PEDIA - Tachypnea (2)

8/10/2019 PEDIA - Tachypnea (2)

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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.


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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


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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


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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 .


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.


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.



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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


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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.


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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


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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


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(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


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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


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PRESCRIPTION:

Alvin Pasuquin, MD

Silliman University Medical Center

Name:________________________________ Age/Sex:______________

Address:___________________________ Date: ________________

___________________________

SIGNATURE

Alvin Pasuquin, MD


Name:________________________________ Age/Sex:______________

Address:___________________________ Date: ________________

___________________________

SIGNATURE

Arianne Rodriguez, MD


Name:________________________________ Age/Sex:______________

Address:_____________________________ Date: ________________

___________________________

SIGNATURE

Arianne Rodriguez, MD


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.


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PEDIA - Tachypnea (2)

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