Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

you know what's going on? Okay, What else can you tell me about how she's been recently? She's She's just being She's just not behaving how she usually does. She's crying a lot more. She feels very hot. Okay. Okay, So this has been going on for the past couple of days. Did you say Okay on, um, eyes there anything you can do to stop crying? Um, while I tried giving her about parastatal, and that helped a little bit, but she's just nothing. She's just been crying constantly for the past two days. Okay, Okay on. Um uh, what have you tried to do to help her? Fever, Just the power of settle more has brought it down a little bit, but it's just keeps coming back up. Yeah. Okay. Have you actually taking a recording? Using, like, say, if the monitor Ah, no, she just feels very hot. Okay, um, Andi has anything like this ever happened to me before? I mean, she had previous infections, you know, the old coughs and sniffles and things. Okay, but, um, nothing like this. Um, Well, I can't really tell why she's hot, because she's not really like I can't couldn't tell you why. No course, um and it's already thin. This particularly concerning you at the moment. Just why she's so upset and why she's so irritable. Okay, okay, fine. I just wanted to get a sort of idea of how things have been over the past few days. I'm gonna ask you some more specific questions now. Yeah. So has she had a cough? It's all over the past few days. No cough. Okay. Does she look? Does she look at their She's been, um, quite tired from breathing? Uh, no, she's not struggling with her breathing. Okay on, But she had a runny nose at all, and no. So has she had any funny turns? So, like, where? Say, her limbs have started moving by right? Randomly? No. Okay. On is she, uh well, the weather. Are there any where he's at the moment? Yes. She's wetting her, not pieces. Much is normal. Great on, um, has has the consistency of her stool change the two. Like I shot anytime. No, Great on. What about in terms of her skin? Have you noticed any, like, Russia's or anything? There was a little bit of a rash. That's coming out on her legs now, actually, now that you mention it coming out of her legs, Okay, it's up. Uh, one or both of the legs. Yeah, it's both of the legs. It's just sort of coming up. Okay. Coming up in the center was in like, there's a bunch of dark ready purple spots and her legs. Okay. Could you be a bit more specific about where they are? Legs like a day. It's just my legs on her entire legs. Okay. Anywhere else? No. Okay, that's fine. On how is how is that eating habits been in the moment? She feels she she's being bottle fed. She's eating okay, a little bit less than usual because she's so busy crying. Okay, so she's bottle fed entries, taking a little bit less of the feet. Right. Aunt, Has she had any instances of vomiting? No. Okay. Um, Andi, what's her own sleeping? Been like recently since the fevers. Come on. Uh, she's being quite when she's not crying, she's just completely knocked out. She's sleeping a lot more than usual. And then when she's not asleep, she's screaming. Okay, fine. Fine. Right. So I'm just a bit about when it's past. So was she Was she born a term? Yes. Okay. And was up through vaginal cesarean section Ah, a China on. Have there been any problems since? Since he's been he's been alive? Um, no. I mean, ah, I had, um, Group B strep. Yeah. Did you get any prophylactic antibiotics for? Yeah, you did. Okay, because, um and so in terms of minutes development, So she's three months at the moment, So prior to Well, firstly, have you had any concerns regarding her developmental monsters? No. Okay, so I just wanted to check. Um, Has she been able to sort of, you know, pay attention to you as you're walking around the room? Yeah. Developmental. Why? She's fine. Okay. Great on. Um is ah. Do you happen to know what her room sent? I'll is from from her height, and I wait, I can't remember, But her growth and everything was fine. Okay on because she had her first lot of immunizations. Ah, I don't want to fax in a her You don't want to accident. Okay. Fine on. Does she have any allergies? Uh, no. None that I know of. Okay, on, um is ah Is there anything that you're hoping for us to achieve today? Just find out why she's got this fever on and do something about it. Okay. Okay. Fine months. It's actually just over seven minutes. Is there anything else that you would have liked to us? Um, I just probably wouldn't want to explore. The rash is a bit further and search history. Okay, fine. Ah, ah. Um all right, Find So in terms of her examination, she's got a temperature of 38.4 degrees. Her heart rate is 1 50 which is a little bit high. Respirators 40 a little bit high, saturating 96% on there on examination, she's in consolable crying in her mother's arms. Um, she's pink warm. Well, perfused moist mucous membranes. But she's irritable, and she's got tense. Anterior fontanel normal tone on. And she's got a bilateral Purpur IQ nonblanching rush on her legs. Okay. Uh, otherwise anti examination is normal. Cardiovascular examination is normal. I don't like some normal. Okay. Ah, fine. So would you investigate Smyrna? Um sorry, I didn't catch Still question. So how would you investigate now? Okay, so I'm I'm done, actually, before we do that. Sorry. Uh, usually summarize the case. Don't you wanna go ahead and quickly summarize? Yeah, sure. So I took a collector history from Miller's mother, Uh, who's a three month old infant, Uh, who had a two day history off fevers that were sometimes responsive to paracetamol associated with. This has been a rush on the legs bilaterally on. But, um, uh appears to be systemically, uh, sort of unwell with uncomfortable cry, slightly reduced feeding on D. Um, significance. She, uh, she has not been vaccinated. Her mother doesn't want her to be immunized. Uh huh. Okay, So while you what is your top differential? And what other differentials do you have for a fever? So my top differential is, uh, in Chicago. Septicemia on my other differentials could include, um, the meningitis. And then, uh, H s P on board, Uh, urinary tract infection of a urinary tract infection. All right, You said men in. Did you say meningitis? All meningococcal step to see me a little. Both a car. I said both. Yeah, Okay. Okay, fine. Um, all right, so how would you investigate? Um, so I want to initiate a septic screen. So, um, Miller would need to be admitted on have regular bite of signs. Uh, this wouldn't be a party, but I got some. But I want to get a urine sample for your analysis. And then So my cost of the culture and sensitivity on Ben, I probably want to insert my tics. It looks for Mina. I want to get a full blood count and crp, um, set of blood cultures. I love cheese. And using these? I think so. Well, to get a attention a, uh, actually a first world, um, on at a chest x ray. Sure. Okay. Ah, right. So Well, what was your differential again? That intercourse septicemia Fine. Okay, so we'll go through. Ah, I'll start sharing the slides now. And rather than go through them, get you to do the management, I think we'll ask on the group chat. Had what people think find. So, can you guys now see the next slide? Yeah, we can see that. Fab. Okay, so, um, I'll quickly feedback on you got most of the things for, um a m from the history and the examination. Well, from the history. Sorry. The only thing that you didn't ask about just a cause of fever is like Aaron, flexion and throat that tonsillitis. So we're talking and drooling. Could be signs of anti sources of infection. Uh um, otherwise pregnancy history ask pretty much everything. I don't mind if some of the information is a bit different. What? I said the slides. Answer of data. Um, you could have asked about whether that she was in scab. Ooh, um, that's the only the thing you ask about. I'm not sure if you asked about whether she was born term on, then input output you asked about. So no peas and feeding Fob, um, family history you could have asked about. But really, that's not that relevant at the moment. But still, you would get marks for that. And you said that you'd have asked about social history. Okay, so, um, that's the mark. Steam torrential for a fever. So when we're talking about fever, we what you want to do think about with your history is what the different sources for infection in Children. Risperidone three is the most common one. And then you got. And obviously, under Risperdal, you've got your bronchiolitis or and you squeeze, uh, upper respiratory tract infections, which is just basically the common cold and bacterial pneumonias. You've got anti sources of infection. So is tonsils, gastroenteritis, UTI and meningitis. So you did really well to ask about one of those ah different symptoms that you would get with them. Vestige a shins. I think you hit much everything. So with a child that comes in usually usually the diagnosis is quite clear where the source of infection is, and you don't need to do any investigations. So if they come in with a cough and you hit, you listen to the chest that it's crackly and we easy, probably bronculitis. You don't need to go and do it Jump in with a chest X ray. In fact, we already do trust that crazy kids. But if you're worried about child, if a they you're thinking about meningitis or septicemia or, uh, yeah, if they're just septic, then you do a septic screen. So blood's full blood count and CRP um the very least. You're in debt, and that's also even if the child is not septic. If you think it's a UTI are, you are going to need a urine dip, lumbar puncture and a blood culture and then with management. So, um, I'll have a look at the question you you would not do a seat. Avoid radiation at all costs. And Children, if only think about radiation if a child is really unwell and usually the register, all the consultants will make that decision. Um, so let me check X sliders of the answer. So child has meningitis. Uh, I'm just trying to keep up with what's going on. So this truck has meningitis? Um, actually, ah, the rash. Yeah. So because there's a rash is meningea cockle step to see Amira's. Well, actually, um, so does anybody know the difference between men and try to send it in? Just a cold septicemia think people can put their hands up over? Yeah. Yeah, fine. Exactly. So the septicemia is when you? Yeah, exactly. So, meningitis TSI is information off the meninges the rash can present if the, um if the bacteria is caused by I think Neisseria meningitidis and that will cause the blanking rash so you can have both meningitis and meningococcus septicemia. So not to be confused with each other. Fine. Um, you don't routinely screen for, uh you don't use a CT to screen for a race. Intracranial pressure before doing an LP, an LP would be contraindicated if Mm okay, fine. I think in this situation, you might hold off with the Yeah, you. I think you guys are actually you might hold off with the lumbar puncture only because there's a tense. I just remember that the case I put tense anterior fontanel, but if there wasn't a 10 Santeria fontanel Ben, you don't need a CT before you do the number country. You don't need to routinely rule out reason to cranial pressure in kids. Fine. Let's move on to the management off meningitis, so I'll just give you the answer. You go in with an A B C D approach, and what that basically means is obviously checking the airway breathing etcetera. If they're needing oxygen, give oxygen. If they're hypovolemia, you can start fluids. You need to start them on a broad spectrum IV Antibiotics. Usually that's care for tax seem, but it really depends on your hospital guidelines. And then, if the child is greater than three months, start them on dexamethasone and then you would also, um, notified public health and you can for prophylactic antibiotics to close contacts. Right. And I'll just put another slide of the management of the of the federal conditions. Antibiotics really depends on your hospital guidelines. So do I have another volunteer for the next one? Okay, M broad, but his the briefing suppose give you, say seconds to have a look. So you're on F one working in pediatrics. You're in. We'll send out the slides. You're in the pediatric assessment unit Mrs. Lee has brought in her six month old boy Brian, as he has had a cough and shortness of breath. You have seven minutes to take history from the patient's mother. You'll then be asked questions by the guide. Hi. Can you hear me? Yeah. Good. So you go out for a second, then. So just let me know whenever you're ready, and then we'll go on to the case. Okay? Okay. In case he's just got a cough in Jordan. Sever. Okay. Thank you. Um, ready whenever you are. Fine. It's the slightest still on the briefing, isn't it? Yeah. Is Thank you. Okay. Come in. Okay. So hi. Hi, then. My name's Emily, um, one of the doctors working today um, you Brian's mom? Yes. Do you mind if I just confirmed his name in his date of birth, please? Yes, it's Brian Lee. And he's born on the 11th. October 2021. Looked laces that makes in six months old. Yes, he's six months old. Lovely. I heard you're a bit worried about ranks. He's got the cough. Do you mind telling me more about this? Yeah. He's just have this cough for the past three days, and it's just it's really bothering him. The case? It started three days ago. Yes. Okay, on. But what type of cough is it? Does it have a particular sound? Or, uh, it just sounds a bit mucky. Like it's coming from his chest a bit wet. That's what it is. Okay, so does he bring it up a bit of mucus with it? Uh, no, no, it just sounds when's okay. Just some things were okay on. It's been going on for three days on, and I mean, I think you mentioned he's struggling to breathe it as well, you know, Uh, yeah, he's been struggling to breathe the last 24 hours, actually. You know, So I brought him in. Okay, so that's just been for the last day. Yeah. Okay. On what's made You think that he's he's struggling to breathe. Can you hear it? Or can you see he's working? Well, he's just he's bean. You can see, like, his ribs. And he's like taking in deep breaths a lot more often. Okay. Okay. Um, did you notice studies in? So bring this on. Were you doing anything unusual with the plane with any toys or anything? No. Just sort of started coming on for actually. Okay. I'm sorry to hear that. Hopefully we can get that sorted out for you today. And has anything like this has happened to Brian before? Yeah, I actually have the fair few coughs and colds. I never really brought him in, but the breathing just scared me a little bit. Okay, so it is. He's had things like this before, but he's never been in hospital with it before. Yeah. Yeah. Okay. Um Andi What? How was he before this? Was he well, or has he hard? So he was fine before. No, it was fine. Okay. And okay, I'm just gonna ask you a few more questions about him just to see what's going on. So how is he feeding at the moment? Is he feeding? Okay, he's got no energy to feed. We've been taking anything at the moment. Okay, so you have noticed, is a bit more bit tired, but lethargic, maybe. Yeah. Just to breakfast to feed. Okay. Um, so he's not even feeding at the moment. Okay? And how long has that been going on for? Just the past day. Ah, yeah. Okay. And so how, uh, how does he normally feed? Is he breast or bottle fed? Bottle cut. Bottle fed. Okay. Um, on. But has he had wet enough pieces normal Or know if he's not eating as much? No, he's not really. He's just had one wet nappy all day all day. Okay. And how about his bowel movements? Has that been normal? Um, no, not really. He's just not really proved very much because he's not drinking much. The case is not food, really, either. Okay. And have you noticed if he's got a temperature, a tool, does he feel hot? Yeah, he feels really hot. For the past three days, he's felt hot. Okay, so he has got the temperature to have you take his temperature. He just feels heart. No, he just feels hot. We just feels okay. Any rashes anywhere? No. No. Um, has he been talking a disease at all? No. No. Um, Andi, Has he been vomiting at all? Ah, no, no. Have you noticed any sort of jerky movement? Strange movements at all. So you know. Okay. Thank you. Sorry. Just some routine questions to us. And I'm just gonna go back a bit about Brian's. So how was that? Was he born, um, a turn? Yes. He was born at term. No problems, no problems. Talk. Okay, so you didn't have to go to intensive care or anything when I was born? Uh, no. No. Okay. On Was the pregnancy okay for you? Yeah. Yeah, Lovely. Um, And have you got any consensus? Brian's development? Um, no. No concerns. No. Does he seem to be growing? Okay, normally your here's Yeah. Okay. On as he had his vaccinations. Are they up today? Uh, yes, yes, that's far. Thank you. Um, on day, Does he have any Any medical conditions at the moment? Uh, known on the hour. Know? So he's not on any any regular medication Know? Is he allergic to anything that you know off? Okay, on. He lives at home with you and Brian. Uh, just me and his dad. Just units dot Any? You guys fits. Um, well, at the moment, Uh, yeah, Well, actually, no, um, his dad has had a bit of a, uh, cold. Okay, so you stopped. Just have to be at the coldest while. Yeah. Yeah. Okay. Um, no problem. Um, um, this is just question. Ask if everyone you know your family noticed issues. Doses? No. No. Okay. Um, is there anything you're worried? This could be a You're any, you know, Any questions you want to ask me? I mean, I think it's probably he's called what his dad has. Yeah, is cold. Um, on. But I just wanted to like I was just a bit worried about the breathing. Really? That was what worried me whether he needs anything for that. Yeah, course I consumed. It's worrying for you, and I'll go and have a chance. My colleagues and hopefully and we'll be able to sort that out for Brian today. Okay. Have you got any questions for me? Know? Okay. Thank you. Okay, So do you want to some rice? Okay, so I saw Brian, a six month old boy who has had a cough for the past three days on, and he's also had shortness of breath for the past 24 hours, and the shortness of breath is now so severe that he's unable to feed. He's only had one. What, nappy In the house? 24 hours. And he's also got reduced bowel movements and potentially dehydrated. Um, he's also had a fever for the past three days. Um, it's not bringing up any mucus. He's got no rash. And on day he's got He's had any vomiting. He's got no neurological symptoms that I'm aware off. Maybe a bit of lethargy on, but he's got no other medical history of note. He had a normal birth. His dad has also had a cold recently on, but yes, nothing to know any social history. Scot, Scot, Scot, family history. That's okay. So, um, examination. His temperature is 38 4, he's got a high. He's got fast heart rate 170. These is tachypnea ah rate of 70. His, um, oxygen saturations are 85% on He looks tired. He's working hard with his breathing, but he's alert. He's got subcostal and intercostal recessions, his head bobbing. He's got experience. Very grunt. His chest is hyperinflated and he's got widespread. Inspiratory crackles and we use isn't otherwise warm to touch moist mucous membranes. Um, Norm Normal tensity anterior fontanel. No rush is normal. Normal tone and T exam is normal. The rest of his examination is normal. Okay, so what? Based on that, what is your what? Your differentials. Um, so my differential would probably be a salon bronculitis or maybe a community acquired pneumonia because that is common in his age group and east seven. So signs of respiratory distress and increased work of breathing. Um, yeah. There's a problem I'll talk to. Could be wrong. Any other differentials for shortness of breath slash cough. Um, could also be creepy. There. There wasn't some of the classic marking cough. Could be a viral induced. We's a swell, but there wasn't really a wheeze described. Um, he did have, um, widespread crackles, and we'll use uh okay. Sorry. I messed up it. Um, yes, it could also be viral induced. Please, then. Okay, that's fine. And So the diagnosis is bronculitis. How would you manage him? Um, so bronchiolitis has it's supported management, Um, considered missing. I can remember. All of it is And his His oxygen was reduced. That 85%. He wasn't feeding? Yeah, case I would. I'd admit him and and probably get a supplemental oxygen. Um, you might consider See, pop if his oxygenation really wasn't while you could consider, um, you know, look, glasses of respiratory distress, but it's I mean, it's mainly supportive management and just sort of monitor in him. Oxygen therapy you might consider give him fluids if he looks like he dehydrated. All right, let's go through it then. So let's not sharing the screen. You had a little boxes? Um, I think, yeah, that was pretty much everything. I think you said that you just forgot to ask about family history. And the only other question you could have asked about is them. Was he coryza? Well, because that will help you with the diagnosis. So right, the differentials for shortness of breath and cough. Most common things kids will that come in short of breath or coughing and they've got a fever is going to be something effective, so we can either be an upper respiratory tract infection, which is basically a cold. It could be bronchial itis, which is basically a that cold. That virus has gone down to the chest. Um, viral induced weeds is also the same thing. It's gone down to the chest, except the presentation of bronchiolitis and viral induced wheezes only slightly different. So Bronculitis is crackles and ways in the chest, whereas viral induced wheeze is mainly just weighs on the chest. And then it could be a bacterial pneumonia. Which is why I says, on the tin, it's just a bacterial and that will that be, that will be, um, that will give you mainly just crackles, and it will usually just be on one side of the trust and then ask him A You don't really tend to diagnose but in kids in the below the Age of five. But you can mention that still and croup, obviously, like you mentioned classically, it's that barking cough fine. So management bronculitis so you wouldn't really investigate, like, just because it's a clinical diagnosis bronculitis and you, it's supportive management. So what that means is, if they're needing oxygen. You give oxygen if they ah, dehydrated, unable to feed you contrite, smaller, more frequent feeds. But in some cases, some kids will need either IV fluids or NGO feeding. Fine. So let's see. I know that this topic could get it confusing. So let's see if there's any questions on that. Ah so bronculitis you don't give salbutamol for. So the reason why is because salbutamol works on the, um, the larger airways. Whereas bronculitis is inflammation off the bronchioles, they are not affected. Is the smaller airways some beautiful does nothing to you might end up giving salbutamol anyway, if you're tourney between it being viral induced weeds or bronculitis. Um, just to make a diagnosis, you would give oxygen two kids very young, and it doesn't matter how old they are. They need oxygen. They need oxygen, um, and fire. And you squeeze, like I said, is not the same as bronculitis on ditz. Ah, you don't I know that we usually say under ones is bronculitis over ones is very induced wheeze, but it's not as cut as that. It's more so violent. Use tweezers, just wheeze bronculitis his wheeze and cramps mainly, and it will be affected by salbutamol, whereas Valium just to ease will be improved by salbutamol. Fine. That, uh, fine. So we'll leave the rest of the questions to be answered. I've just put this sliding because I I like the breakdown. It has off, um, different noises that kids can make and what the diagnosis is based on that. So if you have a kid that snoring, usually that's large tonsils, large adenoids. If you've got a kid with Strider, which is like it's a very classic noise, I couldn't do it if I tried. Um, that classic their breathing in and you can hear like it's very tight. That's croup. Usually it can really be a wonderful access or foreign body. And a wheeze is just that plastic wizard. Whistling noise could be bronculitis like we said violent. You squeeze and ask him a most classically So let's move on to the That's true. Case is keen to do the next one. Have you got a volunteer? Thank you, cuff. All right. I am still sharing the slides on time. But you see that Farb, right? So you are the F two working in pediatrics. You are currently in the pediatric outpatient clinic. Sulaiman is a three year old boy who was referred in by his GP for diarrhea and vomiting. Ah. Okay, fine. You have seven minutes to take history from the patient's mother minutes. Yeah. Okay. You're able to talk now? Yes, now I can Great. Can you hear me? Um, I just read again. Just sorry, because I Yeah, nothing about saying. But I can't. No, that's okay. Well, you know, the three or boy who was referred to a GP for diarrhea and vomiting? Seven. It's take history. The patient's mother on the course of the GP. Oh, no. Sorry. Referred. And by the GP, diarrhea moved yet? That's fine. All right. Okay. Course I can't see the next light. Can you know? No, I can go ahead. Um, hello. My name's Catherine. And one of the fourth you medical student's here in the pediatrics outpatient clinic home. I speaking to please on you are speaking to the mother off. Still a man. Ah, lovely. And do you mind just confirming the patient's name and date of birth? Please? Uh, it's Sulaiman on his day of birth is the 11th October 2021 Great. So sorry. How old does that make sense, Ayman? Three years old. Results have no worry about noise. And so Yeah, I asked what brought you in today? Well, he's being vomiting for ages now for, like, weeks moments. Exactly. Actually, this diarrhea and vomiting, right? Okay. Do you say it's been going off a few months? A couple of months? Okay. On diarrhea and vomiting, you just have a little bit more than that. Um Well, uh, hey has been vomiting, like maybe to talk to or three times a week for the past couple months. Okay. I couldn't really tell you. I'm not sure why he's vomiting. He doesn't seem and well, okay. Okay. Um, what about the diarrhea? Um, yeah, he's just sort of, like has diarrhea few times. The week is Well, it will sort of just be like what? He's eaten. Okay, Okay. And just to ask a few questions about what you think Triggers. Have you noticed anything? Um, I'm not sure. I really don't know. Like, um, some certain meals. I think he doesn't like as much as the others, and he ends up bombing tingling. Right. Okay. So is it that he doesn't like, gets Azzan. The taste of it doesn't might get in the sense that he's evolving. Oh, I mean, isn't I don't think it's It's well with him as in, like in his tummy, I think. Guests. Okay. And so, what sort of foods are they? These, um uh I think he's, ah, be completely honest of view things like, uh, breads. They don't go very well with him. He doesn't seem to like bread very much or anything else. You've noticed that this is agreeing with him? I couldn't tell you. That's the main one that sticks to me. That's fine. That's fine on. Okay. And the vomiting and diarrhea. Did one predate the other? Or did they both start around at the same time? Uh, roughly the same time, To be honest. Okay. Okay. And said he's not been on well himself. Yeah, I mean, he's playing, He's going to nursery. It's just why you see how missing Good. Yeah, and I understand. Just have to ask a few more questions just to get a bottle of it. Has he had a temperature at all? No, no. Any coughs? Colds? No. Any changes in his dues have been tugging at his year old or anything coming up with you hurt? No. No. Great. Okay. And I want to ask a few questions, if that's okay with you about the about his business. Was he born at Tim? Ah, yeah, Yeah. On bowel is how? What sort of problem Outside. What sort of delivery was it? Was it vaginal or C Section C section. Is there any reason why it was a C section? Um, it was choice. Choice. Okay, that's good. Puddin. I did it privately. Okay. No worries. Mm. Right. Okay. And how is the pregnancy? Uh, it was fine yet. Good. Good. Um And when when Solomon was was born, did you go to an M? The ski boots Respect, baby unit? No, no. Okay, but it's And do you have any concerns about his development? As of as of now? Uh, no. No. So he's grown houses Growth moment? Well, he looks a bit skinny. I can't lie to you. I'm not worried that he's not like his hair all his like developmental milestones. But he's always been a bit small, Child. He was growing fine in the beginning and then slowly becoming skinny. They're skinny in terms of height is well as that. Change it all. I think his height's okay. It's okay. Okay. Andi, do you Would you say he's eating less or No, he is. He eats like a house. He's fine. I just don't I don't know. Maybe he's not keeping it in. Okay, I'm sorry. I should have asked before as well. And when he vomits, what exactly does the vomit look like? And it's a straight. It's just what he's eating. Okay. There's no blood in there in the vomit, no blood, unlike wise with stool. What sort of consistency is the stool? Ah, it's just a little bit running to build it. Very occasionally you'll find like it's a vegetable in the habit. Grim. But they're well, yeah, I go. I get, I get it. And nothing we ask about with them with stools. Is it small? Little Ah, Not more than usual. No. Okay. Yeah. Fair enough. Okay. And And this this little Soliman have anymore. We'll have any conditions, medical conditions at all? None that I'm aware of. No, on. Did you take any regular medication? No, no. On important question. We ask everyone is. Does it? Does he have any allergies? Uh huh. None that I'm aware. Roast. Okay. Great. And who's at home with Salomon on by positional home with him? Me and his dad. Is that okay? Any and smoke? Is it at home? No, no. At any conditions that run in the family. Ah, no, not really, No. Okay. No. No kind of diabetes or any autoimmune conditions. It'll ask me anything that that No. No. Okay. Great on again. Sorry to ask you. We just have to ask everyone. Has there ever been any involvement of social services? No, no, no. Great. Great. Okay. And do you have any concerns that what you might think? What? Sorry. What do you think this might be? I don't know whether he's allergic to something. I generally have no idea. Okay. Okay, Now I understand there's anything I can do for you over. So go and talk to my senior now. But is there anything else I can do for you for the time being? Um, no. Just I want to know what's going on. That's really Yeah. No, I am sound. Okay. Well, thank you for talking to me, and I'll go And speaking of side are going to be throwing my c is now and we'll hopefully cut with a plan to try and sort celebrants. Salim it out. That's again. Thank you very much. You want to summarize? Yes. So I've just taken a history. Um from Sulaiman, three year old boy, his mother and who referred to GP today or well at some point for diarrhea and vomiting. The diarrhea vomiting has been present for about about two months. Know every day is only about a few times every week. Um nice history. Oh, thank you. Be tea. But I'm sorry. Can't see your name, but thank you. Um yes. And around food for two months on and vomiting and the diarrhea both started on the same time. The vomiting and diarrhea is a consistency of just the food that he's eating. It tends to be precipitated by eating bread in particular on the mother wasn't able to know any any other triggers. He's He's well within himself. No fevers, no coughs. His developmental stones have been met. I did forget to ask about immunization. I think about right to ask about this and the only, um, about mental feature that was that was mentioned was that he has he has, um, lost weight. Or rather, has it appears quite skinny, in the words of Mother the cell, um, unlived at home with his mom and dad and their no smokers at home on. There's been no involvement of social services. Yes. Okay, so on examination hey, is a fibril that some point for heart rate's 110. Just normal for his age group. Respirator. 25. Blood pressure's okay. 100 over 70 saturating 100% on their He's running around the room and you can see that he's actually very skinny. Go protruding abdomen and wasted buttocks. Um, no signs of respiratory distress. His chest is clear when you listen to it. Abnormal soft, nontender abdomen. Uh, the rest of examinations and remarkable. Okay, So, what would you be? Your top differential as well as, well, other considerations for a young child with vomiting? Yeah, and plus minus diarrhea. Okay, so my top differential in Solomon would be celiac disease, but, uh, the difference is like to consider would be something like gastroenteritis, possibly although, and like, clean it for two months. Um it could be a die remnant. Diarrhea. Sorry, diabetes, but again, unlikely in this age group. Um, given that the loss of weight, um, it could be, um, just ah, uti. Even UT has competed quite generally in, um in Children. Pilot? Yes. Thank you, Mohammed. Parents stenosis is a definite one. Although I believe that's more in younger Children, I believe could be first presentation of, um I'd be I think I just saw IBD. Yes, our people. People giving the answers. Thank you for that. Toddlers. Diarrhea. IBD of Yes. Um, yeah, Well, that would be my French, as I think. All right. And you said your top one was stealing, actually. Uh, yes, definitely, Bob. So how would you investigate him, given your what you think is most likely. Okay, so, um, so the patient's already had an examination then on, but it has been taken so on. General labs have also been taken s so I'd like to take some blood tests I'd like to do a fbc them on to unhuman Tenex as well to look for any, sends a any any cause of anemia out. Also consider doing a CRP in a child just to check for infection. I believe the blood test is called T T G man antibodies. I can't exactly remember the name, but I think it's t TG bodies are also test for I g A. The same time. Um, this would be my initial investigations with patient. I wouldn't want to over investigate him with imaging and and what? Not Okay. And with regards to testing his IGA and anti the TTG antibodies, Yes. What? When? When you test them. Is there anything you want to tell the patients? Yes. So I'd like to ensure that the patient is is eating gluten diet for sleep, either 2 to 6 weeks before the test is taken, I think, Um all right. Okay. Ah, fine. Shall we? Yeah. Okay, fine. How would your monitor him? Celiac disease, then? Okay, so, first of all, I'd like to, um, educate the patients. Are the mother the diagnosis on Explain what exactly involves on also the importance of having to have a gluten free diet for a while for the rest of the life. Really? But reassurance that it's very common on do there are definitely products out there that make easy for you. um, and the restaurants and everything can provide that. I do believe that some some surgeries or hospitals comprise vied gluten free products on prescription. I believe, um I'd also like to, um, refer to gastroenterology if they if they need some more, if they use a follow up Onda. Yes. I'd like to do two week follow up a swell with GP afterwards just to ensure that the just for monitoring off the of the growth and hopefully some weight gain as well. All right. Okay, fine. Let's go through it. Well done When you see the next slides. Yes. Hum. Okay. With regards to your history, I think you had a little the boxes like you mentioned. You just forgot about vaccination. Um, that the the only other thing that I would have liked is if you ask questions to show that you were thinking about whether it could be a neurological cause for the vomiting. So things like space occupying lesions or, um, essentially, that's it. Really? So has the child being clumsier than usual? Had's paralysis or parasthesia or, um, headaches, visual disturbance, that kind of thing with that, Other than that, you pretty much hit all the boxes in terms of So you got pretty much everything from the history differentials for vomiting in young Children. So I tend to think of when we're talking about really in Children, um, Children who usually would not give you a history themselves. The four main things that to be either reflux or we're feeding of something obstructive, infective or allergic. So relax and reflex and overfeeding. You don't see them more in younger kids Obstruction convenient. Um, really Anybody Really? But like you said, pilot stenosis tend to be one of those where there, like, six months, maybe six weeks. Even very young. Um, intussusception could be at this age is all, But you tend to get do you know, classically, Does anybody know what kind of stall you would get with Intussusception? I haven't actually got the charm front of me. Mm, Yeah. Rid current jelly stools. Fine. So you tend to get that even then. That's actually one of the latest signs. And those are the main obstructive causes of bomb it in infection like you mentioned. It's less likely in this situation because this is chronic gastroenteritis and also a good one that you pointed out is UTI. So? So If a child comes in acutely and they've just being vomiting and they're quite young, then you need to do a urine dip to rule out UTI allergy and intolerances. So if this was a younger child who was drinking milk, you would consider cow's milk, protein allergy or cow's milk protein intolerance, depending on how severe the reaction is. In this case, you would probably say intolerance if it was a young child and obviously celiac disease. And then if we're talking about some a child that's a little bit older, we start to think about other diagnoses that we would in adults as well. So, like, drugs and alcohol, pregnancy eating disorders, etcetera. Fine. So that's the differentials vestige a shins. You did really well, So it's serum IGA like he said. And seat tissue transglutaminase, I think, um, antibodies. If that comes back normal, you can do another antibody called and, um, I've really And then, um, if that's still not showing, but you have a high suspicion, you could do a tissue biopsy of the duodenum. So, um um and also considering, like you mentioned, um, full blood count looking for anemia. And then if you find anemia, you can consider things like B 12 folate high in studies. And also because she the child has had, um, diarrhea for longer than seven days. You need to consider doing a stool sample. So that's a still microscopy culture and sensitivity just to make sure, um, that there isn't some sort of chronic, effective diarrhea. And and like you said, the management lifelong blue to free diet remember to refer to the dietician, and then they're going to need follow up regularly. Um, just a check that they're growing okay, that they're not deficient in any micro need nutrients and need replacing. Uh, okay, just gonna be Steve. There's any questions regarding this case. Chronic infective. Diarrhea is caused by lots of different things, but they tend to be weird and wacky. Rare things, I think. Um, so I wouldn't worry too much about that. So who do we have that wants to do? The fitting child. Okay. Was it our ridge? Right. I think I was just the first person to ask. So I'll just a new you research interest. I think someone volunteered before. Oh, is that who is it be done with the You put your hand up again if you want a volunteer Still. Uh, yeah. Oh, Okay. Right. I'll let you talk. Uh huh. Is it heartburn? Yes. Speaking. Cool. Okay. When the second of got to me jobs and things open. Um right. Here's your brief. Your enough one in the emergency department. Mrs. Client has brought in her four year old daughter Tanya, following a fit. You have seven minutes to take history from mother. Okay. You already You tell me. Okay. You already? All right. So high. Hi. My name's urine. I want the F ones on the ward of the movement, and I just confirm your name. Uh, yes, My name is this is supplied. Like, this is my daughter. Tell me, uh, are very nice to meet you. Risk lied. I heard on 10 years. Had a bit of a fit, which wanted to be a bit about what's happened. Uh, yeah, she, like, out of nowhere. She just have this fit in the first thing in the morning while she was watching TV. Okay. And can you describe a bit about what you saw? Well, just she was out there and then all of a sudden she just fell to her side. And then her arms starts a jerking up and down, like really? Like it was quite intense. Okay, well, I'm really sorry. Over, but this will happen to you. Must been quite distressing. How women's. Sorry. I was telling you about the woman's. I mean, she's just a bit miserable. She's not being feeling herself lately, to be honest. Okay, So I'm just gonna ask a few questions about how 10 years been on everything about the four. Just we don't miss anything, is okay. Okay. So has have you had any illnesses recently? Um, she's being feeling very hot, actually. Um, I think she's got some sort of infection or something. I don't know. Okay. And you let me know. And how long is this an infection, But well, she just had this fever for the past three days, and she's not eating very much, and she's not eating very much. Okay, Um, have you noticed before this episode that you had any fits before? No. This is the first time. Okay. Um, before the figures that she was watching TV, did you know a good pain or for over or complain about anything beforehand? No, she was just She just trucks thing. She was a normal self. Okay. And then during the four, you said she was moving her arms up and down, up and down. Okay. Okay. And did you notice her biting of tongue? It'll or having any urinary like we call wetting herself? Um, no, I didn't notice either of those things. Okay, then also, you said she didn't really focus, so Okay, Sorry. What do you mean by that? Well, she just knocked out, okay? And how long we should know talk for for about an hour, Okay. And how long is the feet? It was less than a minute. Less than a minute. Okay. Thank you for giving me all this information just to make sure I don't miss anything else. Um, your daughter she had any cost recently? No. And he told me Upset. Uh, no. Um, in general, has she been feeling well in the cell phone? You said she had a fever? No, she's just being very miserable. Mony feverish, not eating. Refusing to put anything in her mouth. Okay, well, thank you for giving me with this information. Just generally rib on Tanya. How's he been growing? Yes, fine. As you've been keeping up with the charts. Yes. Okay. And you have any concerns regarding her? You know, her development, her social skills and such? No, she's fine. Okay? And you said she's not eating in a moment. But before she was ill, How was her diet? Truly a normal diet. Fine. She's not pitch a picky eater. Okay. And how are her stools at the moment? Um, I think she's not bean for a couple days, I think. Probably because she's just not being eating. Okay, Well, thank you for letting me know and just lost. Like, this might be going back a bit. What? How was your pregnancy return? You, uh, it was fine. Completely normal on off the pregnancy. Was anything okay? Yeah. Okay. Thank you for letting you know. And she opted it with the vaccinations. Yes. Okay. Perfect. Perfect. This time. You have any other past medical history? Um, no. Okay. And did you take any medications? Ah, no. Sorry. That's fine. Any other juice? No. Oh, in the family has anything like this that runs in the family. No. No. Okay. And has anyone else been ill in the family recently? Um, yeah, actually, her little brother. He's had a fever as well. I think he I have. I think he might have some sort of infection or something. Okay. And how old is her little brother? He's about six months. Okay. Six months. And how has he been? Um, he's he's just had a fever for about a day. Really? Okay, well, thank you for letting me know on just in general. Who else lives at home? Um, her and her little brother And the Dodge. Okay. And do you would that work? Um, yes. And what do you do for a living? We're both doctors. Okay, that's great. Um, and does anybody in the house smoke? It'll no. Okay. And this Just a question. We also everyone has social services. Ever been involved in your child's care, you know? Okay. Thank you very much. Just around. Is that anything you think might be going on? Um, I think she might have some solid for infection running. I mean, well, so she have a fever, you know? Okay. And obviously what you're made of background is anything you're spitting specifically concerned about. I mean, I just want I'm a bit worried about the fever, because, I mean, the the fit, because it was very scary. And I've never seen it happened in anybody in my family. Yeah, I can understand. It does sound like, quite quite afraid to have you done the right thing by bringing it here. And just lastly, if anything specific that you expected from this Constitution to do, uh, just want to find out why she had affect. Okay, Well, thank you for speaking to me today, Mrs. Glad I'm going to speak to my seniors. Um, before you leave today, we'll make sure to have some type of plan going forward. Okay. Thank you very much. Healed some eyes. Yeah. So today I took her She from Mrs Clyde, the mother over four year old female with him. Tania, who is coming after a fit episode. Before the fits, the patient was watching TV. During the fits, the patient didn't notice any tongue biting. However, there was some seizure type activity only in terms of arm movements. And often if it's there was a perspective. Face off drowsiness on a little confusion in the daughter and this is all on the background off a feverish owners. Um, otherwise, the pediatric history on 10 has been very well in herself. Ah, growth and development has been normal. Feeding has also been normal, optimal. This stage of illness on there is no significant birth in history. She has no past medical history, no medication history, and she doesn't have any allergies on. There's no family history of any conditions. She's living at home currently with her brother on two parents who are both doctors. Rather is also a what the moment with feverish your anus social. There's no safe voiding issues or social issues at the moment. I'm overall, her mother is just a little bit concerned that this never happens. Where before I would just like to know a little bit about what's happened. All right, so what are your differentials? So I told difference was for Petagna or a feeble convulsion. I would also like to rule out, um, other course of the procedure, potentially head trauma, potentially passing the head. Also, also, it could have been caused by electrolyte abnormalities on lastly, we just like to rule out Oh, any anything could be that might have occurred you to a whole problem. Okay, Um, So what do you think is the most likely? The most likely in this shoulder is a feeble convulsion, in my opinion. All right. How would you investigate? So for investigations are like to take a more thorough history from the patient. Rules like to do. Some examinations are most importantly, your cardiovascular exam, and we'll wait. Hold on. Did I not give you the I don't go through the examination for you. Oh, sorry about that. And we just just realize I missed that. So on examination, she has a temperature of 38.2 degrees. Heart rate is 140 respirators. 25 saturating 96%. From there, she looks hot and miserable. She's cleaning to Mom, reluctant to engage with you. She's okay. She talking to Mom's Her Airways. Okay. She's not in respiratory distress. Pink warm. Well perfused moist mucous membranes. She's not irritable. She's not got any neck stiffness. Normal tone, no rashes. When you look at the back of her throat, issue got bilateral in large tonsils with puss and bilateral on palpations. She's got bilateral cervical lymphadenopathy Her is all clear. Okay, thank you very much. So based on that, do you want to change your, um, differential or keep it the same? I still keep it as people convulsions up. Okay. And with regards to that man, what investigations are you? Are you thinking of doing any investigations or the examination was what you told me. I am thinking that the soffit source of infection is some type of cancer. Latest would like throats for most importantly, I'm not the investigated by the bed, so I would be There is a a new school are not glucose. And the normal baseline bloods was there. He sees you in use. LFTs tier t zero be on for this patient. Currently, we could consider a CT head or MRI. However, I like senior important to know if this is needed in this other small mint. All right, now. All right. So monitor mints of febrile convulsions in how did you manage it? So I'd like to first insure the patient is stable by an 83 approach and also just referred. So my seniors for senior advice, I think the most important thing is just to make sure the patient isn't in status. Epilepticus. It was long as the patient is fine on their know in any, uh, state of seizure of the movement. Most important, management would be medically to sort out the source of infection, which, in this case, as we were saying, was tonsillitis, depending on if this is a bacterial viral course of management would change. If it's bacterial, we most likely need to prescribe some antibiotics For the patient, it is viral. We would just have some support to the patient, some supportive management. Then conservatively, it's really important to reassure the mother to let her know what's going one on. And also to write a list to the GP and let them know what's happened. Fine. Okay. Um, that's right. Okay, let's go through it. Uh, okay. You got your your history. I'm quite happy that you hit pretty much most of the things. Um, just remember to confirm the patient's details in the beginning. Um, otherwise, you, uh So with the history, you could have asked a bit more questions about, um to make it sound like you're thinking about based occupying lesion as well. So maybe asking about headaches, visual disturbance or um, parasthesia paralysis closing this blah blah. But otherwise, I don't think that you would have lost marks anyway with that, but just to give you an extra thing. So fine forensic files. That's how I usually remember. The most common cause is off seizures in kids. So birth, usually congenital things, cerebral palsy, etcetera, things that get anything congenital. And then I infection. So feberal convulsions. Yeah, and then meningitis and careful itis. So if you didn't have a source off infection for her, you might have to think about the possibility of meningitis trauma, which you mentioned. So post concussion asking about trauma actually would have bean quite good, um, and then epilepsy, which is basically, if all else there's no other reason than consider epilepsy on your investigations would be based on what you think is the most likely thing. So if you were thinking more infection and there's nothing obvious source, then obviously you want to do a septic screen. Um, in this case, it was tonsillitis. So, like you said, um, doing a throat swab would have been good. Actually, if you're thinking that this could have been called secondary to a trauma than you would consider doing a CT head. But if it sounds like it's probably epilepsy and you've older everything else, then consider doing an E. G. With regards to management, you mentioned that bacterial, um, bacterial causes off tonsillitis you would manage with antibiotics. This case, do you consider it bacterial or viral? Bearing in mind is on the the examination bilateral enlarged tonsils with purse and bilateral cervical Abilify. Did all this be? Oh, I think it's bacterial. Yeah, So if you're seeing person, the back of the throat is probably bacterial. And also, if you're getting cervical, lymphadenopathy is probably bacterial, so antibiotics would be a shot. So the management managing the tonsillitis to give you antibiotics and the management to federal convulsions would be just reassurance and then keep the child's cool. You can keep the temperature, bring the temperature down with some parents that small. Okay, thank you, no. Yeah. So central criteria is how you would be able to tell whether ah tonsilitis is likely Bacterial or not. Let's see Q and A. Yeah. Ah, I will send the power point buck, but just quickly, I'll show you the list of differentials so that that's how I remember the most common differentials. And if you check you Google something called the stent or criteria that will give that will show you how to differentiate between what's likely viral and what's likely on bacterial tonsillitis. But either way, they both get better on the road, usually. Fine. So who wants to do the last one? The limping child carriage. Right. Um, one second. Let me, uh Well, all right, you see, that's Yeah. So you're enough to working in GP. Mrs. Argument has brought in her three year old son, Ibrahim as he has been limping. You have seven minutes. Take history from the patient's mother because then you'll be asked them questions. Okay, So whenever you're ready, you let me know and we'll move on. Yeah, I'm ready. All right. Okay. Hi. My name's are you on the fourth year, medical students got taking them in their birthdays. Yes. Um, so my son's name is Brahim on, and he is three years old. Nice to meet both today. So what brings you in? So he's just been limping for the past few days. Okay. I'm really sorry to hear that joint. Tell me a bit more about what's been going on so about since three days ago, I started to notice that he's not really being walking on his, um, left leg is much on. Do is just being about when g asking to be carried. Uh huh. Okay. And has this ever happened before it all? Not really, No. Okay. And how far can you walk before it before it's unbearable? Um, I mean, he can walk. It's just being a bit windy, but when he'll walk, he'll just sort of, like, try and avoid walking on his left leg. Okay? On his other leg is completely fine. I think so. Okay. So has he complained of pain anywhere at all? Um, he's not specifically said the word pain, but I'm presuming that his his leg is in pain. Okay, on was gonna ask you a couple of questions. You have to ask your parents. Have you noticed, like his left leg being hot or swollen? No. Have you noticed any fevers recently? Ah, a little bark. It's about a week ago, but he's not got fever now. Okay. And how far? But you have a fever about a week ago. Fine on. Have you noticed any skin changes to his head to toe me. Know? Okay. Find a Z. Complain of any other symptoms at all? Um, no other than that. Not really. Uh huh. Okay. You haven't noticed any, like, rashes anywhere? Not no. On he hasn't, like, fallen or like, um, like, bumped into anything. I mean, he tripped over the counter few days ago, but I don't know, I didn't Really You know, fine. Um, I'm just gonna ask you a couple more questions regarding his birth. So how was the brain born? Who is, um, it was a normal delivery normal delivery on. Do you know what? Wait, he waas. I don't, but I remember it was normal. Okay? On with any complications during the pregnancy, It'll Ah no. Okay. And was Abraham a little like after he was born? Uh, no. Okay, on how is it been feeding recently? He eats well, Good diet. Good on. Is he going to the toilet? Fine. Yeah, Like when the stools Well, yeah, Yeah, Great. Onda Has he had all these immunizations okay on you concerned about his development until, you know, fine. So has different go Any of the conditions? No, on. Is he on any medication of the moment? You know? Okay, on any over the counter medication? No. Have you given him anything for this limp? Oh, yeah, actually, give them but a cow pull. That's that. Really? Okay. And does he have any allergies? No. Okay. And is there a family history of anything I should be aware off? Um, no long wear. If Okay, I'm just gonna ask you a more personal questions. And does anyone in the house smoke? It'll No. On who does he currently live with? Just me. And it's That means that on how is your relationship, like with each other? Ah, okay. Okay. On another personal question, we have to ask Your parents have social services ever being involved to? No. Okay, fine. And you do on that corner Worked all Ah, yeah, both doctors. What? Doctor is fine. So, um, the idea is we have cause this I don't know. But now that you mentioned the cat, I think maybe he tripped over in her himself. Couldn't tell you want to know? Okay. Did you, like, bang his head anywhere at all? No. What injury? Any other part is body. That uh uh. I do. Okay. Have you noticed any bruising anywhere at all? No. Okay. And what do you mean, concerns? We don't want me asking. And I just want to know why he's limping. Whether I should be worried about it, You know, if he heard something. Okay, so we'll try the best fear I was going on and getting the right treatment we can on What do you mean, expectations? Moving on from here. Just finding out what's wrong. Okay, great. So, so five to me. Not embryo. Him for the past couple of days isn't having this limp. He tends to avoid walking on the particular left side. You have side of his name. Hasn't complained of any pain, but he looks to be in some sort of pain as a result recently is tripped over Aziz. Well, yeah, but otherwise he had an infection. A week ago, you had a cold, not a cold. But now he's well, and, you know, concerned about anything else. Yeah. Yeah, that's it is anything I'm I've missed. Um, I think that's it. Really? Okay, Well, thank you very much for speaking to me. I'll speak to my seniors and we'll get back to you soon as possible. Okay. I do want to summarize. In fact, you basically summarized now, actually, do it again, as if you're speaking to the Examiner. Okay, So I spoke to Miss Offerman, the mother of three year olds on Abraham who came in presenting with a limp, which started a couple of days ago. And there's many affecting the left side on. There was no, uh, associated fevers. And he joined swelling or any pain or a theme of President of joint on the pay. The agreements himself had suffered a four recently as well, and also had a infection of the throat a week ago. But then this I don't think anything else is a concern. He was born to know down liver E on off was a normal weight. Uh, there's no relevant social family, your past medical history at all. Okay, fine. So what are your differentials for him? And it is your differential out of them. So my top French on the situation would be transient synovitis. I would also like to consider other causes, which is perhaps disease as well as, um, possible trauma to the hip. Yeah, I just want to rule out, um, it's possible septic joint is all Okay. All right. So how would you investigate him? Okay, so actually, before I forgot again to do the examination, let me explain to you the examination. Sorry. Yes. So temperatures such some 0.4 heart rate is 70 which is normal. Respirators. 20 which is normal, saturating 97% on a roller. 10 playful at the bedside when you ask him to walk. He's got an antalgic gait avoiding his left leg. Got full range of movement off both hips and knees, but the left hip is tender on probation. So based on what would you do any? Did you do any investigations? I think based on my top defense, you're being transit synovitis on Do, um, the patient being right to be stable with this when the only abnormality being on the tenderness on like, palpations. I don't think any urgent investigations need to be coming up, but if the patient deteriorates or ever suspect something more sinister, I may carry out for the investigations. Would you like me to go over those? Ah, no, that's fine. So how would you manage transient synovitis. Okay, um to manage transient sign of itis. I think it's quite a self limiting disease, so management is very supportive. So I would initially like to reassure the parents of what's happening. Tell them that this is self limiting and I'll get better on its own. Yeah, um, are possibly safety net the parents as well and what to look out for in the future. For example, if if the joint comes worse or he developed the everyone develops a temperature or anything like that. Okay, um, I don't like to give the patient any antipyretic for the meantime as well to help with the, uh, if you're slightly pyrexia okay. From pain relief as well. Yeah. Farm. All right, let's go through it, then. Well done. Um ah. So with regards to the history again, you know, pretty much most things, um, asking about fever would have bean Good. Oh, yeah, You did. Actually, You asked about fever. Asked me about, um, weight loss and rushes a swell, because I think one of the things are easy to forget. Um, could cause joint pain. Is New York plastic causes? Um, like, sarcoma is, um the other thing is Oh, The only other thing I would probably say is it's probably not as relevant to ask about the relation relationship between the parents, uh, in this history. Um, just for report, basically. So there you got most of the things from the history because the differential is you're exactly right. Differential would be transient synovitis, but you want to run out of fracture because there is a because a There was history off trauma and B. And even if there's no history of troller, kids will have constantly have tumbles, and the parents will always know about them. So you actually would still do an X ray. And then, obviously you mentioned septic golf, right? It's a swell, but that's very low on that. We don't that's low on their differentials, because moment they don't look septic. They're not February fine, so the differentials of the limping child is a little bit more extensive. These are the most common things. So, like you mentioned, vascular perfect is I think the kids tend to be a little bit older with that effective cause. It's a transient side of itis. Don't miss septic arthritis trauma, so fractures Sufi is slips. A professional epifix see. So if the trial was quite heavy, um, bit obese, that's more likely. They tend to be a little bit older, is normal. Oscar? It shuts. His disease is that's, um, um also the knee knee pain rather than hip pain. So that will be, um, more like kids around 10, 12, 13 years old tends to be more boys and girls, um, who are quite active. They'll get this pain on the tibial tuberosity. And then if you've got all the kids who could potentially get ST I. So we talked about teenagers, you can consider things like reactive arthritis. Ah, juvenile idiopathic are for arthritis. Sock homos. Leukemias can cause joint pains that if you've no not systemic features that don't bother like investigating and then congenital things like developmental displeasure of the hip in younger Children. And if we're talking about just and a child who's and limping child, you can also consider Duchennes muscular dystrophy as well. Fine. So those that's the extensive list off differentials vestige a shins depending on where the pain is, where the tumble was, um, hip knee, your foot X ray. And like you mentioned, the management is very simple reassurance. Rest? Um, Paris. That small ibuprofen, whatever is. And it should be used by itself. Hi. So let's have a look if there's any questions. Otherwise eyes really all of the cases, Doctor. Okay. Oh, the other thing as well. Um, I forgot to put on my list of differential. That's considering nonaccidental injury, but, um, you need a bit more suspicion for that. So if the child hasn't got any, if the child hasn't got any bruise, if this story doesn't affect with with with what the parents is staying, then it's a bit more suspicious. But you don't you don't immediately safe bottle flood concerns for every child that's come in with, like, a fracture or, um a m a bruise. Brian. Um, um, all Children with a new onset live in. Yes. All Children with a new onset limp should be sent to the emergency department just because they need a an x ray. That should be happening in practice. Fine. Okay, I'll stand. What I'll do is I will go through the presentation, just fix up a little bit on, then I can get these sent out to you. Attendees. Whoever sending these out anyway. Fine. Yeah. Happy. We've sent the middle link in the chart. I'll send it again and then we can send all this point. Okay. Thanks, guys. Help! This is helpful.