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of the Carina. Good evening. My name is Sarah, the gym, a pediatric consultant. And, um, this is the second session I'm going to deliver. It's an interactive session, and this is what we deliver in our local medical school. Uh, it is linked to allergy and inflammation. Um, And so in these cases, I would expect you to ask me questions so I can answer, and then you may reach a diagnosis. So case studies interactive session. I hope that you are ready for that. The first cases. A nine month old girl who presented to the emergency department with widespread rash, um, developed around her mouth, then spread to her chest, arms swollen eyelid. She became very irritable. And she wanted twice the pain pain. The parents mentioned that her problem started few minutes following a few bites of white bread with peanut butter. Um, any thoughts? So if you're sitting in the emergency department and then this family walks in 23 hours and then the nurse ask you to come quickly to see this child, any thoughts been shared in the chat. There's nothing. Nothing in the chart. Currently, anybody would like to start the discussion about? What do you think about this girl her age at presentation? What could be the differential diagnosis? Someone has said Allergy. Good salt. So this is the It's not the patient. This is the photo. Similar. So, um, you can see this child. So allergy, um, to what exactly you're thinking about what type of allergy and what can you see in this photo? And what are your thoughts? Um, we've had one answer saying Allergy for carbohydrates and another saying an epileptic shock. Anaphylactic so carbohydrate is non specific. Um, not a common presentation for allergy, but she had peanut butter for the first time. Uh, in a toast. Um, will that make you suspicious for her age? And she has started cleaning. And the family. We're trying to introduce this at the age of nine months. What can you see in the photo? That will make you a bit concerned? So if you go through a b, c d e airway and I can tell you whatever you want to know about this patient breathing circulation, the disability. And don't forget, don't forget to look cause an exposure. When you're looking at this photo, what are the size that you can see that worrying you. And what questions you would like me to tell you about the assessment. There's nothing in the chat currently. But I think since it's a small group, if people want to just a mute themselves. And yes, that would be easier. Yes, please do. Because we can't progress in the second case unless we saw this case. So I'm happy to spend, you know, at much time in this case until we we know what we're doing. Hi, Doctor. Um, so, um, I just want to go through the A t e. Assessment, please. So, um, starting with a is, uh, Anyway, is that, um is the patient talking? Is the patient crying? Talking to the patient Know, So she's as you can see. Um, and I know she's not talking. She's not crying, right? Good question. Yes. Continue, Lola. Okay. So I guess, um, is there anything basically in the patient's map? Like maybe saliva or anything that may be obstructing. So, um, there is you know, you can when you try to listen, you can hear that there is a noisy breathing stridor, right? So if that's the case, then you can't really move on to the big part of the assessment because the airway is kind of, like compromised in this situation. Uh, so there is a strider, as you can see, her face and her lips. Oh, sorry. Then then that's the breathing then. So this is not from the airway. So you are suspecting that she has, um, allergy. So she would have and your edema. So possibly this is causing the stridor. Which indicates a severe allergic reaction, isn't it Because the airplane is involved, so yeah. Okay. Um, so while you're there, you're a junior doctor. You're trying to see everything. The nurse is putting all of the observation. So you are concerned you've asked for a senior to come while you're completing the assessment? What else you would like to know? Is he going to be? Is the patient conscious? I mean, it looks like the patient is sleeping. So you're worried about the patient so the patient will respond to when her mom is talking to her. She may open her eyes. So when we look at a push, the patient is responding to verbal stimuli that will make you more concerned. Isn't it? Yes. OK, so that's the But if you look quickly So you said a you identify that there's a possibility Angioedema Strider Be what? What you would like to to quickly assess the breathing. Yeah, So the respiration So the the child is breathing very fast. Um, when you look at the saturation on the monitor, it's between 92 90. And when you listen, you can hear wheeze bilaterally. That is concerning, okay. And then while you are assessing her with the ness, it's still have got the monitor. So she's nine months heart rate's between 100 and 70 to 100 and 80. Are you concerned about? Maybe not, because usually they they normally have a higher heart rate right within that range, I think. Still high. So there is a bit of a tachycardia, and when you feel her, you look at her. There's more of hives. Similar. Um, and her hands and her feet are cold. Um, the capillary field time when you press centrally, uh, 12345 And you release it and you start counting it goes 123. So are you concerned about this? Yes, because it's taking too long for the capillary refill. More than two seconds. Um, the nurse did not do the BP. She said she doesn't know. Where is the cuff, are you? Do you want the BP in this child or not? Mhm. It would be good. But, uh um, probably Maybe maybe BP is not, uh, never know at this stage, okay. And if I tell you it's the other way around because you have anaphylaxis if you have anaphylaxis, So you are expecting, um yeah, So it's and the tachycardia and the low perfusion with severe allergic reaction. You have a worry that, you know, there's a lot of fluid that went from the intervascular space, um, into, you know, outside. And then this is one of the reason why this child is very sleepy and responding to various stimuli eyes she has anaphylactic sho, and she is hypertensive. So, ideally, in every child who is unwell or attend emergency department even in not in this situation, they have to have one reading of BP. Yes, Children will have a better peripheral vasoconstriction in. They don't rob their BP quicker than adults. But you still have to have a reading of a BP. Any sick child like her. We are concerned. She has severe allergic reaction anaphylaxis. She has tried the She's responding only to verbal stimuli. She's the psychotic. She's the kidney, like she has a prolonged capillary full time. She must have a BP on spot. And when they do, the BP is on the lower side. So when we go to the you have already assessed and she is responding oil into verbal stimuli going to take her blood sugar. But that's a process. And then when you expose how you can find all of the hives of all around So this was a quick assessment. It wouldn't take more than 2 to 3 minutes. While you're, um, senior is coming, You would apply. Keep the child, you know, uh, in a neutral position and apply oxygen supply. Hopefully, that will help. But what is the treatment? What should be the treatment in this case, what is going to save life? So we have a nine month old. You will take the history from the family to confirm that it's only the exposure to peanut. There is no other uh, concerns you have in front of you. Um, widespread rash with angioedema with, uh, you know, presentation of severe allergic reaction. What are the steps to save lives? Everybody can contribute. How would you treat this child? Uh, maybe adrenaline. Okay, so the most the same. You know, the life saving is adrenaline. And in this situation, uh, giving adrenaline, I am. You know, if that's the only thing that can be given by the ambulance, then we give I am adrenaline. Um, And after that, you can repeat that again. If the child is not responding by that time. Hopefully the senior colleague is there, and there is an access an IV access. If there is an IV access, what do you want to give? Have a cannula now. So you have given to lots of I am adrenaline. The child is improving, but you're not still happy. You have a canula the foot a cannula. If they can bloods, we'll talk about that later. But what would you like to do? Do you want to give? Uh, not the priority at the moment. So we have given adrenal. I am hydrocortisone. Is there in the fluids? Fluids fluids. So you want to give a you know, uh, fluids. 20 mils per kg. You don't have the wait for this child, so you have to estimate the weight and give 20 mils per kg of other Heartland solution. Better colitis better. But if you don't have it, it's normal. PSA Lyme and A C O and you give the 20 and then you observe the child. You go through a B C, and you may need to give another adrenaline. That's because you have the cannula. Now a senior colleague and ideally, the anesthetist or the intensive care may decide to give the adrenaline through the cannula. It's a different concentration, while the I am adrenaline, it's one. In 1000. This one will be one in 10,000, so it's for someone senior to do it. But then it can go from I am to IV. And what is the worry about? Um, you know I am. If we repeat, keep repeating. I am. What are we concerned here If we have a hypertense safe child? We said that capital refilled time is prolonged. We're we're We're worried that the absorption of the adrenaline may be delayed you still have to give it. But if there is no quick response, you may have to go to IV. So you have given the adrenaline you have given the IV fluids, you may repeat the IV fluids. You have asked for help early. I've asked your, um, you know, senior to come. You have provided oxygen for this child, and then you will come to see the other parts in the, um, uh, phylaxis pathway, which is high. It's the hydrocortisone and the antihistamine and the salvia to manipulate Isar. So always, if you have a child who you suspect they have anaphylaxis either from food or from WASP or from a P or uh staying or they have anaphylaxis on the ward because they had a medication that they are allergic to. You will assess airway breathing, circulation, disability exposure, and you will start by the adrenaline injection. I am. I am. If you need an IV, there has to be someone senior, and then the IV fluids 20 mils per caging. And then you will come to the antihistamine and, uh, the hydrocortisone and, um, the salbutamol nebulizer. Obviously, if it's not an anaphylaxis, a severe allergic reaction. It's mild to moderate. You will treat by giving just the anti histamine because there is no airway or breathing or neurology involvement. Okay, this is the first patient. I think we spend some time on it, but it's useful. We go through the case Number two if you don't have any question in the case number one. Yep, there's no questions in the chat three months old girl presented to the history of itchy rash that appeared when she was four weeks old. It's mainly affecting the face and the trunk and her limbs. She has been seen by the general practitioner, the family doctor. They gave her emollient cream and hydrocortisone topical cream. Her parents both has history of eczema had in the past. She's breastfeeding was born at 39 weeks by normal vagina delivery. She's thriving and gaining weight. The family are not keen to use the topical steroid, the hydrocortisone. So what would be your thoughts and differential? And how would you approach this child? Feel free to? Yeah, um, use the microphone and whether you have seen a similar case and what would be your assessment? My thoughts of what could Could it be. Are you happy with the plan that the G p or the general practitioner the family doctor provided? And why do you What would you say to the family if they don't want to do the topical? Steroids and the child continue to have the rash. Maybe this is an interaction. Okay, so do you have any differential? So you said the infection. Skin infection. What else could it be from the g p. The treatment that the G P gave any other thoughts? So a rush that appear, that is it shape. It's in her face, and her trunk and her limbs has been ongoing for a while. It's not only one or two days, there is no fever. Um, the rush is, um, you know, sort of, um, red, um, flat. Uh, fam. Both parents had eczema. That may give you a hint. Um, the d p felt like they need to have emollient. She's a cream to use it whenever they're changing the nappy for this baby. But he felt that some parties very inflamed, and they need to use topical steroids. Hydrocortisone. The parents were like, she's only three months and we don't want to use that baby is breastfeeding. As I said, he was gaining weight. And, um, is it eczema or eczema with infection? We're not quite sure, but one of the common presentation is eczema or a topic dermatitis. Um, and, um, the most important thing is, uh, the treatment with the cream, the emollient so that the skin is not dry as well. What is used during the bath? Um, so it's not like bubble bath or written. Um, sometimes the topical steroids can be used, and there is a safe way to use it so that the family are not worried about the side effects of the topical steroids. Um, it is as well, important as you have mentioned Larissa to make sure that there is no infection. So no bacterial infection. It's not oozy. It's not like an MBA to go like and then, in this case, there'll be staph aureus infection, and the child may need oral antibiotics. But the worrying part is if the infection has got her piss simplex and there is exam is, uh, eczema herpeticum. This can be very serious, and the child can be very sick, and then the child may need not just oral acyclovir may require hospital admission an IV acyclovir. Uh, so there is a part about eczema, which is treatment at home and support. And there is a part about family understanding about the complication and as well it is. Um, usually it takes times. You know, the child. This child is lucky. The eczema maybe under control when they are one or two years. But sometimes it can be a long term illness, and therefore the family should understand that can be a flare up, you know, on and off. And it's not just one off that you treat, and then it will go away because they will say we have used the topical steroids, but it came back. So if they understand about the eczema and that it would, it may come back. Um, and that's how and when to use topical steroids went to use emollient and what to look for for severe um, infection. Um, that may help in the control of eczema because chronic eczema can have an effect on the child growth and, um, as you may head, or we had a discussion before. If you have severe eczema at this age, um this may make the child susceptible to develop food allergies as well. So if you have your barrier, the skin barrier is not intact. That may actually contribute to developing, um, food allergies. So I have, um, discussed this case of my own. I don't know whether there is any question, um, about these two cases of food, allergy and eczema, and this is just a, uh, sort of a diagram about, um how There are factors that will make, um, an individual resilient and will not develop allergies. Um, and then there are factors will make use this resilience and make the the individual more susceptible. But people were talking about the hygiene theory, and this is, uh, incomplete theory. It's not only about the exposure to infection on parasites. Um, um, there are different factors. Part of it, as as we mentioned the skin. Another part. It's a weaning process and early introduction of allergic food, and that should all be controlled by the genetic. So epigenetics player, all this is very complex. I'm just giving you a taste of it. Um, in regard to allergy moving on. Unless that is a question. Is there anything in the chat. Larissa. Um, there's nothing in the chair. I can see 20 messages, but I can't see exactly what is written. It's mostly comments from people who ended up saying them out loud. Hmm. Okay. So anyway, if there's any, um, anybody who wants to contribute, please feel free, you know? Or if you have a question, I'm happy to answer it. So case number three. Let's see how many How many k we still have good minutes. Case number three, a nine year old boy has been referred to the Children Assessment Unit. This is like the unit where the acute Children sick Children will come to see a pediatrician with the history of Nonblanching rush on both legs and swelling of his heat, his mom reported the rash appeared about two days ago. She became concerned because there was the barrages spreading and he's not, uh, feeding and eating or, as usual in the last 12 hours start limping, and he they felt that the swelling is getting worse. So what are your thought? Remember the age group and the history? And what are the differential? What? When you have this story, what are the differential? What are the things that you would like to exclude and what you think will be the top of the differential diagnosis. Have you seen a similar case before? Someone's commented? Um, meningitis. So nonblanching rush is important to exclude many, you know, meningococcal concepts is That's right. Um, we know about the, uh, uh, glass sign. You know, there was a very good campaign about if you use the glass and the rash does not disappear that you have to be concerned that there is meningitis. So, yes, this is a non blanching rush. So you are worried that this could be meningitis, So that's part of your differential. What else? Um, there's also a comment of septic arthritis. Okay, Because of the swelling of the you know, it's it's on both sides, so it's not unilateral. Okay, so infection of the joints, maybe we can put that, but at the lower part of the differential. Thank you. What else? When you see the rash, can you see the rash? What would How would you describe this rush? And that's the distribution. Make you think about what could be the cause. Other questions you would like to ask. So we have particular rash. And we have PARAGRAPH, which is a large empty yard. This child does not have bleeding from any other side so that when they're brushing their teeth or they have prolonged it's taxes. This giant had a floor throat about 3 to 4 weeks ago. Um was considered to be viral, and it was not treated for it. This is the first presentation of this rash and of the joint swelling. So it's not recurrent. What else would you be thinking of? What else could cause a meeting? What other illnesses? So we talked about meningitis only? Mm. Someone suggested, um, chicken pox. Okay, So, chicken box, what is the rush? The to the Russian chicken box is vesicular. While this one is pretty QR you can have, um, complication of chicken box, Uh, presenting with a like in a hemorrhagic form. But that didn't start this way. There is no history of fever. Keep think, you know, mentioning differential so we can discuss it. Another suggestion is insect bites, or there's also, um sorry, uh, in Pedigo. Strep toe. You be tiger. Okay. Yeah. So, insect, there is no history of insect bites and there are no hives. It's a wide spreading, a pity chi and joint swelling on both sides. What? What are the most important thing that you would like to exclude? Maybe one or two. And at the differential. So will you not be worried to check the platelets and the coagulation for this child? Because this child may have a genetic thrombocytopenic pepper I t p Okay, that's important. And if you have ti chi and joint swelling, you would like to exclude hematology malignancies. So you will examine the child for in large lymph nodes but splenomegaly other joints. And you will be keen to have a full blood count with a blood film. And although it's patiki eye, it's not like, um or say, um, inflammatory. You would like to make sure that this is not something which is arthritis as inflammatory arthritis rather than septic. So you examined the child. You have requested the investigation. But when you are looking into that and you are explaining to your registrar registrar told you that, did you check the urine? Why do you think your registrar is asking about the urine? And he asked you, did you check the BP any thoughts? Did anybody here about a condition called hell Actual in Pep Ra HSP? No. So this is a typical presentation of HSB and distribution of the rush where a child had some ls, um, viral illness or bacterial. And then a few weeks later, they developed a sort of vasculitis, and this will present as an inflammation within their joints, the skin and sometimes in their gut and so they can have blood in the stool. Uh, and and, uh, so they presented stomach pain. And HSP is self limiting, so there is no, um, treatment. But we worried about the vasculitis in the kidney, which can present as, uh, blood in the urine, blood, blood cells, and sometimes hypertension. And you need to follow up the child only you can give steroids if there is an evidence of significant vasculitis, especially affecting the tummy. But generally, if you are seeing a child who's presenting with particular rash that starts on his legs spreading to the thigh and, um, the back with joint swelling, you have to exclude malignancy. You have to think about I t. P. You have to think, is there It's an inflammation. Is it arthritis. But if it's do you have excluded all of that clinically and by blood test. So this child, his full blood count was normal. His hemoglobin was normal. His white cell count was normal. His platelets were normal. His coagulation was normal. It means that it's not a hematological problem. The CRP was normal is not an infection, it doesn't have fever. It is H S P. So you need to monitor his urine. The G P. Check it like every one week or every two weeks. Make sure that the child will not develop complication. So HSP is a vasculitic legion post infection that can be complicated by vasculitis in different parts of the body the skin, the joints, the gut intestine, the kidneys and rarely the brain. It's not a common presentation usually subsides after a few weeks. Sometimes it can continue for six months. Then it will be called chronic. I don't want to give you a lot of information because I'm not sure how much you can return to the end of the day. But what I'm trying to say is have a differential diagnosis. Even if you didn't know about H S B, you have to have the right approach. Is that okay? Any questions before we move on? They're saying it's okay in the champ. Thank you. 14 year old girl presented to the general practice with a history of abdominal pain for 3 to 4 weeks. Her dad noted fresh blood in the stool in the last 24 hours with history of diarrhea. For weeks and weeks, she reported lethargy and fatigue. Her dad felt that she lost weight and look pale. So you have this presentation. Always. When you are taking such history, you have to have a differential diagnosis. Okay. You have to say what could be the cause. Do you have any other questions that you would like to ask me about this child? Um, in the history or in the examination, you can write or you can you know, a mute yourself and ask questions. I don't want to do all of the talking. Um, someone said past medical slash surgical. I don't know what Ajax means. So this child history, first presentation, she didn't have any previous surgical intervention. Um, or any surgery, uh, then travel abroad. Good question. Now, the child did not travel a protest. Food? Fashion? Yeah. Um, someone else. Lola's asking, um, sexual history. Okay, um, the child say that she's not sexually active, but it's important to ask this question in this age group. Good. Uh, maybe we have to ask this family what does eat. So she has been eating the same standards. They haven't changed anything. Uh, do you have any specific thing that you would like to ask? So she has been off her feet. She's not been eating well for a few weeks. And that things that she looks pale. She's fatigue, She's tired, and, um, she has lost weight. So when we say that she has diarrhea, we need to confirm that's diarrhea. That there is no constipation, that the blood is a fresh blood. Or is it blood mixed small streaks. Is there any mucus? Uh, it's the g l t symptoms. So if you start from the mouth downwards, whether she had before any mouth ulcers, and she said yes, she had mouth ulcers. Um, but currently she doesn't have that, Um, any heartburns? No. Um any. She has nausea. She doesn't feel well. She doesn't want to eat. She is very embarrassed. That she has to run, Uh, you know, to the toilet because of the area. So she has been missing school. And in the last few weeks, she started to have this blood in the stood and she looks pale. She's 14. She had her menarche and her period was regular. But now it is irregular. She does not have any rash. And on systemic, um, you know, assessment. Um, she doesn't have any other symptoms. No joint pain, no joint swelling. And she's not taking any medication. She have never been to hospitals. Um, and her immunization is up to date. So what is your differential diagnosis? Uh, and then she tells you as well that, um, which is not quite, you know, shoes. Just which you open about. You feel that there is pain down below. What would be the differential diagnosis before we start the examination? Um, and there's been a suggestion of, um all sort of color. Sorry. Collotta, active colitis, colitis, and someone suggested Also onset of crones. Good. Um, so an examination when you examine her I'm just going to tell you that she spell there is no Dundas, no enlarged lymph nodes. When you look at Hamas cavity. There are no active ulcers, but they're old healing ulcers on the side. Um, she's listen to the heart. She's a bit, you know, you can hear like a mamma was probably from the pallor. Her chest is clear. Her abdomen is generalized tenderness. Spinning is not enlarged that if it is not enlarged, Um and she allows you to examine her, you know, to examine the anal area. And when you examine, you can see there are some sort of anal fissure, but she doesn't have any constipation. So you would think along the line of inflammatory bowel disease as, um, you know, you mentioned a sedative. Colitis, crone's disease, Possibly ulcerative colitis. Uh, it can be systematic. So you need to check. First of all, she looks pale. She's fatigue. You have a murmur. So you're worried about, you know, anemia from bleeding, And she is a hemoglobin is low. You will do the CRP and the s are and definitive. Mean, you check the stool, um, to check for, you know, inflammatory bowel disease. We'll do the liver function test. And, um, this child will need to be seen by the gastro team. where they will do a colonoscopy and they will take a biopsy or report on that. And then she will go through the line of treatment. Um, uh, which is not the scope here to talk about. But what I'm trying to say is, when you see this child, as some of you said, she may be traveling. Maybe infection. She may ate something that caused a degree of, uh um infection. Um, is it, um, you know, you need to know. Is this bleeding just local? Or she has got bleeding from other side's. The consequences of the bleeding and anemia and how sick and unwell she is. And then the referral for the right investigation so she can start treatment. Okay, I still get the tax on on KPU Case five is a three year old girl was referred to the Children outpatient to a seven week history of being off color and miserable. She is increasingly reluctant to get up in the morning to get dressed for the nursery family reported that she would like to be carried rather than walk around to the nursery. Although she used to easily tired and lacks energy, she has been complaining that her legs and uncle hurts. She's only three years old. Okay. Any other questions that you would like me to answer before we go to the examination? There's nothing in the chair. You have to have an approach when you have certain scenarios. Okay, Um, and and through this approach, you know, when you have this approach, then you will make sure that you have a differential. You complete that in the history and then the examination, and then you tailor your investigation accordingly. So any of that flag signs in the story anything that's worrying you one of commented? Sorry. Someone has commented that you should ask about the diet. Um, and full history. Yeah. The diet is important. Vitamin D can be as well important. Um, um please a mute if you want. Want to ask questions or you want to make comments? I think someone, uh, sorry. Can you hear me? Yes. Okay. Uh, you sorry? You're just asking about red flags? I was thinking, um, initial thing. A three year old girl generally wouldn't be, um, lethargic. They would be full of energy. Generally, you would expect, um, so that would be a red flag. Uh, and the, I suppose the complaining of pain in legs and ankles. Um good. Excellent. Yes, the three year old saying that her legs are hurting. It's not like just one day or two days going on for weeks and weeks. She used to run to the nursery, and now she wants to be picked up and carried. So that's really worrying of color and miserable. Have to listen to the parents, you know, if they tell you that it's like, um, something is that something is must be wrong. So what are we thinking about? OK, so when we are assessing this child and asking questions, what our world differential And if you want to chat, um, someone's commented. Maybe they're not having enough good nutrient. Okay, so we were looking to the nutrition, and, uh, we're not concerned about that at the moment. She's starting not to eat and drink, but that's just recent. But previously eating and drinking appropriately good. That's important to assess the nutrition of the child. Oh, there's been a comment of anemia, vitamin D deficiency. It's important to rule out anemia and vitamin D deficiency, which can cause the problems with back with pain and, you know, lethargy. And if you have a nutritional deficiency that can be a combined iron deficiency and vitamin D deficiency, good. But you also consider maybe like a safeguarding issue. If this is something that's happening, uh, I think with any Children you should always have that the back of your mind as well. And there's she's she's miserable and and not not very motivated to go to nursery. And she's got pain. Her ankles are hurting. Maybe. I mean, he could consider as well. So you are right. Safeguarding is always at the background, and that can be important if we can't identify the course or there is neglect and delay in presentation. Or, you know, um, we are worried about more than neglect that there are other type of, of of of, um, abuse. So to reach that, we were going to examine this child. But what other questions we need to ask. So is there a history of fever, prolonged fever? No, there is no history. Is there a history of a four or a trauma? There is no history. Is there a history of swelling? And mom said, Maybe when I'm trying to put her shoes, Um, seems like although we just bought these shoes about three months ago, it seems like it's, you know, she's not happy as if there is swelling or her uncle, uh, joined. Um, and when you ask them, Is there any issues about, you know, rash? Now? Sometimes you have this rash that appears and disappears. We don't know. And, well, she complaining and exactly in her legs about the pain. Oh, she's pointing to her knees most of the time. Is that waking her from sleep? That's a very important question, because that's worrying. Sometimes, yes. Okay, And then you need to know about the realization about the family social history. And is it a family history of any problems? So to say, Oh, you know, there is a family history of thyroid problem. And, um, Mom has lazy thyroid and she's taking, uh, medication. Um, there is, as well, family history of psoriasis. So when you examine this charge, you what you're worried about your word. This is malignancy, and you're worried. Is this juvenile idiopathic arthritis? Um, and as you mentioned, whether this is something related to nutrition or there's other issues and unlike Nonaccidental injury. So this child, when you examine her, she's not happy. She is not playful. She looks pale. She's a Parexel. She doesn't have any large lymph nodes, but there are swollen, um, knee joints and uncle joints. And she's reluctant to walk and she's walking with, you know, she's in pain, and the family said they have been giving her paracetamol. Sometimes I do proof it. She may pick a little bit, but then she's back to square one. There is no large liver spleen. That's important, because if we have systematic, juvenile idiopathic arthritis, we can help you. But splenomegaly and lymphadenopathy. So, um, you will still do a full blood count with a blood film and, um, to rule out malignancies and leukemia. And then, um, you may think about doing X rays or because there are more than one joint to be useful to discuss with dermatology team. Who will do is our and other tests. Um, and, um, you know, if the full blood count is fine, why cell counts are normal and it's not, you know, on the pathway of malignant hematology, then it will be on the pathway of juvenile idiopathic arthritis. Um, And then the rheumatology team will do further investigation and start the treatment. But it is important to pick on the red flag signs to exclude the serious differential, which are malignancy, to think about arthritis in Children and to refer appropriately and do the first line of investigation. Um, any questions? I can see there are 52 comments. So some some have Some of you have been adding some comments. There's nothing new in the chant. Nothing. Okay, I'm not sure if this Yeah, this was the last case you would be pleased to hear. I'm sure you had a very long day. So this is, um, what we're trying to say that always have a differential. Link them together. It can be the age of the patient. The story, the history, the examination have an approach to Children who are presenting with a possible inflammatory process. So in this session, we try to look at allergy eczema, mom, inflammatory bowel disease, vasculitis, HSP, uh, juvenile idiopathic arthritis differential. That can be malignancy and accidental injury infection. Um, and, um, you know, different, um, sort of investigation that can be done. Do you have any question about these cases I try to today do to make it a session as, um interactive as possible because I'm sure you are getting a lot of, uh, uh, lectures with a lot of information so we can use this information as if you are in, you know, the hospital or seeing patient's face to face. Obviously, it's not that easy, but I hope that helped a little bit. Thank you very much, Doctor. It was really interesting, um, and engaging. Um, we do have we have another nine minutes left. So if anyone has any questions, they'd like to ask or put in the chat, and please do fill in the feedback form. It's very important for us to continue to have feedback every day. Um, for every election. And, um, right before we finish our post firm Sorry. This is difficult in the chat. Well, thank you for facilitating and thank you for those who attended. And I understand that there is some problem with electricity cut. Um, my first, uh, my previous, uh uh, lecture. I have a photo standing in solidarity with the people in Ukraine. It's from my home country in Sudan, where there is an ongoing pro democracy revolution for civic, Democratic state. And the people on the street have been holding the flags. Um, and as well, um, I always end my lecture saying that injustice anywhere is injustice everywhere. So, uh, this is the minimum we can do standing in solidarity, uh, with the people in Ukraine and supporting the medical students.