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APGAR
LENGTH / HEIGHT
(50 cm) Age Transverse-AP 0 1 2
Inches Blue / Pink body/ Blue Completely
Diameter ratio A
Age Centimeters Inches At Birth 1.0 Transverse = AP Pale extremities pink
At Birth 50 20 1y 1.25 Transverse > AP P Absent Slow (<100) > 100
1y 75 30 6y 1.35 Transverse >>> AP Coughs,
(-)
2-12 mo Age x 6 + 77 Age x 2.5 + 30 G Grimaces Sneezes,
Response
Cries
FONTANELS (-) Some flexion / Active
A
Age Gain in 1st Year is ~ 25cm Movement extension movement
0-3 mo + 9 cm 3 cm per mo Appropriate size at birth: 2 x 2 cm (anterior) Good,
R Absent Slow / Irregular
Closes at: Anterior = 18 months, or as early strong cry
3-6 mo + 8 cm 2.67 per mo
6-9 mo + 5 cm 1.6 cm per mo as 9-12 months
8 10: Normal
Posterior = 6 8 weeks or
9-12 mo + 3 cm 1 cm per mo 4 7: Mild / Moderate Asphyxia
2 4 months
0 3: Severe asphyxia
VACCINE AGE DOSE # ROUTE SITE INTERVAL BCG 1. Wheal small abscess ulceration healing / scar formation in
BCG-1 Birth 0.05mL 1 ID R- 12 wks
or 6 wks (NB) Deltoid 2. Deep abscess formation, indolent ulceration, glandular enlargement,
0.1mL suppurative lymphadenitis
(older) DPT 1. Fever, local soreness
DPT 6 wks 0.5mL 3 IM Upper 2. Convulsions, encephalitis / encephalopathy, permanent brain
Outer damage
thigh OPV Paralytic Polio
OPV 6 wks 2 drops 3 PO Mouth 4 wks HEPA B Local soreness
HEPA B 6 wks 0.5mL 3 IM Antero- 4 wks MEASLES 1. Fever & mild rash
lateral 2. Convulsions, encephalitis / encephalopathy, SSPE, death
thigh
MEASLES 9 mos 0.5mL 1 SC Outer 4 wks ACTIVE PASSIVE
upper BCG Diphtheria
arm DPT Tetanus
BCG-2 School entry 0.1mL 1 ID L- OPV Tetanus Ig
Deltoid Hep B Measles Ig
TetToxoid Childbearing 0.5mL 3 IM Deltoid 1 mo then Measles Rabies (HRIg)
Hib Hep A Ig
women 6-12 mos
MMR Hep B ig
Tetanus Toxoid Rubella Ig
Varicella
H.E.A.D.S.S.S. H.E.A.D.S.S.S. NUTRITION
Sexual activities Home Environment AGE WT. CAL CHON
Sexual orientation? With whom does the adolescent live? 0-5 mo 3-6 115 3.5
GF/BF? Typical date? Any recent changes in the living situation? 8-11 mo 7-9 110 3.0
Sexually active? When started? # of persons? How are things among siblings?
Contraceptives? Pregnancies? STDs? 1-2 y 10-12 110 2.5
Are parents employed? 3-6 y 14-18 90-100 2.0
Are there things in the family he/she wants to
Suicide/Depression 7-9 y 22-24 80-90 1.5
change?
Ever sad/tearful/unmotivated/hopeless? 10-12 y 28-32 70-80 1.5
Thought of hurting self/others? Employment and Education 13-15 y 36-44 55-65 1.5
Suicide plans? Currently at school? Favorite subjects? 16-19 y 48-55 45-50 1.2
Patient performing academically?
Safety Have been truant / expelled from school? TCR = Wt at p50 x calories
Use seatbelts/helmets? Problems with classmates/teachers? TCR = CHON X ABW
Enter into high risk situations? Currently employed?
Member of frat/sorority/orgs? Future education/employment goals? Total Caloric Intake : calories X amount of
Firearm at home? intake (oz)
Activities
What he/she does in spare time? Gastric Capacity : age in months + 2
F.R.I.C.H.M.O.N.D. Patient does for fun?
Whom does patient spend spare time? Gastric Emptying Time : 2-3 hours
Fluids Hobbies, interests, close friends?
Respiration 1:1 1:2
Infection Drugs Alacta Bonna
Cardiac Used tobacco/alcohol/steroids? Enfalac Nursoy
Hematologic Illicit drugs? Frequency? Amount? Lactogen Promil
Metabolic Affected daily activities? Lactum S-26
Output & Input [cc/kg/h] N: 1-2 Still using? Friends using/selling? Nan Similac
Neuro
Diet Nestogen SMA
Nutraminogen
Pelargon
Prosobee
Habit 1: Be Proactive
Habit 2: Begin with the end in mind
Habit 3: Put First Things First
Habit 4: Think Win-Win
Habit 5: Seek first to understand and
then to be understood
Habit 6: Synergize
Habit 7: Sharpen the saw
EXPECTED LA SALLIAN
GRADUATE ATTRIBUTES
(ELGA)
Up to 6 mo: 1 half tab per day for 10-14 days reassess after 6 hrs (infant) & 3 hrs (child)
6 months or more: 1 tab or 20mg
OD x 10-14 days
3. Continue feeding
4. Know when to return
TREATMENT PLAN B
CHILDS WT (kg) x 25
if the child wants more ORS than shown, give more
give frequent small sips from a cup
if the child vomits, wait for 10 min then resume
continue breastfeeding whenever the child wants
AFTER 4 HOURS
reassess the child & classify dehydration status
select the appropriate plan to continue treatment
begin feeding the child while at the clinic
ORS
Glucolyte 60 Pedialyte 45 0r 90
ETIOLOGY OF PNEUMONIA
Bacterial
- Streptococcus pneumoniae
- Group B streptococci (neonates)
ARI PROTOCOL (PROGRAM FOR THE CONTROL OF ARI)
- Group A streptococci
- Mycoplasma pnemoniae (adolescents)
- Chlamydia trachomatis (infants)
- Mixed anearobes (aspiration pneumonia)
- Gram negative enteric (nosocomial pneumonia)
Viral
- Respiratory syncitial virus
- Parainfluenza type 1-3 (Croup)
- Influenza types A, B
- Adenovirus
- Metapneumovirus
Fungal
- Histoplasma capsulatum (bird, bat contact)
- Cryptococcus neoformans (bird contact)
Child Age 2months up to 5years
- Mucormycosis (immunosuppressed)
- Coccidioides immitis
- Blastomyces dermatitides
- Pneumocystis carinii (immunosuppressed,
HIV, steroids)
SMR GIRLS
LUDANS METHOD (HYDRATION THERAPY) Stage Pubic Hair Breasts
1 Preadolescent Preadolescent
MILD MODERATE SEVERE Sparse, lightly pigmented, straight, Breast & papilla elevated, as small
DEHYDRATION DEHYRATION DEHYDRATION 2
medial border of labia mound, areola diameter increased
< 15 kg, < 2 y/o 50 cc/kg 100 cc/kg 150 cc/kg Breast & areola enlarged, no contour
3 Darker, beginning to curl, amount
> 15 kg, 2 y/o 30 cc/kg 60 cc/kg 90 cc/kg separation
D5 0.3% in st
1 hr: Plain LR 1st hr: Plain LR 4
Course, curly, abundant but amount < Areola & papilla formed secondary
6-8 hours Next 5-7 hrs: Next 5-7 hrs: adult mound
D5 0.3% in D5 0.3% in Adult, feminine triangle, spread to Mature, nipple projects, areola part of
5
5-7 hours 5-7 hours medial surface of thigh general breast contour
DENGUE PATHOPHYSIOLOGY
> Neonates (<1mo) - RSV
- GBS - Other respiratory viruses
- E. coli - Streptococcus pneumoniae
- other gram (-) bacilli - Haemophilus influenzae (Type B)
- Streptococcus pneumoniae - C. trachomatis
- Haemophilus influenza (Type B) - M. pneumoniae
- Group A Streptococcus
> 1-3 months - Staph aureus
* Febrile pneumonia
- RSV > 2-5 yrs
- Other respiratory viruses - Streptococcus pneumoniae
- Streptococcus pneumoniae - Haemophilus influenzae (Type B)
- Haemophilus influenza (Type B) - C. trachomatis
- M. pneumoniae
* Afebrile pneumonia - Group A Streptococcus
- Chlamydia trachomatis - Staph aureus
- Mycoplasma homilis
- CMV
> MOT: mosquito bite (man as reservior) Biphasic fever (2-7 days) with 2 or more of the ff: Manifestations of DHF plus signs of circulatory failure
1. rapid & weak pulse
> Vector: Aedes aegypti 1. headache 2. narrow pulse pressure (<20mmHg)
2. myalgia or arthralgia 3. hypotension for age
> Factors affecting transmission: 3. retroorbital pain 4. cold, clammy skin & irritability / restlessness
- breeding sites, high human population density, 4. hemorrhagic manifestations
mobile viremic human beings [petechiae, purpura, (+) torniquet test]
5. leukopenia DANGER SIGNS OF DHF
> Age incidence peaks at 4-6 yrs
1. abdominal pain (intense & sustained)
> Incubation period: 4-6 days Dengue Hemorrhagic Fever (DHF) 2. persistent vomiting
3. abrupt change from fever to hypothermia
> Serotypes: 1. fever, persistently high grade (2-7 days) with sweating
- Type 2 most common 2. hemorrhagic manifestations 4. restlessness or somnolence
- Types 1& 3 - (+) torniquet test
- Type 4 least common but most severe - petechiae, ecchymoses, purpura
- bleeding from mucusa, GIT, puncture sites Grading of Dengue Hemorrhagic Fever
> Main pathophysiologic changes: - melena, hematemesis
a. increase in vascular permeability 3. Thrombocytopenia (< 100,000/mm3)
4. Hemoconcentration
extravasation of plasma - hematocrit >40% or rise of >20% from baseline
- hemoconcentration - a drop in >20% Hct (from baseline) following
- 3rd spacing of fluids volume replacement
- signs of plasma leakage
b. abnormal hemostasis [pleural effusion, ascites, hypoproteinemia]
- vasculopathy
- thrombocytopenia
- coagulopathy
> Hyperkalemia may be seen due to Na+ retention - 10 days of Oral Penicillin or Erythromycin
> Ca++ decreases in PSAGN - IM Injection of Benzethine Penicillin
> in ASO titer
- normal within 2 weeks
- peaks after 2 weeks
- more pronounced in pharyngeal infection
than in cutaneous
B. Secondary Prevention
C. Duration of Chemoprophylaxis
KAWASAKI DISEASE
TREATMENT SEIZURES
CDC-CRITERIA FOR DIAGNOSIS:
ADOPTED FROM KAWASAKI Currently Recommended Protocol:
(ALL SHOULD BE PRESENT) > Seizures: sudden event caused by abrupt,
A. IV-Immunoglobulin uncontrolled, hypersynchronous
A) HIGH Grade Fever (>38.5 Rectally) PRESENT discharges of neurons
for AT LEAST 5-days without other Explanation 2g/kg Regimen Infusion EQUALLY Effective in
High Grade Fever of at least 5 days Prevention of Aneurysms and Superior to 4-day > Epilepsy: tendency for recurrent seizures that are
DOES NOT Respond to any kind of Antibiotic! Regimen with respect to Amelioration of Inflammation unprovoked by an immediate cause
as measured by days of
B) Presence of 4 of the 5 Criteria Fever, ESR, CRP, Platelet Count, Hgb, and Albumin > Status epilepticus: >30min or back-to-back
1. Bilateral CONGESTION of the Ocular Conjunctiva w/o return to baseline
(seen in 94%) NOTE: There is a TIME FRAME of 10 days
2. Changes of the Lips and Oral Cavity (At least ONE) > Etiology:
3. Changes of the Extremities (At least ONE) - V ascular : AVM, stroke, hemorrhage
4. Polymorphous Exanthem (92%) B. Aspirin - I nfections : meningitis, encephalitis
5. Cervical Adenopathy = Non-Suppurative Cervical - T raumatic :
Adenopathy (should be >1.5cm) in 42%) HIGH Dose ASA (80-100mg/kg/day divided q 6h) - A utoimmune : SLE, vasculitis, ADEM
should be given Initially in Conjunction with IV-IG - M etabolic : electrolyte imbalance
HARADA Criteria THEN - I diopathic : idiopathic epilepsy
- used to determine whether IVIg should be given Reduced to Low Dose Aspirin (3-5mg/kg/day) - N eoplastic : space occupying lesion
- assessed within 9 days from onset of illness AND - S tructural : cortical malformation,
1. WBC > 12,000 Continued until Cardiac Evaluation COMPLETED prior stroke
2. PC <350,000 (approximately 1-2 months AFTER Onset of Disease) - S yndrome : genetic disorder
3. CRP > 3+
4. Hct <35%
5. Albumin <3.5 g/dL
6. Age 12 months
7. Gender: male
UMBILICAL CATHERIZATION
NEWBORN RESUSCITATION Cathether length
Indications Standardize Graph
AIRWAY: open & clear Vascular access (UV) Perpedicular line from the tip of the shoulder to
Positioning Blood Pressure (UA) and blood gas monitoring in the umbilicus
Suctioning critically ill infants Measure length from Xiphoid to umbilicus and add
Endotracheal intubation (if necessary) 0.5 to 1cm.
Complications Birth weight regression formula
BREATHING is spontaneous or assisted Infection Low line : UA catheter in cm = BW + 7
Tactile stimulation (drying, rubbing) Bleeding High line : UA catheter = [3xBW] + 9
Positive-pressure ventilation Hemorrhage UV catheter length = [0.5xhigh line] + 1
Perforation of vessel
CIRCULATION of oxygenated blood is adequate Thrombosis w/ distal embolization Procedure
Chest compressions Ischemia or infarction of lower extremities, bowel Determine the length of the catheter
Medication and volume expansion or kidney Restrain infant and prep the area using sterile
Arrhythmia technique
Air embolus Flush catheter with sterile saline solution
Place umbilical tape around the cord. Cut cord
RESUSCITAION MEDICATIONS Cautions about 1.5-2cm from the skin.
Never for: Identify the blood vessels.
Omphalitis (1thin=vein, 2thick=artery)
Atropine 0.02 ml/k IM, IV, ET
Peritonitis Grasp the catheter 1cm from the tip. Insert into the
Bicarbonate 1-2 meq/k
Contraindicated in vein, aiming toward the feet.
Calcium 10 mg elem Ca/k slow IV NEC Secure the catheter
Calcium chloride 0.33/k (27 mg Ca/cc) Intestinal hypoperfusion Observe for possible complications
Calcium gluconate 1 cc/k (9 mg Ca/cc)
1g/k = 2 cc/k D50 Line Placement
Dextrose
4 cc/k D25 Arterial line
Epinephrine 0.01 cc/k IV, ET Low line
Tip lie above the bifurcation between L3 & L5
High line
Tip is above the diaphram between T6 & T9
BILIRUBIN
PRETERM:
mg/dl mmol/L
0-1 hr 1-6 17-100
1-2 d 6-8 100-140
3-5 d 10-12 170-200
TERM
mg/dl mmol/L
0-1 hr 2-6 34-100
1-2 d 6-7 100-120
3-5 d 4-12 70-200
1 mo <1 <17
SERUM
ZONE JAUNDICE
BILIRUBIN
I Head & neck 6-8
Upper trunk
II 9-12
to umbilicus
Lower trunk
III 12-16
to thigh
Arms, legs,
IV 15
below
V Hands & feet 15
MKD COMPUTATION
LUMBAR PUNCTURE To diagnose other medical conditions such as:
viral and bacterial meningitis Wt x mkd x preparation [mg/mL] = mL per dose
the technique of using a needle to withdraw syphilis, a sexually transmitted disease
cerebrospinal fluid (CSF) from the spinal canal. bleeding around the brain and spinal cord e.g. 12kg x 10mg x 5ml = 5mL per dose
multiple sclerosis, (affects the myelin coating of 120mg
SPINE the nerve fibers of the brain and spinal cord)
spinal cord stops near L2 Guillain-Barr syndrome, (inflammation of the * If per day, divide total (mL) by the # of divided doses
lower lumbar spine (usually between L3-L4 or nerves)
L45) is preferable Dose x preparation x frequency = mkd
Complication weight
CSF Local pain
clear, watery liquid that protects the central Infection
nervous system from injury Bleeding Paracetamol Drops = Wt: move 1 decimal
cushions the brain from the surrounding bone. Spinal fluid leak point to the left
It contains: Hematoma (spinal subdural hematoma Age Wt
glucose (sugar) Spinal headache 1 10 kg
protein Acquired epidermal spinal cord tumor 2 12
white blood cells 3 14
Rate : 500ml/day or 0.35ml/min Caution & Contraindications 4 16
Range : 0.3-04 ml/min Increased ICP 5 18
Volume : 50ml (infants) Bleeding diasthesis 6 20
150ml (adults) Traumatic Tap
Overlying skin infection 1 drop = 1/20 mL
Indication Unstable patient 1 teaspoonful = 5 mL
to diagnose some malignancies (brain cancer and 1 tablespoonful = 15 mL
leukemia) 1 wineglassful = 60 mL = 2 ounces
to assess patients with certain psychiatric 1 glassful = 250 mL = 8 ounces
symptoms and conditions. 1 grain = 60 mg
for injecting chemotherapy directly into the CSF 1 pint = 500 mL
(intrathecal therapy) 1 quart = 1000 mL
1 ounce = 30 mL
1 Kg = 2.2 lbs
1 lb = 0.45359 Kg
Empirical dose
6 months tsp TID QID
Procedure 6 mos 2 yrs tsp
Apply local anesthetic cream (ideally) 2-6 1 tsp
Position the patient 6-9 1 tsp
Prepare the skin using sterile techniques 9-12 2 tsp
Anesthetize the area with lidocane
Puncture the skin in the midline just caudal to the
spinus process, angle cephalad toward the
umbilicus using a g23 needle
Collect the CSF for analysis
CSF Analysis
1. Gram stain, culture and sensitivity
2. Cell count, differential count
3. Chemistries sugar, protein
4. Special studies
After care
Cover the puncture site with a sterile bandage,
apply pressure packing.
Patients must remain lying down for 4-6 hours
NPO for 4 hrs
CLINICAL FEATURES
CLASSIFICATION BASED ON SEVERITY
RESPIRATORY
MILD MODERATE SEVERE
ARREST
PERSISTENT - talking
INTERMITTENT
MILD MODERATE SEVERE - INF: softer, - at rest
Affects daily Affects daily Limits daily shorter, cry, - INF: stops
- walking
Exacerbation Brief activity & activity & activity & Breathless difficulty feeding Imminent
- can lie down
sleep sleep sleep feeding - hunched
Day-time Sxs <1x/wk >1x/wk daily continuous - prefers forward
Nightime Sxs <2x/mo >2x/mo >1x/wk frequent sitting
PEFR >80% >80% 60 - <80% <60% Talks in sentences phrases words
PEFR VAR <20% 20 - 30% >30% >30% may be usually usually drowsy /
Alertness
FEV1 >80% >80% 60 - <80% <60% agitated agitated agitated confused
often >30
RR bradypnea
mins
Accessory
(+) thoracoabd
muscles & none (+) (+)
movement
retractions