SILLIMAN UNIVERSITY MEDICAL SCHOOL

PEDIATRICS WORKSHEET
SUBMITTED TO: Dr. Desiree Reyes- Gubantes
DATE OF SUBMISSION: December 18, 2014
SUBMITTED BY:
MD III
Pasuquin, Alvin G.
Rodriguez, Arianne S.
PRESENTATION OF HISTORY
Identifying Information
This is a case of ZM, 3-month old, female, from Dumaguete City came in at Silliman Medical Center last February 16, 2014
Chief Complaint: fast breathing
HISTORY OF PRESENT ILLNESS
Condition started three weeks prior to admission when patient was noted to have occasional cough. Two weeks prior to
admission, with persistence of cough, consult was done at a local Health Center and was given Amoxicillin drops for one week,
but no relief was noted. One week prior to admission, cough persisted, this time, associated with decreased in appetite and
undocumented fever. Three days prior to admission, the patient was noted to have episodes of difficulty breathing, feeds for a
shorter period of time, accompanied by incessant crying.
Four hours prior to admission, she was noted to have fast and deep breathing, hence was brought to the ER and was admitted.
REVIEW OF SYSTEMS
Unremarkable.
BIRTH HISTORY
This baby was born term to a primigravid, 20-year-old mother in Provincial hospital, assisted by a doctor, with good cry and
activity at birth. Mother had irregular prenatal check-up but denies any illness during pregnancy. Birth weight was 3.2
kilograms. No meconium staining noted.
NEONATAL HISTORY
APGAR score was 8/9.
IMMUNIZATION HISTORY
BCG was given already at birth as well as the first dose of hepatitis B right before discharge from the hospital. First dose of
tetanus plus oral polio was given already at 6 weeks of age. Hep B2 and HiB1 were also given.
FEEDIG HISTORY
Exclusively breastfed since birth
PAST MEDICAL HISTORY
Unremarkable. The newborn screening was normal
FAMILY HISTORY
No family history of asthma, diabetes and hypertension reported.
DEVELOPMENTAL HISTORY
Social smile and head control developed at 3 months.
PHYSICAL EXAMINATION
General Survey: The patient was examined cuddled, irritable, pale looking, and in cardiorespiratory distress.
Vital Signs:
HR = 160bpm
RR = 65cpm
O2 saturation in room air = 93%
O2 saturation after O2 was given at 2 liters/min = 99%
Temperature = 38C
Anthropometric Data:
Weight = 4.2 kg
Length = 58 cm
BMI = 12.72 kg/m2
Skin:
HEENT:

No rashes. No lesions
Pale lips. No tonsillopharyngeal congestion. No oral lesions noted. No eye and ear discharges. No sunken
eyeballs. No dysmorphic features. There is presence of nasal flaring. Oral mucosa is dry.

C/L:

GUT:

Symmetrical chest expansion with shallow subcostal retractions. There are coarse rales, crackles, and
occasional wheezes on both lung fields.
The precordium is dynamic. Apex beat at 5th ICS LMCL. S1 is normal with a splitting of a 2nd heart sound. A
3/6 murmur is noted on pansystolic left lower sternal border.
Abdomen is slightly globular with normoactive bowel sounds. Liver is palpable at 2 cm below the subcostal
regions. No masses. Spleen is not palpable.
grossly female

Ext:

Cold extremities with fair pulses. CRT is 3 seconds. No edema. No clubbing. No cyanosis.

CVS:
Abd:

NEUROLOGIC EXAMINATION
Unremarkable
PRIMARY WORKING
IMPRESSION

RULE IN

RULE OUT

History:
(+) cough, (+)poor feeding, , (+) fever, (+) vomiting,
(+) poor weight gain, (+) tachypnea,
Acyanotic Heart Disease to
consider Ventricular Septal
Defect, with severe
pneumonia

Physical Exam:
(+)hypoxemia,(+) irritability ,(+) increased
respiratory rate, (+) crackles, (+) rales, (+)
wheezing, (+) cardiorespiratory distress, (+)
retractions, (+) dehydration, (+) nasal flaring, (+)
coryza, (+) pallor (+) heart murmurs

CANNOT BE RULED OUT

Labs:(+) lymphocytosis,(+) ketones, (+) chest xray, (+) 2D-echo

DIFFERENTIAL DIAGNOSES
Laryngotracheobronchitis
(Croup)

Bronchiolitis

History:
(+) cough, (+) low grade fever
Physical Exam:
(+) respiratory distress, (+) wheezing, (+)
subcostal retractions, (+) hypoxemia, (+)
dehydration, (+) tachycardia

Physical exam: (-) hypotonia, (-)

cyanosis, (-) lethargy

Labs: (+) lymphocytosis

History:
(+) feeding difficulties, (+) fever,(+) cough, (+)
tachypnea

History:
(-) congestion, (-) dyspnea, (-) cyanosis

Physical Exam: (+) irritable, (+) wheezing, (+)

nasal flaring, (+) retractions, (+) tachycardia, (+)
rales, (+) wheezing, (+) hypoxemia

Moderate Dehydration

History: (-) hoarseness, (-) barking

cough, (-) inspiratory stridor, (-)
gastroesophageal reflux

History: (+) fever, (+) decreased appetite, (+) poor

weight gain,
Physical Exam: (+) irritability, (+) tachycardia, (+)
tachypnea, (+) dry oral mucosa, (+) abnormal
capillary refill, (+) cool extremities
No laboratory test is necessary for mild to moderate
dehydration.

Physical Exam:(-) otitis media, (-)

apnea
Labs:(-) elevation of total WBC, (-) chest
radiograph showing hyperinflation,
lobar
infiltrates
and
atelectasis,
bronchial wall thickening, air trapping,
flattened diaphragm, increased AP
diameter, peribronchial cuffing, tiny
nodules, linear opacities, and patchy
alveolar opacities
History: (-) diarrhea
Physical Exam: (-) abnormal skin
turgor, (-) decreased pulse rate, (-)
sunken eyballs

Physiologic Anemia

History: (+) difficulty with oral feeding

CANNOT BE RULED OUT

Physical
Exam:
(+)
pale-looking,
(+)
cardiorespiratory symptoms such as tachycardia,
tachypnea, (+) flow murmurs
Labs: (+) low hemoglobin

RATIONAL LABORATORY & DIAGNOSTIC TESTS

LAB. TEST
NORMAL
RESULTS
TEST NECESSITY & RESULT
VALUES
INTERPRETATION
Complete Blood Count Repeat CBC 3 days after admission
Hemoglobin
9-14 g/dl
8.9 g/dl
It is used to screen, diagnose, or
13.2 g/dl
monitor a number of conditions and
(repeat)
diseases that affect RBCs, measure
the severity of anemia and to monitor
response to treatment.

Hematocrit

28-42%

29 %
40% (repeat)

WBC

5,00019,500/cumm

12,500/cumm
12,000/cumm
(repeat)

-Neutrophil(seg)

54-62%

30%
58% (repeat)

-Lymphocyte

25-33%

38%
35% (repeat)

-Monocyte

3-7%

2%
5% (repeat)

-Eosinophil

1-3%

-Basophil

0-0.75%

0%
2 (repeat)
0%

In this case, the patient has low

hemoglobin value in the first test but
went up to normal in the repeat test
3 days after admission. The low hgb
value in the first test is indicative of a
physiologic anemia because
normally, the bone marrow does not
produce new red blood cells between
birth and 3 or 4 weeks of age, causing
a slow drop in the red blood cell
count over the first 2 to 3 months of
life.
It is often used with a hemoglobin
level as a simple and quick evaluation
of RBCs.It is used to determine the
proportion of the patients blood that
is made up of red blood cells, to
screen for, diagnose, and evaluate the
severity of anemia or polycythemia.
Also used to evaluate dehydration.
In this case, the patient has normal
hematocrit value In both the first test
and the repeat test.
White blood cell count is done to
evaluate the patient when results of a
CBC fall outside the reference range
or when you have any number of
signs and symptoms that may be
related to a condition affecting white
blood cells, such as infection,
inflammation, or cancer. It is also
used when you have a condition or
are receiving treatment that is
known to affect WBCs.
Basically, this patient has normal
totalWBC count but there is elevation
in the lymphocyte count which points
out to a viral cause of an infection.

AVAILABILITY

COST
(Pesos)

SUMC, HCH,
NOPH, Private
Laboratories

250

Platelet Count

84-478/uL

254,000/uL
267, 000
(repeat)

Used to help determine the cause of

or potential for excessive bleeding, to
monitor and evaluate platelet
function, and to monitor the presence
and effectiveness of anti-platelet
medications.
In this case the patient has normal
Platelet values.

SERUM ELECTROLYTES
Potassium
3.5-6.0 mmol/L

This test is a regular part of a basic or

comprehensive metabolic panel. This
is ordered to diagnose or monitor
kidney disease since this is elevated
in kidney problems. This is also
necessary to monitor patients with a
suspected heart problems .

SUMC, HCH,
NOPH, Private
Laboratories

250

SUMC, HCH,
NOPH

50

In this case, the patient has normal

potassium level.
Urinalysis
Specific gravity:

Ketones

Protein:

WBC:

RBC:

1.016- 1.022

negative

Negative

less than 5/hpf

0-3 cells/hpf

1.015

+1

Negative

2-3

0-3

Reflect the relative degree of

concentration or dilution of a urine
specimen.
In this case, the patient has a normal
SG.
Ketone is a marker for the starvation
status of the patient.
In this case, the patient has abnormal
ketones in the urine. This means that
fat is continually being broken down
to ketones because the patient has
poor feeding and decreased appetite
resulting to poor weight gain
manifested in our patient.
Normally no protein is detectable in
urine by conventional methods,
although a minute amount is
excreted by the normal kidney. A
color matching any block greater
than 'Trace' indicates significant
proteinuria.
In this case, urine of the patient is
protein negative
This is for detection UTI and must
correlate well with the bacteria in
urine for the infection to be
considered significant.
In this case, the patient has normal
WBC in the urine.
The presence of increased numbers
of erythrocytes in the urine may
indicate a variety of urinary tract and
systemic infections.
In this case, the patient has normal

Bacteria:

Rare

few

RBC in the urine.

This is for detection UTI, but this has
to correlate well with pus cells to
confirm the infection.
In this case, the patient has few
bacteria in the urine with normal
WBC count. This means that this
result is not clinically significant. Few
bacteria is normal to be seen in the
urine.

IMAGIG STUDIES
Chest x-ray

Pneumonic
Chest radiography is considered the
infiltrates are criterion standard for diagnosing the
seen on both
presence of pneumonia. The
lung fields.
presence of infiltrate is required for
Cardiomegaly the diagnosis. It may also reveal
with
VSDs, heart size, increased cardiac
pulmonary
silhouette, etc.
congestion is
also seen.
Two-dimensional
unremarkable
CHD with left
This is used to determine the size and
echocardiography
atrial and
location of virtually all VSDs and to
with Doppler
ventricular
check for blood flow if theres
echocardiography
enlargement,
shunting. Also, this is to monitor and
good
check for ejection fraction.
(2D echo)
ventricular
function and
Doppler echocardiography provides
estimated
additional physiologic information
pulmonary
( RV pressure, PA pressure, and
pressure of
interventricular pressure difference).
60 mmHg.
OTHER LAB TESTS AND DIAGNOSTIC PROCEDURES TO ORDER
TEST
TEST NECESSITY
Blood Typing
This is essential for possible transfusions
ABG Determination
Electrocardiography
(ECG)

unremarkable

The test is used to determine the pH of the blood, the partial pressure of
carbon dioxide and oxygen, and the bicarbonate level. In pneumonia,
hypoxi and respiratory acidosis may be present.
In patients with small VSDs, ECG findings are normal.
In patients with moderate-sized VSDs and with moderate or large left-toright shunts with volume overload in the LV, LV hypertrophy is the rule.
Combined ventricular hypertrophy is common.

SUMC, HCH,
NOPH

350

SUMC, HCH,
NOPH

3,747

AVAILABILITY
SUMC, HCH,
NOPH
SUMC, HCH,
NOPH
SUMC, HCH,
NOPH

In patients with large VSDs and equal ventricular pressures, RV

hypertrophy is demonstrated. In patients with large pulmonary blood
flow, LA hypertrophy is evidenced by biphasic P waves in leads I, aVR,
and V6, with prominent negative deflection in V1.
Acute Phase
In patients with more serious disease, such as those
SUMC, HCH,
Reactants (ESR,
requiring hospitalization or those with pneumonia-associated
NOPH
CRP)
complications, acute-phase reactants may be used in
conjunction with clinical findings to assess response to
therapy.
FINAL DIAGNOSIS: Ventricular Septal Defect (VSD) with Congestive Heart Failure; Severe pneumonia; Concomitant
Moderate Dehydration; Physiologic Anemia

LIST OF PROBLEMS:
1. tachypnea
2. persistent cough
3. decreased appetite
4. poor weight gain
5. fever
6. episodes of difficulty breathing
7. feeds for a shorter period of time
accompanied by incessant crying.
8. Hypoxemia
9. tachycardia
10. pallor
11. irritability
12. cardiorespiratory distress
13. shallow subcostal retractions
14. nasal flaring
15. dry oral mucosa
16. rales, crackles, and occasional wheezes on
both lung fields.
17. murmur
18. cold extremities
19. abnormal capillary refill time

THERAPEUTICS
THERAPEUTIC OBJECTIVES:
1. The infant will be free from further complications of condition.
2. The infant will be normothermic.
3. Febrile convulsions are prevented.
4. The infant will be free from anemia.
5. Absence of cough.
7. Minimize frequency and severity of respiratory infections.
8. The infant will achieve its high degree of wellbeing.
9. Normalize infants growth and development.
10. Control the symptoms of heart failure to allow the baby time to
grow.
11. Increase comfort and decrease parental anxiety.

MANAGEMENT
PARENTS ADVICE AND INFORMATION

Educate the parents/guardians about the babys condition: possible etiology, risk factors, course of disease, signs and
symptoms, complications if left untreated, prognosis and medical options for treatment including its benefits, side
effects, risk and alternatives. Increasing their knowledge about the childs condition to improve medical compliance
and assist in symptom management.
Emphasize importance of medication compliance in optimum management of his condition.
Provide parents with instruction about management of their childs condition. This will empower them to care for
their child.
Educate the parents of the advantages of breastfeeding.
Educate the parents about the importance of immunizations.
Emphasize that the baby is on trust vs. mistrust stage: the needs must be met for a healthy emotional development.

NON-PHARMACOLOGIC MANAGEMENT
Admit. Children and infants who have moderate to severe CAP, as defined by several factors, including respiratory
distress and hypoxemia (sustained saturation of peripheral oxygen, 90 % should be hospitalized for management,
including skilled pediatric medical care.
Vital signs monitoring q 2h. Rectal temperatures are the gold standard for measuring central body temperature
Monitoring Pulse oximetry with or without cardiac monitoring
Place the child on NPO temporarily for an 8-hour-observation
Start Venoclysis with D5 0.3% Sodium Chloride at 20 cc/hr
Provide neutral environmental temperature. Avoid hot or cold extremes which increase oxygen and energy demands
Nutrition: Increase caloric density of feedings to ensure adequate weightv gain. Initiate orogastric feeding (OGT) with
expressed breastmilk 30 cc every 3 hours, increasing gradually to every 3 hours. More than 150 kcal/kg per day
Transfuse packed RBC. Possible red blood cell transfusion for significant anemia in the setting of heart failure, poor
weight gain and respiratory difficulties.
Elevate the head via carrier/ pillows. Positioning of the infant to minimize aspiration risk
Bronchial hygiene: Pulmonary toilet may include chest physiotherapy, positioning to promote dependent drainage,
and incentive spirometry to enhance elimination of purulent sputum and to avoid atelectasis.
Allow rest periods between care; disturb only when necessary for care and procedures.
Assess usual family coping methods and effectiveness.

POSSIBLE SURGERY
INTRACARDIAC REPAIR OF DEFECT
The symptoms of children with heart failure from left-to-right shunts can improve with medical therapy, postponing and possibly
avoiding the need for surgical correction. However, despite maximum medical management, 50 percent of patients with moderate
to large VSDs continue to have tachypnea and or/failure to thrive. These patients undergo surgical closure in infancy, preferably
before six months of age
Indications
Infants <6 months (<3 months for those with trisomy 21) who have uncontrolled heart failure despite maximal
medical and dietary interventions or who have pulmonary hypertension.
Children with a persistent significant shunt (Qp:Qs >2:1) with elevated PA pressures should undergo surgical repair.
Children with a persistent significant shunt and normal PA pressures may be considered for surgical closure.
Subpulmonic and membranous defects, regardless of size, with aortic regurgitation should be surgically corrected
before the aortic valve is permanently damaged.

Drug Name
Efficacy
OXYGEN ADMINISTRATION
O2 inhalation
at 2 L per nasal
cannula

ANTIBIOTICS
Cefuroxime
450 mg IV q8 for
7 days

PHARMACOLOGIC MANAGEMENT
Safety

The therapy increasing the supply

of oxygen to the lungs and thereby
increasing the availability of
oxygen to the body tissues,
especially when the patient is
suffering from hypoxia and/or
hypoxaemia. O2 diffuses through
membranes in the lungs and into
red blood cells. Hemoglobin binds
O2, changing its color from bluish
red to bright red.

Side Effects
Prolonged exposure to high
inspired fractions of oxygen
causes damage to the retina.

Cefuroxime has in vitro activity

against a wide range of grampositive
and
gram-negative
organisms, and it is highly stable
in the presence of beta-lactamases
of certain gram-negative bacteria.
The
bactericidal
action
of
cefuroxime results from inhibition
of cell-wall synthesis.

Side Effects
Diarrhea. Decreased
haemoglobin or hematocrit,
nausea, vomiting, transient rise
in hepatic transaminase,
diaper rash,

Precaution
Oxygen should be used with
caution since it is a pulmonary
vasodilator and may decrease
PVR, increasing left-to-right
shunt, and exacerbating failure

Precaution
Bacterial or fungal overgrowth
of nonsuceptible organisms
may occur with prolonged or
repeated therapy

Suitability

Cost

Oxygen is used as a
medical treatment in
both chronic and acute
cases, and can be used
in
hospital,
prehospital or entirely out
of hospital, dependent
on the needs of the
patient.
diminished
blood oxygen levels
(oxygen
saturation
levels of <92%) is an
indication
for
an
oxygen
supplementation.
Empiric antimicrobial
therapy
must
be
comprehensive
and
should cover all likely
pathogens. Cefuroxime
has
been
recommended as a
component
of
treatment
for
community-acquired
pneumonia

Contraindications
Documented hypersensitivity
ANTIPYRETIC
Paracetamol
(TEMPRA
FORTE)
drops 100 mg/ml
0.5 ml every 4

Endogenous pyrogens produced

by leukocytes cause an elevation
of prostaglandin E (PGE) in the
cerebrospinal fluid. Fever results
when the elevated PGE acts on the
preoptic area of the anterior

Side Effects
Angioedema, dizziness, pruritic
maculopapular rash, Steven
Johnson syndrome, Toxic
epidermal necrolysis, urticaria,
gastrointestinal hemorrhage,

Paracetamol
is
approved for reducing
fever in people of all
ages.

P447
80
mg/0.8
ml

hours for
temperature 37.8
C and above

hypothalamus to decrease heat

loss and increase heat gain.
TEMPRA FORTE has been shown
to inhibit the action of endogenous
pyrogens on the heat-regulating
centers in the brain by blocking
the formation and release of
prostaglandins in the central
nervous system.6-9 Inhibition of
arachidonic acid metabolism is not
requisite for the antipyretic effect
of paracetamol.

leukopenia. Neutropenia,

The pharmacologic effects of betaadrenergic agonist drugs,

including albuterol, are at least in
part attributable to stimulation
through beta-adrenergic receptors
of intracellular adenyl cyclase, the
enzyme that catalyzes the
conversion of adenosine
triphosphate (ATP) to cyclic-3',5'adenosine monophosphate (cyclic
AMP). Increased cyclic AMP levels
are associated with relaxation of
bronchial smooth muscle and
inhibition of release of mediators
of immediate hypersensitivity
from cells, especially from mast
cells.

Side Effects
Tremor, nausea, fever,
bronchospasm, vomiting,
headache, dizziness, cough,
allergic reactions, epistaxis,
dry mouth,

It is a loop diuretic which inhibits

reabsorption of sodium and
chloride ions at the proximal and
distal renal tubules and loop of
Henle. By interfering with
chloride-binding cotransport
system, causes increases in water,
calcium, magnesium sodium and
chloride.

Side Effects
Hyperuricemia, hypokalemia,
anaphylaxis, anemia, anorexia,
diarrhea, dizziness, glucose
intolerance, glycusoria,
headache, hypotension,
hypomagnesemia, muscle
cramps, photosensitivity, rash,
restlessness, weakness

Syrup

Precaution
Use with caution in patients
with G6PD deficiency
Contraindications
Hypersensitivity and severe
active liver disease

BRONCHODILATOR
Salbutamol
(VENTOLIN)
nebulisation
every 6 hours

Bronchodilator
treatments such as
albuterol may or may
not be required
depending on your
symptoms.

P659.80

Precaution
Risk of hypokalemia,
Paradoxical bronchospasm
may occur
Contraindications
Tachycardia secondary to a
heart condition

LOOP DIURETICS
Furosemide
(LASIX) 4 mg IV
every 12 hours

They are used in the

treatment of
hypertension, heart
failure and hepatic,
renal, pulmonary
disease when salt and
water rentention has
resulted in edema/
ascites.

Precaution
Agent is a potent diuretic, that,
if given in excessive amounts,
may lead to profound dieresis
with water and electrolyte
depletion. There is risk of
ototoxicity.
Contraindications
Anuria, documented
hypersensitivity to furosemide
or sulfonamides
ACE INHIBITORS
Captopril

CAPOTEN prevents the conversion

Side Effects

ACE inhibitors are

P430

(CAPOTEN)
2 mg/pptab every
12 hours

of angiotensin I to angiotensin II
by inhibition of ACE, a
peptidyldipeptide carboxy
hydrolase. Inhibition of ACE
results in decreased plasma
angiotensin II and increased
plasma renin activity (PRA), the
latter resulting from loss of
negative feedback on renin release
caused by reduction in angiotensin
II. The reduction of angiotensin II
leads to decreased aldosterone
secretion,
Systemic vascular resistance may
increase in children with VSD for a
variety of reasons. In this setting,
antegrade flow through the aortic
valve decreases and left-to-right
shunting through the defect
increases. Afterload reducing
agents, such as the angiotensin
converting enzyme inhibitors
captopril or enalapril are used to
reduce systemic vascular
resistance, promoting antegrade
flow through the aortic valve and
decreasing the magnitude of the
shunt

Hyperkalemia, hypersensitivity
reactions, skin rash, dysgeusia,
hypotension, pruritus, cough,
chest pain, palpitations,
proteinuria and tachycardia
Precaution
Risk of hyperkalemia
especially with Potassium
sparing diuretics

used to treat
congestive heart
failure. They may be
used to treat systemic
afterload. This
medication reduces
both systemic and
pulmonary pressure,
thereby reducing the
left-to-right shunt.

Contraindications
CAPOTEN is contraindicated in
patients who are
hypersensitive to this product
or any other angiotensinconverting enzyme inhibitor

INOTROPIC AGENTS
Dopamine
Hydrochloride
(DOPAMAX)
5 ug/kg/min

Digoxin
(LANOXIN) 50
mcg/ml given at
0.3 ml every 12

Dopamine is a natural
catecholamine formed by the
decarboxylation of 3,4dihydroxyphenylalanine (DOPA).
Dopamine produces positive
chronotropic and inotropic effects
on the myocardium, resulting in
increased heart rate and cardiac
contractility. This is accomplished
directly by exerting an agonist
action on beta-adrenoceptors and
indirectly by causing release of
norepinephrine from storage sites
in sympathetic nerve endings.
Dopamine 's onset of action occurs
within five minutes of intravenous
administration, and with plasma
half-life of about two minutes, the
duration of action is less than ten
minutes.

All of digoxin's actions are

mediated through its effects on
Na-K ATPase. This enzyme, the
sodium pump, is responsible for
maintaining the intracellular

Side Effects
ventricular arrhythmia (at very
high doses), ectopic beats,
tachycardia, palpitation,
cardiac conduction
abnormalities, widened QRS
complex, bradycardia,
hypotension, hypertension,
vasoconstriction, dyspnea,
nausea, vomiting
Precaution
Careful monitoring required Close monitoring of the
following indices-urine flow,
cardiac output and blood
pressure
Contraindications
This should not be
administered in the presence
of uncorrected
tachyarrhythmias or
ventricular fibrillation.
Side Effects
Nausea, vomiting, abdominal
pain, intestinal ischemia, and
hemorrhagic necrosis of the
intestines, headache,

DOPAMINE is
indicated for the
correction of
hemodynamic
imbalances present in
the shock syndrome
due to myocardial
infarctions, trauma,
endotoxic septicemia,
open heart surgery,
renal failure, and
chronic cardiac
decompensation as in
congestive failure.

LANOXIN increases
myocardial
contractility in
pediatric patients with

per box
of 50s

hours

milieu throughout the body by

moving sodium ions out of and
potassium ions into cells. By
inhibiting Na-K ATPase,
digoxin causes increased
availability of intracellular calcium
in the myocardiumand conduction
system, with consequent
increased inotropy, increased
automaticity, and reduced
conduction velocity
indirectly causes parasympathetic
stimulation of the autonomic
nervous system, with consequent
effects on the sino-atrial (SA) and
atrioventricular (AV) nodes

weakness, dizziness, apathy,

confusion, and mental
disturbances

heart failure.

Precaution
The earliest and most frequent
manifestation of digoxin
toxicity in infants and children
is the appearance of cardiac
arrhythmias, including sinus
bradycardia.
Contraindications
LANOXIN is contraindicated in
patients with ventricular
fibrillation

DISCHARGE

The infant is eligible for discharge when she has documented overall clinical improvement, including level of activity,
appetite, and decreased fever for at least 1224 hours.
Infant is eligible for discharge when she demonstrates consistent pulse oximetry measurements .90% in room air for
at least 1224 hours.
Clinicians should demonstrate that parents are able to administer and children are able to comply adequately with
taking those antibiotics before discharge.
MONITORING AND FOLLOW-UP

Emphasized SO the importance of regular follow-up check-ups and as instructed by physician.

Infants should be followed every two weeks to assess growth parameters. Over time, if nutritional needs are not met,
the infant's length and head circumference may be affected
Patient should be followed-up with a chest radiograph in approximately 6 weeks to ensure resolution of consolidation
and to assess persistent abnormality of the lung parenchyma.
Parents need to be aware that affected infants who may or may not have been anemic at birth are at considerable risk
for developing clinically significant anemia during the first 3-4 months of life. Their baby should have weekly
hematocrit and reticulocyte counts performed and receive simple packed erythrocyte transfusions (20-25 mL/kg of
PRBCs) if clinical symptoms appear if Hb levels fall below 6-7 gm/dL without evidence of a reticulocytosis, i.e.,
reticulocyte count <1%, or <100,000 per L.
Monitor vital signs regularly.
Monitor for progression or worsening of condition.
Advised SO to seek medical advice if any unusuality arises
Encouraged the mother to keep an environment clean and conducive to health for the rapid recovery of infant and to
avoid infection and keep environment quiet to make the patient comfortable
Monitor infant feeding status
Infants with heart failure should undergo non-invasive anatomic evaluation. If failure does not respond to medical
therapy, complete repair is undertaken. If failure responds to medical therapy, including a satisfactory rate of growth,
the infant is followed closely through the first year of life; if pulmonary artery resistance is elevated, intracardiac
repair is performed in the first six months of life. Children with normal PVR, but with a significant left-to-right shunt
should have surgery by one year of age
In children with repaired VSD, which required the use of prosthetic material or device, prophylactic antibiotics are
recommended for dental and respiratory tract procedures during the first six months after the repair.
Administration of the influenza vaccine is suggested for all such children who are older than six months of age.

PRESCRIPTION:
Alvin Pasuquin, MD
Silliman University Medical Center
Name:________________________________ Age/Sex:______________
Address:___________________________ Date: ________________

___________________________
SIGNATURE
Arianne Rodriguez, MD
Silliman University Medical Center
Name:________________________________ Age/Sex:______________
Address:_____________________________ Date: ________________

___________________________
SIGNATURE

Alvin Pasuquin, MD
Silliman University Medical Center
Name:________________________________ Age/Sex:______________
Address:___________________________ Date: ________________

___________________________
SIGNATURE
Arianne Rodriguez, MD
Silliman University Medical Center
Name:________________________________ Age/Sex:______________
Address:___________________________ Date: ________________

___________________________
SIGNATURE

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Atienza, M. et al. (2006). Guide for history taking, physical examination and diagnosis of pediatric patients. 2nd ed. UST.
Philippines.
Bickley, A. et. Al. (2009).BatesGuide to Physical Examination and History Taking. 10thed.
Chernecky, C & Berger B., (2008). Laboratory Test and Diagnostic Procedures. 5th ed. Saunders Elseviers: Philadelphia
Fauci, A. et Al. (2012). Harrisons Principles of Internal Medicine. 18th ed. McGraw-Hill
Medical Publishing Division, USA.
Kliegman, R.M. et al. (2012). Nelson textbook of pediatrics. 19th ed. Elsevier Saunders. Singapore.