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REVIEWER FOR PEDIA OSCE

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ANTHROPOMETRIC MEASUREMENTS 5. Ears
CASE: You have a 1-year old patient and you are asked to compute for the - Position? Low-set ears?
range of ideal values of the following: - Pre-auricular tags?
6. Mouth
1. Weight: 10.5 kg
- Cleft lip? Cleft palate?
2. Head Circumference: 45.16 cm / 17.8 in
- Epstein pearls?
3. Length: 75 cm
- Natal teeth?
4. Approximate number of teeth: six
- Macroglossia?
(A rough rule of thumb is that the age in months minus six gives the average
number of teeth, up to age 2 years.) 7. Neck
- Masses? (e.g., Cystic hygromas, etc)
IDEAL WEIGHT - Clavicular fracture?
Age Kilograms Pounds 8. Chest
At Birth 3kg (Fil) - Tachypnea? Retractions? Barrel-chest?
7 - Breasts?
3.35kg (Cau)
9. Abdomen
3-12 mo Age (mo) + 9 / 2 Age (mo) + 10 (F)
- Omphalocele? Gastroschisis?
Age (mo) + 11 (C)
- Shape? Scaphoid may indicate diaphragmatic hernia
1-6 y Age (y) x 2 + 8 Age (y) x 5 + 17
- Distended? Tender? Presence of masses?
7-12 y Age (y) x 7 – 5 / 2 Age (y) x 7 + 5 - Umbilicus: number of artery and vein? Normal is one artery, two veins
(AVA)
Given Birth Weight: 10. Inguinal Region and Genitalia
Age Using Birth Weight in Grams (Male)
< 6 mo Age (mo) x 600 + birth weight (gm) - Hypospadia? Epispadia? Chordee?
6-12 mo Age (mo) x 500 + birth weight (gm) - Penile length?
- Hydrocele?
LENGTH / HEIGHT - Testes palpable? Cryptorchid?
Age Centimeters Inches (Female)
At Birth 50 20 - size and location of labia, clitoris, etc
1y 75 30 - Discharge?
2-12 y Age x 6 + 77 Age x 2.5 + 30 11. Hips
- check for congenital hip dislocation
Age Gain in 1st Year is ~ 25cm - Perform Ortolani and Barlow maneuvers
0-3 mo + 9 cm 3 cm per mo
3-6 mo + 8 cm 2.67 per mo
6-9 mo + 5 cm 1.6 cm per mo
9-12 mo + 3 cm 1 cm per mo

HEAD CIRCUMFERENCE
Age Inches Centimeters
At Birth 13.8 in 35 cm
< 4 mo + 2 in (1/2 inches / mo) + 5.08cm (1.27cm / mo)
5-12 mo + 2 in (1/4 inches / mo) + 5.08cm (0.635cm / mo)
1-2 yrs + 1 inch 2.54 cm
3-5 yrs + 1.5 in (1/2 inches / year) + 3.81cm (1.27cm / yr) 12. Extremities
6-20 yrs + 1.5 in (1/2 inches / 5 years) + 3.81cm (1.27cm / 5 yrs) - Syndactyly? Polydactyly?
- Simian crease?
NEWBORN CARE - Clubfoot?
Physical Examination of the Newborn 13. Trunk and Spine
1. Skin - Abnormal pigmentation? Hairy patches?
- Color (Plethoric? Jaundice? Pallor? Cyanosis?) - Sacral dimpling?
- Mottling? 14. Anus and Rectum
- Vernix caseosa? - Patency
- Rashes and Birthmarks 15. Nervous System
2. Head - muscle activity and tone?
- Note the general shape of the head
o Caput succedaneum PERFORM THE FOLLOWING:
o Cephalhematoma • Ophthalmic Antibiotic Ointment
o Molding - Prevents ophthalmia neonatorum)
- Inspect for any cuts, bruises secondary to forceps or fetal monitor - Wipe the eyes
leads - Apply an eye antimicrobial (Erythromycin) within 1 hour of birth
- Check the size of the head (microcephalic? Macrocephalic?) • Vitamin K administration
- Fontanels (diamond-shaped anterior; triangular posterior) - Administer Vitamin K 0.5-1 mg IM upper outer quadrant (vastus
lateralis) of the thigh
- To prevent hemorrhagic disease of the newborn
• Took the weight (Average Filipino birth weight: 3 kg)
• Anthropometric measurements
o Birth length (N: 50 cm)
o Head circumference (N: 33-38 cm)
o Chest circumference
o Abdominal circumference
• Check the patency of the anus
• Check the temperature
• Assure proper temperature maintenance

ESSENTIAL NEWBORN CARE (ENC) / UNANG YAKAP


3. Eyes
1. Immediate drying
- Presence of hypertelorism
2. Uninterrupted skin-to-skin contact
- Subconjunctival hemorrhages?
3. Proper cord clamping and cutting
4. Nose
4. Non-separation of the newborn from the mother for early breastfeeding
- Nasal deformation?
initiation and rooming-in
- Asymmetry of the nares?
- Choanal atresia? (Unilateral? Bilateral?)
PHYSICAL EXAMINATION FINDINGS IN A NEWBORN 4. After 5 minutes of resuscitation, the baby is seen with blue
ACROCYANOSIS: cyanosis of hand and feet specially when cool, due to extremities and pink body, HR of 150, coughs and sneezes with
vasomotor instability and peripheral circulatory sluggishness active motor movement and with good strong cry. Give the
LANUGO: Fine, soft, immature hair that frequently covers the scalp and brow and APGAR score. 9
may also cover the face of premature infants; replaced by vellus hair in the term
infant 0 1 2
VERNIX CASEOSA: a white, cream cheese–like substance that serves as a skin Appearance/ Pink body/ Blue
lubricant; usually noticeable on a newborn’s skin at birth in a term neonate; Blue / Pale Completely pink
Color extremities
composed of lipid secretion and desquamated stratum corneum cells; Pulse/Heart
spontaneously shed within 2-3 days after birth Absent Slow (<100) > 100
Rate
MILIARIA CRYSTALLINA: asymptomatic, noninflammatory, pinpoint, clear Coughs,
vesicles may suddenly erupt in profusion over large areas of the body surface, Grimace (-) Response Grimaces
Sneezes, Cries
leaving brawny desquamation on healing Activity/ Some flexion / Active
CAPUT SUCCEDANEUM: a diffuse, sometimes ecchymotic, edematous swelling (-) Movement
Muscle tone extension movement
of the soft tissues of the scalp involving the area presenting during vertex delivery. Respiration Absent Slow / Irregular Good, strong cry
It may extend across the midline and across suture lines. The edema disappears
within the 1st few days of life.
CEPHALOHEMATOMA: a subperiosteal hemorrhage, hence always limited to
the surface of 1 cranial bone.

BALLARD SCORING SYSTEM

Steps in Newborn Resuscitation:


1. Provide warmth
2. Position; clear airway (as necessary)
3. Dry
4. Stimulate by gently rubbing back or flicking the soles
5. Reposition
6. If breathing, HR > 100, cyanotic?
• Give oxygen
7. If persistently cyanotic, HR <100, or apneic?
• Give positive pressure ventilation
8. If HR <60?
• Do chest compressions
9. If still HR <60 after 30 sec of compressions
• Give epinephrine
10. If thickly, limp, and bradycardic?
• Do endotracheal suctioning

ESSENTIAL CHARACTERISTICS OF PERINATAL ASPHYXIA


1. Profound metabolic or mixed academia (pH <7) on an umbilical cord
arterial blood sample
2. Persistence of an APGAR score of 0-3 for > 5 minutes
3. Clinical neurologic sequelae in the immediate neonatal period to include
seizures, hypotonia, coma, or hypoxic-ischemic encephalopathy
4. Evidence of multi-organ system dysfunction in the immediate neonatal
period (for example, cardiovascular, gastrointestinal, hematological,
pulmonary, or renal)

NEWBORN SCREENING
CASE: A relative of a 48-hour neonate knocks at the door of the NICU asking
NEWBORN RESUSCITATION questions about newborn screening.
CASE: You were assigned to catch a baby at the NICU. On the first minute
of resuscitation, the baby is seen with blue extremities and pink body, HR of 1. What are the six conditions tested in NEWBORN SCREENING?
110, grimaces a bit with some flexion of extremities, and slow, irregular Enumerate and give at least 1 clinical manifestation of each.
respiration. Glucose-6-Phosphate Hemolytic anemia à jaundice, anemia,
Dehydrogenase Deficiency renal failure
1. What comprises your APGAR Score? Galactosemia Cataract; liver failure
a. Appearance Congenital Hypothyroidism Macroglossia; hypothermia; Puffy eyelids,
b. Pulse coarse hair, myxedema
c. Grimace
Congenital Adrenal Hyperplasia Virilized girls and failure to thrive
d. Activity
Phenylketonuria Mousy odor with mental retardation
e. Respiration
Maple Syrup Urine Disease sweet-smelling urine, seizure
2. Give the APGAR score: 6
3. How will you resuscitate the baby?
a. Provide warmth 2. This act is also known as the “Newborn Screening Act of 2004”
b. Position, clear airway Republic Act 9288
c. Dry, stimulate, reposition
d. Give O2 Presidential Proclamation No. 540 declares the first week of October of each
year as National Newborn Screening Week.
NEWBORN SCREENING TEST TREATMENT: (based on Dr. W. Santos’ lecture)
• Blood collected after 24 hours from birth Early Onset
• If infant is <24 hours old when specimen is collected, it must be repeated • In the initial treatment of neonatal sepsis it is best to begin
before 14 days old antimicrobial therapy with ampicillin or penicillin in combination
• The heel is the most frequently used site to collect a sample of blood with aminoglycoside. This combination is effective for the majority of
neonatal pathogens.
UMBILICAL CANNULATION Late Onset
Indications: • Vancomycin
- Vascular access (via UV) • Aminoglycoside
- Blood pressure monitoring (via UA) • Amphotericin B (for fungal)
- Blood gas monitoring (via UA) ü The duration of parenteral antibiotic therapy should be 10-14 days.
ü In the presence of meningitis, antibiotic treatment should be given for 14-21
Complications: infection, bleeding, hemorrhage, perforation of vessel;
days.
thrombosis with distal embolization; ischemia or infarction of lower extremities,
bowel, or kidney; arrhythmia if catheter is in the heart; air embolus NEONATAL JAUNDICE
Caution: UA catheterization should never be performed if omphalitis or peritonitis
is present. Contraindicated in the presence of possible necrotizing enterocolitis or
intestinal hypoperfusion
Line Placement:
a. Arterial Line: Low line vs high line
• Low line: The tip of the catheter should lie just above the aortic
bifurcation between L3 and L5
• High line: The tip of the catheter should be above the diaphragm
between T6 and T9
b. UV catheters should be placed in the inferior vena cava above the level of
the ductus venosus and the hepatic veins and below the level of the right Indirect Hyperbilrubinemia: Yellowish
atrium Direct Hyperbilirubinemia: Greenish
c. Catheter length: Determine the length of catheter required using either a
standardized graph or the regression formula. Add length for the height of PHYSIOLOGIC JAUNDICE PATHOLOGIC JAUNDICE
the umbilical stump • Onset ≥ 24 HOL usually on the 3rd day • Early onset < 24 HOL
• Standardized graph: determine the shoulder-umbilical length by of life • TSB increasing more than 5
measuring the perpendicular line dropped from the tip of the shoulder • TSB increasing less than 5 mg/kg/day mg/kg/day
to the level of the umbilicus • Decline to adult levels by the 10th to • TSB concentration exceeding 12.9
• Birth weight (BW) regression formula: 12th day of life mg/dL (FT) and >15 mg/dL (PT)
Low line: UA catheter length (cm) = BW (kg) + 7 • DSB > 2 mg/dL or 20% of TSB (total
High line: UA catheter length (cm) = [3 x BW (kg) + 9] serum bilirubin)
UV catheter length (cm) = [0.5 x high line UA (cm)] + 1 • Persists > 1 wk (FT) or >2 wks (PT)
Steps: [

1. Secure consent BREASTFEEDING JAUNDICE BREASTMILK JAUNDICE


2. Position infant and prepare materials • Occurs in the first week of life • Occurs beyond the first week of life
3. Determine the shoulder-umbilical length and the catheter length needed to • Starvation jaundice until the 3rd week of life
place the tip between the diaphragm and LA • Can be prevented by frequent • Extension of physiologic jaundice
4. Put gloves on breastfeeding • Enhanced enterohepatic absorption
5. Restraint infant, clean, drape, and cut umbilical stump of UCB of unidentified factors in
6. Catheter placement: place marker on catheter at desired length human milk which inhibits hepatic
7. Flush catheter with sterile saline solution glucoronosyl transferase
8. Insert the catheter • β-glucoronidase converts back
9. Collect specimen conjugated bilirubin to unconjugated
10. Secure catheter with both a suture through the cord bilirubin
NEONATAL SEPSIS NECROTIZING ENTEROCOLITIS
Case: A 14-day-old infant, 3.1 kg, born to a 23 G1P1 (1001) via VSD at home ü Most common life threatening emergency in neonatal period
came to your clinic for consult. Patient was noted to have poor suck with 2- ü Characterized by various degrees of mucosal and transmural necrosis
3 episodes of vomiting per day. On day of consult, patient was noted to be ü Cause is multifactorial
febrile.
Risk Factors
1. Immaturity (Prematurity)
1. Diagnosis: Neonatal Sepsis, Late Onset
2. Infection (Bacterial Colonization)
2. Plan:
3. Ischemia (Intestinal Ischemia/Asphyxia)
a. Supportive: IVF
4. Intake (Enteral feeding)
b. Diagnostics: CBC-PC, CRP, Blood CS
5. Immunology
c. Therapeutics: Ampicillin, Gentamycin
Manifestations: Abdominal distention, Gastric residuals/vomiting, Lethargy,
EARLY ONSET LATE ONSET LATE, LATE ONSET Neutropenia/thrombocytopenia, Guaiac (+) (stool occult)
Time of Onset Birth to 7 days 7 – 30 days > 30 days Treatment:
usually <72 hours • No specific treatment
Intrapartum Often present Usually absent Usually absent • Mostly supportive:
complication ü Fluids/electrolyte
Transmission Vertical: maternal Vertical: Environment/ ü Withhold feeding
genital tract Postnatal community ü Antibiotics (ampicillin/gentamicin/metronidazole)
environment • Indication for surgery: perforation
Clinical Fulminant course, Insidious, focal Multisystem or focal
Manifestations multisystem infection,
involvement, meningitis
pneumonia (common)
(common)
Prematurity is the most important neonatal factor predisposing to infection

DIAGNOSTICS:
• Culture from normal sterile sites: blood, CSF, urine
• CBC-PC with differentials
• C-reactive protein (CRP)
• Radiographs (CXR)
• Fluid Analyses: CSF
DIAPHRAGMATIC HERNIA DTaP/DTwP*
• Given IM
• 6 – 10 – 14 wk
• Min age: 6 weeks
• Min interval: 4 weeks
• 4th dose given as early as 12months of age, provided minimum interval of
6months from 3rd dose
• 5th dose 4th yr old (may not be given if 4th dose was administered at age 4
years or older)
*DTaP= diptheria and tetanus toxoids and acellular pertussis vaccine
DTwP= diptheria and tetanus toxoids and whole cell pertussis vaccine

OPV/IPV
• OPV given Per orem (PO) - 2 drops
• IPV given IM
• 6 – 10 – 14
IMMUNIZATION • Min age: 6 weeks
From Must-Know-Lecture... YOU MAY SKIP THIS and JUST STUDY THE TABLE ON THE NEXT PAGE... • Min interval: 4 weeks
Expanded Program of Immunization Vaccines of DOH Philippines (10) • Final dose: 4th birthday and at least 6months from previous dose
1. BCG vaccine • If 4 or more doses have been given prior to age 4 years, an additional dose
2. Hep B vaccine should be administered at age 4-6years
3. DTwP – Hib - HepB
4. OPV/ IPV HAEMOPHILUS INFLUENZAE TYPE B CONJUGATE VACCINE
5. Rotavirus vaccine • Given IM
6. Measles vaccine • 6w – 10w – 14w – 12month – 4yr
7. MMR vaccine • Min age: 6 weeks
8. PCV • Min interval: 4 weeks
9. Td • If 1st dose was given between 7-11months of age
– 2nd dose should be given at least 4 weeks later
Vaccines for Special Groups – 3rd dose at least 8 weeks from 2nd dose
1. JE vaccine • A Booster dose given 12-15months with an interval of 6 months from 3rd dose
2. Cholera vaccine • One dose should be considered for unimmunized children aged 5 year or older
3. Meningococcal vaccines (MCV4/ MPSV4) who have:
4. Typhoid Vaccine – Sickle cell disease
5. Rabies Vaccine – Leukemia
6. Penumococcal Vaccine (PCV/ PPV) – HIV
– Splenectomy
All infants should be immunized except in these three rare situations:
1. Anaphylaxis or a severe hypersensitivity reaction is an absolute ROTAVIRUS VACCINE
contraindication to subsequent doses of a vaccine. Persons with a known • Given per orem (PO)
allergy to a vaccine component should not be vaccinated. • 1st dose: 6 weeks of age
2. Do not give BCG or yellow fever vaccine to an infant who exhibits the • Last dose: not later than 32 weeks of Age
signs and symptoms of AIDS. Other vaccines should be given. • Monovalent Human Rotavirus Vaccine (RV1) given as 2 doses series
3. If a parent strongly objects to an immunization for a sick infant, do not • Pentavalent Human Bovine Rotavirus Vaccine (RV5) given as 3 doses series
give it. Ask the mother to come back when the infant is well. • Min interval: 4 weeks between doses
BACILLUS CALMETTE-GUERIN MEASLES VACCINE
• Intradermal (ID) • Given subcutaneously (SC)
• Earliest possible age after birth, preferably within the first 2 months of life • Age: 9 months
• For infants >2months who are healthy, PPD prior to BCG is not necessary • May be given as early as 6 months of age in cases of outbreaks
• PPD is recommended in infants > 2months prior to BCG if:
– Suspected congenital TB MMR VACCINE
– History of close contact to known or suspected infectious cases of TB • Given SC
– Clinical findings suggestive of TB • Min age: 12 months
– CXR suggestive of TB • 2 doses recommended
Note: PPD induration 5mm is POSITIVE • Children <12months of age given any measles containing vaccine (measles,
• Dose: MR, MMR) should be given 2 additional doses of MMR
– <12 months: 0.05ml – 1st dose 12-15months and should be separated by at least 4 weeks from
– >12 months: 0.1ml measles containing vaccine
– 2nd dose 4-6yrs (But may be administered at an earlier age provided the
HEPATITIS B VACCINE interval between 1st and 2nd is at least 4weeks)
• Given Intramuscular (IM) In EPI, 2nd dose of MMR given to public school students (13 yr old / 1st year high school)
• 0 – 4 – 10 – 14
• Min Age: birth PNEUMOCOCCAL VACCINE (PCV/ PPV)
• 1st dose should be given first 12 hours of life and counted as part of 3-dose • Given IM
primary series • 6 – 10 – 14 – 12months ++
• Subsequent doses are given at least 4 weeks apart • Min Age:
• 3rd dose preferably given >24 weeks of age – PCV: 6weeks
• 4th dose is needed if: – PPV: 2 years of age
– 3rd dose is given <24weeks • 1st vaccination PVC – 3 doses, interval 4 weeks + booster at 6 month after 3rd
– Preterm <2kg whose 1st dose given at birth dose
In EPI schedule, Hepa B is given as monovalent at birth then subsequent doses are given at • Healthy children 2-5 years old who have no previous PCV, may be given 1
6, 10, 14 weeks of age as combination vaccine containing DTwP/HepB/HiB
dose of PVC13 or 2 doses of PCV10, at least 8 weeks apart
• For healthy children, no additional doses of PPV are needed if the PCV series
Hepatitis B Vaccine in Newborn
is completed
• Preterm infants born to HBsAg(-) mothers who are medically stable
• For high risk children ≥2 years of age, PPV is recommended after completing
– may be given 1st dose of HBV @ 30days of chronologically age regardless
the PCV series (Special Groups)
of weight, counted as part of 3 dose primary series
• If Mother is HBsAg(+)
– HBV and HBIg should be given within 12hours of life
• If Mother HBsAg status is unknown
– Give HBV within 12hours
– Determine mother HBsAg as soon as possible
– If HBsAg(+) give HBIg no later than 7days of age
Min Min 3. What is the earliest time to request for urine culture, blood
Vaccine Route Site Dose Schedule
Age Interval culture, and stool culture?
Right 0.05 mL (<12m) a. Urine: after the first week
BCG ID At birth b. Blood: 40-60% first week
deltoid 0.1 mL (>12m)
Antero- c. Stool: after the first week
lateral 4. What drug can you give to this patient?
Hepa B IM 0.5 mL 0–4–10–14 Birth 4 wks Ceftriaxone
aspect of
thigh 5. At what dose will you give this drug?
Upper 50-100 mkD OD IV
outer 6. Give 3 complications of this disease
DPT IM 0.5 mL 6–10–14 6 wks 4 wks a. Intestinal perforation
aspect of
thigh b. Toxic encephalopathy
OPV PO Mouth 2 drops 6–10–14 6 wks 4 wks c. Toxic myocarditis
IPV IM 6–10–14 6 wks 4 wks
6w–10w– TREATMENT: (based on Dra. Cantimbuhan’s lecture)
HiB IM 6 wks 4 wks • Chloramphenicol: 50-100 mkD q6-q8 PO
14w-12m–4y
Rotavirus PO 6 wks 4 wks Alternative drugs:
Outer part • TMP-SMZ 8mg/k/D ÷ 2 doses X 14 days
Measles SC of upper 0.5 mL 9 mos • Amoxicillin 100mg/k/D PO ÷ 3 doses x 14 days
arm • Ampicillin 200 mg/k/D ÷ 4-6 doses x 14 days
MMR SC 12 mos 4 wks • Cefixime 15- 20 mkd for 7- 14 days
PCV IM 6 – 10 – 14 – 6 wks • Azithromycin 8-10 mkd for 7 days
PPV IM 12months ++ 2 yrs Suspected Resistant Strains :
From Dra. Tetangco’s lecture • Cefotaxime: 150 - 200 mg/k/d q hours
• Ceftriaxone: 100 mg/k/d OD x 5-7 days
• Ciprofloxacin: 20-30 mg/k/D ÷ 2 doses x 7-10 days

DENGUE FEVER
CASE: A 7-year old male came for consult at the ER with a chief complaint
of fever. History revealed 4-day fever, moderate to high-grade, associated
with anorexia, body malaise, and petechiae on abdomen and extremities.
PE: Findings showed irritable patient, (+) hepatomegaly with epigastric
tenderness, weak pulses, and cold clammy extremities. At present patient is
afebrile with BP = 100/90 mmHg.

1. Give your complete diagnosis: Dengue Severe


2. Bases for your diagnosis:
a. 4-day fever
b. anorexia
c. petechiae on abdomen and extremities
d. hepatomegaly
e. epigastric tenderness
f. weak pulses
g. cold clammy extremities
h. narrow pulse pressure: 10 mm Hg
3. Management modalities:
a. Diagnostics: CBC-PC; Dengue Duo
b. Therapeutics: Paracetamol for fever
c. Intravenous fluid resuscitation with crystalloid or colloid solution

PEDIATRIC INFECTIOUS DISEASES


TYPHOID FEVER
CASE: A 4-year old child presented with a 5-day history of high-grade
remittent fever, headache, and abdominal pain. No cough and colds noted.
On physical exam T = 39C, RR = 30 cpm, HR = 130 bpm, BP = 100/60 mmHg,
with epigastric tenderness upon palpation of abdomen.

1. Impression: Typhoid Fever


2. What laboratory exams would be useful? Give at least three.
a. CBC
b. Salmonella Test
c. Fecalysis
d. Urinalysis
CASE: A 10-month-old child with 3-day history of diarrhea and vomiting
came in at the ER. Upon PE, patient is awake but restless with slightly
sunken eyeballs, slightly dry oral mucosa, good skin turgor, drinks eagerly.
Vital signs: HR=120; RR=35; T=37.5; Wt=8 kg.

1. Diagnosis: Acute Gastroenteritis with Mild Dehydration (Some


Dehydration)
2. Rehydrate patient using WHO Treatment Plan: 800 mL of ORS in 4 hrs
3. If patient refuses to drink and requires admission, compute for
required fluid administration: 8 kg x 50 cc/kg= D5 0.3% NaCl 400 cc to
run for 6-8 hours

DIARRHEAL DISEASES

MANAGEMENT ACCORDING TO DEGREE OF DEHYDRATION


This is based on Dr. Gorospe’s lecture.
DEGREE OF
SIGNS FLUIDS FEEDING
DEHYDRATION
Volume per volume
replacement
Suitable home
or after each diarrheic
fluids (not salty or
stool: Usual diet or
highly sweetened),
None 50-100 ml (1/4-1/2 cup) formula, continue
ORS, rice water,
if < 2yrs; breastfeeding
vegetable or
100-200 ml (1/2 -1 cup)
chicken soup
if 2-10 yrs; ad libitum for
older children
Breastfeeding, full-
Slightly dry mucus
strength cow milk or
membrane, increased ORS, 30-50 ml/kg
Mild lactose-containing
thirst, slightly reduced in 4-6 hrs
formula, undiluted
urine flow
lactose-free formula
Sunken eyes, sunken
fontanel, loss of skin ORS, 60-90 ml/kg
Moderate Same as above
turgor, dry mucus in 4-6 hrs
membrane
Signs of moderate IV or intraosseus
dehydration plus one or fluids
more of the following: (Ringer’s lactate or
Begin after clinically
rapid, thready pulse, NSS), 30ml/kg in ½
Severe improved and ORS
cyanosis, rapid hr (1 hr for infants)
has begun
breathing, delayed then 70 ml/kg in 2
capillary refill time, ½ hrs (5 hrs for
lethargy, coma infants)
The approximate amount of ORS required (in ml) can also be calculated by multiplying
patient’s weight in kg by 75.

ANTIMICROBIALS USED TO TREAT SPECIFIC CAUSES OF DIARRHEA


ANTIBIOTIC ANTIBIOTIC
CAUSE ALTERNATIVE CAUSE ALTERNATIVE
OF CHOICE OF CHOICE
Tetracycline Furazolidone TMP-SMX 5 Pivmecillinam
12.5 mg/kg QID x 1.25 mg/kg QID x mg/kg TMP & 25 20 mg/kg QID x 5 days
3 days OR 4days OR mg/kg SMX BID x
Shigella 5 days OR
Cholera
TMP-SMX 5 Erythromycin dysentery Ampicillin 25 Fluoroquinolones
mg/kg TMP & 25 12.5 mg/kg QID x 3 mg/kg QID x 5
mg/kg SMX BID x days days
3 days
Metronidazole Metronidazole
10 mg/kg TID x 5 5 mg/kg TID x 5
Amoebiasis Giardiasis
days (10 days for days
severe cases)
Recommendations: 20 mg of Zn supplements for 10- 14 days for children with acute
diarrhea; 10 mg per day for infants < 6 months old

PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA


HOLIDAY-SEGAR METHOD (MAINTENANCE)
CASE: A 2-year old child was brought to the ER due to a week's history of
WEIGHT TOTAL FLUID REQUIREMENT
productive cough and colds. PE revealed a drowsy child with signs of
0 - 10 kg 100 mL / kg
dehydration. Mouth breathing was noted, nailbeds were dusky, RR = 76
11- 20 kg 1000 + [ 50 for each kg in excess of 10 kg] cpm, (+) chest indrawing, and on auscultation, coarse rales were audible on
> 20 kg 1500 + [ 20 for each kg in excess of 20 kg] both lung fields.
LUDAN’S METHOD (HYDRATION THERAPY) 1. Diagnosis: Pediatric Community Acquired Pneumonia (PCAP) – D
MILD MODERATE SEVERE 2. Common Etiologies:
DEHYDRATION DEHYRATION DEHYDRATION a. Streptococcus pneumoniae
< 15 kg 50 cc/kg 100 cc/kg 150 cc/kg b. Haemophilus influenza
> 15 kg 30 cc/kg 60 cc/kg 90 cc/kg c. Respiratory Syncytial Virus (RSV)
1st hr: ¼ Plain LR 1st hr: ⅓ Plain LR 3. Immediate Interventions:
D5 0.3% in a. Nebulize
Next 5-7 hrs: ¾ D5 0.3% Next 5-7 hrs: ⅔ D5
6-8 hours b. Oxygen
in 5-7 hours 0.3% in 5-7 hours
c. Intravenous fluid
4. List down your plan of action:
a. Admit the patient to critical care unit
b. Refer to specialist
c. Diagnostics: Chest x-ray AP/L, CBC PC
d. Supportive: Nebulization, Paracetamol, Fluids
e. Therapeutics:
- Penicillin G (100, 000 units/kg/day in 4 divided doses) is the
drug of choice
• Diagnostics:
1. Urinalysis: hematuria (≥5/hpf), proteinuria, pyuria
2. Hematology/Blood Chemistry: dilutional anemia, normal/increased BUN/Crea, dilutional
hyponatremia, in severe cases à hyperkalemia, hypocalcemia, hyperphosphatemia, metabolic
acidosis
3. Serology
- Antistreptolysin-O: rises 10-14 days after strep pharyngitis
- Anti-DNAse B: single most sensitive indicator of previous strep infection
- Serum C3: depressed in 90-100%; not correlated with severity, sites of infection, nor eventual
outcome; normalizes in 6—8 wks; persistently low levels à suggestive of chronic GN
• Management:
1. Supportive: bedrest, limitation of physical activity; salt restriction (≤2g/day), fluid limitation
(insensible water loss plus previous 24h urine output [half if with diuretics])
2. Drug Therapy: diuretics, anti-hypertensives, antibiotics (controversial; penicillin/erythromycin if
(+) coexistent infection with GN)
3. Monitoring: daily weight, I&O, BP
• Resolution:
o Gross hematuria: 2-3 weeks
o Microscopic hematuria: 6-12 months
o Proteinuria: 3-6 months
o Serum Complement C3: 6-8 weeks
WHO Age-Specific Criteria for Tachypnea o Histologic: 1-2 years
AGE RR
2-12 mos >50 CASE: A 7-year-old male came in to the ER due to sudden onset of tea-
1-5 years >40 colored urine, decreased urination, and edema of extremities. History
>5 years >30 revealed presence of fever, occasional cough, hoarseness, painful
swallowing, and watery secretions.
On examination:
BP=140/90 mmHg; HR=96 bpm; RR= 22 cpm; T=37.8OC
Anicteric sclerae, puffy eyelids, no TPC, no CLAD
SCE, no retractions, no crackles, no wheezes
Adynamic precordium, NRRR
Non-distended abdomen, NABS, soft, nontender, no organomegaly, no
CVA tenderness
(+) scrotal edema
(+) bipedal edema Gr 2-3, no cyanosis, full and equal pulses

1. Primary Working Impression: Acute Glomerulonephritis, Oliguric Phase


2. Currently the patient is at what period of illness? Oliguric Period

URINARY TRACT INFECTION


UTI, Suspect Pyuria or WBC of >5/hpf or 10 mm3
UTI, Probable (-) urine culture; lower colony counts
UTI, Confirmed (+) urine culture >100,000 CFU/mL of a single organism

Most common etiology: Escherichia coli

KAWASAKI DISEASE
CLINICAL CRITERIA:
FEVER persisting at least 5 days or more PLUS presence of at least 4 or more of the
#CasesPaMore: principal features:
Cases Impression • Bilateral conjunctival injection without exudates
• Changes in the lips and oral cavity (Oropharyngeal)
9 months old; RR= 56 with chest indrawing PCAP C • Polymorphous exanthem
2 years old; RR= 50 with coarse crackles PCAP B • Changes in extremities
2 months old; RR= 50 Normal • Cervical lymphadenopathy (>1.5 cm in diameter)
6 months old; RR= 60 with central cyanosis and PCAP C
chest indrawing
1 month old; RR= 65 with chest indrawing Neonatal pneumonia, severe
ACUTE GLOMERULONEPHRITIS (AGN)
Refers to a variety of renal diseases characterized by sudden onset of:
ü Edema ü Hematuria – gross or ü Oligoanuria
significant microscopic
ü Hypertension ü Proteinuria ü Azotemia
In a previously well child

POST-STREPTOCOCCAL ACUTE GLOMERULONEPHRITIS (PSAGN)


• Delayed non-suppurative complication of pharyngeal or skin infection with certain
nephritogenic strains of GABHS.
• Nephritogenic strain can be serotyped according to the antigenic properties of the
M–protein found in the outer portion of the bacterial wall.
• Usually follows Skin (serotype M-49) and Throat (serotype M-12) infection. TYPES OF KAWASAKI DISEASE
• Pathophysiology: • COMPLETE TYPE – presence of fever ≥5 days plus 4 of the clinical criteria
Glomerular immune complex deposition à glomerular infiltration by inflammatory cells à ê basement • INCOMPLETE TYPE/ATYPICAL – presence of fever of ≥5 days plus less than 4 of
permeability à ê glomerular filtration surface area à ê GFR à salt and water retention à ECF the clinical criteria AND coronary artery dilatation on 2D echocardiography
volume expansion à edema/generalized circulatory congestion
• Typical Course:
EARLY
LATENT OLIGURIC DIURETIC
CONVALESCENCE
1-14 days* 7-10 days 7-10 days 7-10 days
Latent period for Complications: BP normalizes and there Residual gross or
post-pharyngitis is - HPN Enceph is progressive clinical significant microscopic
1-2 weeks; for - CHF improvement hematuria
pyoderma is 2-6 - AKI Gross hematuria may Shows improved well
weeks start to improve being
• Manifestations:
1. Hematuria: RBC hemolysis due to glomerular capillary wall leakage
2. Edema: due to fluid retention
3. Hypertension: increased intravascular or ECF volume
4. Cerebral symptoms: related to increased BP
5. Oligoanuria: due to decreased GFR
6. Cardiopulmonary: due to increased ECF (relative hypervolemia)
7. Anemia: due to hemodilution
8. Renal Insufficiency: due to endothelial swelling and PMN leukocyte infliltration
TREATMENT (KAWASAKI DISEASE) FEBRILE SEIZURES
1. IVGG 2 gm/kg single infusion 10 -12 hours
2. ASA 80–100 mg/kg/day in 4 divided doses until afebrile for 2 – 3 days
3. ASA 3–5 mg/kg/day once daily for 6 – 8 weeks
4. If fever persists after 48 hours or recrudescence of fever within 2 weeks,
• 2nd dose IVGG 2 gm/kg
• 3rd dose IVGG 2 gm/kg, if no response
• Methylprednisolone 30 mg/kg daily for 1-3 days based on clinical/ laboratory marker for
inflammation

CASE: A 3-year-old male came in with a 5-day history of high fever,


remittent with appearance of maculopapular rash on trunk. PE revealed
bilateral conjunctivitis, erythema of oral and pharyngeal mucosa with
unilateral cervical lymphadenopathy. HR=115; RR=20; T=39

1. Diagnosis: Kawasaki Disease, Complete Type, in Acute Phase ALTERATIONS IN THE LEVEL OF CONSCIOUSNESS
2. Etiology: Unknown although clinical and epidemiological features CASE: A 7-year-old male came in at the ER with a 3-week history of high-
strongly suggest an infectious cause grade remittent fever. Patient was noted to be irritable 2 weeks prior and 1
3. Phase of the Clinical Course: Acute Phase hour prior to consult had 1 episode of seizure. On PE, patient is drowsy, eye
4. Complications: Giant aneurysm, Myocarditis opening upon painful stimuli, localizes pain, and moans. CT Scan revealed
calcifications on the basal cisterns, dilated ventricles with cerebral edema.
LUMBAR PUNCTURE
• technique of using a needle to withdraw cerebrospinal fluid (CSF) from the 1. GCS Score: E2V2M5 = 9
spinal canal 2. Impression: TB Meningitis
GCS
SPINE Function Infants/Young Older
• spinal cord stops near L2 Eye Opening 4- Spontaneous Spontaneous
• lower lumbar spine (usually between L3-L4 or L4–5) is preferable 3- To speech To speech
2- To pain To pain
CSF 1- None None
Verbal 5- Appropriate Oriented
• clear, watery liquid that protects the central nervous system from injury
4- Inconsolable Confused
• cushions the brain from the surrounding bone. 3- Irritable Inappropriate
• It contains: 2- Moans Incomprehensible
– glucose (sugar) 1- None None
– protein Motor 6- Spontaneous Spontaneous
– white blood cells 5- Localize pain Localize pain
• Rate: 500ml/day or 0.35ml/min 4- Withdraw Withdraw
3- Flexion Flexion
• Range: 0.3-0.4 ml/min 2- Extension Extension
• Volume: 50ml (infants); 150ml (adults) 1- None None

Indications THERAPEUTIC DOSAGES OF DRUGS


• to diagnose some malignancies (brain cancer and leukemia) Drug Therapeutic Dose
• to assess patients with certain psychiatric symptoms and conditions. Diazepam 0.2 – 0.3 mkD
• for injecting chemotherapy directly into the CSF (intrathecal therapy) Cefixime 3 – 8 mkD Q12
• To diagnose other medical conditions such as: Gentamycin 5 – 8 mkD Q8
– viral and bacterial meningitis Rifampicin 10 – 20 mkD OD AC
– syphilis, a sexually transmitted disease Isoniazid 10 – 20 mkD OD AC
– bleeding around the brain and spinal cord Pyrazinamide 15 – 30 mkD OD
– multiple sclerosis, (affects the myelin coating of the nerve Cefuroxime 20 – 40 mkD Q12
fibers of the brain and spinal cord) Metronidazole 30 – 50 mkD q8-q12 PO
– Guillain-Barré syndrome, (inflammation of the nerves)
Erythromycin 30 – 50 mkD q8-q12
Ampicillin 50 – 100 mkD Q6
Complications
Cloxacillin 50 – 100 mkD Q6
• Local pain
Ceftriaxone 50 – 100 mkD OD
• Infection
• Bleeding Paracetamol 10 – 15 mkd q4
• Spinal fluid leak Ibuprofen 6 – 8 mkd q6
• Hematoma (spinal subdural hematoma)
• Spinal headache Epinephrine 0.1 ml/kg
• Acquired epidermal spinal cord tumor
CHEST X-RAY INTERPRETATION (Dr. Lapak’s Way)
1. Is the film acceptable?
Cautions & Contraindications
2. Is it good inspiratory film?
• Increased ICP
3. Exposure?
• Bleeding diasthesis
4. Situs? (Situs solitus, situs inversus, or situs inversus totalis?)
• Overlying skin infection 5. Position? (Levocardiac? Dextrocardiac? Dextroposition?)
• Unstable patient 6. CT ratio (Normal is 0.65 in neonates, 0.6 in children, 0.5 in older children)
Steps:
1. Position the patient
2. Check for landmarks (L4-L5)
3. Prepare the materials (open sterile containers)
4. Put gloves on
5. Clean lumbar area with antiseptic and drape the area with towel 7. Is there chamber enlargement?
6. Palpate again the interspace 8. Vascular markings
7. Insert the needle 9. Great vessels
8. Collect the specimen
9. Withdraw the needle CHAMBER ENLARGEMENTS:
10. Maintain pressure on the are and clean off the antiseptic solution — RVH: Rounding and upliftment of cardiac apex; Retrosternal fullness
— RAE: lateral bulging of the right heart border; elongation of the right heart
border (length of right heart border exceeds 50% of the mediastinal
cardiovascular shadow)
— LAE: Double density, Enlargement of LA appendage, Upliftment of left
mainstem bronchus, Widening of carinal angle
— LVH: lateral and downward displacement of the cardiac apex
RESPIRATORY DISORDERS
BRONCHIAL ASTHMA

ADOLESCENT MEDICINE
HEADSSFIRST

The algorithm is taken from Dr. B. Reyes’ lecture.


CASE: A 5-year-old male came in at your clinic due to difficulty of breathing
with 2-day history of cough and colds. Patient is a known asthmatic with no
maintenance medication, except for Salbutamol nebulization. 2 weeks PTC,
the patient had nocturnal symptoms occurring once a week. On PE,
HR=125, RR=30, T=37.8. Patient is awake, in stooped position, talks in
phrases, chest and lung findings revealed tight airway with occasional
wheezes.

1. Diagnosis: Bronchial Asthma in Acute Exacerbation, Mild-


Moderate(?), Partly Controlled
2. Immediate Management:
a. Oxygen to achieve O2 saturation of 95%
b. Inhaled rapid beta2 agonist continuously for one hour
(but the usual practice is Salbutamol neb q15 x 3 doses)
3. Pathogenesis:
a. Airway hyperresponsiveness
b. Bronchoconstriction
c. Increased mucus production
CROUP vs EPIGLOTTITIS DEPARTMENT OF PEDIATRICS
Chairman: Vicente M. Caluag III
Junior Interns’ Coordinator: Roberto A. Espos Jr. , MD, FPPS
JI Resident Monitor: Dianne Camille Panganiban
Oldest Resident:
Youngest Resident:
Number of Residents:

Hoarseness Nelson’s 20th edition has 35 parts, 727 chapters

CXR: Thumb sign

CASE: A 3-year-old came in to the ER with a 3-day history of fever, cough,


and colds with no relief by self-medication with Ambroxol. One day PTC,
patient had fever, still with cough and colds, and developed hoarseness. At
the ER, VS: HR=110, RR=48, T=39 with noticeable stridor.
1. Diagnosis: Croup / Laryngotracheobronchitis
2. Etiology: Parainfluenza virus in 75% of cases, RSV, adenovirus
3. X-ray finding: Steeple sign
4. Management: Single dose of Dexamethasone (0.6 mg/kg)
5. Differential Diagnosis: Epiglottitis

ACYANOTIC CONGENITAL HEART DEFECTS

CYANOTIC CONGENITAL HEART DEFECTS