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Covey Habit 1: Be Proactive Ability to control ones environment, rather that have it control you. Taking initiative doesnt mean being aggressive, it means recognizing your responsibility to make things happen Habit 2: Begin with the end in mind The habit of personal leadership Lead oneself towards what you consider your aims Based on imagination the ability to envision, to see the potential, to create with our minds what we cannot at present see with our eyes Habit 3: Put First Things First The habit of personal management Create a clear, mutual understanding of what needs to be accomplished, focusing on what, not how; results not methods Spend time. Be patient. Visualize the desired result

Habit 4: Think Win-Win The habit of interpersonal relationship Achievements are largely dependent on co- operative efforts with others Agreements or solutions are mutually beneficial & satisfying Habit 5: Seek first to understand and then to be understood The habit of communication Diagnose before you prescribe Simple, effective & essential in developing & maintaining positive relationships in all aspects of life Habit 6: Synergize The habit of creative cooperation the whole is greater than the sum of its parts See good & potential in other persons contribution Habit 7: Sharpen the saw The habit self-renewal, of continuous improvement Circles & embodies all other habits

1 drop = 1/20 mL 1 teaspoonful = 5 mL 1 tablespoonful = 15 mL 1 wineglassful = 60 mL = 2 ounces 1 glassful = 250 mL = 8 ounces 1 grain = 60 mg Paracetamol Drops 1 pint = 500 mL wt: move 1 decimal 1 quart = 1000 mL point to the left 1 ounce = 30 mL AgeWt 1 Kg = 2.2 lbs 110kg 1 lb = 0.45359 Kg 212 314 416 518 620

BODY TEMPERATURE Subnormal <36.6C Normal 37.4C Subfebrile 35.7 38.0C Fever 38.0C High fever >39.5C Hyperpyrexia >42.0C AGE Preterm Term 0-3 mo 3-6 mo 6-12 mo 1-3 yrs 3-6 yrs 6-12 yrs 12-17 yrs HR (bpm) BP (mmHg) RR (cpm) 120-170 55-75/35-45 40-70 120-160 65-85/45-55 30-60 100-150 65-85/45-55 35-55 90-120 70-90/50-65 30-45 80-120 80-100/55-65 25-40 70-110 90-105/55-70 20-30 65-110 95-110/60-75 20-25 60-95 100-120/60-75 14-22 55-85 110-135/65-85 12-18

*BP cuff should cover 2/3 of arm small cuff: falsely high BP large cuff: falsely low BP

ABG pH: pCO2: pO2:

7.35-7.45 35-45 80-100

HCO3: 22-26mEq/L B.E.: +/- 2mEq/L O2 sat: 97%

Normal Laboratory Values NB Adolescent RBC 4.8-7.1 Infant 3.8-5.5 Child 3.8-5.

M: 4.6-6.2 F: 4.2-5.4

WBC 9-30,000 6-17,500 Neutrophils 61% 61% Lymphocytes 31% 32% Hgb (gm %) 14-24 11-20 Hct (%) 44-64 35-49

60% 30% 11-16 31-46

60% 30% M: 14-18 F: 12-16 M: 40-54 F: 37150-450 0-2 1-6 5-8 12-14

47 Platelets 140-300 (thou/mm3) Reticulocyte 2.6-6.5 Count (%) Bleeding time 1-5 min Clotting time 5-8 min Prothrombin 12-20 time (sec)

200-423 0.5-3.1 1-6 5-8 12-14

150-450 0-2 1-6 5-8 12-14

BMI Asian Caucasian Underweight <18.5 <18.5 Normal 18.5 22.9 18.5 24.9 Overweight 23.0 25 29.9 at risk 23 24.9 Obese I 25 29.9 30 39.9 Obese II 30 >40


Expected Body Weight upto 1 month of age Term Preterm [{age in days) 10] x 20 + BW (gms) [(age in days) 14] x 15 + BW (gms)




ACUTE DIARRHEA (at least 3x BM in 24 hrs) 4 Major Mechanisms 1. Poorly absorbed osmotically active substances in lumen 2. Intestinal ion secretion (increased) or decreased absorption 3. Outpouring into the lumen of blood, mucus 4. Derangement of intestinal motility Rotaviral AGE (vomiting first then diarrhea) ingestion of rotavirus rotavirus in intestinal villi destruction of villi (secretory diarrhea absorption, secretion) AGE Assessment of dehydration (skin pinch test) (+) if > 2 seconds no dehydration if skin tenting goes back immediately

Etiology of AGE Bacteria Viruses Aeromonas Astroviruses Bacillus cereus Caloviruses Campylobacter jejuni Norovirus Clostridium perfringens Enteric adenoviruses Clostridium difficileRotavirus Escherichia coli Cytomegalovirus Plesiomonas shigelbides Herpes simplex virus Salmonella Shigella Staphylococcus aureus Vibrio cholerae 01 & 0139 Vibrio parahaemolyticus Yersinia enterocolitica

Parasites Balantidium coli Blastocyctis hominis Cryptosporidium Giardia lamblia

Types of Dehydration

Classification of the Severity of Dehydration

DIARRHEA TREATMENT PLAN A 4 Rules of Home Treatment 1. Give extra fluid (as much as the child will take) > Breastfeed frequently & longer at each feeding > if the child is exclusively breastfed, give one or more of the following in addition to breastmilk: - ORS solution - food based fluid (e.g. soup, rice, water) - clean water How much fluid to be given in addition to the usual fluid intake: upto 2 years: 50-100 mL after each loose stool 2 years or more: 100-200 mL > give frequent small sips from a cup > if the child vomits, wait for 10 min then resume > continue giving extra fluids until diarrhea stops 2. Give Zinc supplements upto 6 mo: tab or 10mg per day for 10-14 days 6 months or more: 1 tab or 20mg OD x 10-14 days 3. Continue feeding 4. Know when to return

DIARRHEA TREATMENT PLAN B Recommended amount of ORS over 4 hour period Age upto 4 mo 4 mo Wt <6kg 12mo 12mo 6-9.9kg 400-700 2 yrs 2 yrs 10-11.9kg 700-900

5 yrs 12-19kg 900-1400

in mL 200-400

* Use childs age only when weight is not known * Approximate amount of ORS (mL) CHILDS WT (kg) x 25 > if the child wants more ORS than shown, give more > give frequent small sips from a cup > if the child vomits, wait for 10 min then resume > continue breastfeeding whenever the child wants * After 4 hours > reassess the child & classify dehydration status > select the appropriate plan to continue treatment > begin feeding the child while at the clinic

DIARRHEA TREATMENT PLAN C Treat severe dehydration QUICKLY! > start IV fluid immediately > if the child can drink, give ORS by mouth while the IV drip is being set up > give 100mL/kg Lactated Ringers solution Age First give Then give 30mL/kg in: 70mL/kg in: 5 hours

Infants (<12mo)

1 hour*

Children 30 min* (12mo-5yrs)

2 hours

* Repeat once if radial pulse is very weak or not detectable > reassess the child every 15-30 min. if dehydration is not improving, give IV fluid more rapidly > also give ORS (~5mL/kg/hr) as soon as the child can drink [usually after 3-4 hours in infants; 1-2 hours in children] > reassess after 6 hrs (infant) & 3 hrs (child)



NOTE: Computed Value is in mL/day Ex) 25kg child Answer: 1500 + [100] = 1600cc/day

IV-FLUID COMPOSITIONS (Commonly Used for Infants and Children):


Child Age 2months up to 5years

Young Infants <2months

ETIOLOGY OF PNEUMONIA > Bacterial - Streptococcus pneumoniae - Group B streptococci (neonates) - 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) - Aspergillus sp. (immunosuppressed) - Mucormycosis (immunosuppressed) - Coccidioides immitis - Blastomyces dermatitides - Pneumocystis carinii (immunosuppressed, HIV, steroids)

ATYPICAL PNEUMONIA: extrpulmonary manifestations, low grade fever, patchy diffuse infiltrates, poor response to Penicillin, negative sputum gram stain Etiologic Agents Grouped by Age > Neonates (<1mo) - GBS - E. coli - other gram (-) bacilli - Streptococcus pneumoniae - Haemophilus influenzae (Type B) > 1-3 mo * Febrile pneumonia - RSV - Other respiratory viruses - Streptococcus pneumoniae - Haemophilus influenzae (Type B) * Afebrile pneumonia - Chlamydia trachomatis - Mycoplasma homilis - CMV

> 3-12 mo - RSV - Other respiratory viruses - Streptococcus pneumoniae - Haemophilus influenzae (Type B) - C. trachomatis - M. pneumoniae - Group A Streptococcus > 2-5 yrs - RSV - Other respiratory viruses - Streptococcus pneumoniae - Haemophilus influenzae (Type B) - C. trachomatis - M. pneumoniae - Group A Streptococcus - Staph aureus 2-5 yrs - Streptococcus pneumoniae - Haemophilus influenzae (Type B) - C. trachomatis - M. pneumoniae - Group A Streptococcus - Staph aureus

Dengue Pathophysiology

DENGUE > Mode of transmission: mosquito bite (man as reservior) > Vector: Aedes aegypti > Factors affecting transmission: - breeding sites, high human population density, mobile viremic human beings > Age incidence peaks at 4-6 yrs > Incubation period: 4-6 days > Serotypes: - Type 2 most common - Types 1& 3 - Type 4 least common but most severe > Main pathophysiologic changes: a. increase in vascular permeability extravasation of plasma - hemoconcentration - 3rd spacing of fluids b. abnormal hemostasis - vasculopathy - thrombocytopenia - coagulopathy

Dengue Fever Syndrome (DFS) Biphasic fever (2-7 days) with 2 or more of the ff: 1. headache 2. myalgia or arthralgia 3. retroorbital pain 4. hemorrhagic manifestations [petechiae, purpura, (+) torniquet test] 5. leukopenia Dengue Hemorrhagic Fever (DHF) 1. fever, persistently high grade (2-7 days) 2. hemorrhagic manifestations - (+) torniquet test - petechiae, ecchymoses, purpura - bleeding from mucusa, GIT, puncture sites - melena, hematemesis 3. Thrombocytopenia (< 100,000/mm3) 4. Hemoconcentration - hematocrit >40% or rise of >20% from baseline - a drop in >20% Hct (from baseline) following volume replacement - signs of plasma leakage [pleural effusion, ascites, hypoproteinemia]

Dengue Shock Syndrome Manifestations of DHF plus signs of circulatory failure 1. rapid & weak pulse 2. narrow pulse pressure (<20mmHg) 3. hypotension for age 4. cold, clammy skin & irritability / restlessness DANGER SIGNS OF DHF 1. abdominal pain (intense & sustained) 2. persistent vomiting 3. abrupt change from fever to hypothermia with sweating 4. restlessness or somnolence Grading of Dengue Hemorrhagic Fever

Torniquet Test: SBP + DBP = mean BP for 5 minutes 2 if 20 petechial rash per sq. inch on antecubital fossa (+) test Hermans Rash: > usually appears after fever lysed > initially appears on the lower extremities > not a common finding among dengue patients > an island of white in an ocean of red

Recommended Guidelines for Transfusion: Transfuse: - PC < 100,000 with signs of bleeding - PC < 20,000 even if asymptomatic - use FFP if without overt bleeding - FWB in cases with overt bleeding or signs of hypovolemia > if PT & PTT are abnormal: FFP > if PTT only: cryprecipitate Leukopenia in dengue: probable etiology is Pseudomonas therefore: give Meropenem or Ceftazidime

MANAGEMENT OF DENGUE A. Vital Signs and Laboratory Monitoring (Vital Signs and Laboratory Monitoring) Monitor BP, Pulse Rate We have to watch out for Shock (Hypotension)

Management of Hemorrhage

URINARY TRACT INFECTION Suggestive UTI: - Pyuria: WBC 5/HPF or 10mm3 - Absence of pyuria doesnt rule out UTI - Pyuria can be present w/o UTI Presumptive UTI: - (-) urine culture - lower colony counts may be due to: * overhydration * recent bladder emptying * previous antibiotic intake Proven or Confirmed UTI: - (+) urine culture 100,000 cfu/mL urine of a single organism - multiple organisms in culture may indicate a contaminated sample

ACUTE GLOMERULONEPHRITIS (PSAGN) Antecedent Infection (2-3 weeks) Ag-Ab complexes + complement (ASO)

Ag-Ab deposition in GBM

Ab binding to Glomerular Ab C3

Proliferation deposition

Decreased Glomerular surface area Decreased GFR Activation of RAAS Na+ & H2O retention Fluid overload Circulatory congestion EDEMA
CHF; Pulmonary edema Oliguria; Normal or increased Creatinine

Edema, HPN

ACUTE GLOMERULONEPHRITIS Complications of AGN - CHF 2 to fluid overload - HPN encephalopathy - ARF due to GFR STAGES of AGN - Oliguric phase [7-10days] complications sets in - Diuretic phase [7-10days] recovery starts - Convalescent phase [7-10days] ptts usually sent home Prognosis - Gross hematuria 2-3 weeks - Proteinuria 3-6 weeks - C3: 8-12 weeks - microscopic hematuria: 6-12 mo > Hyperkalemia may be seen due to Na+ retention > Ca++ decreases in PSAGN > in ASO titer - normal within 2 weeks - peaks after 2 weeks - more pronounced in pharyngeal infection than in cutaneous

RHEUMATIC FEVER JONES CRITERIA: A. Major Manifestations Carditis (50-60%) Polyarthritis (70%) Chorea (15-20%) Erythema Marginatum (3%) Subcutaneous Nodules (1%) B. Minor Manifestations Arthralgia Fever Laboratory Findings of: Elevated Acute Phase Reactants (ESR / CRP) Prolonged PR interval C. PLUS Supporting Evidence of Antecedent Group-A Strep Infection (+) Throat Culture or Rapid Strep-Ag Test Elevated or Rising Strep-AB Test

TREATMENT OF RHEUMATIC FEVER A. Antibiotic Therapy 10 days of Oral Penicillin or Erythromycin IM Injection of Benzethine Penicillin **NOTE: Sumapen = Oral Penicillin! B. Anti-Inflammatory Therapy 1. Aspirin (if Arthritis, NOT Carditis) Acute: 100mg/kg/day in 4 doses x 3-5days Then, 75mg/kg/day in 4 doses x 4 weeks 2. Prednisone 2mg/kg/day in 4 doses x 2-3weeks Then, 5mg/24hrs every 2-3 days


A. Primary Prevention 10 days of Oral Penicillin or Erythromycin IM Injection of Benzethine Penicillin

B. Secondary Prevention

C. Duration of Chemoprophylaxis

KAWASAKI DISEASE CDC-CRITERIA FOR DIAGNOSIS: ADOPTED FROM KAWASAKI (ALL SHOULD BE PRESENT) A) HIGH Grade Fever (>38.5 Rectally) PRESENT for AT LEAST 5-days without other Explanation High Grade Fever of at least 5 days DOES NOT Respond to any kind of Antibiotic! B) Presence of 4 of the 5 Criteria: 1) Bilateral CONGESTION of the Ocular Conjunctiva (seen in 94%) 2) Changes of the Lips and Oral Cavity (At least ONE) 3) Changes of the Extremities (At least ONE) 4) Polymorphous Exanthem (92%) 5) Cervical Adenopathy = Non-Suppurative Cervical Adenopathy (should be >1.5cm) in 42%

KAWASAKI DISEASE HARADA Criteria - used to determine whether IVIg should be given - assessed within 9 days from onset of illness 1. 2. 3. 4. 5. 6. 7. WBC > 12,000 PC <350,000 CRP > 3+ Hct <35% Albumin <3.5 g/dL Age 12 months Gender: male

IVIg is given if 4 of 7 are fulfilled If < 4 with continuing acute symptoms, risk score must be reassessed daily

TREATMENT: Currently Recommended Protocol: A. IV-Immunoglobulin 2g/kg Regimen Infusion EQUALLY Effective in Prevention of Aneurysms and Superior to 4-day Regimen with respect to Amelioration of Inflammation as measured by days of Fever, ESR, CRP, Platelet Count, Hgb, and Albumin. NOTE: There is a TIME FRAME of 10 days B. Aspirin HIGH Dose ASA (80-100mg/kg/day divided q 6h) should be given Initially in Conjunction with IV-IG THEN Reduced to Low Dose Aspirin (3-5mg/kg/day) AND Continued until Cardiac Evaluation COMPLETED (approximately 1-2 months AFTER Onset of Disease)

SEIZURES > Seizures: sudden event caused by abrupt, uncontrolled, hypersynchronous discharges of neurons > Epilepsy: tendency for recurrent seizures that are unprovoked by an immediate cause > Status epilepticus: >30min or back-to-back w/o return to baseline > Etiology: - V ascular - I nfections : - T raumatic : - A utoimmune - M etabolic : - I diopathic : - N eoplastic : - S tructural : - S yndrome :

: AVM, stroke, hemorrhage meningitis, encephalitis : SLE, vasculitis, ADEM electrolyte imbalance idiopathic epilepsy space occupying lesion cortical malformation, prior stroke genetic disorder

TYPES OF SEIZURES A. Partial Seizures (Focal / Local) Simple Partial Complex Partial (Partial Seizure + Impaired Consciousness) Partial Seizures evolving to Tonic-Clonic Convulsion) B. Generalized Seizures Absence (Petit mal) Myoclonic Clonic Tonic Tonic-Clonic Atonic SIMPLE FEBRILE SEIZURE vs. COMPLEX FEBRILE SEIZURE Febrile Seizure: A seizure in association with a febrile illness in the absence of a CNS infection or acute electrolyte imbalance in children older than 1 month of age without prior afebrile seizures

CLASSIFICATION BY CAUSE A. Acute Symptomatic (shortly after an acute insult) Infection Hypoglycemia, low sodium, low calcium Head trauma Toxic ingestion B. Remote Symptomatic Pre-existing brain abnormality or insult Brain injury (head trauma, low oxygen) Meningitis Stroke Tumor Developmental brain abnormality C. Idiopathic No history of preceding insult Likely genetic component

SIMPLE FEBRILE SEIZURE A. Criteria for an SFS < 15 minutes Generalized-tonic-clonic Fever > 100.4 rectal to 101 F (38 to 38.4 C) No recurrence in 24 hours No post-ictal neuro abnormalities (e.g. Todds paresis) Most common 6 months to 5 years Normal development No CNS infection or prior afebrile seizures B. Risk Factors Febrile seizure in 1st/2nd degree relative Neonatal nursery stay of >30 days Developmental delay Height of temperature C. Risk Factors for Epilepsy (2 to 10% will go on to have epilepsy) Developmental delay Complex FS (possibly > 1 complex feature) 5% > 30 mins => _ of all childhood status Family History of Epilepsy Duration of fever

BRONCHIAL ASTHMA (GINA GUIDELINES) Controlled Day symptoms none Limitation of activities Nocturnal Sx (awakening) Need for reliever Lung function Exacerbation none none < 2x per wk normal none Partly controlled > 2x per wk any any > 2x per wk < 80% > 1x per yr 1x / week Uncontrolled 3 or more symptoms of Partly Controlled Asthma in any week

Tuberculosis (Treatment)
I. Pulmonary TB A. Fully susceptible M. tuberculosis, no history of previous anti-TB drugs, low local persistence of primary resistance to Isoniazid (H) 2HRZ OD then 4HR OD or 3x/wk DOT Microbial susceptibility unknown or initial drug resistance suspected (e.g. cavitary), previous anti-TB use, close contact w/ resistant source case or living in high areas w/ high pulmonary resistance to H. 2HRZ + E/S OD, then 4 HR + E/S OD or 3x/wekk DOT



Extrapulmonary TB Same in PTB For severe life threatening disease (e.g. miliary, meningitis, bone, etc) 2HRZ + E/S OD, then 10HR + E/S OD or 3x/wk DOT

Home Environment With whom does the adolescent live? Any recent changes in the living situation? How are things among siblings? Are parents employed? Are there things in the family he/she wants to change? Employment and Education Currently at school? Favorite subjects? Patient performing academically? Have been truant/expelled from school? Problems with classmates/teachers? Currently employed? Future education/employment goals? Activities What he/she does in spare time? Patient does for fun? Whom does patient spend spare time? Hobbies, interests, close friends?

Drugs Used tobacco/alcohol/steroids? Illicit drugs? Frequency? Amount? Affected daily activiities? Still using? Friends using/selling? Sexual activities Sexual orientation? GF/BF? Typical date? Sexually active? When started? # of persons? Contraceptives? Pregnancies? STDs? Suicide/Depression Ever sad/tearful/unmotivated/hopeless? Thought of hurting self/others? Suicide plans? Safety Use seatbelts/helmets? Enter into high risk situations? Member of frat/sorority/orgs? Firearm at home?

Respiratory Distress Syndrome (Hyaline Membrane Disease)

Male, preterm, low BW, maternal DM, & perinatal asphyxia Corticosteroids:
most successful method to induce fetal lung maturation Administered 24-48 hours before delivery decrease incidence of RDS Most effective before 34 weeks AOG

Microscopically: diffuse atelectasis, eosinophilic membrane Pathophysiology: 1. Impaired/delayed surfactant synthesis & secretion 2. V/Q (ventilation/perfusion) imbalance due to deficiency of surfactant and decreased lung compliance 3. Hypoxemia and systemic hypoperfusion 4. Respiratory and metabolic acidosis 5. Pulmonary vasoconstriction 6. Impaired endothelial &epithelial integrity 7. Proteinous exudate 8. RDS

Respiratory Distress Syndrome (Hyaline Membrane Disease)

Clinical Features: 1. Tachypnea, nasal flaring, subcostal and intercostal retractions, cyanosis, grunting 2. Pallor from anemia, peripheral vasoconstriction 3. Onset within 6 hours of life Peak severity days 2-3 Recovery 72 hours
Retractions: Due to (-) intrapleural pressure produced by interaction b/w contraction of diaphragm & other respiratory muscles and mechanical properties of the lungs & chest wall Nasal flaring: Due to contraction of alae nasi muscles leading to marked reduction in nasal resistance Grunting: Expiration through partially closed vocal cords Initial expiration: glottis closedlungs w/ gasinc. transpulmo P w/o airflow Last part of expiration: gas expelled against partially closed cords Cyanosis: Central tongue & mnucosa (imp. Indicator of impaired gas exchange); depends on total amount of desaturated Hgb

F.R.I.C.H.M.O.N.D. Fluids Respiration Infection Cardiac Hematologic Metabolic Output & Input [cc/kg/h] N: 1-2 Neuro Diet