Fevers (+NNP,Febrile Neutropaenia,) Diarrhoea/Vomiting/Constipation Wheezers

Significant fever: >38.5 x1 or >38.0 x2 Diarrhoea-check anal fissure, inflamm. Severity. High-risk asthma (ICU,last adm,steroids)
Travel [Link]. Fundoscopy before LP. Vomitting-excl post tussive. Poor feeds-excl ulcers Neb @ A&E? Response? Ppting factor?
Rash. Hands & feet. Mouth ulcers. >5/7=?Kawasaki Amt of feeds, PU amt, Activity Dx:< 2:Bronchiolitis(4661),ALTB/Bronchitis(4660)
Dx: Viral fever(0799),NNP(7784),PUO(7806), Dx: GE(0091),Rotavirus(0086),Gastritis(535), 2-4yr: Asthma(493), “1st-wheeze”, FB
Sepsis(0389),Viral rash(0579),UTI(5990) Colic(7890), Mouth ulcers(5289), Freq:<1/mth=IFEA,>1/mth=FEA,>1/wk=PEA
Advice: Fever helps body vs infxn. Brain dmg v IMS(075)[ fever,throat,LN,L+S+,Atypic L,LFT] Advice: Bronchiolitis peak D5. Wheeze  asthma.
rare. Paracet 30mins to work, then sponge. Side fx Kawasaki(4461)[fever,LN,pharynx,tongue,rash] Orders: FBC(fp) cm
of antipyretics. Further ix if fever persists. Pharyngitis/Tonsillitis(462) [>4ys, pain > urti s/s ] NPA [Bronchiolitis/URTI]
Orders: FBC(fp) cm Advice: hydration most impt. still eat after drip. CXR [only if severe/?pneumonia]
If septic: i/v line and FBC, CRP, Bld C/S, drink small amts frequently, any fluid (glucose, SaO2 stat/keep above 92-95%
Ur Dipstick/Feme/C/S. ribena, soya bean), diarrhoa washes germs out. kiv cap gas/electrolytes[K+- w/ freq neb]
NPA,Sputum C/S,CXR if URTI s/s Orders: Stools C/S, Rotavirus. FBC(fp) cm. 2-4 hourly TPR.
kiv ASOT,WWF,BFMP,Dengue sero i/v drip + U/E + Hypocount if poor feeding O2- I/N 1L/min/4L Mask/Puriton neb
Neonatal pyrexia or Febrile Neutropenia: add KCl once U/E back(K+ <4.5) & PU Assess inhaler technique. Asthma counselling.
6 wk – 3 mth w/ localizing signs & well child: AXR(supine) if ?IO. AXR(erect) if ?Perf Meds
FBC, CRP, kiv Blood C/S IMS: FBC/PBF, EBV sero, LFT.[Avoid amox/ampi] Asthma
Urine dipstick +/- Ufeme +/- Ur C/S kiv Thyroid,Ca+/Mg+,Hirsprungs,Fissure if NBO++ Neb 3-6hrly or ½-2hrly x3 (r/v after 3rd neb)
Sputum C/S, NPA, CXR [if URTI s/s] Meds: Abd pain: Infacol (<1 yr), MMT 2.5ml(1- Salbutamol 0.02ml/kg: N/S (total 2mls) @ freq abv
< 1 mth/no apparent source/Abs Neutrophil <500 5yr), 5ml(6-12yr) qds [Severe] ‘’ : Atrovent 0.5-1ml : ‘’ @ freq abv
Above plus: Urine C/S x2 [In-out if NPU by 2h.] Diarrhoea: Lactufort ½-1 sachet bd. [Old/severe] “Long” neb = 4 mls total (eg [Link])
i/v line w/: FBC, CRP, U/E, hypocount, Blood C/S Anal fissure: Lignocaine gel, triple care cream I/V indicated if severe or unable to feed. Call Reg!!
LP – 1)Fundoscopy, verbal consent, +/- sedate Constipation: 1-6 yr: microlax x1 (dulcolax=bullet) Aminophylline: 20kg/kg/24h in D/S(M) drip.
2)No LP if drowsy, focal S/S, or will tx anyway. <1 yr: Glycerine supp. Microlax 1.25ml Load 4mg/kg/30min only in HD & not on Theophy.
3)Document: sterile, landmark, no. of attempts, Then lactulose 0.5ml/kg bd Hydrocortisone 5mg/kg stat/4-6h i/v
traumatic tap, opening P(if done), child subseq well. Abd distension: Excl constipation, IO, Appendix then Prednisolone 2mg/kg/day PO
Normal opening P <10 (15 if older). Flush N/S if  Vomitting: Excl IO, ICP. Promethazine. ?Debridat MDI via babyhaler(<2 yr)/aerochamber(2-12yr)
5 tubes: Feme, C/S }send & trace. Ulcers: Lozenges difflam ½-1 tab 4-6h [>5yrs], 1)Ventolin MDI 1 puff/5kg (max 6 puff) 4-6hr
rbcwbc>500= Oragel [if ulcers easily accessible]. 2)Becotide 2-6 puff bd tail down to 1-2 puff bd
Latex Agglu, Enterovirus C/S, HSV} in fridge Tonsilitis: Pen V 5-10mg/kg or 250mg 6h po 3)Flixotide 50-100microgm bd [2&3 for FEA]
[Sent if Feme abN,, w/ HSV paired sera (plain tb)] Diet/Fluids Oral: Salbutamol 0.1mg/kg PO tds/qds [young kids]
4)Lie flat x6h, hourly TPR & BP x6h. kiv CLC. Oral: - Milk orders see below Theophylline (Neulin) 5mg/kg tds [severe]
5)Trace CSFeme w/i 2hours. - NBM(N+V ++), Clear feeds(Glucose, Soup), Non- Bronchiolitis
Meds milk feeds (Isomil, Milo), Soft diet DOC stat neb salbutamol (as abv) & r/v in ½ hour
Paracetamol 10mg/kg 4/6hr/prn PO[Not if < 3mths] I/V: [if drinking <30-50%/ dry >3%/ vomiting ++] [Responsive]Neb as above
Stat Ibuprofen(Brufen) 5mg/kg PO/Supp[if fever++/ > 3 mths: Normal Maint: (Y x wt)mls D/S(M)/24h [Non-responsive]Neb Puriton 40% or i/n O2 1L/min
hx feb fit. Max 6hrly, discourage if gastric, asthma] add (wt)mls 7.45% KCl over 24h [once U/E & PU] ALTB
NNP where Y=150(D4-1yr), 100(1-5yr), 75(>5yr) Dexamethasone [Link]/kg i/m x3 bd [A&E starts]
[Fundus]: Chloral 30mg/kg(max 1g). Mydriacyl. ½ drip= ½ vol abv/24h & ½ KCl[KCl < 4ml/kg/24h] Neb Adrenaline
[LP sedation]: Midazolam(Dormicum) 0.5mg/kg iv Dehydated: [Total vol=Replace(line 1) + Maint] Allergic rhinitis
[not if <3/12. Dilute in 4ml water for inj to get 1mg/ml] (% dehydration x Wt) mls D/S(R) } over Opticrom nd tds/Betmesol nd bd
[Antidote= Flumazenil (Resus trolley) – 0.01mg/kg bolus then ((Total vol/2)-amt abv) mls D/S(M) } 8h or Zyrtec 2.5mg(2-6yrs)/5-10mg(>6yrs) po qds
then 0.005mg/kg over 60s up to max of 0.05mg/kg or 2mg.
then (Total vol/2)mls D/S(M) over next 16h
[Empirical Antibiotics AFTER LP, Bld, Urine C/S]
add (wt)mls 7.45% KCl over 24h [once U/E & PU]
(1) i/v Ampicillin 50mg/kg 6h until CSF Feme
< 3 mths: “Combi-drip”
normal then 25mg/kg 6h. (All ages)
D5% ___mls/24h + (wtx0.6)mls 20% NaCl/24h
(2)i/v Gentamycin 2mg/kg 8h (age < 1/12)
Resusitation: 10mls/kg N/S bolus/over 15mins. Not
or i/v Ceftriaxone 50mg/kg 12h (age >3/12)
if vomiting because ?cerebral lesion.
(3)i/v Vancomycin 15mg/kg 6h (>6/12 &?S Pneum)
Fitters UTI (5990) Coughers
Age. Feb fit 18mth-5yrs. UTI S/S. UTI risk factors. hx of Ab tx. post tussive vomiting?
Fever,Head injury,Prev fits,Preictal,Meds Adv: Need to excl underlying cause, esp if young. Too breathless to feed?
Duration,GTC/eyes/mouth,bowels/urine Orders: i/v plug, FBC,U/E/Cr,Bld C/S Blood in sputum=?Mallory-weiss
Postictal drowsy(2-3h = normal), paralysis Ufeme(a&e)(TW>1000), Urine C/S x 2 (kiv in-out). Dx: URTI(4659), Pneumoni(482), Bronchopn(485),
PE:Fundus,neck,neurocut stig +/- pre & post Genta lvls (3rddose)(4th if 3rd at night) Mycoplasma(esp 5+yrs)(483), Pertussus
Dx: FebFit(7803),Epilepsy(3459),GER(5301), if young & prolonged tx (eg >3/7)(ask MO/reg) Advice: cough clears [Link]/vomit/swallow
NNSeizure(7790), Meningitis(viral)(3217) Repeat Ufeme & C/S before discharge. and BO out. bisolvon increases cough. How/when
D/C Summary: include ppting cause: eg Viral Fever U/S kidney (non-urgent). Outpt MCU/DMSA. obtain NPA/sputum.
Advice:First aid:Lie lateral, nothing in mouth. See Meds: Orders
Dr if >5mins, no fever, not GTC, Todd’s. 30% recur Start ab only after 2nd Ur C/S up. (1st C/S if toxic) NPA [RSV] }done early morning
this fever or next. Same risk of epilepsy as other Gentamycin 2mg/kg/ 8h i/v once ur C/S up. Sputum C/S }before first feed
kids. No brain dmg. Give fever control advice. (1)then Cephalexin 15mg/kg 8h po once C/S back kiv NPA for Chlamydia IF [Neonates][3214960]
Orders then Cephalexin 7.5mg/kg on po until TCU FBC (fp) cm
(1)U/E/Ca+/PO4 or (2)then Bactrim 4mg/kg 12h po[not if G6PD def] Mycoplasma serology [if age>4,CXR diffuse opac]
(2)Hypocount then Bactrim 2mg/kg on po until TCU [trace:3214941, results: Tue,Thu >4pm, Sat >1pm]
(3)Antiepileptic lvls May start oral bactrim/cephalexin if >2yrs & well. Mantoux: 10U(1ml) intradermal. Read at 72h.
(4)Ix as for ppting factor Give “normal” dose 1/7 before MCU till 1/7 after. CXR (PA) [kiv lateral]
Fit chart Meds
Tepid sponging if TC > 38.5 [Febrile Fit] Antibiotics: Oral: <5yrs=1st 2. >5yrs=last 2.
Meds 1st line listed 1st. Try 2nd line ab if no fx w/ GP’s Ab.
Stat: Chloral 30mg/kg PO [If can’t do fundoscopy] Amoxycillin 16.7mg/kg 8h PO [Pneumococcus]
Stat: Mydriacyl 1 drop each eye, to r/v 15mins after Augmentin 25mg/kg 12h PO [Lobar pneum]
[Do fundoscopy 15mns after. No need if can see] Erythromycin 12.5mg/kg 6h PO [only Mycoplasma]
Paracetamol 10mg/kg 4-6 hrly PO [If febrile] Clarithromycin(Klacid) 7.5mg/kg 12hPO[mycoplas]
[Continue patient’s epileptic meds] I/V: If large patch/v sick. No i/v Erythro/Clarithro
Fit > 5 mins: [Status protocol: Blue book pg 27] Ampicillin 25mg/kg 6h/ bolus
Lie lateral. O2. Nurse to suck, Get help(not code) Augmentin 25mg/kg 12h i/v microdrip
Diazepam 2.5mg(<10kg)/5mg(>10kg) rectal stat Symptomatic
i/v plug. 1 fbc + 2 plain. hypocount. Creps: Bisolvon (Age in Yrs max8)mg tds (cheaper)
i/v diazepam 0.25mg/kg(max 10mg) @ 1mg/min. or Flumacil 50mg(<2yr)-100-200mg(>6yr) bd/tds
rpt x2 if needed. kiv phenytoin then phenobarb. Runny nose: Iliadin nd: 0.01%(<1 yr), 0.025%(1-2),
Talk to parents once help takes over. 0.05%(>2yrs), tds, max 5/7
Meningitis: Cough/RN with no creps (only age >6mth):
-see NNP workup abv- Promethazine 5mg(2-5yr)-10mg(5-10yr) bd-qds
or Chlorpheniramine 0.1mg/kg tds-qds
Cardiac Catheterization NNJ (7740) (Blue baby bk pg 61) DM(2500)/Hypoglycemia. DM p33. Fluids p22.
Copy adm form. Recent URTI/ CI to op. Exact day of [Link] level.T4/TSH/G6PD(health bk) Usu dose. Last f/up & readings. Intercurrent illness.
Orders Type of milk. Feeding well? PU & BO color. Adv:DKA die coz cerebral odema/K+ , not Gluc 
CXR (before 4pm, when cardio team does round) Mom & Dad bld gp. Antenatal hx. Fhx bld disease. Aim=tx acidosis & hydration. Never stop insulin.
ECG Risk factors for kernic: baby bk p62. Orders DKA: pH<7.3. HCO3 < 15.
i/v plug, FBC, U/E, PT/PTT, GXM (?1 unit) PE: Cephalohaem, LoSo, Moro’s, umbilicus. Hrly parm. Strict IO. [Link] except ice.
Fill OT chit & fax. Adv: Peaks D4-5. D1 NNJ pathological. To ICU if <5yr/dry ++/GCS .
Inform cardio reg/mo of location. Orders i/v: U/E. ABG/Venous gas. FBC, ESR.  bld C/S.
Consent taken by cardio. Mom’s ABO+Antibody, w/ Baby’s ABO+DCT. Insulin, C-peptide, islet cell Ab, GAD if newly dx.
Anaest usu order feeds.[>4mth: last milk feed 6h [2 tubes, 2 forms, bottom right of forms, 1 bag] Hourly MicroE & h/c. Chart results.
b4] [<4mth: milk feed 4h & clear feed 2h before] Baby’s FBC+Retic+PBF.(FBC), Total bil(Plain) Large bore hep plug for 2-4 hourly U/E.
Meds Consent, plug & 1 plain for GXM if near exchange. Ufeme. Urine ketostick 2-4hrly till –ve then 8hrly.
Check anaest notes. Emla if anaest setting plug. If high (“prepare” level): Repeat SB 6h. Fasting lipid & thyroid fn. HbA1c(EDTA)
Post op: i/v + gxm tube. Full drip + feeds. Take consent. Non-DKA: Gluc, ketonuria, pH >7.3, HCO3 > 15
Check pulses, site for bleeding. Check if for hep. 2x vol ex = 80ml/kg fresh bld. match mom & baby 5/7 point BSL.[pre meal+10pm+2am=5pt.+post=7pt]
Case notes missing: may have gone for cardiac conf. OAE (outpatient). Abv Ix.
NAI (9955) Rebound/prolonged NNJ: Ufeme, LFT, Thyroid Fn Meds A1)10ml/kg N/S over 15min if [Link] repeat
 Urine C/S, Urine for [R] subst, U/S HBS. then (Deficit(%dry x wt) + Maint) N/S over 12h.
Orders G6PD: Need to stay for 2 weeks. Rephoto if > 220. add 4ml/kg 7.45% K+ unless NPU. Aim K+=4-5.
Fundoscopy
FBC, PT/PTT(if bruise). Skeletal survey (Xrays)
Meds If Na > 150 rehydrate abv over 18h. Total over 72h.
Cord Spirit x1 2)i/v Humulin R/Actrapid 0.1U/kg/h..
Refer MSW
Add 10-15% to feeds during phototx. 3)if pH < 7.1, kiv Bicarb after asking senior.
O&G clinic(rape kit) if sexual.
Bfeeding: ok < 300. stop but express if higher B)After BSL=12-15, & Na+ not falling > 2mM/Hr.
Notes: 1)change N/S to D/S(A) 5%
Cannot discharge until MSW & Police ok.
Fill up SB chart
N/S&D/S(A)[0.9%=154]D/S(R)[.45%]D/S(M) [.23%].
HO can write note to MSW “Fit for discharge” Category Off Prepare Exchange
[% of Na+ g, free water g][Pure water=>cerebral edema]
Only Reg can write medical report. High risk 190 306 2)i/v insulin 0.05U/kg/h. Min of 0.01U/kg/h.
Fill name of Reg on call(not of ward) in case notes. <120h 220 306 340 C/Non-DKA)24h+,alert,pH>7.3,hCO3>15,BSL<12
Dengue Fever (0651) >120h 220 340 425 1)s/c insulin 0.25U/kg/6h (0.125 if < 6yrs) 1-2hr
Incubation 7 days. Nose,gum,GI,PU bleed. No. of lights: ask Wd56 nurses. Double blue: >280. before meal. Stop i/v insulin only ½hr after s/c.
Sch loc/Travel hx. Heel prick 2)start feeds. DM diet = 1000kcal+100/years old
Orders 2 capillary tubes (cotton ended) from closed box. D/Incidental DM)
(1)i/v plug Prick lat/med side. Avoid bone. Usu dosage=1U/kg/d. 1-2U/kg/d if puberty/ill.
(2)fbc, Lft, pt/ptt, Dengue sero, GXM(keep),bfmp. Send w/ tongue depressor/sandwiched btwn sticker. 2/9 Humulin R/Actrapid(short)/Humalog(v short)
[NB: Sero –ve < 4/7, IgG +ve after 7/7][Plt  once fever ] + 4/9 of total Humulin N/Monotard (long) om.
[Watch for effusion, alb , Hct , abd pain, wide pulse P] 2/9 long + 1/9 short on. [if tds, short ompre-lunch]
(3)Ufeme, Stool for OB. if high, excl snack, running around, rebound, then
CRIB/RIB. Hourly TPR. Soft diet. Notify. give sliding scale(in IMR) or h/c>15=(10% of daily
Hourly BP x6 then 4hrly. Keep SBP > 100 (14yr) dose)-1, >20=10% of daily dose. (NOT ½ of h/c!)
Meds if low, don’t omit insulin. Give dose+snack.
Platelets if < 20-30k => (1)Send GXM, (2)call BTS Hypoglycemia(2512):h/c < 3.0. [Pg 64]
MO 2238793/97342721 w/ bld gp & plt lvl & units 2-4mls D10%/kg at 1-2ml/min. h/c 30min later.
req, (3)once approved call KK lab.
Nephrotic Syndrome (5819) Otitis Media(3829)/Pharyngitis(462) Cervical Lymphadenitis(683)/Cellulitis(6829)
= Odema + Proteinuria + Alb  + Lipids .
Coagulopathy. Recent viral infection.
[NB: usu steroid responsive, good prognosis]
d/dx:nephritic syn (haematuria, hypt, post-strept)
Orders
i/v plug if hypotensive.
Fbc, Esr, lft, u/e/cr, fasting cholesterol/lipids,
C3/C4, ASOT. Do all early cm if stable.
Ufeme. Urine Alb:Cr ratio. (Early am better)
Urine C/S. 24h Urine Total Protein. CXR.
Daily albustix.
Measure height (for BSA)
Nephrotic chart. Strict IO. 4 hourly BP.
DOC/?low salt diet
Meds
Prednisolone 60mg/m2 om. Tail later.
kiv lasix only with albumin.

Misc Info: Misc Meds Useful phone numbers kk mainln 62934094

HX/PE Ear:Waxsol 1-3 drops L/R/@ ear on/bd x 3/7 Lab reception 1352 KK DID 6394xxxx
1)BP(usu calf) (“BP when asleep” if crying ++) Chloramphenicol ear drops 2-3 drop bd x 5/7 for Tube request 1354
otitis externa. Exclude perf tm. Biochem 1383 SGH trace 63214950/2
2)Ears, Throat Blood bank 1376 ASOT 63214920
3)Fundus (Fit,Vomit,pre-LP)(Chloral + Mydriacil) Eye: n/s or chloramphenicol eye drops 1/1 ?4hrly Cytogenetics 1392 Mycoplasma 63214941
Ix/Treatment Skin/Cream: Calamine lotion for itchy rash. DNA 1396 RAST test 62357522
1)Diet must be ordered in IMR – even DOC Hydrocortisone 1% for nappy rash/eczema. Haemato 1373 TB LCR 62223191
Betnovate cream ¼ str (6-12 yrs) for eczema Histology 1380
2)FBC(fp) cm available. Microb 1389 BTS Office 62238793
3)Urine dipstick kiv UFeme GMS to extravasation site BTS MO hp 97342721
4)Cap bld: ABG,MicroE [open end cap tube, go to Tetracycline 3% ointment om-tds - supf infection. Wards 1xx0
ICU] Chlorhexidine 0.05%/0.1% lotion for skin A&E 1919 Teo Siak 62696928
Diet orders: 1)NBM(must have drip), sips of water, cleansing. Clinic: ENT 1130 Hong (Metab) 696084566
Clinic: Eye 1930
clear feeds, non-milk feeds/diet(GE)(incl soy, Sedation: Chloral/Midazolam. See Fever/NNP. Clinic J, Rm 1 2065 CDC 62562521
milo), ½-strength milk(>6mth + GE),soft diet(low Coding 2615 CGH 67888833
plt), doc EEG (Linda) 2139 IMH 63850411
Milk orders: 5day-3mth:F/S(M) [wt x 20mls] x8. Lounge 3579Y 2059 NSC 62534455
OT reception 2228 NUH 67795555
3-6mth: F/S(M) [wt x 25mls] x6. Porter 1347 SGH 62223322
> 6mth: Follow-on milk + weaning diet. Xray/DI 2253 TBCU 62569410
> 1year=F/C milk + DOC. TTSH 62566011
Night Pharmcy 2466