HISTORY ELECTROLYTE SOLUTIONS

 General data IVF Glu Na Cl K Ca HCO3

 Chief complaint D5W 5mg/L
 PMHx D10W 100mg/L
o HPN, DM, BA, FDA, Malignancies 0.9 NSS 154 154
o Previous Hospitalization, Accidents, Surgeries, Blood Transfusion reactions
D5LR 130 109 4 3 28
 FHx
D5NM 40 40 13
o HPN, DM, BA, TB, CA
D5NR 140 98 5
 PSHx
D5 0.9
o Occupation, NANS (Non Alcoholic and Non smoker) 50 mg/L
NaCl
o Packs per year:
D5NMK 50 mg/L 40 40 30
1 pack = 1 year = 20 sticks
e.g. 2 packs per day started at 18 yo (age is 26)
2 x 8 years = 16 pack years IVF Na Cl K HCO3 Ca Mg
e.g. 3 sticks per day started at 18 yo (age is 26) ECF 142 103 4 27 5 3
3/20 sticks/pack = 0.15 D5LR 130 109 4 28 5
0.15 x 8 years = 1.2 or 1-2 pack year D5 0.45 77 77
o Shots/glass per sitting, Bottles per day, days per week 3% NaCl 513 513
e.g. 8 shots of whiskey per sitting, 0.9 NaCl 154 154
5 glasses of beer per day in 3 days per week D5W Osm = 278
 OBHx D5W Osm = 556
o MIDAS (Menarche, Interval, Duration, Amount, Symptoms) D5LR Osm = 130
o Coitarche NaHCO3 = 446
o Menopause
o OCP, S/P, PAP, Intermenstrual bleeding
o Postcoital bleeding
o OB Score
o LMP, EDC, AOG
o PNCU
o HBsAg/VDRL
o TT/BT/MTV
o UTI

PHYSICAL ASSESSMENT MECHANICAL VENTILATION

Awake, coherent, ambulatory, not in CPD / wheelchair bound, stretcher bound, per Indication for Intubation
mother’s arm. 1. Impending respiratory failure, apnea
AS (anicteric sclerae) PC (Pinkish Conjunctivae) PERRLA 2. RR >35
Non hyperemic, Non-enlarged tonsils, NCLAD (No Cervical Lymphadenopathy) NNVE 3. PaCO2 > 50
(No Neck Vein Engorgement) 4. PaO2 <60
SCE (Symmetrical Chest Expansion) CBS (Clear Breath Sounds) 5. TV < 3-5 ml/kg
AP (Adynamic Precordium) NCRRR (Normal CR, Regular in Rhythm) 6. VC < 10-15 ml/kg
Soft non-tender abdomen 7. Inspiratory force < 25 cm H20
GNE (Gross Normal Extremities) CRT (Capillary Refill Time) of < 2 sec 8. FEV < 10 ml/kg
9. Vq / Vt > 0.6
DRE (DIGITAL RECTAL EXAM) FINDINGS 10. To deliver high FIO2
(-/+) External Mass 11. Absent
GST (Good Sphincter Tone) 12. pH <7.35
Full/Empty Rectal Vault (feel for fecal material or any mass) VENTILATOR SETTING
If with mass: 1. TV: 6-8 ml/kg (ARDS) 8-10 ml/kg
4x4 cm mass @ 4 o’clock position, tender/nontender, movable/non-movable, 2. Pale: 6-20
prostate enlarged/non-enlarged(for males only please), tender/nontender 3. Mode: AC (Assist Control)
(-/+) stool/blood on examining finger / blood streaked stool if both 4. SIMV (Synchronized Intermittent 1 mV)
5. FIO2
S-O-A-P 6. PEEP 5cm H20
S (Subjective):
INDICATIONS FOR WEANING
 fever, headache, , cough, DOB, abdominal pain vomiting, bowel/urinary
1. Mental status: Awake, Alert
changes, sleep, appetite
2. PaCO2 > 60 mmHg w/ FIO2 < 50%
O (Objective)
3. PEEP < 5 cm
 Vital signs, PE 4. PaCO2 < pH acceptable
A (Assessment) 5. Spontaneous TV < 5mL
 Impression, T/C, diagnosis 6. VC > 10 ml/kg
E.g. Lacerated wound, Post Appendectomy 7. MIP > 25 cm H20
P (Plan) 8. RR < 30/min
 Management, drug prescription, procedures, health teachings 9. Rapid shallow breathing index < 100 (RBI)
 Referral to other department, scheduling of operation 10. Stable vs. Ft a 1-2 hours
E.g. TT 0.5 mL deep IM R deltoid
HTIG 250 ml deep IM L deltoid Spontaneous Trial
E.g. Removal of suture with dressing FIO2 room air 21%
Advised O2 via nasal prong = # LPM x 0.4 x 20
 ELECTROLYTES CUSHING’S TRIAD
a. Corrected Ca = (40-lbs) x 0.02 + s.Ca 1. Increase systolic BP
b. Corrected Na = Na + RBS mg% - 100 x 1.6 / 100 2. Widened pulse pressure
c. Na Deficit = (140 – actual) (0.6 x BW) 3. radycardia /AbN˚ respiratory pattern
d. K Deficit = (D-A) (0.4 x BW) a. Cheyne Stoke breathing
D = 3.5 cardiac
4.5 non-cardiac HEMORRHAGIC STROKE TRIAD
H20 Deficit = 0.6 x kg BW
1. Papilledema
D = 15 CKD 2. Headache
18 NCKD
3. Vomiting
Actual Na – Desired Na / Desired Na
MEIG’S SYNDROME
GLASCOW COMA SCALE 1. Pleural Effusion
2. Polycystic Ovary / Fibromatosis
EYE RESPONSE
3. Hypoalbuminemia
a. Spontaneous eye opening 4
b. Opens to verbal command 3
c. Responds to painful stimuli 2 DENGUE
d. No response 1 GRADE I
 Fever
MOTOR  Non-specific symptoms
a. Obeys with command 6 o Anorexia
b. Localizes pain 5 o Vomiting
c. Flexion withdrawal 4 o Abdominal pain
d. Decorticate / Flexion 3  (+) Torniquet test
e. Decerebrate / Extension 2
f. No response 1 GRADE II
 Grade I + spontaneous bleeding
VERBAL
a. Oriented 5 GRADE III
b. Disoriented 4  Grade II + severe bleeding + circulatory failure
c. Inappropriate 3
d. Incomprehensible 2 GRADE IV
e. No response 1  Grade III + irreversible shock + massive bleeding

FOUR SCALE ABG COMPUTATION

- Full outline of responsiveness

EYE RESPONSE
a. Eyelids open, tracking, blinking to command 4
b. Eyelids open but not tracking 3
c. Eyelids close but open to loud voice 2
d. Eyelids close but no pain 1
e. Eyelids close with pain 0

MOTOR RESPONSE
a. Thumbs up, fist or peace sign 4
b. Localizing to pain 3
c. Flexion response to pain 2
d. Extension response to pain 1
e. No response to pain or generalized 0
myoclonus

BRAINSTEM REFLEXES
a. Pupil and Corneal reflex 4
b. One pupil wide and fixed 3
c. Pupil or corneal reflex absent 2
d. Pupil and corneal reflex absent 1
e. Absent pupil, corneal and cough reflex 0

RESPIRATION
a. Not intubated, regular breathing pattern 4
b. Not intubated, Cheyne-stoke breath pattern 3
c. Not intubated, irregular breathing 2
d. Breath above ventilation rate 1
e. Breath at ventilation rate, apnea 0
 DOPAMINE COMPUTATION CLASSIFICATION OF PTB
Single strength = BW x desired dose / 13.3 Class 0 Class 1
Double strength = BW x desired dose / 16.6  NO PTB EXPOSURE  HISTORY OF EXPOSURE
 Not infected  Neg. Skin test to tuberculin
Single strength = BW x desired dose / 16.6
Class 2
Double strength = BW x desired dose / 33.2
 TB INFECTION
Cardiac Dose = 5  No disease
Renal Dose = 5-10  Positive reaction to tuberculin test
 No clinical, bacteriologic or radiographic evidence of TB
CT SCAN BLEED VOLUME Class 3
Given: 58 mm ~ 5.8  TB CLINICALLY ACTIVE
23.3 mm ~ 2.3  Clinical, bacteriologic, or radiographic evidence of current disease
Class 4
5.8 x 2.3 = 13.34 x 5 (constant) = 66.5 x 5.2 (constant)
 TB NOT CLINICALLY ACTIVE
= 34.684 - (estimated bleeding volume)
 History of episode of TB
 Abnormal but stable radiographic findings
DIAGNOSTIC THORACENTESIS DUE TO HEART FAILURE  No clinical or radiographic evidence of current disease
a. If the effusion are not bilateral and comparable size
b. If the patient is febrile Class 5
c. If the chest has a pleuritic chest pain  TB SUSPECT
d. If effusion persist despite the diuretics therapy  Diagnosis pending
 TB disease should be ruled out within 3 months
LOCATING MYOCARDIAL DAMAGE Signs and Symptoms of TB
Anterior = V2-V4 (L) coronary, LAD  Fever
 Night sweats
Anterolateral = I, qV1, V3 – V6, LAD, circumflexes
 Weight loss
Anteroseptal = V1-V4, LAD  Anorexia
 Weakness
Inferior = II, III, aVF, (R) coronary artery  General Malaise

Lateral = I, aVL, V5, V6, circumflex branch of (L) coronary artery RECOMMENDED DOSAGE FOR INITIAL TREATMENT OF TB
1. Isoniazid = 5 mg/kg, max 300 mg
Posterior = V8 – V9 (R) coronary artery, circumflex artery 2. Rifampicin = 10 mg/kg, max 600 mg
3. Pyrazinamide = 20-25 mg/kg, max 2 g
(R) Ventricular = V4R, V5R, V6R, (R) coronary artery 4. Ethambutol = 15-20 mg/kg

CHEST TUBE THORACOSTOMY JONES CRITERIA OF RF

INDICATIONS Major:
1. Pneumothorax 4. Pleural effusion  Carditis
2. Chylothorax 5. Empyema  Polyarthritis
3. Hemathorax 6. Hydrothorax  Chorea
 Erythema marginatum
TIMING OF TUBE REMOVAL  Subcutaneous nodule
 The timing of tube removal depends on clinical and radiological evidence of
complete expulsion of all contents of pleural cavity with complete expansion of Minor:
the lung  Fever
 Minimal drainage should have occurred over the previous 24 hours (<25 ml/kg)  Polyarthralgia
 When the patient coughs or performs the valsalva maneuver no air leak should  Lab: Inc. ESR / Leukocyte count
ensue  ECG: Prolong P-R interval
 The chest radiograph should confirmed complete expansion of the lung  Elevated anti-streptolysin O, other strep antibody
 The s____ in the fluid in the tube in the underwater seal bottle should be minimal,  (+) throat culture
relating to the normal negative pressured in the chest during the phases of  Rapid Ag test for Group A
respiration  Strep / result: Scarlet Fever
INDICATIONS FOR CTT
Criteria:
 Gross pus on thoracentesis
 2 major/one minor and 2
 Presence of organism on gram stain of the pleural fluid
 (+) evidence of preceding Group A strep infection
 Pleural fluid glucose < 50 mg / dL
 Pleural fluid pH below 7.00 and 0.15 units lower than arterial pH

LIGHT’S CRITERIA
1. Pleural fluid protein / serum protein > 0.5
2. Pleural fluid LDH / serum LDH > 0.6
3. Pleural fluid LDH > 2/3 the upper limit of normal serum LDH

TRANSUDATIVE VS EXUDATIVE FLUID

Transudative Exudative
SG < 1.012 > 1.020
Protein < 3 g/dL >3 g / dL
FP / SP < 0.5 >0.5
LDH <60% >60%
FLDH/SLDH <0.6 >0.6
Cholesterol <45 mg / dL >45 mg / dL
 ACUTE RESPIRATORY FAILURE Refractory Septic Shock
TYPE I or Acute Hypoxemic Respiratory Failure  Septic shock that last > 1 hour and does not respond to fluid or pressure
 Occurs when alveolar flooding and subsequent intrapulmonary shunt administration
physiology occurs Multi-organ Dysfunction Syndrome
 Alveolar flooding may be a consequence of pulmonary edema, pneumonia or  Dysfunction of more than 1 organ requiring intervention to maintain
alveolar hemorrhage homeostasis
 Low pressure pulmonary edema
 Defined by diffused bilateral airspace edema BRONCHIECTASIS
 Is an abnormal and permanent dilatation of bronchi
TYPE II Respiratory Failure  Associated with destruction and inflammatory changes in the wall of the medium
 Occurs as a result of alveolar hyperventilation and results on the inability to sized airways often at the level of segmental or subsegmental bronchi
eliminate CO2 effectivity  The dilated airways frequently contain pools of thick purulent material, while
 Mechanism by which this occurs are categorized by impaired CNS drive to more peripheral airways are often occluded by secretions or obliterated and
breath, impaired strength with failure of neuromuscular function in the replaced by fibrous tissue
respiratory____________  As the result of inflammation it produces airway damage, impaired clearance of
 Reason for diminished CNS drive to breath including drug overdose, brainstem microorganism resulting to vascularity of the bronchial wall increases with
injury, sleep disordered breathing associated enlargement of the bronchial arteries and anastomoses between the
bronchial and pulmonary arterial circulation
Overload Respiratory System due to:
 Increase resistive loads (bronchospasms) INDICATIONS FOR INITIATING HEMODIALYSIS
 Reduced lung compliance (alveolar edema)  Failure of conservative management
 Reduced chest wall compliance (pneumothorax)  Management to relieve
 Increase minute ventilation (pulmonary embolus) a. Pulmonary congestion (unresponsive to high dose furosemide)
b. Severe metabolic acidosis
TYPE III Respiratory Failure c. Severe hyperkalemia
 Occurs as a result of lung atelectasis  BUN >100 mg/dL or creatinine >10mg/dL
 Also called perioperative respiratory failure  Note: For acute renal failure it is best to start dialysis early
 After general anesthesia, decreases in functional residual capacity of
RHEUMATIC ARTHRITIS
dependent lung units
Require 4 out of 2 criteria:
TYPE IV Respiratory Failure o Morning stiffness
 Due to hypoperfusion of respiratory muscles in patients in shock, due to o Arteritis of 2 or more joints
pulmonary edema, lactic acidosis, anemic o Arteritis of hands and joints
o Systemic arthritis
o Rheumatoid nodule
o Serum Rheumatoid factor
o Radiographic changes

DEFINITIONS USED TO DESCRIBE THE CONDITION OF SEPTIC PATIENTS CHILD-PVGH CLASSIFICATION OF CIRRHOSIS
Bacteremia Factor Units 1 2 3
 Presence of bacteria in blood as evidenced by positive blood culture s. Bilirubin umol / L <34 34-51 >51
Septicemia mg / dL <2 2-3 >3
 Presence of microbes and their toxins in the blood s. Albumin g/L >35 30-35 <30
g / dL >3.5 3.0-3.5 <3
SIRS Protime sec 0-4 4-6 >6
 Systemic inflammatory response syndrome INR <1.7 1.7-2.3 >2.3
 Two or more of the following conditions: Easily Poorly
Ascites None
o Fever (oral temp >38˚C) or hypothermia (<36˚C) controlled controlled
o Tachycardia (>90 bpm) Hepatic
o Tachypnea (>24 bpm) None Minimal Advanced
encephalopathy
o Leukocytosis (>12,000/uL) or Leukopenia (<4,000/uL) or > 10% bands  Calculated by adding the score of the 5 factor and can range from 5 – 15
may have a non-infectious etiology
Sepsis CHILD-PVGH Class is either:
 SIRS that has proven or suspected microbial etiology a. Score of 5 – 6
b. Score of 7 – 9
Severe Sepsis c. Score of 10 or Above
 Similar to sepsis “sepsis syndrome”
 Sepsis with one or more signs of organ dysfunction Decomposition
Examples  indicate cirrhosis
1. Cardiovascular: Arterial systolic blood pressure <90 mmHg or Mean Arterial  N/A
Pressure ≤ 70 mmHg that responds to administration of IV  CHILD PVGH Score of 7 or more
2. Renal: Urine output <0.5 ml/kg/hr for 1 hour despite adequate fluid
resuscitation Class 8
3. Respiratory: PaO2/FIO2 <250 or if the lung is the only dysfunctional organ ≤ 200  Listing for liver transformation (accepted criteria)
4. Hematologic: Platelet count <80,000/uL or 50%  in platelet from highest value
recorded over the previous 3 days Hepatic Fibrogenesis
5. Unexplained metabolic acidosis: a pH ≤7.30 or a base deficit ≥ 5.0 meq/L and a  Stellate cell activation
plasma lactate level >1.5 times upper limit of normal for reporting  Collagen production
6. Adequate fluid resuscitation: Pulmonary artery wedge pressure ≥ 12 mmHg or
Central Venous pressure ≥8 mmHg

Septic Shock
 Sepsis with hypotension (arterial blood pressure of ≥ 90 mmHg or
MAP > 70 mmHg
CLINICAL STAGE OF HEPATIC ENCEPHALOPATHY FRAMINGHAM CIRTERIA FOR DIAGNOSIS OF CHF
MS MAJOR CRITERIA
Euphoria, depression, mild confusion, slurred speech,  Paroxysmal Nocturnal Dyspnea
Stage I
disturbance in sleep  Neck vein distention
Stage II Lethargy, moderate confusion  Rales
Stage III Marked confusion, incoherent speech, sleeping but arousable  Cardiomegaly
Stage IV Coma, initially responsive to noxious stimuli, ____ response  Acute pulmonary edema
COMPLICATIONS OF ERCP  S3 gallop
1. Infection  Increased venous pressure (>16 cmH20)
2. Perforation  Positive hepatojugular reflux
3. Pneumothorax
4. Bleeding MINOR CRITERIA
 Extremity edema
MUSCLE STRENGTH  Night cough
O – No muscular contraction  Dyspnea on exertion
1 – Trace contraction  Hepatomegaly
2 – Active movement with gravity eliminated  Pleural effusion
3 – Active movement against gravity  Vital capacity reduced by one-third from normal
4 – Active movement against gravity & slight resistance  Tachycardia (>120 bpm)
5 – Against full resistance

PULSE VOLUME SCALE MAJOR OR MINOR

Weight loss of >4.5 kg over 5 days treatment
O – Absent
+1 – Thready/Weak
+2 – Normal
+3 – Increased
+4 – Bounding

IDEAL PEAK FLOW

Ideal peak flow: Hg (m) – 100 x 5 (+) 175 (M) (+) 170 (F)

N ≥ 80%
PEFR = Peak flow reading / Ideal peak flow x 100 = _____ %

N ≤ 20%
PEFR variability: Highest reading – Lower x 100 = ______%
Highest Reading

GRADING OF MURMURS BLOOD TRANSFUSION

1 – Faint  Please transfuse available _____ unit of patient’s blood type after proper cross
2 – Audible matching
3 – Moderately Loud  Please take baseline CP status and vital signs prior to BT
4 – Loud with palpable thrill  Initially run BT at 5-10 gtts/min for 30 mins then titrate at 15-20 gtts/min if
5 – Loud with thrill, stet partially off without BT reactions
6 – Loud with thrill, w/o stet  Mainline to KVO while on BT
 Monitor VS q15 mins while on BT
NEW YORK HEART ASSOCIATION FUNCTIONAL CLASSIFICATION  Refer for any BT reactions such as fever, chills, dyspnea, hypotension and pruritus
CLASS I  Refer accordingly
 No limitation of physical activity  Thank you.
 No symptoms with ordinary exertion
HUMAN ALBUMIN TRANSFUSION
CLASS II  Please transfuse available _____ unit of 25% human albumin (+20mg
 Slight limitation of physical activity Furosemide) once available
 Ordinary activity causes symptoms  Please take baseline CP status and vital signs prior to transfusion
 Run each unit for 4 hours
CLASS III  Mainline IVF at KVO while on BT
 Marked limitation of physical activity  Monitor VS and CP status Q15 mins while on BT
 Less than ordinary activity causes symptoms  Refer any untoward s/sx accordingly
 Asymptomatic at rest  Thank you.
Or
CLASS IV  Please transfuse available _____cc of 25% human albumin to run for 4 hours
 Inability to carry out any physical activity without discomfort once available
 Symptomatic at rest
PLATELET CONCENTRATE TRANSFUSION
 Please transfuse available _____ unit of platelet concentrate of patient’s blood
type after proper cross matching
 Please take baseline CP status and vital signs prior to BT
 Transfuse each bag after the other to run each bag by 30 minutes to 1 hour
 Mainline to KVO while on BT
 Monitor VS and CP status while transfusing
 Watchout for any untoward s/sx
 Refer accordingly
 Thank you.
 OBSTETRICS & GYNECOLOGY Clearance Labs:
 ECG 12 leads
1st Prenatal Visit  Chest x-ray PA view
1. Prescribe:  CBC, ABO/RH typing, CTBT
 KY jelly #1  Urinalysis
 Surgical gloves 6 ½ #1  Protime
 Glass slides #4  Creatinine, BUM, S. Na, S. K, SGPT, SGOT, FBS, Lipid profile
 Cotton applicator #1  HBSAg

2. Prenatal record MONTHS

1 January 31
3. Routine labs 2 February 28
 CBC, Plt, ABO/RH typing 3 March 31
 FBS 4 April 30
 Urinalysis, Fecalysis 5 May 31
 Anti-TP, HBSAg 6 June 30
 G/S of vaginal discharge 7 July 31
 UTZ 8 August 31
a. Transvaginal UTZ - <12 weeks AOG 9 September 30
b. Transabdominal UTZ - >12 weeks AOG 10 October 31
11 November 30
Indications:
12 December 31
<20 weeks:
Fetal viability
1/7 0.14
Fetal baseline biometry
2/7 0.29
>32 weeks: 3/7 0.43
Fetal growth monitoring 4/7 0.57
5/7 0.71
>37 weeks: 6/7 0.86
Biophysical scoring
Final fetal presentation GRADING OF EDEMA
Placental localizatiwith BPP “Absent” Absent or unilateral
Grade 1 Mild: both feet/ankles
Aging: Grade 2 Moderate: both feet and lower legs hands or lower arms
<22 wks – EARLY Severe: generalized bilateral pitting edema, including both
>22 wks – LATE Grade 3
feet, legs, arms and face

4. Prescribe MTV Post partum

a. All trimester 1. Iron PP
 Ca + Vit D 2. Mefenamic acid
b. <20 weeks 3. Oxytocin ampule
 Vit B complex 4. Co-amoxiclav
c. >20 weeks 5. Cefuroxime
 MTV + Iron
5. Feminine wash BID Post curette
6. Prenatal milk (PNM) 1 glass BID 1. MTV + Iron
2. Mefenamic acid
Prenatal Follow-up 3. Clindamycin
 <28 weeks: q 4 wks
OPD
 28-36 weeks: q 2 wks
<20 wks >20 wks
 >36 weeks: q weekly
MTV + Iron
MTV + Iron
Oral Glucose Tolerance Test: 75 grams Folic acid
Prenatal milk
(24-28 wks) Prenatal milk
Calcium + Vit D
Prescribe: Calcium + Vit D
75 gms glucose solution Vit B complex
Sig: Dissolve ¾ sachet in 200 ml solution of water with 1-5 calamansi
NPO postmidnight Tetanus Toxoid Schedule
50 gms GCT 100 gms OGTT 75 gms OGTT TT1 First contact or as early as possible
Fasting 105 mg/dL TT2 Atleast 4 weeks after TT1
1h 185 mg/dL TT3 Atleast 6 months after TT2 or during next pregnancy
185 mg/dL TT4 At least 1 year after TT3
2h 155 mg/dL
>140 mg/dL 140 mg/dL TT5 Atleast 1 year after TT4
3h 140 mg/dL
mmol/L to g/dL: Divide by 0.055

Counting Fetal Movement

 Within 2 hours postprandial
 At least 10 kicks
 PELVIC EXAM POSTPARTUM ORDERS
 Inspection  Back to room/ward
o Grossly N external genitalia  Full diet once full awake
o Masses, discharges, bleeding  Present IVF to run at 30 gtts/min, D/C if with minimal VB
 Speculum  IVF to ff: D5LR + 10 “u” Oxy to run at30 gtts/min
o Cervix – hyperemic/nonhyperremic; fish mouth deformity/ping pong  Meds:
 IE o Antibiotics
o Cervical dilatation o MA 500 mg/cap q 8 H RTC x 24 H, then prn for pain
o Cervical effacement o Methergin 1 tab TID x 3 days
o Station o Vitamins
o BOW (intact/leaking)  SO:
o Amniotic membrane PROM x days/hours o Monitor VS q 15 min until stable
o Presenting part o Massage uterus prn
 Clinical pelvimetry o Ice pack on hypogastrium
o Inlet o Perilight x 15 min OD
o Midplane o Routine perineal care
 Ischial spines o Watch out for profuse vaginal bleeding
 Sacrum o Refer accordingly
 Sidewalls o Thank you
o Outlet
 EFW DISCHARGE ORDERS (Normal OB)
 BME  MGH
o I (introitus) - admits 2 fingers with ease/snugly  Home Meds
o C (cervix) – open/closed,; firm, doughy  OPD ff-up on Sat @ OB service clinic with photocopy of D/S
o U (uterus) – level of umbilicus  Discharge IE and summary c/o ___
o A (adnexae) – firm/fullness; w/ adnexal masses  TCB anytime if with profuse VB, HA, blurring of vision, Untoward s/sx
o D (discharges) – (+) (-); scanty or minimal bleeding
o E (episiotomy) – with blood/well coaptated wound
 RVE
o Intact rectovaginal septum
o Good sphincter tone
 Abdomen
o Inspection: globular/gravid; linea nigra, striae
o Auscultation: NABS
o Palpation: Leopold’s
o FH, FHB R/L

NSVD ADMITTING NOTES CS ADMITTING NOTES

 Please admit to ROC under the service of ____  Please admit to ROC under the service of__________________
 TPR q 4 hours and record  TPR q 4 hours and record
 Full diet, NPO once in active labor  Full diet, NPO post midnight
 Labs:  Labs:
o CBC o CBC, APC, CT, BT, PT
o HBsAg o Urinalysis
o Urinalysis  Venoclysis
 IVF: D5LR + 10 “u” oxytocin to run at 10-15 gtts/min  Meds:
 Meds o Cefazolin 500mg IVTT q8H x 3 doses then shift to
o Ampicillin 2g IV ANST if PROM Co-Amox 625mg/tab, 1 tab BID
 SO: o Famotidine 20mg IVTT q8H x 3 doses
o Monitor FHB and progress of labor o Ketomed 30mg IVTT q8H x 3 doses
o Puboperineal shave please o Ketomed 10mg q8H to start if patient is on soft diet
o Inform NROD o Tramadol 50mg IVTT q6H prn
o Will inform service consultant on deck  Inform OR
o Refer prn  Secure signed consent
o Thank you  Abdominoperineal prep please
 Side notes  Request 500cc FWB of patient’s blood type as standby
o T P R BP  Dr. _______ for anesthesia
o Wt  Inform NROD
o LMP  Refer accordingly
o EDC  Thank you
o AOG
o FH
o FHB
o CD
o Effacement
o Station
o BOW
o Leopolds
 Final Dx:
o PU FT del via NSVD/1’LTCS/Rpt CS in cephalic presentation to a live Bb
Girl/Boy with BW: BL: AS: PAOG: OB score:
 POST-OP ORDERS POST OP ORDERS (TAHBSO)
 To RR  To RR
 Monitor VS q15 mins until stable  Monitor VS q 15 min, until stable
 NPO x 6 H, then may have sips of CL  Flat on bed x 6 H, then may turn to side
 O2 at 2-3 LPM via nasal prong  NPO x 6 H then may have sips of CL
 Run present IVF @ 30 gtts/min  Present IVF x 30 gtts/min
 IVF to ff:  IVF to ff:
o D5LR + 10 “u” oxytocin x 8 H o D5LR
o D5NM o D5NM + 10 “u” oxytocin x 8 H
o D5LR x 8 H o D5LR x 8 H
 Meds:  Meds:
o Antibiotics  SO:
o Ranitidine (Zantac) 50mg IVTT q8H x 3 doses o MIO q H and record
 SO: o Refer if UO is <30cc/H
o Attach px to O2 at 2-3 LPM via nasal prong o May return blood
o Attach pc to pulse ox o Remove FC @ ___
o MIO q H and record o Apply abdominal binder
o Refer if UO is <30cc/H o Refer PRN
o Remove FC 24H post op o Thank you
o Standby available blood
o Apply abdominal binder NON-STRESS TEST
o Morphine precaution please Test of fetal condition
o Specimen for histopathology
o Watch out for profuse vaginal bleeding, hypotension, tachycardia or any REACTIVE when:
untoward s/sx  At least 2 accelerations of the FHR occurs for at least 15 bpm, lasting for 15 sec
o Refer PRN w/in 20 min period of observation
o Thank you
NONREACTIVE
 May imply that the fetus is acidotic, asleep, or drugs was administered to the
mother
A. EARLY DECELERATION
 Head compression
B. LATE DECELERATION
 Utero-placental insufficiency
C. VARIABLE DECELERATION
 Cord compression ; Fetal distress
 Most common ; Most ominous

TRANS-OUT CONTRACTION STRESS TEST /

Side notes the ff: OCYTOCIN CHALLENGE TEST
 Stable VS  A measure of utero-placental function
 Able to flex both legs  Contraction induced by using IV oxytocin
 (-) vomiting  Record FHB
 Blurring of vision
POSITIVE
Orders  Consistent and persistent late deceleration (50%) of the FHB in the absence
 May refer back to room of uterine hypertonus or supine hypotension
 D/C O2 and pulse oximeter
 Monitor V/S q 15 min until stable NEGATIVE
 MIO q Hly (+ FC) or shift (- FC) and refer if UO <30 cc/H  @ least 3 contractions in 10 mins, each lasting 40 secs, w/o late
 Watch out for profuse vaginal bleeding, hypotension, tachycardia or any deceleration
untoward s/sx
 Refer accordingly SUSPICIOUS
 Thank you  Inconstant late deceleration patterns

ADMITTING ORDERS (Abdomen) HYPERSTIMULATION

 Uterine contractions occur more frequent than every 2 mins, or lasting
 Please admit to ROC under the service of Dr. __
longer than 90 secs, or presence of hypertonus
 TPR q shift and record
 NPO UNSATISFACTORY
 Labs:  Frequency of contractions is <3 per minute
o CBC (save serum)
o Serum pregnancy test
o Urinalysis
 IVF: D5LR + 10 “u” oxytocin x 30 gtts/min
 SO:
o For completion curettage on call
o Secure consent
o Pad count at bedside
o Save specimen passed out
o Please prescribe the ff: Nubain, Benadryl, Dormicum
o Refer for profuse bleeding and other untoward s/sx
o Thank you
 HYPERTENSION PRENATAL CHECK-UPS
140/90 mmHg 0-27 wks q 4weeks
28 wks q 2weeks
Proteinuria 29-35 wks q 2weeks
 >300mg/24H urine sample 36 wks and beyond q 1week
 > 1000mg/random sample 6H apart
 1+ = mild proteinuria TETANUS TOXOID
 2+ to 4+ = heavy proteinuruia 0 20 weeks AOG
*Edema DOES NOT validate Preeclampsia 1 1 month
2 6 months
GESTATIONAL HPN
3 1 year
 HPN w/o Proteinuria (after 20 weeks gestation) 4 1 year
 Confirm 12 weeks Postpartum

PREECLAMPSIA STEROIDS
 (+) HPN, (+) Proteinuria after 20th week 1 dose 28-32 wks
3 doses q 2 wks
ECLAMPSIA OGTT at 24-28wks
 (+) convulsions, (+) Preeclampsia
MAGNESIUM SULFATE DOSES
CHRONIC HPN
 140/90mmHg Loading dose:
4gms slow IV
SUPERIMPOSED PREECLAMPSIA 5gms each buttocks deep IM
 Inc diastole and systole
 Proteinuria Maintenance dose:5gmsIM/IV q 6hrs
 S/Sx of end organ damage Monitor BP, U/O, DTRs-hyporeflexia
Monitor RR
Triad for Sever Preeclampsia
 Hemolysis MgSO4 drip:
 Elevated Liver Enzyme  1-2gms/hr
 Low Platelet Count 1L = 10gm  given 100cc/hr
 10meq/L (about 12mg/dL)
Hypertension Etiology (Williams) >respiratory depression
 Exposed chorionic villi  12meq/L
 Twin pregnancy (Multiple gestation) >respiratory paralysis and arrest
 Vascular disease
 Family history Antidote: Calcium gluconate 1g IV

ABORTION FETAL DEATH

THREATENED ABORTION 1. Tobacco-stained amniotic fluid
 Bloody vaginal discharge or bleeding appears 2. Spalding’ Sign
 Closed vaginal os o significant overlapping of fetal skull bones
 Low abdominal pain 3. Robert’s sign
 Bleeding first, cramping follows o Demonstration of gas bubbles in the fetus
4. Exaggeration of fetal spinal curvature
INEVITABLE ABORTION
 Gross rupture of membrane BIOPHYSICAL SCORING PARAMETERS
 Leaking amniotic fluid 1. Fetal Breathing Movements
 Cervical dilatation 2. Gross Body Movement
3. Fetal Tone
COMPLETE ABORTION 4. Reactive FHR
 Complete detachment 5. Amniotic Fluid
 Internal cervical os closes *Perfect Score is 10/10 or 8/8

INCOMPLETE ABORTION CBC repeated at 28-32 AOG

HbsAg  last trimester
 Internal cervical os opens and allows passage of blood
Alpha fetoprotein  16-18 wks AOG
Mullerian Anomalies
 Segmented mullerian agenensis or hyperplasia PLASMA GLUCOSE RESULTS
 Unicornuate uterus (Blood Glucose testing performed at 24-28wks AOG)
 Bicornuate uterus Time NDDG Coustan & Capenter (mg/dL)
 Septate uterus Fasting 105 95
 Uterus with internal ___? Changes 1st Hr 190 180
2nd Hr 165 155
Induction of labor
3rd Hr 145 140
 Oxy drip but not in labor

Augmentation of Labor
 Oxy drip however in labor
 LEOPOLD’S MANEUVER DELIVERY OF PLACENTA
L1 (Fundal Grip) SHULTZE MECHANISM
 What fetal pole occupies the fundus  Peripheral
 Shiny portion
L2 (Umbilcal grip)
 Fetal back DUNCAN MECHANISM
 Central
L3 (Pawlick’s grip)  Dirty part
 (+) engagement of head or (-) engagement
DEFINE:
L4 (Pelvic grip)  Placenta increta  invades
 Side of cephalic prominence  Placenta percreta  penetrates
 Placenta accrete  attaches
FUNDIC HEIGHT
12wks – 1st felt; above the symphysis pubis Normal Rotation of Umbilical Cord:
16wks – between symphysis and umbilicus  Counter clockwise or Left-handed maneuver
20wks – umbilicus
36wks – below ensiform cartilage PLACENTA PREVIA
Types:
FHB Monitoring
o Totalis  placenta covers cervical os completely
 Every 30mins= low risk
o Partialis  internal os partially covered by placenta
 Every 15mins= high risk
o Marginal  edge of the placenta is at margin of internal os
BISHOP SCORE
Etiology: (P2ALM2)
0 1 2 3
o Previous CS
Dilatation 0 1-2cm 3-4cm 5-6cm o Puerperal Endometritis
Effacement 0-30% 31-50% 51-70% >70% o Advancing age
Station -5/-3 -2 -1 +1/+2 o Multiparity
Cervical o Multiple induced abortions
Posterior Midline Anterior -----
Position Diagnosis:
Cervical o Painless third trimester bleeding
firm medium soft -----
Consistency o UTZ for placental localization
*Scoring: 3-8 difficult induction o Placental Migration (placenta close to the internal os during 2nd trimester
9-favorable induction migrate to fundus as pregnancy advances

MYOMA PLACENTA ABRUPTION

 causes soft tissue dystocia  premature separation of the normally implanted placenta after the 20th week of
 etiology: unopposed estrogen stimulation pregnancy and before birth of fetus
 types: Subserous, Intramural, Submucous
Etiology: (PECSS)
ROT – right occiput transverse o Pre-eclampsia
Montevideo Units – 200 units or pressure of > 60 o External trauma
Depoprovera – injectable CP is G1 to HPN patients o Chronic hypertension
o Short umbilical cord
EXCISION OF BARTHOLIN’S CYST o Sudden uterine decompression
 Hyperplasia (uterus) – provera
 Endocervical LACERATIONS
 Endometrial
For Functional Curettage 1st Degree
 Endometrial  for D & C o Fourchette, perineal skin, vaginal mucosa but not the underlying fascia and
muscle
2nd Degree
AUGMENTATION OF LABOR
o Fascia and muscles of the perineal body but not the anal sphincter
 ↓ amniotic fluid 3rd Degree
 Oligohydramnios (causes) o Extend from vaginal mucosa, perineal skin and fascia up to anal sphincter
o Cord compression but not the rectal mucosa
o Macrosomia 4th Degree
o Deformations o Encompasses extension up to rectal mucosa
o Fetal distress
BRAXTON HICKS CONTRACTION
HYOSCINE N-BUTYL BROMIDE (Buscopan)  for softening of the cervix
 The uterus undergoes palpable but originally painless contractions at irregular
NST: Fetal condition “7 days” intervals from the early stages of gestation

CST: Uteroplacental contraction SIGNS OF PLACENTAL SEPARATION

 Calkin’s Sign (uterus becomes globular & firmer from discoid)
 Sudden gush of blood
 Uterus rises in the abdomen as the detached placenta drops to the lower
segment and vagina
 Lengthening of the cord
 AMONIOTIC FLUID INDEX POSTERIOR COLPORRHAPY
 Normal: 6-24 cm 1. Induction of spinal anesthesia.
 Oligohydramnios: <5 cm 2. Patient is placed in dorsal lithotomy position.
 Low normal: 9-10 3. Asepsis/Antisepsis
 Polyhydramnios: >24 4. Drapings done leaving the operative site exposed
5. Allis clamps are applied at the posterior vaginal mucosa, elevated creating a
CESAREAN SECTION triangle.
6. A transverse incision made at the posterior fourchette. A portion of the
INDICATIONS FOR CESAREAN SECTION
posterior vaginal mucosa is elevated using an Allis clamp and an index finger
 Prior CS covered with gauze is inserted upward and laterally, dissecting the posterior
 Labor dystocia (most frequent indication for 1’ CS) vaginal mucosa of the perirecteal fascia.
 Fetal distress 7. Vertical incision in posterior vaginal mucosa made. Perirectal fascia dissected
 Breech presentation off the posterior vaginal mucosa. The apex of triangle held with Allis clamp. The
POST OP COMPLICATIONS OF CS DELIVERY dissection of perirectal fascia off the vaginal mucosa is started with scalpel but
 Hysterectomy is completed with blunt dissection
 Operative injury to pelvic structures 8. Kelly plication sutures with vicryl 2-0 through the margins of levator ani muscles
 Infection from apex down to posterior fourchette is done and progressively tied.
9. The excess posterior vaginal mucosa trimmed.
 Puerperal fever
10. The perineal fascia closed with interrupted vicryl 2-0
 Transfusion
11. Vicryl 2-0 suture is placed at the apex of vaginal mucosa using continuous
STAGES OF LABOR interlocking stitches to posterior fourchette.
12. Vaginal packing done with 1 os.
 I: Active labor to full cervical dilatation (4-10 cm)
13. Perineal wash done.
 II: Full cervical dilatation to delivery of baby
14. End of procedure.
 II: Delivery of baby to expulsion of placenta
 IV: Delivery of placenta to 1 hour after
ENDOCERVICAL POLYPECTOMY
CARDINAL MOVEMENTS 1. Induction of labor.
 Engagement 2. Sepsis/Antisepsis/drapings done leaving operative site exposed.
 Descent 3. Insertion of straight catheter to empty the urinary bladder.
 Flexion 4. Posterior vaginal retractor positioned, endocervix identified.
 Internal rotation 5. Anterior lip of the cervix grasped with tenaculum forceps.
 Extension 6. Endocervical polyp found.
 External rotation 7. Polyp grasped, twisted, and removed using an ovum forcep.
 Expulsion 8. Vaginal packing inserted.
9. End of procedure.
ASYNCLITISM  such lateral deflection of the head to a more anterior or posterior
position of the pelvis

ANTERIOR COLPORRHAPY 1’ LOW TRANSVERSE CESAREAN SECTION

1. Induction of anesthesia. 1. Induction of spinal anesthesia.
2. Patient is placed in dorsal lithotomy position. 2. Patient in supine position.
3. Asepsis/Antisepsis 3. Insertion of foley catheter.
4. Drapings done leaving the operative site exposed 4. Asepsis/Antisepsis
5. Evacuation of urine using straight catheter. 5. Drapings done, exposing operative site.
6. The lateral edges of the vaginal cuff are held with Allis. Several Allis clamps are 6. Vertical incision done from 2 FB above the symphysis pubis up to 3 FB below the
placed 3-4 cm apart up the midline of anterior vaginal wall. umbilicus. Incision deepened to subcutaneous tissues and transversalis fascia,
7. The vaginal mucosa is undermined for approximately 3-4 cm up to first Allis rectus muscle split, peritoneum cut longitudinally.
clamps placed in midline. 7. Bleeders clamped and ligated as encountered
8. The vaginal mucosa is dissected off the pubovesical cervical fascia and opened 8. Retractors applied exposing pelvic structures
with scissors in the midline. The vaginal mucosa is opened in midline up to next 9. Vesico-uterine folds identified, lifted out and cut 1 cm above the bladder.
Allis clamp. This is continued until the vagina is opened to within 1 cm of urethral 10. Bladder pushed downward and a curvilinear incision is done on the lower
meatus. uterine segment using bandage scissors, bag of water ruptured.
9. The PVC fascia is separated from the vaginal mucosa. The dissection is 11. Rupture of membranes.
continued until bladder and urethra are separated from the vaginal mucosa 12. Amniotic fluid suctioned & fetal head exposed.
and clearly identified and urethral vesical angle has been ascertained. 13. Delivery of baby boy in left occiput transverse position.
10. Kelly plication done with chromic 2-0. The anterior repair is started by placing 14. Umbilical cord doubly clamped and cut.
suture in PVC fascia, starting at the level of first Kelly placation suture 15. Manual extraction of placenta.
11. The edges of vaginal mucosa retracted laterally with Allis clamps and 16. Closure of incision site done layer by layer
remaining PVC fascia is plicated in midline with multiple interrupted mattress a. First (endometrial) layer closed by continuous interlocking stitches
sutures. The edge of vaginal mucosa are held in tension and excessive mucosa using Chromic 1.
trimmed. b. Second (myometrial) layer closed by continuous interlocking stitches
12. The vaginal mucosa is sutured in midline down to previously incised site by using Chromic 1.
continuous interlocking suture c. Third (Vesico-uterine folds) closed by simple continuous stitches using
13. Perineal wash done chromic 2-0.
14. End of procedure. 17. Suction of blood and amniotic fluid and sponge done.
18. Inspection of the ovaries, fallopian tubes and ligaments
19. Parietal peritoneum closed with continuous suture using chromic 2-0
20. Transversalis fascia sutured with continuous interlocking stitches using Vicryl
1-0
21. Subcutaneous tissue sutured simple interrupted stitches using Plain 2-0
22. Skin closed by subcuticular stitches using Vicryl 4-0
23. Incision site painted with betadine
24. Top dressing applied.
25. End of procedure.
 REPEAT LOW TRANSVERSE CESAREAN SECTION TAHBSO
1. Induction of spinal anesthesia. 1. Induction of spinal/epidural anesthesia
2. Patient in supine position. 2. Patient in supine position.
3. Insertion of foley catheter. 3. Insertion of foley catheter done.
4. Asepsis/Antisepsis
4. Asepsis/Antisepsis 5. Drapings done leaving operative site exposed.
5. Drapings done, exposing operative site. 6. Midline incision done from symphysis pubis up to 2 FB below the umbilicus cutting through
6. Old scar removed. Vertical incision done from 2 FB above the symphysis pubis skin, subcutaneous tissue and fascia, rectus muscle split and peritoneum incised.
up to 3 FB below the umbilicus. Incision deepened to subcutaneous tissues and 7. Bleeders clamped and ligated as encountered.
transversalis fascia, rectus muscle split, peritoneum cut longitudinally. 8. Self retaining and bladder retractors were applied to expose pelvic structures.
7. Bleeders clamped and ligated as encountered 9. Moist pack applied.
10. Inspection of the pelvic structures done.
8. Retractors applied exposing pelvic structures
11. Abdominopelvic structures examined revealed that the uterus measures 8x7cms with
9. Vesico-uterine folds identified, lifted out and cut 1 cm above the bladder. smooth serosa. Both ovaries grossly normal .Both measures 3x2 cm. Left fallopian tube
10. Bladder pushed downward and a curvilinear incision is done on the lower dilated to 7x3 cm and its ampullary area containing serous fluid. Right fallopian tube with
uterine segment using bandage scissors. small cystic paratubal masses ~1x1cm.
11. Rupture of membranes. 12. Right round ligament is doubly clamped, then cut and ligated with Chromic 1. The same
12. Amniotic fluid suctioned and fetal head exposed. procedure is done on the opposite side.
13. Delivery of baby boy in left occiput transverse position. 13. Anterior and posterior leaves of the broad ligament opened. Anterior leaf of the broad
14. Umbilical cord doubly clamped and cut. ligament incised to the point of bladder reflection.
14. Infundibulopelvic ligament triply clamped, cut and doubly ligated using Chromic 1-0.
15. Manual extraction of placenta. 15. Vesicouterine folds cut transversely
16. Closure of incision site done layer by layer 16. Bladder dissected by blunt and sharp dissection.
a. First (endometrial) layer closed by continuous interlocking stitches 17. Uterine arteries triply clamped, cut and doubly ligated with Chromic 1-0 on both sides.
using Chromic 1. 18. Pubovesical fascia incised and pushed down with use of sponge
b. Second (myometrial) layer closed by continuous interlocking stitches 19. Cardinal ligaments clamped, cut and suture ligated with Chromic 1-0.
using Chromic 1. 20. Amputation of cervix at level of cervical os.
c. Third (Vesico-uterine folds) closed by simple continuous stitches using 21. Betadinized OS inserted to the vaginal stump.
22. Closure of vaginal stump with continuous interlocking suture using Vicryl 1-0. Stump angles
chromic 2-0. are anchored to the cardinal ligaments on both sides with figure of eight stitches using
17. Suction of blood and amniotic fluid and sponge done. Vicryl 1-0.
18. Inspection of the ovaries, fallopian tubes and ligaments 23. Bleeders clamped and ligated as encountered.
19. Parietal peritoneum closed with continuous suture using chromic 2-0 24. Parietal peritoneum closed with continuous stitches using chromic 2-0.
20. Transversalis fascia sutured with continuous interlocking stitches using Vicryl 1-0 25. Transversalis fascia sutured with continuous stitches using vicryl 1-0.
21. Subcutaneous tissue sutured simple interrupted stitches using Plain 2-0 26. Subcutaneous tissue closed with simple interrupted stitches with Plain 2-0.
22. Skin closed by subcuticular stitches using Monocryl 4-0. 27. Skin closed by subcuticular stitches using Monocryl 3-0.
28. Operative site painted with betadine
23. Incision site painted with betadine 29. Top dressing done.
24. Top dressing applied. 30. Specimen sent for Histopath.
25. End of procedure. 31. End of procedure.

1’ LOW TRANSVERSE CESAREAN SECTION (PFANNENSTIEL) VAGINAL BIRTH AFTER A CESAREAN SECTION (VBAC)
1. Induction of spinal anesthesia.  Allow a trial of labor under double set-up for all previous cesarean of one low
2. Patient in supine position. segment incision after excluding an inadequate pelvis and unless a new
3. Insertion of foley catheter. indication arises
4. Asepsis/Antisepsis  Selection Criteria:
5. Drapings done, exposing operative site. o 1 or 2 prior low-transverse cesarean section delivery
6. Curvilinear incision done from 2 FB above the symphysis pubis up to 3 FB below o Clinically adequate pelvic
the umbilicus. Incision deepened to subcutaneous tissues and transversalis o No other uterine scars or previous rupture
fascia, rectus muscle split, peritoneum cut longitudinally. o Physicians immediately available throughout active labor capable of
7. Bleeders clamped and ligated as encountered monitoring labor and performing an emergency cesarean section
8. Retractors applied exposing pelvic structures delivery
9. Vesico-uterine folds identified, lifted out and cut 1 cm above the bladder. o Availability of anesthesiologist and personnel for emergency cesarean
10. Bladder pushed downward and a curvilinear incision is done on the lower section delivery
uterine segment using bandage scissors
11. Rupture of membranes. EVACUATION CURETTAGE
12. Amniotic fluid suctioned &fetal head exposed
1. Induction of spinal anesthesia.
13. Delivery of live full term baby boy in left occiput transverse position.
2. Patient in dorsal lithotomy position.
14. Umbilical cord doubly clamped and cut.
3. Asepsis/Antisepsis.
15. Manual extraction of placenta.
4. Drapings done leaving the operative site exposed.
16. Closure of incision site done layer by layer
5. Straight Catheterization done.
a. First (endometrial) layer closed by continuous interlocking stitches using
6. Right angle retractor applied to expose cervix.
Chromic 1.
7. Anterior cervical lip grasped with tenaculum forceps at 12 0’clock position.
b. Second (myometrial) layer closed by continuous interlocking stitches using
8. Hysterometer inserted.
Chromic 1.
9. Pre-curettage uterine depth measured 9 cm
c. Third (Vesico-uterine folds) closed by simple continuous stitches using
10. Sharp and dull curettage done in a clockwise manner, evacuated ½ cup of
chromic 2-0
products of conception and placental tissues.
17. Suction of blood and amniotic fluid and sponge done.
11. Post curettage uterine depth was not measured.
18. Inspection of the ovaries, fallopian tubes and ligaments
12. Perineal washing done.
19. Parietal peritoneum closed with continuous suture using chromic 2-0
13. Specimen for histopathology.
20. Transversalis fascia sutured with continuous interlocking stitches using Vicryl 1-0
21. Subcutaneous tissue sutured simple interrupted stitches using Plain 2-0
22. Skin closed by subcuticular stitches using Vicryl 4-0.
23. Incision site painted with betadine
24. Top dressing applied.
25. End of procedure.
 VAGINAL HYSTERECTOMY FRACTIONAL CURETTAGE
1. Induction of anesthesia. 1. Induction of anesthesia.
2. Patient is placed in dorsal lithotomy 2. Patient in dorsal lithotomy position.
3. Asepsis/Antisepsis 3. Asepsis/Antisepsis.
4. Drapings done leaving the operative site 4. Drapings done leaving operative site exposed.
5. Evacuation of urine using straight catheter 5. Straight catheterization done.
6. Vaginal mucosa is incised with a scalpel around the entire cervix. 6. Weight-bearing retractor applied at posterior vaginal wall. Cervix smooth with no
7. Downward traction is applied using tenacula, Metzenbaum used to dissect the erosions.
bladder off the anterior lower uterine segment 7. Application of tenaculum forceps at 12 o’clock position of cervical lip.
8. A sponge covered finger dissects the bladder all the way up to the vesicouterine 8. Endocervical curettage done, evacuated minimal endocervical scrapings.
fold, facilitates entry to anterior cul de sac. 9. Hysterometer inserted. Pre-curettage uterine depth measured 9cm.
9. Right angle retractor is placed under the vaginal mucosa and bladder, elevating 10. Endometrial curettage done. Evacuated ½ teaspoon of endometrial
the bladder. Strong downward traction is applied to the tenacula on the cervix, scrapings/tissues and placental tissues.
and the peritoneal vesicouterine fold is grasped with Allis clamps and incised with 11. Post curettage uterine depth measured, approximately 8 cm.
sharp curved mayo scissors. 12. Tenaculum and retractors removed.
10. Elevating the peritoneal vesicouterine fold with Allis clamps, definite hole can 13. Perineal wash done
be seen. Finger is inserted in the hole. 14. Specimen sent for histopath.
11. Tenacula are brought acutely up toward the pubic symphysis, exposing the cul- 15. End of procedure.
de-sac, second right angle at posterior cul-de-sac
12. The posterior vaginal retractor is removed. The broad ligament is exposed from COMPLETION CURETTAGE
the uterosacral ligaments to the tuboovarian ligament. A finger is placed in the
1. Induction of anesthesia.
posterior cul-de-sac and moved laterally revealing the uterosacral ligament as it 2. Patient in dorsal lithotomy position
attaches to the lower uterine cervix.
3. Asepsis/Antisepsis
13. With the cervix on upward and lateral retraction using the tenacula, a clamp is 4. Drapings done leaving operative site exposed
placed in the posterior cul-de-sac with one blade underneath the uterosacral 5. Insertion of straight catheter.
ligament, and the opposite blade over the uterosacral ligament. This is done to
6. Speculum applied at posterior vaginal wall
prevent possible ureteral damage from clamping the ligaments in lateral 7. Application of tenaculum forceps at 12 o’clock position of cervical lip.
position. 8. Sharp/blunt curette done. Evacuated 1 tablespoon cup of products of
14. Uterosacral ligament is cut using the mayo scissors.
conception.
15. Chromic 1-0 suture is used to suture ligate the uterosacral ligament. 9. Betadine wash done.
16. When tied, the suture is held with a Kelly clamp for traction.
10. End of procedure.
17. With uterus on upward and lateral retraction using the tenacula on the cervix, 11. Specimen sent for histopathology.
cardinal ligaments is clamped adjacent to the lower uterine segment and
incised.
18. Cardinal ligaments is sutured ligated with Chromic 1-0 suture. Suture is held
with a Kelly clamp for traction

19. The remaining portion of the broad ligament attached to lower uterine cervix CRITERIA FOR TIMING OF ELECTIVE REPEAT CS DELIVERY (At least 1):
segment containing the uterine artery is clamped and ligated.
 Fetal heart sounds documented for 20 weeks by non-electronic fetoscope or
20. With all the ligaments on both sides, clamped and ligated, cervix is retracted
for 30 weeks by Doppler
upward in midline with the tenacula. Posterior uterine wall is grasped, the
 It has been 36 weeks since a (+) serum/urine hCG pregnancy test was
fundus is delivered posteriorly.
performed by a reliable laboratory
21. Two cochers clamps are applied to the tubo ovarian round ligaments, incised
 An UTZ measurement of the CRL obtained at 6-11 weeks supports a
close to the fundus.
gestational age at least 39 weeks
22. Infundibulo-pelvic ligament is tied twice using Vicryl 1.0. Second suture ligation
is tied in a fixation stitch, placing the suture in the mid portion of its pedicle.  UTZ obtained at 12-20 weeks confirms the gestational age of at least 39 weeks
23. The anterior and posterior clamps right angle retractors are removed, and the determined by clinical history and PE
weighted posterior retractor is placed in the vagina. Any bleeding from any
pedicle is clamped. ADMITTING NOTES (Ectopic Pregnancy)
24. Cardinal ligaments, uterosacral ligaments and utero ovarian ligaments anchored  Cc:
at the posterior vaginal mucosa.  Imp:
25. Reperitonealization of the pelvis, carried out with purse string sutures.  Please admit pc to ROC under the service of Dr. ___
26. Perineal wash done.  TPR q 4 hours and record
27. End of procedure.  NPO temporarily
 Labs:
DIAGNOSTIC CURETTAGE o CBC, APC
1. Induction of anesthesia. o CT, BT, PT
2. Patient in dorsal lithotomy position o BT w/ Rh
3. Asepsis/Antisepsis o U/A
4. Drapings done leaving operative site exposed o S. Pregnancy test
5. Straight catheter was inserted.  IVF: D5LR 1L X 8 Hrs
6. Cervix dilated with Goodell’s dilator  Meds: None temporarily
7. Retractor applied at posterior & anterior vaginal wall  SO:
8. Application of tenaculum forceps at 12 o’clock position of cervical lip. o Monitor VS, abdominal status hourly
9. Insertion of hysterometer to measure pre-curettage uterine depth of 3 inches. o Refer once lab result is in
10. Blunt curette done in a clockwise manner. Evacuated scanty endometrial o Dr. ___ seen patient at ER
scrapings. o Watch out for any untoward s/sx
11. Perineal wash done o Refer prn
12. Specimen sent for histopath
 ANESTHESIA PEDIATRICS
Pre-meds: WATERLOW’S CLASSIFICATION
 Cefuroxime (Zegen) 1.5 gms IV Wasting Stunting
 Omeprazole 20mg IV Normal ≥90% Normal ≥95%
 Metoclopramide (Plasil) 10mg IV Mild 80-90% Mild 90-95%
Moderate 70-80% Moderate 80-90%
Anesthetic Agent: Bupivacaine 15mg + MgSO4 16mg Severe ≤70% Severe ≤80%
Formula for Wasting
Detailed Technique: RA-SAB
 X-LLDP, SAS 𝐴𝑐𝑡𝑢𝑎𝑙 𝑤𝑡
× 100
 LA w/ 2% Lidocain 𝐼𝑑𝑒𝑎𝑙 𝑤𝑡 𝑓𝑜𝑟 ℎ𝑡
 LP at L3 L4
 CSF clear and free flowing Formula for Stunting
 Intrathecal administration of anesthetic
𝐴𝑐𝑡𝑢𝑎𝑙 𝑙𝑒𝑛𝑔𝑡ℎ 𝑜𝑟 ℎ𝑡
× 100
SIGNS OF MALIGNANCY ON ULTRASOUND 𝐼𝑑𝑒𝑎𝑙 𝑙𝑒𝑛𝑔𝑡ℎ 𝑜𝑟 ℎ𝑡 𝑓𝑜𝑟 𝑎𝑔𝑒
 Septations
 Internal echoes AGE HR BP RR
 Ascites Premature 120-170 55-75/35-45 40-70
 Multiple daughter cysts 0-3 months 100-150 65-85/45-55 35-55
3-6 months 90-120 70-90/50-65 30-45
<5 cm cyst  in postmenopausal women expectant management
6-12 months 80-120 80-100/55-65 25-40
1-3 yr 70-110 90-105/55-70 20-30
3-6 yr 65-110 95-110/60-75 20-25
6-12 yr 60-95 100-120/60-75 14-22
12 yr 55-85 110-135/65-85 12-18

Conversion: to mg/dL
Creatinine divide by 88.4
BUN divide by 0.357
Bilirubin
divide by 17.1
(total, direct, indirect)

SURGERY Hypernatremia
Water deficit = plasma Na conc. – 140 X total body water
FOLEY CATHETER CHANGE PRESCRIPTION 140
Foley catheter f.16 #1 Total body water = wt. x 0.4 (women)
Urobag #1 Wt. x 0.5 (men)
Sterile Gloves s.7 #1 Total divide by 8 divide by 2 = PNSS 1L x rate x 8 hrs
50 cc Sterile Water #1 D5W 1L x rate X 8 hrs
Plaster #1
KY Jelly #1 EXPANDED PROGRAM ON IMMUNIZATION
10cc syringe #2 Interval
Vaccine Age Dose No Route Site between
TETANUS PROPHYLAXIS FOR WOUNDS doses
TT 0.5 ml/amp #1 Birth; ant time after
BCG 1 0.05 ml 1 ID R deltoid
HTIG 250 cc/vial #1 or 6 weeks
3 cc syringe #1 Upper outer
DTaP / DTwP 6 weeks 0.5 ml 3 IM aspect of 4 weeks
thigh
RANSON’S CRITERIA
OPV 6 weeks 0.5 ml 3 PO Mouth 4 weeks
Objective signs of severity of acute pancreatitis
Antero
lateral
On Admission: Hepa B 6 weeks 0.5 ml 3 IM 4 weeks
aspect of
Age > 55 y.o
thigh
Glucose > 200mg/dl
Outer
WBC > 16,000/cumm
Measles 9 months 0.5 ml 1 SC aspect of
LDH > 350 IU/L
upper arm
AST > 250 U/L
BCG 2 School entry 0.1 ml 1 ID L deltoid
1 month
After Initial 48 hrs
Childbearing then
Serum Ca++ < 8mg/dl TT 0.5 ml 3 IM R Deltoid
women 6-12
Arterial PO2 < 60mmHg
months
Base Deficit > 4meq/L
BUN Increase > 5mg/dl
Hematocrit fall > 10%
Fluid Sequestration > 6,000ml
IDEAL WEIGHT FOR HEIGHT
BIRTH TO 2 YEARS OLD TO MONTHS P50 MONTHS P50 YEARS P50
2 YEARS OLD 18 YEARS OLD 15.5 75.35 42.5 92.18 13.25 145.4
LENGTH WEIGHT HEIGHT WEIGHT
16 75.8 43 92.45 13.5 146.42
(CM) (Kg) P50 (CM) (Kg) P50
45-46 2.51 71-72 8.82 16.5 76.24 43.5 92.71 13.75 147.29
47-48 2.90 73-74 9.15 17 76.69 44 92.98 14 148.03
49-50 3.33 75-76 9.49 17.5 77.63 44.5 93.25 14.25 148.64
51-52 3.78 77-78 9.84 18 77.37 45 93.51 14.5 149.14
53-54 4.27 79-80 10.21 18.5 77.71 45.5 93.78 14.75 149.54
55-56 4.77 81-82 10.59 19 78.04 46 94.04 15 149.85
57-58 5.27 83-84 10.99
19.5 78.38 46.5 94.30 15.25 150.09
59-60 5.84 85-86 11.40
61-62 6.32 87-88 11.82
20 78.71 47 94.55 15.5 150.28
63-64 6.81 89-90 12.26 20.5 79.04 94.82 15.75 150.41
65-66 7.26 91-92 12.72 21 79.37 95.08 16 150.52
67-68 7.68 93-94 13.20 21.5 79.70 AGE 16.25 150.66
69-70 8.16 95-96 13.69 22 80.03 IN 16.5 150.76
71-72 8.58 97-98 14.20 22.5 80.35 Y E A R S 16.75 150.88
73-74 8.95 99-100 14.73 23 80.67 17 151.30
75-76 9.34 101-102 15.28
23.5 80.90 ( G I R L S ) 17.25 151.00
77-78 9.75 103-104 15.85
79-80 10.18 105-106 16.45 24 81.32 4 95.08 17.5 151.05
81-82 10.61 107-108 17.06 24.5 81.60 4.25 96.00 17.75 151.10
83-84 11.06 109-110 17.70 25 81.95 4.5 98.11 18 151.15
85-86 11.47 111-112 18.36 25.5 82.23 4.75 99.12 18.25 151.18
87-88 11.96 113-114 19.05 26 82.88 5 101.03 18.5 151.20
115-116 19.76 26.5 82.99 5.25 102.48 18.75 151.22
117-118 20.50
119-120 21.26
121-122 22.06 IDEAL BODY WEIGHT
123-124 22.88 At birth 3kg
125-126 23.73 3-12mo Age (mo)+ 9 /2
127-128 24.62 1-6 yrs Age (yrs)x 2 + 8
129-130 25.54 7-12 yrs [Age (yrs)x 7 – 5 ]/2
131-132 26.49
133-134 27.48
135-136 28.51
137-138 29.58
139-140 30.68

IDEAL HEIGHT FOR AGE

IDEAL BODY WEIGHT GIVEN BIRTH WIEGHT
MONTHS P50 MONTHS P50 YEARS P50
<6mo Age (mo) x 600 + BW in gm
0 48.8 27 83.21 5.5 103.8
6-12 mo Age (mo)x 500 + BW in gm
0.5 50.50 27.5 83.52 5.75 105.16
1 52.20 28 83.82 6 106.51
Exchange Exchange
1.5 53.74 28.5 84.13 6.25 108.83 Consider
Age Photo transfusion if transfusion if
2 55.27 29 84.44 6.5 109.49 Photo
extensive photo intensive photo
2.5 56.62 29.5 84.74 6.75 110.43 </=24d
3 57.97 30 85.04 7 111.72 >/=12 >/=15 >/=20
3.5 59.15 30.5 85.34 7.25 113.00 25-48 >/=25 (430)
(170) (260) (340)
4 60.32 31 85.64 7.5 114.27 >/=15 >/=18 >/=25 >/=30
4.5 61.34 31.5 85.94 7.75 115.54 49-72
(260) (310) (430) (510)
5 62.35 32 86.24 8 116.80 >/=17 >/=20 >/=25 >/=30
5.5 62.23 32.5 86.53 8.25 118.07 >72
(290) (340) (430) (510)
6 64.10 33 86.93 8.5 119.34
6.5 64.85 33.5 87.12 8.75 120.62
EXPECTED BODY WEIGHT
7 65.60 34 87.41 9 121.91
Term: EBW= (Age in days - 10) x 20 + BW in gm
7.5 66.30 34.5 87.70 9.25 123.21
Preterm: EBW= (Age in days - 14) x 15 + BW in gm
8 67.00 35 87.99 9.5 124.54
 Where 10: # of days to recover over physiologic weight loss
8.5 67.79 35.5 88.28 9.75 125.84
20: g/day gained
9 68.38 36 88.57 10 127.15
9.5 68.94 36.5 88.85 10.25 128.56
CARDIAC OUTPUT
10 69.50 37 89.13 10.5 129.94
10.5 70.09 37.5 89.42 10.75 131.35 Newborn: 180-240ml/kg/min or 4ml/beat
11 70.71 38 89.70 11 132.79
11.5 71.25 38.5 89.98 11.25 134.25
12 71.8 39 90.26 11.5 135.76
12.5 72.35 39.5 90.54 11.75 137.29
13 72.9 40 90.81 12 138.86
13.5 73.43 40.5 91.09 12.25 140.47
14 73.95 41 91.36 12.5 141.90
14.5 74.43 41.5 91.63 12.75 143.40
15 74.90 42 91.91 13 144.28
 DEHYDRATION NEW ADMISSION
Pedia ER: 1. Instruct folks “kadto sa ADMITTING SECTION, ihatag ni para matagaan kamo
ER chart”
75 𝑥 𝑘𝑔
ORS (Mix 1 sachet in [ ] cc water a. Fill-up!
4
b. Ask the px before giving this if they are willing to stay in the ER to
#5 complete the work-up
75 𝑥 𝑘𝑔
Sig. Give [ ] solution per hour x 4 hours 2. Fill-in the ER chart with concise hx, PE, admitting dx, plan
4
a. Have the ER chart checked by the ROD
b. Fill up the lab request forms & prescription papers of the patient –
DEGREE OF DHN (WHO)
have ROD sign the prescription
NO DHN SOME DHN SEVERE DHN
c. Instruct the px on where to go next:
Activity Active Irritable Lethargic
i. Labs & dx forms: “ kadto sa cashier para sa billing”
Eyeballs Not sunken Sunken Sunken ii. Prescription: “ kadto sa botica, bakal ka amo ni nga bulong”
Skin turgor 3. Follow-up the dx and labs:
Good Slow Very slow
(abdomen) a. CXR – pre-read after 30min-1H; make sure to bring the ER chart with
Drinks eagerly, Cannot/ unable you and narrate to the radiologist pertinent Hx & PE before
Thirst Not thirsty
very thirsty to drink prereading
b. CBC, platelet – after 6H
LABORATORIES (include in the plan) c. S. electrolytes, urinalysis, fecalysis – after 2H
To be taken post hydration (6H):
 CBC, plt
 S. Na, K
Separate form; instruct folks to buy specimen cup: Fontanels
 Urinalysis - Anterior closes at 18 months (as early as 9=12 months)
 Fecalysis - Posterior 6-8 weeks

TREATMENT Colostrum – 1st 2-4 days postpartum ↑ CHON, vitamins, salt, Ig

No DHN: feeding, fluid, follow-up ↓ fat and sugar
Some DHN: ORS 75ml/kg divided into 4 solutions; give 1 solution q1h x 4h
Severe DHN: PLR/D5LR Absolute Contraindications to BF
Age 70ml/kg 70ml/kg  Galactosemia
≤12mos 1 hr* 5 hrs  Tyrosinemia
>12mos 30mins* 2 ½
*Repeat once if radial pulse is still very weak or not detectable Relative Contratindications to BF
Hypotension:  Psychosis
 PNSS 10cc/kg fast drip  Active TB

Fever > 2 days MultiVitamins:

 Perform tourniquet test  Ascorbic acid
Drops 100mg/mL: Syrup: 100mg/ml
Chest pain <3mos: 0.3ml/day
 Order xray, ECG 15 leads 2-6y/o: 5ml/day
3-12mos: 0.6ml/day
Seizure 7-12y/o: 10ml/day
1-2y/0: 1.2ml/day
 CBC, platelets, electrolytes,
 Start IV: D5 0.3 NaCl KV0  Vit. B complex + hysine + beclizine (Appebon syrup)
 O2 at 1-2 LPM 2-6y/o: 1-2tsp OD
7-14y/o: 2-4tsp OD
O2 sat < 92
 O2 @ 1-2 LPM, then refer  Iron (weight x 5/elem Fe)
*Always have the ROD countersign 1mkday OD- prophylactic Hemarate 30/5
3-6mkday BID-therapeutic Iberet 26.25/5
Paracetamol dose: Zinc RD – 10-20mg/day Incremin 30/5
6-28 (hosp/pedia protocol: 10) mg/kg/mkdose for fever > 37.8 C 10mgdrops- infant Sangobion 12/10
20mg- >2yo Ferlin 30/15
REMEMBER!!!
 ROD makes rounds usually @ 8,12,4  Folic acid
 Monitor v/s q1h 2.5g/ml
 Ask for urine frequency and BM q4h especially for AGE 0.2 mkday
 Pedia office: 134
 Vitamin A
NORMAL HEMATOCRIT VALUES FOR AGE  6-11mos: 100,000IU – 1 dose
 12-71mos: 200,000IU
Age Range (%) Mean (%)  <2yrs: drops
2 weeks 42-66 50 10mg/ml=1ml
3 months 31-41 36  >2yrs: syrup
6 months – 6 yrs 33-42 37 20mg/5ml= 5ml
7 yrs – 12 yrs 34-40 38
Adult:
Male 42-52 47
Female 37-47 42
Source: Nelson textbook of Pediatrics, 15th edition p. 1379
Analgesics/Antipyretic Anti-emetic/ Anti-spasmodic
Paracetamol (Q4h) Mefenamic Acid (q6-8hr) Metoclopramine Nifuroxide (Ercefuryl)
RD: 5-8 mkdose RD: 0.5mkdose PO <6mos- 10ml
RD: 10-15mkdose PO Susp: 50mg/5ml 0.2mkdose IV >6mos- 5ml
10mkdose IV 125mg/5ml Amp: 10mg/2ml, 5mg/2ml Adult: 1cap Q6H
15mkdose-BFC Cap: 250mg/500 Syr: 5mg/5ml Susp: 220mg/5ml
Drops: 100mg/ml Tab: 10mg Cap: 200mg
60mg/0.6mk Aspirin (Q4-6H) Dicycloverine HCL (Q8h) Hyosciene N-Butyl (Bromide) Q6-8h
Syrup: 120mg/5ml RD: 10-15mg/kg/dose upto RD: 2.5-5mg/kg/day
125mg/5ml 60-80mg/kg/24h 6mos-2y.o: 0.5-1ml
350mg/5ml Anti-inflam:60- RD: 0.15mkdose
2y.o-5y.o: 2.5-5ml
Tab: 325mg/tab 100mg/kg/24hPO Amp: 20mg/ml
Drops: 5mg/ml, 15mg/ml
250mg/tab Kawasaki: 80-100mkday Tab: 10mg
Syr: 2mg/ml, 10mg/ml
500mg/tab Tab: 10mg
Amp: 150mg/ml Nimesulide (BID) Domperidone (Motilium) Q8h*15
300mg/ml RD: 2.5-5mkdose RD: 0.3mkdose
100mg/tab Dyspepsia: Adult: 1tab/2tsp Q8h
Ibuprofen Children: 2.5ml Q8h Suspension: 1mg/ml Tab: 10mg
RD: 5-10 mg/kg/dose N/V: Adult: 2tab/4tsp Q6-8h
PO Q6-8H Children: 5ml Q6-8h
Susp: 100mg/5ml Dyspepsia N/V
Forte: 200ng/5ml 10kg 2.5ml 5ml
Cap: 200mg 20kg 5ml 10ml
30kg 7.5ml 15ml

Antacids Antihelminthics
Ranitidine (Q8h-12h) Famotidine (Q12h/IV-Q8h) Mebendazole
RD: 0.75mkose PO 500mg/tab single dose
RD: 0.2mkdose
0.8-1mkdose IV 100mg/tab or 5ml BIDx3 consecutive days
Amp: 25mg/2ml
Amp: 25mg/ml, 50mg/5ml 20mg/ml susp: 5ml BIDx3 consecutive days
Tab: 20mg/40
Tab: 150mg/300mg 50mg/ml susp: 10ml SD
Cimetidine (Q4-6h) Omeprazole Enterobiasis (100mg or 5mg SDrpt 2 or 4 weeks)
RD: 10-15mkday Susp: 20mg/ml, 50mg/ml
<1y.o: 20mkday Tab: 100mg; 500mg
1-12y.o: 20-25mkday *deworm @2-4 yrs old
1mgkday
Liquid: 100mg/5ml Pyrantel Pamoate
Amp: 150mg/ml, 100mg/ml RD: 10-20 mkdose
Tab: 200mg, 400mg Susp: 125mg/5ml
AlMg (Maalox) (Q6h) Ursofalk Tab: 125mg; 850mg
2-4 tabs max: 16tabs Albendazole
*take 30 minutes 1 hr after RD: 75mkday
meal at bedtime Susp: 200mg/5ml
10-15mkday
Susp: 180ml; 355ml Tab: 400mg
200/5ml
Tab: chewable
Fw/flatulence- Quinolones
Almg+dimeticone (Maalox plus) Ciprofloxacin - BID
Vial: 100mg/50ml, 200mg/100ml, 400mg/200ml
Anti-Diarrheals
Paroromycin (Humagel) Erceflora – Bacillus clausii Amebicide
>1mos: 1-2 vials/day Metronidazole Q6h Furazolidone
RD: 20-30mkday 3-4 dived dose
2-11y.o: 1-2 vials/day RD: 30-50 mkday PO
150mg/cap, 150 mg/5ml
Adult: 2-3 vials/day 7.5 mkdose IV
Racecadotril (Hidrasec) Nifuroxamide (Ercefuryl) 15mkdose – loading dose RD: 4-7 mkday
1 mos onwards Vial: 5mg/ml Liquid: 16.7 mg/5ml
RD: 1.5mg/kg/day Q8h IV: 500mg/100 Susp: 50mg/ml
Susp: 125mg/5ml
BW Hidrasec Sachet 200mg/5ml
<6mos: 1tsp BID
<9kg 10mg 1 sachet Paramomycin Etofamide (Kitnos)
>mos: 1tsp TID
9-13kg 10mg 1 sachet RD: 15-20mkayX3 days Q12H
13-27kg 30mg 1 sachet RD: 20-30 mkday
Susp: 100mg/5ml
>27kg 30mg 2 sachet Susp: 150mg/15ml
Tab: 200mg; 500mg
Adult dose: 100mg/cap Q8h
Antihistamine Cephalosporins
Hydroxyzine Hcl (Iterax) Desloratadine (Aerius) 1st Generation 2nd Generation
6-11 mos: 2ml Cefaclor Q8h
Q12h x 5 days
1-5 y.o: 2.5 ml RD: 20-40mkday
RD: 1mg/kg/day or wt/4
6-11y.o: 5ml Drops: 50mg/ml
Syrup: 2mg/ml
>/=12y.o: 10ml Susp: 125mg/5ml
Tab: 10mg; 25mg
Syr: 2.5ml/5ml 250mg/5ml
Amp: 5mg/ml
Tab: 5mg Tab: 315mg; 750mg
Chlorphenamine Maleate Diphenhydramine Hcl Cap: 500mg
Q8h
RD: 0.2mkdose Cefuroxime Q6-8h
RD: 3-5 mkdose PO RD: 20-40mkday PO; 50-
Amp: 10mg/ml
1mkdose IV Cefalexin Q6h 100mkday IV
Vial: 10mg/ml
Syr: 12.5mg/5ml RD: 30-50 mkday PO
Syrup: 2mg/5ml
Cap: 25mg, 50 mg 50-100mkday IV Cefamandol
Tab: 4mg
IV/IM: 50mg/ml Drops: 100mg/ml RD: 50-100mkday
*20kg-1/2 amp IM
>20kg-1amp IM Susp: 125mg/ml
Cetirizine diHCL-OD-BID Levocetirizine 250mg/ml Cefprozil
RD: 0.25-0.27 mkdose Cap: 250mg; 500mg RD: 20-4-mkday
Drops: 10mg/ml Powder: 125mg/5ml; 250mg/5ml
2.5mg/ml Cefazolin Tab: 250mg; 500mg
0.125mkdose RD: 50-100mkday IV x 3dose
Soln: 1mg/ml
Sry: 5mg/5ml Vial: 250mg Cefotiam
Tab: 10mg Inj: 500mg; 1g RD: 50-100mkday
Tab: 200mg
Vial: 0.5g; 1 gm

Cefixime Q12h UTI: 8 TF: 20

RD: 3-6mkday PO, 15mkday
Drops: 20mg/ml
Susp: 100mg/5ml
Cap: 100mg;200mg

Cefdinir
RD: 9-8mkday
Cap: 100mg

Mucolytic 3rd Generation 4th Generation

Carbocysteine (Q8-12h) Erdosteine (Q12h) Cefoperazone Cefepime OD-BID
RD: 30-50 mkday RD: 100-150mkday IV RD: 50-100
Drops: 50mg/5ml Vial: 1.5g Vial: 500mg; 1g; 2g
Syr: 100mg/5ml RD: 10mkday Ceftriaxone BID
Cap: 500mg 10-20kg, 2-6y.o: 2.5ml RD: 50-100mkday
<3mos: 0.25ml 21-30kg, 7-12y.o: 5ml Vial: 500mg; 1 g;
3-5mos: 0.5ml >30kg, >12y.o: 5mlTID/7.5ml BID 250mg
6-8mos: 0.75ml Susp: 115mg/ml; cap: 300mg Ceftazidime
9-12mos: 1 ml RD: 30-50mkday IV
5y.o: 5ml Vial: 250mg; 500mg;
Ambroxol (Q8h) 1g; 2g
D: 1.2-1.8 mkday Cefpodoxime
Liq: 15mg/5ml; 30mg/ml 3-10mkday
Soln for inhalation: 15ml/2ml Susp: 50mg/5ml
Amp: 15mg/2ml Tab: 100mg
Ped drops: 6mg/ml Co-Amoxiclav: 228.5g/5ml; 457/5ml
Tab: 30mg; retard cap 75
Aminoglycosides Antihypertensives
Bronchodilators Furosemide
Salbutamol TID Procaterol RD: 0.5-1mkdose
>/6: 5ml Amp: 20mg/2ml
</=5y.o: 2.5ml Tab: 40mg
RD: 0.13-0.15 mkdose Gentamycin OD-BID
Sry: 2mg/5ml Aminophylline/Theophyline 5-8mkday Hydralazine
100mg/5ml RD: 0.1-0.2mkdose
Amp: 1mg/ml 3-5mkdose Amikacin OD-BID Amp: 20mg/ml
Tab: 2mg 80mg/5ml; 125mg/tab, RD: 12-15mkday – 15 Tab: 10mg; 15mg; 50mg
175mg/tab mkdose OD
Aspirin
75-100mkday
Terbutaline BID TID Bambuterol Vancomycin
1-15y.o: 2.5ml RD: 15mkday Nifedipine Q4-6h
<3y.o: 0.075mkdose 6-12y.o: 5mkdose RD: 10mkdose
Syr: 1.5mg/5ml Oral soln: 1mg/ml Max: 10mg/kg/24h
Soln: 2.5mg/5ml Tab: 10mg
Spironolactone
Amp: 0.5mg/ml
1.3-3mkday QID PO
Tab: 2.5mg
Antifungal Steroids
Nystatin Q6h Fluconazole – OD Prednisone – BID Dexamethasone
Adult & children: 4-6ml RD: 3-6mkday RD: 1mkday BID; 2mkday OD RD: 0.5 – 1mkdose
Infant: 2ml Vial: 3mg/ml Susp: 10mg/5ml 0.3mkdose initial, then 0.1
Tab: 500,000 U Cap: 50, 150, 300mg Syr: 5mg/5ml; 20mg/5ml mkdose 1-2mg/kg Q6h x 4
Susp:100, 000 U/ml Tab: 1, 5, 10, 20, 30, 50mg *xtubate on 3rd dose
Griseofulvin Hydrocortisone
Procaterol (Meptin) BID-TID
Amphothericin B Tab: 125mg/500mg RD: 5mkdose Q6-8h
RD: 0.25mkdose or 0.25xwt
RD: 0.3-0.7mkday LB: 10mkdose
Syr: 5meq/ml
Slow in Infusion Ketoconazole x 5 days OD MD: 5(max 100)
Tab: 25meq, 50meq
*250mcg/kg/day-1mg/kg/day Adult: 200mg/tab Vial inj: 100mg; 250mg; 500mg
Vial: 50mg/5ml; 2mg/ml 5-12y.o: 100mg/tab Erdosteine (Ectrin/Zertin) Aminophylline
Cap: 50mg; 100mg; 200mg 1-4y.o: 50mg/tab 175mg/5ml-10mkday BID; LD: 5-7mkdose
Isoprinosine: 50-100mkday 300mg/cap BID MD: 3-5mkdose
Combivent: 200ug Ipatropium
Macrolides <2y.o: 5-8 drops; 2-3 y.o: 3 drops; >4y.o: 20 drops
Azithromycin OD-BID
RD: 15-20mkday IVIG
Erythromycin q8h Susp: 200mg/5ml Dose: 2g/kg in 12H or 400mg/kg/dose x 5d
RD: 35-50mkday Tab: 250mg; 500mg 2.5g/vial, dilute w/ 50ml diluents to make 50mg/ml administer the ffL
Granules: 200mg/5ml; Vial: 500mg
400mg/5ml Test dose:
Drops: 100mg/2.5ml Chloramphenicol q6h 0.1 0.5ml/kg/H x 15min
Tab: 250-500mg RD: 50-100mkday; 0.2 1ml/kg/H x 15min
75mkday (enteric fever) 0.4 1.5ml/kg/H x 15min
Clarithromycin Q12h FT infant>/=2week: 25- 0.8 2ml/kg/H x 15min
RD: 7.5mkdose; 15mkdose 50mg/kg/day 2.5ml/kg/H x 15min
Susp: 125mg/5ml 3ml/kg/H x 15min
Tab: 250; 500mg Cotrimoxazole BID 3.5ml/kg/H x 15min
RD: 5-8mkday; 8 UTI; 10 BPN 4ml/kg/H x 15min
Roxithromycin OD-BID Susp:
Adult: 150mg/tab; 300mg/tab 200mg/40mg/5ml- *if tolerated in fuse the rest at ____cc/h for 10hr watch out for headache, flushing,
Q12h (40mg/5ml) (wt/2) hypotension, fever and chills
Children: >40kg 400mg/80mg/5ml-
Kiddie tab: 100mg (80mg/5ml)(wt/4) NaHCO3
Tab: 400mg/80mg; BE x wt x 0.3 or 1meq/kg can be given IV push or drip 50mcg/kg NA>1-2 meq/kg
800mg/100mg

Anti- TB drugs AMINOSTERIL COMPUTATION

1-10; R-15; S-20; E-35; P-30 Weight x 1gm x 100 = ___ cc to run for 22hrs, rest for 4hrs
Isoniazid Rifampicin: 6
RD: 5-10 RD: 10-15mkday Ex.
Syr: 100mg/5ml; 200mg/5ml Drops: 100mg/ml Weight: 900g 0.9x 1gm x 100 = 15cc
Tab: 100mg; 200mg; 300mg Cap: 300; 45mg 6
Pyrazinamide Ethambutol 1. Order: Aminosteril 6% 15cc to run for 22 Hrs; rest for 4 Hrs x 2 cycles
RD: 15-30mkday RD: 12-25mkday (TFI 150- 1gm AA - FFP)
Susp: 250mg/5ml Syr: 125mg/5ml ex: FFP x 2 units 18cc/unit
Tab: 500mg Tab: 400mg
Amantadine HCL 150-15cc-15cc-18cc+18cc x weight = 84 ÷ 24 = 3-4cc/Hr IVF rate
Streptomycin
RD: 4.4-8.8mkday 24H
RD: 15-20mg/kg/day
Syr: 50mg/5ml
Vial: 1gm Aminosteril
Tab: 100mg
0.5/kg - increase until 3g/kg
Ribavirin
Weight x RD x 100/6%/24 or Weight x RD/0.694
RD: 10mkdose
*start 1g x 48H then resume at 2g
Syr: 50mg/5ml
Tab: 100mg Conversion of Hyponatremia
1ml=2.5 mEqs NaCL
Anticonvulsants/ Sedatives Weight: 1.8 kg
Midazolam S.Na: 131.4
Phenobarbital D-A x wt x 0.6 (140-131.4 x 1.8 x 0.6 = 9.2 mEqs)+ wt x 3= maintenance (1.8 x 3=5.4)
RD: 0.2mkdose
LD: 10mkday
Tab: 15mg ½ - 4.6 – 1.8 – 6.4
MD: 5mkdose (max 25mkdose)
Amp: 5mg/ml, 5/5, 15/3 ¼ - 2.3 – 1.8 – 4.1 HYPONATREMIA
Phenytoin ¼ - 2.3 – 1.8 – 4.1 D-A x wt x 0.6 ÷ (2-3) maintenance
LD: 10mkdose
Diazepam 1st Shift
MD: 5mkday HYOPCALCEMIA
RD: 0.2-0.8 mkdose D5W- 6.6
Susp: 30/5, 12/5 K/K (?) – 0.1 to 0.3 meqs/k/H
Cap: 30, 100 D5IMB- 50 NK of Body= 50meqs
NaCl- 2.5 (?) K/R –meqs KCL/#Hrs/wt
Hypokalemia
D-A x Weight x 0.3 + (Weight x 2) ?

Weight x 0.2 x 8 x 3 x 2 x Weight

Sk- <3-5% -0.05
<2.5-10%-0.10
Wt X 0.05 x 50 /wt x (2/maintenance)
 DRIPS EPINEPHRINE DRIP
Weight x 0.6 mg = mg added to 100mgD5W
DOPAMINE DRIP
1cc/H = 0.1 ug/kg/min
(200mg/250-800conc) 0.0375/26.6
5cc/H = 0.5 cc/min ml/H= weight x dose x 60
(400mg/250ml-1600conc) 0.075/13.3
10cc/H = 1mg/kg/min concentration
Wt x RD x 60 (0.075)
0.1mkd/0.1cc/kg/dose
SHORT CUT: wt x RD WT X 3(50) X dose (10mg/kg)
6 X Wt in Kg x mcg/K/min = ____mg in 100ml of D5W/NS
mL/Hr
13.3 (800-conc) 6 (100)
 Set your own rate: ex: 4ml/hr
Rate (1cc/hr)
6 x wt x 0.1 mcg/kg/min
Wt x RD 1.6
4ml/h
26.6 (1600-conc)
If weight is 40 kg: 6 x 40 x 0.1 = 6mg in 100ml D5W
4
To check: AD:
Order: Start epinephrine drip: 6mg epinephrine + 100cc D5w x 4cc/Hr
dose given x Prep/60/wt
(0.1 mcg/k/min)
or
WT x RD X 140D/ 1600/24
INSULIN DRIP
Prep: 1U/ml amp
Max: 20
Dose: Infant and Child 0.1Ukg/H (titrate to clinical effect)
Glucose drop: 80-110mg/dl/H

LEVOPHED Weight (kg) x dose x 24 = U in 24ml NS

4mg/4ml; 2mg/ml or
e.g 2ml/ml Weight (kg) x dose x 24 x 5 = U in 120ml of NS
2/100 x 1000= 20 conc *to make: 5ml/H= 0.1U/kg/H

(WT x dose x 60)= ml MIDAZOLAM DRIP

Conc Prep: 5mg/ml amp
To check: ml x conc/60/15= dose Dose: intermittent: 0.05 – 0.15mg/kg/dose
Continuous: 1-2mcg/kg/dose
DRIP FORMULA
6 x wt (kg)x mcg/kg/min – mgin100ml of D5NSS 6 x wt (kg) x mcg/kg/min = mg in 100ml of D5W/NS
MI/H mL/H
Max total dose: 10mg (intermittent)
ISOPROTERENOL/EPINEPHRINE/NOREPINEPHRINE Can cause respiratory depression, hypotension, bradycardia
0.6 x wt (kg) = mgin100ml O
*1ml/H will deliver 0.1 mcg/kg/min
DOPAMINE/ DOBUTAMINE/ AMRINONE/ NITROPRUSSIDE AMIODARONE DRIP
6 x wt (kg)= mg in 100ml Prep: 50mg/ml amp
Dose: infant and child: 5mg/kg over 30 min ff by infusion starting at 5mcg/kg/min
*0.1 ml/H will deliver 1mcg/kg/min
Max dose: 10mcg/kg/min or 20 mg/kg/H must be diluted in D5W
DOPAMINE/ DOBUTAMINE
6 x wt (kg) = # mg to add to diluents to make 100ml volume Infusion concentration should not exceed 2 mg/ml

DOBUTAMINE DRIP Weight (kg) x dose x 60 x 50 = mg in 50mlD5W

Dobu-premix 1000
2.5 – 15mcg/kg/min (max: 40mcg/kg/min)
0.06-1000=250/250 D%W To make: 1ml/H= 1mcg/kg/min
Peak effect: 10-20min
0.03-2000
Prep: 12.5 mg /ml x 20ml/vial= 250mg/250ml (vial)
Wt x dose x 0.06/0.03 NICARDIPINE DRIP
Premix: 1000mcg/ml in 250= 250/250 (1mg/ml)
2000mcg/ml in 250 ml= 500mg/250 (2mg/ml) Prep: 2.5mg/ml= 5mg/10ml ampule
Dose: Child: 0.5-5mcg/kg/min (titrate to clinical effect)
Wt x RD x 60 or wt x RD x 1400/12500 or 6 x wt in kg= ____mg in 100ml Adult: start with 5mg/H, increase dose as needed by
2000 (1mcg/kg/min) 2.5mg/H Q 5 -15 min (Max dose: 15mg/H) decreased by
Ex: 250mg in D5W 250cc(1mg/ml) 500mg in D5W250cc(2mg/ml) 3mg/H as needed to maintain desired response
Mcgtt/min= (Wt x DD)/16.6 ugtts/min=(wt x DD)/33.2
= Wt x DD x 0.06 = Wt x DD X 0.03 MINOPHYLLINE DRIP
*to check: 7.5 – actual x 2000/ 60 /wt LD: 5mg/kg BW in 30cc 5W in a soluset (if px is not maintained on oral theophylline)
actual x conc/60/wt
or
FUROSEMIDE DRIP 25mg/vial dilute 1ml + 4ml NSS to make 5 mg/ml solution.
20 mg/2ml
Aspirate ____mL give per IV infusion for 30 min as LD (5mg/kg)
**4ml + 20cc PNSS to run @ 1cc/h
D5W250cc + Aminophylline 250mg/amp at ____ugtts/min
(weight) 15 x (dose) 0.1 x 24
36 x 2/20 = 3.6 Main drip: 0.4 – 0.8mg/kg/H
3.6/4ml = 0.9 or 1cc Formula ugtts/min = dose x BW

Prep: 10mg/ml amp (2m) Note: maintenance infusion rate must be induced to 0.2 – 0.3 mg /kg/H for elderly
Dose: infant and child: 0.05 mg/kg/H (titrate to clinical effect) patient, pregnant patient and those in CHF. Liver disease or cor pulmonale watch out
Adult: 0.1 mg/kg/H (max: 0.4 mg/kg/H) for hypoglycemia and tachycardia.
 Weight (kg)x dose x 24 = mg in 24 ml of NS to make: 1ml/H = 0.1mg/kg/H
 Weight (kg) x dose x 24 x 5= mg in 120ml NS to make 5ml/H=0.1mg/kg/H

*20mg furosemide + 20cc distilled water to make concentration of 1mg/ml

Infusion rate: 0.05 x weight
eg: 0.05 x mg x 1 = 4 cc
DUET (Double Volume Exchange Transfusion) Laryngoscope Blade Size
Blood volume: 80cc/kg Term/Newborn Size 1
ABC: no correction if <10 B.D
E.g wt: 3kg 2-11 yrs Size 2
3 x 80 x 74-60/74 = 3360/74 >12yrs Size 3
45cc to be exchanged
160-180cc/kg/FWB ET Tube Size & Depth
Mother’s Blood type – wt 80 x 2 Weight Size Depth
500-1000 2.5 7.0
INDICATIONS: 1000-1400 3.0 7.5
Sepsis Corrected WBC:
1400-1900 3.0 8.0
S. Bilirubin >20mg/dl e.g RBC = 7500= 75000/500-15
1900-2200 3.5 8.5
Hypoxia and acidosis for every RBC = 1 WBC
2200-2600 3.5 9.0
Hemolytic dose of NB WBC = 37-15=22 corrected RBC
ABO incompatibility 2600-3000 3.5 9.5
Prematurity 3000-3400 3.5 10
3400-3700 3.5 10.5
COMPLICATIONS: 3700-4100 4.0 11.0
Vascular embolism 4100-4500 4.0 11.5
Infection >4500 4.0 12.0
Cardiac arrhythmia vol overdose
CP arrest
Electrolyte imbalance BELL CLINICAL STAGING OF NEONATAL NECROTIZING ENTEROCOLOTIS (NEC)
1. Suspect,
FIO2: 100% target FiO2 X TRF (S) Infant with suggestive clinical signs but x-ray non diagnostic
79 2. Definitive
Infant w/ pneumatosis intestinalis
GUIDELINES FOR PEDIATRIC PLATELET TRANSFUSION
2a: mildly ill
Children/Adolescents 2b: moderately ill (acidosis, thrombocytopenia/ ascites)
<50 x 109/L and bleeding
<50 x 109/L and invasive procedure 3. Advanced
<20 x 109/L and bone marrow failure with age risk factor 3a: critilac w/ impending perforation
<10 x 109/L and bone marrow failure w/o age risk factor 3b: critical w/ proven perforation

Infants within the 1st 4mos of life

<100 x 109/L and bleeding
<50 x 109/L and invasive procedure
<20 x 109/L and clinically stable
<100 x 109/L and clinically unstable

WATERLOW CLASSIFICATION ELECTROLYTE COMPUTATIONS

> 90 no PEM I. Potassium
75-90 MILD WT for Age: Actual WT x 100%  N= 4-5.6 meq
60-74 MODERATE Wt at P50  N K deliuence: 0.1-0.4meq/kg
<60 SEVERE Deficit = (KD - KA)x wt x 0.6
Maintenance K: 2 x wt
HT for Age= Actual HT X 100 Total K deficit: deficit + maintenance
Ht at P50 Full Incorporation: 40meq/L or 20 mEq/500cc
K infusion rate:
Wt for HT = Actual wt X 100 N= 0.2meq – 0.4meq/kg
Wt at P50 of HT at P50 IV rate x amt of K (meq)
Vol of IVF x Wt
Height WT Deficit: Wt x 50 x __K__
>95 – no stunting >90 – no wasting Maintence – 2 x wt
90-95 –mild 80-90- mild
85-89 – moderate 70-80- moderate II. Sodium 135-145 meq
<85 – severe <70- severe Maintence Na= 3 x Wt Na: 1 meq= 2.3mg/dl
Max target/day: 10 meq K= 1 meq= 3.91mg/dl
INTUBATION
NaHCO3= gr x = 650mg = 7.7meq
ET Tube Size AOG SIZE gr v = 325
<1000 <28 2.5
1000-2000 28-34 3.0 III. Calcium: 8-10 meq
2000-3000 34-38 3.5 IV. Chloride: 98-106 meq
>3000 >38 3.5-4.0 V. CO2 15meq

ET SIZE BY AGE Rate x 24 = ___ ÷ 100= ____ x 4

Premature 2.5mm
0-3 mo 3.0mm MAXIMUM K that can be in cooperated per Liter IVF:
3-7 mo 3.5mm  Parenteral: 40meqs
7-15 mo 4.0mm  Central: 60-80meqs
15-24 mo 4.5mm
DEFICITS
2-10 yrs Age (yrs)+16/4 or Age(yrs)+ 4/4
Na= 135-150/3-4meq/kg/day
10-20 yrs 6-8mm
Na deficit= (Desired 140 – actual) X TBW
TBW (L) = 0.6 x BW (kg) + Maintenance
ET level: size of tube x 3
 CREATININE CLEARANCE PHOTOTHERAPY
(140-age) (wt in kg) x 0.85 (F) 1(m) Indication: PT 10mg% Bilirubin
Creatinine (mg/dl) x 72 PT 15mg% Bilirubin
* ÷ 88.4 → mg/dl
Complication: Osmotic diarrhea, Rashes
STAGING Bronze baby syndrome, Dehydration
1 Kidney damage with NGFR >90
2 Mild ↓ GFK 60-90 Kramer’s Classification
3 Moderate ↓ GFK 30-59 ZONE JAUNDICE EST. LEVELS
4 Severe ↓ GFK 15-24 1 Head/neck 6-8mg/dl
5 Kidnet failure <15 2 Upper trunk 9-10mg/dl
3 Lower trunk to thigh 12-14mh/dl
1. Based on Height 4 Arms/legs/elbow/knees 15-18mg/dl
*0.33 = pretem; lbw, <1 yr 5 Hands/feet >18mg/dl
0.45 = term, infant, <1yr B1 – uncongugated/ indirect
0.55 = children, adolescent female B2 – conjugated/ direct Bilirubin
0.7 = adolescent male
* X ht (cm) RESPONSE TO PHOTOTHERAPY
Serum creatinine (mg/dl)
*check rebound B2 for 12-24H after discharge
2. Adult
Bilirubin Age Action
*Male: 72
<18 - Wean to single photo
Female: 85
140-age x wt </=18 - D/C home
* x Creatinine (mg/dl) </=14 49-7/2 D/C photo
</=15 >72’ D/C photo
Values: Age in hours TSB (mg/dl)
80-120: normal 24-48H <15 15-<20 20-<25 >/=25
50-80: renal impairment 49-72H <18 18-<24 25-<30 >/=30
20-50: renal insufficiency >72H <20 20-<25 25-</=30 >/=30
5-20: renal failure INTENSIVE PHOTO/
Tx/rec OPD PHOTO
<5: uremia PHOTO exctrans

GFR: 125ml/min (75-150)

24 urinary Creatinine
M: 15-20mg/k
F: 10-15mg/k

ACTUAL RETICULOCYTE COUNT (ARC) IV FLUIDS

𝐴𝑐𝑡𝑢𝑎𝑙 𝐻𝑐𝑡 IVF: D10 – 1st24hrs of life
𝑥 𝑅𝑒𝑡𝑖𝑐𝑢𝑙𝑜𝑐𝑦𝑡𝑒 𝐶𝑜𝑢𝑛𝑡 D10IMB – after 24 hours of life
𝐷𝑒𝑠𝑖𝑟𝑒𝑑 𝐻𝑐𝑡
How to replace fluids: 1st 24HDL weight x 80cc/kg – if NPO
Reticulocyte Index: ARC ÷ 2
Day 1 90 cc/kg
= HCT/Ret Count x 2
2 100 cc/kg
3 110 cc/kg
>2= hemolysis
<2= BM suppression 4 120 cc/kg
5 130 cc/kg
6 140 cc/kg
IDEAL TRACHEAL ASPIRATE
7 150 cc/kg
EC < 25
8 160 cc/kg (max)
PMNS> 10
D10IMB = Desired – Actual x volume
BLOOD TRANSFUSION Highest – Lowest
1 “U” – increase Hgb by 2: Hct by 3 Available: D5IMB; D50W, D10W
FWB 20cc/k (max) D10IMB = 10-5 x volume (100)
PRCB 10-15cc/K (15cc/k in neaonates) 50-5
= 5 x 100
FWB: 45
Volume = desired – actual HB x 6 x wt 11ccD50W 11→ D50W (subtract from the volume 100)
= desired – actual Hct x wt + 89ccD5IMB 89→ D5IMB
Rate = volume x 12 gtts/ml = gtts/min D10IMB
60min x 4H
COMPOSITION OF AVAILABLE PARENTERAL FLUIDS
PRBC: IV Na Cl K Mg Ca HCO3
Volume = desired – actual Hgb x 2 x Weight 0.9NSS 154 154 - - - -
= desired – actual Hct x Weight 0.3NSS 51 51 - - - -
Desired Hct = volume/weight + actual Hct LR 130 109 4 - 1.5 Lactate
NR 140 98 5 1.5 - Acetate/Gluconate
Platelet Count: 1U /6KBW NM 40 40 13 1.5 1.5 Acetate
1U=30-50 (raises platelet count by 10K) IMB 25 22 20 1.5 - Acetate
Serum Anion Gap (AG)= Na – (Cl + HCO3)
FFP – 4cc/k/ → ↑APTT by 1gm/dL Urine Anion Gap= (Na + K) – Cl
FFP = Fluid rate (5-20cc/k/h in 4h) Delta Gap= Actual AG – 10
24-Actual HCO3
How to Adjust IVF rate once on Feeding H. Influenzae: 7-10days
Example: IVF: D5IMB (90) S. pneumonia: 10-14 days
WT: 2840gms N. meningitides: 7 days
E. coli, citrobacter, Senatia: ≥ 21 days
Computations: 90 x 2.84kg ÷ 24H = 10-11cc/hr IVF rate Enterococcus: ≥ 14 days
 Advance feeding to 10ccq 3 hrs x 3 feedings
If tolerated, increase to 20cc every feeding until 30cc is reached. MENINGITIS
 Adjust IVF rate accordingly  <1mo: GBS, enterobacteriaceae, listeria, monocytogenes
↓ to 8cc/hr at 10cc feeding Tx: Ampicilin & Cefotaxime
↓ to 6cc/hr at 15cc feeding Alt: Ampicilin & gentamycin
↓ to 5cc/hr at 20cc feeding (nosocomial – Ampi + gentamycin)
↓ to 1cc/hr at 30cc feeding
 1mo-3mo: GBS, S. Pneumoniae, Hi. Influenza, N. meningitides,
10 x 8 ÷ 24 = 3 [IVF – 3 = 8] Enterobacteriaceae
15 x 8 ÷ 24 = 5 [IVF – 5 = 6] Tx: Ampiciliin, Cefotaxine
20 x 8 ÷ 24 = 6 [IVF – 6 = 5]
30 x 8 ÷ 24 = 10 [IVF – 10 = 1]
 >3mo & children – S. Pneumoniae, N. meningitides, H. influenza, neonatal
feeding q3H → 24h ÷ 3h = 8
pathogens
 DC CBG monitoring once 20cc feeding is tolerated.
Tx: Cefotaxime/Ceftiaxone, Vancomycin added for possible penicillin
resistant S. Pneumoniae
BICARBONATE CORRECTION
(15 – initial HCO3) x Vol x Kg BW
UMBILICAL CATHETERIZATION
Serum HCO3 level (meq/L) Volume of Distribution (Vol) Wt x 3 + 9 = answer + 1.2 cm
>10 0.5 2
5-10 0.75
<5 1.0  Allowable Blood loss in Preterm: 10% of BW
 Allowable Blood loss in infants/neonates: 20% of BW
TOTAL PROTEIN SPILLAGE (TPS)
TPS= Total Protein (mg) EPINEPHRINE
BSA (m2) x 24H 1:10, 000 (0.1mg/ml)
FLUID LIMITATION Recommended IV does: 0.1-0.3 mg/kg of 1:10, 000 solutions via umbilical vein
Volume in 24H = 400-500ml x BSA + Urine output in 24H 0.5–1mg/kg via ET
Length: inches to cm, multiply by 2.54
Weight: lbs to kg, divide by 2.2

> 5 years old (>20kgs)D5LR KAWASAKI DISEASE

> 3 years old (<15kg)D50.3Nacl/ D5IMB
 Febrile, examthematous, multisystem vasculitis
(>15kg)D5NM
 Fever for at least 4 days
+ clinical features (at least 4/5)
Deficit <10 kg >10kg
1. Bilateral bulbar conjuctival injection w/o exudates w/ lumbar sparing
Mild 50 30
2. Erythematous mouth & pharynx, strawberry tongue and red, cracked lips
Moderate 100 60
3. Polymorphous, generalized erythematous rash (morbilliform,
Severe 150 90
maculopaular or scarlatiniform )
4. Changes in peripheral extremities (induration of hands and feet w/
Maintenance (24 H) erythematous palm & soles later w/periungual desquamation)
0-3 kg 75cc/kg 5. Acute, nonsuppurative, unilateral cervical lymphadenopathy at least
3-10 kg 100cc/kg 1.5cm in diameter or if w/ coronary actery aneurysims
10-20kg 75cc/kg
20-30kg 60cc/kg ATYPICAL KD – common in <12 mo old
30-40kg 50cc/kg  Coronary artery ectasia/dilatation: confirms diagnosis (1-4 wks DOI)
>40kg 40cc/kg  Labs: CRP > 3.0mg/dl 1st 2 weeks of illness
ESR > 40mm/h
Newborn
↑ PLT ct >450 on days 10-12 of illness
0-1 day old 80cc/kg/hr
“without aspirin & IVIg, fever can last upto 2 weeks or longer. After fevr
2 90cc/kg/hr resolves, pt can remain notablefor 2-3 weeks. Desquamation of groin,
3 100cc/kg/hr finger, toes after 2-3 weeks may occur. ”
4 110cc/kg/hr
5 120cc/kg/hr Treatment
6 130cc/kg/hr  IVIg high dose within 10 days
7 140cc/kg/hr  Aspirin
8 150cc/kg/hr  IVIg: 2g/kg as single dose over 10-12hrs
 Aspirin: 80-100mg/kg/day x 4 doses
Mild Dehydration  After fever is controlled, ↓ Aspirin to 3-5 mg/kg/day, discontinue after 6-8
30-50cc/kg/6h D50.3Nacl weeks if no heart problems
Moderate Dehydration Recommended Dosage and Drip Rate for Kawasaki Patient
60-90cc/kg/6h Dosage: 2g/kg/12hrs
¼ of computed deficit give D5LRX2hrs then ¾ to be given for the next 6hrs D50.6Nacl EX: Pt: 10kg
Severe Dehydration
>100cc/kg/6h Patient total needs: 20g of Immunorel
1/3 with D5LRX2H then 2/3 with D50.3Nacl X 6H Total Volume need: 400ml to be divide by 12 hrs = 33.33ml
Initial Test drip: 33.33ml/4= 8.33ml for 1st hour
Succeeding Drip Rate CEFEPIME
2nd hour: 8.33ml x 16.67ml  Term and preterm infants greater than 28 days of age: 50mg/kg per dose every
Total Volume left: 375ml/10hrs=37.5ml/hr 12 hrs
 Term and preterm infants 28 days of age and younger: 30 mg/kg per dose every
MGH orders for KD 12 hrs
 Repeat CBC, Plt, ESR, after 2 weeks  Meningitis and severe infections due to Pseudomonas aeruginosa or
 Repeat 2D echo after 6 weeks Enterobacter spp: 50mg/kg per dose every 12 hrs
 Home meds: ASA 80mg/tab 1 tab OD x 6 weeks take on full stomach  Administer via IV infusion by syringe pump over 30 minutes or IM.
 No live attenuated vaccine for at least 11 months  To reduce pain at IM injection site, cefepime may be mixed with 1% Lidocaine
without epinephrine
OXYGEN THERAPY
Nasal Cannula CEFOTAXIME
50 mg/kg dose IV infusion on syringe pump over 30 minutes, or IM.
Oxygen Flow rate Est. FIO2 in %
Dosing Interval Chart
1 24%
PMA (Weeks) PostNatal (day) Interval (hours)
2 28%
0 to 28 12
3 32% ≤29
> 28 8
4 36%
0 to 14 12
5 40% 30 to 36
> 14 8
6 44%
0 to 7 12
37 to 44
>7 8
Simple Face Mask
≥45 All 6
5-6 40%
Disseminated Gonococcal Infections: 25 mg/kg per dose IV over 30 minutes or IM
6-7 50%
every 12 hrs for 7 days with a duration of 10 to 14 days if meningitis is documented.
7-8 60%

SCLEREMA NEONATORUM
In an infant, fat has higher saturated-to-unsaturated fatty acid ration compared to
adult fat and thus a higher melting point. Prematurity, hypothermia, shock and
metabolic abnormalities have been postulated to further increase this ratio, possibly
as a result of enzymatic alteration allowing precipitation of fatty acid crystals within
the lipocytes. This condition has been suggested to result in the dramatic clinical
findings in affected skin. X-ray diffraction techniques have confirmed that infants
with sclerema neonatorum have an increase in saturated fats and that the crystals
within the fat cells are composed of triglycerides.

CEFTAZIDIME
RESPIRATORY DISTRESS SYNDROME
 30 mg/kg per dose IV infusion by syringe pump over 30 minutes or IM.
- Deficiency of pulmonary surfactant, a phospholipid protein mixture that decreases  To reduce pain at IM injection site, Ceftazidime may be mixed with 1%
surface tension & prevent alveolar collapse. Lidocaine without epinephrine.
- Type II alveolar cells from 32 weeks AOG Dosing Interval Chart
- Risk of RDS is decreased in babies born >24hrs and <7days after maternal steroid PMA (Weeks) PostNatal (day) Interval (hours)
administration 0 to 28 12
≤29
> 28 8
APNEA – respiratory pause >20sec or a shorter pause assoc. w/ cyanosis, pallor, 0 to 14 12
hypotonia or bradycardia 30 to 36
> 14 8
Causes: Thermal instability, prematurity, infection (NEC, meningitis, neo sepsis), 0 to 7 12
metabolic disorders, CNS problems (Seizures, malformations), drugs (maternal/fetal), 37 to 44
>7 8
decreased O2 delivery (anemia, hypoxemia, L to R shunt)
≥45 All 6
Primary
Disturbance PH Compensatory Response FLUCONAZOLE
Change
 Invasive Candidiasis: 12 to 25 mg/kg loading dose, then 6 to 12 mg/kg per dose
Acute resp. ↑ HCO3 by 1 meq/l for each
↑PaCO2↓ ↓pH IV infusion by syringe pump over 30 minutes or orally.
Acidosis 10mmhg rise in PaCO2
 Consider the higher doses for treating severe infections or Candida strains with
Acute Resp. ↑ ↓ HCO3 by 1-3meq/L for each higher MICs (4 to 8 mcg/ml). Extended dosing intervals should be considered
↓ PaCO2
Alkalosis pH 10mmhg fall in PaCO2 for neonates with renal insufficiency (serum Creatinine greater than 1.3 mg/dl)
Chronic Resp. ↓ ↑ HCO3 by 4meq/L for each  NOTE: the higher doses are based on recent pharmacokinetics data but have
↑PaCO2↓
Acidosis pH 10mmhg rise in PaCO2 not been prospectively tested for efficiency or safety
Chronic Resp. ↑ ↓ HCO3 by 2-5meq/L for each  Prophylaxis: 3 mg/kg per dose via IV infusion twice weekly or orally. A dose of 6
↓ PaCO2
Alkalosis pH 10mmhg fall in PaCO2 mg/kg twice weekly may be considered if Candida strains with higher MICs (4 to
Metabolic ↓ 8mcg/ml). Consider prophylaxis only in VLBW infants at high risk for invasive
↓ HCO3 ↓ PaCO2 by 1 – 1.5 x fall in HCO3
Acidosis pH fungal disease.
Metabolic ↑  Thrush: 6mg/kg on day 1 then 3mg/kg per dose every 24 hrs orally.
↑ HCO3 ↑ PaCO2 by 0.25 – 1 x rise in HCO3
Alkalosis pH
INVASIVE CANDIDIASIS DOSING INTERVAL CHART
Gestational age
PIP – 8 – 10 (Pacterm 12) Post Natal (Days) Interval (hours)
(weeks)
PEEP – 4 0 to 4 48
100-FIO2 ÷ 79 x PEEP = level of compressed air ≤29
>14 24
PEEP – compressed air – level of pure air
0 to 7 48
30 and Older
>7 24
OXACILLIN MEDICAL PROPHYLAXIS
 Usual Dosage: ____mg/kg per dose IV over at least 10 minutes Diphtheria – update DPT immunization status for all age
 Meningitis: 50 mg/kg per dose groups and Erythromycin 4-050mkd in 4 days divided doses X 10 days
(max 2g/day).
DOSING INTERVAL CHART  Alternative: Benzathine Pen G IM single dose
PMA (Weeks) PostNatal (day) Interval (hours)  <30kg – 600,000 units
0 to 28 12  >30kg – 1.2 Million units
≤29
> 28 8
0 to 14 12 NOTE: Close contact should be observed for 7 days for evidence of the disease.
30 to 36
> 14 8
0 to 7 12 Endocarditis – prophylaxis given 30-60 mins after procedure
37 to 44
>7 8  Oral: Amoxicillin 50mg/kg
≥45 All 6  Unable to tolerate PO
 Ampicillin 50mkdose IM/IV or
RANITIDINE  Cefazolin/Ceftriaxone 50mg/kg
 Oral: 2mg/kg per dose every 8 hrs.  Allergic to Penicillin
 IV: Term: 1.5 mg/kg per dose every 8 hours slow push  Cephalexin 50mg/kg or
 Preterm: 0.5 mg/kg per dose every 12 hours slow push  CLindamycin 20mg/kg or
 Continuous IV infusion: 0.0625 mg/kg per hour; dose range. 0.04 to 0.1 mg/kg per  Azithromycin/Clarithromycin 15mg/kg
hour  Allergic & unable to tolerate PO:
 Cefazolin/ceftriaxone 50mg/kg IM or IV or
MEROPENEM  Clindamycin 20mg/kg IM or IV
 Sepsis: 20mg/kg per dose IV
NOTE: No prophylaxis for procedures ________ Respiratory, GIT or GUT
 Less than 32 weeks GA: less than or equal to 14 days PNA, every 12 hrs, greater
than 14 days PNA, every 8 hrs
Hepatitis B
 32 weeks and older GA: less than or equal to 7 days PNA, every 12 hours;
 Newborn with HBsAg (+) mother
greater than 7 days PNA, every 8 hours
- HBIG 0.5mL and Hep B vaccine 0.5ml IM at birth or w/in 12 hrs followed
 Meningitis and infections caused by Pseudomonas species, all ages: 40mg/kg
by Hep B vaccine at 6 weeks after and after 6 months.
per dose every 8 hours.
 Premature & HbsAg (-) mother
 Give an IV infusion over 30 minutes, longer infusion times (up to 4 hrs) may
be associated with improved therapeutic efficacy. - Hep B vaccine delayed until child ≥ 2000 gm
 Sexual contact with HBsAg (+) partner, exposure to blood/ body fluids
- Hep B vaccine + HBIG 0.06ml/kg IM (not later than 14 days from
exposure from sexual contact and with in 7 days for percutaneous
exposure)
 Household/Sexual Contact with Chronic Causes
- Hap B vaccine only
METRONIDAZOLE
Malaria
 Loading dose: 15mg/kg orally or IV infusion by syringe punp over 60 minutes
 Mefloquine (250mg/tab) to start 1 week before travel then weekly until 4
 Maintainance dose: 7.5 mg/kg per dose orally or IV infusion over 60 minutes.
weeks after leaving endemic area as ff:
Begin one dosing interval after dose.
 < 45kg = 5mg/kg (max: 250mg)
 >45kg = 1 tab once a week
DOSING INTERVAL CHART
 Doxycycline daily to start 2-3 days before travel then daily until 4 weeks after
PMA (Weeks) PostNatal (day) Interval (hours)
leaving endemic area
0 to 28 12  8 years old = 2mg/kg up to adult dose of 100mg/day
≤29
> 28 8
0 to 14 12 NOTE: Contraindicated for < 8years and pregnant women
30 to 36
> 14 8
0 to 7 12 Meningococcemia
37 to 44
>7 8  Rifampicin in 2 divided doses X 2days
≥45 All 6 ≤ 1 month – 5mkdose every 12 hrs
≥ 1 month – 10mkdose every 12 hrs (max 600mg)
 Alternative: Ceftriaxone single IM dose
< 15 years old – 125mg
≥ 15 years old – 250mg or

Ceprofloxacin (not for ≤18 years old)

≥ 18 years old: 20mk PO as SD (max 500mg)

Rheumatic Fever
 Benzathine Penicillin 1.2 Million U IM every 4 weeks
- <27kg (60lbs)- 600,000 U IM or
- Penicillin V 250mg PO twice daily for patients allergic to Penicillin:
Erythromycin 250mg PO BID
 Duration:
 RF, (-) carditis: 5 years since last episode ao ARF or until 21 years old
whichever is longer
 RF, (+) carditis w/o residual heart disease (no valvular disease): 10 years
or until 21 years old whichever is longer
 RF, (+) carditis, (+) residual heart disease:
10 years since last episode or at least until 40 years old whichever is longer

NOTE: Consider lifelong prophylaxis for people with severe valvular disease
 VACCINATION SPECIAL ORDERS
Absolute Contraindications Preterm
 Severe anaphylactic/allergic reaction to previous vaccine  Please admit
 Moderate – severe illness ± fever  TPR q15 minutes until stable
 Encephalopathy within 7 days of vaccine (pertussis)  NPO
 Immunodeficiency (Congenital – all live vaccines ) or households contact (OPV)  D10W 250ccx7cc/hr
 Pregnancy (MMR, OPV/IPV )  Labs:
 CBC, APC @24HDL
Relative Contraindications  Blood & RH typing
 Immunosuppressive therapy (all live vaccines)  Na, K, Ca
 Egg allergy (MMR)  BUN, Creatinine 24HDL
 NBS
 Seizure w/in 3 days of last dose (Pertussis)
 ABG, Blood C/S, CBG q6H
 Shock w/in 48 hrs of last dose (Pertussis)
 CXR, APL
 Fever >40.5°C w/in 48hrs of last dose (Pertussis)
 Vit. K 1mg IM now
 Hep B 0.5 ml Im now
Not Contraindications
 Terramycin/Erythromycin ophthalmic ointment
 Mild illness ± low grade fever
 Ampicillin – q12h
 Current antibiotic therapy
 Oxygen
 Positive PPD
 Attach to pulse oximeter
 Prematurity
HBsAg Reactive Mother
- Give HBIg 0.5ml deep IM w/in 12HOL
- CRP at 24HOL
- Blood C/S anytime after birth
 Normal CBG: 60-140
 Bilirubin: B1B2: ÷ 17.1 (start phototherapy if ≥15)
 WBC: ≥20,000 start meds
 IT Ratio- stabs/juvenile/total neutrophils = ≥0.2 (+) infection
 Reticulocyte – actual Hct/0.40 (desired Hct)X Reticulocyte = N 1-1.5
≥ 1.0 = hemolysis
≤ 1 = bone marrow failure (CRT ÷ 2)

NURSERY Seizure Disorder

 Please admit to NICU under the service of Dr. _____  Please admit
 TPR Q15minutes until stable  TPR q4h and record
 Breastfeeding  NPO temporarily
 Labs: CBC, APC, BT, RH typing, NBS at 24h old  Labs: CBS, APC, Urinalysis, fecalysis, CBG now then q6h while on NPO
 IVF: D50.3Nacl 500cc+2meq KCL/150ccIVF post voiding
Medications:  Meds:
1. Terramycin ophthalmic ointment OU  S/O:
2. Vit. K 1mg IM  MIO qshift & record
3. Hep B vaccine 0.5mL IM  Monitor VS q4h & NVS qhour & record
 Seizure precaution at bedside
S/O:  Standby O2, padded tongue depressor at bedside
 Routine newborn care  Replace GI loses volume/volume w/ PLR as sidedrip
 Gastric lavage  Refer PRN
 Suction secretion PRN
 Thermoregulate at 36.5-37.5°C Benign Febrile Seizure
 Daily cord care w/70% IPA  Please admit
 Watch out for tachypnea, tachycardia, alar flaring, retractions  TPR q4h & record
 Refer PRN  NPO temporarily
 Labs: CBC, APC, Urinalysis, Fecalysis, CBC now then q6h while on NPO
Newborn Final Diagnosis:  IVF: D50.3Nacl 50cc+ 2meq KCl/100cc IVF
Fullterm (__wks), AGA, BW=__kg, cephalic via NSVD, Live, Bb.Girl/Boy AS 9,10; IVF post voiding
Neonatal sepsis; Uninvestigated physiologic jaundice  Meds: Paracetamol, Ibuprofen, Diazepam (0.2mkdose)
 S/O:
IVF:  MIO qshift & record
 Monitor VS q4h, neuroVS qhour & record
 TFR x wt/24h/20% (if with phototherapy)
 Seizure precaution
 TFR x wt/24h-fdg-Aminosteril (use formula if w/ Aminosteril & fdg)
 Standby O2, tongue depressor at bedside
 Replace GI losses V/V w/ PLR as sidedrip
eg: wt: 3kg TFR: 80
80x3/24/20%= 20 or  Refer PRN
80x3=240x0.2= 48, next
240/48= 288/24h= 12cc/hr

1st 24h D10w, then

D10IMB
D5IMB
Status Post Lumbar Puncture Orders CRANIAL NERVE EXAMINATION LIST
 Flat on Bed x 4h Rapport with patient  Introductions
 NPO x 4h Sit on edge of bed
 Send the following specimen to lab as ff:  Diagnostic facies  IVC  NGT
 IDC
 TT#3 – CSF cell count, diffount count
 Facial asymmetry
 TT#2 – CSF, sugar & protein General inspection
 Pupil symmetry
 TT#1 – CSF GS/CS, AFB, KOH  Scars  Ptosis  eye patch
 RBS now  eye glasses  Hearing aide
 Monitor VSq15min until stable 1. Ask for change in smell
 Refer patient for any untoward s/sx 2. Test visual acquity  Snellen chart  Left eye  Right eye
Test visual fields  Hat pin  Left eye  Right eye
Test light reflexes  Direct  Consensual  Swinging torch
Status Post Extubation Orders
Test accommodation  Hat pin
 Nebulizer with Racemic epinephrine now Fundoscopy  Optic disc  Retinopathy
 Extubate patient now  Dysconjugate gaze (MLF)
 Nebulize w/ Racemic epinephrine q15minx3doses 3, 4, 6. Test ocular movements ;  H pattern testing  Diplopia
 Nebulize w/ Salbutamol 1nebule q6h ask if diplopia occur  Nystagmus  Vertical  Horizontal
 NPO x 6h  Test Intorsion (if CN3 palsy)
 CXR, APG 6h post extubation  Pin prick testing V1 V2 V3
 Light touch testing  Corneal reflex
 O2 6-10LPM 5. Trigeminal Sensory & Motor  Clench teeth & palpation of masseter muscle
 Watch out for secretions, tachypnea, etc.  Open jaw & ptyerygoid resistance
Note: Racemic Epi: PNSS: 4.7ml Epi: 0.3ml  Jaw jerk
 Forehead wrinkling  Eye closure
7. Test Facial Muscles  Blowing of cheeks  Smiling
 Ear  Mastoid  Parotid  Palate
 Inspection of ear and tympanum
 whisper  High tone 68
8. Test Hearing and Balance  Low tone 100  Rinne’s  R  L
 Weber’s (256Hz)  Nystagmus
 Hallpike’s +/- Epley’s
 Dysphonia  Swallowing
9, 10. Deviation to Normal side  Coughing  Uvual deviation
 Gag reflex
11. test shoulder & neck  Trapezius mm: Shoulder shrug
movements  SCM mm: Head turning
12. Tongue Protrusion; deviation  Wasting  Fasiculation
to affected side  Dysarthria
Ask for BSL
If relevant assess other  Peripheral nervous system
neurological system  Cerebellar system
Summary & interpretation

DRUGS
DRUG RD Preparation
Tab: 30mg
1.2-1.6mkdose
Ambroxol Syr. 15mg/ml
(BID-TID)
Infant drops:6mg/ml
Amp/Vial
10mkdose (LD)
Amikacin (Amikin, 50mg/mlx2ml
15mkdose (MD)
Amikacide, Onikin) 125mg/mlx2ml
15mg/kg/day (BID)
250mg/mlx2ml
Cap:250mg; 500mg
Syr:250mg/5ml
Amoxicillin Ped.drops:
30-50 mkday (TID)
(Pediamox) 125mg/1.25ml
100mg/ml
Vial:500mg
50-100 mkday(IV)
30-50 mkday(oral)
Amphotericin B Vial:50mg/10ml
1mg/kgBW
(alternate day)
Cap:250mg;500mg
50-100 mkday (IV)
Syr:125mg/5ml
Ampicillin 30-50mkday (oral)
Forte Syr:250mg/5ml
(Ampicin, Pensyn) 1mg/kg/BW
Ped drops: 125mg/1.25ml
(alternate day)
Vial:500mg
Tab: 4mg
0.2-0.3 mkdose Amp: 5mg/ml
Antamin
(TID) Vial:5mg/ml x 10ml
Syr: 2mg/5ml
Cap:375mg;625mg
Susp:156.25mg/5ml
228.5mg/5ml
20-40 mkday (BID-
Co-amoxiclav 312.5mg/5ml
TID)
457mg/5ml
IV Vial:300mg;600mg
Tab: 1g
 DRUG RD Preparation DRUG RD Preparation
Tab:250mg;500mg Ethambutol 15 mkday Tab: 400mg;200mg
ASA 75-100 mkday(TID) Enema: 4g Cap:250mg
1mkday (MDR)
Supp:250mg Ferrous sulfate Syr:220mg/5ml
4-6mkday (txc)
Aztreonam 30-50 mkday Drops: 75mg/0.6ml
3-5 mkdose (oral Cap:25mg;50mg Tab:100mg
Furazolidone 4-7mkday
Benadryl TID-QID) Syr:12.5mg/5ml Amp:50mg/5ml
1 mkdose (IV,OD) Inj:50mg/ml Tab:20mg; 40mg
Furosemide 0.5-1 mkdose
0.01 mkdose Q6h Tab:10mg Amp: 10mg/ml
Buscopan Vial: 40mg/ml
0.02-1.5 mkday Amp:20mg Gentamycin 5-8 mkday
10-20 mkday Cap:500mg 80mg/2ml
Carbocisteine (infant)(TID-QID) Syr:100mg/5ml 0.15 mkdose (IV) Tab: 25mg
Hydralazine
30-50 mkday (child) Susp:250mg/5ml 0.75 mkdose (oral) Amp: 20mg/2ml
Tab: 10mg/tab OD HS Hydro Vial:259mg
Ceterizine 0.25 mkday 5 mkdose
Syr: 5mg/5ml cortisone Amp:100mg;250mg;500mg
Cap:250mg;500mg 0.01 mkdose Tab: 100mg
Hyoscine
Cefaclor 20-40 mkday (TID) Susp:125mg/5ml 0.02-0.15 mkday Amp: 20mg
250mg/5ml Tab: 200mg; 400mg; 600mg
Ibuprofen 5-10 mkdose
Cap:500mg Syr: 100mg/5ml
Cefadroxil 25-50 mkday (TID) 5-10 mkday Tab: 300
Syr:125mg/5ml INH
Cefetamet 20 mkday (BID) (premeals) Syr:100mg/5ml
50-100mkday(BID- Tab: 500mg
Cefotaxime Vial: 1g Isoprinosine 50mkday
TID) Syr: 250mg/5ml
Cefepime 50 mkday q8hrs Vial: 500mg; 2g Meclizine 12.5-50 mkday
Ceftazidime 50-100mkday Vial: 500mg; 1g Cap:250mg;500mg
Mefenamic acid 6.5 mkdose (q6hrs)
Cefazolin 50-100mkday Vial: 500mg; 1g Susp:50mg/5ml
50-100 mkday (TID- Vial:250mg; 500mg; 1mg plus 6 mkday
Ceftriaxone Meperidine
QID) 10ml diluents 0.5 mkdose
Tab: 500mg/500mg Syr:5mg/5ml
0.25 mkdose (IV,IM)
50-100 mkday (IV) Susp:125mg/5ml; Metoclopromide Amp:5mg/ml;
Cefuroxime 1 mkday (0ral)
20-40mkday (oral) 250mg/5ml 10mg/2ml
Vial: 250mg; 750mg; 1.5g Tab:250mg; 500mg
Cap:250mg;500mg Susp: 125mg/5ml
30-50 mkday (oral) Metronidazole 30-50 mkday (TID) Inj:500mg
Cefalexin Susp:125mg/5ml; 250mg/5ml
50-100 mkday(IV) Infusion:500mg/100ml
Drops:100mg/ml
Vial:5mg/ml

DRUG RD Preparation DRUG RD Preparation

50-100 Nafcillin 50-100 mkday (TID)
Cephalotin Nalbuphine 0.1-0.2 mkdose 10mg/ml
mkday
25-100 Tab: 5mg; 10mg; 20mg;
Cephradine Cap: 500mg 0.25
mkday Nifedipine 30mg;60mg
Mkdose
Cap:250mg;500mg
50-100 400,000 U/day
Chloramphenicol Susp:125mg/5ml Nystatin Oint: 5g
mkday TID NB: 1.2M U/day
Vial: 1g
Tab:200mg; 400mg Tab: 200mg; 400mg
20 Ofloxacin 20-30mkday
Cimetidine Syr:100mg/5ml IV soln: 200mg/100ml
mkday Tab: 500mg
Amp: 200mg/2ml; 300mg/2ml
Tab:250mg;500mg Susp:120mg/5ml;
Paracetamol 5-25 mkdose (q4hrs)
IV infusion: 250mg/5ml
Ciprofloxacin 20-30mkday 100mg/50ml Drops: 100mg/ml
200mg/100ml 50-100,000 U/mkday
400mg/200ml Penicillin G 200,000-400,000
1.2M “U”
Clarithromycin Tab: 250mg;500mg (Penadur) U/mkday (meningitic
7.5mkday (BID) dose)
(Klaricid) Susp: 125mg/5ml
Cloxacillin Cap: 250mg; 500mg Tab:15mg;30mg; 60mg;
50-100 mkday (QID) 10mkdose (LD)
(Pharex) Oral soln powder:125mg/5ml Phenobarbital 90mg
5mkdose (MD)
Tab: 400mg/80mg; Amp: 130mg/ml
Cotrimoxazole 8-12 mkday (BID) 800mg/160mg Piperacillin (Tazocin) 100-300mkday Vial: 2.25g; 4.5g
Susp: 200mg/40mg/5ml Tab:5mg; 10mg; 20mg
Prednisone 1-2 mkday (BID)
Tab: 2mg; 5mg Susp: 10mg/5ml
Diazepam 0.2 mkdose Tab:500mg
Amp: 10mg/2ml
Cap: 50mg; 150mg; 250mg Pyrazinamide 15-30mkday (BID) Susp:500mg/5ml;
Diflucan 6-13 mkday 250mg/5ml
Vial:2mg/ml
Tab: 500mg 1-2mkdose (BID) Tab:150mg; 300mg
Diloxanide 20mkday (TID) Ranitidine
Susp: 125mg/5ml Q 8-12hrs Amp:25mg/ml; 50mg/2ml
Doxycycline 2-4 mkday Cap: 100mg 10-15mkday Cap:300mg; 450mg; 600mg
Rifampicin
Cap: 250mg;500mg (premeal) Susp:200mg/5ml
Erythromycin 30-50mkday Susp:200mg/5ml; 400mg/5ml Tab: 2mg
Salbutamol
Drops: 100mg/2.5ml 0.15 mkdose (TID- Syr:2mg/5ml
(Ventolin, Asmalin,
QID) MDI:100mcg/dose
Combivent)
Nebule:2.5mg/5ml; 5mg/ml
 DRUG RD Preparation Neurotoxicity
Spirono  Cisplatin – ototoxocity, p. neuropathy
1-3mkday Tab: 25mg; 50mg; 100mg
lactone  Paclitaxel – p. sensory, neuropathy
Streptomycin 20-40mkday Vial: 1g  Vinca Alkaloids – motor , sensory, autonomic neuropathy, adynamic ileus,
Sucralfate urinary bladder atony
1g/dose (QID) Tab: 1g
(Iselpin)
Cardiac Toxicity
Tab: 2.5mg; 5mg
0.075 mkdose  Doxorubicin, Daunomycin – cardiomyopathy
Terbutalline Syr: 1.5mg/5ml
(BID-TID)
Neb: 5mg/2ml Pulmonary Toxicity
Tetracycline 20-50 mkday (QID) Cap: 250mg  Bleomycin – interstitial
Tab: 125mg  Alkylating agent pneumonistis with pulmonary fibrosis
Theophylline 20mkday (q6hrs) SR tab: 250mg
Syr: 80mg/15ml Gastrointestinal Toxicity
 Mathotraxate – hepatic fibrosis
 Vinca Alkaloids – adynamic ileus, urinary bladder atony
Genitourinary Toxicity
 Cisplatin – azotemia, Mg wasting
 Methotrexate – oliguria RF
 Cyclophosphamide/ Ifosfamide – chronic hemorrhagic cyctitis
Dermatologic Toxicity
 Doxorubicin Skin necrosis, sloughing from
 Actinomycin – D drug extravasation
 Vincristine
Gonadal Dysfunction
 Azospermia recovery is uncommon
Hematologic Toxicity
 Granulocytopenia/neutropenuia
- 6-12 days after administration
- Recovery in 21-24 days
ANC= (WBC count)(%segmenters)
- Must be ≥ 1500 for chemo to proceed
 Thrombocytopenia
- Recovers 4-5 days later than granulocytes
- ≥ 100,000/mm3 for chemo to proceed

DRUG RD Preparation HEMODIALYSIS PRESCRIPTION

Blood Flow Rate: 5ml/kg/min
Dialyzer: F4: BSA 0.7
F5: BSA 1.0
F6: BSA 1.3

NSS Flushing 100ml q 15min or Heparin LD: 10-20IU/kg

MD: 10-20IU/kg
Ultrafiltrate 0.2ml/kg/min x ____ hrs
Duration: initial 1.5 – 2 hrs
2nd day: 3hrs
3rd day: maintemance – 4hrs

Bicarbonate bath: prime solution with NSS 120ml

 Weigh patientt pre & post HD and record

 Monitor VS q15mins while on HD
 Watch out for Headache, nausea, disorientation, hypotension, seizure, muscle
cramps & vomiting
 Labs: pre & post HD
 Intradialytic transfusion (if any )
 Initial HD: Mannitol 0.5-1.0g/kg to decrease disequilibrium syndrome in pt w/
elevated BUN (>35mmol/L)
 Refer accordingly.