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Hi, Married. Hi, thanks again for doing this. No, you. No problem. I'm just trying to see where I share my screen here. Um, there should be any green but the bottom. Yeah, I'm just trying to get it up there. Sorry, on the right power point. Sorry, my laptop is having a bit of a nightmare here. Give me a second. Ok, Marie, do you want me to wait a few minutes just for people to join or go on ahead uh, up to you and yet they can continue to join anyway. So. Ok, Crohn's maybe um Mar, I'll go on ahead there now. Sure. Yeah, perfect. You see that there. So that's great. Um I'm gonna have to head on early but Nicole will be joined in and she can send in your feedback form in. Ok. Yeah, no problem. Any problems at all. Just give me a text. Ok, I will. Ok, perfect. Thank you. Bye. Um ok, so we'll make a start there. So, first of all, thanks everyone for joining and hope you're all getting on well with revision and stuff for the exams. Um, so we'll just make a start. So my topic tonight is dermatology. So we're just gonna do a brief overview of um kind of the most common conditions we'll go through plans. So, um I'm gonna focus on taking a dermatology history, an ad assessment of a lesion, then common conditions such as eczema psoriasis, acne and then other common skin conditions. Um I'm gonna focus on cancer, dermatology and then emergency dermatology as well. So just important things to know for exams and also also for um acies as well. There usually is dermatology stations. Um So it's kind of a nice one to be able to bank anyway. So um first of all, then just a dermatology history. So for presenting complaint, a nice genomic to use is Socrates um which you probably use for everything but um s so side effected then onset. So is the lesion or the rash acute or chronic or has it changed over time then um describe the rash. So for instance, the character of it. So um what kind of rash it is or lesion? It is then where the rash I or where it is and has it spread associated symptoms? So, bleeding, itching, crusting, swelling or if the lesion isn't healing, which is obviously um a concern in future. And then um has it changed over time or any exacerbating fee? Anything that exacerbates the rash or lesion? So things that can exacerbate, um for instance, irritants, allergens, heat sweats stress and then also ask about relieving symptoms So, anything they've tried so far such as creams or anything that they find, um, eases, um, the symptoms, then past medical history. Do they have any medical conditions? If, yes, always ask if they are well controlled. Um, and if the current treatment, I, if they're on any current treatment for immunosuppressant or immunosuppressants. So, um, this is an important one. So if the patient is on any immunosuppressants, they're more likely to develop skin conditions such as um squamous cell carcinoma. So that's a good one. That's an important one to know then other complications, hospital admissions and then always ask about a history of HP. So if they have um asthma allergic rhinitis, um and hay fever. So they can also develop eczema from this than a history of systemic disease such as diabetes or IBD. So, um having one of these systemic diseases can kind of lead you down a certain road in terms of trying to diagnose the rash or the lesion because they're more commonly associated with these conditions. Then um it's important to do a specific skin history. So, any history of skin cancer, then questions regarding sun exposure. So do they burn easily on holiday? So, using the Fitzpatrick scale. So um if it's Patrick um scale of one, they'll be more likely to burn and then do they wear sun protection daily? Do they use sun beds, which is obviously a red flag? And then um have they ever had any nasty burns or any nasty burns recently and do their symptoms improve with the sun, for instance, psoriasis or SL E. So the classic butterfly rash, does this worsen with the sun exposure? So this can just help, you know, um what the diagnosis is. So I'm just trying to move screen then ask about family history. So any skin conditions run in the family or if there's a family history of skin cancer, um the patient may be at increased risk of developing this as well. Um, drug history. So they are they on any prescribed medications specifically for the skin or for any other medical conditions? Um, any side effects from their medications and do these correlate with any of the skin conditions? And then over the counter medications, I always ask that and I always ask about herbal remedies and the most important one which is in every history, um, which you'll hear all the time is allergies. So if, yes, then I'll always clarify what kind of reaction they've had. So this is important, um, and kind of similar to asking someone if they have for instance of penicillin allergies. So, um, do they just, is it a really severe allergy or not? So then also ask about skin care products, soaps and cosmetics. Do, are they allergic to any specific products? Um, then in terms of social history, an important thing to put in there is occupation. So does their work affect their skin problem or is there an improvement when they're away from work? So this can be, for example, contact dermatitis. If someone is working for any, working with any, um, specific things or chemicals that really irritate the skin or then if they're exposed to any hazardous substances and work as well, um, always ask about smoking, alcohol, recreational drug use diet. Then if there's an been any recent changes or any foods that act as a trigger. So for example, we'll come on until later for um patients with celiac um disease, they can, this can be linked with um a specific skin condition. And then always ask, it's really important for dermatology histories, ask about impact of quality of impact on their quality of life. So this can really um having a skin condition can really affect someone's quality of life, for instance, their work life, school uni and specifically mood and confidence. So it's important to um always ask about that. Um So just moving on then. So this is the Fitzpatrick scale. Um So it's important to know that in terms of um patients cancer risk and their likelihood to um burn easily. So, um risk of melanomas, then disease specific questions for eczema ask about the atopic triad. So, asthma and allergies um for psoriasis, always ask about joint problems. Any nail problems such as onychitis, ask about the scalp as this is a site which is um very likely to get psoriasis patches, ask about cardiovascular other symptoms, stress mood, alcohol and also key drugs. So alcohol can make psoriasis a lot worse. So, um just um specifically ask about these things. Then in acne, it's important to ask about scarring if they've used any contraception, if this has made it worse or better, um then ask about PCOS symptoms. So patients with Polycystic ovaries um are more likely to have these symptoms. So hair growth, um irregularity with periods and weight gain and also to have acne then also to ask about steroid use. So patients that are on steroids or long term steroids have increased risk of developing acne. Then um in terms of lesions, ask about anticoagulants. Then the song questions in which we spoke about um any previous burns tanning, sunbed outdoor jobs, hobbies. So we went through that already then um moving on then to assessment of a lesion. So the first most important thing to do is general inspection. So where exactly is the lesion? So the specific location and is this in a sun exposed site? So is it like on the head around the ears? Um tips of the nose? So which are more likely to be um sun exposed? So um conditions such as actinic keratosis really um develops in sun exposed areas and then also ask about the size and the number of lesions then on closer inspection and the size is really important. So always, always, always measure the lesions. So this is important for them in the future. If you're comparing um that they can see if it's evolved at all, if it's gotten bigger. So um measure the diameter, um note the shape color and if it's well or ill defined and the morphology, so then moving on to palpation of the lesion, so, assess the consistency, the mobility, the tenderness and the temperature. And um you can use ABCD again, a very common omic. Um But you can use that for pigmented lesions and we'll go through that in a bit and then um it's important to do a lymph node examination if there's concern about malignancy. So if um you're worried about malignant lesion, then check for lymphadenopathy as this can be a sign that the, that the lesion is malignant and then also do a full body examination and systemic check for other specific lesions and then mark that on the skin up, right? So um moving on just to say, I can't see the chart. So um if there's any questions, just pop them in there and we can have a bit a look later. Um So then moving on to eczema. So um these are one eczema acne and psoriasis, I'll focus on um a bit more than the other skin conditions just because they're really common and they commonly come up in exams and commonly come up in a so we actually had a ay in our finals. Um just they're passed on eczema and counseling. So, it's definitely a good one to know inside out. So, eczema, if you're to describe it or describe it to a patient, it's nice to use the brick wall analogy. So um kind of describe an eczema like the skin should be a protective barrier, it should trap moisture in, keep irritants out. But instead there's a breakdown in this barrier and that causes um an impairment and the skin can become dry, bacteria can get in and that causing infections. So another thing that's associated with eczema is the itch scratch cycle. So it's important to focus on this and say that you need to break it down, you need to stop scratching and um as it is a vicious circle. So it's just important to counsel patients on that then avoid irritants or allergens. So things that can exacerbate eczema are stress heat, sweat wool, soap, fragrances and pets. So patients usually have specific ones that will irritate their eczema. And then a good um comparison to know is that on Children, eczema actually occurs in the flexure um positions and also it's very dominantly facial, whereas in adults, it can also occur in the flexure. So like the um but the skin inside the elbow would be the most common or the back of the knees, but it can also occur in hands and feet. So, um and then there's just a wee um photo down there of acute eczema versus chronic. So you can see in acute, um it's very red edematous, very inflamed and angry looking and you can have papules or vesicles. So it's important to really assess it to see if there's um if it looks infected or anything as that changes the treatment plan, obviously. And then in the chronic or dry eczema, you can see the slightly thickened skin. So this occurs when the patients are um itching a lot, um maybe subconscious itching or at night time. But if this is consistent chronic lynch and application can occur, which is kind of um looks like a thickening of the skin. So then treatment of eczema. Um the most important thing is emollients and I put in soap substitutes there. So just um things that maybe uh soap substitutes, so they might irritate the skin as much as normal soaps. Um So you can use, it's good to counsel the patients that they can use light cream during the day and greasy ointments at night. Um So patients seem to tend to prefer this just because um putting on the greasy um ointments during the day probably isn't comfortable. Um So in terms of as I encourage patients to use the emollients liberally, so they can use them as much as they want. Um twice a day is kind of the minimum amount. So it's really important to keep the skin hydrated and protected with the emollients. And then steroids can also be used. Um That's supposed to say hydrocortisone there sorry. Um So, hydrocortisone ointment is the first step in the steroid ladder. And um in terms of OS, it's important to just emphasize for patients that um steroids are very safe if they're used appropriately. But also it's important to emphasize that they must be used sparingly. So one fingertip unit is equivalent to um two palms of the hand in terms of um skin. So then also know the side effects of steroids. So we'll go on to that. I think in the next slide or two slides time the steroids. So yeah, um counseling on steroids then so wash hands before use and after application, one fingertip unit is what I said, equivalent to two hands worth of skin, prescribe the weakest potency, corticosteroid first, that's effective and then work up if this isn't affected, but it's very important to start at the bottom. And then usually only for a short term. And then the maximum strength that can be applied to the face is um so no higher steroids such as bete or Dermovate can be applied to the face just because the skin around the face, specifically around the eyes is so thin um that it can really affect or it can cause skin thinning, which we obviously don't want then side effects of topical steroids which are important to know is as I said, skin thinning folliculitis in large blood vessels, which is angitia easy bruising and then periorbital dermatitis. Um and then as I said, just emphasize to patients that topical steroids are really safe and they don't cause the systemic symptoms that um oral steroids can cause. So this is us, this is quite a common question for Oy. So it's just important to know that and be able to counsel patients and reassure them that they don't actually cause the systemic symptoms and then mild and moderate potency, topical steroids can be safely used in pregnancy. So a good way to remember. Um the potency of steroids is an help every budding dermatologist. So the least potent steroid is hydrocortisone. Then next is E so every so then budding B for be obviously and then D and Dermovate. So it's just a good way to remember because I find it's hard to remember what, which actually comes first, then counseling on emollients. So, um there are just examples of emollients there over on the left hand side of um kind of really light ones to really greasy ones. So it's good to know a couple. Um emollients can come in pump dispensers. So it's good to encourage patients to use this as their cleaner and it reduces the risk of um bacteria contaminating the wound, then apply liberally and frequently um smoothly in the direction of hair growth with which is a good tip and this um reduces the risk of folliculitis. Um Then just in terms of if patients are using both emollients and steroids, always use the emollient first um to soften the skin, moisturize the skin and then apply the steroid um up to half an hour later and then just say about sub substitutes that can reduce irritation. So then eczema complications. So secondary bacterial infections such as vertigo, its staph aureus, golden crust and weeping is the identifying features. And then treatment is hydrogen peroxide, eczema herpeticum, which is um an important one to know for um MCQ. So this is herpes simplex virus and it's usually described as painful, punched out lesions. Um Treatment is oral acyclovir or if it's really severe and the patient's in a lot of pain, you can also use IV acyclovir and then molluscum contagiosum is a common one in MCQ as well. So this is the pox virus and it's umbilicated papules. There's always, well, what they're described at as in M CQ is usually multiple lesions in one area and they tend to present as crops of lesions. So kind of little clumps of lesions that can spread around the body. They're self-limiting. It does take a long time for them to um resolve and they're common in Children, but also in patients in um shared accommodations such as prison or something. Um and then um flucloxacillin can be used if it's a super infection or if it's spreading. So then other types of eczema are listed there. So sero eczema, discoid, eczema um and so on. So if you just want to have a look at them in your own time and maybe know a little bit about them. Um Varicose eczema is a common one in exams and whenever you come on to look at geriatrics, maybe next year. Um So just have a look at that. Then next common condition we're gonna focus on is psoriasis. So, um psoriasis is a chronic inflammatory skin disease due to hyperproliferation of the keratinocytes and inflammatory cell infiltration. So, that's a classic photos of psoriasis. Um kind of what we call the silver scale in lesions. So, erythematous plaques and they're usually a really well defined border. Um It's a chronic autoimmune condition and it usually develops on the extensor surfaces and commonly presents kind of in the hairline or behind the ears as well. So, um good things to know for exams are um signs like I pitch sign, which is whenever um small bleeding can occur and kind of pinpoint um formation after the layer of the scale has been removed off the surface of the plaque. So after plaques removed, little pinpoints of blood can appear and this is a diagnostic feature. Then ko's phenomenon is common as well. So, plaques can occur at sites of trauma. Um Another thing to look out for is psoriatic arthropathy. So, as I said before, um whenever someone presents with psoriasis, it's always important to ask them about any joint um symptoms that they're experiencing. So, um patients can present with things such as arthritis mutilans, which is AFA flexion deformity of the distal interphalangeal joint. So maybe just something to look up as well about the psoriatic arthropathy that can be associated with, with psoriasis and then types of psoriasis. Then chronic plaque psoriasis is the most common type. And typically, um the type that we're all aware of seeing then good psoriasis is a good one to know as well. It's also quite common and um it's a good one to know for MC Qs. So, and this is associated with streptococcal infections for instance, strep throat. So the classic thing for MCQ S, they'll say in the question, stem, the patient presents with tear drop plaques and they've maybe had a recent um streptococcal infection or um throat infection, then palmoplantar um psoriasis. So this occurs in the soles of the feet and palms of the hands and then flexural psoriasis. So this can develop in the axilla, groin and sub area. Then um just to note there onychitis and pitting, which is also associated with psoriasis. So that's an important one for us. Um Just if you're doing, for instance, an assessment or a history to ask patients if they have any nail symptoms as well. Ok. Then moving on to um psoriasis management. Um so it's a bit more complicated than eczema, but um just try to break it down. So, regular emollients to help with the scale loss and reduce itching of the skin or the lesions as well. So, step one is potent topical corticosteroids once daily, and Vitamin D analog once daily, then if this doesn't work and there's no improvement. After eight weeks, you can then, um tell the patient to use the Vitamin D analog twice daily. Then the third step, if it's still not working, um move on to more potent steroid by daily or cold tar preparations as well, then there's other options such as phototherapy. So UVB light or systemic um drugs such as methotrexate or biologics, such as Infliximab, then the Vitamin D analogs and um can also or can be used as well. So there are just other options. So, moving on to acne then, so acne is an inflam inflammatory disease of the pilosebaceous follicles um causes there's multiple causes and um patients can um can have many of these or um it can just um occur. So, androgen effect, increased semen production, obstruction of the pilosebaceous follicles or um this is a bacteria that causes inflammation of the follicles and then leads to acne. So presentation, it typically presents in the face area, the neck and the upper trunk. So I've just added photos there of the different types of acne. So you can have open comedones which are usually blackheads, closed comones, which are described as whiteheads, pustules, nodules or cysts. So it's just important um to know kind of what the differences are there. Um Then just to highlight that acne can be associated with different types of scars So ice pick scars, hypertrophic scars or rolling scars, so they can look very different. Um I add it in there just in um a scale in terms of the severity of acne. So mild, moderate or severe, so severe acne is widespread nodulocystic features or moderate acne that isn't responsive to therapy. So if patients um present with severe acne, they're more likely probably not to respond to the first couple of lines of treatment and will be moved on to AAC. So we'll just go through the management plan for acne. So mild to moderate. First of all, the first step is a 12 week topical combination. So for example, topical benzyl peroxide with um topical clindamycin. So um I think a good thing just to throw in maybe for a for OS is that if a patient is using um benzyl peroxide that this can stain skin or not stain skin, sorry, this can stain um clothing. So it can kind of um stain clothing and look like um maybe perhaps bleach or like an orange staining of clothing. So just make them aware of that. And they'll also um yeah. So maybe on step two then is um topical, topical creams with um oral antibiotics. So I just put in some examples there and examples of oral antibiotics are oral lymecycline or oral doxycycline. So it's important to know then that um tetracyclines can't be used in pregnancy and avoid all retinoids in pregnancy. They can't be used in breastfeeding or in patients under 12 years old. But if a patient is pregnant and um as acne, once treatment, you can use Erythromycin. So, um the topical applications um are always prescribed with um antibiotics. So to avoid antibiotic, step two, to avoid antibiotic resistance and then topical and oral antibiotics should not be prescribed together. So the topical um combinations will be more like them peroxide with an antibiotic as opposed to topical antibiotics and top and oral antibiotics together. Then other options are the combined pill for 3 to 4 months. And then um if none of these um lines of treatment are working, then um patients can be considered for isotone or reactine, but this has to be prescribed by a dermatologist. So it can't be prescribed by a GP or anything. Just a dermatologist can prescribe this because um the patient will have to go through a screening and to see if they're actually eligible for actin or is something that um they'd benefit from. So, dermatologists don't tend to um prescribe this lightly as there's multiple side effects and the side effects are really important to know. So, um reactine is teratogenic. So the patient will be um handled on this and um started on uh um so on a contraception method, then if they're using Roine, they're gonna be very um likely to get sunburn. So photosensitivity. So it's important to tell them to um use sunscreen and then um patients will also tend to have dry skin, dry eyes, dry lips, and then a really important one is to emphasize that reacting has is linked with um affecting mood. So this is an important one for counseling patients. And probably the most important that alongside genic is the most important thing to say whenever you're counseling a patient on this and why it's only prescribed by dermatologists. So now I'm moving on to other skin conditions. So rosacea um typically affects middle age, fair skinned women. So it can present in the convexity of the face. So more likely in the skin or the cheeks, the nose and the chin and then the and the center part of the forehead. So more centrally on the face, it can also be associated with facial flushing, erythema, toland taia and papules and pustules. So, depending on these associated features is how you grade rosacea, um which is um then determines the treatment um that the patient will be started on the eyes can also be affected, causing blepharitis and treatment for this is with topical antibiotics triggers include UV, light spicy food and alcohol. And then um that's just a bit about referral. So if um they have, if patients don't respond to um the management or have um thickening of the skin and the nose. So daily measures. PF camouflage cream avoid triggers. If patients present with erythema flushing, you can start them on topical brimonidine and then um mild to moderate, moving on to other different types of treatment and moderate to severe is topical ivermectin or oral doxycycline. So, blistering conditions then. So, um in terms of diagnosing this, um it's usually diagnosed the biopsy for histology and immunofluorescence. So, pemphigus, vulgaris, the most important thing to say with this is that um a good way to remember. It is pemphigus, it ends in an s and this is a superficial condition. So, when you're comparing pemphigus, vulgaris and bullous pemphigoid, which are commonly confused, confused um which is fair. Um a good way to remember it, it is just end in an S so it's superficial, whereas pemphigoid ends in ad so this is a more deep condition. So, pemphigus vulgaris affects the mucous membranes and it's intraepidermal blisters. Then phi or bullous pemphigoid can a can commonly um occur in elderly patients. It's itchy whereas pemphigus vulgaris isn't and it's a subdermal subepidermal blisters. So it's deeper than pemphigus vulgaris, which is more superficial and um kind of just um rubs the skin will just rub off. Then I mentioned earlier, um skin conditions that are linked with celiac disease. So, dermatitis, herpetiformis, this is a big one for MC Qs and um it's itchy papules and vesicles that occur on the extensor site. So usually I've added a wee photo there. Um it's usually the backs of the elbows. Seborrheic keratosis is a really common skin condition and you'll usually see it um in the middle aged or elderly commonly presents in GP. So patients come in with a really, they're really worried about a lesion because they do look quite aggressive, but they're really, really common and um, easily diagnosed when you've seen a few. So there's often multiple lesions and they're asymptomatic, they look like warty stuck on, well, demarcated waxy papules, sorry, that's meant to be papules and nodules and um, they usually present on the trunk and the face. So, in terms of treatment, then um there's usually no treatment um for these. But if they are symptomatic, for example, if a patient has um a seb K on their bra line and it's really, it's kind of a catching on the bra or something, then they can be removed. So then actin actinic keratosis, which is also a really common condition, is a premalignant skin condition, but this can develop into an sec. So that's why it's important um to monitor. So it's atypical keratinocytes on the epidermis develops in areas of chronic sun exposed, um cause chronic sun exposure. For example, in the head, there's small crusty scaly lesions. So you'll just kind of see a crusting um area on the head and there's usually multiple and in terms of malignant transformation, the things to look out for which um will then make you more worried that this is an SCC and non and Act Act K is 10 nonresponsiveness, non, not responsive to treatment, racing growth or change in the laser on that ulceration treatment, prevent, um, further risk. Avoid the sun, New Sun cream. Fluoro cream, um, 2 to 3 times weekly. So, um, fluoro cream, um, initially makes the skin a lot worse. So it'll make it red angry and the patient may be worried that, um, they're allergic to it or it's irritating skin. So whenever you're counseling the patient on Fluoro Cream, just notify them that this can happen and not to be alarmed that it will get worse before it gets better. And then there's just some other options listed there for in terms of treatment. So, derma of fibroma is a common benign fibrous skin lesions, they're often in areas in which the skin has been um injured. So if there's like a cut in the skin or something, then a dermatic fibroma can develop in this area. So they're usually singular firm papules or nodules often on the limbs. So, in their arms and legs and an ID identify feature of dermato dermatofibroma. So, um a way in which you can rule out other um skin conditions is that whenever you um squeeze the overlying thin skin, that a dimple will form. So whenever you pinch it, a little dimple will form the skin. So that's how, you know, it's a dermatofibroma, then pyogenic granuloma. So this is a rapidly developing benign nodule and overgrowth of capillary blood vessels and it's often on at the site of trauma. So if the patient has like her, for instance, in this picture, um the patient has um had a bit of trauma to the fingertip and um then the capillary blood vessels can just grow and grow and grow until a pyogenic granuloma develops. Um these can bleed really, really easily and ulcerate easily as well. So, um patients often come very alarmed, they can be removed by um that's cautery and or cryotherapy or excision and then um so just take drink, then um they commonly occur during pregnancy um during pregnancy, if these do occur, they um usually resolve spontaneously. Ok. So, moving on to bones disease. So this is a full thickness, squamous dysplasia on the skin. Um It's squamous cell carcinoma in situ and it's seen as erythematous plaques with overlying scale. So 10, 5 to 10% risk of malignant transformation and it's usually well defined plaques found in the lower limbs with um in a patient with chronic sun exposure. Again, it's the same treatment as um actinic keratosis. So, um top of five fluorouracil fluorouracil cream and then there's just some other um treatment. Sorry, I'm just going a bit faster and conscious of time. So, basal cell carcinomas then are a big, big one. We got a question on this in our finals and I think we've been questioned on it before. So just a good one to know. So um this is it commonest type of skin cancer. It's a slow growing locally invasive malignant tumor of the epi of the epidermal creatins. So, risk factors include UV exposure, history of frequent or severe sunbed use type. Um skin type one in terms of the Fitzpatrick scale increase in age male sex immunosuppression. Um A previous history of skin cancer and genetic predisposition. So B CCS um uh tend to present with a pearly surface. So that's how they will be described in MC QS, pearly surface, rolled edges and they can have telangiectasia. So, spider veins and they're usually emerging from the middle of the lesion and kind of um spread outwards. And it's also can be associated with ulceration. They tend to present in the H zone. So the H zone of the face and um these aren't really. So the waiting list for removal of BCCS is really long because there's minimal risk of um invasive of metastases. Um So um they don't tend to remove them um very quickly, but if they are being removed, it's surgical excision by um dermatology or plastics or both. And then um there are some other examples of um treatments. So, moving on to squamous cell carcinomas. So this is a red flag referral as there's um a high risk of metastatic potential, they're classically present as a fleshy nodule with a, with a keratotic surface and they can be ill defined nodular and may ulcerate as well. Um in terms of comparing B CCS and S CS CCS are commonly rapidly grown, whereas B CCS kind of grow gradually over time. So um an SCC will pop up very quickly. They can be flashy, ulcerated, non-healing nodules and they just look really angry. Then um they can also be associated with bleeding or lymphadenopathy. Risk factors are um similar to um uh BCC. So UV exposure, premalignant skin conditions, which um we spoke about. So, actinic keratosis or bones disease and also chronic inflammation, um such as leg ulcers or wound scars and then immunosuppression. So, if a patient is immunosuppressed, they're more likely to develop an SC and then genetic predisposition as well. Um So treatment um of S CCS is surgical excision first. So it's important to this is why it's so important to measure on a SCC or any um skin lesion. So, if it's less than 20 millimeters in diameter, the surgical excision will be of um four margins outside the lesion or four millimeter margins outside the lesion. If it's greater than 20 millimeters, the surgical excision will be six millimeter mar will include six millimeter margins outside the lesion, then most um micrographic surgery. So this might be necessary for illdefined large recurrent tumors. And then other types of treatment can include radiotherapy if they're large or non resectable. OK. So just comparing ABC and an SC. So you can see in the BC, the pearly rolling edges, telangiectasia in the middle comparison to an SC which um is ulcerated fleshy, you can see kind of some bleeding there as well. Ok. So moving on then to malignant melanoma. So you this is um the main one you just do not want to miss. So for example, in GP or dermatology or just any medicine in general like this, you just need to be able to identify this. So types of melanoma, superficial spreading is the most common. Then lentigo maligna melanoma arises from lentigo maligna. So these can be on the face and then kind of um darkening patches of the of skin on the face or something, which is most common and then these can develop into Melanoma. Um You can also have nodular melanoma which grow vertically so quickly metastasize. Um So they're really important to um identify really early on then Aryal and sub subungual melanoma, sorry, my pronunciation of them. Um but they can occur on the nails. So we were chatting earlier about earlier about using ABCD E for a lesion. And this is really important for um describing melanomas or ruling out Melanomas. So with Melanomas, the lesion tends to be asymmetrical. So in terms of shape or color, then border irregularity, color variation. So if there's more than three colors or multiple colors within it and also change. So has the lesion changed over time, you're worried about a melanoma then diameter greater than seven millimeters. And if it's evolving, evolving change, if it's enlarging or changing other symptoms, then are oozing inflammation or change in sensation So, um in terms of melanomas, um the most important prognostic factor is the Breslow depth. So, um this is a measurement of the depth of the melanoma. And then um initially they'll go for a biopsy and um you can read through that yourself. But um negative prognostic factors include obesity, smoking, Vitamin D deficiency. So then uh another important thing to note there is the BR mutation. So if patient has BPH mutation, BRAF mutation identified, then targeted therapies um can be um started as well. And um immunotherapy is also used. So you can see there the Breslow thick thickness, um equates to their five year survival. So if it's less than one millimeter, Breslow thickness in terms of death, then it's 95 to 100% in comparison to greater than four millimeters um death. The patient may only have a 37 to 50% 5 year survival. So that's quite stark. Then moving on. Um I think we're close to the end now. So, um moving on to dermatology emergencies. Um So, um Steven Johnson syndrome um is a really big one. So this is a severe systemic reaction almost always caused by drugs. So the drugs to um be aware of that can cause SJS are penicillins, sulfonamides and lamoTRIgine. Um So, um I think there was a previous OS station on counseling. Um not for third year but for um fourth or fifth year um counseling on lamoTRIgine. So that is one of the main main side effects that you need to know is that lamoTRIgine can cause Steven Johnson syndrome. So then in terms of features of Steven Johnson syndrome, it's a maculopapular rash with target lesions and it involves the mucous membranes. The patient will also present systemically unwell. So that's a big indicating factor and then treatment stop the causative agent, so stop whatever drugs that you think is causing this and also um start supportive treatments such as fluids um to um to stabilize the patient. So, moving on then to toxic epidermal necrolysis um known as tens. So this is also a severe systemic reaction, almost always caused by drugs. And um similarly, it's caused by penicillins, sulfonamides and phenytoin which um in contrast to lamoTRIgine, both antiepileptics, then features of tens is that greater than 30% of the skin will be affected. Um And then um Nikolsky sign positive. So this is also present in um pemphigus, vulgaris, the blistering condition that we spoke about. So this is just like whenever the skin peels away or sloths away with really minimal touch. Um So um you can kind of see there in the photo, it's just the skin is just peeling away and the patient is also systemically unwell in terms of treatment, stop the causative agent again and supportive treatment. And IV immunoglobulins are an option for tens. This is a really important condition to know about as well as S Js um, because the mortality is up to 40% which is quite large. Um, ok, so, um, just moving on to some questions there if we have time. Um, sorry, I'm just checking what time it is. So I think it's 10 to um, 7. So we'll maybe just run through um, a few questions if, um, you want to shout out answers or, um, pop them in the chart and I think maybe if Mare is in the chart, maybe someone can say the answers if um possible. So a 25 year old man presents to the emergency department with a new rash. He has a history of HIV around five days ago. He was prescribed um prophylactic co trimoxazole as his CD four as act four count was 323 cells per cubic millimeter. Um His temperature was 39.4. His heart rate 105. His BP 85/40 on examination, a diffuse erythematous maculopapular rash was present when rubbing the rash, new blisters form and the skin slides off. The rash covers 56% of his total body surface area including the oral mucosa. What best describes the this finding? So I'll just give you a few seconds. Um So yeah. Um So, oh, I can see the chat there. Um So if you just wanna throw me um answers into the chat, they're popping up for me. So I'll just give everyone a few more seconds. Um And we'll move on. So, yeah. D is the right answer for that. So thanks to um those that popped in the chat. Um The answer is well done. Um So D is the right answer. So we describe that with the tens and the um pemphigus vulgaris. So, um unlike touching of the skin, the skin just falls away, so we'll move on to the next one. Ok. So a 28 year old woman returns to the dermatology clinic two weeks after surgery to excise a 1.1 centimeter, pigmented lesion on her right lower leg. Histopathology reports report start states that that's not to be state that the lesion is a superficial spreading melanoma with a clark level three Breslow depth 0.9 millimeters, mitotic index of one unknown ulceration. It has been completely excised. What is the most important pathological prognostic indicator? So again, if you just pop them in the chart there, um we'll get finished up as soon as possible. So um pop the answers in the chart there if you um no, just give him a few more seconds. OK. So if anyone else wants to throw in an answer there or else we'll move on so well done um to whoever popped in a so um Breslow death is the most important prognostic factor so well done. Um OK. So third question, then a 38 year old woman attends A&E complaining of a painful ulcer on her chin on examination, there is a single irregular deep ulcer on her right chin. The ulcer has a pustular surface and a blue overhanging edge, which of the following is the most likely cause of her ulcer. So um yeah, this one we actually haven't covered. So it's OK if no one puts it in, it was just to say we have, I was just popped this in to remind myself just to say that we haven't covered all um dermatology conditions that could come up with an exam. So there definitely are a few more, but we just focused on the main ones. So if anyone even wants to guess um what that is so well done, Kelly. Um It's a so Crohn's disease. So, um IBD, any um IBD conditions such as Crohn's or ulcerative colitis, they're more likely to develop skin conditions. So, um this one, sorry, I'm gonna move. Um Yeah, so this is Crohn's OK, well done and moving on to the last question. Then um a 53 year old woman presents to the GP. She has developed a red rash over her face which is worse following sun exposure. Aside from this, the patient reports no other symptoms and feels well on examination, red papules are visible on her forehead, cheeks and nose. On a background of erythematous skin with telangiectasia, the GP diagnoses her with rosacea, which of the following would be the most appropriate treatment for this patient's rosacea. So, if you just wanna pop in the chat there. We'll give it another second if anyone else wants to pop in and answer. Ok, so we'll finish up there. The answer is C to, so topical ivermectin. So, all done. This is, um, because the Rosacea has their, the, um, red papules and the telangiectasia and it's erythematous. So, c is the right answer. So that's all I have. Um, I've just added in some useful resources there and um just popped in there and um bold dermatology. So the handbook for medical students. So, um this is what um I used for studying for dermatology and I think it's really good. It includes like all the photos and stuff and kind of the most common conditions um that can come up. So if anyone has any questions, feel free to ask and I've also popped my email on the first slide. I think Nicole's also put in a feedback form there. So I'd really appreciate if you um fill that out and give any feedback. So thank you. I'll hang around for a few minutes if anyone has any questions but feel free to fill in the feedback and enjoy your evening. I've been listening. It was all very good, so fast. No, very, very um I speak far too fast. I have too many but I be fine. I'm straight after you for the fourth year. So I feel like there'll be like 3rd and 4th years. No, that's fine. Um, it's hard when you can't see, hey, can you see the track when you're doing it? Because I, II pulled it up there at the end, but I couldn't see it at the start. I think maybe it was just the format I had it on. But, um, yeah, but yeah, we'll send that feedback twice. Hopefully they get it because I don't think they get the slides without following the feedback. So they want the slides, they need the feedback or maybe should have said that. Oh well, well, I said I wrote it on the chat so they can see it and there's um I'll head on if you are keen to get started. Sure. Yeah. For organizing and everything. Um I will stop sharing. OK. So uh how do I stop sharing? Um Do you want to stay on just to see that I can share once you stop sharing just for a wee second? See if it works for me. Um But it says still on your screen. So you just click on the bottom bar where you that? So just would you stay on to see if this works for me? Yeah, it does. So if I click share, can you see this? Yeah. And if I click this, I've got two screens. What one can you see? So I can see. Yeah, you're better at this than I was cause I was meant to have two screens. So I was just working off the slides, but I can see your, a main screen and the next slide and I can also see the list of your other slides. And so like the, uh, the notes, you can see that one. Right. How did I share the other one? Um, desktop two? 00, I wonder if I've done it. Is this it? Yeah. Yeah, I can see your, I'm amazed, I'm amazed that worked great. F well. Yeah. No, really well done. I'm sure is in charge of all the feedback. So she'll send you anything there. That's perfect. Great. Thanks. Right. Thank you so much. Bye bye. Hi guys. So whoever's on so far, I'm just gonna wait until about three or four minutes pass co 59 now just to get everybody on and the ones from Pedes to leave, if there, if there's anyone still left. So if you can just somebody right in the chat that they can hear me, ok? That'd be great. And then we'll get started soon just for those that have joined there. We're gonna start at about three minutes, four minutes past just to let people get in. Give it one more minute. Ca I get started. Mhm. Hopefully you can all see my screen at this stage. It should just be a screen saying pediatrics part two. You shouldn't see the one that is the part with the comments underneath. Hopefully, but Marie should be coming to check it before I start Hi. Hello, thank you for checking Marie. Just to see um you can only see Peds part two and if I click this button here fine, I click like that. I like that one. Yeah. Ok. Yeah. So, and then they upload it. Ok. If there's any technical difficulties guys, would you write in the chat or the whatsapp? I have my phone beside me just so I know cause I might not realize during this that there's an issue and then just remind them as well. Um Did you send in the Dermatology feedback? Yeah, they got the Derm feedback. Yeah. As long as they have to find that. Yeah, maybe that'll keep him here to the end if we can. Yeah. Work for you. Yeah, fab. So welcome guys. So if you know people who don't know me, um I'm Nicole, I'm one of the final years at Queens. I'm on my citizenship and out the, at the minute and I just finished finals. So you had a Pete's talk on Tuesday from and I'm covering different topics this evening. So just a caveat before I start that the feedback needs filled out for these slides. And also there's a few slides in here purely for revision that I have in here that I will say once you get the slides, read this yourself, it's just my notes that I've put into a slide. It's quite a dense slide. So I'm just gonna make you aware that we're not reading through that entire thing, but it is there for your own purposes afterwards. But that's grand. So we'll get started and any issues, put them in the chat, any questions, put them in and sure I'll get back to you at the end or I'll try and keep an eye on it throughout. So, the topics we're gonna cover today are cardiology, respiratory gastro febrile seizures and then a bit of Aussies at the end. So I'm gonna start with this M CQ. I'll give you about 30 40 seconds if you could throw it into the chat, any suggestions. So one month old suffers from intermittent episodes of cyanosis and tachypnea, particularly when distress and examination reveals a harsh ejection, systolic murmur. Given the likely diagnosis. What is the best predictor of the clinical severity of this condition? So the job if I even get five or 10 responses, I'll just keep moving meto so far, so good. And if you don't feel comfortable on the chat, just change us a direct message so that I can see it as well, then if you don't want to, you know, answer from everyone. Grand, a few direct meshes there. Great. OK. So I'll just keep going there with this one. Um Grand. So for those that, that, that said CC is correct, I went too far there. So the diagnosis of this is a toth. So Tetra fallow. So this is a very queen's question and what they do in that is they give you a condition and you think as you read it, ok, I know what this condition is, but not only do you need to know the condition, you need to know parts of that condition, information about it. So once you work out that it's an ejection systolic murmur and that they're cyanotic, you work out, it's a sciatic heart condition. So it's a toss and then you need to know the severity criteria for that. So we have a slide on that as we go through. So I'll chat through it in a wee minute. So this is a slight on fetal circulation, not going to talk great detail about it. But know the shunts, know how they change, know that the umbilical arteries go to the placenta and the umbilical vein comes out. It does come up. Queens love a good anatomy question. It's not a lot, but one or two of them will come up. So be aware of the three shunts and how they close and in what order. And then this is just helpful with knowing that above the nipple line is ejection systolic murmurs and that's your aortic. So it's just pulmonary stenosis and PDA S and then below the nipple line is your V SDS and your um mitral regurg. So that's just a memory aid. So we're gonna start with cyanotic murmurs. First of all. So that is anything that causes shunt from the right side of the heart to the left side of the heart, it's cyanotic because the blood isn't going to the lungs. So the lungs can't get oxygen in and then the blood's not getting oxygenated. So therefore you're blue and that's the easiest way to put it. So that's why I put these lights in blue. So if you want to use the sort of past med way of learning as in patterns mean conditions, then you can work out cyanotic at birth. It's probably a transition to a TGA cyanotic without a murmur, probably a TGA cyanotic and crying on day two of life, more than likely a tough cyanotic with Down syndrome vs DS and then an acquired cyanotic condition way down through the years of life, probably around 2030 40. It's probably Eisenmenger Syndrome. So that's just a, a memoir, but I'm going to talk more about cyanotic conditions now. So the way to remember them, a pediatric reg taught me this and it was really, really helpful. Is it the five Ts? So if you look at the top left picture here, I don't know if you can see my mouse truncus arteriosis, you put finger number one up. So this is number one, it means one vessel leaves the heart and that's why um they can't get oxygen around the body because there's not two vessels, one of the heart transposition of the great arteries means two great vessels are transposed. So normally out of the right side of the heart, you have your pulmonary artery, on your left side, you have your aorta. In this case, they've switched sides. So therefore, no oxygen is getting around the body. So that's part two. Then tricuspid tri means three. So that's why it's the tricuspid valve and it's the third one and that is when the valve fails to form. Then a tetragel tetra means four and a tetra follow has four criteria. That's your pulmonary stenosis, right? Ventricular hypertrophy, overriding aorta and A BSD. So that's who remembers the fourth one. And then that last one has five words. So total anomalous pulmonary venous return. So that's your five parts. So that's how you remember the five cyotic conditions and a wee bit about them. They don't ask anything about it in queens unless it's a tough or else you're doing like a prize exam. The only way it comes up is that they might give you four of them in an M TQ and one of them could be an acyanotic condition and you have to know which one's not the cyanotic condition. So knowing that they all start with TS or gives it away already. But equally, it could be all acyanotic conditions and one cyanotic. So that's how you learn them. They're not too bad, but very little gets asked on it. So how you treat a cyanotic heart condition? So these are duct dependent conditions. What that means is a child cannot survive if they have a shunt going from right to left on its own. That means that you're not getting any blood to the lungs. That means you can't auction your blood and that means you just cannot survive. So, what the child has is another shunt. So they either have a V ASAP D or an ASD. So they'll have an acyanotic duct keeping them alive. So it's important that that does not close in the interim of going to surgery. So how you make sure it doesn't close is you don't oxy at them too much. You keep them aiming sets of about 85%. It sounds counterintuitive, but that's how it works for Children ino and we've seen that a few times, then you give them prostaglandins which will keep a duct like APD or A VSD or an ASD open and limit their fluids. If you think about someone with heart failure, you don't saturate them with fluids because they can't cope. These babies', hearts can't cope with a lot of fluid. So be very strict on your fluid boluses because it can send their lactate skyrocketing. And it's very easy to mix up a cyanotic heart condition with sepsis. So be very cautious of that. And if you're not sure if it is a cyanotic heart condition, then what you do is the nitrogen washout test, which means you give them 100% oxygen for 10 to 15 minutes, this will wash out any nitrogen in their body and anybody that has a cyanotic heart condition, they will still be desin anyone that is a pulmonary condition or respiratory condition, they should improve. And that's how you sort of differentiate between the two of them. So just before I continue moving, check, there's nothing to chat there. Grand. So that's cyanotic heart conditions. I put a wee slide on tops here just to say, learn the four things in red. I'm not going to talk through them. You've seen them 100 times on past med. Normally presents on day two of life and tet spells just be aware that it's when they squat, this increases the peripheral vascular resistance. If you increase that you're increasing pressure on the left side of the heart, that means that instead of the blood shunting from right to left, there's so much pressure on the left, you're pushing the blood back, left to right. And that means it'll force it into the lungs. So that's what you want. So that's all you know, for that. And then that often x-ray says, but shaped heart that that's pathognomonic of a tof management wise, tet spells are just on your monk oxygen beta blockers and maybe a bit of fluid morphine. Anything else. A tof needs surgery? But this one is a tricky one because they present with um ejection systolic murmur due to pulmonary stenosis, but they do have an ejection or a pan systolic from the VSD. But the pulmonary stenosis takes prominence because it's bigger. So that's why you don't get mixed up with. A VSD has a different murmur and it used to confuse me but the pulmonary stenosis takes present. Grand. I know I'm talking very fast but there's a lot to get through. I just be aware that it's an acyanotic condition that they were not cyanotic and in later life it reversed and it's very poor prognosis. They need a heart lung transplant and they don't do very well. So you need to pick up even acyanotic conditions very, very young. I'm not going to talk much more about it. Just be aware that it's something that can come up innocent murmurs or your, your seven ss soft S one S two symptomless systolic short standing sitting and some special tests are normal. Also sick is another one. It's just something that's a loud sound of a baby's heart when they're sick. If you think their chest are so small, the heart's so close to the surface, you're gonna hear the turbulent blood flow because their heart's working so fast, they have a heart rate of 100 and 60 BPM. You're gonna hear that blood going through very quickly. Um Other than that, there's nothing to worry about. These are things you do not refer to the hospital and MC Qs come up with Queens before were asked an innocent murmur. What do you do? And it was, like, send them to the outpatient cardiology, send them to peds, bring them back in 34 weeks. No, it's nothing. You don't do anything for them. It's just reassure the parent and give them a leaflet. That's all you do. Um, so then a cyanotic, let me keep an eye on time. Yeah, we're doing grand. So, V sds are most common than PDA S A sds. They're the opposite. They're left or right shunts. This means the blood is going through the lungs twice. So they're coming on the right side of the heart, going to the lungs, then the left side, going back around the lungs again. So this is why these people can survive for a very long time with these conditions. So VSD is the most common pansystolic murmur. You can get small ones or large ones, small ones don't cause any issue. You leave them for a while, they can close themselves or people can live with them. Large ones, they present with heart failure, failure to thrive chest infections and acutely unwell echo. All all murmurs get an echo. So that one investigation is always an echo and you can do chest x rays as well. So small ones watch and wait. Large ones are going to go for surgery and they're associated with Down syndrome. Turner and fetal alcohol. It's there. Um, there's not much more to say about it. PDA. S this came up in the 2024 Oscar for finals this year. And it was a horrible, horrible station, but it was actually manageable. I didn't know what it was. A lot of people didn't want to commit to an answer. They handed us headphones and we had to listen to the murmur and I don't know about you, but I or you guys, I could never identify through headphones. I need to read the clinical context. So it was a continuous machinery murmur and it was lesbian parents that had adopted a child or went through IVF. And they were really worried and the child was presenting like sick but not cyanotic, not um blue, no apneic episodes just generally not feeding very well and off form. So this was like two weeks, post birth they normally present with and they're just not themselves, normally they close on their own, but they need a bit of extra help after two weeks and you can give them um indomethacin just a another form of an NSAID and if you need to keep it open. And as I said before, the case is you need to keep a PDA open is in your cyanotic condition. So, so if you have, for example, transposition of the arteries and you have the PDA, that PD is what's going to keep you alive in the time for surgery because it's allowing the blood to go to the lungs. So you would keep it open with the prostaglandin in that case. But that was something that took me a while to get my head around. But once I did it all made a lot more sense then on why kids hearts are so friable and so delicate. But yeah, so we'll keep moving. So that's asd, the last one there. And it's a fixed split. If you ever see the word fixed split, there's nothing else that can be other than ASD, not only asymptomatic but if very severe, they can get heart failure. Same again. Chest X ray E CG echoes, you can watch and wait or surgery. It all depends on severity and the risk of arrhythmias in later life. Outflow obstruction is just to note these are more third year that they're all systolic ejection, systolic and then radiofemoral, we're gonna talk about coarctation now. So, coarctation um very common to be associated with turning Turner syndrome. But as a whole, as a condition, very uncommon ejection, systolic murmur at the left upper sternal angle, higher BP on one side than the other. You can check pre and postductal sats sort of to get a reading on the coarctation to see if it's present or not. So let's put a S ATS probe on both fingers and seeing the difference. They normally present as a gray sick baby. They go straight to RSO and they have a metabolic acidosis. You can see red notching on the X ray and it gives like a three signs. So if you look at the top X ray with the blue. It sort of looks like the number three very severe get stent. It's very minimal watch and wait. And as I said, just limit their oxygen, keep them above 85. But in this case, you'll want to probably keep them above 90. And as a PDA will help keep them alive as well because they can actually bypass where the coarctation is. If you look at the top right picture, if you have a PDA there as well, it'll keep them safe for longer. I hope that's all making sense guys. And they're just turners know that that's associated with a bicuspid aortic valve. And coarctation normally present with primary amenorrhea. If it's miss in childhood, it's XO and something that queens haven't asked before. But a consultant told us and to be very cautious of, if you learn about excellent recessive conditions, you all always learn that they're male to male, male, to male. If you've Turner syndrome, you can get a lot more common ex and recessive conditions because you only have one X chromosome. Males only have one X. So they get it and Turner females only have one X. So they'll get it. So the likes of Duchenne muscular dystrophy like DMD, they'll get conditions in females very, very, very rare and very unfortunate if it happens. But it's something that would be like an, a star question if queens were to bring it up and one of the consultants in Derry used to be very gung ho about it. So hope that's all making sense so far. This is just slide for information. It's um to learn about what genetic conditions are associated with. Um what um murmurs. It's for notes. It's for you guys to read, read, it's come up on Queens before about the Williams syndrome. So I've highlighted that but everything else and the Down Syndrome associated with A B sds and I put that here, know every condition like with Down Syndrome, learn that list below about duty Resia SN type of thyroid. It comes up, it's very common and know what like epicanthic folds actually are. I used to learn these words off by heart and pass med, but look at actually what they are and where they are in the eyes and what a strabismus is and what brushfield spots are. I'm not going to go into too much detail. I'm sure you're aware about trisomy. So next M CQ, I'm going to give you about 30 40 seconds to answer this one. I'm not gonna read it out. I'll let you read it. I'm gonna sip a cup of tea. If you could just stick it on three or four, I'll keep moving the quicker, the better. Even if you don't know. Just guess. Yes, I got one or two in there. Now, if you're not confident to write in the chat, just direct message me as I was saying to the guys earlier. Great. You more coming in there. Great, great, great. You're doing very well. Get a one more minute or a couple more seconds cause I wanna keep it moving. We're doing well for time grand. So the answer is e so this is bronchiolitis and I'm going to talk more on the further slides about why it is that. But basically, in summary, this child is 11 weeks old. So you're talking nearly three months, which is a typical presentation of that respiratory condition. All the observation are within normal range, there's a bit of increased work of breathing with the nasal flare and it's an expiratory wheeze. So it's not crip, it's not a pneumonia because at that age, they would have to be more septic to present like that. And even at the ever so slightly a temperature, everything else is completely fine. Um And the wheeze would sort of lead you more towards a bronch than a pneumonia and would steer you away from crip because that's an respiratory whip. But anyway, so that's a big three for respiratory here, crip bronch epiglottitis. And I've put an asthma very small down there. I'm not going to talk about it today. It's the exact same as third year asthma. There's not much more to talk about other than the labs and nor receptor antagonist, depending on what stage of the latter you use with either a sign or BT S. They're different um and the tenon or if they are under 5/5 and over 12, it's different. Everything else is much of a muchness. So I'm not going to spend time on it today. So strider know the viruses and know what one they're associated with. So R SV, parainfluenza, rhinovirus, influenza and h influenza, know what they cause every single child with. Strider. You need to ask about drilling in foreign objects. If you don't, it's very, very dangerous. Was the child left alone? Could they have swallowed something? Do we need to scope them? You always have to rule it out. Queens of as t at the end of ap placement before in the M CQ for our tests that we had and I know you don't have them but everybody messed for an object. There are other conditions there as well. Strider has an eye eye for inspiratory. It's an inspiratory note heard due to partial obstruction of the larynx, it's very dangerous and it is an airway emergency. People don't emphasize that enough. So I'm not talking this full slide. It's far too detailed. I've made it there for vision purposes, but just the age range is to highlight Crip, six months to three years, acute eis 2 to 6 inhaled foreign bodies, laryngomalacia and then bacterial tits. That's very, very, very rare. I never seen it come up before. The only thing I need to highlight is know your dosing for de on crip. I know the criteria to admit. So that part in red, I have under crip about less than six months if they have upper respiratory tract abnormalities such as Down Syndrome or any form of eustachian dysfunction, or if you're queer in Piloti and you can't rule it out or if they are audibly stri at rest, that's very, very dangerous because they're not exerting themselves everything else there. It's for vision purposes. I've put in the condition what I learned and the management and that is exactly what I learned was my tables. I've just pasted it on here so I'll leave it there for you if you have any questions about it. Just ask me in the chat. This is the Wesley Crypt score. It's an D, you don't even know it off by heart. Just know that it exists and know that the higher score, the more severe it is. And when you get down to about over 12, then you're going to think about intubation. It's that bad. But um it's the criteria is consciousness, sis Stridor air entry and retraction of the muscles. That's it. You don't really know anything about it. Just know that it exists no about this. So this has come up before as well in Queens just in a stem of a question, not an X ray. And I said like on X ray, they had a staple sign. So it confirmed it was Crip. You didn't need to know that the staple sign meant Crip. But it helped you answer the question. So if you can see that the epiglottitis one on the left, it looks like someone's thumb is where that arrow is. Like they've press down and smudged it. That's your epiglottitis on the steeple sign for Crypt. They never X ray crip. It's not part of the investigation process. But if you were in doubt or you needed to, people can do it but never write it as an MT answer because you would just stick them on decks and then straight away. So that's just your steeple sign there. You can see the narrowing of the airway due to inflammation and a partial obstruction. This is another table for your own revision. I'm not going to talk about the whole thing, but there's your bronchiolitis from the M CQ question. So it was a respiratory tract infection. It's a winter wheeze normally presents less than six months. Really. Shouldn't come past one years old. It's a child that's past one. It's not br pertussis. I've put in red because it's very topical at the minute and could come up on your Aussies because people that weren't vaccinated during the pandemic and pregnant mum didn't get their vaccines. And I've seen it today in GP, we had a whooping cough in and it's like the 100 day cough. They start vomiting when they're coughing. They get conjunctival hemorrhages and they're very unwell um for a long period of time but they're still able to get up about, but it's just the vomiting episodes and stuff. It's very unpleasant. The poor child today it was just a nightmare. Um, so be aware it could come up in your ay and know about its macrolide antibiotics you treat it with and then cystic fibrosis is queen's favorite. They love it. They normally throw something in whether it's how do you inherit it. What bugs do they pick up normally? Or someone presenting with like a Macon, my, what genetic condition or tested on them? The heel prick test. It's very, very topical with queens. So I know your cystic fibrosis. Well, but I'm not going to go into the whole thing. And then I said I wasn't talking about asthma. So I'm not going to it but learn the rule of threes that a third will grow out of it if they present in childhood, a third will improve in teens and return in adulthood and a third have asthma for the rest of their life. So there's a difference between having asthma as a child and having a viral induced wheeze. If they're under three, it's a viral induced wheeze. You cannot diagnose asthma if they're under three. If they're over three, you can diagnose it. So just be aware of that. But all the rest is the exact same as adulthood. It's grand. Well, it's vomit. We're on gastro. So we've got cardio rest done and we're nearly at half. So we're doing very well for time here. Um, so very liquid vomit. This is topical, topical with Queens. It comes up all the time. So I give you a wee M CQ here if you can answer it as quick as you can. And I know I talk very fast but I have a tendency to run on, which is why I'm talking a bit faster than usual. You could just throw the answer in the chat when you are ready. Great. We've got one in here, two or three more and we'll keep moving. Right. Er, thank you guys for interacting. It makes it a lot easier knowing you are listening. So just read it quickly and move on. So gave born earlier that day, one episode of vomit, he passed meconium normally and he's AEX so he's not septic. His mother reported an uncomplicated birth, uneventful pregnancy that rules out a lot of things already apart from an increased amniotic fluid volume. So x-rays performed what's most likely. So in this case, the answer is, I feel like I'm moving here. So the reason it's b is because this is jal trees. It's on the next slide, I'll talk about it as when we move on. But if I roll out the other ones, corkscrews, corkscrew, I've never heard of. So I've rolled that out already. Intramural bile gas is your neck and your neck is a septic baby and they're normally premature. That's ruled out normal x-ray shouldn't really be ruled out because they've got belly vomit and it targets signs into suction and they have the red currant jelly still. So you're sort of left with B So that's how I work my questions. And if you were on the exam and you were stuck between A and BI had heard a double B but I've never heard of course. So that's how I would have worked that one. Um Grand so Judy Theresa. So history examination, I'm just going to click these. So we have the whole slide there. So um Billy's vomit within the first few hours of life, it's associated with Down Syndrome and polyhydramnios to a blind end. Um It's a very good prognosis. It's not like a terminal illness. They just get the duodenostomy and correction, which means like they open up and open the obstruction and try and stent it open as best they can. So it's a day one, double Wobble Down syndrome, decompress Duodenostomy. It's all your days. So that's how you remember that. And that's the X ray there of your double bubble. So you can see if I don't know if you can see my mouse, but the stomach is one bubble and then the intestine is the second bubble. This is all for revision. I'm not talking about it, but this is all your causes of bilious vomit in green to emphasize the point that it's bilious, vomit, duodenal, atresia, miconia, myleus malrotation with Boulis jal or ileal atresia, neck and intestinal obstruction. There's a lot there, there's a table on pamid. This is a increased table of pamid. I've added my own information on my own notes and treatments as well. Be aware of this table don't get upset if you don't know the whole thing. It's not the end of the world but be aware of these conditions cause bilious vomit. And if you ever go into an aus and say that pyloric stenosis caused bilious vomit, the examiner will want to throttle you because it's the one thing that doesn't on this list. So make sure because I had my peers grip and that's the first question I asked them was they have projectile vomit, what is it? And they didn't, they said a belly condition. So don't mix them up. Ok. So the red flags for any vomiting. So B is a red flag. Any abdo findings, distension, tenderness or mass. If they're projectile vomiting, pyloric extens is a red flag signs of raised ICP. So like the bulging fontanels, you can feel the fluid. Um they're quite irritable, they've got a fever. So you're thinking sepsis or diarrhea, blood and stool or anion or any atopic risk factors or bloody vomit. So things even in an adult that concern you are gonna concern you child, it's much of a muchness. So this is just what them conditions are um with it. So knowing that if an obstruction is distal to the amp below V. If you can see it on this diagram above, then this means that it will be bilious vomit because if you look at the bile duct, then you can see where the bile comes out. So if the obstruction is below that, you're getting bilious vomit. If the obstruction is above it, which is pyloric stenosis, you should have normal colored milky vomit. So it's about where the bile comes into the track. And if you think about that and it makes sense what conditions cause it. So then nonbilious vomit M CQ if he's withdrawing a wee answer for that. So I'll read it an eight week old 3.3 kg. Baby boy has a four day history of projectile vomiting. It occurs minimum 30 minutes after every feed and he's being formula fed 16 ounces a day. The vomit looks milky and he is hungry afterwards. The problem is getting worse, which of the following is the most appropriate initial step. I'll check my child here on me. Great. Keep going. So this is a very queeny question as well that I've put in because you have to not only know what the diagnosis is, then what's the first investigation that you do for that condition? So, no one's saying my answer. Um ok, this is a good learning point. That's fine. Um But us all answering which is great. But um no, I'm saying the answer. No, no, no Well, we got somebody, we got somebody. Great. Ok. So it is capillary, blood gas. I'll explain why. Now. So eight weeks old, their formula fed and it's projectile. The word projectile, you have to clarify in any ay, does it hit the wall or does it Drabble down your shoulder when you hold them over your shoulder, hitting the wall is projected that word in itself. Projectile. Pylos. That's how you get that straight away. If you're still not sure. The fact that it's milky and not bilious should give that away. The only other thing it can be is reflux or gourd. Other than that, there's nothing really else that should cause projectile vomiting even at that gourd, um shouldn't cause it either. So you're only really left with pyloric stenosis. And the fact that the problem is getting worse is because as muscle hypertrophies, the increase amount of feeds the muscle works harder. It gets worse. So the reason it's a capillary blood gas, I'm going to tell you is now. So this is what pyloric stenosis is. It's hypertrophy of the muscle. It causes projectile, milky vomit less than 30 minutes, post feed. Very common in first firstborn boys. A positive family history but not congenital. They have an olive shaped mass at the top of their stomach and that's because of the peristalsis of that hyper hyper muscle. They, they become very unwell because they're not getting any food. They become malnourished. You complete an A to e assessment and you do a gas. The reason you do a gas is because they have the pathognomonic gas of hypochloremic hypokalemic metabolic alkalosis. The reason it's not acidosis, you think vomit is a very acidy. So you're vomiting out the acid. So they're alkalotic and then they're losing a lot of their nutrients. So that's why they get hypokalemia and then there's something to do with the kidneys and transfer, which I will not be able to explain to you guys. But the main thing is don't mix it up with an acidosis. Um Pamid has a lovely explanation of why it's hypochloremic hypokalemic but know that when you vomit your potassium goes down, it doesn't go up. So that's why you need a gas because that's a very quick investigation. If we go back that slide, that can tell you very, very quickly what's going on on and it's what's the most appropriate initial step. So that would tell you straight away, an ultrasound is going to take time reducing the volume of feeds, not fixing the problem because they're still hungry afterwards. And key words are said it looks milky and it's hungry afterwards. Antibiotics. There is no mention of a temperature. Abdominal X ray is taking longer than a gas. A gas is going to tell you the answer to this. So that's why that's the first thing you want to do. So what you do is you stabilize them IV fluids, correct the disturbance. If it's really bad hypokalemia, they'll get potassium and then you just rehydrate, get the gas, test them, feeding them. And then an ultrasound after you've got the gas and that will show like a hamburger appearance. So that is your thickened muscle and then you've got your management. So it's nil by mouth, an NG tube. And then they're going to go for a Rams pylorotomy, which is literally just cutting that muscle open and they can take the section out and reattach it or they can bypass it. So, IC I will read this one out so you can answer this as well. A three month old formula fed baby is considerably unsettled during every feed and usually vomits a small amount afterwards. He is diagnosed with Gord and his parents are advised on correct positioning during feeds and to feed in smaller amounts more frequently. However, this has made no difference to the baby's distress during feeds. Which of the following is the next appropriate step of management. I wanna throw in an answer. Give you some minute. Mhm. To that person. You direct me. Me. That's correct. $100 person. That's correct as well. I'm just gonna give it a month. Mhm. Yeah. Please know this one. Great BJ. Know what it's called. Well, what the name of it is, but I'll tell you in a minute grand we have enough answers there and we're doing well for time. That's great. So the answer is b everybody was right. Um, so a feed thickener. I don't know if anyone's ever heard of it. It's called Carabella. You put it into the milk that they use and it just thickens it up a bit and that makes it easier to swallow for the baby and keep it below the lower esophageal sphincter and keeps the food down. It's the most or the least invasive way and it's not a medication per se. It's thickening the milk. And actually, to note that breast fed mummies can pump, put it in a bottle and then add it to the breast fed breast milk as well. If you want that, that as a mummy that's breastfeeding and having the same difficulties. So it's not just exclusively for bottle fed babies. So, overfeeding, this is so, so common comes up and queens all the time and comes all the time to the pediatric assessment unit. So day one, they get 60 mils per kilogram a day, then they go 30 more, then they go 30 more. Then from day four, they should be on 100 and 50 mils per kilogram a day and that's it. That's what they should be on. So, if you made a baby that's four weeks old, five weeks old, they should be on 100 and 50 mils per kilogram of their weight a day and maintenance fluids. That's sort of more the nice guidance. So, don't worry about any of that. If you ever have to worry about that. It'll be on the fluid balance and then at six months is when you wean a baby. So that's when, whenever you want to move them on to like their soft mushy vegetables and the wee pots and stuff and how many mils an ounce was a random question. I never knew. And there's 30 mils in one ounce. So then you can work out how many ounces they'll have a day, but just know the parts in yellow. So what happens if a baby's being overfed? If a baby's being fed too much and they're vomiting and they can seem completely normal on assessment, then it's an overfeeding diagnosis. It's nonbilious, nonprojective and very milky, they're very well, they're very normal and it's just encouraging the mummy that they're doing the right thing. They're feeding the baby. But just to limit this feeding as best as they can. So the difference between that and gord is, it's normal for babies to have a little bit of reflux when they're born, the muscle at the top of the stomach and the bottom of the esophagus is not fully formed, it hasn't been used yet. So that muscle isn't as strong as it should be. So when babies lie down, the milk comes up, that's fine and it's called like positing. Um, but it's there, it's more significant as the feeding gets more, you give them more volume, so more comes up. So that's sort of how you tell the difference. Um, Gourd is a acid so it's, they become quite unwell. Whereas if they're overfed then they're well, babies. Gourd is a very unwell. Not, no, I wouldn't say unwell, very unwell, but just an uncomfortable baby. And, you know, they're crying a lot, they're irritable, they're scrunching up their legs. That's more so gored and it's acidy. Whereas the positing is just when it dribbles out their mouth or it dribbles down the shoulder. And this is just to show where that muscle is and show that it's not very well formed on babies. So then history and examinations of Gourd. So this is a nonbilious vomit. They're distressed during their feeds, they're crying, they're refusing to eat, they have acid related pains. They may start to get a cough. If you think about somebody in older years, like 56 year olds that get reflux, they start to get a cough and the reflux babies can get the same. They may have a fluctuation in their weight. They might not regain the 10% that they lose at the start of, um, the start of feeding when they're born. They have a normal examination. So I'd be surprised if anyone knew what it was. But this is Sand Sandifer syndrome. I can never say it. I have a slight on the next, it's very unique to Gourd. Um, it's a clinical diagnosis. There's no, there's nothing that you can look at that will tell you this is Gord. It's a consultant saying it's gord. There's no blood, there's no chest x rays, no ultrasounds. It's just how the baby's form is. And you get a lot from the parents history. So if this came up in a history station, it would be so important to ask. When does it happen? How does it happen? Does anything make it worse? Does anything make it better? How often are you feeding them? How much are you feeding them? Do you set them upright? Oh, them questions are really, really important to get this diagnosis. Um Don't worry about hiatus. Turn is it's not relevant but this Sandifer syndrome. So it's a condition whenever babies have paroxysmal dystonic movements with intermittent tonic posture associated with feeding. So what happens is the parent comes in saying their baby's having a seizure and then they show a video and it's straight after they've been fed and they start to posture like this picture that does not mean they're having a seizure. It's their body's response to gord and the reflux that they're having. It's diagnostic of reflux. It can be mistaken for epilepsy for infantile spasms. It's completely normal and the treatment is feeding their modifications, positioning their head upright and giving them some PPI. So it's just something to be very careful of if you think they're having a seizure, but it's always after a feed and it lasts for a couple of seconds and they're fine afterwards. So, how you manage Gourd? Is this this little purple diagram here? Smaller, more frequent feeds, set them upright and wean them add a thickener, as you all said, Carabella or try a two week trial of Gaviscon. If that doesn't work a four week trial of a PPI and if that doesn't work, you're going to consider surgery and then 90% of them resolve by one years old when the muscle is strong enough to fight off the ability of your stomach to send the acid back up the esophagus grand. So we're ok for time yet. This next three slides are for revision. I'm not talking about them. They're for you guys when you get the slides and fill out the feedback, this is every acute abdomen that you can get for pediatrics. I'm not going to talk about it. It's all there. There's the conditions, there's how they present and that's how to manage them. The, the yellow stuff is just really important things to sort of give away the answer like target sign and, and interception and massive rectal bleeding in meckel. Other than that, don't worry about these. This is again the same thing, more syndromes of acute abdomen and how to present. Summarize. It's the past med tables, but I've added a lot more information to them. You can get them in the slides. The last one, I'll just briefly chat when you do a history and you go into your feeding. Make sure you ask is it liquids and solids with feeding issues. And if the baby is making wet and dirty nappies, because this is where the constipation and diarrhea comes in and be careful when a baby presents with diarrhea, that it's not overflow, diarrhea because of being constipated. So if they say, oh, they don't make a lot of motion for 23 weeks and then they have diarrhea. That's because they're going through a cycle called Poo Poo pain routine where they get so constipated with fecal matter, it causes so much pain, they retain the fecal matter and then all of a sudden, um they have explosive diarrhea and it's a vicious cycle. So you have to try and break it and how you break it with a Movicol plan. It's a laxative plan. If you go on Google and search Movicol plan, it teaches you how you give Children laxatives and how you bump up from three a day to six a day to nine a day. Some are on 1012 sachet a day. It's really important to break that when they're really young and then diarrhea is all your gastroenteritis causes. That will be to finals. So be aware about norovirus rotavirus and like toddler's diarrhea, which is peas and carrots. If any question says it was on our finals this year, the baby's diarrhea has carrots in it. It's toddler's diarrhea. It's completely normal. Baby's digestive system takes time to work and because it takes time to work, that's why they get toddler's diarrhea and some of the food just passes straight through and they can't absorb the nutrients. But that's ok. Grand. I feel like I'm yabber yabber. So here's another M CQ. Um, we're nearly there now. We're not too far near the end. So if you want, I'll read it out. So father brings a 16 day old baby, keep that in mind. Um Presenting to the ed, the baby is visibly jaundiced and distressed. The father explains, the baby has not been feeling well since yesterday. Examination reveals hepatomegaly and splenomegaly. A newborn jaundice screen indicates no infection, normal thyroid function, test raised, conjugated bilirubin, liver transaminases and bile acids. The urine is negative for reducing substances, given the most likely diagnosis. What is the first line management option? I tried to highlight the words that are important there. So far, the dr messages are all correct. Mhm All's good, great grand. So you're all right. So you must know your jaundice very well. So surgical intervention. So this is bilary atresia and the way this gives it away is the presenting over 14 days. So that's pathological most of the time. And also the fact that it's conjugated bilirubin is the only really thing that causes that other than alpha one antitrypsin. So that's how you get the answer there. But we're going to talk about that in the slides. Now, reducing substances are whenever you have galactosemia. So that's if you, I can just see it in the chat. If you pee it's the reduction, you know, sugars broke into lactose, galactose and all these other breaking substances. So, if you have a genetic condition called galactosemia, you'll produce reducing sugars in your urine. It's actually come up in a queen's M CQ before and it was so, so, so sneaky. Um it came up last year in our fourth year mock prior to our exams, the queens send you on that MSC A paper. So just have a wee look at reducing sugars and what they are. I don't really have anything on it cause more genetic conditions, but that's what they are just, it's just sugary urine and that's all it is grand jaundice. This is a lovely little jaundice baby. So what is it yellowing of the skin naturally? Um It happens 60% of term babies and 80% of preterm babies. It's a breakdown of hemoglobin from red blood cells due to increased hemoglobin at birth when they have delayed core clamping. That can also cause um jaundice because you're increasing the amount of red blood cells in the baby's circulation by delaying the core clamping, which increases the risk of jaundice. So you improve the outcome of some things, getting more nutrients from the mummy, decreasing or increasing the risk of jaundice. So you weigh it up, red blood cells last about 70 days. So just a no 7090 hepatic bilirubin met metabolism is less efficient in the first few days of life and gut reabsorption increases as milk intake decreases. So, what is chronic? So this is why jaundice is dangerous. This is why we're worried about it. It's an encephalopathy due to the unconjugated bilirubin crossing the blood brain barrier and depositing it in the basal ganglia. Sounds like a lot of gibberish. But basically what it means is the breakdown of red blood cells gets into the brain and poisons the brain. That's the nicest way of putting it. The reason that bilary atresia isn't as dangerous is because it's conjugated. So that doesn't cross the blood brain barrier. Now, it's not as dangerous for conics, but it's more dangerous for other conditions which we'll chat about in a minute. So how they present, that's how they present with encephalopathy. That's what it looks like on a CT scan. I'm not gonna talk more. It's just an encephalo, encephalo phop. I can't say that word baby that presents irritable, abnormal stone apnic seizures like that. So that's why you want to treat this ASAP. So how you do it, you can measure their bilirubin in three different ways vigilantly with a transcutaneous bilirubin nome which is on their sternum or serum bloods. It's the most reliable, most definitive. If they ask you in the M CQ, what is the best way to determine the bilirubin? Always bloods, bloods, bloods and more bloods because it's not as very subjective to do it any other way. Um And you're checking for direct and indirect bilirubin. So you don't need to know these numbers off by heart. I've just put them in the slides there about if it's less than 50 below the phototherapy line, then you want to get in there quickly and repeat and check for risk factors and if it's over 50 do not repeat um because it's more stable. So, risk factors for jaundice is if you're less than 35 or 38 weeks, gestation, previous sibling mother's intention to breastfeed exclusively or visible jaundice in the 1st 24 hours of life. So that's the big worry. So what are your causes? Less than 24 hours? Hemolysis? Rhesus A bog six P. Don't know all of these, I'll tell you what you need, you know, and that's hemolysis and sepsis for 24 hours. Days, 2 to 14 can be absolutely anything but mainly breast milk jaundice and anything. Over three weeks, you worry about biliary atresia. The rest is there for your own note, but just know sepsis and hemolysis for less than 24 and then over three weeks, bilary atresia, everything else falls in the middle. So 1st 24 hours is really, really dangerous in really sick babies. So you need to get urgent assessment, urgent medical review. Do your serum bilirubin very, very quickly within six hours and check where it is on the treatment line, which we're gonna show in a slide following. And also you want to get full blood counts to check. Do they have hemolysis? You want to get the blood group of the mummy? Have they had an a bo incompatibility or rhesus conjugation and then ac screen, do liver function for the bilary atresia and then culture the blood and urine and do a sepsis screen. So you're basically trying to tick every possibility that this jaundice could be by doing that full investigation profile. If anybody goes up to the Peds ward, there is a print out and a tick list of everything that you need to do for a child, less than 24 hours with jaundice and that's on it. So make sure to go up and steal a few notes and sheets up there how you treat it sunlight. If you ever hear midwives say just bring the baby over to the window, it's an old wives tale. It's not going to do the trick. You need to optimize feeding and hydration and get them under a phototherapy blanket, phototherapy light, get the wee goggles on them. The baby sort of sit with sunglasses on in the wee incubators and treat straight away if they're in are unresponsive to phototherapy. You're thinking about exchange transfusions, which is basically taking all the baby's blood out of their body, filtering it in a system like dialysis and putting it all back in or giving them immunoglobulin. And that's if it's like a bo or you're trying to get rid of the blood that's incompatible to the baby. So this is the graph. The only thing I'm circling with this is over 38 weeks. You can't plot it otherwise have these graphs and practice reading them because they can give it to you in an ay. So be aware that if it comes up in an ay where to do it. So below the blue line, you do nothing on the blue line or above phototherapy and above the red. Very worried. And then here's the tree from the M CQ I gave you guys. So if they ever give you a nappy and an Aus or they say the nappy is the baby's piercing chalky stool or anything like that? Ask can I see the nappy last year's fourth years, she got given a chalk nappy and it had like a white play doh in it or something. So if the mummy comes in with a nappy, asked to see it, it's important. Um And it resia anyway, is jaundice over 14 days, it's conjugated. So that's what differentiate from everything else. And it's progressive inflammation and fibrosis of the extrahepatic ducts leading to cholestasis, liver damage and failure. So how you diagnose it? It's conjugated. The baby's very sick, poor growth, dark urine, pale stools, you ultrasound the liver, you can do a Hida scan, not gonna talk about that because I couldn't tell you anything about it or a cm. And that's how the B present very, very, very sick on liver biopsies. Definitive. So, let's see, treatment is a ca procedure or a hepatoportoenterostomy, preferably before eight weeks, the longer you leave it, the more damage is done. And then you replace their vitamin that they lose through their liver function, not just Vitamin K ursodeoxycholic acid, cholesterine, all that to help filter the bilirubin. And a third of them will go on to need a liver transplant. So this is little Maggie cause Maggie's yellow. So how they present and what to be aware of is massive organs like that. M CQ had a pato megaly and splenomegaly genetic conditions. If they're a bit dry, it just means dehydrated if they've got bilary obstruction infection or encephalopathy and also be aware of early jaundice, prolonged jaundice and conjugated hyperbilirubinemia. Grand, only 56 more slides left and we're done guys and we're grand for time. So febrile seizures, I'm not going to talk a lot about this, but six months to five years always check their urine. Always check the glucose. Are they having a hypoglycemic seizure or are they septic? That's why you need them. Two things. A simple typical febrile seizure will last less than 15 minutes will be a generalized tonic clonic and will not reoccur within 24 hours. That is a complex is anything that's not that and a status is over 30 minutes. So how you manage them is what I say. Cal clock cushion call. So what you tell the mummies if you're counseling them or what you tell anyone in A&E and I've had to counsel a few in more than a few, about 10 to 15. It's very, very common, especially in the summer is to tell the mummies when this happens again. I want you to stay calm. I want you to start the clock and when it gets to over five minutes is when you think about an ambulance cushion their head, don't let them hit their head and call for help. So call for help and then an ambulance is at five minutes. You don't give them prophylactic antipyretics. You don't sort of do them with ice. But what you do do is take their clothing off and try and call them down as best as you can. And then it's important to safety net them about complex seizures and what they have to look out for. So a queen's question that came up was what is the chances that someone that has a fever or seizure will have another one? And it's a third. So it's 33%. And then another question is, what is the percentage that go on to have epilepsy? And it's 1 to 2%. So this is more management about seizures. I'm not going to talk about the whole thing because there's a lot there just I said about the ambulances and the one and three. So further feedback of convulsion, there's a one in three chance and risk factors. Are they less than a year and a half? Temperatures, 39 degrees short duration or family history. And then yeah, I said about the epilepsy and stuff. So status there it is as well. Um The only thing do not mix up is that I used to always mix up. It's buccal me. So I thought meda mouth and rectal diaz. So know the difference. It's not buccal diaz. So I always remember mouth midazolam. Um And that's the pathway for kids and no be aware of the term wet flag. It's what we put on every board and reco when a sick kid comes in with a seizure and how you do your doses of LORazepam. You don't need to know what it all stands for and how to break it down. Just know that wet flags a thing. It's really good to say in your AK and other things you'll do for a seizure in a child's having status is urine toxicology. Um You'll cover them for encephalitis meningitis, give them a cyclovir, give them Ceftrixone and avoid an LP until you need it because you might have a raised intracranial pressure. So that's me on the main stuff. I'm going to quickly do a and signpost used to a few resources and we're finished up. I'm amazed at my timing. Um So this is a traffic light system. If you haven't already heard of it, be aware of it and especially where it says other at the bottom in the red box, that's something that comes up a lot about age, less than three months and a temperature over 38 you had met them. So this is the help GPS, know what to refer over to the hospital. So, the ones that I was aware of is if they're pill modeled respirate over 60 grunting. And then the less than three months, over 38 the rest you do not need to know off by heart but be aware that this exists. Respirate came up in fourth year, ay last year, they had to count them not last year, two years ago, sorry, not my year, the year above. And they got a video of Crip and they were asked to calculate the respirate from a video. So these are the parameters. They did not give you the normal range to know and it said a feedback to know what normal ranges were for respirate. I never learned them. My brain did not have the capacity to learn them. But I had a very rough idea of when they're born, it can go anything up to 60 when they're over 12 or the same as an adult, anything in between. I had a rough guestimate. I think I learned that a five year old should be 30. And then around that I worked it out but I wouldn't spend ages. But if you're stuck and you want to print it out and you don't get these slides, grab ap shirt, just a pediatric news shirt. Um A A I came up last year. Um You know what a unit uni form is, it's the form that A&E uses when they're concerned about a child's wellbeing. Um And smack is a good acronym to remember A A I um So safety of the child manage the medical. Always discuss concerns with a senior contact social work and keep clear notes unit is just a referral form. So, and then your developmental milestones are just for me reminding you that they are there. I'm nowhere near talking about them. There are night before job year exams. I did not learn them before that. And there is always one question. There was one in our fourth there and one in our finals. Don't forget the bubbles. It's just something else for me to let you know. We have a lot of pediatric resources on it. It's really, really good. I had my elective in London with the girl that owns this program and it's worldwide now. She's very, very good. She's a pediatric emergency medicine consultant in London. And if you want any more resources, she has brilliant ones there. Akie tips. Um So things just from we did our Mock Aus not in the Galvan yesterday for the fourth years and last week for the third years. And just things that I noted and from previous years, that are really important is that confirm who you are speaking to and the relation of them to the child, do not ask the person you're speaking to their date of birth. You only need the child. If it says on the stem, you're talking about the child. There's no point in asking the mum their date of birth, their name and be polite, but it just seems very odd to ask the mum the date of birth and it happened like 90% of the time yesterday. Do not assume it as a mum and do not assume it as a dad. It can be grannies, granddads. The couple we had in our final year. Oy was a, a female lesbian couple, but one woman was substantially older than the other. Like she had gray hair and looked about 60 the other looked 30 but they were a partner and that's just based on actors. So you had to ask in a nice way. And who are you? And what is your relation to this person or you together today? And what is your relations partnership and ask you in a nice way? Don't be judgmental and don't assume that someone, someone's granny because it comes across really offensive in ay. And if more than one person obviously confirm all attendance and if not a next of kin, check consent with the mother or father or the guardian and document this. Um na I just know about social work and asking about social work. It was forgot a few times yesterday. Check what their developmental milestone is. And does that meet the presenting complaint of the non accidental injury? So what we had in fourth year was a baby had spontaneously rolled off the bed and broke their leg, but the baby hadn't been able to roll yet. So I said to my mum like, what can your baby do? Can they look you, can they talk to you? Can they do in the gag? Can they grip? Have they rolled? No, they haven't. So, how did they fall? Well, my husband told me that he rolled out of bed and that was his first time, but I missed it. So there you go. Confirm that they're different BF GD. Birth fee, growth development, no matter what, peds, history counseling, whatever do BF GD. Don't forget vaccines, allergies, smokers at home and a head to toe on the child when counseling this came up yesterday as well. Really important that if a mom turns around to you and says, oh, I'm really worried about my child. I'm really worried that they could be really sick. A lot of people say, ok, no worries. So, anyway, what were you saying? And da, da, da, da, oh, I'm really worried that they could be dying. Ok. That's fine. Yeah. Move on. You have to address a mother's concern. You have to say I can see that this is really concerning for you and what I want you to know is that you're in the right place and we're gonna do things that can help. So address what mummy say, they're saying it for a reason. These are a with the script. If you don't address what they say, you're gonna lose marks two slides left and we're done, actually one side left and we're done. So peds, other oy types fluids. I didn't have time to do them all today. But practice, practice, practice. If in doubt and you completely freeze on a fluid station. Two thirds the fluids that you're given and avoid potassium, you only give potassium if you know what the baby's potassium is, otherwise don't give it. And if in doubt two thirds is always safer than giving too much prescribing. Make sure you have a pediatric cardi. Sometimes they give an adult and a ps if you're asked to prescribe antibiotics. Like we were in fourth year, babies take oral solutions. They do not take tablets. Three year olds cannot swallow, swallow capsules. Remember that growth charts, make sure you get the correct color, correct age. Like it's like 0 to 11 to 66 to 12 and also practice using a Queen's lecture. There's a really good one by Tom Burke I think, get a, get a growth chart. Watch the lecture and do it as he goes and it's really good. I did it like six or seven times and it taught me a lot. So that's that. And the last thing I have for you guys here and I'm done then I'll send the feedback so you can get the slides if you're interested in pediatrics. There's two prize exams. Um, the one on the left Ulster Pedes Prize is an invite only and it's, if you get high in your pediatric ay overall, you get invited as far as I can remember. It's based solely on the AY and the other one is a self entry. So you can enter it in fifth year and it's nothing to do with fourth year and you just go in and it's 450 true or false questions. And then if you get through to the final round, it's consultant led Aus with real Children with real conditions and there's like 10 different circuits and stations, but it's very educational and really, really helpful. So just someone's interest in peds, it's there to note. So, oh, how do I do that? Whoops. Um Where did I put my powerpoint? Uh OK. The last line was to say thank you in my email. Let me see if I can put it back up. Um OK, I'll just send them the link. I don't know where it went. Give me one second. So this is the pages feedback link. If you have any questions, fire them in the chat there now. Um and I will answer them all happily. I've got time. Where do we see chat? Um, so meeting group chat. That is the feedback for the slides. Even if he's just filled them in and say nothing. If you want the slides, that's also fine. Um, I think I've stopped sharing any questions. Let me know and I'm more than happy. I hope it was helpful. I know it's a lot of information. Um, and I know pe is quite daunting but it's really fun. Mhm. Mhm. I'll stay on when everyone's there. Just if anyone wants to unmute and ask me a question at the end, but I think I stopped sharing my screen. Yeah, thanks so much. You're very, very welcome. These are all very welcome. Thanks for all the nice. Mhm. Thanks very much. Very welcome. And you have any questions, let me know, but if not, I'm gonna tap out. So any questions let me know. No. All good. Ok. See you later.