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So good afternoon. Um Good morning, evening, wherever you are joining us. Uh My name is Sarah. I'm a pediatrician working the National Health Service in the UK. Um delivering a hopefully interactive session on identifying the sick child. We have delivered this session early last year and this is like the second time uh you know, delivering this. So if you have been, you know, you have watched this before, I'm expecting more interaction if you haven't. So please feel free to ask questions and interfere. So um I would like always to start by uh mentioning that global solidarity is very important uh with the people in Ukraine and the people in Turkey and Syria following the earthquake and global solidarity is, is I think the main way for us um to help each other as human beings rather than wait for governments to help the people, whatever they are. So um identifying the sick child um when you are working in pediatrics, most probably as an undergraduate, you will have a time or a period to have a placement in a pediatric ward. Um This time you have to use it to uh utilize your knowledge. Um and get a lot of exposure to see as much Children as you can because then you can develop the skills, you know, the evidence based practice and develop what we call the good feeling when you see Children after you graduate. So it's not only about passing the exam. Um there is a spotting the sick child website and this is very useful where there are videos um that will show um Children with respiratory distress with different types of skin rash and with other different clinical features that will help to compensate if you haven't uh completed your placement. Um Due to the current um conflict issues, uh when looking after Children, we have to appreciate the range which is really wide uh from New Natal period up to um the age of 16 and other countries up to the age of 18 and therefore to gain understanding of the common pathologies for New Neitz. Um you know, premature babies during infancy, preschool and then during the school um age. So you have a very interesting changing pathologies and presentation in pediatrics as well. There is a complex health need um like in adults. So you can have a single problem like asthma or diabetes or you can have a complex problem where a child have got Super Bowls, they, and they have epilepsy and feeding difficulty. And we have Children who have um um you know, oncology, malignant uh illnesses requiring chemotherapy and radiotherapy. And in, in in, in young people, you can as well encounter problems with mental health like depressed self harm and eating disorder, as well as safeguarding and child protection. Children will be influenced by the environment by the social background, by finance, by conflict by war and all of these factors will affect their presentation. The nutrition immunization, interruption of immunization. You may see um you know, measles creeping up after, you know, there was no measles case. You may, you know, people may not be able to identify because has been a long time since they have seen a case of measles safeguarding and protection. As I have mentioned, um access to health as well, access to digital, you know, platforms. So the pathologist can change according to the environment and the social background and other factors. The common presentation in Children are fever. So it's important to mast er um you know, the causes and the assessment of Children with fever. The second will be respiratory problem whether they are upper respiratory tract like uh otitis media, tonsilitis or lower display tract infection like bronchiolitis and community acquired pneumonia. Um uh The third is gastro into style presentation, whether it's gastroenteritis uh from infection or it's abdominal pain. For example, appendicitis, skin rush is one of the common presentation where Children present with different types of Russia's and having a systematic approach about how can I diagnose the rash in a child is very important. It can be just a viral rash that is blanching. You don't have to worry about, it can be a chicken box and you need to give the advice, can be measles, which as we said is not common, but you can have an outbreak. It can be serious which is non blanching like magical conceptus or I T B or you know, malignancy. Uh It can be impetigo, it can be eczema. So there are different types. Um and we will try to cover some of them today. The other common presentation is the limping child and we will have a case and hopefully we can have a differential diagnosis for that. You can have an uncommon or serious presentation and that can be accidental injury can be an an accidental injury. Always think about the red flags. I'm not happy that this child is vomiting and there is green vial in the vomit. This is not common. I have to think about surgical problems. So having the red flag sciences important, some of these will be prematurity is a problem. Um Postnatal risk factors is a problem. Any family who mentioned that the child term blue, you have to be very concerned especially um the first few years of uh months of life because that can be a presentation of congenital heart disease, fever, particularly in babies. We are not happy with that on assessment if there are no femoral pulses because we're worried about computation, funny turn can be a seizure. Uh stopping breathing in a baby can be a significant issue and we come to know why headaches with early morning vomiting. We're talking about increasing turkey. A pressure, blood in the stool can be this entry. That's not a big issue, but blood in the stool can be interception can be salmonella can be, you know, serious um pathology, immune eight can be necrotizing entero colitis babies who are irritable and high pitch cry. But basically we're talking about meningeal irritation, dehydrations of gastroenteritis is common in Children, but you can have severe presentation if the child continued to have vomiting and diarrhea. And you know, there was no any fluid um sort of um intake for a long time collapse and loss of consciousness and the different differential diagnosis. But if the family told you that there was a history of collapse or a history of loss of consciousness, you have to take that seriously. Um And as you can see um the other points as well. So before I proceed, if there any other other questions so far in these um points as an introduction, uh could you go back to the slide? Nutrition? Hello? Yes. And you sit down. Yes, ma'am. Yes. So what is your question? No, I I actually didn't. You saw the next slide up the one that started with nutrition. So it was social. I didn't saw the next slide after, after the social and environmental factor. So it was okay. Okay. Yeah. Thank you, God, ma'am. I got it. Thank you. Thank you. So, do you want me to repeat any point here or just proceed, proceed, ma'am. Thank you. Okay. So, with identifying the sick child, and you want to make sure that you, you know, act appropriately and timely. Uh the main, after you take the history, uh you proceed to the assessment, we're going to take the A B C D E approach and this approach will help you to do an assessment um which is systematic and you manage the problem as you identified you will need as well vital signs. And on the right, this is the pediatric assessment um tool which will include the temperature, desperate ori rate, saturation, heart rate, BP, capillary, refill time, as well as pupil size and any concerns from the nursing staff, any concerns from the parents, then there is a traffic light will tell you if everything is green. You don't have to worry if things are amber, you have to consider an Axion. If things are read, this is serious and you have to deal with it immediately. A stand for airways be for breathing. See for circulation D is this disability or it's a neurology assessment? And do not forget the blood glucose E is exposure and temperature and other will include abdominal examination, E N T, an examination of the whole body, especially if it's a baby. So this is the approach we're going to take on our assessment for the next few cases. Are we happy with that or do you have a question about A B C D? Yeah. So this is what we have mentioned already. So when you assess the fever um in in a child, a child presenting with a febrile illness, um there is a nice guideline which helping the assessment of fever in Children under the age of five. And that will give you a flavor about how to approach assessing fever in Children. Because this is the common presentation that you face. Basically, what you're trying to establish is this a child who is presenting with fever with common illnesses like called like cough, runny nose or this is a child who is presenting with fever with a serious cause meningitis, you know, uh pira nephritis, osteomyelitis, um uh sort of pneumonia. So to establish that after you take the history, you need to assess the child. And if the child is in the green column, you need to reassure the family, advise them about the management of fever and they can go home. But if the child is in the red category, it means you need to act. Now, Children in the yellow or in the orange or the amber category. If you are in a primary setting, you need to send them to see the pediatrician in the hospital. If you are the pediatrician, you have to give them a period of your new work in a pediatric department, you have to give them a period of observation before you send them home. So basically you have a child with a fever. You need to see that this is a child who has got a common illness, not life threatening and I can send them home with safety net versus I have a child with a fever and there is a serious life threatening cause I need to refer them for further intervention. If I'm outside working in the primary setting or if I'm working in the hospital, I need to observe them or act immediately. So if we start uh some of the virtual simulation cases and I would like to hear from you. Uh you know, you can write in the chat. So we have a 20 days old, 20 days old boy, sorry, there is a d missing and not feeding. Well, was brought by his family. He's sleepy. They said that the temperature at home was 38. He was born at 36 weeks. He was born by normal vaginal delivery. There was a history of prolonged rupture of the membranes before delivery. So in the chat, can you tell me what are the risk factors that you can see from this story? Or you can shout if you can open the mic as well. I mentioned that and first of all, the nutrition is important if it's not been feeling well okay and the body temperature is a little bit high. I mean, it's not at the liver. It, it is severe for a young child as this must be so heated up. He's premature. It can be six weeks. Mhm. Um The prolonged rupture of membrane as well cause the prematurity and can be caused by an infection in the mother infection. Yes. So we're worried that the baby picked the infection. So first of all, we have only an unit 21 days old who, as you said, not feeding well, and this is a sign that he's not. Well. So stopping feeding is a serious sign sleep. He says it's signs of dehydration. I mean, cause he's not feeling well. So he's sleepy. Meaning sign, it can be because of the dehydration. It can be from hyper slicing, it can be from the infection. Another sign that we don't like a temperature of 38 is enough for us to say that there is a problem. We don't need more than that. Anything that 38 above it was born preterm. It's a normal vagina delivery. So fine, there was no like a complication more than prematurity, but we have prolonged rupture of the membranes. So there is a high risk of infection. So we already just from hearing that we feel like, oh there is an issue. So let's look at the um uh yes. So let us look at assessment. I mean, how do you would like to assess this child using the A B C D E approach? Well, I will tell you. So if you start asking me about the A P C D assessment, I will answer your questions. Okay. So his airways clear, so his airways favored Peyton, okay. Uh breathing. So his breathing cause his respiratory rate is around uh 65. Um Is there a respiratory sound like strider starter? So um there is no stridor but he is grunting. Yeah. Yeah, you're doing well. It did. You even there are quite a few cases so will not be able to finish them unless you do quickly. So we are still in the proper straight is still in be I'm sorry, I have to, you know, I'll keep you in in be until we finish it. So, so that just like uh you know, sort of we learning process. So airways patent to be is to keep Nick his granting, what else you would like to know? How is the air entry in the chest? So equal air entry. Yeah, symmetrical chest moment. Yes. Any added sound in the chest. Uh no added sounds 26. So how are paradoxical moment? No paradoxical movement. The way I will look at um breathing is as follows. I will look as effort and efficiency. So there is um a nasal flaring, there is recessions. He is the kidney, ECBC, the chest movement is equal bilaterally. I will listen, air entry is equal, I will count the respiratory rate and I will check the saturation. Okay. So his saturation is 90 for this is acceptable. We get worried if it's below 92. So this is respiratory our breathing. Now we move to see. Yeah, it's the child check a Codec. Uh so there is the card so the heart rate is 100 and 80. Mhm. The child perfusing. Well, pink questions. So is the color he looks smuggled. What else you want to ask me about perfusion? A capillary refill? Excellent capillary refill time. So we're going to do it one. So I'm pressing 12345. Then I'm really delayed. Yeah, I've released my finger and I'm telling you that the capillary refill time is three seconds. Are you with it? Um It should be less than two, isn't it? Yes. So it's delayed slightly. Yes, it is delayed. Uh That's it. If it's anything above tude, it is abnormal. So we have the key cardia, we have prolonged capillary refill time. We have modeled skin. What else in? See, do you check BP for young Children? Do you have to take this once? And his BP is 85/50. I will tell you that it's acceptable for his age. Okay. Are you surprised that he's maintaining his BP? Yes, I am surprised. Yes. Okay. So you shouldn't be surprised because babies and Children um usually maintain the BP to the end. Not like adults. So they have a good peripheral vasoconstriction. So if you have a child with low BP is usually very, very thick pre arrest. So this side still we have an opportunity to save him. So his BP is okay. What else in? See we should do. So we have done just to remind you, we have looked at his heart rate, the peripheral time, the color the BP. So any urine output, uh it's reduced urine output. You can listen to the heart. There is no murmur. You can feel the femoral pulses because of his age. They are present bilateral but they are, you know, very thready and see is a time if you want to have an access or to take blood gas and to assess the hydration stages is the child appear hydrated or dry. So the child, you know, there is like dry lips. Um the anterior fontanelle is sunken and already um you have, you know uh said houses perfusion. So it is a poor perfusion. So shall we move to the? Now, do you, do you want an access here? Do you want blood? We need an access and do all the bloods. We will come back to that. Yeah, but we need an access. Definitely here because we're worried about perfusion. So moving to the, what do you want me to tell you when we are taking blood? We can also do a blood sugar. Definitely. So his blood sugar is 2.4. That's the point for Children is 2.6. So that's low. He's hypoglycemic. So he is low. This is another emergency that we need to deal about and this is why we require the access. We're going to come to the management. What else? We have a temperature already? 38 isn't, it wouldn't be the, the temperature, we need to check it again. Check it again. It doesn't matter even if you find it low because you have the history. But the temperature usually if you want it now I can give it to you, but usually it will be, but it is 38 still and then outputs score is child score for those who don't know the up to score. It is alert, respond to his alert is responding to voices, be responding to pain. P U is unresponsive. So he is swinging. So um uh when you are trying to put the cannula, he pulls his hand. Okay. So he's responding to pain. Yeah. Are you, are you concerned concerned? Yes. Yeah. So we get concerned if the child is responding to voice is only at this age or two pain. Yes, sir. Someone wanted to add something. I have a question. Gentlemen want to say something. No, ma'am. So we are concerned now. So, okay. We have done a full. What else? Oh, good. Now we'll go to exposure and yeah, we haven't finished. So I'll tell you what you're looking. Indeed. So you have checked the blood because it's slow. He's responding to pain. You are very concerned. You're looking at his posture, he is floppy. You are checking the pupils by the lights. They are equal and reactive. Okay. That's all. Indeed. And anterior Fontanelle already have told you it is sunken. So we are moving too easy now. Uh examination. So, yeah. So what do you want me to tell you when you're looking at him? Patient structure, whether it's puffy or whether it's something. So his anti fontanel is sunken that from the which is dehydrating. Yeah. And the temperature is a lot of the skin. Got a lot of the skin good. He is modeled. Anything else you would like to tell you about the skin is he? Should he uh I already uh I don't know whether we should check Parini. Um Right now I would check out them but when the baby was born, what? I don't think we, I don't know whether we would check the perineum again. The perineum, I mean perineum is checked, we can check the nappy area. Uh that looks normal. No, because we checked perineum just as the child is born, we might need to check again by the time in 21 days that there is any changes. Yeah. So it is normal. What about the abdomen? Is the abdomen distended? Is there any bowel sounds okay? So good. A lot of questions, I'll answer them. So there are no skin rash. That's important. That's from observation. There are no skin marks, there are no bruises, there is no obvious abdominal distention or abdominal distillery. A shin. In others will be the examination of the abdomen is soft and there is no mass. Uh and in others will be the examination of the nappy. Uh and if you want to do ent examination, so you have all of this information. Do you think this child is well or unwell? And one time? And what is your differential? I think, what are you, what, what do you want to treat first? I think we would, as far as we know, we would create a dehydration and the uh lack of the blue person. Yeah, he's uh so ideally um the dehydration and then um rehydration of glucose. Okay. So we need one person at a time, but I'm like a listen. So we, we have, we are worried that this child is dehydrated. We are worried that this child is hyperglycemic. We have to act on that immediately. That's good. What else is, are you worried about? Why is this child dehydrated and hyperglycemic diabetes, diabetic ketoacidosis. So let us uh let us look into that. So if we have, first of all, look at age, it's not, you can stick to have um diabetes in units, but it's not that common presentation. But what are the criteria of deaky? A high blood, high blood sugar and bike are metabolic acidosis? Okay? So hyperglycemia. What did we say that the blood glucose here, hypoglycemia, hypoglycemia. Okay. So it's not the key. A okay. So we are talking about hypoglycemia. I most probably it is from the child not being, you know, not, you know, being sleepy. I'm not feeding well, but why is the child not feeding while I'm sleeping? What is there is something very clear in the history that will give you uh infection, infections of the child's skeptic. This child is possibly septic. We are worried about substance. So our management will be going to give this child IV Giokos because hypoglycemia is serious, we need to act immediately. So we're going to give him a bolus of blood glucose. We're going to give him IV fluids because we are worried his technocratic and not dehydrate. So we're going to give him IV fluids, but we have to give him good uh dose of IV antibiotics because we are worried about sepsis. And if we don't give him the treatment, we are going to end in septic shock. Okay. So in summary, we have a new in eight who is presenting with the temperature, who's preterm, who have a risk because of prolonged rupture of membrane, who is not feeding well and sleepy. He presented unwell the key Codec to keep Nick parexel dehydrated and hypoglycemic. Well, doctor at what stage then would he have? Um his BP dropped right quite drastically except Ick shock because his BP was fine. Correct. So the septic shock if he is not treated. So he presented at this time, if he presented later or if he presented and we did not identify that and we left him for a longer time, he will go to septic shock. Yeah, sure. Thank you. We have to go to the next case. Okay. We need good interaction like the first case. So we have an eight month old girl presenting with vomiting loose stools with blood parents said that she has episode of screaming. She's not playing, she's lethargic. She is floppy. Just want to lie down. She has cold hands and feet. When you ask them about when was the last time she had we or urine? They said we don't know because she's always having diary. So you have this case. What are the red flag signs that you can see and what other questions you would like to ask me uh talk one other time, please? Mhm I don't know whether people are raising hands or Hannah. You would like to direct them but so that you can listen to each other. Yeah, should we do, should we do with the hands then? So I think as I just the frequency of frequency of vomiting like in one day how much how many times she's vomiting? So she's been vomiting 6 to 8 times. She always vomit whenever they give her any water. So she's dehydrated uh from the history this is what you have. You still have a move to the examination. We're still at the level of the history. But they said to you she's lethargic and floppy and she have cold hands and feet and I'm not sure. When was the last time past student? Would that give you any indication that she may be dehydrated? Yes, ma'am. I mean, war meeting ends loose to the blood. Okay. Okay. Any other question I would like the aspect. Yes. Watch wash this child fed any anything else other than the food, which is the normal regiment of an eight month old dear child like something else. She was being fed something. So you think about food poisoning or food or infection? So she has been eating the normal food that other family has had and she is a breastfeeding. Okay. I might have a diagnosis but which is not the perfect thing to do right now coming to conclusions. But uh so there was a another student. She was as welcome asking questions. Do you want to come now and ask your questions? I don't know her name. I don't know whether she is her hand. Yeah, Christie, shall we move to the assessment? So can ask questions when you're doing the assessment? We haven't finished until you finish. You come. Sorry. Do you have any questions you want to ask or do you want me to take you through the case because of the time? What is the frequency of the stool is um like if she's having loose stool is the same as vomiting or. Yes, lis let me take you through the case on the assessment and so you can go to the assessment. So we have an eight month old since she's breastfeeding. It's important to ask how, what is her feet and what she has been taking, she has been vomiting, but there is no blood, there is no vial. You need to ask these questions. Uh They said there is blood in the stool. You need to ask about the frequency of the blood of the stool. The amount of the blood, is it fresh? Um Is it just mixed? Um And she continued to have this blood in the stool. That's important. And then you have this episode of screaming. You have to link that whether this happened when she passes the blood or is it happens when you know all the time, what is causing the pain while she is screaming? Then we know that she's lethargic and she's floppy. Is she having a fever? Because if she's having a fever, you are thinking of an infectious goes for her vomiting and for her diarrhea, if she's not having a fever, then you have to think about something else. So this will be uh the red flags that you have to look at when you have vomiting and dirty. So there are quite a few red flags. So let us move now to the assessment. Yeah. Take me through the assessment. The A B CS. Yeah, you need to ask. It's okay, I think. Is it Christie? Yes, ma'am. We'll start from airways. They are we clear her airways, clear walking evidence of something, evidence of vomiting. And is he, is the air we clear any, any gurgling sound coming from the throat? No, no, not stretch Elice or Sturgis or anything? No, no. And uh didn't remove to be. Yeah. Is the chest clear? So before we go to the justice, look at the chest. So uh breathing. So her respiratory rate there is um no tachycardia, no tachypnea. So her respiratory rate is 32 and the chest movement is equal. There is no this there are no recessions what I want to know um how would you know that's efficient breathing, saturation, saturation. Yes. A saturation is 96% on room air. So that is acceptable for her. Yeah. And when you listen to the chest, the chest is clear. Are you happy with be? Yes, she's not aspirated. So that's good. Ok. Mhm. See. Okay. Uh huh. Heart rate and BP. So she's eight month old and her heart rate is 100 and 70 which is high. Yeah. Is she warm and perfusing? Know her hands and feet are cold? Okay? You ask uh they're they're checking they're trying to find the machine they will tell you but what can you do immediately by your hand uh feel uh capillary refill. Yeah, so capillary full time again, we're going to press for five seconds. We're going to do that. Uh centrally that means um over the chest, not in her hand and her feet and when you release um it is 1234. So it's four seconds. Okay. So that is delayed. Yeah, so she's under perfused. So, yeah, and they check for you the BP, her BP is uh this historic is a 65/40 and just to let you know by this age we're expecting historic to be 95. So we need to get a cannula access for her as soon as possible. Yeah. So she needs an access. That can be an IV Can Iraq or interosseous accent, you know about necrosis. Yeah, because it may be challenging to get okay. And what test do you want to do if you get bloods? Um uh B B G or a P G we would have checked for, we would also check for cultures as well because it's warm eating and stools. So maybe it could be enteric or uh Yeah. Yeah. It depends on traveling history. It depends whether there is a fever. But what else you would like to see? What are the test that you would like to take if you have a full blood cones? Use Annie's CRP CBC, a urine test. So let us just organize that we're going to take the sugar, the blood glucose important. We're going to look at the full blood count, basically the platelets because she has blood in her stool, going to do the coagulation because she has blood in her stool. We're going to check the used unease because she has been vomiting and we're not sure when was the last time she passed student. So we are worried about acute kidney injury. Okay. So we are doing this and someone is putting a cannula for you. You are very concerned, what is the management you want to tell? Um, when the cannula is in, what do you want, what would you want to happen immediately? Fluid. So we want to give fluids. How much fluids are we going to give? We know she's eight month old and do we have a weight? So we have an estimated weight of around 8 kg. So we're going to give her fluids as normal Saline. We start by 10 mils per kg of normal Saline as test. We need to give her another 10 mils per kg. Can give heart my as well. So you need the isotonic solution, okay. So we are worried about here. We are very concerned. If you are an S A N E A junior doctor, you need to call for help immediately because you have a childhood hypotensive. What did we say about hypertension in Children, septic shock, pre R S situation, whether it's septic or not here. This is, well, this is hypovolemic shock. It's not septic shock, but this child is, you know, uh you know, it's almost at the hypovolemic shock. So you are concerned. So you need to call for help. Okay. So this is A B C D D. We're checking blood sugar. So it was already asked for it when it came. The blood sugar was 2.9 just above 2.4 Children that we are, we will not say normal but it is under lower end. So we are monitoring it but you don't need to rush and give the blood sugar now. But so you have, you have ticked the blood to the cause. What else in do you want to assess alpha score? Okay. So a full score, the patient when you put the candida was not even you know like moving did not pull. Um they're, they're so you are you wear it. Yes, very worried. Okay. That will mean that you need to call for your arrest team esteem. Although the child still have is tachycardia and everything but the child is pre arrest. You don't want the child and the arrest and you do it okay. And then what else you want to assess? So you have assessed people uh reactive. What else I've told you last time? Posture, posture is important. Um So she is uh hypovolemic hypotonic uh in her posture and sloppy and the anterior fontanel in, in babies under the age of one. You need to check it. Uh It is um sunken. Okay. So you have a child who is not hyperglycemic but the blood sugar is low. Uh and you hypo uh tonic and it's not even responding to the cannula. So you are very, very concerned. Then you go to eat. Uh huh. Check the skin for any content. That's what we have checked that. Yeah. What are we checking the temperature? The child temperature is 76.6. So no fever, any, any rashes on the body anywhere. So there is no, there are no rashes when she another student uh or if you want to write so Hannah can read the black. What else would you like to look with observation in this child who has got blood in this too? So when you examine the tummy, the tummy look big. Check the nappy uh that's fresh blood and when you try to examine the tummy, um you feel like there's something as if there is a mass treated for bowel. Sounds uh sluggish. Okay. So this is a surgical emergency. Do you have any idea what it could be at this age? Would it be? Well, villous could be. What else? Uh colitis, necrotizing enterocolitis. I was thinking of virus uh something uh okay. So all of these cases can present with complication can be volvulus, necrotizing enterocolitis common in the younger age. It can be a complicated gastroenteritis, but this can be a presentation of interception. Did you read about Interception? Yes. So if we have a child under the, you know, very young presenting with blood in the stool with no fever, less likely to be infection. Would they have episode of screaming? Who are really very sick? We need to exclude surgical problems at the top of the list is Interception. So you need to call the surgical team, but probably they will take the theater, they will do ultrasound on the table. It's less likely that this child will be treated with ultrasound guided, you know, sort of a radiological intervention possibly would require surgical intervention. Okay. This is not the scope to talk about pediatric surgery, but this is a eye person. I remember when I was a registrar ages ago that I was handed over when I was coming on my shift that this baby had gastro on Fridays were giving half fluid, everything is fine but she's not drinking. And then when you go and take the history and you look at the child, I think this child doesn't look well, this child looks pale. It is more than gastroenteritis. Okay. And when you take the history about the blood, the fresh blood and the episode of screaming, you and you examine the child, um you involve the surgeon and it is a surgical emergency. Okay. Moving on. I just look at the time, I think we have only one case to go. So we have 15 month old boy has fever runny nose. He has a rush, he's drinking fluids but he's not eating. And the parents brought him because of breathing difficulty and noisy breathing. Any other other questions you'd like to ask me in the history. When did the noisy breathing start? So he had a fever for three days and he had the noisy breathing starting about a day ago. It was sudden not a suddenly any. They felt like for the last 24 hours, he had this noisy breathing on and off. Where's the rush all over his body? They tell you okay. And then when the noisy breathing started is when he stopped eating or so he's not been eating and drinking um for the last three days but drink it not eating for the last three days, but drinking passing good amount of urine. What is his position when he's trying to breathe? Like he's trying to access a help like supporting or just lying down feeding. So he has been running around and playing sometimes and sometimes lying on the bed. But this is part of the assessment. If you want to ask me what position, how he's sitting, we can. That's in the assessment. But the family tells you he's running sometimes when the temperature is down, he tries to play but then he's, you know, his back lying down. No, no, while he's lying down like after running, how does the child or the boy breeds like heavy breathing or he's holding something while breathing like access with that. Yeah, he's breathing fast. So the family wouldn't tell you about accessory muscles that will come in the assessment. We are here exploring the story, the history, which is really important before you go ahead. So you have a 15. Uh does this condition has seen same with the child? He uh the the friends he play with or is just him alone? Like the child is playing with friends? The do any of his friends have shown the same symptoms? So he's just a low 1st, 1st to show this? So he is staying at home, he doesn't go to the nursery and with other kids, they may have a cold or you know, a cough, their family don't know. But a good question. So what are, what are you all thinking about? What are you think? There? Is there a question in the chat? Hannah? There's no questions in the chance. So if anyone wants to say something or write it now as the uh basis having. Mhm. I think it's acquired like uh from someone like in a community acquired. Okay. So what are your thoughts? So when you're taking this history, what are you thinking about? What is your differential measles or? Okay. What are the common things? So measles at the end? But what are the common things like this like uh okay. Continue. Sorry. No, you go on I said get you. No, no. Uh I don't know where this child is from because sometimes the rash, depending on what kind of rash it is. It could be also chicken pox. But that, that is completely based on where geographical conditions. Uh okay. Um As, as that, let's just look at the common presentation. You, you have very good. You will explore that if you think it's uh measles. If someone has been traveling, this is a child with staying with the family. It is the winter. He developed fever, running nose. Um and the rush that I will tell you about in the assessment who's drinking fluid, passing urine. But the family felt like he is becoming having this rapid breathing. They think he's like struggling breathing and sometimes, you know, uh the breathing, there is a noise, I don't know about what could be the common differential. Okay. Is it ordinary itis translate this with her young chair? You know, the common thing we we should think about is group uh viral induced reads, bronculitis. Common things that cause noisy breathing at this stage with the fever and the rash. Okay, then we will come to, is it something more complicated which we can explore uh in the history? You want to know whether he is susceptible to measles, you should ask me about his immunization, our mom's he is vaccinated. So there is no reason for him to develop that unless it's very complex. So as I said, always think about the common presentation and then let's think about the more uncommon presentations. Okay. So now I'm giving you that. Let's go to A B C D. Yeah, I'm ready. Are you ready? Yes. Uh While breathing, how fast is the breathing is extremely fast or just normal paced fast, like tachypnea. But in a very fast panel, very, just a little bit more than norm. I'm not going to answer that because you have to start from is the airway okay. So airway is clear, there is no stridor. So group is out of the at least now out of the differential. So airway is, is clear. But when you're looking at him, he has three me nose, runny nose, but the airways is patent okay. Okay then as that were coming to be. Yeah. So you want to know what the respiratory rate, his respiratory rate is fast. It is 56. What else you want to know? You asked me about earlier? How yes, I was breathing as a uh breathing difficulty. He's having uh holding on something or is just breathing like straightforwardly or lying assessable most. So he's sitting on his parents lab but he is um having recessions, intercoastal recessions as of course the uh recessions. What else you want to check for b uh we will check for trails. Any noises, corporate ations, okay. So you want to listen, you're looking the chest is moving equally or listening bilaterally. Air entry is equal uh press sounds are normal, there are added sounds, these added sounds are we expire a Tory? We's bilaterally what else you want to know in b whether it's paradoxical or normal? So there is no paradoxical uh breathing. What else you need to know? What are the important common things you need to know to complete could complete the breathing assessment. Saturation. Yes, sanoba saturation. So his saturation is 90% a room air. Uh Yeah, that's very low. So what is Axion here? We need to take as we are moving to see, what do you want me to do as your nurse? Give him some oxygen. So we need to give him some oxygen. We need to give him a it's 15 liters of oxygen, the a facial mask and then we see the response and then we'll adjust that. What else you okay? So you have a wiz, you're going to move down to see while you're giving the oxygen and seeing the response and then we'll come back to the easy treatment. So you had I had now you see what you want to assess. So this circulation, the capillary refill time. So the capillary refill time is two seconds. Um Is the rush disappearing or so can we do the Glasgow request? We are in see not bad. Okay. So you said the capital a refill time is to second what else you want to do and see heart rate and BP. So the heart rate is 100 and 40 and the BP is 100 over 60. That's fine. Fine. What else you want to do? And see the hydration is a child warm and the freezing color. So his, his, his hands and feet are warm. Um And his color looks, you know, uh there is no like no modeling. So now in see, are you happy? Uh we would also hear every sound of the heartbeat is proper in the proper rhythmic way. I want to listen to the heart sounds are normal. Okay. So are you happy with C Yes, we can move because yeah, so um it has been drinking but not eating. So you want to check the blood to the cause? Is that right? Or am I wrong? Uh But he's breathing as well is abnormal. So do you want just to check the blood due to cost or you want to do like a blood gas? For example uh Yeah, BBg blood glass. So capital E for example, this is what you usually do. Capital blood gasses being done while you complete the assessment. I'll give you the information. Okay. So let's complete the what are, what do you want to know about the child alpo score? People's So Akos call, he is alert responding to his mom looking around, okay. He feels equal and reactive. He's sitting up and he's reaching out for his bottle so we can move the exposure. Now if if he's looking with Yeah. Nine. Okay, then we can check about this rash uh interested in the rush, which is really good. So what do you want to know about the rush? Tell me, is it blanching? Nonblanching rush? Excellent. So the rush always when you have a rush, look at the distribution, the rush is uh present um in his trunk and his limbs. The rush is a macular rash that is blanching. What else you want to ask is that you were talking about Mrs early? So no conjective itis. Oh yes, no feeling of the hands or defeat. Okay. Oral spots like no public spots, public spots, yes. Okay. So um uh anything else you would like to? Are you happy? Now, did you tell us when this rash came on? You? So he's been on one for three days and the rash came on the last day after he ate something or suddenly. So the rash has been there for 24 hours. It's a macular flat rash. That's not itchy. It's not high, it's not ethical. Okay. It's not allergic, it's not. Yeah. So what do you think is happening with this child? See, developing manager, it's a flu, I think. So this child possibly has a viral infection started as an upper respiratory tract infection. He has a launching rush. He has fever with it. He's drinking but not eating. He's well hydrated. He has respiratory distress and he has bilateral ways. The possible diagnosis viral in you truculent. Really? Thank you for letting her take your bronchitis. We call viral viral induced viral group. No group group is the upper airway obstruction. It doesn't have group. There is no stridor. We are talking about expiratory wheeze which is lower. So this is viral induced with or if there are miracles can be bronculitis. Okay. But it's differentiate between upper and lower strider, which is a sound during inspiration is an upper airway obstruction that can be caused by para influenza can be epiglottitis if it's very severe. Uh wheeze is uh is a small airway obstruction. Bronchiolitis is a lower respiratory tract infection by a virus in a specific age group. So this child at the moment, we give him oxygen. He responded to oxygen. We need to make a decision is this bronculitis because we country bronchiolitis apart from oxygen, support the feeding and observe the child, everything is a viral induced with. And this child has got a family history of atrophy. We may consider to try some sort of broncodilator. We will not discuss that today. But what I want you to do today as we are coming to the end of the session, exactly that the common presentation in Children are fever, respiratory problem, abdominal problem, rush an Olympic child. We could not reach these. We need to have a history to understand what's happening. Pick direct flags do A B C D E approach treat appropriately as you are a junior doctor graduated from the medical school. We are expecting you to call for help and senior advice. Is that okay? Thank you. Yes, ma'am. Yeah. Uh would you like to ask in these three cases more likely want to do more cases instead of question? We'll do it in the next session. So I will, I will, I will bring the other cases for the second session. Okay. If you have any questions after that, you can send it to Hannah and I'm happy to answer it in the next session. Thank you very much, Doctor. Good evening. Uh, good evening and thank you for the support. Thank you very much. Bye. Thank you. Just to let everyone know the second session is on the ninth of March. Um, and it's an event, right? So you can book for that now if you want to, um I will eventually post it on the whatsapp group also the link. But if you search for it on event, right? It's there and I will post this difficult now quickly. Okay, I will leave now. Okay. Have a good evening. Thank you. Have a good evening.