OSCE Reviewer

2014 Edition ORAL REVALIDA REVIEWER

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AACCUUTTEE AAPPPPEENNDDIICCIITTIISS SSUURRGGEERRYY

Etiology o E.coli & Bacteroides fragilis

Clinical Manifestations o Abdominal pain cramping, severe, steady at the lower epigastric, within 4-6hrs localizes at RLQ (may vary from different

locations of pain of the appendix) o Anorexia o Vomiting

Signs: o Direct and Indirect tenderness o Rovsing's signpain in the RLQ when palpatory pressure is exerted in the LLQ (indicates site of peritoneal irritation) o Psoas sign have patient lay on the left side as the examiner slowly extends the right thigh, thus stretching the iliopsoas

muscle (indicates an irritative focus proximal to that muscle) o Obturator sign passive internal rotation of the flexed right thigh with the patient supine

Laboratory Findings: o CBC mild leukocytsis, 10,000-18,000 cells/mm3 (acute uncomplicated AP) o Urinalysis to rule out UTI

Imaging Studies o Barium Enema if barium fills the appendix, it is excluded o Plain films o Chest radiograph if referred pain for right lower lobe pneumonic process o CT scan has minimal advantage (dye in the presence of vomiting) o Laparoscopy in lower abdominal complaints; in differentiating gynecologic problem

The Avogardo Scale for Diagnosing Appendicitis

Manifestations Value

Symptoms

Migration of pain 1

Anorexia 1

Nausea/vomiting 1

Signs

RLQ tenderness 2

Rebound 1

Elevated temperature 1

Laboratory values Leukocytosis 2

Left shift 1

Total: 10

o Note: Rupture should be suspected in the presence of elevated temperature (>39C) and a WBC of >18,000cells/mm3

Differential Diagnosis: o Acute Mesenteric Adenitis URTI is present, pain is diffuse, tenderness is not sharply localized as in AP; voluntary guarding

and diarrhea are present; laboratory values are normal o Pelvic Inflammatory Disease right tube inflammation may mimic AP; nausea and vomiting are present in 50% of PID o Ovarian Cyst ruptured right sided cyst may have similar manifestations of AP, patients develop RLQ pain, tenderness,

rebound, fever and leukocytosis o Ruptured Ectopic Pregnancy rupture of right tubal and ovarian pregnancies can mimic AP, development of RLQ pain may

be the first symptoms, hematorcit falls due to internal abdominal hemorrhage o Urinary Tract Infection Acute pyelonephritis, on the right side particularly, may mimic a retroileal acute appendicitis.

Chills, right costovertebral angle tenderness, pyuria, and bacteriuria are usually sufficient to make the diagnosis.

o Peptic Ulcer Disease Perforated peptic ulcer closely simulates appendicitis if the spilled gastroduodenal contents gravitate down the right gutter to the cecal area and if the perforation spontaneously seals, minimizing upper abdominal findings

Treatment Plan: o For possible operation, Adequate hydration should be ensured; electrolyte abnormalities corrected; and pre-existing

cardiac, pulmonary, and renal conditions should be addressed o Administer antibiotics to all patients with suspected appendicitis. If simple acute appendicitis is encountered, there is no

benefit in extending antibiotic coverage beyond 24 hours. If perforated or gangrenous appendicitis is found, antibiotics are continued until the patient is afebrile and has a normal white blood cell count.

o Open Appendectomy McBurney (oblique) or Rocky-Davis (transverse) incision

o Laparoscopic Appendectomy Under general anesthesia, use of 3-4 ports Advantages: decreased operative pain, shorter duration of hospital stay, good wound healing, minimal incision


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AACCUUTTEE aanndd CCHHRROONNIICC CCHHOOLLEECCYYSSTTIITTIISS SSUURRGGEERRYY

ACUTE CHOLECYSTITIS

Clinical Manifestations: o RUQ or epigastric pain that may radiate to the right upper part of the back or the

interscapular area o It is usually more severe than the pain associated with uncomplicated biliary colic o Fever, anorexia, nausea, vomiting are present; patient is reluctant to move, as the

inflammatory process affects the parietal peritoneum. o On PE: focal tenderness and guarding at the RUQ; a mass, the gallbladder and adherent

omentum, is occasionally palpable; however, guarding may prevent this. o Murphy's sign, an inspiratory arrest with deep palpation in the right subcostal area, is

characteristic of acute cholecystitis.

Laboratory Findings: o mild to moderate leukocytosis (12,000 to 15,000 cells/mm

3); but some patients may have a normal WBC

o high WBC (>20,000) is suggestive of a complicated form of cholecystitis such as gangrenous cholecystitis, perforation, or associated cholangitis

o Serum liver chemistries are usually normal, but a mild elevation of serum bilirubin, < 4 mg/mL, may be present along with mild elevation of alkaline phosphatase, transaminases, and amylase.

o Severe jaundice is suggestive of common bile duct stones or obstruction of the bile ducts by severe pericholecystic inflammation secondary to impaction of a stone in the infundibulum of the gallbladder that mechanically obstructs the bile duct (Mirizzi's syndrome).

Differential Diagnosis: o peptic ulcer with or without perforation, pancreatitis, appendicitis, hepatitis, pleuritis

CHRONIC CHOLECYSTITIS (Biliary Colic)

Clinical Manifestations: o Recurrent attacks of pain, episodic o Pain is constant and increases in severity over the first half hour or so, typically lasts 1-5 hours. It is located in the

epigastrium or right upper quadrant and frequently radiates to the right upper back or between the scapula o Pain is occurs typically during the night or after a fatty meal o Often associated with nausea and vomiting o On PE: RUQ tenderness during an episode of pain

Laboratory Findings: o WBC count and liver function tests are usually normal in uncomplicated gallstones o Ultrasound standard diagnostic test for gallstones o CT scans show extrahepatic biliary tree status and adjacent structures o Endoscopic retrograde cholangiography (ERCP) and Endoscopic ultrasound rarely needed for uncomplicated gallstones

but for the stones in the common bile duct, in particular when associated with obstructive jaundice, cholangitis or gallstone pancreatitis.

Management: o For symptomatic gallstones, elective laparoscopic cholecystectomy is the procedure of choice. o Diabetic patients with symptomatic gallstones should undergo cholecystectomy promptly as they are prone to develop

acute cholecystitis o In pregnant women, elective laparoscopic cholecystectomy is allowed during the 2

nd trimester

CCHHOOLLEEDDOOCCHHOOLLIITTHHIIAASSIISS SSUURRGGEERRYY

- Common bile duct stones - RUQ tenderness, nausea, vomiting - Symptoms such as pain and jaundice may be intermittent

Imaging Studies: o Magnatic Resonance Cholangiography (MRC) provides excellent anatomic detail and has a sensitivity and specificity of 95

and 89%, respectively o Ultrasonography o Endoscopic cholangiography is the gold standard for diagnosing common bile duct stones

Management: o Endoscopic cholangiogram o Sphincterotomy and ductal clearance of stones followed by laparoscopic cholecystectomy

Charcots Triad: 1. Fever 2. RUQ Pain 3. Jaundice

Reynolds Pentad: 1. Fever 2. RUQ Pain 3. Jaundice 4. Shock 5. Changes in

sensorium


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MMYYOOCCAARRDDIIAALL IINNFFAARRCCTTIIOONN ((SSTT--SSEEGGMMEENNTT EELLEEVVAATTIIOONN)) MMEEDDIICCIINNEE

- May precipitate various physical exercise, emotional stress or a medical or surgical illness - Chest pain deep and visceral, heavy, squeezing and crushing - Similar to discomfort of angina pectoris, occurs at rest but more severe, lasts longer - Accompanied by weakness, sweating, nausea and vomiting, anxiety and a sense of impending doom, pallor, substernal chest pain of

more >30 minutes - Pericardial friction rub is usually heard

Laboratory Findings: o ECG ST elevation, Q wave

Transmural MI is present if the ECG demonstrates Q wave and loss of K waves Nontransmural MI is considered if ECG shows only transient ST segment and T wave changes

o Serum Cardiac Biomarkers Cardiac-specific troponin-T and troponin-I are biochemical markers which usually rise in patients with STEMI not

seen in healthy individuals. o MB isoenzymes of CK more specific but not diagnostic of a myocardial rather than a skeletal muscle source of CKMB o Non-specific reaction to myocardial injury is associated with PMN leukocytosis, WBC often reaches 12,00-15,00; ESR rises

more slowly than WBC o 2D-Echo cardiac imaging provides abnormalities of wall motion o High-resolution MRI contrast agent (gadolinium) is administered, and images are obtained after a 10-minute delay; a

bright contrast appears in areas of infarction

Differential Diagnosis: o Acute Pericarditis

Chest discomfort radiating from trapezius is not seen in STEMI o Pulmonary Embolism

STEMI may present with sudden onset of breathlessness that may progress to pulmonary edema and embolism

Initial Management: o Pre-hospital Care

Patient may manifest arrhythmias or mechanical complications (pump failure) May cause sudden ventricular fibrillation

o Management in Emergency Department Aspirin in suspected STEMI causes inhibitin of cyclooxygenase I followed by reduction of thromboxane A2 If there is hypoxemia, O2 administration with nasal cannula or face mask at 2-4L/min

o Control of Chest Discomfort Nitroglycerine (sublingual) up to 3 doses of 0.4mg at about 5mins interval should be administered, or IV

nitroglycerine if with ongoing ST segment ischemia shifts. IV -blockers diminishes O2 demand

Hospital Phase Management: o Activity ambulation should be encouraged if without complication o Diet diet rich in potassium, magnesium and fiber but not sodium o Bowel use of stool softener o Sedation diazepam or lorazepam (adverse effect: delirium)

Pharmacotherapy: o Antithrombotic Agents its role is to maintain patency of infarct related artery and reduce thrombosis that can lead to

embolization Clopidogrel reduces risk of clinical events, reinfarction, stroke and death Heparin + Aspirin may help about 6 liver per 1000 patients

o Beta-adrenergic blocker improves the myocardium O2 demand, reduces pain, reduces infarct site, reduces arrhythmias o Inhibition of RAAS reduces mortality rate; reduction in ventricular remodeling with subsequent reduction in the risk of

CHF, indolent to ACE inhibitors

NNOORRMMAALL SSPPOONNTTAANNEEOOUUSS DDEELLIIVVEERRYY ((NNSSDD)) OOBB--GGYYNN

1. Secure consent for procedure 2. Transfer patient to OR 3. Wear cap and mask 4. Place patient in dorsal lithotomy position 5. Asepsis, antiseptic technique 6. Straight catheterization 7. IE (fully dilated cervix, fully effaced, cephalic, intact BOW, station?) 8. Apply sterile drapes 9. Infuse 5cc lidocaine at right mediolateral (RML) wall of vagina, aspirate before infusing


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10. Do RML episiotomy 11. Once babys head is out, rotate gently then pull upward and downward then slide head on fetal back and hold fetal legs 12. Clamp the cord, place one clamp 2cms above the umbilicus, another 13. Deliver placenta using Ritgens maneuver 14. Once placenta is out, inspect cotyledon 15. Give oxytocin, check BP first 16. Do episiorapphy 17. Do final IE 18. Final asepsis and antisepsis 19. Monitor VS q15 for 1 hour then q30 for the next hour, and then q4 thereafter

DDEENNGGUUEE HHEEMMOORRRRHHAAGGIICC FFEEVVEERR PPEEDDIIAATTRRIICCSS

Clinical Manifestations: o Fever of 2-7 days o Headache, muscle and joint pain o Nausea and vomiting o Rashes (Hermans rash)

Laboratory Findings: o Low platelet count (20% from baseline) o Low albumin o Pleural or other effusions

Dengue Shock Syndrome o 4 criteria for DHF, plus:

Evidence of circulatory failure Rapid and/or weak pulse Narrow pulse pressure Cold clammy skin

o Shock

Differential Diagnosis: o Typhoid fever, measles, rubella

Management: o Rehydration management o Palliative treatment, antipyretics o Monitor vital signs, hematocrit, platelet count, level of consciousness

PPCCAAPP PPEEDDIIAATTRRIICC CCOOMMMMUUNNIITTYY AACCQQUUIIRREEDD PPNNEEUUMMOONNIIAA PPEEDDIIAATTRRIICCSS

Clinical Manifestations: o 3mos-5yrs fever, tachypnea and chest indrawing o 5-12yrs fever, tachypnea, crackles o 12yrs and above fever, tachypnea, tachycardia, at least one abnormal chest finding of diminished breath sounds,

rhonchi, crackles or wheezes

Classification:

Variables PCAP-A

Minimal Risk PCAP-B

Low Risk PCAP-C

Moderate Risk PCAP-D

High Risk

Comorbid illness None Present Present Present

Compliant caregiver Yes Yes No No

Ability to follow-up Possible Possible Not possible Not possible

(+)Dehydration None Mild Moderate Severe

Ability to feed Able Able Unable Unable

Age >11 mos >11 mos 60/min >70/min

Respiratory rate, age 1-5 yrs 40/min >40/min 50/min >50/min

Respiratory rate, age >5 yrs 30/min >30/min 35/min >35/min


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Signs of Respiratory Failure:

PCAP-A PCAP-B PCAP-C PCAP-D

Retraction None None Intercostals/subcostal Supraclavicular

Head bobbing None None Present Present

Cyanosis None None Present Present

Grunting None None None Present

Apnea None None None Present

Sensorium Awake Awake Irritable Lethargic/Stupurous/Comatose

Respiratory Complications None None Present Present

Action Plan OPD OPD Admit to regular ward Admit to PICU

Diagnostics: o PCAP A & B Clinical o PCAP C & D:

CXR PA-Lateral WBC count Pleural fluid C/S Blood C/S for PCAP-D Tracheal aspirate upon initial intubation Blood gas and pulse oximetry Sputum C/S for older children

Treatment: o For PCAP A or B DOC: oral amoxicillin (40-50mg/kg/day in 3 divided doses) o For PCAP C and D:

(+)HiB vaccine pen G (100,000u/kg/day in q4) (-)Hib vaccine IV ampicillin (100mg/kg/day q4)

SSEEPPSSIISS NNEEOONNAATTOORRUUMM PPEEDDIIAATTRRIICCSS

Characteristics: o temperature instability, hypotension, poor perfusion with pallor and mottling of skin, metabolic acidosis, tachycardia or

bradycardia, apnea, respiratory distress, grunting, cyanosis, irritability, lethargy, seizures, feeding intolerance, abdominal distention, jaundice, petechiae, purpura, bleeding.

Initial S/S in Newborn Infants: o General fever, temperature instability, poorly feeding, edema o Gastrointestinal abdominal distention, vomiting, diarrhea, hepatomegaly o Respiratory apnea, dyspnea, tachypnea, retractions, flaring, grunting, cyanosis o Cardiovascular pallor, mottling, cold, clammy skin, tachycardia, hypotension, bradycardia o Renal oliguria o CNS irritability, lethargy, tremors, seizure, hyperreflexia, hypotonia, abnormal Moro reflex, irregular respirations, bulging

fontanels, high pitched cry o Hematologic system jaundice, splenomegaly, pallor, petechiae, purpura, bleeding

Differential Diagnosis: o Respiratory Distress Syndrome o Aspiration Pneumonia amniotic fluid, meconium or gastric content

Laboratory Studies: o Blood and CSF culture o Antigen detection (urine, CSF) o Autopsy

Evidence of Inflammation: o Leukocytosis, immature/total neutrophil count ratio o Acute-phase reactions; ESR, CRP o Cytokines, interleukins o Pleocytosis in CSF

Treatment: o Initial treatment with ampicillin and aminoglycoside (gentamicin) o Nosocomial infections methicillin or nafcillin for S.aureus (antistaphylococcal drugs, or) vancomycin for CONS or MRSA o Pseudomonas infections piperacillin, ticarcillin, ceftazidine or an aminoglycoside o Antifungal therapy in infants with very low birth weight o Most gram(-) enteric bacteria ampicillin and an aminoglycoside or 3

rd gen cephalosporin (Cefotaxime or Ceftazidine)

o Enterococci penicillin (ampicillin or piperacillin) + an aminoglycoside o Anaerobic infections clindamycin or metronidazole o GBS penicillin


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TTYYPPHHOOIIDD FFEEVVEERR PPEEDDIIAATTRRIICCSS // FFAAMMIILLYY MMEEDDIICCIINNEE

Salmonella typhi (etiologic agent)

Acquired through contaminated foods and water or close contact with infected person

Clinical Manifestations: o High grade fever (39-40C) o Headache o Rose spots on chest and abdomen o Cough, epistaxis o Abdominal pain, with either constipation or diarrhea o Weakness and fatigue o Severely ill patients may experience delirium, shock, and intestinal hemorrhage

Diagnosis: o Culture blood, urine, stool

1st week blood (+) 40% in the first week 2nd week urine and stool, highly (+) Bone marrow single most sensitive test, (+) in 85-90%, less sensitive if influenced by prior antimicrobial therapy

o Typhi Dot IgM IgG Interpretation (+) (-) Acute infection (+) (+) Recent infection (-) (+) Equivocal

Management: o Susceptible strains 14 day-treatment

Chloramphanicol 50-60mg/kg/day in 4 divided doses, or Cotrimoxazole 800/160 1 tab BID, or Ampicillin or Amoxicillin 100mg/kg/day in 3-4 divided doses

o Resistant strains Ceftriaxone, 7-10 days, 3gm TIV, or Ciprofloxacin (507 days) 500mg tab BID

o Chronic Carrier High dose IV ampicillin or oral amoxicillin with probenecid for 4-6 weeks For adult carriers: Ciprofloxacin

MMEENNIINNGGIITTIISS PPEEDDIIAATTRRIICCSS

Etiology: o First 2 months groups B and D Streptococci, Gram (-) enteric bacilli, and Listeria monocytogenes o 2 months to 12yrs S.pneumoniae, N.meningitidis, H.influenza type B

Epidemiology: o Close contact (e.g. household, daycare centers, military barracks), crowding, poverty, male gender

Transmission: o Person to person contact through respiratory tract secretions or droplets

Clinical Manifestations: o Several days of fever o Upper GI or respiratory symptoms o Meningeal irritation nuchal rigidity, back pain, Kernig sign, Brudzinski sign o Headache, vomiting, cranial nerve neuropathies (10-20%) o Seizures due to cerebritis, infarction or electrolyte disturbances (20-30%)

Diagnosis: o CSF analysis o CBC, platelet count, blood C/S, ESR, ABG o Na, K, BUN, Creatinine, RBS o Urinalysis, Urine G/S, C/S o Stool, throat, nasal C/S o Viral cultures (Coxsakie, Echinococcus, Mumps, EBV, HSV, CMV, Arbovirus) o CXR, ECG, CT scan, MRI, EEG


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Cerebrospinal Fluid Analysis

Normal

Acute Bacterial Meningitis

Viral Meningitis

TB Meningitis

Fungal Meningitis

Anaerobic Meningitis

Pressure (mmH2O) 50-80 Usually high

(100-300) Normal or

slightly high Usually

elevated Usually

elevated Elevated

Leukocytes (mm3)

75, 75% lymphocytes

100 to 10,000 or more;

usually 300-2000 PMN

Rarely >1000 cells

10-500, PMN early, then

lymphocytes predominates in most cases

5-50, PMN early but

mononuclear cells

predominate in most cases

1000-10,000 or more, PMN

predominates

CHON (mg/dL) 20-45 100-500 30-100 100-3000 25-500 50-500

Glucose (mg/dL) >50


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2. 75gram oral glucose tolerance test - Normal value:


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Clinical Manifestations: Symptoms (Classic Triad) Signs

Abdominal pain, colicky Wiggling tenderness (most common sign) Amenorrhea Uterus smaller than AOG Vaginal bleeding hemoperitoneum

Diagnosis: o CBC hemoglobin, hematocrit, and leukocyte count o Lower HCG and progesterone levels o Ultrasound diagnostic criteria:

1. Detection of adnexal mass 2. Absence of gestational sac using transvaginal UTZ when HCG >2,500 mIU/mL at 5-6wks 3. Intrauterine gestational sac rules out an ectopic pregnancy except in a heterotropic pregnancy

Management: o Unruptured Eccyesis

1. Medical management a. Methotrexate b. RU-486 competes for progesterone binding sites

2. Surgical management partial salpingectomy, salpingostomy, salpingotomy o Ruptured Eccyesis (primarily surgical)

1. Radical a. Hysterectomy b. Total salpingectomy with our without oophorectomy

2. Conservative segmental resection

AABBOORRTTIIOONN OOBB--GGYYNN

- termination of pregnancy prior to 20 weeks' gestation or with a fetus born weighing less than 500g

Clinical Manifestations: o Vaginal bleeding o Passage of meaty tissue o Foul-smelling uterine discharge o Fever o Profuse sweating o Moderate tachycardia

Diagnostics: o CBC, UA, Urine chemistry, Electrolytes, Uterine discharge G/S, C/S o Blood culture, CXR, blood chem. o Close monitoring of VS and UO

Management: o Blood transfusion with 7 u PRBC o Antimicrobial therapy ampicillin + gentamicin + clincamycin/metronidazole (TIV) o Completion curettage prompt evacuation of products of conception as follows:

1. Patient placed in dorsal lithotomy position under spinal anesthesia 2. Asepsis/antisepsis 3. Sterile drapes applied 4. Straight catheterization and internal examination posterior vaginal retractor applied to visualize the cervix 5. Anterior lip of the cervix grasped using tenaculum forcep 6. Evacuation of products of conception using ovum forcep 7. Initial hysterometry 8. Curettage done using blunt followed by sharp curette until frothy, gritty and bright red blood obtained 9. Final hysterometry

Types of Abortion

Uterine contraction

Bleeding Cervical dilatation

Uterine size VS gestation

BOW Others

Threatened +/- +/- Closed Compatible Intact (+) FHT

Imminent ++ + Open Compatible Intact (+)FHT

Inevitable +++ ++ Open Incompatible Ruptured (+)FHT

Incomplete +/- ++ Open Incompatible Not appreciated Meaty tissue

Complete - +/- Closed Incompatible Not appreciated Absent of signs of preg.

Missed - Spotting Closed Incompatible Not appreciated (-) FHT

Habitual +/- + Open Compatible +/- (+) FHT


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BBRROONNCCHHIIAALL AASSTTHHMMAA MMEEDDIICCIINNEE && PPEEDDIIAATTRRIICCSS

- Pathophysiologic Hallmark: reduction in airway diameter - Hypoxia - universal finding during acute exacerbations

Classic Symptom Triad: (1) Wheezing, (2) Dyspnea, (3) Cough

Typical Acute Attack: o Often occurs at night o With occupational asthma, attacks may occur at work or after work o Patients experience a sense of constriction in the chest, often with a nonproductive cough o Respiration becomes audibly harsh o Wheezing is first noted during expiration and then with inspiration as well o Expiration becomes prolonged o Mucus plugging and impending suffocation o Accessory muscles become visibly active, and a paradoxical pulse often develops o The end of an episode is frequently marked by a cough that produces thick, stringy mucus

4 Major Classification of Asthma Severity by Clinical Features o Mild, intermittent

- Symptoms occur 2 or fewer times per week. - Asymptomatic between attacks - Exacerbations are brief (hours to at most days) and of varying intensity. - Nocturnal symptoms are rare, less than twice a month. - The FEV1 is >80% predicted during episodes.

o Mild, persistent - Symptoms occur more than 2 times a week but less than once a day. - Exacerbations may affect normal activity. - Nocturnal symptoms occur more than twice a month. - FEV1 is >80% predicted during episodes.

o Moderate, persistent - Symptoms occur daily. - Exacerbations occur more than twice a week and may last days. - Exacerbations affect normal activity. - Nocturnal symptoms occur more than twice a month. - FEV1 is between 60% and 80% during episodes.

o Severe, persistent - Symptoms are continual. - Physical activity is limited. - Exacerbations are frequent. - Nocturnal symptoms are frequent. - FEV1 is always abnormal and < 60% predicted during episodes.

Differential Diagnosis: 1. Chronic Bronchitis 2. Foreign Body Aspiration 3. Chemical Pneumonias 4. Acute Left Ventricular Failure

Diagnosis: o Reversibility 15% in FEV1 after 2 puffs of B-adrenergic agonist o Positive wheal and flare reactions to skin tests o Sputum and blood eosinophilia o Chest radiograph

Management: o Eliminate allergen first, avoid trigger factors o Oxygen at 2-6 lpm via nasal cannula o Nebulization

- Salbutamol neb/inhaler q3-6hours (1 neb/2-4 puffs), or - Ipatropium bromide + Salbutamol (Combivent)

o Drug Therapy: 1. Quick-Relief Medications (Relievers)

a. Adrenergic Stimulants catecholamines, resorcinols, salegenins b. Methylxanthines theophylline c. Antigcholinergic ipatropium bromide


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2. Long-Acting Medications (Controllers) a. Glucocorticoids (inhaled)

- Methylprednisolone - Prednisolone - Prednisone

b. Combined medications - Fluticasone/Salmeterol

c. Mast cell stabilizing agents - Cromolyn - Nedocromil

d. Leukotriene antagonists - Montelukast - Zafirlukast - Zilueton

IIMMMMUUNNIIZZAATTIIOONN PPEEDDIIAATTRRIICCSS

Expanded Program of Immunization (EPI)

Vaccine Route Dosing

BCG ID At birth to 1 week

Hepa B IM At birth to 1 week 4 weeks 14 weeks

DPT IM 6 weeks 10 weeks 14 weeks

OPV IM/PO 6 weeks 10 weeks 14 weeks HiB IM 6 weeks 10 weeks 14 weeks

Rotavirus PO 6 weeks

Measles SC 9 months

MMR SC 12 months

Recommended Vaccines:

Hepa A 12 months (IM)

PCV 6 weeks (IM)

Influenza 6 months (SC/IM)

Varicella 12 months (SC)

HPV 10 years (IM)

Contributors: Badillo, Lawrence Albert (March 2012) | Mirasol, Dave John (Nov. 2012) | Monterola, Francis Pierre (Nov. 2012) | Comia, Ralph Joseph (Nov. 2013) | Fontanilla, Agatha (March 2014)

Date post:	28-Sep-2015
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