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Topnotch IM guide
Yellow Book
Common OB-Gyne Tickler
Compiled by Adrian Alcaraz
THE SEVEN HABITS OF
HIGHLY EFFECTIVE PEOPLE
by Stephen R. Covey
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
Table of Contents
Table of Contents ............................................................................... 3
OB-GYNE NOTES ........................................................................................ 9
Prenatal Clinic Visit ........................................................................... 10
Sides NOTEs ........................................................................................ 10
Direct to DR ....................................................................................... 11
Direct to DR (Preeclampsia - in labor) .......................................... 11
Cesarean Section ............................................................................. 12
Preeclampsia - not in labor............................................................. 13
Eclampsia .......................................................................................... 14
Post-Partum Orders (PPO) ............................................................... 15
Post-Partum Orders (PPO-Preeclampsia) ..................................... 16
Post D&C ............................................................................................ 17
Retained/Incarcerated Placenta .................................................. 18
Oligohydramnios .............................................................................. 19
Premature Rupture of Membrane ................................................. 20
Pre-term.............................................................................................. 21
Placenta Previa Preterm ................................................................. 22
Missed Abortion / Unembryonic pregnancy................................ 23
Threatened Abortion (Septic)......................................................... 24
Threatened Abortion (Non-septic) ................................................ 25
Imminent / Inevitable Abortion ...................................................... 26
Incomplete Abortion (Septic)......................................................... 27
Incomplete Abortion (Non-septic) ................................................ 28
Bowel Prep ......................................................................................... 29
INTERNAL MEDICINE NOTES .................................................................. 30
Infectious .................................................................................................. 31
Upper Respiratory Tract Infection .................................................. 32
Community-acquired Pneumonia................................................. 34
CAP – Low Risk .............................................................................. 35
CAP – Moderate Risk ................................................................... 35
CAP – High Risk ............................................................................. 36
Urinary Tract Infection ...................................................................... 38
Uncomplicated Cystitis................................................................ 39
Acute Uncomplicated Pyelonephritis ....................................... 39
Asymptomatic bacteriuria.......................................................... 41
Recurrent Urinary Tract Infection ............................................... 41
Complicated Urinary Tract Infection ......................................... 42
Catheter-associated UTI ............................................................. 43
Candiduria .................................................................................... 43
Dengue Fever ................................................................................... 44
Dengue Fever - Group A............................................................. 45
Dengue Fever - Group B ............................................................. 46
Dengue Fever - Group C ............................................................ 47
Typhoid Fever .................................................................................... 49
Leptospirosis....................................................................................... 51
Cardiology ............................................................................................... 54
Hypertension: Presentation ............................................................. 55
Hypertensive Urgency vs Emergency ....................................... 59
Angina and Acute Coronary Syndromes ..................................... 60
UAHR/NSTEMI/STEMI ..................................................................... 62
Chronic Stable Angina ................................................................ 66
Pulmonology ........................................................................................... 68
Asthma ............................................................................................... 69
Chronic Obstructive Pulmonary Disease ...................................... 72
Endocrinology ......................................................................................... 74
Diabetes Mellitus ............................................................................... 75
DM Emergency ............................................................................. 76
Sliding Scale Insulin Protocol ....................................................... 79
Insulin Regimens............................................................................ 80
DM – Outpatient ........................................................................... 82
Thyroid Disease ................................................................................. 85
Hyperthyroidism ............................................................................ 85
Hyperthyroidism - Out-patient .................................................... 88
Hypothyroidism ............................................................................. 89
Gastroenterology ................................................................................... 90
Peptic Ulcer Disease ........................................................................ 91
Gastroesophageal reflux disease .................................................. 93
Toxicology ................................................................................................ 94
General Principles of Management .............................................. 95
Alcohol Intoxication ......................................................................... 97
Alcohol Withdrawal ..................................................................... 99
Paracetamol ................................................................................... 100
Silver Jewelry Cleaner .................................................................... 102
Kerosene .......................................................................................... 103
Acids ................................................................................................. 105
Alkali ................................................................................................. 107
Organophosphate ......................................................................... 109
National Poison Control and Management Center ................. 111
PEDIATRICS NOTES ................................................................................ 112
History & Physical Examination ........................................................... 113
H.E.A.D.S.S.S. .................................................................................... 114
F.R.I.C.H.M.O.N.D ............................................................................ 115
Nutrition ............................................................................................ 115
Vital Sign........................................................................................... 116
Anthropometric Measurements ................................................... 116
APGAR Score .................................................................................. 119
Glasgow Come Scale (GCS) ........................................................ 120
Tanner Stages.................................................................................. 121
Immunization ......................................................................................... 125
Expanded Program on Immunization ......................................... 126
Adverse Reactions From Vaccines .............................................. 126
Type of Immunization ..................................................................... 127
Intravenous Fluid ................................................................................... 128
Selection of Fluids ....................................................................... 129
Holiday-Segar Formula .............................................................. 130
Alternative (Ludan’s Method) .................................................. 130
Conversion of microdrops (ugtts) to macrodrop (gtts) ........ 131
Pulmonology ......................................................................................... 132
Pneumonia in Children .................................................................. 133
Revised Risk Classification for Pneumonia .............................. 134
PCAP – D (Pneumonia-II, Pneumonia Very Severe)............. 135
PCAP - D with Acute Gastroenteritis ....................................... 137
PCAP-D with Hyper-reactive Airway Disease ....................... 139
PCAP-D with suspected PTB ..................................................... 142
PCAP-D with Malnutrition .......................................................... 145
PCAP – C (Pneumonia-I, Pneumonia Severe) ....................... 147
Tuberculosis in Children ................................................................. 149
Pleurisy .............................................................................................. 154
Consolidation (Lobar Pneumonia) ............................................. 159
Nosocomial Pneumonia ................................................................ 162
Laryngotracheobronchitis ............................................................. 165
Bronchial Asthma ........................................................................... 167
Stepwise Approach for Managing Asthma in Children ....... 176
Allergology............................................................................................. 178
Anaphylaxis ..................................................................................... 179
Gastroenterology ................................................................................. 184
Diarrheal Diseases .......................................................................... 185
Treatment Plan A ........................................................................ 187
Treatment Plan B ........................................................................ 188
Treatment Plan C ....................................................................... 189
Oresol ........................................................................................... 190
AGE with Hypovolemic Shock .................................................. 191
AGE with Severe Dehydration .................................................. 193
AGE with Some/Mild Dehydration ........................................... 195
Antibiotics used to treat Specific cause of diarrhea ............ 197
Adjunct management for diarrhea ........................................ 198
Infectious ................................................................................................ 199
Dengue Hemorrhagic Fever (DHF) .............................................. 200
Dengue without Warning Signs (DHF Grade I) ...................... 202
Dengue with Warning Signs (DHF Grade II) ........................... 204
Severe Dengue (DHF Grade III – Compensated Shock) .... 206
Recommended Fluid Therapy for Compensated Shock..... 208
Severe Dengue (DHF Grade IV – Hypotensive Shock) ........ 209
Recommended Fluid Therapy for Hypotensive Shock ......... 211
Interpreting Hematocrit Changes ........................................... 212
Management of Dengue ......................................................... 213
Summary of Blood Component Therapy ............................... 217
Typhoid Fever .................................................................................. 218
Bacterial Skin & Soft Tissue Infection ............................................ 220
Tetanus ............................................................................................. 222
Malaria ............................................................................................. 228
Meningococcemia ........................................................................ 232
Viral Exanthem ................................................................................ 235
Urinary Tract Infection (UTI) ........................................................... 237
Nephrology ............................................................................................ 240
Nephrotic Syndrome (NS) ............................................................. 241
Acute Glomerulonephritis (AGN) ................................................. 243
Neonatology ......................................................................................... 245
Ballard Score ................................................................................... 246
Problems in the neonates ............................................................. 247
Neonatal Resuscitation Program ............................................. 248
Essential Intrapartum Neonatal Cure (EINC).......................... 255
S.T.A.B.L.E ..................................................................................... 265
Neonatal Pneumonia .................................................................... 268
Nosocomial Pneumonia/ Infection ............................................. 269
Neonatal Sepsis .............................................................................. 270
Potentially Septic Newborn (PSNB) .............................................. 273
Meconium Aspiration Syndrome (MAS) ...................................... 274
Neonatal Jaundice ........................................................................ 276
Omphalitis ........................................................................................ 279
Perinatal Asphyxia .......................................................................... 280
Prematurity ...................................................................................... 283
For ≥ 34 weeks AOG ................................................................... 284
For < 34 weeks AOG .................................................................. 285
Necrotizing Enterocolitis (NEC) ..................................................... 286
Neonate Hematocrit ≥ 0.65 .......................................................... 288
Well Baby ......................................................................................... 290
Well Baby, Term, AGA, NSVD.................................................... 290
Well Baby, Term, AGA, Cesarean Section ............................. 290
Well Baby, Term, SGA (>2kg) or LGA (>3.7kg) ....................... 291
Well Baby, Term, SGA (<2kg) .................................................... 292
Neurology .............................................................................................. 293
CNS Infections ................................................................................. 294
Suppurative/Bacterial Meningitis ............................................. 297
TB Meningitis ................................................................................ 299
Viral Meningitis ............................................................................ 302
Brain Abscess .............................................................................. 304
Febrile Seizures ................................................................................ 306
Acute Symptomatic Seizure (ASS) ............................................... 309
Hematology........................................................................................... 311
Anemia............................................................................................. 312
Thalassemia/ Thalassemia Syndrome for Blood transfusion ..... 316
ORTHOPEDICS NOTES ........................................................................... 318
Adult < 40 years old........................................................................ 319
Adult ≥ 40 years old ........................................................................ 320
Pediatrics ......................................................................................... 321
MEDICATION .......................................................................................... 322
Computation of Drugs as Drip (Pedia)........................................ 323
Preparation for Desired Dextrocity .............................................. 326
All about Drips (Adult) .................................................................... 327
Guideline to oral switch of antibiotic therapy ........................... 334
Suggested Conversion Regimens ................................................ 335
Common Pediatric Medicine Recommended Dose ............... 336
Cough/Cold Preparation.......................................................... 342
Emergency medicine for pediatrics........................................ 343
Other Drugs ..................................................................................... 344
Pain ............................................................................................... 344
Fever ............................................................................................. 345
Itchiness ....................................................................................... 345
Diaper Rash ................................................................................. 345
Teething ....................................................................................... 345
Decrease Appetite .................................................................... 345
Oral Sores ..................................................................................... 346
Frank Seizure................................................................................ 346
Vertigo ......................................................................................... 346
Impacted Cerumen................................................................... 346
Vomiting....................................................................................... 346
Tinnitus .......................................................................................... 346
Laxatives ...................................................................................... 347
Anti-diarrheals ............................................................................. 347
Ear Drops...................................................................................... 348
Topical Meds ............................................................................... 348
ELECTROLYTES ........................................................................................ 349
General Management Strategy .................................................. 350
Hypokalemia ................................................................................... 351
KCl computation ............................................................................ 352
KCl incorporation (maintenance) ........................................... 352
KCl correction ............................................................................. 353
Hypomagnesaemia ....................................................................... 355
Hypocalcaemia.............................................................................. 356
LABORATORY ......................................................................................... 357
Urinalysis ........................................................................................... 358
Urine Microscopy ........................................................................ 360
Clinical Syndromes of Renal Disease ...................................... 362
Nephrotic vs Nephritic Syndromes .......................................... 363
Serum Creatinine ........................................................................ 364
Normal Values (Pediatrics)............................................................ 368
OB-GYNE NOTES
Doctors’ Guide
Prenatal Clinic Visit
0 – 28 weeks - Monthly
28 – 36 weeks - every 2 weeks
> 36 weeks - weekly
Tetanus Toxoid
TT1 – first contact or as early as possible in pregnancy
TT2 – at least 4 weeks after TT1
TT3 – at least 6 months after TT2
TT4 – at least 1 year after TT3 or during the subsequent
pregnancy
TT5 – at least 1 year after TT4 or during subsequent
pregnancy
Initial Laboratory
CBC plt, CTBT, Blood typing
UA
HBsAg
VDRL
Sides NOTEs
Date:
Time:
BP:
LMP:
AOG:
EDC:
FH:
FHT:
IE: Cervix: cm dilated; % effaced
( ) BOW; Station
Presentation:
Impression: G_P_ ( ); PU; ___weeks AOG by____; __IL
To ward
DAT
Incorporate Oxytocin to present IVF at 1:100 dilution to
run at 20 gtts/min then IVF to consume if no active
bleeding
IVFTF : PLR 1L to run at 20 gtts/min
MEDS:
IF clear meconium
Cefadroxil 500 mg CAP; 1 cap BID for 7 days
IF thin meconium
Cefuroxime 500 mg CAP; 1 cap BID for 7 days
IF moderate to thick meconium
Cefuroxime 500 mg CAP; 1 cap BID for 7 days
Metronidazole 500 mg TAB; 1 tab TID for 7 days
Mefenamic acid 500 mg TAB; 1 tab TID PRN for pain
MV + Iron TAB; 1tab OD OR
Ferrous sulfate + folic acid; 1 tab OD
Monitor VS q15 mins x 1 hr, then q30 mins x 1 hr, then 1
hr until stable, then q4 hr once stable
WOF profuse bleeding and other unusual events
Refer accordingly
Post-Partum Orders (PPO-Preeclampsia)
Oxytocin 10 IU IM now
To ward
DAT
Incorporate Oxytocin to present IVF at 1:100 dilution to
run at 20 gtts/min then IVF to consume if no active
bleeding
SD with D5W 500cc +10g MgSO4 at 20gtts/min
MEDS:
IF clear meconium
Cefadroxil 500 mg CAP; 1 cap BID for 7 days
IF thin meconium
Cefuroxime 500 mg CAP; 1 cap BID for 7 days
IF moderate to thick meconium
Cefuroxime 500 mg CAP; 1 cap BID for 7 days
Metronidazole 500 mg TAB; 1 tab TID for 7 days
Mefenamic acid 500 mg TAB; 1 tab TID PRN for pain
MV + Iron TAB; 1tab OD OR
Ferrous sulfate + folic acid; 1 tab OD
Amlodipine 10mg TAB; 1 tab OD at AM
Losartan 50 mg TAB; 1 tab OD at HS
Clonidine 75 mg TAB; 1 tab SL PRN for BP ≥160/100
mmHg
Monitor VS q15 mins x 1 hr, then q30 mins x 1 hr, then 1
hr until stable, then q4 hr once stable
Insert FBC
I & O q4hr
WOF profuse bleeding and other unusual events
Refer accordingly
Post D&C
Oxytocin 10 IU IM now
To ward
DAT once fully awake
Incorporate Oxytocin to present IVF at 1:100 dilution to
run at 20 gtts/min then IVF to consume if no active
bleeding
MEDS:
Cefadroxil 500 mg CAP; 1 cap BID for 7 days; OR
Clindamycin 500 mg CAP; 1 cap TID for 7 days
Mefenamic acid 500 mg TAB; 1 tab TID PRN for pain
MV + Iron TAB; 1tab OD
Methylergonometrine 1amp IVT now then 1 tab TID x
3 days
Monitor VS q15 mins x 1 hr, then q30 mins x 1 hr, then 1
hr until stable, then q4 hr once stable
WOF profuse bleeding and other unusual events
Refer accordingly
Retained/Incarcerated Placenta
Please admit patient to ward
Secure consent
NPO temporarily
Start IVF w/ D5LR 1L to run 200cc as fast drip then
incorporate oxytocin 1:100 dilution at 20 gtts/min
LABS:
CBC plt, Blood typing
UA
HBsAg
MEDS:
Cephalexin 500 mg TID x 7days; OR
Cefuroxime 1.5 g IVT now then 750 mg IVT q8hr
ANST ( )
Metronidazole 500 mg IVT now then q8 hr
Mefenamic acid 50 0mg TAB; 1 tab TID PRN for pain
MV + Iron TAB; 1tab OD
Methylergonometrine 1amp IVT now then 1 tab TID x
3 days
Monitor VS q15 mins x 1 hr, then q30 mins x 1 hr, then 1
hr until stable, then q4 hr once stable
WOF profuse bleeding and other unusual events
Refer accordingly
Oligohydramnios
Please admit patient to ward
Secure consent
DAT; NPO once in labor
Start IVF w/ D5LR 1L to run 300cc as fast drip then
regulate at 20gtts/min
LABS:
CBC plt, Blood typing
UA
HBsAg
Pelvic UTZ
MEDS:
HNBB 1amp IVT now then q1hr x 2 more doses
O2 inhalation via nasal cannula at 3-5LPM
Position at left lateral decubitus
Monitor VS, FHT & POL q2hr, record please
Perineal prep please
Refer accordingly
Premature Rupture of Membrane
Please admit patient to ward
Secure consent
DAT; NPO once in labor
Start IVF w/ D5LR 1L to run at 20gtts/min
LABS:
CBC plt, Blood typing
UA
HBsAg
MEDS:
Cefuroxime 1.5 g IVT now then 750 mg IVT q8hr ( )
ANST
IF term
HNBB 1amp IVT now then q1hr x 2 more doses
monitor FHT & POL q1hr, record please
Monitor VS q4hr, record please
Nipple stimulation
Awaits vaginal delivery
Perineal prep please
Refer accordingly
No labs necessary
Medications
Amoxicillin 500 mg TID
Co-amoxiclav 625 mg BID (preferred if failed on
Amoxicillin or if with severe symptoms)
Azithromycin 250 mg OD x 5 days or 500 mg OD x 3
days or 1 g OD x 1 dose
Advice
Increased oral fluid intake (at least 2 L/day)
Initial Diagnostics
Chest X-ray
CBC with platelet count
CAP – Low Risk
Subsequent Diagnostics
Sputum GS/CS optional
Antibiotics
Previously healthy
Amoxicillin 1 g TID
Azithromycin 500 mg OD OR Clarithromycin 500
mg BID
Stable co-morbid condition (cover enteric G- bacilli)
Co-amoxiclav 1 g BID
Sultamicillin 750 mg BID
Cefuroxime 500 mg BID
+/- Azithromycin 500 mg OD OR Clarithromycin 500
mg BID
Resolution
For low-risk
Follow-up after 3 to 5 days
For moderate-/high-risk
Step down when clinically improving
Some infections (e.g. ESBL organisms) require a full
course via the IV route
Chest X-ray findings
May take up to 6 months to completely resolve
Vaccination (including those with co-morbid)
Pneumococcal: one time, then q5years
Influenza: annually
Urinary Tract Infection
Symptoms of Urethritis
Acute dysuria, hematuria
Frequency
Pyuria
Recent sexual partner change
Signs of Urethritis
Grossly purulent discharge expressed in genital tract
Symptoms of Cystitis
Dysuria, Urgency
Suprapubic pain
Hematuria, foul-smelling urine, turbid urine
Signs of Cystitis
Suprapubic tenderness
Fever
Uncomplicated Cystitis
Medications (do 7 day regimen in males)
Cotrimoxazole 800/160 PO BID x 3 days
Ciprofloxacin 250 mg PO BID x 3 days
Ofloxacin 200 mg PO BID x 3 days
Norfloxacin 400 mg PO BID x 3 days
Nitrofurantoin 100 mg QID x 7 days
Cefuroxime 125-250 mg PO BID x 3-7 days
Increase OFI
In MALES
U/A or urine cultures in males
Outpatient treatment:
No signs and symptoms of sepsis
Non-pregnant
Likely to comply with treatment
Able to tolerate oral medications
Follow-up after 3-5 days
Diagnostics
Urine GS/CS
Antibiotics
Oral antibiotics
Ciprofloxacin 250 – 500 mg BID x 14 days
Norfloxacin 400 mg BID x 14 days
Ofloxacin 200 mg BID x 14 days
Levofloxacin 250 – 500 mg OD x 10-14 days
Parenteral antibiotics
Ampicillin-sulbactam 1.5 – 3 g IV q6
Ceftazidime 1-2 g IV q8hrs
Ceftriaxone 1-2 g IV OD
Imipenem-cilastin 250-500 mg IV q6-8hrs
Piperacillin-Tazobactam 2.25 g IV q6hrs
Ciprofloxacin 200-400 mg IV q12hrs
Ofloxacin 200-400 mg IV q12hrs
Levofloxacin 500 mg IV OD
Candiduria
May treat if
Symptomatic
Critically ill
Neutropenic
Will undergo urologic procedures/post-renal
transplant
Control diabetes (if present)
Remove catheter, other urinary tract instruments (if
present)
Cystitis
Fluconazole 400 mg LD then 200 mg OD x 7-14
days
Pyelonephritis
Surgical drainage
Fluconazole 6 mg/kg/day OR Amphotericin B IV 0.6
mg/kg/day for 2 to 6 weeks
Dengue Fever
Warning Signs
Abdominal pain or tenderness
Persistent vomiting
Clinical fluid accumulation
Mucosal bleed
Lethargy, restlessness
Liver enlargement > 2 cm
Increase in hematocrit WITH decrease in platelet
count
Severe Dengue
Severe plasma leakage leading to
Shock (Dengue Shock Syndrome)
Fluid accumulation with respiratory distress
Severe bleeding (esp. with use of ASA, Ibuprofen or
corticosteroids)
Severe organ involvement
Liver: AST or ALT > 1000
CNS: Impaired consciousness
Heart and other organs
Initial Diagnostics
CBC with PC
Leukopenia
Thrombocytopenia
Hemoconcentration
Dengue IgM – esp. if with unusual/atypical
manifestations
Dengue NS1
Crea, Na, K, AST, ALT
Elevated AST more than ALT
Liver function: Protime, TB, DB, IB, albumin
Dengue Fever - Group A
Who:
Can tolerate oral fluids
UO every 6 hours
No warning signs
Admit
Hct before fluids
Isotonic solution (pNSS, Ringer’s lactate)
5-7 mL/kg/hr for 1 to 2 hours
3-5 mL/kg/hr for 2 to 4 hours
For obese/overweight: use ideal body weight
May give oral fluids if tolerated
If Hct remains the same/Clinical status stable
2-3 mL/kg/hr for another 2 to 4 hours
If Hct rises/Clinical status worsens
5-10 mL/kg/hr for 1 to 2 hours
Try to maintain UO 0.5 mL/kg/hr
Fluids usually needed for only 24-48 hours
Monitoring
VS q1-4, UO q4-6 then q6-12 if stable
Hematocrit after fluid then q6-12
Transfer to tertiary care if:
Early presentation of shock (2nd or 3rd day)
Severe plasma leakage or shock
Undetectable pulse or BP
Severe bleeding
Fluid overload
Organ impairment
Dengue Fever - Group C
Who:
Severe plasma leakage
Severe hemorrhage
Severe organ impairment
Monitoring
VS q15-30 until out of shock then q1-2
Cardiac monitor
Pulse oximetry
Arterial line if possible
BP
Blood extraction
Bleeding
Avoid intramuscular injections
If mucosal, treat as minor bleeding – resuscitation as
specified
Major Bleeding
Prolonged/refractory shock
Renal/Liver failure or persistent metabolic acidosis
NSAID intake
Anticoagulant therapy
Preexisting PUD
Any form of trauma, including intramuscular
injections
Don’t wait for drop: Hct <0.3 in sepsis is NOT
applicable
5-10 mL/kg pRBC or 10-20 mL/kg of Whole Blood
Platelet concentrates or FFP DO NOT HELP!
May do only if pRBC and FWB does not work
Exacerbates fluid overload
NGT insertion must be done fully lubricated and with
care
Resolution
1 week course
Discharge if
Increasing trend of platelet count
No bleeding
No hemodynamic instability
Advice regarding mosquito control
Ablation of mosquito breeding grounds
Mosquito nets rather than mosquito repellents
Typhoid Fever
Symptoms
High grade fever in past 1 to 2 weeks
Abdominal pain (not always present)
Headache, chills, cough, myalgia/arthalgia,
diarrhea or constipation
Signs
Relative bradycardia at the peak of fever
Hepatosplenomegaly, abdominal tenderness
Rose spots: faint, salmon-colored blanching rash
usually located on the trunk
Diagnostics
CBC with PC (leukocytosis, sometimes leukopenia,
neutropenia)
Crea, Na, K, AST, ALT (slightly elevated LFTs)
Blood CS (sensitivity 90% in first week)
Bone marrow CS (even up to 5 days of therapy)
Duodenal string test/culture
Stool CS (positive in 3rd week if untreated)
Admit if…
Vomiting, diarrhea, abdominal distension
Empirical treatment
Ceftriaxone 1-2 g IV OD x 7-14 days
Cefixime 400 mg PO BID x 7-14 days
Azithromycin 1g PO OD x 5 days
Multidrug resistant
Ciprofloxacin 500 mg PO BID x 5-7 days
Ciprofloxacin 400 mg IV q12 x 5-7 days
Ceftriaxone 2-3 g IV OD x 7-14 days
Azithromycin 1g PO OD x 5 days
Critically ill (shock, obtundation)
Add Dexamethasone 3 mg IV then 1 mg/kg q6 x 8
doses
Admit to ICU
Refer to IDS
Repeat cultures if none were positive
Resolution
Defervescence in 1 week
Return to normal values also in 1 week
Leptospirosis
Symptoms
Wading in floodwater/exposure to mud
Influenza-like illness: chills, headache, nausea,
vomiting, muscle pain (calves, back or abdomen)
Fever, conjunctival suffusion/hemorrhage
Hemoptysis
Decreased urine output, tea-colored urine
Overt jaundice
Diarrhea
Course progresses within 1 week, rarely 2 weeks
Signs
Fever
Conjunctival suffusion
Jaundice and icterus
Calf tenderness
Decreased sensorium
Initial Diagnostics
Lepto MAT/Dri-Dot
BUN, Crea, Na, K, Cl, alb, Ca, Mg (check for acute
renal failure, electrolyte losses)
Urinalysis (concentrated urine vs renal failure; picture
of UTI may confuse you)
CBC with PC (anemia, leukocytosis)
Chest X-ray (check for pulmonary hemorrhage)
Stool CS (for patients with diarrhea)
Urine culture (positive at 2nd to 4th week, and for
several months after)
Mild Leptospirosis
Doxycycline 100 mg PO BID
Ampicillin 500-750 mg PO QID
Amoxicillin 500 mg PO QID
Moderate/Severe Leptospirosis
Penicillin G 1.5 M u IV QID
Ampicillin 1 g IV QID
Amoxicillin 1 g IV QID
Ceftriaxone 1 g IV OD
Erythromycin 500 mg IV QID
Hydration
Based on urine output
Replace electrolytes lost
Transfusion
Based on losses detected by CBC
Control of hemoptysis
Hydrocortisone 50 mg IV q6hrs
Tranexamic Acid 500 mg TID
Weil’s syndrome
Heralded by hemoptysis, renal failure, severe liver
dysfunction, or sepsis
Refer to Infectious Disease specialist
Refer to Renal service for early dialysis
Transfer to ICU
Jarisch-Herxheimer reaction
Occurs in response to antimicrobial therapy, when
massive spirochete kill releases lipoproteins
Simulates worsening of disease
Fever, chills, myalgias, headache
Tachycardia, tachypnea
Increased WBC, neutrophils
Hypotension
Supportive therapy
Subsides after 12-24 hours without revision of meds
Resolution
Jaundice to resolve in 2 to 4 weeks
May discharge if
Creatinine clearance is on upward trend
Urine output at least 0.5 cc/kg/hr
Electrolytes corrected
Platelet/hemoglobin corrected
No ongoing hemoptysis
Prophylaxis
Doxycycline 200 mg PO once a week if exposed
Cardiology
Doctors’ Guide
Hypertension: Presentation
Symptoms
Frequently asymptomatic
Aching nape/occipital area
Symptoms of target organ damage
Signs: Try to detect both cause and effect…
Kidney disease: anemia, oliguria, sallow skin
Cushing’s syndrome: obesity, striae, moon facies,
etc.
Hyper/hypothyroidism
Heart failure
Signs: Taking Blood Pressure
Aneroid instrument vs mercury based instruments
Seated quietly for 5 minutes (Quiet, private, with
comfortable room temperature)
Bladder cuff is at least half of arm circumference
Deflation is 2 mmHg/s
Measure both arms, in supine, sitting and standing
positions (detects coarctation, orthostatic changes)
Measure 1 leg at least once (take ABI)
Palpate all possible pulses
Cardiac examination is important
Auscultate carotid and renal bruits
Diuretics
Examples
Hydrochlorothiazide 12.5 – 25 mg OD-BID
Furosemide 40-80 mg BID-TID
Spironolactone 25-100 mg OD-BID
Good for heart failure
Caution in DM, gout, renal failure
K reducer: furosemide, HCTZ
K retainer: spironolactone
Beta blockers
Examples
Atenolol 25-100 mg OD
Metoprolol 25-100 mg OD-BID
Propranolol 40-160 mg BID (not cardioselective)
Carvedilol 12.5-50 mg BID (combined alpha and
beta)
Good for heart failure, angina, MI, tachycardia
Caution in 2nd or 3rd degree AV block, asthma/COPD
ACE inhibitors
Examples
Captopril 25-200 mg BID-TID
Enalapril 5-20 mg OD
Lisinopril 10-40 mg OD
Ramipril 2.5-20 mg OD-BID
Good for heart failure, MI, DM
Caution in renal failure, hyperkalemia, renal artery
stenosis, pregnancy
May cause cough, angioedema
Angiotensin receptor blockers
Examples
Losartan 25-100 mg OD-BID
Valsartan 80-320 mg OD
Candesartan 2-32 mg OD-BID
Good for heart failure, MI, DM
Caution in renal failure, hyperkalemia, renal artery
stenosis, pregnancy
Used as second-line to ACE-inhibitors
Dihydropyridine CCBs
Examples
Amlodipine 5-10 mg OD
Long-acting Nifedipine 30-60 mg OD
Good for angina
Caution in heart failure, 2nd or 3rd degree AV block
Causes peripheral edema
Non-Dihydropyridine CCBs
Examples
Long-acting Verapamil 120-360 mg OD-BID
Long-acting Diltiazem 180-420 mg OD
Good for angina, MI, DM, tachycardia
Caution in heart failure, 2nd or 3rd degree AV block
Causes peripheral edema
Direct Vasodilators
Examples
ISMN 30-60 mg OD
ISDN 5-10 mg BID-TID
Hydralazine 25-100 mg BID-TID
Nitrates good for angina, MI
Nitrates cause hypotension, headache (must have
at least 8 hours a day drug free), and has reaction
with sildenafil
Hydralazine should not be used in severe coronary
artery disease
BP Targets (JNC 8)
In the general population aged ≥ 60 years
Initiate pharmacologic treatment to lower blood
pressure (BP) at systolic blood pressure (SBP) ≥150
mm Hg or diastolic blood pressure (DBP) ≥ 90
mmHg
Target BP <150/90 mm Hg
In the general population aged < 60 years, including
those with CKD or diabetes
Initiate pharmacologic treatment to lower blood
pressure (BP) at systolic blood pressure (SBP) ≥140
mmHg or diastolic blood pressure (DBP) ≥ 90 mmHg
Target BP <140/90 mm Hg
Follow-up
Adjustment
Diuretics: daily to weekly (electrolyte imbalances)
Beta-blockers: every 2 weeks
ACE-inhibitors and ARBs: every 1 – 2 weeks
CCBs: every 1 – 2 weeks
Vasodilators: Every 1 – 2 weeks
Medications
Nitroprusside: 0.3 ug/kg/min, maximum at 10
ug/kg/min; discontinue if no response after 10
minutes
Nitroglycerin drip: 5 ug/min, titrate at 5-10 ug/min at
3 to 5 minute intervals
10 mg/10mL or 50 mg/50 mL, diluted to 10 mg in
100 mL
Nicardipine drip: 5 mg/h, titrate by 2.5 mg/h at 5-15
minute intervals, maximum at 15 mg/h
2 mg/2mL or 10 mg/10mL, diluted to 10-20 mg in
100 mL
Angina and Acute Coronary Syndromes
Symptoms
Heaviness, pressure, squeezing, localized
retrosternally
Crescendo vs decrescendo
Radiates anywhere between the mandible and
umbilicus
Related to exertion
Signs
High/low blood pressure, tachy/bradycardia
Heart failure
Resolution
Follow-up after 2 weeks
For treadmill exercise test (if appropriate)
Titration of medications
Strengthen previous advice
Diagnostics
12-L ECG
Treadmill exercise test
2D-echo
Crea, Na, K, Mg. Ca, alb
Lipid profile, FBS
Chest X-ray
Medications
Anti-platelet
Aspirin 80 mg OD
Clopidogrel 75 mg OD if ASA-intolerant
Beta blocker
Atenolol 25-100 mg OD
Metoprolol 50-100 mg OD-BID
Carvedilol 6.25-50 mg BID
ACE inhibitor
Captopril 25-200 mg BID-TID
Enalapril 5-20 mg OD
Lisinopril 10-40 mg OD
Ramipril 2.5-20 mg OD-BID
Statin
Atorvastatin 10 mg, max 80 mg @HS
Rosuvastatin 10 mg, max 40 mg @HS
Simvastatin 20 mg, max 80 mg @HS
Diagnostics
ABG (hypercarbia, hypoxemia, alkalosis)
Chest X-ray (rule out infection, other differentials)
12-L ECG (rule out cardiac causes of dyspnea
CBC with PC (infection)
Oxygenation
O2 support
Intubation if in impending/frank respiratory failure
Short acting inhaled beta-agonists
Salbutamol nebulization q5-15
WOF tremors, palpitations
Inhaled anti-cholinergics
Ipatropium bromide nebulization q5-15
WOF Dry mouth, decreased sputum production/dry
cough
Glucocorticoids
Hydrocortisone 50 mg IV q6 or 100 mg IV q8
Budesonide nebule q8
WOF Hoarseness, dysphonia, oral candidiasis,
systemic effects
Aminophylline drip
Mix as 1mg/mL
LD 6 mg/kg over 20-30 minutes
Maintenance at 1 mg/kg/hr (use lower dose in
elderly, or in nonsmokers)
Hook to cardiac monitor
WOF flushing, diarrhea, nausea, vomiting,
arrhythmias
If with status asthmaticus, admit to ICU
Refer to anesthesia if previous measures don’t work
Propofol, Halothane
Treat infection
Most common is still viral URTI (supportive therapy)
See CAP guidelines if with pneumonia
Check if drug is the trigger
Discharge
No wheezing and tolerates room air
No IV glucocorticoids
Infection is treated
Resolution
Home medications:
Oral steroid with tapering schedule
Prednisone at 0.5 -1 mg/kg/d in 2/3-1/3 dosing
Combination inhaled corticosteroid with long-acting
inhaled beta-agonist
Budesonide + Formoterol 160/4.5 or 80/4.5 ug 1-2
puffs BID
Fluticasone + Salmeterol 500/50 or 250/50 or 100/50
1-2 puffs BID
Gargle after use
Rescue doses of short acting inhaled beta-agonists
Salbutamol neb PRN
Outpatient Care
OCS
LABA LABA LABA
ICS low ICS low ICS low ICS low
dose dose dose dose
SABA SABA SABA SABA SABA
Mild Mild Moderate Severe Very severe
intermittent persistent persistent persistent persistent
Symptoms ≤ 2/week 3-6/week Daily Daily Unremitting
3-
Night ≤ 2/month ≥ 5/moth Frequently Nightly
4/month
Smoking cessation
Influenza vaccination annually
Pneumococcal vaccination once then q5 years
Chronic Obstructive Pulmonary Disease
Symptoms
Cough, sputum production, exertional dyspnea
Smoking
Decreased functional capacity
Chronic symptoms
Older age group
Signs
Wheezing
Clubbing, cyanosis
Barrel-chest
Diagnostics
ABG (hypercarbia, hypoxemia)
Chest X-ray (infection, chronic changes –
hyperinflation, fibrosis, cause of COPD)
CBC with PC (infection)
12-L ECG (consider cardiac etiology)
Oxygenation
O2 support
Intubation if in impending/frank respiratory failure
Short acting inhaled beta-agonists AND inhaled anti-
cholinergics
Salbutamol nebulization q5-15
Ipatropium bromide nebulization q5-15
Methylxanthine
Theophylline 10-15 mg/kg in 2 divided doses
Comes in 100, 200, 300, 400, 450 mg
Glucocorticoids
Hydrocortisone 50 mg IV q6 or 100 mg IV q8
Budesonide nebule q8
Shift to Prednisolone/Prednisone 30-40 mg to
complete 2 weeks
Antibiotics
Bronchiectasis with increased sputum production
2 weeks of antibiotics directed against path
WOF
Cor Pulmonale
Right heart enlargement on X-ray, ECG
Prominent neck veins and peripheral edema
Careful diuresis
Furosemide 20-40 mg BID
Spironolactone 25-100 mg OD-BID
Resolution
Complete smoking cessation
Pulmonary Rehabilitation (Refer to Rehab)
Lung volume reduction surgery in severe emphysema
Oxygen therapy
Resting O2 sat < 88%
O2 sat < 90% if with pulmo HTN, cor pulmonale
Influenza vaccination annually
Pneumococcal vaccine once then q5 years
Endocrinology
Doctors’ Guide
Diabetes Mellitus
Symptoms
Weight loss, unexplained
Polyuria, polydipsia
Frothy urine
Decreased vision
Poorly healing wounds, frequent infections
Paresthesias, numbness
Stroke, MI previously
DKA: abdominal pain, nausea, vomiting, young
HHS: poor appetite, increased sleeping time, elderly
Signs
Decreased sensation
Non-healing wound
Skin atrophy, Muscle atrophy
Diabetic dermopathy (necrobiosis lipiodica
diabeticorum)
Renal failure
Retinopathy
DKA: ketone breath, normal abdomen, tachycardic,
tachypneic
HHS: obtundation, dehydration
DM Emergency
Diagnostics
CBC with PC (infection, anemia)
RBS, BUN, Crea, Na, K, Cl, Ca, alb, Mg, P (azotemia,
low albumin, electrolyte imbalances, anion gap)
Plasma ketones if available
ABG
Chest X-ray (and X-ray of involved extremity if with
non-healing wound)
Urinalysis with ketones
12-L ECG
HBA1c (instead of FBS)
CBG
Computations
Osmolality
2(Na + K) + BUN + RBS (in mmol/L)
Normal is 276-290 mmol/L
Anion gap
Na – (Cl + HCO3)
Normal is 10-12 mmol/L
DKA
HHS
Mild Mod Severe
Plasma glucose
>250 >250 >250 >600
(mg/dL)
7.25 – 7.00 -
Arterial pH <7.00 >7.30
7.30 <7.24
Serum HCO3 15 – 18 10 - <15 <10 >15
Urine ketones Positive Positive Positive Small
Serum ketones Positive Positive Positive Small
Effective serum
osmolality Var Var Var >320
(mOsm/kg)
Anion gap >10 >12 >12 <12
Alert / Stupor Stupor
Sensorium Alert
drowsy /coma /Coma
ICU admission
If unstable
pH < 7.00
Decreased sensorium
Refer to Endo
Replace fluids
2-3 L pNSS over first 1-3 hours (10-15 mL/kg/h)
0.45% NSS at 150-300 mL/h
D5 0.45%NSS at 100-200 mL/h if CBG ≤ 250 mg/dL
WOF congestion, hyperchloremia
HHS: if Na > 150, use 0.45% NSS at the onset
Insulin
Start only if K > 3.3
0.1-0.15 u/kg IV bolus
0.1 u/kg/h IV infusion, target CBG 150-250 mg/dL
20 or 100 units regular insulin in pNSS to make 100
cc in soluset dripped via infusion pump (1cc = 1u if
100 u used)
Decrease insulin until 0.05-0.1 u/kg/h
As soon as patient is awake and tolerates feeding,
may start patient on diet
Overlap insulin with subcutaneous insulin
Calculate insulin requirements from insulin drip
used in past 24 hours
Assess precipitant
Noncompliance/missed insulin dose
Infection (UTI, pneumonia)
Myocardial infarction
Drugs
CBG q1-2 hours
Electrolytes and ABG q4 for first 24 hours
NVS, I/O q1
Correct potassium
K < 5.5: 10 mEq/h
K < 3.5: 40-80 mEq/h
Correct acidosis only if pH < 7.0 after initial hydration
pH 6.9-7.0: 50 mEq NaHCO3 + 10 mEq KCl in 200 mL
sterile water x 1h
pH < 6.9: 100 mEq NaHCO3 + 20 mEq KCl in 400 mL
sterile water x 2h
Repeat ABG 2 hours after
Repeat dose q2 hours until pH > 7.0
Correct magnesium
Target 0.8 to 1 mmol/L
Each gram of Mg will increase Mg by 0.1 mmol/L
3g MgSO4 in D5W 250 cc x 12h = 0.3 additional Mg
Inpatient goals
Pre-prandial 90-130 mg/dL
Post-prandial < 180 mg/dL
For thin, insulin sensitive patients
Add 1 unit to errant insulin for every 50 mg/dL above
target
For obese, insulin resistant patients
Add 2 units to errant insulin for every 50 mg/dL
above target
DM – Outpatient
Diagnostics:
FBS, 2-hour post-prandial glucose
Lipid profile
HBA1c
Targets
HBA1c < 7%
Pre-prandial glucose (FBS) 70-130 mg/dL
Post-prandial glucose (2h PPBS) < 180 mg/dL
BP < 140/90
Lipid modification (order of decreasing priority)
LDL < 100 mg/dL
HDL > 40 mg/dL in males, > 50 in females
TG < 150 mg/dL
Medications: Biguanides
Dose
Metformin 500 mg-1g OD, BID, TID (max 3g/day)
Adjust every 2-3 weeks
Goal effect
Reduces HBA1c by 1-2%
Reduces fasting plasma glucose
Good: weight loss
Caution: Renal insufficiency (Crea > 124 mmol/L),
lactic acidosis, GI effects
Hold 24h prior to procedures, while critically ill
Medications: Sulfonylureas
Dose
Glimepiride 1-8 mg OD
Glipizide 2.5-10 mg OD-BID
Take shortly before meals
Goal effect
Reduces HBA1c by 1-2%
Reduces fasting and post-prandial plasma glucose
Caution: weight gain, hypoglycemia, renal
insufficiency (Crea > 124 mmol/L), liver disease
Medications: Thiazolidinediones
Dose
Pioglitazone 15-45 mg OD
Rosiglitazone 1-4 mg OD-BID
Goal effect
Reduces HBA1c by 0.5-1.5%
Reduces fasting and post-prandial plasma glucose
Reduces insulin requirements
Caution: weight gain but redistributes to peripheral
areas, hypoglycemia, renal insufficiency (Crea > 124
mmol/L), liver disease, edema, heart failure
Medications: DPP-IV inhibitors
Dose
Sitagliptin 50-100 mg OD
Vildagliptin 50 mg OD-BID
Goal effect
Reduces HBA1c by 0.5-1.0%
Reduces insulin requirements
Good: does not cause weight gain, minimal
hypoglycemia
Caution: Renal insufficiency (use 50 mg OD if Crea
>124 mmol/L), headache, diarrhea, URTI
Medications: Alpha-glucosidase inhibitors
Dose
Acarbose 25 mg with evening meal
Maximize to 50 - 100 mg with every meal
Goal effect
Reduces HBA1c by 0.5-0.8%
Reduces post-prandial plasma glucose
Good: weight loss
Caution: GI effects (diarrhea, flatulence, abdominal
distention), Renal insufficiency (Crea > 177 mmol/L)
Medications
If 2 drugs aren’t sufficient, insulin is recommended
Cost and compliance are of prime importance
Diet
Fat 20-35%
Minimal saturated fat (<7%)
Minimal transfat
Decreased cholesterol (<200 mg/d)
At least 2 servings of fish (Omega-3 fatty acids)
Carbohydrates 45-65%
Low glycemic index
Sucrose containing food with adjustments in
meds/insulin
Protein 10-35%
High fiber
Exercise at least 150 minutes/week
Monitor blood sugar before, during and after
exercise
CBG > 250 mg/dL, delay exercise
CBG < 100 mg/dL, eat carbohydrate before exercise
Pre-exercise insulin modification
Decrease dose
Inject into non-exercising muscle
Follow-up
Home monitoring of glucose
HbA1c q3-6 months
Medical nutrition therapy and education
Eye examination annually
Foot examination daily by patient, annually by MD
Screening for albuminuria annually
Lipid profile and Crea annually
BP measurement q4 months
Thyroid Disease
Hyperthyroidism
Hypothyroidism
Hyperthyroidism
Symptoms
Hyperactivity, irritability
Heat intolerance, sweating
Palpitations
Weakness, weight loss, diarrhea
Polyuria, oligomenorrhea
Signs
Tachycardia, sometimes atrial fibrillation
Warm, moist skin
Tremors, muscle weakness
Anterior neck mass
Diagnostics
CBC with PC (infection)
12-L ECG (atrial fibrillation, tachycardia)
Chest X-ray (rule out infection, cardiomegaly)
Urinalysis (infection)
Free T4 and TSH (high FT4, low TSH)
Crea, Na, K (low K)
Thyroid UTZ (especially if with nodule/s)
Burch-Wartofsky scoring
Score
25-44: impending storm
≥45: storm
Therapeutics
Propylthiouracil 600 mg LD then 200-300 mg q6hrs
Orally/NGT
By rectum
Saturated solution of Potassium Iodide (SSKI) 5 drops
q6-8hrs, 1 hour after every PTU dose
Propranolol 40-60 mg PO q4hrs
If still no rate control: Verapamil 2.5-5 mg SIVP q15-
30mins, maximum of 20 mg
Use digoxin rarely (decreased potency in
hyperthyroidism)
Glucocorticoids
Dexamethasone 2 mg IV q6
Hydrocortisone 50 mg IV q6
Treat infection, fever aggressively
Correct electrolytes
ICU admission
If stable, may admit to Ward
Refer to Endo
Resolution
Discharge
Taper PTU to 200 mg TID
Heart rate controlled with Propranolol BID
Infection/precipitant treated
Hyperthyroidism - Out-patient
Medication adjustment
Preferably Methimazole 20-30 mg OD
Taper Propranolol until PRN
Follow-up
2-4 weeks with repeat FT4 (same laboratory)
Adjust methimazole based on FT4
TSH may be taken eventually to prove suppression
Dietary avoidance
Seafood
Iodized salt
30 to 50% achieve remission on medical treatment
alone
Usually after 12-18 months
Definitive treatment: once euthyroid
RAI
Surgery
Refer to Endo and GS/ORL
Diagnostics
Free T4, TSH (low FT4, High TSH)
CBC with PC
12-L ECG (documentation of heart rate)
Chest X-ray (enlarged heart, pleural effusion)
Crea, Na, K (hypokalemia)
Thyroid UTZ
Anti-TPO
Therapeutics
Levothyroxine 1.6 ug/kg BW in single dose before
breakfast
If missed dose: may take 2-3 doses of skipped tablets
at once due to long half-life
Follow-up
Repeat TSH after 2-4 weeks
Use same laboratory
Target lower half of TSH range
Gastroenterology
Doctors’ Guide
Peptic Ulcer Disease
Symptoms
PUD: Epigastric pain, usually at night
Metallic/acid taste in the mouth
Melena
NSAID use
Weight loss, early satiety, vomiting
Signs
Epigastric tenderness
Epigastric mass
Melena on DRE (uncommon)
Diagnostics
CBC with PC
EGD with H. pylori biopsy
Urea breath test
FOBT
Chest X-ray
Therapeutics (Active Bleeding)
PPI drip
Omeprazole 80 mg IV bolus
Omeprazole 80 mg in pNSS to make 100 cc x 10
cc/h (8mg/h)
Immediate endoscopy
Therapeutics
Proton pump inhibitors – 2-week trial
Omeprazole 20 mg/d
Esomeprazole 20 mg/d
Lansoprazole 30 mg/d
Administer BEFORE a meal
Long-term: pneumonia, osteoporosis
H2-receptor antagonists
Ranitidine 300 mg @HS
Famotidine 40 mg @HS
Antacids
Usually for symptom relief
Aluminum hydroxide-Magnesium hydroxide
WOF nephrotoxicity
Therapeutics (H. pylori positive)
OCA/OCM regimen
Omeprazole 20 mg BID
Clarithromycin 250-500 mg BID
Amoxicillin 1g BID OR
Metronidazole 500 mg BID
Refer to GI if no response
Follow-up
after 2-4 weeks
Decision to continue PPI dependent on symptoms
Gastric ulcers have risk for malignancy
Gastroesophageal reflux disease
Symptoms
Burning retrosternal chest pain
worsening/precipitated by recumbency
Regurgitation of sour material into mouth
Cough
Dysphagia
Signs
Obesity
Usually normal abdominal PE
Diagnostics
Usually none needed
EGD
CBC with PC
Therapeutics
Proton-pump inhibitors
Omeprazole 20 mg/d
Esomeprazole 40 mg/d
Take 30 minutes before breakfast
Weight reduction
Elevation of head by 4-6 inches during recumbency
Avoid
Smoking
Fatty food, large quantities of food/fluid
Alcohol, mint, orange juice
Calcium channel blockers
Toxicology
Doctors’ Guide
General Principles of Management
Emergency Stabilization
Airway
Breathing: Oxygenation and Ventilation
Circulation: Inotropes
Convulsion cessation
Electrolyte/metabolic correction
Coma
Clinical Evaluation
History:
Time, Mode/Route
Circumstances prior
Pre-existing illnesses or co-morbidities
Home remedies/treatment given
Physical Exam:
Complete
Breath odor
Neurologic PE
Laboratory Examinations
CBC with PC
Urinalysis
RBS, BUN, Creatinine, Na, K, Ca, alb, Mg
ABG
12-L ECG
Bilirubins, PT, AST, ALT, Alk Phos
Chest X-ray (best if PA-upright)
Plain abdominal X-ray
Elimination of the poison
External decontamination
Discard all clothing
Thorough bathing
Eye irrigation
Protective gear for personnel
Empty stomach
Induction of emesis (if ingestion occurred within 1 hour)
Gastric Lavage (50-60 mL of tepid sterile water)
Don’t do in ingestion of caustics, kerosene!
Don’t do if patient is convulsing!
Limit GI absorption
Activated charcoal: 50-100 g in 200 mL H2O
Do multiple doses if with enterohepatic recirculation
Contraindicated in caustics
Follow with Na sulfate up to 2 doses, then soap sud
enema for BM
Demulcent agents
Raw egg albumin: whites of 8-12 eggs
Cathartics
Na sulfate 15 g in 100 mL H2O
Contraindicated in caustics, easily absorbable
chemicals, ileus, severe fluid and electrolyte imbalances
Excretion of absorbed substances
Forced diuresis
Mannitol 20% 1 mL/kg within 10 minutes then 2.5-5 mL/kg
q6 x 8 doses
Must have good urine output
Alkalinization (for weak acids)
NaHCO3 1mEq/kg/dose IV targeting urine pH > 7.5
Acidification (for weak bases)
Ascorbic Acid 1g IV q6 until urine pH ≤ 5.5
Dialysis
Antidotes
Supportive Therapy
Fluid replacement for losses
Electrolyte correction
Prevention of aspiration, decubitus ulcers
Monitoring VS and I/O
Disposition
ER vs Ward vs ICU
Psychiatric evaluation
Social evaluation
Alcohol Intoxication
Blood alcohol (mg/dL)
))
Metabolism
Non-alcoholic: 13 to 25 mg/dL per hour
Alcoholic: 30 mg/dL per hour
Estimated time of recovery
Blood alcohol/metabolic rate
Percent Ethanol
Category Specific %Ethanol
Lager 2 – 3%
Beer Pilson 5 – 6%
Strong 9 -14%
Wine Red/White 7 – 12%
Fortified wine Champagne 15 – 20%
Whiskey, rye, rhum, bourbon, 40 – 50%
Distillates
gin
Local distilled Lambanog, tuba 60 – 80%
Hygiene Perfume/cologne 25 – 95%
Products Mouth wash 15 – 25%
History
Amount ingested
With what substance
PE
Evidence of trauma
Level of sensorium
Diagnostics
Urine ketones
CK MB, MM
Amylase
FOBT
Therapeutics
NPO
Insert NGT
IVF: D5 0.9 NaCl 1L x 8h
Conscious
Therapeutics
Thiamine 100 mg IM/IV
D50-50 100 mL fast drip IV
Refer to Psych
Evaluate for withdrawal
Observe for 6 hours
Discharge on
Thiamine 50 mg TID OR
Vitamin B complex 1 tab TID
Folic Acid OD, Multivitamins OD
Unconscious
Therapeutics
Thiamine 100 mg IM/IV now then q8
D50-50 100 mL fast drip IV
Refer to Neurology
Observe for return of consciousness
Fully awake: Observe for 5-7 days, refer to
Psychiatry
Partially awake: Work-up for decreased sensorium
(NSS?)
Comatose: Naloxone 2 mg IV q2 minutes for a
total of 10mg; work-up for decreased sensorium,
consider HD
Same discharge plans
Alcohol Withdrawal
Symptoms/Signs
Autonomic hyperactivity (sweating, tachycardia)
Increased tremors
Insomnia
Nausea/vomiting
Hallucinations/illusions
Psychomotor agitation/anxiety
Seizures
Therapeutics
Diazepam 2.5-5mg q8 x 3 days then taper for next
2days before discontinuation
Vitamin B complex TID
Folic Acid OD
Resolution
Enroll in quitting program
Advice moderation
Paracetamol
Toxic dose if 150-300 mg/kg
Symptoms vary based on time after exposure
0-24 hours: asymptomatic, nausea, vomiting
24-36 hours: asymptomatic, upper abdominal pain
36-72 hours: onset of liver/renal failure
72-120 hours: jaundice, bleeding, liver/renal failure
History
Time, mode
Intake of other substances/meds
Co-morbidities
Physical Exam
Heart, liver, kidneys
Neurologic examination
Diagnostics
Serum paracetamol
AST, ALT, PT
Watch out for…
Acute Renal Failure
IVF hydration
Refer to Renal for possible Dialysis
Bleeding
Vitamin K 10 mg IV up to q6
Target PT > 60% activity
Hepatic insufficiency
Vitamin B complex
Vitamin K
Electrolyte abnormalities
Hypoglycemia, acidosis, hypokalemia,
hypocalcemia
Silver Jewelry Cleaner
Active compound is cyanide-derived
Binds to cytochrome oxidase enzymes, inhibiting
cellular respiration
SJC: Order Sheet
Diagnostics
ABG
Serum cyanide
CBC with PC
Anticipatory Care
ICU admission
Close monitoring
Treatment for co-ingestants (e.g. alcohol)
Therapeutics
Oxygenation
High flow
Prophylactic intubation esp. if with decreased
sensorium
Na nitrite 300 mg SIVP (over 5 minutes)
Vasodilator, displaces cyanide, producing
methemoglobin
Causes hypotension
Na thiosulfate 12.5 g (50 mL of a 25% solution) SIVP
(over 10 minutes)
Speeds the displacement of cyanide by providing
sulfur for binding
Watch out for…
Decreased sensorium
Aspiration precautions
Prophylactic intubation if warranted
Seizures
Diazepam
Increased oxygen delivery
Hypoxic encephalopathy
Rapidly reversible if antidote given early
If still not reversed, need prognostication by Neuro
Kerosene
History
Time
Amount
Mucous membrane irritation
CNS depression, seizures
Physical Exam
Lung findings: crackles, respiratory distress
Arrhythmia, tachycardia
Sensorial changes
Diagnostics
Chest X-ray (6 hours post-ingestion)
ABG
Watch out for…
Pneumonia
Penicillin G 200,000 u/kg/d in 6 divided doses
Clindamycin 300 mg PO/IV q6
Metronidazole 500 mg PO/IV q6
Gastritis
Al-hydroxide-Mg-hydroxide 30 mL q6
Prolonged PT
Vitamin K 10 mg OD
Seizures
Diazepam 2.5-5 mg SIVP
Refer to Neuro
Acids
Causes coagulation necrosis which forms eschars
Damage is self-limiting
Eventual stenosis of viscus
Diagnostics
Cross-matching
Urine hemoglobin
Chest X-ray upright, plain abdomen
Emergency EGD
Therapeutics
Copious amounts of water to decontaminate
externally
NPO
IVF: D5NSS 1L x 8h
Meperidine 25-50 mg IM
Famotidine 20 mg IV q12
Concentrated acids: Enhance excretion with
Mannitol
Test dose: 1 mL/kg within 10 mins
If with good urine output: 2.5-5.0 mL/kg q6 x 8
doses
Discontinue mannitol if with poor urine output x 2h
Grade Findings
0 Normal
1 Edema, hyperemia of mucosa
Friability, blisters, hemorrhages, erosions, whitish
2A
membranes, exudates, superficial ulcerations
2B 2A + deep discrete or circumferential ulceration
Small scattered areas of multiple ulcerations and
3A
areas of necrosis
3B Extensive necrosis
Watch out for…
Acute abdomen
Surgery
Lifelong vitamin B12 if gastrectomy done
Shock
Fluids, antibiotics as appropriate
Upper airway obstruction
Tracheostomy
Hydrocortisone 100 mg IV q6
Upper GI Bleed
Blood transfusion, surgery
Alkali
Causes liquefaction necrosis
Damage spreads, and may continue for days
Diagnostics
Cross-matching
Urine hemoglobin
Chest X-ray upright, plain abdomen
Emergency EGD
Therapeutics
Copious amounts of water to decontaminate
externally
NPO
IVF: D5NSS 1L x 8h
Meperidine 25-50 mg IM
Famotidine 20 mg IV q12
Extent Findings
First Superficial mucosal hyperemia, mucosal
degree edema, superficial sloughing
Deeper tissue damage, transmucosal (all
Second
layers of the esophagus), with exudates,
degree
erosions
Through the esophagus and into the
Third periesophageal tissues (mediastinum, pleura or
degree peritoneum), deep ulcerations, black
coagulum
Watch out for…
Acute abdomen
Surgery
Lifelong vitamin B12 if gastrectomy done
Shock
Hypovolemic/Septic: Fluids, antibiotics as
appropriate
Neurogenic: Mepedirine 1 mg/kg/dose IV
Upper airway obstruction (Glottic edema)
Tracheostomy
Hydrocortisone 100 mg IV q6
Upper GI Bleed
Blood transfusion, surgery
Organophosphate
Sample Order
Please admit patient
Secure consent
Insert NGT now
NPO
O2 inhalation via facemask at 6LPM
IVF double line:
1st Line: PNSS 1L as Fast drip at Right hand
2nd Line: PLR 1L as Fast drip at Left hand
Monitor V/S Q4hrs
Make a table to monitor Q2hrs the following
parameters:
Mucosa
HR
Bowel sounds
Pupillary size
Diagnostics - STAT
CBC plt
Serum Crea, K, Na
ABG
CBG
AST, ALT
Protein
U/A
CXR PA
12L ECG
Management
Decontamination
Have patient take a bath with soap and water
Change clothes
Activated charcoal 50mg per NGT now, then
Sodium sulfate 15-30 grams in water after 30mins
Repeat Sodium sulfate 15-30 grams in water after
1hour if no BM
Antidote:
Atropine sulfate 0.5mg IVTT now then Q5mins for 2
more doses to achieve HR >60bpm (target normal
100bpm)
Diazepam 5mg IVTT Q8hrs PRN for seizure
CBG monitoring Q6hr while on NPO
National Poison Control and Management
Center
(O2) 554-8400 loc 2311
(O2) 524-1078
0922-896-1541
PEDIATRICS NOTES
Doctors’ Guide
History & Physical
Examination
Doctors’ Guide
H.E.A.D.S.S.S.
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 activities?
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?
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
Nutrition
Body Temperature
Subnormal <36.6°C
Normal 37.4°C
Subfebrile 35.7 – 38.0°C
Fever 38.0°C
High fever >39.5°C
Hyperpyrexia >42.0°C
Anthropometric Measurements
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 ≥ 30.0 ≥ 40.0
Head Circumference
Fontanels
Age Transverse – AP
Inches
Diameter Ratio
At birth 1.0 Transverse = AP
1 year 1.25 Transverse > AP
6 year 1.35 Transverse >>> AP
APGAR Score
0 1 2
Pink body / Blue
A Blue / Pale Completely pink
extremities
P Absent Slow (<100) > 100
(-) Coughs, sneezes,
G Grimaces
Response cries
(-) Some flexion / Active
A
Movement extension movement
R Absent Slow / irregular Good, strong cry
8 – 10 : Normal
4–7 : Mild / Moderate Asphyxia
0–3 : Severe Asphyxia
Glasgow Come Scale (GCS)
2 To pain 2 To pain
1 None 1 None
6 Spontaneous 6 Obeys command
5 Localize pain 5 Localize pain
Motor
4 Withdraw 4 Withdraw
3 Flexion 3 Flexion
2 Extension 2 Extension
1 None 1 None
Crying / Inappropriate
3 3 Screaming 3
screaming words; cries
Incomprehensible
2 Grunts 2 Grunts 2
words
1 None 1 None 1 None
Tanner Stages
Active Passive
BCG Diphtheria
DPT Tetanus
OPV Tetanus Ig
Hep B Measles Ig
Measles Rabies (HRIg)
Hib Hep A Ig
MMR Hep B ig
Tetanus Toxoid Rubella Ig
Varicella
Intravenous Fluid
Doctors’ Guide
Selection of Fluids
Fluid of
Condition Need to supply Comments
Choice
Diarrhea
Loss of water & Water & Plain LR May shift to D5LR
electrolyte electrolyte if patient is
Loss of K thru K already hydrated
GIT Bicarbonate / May use D3LR if
Metabolic Lactate patient has poor
Acidosis intake
Shock
Loss of water & Water & Plain LR PNSS/ 0.9% NaCl
electrolyte electrolyte (bolus) is an alternative
Metabolic choice, but one
Acidosis must watch out
for
hyperchloremic
acidosis
Vomiting
Loss of water & Water & Plain If committing
electrolyte electrolyte NSS / progresses K loss
Metabolic 0.9% must be
Acidosis NaCl replaced. Plain LR
can be the
alternative
choice
Initial Post-op
Maintenance Water & D5LR Avoid blousing
Loss of water & electrolyte with Dextrose
electrolyte Dextrose May use D5NS as
NPO an alternative
Hypotonic
Maintenance Water & D5IMB Should not be
Low K electrolyte D5NM used for hydration
K
Dextrose
Hypotonic
Maintenance Water & D5 Usually used for
Normal/slight electrolyte 0.3NaCl cardiac and
high Na Dextrose hema-once
Normal/slight patients
high K
Risk for high K
Holiday-Segar Formula
NOTE:
HRAD improving thru salbutamol nebulization is
suggestive of asthma, if not we may be dealing with
bronchiolitis especially for patients under 6months old
for bronchiolitis adding racemic solution nebulization
may help. How to prepare diluted epinephrine as
alternative racemic solution:
mix epinephrine of diluted epinephrine 0.30 cc with
sterile water of 3.70 cc, to come up with a 4 cc
solution
use 2 cc of this solution for nebulization with
frequency dependent on the assessment
Dosages of Penicillin G can he mixed with PNSS 20-
30cc in soluset to run as drip for 30 minutes.
Once with improvement within 72 hours;
shift O2 to nasal or discontinue
start feeding
shift medication to oral preparation
Chloramphenicol IV to Chloramphenicol oral
Paracetamol IV to paracetamol oral
Penicillin IV to Amoxicillin OR Co-amoxiclav oral
Ceftriaxone IV to Co-amoxicillin or Cefixime oral
Consider sending the patient home
Advice proper hygiene and good nutrition
If with no improvement after 72 hours, consider shifting
of medication or refer to tertiary hospital or to
specialists.
If patient shows improvement initially (afebrile,
improved respiratory rate) within 72 hours, but
manifests new onset of symptoms later (recurrence of
fever, tachypnea), consider Nosocomial or hospital-
acquired pneumonia/infection (see sample orders for
infection at Nosocomial Pneumonia).
PCAP-D with suspected PTB
Basis: The child has manifested signs and symptoms of
PCAP-D plus positive history of exposure to TB patients
and is TB symptomatic. TB symptomatic is define as a
child with any three (3) or more of the following signs
and symptoms:
History of cough ≥ 2 weeks
Unexplained fever of ≥ 2 weeks
Weight loss, loss of appetite, failure to gain weight
Failure to respond to 2 weeks of appropriate
antibiotics for lower respiratory infection
Failure to regain previous state of health after 2
weeks of a viral infection or exanthema
Fatigue, reduced playfulness or lethargy
Sample Orders:
Please admit to ICU
Secure consent
TPR Q4
NPO
Take initial O2 sat at room air via pulse oximeter
Labs:
CBC, plt
CXR AP/L
ABG
PPD or sputum examination
IVF: D5LR or D5IMB at full maintenance or hydration
rate
Meds:
For 3mons – 5yo:
Primary Therapy
Chloramphenicol 100mg/kg/day IVTT Q6hrs
Alternative Therapy
Ceftriaxone 100mg/kg/day IVTT Q12hrs OR OD
( ) ANST
For 5yo above
Primary Therapy
Penicillin Na 200,000-300,000 IU/kg/day slow IVTT
OR as drip Q6 ( ) ANST
Alternative Therapy
Ceftriaxone 100mg/kg/day IVTT Q12 or OD
( ) ANST
Supportive Therapy
Paracetamol 10mg/kg/d IVTT Q4 pm for temp ≥≥
38°C
Once diagnosis of PTB is confirmed start Anti-TB
medication
Rifampicin 10mg /kg/day OD PO OR NGT
Isoniazid 10mg /kg/day OD PO OR NGT
Pyrazinamide 15mg/kg/day OD PO OR NGT
O2 inhalation via facemask at 6 LPM
Place patient on moderate high back rest
Monitor V/S Q4 to include O2 saturation
Refer for cyanosis, progress of DOB, seizure, hemoptysis
or any untoward events
NOTEs
Anti-TB drugs are continued for at least 6 months. Two
(2) months for Pyrazinamide and six (6) months for
Isoniazid and Rifampicin. Follow-up visits should be
advised accordingly.
Dosages of Penicillin G can he mixed with PNSS 20-
30cc in soluset to run as drip for 30 minutes.
If NOTEd with wheezing may start nebulization with 1
nebule salbutamol with frequency dependent on
physician’s assessment.
Once with improvement within 72 hours;
shift O2 to nasal or discontinue
start feeding
shift medication to oral preparation
Chloramphenicol IV to Chloramphenicol oral
Paracetamol IV to paracetamol oral
Penicillin IV to Amoxicillin OR Co-amoxiclav oral
Ceftriaxone IV to Co-amoxicillin or Cefixime oral
Consider sending the patient home
Advice proper hygiene and good nutrition
If with no improvement after 72 hours, consider shifting
of medication or refer to tertiary hospital or to
specialists.
If patient shows improvement initially (afebrile,
improved respiratory rate) within 72 hours, but
manifests new onset of symptoms later (recurrence of
fever, tachypnea), consider Nosocomial or hospital-
acquired pneumonia/infection (see sample orders for
infection at Nosocomial Pneumonia).
PCAP-D with Malnutrition
Sample Orders:
Please admit to ICU
Secure consent
TPR Q4
NPO
Take initial O2 sat at room air via pulse oximeter
Labs:
CBC, plt
CXR AP/L
ABG
IV: D5LR or D5IMB at full maintenance rate (may shift to
heplock once on DAT)
Meds:
For 3mons – 5yo:
Primary Therapy
Chloramphenicol 100mg/kg/day IVTT Q6hrs
Alternative Therapy
Ceftriaxone 100mg/kg/day IVTT Q12hrs OR OD
( ) ANST
For 5yo above:
Primary Therapy
Penicillin Na 200,000-300,000 IU/kg/day slow IVTT
OR as drip Q6 ( ) ANST
Alternative Therapy
Ceftriaxone 100mg/kg/day IVTT Q12 or OD ( )
ANST
Supportive Therapy
Paracetamol 10mg/kg/d IVTT Q4 pm for temp ≥
38°C
May ADD:
Oxacillin 100mg/kg/day slow IVTT Q6
( ) ANST
Gentamycin 5mg/kg/day slow IVTT OD
O2 inhalation via facemask at 6 LPM
Place patient on moderate high back rest
Monitor V/S Q4 to include O2 saturation
Refer for cyanosis, progress of DOB, Seizure or any
untoward events
NOTE:
Dosages of Penicillin G can he mixed with PNSS 20-
30cc in soluset to run as drip for 30 minutes.
If NOTEd with wheezing may start nebulization with 1
nebule salbutamol with frequency dependent on
physician’s assessment.
Once with improvement within 72 hours;
shift O2 to nasal or discontinue
start feeding
shift medication to oral preparation
Chloramphenicol IV to Chloramphenicol oral
Paracetamol IV to paracetamol oral
Penicillin IV to Amoxicillin OR Co-amoxiclav oral
Ceftriaxone IV to Co-amoxicillin or Cefixime oral
Consider sending the patient home
Advice proper hygiene and good nutrition
If with no improvement after 72 hours, consider shifting
of medication or refer to tertiary hospital or to
specialists.
If patient shows improvement initially (afebrile,
improved respiratory rate) within 72 hours, but
manifests new onset of symptoms later (recurrence of
fever, tachypnea), consider Nosocomial or hospital-
acquired pneumonia/infection (see sample orders for
infection at Nosocomial Pneumonia).
PCAP – C
(Pneumonia-I, Pneumonia Severe)
Sample Orders:
Please admit
Secure consent
TPR Q4
NPO
Take initial O2 sat at room air via pulse oximeter
Labs:
CBC, plt
CXR AP/L
ABG
IV: D5LR or D5IMB at full maintenance rate + deficit%
Meds:
For (+) Hib Immunization:
Penicillin Na 200,000-300,000 IU/kg/day slow IVTT
OR as drip Q6 ( ) ANST
For (-) or incomplete Hib Immunization:
Ampicillin 100mg/kg/day IVTT Q6 ( ) ANST
Alternative Therapy
Cefuroxime 100mg/kg/day IVTT Q8 ( ) ANST OR
Ampicillin-Sulbactam 150mg/kg/day IVTT Q8
( ) ANST
Supportive Therapy
Paracetamol 10mg/kg/d IVTT Q4 pm for temp ≥
38°C
Start O2 inhalation via facemask at 6 LPM
Place patient on moderate high back rest
Monitor V/S Q4 to include O2 saturation
Refer for cyanosis, progress of DOB, seizure or any
untoward events
NOTE:
Dosages of Penicillin G can he mixed with PNSS 20-
30cc in soluset to run as drip for 30 minutes.
If NOTEd with wheezing may start nebulization with 1
nebule salbutamol with frequency dependent on
physician’s assessment.
Once with improvement within 72 hours;
shift O2 to nasal or discontinue
start feeding
shift medication to oral preparation
Chloramphenicol IV to Chloramphenicol oral
Paracetamol IV to paracetamol oral
Penicillin IV to Amoxicillin OR Co-amoxiclav oral
Ceftriaxone IV to Co-amoxicillin or Cefixime oral
Consider sending the patient home
Advice proper hygiene and good nutrition
If with no improvement after 72 hours, consider shifting
of medication or refer to tertiary hospital or to
specialists.
If patient shows improvement initially (afebrile,
improved respiratory rate) within 72 hours, but
manifests new onset of symptoms later (recurrence of
fever, tachypnea), consider Nosocomial or hospital-
acquired pneumonia/infection (see sample orders for
infection at Nosocomial Pneumonia).
Tuberculosis in Children
Diagnosis of TB in Children
The PPS consensus confirmed that a ―positive culture
with or without a positive smear for M. tuberculosis is
a gold standard for the diagnosis of TB. However, in
the absence of bacteriological evidence, a child is
presented to have active TB if three (3) or more of
the following criteria are present:
1. Exposure to adult TB
2. TB symptomatic (as previously mentioned)
3. Positive Purified Protein Derivative (PPD) testing
4. Chest X-ray suggestive of TB
5. Other diagnostic test (ODT) findings suggestive of
TB (eg. Histological)
Classification of Tb in children
Pulmonary TB – formation of lesion mainly in the lungs
Primary Tuberculosis
Progressive Primary Tuberculosis
Eg. miliary TB, TB pleural effusion
Extra-pulmonary TB
Mild extra-pulmonary disease
Eg. Cervical adenitis
Serious or complicated extra-pulmonary TB
Eg. Pott’s disease, TB meningitis
Spectrum of TB
Criteria TB TB Infection TB Disease
Exposure
Exposure Yes Yes Yes
Signs &
None None Positive
Symptoms
Positive Positive
PPD Negative (but negative in (but negative in
many children)a many children)a
(maybe positive,
Chest
Negative Negative negative or
X-ray
unreliable)b
Sputum (maybe positive,
Negative Negative
Exam negative)c
Other
Negative (may be positive)d (maybe positive)d
Diagnostics
a may be false negative in many children due to several factors
b may be positive, showing hilar adenopathy and the Ghon complex;
variable findings
c may be negative due to paucibacillary nature in children and difficult of
I : TB Exposure
Age Regimen Remarks
3 months Isoniazid
Less (as intensive Re-evaluation after 3 months
than 5 treatment, to be and revise treatment
years modified based on accordingly
follow-up PPD result)
Immediate prophylaxis is
controversial for >5 years old,
but is recommended by some
experts especially for
≥5
3 months Isoniazid undernutrition and
years
immunocompromised state
Re-evaluation and classification
of TB and revision of treatment
flee well
II : Latent TB Infection (LTBI)
Condition Regimen Remarks
PPD conversion within past 1-2
9 months Isoniazid
years, (-)CXR
PPD (+) not due to BCG, (-
9 months Isoniazid
)CXR, (-) previous treatment
PPD (+) with stable/healed
9 months Isoniazid
lesion, (-) previous treatment In the
PPD (-) with stable/healed presence of
lesion, (+) previous treatment, primary
at risk for reactivation due to 1 – 2 months Isoniazid Isoniazid
a. Measles, pertussis, etc. Isoniazid for the resistance,
b. Conditions/drugs inducing duration of give 6 month
immunosuppression immunosuppression Rifampicin
(IDDM. Leukemia, Chronic
dialysis)
HIV infection/ persons at risk for
infection but HIV status is 12 months Isoniazid
unknown
Types of Pleurisy:
Dry/Plastic/Parapneumonic
associated with acute bacterial infections (S. aureus,
S. pyogenes, S. pneumoniae) viral pulmonary
infection, TB, connective tissue diseases like
rheumatic fever
limited to visceral pleura with small amount of yellow
serous fluids and adhesions between pleural
surfaces
Serofibrinous/Serosaguinous
associated to lung infection
inflammatory condition of the abdomen or
mediastinum
metastatic neoplasm
fibrinous exudates on pleural space and an
exudative effusion of serous fluid in the pleural cavity
Purulent/ Empyema
pus in the pleural space
associated with staphylococci, less frequent with
pneumococci and H. influenza
Clinical Manifestations:
Fever
Pain exaggerated by deep breathing, coughing and
straining/ Respiratory distress
Friction rub
Dullness on percussion
Decrease breath sounds on affected area
Decrease fremitus on affected
NOTE:
If thoracentesis is done, the fluid aspirated should be
replaced with (same amount) PNSS thru IV push.
Dosages of Penicillin G can he mixed with PNSS 20-
30cc in soluset to run as drip for 30 minutes.
If NOTEd with wheezing may start nebulization with 1
nebule salbutamol with frequency dependent on
physician’s assessment.
Once with improvement within 72 hours;
shift O2 to nasal or discontinue
start feeding
shift medication to oral preparation
Chloramphenicol IV to Chloramphenicol oral
Paracetamol IV to paracetamol oral
Penicillin IV to Amoxicillin OR Co-amoxiclav oral
Ceftriaxone IV to Co-amoxicillin or Cefixime oral
Consider sending the patient home
Advice proper hygiene and good nutrition
If with no improvement after 72 hours, consider shifting
of medication or refer to tertiary hospital or to
specialists.
If patient shows improvement initially (afebrile,
improved respiratory rate) within 72 hours, but
manifests new onset of symptoms later (recurrence of
fever, tachypnea), consider Nosocomial or hospital-
acquired pneumonia/infection (see sample orders for
infection at Nosocomial Pneumonia).
Consolidation
(Lobar Pneumonia)
Definition:
Lobar pneumonia is an acute exudative
inflammation of an entire pulmonary lobe,
produced in 95% of cases by S. pneumonia.
Consolidation is a pathologic disease process that
takes place with certain types of lung infections. It is
a solidification of fluids from pulmonary edema,
inflammatory exudates, pus, inhaled water, or blood
into a firm and dense mass.
Manifestations:
Fever
Cough
Expansion of the thorax on inspiration is reduced on the
affected side
Vocal fremitus is increased on the side with
consolidation
Percussion is dull in affected area
Inspiratory crackles
Vocal resonance is increased
Pleural rub may be present
Sample Orders:
Please admit
Secure consent
TPR Q4
NPO
Labs:
CBC, plt
CXR AP/L
IV: D5LR or D5IMB at full maintenance rate + deficit (%)
Meds:
Primary Therapy
Penicillin Na 200,000-300,000 IU/kg/day slow IVTT
OR as drip Q6 ( ) ANST ±
Gentamycin 5mg/kg/day IVTT OD OR
Amikacin 10-15mg/kg/day IVTT OD
Alternative Therapy
Ceftriaxone 100mg/kg/day IVTT Q12 OR OD ( )
ANST OR
Cefotaxime 100mg/kg/day IVTT Q6 OR q12 ( ) ANST
OR
Chloramphenicol 100mg/kg/day IVTT Q6 AND
Gentamycin 5mg/kg/day IVTT OD OR
Amikacin 10-15mg/kg/day IVTT OD
Supportive Therapy
Paracetamol 10mg/kg/dose IVTT Q4 PRN for temp
≥ 38°C
O2 inhalation via facemask at 6 LPM
Do chest physiotherapy as frequent as possible
Place patient on moderate high back rest
Monitor V/S Q4 to include O2 saturation
Refer for cyanosis, progress of DOB, seizure or any
untoward events
NOTE:
Dosages of Penicillin G can he mixed with PNSS 20-
30cc in soluset to run as drip for 30 minutes.
If NOTEd with wheezing may start nebulization with 1
nebule salbutamol with frequency dependent on
physician’s assessment.
Once with improvement within 72 hours;
shift O2 to nasal or discontinue
start feeding
shift medication to oral preparation
Chloramphenicol IV to Chloramphenicol oral
Paracetamol IV to paracetamol oral
Penicillin IV to Amoxicillin OR Co-amoxiclav oral
Ceftriaxone IV to Co-amoxicillin or Cefixime oral
Consider sending the patient home
Advice proper hygiene and good nutrition
If with no improvement after 72 hours, consider shifting
of medication or refer to tertiary hospital or to
specialists.
If patient shows improvement initially (afebrile,
improved respiratory rate) within 72 hours, but
manifests new onset of symptoms later (recurrence of
fever, tachypnea), consider Nosocomial or hospital-
acquired pneumonia/infection (see sample orders for
infection at Nosocomial Pneumonia).
Nosocomial Pneumonia
Definition:
Nosocomial pneumonia refers to any pulmonary
infection; retracted by a patient in a hospital at least
48 – 72 hours after being admitted.
usually caused by bacteria, rather than a virus. It
lengthens a hospital stay by 1— 2 weeks.
Etiology:
Bacteria:
Gram negative bacilli (52%)
Staphylococcus aureus (19%)
Enterobacter spp (18.1%)
Pseudomonas aeruginosa (17.4%)
Hemophilus spp. (5%)
Klebsiella pneumomiae
Manifestation:
Recurrence of fever after being afebrile
Recurrence of tachypnea and/or respiratory distress
Cough
Chills
Shortness of breath
Loss of appetite
May have Nausea and vomiting
Crackles or decreased breath sounds
Sample Orders:
Please admit
Secure consent
TPR Q4
NPO
Labs:
CBC, plt
CXR AP/L
Blood C/S
IV: D5 LR or D5IMB at full maintenance rate + deficit (%)
Meds:
Primary Therapy
Ceftazidime 100mg/kg/day IVTT Q6 ( ) ANST PLUS
Amikacin 15mg/kg/day IVTT OD
Alternative Therapy
Cefipime 100mg/kg/day IVTT Q12 OR OD ( ) ANST
OR
Piperacillin + Tazobactam 150mg/kg/day IVTT Q6
( ) ANST OR
Meropenem 60mg/kg/day (max = 120mg/kg/day)
IVTT Q8 PLUS
Amikacin 10-15mg/kg/day IVTT OD
IF MRSA is highly suspected, ADD
Vancomycin 40-60mg/kg/day to run as drip for 1
hour Q6
Supportive Therapy
Paracetamol 10mg/kg/dose IVTT Q4 PRN for temp
≥ 38°C
O2 inhalation either nasal cannula at 3 LPM OR
facemask at 6 LPM
Place patient on moderate high back rest
Monitor V/S Q4 to include O2 saturation
Refer for cyanosis, progress of DOB, seizure or any
untoward events
NOTEs
The antibiotic treatment ranges from 7 to 10 days
If NOTEd with wheezing may start nebulization with 1
nebule salbutamol with frequency dependent on
physician’s assessment.
If with no improvement after 72 hours, consider referral
to tertiary hospital or to specialists.
If patient goes on HAMA, we don’t have any choice
but to shift to oral medication that can cover the
causative microorganisms either by growth or
incidence (like Chloramphenicol, Ciprofloxacin,
Levofloxacin, Moxifloxacin). It is the attending
physician’s call to choose the best management for
the patient.
Laryngotracheobronchitis
Definition:
Asthma is a chronic inflammatory disorder of the
airways resulting in episodic airway obstruction.
Chronicallt, inflamed airways are hyperresponsive,
they become obstructed and airflow is limited (by
bronchoconstriction, mucus plugs and increased
inflammation) when airways are exposed to various
risk factors.
Common Risk Factors in children include exposure to:
Allergens
House dust mites
Animals (dogs, cats)
Cockroaches
Molds
Tobacco smoke
Biomass fuels
Respiratory (viral) infection
Emotional stress
Some drugs (NSAIDs, Aspirin, β-blockers)
Physical Findings
Tachypnea
Dyspnea with prolonged expiratory
Wheezing (maybe absent in severe spasms)
Prominent accessory respiratory muscles
involvement (nasal flare, intercostals/subcostal
retractions)
Cyanosis
Tachycardia
Hyperinflation of the chest
Pulsus paradoxus
NOTE
Not all young children who wheeze have Asthma, the
younger the child, the greater the likelihood that an
alternative diagnosis my explain recurrent wheeze
Diagnosis
There are three ways to diagnose asthma, it can be
through:
Classification of Asthma based on severity
Level of Asthma symptom control
Severity of Asthma Exacerbation
The diagnosis of asthma using the classification based
on severity is usually used for patient who comes in for
consult for the FIRST TIME and without any
exacerbation or attack at the time of consult. This
diagnosis serves as an initial approach to
management (see Stepwise Approach for Managing
Asthma in Children)
NOTE
Once with improvement within 24 hours:
Shift O2 to nasal or discontinue
Start feeding
May shift medication to oral preparation (if
indicated)
Consider sending the patient home
Advice home management according to the
diagnosis based on severity or level of control as
shown in succeeding tables
Stepwise Approach for Managing Asthma in Children
Intermittent Asthma Persistent Asthma: Daily Medications
STEP DOWN: if possible (and Asthma is well controlled at STEP UP: if needed (first check inhale technique, adherence,
Age Therapy least 3 months) environmental control, and comorbid condition)
NOTE:
Dopamine drip maybe considered for hypotension
Consider intubation for angioedema of the epiglottis
and laryngospasm, and stridor and excessive use of
accessory muscles for respiration.
Gastroenterology
Doctors’ Guide
Diarrheal Diseases
Definition:
passage of unusually loose or watery stools, usually
at least three times in a 24 hour period.
It is the consistency of the stools rather than the
number that is most important (WHO 2004).
The pathogenesis of most episodes of diarrhea can
be explained by secretory, osmotic, or motility
abnormalities or a combination of those.
Ecology:
It can be divided into 6 ―Is‖ namely Infection,
Inflammation, Infestation, Indigestion, In-absorption
(appropriate term is Malabsorption), and Idiopathic.
Mode of transmission:
Infectious agents that cause diarrheal disease are
usually spread by the fecal-oral route, specifically by:
ingestion of contaminated food or water
contact with contaminated hands
Host factors associated with increase susceptibility to
diarrheal diseases
Malnutrition
Immunodeficiency or immunologic suppression
Reduced gastric acidity
Decrease intestinal motility
Effective Preventive Intervention:
breastfeeding
improved practices
use of clean water
practice of good hygiene (like proper handwashing)
measles immunization
proper and good food handling
Child with diarrhea**
A B C
Lethargic,
Condition Well, alert Restless, irritable
unconscious
Eyes Normal Sunken Very sunken/dry
Tears Present Absent Absent
Moist Dry Very dry
Mouth /
Drinks normally, Thirsty, drinks Drinks poorly or
Tongue
not thirsty eagerly not able to drink
Goes back Goes back Goes back very
Skin Pinch
quickly slowly slowly
Weight
< 5% 5 – 10% >10%
loss
Fluid
≤ 50 mg/kg 50 – 100 mg/kg > 100 mg/kg
deficit
▼ ▼ ▼
If the patient If the patient
has 2 or more has 2 or more
NO SIGNS OF signs in B, the signs in C, the
DEHYDRATION patient has patient has
SOME SEVERE
DEHYDRATION DEHYDRATION
▼ ▼ ▼
Treatment Treatment Treatment
Plan A Plan B Plan C
NOTE:
Only 2 parameters needed in category
Ask for presence of blood in the stools. If present, treat
with appropriate antibiotics for shigella or amoebiasis.
Treatment Plan A
Hydrite
2 tab in 200ml water or 10sachets in 1L water
Pedialyte 45 0r 90
Prevention of DHN & to maintain normal fluid
electrolyte balance in mild to moderate dehydration
Pedialyte mild 30
To supplement fluid & electrolyte loss due to active
play, prolonged exposure, hot and humid environment
Cholera:
Tetracycline 12.5 mg/kg/day PO Q6 x 3 days (for > 8
yo); OR
Erythromycin 12.5 mg/kg/day PO Q6 x 3 days; OR
Cotrimoxazole 8mg/kg/day PO Q12 x 7 days (based
on Trimethoprim)
Shigella Dysentery:
Ciprofloxacin 15 mg/kg/day PO Q12 x 3 days
Ceftriaxone 100 mg/kg/day IVTT OD; Q12 x 2-5 days
( ) ANST
Parasitism:
Mebendazole 100 mg PO BID for 3days or 500mg single
dose
Albendazole 400 mg PO single dose
Complications:
Central Nervous System (Dengue Encephalopathy)
Convulsion,
Change in consciousness,
spasticity/hyporeflexia,
CSF-normal
Cardiac Involvement
Renal Manifestation (hematuria)
Hepatic manifestations (jaundice, increase liver
enzymes)
Dengue without Warning Signs
(DHF Grade I)
Sample Orders:
Please admit
Secure consent
TPR Q4
DAT with no dark colored food
Labs:
CBC, plt, blood typing
serial hct/plt Q8 or Q12
baseline PT, aPTT
PCR
Dengue NS1 (most sensitive at 1st – 5th day of illness
onwards)
Dengue duo (most sensitive at 5th day of illness
onwards)
Intravenous Therapy
Infant <6 months old:
D5 0.45% at maintenance rate (see Intravenous )
Ages > 6 months old:
D5LR or Plain LR at maintenance rate (see
Intravenous )
IF with mild dehydration but NOT in shock, add the
following to the TFR
≤ 12 months old: 50 cc/kg in 24hrs
≥ 12 months old: 30 cc/kg in 24hrs
Meds:
Paracetamol 10mg/kg/d IVTT Q4 pm for temp ≥ 38°C
I & O Qshift and record quantitatively
Monitor V/S to include BP
Refer for hypotension, narrow pulse pressure, and signs
of bleeding
NOTE:
DO NOT give aspirin or ibuprofen in dengue
For obese patients, use ideal weigh for computation of
the TFR
Dengue with Warning Signs
(DHF Grade II)
Sample Orders:
Please admit
Secure consent
TPR Q4
DAT with no dark colored food
Labs:
CBC, plt, blood typing
serial hct/plt Q8 or Q12
baseline PT, aPTT
PCR
Dengue NS1 (most sensitive at 1st – 5th day of illness
onwards)
Dengue duo (most sensitive at 5th day of illness
onwards)
IV: D5LR or Plain LR using the following rates:
Start at 5 – 7 cc/kg/hr for 1 – 2 hours, then
Reduce to 3 – 5 cc/kg/hr for 2 – 4 hours, and then
Reduce to 2 – 3 cc/kg/hr or less according to
response
Meds:
Paracetamol 10mg/kg/dose IVTT Q4 PRN for temp ≥
38°C
Ranitidine 3 mg/kg/day IVTT Q8 PRN for epigastric
pain
Vitamin K 3 – 5 mg; PRN for bleeding
Tranexamic acid 15 – 20 mg/kg Q6 for bleeding
I & O Qshift and record quantitatively
Monitor V/S to include BP
Refer for hypotension, narrow pulse pressure, and signs
of bleeding
NOTE:
DO NOT give aspirin or ibuprofen in dengue
For obese patients, use ideal weigh for computation of
the TFR
Severe Dengue
(DHF Grade III – Compensated Shock)
Sample Orders:
Please admit
Secure consent
TPR Q4
DAT with no dark colored food
Labs:
CBC, plt, blood typing
serial hct/plt Q8 or Q12
baseline PT, aPTT
PCR, AST, ALT
Dengue NS1 (most sensitive at 1st – 5th day of illness
onwards)
Dengue duo (most sensitive at 5th day of illness
onwards)
IV: Plain LR using the following rates (see
Recommended Fluid Therapy for Compensated Shock)
Start at 10 cc/kg/hr over 1 hour, if with improvement
Regulate to 5 – 7 cc/kg/hr for 1 – 2 hours, then
Reduce to 3 – 5 cc/kg/hr for 2 – 4 hours, and then
Reduce to 2 – 3 cc/kg/hr or less according to
response
Meds:
Paracetamol 10mg/kg/dose IVTT Q4 PRN for temp ≥
38°C
Ranitidine 3 mg/kg/day IVTT Q8 PRN for epigastric
pain
Vitamin K 3 – 5 mg; PRN for bleeding
Tranexamic acid 15 – 20 mg/kg Q6 for bleeding
I & O Qshift and record quantitatively
Monitor V/S to include BP
Refer for hypotension, narrow pulse pressure, and signs
of bleeding
NOTE:
Colloid fluids maybe started anytime during the fluid
resuscitation
Dopamine may be started in separate line if maximum
of 60 cc/kg of PNSS is administered (or equivalent to 3
pushes of 20 cc/kg)
FWB or PRBC transfusion is needed if loss or on-going
loss is significant.
DO NOT give aspirin or ibuprofen in dengue
For obese patients, use ideal weigh for computation of
the TFR
Recommended Fluid Therapy for Compensated
Shock
Severe Dengue
(DHF Grade IV – Hypotensive Shock)
Sample Orders:
Please admit
Secure consent
TPR Q4
DAT with no dark colored food
Labs:
CBC, plt, blood typing
serial hct/plt Q8 or Q12
baseline PT, aPTT
PCR, AST, ALT
Dengue NS1 (most sensitive at 1st – 5th day of illness
onwards)
Dengue duo (most sensitive at 5th day of illness
onwards)
IV: Plain LR using the following rates (see
Recommended Fluid Therapy for Hypotensive Shock)
Push 10 cc/kg/hr over 15 minutes, if with
improvement
Regulate to 10 cc/kg/hr over 1 hour, then
Regulate to 5 – 7 cc/kg/hr for 1 – 2 hours, then
Reduce to 3 – 5 cc/kg/hr for 2 – 4 hours, and then
Reduce to 2 – 3 cc/kg/hr or less according to
response
Meds:
Paracetamol 10mg/kg/dose IVTT Q4 PRN for temp ≥
38°C
Ranitidine 3mg/kg/day IVTT Q8 PRN for epigastric
pain
I & O Qshift and record quantitatively
Monitor V/S to include BP
Refer for hypotension, narrow pulse pressure, and signs
of bleeding
NOTE:
Colloid fluids maybe started anytime during the fluid
resuscitation
Dopamine may be started in separate line if maximum
of 60 cc/kg of PNSS is administered (or equivalent to 3
pushes of 20 cc/kg)
FWB or PRBC transfusion is needed if loss or on-going
loss is significant.
DO NOT give aspirin or ibuprofen in dengue
For obese patients, use ideal weigh for computation of
the TFR
Recommended Fluid Therapy for Hypotensive Shock
Interpreting Hematocrit Changes
Transmission
Ingestion of contaminated food and water
Incubation period
For gastroenteritis usually is 12 to 36 hours (max 6 to
72 hours).
For enteric fever, the incubation period is usually 7 to
14 days (as high as 3 to 60 days).
Symptoms:
School-age Children and adolescents:
Pea soup diarrhea followed by constipation
Fever (rises in a stepwise fashion)
malaise
anorexia
myalgia
headache
abdominal pain develop over 2-3 days
Complications:
Intestinal perforation
GI hemorrhage
Peritonitis
Hepatic or splenic abscess
DIC, myocarditis, meningitis
Sample Orders:
Please admit
Secure consent
TPR Q4
DAT
Labs:
CBC, plt
Serum Na, K
Culture (Blood; urine- second week; Stool- third
week)
Typhi Dot (if illness is 4 days or above)
Malarial smear (for differential)
IVF: D5LR or D5IMB at full maintenance rate
Meds:
Fully susceptible strains
Chloramphenicol 100mg/kg/day IVTT Q6 x 14 days;
OR
Cotrimoxazole 8-10 mg/kg/day PO Q12 x 14 days;
OR
Amoxicillin 75-100 mg/kg/day PO TID x 14 days; OR
Cefixime 50-75mg/kg/day PO BID x 14 days
Quinolone/Multidrug-resistant strains
Azithromycin 8-10 mg/kg/D PO OD x 7 days; OR
Ceftriaxone 100mg/kg/day IVTT OD or Q12 x 5-7
days ( ) ANST; OR
Cefixime 20 mg/kg/day PO BID x 14 days; OR
Ofloxacin/Ciprofloxacin 15mg/kg/day x 14 days
Supportive Therapy
Paracetamol 15mg/kg/dose PO Q4 pm for temp ≥
38°C
Monitor V/S Q4
Refer for persistent abdominal pain, DOB, change of
sensorium, seizure or any untoward events
Bacterial Skin & Soft Tissue Infection
Definition:
single most common diagnosis among children with
skin problems. The most common bacterial skin
infection in children is impetigo, which makes up
approximately 10% of all skin problems.
Sample Orders:
Please admit
Secure consent
TPR Q4
DAT
Labs
CBC, plt
CXR AP/L
IV: D5LR or D5IMB at full maintenance rate
Meds:
Punctured wounds (P. Aeuruginosa, S.aureus,
Streptococcus, Anaerobes)
Oxacillin 100-200 mg/kg/day slow IVTT Q6 ( )ANST
PLUS
Amikacin 15mg/kg/day IVTT OD OR
Ceftazidime 100mg/kg/day IVTT Q6 ( ) ANST
Interpretation of TNS:
Score of 0 : recovery improbable
Score of 15 : recovery expected
NOTE: Reassessment of TNS should be done every 24 hours
Sample Orders:
Please admit to Isolation
Secure consent
TPR Q2
NPO temporarily
Labs:
CBC, plt
Na, K
CXR APL
RBS
IV: D5LRlLi to run as maintenance rate
Meds:
To neutralize circulating toxin
For NEONATES:
TIG 3,000 Units IM OR
ATS 5,000 Units IM and another 5,000 units IVTT
For OLDER:
TIG 3,000 Units IM OR
ATS 10,000 Units IM and another 10,000 units IVTT
( ) ANST
Tetanus toxoid 0.5 cc IM
To eradicate vegetative forms of C. tetani
Penicillin 100 mg/kg/day IVTT OR as drip Q6
( ) ANST OR
Metronidazole 30 mg/kg/day IVTT Q8
To control muscular spasms*
Diazepam 0.2mg/kg/dose slow IVTT Q2hours
May consider Midazolam drip 1-2ugm/kg/hr
To provide other supportive and symptomatic care
Paracetamol 10mg/kg/dose IVTT Q4 PRN for temp
≥ 38°C
Ranitidine 2-4 mg/kg/day IVTT Q8
Debridement of necrotic tissues (refer to surgery)
1 & O Q shift and record quantitatively
Monitor V/S but avoid stimuli (tactile, noise, light)
Clean wound with hydrogen peroxide and betadine
Refer for uncontrolled spasms
May need to refer to anesthesia for sedation
Secure airway either thru intubation or tracheostomy
Once intubated, hook to mechanical ventilator if
available
*CAUTION:
Using of Diazepam and Midazolam especially with
inappropriate dosaging may cause respiratory
depression. It warrants close monitoring of the patient’s
condition.
If the treating physician is not confident enough to
manage the case, referral to higher level of health
care may be the appropriate move.
Malaria
Definition
Malaria is the most common acute and chronic
parasitic disease in humans characterized by
paroxysms of fever, chills, sweats, fatigue, anemia
and splenomegaly.
Etiology
plasmodium falciparum (most frequent)
plasmodium vivax
mixed infection (Pf and Pv)
plasmodium malariae
plasmodium ovale (rare)
Common symptoms
fever and chills
splenomegaly
anemia
Control and preventive measures
Treatment of infected persons
Chemoprophylaxis for travelers to endemic area
Reduction of contact with mosquitoes through the
use of insect repellents, protective clothes, mosquito
nets and screens
Eradication of Anopheles mosquitoes through the
use of insecticides and other measures
Geographical Distribution
generally considered rural in distribution
seen mostly in hinterlands and newly opened
settlement areas
local experience show cases reported in areas
adjacent to urban centers
cases in Western Mindanao are common from island
provinces of ARMM like Basilan, Sulu (Tongkil) and
Tawi-tawi.
Malaria: Diagnostic Approach
Sample Orders:
Please admit
Secure consent
TPR Q4
DAT
Labs:
CBC, plt, blood type
CXR AP/L
Malarial Smear or
ICT-Malaria
Baseline BUN, Creatinine, liver function tests,
IV: D5LR or D5IMB at full maintenance rate
Meds:
Uncomplicated P. falciparum Malaria
Coartem tab:
For weight 25kg to less than 35kg- needs 18 tabs
3 tabs PO, then 3 tabs after 8 hrs, then 3 tabs BID
for 2 days
For weight 15kg to less than 25kg- needs 12 tabs
2 tabs PO, then 2 tabs after 8 hrs, then 2 tabs
BED for 2 days
For weight 5kg to less than 15kg- needs 6 tabs
1 tabs PO, then 1 tabs after 8 hrs, then 1 tabs
BED for 2 days
Primaquine (26.3 mg or 15 mg base tablet) on Day
3 ONLY
Above 12 years old : 3 tabs
7-11 years old : 2 tabs
4-6 years old : 1 tab
1-3 years old : ½ tab
Below 1 year old : contraindicated
Uncomplicated P. vaxix Malaria
Chloroquine-sensitive P. vivax, P. Ovale,
P.falciparum:
Chloroquine 10mg base/kg PO initially for Day 0
and 1; then 5mg base/kg on Day 2; PLUS
Primaquine 0.3 mg base/kg PO daily for Day 3-
17 (for vivax and ovale)
Chloroquine-resistant plasmodium and severe P.
falciparum:
Quinine dihydrochloride 20 mg/kg in 500cc D5W
or NSS over 4 hours initially, then 10 mg/kg in
500cc D5W or NSS as drip over 4 hours Q8 hours.
Shift to oral quinine sulfate 10 mg/kg TID as soon
as oral drugs are tolerated to complete 7 days
of treatment
Refer for abdominal pain, change of sensorium, DOB,
seizure or any untoward events
Meningococcemia
Definition
Meningococcemia is a result of invasive
meningococcal infection in which the onset is
abrupt.
Etiology
Neisseria meningitides
a gram negative diplococcus with at least 13
serogroups. This is thought to be acquired by a
respiratory route.
Incubation Period
1 – 10 days, but an average of less than 4 days
Clinical Manifestations: Mimics viral infections
pharygitis
fever
chills
malaise
macular, maculo-papular or petechial rashes in
rapid progression
In fulminant cases: plus ― Waterhouse-Friderichsen
Syndrome
Purpura
DIC
Shock
Coma
Death : despite of appropriate management
Sample Orders:
Please admit in isolation
Secure consent
TPR Qhourly
NPO
Labs:
CBC, plt
CXR AP/L
Na, K
Blood C/S
Gram staining (purpuric scrapping)
CSF Analysis
IV: D5LR or D5IMB at full maintenance rate + 12%
Meds:
Penicillin 100,000-300,000 Units/kg/day mixed with
20cc PNSS to run as drip Q6 ( )ANST
Paracetamol 10mg/kg/dose IVTT Q4 PRN for temp ≥
38°C
Diazepam 0.2 mg/kg/dose slow IVTT PRN for frank
seizure*
For succeeding seizure episodes*
ADD: Phenobarbital 10mg/kg slow IVTT, then
repeat another 10mg/kg slow IVTT 30mins after
the first dose, then give maintenance dose of 5
mg/kg/day slow IVTT Q12
Ranitidine 2-4mg/kg/day IVTT Q8
O2 inhalation either nasal cannula at 3 LPM or
facemask at 6 LPM
Monitor V/S Q4 to include O2 saturation
Refer for cyanosis, progress of DOB, seizure or any
untoward events
NOTE:
For SHOCK:
Push 20cc/kg PNSS IV bolus (may repeat upto 3x if
still with no pulse)
Dopamine may be started in separate line if
maximum of 60cc/kg of PNSS bolus is already
administered
Viral Exanthem
A rash associated with a viral infection; it may be caused
by an immune hyper-reaction or by the toxins released
by the virus. It is usually widespread across the body
and can vary in characteristics depending on the virus
involved. Some causes are self-limiting while others
may require supportive or specific treatment.
Etiology:
E. coli - 80-90%
Others include
Klebsiella species, Enterobacteria species
Coagulase negative Staphylococcus
Uncommon organisms causing UTI in ambulatory
children
H. influenza, Adenoviruses, Enterococci
Post- instrumentation
Proteus, Pseudomona, Staphulococcus aureus,
Streptococcus, Enterococcus and Klebsiella
Approach to Urinary Tract Infection
Definition:
Is a clinical syndrome characterized by generalized
edema/anasarca, heavy proteinuria (albuminuria),
and hypoalbuminemia, with or without
hypercholesterolemia/hyperlipidemia. It is important
that heavy proteinuria is quantified to make a
definitive diagnosis. By definition, heavy proteinuria is
40mg/m2/hr in a 24 hour urine collection. You may
suspect nephrotic syndrome if albumin in the dipstick is
3+ or 4+. Hypoalbuminemia is defined as albumin
<25g/L.
Sample Orders:
Please admit
Secure consent
TPR Q2 to include BP
Diet:
Low salt, low fat diet
Encourage egg white intake
Labs:
CBC, plt, blood typing
Urinalysis
CXR AP/L (if pleural effusion is considered)
TPAG
Serum cholesterol
Serum creatinine
Serum Na, K
Serum C3
No fluid restriction is necessary unless with signs of
volume overload (neck vein engorgement,
hypertension, pulmonary congestion, congestive heart
failure). If necessary initially limit fluid at 500mL/BSA/day
(orally)
7-3 shift = 45% of computed fluid
3-11 shift = 45% of computed fluid
11-7 shift = 10% of computed fluid
Meds:
If free from infection
Prednisone 60mg/m2/day or 2mg/kg/day PO OD
(max of 60mg/day)
Antibiotics coverage (if needed according to
specific consideration)
O2 inhalation either nasal cannula at 3 LPM (if
necessary)
Transfusions (if necessary)
Transfuse human albumin 1-2gm/kg/dose as drip for
1-2 hours
Give furosemide 0.5-1mg/kg/dose SIVP mid and
post blood transfusion
I & O Q shift and record quantitatively
Provide empty IV bottle to watcher for purpose of
urine measurement.
Refer for hypertension, cyanosis, seizure, DOB and
other untoward events
Acute Glomerulonephritis (AGN)
Definition:
AGN is a clinical pattern characterized by an acute
onset of degrees of hematuria, hypertension, edema,
and oliguria. A history of pharyngitis or
impetigo/pyoderma, 1-3 weeks prior to the clinical
manifestation is usually present.
Sample Orders:
Please admit
Secure consent
TPR Q2 to include BP
Diet:
Low salt, low fat diet
Labs:
CBC, plt, blood typing
Urinalysis with RBC morphology
ASO titer (if financially able)
Serum C3 complement (if available)
CXR AP/L (if pulmonary congestion is considered)
Fluid Restriction (orally)
Ideal Computation: 500cc/BSA/day (may
discontinue restriction if normotension is achieved)
7-3 shift = 45% of computed fluid
3-11 shift = 45% of computed fluid
11-7 shift = 10% of computed fluid
Meds:
Phenoxymethylpenicillin K (Sumapen) 50mg/kg/day
PO Q6
Furosemide 1-2mg/kg/day IVTT Q4-6
Nifedipine 0.6-1mg/kg SL PRN for hypertension (BP ≥
P99 of the normal BP range for age, sex, and height,
or if patient is symptomatic – with headache, seizure,
blurring of vision)
If hypertension is not yet controlled:
May add Captopril 0.3-0.5mg/kg/dose PO Q8hrs
O2 inhalation either nasal cannula at 3 LPM (if
necessary)
I & O Q shift and record quantitatively
Provide empty IV bottle to watcher for purpose of
urine measurement.
Refer for hypertension, cyanosis, seizure, DOB and
other untoward events
NOTE
Phenoxymethylpenicillin K (Sumapen) 50mg/kg/day PO
Q6 is currently nor routinely recommended.
Technically, you do not have to treat the infection
since it is POST-INFECTIOUS. However, if the patient is still
febrile or toxic looking you may opt to give to treat the
possible nephritogenic strains
Neonatology
Doctors’ Guide
Ballard Score
Problems in the neonates
About 99% of all newborns are considered well-baby,
thus skills on Essential Intrapartum Newborn Care (EINC)
is a MUST
About 1% require extensive resuscitation efforts, thus
health workers should require Neonatal Resuscitation
Program (NRP) training
Approximately 10% require some assistance after birth.
With this, competencies on what to carry out (whether
EINC or NRP) are very important
Most of the newborns underwent extensive
resuscitation and few of those delivered well baby
(e.g. with imperforated anus) may need transfer to
other hospital, thus, health worker must also need to
know the neonatal transport program known as STABLE
(Sugar, Temperature, Airway, Blood pressure,
Laboratory works, Emotional support)
BIRTH
Term gestation?
YES
Clear amniotic fluid? See Essential Intrapartum
Breathing/crying? Neonatal Cure (EINC)
Good muscle tone?
NO
See S.T.A.B.L.E
Neonatal Resuscitation Program
NOTE
NRP, 2010 removes the question regarding amniotic
fluid in the initial assessment of the program. However,
this clue may still be as relevant in our setting
1. Initial steps of resuscitation:
―WADS-R‖ (Warmth, Airway clearing, Dry, Stimulate,
Reposition)
Initial Steps Important Inputs
The goal is to achieve normothermia and avoid
iatrogenic hyperthermia
VLBW infants need additional warming techniques
such as covering them with plastic wrapping and/or
Warmth/
placing them under radiant heat.
Temperature
Other techniques to maintain temperature in the
Control
delivery room are drying, warming pads, increased
environmental temperature, and if the baby is stable,
placing him/her skin-to-skin with the mother covered
with a blanket (EINC)
Routine intrapartum oropharyngeal suctioning is no
longer routinely recommended for newborns born to
Airway mothers with meconium stained amniotic fluid.
Clearing of ONLY non-vigorous newborns (poor respiratory effort,
Meconium heart rate < 100bpm, poor muscle tone) require
endotracheal suctioning (DO NOT do PPV to these
newborns).
Dry the newborn completely and discard the wet
linens, including those upon which the newborn is
lying.
Dry
Drying should be thorough but gentle, avoid vigorous
rubbing or attempts to clean all blood or vernix from
the body.
Stimulate Drying is a form of stimulation
Place the newborn with head in midline position with
Reposition
slight neck extension
NOTE
Do periodic evaluation of respiration, heart rate and color at 30 seconds
interval after the immediate post-delivery assessment. It may take
>10minutes for the newborn to achieve good color
NOTE
Administration of oxygen depends on the assessment of the physician
based on respiration and color. Further resuscitative measure should be
guided also by assessment of respiration, heart rate and color,
2. Positive Pressure Ventilation (PPV)
Indications:
Newborn remains apneic or gasping
If the heart rate remains <100bpm 30 seconds after
administering the initial steps OR
The newborn continues to have persistent central
cyanosis despite administration of oxygen
supplementation
Important inputs
Devices Initial Breaths and Assisted Assisted Ventilation for the
Ventilation Preterm
1. Flow inflating Initial peak inflating Most preterm infants
bag pressure for the initial can be ventilated with
2. Self-inflating breath 30-40cm H2O an initial inflation
bag and 20-30cm H2O for pressure of 20-25 cm
3. T-piece subsequent breaths H2O although of some
resuscitator Assisted breaths 40-60 who do not respond
4. Laryngeal per minute is require a higher
mask commonly used pressure
Primary measure of Prompt improvement
adequate response to in heart rate should be
assisted ventilation is obtained
prompt improvement
in heart rate of
>100bpm
CAUTION: Never do PPV for meconium aspirated newborn
and for newborn with congenital diaphragmatic
hernia.
3. Endotracheal Intubation:
Indications:
Tracheal suctioning for meconium is required.
Bag-mask ventilation is ineffective or prolonged
Chest compressions are performed
Endotracheal administration of medication is desired
Special circumstances: Congenital Diaphragmatic
Hernia or extremely low birth weight (< l,000 g)
NOTE:
Prompt increase in heart rate is the BEST indicator of
correct tube placement and effective ventilation
Predicted Endotracheal tube (ETT) Size & Depth according
to Weight and Gestational Age
ETT Depth (cm
Gestational Age Weight ETT size Laryndoscope Blade
from the upper
(weeks) (gm) (mm) (Straight/Miller)
lip)
24 700 2.5 7 < 1,000 gm
26 900 2.5 7 Size #00
28 1,100 2.5 – 3.0 7
1,000 – 2,000 gm
30 1,350 3.0 7
Size #0
32 1,650 3.0 7
34 2,100 3.5 8
>2,000 gm
36 2,600 3.5 8
Size #1
38 3,000 3.5 – 4.0 9
Indication:
Heart rate of <60bpm despite adequate ventilation
with supplementary oxygen for 30 seconds.
Location
Lower third of the sternum
Techniques:
2 thumb technique
2 thumb technique with fingers encircling the chest
and supporting the back (recommended)
2 fingers technique
2 fingers technique with send hand supporting the
back
Rate
120 events / min
Compressions : Ventilation
3 : 1 ratio
90 compressions and 20 ventilation per minute
Depth
1/3 of the antero-posterior diameter of the chest
5. Medication
Medication Indication Route Dose
Epinephrine If heart rate remains 0.001 – 0.03
<60bpm after adequate mg/kg/dose
ventilation with 100% Intravenous Using
oxygen and chest 1:10,000
compression (0.1mg/ml)
Endotracheal
(if IV access Upto
is not 0.1mg/kg
available)
Volume When volume loss is
expander suspected or the
Plain NSS or newborn appears to be Intravenous 10ml/kg
Plain LRS in shock ( pale, poor
perfusion, weak pulse)
Naloxone For narcotic-induced
(not a routine CNS depression
part of initial
resuscitation) Heart rate and color
must be restored before
Intravenous
considering this drug
or 0.1mg/kg
Intramuscular
CAUTION: Avoid in
babies whose mother is
suspected of
having long term
exposure to opioids
Essential Intrapartum Neonatal Cure (EINC)
EINC/ENC Protocol is series of time bound,
chronologically-ordered, standard procedures that a
baby receives at birth. It contains four time-bound
interventions:
immediate drying
skin to skin contact followed by clamping of the
cord after 1 to 3 minutes
non-separation of baby from mother
Breastfeeding initiation.
EINC
Rationale
immediate drying prevents hypothermia, which is
extremely important to survival
Delayed cord clamping until the umbilical cord stops
pulsating decreases anemia in one of every three
premature babies and prevents brain hemorrhage in
one out of two. It prevents anemia in one out of every
seven term babies
Keeling the mother and baby in uninterrupted skin-to-
skin contact prevents hypothermia, increases
colonization with protective family bacteria and
improves breastfeeding initiation and exclusivity
Breastfeeding within the first hour of life prevents an
estimated 19.1% of all neonatal deaths
Immediate Newborn Care (The First 90 minutes)
TIME BAND:
At perineal bulging, with presenting part visible (2nd
stage of labor)
INTERVENTION:
Prepare for the delivery
ACTION:
Ensure that delivery area is draft-free and between
25 – 28⁰C using a room thermometer.
Wash hands with clean water and soap.
Double glove just before delivery.
TIME BAND:
Within the 1st 30 second
INTERVENTION:
Dry and provide warmth.
ACTION:
Call out the time of birth
Use a clean, dry cloth to thoroughly dry the baby by
wiping the eyes, face, head, front and back, arms
and legs.
Remove the wet cloth.
Do a quick check of newborn’s breathing while
drying.
NOTE:
During the first 30 seconds:
Do not ventilate unless the baby is floppy/limp and
not breathing.
Do not suction unless the mouth/nose are blocked
with secretions or other material.
TIME BAND:
If after 30 second of thorough drying, newborn is
NOT BREATHING or is gasping
INTERVENTION:
Re-position, suction and ventilate
ACTION:
Clamp and cut the cord immediately.
Call for help.
Transfer to a warm, firm surface.
Inform the mother that the newborn has difficulty
breathing and that you will help the baby to
breathe.
Start resuscitation protocol. (See Neonatal
Resuscitation Program)
NOTES:
If the baby is non-vigorous (limp/floppy and not
breathing) and meconium-stained, and;
Health worker not skilled at advanced resuscitation
(or skilled but not equipped with intubation needs):
Clear the mouth
Start bag/mask ventilation
Refer and transport
Health worker with advanced skills at resuscitation:
Intubate the baby and provide positive-pressure
ventilation
Refer and transport as necessary
When appropriate, and when personnel skilled in
advanced resuscitation (intubation, cardiac
massage) are available, refer to appropriate
guidelines.
TIME BAND:
If after 30 secs of thorough drying, newborn is
BREATHING OR CRYING
INTERVENTION:
Do skin-to-skin contact
ACTION:
If a baby is crying and breathing normally, avoid any
manipulation, such as routine suctioning, that may
cause trauma or introduce infection.
Place the newborn prone on the mother’s abdomen
or chest skin-to-skin.
Cover newborn’s back with a blanket and head
with a bonnet.
Place identification band on ankle.
NOTES:
Do not separate the newborn from mother, as long
as the newborn does not exhibit severe chest in-
drawing, gasping or apnea and the mother does
not need urgent medical stabilization e.g. emergent
hysterectomy.
Do not put the newborn on a cold or wet surface.
Do not wipe off vernix if present.
Do not bathe the newborn earlier than 6 hours of
life.
Do not do footprinting.
If the newborn must be separated from his/her
mother, put him/her on a warm surface, in a safe
place close to the mother.
INTERVENTION:
Palpate the mother’s abdomen.
Exclude a second baby. If there is a 2nd baby, get
help. Deliver the second newborn. Manage as in
Multi-fetal pregnancy
ACTION:
If a baby is crying and breathing normally, avoid any
manipulation, such as routine suctioning, that may
cause trauma or introduce infection.
TIME BAND:
1 - 3 minutes
INTERVENTION:
Do delayed or non-immediate cord clamping
ACTION:
Remove the first set of gloves immediately prior to
cord clamping.
Clamp and cut the cord after cord pulsations have
stopped (typically at 1 to 3 minutes)
Put ties tightly around the cord at 2 cm and 5 cm
from the newborn’s abdomen.
Cut between ties with sterile instrument.
Observe for oozing blood.
NOTE:
Do not milk the cord towards the newborn.
After cord clamping, ensure 10 IU IM is given to the
mother. Follow other protocols per PCPNC
TIME BAND:
WITHIN 90 min of age
INTERVENTION:
Provide support for initiation of breastfeeding
ACTION:
Remove the first set of gloves immediately prior to
cord clamping.
Leave the newborn on mother’s chest in skin-to-skin
contact.
Observe the newborn. Only when the newborn
shows feeding cues (e.g. opening of mouth,
tonguing, licking, rooting), make verbal suggestions
to the mother to encourage her newborn to move
toward the breast e.g. nudging.
Counsel on positioning and attachment. When the
baby is ready, advise the mother to:
Make sure the newborn’s neck is not flexed nor
twisted.
Make sure the newborn is facing the breast, with
the newborn’s nose opposite her nipple and chin
touching the breast.
Hold the newborn’s body close to her body.
Support the newborn’s whole body, not just the
neck and shoulders.
Wait until her newborn’s mouth is opened wide.
Move her newborn onto her breast, aiming the
infant’s lower lip well below the nipple
Look for signs of good attachment and suckling:
Mouth wide open
Lower lip turned outwards
Baby’s chin touching breast
Suckling is slow, deep with some pauses
If the attachment or suckling is not good, try again
and reassess.
NOTES:
Health workers should not touch the newborn unless
there is a medical indication.
Do not give sugar water, formula or other
prelacteals.
Do not give bottles or pacifiers.
Do not throw away colostrum.
If the mother is HIV-positive, of PCPNC for special
counseling.
INTERVENTION:
Do eye care
ACTION:
Administer erythromycin or tetracycline ointment or
2.5% povidone-iodine drops to both eyes after
newborn has located breast.
Do not wash away the eye antimicrobial.
TIME BAND:
From 90 Min - 6 Hrs
INTERVENTION:
Give Vitamin K prophylaxis
ACTION:
Wash hands.
Inject a single dose of Vitamin K 1 mg IM. (If parents
decline intramuscular injections, offer oral vitamin K
as a 2nd line).
INTERVENTION:
Inject hepatitis B and BCG vaccinations at birth
ACTION:
Inject hepatitis B vaccine intramuscularly and BCG
intradermally.
Record.
INTERVENTION:
Examine the baby
ACTION:
Thoroughly examine the baby.
Weigh the baby and record.
INTERVENTION:
Cord care
ACTION:
Wash hands.
Put nothing on the stump.
Fold diaper below stump. Keep cord stump loosely
covered with clean clothes.
If stump is soiled, wash it with clean water and
soap. Dry it thoroughly with clean cloth.
Explain to the mother that she should seek care if
the umbilicus is red or draining pus.
Teach the mother to treat local umbilical infection
three times a day.
Wash hands with clean water and soap.
Gently wash off pus and crusts with boiled and
cooled water and soap.
Dry the area with clean cloth.
Paint with gentian violet.
Wash hands.
If pus or redness worsens or does not improve in 2
days, refer urgently to the hospital
NOTES:
Do not bandage the stump or abdomen.
Do not apply any substances or medicine on the
stump.
Avoid touching the stump unnecessarily.
INTERVENTION:
Provide additional care for a small baby or twin
ACTION:
If the newborn is delivered 2 months earlier or weighs
< 1500 g, refer to specialized hospital.
If the newborn is delivered 1-2 months earlier or
weighs 1500 - 2500 g (or visibly small where scale not
available), see Additional care for small newborns
NOTES:
Encourage the mother to keep her small baby in
skin-to-skin contact.
If mother cannot keep the baby in skin-to-skin
contact because of complications, wrap the baby
in a clean, dry, warm cloth and place in a cot.
Cover with a blanket. Use a radiant warmer if the
room is not warm or the baby small.
Do not bathe the small baby. Keep the baby clean
by wiping with a damp cloth but only after 6 hours.
S.T.A.B.L.E
STABLE is an acronym used for neonatal stabilization
focusing on the five basic physiologic areas plus
emotional support to the family before transporting the
baby to other health institution for further
management. This stands for Sugar, Temperature,
Airway, Blood pressure, Laboratory works, Emotional
support
Definition:
Nosocomial pneumonia refers to any pulmonary
infection contracted by a patient in a hospital at least
48-72 after being admitted. It is usually caused by
bacteria, rather than a virus. It lengthens a hospital stay
by 1-2 weeks.
Risks:
Exposure to instrumentation
Mechanical ventilator
Suctions
IV sites
Others
Sample Orders:
Please admit to SNU
Secure consent
TPR Q2
NPO
Labs:
CBC, plt
CXR AP/L
RBS
Blood C/S
IV: D5IMB 500cc to run (100cc/kg/day)
Meds:
Ceftazidime 100mg/kg/day IVTT Q6 ( ) ANST PLUS
Amikacin 15mg/kg/day IVTT OD
Paracetamol 12mg/kg/dose IVTT Q4 PRN for temp ≥
38°C
O2 inhalation either nasal cannula at 3 LPM or
facemask at 6 LPM (depending on respiratory effort)
Place patient on moderate high back rest
Monitor O2 sat Q2hours & refer for ≤ 95%
Refer for cyanosis, progress of DOB, seizure or any
untoward events
Neonatal Sepsis
Definition:
Neonatal Sepsis is a clinical syndrome of systemic illness
accompanied by bacteremia occurring in the first
month of life.
Classification:
Early-onset Sepsis (EOS)
presents on the first 5-7 days of life
usually multi-system and fulminant illness with
prominent respiratory symptoms
associated with intrapartum and perinatal
complications
Late-onset Sepsis (LOS)
presents as early as 5 days of life
usually insidious but it can be fulminant as well
not associated with obstetric complications
Risk factors:
Prematurity
Rupture of membrane (more than 18 hours)
Maternal peripartum fever or infection
Resuscitation at birth
Multiple gestation
Invasive procedures
Clinical Manifestations:
Temperature Instability
Hypothermia- usually bacterial sepsis
Hyperthermia- usually viral cause
Change in behavior
Poor activity
Poor cry
Lethargy
Feeding problem
Feeding intolerance, vomiting, diarrhea
Abdominal distention with or without visible loops
Skin
Cyanosis, Mottling, Rashes, Sclerema, Jaundice
Cardiopulmonary
Tachypnea
Respiratory distress (grunting, flaring etc...)
Tachycardia
Metabolic
Hypoglycemia, Hyperglycemia, Acidosis
Sample Orders:
Please admit to SNU/NICU
Secure consent
TPR Q2
NPO
Labs:
CBC, pit, blood typing
RBS
Na, K
Blood CS
CXR AP/L (as needed)
IV:
For 1 day old neonate:
D10W 500cc to run (80cc/kg/day)
For 2 days old neonate onwards:
D10IMB500cc to run (100cc/kg/day)
Meds:
Ampicillin 100 mg/kg/day IVTT Q12 (for age <7days)
OR Q6 (for age > 7days) PLUS
Gentamycin 5 mg/kg/day IVTT OD OR
Amikacin 15 mg/kg/day IVTT OD
O2 inhalation either nasal cannula at 3 LPM OR
facemask at 6 LPM
Keep thermoregulated
Routine NB care
Vitamin K 1mg SQ
Cord care
Erythromycin eye ointment OU
BCG/ Hepa B vaccines
NB screening test
ATS 1,500 units IM (if home delivered)
Monitor O2 sat Q2hours & refer for < 95%
Check hgt now then Q6 & refer for ≤40 or ≥140 mg/dL
Refer for poor suck, cyanosis, DOB, seizure, and other
untoward events
Potentially Septic Newborn (PSNB)
Basis:
Premature Rupture of Membrane (more than 18
hours)
History of maternal fever or infection
History of attempted home delivery
Unsterile internal examination (usually by hilots)
Otherwise the baby has good suck, cry and activity
Action:
the neonate should be managed as Sepsis until
Blood C/S results will reveal no growth.
Sample Orders:
Please admit to SNU/NICU
Secure consent
TPR Q2
Start feeding Q2 as tolerated
Labs:
CBC, pit, blood typing
RBS
Blood C/S
Insert IV and place on heplock
Meds:
Ampicillin 100 mg/kg/day IVTT 012 PLUS
Gentamycin 5 mg/kg/day IVTT OD OR
Amikacin 15 mg/kg/day IVTT OD
Keep thermoregulated
Routine NB care
Vitamin K 1mg SQ
Cord care
Erythromycin eye ointment OU
BCG/ Hepa B vaccines
NB screening test
ATS 1,500 units IM (if home delivered)
Check hgt now then Q6 & refer for ≤ 40 or ≥140 mg/dL
Refer for poor suck, cyanosis, DOB, seizure, and other
untoward events
Meconium Aspiration Syndrome (MAS)
Definition:
MAS is an obstruction of the airway with a meconium
which interferes with gas exchange and leads to acute
or chronic hypoxia and/or infection.
Pathophysiology:
Airway Obstruction
Big airway may cause atelectasis
Small airway may lead to air trapping due to ball-
valve effect, and later result to air leak that causes
pneumothorax or pulmonary interstitial
emphysema.
Chemical Pneumonitis
Inactivation of existing sulfactant
Risk Factors:
Post term pregnancy
pre-eclampsia-eclampsia
maternal hypertension
maternal diabetes mellitus
Oligohydramnios
Clinical Manifestations:
meconium stained umbilicus and/or nail beds
tachypnea
difficulty of breathing
nasal flare
± intercostal retraction
cyanosis
Sample Orders:
Please admit
Secure consent
TPR Q2
NPO
Labs:
CBC, plt, blood typing
CXR AP/L (preferably 4 hours after)
IV:
For 1 day old neonate:
D10W 500cc to run (80cc/kg/day)
For 2 days old neonate onwards:
D10IMB 500cc to run (100cc/kg/day)
Meds:
Ampicillin 100 mg/kg/day IVTT Q12 PLUS
Gentamycin 5 mg/kg/day IVTT OD OR
Amikacin 15 mg/kg/day IVTT OD
O2 inhalation either nasal cannula at 3 LPM or
facemask at 6 LPM (depending on respiratory effort)
if with minimal pneumothorax or
pneumomediastinum:
may give Nitrogen wash by O2 hood at 10 LPM
may do endotracheal intubation if needed
Keep thermoregulated
Routine NB care
Vitamin K 1mg SQ
Cord care
Erythromycin eye ointment OU
BCG/ Hepa B vaccines
NB screening test
Monitor O2 sat Q2hours & refer for < 95%
Refer for cyanosis, DOB, seizure, and other untoward
events
Neonatal Jaundice
Definition;
Neonatal Jaundice is a clinical condition by which
there is an increase m the total serum bilirubin resulting
from a high rate of bilirubin production compared to
that of elimination
Pathophysiology:
Physiologic Jaundice
Breast feeding and Jaundice
Breast-feeding jaundice
Breast milk jaundice
Pathologic Jaundice with its common causes:
ABO incompatibility
Sepsis
Definition:
Omphalitis is characterized by erythema and/or
induration of the periumbilical area with purulent
discharge from the umbilical stump.
Sample Orders:
Please admit to SNU
Secure consent
TPR Q2
Encourage breastfeeding
Labs:
CBC, plt, blood typing
RBS
CXR AP/L (as needed)
Blood C/S
Gram stain of umbilical discharge
IV: D5IMB 500cc to run (100cc/kg/day)
Meds:
Oxacillin 100mg/kg/day IVTT Q6
May add:
Gentamycin 5mg/kg/day IVTT OD OR
Amikacin 15mg/kg/day IVTT OD
Keep thermoregulated
(If home delivered) Routine NB care
Vitamin K 1mg SQ
Cord care
Erythromycin eye ointment OU
ATS 1,500 units IM
Refer for cyanosis, DOB, seizure, and other untoward
Perinatal Asphyxia
Definition:
Perinatal Asphyxia is a condition caused by a lack of
oxygen in respired air, resulting in impending or actual
cessation of apparent life. It is a condition of impaired
blood gas exchange that, if it persists, leads to
progressive hypoxemia and hypercapnia with a
metabolic acidosis.
Mechanisms of Asphyxia:
Interruption of the umbilical circulation (cord
compression)
Inadequate perfusion of the maternal side of the
placenta (maternal hypotension, hypertension,
abnormal uterine contractions).
Impaired maternal oxygenation (anemia)
Altered placental gas exchange (previa)
Failure of the neonate to accomplish lung inflation
Essential Characteristics based on joint definition of
American Academy of Pediatrics (AAP) and American
College of Obstetricians and Gynecologists (AOCG):
Profound metabolic or mixed academia (pH <7.0)
on umbilical cord arterial blood sample;
persistence of an APGAR score of 0-3 for >5min;
neurologic manifestations in the immediate
neonatal period to include seizures, hypotonia,
coma and hypoxic-ischemic encephalopathy (HIE);
and
evidence of multiorgan system dysfunction in the
immediate neonatal period to include shock,
hypotension, oliguria, NEC, ARDS,
thrombocytopenia, acidosis, hypoglycemia and
many more.
Sample Orders:
Please admit
Secure consent
TPR Qhourly
NPO
Labs:
CBC, plt, blood typing
CXR AP/L
Cranial X-ray and UTZ (if forceps delivery)
ABG (if available)
IV:
For 1 day old neonate:
D10W 500cc to run (80cc/kg/day)
For 2 days old neonate onwards:
D10IMB 500cc to run (100cc/kg/day)
If the patient is still on NPO, otherwise may shift
to D5IMB instead
Meds:
Ampicillin 100 mg/kg/day IVTT Q12 PLUS
Gentamycin 5 mg/kg/day IVTT OD OR
Amikacin 15 mg/kg/day IVTT OD
May ADD:
Citicoline 100mg/kg/day IVTT Q6,8,12
For Seizure:
Phenobarbital 10mg/kg slow IVTT, then repeat
another 10mg/kg slow IVTT 30mins after the first
dose, then give maintenance dose of 5
mg/kg/day Q12
If intubated,
may give diazepam 0.2mg/kg/dose slow IVTT for
frank seizure
O2 inhalation facemask at 6 LPM; If with poor Apgar
Score with or without poor respiratory effort
Intubate the patient and place on continuous
ambu-bagging or hook to mechanical ventilator
Keep thermoregulated
Routine NB care
Vitamin K 1mg SQ
Cord care
Erythromycin eye ointment OU
BCG/ Hepa B vaccines
NB screening test
ATS 1,500 units IM (if home delivered)
Monitor O2 sat Q2& refer for ≤ 95%
1 & O monitoring and record quantitatively
Refer for cyanosis, DOB, episodes of seizure, and other
untoward
Prematurity
Definition:
A preterm neonate is one whose birth occurs through
the end of the last day of the 37th week.
Risks:
Low socioeconomic status
Mother younger than 16 years or older than 35 yo.
Maternal activity
Maternal Illness
Multiple-gestation births
Prior poor birth outcome
Obstetric factors
Fetal condition
Unintentional early delivery
Problems of prematurity
Respiration
RDS, Apnea, Brochopulmonary Dysplasia
Neurologic
Perinatal depression, Intracranial hemorrhage
Cardiovascular
Hypotension
Hypovolemia, Cardiac dysfunction, Vasodilation
due to sepsis
Hematologic
Anemia, Hyperbilirubinemia.
Gastrointestinal
Necrotizing enterocolitis
Temperature regulation
Hypothermia or hyperthermia
Immunologic
Prone to infection due to deficiency in humeral
and cellular immune response
For ≥ 34 weeks AOG
Definition:
NEC is an acquired neonatal disorder representing an
end expression of serious intestinal injury after a
combination of vascular, mucosal, and metabolic
insults to a relatively immature gut (Gomela).
Risk Factors:
Prematurity
Asphyxia
Enteral Feeding
Polycythemia and hyperviscosity syndromes
Exchange Transfusion
Feeding volumes
Enteric Pathogenic microorganism
Clinical Manifestations according to Stage:
Stage I: Suspected NEC
Systemic signs are nonspecific, including apnea,
bradycardia, lethargy, and temperature instability.
Intestinal findings include feeding intolerance,
recurrent gastric residuals, and guaiac-positive
stools.
Radiologic findings are normal or nonspecific.
Stage IIA: Mild NEC
Systemic signs are similar to those in Stage I.
Intestinal findings include prominent abdominal
distention with or without tenderness, absent bowel
sounds, and gross blood in the stools.
Radiographic findings include ileus, with dilated
loops with focal areas of pneumatosis intestinalis.
Stage IIB: Moderate NEC
Systemic signs include Stage I signs plus mild acidosis
and thrombocytopenia.
Intestinal findings include increasing distention,
abdominal wall edema and tenderness with or
without a palpable mass.
Radiographic findings include extensive
pneumatosis and early ascites.
Stage IIIA: Advanced NEC
Systemic signs include respiratory and metabolic
acidosis, assisted ventilation for apnea, decrease
blood pressure and urine output, neutropenia, and
coagulopathy.
Intestinal findings include spreading edema,
erythema or discoloration and induration of the
abdominal wall.
Radiographic findings include prominent ascites,
paucity of bowel gas, and possibly a persistent
sentinel loop.
Stage MB: Advanced NEC
Systemic findings reveal generalized edema,
deteriorating vital signs and laboratory indices,
refractory hypotension, shock syndrome, DIC and
electrolyte imbalance.
Intestinal findings reveal a tense, discolored
abdomen and ascites
Radiographic findings commonly show absent
bowel gas and often evidence of intraperitoneal
free air.
Advice:
NEC that may be admitted in rural setting is Stage I:
Suspected NEC. Other stages should be referred to
tertiary care.
NOTE:
Dopamine may be started at 5 ug/kg/min for
improvement of G.I. and renal perfusion.
Risks
Hyperglycemia or hypoglycemia
Polycythemia
Definition of Terms:
Meningitis refers to inflammation of the
leptomeninges, the connective tissue layer in close
proximity to the surface of the brain.
Encephalitis refers to inflammation of brain
parenchyma.
Meningoencephalitis is the involvement of structures
affected in meningitis and encephalitis.
Etiology:
Suppurative/Bacterial Meningitis:
0-2 months:
E. coli; gram (-) bacilli; S. pneumoniae
2mons-5years:
H. Influenza; S. Pneumoniae; N. Meningitides
> 5 years old:
S. Pneumoniae; N. Meningitides
TB Meningitis:
Mycobacteria Tuberculosis
Viral Meningitis:
Enterovirus
Encephalitis:
Secondary (Para infectious or Post infection)
Encephalitis:
Measles, Varicella, Rubella
Slow Viral Infections:
SSPE (Subacute Slerosing Panencephalitis)
Progressive Rubella Panencephalitis
• Virus:
Herpes simplex (all ages)
Enteroviruses (infants and children)
Rabies (infants and children)
Varicella (all ages)
Brain Abscess
Streptococcus, Bacteroides fragilis, S. Aureus
Clinical Manifestation of CNS infection
Signs and Older infants and
Neonates
Symptoms children
Fever or Fever
hypothermia Anorexia
Abnormally sleepy Confusion
or Lethargic Irritability
Refuse or poor Photophobia
Nonspecific
feeding Nausea
Cyanosis Vomiting
Grunting Headache
Apneic episodes Seizure
Vomiting
(+) or (-) neck Neck rigidity
Meningeal
rigidity Kemig’s sign
inflammation
Brudzinski sign
Bulging fontanel Headache
Diastasis of sutures Bulging fontanel
Convulsions Diastasis of
Opisthotonus sutures
Increase ICP (infants)
Papilledema
Mental confusion
Altered state of
consciousness
Hemisparesis Hemisparesis
Ptosis Ptosis
Focal neurologic
Facial nerve palsy Deafness
signs
Optic neuritis
Facial nerve palsy
CSF Difference in CNS Infection:
Opening
Glucose Protein
CSF Findings pressure Cell count
(mg/dL) (mg/dL)
(mmH2O)
50 – 75% (at
least 50% of
Normal 90 – 180 0 – 5 lymphocytes 15 – 40
simultaneous
serum glucose)
100 – 5,000
Bacterial
200 – 300 neutrophils, usually Reduced. <40 100 – 1,000
Meningitis
>80%
100 – 200,
but upto
TB Usually <500
180 – 300 Reduced. <40 1,000 if
Meningitis lymphocytes
CSF block
is present
10 – 300 lymphocytes;
Normal
may be >1,000 in
occasionally
Viral echovirus and mumps
90 - 200 slightly reduced 50 - 100
Meningitis meningitis with upto
in mumps
80% neutrophilic
meningitis
predominance
Viral
180 – 300 0 – 500 lymphocytes Normal 50 - 100
Encephalitis
Sample Orders:
Please admit
Secure consent
TPR Q2 to include BP monitoring
NPO
Labs:
CBC, plt
CXR AP/L
Serum Na, K
CSF analysis (review previous page for
contraindications)
IVF: D5LR at full maintenance rate
Meds
For 0-2 months:
Ampicillin 300mg/kg/day IVTT Q12 (for age
<7days) or Q6 (for age > 7days) PLUS
Gentamycin 5mg/kg/day IVTT OD OR
Amikacin 15mg/kg/day IVTT OD OR
Cefotaxime 200mg/kg/day IVTT Q12 (for age
<7days) or Q6 (for age > 7days)
For 2months to 5 years old:
Chloramphenicol 100mg/kg/day IVTT Q6 AND/OR
Penicillin G 300,000 Units as drip Q6 ( )ANST OR
Ampicillin 300mg/kg/day IVTT Q6 ( ) ANST OR
Ceftriaxone 100mg/kg/day IVTT OD OR Q12
( ) ANST
More than 5 years old
Penicillin G 300,000 Units as drip Q6 ( )ANST
AND/OR
Chloramphenicol 100mg/kg/day IVTT Q6 OR
Ceftriaxone 100mg/kg/day IVTT Q12 ( ) ANST OR
Cefotaxime 200mg/kg/day IVTT Q6 ( ) ANST
For increase ICP (decompression):
Mannitol 5cc/kg as IV bolus, then Q4 (BP should be
at normal for age before administration of this
meds) OR
Sodium Lactate (Totilac) 5cc/kg as LD, then 1cc/kg
Qhourly
For Seizure:
Diazepam 0.2mg/kg/dose slow IVTT PRN for frank
seizure
Phenobarbital 10mg/kg slow IVTT as LD, then give
same dose 30mins after the first dose, then
maintain at 5mg/kg/day Q12 (is usually started if
patient has a history of more than 1 seizure
episodes)
Paracetamol 10mg/kg/dose Q4 PRN for temp ≥
38°C
Secure consent for lumbar tap procedure (hold the
procedure if with contraindications).
I & O monitoring and record quantitatively
O2 inhalation via facemask at 6 LPM
Place patient on moderate high back rest
Monitor V/S Q2 to include O2 saturation
Refer for cyanosis, DOB, seizure, apnea or any
untoward events
Sample Orders:
Please admit
Secure consent
TPR Q2 to include BP & O2 saturation monitoring
NPO except oral meds by OGT
Labs:
CBC, plt
CXRAP/L
Serum Na, K
CSF analysis (review contraindications)
PPD or sputum examination (if applicable)
IVF: D5LR at full maintenance rate
Meds:
Anti-TB meds (first l-2months)
Isoniazid 10-15 mg/kg/day PO(max : 300mg/D)
PLUS
Rifampicin 10-20 mg/kg/day PO (max : 600mg/D)
PLUS
Pyrazinamide 10-40 mg/kg/day PO (max : 2g/D)
PLUS
Streptomycin 20-40 mg/kg/day IM (max : 1g/D) OR
Ethambutol 15-20 mg/kg/day PO (requires visual
monitoring)
Anti-TB (for the next 9-12 months)
Isoniazid 10-15 mg/kg/day PO(max : 300mg/D)
PLUS
Rifampicin 10-20 mg/kg/day PO (max : 600mg/D)
For increase ICP (decompression):
Mannitol 5cc/kg as IV bolus, then Q4 (BP should be
at normal for age before administration of this
meds) OR
Sodium Lactate (Totilac) 5cc/kg as LD, then 1cc/kg
Qhourly
For Seizure:
Diazepam 0.2mg/kg/dose slow IVTT PRN for frank
seizure
Phenobarbital 10mg/kg slow IVTT as LD, then give
same dose 30mins after the first dose, then
maintain at 5mg/kg/dayQ12 (is usually started if
patient has a history of more than 1 seizure
episodes)
Paracetamol 10mg/kg/dose Q4 PRN for temp ≥ 38°C
Secure consent for lumbar tap procedure (hold the
procedure if signs of increase ICP are NOTEd.
Refer to surgery for evaluation and management (if
the patient has evidence of obstructive hydrocephalus
and neurological deterioration)
I & O monitoring and record quantitatively
O2 inhalation via facemask at 6 LPM
Place patient on moderate high back rest
Refer for cyanosis, DOB, seizure, apnea or any
untoward events
NOTE:
For Stage II and Stage III, some pediatricians practice
and suggest the use of:
Prednisone l -2mg/kg for 6-8 weeks with tapering of
dosage on the 2nd half of the course.
Dexamethasone 6mg/m2 Q4 or Q6 for consistent
elevation of ICP to reduce edema.
Viral Meningitis
Important information:
higher incidence during summer to fall months
no specific antiviral therapy
treatment is supportive with IV fluids
outcome is usually a full recovery
Sample Orders:
Please admit to Ward
Secure consent
TPR Q2 to include BP monitoring
NPO
Labs:
CBC, plt
CXR AP/L
Serum Na, K
CSF analysis (review contraindications for LP)
IVF: D5LR at full maintenance rate
Meds:
Acyclovir 10 mg/kg IV infusion Q8 for at least 10days
For Seizure:
Diazepam 0.2mg/kg/dose slow IVTT PRN for frank
seizure
Phenobarbital 10mg/kg slow IVTT as LD, then give
same dose 30mins after the first dose, then
maintain at 5mg/kg/dayQ12 (is usually started if
patient has a history of more than 1 seizure
episodes)
Paracetamol 10mg/kg/dose Q4 PRN for temp ≥ 38°C
Secure consent for lumbar tap procedure (hold the
procedure if signs of increase ICP are NOTEd)
I & O monitoring and record quantitatively
O2 inhalation via facemask at 6 LPM
Place patient on moderate high back rest
Monitor V/S Q2 to include O2 saturation
Refer for cyanosis, DOB, seizure, apnea or any
untoward events
Brain Abscess
Mechanisms:
Direct extension of contiguous infection
Penetrating head injuries
Hematogenous spread
Sample Orders:
Please admit
Secure consent
TPR Q2 to include BP monitoring
NPO
Labs:
CBC, plt
CXR AP/L
Serum Na, K
Cranial CT scan
IVF: D5LR at full maintenance rate
Meds:
Penicillin G 300,000/kg/day Units as drip Q6 ( )ANST
(for streptococci coverage) PLUS
Metronidazole 30mg/kg/day IVTT Q8 (for
Bacteroides fragilis coverage) PLUS
Oxacillin 200mg/kg/day IVTT Q6 ( )ANST (for
staphylococcus aureus coverage)
For Seizure:
Diazepam 0.2mg/kg/dose slow IVTT PRN for frank
seizure
Phenobarbital 10mg/kg slow IVTT as LD, then give
same dose 30mins after the first dose, then
maintain at 5mg/kg/day Q12 (is usually started if
patient has a history of more than 1 seizure
episodes)
Paracetamol 10mg/kg/dose Q4 PRN for temp ≥ 38°C
Secure consent for lumbar tap procedure (hold the
procedure if signs of increase ICP are NOTEd).
Refer to surgery for evaluation and management
I & O monitoring and record quantitatively
O2 inhalation via facemask at 6 LPM
Place patient on moderate high back rest
Monitor V/S Q2 to include O2 saturation
Refer for cyanosis, seizure, or any untoward events
Febrile Seizures
Definition:
Febrile Seizures are seizures in 3 months to 6 years old
children associated with fever in the absence of CNS
infection, acute electrolyte imbalance or history of
afebrile seizures in a young child.
Types of Febrile Seizures:
Simple
characterized as brief (<15mins), generalized
(usually tonic-clonic) and a single event in 24 hours
of the same febrile illness.
1 to 1.5% develops epilepsy
Complex
characterized as prolonged (>10-15mins), focal
seizures and recurrent within 24 hours of the same
febrile illness.
4 to 15% develops epilepsy
Febrile Myoclonus
seizure type is myoclonus
Febrile Status Epilepticus
duration of seizure is > 30mins
Risk factors for recurrent Febrile Seizures:
Family history of febrile seizures
Shorter duration of fever (about 1hr) before seizure
Ages < 19 mos of first febrile seizure
Low temperature (close to 39°C triggering seizure
Risk factors for Epilepsy:
Family history of epilepsy
Short duration of fever (about 1hour) before seizure
Complex febrile seizures
Sample Orders:
Please admit
Secure consent
TPR Q2
NPO temporarily
Labs:
CBC, plt
Urinalysis
CXR AP/L
CSF Analysis (for ages 18 months below or with signs
of CNS infection)
Na, K, Mg, Ca, RBS (if applicable)
IV: D5LR or D5IMB at full maintenance rate
Meds:
Paracetamol 10-15mg/kg/dose Q4 IVTT RTC for temp
≥ 38°C
For Seizure:
Diazepam 0.2mg/kg/dose slow IVTT PRN for frank
seizure
Phenobarbital 10mg/kg slow IVTT as LD, then give
same dose 30mins after the first dose, then
maintain at 5mg/kg/day Q12 (For Complex Febrile
Seizure)
O2 inhalation via facemask at 6 LPM
Secure consent for lumbar tap procedure (to rule out
CNS infection)
Place patient on moderate high back rest
Monitor V/S Q2 to include O2 saturation
Refer for cyanosis, progress of DOB, Seizure or any
untoward events
NOTE:
The focus of infection should be worked up. If
coverage is needed, appropriate antibiotics may be
started.
Algorithm: Evaluation and Management of a Child with a
First Simple Febrile Seizure
Acute Symptomatic Seizure (ASS)
Definition:
ASS occurs only in association with precipitants or
triggered factors. This is also known as Situation-related
seizures.
Precipitating factors:
Fever in young children
Sleep deprivation
Hypertension
Metabolic imbalance
Alcohol or drug abuse
Acute head trauma
CNS infection
Sample Orders:
Please admit
Secure consent
NPO temporarily
Labs:
CBC, plt
Urinalysis
CXR AP/L
CSF Analysis (review contraindications)
Na, K, Mg, Ca, RBS
IV: D5LR or D5IMB at full maintenance rate
Meds:
Find and treat the focus causing the seizure
For Seizure:
Diazepam 0.2mg/kg/dose slow IVTT PRN for frank
seizure
Phenobarbital 10mg/kg slow IVTT as LD, then give
same dose 30mins after the first dose, then
maintain at 5mg/kg/day Q12
May start antibiotics for meningitis if on admission,
CNS infection is highly considered
Paracetamol 10-15mg/kg/dose Q4 IVTT RTC for temp
≥ 38°C
O2 inhalation via facemask at 6 LPM
Secure consent for lumbar tap procedure (to rule out
CNS infection)
Place patient on moderate high back rest
Monitor V/S Q2 to include O2 saturation
Refer for cyanosis, DOB, seizure or any untoward events
Hematology
Doctors’ Guide
Anemia
Definition:
Anemia is a reduction of the RBC volume or
hemoglobin concentration below the range of values
occurring in healthy persons (Nelsons)
Complete History includes but not limited to:
blood loss
fatigue
pica
medication exposure
growth and development
nutritional history
menstrual history
ethnic background
history of hyperbilirubinemia
family history of anemia, splenectomy, or
cholecystectomy
Physical Examination
pallor
jaundice
glossitis
tachypnea
tachycardia
cardiac murmur
hepatosplenomegaly
signs for systemic illness
Causes of Anemia
Problems in production
Factory problem (eg. aplastic anemia,
thalassemia)
Raw materials problem (eg. Folic acid deficiency,
Vitamin B12 deficiency)
Problems in destruction (eg. malaria, sickle cell
anemia)
Blood Loss (eg. occult blood loss 2° to typhoid fever,
trauma, APCD)
Classification through Peripheral Blood Smear (PBS):
Microcytic anemia
Macrocytic anemia
Normocytic anemia
Differential Diagnoses based on PBS and Reticulocyte
count:
Retic Microcytic Normocytic Macrocytic
Count anemia anemia anemia
Folic acid
Chronic disease deficiency
Iron deficiency
Malignancy Vit B12
Lead poisoning
Renal failure deficiency
Low Chronic disease
Juvenile Aplastic anemia
Protein
Rheumatoid Drug-induced
malnutrition
arthritis Trisomy 21
Hypothyroidism
Thalassemia
Acute blood
trait
Normal loss
Sideroblastic
Hypersplenism
anemia
Thalassemia G6PD
High Active hemolysis
syndrome Hypersplenism
NOTE:
Some signs of high output failure in anemic patients
are diaphoresis, tachypnea, tachycardia, hemic or
gallop murmur, cardiomegaly, hepatomegaly.
Thalassemia/ Thalassemia Syndrome for Blood
transfusion
Sample Orders:
Please admit to Ward
Secure consent
TPR Q4
DAT (low iron diet)
Labs:
CBC, plt, blood typing
CXR AP/L (if needed)
IV: PNSS 1L at maintenance rate
Meds:
Paracetamol 10mg/kg/dose IVTT Q4 PRN for temp
≥38°C
Secure PRBC of patient blood type, properly screened
and crossmatched, then transfuse 10-15cc/kg in 4
hours
Give furosemide 0.5mg/kg/dose mid and post blood
transfusion
(may repeat blood transfusion 12 hours after the
previous BT)
Please repeat CBC 4-6 hours post blood transfusion
Place patient on moderate high back rest
Refer for transfusion reaction like allergy, cyanosis,
DOB, seizure or any untoward events
ORTHOPEDICS NOTES
Doctors’ Guide
Adult < 40 years old
Sample orders
Please admit patient
Secure consent
DAT/NPO
Monitor V/S q4hrs
Monitor I & O q4hrs
Start IVF of D5LR 1L to run at KVO OR 20gtts/min
If patient is Diabetic use PLR
Diagnostics
X-ray of affected extremity
CBC plt, Blood typing
Meds
Ketorolac 30mg IVTT now then q8hrs ( ) ANST; PRN for
pain
For severe pain
Tramadol 50mg IVTT now then q6hrs, hold if BP
<90/60mmHg
For Open Fracture
Cefazolin 1gm IVTT now then q8hrs ( ) ANST
ATS 3,000 IU IM at left deltoid ( ) ANST
TT 0.5ml IM at right deltoid (if TT given more than
2yrs or when wound is dirty)
If febrile
Paracetamol 300mg IVTT now then q4hr, PRN for
fever ≥ 38ºC
Immobilize affected extremity
Watch out for excessive bleeding
Do daily wound dressing
Refer
Sample orders
Please admit patient
Secure consent
DAT/NPO
Monitor V/S q4hrs
Monitor I & O q4hrs
Start IVF of D5LR 1L to run at KVO OR 20gtts/min
If patient is Diabetic use PLR
Diagnostics
X-ray of affected extremity
CBC plt, Blood typing
ECG 12L
CXR PA upright
Serum Crea
U/A
Meds
Ketorolac 30mg IVTT now then q8hrs ( ) ANST; PRN for
pain
For severe pain
Tramadol 50mg IVTT now then q6hrs, hold if BP
<90/60mmHg
For Open Fracture
Cefazolin 1gm IVTT now then q8hrs ( ) ANST
ATS 3,000 IU IM at left deltoid ( ) ANST
TT 0.5ml IM at right deltoid (if TT given more than
2yrs or when wound is dirty)
If febrile
Paracetamol 300mg IVTT now then q4hr, PRN for
fever ≥ 38ºC
For CP eval
Immobilize affected extremity
Watch out for excessive bleeding
Do daily wound dressing
Refer
Pediatrics
Sample orders
Please admit patient
Secure consent
DAT/NPO
Monitor V/S q4hrs
Monitor I & O q4hrs
Start IVF of D5LR 1L to run at KVO
Diagnostics
X-ray of affected extremity
CBC plt, Blood typing
CXR APL
Meds
Ketorolac 15mg IVTT now then q8hrs ( ) ANST; PRN for
pain
For severe pain
Tramadol 50mg IVTT now then q6hrs, hold if BP
<90/60mmHg
For Open Fracture
Cefazolin 500gm IVTT now then q8hrs ( ) ANST
ATS 1,500 IU IM at left deltoid ( ) ANST
TT 0.5ml IM at right deltoid (if patient is >7yo or TT
given more than 2yrs or when wound is dirty)
If febrile
Paracetamol 150mg IVTT now then q4hr, PRN for
fever ≥ 38ºC
For Peida eval
Immobilize affected extremity
Watch out for excessive bleeding
Do daily wound dressing
Refer
MEDICATION
Doctors’ Guide
Computation of Drugs as Drip (Pedia)
)
)
)
NOTE: Let us put a constant unit for the desired rate in this
formula. (Our Constant is 10 ml/hr)
From: The Harriet Lane Handbook
Example: We want to start Dopamine drip to our
patient:
Example Order:
Please start Dopamine drip as follows:
D5 Water = 38.8 cc
Dopamine (8) = 1.2 cc
40 cc/shift or at 5ugtts/min
Dobutamine in 12.5mg/ml
)
Preparation for Desired Dextrocity
Conversion of D5 to:
D7.5 = mix 475ml of D5 with 25ml of D50-50
D10 = mix 450ml of D5 with 50ml of D50-50
D12.5 = mix 425ml of D5 with 75ml of D50-50
All about Drips (Adult)
OR
8. Dopamine-Lasix Drip:
75 ml of Dopamine Pre-mix (D5W 250 ml+
Dopamine 200 mg) + 25 ml of Lasix 250 mg in a
soluset (Total of 100 ml) to run at 6-8 ugtts/min
OR
IV Oral
1 – 2 g IV 500mg – 1g PO
Ampicillin Amoxicillin
QID TID
500 mg IV
Azithromycin Roxithromycin 300 PO OD
OD
Benzyl Phenoxymethyl
1.2g IV QID 500mg PO QID
penicillin penicillin
No oral formulation
Ceftriaxone 1g IV OD Choice of oral antibiotic depends on
infection site/microbiology
Cephazolin 1g IV TID Cephalexin 500mg PO QID
200‐400mg 250‐500mg PO
Ciprofloxacin Ciprofloxacin
IV BID BID
Flucloxacillin 1g IV QID Flucloxacillin 500mg PO QID
600‐900mg 300‐600mg PO
Lincomycin Clindamycin
IV TID TID
200‐400mg 200‐400mg PO
Fluconazole Fluconazole
IV OD OD
500mg IV
Metronidazole Metronidazole 400mg PO TID
BID
Common Pediatric Medicine Recommended Dose
ANTIBIOTICS
Loading Dose
15mg/kg
Amikacin 50, 100, 500 mg/vial
Maintenance Dose
10mg/kg/day IV OD
100mg/ml
Amoxicillin 125mg/5ml 30-100 mg/kg/day, TID PO
250mg/5ml
Amoxicillin content:
Amoxicillin + 125mg/5ml;
Clavulanic acid OR 250mg/5ml 30-50 mg/kg/day, BID or TID PO
Co-amoxiclav 200mg/5ml;
400mg/5ml
Amoxicillin 250/250mg/5ml
30-50mg/kg/day TID, PO
+Sulbactam 500mg/250mg/vial
75-100mg/kg/day Q6-8, IV
(Ultramox) with diluent
50-100 mg/kg/day
Ampicillin 100,250,500 mg/vial Meningitis
200-400 mg/kg/day; Q6 IV
30-50mg/kg/day BID, PO
Ampicillin +
250mg/5ml 150mg/kg/day IVT Q8
Sulbactam
375,750,1.5g/vial (max 6 g for mild)
(Unasyn)
(max 12 g for severe)
Day 1
10 mg/kg on
Azithromycin 200mg/5ml
Day2-3
5mg/kg/day on BID, PO
50mg/ml;
Cefaclor
125 mg/5ml; 20-40 mg/kg/day; Q8, PO
(2nd gen)
250 mg/5ml
Cefadroxil
250mg/5ml 25-50 mg/kg/day; TID, PO
(1st gen)
Cefalexin 125mg/5ml
25-50 mg/kg/day; TID, PO
(1st gen) 250mg/5ml
Cefazolin
500mg, 1g/vial 50-100 mg/kg/day; Q6-8, IV
(1st gen)
4-8mg/kg/day BID;
Cefixime 20mg/ml
Typhoid fever
(3rd gen) 100mg/5ml
20mg/kg/day BID PO
Cefotaxime
500mg. 1g, 2g.vial 50-150 mg/kg/day; Q6-12, IV
(3rd gen)
Ceftazidime
250, 500mg,1g/vial 50-100 mg/kg/day; Q8-12, IV
(3rd gen)
Ceftriaxone
250, 500, 1g/vial 50-100 mg/kg/day; Q12 or OD, IV
(3rd gen)
250, 759mg/vial
Cefuroxime 20-30 mg/kg/day BID PO
125mg/5ml
(2nd gen) 50-100 mg/kg/day; Q8 for IV
250mg/5ml
125mg/5ml
Chloramphenicol 50-100 mg/kg/day; Q6 PO or IV
1g/vial
125mg/5ml
Clarithromycin 7.5-15 mg/kg/day BID, PO
250mg/5ml
10-30 mg/kg/day; TID, PO
Clindamycin 75mg/5ml
25-40 mg/kg/day; Q6-8, IV
125 mg/5ml
Cloxacillin 250 mg/5ml 50-100 mg/kg/day; Q6 IV or PO
250, 500 mg/vial
200/40/5ml
5-8 mg/kg/day (based on Trim);
Cotrimoxazole 400/80/5ml
BID
(Trim/Sulfa)
Doxycycline 25mg/5ml 2-4 mg/kg/day; BID, PO
Erythromycin 200, 400 mg/5ml 30-50 mg/kg/day; Q6, PO
Gentamycin 20, 40, 80 mg/vial 5-8 mg/kg/day; OD
250, 500, 750mg/tab
10 mg/kg/dose; OD – BID
Levofloxacin 5mg/ml solution for
(max: 500mg/day)
IV infusion, 100ml
Mild to moderate
60mg/kg/day
Meropenem 500mg, 1g/vial
Severe
120mg/kg/day; Q8, IV
Oxacillin 500mg; 1gram/vial 100-300 mg/kg/day; Q4-6h IV
600T u/vial
Penicillin G 600,000 u/kg IM, every 21 days
1.2M u/vial
Benzathine (max: 1.2 mil U/dose)
2.4M u/vial
Penicillin G 5mil u/vial 100,000-300,000 U/kg/day, Q6 IV or
Sodium 1mil n/vial as DRIP
Piperacillin + 2g/250mg/vial
150-300mg/kg/day; Q6, IV
Tazobactam 4g/500mg/vial
125mg/5ml
Tetracycline 25-50 mg/kg/day; TID, PO
250; 500mg cap
Vancomycin 500mg/vial 40-60mg/kg/day; Q6 as DRIP
ANTI-VIRAL
200mg cap
15-30mg/kg/day IVT Q8-12
Acyclovir 400, 800mg tab
80mg/kg/day TID, PO
200mg/5ml susp
6 – 12yo
5ml 6 x a day, PO
2 – 6yo
3ml 6 x a day, PO
Inosiplex 250mg/5ml 1 – 2yo
(Immunosine) 500mg tab 2ml 6 x a day, PO
6mons – 1yo
1.5ml 6 x a day, PO
<6mons
1ml 6 x a day, PO
Loading Dose
Methixoprinol
100mg/kg/day
Linosine 250mg/5ml
Maintenance Dose
(Isoprinosine)
50 mg/kg/day, PO
ANTI-FUNGAL
Test dose:
0.1 mg/kg/dose; infuse over 20-
60mins
If tolerated:
Amphotericin B 50 mg/vial start therapeutic dose at 0.25
mg/kg/day
Maintenance dose:
0.25-1 mg/kg/dose OD; infuse over
2-6 hours
12mg/kg IV or PO
Fluconazole
50,150,200mg cap Loading dose
2g/vial 6mg/kg IV or PO then
maintenance dose OD
Miconazole
(Daktarin oral Oral gel 2% Apply to mouth lesions TTD or QID,
paste) local application
Cough/Cold Preparation
Examples Age Empiric Doses: per orem
Ambroxol < 6mon 1/4 tsp TID,QID
Carbocisteine 6mon – 2yo 1/2 tsp
Mucosolvan 2 – 6yo 1 tsp
Sinecod 6 – 9yo 1.5 tsp
PPA 9 – 12yo 2 tsp
Emergency medicine for pediatrics
Recommended dose
Drugs Computation
0.04mg/kg SC
Atropine
0.01 – 0.02m/k/dose IV OR ET
Hypertensive Crisis:
Diazoxide IV 1 – 2mg/kg given in 15 – 30sec
Max: 5mg/kg (LD)
For asystole and bradycardia:
IV/ET 0.1 – 0.3 ml/kg Q3 – 5 mins
(1:10,000 dilution or 0.1 mg/ml)
Epinephrine
(1:1000 solution) For anaphylaxis
0.01mg/kg IM at the mid-antero-lateral
aspect of thigh
(1:10,000 dilution or 0.1 mg/ml)
Glucagon 0.03mg/kg SC, IM or IV
IV 0.1 – 0.5mg/kg
Hydralazine
Max: 2mg/kg IV; Q3-6hrs
Diabetic Ketoacidosis:
Insulin
IV infusion 0.05 – 0.1 U/kg/hr
0.25g/kg IV OR 5cc/kg IV bolus
Mannitol
(max : 1 – 2g/kg w/in 2 – 6hrs)
1 – 2 mEq/kg/dose IV
NaHC03
(0.5 mEq/ml sol’n in NB)
Other Drugs
Pain
NSAIDS
ASA 80-160 mg PO OD
Paracetamol 500-650 mg PO up to q4
Ibuprofen 400 mg PO up to q4
Naproxen 250-500 mg up to q12
Ketorolac 15-60 mg IM/IV up to q4
Celecoxib 100-200 mg PO up to q12
Advantages
Deals well with inflammatory pain (muscle and
joint pain, malaise from infection, etc.)
Absorbed well from the GI tract
Disadvantages
GI irritation (except paracetamol)
Peptic ulcer
Nephropathy
Increases blood pressure
Selectivity for COX-2
Decreases GI symptoms
Increases cardiovascular risk
Narcotics
Tramadol 50-100 mg PO up to q4
Morphine 60 mg PO up to q4 (need S2)
Advantages
Broadest efficacy
Very rapid especially if IV
Disadvantages
Nausea and vomiting
Constipation
Sedation
Respiratory depression
Anti-convulsants
Phenytoin 300 mg @ HS
Carbamazepine 200-300 mg up to q6
Clonazepam 1mg up to q6
Gabapentin 600-1200 mg up to q8
Pregabalin 150-600 mg up to BID
Advantages
Effective for neuropathic pain (e.g. trigeminal
neuralgia, DM nephropathy)
Disadvantages
Hepatic toxicity, Dizziness, GI symptoms
Heart conduction disturbances
Fever
Itchiness
Diaper Rash
Teething
Decrease Appetite
Buclizine + MV tab OD
Vitamin B complex
Oral Sores
Frank Seizure
Vertigo
Impacted Cerumen
Vomiting
Tinnitus
Ofloxacin 3 gtts
Cetirizine
Laxatives
Bisacodyl (Dulcolax) 5 mg tab, PO 1-2 tabs HS
Bisacodyl 10 mg suppository, Per Rectum
Lactulose (Duphalac) PO-1-2 tbsp HS
Mg(OH)2 (Phillips Milk of Magnesia) 311 mg tab, PO, 2-4
tabs
Mg(OH)2 425 mg/5 ml syrup, PO, 2-4 tbsp in 1/2 glass of
H2O
Na Picosulfate (Laxoberal) 5 mg tab PO- 1-2 tab HS
Na Picosulfate 1 mg/ml syrup PO- 1-2 tsp HS
Psyllium Hydrophilic Mucilloid (Metamucil) 5.9 gm
sachet, PO 1 sachet/glass of water OD-TID
Standardized Senna Concentrate (Senokot) 187 mg
tab, PO, 2-4 tabs OD-BID
Standardized Senna Concentrate 0.337 mg/3 gm
granules, PO, 1-2 tsp granules BlD
Anti-diarrheals
Antibiotics
Aerosporin (3 drops TID)
Garamycin (3 drops BID)
Inoflox (3-5 drops BID)
Lignosporin with Lidocaine (3 drops TID)
Chloramphenicol (2 drops QID)
Antibiotics with Corticosteroids:
Aplosyn otic (3-4 drops BID or QID)
Cortisporin (3-4 drops BID or QID)
Garasone (3-4 drops BID or QID)
Others:
Otosol
Irwax
Auralgan
Topical Meds
Topical Antibiotics:
(Bactroban)
Gentamycin
Silver Sulfadiazine
Topical Antibiotics 4- Steroids
(Betnovate)
Topical Antifungal
Fungistin
Miconazole
Topical Antifungal + Steroids
Aplosyn C
Topical Antifungal + Steroid + Antibacterial
Triderm
Topical Antifungal + Steroid + Antibacterial +
Antihistamine
Quadriderm
Topical Antihistamine
IIWSQ
ELECTROLYTES
Doctors’ Guide
General Management Strategy
Monitor serum potassium, magnesium and calcium
frequently in patients with vomiting/diarrhea and
patients receiving injectable.
Check for signs of dehydration in patients with vomiting
and diarrhea. Start oral or intravenous rehydration
therapy immediately until volume status is normal.
Check ECG in patients with significant serum
electrolyte disturbances. Drugs that prolong the QT
interval should be discontinued in patients with
evidence of QT interval prolongation.
Electrolyte abnormalities are reversible upon
discontinuation of the injectable. Even after
suspending the injectable, it may take weeks or
months for this syndrome to disappear, so electrolyte
replacement therapy should continue for several
months after completion of the injectable phase of
multidrug-resistant tuberculosis (MDR-TB) treatment.
Hypokalaemia and hypomagnesaemia are common
in patients receiving MDR-TB treatment
Hypokalemia
Hypokalaemia - serum potassium <3.5 mEq/l.
Severe hypokalaemia or symptomatic
hypokalaemia is <2.0 mEq/l
Hospitalization is necessary in severe cases of
hypokalaemia.
Hypokalaemia may be refractory if concurrent
hypomagnesaemia is not also corrected.
If unable to check serum magnesium, give empiric
oral replacement therapy in all cases of
hypokalaemia with magnesium gluconate, 1000 mg
twice daily.
Dietary intake of potassium should be encouraged -
Bananas, oranges, tomatoes and grapefruit juice
Amiloride 5 to 10 mg orally daily or spironolactone
25 mg orally daily may decrease potassium and
magnesium wasting due to the injectable
Potassium
Dosing Monitoring frequency
level
> 3.5 None Monthly
3.3 – 3.5 40 mEq PO OD Monthly
60 – 80 mEq PO
2.9 – 3.2 Weekly
OD
2.7 – 2.8 60 mEq PO TID One to two days
2.4 – 2.6 80 mEq PO q8h Daily
10 mEq/hr IV and One hr after indusion,
< 2.4
80 mEq PO q6-8h q6h with IV replacement
Example:
Desire dose = 3 mEqs/kg
D5LR Volume = 1000ml
IV rate = 42 ugtts/min (Holiday-segar)
Patient Weight = 10kg
= 30,000
1,008
= 29.7mEqs
Sample Orders:
IV: D5LR 1Liter + 30mEqs KCL to run in 42ugtts/min
KCl correction
NOTE
K correction using peripheral line only used in volume
depleted patients
KCl is a dangerous drug if accidentally given as fast
drip, so it is warranted to accurately regulateits
administration
Repeat serum K+ 6hours after end of KCl drip, if still low
may consider to give another correction until serum K +
is 3.5mEqs/L (SI: 3.5mmol/L)
Hypomagnesaemia
Hypomagnesaemia is defined as serum magnesium
<1.5 mEq/l.
If unable to check serum magnesium, give empiric oral
replacement therapy in all cases of hypokalaemia with
magnesium gluconate, 1000 mg twice daily.
Amiloride 5 to 10 mg orally daily or spironolactone 25
mg orally daily may decrease potassium and
magnesium wasting due to the injectable and may be
useful in severe cases that are refractory to
replacement therapy.
Magnesium Monitoring
Dosing
level frequency
> 1.9 None Monthly
1000 mg – 1200
1.5 – 1.9 Monthly
mg
1.0 – 1.4 2000 mg One to seven days
3000 mg – 6000
< 1.0 Daily
mg
NOTE: Quantities greater than 2000 mg are usually given by
IV or intramuscular (IM). The normal preparation is
magnesium sulfate 2 g in 100 ml or 4 g in 250 ml of 5%
dextrose or normal saline. Do not exceed an infusion
rate of 150 mg/min (2 g in 100 ml administered over
one to two hours, 4 g in 250 ml administered over two
to four hours).
Hypocalcaemia
Calcium Monitoring
Dosing
level* frequency
> 8.5mg/dl
None
(>4.2mEq/l)
7.5 – 8.4 500 mg TID Monthly
One to two
7.0 – 7.4 1000 mg TID
weeks
Consider IV and taper One to four
< 7.0
to 1000 mg TID days
Microalbuminuria
Marker of silent DM nephropathy
Significant predictor or overt nephropathy
First manifestation of injury to the glomerular filtration
barrier
Types of Proteinuria
Orthostatic or Postural
Functional
High fever, exercise, heat stroke, CHF
Glomerular
Tubular
Overflow
Hyperglobulinemic states
Urine Microscopy
Component Types
Urates, calcium, oxalate, triple
Crystals
phosphates, cystine, drugs
Red blood cells, white blood cells, tubular
Cells
cells, fat bodies, squamous cells
Casts Hyaline, granular, RBC, WBC, broad, waxy
Organisms Bacteria, yeasts, trichomonas
Miscellaneous Spermatozoa, mucus treads
Hematuria
May originate anywhere from the glomerulus to the
urethral meatus
Normal: RBC in the urine is between 0 – 2 / HPF
Abnormal: > 3 RBC / HPF
Shape of RBC is important:
Normal shape RBC – originate from collecting system
Dysmorphic RBC - originate from glomerulus
Causes of hematuria
Hematuria + proteinuria, Glomerular pathology
RBC casts
Hematuria coincident with IgA nephropathy
URTI, occasional proteinuria
Hematuria days or weeks Acute post-streptococcal
after URTI glomerulonephritis
Hematuria with Pyuria UTI, glomerulonephritis
Hematuria, Crystals Stone disease
Other cells
Eosinophils – seen in allergic interstitial nephritis,
atheroembolism
Epithelial cells
squamous cells – contaminant
transitional cells – from pelvis to urethral lining renal
tubular cells - large amount seen in ATN
Cockcroft-Gault Formula*
) )
)
Creatinine Clearance
Widely used method to estimate GFR
Albumin:
Adult 3.5-5.0 g/dL (SI: 35-50 g/L)
Child 3.8-5.4 g/dL (SI: 38-54 g/L)
Alkaline Phosphatase:
Adult 20-70 U/L
Child 20-150 U/L
Ammonia:
Adult 10-80 mg/dL (SI: 5-50 mmol/L).
To convert mg/dL to mmol/L, multiply by 0.5872
Bilirubin:
Total, 0-3-1.0 mg/dL (SI: 3.4-17.1 mmol/L).
Direct, <0.2 mg/dL (SI: <3.4 mmol/L).
Indirect, <0.8 mg/dL (SI: <3.4 mmol/dL).
To convert mg/dL to mmol/L, multiply by 17.10
Calcium, Serum:
Infants to 1 month: 7-11.5 mg/dL (SI: 1.75-2.87
mmol/L).
1 month to 1 year: 8.6-11.2 mg/dL (SI: 2.15-2.79
mmol/L).
>1 year and adults: 8.2-10.2 mg/dL (SI: 2.05-2.54
mmol/L).
Ionized: 4.75-5.2 mg/dL (SI: 1.19-1.30 mmol/L).
To convert mg/dL to mmol/L, multiply by 0.2495.
Chloride, Serum:
97-107 mEq/L (SI: 97-107 mmol/L)
Cholesterol:
Total. Normal. To convert mg/dL to mmol/L, multiply
by 0.02586.
Creatinine Phosphokinase (Kinase) (CP, CPK):
24-145 mU/mL (SI: 25-145 U/L)
Creatinine, Serum:
Adult male <1.2 mg/dL (SI: 106 mmol/L)
Adult female <1.1 mg/dL (SI: 97mmol/L)
Child 0.5-0.8 mg/dL (SI: 44-71 mmol/L)
To convert mg/dL to pmol/L, multiply by 88.40
Erythropoietin (EPO):
5-36 mU (5-36 IU/L)
Fecal Fat:
2-6 g/d on an 80-100 g/d fat diet.
72-h collection time. Sudan III stain, random <60
droplets fat/hpf
Ferritin:
Male 15-200 ng/mL (SI: 15-200 mg/L).
Female 12-150 ng/mL (SI: 12-150 mg/L)
Glucose:
Fasting, 70-105 mg/dL (SI: 3.89-5.83 nmol/L). 2 h
postprandial <140 mg/dL (SI: <7.8 nmol/L).
To convert mg/dL to nmol/L, multiply by 0.05551.
Iron:
Males 65-175 mg/dL (SI: 11.64-31.33 mmol/L).
Females 50-170mg/dL (SI: 8.95-30.43 mmol/L).
To convert mg/dL to mmol/L, multiply by 0.1791.
Magnesium:
1.6-2.6 mg/dL (SI: 0.80-1.20 mmol/L)
Osmolality, serum:
278-298 mOsm/kg (SI: 278-298 mmol/kg)
Phosphorus:
Adult 2.5-4.5 mg/dL (SI: 0.81-1.45 mmol/L).
Child 4.0-6.0 mg/dL (SI: 1.29-1.95 mmol/L).
To convert mg/dL to mmol/L, multiply by 0.3229
Potassium, Serum:
3.5-5 mEq/L (SI: 3.5-5mmol/L)
Sodium, Serum:
136-145 mmol/L
Uric Acid:
Males: 3.4-7 mg/dL (SI: 202-416 mmol/L).
Females: 2.4-6 mg/dL (SI: 143-357 mmol/L).
To convert mg/dL to mmol/L, multiply by 59.48.
Zinc:
60-130 mg/dL (SI: 9-20 mmol/L)