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Hello, Yvonne. Um, we'll just give people a couple of minutes to try. Um, and then we'll kick off. Ok, fab. Um, we will kick off now, if someone can just put in the chart, if you can all hear me properly, that would be fantastic. So we can just kick off. Anyone can message in the chat that they can hear me and see my screen. Yes. No, maybe. Ok, we'll kick off and I'll show some more message if there's issues and we're not presenting properly. That's fine. Um, so my name is uh doctor. I am a pediatric sho here in the UK with about two years of experience with pediatrics near it. Now, um, we recently just some of the first part of the Royal college exams. Um, and today we're doing an ask to see the patient. Uh part two. So if you haven't checked that part one, it's a fun presentation where we go through some common situations and common things like hyperglycemia free prescribing, um and bronchiolitis. Uh and today we're gonna do some different scenarios. Um, so I recommend for the presentation that you kind of have something to write on um whether that be um, paper and pen or your phone. Uh I know, I prefer just discovering my phone or something to scribble on to. Um, but it would really help if you had that whilst we were doing it. Um And this is kind of our prep presentation knowledge quiz. Um So let's do is to gauge uh uh everyone else's own knowledge and you don't need to share it to anyone else. But if you take a couple of minutes to, to answer these questions that are set up here, uh, and we're gonna be going through the answers on at the end of the presentation. If you can't answer any of them. That's absolutely fine. That's kind of what the presentation is for. Um If you can answer them all, that's still fine. We'll still hopefully be able to teach you something throughout the presentation to let you hopefully pick up something, um, fabulous. So I'll give you all a couple of minutes to try and sort that out and answer them. Ok. Uh Like I said, we'll get through these questions at the end, but we'll just jump into the first scenario. Um So you are the F one parking on the pediatric assessment unit and your registrar has gone to A&E to see a patient with difficult access requiring a cannula. The team has just told you a, a child, the registrar accepted earlier from today. It's just an award and there's no GP that's ok available for them. Uh The triage team has told you that they've come with a fever and a cough. That's about all the history that you have at this point in time. Um And so we'll just go through some basic information you can get from the triage sheets. So we've got a female called Tony who's five years old and weighs about 18 kg and with grandma, she's got no past medical history. Uh and her current complaints are uh fever and cough. Um So for this first case, just from the based off that information should already be gathering an, an idea of what this patient might be presenting with what your kind of differentials might be moving forward. And again, remembering those common things are common and rare things are rare. So when we hear who we think horses, not zebras, so you're common for differentials or, or differentials might be at this point if you think about them. Um But you're thinking about things like low t infections, thinking things like uh upper tract infections, you're thinking of potential sepsis because things we don't want to miss, obviously, we're thinking about things that can uh is this going to be a viral picture? Is it going to be a bacterial picture? How am I going to differentiate that? And those are the questions you should be having in your head so that you can kind of know the questions you asked to the patient to kind of exclude any differentials you might have there. Um, so if we move on to kind of a history of the presenting complaint. Um, so I have Tony has had a four day history of a cough which is a dry cough or no cough. She had no heart disease, uh, no cris symptoms, uh, and she had fever for two days, uh, up to 38.5 degrees, but it doesn't come down with paracetamol. And grandma has not tried any Ibuprofen. She's no longer eating, but drinking over 50% of her normal fluids, no diarrhea or some vomiting after she tries to eat. Um, no preceding illnesses on foreign travel. Uh She had all her safe scheduled vaccinations. She had no relevant birth history, uh social history. His grandma has a parental responsibility for this child. Um and she's been developing well, gaining weight along her centiles and her sibling four year old male has been recently unwell of a cold. Now again, we can go think back to kind of differentials at this point that we already mentioned, thinking about uh low infections, think about upper tract infections, think about sepsis, think about pneumonia. Um We haven't particularly ruled out any of them. Um This could still be kind of a septic child depending on what the child looked like in front of you. Um, but we have a kind of a child that we haven't examined yet essentially with a, with a cough at this point in time, which is causing them to potentially have some vomiting as well. Um, we've got someone else in the household, uh, who's also recently been unwell. Um, which kind of could point towards a more infective nature that we're already thinking about as well. Um, so our first question is, what kind of advice should we be giving to parents? Um, or guardians about 12 and Ibuprofen. Uh, it's a really common question you'll have from parents and guardians about their child and when they should be giving Ibuprofen, when they should be giving uh paracetamol. So I'll give you a minute to kind of or five seconds to think about when you would be thinking about giving this to a child. And when would you be advising it? I know it's quite easy to think about on the ward because often the nurses will just say, can you prescribe this for a child? They've got a temperature but kind of when you're discharging patients or giving kind of safety netting advice, it's really good to be really clear, especially in new parents about when what they can give and when they can give it. So, um paracetamol, we can obviously give kind of four times a day maximum. Uh and we can give it a minimum dosage interval of about four hours, Ibuprofen. We can give three times a day with a minimum dose of intra around six hours. Um But what we really wanna kind of say is we, we don't want parents to, to panic and give them both at the same time. You wanna kind of spread those out throughout the day so that you have kind of good antibiotic cover throughout the entire day. Um So you're aiming for kind of good temperature control when the child is distressed by that temperature. So, uh obviously, temperature is a normal process. Um We don't particularly mind if a child has a high temperature when they're unwell, that's kind of expected. Um But if they are distressed by that temperature, then we will try and aim to control it. Um Other ways you can and see people kind of controlling temperatures is kind of stripping the child off. Um putting them in a colder environment sometimes. Um This can be a measure we can use. However, if that's going to make a child more distressed and make them more upset, it's not something we recommend. So as long as they're comfortable when they're doing that and it's not kind of inappropriate temperatures. Um So we're not sticking them outside uh on a day like today and that's something we can use um to kind of help pull the child off. Um But I'll move on to the next part of this case, which is the observations. So our temperature is 40 degrees. Uh our heart rates are under 100 and 40 respirate is 24. Uh BP is 94 to 64 and saturations are 100% with no additional workup breathing. Um So we've got a actual child. Um which kind of explains why we've got a little bit of a high heart rate as well. Our respirate is normal, our BP is fine uh and our saturation is obviously OK. So, on examination, uh it's always good to kind of approach things through a system in a fashion. And uh most people will use an A three system for examining a patient uh who's acutely unwell. Um So, um airway is patent and own as it will be for most Children in there. Anyway, just to kind of emphasize what we're doing. Um B your chest is clear, we've got equal element, but actually, there's no increased work of breathing. There's no wheeze. Uh see our heart sounds uh and uh plus one plus two plus a soft murmur loudest in the kind of the left sternal edge um which can be kind of a reference to a still's murmur. Um The uh the child is active and alert. Um in a younger child, you might have to comment on to the anterior fontanel here, but in an older child such as five, you could probably comment on uh their G CS at this point. Um Either the abdomen is soft, nontender, no megaly, spinal and submandibular lymphadenopathy. Um There's some enlarged FMS tonsils which are kind of grade free with some white that go and I don't know why I put about the lymphopathy twice. That's why. Um, so at this point in time I'll just pick up one of the poll. Uh, so we'll just run this one. Um, so what's our most likely kind of diagnosis at this point in time? Um, so give you all kind of minute to, to think about it. There, any answers you can think of. Uh, so we've got tonsillitis and pneumonia. So probably our most common different on this case is gonna be uh tonsillitis based on the examination findings. Um, pneumonia obviously is a kind of we have evidence on a chest X ray. Um Our, it doesn't appear to be a kind of a septic child. We don't appear to be kind of shocked doing clinically really unwell right now. Um So yeah, we're looking at more of the kind of tonsillitis picture. Um We've mentioned on this slide, a kind of a grade three and large tonsils and it's quite uh useful to understand kind of what this means. So you can kind of have an objective way of grading tonsils. So I've just got a, a quick picture for you here. Um So, um, often impedes you'll get referred, um Children uh with uh of unknown origin GPS or anything. We don't know what's going on. This child is unwell, can't find anything we've examined everywhere. There's no source. Um And that can kind of be either with like they've got some tummy pain, you've just got fever, they've got a cough. Um, so it just kind of a wide range of presentations in pediatrics. Um And so you have to kind of examine systemically and thoroughly everywhere. Um, and then it's important to understand kind of what are the tonsils I've had, people are saying they look, uh the tonsils are pull to the side and they say, well, do you mean the UVEA? Um And so, um just a nice little diagram to show kind of where the grading is. Um And this is particularly important in, in kind of other conditions as well. We're thinking about uh like an tis and stuff like that and um and just like uh swollen tonsils causing things like uh osa uh and enlarged tonsils, generally causing uh sleep apnea. Um So it's useful to diagram to kind of have an objective way of describing how big so tonsils are. Um obviously in an ideal world, this is the lovely view. You'll be able to see if someone's tonsils and a child will be really happy and open their mouth for you. Um This isn't the experience that I've had and I doubt it'll be the experience that you'll have more often than not. You'll have an upset uh unwell child in front of you who does not want to be examined has probably been examined already by someone else. Uh So already knows what's going to happen as soon as they see that little tongue depressor come out. Um So it's a good idea to get a kind of a good script of how to tell parents how to hold their child for the examination. So, um the way I usually ask parents is that I ask them if you put the child on your lap with their back facing uh your chest. Um If you put one arm over both of their arms and one arm on the forehead, um, to kind of create them in like a seatbelt, um, type style. Um, that kind of gives you the best chance of holding that child's head still and so that they don't use their arms, um, to kind of, um, pull you away. Um, one thing is that you just need to kind of watch out for the legs as well because you might, uh, catch a stray kick. Um, it's a kind of occ hazard, unfortunately, um, in Children that may be a bit more cooperative, then you can try and get them to open them up on them, say, um, saying, ah, roaring like a lion screaming as loud as they can. And that's kind of like different ways. You can kind of encourage them to open them up and it's worth trying that before you shove a tongue, the person down there for AM and gag. Um, because they'll probably thank you for it to that. But in the terms that they were just scream the rest of the examination. Uh So it's something usually done at the end of an exam. Um, and, um, when you're not suspecting things like Stridor, um, and you're concerned about the kind of the airway at that point in time. So if you are concerned about Stridor, um or concerned about the airway at any point, then you should not examine the child. Um, and you should just leave the child alone and get a senior support before you think about examining the child. Um So we'll move on to the next thing which is kind of the fever pain score. Um So um we've got a child with tonsillitis and we need to know how to kind of treat this child best. Um So we're kind of referring to guidelines here and guidelines suggest is and the fever pain. So score or the central scoring system. Um I personally prefer fever pain. It's got a little bit more kind of accuracy in terms of uh on the higher end of things, you've got a kind of a 65% chance if you got a five out of five fever pain score, whereas a cent score was closer to kind of a 50% chance of a streptococcal infection. Um So each um fever pain criteria scores a maximum of one point. Um So a maximum of five points totally um score of kind of 101 is about a 13 to 18% chance of a streptococcal infection. Um two or three is meant to be about a 34 to 40% chance, whereas four or five is closer to 65% or so. Um And that's the kind of likelihood of it being a streptococcal infection. Um So in this patient, we have had fever, we've had a cough. So we don't go for that. Uh Our symptom onset was kind of four days ago, but we have kind of permanent uh tonsils and we have kind of tonsillar inflammation. Um So we score three out of five um and kind of how we reference that across to what we would actually do next. Um So this is kind of a generic guideline of what you would do. You can obviously differentiate from this depending on um how you think the clinical picture is. But um we can give kind of a delayed antibiotics in this case. Um with the advice that if the child doesn't improve over the next 48 hours, if you feel like they deteriorated in any way, you can kind of start treatment at home. Um And like I mentioned, kind of this is only to support your clinical uh judgment. It's not to kind of replace what you think at this point in time. So if you think that's quite, they, they don't really score very high, but they've got really perent tonsils and, and you're worried that this could be more of a streptococcal infection, then um Absolutely go and treat. Um, but it's really important to kind of understand what we are, what the aims of the treatment are uh in terms of um strep cough infections and, and why we treat so that you can kind of understand um what we're trying to prevent and therefore give kind of bits of extra information in terms of the safety netting and have that in the back of your mind, in terms of extra risk factors for streptococcal infections as well. Um So what we're trying to treat is more often than not uh prevent either rheumatic fever or rheumatic heart disease. Um So that's, that's um our main thing that we're trying to kind of prevent or treat in this case. Um So if you kind of a quick, a quick look at what rheumatic fever is, um it is a type three hypersensitivity reaction due to streptococcal a infections. Um So just a quick reminder, type three reactions are due to a antibody immune complex. Um And we'll find in rheumatic fever, it's kind of typically presents kind of 1 to 5 weeks later with the kind of the medium being around three weeks. Um So medium presentation is usually three weeks after a streptococcal throat infection or sometimes a streptococcal skin infection. Um It is the worldwide leading cause of pediatric cardiac problems and cardiac death in a pediatric population. Um and it's a huge problem more in terms of kind of low and middle income countries. Um And I'll move on to that in a moment. Um But we need the um the diagnosis is sorry, is based off the Jones criteria. So, um Jones criteria requires um evidence of a strep um infection in the first place. So that can be kind of a positive culture, a positive swab culture um or kind of a oitis if the child's not presented for the initial infection, um or we haven't had a positive culture. In that way, we can use a otitis to kind of demonstrate that we've had a streptococcal infection. Um And then the rest of the Jones criteria suggest that we need to have two major criteria um or one major criteria or, and two minor criteria to fulfill the diagnosis and then just to quickly go through the major criteria, um you're looking at kind of things like polyarthritis, carditis. Uh S name is chorea erythema margin and subcutaneous nodules. Um So again, that is polyarthritis, cardiac carditis, Ham's chia erythema imagin and subcutaneous nodules. And it's quite useful to remember those major criteria. Um Just so you can get kind of really accurate and really good safe netting advice. Um And moving forward. Um If you're looking at discharging these Children, um I mentioned already it's more common in low middle in countries. Um That's particularly due to the introduction of antibiotic treatment for potential strep a uh infections. So, um that's kind of the exact the the reason why it's less common in high income countries just because we are better at treating it better at recognizing potential cases. Now, um it's still endemic in some lower middle-income countries. Uh in particular, um indigenous population of New Zealand and Australia um may make you feel like if the child kind of recently traveled there, it may make you more likely to uh diagnose or treat this child as if they had a streptococcal infection. Um, so if we go to our case, although our kind of fever pain score was three out of five, if, in the case, we had a recent travel to, to India or Sub Saharan Africa. Um, we have, have a lower threshold for kind of starting treatment in the child to prevent uh, rheumatic fever. Fabulous. And then we'll do a couple of what ifs. Um, so what if, first of all, Tony had never had her vaccinations and on examination, uh, there's a grave film covering her tonsils? What might the most likely differential be? In that instance? I just run another pole for you. So that is, or if Tony had never had her vaccinations and examinations, er, showed that she had a gray film covering her tonsils, what might be the most likely differential in that instance, what organism might be kind of causing it here? Give you guys a minute to kind of think on this. Um, it's not something we kind of might see as often it's kind of very classical in terms of textbook in terms of exams as well. And it's good to kind of remember this presentation moving forward as well. And I hope none of you have to see a presentation of it as well. Just see, let me give you guys a minute still. OK, we might be struggling with this one a bit more and that's absolutely fine. Um But so the answer is going to be diphtheria. Um So diphtheria kind of classically causes the gray pseudomembrane covers tonsils, which is kind of described in this case, it's obviously not kind of relatively uncommon in the UK due to a vaccination schedule. But again, um we're seeing a small like rise in the incidence or prevalence of um Children who have not been vaccinated. Um So it may be something you might consider in uh a child who's kind of traveled from abroad who's unvaccinated. Um and has kind of those clinical features of those that kind of gray film covering the tonsils and potentially some kind of breathing distress at that point in time as well. So it would be one of your concerns as well. Um I'll move on to the next question. So again, a very similar kind of what if scenario. Um So what if Tony had a white coating over her tongue and red papules and a widespread raised rash with a rough texture? So I'll just throw in another hole for everyone. So what if Tony had a white coating over her tongue, red papules and a widespread raised rash with a rough texture. What might be thinking about at this point in time in general, I'll give everyone kind of a minute to think about this. Fabulous. Um, so our answer here is going to be uh scarlet fever. Um So if we kind of go through our differentials that open up Kawasaki, you're thinking about your five days of fever, your squamous. Um this conversation of the digits, you're thinking of your dry cracked lip, your conjunctivitis. Um and the generally kind of unwell child in front of you scarlet fever. You classically here, you've got described the strawberry tongue, which initially starts as a white, white coating over the tongue with red papules and then moves to kind of later on to a very red tongue with, with, with red kind of pops on top of that as well. Um So you got that classic kind of white strawberry tongue moving into a red strawberry tongue in a later presentation. And then our widespread rough textured rashes are sun paper rash, which again, uh we love to throw out on exams, but we don't like to call it sun paper rash as an exam sometimes to make it a little bit harder. So they like to, you can refer to it as a rough texture, but when you do feel it, it it has a rough texture to it, um measles can present with a um with a, a rash as well. Uh And can we can have some kind of um mouth signs associated with it? It's usually a um post navicular rash which spreads to the rest of the trunk or. Um So you get kind of that migration of the rash moving downwards. Um And then obviously you get the um the car spots and stuff as well and then Parvovirus B 19 is our slap cheek. Um, so I'm thinking about kind of bright red cheeks in that case there. And then, um, again, another, what if, um, so what if been sent to a GP and then started on a course of amoxicillin and then she presents to any with a rash, um, which looked like the following. So again, I'll give her a quick poll for this as well. Uh Sorry, it's the pole part of the presentation, isn't it? Um So I'll put the rash up there for a minute. So everyone gets a good chance to answer. Um, but again, Tony's been seen by her GP and she started on a course of amoxicillin and then following that presented to the rash due to pin to a, with a rash, which was the following. Mum's wondering, has she had an allergic reaction? Um, what's going on? Fabulous stuff. Um, so you may have noticed in this case, it's a semi trick answer in that all three answers are correct. So, uh Epstein Barr obviously is also known as mononucleosis or glandular fever. Um It's a little bit more common in that of the older age groups. So you're looking at closer to about 14 to 25 or so um as it passed for your saliva, so also known as kind of kissing disease in some circles. Um and you commonly have this kind of hypersensitivity reaction, um which is not an allergic reaction to amoxicillin. Um But you get this um forward looking appearance of the rash um associated with penicillin treatment in this, in this uh a group of patients. Um So that's great. So, um if we go back to our original Tony, so not Tony with the Epstein Barr, not Tony with rheumatic fever, not Tony with, I don't know what else I gave her. Um, not with Scarlett fever and not with dip. So original Tony um with a um fever pain score of three. who is kind of not eating but drinking and clinically well, well, well hydrated. Um and doing generally quite well. Um How do we treat her? So, um our first line antibiotics for a potential kind of streptococcal infection is um phenoxymethylpenicillin or pen V is what is commonly referred to as. Um, and it's usually kind of a 5 to 10 day course. Um Now, um, if you were concerned about strep cough infection, like we mentioned particularly. Um, so if you had any kind of travel history or she was really unwell. Um, you might think about just starting that straight away. Um, and that's absolutely your clinical judgment. That's fine. Um, Dilem, um, or benzoine hydrochloride, um, is a really kind of useful thing particularly in pediatrics. Um, so it's a local topical NSAID, which can be quite useful in kind of acute pharyngitis or tonsillitis to allow patients to eat and drink, particularly in Children who will vomit quite often if they, um if anything kind of touches that sore area at the back and cause them to vomit and they're o often able to kind of communicate that's where it hurts and that's what's causing the problem. Sometimes they will tell you I've got tummy pain and they will have kind of tonsillitis picture and that's where that kind of comes from is that when they're trying to swallow, they'll have that kind of pain, um which can cause them to vomit. Um So it's uh useful to, to think about Dipam um and trial dila particularly in a dehydrated child. Um or someone you're looking to kind of discharge home who's not drinking. Um Going back to what we said about our last uh asked to see the patient session about kind of your fluid challenges as well, but we're giving kind of 5 to 10 meals every 5 to 10 minutes. Um And then seeing kind of how they're doing in that presentation whilst that on our unit, we have the luxury of kind of um assessing them over a period of an hour and seeing if they can kind of tolerate um, fluids and if they can tolerate it with Dila, that's absolutely fine. If that helps, we can send them home with Di um, so we can give it kind of before they try to eat and drink anything as a general advice and can be given kind of every two hours after the initial dose. Um So I think it's one spray for every 4 kg the patient weighs um but it has to be an f as always. Um And then we move on to our safety netting advice. So, um particularly important in in cases like this where you're discharging a child's home or potentially hoping to discharge this child home, um which obviously will probably be a senior decision at this point in time, but they may get, get you to, to do it after you've discussed it with them. Um Or after the child has passed their third challenge on the ward if they, if that's what they require. Um So good safe netting advice is kind of what generally the first bit is what I usually say to most patients. So if your child's becoming more lethargic, if it's persisting for more than five days, if you've got less than a 50% of their normal fluid intake, or if they're generally unwell or you're otherwise concerned, then to bring them back for reassessment and lots of units will give them kind of a 24 hour, 48 hour open access for these patients so that if they do deteriorate further, um they don't have to go back to A&E they don't have to go back to kind of um GP. And this is really useful, particularly in the patient groups that are kind of like um scoring 0 to 1. So there's no kind of antibiotics indicated, parents can feel that they've kind of been fobbed off a little bit and you're just telling them it's most likely gonna be a viral infection. It's fine, bla, bla. Um But um this is a good way to kind of like encourage them. No, I think it'll be fine. Your patient, your child doesn't need antibiotics and it's not indicated, then I think it's gonna be have more harmful effects and good effects. So, obviously, if every drug has kind of negatives, um so often antibiotics, you can often cite that they might give them diarrhea uh and kind of worsen problems in that regard. Um So um it can kind of make them happier if you kind of think about giving them some open access as well and give them, makes them safer. And again, it can give you kind of peace of mind as well that um this child's uh discharging without kind of treatment or antibiotic treatment, um has a way to come back, should things kind of worsen or develop? Um And then um the last kind of line for si think is specific for the um rheumatoid fever, which again, as we mentioned is the thing you're trying to treat. Um the thing you have about most is kind of prevention of this. So any joint pain, any rashes, any jerky movements, any limb swelling, chest pain or hematuria. And and I've just phoned in hematuria for kind of like a post strep nephritis picture as well, which we're not gonna go into today. But um it's kind of AAA complication of streptococcal infections as well. Um And obviously, as well as uh joint pain being a feature of the Jones criteria for rheuma, rheumatoid um fever. It can also be kind of just a picture of a standalone reactive arthritis or post reactive arthritis as well. So as I mentioned, kind of, I'll take, take home points for, for this kind of case and for this, um this week's presentation, it's our advice about antipyretics. Um So advising them again to kind of spread that administration out alternate doses so they can charge can remain comfortable throughout the day and not to kind of give everything together at the same time. Um How grading tonsils. So um if you ever kind of have any questions about it, just quickly search up the image after you've seen the child. So you can kind of compare it to what you think it would be. It gives a nice kind of objective opinion that the next day, the clinician who's reviewing them might not be yourself. But again, can see, are these tonsils getting bigger? Are they getting smaller? Are they always this great? Is this kind of potentially a picture of like um just a patient who has enlarged tonsils and then thinking about kind of other problems like OSA as well associated with that. Um and then our fever pain score. Um So again, to go through that again, we're thinking about how we'd ask that during our kind of history and our exam. So fever in the last 24 hours, symptom onset of less than three days, absence of cough, inflamed tonsils and to date on the tonsils, um A can cause rheumatic fever, type three hypertensive reaction and the leading cause of cardiac problems worldwide in pediatrics, um which can also cause scarlet fever, um which is classical our sun paper rash in our strawberry tongue and a rash after a course of amoxicillin for a sore throat or pharyngitis or even a tonsillitis. Um You should be thinking of a high suspicion of is this kind of a mononucleosis glandular fever, Epstein Barr picture. Um In which case as well, we need to be thinking about different safety, letting advice in terms of kind of avoiding um um active contact spots in case of kind of spur megaly, um and splenic rupture and stuff like that as well. Um So I'll move on to our post presentation called knowledge quiz. Um I'll give everyone another minute to kind of read through your questions again and think about any answers you might want to change now that you know the answers, hopefully. Um So we'll go through this in just a moment as well and then we'll give an opportunity for anyone to ask any questions by either just uh unmute yourself after this or popping it into the chat. Um So if you want to think of any questions, you might have as well. If you don't want to change any of your answers, then um that's absolutely fine. If you pop it in the chart, I'll check it in just a moment and then we can move on to the rest of it. Um So, um what is the name of the criteria used to determine the likelihood of a streptococcal throat infection? Um We can use the fever pain scoring system or the cental scoring system. It didn't really go through cental today. Um As I mentioned, the fever pain is a bit more specific. Um But if you would like to use uh cental, I think the evidence base is, is just as good really. Um What are the features of criteria as you mentioned already is the absence of cough. It's the fever in the last 24 hours, the symptoms onset of less than three days per tonsils and inflamed tonsils. So, those are the questions you need to be asking in your examination, if you feel like the child might have tonsilitis, um preventing what complication is one of the main indications of treating kind of an infection or tonsillitis with antibiotics. Um And we're thinking about um rheumatoid disease, obviously, uh I will also allow um a kind of a post streptococcal nephritis and post reactive arthritis as um although this wasn't something I went to into in today's talk, obviously, both causes of kind of post strep infections. Um, but mainly what we have spoken about today is kind of rheumatoid, um, rheumatic fever, sorry. And then what is dim or Benzide hydrochloride? Um, it is a topical NSAID, um, which is particularly useful to encourage oral intake in the pediatric population for patients with er, inflamed or sore throats. Um, so you can feel free to contact me by uh, any questions you've got right now in the chat or, or meeting yourself. Um, or just let me know kind of what you want to see me cover in future presentations. Happy to cover any kind of pediatric or neonatal topics that you don't understand, uh, or that you're not happy with. Um, if not, I'll be kind of continuing the ask to see the patient series um, as soon as I can, um, with the next presentation and then number um, on a different case, um, I'll send the feedback form into the chart now and have a look at it. All right. No. Fabulous. So, forms in the chart, make sure you fill it in so that you get your certificate of attendance. Um, please do pop anything in the chart if you have any questions at all. Um, I'm very happy to answer anything about, kind of see what it's like to be working in pediatrics in the UK or what, um, exams are initially like for training in pediatrics, um, applications to ps anything you want me to go through, just put in the chart and I'll, I would go for it now with you guys or set up for another session if it's something you wanna see in the future. But thank you very much. If not, uh, I'll stick around for the next five minutes. Um, if anyone wants to, um, email or anything like that I put up in the chat and I'll stop talking now as well.