THE SEVEN HABITS OF HIGHLY EFFECTIVE PEOPLE

by Stephen R. Covey

Habit 1: Be Proactive•Ability to control one’s environment, rather that have it control you.•Taking initiative doesn’t mean being aggressive, it means recognizing your responsibility to make things happen

Habit 2: Begin with the end in mind•The habit of personal leadership•Lead oneself towards what you consider your aims•Based on imagination – the ability to envision, to see the potential, to create with our minds what we cannot at present see with our eyes

Habit 3: Put First Things First•The habit of personal management•Create a clear, mutual understanding of what needs to be accomplished, focusing on what, not how; results not methods•Spend time. Be patient. Visualize the desired result

Habit 4: Think Win-Win•The habit of interpersonal relationship•Achievements are largely dependent on co- operative efforts with others•Agreements or solutions are mutually beneficial & satisfying

Habit 5: Seek first to understand and then to be understood

•The habit of communication•Diagnose before you prescribe•Simple, effective & essential in developing & maintaining positive relationships in all aspects of life

Habit 6: Synergize•The habit of creative cooperation•“the whole is greater than the sum of its parts”•See good & potential in other person’s contribution

Habit 7: Sharpen the saw•The habit self-renewal, of continuous improvement•Circles & embodies all other habits

1 drop = 1/20 mL1 teaspoonful = 5 mL1 tablespoonful = 15 mL1 wineglassful = 60 mL = 2 ounces1 glassful = 250 mL = 8 ounces1 grain = 60 mg1 pint = 500 mL1 quart = 1000 mL1 ounce = 30 mL1 Kg = 2.2 lbs1 lb = 0.45359 Kg

Paracetamol Dropswt: move 1 decimal point to

the leftAge Wt110kg212314416518620

BODY TEMPERATURE

Subnormal <36.6°C

Normal 37.4°C

Subfebrile 35.7 – 38.0°C

Fever 38.0°C

High fever >39.5°C

Hyperpyrexia >42.0°C

AGE HR (bpm) BP (mmHg) RR (cpm)

Preterm 120-170 55-75/35-45 40-70

Term 120-160 65-85/45-55 30-60

0-3 mo 100-150 65-85/45-55 35-55

3-6 mo 90-120 70-90/50-65 30-45

6-12 mo 80-120 80-100/55-65 25-40

1-3 yrs 70-110 90-105/55-70 20-30

3-6 yrs 65-110 95-110/60-75 20-25

6-12 yrs 60-95 100-120/60-75 14-22

12-17 yrs 55-85 110-135/65-85 12-18

*BP cuff should cover 2/3 of arm

small cuff: falsely high BP

large cuff: falsely low BP

ABG

pH: 7.35-7.45 HCO3: 22-26mEq/L

pCO2: 35-45 B.E.: +/- 2mEq/L

pO2: 80-100 O2 sat: 97%

Normal Laboratory Values

NB Infant Child Adolescent

RBC 4.8-7.1 3.8-5.5 3.8-5. M: 4.6-6.2

F: 4.2-5.4

WBC 9-30,000 6-17,500 5-10,000 6-10,000

Neutrophils 61% 61% 60% 60%

Lymphocytes 31% 32% 30% 30%

Hgb (gm %) 14-24 11-20 11-16 M: 14-18

F: 12-16

Hct (%) 44-64 35-49 31-46 M: 40-54 F: 37-47

Platelets 140-300 200-423 150-450 150-450

(thou/mm3)

Reticulocyte 2.6-6.5 0.5-3.1 0-2 0-2

Count (%)

Bleeding time 1-5 min 1-6 1-6 1-6

Clotting time 5-8 min 5-8 5-8 5-8

Prothrombin 12-20 12-14 12-14 12-14

time (sec)

BMI

Asian Caucasian

Underweight <18.5 <18.5

Normal 18.5 – 22.9 18.5 – 24.9

Overweight ≥ 23.0 25 – 29.9

at risk 23 – 24.9

Obese I 25 – 29.9 30 – 39.9

Obese II ≥ 30 >40

ANTHROPOMETRIC MEASUREMENTS

Expected Body Weight upto 1 month of age

Term [{age in days) – 10] x 20 + BW (gms)

Preterm [(age in days) – 14] x 15 + BW (gms)

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ACUTE DIARRHEA (at least 3x BM in 24 hrs)

4 Major Mechanisms

1. Poorly absorbed osmotically active substances in lumen

2. Intestinal ion secretion (increased) or decreased absorption

3. Outpouring into the lumen of blood, mucus

4. Derangement of intestinal motility

Rotaviral AGE (vomiting first then diarrhea)

ingestion of rotavirus rotavirus in intestinal villi destruction of villi

(secretory diarrhea absorption, secretion) AGE

Assessment of dehydration (skin pinch test)

(+) if > 2 seconds

no dehydration if skin tenting goes back immediately

Etiology of AGE

Bacteria Viruses

Aeromonas Astroviruses

Bacillus cereus Caloviruses

Campylobacter jejuni Norovirus

Clostridium perfringens Enteric adenoviruses

Clostridium difficile Rotavirus

Escherichia coli Cytomegalovirus

Plesiomonas shigelbides Herpes simplex virus

Salmonella

Shigella

Staphylococcus aureus

Vibrio cholerae 01 & 0139

Vibrio parahaemolyticus

Yersinia enterocolitica

Parasites

Balantidium coli

Blastocyctis hominis

Cryptosporidium

Giardia lamblia

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DIARRHEA TREATMENT PLAN A

4 Rules of Home Treatment

1. Give extra fluid (as much as the child will take)> Breastfeed frequently & longer at each feeding> if the child is exclusively breastfed, give one or more of the following in addition to breastmilk:

- ORS solution- food based fluid (e.g. soup, rice, water)- clean water

How much fluid to be given in addition to the usual fluid intake:upto 2 years: 50-100 mL after each loose stool2 years or more: 100-200 mL

> give frequent small sips from a cup> if the child vomits, wait for 10 min then

resume> continue giving extra fluids until diarrhea

stops

2. Give Zinc supplementsupto 6 mo: ½ tab or 10mg per day for 10-14 days6 months or more: 1 tab or 20mg OD x 10-14 days

3. Continue feeding

4. Know when to return

DIARRHEA TREATMENT PLAN B

Recommended amount of ORS over 4 hour period

Age upto 4 mo - 12mo - 2 yrs –

4 mo 12mo 2 yrs 5 yrs

Wt <6kg 6-9.9kg 10-11.9kg 12-19kg

in mL 200-400 400-700 700-900 900-1400

* Use child’s age only when weight is not known

* Approximate amount of ORS (mL)

CHILDS WT (kg) x 25

> if the child wants more ORS than shown, give more

> give frequent small sips from a cup

> if the child vomits, wait for 10 min then resume

> continue breastfeeding whenever the child wants

* After 4 hours

> reassess the child & classify dehydration status

> select the appropriate plan to continue treatment

> begin feeding the child while at the clinic

DIARRHEA TREATMENT PLAN C

Treat severe dehydration QUICKLY!

> start IV fluid immediately

> if the child can drink, give ORS by mouth while the IV drip is being set up

> give 100mL/kg Lactated Ringer’s solution

Age First give Then give

30mL/kg in: 70mL/kg in:

Infants 1 hour* 5 hours

(<12mo)

Children 30 min* 2 ½ hours

(12mo-5yrs)

* Repeat once if radial pulse is very weak or not detectable

> reassess the child every 15-30 min. if dehydration is not improving, give IV fluid more rapidly

> also give ORS (~5mL/kg/hr) as soon as the child can drink [usually after 3-4 hours in infants; 1-2 hours in children]

> reassess after 6 hrs (infant) & 3 hrs (child)

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ETIOLOGY OF PNEUMONIA

> Bacterial - Streptococcus pneumoniae - Group B streptococci (neonates) - Group A streptococci - Mycoplasma pnemoniae (adolescents) - Chlamydia trachomatis (infants) - Mixed anearobes (aspiration pneumonia) - Gram negative enteric (nosocomial pneumonia)

> Viral - Respiratory syncitial virus - Parainfluenza type 1-3 (Croup) - Influenza types A, B - Adenovirus - Metapneumovirus

> Fungal - Histoplasma capsulatum (bird, bat contact) - Cryptococcus neoformans (bird contact) - Aspergillus sp. (immunosuppressed) - Mucormycosis (immunosuppressed) - Coccidioides immitis - Blastomyces dermatitides - Pneumocystis carinii (immunosuppressed, HIV,

steroids)

ATYPICAL PNEUMONIA: extrpulmonary manifestations, low grade fever, patchy diffuse infiltrates, poor response to Penicillin, negative sputum gram stain

Etiologic Agents Grouped by Age

> Neonates (<1mo)

- GBS

- E. coli

- other gram (-) bacilli

- Streptococcus pneumoniae

- Haemophilus influenzae (Type B)

> 1-3 mo

* Febrile pneumonia

- RSV

- Other respiratory viruses

- Streptococcus pneumoniae

- Haemophilus influenzae (Type B)

* Afebrile pneumonia

- Chlamydia trachomatis

- Mycoplasma homilis

- CMV

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

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

2-5 yrs - Streptococcus pneumoniae - Haemophilus influenzae (Type B) - C. trachomatis - M. pneumoniae - Group A Streptococcus - Staph aureus

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DENGUE

> Mode of transmission: mosquito bite (man as reservior)> Vector: Aedes aegypti> Factors affecting transmission:

- breeding sites, high human population density, mobile viremic human beings

> Age incidence peaks at 4-6 yrs> Incubation period: 4-6 days> Serotypes:

- Type 2 – most common- Types 1& 3- Type 4 – least common but most severe

> Main pathophysiologic changes:a. increase in vascular permeability

extravasation of plasma

- hemoconcentration - 3rd spacing of fluids

b. abnormal hemostasis - vasculopathy - thrombocytopenia

- coagulopathy

Dengue Fever Syndrome (DFS)

Biphasic fever (2-7 days) with 2 or more of the ff:

1. headache

2. myalgia or arthralgia

3. retroorbital pain

4. hemorrhagic manifestations

[petechiae, purpura, (+) torniquet test]

5. leukopenia

Dengue Hemorrhagic Fever (DHF)

1. fever, persistently high grade (2-7 days)

2. hemorrhagic manifestations

- (+) torniquet test

- petechiae, ecchymoses, purpura

- bleeding from mucusa, GIT, puncture sites

- melena, hematemesis

3. Thrombocytopenia (< 100,000/mm3)

4. Hemoconcentration

- hematocrit >40% or rise of >20% from baseline

- a drop in >20% Hct (from baseline) following volume replacement

- signs of plasma leakage

[pleural effusion, ascites, hypoproteinemia]

Dengue Shock Syndrome

Manifestations of DHF plus signs of circulatory failure

1. rapid & weak pulse

2. narrow pulse pressure (<20mmHg)

3. hypotension for age

4. cold, clammy skin & irritability / restlessness

DANGER SIGNS OF DHF

1. abdominal pain (intense & sustained)

2. persistent vomiting

3. abrupt change from fever to hypothermia with sweating

4. restlessness or somnolence

Grading of Dengue Hemorrhagic Fever

Torniquet Test: SBP + DBP = mean BP for 5 minutes

2

if ≥20 petechial rash per sq. inch on antecubital fossa

(+) test

Herman’s Rash:

> usually appears after fever lysed

> initially appears on the lower extremities

> not a common finding among dengue patients

> “an island of white in an ocean of red”

Recommended Guidelines for Transfusion:

Transfuse:

- PC < 100,000 with signs of bleeding

- PC < 20,000 even if asymptomatic

- use FFP if without overt bleeding

- FWB in cases with overt bleeding or signs of hypovolemia

> if PT & PTT are abnormal: FFP

> if PTT only: cryprecipitate

Leukopenia in dengue: probable etiology is Pseudomonas

therefore: give Meropenem or Ceftazidime

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URINARY TRACT INFECTION

Suggestive UTI:

- Pyuria: WBC ≥ 5/HPF or 10mm3

- Absence of pyuria doesn’t rule out UTI

- Pyuria can be present w/o UTI

Presumptive UTI:

- (-) urine culture

- lower colony counts may be due to:

* overhydration

* recent bladder emptying

* previous antibiotic intake

Proven or Confirmed UTI:

- (+) urine culture ≥ 100,000 cfu/mL urine of a single organism

- multiple organisms in culture may indicate a contaminated sample

ACUTE GLOMERULONEPHRITIS (PSAGN)

Antecedent Infection (2-3 weeks)

Ag-Ab complexes + complement (ASO)

Ag-Ab deposition in GBM Ab binding to Glomerular Ab

C3

Proliferation deposition

Decreased Glomerular surface area

Decreased GFR

Activation of RAAS

Na+ & H2O retention

Fluid overload

Circulatory congestion EDEMA

Hematuria

Oliguria;Normal or increased Creatinine

Edema,HPN

CHF;Pulmonary edema

ACUTE GLOMERULONEPHRITIS

Complications of AGN

- CHF 2° to fluid overload

- HPN encephalopathy

- ARF due to GFR

STAGES of AGN

- Oliguric phase [7-10days] – complications sets in

- Diuretic phase [7-10days] – recovery starts

- Convalescent phase [7-10days] – ptts usually sent home

Prognosis

- Gross hematuria 2-3 weeks

- Proteinuria 3-6 weeks

- C3: 8-12 weeks

- microscopic hematuria: 6-12 mo

> Hyperkalemia may be seen due to Na+ retention

> Ca++ decreases in PSAGN

> in ASO titer

- normal within 2 weeks

- peaks after 2 weeks

- more pronounced in pharyngeal infection than in cutaneous

RHEUMATIC FEVER

• JONES CRITERIA:

• A. Major Manifestations

– Carditis (50-60%)

– Polyarthritis (70%)

– Chorea (15-20%)

– Erythema Marginatum (3%)

– Subcutaneous Nodules (1%)

• B. Minor Manifestations

– Arthralgia

– Fever

– Laboratory Findings of:

• Elevated Acute Phase Reactants (ESR / CRP)

• Prolonged PR interval

• C. PLUS Supporting Evidence of Antecedent Group-A Strep Infection

– (+) Throat Culture or Rapid Strep-Ag Test

– Elevated or Rising Strep-AB Test

TREATMENT OF RHEUMATIC FEVER

• A. Antibiotic Therapy

– 10 days of Oral Penicillin or Erythromycin

– IM Injection of Benzethine Penicillin

• **NOTE: Sumapen = Oral Penicillin!

• B. Anti-Inflammatory Therapy

• 1. Aspirin (if Arthritis, NOT Carditis)

• Acute: 100mg/kg/day in 4 doses x 3-5days

• Then, 75mg/kg/day in 4 doses x 4 weeks

• 2. Prednisone

• 2mg/kg/day in 4 doses x 2-3weeks

• Then, 5mg/24hrs every 2-3 days

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KAWASAKI DISEASE

 

CDC-CRITERIA FOR DIAGNOSIS: ADOPTED FROM KAWASAKI (ALL SHOULD BE PRESENT)

 

A) HIGH Grade Fever (>38.5 Rectally) PRESENT for AT LEAST 5-days without other Explanation

“High Grade Fever of at least 5 days”

DOES NOT Respond to any kind of Antibiotic!

 

B) Presence of 4 of the 5 Criteria:

1) Bilateral CONGESTION of the Ocular Conjunctiva (seen in 94%)

2) Changes of the Lips and Oral Cavity (At least ONE)

3) Changes of the Extremities (At least ONE)

4) Polymorphous Exanthem (92%)

5) Cervical Adenopathy = Non-Suppurative Cervical Adenopathy (should be >1.5cm) in 42%

 

KAWASAKI DISEASE

 

HARADA Criteria

- used to determine whether IVIg should be given

- assessed within 9 days from onset of illness

1. WBC > 12,000

2. PC <350,000

3. CRP > 3+

4. Hct <35%

5. Albumin <3.5 g/dL

6. Age 12 months

7. Gender: male

 

•IVIg is given if ≥ 4 of 7 are fulfilled

•If < 4 with continuing acute symptoms, risk score must be reassessed daily

TREATMENT: Currently Recommended Protocol:

A. IV-Immunoglobulin

2g/kg Regimen Infusion EQUALLY Effective in Prevention of Aneurysms and Superior to 4-day Regimen with respect to Amelioration of Inflammation as measured by days of Fever, ESR, CRP, Platelet Count, Hgb, and Albumin.

NOTE: There is a TIME FRAME of 10 days

 

B. Aspirin

HIGH Dose ASA (80-100mg/kg/day divided q 6h) should be given Initially in Conjunction with IV-IG

THEN

Reduced to Low Dose Aspirin (3-5mg/kg/day)

AND

Continued until Cardiac Evaluation COMPLETED

(approximately 1-2 months AFTER Onset of Disease)

SEIZURES

> Seizures: sudden event caused by abrupt, uncontrolled, hypersynchronous discharges of neurons

> Epilepsy: tendency for recurrent seizures that are unprovoked by an immediate cause

> Status epilepticus: >30min or back-to-back w/o return to baseline

> Etiology:

- V ascular : AVM, stroke, hemorrhage

- I nfections : meningitis, encephalitis

- T raumatic :

- A utoimmune : SLE, vasculitis, ADEM

- M etabolic : electrolyte imbalance

- I diopathic : “idiopathic epilepsy”

- N eoplastic : space occupying lesion

- S tructural : cortical malformation, prior stroke

- S yndrome : genetic disorder

TYPES OF SEIZURES

A. Partial Seizures (Focal / Local)

– Simple Partial

– Complex Partial (Partial Seizure + Impaired Consciousness)

– Partial Seizures evolving to Tonic-Clonic Convulsion)

 

B. Generalized Seizures

– Absence (Petit mal)

– Myoclonic

– Clonic

– Tonic

– Tonic-Clonic

– Atonic

SIMPLE FEBRILE SEIZURE vs. COMPLEX FEBRILE SEIZURE

Febrile Seizure: “A seizure in association with a febrile illness in the absence of a CNS infection or acute electrolyte imbalance in children older than 1 month of age without prior afebrile seizures”

CLASSIFICATION BY CAUSE

A. Acute Symptomatic (shortly after an acute insult)

– Infection

– Hypoglycemia, low sodium, low calcium

– Head trauma

– Toxic ingestion

 

B. Remote Symptomatic

– Pre-existing brain abnormality or insult

– Brain injury (head trauma, low oxygen)

– Meningitis

– Stroke

– Tumor

– Developmental brain abnormality

 

C. Idiopathic

– No history of preceding insult

– Likely “genetic” component

SIMPLE FEBRILE SEIZURE

A. Criteria for an SFS

– < 15 minutes

– Generalized-tonic-clonic

– Fever > 100.4 rectal to 101 F (38 to 38.4 C)

– No recurrence in 24 hours

– No post-ictal neuro abnormalities (e.g. Todd’s paresis)

– Most common 6 months to 5 years

– Normal development

– No CNS infection or prior afebrile seizures

 

B. Risk Factors

– Febrile seizure in 1st/2nd degree relative

– Neonatal nursery stay of >30 days

– Developmental delay

– Height of temperature

 

C. Risk Factors for Epilepsy (2 to 10% will go on to have epilepsy)

– Developmental delay

– Complex FS (possibly > 1 complex feature)

– 5% > 30 mins => _ of all childhood status

– Family History of Epilepsy

– Duration of fever

 

BRONCHIAL ASTHMA (GINA GUIDELINES)

Controlled Partly controlled

Uncontrolled

Day symptoms

none > 2x per wk 3 or more symptoms of Partly Controlled Asthma in any week

Limitation of activities

none any

Nocturnal Sx (awakening)

none any

Need for reliever

< 2x per wk > 2x per wk

Lung function normal < 80%

Exacerbation none > 1x per yr 1x / week

Tuberculosis (Treatment)I. Pulmonary TB

A. Fully susceptible M. tuberculosis, no history of previous anti-TB drugs, low local persistence of primary resistance to Isoniazid (H)

2HRZ OD then 4HR OD or 3x/wk DOT

B. Microbial susceptibility unknown or initial drug resistance suspected (e.g. cavitary), previous anti-TB use, close contact w/ resistant source case or living in high areas w/ high pulmonary resistance to H.

2HRZ + E/S OD, then 4 HR + E/S OD or 3x/wekk DOT

I. Extrapulmonary TB

Same in PTB

For severe life threatening disease (e.g. miliary, meningitis, bone, etc)

☤ 2HRZ + E/S OD, then 10HR + E/S OD or 3x/wk DOT

H.E.A.D.S.S.S.Home Environment☤ With whom does the adolescent live?☤ Any recent changes in the living situation?☤ How are things among siblings?☤ Are parents employed?☤ Are there things in the family he/she wants to change?

Employment and Education☤ Currently at school? Favorite subjects?☤ Patient performing academically?☤ Have been truant/expelled from school?☤ Problems with classmates/teachers?☤ Currently employed?☤ Future education/employment goals?

Activities☤ What he/she does in spare time?☤ Patient does for fun?☤ Whom does patient spend spare time?☤ Hobbies, interests, close friends?

H.E.A.D.S.S.S.Drugs☤ Used tobacco/alcohol/steroids?☤ Illicit drugs? Frequency? Amount? Affected daily activiities?☤ Still using? Friends using/selling?

Sexual activities☤ Sexual orientation?☤ GF/BF? Typical date?☤ Sexually active? When started? # of persons?

Contraceptives? Pregnancies? STDs?

Suicide/Depression☤ Ever sad/tearful/unmotivated/hopeless?☤ Thought of hurting self/others?☤ Suicide plans?

Safety☤ Use seatbelts/helmets?☤ Enter into high risk situations?☤ Member of frat/sorority/orgs?☤ Firearm at home?

Respiratory Distress Syndrome(Hyaline Membrane Disease)

☤ Male, preterm, low BW, maternal DM, & perinatal asphyxia☤ Corticosteroids:

• most successful method to induce fetal lung maturation• Administered 24-48 hours before delivery decrease incidence

of RDS• Most effective before 34 weeks AOG

☤ Microscopically: diffuse atelectasis, eosinophilic membrane

Pathophysiology:1. Impaired/delayed surfactant synthesis & secretion2. V/Q (ventilation/perfusion) imbalance due to deficiency of

surfactant and decreased lung compliance3. Hypoxemia and systemic hypoperfusion4. Respiratory and metabolic acidosis5. Pulmonary vasoconstriction6. Impaired endothelial &epithelial integrity7. Proteinous exudate8. RDS

Respiratory Distress Syndrome(Hyaline Membrane Disease)

Clinical Features:1. Tachypnea, nasal flaring, subcostal and intercostal

retractions, cyanosis, grunting2. Pallor – from anemia, peripheral vasoconstriction3. Onset – within 6 hours of life

Peak severity – days 2-3Recovery – 72 hours

Retractions:☤ Due to (-) intrapleural pressure produced by interaction b/w

contraction of diaphragm & other respiratory muscles and mechanical properties of the lungs & chest wall

Nasal flaring:☤ Due to contraction of alae nasi muscles leading to marked reduction

in nasal resistanceGrunting:☤ Expiration through partially closed vocal cordsInitial expiration: glottis closedlungs w/ gasinc. transpulmo P w/o

airflowLast part of expiration: gas expelled against partially closed cordsCyanosis:☤ Central – tongue & mnucosa (imp. Indicator of impaired gas

exchange); depends on total amount of desaturated Hgb

F.R.I.C.H.M.O.N.D.

☤Fluids

☤Respiration

☤ Infection

☤Cardiac

☤Hematologic

☤Metabolic☤Output & Input [cc/kg/h] N: 1-2

☤Neuro

☤Diet