Download - PEDIA - Tachypnea (2)
-
8/10/2019 PEDIA - Tachypnea (2)
1/12
SILLIMAN UNIVERSITY MEDICAL SCHOOL
PEDIATRICS WORKSHEETSUBMITTED TO: Dr. Desiree Reyes- Gubantes DATE OF SUBMISSION: December 18, 2014
SUBMITTED BY:
Pasuquin, Alvin G.
Rodriguez, Arianne S.
MD III
PRESENTATION OF HISTORY
Identifying InformationThis is a case of ZM, 3-month old, female, from Dumaguete City came in at Silliman Medical Center last February 16, 2014
Chief Complaint: fast breathing
HISTORY OF PRESENT ILLNESS
Condition started three weeks prior to admission when patient was noted to have occasional cough. Two weeks prior t
admission, with persistence of cough, consult was done at a local Health Center and was given Amoxicillin drops for one week
but no relief was noted. One week prior to admission, cough persisted, this time, associated with decreased in appetite an
undocumented fever. Three days prior to admission, the patient was noted to have episodes of difficulty breathing, feeds for
shorter period of time, accompanied by incessant crying.
Four hours prior to admission, she was noted to have fast and deep breathing, hence was brought to the ER and was admitted.
REVIEW OF SYSTEMS
Unremarkable.
BIRTH HISTORYThis baby was born term to a primigravid, 20-year-old mother in Provincial hospital, assisted by a doctor, with good cry an
activity at birth. Mother had irregular prenatal check-up but denies any illness during pregnancy. Birth weight was 3.
kilograms. No meconium staining noted.
NEONATAL HISTORY
APGAR score was 8/9.
IMMUNIZATION HISTORY
BCG was given already at birth as well as the first dose of hepatitis B right before discharge from the hospital. First dose o
tetanus plus oral polio was given already at 6 weeks of age. Hep B2 and HiB1 were also given.
FEEDIG HISTORY
Exclusively breastfed since birth
PAST MEDICAL HISTORY
Unremarkable. The newborn screening was normal
FAMILY HISTORY
No family history of asthma, diabetes and hypertension reported.
DEVELOPMENTAL HISTORY
Social smile and head control developed at 3 months.
PHYSICAL EXAMINATION
General Survey: The patient was examined cuddled, irritable, pale looking, and in cardiorespiratory distress.
Vital Signs:
HR = 160bpm
RR = 65cpm O2 saturation in room air = 93%
O2 saturation after O2 was given at 2 liters/min = 99%
Temperature = 38C
Anthropometric Data:
Weight = 4.2 kg
Length = 58 cm
BMI = 12.72 kg/m2
Skin: No rashes. No lesions
HEENT: Pale lips. No tonsillopharyngeal congestion. No oral lesions noted. No eye and ear discharges. No sunken
eyeballs. No dysmorphic features. There is presence of nasal flaring. Oral mucosa is dry.
-
8/10/2019 PEDIA - Tachypnea (2)
2/12
C/L: Symmetrical chest expansion with shallow subcostal retractions. There are coarse rales, crackles, and
occasional wheezes on both lung fields.
CVS: The precordium is dynamic.Apex beat at 5 thICS LMCL. S1 is normal with a splitting of a 2ndheart sound.
3/6 murmur is noted on pansystolic left lower sternal border.
Abd: Abdomen is slightly globular with normoactive bowel sounds. Liver is palpable at 2 cm below the subcosta
regions. No masses. Spleen is not palpable.
GUT: grossly female
Ext: Cold extremitieswith fair pulses. CRT is 3 seconds.No edema. No clubbing. No cyanosis.
NEUROLOGIC EXAMINATION
Unremarkable
PRIMARY WORKING
IMPRESSION
RULE IN RULE OUT
Acyanotic Heart Disease to
consider Ventricular Septal
Defect, with severe
pneumonia
History:
(+) cough, (+)poor feeding, , (+) fever, (+) vomiting,
(+) poor weight gain, (+) tachypnea,
Physical Exam:
(+)hypoxemia,(+) irritability ,(+) increased
respiratory rate, (+) crackles, (+) rales, (+)
wheezing, (+) cardiorespiratory distress, (+)
retractions, (+) dehydration, (+) nasal flaring, (+)coryza, (+) pallor (+) heart murmurs
Labs:(+) lymphocytosis,(+) ketones, (+) chest x-
ray, (+) 2D-echo
CANNOT BE RULED OUT
DIFFERENTIAL DIAGNOSES
Laryngotracheobronchitis
(Croup)
History:
(+) cough, (+) low grade fever
Physical Exam:
(+) respiratory distress, (+) wheezing, (+)
subcostal retractions, (+) hypoxemia, (+)
dehydration, (+) tachycardia
Labs:(+) lymphocytosis
History: (-) hoarseness, (-) barking
cough, (-) inspiratory stridor, (-)
gastroesophageal reflux
Physical exam: (-) hypotonia, (-)
cyanosis, (-) lethargy
Bronchiolitis History:
(+) feeding difficulties, (+) fever,(+) cough, (+)
tachypnea
Physical Exam: (+) irritable, (+) wheezing, (+)
nasal flaring, (+) retractions, (+) tachycardia, (+)
rales, (+) wheezing, (+) hypoxemia
History:
(-) congestion, (-) dyspnea, (-) cyanosis
Physical Exam:(-) otitis media, (
apnea
Labs:(-) elevation of total WBC, (-) ches
radiograph showing hyperinflation
lobar infiltrates and atelectasi
bronchial wall thickening, air trapping
flattened diaphragm, increased A
diameter, peribronchial cuffing, tinnodules, linear opacities, and patch
alveolar opacities
Moderate Dehydration History: (+) fever, (+) decreased appetite, (+) poor
weight gain,
Physical Exam: (+) irritability, (+) tachycardia, (+)
tachypnea, (+) dry oral mucosa, (+) abnormal
capillary refill, (+) cool extremities
No laboratory test is necessary for mild to moderate
dehydration.
History: (-) diarrhea
Physical Exam: (-) abnormal ski
turgor, (-) decreased pulse rate, (-
sunken eyballs
-
8/10/2019 PEDIA - Tachypnea (2)
3/12
RATIONAL LABORATORY & DIAGNOSTIC TESTSLAB. TEST NORMAL
VALUES
RESULTS TEST NECESSITY & RESULT
INTERPRETATION
AVAILABILITY COST
(Pesos)
Complete Blood Count Repeat CBC 3 days after admission
Hemoglobin 9-14 g/dl 8.9 g/dl
13.2 g/dl
(repeat)
It is used to screen, diagnose, or
monitor a number of conditions and
diseases that affect RBCs, measure
the severity of anemia and to monitor
response to treatment.
In this case, the patient has low
hemoglobin value in the first test but
went up to normal in the repeat test
3 days after admission. The low hgbvalue in the first test is indicative of a
physiologic anemia because
normally, the bone marrow does not
produce new red blood cells between
birth and 3 or 4 weeks of age, causing
a slow drop in the red blood cell
count over the first 2 to 3 months of
life.
SUMC, HCH,
NOPH, Private
Laboratories
250
Hematocrit 28-42% 29 %
40% (repeat)
It is often used with a hemoglobin
level as a simple and quick evaluation
of RBCs.It is used to determine the
proportion of the patients blood that
is made up of red blood cells, toscreen for, diagnose, and evaluate the
severity of anemia or polycythemia.
Also used to evaluate dehydration.
In this case, the patient has normal
hematocrit value In both the first test
and the repeat test.
WBC
-Neutrophil(seg)
-Lymphocyte
-Monocyte
-Eosinophil
-Basophil
5,000-
19,500/cumm
54-62%
25-33%
3-7%
1-3%
0-0.75%
12,500/cumm
12,000/cumm
(repeat)
30%58% (repeat)
38%
35%(repeat)
2%
5% (repeat)
0%
2 (repeat)
0%
White blood cell count is done to
evaluate the patient when results of a
CBC fall outside the reference range
or when you have any number of
signs and symptoms that may be
related to a condition affecting whiteblood cells, such as infection,
inflammation, or cancer. It is also
used when you have a condition or
are receiving treatment that is
known to affect WBCs.
Basically, this patient has normal
totalWBC count but there is elevation
in the lymphocyte count which points
out to a viral cause of an infection.
Physiologic Anemia History: (+) difficulty with oral feeding
Physical Exam: (+) pale-looking, (+)
cardiorespiratory symptoms such as tachycardia,
tachypnea, (+) flow murmurs
Labs: (+) low hemoglobin
CANNOT BE RULED OUT
-
8/10/2019 PEDIA - Tachypnea (2)
4/12
Platelet Count 84-478/uL 254,000/uL
267, 000
(repeat)
Used to help determine the cause of
or potential for excessive bleeding, to
monitor and evaluate platelet
function, and to monitor the presence
and effectiveness of anti-platelet
medications.
In this case the patient has normal
Platelet values.
SERUM ELECTROLYTESPotassium 3.5-6.0 mmol/L 4 This test is a regular part of a basic or
comprehensive metabolic panel. This
is ordered to diagnose or monitor
kidney disease since this is elevated
in kidney problems. This is also
necessary to monitor patients with a
suspected heart problems .
In this case, the patient has normal
potassium level.
SUMC, HCH,
NOPH, Private
Laboratories
250
Urinalysis
Specific gravity: 1.016- 1.022 1.015 Reflect the relative degree of
concentration or dilution of a urinespecimen.
In this case, the patient has a normal
SG.
SUMC, HCH,
NOPH
50
Ketones negative +1 Ketone is a marker for the starvation
status of the patient.
In this case, the patient has abnormal
ketones in the urine. This means that
fat is continually being broken down
to ketones because the patient has
poor feeding and decreased appetite
resulting to poor weight gainmanifested in our patient.
Protein: Negative Negative Normally no protein is detectable in
urine by conventional methods,
although a minute amount is
excreted by the normal kidney. A
color matching any block greater
than 'Trace' indicates significant
proteinuria.
In this case, urine of the patient is
protein negative
WBC: less than 5/hpf 2-3 This is for detection UTI and must
correlate well with the bacteria inurine for the infection to be
considered significant.
In this case, the patient has normal
WBC in the urine.
RBC: 0-3 cells/hpf 0-3 The presence of increased numbers
of erythrocytes in the urine may
indicate a variety of urinary tract and
systemic infections.
In this case, the patient has normal
-
8/10/2019 PEDIA - Tachypnea (2)
5/12
RBC in the urine.
Bacteria: Rare few This is for detection UTI, but this has
to correlate well with pus cells to
confirm the infection.
In this case, the patient has few
bacteria in the urine with normal
WBC count. This means that this
result is not clinically significant. Few
bacteria is normal to be seen in theurine.
IMAGIG STUDIES
Chest x-ray unremarkable Pneumonic
infiltrates are
seen on both
lung fields.
Cardiomegaly
with
pulmonary
congestion is
also seen.
Chest radiography is considered the
criterion standard for diagnosing the
presence of pneumonia. The
presence of infiltrate is required for
the diagnosis. It may also reveal
VSDs, heart size, increased cardiac
silhouette, etc.
SUMC, HCH,
NOPH
350
Two-dimensional
echocardiographywith Doppler
echocardiography
(2D echo)
unremarkable CHD with left
atrial andventricular
enlargement,
good
ventricular
function and
estimated
pulmonary
pressure of
60 mmHg.
This is used to determine the size and
location of virtually all VSDs and tocheck for blood flow if theres
shunting. Also, this is to monitor and
check for ejection fraction.
Doppler echocardiography provides
additional physiologic information
( RV pressure, PA pressure, and
interventricular pressure difference).
SUMC, HCH,
NOPH
3,747
OTHER LAB TESTS AND DIAGNOSTIC PROCEDURES TO ORDER
TEST TEST NECESSITY AVAILABILITY
Blood Typing This is essential for possible transfusions SUMC, HCH,
NOPHABG Determination The test is used to determine the pH of the blood, the partial pressure of
carbon dioxide and oxygen, and the bicarbonate level. In pneumonia,
hypoxi and respiratory acidosis may be present.
SUMC, HCH,
NOPH
Electrocardiography
(ECG)
In patients with small VSDs, ECG findings are normal.
In patients with moderate-sized VSDs and with moderate or large left-to-
right shunts with volume overload in the LV, LV hypertrophy is the rule.
Combined ventricular hypertrophy is common.
In patients with large VSDs and equal ventricular pressures, RV
hypertrophy is demonstrated. In patients with large pulmonary blood
flow, LA hypertrophy is evidenced by biphasic P waves in leads I, aVR,
and V6, with prominent negative deflection in V1.
SUMC, HCH,
NOPH
Acute Phase
Reactants (ESR,
CRP)
In patients with more serious disease, such as those
requiring hospitalization or those with pneumonia-associated
complications, acute-phase reactants may be used in
conjunction with clinical findings to assess response to
therapy.
SUMC, HCH,
NOPH
FINAL DIAGNOSIS: Ventricular Septal Defect (VSD) with Congestive Heart Failure; Severe pneumonia; Concomitant
Moderate Dehydration; Physiologic Anemia
-
8/10/2019 PEDIA - Tachypnea (2)
6/12
THERAPEUTICS
LIST OF PROBLEMS:
1. tachypnea
2. persistent cough
3. decreased appetite
4. poor weight gain
5. fever
6. episodes of difficulty breathing
7. feeds for a shorter period of time
accompanied by incessant crying.8. Hypoxemia
9. tachycardia
10. pallor
11.
irritability
12. cardiorespiratory distress
13. shallow subcostal retractions
14. nasal flaring
15. dry oral mucosa
16. rales, crackles, and occasional wheezes on
both lung fields.
17. murmur
18. cold extremities
19.
abnormal capillary refill time
THERAPEUTIC OBJECTIVES:
1. The infant will be free from further complications of condition.
2. The infant will be normothermic.
3. Febrile convulsions are prevented.
4. The infant will be free from anemia.
5. Absence of cough.
7. Minimize frequency and severity of respiratory infections.
8. The infant will achieve its high degree of wellbeing.
9. Normalize infants growth and development. 10. Control the symptoms of heart failure to allow the baby time to
grow.
11. Increase comfort and decrease parental anxiety.
MANAGEMENT
PARENTSADVICE AND INFORMATION
Educate the parents/guardians about the babys condition: possible etiology, risk factors, course of disease, signs and
symptoms, complications if left untreated, prognosis and medical options for treatment including its benefits, side
effects, risk and alternatives. Increasing their knowledge about the childs condition to improve medi cal compliance
and assist in symptom management.
Emphasize importance of medication compliance in optimum management of his condition.
Provide parents with instruction about management of their childs condition. This will empower them to care for
their child. Educate the parents of the advantages of breastfeeding.
Educate the parents about the importance of immunizations.
Emphasize that the baby is on trust vs. mistrust stage: the needs must be met for a healthy emotional development.
NON-PHARMACOLOGIC MANAGEMENT
Admit.Children and infants who have moderate to severe CAP, as defined by several factors, including respiratory
distress and hypoxemia (sustained saturation of peripheral oxygen, 90 % should be hospitalized for management,
including skilled pediatric medical care.
Vital signsmonitoring q 2h. Rectal temperatures are the gold standard for measuring central body temperature
Monitoring Pulse oximetry with or without cardiac monitoring
Place the child on NPO temporarily for an 8-hour-observation
Start Venoclysis with D5 0.3% Sodium Chloride at 20 cc/hr
Provide neutral environmental temperature.Avoid hot or cold extremes which increase oxygen and energy demands
Nutrition:Increase caloric density of feedings to ensure adequate weightv gain. Initiate orogastric feeding (OGT) with
expressed breastmilk 30 cc every 3 hours, increasing gradually to every 3 hours. More than 150 kcal/kg per day
Transfuse packed RBC.Possible red blood cell transfusion for significant anemia in the setting of heart failure, poor
weight gain and respiratory difficulties.
Elevate the head via carrier/ pillows. Positioning of the infant to minimize aspiration risk
Bronchial hygiene: Pulmonary toilet may include chest physiotherapy, positioning to promote dependent drainage,
and incentive spirometry to enhance elimination of purulent sputum and to avoid atelectasis.
Allow rest periods between care; disturb only when necessary for care and procedures.
Assess usual family coping methods and effectiveness.
-
8/10/2019 PEDIA - Tachypnea (2)
7/12
POSSIBLE SURGERY
INTRACARDIAC REPAIR OF DEFECT
The symptoms of children with heart failure from left-to-right shunts can improve with medical therapy, postponing and possibly
avoiding the need for surgical correction. However, despite maximum medical management, 50 percent of patients with moderate
to large VSDs continue to have tachypnea and or/failure to thrive. These patients undergo surgical closure in infancy, preferably
before six months of age
Indications
Infants
-
8/10/2019 PEDIA - Tachypnea (2)
8/12
hours for
temperature 37.8
C and above
hypothalamus to decrease heat
loss and increase heat gain.
TEMPRA FORTE has been shown
to inhibit the action of endogenous
pyrogens on the heat-regulating
centers in the brain by blocking
the formation and release of
prostaglandins in the central
nervous system.6-9 Inhibition of
arachidonic acid metabolism is notrequisite for the antipyretic effect
of paracetamol.
leukopenia. Neutropenia,
Precaution
Use with caution in patients
with G6PD deficiency
Contraindications
Hypersensitivity and severe
active liver disease
Syrup
BRONCHODILATOR
Salbutamol
(VENTOLIN)
nebulisation
every 6 hours
The pharmacologic effects of beta-
adrenergic agonist drugs,
including albuterol, are at least in
part attributable to stimulation
through beta-adrenergic receptors
of intracellular adenyl cyclase, the
enzyme that catalyzes the
conversion of adenosine
triphosphate (ATP) to cyclic-3',5'-
adenosine monophosphate (cyclic
AMP). Increased cyclic AMP levels
are associated with relaxation of
bronchial smooth muscle and
inhibition of release of mediators
of immediate hypersensitivity
from cells, especially from mast
cells.
Side Effects
Tremor, nausea, fever,
bronchospasm, vomiting,
headache, dizziness, cough,
allergic reactions, epistaxis,
dry mouth,
Precaution
Risk of hypokalemia,
Paradoxical bronchospasm
may occur
Contraindications
Tachycardia secondary to a
heart condition
Bronchodilator
treatments such as
albuterol may or may
not be required
depending on your
symptoms.
P659.80
LOOP DIURETICS
Furosemide
(LASIX) 4 mg IVevery 12 hours
It is a loop diuretic which inhibits
reabsorption of sodium andchloride ions at the proximal and
distal renal tubules and loop of
Henle. By interfering with
chloride-binding cotransport
system, causes increases in water,
calcium, magnesium sodium and
chloride.
Side Effects
Hyperuricemia, hypokalemia,anaphylaxis, anemia, anorexia,
diarrhea, dizziness, glucose
intolerance, glycusoria,
headache, hypotension,
hypomagnesemia, muscle
cramps, photosensitivity, rash,
restlessness, weakness
Precaution
Agent is a potent diuretic, that,
if given in excessive amounts,
may lead to profound dieresis
with water and electrolytedepletion. There is risk of
ototoxicity.
Contraindications
Anuria, documented
hypersensitivity to furosemide
or sulfonamides
They are used in the
treatment ofhypertension, heart
failure and hepatic,
renal, pulmonary
disease when salt and
water rentention has
resulted in edema/
ascites.
ACE INHIBITORS
Captopril CAPOTEN prevents the conversion Side Effects ACE inhibitors are P430
-
8/10/2019 PEDIA - Tachypnea (2)
9/12
(CAPOTEN)
2 mg/pptab every
12 hours
of angiotensin I to angiotensin II
by inhibition of ACE, a
peptidyldipeptide carboxy
hydrolase. Inhibition of ACE
results in decreased plasma
angiotensin II and increased
plasma renin activity (PRA), the
latter resulting from loss of
negative feedback on renin release
caused by reduction in angiotensinII. The reduction of angiotensin II
leads to decreased aldosterone
secretion,
Systemic vascular resistance may
increase in children with VSD for a
variety of reasons. In this setting,
antegrade flow through the aortic
valve decreases and left-to-right
shunting through the defect
increases. Afterload reducing
agents, such as the angiotensin
converting enzyme inhibitors
captopril or enalapril are used to
reduce systemic vascular
resistance, promoting antegrade
flow through the aortic valve and
decreasing the magnitude of the
shunt
Hyperkalemia, hypersensitivity
reactions, skin rash, dysgeusia,
hypotension, pruritus, cough,
chest pain, palpitations,
proteinuria and tachycardia
Precaution
Risk of hyperkalemia
especially with Potassium
sparing diuretics
Contraindications
CAPOTEN is contraindicated in
patients who are
hypersensitive to this product
or any other angiotensin-
converting enzyme inhibitor
used to treat
congestive heart
failure. They may be
used to treat systemic
afterload. This
medication reduces
both systemic and
pulmonary pressure,
thereby reducing the
left-to-right shunt.
per box
of 50s
INOTROPIC AGENTS
Dopamine
Hydrochloride
(DOPAMAX)
5 ug/kg/min
Dopamine is a natural
catecholamine formed by the
decarboxylation of 3,4-
dihydroxyphenylalanine (DOPA).
Dopamine produces positivechronotropic and inotropic effects
on the myocardium, resulting in
increased heart rate and cardiac
contractility. This is accomplished
directly by exerting an agonist
action on beta-adrenoceptors and
indirectly by causing release of
norepinephrine from storage sites
in sympathetic nerve endings.
Dopamine 's onset of action occurs
within five minutes of intravenous
administration, and with plasma
half-life of about two minutes, theduration of action is less than ten
minutes.
Side Effects
ventricular arrhythmia (at very
high doses), ectopic beats,
tachycardia, palpitation,
cardiac conductionabnormalities, widened QRS
complex, bradycardia,
hypotension, hypertension,
vasoconstriction, dyspnea,
nausea, vomiting
Precaution
Careful monitoring required -
Close monitoring of the
following indices-urine flow,
cardiac output and blood
pressure
Contraindications
This should not be
administered in the presence
of uncorrected
tachyarrhythmias or
ventricular fibrillation.
DOPAMINE is
indicated for the
correction of
hemodynamic
imbalances present inthe shock syndrome
due to myocardial
infarctions, trauma,
endotoxic septicemia,
open heart surgery,
renal failure, and
chronic cardiac
decompensation as in
congestive failure.
Digoxin
(LANOXIN) 50
mcg/ml given at
0.3 ml every 12
All of digoxin's actions are
mediated through its effects on
Na-K ATPase. This enzyme, the
sodium pump, is responsible for
maintaining the intracellular
Side Effects
Nausea, vomiting, abdominal
pain, intestinal ischemia, and
hemorrhagic necrosis of the
intestines, headache,
LANOXIN increases
myocardial
contractility in
pediatric patients with
-
8/10/2019 PEDIA - Tachypnea (2)
10/12
hours milieu throughout the body by
moving sodium ions out of and
potassium ions into cells. By
inhibiting Na-K ATPase,
digoxin causes increased
availability of intracellular calcium
in themyocardiumand conduction
system, with consequent
increased inotropy, increased
automaticity, and reducedconduction velocity
indirectly causes parasympathetic
stimulation of theautonomic
nervous system,with consequent
effects on the sino-atrial (SA) and
atrioventricular (AV) nodes
weakness, dizziness, apathy,
confusion, and mental
disturbances
Precaution
The earliest and most frequent
manifestation of digoxin
toxicity in infants and children
is the appearance of cardiac
arrhythmias, including sinusbradycardia.
Contraindications
LANOXIN is contraindicated in
patients with ventricular
fibrillation
heart failure.
DISCHARGE
The infant is eligible for discharge when she has documented overall clinical improvement, including level of activity,
appetite, and decreased fever for at least 1224 hours. Infant is eligible for discharge when she demonstrates consistent pulse oximetry measurements .90% in room air for
at least 1224 hours.
Clinicians should demonstrate that parents are able to administer and children are able to comply adequately with
taking those antibiotics before discharge.
MONITORING AND FOLLOW-UP
Emphasized SO the importance of regular follow-up check-ups and as instructed by physician.
Infants should be followed every two weeks to assess growth parameters. Over time, if nutritional needs are not met,
the infant's length and head circumference may be affected
Patient should be followed-up with a chest radiograph in approximately 6 weeks to ensure resolution of consolidation
and to assess persistent abnormality of the lung parenchyma.
Parents need to be aware that affected infants who may or may not have been anemic at birth are at considerable riskfor developing clinically significant anemia during the first 3-4 months of life. Their baby should have weekly
hematocrit and reticulocyte counts performed and receive simple packed erythrocyte transfusions (20-25 mL/kg of
PRBCs) if clinical symptoms appear if Hb levels fall below 6-7 gm/dL without evidence of a reticulocytosis, i.e.,
reticulocyte count
-
8/10/2019 PEDIA - Tachypnea (2)
11/12
PRESCRIPTION:
Alvin Pasuquin, MD
Silliman University Medical Center
Name:________________________________ Age/Sex:______________
Address:___________________________ Date: ________________
___________________________
SIGNATURE
Alvin Pasuquin, MD
Silliman University Medical Center
Name:________________________________ Age/Sex:______________
Address:___________________________ Date: ________________
___________________________
SIGNATURE
Arianne Rodriguez, MD
Silliman University Medical Center
Name:________________________________ Age/Sex:______________
Address:_____________________________ Date: ________________
___________________________
SIGNATURE
Arianne Rodriguez, MD
Silliman University Medical Center
Name:________________________________ Age/Sex:______________
Address:___________________________ Date: ________________
___________________________
SIGNATURE
REFERENCES:
Atienza, M. et al. (2006). Guide for history taking, physical examination and diagnosis of pediatric patients. 2nd ed. UST.
Philippines.
Bickley, A. et. Al. (2009).BatesGuide to Physical Examination and History Taking . 10thed.
Chernecky, C & Berger B., (2008). Laboratory Test and Diagnostic Procedures. 5thed. Saunders Elseviers: Philadelphia
Fauci, A. et Al. (2012). Harrisons Principles of Internal Medicine. 18thed. McGraw-Hill
Medical Publishing Division, USA.
Kliegman, R.M. et al. (2012). Nelson textbook of pediatrics. 19th ed. Elsevier Saunders. Singapore.
-
8/10/2019 PEDIA - Tachypnea (2)
12/12