW 5 y/o 2O < 153 mg/dL
7X BW 7 y/o - Determine type of control
10X BW 10 y/o - If uncontrolled DM, risk of LGA/macrosomia, SGA, hypoglycemia,
neurodevelopmental delay
- BW: 2.5 – 3.5 kg
- Average weight: 3.5 kg at birth, 10 kg in 1 y/o - Antenatal Ultrasound
20 kg at 5 y/o, 30 kg at 10 y/o - Frequency
- Daily weight gain: 20 – 30 g/day for first 3 – 4 months - Findings, BPS, AFI/ SVP
15 – 20 g/day for the rest of Y1 - Congenital scan
- Annual weight gain: 5 lbs. from 2 y/o to puberty - Maternal history of HTN, DM, Asthma, Thyroid
- UTI / Asymptomatic Bacteriuria
FORMULAS: - Date of occurrence
- 0-6 mo: age in mo x 600 + BW - Treated or not?
- 6-12 mo: age in mo x 500 x BW - Significant if it occurred during labor ~ risk of chorioamnionitis
- 3 – 12 mo: (age in mo +9) /2 - Vaginal infections
- 1 – 6 years: age in years x 2 + 9 - Date of occurrence
- 7 – 12 yrs: (age in years x 7 – 5)/2 - Treatment given
- Association with preterm labor
HEIGHT - Preterm labor
- BL: 48 – 53 cm (50 cm) - Manifestation and treatment
- Increase 50% by 1 year (75 cm) - Use of MV, folic acid and FeSO4
- 2x – 4 yrs
- 3x – 13 years * CAPUT SUCCEDANEUM
- Often midline, crosses suture lines
- Average length: 20 inches at birth - resolve within ________________
30 inches at 1 y/o (↑ 5-%)
- At 3 y/o, average child is 3 feet tall * CEPHALHEMATOMA
- At 4 y/o, average child is 40 inches tall (double the birth - unilateral, does not cross the suture liunes
length) - resolve within _______________
- Average annual gain: 2 – 3 inches from 4 y/o to puberty - associated with jaundice
AGE CENTIMETERS INCHES * ROR , OU

At Birth 50 20 - congenital cataract
1 y/o 70 30 - often caused by congenital rubella
2 – 12 y/o Age x 6 +77 Age x 2.5 + 30
* Intact clavicles
HEAD CIRCUMFERENCE: * MURMUR
- At birth: 33- 38 cm (35 cm) - most common: systolic murmur representing a closing PDA (anatomic:
- 75% of adult size by 1 year Functional
* 2 UA, 1 UV
Age Appox Wt Growth in Growth in RDA
- if 2 – vessel cord: may be a normal variant but may also be associated with renal/
Gain (g/d) Lt/Ht HC (kcal/kg/d)
anomaly
(cm/mo) (cm/mo)
0-3 mo 30 3.5 2.0 115 * NO PALPABLE MASS
3-6 mo 20 2.0 1.0 110 - If present, most common renal mass ~ hydronephrosis
6-9 mo 15 1.5 0.5 100
9-12 mo 12 1.2 0.5 100 * GROSSLY MALE/ FEMALE GENITALIA
1 – 3 yr 8 1.0 0.25 100 - Ambiguous genitalia ~ CAG
4 – 6 yr 6 3 cm/yr 1 cm/yr 90 – 100
* BILATERALLY DESCENDED TESTES
Mid-parental height - may be undescended at birth ~ normal
- Boys: [(maternal ht in cm + 13) + paternal ht in cm] /2 - if it remains undescended  refer to Surgery
- Girls: [maternal ht in cm + (paternal ht in cm – 13)] /2 - if bilaterally undescended, may be hormonal cause (CAH)
*if will use height in inches, may replace the factor 13 with 5
* FULL FEMORAL PULSE
- Only assess other pulses if (+) weak pulses suggestive of coarctation of the Aorta
HISTORY and PE
- Maternal and Paternal Profile including blood type
- LMP for dating of pregnancy
- Exposure to viral exanthema, radiation, smoking, alcohol intake, illicit
drug use
DEVELOPMENTAL MILESTONES:
MOTOR ADAPTIVE LANGUAGE SOCIAL
1st 4 Generally flexed, turns head “Doll’s eye” Crying Visual preference for human
weeks from side to sidem head sags Moro reflex face
on ventral suspension
1 mo Holds head up momentarily, Watches a person, Alerts, throaty, Body movements in cadence
head lags when pulled to fixates on object at midline gurgling sounds w/ voice of other in social
sitting Hands closed contact, Reflex smile
2 mo Head sustained in plane of Follows moving object 180 Coos Social smile
body on ventral suspension. degrees Listens to voice
Head lags when pulled to
sitting
3 mo Head above plane of body on Typical Moro response has not “aah, ngah” Sustained social contact,
vertical suspension, reaches persisted, makes defensive Listens to music
toward and misses object, movements or selective
waves at toy, early head withdrawal reactions
control with bobbing, back
rounded
4 mo Lifts head & chest in approx Sees pellet, but makes no move LOL
vertical axis, legs extended, to reach for it May show displeasure if
symmetric posture, hands in social contact is broken,
midline, reaches and grasps obj Excited at sight of food
and brings to mouth, no head
lag when pulled to sitting
7 mo Rolls over, pivots, crawls or Reaches out for and grasps large Forms polysyllabic {Prefers mother, babbles,
creep crawls, lifts head, rolls object, transfers objects from vowel sounds enjoys mirror, responds to
over, squirms, sits briefly with hand to hand, grasp uses radial changes in emotional content
support of pelvis, leans pals, rakes at pellet of social content
forward on hands, bounces
actively
10 mo Sits up alone and indefinitely Picks up pellet with unassistet Repetitive constant Responds to sound of name,
without support, back straight, pincer, releases object on request sounds, ‘mama’, dada plays peek-a-boo, or pat-a-
pulls to stand, cruises or walks, cake
holding on to furniture Waves bye bye
12 mo Walks with 1 hand held Makes tower of 3 cubes, makes a Says a few words Plays simple ball game, makes
Rises independently, takes line with crayon, inserts raisin in besides ‘mama’ & postural adjustment to
several steps bottle papa dressing
15 mo Walks alone Makes a tower of 4 cubes, Jargon, follows simple Indicates some desires or
Crawls upstairs imitates scribbling and vertical commands, may name needs by pointing
stroke, dumps raisin from bottle a familiar object, Hugs parents
responds to name
18 mo Runs stiffly, sits on small chair, Makes tower of 4 cubes, imitates 10 words (average, Feeds self, seeks help when in
walks up stiars with 1 hand scribbling and vertical stroke, names pictures, ID 1 trouble, may complaon when
held, explores drawers and dumps raisin from bottle or > body parts wet or soilder, kisses with
wastebaskets pucker
24 mo Runs wells, jumps, walks up Makes tower of 7 cubes, circular Puts 3 workds Handles spoon well, often tell
and down stairs one step at a scribbling, imitates horizontal together (subject, about immediate
time, opens doors, climbs on stroke, folds paper once verb, object) experiences, helps to undress,
furniture imitatively listen to stories with pictures
30 mo Goes up stairs on alternating Makes tower of 9 cubes, makes Refers to self by Helps put things away,
feet vertical and horizontal strokes, pronoun ‘I’, knows full pretends play, handles spoon
imitates circular stroke name well
3 yrs Rides tricycle, Stand, Makes tower of 10 cubes, Knows age and sex, Plays simple games, helps in
momentarily on one foot imitates construction of bridge of counts 3 objects dressing, washes hands
- HANDEDNESS 3 cubes, copies circle, imitates correctly, repeats 3
- 20 PRIMARY TEET cross no.
4 yrs Hops on one foot, throws ball Copies bridge, imitates Counts 4 pennies Plays with several children,
overhead, uses scissors to cut construction of ‘gate’ of 5 cubes, accurately, tells story, w/ beginning of social
out pictures, climbs well copies CROSS & , Draws man w/ past etnse, sing songs interaction and role-playing,
- VA 20/ 20 2 -4 parts beside head, identifies from memory goes to toilet alone
longer of 2 lines

5 yrs Skips Names 4 colors, rpt Dresses and undresses
Jumps over low obstacles sentences of 10 Ask questions about meaning
Copies , names heavier of 2 syllables, counts 10 of words
weights, tie shoe laces pennies correctly, Role- playing
future tense

6 yrs Repeats 5 digits,
knows R from L hand
Copies
FONTANEL CLOSURE SCHOOL AGE CHILDREN

- Anterior Fontanel: 9 – 18 months - Slow to remember facts
- Posterior fontanel: 6 – 8 weeks - Slow to learn new skills, relies heavily on memorization
- Poor coordination, unaware of physical surroundings and
TOOTH ERUPTION (3-16 months) prone to accidents
- No of teeth (1st year) = age in mo – 6 - May be awkward and clumsy, and has trouble with fine motor
- 5 – 7 mo – 1st tooth to appear: lower central incisor skills
- 3 years – 20 primary teeth
- 6 – 8 years – 32 secondary teeth READING SKILLS (FOR SCHOOL AGE CHILDREN):
- 6 years – eruption of 1st molars and loss of deciduous teeth Slow in learning connection between letters and sounds
- 9 years – 8 permanent incisor and 4 permanent molars Confuse basic words
- 11 – 12 years – premolars erupt Repeats, omits or adds words
- Delayed tooth eruption: no teeth by 13 month Does not read fluently
Does not like reading at all
CRYING PHASE: Avoids reading aloud
- at 6 weeks: 3 hours/ day Uses fingers to follow a line of print when reading
- By 3 months: decrease to <1 hour Makes consistent reading errors:
- Colic: > 3 hours/day, 3 days/ week - Letter reversals: b-d, p-q
- Letter inversion: m – w
TOILET TRAINING: - Transpositions: felt – melt
- Daytime bladder control proceeds bowel control - Word reversals: was – saw
- Girls preceed boys - Number reversals: 14 – 41
- Bedwetting is normal up to 4 years in girls and 5 years in Draw a Person Test: 1 Point / part
boys
Mental Age = (# of points x 3 months + 36) / 12
TEMPER TANTRUMS HEADS/SF/ FIRST

- Appear by end of 1 year and peak between 2 0 4 years Home, Education/ School, Abuse, Drugs, Safety, Sexuality/ Sexual
- Problem if > 15 mins or > 3x/day identity, Family/ Friends, Image, Recreation, Spirituality and
Connectedness, Threats and Violence
VISUAL ACUITY
- 20/30 by 3 years
- 20/20 by 4 years
RED FLAGS OF DEVELOPMENT:
MOTOR DELAY
- Poor head control by 3 months
- Hand still fisted by 4 months
- Unable to hold object by 7 months
- Does not sit independently by 10 months
- Cannot stand on one leg by 3 years
LANGUAGE DELAY
- Does not turn to sound by 6 months
- Does not babble or use gestures by 12 months
- No single word utterance by 16 months
- No 2 word phrases by 2 years
- No 3 word sentences by 3 years
PSYCHOSOCIAL DELAY
- No social smile by 3 months
- Not laughing in playful situation by 6 months
- Hard to console, stiffens when approached by 1 year
- In constant motion, resists discipline
- Does not play with other children at 3 years
COGNITIVE DELAY
- 2 months – not alert to mother
- 6 months – not searching for dropped object
- 12 months – no object permanence
- 18 months – no interest in cause and effect games
- 2 years – does not categorize similarities
- 3 years – does not know full name
- 4 ½ - cannot count sequentially
- 5 years – does not know letters/ colors
- 5 ½ years – does not know own birthday or address
CONSULTANT RM LOCAL CLINIC HOURS SUN GLOBE/SMART HOME PHONE
ANDAYA, Agnes G. 426 2208 M – S 10 – 12 PM 09328787515 0919-2874210 722-2716, 712-1444
712-1416
ATIENZA, Melinda M. 542 2423 T 2 – 4 PM Th/S 9-11 AM 0922-8787196 0920-9182827 951-5776, 432-5059
BALOTRO-Torres, Ma. Cristina 416 2471 MWF 2 – 4 PM 0922-8153352
BANDONG, Ma. Conchitina C. 419 2656 MW 10 – 12 PM 0922-8787601 0928-5082904
BAUZON, Aurora F. 441 2225 M – S 10:30 – 12:30 PM 0922-8787383 0917-8804271 929-3312
BERNAL, Christina B. 415 2512 M/Th/F 4 – 6 PM 0922-8787010 0920-9788588
BRAGANZA, Kat 0917-8641029
BUZON, Rosalia M. 517 2475 M 4-6, TS 1-4, W 10-4, Th12-1.4-6 0922-8787297 0917-8551380 722-2639, 723-3844
CABANSAG, Ma. Rosario F. 538 2396 MWF 2–4 PM 0925-8944079 829-8092
CANONIGO, Beatrice B. 428 2230 M/W/Th/S 10–1 PM 0922-8787107 0917-3262833 850-9406, 807-9168
CARANDANG, Enrique H. 505 2466 M – F 4–6 PM Sat 8–12nn 2-4 PM 0922-8787376 0906-5790020 742-0550
CASTRO, Rebecca A. 437 2494 MTThF 11-1 PM, S 11-2 PM 0922-8787365 0928-5002241 920-0795
CHAN, Antonio E. 405 2479 M – S 12 – 2 PM 0922-8787663 0917-8303289 926-7451
CHAN, Remedios D. 437 2494 M – S 10 – 12 PM, S 9 – 12 PM 0922-8787053 0918-9202205 412-4617, 724-1008
CHIONG, Mary Anne D. 511 496-5780 T/Th 11 – 1 PM 0917-5304627
CHUA, Mary 0917-5200432 372-7523
CO, Benjamin G. 538 2396 Sat 10 – 12 ( Wed 8 – 9 am) 0917-8441454 842-2148, 742-6880
CO, Lourdes 0917-8523389 986-7818
CUASO, Charles C. 0917-3274229 634-3840, 633-0552,
632-0303
DE CASTRO, Citadel C. 404 2227 M/T 10-2PM, F 9-12PM, Sat 9 – 2 PM 0922-8787150 0917-8917005 681-3269, 646-6991
0908-8831778
0928-2790338
DE LEON, Ma. Rhodora G. 405 2479 M 10-12 PM (T by appointment), 0922-8787653 0916-7818040 433-1662
DE SAGUN, Rosalina Q. 418 2270 M-F 10 – 12 PM, Sat by app. 0922-8819726 0917-8190721
DENIEGA, Lester A. 0922-8787195 0929-5152977 913-2578
DIONISIO, Sheryl T/F 7 – 12 PM Th 7 – 11 AM 0918-5762467
DIZON, Ma. Charina Asteria B. 539 2212 Tth 10 – 1 PM 0917-7960318 828-8976, 433-2858
FLORENTINO, Alvin 0906-3156644 371-8197
FLORES, Dennis S. 408 2485 T Th 10 – 1 PM (TThSat 2- 4 PM) 0922-8980020 0917-8866391
FLORES, Lourdes Q. 442 2429 M – Th 10 – 12 PM (By appointment) 0922-8787604 0917-5164895 722-2104
FLORES, Marites R. 413 2489 0922-8371271 0908-8626361
GALUTIRA, Paul Joseph 415 2512 T/Sat 3-5 PM, Th 10-2 PM
GO, Olivia C. 526 2675 M-F 10-12 PM, Sat 1-4 PM 0922-8627815 0917-8112678 671-5805
GONZALEZ, Matilde G. 538 2396 TThS 1-3 PM 0922-8787156 0918-2355325 426-0342
0921-9720196
HERNANDEZ. Emilio Jr. A 419 2656 M/F 4 -6 PM 0917-8991340
HERNANDEZ, Flerida G. 415 2512 M-W 2-5 PM, Sat 3-5 PM 0933-8566483 0917-7910283 732-5363
(M 4-6, W and Sat 2-5)
ILAO, Mary 0933-6617274 0919-4448273
JAUCIAN, Imelda L. 413 2489 M -Sat 2 -6 PM 0922-8787176 0917-8800013 855-7112
JUICO, MELISSA 0922-8703045 0917-6493459
KHO, Josie N. 504 2406 Tth 10 -12 PM 0922-8787849 0917-6261432 347-7849, 242-6472
LAGAMAYO, Magdalena J. 515 2497 T 2-4 PM 0922-8237115 0917-5238228 371-0393, 374-7115
LERMA, Iluminada M. 413 2489 M-S 2-6 PM 0922-8787239 0916-5080004 742-5989
0917-8787239
LLAMAS, Agnes G. 447 2235 M – Sat 10 - 1 0922-8787124 0920-9239733 851-5840
LOPEZ, Ma. Philomena G. 415 2512 M – Sat 10 - 12 0922-8787009 0918-9105872 984-7574
MANAYSAY, Kathie 0923-2216051
MONREAL, Portia Menelia D. 419 2656 T/F 10-1 PM, Sat by apt 0917-8441880
MORAL, Rustica L. 0922-8787341 0920-9607850 721-7002, 726-1253
740-2508, 740-2986
MORAL-VALENCIA, Ma 407 2508 TTh 2-4 PM 0922-8808324 0917-6209657 726-1253
Antonina (HIJ M/F 9-12PM S12-2PM)
NOCHE, Miguel Jr. L. 416 2471 MTThFS 10-12 PM 0917-5814169 723-3679
OLONAN, Leoncia N. 438 2487 M-S 10-12 PM 0922-8787019 0917-8911954 928-8968
ONG, John A. 532 2642 TthS 9 - 12 PM 0922-8256937 0920-9073845
ONG, Remedios C. 504 2406 MWF 2 -4 PM 0922-3708687 0917-2478273 994-1820
PANGILINAN, Cathy 0917-8977445
PAULINO, Aliw P. 515 2497 M-F 10-12 PM. 4 – 6 PM 0922-8787360 0918-9395174
PE BENITO, Rhandy 0922-8543225
PERALTA, Ma. Louisa U. 503 2436 M-S 1 - 3 PM 0917-8551229 716-0860
PLATON, Karissa T. M/T 9-2 PM, Th 10-4 PM F 9-1PM 0917-3280426
PUTULIN, Anna S. 538 2396 TFS (exc 1st Sat) 10 – 12 PM 0922-9437209 0917-8970432
REGAL, Mary Agnes S. 531 2514 M-S 10-1 PM 0922-8787125 931-5852
REYES, Ma. Ruth S. 0922-8712289 0917-7165964
RIGOR, Eustacia M. 0932-2701811 0915-6286246 741-5812, 781-4167
RIVERA, Clara R. 428 2230 M-F (except Th) 2-5 PM 0922-8787217 0917-8160211 931-9398, 951-2211
RODRIGUEZ, Edwin V. 511 2452 MTh 4-6 PM 0922-8488617 0917-8976074
SALAZAR, Ma. Noemi T. 511 2452 By appointment 0922-8787238 0920-9618550 936-9344
SANTOS, Kristine Marie G 403 2274 Sat 10 – 12 PM W & F by apt 0922-8973068 0918-9019267
SANTOS, Wildredo R. 538 2396 MTWF 11-1 PM Sat 11 – 2 PM 0922-8027453 0917-5027453 438-1783
SIBULO, Ma. Carole Lisa C. 419 2656 M 4 -6 PM 0922-8787605 0917-5227653 732-7816
SY. DOLORES B. 0922-8787356 0917-7950308 807-8278, 807-3004
VILLAR, Estrellita P 0917-9495875 927-5218
RESIDENTS
HIZON, ELICE MARIE C. 09253162628
ARQUILLO, MARIA L. 09420959082
GO, JAMIE OLIVIA C. 09328472331
GO, MARY JANE TIFFANY L. 09228288773
HERNANDEZ, HAZEL ANNE H. 09334549800
LAYUG, ELBERT JOHN B. 09322293241
NEPOMUCENO, CHRISTINA C. 09435178919
PAULINO, JOHN WINSTON W. 09332179894
YU, JOHANNA CARMINA G. 09228780369
CABARLES, RAISSA BIANCA L. 09228526060
CUNANAN, TAIRA D. 09327430026
GARCIA, CATHERINE JOYCE D. 09228830464
GENEROSO, LYNETTE AZIE P. 09420106049
JAMES, NICOLE KRIS C. 09258701028
LAO, SHARIADNE DAYNE D. 09228809536
MIRASOL, ALGENE GRACE L. 09257427900
SAN JOSE, LAURICE S. 09433111472
SUAYBAGUIO, MARIA SABRINA A. 09422927280
SUDERIO, GELLINA ANN R. 09255020490
TULABOT, PAMELA G. 09430393146
VALDEZ, JOANNA ALMAVERA R. 09420267787
ANDRES, MYKA 0922 294 0184
APOSTOL, MIU 0923 424 3705 / 09260091672
CANTILLEP, ARLYN 0923 849 6012
CARPIO, IVAN JOHN 0933 298 4688
GONZALES, NHEL 0925 742 0464
IMPROGO, LALAINE 0922 890 9571/ 0917 715 5276
MALONG, APRIL JOY 0932 247 9011/ 0917 703 3597
MERQUITA, KEVIN 0933 857 0030/ 0917 868 8286
PAGUYO, MARY ABIGAIL 0917 777 1722/ 0932 873 9922
PENULIAR, KRYSTEL 0908 895 0603
RAYMUNDO, NICOLINE 0922 845 4942/ 09175720839
REYES, LISHA 0932 862 7404/ 09178802707
TAN, MERVYN 0917 529 6195/ 0922 420 5481
VALERIO, MONIQUE 0933 681 9409
BIRTHDAYS
RESIDENTS
JANUARY AUGUST
19 PAGUYO, MARY ABIGAIL 12 CABARLES, RAISSA
23 SUAYBAGUIO, SHA SEPTEMBER
FEBRUARY 1 MIRASOL, ALGENE
4 SUDERIO, GELLINA 4 PAULINO, WINSTON
12 YU, JOHANNA 5 RAYMUNDO, NICOLINE
15 TULABUT, PAMELA 9 TAN, MERVYN
MARCH 18 IMPROGO, LALAINE
8 VALDEZ, JOANNA 26 HIZON, ELICE
28 ANDRES, MYKA
APRIL
17 MALONG, APRIL JOY OCTOBER
2 SAN JOSE, LAURICE
MAY
6 CARPIO, IVAN JOHN
15 GENEROSO, LYNETTE
8 CUNANAN, TAIRA
21 MERQUITA, KEVIN
13 ARQUILLO, MARIA
JUNE 28 JAMES, NICOLE
2 LAO, SHARIADNE 31 APOSTOL, MIU
3 HERNANDEZ, HAZEL
NOVEMBER
3 PENULIAR, CHRISTEL
21 GONZALES, NHEL
27 GO, JAMIE
27 CANTILLEP, ARLYN
JULY DECEMBER
5 GARCIA, CATHERINE
3 VALERIO, MONIQUE
18 GO, MARY JANE
14 LAYUG, ELBERT
26 REYES, LISHA
21 NEPOMUCENO, TINA
CONSULTANTS
JANUARY JULY
17 CHAN, ANTONIO 4 LLAMAS, AGNES G.
21 CUASO, CHARLES 15 CARANDANG, ENRIQUE
27 LOPEZ, MA. PHILOMENA AUGUST
28 HERNANDEZ, FLERIDA 8 SY, DOLORES
FEBRUARY 16 CASTRO, REBECCA
11 FLORES, LOURDES 25 KHO, JOSIE
MARCH 26 ATIENZA, MELINDA
5 SIBULO, MA. CAROLE SEPTEMBER
7 CHIONG, MARY ANNE 11 OLONAN, LEONCIA
11 GONZALEZ, MATILDE 19 SALAZAR, MA. NOEMI
25 BUZON, ROSALIA 25 JAUCIAN, IMELDA
APRIL OCTOBER
10 FLORES, DENNIS 1 CHAN, REMEDIOS
13 ONG, REMEDIOS 11 RIVERA, CLARA
28 RODRIQUEZ, EDWIN 18 ANDAYA , AGNES
MAY 19 CABANSAG, MARIA ROSARIO
8 BERNAL, CHRISTINE 26 MORAL, RUSTICA
10 CANONIGO, BEATRICE NOVEMBER
14 ONG, JOHN 4 NOCHE, MIGUEL
28 LERMA, ILUMINADA 18 BAUZON, AURORA
JUNE 20 REGAL, MARY AGNES
3 GO. OLIVIA DECEMBER
7 CO, BENJAMIN 9 VILLAR, ESTRELLA P.
9 SANTOS, WILFREDO R. 29 PERALTA, MA LUISA
12 HERNANDEZ, EMILIO JR
JANUARY ROTATIONS
CD
225/Malward/ GI nutrition referral Ivan John Carpio
226/ ID Referral Mervyn Tan
227/ Pulmo/ Allergo Referral Monique Valerio
224 Elbert John Layug
PS/ ER senior Maria Arquillo
ER Nicoline Raymundo
Sick Child clinic Laurice San Jose/ Myca Angelique Andres
Wellness/ CPU/ Adolescent/ Genetics Marie Christel Penuliar
Nephro/ Rheuma/ Neurodev Hazel Anne Hernandez
Pulmo/ Allergo/ ID Algene Grace Mirasol
Cardio/ Endo/ Neuro Lynettte Azie Generoso
BCI/ Research John Winston Paulino
Newborn CD/ High-risk Newborn Taira Cunanan/ Raissa Bianca Cabarles/ Nhel Eric Gonzales/ Mary Rose Apostol
PD
TR Jamie Olivia Go/ Joanna Almavera Valdez/ Nicole Kris James/ Lalaine Improgo/
Mary Abegail Paguyo
PICU Maria Catherine Joyce Garcia/ Shariadnes Dayne Lao
SAW Mary Jane Go/ Maria Sabrina Suaybaguio/ Kevin Merquita/ Arlyn Cantillep
Newborn Private Johanna Carmina Yu/ Gellina Ann Suderop/ Lisha Alyanna Reyes/ April Joy Malong
Community Pamela Tulabut
ATTENDANCE: Monday to Saturday Time in 7:00 AM (6:55 AM during Wednesday and Thursday)
ACTIVITIES:
SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY
1st ADCON - CDC WARD AUDIT Grandrounds ER Con JAO Nelson Hour or
Pharmacon DSF Echo Lecture
2nd ADCON – LQF, RCO Peer Review ER Con RCO Wellness
Pharmacon DSF
3rd ADCON – CDC WARD AUDIT Grandrounds TR Con CDC, Journal Club c/o
AMV, ERA BGC
Pharmacon DSF
4th ADCON – CDC AUDIT - OPD, Peer Review ER Con AFB Neo CTB
ER, NSU/NICU. Pharmacon DSF
5th PICU alternating Pharmacon DSF
Ward Residents:
TUESDAY WEDNESDAY FRIDAY
7 – 8 AM Hematology
(FGH with Chronic Resident)
8 – 9 AM Rounds at Chronic Ward (FGH with
Chronic Resident)
9 – 10 AM Nephrology Lecture (RDC)
11 – 12 NN Nephrology (RFC with rotator)
1 – 3 PM Pharmacology (AGL w/ Acute ward residents)
OPD Residents:
MONDAY TUESDAY FRIDAY
7 – 8 AM ER Conference (OCG with OPD OPD Conference (MMA with OPD Resident) Neurology Conference (RDP with
Resident) Rotator)
1 – 2 PM Pulmonology Conference (OCG with Neurology Conference (RQD with Rotator)
OPD Resident)

Pediatric Notes Draft 12 1

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COMMON OPD DRUGS

ACUTE OTITIS MEDIA INTERTRIGO/ DIAPER DERMATITIS

INFECTIOUS DIARRHEA TINEA VERSICOLOR/ CORPORIS

* Drugs that interfere with albumin = Jaundice

ACUTE ABDOMEN INDICATION FOR FECALYSIS:

 Admit to __ under the service of Dr ____ _

POST STREPTOCOCCAL GLOMERULONEPHRITIS NEPHROTIC SYNDROME

CYCLOPHOSPHAMIDE INFUSION – NEPHROLOGY CYCLOPHOSPHAMIDE INFUSION

> Monitor vital signs every 1 hour while on cyclophosphamide

* Why give Diphenhydramine to patients taking Metoclopramide?

RETINOBLASTOMA GBM (admitted due to HTN)

LUMBAR PUNCTURE THORACENTESIS

Blood volume: Preterm 100 cc/kg

PONDERAL INDEX = (Wt in gm ÷ Lt in cm) x 100

HARRIS – BENEDICT EQUATION for RESTING ENERGY EXPENDITURE (REE)

= (10 × weight in kg) + (6.25 × height in cm) - (5 × age in years) - 161

Ideal Body Weight for OVERWEIGHT/ OBESE PATIENTS)

Ventricular Tachycardia (VTach) Asystole

Bradycardia: HQCPR, Epi, Atropine

ET SIZE (internal diameter in mm) ET DEPTH (LIP to TIP measurement in cm)

* Total Fluid Replacement (TFR) = Maintenance + Deficit

Homemade: 1L or water + ½ tsp salt + 6 tsp sugar

COMPOSITION OF APPROPRIATE ORAL REHYDRATION SOLUTIONS

ELECTROLYTE COMPOSITION OF BODY FLUIDS

Calcium 40 2 Estimated Creatinine Clearance

EFFECTIVE OSMOLALITY FLUID LIMIT

ANION GAP = Na+ - (Cl- + HCO3-) SODIUM LIMIT

Body Weight Fluids/day Hourly rate

FLUID MANAGEMENT OF DEHYDRATION:

To concoct FLUIDS: Amount of NaCl = (%) x vol

For severe symptomatic hyponatremia:

NaCl: 1gm contains 18 mmol Na

If Euvolemic, calculate water replacement required for tonicity change:

Hypernatremic Dehydration: (Nelson’s)

(Harriet) Free Water Deficit (FWD) (L)

(Chiu-Yap) FWD = [(measured Na x BW x 0.6 / desired Na] – (0.6 x BW)

TOTILAC (Hypertonic lactate)

SEVERE DENGUE MANAGEMENT:

Criteria for discharge:

 Passive immunization (Ig) lasts for 3 – 4 months

CONTRAINDICATIONS & PRECAUTIONS: TETANUS TOXOID

PPV: HIGH RISK MEDICAL CONDITIONS

VERORAB: (inactivated purified rabies vaccine prepared on vero cell line)

5 VACCINES: DTaP, Hib, Hep B

COMBINATION VACCINES: (source vaccine inserts)

LEVELS of ASTHMA CONTROL

TYPES OF ASTHMA (SEVERITY)

PREDICTED PEFR (6 – 17year old)

Height PEFR Height PEFR Dr. Ong Style:

PREFERRED INHALER DEVICE

SIX PART PROGRAM TO MANAGE AND CONTROL ASTHMA

GOALS FOR SUCCESSFUL MANAGEMENT OF ASTHMA

Acute Urticaria (<6 weeks)

Chronic Urticaria: (> 2x/ week for > 6 weeks)

NEW ASPIRIN TRIAD

AT LEAST 1 of 3 CRITERIA FULFILLED:

Pathophysiology: Skin barrier dysfunction

FUNCTIONAL CONSTIPATION K59

* Delay/ difficulty in defecation for > 2 weeks causing

* Goal: BM > 3x/week, easy BM, Bristol 4-6

HISTORY FUNCTIONAL HIRSCHPRUNG

 Severe malnutrion (z < -3)

MALWARD COMPUTATIONS / REFERENCE:

TEN STEPS TO RECOVERY Population Energy(kCal) CHON (g)

 Admit to under the service of Dr __ _