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Hi, everyone. Can you hear us? Ok, let us know in the chat if you can, Jessica. Do you wanna try sharing your screen again? Yeah, we'll give it a go now. Perfect. Can everyone see the slides? Ok. Yeah, it's looking like people can Jessica. Um, and I think we probably, I think people are kind of slowly trickling in. Um, but it's up to you whenever you want to start. Um, go for it. Um, and in the chat, if you need anything, people will tell you if they can't do the slides, um, if they need you to speak up, et cetera, et cetera. Um, but yeah, I will let you start whenever you want fab does that still show as a full screen or is that showing the metal platform? It shows as a full screen that we can see the whole of your slides. Um, it's just within the stage on the metal platform. Ok, we'll go with that then at least I can see the chat and things. Perfect. So that'll still work. Ok, let me just put that over there. Ok. How many do we have? Ok. So we're about five past. So we'll just get started if there's any issues at all. So you can't hear me or if it feels like I'm shouting down the MS, I'm using a new headset. Just let me know um pop questions in the chart as we go along more than happy with that. Um And we'll get started. So um as you probably already know, this is obviously Code Blue teaching. So some sponsors here, um you get some discounted over there if you're interested. And as always disclaimer that it doesn't replace any of your formal teaching from your university, um just aiming to supplement what teaching you get already. So general introduction. So I'll do an introduction to um the teaching, but also to myself. So my name is Jess. I'm a current F two in the Northwest, currently working in A&E with an interest in Pedes. Hence why I'm doing the teaching today. So we'll probably do the teaching for about 40 45 minutes allowing like 10 to 15 minutes for questions and then you can all get up and enjoy the rest of your evening. So if things are gonna cover so pediatric case history taking and examination, just briefly touch on those. We're then gonna work through three case based discussions and we're gonna sort of talk around and bring in different themes as we go through them. And then as I say some time for questions at the end, let me just make sure I can see the chart. There we go. Ok. So pediatric case you're taking. So it should mention as well. I'm gonna try and make this as interactive as possible. Feel free to pop stuff in the chat or turn your mic on. So generic question, how does the structure of a pediatric history differ from an adult history? Any suggestions in the chart? I'm sure you all know this, but just a good introduction. Yeah. Amazing. So we've got that we rely more on the collateral history depending on the child's age. Exactly. And really important when you're actually in clinical practice to document who you got the history from. Did you get it from the child or did you get it from mom? Amazing. And then we've talked about inquiring about birth circumstances development, et cetera. So just before we went through the cases, thought it'd be worth highlighting this. Always think about who they're with. What's the relation to the child, the usual history of complaint, past medical history, et cetera. But we've got this extra bit about sort of antenatal and birth history. Don't forget to ask about the pregnancy as well for mum, um the development under immunization. So those things are specific to peds. Obviously, you want relevant family history, social history for peds is gonna be a bit different. So rather than your classic alcohol smoking, which obviously may be relevant in an older child, but you're gonna think about things like, are they at nursery Are they at school? Are they enjoying it? Are they thriving as expected, et cetera? So mean uselessly on we're gonna talk, go through a respiratory case based discussion. So you've got a six month old baby, brought, brought to A&E with five days with coral symptoms, worsening, difficulty in breathing with reduced feeds. No past medical history. Born at term via vaginal delivery with no complications, they're developing as expected and their immunizations are up to date. So, what other things would you want to ask to try and ascertain what's going on again? Pop them in the chat, turn your mic on whichever you prefer. Just generic things. Brilliant. Getting lots of responses coming through. Thank you. So, yep, fever or rashes, cough. Brilliant. Anything else? Anything else you can think of? Brilliant? So we started to think about any sound abuse or any added noises thinking about like upper airway sounds anyone else in the family. Unwell. Brilliant. Yeah, I think this is an infectious sort of picture where they have caught it from number of wet and soiled nappies. Brilliant feeding happened before. Amazing. So you've nailed a lot of the key ones really. So things that I thought about asking and I generally asking a so it was mentioned about rashes because you're thinking obviously sepsis. But loads of other things that can cause rashes, the wet nappies in the bowels and I think whoever popped it in the chat did distinguish between the wet nappies and the bowels and really important just to, you know, clarify that with mom and dad because obviously there's changed napping. If you asked if they had wet, wet nappies, they might not clarify, you know, which one. So asking how many wet nappies is it a good amount? How many would they have normally had? Just to try and gauge an idea of what the urine output is? We mentioned, fever is really important in Children. They often give us an indicator of, you know, whether they're unwell or not. As they can't often tell us we've talked about feeding specifically asking sort of what amount of their usual feeds they're taking a couple of things we didn't mention were things like engagement. So by this, I mean, you know, is the baby sort of engaging with mum and dad as expected when you're in the room, are they trying to look at you or are they just not interested at all? Are they drowsy, lethargic, et cetera? Another really key thing um in a particularly young child presenting with any respiratory condition would be apneas. Um Often one that's frequently forgotten to ask about. Um often mom and dad will mention if there's anything significant but again, really good one to think about. Um and we'll talk about why later, but really well done. Thank you for those responses. So moving on from that. So think about the history and going on to the examination, what type of things would you be looking for on examination? And the key thing here is looking for getting some responses? Great, amazing. So we're all using that sort of buzzword of the work of breathing. So people suggested like nasal flaring head bobbing, et cetera muscle use brilliant costal recession for teel talk. Yeah, we look for rashes, brilliant. So you've also got what I'm getting at here. So in any kid who have any respiratory condition, we always think about work of breathing. Um And this is something that you must must for your finals, but also for when you qualify, you must be confident at recognizing increased work of breathing in kids because I can tell you now in A&E 80% of it is respiratory stuff and you're constantly assessing work of breathing. So the things that we can look for for work of breathing, we've mentioned nasal flaring tracheal tugs obviously sucking in at the p recessions. You've got both intercostal and sort of subcostal recessions. You can also when it's really severe, get sternal recessions, that's generally in the sort of really younger babies, but literally their sternum ends up pushing in and out cyanosis, both peripheral and central upper airway sounds, sees sore breathing. So this is when the chest and the tummy sort of move up and down like seesaw indicating there's an increased work of breathing and rashes, as we've said, the only other thing I've put mentioned on here is the Fontanels, obviously, if you're thinking about hydration in babies, we generally don't measure their BP. We do do the cap refill, but having a fear of the fontanels can also give you an idea of how hydrated they are. Welcome. Now, I'm hoping these will work. So, let's have a little play. Oh, so can everybody see that before I keep playing it fab? So I want you to have a look again and just have a think about what you think you can see. Ah, ah, um, so in the chart, what kind of things do you think you can see there? Because we always talk about it, but actually recognize that the child can be a bit harder. So, what things did people see in that video? Brilliant. So, yeah, we've got costal recessions and I'd argue, you've probably got sub and intercostal there. The intercostal ones you can generally see better at the sides if you're not sure. Have a look at the sides. Accessory muscles. Yeah. Yeah, I argue. Think there could be some grunting there. It can be sometimes tricky with grunting between. Are they nasally congested? Versus sort of, is it natural grunt of the upper airway? See, sore breathing. Yeah, you could see their, their belly coming out. Subcostal recession. Great. If you look closely, you can also as well see a bit of tracheal talk. I know the head's not fully back if you just sort of look in the neck you can see it being sucked in at times when they're breathing. And if you look closely at the nostril, you can all see a little bit of nasal flaring as well. Really good trick for looking for to get mum and dad to hold them and just slightly lower the head down so that you can properly see um, their neck just because of how babies are. It's really difficult to look sometimes and then let's have a quick look at the next one again. Have a think what you think, you see, what do you think? I mean, it does tell you but head bobbing exactly where it tells you at the top there. But, um, not one you see often it's quite a severe sign of respiratory distress. But I think often when people don't fully understand what it is, but that's a really good example of head bobbing. I've only seen it once in A&E. Um, and obviously we're sort of getting into the, the peak of conditions for kids. So not one you see as often as the recessions, the peel tug, et cetera, but one to be aware of. Ok. So just moving on from that, I thought I couldn't do peds and I couldn't do sort of, you know, particularly younger Children without mentioning the nice traffic light system. You don't need to know off by heart in terms of the heart rate ranges, respirate ranges, et cetera, but really useful to be aware of some of the features that are gonna make you more concerned about an unwell child. So I'd definitely make sure you're familiar with that. So when we do our examination, they're engaging, they're looking around, they do have a tracheal tug, but it's just mild. They've got some subcostal recessions on auscultation of the chest. There's some widespread crepitations and wheeze normal heart sounds. No rashes. Fontanels are ok with a good cap refill. Heart rate is 1.52. It's a little bit tacky for their age. Respirate 52 again, a little bit tachy for their age and sat to 95% on room air. So I've just popped your pews here again. Probably something you're all aware of. But just remember there are different pews charts for different ages. You don't need to remember all the different ranges, but just be aware that it's different for each age. And you can see here at the top that they do score for their work of brain. So again, another reason why you really need to be confident at assessing that. So based on what we've got, what's your working diagnosis and why? Ok. So I'll wait for a couple more suggestions and then and try and if you can in your answer, put, why you think that's your diagnosis? What in the history is pointing you towards that. So I've got one take so far. So if we summarize, it says six month old five day history of coral symptoms. So, snotty nose, things like that. But in the last day or so they become more short of breath and reduced fees. So, mum's concerned and brought them in when you examine, they've got a mild increased work of breathing and when you listen to their chest, they've got widespread wheeze and cramps fab. So we're getting some answers. So everyone is saying bronchiolitis, some of the reasons being the age, the viral symptoms, the respiratory picture brilliant. And you're right, it's bronchiolitis really, really common. Key things in the history is the age. So bronchiolitis generally less than 12 months, it's generally got a history of carrizal symptoms and typically it peaks at about five days. So you'll generally get a few day history of carrizal symptoms if it's just they got carrizal symptoms yesterday and then they're unwell today. It doesn't quite fit. Obviously, it's still possible but usually worse around sort of day 5 to 7. The reduced feed is really common again in bronchiolitis. Um If anyone think why they often have reduced feeds when they've got bronchiolitis, any ideas. And this is one you'll commonly have to explain to parents because they become really concerned when babies are feeding. So you've got Yeah. Yeah. So the main reason is it makes it hard to breathe. So babies, especially when they're born, they are like obligate like nasal breathers because obviously they have to feed. But as they start to get older, particularly when they get sort of a few months old, they start to breathe through their, their mouth as well. So they're using a combination of both. But then when they've got bronchiolitis, when they're feeding, they also have to breathe through their nose. But they've got this upper respiratory tract infection often got a lot of congestion. So it makes it a lot harder to breathe. So you'll find they'll be reluctant to feed for prolonged periods of time. Also having a really full tummy can make it harder for them to breathe. So they often don't like that feeling of having a full tummy. So they'll be off having the feeds generally. And I think sort of explaining that to mom and dad um can often really help ease the anxiety. It's completely normal for them to be off their feet when they're struggling with their breathing simply because of how the babies breathe. So just a quick bit of sort of pathophysiology, et cetera. So I would suggest inflammation of the bronchial is most commonly RSV and generally less than 12 months in terms of why it affects infants so badly. I always pronounce this wrong. Forgive me. But Purcell's law where the radius is to the power of four on the bottom. The reason babies are so badly affected by the virus is because their airways are already narrowed. So you get a bit of inflammation, so you're narrowing already tiny airways. So it makes it difficult to breathe. And again, that's something really useful to explain to parents because they think, well, it's just a virus. Why are they so unwell but explaining why that makes a baby so unwell can again, help them understand, help ease that anxiety and make them more confident in managing this at home if appropriate, thinking about where to management, manage them. So criteria for admission, again, these are things I would really be familiar with. Um, because it's probably fair game to ask you this. You know, you wouldn't be making those decisions but being aware of it. So we generally say 50 to 75% less, um, 50 or 75% or less of their normal feeds. One thing just to bear in mind it is really, really common is so many people overfeed their babies. So we generally say about 100 and 50 mil per kilogram. So if mum tells you, oh, they've only having this much and you work it out about 70% of their normal feed. If you actually work it out of what percentage is of what they should be having. Often a lot of them are ok. And then it's actually explained to them that so they're overfeeding and actually overfeeding them can make all this worse. So when you're looking at their, how much feed they're having, always look at what they should be having and his mum over feeding them or dad. And also look at, are they hydrated as well? Because sometimes obviously parents become concerned, they feel like they're really not taking much food, but actually they must be taking enough because the fontanels are fine. They've got good urine output, good cap refill, et cetera. So really take it into context and just think about what they should be having feed wise anyway, saturations less than 92 apneas high puss. Generally, we don't seem to send any anyone home with a PS of two or above really, to be completely honest. Um You generally want to send them to peas for further assessment, at least in our A&E and generally at the lesson sort of three months or got any preexisting conditions. Again, you'd just be more conscious and you probably seek pediatric opinion if you were working in A&E. Another thing that's often mentioned is this parental and cars of confidence and concern. Um Definitely worth addressing, you know, if mum's really anxious or something like that, it may be that you admit them. But often if you can give them these bits of information that we've talked about that can really ease that anxiety. And I know I definitely had an owy explaining bronchiolitis to a parent and talking about all the things of why it causes them to be, you know, so short of breath, why it affects their feeding, what mum can do, et cetera. So management of bronch as you'll know, generally supportive. So we can give oxygen. Just make a little note that it is different, the threshold for oxygen if they're less than six weeks or more than six weeks. And it's different from adults where we generally say sort of less than 94. So less than six weeks, 92 more than six weeks, 90 we can support their intake. So we can do this by giving them supplemental IV fluids. We can do an NG if necessary. But as I've already mentioned, the key thing here is to avoid overfeeding. So generally bronch babies who are admitted will be on about 75% of feed. Anyway, it'll be purposely reduced so that they don't have that full tummy to help with their work of breathing. You can also do saline nasal drops and suction and ventilatory support, which can be in the form of vapor firm CPAP or a very severe um intubation is everybody happy with what Vapo FM is because you'll have probably seen it a lot on the wards, but is everybody happy with what it is? No. Ok. So Vapo the is basically just humidified oxygen given at pressure. Um So it's just sort of a different way of giving the oxygen. It's not, you know, not the same sort of pressure as the CPAP. It's basically just this humidified oxygen, um which just helps a bit better with the breathing. So if you're going on steps, you just have oxygen, then you'd go to V then you'd go to CPAP but then intubation. So what if it was a two year old presenting with a five day history of coral symptoms, cough and worsening, shortness of breath. I've put here what would be differentials but clearly not um put on animation on this one. So we've got it up here. But I think the main point I'm trying to stress is that all these respiratory conditions can really become a bit confusing, impedes. So try and learn the key things that are gonna distinguish them from each other. So one good thing is age bronch, generally less than 12 things like asthma. We only think about over five years croup. You've got this classic barky cough, viral wheeze. You generally only gonna hear wheeze, you shouldn't really be hearing crepitations or anything like that. Um A pneumonia, the main thing there is gonna be focal crepitations. So, whereas in things like bronchiolitis, you'll hear them all over the chest. If you've got focal one sided crepitations, you're more likely thinking pneumonia. Ok. Again, whilst on the topic, vaccination schedule, I know it. II hated learning it um, at med school, but it is something that's worthwhile knowing even if you just know, you know, briefly when they have them and roughly what they have when you, you don't need to know it inside out. But that's gonna help you in thinking about what could be wrong whether or not they've had their vaccinations and particularly when you've got your premature baby just making sure you clarify what they've had. Um, they should be having it as per the usual schedule. Um But again, just check that and as boring as it is, I would make sure you learn at least have an idea of the vaccination schedule. So, key things we've covered in that case. So we talked about history taking how to examine an unor child. And as I say, knowing how to identify an unworldly child, looking at things like the nice traffic like system, um knowing how to identify respiratory distress is really, really key skills as a foundation doctor, you because as a foundation doctor, you aren't gonna be expected to make, you know, make big decisions about the treatment, but you are expected to recognize an unwell child. Um and then we've had a quick touch on common pediatric respiratory conditions. Is there any questions on that before we move on? So it's about four weeks early. So generally they like to do it just at the age they should be. So, you know, when they are eight weeks old, as in just eight weeks from the womb, the reason being is that the premature babies are actually more at risk than the full term baby. So that's the argument for having them at the usual schedule. Um And that's what would generally always be advocated and most of them do have that. But again, just worthwhile checking any other questions. I'll keep an eye on the chart and I'll just sort of introduce the next one. So I felt like I couldn't do a Peds presentation without touching on mental health. Um Obviously, there's a wide range of the acute presentations of mental health impedes and the chronic, but it's becoming increasingly more common. Um And it's something that you could encounter whenever you do where you do peds, where you do G ep A&E even as adults, you will see some of these Children who then obviously become grown ups with these conditions and just going back to the questions, the traffic light system. Um I'll make sure you get access to these slides, but it's like a nice um basic traffic light system. There's green, yellow, amber and certain signs and symptoms fall into either green, yellow or amber and it's just there to try and help you recognize an unwell child. And it's designed for kids under five. If you type in nice traffic light system, it'll come up on the internet, but it's just a good resource for knowing how to recognize an unwell child, but it is different from the Pugh score. So mental health. So you've got a six year old child brought to the GP by a parent due to concerns about her development school have expressed concerns by a communication skills and a lack of social interaction. She's got no past medical history. She was born at home with no complications. No antenatal issues, older brother who is developing as expected, mum noticed from an early age that she was different to her brother but didn't feel it was impacting her life until she started school. So touching on development, what domains can we split development into? So what sort of categories can we think about? So you've got fine motor gross motor speech, social. Exactly. Brilliant. And James said the same. So yeah, you've got your four main domains here, gross motor vision and fine motor, hearing, speech and language, social, emotional and behavioral, again, development and similar to the vaccines. It's just one of them that it can be a bit tedious to learn. But again, worthwhile, I always like to picture it as I had almost like a child in my head and thought about the journey what they would do. But however, you best remember it, these images are from geeky medics and just give you, you know, a generally good idea. So thinking like gross motor, you'll be able to have some head control 6 to 8 weeks, be sitting up 6 to 8 months, start crawling um sort of 8 to 9 and then standing by 12 and for some of them will be walking. You'll often hear a lot about this sort of building blocks as well. Um Not something I've seen done commonly, probably only like community peds, click and things. But a come on in exams for the drawing, you might have seen people do like a stick man. Um I think if you do that, you'll find it so that can help the way you draw the stick man can help you remember the different ages, speech and language and then your social motion behavior. So key ones for the social will be like when they smile, when they start to reach out for things, when they start to feed themselves. So you get some more history from the school who say that she doesn't play with all the Children at break time and shows no interest in imaginative play. However, she will happily spend hours in school greenhouse, tending to the flowers, she becomes distressed, the class routine changes and it is very difficult to calm her down. So what's your top differential and why? Ok, good. So a couple of people saying autism, now, what makes you say autism, what sort of features in that history are making you think that because you've got poor social skills thinking about the routine, liking one thing? Yeah, great. So you're right. It is autism. And can anybody think sort of what three categories we can split autism symptoms into? And we've got sort of one of each in this history. So if we think about the sort of three categories you've generally got social communication behavior. And that's one of those you ever asked to define what autism is, explain what it is, it's thinking about the social communication and behavioral elements. So, I mean, I won't go through them all because you see them on the screen. But for like, this young girl, we've got, she's not interactive, not having imaginative play doesn't seem to be making much friendships, like physical contact, communication wise. They can often take things literally or really struggle to express their emotions and behavior. As you've got the classic sterical um sort of behavior movements, intense interest, apologies for the typos have been on nights when I made this power point. Um And often you might get restricted food preferences. Now I popped the arrow on here just to remind you that it electrum. So you can get a really, you know, broad presentation of autism. Does anybody know which gender it's more common in and any idea why? Why? Yeah, good. So I've got a couple of people say male and it is more common in males. It's about 3 to 1. Does anyone know why it's more common or why we think it's more common? So you're right. It is more common in males as I said about 3 to 1. Um A lot of the theories at the moment is that it's more common in males in terms of the statistics because females are generally better at hiding it. If you think about some of the symptoms, um symptoms and signs, often they think that girls sort of copy and mirror other people's behavior a bit better. So they almost disguise it more. So it's not necessarily that it is more common in males, but at the moment, diagnostically, it is. Um but there's quite a lot of work going into trying to get better at diagnosing it in young females. And yes, as far as I said, they generally tend to hide it better by following, following others actions um really, really prevalent and as I've said before, something you will see in pes, but also in adults, you will come across autism wherever you work. So something worth being aware of it does have a lot of associated conditions. Um You've got depression ad HD is a really common one, auditory processing disorders. Um Lots of um other conditions there. So in terms of the management of ASD, if you were asked this being an sy or in any kind of question, what would be the buzzword for managing autism as soon as you say this word they go. Oh yeah, they know what they're on about. So you got bi Yeah, I completely agree that that wasn't the word I was thinking of in terms of management, but you're right, you definitely do address all of those. So, you know, would be another buzzword psychotherapy. We sort of do less psychotherapy um in Children with autism. But yeah, II got it right. So M MDT, so I completely agree. Uh psychosocial is obviously the crux of the management. But the main thing that you want to say is an MDT. It requires so many different clinicians to help manage autism. And that that is the key is if you were on, you say, oh, it would require an MDT approach, addressing all your biopsychosocial issues, et cetera. Listed. Just some of the people that are involved here often heavily involves a school um charities, etcetera because you got to think about the environment. A lot of these Children struggle with is school. So you're gonna work very closely with schools, charities, other people that help in that situation and of course, managing the other associated conditions. So it can be quite tricky one to manage really because you've got to coordinate it between all these different groups. I would always say MDT management, so not autism, but AD HD is really common in people with autism and vice versa. Like comorbid conditions just want to touch briefly on the difference between adhd. So attention deficit IV disorder and A DD. Basically, as you can see from the slide adhd, they'll generally have inattention hyperactivity and impulsiveness. Whereas A DD, they just suffer from the inattention. Similarly, like with autism, if you ask to think about three categories of RA HD, you think about inattention, high activity and impulsiveness or high proactivity and impulse often get sort of put together the key thing or diagnose in either of these is that it is present in at least two settings. So this again can be a really tricky one to diagnose because you have to get people to go into school and do school reports. You have to then get home reports, people going and observing how they are at home. And you can imagine the impact that has both on the child and their learning. But the stress it causes for mom and dad when it takes so long to diagnose these conditions and then get the funding in place to help support them in terms of the management. A lot of it is about parental and child education. There's quite a lot of courses for parents with Children with ADHD. Obviously you'll involve the school eliminating triggers. So they often talk about sort of sugary foods. E numbers can be big triggers for Children, um, ad HD and then obviously medications, um, which are generally CNS stimulants and there's a few different ones for that. What, what do we think of these medications? Are they nice medications? Are they tolerable medications? What do we know about the medications for adhd? Brilliant. Yeah. So you've got the idea that they, they aren't nice drugs, they can have lots of side effects. Um, as we mentioned, particularly like cardiovascular side effects. So people have to have extensive cardiovascular assessment before they have to have regular BP checks. They have to have their weight check, their height check. Obviously, thinking about growth and anything that's gonna potentially impair growth in a child, um, is something that we're gonna take really seriously. So, I think, you know, there's often a bit of a, a stigma when people maybe don't medicate their child. And, you know, I know I have friends who work in school and think, gosh, why you just put them on medication? There's, there's another kid who's on medication that's so much better. But actually, people don't always realize the serious side effects of these medications. So making sure you're aware of those things like weight loss, um the cardiovascular implications, growth effects, et cetera, and the monitoring that these kids have to have for that. So key area is covered here. So we've talked a little bit about development again, just something that have to go away in your own time and have a little look at and learn some of them asd associated conditions really common. I would make sure you're really confident with autism because I'd be surprised if it didn't come up somewhere at some point, even if it's in your finals or um in your foundation training and AD HD and A DD. Obviously, there's lots of other mental health thinking, you know, your suicide self harm. A lot of those are managed quite similarly to adults. So I've not touched too much on them. Ok. So the next one, I think this is my sort of the last case, it's kind of kind of dermatology before we move on any questions. Um on the mental health case again, I'll start talking through this one but feel free to pop them in the chat. So we've got a four year old boy brought to the GP due to a rash on his legs. What else do you want to know? I'm not giving you much. So, I'm sure there's loads that you want to know. Brilliant, getting lots of responses coming and keep them coming. So when did it start to the history of the rash? When did it start? Where on the body did it start? How has it evolved? Is it blanching? Really, you know, key one here one that parents are often aware of when you're lost again, they come in saying I did the glass test and it didn't disappear. Is it itchy? Yes or associated symptoms? Is it itchy? Is it painful? Is it discharging? Are they systemically well or unwell again, kids can get so many rashes. So actually recognize that they well or unwell is going to help you get rid of a lot of differentials. And again, thinking about fever how it looks. Yeah. So we'll definitely touch on describing rashes probably much to your delight, discharge yet. Any trigger. Brilliant. Nice. Yes. Associated symptoms extending beyond the rash. Actually sort of systemic symptoms like joint pain, lethargy, et cetera. Brilliant thinking about your case. So, are they eating and drinking interest in plain? And that's the question that you're gonna ask in any history even when they're, you know, 1011, 12. Brilliant, well done. Guys. So I've just sort of summarized it here. I think we've touched on most of it. So, more information about the rash, any associated symptoms, any bruising quite a specific question. And one I never would have thought of asking until I'd seen a few cases in A&E and we'll touch on that later, whether they're well in the cell, any recent illness, red flag features. So we've talked there about things like blanching, et cetera, whether they're well or unwell. And again, as always immunizations. So mum noticed a few pink spots in his legs last night but didn't think much of it. But then when he woke up this morning, it spread generally went well in himself, but he did have a bit of a cold last week, but it wasn't anything too severe. Mum has done the glass test at home and he's concerned as it doesn't disappear. He had a recurrent croup of the child but nothing else significant. His immunizations are up to date and he's not on any foreign travel anywhere. So, oh, they're frozen. OK. Hold on. Let me see. Right. Let me just stop sharing this and let me just share again one second guys. Thanks for letting me know. Is that visible now or is it still frozen on the other one? Well, thank you. Sorry, not quite sure what happened there. So now you can describe the rash. So I want you to try and think of your dermatology terms that I'm sure you all hate learning, using the thought of describing a rash brings fear. But again, I actually had an Os on describing a rash. So, and it will help you in F one when you're doing those dermatology calls and they're asking you what it looks like. So, any ideas, how would you describe this rush? So, yeah, I've got it from a couple of people. Yes. So diffuse like that. So, you know, it's not just in one area. So it's a diffuse across the legs. You've mentioned macules. So we'll jump sort of the difference between um of macules after. Yeah, I know it's not, not the clearest. I, so you can't see anything jam in it, but you're right. So of purpuric diffusely across the legs. So quick recap. This is directly from geeky me. They've got a really good sort of rash describing section. Um So you've got just knowing the difference between like your pure and your eys. So like your tiny little dots when they start to coalesce together to form slightly bigger bit, you'd call them purpura and then your emos. So if you've been really picky, I guess he would probably um but he probably would have some area of purpura um in real life. That's just the best image I had in terms of describing rashes. Again, rashes are really common in people. So this is relevant but also some derm revision for you. A mnemonic that I got taught for describing a rash was scam so s for sight and distribution. So where is it? So his is on his legs. And as we said, it's diffuse the color and configuration. So his aren't, you know, for him, the configuration is not too relevant because it's more the morphology but the color is purple p associated features. He probably doesn't have any but if there's any crusting, any discharge, any scaling, any dry skin. Um And then the morphology, which is what we've, we've talked about there. So I found this really useful um just as a framework for describing your rashes you may have been taught of, but just the one I got. So what are your differential? So he's got this non blanching slash purpuric rash. What would you be thinking about? Ok. So I got a few things coming in. So you've got suggestion of meningitis IJ nephropathy HSP. Good. Any other suggestions? Because there's quite a few differentials. It could be for this one. A good. Yeah. So I acute lymphatic leukemia. Uh So we've got quite a few there. So nonblanching rash, you've got a lot of differentials V itp added there. So these are the most common ones I thought of them. There's probably even more out there. But idiopathic from P HSP H US, meningococcal septicemia D IC leukemia. Sometimes if they've been really sort of forcefully coughing, vomiting, they can come out of this rash. Probably not typically on their legs. Um but they can get it. Um, if they have been really vomiting and coughing, obviously, non accidental injury doesn't look like it in this case, but just always something to consider in anyone with a rash bruise mark, just ask yourself, could this be nonent injury? Is there a safeguarding issue here? So, out of those differentials, which is most likely and why? So in the chart pop, what you think is most likely but more importantly why? OK. So you got ICP because it's, well, uh any of us, I give you a little bit of time just pop it in and you can pop why you think it is or if you're not sure what, which one it is, tell me which ones you don't think it is and why? OK. So I got another ITP some for HSP because he's had an infection. Yes, he did have a cold last week and we're born for HSP. So we're 5050 at the moment between ITP and HSP. Any other suggestions or are people, you know why people don't think it's any of the others? So if we work through them, so ITP. So a couple of people have mentioned that in the chat um the rash fit, you're right. Children are generally well with ITP. So that will also fit not mentioning the history, but I guess the question we could ask and why I put it in the initial question is, is there any bruising often kids who got IP might have some bruising kids are always banging themselves, et cetera. And if those who got low platelets, they're often prone to bruising and bleeding. If I tell you this little boy hasn't got any bleeding, hasn't got any bruising, would that maybe make you change your mind for those who said itp. So it might make it less likely the HSP. The key thing that might make you think about that is that history of a cold last week hemolytic uremic syndrome, we generally probably expect him to be a little bit more unwell. He might be lethargic with the anemia. Um He might have some urinary symptoms, et cetera, sepsis. I think we're probably all confident in saying he's definitely not got septicemia if he's generally well in himself D IC. Again, we probably think about had he got some more bleeding, bruising leukemia would be more unwell. Doesn't sound like he's had really thoughtful cough and vomit and it's on his legs. So less likely. And as we said, it, it doesn't fit with non accidental injury. So if we, I'll come back to this question on the next slide, but in terms of diagnosis, in this case, it's most likely HSP. So for ITP, completely see where you're coming from as well and it's a really valid argument with ITP. They might have some bruising and bleeding. Um So that might make you lean more towards that, but the key thing in this history is that he had the upper respiratory tract infection. So the cold about a week ago. So, HSP. So it's an IJ vasculitis generally post infection commonly group a strep which generally gives an upper respiratory tract infection. Most commonly under tens and generally affects males more than females, signs and symptoms. The rash, like what we've seen, they might have a low grade fever, but the males have no fever, generally have a recent upper respiratory tract or gi infection within the preceding weeks. And they can have these associated gi joint systems and renal involvement. Now, you might ask why wasn't that in the stem? Well, sometimes these don't present until a few days or weeks after the rash. So that's why I haven't included them in the history because often they won't have those yet. But if they are gonna have extra symptoms, the most common is joint. So things like joint pain, gi symptoms that can range from just a bit of tummy ache or they can get bleeding, um colitis, etcetera and same with the kidney involvement, they might just get some microscopic hematuria or it can be ring, they can have like renal failure. So again, the a just to there's a spectrum but just note that these sort of extra manifestations don't always appear to later down the line of investigations for this. So I probably definitely do a urine dip, especially anyone coming in a rash. Because it can help you think about what's the most likely diagnosis, bloods sometimes. So we don't always do bloods in kids, particularly if they're. Well, as I mentioned on the other side, how you'd manage this patient if he's, well, he probably doesn't need to go to A&E probably just needs some safe netting monitoring, dip his urine, see what you get there. Um So the main point is to highlight there is obviously in kids, we have a much lower threshold for investigation. And a common thing to think about is where you're gonna manage these kids if they're well or unwell. So nonblanching rash is just a little bit um of a summary there because it can all be confusing and a lot of things impeded with the respiratory conditions or rashes are really pattern recognition and picking out the key bits in history. So, sepsis are generally be unwell H US. They're gonna have some thrombocytopenia AKI anemia. So they might have some bleeding, some bruising, reduce urine output, the itp. So idiopathic thrombocytopenic, um they'll have this immune media destruction of the platelets. Uh again, that can follow a viral illness. Um but sort of the HSP was more fitting with that last case and ITP generally self limiting, but you can refer to him if it's severe and they can get steroids and autoimmune expressive therapy, et cetera, but most of them do get better on their own. So just sort of getting used to that sort of pattern recognition. Um The different rashes I guess, got to mention non accidental injury. And I talk about p key thing, just always ask the question, think about it. If you're not concerned, raise it, raise it to the relevant leads. Um I just popped a couple of pictures here. So for the skeletal, for the scleral survey, it's a common one we do in nonmobile Children presenting with fractures or mobile Children with fractures that don't aren't consistent with their level of mobility. And then your retinal hemorrhages thinking about shaken baby syndrome. So again, just something to be aware of, we can't do ap at all. We're unfortunately mentioning it. So key things covered here. So we talked about describing the rash is a bit of derm revision, non blanching rash differentials, a brief discussion on investigations impede. Just remember when we have a lower threshold thinking about will it actually change our management? Because obviously, investigations like things like blood cannulas cause distress to the child, which has a lasting impact on their interaction with healthcare in the future. And then anything like imaging chest x rays is all radiation. And then obviously we touched on non accidental injury. Any questions um on the rash ca and like that just before I quickly summarizing me. Well, I'll let you just pop them in the chart and I'll just have a quick. So the main thing I put this on here, this is the UK MLA for it is huge. There was no way I could do a lot of peds in an hour. PS could be a whole revision series on its own as you probably know that when you've done the block, it can feel really content heavy. I've tried to pick out key things that are relevant to lots of different aspects of peas and the key things as a foundation doctor who has worked in A&E done a little bit in pediatrics. The key things that I felt I needed to know, which is definitely recognizing an unwell child, recognizing respiratory distress, knowing about rashes. Um and thinking about your sort of mental health conditions and things, but it is massive, you know, we've not talked about sort of fevers, but there's loads we haven't talked about. But the key thing here is just to emphasize how much there is. So we couldn't cover it all. But yeah. So any questions on anything that we've done before? Any questions about anything, really anything in general? Yeah. So high yield pharmacology and psi would definitely say fluids. So you need fluid calculations. So for peas, it's a bit different. So you do, I'm pretty sure. But again, I always check this prescribing fluids 100 mils per kg for the 1st 10 kg, 50 mils per kg for the next 10 kg and then 20 mils per kilo for anything remaining after that's um really high yield one. So definitely learn that, um, I guess not pharmacology itself but for all the respiratory conditions, making sure which ones making sure, you know, which ones you use things like bronchodilators for. Like, we don't use them in bronchiolitis. I think the common thing, any respiratory condition, I'll just give them some is albut, but just knowing what you use for which, like we don't use it in crude, we'd give dexamethasone, et cetera. Um, dexamethasone dosing group. again, that's probably a common one that you'd, you'd want to know and be expected to know. But I generally say fluids would be a high yield one in terms of pharmacology, so hard to do with HSP from ITP. So yeah, they can be really similar. Um They can look the same, they can both present after like a viral illness. Um One good way is obviously, is any associated symptoms with the HSP. What I found when I've seen it in A&E is dip in the urine. Um So they'll often have like microscopic hematuria and for ITP, just remembering obviously, it's low platelets. So they're more likely to have some bruising and some bleeding kids are always knocking themselves. So I can guarantee, you know, they're gonna have probably gonna have some bruises. But that's why I've mentioned in the history. I always just ask about the bleeding bruising just because I've seen a case in A&E and I didn't thought to ask that question, but someone mentioned it to me as a good sort of distinguisher. But again, like a lot of things in medicine, we don't always know the answer, but it's recognizing the well patients from the unwell patients. Um, and both of them, if they're well is sort of supportive treatment anyway. So sometimes you might just have to see how it evolves, see if they develop the other symptoms. I hope that makes it a bit clearer. No worries. Any other questions on any of the cases? Um Anything pees at all. So as I say, apologies, couldn't cover much impeded. I didn't want to overwhelm you tried to focus on some of the high yield things and as I say, real focus on recognizing unwell Children. Um I hope it was useful. I believe that you'll be sent some feedback. Um If you could complete that, you know, good feedback improvement, all really useful. I'd really appreciate it. Um I'll hang around for another five minutes for any questions, but if not, I hope you have a good evening and best of luck with the rest of your training. I believe the feedback will be emailed to you. That's what I've been told. Well, they put here a QR code but they didn't give me one. So I assume that they will send you a feedback. I hope that they will. Yeah, they said they'll send out a feedback form to everybody, I assume via email. Thank you. Thank you guys for coming. I really appreciate it as well. Um I'll make sure the slides get sent to you and I'll attach my email as well. So if any questions at all, feel free to give me an email, be it about p foundation training. Um, like I was less than full time, less and full time in two. So can answer generic questions about that if that's something anyone's considering ha more than happy to answer any questions. Ok. It looks like there's sort of no further questions and quite a few people are leaving the session now. So thank you, everyone and, um, I'll leave it there.