Revalida Review

Topics

History taking and PE

Common Ward Cases

Common OPD Cases

Immunizations

History taking and

Physical
Examination

History Taking
I. General Data
II. Chief Complaint
III. History of Present Illness
IV. Review of Systems
V. Personal History
A. Gestational, Birth, Neonatal (<2 yo)
B. Feeding History
C. Developmental/ Behavioral
D. HEAADSSFIRST

HEAADSSFIRST
Home
Education/ School
Abuse
Drugs
Safety
Sexuality/ Sexual Identity
Family/Friends
Image
Recreation
Sprituality
Threats and Violence

VI. Past Illnesses

VII. Immunization History
VIII. Family History
VIII. Socioeconomic History
IX. Environmental History

Common Ward Cases

Common Ward Cases

Pneumonia
Bronchial
Dengue
Acute

Asthma

Fever/Dengue Hemorrhagic Fever

Gastroenteritis

Cellulitis
Simple
Sepsis

Febrile Seizure

Common OPD Cases

Common OPD Cases

Acute

nasopharyngitis

Bronchial
Acute

Asthma

Otitis Media

Pneumonia
Pulmonary
Allergic

Tuberculosis

rhinitis, Impacted cerumen, Acute

Viral Illness

Asthma

Asthma
A

chronic inflammatory disorder of the airways

airway

hyperresponsiveness -> leads to recurrent

episodes of wheezing, breathlessness, chest tightness,
and coughing

often

reversible airflow limitation

Global Initiative for Asthma

Source: Peter J. Barnes, MD

Factors that Influence Asthma Development and

Expression
Host Factors
Genetic
- Atopy
- Airway hyperresponsiveness
Gender
Obesity

Environmental Factors
Indoor allergens
Outdoor allergens
Occupational sensitizers
Tobacco smoke
Air Pollution
Respiratory Infections
Diet

Global Initiative for Asthma

Differential Diagnosis of Asthma in

Children 5 years or younger

Infection
Recurrent
Chronic

resp. tract infections

rhinosinusitis

tuberculosis

Congenital
Tracheomalacia
Cystic

fibrosis

BPD
Congenital

malformation causing narrowing of the intrathoracic airways

Mechanical
Foreign
GER

body aspiration

Diagnosis
In

young children, the diagnosis of asthma

can be confirmed by a clinical response to
an inhaled bronchodilator.

In

children aged 7 years and over, use

spirometry to confirm the diagnosis of
asthma.

Levels of Asthma Control in Children 5 Years and Younger

Characteristic

Controlled
(All of the following)

Partly Controlled
(Any measure present in
any week)

Uncontrolled
(3 or more of
features of partly
controlled asthma
in any week)

Daytime
None
symptoms:
less than twice/week)
wheezing, cough,
difficult breathing

More than twice/week

More than twice/week

Limitations of
activities

Any
Any
(may cough, wheeze, or have
difficulty breathing during
exercise, vigorous play, or
laughing)

None
(child is fully active, plays
and runs without limitations
or symptoms)

Nocturnal
None
symptoms/awake (including no nocturnal
ning
coughing during sleep)

Any
Any
(typically coughs during sleep
or wakes with cough,
wheezing, and/or difficult
breathing)

Need for
reliever/rescue

>2 days/week

2 days/week

>2 days/week

controlled

REDUCE

LEVEL OF CONTROL

TREATMENT OF ACTION

maintain and find lowest controlling step

consider stepping up to gain
control

uncontrolled

step up until controlled

INCREASE

partly controlled

exacerbation

REDUCE
STEP

STEP

treat as exacerbation

TREATMENT STEPS

INCREASE

STEP

STEP

STEP

Global Initiative for Asthma

Asthma Management Approach

Asthma Education
Environmental Control
As needed rapid-acting B2- agonist
Controlled
on rapid-acting B2agonist prn

Partly Controlled
on rapid-acting B2agonist prn

Continue rapid-acting
B2- agonist prn

Controller options
low-dose inhaled
glucocorticosteroid
Leukotriene modifier

Uncontrolled
Or Partly controlled
on low-dose inhaled
glucocorticosteroid

Double low-dose
inhaled
glucocorticosteroid
low-dose inhaled
glucocorticosteroid +

Controller Medications
Inhaled glucocorticosteroids
Leukotriene modifiers
Long-acting inhaled -agonists in combination with
2
inhaled glucocorticosteroids
Systemic glucocorticosteroids
Theophylline
Cromones
Anti-IgE

Global Initiative for Asthma

Reliever Medications
Rapid-acting inhaled 2-agonists
Systemic glucocorticosteroids
Anticholinergics
Theophylline
Short-acting oral 2-agonists
Global Initiative for Asthma

Pneumonia

CLASSIFICATION
PROVIDED BY
Philippine Academy of
Pediatric
Pulmonologists
Philippine Health
Insurance Corp
World Health
Organization

pCAP A or B
---

pCAP C
Pneumonia I

pCAP D
Pneumonia II

Nonsevere

Severe

Very severe

1. Dehydration
2. Malnutrition

none
none

moderate
moderate

severe
severe

3. Pallor
4. Respiratory rate
3 to12 months
1 to 5 years
> 5 years

none

present

present

>50/min to
<60/min
>40/min to
<50/min
>30/min to

>60/min to
<70
>50/min
>35/min

>70/min
>50/min
>35/min

mild

5. Signs of respiratory
failure
a. Retraction
b. Head bobbing
c. Cyanosis
d. Grunting
e. Apnea
f. Sensorium

pCAP A or B

pCAP C

pCAP D

None
None
None
None
None
None

IC/subcostal
+
+
None
None
Irritable

Supraclavicular/IC/SC
+
+
+
+
Lethargic/stuporous/co
matose

1. Chest x ray findings of

any of the following:
effusion; abscess; air
None
leak or lobar
consolidation
2. Oxygen saturation at
room air using pulse
oximetry

95%

<95%

<95%

1. Site-of-care

Outpatient

Ward

ICU

Etiologic Agents

Streptococcus pneumoniae- 3wk to 4yr of age

Mycoplasma pneumoniae andChlamydophila

pneumoniae - children 5yr and older

RSV, Influenza virus- < 3 yo

Other viruses causing pneumonia: Parainfluenza,

adenovirus, rhinovirus, human metapneumovirus

AGE
GROUP

FREQUENT PATHOGENS (IN ORDER OF FREQUENCY)

Group B streptococcus,Escherichia coli,other gramNeonates

negative bacilli,Streptococcus pneumoniae, Haemophilus
(<3wk)
influenzae(type b,*nontypable)
RSV, other respiratory viruses (parainfluenza viruses,
influenza viruses, adenovirus),S. pneumoniae, H.
3wk-3mo
influenzae(type b,*nontypable); if patient is afebrile,
considerChlamydia trachomatis
RSV, other respiratory viruses ,S. pneumoniae, H.
4mo-4yr influenzae(type b,*nontypable),Mycoplasma
pneumoniae,group A streptococcus
M. pneumoniae, S. pneumoniae, Chlamydophila
pneumoniae, H. influenzae(type b,*nontypable),
influenza viruses, adenovirus, other respiratory
5yr
viruses,Legionella pneumophila

Treatment
pCAP

A or B without previous antibiotic

Amoxicillin
40-50

mg/kg/day q8 x 7 days
Drug of choice

Azithromycin
10

mg/kg/day QD x 3 days

Clarithromycin
15

mg/kg/day BID x 7 days

pCAP C, without previous antibiotic

penicillin G
100,000

units/kg/day in 4 divided doses

the drug of choice if has patient completed Hib
vaccination

ampicillin
100

mg/kg/day in 4 divided doses

Drug of choice if patient completed Hib vaccination or
immunization status unknown

pCAP C, without previous antibiotic

>

15 years of age :

parenteral non-antipseudomonal -lactam (lactam/-lactamase inhibitor combination

(BLIC), cephalosporin or carbapenem]
+

extended macrolide [azithromycin or

chlarithromycin] or respiratory
fluoroquinolones [levofloxacin or moxifloxacin]

Acute
Gastroenteriti
s

Acute Gastroenteritis

passage of stool at least twice the normal bowel

movement wherein the stools follow the shape of
the container.

in infants and children, stool output of greater

than 10 g/kg/day (normal = 5-10 g/kg/day) and
more than the adult limit of 200 g/24 hour.

excessive loss of fluid and electrolyte in the stool

Acute Gastroenteritis

Acute diarrhea <14 days

Chronic Diarrhea >14 days

Pathophysiologic Mechanisms of Diarrhea

Osmotic diarrhea

Secretory Diarrhea

Mutations in apical membrane transport

proteins

Reduction in anatomic surface area

Alteration in Intestinal motility

Clinical Evaluation of Dehydration

Mild

Moderate

Severe

Pulse

N/
Increased

tachycardia

Rapid and weak or absent

appearance

alert

Maybe restless,
irritable

Drowsy, depressed
consciousness

fontanels

flat

soft

sunken

tears

normal

decreased

none

eyes

normal

sunken

Very sunken

UO

decreased

Little or no UO

none

Mucous
membranes

normal

dry

parched

Skin turgor

normal

Mild delay

poor

skin

normal

Cool, pale

Cold, mottled

CRT

normal

>1.5 sec

> 3 sec

Maintenance Fluid (Holliday Segar)

100

ml/kg for the 1st 10 kg of wt.

1000

+ 50 ml/kg for the 2nd 10 kg of wt.

1500

+ 20 ml/kg for wt > 20 kg

IV hydration (Ludans Method)

Mild

< 15 kg or 50
< 2 yo
>15 kg or 30
> 2 yo

Moderat Severe
e
dehydratio
n
100
150 ml/kg
60

90

Contents of IV Fluid Preparations

D5 0.3%
D5 IMB
D5 NM
D5 NR
PNSS
D5NS
Ringers
Lactate
(RL)

Na
(mEq/L)

K
(mEq/L)

Cl
(mEq/L)

Dextrose
(gm/L)

51
25
40
140
154
154
130

20
13
5
-

51
22
40
98
154
154
109

50
50
50
50
50
50

Indications for admission

Massive

stool losses

Insufficient
Persistent
Below

intake/ failure of ORS

vomiting

3 months of age

Presence

of other severe infections

( pneumonia, sepsis, CNS infection)

Earliest Detectable Signs

Tachycardia

Dry skin and mucous membranes

Sunken fontanels

Circulatory Failure (coolness, mottling of

extremities)

Loss of skin elasticity

Delayed cap refill

Top 3 Most Common Etiologic Agents

Rotavirus
Escherichia

coli

Microorganism

not specified

Top 3 Most Common Etiologic Agents of

Bloody Diarrhea
Enteroinvasive
Salmonella
Shigella

Escherichia coli

spp.

dysenteriae

When do you request for fecalysis?

If

there is an epidemic

Chronic
Bloody

diarrhea >14 days

diarrhea

Management
ORS

75

Sodium

75
Glucose 75
Chloride 65
Potassium 20
Citrate 45
Zinc
<6

months old: 10mg elemental zinc

>6 months old: 20 mg elemental zinc

Zinc

Immunomodulator: metalloenzyme,
polyribosomes, cell membrane, and cellular
function

Cellular growth and function of the immune

system

Reduces the severity and duration of diarrhea in

children less than 5 years of age

Pulmonary
Tuberculosis

ETIOLOGY
Mycobacterium

tuberculosis
Acid-fast bacilli, aerobic, slow-growing

Non-tuberculous

mycobacteria
Rarely causes pulmonary disease in
immunocompetent children
May cause lymphadenopathy

Definition of Terms/Pathology
Primary

Focus
Primary lesion

Primary

Complex
Primary focus, regional lymph nodes and
connecting lymphatic vessels

Ghon

Complex
Calcified primary complex

TRANSMISSION

Person to person by mucus droplets

Marker of contagiousness: (+) bacilli in sputum

Children are rarely contagious because they have

few bacilli in endobronchial secretions, little
cough and diminished force of cough

Most become non-infectious within 2 weeks of

starting treatment

CLASSIFICATION
Class I. TB Exposure
Class II. TB Infection
Class III. TB Disease
Class IV. TB Inactive

CLASS I. TB EXPOSURE
(+)

exposure to adult or adolescent with

active TB

No

symptoms or signs yet

(-)

Mantoux

CLASS II. TB INFECTION

(+)

Mantoux test

With

or without exposure

Normal

CXR, no signs & symptoms

Preclinical

state of TB

CLASS III. TB DISEASE

3 or more of the following:

1. Exposure to an adult/adolescent with active

TB
2. (+) Mantoux test
3. Signs & symptoms suggestive of TB
4. Abnormal CXR suggestive of TB
5. Laboratory findings suggestive of TB
(histological, cytological,biochemical,
immunological &/or molecular)

CLASS IV. TB INACTIVE

(+)CXR evidence of healed/calcified TB, (+)PPD

test

With or without history of previous TB

With or without previous chemotherapy

No signs & symptoms suggestive of TB

(-) smear/culture of TB

INCUBATION PERIOD

2-10 weeks from exposure to development of a

(+) skin test

Takes months to years from infection to disease,

but may become dormant and never progress

CLINICAL FORMS

Primary Pulmonary TB

Progressive Pulmonary TB

TB

Pneumonia
Endobronchial TB
TB Pleural Effusion

Miliary TB / Disseminated TB

Extrapulmonary TB

SIGNS & SYMPTOMS

Cough/wheezing >2 weeks
Fever >2 weeks
Painless cervical &/or other lymphadenopathy
Poor weight gain, loss of weight/appetite
Failure to make a quick return to normal health after
an infection (measles, tonsillitis, whooping cough)
Failure to respond to appropriate antibiotic therapy
(pneumonia, otitis media)

DIAGNOSTIC TESTS
1.Skin

Tests

Tuberculin

Skin Test/ Mantoux Test

Multiple Puncture Test
2.Chest

X-ray (PA & lateral)

3.Isolation

of MTB

Culture

& Sensitivity Gold Standard

BACTEC Radiometric System
4.Others
BCG
Molecular

biologic techniques

Definition of Positive Mantoux Skin Test

High Risk
> 5 mm

Known contacts of
infectious case

Moderate Risk
> 10 mm

Low Risk
> 15 mm

Children younger than 4

years; those who have
diabetes, renal failure,
or are malnourished

Children > 4 years

with no personal
or environmental
risk factors

Suspected TB,
abnormal chest X-ray,
other signs or
Children of foreign-born
symptoms
parents from high
prevalence areas
HIV(+), other
immunosuppressive
states

Medically indigent city

dweller, exposure to
high-risk adults

Chest Radiograph

PA & Lateral

Sensitivity 83%

Specificity 36%

Hilar adenopathy (92%) with or without

parenchymal focus

Duration of hilar adenopathy: >12months

Chest Radiograph

Complications: pleural effusion, cavitary lesion,

tuberculoma(coin shadow), atelectasis,
consolidation

Miliary pattern

Calcification

May be normal in 10% with proven primary TB

PRIMARY DRUGS USED FOR

TUBERCULOSIS
1.Isoniazid

(H)

2.Rifampicin

(R)

3.Pyrazinamide
4.Ethambutol

(Z)

(E)

5.Streptomycin

(S)

PREVENTION
1.Detection

and appropriate treatment of all TB

excretors (source cases)

2.BCG

vaccination of newborns

3.Chemoprophylaxis

Dengue Fever

Dengue Fever

Dengue is the most prevalent mosquito-borne

viral disease

"break-bone fever

Dengue Fever
Probable:
Acute

febrile illness w/ 2 or more

constitutional symptoms:

Headache,

retroorbital pain, arthralgia,

rash, hemorrhagic manifestations,
leukopenia

And

supportive serology

Dengue Fever
Confirmed:
viral
PCR

culture isolation

Dengue Hemorrhagic Fever

The following must all be present:

1.Fever

or history of fever, lasting for 2-7 days, occasionallybiphasic

2.Hemorrhagic

tendencies:

petechiae, ecchymoses, purpura

bleeding from mucosa, GIT, injection sites
hematemesis or melena
3. Thrombocytopenia (100,000 cells/mm 3 or less)
4. Presence of plasma leakage due to increased vascular permeability
-

Rise in Hct 20 % above baseline ,drop in hematocrit after volume loss following volume
replacement of >20% from baseline, pleural effusion, ascites, hypoproteinemia

DHF Grade 1

Fever accompanied by non-specific constitutional

signs and symptoms such as anorexia, vomiting,
abdominal pain,

Only hemorrhagic manifestation: (+) tourniquet

test, and or easy bruising

DHF Grade 2
Manifestations
Plus

of Grade 1 patients

spontaneous bleeding
(mucocutaneous, GIT)

DHF Grade 3 (DSS)

Circulatory

failure manifested by rapid,

weak pulse, and narrowing of pulse
pressure or hypotension

In

the presence of cold, clammy skin and

restlessness

DHF Grade 4 (DSS)

Profound

shock with undetectable blood

pressure or pulse

Measles/Rube
ola

MEASLES/RUBEOLA
highly

contagious viral
disease

Measles

virus- RNA virus

in the family
Paramyxoviridae

infectious

from 4 days
before to 4 days after the
appearance of the rash

Measles

incubation period: 8-12 days

Transmission: aerosol droplets

prodromal phase begins with a mild fever followed

by the onset of conjunctivitis with photophobia,
coryza, a prominent cough, and increasing fever

Koplik spots- pathognomonic sign

- bluish white spots in the center on
the inner aspects of the cheeks at the level of the
premolars

TREATMENT

Supportive

maintenance

of good hydration

antipyretics

Vitamin A supplementation is given for 2 doses 24

hours apart as follows:
Infants

<6 months of age: 50,000 IU/day PO

Age 6-11 months: 100,000 IU/day PO
>1 year old: 200,000 IU/day PO

Give as soon as diagnosis is made regardless of

when the last dose of Vitamin A was given

Antiviral therapy

The measles virus has been shown to be susceptible

to ribavirin in vitro. There are however, no controlled
trials conducted for the use of ribavirin for measles
in children.

Thus, this is not recommended

Antibiotics

For those w/ pneumonia, ear infections

Postexposure Prophylaxis
measles

vaccine within 72 hours or 3 days

after exposure to measles

Human Immunoglobulin
Indications:
Immunocompromised
Infants

6 months to 1 year (this is because

morbidity is high in children <1 year of age)

Infants

<6 months of age born to mothers w/o

measles immunity

Pregnant

women

Recovery within 2-3 weeks

COMPLICATIONS
blindness,

encephalitis, severe diarrhea,

ear infection and pneumonia

Sources
Nelson Textbook of Pediatrics
Pediatric Infectious Disease Society of the
Philippines
http://www.ginasthma.org/
Philippine Academy of Pediatric Pulmonologists,
Inc.
http://www.pps.org.ph/images/forms_pdf/ANNOU
NCEMENT/revised%20guidelines%20fluid
%20management%20oct%202012.pdf

What to Bring on Revalida

Day?
Nelsons Textbook of Pediatrics- 19th edition official reference
Bluebook
Stethoscope, Sphygmomanometer, Penlight, Otoscope,
Fundoscope, Tongue depressor
Materials for Neuro exam ( reflex hammer, etc)
Rosary in your pocket

Thank you and God

bless Batch 2015!